newborn vomiting
Introduction
Introduction to neonatal vomiting Neonatal vomiting refers to the reversal of the contents of the stomach and a part of the contents of the small intestine in the digestive tract. The reflex action from the oral cavity is a manifestation of dysfunction of the digestive tract. A typical vomiting action has three steps: 1 peristalsis begins at the corpus, and downward conduction stays at the gastric notch where a strong contraction occurs and the stomach contents cannot advance downward. 2 The epiglottis is closed, and the soft palate is lifted up to separate the pharynx from the passage of the trachea and nasal cavity. 3 The cardia is open, the esophagus is loose, the diaphragm is fixed in the deep inhalation position, the abdominal muscles contract suddenly, and the contents of the stomach are squeezed out through the esophagus. Newborn vomiting is not as typical as adults or children. It is vomiting after birth, and vomiting is increased after feeding, which is non-ejection vomiting. The vomit is a foamy mucus, and the bloody one is a brown liquid. More than 1 to 2 days after birth, the swallowed amniotic fluid and the contents of the birth canal are swallowed, and the vomiting disappears. If there are no other complications, the child is generally normal, without cyanosis and cough, lighter does not require special treatment, and severe cases can be cured by washing the stomach with 1% sodium bicarbonate 1 or 2 times. basic knowledge The proportion of sickness: 0.1% - 0.3% (mostly caused by swallowing amniotic fluid) Susceptible population: newborn Mode of infection: non-infectious Complications: neonatal asphyxia, sudden death, aspiration pneumonia
Cause
Causes of neonatal vomiting
The symptoms of vomiting are caused by many different causes, which are related to the anatomical and physiological characteristics of the newborn, such as immature cerebral cortex, poor control of the vomiting center, poor development of elastic fibers in the esophageal muscle layer, and sphincter Relaxation and pyloric sphincter strength, small gastric capacity and more input, gastric mucosa is sensitive to various stimuli, etc. Digestive tract malformation is also an important cause of vomiting, and should be clearly diagnosed in a timely manner. Common causes are:
Systemic diseases (40%):
A variety of digestive diseases can cause vomiting, mainly congenital malformations of the digestive tract, obstruction, inflammation, infection, bleeding, dysfunction and so on.
1, digestive system dysfunction: such as uncoordinated swallowing function, gastroesophageal reflux, achalasia, pyloric fistula, meconium constipation, meconium discharge delay.
2, the digestive tract mucosa is stimulated: such as swallowing syndrome, stomach bleeding, stress ulcers, milk allergies.
3, digestive system inflammation: such as acute gastritis, acute enteritis, necrotizing enterocolitis, peritonitis.
4, digestive tract obstruction: most caused by congenital malformations.
1 upper gastrointestinal obstruction: esophageal tracheal fistula, esophageal atresia, esophageal hiatus hernia, gastric torsion, pyloric hypertrophic stenosis, annular pancreas, congenital diaphragmatic hernia.
2 lower digestive tract obstruction: such as poor intestinal rotation, intestinal deformity, intestinal stenosis, intestinal atresia, congenital megacolon, anal atresia, etc., rare diseases such as incarcerated hernia, intussusception and so on.
Systemic disease (30%):
Many systemic diseases can cause vomiting, and the following are common:
1, infection: neonatal infections often cause vomiting, such as sepsis, respiratory infections, urinary tract infections.
2, increased intracranial pressure: diseases that cause increased intracranial pressure can cause vomiting, such as central nervous system infections, cerebral edema, hydrocephalus, intracranial hemorrhage, intracranial tumors.
3, congenital metabolic diseases: some congenital metabolic diseases due to metabolic disorders leading to vomiting, such as amino acid metabolism disease hyperammonemia, phenylketonuria, glycineemia, glucose metabolism disease galactosemia, maple syrup Symptoms, adrenal hyperplasia and so on.
Other factors (10%):
Some non-disease factors can also cause vomiting in newborns.
1. Improper feeding: improper feeding is a common cause of vomiting in newborns, especially in infants and young children. The main reasons are: the frequency of feeding is too frequent, the amount of feeding is too much, the concentration is not suitable, the milk is too hot or too cold, and the milk is changeable. The nipple hole is too large or too small, the mother's nipple sinks; after the feeding, the supine position, the body position is hyperactive, due to excessive feeding, or swallowing too fast, swallowing air, etc., often occurs after the milking is completed.
2, drugs: Many drugs can cause digestive tract reactions, vomiting, such as erythromycin, amphotericin B and so on.
