1例疑诊细菌性肝脓肿患者的循证治疗

目的为1例疑诊细菌性肝脓肿患者制定合理的外科治疗方案。方法针对患者的临床问题，以肝脓肿、开腹引流和腹腔镜等MeSH主题词和自由词，计算机检索Cochrane图书馆（2007年第4期）、MEDLINE（1996～2008．1）、ACP Journal Club（1991．1—2008．1）和中国期刊全文数据库（1994～2008．1），查找相关的系统评价、随机对照试验和临床回顾性研究等，并对所获证据进行质量评价。结果我们没有检索到关于腹腔镜引流与开腹引流对比治疗肝脓肿的系统评价和大样本随机对照试验，因此选择了与临床问题密切相关的4篇回顾性临床研究。其结果提示腹腔镜下引流治疗肝脓肿安全有效，具有手术时间短、创伤小、恢复快、费用低、并发症少等优点，是开腹手术的理想替代术式。但因病例数有限，还需要高质量、大规模临床随机对照试验来证实，因此我们结合医生经验和患者意愿，对该患者未采用腹腔镜引流治疗，而是实施开腹引流手术，最终患者痊愈出院。结论现有的4篇回顾性研究虽显示腹腔镜对肝脓肿患者安全有效，但患者例数有限，尚需高质量、大样本的随机对照试验证实。     

The Liver in Crohn's Disease

Clinical, haematological, biochemical, bacteriological, histological,and immuno-logical data of 100 patients with Crohn's diseasehave been examined with special reference to liver disease anddysfunction. Several significant points emerged from the clinical data. Therewas a high frequency of colonic involvement (57 per cent), andalso a very high proportion of patients (48 per cent) with systemiccomplications, the commonest systemic complications being iritis(19 per cent) and sacro-ileitis (15 per cent). Nearly three-quarters(71 per cent) of the patients had been operated on at some timeand 57 per cent had had one or more bowel resections. Localcomplications had occurred in 52 per cent of patients. Biochemical liver dysfunction was common, occurring in 26 (26per cent) patients, the BSP being the test most frequently abnormal.Two patients with established chronic liver disease had considerablebiochemical liver dysfunction, but about half the patients withlesser pathological changes in the liver had no biochemicalliver dysfunction. Of the 39 patients who underwent liver biopsy, 19 (19 per cent)had pathological changes in the liver, the commonest changesfound being pericholangitis (8 per cent), focal necrosis (6per cent), and fatty change (4 per cent). Only two patientshad chronic liver disease, one patient having chronic activehepatitis and the other portal cirrhosis associated with haemosiderosis. Culture of liver tissue for bacteria or L forms was uniformlynegative. Immuno-logical studies proved unrewarding in relationto liver disease and dysfunction in patients with Crohn's disease.However, two significant differences did emerge in comparingthe results of the immunological tests in ulcerative colitiswith those in Crohn's disease. Positive immunofluorescence teststo human colon were found in 12·7 per cent of patientswith ulcerative colitis, compared with only 2·3 per centof patients with Crohn's disease. There was also a significantdifference in IgM levels, with low values of IgM more frequentin Crohn's disease and high values more frequent in ulcerativecolitis; further research will be necessary to determine theunderlying reasons for this difference. The finding that the hepatic changes in Crohn's disease areremarkably similar to those in ulcerative colitis, both in frequencyand in type, leads to several possible explanations. First,ulcerative colitis and Crohn's disease may be different manifestationsof a single disease. Secondly, the liver disease and the otherremote complications, which are also similar in Crohn's diseaseand ulcerative colitis, may be a consequence of chronic inflammatorydisease of the intestine, irrespective of its exact nature.Thirdly, ulcerative colitis and Crohn's disease may both begeneralized diseases in which the brunt falls upon the intestinaltract. The aetiology of the hepatic lesions remains obscure but somedeductions can be drawn from the present data. From clinicalconsiderations, the overt liver disease appears to behave likea viral hepatitis which has become chronic. There is no evidenceto support the view that homologous serum hepatitis from bloodtransfusion is the significant factor. Drugs do not appear tobe of any great relevance. Immunological relationships are essentiallynegative. Portal bacteraemia appears to be an unlikely causeof the overt chronic liver disease encountered in the presentstudy.     

