缺血性肠病临床特点及肠道血管病变的CT影像研究

发布时间：2018-02-20 07:42

本文关键词： 急性肠系膜缺血慢性肠系膜缺血缺血性结肠炎动脉粥样硬化钙化　出处：《中国人民解放军医学院》2014年博士论文　论文类型：学位论文

【摘要】：随着人口老龄化及动脉粥样硬化疾病患病率的增加，缺血性肠病（ischemicbowel disease，ICBD）的发病率日益增高，尽管诊疗技术的改进，急性肠系膜缺血（Acute mesenteric ischemia，AMI）死亡率仍在50%-90%。慢性肠系膜缺血（Chronic mesenteric ischemia，CMI）的腹痛症状长期困扰着严重动脉硬化的老年患者。缺血性结肠炎（Ischemic colitis，IC）常见于低血压等全身循环改变的状况，延误诊治往往导致凶险的预后。因此加深对该类疾病的认识，深入了解其患病与死亡相关危险因素，实施有效的二级预防，将为降低ICBD发病率及预后改善起到重要作用。目的探讨ICBD患者临床表现、CT影像特点及死亡相关危险因素，深入探究急性肠系膜上动脉血栓栓塞（acute superior mesenteric artery thromboembolism，ASMATE）的血管病变基础，为更加全面认识和深刻理解ICBD提供有力依据。方法 1、对2000年1月—2013年12月间解放军总医院确诊的ICBD患者的病历资料进行回顾性分析，包括一般资料，临床表现，辅助检查检验，诊疗方式，结局等。 2、对其中2008年以后入院诊断明确并在我院行腹部CT检查者的CT影像资料进行详尽复习，探寻与ICBD死亡相关的肠道病变CT影像特点。 3、借鉴冠脉钙化积分方法（The Agatston calcium scores）评估肠系膜上动脉（Superior mesenteric artery，SMA）及其开口上下各3cm段腹主动脉钙化积分，并详细描述钙化斑块形态及分布特点；借助volume软件测定非钙化体积，从钙化及非钙化角度理解肠道动脉粥样硬化进程，进而探讨肠道动脉粥样硬化与ICBD的关系。结果诊断确凿资料详实的ICBD309例，男223例，女86例，男：女=2.59：1。平均年龄61±17岁，其中AMI189例，CMI13例，IC107例，前者包括ASMATE79例，急性肠系膜静脉血栓(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患者的临床特点分析：（1）79例ASMATE患者的临床特点：男：女=2.04：1。平均年龄63岁，生存50例，死亡率36.71%。生存组体重减轻发生率高于死亡组（P=0.034）；腹膜刺激征、低血压、白细胞数和中性粒细胞比例均低于死亡组（P=0.001，P=0.006，P=0.006，P=0.006）；血红蛋白降低的例数少于死亡组（P=0.007）。生存组发病至接受治疗平均时间、平均肠切除长度短于死亡组（P=0.003，P=0.023）。生存组行二次肠切除例数、有腹腔积液、血性积液及积液量1000ml以上者的数目低于死亡组（P=0.007，P0.001，P=0.004，P=0.016）。51例肠切除的患者中，小肠+结肠切除组术前白细胞数及死亡率高于单纯小肠切除组（P=0.046，，P0.001）。死亡的29例中行开腹手术高于介入治疗（P=0.007）。按栓塞病因分为血栓组41例，栓塞组38例。血栓组行小肠+结肠切除及伴外周动脉粥样硬化症的比例高于栓塞组（P=0.011，P=0.044）；而房颤及外周动脉栓塞的比例低于栓塞组（P0.001，P=0.043）。（2）96例ASMVT患者的临床特点：男：女=3：1。平均年龄46岁。生存组83例，死亡组13例，死亡率13.54%。孤立性系膜静脉血栓（mesenteric venous thrombosis, MVT）39例，联合MVT57例。死亡组合并重症胰腺炎及孤立MVT的例数高于生存组（P0.001，P=0.004）。开腹手术组患者自发病至接受治疗的时间最短、孤立MVT发生率最高、死亡率也高于介入溶栓组及保守治疗组。保守治疗组中则无死亡病例。孤立MVT组出现腹膜刺激征者、行开腹手术及发生肠坏死例数均高于联合MVT组（P0.001，P=0.023，P=0.012）；发生于脾切除术后病史者低于联合MVT组（P=0.002）。（3）14例NOMI患者的临床特点：男：女=1.33：1。生存组10例，死亡组4例，死亡率28.57%。平均年龄66岁,生存组平均年龄及服用NSAIDS例数低于死亡组（P=0.04，P=0.011）。手术治疗9例，保守治疗5例。手术治疗中8例行肠切除，其中小肠缺血3例，弥漫性肠缺血4例，结肠缺血1例。死亡组4例均为弥漫性肠缺血患者，弥漫性肠缺血在生存组与死亡组间比较差异具有统计学意义（P=0.002）。 2、13例CMI患者的临床特点: 男：女=2.25：1，平均年龄68岁。