Colonic Strictures Following Nonoperative M anagement of N ecrotizing Enterocolitis By H. Stein, I. Kavin, and E. N. Faerber

H E R E H A S BEEN an increasing awareness of necrotizing enterocolitis in neonates in the past 10 yr. 1-3 Whether this reflects more accurate diagnosis of the condition or a true increasing incidence is not certain. It seems likely that the incidence has increased particularly in view of the fact that m a n y more newborns, especially premature ones who are " a t risk," are now surviving; it is these infants who are particularly susceptible to necrotizing enterocolitis. 4 M a n y factors have been suggested to be of etiologic significance; neonatal asphyxia, hypothermia, and apnoeic bouts are, particularly in premature babies, 4-7 believed to be of importance in inducing the shock-like state predispOsing to the devitalization of the bowel that precedes necrotizing enterocolitis. A relationship to exchange transfusion seems well established. 8'9 Recently, a series of premature babies from this hospital in w h o m gastroenteritis and Salmonella infection were u n d o u b t a b l y etiologic factors was described, l~ The mortality of this condition is high and the m a n a g e m e n t remains contentious. ~~Most authors 6'8'~ believe that operative intervention is indicated but some favor nonoperative therapy with intravenous feeding, gastric suction, and antibiotics. ~ It is our experience that the o u t c o m e relates more closely to the background and etiology than the therapy. In the p r e m a t u r e babies reported previously from this hospital in whom there was a b a c k g r o u n d of severe gastrointestinal infection, the prognosis was uniformly bad with any treatment. ~~However, in our experience, full-term babies who develop necrotizing enterocolitis after exchange transfusion do well with either nonoperative or surgical treatment. Clearly, if nonoperative therapy is as effective as surgery, then the former must be the therapy of choice. However, we have recently had a series of cases of necrotizing enterocolitis treated without operation in which large bowel strictures have been observed following recovery. We report five consecutive cases in which strictures occurred following nonoperative therapy of necrotizing enterocolitis. The relevant features are found in Table 1.

T

DISCUSSION

There are relatively few reports of follow-up studies in cases of necrotizing enterocolitis and only rarely is there mention of strictures as a complication. Krasna et al. ~2 described four cases and Stevenson et al. 6 six cases in a series of 21 affected babies. Krasna et al. ~2 state that since few infants treated medically

From the Departments of Pediatrics and Radiology, Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa. Address for reprint requests: E. N. Faerber, M.B., B.Ch., D.M.R.D., 42 Muirfield Rd., Greenside Ext., Johannesburg 2001, South Africa. 9 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 10, No. 6 (December), 1975

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STEIN ET AL

Fig. 1,

Barium enema studies demonstrating strictures in each of the five patients.

survive, there are as yet too few cases recorded to determine how often this disease leads to stricture. Our cases were medically treated and, although they lacked prolonged follow-up, it would appear that, when looked for, stricture is a c o m m o n complication. Krasna et al. t2 also state that a history of neonatal necrotizing enterocolitis should be looked for when patients present with stenosis of the colon. It is our experience that a p r o p o r t i o n of babies following exchange transfusion briefly develop blood in the stools with no other evidence of necrotizing enterocolitis. It may well be that these babies may have mild de-

NECROTIZING ENTEROCOLITIS

945

See legend facing page.

grees o f necrotizing enterocolitis and, although recovering fully at the time, later develop strictures. We propose carrying out a follow-up study on these patients. In the patients reported by Krasna et al., ~2 three of the strictures were in the colon and one in the terminal ileum. In our series all were sited in the colon. It would be important to determine just how frequent the complication of stricture is in those medically managed as well as in those surgically m a n a g e d where ileostomy is carried out. In any event it is i m p o r t a n t to be aware that strictures are an important complication of necrotizing enterocolitis and that routine radiologic follow-up studies on these cases should be carried out. SUMMARY

Five consecutive cases of neonatal necrotizing enterocolitis o p e r a t i v e l y h a d c o l o n i c s t r i c t u r e s . F o u r o f five p a t i e n t s s u r v i v e d .

treated

non-

ACKNOWLEDGMENT

We thank Professor S. Wayburne, Dr. A. Solomon, and Professor M. Dinner of the Departments of Pediatrics, Radiology, and Pediatric Surgery, respectively, for their assistance. REFERENCES

1. Beck JM, Dinner M, Chappel J: Enterocolitis following exchange transfusion. S Afr J Surg 9:39, 1971 2. Editorial: Br Med J 3:121, 1970 3. Blanc WA: Amniotic infection syndrome. Clin Obstet Gynecol 2:705, 1959 4. Fetterman GH: Neonatal necrotizing enterocolitis. Pediatrics 48:345, 1971

5. Lloyd JR: The etiology of gastrointestinal perforations in the newborn. J Pediatr Surg 4: 77, 1969 6. Stevenson JK, Graham CB, Oliver TK, et al: Neonatal necrotizing enterocolitis. Am J Surg 118:260, 1969 7. Singleton EB, Rosenberg HM, Samper L:

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