婴幼儿急性阑尾炎的诊治体会

目的 探讨婴幼儿急性阑尾炎的诊断及治疗特点.方法收集我院自2003年11月～2009年12月期间共收治的49例婴幼儿急性阑尾炎的临床资料,总结分析临床特点及治疗经验.结果 49例均有发热、腹痛、中性粒细胞升高的主要临床表现,25例有腹胀、呕吐,15例有腹泻,9例有肠梗阻,49例均行手术治疗,经术中及病理证实诊断,术后均恢复良好.结论 婴幼儿急性阑尾炎因发作时缺乏典型的病史和腹部体征,常易误诊和延误治疗,发热、腹痛、中性粒细胞升高仍为其诊断的主要依据,婴幼儿急性阑尾炎一经诊断应尽早积极手术治疗,以避免严重并发症的发生.     

Ultrasonography in the diagnosis of acute appendicitis

By analysis of as group of 147 patients operated in 1996 at the Surgical Clinic of the Faculty Hospital in Hradec Králové on account of acute appendicitis the author evaluates the importance of ultrasonographic examination for the diagnosis. Its sensitivity was, consistent with data in the literature, 64.1%. US examination is valuable in particular in doubtful clinical diagnosis, the clinical examination remains however the basis in the diagnosis of acute appendicitis.     

CT of appendicitis in children

PURPOSE: Our goal was to review the CT findings and to help define the role of CT in the evaluation of appendicitis in children. METHOD: Of 730 children with surgically proven appendicitis, 22 underwent preoperative CT evaluation. Their CT scans and operative and pathology records were retrospectively reviewed. The CT scans were evaluated for appendiceal wall thickness, diameter, and location, appendicoliths, pericecal inflammation, phlegmon, abscess, free fluid, small bowel dilatation, and bowel wall thickening. Criteria for diagnosing appendicitis were (a) appendiceal wall thickening (> 1 mm) or (b) presence of abscess, phlegmon, or pericecal inflammation associated with appendicolith(s). Prospective reports of ultrasound examinations performed within 2 days of the CT scans were available in 14 children and were correlated with the CT findings. RESULTS: An abnormally thickened appendix, with a diameter ranging from 9 to 18 mm, was seen in four children. Three appendices were retrocecal and one was near the cecal tip, anterior to the iliac vessels. Appendicoliths were present in 10 children, multiple in 1. Abscesses were seen in 13 of 22 children, multiple in 5. Phlegmon was seen in five children and pericecal inflammation in two. Bowel wall thickening was present in seven children and small bowel dilatation was noted in six. Other findings included free fluid, hydronephrosis, thickening of urinary bladder wall, air in the uterus and vagina, adenopathy, and thickening of the abdominal wall musculature. CT was diagnostic of appendicitis in 11 of 22 children (50%). In 14 children with both ultrasound and CT studies, CT was slightly better in diagnosing appendicitis and visualizing the abnormal appendix and was superior in defining the presence and extent of abscess and inflammation in 9 of 14 children. CONCLUSION: CT is a useful adjunct in diagnosing appendicitis in children, with a major role in cases of complicated appendicitis.     

Transvaginal ultrasonography in the diagnosis of pelvic adhesions

We studied the role of transvaginal ultrasonography and clinical factors in the diagnosis of pelvic adhesions in a population of 139 consecutive pre-menopausal non-pregnant women submitted to diagnostic and/or operative laparoscopy between February 1995 and November 1996. All patients underwent transvaginal ultrasonography and were interviewed within 2 days of their laparoscopy. The ultrasonographic impressions were then compared with the laparoscopic diagnosis. Patients were classified as having tuboperitoneal abnormalities if evidence of fimbrial, peritubal and/or peri-ovarian adhesions was encountered during surgery. The overall agreement between the ultrasound test result and the surgical findings was calculated using the kappa index. The adhesion of the ovary to the uterus, as evaluated by transvaginal ultrasonography, is most accurate in diagnosing pelvic adhesions (kappa = 0.5) in comparison with the other ultrasonographic findings and clinical parameters. According to the logistic regression equation that was obtained, the probability of the presence of pelvic adhesions varied between a minimum of 12% for patients with no risk factors to a maximum of 93% for patients with three risk factors (previous pelvic surgery and transvaginal ultrasound findings of blurring of the margins of the ovary and adhesion of the ovary to the uterus).     

