两种体表测量法在PICC置管深度评估中的效果比较

目的探讨PICC导管末端置于体内最适位置的最佳体外测量方法。方法将86例行PICC置管患者随机分为观察组和对照组各43例。观察组采用从右上肢穿刺点至右胸锁关节＋4cm,或者从左上肢穿刺点至右胸锁关节＋4cm的测量法,对照组采用从穿刺点至右胸锁关节,再向下反折至第3肋间的测量法,置管到达测量长度后,摄胸部X线片定位。比较两组PICC导管末端置入上腔静脉及置于最适位置的成功率、置管长度。结果观察组置入最适位置36例,成功率92．31％,置入上腔静脉39例,成功率90．70％;对照组置入最适位置12例,成功率38．71％,置入上腔静脉31例,成功率72．09％。观察组PICC导管置入上腔静脉及最适深度的成功率显著高于对照组,差异有统计学意义（χ^2分别为3．785,4．572;P〈0．05）,观察组和对照组两组测得置管长度分别为（48．43±3．20）,（50．46±3．20）cm,与实际置管长度差异无统计学意义（t分别为1．024,1．509;P〉0．05）。结论采用从右上肢穿刺点至右胸锁关节＋4cm,从左上肢穿刺点至右胸锁关节＋4cm的测量方法准确,可提高PICC置管的成功率。     

A case of ovarian dermoid cyst with malignant transformation perforated into the rectosigmoid colon and small intestine

A 72-year-old female was admitted to hospital with diarrhea containing hair. The abdominal plain film showed teeth-like structures in the right lower quadrant. Barium enema and endoscopic examination were performed, and the results indicated a possible dermoid cyst perforated into the rectosigmoid colon and small intestine. The operation revealed a dermoid cyst of the right ovary perforated into the rectosigmoid colon and small intestine. Histopathologically, a dermoid cyst and in part well-differentiated squamous cell carcinoma invading the rectosigmoid and small intestine were demonstrated.     

The interrater variation of ED abdominal examination findings in patients with acute abdominal pain

OBJECTIVE: The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings. METHODS: Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic. RESULTS: A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians. CONCLUSIONS: There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.     

自发性胆囊内瘘43例分析

目的：总结自发性胆囊内瘘的诊治经验。方法：对43例胆囊内瘘的病例进行回顾性病例分析。结果：43例中胆囊十二指肠瘘28例，胆囊结肠瘘8例，胆囊胆总管、肝总管瘘9例，胆囊胃瘘3例，其中同时有两处瘘7例。术前B超检查41例，9例提示胆囊积气；1例提示胆囊壁腹腔面消失，右下腹探得结石影。7例术前行腹部平片检查，4例提示小肠梗阻；6例见结石影；2例显示胆道积气。8例行CT检查，其中2例显示胆囊、胆管气体。3例行ERCP，其中1例见十二指肠有异常造影剂溢出。术前仅9例考虑到胆囊内瘘的诊断，其余均在术中发现。43例均行胆囊切除或部分切除，37例胆囊胃肠瘘行瘘口修补，其中5例因瘘口过大利用部分胆囊壁来修补；4例胆囊胆管瘘在取尽结石后，经瘘口置T管引流，瘘口较大者亦利用胆囊壁修补。术后1例因感染性休克死亡；1例有少量胆漏，经引流治愈，其余均恢复良好。结论：萎缩性胆囊炎、胆囊结石应警惕合并胆囊内瘘。出现以下情况提示胆囊内瘘：(1)B超、CT、腹部平片发现胆道积气。(2)CT、腹部平片提示肠梗阻。有下列情况可确诊胆囊内瘘：(1)B超发现胆囊腹腔面消失。(2)B超、CT、腹部平片提示原有明确的胆囊结石消失或在异位出现。(3)ERCP、PTC等发现非胆管开口有胆汁或造影剂溢出。(4)口服造影剂或钡剂灌肠见造影剂进入胆囊。治疗应修补瘘口，瘘口过大可利用部分胆囊壁来修补。     

Adult colocolic intussusception: demonstration by conventional MR techniques: a case report

Intussusception is a rare condition in adults. We report a case of a 69-year-old woman referred to our institution for lower left quadrant abdominal pain, weight loss, and occasional episodes of constipation and rectal hemorrhage. The patient underwent plain radiography, ultrasonography, and magnetic resonance imaging of the pelvis. The final diagnosis was colocolic intussusception due to a neoplastic lead point.     

