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新生儿坏死性小肠结肠炎课件_11

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新生儿坏死性小肠结肠炎ppt 新生儿坏死性小肠结肠炎 新生儿坏死性 小肠结肠炎 新生儿坏死性 新生儿坏死性小 新生儿坏死性小肠结肠炎课件 坏死性小肠结肠炎
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单击此处编辑母版副标题样式 *1 单击此处编辑母版标题样式 l 新生儿坏死 性小肠结肠炎 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 概念 新生儿坏死性小肠结肠炎(NEC)临床以腹胀、呕吐、腹泻、便血为主要表现,腹部X线平片以肠壁囊样积气为特征,病理以回肠远端和结肠近端坏死为特点。是新生儿尤为早产儿阶段胃肠道的 一种严重、需要急救治疗的疾病。病死率为10%~50% 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因和发病机制: 病因尚未完全明了,当诸多有害因素单独或联合作用,其损伤性超过机体可能耐受的某一阈值足以引发肠道坏死时,就形成了新生儿坏死性小肠结肠炎。 发病与下列因素有关: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因和发病机制: 1. 各种原因使肠壁缺血缺氧被认为是发病的直接因素. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (1) 新生儿窒息、缺氧、低血压、休克、酸中毒等情况下,引起机体防御性反射,肠系膜血管强烈收缩,血流重新分配,保证心、脑重要器官的血流供应,减少肠管血流量。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 有研究证明在窒息缺氧时,肠壁血流可减少到正常的35%~40%,回肠末端及升结肠血灌流量可减少到正常的10%~30%,因而使肠壁缺血,肠粘膜屏障损害。此外在应激状态下,血管运动肠多肽、肾上腺素等使肠粘膜及粘膜下层血流减慢,毛细血管阻力增加,发生动静脉短路,更可促成肠粘膜缺血。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (2) 动脉导管未闭,肺动脉高压等时的血液左向右分流,影响体循环量,致内脏灌流量减少。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (3) 脐动脉插管可引起血管痉挛或血栓形成:交换输血速度过快时可因中断门静脉回流,产生血栓,造成肠壁粘膜损伤。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (4) 新生儿红细胞压积较高,早产儿、低体重儿更易发生血液浓缩,血粘稠度增高致心排出量减少,使肠粘膜微循环障碍,造成肠粘膜损伤。新生儿红细胞增多症时也可因血粘稠度增高而致肠粘膜损伤。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (5) 喂养因素 奶方配制过浓,渗透压过高(460mOsm/L);空肠导管喂以高渗乳汁或高渗药物溶液,肠腔内的高渗使大量液体从肠壁血管转入肠腔使肠粘膜受损。人工喂养儿(尤为早产儿)每日增加奶量过快过多可加剧乳糖及蛋白质吸收不良,奶量过多膨胀使肠腔内压升高,导致粘膜血流灌注减少而受损伤。有认为早产儿配制奶方如渗透压400mOsm/L及有可能损伤肠粘膜。高渗液一般不致损伤正常肠粘膜,但对已有缺血的肠粘膜则易造成损害。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因和发病机制: 2.感染及炎症 不少学者认为感染是产生NEC的主要原因,从集中流行发病和散发的病人大便培养出的病源大多是大肠埃希杆菌、克雷白菌、绿脓杆菌和一些其他致病力不强的细菌。也有查出病毒或真菌的报道。坏死性小肠结肠炎也可由细菌产生的毒素直接引起,除上述细菌外,凝固酶阴性葡萄球菌,顽固梭状芽孢杆菌,酪酸梭状芽孢杆菌金黄色葡萄球菌等均可产生毒素诱发损伤,引起炎症。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因和发病机制: 3.早产 NEC多发生在1500g以下的极低体重儿,主要因为 : With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1)免疫功能低下,肠粘膜内可以产生免疫球蛋白的B细胞少,只有少量分泌型IgA产生,IgA可与细菌抗原结合,阻止细菌在肠粘膜上皮表面的吸附并抑制细菌生长。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2)胃肠发育不成熟、运动弱、 胃酸量少,胃内容物易滞留,即增加食物发酵的机会,又增加肠内致病菌落发展的危险性; With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3)肠道乳糖酶活性不高,使小肠未消化的乳糖过多,引起细菌发酵产物增多,一旦未消化的蛋白质与有机酸结合,便会因多余的化学介质(如组织胺、花生四烯酸代谢产物及氧自由基)的积累而出现有害的组织学及生物化学效应。肠腔内的发酵产物、细菌抗原及来自细菌壁的胞壁酰酞又进一步在结肠粘膜产生局灶性炎症效应。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4.再贯注损伤 新生儿窒息、呼吸衰竭、低血压、休克等重症时,机体或某一器官缺血、缺氧,经抢救好转又重新获得氧和血液灌注后发生由氧自由基引起的肠壁非缺血、缺氧性损害,进一步降低肠粘膜的屏障作用。