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Necrotizing enterocolitis is the most common gastrointestinal emergency in the newborn. The syndrome strikes premature infants during the first 2 weeks of life. Abdominal distention, lethargy, and feeding intolerance are early signs of NEC that may progress to gastrointestinal bleeding and hemodynamic instability. The radiographic hallmark of NEC is pneumatosis intestinalis (air in the bowel wall). The ileum and colon are the usual sites of crepitant intestinal necrosis, leading frequently to perforation. In spite of appropriate medical therapy, about half of the infants with NEC develop intestinal gangrene or perforation and require surgery, consisting of bowel resection and enterostomy formation. The most common late complication, intestinal stricture, occurs in 15 to 35 per cent of recovered infants. Overall mortality from NEC ranges from 20 to 40 per cent. The etiology of NEC is poorly understood and is considered to be multifactorial, related to ischemia, bacterial colonization, and formula feedings in a susceptible infant. Future progress in the treatment of NEC may be achieved by earlier detection of necrosis, modification of gastrointestinal flora, or by bolstering the deficient gastrointestinal immune mechanisms of the premature neonate.
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PMID:Necrotizing enterocolitis of the neonate. 265 67

Pneumatosis intestinalis (PI) is a well-recognized manifestation of necrotizing enterocolitis (NEC) in the newborn--a condition that often requires surgical intervention for infarcted bowel. However, little information is available concerning PI in older children or its management. Sixteen older infants and children (greater than 2 months) had x-ray findings of PI (intramural air). There were eight girls and eight boys ranging in age from 2 months to 8 years. Associated conditions included short bowel syndrome (SBS) (8), congenital heart disease (2), iron ingestion (1), nesidioblastosis (1), hemolytic anemia (1), rheumatoid arthritis (1), bronchopulmonary dysplasia (BPD) (1), and malrotation (1). Clinical presentation included abdominal distension (13), bloody diarrhea (12), bilious emesis (5), and lethargy (5). Two patients on steroids had unsuspected PI identified as an incidental operative finding during pancreatectomy for nesidioblastosis (1) and splenectomy for hemolytic anemia (1), respectively. Only four other children (iron toxicity, postcardiac catheterization, rheumatoid arthritis, and BPD required surgical intervention. Each manifested peritioneal irritation, acidosis, and hypotension or had pneumoperitoneum on abdominal x-ray. In ten of 14 patients, PI was managed nonoperatively with nasogastric suction, fluid resuscitation, intravenous (IV) antibiotics (seven to ten days), and repeated abdominal x-ray and physical examinations. Children with SBS comprised 50% of the total number of patients and eight of ten treated by observation. All had associated viral syndromes (rotavirus) or rhotozyme-positive stools and developed bloody diarrhea. There were two deaths (12.5%) in patients with iron toxicity and congenital heart disease who required resection of gangrenous bowel. All of the other patients survived.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Pneumatosis intestinalis in children beyond the neonatal period. 267 35

We report the results of a two-part study examining the frequency of symptoms and other findings associated with neonatal polycythemia. In the first part of the investigation, we evaluated the occurrence and features of the disorder in a cohort of 3,768 infants born at our institution that had been screened for the disorder during a 4-year period. Fifty-five infants (1.46%) had neonatal polycythemia. Of these infants, 85% had features associated with the disorder. Frequent signs and symptoms included "feeding problems" (21.8%), plethora (20.0%), lethargy (14.5%), cyanosis (14.5%), respiratory distress (9.1%), jitteriness (7.3%), and hypotonia (7.3%). Other findings included hypoglycemia (40.0%) and hyperbilirubinemia (21.8%). Of the polycythemic infants, 14.5% had no clinical symptoms or associated laboratory abnormalities. In the second portion of the study, we reviewed the features of polycythemia in all infants so diagnosed who were born in United States Army hospitals, worldwide, during a 5-year period. There were 220,050 infants born during this period; 932 (0.42%) were diagnosed as having neonatal polycythemia. Frequent findings were hyperbilirubinemia (33.5%), hypoglycemia (13.0%), and respiratory distress (6.6%). In this large group, only 13 (1.4%) had necrotizing enterocolitis, and nine (1.0%) were thrombocytopenic. Several findings among the 932 infants were unexpected. Six of the infants (only one premature) had intracranial hemorrhages. Additionally, three of the 932 had gonadal dysgenesis and three had cystic fibrosis. We found that premature infants were not less prone to having polycythemia and that the overall frequency of the disorder was less than that which has been previously reported.
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PMID:Neonatal polycythemia: frequency of clinical manifestations and other associated findings. 372 98

