Research Article | | Peer-Reviewed

Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features

Received: 2 October 2023     Accepted: 17 October 2023     Published: 11 November 2023
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Abstract

Objective: To evaluate outcome and survival rate we focused on the severity of necrotizing enterocolitis without (NEC) or with perforation (NECp) and spontaneous intestinal perforation (SIP) and their influence on clinical deterioration and surgical complications. Methods: Aim was to compare the clinical features, radiographic findings and outcome of SIP, NEC and NECp. Focus was on a potential risk profile and 76 preterm were included. Results: Symptoms started earlier in SIP (p < 0.001). Systemic signs were led by body temperature instability (p = 0.014), hypotension (p = 0.022), manifested sepsis (p = 0.011), septic shock (p = 0,010) and disseminated intravascular coagulation (p = 0.021). The Bell classification was suitable for staging NEC (p < 0.001) and indication for laparotomy (p < 0.001), but postinterventional 17% has to be upgraded to stage IIIb (p < 0.001). Abdominal distension (p = 0.003) and -resistance (p = 0.033) were significantly more often found in NEC, while bloody stool (p = 0.035), oedematous abdominal wall (p = 0.044) and abdominal skin discoloration (p < 0.001) were typical for NECp or SIP, like an abdominal wall erythema (p = 0.049) for NECp. Radiographically signs like pneumatizes intestinalis (p < 0.001), bowel dilatation (p = 0.012) and thickened intestinal walls (p < 0.001) were less present in SIP, contrary to a pneumoperitoneum (p < 0.001), but survival rate did not differ. Conclusion: BELL classification is suitable for assigning NEC, but the degree of severity was underestimated in 17% of preterm. Focus should be on sick preterm with a coagulation disorder/ DIC, after resuscitation, glucose utilization disorder, septic shock or manifested sepsis. Intubation or high frequency ventilation were additionally risking for NECp followed by higher mortality rate.

Published in American Journal of Pediatrics (Volume 9, Issue 4)
DOI 10.11648/j.ajp.20230904.14
Page(s) 210-216
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2023. Published by Science Publishing Group

