急性胆囊炎并发胆囊穿孔的超声诊断价值

目的　为探讨急性胆囊炎并发胆囊穿孔的超声诊断价值 ,对我院收治的 8例上述患者资料进行了回顾性分析。方法　 8例急性胆囊炎并发胆囊穿孔患者 ,男 3例、女 5例 ,年龄 5 5～ 83岁 ,平均年龄 (6 7.2 5±9.6 0 )岁。使用东芝 6 0 0 0型超声诊断仪 ,探头频率 3.5～ 6 .0 MHz,患者取平卧位或左侧卧位检查。结果　 8例穿孔患者胆囊壁连续性中断 ,缺损大小在 0 .2 cm～ 1 .1 cm不等 ,其周围可见局限性积液 ,范围在 0 .8cm× 0 .9cm～ 5 .1 cm× 3.4 cm。囊内均可见结石影像 ,1例合并有胆总管结石 ,另 1例合并胆总管肿瘤。 8例患者胆囊腔内均可见密集点状回声 ,为淤积的胆汁影像。穿孔的部位 :1例位于胆囊底部 ,3例位于体部 ,4例位于颈部。结论　在急性胆囊炎并发胆囊穿孔的病例中 ,应用超声全面细致地检查不仅可直观迅速地明确有无穿孔、穿孔的部位、大小以及腹腔积液的情况 ,可动态观察 ,对疗效评估并适时调整治疗 ,有一定的价值     

超声诊断胆囊穿孔的应用价值

目的探讨超声检查对胆囊穿孔的诊断价值。方法对32例临床疑诊胆囊疾病并发穿孔的患者术前行超声检查,检查结果与手术结果进行对照分析。结果超声探查胆囊穿孔,其诊断准确率达81．3％,敏感性为92.9％;频率在一定范围内增高（5-7．5MHz）,声像图更能清楚的显示穿孔部位。结论超声检查特别是高频超声诊断胆囊穿孔准确性较高,可作为诊断胆囊穿孔的重要检测手段。     

Acute acalculous cholecystitis in acute renal failure

Acute acalculous cholecystitis developed in 16 of 92 patients with acute renal failure who had no prior or coincidental biliary tract disease. The cause of this complication is considered to be multifactorial. Risk factors include sepsis, previous surgery, trauma, total parential nutrition, intermittent positive pressure ventilation, opiate sedation, multiple transfusions and hypotension. One patient had 5 risk factors, 15 had 6 or more. Diagnosis was based on clinical suspicion, serial ultrasound scanning and serial estimations of white cell count, liver function and C-reactive protein. Four patients were treated conservatively with antibiotics and ultrasound observation, 10 underwent cholecystotomy and 2 patients had cholecystectomy. Eleven patients survived (69% survival). No patient treated by cholecystotomy required further surgery to the biliary tract. Acute acalculous cholecystitis has become a significant complication in our “high risk” acute renal failure population as intensive care has advanced and patients are surviving longer. Prompt and appropriate treatment will prevent it contributing significantly to the already high mortality of acute renal failure. Anticipation is the watchword.     

Meckel Diverticulum Presenting as Abdominal Pain and Subsequent Bowel Perforation

BackgroundAbdominal pain is a common presenting symptom with a broad array of potential etiologies. Meckel diverticulum (MD), the most common congenital gastrointestinal malformation, classically presents with painless gastrointestinal bleeding. However, it can also lead to diverticulitis, intussusception, or obstruction, manifesting as abdominal pain.Case ReportA 2-year-old boy presented to the emergency department with intermittent abdominal pain, vomiting, and loose stools. Abdominal ultrasound findings were consistent with ileitis and ileocolic intussusception, but no such intussusception was seen during fluoroscopic air enema. The patient was admitted for serial abdominal examinations and subsequently developed an acute abdomen. Emergent laparotomy revealed a perforated MD. Small bowel resection and primary anastomosis were performed and no complications developed.Why Should an Emergency Physician Be Aware of This?The presence of an MD can lead to diverticulitis, intussusception, or obstruction, putting the patient at risk of bowel perforation. As such, it is important to consider MD in the differential diagnosis of patients with abdominal pain. In cases in which sonographic findings are ambiguous or transient, additional observation or alternative imaging, such as computed tomography, should be strongly considered.     

