粘连性肠梗阻手术指征多因素分析

目的探讨粘连性肠梗阻手术指征的多因素预测方法。方法回顾性分析安徽医科大学第一附属医院普外科1996年1月至2010年1月期间住院的2034例粘连性肠梗阻患者(进入分析模型有1992例),利用logistic多因素回归分析法,将可能影响粘连性肠梗阻急诊手术指征的17项因素〔梗阻持续时间、发作次数、腹部手术史、持续或剧烈腹痛、剧烈或频繁呕吐、严重腹胀、便血、发热、心率、休克或低血压、触及肿大肠襻、肠鸣音减弱、腹膜炎、外周血白细胞(WBC)计数、腹部立位X线平片示梗阻肠襻固定且扩张加重、腹腔游离气体及B超提示腹腔积液〕进行logistic回归分析,根据logistic回归分析理论得出粘连性肠梗阻需急诊手术几率的预测公式。结果根据logistic多因素及逐步回归分析得出梗阻持续时间、第一次发作、出现持续或剧烈腹痛、临床体检发现心率增快、出现腹膜炎体征、腹部立位X线平片见梗阻肠襻固定且扩张加重、B超提示腹腔积液及外周血WBC计数增高8项指标可以预测粘连性肠梗阻患者是否需急诊手术。其预测公式为:logit(P)=expZ/(1+expZ),其中Z={-7.813+〔-1.942×X1(1)/2.290×X1(2)/2.765×X1(3)〕+2.801×X2+2.692×X4+10.610×X9(1)/13.279×X9(2)+3.422×X13+〔-3.048×X14(1)/16.992×X14(2)〕+6.113×X15+2×X17},式中:X1(1)=梗阻持续时间3～5d,X1(2)=梗阻持续时间5～7d,X1(3)=梗阻持续时间≥7d;X2=发作次数;X4=持续或剧烈腹痛;X9(1)=心率60～100次/min,X9(2)=心率≥100次/min;X13=腹膜炎;X14(1)=WBC计数(10～20)×109/L,X14(2)=WBC计数≥20×109/L;X15=腹部立位X线平片示梗阻肠襻固定且扩张加重;X17=B超示腹腔积液。P0.5时则需急诊手术。本组结果符合率为99.00%,敏感性为96.17%,特异性为99.53%。随后利用2010年1月至2010年4月期间收治的粘连性肠梗阻患者105例对上述预测公式进行评价,符合率为96.20%,敏感性为90.00%,特异性为96.84%。结论预测公式有较好的实用价值,公式中各项系数还可随病例数增加进行修正。     

巨大肠结石致小肠梗阻1例

<正>患者男,81岁。因腹痛、腹胀、呕吐伴停止排气、排便3d由内科转入。腹式呼吸减弱,阵发性腹痛发作时,腹部隐约可见肠型及蠕动波,中下腹偏右侧拒按,压痛,肠鸣音活跃,可闻及气过水音。立位腹平片、腹部CT提示肠梗阻,小肠管扩张、积气、积     

成人急性肠梗阻手术治疗预测因子的多因素分析

目的探讨成人急性肠梗阻手术治疗的预测因子,建立手术治疗的预测模型。方法回顾性分析2006年1月至2009年6月住院治疗的541例肠梗阻的患者资料。结果患者高热（T〉38.5℃）、非手术治疗时间、恶心呕吐、腹痛进行性加重、腹部包块、腹膜炎体征、白细胞计数、血红蛋白、尿素氮、肌酐、总胆红素、肌酸激酶水平和腹部手术史13个危险因素与急性肠梗阻手术治疗密切相关。Logistic回归预测模型预测肠梗阻是否需要手术治疗的准确度为75.8%,敏感度为68.4%,特异度为83.1%。结论 Logistic回归模型能较好地判断成人急性肠梗阻是否需要手术治疗。     

腹腔镜对腹部疑难病例的诊治探讨(附4例报告)

