腹部异常表现与鉴别诊断-腹水

AbnormalAbdominalFindingsandTheirRespectiveDifferentiation

---Ascites

1freefluidaccumulationwithintheabdominalcavityDefinitionofAscites2DefinitionofAsciteslittlefreefluidwithintheabdominalcavityinnormalcases

theamountoffreefluidislessthan200ml

excessivefreefluidaccumulateswithintheabdominalcavity---ascites

3HeartLiverKidneyperitoneumNutritionLymphaticsystemFemalereproductivesystemRuptureofabdominalvisceraothersAscites4CardiovascularDiseases

√congestiveheartfailure

√pericarditis(心包炎)

√pericardiactamponade(心包压塞)

√obstructionofinferiorvenacavaEtiologyofascites5EtiologyofascitesHepaticandPortalSystemDiseases

√hepaticcirrhosis

√hepaticcarcinoma

√inflammationofportalveinandtheformationofitsthrombosis

√ruptureofhepaticabscess

themostcommonagentsresponsibleforascites

6EtiologyofascitesRenaldiseases

√glomerulonephritis(肾小球肾炎),√Nephrotictubuledisease√renalcarcinomaPeritonealDisease

√peritonitis

√malignantperitonealtumor

InChina,tuberculoseperitonitisisverycommon.

7EtiologyofascitesInadequatenutrition

√edemacausedbyhypoalbuminemia√deficiencyofVitaminB1Lymphaticsystemdiseases

√filariasis(丝虫病)

√lymphomawithinabdominalcavity

√theobstructionofthoracicduct(胸导管)orcisternachyli(乳糜池)Elephantiasis（象皮肿）ofthescrotum8EtiologyofascitesFemalereproductivesystemdiseases

√theruptureofFallopiantube(输卵管)causedbyectopicpregnancy/extra-uterinepregnancy

√tumorsoffemalereproductivesystemRuptureofabdominalviscera

√ruptureofstomach,bowel,liver,spleen,orgallbladder

9EtiologyofascitesMiscellaneous

√myxedema(粘液性水肿)

√MeigssyndromeMeigssyndrome

√thetriad(三联症)ofbenignovarianfibroma(纤维瘤)withascitesandpleuraleffusion

√resolvesafterresectionofthetumor10similartothepathogenesisofedema(AlterationofStarlingforces)

√

increasedhydrostaticpressure

√

decreasedplasmacolloidoncoticpressure

√

impedimentoflymphaticcirculation

√

renalfactorsPathogenesisofascites11≠Portalvein↑Hydrostaticpr.inp.v.sAscites↓Ingestion≠Absorption↓Synthesis↑DegradationPlasmaAlbumin↓PlasmaColloidOncoticPressure↓12lymphomaMetastatictumorfilariasis≠Thoracicduct≠CisternaChyli≠LymphaticCirculationAbdominalCavityAscitesseep13HepaticCirrhosis≠IntrahepaticVessels↑HepaticlymphaAbdominalcavityinflammation↑

PeritonealCapillaryPermeabilityAscites↓RenalBloodperfusion↓GlomerularfiltrationWaterAndSodiumRetentionExtravasatefacilitate14

todeterminewhetherthereisrealascitesornot？

toascertainthespecifictypeofascitesanditsprobablecause！DiagnosisandDifferentiationofascites15Todeterminewhetherthereisascitesornot？

Question:Whataretheprobablesignswhichmayindicateascites?

16

√alargeamountoffreefluidwithintheabdomen---abdominalwallcanbelaxinsupineposition,fluidcandepositatbothlateralsides

√thecontourjustlikeafrogbelly

Inspection17√liesononesideorsits,thelowerpartofabdominalwallwillbebulged,asfromthemovementoffreefluid.√long-termascites---theappearanceoftheumbilicusisprotrudedoreverted(umbilicalhernia).