Abdominal pain in HIV infection.

The causes of abdominal pain in patients with AIDS are different from those of the general population, and there are no guidelines as to which investigations are optimal. We reviewed our experience of 63 patients who presented with abdominal pain as the main reason for admission to the AIDS unit at St Stephen's and Westminster Hospital between January 1988 and January 1990. All patients were assessed within the same structured diagnostic programme. Thirty-five had upper abdominal pain, predominantly in the right upper quadrant in 27; seven had lower abdominal pain, which was concentrated in the right iliac fossa in three; 21 had diffuse abdominal pain. The causes of pain were determined satisfactorily in the majority of patients using routine gastroenterological investigations. The predominant site of pain had considerable predictive value in the diagnosis. The commonest cause of right upper quadrant pain was sclerosing cholangitis (17 of 27); endoscopic retrograde cholangio-pancreatography was necessary for a confident diagnosis. Diarrhoea was frequently associated (15 of 21) with diffuse abdominal pain; the commonest cause (six of 21) was cytomegalovirus colitis. Neoplasia was the cause of abdominal pain in eight patients. The other causes of abdominal pain and the utility of various investigations are discussed. An investigatory route which may provide maximum information has been suggested.     

Abdominal lymphadenopathy in benign diseases: sonographic detection and clinical significance.

We prospectively evaluated the frequency of lymphadenopathy in the right upper abdominal quadrant as detected by sonography in 650 consecutive unselected patients, after excluding patients with a known lymphoma or abdominal carcinoma and patients with acquired immunodeficiency disease. Evidence of enlarged lymph nodes (few in number, with an elongated shape and isoechoic to the liver, 8 to 22 mm in size), found primarily in the gastrohepatic ligament and porta hepatis, was seen on sonographic scans in 106 patients (16.3%). Associated conditions in 69 of 106 patients (65%) were hepatobiliary or pancreatic diseases and, less frequently, other benign entities (12 patients; 11.3%); in 25 cases (23.5%) no significant abdominal or systemic disease was present. Comparison with CT or surgical findings, or both, was available in 36 cases. We conclude that lymphadenopathy in the right upper abdominal quadrant may be found in relation to different non-neoplastic conditions as well as in the absence of any significant intra-abdominal disease. The frequency of this finding on sonographic scans must be recognized to prevent misdiagnosis of lymphoma or metastatic disease as well as to avoid overstaging of local (hepatobiliary, pancreatic, gastric) neoplasms.     

腹腔镜在右下腹痛诊断和治疗中的应用体会

目的探讨腹腔镜在右下腹痛的病因诊断和治疗中的作用。方法回顾分析我院经腹腔镜诊断或治疗的90例右下腹痛患者的临床资料。结果术前已明确诊断的54例右下腹痛患者采取腹腔镜治疗后腹痛均完全缓解;31例不明原因的右下腹痛患者经腹腔镜探查后30例获确诊;5例误诊患者,经腹腔镜探查后纠正诊断。所有患者术后无并发症发生。结论腹腔镜是诊断和治疗右下腹痛的有效手段。     

Evaluation of acute abdominal pain in adults

Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of the history and physical examination are helpful (e.g., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little predictive value for appendicitis). The American College of Radiology has recommended different imaging studies for assessing abdominal pain based on pain location. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain. It is also important to consider special populations such as women, who are at risk of genitourinary disease, which may cause abdominal pain; and the elderly, who may present with atypical symptoms of a disease.     

