Intestinal enterocolitis in newborns: necrotizing, ulcerative

Enterocolitis in newborns is not so common, but its complications are very serious and the child may suffer throughout life. It is very important to know the main causes of the disease and prevent enterocolitis. Treatment of this pathology includes several stages and implies the peculiarities of the child's diet in the future.

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Epidemiology

Statistics on the prevalence of enterocolitis in newborns indicate that this pathology occurs in less than 2% of healthy full-term babies, but more than 95% of cases of this pathology are premature babies with low and extremely low body weight. Both the prematurity factor and body weight play an important role in the development of enterocolitis, because the lower these indicators, the more often such babies develop intestinal damage. Among children who are in the intensive care unit, about 7% may later have enterocolitis.

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Causes enterocolitis in newborns.

The causes of enterocolitis in newborns are not limited to a few points, but are continuously associated with the pathogenesis of the disease. The most significant cause of enterocolitis can be considered the population of the intestine with pathogenic microorganisms. Under normal conditions, the intestines of a healthy newborn baby begin to be colonized with microorganisms a few hours after birth. When a child is born healthy, he is placed on his mother's stomach for contact with her skin. This moment is very important, since this is the factor in the colonization of the skin and mucous membranes of the child with beneficial flora. On the mother's skin there are bacteria familiar to the child, which help to colonize not only the skin, but also the intestines. These bacteria enter the intestines and are the first to colonize it. In the first few days, coccal microorganisms are detected in the child in small quantities. Already after three days, due to the beginning of breastfeeding, lactobacilli and bifidoflora appear in the intestines. When it comes to premature babies, these phases of colonization are disrupted. At the same time, many pathogenic microorganisms appear in the intestines. They come from the amniotic fluid, the external environment, and also from contact with medical instruments and hospital flora. Gradually, these microorganisms multiply and there are more and more pathogenic cocci and bacilli. They cause an inflammatory process in the intestinal mucosa, which spreads to all parts of the intestines. After all, in newborn babies, the inflammatory process cannot be limited due to the weakness of local and systemic protection.

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Risk factors

Such causes can develop against the background of various factors. The main risk factors for the development of enterocolitis in newborns are the following:

• hypoxia and asphyxia of newborns leads to circulatory failure in all organs;
• congenital malformations and lung diseases that are accompanied by persistent gas exchange disorders;
• hypovolemic shock and hypotension reduce pressure in the superior mesenteric artery and increase intestinal ischemia;
• breech birth and multiple pregnancy increase the risk of prematurity;
• severe hemolytic conditions and exchange transfusion surgeries;
• congenital heart defects with insufficient cardiac output reduce the blood supply to the intestine;
• congenital intestinal anomalies, congenital intestinal obstruction, Hirschsprung's disease;
• postoperative period with interventions on other organs and systems;
• complicated pregnancy with severe gestosis, chronic fetoplacental insufficiency;
• polycythemia;
• the use of certain medications.

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Pathogenesis

The pathogenesis of enterocolitis in newborns is not limited to a simple inflammatory process in the intestine. Violation of normal nutrition is one of the links in the pathogenesis of necrotic changes. After all, a healthy full-term child is inclined to be breastfed immediately. If the child is premature, the intestinal mucosa cannot immediately accept enteral nutrition and the early start of such nutrition can increase inflammatory changes. And this can be one of the important reasons for the development of enterocolitis and the increase in inflammatory changes.

Ischemic changes are the third important cause of enterocolitis. Insufficient blood circulation in the intestinal arteries leads to disruption of normal epithelialization of the intestinal mucosa. Such ischemia further increases inflammation and maintains necrotic changes in enterocolitis.

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Symptoms enterocolitis in newborns.

The first signs of enterocolitis may appear in the second week of the baby's life, but they may also first appear in the first three months. Everything depends on the intrauterine age of the child - the smaller the child and its weight, the later the pathology develops.

Depending on the course of the process, there are different types of enterocolitis: fulminant, subacute and acute enterocolitis. The stages of development depend on this type and the symptoms are also characteristic of a separate type of pathology.

Symptoms of enterocolitis in newborns with a lightning course develop very quickly. Everything begins on the 3rd-5th day of the child's life. As a rule, such lesions are susceptible to children with congenital pathologies or intestinal diseases. The entire clinical picture develops very quickly - over 5 days - which often leads to a fatal outcome.

