85例结核性腹膜炎的临床表现及随访分析

目的回顾性分析结核性腹膜炎(tuberculous peritonitis,TBP)患者的临床表现及诊断方法,为提高临床对TBP的正确诊断率提供可借鉴的经验。方法收集2012年1月至2016年10月重庆医科大学附属第一医院85例资料完整、临床疑诊为TBP并行诊断性抗结核治疗的患者,随访抗结核治疗结果 3～12个月,并对其临床资料进行回顾性分析。结果本组疑诊TBP患者诊断符合率为77. 6%。其中腹腔镜及病理学检查阳性率最高(100%),腹部CT检查次之(93. 8%)。对于年龄40岁患者,腹部CT检查对TBP的诊断符合率高达100%,但随年龄增加,诊断符合率逐渐下降。结论 TBP临床表现不典型,诊断较困难,实验室检查的灵敏度及特异度差。腹腔镜及病理学检查是诊断TBP的金标准,但临床实施和组织标本获取较困难。因此,腹部CT检查结合患者年龄并采用排除诊断法,是诊断TBP的关键。     

18例脾结核临床分析

目的探讨脾结核的诊断及治疗措施。方法对18例脾结核患者的临床资料进行回顾性分析。结果18例病人中表现为发热14例(占77.7%),腹痛9例(占50.0%),发热病程为1周至12个月,平均热程为2个月。其他较常见症状体征为腹胀4例(占22.2%)、盗汗4例(22.2%)、乏力5例(占27.8%)、纳差7例(38.9%)、贫血7例(38.9%)、脾肿大9例(占50%)。手术及病理诊断12例,1例胃液发现抗酸杆菌确诊,5例经试验性抗结核治疗有效确诊。18例病人中10例合并脾外结核。确诊前误诊9例(50%)。2例病人死亡,余16例均经手术及或1年以上的抗结核治疗,经随访预后良好。结论脾结核以长程发热和腹痛为突出表现,误诊率高,诊断主要依靠脾切除病理学检查及诊断性治疗,选择性手术治疗及系统性抗结核治疗是脾结核的主要有效治疗手段。     

疑难性腹部疾病诊断的费用效果分析

腹痛、腹水和腹块是临床常见征象,结合病史,体征和常规化验检查,大部分患者可获明确诊断,但仍有约1/3的病例难以诊断。对疑难性腹部疾病,目前主要依靠常规生化、腹水实验室、胃肠镜等检查,然而,甚至在进行了CT,MRI等影象学检查之后仍不能明确诊断。因此不明原因的腹痛、腹水、腹块的病因诊断一直是临床的一大难题。腹腔镜检查由于技术的更     

疑难腹水患者腹腔镜检查结果分析

疑难腹水患者常见的病因是结核和恶性肿瘤。临床工作中，部分腹水患者经常规检查、B超、CT甚至MRI等检查后病因仍不明确，部分患者可能未得到满意诊治，甚至可能因为长期的抗结核治疗造成肝功能受损或延误诊断。近年来腹腔镜的应用为疑难腹水的诊断提供了有力的手段，本文总结62例临床疑难腹水病例，行常规检查及腹腔镜检查后获得明确诊断的资料，报道如下。     

