1例罕见肝内局限性积气征患者的MDT诊治经验与体会
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摘要
目的总结罕见肝内局限性积气征病例的多学科协作(multidisciplinary team,MDT)诊治经验及体会,并探讨其与其他常见不同类型肝内积气征病例的临床鉴别。方法回顾性分析新疆维吾尔自治区职业病医院收治的1例罕见肝内局限性积气征病例的临床病理资料。结果 1例60岁女性患者,门诊以"腹痛待诊?感染性休克"收住入院。经MDT讨论,在早期纠正电解质紊乱和低蛋白血症及输注血小板抗休克治疗后,行B超引导下经皮经肝右叶病灶置管引流,引出脓性液10 m L,引出气体200 m L,留置引流管,第6天时拔除引流管。亚胺培南西司他丁钠注射液抗炎治疗5 d后降级为头孢唑肟(三代头孢)注射液继续抗炎治疗6 d并同时进行血糖控制。治疗后第7天时,右上腹胀痛缓解,无发热、呕吐等症状,饮食及大小便正常;体格检查正常;腹部CT示肝右叶局限性积气病灶基本吸收,肝右叶积气病灶引流管间断拔除(病灶愈合);实验室检查结果基本恢复正常或接近正常。治疗后第12天时出院,出院后1个月时随访患者无不适症状,腹部CT提示肝脏无异常病变。结论外科医生要充分认识各种不同类型的肝内积气征,以便快速明确病因并采取有效措施,以提高疾病治愈率及减少并发症的发生。
Objective To summarize experience of multidisciplinary team(MDT) in diagnosis and treatment of rare patient with circumscriptus intrahepatic pneumatosis and explore its clinical differentiation with other common types of intrahepatic pneumatosis. Method The clinicopathologic data of rare patient with circumscriptus intrahepatic pneumatosis admitted to the Occupational Disease Hospital of Xinjiang Uygur Autonomous Region were retrospectively analyzed. Results A 60-year old female patient was admitted to this hospital with "abdominal pain and septic shock".After the MDT discussion and analysis, the treatment regimens were decided as follows: the early anti-shock treatment,corrections of electrolyte disorder and hypoalbuminemia, platelet transfusion, ultrasound guided percutaneous catheter drainage(200 mL gas and 10 mL pus, the pneumonic Klebsiella which proved by the bacterial culture). The drainage tube was removed on postoperative day 6. After 5 d of the anti-inflammatory treatment with imipenem and statin sodium injection, it was downgraded to the cefazoxime(the third-generation cephalosporin) injection, and the anti-inflammatory treatment was continued for 6 d as well as the blood glucose was controlled. On the 7 th day after the treatment, the right upper abdomen pain was relieved and without positive sign. The abdominal CT showed the localized pneumoconiosis in the right lobe of the liver was completely absorbed. The result of laboratory examination was basically normal. The patient was discharged on the 12 th day after the operation and had no discomfort symptoms on month 1 after the operation. The abdominal CT showed the liver was not abnormal. Conclusion Surgeons should be fully aware of various types of intrahepatic pneumatosis so as to sufficiently investigate pathophysiological clue of disease to improve cure rate and reduce complications.
Objective To summarize experience of multidisciplinary team(MDT) in diagnosis and treatment of rare patient with circumscriptus intrahepatic pneumatosis and explore its clinical differentiation with other common types of intrahepatic pneumatosis. Method The clinicopathologic data of rare patient with circumscriptus intrahepatic pneumatosis admitted to the Occupational Disease Hospital of Xinjiang Uygur Autonomous Region were retrospectively analyzed. Results A 60-year old female patient was admitted to this hospital with "abdominal pain and septic shock".After the MDT discussion and analysis, the treatment regimens were decided as follows: the early anti-shock treatment,corrections of electrolyte disorder and hypoalbuminemia, platelet transfusion, ultrasound guided percutaneous catheter drainage(200 mL gas and 10 mL pus, the pneumonic Klebsiella which proved by the bacterial culture). The drainage tube was removed on postoperative day 6. After 5 d of the anti-inflammatory treatment with imipenem and statin sodium injection, it was downgraded to the cefazoxime(the third-generation cephalosporin) injection, and the anti-inflammatory treatment was continued for 6 d as well as the blood glucose was controlled. On the 7 th day after the treatment, the right upper abdomen pain was relieved and without positive sign. The abdominal CT showed the localized pneumoconiosis in the right lobe of the liver was completely absorbed. The result of laboratory examination was basically normal. The patient was discharged on the 12 th day after the operation and had no discomfort symptoms on month 1 after the operation. The abdominal CT showed the liver was not abnormal. Conclusion Surgeons should be fully aware of various types of intrahepatic pneumatosis so as to sufficiently investigate pathophysiological clue of disease to improve cure rate and reduce complications.
