paraduodenal hernia
Introduction
Introduction to duodenal fistula During embryonic development, part of the intestine and/or intestinal fistula is enclosed in the retroperitoneal crypt adjacent to the duodenum, called paraduodenal hernia, also known as mesentericher congenital hernia of mesocolon. Congenital colonic hernia (regenitalherniaof mesocolon) and retroperitoneal hernia (retroperitonealhernia), due to abnormal rotation of the midgut during the embryonic period, is congenital intra-abdominal hernia, especially on the left side. basic knowledge The proportion of illness: 0.006%-0.009% Susceptible people: no special people Mode of infection: non-infectious Complications: nausea and vomiting
Cause
Cause of duodenal paralysis
(1) Causes of the disease
There are several crypts in the normal retroperitoneum, such as the duodenum, the lower crypt, the duodenal crypt (Landzerts crypt), the duodenal crypt, the duodenal jejun crypt, the small intestine Mesenteric abdominal wall crypts (Waldeyers crypt), etc., they are generally small, do not cause pathological phenomena, if the embryonic development of the midgut torsion abnormalities, so that part of the small intestine or intestinal fistula is wrapped in the retroperitoneal crypt, that is, ten Two fingers next to each other.
(two) pathogenesis
The pathogenesis of duodenal paralysis is unclear.
Treitz (1857) first described many folds and crypts in the duodenal area, and Jonnesco (18891890) divided it into two types: the left duodenal parasitoid and the right duodenal paralysis. And found that the left side of the duodenum is more common, BGAMoynihan (1899) described 9 different crypts around the duodenum, and in 1906 proposed the expansion of the duodenal crypt The formation of duodenal paralysis, Landzerts crypt is the main cause of the left duodenal paralysis, Waldeyers crypt is the cause of the right duodenal paralysis, and Andrews (1923) proposed "The theory of midgut developmental disorders", he believes that duodenal paralysis is "congenital peritoneal dysplasia surrounding the small intestine in the retroperitoneal crypt above the colon", most scholars agree with the latter theory.
Normal embryo development until the 5th week, because the growth rate of the midgut is faster than the body cavity, temporarily into the umbilical cord to form a physiological umbilical hernia, the midgut is divided into two parts, the anterior segment of the artery and the posterior segment of the artery, with the superior mesenteric artery as the boundary. The anterior segment develops into the majority of the small intestine, and the posterior segment of the artery develops into the distal ileum and the right half of the colon. After about 10 weeks, the volume of the body cavity increases, and the midgut that protrudes into the umbilical cord outside the body cavity begins to retract into the body cavity, and the midgut The anterior segment of the artery is first retracted into the abdominal cavity, passes under the superior mesenteric artery, and rotates counterclockwise. The anterior segment of the artery rotates to the left side of the superior mesenteric artery. The posterior segment of the artery rotates counterclockwise to the right side above the mesenteric artery. The result is the cecum. The colon is transferred to the right lower abdomen, and the small intestine is located below the transverse colon. Some scholars divide the process into three phases: Phase I, starting from embryonic development to the fifth week, because the midgut grows faster than the body cavity, temporarily forming into the umbilical cord through the umbilical ring. Physiological umbilical hernia; stage II, the anterior segment of the artery (duodenal part) retreats to the abdominal cavity, and rotates 270 degrees counterclockwise after the superior mesenteric artery; Period, the posterior segment of the artery (right colon) retracts to the abdominal cavity, in front of the superior mesenteric artery, rotates 270 degrees counterclockwise until the end of the rotation at 12 weeks, the right colon moves to the normal position of the right abdomen, but the intestine and its The fixation of the mesentery may not be completed until birth.
