急性肠系膜缺血性疾病23例诊治分析
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摘要
目的:通过分析急性肠系膜缺血性疾病患者的临床资料,探讨急性肠系膜缺血性疾病的临床诊断和治疗。
方法:收集我院2002年1月至2010年12月的23例急性肠系膜缺血性疾病病例,对其临床特征、诊断及治疗进行回顾性分析。
结果: 23例患者中,男11例,女12例,平均年龄65岁。既往合并心脏病21例、高血压12例、糖尿病7例、手术史8例,腔隙性脑梗2例。其中,83%(19/23)的患者主要以腹痛、腹胀,恶心、呕吐,便血症状就诊,56.5%(13/23)的患者在就诊时已经出现腹膜炎刺激征象。在实验室检查中,白细胞升高比率为78.3%(18/23),中性粒细胞升高比率为73.9(17/23);D二聚体阳性率为66.7%(2/3);在影像学检查中,彩超检查的阳性率为37.5%(3/8);CT检查确诊率为75%(7/8),1例行肠系膜血管造影(DSA)检查,确诊为肠系膜动脉血栓;腹部手术探查确诊率为56.5%(13/23)。在本组23例资料中,首诊确诊率为21.8%(5/23),早期误诊率78.3%(18/23)。本组治疗方式分非手术治疗和手术治疗。其中6例经过单纯的罂粟碱扩容或肝素抗凝等保守治疗后,1例未愈自行出院,5例死亡;1例经过球囊扩张术治疗后,好转出院。余16例患者接受手术治疗结合全身治疗,术前、术中、术后依具体情况应用适量的扩张剂、抗凝剂、溶栓剂。其中,4例行小肠部分切除术,6例行小肠大部分切除术,3例行小肠大部分及右半结肠切除术,1例行横结肠切除术,1例行小肠部分及横结肠切除术。除1例因腹中肠管已全部坏死,无法切除后死亡,其余患者均治愈出院。本组69.6%(16/23)的病例经过手术治疗,手术治愈率93.8%(15/16)。术后发生短肠综合症1例,并发症发生率6.67%(1/15)。死亡率26.1%(6/23)。
结论: AMI缺乏典型的临床特征和特异性及敏感性的检查方式,诊断困难,死亡率高;早期诊断及选择合适的治疗方法是降低死亡率的关键。
Objective:To investigate the clinical features, diagnosis and surgical treatment of acute mesenteric ischemia.
Methods:A retrospective analysis of acute mesenteric ischemia was made by collecting 23 patients information who were treated in The Second Affiliated Hospital of Dalian Medical University from January 2002 to December 2010.
Results: There were 11 males and 12 females patients with the mean age of 65 years. 21 cases had associated with heart disease, 12 cases with hypertension, 7 cases with diabetes, 8 cases with surgery history and lacunar cerebral infarction appeared in 2 cases. 83%(19/23)patients had manifestation of abdominal pain, bloating, nausea, vomiting, blood stool and 56.5%(13/23)cases had emerged with signs of peritonitis stimulaiton. According to the laboratory tests, the ratio of elevated white blood cell was 78.3% and neutrophil was 73.9%, respectively. The appearance ratio of D-dimmer masculine was 66.7%(2/3). In imaging examinations, the diagnosis was positive in color dopplar ultrasound of 37.5% (3/8) and in CT examination of 75% (3/4), 1 case was diagnosed as mesenteric artery thrombosis followed by routine mesenteric angiography (DSA) check, The diagnosis rate by abdominal surgical exploration was 56.5% (13/23). In 23 cases, the primary accurate rate of diagnosis was 21.8% (5/23) and the misdiagnostic rate was 78.3% (18/23). The treatment included drug therapy and surgery treatment. 6 patients were treated conservatively with papaverine by simple expansion or heparin anticoagulation etc, 1 patient was unhealed with the result of discharging from hospital , 5 cases were died;1 case was improved and discharged by balloon dilation treatment. The remaining 16 patients underwent surgical treatment combined with systemic therapy and were applied with an appropriate amount of vasodilator, anticoagulant and thrombolytic agent for preoperative, intraoperative and postoperative. 4 patients were operated by routine partial small bowel resection, 6 underwent most of the small bowel resection, 3 cases were conducted with most of the small intestine resection and right hemicolectomy, 1 patient was received regular transverse colon resection, and 1 underwent the transverse colon resection along with routine part of small intestine. The above patients were cured and discharged except for 1 case death because of the necrotic bowel without capable removal situation. In this group 69.6% (16/23) of patients underwent surgery treatment and cure rate was 93.8% (15/16). 1 case was associated with short bowel syndrome postoperatively. The complication appearance rate was 6.67%(1/15). Mortality rate reached 26.1 (6/23).
