小肠出血病因及诊疗

<正>小肠解剖学上包括十二指肠、空肠及回肠。从狭义上来说小肠出血是指Treitz韧带以下的空肠和回肠出血;因十二指肠出血相对常见且可直接通过胃镜检查,故并不包括在小肠出血范围内。小肠出血为消化道系统的少见疾病,且小肠活动度大,位置多不固定,出血时临床表现无明显特异性,故诊断存在一定困难。随着推进式小肠镜、双气囊小肠镜、胶囊内镜、气钡双层造影、核素现象及选择性动脉造影等技术的发展,小肠出血的诊断准确性有所     

小肠出血诊断分析(附30例报告)

目的 探讨小肠出血的诊断方法。方法 对３０例病理证实的小肠出血术前行小肠气钡造影，核素显像，血管造影，剖腹探查和术中肠镜检查。结果 阳性率为：气钡造影４６．２％（６／１３），核素显像８７．５％（１４／１６），血管造影６６．７％（１０／１５），定位符合率为：气钡造影６６．７％（４／６），核素显像４２．９％（６／１４），血管造影９０．０％（９／１０），出血术前检查阳性率９０．０％，（１８／２０），间歇     

小肠出血：附29例分析

分析１９８４年～１９９２年收治并经手术和病理证实的小肠出血２９例。结果表明原发性小肠肿瘤在小肠出血原因中居首位（６５．５％）。小肠插管分段气钡造影对小肠出血具有重要的诊断价值（阳性率７３．６％），认为当临床上高度怀疑小肠病变时，此法应列为首选。     

小肠出血的诊断和治疗(附76例报告)

目的探讨小肠出血的病因、诊断和治疗措施。方法对我院近8年收治的病因明确的76例小肠出血病人的临床资料进行回顾性分析。结果本组小肠出血病人肿瘤占首位(37/76),其中包括小肠间质瘤32例,其余依次为美克尔憩室(21/76)、血管病变(15/76)及异位胰腺(3/76)。经数字减影血管造影诊断21例,小肠气钡双重对比造影诊断13例,腹腔核素扫描诊断11例,小肠镜检查诊断6例,腹腔镜探查诊断21例,剖腹探查诊断4例。全组病人均经手术治疗,手术方式以包括病变在内的小肠部分切除术为主(68/76)。随访时间6月～5年,临床疗效满意。结论气钡双重对比造影、核素扫描、数字减影血管造影、腹腔镜探查及剖腹探查是诊断小肠出血的主要手段。包括病变在内的小肠部分切除术是治疗小肠出血最有效方法。     

隐匿性并复发性小肠出血的外科诊治经验

隐匿性并复发性小肠出血在临床上较少见,且出血部位和性质有时很难确定［１］,收集我院１９８８年至１９９８年４７例小肠出血病例．就其诊断和治疗体会报道如下。 １．临床资料：４７例中男性２８例、女性１９例,年龄２２～７５岁、间断复发性便血４２例,隐性出血５例;腹痛３３例,腹部包块１０例;发热８例;贫血４５例。既往已作手术探查１２例,术后又复发小肠出血。检查：小肠气钡造影检查３４例,阳性率５６．５％（１９例）,其中发现小肠肿瘤１２例,小肠憩室６例,小肠炎性病变１例。小肠稀钡灌肠检查１２例,阳性率４１．７…     

小肠出血45例分析

目的:探讨小肠出血的病因、诊断和治疗方法.方法:回顾性分析1998～2005年经手术及病理证实的小肠出血45例的临床资料.结果:小肠出血原因中血管畸形(19例)占首位,其次为炎性肠病(13例)、小肠憩室(10例)及家族性肠息肉病(3例).45例均经手术治疗.结论:诊断小肠出血的主要手段包括小肠气钡双重造影、选择性肠系膜血管造影及核素扫描.对原因不明的反复出血应行诊断性剖腹探查.     

小肠出血42例诊断与治疗分析

目的 探讨小肠出血的病因、诊断与治疗.方法 对我院2001年1月至2009年1月间收治的42例小肠出血患者的临床资料进行回顾性分析.结果 小肠出血原因以肿瘤占首位(19 例),其次为小肠憩室(10例)、血管畸形(6例)、小肠系膜静脉血栓(4例)、急性出血坏死性肠炎(3例).全组患者均行手术治疗,术后发生短肠综合征1例.所有患者均无再出血发生.结论 小肠出血常见病因为肿瘤,其次为憩室.小肠气钡双重造影、数字减影血管造影、核素扫描是诊断小肠出血的主要措施.小肠部分切除是治疗小肠出血最有效的方法.     