肺错构瘤的综合影像学诊断

目的探讨肺错构瘤的X线、CT表现及其诊断价值。方法回顾性分析16例经手术病理证实的肺错构瘤的影像学资料。结果左肺发病6例,右肺10例;除2例出现浅分叶外,其余所有病灶均表现为边界清楚的类圆形结节影,所有病例均为单发病灶。5例胸片病灶表现为边界清楚结节影;11例行cT检查,均表现为边界清楚的结节影,9例薄层扫描可见病灶内脂肪,增强扫描后病变呈轻度强化。结论x线有助于错构瘤的检出,薄层cT平扫及增强扫描对其诊断价值较高。     

Intestinal perforation after the incidental ingestion of a fishhook

The vast majority (75%) of ingested foreign bodies pass through the gastrointestinal tract spontaneously and require no surgical intervention. Indeed, the emergency department (ED) management of ingested foreign bodies is largely based on the age of the patient and the time elapsed since ingestion, as well as the physical characteristics of the foreign body. We present this case to emphasize the importance of radiologic imaging studies in the ED management of adults with an acute abdomen of unknown etiology. A 44-year-old woman presented to the ED with right upper quadrant pain of 2 days duration. There was evidence of localized peritoneal irritation on physical examination. A radio-opaque fishhook-shaped object was visualized on the plain abdominal film. Helical computed tomography demonstrated a metallic object in the small bowel with extension through the thickened and inflamed intestinal wall. The patient did not report known ingestion of a foreign body. At exploratory laparotomy, a fishhook was recovered despite the patient's unawareness of having ingested a foreign body. The ED management of an otherwise healthy adult with an acute abdomen was facilitated with plain film radiography and abdominal computed tomography.     

Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy

BACKGROUND AND STUDY AIMS: We aimed to study the technical feasibility, safety, efficacy and complications of endoscopic feeding tube placement in patients who had previously undergone subtotal gastrectomy. We also investigated whether jejunal feeding tube placement (percutaneous endoscopic jejunostomy [PEJ]) is superior to gastric feeding tube placement (percutaneous endoscopic gastrostomy [PEG]) in the prevention of aspiration pneumonia in patients with subtotal gastrectomy. PATIENTS AND METHODS: A retrospective cohort study was carried out which included 48 patients treated between 1995 and 2001. Participants were selected from 3400 patients who were referred for PEG placement. The study group consisted of 15 consecutive patients with a prior subtotal gastrectomy. The control group comprised 33 randomly selected patients with intact stomachs. The primary end point of the study concerned the safety of PEG placement. The secondary end points included the efficacy and technical difficulty of the procedure. RESULTS: PEG/PEJ placement was successful in 14 of the 15 patients (93 %) who had previously had a subtotal gastrectomy. None of the study patients developed procedure-related complications. Feeding intolerance was more common in patients with gastrectomy compared with patients with an intact stomach, but the difference did not reach statistical significance (10 % vs. 3 %, P>0.05). A significantly higher incidence of pneumonia was observed in patients with gastrectomy compared with patients with an intact stomach (P=0.01). Subgroup analysis showed that the risk was higher with jejunal tube placement compared with gastric tube placement (42 % vs. 12 %, P=0.001). CONCLUSION: PEG/PEJ placement in patients with gastrectomy is a technically safe procedure. These patients are at higher risk of aspiration pneumonia and risk is higher with jejunal tube placement compared with gastric tube placement.     

Three-dimensional gray scale ultrasonographic imaging of the celiac axis: preliminary report.

