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Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

Yıl 2016, Cilt: 8 Sayı: 2, 65 - 82, 30.03.2016

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Abstract

Necrotizing enterocolitis (NEC) is one of the most common gastro intestinal emergencies in the newborn infant. It is a disorder characterized by ischemic necrosis of the intestinal mucosa. It occurs in 1 to 3 per 1000 live birthsand it is responsible of 1 to 7.7 percent of admissions to neonatal intensive care units. Incidence of NEC decreases withincreasing gestational age and birth weight and is about 6 to 7 percent in very low birth weight infants. The specificfindings vary on the progression of the disease and the presence of underlying pathogenic factors. The pathogenesisof NEC is still unknown, but it is probably a heterogeneous disease resulting from multiple factors that result in mucosal injury. Prematurity, microbial bowel overgrowth, feeding, impaired mucosal defense, circulatory instability ofthe intestinal tract, medications that cause intestinal mucosal injury or microbial overgrowth may play role in the pathogenesis. The clinical presentation of NEC consists of systemic and abdominal signs. The diagnosis of NEC dependson characteristic clinical findings such as rectal bleeding,abdominal distension and radiologic findings. The differential diagnosis of NEC includes the conditions that cause rectal bleeding, abdominal distension, gastric retention, or intestinal perforation. Spontaneous intestinal perforation (SIP) should be considered in differential diagnosis of NEC.Spontaneous intestinal perforation is an isolated perforation of the newborn, typically found at the terminal ileum.There are differences between NEC and SIP for etiology,clinical and laboratory findings and management approac-hes. It is important to make differential diagnosis between these two antities. Medical treatment should be initiated immediately when NEC is suspected. Medical management consists of supportive therapy, antibiotic therapy,and laboratory and radiological monitoring. The prognosis of NEC has improved by neonatal intensive care advances in early diagnosis and aggressive treatment but it hasstill significant morbidity. Preventive measures for NEC arepreventing prematurity, breastfeeding and prevention of chorioamnionitis and neonatal infections.

