acute hemorrhagic necrotizing enteritis in children
Introduction
Brief introduction of acute hemorrhagic necrotic enteritis in children Acute hemorrhagic necrotic enteritis is a digestive system emergency characterized by acute extensive, hemorrhagic and necrotic inflammation of the small intestine, also known as acute necrotizing enterocolitis or segmental enteritis. Clinically, sudden onset, abdominal pain, diarrhea The main feature of blood in the stool is that the onset is urgent and the condition changes rapidly. Most of the children have severe symptoms, often accompanied by shock, and the mortality rate is extremely high. If the diagnosis is delayed or improperly treated, the sick child can die within a few days. basic knowledge The proportion of sickness: 0.01% - 0.03% Susceptible people: children Mode of infection: non-infectious Complications: shock peritonitis intestinal obstruction dehydration jaundice
Cause
Causes of acute hemorrhagic necrotic enteritis in children
(1) Causes of the disease
Not fully understood, may be related to the following two factors:
1. There are certain bacteria and toxins produced in the intestine: It is more likely to use C-type Clostridium perfringens B toxins. Because of the anaerobic culture of feces in this disease, the detection rate of this bacteria and its B-toxin The positive rate of serum antibody was significantly higher than that of the normal population. The bacteria liquid was injected into the small intestine of guinea pigs, which caused hemorrhagic lesions in the intestines to die.
2. Reduced trypsin activity in sick children: The above B toxin can be hydrolyzed by enteral trypsin to lose pathogenic effect, long-term protein malnutrition and/or regular consumption of sweet potato, corn and other foods rich in trypsin inhibitors, The intestinal trypsin activity is significantly reduced, making the sick child prone to disease, which may explain why the disease is high in rural poverty-stricken areas.
(two) pathogenesis
The typical pathological changes of necrotizing enterocolitis are necrotic inflammatory changes. Starting from the submucosal layer, with the expansion of the lesion, it can develop into the muscular layer and the mucosa, causing multiple layers of intestinal wall congestion and edema, necrotic mucosa after shedding. Form ulcers, continue to develop up to the muscular layer, serosal layer, and perforation caused by peritonitis, lesions are more common in the lower part of the jejunum and upper ileum, but also in the duodenum and colon children, severe cases of small intestines can be affected, generally It is scattered, segmental, some are 1 to 2 or more than 2, each length is different, the shortest is more than 10 cm, the elder can reach 100cm, the boundary is clear, the damaged intestinal wall is thick, brittle Loss of elasticity, expansion, heavy serosal surface with cellulose adhesion, intestinal cavity filled with jam-like blood, microscopically visible lesions in all layers of the intestinal wall have inflammatory cell infiltration, lymphocytes, eosinophils, monocytes Plasma cells are dominant, mucosa can be necrotic or shedding, large areas of hemorrhage, necrosis and edema in the submucosa, telangiectasia and congestion, turbidity in the abdominal cavity, purulent or bloody exudate, lesion recovery Not left chronic granulomatous changes, causing intra-abdominal adhesions are rare.
Prevention
Prevention of acute hemorrhagic necrotic enteritis in children
Because the cause is not known, factors that may cause disease, such as intestinal infections and protein malnutrition, should be prevented.
1, regular physical examination: to achieve early detection, early diagnosis, early treatment.
2, good follow-up: to prevent the disease from getting worse.
3, enhance physical fitness, improve their own immunity: pay attention to work and rest, participate in physical exercise, eat more fresh fruits and vegetables rich in vitamins.
4. Prevent infection.
Complication
Complications of acute hemorrhagic necrotic enteritis in children Complications, shock, peritonitis, intestinal obstruction, dehydration, jaundice
Often complicated by toxic shock, peritonitis, intestinal obstruction; concurrent dehydration, acidosis, jaundice, convulsions and so on.
