Мезентериальный тромбоз представляет собой нарушение кровообращения в брыжеечных сосудах кишечника.
В большинстве случаев это осложнение после инфаркта миокарда, мерцательной аритмии или медленного сепсиса. Болезнь возникает из-за эмболии и тромбоза брыжеечных сосудов.
Патология поражает людей пожилого и среднего возраста, поскольку в сосудах происходят атеросклеротические изменения в течение всей жизни.
Тромб перекрывает просвет артерий или вен, что нарушает питание стенок кишечника, приводя к инфаркту пораженных тканей.
Тромбоз вен наблюдается гораздо реже, чем тромбоз артерий. В редких случаях диагностируется закупорка вен и артерий одновременно, эта форма называется смешанной.
Содержание
Код МКБ-10
Согласно международной классификации болезней (код по МКБ 10) мезентериальный тромбоз кодируется, как К55.0. Патология включена к острым сосудистым заболеваниям кишечника.
Почему нарушается ток крови?
Просвет сосудов может перекрываться первично или вторично. В первом случае причинами являются травмы, тромбозы и эмболии, а во втором – болезнь развивается в результате продолжительных изменений в стенках сосудов или вне их.
К первичным причинам относятся:
Травмы – сильные удары в область живота;
Инфаркт миокарда;
Аневризма сердца и прочие патологии сердечно-сосудистой системы.
Факторы патологии могут быть разными (эмболия, травмы или тромбоз), но все они приводят к ишемии кишечника.
К вторичным причинам принято относить следующие:
Стеноз атеросклеротического происхождения;
Понижение сердечной деятельности, параллельно происходит падение артериального давления;
Опухоли тонкого или толстого кишечника, сдавливающие артерии;
Операции на аорте, проводимая для реконструкции сосуда.
Как устроено кровоснабжение
Артерии и вены располагаются практически параллельно. От брюшной аорты отходят два крупных сосуда: верхняя и нижняя брыжеечные артерии. Они полностью снабжают кровью кишечник.
Схема кровоснабжения распределяется следующим образом:
Верхняя брыжеечная артерия
Нижняя брыжеечная артерия
Поперечно-ободочная кишка (70%)
Поперечно-ободочная кишка (30%)
Слепая кишка
Нисходящая кишка
Восходящая
Сигмовидная
Тонкий отдел кишечника
Прямая кишка
В 90% случаев мезентериальный тромбоз наблюдается в верхней брыжеечной артерии, в 10 – 15% массы закрывают просвет в нижней артерии.
Эмболы могут закрыть просвет брыжеечной артерии, попав в нее из сердца (если оторвется пристеночный тромб), из грудных и брюшных отделов аорты или в случае травм.
Тромботические массы могут образовываться и в венах. К их образованию ведут воспалительные процессы в кишечнике, застои в нижележащих сосудах, любые другие факторы, повышающие вязкость крови.
Какие бывают виды ишемии при мезентериальном тромбозе?
В медицинской практике выделяют три степени тяжести болезни. Они зависят от диаметра поражения мезентериальных сосудов и нарушения коллатерального потока.
Декомпенсированная форма – самая тяжелая стадия. Временной промежуток до 2 часов – обратимое время, когда можно восстановить кровоснабжение. Промежуток от 4 до 6 часов – частично обратимое, прогноз не всегда благоприятен, ухудшение может наступить в любой момент, поскольку артериальный и венозный поток крови полностью нарушается. Свыше 6 часов наблюдается гангрена кишечника.
Субкомпенсированное нарушение кровоснабжения – эту форму можно спутать с другими болезнями. Острая сосудистая недостаточность выражена сходными симптомами.
Компенсированная степень – хроническая ишемия, при ней функцию кровотока берут на себя коллатерали.
Симптомы мезентериального тромбоза
Признаки тромбоза зависят от того, на каком уровне перекрыты брыжеечные артерии и от формы ишемии кишечника.
Больной внезапно чувствует сильную и острую боль, она возникает при субкомпенсированной форме. В случае декомпенсационной формы заболевания болезненные ощущения ослабевают, и происходит мнимое улучшение, что объясняется отмиранием нервных окончаний (ни одна артерия больше не кровоснабжает кишечник);
Проявления перитонита – во время пальпации ощущаются напряженные мышцы, живот плотный и вздутый;
У больных нарушается дефекация – на начальной стадии субкомпенсированной формы вероятен жидкий стул, в котором видны примеси крови и слизи. При декомпенсации наблюдается некроз тканей, моторика кишечника пропадает и стул исчезает;
Интоксикация организма – наблюдается, если у пациента началась гангрена (прогноз в большинстве случаев неблагоприятен). Для данного симптома характерна рвота, тошнота, понижение артериального давления;
Шоковое состояние – у человека синеют губы и бледнеют кожные покровы, отмечается повышенное сердцебиение и нитевидный пульс.