Pathogenesis
Vomiting is caused by a series of complex nerve reflexes in the digestive tract and other related organs. When the excitatory impulse of any part of the reflex arc increases or strengthens, vomiting occurs, causing neonatal vomiting. The reason is different from other age groups. The difference depends on the anatomy of the newborn, the physiological characteristics and the rapid changes in the internal and external environment after birth. It also depends on the organs in the embryonic period, especially the front and middle. Post-rectal differentiation and development, the vomiting center under the fourth ventricle and its higher center, stimulated by toxins produced by systemic inflammation or metabolic disorders, or elevated intracranial pressure, can cause vomiting, some common cases of internal medicine Caused by vomiting, such as swallowing amniotic fluid or birth canal blood at birth, stimulating gastric mucosa often cause vomiting, gastroesophageal reflux GER, is a common cause of neonatal vomiting, mainly with the lower esophageal sphincter of the newborn, relaxation of gastric emptying, Increased intra-abdominal pressure and other factors, vomiting caused by pyloric palsy, caused by temporary dysfunction of pyloric neuromuscular function, often appear shortly after feeding threw up.
The anatomical and physiological characteristics of the neonatal digestive system are esophageal relaxation, poor peristaltic function, horizontal vertical adult, small volume, loose upper and upper esophageal junctions, and pylorus at the lower end of the stomach and duodenum. Relatively tight, so that the esophagus and stomach shape like a long neck open bottle, the stomach is easy to flow back through the esophagus, intestinal nerve movement function is poor, poor adaptability, high susceptibility, secretion of gastric acid and protease The function is poor. Due to the above-mentioned various anatomical, physiological and postnatal environmental temperatures, nutrient intake, metabolism, excretion, etc., newborn babies, especially premature babies, are prone to vomiting.
Prevention
Neonatal vomiting prevention
If the mother should pay attention to breast care during pregnancy, the nipple depression should gradually pull out the teat so that the baby can suck the baby after birth. When feeding the bottle, pay attention to the nipple hole not too big, prevent the milk from being too urgent, overshoot Do not feed too much or the amount of feeding is too large. Do not let the baby cry too much before feeding. Do not suck the fake nipple with the eye. When feeding, make the milk in the bottle full of teats. This can prevent the baby from inhaling the stomach. More air causes vomiting. In addition, don't flip the baby too early after feeding. It is best to put the baby upright and gently pat the back so that he can play a few "full" and then put it back on the bed, so the baby is not easy. If vomiting occurs, it is best for the child who is prone to vomiting to raise his bedside and sleep on the head side to prevent suffocation or suffocation.
Complication
Neonatal vomiting complications Complications, neonatal asphyxia, sudden aspiration pneumonia
The main complications caused by vomiting are:
1. Asphyxia and sudden death: Newborn vomiting will cause vomit into the respiratory tract, suffocation, such as vomiting, not found in time can lead to sudden death.
2. Inhalation syndrome: Inhalation pneumonia can occur when vomit enters the airway, coughing occurs, breathing is difficult, and inhalation can cause prolonged inhalation pneumonia.
3. Apnea: apnea can occur in vomiting in premature infants.
4. Bleeding: Severe vomiting can cause damage to the gastric mucosa, bleeding occurs, and the vomit is bloody.
5. Water and electrolyte disorders: vomiting is more frequent, due to the loss of a large amount of water and electrolytes, resulting in water and electrolyte balance disorder, children with dehydration, acidosis, hyponatremia and so on.
Symptom
Neonatal vomiting symptoms common symptoms nausea and vomiting, abdominal distension, bowel, refusal to eat full abdominal pain and galactorrhea
1, galactorrhea
Most of the children have more or less co-existing galactorrhea in the neonatal period. The galactorrhea does not belong to true vomiting. There is no series of excitatory reflexes involved in neuromuscular involvement during vomiting. The galactorrhea can appear shortly after emergence. It means that 1 to 2 mouths of milk will flow back into the mouth or spit after feeding. Changing body position after feeding will also cause galactorrhea. The spilled ingredients are mainly white milk. If the milk stays in the stomach for a long time, it can contain milk clot. The galactorrhea does not affect the growth and development of the newborn, and gradually decreases with the increase of age. It disappears about 6 months after birth. It is generally believed that the cause of galactorrhea is caused by the development of the elastic tissue and muscle tissue of the neonatal esophagus. deal with.
2, swallowing movements are not coordinated
Does not belong to true vomiting, mainly seen in a premature infant, or in children with craniocerebral and cranial neuropathy, is a pharyngeal neuromuscular dysfunction, caused by uncoordinated swallowing movements, manifested as frequent secretions in the pharynx Partial retention, part of the milk enters the esophagus when swallowing, part of it flows out of the nasal cavity and mouth, and partially flows into the respiratory tract, causing neonatal pneumonia. The function of the premature baby gradually matures after several weeks or months, and can recover spontaneously, the prognosis of the nervous system injury. It depends on the recovery of the nervous system itself.