Keywords

Neonatology, Nec, Bell Classification, Survival, Outcome

References
[1] Wadhawan R, Oh W, Vohr BR, Saha S, Das A, Bell EF, et al. Spontaneous intestinal perforation in extremely low birth weight infants: association with indometacin therapy and effects on neurodevelopmental outcomes at 18-22 months corrected age. Archives of disease in childhood Fetal and neonatal edition. 2013; 98(2): F127-32.
[2] Stanford A, Upperman JS, Boyle P, Schall L, Ojimba JI, Ford HR. Long-term follow-up of patients with necrotizing enterocolitis. Journal of pediatric surgery. 2002; 37(7): 1048-50; discussion -50.
[3] Neu J. Necrotizing enterocolitis: the mystery goes on. Neonatology. 2014; 106(4): 289-95.
[4] Tiwari C, Sandlas G, Jayaswal S, Shah H. Spontaneous intestinal perforation in neonates. Journal of neonatal surgery. 2015; 4(2): 14.
[5] Gephart SM, Gordon PV, Penn AH, Gregory KE, Swanson JR, Maheshwari A, et al. Changing the paradigm of defining, detecting, and diagnosing NEC: Perspectives on Bell's stages and biomarkers for NEC. Seminars in pediatric surgery. 2018; 27(1): 3-10.
[6] Zani A, Eaton S, Puri P, Rintala R, Lukac M, Bagolan P, et al. International survey on the management of necrotizing enterocolitis. European journal of pediatric surgery: official journal of Austrian Association of Pediatric Surgery [et al] = Zeitschrift fur Kinderchirurgie. 2015; 25(1): 27-33.
[7] Robinson JR, Rellinger EJ, Hatch LD, Weitkamp JH, Speck KE, Danko M, et al. Surgical necrotizing enterocolitis. Seminars in perinatology. 2017; 41(1): 70-9.
[8] Loh M, Osborn DA, Lui K. Outcome of very premature infants with necrotising enterocolitis cared for in centres with or without on site surgical facilities. Archives of disease in childhood Fetal and neonatal edition. 2001; 85(2): F114-8.
[9] Frost BL, Modi BP, Jaksic T, Caplan MS. New Medical and Surgical Insights Into Neonatal Necrotizing Enterocolitis: A Review. JAMA pediatrics. 2017; 171(1): 83-8.
[10] Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatric clinics of North America. 1986; 33(1): 179-201.
[11] Rich BS, Dolgin SE. Necrotizing Enterocolitis. Pediatrics in review. 2017; 38(12): 552-9.
[12] Najaf TA, Vachharajani NA, Warner BW, Vachharajani AJ. Interval between clinical presentation of necrotizing enterocolitis and bowel perforation in neonates. Pediatric surgery international. 2010; 26(6): 607-9.
[13] Bohler T, Bruder I, Ruef P, Arand J, Teufel M, Mohrmann M, et al. Necrotizing enterocolitis and focal intestinal perforation in neonatal intensive care units in the state of baden-wurttemberg, Germany. Pediatric reports. 2014; 6(1): 5194.
[14] McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. The Cochrane database of systematic reviews. 2018; 2: Cd004210.
[15] Samuels N, van de Graaf RA, de Jonge RCJ, Reiss IKM, Vermeulen MJ. Risk factors for necrotizing enterocolitis in neonates: a systematic review of prognostic studies. BMC pediatrics. 2017; 17(1): 105.
[16] Esposito F, Mamone R, Di Serafino M, Mercogliano C, Vitale V, Vallone G, et al. Diagnostic imaging features of necrotizing enterocolitis: a narrative review. Quantitative imaging in medicine and surgery. 2017; 7(3): 336-44.
[17] Li YF, Lin HC, Torrazza RM, Parker L, Talaga E, Neu J. Gastric residual evaluation in preterm neonates: a useful monitoring technique or a hindrance? Pediatrics and neonatology. 2014; 55(5): 335-40.
[18] Linder N, Hammel N, Hernandez A, Fridman E, Dlugy E, Herscovici T, et al. Intestinal perforation in very-low-birth-weight infants with necrotizing enterocolitis. Journal of pediatric surgery. 2013; 48(3): 562-7.
[19] Gephart SM, Fleiner M, Kijewski A. The ConNECtion Between Abdominal Signs and Necrotizing Enterocolitis in Infants 501 to 1500 g. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2017; 17(1): 53-64.
[20] Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. Journal of pediatric surgery. 1994; 29(5): 663-6.
[21] Khalak R, D'Angio C, Mathew B, Wang H, Guilford S, Thomas E, et al. Physical examination score predicts need for surgery in neonates with necrotizing enterocolitis. Journal of perinatology: official journal of the California Perinatal Association. 2018; 38(12): 1644-50.
[22] Starr R, De Jesus O, Shah SD, Borger J. Periventricular Hemorrhage-Intraventricular Hemorrhage. StatPearls. Treasure Island (FL) 2021.
[23] Ahle M, Ringertz HG, Rubesova E. The role of imaging in the management of necrotising enterocolitis: a multispecialist survey and a review of the literature. European radiology. 2018; 28(9): 3621-31.
[24] De Bernardo G, Sordino D, De Chiara C, Riccitelli M, Esposito F, Giordano M, et al. Management of NEC: Surgical Treatment and Role of Traditional X-ray Versus Ultrasound Imaging, Experience of a Single Centre. Current pediatric reviews. 2019; 15(2): 125-30.
[25] van Druten J, Khashu M, Chan SS, Sharif S, Abdalla H. Abdominal ultrasound should become part of standard care for early diagnosis and management of necrotising enterocolitis: a narrative review. Archives of disease in childhood Fetal and neonatal edition. 2019; 104(5): F551-f9.
[26] Yikilmaz A, Hall NJ, Daneman A, Gerstle JT, Navarro OM, Moineddin R, et al. Prospective evaluation of the impact of sonography on the management and surgical intervention of neonates with necrotizing enterocolitis. Pediatric surgery international. 2014; 30(12): 1231-40.
[27] Deeg KH. Sonographic and Doppler Sonographic Diagnosis of Necrotizing Enterocolitis in Preterm Infants and Newborns. Ultraschall Med. 2019; 40(3): 292-318.
[28] Shah TA, Meinzen-Derr J, Gratton T, Steichen J, Donovan EF, Yolton K, et al. Hospital and neurodevelopmental outcomes of extremely low-birth-weight infants with necrotizing enterocolitis and spontaneous intestinal perforation. Journal of perinatology: official journal of the California Perinatal Association. 2012; 32(7): 552-8.
[29] Gephart SM, McGrath JM, Effken JA, Halpern MD. Necrotizing enterocolitis risk: state of the science. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2012; 12(2): 77-87; quiz 8-9.
[30] Fisher JG, Jones BA, Gutierrez IM, Hull MA, Kang KH, Kenny M, et al. Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis. Journal of pediatric surgery. 2014; 49(8): 1215-9.
[31] Hansen ML, Juhl SM, Fonnest G, Greisen G. Surgical findings during exploratory laparotomy are closely related to mortality in premature infants with necrotising enterocolitis. Acta paediatrica (Oslo, Norway: 1992). 2017; 106(3): 399-404.
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  • APA Style

    Kapapa, M., Hahne, J., Serra, A. (2023). Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features. American Journal of Pediatrics, 9(4), 210-216. https://doi.org/10.11648/j.ajp.20230904.14

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    ACS Style

    Kapapa, M.; Hahne, J.; Serra, A. Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features. Am. J. Pediatr. 2023, 9(4), 210-216. doi: 10.11648/j.ajp.20230904.14

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    AMA Style

    Kapapa M, Hahne J, Serra A. Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features. Am J Pediatr. 2023;9(4):210-216. doi: 10.11648/j.ajp.20230904.14

