Possible Genetic Links to Necrotizing Enterocolitis

Necrotizing enterocolitis, otherwise known as NEC, is one of the most common and

potentially fatal gastrointestinal emergencies found in neonates (premature infants). Though the

exact pathogenesis, or origination, of this disease is unknown, it is thought to stem from impaired

blood flow in the gastrointestinal organs, and/or an abnormal inflammatory or immune response

(Szpecht et al., 2017). For any of these reasons, the immature nature of these neonates’ intestines

allows for viral and bacterial infection, eventually leading to the perforation or rupture of the

bowel and the subsequent spillage of stool into the abdomen (Ford, 2017).

The signs and symptoms of early NEC are fairly generic— a tender and distended

abdomen, the emesis of bile, etc. (Ford)— so it can be difficult to diagnose early on (Franklin et

al., 2015). The unpredictable nature of this disease makes treating patients extremely difficult. In

fact, according to Franklin et al. (2015), “Although overall mortality among [extremely

premature neonates] has declined, deaths related to NEC have increased”(p. 1). As a future

medical professional in the Neonatal Intensive Care Unit (NICU), I know that I will have

patients who battle NEC, and I feel that it is important for me to understand its inner workings so

that I can give each of my patients the greatest chance at life possible.

With that said, finding a genetic marker linked to NEC is of high importance to me; it

would allow neonatologists to diagnose infants earlier and with more accuracy— essentially

leading to a much higher survival rate amongst those with NEC. Furthermore, the discovery of

genetic differences in those with NEC may provide information about the malfunctionings in the

body that lead to its pathogenesis. This is of the utmost importance, because once medical

practitioners understand the pathogenesis of NEC, they can treat it by targeting the source, not
just the symptoms. Further experimentation must be done in order to finalize results, but there

are many promising genetic links to Necrotizing Enterocolitis that come in the form of single

nucleotide polymorphisms (Franklin et al., 2015).

Single nucleotide polymorphisms, or SNPs, can greatly mutate an organism’s genetic

code with only the slightest of changes. SNPs are naturally occurring alterations to individual

nucleotides in the DNA (Franklin et al., 2015). A change to something as small as a nucleotide

might seem trivial, but it can wreak havoc in the body. Nucleotides are the genetic “building

blocks” of DNA; when paired with their corresponding monomer, they form base pairs.

Nucleotides are composed of deoxyribose sugar, a phosphate group, and a purine or pyrimidine

base. These purine bases are known as adenine and guanine, and the pyrimidines are thymine

and cytosine. Base pairs are formed when hydrogen bonds form between a monomer containing

a purine base and a corresponding monomer with a pyrimidine base; specifically: when adenine

pairs with thymine, and guanine pairs with cytosine. Each base pair participates in coding for

proteins that will, in turn, characterize the physical manifestations of our genes. A given

sequence of three bases will in turn code for one amino acid, and a string of amino acids code for

a single protein. An organism’s protein production dictates everything from hair color, to the

immune response. A variance in even one individual nucleotide has the capacity to modify the

entire DNA sequence, and therefore, the protein production of an organism (​Heller, Orians,

Purves, & Sadava, 2004).

According to the research of Szpecht et al. (2017), a polymorphism in the eNOS gene

was found to increase one’s risk of NEC twentyfold. In their research, 100 infants of single

pregnancies born without congenital abnormalities, before 32 weeks of gestation, were placed
into two groups— with NEC and without NEC— and their DNA was compared accordingly.

Those who were found to have a ‘T’ allele where there was normally a ‘G’ nucleotide, were 20

times more likely to develop NEC.

The eNOS gene controls the synthase of nitric oxide, an important influence in the body’s

antimicrobial activities (NCBI, 2017-a). Nitric oxide is also thought to act as a vasodilator,

dilating the blood vessels to aid in circulation and decrease blood pressure (Whitaker, 2017).

