Clinical Correlates of Cholestasis in Preterm Infants with Surgical Necrotizing Enterocolitis

Abstract

Background: We sought to investigate the clinical determinants and outcomes of cholestasis in preterm infants with surgical necrotizing enterocolitis (sNEC).

Methods: Retrospective comparison of clinical information in preterm infants who developed cholestasis vs those who did not.

Results: Sixty-two (62/91, 68.1%) infants with NEC developed cholestasis at any time following the onset of illness. Cholestasis was seen more frequently in those who had received ionotropic support at 24 hours following sNEC diagnosis (87.1% vs 58.6%; p = 0.002), had higher mean C-reactive protein levels 2 weeks after NEC diagnosis (p = 0.009), had blood culture-positive sepsis [25 (40.3%) vs 4 (13.8%); p = 0.011], received parenteral nutrition (PN) for longer durations (108.4 ± 56.63 days vs 97.56 ± 56.05 days; p = 0.007), had higher weight-for-length z scores at 36 weeks' postmenstrual age [-1.0 (-1.73, -0.12) vs -1.32 (-1.76, -0.76); p = 0.025], had a longer length of hospital stay (153.7 ± 77.57 days vs 112.51 ± 85.22 days; p = 0.024), had intestinal failure more often (61% vs 25.0%, p = 0.003), had more surgical complications (50% vs 27.6%; p = 0.044), and had >1 complication (21% vs 3.4%; p = 0.031). Using linear regression, the number of days after surgery when feeds could be started [OR 15.4; confidence interval (CI) 3.71, 27.13; p = 0.009] and the postoperative ileus duration (OR 11.9, CI 1.1, 22.8; p = 0.03) were independently associated with direct bilirubin between 2 and 5 mg/dL (mild-moderate cholestasis) at 2 months of age. The duration of PN was independently associated with direct bilirubin >5 mg/dL (severe cholestasis) at 2 months of age in these patients.

Conclusion: Cholestasis was seen in 68% of infants following surgical NEC. The most likely contributive factors are intestinal failure and subsequent PN dependence for longer periods. Our data suggest that identification and prevention of risk factors such as sepsis and surgical complications and early feeds following NEC surgery may improve outcomes.

Keywords: Adhesions; Anthropometric; Bell’s criteria; Cholestasis; Farnesoid X; Fenton growth; Fish oil-containing lipid emulsion; Fistula; Ileocecal valve; Infant; Intestinal failure; Intralipids; Liver X receptors; Logistic regression; Necrotizing enterocolitis; Neonate; Outcome; Parenteral nutrition; Perforations; Pneumatosis; Pneumoperitoneum; Portal venous gas; Premature; Preterm; Soybean oil–medium chain triglycerides–olive oil–fish oil; Stricture; Surgical site infection; Term-equivalent age; Weight-for-length; Wound dehiscence; z-scores.