老年人缺血性肠病诊治中国专家建议(2011)

缺血性肠病分为急性肠系膜缺血(acute mesenteric ischemia,AMI)、慢性肠系膜缺血(chronic mesenteric ischemia,CMI)和缺血性结肠炎(ischemic colitis,IC).本建议拟通过介绍缺血性肠病的临床特点、诊断标准、治疗原则,为临床医师提供诊断和防治依据,本建议不包括门静脉高压所致肠系膜静脉血栓形成引起的肠缺血.     

老年人缺血性肠病的诊治进展

随着人口老龄化趋势加剧及人们生活方式的改变,缺血性肠病(IBD)的发病率逐年升高,50岁以上的中老年人已成为IBD的主要发病人群。近年来发现血清生物学标志物SM22、平均血小板体积(MPV)、CT血管造影(CTA)、多排螺旋CT(MDCT)对急性肠系膜缺血(AMI)的诊断具有较高的敏感度和特异度;磁电图(MENG)能识别慢性肠系膜缺血(CMI)患者肠道慢波节律,可提高CMI的诊断效率。经肠系膜动脉血管成形术和支架植入术可作为伴有慢性疾病的老年AMI及CMI患者首选的治疗方法,在血运重建术后行吲哚菁绿(ICG)荧光灌注有利于提高AMI的治疗效果,从而降低病死率。     

12例缺血性肠病的临床分析

目的分析缺血性肠病（ischemic bowel disease,IBD）的临床特点、诊断及治疗。方法回顾性分析12例患者临床表现、合并症、腹部血管CT成像（CT angiography,CTA）或腹部血管彩超、电子结肠镜、治疗等。结果急性缺血性肠病3例,2例经手术治疗,1例发病72h内死亡。慢性缺血性肠病9例,8例经内科治疗好转,1例死亡。结论急性缺血性肠病多见于肠系膜上动脉闭塞,早诊断、早治疗较重要,出现肠坏死预后差。慢性性缺血性肠病多见于肠系膜上、下动脉狭窄及灌注不足,内科治疗疗效良好。肠道排空障碍可能是IBD的早期表现。     

肠系膜血管病

肠系膜血管病也称缺血性肠病，是由各种原因引起的肠道急性或慢性血流灌注不良所致的肠壁缺血性疾病。此疾病可累及全消化道，早期诊断是关键。现就我院消化科2001年3月至2002年5月收治的22例缺血性肠病病例分析如下。     

血浆D-二聚体检测对缺血性肠病鉴别诊断价值的探讨

缺血性肠病是由各种原因引起的肠道急性或慢性血流灌注不良所致的肠壁缺血性疾病，病变侵及黏膜层和黏膜下层，包括缺血性结肠炎、肠系膜动脉栓塞、肠系膜静脉栓塞等。随着社会人口日益老龄化，缺血性结肠炎的患病率也有增加，其临床表现有腹痛、便血、腹泻，严重者可以出现肠坏死、肠穿孔、腹膜炎甚至出现感染性休克。国内外多报道缺血性结肠炎的内镜检查，而未见有关血浆D-二聚体变化的报道。本研究旨在探讨内镜检查及血浆D-二聚体检测对于缺血性肠病鉴别诊断及其判断预后的价值。     

缺血性肠病与心脑血管病变

1 缺血性肠病缺血性肠病在我国常见,是由各种原因引起肠道供血不足而形成的一组综合征,可表现为从轻的、可逆性的肠缺血到肠梗塞和肠坏疽,临床上分成急性和慢性两种类型,慢性缺血性肠病包括腹绞痛、腹腔动脉压迫综合征,急性缺血性肠病包括肠系膜上动脉栓塞和血栓形成、急性非肠系膜血管阻塞性肠梗塞、肠系膜静脉血栓形成和缺血性结肠炎,其临床表     

肠系膜血管缺血外科诊治进展

肠系膜血管缺血(acute mesenteric ischemia,AMI)是潜在致命的血管性急腹症.死亡率很高,且发病率不断上升.形成AMI的原因是多样的,临床经过和预后取决于基础的病理状态.尽管对肠系膜缺血病理生理研究的深入和现代治疗方法上的改进,存活率没有显著的提高.AMI仍然存在诊断上的挑战,延误诊断会提高死亡率.临床表现在大多数病例没有特征性.当肠缺血迅速的发展为不可逆的肠坏死,随后出现严重的代谢紊乱,最后发展成为多器官功能不全以致死亡.及时地诊断和处理,快速有效地恢复肠系膜血流是改善预后的关键.     

