WeChat ID medlive-surgery Intro 定期推送普外科专业资讯 新朋友点上方蓝字快速关注 信源：Medscape>Case Challenges,A 60-Year-Old Man With Intense Left-Sided Abdominal Pain,Pramod Gupta,MD;Jitendra Gohil,MD Background 背景 A 60-year-old man presents to the emergency department with a 1-day history of crampy,moderately intense,left-sided abdominal pain.The pain is constant and is exacerbated by movement;it is relieved by lying still.The patient has not experienced anorexia and has not eaten since the evening before. 患者，男，60岁，因左侧腹部痉挛性、中度剧烈疼痛持续一天来急诊。疼痛呈持续性，并因移动而恶化；静止不动时较为缓和。患者不曾患有厌食症，但从前一天晚上开始已无食物摄入。 He has had several loose brown stools but denies any nausea or vomiting.The stool in his bowel movements is not blood-streaked and does not appear tarry.He denies any recent travel or camping and has not eaten any uncooked or undercooked foods.He reports feeling febrile,sweaty,and generally fatigued.No urinary symptoms,such as dysuria or increased frequency,are reported.He has not had any recent contact with sick people. 患者大便呈棕色，无恶心和呕吐。在排泄中的便块没有血线，且也无焦油样表现。他拒绝了最近所有的旅行或野营，而且没有吃任何未煮过的或未煮熟的食物。患者发热、盗汗且四肢无力。没有泌尿系统症状，如排尿困难或尿频。近期也并未接触患病人群。 He denies having had similar episodes in the past.His medical and surgical histories are unremarkable,although he did have a screening barium enema examination 3 years ago.He is a nonsmoker and denies any heavy or regular alcohol consumption.He does not take any prescription or over-the-counter medications. 患者在过去没有类似症状发作。尽管他3年以前进行了钡灌肠筛查，他的病史和手术史也无值得注意的内容。同时不吸烟不酗酒。也没有服用过任何处方药和非处方药。 On physical examination,the patient has an elevated temperature of 101.3°F,blood pressure of 130/76 mm Hg,pulse of 110 beats/min,and respiratory rate of 20 breaths/min.The patient is not in acute distress,but he is mildly ill-appearing and diaphoretic.His oropharynx is clear,with slightly dry mucous membranes.His lungs are clear to auscultation,and his heart rate is regular,without murmurs. 在体检中，患者体温升高到38.5摄氏度，血压130/76 mm Hg，心跳110次/min，呼吸频率20次/min。患者并未发生急性呼吸窘迫，但具有轻度的疾病表现和发汗。口咽检查结果清晰，粘膜轻度干燥。肺部听诊清晰，且心跳频率规律无杂音。 The abdominal examination reveals moderate tenderness in the left lower quadrant,with voluntary guarding.No rebound tenderness is noted.No costovertebral angle tenderness or inguinal hernias are appreciated,and his genital examination findings are normal.Upon digital rectal examination,the patient is tender on the left side of the rectal vault,and the stool is noted to guaiac-negative.The remainder of the physical examination findings are unremarkable. 腹部检查显示左下腹有中度压痛，及肌紧张。无反跳痛。无肋椎角压痛或腹股沟疝，且生殖器检查正常。在直肠指检中，患者直肠穹窿左侧有压痛，且粪便检查阴性。患者的体检发现无需要注意的部分。 Serum laboratory testing is remarkable only for an elevated white blood cell count of 16×103 cells/µL,with a neutrophil predominance;the urinalysis is unremarkable.A standard radiograph of the abdomen is obtained,which does not show any significant abnormalities(Figure 1).The patient then underwent CT of the abdomen and pelvis(Figures 2 and 3). 血清实验室检测值得注意的只有升高的白细胞计数：16×103个/µL，和显著的中性粒细胞增多；尿检无需要注意的内容。X光片没有显示任何值得注意的异常情况(图1)。 患者随后接受了腹部和骨盆的CT扫描(图2和3)。 What is the diagnosis? 诊断是什么？ Hint:This is the most common acute condition related to the sigmoid colon.、 提示：这是与乙状结肠相关的最常见的急性病症。 