新生儿宫内肠扭转临床与超声特点及预后分析

肖秀漫; 朱利斌; 姜娜; 潘尹; 林进汉; 王荣跃; 朱将虎; 陈尚勤

doi:10.16766/j.cnki.issn.1674-4152.002987

新生儿宫内肠扭转临床与超声特点及预后分析

doi: 10.16766/j.cnki.issn.1674-4152.002987

1.
温州医科大学附属第二医院育英儿童医院新生儿科，浙江温州 325027
2.
温州医科大学附属第二医院育英儿童医院小儿外科
3.
温州医科大学附属第二医院育英儿童医院超声科
4.
温州医科大学附属第二医院育英儿童医院产科

基金项目:

浙江省基础公益研究计划项目 LGF21H040009

温州市基础性科研项目 Y2020075

详细信息

通讯作者:
陈尚勤，E-mail: csq5725@126.com

中图分类号: R722 R445.1
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出版历程
- 收稿日期: 2021-12-24

Clinical and ultrasonic characteristics and prognosis of neonatal intrauterine volvulus

1.
Department of Neonatology, Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China

摘要

摘要: 目的分析宫内肠扭转患儿的临床特点和预后，为减少漏诊误诊、改善预后提供依据。方法回顾性分析2015年6月—2020年4月温州医科大学附属第二医院育英儿童医院收治的经生后术中证实为宫内肠扭转患儿的临床资料。结果共10例患儿纳入研究，男4例，女6例；剖宫产6例，阴道分娩4例；早产6例(4例因宫内窘迫行剖宫产)，足月4例。产前二维超声显示7例有肠管扩张，2例有典型的“漩涡征”，3例有腹水，4例二维超声表现为腹腔囊性包块，2例存在羊水过多。产前胎心率异常5例。生后主要表现为立即出现腹胀(10例)，呕吐胆汁样物质(4例)，胎便未排8例(8例)，血便(2例)，贫血(7例)；腹腔穿刺7例，6例为血性不凝血，1例为粪汁样液。10例患儿均在48 h内手术，术中节段性肠扭转5例，中肠扭转5例。7例肠管坏死，其中1例肠管大范围坏死，家属术中放弃治疗；1例因住院期间继发感染放弃治疗死亡。8例存活，存活率为80%(8/10)。结论产前二维超声提示典型“漩涡征”、肠管扩张伴腹水或腹腔包块进行性增大时需警惕胎儿宫内肠扭转。若产前二维超声提示肠管扩张，生后立即出现腹胀、呕吐胆汁样物质或血便等消化道症状，同时伴有贫血，应高度怀疑宫内肠扭转，腹腔穿刺液为血性基本能明确诊断。多学科合作，选择合适的时机分娩，生后尽早手术探查和积极的围手术期治疗是提高患儿存活率的关键。
- 宫内肠扭转 /
- 临床特点 /
- 超声 /
- 预后 /
- 新生儿
Abstract: Objective To analyse the clinical characteristics and prognosis of children with intrauterine volvulus for reducing misdiagnosis and improving prognosis. Methods A retrospective review was conducted with intrauterine volvulus confirmed by postnatal operation in Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University from June 2015 to April 2020. Results Ten children (4 males and 6 females) were included in the study. Six of them were born through caesarean section and 4 were via vaginal delivery. Among the children, 6 were preterm infants (4 cases born for caesarean section due to foetal distress) and 4 were full-term infants. Of the 10 foetuses, 7 had intestinal dilatation, 2 showed typical "vortex sign", 3 had ascites, 4 had abdominal cystic mass and 2 had polyhydramnios, which was discovered by antenatal 2D ultrasound. 5 cases had abnormal foetal heart rate before delivery. Among all the cases, 10 had abdominal distension, 4 vomited bile-like material, 8 had no foetal discharge, 2 had bloody stool immediately after birth and 7 had anaemia. Of the 10 cases, 7 had abdominal puncture, 6 had uncoagulable blood and 1 had faecal turbid liquid. All the 10 cases were operated within 48 hours, 5 cases with segmental volvulus and 5 cases with midgut volvulus. Eight cases were recovered and discharged from hospital. One neonate died because of massive necrosis of small intestine, and one baby died due to secondary infection. The survival rate was 80% (8/10). Conclusion Foetal intrauterine volvulus should be considered when prenatal ultrasound showed typical "vortex" sign and intestinal dilatation with ascites or progressive enlargement of abdominal cystic mass. If prenatal ultrasound showed intestinal dilatation and the patient had gastrointestinal symptoms such as abdominal distension, vomiting bile-like material or bloody stool immediately after birth, accompanied by anaemia, then intrauterine volvulus should be highly suspected. If peritoneal puncture fluid was bloody, then a definite diagnosis could be made. The key to improve the survival rate was multidisciplinary cooperation, the right time for delivery, early operation and active perioperative treatment.
- Intrauterine volvulus /
- Clinical features /
- Ultrasound /
- Prognosis /
- Neonate
利益冲突 无

