Necrotizing Enterocolitis(Enterokolitis Nekrotikans)

N.E.C

Pembimbing: dr. Hartaniah Sadikin, Sp.A

Presentasi oleh:Patrick Hiskia Hasiholan Situmeang

Definisi Necrotizing

kematian jaringan Entero

saluran pencernaan (usus halus) Colli

saluran pencernaan (usus besar) -itis

peradangan

Definisi

• Kegawatan (emergencies) abdomen pada bayi baru lahir (bayi prematur)

• 1 – 2 minggu pertama kehidupan• Ditandai dengan peradangan pada

saluran cerna (usus halus dan usus besar) sampai dengan kematian jaringan (nekrotisasi) akibat berbagai faktor

http://kidshealth.org/parent/medical/digestive/nec.html

Anatomi Saluran Cerna

http://www.mountnittany.org/assets/images/krames/85061.jpg

http://go2.wordpress.com/?id=725X1342&site=usebrains.wordpress.com&url=http%3A%2F%2Fusebrains.files.wordpress.com%2F2008%2F11%2Fclip-image002.jpg

Anatomi Saluran Cerna

http://www.lighterliving.com/uploads/images/intestinaldiagram.jpg

Saluran Cerna Bayi Prematur

• IgA, Limfosit T• Respon Antibodi• Permeabilitas membran epitel GI• Motilitas GI• Lapisan Mucin tipis dan permeabel

McElroy, Steven M.D.:Neonatal NEC pp 34.Vanderbilt University.Vanderbilt Children Hospital.April 2008

Predileksi NEC

http://medimages.healthopedia.com/ large/necrotizing-enterocolitis.jpg

Ileum terminalis - caecum

Epidemiologi

http://knol.google.com/k/-/-/Mpv6w2_G/cMzxJA/fig%201.jpg

Faktor Resiko

Carol Rees Parish, R.D.: NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #59, Practical Gastroenterology, February 2008

Patofisiologi

Faktor Defensive Usus

http://neoreviews.aappublications.org – Jesse, Nathan M.D.;Necrotizing Enterocolitis: relationship to innate immunity, Clinical features, and Strategies for Prevention

aq

http://knol.google.com/k/-/-/Mpv6w2_G/cMzxJA/fig%208.jpg

Diagnosis NEC

• Modifikasi kriteria Bell’s Staging oleh Walsh dan Kliegmann

• 3 stadium1. Suspected NEC2. Proven /

Definite NEC3. Advanced /

Severe NEC

http://knol.google.com/k/-/-/Mpv6w2_G/cMzxJA/fig%202.jpg

Diagnosis NEC

Stadium I – Suspected NEC

• Faktor – faktor resiko untuk terjadinya stress perinatal

• Instabilitas suhu tubuh, disertai keadaan letargi, apnoe, bradikardia

• Gejala saluran pencernaan, bayi malas makan, meningkatnya residu saluran pencernaan, emesis, distensi abdomen ringan, tes darah samar feces positif

• Gambaran radiologis densitas ringan, dilatasi lumen usus

Normal

• Gambaran Radiologis

Dilatasi lumen

Stadium II – Proven NEC

• Gejala seperti stadium I, tetapi:– Distensi abdomen lebih

berat – Bising usus menghilang – Perdarahan lewat tinja

lebih jelas (gross bleeding)

– Asidosis metabolik ringan

– Radiologis:• pneumatosis

intestinalis • portal vein gas• tanda – tanda ascites

Stadium III – Advanced NEC

• Gejala 2 stadium sebelumnya ditambah:– tanda – tanda shock

(septic), – peritonitis

generalisata, – eritema pada

abdomen– Radiologis

• pneumoperitoneum

Pneumoperitoneum (football sign)

Tatalaksana

• Puasa (NPO) dan oksigenasi adekuat• Selang hidung-lambung (NGT)• Infus untuk cairan dan nutrisi cukup• Antibiotik• Pemeriksaan serial foto polos

abdomen

Tatalaksana

• Nutrisi

• Antibiotik– Clindamycin 15 – 40 mg/kg/hari terbagi 3-4x; – Gentamycin 2,5 mg/kg/x, 1-2x/hari – Metronidazole 7,5 – 15 mg/kg/hari

III B

III A

II B

II A

Indikasi Pembedahan

• Absolut:– Perforasi pneumoperitoneum– Perburukan gejala klinis dengan terapi maksimal– Obstruksi intestinal– Sepsis– Jaringan nekrotik striktura

