腹腔内高压与腹腔间室综合征_杨新平

【文章编号】1007-9424(2002)06-0451-03·综　述·

腹腔内高压与腹腔间室综合征

杨新平1综述　姜洪池2审校

【摘要】　目的　研究腹腔内高压和腹腔间室综合征的概念及其病理生理变化。方法　采用文献回顾的方法对腹腔内高压和腹腔间室综合征的概念及病理生理学进展加以综述。结果　腹腔内高压和腹腔间室综合征的概念已逐渐被接受,其病理生理变化主要有:①胃肠血流减少;②呼吸道阻力增加,肺顺应性下降;③心输出量减少,周围循环阻力增加;④少尿甚至无尿;⑤颅内压升高;⑥肝脏血流减少;⑦腹壁顺应性降低。结论　腹腔内高压和腹腔间室综合征的概念应用增多,最易累及呼吸系统、心血管系统和泌尿系统,其次是胃肠道、中枢神经系统、肝脏和腹壁。心输出量减少和肺顺应性下降是引起脏器功能障碍的始动因素。

【关键词】 腹腔内高压 腹腔间室综合征 病理生理学

【中图分类号】R656.02 【文献标识码】A

Intra-Abdominal Hypertension and Abdominal Compartment Syndro me　YAN G X in-ping＊,JIANG H ong-chi.＊Depart-ment o f Surger y,Huangpu Center Hos pital,Shanghai200002

【Abstract】　Objective　To study the concepts and pathophysiology of intra-abdominal hypertens ion(IAH)and abdominal compartment s yndrome(ACS).Methods　Relevant in formation was gathered from previous original articals,and b y checking the latest issues of appropriate journals.Meantime computerised MEDLINE search from1998to August2001was conducted using the Medical Subject Heading and textwords“abdominal”,“compartment syndromes”,“intra-abdominal”and“hypertention”and“pressure”.Then the literature in the recent two years about the advances of IAH and ACS were reviewed.Especiall y the concepts,pathophysiology and clinical application of IAH and ACS were mainly s ummarized.Results　Akin to compartment s yndrome,the pathophysiological effects of increased intra-abdominal pressure developed well before any clinical evidence of compartment syndrome.These changes included①reduction of gastro-intestinal blood flow,②increase of respiratory airway press ure whereas decrease of pulmonary compliance,③decline in cardiac output but rise in peripheral vascular pressure,④oliguria even anuria,⑤increase of intra-cranial pressure,⑥decrease of hepatic blood flow,⑦decrease of abdominal wall compliance.ACS can be defined as dysfunction of various organs caused by a progressive unphysiologic increase of the intra-abdominal pressure.Clinically the syndrome is characterised by inadequate ventilation, tensely distended abdomen and oliguria or anuria.Early decompression by simple laparotomy and delayed closure is the treatment of choice.Conclusion　The concepts of IAH and ACS have been increas ingl y accepted.They mainly affects the respiratory,cardiovascular and renal s ystems;secondaril y affect gastro-intestinal,central nervous s y stems,liver and abdominal wall.The reduction of cardiac output and pul monary compliance are probably promoting factors inducing organ dysfunction.

【Key words】 Intra-abdominal hypertension Abdominal compartment syndrome Pathophysiology

腹腔内高压(intra-abdominal h ypertension,IAH)和腹腔间室综合征(abdominal compart ment syndrome,ACS)是一种危重征象,其危害不仅仅限于腹腔,它可通过直接或间接的方式影响机体的多个器官和系统[1],因而IAH ACS具有重要的临床价值,近几年来成为关注的焦点。现对其概念及其造成的多系统损害及有关诊治综述如下。

1　IAH和ACS的概念

1.1　正常腹腔内压力(intra-abdominal pressure,IAP)

　【作者单位】1.上海市黄浦区中心医院外科(上海200002);2.哈尔滨医科大学第一临床医学院普外科(哈尔滨150001)

　【作者简介】杨新平(1972年-),男,河南省新野县人,医学硕士,主治医师,从事胃肠外科工作。 IAP主要是由腹腔内脏器的静水压产生,正常情况下IAP 平均为0kPa(1kPa=7.5mm Hg),和大气压相近。Tons等[2]对377例患者的IAP进行测定,认为正常值为0～0.93kPa(0～7 mm Hg),而择期手术后IAP为0.67～1.60kPa(5～12mm Hg)。Sanchez等[3]对77例住院患者的IAP进行测定,认为正常值平均为0.87kPa(6.5mm Hg),波动范围在0.03～2.16kPa(0.2～16.2mm Hg),并与体重面积指数有关,且受既往腹部手术的影响。可见对IAP的正常值尚有争论。

1.2　IAH概念

IAP≥1.33kPa(10mm Hg)即为IAH。根据IAP的高低可将IAH分为4级[4]。IAP达1.33～1.87kPa(10～14mm Hg)为Ⅰ级,IAP达2.00～3.20kPa(15～24mm Hg)为Ⅱ级,IAP达3.33～4.67kPa(25～35m m Hg)为Ⅲ级,IAP>4.67kPa(35mm Hg)为Ⅳ级。IAH级别不同所引起的病理生理改变也大不相同,其处理