胃镜检查致纵隔气肿一例

患者男,59岁,因烧心、反酸行胃镜检查,术中进镜顺利,诊断为浅表性胃炎.患者既往有糖尿病病史10年,无其他特殊病史.胃镜检查过程中患者精神紧张,恶心、呕吐明显,并伴有剧烈咳嗽.术后当日患者诉咽部不适,无胸骨后疼痛及胸闷、呼吸困难等表现,白细胞计数4.04×109/L,中性粒细胞比52.3％,血沉8 mm/h,C反应蛋白0.05 mg/L.次日中午患者进食时出现恶心、呕吐,并伴有咽部不适感,无发热、胸骨后疼痛,无咳嗽及呼吸困难.术后第2天患者出现右胸隐痛,颈前、前胸皮肤有握雪感,体温38.0℃,白细胞计数9.98×109/L、中性粒细胞比74.3％、血沉39 mm/h、C反应蛋白16.70 mg/L,胸片示皮下少量气肿、右侧包裹性胸腔积液,CT示右侧肺炎、双侧胸腔积液、纵隔气肿.遂予禁饮食、静脉营养支持、广谱抗生素治疗,并行血培养检查.上消化道泛影葡胺造影未见穿孔;喉镜示咽部充血,未见穿孔;复查胃镜示食管黏膜光滑,未见穿孔及瘘道形成.术后第3天患者仍有右胸痛及咽部不适,症状无加重,体温38.5℃.术后第4天患者胸痛减轻,体温波动在37.5℃左右,白细胞计数7.80×109/L,中性粒细胞比66.5％,血沉23 mm/h,C反应蛋白5.60 mg/L.术后第5天患者胸痛明显减轻,体温恢复正常,血培养回报阴性,白细胞计数5.04×109/L,中性粒细胞比65.2％,血沉17 mm/h,C反应蛋白1.80 mg/L,复查CT示纵隔气肿及胸腔积液范围明显吸收.遂改流质饮食,次日停用抗生素,停药1周后复查CT示基本恢复正常.     

纤维支气管镜检查术后发热的临床表现及特点

目的评价纤维支气管镜术（纤支镜）后发热的发生率和临床特点。方法前瞻性地观察和分析了从2005年2月至2007年8月呼吸科住院患者纤支镜术后发热的临床表现。结果153例住院行纤支镜检查患者,28例（18%）患者出现了术后发热,其中23例（15%）患者未经处理,体温在24h内降至正常,另4例发热持续3~5d,给予对症处理。平均术后开始发热时间（3.3±1.6h）,平均发热持续时间（9.6±5.7h）。术后发热和不发热患者纤支镜术后外周血中性粒细胞计数均显著高于术前（P均〈0.01）,但发热患者术后外周中性粒细胞升高比不发热患者更明显（P均〈0.01）。结论纤支镜术后短期发热是一比较常见的术后并发症,无需特殊处理治疗。     

中性粒细胞VCS参数在血培养阴性感染性心内膜炎中的临床应用

目的：探讨中性粒细胞VCS等参数在血培养阴性的感染性心内膜炎疾病中的变化及临床意义。方法：使用BeckmanCoulter LH 750全自动血液分析仪对64例血培养阴性感染性心内膜炎患者,50例正常对照者进行常规血液分析。收集各组WBC总数及中性粒细胞VCS参数。对各组间均数进行t检验来判断差异有无统计学意义。结果：64例血培养阴性的感染性心内膜炎患者的WBC总数比正常对照组略高,差异有统计学意义（P〈0.05）。中性粒细胞平均体积（MNV）和体积分布宽度（MNV-SD）均明显高于正常对照组,均差异有统计学意义（P〈0.01或P〈0.05）。中性粒细胞平均传导率（MNC）也高于正常对照组,差异有统计学意义（P〈0.05）。但中性粒细胞平均光散射（MNS）与正常对照组比较差异无统计学意义（P〉0.05）。ROC曲线显示,血培养阴性的感染性心内膜炎患者的MNV的曲线面积达到0.879,MNC的曲线面积达到0.756。在MNV≥140时,其敏感性和特异性分别为80%,82%。结论：中性粒细胞VCS参数对血培养阴性的感染性心内膜炎有较好的早期诊断提示作用。     

