急性胰腺炎相关性肝门静脉积气2例报告并文献复习
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摘要
目的:总结急性胰腺炎相关性肝门静脉积气(HPVG)的临床特征、发病机理、治疗及预后。方法:回顾性分析收治并诊断为急性胰腺炎相关性HPVG的2例患者的临床资料并进行相关文献复习与讨论。结果:病例1,男性,65岁,因腹痛10d入院,诊断为急性胆源性胰腺炎,入院时CT未显示HPVG,病程中腹胀加重并于入院1个月后出现感染性休克表现,复查腹部CT提示HPVG、胰腺内及胰腺周围大量坏死组织包裹,保守治疗3d后因症状仍进行性加重而自动出院,出院1周后死亡。病例2,女性,70岁,腹痛1d入院,入院时即表现为感染性休克,入院CT提示胰腺炎、HPVG伴腹膜后散在积气,当日急诊行腹腔镜探查+中转开腹胰腺被膜切开减压+腹腔引流术,术后休克持续加重并出现多脏器功能不全不能纠正,于术后4d自动出院并于当日死亡。既往文献报道胰腺炎相关性HPVG11例,临床主要表现为腹痛,诊断主要依赖B超和CT检查,其中6例死亡,5例存活。结论:胰腺炎相关性HPVG发病率低,但常合并肠管缺血坏死,病死率较高,应该在保守无效后积极进行手术干预。
Objective: To summarize the clinical features, pathogenesis, diagnosis and treatment as well as prognosis of hepatic portal venous gas(HPVG) associated with pancreatitis. Methods: The clinical data of 2 patients admitted and diagnosed as HPVG associated with acute pancreatitis were retrospectively analyzed. The relevant literature was reviewed and discussed.Results: Case 1 was a male patient, 65 years of age, who was admitted due to abdominal pain for 10 d and then diagnosed as acute biliary pancreatitis. Abdominal CT did not show HPVG on admission. In this patient, the abdominal distension aggravated during the progress of the disease and signs of septic shock appeared one month after admission; abdominal CT reexamination showed HPVG and a large amount of walled-off necrotic debrisin the pancreas and peripancreatic region. The patient was discharged on his own request because of progressive deterioration after 3-d conservative treatment, and died one week after discharge. Case 2 was a 70-year old woman who was admitted for severe abdominal pain for 1 d, and presented with septic shock on admission. CT showed pancreatitis with HPVG and scattered gas collections in the retroperitoneal space. Emergency laparoscopic exploration and converted open incision of the pancreatic capsule for decompression plus abdominal drainage were performed. The situation continued to deteriorate and multiple organ dysfunction could not be corrected after operation. The patient was discharged on her own request 4 d after operation and died on the same day. There were 11 cases of HPVG associated with acute pancreatitis reported by previous literature, of whom, the main manifestation was abdominal pain, and diagnosis of the disease was mainly dependent on CT and B ultrasound, 6 cases died and 5 cases survived.Conclusion: HPVG associated with acute pancreatitis is a rare condition, but it is always complicated with intestinal ischemia and necrosis, and results in a high mortality rate. Aggressive surgical management should be performed if conservative treatment fails.
Objective: To summarize the clinical features, pathogenesis, diagnosis and treatment as well as prognosis of hepatic portal venous gas(HPVG) associated with pancreatitis. Methods: The clinical data of 2 patients admitted and diagnosed as HPVG associated with acute pancreatitis were retrospectively analyzed. The relevant literature was reviewed and discussed.Results: Case 1 was a male patient, 65 years of age, who was admitted due to abdominal pain for 10 d and then diagnosed as acute biliary pancreatitis. Abdominal CT did not show HPVG on admission. In this patient, the abdominal distension aggravated during the progress of the disease and signs of septic shock appeared one month after admission; abdominal CT reexamination showed HPVG and a large amount of walled-off necrotic debrisin the pancreas and peripancreatic region. The patient was discharged on his own request because of progressive deterioration after 3-d conservative treatment, and died one week after discharge. Case 2 was a 70-year old woman who was admitted for severe abdominal pain for 1 d, and presented with septic shock on admission. CT showed pancreatitis with HPVG and scattered gas collections in the retroperitoneal space. Emergency laparoscopic exploration and converted open incision of the pancreatic capsule for decompression plus abdominal drainage were performed. The situation continued to deteriorate and multiple organ dysfunction could not be corrected after operation. The patient was discharged on her own request 4 d after operation and died on the same day. There were 11 cases of HPVG associated with acute pancreatitis reported by previous literature, of whom, the main manifestation was abdominal pain, and diagnosis of the disease was mainly dependent on CT and B ultrasound, 6 cases died and 5 cases survived.Conclusion: HPVG associated with acute pancreatitis is a rare condition, but it is always complicated with intestinal ischemia and necrosis, and results in a high mortality rate. Aggressive surgical management should be performed if conservative treatment fails.
