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《中华消化外科杂志》2018年9月第17卷第9期论著

肠系膜上静脉血栓远期并发缺血性肠病的诊断与治疗

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引用本文:
孙世龙,丁威威,王士凯,等.肠系膜上静脉血栓远期并发缺血性肠病的诊断与治疗[J].中华消化外科杂志,2018,17(9):924-928.DOI:10.3760/cma.j.issn.1673-9752.2018.09.010.
【摘要】

目的:探讨肠系膜上静脉血栓远期并发缺血性肠病的诊断与治疗要点。
方法:采用回顾性横断面研究方法。收集2009年1月至2017年6月解放军南京总医院收治的36例肠系膜上静脉血栓远期并发缺血性肠病患者的临床资料。诊断方法:询问病史,体格检查,实验室检查,影像学检查。治疗方法:根据患者营养状态行肠外营养支持治疗,择期行一期肠切除联合肠吻合术或行一期肠切除造口术;二期行确定性手术恢复消化道连续性。术后予抗凝治疗。观察指标:(1)临床特点。(2)治疗情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者出院后相关并发症发生情况。随访时间截至2017年12月。偏态分布的计量资料以M(P25,P75)和M(范围)表示。
结果:(1)临床特点。①主要临床表现:餐后不适34例,腹痛33例,腹胀27例,恶心、呕吐20例,肛门停止排气排便17例,伴不同程度体质量下降14例,最严重者1个月内体质量减轻20 kg。30例患者临床表现≥3种。②36例患者急性生理与慢性健康评价 (APACHE)Ⅱ分数为4分(2分,6分)。③实验室检查情况:36例患者血清总蛋白为55.8 g/L(45.2 g/L,59.1 g/L),白蛋白为30.6 g/L(27.3 g/L,37.5 g/L),前白蛋白为100.0 g/L(86.0 g/L,132.0 g/L),上述指标均降低。④影像学检查情况:腹部增强CT扫描检查中,16例为门静脉海绵样变性,12例门静脉主干通畅但肠系膜上静脉主干未显影、伴广泛侧支循环,8例门静脉和肠系膜上静脉主干均显影。仅1例患者明显节段性肠壁水肿、肠腔狭窄。消化道X线造影检查中,部分肠腔狭窄萎缩伴肠黏膜消失28例,肠管完全梗阻8例。(2)治疗情况:36例患者中,24例行一期肠切除联合肠吻合术,12例行一期肠切除造口术(其中11例行二期确定性手术恢复消化道连续性,1例因高龄拒绝行二期确定性手术恢复消化道连续性)。 36例患者肠管切除长度为30 cm(15 cm,80 cm);仅1例行一期肠切除联合肠吻合术患者术后发生小肠瘘,经保守治疗后自愈,其余患者无并发症发生。(3)随访情况:36例患者均获得术后随访,随访时间为3~ 10个月,中位随访时间为6个月。随访期间,7例患者继发门静脉高压症,予对症治疗,5例好转,2例因严重消化道出血死亡;其余患者无相关并发症发生。
结论:肠系膜上静脉血栓远期并发缺血性肠病以餐后不适和肠梗阻症状为主要临床表现,患者营养状态差、感染较轻,腹部CT联合消化道X线造影检查对诊断具有重要价值。早期积极行手术切除病变肠管,术后评估出血风险予抗凝治疗是主要治疗方式。

【Abstract】

Objective:To explore the diagnosis and treatment of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.
Methods:The retrospective cross-sectional study was conducted. The clinical data of 36 patients with mesenteric venous thrombosis secondary to long-term ischemic enteropathy who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2009 to June 2017 were collected. Diagnostic methods: history inquiry, physical examination, laboratory test and image finding. Treatment methods: parenteral nutrition support, selective stage 1 bowel resection with anastomosis or stage 1 bowel resection and colostomy, definitive stage 2 operation for recovering digestive tract. Anticoagulation therapy was performed. Observation indicators: (1) clinical characteristics; (2) treatment; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to December 2017. Measurement data with skewed distribution were described as M (P25, P75) and M (range).
Results:(1) Clinical characteristics: ① the main clinical manifestations: 34, 33, 27, 20, 17 and 14 patients showed respectively discomfort after meal, abdominal pain, abdominal distension, nausea with vomiting, stop of analis exhaust and defecation and weight loss of different degree, and the worst patient lost 20 kg within 1 month. The clinical manifestations of 30 patients were more than 3. ② The score of acute physiology and chronic health evaluation (APACHE)Ⅱ in 36 patients was 4 (2, 6). ③ Laboratory test: total protein (TP), albumin and prealbumin were 55.8 g/L (45.2 g/L, 59.1 g/L), 30.6 g/L (27.3 g/L, 37.5 g/L) and 100.0 g/L (86.0 g/L, 132.0 g/L), respectively, showing a decreased trend. ④ Imaging finding: enhanced scans of abdominal CT showed the portal cavernous in 16 patients, the absence of main trunk of superior mesenteric vein with extensive collaterals in 12 patients, and dovelopment of portal vein and main trunk of superior mesenteric vein in 8 patients. One patients had intestinal edema and stenosis. X-ray contrast examination of digestive tract showed intestinal stenosis with mucosal erosion in 28 patients and complete intestinal obstruction in 8 patients. (2) Treatment: of 36 patients, 24 underwent stage 1 bowel resection with anastomosis and other 12 received stage 1 bowel resection and colostomy (11 undergoing definitive stage 2 operation for recovering digestive tract and 1 refusing stage 2 operation due to advanced age). The length of resected bowel was 30 cm (15 cm, 80 cm). One patient with stage 1 bowel resection with anastomosis was complicated with small bowel fistula, and was cured by conservative treatment. There was no complication in other patients. (3)Follow-up: all 36 patients were followed up for 3- 10 months, with a median time of 6 months. During the follow-up, 7 patients were complicated with secondary portal hypertension, 5 of 7 were improved by symptomatic treatment, and 2 died of severe digestive tract bleeding; other patients had no related complications.
Conclusions:The discomfort after meal and bowel obstruction are the main clinical manifestations of mesenteric venous thrombosis secondary to long-term ischemic enteropathy. The abdominal CT with X-ray contrast examination benefits to diagnosis of patients with poor nutrition status and mild infection. The main strategy includes early surgical resection and postoperative anticoagulation therapy after bleeding risk evaluation.

DOI:10.3760/cma.j.issn.1673-9752.2018.09.010
基金项目:国家自然科学基金(81770532);全军后勤科研项目(CNJ16C010);江苏省青年医学重点人才项目 (QNRC2016901)
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