Conclusions: Being lack of typical clinical features and specificity and sensitivity examination way, the mortality of AMI is still high. Early diagnosis and right treatment is the key to reduce mortality.
方法:收集我院2002年1月至2010年12月的23例急性肠系膜缺血性疾病病例,对其临床特征、诊断及治疗进行回顾性分析。
结果: 23例患者中,男11例,女12例,平均年龄65岁。既往合并心脏病21例、高血压12例、糖尿病7例、手术史8例,腔隙性脑梗2例。其中,83%(19/23)的患者主要以腹痛、腹胀,恶心、呕吐,便血症状就诊,56.5%(13/23)的患者在就诊时已经出现腹膜炎刺激征象。在实验室检查中,白细胞升高比率为78.3%(18/23),中性粒细胞升高比率为73.9(17/23);D二聚体阳性率为66.7%(2/3);在影像学检查中,彩超检查的阳性率为37.5%(3/8);CT检查确诊率为75%(7/8),1例行肠系膜血管造影(DSA)检查,确诊为肠系膜动脉血栓;腹部手术探查确诊率为56.5%(13/23)。在本组23例资料中,首诊确诊率为21.8%(5/23),早期误诊率78.3%(18/23)。本组治疗方式分非手术治疗和手术治疗。其中6例经过单纯的罂粟碱扩容或肝素抗凝等保守治疗后,1例未愈自行出院,5例死亡;1例经过球囊扩张术治疗后,好转出院。余16例患者接受手术治疗结合全身治疗,术前、术中、术后依具体情况应用适量的扩张剂、抗凝剂、溶栓剂。其中,4例行小肠部分切除术,6例行小肠大部分切除术,3例行小肠大部分及右半结肠切除术,1例行横结肠切除术,1例行小肠部分及横结肠切除术。除1例因腹中肠管已全部坏死,无法切除后死亡,其余患者均治愈出院。本组69.6%(16/23)的病例经过手术治疗,手术治愈率93.8%(15/16)。术后发生短肠综合症1例,并发症发生率6.67%(1/15)。死亡率26.1%(6/23)。
结论: AMI缺乏典型的临床特征和特异性及敏感性的检查方式,诊断困难,死亡率高;早期诊断及选择合适的治疗方法是降低死亡率的关键。
Objective:To investigate the clinical features, diagnosis and surgical treatment of acute mesenteric ischemia.
Methods:A retrospective analysis of acute mesenteric ischemia was made by collecting 23 patients information who were treated in The Second Affiliated Hospital of Dalian Medical University from January 2002 to December 2010.
Results: There were 11 males and 12 females patients with the mean age of 65 years. 21 cases had associated with heart disease, 12 cases with hypertension, 7 cases with diabetes, 8 cases with surgery history and lacunar cerebral infarction appeared in 2 cases. 83%(19/23)patients had manifestation of abdominal pain, bloating, nausea, vomiting, blood stool and 56.5%(13/23)cases had emerged with signs of peritonitis stimulaiton. According to the laboratory tests, the ratio of elevated white blood cell was 78.3% and neutrophil was 73.9%, respectively. The appearance ratio of D-dimmer masculine was 66.7%(2/3). In imaging examinations, the diagnosis was positive in color dopplar ultrasound of 37.5% (3/8) and in CT examination of 75% (3/4), 1 case was diagnosed as mesenteric artery thrombosis followed by routine mesenteric angiography (DSA) check, The diagnosis rate by abdominal surgical exploration was 56.5% (13/23). In 23 cases, the primary accurate rate of diagnosis was 21.8% (5/23) and the misdiagnostic rate was 78.3% (18/23). The treatment included drug therapy and surgery treatment. 6 patients were treated conservatively with papaverine by simple expansion or heparin anticoagulation etc, 1 patient was unhealed with the result of discharging from hospital , 5 cases were died;1 case was improved and discharged by balloon dilation treatment. The remaining 16 patients underwent surgical treatment combined with systemic therapy and were applied with an appropriate amount of vasodilator, anticoagulant and thrombolytic agent for preoperative, intraoperative and postoperative. 4 patients were operated by routine partial small bowel resection, 6 underwent most of the small bowel resection, 3 cases were conducted with most of the small intestine resection and right hemicolectomy, 1 patient was received regular transverse colon resection, and 1 underwent the transverse colon resection along with routine part of small intestine. The above patients were cured and discharged except for 1 case death because of the necrotic bowel without capable removal situation. In this group 69.6% (16/23) of patients underwent surgery treatment and cure rate was 93.8% (15/16). 1 case was associated with short bowel syndrome postoperatively. The complication appearance rate was 6.67%(1/15). Mortality rate reached 26.1 (6/23).
