子宫角妊娠的超声特征与误诊分析

目的总结子宫角妊娠超声声像图特征和鉴别诊断要点.方法 与手术病理检查结果对比,对常规腹部超声及经阴道超声诊断的93例子宫角妊娠患者的术前超声声像图表现及超声分型特征进行总结.结果 与手术病理诊断结果对比显示,术前超声诊断子宫角妊娠与手术病理诊断符合66例(82.5%,66/80),其中妊娠囊型子宫角妊娠55例,混合包块型子宫角妊娠11例;误诊为输卵管间质部妊娠11例、残角子宫妊娠2例、绒癌1例;术前超声误诊率为17.5%(14/80);术前超声表现为附件区异位妊娠包块13例,术中显示为子宫角妊娠包块破裂,超声未定位和分型诊断.子宫角妊娠的超声特征为妊娠囊位于膨隆的一侧子宫角,周边有薄层肌壁包绕,子宫角妊娠包块与宫内膜相连.14例子宫角妊娠误诊原因:(1)超声显示子宫角包块与子宫内膜不连接、包块不为子宫肌层包绕,误诊为输卵管间质部妊娠.(2)子宫角外侧肌层厚,误诊为残角子宫妊娠.(3)子宫角包块血流丰富,肌层菲薄,误诊为绒癌.结论 经腹部联合经阴道超声能对子宫角妊娠病变做出准确诊断,依据超声诊断要点综合评估有助于子宫角妊娠的鉴别诊断.     

手术治疗绞窄性肠梗阻68例

目的探讨绞窄性肠梗阻的诊断与治疗。方法选择绞窄性肠梗阻患者68例,所有患者均在禁食、胃肠减压、静脉营养支持及纠水、电解质和酸碱失衡等基础上进行手术治疗。行肠套叠复位术5例,行X线下充气复位术4例,行粘连松解术24例,行右半结肠切除、回横吻合术17例,行部分及大部分小肠切除、端端吻合术11例,行乙状结肠切除、降结肠造瘘术7例。结果术前确诊为绞窄性肠梗阻47例(69.1%)。以单纯性肠梗阻保守治疗无效或者其他急腹症行腹部探查后确诊为绞窄性肠梗阻21例(30.9%)。治愈65例(95.6%);死亡3例(4.4%),分别为感染引起中毒性休克1例、多脏器功能衰竭1例,严重水、电解质紊乱1例。结论绞窄性肠梗阻应根据临床特征和辅助检查综合分析,把握手术时机,早期诊断以及及时手术治疗是保证救治成功的关键。     

肾上腺髓质脂肪瘤23例报告

目的:探讨肾上腺髓质脂肪瘤(adrenal myelolipoma,AML)的临床特点,提高对AML的诊治水平.方法:对23例AML患者的体格检查、实验室检查、影像学检查、治疗、术后病理检查及随访资料进行数理分析.结果:23例中,伴有腰部胀痛3例.其中高血压1例,库欣综合征1例,无明显自觉症状18例.腹部检查触及上腹部包块3例,有上腹部及腰背部触叩痛5例.行B超、CT或MRI术前确诊为AML 22例(96%).经腰部11肋切口开放性手术单纯肿瘤切除18例,腹腔镜切除5例.23例患者均顺利完成手术,术后病理活组织检查均证实为AML.20例随访6个月～10年,均存活,未见肿瘤复发.结论:绝大多数AML无临床症状,影像学检查是术前诊断AML的主要手段,开放性手术或腹腔镜下单纯切除肿瘤可有效治疗该病.     

