梗阻性重型胆石性胰腺炎的临床处理

目的 探讨梗阻性重型胆石性胰腺炎的病变特点及处理原则.方法 分析温州医学院第一附属医院1997年1月~2005年10月期间收治的10例梗阻性重型胆石性胰腺炎患者的临床资料.结果 (1)6例患者存在胆总管结石,4例胆总管内未见结石;(2)4例出现Charcot三联征,1例出现Renyolds五联征;8例以右上腹痛为主,仅1例出现左上腹痛;6例呈胰头部局灶性坏死;2例见散在斑点状坏死;2例见弥漫性坏死灶.(3)外科收治的8例患者,全部采取早期手术治疗而获得治愈;内科收治的2例患者采取早期传统保守治疗,1例病情恶化第8天自动出院,1例病情好转遗留胆石病变出院.结论 (1)胆管梗阻可导致胆石性胰腺炎,梗阻是原因,病因不除,疾病难以控制;(2)胆总管内未见结石的胆石性胰腺炎也可出现胆道梗阻,应引起临床重视;(3)梗阻性重型胆石性胰腺炎的病变特点:胆道症状突出,胰腺病变以局灶性胰头部坏死为主;⑷梗阻性重型胆石性胰腺炎应采取早期手术治疗,由外科收治较为合理.     

内脏型带状疱疹致胆汁淤积性肝炎一例

目的为提高临床对内脏型带状疱疹诊治水平。 方法报道以严重持续性上腹痛伴进行性黄疸为主要表现的1例72岁男性内脏型带状疱疹患者临床诊治过程。 结果患者经抗病毒治疗后疱疹皮损痊愈但病情反复,肝组织活检显示肝细胞内仍可见病毒包涵体和胆汁淤积。免疫组织化学染色结果显示带状疱疹病毒染色阳性。经长时间抗病毒治疗后患者内脏型带状疱疹痊愈。 结论内脏型带状疱疹抗病毒治疗应延长疗程。     

Successful Resection of an Infected Duodenal Duplication Cyst After Percutaneous Cyst Drainage: Report of a Case

We report a case of a duodenal duplication cyst complicated by infection. An 8-year-old boy was brought to our hospital with severe abdominal pain and a fever of 39.8°C. He had a 5-year history of occasional abdominal pain with vomiting. On examination, a cystic mass was felt under the liver. We performed percutaneous drainage of the cyst under a suspected diagnosis of a choledochal cyst complicated by acute biliary infection. A contrast study through the drainage tube and surgical exploration revealed a duodenal duplication cyst communicating with the second part of the duodenum. The patient had an uneventful recovery and remains well 5 years after surgery. To the best of our knowledge, this is the first documented case of an infected duodenal duplication cyst successfully treated by resection after percutaneous drainage.     

Fatal ischemia of bowel and rectus abdominal muscle after off pump coronary artery bypass grafting in a dialysis patient

We have experienced a case which developed mesenteric ischemia followed by necrosis of the rectus abdominal muscle after off pump coronary artery bypass grafting (OPCAB). A 62-year-old man with a history of long-term hemodialysis was diagnosed with left main trunk disease. He underwent triple OPCAB uneventfully. No inotropic agents were needed perioperatively. He underwent normal hemodialysis on the first postoperative day, and then complained of severe abdominal pain with progressive metabolic acidosis. A 170 cm length of the ileocecal segment fell into necrosis and was excised and an ileostomy was constructed in an emergency setting. He developed another abdominal pain 6 days after the second operation. An additional surgery confirmed necrosis of the right rectus abdominal muscle complicated with a significant infection. He developed mediastinitis and died of multi-system organ failure 37 days after OPCAB. The mechanism of this serious complication is discussed.     