Kaynakça

  • Kaynaklar 1.Neu J. Necrotizing enterocolitis: the search for a unifying pat-hogenic theory leading to prevention. Pediatr, Clin North Am1996; 43:409. 2.Kosloske AM. Epidemiology of necrotizing enterocolitis.Acta Paediatr Suppl 1994; 396:2. 3.Horbar JD, Badger GJ, Carpenter JH, et al. Trends in mor-tality and morbidity for very low birth weight infants, 1991-1999. Pediatrics 2002; 110:143. 4.Sankaran K, Puckett B, Lee DS, et al. Variations in inciden-ce of necrotizing enterocolitis in Canadian neonatal intensi-ve care units. J PediatrGastroenterolNutr 2004; 39:366. 5.Lee SK, McMillan DD, Ohlsson A, et al. Variations in prac-tice and outcomes in the Canadian NICU network: 1996-1997.Pediatrics 2000; 106:1070. 6.Schanler RJ.Clinical features and diagnosis of necrotizing en-terocolitis in newborns. In: UpToDate, Abrams SA Nov 13 2015 7.Ostlie DJ, Spilde TL, St Peter SD, et al. Necrotizing entero-colitis in full-term infants. J PediatrSurg 2003; 38:1039. 8.Lambert DK, Christensen RD, Henry E, et al. Necrotizing en-terocolitis in term neonates: data from a multihospital health-care system. J Perinatol 2007; 27:437. 9.Short SS, Papillon S, Berel D, et al. Late onset of necrotizingenterocolitis in the full-term infant is associated with increa-sed mortality: results from a two-center analysis. J Pediatr-Surg 2014; 49:950. 10.Kliegman RM, Walker WA, Yolken RH. Necrotizing entero-colitis: research agenda for a disease of unknown etiology andpathogenesis. Pediatr Res 1993; 34:701. 11.Holman RC, Stoll BJ, Clarke MJ, Glass RI. The epidemiologyof necrotizing enterocolitis infant mortality in the United Sta-tes. Am J Public Health 1997; 87:2026. 12.Morriss FH Jr, Moore M, Gibson T, West MS. Motility of thesmall intestine in preterm infants who later have necrotizingenterocolitis. J Pediatr 1990; 117:S20. 13.Bauer CR, Morrison JC, Poole WK, et al. A decreased inci-dence of necrotizing enterocolitis after prenatal glucocorti-coid therapy. Pediatrics 1984; 73:682. 14.Halac E, Halac J, Bégué EF, et al. Prenatal and postnatal cor-ticosteroid therapy to prevent neonatal necrotizing enteroco-litis: a controlled trial. J Pediatr 1990; 117:132. 15.Clark DA, Miller MJ. Intraluminal pathogenesis of necroti-zing enterocolitis. J Pediatr 1990; 117:S64. 16.Morgan J, Young L, McGuire W. Slow advancement of ente-ral feed volumes to prevent necrotising enterocolitis in verylow birth weight infants. Cochrane Database Syst Rev 2011;:CD001241. 17.Morgan J, Young L, McGuire W. Delayed introduction of prog-ressive enteral feeds to prevent necrotising enterocolitis in verylow birth weight infants. Cochrane Database Syst Rev 2014;12:CD001970. 18.La Gamma EF, Browne LE. Feeding practices for infants we-ighing less than 1500 G at birth and the pathogenesis of nec-rotizing enterocolitis. ClinPerinatol 1994; F:271. 19.Schanler RJ, Shulman RJ, Lau C, et al. Feeding strategies forpremature infants: randomized trial of gastrointestinal primingand tube-feeding method. Pediatrics 1999; 103:434. 20.Bombell S, McGuire W. Early trophic feeding for very low birthweight infants. Cochrane Database Syst Rev 2009; :CD000504. 21.Hunter CJ, Upperman JS, Ford HR, Camerini V. Understan-ding the susceptibility of the premature infant to necrotizingenterocolitis (NEC). Pediatr Res 2008; 63:117. 22.Hooper LV, Wong MH, Thelin A, et al. Molecular analysis ofcommensal host-microbial relationships in the intestine. Sci-ence 2001; 291:881. 23.Patel RM, Denning PW. Intestinal microbiota and its relati-onship with necrotizing enterocolitis. Pediatr Res 2015;78:232. 24.Stewart CJ, Marrs EC, Magorrian S, et al. The preterm gutmicrobiota: changes associated with necrotizing enterocoli-tis and infection. ActaPaediatr 2012; 101:1121. 25.Jacquot A, Neveu D, Aujoulat F, et al. Dynamics and clini-cal evolution of bacterial gut microflora in extremely prema-ture patients. J Pediatr 2011; 158:390. 26.Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposu-re in the newborn intensive care unit and the risk of necroti-zing enterocolitis. J Pediatr 2011; 159:392. 27.Cotten CM, Taylor S, Stoll B, et al. Prolonged duration of ini-tial empirical antibiotic treatment is associated with increa-sed rates of necrotizing enterocolitis and death for extremelylow birth weight infants. Pediatrics 2009; 123:58. 28.Stuart RL, Tan K, Mahar JE, et al. An outbreak of necrotizingenterocolitis associated with norovirus genotype GII.3. Pedi-atr Infect Dis J 2010; 29:644. 29.Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006;368:1271. 30.Warner BB, Ryan AL, Seeger K, et al. Ontogeny of salivaryepidermal growth factor and necrotizing enterocolitis. J Pe-diatr 2007; 150:358. 31.Schanler RJ. Pathology and pathogenesis of necrotizing en-terocolitis in newborns. In: UpToDate, Abrams SA Jan 18 2016 32.Mohamed A, Shah PS. Transfusion associated necrotizing en-terocolitis: a meta-analysis of observational data. Pediatrics2012; 129:529. 33.Stritzke AI, Smyth J, Synnes A, et al. Transfusion-associatednecrotising enterocolitis in neonates. Arch Dis Child Fetal Neo-natal Ed 2013; 98:F10. 34.Keir AK, Wilkinson D. Question 1 * do feeding practices du-ring transfusion influence the risk of developing necrotisingenterocolitis in preterm infants? Arch Dis Child 2013;98:386 35.Guillet R, Stoll BJ, Cotten CM, et al. Association of H2-bloc-ker therapy and higher incidence of necrotizing enterocolitisin very low birth weight infants. Pediatrics 2006; 117:e137. 36.Yee WH, Soraisham AS, Shah VS, et al. Incidence and timingof presentation of necrotizing enterocolitis in preterm infants.Pediatrics 2012; 129:e298. 37.Sharma R, Tepas JJ 3rd, Hudak ML, et al. Portal venous gasand surgical outcome of neonatal necrotizing enterocolitis. JPediatr Surg 2005; 40:371. 38.Muchantef K, Epelman M, Darge K, et al. Sonographic andradiographic imaging features of the neonate with necrotizingenterocolitis: correlating findings with outcomes. Pediatr Ra-diol 2013; 43:1444. 39.Faingold R, Daneman A, Tomlinson G, et al. Necrotizing en-terocolitis: assessment of bowel viability with colordoppler US.Radiology 2005; 235:587. 40.Gordon PV, Swanson JR, Attridge JT, Clark R. Emerging trendsin acquired neonatal intestinal disease: is it time to abandonBell's criteria? J Perinatol 2007; 27:661. 41.Schanler RJ.Management of necrotizing enterocolitis innewborns. In: UpToDate, Abrams SA Oct 15 2015 42.Brook I. Microbiology and management of neonatal necro-tizing enterocolitis. Am J Perinatol 2008; 25:111. 43.Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and ma-nagement of complicated intra-abdominal infection in adultsand children: guidelines by the Surgical Infection Society andthe Infectious Diseases Society of America. Clin Infect Dis2010; 50:133. 44.Tepas JJ 3rd, Sharma R, Leaphart CL, et al. Timing of sur-gical intervention in necrotizing enterocolitis can be determi-ned by trajectory of metabolic derangement. J PediatrSurg2010; 45:310. 45.Rao SC, Basani L, Simmer K, et al. Peritoneal drainage ver-sus laparotomy as initial surgical treatment for perforated nec-rotizing enterocolitis or spontaneous intestinal perforation inpreterm low birth weight infants. Cochrane Database Syst Rev2011; :CD006182. 46.Duro D, Kalish LA, Johnston P, et al. Risk factors for intes-tinal failure in infants with necrotizing enterocolitis: a Gla-ser Pediatric Research Network study. J Pediatr 2010;157:203.32. 47.Hull MA, Fisher JG, Gutierrez IM, et al. Mortality and ma-nagement of surgical necrotizing enterocolitis in very low birthweight neonates: a prospective cohort study. J Am Coll Surg2014; 218:1148. 48.Fitzgibbons SC, Ching Y, Yu D, et al. Mortality of necrotizingenterocolitis expressed by birth weight categories. J Pediatr-Surg 2009; 44:1072. 49.Lambert DK, Christensen RD, Baer VL, et al. Fulminant nec-rotizing enterocolitis in a multihospital healthcare system. JPerinatol 2012; 32:194. 50.Clark RH, Gordon P, Walker WM, et al. Characteristics of pa-tients who die of necrotizing enterocolitis. J Perinatol 2012;32:199. 51.Pike K, Brocklehurst P, Jones D, et al. Outcomes at 7 yearsfor babies who developed neonatal necrotising enterocolitis:the ORACLE Children Study. Arch Dis Child Fetal NeonatalEd 2012; 97:F318. 52.Hintz SR, Kendrick DE, Stoll BJ, et al. Neurodevelopmentaland growth outcomes of extremely low birth weight infants af-ter necrotizing enterocolitis. Pediatrics 2005; 115:696 53.Karagol BS1, Zenciroglu A, Okumus N, Polin RA. Randomi-zed controlled trial of slow vs rapid enteral feding advance-ments on the clinical outcomes of preterm infants with birthweight 750-1250g. JPEN J Parenter Enteral Nutr. 2013Mar;37(2):223-8. 54.Quigley M, McGuire W. 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Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon

Yıl 2016, Cilt: 8 Sayı: 2, 65 - 82, 30.03.2016

Öz

Öz

Nekrotizan enterokolit (NEK) yenidoğan bebeklerde görülen en önemli gastrointestinal acil durumlardan biridir. İntestinal mukozanın iskemik nekrozu ile karakterizedir.Her 1000 canlı doğumda 1-3 oranında görülebilen NEK, yenidoğan yoğun bakımlara yatışların % 1-7,7’sinden sorumludur. İnsidansı, doğum ağırlığı ve gebelik yaşıarttıkça azalır. Spesifik bulgular hastalığın progresyonu ve altta yatan patojenik faktörlere göre değişiklik gösterir. Nekrotizan enterokolit patogenezi tam bilinmemektedir ancak olasılıkla mukozal hasar ile sonuçlanan çoklu faktörlerin neden olduğu heterojen bir hastalıktır. Prematürite, mikrobial fazla çoğalma, beslenme, bozuk mukozal savunma, intestinal kanalın bozulmuş dolaşımı, mukozal hasara ve mikrobiyal fazla çoğalmaya ve intestinal mukoza hasarına sebep olan ilaçlar patogenezde roloynar. NEK’in klinik bulguları sistemik ve abdominal bulgulardan oluşur. Nekrotizan enterokolit tanısı abdominal distansiyon, rektal aşikâr ya da gizli kanama gibikarakteristik klinik bulguların varlığı ve abdominal radyolojik bulgulara dayanır. NEK ayırıcı tanısında rektal kanama, abdominal distansiyon, gastrik retansiyon veya intestinal perforasyon yapan durumlar yer alır. Spontan intestinal perforasyon (SIP) NEK ayırıcı tanısında düşünülmelidir. İzole bir perforasyon olan SİP tipik olarak terminal ileumda görülür. Nekrotizan enterokolit ve SİP’un klinik ve laboratuar bulguları ve tedavi yaklaşımlarında farklılıklar vardır ve ayırıcı tanının yapılması önemlidir. Tıbbi tedavi NEK’ten şüphelenildiği anda acilen başlanmalıdır. Acil yaklaşım destek tedavi, antibiyotik tedavisi ve yakın laboratuar ve radyolojik takibi kapsar. Yenidoğan yoğun bakımındaki ilerlemeler, erken tanı ve agresif tedavi; NEK’li bebek-lerde prognozu iyileştirmiştir ancak halen önemli bir morbidite nedenidir. Prematüreliğin önlenmesi, anne sütü ile beslenme, korioamniyonit ve neonatal enfeksiyonların önlenmesi NEK için koruyucu önlemlerdir.

