Case 81-高點醫護網
高點醫護網

篇名
Case 81
說明
今日案例:
10 天大男童,出生體重為2,050 公克,出生週數為34 週,因腹脹求診,身體診查顯示倦怠、活力不佳…
敘述 【此題目來自考選部】
10 天大男童,出生體重為2,050 公克,出生週數為34 週,因腹脹求診,身體診查顯示倦怠、活力不佳。血液檢查:白血球9,250/μL(segment 15%,band form 22%,lymphocyte 30%,monocyte 1%,eosinophil 1.2%),血紅素為15 g/dL,血小板220,000 /μL。ALT 77 U/L、AST 72 U/L。腹部外觀、X光、大便如圖所示
請問
考慮最有可能之診斷為何?
解答
壞死性小腸結腸炎(Necrotizing enterocolitis,NEC)
說明
壞死性小腸結腸炎(Necrotizing enterocolitis,NEC)是一種發生在早產兒的常見病,除可能引起腸壞死之外,嚴重時會有生命危險,是早產兒第二常見死亡原因。根據統計,出生越早的嬰兒,越容易得NEC(the timing of its onset is generally inversely proportional to the gestational age of the baby at birth),而體重低於1500克的新生兒(very low-birth-weight infants),也有5%-10%罹患NEC的可能。NEC最常發生在回腸遠端和結腸近端(回盲瓣附近),小腸很少受累,腹部X光可見部分腸壁囊樣積氣等特點。

導致NEC的病因仍不明確,細菌如大腸桿菌、克雷白桿菌、綠膿桿菌、沙門氏菌、梭狀芽胞桿菌等感染是其中因素之一,可造成腸黏膜損傷;此外,根據觀察,餵養配方奶粉比母乳餵養的嬰兒易罹患NEC,其發生機率可高出十倍,可能是母乳中的免疫球蛋白具有保護嬰兒抗感染作用,所以發生NEC較少;藥物可損傷腸黏膜,食物中營養成分有利於腸道細菌生長。

NEC初期症狀包括餵養不耐受(feeding intolerance)、胃殘留物增多(increased gastric residuals)、腹脹(abdominal distension)、便血(bloody stools)。症狀可迅速惡化,引起腸穿孔(intestinal perforation)、腹膜炎(and peritonitis)。NEC可藉Bell三步驟來診斷,初期診斷是往往根據醫師經驗來判斷,臨床確診則需要影像學檢查來協助(Specific radiographic signs of NEC are associated with specific Bells stages of the disease):
Bells
stage 1
Suspected disease
  1. Mild systemic disease (apnoea, bradycardia, temperature instability)
  2. Mild intestinal signs (abdominal distention, gastric residuals, bloody stools)
  3. Non-specific or normal radiological signs
Bells
stage 2
Definite disease
  1. Mild to moderate systemic signs
  2. Additional intestinal signs (absent bowel sounds, abdominal tenderness)
  3. Specific radiologic signs (pneumatosis intestinalis or portal venous air)
  4. Laboratory changes (metabolic acidosis, thrombocytopaenia)
Bells
stage 3
Advanced disease
  1. Severe systemic illness (hypotension)
  2. Additional intestinal signs (striking abdominal distention, peritonitis)
  3. Severe radiologic signs (pneumoperitoneum)
  4. Additional laboratory changes (metabolic and respiratory acidosis, disseminated intravascular coagulation)
關鍵詞
壞死性、小腸結腸炎、大腸桿菌、克雷白桿菌、腸道細菌
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