Acute enterocolitis develops over several days and has successive stages. In the first stages, the intestinal mucosa of a certain area is affected. In this area of the intestine, inflammation occurs with difficulty in blood circulation throughout the intestine, which increases ischemia. Then the process spreads to the distal areas of the intestine, which increases clinical manifestations. In the last stage, necrotic areas form along the entire length of the intestine, which leads to perforation.

Necrotic enterocolitis in newborns develops against the background of a long-term inflammatory process in the intestine. The first symptoms appear in the child in the form of digestive disorders. Vomiting is the most common symptom of this pathology. The child does not digest food and vomits almost everything. Any feeding ends with profuse vomiting of all the food eaten. Since there is an inflammatory process, there are also systemic manifestations - the body temperature may rise. But children do not always react with such a symptom, so it is not the key one. The stool is disturbed in the form of diarrhea. It has a mucopurulent nature, and then, with massive damage to the mucous membrane, streaks of blood may appear.

Such intense inflammation in the intestines disrupts the absorption of nutrients, so the child does not gain weight, and eventually loses it. He refuses to eat, since the digestion process brings him a lot of unpleasant sensations. The abdomen is constantly bloated, colic bothers and therefore the newborn is capricious. Often the abdomen feels hard and does not respond to palpation.

Subacute course of the disease is characterized by a gradual increase in these symptoms. Episodes of abdominal distension may be periodic, and the child may not gain weight well. With such a long-term inflammatory process, intestinal obstruction may develop.

Ulcerative enterocolitis in newborns develops against the background of long-term inflammatory processes, and at the same time, ulcers of varying depths form on limited areas of the mucous membrane, which can subsequently perforate.

It often happens that ulcerative and inflammatory changes are not expressed, and only infectious damage prevails. The causative agent of such inflammation is most often staphylococcus. Staphylococcal enterocolitis in newborns is characterized by the clinical picture of an infectious lesion of the intestine. In this case, the symptoms characteristic of any intestinal infection prevail - vomiting, diarrhea, dehydration, impaired absorption and weight loss.

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Complications and consequences

The consequences of enterocolitis can be very serious, because intestinal perforation is one of the most common manifestations. Untimely diagnosis and treatment can lead to death. Children after enterocolitis have a very difficult rehabilitation stage, since the normal state of the intestine is disrupted, and the necessary flora is not there for a long time. This is manifested by persistent functional disorders in the child in the neonatal period and during the first year of life. If there was surgical intervention on the intestine, then frequent complications can be adhesive processes, which subsequently lead to the development of intestinal obstruction.

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Diagnostics enterocolitis in newborns.

Timely diagnostics allows to determine the treatment tactics in time and prevent the development of complications. Therefore, the earliest diagnostics is the main task.

Since most cases of ulcerative necrotic enterocolitis in newborns occur in premature babies, such children are still in the intensive care unit. Therefore, diagnostics should begin there, with a thorough examination of the child and his/her examination during dynamic observation every three hours.

Symptoms that may suggest intestinal damage are vomiting, diarrhea, and bloating. The tummy is hard upon examination and palpation, causing discomfort to the baby.

The tests do not allow to accurately determine the pathology and its localization. Therefore, instrumental diagnostics of enterocolitis in this case is a priority in diagnostics.

Radiography and ultrasound diagnostics are the priority methods in diagnosing enterocolitis in newborns.

Direct radiography allows us to determine several symptoms characteristic of enterocolitis. When only infiltration and inflammation of the mucous membrane occurs, we can determine increased pneumatization of intestinal loops, enlargement of the liver due to impaired blood circulation, and unequal expansion of various sections.

When changes in the intestine are accompanied by ischemia, a certain part of the intestinal loop may become immobile due to deep changes in its wall. In this case, in the lateral position on the radiograph, this loop will be immobile, as well as in the direct projection.

If diagnostic radiography is performed at the stage of deep wall damage, then pneumatization covers all areas of the intestine. And even in the intestinal wall, gas areas can be identified when it enters the abdominal cavity through the wall. At the stage of perforation formation in enterocolitis, air from the intestine enters the abdominal cavity and is determined on the radiograph already in the liver area.

Ultrasound diagnostics, in addition to increased air content, allows one to determine thickening of the intestinal wall. For enterocolitis, the most constant echographic symptom is the presence of intestinal loops overstretched with liquid contents. At the initial stages, this may be the only symptom that allows one to diagnose enterocolitis. A sign of deterioration in the child's condition may be dilation of the portal vein and detection of air there according to the results of an ultrasound examination.

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Differential diagnosis

Differential diagnostics of enterocolitis should be carried out when the first symptoms appear, as they may be similar to other diseases. It is very important to differentiate enterocolitis from congenital intestinal anomalies, Hirschsprung's disease, congenital or acquired intestinal obstruction, intestinal intussusception.

Hirschsprung's disease is the absence of nerve endings in the intestinal mucosa. In the neonatal period, the main manifestations of the disease may be diarrhea combined with symptoms of functional intestinal obstruction.

The characteristic symptoms of the disease are similar to those of enterocolitis: constipation alternating with normal stool or diarrhea (due to the addition of enterocolitis), vomiting, and intoxication. With this course of the disease, persistent diarrhea syndrome is quite typical, but there are no pronounced necrotic changes in the intestine, as with enterocolitis. There is also no inflammatory process in the intestine with Hirschsprung's disease, and it is not possible to isolate any pathogenic microorganisms during bacteriological examination.

Incomplete intestinal rotation is one of the congenital intestinal anomalies, with which enterocolitis must be differentiated. The first sign of volvulus with incomplete rotation is sudden vomiting with bile, and the abdomen may even sink in. With proximal intestinal obstruction, the distal colon is emptied and the stool is not changed. With impaired blood supply, blood begins to flow from the rectum. Enterocolitis with incomplete rotation can be differentiated by the main symptom - the detection of bile in vomit.

With complete obstruction, intestinal ischemia develops rapidly, with a hard, enlarged abdomen, hypovolemia, and shock. Pain on palpation varies and depends on the degree of circulatory impairment, but signs of peritonitis are always present. Here, differentiation is somewhat more difficult. An accurate diagnosis can be made using Doppler ultrasound or irrigogram data. Often, preference is given to emergency laparotomy without these studies, since this will prevent the loss of significant intestinal length.

Treatment enterocolitis in newborns.

Taking into account all the mechanisms of enterocolitis pathogenesis, appropriate treatment is also carried out. Prevention of perforation and other infectious complications is mandatory in treatment. The first issue that is resolved in this case is the cessation of enteral nutrition for some time, and depending on the severity of the pathology, only parenteral nutrition or partially parenteral nutrition is possible.

For children diagnosed with enterocolitis at the last stage with the risk of perforation, they switch to full parenteral nutrition. The calculation of the main nutrients is carried out according to the child's needs, taking into account his body weight. Special nutritional mixtures are used that contain protein, fats and glucose. In addition, infusion therapy for the child is calculated taking into account daily needs.

If enterocolitis is diagnosed at the initial stages, then it is possible to reduce enteral nutrition by feeding the child through a tube with expressed breast milk. The remaining nutrients are calculated according to the child's needs.

Treatment of enterocolitis in newborns with medications must necessarily include antibacterial therapy. After all, one of the main links in the pathogenesis of the disease is bacterial inflammation of the intestinal wall. The use of antibiotics, given the very aggressive intestinal flora, does not begin with the weakest drugs, but with highly effective and strong drugs. Infusion therapy is carried out in parallel, and by the end of treatment, probiotics are carefully added, which normalize the flora and reduce the irritating effect of other drugs. Probiotics are usually taken after the child is discharged for one to two months. Among antibacterial agents, a combination of ampicillin antibiotics with aminoglycosides or carbapenems is most often used.

