特发性乙状结肠穿孔24例老年患者临床分析

目的 探讨老年人特发性乙状结肠穿孔的临床特征。方法 回顾性分析老年特发性乙状结肠穿孔患者24例的发病诱因、临床特征和治疗效果。结果 24例平均年龄68．7岁，均突然发病，平均病程5．2h。19例有习惯性便秘。表现为全腹膜炎21例(87．5％)，局限性腹膜炎3例，术前仅确诊4例，误诊20例(83．3％)，其中误诊为急性阑尾炎穿孔9例，上消化道穿孔7例，绞窄性肠梗阻4例。24例均行手术治疗，20例痊愈出院；死亡4例(16．7％)，3例死于感染中毒性休克，1例死于并发肺部感染。结论 认真询问病史，加强认识，对本病诊断极为重要；早期手术是治疗本病的根本措施，正确处理穿孔、彻底清洗腹腔、清洁肠道及术后充分引流是治疗本病的关键。     

急性重症胰腺炎25例误诊分析

1998年1月-2006年9月,我院收治的重症急性胰腺炎患者中25例曾被误诊。现将误诊中的经验教训报告如下。临床资料：被误诊而经手术证实的急性胰腺炎25例,男10例,女15例;平均年龄54．6岁。其中水肿型8例,出血坏死型17例,共死亡10例（出血坏死型7例,水肿型3例）。术前诊断：弥漫性腹膜炎14例（胆源性2例,疑为胃肠穿孑L6例,阑尾穿孔4例,原因不明2例）,肠梗阻2例,腹部炎性肿块2例,胆道感染3例,胆道术后休克原因不清2例,急性阑尾炎2例。临床表现主要为上腹或全腹剧痛,呕吐及腹胀。     

结肠造瘘口并发症分析

1980～1987年我院共施行结肠造瘘术66例,其中肛管直肠乙状结肠癌47例,结直肠损伤、先天性肛管直肠闭锁及腹部肿瘤致直肠梗阻各5例,结肠梗阻4例。术后并发造瘘肠管坏死、造瘘口狭窄及感染、造瘘肠管回缩及脱垂10例,术后并发症发生率为15%。其中再次手术者4例(6.0%),较国内外报道(19.1%、7.9%)为低。1.造瘘口感染:本组4例。其中2例为结肠肿瘤穿孔行急症剖腹探查术。肠癌引起急性穿孔多属病程晚期,穿孔前已呈明显恶病质,穿孔早期可出现休克。据报道,休克状态下组织细胞缺血缺氧,抵抗力降低,切口及腹腔感染率可达66.7%。手术操     

缺血性结肠炎102例临床分析

缺血性结肠炎(ischemic colitis,IC)是由于肠道血液供应不足或回流受阻致肠壁缺氧损伤引起的急性或慢性炎性病变.临床表现有腹痛、便血及腹泻,严重者可致肠坏死、穿孔、腹膜炎及感染中毒性休克,是下消化道出血的原因之一.现将2003年1月至2010年12月102例诊断为IC患者的临床特点及内镜表现报道如下.     

自发性结肠穿孔5例

目的通过回顾性分析以揭示影响本组病例愈后的主要因素．方法近年来我院共收住自发性结肠穿孔患者5例，男3例，女2例；年龄51岁～81岁，平均72．2岁，发病前均体健；临床表现为突发剧烈腹痛，明显腹膜炎体征，腹穿抽得脓性粪臭腹水；术前误诊为上消化道穿孔3例，阑尾炎及胰腺炎各1例；均为乙状结肠穿孔，行肠穿孔修补外置术3例，肠穿孔修补加近端结肠造瘘2例．结果发病8h内手术3例，2例出现休克症象，1例术后并发腹腔脓肿，肺部感染，均治愈；发病14h，24h手术各1例，术前均出现难以纠正的低血压，术中术后血压极不稳定，分别于术后1d，4d死于多器官功能衰竭．结论本病愈后差，死亡率高，早期诊断早期手术是降低死亡率的关键．     

