急性肠系膜血管缺血性疾病的诊断与治疗（附67例报告）

Diagnosis and treatment of acute mesenteric ischemia： a report of 67 cases

目的分析急性肠系膜血管缺血性疾病（acute mesenteric ischemia，AMI）的临床特点，总结此病的诊断和治疗经验。方法回顾1993～2011年北京大学第一医院明确诊断的67例AMI患者的临床资料，进行统计学分析。结果67例患者中，共死亡15例。初步诊断正确的患者死亡率低（25．5％VS40．0％，P=0．051）。手术治疗52例，死亡12例，术后并发症16例，包括短肠综合征2例。经手术证实肠坏死50例患者中，术前没有明确腹膜炎体征的有14例（28．0％）。非手术治疗15例，死亡3例。88．9％患者D-二聚体升高。32．4％患者血淀粉酶升高。超声探及血管血流异常的敏感率41．7％，发现肠壁增厚、腹腔积液等间接征象的总敏感率81．3％。CT对AMI的直、间接征象的总敏感率90．9％。血管造影敏感率100．0％。存在“症状重、体征轻”特点的患者自出现症状到就诊的时间间隔短[（1．4±0．6）dVS（4．2±4．1）d，P=0．041]。肠壁全层坏死的患者腹腔积液为脓性或血性的比例高（92．6％VS66．7％，P=0．031）。急性肠系膜动脉缺血的患者中突发剧烈腹痛、房颤、年龄大于60岁（含60岁）的比例高于静脉缺血患者，而静脉缺血患者中持续性腹痛、伴有肝硬化的比例更高。年龄大于60岁、有腹腔积液和大便有血的患者死亡率高。结论初步诊断正确的患者死亡率低。没有腹膜炎体征不能除外肠坏死。“症状重、体征轻”的特点多见于发病早期。对疑似患者及时行腹部超声及CT检查有助于及早诊断。对有腹腔积液的疑似患者，应积极行诊断性穿刺。

Objective To analyze the clinical features of acute mesenteric ischemia （AMI）. Methods Clinical data of 67 AMI patients admitted to the First Hospital of Peking University from 1993 to 2011 were investigated retrospectively. Results There were 15 deaths in 67 AMI patients. Correctly initial diagnosed patients had lower mortality rate （25.5% vs 40.0% , P = O. 051 ）. 52 patients were treated surgically, with 12 deaths. 16 patients had post- operation complications, including 2 cases of short bowel syndrome. 14 of 50 surgical confirmed bowel necrosis patients had no sign of peritonitis pre-operatively. 15 patients were treated non- surgically, with 3 deaths. 88.9% of 67 patients had elevated D -dimer, while 32.4% had abnormal serum amylase. Uhrasound had a sensitivity of 41.7% in detecting abnormal blood tlow in mesenteric vessels, and a sensitivity of 81.3% in showing bowel wall thickening, ascites, and other indirect signs. CT had an overall sensitivity of 90.9%. Angiography sensitivity was 100.0%. Greater pain in proportion compared to the physical examination findings was in early onset of the illness [ 1.4 ± 0.6） d vs （4.2 ± 4.1 ） d, P = 0. 041 ]. Patients with full - thickness necrosis of the intestinal wall had higher rate of purulent or bloody ascites, comparing with partial - thickness necrosis （92.6% vs 66.7% , P = 0. 031 ）. Acute mesenteric artery ischemia patients had higher rates of sudden severe abdominal pain, atrial fibrillation, and age over 60 years （ including 60 years）, comparing with mesenteric venous ischemia, while the venous ischemia had higher rates of persistent abdominal pain and liver cirrhosis. Patients older than 60 years old, or with peritoneal fluid, or blood in the stool had higher mortality rate. Conclusion Correctly initial diagnosed patients have lower mortality rate. With no sign of peritonitis, bowel necrosis can not be fully excluded. Pain that is greater in proportion compared to the physical examination findings is in early onset. Ultrasound and CT scan are helpful for early diagnosis in suspected patients. For suspected patients with peritoneal effusion, diagnostic paracentesis is recommended.