急性肠系膜上动脉栓塞临床误诊探析

Clinical Misdiagnosis of Acute Superior Mesenteric Artery Embolism

目的 探讨急性肠系膜上动脉栓塞(SMAE)的临床特点、诊治方法及误诊原因、防范措施。方法 回顾性分析2015年1月—2022年1月收治的早期误诊的SMAE 8例的临床资料。结果 本组有风湿性心脏瓣膜病史和心房颤动史各4例。2例以中上腹痛、腹胀、腹泻伴恶心、呕吐、发热就诊,查血白细胞、中性粒细胞、血尿淀粉酶升高,腹部B超检查示胰腺稍大,误诊为急性胰腺炎。2例因进食刺激性食物后出现上腹部隐痛,伴恶心、呕吐、腹泻就诊,误诊为急性胃肠炎。2例因上腹痛、腹胀伴恶心、呕吐就诊,腹部X线检查示小肠轻度扩张、多个短小气液平面,误诊为急性肠梗阻。2例因右下腹痛、腹泻,伴发热、呕吐,排黄色稀水样便就诊,有腹膜刺激征,查血白细胞、中性粒细胞升高,误诊为急性阑尾炎。误诊时间17~23 h。8例经腹主动脉CT血管造影术或剖腹探查术确诊为SMAE,予手术切除坏死肠管及肠系膜后行肠管端端吻合。术后给予相应治疗,死亡4例,存活至今和失访各2例。结论 临床遇及以急腹症表现就诊患者时,若剧烈腹痛症状与体征不符,应仔细询问病史,开拓诊断思维,考虑到SMAE,并及早行特异性检查甚至手术探查,以早期确诊并治疗。

Objective To investigate the clinical characteristics,diagnosis and treatment,causes of misdiagnosis and preventive measures of acute superior mesenteric artery embolism(ASMAE).Methods The clinical data of 8 patients with ASAME misdiagnosed at early stage from January 2015 to January 2022 were retrospectively analyzed.Results There were 4 cases with a history of rheumatic heart valve and atrial fibrillation respectively.Two patients presented with upper middle abdominal pain,distension,diarrhea accompanied by nausea,vomiting,and fever in the middle and upper abdomen.Elevated levels of white blood cells,neutrophils,and hematuria amylase were detected.B-ultrasound examination of the abdomen showed slightly larger pancreas,which was misdiagnosed as acute pancreatitis.Two cases of epigastric dull pain accompanied by nausea,vomiting and diarrhea after eating irritating food were misdiagnosed as acute gastroenteritis.Two patients presented with upper abdominal pain,distension accompanied by nausea and vomiting.Abdominal X-ray examination showed mild intestinal dilation and multiple short gas-fluid levels,which was misdiagnosed as acute intestinal obstruction.Two patients presented with right lower abdominal pain,diarrhea,accompanied by fever,vomiting,yellow watery stool,signs of peritoneal irritation,elevated leukocytes and neutrophils,and were misdiagnosed as acute appendicitis.The duration of misdiagnosis was 17-23 h.Abdominal aortic CT angiography and exploratory laparotomy were used to confirm the diagnosis of SAME in all 8 cases.The necrotic bowel and mesentery were surgically removed and end-to-end intestinal anastomosis was performed.After operation,they were given corresponding treatment,of whom 4 cases died,2 cases survived and 2 cases were lost to follow-up.Conclusion In the clinical treatment of patients with acute abdominal symptoms,if the symptoms are inconsistent with signs of severe abdominal pain,the medical history should be carefully inquired,the diagnostic thinking should be developed,SAME should be taken into consideration,and specific examination or even surgical exploration should be carried out as soon as possible for early diagnosis and treatment.