Necrotizing EnteroColitis


Over the years (yes, we have been doing the Ped EM Morsels that long), we have covered several intestinal disasters: for example, HSP and Intussusception, Malrotation, Intussusception, Hirschsprung’s and Enterocolitis. Yes, the differential for the neonate or young child with vomiting can be vast and severe, but let us not forget the most common GI emergency that occurs in the neonatal period – Necrotizing Enterocolitis.

 Necrotizing Enterocolitis (NEC)

  • Basics

    • NEC is an inflammatory process of the bowel that leads to necrosis and potential bowel perforation.
    • The inflammation also leads to disruption of the integrity of the bowel:
      • Increased risk for transmigration of intestinal bacteria.
      • Increased risk for third-spacing of fluids.
    • Etiology is still unclear.
  • Stages

    • Stage I
      • Suspected or Early NEC
      • May have nonspecific symptoms (ex, apnea / ALTE, lethargy, vomiting)
      • Feeding intolerance, vomiting, or ileus
        • Nonspecific dilated loops of bowel with air-fluid levels can be seen.
    • Stage II
      • Definite NEC with radiographic abnormalities
      • Intestinal dilation, pneumatosis intestinalis, and/or pneumatosis gastralis can be seen.
      • Air in the portal system may also been seen.
      • Initial therapy may be medical management with stabilization, bowel rest, and IV antibiotics.
    • Stage III
      • Acutely ill with advanced disease and perforation
      • Marked abdominal distension, acidosis, DIC, and Shock
      • Requires resuscitation and emergent surgery.
  • Prematurity vs Full Term

    • Unquestionably, NEC is primarily associated with prematurity, but…
      • It is now, not rare for premature children to be discharged from the hospital before they reach 40 Weeks postconceptual age.
      • ~10% of the cases of NEC occur in Full Term children.
      • Generally, NEC develops between the 30th and 40th week of postconceptual age.
    • NEC occuring in Full Term patients:
      • Is almost always seen in children with other concurrent illnesses or conditions:
        • Congenital Heart Disease
        • Asphyxia
        • Abdominal Wall defects
        • Polycythemia
        • Sepsis
        • etc.
      • Often seen to occur at a younger day of life then their premature counterparts
        • Likely associated with the earlier initiation of feeds.

      MORAL of the Story – NEC can present to you in the Emergency Department!

  • Presentation

    • Varies with the severity of the condition… making your job difficult once again.
    • Early in the course, NEC presentation can be very subtle.
      • Mild abdominal distension.
      • Feeding intolerance.
      • It may be overlooked and the vomiting attributed to “over-feeding.”
    • As NEC progresses, the abdominal exam becomes more concerning.
      • Tenderness
      • Decreased bowel sounds.
      • Occult blood or gross blood in stool.
      • Abdominal wall erythema or induration/edema
    • In its most severe form, the presentation is overt shock.
    • Bilious emesis in a neonate, even one who appears well, deserves your concern!
  • Imaging

    • Plain X-Rays of the abdomen
    • May need to add cross-table lateral or decubitus views to increase sensitivity.
  • Treatment

    • Resuscitate as needed!!
    • Early surgical consultation (even for the mild, Stage I)
    • NPO
    • Gastric decompression
    • Broad-Spectrum antibiotics
      • Ampicillin, Gentamicin, and Clindamycin or Metronidazole.


Lambert DK, Christensen RD, Henry E, Besner GE, Baer VL, Wiedmeier SE, Stoddard RA, Miner CA, Burnett J. Necrotizing enterocolitis in term neonates: data from a multihospital health-care system. J Perinatol. 2007; 27(7): 437-43.

Ostlie DJ, Spilde TL, St Peter SD, Sexton N, Miller KA, Sharp RJ, Gittes GK, Snyder CL. Necrotizing enterocolitis in full-term infants. J Pediatr Surg. 2003; 38(7): 1039-42.

Hostetler MA, Schulman M. Necrotizing enterocolitis presentin in the Emergency Department: Case report and review of differential considerations for vomiting in the neonate. J Emergency Medicine. 2001; 21(2): 165-70.


Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. […] in the ED.  The differential is vast and includes some terrible conditions (ex, Intussusception, Necrotizing Enterocolitis, Malrotation) as well as rather common conditions (ex, Constipation).  Naturally, we have all been […]

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