腹腔镜胆囊切除术后再疼痛的原因分析及预防

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）后再疼痛的原因及其预防措施。方法回顾性分析2000年1月～2006年1月168例LC术后再疼痛患者的临床资料（非切口创伤引起;LC术后并发症引起;LC术后1年内又出现类似术前症状;LC术前症状符合胆囊炎并胆囊结石症状,而未能进一步完善诊断,术后又出现LC术前相同症状及新发症状,考虑为其他病因引起的LC术前疼痛症状）。并对其术后再疼痛的原因及处理进行总结。结果颈肩痛24例;戳口痛5例;持续性腹腔内疼痛71例,其中28例胆漏,23例继发胆总管结石,6例术后急性胰腺炎,残株胆囊炎和（或）胆囊管残余结石8例,肝下间隙积液感染5例,十二指肠球部溃疡1例;阵发性腹部疼痛32例,其中9例为肠蠕动亢进,23例胆道运动障碍;黄疸并疼痛31例,其中右肝管狭窄肝内胆管局灶性扩张7例,胆管炎10例,肝外胆管残余结石11例,壶腹癌2例,胆总管下端癌1例;胆道蛔虫症2例;腹胀诱发疼痛2例;剧烈恶心、呕吐诱发疼痛1例。168例均症状缓解,其中再手术、ERCP＋EST治疗86例,非手术治疗82例。168例随访1～36个月,无其他并发症发生。结论LC术后疼痛的原因涉及到围手术期的每个环节;完善LC术前检查,重视术中术后的每个环节是减少LC术后疼痛的关键。     

腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛

目的 评价腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛的止痛效果。方法 105例晚期癌症患者，67例伴有后腹膜淋巴结广泛肿大并包绕神经、血管，均有顽固性上腹痛，经CT导引穿人隔脚前及后腹膜肿大淋巴结内行两侧腹腔神经丛无水乙醇阻滞术。结果 经4个月随访观察，在2周、1个月、2个月、3个月、4个月，止痛总有效率分别为100％、98．09％、97．05％、93．81％、90．42％。在止痛效果显著者，可观察到无水乙醇扩散较完全，能从两侧包绕腹主动脉，肿大的淋巴结有明显坏死。本组无严重并发症。结论 CT导引下腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛是一种安全、有效的方法，应推广应用。     

Clinical manifestations of adrenal hemorrhage

Thirty-four patients with adrenal hemorrhage were treated at the University of California Hospitals, San Francisco, from 1960 through 1973. In two cases the condition was diagnosed at operation and in thirty-two the diagnosis was made at postmortem examination. In only seven of these thirtyfour patients were the abdominal symptoms and signs clearly attributable to adrenal hemorrhage. In the remaining twenty-seven patients the clinical manifestations were marked by other intra-abdominal problems or by severely altered mentation.The most common clinical manifestations in these seven patients were profound prostration, fever, mental aberrations, emesis, and weakness with severe, constant, localized, upper abdominal pain. Awareness of the sequence of symptoms and the predisposing factors of adrenal hemorrhage will make the diagnosis more apparent and treatment more successful.     

Emphysematous necrotizing pancreatitis

The authors present an additional case of emphysematous necrotizing pancreatitis caused by Escherichia coli. Emphysematous necrotizing pancreatitis represents a rare and potentially life-threatening infection and is characterized by gas formation within or around the pancreas. A 26-year-old man presented with severe upper abdominal pain and vomiting, 7 hours from onset. Acute pancreatitis was initially diagnosed based on high amylase level, abdominal ultrasonography and primary CT scan. On the 7th day he developed fever, increasing abdominal pain and shortness of breath. On the second abdominal CT scan, the pancreatic bed was filled with gas. The diagnosis of emphysematous necrotizing pancreatitis was confirmed at laparotomy. The patient was treated successfully by extensive pancreatic necrosectomy, open packing and scheduled repeated debridements. Culture from the lesser sac, and retroperitoneal space, examined for aerobes and anaerobes, revealed growth of Escherichia coli. The authors analyze and discuss pathogenesis, diagnosis and treatment of emphysematous necrotizing pancreatitis. Based on the available data and this case, early surgical debridement and appropriate antibiotics appear to be the preferred treatment.     

