以慢性腹痛為表現的靜脈硬化性大腸炎之病例報告

Phlebosclerotic Colitis Presenting as Chronic Abdominal Pain: A Case Report

靜脈硬化性大腸炎是一種較少見的靜脈非阻塞性病變引起腸缺血的疾病。雖然大多數靜脈硬化性大腸炎是良性，但是嚴重時可能會引起腸穿孔、腸阻塞、腸出血等嚴重併發而致命。臨床上，主要是以慢性腹痛或腹瀉表現。因為慢性腹痛或腹瀉為非特異性症狀，所以在診斷上經常會被延誤。確定診斷主要是靠放射線檢查看到腸系膜靜脈線狀鈣化，大腸內視鏡檢查的特性是大腸壁呈現暗紫色。其病因及致病機轉至今並無定論。因為大部分個案是在亞洲，而且很多個案都有服用草藥，因此靜脈硬化性大腸炎與草藥的相關性愈來愈被重視。保守療法及停用草藥是靜脈硬化性大腸炎的第一線治療，對於有腸穿孔、阻塞、出血等嚴重併發症及保守療法後症狀持續或復發的個案，建議進行手術治療。

本篇病例報告一位48歲女性個案，腹痛長達11年，上消化道內視鏡檢查有胃潰瘍及胃食道逆流。在給予足夠劑量的抗潰瘍及胃食道逆流的多種藥物後，腹痛仍無法得到緩解而且繼續惡化，進一步大腸鏡檢查發現升結腸至盲腸黏膜呈現暗紫色及靜脈充血。腹部電腦斷層掃描發現上腸系膜靜脈多處線條狀鈣化及大腸壁增厚，診斷個案是靜脈硬化性大腸炎。進一步詢問用藥史，個案長期服用草藥長達約20年之久。給予個案保守性治療及停用草藥後病情穩定，繼續門診追蹤中。希望藉此病例報告提醒基層醫師對於鑑別診斷慢性腹痛時，應想到此較少見、但是會致命的靜脈硬化性大腸炎，尤其是有在服用草藥的個案。

 

A rare but fatal non-occlusive bowel ischemic disease, phlebosclerotic colitis is often delayed in diagnosis as it is mostly presented as chronic abdominal pain or diarrhea, which are nonspecific symptoms. Its diagnosis mainly relies on linear calcification of the mesenteric vein on radiographic examination and dark-purple discolorations of the mucosa in colonoscopic findings. The cause and pathogenesis of the disease have not been confirmed, but since most of the cases are Asian and many of them have taken herbal medicine, the correlation between phlebosclerotic colitis and herbal medicine has drawn increasing attention. Discontinuation of herbal medicine and conservative treatment are the first-line therapy for phlebosclerotic colitis, and surgical intervention is recommended for patients with severe complications, including perforation, intestinal obstruction, hemorrhage, and persistent or recurrent symptoms after conservative treatment.

We presented a 48-year-old female with abdominal pain for up to 11 years. Esophagogastroduodenoscopy showed a gastric ulcer and reflux esophagitis. After administration of high dose H2-receptor antagonist, high dose proton pump inhibitor, musculotropic spasmolytic and anti-foaming agent, abdominal pain was not alleviated but deteriorating. Colonoscopy showed dark-purple discolorations of the mucosa and engorged veins distributed from the ascending colon to the cecum. Phlebosclerotic colitis was diagnosed with abdominal CT scan, which revealed multiple linear calcifications of the superior mesenteric vein and colon wall thickening. As indicated by her medication history, the patient had long-term oral intake of herbal medicine for 20 years. With conservative treatment and discontinuation of herbal medicine, her condition became stable enough for outpatient follow-up. This case report should help remind primary physicians to consider the rare but potentially fatal phlebosclerotic colitis for patient with chronic abdominal pain, especially those who are taking herbal medicine.