以顽固性酸中毒发病的糖尿病并肝脓肿病例分析

目的探讨糖尿病酮症酸中毒并肝脓肿的临床特点,以提高对该病的认识。方法对以顽固性酸中毒发病的糖尿病并肝脓肿1例的临床资料进行回顾性分析。结果本例为51岁女性患者,因出现心悸、气短、呼吸困难、腹胀、腹痛入院。患2型糖尿病5年,未系统诊治。入院后即刻查血糖31.5 mmol/L,二氧化碳结合力7.3 mmol/L,诊断为糖尿病酮症酸中毒,予胰岛素控制血糖、积极补液等治疗,酸中毒仍不能纠正,详细追问病史,自述发病前曾有负重史及肝区挫伤史,遂急行肝脏CT检查示肝肾间隙囊性占位性病变,后证实为血肿继发脓肿,于超声引导下穿刺抽脓并置管引流,引流液行细菌培养为肺炎克雷伯杆菌,根据药物敏感试验结果合理使用抗生素并予控制血糖、补液等治疗,酸中毒纠正,复查CT示脓肿体积缩小,症状明显好转后出院。结论难以纠正的糖尿病酮症酸中毒应仔细查找病因,合并外伤致脏器破裂出血后继发脓肿临床表现不典型,易误漏诊,早期诊断可提高救治成功率。     

化脓性肝脓肿的CT诊断(附44例分析)

目的探讨化脓性肝脓肿(PLA)CT平扫及增强扫描的影像学特点.方法回顾性分析44例经穿刺活检、手术病理或临床随访证实的PLA患者CT及临床资料.结果44例PLA患者多有发热、腹痛、血象异常等急性感染症状;24例PLA(55%)具有典型CT表现,20例(45%)表现不典型.44例中CT明确诊断PLA37例,提示PLA可能6例,误诊为肝癌1例.结论CT表现比较典型的PLA,结合临床症状诊断不难;而不典型PLA,综合分析增强扫描尤其是动态和延时扫描特征可提高诊断准确性.     

Pyogenic liver abscess in Crohn's disease

We describe six cases of pyogenic liver abscess occurring among 1227 Crohn's disease patients admitted to The Mount Sinai Hospital from 1960 through 1982, and review the features of the seven similar cases that have been previously reported. Mechanisms of formation of liver abscess in these 13 patients included direct extension of intraabdominal abscess (three cases), propagation via the portal vein (eight cases), biliary complications (one case), or metastatic cancer (one case). Five of the 13 patients died. All five deaths occurred among the eight patients with multiple abscesses; all five patients with solitary abscess survived. The mean age of the patients who died was 56 years, versus 37 years for the survivors. Three of the four patients treated with antibiotics only died; only two of the nine patients who underwent some form of drainage succumbed. Mortality was usually attributable to failure in making the diagnosis, especially as liver function test abnormalities were often subtle. Furthermore, the generally nonspecific clinical signs and symptoms were often obscured by underlying bowel disease. If a high index of suspicion is maintained, CT scanning and ultrasonography should reveal the lesion at an early stage, so that the necessary drainage procedure can be carried out, with or without concomitant resection of affected bowel and drainage of intraabdominal abscess.     

不典型肝脓肿的CT诊断

目的:分析不典型肝脓肿的CT表现,提高对肝脓肿的诊断水平。材料与方法:回顾分析经临床病理证实的30例不典型肝脓肿的CT平扫及三期强化特点,并与肝癌、肝转移瘤、肝血管瘤等对照分析。结果:按照肝脓肿病变发展阶段不同,不典型肝脓肿可分为早期肝脓肿(25例,有两种表现形式:小房腔性和团块状肝脓肿),和纤维肉芽肿性肝脓肿(5例)。结论:不典型肝脓肿在不同病理演变时期其CT平扫表现不同,动态三期强化扫描有助于提高诊断符合率。     

Pyogenic Liver Abscess: A Retrospective Study of 105 Cases in an Emergency Department from East China

Background

Pyogenic liver abscesses have become common in emergency departments (EDs) in recent years in Shanghai, China due to a variety of risk factors contributory to the disease.

细菌性肝脓肿合并糖尿病与非合并糖尿病患者临床特征的差异性

目的了解细菌性肝脓肿合并糖尿病与非合并糖尿病患者临床特征的差异性,为进一步指导临床诊治及护理提供依据。方法回顾性分析并总结2005年1月至2011年1月哈尔滨医科大学附属第四医院收治的细菌性肝脓肿合并糖尿病患者(糖尿病组)151例以及非合并糖尿病患者(非糖尿病组)145例的临床资料,分析两组患者临床资料之间的差异。结果细菌性肝脓肿合并糖尿病组患者年龄[(62.5±11.4)岁]明显高于非糖尿病组的[(58.0±16.2)岁](P<0.05);糖尿病组心血管疾病发病率较非糖尿病组高,但合并恶性肿瘤的发生率相对较低(P<0.05)。在血及脓培养中,肺炎克雷白杆菌是最常见的病原菌,其中糖尿病组肺炎克雷白杆菌阳性检出率明显高于非糖尿病组(P<0.05)。结论细菌性肝脓肿合并糖尿病患者与非合并糖尿病患者具有不同的临床特征,应引起临床医生及护理工作者的重视。     

