1. Abdominal Emergencies in Children
NEC, Haemorrhagic Disease of Newborn, Perforations
Sharon Cox
Red Cross War Memorial Children’s Hospital and University of Cape Town

2. NEC Incidence At risk neonates Premature Stressed Diagnosis
Clinical: Distension, vomiting
Sepsis
Radiology

3. NEC Medical management Full ICU support IVI antibiotics NPO, NGT TPN
Vit K
Refer surgery

4. Why Operate? Improve patient condition
Remove ischemic/ necrotic bowel and spilled intraperitoneal fluid, stool
30 – 50%
Keep complications low
How to achieve this is controversial and lacking good level of evidence

5. What is the evidence?  Incidence Mortality Higher: selection bias
Multiple studies over 3 decades, majority small case series
Conflicting results
Recent breakdown of institutional and geographic barriers, investigators working together
Multi-center RCT commenced and results starting to be evaluated

6. Indications Absolute Perforation: free air on AXR Intestinal Stricture
Relative
Fixed intestinal loops on AXR
Palpabable mass
Abdominal wall erythema
Failure of medical treatment*
Portal venous gas*
Thrombocytopaenia
Necrotizing enterocolitis — bench to bedside: novel and emerging strategiesYigit S. Guner, MD, Nikunj et al Seminars in Pediatric Surgery (2008) 17, .

7. Perforation - Free Air No dispute since early 70’s
Only universally accepted absolute indication
Indication in 30 to 40% of cases
Will never be a trial/evidence
But: Pneumoperitoneum is not always demonstrable on AXR
50% to 75% of patients with perforation
overall specificity for pneumoperitoneum was 92% and positive predictive value, 88%
newer techniques are being evaluated - ultrasound

8. Positive Paracentesis
Kosloske 1982: Fluid for bile, bacteria – Good indicator of gangrenous bowel
Ricketts et al reported positive Paracentesis (>0.5 ml of flee-flowing brownish fluid and/or positive for bacteria on Gram stain) as an indication for operation
Paracentesis can be used to aid decision-making in neonates who don’t meet absolute criteria for surgery
False negatives described: sealed perforation

9. Fixed loop Persistent loop (>24hrs) on serial X Rays
Specificity and PPV for gangrenous bowel close to 100%
Low prevalence
O’Neill, Grossfelt 1998; Caty, Azizkhan % recover without undergoing surgery
Pneumatosis intestinalis. Loren G Yamamoto, Kapiolani Medical Center for Women & Children, University of Hawaii

10. Palpable Mass
Is cited as evidence of localized perforation with abscess formation
Specificity and PPV for gangrenous bowel close to 100%
Prevalence less than 10%
Limited use
Indication for surgery if associated with continued sepsis or obstruction (Stringer, Spitz 1993)

11. Abdominal Wall Erythema
Indication for surgery if associated with continued sepsis or obstruction
Specificity and PPV for gangrenous bowel almost 100%
Prevalence less than 10%
Subjective
Limited use ©

12. Portal venous Gas Assoc with poor prognosis in many studies
Conclusion: “Should be considered operative indication”
Not universally accepted
Rowe et al 1998, 90% with PVG will develop necrosis, 50% will have pan intestinal involvement
Sharma and Tepas et al* 30/64 (47%) survived without surgery
* Sharma R, Tepas JJ et al; Portal Venous Gas and Surgical Outcome of Neonatal NEC. J Pediatr Surg 40: 371 –

13. Clinical Deterioration
Deterioration despite adequate medical therapy has often been used as a broad term to indicate likely intestinal gangrene and has been cited as the commonest indication (59%) for surgery
Broad term, no statistics to confirm

14. Thrombocytopaenia
Sudden platelet drop is considered indication of gangrenous bowel
Ververidids et al – greater extent of disease, lower platelets
Severe thrombocytopaenia: sens: 69%, spec: 60% PPV: 89% - predict gangrene
Rapid Platelet fall sens: 32%, spec: 89% PPV 92%
Therefore, thrombocytopaenia cannot predict extent of disease or predict need for lap

15. Stricture
>30% NEC patients and >50% of surgically managed patients will develop stricture
Post-NEC strictures are believed to occur as a consequence of scarring after ischemic intestinal injury
No specific criteria can be identified to predict at risk patients
Evidenced by feed intolerance, abdo distension, vomiting, bradycardia and apneas
Most in colon, sigmoid
Routine imaging of distal bowel prior to closure of stoma is suggested
Source: Appl Radiol Online © 2003 Anderson Publishing. Ltd.

16. Optimal timing Optimal timing
After severe ischaemia and demarcation
Before perforation
Avoid unnecessary surgery: increased loss of bowel due to lack of demarcation
Prevent complications of advanced intraperitoneal sepsis
Identifying this window is a challenge (imaging? Biological markers?)

17. New Techniques
Colour Doppler and standard US imaging of bowel offer a useful non invasive method to evaluate intestinal blood flow
Abdominal US is can delineate free air, intramural gas, portal venous gas, fluid collections, bowel wall thinning/thickening, increased bowel wall echogenicity, and perfusion
One factor limiting it’s expansion may be the timely availability of a radiologist

18. Summary Absolute: free air
Relative: Evidence scanty – need critical evaluation
3 decades after initial description NEC remains a challenge to the Paediatric Surgeon, optimal management continues to generate debate
Clear and deliberate educated judgment on individual patient basis

19. Management Percutaneous drainage Surgical exploration Resection
Glove drain
Urine bag
Local and adrenaline
Temporary measure
Surgical exploration
Resection
Primary anastomosis
Stoma formation
Laparoscopic assessment – Fluorescin and UV light
Continued ICU support
TPN

20. Surgical Management Resect and anastomosis Conservative
Diverting stoma
Clip and drop
Early Closure
Diverting stoma
Continued Medical Management
Late Closure
Resect and anastomosis
Medical Management
Laparotomy
NEC
Stenting
Surgical Intervention
Laparotomy
Lapscope
Conservative
Planned Laparotomy
Drain
Laparotomy for deterioration
Indications for surgery
Drain as definative management
Delayed lap for strictures

21. Perforations NEC >50% Meconium ileus Spontaneous Gastric Ileal
Rectal
Traumatic
Instrumentation
Nasal Ventilation
Co-existent pathology
CMV Colitis

22. Rectal Perforation Very rare Characteristic features
Recent series of 9 cases
Treatment is stoma, drainage, image rectum, close stoma

23. Associations Steroids, NSAID Systemic candidiasis
Conditions that diminish bowel perfusion – cardiac lesions, umbilical catheters
Nasal ventilation
Instrumentation
Cystic Fibrosis

24. Presentation First few days of life Sepsis: relatively well
Feed intolerance and vomiting
Abdominal distension
Respiratory distress
‘Blue’ discolouration
Free Air
Football sign
Saddle bag sign
Arcade sign
No pneumatosis, portal gas
Water soluble contrast study

25. Management Resus NPO, NGT IVI antibiotics
Percutaneous drainage before transfer
Relieve respiratory distress
Slow progression to severe sepsis
Surgery
Primary closure
Stoma

26. Prognosis Cause: NEC vs Other Prematurity UWFA Delay in transfer
Immune status

27. Haemorrhagic Disease Rare Vitamin K deficiency Bleeding sites:
Umbilicus
Mucous membranes
GIT
Venepunctures
Intracranial
Intra abdominal

28. Neonatal haemoperitoneum
Haemorrhagic disease of the newborn
Haemophillia
Not for surgical intervention
Congenital angioma of the liver