老年急腹症外科治疗97例

目的:探讨老年急腹症的外科治疗策略.方法:对2006-2011年收治的97例老年急腹症患者的年龄分布、并存病种类、急腹症原因和手术方法、预后等进行回顾性分析.结果:全组年龄60-98岁(平均69岁±8岁):60-69岁63例,70-79岁23例,80岁以上11例.从发病到就诊所用时间2-240h(69h±61h).引起急腹症的原因包括急性阑尾炎/伴穿孔26例(27%),肠梗阻25例(26%),空腔脏器穿孔18例(18%),嵌顿疝15例(16%),肠道肿瘤11例(11%),原发性腹膜炎2例(2%).并存1种疾病者21例(22%),2种36例(37%),3种32例(33%),4种以上8例(8%).经过以外科手术为中心、多学科联合围手术期处理,行阑尾切除术22例(23%),腹腔引流术8例(8%),肠粘连松解术16例(16%),肠造瘘术13例(13%),肠部分切除11例(11%),穿孔修补术18例(18%),腹股沟疝还纳、疝修补术15例(16%),术后痊愈且没有并发症41例(42%).共52例(54%)发生1种或数种并发症,其中并发肺部感染38例(39%),应激性溃疡4例(4%),泌尿系统感染6例(6%),肾功能异常2例(2%),心功能不全3例(3%),切口感染7例(7%),切口裂开4例(4%),维尼克脑病1例(1%),均经及时治疗后痊愈出院.死亡2例(2%),放弃治疗2例(2%).结论:采取快速和创伤最小的麻醉手术治疗,配合多学科协作治疗老年急腹症可以取得满意的临床效果.     

非感染性坏死性胰腺炎手术时机的探讨--附62例临床病例报告

目的探讨急性重症胰腺炎非感染性胰腺坏死手术时机.方法对62例非感染性坏死性胰腺炎进行临床和CT评估以决定手术指征,根据手术发现对手术治疗的时机进行评估分析.结果经CT评估病灶大于6 cm、术前诊断为非感染性胰腺坏死41例患者中,32例发病3 ～ 4周后手术治疗.术中发现大网膜及肠系膜根部见大量皂化斑,正常胰腺与坏死胰腺组织分界清楚,10例患者胰腺坏死已合并感染,感染发生率为25%;术后5例患者死亡,病死率为12%;发病2周内手术治疗的9例患者,术中发现正常胰腺组织与坏死胰腺组织之间分界不十分清楚,胰腺及胰周组织水肿明显,术后有1例患者死亡.CT评估病灶小于6 cm,但胰周及腹膜后大片脂肪坏死、液体积聚、消化道有压迫梗阻症状的21例患者全部于发病后3 ～ 4周手术治疗,术中见4例患者胰腺坏死合并感染,3例有粘连性或压迫性消化道梗阻,术后2例死于腹腔内感染和多器官功能衰竭.结论对急性胰腺炎非感染性胰腺坏死,是否需要手术清除坏死组织,应行定期CT评估分析,对于病灶大于6 cm和/或病灶不足6 cm但胰周及腹膜后大片脂肪坏死、液体积聚并有消化道压迫梗阻症状患者,应行手术治疗.手术时机宜在发病后3 ～ 4周.过早手术,坏死组织与正常组织尚未完全分离,术中易出血,增加手术难度和再次手术的机会;过迟手术,坏死组织已合并感染,腹腔内感染严重,需再次手术甚至多次手术.     

感染性心内膜炎瓣膜损害的诊断及手术效果

目的:回顾性分析感染性心内膜炎瓣膜损害的诊断方法和手术效果。方法:2000年1月至2008年5月之间行手术治疗的感染性心内膜炎瓣膜损害者共119例,术前均进行血培养和彩色超声心动图检查。急诊手术32例,择期手术82例,所有病人经外科手术彻底清除感染病灶及周围坏死组织,纠正心内畸形,施行瓣膜置换。结果:术前超声发现赘生物115例(96.6%),瓣膜穿孔20例(16.8%),血培养结果阳性32例(26.9%);术中发现心内赘生物115例,穿孔21例,与术前超声检查结果无显著差异(P0.05);术后死亡5例(4.2%),其中急诊术后早期死亡2例(6.25%),择期术后早期死亡3例(3.66%),两组死亡率无显著性差异(P0.05)。结论:超声心动图检查可作为临床上确诊感染性心内膜炎的重要依据,对已确诊的患者应努力控制感染并尽早手术。     