引文
1王凇,郝艳红,杨薇,等.肝癌射频消融后肝脓肿的发生率及危险因素分析.中国介入影像与治疗学,2018, 15(1):37-41.
2胡贤铧,廖彩虹,张云轩.多层螺旋CT扫描在不典型肝脓肿诊断中的价值.中国继续医学教育,2018, 10(21):46-48.
3廖政戎.肝脓肿合并2型糖尿病的临床特征分析及疗效评估.糖尿病新世界,2018, 21(16):23-24.
4边芳.肝脓肿的CT诊断及临床鉴别.现代医用影像学,2018,27(2):561-562.
5史凤霞,刘建滨,郭一清.胆囊内瘘的影像表现.临床放射学杂志,2018, 37(3):424-427.
6杨艳,周中银,姬盼盼,等.胆囊结肠瘘的诊治进展.医学研究杂志,2016, 45(11):191-193.
7王晓东,刘洋,徐刚.门静脉积气的CT影像表现及临床意义.中国医疗前沿,2012, 7(9):67, 61.
8刘灵军,于洋,李肖.门静脉积气临床与影像学研究进展.中华临床医师杂志(电子版),2011,5(23):7061-7063.
9张莹,刘欣,张文耀,等.螺旋CT检查急性缺血性肠病所致门静脉和肠壁积气的表现特点及其临床诊断价值研究.实用肝脏病杂志,2018, 21(5):793-796.
10于涛,薛娟,刘莉娜,等.急性重型减压病致肝内多发积气的CT改变.中华航海医学与高气压医学杂志,2018, 25(2):116-117.
11蔡庆虎,张燕绒,张海荣,等.缺血性肠病所致肝门静脉和肠壁积气的螺旋CT影像特征与诊断价值.中华肝胆外科杂志,2017, 23(5):296-299.
12 Abboud B, El Hachem J, Yazbeck T, et al.Hepatic portal venous gas:physiopathology, etiology, prognosis and treatment. World J Gastroenterol, 2009,15(29):3585-3590.
13 Nelson AL, Millington TM, Sahani D, et al. Hepatic portal venous gas:the ABCs of management. Arch Surg, 2009, 144(6):575-581.
14何佳妹.彩超对肝内三种常见强回声病灶的鉴别与诊断研究.医学信息,2018, 31(12):160-162.
15曾邦峰,余晖.不典型肝脓肿的影像学表现及鉴别诊断.医学综述,2017, 23(21):4342-4346.
16邵永良,钟丽琴,孙云峰,等.CT检查在囊性肝内胆管细胞癌与肝脓肿诊断中的作用分析.健康研究,2016, 36(2):150-152.
17姚敏学,冯秋鹏,鲍磊,等.门静脉积气一例.中华急诊医学杂志,2016,25(3):355.
18张怀信,蒋雪峰,朱玉春,等.肝脏门静脉积气1例.西南军医,2015,(3):326-327.
19刘远高,李昌松,钟台声.细菌性肝脓肿的CT、MRI影像诊断及鉴别诊断.中国CT和MRI杂志,2014,12(6):58-60.
20于明安,梁萍,于晓玲,等.肝内转移,性胆管癌合并胆管积气微波消融后肝脓肿发生及原因分析.中国超声医学工程学会成立30周年暨第十二届全国超声医学学术大会论文汇编.西安:中国超声医学工程学会,2014:586.
21周春,周建桥,詹维伟,等.门静脉积气的超声表现(6例报道及文献复习).肿瘤影像学,2014, 23(2):133-136.
22严涵.肝内胆管积气临床超声诊断与鉴别诊断价值分析.中国中医药咨讯,2011,03(18):459.
