Liver hemorrhage during laparotomy in patients with necrotizing enterocolitis

Major liver hemorrhage (LH) without obvious iatrogenic injury was recently observed in several patients during operation for necrotizing enterocolitis (NEC). The purpose of this study was to determine the incidence and risk factors associated with the development of LH in patients with NEC. Methods: The hospital charts of patients with NEC who underwent surgical exploration during a 5-year period (1989-1994) were reviewed. The patients in whom LH developed without obvious significant iatrogenic liver injury were compared with those who did not have LH. Results: Eight of the 68 patients reviewed had LH. The survival rate for those with LH was 13%, compared with 88% for those without LH (P < .001). The patients with LH had a younger gestational age (28 ± 3 weeks v 32 ± 5 weeks) and a lower birth weight (1,202 ± 489 g v 1,649 ± 686 g); however, the differences were not significant. The patients with LH had significantly lower preoperative mean arterial blood pressure (35 ± 1 mm Hg v 46 ± 3 mm Hg; P < .001) and required greater fluid intake (272 ± 28 mL/kg/d v 186 ± 9 mL/kg/d; P < .01) for the 24 hours preceding surgery. Conclusion: LH is as an important and lethal complication associated with laparotomy in very small infants with NEC. The presence of hypotension and the administration of large amounts of volume in the preoperative period appear to be risk factors. Earlier surgical intervention and restoration of blood pressure using inotropic agents, once a particular level of fluid administration has been achieved, my be preventive.