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<Case
Presentation>
A 73 y/o female patient was sent to our hospital
because of several episodes of bloody stool noted in recent
one week.
She is a case of
DM, which was diagnosed for more than 10 years. Besides, she
ever suffered twice stroke episodes and spine compression
fracture, so she got bed ridden for 2 years,
and she lived at nursing home in recent one year. According
her family’s statement, constipation was more severe
in recent one month and later poor appetite,
nausea and vomiting developed gradually. In recent one
week, several episodes of bloody stool were noted, and progressive
vomiting situation, twice high fever (up to 39℃) also
happened during this period. Abdominal colicky pain was also complained frequently.
Because of bloody stool persisted, she was sent to
our hospital for further survey and management.
She looked very weak, and persisted nausea sensation with
abdominal distention was also complained. The vital sign when
admission was as below: blood pressure: 130/84 mmHg, body
temperature: 37.8℃, respiratory rate: 28 per minutes, heart
beats: 118 beats per minutes. Her conjunctiva was slightly
pale. The breathing sound showed diffuse inspiratory crackle
over right upper and middle lung field. A grade II/VI systolic
murmur was heard at left lower sternal border and apex.
Abdominal examination showed distention with tympanic sound
and hyperactive bowel sound, like metallic sound. Diffuse
tenderness was complained but there was not rebounding pain
sign, nor muscle guarding. Shift dullness sign also showed
negative. The bloody, mucus stool with a soft mass with smooth
surface and a central depressed area was noted when performing
digital examination. There was not significant finding in
other physical examination.
Table 1 Blood routine
data
|
RBC |
Hb |
Hct |
MCV |
PLT |
WBC |
Seg |
|
M/μL |
g/dL |
% |
fL |
K/μL |
K/μL |
% |
|
3.09 |
8.2 |
24.5 |
82.5 |
307 |
18.1 |
85% |
Table 2 Biochemistry
data
|
TP |
Alb |
BUN |
Cr |
GOT |
GPT |
|
g/dL |
g/dL |
mg/dL |
mg/dL |
U/L |
U/L |
|
4.96 |
2.83 |
60.8 |
1.01 |
37 |
14 |
|
CRP |
Sugar |
Na |
K |
Cl |
|
μg/mL |
mg/dL |
mmol/L |
mmol/L |
mmol/L |
|
74.3 |
206 |
127 |
3.9 |
96 |
Other data:
CEA: 28.6
ng/mL,
Because of the persisted bloody stool, blood transfusion
with packed RBC was given. The chest X-ray showed air-space
lesion at right upper and middle lung, and aspiration
pneumonia was impressed. Augmentin was used for
aerobic-anaerobic organism. Plain radiographs showed small
intestine gas and distended ascending, transverse, and
descending colon. Bowel gas disappeared below the sigmoid
colon. Colonoscopy was performed later, and it revealed a
rectal mass circumferentially with smooth surface at 8cm above
anal verge, and colonoscopy could not pass through. Colonic
intussusception was impressed, and abdominal CT also revealed
typically “sausage-shape” appearance at rectosigmoid colon.
Besides, several hypodense lesions were also found in liver.
Because of the diagnosis and gastrointestinal tract
obstrucion, she was transferred to surgical ward for
operation. The intussusception section was excised, and a huge
polypoid lesion was found within it, which was confirmed to be
adenocarcinoma pathologically.
After surgical intervention, the family preferred
supportive care because of her old age and liver metastasis.
So she was sent to nursing home after general condition became
stable.
 案例分析
病患之臨床症狀是解血便及機械性腸阻塞，並表現出腹痛、腹漲、便秘、快速腸音、嘔吐、食慾不振等情形。在聽診部分腸阻塞可聽到高頻率、高活動性的腸音，如此患者的腸音似所謂的金屬聲（metallic
sound）。若腸音變為低活動性且合併腹膜炎，則可能是腸子已產生絞扼甚至破裂了。腹部X光是簡單且重要的工具，可以看到擴張的腸子及約略的阻塞部位，如本例之小腸及部分大腸擴張，但乙狀結腸及直腸部分腸氣消失，且肛診亦有異狀，便可定位出阻塞部位在大腸末端處。經其他影像學協助診斷為腸套疊，之後接受手術切除。於腸套疊段發現腫塊，經病理檢查證實為大腸癌，且轉移至肝臟。
腸套疊是造成腸道阻塞的原因之一，好發於小孩子，成人則不多見。孩童發生腸套疊的典型症狀為腹痛、腹部腫塊及解血便，造成原因多為
idiopathic。成人發生腸套疊，症狀及原因則不相同。臨床症狀大多以腸阻塞來表現，而超過90%可找出原因，包括腸道之良性、惡性腫瘤。以大腸而言，約半數病例是肇因於惡性腫瘤，且原發性腫瘤為多，如本例即肇因於大腸癌。治療部分亦不同於孩童，切除腸套疊部分是治療首選。部分理論建議於乙狀結腸—直腸病灶，先以人工解套，以保留較長之直腸，免於做人工肛門，但易有併發症，如腫瘤擴散、腸破裂、血管栓塞等、仍未定論。
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Case Discussion
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