1. Ampisulbin is one of the antibiotics that are often used in the treatment of newborns, and in the treatment of enterocolitis it is used in combination with other antibiotics. The active substance of the drug is ampicillin, which is protected by sulbactam. The antibiotic is effective against most types of E. coli that can cause intestinal colonization. The dosage of the drug can be up to 150 milligrams per day, divided into 2-3 doses. The route of administration is intramuscular or intravenous. Side effects can be in the form of allergic reactions, disruption of the normal intestinal flora.
2. Amikacin is an antibiotic from the aminoglycoside group, which is often used in combination with other drugs for a broader antibacterial effect. The drug acts by incorporating a bacterial cell into the structure of the rybosomes, thus disrupting protein synthesis and killing the bacteria. This is how the bactericidal effect of this drug is achieved. Its dosage is 15 milligrams per kilogram of body weight per day. The method of administration is intravenous or intramuscular, divided into 2 doses. Side effects may include irreversible hearing loss, as well as toxic effects on the kidneys. There may be local manifestations in the form of contraction of muscle fibers, fluctuations in blood pressure.
3. Imipenem is an antibiotic from the carbapenem group, which has unique resistance to most bacteria. The mechanism of action of the drug is to disrupt the synthesis of proteins that are part of the structure of the inner wall of bacteria. The method of administration of the drug is intravenous, 2 times a day. Dosage is 20 milligrams per administration. Side effects of the drug are most often manifested in the form of local reactions - thrombophlebitis, local allergic manifestations and allergic skin reactions, bone marrow dysfunction. Precautions - it is necessary to monitor hematological parameters during long-term therapy with this antibiotic.
4. Enterozhermina is a probiotic that contains spores of the Bacillus clausii strain. The drug not only populates the intestines with beneficial flora, but this strain of microorganisms also synthesizes a huge amount of B vitamins. This is very important against the background of enterocolitis, since this disease reduces the ability of the intestine to absorb all vitamins. The dosage of the drug for newborns with enterocolitis is one bottle of suspension once a day. Method of administration - the drug must be dissolved in breast milk or formula. Side effects are rare, colic may appear in the initial stages of therapy. Precautions - it is not recommended to dissolve the drug in hot milk, as this can affect the vital activity of the bacterial spores contained in the drug.
5. Prema is a new generation probiotic, which includes Lactobacillus rhamnosus GG - a beneficial bacterium that not only normalizes the intestinal flora, but also prevents the development of allergic diseases in the future. The dosage of the drug in the form of drops is ten drops once a day. Side effects are rare, there may be slight bloating at the beginning of therapy, but then all the flora is normalized and normal digestion processes are restored.

Surgical treatment of enterocolitis is used quite often, especially in case of late diagnosis. As is known, intestinal perforation is the final stage of enterocolitis. Therefore, at the first symptoms of peritonitis, surgery is performed immediately. Symptoms of perforation are a sharp deterioration in the child's condition, bloating, it is hard in all parts when palpated, and the child immediately reacts with a loud cry. A systemic inflammatory reaction develops with the development of intoxication syndrome. The essence of surgical treatment is to eliminate the perforation and sanitize the abdominal cavity. The postoperative period is carried out using antibacterial and detoxification therapy.

Vitamins can be used after the child has recovered. For this purpose, it is necessary to carefully select the preparations so that there is no irritating effect on the intestines.

After enterocolitis, digestive disorders in a child with frequent constipation or diarrhea may remain for a long time. Therefore, in the period of remote consequences, physiotherapeutic treatment in the form of massages, iontophoresis after surgery can be used.

Folk treatment of enterocolitis in newborns is not used, since children after enterocolitis in the neonatal period are very vulnerable in terms of nutrition and the use of any means, including homeopathic and herbs.

Forecast

The prognosis for enterocolitis is favorable for life. Approximately 50% of neonates with NEC who receive adequate therapy have a complete clinical recovery and do not have problems with feeding in the future.

In some cases, narrowing of the intestine and "short bowel" syndrome may occur, which may require surgical correction, even if previous conservative treatment was successful. Another problem may be the occurrence of malabsorption syndrome. This concerns most cases of newborns who required surgical intervention for NEC and these children had a need to remove part of the intestine.

Of newborns who have undergone surgical treatment, approximately two thirds survive. Mortality in NEC is higher in very premature babies. Prevention of enterocolitis is the influence on possible risk factors for the development of pathology, healthy parents, to avoid the birth of a premature baby.

Enterocolitis in newborns is more common in children with low body weight, so premature babies are at risk. Given the possible complications and high mortality, there is an increased need for timely diagnosis on the part of doctors, and on the part of parents - these are preventive measures to prevent the development of such a disease.

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