碘伏溶液冲洗胃黏膜对超声内镜引导下细针穿刺术后菌血症发生率的影响

目的研究碘伏溶液冲洗胃黏膜是否能降低超声内镜引导下细针穿刺术（EUS-FNA）后菌血症的发生率。方法选取20条成年杂种犬作为实验动物,随机分成2组,每组10条。实验组FNA术前使用10ml 0．5％碘伏溶液冲洗胃黏膜,对照组FNA术前使用10ml生理盐水。分别于EUS检查前,EUS检查后FNA术前,FNA术后5、15及30min采血进行血培养。结果实验组血培养中3条犬出现有意义的菌血症,对照组1条犬出现有意义的菌血症,对比2组菌血症的发生率,差异无统计学意义（P=0．582）。结论应用0．5％碘伏溶液冲洗胃黏膜不能减少EUS-FNA术后菌血症发生率。     

冠心病患者PTCA前后外周血CD11b、CD62P表达变化及意义

采用流式细胞仪检测23例健康体检者（对照组）及41例冠心病患者（观察组）,经皮冠状动脉腔内成形术（PTCA）术前72、2h、术后30min及24、72h外周血中性粒细胞和单核细胞表面CD11b、CD62P的表达。结果观察组患者外周血中性粒细胞和单核细胞CD11b平均荧光强度（MFI）和CD62P阳性细胞百分比较对照组明显升高。PTCA术后24hCD11b荧光强度和CD62P阳性细胞百分比较术前72、2h明显升高。血小板CD62P与中性粒细胞CD11b呈正相关（r=0．253）。认为PTCA术后中性粒细胞和单核细胞CD11b及血小板CD62P表达上调,且可作为反映PTCA后炎症反应和血栓形成状况的指标。     

改良经口内镜下肌切开术在治疗贲门失弛缓症中的应用研究（含视频）

目的 比较改良经口内镜下肌切开术（Liu-POEM）与传统POEM在治疗贲门失弛缓症中的差异。 方法 采用回顾性研究方法，选择30例完成Liu-POEM的患者和应用Liu-POEM之前近期完成传统POEM的30例患者为研究对象，通过对比两种术式的总手术时间、术后并发症及症状评分（Eckardt评分）来评价Liu-POEM的安全性和有效性。 结果 Liu-POEM平均总手术时间为（27.13±11.42）min，平均肌切开时间为（13.20±5.09）min；术后无患者出现纵隔及皮下气肿，无发热。传统POEM平均总手术时间为 （51.22±25.63）min，平均肌切开时间为 （11.18±7.61）min；术后有3例（10％）患者出现皮下气肿，未经特殊治疗，术后2 d自行吸收；1例患者术后发热1 d，最高体温37.6 ℃，物理降温后体温恢复正常。所有患者术后Eckardt评分＜3分。术后随访3～12个月，均无远期并发症发生。 结论 Liu-POEM具有操作技术简单，手术时间短，手术创伤小的优点。     

肝硬化患者产超广谱β-内酰胺酶大肠埃希菌菌血症的危险因素及预后相关分析

目的研究肝硬化患者产超广谱β-内酰胺酶（ESBLs）大肠埃希菌菌血症的危险因素以及影响其预后的相关因素。方法采用病例对照设计,回顾性分析解放军第三○二医院2001—2006年30例大肠埃希菌菌血症肝硬化患者的临床资料,同时选择与阳性患者性别、年龄及培养日期最接近的ESBLs阴性大肠埃希菌菌血症肝硬化患者30例作为病例对照。分析患者初次血培养阳性时的基础疾病、体温、白细胞数及中性粒细胞数、抗生素使用情况、临床合并症、免疫抑制治疗、有创操作、住院时间及培养前、后住院时间等;分析患者菌血症预后与抗生素使用的关系。统计处理采用SPSS10.0软件。均数比较采用Student′st检验;计数资料比较采用Fisher精确检验（双边）;如Fisher精确检验相差显著,做比数比和可信区间及M-Hχ^2检验;危险因素相关性分析采用逻辑回归分析。结果预用头孢类抗生素是ESBLs阳性大肠埃希菌菌血症肝硬化患者感染独立危险因素（OR=5.675,χ^2MH=8.076,P=0.004）。不适当抗生素治疗导致感染预后不好（OR=22.000,χ^2MH=6.658,P=0.010）。结论谨慎使用头孢菌素,特别是第三代头孢菌素能够降低产ESBLs大肠埃希菌菌血症的发病率。     