腹茧症的临床诊治分析（附10例报告）

目的探讨腹茧症的临床特点及诊治方法。方法结合文献回顾性分析1985年8月至2008年8月我院收治的10例腹茧症患者的临床资料。结果10例中9例表现为急、慢性肠梗阻的症状,2例有腹部包块。10例患者均进行了腹部x线平片检查,均发现不完全性肠梗阻;2例发现腹膜及肠管管壁增厚强化,肠壁间粘连紧密;3例发现腹腔内小肠径路紊乱,聚集成团,似可见增厚的包膜包裹。4例行消化道造影检查,示小肠集中于中腹部。4例经非手术治疗获得缓解,6例经腹腔镜及剖腹探查术中均发现全部或部分小肠被一层灰白色致密坚韧的纤维膜包裹,行粘连松解、肠排列术等,术后6例除结肠癌病例外全部治愈。结论患者反复出现急性或慢性肠梗阻症状而又无其他原因解释或合并腹部包块者,应考虑腹茧症的可能。术前放射学检查对本病有诊断价值。手术是其主要的治疗方法,术前应充分非手术治疗准备。     

术前CT判断食管癌可切除性

目的探讨术前CT扫描在食管癌可切除性评估中的价值.方法107例食管癌患者,术前全部行胸部CT平扫,45例增强扫描.将CT扫描结果与手术、病理相对照.结果107例中,102例行手术切除,食管癌切除率为95.3%(102/107);其余5例因食管癌侵犯邻近组织而仅行探查术.食管癌术前表现与手术所见一致性较好(Kappa=0.482,P＜0.001).结论术前CT扫描判断食管癌能否切除具有很高的临床价值,可减少不必要的外科手术.     

粘连性肠梗阻的手术治疗时机

腹部手术后的粘连已成为肠梗阻的首位病因,占肠梗阻病因的60%以上,尤其是盆腔手术后(如妇科手术,阑尾切除术和结直肠手术后).下腹部手术后容易产生粘连性肠梗阻的原因是小肠更为游离,而上腹部小肠则相对固定,约90%的粘连性不全小肠梗阻可通过保守治疗获得缓解,但其中5%可能复发,单纯粘连性肠梗阻的松解手术死亡率<5%.     

115例肠梗阻手术方式的选择及疗效

目的探讨肠梗阻手术方式的选择及疗效。方法回顾分析115例肠梗阻患者的临床资料,其中83例(72.17%)粘连性肠梗阻、嵌顿疝、肠扭转、肠套叠、内疝分别行粘连或嵌顿疝松解、扭转或套叠肠管复位;结直肠肿瘤24例(20.87%)中14例(12.17%)行根治性手术,4例(3.48%)行姑息性切除术,4例(3.48%)行结肠造口,2例(1.73%)行短路手术,术后均经病理确诊;其余8例均在探查后行相应的手术。结果 115例中,89例均治愈,拟坏死肠管共切除30例(26.08%);术后19例(16.52%)发生并发症:切口感染6例(5.21%),肺部感染4例(3.48%),吻合口瘘5例(4.35%),术后出血1例(0.87%),腹腔感染3例(2.6%);术后死亡7例(5.21%)。粘连性、肿瘤性及斜股疝嵌顿为肠梗阻的前三位病因,且这三类肠梗阻并发症发生率差异无统计学意义(P>0.05)。结论早期诊断、把握手术适应证、积极合理的治疗能够降低肠梗阻的并发症与病死率。     

135例高龄胃癌患者的外科治疗

目的探讨高龄胃癌患者的临床特点及外科治疗方法.方法回顾性分析经手术治疗的135例70岁以上胃癌患者的临床资料.结果高龄患者病变分期晚,Ⅲ、Ⅳ期占67.4%;术前合并症占68.1%;肿瘤切除率为76.3%;术后并发症占29.6%,其中术前营养不良者并发症发生率高于营养状况良好者,二者相比有非常显著性意义(P＜0.01);手术死亡率为2.2%;肿瘤切除者5年存活率为30.1%(31/103).结论高龄胃癌患者术前营养状况的改善以及合并症的处理是围手术期的重要环节,手术切除是高龄胃癌患者的首选治疗方案,手术方式应强调个体化原则.     

