新生儿牛奶蛋白过敏性直肠结肠炎11例临床分析

Clinical analysis of neonatal milk protein-induced allergic proctocolitis

目的分析新生儿牛奶蛋白过敏性直肠结肠炎(allergic proctocolitis,AP)的临床特点,提高对本病的诊治水平。方法回顾性分析2018年1月至2020年6月湖北省妇幼保健院新生儿科收治的牛奶蛋白AP患儿资料,包括临床表现、相关实验室及影像学检查、电子结肠镜与组织病理学检查、皮肤点刺试验结果,以及诊疗经过与转归情况。结果共纳入11例AP患儿。首发症状最常见血便,其次是腹胀、腹泻、呕吐。11例均出现血便,腹胀5例,腹泻3例,呕吐3例,发热、反应低下、呼吸暂停各1例。混合喂养4例,人工喂养7例,发病日龄3~12 d(平均8.1 d)。便常规均提示潜血阳性,2例有白细胞、红细胞,便培养均阴性。血炎性指标正常9例,超敏C反应蛋白、降钙素原增高2例,嗜酸性粒细胞比例增高8例,皮肤点刺试验阳性3例。胸腹立卧位X线片正常4例,局部肠管充气、扩张3例,局部肠壁水肿、增厚2例,肠管排列与走行僵硬、肠壁透亮影2例。腹部超声正常2例,肠胀气6例,肠胀气伴少量腹腔积液或肠蠕动差3例。11例肠镜检查均可见肠黏膜充血、水肿,伴肠黏膜糜烂8例、黏膜出血5例、溃疡灶5例。组织病理学示结肠黏膜间质可见炎性细胞浸润,局灶区间可见嗜酸性粒细胞浸润,5~30个/HPF。起病后均调整为深度水解配方奶或氨基酸配方奶喂养,3~7 d(平均4.3 d)后症状消失。结论新生儿AP可发生在生后第1周内,血便是主要临床症状,缺乏特异性临床特征及检查手段,临床需依据症状、实验室与影像学检查结果、诊断性回避牛奶蛋白后症状明显改善、结肠镜及病理活检特征性改变并排除其他病因后诊断。回避过敏原是主要干预措施,预后良好。

Objective To study the clinical features of eleven neonates with milk protein-induced allergic proctocolitis(AP)and improve the diagnosis and treatment of AP.Method From January 2018 to June 2020,AP patients admitted to the neonatal department of our hospital were retrospectively reviewed,including clinical manifestations,relevant laboratory and imaging examinations,electronic colonoscopy,histopathologic features,skin prick test results,treatment and outcome.Result A total of 11 AP cases were included.(1)Clinical features:The onset symptoms included bloody stool,abdominal distension,diarrhea and vomiting.All 11 cases had bloody stool,5 cases had abdominal distension,3 cases had diarrhea,3 cases had vomiting,1 case had fever,1 case had lethargy and 1 case had apnea.4 cases were breast-and-formula-mixed-fed and 7 cases were formula-fed.Age of onset was 3~12 days(mean 8.1 days).(2)Laboratory and imaging examination:All cases had positive occult blood on stool routine test,2 cases had WBC and RBC in the stool and negative stool culture.9 cases had normal inflammatory index in the blood,2 cases had increased hypersensitive C-reactive protein and procalcitonin,8 cases had increased eosinophil ratio and 3 cases had positive skin prick test.4 cases had normal chest and abdominal X-ray images,3 cases had intestinal inflation and dilation,2 cases had focal intestinal wall edema and thickening and 2 cases had rigid intestinal appearance and intestinal wall lucency.2 cases had normal abdominal ultrasound,6 cases had intestinal flatulence and 3 cases had intestinal flatulence with small amount of abdominal fluid or poor peristalsis.(3)Colonoscopy and histological features:All 11 cases had intestinal mucosa congestion and edema,8 cases had erosion,5 cases had mucosa bleeding and 5 cases had ulcer.Histopathology showed inflammatory cell infiltration in colonic mucosa and eosinophilic granulocyte infiltration in the focal region(5~30 units/HPF).(4)Clinical outcome:The patients were fed with deep-hydrolyzed formula milk or amino acid formula milk and the symptoms disappeared after 3~7 days(mean 4.3 days).Conclusion Neonatal AP may occur during the first week of life and bloody stool is the main symptom.Due to the lack of specific clinical features and examination methods,clinical diagnosis should be established based on multiple factors including clinical symptoms,laboratory and imaging examination results,significant improvement of symptoms after milk protein avoidance,colonoscopy results and pathological biopsy.Exclusion of other etiologies is needed.Avoidance of allergens is the main intervention measure and the prognosis is good.