Зона тромба
Диагностика
Чем быстрее будет поставлен точный диагноз, тем больше шансов на положительный исход лечения больного. Врачу необходимо собрать анамнез болезни, расспросить пациента о характере и времени появления болей, частоте стула. Это поможет определиться в выборе хирургического лечения.
В анализе крови наблюдается ярко выраженный лейкоцитоз (более 20 * 10 9 л). На рентгенограмме брюшной полости заметны тонкокишечные уровни жидкости.
Основными способами диагностики являются:
Лапароскопия – один из решающих методов, позволяет быстро осмотреть кишечник, установить непроходимость брыжейки и определить стадию ишемии, ведь в запасе у хирурга не более двух часов;
УЗИ органов живота – процедура оказывает помощь в дифференциальной диагностике, чтобы исключить возможность других заболеваний;
Селективная ангиография – процедура, устанавливающая уровни перекрытия артерий, необходима для оказания неотложной помощи. Но многие хирурги сходятся во мнении, что нецелесообразно затрачивать время на ангиографию, при стремительном течении мезентериальный тромбоз окончится летально.
Лапароскопия кишечника
Если нет возможности провести лапароскопию, то хирурги проводят лапаротомию – операция, во время которой делается большой разрез по средней линии живота.
В процесс лапаротомии врачи производят следующие манипуляции:
Пальпируют сосуды, чтобы определить местонахождение тромба (каждая мезентериальная артерия и вена должны быть осмотрены хирургом);
Выявляют границы жизнеспособных тканей кишечника;
Полностью осматривают органы брюшной полости, оценивая их состояние;
Выявляют пульсацию артерий, устанавливая состояние кровоснабжения кишечника.
Дифференциальная диагностика
Мезентериальный тромбоз легко спутать с другими болезнями, что связано с размытой клинической картиной.
Патология схожа со следующими заболеваниями:
Панкреатит острой формы;
Острый холецистит;
Аппендицит;
Схожие признаки характерны и для острой кишечной непроходимости.
Диагностика мезотромбоза — введение катетера
Как лечат мезотромбоз?
Заболевание поддается только хирургическим методам лечения. Операцию проводят под эндотрахеальным наркозом. При первых признаках патологии больному требуется неотложная помощь.
Спазмолитические и обезболивающие препараты стирают симптомы и затрудняют постановку диагноза, это затягивает возможность проведения операции и что приводит к летальному исходу.
Оперативное вмешательство состоит из важных, обязательных для выполнения частей:
Врач должен определить пульсацию в артериях, находящихся на границах с пораженными кишками.
В процессе операции хирург при необходимости проводит резекцию – удаляет участок некротической кишки, затем сшивает верхнюю и нижнюю границы.
Если некротических изменений еще нет, то доктор должен найти способ, чтобы восстановить кровоснабжение кишечника и снять ишемию с пораженного участка.
Восстановление кровоснабжения может проходить двумя способами:
Хирург аккуратно выдавливает тромб из сосудов (артерии или вены) пальцами;
Между крайними границами затромбированного участка создается обводной шунт.
В период восстановления после оперативного вмешательства больному назначают антикоагулянты, средства разжижающие кровь («Гепарин»). Терапия данными препаратами проводится под регулярным контролем протромбированного индекса и МНО.
Если некротический участок кишечника удален (например: часть восходящей или тонкой кишки), а нормальное кровоснабжение не восстановлено, то в 80 % случаев ситуации оканчиваются летальным исходом.
Прогноз
Заболевание выявляется во время операций гораздо чаще, чем регистрируется. Дело в том, что клиника мезентериального тромбоза схожа со многими другими патологиями. Она маскируется под видом аппендицита, холецистита, кишечной непроходимости. Времени не всегда хватает, чтобы поставить правильный диагноз.
По данным патологоанатомов мезентериотромбоз составляет до 2,5% случаев. Если операция была проведена в течении первых часов с момента возникновения тромба, то велика вероятность выздоровления.
Если хирургическое вмешательство было проведено после 12 часов, то вероятность смертельного исхода – до 90 %.
Это группа сходных по течению и прогнозу патологических состояний, обусловленных нарушениями кровотока в артериальном, венозном или микроциркуляторном русле брыжеечных сосудов. Данная патология относится к разряду тяжелейших заболеваний, с которыми приходится сталкиваться хирургу в своей практической деятельности, и сопровождается в настоящее время крайне высокой летальностью (67-92%). Неудовлетворительные результаты лечения обусловлены, в первую очередь, поздней диагностикой и неадекватной хирургической тактикой.
Острые нарушения мезентериального кровообращения чаще встречаются у пациентов пожилого и старческого возраста. Хотя средний возраст больных составляет около 70 лет, это не исключает возможность развития заболевания и у молодых людей. Доля умерших от инфаркта кишечника в возрасте до 40 лет составляет около 10%, причём половина умерших моложе 30 лет. Среди больных заметно преобладают женщины. В последние годы острые нарушения мезентериального кровообращения стали встречаться чаще, что связано как с увеличением продолжительности жизни людей, так и с распространением врождённых и приобретённых тромбофилических состояний.