Spontaneous fistulization of a pancreatic abscess to colon and duodenum treated with percutaneous drainage

Pancreatic fistulas are rare clinical entities associated with severe pancreatitis. A 39-year-old man who had been diagnosed and treated for severe pancreatitis 2 months ago presented with abdominal pain, fever, and vomiting. The abdominal computed tomography (CT) demonstrated a peripancreatic abscess and a duodenal fistula communicating the first part of duodenum, which was also verified with fluoroscopy. A size 14-French catheter with pig-tail tip was inserted primarily with a Seldinger 2-step technique through percutaneous route under CT-guidance to avoid intervening bowels or solid organs. The patient's clinic improved and treatment was stopped on the 18th day. On the 26th day of the first intervention, the patient had fever and abdominal pain and his clinic was deteriorated. A second fluoroscopic examination revealed that the duodeno pancreatic fistula was closed while a new 1 has developed into the ascending colon. With aggressive nutrition support, antibiotics and repeated drainage of the abscess pouch a dramatic clinical improvement was observed. Control abdominal CT demonstrated the resolution of pancreatic abscess on the 62nd day.     

Type B aortic dissection with early presentation mimicking acute pyelonephritis

Aortic dissection is a life-threatening illness requiring early diagnosis and treatment. Uncommon early presentations mimicking various illnesses can delay diagnosis. This case study describes a 44-year-old woman with type B aortic dissection initially presenting as acute pyelonephritis (APN). Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration. Abdominal computed tomography showed type B aortic dissection complicated with a small bowel infarct, ischemic ascending colon and left renal infarct. Emergency surgical interventions of small bowel resection, ileoduodenostomy and cholecystectomy were performed; a second laparotomy was subsequently performed for anastomosis leakage. The patient died due to septic shock with multiorgan failure. Aortic dissection initially mimicking APN is rare. Accurate early diagnosis of aortic dissection with indeterminate presentation is crucial. Early surgical intervention for visceral organ ischemia is important to preventing morbidity and mortality.     

Abdominal organ infarction encountered immediately after surgery of primary lung cancer

Very rare cases of abdominal organ infarction after surgery of primary lung cancer were reported. Case 1: Patient 1 was a 70-year-old man who underwent left upper lobectomy and ND 2a in June 1999 based on the clinical diagnosis of stage IA lung cancer. On the 4th postoperative day, the patient developed fever and right flank pain. Abdominal computed tomography (CT) demonstrated a specific finding compatible with renal infarction. The etiology could not be determined. The patient was treated conservatively. However, severe atrophy of right kidney was demonstrated by following CT performed 3 years later. Case 2: Patient 2 was a 70-year-old woman who underwent left upper lobectomy and ND 2a in December 2002 based on the clinical diagnosis of stage IA lung cancer. On the 4th postoperative day, the patient developed abdominal pain in the left upper quadrant, nausea and vomiting which had lasted for 10 days. Abdominal CT demonstrated a wedge-shaped filling defect at spleen compatible with splenic infarction. The etiology could not be determined. The patient was treated conservatively with prophylactic antibiotic therapy and followed closely. Partial atrophy of spleen was demonstrated by following CT performed 4 months later.     