• Relatif:– Perubahan warna dinding perut yang progresif– Looping dan dilatasi usus serta pneumatosis

intestinalis bermakna pada foto polos– Portal Vein Gas

Surgery

Peritoneal Drainage Laparatomy

• VLBW - Severe NEC• Tidak ada

kemajuan klinis selama 12 – 24 jam laparatomi

• Gangren - Sepsis• penentuan:

• Reseksi dan enterostomi

• Reseksi dan anastomosis primer

• Diverting jejunostomi

Komplikasi • Komplikasi penyakit dan tindakan:– Asidosis metabolik– DIC– Peritonitis– Abses– Striktura– Short gut – syndrome– Neurodevelopmental delay (50% pasien)

Prognosis

• Angka mortalitas 25 %• Dapat pulih dan tidak mengalami

gangguan pencernaan stadium dini terdiagnosis, tanpa komplikasi

Pencegahan

• ASI untuk bayi – bayi baru lahir• Probiotik

Air Susu Ibu• Faktor anti infeksi

– pH rendah • menghalangi pertumbuhan kuman colliform dan

jamur

– Meningkatkan kadar lisozym– Laktoferin-laktoperoksidase– Induksi imunitas enterik pasif

• SIgA• Sel T• Sel B

– Pengendalian flora usus (prebiotik-FOS,GOS)

• Faktor osmolaritas– Hiposmolaritas ASI

Bakterisid

Probiotik

• Mikroorganisme hidup• Saluran cerna manusia• Jumlah cukup • Bermanfaat

Probiotik

• 95% di ASI• Muncul hari ke – 7• homofermentasi

Prebiotik

• NDO (non digestable-oligosaccharides):– FOS (Fructo-Oligosaccharides)– TOS (Transgalacto-

Oligosaccharides)– Lactulose

Daftar Pustaka1. Avery, Gordon. B M.D., Ph.D. Neonatology: Pathophysiology and Management of the Newborn 3rd edition. pp

1220 – 1222:Section 47. Nutrition, Disorder of Nutrition. Fletcher, Anne B. Philadelphia: J. B. Lippincott Company.1987.

2. Bourlioux, Pierre et al. The Intestine and Its Microflora are Partners for the Protection of the Host: report on the Danone Symposium “The Intelligent Intestine”. Am Jou of Clinical Nutrition. 2002. Diunduh dari www.ajcn.org 3 Maret 2010.

3. Epelmann, Monica M. D. et al. Necrotizing Enterocolitis: Review of State-of-the-Art Imaging Findings with Pathologic Correlation. Radio Graphics Vol. 27:285 – 305. 2007. Diunduh dari: radiographics.rsna.org/content/27/2/285.full 3 Maret 2010.

4. Gomella, Tricia Lacy, M. Douglas Cunningham, Fabien Gabriel Eyal, Karin E. Zenk. Neonatology: Management, Procedures, On-call Problems, Diseases, and Drugs 5th edition. pp 482 – 487: Section 71. Necrotizing Enterocolitis and Spontaneous Intestinal Perforation.University of Michigan: Lange Medical Books.2004.

5. Hackam, David J M. D, Ph.D. Necrotizing Enterocolitis: A Leading Cause of Death and Disability in Newborn Children. Diunduh dari: http://knol.google.com/k/necrotizing-enterocolitis# 3 Maret 2010.

6. Henry Marion C. W M.D., R. Lawrence Moss, M.D. Surgical Therapy for Necrotizing Enterocolitis: Bringing Evidence to the Bedside. Diunduh dari: www.uftm.edu.br/discirped/textos/AVIdiscirped070102093945.pdf 4 Maret 2010

7. Jesse, Nathan and Josef Neu. Necrotizing Enterocolitis: Relationship to Innate Immunity, Clinical Features, and Strategies for Prevention. NeoReviews 2006;7;e143-e150. Diunduh dari: http://neoreviews.aappublications.org/cgi/content/full/neoreviews;7/3/e143

8. Reuters Health Information. SGA Preemies Face Excess Mortality from Lung Disease and Necrotizing Enterocolitis. Diunduh dari: http://www.medscape.com/viewarticle/709365. 3 Maret 2010.

9. Reuters Health Information. Human-Milk-Only Diet Lowers Necrotizing Enterocolitis Risk in Preemies. Diunduh dari: http://www.medscape.com/viewarticle/715321. 4 Maret 2010.

10. Springer, Shelley C M.D. Necrotizing Enterocolitis: Overview etc. Diunduh dari: http://emedicine.medscape.com/article/977956 3 Maret 2010.