我院近两年来用腹腔镜在诊断腹部疾病特别是诊治腹部疑难病例中取得了一定的效果 ,现报告如下。1　病例简介例 1,女 ,5 5岁。因腹胀腹痛伴肛门未排气 5ｄ收住院。Ｘ线腹部立位平片示小肠梗阻。入院诊断为机械性小肠梗阻。经保守治疗 11ｄ症状缓解 ,为进一步明确病因 ,行腹腔镜腹腔探查术 ,术中见回 -回肠、回 -结肠套叠 ,经腹腔镜手术松解肠套叠 ,术后康复出院。例 2 ,男 ,6 3岁。因胃癌术后 5年 ,腹痛 19ｈ收住院 ,Ｘ线腹部立位平片示肠梗阻。入院诊断为胃癌术后、机械性肠梗阻 ,行腹腔镜腹腔探查术 ,术中见小肠肿瘤 ,其余脏器无异常 ,转开…     

149例粘连性肠梗阻诊治体会

目的：探讨粘连性肠梗阻的病因、诊断及治疗。方法：对1996-2001年我科收治的149例粘连性肠梗阻患者的临床资料进行回顾性总结、分析。结果：本组149例均发生于腹腔手术后，主要症状是腹痛、腹胀、呕吐、肛门停止排气、排便，体征为腹胀、肠型、肠鸣亢进、腹部压痛。行腹部X线平片检查140例，泛影葡胺胃肠道造影18例，149例均确诊，其中不完全性肠梗阻112例，完全性肠梗阻37例。行非手术治疗123例，手术治疗26例，全组均治愈或好转。结论：腹腔手术是形成粘连性肠梗阻的主要因素，诊断主要依靠病史、体征及腹部X线摄片检查，泛影葡胺胃肠道造影对明确梗阻部位有较大帮助，也有一定治疗作用。粘连性不全性肠梗阻非手术治疗成功率高，而完全性肠梗阻或出现肠绞窄时应积极手术，掌握手术时机十分重要。     

腹腔镜肠粘连松解术1例报告

患者男,23岁,因腹痛、腹胀、呕吐、肛门停止排气2d入院。腹痛呈阵发性,无发热。2003年因急性阑尾炎行开腹阑尾切除术,术后第3d肛门才排气,切口愈合不良。入院时生命体征平稳,腹微膨隆,右下腹约6 cm陈旧性手术疤痕,腹软右下腹压痛,无反跳痛,叩诊鼓音,肠鸣音亢进,腹立位平片示肠管扩张多个气液平面,WBC 7.8×109/L,诊为粘连性肠梗阻。入院后予以胃肠减压、维持水电解质酸碱平衡、预防性应用抗生素等保守治疗48h,患者腹痛加重、发作频繁,腹稍膨隆,压痛明显,轻度反跳痛,肠鸣音减弱,腹立位平片示肠管扩张较入院时稍明显,故而急诊手术行腹腔镜下…     

成人急性大肠梗阻手术治疗预测因子的多因素分析

目的 :探讨成人急性大肠梗阻手术治疗的预测因子,建立手术治疗的预测模型。方法 :回顾性分析2008年1月—2012年1月住院治疗的306例大肠梗阻的患者资料。结果:患者高热(体温38.5℃)、非手术治疗时间、腹痛进行性加重、腹部压痛包块、腹膜炎体征、腹部手术史、白细胞计数、乳酸脱氢酶、尿素氮水平、CT检查见肠壁不规则增厚、结肠截断征、结肠内稀便、结肠内粪块等13个危险因素与大肠梗阻手术治疗密切相关。对有意义的13个变量行多因素Logistic回归分析,共有8个因素进入Logistic回归方程,按其作用的强度依次为:高热、肠壁不规则增厚、腹部压痛包块、腹膜炎体征、结肠内稀便、乳酸脱氢酶、白细胞计数和结肠内粪块。Logistic回归预测模型预测结肠梗阻是否手术治疗的准确度为88.56%(271/306),敏感度为94.58%(227/240),特异度为66.67%(44/66)。结论:8个因素Logistic回归模型可较好的预测成人急性大肠梗阻是否需要手术治疗。     

