陳浩鑫，鄭楚發(fā)，黃盛鑫，彭云恒

·誤診研究：消化系疾病·

腹腔內結石誤診為膽總管結石一例

陳浩鑫，鄭楚發(fā)，黃盛鑫，彭云恒

目的探討腹腔內結石的臨床特征及誤診原因。方法回顧性分析我院近期收治的誤診為膽總管結石的腹腔內結石1例的臨床資料。結果本例因右上腹痛1月余入院。曾就診當?shù)蒯t(yī)院，診斷為膽總管結石，予對癥治療后癥狀稍好轉，但仍反復發(fā)作。入院后行血常規(guī)、肝功能、腹部CT等檢查并于氣管插管全身麻醉下行腹腔鏡探查術，術后結合組織病理檢查結果，確診為腹腔內結石并感染、慢性膽囊炎，予抗感染等治療后好轉出院。隨訪10個月，未出現(xiàn)相關并發(fā)癥。結論臨床遇及右上腹痛且予對癥治療后癥狀未見緩解者，要考慮到腹腔內結石的可能，完善相關檢查是避免或減少誤診誤治的關鍵。

腹腔內結石；誤診；膽總管結石

腹腔結石是臨床少見病，而位于右上腹的腹腔結石若合并感染，可出現(xiàn)類似膽石癥的臨床表現(xiàn)，進而誤診。我院近期收治誤診為膽總管結石的腹腔內結石1例，現(xiàn)分析報告如下。

1 病例資料

男，75歲。因右上腹痛1月余入院。1個月前無明顯誘因出現(xiàn)持續(xù)性右上腹痛，無放射性疼痛，偶有惡心、嘔吐，無發(fā)熱、畏寒，在當?shù)蒯t(yī)院行彩色多普勒超聲檢查示：膽總管結石，膽囊炎，予抗感染治療后癥狀稍緩解，但仍反復發(fā)作，為進一步診治就診我院，以膽總管結石收入院。30余年前因上消化道穿孔行胃次全切除術。查體：生命體征平穩(wěn)，心肺檢查未見異常；上腹正中可見長約8 cm的手術瘢痕，右上腹輕壓痛，無反跳痛及肌緊張。查血白細胞17.3×109/L，中性粒細胞0.825；總膽紅素11.4 μmol/L，丙氨酸轉氨酶11 U/L，天冬氨酸轉氨酶19 U/L。腹部CT示：膽囊壁增厚，邊緣毛糙；膽總管上段見直徑約2.2 cm的球形高密度影，周圍脂肪間隙渾濁；肝內膽道無擴張，考慮：膽囊炎，膽總管上段結石(圖1)。初步診斷為膽總管結石并膽道感染、慢性膽囊炎，予抗感染治療2 d后于氣管插管全身麻醉下行腹腔鏡探查術。術中見上腹腔嚴重粘連，膽囊、十二指腸球部及大網(wǎng)膜與肝臟臟面粘連致密，膽囊壁厚，呈慢性炎癥改變；膽總管無明顯擴張，右后方至下腔靜脈前方Winslow孔見一4.5 cm×3.0 cm大小的腫物，與膽囊粘連，表面充血水腫，組織糜爛，觸之易破，破潰后有膿液流出，腫物內可見約2.2 cm×2.0 cm大小的黃色類圓形結石樣物質，表面完整(圖2)。術中切除膽囊及腫物，吸盡膿液，于Winslow孔放置引流管1根。術后病理報告：見較多炎性滲出物，細胞結構不清。確診為腹腔內結石并感染、慢性膽囊炎，予抗感染等治療后拔除引流管并痊愈出院。隨訪10個月，未出現(xiàn)相關并發(fā)癥。

圖1腹腔內結石術前腹部CT示：膽總管上段見直徑約2.2 cm的球形高密度影；肝內膽道無擴張

圖2腹腔內結石術中所見：膽總管右后方至下腔靜脈前方Winslow孔見一4.5 cm×3.0 cm大小的腫物，表面充血水腫，觸之易破，腫物內可見約2.2 cm×2.0 cm大小的黃色類圓形結石樣物質，表面完整

