阑尾炎和疝气

1、AppendixIninfants,theappendixisaconicaldiverticulumattheapexofthececum,butwithdifferentialgrowthanddistentionofthececum,theappendixultimatelyarisesontheleftanddorsallyapproximately2.5cmbelowtheileocecalvalve.Theaptaeniaofthecolonconvergeatthcbaseoftheappendix,anarrangementthathelpsinlocatingthisstru

2、ctureatoperation.Theappendixisfixedretrocecallyin16%ofadultsandisfreelymobileintheremainder.Theappendixinyouthischaracterizedbyalargeconcentrationoflymphoidfolliclesthatappear2weeksafterbirthandnumberabout200ormoreatage15.Thereafter,thereisprogressiveatrophyoflymphoidtissue,concomitantwithfibrosisof

3、thewallandpartialortotalobliterationofthelumen.Iftheappendixhasaphysiologicfunction,itisprobablyrelatedtothepresenceoflymphoidfollicles.Reportsofastatisticalrelationshipbetweenappendectomyandsubsequentcarcinomaofthecolonandotherneoplasmsinhumansarenotsupportedbycontrolledstudies.conical圆锥的;圆锥形的diver

4、ticulum肠盲囊,小囊突,憩室apex顶点,最高点cecum盲肠distention膨胀;延伸dorsally背侧地ileocecalvalve回盲瓣retrocecally盲肠后的lymphoidfollicles淋巴样滤泡,淋巴小结;progressiveatrophy萎缩concomitant伴发的,伴行的,并发的concomitantwith协同obliteration涂去,抹消,删除lumen管腔,流明,腔appendectomy阑尾切除术neoplasm肿瘤ileocecallymphoidappendicitis阑尾炎HerniaAnexternalherniaisanabn

5、ormalprotrusionofintra-abdominaltissueorthewholeorpartofaviscusthroughanopeningorfascialdefectintheabdominalwall.About75%ofherniasoccurinthegroin(indirectinguinal,directinguinal,femoral).Incisionalandventralherniascompriseabout10%;umbilical,3%;andothers,about3%.Generally,ahernialmassiscomposedofcove

6、ringtissues(skin,subcutaneoustissues,etc),aperitonealsac,andanycontainedviscera.Particularlyiftheneckofthesacisnarrowwhereitemergesfromtheabdomen,bowelprotrudingintotheherniamaybecomeobstructedorstrangulated.Iftheherniaisnotrepairedearly,normaltissuesmaybecompressed,thedefectmayenlarge,andoperativer

7、epairmaybecomemorecomplicated.Thedefinitivetreatmentofherniaisearlyoperativerepair.Areducibleherniaisoneinwhichthecontentsofthesacreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientisrecumbent.Anirreducible(incarcerated)herniaisonewhosecontentscannotbereturnedtotheabdomen,usuallybecaus

8、etheyaretrappedbyanarrowneck.Thetermincarcerationdoesnotimplyobstruction,inflammation,orischemiaoftheherniatedorgans,thoughincarcerationisnecessaryforobstructionorstrangulationtooccur.Thoughthelumenofasegmentofbowelwithintheherniasacmaybecomeobstructed,theremayinitiallybenointerferencewithbloodsuppl

9、y.Compromisetothebloodsupplyofthecontentsofthesac(eg,omentumorintestine)resultsinastrangulatedhernia,inwhichgangreneofthesacanditscontentshasoccurred.Theincidenceofstrangulationishigherinfemoralthanininguinalhernias,trusion前突,突出2.inguinal腹股沟的3.femora

10、l大腿的,大腿骨的,股的,股动脉,股骨的Incisional切入的,切开的ventral腹部,腹侧的,腹的,腹面的umbilical脐的2.subcutaneous皮下的peritoneal腹膜的sac囊;液囊viscera内容;肠strangulated胀缩不均的,窒息的,绞窄的reducible可复位的,可还原的，可变形的,可缩小的spontaneously自发地,自然产生地recumbent侧卧的,休息的irreducible不能复位的（incarcerated箝闭的,狭窄的）trapped捕集的,捕获的,收集的,截留incarceration监禁,嵌顿,箝闭imply暗示,意指,蕴涵i

