腸系膜上動(dòng)脈壓迫綜合征課件

腸系膜上動(dòng)脈壓迫綜合征

superiormesentericarterysyndrome（SMAS）1Patient`sdataName：陳X澆Sex：maleAge：16Admission

Date:2010.10.222ChiefcomplaintIntermittentvomiting6years,rccurrent1day.3Historyofpresentillness1.患者6年前，無明顯誘因出現(xiàn)嘔吐，嘔吐前有上腹部悶脹感，經(jīng)噯氣后嘔吐，悶脹癥狀才能緩解，1天數(shù)次。每年發(fā)作1~2次，月份約在4月~12月。2.解放軍180醫(yī)院：1.慢性胃炎，2.植物神經(jīng)功能紊亂。3.第一醫(yī)院：神經(jīng)性嘔吐。4.福建省立醫(yī)院：1.胃炎，2.腸易激綜合征可能。4PastMedicalHistoryDeniedhepatitis,tuberculosisandotherinfectiousdiseaseshistory.Denieddiabetes,hypertension,heartdisease,Deniedhistoryoftraumaandsurgicalhistoryanddeniedhistoryofbloodtransfusion,。Nohistoryofdrug、foodallergy.Unknownvaccinationhistory.5PhysicalexaminationnovaricoseveinonabdominalwallwithtendernessatcentralabdomenandatMcBurneypointnoreboundtendernesswithoutpalpation-lumpatabdomen,murphyssign(-)shiftingdullness(-).Bowelsounds4/min.Edemaoflowerextremities:no6Auxiliaryexamination2009.08.17Uppergastrointestinalcontrast：十二指腸淤積癥。胃炎；胃、小腸蠕動(dòng)較慢20100921Uppergastrointestinalcontrast：Consistentwithsuperiormesentericarterycompressionsyndrome7十二指腸：球部呈三角形，未見明確龕影及充盈缺損影，無壓痛、激惹現(xiàn)象；十二指腸降段和部分水平段迂曲擴(kuò)張，于水平段中部似可見一筆桿樣壓跡、粘膜未見破壞表現(xiàn)，升段未見異常8910Diagnosis

superiormesentericarterysyndrome11DifferentialDiagnosis根據(jù)患者嘔吐的臨床表現(xiàn)，應(yīng)該考慮哪些疾??？1.急性胃腸炎(Acutegastroenteritis)2.膽道蛔蟲:(Biliaryascariasis)3.先天性食管閉鎖：(Congenitalesophagealatresia)4.先天性肥厚性幽門狹窄(Congenitalhypertrophicpyloricstenosis)5.胃神經(jīng)官能征:(Stomachandneuroticsymptoms)12Treatment十二指腸空腸吻合術(shù)

duodenojejunostomy13Operation

全麻下取上腹切口，長10厘米，切開腹壁各層進(jìn)腹，見12指腸水平部膨大,於上腸系膜動(dòng)脈及腹主動(dòng)脈夾角處12指腸壓迫扁塌,行十二指腸空腸造瘺術(shù).14Discussion15解剖（一）分部與毗鄰1、十二指腸上部：起始處為腹膜內(nèi)位，其余為腹膜外位。長4~5cm前上方：肝、膽囊下方：胰頭、胰頸后方：膽總管、下腔靜脈胃十二指腸動(dòng)脈、肝門靜脈、、16十二指腸降部:腹膜外位器官。長約7~8cm。其內(nèi)面的內(nèi)后壁有十二指腸縱襞、十二指腸大乳頭和/或十二指腸小乳頭。前方：肝、小腸內(nèi)側(cè)：胰頭、胰管、膽總管外側(cè)：結(jié)腸右曲后方：右腎門、右腎血管、右輸尿管17十二指腸水平部：腹膜外位器官。長10~12cm。上方：胰頭和鉤突后方：右輸尿管、下腔靜脈和腹主動(dòng)脈前方：右側(cè)份與小腸袢相鄰，左側(cè)份有腸系膜根和其中的腸系膜上動(dòng)、

靜脈跨過。當(dāng)腸系膜上動(dòng)脈起點(diǎn)過低時(shí)，可能會壓迫十二指腸水平部而引起十二指腸郁積、擴(kuò)大甚至梗阻，稱十二指腸上動(dòng)脈壓迫綜合征18水平部：腹膜外位上方：胰頭，鉤突后方：右輸尿管，下腔靜脈，腹主動(dòng)脈前方：小腸袢，腸系膜根及上動(dòng)靜脈！十二指腸上動(dòng)脈壓迫綜合征（wilkie綜合征）：腸系膜上動(dòng)脈與腹主動(dòng)脈的夾角和水平部太擠造成的。19

十二指腸升部長2~3cm。以十二指腸空腸曲與空腸相續(xù)。位于十二指腸空腸曲左側(cè)、橫結(jié)腸系膜根下方的一條皺襞為十二指腸上襞（十二指腸空腸襞），是手術(shù)確認(rèn)空腸的始部。2021SuperiorMesentericArterySyndromeCompressionof3rdportionofduodenumbetweentheaortaandsuperiormesentericartery(SMA)NarrowingofanglebetweenSMAandaorta

SMAusuallyformsanangleof45degreeswiththeaorta

Females>males

Pathophysiology

222324Etiologies

Prolongedbedrestinsupineposition(bodycast,whole-bodyburns,surgery)

Substantialand,frequently,rapidweightloss

Anorexianervosaormalnutrition

Lossofabdominalmuscletone(asinpregnancy)Maybecongenital

Exaggeratedlumbarlordosis

SuperiorMesentericArterySyndrome25Clinicalfindings

Epigastricpain

Nausea

Repetitivevomiting

Abdominalcramping

Typicallyfindingsareworstinsupinepositionandmayberelivedbychangingtotheproneorleftlateraldecubituspositions

Associatedwithahigherthannormalincidenceofpepticulcerdiseaseandhyperchlorhydria

SuperiorMesentericArterySyndrome26Uppergastrointestinaltractseriesshowsdilatationofsecondportionofduodenum.Imagingfindings

27Uppergastrointestinalseriesshowingduodenaldilation(whitearrow）28ThemeasurementoftheSMA-aorultrasonographyimages.a.TheangleintheSMAScasewas7°.b.Theangleinthecontrolsubjectwas32°taangleonsagittalSMA-aorultrasonography29AxialCTscansoftheupperabdomenshowadilated2ndportionoftheduodenum(D)

justproximaltoanarrowedsegmentofthe3rdportionoftheduodenum(greenarrow)

compressedbetweenthesuperiormesentericartery(redarrow)andtheaorta(blackarrow)

SMA>red30SurgicalTreatmentKeypoint：

（a）divisionofthesuspensoryligament.

（b）bypassoftheobstructedsegmentoftheduodenum.311.十二指腸血管前移術(shù)2.十二指腸空腸側(cè)側(cè)吻合3.十二指腸空腸Roux-en-Y吻合術(shù)3233病因病理

正常腸系膜上動(dòng)脈在L1水平開口于主動(dòng)脈，向下進(jìn)入腸系膜根部，十二指腸水平段、升段交界部于L3水