23李俊华,任明思.上消化道穿孔致肝包膜下积液积气1例.医学影像学杂志,2010, 20(6):822-822, 853.
24安剑萍.肝内胆管积气的超声诊断与鉴别诊断.实用临床医学,2009, 10(8):82-83,封4.
25周建桥,周春,吴志远,等.门静脉积气超声表现3例.中华超声影像学杂志,2006,15(7):557.
2胡贤铧,廖彩虹,张云轩.多层螺旋CT扫描在不典型肝脓肿诊断中的价值.中国继续医学教育,2018, 10(21):46-48.
3廖政戎.肝脓肿合并2型糖尿病的临床特征分析及疗效评估.糖尿病新世界,2018, 21(16):23-24.
4边芳.肝脓肿的CT诊断及临床鉴别.现代医用影像学,2018,27(2):561-562.
5史凤霞,刘建滨,郭一清.胆囊内瘘的影像表现.临床放射学杂志,2018, 37(3):424-427.
6杨艳,周中银,姬盼盼,等.胆囊结肠瘘的诊治进展.医学研究杂志,2016, 45(11):191-193.
7王晓东,刘洋,徐刚.门静脉积气的CT影像表现及临床意义.中国医疗前沿,2012, 7(9):67, 61.
8刘灵军,于洋,李肖.门静脉积气临床与影像学研究进展.中华临床医师杂志(电子版),2011,5(23):7061-7063.
9张莹,刘欣,张文耀,等.螺旋CT检查急性缺血性肠病所致门静脉和肠壁积气的表现特点及其临床诊断价值研究.实用肝脏病杂志,2018, 21(5):793-796.
10于涛,薛娟,刘莉娜,等.急性重型减压病致肝内多发积气的CT改变.中华航海医学与高气压医学杂志,2018, 25(2):116-117.
11蔡庆虎,张燕绒,张海荣,等.缺血性肠病所致肝门静脉和肠壁积气的螺旋CT影像特征与诊断价值.中华肝胆外科杂志,2017, 23(5):296-299.
12 Abboud B, El Hachem J, Yazbeck T, et al.Hepatic portal venous gas:physiopathology, etiology, prognosis and treatment. World J Gastroenterol, 2009,15(29):3585-3590.
13 Nelson AL, Millington TM, Sahani D, et al. Hepatic portal venous gas:the ABCs of management. Arch Surg, 2009, 144(6):575-581.
14何佳妹.彩超对肝内三种常见强回声病灶的鉴别与诊断研究.医学信息,2018, 31(12):160-162.
15曾邦峰,余晖.不典型肝脓肿的影像学表现及鉴别诊断.医学综述,2017, 23(21):4342-4346.
16邵永良,钟丽琴,孙云峰,等.CT检查在囊性肝内胆管细胞癌与肝脓肿诊断中的作用分析.健康研究,2016, 36(2):150-152.
17姚敏学,冯秋鹏,鲍磊,等.门静脉积气一例.中华急诊医学杂志,2016,25(3):355.
18张怀信,蒋雪峰,朱玉春,等.肝脏门静脉积气1例.西南军医,2015,(3):326-327.
19刘远高,李昌松,钟台声.细菌性肝脓肿的CT、MRI影像诊断及鉴别诊断.中国CT和MRI杂志,2014,12(6):58-60.
20于明安,梁萍,于晓玲,等.肝内转移,性胆管癌合并胆管积气微波消融后肝脓肿发生及原因分析.中国超声医学工程学会成立30周年暨第十二届全国超声医学学术大会论文汇编.西安:中国超声医学工程学会,2014:586.
21周春,周建桥,詹维伟,等.门静脉积气的超声表现(6例报道及文献复习).肿瘤影像学,2014, 23(2):133-136.
22严涵.肝内胆管积气临床超声诊断与鉴别诊断价值分析.中国中医药咨讯,2011,03(18):459.
23李俊华,任明思.上消化道穿孔致肝包膜下积液积气1例.医学影像学杂志,2010, 20(6):822-822, 853.
24安剑萍.肝内胆管积气的超声诊断与鉴别诊断.实用临床医学,2009, 10(8):82-83,封4.
25周建桥,周春,吴志远,等.门静脉积气超声表现3例.中华超声影像学杂志,2006,15(7):557.