【医学英语第8期】临床篇之普外科学（一）

本期为普外科疾病的开篇第一讲，普外科(Department of General Surgery)是以手术为主要方法治疗肝脏、胆道、胰腺、胃肠、肛肠、血管疾病、甲状腺和乳房的肿瘤及外伤等其它疾病的临床学科，是外科系统最大的专科。本期主要讨论急性胰腺炎和阑尾炎这两种常见急腹症。

急性胰腺炎是多种病因导致胰酶在胰腺内被激活后引起胰腺组织自身消化、水肿、出血甚至坏死的炎症反应。临床以急性上腹痛、恶心、呕吐、发热和血胰酶增高等为特点。

急性阑尾炎是外科常见病，居各种急腹症的首位。转移性右下腹痛及阑尾点压痛、反跳痛为其常见临床表现，但是急性阑尾炎的病情变化多端。多为持续伴阵发性加剧的右下腹痛、恶心、呕吐，多数病人白细胞和嗜中性粒细胞计数增高。右下腹阑尾区（麦氏点）压痛，则是该病重要体征。

案例分析

Case 1：A 50-year-old HIV-positive man presents to his primary care physician with a 1-day history of nausea and vomiting. He also has severe epigastric pain radiating to the back. Review of the patient’s medical history reveals that he is taking the reverse transcriptase inhibitor didanosine. Laboratory testing reveals at amylase level five times higher than normal and a lipase level six times than normal.

案例1：50岁AIDS患者主诉恶心呕吐1天，同时伴有严重背部放射痛。患者目前正在服用地达诺新治疗，实验室检查显示淀粉酶高于正常值5倍，脂肪酶高于正常6倍。

1. What is the most likely diagnosis?

Acute pancreatitis.

急性胰腺炎

诊断特点：中上腹疼痛+腰背部放射痛+血尿淀粉酶/脂肪酶显著升高

2. What are the top three conditions to consider in the differential diagnosis?

a. Cholelithiasis: refers to the presence of gallstones in the gallbladder that can obstruct the cystic duct. This obstruction can lead to biliary colic (more prolonged, constant pain due to inflammation of the gallbladder)

b. Intestinal obstruction: often presents with abdominal pain, nausea, and vomiting but also with changes in bowel habits.

c. Acute coronary syndrome: should be considered in patients 50 years of age or older with abdominal pain and associated risk factors.

主要鉴别诊断（腹痛鉴别）

a. 胆石症：有结石病史，胆绞痛特点（短时间内反复出现，与进食油腻食物相关），向肩背部放射

b. 肠梗阻：有腹痛、恶心呕吐，多伴有排便习惯改变

c. 急性冠脉综合征：多见于50岁以上，有心血管危险因素，多为类似胃疼表现

3. Why is this condition more common in patients with HIV infection?

Patients with HIV and/or AIDS are susceptible to infection with organism such as cytomegalovirus, and cryptosporidium, all of which can cause pancreatitis.

诱发原因：HIV感染者常见巨细胞病毒、隐孢子菌感染，均可诱发胰腺炎；HIV治疗药物如地达诺新也能引起急性胰腺炎（题干中患者有服用）。

4. What is the appropriate treatment for this condition?

Most cases (85-90%) are self-limited and resolve within 4-7 days of the start of treatment. Typical treatment for acute pancreatitis includes avoiding oral intake, aggressive intravenous fluid resuscitation, pain control, and possibly nasogastric tube placement to decrease gastric secretions in the stomach. Antibiotics are not recommended in uncomplicated pancreatitis but may be of use in severe, necrotizing pancreatitis.

治疗措施：此类胰腺炎多为自限性，或者治疗4-7天可以治愈。经典治疗包括禁食、大量补液、止痛、鼻饲管以减少胃酸分泌。抗生素除严重坏死型胰腺炎外一般不推荐使用。

Case 2: A 25-year-old woman presents to her physician with a 3-day history of crampy abdominal pain that started in the epigastrium. She also reports nausea, low-grade fever and loss of appetite. She denies changes in urination or bowel habits, dysuria, or recent sick contacts. Her last menstrual period was 2 weeks ago. Relevant laboratory findings are as follows:

WBC count: 13,000/mm3

β-HCG: negative

Urinalysis: Negative for blood, WBCs, leukocyte esterase, and protein

案例2：25岁女性主诉3天上腹部痉挛样疼痛，同时伴有呕吐、低热和纳差。否认排尿及排便习惯改变，无少尿或近期与病患接触史。末次月经为2周以前，实验室检查：

白细胞13,000/mm3, β-HCG阴性，尿检无异常

1. What is the most likely diagnosis?

Appendicitis

急性阑尾炎

诊断：右下腹压痛反跳痛+呕吐低热+血白细胞升高，其他检查一般无异常。

2. What other conditions should be considered in the differential diagnosis of a 25-year-old female with abdominal pain?

a. Genitourinary: ruptured Graafian follicle, ectopic pregnancy, pelvic inflammatory disease, and ovarian torsion

b. Gastrointestinal: Crohn disease, peptic ulcer

c. Renal: Urinary tract infection, cystitis

主要鉴别诊断：

a. 生殖系统：异位妊娠（尿检可排除），卵泡破裂、卵巢囊肿蒂扭转（急性发作、剧烈疼痛）

b. 消化系统：克隆病（排便习惯改变可排除）、胃溃疡（多有病史）

c. 泌尿系统：泌尿系统感染（多有尿路感染特征、尿常规异常），膀胱炎

3. What is the pathophysiology of this condition?

Obstruction is often implicated as the cause of appendicitis but is not required for disease progression. The appendiceal lumen may become obstructed by a fecalith, mucosal secretions, lymphoid hyperplasia or an infection process resulting in a distended appendix, elevated intraluminal pressure, and subsequent arterial insufficiency and tissue death.

病理生理表现：梗阻是最常见诱因，多见于粪石、粘性分泌物、淋巴结增生；其次是感染，导致阑尾扩张、腔内压力升高，最终至供血不足、组织坏死。

4. What is the appropriate treatment for this condition?

Surgery is the preferred treatment, along with supportive intravenous fluids and empiric antibiotics (in case of rupture). The gold standard for diagnosis is CT scan of the abdomen with contrast.

治疗：手术治疗首选。辅以补液以及经验性抗生素治疗（防止阑尾破裂），诊断金标准为腹部CT扫描。（下图可见阑尾结石致密影）

词汇拾零