老年人自发性乙状结肠穿孔：附21例报告

目的：探讨老年人自发性乙状结肠穿孔的病因、临床表现及处理原则。方法：回顾性分析2007年11月—2012年10月诊断明确的21例老年人自发性乙状结肠穿孔的临床资料。结果：全组男12例，女9例；平均年龄67（62~73）岁。多数患者以突发性急性腹痛就诊，患者均有不同程度的习惯性便秘史，术前出现感染性休克3例。全组中术前诊断为乙状结肠穿孔仅4例，误诊率为80.95%。21例患者均行Hartmann术，术后仍出现感染性休克3例，经过积极抗休克及抗感染治疗后好转；术后发生切口感染8例，肺部感染6例，经抗感染对症治疗治愈；并发多器官功能障碍综合征（MODS）3例，经过积极抢救及相应处理后治愈1例，死亡2例均为紧贴后腹膜乙状结肠后壁穿孔。19例治愈出院且于术后3~6个月行乙状结肠造瘘口还纳术。结论：老年人自发性乙状结肠穿孔缺乏特异性的临床表现，行腹腔穿刺及腹部X线、肛肠指诊对诊断有所帮助。早诊断、早期积极抗休克、抗感染、维持水电解质及酸碱平衡、尽早手术及行对症处理，预防并发症是保证患者康复的关键。

Spontaneous perforation of sigmoid colon in elderly patients: a report of 21 cases

Objective: To investigate the etiology, clinical characteristics and management of spontaneous perforation of the sigmoid colon in elderly patients. Methods: The clinical data of 21 elderly patients with definite diagnosis of spontaneous perforation of the sigmoid colon from November 2007 to October 2012 were retrospectively analyzed. Results: Of the patients, 12 cases were males and 9 were females with an average age of 47 (62–73) years. The majority of these patients were admitted for acute abdominal pain, all of them had experienced habitual constipation of varying degrees, and 3 cases developed septic shock before surgery. In the entire group of 21 patients, only 4 cases were diagnosed as sigmoid colonic perforation, and the misdiagnosis rate was 80.95%. All of the 21 patients underwent Hartmann''s procedure and, after surgery, there were still 3 cases who developed septic shock that was resolved after aggressive anti-infective and anti-shock supportive therapies; wound infection and pulmonary infection occurred in 8 and 6 cases respectively, which were cured by anti-infective and symptomatic treatment; 3 cases were complicated by multiple organ dysfunction syndrome (MODS), and one of them was cured after emergent care, while the other 2 cases died from perforation of the retroperitoneal sigmoid colon. Nineteen patients were cured and discharged from the hospital, and their sigmoid colostomy was closed 3–6 months later. Conclusion: The clinical manifestations of spontaneous perforation of the sigmoid colon in old patients are not specific, and abdominal paracentesis, X-ray, and digital anorectal examination are helpful for the diagnosis. Increased understanding of this condition, early diagnosis and intervention including aggressive anti-shock and anti-infective therapy, maintenance of water-electrolyte and acid-base balance, and early surgical and symptomatic treatment, as well as prophylaxis of complications are important to ensure the recovery of these patients.