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 综上所述,发病机制中许多因素是互相关连,构成了形成NEC的必不可少的环节。可以认为新生儿NEC是尚不成熟的胃肠道对多种有害因素所产生的最后相同反应。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病理 肠道病变的范围可局限也可能较广泛,甚至可影响到全消化道。最常受侵犯的是升结肠近端和回肠末端。肠腔极度充气,肠粘膜呈斑片状或大片状坏死,肠壁可见不同程度积气。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 镜下见粘膜呈凝固性坏死,粘膜下层有弥漫性出血或坏死。肌肉层也有断续的坏死区。严重者整个肠壁全层坏死,常伴肠穿孔。临床上发生DIC者,在肠粘膜血管内可见微血栓,尸解时还可同时发现肺膨胀不全、肺透明膜病变、肺出血和颅内出血等病变,提示有围产期缺氧。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现 本症无明显的季节性,多见于早产儿、足月小于胎龄儿,男婴较女婴多见。于生后2~3周内发病,大多发生于生后2~12天。有报道于生后24小时内发病者。轻症只表现为腹胀及胃储留,重者如败血症伴中毒性肠麻痹。本症有三个主要表现。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1.腹胀 : 常为首发症状,先有胃排空延迟、胃储留,而后全腹胀。肠鸣音减弱或消失。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.呕吐: 呕吐物带胆汁或咖啡样物。无呕吐的患儿常可自胃中抽出含胆汁或咖啡渣样胃内容物。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3.腹泻、血便 : 一般先有腹泻,排水样便,一日5~6次至10次左右。起病1~2日或数日后可排血便,可为鲜血、果酱样或黑便或仅于大便中带血丝。偶有表现为便秘者。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4.大多数病例病情发展快 感染中毒表现严重,精神萎靡、反应差,可有体温不升、青紫、黄疸、休克、酸中毒。严重者可有DIC表现,四肢厥冷、苍白甚至面色青灰。早产儿易有呼吸暂停、心动过缓。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 5.其他 并发败血症者,全身中毒症状更重。并发腹膜炎时,腹胀严重,患儿情况更差,腹壁发红、发硬或发亮、浮肿,早期可有压痛。腹腔可有液体。如发生肠穿孔则有气腹。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society X线检查 X线腹部平片检查对本症的诊断价值极大,如一次腹部平片无阳性发现时,应多次摄片连续观察其动态改变。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1. 早期 1)小肠轻中度胀气为主,结肠少气或无气或小肠结肠普遍胀气; 2)部分胀气的肠管可演变为外形僵硬、分节、管腔不规则或狭窄变细; 3)肠粘膜及肠间隙增厚、模糊; 4)胃泡多中度胀气部分有储留液。 上述各异常影像的病理基础是粘膜及粘膜下层充血、水肿、出血、坏死。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.进展期 呈现典型NEC的X线征。 1)肠管中度扩张,肠腔内可见多个细小液平面,呈阶梯状改变,提示病变累及肌层。 2)粘膜下层可见肠壁囊样积气影像,表现为小囊泡或串珠状积气在粘膜下及浆膜下合并存在。 3)门静脉积气影; 4)腹膜外积气或胃壁积气影像。 5)腹腔积液或气腹影:肠穿孔常有气腹,腹膜炎时腹腔内有积液,可见下腹部密度较深。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 腹立位片,胃泡扩大肠管胀气 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 肠管胀气,肠壁积气,门静脉积气 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 液气腹、胃壁积气 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 实验室检查: 1 粪便检查 潜血试验多阳性 ,粪便培养细菌多阳性。以大肠埃细菌、克雷白菌等多见。粪便镜检可见多量的红细胞、白细胞。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2 血象 白细胞增高,有核左移现象,血小板多降低。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3 血培养 如阳性大多为革兰氏阴性杆菌,与粪便培养可得一致细菌。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4 腹腔穿刺 穿刺液涂片及培养大多为杆菌。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 5 腹部B超 有时可见肝实质及门脉内间歇出现气体栓塞,还有助于发现腹水和炎性团快。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 6 超声心动图 有时可见下腔静脉内有微小气泡进入右心室。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society NEC的分期 Ⅰ期: 全身症状和体征:体温不稳定,呼吸暂停,神萎。 