小肠异物致嵌顿性股疝穿孔1例
A Case of Intestinal Foreign Body Causing Perforation of Incarcerated Femoral Hernia
DOI: 10.12677/ACRS.2021.103008, PDF, HTML, XML, 下载: 149  浏览: 210 
作者: 施 猛, 杨 亮, 黄 枫, 曹文杰, 刘伟东, 许 添:南昌大学第二附属医院胃肠外科,江西 南昌;邓小荣*:dengxr77@163.com
关键词: 股疝嵌顿异物鱼刺肠穿孔Femoral Hernia Incarceration Foreign Body Bones Intestinal Perforation
摘要: 目的:探讨小肠异物致嵌顿性股疝穿孔的临床特点、诊断及治疗。方法:回顾性分析南昌大学第二附属医院胃肠外科2021年2月收治的一名小肠异物致嵌顿性股疝穿孔患者的临床资料。结果:术前盆腔CT提示左侧腹股沟管扩大,部分小肠疝入,其内可见一高密度影。腹腔镜探查发现左股静脉内侧股管处可见小肠肠管疝入,牵拉肠管可见肠管卡压处有长约3 cm鱼刺刺破肠管,嵌顿处肠管可见一圈发黑,术中诊断为“左侧嵌顿性股疝”,予以行“腹腔镜左侧股疝补片修补术 + 小肠部分切除术”,术后恢复顺利,痊愈出院。结论:小肠异物致嵌顿性股疝穿孔,临床上极为少见,术前诊断及术中及时发现异物极为重要,需引起广大临床医师的重视。
Abstract: Objective: To investigate the clinical features, diagnosis and treatment of enteric foreign bodies with incarcerated femoral hernia. Methods: The clinical data of a patient with intestinal foreign body with incarcerated femoral hernia admitted in Department of gastrointestinal surgery, Second Affiliated Hospital of Nanchang University in February 2021 were analyzed retrospectively. Results: Preoperative pelvic CT showed that the left inguinal canal was enlarged, part of the small intestine was herniated, and a high-density shadow could be seen in it. Laparoscopic exploration found that there was a small intestinal hernia in the femoral tube of the left femoral vein, a fish bone about 3 cm long punctured the intestinal tube at the compression of the intestinal tube at the traction, and a circle of blackening at the incarcerated intestinal tube. During the operation, it was diagnosed as “left incarcerated femoral hernia”, and “laparoscopic left femoral hernia patch repair + partial small bowel resection” was performed. The postoperative recovery was smooth and the patient was discharged. Conclusion: Intestinal foreign body with incarcerated femoral hernia is very rare in clinical practice. Preoperative diagnosis and intraoperative discovery of foreign bodies are very important, which should be paid attention to by clinicians.
文章引用:施猛, 杨亮, 黄枫, 曹文杰, 刘伟东, 许添, 邓小荣. 小肠异物致嵌顿性股疝穿孔1例[J]. 亚洲外科手术病例研究, 2021, 10(3): 51-55. https://doi.org/10.12677/ACRS.2021.103008

1. 引言

腹外疝是腹部外科最常见的疾病之一,其中以腹股沟疝发生率最高,占90%以上,股疝次之,占5%左右。股疝患者,由于股管几乎是垂直向下的,疝内容物似直线状下坠,加上股环本身狭小,周围韧带坚韧,因此容易发生嵌顿和绞窄。肠道异物在临床并不少见,多数患者无临床症状,异物多能通过肛门自行排出,但也有些病人因异物排出困难或有并发症则需要手术治疗。小肠异物致嵌顿性股疝穿孔临床少见,国内外文献鲜有报道。本文报道南昌大学第二附属医院胃肠外科2021年收治的1例小肠异物致嵌顿性股疝穿孔诊治体会。

