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【摘要】目的探讨术后早期炎性肠梗阻的特点及治疗原则。方法回顾性分析近期经治的术后早期炎性肠梗阻9例。结果1例患者经手术治疗，分离粘连时引起多发性肠破裂、肠瘘，后经保守治疗治愈；8例患者均经胃肠减压、抗炎、应用生长抑素等保守治疗治愈，平均治愈时间为21．5d，无1例肠坏死。结论术后早期炎性肠梗阻的特点：(1)发生于腹部手术后早期，虽有机械性因素，但大多都是腹腔内炎症所致广泛粘连引起；(2)症状以腹胀为主，腹痛相对轻，部分患者有少量肛门排气排便，体征虽典型，但较少发生绞窄；(3)保守治疗大都有效，治疗上最好先予以生长抑素为主的保守治疗，应严密观察，如出现肠坏死、腹膜炎征象时则再及时中转手术。
Treatment of early postoperative inflammatory small bowel obstruction
HU Zhiming,ZHOU Shouchun,ZHAO Dajian,et al.
Department of Surgery,Zhejiang Provincial People′ s Hospital,Hangzhou 310014,China
【 Abstract】 Objective To investigate the clinical characteristics and treatmnet principles of early postoperative inflammatory small bowel obstruction.Methods Clinical data of 9 cases of early postoperative inflammatory small bowel obstruction was analyzed retrospectively.Results One patient underwent operation,during which multiple rupture of small intestine happened,and resulted in postoperative fistula.This patient recovered after conservative treatment.Other 8 patients recovered after non-operative treatment including gastrointestinal decompression,administration of antibiotics and somatostatin,etc.The mean cure time was 21.5 days and none had intestinal necrosis.Conclusions The characterstics of early postoperative inflammatory small bowel obstruction:(1)It always occurs during the early stage after abdominal operation,mainly because of intestinal adhesions resulted from abdominal inflammation.(2)The main symptoms include abdominal distention and mild abdominal pain.Passage of flatus or stool happens in some patients.Although the signs are typical,strangulation seldom occurs.(3)Conservative treatments including somatostatin are effective.Surgical intervention is imperative once intestinal necrosis or peritonitis happen.
【 Key words】 Inflammatory bowel disease; Postoperative complication; Intestinal obstruction; Conservative treatment
术后早期炎性肠梗阻(early postoperative inflammatory small bowel obstruction,EPISBO)为腹部外科手术常见并发症之一，其诊断主要依靠临床、体征，并排除其他梗阻原因而获得。病情常反复发作，病程长。患者在发病前一般均接受过1次或多次手术，体质情况差。对这类患者再梗阻时是否需要手术解除、手术指征如何、何时手术是值得探讨的问题，如处理不当会引起多发肠瘘、重症感染等严重并发症。现将我科1995年以来收治术后早期炎性肠梗阻9例的治疗情况，总结报告如下。
临床资料
一、一般资料
本组9例早期炎性肠梗阻的诊断条件为：(1)腹部手术后3～30d有明显的肠梗阻表现；(2)无肠绞窄的情况，无明显腹腔感染、脓肿；(3)无低血钾、腹膜后创伤等致麻痹性肠梗阻的因素存在。有4例由外院手术后转来本院，另5例本院手术后发生。男性7例，女性2例；平均年龄49．2岁。发病前有1次腹部手术史者4例，2次腹部手术史者3例，3次腹部手术史者2例。前次手术类别以胃手术和肠粘连松解较多，共5例，其余为阑尾切除术后2例，胆道术后1例，妇科术后1例。术后早期肠梗阻的临床表现，本组9例以腹胀、腹痛和腹部轻压痛为主，7例有恶心、呕吐，6例停止肛门排气排便，2例有肠鸣音亢进，1例可见肠型。X线腹部平片9例均表现为阶梯状液平面的典型机械性肠梗阻征象。本组5例有营养不良，表现为体重下降、低蛋白血症。术后出现肠梗阻时间都在4周以内。
二、治疗
本组8例予保守治疗，具体为胃肠减压，应用肾上腺皮质激素和生长抑素，维持水电解质和酸碱平衡，肠外营养支持，同时密切观察病情变化。保守治疗时间平均21．5d(12～29d)，均治愈。另1例(为阑尾切除术后28d发病者)先行手术治疗，在分离粘连时引起了多发性肠破裂和术后肠瘘，后改保守治疗，历时71d治愈。
讨论
术后早期炎性肠梗阻“早期”的期限有多长一直存在争议[1-4]，倾向于4周者占大多数，本组9例均在术后4周内发生，故我们亦同意此观点。因为太早亦不能排除原发病和手术的影响；太迟与后期其它因素引起的肠梗阻难以区别。