【作者】 李畅；

【导师】 孙立波；

【作者基本信息】 吉林大学 ， 外科学， 2009， 硕士

【摘要】 目的探讨缺血性肠疾病的临床特点和最佳手术时机,提高对该疾病诊治的认识。方法回顾性分析我院外科自2004年1月至2008年12月经手术、影像学或超声证实的22例肠系膜动脉栓塞及肠系膜静脉血栓形成患者,对其临床表现及辅助检查结果进行回顾性分析,结合相关文献,探讨该疾病的一些特点。结果22例患者男性13例,女性9例。患有高血压,房颤,心瓣膜病,糖尿病等导致栓塞和/或血栓形成的基础疾病14例。患者全部伴有腹痛,停止排气、排便4例,血便9例,恶心、呕吐7例。全部患者腹部有压痛,18例有不同程度的反跳痛和腹肌紧张,其中包括3例表现为板状腹体征。17例行腹腔穿刺检查,其中13例抽出血性腹水。22例行超声及X线检查,1例行CT检查,3例行数字减影血管造影(DSA)检查。17例行手术,其中3例死亡或因失去治疗时机而放弃继续治疗自动出院。5例行溶栓、抗凝等保守治疗,其中1例死亡。患者病情进展快,多在发病24小时内出现腹部压痛,反跳痛,肌紧张,肠麻痹等急腹症表现。22例患者中6例误诊为急性胃肠炎或急性胰腺炎等常见急腹症。结论(1)DSA、CT及超声检查是诊断缺血性肠疾病的良好手段,超声、CT更加直接、迅速、方便。(2)WBC升高至20.0×109/ L,同时伴有腹痛、血便的患者,应积极考虑手术,若辅助检查提示肠壁增厚,则肠管坏死范围较大。(3)缺血性肠疾病发病率低,临床表现无特异性,误诊率高,病情进展快,后果严重。(4)有明显的相关因素,与患者高龄、高血压、心房纤维颤动、糖尿病、冠状动脉粥样硬化性心脏病、肝硬化有较高的相关性。更多还原

