经内镜肠道植管靶向回肠给药成功治疗远端回肠粪石嵌顿
2024年8月本团队在内镜领域国际顶刊《Endoscopy》首次报道经内镜肠道植管术（TET）靶向回肠给药解除小肠巨大粪石嵌顿，这是TET技术在Endoscopy发表的第三篇论文。该论文题目为“Successful management of fecalith impaction in the distal ileum using a transendoscopic enteral tube for targeted drug delivery”。研究报道了一名69岁男性因“腹痛、腹胀一周，伴恶心呕吐一天”就诊。CT显示远端小肠壁增厚狭窄，狭窄口上方见一直径约3.4×2.8 cm的腔内高密度影，近段肠道扩张伴气液平，予以补液、灌肠以及口服泻药通便等保守治疗，症状无好转。肠道超声提示远端回肠仍有强回声团块。考虑诊断：回肠粪石嵌顿、回肠狭窄、不全性肠梗阻。患者行小肠镜检查，尝试内镜下取出异物。镜下发现距回盲瓣约40cm远端回肠见黑色粪石嵌顿，粪石周围可见环形溃疡伴狭窄。术中尝试球囊导管辅助取石和钬激光碎石术，但由于粪石的特性及肠道狭窄，均未成功。炎性溃疡性狭窄行内镜下狭窄切开和扩张亦存在较大风险。最终，在粪石下方放置TET管拟靶向回肠给药。术后经TET予地塞米松（10mg/d*3d）灌肠治疗炎性狭窄。三天后复查CT显示远端回肠炎症明显改善，粪石已移至近回盲瓣附近。为促进粪石排出，经TET注入了泛影葡胺溶液。一天后患者成功排出粪石。患者术中及术后均未出现并发症。本案例经TET靶向回肠给药成功治疗远端回肠粪石嵌顿，避免了外科手术，对于远端回肠粪石梗阻的治疗或许具有特殊的价值和意义。
图 1 Computed tomography revealed distal small intestinal wall thickening with a 3.4 × 2.8 cm high-density intraluminal foreign body (red arrow). a Transverse plane. b Coronal plane.
图 2 A black fecalith was impacted in the distal ileum, approximately 40 cm from the ileocecal valve, and surrounded by a circular ulcer with stenosis.
图 3 Computed tomography images of the distal ileum before (a) and after (b) treatment. The red arrow indicates the thickening and stenosis of the distal ileum wall before treatment, as well as fecalith retention above the intestinal stenosis. The green arrow shows significant improvement in inflammation of the distal ileum, with no observed thickening or stenosis of the intestinal wall, following the delivery of dexamethasone into the ileum via the transendoscopic enteral tube.
图 4 Following the targeted administration of dexamethasone into the ileum through the transendoscopic enteral tube (green arrow) to treat inflammatory stenosis, the fecalith (red arrow) was expelled through the narrowed intestine to the terminal ileum near the ileocecal valve. The blue dotted circle indicates clips fixed onto the intestinal wall. The yellow arrow shows a nasojejunal tube. a Computed tomography transverse plane. b Three-dimensional image.
图 5 The hard fecalith from the ileum (3.4 × 2.8 cm).
Reference：Wen Q, Cui B, Yu Y, Zhang F. Successful management of fecalith impaction in the distal ileum using a transendoscopic enteral tube for targeted drug delivery. Endoscopy. 2024 Dec;56(S 01):E736-E737. doi: 10.1055/a-2376-7350.
第一作者：温泉
通讯作者：张发明