Enhanced ultrasonography in the diagnosis of renal tumors

Possible impairment of the L-arginine-nitric oxide (NO) pathway in the rostral ventrolateral medulla of adult spontaneously hypertensive rats (SHR) was investigated by microinjecting N(G)-nitro-L-arginine methyl ester (L-NAME), NOC 18 (an NO donor), or L-arginine. Unilateral injection of L-NAME (10 nmol/50 nL) into the rostral ventrolateral medulla significantly increased mean arterial pressure (MAP) in both SHR and Wistar-Kyoto rats (WKY). The increases in MAP did not differ significantly between the two strains (15+/-3 versus 10+/-2 mm Hg, respectively; n=8). In contrast, microinjection of L-arginine elicited significant (P<.05) dose-dependent decreases in MAP in both strains, and these depressor responses were significantly greater in SHR than in WKY (in 10 nmol of L-arginine: -29+/-2 versus -15+/-2 mm Hg, respectively; n=8, P<.01). Similarly, microinjection of NOC 18 (10 nmol/50 nL) reduced MAP in both strains, and the depressor response was also significantly greater in SHR than in WKY (-38+/-7 versus -22+/-3 mm Hg, respectively; n=8, P<.05). These results suggest that the L-arginine-NO pathway in the rostral ventrolateral medulla is impaired in SHR and that this impairment may contribute to the increase in arterial pressure in this animal model of genetic hypertension.     

Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities

STUDY OBJECTIVE: To investigate the value of transvaginal ultrasonography, aspiration biopsy, and hysteroscopy combined with curettage or directed biopsy in detecting endometrial pathology in women with abnormal uterine bleeding. DESIGN: Prospective, nonrandomized study. SETTING: A university-affiliated hospital. PATIENTS: One hundred twenty-two premenopausal and 78 postmenopausal women with abnormal uterine bleeding. INTERVENTIONS: The women underwent transvaginal ultrasonography (TVS) combined with aspiration Pipelle biopsy. They were scheduled for hysteroscopy and endometrial sampling by curettage or directed biopsy within 4 weeks. MEASUREMENTS AND MAIN RESULTS: Ultrasonographic findings were evaluated on the basis of final diagnoses established by hysteroscopy and histologic examination. The endometrium was measured at its thickest part in the longitudinal plane. In premenopausal women, endometrial thickness was measured during the early proliferative phase of the cycle. Ultrasound examination was considered negative if single-layer thickness was less than 5 mm in the absence of endometrial projections. In all other cases it was classified as positive. For postmenopausal women the cutoff point was 4 mm (single layer). In postmenopausal women with endometrial thickness less than 4 mm, as well as in premenopausal patients with negative TVS, the combination of TVS and aspiration biopsy missed only one case of atypical hyperplasia. In premenopausal patients TVS clearly detected 73% of polyps and myomata, permitting diagnostic and surgical hysteroscopy to be performed at the same time. In postmenopausal women with endometrial thickness 4 mm or greater, aspiration biopsy failed to detect two cases of atypical hyperplasia and one of focal adenocarcinoma. Pipelle sampling was technically infeasible in a woman with endometrial cancer because of a stenotic cervix. It also missed the majority of benign lesions (polyps and myomas). CONCLUSIONS: Transvaginal ultrasound seems to be an excellent initial diagnostic method, with high sensitivity in diagnosing endometrial abnormalities. Its combination with aspiration biopsy seems to be safe in women with a thin endometrium. Hysteroscopy is necessary in postmenopausal women with an endometrium of 4 mm or more, as well as in premenopausal patients with endometrial thickness more than 5 mm (preovulatory phase of the cycle) and in those with suspected polyps or myomas.     