小肠出血的病因及诊断方法分析

目的探讨小肠出血的病因和诊断方法。方法回顾性分析32例确诊的小肠出血病例的临床资料。结果病因以小肠肿瘤最为多见（46．8％），其他依次为憩室（25．0％）、炎性疾病（15．6％）及血管畸形（12．5％）。检查方法以小肠气钡双重造影开展较普遍。小肠气钡双重造影、血管造影、核素扫描和小肠镜在小肠出血病人中阳性检查率的比较无显著性差异（X^2=3．796，P=0．284）。结论 小肠出血病例中，小肠肿瘤为最常见病因．合理应用小肠气钡双重对比造影等检查方法，是提高小肠出血诊断率的主要手段。     

27例空回肠出血的诊断分析

目的　对经手术证实的 2 7例空回肠出血患者进行分析 ,探讨空回肠出血的病因诊断。方法　 2 7例空回肠出血患者分别进行B超、小肠气钡造影、选择性血管造影、术中肠镜等检查 ,最后均以手术及病理证实。结果　出血原因中 ,肿瘤 14例 (5 1.9% ) ,血管发育不良 5例 (18.5 % ) ,Meckel憩室 4例 (14 .8% ) ,Crohn’s病 3例 (11.1% )空肠非特异性溃疡 1例 (3.7% )。术中肠镜检查 6例 ,阳性诊断率为 83.3%(5 6 ) ,阳性符合率为 10 0 % ;选择性动脉造影 12例 ,阳性诊断率为 6 6 .7% (8 12 ) ,阳性符合率为 87.5 % ;气钡双重造影 17例 ,阳性诊断率为 2 3.5 % (4 17) ,阳性符合率为 10 0 % ;B超检查 2 7例 ,阳性率为 2 5 .9% (7 2 7) ,阳性符合率为 85 .7%。结论　肿瘤为空回肠出血的主要原因。除传统的诊断方法外 ,B超在空回肠出血的诊断中也具有较为重要的作用     

下消化道出血的早期诊断：附80例报告

探讨下消化道出血的早期诊断。主要经常规小肠钡餐、小肠气钡双重造影、动脉造影（其中７例通过动脉导管放入钢丝标记）、核素扫描、纤维结肠镜等单项或多项检查，最终经手术和病理确诊。８３８％病变位于空、回肠，１６２％位于结、直肠。血管畸形占３５０％，小肠平滑肌肿瘤占２６２％。各科医生密切配合、合理掌握各种诊断手段适应证和时机可望早期诊断下消化道出血。经动脉导管放置钢丝标记出血部位有益术中找出病灶所在肠段。     

空肠回肠间质瘤的诊断和治疗

目的 探讨空肠回肠间质瘤诊断和治疗经验。方法 对我院1993～2003年收治的有完整资料经术后病理和免疫组化证实的15例空肠回肠间质瘤病例进行回顾性分析。结果 本组病人主要临床表现为黑便、腹痛、头晕、乏力。术前选择性血管造影发现小肠出血2例、核素扫描发现小肠出血1例。剖腹探查确诊7例,腹腔镜腹腔探查确诊4例,术前明确诊断的仅1例。发病至确诊时间2月～7年。14例病人行间质瘤切除、小肠吻合术,1例肿瘤无法切除的病人行口服Gleevec保守治疗。随访2月～9年,除1例病人死于其它疾患,1例在继续服用格列卫治疗外,余13例病人均健在,空肠回肠问质瘤无复发。结论 空肠回肠间质瘤缺乏特征性临床表现及有效诊断手段,易致长期延误诊治。对长期不明原因的消化道出血病人及早行剖腹探查或腹腔镜腹腔探查是避免空肠回肠间质瘤长期延误诊治、改善病人预后的关键。     

Small bowel melaena: 2 cases diagnosed by angiography

Two cases of small bowel tumour presenting with melaena are reported. Selective visceral arteriography was found to be invaluable in the management of these cases. The first case presented with intermittent bleeding causing anaemia. Conventional barium studies of the small and large bowel revealed no abnormality. Superior mesenteric angiography revealed a mass lesion in the jejunum, with features characteristic of a leiomyoma. The second case presented with massive gastrointestinal bleeding. Selective visceral angiography was performed initially and revealed a large, mainly avascular, mass lesion in the ileum. Pathological examination showed a leiomyoma which had undergone cystic degeneration. The value of selective angiography in patients with suspected small bowel bleeding is discussed..     