孤立性胰腺结核国内文献的荟萃分析

目的:探讨孤立性胰腺结核的临床特征和诊断方式.方法:报告1例孤立性胰腺结核,并结合国内34篇文献共49例孤立性胰腺结核病例进行荟萃分析.结果:49例病例中男25例,女24例,男女之比1∶1.08.平均年龄36.65岁±12.73岁.平均病程4.06mo±3.15mo.临床主要表现为腹痛(63.27%)、体质量下降(59.18%)、发热(36.73%)、黄疸(34.69%)等,其他表现有腹胀、恶心呕吐、盗汗、乏力等.实验室检查呈血沉增快(85.71%)、PPD阳性(5/9)、CA19-9升高(2/8).在CT检查中75.61%的病例显示有胰腺多发低密度结节样病灶,多伴有胰腺周围淋巴结增大(34.15%),少数表现有钙化影像、肝内外胆管及胰管扩张和胰腺假性囊肿等.在B超检查中51.06%的病例显示有胰腺肿大和胰腺不规则低回声区,少数病例伴有胰管扩张、肝内外胆管扩张等.确诊前55.1%的病例被误诊为胰腺肿瘤,其他误诊为胰腺假性囊肿、胰腺炎、胆总管癌等.全部病例均经病理组织学检查确诊,其中CT或B超引导下活体组织检查各2例,45例经剖腹探查术后经病理学确诊,病理组织学可见干酪样坏死或干酪样肉芽肿形成,82.22%的病例伴有胰腺周围淋巴结结核.正规的抗结核药物治疗有效者占95.92%,其中剖腹探查病例除抗结核药物治疗外,选择病灶引流(15.56%)、局部病变切除(8.89%)和胰十二指肠切除(8.89%)的手术方式.结论:孤立性胰腺结核极为少见,确诊前多被误诊.临床上缺乏典型的结核中毒症状,多表现有腹痛、体质量下降和血沉增快,少数表现有发热、黄疸和乏力等.易被误诊为胰腺肿瘤、胰腺炎等.腹部CT等影像学检查是重要的诊断手段,确诊主要依据病理组织学检查.抗结核药物对孤立性胰腺结核治疗有效,必要时可选择手术治疗.     

肝结核20例临床分析

目的 探讨肝结核的诊断和治疗措施.方法 对20例肝结核患者的临床资料进行回顾性分析.结果 20例患者中表现为发热、盗汗、纳差、腹痛、腹胀和腹泻分别为10例(50%)、4例(20%)、12例(60%)、8例(40%)、12例(60%)、4例(20%)和无症状3例(15%).腹部B超及CT检查发现肝内占位性病变15例,肝内有钙化灶2例,肝脏肿大3例.手术及病理诊断肝结核15例,2例因肝内有钙化灶诊断为肝结核,另3例采用诊断性抗结核治疗有效诊断为肝结核.20例患者中有16例合并肝外结核.所有患者均经过1.5年以上的抗结核治疗,经随访预后良好.结论 肝结核患者的临床和影像学表现多样,且无特异性,误诊误治率高.确诊的主要手段是肝脏病理学检查及诊断性治疗,系统的抗结核治疗及选择性手术治疗是肝结核患者的有效治疗手段.     

肾结核155例诊治分析

目的 探讨肾结核的临床表现、诊断和治疗,以提高早期诊治水平. 方法 回顾性分析我院2003年7月—2014年4月收治的155例肾结核患者的临床资料.结果 肾结核高发年龄段是40~60岁(47.1%).将患者分为2组,具有3种或以上临床常见症状者为典型肾结核组(典型组),有患者94例;其余为不典型肾结核组(不典型组),有患者61例.临床最常见的症状依次为尿急(62.6%)、尿频(60.0%)、腰痛(54.3%)、尿痛(51.6%)和血尿(44.5%),腰痛是不典型肾结核组最常见的症状(49.2%).132例患者行尿沉渣找抗酸杆菌检查,阳性率为31.8%.超声检查结果异常率为84.5%,诊断符合率为38.1%.CT检查结果异常率为95.1%,诊断符合率为79.9%. 123例患者行手术治疗,其余32例患者接受抗结核药物治疗. 结论 肾结核的诊断主要依靠临床症状、 实验室检查和影像学检查,CT对明确诊断有重要意义. 肾结核早期诊断困难且需要综合分析判断. 手术是中晚期肾结核的重要治疗手段.     

肠系膜静脉血栓形成所致腹痛的临床分析

腹痛是由多种病因所致的常见临床症状，肠系膜静脉血栓形成(MVT)为一引起腹痛的少见病因，其诊断困难，易贻误治疗。目的：探讨MVT所致腹痛的临床特点。方法：回顾性分析总结1996～2001年我院10例MVT所致的腹痛病例。结果：10例患者的主要临床表现均为中上腹部持续性疼痛，体征与腹痛程度不平行。伴随症状和体征依次为恶心、呕吐(40．0％)、腹泻(30．0％)、发热(20．0％)、腹水(20．0％)和黑便(10．0％)。7例患者伴自身免疫性疾病，其中4例为抗心磷脂抗体综合征。2例患者有高血压和冠心病。主要实验室异常为白细胞升高(50．0％)和抗心磷脂抗体阳性(40．0%)。明确诊断主要依靠腹部彩色多普勒超声检查(90．0％)。治疗以抗凝治疗为主，同时应积极治疗原发病，保守治疗无效时应考虑手术治疗。结论：对于伴有高凝状态基础病变的腹痛患者，特别是有自身免疫性疾病的女性患者，应考虑到MVT的可能。     