Этиология и патогенез [ править ]
Среди практических хирургов до настоящего времени бытует два мифа относительно острых нарушений мезентериального кровообращения. Первый: «Такое заболевание существует, но встречается оно крайне редко». Второй: «Если у больного развился мезентериальный тромбоз, то шансов на выздоровление практически нет». Обе точки зрения, безусловно, имеют определённые основания, однако далеко не всегда соответствуют действительности.
Число умерших от инфаркта кишечника превышает число летальных исходов от такого распространённого заболевания, как острый аппендицит. К этим цифрам необходимо приплюсовать благоприятные исходы лечения и случаи наступившей спонтанно или под действием консервативной терапии компенсации или субкомпенсации мезентериального кровотока и тогда становится ясно, что эта патология вовсе не относится к разряду казуистических.
Возникновение инфаркта кишечника связано с окклюзией магистральных брыжеечных артерий и вен, а также нарушениями на уровне микроциркуляторного русла при проходимых мезентериальных сосудах в результате резкого снижения перфузии кишечной стенки вследствие различных причин. Среди больных с развившемся инфарктом кишечника доля больных с окклюзионными нарушениями мезентериального кровообращения составляет около 90%. Наиболее часто наблюдают эмболии, артериальный тромбоз, реже — тромбоз брыжеечных вен. Необходимо учитывать, что истинная частота неокклюзионных нарушений значительно выше 10%, однако у данной категории больных на фоне интенсивной терапии по поводу различных иных тяжёлых заболеваний часто наступает компенсация мезентериального кровотока без нарушений жизнеспособности кишечника, в связи с чем верификация истинной распространённости данного вида патологии затруднена.
Окклюзионные нарушения мезентериального кровообращения
а) Эмболия мезентериальных артерий встречается наиболее часто. Основные заболевания, при которых происходит формирование тромбоэмболов в левых отделах сердца и аорте — врождённые и приобретённые пороки сердца, инфаркт миокарда, нарушения сердечного ритма, аневризмы сердца и аорты, атеросклеротические поражения сердца и сосудов. Эмболии мезентериальных артерий нередко сопровождаются эмболиями других артерий большого круга кровообращения, что значительно ухудшает прогноз лечения.
Инфаркт кишечника чаще всего развивается при эмболии устья или ствола верхней брыжеечной артерии. Большая частота эмболии верхней брыжеечной артерии по сравнению с нижней (в 20-40 раз) объясняется более высоким расположением сосуда, острым углом отхождения от аорты, большим диаметром просвета. Безусловно, эмболия нижней брыжеечной артерии встречается чаще, чем диагностируется, но проходит незамеченной вследствие компенсации кровотока через хорошие коллатеральные связи с системами верхней брыжеечной и внутренних подвздошных артерий.
б) Тромбоз мезентериальных артерий по частоте занимает второе место после эмболий. Тромбоз может локализоваться на одном или нескольких уровнях артериальной системы брыжейки. Сосудистая операция выполнима лишь при поражении на уровне ствола верхней брыжеечной артерии.
в) Сдавление (прорастание) мезентериальных артерий и вен злокачественными опухолями с последующим тромбозом наблюдают при метастазах рака желудка или поджелудочной железы в корень брыжейки.
г) Сочетанная окклюзия артерий и вен кишечника наблюдается при травме с их отрывом или при прошивании обоих сосудов, а также при относительно больших сроках заболевания, когда к окклюзии артерии или вены присоединяется вторичный тромбоз другого сосуда.
Неокклюзионные нарушения мезентериального кровообращения
При неокклюзионных нарушениях мезентериального кровотока расстройства микроциркуляции в кишечнике возникают первично и бывают связаны с целым рядом патогенетических факторов. Первостепенное значение при этом имеют падение перфузионного давления и ангиоспазм. Давление в мезентериальных артериях резко снижается в результате малого сердечного выброса и выраженной артериальной гипотензии, особенно при стенозе устья верхней брыжеечной артерии. Комбинация факторов, приводящих к неокклюзионному инфаркту кишечника, может быть самой разнообразной.
Клинические проявления [ править ]
Клинические признаки в первую очередь зависят от вида нарушения мезентериального кровообращения, распространённости поражения и стадии заболевания. Наиболее яркую и характерную клиническую картину наблюдают при острых нарушениях артериального мезентериального кровообращения, особенно при эмболии, которую и считают самой частой причиной заболевания.
Начало заболевания характеризуется внезапным, неожиданным для больного появлением сильных, нестерпимых болей в животе. Эти боли возникают без каких-либо продромальных проявлений, на фоне вполне удовлетворительного самочувствия. В анамнезе у таких пациентов обычно имеется эмбологенное заболевание сердца. Наиболее жестокие боли характерны для начала заболевания в стадии ишемии, которая длится около 6 ч.
