消化内科病案讨论

CaseDiscussionGeneralSurgeryDepartmentDr.HuJiankun010203PatientXXXMale57yearsoldNo.913122Admission:Aug.9th,2004ChiefComplaint:Abdominalpainfor2monthsHistoryofpresentillness(1):Thepatientcomplainedthat2monthsago,heappearedabdominalpainforhalfahourwithoutanyprecipitatingfactor.Itismidandupperabdominaldistendingpain,withburningsensation,sourregurgitation,belching,withoutnausea,vomiting,withoutmelaena,hemafecia,dizziness.Inthelocalhospital,thegastroscopyshowed“gastriculcer”…Afterillness,thepatient’sspiritandappetiteispoor,urinationanddefecationisnormal,sleepingisnotwell,andtheweightdecreased5Kg.Thenhewenttoourhospitalandtookgastroscopyexam.Andtheresultshowed“Gastricfundusandantrumpoordifferentiatedadenocarcinoma”.Thenhewasadmittedinourdepartment.Historyofpresentillness(2):010302PastHistory:1yearago,hewasillwith“pneumonia”.Denyinghepatitisandtuberculosis.Otherswerenormal.01PersonnelHistory:Smoking30years,10-20/Day;Nodrinking.02MaritalHistoryandFamilyHistory:normal.03PhysicalExamination(PE):Temperature36.6℃Pulse82bpmRespiration20timesperminuteBP14.5/8.5KPa.Consciousness;skinandscleraarenotxanthochromia;bulbarconjunctivaispale;superficiallymphnodesarenotpalpated;heartandlungsarenormal…Totalabdomenissoftwithouttenderness,reboundtendernessandmusculartension.Therearenomasspalpatedintotalabdomen.Splashingsoundisnegative.Liverandspleenarenotpalpated.Murphysignisnegative.Bothlowerlimbsarenotswollen.PhysicalExamination(PE):0102sthemostpossiblediagnosisofthispatient?methodsshouldbedonetoverifythediagnosis?rethesurgeryindicationsforgastriculcer?surgeryshouldbeperformedforthispatientandwhy?3214Questions:Examinationbeforeadmission:Gastroscopy(1):Gastricfundushasenormousulcerousneoplasmwithcloudymuscus.Andperipheralmucosaisnodelikescabrosity.Thequalityisbrittle.Lesioninvolved2/3circleofcardia.MorecoffeesecretionisseeninMuscusLake.The1.2×1.5cmulcerous

neoplasmsareineachofgastricantrum,greatercurvatureandposteriorwall…Gastroscopy(2):

TheyarewithmuscusandperipheralmucosaishyperemicAndredswollen.Andtheyareeasilyhemorrhaged.Lesionledcavityofgastricantrumtodeformation,strictureandpylorustomalformed,poorswitch.Examinationbeforeadmission:

PreoperativeExams:BariummealExam:Gastricantrumisstricture,anditboundwithgastricwallclearly.Mucosalplicaeofgastricantrumaredisruptionandflat.Itcanbeseenobviousfillingdefectanddouble-egdedsign.Bariumpasseditslowly.Result:Occupationlesioningastricantrum.

Whatpreparationsshouldbedone0102preoperatively?Pathologicexam:Gastricantrumandfunduspoordifferentiatedadenocarcinoma(moresigner-ringcellcarcinoma)BloodRoutine:RBC3.25×1012/L,Hb106g/L,plt237×109/L,WBC5.91×109/L,N%64.6%,LY%29.9%Examinationbeforeadmission:PreoperativeExams:Biochemistry:ALT52IU/L(5-55)AST37IU/L(5-46)A/A0.71Alb33.9g/L(35-55)A/G1.73(1.2-2.5)

GLU5.00mmol/L(3.9-5.9)GGT4IU/L(6-46)

CK34IU/L(19-226)

Na142.8mmol/L(135-145)K3.81mmol/L(3.5-5.0)

Cl107.2mmol/L(100-110)Ca2.04mmol/L(2.1-2.7)Bloodcoagulationtest:PT12.0Sec(11.0-14.8)APTT32.0Sec(30.0-45.0)

FIB3.46g/L(2.0-4.0)