Computed tomography as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis

The sonographic and computed tomographic (CT) findings were reviewed in 17 patients with acute acalculous cholecystitis (AAC) over a 6-year period from 1984 to 1989. Of the six patients in whom both ultrasound and CT were performed, CT revealed marked gallbladder (GB) wall abnormalities, including perforation, and pericholecystic fluid collections in five patients not demonstrated by sonography. Of the total group, five patients had GB wall thicknesses of 3 mm (normal) at pathologic examination, which demonstrated a spectrum of disease ranging from acute hemorrhagic/necrotizing, to gangrenous acalculous cholecystitis with perforation. Sonography was falsely negative or significantly underestimated the severity of AAC in seven of the 13 patients examined by sonography. CT because of its superior ability to assess pericholecystic inflammation may provide additional diagnostic information even after a thorough sonographic study in cases of AAC.     

乙状结肠自发性破裂9例临床分析

目的：探讨乙状结肠自发性破裂的病因、临床特点和治疗效果。方法：回顾性分析9例乙状结肠破裂的病因、病程、就诊时间对治疗效果和预后的影响。结果：乙状结肠自发性破裂多数为老年病人，中毒症状重，临床上易漏诊、误诊，并发症发生率及死亡率高。就诊时问晚、手术治疗迟和伴有恶性肿瘤的病人预后极差。结论：早期确诊，尽早手术，术中仔细探查，合理施治，是改善其预后的关键。     

自发性食管破裂临床分析--附18例报告

目的：探讨自发性食管破裂的早期诊断与治疗的必要性。方法：自1986年8月～2001年6月，18例自发性食管破裂病人接受外科治疗，开胸手术裂口修补5例；食管切除、食管胃胸膜顶吻合2例；裂口修补加胃造瘘3例；单纯胸腔闭式引流加空肠造瘘8例。结果：开胸手术10例，死亡1例，平均住院25d。保守治疗8例，死亡5例，死亡率(5／8)62．5％，平均住院45d。结论：自发性食管破裂早期诊断是治疗的关键，一旦诊断明确应积极开胸手术，即使发病超过24h，只要全身条件允许也应积极手术治疗。食管切除，食管胃吻合，较其它术式更为安全。     

经皮经肝胆囊穿刺置管引流在老年急性胆囊炎患者中的应用

目的：总结B超引导下经皮经肝胆囊穿刺引流(UPTGD)对老年急性胆囊炎患者的治疗经验。方法：对1990年1月至2001年12月期间接受UPTGD治疗的113例老年急性胆囊炎患者的临床资料进行回顾性分析：结果：所有患者均穿刺置管成功。110例(97．3％)获得有效的胆囊引流,108例(95．6％)治愈。91例于急性胆囊炎治愈后2周至3月行择期胆囊切除术,3例行胆囊的“化学性切除。”1例发生胆囊出血,2例出现胆汁腹腔漏。全组无1人因急性胆囊炎及相关的治疗而死亡。3例行胆囊化学性切除的患者随访分别达1．5、2及3年,患者无症状出现,并且B超证实胆囊腔完全闭锁。结论：UPTGD是治疗老年性胆囊炎患者的一项安全、简便、有效的方法。     

急性非外伤性结肠穿孔诊治体会

目的:探讨急性非外伤性结肠穿孔的病因、诊断及治疗.方法:回顾性分析15例急性非外伤性结肠穿孔病例的处理.结果:穿孔原因为癌性穿孔7例,缺血性穿孔2例,溃疡性结肠炎2例,穿孔原因不明4例.术前2例考虑为左半结肠穿孔.右半结肠穿孔病例采用病灶切除一期吻合,左半结肠穿孔病例采用Hartmann手术为主,3例死亡病例手术时间距起病都超过24小时.结论:急性非外伤性结肠穿孔以肿瘤最多见;本病术前诊断较困难;早诊断、早治疗是提高急性非外伤性结肠穿孔抢救成功率的主要措施.     

超声引导下经皮经肝胆囊穿刺置管引流治疗急性重症胆囊炎

目的:观察利用超声引导下经皮经肝胆囊穿刺置管引流(PTGCD)治疗急性重症胆囊炎的临床疗效。方法:24倒有胆囊切除禁忌的急性重症胆囊炎患者,在超声引导下行PTGCD。结果:一次性置管成功率100%(24/24)。术后1 d临床症状缓解率100%,无严重的并发症。10例非结石性胆囊炎患者于引流后3～4周,造影示无胆囊管梗阻后拔管;14例结石性胆囊炎患者,8例于2～3个月后行胆囊切除术,6例不能手术患者无症状长期置管,其中4例死于的肿瘤进展。结论:PTGCD对急诊胆囊切除手术禁忌的急性重症胆囊炎患者是一种简单、安全、有效的缓解症状的方法。     

Emergency Ultrasound of the Gall Bladder: Comparison of a Concentrated Elective Experience vs. Longitudinal Exposure During Residency

Background

It is unknown how an intensive emergency ultrasound (EUS) experience compares with comparable exposure done over the course of residency training.

