Acute hemorrhagic necrotizing enteritis

　　The etiology of acute hemorrhagic necrotizing enteritis has not been fully elucidated. It is currently believed that the onset of the disease is related to the infection of Welchii bacillus (Clostridium perfringens type C) that produces B toxin. The B toxin can cause necrosis of intestinal tissue and produce gangrenous enteritis. The occurrence of the disease is not only related to eating contaminated meat, but also to other dietary factors, such as sudden changes in dietary habits, from eating more vegetables to eating more meat, which changes the intestinal ecology, favoring the proliferation of Welchii bacillus; or if the diet is mainly sweet potatoes, the large presence of trypsin inhibitors in the intestines reduces the destruction of B toxin.

　　After acute hemorrhagic necrotizing enteritis, local mesenteric lymph node enlargement and softening can be seen; liver fatty degeneration, acute splenitis, interstitial pneumonia, pulmonary edema; some may also be accompanied by adrenal focal necrosis. Severe cases may have symptoms of toxicity such as shock and intestinal paralysis, and complications such as intestinal perforation, and the following will be introduced in detail.

　　1. Intestinal obstruction

　　Due to the action of bacteria and endotoxins, the intestinal wall becomes congested, edematous, loses elasticity, and stops peristalsis, leading to intestinal stasis and symptoms of intestinal obstruction. Clinically, it is easy to be misdiagnosed as mechanical intestinal obstruction.

　　2. Shock and disseminated intravascular coagulation (DIC)

　　Bacteria and endotoxins absorbed into the blood cause systemic toxicity and hemodynamic disorders, about 1/4 of the patients may develop toxic shock, or accompanied by DIC.

　　Acute hemorrhagic necrotizing enteritis (AHNE) is a life-threatening fulminant disease. The typical symptoms of this disease mainly include the following points:

　　1. Medical history

　　Onset is acute, and there is often a history of unclean eating before onset. Exposure to cold, fatigue, intestinal ascaris infection, and malnutrition are predisposing factors.

　　2. Abdominal pain

　　Onset is acute, with sudden abdominal pain, which is often the first symptom, mostly around the umbilicus. In the early stage, it often manifests as gradually increasing cramping pain around the umbilicus or upper abdomen, which then gradually becomes persistent pain with periodic exacerbation.

　　3. Diarrhea

　　Diarrhea may occur after the occurrence of hematochezia and abdominal pain. The stool is initially paste-like with fecal matter, and then gradually becomes yellow water-like, followed by white water-like or red bean soup and jam-like, even red or dark red blood clots, and the stool is less and has a bad smell. There is no urgent need to defecate. The amount of bleeding is not fixed, and the mild may only have diarrhea, or may only be positive for fecal occult blood without hematochezia; severe may reach hundreds of milliliters a day. The duration of diarrhea and hematochezia is short, only 1～2 days, and the long may reach over a month, and may present intermittently or repeatedly. Severe diarrhea may lead to dehydration and metabolic acidosis.

　　4. Nausea and vomiting

　　It often occurs simultaneously with abdominal pain and diarrhea. The vomit may be yellow water-like, coffee-like, or bloodwater-like, and may also vomit bile.

　　5. General symptoms

　　General symptoms such as malaise, weakness, and fever may appear after onset. The body temperature is generally 38～39℃, a few may reach 41～42℃, but fever usually recedes after 4～7 days, and it is rare to last for more than 2 weeks.

　　6. Abdominal signs

　　Relatively rare. Sometimes there may be abdominal distension, and the intestinal type may be seen. There may be significant tenderness around the umbilicus and upper abdomen. Early bowel sounds may be hyperactive, and then may weaken or disappear.

　　Acute hemorrhagic necrotizing enteritis should pay attention to dietary hygiene and good rest during the high-incidence summer and autumn seasons. Children of appropriate age should follow the national immunization plan for regular deworming and combine work with rest. Pay attention to the following aspects in diet to reduce the occurrence of acute hemorrhagic necrotizing enteritis.

　　1, Avoid eating undercooked or spoiled meat, especially raw meat during the high-incidence season.

　　2, Avoid eating foods that destroy intestinal protease in large quantities, such as sweet potatoes, especially when eating raw seafood or possibly undercooked grilled meat (such as lamb skewers), avoid eating large quantities of such foods at the same time.

　　3, Balanced diet, avoid overeating and binge eating.

　　Acute hemorrhagic necrotizing enteritis has an acute onset. Due to unclean diet and other reasons, the disease can occur suddenly. Generally, the following examinations are needed for this disease.

　　1, Blood count

　　Peripheral blood leukocyte count is increased, even up to 40×10^9/L or more, mainly neutrophils, often with left shift of the nucleus. Red blood cells and hemoglobin are often decreased.