Small intestine diverticula:Is there anything new?

AIM:To globally approach the clinical entity of small bowel diverticulosis and, at the same time, set out the treatment options. METHODS: We analysed 77 cases of diverticula located in the duodenum, jejunum and ileum that were treated in our department, evaluating the symptoms, diagnostic approach and offered treatment. RESULTS: Almost half of the diverticula (46.7%) were incidentally discovered and Meckel’s diverticula represented the majority (43%) that were actually the only true diverticula. A high complication rate (53%) which included inflammation with or without perforation (22%), bleeding (10%) or obstructive ileus (12%) due to small bowel diverticulosis was reported. The preoperative diagnosis was often impossible (44% of complicated cases). CONCLUSION: Although small bowel diverticulosis has a low incidence, it should be in the clinician’s mind in order to avoid misdiagnosis.     

Intestinal bleeding from arteriovenous malformations of the small bowel in a patient with Cowden syndrome: report of a case

This report presents the case of a patient with Cowden syndrome who had arteriovenous malformations (AVMs) at the jejunum and the ileum and experienced intestinal bleeding. A 54-year-old Japanese male presented with general fatigue and melena. Endoscopic examinations showed gastrointestinal polyposis from the esophagus to the rectum. However, the site of bleeding was not identified. There were some papules on his face and neck. He also had macrocephaly and had multiple papillomas along the gum-line. These findings indicated a clinical diagnosis of Cowden syndrome. Enhanced computed tomography (CT) and angiography analyses indicated the presence of AVMs at the jejunum and the ileum. He was treated with partial resection of the jejunum and ileum including these two AVMs. This was a rare case of two AVMs involving the small bowel in a patient with Cowden syndrome. Enhanced CT was very useful and convenient for the detection of gastrointestinal AVMs in this case.     

Gastrointestinal stromal tumors. A case of small intestine stromal tumor (SIST) with an uncertain biological aspect

Tumors of the small intestine are relatively rare. The diagnosis is difficult to establish because the symptoms are vague and non-specific. Although the small intestine constitutes 75% of the length and over 90% of the mucosal surface area of the gastrointestinal tract, only 1 to 2% of gastrointestinal malignancies occur in this segment. Metastases are usually present at the time of diagnosis. The outcome of these patients can be improved if the possibility of a malignant small bowel tumor is considered in all cases of unexplained abdominal pain or gastrointestinal bleeding, especially in younger age. Malignant tumors occur with increasing frequency in distal small bowel with a preponderance of malignant lesions in the ileum compared with the jejunum and the duodenum. Adenocarcinoma is the most common tumor of the primary malignant small bowel tumors, followed by carcinoid, lymphoma and leiomyosarcoma. Mesenchymal tumors of the gastrointestinal tract, traditionally regarded as smooth muscle tumors, have demonstrated different cellular differentiations based on immunohistochemical and ultrastructural features. Therefore the terms leiomyoma and leiomyosarcoma have been replaced by a more encompassing term, gastrointestinal stromal tumor (GIST). The majority of GISTs occurs in the stomach; stromal tumors involving the small intestine (SISTs) are far less common but seem to have greater malignant potential. The clinical a case of a small intestinal stromal tumor (SIST), localised in the jejunum and characterised by an uncertain histological aspect, is presented and a review of the literature is made.     

小肠平滑肌肿瘤与下消化道出血：附33例报告

探讨出血型小肠平滑肌肿瘤的临床特点及其诊断。方法回顾性病例分析。结果出血型小肠平滑肌肿瘤具有下列临床表现（１）反复间隙性消化道出血。（２）大多数病人的年龄在４０岁以下。（３）位于空肠部位的肿瘤约为回肠的３倍。     

Gastrointestinal adaptation following small bowel bypass for obesity.