The right duodenal paralysis is the middle segment of the midgut that cannot be rotated counterclockwise or incompletely. It occurs in the second phase of the rotation of the midgut. After the rotation is only 90°, it stops rotating and stays in the upper right abdomen. During this process, the posterior segment of the midgut rotates normally and overlies it, causing a large number of adjacent small intestines to be covered by the right mesenteric ridge, located in Waldeyer's crypt, and fixed to the right posterior peritoneum, causing some or all of the small intestine to be wrapped. Behind the cecum and ascending mesenteric membrane, the right duodenal paralysis is formed. The superior mesenteric artery and ileum artery form the leading edge of the ankle ring. The ascending colon and its mesangium constitute the anterior wall of the hernia sac. When treating the right duodenal paralysis, it is often separated from the right colon, the colon is placed on the left abdomen, and the small intestine is left on the right side. Callander (1935) proposes the mechanism of the left duodenal paralysis and the right Different sides, under normal circumstances, the anterior segment of the midgut artery is located on the left side of the superior mesenteric artery, and the right colon is located in the normal position of the right lower abdomen. The duodenum and the mesentery merge with the peritoneum of the retroperitoneal wall. If this fusion does not occur, A potential gap (Landzerts crypt), when the small intestine moves to the left posterior part of the abdominal cavity, falls into the Landzerts crypt, the small intestine is wrapped under the descending mesenteric, and forms the left duodenal paralysis, descending colon and its The mesangium forms the anterior wall of the hernia sac, and the inferior mesenteric vessels form the leading edge of the ankle ring, which causes the cecum to be located to the right of the midline of the lower abdomen.
The left anastomosis of the duodenal fistula opens to the right side, the inferior peritoneum of the anterior border has mesenteric movement, the vein passes, the sac is in the Landzerts crypt on the left side of the small mesentery, and the anterior sac is the descending mesenteric membrane. There is a psoas muscle, a left kidney and a ureter, and the descending colon can be pushed to the left side of the hernia sac. It can also ride in front of the sac, and the ring of the right side of the duodenum opens to the left. The anterior border of the ankle ring has mesenteric motion, vein or ileal artery, and the sac is in the Waldayer's crypt on the right side of the small mesentery. It is located behind the transverse mesenteric membrane, and the cystic sac of the duodenum is single. The peritoneum is the small intestine, which can be a single intestinal fistula or all small intestines.
If there is no obvious pressure, adhesion or torsion in the intestinal tract in the ring or the sac, some patients with duodenal paralysis may have no obvious symptoms. When they are pressed by the ankle ring, they adhere to the neck of the sac. Adhesion or torsion in the sac can cause different degrees of intestinal obstruction. Once incarceration occurs, it not only causes intestinal stenosis in the sac, but also causes strangulation, necrosis or perforation, and also makes the mesentery at the leading edge of the ankle ring. On the upper (lower) movement, the vein is pushed and squeezed. In severe cases, the blood supply to the outer gut of the sac in the blood supply area may be hindered, and even ischemia and necrosis may occur.
Prevention
Prevention of duodenal fistula
1. Do not drink alcoholic beverages for a long time, quit smoking and drinking hobbies, do not overeat pickles, sour, spicy and irritating foods, and banned mildew foods. It is more important for people with chronic pharyngitis to develop good eating habits. If you are less than enough, eat more fresh fruits and vegetables.
2. Maintain proper temperature and humidity in the cold season, pay attention to air circulation. Room temperature should be 20 ° C, do not cover too much bedding when sleeping at night, to avoid excessive temperature or excessive drying, causing throat discomfort. Do not sleep in the wind, take a break after strenuous labor, do not rinse the cold bath immediately. Those with acute pharyngitis caused by colds should drink hot water or ginger soup to increase sweating. Note that the stool is smooth. Timely treatment of acute inflammation, to prevent the evolution of chronic, chronically diseased organs, more likely to malignant.
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Duodenal fistula complications Complications, nausea and vomiting
It can smell high-pitched bowel sounds, the intestinal tube is twisted, the tenderness is obvious after necrosis, the bowel sounds disappear, and the patient has symptoms of systemic poisoning.
Symptom
Symptoms of duodenal fistula Common symptoms Bowel and abdominal pain, bowel sounds disappear, nausea and bloating
The clinical manifestations of the patients are not only related to the presence or absence of small bowel obstruction, but also closely related to the degree of intestinal obstruction, the presence or absence of incarceration and strangulation, and the most common symptoms and signs of complete or incomplete small bowel obstruction.
