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临床病例讨论——腹胀、腹水、腹膜后囊肿、多发骨质破坏

2014-06-26 雷静静, 刘琦, 李屹, 曹贤, 周力 中华内科杂志

患者男,57岁。因“腹胀1个月,双下肢水肿1 d”于2011年11月25日入院。患者1个月前无明显诱因出现腹部胀满不适,无腹痛,无呕血、黑便,自服多潘立酮疗效不显,腹胀呈进行性加重,以“腹胀 原因待查”收入院。自发病以来患者精神、饮食、睡眠欠佳,大小便无异常,体重无明显增减。既往慢性咳嗽、咯痰5年余,以冬季较重,否认糖尿病史。个人史: 吸烟38年,40支/d,饮酒38年,300~350

患者男,57岁。因“腹胀1个月,双下肢水肿1 d”于2011年11月25日入院。患者1个月前无明显诱因出现腹部胀满不适,无腹痛,无呕血、黑便,自服多潘立酮疗效不显,腹胀呈进行性加重,以“腹胀 原因待查”收入院。自发病以来患者精神、饮食、睡眠欠佳,大小便无异常,体重无明显增减。既往慢性咳嗽、咯痰5年余,以冬季较重,否认糖尿病史。个人史: 吸烟38年,40支/d,饮酒38年,300~350 g/d(折合为乙醇的量)。婚育史无特殊。入院体检:体温37.2℃,脉搏82次/min,呼吸20次/min,血压130/90 mmHg(1 mmHg=0.133 kPa);体形消瘦,慢性病容,全身皮肤黏膜色泽正常,未见肝掌、蜘蛛痣;桶状胸,双肺叩诊呈过清音;腹膨隆,未见腹壁静脉曲张,全腹无压痛、反跳痛,肌 张力增强,移动性浊音(+);脊柱四肢无畸形,活动可,双下肢水肿;神经系统检查未见阳性体征。血常规:WBC 6.21×109/L,中性粒细胞0.68,RBC 4.52×1012/L,Hb 139 g/L,PLT 475×109/L; 血生化:血清总蛋白61 g/L,白蛋白34 g/L,球蛋白27 g/L,胆红素和转氨酶正常,血糖5.68 mmol/L,尿素氮3.6 mmol/L,肌酐68.5 μmol/L,钙2.0 mmol/L,钾3.0 mmol/L,血淀粉酶762 U/L,前白蛋白131 mg/L,胆碱酯酶4 871 U/L;ESR 76 mm/1h。免疫固定电泳:类弹性蛋白(ELP) 阴性,IgG 阴性,IgA阴性,IgM阴性,κ轻链阴性,λ轻链阴性。抗核抗体、抗平滑肌抗体、抗中性粒细胞胞浆抗体、抗线粒体抗体、抗可溶性抗原(ENA)多肽抗体 谱、类风湿因子均阴性。甲状腺功能测定正常。尿常规、粪常规正常。尿淀粉酶1 050 U/L。PPD试验呈弱阳性。入院后抽腹水3次,其中2次查腹水常规:黄色、混浊,蛋白(+~++),有凝块,细胞总数分别为2.30×109/L和1.43×109/L,有核细胞计数分别为380×106/L和540×106/L(单 个核细胞分别占80%和82%);2次腹水生化检查:蛋白分别为37 g/L和36 g/L,葡萄糖分别为6.40 mmol/L和5.58 mmol/L,乳酸脱氢酶分别为175 U/L和203 U/L;3次腹水淀粉酶均升高,依次为7 796、5 827和3 781 U/L;3次腹水抗酸杆菌、革兰染色和脱落细胞检查均阴性,血清和腹水腺苷脱氨酶(ADA)、甲胎蛋白和癌胚抗原测定均正常;腹水肿瘤标志物:铁蛋 白>3 630 pmol/L、CA125> 600 kU/L、CA19-9 为214 kU/L;血清肿瘤标志物:铁蛋白2 360 pmol/L、CA125 为232 kU/L、CA19-9为20 kU/L,均增高。胃镜提示慢性非萎缩性胃炎。头部和胸腹部CT检查示(图1,2):(1)颅骨、胸腰骶椎体及肋骨、左侧髂骨多发骨质破坏,考虑骨转移瘤,骨髓瘤不除外;(2)腹膜后囊实性占位,胰腺假性囊肿?肿瘤?;(3)肝左叶病变,转移瘤?;(4)右肺中叶局限不张,右侧胸腔少量积液,腹腔、盆腔 大量积液,腹膜增厚,考虑转移;(5)右肾结石。骨髓穿刺细胞学检查未见异常。

于2011年12月8日就患者多浆膜腔积液和多发骨质破坏原因行全院讨论。

原始出处:
雷静静,刘琦,李屹,曹贤,周力. 临床病例讨论第434例——腹胀、腹水、腹膜后囊肿、多发骨质破坏[J]. 中华内科杂志, 2014, 53(5): 422-424.
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    2014-06-28 qindq
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    2014-06-28 Eleven17
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    2014-06-28 xuyong530

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