本文關(guān)鍵詞： 急性腸系膜缺血 慢性腸系膜缺血 缺血性結(jié)腸炎 動脈粥樣硬化 鈣化　出處：《中國人民解放軍醫(yī)學(xué)院》2014年博士論文　論文類型：學(xué)位論文

【摘要】：隨著人口老齡化及動脈粥樣硬化疾病患病率的增加，缺血性腸病（ischemicbowel disease，ICBD）的發(fā)病率日益增高，盡管診療技術(shù)的改進，急性腸系膜缺血（Acute mesenteric ischemia，AMI）死亡率仍在50%-90%。慢性腸系膜缺血（Chronic mesenteric ischemia，CMI）的腹痛癥狀長期困擾著嚴(yán)重動脈硬化的老年患者。缺血性結(jié)腸炎（Ischemic colitis，IC）常見于低血壓等全身循環(huán)改變的狀況，延誤診治往往導(dǎo)致兇險的預(yù)后。因此加深對該類疾病的認(rèn)識，深入了解其患病與死亡相關(guān)危險因素，實施有效的二級預(yù)防，將為降低ICBD發(fā)病率及預(yù)后改善起到重要作用。 目的 探討ICBD患者臨床表現(xiàn)、CT影像特點及死亡相關(guān)危險因素，深入探究急性腸系膜上動脈血栓栓塞（acute superior mesenteric artery thromboembolism，ASMATE）的血管病變基礎(chǔ)，為更加全面認(rèn)識和深刻理解ICBD提供有力依據(jù)。 方法 1、對2000年1月—2013年12月間解放軍總醫(yī)院確診的ICBD患者的病歷資料進行回顧性分析，包括一般資料，臨床表現(xiàn)，輔助檢查檢驗，診療方式，結(jié)局等。 2、對其中2008年以后入院診斷明確并在我院行腹部CT檢查者的CT影像資料進行詳盡復(fù)習(xí)，探尋與ICBD死亡相關(guān)的腸道病變CT影像特點。 3、借鑒冠脈鈣化積分方法（The Agatston calcium scores）評估腸系膜上動脈（Superior mesenteric artery，SMA）及其開口上下各3cm段腹主動脈鈣化積分，并詳細(xì)描述鈣化斑塊形態(tài)及分布特點；借助volume軟件測定非鈣化體積，從鈣化及非鈣化角度理解腸道動脈粥樣硬化進程，進而探討腸道動脈粥樣硬化與ICBD的關(guān)系。 結(jié)果 診斷確鑿資料詳實的ICBD309例，男223例，女86例，男：女=2.59：1。平均年齡61±17歲，其中AMI189例，CMI13例，IC107例，前者包括ASMATE79例，急性腸系膜靜脈血栓(Acute superior mesenteric venous thrombosis，ASMVT)96例，非梗阻性系膜缺血(Nonocclusive mesenteric ischemia，NOMI)14例。 1、189例AMI患者的臨床特點分析： （1）79例ASMATE患者的臨床特點： 男：女=2.04：1。平均年齡63歲，生存50例，死亡率36.71%。生存組體重減輕發(fā)生率高于死亡組（P=0.034）；腹膜刺激征、低血壓、白細(xì)胞數(shù)和中性粒細(xì)胞比例均低于死亡組（P=0.001，P=0.006，P=0.006，P=0.006）；血紅蛋白降低的例數(shù)少于死亡組（P=0.007）。 生存組發(fā)病至接受治療平均時間、平均腸切除長度短于死亡組（P=0.003，P=0.023）。生存組行二次腸切除例數(shù)、有腹腔積液、血性積液及積液量1000ml以上者的數(shù)目低于死亡組（P=0.007，P0.001，P=0.004，P=0.016）。51例腸切除的患者中，小腸+結(jié)腸切除組術(shù)前白細(xì)胞數(shù)及死亡率高于單純小腸切除組（P=0.046，，P0.001）。死亡的29例中行開腹手術(shù)高于介入治療（P=0.007）。 按栓塞病因分為血栓組41例，栓塞組38例。血栓組行小腸+結(jié)腸切除及伴外周動脈粥樣硬化癥的比例高于栓塞組（P=0.011，P=0.044）；而房顫及外周動脈栓塞的比例低于栓塞組（P0.001，P=0.043）。 （2）96例ASMVT患者的臨床特點： 男：女=3：1。平均年齡46歲。生存組83例，死亡組13例，死亡率13.54%。孤立性系膜靜脈血栓（mesenteric venous thrombosis, MVT）39例，聯(lián)合MVT57例。死亡組合并重癥胰腺炎及孤立MVT的例數(shù)高于生存組（P0.001，P=0.004）。 開腹手術(shù)組患者自發(fā)病至接受治療的時間最短、孤立MVT發(fā)生率最高、死亡率也高于介入溶栓組及保守治療組。保守治療組中則無死亡病例。 孤立MVT組出現(xiàn)腹膜刺激征者、行開腹手術(shù)及發(fā)生腸壞死例數(shù)均高于聯(lián)合MVT組（P0.001，P=0.023，P=0.012）；發(fā)生于脾切除術(shù)后病史者低于聯(lián)合MVT組（P=0.002）。 （3）14例NOMI患者的臨床特點： 男：女=1.33：1。生存組10例，死亡組4例，死亡率28.57%。平均年齡66歲,生存組平均年齡及服用NSAIDS例數(shù)低于死亡組（P=0.04，P=0.011）。 手術(shù)治療9例，保守治療5例。手術(shù)治療中8例行腸切除，其中小腸缺血3例，彌漫性腸缺血4例，結(jié)腸缺血1例。死亡組4例均為彌漫性腸缺血患者，彌漫性腸缺血在生存組與死亡組間比較差異具有統(tǒng)計學(xué)意義（P=0.002）。 2、13例CMI患者的臨床特點: 男：女=2.25：1，平均年齡68歲。全部患者均有一種以上動脈硬化相關(guān)疾病�；颊呒韧膬�(nèi)鏡檢查率（11/13,84.62%）。4例消化性潰瘍患者C13尿素呼氣試驗檢測幽門螺桿菌（Helicobacter pylori，HP）均陰性，其中2例行SMA+CA支架置入，2例行SMA支架置入。 13例患者均有SMA病變，SMA中重度狹窄率（9/13，69.23%）高于CA（3/13，20.07%）和IMA（3/13，20.07%）。僅SMA單支血管病變者（2/13,15.38%），CA和SMA兩支病變者（6/13，46.15%），三支均有病變者（5/13,38.46%）。無孤立性IMA狹窄或梗阻病例。 3、107例IC患者的臨床特點： 男：女=3.12：1，平均年齡70歲。潰瘍組51例，非潰瘍組56例。潰瘍組有慢性便秘、COPD病史及應(yīng)用腸溶阿司匹林的比例均高于非潰瘍組（P=0.024，P=0.020，P=0.030）； 共有69例（64.49%）行腹部增強CT檢查，CT顯示CA或SMA或IMA粥樣硬化或鈣化者共51例（73.91%），未見腹部血管異常者18例，潰瘍組合并腹部血管基礎(chǔ)病變、平均住院時間及平均血白細(xì)胞數(shù)均高于非潰瘍組（P=0.027，P0.05，P=0.020）；而血紅蛋白低于非潰瘍組（P=0.044）。 4、腸道缺血相關(guān)CT影像特點： 符合入選標(biāo)準(zhǔn)的151例患者中，ASMATE51例，ASMVT53例，NOMI8例，CMI10例，IC29例。生存組115例，死亡組36例。死亡組腹腔積液、門脈系膜積氣、腸壁積氣及腹腔游離氣體比例均高于生存組（P0.001，P0.001，P0.001,P=0.003）。 對51例ASMATE患者進行腸道動脈CT影像分析，生存組30例，死亡組21例。SMAT33例，SMAE18例；栓子栓塞部位分別為SMA遠(yuǎn)端、中結(jié)腸動脈以及右結(jié)腸、回結(jié)腸、空腸動脈、回腸動脈等外周分支動脈。由腹主動脈病變累及導(dǎo)致SMA開口血栓形成共11例（33.33%）。而因管壁本身動脈粥樣硬化等因素導(dǎo)致的狹窄26例（50.98%）。其中腹主動脈鈣化及非鈣化因素導(dǎo)致管腔狹窄10例（38.46%）。 5、動脈粥樣硬化相關(guān)CT影像特點： ASMATE患者40例設(shè)為病例組，非缺血性腸病40例設(shè)為對照組。病例組目標(biāo)段腹主動脈總平均鈣化積分為749.91高于對照組382.36，但差異無統(tǒng)計學(xué)意義（P=0.361）。病例組以塊狀鈣化和環(huán)周鈣化為主，而對照組以點狀或條形鈣化為主，病例組更嚴(yán)重的鈣化程度與對照組比較差異有統(tǒng)計學(xué)意義（P0.001）。病例組鈣化斑塊分布于SMA開口水平以上者、目標(biāo)段腹主動脈非鈣化體積均高于對照組（P=0.046，P=0.031），SMA開口部直徑小于對照組（P0.001）。 結(jié)論 1、（1）出現(xiàn)腹膜刺激征、低血壓、白細(xì)胞數(shù)和中性粒細(xì)胞比例升高、血紅蛋白降低、更長的發(fā)病至接受治療時間、平均腸切除長度更長、行小腸+結(jié)腸切除、二次腸切除、以及腹腔積液、血性積液、超過1000ml以上的積液都是ASMATE患者死亡的預(yù)測因素；而與慢性缺血相關(guān)的體重減輕是生存的保護性因素；ASMAT患者常伴動脈粥樣硬化疾病且更多需行小腸+結(jié)腸切除；而房顫及外周動脈栓塞的患者更易發(fā)生ASMAE。 （2）孤立MVT更易出現(xiàn)腹膜刺激征，更易發(fā)生腸壞死而需行開腹手術(shù)；聯(lián)合MVT易發(fā)生在脾切除術(shù)后病史者；重癥胰腺炎基礎(chǔ)上發(fā)病是ASMVT死亡的危險因素。 （3）有NSAIDS用藥史和發(fā)生彌漫性腸缺血是NOMI死亡的預(yù)測因素。 2、CMI多發(fā)生于有嚴(yán)重動脈粥樣硬化的老年人，但腸道血管單支病變也可能發(fā)病。老年患者非HP相關(guān)、非NSAIDS相關(guān)潰瘍或胃腸炎癥，應(yīng)想到CMI的可能。部分患者隨著病程延長以及年齡的增長，達到癥狀的自行緩解。 