143. Operationsindikation bei akuter Pankreatitis

Zusammenfassung Die Indikation zur Operation bei der AHNP ist bestimmt durch den Schweregrad und die Verlaufsdynamik der Erkrankung: Beides muß täglich neu kontrolliert und abgeschätzt werden, wobei hilfreiche Parameter vor allem das klinische Bild und einfache Labordaten sind. Die Computertomographie trägt nur bedingt zur Indikation bei. Eine Frühoperation ist indiziert bei Versagen der Intensivtherapie, Sepsis und vor allem bei drohender Nieren- und Lungeninsuffizienz. Eine Operation im postakuten Stadium sollte ebenfalls bei septischen Komplikationen durchgeführt werden. Engmaschige Verlaufskontrollen sind hier erforderlich.

---

Indication for surgery in acute pancreatitis

Summary The indication for surgery in acute hemorrhagic necrotizing pancreatitis (AHNP) depends on the severity of the disease and the clinical course. Both factors must be determined daily, based on clinical and laboratory data. CAT-scan does not contribute much to indication. An early operation is necessary if despite an optimal intensive care septic symptoms and signs persist and renal and respiratory failure occur. Surgery is indicated 2–3 weeks after onset of AHNP if septic complications (re)-occur. A close follow up is mandatory.

     

Atypical hemolytic uremic syndrome in human immunodeficiency virus-1-infected children

We describe the clinical and pathological findings of the hemolytic uremic syndrome (HUS) in two children with human immunodeficiency virus (HIV) infection. Both patients presented with microangiopathic hemolytic anemia, thrombocytopenia, and subsequently developed renal failure. The diagnosis of HUS was confirmed by renal histopathology in both patients. None of these children presented with bloody diarrhea, evidence of circulating antibody response to Escherichia coli O157 lipopolysaccharide, or other known risk factors for HUS, except for the presence of HIV infection. Each patient was treated with intravenous plasma infusion and renal replacement therapy. Their clinical course was characterized by non-oliguria and lack of significant hypertension throughout the acute phase of the disease. Despite these favorable clinical parameters, both patients developed end-stage renal failure. The etiology of this atypical HUS characterized by poor renal survival remains unknown and the role of HIV infection in its pathogenesis, although possible, is unclear. Received March 5, 1996; received in revised form and accepted October 15, 1996     

Acute subdural hematoma: Outcome and outcome prediction

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome.Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively.Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9–15) and 23% of patients with a low GCS score (3–8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21–40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion.Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.     

大鼠马桑内酯急性局灶型癫痫大脑运动皮质的形态计量研究

用微量马桑内酯注入Ｗｉｓｔａｒ大鼠左侧前肢运动皮质，造成急性局灶型癫痫。用光镜、电镜和体视学方法研究其运动皮质第Ｖ层结构的改变。结果显示：癫痫大鼠运动皮质灶区、灶旁区的神经细胞数和胶质细胞数均分别比对照大鼠灶区和灶旁区显著减少；灶区神经毡中突触性终末数，显著减少；突触性终末的面积分数明显减少，而树突的面积分数无变化；神经胶质突起的面积分数增加。     

Acute severe combined demyelination

We present a second case in which Guillain-Barré syndrome (GBS) and acute disseminated encephalomyelitis (ADEM) appeared simultaneously, both in acute and fulminant form. The patient, a 10-year-old girl, presented with acute onset of coma and flaccid, areflexic quadriparesis. The elevated CSF protein levels and delayed F waves fulfilled the criteria of GBS and an MRI study revealed extensive multifocal demyelination compatible with a diagnosis of ADEM. Prompt clinical response followed by complete recovery was achieved by treatment with corticosteroids. It is suggested that acute severe combined demyelination might constitute a separate entity in which the demyelinating process, involving simultaneously the central and the peripheral nervous systems, indicates immune response against a component of the myelin of one system carrying cross-antigenicity with the other.     

Local fibrinolysis for superior mesenteric artery thromboembolism

A 66-year-old man with atrial fibrillation was referred soon after developing left lower limb and abdominal pain with rectal bleeding. An immediate flush aortogram showed embolic occlusion of the left distal superficial femoral artery and superior mesenteric artery (SMA), 3 cm from its ostium. Recombinant tissue plasminogen activitor (rtPA) 40 mg was selectively in stilled in the SMA in two boluses. Abdominal symptoms resolved within 48 h, and complete recanalization of the SMA was shown on angiography. Exploratory laparotomy after 72 h showed a normal small bowel and right colon, and was completed by femoropopliteal embolectomy. Six months later, the patient remained asymptomatic.     

Gadolinium ring enhancement and mass effect in acute disseminated encephalomyelitis

A 9-year-old boy presented with a subacute history of optic neuritis followed by brainstem involvement, with fever and a lymphocytic pleocytosis in the cerebrospinal fluid. Gadolinium-enhancing ring lesions were demonstrate in the white matter of the cerebrum, brainstem and cerebellum on day 17 of the illness, all appearing simultaneously as part of a monophasic illness. A parietal lesion exerted mass effect. Needling and biopsy yielded no evidence of a pyogenic lesion, tumour or tuberculosis and showed vasculitis. There was insufficient material for myelin staining. Dexamethasone therapy lead to rapid improvement of the radiological lesions: MRI and CT on day 34 of the illness showed complete clearing of the lesions except for residual abnormality at the biopsy site.     

654─2在小儿急性脑水肿及中枢性呼吸衰竭中的应用探讨

感染性脑水肿病儿在感染得到有效控制，应用654—2（山莨菪碱）后未再用脱水剂，笔者认为．654—2具有解除脑血管痉挛及微循环障碍的作用。急性脑水肿在脱水剂应用后，用654—2有利于脑水肿液的吸收和回流。目前，治疗小儿捂热综合征（IMS）之细胞内水肿仍没有有效的方法，研究结果表明654—2能改善脑细胞供氧．其还能通过解除呼吸中枢血管痉挛而治疗中枢性呼吸衰竭。     

儿童急性荨麻疹的心电图观察

目的 了解儿童急性荨麻疹对心脏的影响。方法 对急性荨麻疹患儿593例行常规心电图检查。结果 33例(5．6％)患儿出现心电图异常改变，主要表现为I度房室传导阻滞、室性早搏、T波低平。皮损消失后心电图亦恢复正常。结论 急性荨麻疹患儿可伴有心脏的损害，临床上应予以重视。     

急性阑尾炎术中外用过氧化氢液冲洗疗效观察─—附50例报告

本文报导采用过氧化氢液在急性阑尾炎术对局部腹腔及切口进行冲洗的方法。并用５０个病例进行了对比分析。认为此法简单、可靠。对腹腔脓肿，预防切口感染有一定效果。可适用于一般基层医院。