急性肠系膜血管缺血性疾病的诊断和治疗

目的探讨急性肠系膜血管缺血性疾病（AMI）的诊断和治疗方法。方法回顾性分析26例AMI患者的临床资料。结果本组15例CT平扫诊断5例,10例行64排螺旋CT扫描及三维重建诊断8例,行血管造影者9例诊断7例。22例行急诊手术（肠系膜上动脉取栓4例,肠切除18例）;4例采用以溶栓为主的非手术治疗。12例痊愈出院,死亡10例。结论多排螺旋CT肠系膜血管成像和血管造影有助于AMI的早期诊断。早期手术治疗可降低病死率。     

急性肠系膜动脉缺血性疾病的诊治分析——附27例报道

目的:探讨急性肠系膜动脉缺血的诊断和治疗方法。方法:回顾性分析自2002年5月至2008年12月我院共收治肠系膜动脉缺血性疾病患者27例。急诊行手术治疗21例,其中单纯行肠系膜上动脉取栓术9例,肠系膜上动脉切开取栓加肠切除吻合术8例,单纯肠切除吻合术3例,肠切除加肠造瘘术1例。保守治疗6例。结果:手术治疗21例,1例于死于感染性休克,5例出现短肠综合征,经胃肠外营养等对症治疗后症愈出院,6例行保守治疗者均症状减轻,好转出院。结论:彩超是早期诊断肠系膜动脉缺血的重要手段,及时手术和加强术后监护是提高疗效的关键。     

肠系膜炎症性静脉栓塞病的研究进展

肠系膜炎症性静脉栓塞病(MIVOD)是肠系膜缺血性疾病中一种特殊的类型,其组织学特点是孤立性的肠系膜炎症性静脉闭塞,病变不累及肠系膜动脉,同时又无系统性脉管炎和其它可导致肠系膜静脉炎症的疾病存在。由于该病主要依靠术后病理诊断,早期正确诊断很困难,因而在治疗上尚无有效的内科治疗方法,所有患者均需外科手术治疗,而且手术切除病变肠段后症状可缓解,是目前比较有效的治疗方法。     

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.     

Endovascular treatment of mesenteric ischemia

Objectives: Our goal was to describe a single‐center's experience in managing acute and chronic mesenteric ischemia with endovascular therapies. Background: Open surgical revascularization has been considered the historical gold standard treatment for mesenteric ischemia though it poses considerable morbidity and mortality risk. An aging population with increased comorbidities makes endovascular treatment a more attractive treatment option. Methods: Consecutive subjects receiving percutaneous mesenteric interventions for acute and chronic mesenteric ischemia from 2004 to 2010 were identified retrospectively. Information on comorbidities, symptoms, screening tests, procedural outcomes, and follow up was obtained. Results: Thirty‐one patients received percutaneous mesenteric interventions during this period. The mean age of the population was 65.0 years with roughly equal proportions of males (48.4%) and females (51.6%). Traditional cardiovascular risk factors were highly prevalent (hypertension 45.2%, diabetes 25.8%, dyslipidemia 38.7%, nicotine use 45.2%). Procedural success was 93.5%; no periprocedural complications were reported. During a mean follow up of 13 months, 16.1% required repeat revascularization and 22.6% died. Endovascular treatment of acute mesenteric ischemia was successful (n = 8) and no patient required open surgical revascularization acutely or during follow‐up. Conclusions: Endovascular treatment of mesenteric ischemia is a safe and effective therapy with acceptable long‐term results. Our experience with acute mesenteric ischemia suggests that percutaneous treatment may be an effective alternative to surgical revascularization in appropriately selected patients. © 2011 Wiley Periodicals, Inc.     

