Pathology and pathogenesis of necrotizing enterocolitis in newborns

Author Richard J Schanler, MD Section Editor Steven A Abrams, MD Deputy Editor Melanie S Kim, MD

Last literature review version 18.3: September 2010 | This topic last updated: August 2, 2010 (More)

INTRODUCTION Necrotizing enterocolitis (NEC), the most common gastrointestinal emergency in the newborn infant, is a disorder manifested by ischemic necrosis of the intestinal mucosa [1]. It is associated with inflammation, invasion of enteric gas forming organisms, and dissection of gas into the muscularis and portal venous system.

NEC occurs in 1 to 3 per 1000 live births and is seen predominately in premature infants with an incidence of about 6 to 7 percent in very low birthweight (VLBW) infants (birthweight <1500 g). Although early recognition and aggressive treatment of this disorder has improved clinical outcomes, NEC accounts for substantial long-term morbidity in survivors of neonatal intensive care, particularly in VLBW infants.

First described in 1965, the etiology of NEC remains uncertain [2-4].

The pathology and the current understanding of the pathogenesis of NEC are reviewed here. The clinical features, management, and prevention of this disorder are discussed separately. (See "Clinical features and diagnosis of necrotizing enterocolitis in newborns" and "Management of necrotizing enterocolitis in newborns" and "Prevention of necrotizing enterocolitis in newborns".)

PATHOLOGY The pathology of NEC is primarily due to changes from intestinal infarction [5]. The specific findings vary and depend upon the progression of the disease and the presence of underlying pathogenic factors. The terminal ileum and colon are involved in the majority of cases, although the entire gastrointestinal tract is affected in severe cases.

On gross examination, the bowel appears distended and hemorrhagic. Subserosal collections of gas occasionally are present along the mesenteric border. Gangrenous necrosis occurs on the antimesenteric border, and perforation may be present. As the gut heals, thickening of the bowel wall, fibrinous adhesions, and areas of stenosis appear.

The major histologic findings in NEC are mucosal edema, hemorrhage, and transmural bland necrosis. Other findings include acute inflammation, secondary bacterial infiltration, and collections of gas. Vascular thrombi are rare.

PATHOGENESIS The pathogenesis of NEC remains unknown, but it is probably a heterogeneous disease resulting from multiple factors that result in mucosal injury in a susceptible host. The following factors have been implicated in the pathogenesis of NEC (figure 1):

PrematurityMicrobial bowel overgrowthMilk feedingImpaired mucosal defenseCirculatory instability of the intestinal tractMedications that cause intestinal mucosal injury or enhance microbial overgrowth

Currently, epidemiologic studies have identified prematurity and milk feeding as consistent risk factors for NEC [4,6].

Prematurity About 90 percent of NEC cases occur in premature infants born who have been fed enterally. The following factors due to immaturity of the gastrointestinal tract and immune system are thought to predispose the preterm infant to NEC [7] (figure 2) [8].

Immature mucosal barrier with increased permeability and bacterial penetration into the intestinal wall (translocation) compared to term infants. (See 'Impaired mucosal defense' below.)Immature local host defenses with diminished concentrations of secretory IgA, mucosal enzymes (eg, pepsin and proteases), and other protective agents (eg, lactoferrin), and increased gastric pH, which promotes bacterial overgrowth.Immature bowel motility and function. Premature infants have decreased small bowel motility, resulting in delayed transit time, which increases bacterial proliferation and overgrowth [9].

Bacterial overgrowth and increased intestinal permeability are factors that contribute to greater bacterial translocation from the intestinal lumen into the intestinal tissue leading to an inflammatory response with activation of cytokines [9]. (See 'Inflammation' below.)

Exposure to glucocorticoids matures intestinal barrier function, and antenatal treatment has been proposed to reduce the incidence of NEC [10,11]. (See "Antenatal use of glucocorticoids in women at risk for preterm delivery", section on 'Reduction of IVH, NEC, NNM, infection'.)

Term infants NEC in term infants is generally associated with predisposing or underlying conditions, such as congenital heart disease, perinatal asphyxia, polycythemia, sepsis, and respiratory disease. (See "Clinical features and diagnosis of necrotizing enterocolitis in newborns", section on 'Epidemiology'.)

Milk feeding More than 90 percent of infants who develop NEC have received milk feeding, although NEC also occurs in infants who have never been fed [12]. Enteral feeding may contribute to the pathogenesis of NEC because human milk and commercial formulas serve as substrates for bacterial proliferation in the gut.

Newborns, especially premature infants, have not developed the ability to completely digest and absorb nutrients. As a result, bacterial fermentation products of incompletely digested carbohydrates and lipids (eg, reducing substances, organic acids, short chain fatty acids, carbon dioxide, and hydrogen gas) in the intestine of premature infants may cause mucosal injury. Delayed transient time due to impaired motility in the premature infant exacerbates this process. Supportive data was provided by a study using an animal model that

demonstrated a mixture of casein, organic acids, and low pH led to mucosal injury with infiltration of cellular elements and vasoactive compounds [13].

Although NEC is associated with enteral feeds, limited data suggest that the following feeding-related factors are not important in the development of NEC:

The rate of advancement of feedings has not been associated with the risk of NEC [14,15]. In a trial of 185 premature infants, the incidence of NEC was similar in infants whose volume of formula was increased by 15 or 35 mL/kg per day [14]. The lack of a relationship between the rate of feeding advancement and NEC also was supported in a systematic review [15].Other systematic reviews demonstrated that the timing of the initiation of feedings (before or after four days) was not related to NEC [16,17]. Delaying the initiation of enteral feeding in at-risk infants is not protective. (See "Nutritional composition of human milk and preterm formula for the premature infant".)Providing minimal enteral or trophic feeding does not increase the incidence of NEC [17-19].

Human milk Human milk, compared to formula, is more protective against NEC in premature infants. Factors present in human milk may play a role in this protection by reducing inflammation or the introduction of foreign antigens in the gastrointestinal tract. Human milk feeding is associated with a lower intestinal pH to facilitate the growth of non-pathogenic bacteria, which counteract pathogenic bacteria. The mucus coat of the intestine is less affected by human milk and growth factors within human milk (such as epidermal growth factors) repair disruptions in this layer. Human milk improves intestinal motility, which avoids milk stasis and decreases intestinal permeability. Human milk also stimulates the mucosal defense system so that local immune activation is thwarted. Protective factors within human milk include platelet activating factor acetylhydrolase, secretory Immunoglobulin A, cytokines (IL-10, IL-11),

epidermal growth factor [20], nucleotides, glutamine, and antioxidants such as vitamin E, carotene, and glutathione. The benefits of human milk compared to formula in reducing the risk of NEC in premature infants are discussed elsewhere. (See "Human milk feeding and fortification of human milk for premature infants" and "Infant benefits of breastfeeding", section on 'Gastrointestinal function'.)

Microbial colonization Bacterial colonization is believed to play a pivotal role in the development of NEC because NEC does not occur in utero when the gut is sterile. After delivery, rapid colonization of the intestinal tract by commensal bacteria from the maternal rectovaginal flora occurs. These bacteria play a symbiotic role with the intestine through toll-like receptors by regulating the expression of genes involved in intestinal physiology, postnatal maturation, and function (eg, barrier, digestion, angiogenesis, and production of IgA), and protection against more pathologic organisms [8,21-23]. Pathologic host-bacterial interactions may induce pro-inflammatory and pro-apoptotic responses in the intestinal host cells mediated by signaling pathways, such as the NF-kappa B pathway [8,22].

Although, there are limited data regarding these roles of bacteria in prenatal and postnatal intestinal development, intestinal noncommensal bacterial overgrowth appears to affect intestinal maturation and increase inflammation and apoptosis. In addition, overgrowth of noncommensal bacteria may result in endotoxin release, which may cause direct mucosal injury. This appears to occur in the absence of a primary infection, particularly in most sporadic cases of NEC in which infectious agents play a secondary role in the disease process [8]. Approximately 20 to 30 percent of infants with NEC have associated bacteremia, which is most likely seeded by intestinal bacteria that is translocation through the damaged intestinal mucosa [4]. In some cases, especially in outbreaks of NEC, primary infection by pathogenic bacteria may occur [8].