Conclusions: Being lack of typical clinical features and specificity and sensitivity examination way, the mortality of AMI is still high. Early diagnosis and right treatment is the key to reduce mortality.
引文
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2. Tabarov MS, Kudryashov YA. Dilatory humoral adrenergic reactions of regional veins and arteries during systemic hypoxia. Bull Exp Biol Med,2002,133(1):35 - 37.
3. Menon NJ, Amin AM, Mohammed A, et al. Acutemesenteric ischaemia. Acta ChirBelg,2005,105(4):344 - 354.
4. Acosta S,Ogren M, Sternby NH, et al. Clinical implication for the management of acute thromboembolic, occlusion of the superior mesenteric artery. Ann Surg,2005,241(3):516 - 522.
5.皮执民.消化外科学[M].北京:人民卫生出版社,2002:464.
6. BraburyAW,Brittenden J,McBride K, et al. Mesenteric ischemia: a multidisciplinary approach. BrJ Surg,1995,82(11):1446 - 1459.
7. LutherB,Moussazadeh K,MullerBT, et al. The acute mesenteric ischemia2not understood or incurable? Zentralbl Chir, 2002, 127 (8): 674 -684.
8. Char DJ, Cuadra SA, Hines GL, et al. Surgical intervention for acute intestinal ischemia: experience in a community teaching hospital. VascEndovascular Surg,2003,37(4):245 - 252.
9.陈国玉、杨力.医师进修杂志2005年6月第28卷第6期:3-5.
10. Hassan HA,Raufman JP.Mesenteric venous thrombosis.
11.谭显金.急性肠系膜缺血疾病的研究现状和进展[J/CD] .中华临床医师杂志:电子版,2009,3(4):640 - 645.
12. Bergan JJ , Dean RH , Conn J Jr , et al. Revascularizaion in treatment of mesenteric infarction[J ] .Ann Surg , 1975, 182(4) :430.
13.吴小剑,兰平,覃建章,等.急性肠系膜血管供血不全的诊断和治疗[J ] .中国实用外科杂志2002,22(2) :97.
14.陈孝平,石应康,邱贵兴等.外科学人民卫生出版社.
15.刘洪健.A非闭塞性急性肠系膜缺血的诊断和治疗,中国医师杂志2005,1月第7卷第1期:103.
16.房立君,王丹,刘杰.急性肠系膜缺血性疾病的临床分析.医护论坛2009,12月第6卷第
36期:181-182.
17. Block T, Nilsson TK, BjrckM, etal. Diagnostic accuracyofplasma biomarkersfor intestinal ischaemia. Scand J ClinLab Invest,2008,68(3):42 - 248.
18. Cronk DR, Houseworth TP,CuadradoDG, etal. Intestinalfatty acid bindingprotein ( I2FABP) for the detection of strangulatedmechanical small bowelobstruction. Curr Surg,2006,63(5):322 - 325.
19.王世文,黄华新,何津春,等.急性缺血性肠炎的血清酶及部分生化指标变化.中国胃肠外科杂志1999,2:149-150.
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31.丁良福,黄辉,房鸿飞,金键,季惠.急性肠系膜缺血性疾病22例诊治分析.外科理论与实践.2010年第15卷第11期:296-298.
32.杨春明.急性肠系膜缺血.医师进修杂志,2005年6月第28卷第6期,外科版:1-3.