Objective

Our objective was to compare the accuracy of EUS of the gall bladder done by physicians after a 2-week EUS elective with similarly numbered examinations done by physicians longitudinally over several years of residency training.

Methods

This was a secondary analysis of a previously reported prospective study of EUS for biliary disease. The 21^st−40^th examinations were compared between those who participated in an EUS elective and those who did not. The gold standard was ultrasound done by the Department of Radiology.

Results

Mean time to complete 40 EUS examinations for biliary disease was 14 months for those participating in an EUS elective compared with 29 months for those who did not. One hundred and ninety-one examinations (49%) were done by 19 operators who did not participate in an EUS elective and 202 examinations (51%) were done by 23 operators who completed an EUS elective. There was no statistical difference between the two groups with regard to detecting the presence of gall stones, gall bladder wall thickening, pericholecystic free fluid, ductal dilation, or sludge.

Conclusions

Physicians who participated in a 2-week, semi-structured EUS elective demonstrated EUS accuracy for biliary disease that was comparable with those who performed the same number of examinations over a longer period of time.     

Acute cholecystitis due to strangulation of a floating gallbladder by the lesser omentum

We report a unique case of acute cholecystitis due to strangulation of a floating gallbladder by the lesser omentum, which could be detected by abdominal ultrasonography. We believe this case to be the first case of reported literatures in English.     

Acute acalculous cholecystitis and cardiovascular disease: a land of confusion

Acute acalculous cholecystitis (AAC) can be defined as acute inflammatory disease of the gallbladder without evidence of gallstones. The first case was reported in 1844 by Duncan et al.; however, some cases may have been missed previously in view of the complexity of the diagnosis. Several risk factors have been identified, and cardiovascular disease (CVD), in view of its multiple mechanisms of action, seems to play a key role. Atypical clinical onset, paucity of symptoms, overlap with comorbidities, and lack of robust, controlled trials result often in under or misdiagnosed cases. Moreover, laboratory results may be negative or not specific in the late stage of the disease, when a surgical treatment cannot be longer helpful if complications arise. A rapid diagnosis is therefore essential to achieve a prompt treatment and to avoid further clinical deterioration. In this short review, we would present the current evidence regarding epidemiology, pathophysiology, and clinical presentation of the complex relation between AAC and CVD. Then, we fully emphasize the role of ultrasound to achieve an early diagnosis and an appropriate treatment in suspected cases, reducing mortality and complications rates.     

胃十二指肠溃疡急性穿孔手术时机和手术方式探讨

目的 :探讨胃十二指肠溃疡急性穿孔手术治疗的时机和方式。方法 :按穿孔时间、年龄及腹腔积液量分组 ,评价手术时机 ;分析手术病人的住院时间、术后溃疡复发率及再手术率。结果 :穿孔时间 >8h ,年龄 >6 0岁 ,腹腔积液量 >2 0 0ml组与相应对照组手术率差异有显著意义。单纯缝合修补组住院时间显著低于胃大部切除术组 ,而溃疡复发率及再手术率二组无显著差异。结论 :穿孔时间、年龄及腹腔积液量对胃十二指肠溃疡急性穿孔手术时机的选择有重要意义 ;单纯缝合修补术应成为手术治疗的主要方式。     

154例消化性溃疡穿孔的诊疗体会

目的:探讨消化性溃疡穿孔的诊断及治疗方法。方法:回顾分析2000～2005年收治的154例消化性溃疡穿孔患者临床表现、诊断及治疗方法。结果:154例中,术前确诊143例(92.8%),误诊11例(7.1%)。非手术治疗31例(20.1%),全部治愈;穿孔修补术35例(22.7%);胃大部切除术88例(57.1%);术后无十二指肠残端破裂、再穿孔、吻合口瘘等近期并发症。结论:术前X线、B超及腹腔穿刺联合应用可提高溃疡穿孔的确诊率,胃大部切除术与单纯溃疡穿孔修补术或非手术治疗近期并发症的发生无显著性差异,但远期疗效优于后两者。     