Боли в животе — основной и наиболее яркий симптом заболевания. Обращают внимание крайне беспокойное поведение больного, стоны, крики, мольбы о помощи. Больного сложно даже просто осмотреть, он мечется, подтягивает ноги к животу, принимает коленно-локтевое положение. Кожные покровы становятся бледными, выступает холодный пот, на лице — гримаса ужаса. Для заболевания характерна выраженная тахикардия. При аритмиях дефицит пульса достигает 50-60 в минуту. АД повышается на 30-40 мм рт.ст. (симптом Блинова). Подобная реакция особенно характерна для эмболии ствола верхней брыжеечной артерии. У больных с острым инфарктом миокарда заболевание, напротив, может начинаться с коллапса.
Интенсивность болей сравнима с болевым синдромом при странгуляционной кишечной непроходимости. Характерной особенностью болей в этот период служит отсутствие обезболивающего эффекта даже от морфина. Тяжесть состояния в этот период определяется в основном болевым шоком и гемодинамическими нарушениями. Для стадии ишемии характерна локализация болей в эпигастральной области, что связано с раздражением солнечного и верхнебрыжеечного сплетений. В последующем боли перемещаются в район месторасположения поражённой кишки. Несоответствие между выраженным болевым синдромом и отсутствием перитониальной симптоматики очень часто выступает на этой стадии предпосылкой для диагностических ошибок.
При ограниченных поражениях кишечника острота болевого синдрома может быть выражена в меньшей степени, поведение больных более спокойное.
Другой характерный симптом — ишемическое опорожнение кишечника. В самом начале заболевания рефлекторно возникают одно-двукратная рвота желудочным содержимым и жидкий стул за счёт спастического сокращения кишечной трубки в ответ на острую ишемию. У ряда больных в стадии ишемии отмечают длительный понос, что приводит к диагностическим ошибкам. В каловых массах через несколько часов от начала заболевания появляется кровянистая слизь, напоминающая малиновое желе. Симптом наиболее выражен в стадии инфаркта.
В стадии инфаркта (обычно она начинается спустя 6-12 ч от начала заболевания и продолжается в течение 12-24 ч) боли несколько уменьшаются вследствие некротических изменений в стенке кишки и гибели болевых рецепторов. Поведение больных становится более спокойным, проходит чувство страха. Появляется лёгкая эйфория, обусловленная развивающейся интоксикацией. В рвотных массах и стуле наблюдают примесь крови. АД нормализуется, пульс, наоборот, учащается. Число лейкоцитов повышается до 20-40×109/л.
В стадии перитонита начинают преобладать боли по всему животу. Они усиливаются при перемене положения тела, кашле, пальпации, что связано с развитием воспалительных изменений в брюшной полости. В отличие от стадии ишемии и инфаркта болевые ощущения уменьшаются при назначении наркотиков. Общее состояние больных резко ухудшается в связи с резко выраженным эндотоксикозом, обезвоживанием, нарушениями водно-электролитного баланса, развитием метаболического ацидоза. Больные адинамичны, у некоторых появляется бред. Рвотные массы приобретают неприятный гнилостный запах. Наступает задержка стула и газов.
Острые сосудистые болезни кишечника: Диагностика [ править ]
Объективные симптомы при исследовании живота
В первые часы заболевания живот не вздут, конфигурация его не изменена, брюшная стенка участвует в акте дыхания. Симметричное вздутие живота возникает в поздней стадии заболевания — при развитии перитонита.
Для стадии ишемии, особенно в первые часы заболевания, характерно отсутствие болезненности при глубокой пальпации живота. В стадии инфаркта выраженная пальпаторная болезненность наблюдается у всех больных. Обращает внимание несоответствие зоны болезненности локализации спонтанных болей в животе. В стадии перитонита преобладают боли по всему животу, болезненность определяется уже при поверхностной пальпации.
Особенностью клинического проявления перитонита при острых нарушениях мезентериального кровообращения считают более позднее, по сравнению с другими формами вторичного перитонита, возникновение симптома Щёткина- Блюмберга. Именно поэтому диагностику нельзя строить только на наличии этого признака. Мышечное напряжение локализуется вначале соответственно месту поражения кишечника или внизу живота. Следует помнить, что перитонит у таких больных обычно имеет распространённый характер, так как поражаются большие участки кишечника, а процесс деструкции протекает быстро. Поэтому локальные проявления перитонита не отражают в должной мере его распространённость.
В стадии инфаркта диагностируют патогномоничный для заболевания симптом Мондора, который заключается в пальпации умеренно болезненного инфильтрата мягкоэластической консистенции без чётких границ. Симптом обусловлен резким отёком поражённой инфарктом кишки и брыжейки. Определение симптома Мондора в правой подвздошной области может явиться причиной ошибочного диагноза аппендикулярного инфильтрата.