18Puddletest(水坑试验)positiveinelbow-kneeposition

---atleast120mlfreefluidinabdominalcavity

Auscultation

---Puddletest19Avolumeoffreefluidintheperitonealcavitygreaterthan1000mlcanbedetectedwiththismethod.

Percussion

---shiftingdullness20Elbow-kneeposition

---puddletestThepuddletestcandetectaslittleas120mLoffluid21Palpation

---Fluidwavethrill(液波震颤)presentonlywhenthereisareasonablylargeamountoffluid,usually3000-4000ml

22Differentiationfromabdominalbulge

Overlyobesity

√veryfat,withthicklayerofabdominalwall

√

obviousinversionofumbilicus√withoutshiftingdullness

23DifferentiationHugeovariancyst

√

alargeareaofdullnessatmidabdomen

√

tympanyatlaterals(bowelscouldbepushedtothebilateralflanks)√Thedullnessofovariancystcouldnotshift.

24DifferentiationRulerpressingtest

√todifferentiatehugeovariancystfromrealascites

√takethesupineposition,ahardruleronthepatient’sabdominalwallhorizontally,pressestherulerdownwardwithtwohands

25DifferentiationIfhugeovariancystexists,thepulsationofabdominalaortawillconducttotherulerviathecyst,leadingtorhythmicpulsationofthehardruler.Iffreefluid,notcyst,existsintheabdominalcavity,thepulsationofabdominalaortacouldnotconduct,sothehardrulerhasnosuchrhythmicpulsation.26toascertainthetypeofascitesanditscause

history

Ageorgender

√

Tuberculoseperitonitisorabdominallymphoma(amongyoungpatients)

√

hepaticcirrhosis(amongmiddle-agedpatients)

27toascertainthetypeofascitesanditscause√Forfemalepatients---ovariancarcinomaorectopicpregnancy

√Formalepatients---hepaticcirrhosis28toascertainthetypeofascitesanditscausepasthistory√thepasthistoryofhepatitisorschistosomiasis(血吸虫病)---probablehepaticcirrhosis

√thepasthistoryoftuberculosis---tuberculoseperitonitis29toascertainthetypeofascitesanditscause√

apasthistoryofheartdisease,

edema,jugularveinengorgement(颈静脉怒张)andhepatomegaly---congestiveheartfailure30toascertainthetypeofascitesanditscausephysicalexamination

vitaldiagnosticcluesforthedeterminationofthesourcesandqualitiesofascites31toascertainthetypeofascitesanditscauseTuberculoseperitonitis

√fever,nightsweat(盗汗),someabdominaldiscomfort

√abdominaltenderness,doughkneadingsensation(揉面感；柔韧感)orreboundtenderness(peritonealirritation)32toascertainthetypeofascitesanditscause√accompaniedbyjaundiceorhemorrhagetendency---chronichepaticdisease.

√

splenomegaly,orabdominalwallvaricosis(腹壁静脉曲张)---portalhypertension33toascertainthetypeofascitesanditscause√

cyanosis,jugularveinengorgement,hepatomegaly,oredemaofthelowerextremities(cardiacedema)---congestiveheartfailure34toascertainthetypeofascitesanditscause√accompaniedbyabdominalmass---carcinoma35toascertainthetypeofascitesanditscause√Asciteswithlethargy,coldintolerance,orchangeintheskinandvoice---myxedema(粘液性水肿)√Connectivetissuediseases---complicatedbyascitesasamanifestationofserositis(浆膜炎).36Abdominalparacentesis---themostrapidandperhapsthemostcost-effectivemethodofdiagnosingthecauseofascitesformation

Traditionally,ascitescouldbeclassifiedintoexudate(渗出液)

andtransudate(漏出液)

.