Kaynakça

  • Kaynaklar 1.Neu J. Necrotizing enterocolitis: the search for a unifying pat-hogenic theory leading to prevention. Pediatr, Clin North Am1996; 43:409. 2.Kosloske AM. Epidemiology of necrotizing enterocolitis.Acta Paediatr Suppl 1994; 396:2. 3.Horbar JD, Badger GJ, Carpenter JH, et al. Trends in mor-tality and morbidity for very low birth weight infants, 1991-1999. Pediatrics 2002; 110:143. 4.Sankaran K, Puckett B, Lee DS, et al. Variations in inciden-ce of necrotizing enterocolitis in Canadian neonatal intensi-ve care units. J PediatrGastroenterolNutr 2004; 39:366. 5.Lee SK, McMillan DD, Ohlsson A, et al. Variations in prac-tice and outcomes in the Canadian NICU network: 1996-1997.Pediatrics 2000; 106:1070. 6.Schanler RJ.Clinical features and diagnosis of necrotizing en-terocolitis in newborns. In: UpToDate, Abrams SA Nov 13 2015 7.Ostlie DJ, Spilde TL, St Peter SD, et al. Necrotizing entero-colitis in full-term infants. J PediatrSurg 2003; 38:1039. 8.Lambert DK, Christensen RD, Henry E, et al. Necrotizing en-terocolitis in term neonates: data from a multihospital health-care system. J Perinatol 2007; 27:437. 9.Short SS, Papillon S, Berel D, et al. Late onset of necrotizingenterocolitis in the full-term infant is associated with increa-sed mortality: results from a two-center analysis. J Pediatr-Surg 2014; 49:950. 10.Kliegman RM, Walker WA, Yolken RH. Necrotizing entero-colitis: research agenda for a disease of unknown etiology andpathogenesis. Pediatr Res 1993; 34:701. 11.Holman RC, Stoll BJ, Clarke MJ, Glass RI. The epidemiologyof necrotizing enterocolitis infant mortality in the United Sta-tes. Am J Public Health 1997; 87:2026. 12.Morriss FH Jr, Moore M, Gibson T, West MS. Motility of thesmall intestine in preterm infants who later have necrotizingenterocolitis. J Pediatr 1990; 117:S20. 13.Bauer CR, Morrison JC, Poole WK, et al. A decreased inci-dence of necrotizing enterocolitis after prenatal glucocorti-coid therapy. Pediatrics 1984; 73:682. 14.Halac E, Halac J, Bégué EF, et al. Prenatal and postnatal cor-ticosteroid therapy to prevent neonatal necrotizing enteroco-litis: a controlled trial. J Pediatr 1990; 117:132. 15.Clark DA, Miller MJ. Intraluminal pathogenesis of necroti-zing enterocolitis. J Pediatr 1990; 117:S64. 16.Morgan J, Young L, McGuire W. Slow advancement of ente-ral feed volumes to prevent necrotising enterocolitis in verylow birth weight infants. Cochrane Database Syst Rev 2011;:CD001241. 17.Morgan J, Young L, McGuire W. Delayed introduction of prog-ressive enteral feeds to prevent necrotising enterocolitis in verylow birth weight infants. Cochrane Database Syst Rev 2014;12:CD001970. 18.La Gamma EF, Browne LE. Feeding practices for infants we-ighing less than 1500 G at birth and the pathogenesis of nec-rotizing enterocolitis. ClinPerinatol 1994; F:271. 19.Schanler RJ, Shulman RJ, Lau C, et al. Feeding strategies forpremature infants: randomized trial of gastrointestinal primingand tube-feeding method. Pediatrics 1999; 103:434. 20.Bombell S, McGuire W. Early trophic feeding for very low birthweight infants. Cochrane Database Syst Rev 2009; :CD000504. 21.Hunter CJ, Upperman JS, Ford HR, Camerini V. Understan-ding the susceptibility of the premature infant to necrotizingenterocolitis (NEC). Pediatr Res 2008; 63:117. 22.Hooper LV, Wong MH, Thelin A, et al. Molecular analysis ofcommensal host-microbial relationships in the intestine. Sci-ence 2001; 291:881. 23.Patel RM, Denning PW. Intestinal microbiota and its relati-onship with necrotizing enterocolitis. Pediatr Res 2015;78:232. 24.Stewart CJ, Marrs EC, Magorrian S, et al. The preterm gutmicrobiota: changes associated with necrotizing enterocoli-tis and infection. ActaPaediatr 2012; 101:1121. 25.Jacquot A, Neveu D, Aujoulat F, et al. Dynamics and clini-cal evolution of bacterial gut microflora in extremely prema-ture patients. J Pediatr 2011; 158:390. 26.Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposu-re in the newborn intensive care unit and the risk of necroti-zing enterocolitis. J Pediatr 2011; 159:392. 27.Cotten CM, Taylor S, Stoll B, et al. Prolonged duration of ini-tial empirical antibiotic treatment is associated with increa-sed rates of necrotizing enterocolitis and death for extremelylow birth weight infants. Pediatrics 2009; 123:58. 28.Stuart RL, Tan K, Mahar JE, et al. An outbreak of necrotizingenterocolitis associated with norovirus genotype GII.3. Pedi-atr Infect Dis J 2010; 29:644. 