В начале заболевания может определяться обычная или даже усиленная перистальтика, что свидетельствует о жизнеспособности кишечника. Однако в дальнейшем она очень скоро ослабевает. На стадии гангрены кишечника характерный признак — полное отсутствие кишечных шумов, при этом над брюшной полостью выслушиваются сердечные тоны.
В стадии инфаркта начинает определяться притупление в отлогих местах живота, где скапливается выпот.
Большое значение имеет пальцевое ректальное исследование, при котором можно обнаружить кровянистые выделения.
Ангиографическое исследование — специфический и наиболее объективный метод диагностики данного заболевания. Необходимую информацию получают с помощью аортографии в двух проекциях (прямой и боковой) с последующей селективной мезентерикографией. Наличие дефектов контрастирования и отсутствие заполнения ствола и ветвей мезентериальных артерий подтверждают диагноз вне зависимости от стадии заболевания. Окклюзия сосуда может быть выявлена ещё до развития инфаркта кишечника. Выделяют артериальную, капиллярную и венозную фазы прохождения контрастного вещества через сосудистое русло брыжейки и кишечной стенки. Каждая из них даёт определённую информацию и важна в диагностике различных видов нарушений мезентериального кровообращения. Существует возможность сделать заключение о жизнеспособности стенки кишки. Метод высокоинформативен, но, к сожалению, использование его в экстренных ситуациях возможно только в специализированных лечебных учреждениях.
Лапароскопия может быть проведена практически в каждом хирургическом стационаре, но из этого не следует, что она всегда необходима при подозрении на данное заболевание. Нет никакой необходимости прибегать к эндоскопии, когда диагноз перитонита не вызывает сомнений. В такой ситуации его причина должна быть уточнена во время экстренного хирургического вмешательства. Применение лапароскопии оправдано, если у хирурга имеются сомнения в необходимости неотложной лапаротомии.
Другие современные методы исследования, такие как УЗИ, КТ, МРТ, а также обзорная рентгенография органов брюшной полости, несмотря на возможность выявления отдельных диагностически значимых признаков, в основном могут быть использованы для исключения иной ургентной абдоминальной патологии.
При невозможности использовать специальные методы диагностики и обоснованном подозрении на острое нарушение мезентериального кровообращения показана диагностическая лапаротомия.
Дифференциальный диагноз [ править ]
Острые сосудистые болезни кишечника: Лечение [ править ]
Лечение острых нарушений мезентериального кровообращения в подавляющем большинстве случаев предполагает проведение экстренного хирургического вмешательства, которое должно быть предпринято, как только установлен диагноз или возникло обоснованное подозрение на это заболевание. Только активная хирургическая тактика даёт реальные шансы на спасение жизни больных. Консервативные методы лечения должны использоваться в сочетании с оперативными, дополняя, но ни в коем случае не заменяя их. Терапевтические и реанимационные мероприятия, проводимые в ситуациях, когда возможно развитие неокклюзионных нарушений мезентериального кровотока, эффективны лишь до появления клинической симптоматики со стороны органов брюшной полости и могут рассматриваться только в качестве профилактических мероприятий.
Оперативное вмешательство должно решать следующие задачи:
1) восстановление мезентериального кровотока;
2) удаление нежизнеспособных участков кишечника;
3) борьбу с перитонитом.
Характер и объём хирургического вмешательства в каждом конкретном случае определяются рядом факторов: механизмом нарушения мезентериального кровообращения, стадией заболевания, локализацией и протяжённостью поражённых участков кишечника, общим состоянием больного, хирургическим оснащением и опытом хирурга. Все виды операций сводятся к трём подходам:
— комбинации этих способов.
Очевидно, что сосудистые операции наиболее целесообразны. Речь, как правило, идёт о вмешательстве на верхней брыжеечной артерии. Восстановление кровотока по мезентериальным артериям в течение первых 6 ч с момента окклюзии обычно приводит к предотвращению гангрены кишечника и восстановлению его функций. Однако и при поступлении больного в более поздние сроки, когда наступают необратимые изменения более или менее протяжённого участка кишечника, помимо его удаления может понадобиться операция на мезентериальных сосудах для восстановления кровотока в пока ещё жизнеспособных его отделах. Вот почему в большинстве случаев приходится сочетать сосудистые операции и резекционные вмешательства.
Профилактика [ править ]
Предотвратить возникновение тромбоэмболий артериального русла кишечника можно путём своевременного хирургического лечения аортальных и митральных пороков сердца, адекватной антиаритмической терапии и длительным применением непрямых антикоагулянтов у пациентов с постоянной формой мерцательной аритмии. Профилактика атеротромбоза заключается в постоянном приёме дезагрегантных средств. Для предупреждения венозного мезентериального тромбоза необходимо выявлять и коррегировать тромбофилические состояния.
