Enterocolitis of the intestine in newborns: necrotizing, ulcerative

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

[1], [2]

Epidemiology

Statistics of the distribution of enterocolitis in newborns suggest that this pathology occurs in less than 2% of healthy term infants, but more than 95% of cases of this pathology are preterm infants with small and extremely low body weight. Both the prematurity factor and the body weight play an important role in the development of enterocolitis, because the less these indicators, the more often these children develop intestinal damage. Among the children who are in the intensive care unit, about 7% in the future may have enterocolitis.

[3], [4], [5], [6], [7], [8], [9], [10], [11], [12],

Causes of the enterocolitis in newborns

The causes of enterocolitis in newborns are not limited to a few items, and they are continuously associated with the pathogenesis of the disease. The most significant cause of enterocolitis is the intestinal population of pathogenic microorganisms. In normal conditions in a healthy newborn baby the intestine begins to be colonized by microorganisms a few hours after birth. When a child is born healthy, he is laid on his mother's stomach to contact her skin. This moment is very important, because this is the factor of colonization of the skin and mucous membranes of the child with a useful flora. On the skin of the mother are bacteria that are familiar to the child, which help to colonize not only the skin, but also the intestines. It is these bacteria that enter the intestine and colonize it first. In the first few days of the child, cocci microorganisms are detected in small amounts. Already after three days in connection with the onset of breastfeeding, lactobacilli and bifidoflora appear in the intestine. When it comes to preterm babies, these phases of settlement are violated. In this case, many pathogenic microorganisms appear in the intestine. They come from the amniotic fluid, the external environment, as well as by contact with medical instruments and hospital flora. Gradually these microorganisms multiply and pathogenic cocci and chopsticks become more and more. They cause an inflammatory process in the intestinal mucosa, which spreads to all parts of the intestine. After all, in newborn babies the inflammatory process can not be limited due to the weakness of local and systemic protection.

[13], [14], [15], [16], [17], [18]

Risk factors

Such reasons can develop against a background of different factors. The main risk factors for enterocolitis in newborns are as follows:

• hypoxia and asphyxia of newborns leads to circulatory failure in all organs;
• congenital malformations and lung diseases, which are accompanied by persistent violations of gas exchange;
• hypovolemic shock and hypotension reduces pressure in the superior mesenteric artery and increases intestinal ischemia;
• birth in pelvic presentation and multiple pregnancy increases the likelihood of prematurity;
• severe hemolytic conditions and operations for replacement blood transfusion;
• congenital heart defects with insufficient cardiac output decrease the blood supply of the intestine;
• congenital abnormalities of the intestine, congenital intestinal obstruction, Hirschsprung's disease;
• Postoperative period with interference with other organs and systems;
• complicated course of pregnancy with severe gestosis, chronic fetoplacental insufficiency;
• polycythemia;
• use of some medications.

[19], [20], [21], [22], [23], [24], [25],

Pathogenesis

The pathogenesis of enterocolitis development in newborns is not limited to a simple inflammatory process in the intestine. The disturbance of normal nutrition is one of the links in the pathogenesis of necrotic changes. After all, a healthy full-term baby is positioned to be immediately breastfed. If the baby is premature, the intestinal mucosa can not immediately perceive enteral nutrition and the early onset of such nutrition can exacerbate inflammatory changes. And this can be one of the important reasons for the development of enterocolitis and the intensification of inflammatory changes.

Ischemic changes are the third important cause of enterocolitis development. Inadequate circulation of the arteries of the intestine leads to a disruption of the normal epithelization of the intestinal mucosa. Such ischemia further intensifies inflammation and supports necrotic changes in enterocolitis.

[26], [27], [28], [29], [30]

Symptoms of the enterocolitis in newborns

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

Depending on the course of the process, different types of enterocolitis are distinguished: fulminant, subacute and acute enterocolitis. Stages of development depend on this species and the symptoms are also characteristic of a particular type of pathology.

Symptoms of enterocolitis in newborns with fulminant flow develop very rapidly. Everything starts on the 3-5th day of the child's life. As a rule, children with congenital pathologies or intestinal diseases are affected by such lesions. The entire clinical picture develops very quickly - for 5 days - which often leads to death.

Acute enterocolitis develops over several days, and it has successive stages. At the first stages, the intestinal mucosa of a particular site is affected. In this part of the intestine inflammation occurs with difficulty of circulation throughout the intestines, which increases ischemia. Further, the process spreads to the distal parts of the intestine, which intensifies clinical manifestations. At the last stage, necrotic areas are formed along the entire length of the intestine, which leads to perforation.

