Unifying Concepts

Diagnostic Criteria for Necrotizing Enterocolitis (NEC)

Necrotizing enterocolitis is among the most common and devastating diseases in neonates. The excessive inflammatory process initiated in the highly immunoreactive intestine in necrotizing enterocolitis extends the effects of the disease systemically, affecting distant organs such as the brain and placing affected infants at substantially increased risk for neurodevelopmental delays.

Diagnostic Criteria for Necrotizing Enterocolitis (NEC)
Suspected necrotizing enterocolitis

  • Abdominal distention without radiographic evidence of pneumatosis intestinalis, portal venous gas, or free intraperitoneal air
  • Unexpected onset of feeding intolerance

Definitive medical necrotizing enterocolitis

  • Abdominal distention with pneumatosis intestinalis, portal venous gas, or both
  • Other radiographic signs such as fixed, dilated loops of intestine and ileus patterns are not pathognomonic but should be treated as such

Surgical necrotizing enterocolitis

  • Free intraperitoneal air on abdominal radiograph after initial medical signs and symptoms
  • Persistent ileus pattern, abdominal distention, and radiographs that show an absence of bowel gas, coupled with deteriorating clinical and laboratory values (e.g., decreasing neutrophil and platelet counts)

Modified Bell´s Staging Criteria for Necrotizing Enterocolitis (NEC)

Stage Systemic signs Abdominal signs Radiographic signs Treatment
Temperature instability, apnea, bradycardia, lethargy Gastric retention, abdominal distention, emesis, heme-positive stool Normal or intestinal dilation, mild ileus NPO, antibiotics x 3 days
Same as above Grossly bloody stool Same as above Same as IA
Definite, mildly ill
Same as above Same as above, plus absent bowel sounds with or without abdominal tenderness Intestinal dilation, ileus, pneumatosis intestinalis NPO, antibiotics x 7 to 10 days
Definite, moderately ill
Same as above, plus mild metabolic acidosis and thrombocytopenia Same as above, plus absent bowel sounds, definite tenderness, with or without abdominal cellulitis or right lower quadrant mass Same as IIA, plus ascites NPO, antibiotics x 14 days
Advanced, severely ill, intact bowel
Same as IIB, plus hypotension, bradycardia, severe apnea, combined respiratory and metabolic acidosis, DIC, and neutropenia Same as above, plus signs of peritonitis, marked tenderness, and abdominal distention Same as IIA, plus ascites NPO, antibiotics x 14 days, fluid resuscitation, inotropic support, ventilator therapy, paracentesis
Advanced, severely ill, perforated bowel
Same as IIIA Same as IIIA Same as above, plus pneumoperitoneum Same as IIA, plus surgery

DIC: disseminated intravascular coagulation

NPO: “nil per os” or nothing by mouth



  1. Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am. 1996 Apr;43(2):409-32. [Medline]

  2. Caplan MS, Jilling T. New concepts in necrotizing enterocolitis. Curr Opin Pediatr. 2001 Apr;13(2):111-5. [Medline]

  3. Neu J, Walker WA. Necrotizing Enterocolitis. N Engl J Med 2011; 364:255-264 [Medline]
Created: May 25, 2006
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