29.Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006;368:1271. 30.Warner BB, Ryan AL, Seeger K, et al. Ontogeny of salivaryepidermal growth factor and necrotizing enterocolitis. J Pe-diatr 2007; 150:358. 31.Schanler RJ. Pathology and pathogenesis of necrotizing en-terocolitis in newborns. In: UpToDate, Abrams SA Jan 18 2016 32.Mohamed A, Shah PS. Transfusion associated necrotizing en-terocolitis: a meta-analysis of observational data. Pediatrics2012; 129:529. 33.Stritzke AI, Smyth J, Synnes A, et al. Transfusion-associatednecrotising enterocolitis in neonates. Arch Dis Child Fetal Neo-natal Ed 2013; 98:F10. 34.Keir AK, Wilkinson D. Question 1 * do feeding practices du-ring transfusion influence the risk of developing necrotisingenterocolitis in preterm infants? Arch Dis Child 2013;98:386 35.Guillet R, Stoll BJ, Cotten CM, et al. Association of H2-bloc-ker therapy and higher incidence of necrotizing enterocolitisin very low birth weight infants. Pediatrics 2006; 117:e137. 36.Yee WH, Soraisham AS, Shah VS, et al. Incidence and timingof presentation of necrotizing enterocolitis in preterm infants.Pediatrics 2012; 129:e298. 37.Sharma R, Tepas JJ 3rd, Hudak ML, et al. Portal venous gasand surgical outcome of neonatal necrotizing enterocolitis. JPediatr Surg 2005; 40:371. 38.Muchantef K, Epelman M, Darge K, et al. Sonographic andradiographic imaging features of the neonate with necrotizingenterocolitis: correlating findings with outcomes. Pediatr Ra-diol 2013; 43:1444. 39.Faingold R, Daneman A, Tomlinson G, et al. Necrotizing en-terocolitis: assessment of bowel viability with colordoppler US.Radiology 2005; 235:587. 40.Gordon PV, Swanson JR, Attridge JT, Clark R. Emerging trendsin acquired neonatal intestinal disease: is it time to abandonBell's criteria? J Perinatol 2007; 27:661. 41.Schanler RJ.Management of necrotizing enterocolitis innewborns. In: UpToDate, Abrams SA Oct 15 2015 42.Brook I. Microbiology and management of neonatal necro-tizing enterocolitis. Am J Perinatol 2008; 25:111. 43.Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and ma-nagement of complicated intra-abdominal infection in adultsand children: guidelines by the Surgical Infection Society andthe Infectious Diseases Society of America. Clin Infect Dis2010; 50:133. 44.Tepas JJ 3rd, Sharma R, Leaphart CL, et al. Timing of sur-gical intervention in necrotizing enterocolitis can be determi-ned by trajectory of metabolic derangement. J PediatrSurg2010; 45:310. 45.Rao SC, Basani L, Simmer K, et al. Peritoneal drainage ver-sus laparotomy as initial surgical treatment for perforated nec-rotizing enterocolitis or spontaneous intestinal perforation inpreterm low birth weight infants. Cochrane Database Syst Rev2011; :CD006182. 46.Duro D, Kalish LA, Johnston P, et al. Risk factors for intes-tinal failure in infants with necrotizing enterocolitis: a Gla-ser Pediatric Research Network study. J Pediatr 2010;157:203.32. 47.Hull MA, Fisher JG, Gutierrez IM, et al. Mortality and ma-nagement of surgical necrotizing enterocolitis in very low birthweight neonates: a prospective cohort study. J Am Coll Surg2014; 218:1148. 48.Fitzgibbons SC, Ching Y, Yu D, et al. Mortality of necrotizingenterocolitis expressed by birth weight categories. J Pediatr-Surg 2009; 44:1072. 49.Lambert DK, Christensen RD, Baer VL, et al. Fulminant nec-rotizing enterocolitis in a multihospital healthcare system. JPerinatol 2012; 32:194. 50.Clark RH, Gordon P, Walker WM, et al. Characteristics of pa-tients who die of necrotizing enterocolitis. J Perinatol 2012;32:199. 51.Pike K, Brocklehurst P, Jones D, et al. Outcomes at 7 yearsfor babies who developed neonatal necrotising enterocolitis:the ORACLE Children Study. Arch Dis Child Fetal NeonatalEd 2012; 97:F318. 52.Hintz SR, Kendrick DE, Stoll BJ, et al. Neurodevelopmentaland growth outcomes of extremely low birth weight infants af-ter necrotizing enterocolitis. Pediatrics 2005; 115:696 53.Karagol BS1, Zenciroglu A, Okumus N, Polin RA. Randomi-zed controlled trial of slow vs rapid enteral feding advance-ments on the clinical outcomes of preterm infants with birthweight 750-1250g. JPEN J Parenter Enteral Nutr. 2013Mar;37(2):223-8. 54.Quigley M, McGuire W. 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Toplam 1 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm makale
Yazarlar