Symptom
Acute hemorrhagic necrotic enteropathic symptoms in children Common symptoms Diarrhea High fever Abdominal pain Blood in the ascites of the ascites Facial pale pale abdomen tenderness Astragalus bloating
Generally no prodromal symptoms, rapid onset, mainly manifested as abdominal distension, abdominal pain, vomiting, diarrhea, bloody stools, fever, many children with severe poisoning symptoms within 1 to 2 days, even shock, abdominal pain is persistent, with paroxysmal Intensified, often full abdominal pain, can also be confined to the lesions, vomiting, diarrhea soon after the onset, the stool is initially watery, containing mucus, then become bloody stools, some sick children without diarrhea, abdominal pain 1 to 2 days later Beginning of blood in the stool, the amount of blood in the stool is not equal, a large number of blood in the stool are dark red, accompanied by corruption and odor, in the form of washing meat or red jam, some children appear bloody after a few hours of onset, fever is around 38 °C, The body temperature of severe poisoning can be as high as 39~40°C or lower than normal. The symptoms of infants and young children are atypical, dehydration, acidosis symptoms are obvious, and some may have extraintestinal symptoms such as jaundice, cough, liver spleen and convulsions. Because of the different degrees of lesions in the various layers of the intestinal wall, clinically different symptoms may occur, which are manifested in the following types:
1. Diarrhea blood type: mainly with mucosal exudative lesions, soft abdominal and no tenderness, should be treated conservatively.
2. Intestinal obstruction type: The intestinal muscle layer is severely infested and swollen, the intestinal tube is stiff, the peristalsis is lost, and the clinical symptoms of mechanical intestinal obstruction appear.
3. Peritonitis type: There is a large amount of inflammatory cell infiltration and exudation in the serosal layer, a large amount of inflammatory exudate in the abdominal cavity, or a bloody liquid due to necrosis, and clinical manifestations of peritoneal inflammation.
4. Poisoning shock type: The symptoms of systemic poisoning in this type of child are more serious. In the early stage, the face is pale, the spirit is wilting, the power is weak, the limbs are cold, the pulse is weak, the blood pressure is low, and even the blood is not detected. The tongue is red and slightly dark purple. Yellow greasy tongue coating, sometimes accompanied by a small amount of bloody stools, dehydration and electrolyte imbalance, slightly abdominal swelling and muscle tension, suspected of strangulated intestinal obstruction.
Examine
Examination of acute hemorrhagic necrotic enteritis in children
1. Blood routine examination: the total number of white blood cells and neutrophils increased, and there were nuclear left shift, poisoning particles and vacuoles; platelets decreased, and severe cases were more obvious.
2. Regular examination of stool: a large number of red blood cells, a small number of white blood cells, strong positive occult blood test, Gram staining showed more Gram-positive bacillus, sometimes visible necrotic intestinal mucosa and pseudomembrane.
3. Stool culture: Most of them can be isolated from Clostridium perfringens, and can also have pathogenic Escherichia coli, Shigella, and Salmonella.
4. Coagulation mechanism examination: clotting time is often prolonged, prothrombin time is prolonged, plasma protamine paracoagulation test is more positive, and clotting factors are reduced to varying degrees.
5. Electrolyte detection: low blood sodium, hypokalemia, low chlorine and acidosis.
6. Significant reduction in stool trypsin activity was detected.
7. X-ray examination: X-ray manifestations of acute necrotic enteritis are diverse, and different clinical types of different stages have different X-ray manifestations due to pathological changes. Abdominal supine and standing X-ray films are diagnosed. The main method of the disease, because of the risk of intestinal perforation in this disease, it is forbidden to do barium meal and barium enema examination, the acute phase of the film every 6 hours to observe the changes in the condition, early in the small intestine flatulence, the widening of the intestinal wall is due to the intestine Mucosal and submucosal edema, congestion, necrosis, cystic gas accumulation in the intestinal wall of mild to moderate disease, increased fluid in the intestinal lumen, widening of the intestinal space (eg, the intestinal gap widened more than 5cm has diagnostic significance), intestinal mucosal folds Thick or fuzzy, and even the edges are deep zigzag changes. Some patients have large-span arches or stepped arrangements in the intestines. Large intestines have large or segmental necrosis or perforation. X-ray shows dynamic intestinal obstruction and intestinal paralysis. Local intestinal stenosis, stiffness, loss of normal soft curvature, obvious gas-liquid level, increased or increased progressive exudate in the peritoneal cavity, central convergence of the intestine to the abdomen, widening of the distance between the intestine and the abdominal wall, and increased density of the entire abdomen If a segment of the intestine is necrotic, it can be seen that the intestinal fistula is dilated, the power is lost, the position and shape are fixed, suggesting that the lesion is severe, and the perforation or perforation is about to be performed. The pneumoperitoneum is the X-ray feature of the perforation of the intestine, and the free gas is in the anterior abdominal wall and the inflatable intestine. There is an inverted triangle with a translucent shadow.
