空肠近端巨大粪石性肠穿孔1例

2019-01-09 余含笑 朱雪娥 中国临床医学影像杂志

男,64岁。2年前行胃大部分切除手术,术后恢复较好,于2月前无明显诱因下出现明显纳差乏力,伴有恶心呕吐,外院对症治疗后症状无好转。1周前开始腹痛,伴肛门停止排便排气5天。

男,64岁。2年前行大部分切除手术,术后恢复较好,于2月前无明显诱因下出现明显纳差乏力,伴有恶心呕吐,外院对症治疗后症状无好转。1周前开始腹痛,伴肛门停止排便排气5天。
 
查体:腹软,腹部正中见一长约15 cm的陈旧性疤痕,局部压痛明显,无反跳痛,左下腹可触及一3 cm包块,活动可,肠鸣音未闻及。于我院行全腹部CT平扫及增强,影像学检查见图1,2。
 




图1,2 CT增强冠状位(图1)及轴位(图2)示空肠近端见5 cm×5 cm×10 cm大小团块影,边界清,其内呈蜂窝状或筛孔状混杂密度及多发气泡影,增强未见明显强化,考虑粪石。其近段十二指肠未见扩张(肠减压后)。腹腔见散在小气泡,提示胃肠道穿孔。腹、盆腔见少量积液。
 
手术及病理检查:急诊行“剖腹探查+肠粘连松解+空肠部分切除吻合+腹腔引流术”,术中见:小肠管、横结肠与腹壁、肝脏面广泛粘连。全腹腔大量黄褐色稀薄脓性积液及脓苔,量约400mL左右,小肠间以纤维素性粘连为主,近端空肠处肠腔内有一巨大粪石,约10 cm×5 cm×4 cm,形成完全梗阻。粪石段空肠表面肠壁见一约直径2 cm破裂口,肠系膜侧另见一直径0.8 cm穿孔,远端肠管颜色、血运等正常。大体标本见:空肠近端肠壁扩张变薄,壁厚0.1 cm,距扩张端0.5 cm处见一直径约4 cm穿孔。
 
镜下病理诊断为近端空肠内巨大粪石致十二指肠以上完全梗阻,伴空肠近端肠穿孔及腹膜炎。
 
讨论
 
粪石性肠穿孔较少见,多见于慢性便秘的老年患者,有文献将Embase、MEDLINE、PubMed和Cochrane数据库于1998~2011年间发表的137例关于粪石性穿孔的24篇文章进行分析,发现穿孔最常见的部位是结直肠,其中乙状结肠(50%)、直肠乙状结肠交界处(24%)较多见,因为此处粪便水分少,肠壁血供少,肠腔管径小。其次是盲肠(5.2%),而其他部位极少见(小于2.2%)。
 
文献报道空肠穿孔可继发于机械操作损伤、异物、炎症、肿瘤或先天性肠道病变等,粪石所致穿孔极少见。粪石性穿孔,常因粪石嵌顿于肠腔狭窄处,使局部压力增高,毛细血管灌注减少,组织缺血缺氧,引起局部炎症反应和坏死,导致溃疡和穿孔。而粪石嵌顿常发生在小肠远端至回盲瓣附近,因为此处肠管直径最小,蠕动波也较弱,并有回盲瓣阻挡,并且位置相对较低。故本例屈氏韧带以远的空肠近端粪石嵌顿并穿孔较罕见,分析病因可能如下:小肠粪石主要来自于肠道原发性粪石、胃粪石及胆结石。
 
本例患者无明显胆石症病史,而于2年前行胃部手术,文献报道胃切除术后胃粪石发生率可高达5%~12%,所以首先考虑其粪石来源于胃。粪石可形成于胃术后的9月到30年,术后粘连更利于粪石嵌顿继发肠梗阻。另外,本例可能与胃术后胃肠道吻合口的大小有关,吻合口较大时,胃部形成粪石较大,排入小肠时易嵌顿于近吻合口小肠近端较窄部位,同时屈氏韧带将十二指肠空肠固定于腹后壁,可能更加限制了屈氏韧带远端空肠蠕动,致使粪石嵌顿,继发肠壁穿孔。该患者没有典型腹膜炎表现,可能由于穿孔时间不长,周围肠管粘连限制了消化液扩散。
 
总之,此例粪石性空肠穿孔,仅根据临床表现易漏诊或难以诊断。结合胃部切除史及临床梗阻表现,要考虑到肿瘤性、粘连性或粪石性等可能病因,X线检查或上消化道造影难以鉴别,CT可以高效观察患者胃肠道解剖结构和病变部位,判断粪石情况、肠梗阻及穿孔的严重程度,明确病因。影像医生应紧密结合临床,及时为临床医生提供有价值的信息参考,以免延误治疗。
 
原始出处:

余含笑,朱雪娥.空肠近端巨大粪石性肠穿孔1例[J].中国临床医学影像杂志,2018(01):71-72.

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