Hayama Tamuro, Shioya Takeshi, Hankyo Meishi, Shimizu Takao, Shibuya Hajime, Komine Osamu, Watanabe Yoshimasa, Nanbu Kotaro, Yamada Taro
Department of Surgery, Saitama Citizens Medical Center.
J Nippon Med Sch. 2017;84(2):83-86. doi: 10.1272/jnms.84.83.
Primary volvulus of the small intestine associated with chylous ascites is very rare, with only four reported cases. In this paper, we report a new case of primary volvulus associated with chylous ascites.
The patient was a 70-year-old man. After experiencing bloating and abdominal pain for several hours, he called an ambulance and underwent an emergency examination at our hospital. Abdominal distension, pressure pain, and rebound tenderness were observed throughout his entire abdomen. The patient had a history of hypertension for which he was receiving oral treatment. Abdominal contrast-enhanced computed tomography (CT) revealed an edematous change in the intestinal membrane and volvulus of the small intestine. As findings suggestive of ischemia were observed in part of the intestines, emergency surgery was performed on the day of admission. Open surgery revealed approximately 500 mL of chylous ascites in the abdominal cavity. The small intestine had twisted 180° in a counter-clockwise direction at the root of the superior mesenteric artery, and the mesentery appeared milky white with edematous changes extending 75 to 240 cm from the ligament of Treitz. There was no evidence of intestinal necrosis; therefore intestinal resection was not performed. The volvulus of the small intestine was corrected. Moreover, because there was no other underlying disease observed, surgery was completed. The ascites collected during surgery revealed high levels of triglycerides at 332 mg/dL, and chylous ascites was diagnosed. An abdominal CT performed on the third day after surgery showed an improvement in intestinal edema, and primary volvulus of the small intestine associated with chylous ascites was diagnosed. Postoperative progress was good, and the patient was discharged on hospital day 10.
原发性小肠扭转合并乳糜性腹水非常罕见，仅有4例报道。在本文中，我们报告1例原发性小肠扭转合并乳糜性腹水的新病例。
患者为一名70岁男性。在经历数小时腹胀和腹痛后，他呼叫救护车并在我院接受急诊检查。全腹均观察到腹胀、压痛和反跳痛。患者有高血压病史，正在接受口服治疗。腹部增强计算机断层扫描（CT）显示肠膜水肿改变及小肠扭转。由于部分肠段观察到提示缺血的表现，入院当天即进行了急诊手术。开放手术发现腹腔内有约500 mL乳糜性腹水。小肠在肠系膜上动脉根部逆时针扭转180°，肠系膜呈乳白色，水肿改变从Treitz韧带延伸75至240 cm。没有肠坏死的证据；因此未进行肠切除。小肠扭转得到纠正。此外，由于未观察到其他基础疾病，手术完成。手术中收集的腹水显示甘油三酯水平高，为332 mg/dL，诊断为乳糜性腹水。术后第3天进行的腹部CT显示肠水肿有所改善，诊断为原发性小肠扭转合并乳糜性腹水。术后恢复良好，患者于住院第10天出院。
