Ulcer and necrotic coloenteritis

Description:

Necrotic coloenteritis of newborns — the nonspecific inflammatory disease caused by infectious agents against the background of immaturity of mechanisms of local protection and/or hypoxemic - ischemic damage mucous intestines, inclined to generalization with development of system inflammatory reaction. By D. Kloerti (2002) definition, NEK — an acute necrotic intestinal syndrome of not clear etiology.

Snowballing of a neonatology and resuscitation made possible survival of the children who were born deeply premature, had a hypoxia in labor and having signs of pre-natal or intranatal infection, and also born with heavy inborn malformations of digestive tract and/or cardiovascular system. The vast majority of these children (90%) — premature with body weight less than 1500 therefore NEK call "a disease of survivors premature".

In the period of a neonatality of NEK meets in 2–16% of cases depending on gestational age, about 80% from them are the share of premature children with low body weight at the birth. Occurs at premature NEK in 10–25% of cases. Incidence of NEK at newborns, according to various authors, is ranging from 0,3 to 3 on 1000 children. Rate of mortality is much higher in group of premature newborns, among children with a syndrome of a delay of pre-natal development and fluctuates ranging from 28 to 54%, and after operative measures — 60%, despite intensive joint efforts of neonatolog, children's surgeons, intensivists, and also development of modern technologies of nursing and treatment of newborns. In the countries where the level of the birth of premature children low (Japan, Switzerland), NEK meets less often — frequency of 2,1% among all children coming to neonatologichesky intensive care units.

Symptoms of the Ulcer and necrotic coloenteritis:

Clinical signs of NEK can be divided conditionally on system, abdominal and generalized.

Treat system: respiratory distress, apnoea, bradycardia, lethargy, thermolability, excitability, bad food, hypotension (shock), decrease in peripheral perfusion, acidosis, oliguria, bleeding.

To abdominal — swelling and a hyperesthesia of a stomach, stomach aspirates (the food remains), vomiting (bile, blood), impassability of intestines (easing or disappearance of intestinal noise), an erythema or hypostasis of an abdominal wall, the constant localized weight in a stomach, ascites, bloody stools.

The fulminant current of NEK is characteristic of the full-term newborns who had in labor asphyxia, an injury of a head and/or spinal cord, a hemolitic disease and at defects of a GIT. The apnoea and the need for respiratory support are typical, disturbances of fabric perfusion or acute cardiovascular insufficiency are possible. There are vomiting or large residual volume in a stomach before feeding. Gregersen's reaction positive. Sometimes considerable impurity of blood in a chair.

The acute current of NEK is characteristic of premature newborns with body weight at the birth less than 1500. The disease begins on the 2-4th weeks of life with pronounced symptoms from an abdominal cavity: vomiting and vomiting, refusal of food, abdominal distention, disturbance of a passage on intestines. Soon the somatic symptoms testimonial of intoxication and dysfunction of vitals and systems join.

Subacute current of NEK usually for premature children with extremely low body weight. The symptomatology develops gradually from 3rd week of life. Early symptoms — emergence of an intolerantnost to an enteroalimentation and change of character of a chair. The meteorism, but a stomach often soft is usual at a palpation, muscle tension of an abdominal wall can be absent, and at auscultation it is possible to find noise of a vermicular movement. Such patients demand the immediate beginning of therapy and inspection (frequent roentgenograms and a research of a chair on the occult blood). For lack of treatment this NEK form demonstrates heavy system and radiological symptomatology usually within 24–36 hours.

Among the given diagnostic tests and informative changes in a gemogramma (a leukocytosis / leukopenia, shift of a leykoformula to the left, thrombocytopenia), increase in the S-reactive protein, acidosis, an electrolytic imbalance, an intersticial pneumatosis and gas in portal venous system according to ultrasonic and radiological researches of abdominal organs are the most constant.

For definition of stages of NEK in addition to the above described criteria criteria Bella in Walsh and Klyaygman's modification are used.