33. Stone HH,Strom PR,Mullins RJ.Management of the major co~ lopathy with onset during laparotomy[J].Ann Surg,1983,197(5):532-535.
34.李宁.外科新理念:损伤控制性手术[J].实用外科杂志,2006,27(1):29-31.
1. Brandt LJ, Boley SJ. Intestinal ischemia.In:Feldman LS, Sleisenger MH,editors. Sleisenger andFordtran’s gastrointestinal and liver disease.Philadelphia: WB Saunders, 2002.2 321-2 328
2. Schoots IG, Levi MM, Reekers JA,et al.Throm-bolytic therapy for acute superior mesenteric artery occlusion. J Vasc Interv Radiol 16:317-329, 200.
3.辛世杰,王雷.急性肠系膜血管缺血性疾病病因及处理.中国实用外科杂志2009年11月第29卷第11期:903-906.
4. KassahunWT,SchulzT,Richter O,et al: Unchanged high mortalityrates from acute occlusive intestinal ischemia: Six year review. Lange-nbecks Arch Surg 393:163-171, 2008.
5. Oldenb.urgWA, Lau LL, Rodenberg TJ, et al: Acute mesenteric ischemia:A clinical review. Arch Intern Med 164:1054-1062, 2004.5
6. Char DJ, Cuadra SA, Hines GL, et al. Surgical intervention for acute intestinal ischemia: experience in a community teaching hospital. VascEndovascular Surg,2003,37(4):245 - 252.
7. Char DJ, Cuadra SA, Hines GL, et al. Surgical intervention for acute intestinal ischemia: experience in a community teaching hospital. VascEndovascular Surg,2003,37(4):245 - 252.
8. BraburyAW,Brittenden J,McBride K, et al. Mesenteric ischemia: a multidisciplinary approach. BrJ Surg,1995,82(11):1446 - 1459.
9. LutherB,Moussazadeh K,MullerBT, et al. The acute mesenteric ischemia2not understood or incurable? Zentralbl Chir, 2002, 127 (8): 674 -684.
10.陈国玉、杨力.医师进修杂志2005年6月第28卷第6期3-5.
11. Hassan HA,Raufman JP.Mesenteric venous thrombosis.
12.王晓东,孙魏.肠系膜血管缺血外科诊治进展.世界华人消化杂志,2007年4月28日;15(12):1400-1405.
13.谭显金.急性肠系膜缺血疾病的研究现状和进展[J/CD].中华临床医师杂志:电子版, 2009,3(4):640 - 645.
14. Bergan JJ, Dean RH, Conn J Jr, et al. Revascularizaion in treatment of mesenteric infarction[J ] .Ann Surg , 1975, 182(4) :430.
15.吴小剑,兰平,覃建章,等.急性肠系膜血管供血不全的诊断和治疗[J ].中国实用外科杂志, 2002,22(2) :97.
16.房立君,王丹,刘杰.急性肠系膜缺血性疾病的临床分析.医护论坛,2009,12月第6卷第36期:181-182.
17.陈孝平,石应康,邱贵兴,等.外科学.人民卫生出版社.
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19. Acosta S, Nilsson TK, Bjorck M: Preliminary study of D-dimer as a possible marker of acute bowel ischaemia. Br J Surg. 2001,88:385-388.
20.王世文,黄华新,何津春,等.急性缺血性肠炎的血清酶及部分生化指标变化.中国胃肠外科杂志.1999;2:149—150.
21. Cronk DR, Houseworth TP,CuadradoDG, etal. Intestinalfatty acid bindingprotein ( I2FABP) for the thedetection of strangulatedmechanical small bowelobstruction. Curr Surg,2006,63(5):322 - 325.
22.晓玮,谢鹏雁.缺血性肠病的诊断与治疗.中国医刊2003,38:2-4.
23. Roobottom C, Dubbins P. Significant disease of the celiac and superior mesenteric in a symptomatic patients predictive value of Doppler sonography[J]. Am Roentgenol, 1993,161(5): 985-988.
24. LAGHI A,IANNACCONE R,CATALARO C,et a1.Multislice spiral computed tomo~aphy angiography of mesenterlc arteries [1etter]O].Lacent,2001,358:638—639.