Tumormarker:CEA43.52ng/ml(0-3.4)PreoperativeExams:PreoperativeExams:RoutinetestofPretransfusion:NegativeECG:NormalB-ultrasound:NegativeLungsfunction:NormalPreoperativeExams:ChestRadiography:Thoraxpresentbarrel-shaped,thickeningoflungs’shadowincreased;lungstextureincreased,roughanddisorganization;incongruousshadowinbothlungs.Result:1.Bilaterallungschronicbronchitis,pulmonaryemphysemachanging,middlefield-lateralbandofrightlunghascalcificshadow;2.Shadowofheartisnormal.1243RoutineofSurgeryNursing;Fasting;Gastrointestinaldecompression;UsingOfloxacinandMetronidazole.1234PreoperativeTreatments:discovery?HowtodescribetheoperativeOperationinAug18thIntra-operativeFinding(1):peritoneumandpelvicflooraresmoothandnon-tubercles.Thereareafewbuffascitesinabdominalcavity;01andmesenteryoflargeandsmallbowelsdon’thaveenlargedlymphnodes…Liverdoesn’thavemetastasis.Spleenisnormal.Duodenum02Intra-operativeFinding(2):5×5×4cmmassinprepylorusareaofgastricantrum,andserosaisinvolved.Themassismobile.Thecaputpancreaticisn’tinfiltrated.Superiorandinfra-pyloruslymphnodesenlarged…Andanother5×5×5cmmassispalpatedinlessercurvatureofgastriccardia.Serosaisinvolved.Leftgastricwallandesophagusaren’tinfiltrated.Leftandrightpylorusandlessercurvatureofgastricbodylymphnodesareenlarged.Intra-operativeFinding(3):ResectedspecimenItcanbeseenthatbloodvesselsofgastric

antrumwallandpylorusanteriorlayerinanatomicalspecimenhavebeenthicken.Thecentralhave3×3×1cmulcer.Itpenetratedtotallayersandinvolvedserosa.Separatinglymphnodesfromlowerpylorus…

The5×5×5cmmassinlessercurvatureofgastriccardiainvolvedtotallayersandserosa.Another4×4×1.5cmulcerouscarcinomaisinpylorus.Lessercurvaturelymphnodesisfusionandenhanced.Andleftandrightparacardialymphnodesareenhanced.03EsophagojejunostomyRoux-en-Y;02RadicalTotalGastrectomy;01OperationType:04Precolonicanastomosis.01Howtodealwiththepatient02postoperatively?Long-termcomplicationsaftergastrectomy1.Recurrentpepticulceration2.dumpingsyndromeCause:therapidemptyingofgastriccontentsisassociatedwiththedumpingsyndrome.High-carbohydratemealstendtoworsenthesymptomsThissyndrome,appearingaftermeals,ischaracterizedbytachycardia,diaphoresis/sweat,hypotension,andabdominalmpain,doesnotincludediarrhea.1Earlydumping---foodpassesrapidlyintothesmallbowel,thecontentsproduceanosmoticgradientwhichdrawsalargevolumeoffluidintothebowelfromthebloodstream----transienthypovolaemia2Latedumping---alargebolusofcarbohydrate-richfoodintothesmallbowelprovokesasteepriseinbloodglucoseconcentration;thisprovokesanexcessiveinsulinresponse,followedbyreboundhypoglycaemia.Oftenmoreseverethanearlydumping.WeightlossIrondeficiencyanaemia---duetoreducedironabsorptionVitaminB12deficiency---duetolossofgastricintrinsicfactor---maypresentasmacrocyticanaemiaOsteomalacia---duetomalabsorptionofbothcalciumandvitaminD23413.Malabsorption4.BilerefluxgastritisBRGcanoccurwhenpylorusablationisassociatedwithbilestasisinthestomach.BRGcanalsooccurwithgastrojejunostomy,whenbileiscontinuallypouredintothegastricremant.TreatmentMedicine/orrevisingtheBillrothanatomytoaRoux-en-Ygastrojejunostomyasthelastchoice0102PostgastrectomygastricremnantcancerTheoperationmostcommonlyassociatedwiththiscomplicationisBillroth-Iiprocedure5.PostgastrectomycancerPostvagotomycomplicationsRecurrentpepticulcerationRecurrentrate:3-10%GastrectomyDysphagiaOccurancerate:10-15%RecoveryspontaneouslyGastricdecompression3.GastricretentionDevascularizationofthelessercurvatureRequiringexploration,debridement,andclosuretheperforation4.GastricischemicperforationWateryinnatureTendstobeworseimmediatelyaftertheoperationandimproveswithtimeAntidiarrhealpreparationstolessenthesymptomsOctreotidehassomebenifit32145.DiarrheaEarlygastriccanceroccurspredominantlyinthedistalstomach.Earlygastriccancerisdefinedasdiseaseinvolvingthemucosaorsubmucosawithorwithoutlymphnode