3, improper feeding
About 1/4 of the vomiting of the newborn, the frequency of feeding is too frequent, the amount of feeding is too much, the nipple hole is too large or too small, the nipple is sunken, causing a large amount of air to be inhaled, the teat is put into the mouth too much, irritating the pharynx, milk Too hot or too cold, milk changes and concentration is not suitable, crying after feeding, severe premature tumbling of children, etc., are easy to cause neonatal vomiting, vomiting can be light and heavy, not every time After vomiting, the vomit is milk or milk, and does not contain bile. The above situation occurs mostly in the first child, which is caused by the lack of feeding experience of the mother. The improved feeding method can prevent vomiting.
4, swallowing syndrome
About 1/6 of the vomiting of newborns. Under normal circumstances, the digestive tract has completely formed at the age of four months. The fetus swallows amniotic fluid to the gastrointestinal tract, and there is no obvious stimulation to the fetal gastric mucosa. Expired, dystocia, intrauterine distress or suffocation, fetal swallowing too much amniotic fluid, contaminated amniotic fluid, secretions in the birth canal or blood, can stimulate the stomach mucosa to cause vomiting, vomiting can be expressed as vomiting after birth, vomiting after feeding Exacerbation is non-ejection vomiting, vomit is foamy mucus, and bloody ones are brown liquid, more than 1 to 2 days after birth, the swallowed amniotic fluid and the contents of the birth canal are spit out, vomiting disappears. If there are no other complications, the child is generally normal, without cyanosis and cough, lighter does not require special treatment, and severe cases can be cured by washing the stomach with 1% sodium bicarbonate 1 or 2 times.
5, intragastric bleeding
Neonatal hemorrhagic disease, stress gastrointestinal ulcer, diffuse intravascular coagulation and other gastrointestinal bleeding, blood stimulation of the gastric mucosa can cause neonatal vomiting, often accompanied by symptoms and signs of primary disease, vomiting, choose A proper laboratory test can make a definitive diagnosis.
6, the role of drugs
Bitter taste drugs can stimulate the stomach mucosa to cause vomiting in newborns. For example, some Chinese medicine preparations, some drugs such as erythromycin, chloramphenicol, amphotericin B, ipecac syrup, calcium chloride, etc. can cause vomiting by itself. Naturally relieved after use, when pregnant women or nursing mothers use digitalis, imidin, etc., the drug can enter the newborn through the placenta blood or milk, causing neonatal vomiting.
7, infection
Vomiting caused by infection is the most common condition in neonatal medicine. The infection can come from the gastrointestinal tract or outside the gastrointestinal tract. It is more common in the gastrointestinal tract. Nearly all infections in the gastrointestinal tract can cause neonatal enteritis. Vomiting is Early symptoms of neonatal enteritis, vomit is the contents of the stomach, a few contain bile, followed by diarrhea, easy to combine with water, electrolyte imbalance, vomiting disappears after treatment, pathogens causing gastrointestinal infections in newborns including bacteria, viruses , fungi, etc., common bacteria are Escherichia coli, Salmonella, Proteus, golden yellow grape, etc., virus infection is most common with rotavirus, coronavirus, astrovirus, adenovirus, Coxsackie virus, ang It can also be caused by viruses, etc. The most common fungus in the fungus is the white fungus, which often causes neonatal thrush and fungal esophagitis, which directly causes neonatal vomiting. Fungal enteritis may cause neonatal diarrhea and vomiting. Due to the widespread use of antibiotics, fungal infections have an increasing clinical trend.
Vomiting caused by gastrointestinal infections is also common. All upper respiratory tract infections, bronchitis, pneumonia, umbilical inflammation, skin, mucous membranes, soft tissue infections, myocarditis, meningitis, urinary tract infections and sepsis can cause vomiting. Etc., the vomit is the contents of the stomach, generally without bile, and the vomiting disappears after the infection is controlled.
8, neonatal hepatitis
The incidence of neonatal hepatitis in China is high, so it is listed separately. Many kinds of pathogens can cause neonatal hepatitis, but most of them are caused by viral infection, mainly cytomegalovirus and hepatitis B virus, Epstein-Barr virus, bacteria. Listeria, Staphylococcus aureus, Escherichia coli, etc. can cause liver lesions, Toxoplasma gondii, Treponema pallidum and Leptospira can also cause neonatal hepatitis. Neonatal hepatitis occurs in Inner Mongolia Autonomous Region 28 days after birth, so most Infection may occur during intra-fetal delivery. Mother-to-child transmission is the main route of neonatal infection. Neonatal hepatitis is often slow and insidious. Some children present with jaundice, fever, liver enlargement, vomiting, and low appetite in the neonatal period. Some children are only vomiting, but a few of them can develop severe chronic liver disease. Individuals have severe symptoms, severe jaundice, terracotta stool, hepatosplenomegaly, ascites, and even Major bleeding, liver coma, etc.
