CASE 5
ACUTE ABDOMINAL PAIN
急性腹痛
History
A 56-year-old woman presents to the emergency department complaining of abdominal pain. Twenty-four hours previously she developed a continuous pain in the upper abdomen which has become progressively more severe. The pain radiates into the back.She feels nauseated and alternately hot and cold. Her past medical history is notable for a duodenal ulcer which was successfully treated with Helicobacter eradication therapy 5 years earlier. She smokes 15 cigarettes a day, and shares a bottle of wine each evening with her husband.
abdomen 腹腔，腹部
progressive more severe 进行性加重
radiate into the back 放射至背部（放射至左肩背通常为心脏疾病如心梗，放射至右肩背通常为胆囊疾病如胆囊炎）
alternately hot and cold 冷热交替
duodenal ulcer 十二指肠溃疡
Helicobacter eradication therapy 幽门杆菌根治治疗
Examination
The patient looks unwell and dehydrated（脱水）. She weighs 115 kg. She is febrile（发热的）, 38.5°C, her pulse is 108/min and blood pressure 124/76 mmHg. Cardiovascular and respiratory system examination is normal. She is tender in the right upper quadrant and epigastrium, with guarding and rebound tenderness. Bowel sounds are sparse.
Bowel sound 肠鸣音
sparse 原意是稀疏的，这里表示肠鸣音减弱
Investigation
| 项目 | 结果 | 参考范围 |
|---|---|---|
| Haemoglobin | 14.7 g/dL | 11.7–15.7 g/dL |
| White cell count | 19.8*109/L | 3.5–11.0109/L* |
| Platelets | 239 *109/L | 150–440*109/L |
| Sodium | 137 mmol/L | 135–145 mmol/L |
| Potassium | 4.8 mmol/L | 3.5–5.0 mmol/L |
| Urea | 8.6 mmol/L | 2.5–6.7 mmol/L |
| Creatinine | 116 umol/L | 70–120 umol/L |
| Bilirubin | 19 umol/L | 3–17 umol/L |
| Alkaline phosphatase | 58 IU/L | 30–300 IU/L |
| Alanine aminotransferase（AAT） | 67 IU/L | 5–35 IU/L |
| Gamma-glutamyl transpeptidase | 72 IU/L | 11–51 IU/L |
| C-reactive protein（CRP） | 256 mg/L | ＜5 mg/L |
haemoglobin 血红蛋白（反应贫血情况的指标）
platelet 血小板
sodium 钠
potassium 钾
urea 尿素
creatinine 肌酐（反应肾功能情况的指标）
bilirubin 胆红素
Alkaline phosphatase 碱性磷酸酶
Alanine aminotransferase 谷丙转氨酶（反应肝功能的指标之一）
Gamma-glutamyl transpeptidase γ-谷氨酰转移酶
C-reactive protein C反应蛋白（反应炎症/感染的指标之一）
Questions
• What is the most likely diagnosis? 最可能的诊断是什么？
• How would you manage this patient? 你会怎么处理？
This woman has acute cholecystitis（急性胆囊炎）. Cholecystitis is most common in obese（肥胖）, middle-aged women, and classically is triggered by eating a fatty meal. Cholecystitis is usually caused by a gallstone（胆结石） impacting in the cystic duct（胆囊管）. Continued secretion by the gallbladder leads to increased pressure and inflammation of the gallbladder（胆囊体） wall. Bacterial infection is usually by Gram-negative（革兰氏阴性） organisms and anaerobes（厌氧菌）. Ischaemia（缺血） in the distended（本意是膨胀的，这里表示扩张的） gallbladder can lead to perforation（穿孔） causing either generalized peritonitis（全腹腔炎症） or formation of a localized abscess（局限性脓肿）. Alternatively the stone can spontaneously disimpact and the symptoms spontaneously improve. Gallstones can get stuck in the common bile duct（胆管） leading to cholangitis（胆管炎） or pancreatitis（胰腺炎）. Rarely, gallstones can perforate through the inflamed gallbladder wall into the small intestine and cause intestinal obstruction（肠梗阻） (gallstone ileus胆石性肠梗阻). The typical symptom is of sudden-onset（突发） right upper quadrant abdominal pain（右上腹痛） which radiates into the back. In uncomplicated cases the pain improves within 24 h. Fever suggests a bacterial infection.Jaundice（黄疸） usually occurs if there is a stone in the common bile duct. There is usually guarding and rebound tenderness in the right upper quadrant (Murphy’s sign墨菲氏征).
In this patient the leucocytosis（白细胞增多症） and raised CRP are consistent with acute cholecystitis. If the serum bilirubin（血胆红素） and liver enzymes（肝酶，包括谷丙转氨酶，谷草转氨酶等） are very deranged, acute cholangitis due to a stone in the common bile duct should be suspected. The abdominal X-ray is normal; the majority of gallstones are radiolucent and do not show on plain films.
Differential diagnosis
The major differential diagnoses of acute cholecystitis include perforated peptic ulcer, acute pancreatitis, acute hepatitis, subphrenic abscess, retrocaecal appendicitis and perforated carcinoma or diverticulum of the hepatic flexure of the colon.Myocardial infarction or right lower lobe pneumonia may also mimic cholecystitis.
differential diagnosis 中的differential表示不同的，所以这里表示鉴别诊断，和不同的疾病的鉴别
perforated peptic ulcer 消化道溃疡穿孔，ulcer 溃疡，perforate 穿孔
hepatitis 肝炎
subphrenic abscess 膈（肌）下脓肿
retrocaecal appendicitis盲肠后阑尾炎
diverticulum 憩室
colon 结肠 ，hepatic flexure 肝曲，hepatic flexure of the colon结肠肝曲
Myocardial infarction 心肌梗死
right lower lobe pneumonia 这里的 lobe表示叶，所以这里的意思是右下肺炎
This patient should be admitted under the surgical team. Serum amylase（血淀粉酶，反应胰腺炎情况的指标之一） should be measured to rule out pancreatitis. Blood cultures（血培养） should be taken. Chest X-ray should be performed to exclude pneumonia, and erect abdominal X-ray to rule out air under the diaphragm（膈肌） which occurs with a perforated peptic ulcer. An abdominal ultrasound（超声） will show inflammation of the gallbladder wall. The patient should be kept nil（本意为空，程序中数学上多用这个表达，还有一个相近的是null，这里表示保证口腔里无异物，口腔内是空的） by mouth, given intravenous（静脉使用） fluids and commenced on intravenous cephalosporins（先锋霉素，就是现在所说的头孢菌素） and metronidazole（灭滴灵，通用名叫甲硝唑）.
The patient should be examined regularly for signs of generalized peritonitis or cholangitis. If the symptoms settle down the patient is normally discharged to be readmitted in a few weeks once the inflammation has settled down to have a cholecystectomy（胆囊切除术）.
网友评论