肠道症状和体征:胃残留奶增加,中腹部膨胀,呕咖啡样物,大便潜血阳性。 腹部X线平片:肠充气或正常,肠功能性梗阻(轻) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Ⅱ期 全身症状和体征:同上,轻度代酸和轻度血小板减低。 肠道症状和体征:同上,肠鸣音消失,腹部可有压痛,无/有腹壁红肿,粪带血或黑色。 腹部X线平片:肠胀气,肠功能性梗阻,肠壁囊样积气,无/有腹水。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Ⅲ期 全身症状和体征: 同上,低血压,重度呼吸暂停,重度呼酸和代酸,无/有DIC。 肠道症状和体征:同上,腹膜炎体征,压痛明显,腹胀明显,无/有肠穿孔粪黑色或鲜血。 腹部X线平片:同上,可出现腹水,无/有气腹。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 诊断和鉴别诊断 凡新生儿特别是早产儿、足月小于胎龄儿,围产期有明显缺氧史或其他诱因者应密切观察,有精神面色改变,出现腹胀,轻度腹泻时立即摄腹部X线片并做大便潜血试验对早期诊断有助,一次腹部X线片未见阳性表现者,应连续做X线片的动态观察,往往在第2次、第3次腹片即可见NEC的X线表现。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 鉴别诊断 1 中毒性肠麻痹 : 无便血,X线片上无肠壁积气。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2 机械性小肠梗阻 : 腹部X线片上液面的跨度较大,肠壁较薄,无肠间隙增宽模糊,无肠壁积气,再结合临床易区别。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3 先天性巨结肠: 以腹胀、排便困难为主,无血便。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4 新生儿出血症 : 腹部不胀,腹部X线片无肠腔充气和肠积气,维生素K治疗有效。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 5 胎粪性腹膜炎 : 个别病例的腹部X线片偶可见散在小囊泡样肠壁积气,但可有典型的异常钙化影,再结合临床不难鉴别。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 6 肠扭转: 肠扭转时机械性肠梗阻症状重,呕吐频繁,腹部X线片示十二指肠梗阻影像,腹部密度均匀增深,并存在不规则多形气体影,无明显充气扩张的肠曲。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 7 自发性胃穿孔 : 发病突然,奶后突然腹胀、呼吸窘迫、发绀。腹部X线片仅见气腹无肠壁积气或肠管胀气。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治疗 遇新生儿出现腹胀、胃潴留等,不论有无放射线征,均应怀疑NEC,即应开始进行严密监护和治疗。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1 绝对禁食: 用鼻胃管持续抽吸排空胃内容物。由静脉供应液体、电解质和营养物质。禁食时间视病情发展而定,一般8~12天。轻症有时禁食5~6天即可,重症有时需禁食10~15天或更长。待腹胀呕吐消失,大便潜血转阴,有觅食反射,临床一般情况明显好转,可开始恢复饮食。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 先试喂开水一次,再试喂5%糖水两次,每次3~5ml,如未发生呕吐、腹胀等情况,可改喂母乳或1:1稀释的配方奶,从每次3~5 ml开始,以后可渐增加,每次增加2ml,切忌用高渗乳汁。喂奶前先从胃管中抽吸胃内容物,如胃内潴留量超过2ml,则停喂一次。如进食后又出现腹胀呕吐或胃内经常潴留超过2ml,即应再行禁食至症状消失,再重新开始。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 有时可如此反复几次才得成功。不可开奶过早或加奶过快,否则都易复发,甚至病情恶化。禁食期间营养和液体不足部分由全肠外营养液或部分营养液补充,可以从周围静脉滴入。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.抗生素 : 静脉滴入第三代头孢类药物如头孢他啶、头孢曲松。如大便培养阳性可根据药敏试验结果选用敏感抗生素。对厌氧菌可选用甲硝唑静注。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3.加强护理 : 如保温、供氧、保持口腔、皮肤清洁卫生,做好消毒隔离,防止交叉感染,记出入量及胃肠减压抽吸量。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4.外科治疗 指征为: 1)发生气腹; 2)腹膜炎症状体征明显,腹壁明显红肿,有肌卫等多示有肠坏死或有脓肿; 3)经内科积极治疗临床情况继续恶化。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 预防 : 1 预防早产。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2 提倡母乳喂养,必须人工喂养者(尤为早产儿)采用每次少量增乳量的喂养方案以降低发生NEC的危险。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In
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