巨大阿米巴肝脓肿误诊一例

男,55岁。因发热、腹痛、腹泻、排果酱样便7天入院。否认阿米巴感染者密切接触史。入院前1周出现畏寒、发热,体温在38℃左右,用退热药（药名及剂量不详）体温可暂降,伴有以右侧腹部为主的阵发性钝痛,每日腹泻果酱样稀便4～6次,量较多,无里急后重感,便后腹痛消失,食欲缺乏,无恶心及呕吐,口干,尿少,在村医院按肠炎予庆大霉素16万单位静脉滴注及对症治疗无效,体温升至39℃,遂前往镇医院就诊。彩超检查示肝左叶囊肿。予禁食,应用青霉素等治疗,症状无缓解,肝区钝痛加剧,体重下降约5kg,考虑肝囊肿伴感染。患者为进一步诊治到我院,门诊以发热原因待查：①肝脓肿？②肝囊肿？收入院。查体：体温37．8℃,脉搏92／min,血压106／66mmHg。精神一般。皮肤弹性欠佳,巩膜无黄染,咽部无充血,扁桃体不大。双肺呼吸音清,未闻及干湿性哕音。心率92／min,律齐,各瓣膜区未闻及杂音。     

Anaemia in Crohn's Disease

Sixty-three patients admitted to hospital with an exacerbationof Crohn's disease were investigated. Anaemia was found in 79per cent of males and 54 per cent of females. Low levels ofserum iron (65 per cent), total iron-binding capacity (22 percent), serum vitamin B₁₂, (16 per cent), serum folate (64 percent), and red-cell folate (35 per cent) were also present.With the exception of the serum vitamin B₁₂, these levels weredirectly related to the severity of the disease and were lessreduced in patients with post-operative recurrences. There wasa poor correlation with the site of disease. The serum iron, iron-binding capacity, and transferrin saturationwere unreliable in the diagnosis of iron deficiency. An increasedTIBC usually indicated iron deficiency and a subnormal TIBCsuggested chronic inflammation but did not exclude iron deficiency.Based on the examination of bone marrow iron stores, evidenceof iron deficiency was found in 18 (39 per cent) of 46 patients.The incidence of iron deficiency may have been over emphasizedin the past because bone marrow iron stores have not alwaysbeen examined. Of the 46 patients who had bone marrow aspirated, 18 (39 percent) were megaloblastic. Folate deficiency was implicated asthe underlying cause in 11 and vitamin B₁₂ deficiency in sixpatients; one patient had both deficiencies. Vitamin B₁₂, deficiencywas usually associated with ileal resection, while folate deficiencywas probably due to dietary deficiency and/or increased folaterequirements. Vitamin B₁₂, or folate deficiency should not beimplicated as the cause of anaemia on the basis of serum levelsalone. Moreover, the finding of megaloblastic change in themarrow should not obscure the importance of coexisting irondeficiency or the effects of the inflammatory disease processon erythropoiesis. When there is clear evidence of iron, folate, or B₁₂-deficiencyanaemia this should be treated with appropriate haematinics,although the response may be suboptimal until the inflammatoryprocess is suppressed. As the disease process itself aggravatesthe severity of the anaemia, there will probably be a partialresponse to any treatment which reduces the activity of thedisease.     

Mortality in Crohn's Disease

Two hundred and nineteen Cardiff residents were identified withCrohn's disease between 1934 and 1976, during which period 40of them died. Young patients diagnosed under the age of 20 yearshad a significantly raised standardized mortality ratio (SMR)which was 11. The risk of death was particularly high duringthe first two and a half years after diagnosis and again afterthe disease had been present for more than about 13 years. Casefatality has not diminished during the last 40 years despitechanges in treatment.     

肝脓肿超声造影成像特点分析

目的研究肝脓肿的超声造影灌注动态变化； 方法7例肝脓肿患者进行超声造影观察，分析其造影增强的图像特点； 结果肝脓肿的造影特点表现在动脉相为；厚间隔环状强化带，内部筛孔样强化；表现在延迟期为：边缘清晰的强化缺失或边缘模糊的强化缺失； 结论超声造影能有效地对肝脓肿进行诊断和治疗随访。     

康复新液治疗胸壁结核脓肿合并化脓感染切口愈合不良疗效观察

我院2004-03～2006—04采用康复新液及链霉索等联合治疗胸壁结核脓肿合并化脓感染切口愈合不良，疗效良好，现报告如下。     

计算机断层摄影引导下经皮细菌性肝脓肿穿刺置管引流

  目的  评价计算机断层摄影(computed tomography, CT)引导下经皮穿刺引流治疗细菌性肝脓肿的安全性和有效性。  方法  回顾性分析2004年1月至2010年12月, 54例在本院行CT引导下细菌性肝脓肿穿刺置管引流患者的临床及影像学资料。  结果  54例肝脓肿患者中37例为单一病灶, 17例为多发病灶; 脓肿平均最大径为(10.5±5.6)cm; 穿刺技术成功率为100%, 无严重并发症发生, 全部患者穿刺引流治疗后症状得到改善。41例患者在住院期间拔除外引流管, 平均置管时间(20.6±7.8)d; 另13例患者症状好转后, 带管出院。  结论  CT引导下经皮穿刺引流治疗细菌性肝脓肿安全而有效。