直肠巨大钡粪石1例报告

患者女,62岁,腹痛、腹胀1d,有间歇性呕吐,既往有腹部手术史。临床拟诊粘连性肠梗阻而摄腹部立卧位片。卧位片示左中上腹小肠充气、扩张,内径2.5cm;立位片见左中上腹扩张的小肠有数个高低不一的气液平面,宽约3cm,肠管黏膜呈弹簧状。诊断为机械性单纯性小肠梗阻,梗阻位置较高。照     

急性输入襻梗阻四例

例1 男,46岁.胃癌根治性全胃切除消化道Roux-en-Y重建术后10个月,吞咽困难5个月,加重10d于2009年1月31日入消化内科.行胃镜检查见食管-空肠吻合下约5 cm处肿瘤复发,管腔缩窄,勉强进镜打气后出现阵发性腹痛、呕吐转外科,呕吐物不含胆汁.体检:上腹膨隆,正中见切口瘢痕,可见肠型,有压痛.腹部立位平片示左上腹部、中腹肠管明显扩张并见多个液平;拟诊小肠闭襻性梗阻急诊手术,见中段空肠束带压迫致近端小肠扩张,距屈氐韧带6 cm处小肠肿唐复发,肠壁缩窄致输入襻十二指肠明显扩张,肠壁菲薄;结肠脾曲肿瘤复发并固定致近端结肠梗阻;遂行输入襻小肠复发肿瘤切除+束带松解+空肠回肠造瘘术;术后肠梗阻症状缓解.     

肠重复畸形脐尿管未闭并感染肠梗阻一例报道

患者 :男性 ,4岁。因腹痛 8ｄ ,肛门停止排气、排便 5ｄ入院。入院体检 :体温 38.0℃ ,脉搏 118次 /ｍｉｎ。急性痛苦病容。腹部膨隆 ,脐部突出。脐下偏右触及一 6 .0ｃｍ× 7.0ｃｍ包块 ,质硬 ,与腹壁相连。全腹压痛 ,反跳痛 ,腹肌紧张 ,以包块处明显。移动性浊音阴性。上腹肠鸣音 2～ 3次 /ｍｉｎ ,下腹部未闻及肠鸣音。辅助检查 :血常规 :ＷＢＣ15 .5× 10 9/Ｌ ,ＲＢＣ4 .3× 10 12 /Ｌ ,Ｎ 0 .76 ,Ｌ0 .2 4。Ｂ型超声探及下腹部一 8.0ｃｍ×7.0ｃｍ包块。立位腹部平片 :见多个阶梯状液平面。诊断 :①小肠机械性肠梗作者单位 :6780 0 0…     

原发性腹茧症的诊断与治疗

目的 探讨腹茧症临床特点及诊治方法。方法分析2000年7月-2004年2月收治的9例腹茧症患者的临床资料。结果9例中8例表现为急、慢性肠梗阻的症状。5例有腹部包块。9例患者中8例术前进行了腹部X线平片、CT检查,均发现不全性肠梗阻。4例CT发现腹膜及肠管管壁增厚强化,肠壁间粘连紧密;4例CT发现腹腔内小肠径路紊乱,聚集成团,似可见增厚的包膜包裹。3例进行了消化道钡餐检查,其中1例无异常,1例不全性肠梗阻,1例小肠集中于中腹部。剖腹术中均发现全部或部分小肠被一层灰白色致密坚韧的纤维膜包裹。行粘连松解、肠排列术等,术后9例全部治愈。结论患者反复出现急性或慢性肠梗阻症状,而又无其他原因解释或合并腹部包块者,应考虑腹茧症的可能。术前放射学检查对本病的诊断很有价值。手术是主要的治疗方法。     

Prospective evaluation of abdominal sonography for the diagnosis of bowel obstruction.