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  • @article{10.11648/j.ajp.20230904.14,
      author = {Melanie Kapapa and Janina Hahne and Alexandre Serra},
      title = {Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features},
      journal = {American Journal of Pediatrics},
      volume = {9},
      number = {4},
      pages = {210-216},
      doi = {10.11648/j.ajp.20230904.14},
      url = {https://doi.org/10.11648/j.ajp.20230904.14},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajp.20230904.14},
      abstract = {Objective: To evaluate outcome and survival rate we focused on the severity of necrotizing enterocolitis without (NEC) or with perforation (NECp) and spontaneous intestinal perforation (SIP) and their influence on clinical deterioration and surgical complications. Methods: Aim was to compare the clinical features, radiographic findings and outcome of SIP, NEC and NECp. Focus was on a potential risk profile and 76 preterm were included. Results: Symptoms started earlier in SIP (p < 0.001). Systemic signs were led by body temperature instability (p = 0.014), hypotension (p = 0.022), manifested sepsis (p = 0.011), septic shock (p = 0,010) and disseminated intravascular coagulation (p = 0.021). The Bell classification was suitable for staging NEC (p < 0.001) and indication for laparotomy (p < 0.001), but postinterventional 17% has to be upgraded to stage IIIb (p < 0.001). Abdominal distension (p = 0.003) and -resistance (p = 0.033) were significantly more often found in NEC, while bloody stool (p = 0.035), oedematous abdominal wall (p = 0.044) and abdominal skin discoloration (p < 0.001) were typical for NECp or SIP, like an abdominal wall erythema (p = 0.049) for NECp. Radiographically signs like pneumatizes intestinalis (p < 0.001), bowel dilatation (p = 0.012) and thickened intestinal walls (p < 0.001) were less present in SIP, contrary to a pneumoperitoneum (p < 0.001), but survival rate did not differ. Conclusion: BELL classification is suitable for assigning NEC, but the degree of severity was underestimated in 17% of preterm. Focus should be on sick preterm with a coagulation disorder/ DIC, after resuscitation, glucose utilization disorder, septic shock or manifested sepsis. Intubation or high frequency ventilation were additionally risking for NECp followed by higher mortality rate.
    },
     year = {2023}
    }
    

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  • TY  - JOUR
    T1  - Bowel Perforation in Preterm: Predictive Power of Bell Classification and Clinical Features
    AU  - Melanie Kapapa
    AU  - Janina Hahne
    AU  - Alexandre Serra
    Y1  - 2023/11/11
    PY  - 2023
    N1  - https://doi.org/10.11648/j.ajp.20230904.14
    DO  - 10.11648/j.ajp.20230904.14
    T2  - American Journal of Pediatrics
    JF  - American Journal of Pediatrics
    JO  - American Journal of Pediatrics
    SP  - 210
    EP  - 216
    PB  - Science Publishing Group
    SN  - 2472-0909
    UR  - https://doi.org/10.11648/j.ajp.20230904.14
    AB  - Objective: To evaluate outcome and survival rate we focused on the severity of necrotizing enterocolitis without (NEC) or with perforation (NECp) and spontaneous intestinal perforation (SIP) and their influence on clinical deterioration and surgical complications. Methods: Aim was to compare the clinical features, radiographic findings and outcome of SIP, NEC and NECp. Focus was on a potential risk profile and 76 preterm were included. Results: Symptoms started earlier in SIP (p < 0.001). Systemic signs were led by body temperature instability (p = 0.014), hypotension (p = 0.022), manifested sepsis (p = 0.011), septic shock (p = 0,010) and disseminated intravascular coagulation (p = 0.021). The Bell classification was suitable for staging NEC (p < 0.001) and indication for laparotomy (p < 0.001), but postinterventional 17% has to be upgraded to stage IIIb (p < 0.001). Abdominal distension (p = 0.003) and -resistance (p = 0.033) were significantly more often found in NEC, while bloody stool (p = 0.035), oedematous abdominal wall (p = 0.044) and abdominal skin discoloration (p < 0.001) were typical for NECp or SIP, like an abdominal wall erythema (p = 0.049) for NECp. Radiographically signs like pneumatizes intestinalis (p < 0.001), bowel dilatation (p = 0.012) and thickened intestinal walls (p < 0.001) were less present in SIP, contrary to a pneumoperitoneum (p < 0.001), but survival rate did not differ. Conclusion: BELL classification is suitable for assigning NEC, but the degree of severity was underestimated in 17% of preterm. Focus should be on sick preterm with a coagulation disorder/ DIC, after resuscitation, glucose utilization disorder, septic shock or manifested sepsis. Intubation or high frequency ventilation were additionally risking for NECp followed by higher mortality rate.
    
    VL  - 9
    IS  - 4
    ER  - 

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Author Information
  • Division of Pediatric Surgery, Department of Surgery, University Medical Centre Ulm, Ulm, Germany

  • Department of Pediatric and Adolescent Medicine, University Medical Centre Ulm, Ulm, Germany

  • Division of Pediatric Surgery, Department of Surgery, University Medical Centre Ulm, Ulm, Germany

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