Small intestinal morphologic and biochemical changes were studied following jejuno-ileal bypass for obesity after body weight stabilization had occurred. Four patients underwent biopsy of in-continuity and bypassed jejunal and ileal segments of the small intestine 11 to 22 months after the bypass operation. Microscopically, marked mucosal villus hypertrophy of the in-continuity bowel was observed, especially in the ileum. Bypassed jejunal mucosa underwent atrophy compared with pre-bypass jejunum, whereas bypassed ileum appeared similar microscopically to pre-bypass ileum. The specific activities of mucosal disaccharidase enzymes (maltase, sucrase, lactase and trehalase) in units per mg protein remained similar to pre-bypass levels in segments of the in-continuity jejunum and the bypassed jejunum and ileum. On the other hand, elevated mucosal disaccharidase levels were measured in biopsy specimens of the in-continuity ileum. Total enzyme activity per unit length of intestine, however, was estimated to be elevated in both in-continuity jejunum and ileum secondary to mucosal villus hypertrophy. These data indicate that following small bowel bypass: (1) the in-continuity ileum undergoes greater biochemical and morphologic adaptation than the jejunum; and (2) intraluminal nutrients and chyme appear to be essential to maximal intestinal adaptation.     

Small bowel tumors. Clinical course and therapeutic aspects

The small bowel tumors are rare and their diagnosis is difficult. Therefore, they are usually discovered in advanced stages and often a surgical intervention is imposed due to acute complications generated by the tumors. Sometimes, they are accidentally found during other surgical procedures. We present 25 cases of small bowel tumors treated between 1996-2005. Among these cases, 4 (16%) were located in the duodenum, 10 (40%) in the jejunum and 10 (40%) in the ileum. In one case, there were multiple tumor locations spread along the mesenterial bowel and mesentery. Recently, pre- operative diagnosis has become more accurate due to modem imaging modalities, such as computed tomography, which has established the diagnosis in 12 cases. From the therapeutical perspective, the surgical intervention (spread segmentary resections/enterostomies) is the only method which improves survival rate. In our study, this approach was possible in 15 patients (60%). It was noticed that the tumor recurrences are frequent and occur early. Post-operative morbidity (12 cases--48%) and mortality (3 cases--12%) rates remain rather high.     

An experimental technique to assess the immunologic consequences of segmental small bowel transplantation

BACKGROUND: The amount of native small bowel required for adequate nutrition is variable, but lies between 10% and 20% of full length. Currently, for patients requiring small bowel transplantation (SBT), standard practice is to transplant the entire small bowel if space permits. Few experimental studies have addressed the effect of the length of small bowel transplanted on immune responses and in those that have, the amount of mesenteric lymph node (MLN) transplanted has always been a potential confounding factor, as have differences between jejunum and ileum. METHODS: Full-length and segmental heterotopic rat SBT was performed between PVG donor and DA recipients. To transplant reduced length small bowel grafts but to exclude immunologic differences between jejunum and ileum, equal lengths of bowel were resected from proximal and distal ends in the donor. A proportional amount of MLN was carefully dissected using a microvascular technique and then excised. Serial serum samples from the transplant recipients were tested for anti-PVG (rejection) and anti-DA (graft-versus-host) antibodies using a two-color flow cytometric technique, described previously, with the aim of looking for differences in immunologic responses to full and segmental grafts. RESULTS: We have established a model of segmental SBT that includes a proportional amount of MLN and is free from differences between jejunum and ileum. Preliminary data have demonstrated the development of circulating anti-host and anti-graft antibodies with time for both full-length and segmental SBT.     

Jejunoileal arteriovenous malformation: localization for resection by segmental bowel staining techniques.

Arteriovenous malformations, submucosal vascular lakes, of the jejunum and ileum which cause chronic gastrointestinal bleeding and anemia are easily identified before operation by selective arteriography but difficult at operation owing to lack of physical signs. This report is concerned with a patient who had such a lesion located in the proximal jejunum. The involved segment was easily identified at operation by injection of Indigo Carmine solution during operation into the involved jejunal artery subselectively catheterized immediately prior to operation. The duration of jejunal staining before resection was 45 minutes in this case and varied from 35 to 55 minutes in five other patients who had right colectomy for carcinoma, providing the opportunity to inject accurately in a conveniently located radiology suite before operation. Safe, convenient, longer periods of staining which could be performed at the time of original diagnosis were demonstrated in dog experiments using "biologic" colloidal carbon in which the bowel segment was well stained at the time of sacrifice five days after injection. There were no gross or microscopic signs of injury to bowel.