肝移植术后肠瘘临床特点及诊疗分析

Practical points in the clinical characteristics and diagnosis of intestinal perforation after liver transplantation

目的探讨肝移植术后发生肠瘘的诊断及治疗经验。方法回顾性分析2016年1月至2022年8月期间就诊于首都医科大学附属北京友谊医院确诊为肠瘘的20例肝移植受者的临床资料,收集并分析术后肠瘘患者临床症状、实验室数据、影像学资料、治疗方法及预后。结果儿童受者术后肠瘘的发病率为2.8%(18/642),成人为0.4%(2/487)。20例肠瘘患者中儿童受者18例(90%),肠瘘中位发生时间为术后13.5(3.0~404.0)d。成人2例,肠瘘发生时间为术后2年及16 d。术后肠瘘的主要临床表现为发热、腹胀、腹痛,部分可出现腹泻、呕吐等。7例患者行立位腹平片,4例可见膈下或腹腔内多量游离气体。2例患者行胃肠道造影,均可见造影剂外溢。20例肠瘘患者均行病原学培养,70%(14/20)患者细菌培养阳性。95%(19/20)的肠瘘患者行剖腹探查术,其余1例成人患者行保守治疗。2例患儿死亡,均死于重症感染。结论肝移植术后肠瘘可导致感染的发生及加重,且术后使用激素及免疫抑制剂增加了术后感染的风险。因此监测引流液化验及细菌培养结果,及时调整抗感染用药方案,一旦确诊立即行剖腹探查及肠修补术是至关重要的。

Objective To investigate the experience of the diagnosis and treatment of intestinal perforation after liver transplantation.Methods We retrospectively analyzed the clinical symptoms,laboratory data,imaging data,treatment methods and prognosis of 20 intestinal perforation patients after liver transplantation admitted at Beijing Friendship Hospital from January 2016 to August 2022.Results The incidence of intestinal perforation in liver transplant recipients was 2.8%(18/642)in children and 0.4%(2/487)in adults.Among 18 pediatric recipients,the median time of onset was 13.5(3.0~404.0)days after liver transplantation.The onset time of the adult recipients was 2 to 16 days after liver transplantation.The main clinical manifestations of intestinal perforation were fever,abdominal distension and pain.Some patients developed diarrhea and vomiting.Plain abdominal radiographs in a vertical position were performed in 7 recipients.Subdiaphragmatic and intra-abdominal free air was observed in 4 recipients.Two recipients underwent gastrointestinal angiography,which showed contrast media extravasation.70%(14/20)of recipients were positive for bacterial culture.95%(19/20)recipients underwent exploratory laparotomy.Conservative treatment was performed in an adult patient.Two pediatric recipients died of severe infection.Conclusion Intestinal perforation after liver transplantation can lead to the occurrence and aggravation of infection.The use of hormones and immunosuppressants increases the risk of infection.Monitoring the drainage fluid properties and bacterial culture,timely adjusting the anti-infective drug regimen,and performing exploratory laparotomy and intestinal repair are important means to treat intestinal perforation in recipients after transplantation.