Neonatal vomiting and blood in stool
Introduction
Introduction to neonatal hematemesis and blood in the stool Hematemesis and blood in the stool are common symptoms of neonatal gastrointestinal bleeding. Under normal circumstances, gastrointestinal bleeding above the duodenal levator (also known as Treitz ligament) is called upper gastrointestinal bleeding, mainly hematemesis; Lower gastrointestinal bleeding for blood (hematochezia), when the lower gastrointestinal tract bleeding, or intestinal pressure is higher than the intragastric pressure, bloody fluid can flow back into the stomach and esophagus, can also cause hematemesis; When the amount of bleeding exceeds 3 ml, there may be black stools. That is, there is no hematemesis when it is black, and there is often black stool when it is hematemesis. basic knowledge The proportion of illness: 0.005%-0.008% Susceptible population: newborn Mode of infection: non-infectious Complications: neonatal hemorrhagic anemia, hemorrhagic shock
Cause
Neonatal hematemesis and blood in the cause of blood in the stool
False factors (30%)
When the baby gives birth, he swallows the blood of the mother's birth canal or inhales the bleeding of the breast. The Apt test can identify the blood of the mother blood and the newborn. As well as mouth, bleeding after nasal injury, swallowing into the digestive tract can be neonatal hematemesis and blood in the stool.
Cause of bleeding (30%)
Neonatal hemorrhagic disease caused by vitamin K deficiency, more than 2 to 3 days after birth, hematemesis and blood in the stool, severe bleeding can occur in other parts, late vitamin K deficiency, hemorrhage, blood in the stool. Other less common systemic bleeding disorders, such as DIC, neonatal thrombocytopenic purpura and various congenital clotting factor deficiencies can be caused.
Digestive tract disease (25%)
(1) reflux esophagitis: clinical manifestations of intractable vomiting, may have hematemesis or blood in the stool, often accompanied by malnutrition and growth and development. (2) stress ulcer: hypoxia, intracranial hypertension, severe infection can cause stress ulcers, gastrointestinal bleeding. (3) acute gastroenteritis: acute gastrointestinal inflammation caused by most pathogens, in addition to fever, vomiting, diarrhea, severe cases of blood in the stool and hematemesis. (4) intestinal obstruction: clinical manifestations of vomiting, abdominal distension, hematemesis or blood in the stool. (5) sigmoid colon, rectal and anal diseases: mostly polyps, anorectal fistula, anal fissure caused by bloody stools.
Pathogenesis
Systemic, coagulopathy, due to abnormal changes in the coagulation phase can cause gastrointestinal bleeding, which is most common in neonatal hemorrhagic and critically ill children, congenital allogeneic or passive immune platelets Reduced purpura, or a variety of congenital coagulation factor deficiency is less common.
Reflux esophagitis is rare in newborns and small babies, and it is becoming more and more important. It may be associated with relaxation of the cardia. The pressure in the intestinal tract is related to the reflux of gastric juice into the esophagus. Gastric acid and gastric digestive enzymes can corrode the esophageal mucosa. Causes vomiting and hematemesis.
Most of the neonatal gastric ulcers are stress ulcers. The stomach acidity of the first day of newborn children is very high, reaching the highest peak at 24h (pH 1.3-4.0), and then the gastric acid secretion is hyperthyroidized, which lasts for 10 days after birth, especially The first 2 to 4 days is very much, which is related to the pro-gastrin stimulation of the mother and the stress state during childbirth. The increase of intracranial pressure also causes stress ulcer, and the ulcer can also be seen in the esophagus or duodenum. In the past 10 years, it has been considered that neonatal stress gastric ulcer is common, often in the early stage of neonatal, causing hematemesis and blood in the stool.
Acute gastroenteritis is mainly in the small intestine, but severe fulminant can also affect the stomach, esophagus and rectum, caused by various pathogens, causing hematemesis and/or blood in the stool, especially in the necrotizing small intestine colon in premature infants. Inflammation (NEC) is more serious.
Various internal and surgical diseases caused by paralytic and/or mechanical intestinal obstruction, but mainly caused by internal diseases, gastrointestinal mucosal damage caused by severe vomiting, rupture can also cause bleeding, especially esophagus-stomach The stomach, duodenum and other joints, other rare mesenteric vascular embolization or thrombosis, intestinal polyps, hemangioma, multiple intestinal telangiectasia, diverticulum and other diseases can cause gastrointestinal bleeding.