原发性十二指肠恶性肿瘤的诊断和治疗：附54例报告

目的：探讨改善原发性十二指肠恶性肿瘤的诊断和治疗方法。方法：回顾性分析6年间收治原发性十二指肠恶性肿瘤54例的临床资料。结果：肿瘤位于球部6例（11.1%）、降部44例（81.5%），其中乳头部38例（占降部的86.4%，总数的70.4%），水平部2例（3.7%），升部2例（3.7%）。腺癌50例（92.6%）。主要症状有黄疸、上腹部痛、体重下降伴纳差、腹胀、消化道梗阻等。上腹部压痛72.0%，无阳性体征20.0%，腹块8.0%。术前合并胆囊病变率37.0%。术前经十二指肠镜、ERCP确诊率为94.4%及77.8%。术前确诊为原发性十二指肠癌15例（27.8%）,胰十二指肠切除38例，节段性十二指肠切除1例，姑息性手术9例，失去手术时机6例。手术切除率88.9%，根治性切除率72.2%。行胰十二指肠切除3年和5年生存率分别为40.6%和21.9%;姑息性手术3~24个月死亡，未行手术者半年内死亡。结论：十二指肠恶性肿瘤以降部乳头最多见，以腺癌为主，进展期症状复杂，腹部体症特异性表现低，易合并胆囊病变，术前确诊率低。十二指肠镜和ERCP是诊断的首选方法。胰十二指肠切除可延长生存期。     

胰管结石与并发胰腺癌

目的 提高胰管结石及合并胰腺癌的诊治水平。方法 报告1979－2000年间43例胰管结石其中8例合并胰癌的临床资料。结果 病因学以性胰腺炎及蛋白质－热卡－营养不良性胰腺炎（热带性胰腺炎）为主，主要症状是腹痛、腰背痛、内外分泌功能障碍，结合BUS，CT，ERCP等影像学诊断依据，如果近期症状加重－－严重腰背痛，出现黄疸，BUS，CT有胰占位，血CEA升高，应考虑癌变。结论 胰管空肠侧侧吻合是首选治疗，如胰头结石取不净，伴有黄疸或术后疼痛消除不明显，可加行胰头切除，癌变者则行胰十二指肠切除或胰体尾部切除术。     

Spontaneous rupture of a left gastroepiploic artery aneurysm in a patient with autosomal-dominant polycystic kidney disease

Autosomal-dominant polycystic kidney disease (ADPKD) has been known to be associated with a variety of vascular diseases. We present a hemodialysis patient with ADPKD who died of a massive intraperitoneal hemorrhage caused by the spontaneous rupture of a left gastroepiploic artery aneurysm. A 64-year-old male was admitted to our hospital with acute upper abdominal pain and hemorrhagic shock. An abdominal angiography showed three aneurysms and the source of hemorrhage was assumed to be the left gastroepiploic artery aneurysm. The patient died of severe metabolic acidosis and disseminated intravascular coagulation (DIC) on the second hospital day. At autopsy, there was massive bleeding into the abdominal cavity, and pathological examination of the left gastroepiploic artery aneurysm revealed a dissecting aneurysm. This is the first case describing a rupture of a gastroepiploic aneurysm in a patient with ADPKD.     

Digoxin-induced abdominal pain in a patient undergoing maintenance hemodialysis.

A patient who had recently been started on digoxin developed acute severe right upper quadrant pain shortly after hemodialysis. He underwent an extensive work-up for abdominal pain but all findings were normal. With reduction of digoxin dosage, a substantial relief of pain was achieved. The pain totally resolved when digoxin was discontinued and recurred when it was restarted. Cardiac glycosides may be a cause of abdominal pain in patients undergoing maintenance hemodialysis and this side effect should be considered before costly work-up is performed.     

Adrenal pseudocyst: Diagnosis and laparoscopic management - A case report

Cysts of the adrenal gland are rare and are usually discovered incidentally. Large adrenal cysts can however present with severe abdominal pain and can be complicated by haemorrhage, rupture or infection. Adrenal pseudocysts appear to result from haemorrhage within a normal adrenal gland and can expand to accommodate massive amounts of fluid.We report the case of a 39-year-old woman who presented with worsening right upper quadrant pain. An ultrasound scan of the abdomen confirmed a large 29 cm × 20 cm × 17 cm cyst that appeared to originate in the upper pole of the right kidney causing displacement of the liver and right kidney.Following complete aspiration the cyst re-accumulated and an MRI scan demonstrated a thickened and irregular cyst wall with haemorrhagic fluid. Laparoscopic right adrenalectomy was performed and the histopathological diagnosis was confirmed as an adrenal pseudocyst.     

