Ileus in children presenting with diarrhea and severe acute malnutrition: A chart review.
Ileus in children presenting with diarrhea and severe acute malnutrition: A chart review.
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DOI：
10.1371/journal.pntd.0005603
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发表时间：
2017-05
影响因子：
3.8
通讯作者：
Ahmed T
中科院分区：
文献类型：
--
作者：
Chisti MJ;Shahid AS;Shahunja KM;Bardhan PK;Faruque ASG;Shahrin L;Das SK;Barua DK;Hossain MI;Ahmed T
5岁以下的严重营养不良儿童因腹泻病需要住院治疗，在住院期间经常发生肠梗阻，往往导致致命的后果。然而，没有关于此类儿童肠梗阻的危险因素和结局的数据。我们的目的是评估住院期间肠梗阻的预测因素及其结局。这是一项回顾性病历审查，纳入了2011年4月至2012年8月期间在孟加拉国国际腹泻病研究中心达卡医院住院的5岁以下严重营养不良腹泻儿童。我们使用电子数据库从以前住院的儿童中提取图表。对45例肠梗阻患儿和261例非肠梗阻患儿的临床和实验室特征进行了比较。病例首先通过体格检查观察异常肠鸣音确定，并通过腹部X线片证实。对于该比较，卡方检验用于测量比例差异，Student t检验用于计算正态分布数据的平均值差异，Mann-Whitney检验用于非正态分布数据。最后，在确定肠梗阻的独立危险因素时，进行逻辑回归分析。如果患儿在住院期间出现腹胀、肠鸣音亢进或迟缓或缺失，且影像学证据显示腹部气液水平，则定义为肠梗阻。调整潜在混杂因素的Logistic回归分析显示，不愿进食是肠梗阻住院的独立危险因素（比值比[OR] = 3.22，95%置信区间[CI] = 1.24-8.39，p = 0.02），脓毒性休克（OR = 3.62，95% CI = 1.247-8.95，p<0.01）和低钾血症（OR = 1.99，95% CI = 1.03-3.86，p = 0.04）。在单变量分析中，与对照组相比，病例组的死亡率显著较高（22% vs. 8%，p<0.01）;然而，在多变量回归分析中，在调整潜在混杂因素（如感染性休克）后，未发现肠梗阻与死亡之间的相关性（OR = 2.05，95% CI = 0.68-6.14，p = 0.20）。在一个单独的回归分析模型中，在调整了潜在的混杂因素如肠梗阻、不愿进食、低钾血症、低钙血症和输血后，脓毒性休克（OR = 168.84，95%CI = 19.27-1479.17，p<0.01）成为严重营养不良儿童死亡的唯一独立预测因素。这项研究表明，在住院的严重营养不良儿童中，确定肠梗阻的简单独立入院风险因素和死亡风险因素可能会促使临床医生在管理这些疾病时更加警惕，特别是在资源有限的情况下，以减少此类儿童的肠梗阻和肠梗阻相关的致命结局。儿童营养不良和腹泻是包括孟加拉国在内的中低收入国家的重要问题。严重急性营养不良（SAM）和腹泻是全球五岁以下儿童死亡的三分之一以上。大多数死亡是由于SAM和/或腹泻的并发症。SAM和腹泻可能同时出现在儿童中，通常伴有严重的并发症。肠梗阻是此类住院儿童常见的致命并发症，并伴有腹胀和过度活跃、迟缓或听诊器听不到肠鸣音。肠梗阻是由腹部多个气液平面的放射学证据证实的。然而，导致肠梗阻的潜在因素及其在患有严重急性营养不良的腹泻儿童中的管理尚不清楚。我们的研究旨在通过回顾2011年4月至2012年8月期间以前入院的儿童的数据，确定这些风险因素和此类儿童肠梗阻的结局。在306名严重营养不良的孟加拉国5岁以下腹泻儿童中，有45名患有肠梗阻。肠梗阻与不愿进食、感染性休克和低钾血症独立相关，与无肠梗阻的患者相比，其病死率更高。
Severely malnourished children aged under five years requiring hospital admission for diarrheal illness frequently develop ileus during hospitalization with often fatal outcomes. However, there is no data on risk factors and outcome of ileus in such children. We intended to evaluate predictive factors for ileus during hospitalization and their outcomes. This was a retrospective chart review that enrolled severely malnourished children under five years old with diarrhea, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh between April 2011 and August 2012. We used electronic database to have our chart abstraction from previously admitted children in the hospital. The clinical and laboratory characteristics of children with (cases = 45), and without ileus (controls = 261) were compared. Cases were first identified by observation of abnormal bowel sounds on physical examination and confirmed with abdominal radiographs. For this comparison, Chi-square test was used to measure the difference in proportion, Student’s t-test to calculate the difference in mean for normally distributed data and Mann-Whitney test for data that were not normally distributed. Finally, in identifying independent risk factors for ileus, logistical regression analysis was performed. Ileus was defined if a child developed abdominal distension and had hyperactive or sluggish or absent bowel sound and a radiologic evidence of abdominal gas-fluid level during hospitalization. Logistic regression analysis adjusting for potential confounders revealed that the independent risk factors for admission for ileus were reluctance to feed (odds ratio [OR] = 3.22, 95% confidence interval [CI] = 1.24–8.39, p = 0.02), septic shock (OR = 3.62, 95% CI = 1.247–8.95, p<0.01), and hypokalemia (OR = 1.99, 95% CI = 1.03–3.86, p = 0.04). Mortality was significantly higher in cases compared to controls (22% vs. 8%, p<0.01) in univariate analysis; however, in multivariable regression analysis, after adjusting for potential confounders such as septic shock, no association was found between ileus and death (OR = 2.05, 95% CI = 0.68–6.14, p = 0.20). In a separate regression analysis model, after adjusting for potential confounders such as ileus, reluctance to feed, hypokalemia, hypocalcemia, and blood transfusion, septic shock (OR = 168.84, 95% CI = 19.27–1479.17, p<0.01) emerged as the only independent predictor of death in severely malnourished diarrheal children. This study suggests that the identification of simple independent admission risk factors for ileus and risk factors for death in hospitalized severely malnourished diarrheal children may prompt clinicians to be more vigilant in managing these conditions, especially in resource-limited settings in order to decrease ileus and ileus-related fatal outcomes in such children. Childhood malnutrition and diarrhea are important problems in lower and middle-income countries, including Bangladesh. Severe acute malnutrition (SAM) and diarrhea are responsible for more than one third of all deaths in children below five years old globally. Most of these deaths occur because of complications of SAM and/or diarrhea. SAM and diarrhea may simultaneously present in a child, often with serious complications. Ileus is a common fatal complication in such hospitalized children, and is accompanied by abdominal distension and hyperactive, sluggish, or absent bowel sounds heard using a stethoscope. Ileus is confirmed by radiologic evidence of multiple gas-fluid levels in the abdomen. However, the underlying factors contributing to ileus and its management in diarrheal children with severe acute malnutrition is unknown. Our study aimed to ascertain these risk factors and the outcome of ileus in such children by reviewing the data of previously admitted children between April 2011 and August 2012. Of 306 severely malnourished Bangladeshi under-five-year-old children with diarrhea enrolled for 17 months, 45 had ileus. Ileus was independently associated with a reluctance to feed, septic shock, and hypokalemia and had a higher case-fatality rate compared to those without ileus.