Generalized symptoms remind septic process and are expressed by slackness, hypotonia, pallor, a respiratory distress, an oliguria, persistent cyanosis and bleeding. The more the listed generalized signs are expressed, the disease severity is more.
Early symptoms of a disease are not specific and variable — from intolerantnost signs to an enteroalimentation to a catastrophic current with a clinical picture of sepsis, shock and peritonitis. The syndrome of oppression of TsNS, an apnoea and signs of the broken perfusion of fabrics — a positive symptom of "a white spot", peripheral cyanosis, acidosis, a hyperglycemia, temperature instability dominate. The meteorism, a delay of evacuation of gastric contents, diarrhea, a chair with blood impurity are usual.

The progressing process is shown by an erythema and puffiness of an abdominal wall, the growing tension of abdominal muscles. Identification at a deep palpation of a stomach of dense masses demonstrates the covered perforation of intestines or widespread peritonitis. At auscultation there are no noise of a vermicular movement, but physical data are very poor.

Reasons of the Ulcer and necrotic coloenteritis:

NEK of a multifaktorialn. It is considered that NEK — a heterogeneous disease and its main components are the ischemia postponed in the perinatal period, abnormal colonization of intestines of the newborn and inadequate character of food of the child in the early post-natal period.

Risk factors of development of NEK: perinatal asphyxia (deterioration in blood supply of intestines due to increase in blood supply of a brain and heart), catheterization of an umbilical artery (a vasospasm and a thromboembolism), a polycythemia (reduction of a blood-groove in intestines vessels), arterial hypotension (decrease in a blood-groove in intestines), immaturity of immune system, nutritious mixes (are substrate for growth of microorganisms, at an enteroalimentation of NEK develops more often), a direct bacterial invasion, use of hypertonic salt solutions, direct injury of a mucous membrane of intestines), an allergy to milk, absence of IgA in milk (Gomella, 1998). In emergence of NEK play a role: prematurity, the postponed hypoxia in the anti-and intranatal period, the infectious reasons, food problems, existence of inborn and hereditary pathology, preferential digestive tract.

Treatment of the Ulcer and necrotic coloenteritis:

First of all at dysfunction of breath additional supply of oxygen or artificial ventilation of the lungs is provided. At disturbance of a hemodynamics blood circulation support — completion of OTsK is carried out. Freshly frozen plasma at the rate of 10 ml/kg of body weight as she is the only donator of antithrombin-III and a source of other blood-coagulation factors is for this purpose used. Low doses of a dopamine (2–5 mkg/kg/min.) are applied to normalization of a renal and intraorganic blood-groove. At disturbance of an acid-base homeostasis there can be a need of administration of sodium bicarbonate.

The essential moment under the authority of newborns with this pathology in many respects defining an outcome and the forecast of a disease is the termination of all types of enteral feeding, including giving medicines of per os, correctly carried out full parenteral food (FPF) through a peripheral vein.

Transition from PPP to natural feeding — process long, multi-stage, being in direct dependence on weight of a current and stage of NEK. The enteroalimentation renews in 3–5 days after normalization of evakuatorny function of a stomach, a X-ray pattern and disappearance of clinical symptoms of dysfunction of digestive tract that comes usually by 10-12th day from the beginning of a disease. Since the distilled water or solution of glucose, gradually it is necessary to pass to the mixes divorced by 4 times. At achievement of 50% of volume of enterally entered mix of the total amount of liquid it is necessary to pass to cultivation 1: 2, and then 3: 4 up to the full volume. Thus, the child with NEK passes the following stages of food: the full parenteral, combined parenteral food and artificial enteral (EIP), full EIP, additional EIP and natural feeding, is also in conclusion transferred to natural feeding.

Considering requirements to the mixes applied as enteral artificial nutrition and also the fact that against the background of long antibacterial therapy heavy dysbacteriosis and secondary insufficiency often develop, especially after heavy reconstructive operations, it is recommended to use as the first mix delactosed and hypolactose mixes like Nutrimigen, "Nutrisoya", Alpr, Alfare, Pregestimil, Nenatal, etc. It allows to reduce considerably processes of fermentation in intestines, to improve digestion and absorption of ingredients.

Vitamins, electrolytes (except potassium), microelements are included into the scheme PPP from first days.

Obligatory component of therapy are antibiotics of a broad spectrum of activity. Preference is given to generation cephalosporins III in combination with aminoglycosides. An alternative to them are imipenema with metronidazole.