Neonatal vomiting and blood in stool
Introduction
Introduction 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.
Cause
Cause
False factors:
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 :
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 diseases:
(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 bleeding occurs, the iron in the blood hemoglobin is combined with the sulphide in the intestine by the action of bacteria and enzymes to become iron sulphate, so that the stool is black tar-like stool; When too much and quickly pass through the intestines, red blood can also be present, and the amount of bleeding often reaches 40ml or more.
Examine
an examination
Related inspection
Blood routine abdominal plain film
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
Differential diagnosis
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.