Some patients may have no obvious symptoms, but most of them manifest as long-term incomplete small bowel obstruction, such as repeated episodes of months or years of intermittent, spastic abdominal pain, lasting for a few minutes or hours, holding their breath, torso upright or over Stretched and increased after eating, supine or fasting relief, can not heal self-healing, but repeated attacks, and often accompanied by post-meal nausea, vomiting and bloating.
Once the obstruction is converted to completeness or even intestinal strangulation, persistent abdominal pain can occur, and paroxysmal aggravation, accompanied by frequent, severe bilious vomiting, for most of the small intestine in the hernia sac, obstructing the proximal small intestine Not much, abdominal distension is not obvious, the abdomen can touch the mass, the shape and size are different due to the intestines. The mass is percussed with drum sound, light tenderness, high-pitched bowel sounds, intestinal tube stranding, necrosis After the tenderness is obvious, the bowel sounds disappear, and the patient has symptoms of systemic poisoning.
Examine
Examination of duodenal paralysis
X-ray inspection
(1) Abdominal fluoroscopy or plain film: visible small left intestine on the left or right side, dilated gas or fluid in the intestine, and other signs of intestinal obstruction.
(2) gastrointestinal sputum angiography: helpful for the diagnosis of duodenal paralysis, only suitable for patients with signs of intestinal obstruction symptoms, typical image: 1 mass of small intestinal fistula gathered in the abdomen left or right On the side, the intestines are not easy to separate, pushing or changing the position of the patient by hand, and the small intestines do not move, just like in the bag. 2 sputum in the small intestine through the slow; small pelvis in the pelvic cavity, the position of the terminal ileum is normal, the colon and stomach position often change, the characteristic image of the right duodenal paralysis: small intestine aggregation group ( block) Located in the right abdomen, the stomach often hangs down to the left side of the small intestine mass (squat block) when the patient is erect, the descending colon is on the left side, the ascending colon can be on the right side, the rear side, the front side or the left front side, the left side twelve Refers to the image of the para-intestinal hernia: the small intestine converges into an oval lumps and is located in the left abdomen. The stomach often rides over the small intestine mass (the mass of the small intestine). There is a translucent band between the two, the ascending colon is on the right side, and the descending colon Available in front of it, left or rear.
(3) Selective mesenteric angiography: the right side of the duodenum can be seen from the left side of the superior mesenteric artery, but in the opposite direction, to the right into the small intestine, visible in the left side of the duodenum The position of the superior mesenteric artery at the root is unchanged, but the jejunal artery enters the descending colon with the intestinal fistula behind the inferior mesenteric artery. It can also be seen that the proximal jejunal artery moves toward the intestine in the posterior direction.
(4) CT scan: the left duodenal fistula may have a group of intestinal fistulas located between the stomach and the pancreas. At the level of the Treitzs ligament or the back of the pancreas, the intestines wrapped in a mass are lacking between the normal intestines. Interdigitation, visible dilatation of the intestine and gas-liquid level, right duodenal paralysis, can be seen in the right middle abdomen to expand the intestine and gas-liquid level, jejunal movement, vein branch behind the superior mesenteric artery.
2.B-ultrasound
The clear echoes of the masses can be seen with or without bowel movements, and the internal tubular or cystic morphology of the mass changes with time and diet.
Diagnosis
Diagnosis and identification of duodenal fistula
Duodenal paralysis is rare in clinical practice, with no specific symptoms. Preoperative diagnosis is difficult. Consider the following points to consider the possibility of para-duodenal fistula.
1. History: The patient has long-term incomplete small bowel obstruction, such as recurrent intermittent, abdominal abdominal pain, torso straight or overextended and increased after eating, with nausea and vomiting, abdominal distension, etc.; or on this basis Sudden symptoms of acute intestinal obstruction.
2. Signs: There may be signs of incomplete or complete small bowel obstruction.
3. Imaging examination.