【Abstract】 Ischemic bowel disease is the ischemic disease of intestine caused by acute or chronic intestinal blood flow dys-perfusion. The disease’s characterization is that the early symptoms and signs not only don’t correspond but also are nonspecific. It is difficult to make the right judgments of the extent of bowel ischemic in time, so the disease is misdiagnosed easily and the disease develops into intestinal necrosis rapidly and easily. Especially the mesenteric vascular obstructive disease, it is more difficult to judge patient’s condition and give treatment in time. Therefore the key of the treatment is to diagnose clearly and take corresponding measures as soon as possible.Objective: To investigate Clinical features and the best time to operation, then improve the level of diagnosis and treatment in the ischemic bowel disease.Methods: The clinical data of 22 cases with mesenteric artery embolization or mesenteric venous thrombosis from January 2004 to December 2008 have been analyzed retrospectively.Their clinical manifestations and auxiliary examination results were analyzed, combined with relevant literature, to explore some of the features of the disease. In accordance with the treatment methods, the cases are divided into non-surgical groups(A1) and surgical group(A2), there are 5 cases in group A1, 2 cases of male, 3 cases of female, aged 28-72 years old, the average age of 53.00±18.84 years old. There are 17 cases in group A2, 11 cases of male , 6 cases of female , aged 25-76 years old, the average age of 53.06±15.61 years old. Tested no significant difference between the two groups (P> 0.05). In accordance with the length of bowel necrosis seen during operation, the cases are divided into the length of bowel necrosis less than 200cm groups(B1) and the length of bowel necrosis greater than or equal to 200cm group(B2). There are 8 cases in group B1, 6 cases of male, 2 cases of female, aged 25-70 years old, the average age of 47.5±17.15 years old. There are 9 cases in group B2, 4 cases of male, 5 cases of female, aged 28-76 years old, the average age of 55.75±12.02 years old. Tested no significant difference between the two groups (P> 0.05). In accordance with the location of embolism or thrombosis, the cases are divided into arterial embolization group(C1) and the venous thrombosis group(C2). There are 11 cases in group C1, 8 cases of male, 3 cases of female, age 40-76 years old, the average age of 57.91±15.66 years old. There are 11 cases in group C2, 5 cases of male, 6 cases of female, aged 25-67 years old, the average age of 48.18±15.33 years old. Tested no significant difference between the two groups (P> 0.05). The expansion of intestine、flat of liquid-gas、bowel wall thickening and ascites prompted by white blood cell count, the results of X-ray and ultrasound examination are compared between A1 and A2, B1 and B2, C1 and C2,respectively.Results: In the 22 cases, 13 cases of male, 9 cases of female. All cases had abdominal pain, 4 cases stopped the exhaust and defecation, 9 cases had bloody stool, 7 cases had nausea and vomit. All patients have abdominal tenderness, 18 patients with varying degrees of rebound tenderness and abdominal muscle tension, including the 3 cases which showed tabulate venter. There are 17 patients did celiocentesis, of which 13 cases have hemic hydrogaster ascites.All cases did ultrasound and X-ray examination, 1 case did CT examination, 3 cases did digital subtraction angiography (DSA) . 17 cases had surgery, in which 3 cases were dead or gave up the treatment and discharged automatically because of the loss of operation time. 5 cases had conservative treatment such as thrombolysis, anticoagulation and so on. In which 1 case was dead. The disease developed rapidly, the performance of acute abdomen such as abdominal tenderness, rebound tenderness, musclar tension , enteroparalysis would occur in 24 hours. 6 cases were misdiagnosed as common acute abdomen such as acute gastroenteritis or acute pancreatitis in the 22 cases. 9 patients had hypertension , 11 patients had atrial fibrillation,4 patients had coronary atherosclerotic heart disease, 3 patients had diabetes, 2 patients had pulmonary heart disease, 2 patients had liver cirrhosis,8 patients had non of the above-mentioned diseases. It is suggestion that ischemic bowel disease’s morbidity in patients with elderly patients, high blood pressure, atrial fibrillation, diabetes, coronary atherosclerotic heart disease and liver cirrhosis is significantly higher than those without the above-mentioned factors. The white blood cell count in surgical group is higher than that of non- surgical group(P<0.05). Examinations in the expansion of intestine、flat of liquid-gas、bowel wall thickening and ascites have no statistical significance (P> 0.05).That suggest when white blood cell count increased to 20.0×109/L, the process of the disease enters into the irreversible intestinal necrosis period, the operation should be taken as soon as possible. In the length of bowel necrosis greater than or equal to 200cm group, the positive rate of the bowel wall thicken in abdominal color Doppler ultrasound examination is higher than the length of bowel necrosis less than 200cm groups(P<0.05). The white blood cell count and the examination prompted the expansion of intestine、flat of liquid-gas and ascites have no statistical significance (P> 0.05). In mesenteric venous thrombosis group,the positive rate of the bowel wall thicken in abdominal color Doppler ultrasound examination is higher than mesenteric artery embolization group (P<0.05). The white blood cell count and the examination prompt the expansion of intestine、flat of liquid-gas and ascites have no statistical significance (P> 0.05).So when the examination prompt irregular bowel wall thickening, mesenteric venous thrombosis is usually possible, and the period of intestinal ischemia is late, the extent of bowel necrosis maybe large. The operation is necessary.Conclusion:(1)DSA,CT and ultrasound are good auxiliary examination to diagnose ischemic bowel disease.Ultrasound and CT are more direct, quicke and easy.(2)Patients with WBC increased to 20.0×109/L,accompanied with abdominal pain, bloody stool should be considered to operation immediately.if examination suggest bowel wall thicken, the extent of bowel necrosis maybe larger. (3)Ischemic bowel disease incidence rate is low and clinical manifestations are non-specific, the rate of misdiagnosis is high, the disease progresses is rapid and the consequences could be serious.(4)Ischemic bowel disease’s morbidity associates with elderly patients, hypertension, atrial fibrillation, diabetes, coronary atherosclerotic heart disease and liver cirrhosis.更多还原