The use of probiotic therapy has been proposed to reduce bacterial overgrowth of more invasive bacteria and promote commensal intestinal bacteria, which inhibit inflammatory pathways, thereby decreasing the risk of NEC [8,22]. However, the current use of probiotics should be limited to clinical trials until there is unequivocal evidence that confirms the efficacy and safety of probiotic therapy compared to other preventive modalities, and establishes the most effective regimen for premature infants (ie, bacterial strain, dosing, and timing and duration of therapy). (See "Prevention of necrotizing enterocolitis in newborns", section on 'Probiotics'.)

In contrast, prolonged initial empiric antibiotic therapy greater than five days duration is associated with an increased risk of NEC or death, most likely due to a change in the bacterial colonization of the gastrointestinal tract [8].

Primary infection NEC may be due to primary invasions of the gut by pathogenic enteric bacteria. Bacterial organisms usually found in the distal gastrointestinal tract have been recovered from the blood and peritoneal cavities of patients with NEC. These organisms include Escherichia coli, Klebsiella pneumoniae, Pseudomonas, and Clostridium difficile [24-26]. In particular, Clostridium species, a toxin-producing bacteria that is associated with pseudomembrane formation, submucosal and subserosal gas blebs, and intestinal gangrene, has been associated with more severe NEC [27,28].

In addition to these bacteria, viral and fungal pathogens have been isolated in some sporadic cases of NEC and in epidemic outbreaks [29,30]. Virus particles have been isolated from the stools of infants with NEC and their caregivers, including their mothers, the midwives, and the nursery nursing staff. Injury

caused by infectious agents may be aggravated by inflammatory mediators. (See 'Inflammation' below.)

The use of molecular techniques may prove to be a useful tool in evaluating the role of infection in the pathogenesis of NEC. In a small prospective study, stool samples from 12 infants less than 34 weeks gestation who were admitted to the neonatal intensive care unit were analyzed using PCR and gel electrophoresis [31]. Clostridium perfringens was recognized during the first two weeks of life in the three infants who later developed NEC but not in the nine infants who did not.

Impaired mucosal defense Premature infants are susceptible to the development of NEC because immunologic and gastrointestinal immaturity results in altered host resistance. The impairment of the mucosal barrier allows bacteria to gain access to deeper tissues resulting in inflammation. (See 'Inflammation' below.)

Mucosal defense in the gut is mediated by several interrelated components, some of which provide a physical barrier and others a biochemical and immunologic barrier [32,33]. Factors that contribute to innate resistance include luminal pH, enzymes, mucins, epithelial barriers, and gut motility, as well as nonspecific antimicrobial factors, such as lactoferrin and lysozyme.

Premature infants have lower concentrations or more immature function of contributing mucosal defense factors than do term infants and adults [4].

The intestinal mucin barrier, which hampers bacterial epithelial binding and enhances bacterial removal, is not fully developed in very premature infants. An immature mucin layer increases bacterial intestinal penetration and adherence, which may result in injury or cause inflammation. As a result, premature infants are more susceptible to enteric infections or mucosal inflammation [1,22].Secretory IgA, the major gastrointestinal immunoprotective antibody, is absent from the human intestinal mucosa at birth.Paneth cells are secretory enterocytes located at the base of the small intestinal crypts that release lysozyme, phospholipase A2, and antimicrobial peptides (defensins and cathelicidins) that help regulate the intestinal bacterial populations. Animal and human studies suggest that the expression of defensins and number of Paneth cells are lower in premature infants and fetuses than in term infants and adults [22,34].Tight junctions between epithelial cells maintain the semipermeable property of the intestinal tract. In premature infants, there is increased permeability most likely due to immaturity of the composition and function of the tight junctions [34]. Further disruption of these tight junctions occurs because of alterations in host-bacterial interactions, which may induce inflammation. (See 'Microbial colonization' above and 'Inflammation' below.)Growth factors, such as epidermal growth factor (EGF), are important in intestinal development and preservation of gut barrier function [35]. Animal models and studies in humans suggest a predictive or protective role for EGF in the pathogenesis of NEC. In one study, an EGF receptor mice knockout model demonstrated hemorrhagic necrosis, a pathologic finding similar to that seen in infants with NEC [36]. Another animal study showed EGF supplementation reduced the incidence of NEC in a neonatal rat model of NEC [37-40].