Прочее [ править ]
Острые нарушения мезентериального кровообращения, протекающие с декомпенсацией кровотока, без оперативного лечения заканчиваются смертью больных. До 75% больных погибают на 1-4-е сут с момента начала заболевания. В основном это больные с эмболиями, артериальным тромбозом и неокклюзионными видами нарушения мезентериального кровообращения, в более поздние сроки — больные с венозным тромбозом.
Результаты оперативного лечения всё ещё далеки от удовлетворительных. Даже в крупных клиниках летальность составляет 67% и выше. Лучшие результаты получены после сосудистых операций в первые часы заболевания — до 75% выздоровевших. Оптимизм внушает факт постоянного улучшения с течением времени непосредственных результатов лечения.
В отдалённом послеоперационном периоде снижение массы тела отмечают около трети пациентов, синдром короткой кишки — около 20%. У остальных на фоне диеты и поддерживающей ферментной терапии наступает компенсация пищеварения. Выживаемость через 2 года составляет около 70%, через 5 лет — 50%. Причина летальных исходов в этом периоде — в основном сердечно-сосудистые заболевания. Длительный приём непрямых антикоагулянтов (варфарин и др.) в профилактических дозах улучшает отдалённые результаты.
Что относится к симптомам мезентерального тромбоза, риск и компоненты терапии
Такая болезнь в большинстве случаев приводит к смерти, если вовремя не оказать помощь и не провести оперативную терапию. Симптомы мезентериального тромбоза, причины его развития и лечение – информация, которую полезно знать каждому.
Характеристика заболевания
В традиционной медицине диагноз #171;мезентериальный тромбоз#187; обозначается кодом по МКБ-10 К-55.0, сюда же включены сосудистые патологии кишечника.
Патология поражает верхнюю брыжеечную артерию и всего в 10% случаев #8212; нижнюю. Диагноз #171;тромбоз кишечника#187; встречается в одинаковом соотношении у мужчин и у женщин. Развивается преимущественно в возрасте от 50 лет.
Рекомендация! В среднем и пожилом возрасте проходить полный профилактический осмотр не реже одного раза в год.
Классификация
На данный момент заболевание делят на несколько групп:
Каждый тип патологии имеет характерные клинические проявления. Мезентериальный тромбоз по симптоматике схож с острыми расстройствами желудочно-кишечного тракта. И в большинстве случаев нуждается в экстренной медицинской помощи.
К тромбообразованию могут привести два процесса: эмболия тромба, который сформировался не в кишечнике, а в другой области кровотока, либо развитие тромба из сгустка крови или атеросклеротической бляшки. Выделяются факторы, которые могут спровоцировать развитие заболевания:
Для снижения рисков развития патологии необходимо сократить или исключить большую часть вышеперечисленных факторов и регулярно проходить профилактические осмотры.
Симптоматика
Тромбоз сосудов брыжеечных артерий имеет яркую клиническую картину, к числу основных признаков заболевания относят:
интенсивный резкий болевой синдром в области живота, локализация зависит от этапа развития патологии и от степени поражения;
Совет! При отсутствии движений или в положении лежа на спине боль облегчается.
Диагностика тромбоза мезентериальных сосудов
Облегчает выявление патологии характерное для брыжеечного тромбоза сочетание с сердечно-сосудистыми заболеваниями.
В современных больницах при подозрении на патологический процесс в сосудах кишечника в обязательном порядке назначается ряд лабораторных и клинических исследований.
После проведения комплекса диагностических мер лечащий врач поставит точный диагноз и назначит подходящий терапевтический курс.
Дифференциальная форма диагностики
Тромбоз необходимо дифференцировать от:
язвы двенадцатиперстной кишки и желудка;
острого аппендицита;
непроходимости кишечника по механическому типу;
острого течения холецистита, панкреатита.
Именно поэтому при поступлении больного с симптоматикой, схожей с тромбозом, его госпитализируют в хирургическое отделение.
Для лечения мезентерального тромбоза только в редких случаях назначается консервативный метод, в основном – хирургический.
Назначаются препараты из группы дезагрегантов: трентал, гемодез. Консервативное лечение проходит под контролем лечащего врача.
На более поздних стадиях диагностики, когда болезнь запущена или произошел некроз кишечника, то обязательно проводится операции. Хирургическое вмешательство такого рода проходит под общим наркозом.
Если некротические изменения кишечника не выявлены:
Эндартерэктомия, в ходе которой происходит вычищение артерий от атеросклеротических бляшек.
При некрозе кишечника единственный выход – резекция омертвевшей области, сшивание неповрежденных частей. После оперативного вмешательства все пациенты помещаются в реанимацию. На послеоперационном этапе питание больного производится через капельницы.
Прогноз тромбоза при своевременном обращении, правильной диагностике и качественное лечении, как правило, положительный.
Следует отметить, что из-за сложности выявления и поздних обращений смертность при тромбозе данной формы составляет порядка 70%.