9, neonatal necrotizing enterocolitis
At present, it is believed that infection plays a major role in the pathogenesis of this disease. It is more common in premature infants and low birth weight infants. It is mainly manifested by abdominal distension, diarrhea, vomiting and blood in the stool. The symptoms of infection are serious, and severe cases often have sepsis, shock, peritonitis. Intestinal perforation, X-ray plain film examination showed common flatulence of the intestine, stiff shape of the intestine, cystic gas accumulation in the intestinal wall, and accumulation of gas in the portal vein. In recent years, ultrasound examination of portal vein gas accumulation, intrahepatic vascular gas accumulation, and abdominal cavity accumulation Liquid, pneumoperitoneum, etc. are more sensitive than X-ray, and have become an important diagnostic tool for this disease.
10, gastroesophageal reflux
Many newborns have reflux phenomenon, but there are obvious signs of about 1 / 300 ~ 1 / 1000, the reason may be related to esophageal neuromuscular dysplasia, and sometimes with esophageal hiatus hernia, more than 90% of the children Vomiting can occur within the first week afterwards, often occurs when lying down, vomit is milk, does not contain bile, vomit can be mixed with blood, long-term gastroesophageal reflux, can cause reflux esophagitis and esophageal ulcer In the past, it was thought that taking a semi-recumbent position could reduce vomiting. The current study proves that the effect is not obvious. On the contrary, it may increase the occurrence of sudden infant death syndrome. Some people think that a small number of feedings can reduce the stomach contents and thus reduce gastroesophageal reflux. If there are no abnormalities in the anatomy, it can heal itself for several months after birth.
11, achalasia
Occurred in adolescence and adults, children before the age of 4 accounted for only 5% or less, manifested as intermittent dysphagia, milk spillage after feeding, slow weight gain, esophageal dilation in the perspective of barium meal, narrow cardia, no or less peristalsis of esophagus Waves, fluid levels are sometimes seen in the esophagus, with little or no gas in the stomach.
12, pyloric
For the temporary dysfunction of the pylorus, more than one week after birth, intermittent jet vomiting, not every time after the milk spit, vomit is milk, can have milk, no bile, for systemic nutrition The effect is small, the stomach type and peristaltic fluid are less common in the examination, and the enlarged pyloric sphincter is not touched by palpation, which is effective with atropine.
13, meconium constipation
98% of normal newborns are discharged meconium within 48 hours after birth. If they do not defecate or have a few bowel movements within a few days after birth, they will cause irritability, bloating, refusal of milk and vomiting. Vomiting contains bile, full abdominal bulging, sometimes Visible intestinal type, can touch dry hard feces, active bowel sounds, abdominal X-ray film full abdominal tube dilatation, visible liquid level and granular meconium shadow, anal examination can touch dry meconium, saline enema After a large amount of sticky meconium is discharged, the symptoms can be alleviated.
14, neonatal constipation
Mostly due to poor intestinal motility, a few newborns only have bowel movements once every 3 to 5 days. Milk is more common in feeding children. When constipation is prolonged, abdominal distension and vomiting occur. The characteristics of vomiting are similar to meconium constipation. Symptoms after laxation Lifted, and soon appeared again, most of them naturally eased after the full moon.
15, increased intracranial pressure
More common neonates, neonatal intracranial hemorrhage, intracranial hematoma, hypoxic ischemic encephalopathy, meningitis caused by various infections, encephalitis, etc., can cause increased intracranial pressure, vomiting when intracranial pressure increases Spray, vomit is milk or milk, generally does not contain bile, sometimes with brown blood samples, children often accompanied by irritability or lethargy, coma, screaming, fullness of the anterior humerus, cranial suture and other neurological symptoms and signs Give dehydration and reduce vomiting after reducing intracranial pressure.
16, genetic metabolic disease
Most have a family history
(1) Amino acid metabolism disorders include many diseases such as phenylketonuria, cysteineemia, congenital lysine intolerance, glycineemia, and valine-induced vomiting. There are various symptoms that are unique to the disease, such as light skin and hair color, special mildew in the urine, poor growth, coma, acidosis, nystagmus, etc. Blood tests can confirm the diagnosis.
(2) Glucose metabolism disorders such as galactosemia, maple glycemia, etc., normal at birth, vomiting, diarrhea, etc. soon after eating, and later jaundice, hepatomegaly, cataracts, etc.
(3) There are many types of congenital adrenal hyperplasia, such as 21-hydroxylase deficiency, 11-hydroxylase deficiency, 18-hydroxylase deficiency, 18-oxidase deficiency, 3-hydroxydehydrogenase deficiency, 17 Lack of hydroxylase, lack of 17,20 lyase, etc., of which 21-hydroxylase deficiency is the most typical, short-term after birth, drowsiness, vomiting, dehydration, electrolyte imbalance, acidosis, etc., the external genital sex is unclear, male penis is large Or hypospadias, cryptorchidism, baby girl with clitoris hypertrophy, part of the labia majora fusion like male genital hypospadias or cryptorchid scrotum, check plasma corticosteroids and its precursor steroids, such as cortisol, 17-hydroxyprogesterone , dehydroepiandrosterone, androstenedione can assist in diagnosis.