OBJECTIVE: The authors determined the utility of sonography compared with plain x-rays in the diagnosis of bowel obstruction. In a contemporaneous group of patients, they compared the cost of operative versus nonoperative management of small bowel obstruction. SUMMARY BACKGROUND DATA: Nonoperative treatment of simple bowel obstruction usually succeeds. However, because of the difficulty in assured diagnosis and the possibility of strangulation or other complication, exploration of suspected bowel obstruction is recommended. Most of these explorations could be avoided if diagnostic accuracy were better, yielding a desirable decrease in the overall cost of managing bowel obstruction. METHODS: Fifty patients whose clinical or plain x-ray findings suggested bowel obstruction underwent prospective evaluation by abdominal sonography and by flat and upright abdominal x-rays. Presence or absence of bowel obstruction was determined at laparotomy and by clinical evolution of the abdominal episode. Direct costs of care were determined from the hospital and physician bills of 54 patients treated contemporaneously with the sonography study. RESULTS: Sonography demonstrated bowel obstruction by showing fluid-filled dilated bowel loops proximal to collapsed bowel in 22 patients with one false-positive and three false-negative examinations. X-rays demonstrated bowel obstruction in 32 patients with nine false-positive and one false-negative examination. Cost data showed that operative treatment of simple bowel obstruction increased costs nearly eightfold. CONCLUSIONS: Sonography is as sensitive but more specific than plain x-rays in the diagnosis of bowel obstruction. Management based on sonographic findings has the potential to reduce costs of surgical care.     

Diagnostic value of plain abdominal radiographs in patients with acute abdominal pain

OBJECTIVE: A prospective study was performed over a 3-month period in a tertiary referral centre to evaluate the appropriateness and contribution of plain abdominal radiographs (PAR) in the diagnosis and management of adult patients presenting with acute abdominal pain. METHODS: Forward stepwise logistic regression was used to examine the correlation between PAR findings and the final diagnosis. The Chi-squared test was used to determine any changes in patient management including requirement for surgical intervention based on PAR findings (p < 0.05). RESULTS: Of 168 patients (246 PAR), 59 (35%) had positive findings on PAR. PAR were most sensitive in cases of intestinal obstruction (odds ratio, OR = 33.548, r = 0.561). The sensitivity was further increased if three of the following predictive signs were present: exaggerated bowel sounds (OR = 13.350, r = 0.154), abdominal distension (OR = 2.993, r = 0.234) and age over 50 years (OR = 2.301, r = 0.027). PAR were non-diagnostic in 82% of patients with acute abdominal pain (p < 0.001). CONCLUSION: PAR do not play a major role in influencing the management of patients with acute abdominal pain without coexisting bowel obstruction.     

Surgical management of infantile ulcerative enteritis

Infantile transmural ulcerative enteritis is a disorder of early infancy characterized by feeding difficulties, intermittent and progressive diarrhea, cachexia, anemia, abdominal distention, and small-bowel dilation which may progress to intestinal obstruction. The pathologic process, of unknown etiology, involves a transmural enteritis with deep undermining mucosal ulceration, not unlike that seen in Crohn's disease, except that granulomas are usually not present. The early stages of the disease may be reversible if the bowel is simply placed at rest by use of intravenous nutrition. In the later stages of the illness, there is progressive mechanical and functional intestinal obstruction due to inflammatory constriction of the distal small bowel and lack of effective peristalsis through the inflammed segments. The terminal stages are characterized by marked abdominal distention, complete obstruction, septicemia, and death.It is during the period of abdominal distention due to progressive intestinal obstruction that surgical intervention is of benefit. A cutaneous enterostomy proximal to the involved segments of small intestine serves to decompress the bowel, to minimize bacteremia, and to allow the distal inflamed intestine to heal. Total intravenous nutrition is mandatory for a period of several weeks until there is healing of the distal small bowel and closure of the enterostomy. In all surviving infants, bowel function has returned to normal and there have been no long-term sequelae or recurrences.     

Intrauterine intussusception causing intestinal atresia

The patient presented at the age of 2 days with persistent bilious vomiting, failure to pass meconium and urine, and progressive abdominal distension dating from birth, and a clinical diagnosis of intestinal obstruction was made. This was confirmed by plain abdominal radiographs. At laparotomy atresia of the terminal ileum was found. The proximal and distal segments of the bowel ended blindly and there was a V-shaped defect in the adjoining mesentery. The blind ends were resected and an end-to-back anastomosis was performed. The lumen of the resected distal segment contained an intussusceptum.     