Necrotizing enterocolitis in newborns is already developing against a background of prolonged inflammatory process in the intestine. The first symptoms appear in the child in the form of digestive disorders. Vomiting is the most frequent symptom of this pathology. The child does not digest food and practically tears it all out. Any feeding ends with a profuse vomiting of all the food eaten. As there is an inflammatory process, that is also system displays - the body temperature can raise. But kids do not always react with such a symptom, so it is not key. Violated stool in the form of diarrhea. It has a mucus-purulent character, and then, with massive damage to the mucosa, blood veins may appear.

Such intense inflammation in the intestine disturbs the absorption of nutrients, so the child does not gain weight, and eventually loses it. He refuses to eat, as the process of digestion brings him many unpleasant sensations. The abdomen is constantly swollen, the colic disturbs and therefore the newborn is cranky. Often the sensation of the stomach is firm and does not lend itself to palpation.

The subacute course of the disease is characterized by a gradual increase in these symptoms. Episodes of bloating may be periodic, and the child may not gain weight in weight. With such a prolonged inflammatory process, bowel obstruction can develop.

Ulcerative enterocolitis in newborns is already formed against the backdrop of prolonged inflammatory processes, and ulcers of different depths are formed in limited areas of the mucosa, which can later be perforated.

It often happens that ulcerative and inflammatory changes are not expressed, and only infectious lesions predominate. The causative agent of this inflammation is often staphylococcus. Staphylococcal enterocolitis in newborns is characterized by a clinic of infectious bowel disease. In this case, the symptoms characteristic of any intestinal infection - vomiting, diarrhea, dehydration, impairment of absorption and loss in weight, predominate.

[31], [32], [33]

Complications and consequences

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

[34], [35], [36], [37], [38], [39]

Diagnostics of the enterocolitis in newborns

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

Since most cases of ulcerative necrotic enterocolitis in newborns occur in premature infants, these children are still in the intensive care unit. Therefore, the diagnosis should begin even there, with a careful examination of the child and a dynamic examination every three hours.

Symptoms that can lead to the thought of bowel damage are vomiting, diarrhea, bloating. The tummy is on examination and palpation is hard, brings discomfort to the baby.

Analyzes do not allow you to accurately determine the pathology and its localization. Therefore, the diagnostic diagnosis of enterocolitis in this case is a priority in diagnosis.

Radiography and ultrasound diagnosis are priority methods in the diagnosis of enterocolitis in a newborn.

Direct radiography allows you to identify several symptoms that are characteristic of enterocolitis. When there is only infiltration and inflammation of the mucous membrane, it is possible to determine the increased pneumatization of the intestinal loops, the enlargement of the liver due to a violation of its circulation, as well as the unequal expansion of various departments.

When changes in the intestines are accompanied by ischemia, a certain part of the intestinal loop can become fixed due to profound changes in its wall. In this case, in the lateral position on the roentgenogram, this loop will be fixed, as well as in the direct projection.

If diagnostic radiography is performed at the stage of deep damage to the wall, pneumatization covers all areas of the intestine. And even in the wall of the intestine, it is possible to determine the areas of the gas when it hits the abdominal cavity already through the wall. At the stage of formation of perforation with enterocolitis, air from the intestine enters the abdominal cavity and is determined on the roentgenogram already in the region of the liver.

Ultrasound diagnostics, in addition to the high air content, can determine the thickening of the intestinal wall. For enterocolitis, the most constant echographic symptom is the presence of overgrown liquid contents of the intestinal loops. In the initial stages this may be the only symptom that allows you to diagnose enterocolitis. An indication of the deterioration of the child's condition may be the expansion of the portal vein and the determination of air there by the results of ultrasound.

[40], [41], [42], [43], [44], [45]

Differential diagnosis

Differential diagnosis of enterocolitis should be carried out at the appearance of the first symptoms, as they may be similar to other diseases. It is very important to differentiate enterocolitis with congenital abnormalities of the intestine, Hirschsprung disease, congenital or acquired intestinal obstruction, 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 become diarrhea in combination with symptoms of functional bowel obstruction.

Characteristic symptoms of the disease have similar symptoms with enterocolitis constipation alternating with normal stool or diarrhea (due to accession of enterocolitis), vomiting, intoxication. With such a course of the disease, a stable diarrheal syndrome is quite typical, but there are no pronounced necrotic changes in the intestine, as with enterocolitis. Also, there is no inflammatory process in the intestines with Hirschsprung's disease, and any pathogenic microorganisms can not be isolated by bacteriological examination.

An incomplete turn of the intestine is one of the congenital anomalies of the intestine with which it is necessary to differentiate enterocolitis. The first sign of a turn in the unfinished rotation is a sudden vomiting with bile, while the stomach may even sink. With proximal bowel obstruction, the distal colon is emptied and the stool is not changed. With the violation of the blood supply, the discharge of blood from the rectum begins. Enterocolitis with incomplete rotation can be differentiated according to the main symptom - the definition of bile in vomiting.