16例脾结核临床分析

目的 探讨脾结核的诊断和治疗措施.方法 对16例脾结核患者的临床资料进行回顾性分析.结果 16例病人中表现为发热、盗汗、腹胀、腹痛和脾肿大分别为11例次(68.8%)、6例次(37.5%)、8例次(50%)、10例次(62.5%)和13例次(81.2%).腹部B超及CT检查10例有脾内占位性病变,3例脾内有钙化灶,另3例为脾弥漫性肿大.手术及病理诊断脾结核9例,3例因脾内有钙化灶诊断脾结核,另4例诊断性抗结核治疗有效而诊断脾结核.16例病人中有8例合并脾外结核.所有病人都经过半年以上的抗结核治疗,经随访预后良好.结论 脾结核诊断主要依据睥病理学检查及诊断性治疗,系统性抗结核治疗及选择性手术治疗是脾结核的主要有效治疗手段.     

类似进展期卵巢癌的老年女性结核性腹膜炎临床分析(附三例报告)

目的 探讨绝经后老年女性结核性腹膜炎与晚期卵巢癌的临床特点,并对相关文献进行复习.方法 回顾性分析了2003年1月至2009年9月卫生部北京医院收治的60岁以上老年女性被确诊为结核性腹膜炎的3例患者临床资料.并进行文献复习,探讨结核性腹膜炎的误诊原因及诊断方法.结果 3例患者均表现出类似晚期卵巢癌的临床症状:胸水、腹水、盆腹腔包块及腹胀,进行性消瘦,肿瘤抗原125(CA125)升高.其中2例患者接受了剖腹探查术,均未发现恶性肿瘤.3例患者均接受了抗结核治疗.其中2例患者在治疗中胸水、腹水消失.结论 结核性腹膜炎老年女性患者易被误诊为卵巢癌,从而接受手术治疗.腹腔镜活检是诊断结核性腹膜炎安全有效的方法.剖腹探查是不能行腹腔镜手术患者的另一选择.     

Tuberculous peritonitis in Egypt: the value of laparoscopy in diagnosis.

Abdominal laparoscopy was performed on 200 patients with undiagnosed ascites. It was unsuccessful in one patient with tuberculous peritonitis because of extensive adhesions. A presumptive diagnosis of tuberculous peritonitis based on clinical findings and peritoneal tubercles or adhesions visualized during laparoscopy was made in 90 of these patients. The diagnosis was confirmed in 88 by histopathology, bacteriology, or therapeutic response. Two of the 109 remaining patients who had other presumptive diagnoses made during laparoscopy were eventually confirmed to be cases of tuberculous peritonitis. Of 91 patients with tuberculous peritonitis included in this series, 79% were females, with the majority (79%) of them being of child-bearing age. Half had been ill for longer than one month. The most frequent complaints were abdominal pain, fever, anorexia, night sweats, abdominal swelling, and weight loss. Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions. Pleural effusion was present in 15% and pulmonary tuberculosis was detected in only two patients. Biopsy samples taken during laparoscopy showed that 60% had noncaseous granulomas and 33% had caseous granulomas. Mycobacterium tuberculosis was detected in 77%, with guinea pig inoculation having the highest sensitivity, followed by culture, and lastly by acid-fast smear. Mycobacterium tuberculosis was isolated more easily from biopsy samples than from ascitic fluid. Nine of 20 M. tuberculosis isolates that were identified as to species were M. bovis. Tuberculous peritonitis, a frequent cause of febrile ascites in Egyptian women, was easily diagnosed by histopathologic and bacteriologic studies of biopsy samples taken at laparoscopy. All patients responded rapidly to antituberculosis therapy.     