成人Still病32例临床分析

目的探讨成人Still病的临床特点,提高诊断的正确率。方法回顾分析32例成人Still病的临床表现及化验检查,分析其临床特点。结果高热（体温≥39．0℃）、一过性皮疹、关节痛、白细胞、中性粒细胞增高（白细胞≥12．0×10^9／L,中性粒细胞≥80％）、血清铁蛋白增高,血沉、C-反应蛋白增高,肝脾淋巴结肿大是多见的表现,非甾体类抗炎药加糖皮质激素或／和免疫抑制剂是常用的治疗方法。结论成人Still病临床表现及实验室检查缺乏特异性,诊断时应符合参考诊断标准并除外其他疾病。     

氯沙坦对冠心病冠脉介入治疗患者肾功能的保护作用观察

目的 探讨氯沙坦对冠心病冠状动脉介入诊疗患者肾功能的保护作用及机制.方法 221例接受冠状动脉造影（CAG）或经皮冠状动脉介入术治疗（PCI）的冠心病患者随机分为三组.对照组（72例）术前不服用氯沙坦;低剂量组（74例）及高剂量组（75例）术前1d开始分别晨服氯沙坦50、100 mg,1次/d.分别于术前和术后24h检测各组血尿酸（SUA）、肌酐（Scr）、尿素氮（BUN）、肾素活性、血管紧张素Ⅱ（AngⅡ）及醛固酮水平,采用MDRD方法估算肾小球滤过率（eGFR）;采用ELISA法检测血清和尿液中性粒细胞明胶酶相关脂质运载蛋白（NGAL）和半胱氨酸蛋白酶抑制物C（CysC）水平.记录对比剂急性肾损伤（CIAKI）发生率.随访90d观察用药依从性并记录临床事件.结果 三组共发生CIAKI8例,其中对照组、高剂量组各2例,低剂量组4例.与对照组相比,低剂量组和高剂量组术后血SUA和BUN均降低（P均＜0.01）,呈剂量依赖性;对照组术后血Scr、血NGAL和血Cysc升高、eGFR降低（P均＜0.05）,低剂量组术后血CysC升高（P＜0.05）.结论 氯沙坦可降低冠心病患者介入诊疗术后血尿酸水平,改善肾功能,其机制可能与阻断肾素—血管紧张素系统、降低围手术期血尿酸水平有关.     

急性阑尾炎不同时期中性粒细胞活性与功能的变化及意义

目的比较急性阑尾炎感染期与恢复期中性粒细胞活性和吞噬能力的变化及中性粒细胞吞噬异物后死亡方式的差异及其临床意义。方法以珠江医院普通外科2010年,10例成年急性阑尾炎患者静脉全血作为样本,用磁珠分选法分离中性粒细胞,检测其0、12、24、48及72h细胞存活情况;在中性粒细胞中加入CFSE标记的珠子共同培养1～6h,流式细胞仪（FCS）检测中性粒细胞的活性及其吞噬情况。结果体外培养感染期患者中性粒细胞72h仍存活,正常人及恢复期患者中性粒细胞24h即出现大量死亡。病人感染期中性粒细胞在2h可达最大吞噬量,吞噬后细胞多发生凋亡;恢复期中性粒细胞在4h达到最大吞噬量,吞噬后细胞多发生坏死。结论感染期中性粒细胞活性明显高于正常人和恢复期患者的中性粒细胞。在感染期中性粒细胞吞噬异物后以细胞凋亡为主,而在恢复期中性粒细胞吞噬异物后细胞以坏死为主。这可能与不同时期中性粒细胞功能活化有关。     

Bacteremia after upper gastrointestinal endoscopy.