11、schemia局部缺血,缺血strangulation勒颈,勒颈窒息omentum网膜gangrene坏疽,疝腹外疝是腹腔内组织或部分或整个脏器通过腹壁的孔穴或筋膜缺损处所造成的不正常突出。约75的疝发生在腹股沟区（直疝、斜疝、股疝）。切口疝和腹壁疝各约占10；脐疝3，其余的约3。一般而言，疝块由覆盖组织（皮肤、皮下组织等）、腹膜囊和囊内的任何一个内脏所组成。特别是当疝囊颈部即腹腔的突出处狭小，肠管突入疝囊后可形成梗阻或绞窄。疝如不及早修复，正常组织可受压，缺损处变大、手术修复变得更为复杂。疝的根本治疗是早期手术修复。可复性疝是指疝内容可自行回纳，或在病人仰卧时用手挤入腹腔。不可复性（箝闭性）

12、疝是指疝内容物不能回纳入腹腔，通常起因于狭窄的颈部受阻。尽管发生梗阻或绞窄前需有箝闭，然而箝闭一词并不意味被疝入的器官有梗阻，发炎或缺血。虽然疝囊内肠襻的腔可有阻塞，但开始时并不影响血液的供应。当囊内器官（姐网膜或肠管）血供受到损害就形成绞窄性疝，随即出现疝囊及疝内容的坏疽。股疝的绞窄发生率较腹股沟疝高，其他类型的疝也可发生绞窄。CholecystitisCholecystitisisinflammationofthegallbladderwall,usuallyresultingfromagallstoneobstructingthecysticduct.Acutecholecystitis

13、isthesuddenonsetofinflammationofthegallbladder,resultinginsevere,steadyupperabdominalpain(biliarycolic),whichmayoccurrepeatedly.Chroniccholecystitisislong-standinginflammationofthegallbladdercharacterizedbyrepeatedattacksofpain(gallbladderattacks)overaprolongedperiod.Atleast95%ofpeoplewithacutechole

14、cystitishavegallstones.Theinflammationalmostalwaysbeginswithoutinfection,althoughinfectionmayfollowlater.Rarely,acutecholecystitisoccursinapersonwithoutgallstones(acalculouscholecystitis).Acalculouscholecystitisisaseriousdisease.Ittendstooccuraftermajorinjuries,operations,burns,bodywideinfections(se

15、psis),andcriticalillnessesparticularlyinpeoplereceivingprolongedintravenousfeedings.Itcanoccurinyoungchildrenaswell,perhapsoriginatingasaninfection(viralorother).Inchroniccholecystitis,thegallbladderisdamagedbyrepeatedattacksofacuteinflammation,usuallyfromgallstones,andmaybecomethick-walled,scarred,

16、andsmall.Thegallbladdergenerallycontainssludgeorgallstonesthatoftenobstructitsoutletorthecysticduct.SymptomsAgallbladderattack,whetherinacuteorchroniccholecystitis,beginsassevere,steadypain(biliarycolic),usuallyintherightupperpartoftheabdomen.Thepersontypicallyfeelsasharppainwhenadoctorpressesontheu

17、pperrightpartoftheabdomen.Thepainmayworsenwhenthepersonbreathesdeeplyandoftenextendstothelowerpartoftherightshoulderblade.Thepainmaybecomeexcruciating;nauseaandvomitingareusual.Thepainusuallylastsmorethan12hours.Withinafewhours,theabdominalmusclesontherightsidebecomerigid.Feveroccursinaboutonethirdo

