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胰腺黏液性囊腺瘤并发急性胰腺炎一例并文献复习

2011-11-21叶舟廖专陈志平林克荣张志坚

中华胰腺病杂志 2011年3期
关键词:性囊胰管黏液

叶舟 廖专 陈志平 林克荣 张志坚

胰腺黏液性囊腺瘤并发急性胰腺炎一例并文献复习

叶舟 廖专 陈志平 林克荣 张志坚

患者女,62岁。因“突发右上腹痛7 d”于2010年4月19日收入我科。腹痛呈持续性绞痛,并向右侧肩背部及上腹部两侧条带状放射,随体位改变不能缓解,伴腹胀、嗳气、呕吐数次,呕吐物为黄色胃内容物,非喷射性。门诊实验室检查:血淀粉酶405 U/L,血糖9.6 mmol/L,总胆红素10.5 μmol/L。B超示胰腺增大、主胰管扩张、胰头显示不清;胆囊泥沙样结石;肝脾未见明显异常。患者10余年前曾有一次急性胰腺炎发作史。体检:腹肌无明显紧张,上腹压痛、反跳痛阳性,肝脾肋下未触及,麦氏点无压痛,Murphy征阳性,肝肾区叩击痛阳性。实验室检查:WBC 12.97×109/L,中性88.28%;血细胞沉降率91.0 mm/h,CRP 186.0 mg/L;淀粉酶121 U/L,血糖12.2 mmol/L,胆固醇6.61 mmol/L;CA19-9 61.16 U/ml,CEA、AFP、CA125均正常。入院后给予抗感染、制酸、抑制胰酶分泌、补液、保肝、改善循环等处理后腹痛症状缓解。复查WBC 9.36×109/L,淀粉酶28 U/L,血糖8.7 mmol/L,CRP 99.7 mg/L。2010年4月23日上腹部MRI +MRCP示:(1)胰腺多发囊性改变,考虑囊腺瘤,跟主胰管相通;(2)胰腺炎,胆囊结石,左肾囊肿(图1)。转入普外科行剖腹探查。术中见胆囊肿大,内触及结石;整个胰腺布满囊性瘤,呈葡萄状,在胰头后方,切开胰腺,完整剥离出其中一个囊肿,送冷冻病理检验。行胆囊切除术+胰肠吻合术。病理检查示胰腺黏液性囊腺瘤。术后至今3月余,患者无明显不适。

图1 患者的MRCP(a)和MRI(b、c、d)征象图

讨论胰腺囊腺瘤比较少见,约占胰腺良性囊性病变的10%,它好发于中年妇女。根据囊腺瘤的形态、起源和生物学特征,分为浆液性囊腺瘤和黏液性囊腺瘤两种类型。浆液性囊腺瘤以小囊为主,切面呈蜂窝多孔状,有结缔组织间隔,其内皮由单层扁平细胞或立方细胞组成;细胞及其核型似中央腺泡细胞,无异形性,无核分裂象;囊肿内壁光滑无乳头状突起;无恶变倾向。黏液性囊腺瘤的囊肿较大,切面多为大的单房性或多房性囊肿,囊内充满黏液;囊壁内皮由柱状细胞组成,瘤细胞内含有丰富黏液,但无糖原存在;囊肿内壁光滑或有乳头状突起;具有潜在的恶变危险。浆液性囊腺瘤的好发年龄为55~73岁;而黏液性囊腺瘤较年轻,为49~63岁。本病偶见于12岁的儿童,甚至6~16个月的婴儿。

本病例患者以急性胰腺炎症状入院,腹部彩超示胰腺增大,主胰管扩张,胆囊有泥沙样结石。首先考虑胆源性急性胰腺炎,后经MRCP示胰腺多发囊腺瘤,转入普外科剖腹探查,术中取活检送冷冻病理检查,示胰腺黏液性囊腺瘤。最后确诊为胰腺黏液性囊腺瘤并发急性胰腺炎。胰腺黏液性囊腺瘤并发急性胰腺炎的原因考虑为胰腺囊腺瘤跟主胰管相通。这类患者治疗上首先仍需按急性胰腺炎治疗,给予胃肠减压、抑制胰酶分泌、抑制胃酸分泌、抗感染、补液、改善循环等,同时行影像学检查以此判断急性胰腺炎是否由胰腺囊腺瘤引起。

胰腺囊腺瘤最常见的临床表现为上腹胀痛或隐痛、上腹部肿块,其次有体重减轻、黄疸、消化道出血、各种胃肠道症状和肝转移。经近10年文献检索,国内报道胰腺黏液性囊腺瘤共10例[1-7],但均无并发急性胰腺炎。国外17篇文献报道187例胰腺囊腺瘤[8-24],其中伴有急性胰腺炎7例[11-14,21-23]。

分析国外7例和本文1例患者的资料,胰腺黏液性囊腺瘤并发急性胰腺炎有以下特征:(1)患者绝大多数为女性(男性1例,女性7例)。(2)年龄9~71岁,平均年龄45岁,以30~60岁中年患者居多。(3)临床症状均为上腹胀痛,可伴胃肠道出血。(4)影像学检查均提示胰腺囊腺瘤,肿瘤最长径为2.5~16 cm;5例单房型,3例多房型;5例行MRI、MRCP或ERCP检查者4例发现囊腺瘤与主胰管相通。(5)一般采用腹腔镜治疗(3例)或手术治疗(5例),腹腔镜治疗包括腹腔镜下胰腺囊腺瘤切除术、腹腔镜下胰腺末端切除术等;手术治疗包括远端胰腺切除、脾切除、胰腺囊腺瘤切除、胰空肠吻合术等,公认的成功治疗方法是胰腺末端切除术或胰次全切除术合并脾切术[1,4-9]。

[1] 王伟,刘绪舜,王峰.伴肿瘤标记物增高的胰腺囊腺瘤1例.临床肿瘤学杂志,2007,12:637-638.