17, allergic diseases
Pediatric vomiting can occur when drugs are allergic to drugs, milk proteins, and legume proteins. Newborns are more commonly allergic to milk proteins, often 2 to 6 weeks after birth, mainly due to vomiting 24 to 48 hours after feeding milk. , bloating, diarrhea, stool contains a lot of milk pieces and a small amount of mucus, dehydration, malnutrition, etc., vomiting disappears after the milk is stopped.
18, esophageal atresia and esophageal tracheal fistula
The incidence rate is 1/3000-1/4500, premature infants account for about 1/3, the disease is divided into 5 types, type I, type II gastrointestinal tract is not inflated, III, IV, V type gastrointestinal tract are inflated, Clinically, the most common type III, accounting for 85% to 90% of all children, due to fetal esophageal atresia, can not swallow amniotic fluid, the mother often has too much amniotic fluid cough, bruising and aspiration pneumonia, and even suffocation, lower nose When the stomach tube is blocked or folded back from the oral cavity, X-ray examination can clearly observe the obstruction of the nasogastric tube, and at the same time, the position of the blind end can be understood. Further examination can be performed by injecting 1 to 2 ml of lipiodol angiography through the catheter, which can show the lock more clearly. At the same time, observe the presence or absence of fistula. After the filming, the iodized oil should be taken out in time to avoid inhalation into the trachea. The current reason for the low survival rate in the country is mainly due to the delay of diagnosis until aspiration pneumonia occurs, even after severe infection. Only after receiving treatment, some people advocate that the suspicious child in the delivery room under the nasogastric tube, you can get timely diagnosis and treatment, improve the survival rate of surgery.
19,
The incidence rate is 3.1/1000 in China and 1/2200 in foreign countries. The clinical classification is posterolateral hernia, posterior sternum and esophageal hiatus hernia. Lateral lateral hernia is also called thoracic and abdominal hernia, accounting for 70% to 90% of all hernias. On the left side, often accompanied by poor intestinal rotation, congenital heart disease and lung dysplasia, paroxysmal shortness of breath and cyanosis after birth, such as bowel insufficiency with bowel rotation or into the chest, the performance is intense Vomiting, severe systemic condition rapidly deteriorated, the mortality rate is very high, the upper abdominal depression is a boat-like appearance, abnormal breathing can be seen, X-ray examination can confirm the diagnosis, inflated intestinal tract and stomach bubble, atelectasis, Displacement of the mediastinum to the contralateral side, reduction or lack of abdominal inflation, surgical treatment of posterior lateral ankle emergency, the issue of timing of surgery is still controversial, because often combined with other malformations, the mortality rate is still relatively high.
20, esophageal hiatus hernia
It is a congenital diaphragmatic muscle development defect, which causes part of the stomach to enter the thoracic cavity through the esophageal hiatus. Esophageal hiatus hernia is divided into esophageal hiatus sliding hernia, esophageal paralysis and mixed type, 85% of children have vomiting within the first week after birth, 10 % occurs within 6 weeks after birth, does not vomit during standing position, vomiting is obvious when lying, may be jet vomiting, vomit is milk, may contain brown or brown blood, and some children may cause secondary pyloric fistula Clinically, it is very similar to pyloric hypertrophic stenosis. One third of infants can have aspiration pneumonia. Gastric ulcer can occur in esophageal fistula. Occasionally, gastric necrosis can occur. Emergency surgery is needed. Vomiting can last from 12 to 18 months. Most children When the body is upright, it can disappear. The diagnosis mainly relies on X-ray examination. The meal can be diagnosed by sputum stomach bubble or gastric mucosa. Sliding sputum can disappear in the process of infant growth and development. Generally, body position therapy is used to treat severe anemia. Obstacles, large intragastric or small esophageal fistula, advocate surgical treatment.
21, hypertrophic pyloric stenosis
The third place of congenital digestive tract malformation, the incidence rate is 0.3/1000-1/1000, the incidence of male infants is high, the ratio of male to female is 4:1, more common in term infants, there is genetic tendency, vomiting begins in the second after birth. Around week, vomiting is persistent, progressive, and gradually develops into jet vomiting. The vomit is milk and milk, a large amount, sour smell, bile, vomiting shortly after each feeding or during feeding. Appetite is good, hunger is strong, after repeated vomiting, the child's weight does not increase, the urine and urine are reduced, the abdominal examination can be seen with obvious stomach type and smoothness, and the gastric peristaltic wave in the opposite direction can be touched on the right side of the lower rectus abdominis. Olive-sized hard mass, hypertrophic pyloric sphincter, dehydration, hypoxemia, hypokalemia and acid-base balance disorder in severe vomiting, gastric enlargement in barium meal, prolonged gastric emptying, typical pyloric The change of the beak-like, and the narrow and prolonged pyloric can be diagnosed. In recent years, in the diagnosis of hypertrophic pyloric stenosis, ultrasonography has a tendency to replace the barium meal examination. Ultrasound can directly see the hypertrophic pyloric sphincter. Standard pyloric muscle thickness or length exceeding 4mm pyloric than 14mm can be diagnosed, surgical treatment after diagnosis to good effect.