Microbial activities and blood flow are two prominent components in the pathogenesis of

necrotizing enterocolitis, as the bacterial infection of the intestines and the ischemia of the bowel

are two of its major physical manifestations. If a dearth of nitric oxide is the root cause of these

symptoms, infants may be successfully treated with supplements of nitric oxide. Similarly,

infants with NEC have been found to be malnourished, as they are fed using formula, rather than

breast milk. An arginine-deficient diet has been found to decrease NO levels, so, conversely, an

arginine-rich formula diet may counteract the effects of NEC (Luiking, Engelen, Deutz, 2010).

Though the results of this experiment are highly plausible and in accordance with

previous knowledge of the disease, the small amount of viable subjects with NEC (22 neonates)

does not give an inclusive picture of all neonates with necrotizing enterocolitis. This leads me to

believe that a follow-up study must be done with more test subjects in order to confirm that these

findings were not skewed by the small amount of data obtained.

In the recent research of Franklin et al. (2015), buccal swabs (DNA samples taken from

the inner cheek) of infants without NEC with a gestation period of less than 32 weeks were

compared to those of infants diagnosed with stage II or III NEC. Caucasian infants who had a
‘C’ allele instead of a ‘G’ nucleotide in the IL-6 gene were found to be six times more likely to

develop NEC (black test subjects did not display this link).

The IL-6 gene codes for a proinflammatory cytokine— a protein which signals for other

cells to engage in the inflammatory response (Heller et al., 2004). Extreme inflammation of the

intestines is another key aspect of necrotizing enterocolitis, and can lead to their perforation

(Ford, 2017). In fact, the report of Franklin et al. (2015) states that “Multiple studies have shown

that proinflammatory cytokines are increased in the serum and tissue of patients with NEC [and]

several studies have demonstrated that neonates with NEC [have] a significantly higher elevation

of serum inflammatory cytokines than infants with other gastrointestinal diseases” (p. 6). Perhaps

in the future neonatologists can prevent the devastating effects of inflammation on NEC patients

by administering medications that inhibit such cell signalling that the IL-6 cytokines initiate,

such as aspirin, or ibuprofen.

The IL-6 gene is also thought to aid in the maturation of B-cells (NCBI, 2017-e). B-cells

are white blood cells that are instrumental in the production of antibodies, which, in turn, fight

off pathogens. A polymorphism in the IL-6 gene could potentially inhibit an organism from

producing antibodies, making a patient extremely vulnerable to fatal infections. In patients with

NEC, this means that their body can not combat the viral or bacterial infection causing the

necrosis of their intestines.

Similar results were found in a recent experiment conducted by Tremblay et al. (2016), in

which the DNA found in resected ileums of preterm infants without NEC was compared to that

of preterm infants with NEC. Neonates with NEC showed differential expression of the MX1,

OAS1, and OAS2 genes in comparison to those without NEC.

 All three of these genes are involved in the body’s antiviral response by inhibiting the

replication of viral RNA (NCBI, 2017-b,c,d). Though the discoveries presented by this team’s

experiment are intriguing, the statistical significance of their results must be put into question. It

could be argued that the group of infants without NEC may not truly be an effective control;

every infant participating in this study had their ileum resected because of some type of

gastrointestinal emergency, so those posing as the “non-NEC” group may not accurately

represent healthy neonates.

For now (assuming that the immune systems of patients diagnosed with NEC are, indeed,

compromised) antiviral and antibiotic medication might be the best way to prevent the disease

from fully manifesting throughout the intestines. However, in the future, stem cells could be used

to artificially create T-cells (cells involved in the antiviral immune response) or B-cells for

neonates with NEC to help them naturally fight off infections.