Necrotizing enterocolitis is an uncommon but dangerous disease in premature infants. Ten cases, seen over a three-year period at the Stanford University Medical Center, represented an incidence of 0.4 percent. The patients, six of whom died, derived from a general population, in contrast to the large series of patients reported in the literature in which the incidence was from 0.9 percent to 3.7 percent.(3-6)The initial symptoms-rapid respiration, periodic breathing, lethargy and irritability-were identical to those which occurred in numerous infants who had respiratory disease. Subsequent symptoms (abdominal distension, in 100 percent; vomiting, 80 percent; apneic spells, 70 percent; jaundice, 70 percent; guaic-positive stools, 60 percent) were those of nonspecific acute abdominal disease. The radiologist first made the diagnosis in 90 percent of cases. Interstitial air in the wall of the gut and the retroperitoneum, and portal vein gas were the most diagnostic radiographic features. Barium contrast studies were not helpful, and in one case led to the erroneous diagnosis of small bowel volvulus. Plain abdominal radiographs must be taken of all premature infants with symptoms of nonspecific acute abdominal disease. If the radiographs are negative, but symptoms continue, they should be repeated at frequent intervals, for early diagnosis is critical to institution of proper therapy.
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PMID:Neonatal necrotizing enterocolitis. Clinical and radiological features. 481 93

Necrotizing enterocolitis was found in 77 infants over a 5 year period. Diagnosis of NEC was established on 4.9 + 4.8 days in babies with birth weight of 1667 + 577 grams and the gestational age of 33.3 + 2.6 weeks. Definite disease occurred in 33 (42.9%) babies while there was strong suspicion in another 44 (57.1%) babies. Prefeed gastric residue (98.7%), abdominal distension (97.3%), lethargy (78.7%), hypotonia (60%) and jaundice (48%) were the main presenting features. However, blood in stools and abdominal wall erythema were found in 38.7% babies. About one third of infants had a positive blood culture. Pneumatosis intestinalis was present in 83.9% of babies and pneumoperitoneum was seen in 35.5% of neonates with NEC. Ileo-ceco-colic region was the commonest site of involvement. Overall survival was 61% and survival with Stage III was only 13%. Birth weight less than 1500 g, gestational age less than 32 weeks, erythema of the abdominal wall, intra-abdominal mass, portal venous gas in abdominal X-ray and Gram negative septicemia were associated with higher mortality.
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PMID:Neonatal necrotizing enterocolitis: a clinical study. 807 31

Necrotizing enterocolitis (NEC) is the most serious and frequently acquired gastrointestinal disorder in neonates. The pathogenesis of NEC is unknown, but it may result from a disturbance of the delicate balance among gastrointestinal perfusion, enteric organisms, and enteral feeding. Risk factors for NEC include prematurity, hypoxic-ischemic insult, and formula or breast milk feedings. The clinical spectrum of NEC is multifactoral and ranges from temperature instability, apnea, lethargy, abdominal distention, bilious residuals, and guaiac-positive stools to septic shock, disseminated intravascular coagulation, and death. Medical management is usually adequate treatment for NEC. Surgical treatment is considered if medical management is inadequate to control the spread of the disease. Health care team members must be constantly alert to the presentation of NEC. Expeditious treatment will positively influence the outcome of the disease.
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PMID:Necrotizing enterocolitis. 1037 56

Necrotizing enterocolitis (NEC) is primarily a disease process of the gastrointestinal (GI) tract of premature neonates that results in inflammation and bacterial invasion of the bowel wall. Despite advances in the care of premature infants, NEC remains one of the leading causes of morbidity and mortality in this population. It occurs in 1-5% of all neonatal intensive care admissions and 5-10% of all very low birthweight (<1500 g) infants. Although research has presented an interesting array of potential contributing factors, the precise aetiology of this multifactorial disease process remains elusive. Historically, it was believed that NEC arose predominantly from ischaemic injury to the immature GI tract, yet alternate plausible hypotheses indicate that many factors are likely to be involved. These may include issues related to the introduction and advancement of enteric feeding, alterations in the normal bacterial colonization of the GI tract, bacterial translocation and activation of the cytokine cascade, decreased epidermal growth factor, increased platelet activating factor, and mucosal damage from free radical production. Clinical manifestations of NEC may be vague, including increased episodes of apnoea, desaturations, bradycardia, lethargy and temperature instability. There may also be GI-specific symptoms such as feeding intolerance, emesis, bloody stools, abdominal distention and tenderness, and abdominal wall discolouration. Laboratory values may be indicative of infection, coagulation abnormalities and fluid retention. Radiographic signs may include ileus, dilated or fixed intestinal loops, air in the intestinal wall or free air in the abdomen. Medical treatment typically consists of bowel rest and decompression, antibacterial therapy, and management of other haematological or electrolyte imbalances. Increased respiratory and cardiovascular support is sometimes needed. In neonates who do not respond adequately to medical management, or if pneumoperitoneum is present, surgical intervention may occur with either use of a peritoneal drain or laparotomy. Advances in antenatal and neonatal care have resulted in increased survival of extremely preterm neonates. As this at-risk population continues to increase, an effective preventative strategy for NEC is needed. One preventative strategy is the use of antenatal corticosteroids to enhance maturation of the fetus if preterm delivery is likely. Recommendation of use of breast milk, early initiation of trophic feeds and judicoius advancement of enteric feeds are current postnatal strategies. Other preventative strategies that have been investigated include the use of oral antibacterials, antioxidants, supplementation of arginine and epidermal growth factor, none of which have changed clinical practice. Recent promising data indicate that prophylactic use of probiotics may play a role in preventing the onset of NEC. However, more large-scale, definitive studies are needed.
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PMID:Necrotizing enterocolitis in newborns: pathogenesis, prevention and management. 1854 33