18、fpeoplebutislesslikelyinolderpeople.Thefevertendstobeslightatfirst,thenrisesgraduallytoabove100F(38C).Typically,anattackofcholecystitissubsidesin2to3daysandcompletelydisappearsinaweek.Iftheattackpersists,itmaysignalaseriouscomplication.Ahighfever,chills,amarkedincreaseinthewhitebloodcellcount,andace

19、ssationofthenormalpropulsivemovementsoftheintestine(ileus(seeEmergencies:Ileus)suggestformationofanabscess(apus-filledpocketofinfection),gangrene(deathoftissue),oraperforated(pierced)gallbladder.Othercomplicationsmayoccur.Agallbladderattackaccompaniedbyjaundice(seeClinicalManifestationsofLiverDiseas

20、e:Jaundice)andotherevideneeofabackupofbileintotheliver(cholestasis),suchaspassinglight-coloredstools,indicatesthatthecommonbileductisobstructed(usuallypartially)byastone.Ifbloodtestresultsrevealanincreasedlevelofapancreaticenzyme(amylaseorlipase),thepersonmayhaveinflammationofthepancreas(pancreatiti

21、s)causedbyastoneobstructingthepancreaticduct.Inacalculouscholecystitis,typicallythepersonhasnoprevioussymptomsorotherevidenceofgallbladderdiseaseandexperiencessudden,excruciatingpainintheupperabdomen.Usually,thediseaseisverysevereandcanleadtogangreneorruptureofthegallbladder.Ifthepersonhasothersever

22、eproblems(forexample,thepersonisintheintensivecareunit),acalculouscholecystitisatfirstmaybeoverlooked.DiagnosisDoctorsdiagnosecholecystitis,bothacuteandchronic,basedonthepersonssymptomsandtheresultsofteststhatsuggestgallbladderinflammation.Increasedlevelsofwhitebloodcellssuggestinflammationorinfecti

23、onorboth.Ultrasoundscansoftenconfirmthepresenceofgallstonesinthegallbladder,whichmayberesponsiblefortheattacks.Ultrasoundscanscanalsoshowthickeningofthegallbladderwall,whichistypicalofchroniccholecystitis.Cholescintigraphyisanimagingtechniquethatisusefulwhenacutecholecystitisisdifficulttodiagnose.In

24、thistest,aradioactivetracerisinjectedintravenouslyanditsmovementfromtheliverthroughthebiliarytractisfollowed.Imagesaretakenoftheliver,bileducts,gallbladder,andupperpartofthesmallintestine.Ifthetracerdoesnotfillthegallbladder,itispresumedthatthecysticductisobstructedbyagallstone.TreatmentApersonwitha

25、cuteorchroniccholecystitiswhoexperiencesagallbladderattackusuallyishospitalized,isgivenfluidsandelectrolytesintravenously,andisnotallowedtoeatordrink.Adoctormaypassatubethroughthenoseandintothestomach,sothatsuctioningcanbeusedtokeepthestomachemptyandreducefluidaccumulatingintheintestines,whichdonotw

26、orkproperlybecauseoftheinflammationoftheabdominalcavity.Antibioticsusuallyaregiven.Inacutecholecystitis,ifthediagnosisiscertainandtheriskofsurgeryissmall,thegallbladderusuallyisremovedduringthefirstdayortwooftheillness.Ifnecessary,gallbladderremovalmaybedelayed;iftheattacksubsides,removalmaywait6wee

27、ksormore.Ifacomplicationsuchasanabscess,gangrene,orperforationofthegallbladderissuspected,immediatesurgeryisnecessary.Inchroniccholecystitis,treatmentgenerallyinvolvessurgicalremovalofthegallbladder,usuallybylaparoscopiccholecystectomy,oncetheacuteepisodesubsides.Inacalculouscholecystitis,immediates

