Cvetković Danica, Živković Vladimir, Damjanjuk Irina, Nikolić Slobodan
Institute of Forensic Medicine, University of Belgrade - School of Medicine, 31a Deligradska str, Belgrade, 11000, Serbia.
Forensic Sci Med Pathol. 2019 Mar;15(1):136-139. doi: 10.1007/s12024-018-0007-6. Epub 2018 Aug 4.
Two cases of intestinal obstruction in the mentally disabled are reported. The first case concerns 61-year-old oligophrenic woman who resided in a nursing home, where she was found hypotensive and unresponsive. Upon opening the peritoneal cavity at autopsy, extremely dilated (measuring on average 12 cm in diameter) loops of the colon emerged- they compressed the small intestine and other intraperitoneal organs, lifting both hemidiaphragms deep into the pleural cavity. Lodged firmly into the rectum, a partly disintegrated sanitary pad was found. In the second case, young man with Down syndrome was found dead in his room in a nursing facility. At autopsy, a massively dilated stomach and intestinal loops emerged, interposing one of the loops between the liver and right hemidiaphragm (pushing it to the 3rd intercostal space). This was caused by a volvulus - the cecum, the entire ascending colon and hepatic flexure were gangrenous, dilated (the maximum diameter was 15 cm) and twisted in a full circle around the mesenteric attachment. There were no signs of colon perforation. In both cases, intellectual disability was at the core of poor communication and delayed medical treatment, which led to a fatal outcome. Caregivers must be trained to recognize distress in the mentally disabled, especially since the symptoms and signs of gastrointestinal diseases may be subtle, or at least less recognizable. By performing careful physical examination medical staff should search more cautiously for these signs. Any suspicion of mistreatment or neglect of the mentally impaired requires a medico-legal investigation and autopsy.
报告了两例智障患者肠梗阻的病例。第一例涉及一名61岁的智力低下女性，她住在一家养老院，在那里被发现血压过低且无反应。尸检时打开腹腔，发现结肠极度扩张（平均直径达12厘米），这些扩张的结肠压迫小肠和其他腹腔内器官，将双侧膈肌向上顶入胸腔深部。在直肠内牢固地嵌塞着一块部分解体的卫生巾。第二例，一名患有唐氏综合征的年轻男子被发现死于护理机构的房间内。尸检时，发现胃和肠袢大量扩张，其中一个肠袢位于肝脏和右膈肌之间（将膈肌推至第三肋间间隙）。这是由肠扭转引起的——盲肠、整个升结肠和肝曲均已坏疽、扩张（最大直径为15厘米），并围绕肠系膜附着处扭转了一整圈。没有结肠穿孔的迹象。在这两例中，智力残疾是沟通不畅和延误治疗的核心问题，最终导致了致命的后果。护理人员必须接受培训，以便识别智障患者的痛苦，尤其是因为胃肠道疾病的症状和体征可能很细微，或者至少不那么容易识别。医务人员应通过仔细的体格检查更谨慎地寻找这些体征。任何对智障患者虐待或忽视的怀疑都需要进行法医学调查和尸检。
