門脈ガス血症を併発した非閉塞性腸管虚血症(NOMI), 腸管虚血か腸管壊死か対照的な2例  [in Japanese] Two cases of nonocclusive mesenteric ischemia with hepatic portal venous gas : differentiating between bowel ischemia and bowel necrosis  [in Japanese]

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Abstract

非閉塞性腸管虚血症(nonocclusive mesenteric ischemia; NOMI)は,低灌流に引き続いて発生する腸管の動脈攣縮によるもので,虚血が不可逆的になると腸管壊死を引き起こす。門脈ガス血症(hepatic portal venous gas; HPVG)や腸管嚢腫様気腫像,高乳酸血症などの腸管壊死を示唆するとされる所見を伴っていながら,結果的に全層性の腸管壊死がみられなかった例を対照的な壊死症例と合わせて 2 例報告する。症例はいずれもショック状態で当センターへ搬送となった。HPVG,腸管嚢腫様気腫像,高乳酸血症などを認め,臨床上腸管壊死を強く疑い緊急開腹手術を施行した。 1 例は小腸の全層壊死を伴っており腸管切除術を施行し, 2 例目は壊死が粘膜に限局していたことから,second look手術を施行し腸管切除を回避することが可能であった。NOMIの症例において腸管壊死を示唆する門脈ガス血症,腸管嚢腫様気腫像等を認めた場合は,腸管壊死を疑い一般的に開腹術が妥当な治療と考えられる。しかしながら,本症例によりこれらの所見を伴う症例において必ずしも腸管壊死を伴わない場合があることが示された。ただし,現時点では腸管壊死の有無を確実に術前診断するすべはなく,開腹術はやむなしと思われる。

Nonocclusive mesenteric ischemia (NOMI) is induced by mesenteric vasospasm after inadequate perfusion of the mesenteric artery. Persistence of mesenteric vasospasm and ischemia of the intestine induce bowel necrosis. We report two cases of NOMI, both of which had signs of bowel necrosis: hepatic portal venous gas (HPVG) and bowel pneumatosis on CT, and hyperlactacidemia. However, at operation, one demonstrated transmural necrosis while the other did not. Both patients were in shock on arrival at our emergency center. As both had the above-mentioned signs of bowel necrosis, we performed emergency laparotomy. One had transmural necrosis of the small intestine, requiring enterectomy. As the other patient had mucosal necrosis only, we avoided enterectomy by performing a second-look operation. In NOMI, when CT shows signs of bowel necrosis such as HPVG and bowel pneumatosis, emergency laparotomy is generally considered appropriate. However, one of our cases did not have transmural necrosis despite these findings. But at the current moment there is no reliable tool of preoperative diagnosis of bowel necrosis, clinicians therefore have no other choice of performing laparotomy.

Journal

  • Nihon Kyukyu Igakukai Zasshi

    Nihon Kyukyu Igakukai Zasshi 19(12), 1101-1106, 2008-12-15

    Japanese Association for Acute Medicine

References:  12

Cited by:  5

Codes

  • NII Article ID (NAID)
    10024808961
  • NII NACSIS-CAT ID (NCID)
    AN10284604
  • Text Lang
    JPN
  • Article Type
    Journal Article
  • ISSN
    0915924X
  • Data Source
    CJP  CJPref  J-STAGE 
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