急性肠系膜静脉血栓形成8例临床分析

目的探讨急性肠系膜静脉血栓形成(AMVT)的诊治要点。方法回顾性分析我院1995年7月至2003年6月经手术确诊的8例AMVT的临床特点及诊治情况。结果8例术前均以急腹症就诊,疑诊AMVT2例,8例均手术后确诊。1例为肠系膜上静脉主干血栓形成,全小肠坏死,术后2d死亡。余7例部分肠系膜静脉栓塞及肠坏死,6例治愈,1例并发双下肢深静脉血栓形成。5例明确病因。结论AMVT大多数以急腹症就诊,早期腹痛明显而体征轻微是其临床特点,临床诊断较困难。对有急性弥漫性腹膜炎、可疑肠坏死和血流动力学不稳的患者应立即手术治疗。     

老年溃疡病穿孔误诊原因分析

1995～ 2 0 0 1年 ,我们收治 6 0岁以上老年溃疡病穿孔患者 5 2例 ,其中因误诊为其它疾病而进行手术 9例 ,现将误诊原因进行分析。临床资料 :本组男 41例 ,女 11例 ;年龄 6 3～ 82岁 ;病程10～ 2 1天。主要临床表现为初期剧烈腹痛 ,多位于上腹部或右上腹部 ,迅即延及全腹 ,半数患者伴有恶心、呕吐、右肩背部放射痛 ;3～ 5小时后出现高热、肠麻痹、血压低等症状。初诊时误诊为十二指肠球部溃疡穿孔 6例 ,胃穿孔 3例 ,急性阑尾炎 5例 ,腹膜炎 2例 ,胆囊炎及急性胰腺炎各 1例。误诊原因分析 :1临床表现不典型。老年人机体反应差 ,当溃疡穿孔引…     

Ogilvie's syndrome: a rare cause of the acute abdomen

Ogilvie's syndrome (acute colonic pseudo-obstruction) is a rare clinical disease characterized by segmental distension of the proximal colon caused by a paralysis without mechanic obstruction. It may be a sequel of underlying neurological, medical or surgical disease. Risk factors are respiratory decompensation, electrolyte disturbances and different drugs. A special kind is the primary idiopathic pseudoobstruction with a high risk of perforation or necrosis. Especially elderly patients (> 70 years) with cardiovascular or neurologic diseases and accordant drugs are concerned. Clinical symptoms are progressive abdominal distension and abdominal pain like an acute abdomen. The differential diagnosis of a mechanic ileus is important for further treatment. This case report should draw attention to this rare disease.     

Neutropenic enterocolitis: Current issues in diagnosis and management

Neutropenic enterocolitis or typhlitis (from the Greek word typhlon, meaning cecum) is a clinical syndrome that occurs in the setting of disease or chemotherapy-induced neutropenia. The disease is characterized by an inflammatory process involving colon and/or small bowel, and it can result in ischemia, necrosis, bacteremia, hemorrhage, and perforation. The classic clinical features include fever and abdominal pain. The diagnosis is supported by the findings of bowel wall thickening on ultrasonography or CT imaging. The management of neutropenic enterocolitis is controversial. Neither prospective nor high-quality retrospective studies concerning medical or surgical therapies are available. Most authors will recommend initial conservative management with bowel rest, intravenous fluids, total parenteral nutrition, broad-spectrum antibiotics and normalization of neutrophil counts. Surgical intervention is recommended in the setting of obstruction, perforation, persistent gastrointestinal bleeding despite correction of thrombocytopenia and coagulopathy, and clinical deterioration.     

Diagnosis and treatment of spontaneous colonic perforation： Analysis of 10 cases

AIM： To investigate the etiology, diagnosis and treatment of spontaneous perforation of the colon.
METHODS： The clinical data of 10 cases of spontaneous perforation of the colon, observed at Fuding hospital from January 2004 to December 2007, were analyzed retrospectively.
RESULTS： The mean age at onset was 65 years （range from 45 to 73）. Seven patients had a history of chronic constipation. All patients complained of sudden lower abdominal pain. The perforation occurred after coloclysis and administration of senna leaves in two patients. Nine patients had signs of peritoneal irritation. Seven cases underwent abdominal paracentesis, which was diagnostic in six. Only one case was definitely diagnosed prior to surgery. One patient underwent neoplasty of the colon, another a partial resection of colon, six a neoplasty of the colon plus sigmoid colostomy, and two underwent Hartmann surgery. All perforation sites were opposite to the mesenteric edge. The perforation sites were located on descending colon in one case, sigmoid colon in three cases, and rectosigmoid colon in six cases. In five patients, surgical pathological examination was consistent with the microscopical changes of colonic perforation caused by feces. Three patients died after surgery.
CONCLUSION： Spontaneous perforation of the colon most commonly occurs among the elderly with chronic constipation. Abdominal paracentesis is helpful for the diagnosis. The perforation site is located opposite to the mesenteric edge. Sigmoid colon and rectosigmoid colon are the most frequent locations. Neoplasty of the colon and sigmoid colostomy are the most frequent treatment. The prognosis is bad and the mortality rate after surgery is high.     