A Acute diverticulitis  A 急性结肠憩室炎 B Colon cancer     B 结肠癌 C Acute bacterial peritonitis    C 急性细菌性腹膜炎 D Acute appendicitis    D 急性阑尾炎 正确答案为  A 急性结肠憩室炎 Discussion 讨论 Acute diverticulitis results from inflammation of a diverticulum(small mucosal and submucosal herniations through the circular muscle layer of the colonic wall)secondary to fecal obstruction.The obstruction typically occurs at the neck of the diverticulum;solidified stool,which typically forms a fecalith,abrades the mucosa within or at the neck of the diverticulum. 急性结肠憩室炎由憩室（穿过结肠壁环肌层的小型粘膜或粘膜下层）的炎症引起，次要原因是粪便梗阻。梗阻通常发生在憩室颈部；固化的粪便，典型例子为粪石，磨损憩室颈部的粘膜层。 In uncomplicated cases(typically characterized by a well-appearing patient without peritonitis and systemic signs/symptoms),the inflammatory process is confined to the colonic wall;however,the obstruction,with subsequent high intraluminal pressure within the diverticula,can lead to a microperforation that in turn allows translocation of bacteria through the colonic wall,formation of a pericolic abscess,and diffuse peritonitis. 在单纯性的病例中（通常特征为表面上表现很好的患者，无腹膜炎和系统性症状），炎性病变过程限制在了结肠壁中；然而梗阻，在憩室内管腔高压之后，会造成微穿孔，使细菌依次移动通过结肠壁，构成结肠周围脓肿和弥漫性腹膜炎。 Only 2%-4%of patients diagnosed with diverticulitis are younger than 40 years;the condition is predominantly found in elderly populations. 只有2%-4%诊断为憩室炎的患者年龄小于40岁；该病症绝大部分在年龄较大的人群中发现。 Diverticulosis is an intestinal disorder that is characterized by the presence of many diverticula;it occurs equally in men and women,with a higher prevalence in cultures with a low-fiber diet(which is believed to decrease stool transit time,thereby causing increased intraluminal pressure and resulting in mucosal herniations).The colonic diverticula themselves are most commonly found in the sigmoid and descending colon,although less commonly,patients(particularly those of Asian descent)develop diverticula of the right colon.Approximately one third of the population has diverticulosis by age 50 years,and about two thirds have it by age 85 years.Approximately 10%-25%of patients with known diverticulosis go on to develop diverticulitis. 憩室病是以多憩室出现为特征的肠道功能紊乱；它同样发生在男性和女性中，在受教良好但低纤维饮食的人群中极为普遍（为了减少排便时间，从而造成了管腔内压力升高并引起粘膜疝出）。结肠憩室本身是在乙状结肠和降结肠中最常见，尽管很少发生，有患者（特别是亚洲裔）在右半结肠生长憩室。大约1/3的人在50岁时患憩室病，约2/3的人在85岁患有。约10%-25%已知患有憩室病的患者发展为憩室炎。 The classic presentation of diverticulitis is steady,deep abdominal pain that is often initially diffuse and vague,but later localizes in the left lower quadrant of the abdomen.Abdominal bloating;stool changes,such as diarrhea or constipation;and flatulence frequently accompany acute diverticulitis.Fever,fatigue,and anorexia are also common symptoms.Colonic inflammation may irritate the bladder or the ureters,leading to urinary frequency and dysuria. 憩室炎的经典表现是持续的，深层的腹部疼痛，通常最初为发散性疼痛，之后停留在左下腹。腹部胀气，排便改变，例如腹泻或便秘；且急性结肠憩室炎经常伴随胃气胀。发热、疲劳和食欲减退也是常见症状。结肠炎症可能压迫膀胱或输尿管，导致尿频和排尿困难。 Physical examination may reveal fever;localized,left lower quadrant abdominal tenderness;mild abdominal distention;and,at times,a left lower quadrant mass.The palpated mass is likely to be inflamed loops of bowel or,possibly,an abscess.Digital rectal examination may demonstrate left-sided tenderness and occult blood in the stool. 体检可能显示发热；局部性左下腹压痛；轻微腹胀；有时会有左下腹肿块。可触及的肿块可能为发炎的肠段，也可能是脓肿。直肠指检可能表明左下腹压痛和粪便潜血。 The differential diagnosis of acute sigmoid diverticulitis is broad and includes inflammatory bowel disease;irritable bowel syndrome;appendicitis;ischemic colitis;colon cancer;urolithiasis;urinary tract infection;and in women,numerous obstetric/gynecologic conditions,such as tubo-ovarian abscesses and ovarian cysts. 