3、慢性便秘、有COPD病史、服用阿司匹林腸溶片以及白細(xì)胞升高，血紅蛋白降低是IC潰瘍性病變形成的預(yù)測因素,有腸道動脈病變基礎(chǔ)的患者發(fā)生IC時更易形成潰瘍性病變；IC潰瘍型患者住院時間更長。 4、腸道CT顯示腹腔積液、門脈系膜積氣、腸壁積氣及腹腔游離氣體是ICBD患者死亡的預(yù)測；腹主動脈病變可能累及SMA開口引發(fā)SMA狹窄或血栓性事件發(fā)生。 5、腹主動脈更嚴(yán)重的環(huán)周型及塊狀鈣化、位于SMA開口水平以上的鈣化斑塊、更大的非鈣化負(fù)荷以及SMA開口部位非鈣化病變導(dǎo)致的管腔狹窄是ICBD發(fā)生的血管危險因素。 6、由于本大型醫(yī)療機構(gòu)收治患者多為疑難危重等原因，本組所顯示的各類型ICBD所占比例及男女患病比例尚不能代表該病的人群發(fā)病率及性別比。
[Abstract]:With the aging of the population and the increase in the prevalence of atherosclerotic disease, ischemic bowel disease (ischemicbowel disease, ICBD) the incidence is increasing, although the techniques of diagnosis and treatment of acute mesenteric ischemia (Acute, mesenteric ischemia, AMI) mortality remains 50%-90%. Chronic mesenteric ischemia (Chronic mesenteric, ischemia, CMI) in elderly patients with long-standing symptoms of abdominal pain severe arteriosclerosis. Ischemic colitis (Ischemic colitis, IC) is common in systemic hypotension change condition, delayed diagnosis and treatment often lead to dangerous prognosis. Therefore deepen our understanding of the disease, understand the prevalence and risk factors related to mortality, the implementation of two grade prevention effectively, will be an important role for reducing the incidence of ICBD and improve the prognosis.
objective
To investigate the clinical manifestations of patients with ICBD, CT imaging features and risk factors related to mortality, in-depth study of acute superior mesenteric artery embolism (acute superior mesenteric artery thromboembolism, ASMATE) of the vascular disease foundation, for a more comprehensive understanding and a deep understanding of ICBD provide a strong basis.
Method
1, we retrospectively analyzed the medical records of ICBD patients who were diagnosed in PLA General Hospital from January 2000 to December 2013, including general information, clinical manifestations, auxiliary examination, diagnosis and treatment, and outcome.
2, we made a detailed review of the CT imaging data of those who had been admitted for diagnosis and underwent abdominal CT examination after 2008, and explored the CT imaging characteristics of intestinal lesions associated with ICBD death.