In a study of human neonates with gestational ages 32 weeks gestation, infants who developed NEC had lower salivary epidermal growth factor (sEGF) levels at one week of age when compared to infants without NEC [41]. In infants with NEC compared to those without NEC, there was also a greater increase in sEGF levels from week one to week two of life.

Further investigations on the role of EGF in the pathogenesis of NEC are required to determine whether there is a role for EGF in either predicting or preventing NEC [20].

Circulatory instability Ischemic insult to the gastrointestinal tract has been proposed as a major contributor to NEC, although most infants with NEC have not had an obvious perinatal hypoxic-ischemic event [24,42,43]. Circulatory events that have been implicated in the development of NEC include perinatal asphyxia [44], recurrent apnea, hypoxia from severe respiratory distress syndrome, hypotension, congenital heart disease [45], patent ductus arteriosus, heart failure, umbilical arterial catheterization, anemia, polycythemia [46,47], and exchange transfusion [48]. A diminished blood supply to the gut may contribute to the pathogenesis of NEC in infants exposed to cocaine [49].

Many of these observations have occurred in term infants. In premature infants with NEC, the predisposing role of circulatory instability remains unproven in premature infants with NEC [24,43]. In case-controlled studies, episodes of hypoxia and/or hypotension occur with the same frequency in premature infants with or without NEC [50]. In addition, other manifestations of hypoxic-ischemic injury (eg, acute tubular necrosis and intraventricular hemorrhage) do not correlate with the development of NEC.

These findings have led to the hypothesis that a subtle reduction in blood flow and subsequent reperfusion occurring in response to hypoxia may contribute to bowel injury. Although the regulation of mesenteric blood flow in the newborn is poorly understood, one small prospective trial reported that high vascular resistance of the superior mesenteric artery determined by Doppler flow velocity on the first day of life was associated with an increased risk of NEC [51]. In a

prospective case-controlled study of term infants with congenital heart disease, persistent diastolic flow reversal in the abdominal aorta was associated with increased risk of NEC [45].

Medications The administration of hyperosmolar medications and/or formulas can cause mucosal injury and may result in NEC [52]. Oral medications such as theophylline, multivitamins, or phenobarbital contain hypertonic additives that might irritate the intestinal mucosa. Instillation of hyperosmolar contrast agents into the bowel for diagnostic radiographic studies also can cause mucosal injury because of fluid shifts, bowel distention, and ischemia. Isotonic contrast agents should be used to avoid this complication. Hyperosmolar formulas, such as those concentrated above recommended strengths or containing multiple additives, should be avoided in the first few weeks after birth.

Histamine type 2 receptor (H2) antagonists, such as cimetidine, ranitidine, and famotidine, are associated with higher rates of NEC. This was illustrated in a report from the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network [53]. In this study of 11,072 premature infants (birth weight 401 to 1500 g) from 1998 to 2001, the incidence of NEC was 7.1 percent. Infants with NEC compared to matched controls were more likely to have received H2-antagonists (OR 1.71, 95% CI 1.34 to 2.19). A possible explanation for this finding is that gastric acidity, which may reduce the risk of NEC by inhibiting bacterial growth [54], was lowered by the use of H2antagonists.

Inflammation Inflammatory mediators induced by ischemia, infectious agents, or mucosal irritants may further aggravate mucosal injury [22,55]. These soluble inflammatory cytokines, including tumor necrosis factor (TNF), interleukins (IL1, IL-6, IL-8, IL10, IL12, and IL-18), and platelet activating factor (PAF),

increase vascular permeability and attract inflammatory cells. Levels of these cytokines are increased in premature infants with NEC and correlate with the severity of the disease [22,56-59].