If the blood stays in the stomach for a short period of time or the amount of bleeding is large, the bloody liquid that is vomited is bright red or dark red; if the amount of bleeding is small and (or) the blood stays in the stomach for a long time, the hemoglobin is denatured due to gastric acid. The vomit is black in coffee slag. When the higher gastrointestinal hemorrhage occurs, the iron in the blood hemoglobin is combined with the sulphide in the intestine by the action of bacteria and enzymes to form iron sulphide, so that the stool is black tar-like stool; When the amount is too much and quickly passes through the intestine, red blood can also be present, and the amount of bleeding often reaches 40 ml or more.
Prevention
Neonatal hematemesis and blood in the stool
In order to prevent natural bleeding in newborns, vitamin K can be taken orally by pregnant women before birth; dystocia, premature delivery or gastrointestinal malformation of newborns, postpartum injection of vitamin K, active treatment of infectious diseases, active prevention and treatment of DIC, stress ulcers, The occurrence of acute gastroenteritis and the like.
Complication
Neonatal hematemesis and blood in the stool Complications neonatal hemorrhagic anemia hemorrhagic shock
Hemorrhagic anemia and/or hemorrhagic shock can occur when a large number of blood loss can cause a series of systemic symptoms, when the blood loss exceeds 1/5 of the systemic blood volume.
Acute hemorrhagic shock disease children have not presented hematemesis and blood in the stool, they have weak body, crying weakness, pale skin mucous membrane, fast heart rate and heart sound weakness, blood pressure drop and shock signs, but also exclude infection poisoning, central nervous system damage, For reasons such as respiratory distress and heart failure, acute hemorrhagic shock should be considered. It is necessary to observe whether there is blood loss from the gastrointestinal tract.
Symptom
Neonatal hematemesis and blood in the stool symptoms Common symptoms Black stool bloody stools brown gastrointestinal bleeding upper gastrointestinal bleeding paralysis blood pressure drop shock ecchymosis
1. False hematemesis and/or blood in the stool
(1) swallowing into maternal blood: neonatal oral iron, sputum preparation, phenolphthalein or Chinese herbal medicine can cause pseudo-gastrointestinal bleeding, but it is rare, blood is swallowed into the mother's birth canal during childbirth, or inhaled milk nipple The maternal blood of the erosion, causing neonatal pseudo-heavy and/or blood in the stool is more common, the child is generally in good condition, no anemia or hemorrhagic shock, hemoglobin anti-alkaline test (Apt test), can determine blood as maternal blood .
(2) swallowing into your own blood: newborns may also cause hematemesis and/or blood in the stool due to swallowing blood into their nasopharyngeal or airways. They need to be differentiated from true gastrointestinal bleeding. Usually, often There are traumatic history and local injury, such as intubation, bleeding, black tar, stool wet diaper on the edge of the stool (not wet can add water) blood red, occult blood or microscopic examination of red blood cells can be positive.
2. Systematic
Coagulation diseases have manifestations of extra-gastrointestinal bleeding, such as skin, subcutaneous bleeding points, ecchymoses, etc., abnormal changes in coagulation phase examination, among which DIC is the most common in severely ill children, and DIC children have severe clinical manifestations. , scleredema or RDS, etc., congenital allograft or passive immune thrombocytopenic purpura or a variety of congenital coagulation factor deficiency is rare, often with a positive family history and corresponding out, abnormal blood coagulation.
In the neonatal period, the most common such diseases are neonatal hemorrhagic disease. The neonatal hemorrhagic disease often causes hematemesis 2 to 6 days after birth. When the amount of bleeding is large, the vomit is mostly blood, and other components are not mixed. The amount of early bleeding is not When there is no major organ bleeding, the child is generally in good condition, late vitamin K deficiency, common in neonates who have long-term antibiotics, parenteral nutrition or mother's partial eclipse and breastfed, and found that bleeding is given vitamins. K1 5 ~ 10mg intravenous or intramuscular injection, fresh whole blood or dry frozen plasma, can be used to stop bleeding.