胃肠吻合器在胃十二指肠溃疡急性穿孔手术中的临床应用

【目的】探讨胃肠吻合器在胃十二指肠溃疡急性穿孔手术中的应用价值。【方法】2003年6月至2006年6月收治胃十二指肠溃疡急性穿孔病例72例,根据手术中吻合方法分为研究组(吻合器吻合组)和对照组(手工吻合组)。研究组36例,其中十二指肠球部溃疡穿孔28例,胃窦部溃疡穿孔6例,胃小弯溃疡穿孔2例;采用BillrothⅠ术式治疗26例,BillrothⅡ式8例,Roux-en-y胃肠吻合2例。对照组36例,十二指肠球部溃疡穿孔25例,胃窦部溃疡穿孔5例,胃小弯溃疡穿孔6例;采用BillrothⅠ术式治疗20例,BillrothⅡ式12例,Roux-en-y胃肠吻合4例。【结果】研究组手术时间(112.0±21.1min)较对照组(165.0±23.8min)短(P<0.01),术后胃肠功能恢复时间(43.6±5.6h)较对照组(63.6±10.7h)短(P<0.01),术中出血量(130±10mL)较对照组(220±14mL)少(P<0.01),住院时间较对照组短。研究组无吻合口瘘,无吻合口狭窄及出血,对照组发生吻合口狭窄1例、吻合口漏1例、吻合口出血2例,研究组并发症明显低于对照组(P<0.01)。【结论】胃十二指肠溃疡急性穿孔时应用胃肠吻合器行胃大部切除术具有出血少、手术时间短、胃肠功能恢复快、术后并发症少等特点,值得推广应用。     

急性上消化道穿孔的螺旋CT诊断

目的 探讨螺旋CT对急性上消化道穿孔的诊断价值。方法 对49例经手术证实的急性上消化道穿孔患者的 CT 影像资料进行回顾性分析。结果 49例患者中,十二指肠溃疡穿孔33例（67.35%）;胃溃疡穿孔16例（32.65%）,其中胃窦前壁穿孔9例（56.25%）,胃小弯前壁穿孔7例（43.75%）。腹腔游离气体49例（100.00%）,腹腔积液46例（93.88%）,胃肠道壁不规则增厚或周围脂肪层模糊23例（46.94%）。结论 通过螺旋CT诊断上消化道穿孔的患者,可以明确患者穿孔的病灶,能弥补X线平片的不足,为临床外科急腹症提供快速而可靠的诊断依据。     

Clinical characteristics of patients with newly developed acute cholecystitis after admission to the intensive care unit

IntroductionCritical care patients have many risk factors for acute cholecystitis (AC). However, less data are available regarding newly developed AC in critically ill patients.ObjectivesTo investigate the clinical features of AC occurring in critically ill patients after admission to an intensive care unit (ICU).MethodsWe performed a retrospective cohort study from January 2006 to August 2016 at a tertiary care university hospital. We included patients diagnosed with AC with or without gallstones after ICU admission. All cases of AC were confirmed by gastroenterologists or general surgeons. We excluded patients with AC diagnosed before or at the time of ICU admission.ResultsA total of 38 patients were diagnosed with AC after ICU admission between January 2006 and August 2016. Seventeen (44.7%) had acute acalculous cholecystitis, while 21 (55.3%) had acute calculous cholecystitis. The median age was 73 years (interquartile range = 63–81 years), and 22 (57.9%) patients were male. The most common reason for ICU admission was pneumonia or sepsis. The median interval from ICU admission to diagnosis of AC was 11 days (interquartile range = 4.8–22.8 days). Before AC diagnosis, almost 90% of patients used total parenteral nutrition, 68% used opioids, 76% were mechanically ventilated, and 42% received vasoactive drugs. More than half of patients underwent cholecystectomy, and all surgically resected gallbladders had pathology results for cholecystitis. Gangrenous cholecystitis was observed in five patients with acute calculous cholecystitis. The overall mortality was 42.1%, and 1/3 of these deaths were directly associated with AC. The average length of stay in the ICU and hospital was 26.5 and 44.5 days, respectively.ConclusionThe development of AC in the ICU should be carefully monitored, especially in patients who have been infected and admitted to the ICU for more than 10 days. Proper diagnosis and treatment at a critical time could be lifesaving.