Difficulty Diagnosis of a Lethal Gastrointestinal Complication after Cardiac Surgery: Ischemia Bowel Combined with Gastrointestinal Hemorrhage

導致病患死亡的心臟手術後消化道併發症：腸系膜缺血合併消化道出血－診斷上的困難

邱韋欽(Wei-Chin Chiou) ； 陳美如(Mei-Zu Cheln) ； 劉殷佐(Yin-Tso Liu) ； 張士文(Shih-Wen Chang) ； 吳怡良(Yi-Liang Wu) ； 廖憲華(Hsien-Hua Liao)

《重症醫學雜誌》 9卷4期 (2008/12) Pp. 275-282

https://doi.org/10.30035/TCCM.200812.0007

摘要

對於心臟手術後的患者，消化道併發症的發生率大約是1%，其中以消化道出血最爲常見，而死亡率最高的則是急性腸系膜缺血。此篇敘述的案例是心臟手術後同時發生消化道出血與急性腸系膜缺血的併發症。以此案例而言，因爲臨床上心臟手術後的消化道併發症，在經驗上以消化道出血最爲常見，再加上抗凝血藥物使用的病史與內視鏡的確定診斷，症狀會被認爲是消化道出血所引起，治療的方法也會根據消化道出血來制定，但消化道出血與急性腸系膜缺血的治療方法不僅完全不同，更會因爲保守的支持性療法，造成急性腸系膜缺血早期診斷的困難與延遲，而使得死亡率更高。根據文獻的回顧與此案例的經驗，早期安排多層螺旋電腦斷層血管攝影，針對消化道出血的出血點偵測以及動脈血管攝影與栓塞有助益，也可利用腸壁的顯影不足來早期診斷腸系膜缺血，對於死亡率的降低，將扮演重要的角色。

關鍵字

腸系膜缺血 ； 消化道出血 ； 多層螺旋電腦斷層

並列摘要

Gastrointestinal complications following cardiac surgery are uncommon. However, among these complications, that with the highest incidence rate is gastrointestinal hemorrhage, whereas the highest mortality rate is associated with acute mesenteric ischemia. Here, we report a case of coronary artery disease which received coronary artery bypass grafting surgery. Following the patient's discharge from our hospital, gastrointestinal hemorrhage was noted. The clinical presentations were hematemesis and melena. The treatment of gastrointestinal hemorrhage entails adequate resuscitation and panendoscopy for hemostasis. It is also necessary to closely monitor indicators of the invasive treatment such as unstable hemodynamic status, blood transfusion requiring more than 5 units, and rebleeding after treatment. Owing to the coexistence of acute mesenteric ischemia and gastrointestinal hemorrhage in this patient, the treatment modality of gastrointestinal hemorrhage made the diagnosis of acute mesenteric ischemia more difficult and more time consuming (due to the symptoms and signs of gastrointestinal hemorrhage). Consequently, without early awareness and prompt treatment, such as laparotomy or endovascular management, mortality in patients with similar multiple conditions will increase dramatically. From a review of the literature, and on the basis of our experience, we have come to recognize the important role played by multi-detector row computed tomography (MDCT) angiography in diagnosing this difficult condition. The patient in the present study had gastrointestinal hemorrhage with unstable hemodynamic status after adequate resuscitation and angiography with endovascular treatment had been indicated, MDCT angiography enabled identification of the site of bleeding and also detected the poor circulation status of the bowel wall (this finding implying the poor mesenteric circulation). In order to improve the difficult diagnosis and high mortality associated with the type of condition observed in this patient, we suggest early MDCT angiography since it is both non-invasive and is able to detect multiple conditions.

並列關鍵字

Mesenteric ischemia ； Gastrointestinal hemorrhage ； Multi-detector row computed tomography