28、urgeryisnecessarytoremovethediseasedgallbladder.Aftergallbladderremovalforcholecystitiswithgallstones,asmallpercentageofpeopledevelopneworrecurringepisodesofpainthatfeellikegallbladderattackseventhoughtheynoIongerhaveagallbladder.Thecauseoftheseepisodesisnotknown,butepisodesmayresultfromanabnormalfu

29、nctionofthesphincterofOddi,theopeningatthebaseofthebileductthatcontrolsthereleaseofbileintothesmallintestine.Painisbelievedtoresultfromincreasedpressureintheductscausedbyresistaneetotheflowofbileorpancreaticsecretions.Insomepeople,smallgallstonesremainingaftersurgerymaycausepain.Adoctorcanuseendosco

30、picretrogradecholangiopancreatographytowiden(bycutting)thesphincterofOddi.Thisprocedureusuallyrelievessymptomsinpeoplewhohavearecognizableabnormalityofthesphincter.Inmanyothers,thepainiscausedbyanotherproblem,suchastheirritablebowelsyndromeorevenpepticulcerdisease.gallbladder胆囊upperabdominalpain上腹痛(

31、右下rightlower)腹痛abdominalpainbiliary胆道的，胆的，胆汁的colic绞痛，疝痛，疝气acalculouscholecystitis无结石胆囊炎sepsis败血症，脓毒症intravenous静脉内的，静脉注射静originate发起,开始,创造,发明Acutegallstonecholecystitisintheelderly:treatmentwithemergencyultrasonographicpercutaneouscholecystostomyandintervallaparoscopiccholecystectomy.MacriA,ScuderiG

32、,SaladinoE,TrimarchiG,TerranovaM,VersaciA,FamulariC.EmergencySurgeryUnit,UniversityofMessina,Messina98125,Italy.amacriunime.itBACKGROUND:Thetreatmentofacutecholecystitisintheelderlyisstillasubjectofdebate,particularlywithreferencetothetimingofsurgeryandtheroleoflaparoscopy.PATIENTS:FromJanuary1994to

33、June2002weobserved27patientsagedover70yearswithacutecalcolouscholecystitis.Thepatientsweresubmittedtoultrasonographicpercutaneouscholecystostomywithin12hoftheacuteattack.Fortwopatients(7.4%)athighoperativerisk,wechoseaconservativetreatment.Twenty-fivepatients(92.6%)weresubmitted,in15cases(60%)within

34、5daysandin10patients(40%)within8days,toalaparoscopiccholecystectomy.Statisticalsignificaneewasacceptedwhenthevalueofpwaslessthan0.05.RESULTS:Ultrasonographicpercutaneouscholecystostomywasperformedsuccessfullyinallpatients,withoutmajormorbidityormortality,andcompleteresolutionofclinicalsymptomswasobt

35、ainedwithin48h.Theconversionrateoflaparoscopywas20%(13.3%inpatientssubmittedtosurgerywithin5daysand30%inthegroupsubmittedwithin8days-p0.05).Thepostoperativemorbidityratewas24%;itwashigher(40%versus15%)inpatientsconvertedtolaparotomy(p0.05);mortalitywas4%.Theperiodofhospitalizationwas11daysinpatients

36、operatedlaparoscopicallyand21daysinthoseconvertedtoopencholecystectomy(p0.001).CONCLUSIONS:Themorerationaltreatmentofacutecalcolouscholecystitisinelderlypatientsisrepresentedbyultrasonographicpercutaneouscholecystostomyfollowed,within5days,bylaparoscopiccholecystectomyusinganabdominalinsufflationmax

37、imumto12mmHgandalimited10-15degreeshead-uptilt.Percutaneouscholecystostomyforhigh-riskpatientswithacutecholecystitis.Welschbillig-MeunierK,PessauxP,LebigotJ,LermiteE,AubeCh,BrehantO,HamyA,ArnaudJPDepartmentofVisceralSurgery,ChuAngers,4rueLarrey,49033,AngersCedex,France.BACKGROUND:Cholecystectomyremainsthebesttreatmentfor