The clinical picture of acute appendicitis in children

The authors describe 3860 child patients operated on account of acute appendicitis and analyse the data with regard to age, sex, year of incidence and surgical finding. The highest incidence of acute appendicitis is between 8 and 11 years with a peak at the age of 10 years. It is more frequent in boys (58.3%) than in girls (43.7%), the ratio being 1.3:1. It occurs more often during the cold months (46.5%), in autumn (27.3%) and in winter (25.7%). The number of gangrenous appendicitis is 34.7%-56.7% in boys and 43.5% in girls. The highest rate of missed appendicitis is at the age of the highest incidence (15.2%) with a peak at the age of 10 years (17.8%) and in January (13.3%). The highest incidence of perforated appendicitis is also at the age of the highest incidence (14.9%) with the peak at the age of 8 years (15.6%) and in June (13.5%). Perforation is more frequent in boys (58.1%) than in girls (49.9%). The number of "negative" appendicitis is 15.8%. Prevention of acute appendicitis still remains open due to lack of knowledge of its etiopathogenesis.     

Use of ultrasonography in the diagnosis of tracheal collapse

Ultrasonographic imaging of the cervical trachea was performed with the neck in both a neutral and a hyperextended position in 10 dogs with tracheal collapse. Tracheoscopy was used to confirm a diagnosis of tracheal collapse. The ultrasound investigation was repeated in 10 dogs of similar size but without tracheal abnormality. The ultrasonographic findings of the affected dogs were compared with those of the normal group and showed an alteration in the shape of the tracheal lumen in the ventrodorsal projection. This study highlights the possibility of identifying changes in the shape of the tracheal lumen during ultrasound investigations as an aid to the diagnosis of tracheal collapse.     

Doppler-duplex ultrasonography in the diagnosis of cavernous portal vein

Prehepatic portal hypertension caused by cavernous transformation of the portal vein has been more and more considered as a multiorgan disease with circulatory changes in numerous organs related to systemic and splanchnic vascular network [1]. Honeycomb-like, spongy, cavernous portal vein is a rare clinical and pathoanatomical entity which usually results from portal vein thrombosis. Recanalization and neovascularization processes lead to cavernomatous transformation of the portal vein lumen and formation of periportal collateral hepatopetal venous varices (Petren's veins) [5, 6]. Recently, with Doppler ultrasonography and angiography cavernous portal vein has been identified as the cause of prehepatic portal hypertension. Usage of color Doppler and duplex Doppler ultrasonography has greatly contributed to diagnostic efficiency, while therapeutically, the disease remains a serious and controversial problem. METHODS: At the Institute of Digestive Diseases, Clinical Centre of Serbia, 8 patients with cavernous portal vein were studied in the period 1995-1997. Real-time duplex and color Doppler ultrasonography (Toshiba-SSA 100A with sector duplex probe 3.75 MHz, and 9 ATL with color Doppler convex duplex probe 3.5 MHz) were used. Indirect (arterial) portography was used for imaging of lienoportal system in the venous phase of angiography as follows: catheterization (Seldinger's technique) of the coeliac trunk or lienal artery, and catheterization of the superior mesenteric artery. Indirect portography was performed by injection of 60-80 ml of the contrast medium by an automatic pump, at 10-14 ml/sec, i.e. 8-10 ml/sec by the digital technique [7]. Peroral fiberendoscopy was performed in all patients by Olympus GIF-XQ 10 endoscope. RESULTS: In our study the conventional ultrasonographic examination failed to provide an appropriate image of the normal portal vein. In hepatoduodenal ligament multiple tubular and round structures were seen, revealing an atypical honeycomb or spongycavernous shape of the venous lumen (Figs. 1 and 2). Doppler ultrasonography of the lumen of these venous collateral structures revealed a continuous, hypokinetic flow, mid-rate 7.4 cm/sec, which was always hepatopetally directed (to the liver). Color Doppler ultrasonography detected extensive portosystemic collateralls in all patients, and varices in the gallbladder wall in 1 patient. The results of indirect portography correlated well with Doppler ultrasonographic findings. In all patients hepatopetal flow was found (Figs. 3 and 4). The aetiology was diverse: idiopathic, liver cirrhosis, haematological diseases, Crohn's disease and Marfan's syndrome. Two patients had IV degree varices in the distal third of the oesophagus, and 4 patients had II/III degree varices. Patients with posthepatic liver cirrhosis and Crohn's disease had no varices in the distal third of the oesophagus and gastric fornix. DISCUSSION: Since Pick (1909) described this malformation as the hepatopetal collateral, the haemodynamic concept of this entity has not been changed. Doppler ultrasonography and angiography confirm that the blood flow in cavernomas is hepatopetal, i.e. compensated and functional. Cavernous transformation of the portal vein is clinically manifested by bleeding from oesophagogastric varices. Haemathemesis is the most alarming complication and may be the first clinical sign. The haemorrhage is usually recurrent and profuse, but in most cases it is tolerated well owing to preserved hepatic function in patients without liver cirrhosis [19]. Portosystemic collateral circulation may take place via retroperitoneal and other spontaneous venous shunts, not involving the left gastric vein or vv. gastricae breves, when oesophagogastric varices are absent (our patient with Crohn's disease and posthepatitic B cirrhosis). Splenomegaly with hypersplenism is always present with cavernous transformation of the portal vein, and usually precedes the occurrence of gastrointestinal hae     

