Rami Reddy Srinivas R, Cappell Mitchell S
Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI, 48073, USA.
Oakland University William Beaumont School of Medicine, Royal Oak, MI, 48073, USA.
Curr Gastroenterol Rep. 2017 Jun;19(6):28. doi: 10.1007/s11894-017-0566-9.
This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy.
SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
本研究旨在系统回顾小肠梗阻（SBO），重点关注诊断/治疗方面的近期变化。
在美国，SBO的发病率约为每年35万例。病因包括粘连（65%）、疝（10%）、肿瘤（5%）、克罗恩病（5%）以及其他（15%）。肠扩张主要发生在梗阻近端，主要源于吞咽空气，其次源于肠腔内液体蓄积。扩张会增加肠壁张力，减少黏膜灌注，导致细菌增殖，并降低肠壁抗张强度，从而增加肠穿孔风险。典型的临床四联征为腹痛、恶心呕吐、腹胀以及便秘至完全性肠梗阻。体格检查可能发现烦躁不安、急性病容以及脱水和脓毒症迹象，包括心动过速、发热、黏膜干燥、低血压/直立性低血压、腹胀以及肠鸣音减弱。严重的直接压痛、不自主肌卫、腹部僵硬和反跳痛提示进展期SBO，显著的白细胞增多、中性粒细胞增多、杆状核细胞增多以及乳酸酸中毒也是如此。鉴别诊断包括术后肠梗阻、麻醉性肠病、结肠假性梗阻、肠系膜缺血以及大肠梗阻。内科复苏包括静脉补液、纠正电解质异常、静脉使用抗生素、禁食以及鼻肠管吸引。口服和静脉注射泛影葡胺造影的腹部CT在检测/诊断SBO方面具有高度敏感性和特异性。SBO通常通过内科治疗缓解，但对于持续性完全性梗阻、肠穿孔、严重缺血或内科治疗后临床恶化的情况，则需要手术治疗，优先选择腹腔镜手术。总体死亡率为10%，但肠坏死/穿孔时死亡率会升至30%。SBO的关键在于早期诊断，强调腹部CT检查；积极的内科治疗，包括补液、使用抗生素和禁食；以及内科治疗失败时进行手术。