During 24 months, 200 upper gastrointestinal endoscopies were performed on 193 patients. Blood cultures were obtained before and five and 30 minutes after the procedure using thiol (50 ml) and trypticase soy broth (100 ml) media. The mean endoscopic time was 34 minutes. Sixteen patients developed bacteremia (8%). Twelve groups of microorganisms were detected in positive blood cultures: Streptococcus (5 species), Lactobacillus sp, Veillonella alcalescens, Staphylococcus aureus, Staph epidermidis, Propioni-bacterium acnes, Corynebacterium acnes, and Bacillus subtilis. Seven patients had positive blood cultures at five and 30 minutes, eight at five minutes, and one at 30 minutes only. There was no clear correlation of bacteremia with the age or previous history of the patient, biopsy, active bleeding, endoscopic time, or findings. A follow-up study of all patients for six months to two years indicated no complications related to endoscopy and/or bacteremia.     

Low Incidence of Bacteremia Following Endoscopic Retrograde Cholangiopancreatography (ERCP)

Fifty patients (29 females) undergoing ERCP were studied prospectively for the occurrence of bacteremia associated with this endoscopic procedure. Each patient had blood samples drawn for aerobic and anaerobic cultures before endoscopy, after entering the duodenum, 5 and 15 minutes after cannulation of the papilla of Vater. Subcultures were made at 24 and 48 hours for a total of 1,200 cultures. No positive cultures were obtained in 48 patients. One patient developed a Staphylococcus epidermidis bacteremia during the procedure. The cleansing technic for the instruments consisted of alcohol and water only. Prophylactic antiobiotics were not administered. In contrast to other gastrointestinal procedures, our results suggest that bacteremia is an uncommon occurrence in ERCP despite the longer duration of the procedure and instrumentation of a sterile duct system.     

经口内镜下肌切开术治疗贲门失弛缓症疗效分析

目的探讨经口内镜下肌切开术（POEM）治疗贲门失弛缓症的疗效及安全性。方法对40例贲门失弛缓症患者进行POEM治疗,手术前后评估症状及食管造影、食管测压、胃镜等检查,于术后第6天、1个月、3个月、6个月评估疗效,并观察手术并发症。结果40例贲门失弛缓症患者均顺利完成POEM,手术时间（57．2±18．4）min,术中有2例出现纵隔和皮下气肿。术后缓解率100％（Eekardt评分≤3分）,平均随访13．3个月,复发2例,半年缓解率90％。食管测压术前食管下括约肌平均静息压30．6mmHg（1mmHg=Q133kPa）,术后15．8mmHg（P=0.001）;术前平均综合松弛压28．1mmHg,术后12．2mmHg（P=0．000）;平均食管最宽径术前4．2cm,术后3．1cm（P〈0．001）。结论POEM治疗贲门失弛缓症安全、有效,短期疗效肯定,并发症少,长期疗效及远期并发症有待随访研究。     

Bacteremia with upper gastrointestinal endoscopy.

Fifty patients undergoing upper gastrointestinal fiberoptic endoscopy were studied prospectively for the development of bacteremia by aerobic and anerobic blood cultures obtained before, during, and at 5 and 30 minutes after the procedure. Forty-six patients were culture negative; four had positive cultures at 5 or 30 minutes after the procedure, or at both times. The level of bacteremia as estimated by pour plates was very low. Bacteremia did not correlate with the performance of biopsy or the type of mucosal abnormality found. It is concluded that only very high-risk patients should receive antimicrobial prophylaxis before this procedure. The minor risk of this low-level bacteremia should not be considered a contraindication to the performance of upper gastrointestinal endoscopy.     