引文
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[2]申鼎成,刘志勇,黄耿文,等.电极片定位超声引导下经皮穿刺置管引流治疗感染性胰腺坏死:附61例报告[J].中国普通外科杂志,2017,26(9):1168-1173.doi:10.3978/j.issn.1005-6947.2017.09.014.Shen DC,Liu ZY,Huang GW,et al.Percutaneous catheter drainage under positioning of electrode plates and ultrasound guidance:a report of 61 cases[J].Chinese Journal of General Surgery,2017,26(9):1168-1173.doi:10.3978/j.issn.1005-6947.2017.09.014.
[3]van Santvoort HC,Bakker OJ,Bollen TL,et al.A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome[J].Gastroenterology,2011,141(4):1254-1263.doi:10.1053/j.gastro.2011.06.073.
[4]Raraty MG,Halloran CM,Dodd S,et al.Minimal access retroperitoneal pancreatic necrosectomy:improvement in morbidity and mortality with a less invasive approach[J].Ann Surg,2010,251(5):787-793.doi:10.1097/SLA.0b013e3181d96c53.
[5]Werner J,Hartwig W,Hackert T,et al.Surgery in the treatment of acute pancreatitis--open pancreatic necrosectomy[J].Scand J Surg,2005,94(2):130-134.doi:10.1177/145749690509400209.
[6]Petrov MS,Shanbhag S,Chakraborty M,et al.Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis[J].Gastroenterology,2010,139(3):813-820.doi:10.1053/j.gastro.2010.06.010.
[7]Wolfe JN,Evans WA.Gas in the portal veins of the liver in infants;a roentgenographic demonstration with postmortem anatomical correlation[J].Am J Roentgenol Radium Ther Nucl Med,1955,74(3):486-488.
[8]Susman N,Senturia HR.Gas embolization of the portal venous system[J].Am J Roentgenol Radium Ther Nucl Med,1960,83:847-850.
[9]Liang HH,Wang W,Hung CS,et al.Branch-type gas in the liver[J].J Emerg Med,2013,44(5):e363-364.doi:10.1016/j.jemermed.2012.11.029.
[10]Chung H,Lilien LD.Portal venous gas:a clinical finding in obstructed infracardiac total anomalous pulmonary venous connection[J].Pediatr Cardiol,2012,33(4):669-671.doi:10.1007/s00246-012-0195-x.
[11]Siswojo A,Ihle BU.Hepatic portal venous gas in a patient with intestinal necrosis[J].Emerg Med Austmlas,20l0,22(2):187-188.doi:10.1111/j.1742-6723.2010.01274.x.
[12]Alqahtani S,Coffin CS,Burak K,et al.Hepatic portal venous gas:a report of two cases and a review of the epidemiology,pathogenesis,diagnosis and approach to management[J].Can J Gastroenterol,2007,21(5):309-313.
[13]Suzuki S,Takeuchi Y,Ishihara R,et al.Hepatic Portal Venous Gas Following Colonic Endoscopic Submucosal Dissection[J].Intern Med,2019,58(5):755-756.doi:10.2169/internalmedicine.1771-18.
[14]Chan SC,Wan YL,Cheung YC,et al.Computed tomography findings in fatal cases of enormous hepatic portal venous gas[J].World J Gastroenterol,2005,11(19):2953-2935.
[15]Park HC,Lee WS,Joo SY,et al.Hepatic portal venous gas associated with acute pancreatitis:reports of two cases and review of literature[J].Korean J Gastroenterol,2007,50(2):131-135.
[16]Wu JM,Wang MY.Hepatic portal venous gas in necrotizing pancreatitis[J].Dig Surg,2009,26(2):119-120.doi:10.1159/000206147.
[17]Martin-Smith JD,Larkin JO,Hogan JG,et al.Necrotizing pancreatitis presenting with pneumatosis coli and hepatic portal venous gas[J].ANZ J Surg,2011,81(6):467-468.
[18]Vongsuvanh R,Pleass H,van der Poorten D.Acute necrotizing pancreatitis,gastric ischemia,and portal venous gas complicating intragastric balloon placement[J].Endoscopy,2012,44(Suppl 2UCTN):E383-384.doi:10.1055/s-0032-1310146.