3, from the coronary calcification score method (The Agatston calcium scores) of superior mesenteric artery (Superior mesenteric artery, SMA assessment) and the opening of the 3cm segment of abdominal aortic calcification, and a detailed description of the morphology and distribution of calcification plaque characteristics; Determination of non calcification volume by means of volume software, to understand the process of atherosclerosis from intestinal calcified and non calcified point of view, to investigate the relationship between atherosclerosis and intestinal ICBD.
Result
ICBD309 diagnosis of solid informative cases, male 223 cases, female 86 cases, male: female =2.59:1. mean age 61 + 17 years, of which AMI189 cases, CMI13 cases, IC107 cases, the former includes ASMATE79 cases of acute mesenteric venous thrombosis (Acute superior mesenteric venous thrombosis, ASMVT) in 96 cases, non obstructive mesenteric ischemia (Nonocclusive mesenteric ischemia, NOMI) in 14 cases.
Analysis of clinical characteristics of 1189 patients with AMI:
(1) the clinical characteristics of 79 patients with ASMATE:
Male: female =2.04:1. the average age of 63 years, 50 cases survived, the mortality rate of 36.71%. was higher than the survival group weight loss death group (P=0.034); peritoneal irritation, low blood pressure, white blood cell count and neutrophil percentage were lower than the death group (P=0.001, P=0.006, P=0.006, P=0.006); the number of cases of lower hemoglobin less than death group (P=0.007).
The survival group from onset to treatment the average time, average length of short bowel resection in death group (P=0.003, P=0.023). The survival group two cases of intestinal resection, ascites, the number and amount of effusion hemorrhagic effusion more than 1000ml lower than the death group (P=0.007, P0.001, P=0.004, P, =0.016).51 cases of intestinal resection in patients with small bowel and colon resection of white blood cell count and mortality rate is higher than the simple small intestine resection group (P=0.046, P0.001). The death of 29 cases underwent laparotomy than interventional treatment (P=0.007).
According to the etiology of thrombosis, 41 cases were divided into thrombus group and 38 cases in embolization group. The proportion of small bowel + colectomy and peripheral atherosclerosis in thrombosis group was higher than that in embolization group (P=0.011, P=0.044), while the proportion of atrial fibrillation and peripheral artery embolism was lower than that of embolization group (P0.001, P=0.043).
(2) the clinical characteristics of 96 patients with ASMVT:
Male: female =3:1. average age is 46 years old. Survival group 83 cases, death group 13 cases, mortality 13.54%. solitary mesenteric venous thrombosis (MVT) 39 cases, combined with MVT57 cases. Death combined with severe pancreatitis and isolated MVT number is higher than survival group (P0.001, P= 0.004).
Patients in the open surgery group had the shortest time from onset to treatment, the incidence of isolated MVT was the highest, and the mortality rate was higher than that of interventional thrombolysis group and conservative treatment group.
In the isolated MVT group, the number of cases with peritoneal irritation was higher than those in the combined MVT group (P0.001, P=0.023, P=0.012), and the incidence of postoperative history after splenectomy was lower than that in the combined MVT group (P=0.002).
(3) the clinical characteristics of 14 patients with NOMI:
Male: female =1.33:1. survival group 10 cases, death group 4 cases, mortality 28.57%. average age 66 years old, survival group average age and taking NSAIDS case number is lower than death group (P=0.04, P=0.011).
Surgical treatment of 9 cases, 5 cases of conservative treatment. Surgical treatment of 8 cases of intestinal resection, including 3 cases of intestinal ischemia, 4 cases of diffuse intestinal ischemia, 1 cases of colonic ischemia death. 4 cases were patients with diffuse intestinal ischemia, diffuse intestinal ischemia in between survival group and death group was statistically significant (P=0.002).
Clinical features of 2,13 patients with CMI:
Male: female =2.25:1, with an average age of 68 years. All the patients had more than one disease arteriosclerosis. Endoscopy in patients with previous rate (11/13,84.62%) of.4 patients with peptic ulcer C13 urea breath test for detection of Helicobacter pylori (Helicobacter pylori, HP) were negative in 2 cases, the SMA+CA stent, 2 cases SMA stent implantation.
13 patients had SMA lesions, SMA stenosis rate (9/13,69.23%) was higher than that of CA (3/13,20.07%) and IMA (3/13,20.07%). Only SMA single vessel disease (2/13,15.38%), CA and SMA in two lesions (6/13,46.15%), three had lesions (5/13,38.46%). No isolated IMA stenosis or obstruction cases.
