儿童慢性肠系膜缺血致急性肠坏死一例并文献复习

目的探讨儿童慢性肠系膜缺血的临床特点及诊治方法,提高儿科医生对本病的诊疗水平。方法回顾性分析首都医科大学附属北京儿童医院收治的1例12岁因慢性肠系膜缺血所致的急性肠坏死女性患儿,体重14 kg,身高115 cm,曾有6年餐后腹痛病史,以持续性腹痛3 d,伴呕吐入院。入院诊断为急性消化道穿孔。急诊行开腹探查,术中见空、回肠总长约150 cm(无肠旋转不良),小肠远端约80 cm肠管缺血性坏死,并2处穿孔。行坏死肠管切除,近端空肠造瘘术。术后待病情稳定后,行肠系膜上动脉超声、腹部增强CT及腹腔血管数字减影血管造影均提示肠系膜上动脉管径细小,血流缓慢。通过Pubmed、Springer Link、中国知网、万方数据库检索2019年10月前的相关文献,并进行总结分析。结果术后1个月行关瘘术后,给予经口饮食并于关瘘术后14 d出院。出院后1个月随访,患儿可进普食,但餐后腹痛症状无缓解,体重不增。术后半年,餐后腹痛症状缓解,体重未增长。结合影像学检查,考虑患儿急性小肠缺血坏死由慢性肠系膜缺血所致。文献检索,共有59例儿童慢性肠系膜缺血的病例报道。患儿的主要症状包括餐后不适或腹痛19例(51.4%),生长发育停滞或体重下降5例(13.5%),高血压或恶性高血压3例(8.1%),消化道出血并出血性结肠炎1例(2.7%),缺血性胃炎伴溃疡1例(2.7%),无明确症状17例(45.9%)。狭窄受累的血管包括:腹腔干、肠系膜上动脉、肠系膜下动脉、肾动脉、髂外动脉、前支主动脉。治疗方法包括开腹手术血管成形术和介入治疗下的球囊扩张血管成形术。绝大部分有症状的患儿,一次或多次治疗后症状缓解。结论儿童慢性肠系膜缺血诊断困难,若能及时诊治,预后较好,否则可能造成严重的并发症。

Acute intestinal necrosis due to chronic mesenteric ischemia in a child: one case report with a review of the literature

Objective To explore the clinical characteristics of chronic mesenteric ischemia in children and to improve the diagnosis and treatment of this disease by pediatricians.Methods A retrospective review was performed for a 12-year-old girl with acute intestinal necrosis due to chronic mesenteric ischemia.With a weight of 14 kg and a height of 115 cm,there was a 6-year history of postprandial pain with a 3-day history of severe abdominal pain and vomiting.With a preoperative diagnosis of intestinal perforation,an emergency laparotomy revealed that the total length of jejunum and ileum(non-malrotation)was around 150 cm and the distal 80-cm of ileum became gangrenous with 2 perforations.Gangrenous ileum was resected and distal jejunostomy performed.After her condition stablized,duplex ultrasonography,computed tomography angiography and digital subtraction angiography(DSA)were performed successively.The diameter of superior mesenteric artery was small with a slow blood flow.At Month 1 post-operation,stoma was closed and she was discharged 14 days later with a semi-liquid diet.At Month 1 follow-up,she resumed an ordinary diet.However,the symptoms of postprandial abdominal pain were not relieved and there was no weight gain.At Month 6 after discharge,post-prandial abdominal pain was relieved without gaining weight.Base on imaging studies,acute intestinal ischemic necrosis was probably caused by chronic mesenteric ischemia.And the relevant literature reports were retrieved from the databases of PubMed,Springer Link,China National Knowledge Infrastructure(CNKI)and WanFang prior to October 2019.Results A total of 59 children of chronic mesenteric ischemia were reported.The major symptoms included discomfort or abdominal pain(n=19,51.4%),growth arrest or weight loss(n=5,13.5%),hypertension or malignant hypertension(n=3,8.1%),gastrointestinal bleeding with hemorrhagic colitis(n=1,2.7%),ischemic gastritis with ulcer(n=1,2.7%)and no definite symptoms(n=17,45.9%).The vessels involved in stenosis included celiac trunk,superior mesenteric artery,inferior mesenteric artery,renal artery,external iliac artery and anterior branch aorta.Treatments included open abdominal angioplasty and balloon angioplasty under interventional therapy.For most symptomatic children,the symptoms became relieved after one or more treatments.Conclusions The diagnosis of chronic mesenteric ischemia in children is rather difficult.If the diagnosis and treatment are timely,the prognosis is generally decent.Otherwise severe complications may occur.