neonatal gastric perforation
Introduction
Introduction to neonatal gastric perforation Neonatal gastric perforation (neonatal gastric perforation) is a rare acute abdomen in pediatric surgery. According to the literature, the incidence of blacks is higher than that of whites. It usually occurs 2 to 7 days after birth, and the mortality rate is very high. In recent years, due to the development of neonatal surgery and anesthesia technology, rational use of antibiotics and supportive therapy has led to a significant decline in the mortality rate. Postoperative survival rate and children's Weight is directly related to timely diagnosis. Romas reported a 45% survival rate for patients undergoing gastric perforation within 12 hours and a survival rate of 25% for more than 12 hours. Explain the importance of early diagnosis and surgical treatment. basic knowledge Sickness ratio: 0.00052% Susceptible people: children Mode of infection: non-infectious Complications: acute diffuse peritonitis shock
Cause
Causes of neonatal gastric perforation
(1) Causes of the disease
The opinions about the cause of this disease are not uniform, and are generally considered to be related to the following factors:
1. Muscle wall muscle defect: During embryonic development, the digestive tract is from the inside, the mesoderm, the endoderm constitutes the submucosal epithelium, and the mesoderm constitutes the muscle layer. When the embryo is 3 to 4 weeks, the stomach is the fusiform part of the esophageal dilatation, embryo At 5 to 6 weeks, the left end of the stomach begins to have the mesoderm of the mesoderm ring, starting at the lower end of the esophagus. The embryo gradually develops to the stomach and the bottom of the stomach at 6 to 7 weeks, and the slant of the stomach is 9 weeks after the embryo. The muscle fiber can be developed by the ring muscle, and finally the longitudinal muscle is formed. Until the embryo is 4 months, the development is still not perfect, but the longitudinal muscle of the late embryo is developed faster, especially at the bottom of the stomach. The oblique muscle develops slowly, so it is under the cardia after birth. The stomach wall is still weak, such as a developmental disorder, which can form a defect in the muscular layer.
2. Stomach contraction tension unevenness: When the muscle wall of the stomach wall is deficient, the tension of the stomach contraction is not uniform, which may cause the stomach to rupture.
3. Excessive expansion of the large curved part of the cardia: Some scholars believe that during the process of gastric formation, the excessive expansion of the large curved part of the cardia (such as after the child swallows) increases the intragastric pressure and the muscle layer breaks to the perforation.
The gastric wall muscle defect is most common in the fundus and the large curved side. Kneisil proposes that this is a weak gap in which the normal muscular layer is not yet fully developed. This small muscular layer is likely to be a normal neonatal stomach muscle layer that has not yet developed. Completely, there is an interlacing gap between the muscle bundles, which is a normal development process, but it continues to develop well soon after birth, and these gaps disappear.
4. Ischemia of the gastrointestinal wall: There are still many authors who do not agree that the thinning of the gastrointestinal muscle layer is a congenital malformation. On the contrary, it may be the result of ischemia of the gastrointestinal wall. They suggest that ischemia is caused by perforation. Common causes, when suffocation, hypoxemia, dystocia and bleeding, etc., the body's blood flow compensatory redistribution, so that the blood supply to the gastrointestinal tract, kidney and peripheral vascular bed is reduced to ensure the blood supply to the heart and brain, if This compensatory protection is too strong in local reactions to produce perforation due to gastrointestinal ischemia.
(two) pathogenesis
Gastric rupture is more common in the large curvature of the stomach, necrosis of the gastric wall at the rupture, showing linear rupture or tearing of the sarcolemma, and submucosal tearing, the edge of the rupture is neat, but there is irregular necrotic area, and the surrounding stomach wall is gradually thinner. The ruptured muscle layer is broken, the oblique muscle and longitudinal muscle are absent, and the mucosa remains. The submucosal layer and the sarcolemma layer form the stomach wall, and inflammatory cell infiltration can be seen.
Prevention
Neonatal gastric perforation prevention
At present, there is no relevant content description, mainly prevention and timely detection of timely treatment.
Complication
Neonatal gastric perforation complications Complications acute diffuse peritonitis shock
Diffuse peritonitis is a major complication of neonatal gastric perforation and can cause shock and multiple organ failure to be the leading cause of death in neonatal gastrointestinal perforation.
Symptom
Symptoms of neonatal gastric perforation Common symptoms Refusal of abdominal pain, nausea, phlegm, venting, abdominal wall, venous distraction, mobile, voiced, peritonitis, gastric wall, muscular layer defect, edema
There is no obvious prodromal symptoms in this disease. A small number of sick children have nausea, vomiting and refusal. The vomit is mucus and milk. It may be accompanied by a small amount of bloody liquid or coffee-like substance. Generally, there may be feces discharged, but as the disease progresses, Paralytic ileus appears, stop defecation, venting, and even discharge blood.
After the rupture of the stomach, a large amount of gas enters the abdominal cavity, and the diaphragm rises and affects the ventilation. The child shows cyanosis of the lips and difficulty breathing. Due to diffuse peritonitis, a large amount of toxin is absorbed by the peritoneum, and toxic shock can occur, and there is paleness, cyanosis, and cold limbs. And skin pattern, etc., abdominal abdomen, abdominal wall venous engorgement, abdominal wall edema or accompanied by muscle tension, full abdominal sputum drum sound, liver dullness disappeared, there may be mobile dullness and bowel sounds disappear.
Examine
Neonatal gastric perforation
1. Abdominal X-ray examination: the diaphragm of the standing position can be seen on both sides of the diaphragm, the liver and spleen shadow are located on both sides of the middle and abdomen spine, a large amount of free gas under the armpit, especially on the right side, can occupy 2/3 of the whole abdomen. And there is a large amount of liquid volume in the lower abdomen, so a gas-liquid plane across the entire abdomen can be seen.
Many authors believe that there is no obvious clinical manifestation or X-ray signs in the early stage of spontaneous gastrointestinal perforation in low birth weight infants. Judy reported 6 cases of very low-weight children with gastric perforation. X-ray abdominal examination did not find underarm free gas in 5 cases, thus diagnosis It has certain difficulties, but timed repetitive filming and abdominal puncture can help to diagnose quickly.
2. Abdominal puncture experience of Kosloske and Lilly, after the skin preparation with the disinfectant for the flank, insert the 22 or 25 needle, and then connect the syringe. If the needle retreats, it indicates that there is gas. This process is safe. However, it must be noted that the free gas in the abdominal cavity does not necessarily indicate the perforation of the digestive tract. It may occur in the infection of the whole abdomen or abdominal cavity caused by alveolar rupture, and may not even find the cause.
Diagnosis
Diagnosis and differentiation of neonatal gastric perforation
Diagnosis depends mainly on clinical manifestations, 2 to 7 days after birth, sudden abdominal pain, diffuse peritonitis, abdominal plain film showing a large amount of free gas under the eyes.
It should be distinguished from fecal peritonitis. In the fecal peritonitis, the diaphragm is stuck with the liver. There is no or only a small amount of free gas in the right axilla. The small intestine is located in the middle of the abdomen and sticks into a group. Therefore, there is only a small gas-liquid plane in the abdominal plain film. The calcification point can be seen.