Профилактика тромбоза
Меры по предотвращению развития патологии и дополнительные рекомендации при мезентеральном тромбозе схожи и заключаются в следующем:
Что относится к симптомам мезентерального тромбоза, риск и компоненты терапии
Такая болезнь в большинстве случаев приводит к смерти, если вовремя не оказать помощь и не провести оперативную терапию. Симптомы мезентериального тромбоза, причины его развития и лечение – информация, которую полезно знать каждому.
Характеристика заболевания
В традиционной медицине диагноз #171;мезентериальный тромбоз#187; обозначается кодом по МКБ-10 К-55.0, сюда же включены сосудистые патологии кишечника.
Патология поражает верхнюю брыжеечную артерию и всего в 10% случаев #8212; нижнюю. Диагноз #171;тромбоз кишечника#187; встречается в одинаковом соотношении у мужчин и у женщин. Развивается преимущественно в возрасте от 50 лет.
Рекомендация! В среднем и пожилом возрасте проходить полный профилактический осмотр не реже одного раза в год.
Классификация
На данный момент заболевание делят на несколько групп:
Каждый тип патологии имеет характерные клинические проявления. Мезентериальный тромбоз по симптоматике схож с острыми расстройствами желудочно-кишечного тракта. И в большинстве случаев нуждается в экстренной медицинской помощи.
К тромбообразованию могут привести два процесса: эмболия тромба, который сформировался не в кишечнике, а в другой области кровотока, либо развитие тромба из сгустка крови или атеросклеротической бляшки. Выделяются факторы, которые могут спровоцировать развитие заболевания:
Для снижения рисков развития патологии необходимо сократить или исключить большую часть вышеперечисленных факторов и регулярно проходить профилактические осмотры.
Симптоматика
Тромбоз сосудов брыжеечных артерий имеет яркую клиническую картину, к числу основных признаков заболевания относят:
интенсивный резкий болевой синдром в области живота, локализация зависит от этапа развития патологии и от степени поражения;
Совет! При отсутствии движений или в положении лежа на спине боль облегчается.
Диагностика тромбоза мезентериальных сосудов
Облегчает выявление патологии характерное для брыжеечного тромбоза сочетание с сердечно-сосудистыми заболеваниями.
В современных больницах при подозрении на патологический процесс в сосудах кишечника в обязательном порядке назначается ряд лабораторных и клинических исследований.
После проведения комплекса диагностических мер лечащий врач поставит точный диагноз и назначит подходящий терапевтический курс.
Дифференциальная форма диагностики
Тромбоз необходимо дифференцировать от:
язвы двенадцатиперстной кишки и желудка;
острого аппендицита;
непроходимости кишечника по механическому типу;
острого течения холецистита, панкреатита.
Именно поэтому при поступлении больного с симптоматикой, схожей с тромбозом, его госпитализируют в хирургическое отделение.
Для лечения мезентерального тромбоза только в редких случаях назначается консервативный метод, в основном – хирургический.
Назначаются препараты из группы дезагрегантов: трентал, гемодез. Консервативное лечение проходит под контролем лечащего врача.
На более поздних стадиях диагностики, когда болезнь запущена или произошел некроз кишечника, то обязательно проводится операции. Хирургическое вмешательство такого рода проходит под общим наркозом.
Если некротические изменения кишечника не выявлены:
Эндартерэктомия, в ходе которой происходит вычищение артерий от атеросклеротических бляшек.
При некрозе кишечника единственный выход – резекция омертвевшей области, сшивание неповрежденных частей. После оперативного вмешательства все пациенты помещаются в реанимацию. На послеоперационном этапе питание больного производится через капельницы.
Прогноз тромбоза при своевременном обращении, правильной диагностике и качественное лечении, как правило, положительный.
Следует отметить, что из-за сложности выявления и поздних обращений смертность при тромбозе данной формы составляет порядка 70%.
Профилактика тромбоза
Меры по предотвращению развития патологии и дополнительные рекомендации при мезентеральном тромбозе схожи и заключаются в следующем:
Тромбоз мезентериальных сосудов кишечника
Тромбоз в венах встречается реже, чем в мезентериальных артериях. Смешанная форма, при которой происходит закупорка и вен, и артерий, наблюдается редко в слишком запущенных случаях.
Заболевание представляет трудности в диагностике. 1/10 часть летальных случаев от инфаркта кишечника приходится на лиц моложе 40 лет. Женщины более подвержены этому виду патологии, чем мужчины.
Особенности кровоснабжения кишечника
Верхняя мезентериальная артерия несет кровь к тонкому кишечнику, слепой, восходящей и большей части поперечно-ободочной кишкам. Она выполняет 90% поставок крови, поэтому поражение более распространенное и клинические тяжелое.
Нижняя брыжеечная артерия питает значительно меньший участок (30% поперечно-ободочной кишки, нисходящую, сигмовидную, прямую).