25. Kimuta W, Mossner J. Role of hypertriglyceridemia in the pathogenesis of experimental acute pancreatitis in rats. Int J Pancreatol, 1996,20:177-178.
26. Sakorafas G, Tsiotou A. Etiology and pathogenesis of acute pancreatitis. J Clin Gastroenterol, 2000,30:343-356.
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28. Sze DY,0‘Sullivan GJ,Johnson DL,etal.Mesenteric and portal venous thrombosis treated by transjugular mechanical hromboysis[J]. AJR,2000,175:732-734.
29.李选.缺血性肠病的介入治疗[JJ].中国实用外科杂志,2006,26(6):416-41 8.
30.杨春明.急性肠系膜缺血.医师进修杂志2005年6月第28卷第6期外科版:1-3.
31. Timothy A, Stefan Acosta, Bj?rn Sonesson. Endovascular Techniques in Acute Arterial Mesenteric Ischemia. Semin Vasc Surg. 2010,23:29-35.
32.丁良福,黄辉,房鸿飞,金键,季惠.急性肠系膜缺血性疾病22例诊治分析.外科理论与实践.2010年第15卷第11期:296-298.
33.Stone HH,Strom PR,Mullins RJ.Management of the major co~ lopathy with onset during laparotomy[J].Ann Surg,1983,197(5):532—535.
34.李宁.外科新理念:损伤控制性手术[J].实用外科杂志2006,27(1):29-31.
2. Tabarov MS, Kudryashov YA. Dilatory humoral adrenergic reactions of regional veins and arteries during systemic hypoxia. Bull Exp Biol Med,2002,133(1):35 - 37.
3. Menon NJ, Amin AM, Mohammed A, et al. Acutemesenteric ischaemia. Acta ChirBelg,2005,105(4):344 - 354.
4. Acosta S,Ogren M, Sternby NH, et al. Clinical implication for the management of acute thromboembolic, occlusion of the superior mesenteric artery. Ann Surg,2005,241(3):516 - 522.
5.皮执民.消化外科学[M].北京:人民卫生出版社,2002:464.
6. BraburyAW,Brittenden J,McBride K, et al. Mesenteric ischemia: a multidisciplinary approach. BrJ Surg,1995,82(11):1446 - 1459.
7. LutherB,Moussazadeh K,MullerBT, et al. The acute mesenteric ischemia2not understood or incurable? Zentralbl Chir, 2002, 127 (8): 674 -684.
8. Char DJ, Cuadra SA, Hines GL, et al. Surgical intervention for acute intestinal ischemia: experience in a community teaching hospital. VascEndovascular Surg,2003,37(4):245 - 252.
9.陈国玉、杨力.医师进修杂志2005年6月第28卷第6期:3-5.
10. Hassan HA,Raufman JP.Mesenteric venous thrombosis.
11.谭显金.急性肠系膜缺血疾病的研究现状和进展[J/CD] .中华临床医师杂志:电子版,2009,3(4):640 - 645.
12. Bergan JJ , Dean RH , Conn J Jr , et al. Revascularizaion in treatment of mesenteric infarction[J ] .Ann Surg , 1975, 182(4) :430.
13.吴小剑,兰平,覃建章,等.急性肠系膜血管供血不全的诊断和治疗[J ] .中国实用外科杂志2002,22(2) :97.
14.陈孝平,石应康,邱贵兴等.外科学人民卫生出版社.
15.刘洪健.A非闭塞性急性肠系膜缺血的诊断和治疗,中国医师杂志2005,1月第7卷第1期:103.
16.房立君,王丹,刘杰.急性肠系膜缺血性疾病的临床分析.医护论坛2009,12月第6卷第
36期:181-182.
17. Block T, Nilsson TK, BjrckM, etal. Diagnostic accuracyofplasma biomarkersfor intestinal ischaemia. Scand J ClinLab Invest,2008,68(3):42 - 248.
18. Cronk DR, Houseworth TP,CuadradoDG, etal. Intestinalfatty acid bindingprotein ( I2FABP) for the detection of strangulatedmechanical small bowelobstruction. Curr Surg,2006,63(5):322 - 325.
19.王世文,黄华新,何津春,等.急性缺血性肠炎的血清酶及部分生化指标变化.中国胃肠外科杂志1999,2:149-150.
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