急性乙状结肠憩室炎的鉴别诊断很广泛并包含炎症性肠病；肠道激惹综合征；阑尾炎；缺血性结肠炎；结肠癌；尿石症；尿道感染；在女性中，包括很多妇产科疾病，如输卵管卵巢脓肿和卵巢囊肿。 The complications of acute diverticulitis include formation of a pericolic abscess,frank colonic perforation leading to free intra-abdominal air,local adhesions,purulent or fecal peritonitis,sepsis,bowel obstruction,and fistula formation between the colon and the bladder or vagina.Fistula formation is more common in the setting of recurrent diverticulitis,with the most common type being a colovesicular fistulathat is characterized by fecaluria,pneumaturia,or typical urinary tract infection symptoms. 急性憩室炎的并发症包括结肠周围脓肿的形成，明显的结肠穿孔导致腹胀气，局部黏连，化脓性或粪便性腹膜炎，败血症，肠梗阻和结肠与膀胱或阴道之间的瘘形成。管瘘在复发的憩室炎中很常见，结肠膀胱瘘是最常见的类型，它是以粪尿、气尿为特征的典型尿道感染症状。 The initial evaluation of a patient with suspected acute diverticulitis generally includes physical examination;complete blood cell count;urinalysis;and,when indicated by the presence of peritonitis,plain radiography of the abdomen to rule out colonic perforation.Plain films are of limited value;however,they may show colonic obstruction,mild ileus,or bowel distention.Leukocytosis is found in only 36%of cases of acute diverticulitis. 患有疑似急性憩室炎的患者的初始诊断通常包括体检；全部血细胞计数；尿分析；和当腹膜炎出现时，腹部平片X线摄影排除结肠穿孔。平片的价值有限；然而，他们可能显示出结肠梗阻，轻微梗阻和肠管扩张。只在36%的急性憩室炎中发现白细胞增多。 The preferred imaging modality for diagnosis of acute diverticulitis is CT,because it both determines the extent of the disease and detects complications.Abdominal ultrasonography can also be used,but it lacks specificity and is operator-dependent.Barium contrast studies and colonoscopy/sigmoidoscopy should be avoided in the setting of acute diverticulitis because of the risk for bowel perforation;however,these examinations are often performed after resolution of the acute stage to evaluate for the presence of complications,such as fistula formation or other colonic abnormalities. 急性憩室炎首选的诊断成像方式是CT，因为它能在测定疾病范围的同时发现并发症。也可以使用腹部超声扫描，但是它缺少特异性且依赖于操作。因会有肠穿孔的风险，在急性憩室炎的情况下应避免钡剂造影研究和结肠镜检查/乙状结肠镜检查；然而，在决定了用来评估并发症（如管瘘或其他结肠异常情况）出现的急性等级之后，经常使用这些测试。 The management of patients with acute diverticulitis depends on the severity of the illness,but medical management alone is commonly successful.Well-appearing patients who are able to tolerate oral intake and do not have systemic symptoms,peritonitis,or complications seen on CT may be treated as outpatients. 患有急性憩室炎的患者的治疗取决于病症的严重程度，但单独使用医疗手段通常是成功的。口服耐受且无任何系统性症状，腹膜炎，或在CT上不显示并发症的，表象良好的患者可能会作为门诊患者进行治疗。 Some nontoxic-appearing patients with a history of diverticulitis who present with their typical symptoms may be treated empirically as outpatients,without repeat imaging,if no significant comorbidities(eg,an immunocompromised state,diabetes,or cancer)are noted.All patients treated at home require close follow-up care and reexamination,and they should be given detailed return precautions for worsening pain or systemic illness. 如果没有明显的并发症（举例，免疫受损的状态，糖尿病或癌症）需要注意，一些无毒性表现的、具有憩室炎病史并具有典型症状的患者可能被当做门诊患者以经验进行治疗，无重复成像。所有在家进行治疗的患者需要密切随访关注和再检查，而且应密切注意他们的疼痛加重或出现系统性疾病。 Treatment of uncomplicated acute diverticulitis consists of bowel rest,broad-spectrum antibiotics,and pain control.Outpatients may be instructed to begin with a clear liquid diet and advance slowly as tolerated,whereas inpatients should be kept hydrated with intravenous fluids.Antibiotic regimens should cover gram-negative bacteria and anaerobes.A combination of either trimethoprim/sulfamethoxazole or ciprofloxacin,with either metronidazole or clindamycin,is the primary recommended treatment regimen.Monotherapy with amoxicillin/clavulanic acid is an acceptable alternative regimen. 