Asciticfluidanalysis37AsciticfluidanalysisTransudate---clearortransparentappearance,proteinconcentration<25g/L,specificgravity<1.018,cellcount<100/μLandnegativebacteriacultureExudate---cloudyoropaqueappearance,proteinconcentration25g/L,specificgravity>1.018,cellcount>500/μLandoftenwithpositivebacterialcultureininfectedascites

38

transudate漏出液exudate渗出液etiologyportalhypertension,heartfailure,renaldiseasemalignanttumor,inflammation(tuberculosis),pancreaticdiseaseappearancetransparentorclear(opalescent/milky;bloody;purulent)opaqueorcloudycoagulationnegativepositiveproteinconcentration<25g/L25g/Lbacteriumnoyesininfectedonescellcount/mm3<100>500specificgravity比重<1.018>1.01839Transudateisoftencausedbyportalhypertensionasaresultoflivercirrhosis,heartfailureorrenaldisease.

Exudateismoreoftencausedbymalignanttumor,inflammationsuchastuberculosisorpancreaticdisease.Thetransudateasciticfluidcouldchangeintoexudatewhenspontaneousbacterialperitonitisoccurs.

40Serum-AscitesAlbuminGradient,SAAG(血清-腹水白蛋白梯度)

serumalbumin–asciticfluidalbumin11g/L---portalhypertension

Thehigherthegradient,thegreatertheportalpressure.

serumalbumin-asciticfluidalbumin<11g/L---notportalhypertension41SAAGconceptofhigh-albumingradienthassupplantedthatoftransudateconceptoflow-albumingradienthasreplacedthatofexudate42SAAGCirrhosis---themostcommoncauseofahigh-albumingradient

Peritonealcarcinomatosis---themostcommoncauseofalow-albumingradient43AnusandRectumExamMostdisordersaffectingtheanorectumcanbediagnosedbyhistoryandphysicalexamination,includingperianalinspectionandpalpation,digitalrectalexamination,anoscopicexamination,andproctosigmoidoscopicexamination.Withthepatientineithertheleftlaterallyingposition,theinvertedelbow-kneeposition,orsquattingposition,theperianalregioncanbeinspectedandpalpated.44Inspection

Atresia（闭锁）andstrictureofanus:usuallyseeninnewborncongenitaldeformity.TraumaandinfectionofanusAnalfissure（肛裂）【肛管下段齿状线以下深达皮肤全层的裂口或感染性溃疡】45ANALFISSUREasmalltearorcutintheskinliningtheanuswhichcancausepainand/orbleeding.extremepainduringdefecationandredbloodstreakingthestool;trytoavoiddefecationbecauseofthepain.46Hemorrhoids痔Thetermhemorrhoidsreferstoaconditioninwhichtheveinsaroundtheanusorlowerrectumareswollenandinflamed.

Hemorrhoidsmayresultfromstrainingtomovestool.Othercontributingfactorsincludepregnancy,aging,chronicconstipationordiarrhea,andanalintercourse.

Hemorrhoidsareeitherinsidetheanus(internal)orundertheskinaroundtheanus(external)orbothofthem(mixed).47Internalhemorrhoidsareaplexusofsuperiorhemorrhoidalveinsabovethemucocutaneousjunctionwhicharecoveredbymucosa.【齿状线以上的直肠上静脉曲张所致的静脉团，表面覆盖直肠粘膜，肛门内口见紫红色包块，排便时可突出肛门口外】Externalhemorrhoidsoccurbelowthemucocutaneousjunctioninthetissuesbeneaththeanalepitheliumoftheanalcanalandtheskinoftheperianalregion.【齿状线以下的直肠下静脉曲张所致的静脉团，表面覆盖肛管皮肤，肛门外口见紫红色包块】Themixedhemorrhoidshavecharactersbothofinternalandexternalhemorrhoids.【齿状线上、下的静脉曲张所致的静脉团，上部覆盖直肠粘膜，下部覆盖肛管皮肤】48Anorectalfistula:Theconceptofanorectalfistulaisthatthetwoopeningsofperianalskinandrectumareconnectedbyahollowtract,usuallyduet