非手术治疗在儿童外伤性十二指肠血肿伴上消化道梗阻中的应用价值

目的探讨非手术治疗在儿童外伤性十二指肠血肿伴上消化道梗阻中的治疗效果及意义。方法回顾性分析西南医科大学附属医院儿外科近3年收治的8例十二指肠血肿伴上消化道梗阻患者的临床资料,其中男性5例,女性3例,年龄5~16岁,平均9.1岁,均有腹部外伤病史,主要临床表现为恶心、呕吐、腹痛,入院CT均提示有十二指肠血肿伴上消化道梗阻,排除消化道穿孔及活动性出血后给予禁食、持续胃肠减压、预防感染、补液、营养支持,部分淀粉酶升高患者给予生长抑素等对症处理,并定期复查血常规、血电解质,维持内环境稳定。检索万方数据库、维普、知网、Pubmed、Medline数据库截至2020年2月已公开发表的关于儿童外伤性十二指肠血肿治疗的相关文献,并进行分析。结果7例给予保守治疗获得治愈,胃肠减压量在确诊后3~5天达到高峰,在确诊后4~18天开始减少,恢复饮食时间为确诊后8~26天,平均15.2天,部分患者应用静脉营养约10天后肝肾功能检查提示肝酶学指标及胆红素轻度升高,予以保肝药物治疗及恢复饮食后逐渐降至正常,随访6个月至3年未见异常,1例保守治疗3周(包括院外治疗1周)后症状无缓解,复查CT提示血肿大小无变化,给予经腹腔血肿切开引流手术治疗后获得痊愈,随访2年,因粘连性不全性肠梗阻住院一次,经保守治疗痊愈。通过文献检索到31篇儿童外伤性十二指肠血肿相关文献,结合本组8例,共339例,其中手术治疗189例,手术时间为确诊后1~30天;保守治疗150例,保守治疗时间7~29天。结论诊断明确的十二指肠血肿在排除活动性出血及穿孔后,经过抗休克、止血等对症处理后生命体征平稳的患者应首选保守治疗,观察记录胃肠减压量和颜色的变化对判断疾病的转归及治疗方案的制定有重要的指导作用。若胃肠减压液的量逐渐减少、颜色变淡,保守时间可延长至3周或更长;若保守治疗超过3周梗阻症状无缓解甚至加重,此时血肿部位多已液化,可选择行手术治疗或经皮血肿引流术,手术操作简单、效果好。

Value of non-operative measures for children duodenal intramural hematoma due to blunt abdominal trauma with gastrointestinal obstruction

Objective To explore the therapeutic efficacy and significance of non-operative measures for duodenal intramural hematoma due to blunt abdominal trauma with gastrointestinal obstruction.Methods The clinical and imaging data were retrospectively analyzed for 8 children diagnosed as duodenal intramural hematoma due to blunt abdominal trauma with gastrointestinal obstruction over the last 3 years.There were 5 boys and 3 girls with an average age of 9.1(5-16)years.All Children'suffered blunt abdominal trauma.Their clinical symptoms were nausea,vomiting and abdominal pain.The scans of computed tomography(CT)hinted at duodenal hematoma with gastrointestinal obstruction without gastrointestinal perforation and active bleeding.Treatment options included fasting,continuous gastro-intestinal decompression while recording color and amount of drainage fluid,prophylactic antibiotics,total parenteral nutrition(TPN),somatostatin for abnormal amylase and regular monitoring of blood routine,biochemical profiles and electrolytes for maintaining homeostasis.The relevant reports were retrieved from the databases of Wanfang,CQVIP,CNKI,PubMed and MedLine prior to February 2020.Results Seven cases were cured non-operatively.Oral feeding was resumed at an average posttraumatic time of 15.2(8-26)days.The amount of gastrointestinal decompression peaked at 3-5 days after injury and began to drop at 4-18 days.There were the elavations of aminopherase and bilirubin after 10 days with TPN in some children and decreased after hepatoprotective therapy and oral feeding.After a follow-up period of 6 months to 3 years,there was no occurrence of any complication.The symptoms of one child were not relieved after 3 weeks of conservative measures(including 1 week at another hospital).CT reexamination indicated no change in hematoma size.Finally the child recovered after surgery.During a follow-up period of 2 years,there was hospitalization for adhesive ileus and the child recovered after conservative measures.A total of 339 children with traumatic duodenal hematoma were retrieved from 31 literature reports,including 8 cases in our cohort.Among them,189 cases were operated(1-30 days after injury)and 150 cases received conservative treatment(7-29 days).Conclusion Conservation treatment should be a first choice for duodenal hematoma without active bleeding or perforation and vital signs remain stable after antishock and hemostasis,etc.The variations of volume and color of gastrointestinal decompression may guide the outcomes and treatments of diseases.The duration of conservation treatment should be extended to 3 weeks or longer if volume of gastrointestinal drainage becomes less and color weaker.Surgery should be performed if there is no symptomatic relief after conservative treatmen for over 3 weeks.Operation is simple with an excellent outcome since hematoma has liquefied.Open surgery or percutaneous drainage is desired.