Atherosclerotic inferior mesenteric artery stenosis resulting in large intestinal hypoperfusion: A paradigm shift in the diagnosis and management of symptomatic chronic mesenteric ischemia

Symptomatic chronic mesenteric ischemia results from intestinal hypoperfusion and is classically thought to result from involvement of two or more mesenteric arteries. The celiac artery and superior mesenteric artery are most frequently implicated in this disease process, and their involvement usually results in symptoms of small intestinal ischemia. Symptomatic chronic mesenteric ischemia resulting predominantly from inferior mesenteric artery involvement has largely been overlooked but does gives rise to its own, unique clinical presentation with symptoms resulting from large intestinal ischemia. We present four patients with atherosclerotic inferior mesenteric artery stenosis with symptomatic chronic mesenteric ischemia that have unique clinical presentations consistent with large intestinal ischemia that resolved following percutaneous endovascular treatment of the inferior mesenteric artery stenosis. These cases represent a novel approach to the diagnosis and management of this disease process and may warrant a further subclassification of chronic mesenteric ischemia into chronic small intestinal ischemia and chronic large intestinal ischemia.© 2012 Wiley Periodicals, Inc.     

Ischemic colitis and large bowel infarction: A case report

Ischemic bowel disease results from an acute or chronic drop in the blood supply to the bowel and may have various clinical presentations, such as intestinal angina, ischemic colitis or intestinal infarction. Elderly patients with systemic atherosclerosis who are symptomatic for the disease in two or more vascular beds have multiple comorbidities and are particularly at risk. The clinical evolution and outcome of this disease are difficult to predict because of its pleomorphic aspects and the general lack of statistical data. In this paper, we present the case of a patient who was monitored in our unit for six years. For this patient, we encountered iterative changes in the clinical pattern, beginning with chronic “intestinal angina” and finishing with signs of acute mesenteric ischemia after an episode of ischemic colitis. This evolution is particularly rare in clinical practice, and the case is instructive because it raises discussions about the natural history of the condition and the therapeutic decisions that should be made at every stage of the disease. An important lesson is that ischemic bowel disease should always be considered in patients who have multiple risk factors for atherosclerosis and have experienced recurrent “indistinct” abdominal symptoms. In these cases, aggressive investigation and therapeutic decisions must be taken whenever possible. Despite an absence of standardized protocols, angiographic evaluation and revascularization procedures have beneficial outcomes. Current advances in endovascular therapy, such as percutaneous transluminal angioplasty with stenting, should be increasingly used in patients with chronic mesenteric ischemia. Such therapy can avoid the risks that are associated with open repair. However, technical difficulties, especially in severe stenotic lesions, frequently occur.     

Ileocolic to Right Iliac Arterial Transposition for the Treatment of Chronic Mesenteric Ischemia

The treatment of chronic mesenteric ischemia remains challenging and controversy exists over the best interventional option. Endovascular treatment has emerged as first-line management due to its associated lower morbidity and mortality than surgical reconstruction. However, open mesenteric reconstructions continue to play an important role in patients with lesions that are unsuitable for an endovascular option. Mesenteric operations utilize the aorta or iliac artery as the inflow source for a vein or prosthetic bypass to the celiac artery or superior mesenteric artery. We describe an exceptional case of chronic mesenteric ischemia due to atherosclerosis that was treated successfully with a novel ileocolic to right iliac arterial transposition.     

Characterization of ischemic colitis associated with myocardial infarction: an analysis of 23 patients

Purpose

The study characterizes the clinical presentation of ischemic colitis (IC) associated with myocardial infarction (MI) and helps determine whether the primary mechanism for this association is thrombus, embolus, or localized nonocclusive mesenteric ischemia (NOMI) associated with systemic hypotension.

Methods

We compared 23 study patients presenting with IC occurring simultaneously with or within 3 days after MI who were admitted to 5 medical centers versus (1) 32 patients with IC without MI (IC-controls) or (2) 32 patients with MI without IC (MI-controls).