腹腔内巨大精原细胞瘤2例报告

1病例资料 例1∶53岁男性患者,发现右侧腹部包块渐大2年余,病程中有腹胀,腹部隐痛不适,无发热,进食正常,无大小便异常,期间未行任何治疗,近期包块增大明显.于2008年4月13日就诊南昌大学第一附属医院,体检:全身状况尚可,右侧中下腹明显隆起,可触及一囊性包块,上至右侧肋缘下3指,左侧超过中线约1指,无明显压痛,右侧隐睾.余未见异常,B超及CT均提示右侧腹部囊实性混合包块.完善术前检查及术前准备,包括肠道准备后行剖腹探查,术中发现右侧腹腔巨大囊实性混合包块,囊液清亮,包块基底伴于右下腹,包块与回盲部紧密粘连,腹腔内未见明显肿大淋巴结,将囊液吸尽后分离肿块与腹腔内脏器主要是肠管的粘连,因肿块与回盲部粘连无法分开,而行右半结肠与肿块联合切除,术后病理证实为精原细胞瘤并囊性病变.术后予以手术区域放疗,随访3年2个月,健康存活.     

老年人结肠癌致肠梗阻的处理

目的探讨老年人结肠癌致肠梗阻的处理和Ⅰ期切除吻合术的疗效.方法总结70例老年结肠癌致肠梗阻处理的临床资料,其中60例Ⅰ期切除吻合术,术中排空肠道,采用全层间断内翻吻合术吻合肠管,用低渗温水冲冼腹腔,关腹前留置5-Fu500～1000 mg于腹内.结果切口感染8例,裂开2例,吻合口瘘3例,无围手术期死亡.术后随访1、3、5、10年生存率依次为94.2%(66/70)、87.9%(58/66)、72.4%(42/58)、52.4%(22/42).结论老年结肠癌致肠梗阻采用Ⅰ期切除吻合是可行的.     

Contrast-enhanced power Doppler sonography of the intestinal wall in the differentiation of hypervascularized and hypovascularized intestinal obstructions in patients with Crohn's disease.

OBJECTIVE: To use power Doppler sonography to quantify the vascularization in the area of stenosed bowel segments in patients with Crohn's disease and to draw conclusions from these findings with regard to the development of these stenoses. METHODS: The study collective included 11 patients with confirmed Crohn's disease and sonographically visualized stenoses of the small bowel together with intermittent abdominal cramping as a clinical correlate. Power mode examination was repeated after application of a sonographic signal-enhancing agent. Semiquantitative evaluation based on the sonographically indicated degree of vascularization led to the presumptive diagnosis of either inflammatory or cicatricial intestinal obstruction. Sonographic diagnoses were compared with the findings of surgery and subsequent histologic examination or with patients' clinical responses to conservative therapy. RESULTS: Nine of 11 patients underwent surgery within 1 year of examination. All 3 cases in which sonography had facilitated the diagnosis of cicatricial stenosis were confirmed at postoperative histologic examination; similarly, the surgical and histologic findings in the other 6 patients confirmed the sonographic diagnosis of inflammatory stenosis. CONCLUSIONS: Power Doppler sonography in combination with the use of a signal-enhancing agent appears to be effective in the recognition of predominantly cicatricial stenoses in patients with Crohn's disease.     

姑息性手术治疗消化道恶性肿瘤致肠梗阻的效果及预后

目的分析姑息性手术治疗消化道恶性肿瘤致肠梗阻的效果及预后。方法选择2016年1月至2019年7月本院收治的52例消化道恶性肿瘤致肠梗阻患者为研究对象,根据患者选择术式的不同将其分为根治组与姑息组,各26例。根治组行根治性手术治疗,姑息组实施姑息性手术治疗。比较两组患者的治疗效果、恢复时间、治疗前、后生存质量评分及肠梗阻复发率。结果姑息组的症状改善率显著高于根治组(P<0.05)。姑息组的初次经口进食时间、肠内营养支持时间及住院时间均显著短于根治组(P<0.05)。治疗后,姑息组的生理领域、心理领域、环境领域及认知能力评分均高于根治组(P<0.05)。姑息组的肠梗阻复发率显著低于根治组(P<0.05)。结论姑息性手术治疗消化道恶性肿瘤致肠梗阻,可快速改善患者的胃肠功能状态,缩短治疗及住院时间,且患者术后肠梗阻复发率相对较低,建议临床推广使用。     

