常见的NEC(新生儿坏死性小肠结肠炎).ppt

* 肠壁损害：由于新生儿窒息/肺透明膜病、严重败血症、休克、低血压、缺氧等情况引起血液重新分布，肠管血液供应减少，可达正常情况下的35％~50%，肠壁肌肉缺血痉挛，加重缺血性损伤。肠管粘液分泌减少，屏障作用削弱，损伤加重。 肠缺血：宫内胎盘血流减少和生后系统血流减少如PDA先心病等情况下NEC风险增加。NEC动物试验显示肠道缺血引发的细胞因子风暴如PAF血小板活化因子，TNF-A，补体，前列腺素，白细胞介素等导致去甲肾上腺素释放血管收缩，内脏缺血再灌注损伤。黏膜屏障破坏可导致肠坏死，细菌异位，内毒素损伤组织。白细胞激活，肠道上皮细胞在酶作用下产生氧自由基加重损伤，细胞坏死，实验证明PAF抑制剂可减轻肠道黏膜损伤。 * 致病菌在肠道内酵解碳水化合物的产物 乙酸、丙酸、丁酸 主要部位结肠 正常菌群可分解糖类为乳酸 不损伤肠道黏膜 菌群失调，SCFAs产生过度，损伤黏膜 增加肠腔渗透压 增加回盲部反流 增加致病菌繁殖 * LAB检查：持续几天的酸中毒，血小板减少，血糖升高提示NEC 白细胞大于30乘109，PH7.25，血糖在24小时内升高超过1.5mmol/L提示肠穿孔。 诊断NEC后头3天出现严重血小板减少提示肠坏死发生率及死亡率增加。但是血小板不能单独作为疾病的严重程度及预后指标。 监测血中细胞因子的水平对于判断NEC的严重度也有帮助。 I-FABP存在于小肠绒毛顶端细胞内，具有组织特异性，测定血中水平有助于诊断肠黏膜损伤程度，早期就明显升高，有Guthmann报道L-FABP在I期就有增加，更敏感。Reed认为CBG更早 * In addition to bowel dilation suggestive of an obstruction, this radiograph shows a more obvious case of pneumatosis intestinalis. A large segment of bowel in the patients left lower region (cigar shaped) shows obvious intramural air along its length. In a meta-analysis of trial data, enteral probiotics supplementation significantly reduced the incidence of severe NEC (stage II or more) (typical relative risk (RR) 0.43, 95% confidence interval (CI) 0.33 to 0.56; 20 studies, 5529 infants) and mortality (typical RR 0.65, 95% CI 0.52 to 0.81; 17 studies, 5112 infants). There was no evidence of significant reduction of nosocomial sepsis (typical RR 0.91, 95% CI 0.80 to 1.03; 19 studies, 5338 infants). 第一部分 Epigenetics of PPHN * There was no evidence of an effect on long-term growth rates or neurodevelopmental outcomes. Meta-analysis of data from five trials demonstrated a statistically significantly higher incidence of necrotising enterocolitis in the formula fed group: typical relative risk 2.5 (95% confidence interval 1.2, 5.1); typical risk difference: 0.03 (95% confidence interval 0.01, 0.06; number needed to harm: 33 (95% confidence interval 17, 100). 第一部分 Epigenetics of PPHN * The trials defined delayed introduction as later than five to seven days after birth and early introduction as less than f