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患者**,女,38岁,已婚,因“间断性腹痛伴发热3年余”于2012-12-25入院。
患者3年前无明显诱因出现脐周疼痛,为持续性绞痛,排便、排气后可缓解,伴发热,体温最高达37.5℃,伴里急后重,无恶心、呕吐,无嗳气,偶有反酸、烧心,无上腹部饱胀感,未予治疗,2012年12月14日于我院就诊,门诊肠镜提示溃疡性结肠炎,病理提示溃疡性结肠炎,胃镜提示慢性胃炎,现患者为行进一步治疗来我院就诊,门诊以“溃疡性结肠炎”收入我科。患者自发病以来,睡眠、饮食可,小便正常,体重无明显减轻。查体未见明显阳性体征。肠镜(2012-12-14,我院):全结肠粘膜充血、水肿,散在片状糜烂,未见炎性息肉及桥型粘膜增生以升结肠和直肠为重。病理(2012-12-16,我院):(回盲部)粘膜慢性活动性炎,间质内大量淋巴细胞、浆细胞及中性粒细胞浸润,局灶腺体破坏伴隐窝脓肿形成,请结合临床考虑溃疡性结肠炎。
患者主诉间断性腹痛3年余入院,无腹泻及粘液脓血便,偶有里急后重,无关节、皮肤、眼、口等肠外表现,结肠镜检查提示全结肠粘膜充血、水肿,散在片状糜烂,未见炎性息肉及桥型粘膜增生以升结肠和直肠为重,病理提示溃疡性结肠炎,故诊断明确;患者此次为初次诊断,故临床类型为初发型;无腹泻,无粘液脓血便,发热体温小于37.5℃,脉搏小于90次/分,血红蛋白126g/L,血沉(ESR)19.0mm/h,故严重程度为轻度;病情分期根据Mayo指数未2-3分,考虑现为轻度活动期,根据结肠镜检查情况病变范围为全结肠,无肠外表现和并发症;3、目前可予美沙拉嗪缓释颗粒剂口服并双歧杆菌三联活菌胶囊调整肠道菌群治疗。
患者病情平稳,仍诉偶有腹痛,较前有明显好转,睡眠饮食可,大小便正常,精神状况可。查体未见明显阳性体征。
患者李某,女性,42岁,霍邱县三流乡人
病例特点:患者系“腹胀1年余加重1月余伴乏力纳差”入院,
患者1年前出现呈间断性腹胀不适,未予重视。入院前1月腹胀明显加重伴有乏力、纳差。
病程中无畏寒发热,无恶心呕吐,无咳嗽。入院后查体:慢性病容,贫血貌,腹膨隆,肝肋下2cm.,脾脏未触及明显肿大,上腹部轻度压痛,腹水征(+)双下肢轻度凹陷性水肿。肛诊阴性。辅助检查:血常规WBC 11.9*10*9/L,HGB37g/l, 尿常规示白细胞(2+),尿培养+药敏示:大肠埃希菌感染。生化示:总胆红素33.0umol/l,直接胆红素18.6umol/L,间接胆红素14.4umol/L,白蛋白30.7g/l,GLU 6.93mmol/L,上腹部彩超示:1.肝脏弥漫性损害伴腹水(中等量),2.胆囊炎,胆囊壁水肿 3.胆囊壁胆固醇结晶,4.脾脏轻度肿大,上腹部CT示:肝硬化伴脂肪肝,胆囊结石,腹盆腔积液,腹水深度8.8cm,肿瘤标志物示:CA125 330.774IU/Ml,CA199 154.39IU/ML,CA153 26.62KU/L, 腹水肿瘤指标:CA125 124.424IU/Ml,CA199 53.83IU/ML,胃镜示:1.食管胃底静脉曲张2.糜烂性胃炎,HP(+),肠镜考虑患者长期腹水,易出现肠穿孔,形成腹膜炎暂缓。盆腔CT:子宫、卵巢未见明显异常。妇检行宫颈TCT检查,报告意见:鳞状上皮细胞极少。
诊断:1.酒精性肝硬化伴腹水;重度贫血;2.泌尿系感染;3.消化道肿瘤,4.妇科恶性肿瘤,胃镜示:1.食管胃底静脉曲张2.糜烂性胃炎,HP(+),故排除胃癌的可能性;子宫附件影像学检查及宫颈刮片未发现明显异常,暂排除妇科肿瘤。
治疗:经抗感染治疗、利尿、输血、营养支持、抑酸护胃治疗。
出院情况:一般情况尚可,腹胀不适较前明显改善。复查HGB66g/L 腹水深度2.7cm
建议随访