CT平扫对结核性腹膜炎的诊断价值

目的 探讨结核性腹膜炎的CT平扫表现特征。方法 回顾性分析46例有CT扫描资料的结核性腹膜炎患者,其中经手术病理证实6例,腹腔穿刺证实2例,腹腔镜检证实4例,试验性治疗诊断34例。观察内容包括结核性腹膜炎累及壁腹膜、大网膜、肠系膜及腹膜后间隙的CT表现特征。结果 （1）壁腹膜增厚33例,其中均匀、光滑增厚27例,局部不规则增厚6例;（2）腹腔积液31例,其中20例为少量积液;（3）大网膜增厚26例,表现为污迹样增厚22例,饼状增厚2例;（4）肠系膜受累32例,其中9例合并小结节影：（5）淋巴结增大16例;（6）肠壁增厚1例,肠间距增宽2例。结论 结核性腹膜炎CT平扫的主要表现有少量腹腔积液、均匀性腹膜增厚、大网膜污迹样增厚,以及肠系膜、肠管受累与腹腔淋巴结增大,CT平扫能为结核性腹膜炎的诊断提供重要信息。     

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE: To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis. METHODS: Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features. RESULTS: The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment. CONCLUSION: Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.     

Tuberculous peritonitis in children：Report of nine patients and review of the literature

AIM：To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007. METHODS： We reviewed the medical records of 9 children with tuberculous peritonitis. RESULTS： Nine patients （5 boys, 4 girls） of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications. CONCLUSION： Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.     

Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period.

This study analysed clinical features and laboratory investigations in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy at this hospital between 1984 and 1988. Tuberculous peritonitis was found in 2% of all patients with tuberculosis and in 59.8% of all those with abdominal tuberculosis admitted to the hospital during the study period. Tuberculous peritonitis was more common in women than men (1.4:1) and was most frequently encountered in the third and fourth decades of life. The commonest presenting symptoms were abdominal swelling (73.1%), fever and night sweats (53.8%), anorexia (46.9%), weight loss (44.1%), and abdominal pain (35.9%). The mean duration of symptoms was 1.5 months. Ascites was the commonest (95.2%) physical sign. Tuberculin skin testing was positive in 57.6% of patients (n = 118). The mean erythrocyte sedimentation rate was 75 mm/1st hour (n = 58). Chest radiography on 98 patients showed pleuropulmonary pathology in 40 patients (40.8%). Sputum examination confirmed active pulmonary tuberculosis in 26 patients. The ascitic fluid was an exudate in 96.4% and a transudate in 3.6% of patients, with 91.3% showing a straw coloured ascites. Cirrhosis, detected by biopsy specimen, was a finding in 6.2% of patients.     

结核性阑尾炎的诊断与治疗

目的探讨结核性阑尾炎的诊断和治疗方法。方法对１９６８～１９９７年收治的４６５２例阑尾炎中，经病理确诊的１２例（占０２６％）结核性阑尾炎作回顾性分析。结果本组病例的平均发病年龄为３５岁，女性多见，男女比为１∶２，多为继发（７例）。１２例中增殖型７例，溃疡型３例，混合型２例。术前均误诊，术中确诊２例。１２例均手术治疗，单纯阑尾切除７例，盲肠部分切除２例，右半结肠切除１例，合并回盲部淋巴结切除２例，术后抗结核治疗９例。１２例均顺利痊愈，无并发症。结论结核性阑尾炎发病率低，临床表现无特异性，术前确诊困难，要注意术中观察并重视病理检查。应早期手术和术后抗结核治疗，防止并发症产生。     

Presentation and role of peritoneoscopy in the diagnosis of tuberculous peritonitis

This study represents the clinical and laboratory features of 135 tuberculous peritonitis cases in whom peritoneoscopic investigation was used routinely. Disease was more common in women than men (1.5:1) and was most frequently encountered in the third and fourth decades in life. The most common presenting symptoms were abdominal distension (96%), abdominal pain (82%), weight loss (80%), weakness (76%), loss of appetite (73%) and fever (69%). The most common physical findings were ascites (96%), fever (75%) and abdominal tenderness (43%). One hundred and twenty-nine cases (95.5%) showed exudative type tuberculous peritonitis with variable amounts of ascites and filmy adhesions. In six patients (4.5%) the disease was of the plastic (dry) type. Peritoneoscopic investigations of 139 patients suggested tuberculous peritonitis but four cases showed histologically proven malignancy (3%). Laparoscopic diagnoses of the remaining cases were confirmed by histology (97%). The laparoscopic appearance of scattered yellowish-white nodules, approximately 1-5 mm in size, on the peritoneal surfaces, and filmy adhesions were suggestive of tuberculous peritonitis. A non-fatal colon perforation occurred as a major complication. After antituberculous therapy patients were followed for at least 1 year. Peritoneoscopy with simultaneous biopsy is the ideal and most accurate diagnostic modality in the diagnosis of tuberculous peritonitis.     

Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis

OBJECTIVE: To better identify which clinical, laboratory, radiological and invasive procedures were most useful in diagnosing tuberculous peritonitis and to assess the methods in order to reach the diagnosis in future cases. METHODS: Tuberculous peritonitis cases diagnosed between 2000 and 2006 were reviewed retrospectively. Their clinical presentation, physical examination, laboratory and diagnostic methods were evaluated. RESULTS: Twenty‐three cases of tuberculous peritonitis were diagnosed. The mean age of the patients were 30 ± 11 years and 16 were women. The mean duration of symptoms prior to diagnosis was 3.6 months. All patients presented with abdominal pain. Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was <1.1 g/dL in all. An ascites fast bacilli smear was positive in 12 (52.2%) patients. Skin tests with purified protein derivative, adenosine deaminase and polymerase chain reaction were performed in seven, four and five patients, respectively. The tuberculous culture was positive in only two. The most common radiological findings were ascites (100%) and omental involvement (65.2%). A laparoscopy was performed in nine of 23 patients. A total of 22 patients completed anti‐tuberculous therapy successfully and were cured, except one with cirrhosis. CONCLUSION: Tuberculous peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. Although both non‐invasive and invasive tests have additional benefits, clinician suspicion is still the first step for the diagnosis of tuberculous peritonitis.     

Abdominal tuberculosis in urban Britain--a common disease

Between 1973 and 1983 abdominal tuberculosis was responsible for the admission of 90 patients to a west London district general hospital. Over the same period Crohn's disease was newly diagnosed in 102 hospitalised patients. In contrast with Crohn's disease, the majority (75) of tuberculous patients were Asian immigrants. Mean duration of residence in the United Kingdom was 4 +/- 0.9 (SD) years, and mean age at presentation was 34.9 +/- 1.1 years. Forty per cent of tuberculosis patients presented as an acute emergency to physicians, surgeons, or gynaecologists while the remainder presented a more insidious, chronic picture. Five groups of tuberculous patients were recognised. Forty two subjects had intestinal tuberculosis characterised by pain (100%), abdominal mass (43%) and abnormal contrast radiology (100%). Ten of these underwent emergency laparotomy for intestinal obstruction or perforation. Twenty seven patients had tuberculous peritonitis although only 16 had ascites. Eight patients presented with pyrexia and granulomatous hepatitis. Five had pulmonary and abdominal tuberculosis. The remaining eight patients represented a miscellaneous group. The diagnosis of abdominal tuberculosis was established histologically (60 cases), bacteriologically (six cases) or radiologically (24 cases). Chest radiograph, tuberculin skin testing and paracentesis were usually unhelpful. Five severely ill patients died. The remainder recovered completely after specific triple chemotherapy and response to treatment was usually evident within 14 days. In urban Britain tuberculosis is an important cause of abdominal disease. Prognosis is excellent following specific therapy.     

T淋巴细胞斑点试验在结核性腹膜炎诊断中的临床应用价值

[目的]研究T淋巴细胞斑点试验(T-SPOT.TB)在结核性腹膜炎临床诊断中的应用价值。[方法]对40例结核性腹膜炎、38例非结核性腹膜炎的患者的腹腔积液实施T-SPOT结核试验。[结果]40例结核性腹膜炎患者中T-SPOT.TB阳性36例(阳性率90.00%),对照组38例非结核性腹膜炎T-SPOT.TB阳性3例(阳性率7.89%)。[结论]T-SPOT.TB是一种鉴别腹腔积液是否为结核性腹膜炎的较好的方法,具有很好的临床应用价值。