Gut and eyes
Modified Bell's staging for NEC
Stages necrotising enterocolitis from systemic signs, abdominal signs and X-ray findings (stages IA to IIIB).
For education. Check against your unit's guidance and a second clinician before use.
Use the table below. Suspected NEC needs urgent senior review: stop feeds, and follow your unit's NEC pathway with the surgical team as needed.
Modified Bell's staging (Walsh and Kliegman 1986)
| Stage | Systemic signs | Abdominal signs | X-ray |
|---|---|---|---|
| IA Suspected | Temperature instability, apnoea, bradycardia, lethargy | Increased gastric residuals, mild distension, vomiting, blood in stool on testing | Normal, or bowel dilatation, mild ileus |
| IB Suspected | As IA | As IA, plus bright red blood from the rectum | As IA |
| IIA Definite, mildly ill | As IA | As IB, plus absent bowel sounds, with or without tenderness | Bowel dilatation, ileus, pneumatosis intestinalis |
| IIB Definite, moderately ill | As IIA, plus mild metabolic acidosis and low platelets | As IIA, plus definite tenderness, with or without abdominal cellulitis or a right lower quadrant mass | As IIA, plus portal venous gas, with or without ascites |
| IIIA Advanced, bowel intact | As IIB, plus low blood pressure, bradycardia, severe apnoea, combined respiratory and metabolic acidosis, DIC, neutropenia | As IIB, plus signs of peritonitis, marked tenderness and distension | As IIB, plus definite ascites |
| IIIB Advanced, bowel perforated | As IIIA | As IIIA | As IIIA, plus pneumoperitoneum |
How this is calculated
- Each stage adds to the one before. Stage I is suspected NEC, stage II definite NEC, stage III advanced NEC (IIIB with bowel perforation).
Sources
Checked by NICUlearn, 6 Oct 2026.