The use of minimally invasive surgery in the management of idiopathic omental torsion: The diagnostic and therapeutic role of laparoscopy

Omental torsion is an unusual and infrequently encountered cause of acute abdominal pain in adults. Computed tomography (CT) is a useful adjunct to clinical history and examination in establishing the diagnosis; however, definitive diagnosis is frequently established at the time of exploratory surgery. Treatment may be conservative or operative, with laparoscopic resection the surgical approach of choice. We report the case of a 60-year-old man who presented with a 3-day history of severe right-sided abdominal pain. Abdominal CT scan revealed a right upper quadrant mass with a whirl-like appearance, suspicious for omental infarction. Diagnostic laparoscopy was undertaken, the diagnosis confirmed and the diseased omentum resected. The patient was discharged the following day and made an uncomplicated recovery.     

A case of acute type B aortic dissection: limited role of laboratory testing for the diagnosis of mesenteric ischemia.

A 30-year-old man with severe back and abdominal pain was referred to our hospital because of a recurrence of acute type B aortic dissection. A computed tomography scan showed a 3-channel dissection and a severe narrowing of the true lumen of the descending aorta to the abdominal aorta because of the expansion of the newly formed second false lumen. Although laboratory testing, including creatine phosphokinase, lactate dehydrogenase, and lactate levels, indicated no visceral ischemia, abdominal pain requiring narcotics treatment had to be continued for more than 1 week. Based on the symptoms and computed tomography findings, the patient finally underwent aortic replacement, fenestration, and a reconstruction of the inferior mesenteric artery, after which the abdominal pain disappeared. Operative findings confirmed a pale shrunken intestine, indicative of mesenteric ischemia. The present case is a good demonstration revealing that mesenteric ischemia still remains a diagnostic challenge, and suggests that currently available laboratory markers are not sensitive enough to detect the presence of ischemia. A strong clinical suspicion for mesenteric ischemia may be the only key to preventing a catastrophic outcome in this condition.     

Pancreatic tail pseudocyst associated with spontaneous resolution of intrasplenic pancreatic pseudocyst

A 27-year-old man, an alcohol abuser, had alcoholic pancreatitis complicated by a 3.2 cm pancreatic tail speudocyst and intrasplenic pseudocysts presenting with left upper quadrant pain of one-month duration. Surgical resection or percutaneous drainage of the cystic lesions of the pancreas and the spleen was refused. Analgesic agents were given for relief of abdominal pain. Three months later, another episode of alcoholic pancreatitis occurred. A computed axial tomographic scans of the abdomen showed diffuse enlargement of the pancreas with a 3.0-cm pseudocyst in the pancreatic tail, but there was no evidence of previous intrasplenic pseudocysts. The patient was treated conservatively and was discharged on the 7th hospital day. There was no recurrence of abdominal pain after 3 months follow-up.     

Emphysematous gastritis: A young diabetic's recovery

IntroductionEmphysematous gastritis (EG) is a rare and often fatal disorder involving infection of the gastric wall by gas-forming organisms.Presentation of caseWe present the case of a 25-year-old diabetic man with severe gastroparesis, who complained of vomiting and right upper quadrant pain. The surgical consultant exam in the emergency department revealed a tender but not acute abdomen. On abdominal computed tomographic imaging, there was gas throughout the wall of the stomach but no evidence of gastric perforation. The patient was treated non-operatively with antibiotics, bowel rest, serial abdominal exams, and upper endoscopy (EGD).DiscussionEG has been associated with overall mortality rates exceeding 50%. Early recognition and administration of antibiotics is essential to reduce mortality risk. Indications for laparotomy include perforation or uncontrolled sepsis.ConclusionEG can occur in diabetics with gastroparesis complicated by a bezoar and hyperemesis. Gastric pneumatosis is not an absolute indication for celiotomy as antibiotics and surgical vigilance may be appropriate and curative therapy.