The vessels of the celiac axis were evaluated in 16 healthy volunteers with three-dimensional gray scale ultrasonography. Sonographic volume data sets were obtained from both sagittal and transverse planes. The visualization of specific branches of the celiac artery (hepatic, splenic, left gastric, gastroduodenal, left hepatic, right hepatic, right gastric) was evaluated, and each vessel was placed in one of four categories on the basis of the appearance of the specific vessel and image clarity (not seen, poorly seen, adequately seen, well seen). Each vessel was evaluated on an initial two-dimensional scan and on a second scan using the entire volume to optimize and follow the designated vessel using rotating, referencing, and scrolling display capabilities. The ability to manipulate an entire volume improved visualization of the selected vessels as noted by an improved score. The proportion of vessels in the "not seen" and "poorly seen" categories decreased from the initial scan (62.5%) to the scan utilizing the entire volume (36%). Alternatively, the percentage of vessels in the "adequately seen" to "well seen" categories improved from 37.50% on the initial examination to 64% on the scans using the entire volume to depict vascular anatomy. The optimal plane to image each vessel depended on the course of a specific vessel. For optimal imaging of all the selected vessels, both sagittal and transverse volume acquisitions and both sagittal and transverse planes were needed. Three-dimensional imaging provided a new imaging plane (coronal) that was useful in following and identifying vessels, especially those vessels coursing in a right to left direction. Vascular variants were identified by this technique in two of 16 subjects. Vascular imaging was improved with three-dimensional ultrasonography, and this imaging method may provide additional assistance in decision making when evaluating abdominal vessels.     

Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury.

The objectives of this study were to define where fluid accumulation is shown on screening ultrasonography after blunt abdominal trauma and to determine how fluid accumulation patterns are associated with the site of injury. From 1994 to 1998, 2,693 screening examinations for blunt abdominal trauma were performed, in which 7 regions were examined for fluid. On the basis of a preliminary analysis of patients with solitary injuries, all 194 patients with sonographically detected fluid were grouped by fluid accumulation pattern. Fluid patterns were compared with sites of injury. The patterns differed between hepatic and splenic injuries. Fluid in the left upper quadrant, in both upper quadrants, or diffusely distributed suggested splenic injury, whereas fluid in the right upper quadrant or the right upper quadrant and lower recesses suggested hepatic injury (P < .0001). Fluid accumulation was random after enteric injury. Patients with extraperitoneal injury had no fluid or had fluid focally at the injury site. The ability to predict the injury site on the basis of fluid patterns should expedite treatment of hemodynamically unstable patients with blunt abdominal trauma.     

Efficacy of plain abdominal radiography in patients with biliary tract disease

A retrospective review was performed to determine the usefulness of plain abdominal radiographs in patients presenting to the emergency department with gallbladder disease. Patients with the clinical diagnosis of biliary tract disease were divided into two groups: those with confirmed biliary tract disease and those who did not have gall bladder disease. There were no major radiologic findings (pneumoperitoneum, pneumobilia, or bowel obstruction) in any patient with biliary tract disease. No significant difference was noted in the incidence of minor radiologic findings (right upper quadrant calcification, mild ileus and right basilar atelectasis) in patients with biliary colic and acute cholecystitis. Additionally, there was no significant difference in minor findings between patients with biliary tract and nonbiliary tract disease. Plain abdominal radiographic findings were found to be nonspecific in patients with gallbladder disease and not useful in differentiating between patients with biliary colic and acute cholecystitis. Our results also suggest that plain abdominal radiographic findings are not useful in differentiating between patients with and without biliary tract disease, although the selection of patients without biliary tract disease may have biased this finding.     

无气腹穿刺腹腔镜手术

目的 探讨无气腹穿刺腹腔镜手术的可行性与临床意义。方法 麻醉后在腹肌充分松弛的情况下，在脐周作1cm左右的皮肤切口，主刀和助手提脐部两侧腹壁皮肤，用穿刺锥直接穿刺，根据手感，当穿刺锥进入腹腔后，手掌离开穿刺锥，将trocar向内推进3～5cm，取出穿刺锥，接上气腹管建立气腹。结果 112例病人直接裸穿(无保护鞘)，无胃肠道和大血管损伤。结论 穿刺锥比较钝，只要操作技术熟练，不容易导致胃肠道和大血管损伤。放入第一支trocar时，不一定必须事先建立气腹。缺乏经验和操作粗暴是穿刺性损伤的主要原因。初学者不能盲目选择。     

Long-term percutaneous endoscopic gastrostomy: characteristic computed tomographic findings