Results

Of 17,500 patients admitted to the study sites with MI, 23 (0.13%) had IC. Study patients had a high in-hospital mortality of 39%. An Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 15 was a significant predictor of mortality in these patients (P<.04). Compared with the IC-controls, study patients had a significantly lower mean arterial pressure (MAP) (76.0 ± 17.1 mm Hg vs 98.3 ± 18.6 mm Hg, P<.0001) and a significantly higher rate of hypotension (57% vs 9%, odds ratio [OR] = 12.6, confidence interval [CI]: 3.10-49.7, P<.001). The 2 groups, however, had a similar mean number of risk factors for thromboembolism per patient. Study patients had more severe illness than IC-controls, as demonstrated by mean APACHE II scores (19.0 ± 5.5 vs 10.4 ± 4.8, P<.0001). Study patients had a significantly higher incidence of complications, including respiratory failure (57% vs 13%, P=.001), altered mental status (48% vs 13%, P<.01), and renal insufficiency or failure (61% vs 28%, P<.04). Study patients had a significantly lower minimum hematocrit. Study patients had a significantly higher rate of prolonged hospitalization (>30 days) or in-hospital death (74% vs 19%, OR = 12.3, CI: 3.47-43.5, P<.0001). Compared with MI-control patients, study patients had a significantly lower MAP, significantly higher rate of hypotension, much higher mean APACHE II score, much higher incidence of complications, and significantly worse hospital outcome.

Conclusions

Patients with both IC and MI present as a clinically distinct group from patients with either IC alone or MI alone. They have significantly more complications and worse in-hospital prognoses. They present with a dramatically lower MAP and a higher frequency of hypotension. This last finding suggests that the most common and most important mechanism for IC with MI may be hypotension from cardiogenic shock. Hypotension is the cardinal risk factor for generalized NOMI with acute mesenteric ischemia and may be an important risk factor for localized NOMI with IC. An APACHE II score greater than 15 may be a predictor of mortality from IC after MI.     

Role for endovascular therapy in chronic mesenteric ischemia

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.     

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

Mesenteric ischemia(MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI(CMI), with the first being subdivided into four categories. Therefore, acute MI(AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and nonocclusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography(CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.     

Isolated Spontaneous Mesenteric Artery Dissection: A Rare Entity

Isolated spontaneous dissection of the mesenteric artery in the absence of involvement of the aorta or its branches is an uncommon vascular entity. It is generally seen in males and presents with gastrointestinal symptoms due to mesenteric ischemia. However, asymptomatic cases are increasingly being diagnosed due to increased use of computed tomography (CT) angiography. The course is usually self-limiting, and conservative management with bowel rest, strict blood pressure control, anticoagulants, sedatives for pain, and close observation usually suffices. Surgery or endovascular stenting is usually reserved for those exhibiting bowel ischemia or impending rupture. We report a case of a young female with isolated spontaneous mesenteric artery dissection with thrombus, which did not improve with medical therapy and was managed promptly by surgery due to the presence of bowel ischemia.     

Acute arterial mesenteric ischemia and reperfusion:Macroscopic and MRI findings,preliminary report

AIM:To explore the physiopathology and magnetic resonance imaging(MRI)findings in an animal model of acute arterial mesenteric ischemia(AAMI)with and without reperfusion.METHODS:In this study,8 adult Sprague-Dawley rats underwent superior mesenteric artery(SMA)ligation and were then randomly divided in two groups of 4.In groupⅠ,the ischemia was maintained for 8 h.In groupⅡ,1-h after SMA occlusion,the ligation was removed by cutting the thread fixed on the back of the animal,and reperfusion was monitored for 8 h.MRI was performed using a 7-T system.RESULTS:We found that,in the case of AAMI without reperfusion,spastic reflex ileus,hypotonic reflex ileus,free abdominal fluid and bowel wall thinning are present from the second hour,and bowel wall hyperintensity in T2-W sequences are present from the fourth hour.The reperfusion model shows the presence of early bowel wall hyperintensity in T2-W sequences after 1 h and bowel wall thickening from the second hour.CONCLUSION:Our study has shown that MRI can assess pathological changes that occur in the small bowel and distinguish between the presence and absence of reperfusion after induced acute arterial ischemia.