22, pyloric front diaphragm
For less congenital dysplasia, the diaphragm is located 1.5 to 3 cm away from the pyloric palpebral, most of the diaphragm has a hole in the center, and the phenomenon of complete obstruction of the upper digestive tract occurs after the non-porous septum. When the diaphragm hole is small, it can develop in the neonatal period. Excessive vomiting after eating, often sprayed, vomiting traits and content similar to hypertrophic pyloric stenosis, but the palpation of the abdomen can not reach the mass, the pyloric tube can not be seen in the barium meal examination, bending and duodenal bulb pressure The characteristics of hypertrophic pyloric stenosis such as traces can be seen in the stenosis 1 to 2 cm before the pylorus. The disease needs surgical removal of the diaphragm.
23, stomach twist
Gastric torsion is divided into two types: organ axis type torsion and retinal axis type torsion are more common in organ axis type, accounting for about 85%. Neonates are prone to stomach ligaments and stomach is horizontal, so it is prone to gastric torsion. After birth, there is a history of spitting milk or overflowing milk. It is also possible to start vomiting within a few weeks after birth. The vomiting is different, and it is spray vomiting or non-spray vomiting. It is often vomiting after milk, and it is more common when the child moves after milk. Obviously, vomit does not contain bile, vomiting can affect growth and development, vomiting can be stopped after barium meal, and patients with severe symptoms undergo gastric fixation.
24, congenital intestinal atresia
Is a common cause of intestinal obstruction in the neonatal period, accounting for 1/3 to 1/4, more than male infants, the incidence rate is 1 / 1500 ~ 1 / 2000, low birth weight infants account for 1 ~ 3, atresia can occur in Any part of the intestine, with the most ileum, accounting for 50%, the duodenum accounted for 25%, the jejunum is less, the colon is rare, some children with other malformations, such as esophagus can be divided into membrane type, cable type, two-stage type And multiple hair styles, which occur in the upper part of the duodenum and jejunum, are called high intestinal atresia, mostly membrane type. When there is high position, there is often a history of polyhydramnios. The higher the atresia, the earlier the vomiting occurs, duodenal atresia. Vomiting occurs when the first feeding occurs, and the vomit is the contents of the stomach and duodenal secretion. Except for a few cases of closure at the proximal end of the ampulla, most of the vomit contains bile, with the number of feedings. Increased, children with vomiting gradually increased, persistent repeated vomiting, a small amount of feces can be discharged, abdominal distension or mild bulging, occurs in the lower jejunum, ileum and colon called low intestinal atresia, low intestinal atresia For bloating, vomiting often begins 1 to 2 days after birth, and vomit is present. Fecal-like, odorous, meconium-free or mucus-like meconium, when the high intestine is locked, the anteroposterior fluoroscopy or radiograph can be seen in 2 to 3 liquid levels, called the two-bubble sign or the three-bubble sign. In the low intestinal atresia, multiple enlarged intestinal fistulas and fluid levels can be seen. The lower intestinal tract is not inflated, and the fetal colon is visible in the barium enema. Surgical treatment is the only effective method, but the mortality rate is still high. One of the reasons is Children often have other malformations. On the other hand, they are diagnosed too late. Children often die from secondary intestinal perforation, peritonitis, intestinal necrosis, and aspiration pneumonia. Therefore, some people advocate that when the amniotic fluid is too much, the lower stomach tube will be taken immediately after birth. If you take out 15 to 20 ml or even more bile-contaminated gastric juice, you should take active measures to prompt upper gastrointestinal obstruction.
25, intestinal stenosis
Less common in intestinal atresia, mostly membranous stenosis, duodenum occurs most, followed by ileum, jejunum, colon is less common, the higher the site of stenosis, the earlier the symptoms appear, the more obvious the stenosis, the symptoms The more serious, the main symptoms are vomiting and bloating. Most vomits contain bile, which can be discharged from normal stools. The upper intestinal stenosis is bulging in the upper abdomen, and the gastric fluid peristaltic wave is seen. The lower intestinal stenosis is full bloating, and the intestinal type and intestinal peristalsis are visible. With bowel sounds hyperthyroidism, abdominal X-ray examination showed enlargement of the upper end of the stenosis, barium meal angiography can confirm the diagnosis, positively improve the general condition of the child after diagnosis, and perform partial stenosis.
26, poor intestinal rotation
It is a common digestive tract malformation, accounting for the fourth place in the domestic digestive tract malformation, more than 70% of the symptoms appear in the neonatal period, 30% occur in the low birth weight infants, in the embryo about 10 weeks, the midgut returns to the abdominal cavity During the process, there is a counterclockwise rotation from left to right. The rotation of the midgut can stop the rotation of the intestine at any time. Due to the different timing of the rotation, the following conditions can occur in the neonatal period:
1 The cecum is located in the middle upper abdomen or the right upper abdomen. The cecum or the cecal ligament from the cecum to the right posterior abdominal wall compresses the second and third parts of the duodenum, causing incomplete obstruction.
