消化系统疾病30胃肠道中英文12a校abdominal effusion unterer

ClinicofSmallAnimalLudwigilianUniversityofAbdominaleffusionHeart,liverorneosia?StefanUntererDiplomateECVIMClinicofSmallAnimalLudwigilianUniversityofOverviewabdominal腹部渗出的综Recognition Classification Pathophysiology病理生理problem-orientedapproach问题导向式方symptomatictherapy对症治识historyofabdominaldistention腹部膨胀的病DD:organomegaly,tumor,adipositas,distendedbladder,pregnancy, 胱扩张，怀孕，physicalexamination体格检severeeffusionundulationmildeffusion:„slippery“feelingonoftennot识-rays:lossof DD:tumor,peritonitiswithouteffusion,鉴别诊断：肿瘤，无渗出的腹膜炎，恶病ltraybestmethodtoidentifyeffusionsmallamountstendtoaccumulate少量的渗出易积聚在局craniallyto 头betweenliverlobes肝叶之识 edcasesstandingpatient,lineaalba,umbilicalrelativelysafecomplicationsrare)并发症（很少见bleedingduetocoagulopathybleedingduetoorgan iatrogenicinfection医 Initialdiagnostic初步诊断步firstheartmurmur,arrhythmia,muffledheartsounds,congestedjugularveinsright-心杂音，心率不齐，心音不清，颈静脉充右心衰Jaundiceliver肝衰，胆管破裂或阻Initialdiagnostic初步诊断步firstFeverinfl toryLymphadenopathy 病malignantInitialdiagnostic初步诊断步effusion ysisforTransudate漏出modifiedFoto:Prof.J.Foto:Prof.J.Blood血Chyle乳糜Urine尿Bile胆分 漏出 渗出protein(g/dl)spec.grav. nucleatedcell

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PCV通常PCV>10%(oratleast¼ofperipheralPCV>10%（或者至少达到1/4的外周血液distinguishingiatrogeniccontamination„fresh“bloodbyiatrogenicorganaspiration分Chylemilky,cloudytriglycerideseffusion>Urineyelloweffusioncreatinine/potassiumeffusion>肌酐/钾Bilecogniac-colouredeffusionCasesignalement特GermanShepherdDog5months5maleintacthistory病

Casewithownersince6weeks主人饲养6picky weight lethargicforafewdistendedabdomenforafewCasephysicalexamination体格检QARrectaltemp.38.2°C直肠温度HR80bpm心率pinkmucousmembranesRR28/minCachecticundulatingabdomenCaseinitial n ysisabdominalultrasound腹部BthoracicradsCaseinitial n ysisabdominalultrasound腹部BthoracicradsCasefluid ysismacroscopic:slightlyred,clearprotein:1.4g/dl1.4spec. ：nucleatedcellcount:200cells/µlcytologylowcellularitymixedcellularmpopulation,erythrocytes,mesothelialcells,lymphocytes,non-degeneratedneutrophils 的中性粒细胞混Caseinterpretation:puretransudate归类：单纯的漏出lowcellularity,lowproteinApre-hepaticportalhypertensionA：肝前性门脉高disturbeddrainagefromportalveins门脉系统紊connectionportalveinwithartery(hepaticarteryportovenousfistula)门静脉与动脉（肝动脉-门静脉瘘BhypalbuminemiaB：低蛋白血Casepre-hepaticportalhypertension肝前门静脉高disturbeddrainagefromportalconnectionbetweenportalveinand n漏出液的诊断计nextalbumin-/totalproteinmeasurement白蛋白-/总蛋白计albuminmajorcomponentofoncotic白蛋白是胶体渗透压的主要成albumin<1.5 effusion白蛋白<1.5 渗albumindecreased,but>1.5白蛋白下降，但1.5hypalbuminemiaprobablynotsolereasonforfurtherdiagnostictests n漏出液的诊断计Hpalbuineiarenalloss➔urinedipstick;better:UP/C尿液试纸条；最好是尿蛋白/肌酐比dipstickinprecise:dilutedurine尿液试纸 确：稀释尿液UP/C>1consistentwithincreased尿蛋白/肌酐1提示丢失增UP/Cmostly>5,ifsignificant尿蛋白/肌酐>5提示明显的蛋白 n漏出液的诊断计Hypalbuminemia低蛋白血decreasedproduction➔liverenzymeactivities;better:bile检测肝酶活性；最好是胆汁酸测liverenzymeactivitieswithsign.liverdiseasenotalwayselevated(livercirrhosis,neosia,chronic肝酶活性是一个指标，一些肝脏疾病并不能很好地被评（肝硬化，肿瘤，慢性肝炎post-prandialbileacidsmoresensitivethan餐后胆汁酸测试比禁食下测试更敏 n漏出液的诊断计Hpalbuineiaintestinalloss➔excludeliverandkidneys;better:intestinal排除肝脏肾脏原因；最好做肠道活组织检noeasylabtestforprotein-loosing(α1-antitrypsinonlyin对于蛋白丢失性肠病没有简易 检测方法（只 有抗胰蛋白酶endoscopicbiopsiesmostly大多数情况下内窥镜活检是足够 n漏出液的诊断计Hypalbuminemia低蛋白血othercausesrarelyleadtosevereVasculitis Malnourishmentreferencex5.5–7.45–0.35–x150–x5–x0.04–x1–x0–segmentedx3–x0–x0–reference0-16-0-AP00-0-cholines2280-0-0-0-0-refrence90–0-bile0–3.1–0.27–48–25–3.3–32–3.33–0-referenceP0.71–99-143-K3.9–total2.4–11-0.7–UrineUrinereferencecollection收集方--5.5-+--------+-spec.1.015–Erys2–Caseabdominalultrasound腹部Bliverappearsverysmall,ratherlivermarginsappearirregularbecauseofsevereeffusiononlycautiousCaseHypalbuminemiaportalhypertensionhypalbuminemiapresent,butdoesnotex severeabdominaleffusioneffusionhypalbuminemiaandportalhypertensionCasediagnosis:juvenilelivercirrhosisModifiedcharactriedslightlyhigherproteincontent(>2.5lowcell蛋白质含量更高一些2.5➢mostcommoncauseformod.引 的常见原congestiveright-sidedheartfailure充血性右心衰liverdisease肝脏疾 siaModified➢ed=cllen deuy tmn.apositive

