acute superior mesenteric vein thrombosis
Introduction
Introduction to acute superior mesenteric vein thrombosis Acute superior mesenteric vein thrombosis (acutesuperiormesentericvenous thrombosis) is insidious, with no specific symptoms and signs in the early stage. Routine examination is not easy to diagnose. Most patients have a diagnosis after peritonitis or even laparotomy, and often lose the best treatment opportunity. Surgical thrombectomy, necrotic intestines, and active anticoagulant therapy are effective measures to improve patient survival and reduce thrombus recurrence. basic knowledge The proportion of illness: 0.0025% Susceptible people: no specific population Mode of infection: non-infectious Complications: peritonitis
Cause
Acute mesenteric venous thrombosis
(1) Causes of the disease
The superior mesenteric venous thrombosis is divided into primary and secondary, the former cause is unknown, the incidence rate is 10% to 20%, and some of these patients have had peripheral phlebitis such as migratory phlebitis, the latter Often issued in:
1 cirrhosis or extrahepatic compression causes portal vein congestion and blood stasis;
2 intra-abdominal infections such as suppurative appendicitis, pelvic inflammatory disease, etc.;
3 certain blood diseases such as polycythemia vera, as well as hypercoagulable state caused by oral contraceptives;
4 trauma caused by abdominal trauma or surgery, the condition is serious, often accompanied by shock;
5 abdominal cavity malignant tumor directly oppresses the mesenteric venous blood flow;
6 congenital coagulation abnormalities, such as hereditary antithrombin III deficiency, hereditary protein C deficiency, hereditary protein S deficiency, etc., which is more common in young patients, has a history of deep vein thrombosis.
(two) pathogenesis
After venous thrombosis, the thrombus can spread to the far and near end. When the venous return in the affected intestine is completely blocked, the intestine is congested and edema, and there is a point-like hemorrhage under the serosa, which gradually spreads into flaky hemorrhage until hemorrhagic necrosis of the intestine. Bloody fluid exudates from the intestinal wall and mesentery to the intestine and abdominal cavity, resulting in decreased blood volume, blood concentration, cardiopulmonary failure, etc., and acute occlusion of the vein can reflexively cause stenosis of the visceral artery and accelerate thrombosis, accelerate the process of intestinal necrosis Most of the venous thrombosis involves only a segment of the jejunum or ileum vein, which causes less necrosis of the whole small intestine, but the thrombus is easy to re-form, so it is easy to relapse, and sometimes multiple surgical treatments are needed.
Prevention
Acute mesenteric venous thrombosis prevention
The prognosis is slightly better than that of intestinal infarction caused by arterial occlusion. The most important prognostic factor is early surgical treatment prior to extensive thrombosis.
Complication
Acute mesenteric venous thrombosis Complications peritonitis
Intestinal necrosis is a serious complication of the disease. The thrombus can spread to the far end. When the venous return in the affected intestine is completely blocked, the intestine is congested and edematous, and there is punctiform hemorrhage under the serosa. It gradually spreads into flaky hemorrhage until hemorrhagic necrosis of the intestine. A large amount of bloody fluid exudes from the intestinal wall and mesentery to the intestinal cavity and abdominal cavity. , resulting in reduced blood volume, blood concentration, cardiopulmonary failure and so on. Acute occlusion of the vein is still reflexively causing stenosis of the visceral artery and accelerating thrombosis. Accelerating intestinal necrosis. Most of the venous thrombosis involves only a segment of the jejunum or ileum vein, which causes less necrosis of the whole small intestine. However, the thrombus is easy to re-form and is therefore prone to recurrence, sometimes requiring multiple surgical treatments.
Symptom
Acute mesenteric venous thrombosis symptoms Common symptoms Constipation Abdominal discomfort Diarrhea Abdominal pain Peritoneal irritation Peritonitis
The onset is slow, ranging from a few days to several weeks. The clinical manifestations are acute mesenteric ischemia, and the performance does not correspond to the symptoms.
1. Abdominal pain
In the early stage, only mild total abdominal pain or abdominal discomfort, constipation or diarrhea, about 27% of patients may have abdominal pain more than 30 days. Abdominal examination, although severe abdominal pain, but the signs are mild.
2. Total peritonitis
As the disease progresses, venous blood flow is blocked, severe intestinal function is impaired, sudden severe abdominal pain, accompanied by vomiting, diarrhea and bloody stools, blood is more common than arterial occlusion, physical examination: obvious peritoneal irritation, intestinal The sound is weakened or disappeared, the body temperature rises, and the hemorrhagic fluid can be drawn by abdominal puncture.
Examine
Examination of acute superior mesenteric vein thrombosis
Blood routine
White blood cell counts were significantly elevated.
2. Hemoglobin and red blood cell ratio increase, suggesting blood concentration.
3. Serum phosphate, amylase and creatinine phosphokinase are elevated, but lack specificity.
4. The positive rate of serum lactate determination can reach 85.1%91.4%, but it often appears after arterial ischemia and intestinal necrosis, and it does not help the early diagnosis of this disease.
5. Blood gas analysis
PH decreased, SB decreased, BE was negative, and carbon dioxide binding decreased, suggesting the occurrence of metabolic acidosis.
6. X-ray inspection
(1) Abdominal plain film: showing large intestine gas accumulation or gas-liquid level.
(2) CT scan: can show thrombosis of the portal system, the correct rate is above 90%.
(3) Selective superior mesenteric artery angiography: Arteriography can only provide indirect signs of the disease, and the relative diagnosis of intravenous superior mesenteric artery angiography is of great significance. A small number of patients can show portal vein or mesenteric venous thrombosis. Most of them appear as delayed or no venous phase.
7. Color Doppler
Early detection of thrombosis in the mesenteric vessels, especially in the portal vein, can be 100% positive, but color Doppler ultrasound is susceptible to intestinal gas interference, which requires higher technical and experience of the examiner.
8. abdominal puncture
Bloody liquid can be withdrawn.
Diagnosis
Diagnosis and diagnosis of acute superior mesenteric vein thrombosis
Diagnostic criteria
The following conditions should be highly suspected of the possibility of the disease.
History
Common causes of portal venous stasis, hypercoagulant or vascular injury, such as cirrhosis portal hypertension, congestive heart failure, protein C and S deficiency, clotting factor abnormalities, thrombocytosis, polycythemia, pregnancy, long-term oral contraception Drug, splenectomy, dehydration, etc.
2. Clinical manifestations
In the early stage, the patient developed symptoms of acute abdomen that were inconsistent with symptoms and signs, namely severe severe abdominal pain and mild signs; accompanied by frequent vomiting, bloody stools, etc.
3. Auxiliary inspection
CT and selective mesenteric angiography show that venous blood flow is blocked during venous thrombosis and can help to rule out mesenteric artery obstructive disease.
Differential diagnosis
The disease must be differentiated from acute pancreatitis, intussusception, and digestive tract perforation.