2 討論

腹腔內結石是一種較少見疾病，發(fā)病原因不明確[1-2]，可由繼發(fā)性因素或醫(yī)源性因素引起，結石核心由血塊、細菌團、脫落的上皮細胞或未吸收的縫線構成，在膠質基質的參與下逐漸沉積、擴大，進而形成結石[3]，也可由醫(yī)源性結石殘留引起[4-5]，合并感染可引起相應的臨床癥狀。腹腔內殘留結石及基質沉積形成的較大結石可根據(jù)癥狀、體征等選擇觀察、對癥處理和手術治療等措施。

本例結石位于膽總管后方Winslow孔，加之30年前因消化道穿孔行胃次全切除術，考慮可能由于血塊、細菌團、脫落的上皮細胞或食物殘渣沉積于膽總管后方，構成了結石的核心，在長達30年的時間中基質不斷沉積，逐漸形成結石。

手術治療應遵照操作指南，把握手術適應證，術前注意患者是否有黃疸，血常規(guī)、膽紅素及其他肝功能指標是否異常[6]；其次，行膽總管切開取石術前，仔細探查膽總管及周圍情況，確認膽總管是否有結石及其部位、膽總管擴張程度等。若術中探查與手術預期方案相差甚遠，應根據(jù)具體情況調整方案[7]，減少醫(yī)源性損傷。本例術中發(fā)現(xiàn)腹腔內結石，及時調整方案，術后予對癥治療后癥狀好轉。

分析本例誤診的主要原因是醫(yī)師對腹腔內結石認識不足，過分依賴影像學檢查結果，術前未仔細閱片，加上結石位于膽總管旁，依據(jù)入院時臨床表現(xiàn)、醫(yī)技檢查等，誤診為膽總管結石并膽道感染。術后通過多角度閱片，不難發(fā)現(xiàn)該結石位于膽總管之外，而膽總管內未見結石，且結石以上膽總管及肝內外膽道無擴張，與膽總管結石典型的CT影像學表現(xiàn)不符[8]。提示臨床應加強對腹腔內結石的認識，仔細查體，反復閱讀影像學資料[9]，若術前診斷不明確者，可行磁共振膽胰管造影、胰膽管逆行造影等檢查[10-11]，減少醫(yī)源性損傷，避免誤診誤治。

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AbdominalIntracavitaryCalculiMisdiagnosedasCommonBileDuctCalculiaCaseReport

CHEN Hao-xin, ZHENG Chu-fa, HUANG Sheng-xin, PENG Yun-heng
(The First Department of General Surgery, Shantou Hospital Affiliated to Sun Yat-sen University, Shantou, Guangdong 515000, China)

ObjectiveTo investigate clinical features and misdiagnosed causes of abdominal intracavitary calculi.MethodsClinical data of one patient with abdominal intracavitary calculi, who was misdiagnosed as having common bile duct calculi, was retrospectively analyzed.ResultsThe patient was admitted for pain in right hypochondrial region for more than one month. The patient was misdiagnosed as having common bile duct calculi in local hospital, and patient's symptoms had be improved a little after symptomatic treatment, but the condition was recurrent. After admitting in our hospital, examinations such as blood routine, liver function, computed tomography (CT) scan for abdomen and laparoscopic approach surgery under tracheal cannula and intubation anesthesia were performed, and the patient was confirmed as having abdominal intracavitary calculi combined with infection and chronic cholecystitis according to histopathologic result. The patient was discharged after condition had been improved by anti-infectious therapy. No related complication was found with 10 months of follow-up.ConclusionClinicians should take into account the possible of abdominal intracavitary calculi for patients with pain in right hypochondrial region without remission by symptomatic treatment. Related examinations should be performed completely in order to avoid misdiagnosis and mistreatment.

Abdominal intracavitary calculi; Misdiagnosis; Choledocholithiasis

515000 廣東 汕頭，中山大學附屬汕頭醫(yī)院普外一科

R572

A

1002-3429(2017)12-0013-02

10.3969/j.issn.1002-3429.2017.12.006

2017-08-16 修回時間：2017-09-29)