2 The cecum is located in the upper abdomen or the middle abdomen, and the small mesenteric root is not fixed in the posterior abdominal wall, which is prone to intestinal torsion.
3 The cecum has reached the right lower abdomen, but the mesentery has not completely merged with the posterior abdominal wall to form a "swimming cecum", which is prone to colonic torsion and causes incomplete intestinal obstruction.
4 In a small number of cases, the duodenal fistula is located in front of the mesenteric artery. The first segment of the jejunum is entangled by the peritoneal ligament and compressed to form an incomplete obstruction of the jejunum.
5 The intestine reverse rotation, so that the small mesentery is located in front of the transverse colon, causing obstruction of the transverse colon. Due to the diversified pathological structure, the clinical manifestations are very different. A few cases can be asymptomatic for life, and most of the symptoms appear in the neonatal period, mainly as High incomplete obstruction, usually vomiting 3 to 5 days after birth, vomiting can be intermittent, light and heavy, vomit is milk, contains bile, fetus excretion after birth, such as torsional reduction, the symptoms disappear If gastrointestinal bleeding occurs, suggesting intestinal necrosis, followed by intestinal perforation and peritonitis, positive peritoneal irritation, toxic shock, etc., if not timely surgery, can die in a short period of time, X-ray standing film visible stomach and Duodenal dilatation, there are double bubble sign, jejunum, oligo or lack of gas in the ileum, barium enema shows that most of the colon is located in the left abdomen, the cecum is located in the left upper abdomen or mid-abdominal can be diagnosed.
27, meconium peritonitis
Intestinal perforation during fetal period causes meconium to flow into the abdominal cavity, causing peritoneal asepticity, chemical inflammation, called meconium peritonitis, clinical manifestations vary depending on the time of intestinal perforation, combined with X-ray characteristics, usually divided into three types :
1 intestinal obstruction type, you can see obstructive symptoms after birth, such as vomiting, refusal of milk, bloating, constipation, etc. X-ray standing film can be seen enlarged in the intestine, accompanied by multiple liquid levels, visible calcification plaque.
2 peritonitis type, due to intestinal perforation until birth is still open, quickly cause suppurative peritonitis or pneumoperitoneum after birth, according to the type of pneumoperitone can be divided into two types, one is free pneumoperitoneum, intestinal perforation is open, suffering General condition is poor, may be accompanied by dyspnea and purpura, abdominal distension is significant, abdominal wall is red, bright, abdominal wall varicose veins, sometimes peritoneal effusion can be drained to the scrotum, causing redness and swelling of the scrotum, abdominal percussion is drum sound and mobile dullness, The bowel sounds are reduced or disappeared, the calcification of the abdominal X-ray film is visible, sometimes the calcification point is also seen in the scrotum, and the other is the limited pneumoperitoneum. The intestinal perforation is wrapped by cellulose adhesion to form a mask cyst, which contains effusion. And gas, pseudo-cysts on the wall or other parts of the abdominal cavity can be seen calcification, this type can develop into diffuse peritonitis or localized abdominal abscess.
3 latent intestinal obstruction type, intestinal perforation has been closed at birth, but intestinal adhesions in the abdominal cavity, manifested as recurrent intestinal obstruction after birth, abdominal X-ray film visible calcification, mild fasting, gastrointestinal decompression , enema and other treatments, can be alleviated, if the symptoms of pneumoperitoneum or intestinal obstruction can not be alleviated, surgery should be treated as soon as possible.
28. Congenital megacolon
Is a common digestive tract malformation, accounting for the second place in the digestive tract malformation, the incidence of our country is about 1 / 2000-1 / 5000, the ratio of male to female is 4:1, there is a family morbidity, due to the colonic terminal wall muscle Interstitial plexus hypoplasia, no ganglion cells, the affected intestines are often in a paralyzed state and narrow, feces accumulate in the proximal colon, the intestinal wall is dilated and thickened above the stenosis, resulting in a huge colon, according to the extension of the ganglion-free intestinal segment The range can be divided into 5 types:
1 short segment, the lesion is limited to the lower end of the rectum, accounting for about 8%.
2 common segment type, the most common, lesions from the anus up to the distal end of the sigmoid colon, accounting for about 75%.
3 long segment type, the diseased intestine segment extends above the descending colon, accounting for about 20%.
4 total colon type, lesions including the entire colon and ileum end, accounting for about 2%.
