急性肠系膜上动脉栓塞的诊断与治疗

目的肠系膜上动脉(SMA)栓塞发病率低,但是起病急剧,进展迅速,病情险恶,误诊率及死亡率较高.通过对其病因和临床特点进行初步分析,探讨该病诊断方法及治疗原则.方法回顾性总结1990年10月～2001年10月间15例急性肠系膜上动脉栓塞病人的临床资料,并结合文献中关于该病的报道进行综合讨论分析.结果该组病人发病前9例合并风湿性心脏病,4例合并冠心病,3例既往有肢体动脉栓塞史.均以突发急剧腹痛为最初表现.术前确诊6例(40%),9例分别误诊为出血坏死性肠炎,重症胰腺炎,机械性肠梗阻.2例在发病7～9h内急诊行肠系膜上动脉取栓术,术中肠管血运恢复,避免了肠切除.其余13例分别行小肠部分切除术2例,小肠大部切除术7例,小肠广泛切除及右半结肠切除术4例.10例死于术后1个月内,死亡原因主要为感染性休克和多脏器功能衰竭.结论对于既往有器质性心脏病或肢体动脉栓塞病史的患者突发急剧腹痛,应该警惕肠系膜上动脉栓塞的可能.肠系膜上动脉造影有助于早期诊断.及时行肠系膜上动脉取栓术可避免肠坏死或缩小肠管切除的范围.在严格掌握适应证的前提下可以对部分病例进行动脉内溶栓治疗.

Diagnosis and management of acute superior mesenteric artery embolism

Objective: Superior mesenteric artery (SMA) embolism was an infrequent abdominal emergency with unspecific clinical presentations. The morbidity and mortality were significant. The aim of this retrospective study was to discuss the manifestations, diagnosis and management of acute SMA embolism. Methods: From Oct, 1990 to Oct, 2001, 15 patients were operated on for acute SMA embolism. They were analysed according to symptoms, examinations, diagnosis, operative procedure and prognosis. Results: 9 patients had medical history of rheumatic heart disease and 4 patients had coronary heart disease. All patients presented sudden abdominal pain as the initial manifestation. Precise preoperative diagnosis was made in 6 case (40%). 9 patients were misdiagnosed as necrotizing enteritis, strangulated intestinal obstruction, nerotizing pancreatitis, respectively. Embolectomy was performed in 2 cases within 7~9 hours after the onsets of abdominal pain that bowel resection was avoided. Other operation methods included partly bowel resection in 2 cases, mass bowel resection in 7 cases, extended bowel resection with right hemicolectomy in 4 cases. Within one month after operation, 10 patients died due to multi-organ failure or septic shock. Conclusions: Acute SMA embolism ought to be suspected in every patient with uncertain sudden abdominal pain, especially in those who had atrial fibrillation or limbs embolism previously. Mesenteric angiography is the definite method for diagnosis. The standard treatment is laparotomy with embolectomy or resection of the gangrenous segment of the bowel, or both. Alternative treatment such as intra-arterial thrombolysis may be considered in selected patients.