Despite these promising breakthroughs, there is still much to be learned about necrotizing

enterocolitis. The research done by Franklin et al. (2015), Szpecht et al. (2017), and Tremblay et

al. (2016) is exciting, but only constitute theories, and theories must be tested. Repeated

experiments with a larger variance of test subjects would rule out possibilities of confounding

variables, and hopefully solidify the results that were already reported. Additionally, now that the

possible genetic links to NEC have been narrowed down a bit, further research would be more

focused and much easier to conduct. Experimental treatments based upon the results of these

observational studies would also be helpful in gaining insight on this disease. For example,

improved bowel conditions of patients given anti-inflammatories would reinforce the theory that

cytokine protein mutations cause NEC.

 The information I learned from researching this topic will no doubt help me to be a

well-equipped medical practitioner in the NICU. In the future I will be able to encourage the

genetic testing of my patients, especially those who display gastrointestinal problems, so that

they are given the best chance at survival against NEC. In addition, these new insights will allow

me to more efficiently treat my patients, because I now have an extensive understanding of the

possible root causes of the disease. But perhaps most importantly, I will be exceedingly more

capable in educating the worried parents of my patients on necrotizing enterocolitis, and how it

may affect their child.

 References

Ford, H. R. (2017). Necrotizing enterocolitis. Retrieved from

https://www.chla.org/necrotizing-enterocolitis

Franklin, A. L., Said, M., Cappiello, C. D., Gordish-Dressman, H., Tatari-Calderone, Z.,

Vukmanovic, S., ... & Sandler, A. D. (2015). Are immune modulating single nucleotide

polymorphisms associated with necrotizing enterocolitis?. ​Scientific reports​, ​5​. doi:

10.1038/srep18369

Heller, H. C., Orians, G. H., Purves, W. K., & Sadava, D. (2004) Life: The science of biology.

Sinauer Associates, Inc.

Luiking, Y. C., Engelen, M. P., & Deutz, N. E. (2010). Regulation of nitric oxide production in

health and disease. ​Current opinion in clinical nutrition and metabolic care​, ​13​(1), 97.

doi: 10.1097/MCO.0b013e328332f99d

NCBI (2017-a). NOS3 nitric oxide synthase 3 [Homo sapiens (humans)]. Retrieved from

https://www.ncbi.nlm.nih.gov/gene/4846

NCBI (2017-b). MX1 MX dynamin like GTPase 1 [Homo sapiens (humans)]. Retrieved from

https://www.ncbi.nlm.nih.gov/gene/4599

NCBI (2017-c). OAS1 2’-5’-oligoadenylate synthetase 1 [Homo sapiens (humans)]. Retrieved

from https://www.ncbi.nlm.nih.gov/gene/4938

NCBI (2017-d). OAS2 2’-5’-oligoadenylate synthetase 2 [Homo sapiens (humans)]. Retrieved

from https://www.ncbi.nlm.nih.gov/gene/4939

NCBI (2017-e). IL6 interleukin 6 [Homo sapiens (humans)]. Retrieved from

https://www.ncbi.nlm.nih.gov/gene/3569
Szpecht, D., Neumann-Klimasińska, N., Błaszczyński, M., Seremak-Mrozikiewicz, A.,

Kurzawińska, G., Cygan, D., ... & Gadzinowski, J. (2017). Candidate gene analysis in

pathogenesis of surgically and non-surgically treated necrotizing enterocolitis in preterm

infants. ​Molecular and Cellular Biochemistry​, 1-11. doi: 10.1007/s11010-017-3135-5

Tremblay, É., Thibault, M. P., Ferretti, E., Babakissa, C., Bertelle, V., Bettolli, M., ... & Lu, P.

(2016). Gene expression profiling in necrotizing enterocolitis reveals pathways common

to those reported in Crohn’s disease. ​BMC medical genomics​, ​9​(1), 6. doi:

10.1186/s12920-016-0166-9

Whitaker, Julian. (2017). Boost nitric oxide levels to improve health. Retrieved from

https://www.drwhitaker.com/boost-nitric-oxide-levels-to-improve-health