Small bowel perforation caused by thermal injury during colonic polypectomy: A case report and literature review

Rationale:Iatrogenic gastrointestinal perforation is a known uncommon complication of colonoscopy. The perforation usually occurs in the colon itself. Rarely, colonoscopic procedures can also cause the perforations of the small intestine.Patient concerns and diagnoses:We describe the case of a 70-year-old man who experienced abdominal pain several hours after electrical polypectomy in the transverse colon. Urgent abdominal computed tomography scans showed a few bubbles on the frontal surface around the liver and a little extraluminal free air in the upper abdomen. Urgent exploratory laparotomy revealed a round perforation with a diameter of approximately 5 mm in the ileum 80 cm proximal to the ileocecal valve, accompanied by the outflow of intestinal contents. A small bowel perforation by thermal injury was diagnosed during colonic polypectomy.Interventions and outcomes:The ileal perforation was repaired primarily after debridement of the perforation site and abdominal cavity. The patient recovered well after surgery. Histopathological examination of the perforation site demonstrated inflammatory necrosis and infiltration of inflammatory cells.Lessons:Small bowel perforation should be considered after colonoscopic procedures although the incidence is exceedingly rare. Urgent exploratory laparotomy is warranted when a visceral perforation is identified after colonoscopy.     

Vascular Ehlers-Danlos Syndrome Without the Characteristic Facial Features: A Case Report

As a type of Ehlers-Danlos syndrome (EDS), vascular EDs (vEDS) is typified by a number of characteristic facial features (eg, large eyes, small chin, sunken cheeks, thin nose and lips, lobeless ears). However, vEDs does not typically display hypermobility of the large joints and skin hyperextensibility, which are features typical of the more common forms of EDS. Thus, colonic perforation or aneurysm rupture may be the first presentation of the disease. Because both complications are associated with a reduced life expectancy for individuals with this condition, an awareness of the clinical features of vEDS is important.Here, we describe the treatment of vEDS lacking the characteristic facial attributes in a 24-year-old healthy man who presented to the emergency room with abdominal pain. Enhanced computed tomography revealed diverticula and perforation in the sigmoid colon. The lesion of the sigmoid colon perforation was removed, and Hartmann procedure was performed. During the surgery, the control of bleeding was required because of vascular fragility. Subsequent molecular and genetic analysis was performed based on the suspected diagnosis of vEDS. These analyses revealed reduced type III collagen synthesis in cultured skin fibroblasts and identified a previously undocumented mutation in the gene for a1 type III collagen, confirming the diagnosis of vEDS. After eliciting a detailed medical profile, we learned his mother had a history of extensive bruising since childhood and idiopathic hematothorax. Both were prescribed oral celiprolol. One year after admission, the patient was free of recurrent perforation.This case illustrates an awareness of the clinical characteristics of vEDS and the family history is important because of the high mortality from this condition even in young people. Importantly, genetic assays could help in determining the surgical procedure and offer benefits to relatives since this condition is inherited in an autosomal dominant manner.     

Severe colonic complications of pancreatic disease

INTRODUCTION: Colonic involvement in pancreatic disorders is rare but potentially fatal. Extension of contiguous inflammation or neoplasm, autodigestive effects of enzymes, or dissection of a pseudocyst or abscess may involve the colon producing obstruction, perforation, hemorrhage, or abdominal pain. RESULTS: Nine patients with pancreatic disease requiring colonic resection were identified. Cases included pancreatic abscess producing colonic necrosis (2). pancreatic carcinoma invading the colon (3). extension of pancreatitis producing a colonic stricture (3). and pseudocyst eroding into the splenic flexure (1). Presentation was varied, including rectal bleeding (2). clinical deterioration during severe pancreatitis (4). and large bowel obstruction (3). The 3 cases due to malignancy, 1 of which was recurrent, presented with primary large bowel symptoms suggesting intestinal obstruction rather than pancreatic disease. Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. CONCLUSIONS: Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Colonoscopy, contrast x-rays, or CT scan may be vital in selected cases to detect underlying pathology. Clinicians should be aware that acute or chronic pancreatitis or pancreatic carcinoma may compress, erode, or inflame the large bowel, resulting in life-threatening colonic necrosis, bleeding, obstruction, or perforation.     