Temporary intestinal occlusion induced by a "patency capsule" in a patient with Crohn's disease

A 26-year-old woman was admitted for the investigation of abdominal symptoms related to ileal Crohn's disease. The patient had been diagnosed 3 years previously with systemic sclerosis, and had been experiencing digestive complaints for 6 months. A first computed tomography (CT) scan showed ileal intestinal mucosal alterations, associated with a sclerolipomatosis and suspicion of ileal stenosis. An ileocolonoscopy was then performed and showed ulcers in the terminal ileum with nonspecific inflammatory changes found on biopsies, both suggesting the diagnosis of Crohn's disease. The patient was admitted for M2A capsule endoscopy, in order to clarify the respective roles of systemic sclerosis and Crohn's disease with regard to the symptoms and secondarily to determine the anatomical extent of the Crohn's lesions. A patency capsule was administered, for detection of intestinal stenosis before capsule endoscopy was done. At 30 hours after capsule ingestion, the patient complained of abdominal pain and nausea and experienced intestinal obstruction due to the blockage of the patency capsule in the ileal stenosis. The capsule dissolved after 76 hours and the patient then improved. After a few days, the patient underwent ileocecal resection. Pathological examination of the surgical specimen confirmed the presence of an ileal stenosis 17 cm in length. In some circumstances a patency capsule may dissolve slowly, leading to transitory intestinal obstruction requiring medical intervention. It should thus be used cautiously under clinical surveillance in patients with Crohn's disease.     

Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease

BACKGROUND AND STUDY AIMS: Intestinal tuberculosis and Crohn's disease are chronic inflammatory bowel disorders that are difficult to differentiate from one another. This study aimed to evaluate the diagnostic value of various colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease. PATIENTS AND METHODS: Colonoscopic findings on initial work-up were prospectively recorded in patients with an initial diagnosis of either intestinal tuberculosis or Crohn's disease. These findings were analyzed after a final diagnosis of intestinal tuberculosis (n = 44) or Crohn's disease (n = 44) had been made after follow-up. RESULTS: Four parameters (anorectal lesions, longitudinal ulcers, aphthous ulcers, and cobblestone appearance) were significantly more common in patients with Crohn's disease than in patients with intestinal tuberculosis. Four other parameters (involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps) were observed more frequently in patients with intestinal tuberculosis than in patients with Crohn's disease. We hypothesized that a diagnosis of Crohn's disease could be made when the number of parameters characteristic of Crohn's disease was higher than the number of parameters characteristic of intestinal tuberculosis, and vice versa. Making these assumptions, we calculated that the diagnosis of either intestinal tuberculosis or Crohn's disease would have been made made correctly in 77 of our 88 patients (87.5 %), incorrectly in seven patients (8.0 %), and would not have been made in four patients (4.5 %). CONCLUSIONS: A systematic analysis of colonoscopic findings is very useful in the differential diagnosis between intestinal tuberculosis and Crohn's disease.     

