腹腔内结石误诊为胆总管结石一例

陈浩鑫，郑楚发，黄盛鑫，彭云恒

·误诊研究：消化系疾病·

腹腔内结石误诊为胆总管结石一例

陈浩鑫，郑楚发，黄盛鑫，彭云恒

目的探讨腹腔内结石的临床特征及误诊原因。方法回顾性分析我院近期收治的误诊为胆总管结石的腹腔内结石1例的临床资料。结果本例因右上腹痛1月余入院。曾就诊当地医院，诊断为胆总管结石，予对症治疗后症状稍好转，但仍反复发作。入院后行血常规、肝功能、腹部CT等检查并于气管插管全身麻醉下行腹腔镜探查术，术后结合组织病理检查结果，确诊为腹腔内结石并感染、慢性胆囊炎，予抗感染等治疗后好转出院。随访10个月，未出现相关并发症。结论临床遇及右上腹痛且予对症治疗后症状未见缓解者，要考虑到腹腔内结石的可能，完善相关检查是避免或减少误诊误治的关键。

腹腔内结石；误诊；胆总管结石

腹腔结石是临床少见病，而位于右上腹的腹腔结石若合并感染，可出现类似胆石症的临床表现，进而误诊。我院近期收治误诊为胆总管结石的腹腔内结石1例，现分析报告如下。

1 病例资料

男，75岁。因右上腹痛1月余入院。1个月前无明显诱因出现持续性右上腹痛，无放射性疼痛，偶有恶心、呕吐，无发热、畏寒，在当地医院行彩色多普勒超声检查示：胆总管结石，胆囊炎，予抗感染治疗后症状稍缓解，但仍反复发作，为进一步诊治就诊我院，以胆总管结石收入院。30余年前因上消化道穿孔行胃次全切除术。查体：生命体征平稳，心肺检查未见异常；上腹正中可见长约8 cm的手术瘢痕，右上腹轻压痛，无反跳痛及肌紧张。查血白细胞17.3×109/L，中性粒细胞0.825；总胆红素11.4 μmol/L，丙氨酸转氨酶11 U/L，天冬氨酸转氨酶19 U/L。腹部CT示：胆囊壁增厚，边缘毛糙；胆总管上段见直径约2.2 cm的球形高密度影，周围脂肪间隙浑浊；肝内胆道无扩张，考虑：胆囊炎，胆总管上段结石(图1)。初步诊断为胆总管结石并胆道感染、慢性胆囊炎，予抗感染治疗2 d后于气管插管全身麻醉下行腹腔镜探查术。术中见上腹腔严重粘连，胆囊、十二指肠球部及大网膜与肝脏脏面粘连致密，胆囊壁厚，呈慢性炎症改变；胆总管无明显扩张，右后方至下腔静脉前方Winslow孔见一4.5 cm×3.0 cm大小的肿物，与胆囊粘连，表面充血水肿，组织糜烂，触之易破，破溃后有脓液流出，肿物内可见约2.2 cm×2.0 cm大小的黄色类圆形结石样物质，表面完整(图2)。术中切除胆囊及肿物，吸尽脓液，于Winslow孔放置引流管1根。术后病理报告：见较多炎性渗出物，细胞结构不清。确诊为腹腔内结石并感染、慢性胆囊炎，予抗感染等治疗后拔除引流管并痊愈出院。随访10个月，未出现相关并发症。

图1腹腔内结石术前腹部CT示：胆总管上段见直径约2.2 cm的球形高密度影；肝内胆道无扩张

图2腹腔内结石术中所见：胆总管右后方至下腔静脉前方Winslow孔见一4.5 cm×3.0 cm大小的肿物，表面充血水肿，触之易破，肿物内可见约2.2 cm×2.0 cm大小的黄色类圆形结石样物质，表面完整

2 讨论

腹腔内结石是一种较少见疾病，发病原因不明确[1-2]，可由继发性因素或医源性因素引起，结石核心由血块、细菌团、脱落的上皮细胞或未吸收的缝线构成，在胶质基质的参与下逐渐沉积、扩大，进而形成结石[3]，也可由医源性结石残留引起[4-5]，合并感染可引起相应的临床症状。腹腔内残留结石及基质沉积形成的较大结石可根据症状、体征等选择观察、对症处理和手术治疗等措施。

本例结石位于胆总管后方Winslow孔，加之30年前因消化道穿孔行胃次全切除术，考虑可能由于血块、细菌团、脱落的上皮细胞或食物残渣沉积于胆总管后方，构成了结石的核心，在长达30年的时间中基质不断沉积，逐渐形成结石。

手术治疗应遵照操作指南，把握手术适应证，术前注意患者是否有黄疸，血常规、胆红素及其他肝功能指标是否异常[6]；其次，行胆总管切开取石术前，仔细探查胆总管及周围情况，确认胆总管是否有结石及其部位、胆总管扩张程度等。若术中探查与手术预期方案相差甚远，应根据具体情况调整方案[7]，减少医源性损伤。本例术中发现腹腔内结石，及时调整方案，术后予对症治疗后症状好转。

分析本例误诊的主要原因是医师对腹腔内结石认识不足，过分依赖影像学检查结果，术前未仔细阅片，加上结石位于胆总管旁，依据入院时临床表现、医技检查等，误诊为胆总管结石并胆道感染。术后通过多角度阅片，不难发现该结石位于胆总管之外，而胆总管内未见结石，且结石以上胆总管及肝内外胆道无扩张，与胆总管结石典型的CT影像学表现不符[8]。提示临床应加强对腹腔内结石的认识，仔细查体，反复阅读影像学资料[9]，若术前诊断不明确者，可行磁共振胆胰管造影、胰胆管逆行造影等检查[10-11]，减少医源性损伤，避免误诊误治。

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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 广东 汕头，中山大学附属汕头医院普外一科

R572

A

1002-3429(2017)12-0013-02

10.3969/j.issn.1002-3429.2017.12.006

2017-08-16 修回时间：2017-09-29)