With complete obstruction, ischemia of the intestine, with a firm, enlarged abdomen, hypovolemia and shock develops rapidly. Soreness in palpation is different, and depends on the degree of disturbance of blood circulation, but signs of peritonitis are always present. Here the differentiation is a little more difficult. An accurate diagnosis can be made using Doppler ultrasound or according to irigograms. Often, preference is given to emergency laparotomy without these studies, as this will prevent the loss of a significant length of the gut.

Treatment of the enterocolitis in newborns

Taking into account all mechanisms of pathogenesis of enterocolitis, appropriate treatment is also carried out. Mandatory treatment is the prevention of perforation and other infectious complications. The first question that is solved in this case is the cessation of enteral nutrition for a while, and depending on the severity of the pathology, only parenteral nutrition or partially parenteral nutrition is possible.

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

If enterocolitis is diagnosed at the initial stages, it is possible to reduce enteral feeding with feeding the baby through the probe expressed by breast milk. The remaining nutrients are calculated according to the needs of the child.

Treatment of enterocolitis in newborns with the help of medicines should 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 flora of the intestine, does not begin with the standard of the weakest means, but with highly effective and strong drugs. In parallel, the infusion therapy is performed, and by the end of the treatment probiotics are added with caution, which normalize the flora and reduce the irritating effect of other drugs. The reception of probiotics, as a rule, continues after the discharge of the child for one to two months. Among antibacterial agents, a combination of ampicillin antibiotics with aminoglycosides or carbapenems is often used.

1. Ampisulbin is one of the antibiotics that are often used in the treatment of newborns, and in the therapy 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 Escherichia coli, which can cause colonization of the intestine. 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, a violation of 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 including a bacterial cell in the fish structure and thus the protein synthesis is broken and the bacterium dies. Thus, the bactericidal effect of this drug is realized. Dosage of it - 15 milligrams per kilogram of body weight per day. The route of administration, intravenous or intramuscular, is divided into 2 divided doses. Side effects can be in the form of irreversible hearing impairment, 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 a unique resistance to most bacteria. The mechanism of action of the drug is a violation of the synthesis of proteins that enter the structure of the internal wall of bacteria. Method of application of the drug - intravenous, 2 times a day. Dosage is 20 milligrams per administration. Side effects of the drug are often manifested in the form of local reactions - thrombophlebitis, local allergic manifestations and allergic skin reactions, malfunctioning of the bone marrow. Precautions - you need to monitor hematologic parameters with prolonged therapy with this antibiotic.
4. Enterojermina is a probiotic, which includes spores of the Bacillus clausii strain. The drug not only colonizes the intestine with a useful flora, but also this strain of microorganisms synthesizes a huge amount of B vitamins. This is very important against enterocolitis, because with this disease the ability of the intestine to absorb all vitamins decreases. Dosage of the drug for newborns with enterocolitis - one bottle of suspension once a day. Method of use - the drug must be dissolved in the chest salt or mixture. Side effects are rare, there may be colic in the early stages of therapy. Precautions - it is not recommended to dissolve the medicine in hot milk, as this can affect the vital activity of bacteria spores contained in the preparation.
5. Prama is a new generation probiotic that includes Lactobacillus rhamnosus GG, a useful bacterium that not only normalizes the intestinal flora, but also prevents the development of allergic diseases in the future. Dosage of the drug in the form of drops - ten drops once a day. Side effects are infrequent, there may be a slight swelling of the tummy at the beginning of therapy, but then the whole flora is normalized and the processes of normal digestion are restored.

Surgical treatment of enterocolitis is used quite often, especially with late diagnosis. As is known, perforation of the intestine is the final stage of enterocolitis. Therefore, with the first symptoms of peritonitis, immediate surgery is performed. Symptoms of perforation is a sharp deterioration of the child's condition, bloating, he is palpating hard in all departments and the child immediately reacts with a strong cry. A systemic inflammatory reaction develops with the development of intoxication syndrome. The essence of surgical treatment is to eliminate the perforation and sanitization of the abdominal cavity. The postoperative period is conducted with the use of antibacterial and detoxification therapy.

Vitamins can be used after the child's recovery. To this end, you need to carefully select the drugs, so that there is no irritating effect on the intestines.

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

Alternative treatment of enterocolitis in newborns is not used, because babies after enterocolitis in the period of newborns are very vulnerable in terms of nutrition and the use of any means, including homeopathic and herbs.

Forecast

The prognosis of enterocolitis is favorable for life. Approximately 50% of newborns with NEC who receive adequate therapy have complete clinical recovery and have no problems with feeding in the future.

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

Of the newborns who received surgical treatment, approximately two-thirds survive. Mortality in NEC is higher in deeply premature babies. Prevention of enterocolitis - is the impact 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 young children, so premature babies are at risk. Given the possible complications and high mortality, the need for timely diagnosis by doctors increases, and on the part of parents it is preventive measures to prevent the development of such a disease.

[46], [47], [48], [49]