　　2, Fecal examination

　　The appearance is dark red or bright red, or strong positive occult blood test, and under the microscope, a large number of red blood cells are seen, occasionally with shed intestinal mucosa. There may be a small or moderate amount. Under certain conditions, fecal gas gangrene bacterium culture and endotoxin detection can be performed.

　　3, X-ray examination

　　The abdominal flat film can show intestinal paralysis or mild to moderate intestinal dilation. Barium enema examination can show thickening of the intestinal wall, significant edema, and disappearance of colonic haustra. In some cases, there may be gas between the intestinal walls, which is a sign of partial intestinal wall necrosis caused by bacterial invasion of the colon; or there may be ulcers or polypoid lesions and rigidity. Some cases may also present with intestinal spasm, stricture, and cystic gas in the intestinal wall.

　　For patients with acute hemorrhagic necrotizing enteritis, in addition to medication, a reasonable diet is very important for the cure of the disease. Below, I will teach you how acute hemorrhagic necrotizing enteritis patients should eat.

　　One, the patient's diet should mainly consist of low-fat and low-fiber foods. In the early stage, only light liquid foods such as thick rice porridge, dilute fruit juice, soup, and hot tea can be eaten to quench thirst.

　　Two, a large amount of beverages rich in vitamin C, such as fresh orange juice and tomato juice, should be consumed daily. If possible, fortified vitamin C juice is even more ideal (that is, beverages containing vitamin C tablet extracts).

　　Three, after the frequency of defecation decreases, some liquid foods such as meat soup (without oil), milk, soy milk, and egg drop soup can be consumed. Subsequently, a light, low-fat, and low-fiber semi-liquid diet can be gradually introduced, such as rice porridge, lotus root starch, and noodles.

　　Four, when diarrhea completely stops, soft foods such as egg custard, fish slices, minced tender meat, and vegetable puree can be increased. Even if the appetite is strong, only a small amount of food should be eaten in multiple meals, and the total amount of food per meal should not be too much to facilitate digestion.

　　Five, when the fermentation in the intestines is too strong, it is advisable to eat foods containing protein and a small amount of fat, such as milk, eggs, soy milk, tofu, etc.; and to eat less sugar, as sugar is easy to ferment and produce gas. When the putrefaction in the intestines is very strong, it is advisable to eat starchy foods such as potatoes, taros, rice, and flour; and to eat less meat, eggs, fish, and other protein-rich foods that are easy to cause intestinal putrefaction.

　　The treatment of acute hemorrhagic necrotizing enteritis should mainly be non-surgical, strengthening systemic supportive therapy, correcting water and electrolyte imbalance, alleviating poisoning symptoms, actively preventing and treating toxic shock and other complications. The following is an introduction to common non-surgical treatment methods.

　　1. General treatment

　　Rest, fasting, and during the period of abdominal pain, hematochezia, and fever, complete bed rest and fasting should be maintained. Only after vomiting stops, hematochezia decreases, and abdominal pain subsides can fluid diet be gradually increased. During the period of fasting, high-nutrition fluids such as 10% glucose, compound amino acids, and hydrolyzed protein should be infused intravenously. Early intake of food may lead to recurrence of the disease, but delayed recovery of food intake may affect nutritional status and delay recovery. Severe abdominal distension and vomiting can be treated with gastrointestinal decompression. Antispasmodics can be given for abdominal pain.

　　2. Correcting water and electrolyte imbalance

　　This disease is more common with dehydration, sodium loss, and potassium loss. The total volume and composition of fluid infusion can be determined according to the condition.

　　3. Antishock

　　Rapidly replenish the effective circulating blood volume. In addition to replenishing crystalloids, appropriate amounts of plasma, fresh whole blood, or human serum albumin and other colloidal fluids should be infused. For patients with unraised blood pressure, vasoactive drugs can be used in conjunction with drug treatment, such as α-receptor blockers, β-receptor stimulants, or anisodamine, etc., which can be selected according to circumstances.

　　4. Antibiotics

　　Controlling intestinal infection can alleviate clinical symptoms, and commonly used antibiotics include ampicillin, chloramphenicol, gentamicin, kanamycin, amoxicillin, Tazocin, polymyxin, and cephalosporins, etc., usually selected in combination with two.

　　5. Adrenal cortical hormones

　　It can alleviate the symptoms of poisoning, suppress allergic reactions, and also help correct shock, but there is a risk of aggravating intestinal bleeding and causing intestinal perforation. Generally, it should not be used for more than 3-5 days and should be administered intravenously.

　　6. Symptomatic therapy

　　Severe abdominal pain can be treated with meperidine; patients with high fever and restlessness can be given oxygen inhalation, antipyretic drugs, sedatives, or physical cooling.

　　7. Antitoxic serum

　　The intravenous infusion of antitoxic serum against Welchii bacillus has good curative effect.