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1、Case Conference Ischemic ColitisR2 胡家瑞胡家瑞Patients dataName :周X丽 Sex:female Age:86years Time of admission:2011.02.10Chief complainChief complainRepeatedly abdominal pain and diarrhea two weeks, aggravated 1day.Present historyNo obvious significant to recurring diarrhea accompany with left upper quadr
2、ant two weeks.Came to OPD and drug treatment several times but no significant improvement.Symptoms aggravated 1day, accompany with periumbilicalcolic, no fever, chills, bloody stools.CT finding：Ascending colon and transverse colon minor swelling, consider inflammation.Past medical historyHTN(-) 5 ye
3、ars without regular monitoring .Smoking (-)Alcohol(-)DM(-)Coronary heart disease(-)Surgical history (-)Physical examinationVital sign: T 36.1 P 75次/分 R 19次/分 BP 131/90mmHg。Body weight lossSkin and sclera :no stained yellow CV: The heart beat is regular. There was no murmurs clicks or rubs.Physical e
4、xaminationAbd: no varicose vein on abdominal wall Grey-turner(-),Cullen(-) Mild tenderness at upper abdomen without palpation-lump at abdomen, murphys sign(-) shifting dullness(-). Bowel sounds 3/min. Edema of lower extremities:noAuxiliary examination1.Blood examination2. Abdomen CTLaboratory HS-CRP
5、 121.54 mg/L HNa 133.3 mmol/L 134-148 K 2.55 mmol/L 3.0-4.8 Cl 93.1 mmol/L 102-112 WBC 9.0 109/L M3.9-10.6Segment 87.0 %BUN 2.61 mmol/LCreatinine 91.82 umol/L AST/GOT 24 U/L ALT/GPT 11 U/LHemoglobin 122 g/L M135-175 Platelets 263 109/L 150-400 便常规 PUS 100 HPF，RBC 8-25 HPF，O.B. 阳性 H。Initial Diagnosis
6、Abdominal pain, diarrhea of unknown origin: acute colitis？Electrolyte imbalance: hypokalemiaHypertensionT12 vertebral compression fracturesProgression Note 2011.02.16palpitations; asthma, orthopnea, Lower extremity edema;EKG、2D echo、Holder show AF. then 02.18 transfered to cardiology continue treatm
7、ent.2011.02.22 significantly abdominal pain and rebound tenderness. CT show massive ascites.Consider thromboembolic intestine? Acute intestinal necrosis? Consult GS and arranged emergency surgery.Operation横结肠及部份降结肠切除术 结肠造瘘(Colostomy)术 术中见腹内脓疡及腹水约800毫升，横结肠坏死并穿 孔;局部明显沾粘, 切除横结肠及部份降结肠切除术, 清除腹腔脓性渗出。盆腔置引流
8、管4根，出腹壁固定。 依次关腹。横结肠近端切缘拉出腹壁做一结肠造瘘DiscussionIncidence在胃肠道的缺血性疾病中占50% ，多见 于60岁以上老年患者每年缺血性结肠炎总发病率为4.5-44/1万住院率达1/1 000-1/2000Higgins研究发现在肠易激综合征、慢性 阻塞性肺病患者中发病率增加2-4倍Higgins PD, Davis KJ, Laine L. Systematic review: the epidemiology of ischaemic colitis. Aliment Pharmacol Ther 2004; 19: 729-738Vascular S
9、upply of the ColonVascular Supply Superior mesenteric artery (SMA)Ileocolic artery terminal ileum, cecum, appendix, prox ascending colonRight colic artery ascending colon, hepatic flexureMiddle colic artery transverse colonInferior mesenteric artery (IMA)Left colic artery descending, transverse colo
10、n, splenic flexureSigmoid arteries sigmoid and descending colonSuperior rectal artery proximal rectumCollateral flowMarginal artery of Drummond collateral connection between SMA and IMA along the mesenteric borderIMA and internal iliac supply good collaterals to the rectumLocation of ischemia by reg
11、ionsOther areas refer to combination of different regions. Data from: Reinus, JF, Brandt, LJ, Boley, SJ, Gastroenterol Clin North Am 1990; 19:319心血管疾病IBS（肠易激综肠易激综 合症合症）休克痢疾长期服用避孕药结肠癌 呕吐 便秘腹主动脉及心血管手术消化不良Chang L,Kahler KH,Sarawate C,et al.Assessment of potential risk factors associated with ischaemic
12、colitis.Neurogastroenterol Motil,2008,20:36-42Causes of colonic ischemiaManifestations 1.The onset is characteristically acute, with generalized abdominal pain, usually in the left lower quadrant, followed within 24 hours by bloody diarrhea or rectal bleeding .2.Dilation of the colon and physical si
13、gns of peritonitis are seen in severe cases. 3.With the gangrenous type, both symptoms and signs progress rapidly.Progressive clinical stagesHyperactive phase: Soon after occlusion or hypoperfusion, severe pain dominates with frequent passage of bloody, loose stools.Paralytic phase: The pain usually
14、 diminishes, becomes more continuous, and diffuses.Shock phase: Massive fluid, protein, and electrolytes start to leak through a damaged, gangrenous mucosa, requiring rapid surgical intervention. Radiological imaging/Endoscopic studiesPlain abdominal x-rayComputed TomographyMay be normal initiallyTh
15、ickening of bowel wall in segmentalPneumatosis and gas in mesenteric veins in advanced stagesEndoscopy Colonoscopy with biopsy histopathology is the gold standard for diagnosis of ICDiagnostic StrategyNo specific serum markers proven in the diagnosis of intestinal ischemia.Abdominal films may reveal thumb printing from submucosal hemorrhage and edema . * (barium enema is contraindicated in cases of gangrenous ischemic colitis because of the risk of perforat
