急性肠系膜静脉血栓形成27例诊治经验

Acute mesenteric venous thrombosis： experience of 27 cases

目的总结急性肠系膜静脉血栓形成（MVT）的诊治经验。方法回顾性研究1983年至2007年7月收治的27例急性MVT的临床资料。结果27例患者病程1～14d，平均6．1d。既往有门静脉高压症、下肢静脉血栓、肠系膜静脉血栓等病史或合并其他高凝状态者18例（66．7％）。本组超声、CT、血管造影及外周血D-二聚体（D-Dimer）水平对急性MVT的诊断敏感性分别为70．6％（12／17）、75．0％（6／8）、100％（6／6）、100％（6／6）。16例腹腔穿刺抽出血性腹水者均已继发肠管坏死。11例行溶栓、抗凝治疗，4例有效（36．4％）。22例接受手术治疗，均行坏死肠管切除术，其中3例术中行经肠系膜上静脉血栓取出术。3例术后并发下肢深静脉血栓，1例并发心肌梗死，3例继发短肠综合征。4例手术后一周内急性MVT复发。8例在发病后1个月内死亡，其中7例为手术后死亡。19例存活的患者均接受了抗凝治疗。15例得到随访，其中7例长期服用抗凝药物。结论对于急性MVT，血D-Dimer水平的检测以及针对肠系膜血管的影像学检查是尽早确诊的关键。对无活动性出血和腹膜炎的病例，首选考虑进行抗凝溶栓治疗。对已继发肠管坏死者应进行手术。

Objective To summarize the diagnostic and therapeutic experiences of acute mesenteric venous thrombosis（MVT）. Methods The clinical data of 27 cases of acute MVT treated between 1983 and July 2007 were analyzed retrospectively. Results The courses of disease were from 1 to 14 days（ mean, 6. 1 days）. Eighteen cases （66. 7% ） had the history of portal hypertension, deep vein thrombosis, acute MVT or other hypercoagulability. The diagnostic sensitivity of ultrasonography, CT, angiography and serum D-Dimer level were 70. 6% （ 12/17 ）, 75.0% （ 6/8 ）, 100% （ 6/6 ）, 100% （ 6/6 ）, respectively. Bowel necrosis occurred in all the 16 cases with bloody ascites. The thrombolytic and anticoagulation therapy are effective in 36.4% of cases （4/11）. Twenty-two cases received operation, and resection of necrotic bowel was performed in all and thrombectomy in 3 cases. The main postoperative complications included 3 cases of deep vein thrombosis, 1 acute cardiac infarction,3 short bowel syndrome. MVT recurred in 4 cases within a week after operation. Eight patients died within a month after confirmed with acute MVT, in which 7 patients died after operation. Anticoagulation medication was implemented in all the 19 survived patients. Fifteen patients were followed-up for 1-120 months （ mean, 39.2 months）, 7 of them continued the anticoagulation therapy during this period. Conclusions The determination of serum D-Dimer level and such adjuvant examinations as ultrasonography, CT and angiography are important diagnostic means for acute MVT. Anticoagulation and thrombolysis should be considered firstly if there is no active bleeding and bowel necrosis. We recommend laparotomy when bowel necrosis is suspected.