Color duplex ultrasonography in the diagnosis of temporal arteritis

BACKGROUND: The diagnosis of temporal arteritis usually requires a biopsy of the temporal artery. We examined the usefulness of color duplex ultrasonography in patients suspected of having temporal arteritis. METHODS: In this prospective study, all patients seen in the departments of rheumatology and ophthalmology from January 1994 to October 1996 who had clinically suspected active temporal arteritis or polymyalgia rheumatica were examined by duplex ultrasonography. The final diagnoses, made according to standard criteria, were temporal arteritis in 30 patients, 21 with biopsy-confirmed disease; polymyalgia rheumatica in 37; and negative histologic findings and a diagnosis other than temporal arteritis or polymyalgia rheumatica in 15. We also studied 30 control patients matched for age and sex to the patients with arteritis. Two ultrasound studies were performed and read before the biopsies; one ultrasonographer was unaware of the clinical information. RESULTS: In 22 (73 percent) of the 30 patients with temporal arteritis, ultrasonography showed a dark halo around the lumen of the temporal arteries. The halos disappeared after a mean of 16 days (range, 7 to 56) of treatment with corticosteroids. Twenty-four patients (80 percent) had stenoses or occlusions of temporal-artery segments, and 28 patients (93 percent) had stenoses, occlusions, or a halo. No halos were identified in the 82 patients without temporal arteritis; 6 (7 percent) had stenoses or occlusions. For each of the three types of abnormalities identified by ultrasonography, the interrater agreement was > or =95 percent. CONCLUSIONS: There are characteristic signs of temporal arteritis that can be visualized by color duplex ultrasonography. The most specific sign is a dark halo, which may be due to edema of the artery wall. In patients with typical clinical signs and a halo on ultrasonography, it may be possible to make a diagnosis of temporal arteritis and begin treatment without performing a temporal-artery biopsy.     

Leucocyte elastase as a marker in the diagnosis of acute appendicitis

OBJECTIVE: To investigate the value of measuring the activity of the leucocyte elastase complex in plasma in the diagnosis of acute appendicitis, either as a single or four-hourly test. DESIGN: Open study. SETTING: Teaching hospital, Sweden. SUBJECTS: 165 consecutive patients admitted with suspected acute appendicitis. MAIN OUTCOME MEASURES: Correlation of concentrations of leucocyte elastase complex (elastase) and total white blood cell count (WBC) with C-reactive protein concentration and histological appearance of the appendix. RESULTS: Of 165 patients, 101 patients had their appendixes removed, and of these 86 had histologically confirmed appendicitis. An elastase value of less than 54 micrograms/l was considered to be the reference range. Elastase activity measured on admission gave a sensitivity of 61% and a specificity of 43% for acute appendicitis compared with the WBC which had a sensitivity of 81% and a specificity of 36%. The above blood tests were taken on two or more occasions four hourly after admission in 29 patients. Appendicitis was found in 25 of the 29 cases (87%), in which repeated tests showed a significant reduction in WBC together with a definite but not significant reduction in the elastase activity during the preoperative period. Repeated tests were of no value. CONCLUSIONS: Measurement of the leucocyte elastase complex in plasma does not increase the accuracy of the diagnosis of acute appendicitis. There was no significant correlation between the leucocyte elastase activity and the total white cell count.     