[2] 孟庆富.临床上胰腺囊腺瘤与囊腺癌的确诊分析.中国医药指南,2008,6:501-502.

[3] 左石,孙诚谊,刘兴贵,等.胰体尾部囊腺瘤并脓肿形成1例.贵阳医学院学报,2003,4:376.

[4] 陈平.胰腺囊腺瘤1例.成都医学院学报,2003,5:29.

[5] 陈瑞民,邱日升,赖李明.胰腺囊腺瘤的CT诊断.海南医学,2008,19:19,48.

[6] 陈玉祥,颜磊.胰腺囊腺瘤的诊断与治疗(附3例报告).肿瘤预防与治疗,2008,21:107-108.

[7] 孙岩,武艳,邹玉凤,等.胰腺粘液性囊腺瘤3例并文献复习.当代医学,2009,15:84-85.

[8] Bournet B,Kirzin S,Carrère N,et al.Clinical fate of branch duct and mixed forms of intraductal papillary mucinous neoplasia of the pancreas.Gastroenterol Hepatol,2009,24:1211-1217.

[9] Allen PJ,Qin LX,Tang L,et al.Pancreatic cyst fluid protein expression profiling for discriminating between serous cystadenoma and intraductal papillary mucinous neoplasm.Ann Surg,2009,250:754-760.

[10] Beger HG,Gansauge F,Siech M,et al.Duodenum-preserving total pancreatic head resection for cystic neoplastic lesions in the head of the pancreas.J Hepatobiliary Pancreat Surg,2008,15:149-156.

[11] McEvoy MP, Rich B, Klimstra D,et al. Acinar cell cystadenoma of the pancreas in a 9-year-old boy.J Pediatr Surg,2010,45:e5-e9.

[12] Mizutani S,Nakamura Y,Ogata M,et al.A case of giant mucinous cystic neoplasm of the pancreas resected with laparoscopic surgery.J Nippon Med Sch,2009,76:212-216.

[13] Morel A,Marteau V,Chambon E,et al.Pancreatic mucinous cystadenoma communicating with the main pancreatic duct on MRI. Br J Radiol,2009,82:e243-e245.

[14] Murao S,Hosokawa H,Yokota K,et al. Huge mucinous cystic neoplasm of the pancreas in a young diabetic woman. Intern Med,2008,47:2097.

[15] Pitiakoudis M,Zezos P,Oikonomou A,et al.Laparoscopic resection of a pancreatic serous cystadenoma preserving the integrity of main pancreatic duct:a case report.Cases,2009, 2:8318.

[16] Agarwal N,Kumar S,Dass J,et al.Diffuse pancreatic serous cystadenoma associated with neuroendocrine carcinoma:a case report and review of literature.JOP,2009,10:55-58.

[17] Leonard D,Baulieux J,Rode A,et al.Multiple synchronous serous cystadenomas of the pancreas:uncommon CT and MRI findings.J Hepatobiliary Pancreat Surg,2007,14:600-603.

[18] D′Onofrio M,Gallotti A,Martone E,et al.Solid appearance of pancreatic serous cystadenoma diagnosed as cystic at ultrasound acoustic radiation force impulse imaging.JOP,2009,10:543-546.

[19] King JC,Ng TT,White SC,et al.Pancreatic serous cystadenocarcinoma: a case report and review of the literature.J Gastrointest Surg,2009,13:1864-1868.

[20] Salemis NS,Tsohatarides E.Giant serous cystadenoma of the pancreas Journal compilation.ANZ J Surg,2008,78:930.

[21] Fischer CP,Pope I,Garden OJ.Mucinous cystic tumour of the pancreas presenting with acute pancreatitis.HPB,2001,3:271-273.

[22] Hisa T,Ohkubo H,Shiozawa S,et al.Mucinous cystadenoma of the pancreas with huge mural hematoma.Patho Int,2009,59:762-765.

[23] Shinzeki M,Hori Y,Fujino Y,et al.Mucinous cystic neoplasm of the pancreas presenting with hemosuccus pancreaticus:report of a case.Surg Today,2010,40:470-473.

[24] Jacob S,Rawat P,Mark RP.Serous microcystic adenoma (glycogen rich cystadenoma) of the pancreas.Indian J Pathol Microbiol,2010,53:106-108.

2010-09-06)

(本文编辑:屠振兴)

10.3760/cma.j.issn.1674-1935.2011.03.025

350000 福州,南京军区福州总医院消化内科(叶舟、陈志平、林克荣、张志坚);第二军医大学长海医院消化内科(廖专)

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