Absence of significant bacteremia during urinary catheter manipulation in patients with chronic indwelling catheters

The objective of this study was to quantify the microorganisms present in blood at urinary catheter removal and at reinsertion in patients with chronic indwelling urinary catheters. This was a prospective study during a 4-month period at a university-affiliated geriatric medical center. Our subjects were 33 patients with chronic indwelling urinary catheters and positive urinary cultures; the urinary catheter was usually changed once a month. A peripheral vein line was used for blood withdrawal and urinary cultures and quantitative blood cultures (Isolator) were performed during and shortly after urinary catheter removal and insertion. All patients had significant bacteriuria (greater than 10(5) cfu/mL) with an average of 2.3 microorganisms. Among the 46 sequential quantitative blood cultures performed, only two patients had bacteremia from the urinary source and at a very low concentration; one patient had 0.13 cfu/mL Str. faecalis in blood 5 minutes after removal of the urinary catheter, and the other 0.1 cfu/mL Proteus mirabilis 5 minutes after reinsertion of a new urinary catheter. None of the patients had any subjective or objective clinical problem during the 36 hours after the urinary manipulation. Clinical symptoms and bacteremia are rare events, and prophylactic antibiotics do not appear necessary during urinary catheter removal and reinsertion in elderly institutionalized patients. Further studies are necessary to identify risk factors in the rare instances of patients with bacteremia.     

Diagnosis of recurrent rectal carcinoma by EUS-guided fine-needle aspiration

BACKGROUND: Endoscopic mucosal resection has become a popular alternative for the treatment of early-stage neoplasia of the gastrointestinal tract. However, there are still no data on the frequency of bacteremia associated with this form of treatment. METHODS: We conducted a prospective study of 21 men and 17 women undergoing endoscopic mucosal resection with a cap-fitted panendoscope for upper gastrointestinal lesions. Blood cultures were performed before, 10 minutes after, and 4 hours after the procedure for both aerobic and anaerobic bacteria. RESULTS: Blood culture at baseline was negative in all the patients. Two of 38 patients (5.3 %) had positive blood culture at 10 minutes after the procedure. The isolated microorganisms were Streptococcus salivarius and Corynebacterium species. All patients had negative blood cultures 4 hours later. None of these 38 patients had any symptoms or signs associated with infection. CONCLUSIONS: Bacteremia associated with endoscopic mucosal resection is infrequent and transient.     

Incidence of fever and bacteremia following transbronchial needle aspiration

Fiberoptic bronchoscopy and transbronchial needle aspiration were performed on 50 occasions in 47 afebrile patients. The aspirations were followed by endobronchial or transbronchial biopsies in 22 patients, as well as bronchial brushings and washings where appropriate. Blood for cultures was drawn at 5 and 30 minutes following needle aspiration, as well as at the time of any temperature above 38 degrees C during the 24 hours following the procedure. In five (10 percent) of the 50 cases, there was temperature greater than 38 degrees C (100.4 degrees F) in the 24 hours following the bronchoscopy; in no patient were cultures of blood positive, whether done early after the procedure or at the time of fever. We conclude that transbronchial needle aspiration, a new procedure gaining widespread popularity in diagnostic thoracic medicine, is not associated with clinically detectable bacteremia. This procedure should not require antimicrobial prophylaxis in patients susceptible to endocarditis.     

Viridans streptococcal bacteremia after esophageal stricture dilation

Background: The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation. Methods: Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation. Results: A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients (p = 0.001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation. Conclusions: These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis. (Gastrointest Endosc 1998;48:568-73.)     

The Absence of Bacteremia During Colonoscopy

Seventy-nine blood cultures were obtained from 15 patients undergoing diagnostic colonoscopy. Aerobic and anaerobic culture technics showed no evidence of bacteremia during or after the procedure. The colonoscope was passed to the cecum in 12 of the 15 patients. The time of the procedure varied from 15–60 minutes with an average of 30 minutes. The results of this study supplies further evidence that bacteremia during colonoscopy is an infrequent occurrence.     

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients

BACKGROUND/GOALS: Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy. STUDY: A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated. RESULTS: Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified. CONCLUSIONS: Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.