全部患者均有一种以上动脉硬化相关疾病。患者既往的内镜检查率（11/13,84.62%）。4例消化性溃疡患者C13尿素呼气试验检测幽门螺杆菌（Helicobacter pylori，HP）均阴性，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病变，SMA中重度狭窄率（9/13，69.23%）高于CA（3/13，20.07%）和IMA（3/13，20.07%）。仅SMA单支血管病变者（2/13,15.38%），CA和SMA两支病变者（6/13，46.15%），三支均有病变者（5/13,38.46%）。无孤立性IMA狭窄或梗阻病例。 3、107例IC患者的临床特点：男：女=3.12：1，平均年龄70岁。溃疡组51例，非溃疡组56例。溃疡组有慢性便秘、COPD病史及应用肠溶阿司匹林的比例均高于非溃疡组（P=0.024，P=0.020，P=0.030）；共有69例（64.49%）行腹部增强CT检查，CT显示CA或SMA或IMA粥样硬化或钙化者共51例（73.91%），未见腹部血管异常者18例，溃疡组合并腹部血管基础病变、平均住院时间及平均血白细胞数均高于非溃疡组（P=0.027，P0.05，P=0.020）；而血红蛋白低于非溃疡组（P=0.044）。 4、肠道缺血相关CT影像特点：符合入选标准的151例患者中，ASMATE51例，ASMVT53例，NOMI8例，CMI10例，IC29例。生存组115例，死亡组36例。死亡组腹腔积液、门脉系膜积气、肠壁积气及腹腔游离气体比例均高于生存组（P0.001，P0.001，P0.001,P=0.003）。对51例ASMATE患者进行肠道动脉CT影像分析，生存组30例，死亡组21例。SMAT33例，SMAE18例；栓子栓塞部位分别为SMA远端、中结肠动脉以及右结肠、回结肠、空肠动脉、回肠动脉等外周分支动脉。由腹主动脉病变累及导致SMA开口血栓形成共11例（33.33%）。而因管壁本身动脉粥样硬化等因素导致的狭窄26例（50.98%）。其中腹主动脉钙化及非钙化因素导致管腔狭窄10例（38.46%）。 5、动脉粥样硬化相关CT影像特点： ASMATE患者40例设为病例组，非缺血性肠病40例设为对照组。病例组目标段腹主动脉总平均钙化积分为749.91高于对照组382.36，但差异无统计学意义（P=0.361）。病例组以块状钙化和环周钙化为主，而对照组以点状或条形钙化为主，病例组更严重的钙化程度与对照组比较差异有统计学意义（P0.001）。病例组钙化斑块分布于SMA开口水平以上者、目标段腹主动脉非钙化体积均高于对照组（P=0.046，P=0.031），SMA开口部直径小于对照组（P0.001）。结论 1、（1）出现腹膜刺激征、低血压、白细胞数和中性粒细胞比例升高、血红蛋白降低、更长的发病至接受治疗时间、平均肠切除长度更长、行小肠+结肠切除、二次肠切除、以及腹腔积液、血性积液、超过1000ml以上的积液都是ASMATE患者死亡的预测因素；而与慢性缺血相关的体重减轻是生存的保护性因素；ASMAT患者常伴动脉粥样硬化疾病且更多需行小肠+结肠切除；而房颤及外周动脉栓塞的患者更易发生ASMAE。（2）孤立MVT更易出现腹膜刺激征，更易发生肠坏死而需行开腹手术；联合MVT易发生在脾切除术后病史者；重症胰腺炎基础上发病是ASMVT死亡的危险因素。（3）有NSAIDS用药史和发生弥漫性肠缺血是NOMI死亡的预测因素。 2、CMI多发生于有严重动脉粥样硬化的老年人，但肠道血管单支病变也可能发病。老年患者非HP相关、非NSAIDS相关溃疡或胃肠炎症，应想到CMI的可能。部分患者随着病程延长以及年龄的增长，达到症状的自行缓解。 3、慢性便秘、有COPD病史、服用阿司匹林肠溶片以及白细胞升高，血红蛋白降低是IC溃疡性病变形成的预测因素,有肠道动脉病变基础的患者发生IC时更易形成溃疡性病变；IC溃疡型患者住院时间更长。 4、肠道CT显示腹腔积液、门脉系膜积气、肠壁积气及腹腔游离气体是ICBD患者死亡的预测；腹主动脉病变可能累及SMA开口引发SMA狭窄或血栓性事件发生。 5、腹主动脉更严重的环周型及块状钙化、位于SMA开口水平以上的钙化斑块、更大的非钙化负荷以及SMA开口部位非钙化病变导致的管腔狭窄是ICBD发生的血管危险因素。 6、由于本大型医疗机构收治患者多为疑难危重等原因，本组所显示的各类型ICBD所占比例及男女患病比例尚不能代表该病的人群发病率及性别比。
[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.

【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R574

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