A 600-gram, 25-week gestational age infant has feeding intolerance, abdominal distention, bloody stools and localized right lower quadrant erythema with pneumatosis on radiograph. He is started on broad spectrum antibiotics, but subsequently develops pneumoperitoneum and an abdominal drain is placed. Twenty-four hours later, he has increasing vasopressor requirements and has stopped making urine. His radiograph is as shown.

 

 

 

[size=20px]The next best step in managing this infant with perforated necrotizing enterocolitis is

 

A placing another drain.

 

B changing antibiotic therapy.

 

C laparotomy.

 

D administration of corticosteroids.

 

E administration of probiotics.[/size]

A

C

correct answer

C laparotomy

 

This patient has necrotizing enterocolitis (NEC) treated with peritoneal drainage (PD) with evidence of ongoing physiologic deterioration and significant intraperitoneal air - both of which suggest failure of source control of sepsis. The two randomized control trials which compared peritoneal drainage with laparotomy reported rates of early (i.e. within a few days) failure of PD requiring laparotomy ranging to range from 11 to 74%. In the described patient, a laparotomy is required to identify and resect necrotic bowel or make a diagnosis of NEC totalis.

 

NEC is thought to be caused by multiple enteric organisms and broad spectrum antibiotics are needed. Interestingly, there are no trials to support any particular combination of antibiotics in NEC. Clostridium has been shown to grow in the peritoneal fluid and blood cultures of infants with rapidly progressing NEC. Some experts have advocated the use of steroids in vasopressor-resistant hypotension, but sepsis source control has to be accomplished first. Placing a second drain would likely not accomplish source control as the first drain appears to be appropriately placed.