3. Gastrointestinal bleeding disorders
(1) reflux esophagitis: vomiting, hematemesis, weight loss and other symptoms, can also be without any symptoms, endoscopy, thin meal examination, can be found in superficial lesions, the pH value is below 5.0 Diagnostic value, localized hemostasis by electrocautery.
(2) stress ulcer: neonatal stress gastric ulcer is common, gastric acid secretion is hyperthyroidism, sustainable to the 10th day after birth, especially in the first 2 to 4 days, the increase in intracranial pressure also causes stress Sexual ulcers, often in the early stage of neonatal, with hematemesis and blood in the stool, the amount of blood and old and new, medical conservative treatment can be cured, ulcers can also be seen in the esophagus or duodenum.
(3) Acute gastroenteritis: there may be hematemesis and/or blood in the stool, especially in necrotizing enterocolitis (NEC), which is more common in premature infants. Children have fever, weakness, vomiting, diarrhea, etc. Common symptoms of gastroenteritis, stool is mucus and blood, there is blood, jam or black stool; vomiting blood or coffee-like brown-black blood, often have bile or intestinal contents.
Allergic enteritis caused by cow's milk and even soy flour may also have hematemesis and/or blood in the stool, but it is rare to stop the protein food.
(4) intestinal obstruction: the main cause of lower gastrointestinal bleeding in neonates is intestinal obstruction, including paralytic and/or mechanical intestinal obstruction caused by various internal and surgical diseases, but mainly caused by internal diseases, children Nutrition, poor development, severe vomiting causes gastrointestinal bleeding.
(5) Anal, rectal and sigmoid diseases: more bloody stools than black tar, mostly severe constipation, polyps, anal-rectal fissure.
4. Systemic symptoms
In addition to the above-mentioned manifestations such as hematemesis and blood in the stool, a series of systemic symptoms can be caused by a large amount of blood loss. When the blood loss exceeds 1/5 of the systemic blood volume, hemorrhagic anemia and/or hemorrhagic shock can be manifested. The heart rate is increased, the limbs are cyanotic, the hair is cold, the blood pressure is lowered, the skin is faint, the spirit is wilting and the irritability alternates.
Detailed medical history and physical examination, comprehensive physical examination including anal examination, observation or laboratory examination of vomiting and diarrhea traits, determine whether there is gastrointestinal bleeding, follow the principle of diagnosis and characterization of the disease, and quickly make a judgment.
1. Determine if the bleeding comes from the newborn. First determine whether the bleeding is from the mother or the newborn itself. It can be used for the Apt test.
2. Determine the bleeding site to determine whether the bleeding comes from the upper digestive tract or the lower digestive tract. The initial positioning of the bleeding is to determine the gastrointestinal bleeding above the duodenal levator muscle, or the following gastrointestinal bleeding.
(1) Upper gastrointestinal bleeding: The main clinical manifestations of acute upper gastrointestinal bleeding are hematemesis and melena, which are mainly judged according to the traits of bloody stools. The leucorrhea is often upper gastrointestinal bleeding, because in general, the upper digestive tract When bleeding, the iron in the blood hemoglobin combines with the intestinal sulfide to become iron sulfide, the stool is tar-like black, but if the amount of bleeding is large, the intestinal peristalsis is too fast, then there is dark red or even bright red blood, gastric lavage after gastric lavage When the liquid carries blood, it is the gastrointestinal bleeding above the stomach, but the operative damage to the mucosa due to the stomach tube should be excluded.
(2) Lower gastrointestinal bleeding: Most of the lower gastrointestinal bleeding is more red or bright red blood; biliary biliary bleeding is often lower gastrointestinal bleeding, but the bleeding is often in the upper part of the lower digestive tract; According to the correlation between blood loss and hematemesis and/or blood in the stool, lower gastrointestinal bleeding requires immediate elimination of hemorrhage in the anus, rectum or sigmoid colon.
However, there are exceptions for both. For example, if there is more bleeding under the pylorus, blood can only flow into the stomach, which can also cause hematemesis. If the amount of bleeding above the pylorus is small, all the blood will flow into the intestine without causing vomiting and reflex. If necessary, special measures should be taken. The method of examination to determine the location and nature of the bleeding.