Esophageal Necrosis and Perforation Associated with the Anticardiolipin Antibody Syndrome

The anticardiolipin antibody syndrome has been previously associated with seven cases of gastrointestinal ischemia involving the duodenum, jejunoileum, or colon. In prior cases patients presented with gastrointestinal bleeding, abdominal pain, or an acute abdomen without gastrointestinal perforation. A patient with prior pulmonary emboli, right leg thrombophlebitis, and right popliteal artery thrombosis associated with anticardiolipin antibodies developed fatal esophageal ischemia. Postmortem examination revealed esophageal necrosis and perforation due to esophageal vascular thrombosis, as well as ischemic colitis and numerous other thromboembolic phenomena. This case report extends the gastrointestinal manifestations of the anticardiolipin antibody syndrome by describing esophageal involvement and by reporting the first case of alimentary tract perforation.     

特发性肠系膜静脉硬化性肠炎临床特点分析

目的:分析总结特发性肠系膜静脉硬化性肠炎的临床表现、影像学及结肠镜检查特征、治疗及转归等,旨在加强临床医生对该疾病的认识。方法:报道1例北京医院消化科收治的特发性肠系膜静脉硬化性肠炎患者,该患者因腹痛腹胀、停止排便排气3个月,再发伴呕吐2 d入院,结合患者病史、症状、体征、影像学及肠镜结果等,考虑患者不完全性肠梗阻病因...     

Colonic lymphoma in the transplant patient

Summary A 64-year-old male renal transplant recipient developed rectal bleeding caused by a primary lymphoma of the colon, an unusual site for initial disease involvement. Renal transplant recipients may be at increased risk for the development of primary colonic lymphoma, a diagnosis that should be considered in transplant patients who develop abdominal pain, rectal bleeding, or intestinal perforation. The unique clinical features and special management considerations of colonic lymphoma in the renal transplant recipient are discussed.     

青黛相关缺血性结肠黏膜损伤的内镜及临床特点分析

目的 分析青黛所致缺血性结肠黏膜损伤的临床特点,提高对该疾病的认识及防治效果.方法 收集北京大学第三医院2005年12月至2010年12月因服用含青黛成分中成药后出现缺血性结肠黏膜损伤的13例患者资料,对其临床及内镜表现进行分析,总结该型结肠黏膜损伤的特点.结果 患者的年龄为(60.6±14.1)岁,男女比例为1:1.6.患者因银屑病或特发性血小板减少性紫癜(11P)服用复方青黛丸(胶囊)或升血小板胶囊,平均服药时间为(3.6±2.3)个月.临床表现为腹痛及血便,13例患者中8例便血前有排水样便的表现.肠镜下病变形态、病理活检符合缺血性损伤的表现,病变较重,并呈慢性炎表现.扩血管治疗疗效明确,平均止血时间(1.7±0.8)d,预后良好.随访3个月均无复发.结论 银屑病和ITP患者服用含青黛成分中成药可导致结肠黏膜损伤,严重者可致缺血性黏膜损伤,临床应用该类药物时应进行认真评估及观察.

Abstract：

Objective By analysing the clinical features of Indigo Naturalis-associated ischemic lesion of colon mucosa to improve the precautionary and therapeutic level of the disease.Methods Thirteen patients diagnosed as Indigo Naturalis-associated ischemic lesion of colon mucosa in Peking University Third Hospital from 2005 to 2010 were reviewed.The endoscopic and clinical features were analysed.Results The 13 patients with an average age of(60.6±14.1)years old were prescribed Chinese traditional medicine containing Indigo Naturalis for psoriasis or idiopathic thrombocytopenic purpura(ITP).The ratio of males to females was 1:1.6.The typical manifestations were abdominal pain and bloody stool with watering diarrhea before bloody stool in 61.5%patients.Endoscopic and pathological characteristics were coincident with ischemic lesion and more like a chronic index.Vasodilatic medicine was effective and the average hemostatic time was(1.7±0.8)days.The prognosis was well and no recurrence was found during 3 months follow-up.Conclusions Patients having psoriasis or ITP treated with Chinese traditional medicine containing Indigo Naturalis have an inclination to colon mucosa lesions, even ischemic lesion. Careful assessment and observation before prescribing arc necessary in these patients.