This cascade of cellular events may be mediated at least in part by PAF, which is synthesized by many cell types, including macrophages, neutrophils, eosinophils, and endothelial cells [60]. In animals, administration of PAF causes intestinal necrosis as well as systemic hypotension, capillary leakage, pulmonary hypertension, neutropenia, and thrombocytopenia [60].

These observations may be applicable to humans. Plasma concentrations of PAF are higher in infants taking milk feedings, although the acetylhydrolase present in human milk breaks down PAF [60]. Plasma acetylhydrolase activity is lower in infants with NEC compared to controls and may contribute to the increased concentrations of PAF [56].

Medications or conditions that affect cytokines or oxygen free radicals can contribute to the development of NEC [60]. For example, a deficiency of magnesium or copper can increase the synthesis or activity of cytokines and oxygen-free radicals, leading to intestinal injury [61]. In addition, in a trial of vitamin E administration to prevent retinopathy of prematurity, NEC occurred more often in treated infants with high levels of serum tocopherol (greater than 3.5 mg/dL) [62]. The mechanism may be due to a reduction of antimicrobial defenses by excessive scavenging of oxygen free radicals. On the other hand, treatment with vitamin E is not associated with NEC in infants with lower serum tocopherol concentrations.

Intestinal vascular resistance Mucosal injury and inflammation may alter the balance of endogenous vasoactive agents, which may contribute to the development of NEC with changes in the intestinal vascular resistance and microcirculation [33,63-65]. Data are limited on the roles of nitric oxide, the primary vasodilator, and endothelin-1, a potent vasoconstrictor, in the pathogenesis of NEC.

Endothelin -1 (ET-1) In a pathologic study of resected intestinal specimens from infants with suspected NEC, there were increased levels of ET-1 in areas that demonstrated histological findings consistent with NEC as compared to nonaffected tissue from the same specimen [65]. In addition, arterioles showed increased vasoconstriction in affected compared to nonaffected tissue that was reversed by an endothelin receptor antagonist.Nitric oxide (NO) The limited data available on the role of NO are conflicting. In one report, inducible NO synthase (iNOS) gene and protein expression were detected more often in apical enterocytes in infants undergoing surgical resection for NEC than for intestinal atresia or other noninflammatory conditions [64]. These results would suggest that increased NO may contribute to failure of gut barrier function, bacterial translocation, and direct intestinal damage.

In contrast, another study reported that although endothelial NO synthase (eNOS) was present in specimens from infants undergoing surgical resection for NEC and control patients with intestinal atresia, eNOS function was impaired, resulting in decreased NO production in arterioles from NEC specimens compared to controls [37]. Arterioles from patients with NEC failed to normally dilate in response to acetylcholine stimulation or increased arteriolar.

SUMMARY Necrotizing enterocolitis (NEC), the most common gastrointestinal emergency in the newborn infant, is a disorder manifested by

ischemic necrosis of the intestinal mucosa associated with inflammation, invasion of enteric gas forming organisms, and dissection of gas into the muscularis and portal venous system.

The pathologic findings of NEC vary depending upon the progression of the disease. In general, the bowel appears distended and hemorrhagic on gross examination. The major histologic findings include mucosal edema, hemorrhage, and transmural bland necrosis. (See 'Pathology' above.)

Although the pathogenesis of NEC remains unknown, it is probably caused by multiple factors in a susceptible host. Prematurity and milk feeding are established risk factors for NEC, with 90 percent of cases occurring in enterally fed premature infants. Immaturity of the gastrointestinal tract appears to predispose premature infants to NEC because it results in impaired mucosal defense, and intestinal motility and function. These factors result in microbial overgrowth and an increased likelihood of mucosal injury leading to inflammation, ischemia, and necrosis, and the development of NEC. (See 'Pathogenesis' above.)

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