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图 1 病例4转产前胎儿超声影像

注：术中明确中肠扭A为孕34周二维超声显示胎儿肠管扩张(箭头)；B为胎儿肠管扩张伴腹腔积液(箭头)。

Figure 1. The fetal ultrasound image for case 4 before conversion

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图 2 病例5产前胎儿超声影像

注：术中明确中肠扭转A为孕34周二维超声显示胎儿肠管扩张，肠壁增厚，呈“漩涡”征；B为孕34周扩张的肠管壁少量血流信号；C为超声显示腹腔积液(箭头)。

Figure 2. Prenatal fetal ultrasound image for case 5

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图 3 病例3产前胎儿超声影像

注：术中明确节段性肠扭转A为孕29⁺周二维超声显示胎儿腹腔液实混合回声团，大小约70 mm×50 mm；B为孕29⁺周混合回声团少量血流信号；C为孕31周超声显示液实混合回声团增大，约82 mm×54 mm；D为孕31周混合回声团未见血流信号。

Figure 3. Prenatal fetal ultrasound image for case 3

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表 1 10例肠扭转诊断孕周、产前超声表现及分娩方式

Table 1. Diagnostic gestational age, antenatal ultrasound findings and mode of delivery in 10 cases of intestinal volvulus

病例号	诊断孕周	产前超声表现	分娩方式
1	20周	肠管扩张	孕35⁺周胎心减慢、宫内窘迫剖宫产
2	31周	腹腔囊性包块，随访超声腹腔囊性包块进行性增大	孕39⁺周胎心监护基线平、宫内窘迫剖宫产
3	29周	腹腔囊性包块、肠管扩张、羊水过多	孕32⁺周胎膜早破阴道分娩
4	34周	肠管扩张、腹腔积液	孕34⁺周胎心慢、宫内窘迫剖宫产
5	34周	漩涡征、肠管扩张、腹腔积液	孕34⁺周胎心慢、宫内窘迫剖宫产
6	26周	漩涡征、肠管扩张、腹腔积液	孕35⁺周胎膜早破阴道分娩
7	22周	肠管扩张、肠壁增厚	孕38⁺周阴道分娩
8	34周	腹腔囊性包块	孕37⁺周阴道分娩
9	38周	肠管扩张	孕38⁺周羊水少剖宫产
10	32周	腹腔囊性包块、羊水过多	孕32⁺周胎心慢、宫内窘迫剖宫产

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表 2 10例患儿手术小时龄、手术方式、术中所见及随访结果

Table 2. Operative age, operative method, intraoperative findings and follow-up results of 10 cases

病例号	手术时间	手术方式	术中所见	住院时间及伴发畸形	随访结果
1	生后12 h内	坏死肠管切除+小肠双腔造瘘	小肠坏死，自身顺时针扭转720°；胆囊呈条索状；胆道闭锁可能	77 d合并胆道闭锁	好转出院，后因胆道闭锁行肝移植，现纠正月龄17个月，生长发育基本同正常同龄儿
2	生后24 h	肠系膜囊肿切除+肠扭转复位	肠系膜附着不全，囊肿位于肠系膜，中肠顺时针扭转720°，大部分小肠坏死，剩余小肠10 cm	2 d	因小肠基本坏死，家属放弃治疗后死亡
3	生后12 h	肠扭转复位+坏死小肠切除+小肠-小肠吻合术	小肠逆时针扭转540°，扭转的小肠坏死	34 d	现16个月龄，生长发育同正常同龄儿
4	生后12 h	坏死小肠切除，空肠-升结肠吻合	肠管根部系膜顺时针扭转1 080°，扭转肠管坏死发黑	25 d	现3周6个月龄，生长发育同正常同龄儿
5	生后12 h内	坏死小肠切除，末端回肠-升结肠吻合	中肠顺时针扭转1 080°，扭转肠管坏死发黑	19 d	现3周3个月龄，生长发育同正常同龄儿
6	生后12 h	闭锁肠管切除，回肠-结肠侧端吻合+末端回肠造瘘术	小肠距回盲部2 cm闭锁，闭锁近端回肠扭转，闭锁远端小肠+回盲部+升结肠均细小	66 d	住院期间继发感染，家属放弃治疗死亡
7	生后24~48 h	部分小肠+回盲部+部分升结肠切除，小肠-升结肠吻合	中肠系膜附着发育不良伴逆时针扭转900°，扭转肠管发黑坏死，肠穿孔	32 d胼胝体急性脑梗死，右侧颞顶叶脑软化	现5周6个月龄，生长发育落后于正常同龄儿
8	生后48 h	ladds术+肠切除肠吻合	部分小肠逆时针扭转540°，扭转的中肠有一段肠管极度扩张、水肿	27 d	现15个月龄，生长发育同正常同龄儿
9	生后24~48 h	闭锁肠管切除+肠吻合	距十二指肠悬韧带70 cm有一索带，其远端20 cm肠管顺时针扭转720°，形成闭锁	17 d	现13个月龄，生长发育同正常同龄儿
10	生后24~48 h	坏死肠管切除+末端回肠双腔造瘘+肠粘连松解	腹腔大量粘连，囊腔为肠扭转后近端扩张肠管，扭转肠管坏死穿孔，距离十二指肠悬韧带60 cm处肠管扭转360°后闭锁	85 d	纠正月龄6个月，生长发育基本同正常同龄儿

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