急性原发性肠系膜上静脉血栓形成17例临床诊治分析

Diagnosis and management of acute primary superior mesenteric venous thrombosis:a report of 17 cases

目的:探讨急性原发性肠系膜上静脉血栓形成(APSMVT)的临床诊断与治疗。方法:回顾性分析我院1998年至2007年收治的17例APSMVT的临床资料。结果:17例病人(100%)均有持续性渐行加重的腹痛,常见伴随症状有恶心呕吐(82%)、消化道出血(53%)、肠梗阻(53%)、发热(59%)等。11例(65%)腹腔穿刺获血性腹水。17例均行超声检查,1例术前明确诊断;14例CT检查中2例增强扫描后得以确诊,12例平扫可见间接征象。16例行坏死肠段切除手术及抗凝治疗,其中3例首次剖腹探查未见异常,在症状未缓解或加重后再次手术发现肠坏死并行肠切除。2例病人行经皮肝穿刺肠系膜上静脉导管溶栓治疗,1例血栓复发者行肠系膜上动脉导管溶栓后治愈。3例术后因脓毒症死亡。结论:APSMVT术前诊断困难,对不明原因急性剧烈腹痛者应及时怀疑本症,早期发现、早期治疗方能提高本病的治愈效果。病程早期可采用介入溶栓疗法,后期出现肠坏死征象者应及时手术,并予以抗凝治疗。

Objective To elucidate the clinical manifestation, diagnosis and management of acute primary superior mesenteric venous thrombosis （APSMVT）. Methods The clinical data of 17 patients with acute primary superior mesenteric venous thrombosis were analyzed retrospectively. Results Among the 17 cases, the most common presenting symptom was aggravating abdominal pain （100%） with insidious onset, associated with nausea and （or） vomiting （82%）, gastrointestinal bleeding （53%）, bowel obstruction （53%） and fever （59%）, etc. All the patients had signs of acute peritonitis, and hemorrhagic ascites was found in 11 cases. Uhrasonography was performed in all the patients, and only in one case thrombus was detected in superior mesenteric venous （SMV）. CT scans were performed in 14 patients, and diagnosis was confirmed in two patients demonstrated with mesenteric venous filling defect, whereas the other 12 showed edematous or dilated small bowel or mesenteric stranding, which strongly suggested the diagnosis of APSMVT. Sixteen patients underwent resection of the infarcted bowel with primary anastomosis and starting immediate anticoagulation postoperatively. Three of them had a second-look exploration for delayed intestinal infarction, which did not show any sign of APSMVT during the first exploration,but the conditions gradually deteriorated postoperatively. Interventional thrombolytic therapies were performed in 2 cases through percutaneous transhepatic approach, and in one patient through the superior mesenteric artery for recurrent thrombogenesis. Three died of sepsis postoperatively. Conclusions Diagnosis of intestinal ischemia from APSMVT is difficult and often delayed. APSMVT should be strongly suspected in patients presenting unfathomable acute abdominal pain. Uhrasonography and CT scanning should be resorted to. Early discovery and treatment may improve the outcome. In early cases, thrombolytic therapy could be tried; and explorative operation should be carried out when conditions become compulsory. Accompanying anticoagnlation is also recommended.