盲肠憩室出血1 例

2018-02-13 佚名 现代消化及介入诊疗

患者,男性,66岁,因“便血2小时”入院;有“高血压”病史8年,一直口服“左氨氯地平片2.5mg1日1次”治疗;有“阵发性房颤”病史5年,一直口服“阿司匹林肠溶片0.1g1日1次、稳心颗粒5g1日3次及曲美他嗪片20mg1日3次”;否认食物及药物过敏史。

【一般资料】

患者,男性,66岁,因“便血2小时”入院;有“高血压”病史8年,一直口服“左氨氯地平片2.5mg1日1次”治疗;有“阵发性房颤”病史5年,一直口服“阿司匹林肠溶片0.1g1日1次、稳心颗粒5g1日3次及曲美他嗪片20mg1日3次”;否认食物及药物过敏史。

【入院查体】

血压158/90mmHg,体温36.5℃,呼吸19次/min,脉搏84次/min,神志清,精神可,皮肤巩膜无黄染,无贫血貌,未见肝掌及蜘蛛痣,双侧锁骨上淋巴结未及肿大,腹部平坦,未见腹壁静脉曲张,全腹无压痛,无反跳痛,肝脾肋下未及,腹部未触及包块,肠鸣音3次/min,肛门指检未触及包块,指套染有少量鲜血。入院后查血常规:WBC3.63g/L,Hgb64.0g/L,PLT89g/L。CRP11.48mg/L。血肿瘤标记物示CA-153、AFP、CEA、CA-125、SCC、CA72-4,CA-50,Ca-199均正常范围。肝功能:ALB29.88g/L,TP45.61g/L,ALT14.5U/L,AST14.5U/L,GGTP35.0U/L,ALP37.8U/L。大便常规及隐血示隐血4+,红细胞大于50个/HP,白细胞1~3个/HP。入院后急行结肠镜检查示盲肠多发憩室,其中一个憩室附着血痂,冰盐水不能冲掉。行胃镜检查提示慢性浅表性胃炎,十二指肠降部憩室,未见活动性出血。予以奥曲肽针减少内脏血流止血;予头孢噻肟钠针抗感染及输血、补液等治疗,患者出血停止,复查大便常规及隐血阴性后出院。

【讨论】

结肠憩室是指结肠黏膜经肠壁肌层缺损处向外形成囊状突出的病理结构,多个憩室则称之为结肠憩室病。本病在西方国家较为常见,是西方国家下消化道出血的常见原因,占消化道出血的17%~40%,在我国及其他发展中国家发病率较低,据上海华东医院项平教授等报道,在其观察的1431例下消化道出血中仅有13例属结肠憩室病出血,仅占0.9%。故本病例在我国属少见病例。其典型表现是无痛性出血,可以表现为大出血,好发于老年人,多伴有动脉硬化及动脉血管畸形,受化学性或机械性损害而诱发。憩室出血其部位欧美人多在乙状结肠,而亚裔及我国通常以右半结肠憩室为多。该病例为老年男性,有高血压、心房纤颤等多种基础疾病,憩室发于右半结肠,与流行病学特点相符合。本病病因尚不清楚,绝大多数为后天形成,为退行性变。大肠动力紊乱、低纤维膳食摄入和肠壁完整性缺陷被认为是大肠憩室的主要发病机制。有学者通过对大量文献的综合分析归纳,认为:低纤维饮食、慢性疾病长期的药物治疗等因素的综合作用引起肠腔内压力变化以及肠壁结构和运动能力改变,导致了憩室疾病的出现。憩室内压力增高以后可引起黏膜坏死或粪石直接损伤黏膜就可出现出血。另外,老年人,易发生动脉粥样硬化,毛细血管脆性也会增加,从而导致憩室黏膜下血管破裂,引起出血。与西方发达国家相比,国人膳食中纤维素含量高,可能是结肠憩室发生率低的原因。憩室出血的诊断主要依靠钡灌肠、肠镜或者手术探查。出血时可行血管造影及核素扫描明确出血部位并进行治疗,但是不能诊断是由憩室病引起的出血。急诊肠镜检查和治疗是老年患者优先考虑的诊断和治疗方法,有2/3的患者得以明确诊断,1/3的患者能成功止血,检查的最好时机是在住院后24h内。影响因素主要是异物、凝血块、食物或粪便残渣,因此在内镜观察及治疗之前,需用冰生理盐水等进行充分地清洗,治疗方法包括禁食、静脉使用生长抑素及其类似物,抗感染治疗,内镜下可直接电凝或金属钛夹等单独或联合应用。如内科治疗无效,可考虑手术治疗。随着我国老年化社会的到来,国人生活水平的提高,饮食结构的改变,该病的发生率也越来越高,在临床上应引起重视。

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    2018-03-25 青山颖钰

    学习了

    0

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    2018-02-15 zutt
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    2018-02-13 有备才能无患

    结肠憩室是指结肠黏膜经肠壁肌层缺损处向外形成囊状突出的病理结构.多个憩室则称之为结肠憩室病.

    0

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    2018-02-13 惠映实验室

    学习.谢谢分享.

    0