Rectal Perforations After Barium Enema: A Review
Rectal Perforations After Barium Enema: A Review
复制标题
钡剂灌肠后直肠穿孔：回顾
DOI：
--
复制
发表时间：
2006
影响因子：
3.9
通讯作者：
C. Dejong
中科院分区：
文献类型：
--
作者：
P. W. Feiter;P. Soeters;C. Dejong
钡灌肠术中发生直肠损伤是一种罕见但危及生命的并发症。关于这一主题的最后一篇评论发表于十多年前。在目前的审查中，我们提出了一个概述的主题，并特别关注的变化，在治疗策略和发展的风险较小的可视化technology.MethodsA文献检索进行了PubMed图书馆使用的关键词钡灌肠，并发症，腹膜炎，和直肠穿孔-以及相关的文章和其他参考资料，从这些文章中获得。相关.其他原因与结直肠壁薄弱或梗阻有关。已描述了五种类型的穿孔：1）肛提肌下方的肛管穿孔; 2）不完全穿孔; 3）腹膜后穿孔; 4）邻近内脏的透壁穿孔; 5）游离腹腔穿孔。大多数不完全性穿孔和一半的腹膜后穿孔的临床症状很轻微。腹膜内穿孔导致最灾难性的过程，开始直肠出血和轻度腹部投诉。随后迅速发生进行性脓毒症和腹膜炎，并导致高死亡率。壁内或腹膜后小穿孔并不总是需要手术。这些可以保守治疗，只有在大量外渗或渗出的情况下才需要手术清创。建议对较大的直肠粘膜病变或肛门括约肌病变进行手术修复。直肠周围脓肿需要引流。腹膜内穿孔伴严重外渗需要在重症监护环境中立即进行积极的手术治疗，因为休克的威胁很高。腹膜内穿孔、漏诊穿孔、钡剂外渗、结肠准备不良和钡剂静脉内渗在外科上是不利的。腹腔穿孔最常见的晚期并发症是肠梗阻。钡灌肠技术的熟练是预防直肠穿孔的最重要因素。近几十年来，由于支持性和重症监护的进步，总体死亡率从约50%降至35%。由于这些进步，采取了更积极的手术策略。随着内窥镜检查的出现，钡灌肠较少。因此，并发症的绝对发生率有所下降。预计在未来钡灌肠将取代更敏感和风险更低的技术，如CT结肠成像和磁共振结肠成像。
PurposeRectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject andespecially focus on changes in treatment strategies anddevelopments of less risky visualization techniques.MethodsA literature search was performed in the PubMed library using the key words—barium enema, complications, peritonitis, and rectal perforation—as well as related articles and other references obtained from these articles.ResultsThe most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention.ConclusionsRectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography.