Clinical characteristics and outcomes of neonatal gastrointestinal perforation

doi:10.3877/cma.j.issn.1673-5250.2022.06.012

Objective

To investigate the etiology, clinical characteristics, treatment and outcomes of neonatal gastrointestinal perforation.

Methods

From January 2020 to April 2022, 63 neonates with gastrointestinal perforation were selected into this study. According to different kinds of digestive tract perforation, they were divided into intestinal perforation group (n=51), gastric perforation group (n=8) and unknown perforation group (n=4). The general clinical data, laboratory and imaging findings, operation-related conditions, postoperative treatment and prognosis of those 63 newborns were retrospectively analyzed. The procedure followed in this study conformed to the regulations of the Ethics Committee of West China Second University Hospital, Sichuan University and was approved by the Ethics Committee[2022(141)].

Results

①Causes of perforation: gastric perforations of neonates in gastric perforation group all were caused by congenital myometrial defect of gastric wall (8/8). Intestinal perforations of neonates in intestinal perforation group all were caused by various diseases, including neonatal necrotizing enterocolitis (NEC) (74.5%, 38/51), spontaneous intestinal perforation (SIP) (13.7%, 7/51), intestinal atresia (5.9%, 3/51), tracheoesophageal fistula and esophageal atresia (TEA) (2.0%, 1/51), meconium peritonitis (2.0%, 1/51) and Hirschsprung′s disease (2.0%, 1/51). ②Clinical manifestations: the main clinical manifestations were abdominal distension, shortness of breath, dyspnea and poor reaction, et al. ③Auxiliary inspection: 53 newborns (81.0%, 53/61) with gastrointestinal perforation showed the free gas in abdominal X-ray examination. ④Treatment: among 63 newborns, 60 cases (95.2%) underwent exploratory laparotomy, among them, 38 cases underwent laparotomy, 12 cases underwent abdominal drainage, and 10 cases underwent abdominal drainage + laparotomy. Other 3 cases were treated conservatively. ⑤Outcomes: 45 newborns (75.0%, 45/60) recovered enteral nutrition after operation, 40 cases (63.5%) were cured and discharged, 17 cases (27.0%) were discharged against medical advice, 6 patients (9.5%) died in hospital.

Conclusions

NEC, SIP and congenital myometrial defect of gastric wall are the main causes of neonatal gastrointestinal perforation. Combined with clinical manifestations and imaging examination, early identification and active surgery may reduce the mortality rate of neonatal digestive tract perforation.

Key words: Infant, newborn, diseases, Gastrointestinal tract, Perforation, Parenteral nutrition, Enterocolitis, necrotizing, Laparotomy, Conservative treatment, Infant, newborn

表1 3组新生儿消化道穿孔患儿一般临床资料

项目	肠穿孔组(n＝51)	胃穿孔组(n＝8)	穿孔部位未明组(n＝4)
性别[例数(%)]
男	27(52.9)	8	2
女	24(38.1)	0	2
出生胎龄[周，M(Q₁，Q₃)]	34.0(30.6~37.9)	33.2(30.6~34.7)	28.3(26.0~31.3)
出生体重[g，M(Q₁，Q₃)]	1 930(1 350~2 850)	1 880(1 365~2 138)	1 010(770~1 260)
穿孔日龄[d，M(Q₁，Q₃)]	8(5~16)	2.5(1.3~3.0)	6.0(2.5~8.8)
足月儿[例数(%)]^a	15(29.4)	0	0
早产儿[例数(%)]^a	36(70.6)	8	4
28周≤出生胎龄<32周[例数(%)]^a	15(29.4)	3	2
出生胎龄<28周[例数(%)]^a	5(9.8)	0	2
2 500 g<出生体重≤3 999 g[例数(%)]^a	16(31.4)	0	0
出生体重<2 500g[例数(%)]^a	35(68.6)	8	4
1 000 g≤出生体重<1 500 g[例数(%)]^a	15(29.4)	3	2
出生体重<1 000 g[例数(%)]^a	5(9.8)	0	2
IVF-ET[例数(%)]^a	11(21.6)	1	1
生后1 min Apgar评分≤7分[例数(%)]^a	12(27.3)	0	2
外院转入[例数(%)]^a	31(60.8)	3	0
本院出生[例数(%)]^a	20(39.2)	5	4