中国Crohn病患者85例与美国Crohn病患者68例临床特征及治疗手段:1985～2004年回顾性分析

背景：Crohn病症状复杂多变，缺乏特异性，与肠内病变的部位，范围，严重程度，有无并发症等有关，诊断多困难。因该病病因不甚清楚，尚缺乏根治性治疗。国内外报道Crohn病患者在临床表现和治疗措施方面亦有所不同。目的：探讨中国与美国Crohn病患者的临床特征及治疗的不同。设计：回顾性病例分析。单位：解放军总医院消化内科。对象：收集解放军总医院1985／2004期间住院的Crohn病患者85例和美国佛罗里达克利夫兰医院（Cleveland Clinic Florida，CCF）1985／2004Crohn病患者68例的病例资料。Crohn病的诊断依据WHo标准，根据患者内镜或X射线平片表现及病理特征做出诊断。方法：比较两医院患者的临床资料包括：年龄，性别，家族史，肠外表现，病变部位，病变特征，药物治疗及手术治疗。组间计数资料差异比较采用r检验。主要观察指标：Crohn病发病年龄、家族史、肠外表现、病变部位、病变特征、药物治疗及手术治疗。结果：①一般情况及肠外表现：解放军总医院男性患者与女性患者比例1．74：1，CCF为男：女=1：1．43。CCF患者家族史阳性率和肠外表现发生率分别为7％，34％，均高于解放军总医院（1％，14％，r=4．6312，8．315O，P〈0．05）。②病变部位与病理特征：解放军总医院患者病变部位累及回肠末端（69％）较多，无一例累及肛周，病变以溃疡（66％）多见，溃疡、肠腔梗阻发生率分别为66％和14％，高于CCF患者（25％和4％，Х^2=25．3092，4．0246，P〈0．05）。CCF患者累及结肠及直肠较多，肛周瘘管或直肠阴道瘘（51％）较多，肛周病变、腹腔内瘘发生率分别为51％和9％，显著高于解放军总医院（0和6％，Х^2=38．4290，0．1482，P〈0．05）。③治疗：解放军总医院治疗药物以SASP（54％），5-ASA（19％）及甲硝唑（21％）为主，CCF患者以激素（60％），硫唑嘌呤（34％），infliximab（46％）为主。CCF患者接受手术治疗率明显高于301医院（96％，49％，Х^2=36．1459。P〈0．01）。结论：301医院与CCF的Crohn病患者临床特征和治疗手段有明显差异，临床特征的不同是两者在治疗方法上采取不同措施的原因之一。     

Acute Surgical Abdomen Due to Phytobezoar-induced Ileal Obstruction

Background

Phytobezoar-induced small bowel obstruction is an uncommon clinical entity accounting for 2–4.8% of all mechanical intestinal obstructions. In addition, presentation with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients.

Objectives

The aim of this report is to present a very rare case of a phytobezoar-induced small bowel obstruction in a male patient who presented with acute surgical abdomen. A correct preoperative diagnosis was made based on the patient’s history and characteristic imaging features on the emergency computed tomography (CT) scan.

Case Report

A 55-year-old man with previous gastrectomy presented with typical manifestations of acute abdomen. CT scan demonstrated dilatated small bowel loops and an intraluminal ileal mass with a mottled appearance. At exploratory laparotomy, a phytobezoar was found impacted in the terminal ileum and was removed through an enterotomy.

Conclusions

Phytobezoar should be considered in patients with previous gastric outlet surgery who present with bowel obstruction and features of acute surgical abdomen. The presence of a well-defined intraluminal mass with a mottled gas pattern on emergency CT scan is suggestive of an intestinal phytobezoar.     

肠梗阻指数对于老年肠梗阻患者手术时机选择的临床意义

目的探讨肠梗阻指数对于老年肠梗阻患者治疗方式的指导价值。方法选择2015年1月至2019年12月航天中心医院与首都医科大学附属北京康复医院住院的老年性肠梗阻患者178例,对患者肠梗阻指数与临床特征,治疗方式及治疗效果的相关性进行分析。结果患者平均肠梗阻指数12.4分,中位12(3~22)分。手术治疗患者肠梗阻指数显著高于保守治疗患者,差异有显著性(P<0.001),手术治疗组≥10分患者93例(94.9%),保守治疗组≥10分患者44例(55.0%)。以10分作为判断手术标准,敏感性为94.9%,特异性为45.0%,阳性预测值67.8%,阴性预测值87.8%。以12分作为判断手术标准,敏感性为40.8%,特异性为82.5%,阳性预测值74.1%,阴性预测值53.2%。患者性别、年龄、肠梗阻病因分组中肠梗阻指数差异无显著性(P>0.05);而并存疾病及临床结局肠梗阻指数分布差异有显著性(P<0.05)。肠梗阻病因中,机械性肠梗阻142例(79.8%),>12分者51例(35.9%);并存疾病及死亡患者肠梗阻指数均显著升高,差异有显著性(P<0.05)。不同病因分组中,机械性肠梗阻患者手术治疗患者肠梗阻指数显著高于保守治疗组,差异有显著性(P<0.001),而其他病因差异均无显著性(P>0.05)。结论肠梗阻指数评分法对于老年肠梗阻患者手术时机的选择有一定的指导价值,可在全面评估、综合分析判断的基础上,决定是否手术治疗。     