Oral Urografin in Postoperative Small Bowel Obstruction

The aim of our study was to determine whether Urografin has the potential to offer surgeons a way of differentiating complete from partial small bowel obstruction and whether partial small bowel obstruction can be treated nonoperatively. Altogether 116 patients who had postoperative small bowel obstructions without any toxic signs underwent Urografin studies. Urografin (40 ml) mixed with 40 ml of distilled water was administrated either orally or via nasogastric tube to each patient. Serial plain abdominal radiographs were taken 2, 4, and 8 hours later. A total of 74 patients (63.8%) whose contrast medium reached the colon within the first 8 hours were considered to have partial obstruction and were successfully treated with intravenous hydration and nasogastric decompression. The remaining 42 patients (36.2%) in whom the contrast medium failed to reach the colon within the first 8 hours were regarded as having complete obstruction, and 34 of those patients (81.0%) underwent surgery; 8 (19.0%) received conservative treatment. Adhesion bands with complete bowel obstruction were observed in all 34 patients (100.0%) during laparotomy. Regardless of the presence of an air-fluid level on a plain abdominal radiograph or abdominal pain, a liquid diet followed by a soft diet could be given to those patients whose Urografin emptied into the colon. All the patients with partial bowel obstruction were treated successfully with nonoperative methods. The presence of Urografin in the colon within 8 hours of ingestion as an indicator for nonoperative treatment had a sensitivity of 90.2%, a specificity of 100%, and an accuracy of 93.1%. Urografin, a safe and reliable water-soluble contrast medium, can be used to differentiate partial intestinal obstruction from complete intestinal obstruction. Early oral intake was found to be a major advantage of Urografin use in this study, and the potential of Urografin use to shorten the period of conservative treatment for postoperative small bowel obstruction needs further investigation.     

肠梗阻治疗策略选择的今日观

肠梗阻由肠道机械性或功能性阻碍了消化产物正常的通过。它可以发生于胃远端、小肠、大肠,通常急性发病。虽然许多病例不需要手术治疗,但仍然是一个外科问题。肠梗阻原因繁多,应根据不同的发病原因,采取治疗手段也多种多样。通常手术治疗和针对病因的治疗是必需的,非手术治疗也是必需的。如今,心理治疗在治疗肠梗阻中的价值受到越来越多的关注。     

Intestinal obstruction

Intestinal obstruction is a common surgical emergency. In the developed world approximately 20% of patients with acute abdominal pain admitted to surgical units have intestinal obstruction and 80% of these will have small bowel obstruction. In the western world, adhesional obstruction is by far the most common cause of small bowel obstruction, reflecting the increasing number of abdominal surgical procedures being performed. Malignancy is the leading cause of obstruction of the large intestine. The cardinal clinical features are vomiting, abdominal pain, distension and gross constipation which differ in predominance depending on the site of the obstruction. Management of bowel obstruction requires prompt identification, meticulous attention to fluid and electrolyte balance and timely surgical intervention.     

生物胶体液对腹部手术后粘连性肠梗阻的预防作用

目的探讨生物胶体液对预防术后粘连眭肠梗阻及促进术后胃肠功能恢复的作用。方法140例腹部手术患者随机分为研究组71例和对照组凹例，研究组术中使用生物胶体液冲洗手术区域并保留部分于腹腔内，对照组未使用，比较2组术后粘连性肠梗阻发生率和对术后胃肠功能恢复的影响。结果研究组术后粘连性肠梗阻发生率明显低于对照组，差异有统计学意义（P〈0．05），并且可促进术后胃肠功能恢复，缩短患者的住院时间（P〈0．05）。结论腹部手术中应用生物胶体液安全有效，对预防粘连性肠梗阻、促进术后胃肠功能恢复有显著作用，可作为术中的常规操作推广应用。