Clinical features of 3107 patients with IC:
Male: female =3.12:1, the average age is 70 years old. There are 51 cases in ulcer group and 56 cases in non ulcer group. There is chronic constipation in ulcer group. The history of COPD and the proportion of enteric coated aspirin are all higher than those in non ulcer group (P=0.024, P=0.020, P=0.030).
A total of 69 cases (64.49%) underwent abdominal CT examination, CT CA or SMA or IMA or atherosclerotic calcification in 51 cases (73.91%), 18 cases of abdominal vascular abnormalities, ulcer and abdominal vascular lesions combined basis, the average hospitalization time and the average number of white blood cells were higher than those in non ulcer group (P=0.027, P0.05, P=0.020); while the hemoglobin is lower than the non ulcer group (P=0.044).
4, the characteristics of CT image related to intestinal ischemia:
Among the 151 patients who met the inclusion criteria, there were ASMATE51 cases, ASMVT53 cases, NOMI8 cases, CMI10 cases and IC29 cases. The survival group was 115 cases, and the death group was 36 cases. The abdominal cavity effusion, portal mesentery accumulation, intestinal wall gas accumulation and peritoneal free gas ratio in the death group were all higher than those in the survival group (P0.001, P0.001, P0.001, P=0.003).
Analysis of intestinal artery CT image in 51 ASMATE patients, 30 cases in survival group and death group 21 cases.SMAT33 cases, SMAE18 cases; embolization site were SMA distal, middle colic artery and right colon, ileum and colon, jejunal artery, iliac artery peripheral branch artery. SMA opened a total of 11 cases caused by thrombosis abdominal aorta lesions (33.33%). Due to the wall itself and other factors lead to the atherosclerotic stenosis in 26 cases (50.98%). The abdominal aortic calcification and non calcification factors lead to luminal stenosis in 10 cases (38.46%).
5, atherosclerosis related CT imaging features:
40 ASMATE patients were divided into the case group and the non ischemic bowel disease in 40 cases as control group. Cases of abdominal aortic calcification in the target segment total average score was 749.91 higher than 382.36 in the control group, but the difference was not statistically significant (P=0.361). Patients with massive calcification and circumferential calcification, while the control group with the dot or bar calcification, there was significant difference between the degree of calcification were more severe and the control group (P0.001). Cases of calcified plaque located at the SMA opening level above, the target segment of abdominal aortic calcification in non volume were higher than the control group (P=0.046, P=, SMA 0.031) opening diameter less than that of the control group (P0.001).
conclusion
1, (1) peritoneal irritation, low blood pressure, white blood cell count and neutrophil percentage increased, hemoglobin decreased, longer onset to treatment time, the average length of intestinal resection, for small bowel and colon resection, two intestinal resection, and ascites, blood accumulates fluid, effusion of more than 1000ml above all is a predictor of death in patients with ASMATE associated with chronic ischemia; and weight loss is a protective factor for survival; ASMAT is common in patients with atherosclerotic disease and more need for small bowel and colon resection; and atrial fibrillation and peripheral arterial embolism were more susceptible to ASMAE.
(2) isolated MVT is more prone to peritoneal irritation, and is more prone to intestinal necrosis and open surgery. Combined MVT is easy to occur after splenectomy history. Severe pancreatitis is a risk factor for ASMVT death.
(3) the history of NSAIDS medication and the occurrence of diffuse intestinal ischemia are the predictors of NOMI death.
2, CMI occurs in severe atherosclerosis in the elderly, but single intestinal vascular lesions may also disease. Elderly patients with non HP related and non NSAIDS related ulcer or gastrointestinal inflammation, CMI should be considered as possible. Some patients with the prolongation of the duration and the growth of the age, symptoms relieved to.
3, chronic constipation, a history of COPD, taking Aspirin Enteric-coated Tablets as well as the increase of white blood cell, hemoglobin decreased formation of IC is a predictor of ulcerative lesions, easily formed ulcer lesions based on intestinal artery disease patients had IC; hospitalized longer IC ulcer patients.
4, intestinal CT showed peritoneal effusion, portal mesentery accumulation, intestinal wall gas accumulation and peritoneal free gas were the predictor of death in ICBD patients. Abdominal aortic disease may involve SMA opening and cause SMA stenosis or thrombotic events.
5, the more severe circumferential and massive calcification of abdominal aorta, calcified plaque above SMA level, larger non calcification load and vascular stenosis caused by non calcification of SMA opening site are risk factors for ICBD.
6, due to the fact that most of the patients in this large medical institution are difficult and critically ill, the proportion of all types of ICBD and the proportion of male to female can not represent the incidence and sex ratio of the population.

【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R574

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