治疗单纯性急性憩室炎由肠道休息，广谱抗菌素和疼痛控制构成。可以指导门诊患者首先进行流质饮食并慢慢提升耐受性，反之，住院患者应使用静脉输液保持体内水分。抗生素疗法应覆盖革兰阴性菌和厌氧菌。甲氧苄氨嘧啶/磺胺甲基异恶唑或环丙沙星的合剂首次被推荐到治疗计划中。阿莫西林和克拉维酸单一疗法是为人们所接受的替代治疗方案。 Patients should be admitted to the hospital if they cannot tolerate oral intake of fluids,are immunocompromised,demonstrate signs of systemic toxicity(such as tachycardia and fever),or have developed evidence of peritonitis or intra-abdominal complications.These patients should receive nothing by mouth and be given intravenous antibiotics.Ciprofloxacin or an aminoglycoside may be paired with metronidazole or clindamycin as the recommended antibiotic regimen.A monotherapeutic agent,such as piperacillin/tazobactam,ampicillin/sulbactam,or ertapenem,may also be used. 如果患者们不能忍受摄入流食，免疫力降低，显示系统毒性征兆（如心动过速和发热），或有证据显示腹膜炎或腹腔内并发症时，应入院。这些患者应禁食并使用静脉注射抗生素。作为推荐的抗生素疗法，环丙沙星或氨基葡糖苷可与甲硝唑或克林霉素搭配使用。单一药剂治疗，例如哌拉西林/三唑巴坦，氨比西林/舒巴克坦，或厄他培南也可以使用。 Selected abscesses detected by ultrasonography or abdominal CT may be drained percutaneously,whereas perforations,fecal peritonitis,and fistula formation all require surgical consultation.Abscesses less than 5 cm in diameter can be treated with antibiotics alone,although evaluation by a surgeon should still be sought.Recurrent diverticulitis and complicated diverticulitis are indications for partial colonic resection. 通过US或腹部CT检测到的选择后的脓肿可以经皮下引流，然而穿孔，粪便性腹膜炎和管瘘全部需要外科会诊。尽管仍应寻求外科医生的评估，但直径小于5cm的脓肿可以只使用抗生素进行治疗。复发的憩室炎和复杂性憩室炎是结肠局部切除的指征。 Approximately 10%-25%of patients who are medically managed have recurrent attacks and are at an increased risk for subsequent complications.Of note,patients younger than 40 years are more likely to have recurrences and are more likely to benefit from elective sigmoid resection. 大约10%-25%的进行医疗管理的患者有反复发作且处在随之而来并发症的升高的风险中。众所周知，年龄小于40岁的患者更可能复发且在选择性切除乙状结肠中更有可能获益。 In this case,the axial CT images of the abdomen at the level of the pelvis(Figures 2 and 3)show acute diverticulitis of the sigmoid colon.Multiple diverticula(arrowheads)and wall thickening are noted(Figure 4),and inflammatory stranding is seen in the sigmoid mesentery(Figure 5).No free air or abscess formation is evident.The screening barium enema performed 3 years ago(Figure 6)shows multiple diverticula in the sigmoid and descending colon(arrowheads). 在该病例中，在骨盆水平的腹部CT成像(图2和3)显示急性乙状结肠憩室炎。 多个憩室（箭头所指）和肠壁增厚已标注出来（图4），而且在乙状结肠肠系膜中发现炎性疾病（图5）。无明显的游离气体或脓肿形成。 3年前实施的钡灌肠筛查(图6)显示在乙状结肠和降结肠中有多重憩室(箭头所指)。 Because of systemic signs and symptoms of infection,this patient was admitted to the hospital.He was placed on bowel rest and started on intravenous metronidazole and ciprofloxacin.Over the next 2 days,the patient defervesced and his leukocytosis resolved.His diet was advanced to a full diet,and he was discharged from the hospital on a 10-day course of amoxicillin/clavulanic acid. 因为系统性征兆和感染症状，该患者入院接受治疗。他接受了肠道休息并静脉滴注甲硝唑和环丙沙星。在接下来的两天，该患者已退烧且白细胞增多已解决。他的饮食状况良好，在出院时带有疗程为十天的阿莫西林/克拉维酸。 点击 ↓ 阅读原文，查看更多普外科资讯~ Learn about writing a valuable comment Author requires users to follow Official Account before leaving a comment Write a comment Write a comment Loading Most upvoted comments above Learn about writing a valuable comment Scan QR Code via WeChat to follow Official Account