Patients with a long-term PEG may suffer from complications and received physical and endoscopic examinations. However, these examinations do not provide information between skin and stomach. We present the findings of computed tomography (CT) for patients with long-term percutaneous endoscopic gastrostomy (PEG). After 1 year PEG (183 patients), 57 patients had received CT examinations. Skin indentation, soft-tissue thickening, peritoneal gap, internal bumper migration, and clinical abnormalities detected by CT examination were recorded. Thickness of subcutaneous fat, muscle, and abdominal wall along the tract were measured. The same parameters at 3 cm away from the tract were obtained for comparison. CT demonstrated that 28 (49.1%) patients present soft-tissue thickening, 19 (33.3%) patients present skin indentation, and 24 (42.1%) patients present a peritoneal gap. One patient with internal bumper migration, 3 patients had buried bumper syndrome, 2 patients had gastric herniation, and 1 patient had esophageal cancer metastasizes to the PEG site. Thickness of subcutaneous fat, muscle, and abdominal wall decreased significant. CT can provide detailed anatomy and orientation along the PEG tube. Familiarity of the CT appearance can minimize potential complications before PEG tube replacement.     

经颈静脉肝内门体分流术术前穿刺点的动态增强MRA定位

目的 探讨动态增强MRA(DCE-MRA)在经颈静脉肝内门体分流术(TIPS)术前定位中的作用. 方法 收集46例肝硬化门脉高压患者的MRA图像,测量并根据测量结果进行穿刺. 结果 肝静脉穿刺点到门静脉穿刺点平面上下垂直距离(AA')为(22.63±10.21)mm;肝静脉穿刺点到门静脉穿刺点平面前后垂直距离(A'A')为(13.93±1.07)mm;前后穿刺角度为(31.64±9.23)°;肝静脉、门静脉穿刺点距椎体右缘距离分别为(23.51±2.12)mm、(38.51±5.36)mm;左右穿刺角度为向右偏(33.57±8.93)°.45例穿刺成功,且穿刺次数较少. 结论 门静脉穿刺点位置变化较大,定位需个体化.DCE-MRA是一种有价值且无损伤的定位方法,对TIPS术前定位有重要意义.     

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound

Background: Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. Methods: We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. Results: Rigler's triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. Conclusion: The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings. Received: 7 July 2000/Revision accepted: 4 October 2000     

Dispersal of tumour cells within the peritoneal cavity during laparoscopy

Summary

Disagreement exists about whether laparoscopy results in dispersal of tumour cells during laparoscopic cancer surgery and whether this results in the development of port-site metastases. Recent experimental work suggests that CO₂, but not He, insufflation promotes the development of port-site metastases, suggesting that metabolic or immunological factors might also contribute to this problem. This study investigated whether insufflation results in an initial redistribution of tumour cells; and looked at the contribution of mechanical insufflation factors for the development of port-site metastases. A suspension of radio-labelled cancer cells was introduced into the left upper quadrant of the peritoneal cavity of 17 Dark Agouti rats, which underwent laparoscopy with CO₂ pneumoperitoneum, gasless laparoscopy, or laparotomy. Surgery continued for a further 30 min, after which the rats were killed and the radioactivity present on the peritoneal surface of the anterior and lateral abdominal wall, and the laparoscopy port sites, was determined by scanning standardised samples of the abdominal wall with a y counter. There was less contamination of the abdominal wall from laparotomy than laparoscopy, irrespective of technique. No differences in contamination between the two laparoscopy groups could be demonstrated. Contamination of the port sites was similar except at the site through which the cells were originally introduced, where a greater radioactivity concentration was seen following gasless laparoscopy. This study suggests that it is not the use of gas insufflation during laparoscopy which is responsible for redistribution of tumour cells from a tumour site, but that redistribution is related to some other aspect of the laparoscopic environment. It is possible, when this finding is considered alongside previously reported studies, that a metabolic or immune disturbance, due to other properties of CO₂ insufflation, could cause this problem. This possibility is being investigated further.