Laboratory diagnosis of plague

Recently, progress of studies and technique developments on human and mammalian fertilization and early embryonic development in vitro are markedly. At the present time, however, some problems are remaining. In mammalian embryo culture, the major obstacles to progress in analysing epigenic regulation of development in other than the mouse and rabbit are the infamous blocks to development in vitro. At the present time, further studies are needed to dissolve the precise mechanism of these blocks. Factors which affect on embryo development are a great number and analysis of them is considered to be important for clinical application of the embryo culture system. Intracytoplasmic sperm injection(ICSI), at the present time, is employed widely for basic research and the treatment of male infertility. Using ICSI, recent studies are showing that mouse round spermatids can fertilize mature oocyte and the fertilized oocytes(embryos) develop into normal offspring after embryo transfer to foster mothers. Also, a recent report indicates development of normal mice from oocytes injected with secondary spermacyte nuclei. However, since some unsolved problems on spermatogenic cells such as round spermatids and secondary spermacytes remain, further studies are needed.     

Laboratory evaluation in the diagnosis of Lyme disease

PURPOSE: To provide a qualitative evaluation of the predictive value of the laboratory diagnosis of Lyme disease and to use the resultant data to formulate guidelines for clinical diagnosis. DATA SOURCES: A MEDLINE search of English-language articles or articles with English-language abstracts published from 1982 to 1996. DATA EXTRACTION: Sensitivity, specificity, and likelihood ratios were calculated, and a random-effects model was used to combine the proportions from the eligible studies. Prespecified criteria were used to determine which studies were eligible for analysis. DATA SYNTHESIS: Laboratory testing in general is not clinically useful if the pretest probability of Lyme disease is less than 0.20 or greater than 0.80. When the pretest probability is 0.20 to 0.80, sequential testing with enzyme-linked immunosorbent assay and Western blot is the most accurate method for ruling in or ruling out the possibility of Lyme disease. CONCLUSIONS: Laboratory testing is recommended only in patients whose pretest probability of Lyme disease is 0.20 to 0.80. If the pretest probability is less than 0.20, testing will result in more false-positive results than true-positive results; a negative test result in this situation effectively rules out the disease.     

Evaluation of intraductal ultrasonography in the diagnosis of pancreatic cancer

An intraductal ultrasound (IDUS) probe which is inserted via the papilla into the main pancreatic duct (MPD) was evaluated in the diagnosis of 20 patients with pancreatic cancer. The examination was successfully performed with the probe in 17 of the patients (85%). Due to its high frequency (30 MHz) the probe only allowed visualization of the ductal wall and the immediate periductal vicinity (up to about 10 mm). In 15 of the 20 patients the tumors were surgically resected and IDUS scanning was also performed in vitro on the resection specimens, the results being compared to those of histopathological examination. Of these 15 patients, 13 were found to have ductal adenocarcinomas and all but one had been unequivocally diagnosed as having such by ultrasonography (US), computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS). IDUS showed an echorich area (corresponding to cancerous canaliculi on histopathological examination), surrounded by an echopoor area (abundant stroma). This pattern was classified as type I. In two patients with intraductal papillary carcinomas in whom a conclusive diagnosis was not established on US, CT, EUS or ERCP, IDUS showed tumorous tissue with an inhomogeneous echopattern outside (type II) or within (type III) the duct. These results show that IDUS offers valuable diagnostic information complementary to ERCP especially in cases of intraductal papillary tumors. Whether the high resolution imaging of the duct and the paraductal tissue can be used to differentiate between the different forms of pancreatic lesions (inflammation, neoplasms) has to be investigated further.     

Role of ultrasonography in the early diagnosis of ovarian cancer

BACKGROUND: Malign ovarian carcinomas are the main cause of death from gynaecological cancer. In fact, only in 30% of cases is it diagnosed at an early stage. In our study the possibility of an early diagnosis of the ovarian malignant neoplasia was evaluated. METHODS: One hundred and thirty-nine women with adnexal swelling were subjected to pelvic echography. The sample was selected during routine gynaecological checkups. RESULTS: All the cases showing a mass diameter exceeding 25 mm were classified as positive. Echotomography showed 129 cases of positive ovarian mass with an accurate diagnosis in 92.27%. Integrating the results of echography with those of radioimmunoassay an early diagnosis of ovarian cancer was achieved in 92.53 of the cases. CONCLUSIONS: A routine pelvic examination associated with pelvic echotomography represent an effective protocol for the diagnosis of ovarian cancer at an early stage.