颈静脉阳性搏siitolaf颈静脉反射阳dtModifiedpericardialmuffledheartsounds心音不„poundingpulses脉搏沉„rounded“onthoracicrads胸片上心脏呈圆ECGelectricalternans电交ModifiedpericardialModifiedpericardialModifiedtricuspid systolicheartmurmur心脏收缩期杂loudestonrightthorax听诊右侧心音definitivediagnosiswithecho确诊需要超tricuspid闭锁不rightatrium右心房扩dilatedliver肝静脉扩Modifiedtricuspid systolicheartmurmur心脏收缩期杂loudestonrightthorax听诊右侧心音definitivediagnosiswithecho确诊需要超tricuspid闭锁不rightatrium右心房扩dilatedliver肝静脉扩ModifiedCardiomyopathysoftheartsounds心音疲poss.systolicheartmurmur有时会有收缩期杂weakpulses脉搏poss.enlargedheartshapeonthoracic有时在胸部放射片上会显示心影增definitivediagnosiswithecho确诊需心脏超enlargedventricularandatrialdimensions心房、心室diminishedcontractility收缩力下Modifiedliverintra-hepaticportalhypertensioncompressionofliversinusoids pronetoeffusionbysaltandwater(activationofrenin-tensine-aldosterone水盐潴留也可能形成渗（肾素-血管紧张素-醛固酮系统的激活Modifiedliverifposthepaticportalhypertension(esp.byheartfailure)excludedascauseformod.transudate&liverenzymeactivity/functionparameters如果是肝后门静脉高压（如心衰）造成性指标可能正hepatic

，肝酶ModifiedliverCAUTION:注eveninpost-hepaticcongestion(e.g.right-sidedheartfailure)liverenzymeacitivitiescanbeincreaseddueto即使是肝后性阻塞（如右心衰竭）病例中，肝酶活性也可能会为缺氧而升fordefinitivediagnosis,therapy,andprognosisliverbiopsy肝脏活检对于确诊、治疗、预后判断都很重ModifiedNeo siaafterexclusionpost-hepaticportalhypertensionliver在排除了肝后门静脉高压和肝脏疾病之occult siamost隐蔽的肿瘤可能性最obstructionofcapillaries堵塞毛细血secondary tion炎症继ModifiedNeo siainmostpatientsno sticcellson大部分病例中，细胞学检查时看不到肿瘤细reactivemesothelialcellscouldbeconfused sticcellsCAUTION!反应性间皮细胞可能与肿瘤细 注意ultrasoundusefulforidentificationofabdominal B超对于识别腹部肿瘤很有advanceddiagnosticimaging:CT,Modifiednodiagnosisafterinitialdiagnosticlaparotomy+biopsies(liver,mesentery,lymphnodes,GItract,anyabnormaltissue)活组织检查（肝脏，肠系膜， ，胃肠道，任何腹腔组织+measureportalvein测量门静脉压+mesentericvenoportogramclassification

渗出highproteincontent(>2.5蛋白含量高2.5highnuclearcellcount(>7000有核细胞数量多7000neutrophilseffusion>渗出液中的中性粒细胞>血液中initialdecision初步定Septic败血渗出septiceffusion败血症性渗细mostlyneutrophils主要是中性细 intracellularbacteria胞内细CAUTIONpatientsrecieving接受抗生素治疗的患lessneutrophils中性粒细胞减-oronlymildlydegenerated没有或仅轻度的细bacteria渗出septiceffusion败血症性渗perforatedGItract胃肠道穿foreign 异hematogenicdissemination血液散rupturedintraabdominalabscess腹腔内脓肿破Iatrogenic医源septic败血症性渗出需要开腹