[19]Chan AC,Poon RT.Portal venous gas and pneumatosis intestinalis in necrotizing pancreatitis[J].Clin Gastroenterol Hepatol,2014,12(7):e57-58.doi:10.1016/j.cgh.2013.10.010.
[20]Ansari MM,Mushtaq N,Pateria V,et al.Gas in Hepatic Portal Veins with Gastric Massive Dilatation and Pneumatosis in Acute Pancreatitis[J].J Clin Diagn Res,2015,9(10):PD05-7.doi:10.7860/JCDR/2015/11941.6634.
[21]McNicholas DP,Kelly ME,Das JP,et al.Disappearing portal venous gas in acute pancreatitis and small bowel ischemia[J].Radiol Case Rep,2017,12(2):269-272.doi:10.1016/j.radcr.2017.01.006.
[22]Moussa M,Marzouk I,Abdelmoula K,et al.Role of Computed tomography in predicting prognosis of Hepatic portal venous gas[J].Int J Surg Case Rep,2017,30:177-182.doi:10.1016/j.ijscr.2016
[23]史逸华,戴灵波,肖德双,等.腹腔间隔室综合征伴肝门静脉积气[J].中华普通外科杂志,2018,33(11):960-961.doi:10.3760/cma.j.issn.1007-631X.2018.11.019.Shi YH,Dai LB,Xiao DQ,et al.Abdominal compartment syndrome accompanied with Hepatic portal venous gas[J].Zhong Hua Pu Tong Wai Ke Za Zhi,2018,33(11):960-961.doi:10.3760/cma.j.issn.1007-631X.2018.11.019.
[24]姚敏学,冯秋鹏,鲍磊,等.门静脉积气一例[J].中华急诊医学杂志,2016,25(3):355.doi:10.3760/cma.j.issn.1671-0282.2016.03.020.Yao MX,Feng QP,Bao L,et al.One case report of portal venous gas[J].Chinese Journal of Emergency Medicine,2016,25(3):355.doi:10.3760/cma.j.issn.1671-0282.2016.03.020.
[25]汪登亮,康权,彭飞,等.食管破裂致不典型肝门静脉积气一例[J].中华普通外科杂志,2018,33(4):344-345.doi:10.3760/cma.j.issn.1007-631X.2018.04.022.Wang DL,Kang Q,Peng F,et al.Hepatic portal venous gas caused by esophageal rupture:a report of one case[J].Zhong Hua Pu Tong Wai Ke Za Zhi,2018,33(4):344-345.doi:10.3760/cma.j.issn.1007-631X.2018.04.022.
[26]Abboud B,El Hachem J,Yazbeck T,et al.Hepatic ponal Venous gas:physiopathology,etiology,prognosis and treatment[J].World JGastroenterol,2009,15(29):3585-3590.
[27]Liebman PR,Patten MT,Mann J,et al.Hepatic--portal venous gas in adults:etiology,pathophysiology and clinical significance[J].Ann Surg,1978,187(3):281-287.
[28]宁彩虹,黄耿文,申鼎成,等.真菌感染性胰腺坏死的临床分析:附46例报告[J].中国普通外科杂志,2018,27(9):1155-1159.doi:10.7659/j.issn.1005-6947.2018.09.011.Ning CH,Huang GW,Shen DC,et al.Clinical analysis of fungal infected pancreatic necrosis:a report of 46 cases[J].Chinese Journal of General Surgery,2018,27(9):1155-1159.doi:10.7659/j.issn.1005-6947.2018.09.011.
[29]申鼎成,周书毅,黄耿文,等.多重耐药菌感染的包裹性胰腺坏死的外科治疗策略[J].中国普通外科杂志,2016,25(9):1319-133.doi:10.3978/j.issn.1005-6947.2016.09.016.Shen DC,Zhou SY,Huang GW,et al.Surgical treatment strategies for wall-off pancreatic necrosis with multi-drug resistant organism infections[J].Chinese Journal of General Surgery,2016,25(9):1319-133.doi:10.3978/j.issn.1005-6947.2016.09.016.
[30]刘国华,戴东,谭小宇,等.循PCD引流管路径微小切口联合经皮肾镜治疗重症急性胰腺炎感染性坏死[J].中国普通外科杂志,2018,27(3):335-342.doi:10.3978/j.issn.1005-6947.2018.03.011.Liu GH,Dai D,Tan XY,et al.Small incision along the PCD tube tract combined with percutaneous nephroscope in treatment of severe acute pancreatitis complicated with infected necrosis[J].Chinese Journal of General Surgery,2018,27(3):335-342.doi:10.3978/j.issn.1005-6947.2018.03.011.
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