Uzm. Dr. Ece Koyuncu Bu kişi benim

Yayımlanma Tarihi 30 Mart 2016
Yayımlandığı Sayı Yıl 2016 Cilt: 8 Sayı: 2

Kaynak Göster

APA Koyuncu, U. D. E. (2016). Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon. Klinik Tıp Pediatri Dergisi, 8(2), 65-82.
AMA Koyuncu UDE. Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon. Pediatri. Mart 2016;8(2):65-82.
Chicago Koyuncu, Uzm. Dr. Ece. “Nekrotizan Enterokolit Ve Spontan İntestinal Perforasyon”. Klinik Tıp Pediatri Dergisi 8, sy. 2 (Mart 2016): 65-82.
EndNote Koyuncu UDE (01 Mart 2016) Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon. Klinik Tıp Pediatri Dergisi 8 2 65–82.
IEEE U. D. E. Koyuncu, “Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon”, Pediatri, c. 8, sy. 2, ss. 65–82, 2016.
ISNAD Koyuncu, Uzm. Dr. Ece. “Nekrotizan Enterokolit Ve Spontan İntestinal Perforasyon”. Klinik Tıp Pediatri Dergisi 8/2 (Mart 2016), 65-82.
JAMA Koyuncu UDE. Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon. Pediatri. 2016;8:65–82.
MLA Koyuncu, Uzm. Dr. Ece. “Nekrotizan Enterokolit Ve Spontan İntestinal Perforasyon”. Klinik Tıp Pediatri Dergisi, c. 8, sy. 2, 2016, ss. 65-82.
Vancouver Koyuncu UDE. Nekrotizan Enterokolit ve Spontan İntestinal Perforasyon. Pediatri. 2016;8(2):65-82.