老年人大肠癌致肠梗阻临床分析

本院１０年间住院的老年人肠梗阻５８５例,其中大肠癌导致肠梗阻６５例占１１．１％,对老年人癌性梗阻,老年群体特点,病理分型,临床表现,内科并存病,诊断要点,治疗选择,环境因素影响,合理的检查手段及手术时机的等进行全面临床分析。结果提示：对老年人肠道疾病,尤其出现肠道梗阻症状时,首先应考虑淡大肠癌,一旦确诊应积极切除原发病灶,减轻瘤负荷以延长患者的寿命,提高生存质量,为放,化疗打下基础。     

Ultrasonographic findings correspond to clinical, endoscopic, and histologic findings in inflammatory bowel disease and other enterocolitides.

OBJECTIVE: To compare results obtained by abdominal ultrasonography with clinical findings, including endoscopic and histologic findings, to evaluate the location and activity of inflammatory bowel disease, including disease controls in children. METHODS: Ninety-two ultrasonographic scans and 41 colonoscopic examinations with biopsies were performed in 78 patients (1 month to 17.8 years of age) with Crohn's disease (n = 26), ulcerative colitis (n = 21), inflammatory bowel disease of indeterminate type (n = 2), and disease controls (other intestinal disorders, including infectious and ischemic lesions; n = 29). Laboratory parameters for inflammatory bowel disease were determined, and disease activity was assessed by a combination of clinical and laboratory data. Bowel wall thickness and echo texture were recorded in a standardized way by ultrasonography and compared with endoscopic and histologic findings in a segment-by-segment comparison. RESULTS: Sensitivity and specificity of ultrasonography in detecting patients with severe macroscopic lesions depicted on endoscopy were 77% and 83%, respectively. Sensitivity and specificity of ultrasonography in detecting patients with severe histologic inflammation were 75% and 82%. There was a statistically significant correlation between maximal bowel wall thickness and disease activity score (P < .01). CONCLUSIONS: Abdominal ultrasonography may be helpful in evaluating the location, severity, and inflammatory activity of inflammatory bowel disease in children and young adults.     

Long-term outcome of endoscopic balloon dilation in obstructive gastrointestinal Crohn's disease: a prospective long-term study

Background The short- and long-term results of balloon dilation therapy in Crohn's patients with non-anastomotic obstructive gastrointestinal lesions are investigated.Materials and methods Fifty-five patients with Crohn's disease who had obstructive gastrointestinal lesions were treated prospectively by endoscopic balloon dilation.Short-term results Eight of the initial dilations were unsuccessful giving no symptomatic relief (14.5%).Long-term results The subjects of the long-term prognosis were 40 cases followed up for more than 6 months (average 37 months) and their strictures were non-anastomotic in more than half (59%). Avoidance of surgery, was possible in 31 of 40 patients (78%). Surgery was avoided in 92%, 81% and 77% of patients after one, two, and three years, respectively (Kaplan-Meier's method). There was no difference in long-term outcome between anastomotic strictures and strictures in the absence of prior surgery.Conclusion Our results suggest that, (1) strictures in the absence of prior surgery might be treated in this way as well as anastomotic strictures; (2) if followed for a prolonged time period, more than 70% of patients, who have undergone balloon dilation for obstructive gastrointestinal Crohn's disease, may be able to avoid surgery.