表1 3组新生儿消化道穿孔患儿一般临床资料

项目	肠穿孔组(n＝51)	胃穿孔组(n＝8)	穿孔部位未明组(n＝4)
性别[例数(%)]
男	27(52.9)	8	2
女	24(38.1)	0	2
出生胎龄[周，M(Q₁，Q₃)]	34.0(30.6~37.9)	33.2(30.6~34.7)	28.3(26.0~31.3)
出生体重[g，M(Q₁，Q₃)]	1 930(1 350~2 850)	1 880(1 365~2 138)	1 010(770~1 260)
穿孔日龄[d，M(Q₁，Q₃)]	8(5~16)	2.5(1.3~3.0)	6.0(2.5~8.8)
足月儿[例数(%)]^a	15(29.4)	0	0
早产儿[例数(%)]^a	36(70.6)	8	4
28周≤出生胎龄<32周[例数(%)]^a	15(29.4)	3	2
出生胎龄<28周[例数(%)]^a	5(9.8)	0	2
2 500 g<出生体重≤3 999 g[例数(%)]^a	16(31.4)	0	0
出生体重<2 500g[例数(%)]^a	35(68.6)	8	4
1 000 g≤出生体重<1 500 g[例数(%)]^a	15(29.4)	3	2
出生体重<1 000 g[例数(%)]^a	5(9.8)	0	2
IVF-ET[例数(%)]^a	11(21.6)	1	1
生后1 min Apgar评分≤7分[例数(%)]^a	12(27.3)	0	2
外院转入[例数(%)]^a	31(60.8)	3	0
本院出生[例数(%)]^a	20(39.2)	5	4

表2 3组新生儿消化道穿孔患儿腹水培养和血培养病原菌分布

病原菌	腹水培养		血培养			合计
病原菌	胃穿孔组(n＝4)	肠穿孔组(n＝18)	胃穿孔组(n＝1)	肠穿孔组(n＝5)	穿孔部位未明组(n＝1)	合计
G^－菌	2	7	1	1	0	11
肺炎克雷伯菌	1	2	1	1	—	5
铜绿假单胞菌	1	—	—	—	—	1
大肠埃希菌	—	2	—	—	—	2
阴沟肠杆菌	—	1	—	—	—	1
鲍曼不动杆菌	—	1	—	—	—	1
脆弱拟杆菌	—	1	—	—	—	1
G⁺菌	3	17	0	4	1	25
溶血葡萄球菌	2	3	—	1	—	6
口腔/缓症链球菌	1	—	—	—	—	1
屎肠球菌	—	9	—	1	1	10
粪肠球菌	—	3	—	—	—	3
表皮葡萄球菌	—	2	—	1	—	3
金黄色葡萄球菌	—	—	—	1	—	1
合计	5	24	1	5	1	36

表2 3组新生儿消化道穿孔患儿腹水培养和血培养病原菌分布

病原菌	腹水培养		血培养			合计
病原菌	胃穿孔组(n＝4)	肠穿孔组(n＝18)	胃穿孔组(n＝1)	肠穿孔组(n＝5)	穿孔部位未明组(n＝1)	合计
G^－菌	2	7	1	1	0	11
肺炎克雷伯菌	1	2	1	1	—	5
铜绿假单胞菌	1	—	—	—	—	1
大肠埃希菌	—	2	—	—	—	2
阴沟肠杆菌	—	1	—	—	—	1
鲍曼不动杆菌	—	1	—	—	—	1
脆弱拟杆菌	—	1	—	—	—	1
G⁺菌	3	17	0	4	1	25
溶血葡萄球菌	2	3	—	1	—	6
口腔/缓症链球菌	1	—	—	—	—	1
屎肠球菌	—	9	—	1	1	10
粪肠球菌	—	3	—	—	—	3
表皮葡萄球菌	—	2	—	1	—	3
金黄色葡萄球菌	—	—	—	1	—	1
合计	5	24	1	5	1	36

表3 3组新生儿消化道穿孔患儿治疗方案

组别	例数	仅剖腹探查术	仅腹腔引流术	腹腔引流术+剖腹探查术	保守治疗
肠穿孔组	51	31(60.8)	10(19.6)	9(17.6)	1(0.2)
胃穿孔组^a	8	7	0	1	0
穿孔部位未明组^a	4	0	2	0	2
合计	63	38(60.3)	12(20.0)	10(15.9)	2(3.2)

表3 3组新生儿消化道穿孔患儿治疗方案

组别	例数	仅剖腹探查术	仅腹腔引流术	腹腔引流术+剖腹探查术	保守治疗
肠穿孔组	51	31(60.8)	10(19.6)	9(17.6)	1(0.2)
胃穿孔组^a	8	7	0	1	0
穿孔部位未明组^a	4	0	2	0	2
合计	63	38(60.3)	12(20.0)	10(15.9)	2(3.2)

