闌尾炎和疝氣

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

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

3、thewallandpartialortotalobliterationofthelumen.Iftheappendixhasaphysiologicfunction,itisprobablyrelatedtothepresenceoflymphoidfollicles.Reportsofastatisticalrelationshipbetweenappendectomyandsubsequentcarcinomaofthecolonandotherneoplasmsinhumansarenotsupportedbycontrolledstudies.conical圓錐的;圓錐形的diver

4、ticulum腸盲囊,小囊突,憩室apex頂點(diǎn),最高點(diǎn)cecum盲腸distention膨脹;延伸dorsally背側(cè)地ileocecalvalve回盲瓣retrocecally盲腸后的lymphoidfollicles淋巴樣濾泡,淋巴小結(jié);progressiveatrophy萎縮concomitant伴發(fā)的,伴行的,并發(fā)的concomitantwith協(xié)同obliteration涂去,抹消,刪除lumen管腔,流明,腔appendectomy闌尾切除術(shù)neoplasm腫瘤ileocecallymphoidappendicitis闌尾炎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腹股溝的3.femora

10、l大腿的,大腿骨的,股的,股動(dòng)脈,股骨的Incisional切入的,切開的ventral腹部,腹側(cè)的,腹的,腹面的umbilical臍的2.subcutaneous皮下的peritoneal腹膜的sac囊;液囊viscera內(nèi)容;腸strangulated脹縮不均的,窒息的,絞窄的reducible可復(fù)位的,可還原的，可變形的,可縮小的spontaneously自發(fā)地,自然產(chǎn)生地recumbent側(cè)臥的,休息的irreducible不能復(fù)位的（incarcerated箝閉的,狹窄的）trapped捕集的,捕獲的,收集的,截留incarceration監(jiān)禁,嵌頓,箝閉imply暗示,意指,蘊(yùn)涵i

11、schemia局部缺血,缺血strangulation勒頸,勒頸窒息omentum網(wǎng)膜gangrene壞疽,疝腹外疝是腹腔內(nèi)組織或部分或整個(gè)臟器通過腹壁的孔穴或筋膜缺損處所造成的不正常突出。約75的疝發(fā)生在腹股溝區(qū)（直疝、斜疝、股疝）。切口疝和腹壁疝各約占10；臍疝3，其余的約3。一般而言，疝塊由覆蓋組織（皮膚、皮下組織等）、腹膜囊和囊內(nèi)的任何一個(gè)內(nèi)臟所組成。特別是當(dāng)疝囊頸部即腹腔的突出處狹小，腸管突入疝囊后可形成梗阻或絞窄。疝如不及早修復(fù)，正常組織可受壓，缺損處變大、手術(shù)修復(fù)變得更為復(fù)雜。疝的根本治療是早期手術(shù)修復(fù)。可復(fù)性疝是指疝內(nèi)容可自行回納，或在病人仰臥時(shí)用手?jǐn)D入腹腔。不可復(fù)性（箝閉性）

12、疝是指疝內(nèi)容物不能回納入腹腔，通常起因于狹窄的頸部受阻。盡管發(fā)生梗阻或絞窄前需有箝閉，然而箝閉一詞并不意味被疝入的器官有梗阻，發(fā)炎或缺血。雖然疝囊內(nèi)腸襻的腔可有阻塞，但開始時(shí)并不影響血液的供應(yīng)。當(dāng)囊內(nèi)器官（姐網(wǎng)膜或腸管）血供受到損害就形成絞窄性疝，隨即出現(xiàn)疝囊及疝內(nèi)容的壞疽。股疝的絞窄發(fā)生率較腹股溝疝高，其他類型的疝也可發(fā)生絞窄。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膽囊upperabdominalpain上腹痛(

31、右下rightlower)腹痛abdominalpainbiliary膽道的，膽的，膽汁的colic絞痛，疝痛，疝氣acalculouscholecystitis無(wú)結(jié)石膽囊炎sepsis敗血癥，膿毒癥intravenous靜脈內(nèi)的，靜脈注射靜originate發(fā)起,開始,創(chuàng)造,發(fā)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