消化科病例

Case6A43-year-oldmanpresentswitha16-hourhistoryofintermittent,crampyabdominalpainandbiliousvomiting.Hestatesthatthesymptomsbeganapproximately3hoursafterlunchonthepreviousday,improvedaftervomiting,butreturnedafter1to2hours.Hehadabowelmovementshortlyaftertheonsetofthepain,buttherehasbeennopassageofflatusorstoolsincethen.Thepatientdeniesanysimilarepisodespreviouslyandhasnocurrentmedicalproblems.Heunderwentexploratorylaparotomyforagunshotwoundtotheabdomen3yearspreviously.Onexamination,histemperatureis100.5F,pulserate105/min,bloodpressures140/80mmHg,andrespiratoryrate24/min.theabdomenisdistended,withawell-healedmidlinesurgicalscar.Theabdomenistenderthroughoutwithnomassesorperitonitis.Thebowelsoundsarehypoactivewithoccasionalhighpitchedrushes.Noherniasareidentified.Arectalexaminationrevealsnomassesandnostoolintherectalvault.Laboratorystudiesrevealnormalelectrolytelevels.Hiswhitedbloodcell(WBC)countsis16,000/mm3with85%neutrophils,4%bands,10%lymphocytes,and1%monocytesthehemoglobinandhemotocritvaluesare18g/dLand48%,respectively.Theserumamylasevalueis135IU/L.Anabdominalradiographwasobtained.Whatisyournextstepinmanagement?Whatarethecomplicationsassociatedwiththisdiseaseprocess?Whatistheprobabletherapy?Answerstocase6:smallbowelobstructionNextstepinmanagement:placeanasogastric(NG)tubetodecompressthestomach,beginfluidresuscitation,placeaFoleycathetertomonitorurineoutputandassesshisresponsetothefluidresuscitation.Complicationsassociatedwiththisdiseaseprocess:Mechanicalsmallbowelobstructionmayleadtostrangulation,bowelnecrosis,andsepsis.Vomitingmayresultinaspirationpneumonitis(pneumonia).Whenunrecognizedoruntreated,intravascularfluidloss(fromthird-spacefluidlossandvomiting)canleadtoprerenalazotemiaandacuterenalinsufficiency.Case8A46-year-oldwomanpresentswitha24-hourhistoryofabdominalpainthatbeganapproximately1hourafteralargedinner.Thepaininitiallybeganasadullacheintheepigastriumbutthenlocalizedintherightupperquadrant(RUQ).Shedescribessomenauseabutnovomiting.Sinceherpresentationtotheemergencycenter,thepainhasimprovedsignificantlytothepointofherbeingnearlypain-free.Shedescribeshavinghadsimilarpaininthepastwithallpreviousepisodesbeingself-limited.HerpastmedicalhistoryissignificantfortypeIIdiabetesmellitus.Onphysicalexamination,hertemperatureis38.1℃(99F),andtherestofhervitalsignsarenormal.TheabdomenisnondistendedwithminimaltendernessintheRUQ.Findingsfromtheliverexaminationappearnormal.Therectalandpelvicexaminationsrevealnoabnormalities.Hercompletebloodcountrevealsawhitebloodcell(WBC)countof13000/mm3.Serumchemistrystudiesdemonstratetotalbilirubin1.8mg/dL,directbilirubin0.6mg/dL,alkalinephosphatese149U/L,AST45U/L,andALT30U/L.UltrasonographyoftheRUQdemonstratesstonesinthegall-bladder,athickenedgallbladderwall,andacommonbileductdiameterof4.0mm.Whatisthemostlikelydiagnosis?Whatisthebesttherapy?Whatarethecomplicationsassociatedwiththisdiseaseprocess?Answerstocase8:gallstonediseaseDiagnosis:cholecystitis,likelyacuteandchronic.Besttherapy:laparoscopiccholecystectomyisthepreferredtreatmentforallpatientswithareasonablelifeexpectancyandnoprohibitiverisksforgeneralanesthesiaandabdominalsurgery.Complications:complicationsfromgallstonediseaseincludeacuteandchroniccholecystitis,pancreatitis,choledocholithiasis,cholangitis,andgallstoneileus(胆石性肠梗阻).Case9A38-year-oldmanpresentsattheemergencycenterwithtarrystoolsandafeelingoflight-headedness.Thepatientindicatesthatoverthepast24hourshehashadseveralbowelmovementscontainingtarrycoloredstoolsandforthepast12hourshasfeltlight–headed.Hispastmedicalandsurgicalhistoryareunremarkable.Thepatientcomplainsoffrequentheadachesduetowork-relatedstress,forwhichhehasbeenself-medicatingwithsixtoeighttabletsofibuprofenadayforthepast2weeks.Heconsumestwotothreemartinisperdayanddeniestobaccoorillicitdruguse.Onexaminations,histemperatureis37.0℃(98.6F),pulserate105/min(supine),bloodpressure104/80mmHg,andrespiratoryrate22/min.Hisvitalsighsuprightarepulse120/minandbloodpressures90/76mmHg.Heisawake,cooperative,andpale.Thecardiopulmonaryexaminationsareunremarkable.Hisabdomenismildlydistendedandmildlytenderintheepigastrium.Therectalexaminationrevealsmelanoticstoolsbutmassesinthevault.Whatisyournextstep?Whatisthebestinitialtreatment?Answerstocase9:upperGItracthemorrhageNextstep:thefirststepinthetreatmentofpatientswithupperGIhemorrhageisintravenousfluidresuscitation.Theetiologyandseverityofthebleedingdictatetheintensityoftherapyandpredicttheriskoffurtherbleedingand/ordeath.Bestinitialtreatment:promptattentiontothepatients’airway,breathing,andcirculationismandatoryforpatientswithacuteupperGIhemorrhage.Afterattentiontotheairway,breathing,andcirculation(ABC’s),thepatientispreparedforendoscopytoidentifytheetiologyorsourceofthebleedingandpossibleendoscopictherapytocontrolhemorrhage.