3. Excluding systemic diseases and bleeding caused by coagulopathy. Most of the acute gastrointestinal bleeding is caused by digestive tract diseases. A few cases may be local manifestations of systemic diseases. In general, the clinical signs of the former are mainly reflected in digestion. Local, the latter is more obvious systemic symptoms, in addition to gastrointestinal bleeding, there are often other parts of the bleeding phenomenon, detailed medical history and physical examination and other hematological examinations, to help diagnose.
Examine
Neonatal hematemesis and blood in the stool
1. routine examination: blood routine, platelet, out, clotting time, prothrombin time and other general examinations, systemic out, coagulation disease, out, abnormal changes in blood coagulation phase, such as DIC or vitamin K deficiency, etc. Congenital allogeneic or passive immune thrombocytopenic purpura or various congenital coagulation factor deficiency, abnormal blood coagulation.
2. Fecal examination: Red blood cells were found, and the occult blood test was strongly positive. Children with acute gastroenteritis may have mucus and bloody stools and blood.
3.Apt test: to identify the blood as maternal blood or the blood of the newborn, take the baby's vomit or fecal blood, add 5 times water and mix well, centrifuge at 2000 rev / min for 2 min, take the pink supernatant (5 parts) in a test tube, add 1% sodium hydroxide (1 part), observe the result after 2 minutes, if the test solution changes from pink to yellowish brown, it shows adult hemoglobin (HbA), indicating that the blood is maternal blood; Still pink, the blood comes from the newborn, and the newborn swallows blood into the nasopharyngeal cavity or airway, mainly fetal hemoglobin (HbF).
4. Endoscope
(1) fiber esophagoscopy, gastroscope, duodenoscopy: it is superior to X-ray barium angiography, the diagnosis rate is 75% to 90%, while the latter is only 50%, can determine the bleeding above or below the Treitz ligament Can see the source of bleeding (positive rate of 77%) and specific bleeding; can be biopsy and hemostasis under direct vision; and can observe superficial and minor lesions that are difficult to detect by X-ray examination; For examination, children with GIF-P2 or GIF-P3 type mirror, under general anesthesia or local anesthesia plus atropine, must correct the coagulopathy and hemodynamic instability before microscopic examination, keep the airway unobstructed, and use Antibiotics prevent infection.
(2) fiberoptic colonoscopy, colonoscopy: first gutoscopy, before the colonoscopy, generally do the barium enema examination, which is different from the upper digestive tract examination, using PCF (Olympus) or FC-34MA Endoscopic, small babies can also be replaced with small-caliber gastroscopes.
5. X-ray inspection
(1) Abdominal plain film: Take the supine, erect or lateral lateral abdominal plain film to exclude intestinal obstruction and intestinal perforation, especially for neonatal small intestine torsion, necrotic enteritis and meconium peritonitis.
(2) sputum angiography: rare meal in the non-acute bleeding period has a certain value, often with methyl cellulose for double-layer comparison, can also be injected into the duodenum after intubation for small bowel angiography ( With or without methylcellulose, barium enema often helps in the diagnosis of intussusception.
6. Nuclide scanning: It is an effective and accurate method of examination. Using 99mTc-sulfur gel or other citrate-labeled red blood cell scan, it is most valuable for subacute or intermittent bleeding, and the false positive is 15%. The false negative is up to 25%.
7. Angiography: For the examination of bleeding cases above 1.5~2.0ml/min, for cases with large amount of bleeding and inoperability, embolization can be used to stop bleeding, but because of the above-mentioned series of more advanced and non-invasive examination methods, This method is currently rarely used.
Diagnosis
Diagnosis of neonatal hematemesis and blood in the stool
1. Exclusion of pseudo-heavy hemorrhage and/or blood in the stool including blood transfused into the mother's body and blood outside the neonatal gastrointestinal tract, the Apt test is helpful for this differential diagnosis.
2. Exclude systemic outbreaks, blood coagulation disorders are detected before blood transfusion (or plasma), injection of anticoagulants such as vitamin K, coagulation phase is essential, the most important is to make early diagnosis and treatment of neonatal hemorrhagic disease, At the same time, it excludes infection, central nervous system damage, respiratory distress and heart failure.