Венозный отток из кишечника направляется в воротную вену. Затруднение наступает при ее сужении от болезней печени. Коллатеральное кровообращение образуется группой портокавальных анастомозов между воротной и полыми венами. В худшем положении находится тонкий кишечник. Он не имеет развитой коллатеральной сети.
Откуда поступают тромбы и эмболы?
По артериальной системе эмбол может дойти до брыжейки:
Венозная кровь, имея обратное направление и наклонность к снижению скорости и повышению вязкости, более подвержена образованию собственных тромботических масс. К образованию тромбов в венах ведут:
Виды поражения сосудов кишечника
Классификация патологии включает разные стороны механизма поражения.
По причинам различают:
артериальный тромбоз и эмболию;
венозный тромбоз;
вторичный тромбоз мезентериальных сосудов при болезнях аорты;
нарушение проходимости сосудов из-за сдавления прорастающими опухолями;
последствие перевязки сосудов при хирургическом вмешательстве.
В зависимости от степени нарушения кровотока выделяют стадии:
Патологическими последствиями тромбоза могут быть:
ишемия кишечной стенки;
участок инфаркта;
разлитой перитонит.
Светлые участки — жизнеспособные ткани, темные — зона инфаркта
В хирургии выделяется стадия функциональной острой непроходимости мезентериальных сосудов, при которой нет органического поражения, а патологию вызывает временный спазм.
Максимальным поражающим фактором является травма живота. Компенсация не успевает развиться в полной мере. Включаются защитные механизмы повышения свертываемости крови, что утяжеляет состояние пациента.
Стадии и формы нарушения кровоснабжения
Любые нарушения кровообращения вызывают ишемию кишечника.
В компенсированную стадию происходит полное замещение нарушенного просвета сосуда поступлением крови по коллатералям. Такая форма характерна для хронической ишемии с постепенным течением заболевания.
Субкомпенсация тоже зависит от коллатералей, но имеет клинические проявления.
При декомпенсации весь период делится на 2 фазы:
в первые 2 часа возможны обратимые изменения с полным восстановлением кровоснабжения поврежденного участка;
через 4–6 часов наступает необратимая фаза гангренозных изменений.
Клинические признаки тромбоза
Симптомы проявления острого тромбоза мезентериальных сосудов определяются уровнем перекрытия кровообращения и формой ишемии.
Внимания требуют любые, даже кратковременные, боли в животе
Признаки преддтомбоза, вызванного артериальной недостаточностью, можно выявить при расспросе и уточнении жалоб пациента:
боли в животе по ходу кишечника становятся интенсивнее после еды, длительной ходьбы;
наклонность к неустойчивому стулу, чередованию поноса и запора;
неясное похудение.
Тромбоз мезентериальных вен протекает мягче и медленнее. Чаще является хроническим процессом.
Диагностика
Чтобы правильно поставить диагноз, врачу важно получить ответы на вопросы о начальных проявлениях, длительности болей, характеристике стула.
Решающим способом является диагностическая лапароскопия, которая позволяет осмотреть кишечник и уточнить стадию ишемических изменений, локализацию участка.
Лейкоцитоз со сдвигом формулы влево не дает определенной информации, поскольку он присущ многим заболеваниям. Повышенный уровень фермента лактатдегидрогиназы указывает на наличие некротизированных тканей.
Определенную помощь в дифференциальной диагностике может оказать УЗИ живота, рентгеноскопия. Готовить пациента и тратить время на ангиографию не рационально.
Проведение ревизии кишечника позволяет обнаружить тромб или участок ишемии
При отсутствии возможности в проведении лапароскопии врачи приступают к лапаротомии — операции с большим разрезом по средней линии живота:
осматривают (проводят ревизию) органы брюшной полости, кишечник;
пальпируют сосуды брыжейки с целью выявления тромба;
оценивают достаточность пульсации артерий;
определяют границы жизнеспособных тканей.
При тромбозе вен показана фибринолитическая терапия в первые 6 часов.
В ходе операции врач должен найти способы:
при отсутствии некротических изменений восстановить проходимость кровотока по сосуду для снятия ишемии с пораженного участка кишечника;
удалить измененную кишку или ее часть и сшить верхний и нижний концы.
Восстановление кровоснабжения проводится таким путем:
выдавливание тромба пальцами;
создание обводного шунта между верхним и нижним уровнем стеноза, минуя затромбированный участок.
В послеоперационном периоде больному назначаются большие дозы Гепарина для разжижения крови.
Ангиограмма кишечных артерий в экстренном случае затруднена, поскольку требует подготовки пациента
Как проявляется хроническая форма тромбоза
О хронической форме тромбоза следует думать у пациентов с сердечной недостаточностью, осложненным инфарктом миокарда. В клинике выделяют 4 стадии:
Прогноз
Смертельных случаев, по информации патологоанатомов, – 1–2,5% в общебольничной летальности. Это тромбозы в стадии инфаркта и разлитого перитонита. Позднее проведение операции (после 12 часов) означает высокую смертность (до 90%).
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