2. 临床资料

患者女性,75岁,因发现左侧腹股沟区肿物伴胀痛5天,于2021年02月23日以“左侧嵌顿性腹股沟疝”收入院。患者发病来,大小便正常。既往曾于36年前行子宫切除术,无高血压、糖尿病等慢性病史,无结核、乙肝等传染病史。入院查体:神志清楚,生命体征平稳,心肺查体未见阳性体征,左侧腹股沟内下方可触及一边界不清肿物,鸽蛋大小,伴轻压痛,腹平坦,腹肌软,全腹无明显压痛、反跳痛及肌紧张,肠鸣音正常。盆腔CT提示左侧腹股沟管扩大,见部分小肠疝入,其内可见一高密度影,见图1。体表包块彩超提示左侧腹股沟区可见一不规则异常混合回声团块,其间尚可见闪动的气体回声和肠蠕动,CDFI于其内可探及少许点状血流信号,见图2。血常规、凝血功能、肝功能、肾功能、电解质等检查均未见明显异常。入院诊断:左侧嵌顿性腹股沟疝。

完善术前准备后,于2021年2月26日在全麻下行腹腔镜探查,术中发现左股静脉内侧股管处可见小肠肠管疝入,牵拉肠管可见肠管卡压处有长约3 cm鱼刺刺破肠管,嵌顿处肠管可见一圈发黑,见图3图4;余肠管未见明显异常,右侧腹股沟区未见异常。术中诊断:1、左侧嵌顿性股疝,2、胃肠道异物。取出鱼骨,予以行“腹腔镜左侧股疝补片修补术 + 小肠部分切除术”,然后予以生理盐水冲洗腹腔,放置引流管。

Figure 1. Pelvic CT showed that the left inguinal canal was enlarged, part of the small intestine was herniated, and a high-density shadow could be seen in it

图1. 盆腔CT提示左侧腹股沟管扩大,见部分小肠疝入,其内可见一高密度影

Figure 2. Color ultrasound showed an irregular mixed echo mass in the left groin area, with flashing gas echo and bowel peristalsis, and a few dotted blood flow signals detected by CDFI

图2. 左侧腹股沟区可见一不规则异常混合回声团块,其间尚可见闪动的气体回声和肠蠕动,CDFI于其内可探及少许点状血流信号

Figure 3. Fish bones were removed, about 3 cm long

图3. 术中取出的鱼骨,长约3 cm

Figure 4. Herniation of the small intestine in the femoral canal, one circle of blackness and two perforations can be seen during the operation

图4. 术中见股管处小肠肠管疝入,可见一圈发黑,两处破口

术后追问病史,患者诉10日前,有意外吞食鱼刺史。术后予禁食、抗感染、营养补液等对症支持处理,9日后拆线,切口Ⅰ期愈合出院。

3. 讨论

肠道异物是临床常见疾病,以6个月~5岁的儿童多见 [1] [2],大部分异物可自行通过胃肠道,但大约有10%的异物无法排出,这些异物大多数是较大、较锋利或者有毒的异物,如鱼骨、纽扣、电池或磁性异物,可引发穿孔、出血、梗阻等并发症。肠道异物导致的穿孔的患者大多数有吞食异物后出现腹痛、恶心、呕吐,腹部压痛、反跳痛及肌紧张等典型急性腹膜炎体征,腹部X线检查了解膈下有无游离气体和肠梗阻,而做出明确诊断 [3]。但部分患者由于穿孔部位较小、穿孔时间较长形成局部包裹或穿孔至腹膜后可无明显急性腹膜炎症状和体征,诊断较为困难 [4]。本案例患者就无明显穿孔表现,对于此类患者应详细追问病史,明确患者吞服异物时间、大小、种类、数量以及目前可能所处位置,要进一步探查是否形成肠穿孔,术前行X线、CT,必要时行消化道钡餐、胃镜、B超等检查明确诊断,以免漏诊误诊,造成严重后果。在治疗上,早期摄入的异物可在全麻或局麻下内窥镜下取出 [5]。内窥镜无法取出的异物,对于短小光滑能够排出的异物,让患者正常饮食或进食多纤维素食物,口服液状石蜡促进异物排出 [6],对于较大、较锋利或有毒的异物,无法自行排除或出现严重并发症者应及时采取手术治疗 [7]。