5 no ganglion cell syndrome in the whole intestine, less common, the first symptom is delayed meconium discharge, constipation, about 90% of cases have no fetus discharge within 24 hours after birth, most of them have low intestinal obstruction symptoms 2 to 6 days after birth. Vomiting, the number of vomiting gradually increased, vomit contains bile or fecal-like substances, abdominal bulging, skin brightening, venous engorgement, visible intestinal type and peristaltic waves, bowel sounds hyperthyroidism, anal finger diagnosis rectal ampulla emptiness, and can feel A narrowing ring, when the finger is withdrawn, a large amount of feces and gas are discharged with the finger, the pressure is very large, and the blast is discharged, and the symptoms are relieved. After a few days, constipation, vomiting, and abdominal distension occur again, often requiring bowel or finger washing. The diagnosis can be relieved again. In the advanced stage, enterocolitis can be complicated, intestinal perforation, etc. X-ray standing abdominal examination shows that the intestine is generally flatulent, and the rectum is not inflated. The barium enema is the main diagnostic method. The rectum is seen, and the distal end of the sigmoid colon is narrow. The proximal and descending colon of the sigmoid colon is obviously dilated, and the peristalsis is weakened. After 24 hours, the colon is often left with expectorant retention. The rectal pressure test shows that the pressure in the anal canal is continuously increased. Biopsy and electromyography are also helpful for clinical diagnosis, but less in newborns. For patients with mild and undiagnosed, medical therapy can be used, that is, daily or every other day with warm saline to avoid fecal deposition. The special dilator expands the intestines once a day. In recent years, it advocates the use of one-stage radical surgery in the neonatal period, which can achieve better results. For children with concurrent infection or poor general condition, medical therapy should be used first. After the general condition of the child is improved, the radical operation is performed.
29, anal and rectal malformations
Mainly refers to the anal and rectal atresia or stenosis, is the highest incidence of gastrointestinal malformations in the neonatal period, about 0.75/1000, clinical can be divided into 4 types,
1 anal stenosis.
2 anal membrane lock, the anal skin and the rectum are separated by a membrane, which is a low anal atresia.
3 anorectal hypoplasia, there is only one depression in the anus, there is a considerable distance between the rectum and the anal depression, which is a high anal atresia.
4 rectal atresia, anus, anal canal normal, but there are different distances between anal canal and rectum, clinically less common, about 50% of anorectal atresia combined with various fistulas, male infants have rectal bladder spasm, rectal urethra The sputum and rectum will be paralyzed, the baby girl has rectal vaginal fistula, rectal vestibular palpebral and rectal perineum, etc., children with anal and rectal malformations often have genitourinary malformations and other parts of the digestive tract, due to the deformity of the child. More, combined with fistula or other malformations, clinical manifestations are also different, anorectal atresia, no fetus excretion after birth, and later gradually appear low intestinal obstruction symptoms, such as bloating, vomiting, vomit with bile and fecal-like substances, symptoms gradually Exacerbation, most children can be found without anal or anal abnormalities by careful examination. Clinical suspicious cases can be examined in the inverted position after 24 hours of birth. The children will be headed before the filming. Inverted for a few minutes, a metal marker on the skin of the anal depression, you can determine the type of lock and the position of the lock, the intestine End and anal folds are low-level at least 2cm, the operation is relatively simple, more than 2cm is called high-level atresia, the operation is more complicated, such as combined fistula can be used for fistula angiography, ultrasound can also accurately detect the rectal blind end and anus skin Distance, anal stenosis can be treated with anal sphincter, and other types require surgery.
Examine
Neonatal vomiting check
Laboratory inspection
1. Blood: When vomiting causes aspiration pneumonia and prolonged unhealed, there may be infectious blood, such as vomiting caused by infection, such as sepsis, respiratory infection, urinary tract infection, etc., also infectious blood.
2. Blood gas analysis and blood biochemical examination: can understand whether the child has acidosis, electrolyte imbalance, blood sodium, potassium, chlorine and liver function, etc., can be combined with specific conditions.
3. Urine, routine: should do urine, routine and fecal occult blood test.
4. Cerebrospinal fluid examination: central nervous system infection or intracranial hemorrhage, cerebrospinal fluid examination has a corresponding change.
5. Endocrine and genetic metabolic disease examination: If the digestive tract, central nervous system and other diseases have been excluded, and the child is still frequently vomiting, further examination should be done for endocrine and metabolic diseases. Some congenital metabolic diseases cause vomiting due to metabolic disorders. Such as amino acid metabolic diseases (hyperammonemia, phenylketonuria, glycineemia), glucose metabolism diseases (galactosemia, maple syrup), adrenal hyperplasia, etc., should be used as blood ammonia, blood glucose and other related laboratories an examination.
Auxiliary inspection
1. X-ray inspection:
1 Abdominal fluoroscopy and radiography: Abdominal fluoroscopy and radiography are the most commonly used diagnostic methods for neonatal vomiting. In order to better observe the flatulence and fluid level of flatulence, vertical fluoroscopy and radiography should be used, or lateral position should be used. Horizontal projection method.
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Differential diagnosis
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BCT