表4 不同病因所致新生儿消化道穿孔的临床特点

项目	NEC组(n＝38)	非NEC组(n＝20)	病因未明组(n＝5)^c
性别[例数(%)]
男	20(52.6)	15(75.0)	2
女	18(47.3)	5(25.0)	3
出生胎龄[周，M(Q₁，Q₃)]	35.0(30.5，35.0)	32.4(30.6，34.7)	29.6(26.3，31.3)
出生体重[g，M(Q₁，Q₃)]	1 995.0(1 395.0，2 907.0)	1 685.0(1 315.0，2 222.5)	1 040.0(840.0，1 300.0)
穿孔日龄[d，M(Q₁，Q₃)]	9.5(5.8，17.0)	3.5(2.0，8.5)	4.0(2.5，8.5)
足月儿[例数(%)]	12(31.6)	3(15.0)	0
早产儿[例数(%)]	26(68.4)	17(85.0)	5
辅助检查
气腹[例数(%)]	30(78.9)	16(80.0)	5(100.0)
腹水培养(G⁺例数/G^－例数)^a	16/7	4/2	－
血培养(G⁺例数/G^－例数)^b	1/1	3/1	1/0
术前Hb最低值[g/L，M(P₁，P₁₀₀)]	107(79，194)	151(92，195)	111(75，196)
术前PLT最低值[×10⁹/L，M(P₁，P₁₀₀)]	111.5(4.0，534.0)	235(6.0，554.0)	49.0(47.0，170.0)
术前CRP>10 mg/L[%(n/n′)]	86.8(33/38)	26.3(5/19)	0(0/3)
治疗方案[%(n/n′)]
仅剖腹探查术	57.9(22/38)	84.2(16/19)	0(0/3)
仅腹腔引流术	21.1(8/38)	5.3(1/19)	100.0(3/3)
腹腔引流术+剖腹探查术	21.1(8/38)	10.5(2/19)	0(0/3)
术后恢复肠内营养[%(n/n′)]	76.3(29/38)	73.7(14/19)	66.7(2/3)
手术至恢复喂养时间[d，M(P₁，P₁₀₀)]	7.0(3.0，19.0)	7.5(3.0，21.0)	14.5(14.0，15.0)
结局[例数(%)]
治愈出院	26(68.4)	13(65.0)	1
住院死亡	3(7.9)	3(15.0)	0
自动出院	9(23.7)	4(20.0)	4

表4 不同病因所致新生儿消化道穿孔的临床特点

项目	NEC组(n＝38)	非NEC组(n＝20)	病因未明组(n＝5)^c
性别[例数(%)]
男	20(52.6)	15(75.0)	2
女	18(47.3)	5(25.0)	3
出生胎龄[周，M(Q₁，Q₃)]	35.0(30.5，35.0)	32.4(30.6，34.7)	29.6(26.3，31.3)
出生体重[g，M(Q₁，Q₃)]	1 995.0(1 395.0，2 907.0)	1 685.0(1 315.0，2 222.5)	1 040.0(840.0，1 300.0)
穿孔日龄[d，M(Q₁，Q₃)]	9.5(5.8，17.0)	3.5(2.0，8.5)	4.0(2.5，8.5)
足月儿[例数(%)]	12(31.6)	3(15.0)	0
早产儿[例数(%)]	26(68.4)	17(85.0)	5
辅助检查
气腹[例数(%)]	30(78.9)	16(80.0)	5(100.0)
腹水培养(G⁺例数/G^－例数)^a	16/7	4/2	－
血培养(G⁺例数/G^－例数)^b	1/1	3/1	1/0
术前Hb最低值[g/L，M(P₁，P₁₀₀)]	107(79，194)	151(92，195)	111(75，196)
术前PLT最低值[×10⁹/L，M(P₁，P₁₀₀)]	111.5(4.0，534.0)	235(6.0，554.0)	49.0(47.0，170.0)
术前CRP>10 mg/L[%(n/n′)]	86.8(33/38)	26.3(5/19)	0(0/3)
治疗方案[%(n/n′)]
仅剖腹探查术	57.9(22/38)	84.2(16/19)	0(0/3)
仅腹腔引流术	21.1(8/38)	5.3(1/19)	100.0(3/3)
腹腔引流术+剖腹探查术	21.1(8/38)	10.5(2/19)	0(0/3)
术后恢复肠内营养[%(n/n′)]	76.3(29/38)	73.7(14/19)	66.7(2/3)
手术至恢复喂养时间[d，M(P₁，P₁₀₀)]	7.0(3.0，19.0)	7.5(3.0，21.0)	14.5(14.0，15.0)
结局[例数(%)]
治愈出院	26(68.4)	13(65.0)	1
住院死亡	3(7.9)	3(15.0)	0
自动出院	9(23.7)	4(20.0)	4

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