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中华疝和腹壁外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (04) : 474 -478. doi: 10.3877/cma.j.issn.1674-392X.2024.04.024

病例分析

左侧膈膨升伴急性胃扭转、游离脾一例并文献综述
曾兵1, 甘文昌1, 彭绍勇1, 刘付恒1, 元志龙1, 周太成1, 陈双1,(), 李英儒1,()   
  1. 1. 510655 广州,中山大学附属第六医院普通外科、疝和腹壁外科;510655 广州,广东省结直肠盆底疾病研究重点实验室;510655 广州市黄埔区中六生物医学创新研究院
  • 收稿日期:2024-06-24 出版日期:2024-08-18
  • 通信作者: 陈双, 李英儒
  • 基金资助:
    国家临床重点专科,国家自然科学基金(81973858, 82172790); 广东省消化系统疾病临床医学研究中心项目(2020B1111170004); 广东省自然科学基金(2019A1515011200); 广东省医学科学技术研究基金(A2021061); 广东省中医药局科研课题(20191401,20211086,20221094); 广州市科技计划项目(2023A04J1816)

Left diaphragmatic eventration with acute gastric volvulus and wandering spleen: A case report and literature review

Bing Zeng, Wenchang Gan, Shaoyong Peng   

  • Received:2024-06-24 Published:2024-08-18
引用本文:

曾兵, 甘文昌, 彭绍勇, 刘付恒, 元志龙, 周太成, 陈双, 李英儒. 左侧膈膨升伴急性胃扭转、游离脾一例并文献综述[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(04): 474-478.

Bing Zeng, Wenchang Gan, Shaoyong Peng. Left diaphragmatic eventration with acute gastric volvulus and wandering spleen: A case report and literature review[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2024, 18(04): 474-478.

膈膨升是一种罕见的膈肌病变,其发病率约为0.05%,男性、左侧较为常见[1]。该病变最初由Jean Louis Petit于1774年描述,直到1829年Beclard才在文献中正式使用了"膈膨升"这一术语[2]。膈膨升的病理基础是膈肌的肌纤维或胶原的缺失,导致部分或全部膈肌被纤维弹性组织所取代,使得膈肌的一部分或一侧异常抬高。其解剖学特点是膈肌的连续性保持完整,与胸骨、肋骨和腰背脊柱保持正常连接[3]。膈膨升的症状包括咳嗽、胸痛、心律失常、反复肺部感染等,少数患者可出现胃扭转。膈疝,尤其是Bochdalek疝[4]在影像学上与其具有一些共同特点,是导致临床误诊的重要原因,需要作二维重建CT予以鉴别。由于不同类型的膈肌病变在手术入路和方式上存在一定的差异,误诊可能会导致不适当的治疗策略。因此,如何进行准确的诊断至关重要。我们报道1例以急性胃扭转为主要临床表现的左侧部分膈膨升病例,旨在提高对本病的认识,减少误诊。

图1 患者胸腹部CT注:1A冠状位显示左侧膈肌抬高并凸向胸腔,胃扩张伴扭转;1B冠状位显示左下肺受压迫;1C矢状位显示左后侧膈肌向胸腔凸出。黄色箭头显示凸起的膈肌是完整延续的,蓝色箭头为扩张的胃腔,红色箭头为脾脏。
图2 患者上消化道造影注:2A、2B显示左侧膈肌升高,胃扩张,胃呈系膜轴向扭转征象。
图3 保守治疗1周后患者胸腹部CT注:3A、3B显示左侧膈肌抬高并凸向胸腔,脾脏移位到左侧膈顶,胃扩张较前减轻,贲门和胃窦的解剖位置恢复正常。红色箭头为脾脏,蓝色箭头为胃腔,黄色箭头为贲门,白色箭头为幽门。
图4 基于患者首次CT的三维可视化重建注:4A左后侧膈肌凸向胸腔,胃、左肾及结肠脾曲突入膨升的空间,左肺部分受压;4B胃呈系膜轴扭转征象;4C左后侧膈肌是完整连续的。红色箭头显示膨升膈肌的部位为左后侧。
图5 患者腹腔镜手术探查所见及手术过程注:5A~5C手术探查证实为左后侧膈膨升,中上部胃可见系膜轴向扭转的痕迹,脾脏位于膈顶;5D~5F游离胃底并进行胃固定。
图6 术后第5天患者胸部X线片注:6A、6B显示无胃扭转征象。
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