股疝是一种常见疾病,是体内脏器或组织由股环、经股管向卵圆窝突出的腹外疝,发病率约占腹外疝的3%~5%,多见于40岁以上女性 [8]。多表现为腹股沟韧带下方一半球形肿块。由于股管的解剖位置特殊,且股环本身狭小,股疝约半数以上病例发生嵌顿,如发生嵌顿可出现明显疼痛和肠梗阻症状,一旦嵌顿又可迅速发展为绞窄性疝 [9]。如不及时发现和处理,可出现肠坏死、肠穿孔、腹膜炎等并发症,从而危及患者生命 [10]。易复性股疝由于缺乏特异性临床表现,尤其是年龄大,腹壁松弛,肥胖者,局部脂肪堆积的患者,极易误诊,常误诊为腹股沟斜疝、脂肪瘤、子宫圆韧带囊肿、淋巴结炎等疾病,延误患者治疗 [11]。股疝一经确诊,应及时手术治疗,对于嵌顿性绞窄性股疝更应紧急手术 [12]。

小肠异物致嵌顿性疝穿孔临床少见,部分患者腹膜炎症状不典型,极易漏诊误诊,多数是在术中才发现异物存在,国内外鲜有相关文献报道。Akhtar等人报告了3例肠道异物病例,其中有2例分别与造口旁疝和切口疝相关 [13]。Tay GC等人报告了一位腹股沟疝患者出现腹股沟区疼痛,手术探查发现左侧腹股沟疝囊内有两个鸡骨 [14]。Ben-Aharon U等人报告了一位患者15年前因喉癌行全喉切除术,部分咽切除术和部分食管切除术,术中放置的聚乙烯管脱落,导致腹股沟疝穿孔 [15]。张超峰等人报告了1腹股沟斜斜疝嵌顿患者,术中发现疝内容物含骨性异物 [16]。这些病例大多数是根据患者感染情况及肠管活性,选择肠切除吻合术 [14] 或肠修补术,也有患者因穿孔较小,时间较长,穿孔已自行闭合,取出异物后仅行疝修补术 [16],术后再予以抗感染等对症治疗,均获得了较好的疗效。

本案例中,该患者腹膜炎症状不典型,术前盆腔CT发现疝囊高密度影误以为粪石,术中才发现小肠嵌顿处鱼骨刺破肠管,分析其发病过程可能是肠管进入疝囊时,肠管内的鱼骨恰好穿过疝环进入疝囊,当疝囊内肠管回缩腹腔时,鱼骨无法通过疝环,导致部分肠管无法回缩,继而穿孔。幸运的是,该患者及时行手术治疗,并且在术中发现异物,未造成严重后果。

本例治疗体会:(1) 腹外疝患者伴疼痛,不可仅满足于嵌顿疝诊断,要考虑到合并肠道异物,详细询问病史,必要时完善相关影像学检查,结合临床资料综合分析,排除异物的可能,本案例患者术前盆腔CT检查已发现疝囊高密度影,但当时未予以重视,未进一步询问有无吞食异物病史。(2) 对于怀疑嵌顿的腹外疝患者应尽快手术,推荐腹腔镜手术,不仅可以减少创伤和感染,而且可以防止异物对术者造成伤害。(3) 腹外疝手术应充分探查腹腔,不仅要检查肠管有无穿孔坏死,还需仔细检查有无异物,有些患者无意间吞食异物穿孔,腹膜炎症状也不典型,不可放松警惕,手术完毕前应该再探查1次,防止有异物遗留。

NOTES

*通讯作者。

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