Diagnosis
Diagnosis and diagnosis of acute hemorrhagic necrotic enteritis in children
diagnosis
When children have sudden abdominal pain, vomiting, diarrhea, blood in the stool and symptoms associated with high fever and poisoning, the possibility of this disease should be considered. X-ray examination is helpful for diagnosis. Intestinal flat film can be seen in the small intestine, and the intestine is stiff. Thickening, blurred contours, thickening of mucosal folds, widening of intestinal space, and a stepped liquid level of varying size in the abdomen of the intestinal obstruction. In severe cases, the intestinal wall is necrotic and the gas in the intestinal lumen enters the intestinal wall or bacteria. Gas production and saccular gas accumulation in the intestinal wall, if the gas through the intestinal wall venules to the superior mesenteric vein and then to the portal vein can show portal vein gas accumulation, intestinal perforation when the flat standing film see the underarm gas.
1. Diagnostic points
(1) Sudden abdominal pain, diarrhea and bloody stools, vomiting, abdominal distension, severe shock and DIC.
(2) Abdominal tenderness, severe intestinal obstruction and so on.
(3) Abdominal X-ray film has characteristic changes.
(4) The increase of white blood cells and neutrophils, strong fecal occult blood, according to the above points, generally can establish a diagnosis, in order to fight for early diagnosis, in addition to improving the vigilance of the disease, anal finger test found sputum bloody stool and fecal occult blood test Positive, help early detection of bloody stools, the disease needs to be differentiated from dysentery, infantile diarrhea, allergic purpura (gastrointestinal type), appendicitis, intussusception, intestinal obstruction, peritonitis.
2. Stage of illness
According to the symptoms of the whole body and intestines, signs and X-ray changes, Walsh is equal to 1986, divided into acute necrotizing enteritis divided into IA, IB, IIA, IIB, IIIA, IIIB phase 6, IA: no diarrhea, fecal occult blood test positive IB: gross bloody stool; this period only shows flatulence under X-ray, IIA: abdominal pain with typical acute necrotic enteritis, blood in the stool, vomiting, bloating and poisoning symptoms, and intestinal wall and portal vein with typical necrotic enteritis X-ray performance, IIB: typical symptoms and X-ray performance is more serious than IIA, IIIA: extensive peritonitis and ascites sign, IIIB: intestinal perforation and pneumoperitoneum, IA, IB stage is suspected diagnosis; IIA, Stage IIB is a typical acute necrotic enteritis, IIA is mild, IIB is moderate; IIIA, IIIB is severe acute necrotic enteritis.
Differential diagnosis
1. Bacterium: for pus and blood, mucus, frequent, heavy and heavy, stool culture can be found dysentery bacilli.
2. Enteritis: such as Salmonella, typhoid fever, pathogenic Escherichia coli and other enteritis, infancy onset, stool culture can be found in pathogenic bacteria.
3. Abdominal allergic purpura: repeated bleeding and purpura, no diarrhea.
4. Acute intussusception: more common in infants and young children, the abdomen can touch the mass, and the sputum or gas enema can confirm the diagnosis and reset.
5. Strangulated mechanical intestinal obstruction: for complete intestinal obstruction, the X-ray standing plain film sees the high level of intestinal gas accumulation in the liquid level and colon without gas, and X-ray signs of enteritis.
6. Crohn's disease: chronic recurrent inflammation of the digestive tract. Pathological changes include eosinophils, plasma cells, lymphocytes infiltration, and granulomatous changes, which can form intestinal stenosis, internal hemorrhoids and adhesions.
