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A 41-year-old woman was admitted
because of epigastralgia and tea-colored urine for 4 days.
She was a housewife living in
Taipei without any known systemic diseases, such as
hypertension, diabetes, liver or renal diseases. No habit of
smoking, drinking and no recent travel history were noted. She
had born two children uneventfully.
She bothered from nausea and
progressive epigastric dull pain with soreness of back since 4
days ago. No obvious alleviating and aggravating factors were
noted. She visited a local clinic and the symptoms partially
relieved after medication. However, tea-colored urine was
noted 2 days later. Abnormal liver function (GOT: 136 IU/L,
GPT: 408 IU/L, Total bilirubin: 4.4 mg/dl) was noted at
another hospital. So she was transferred to ER for help.
At ER, her consciousness was clear
and oriented. The temperature was 38° C, pulse rate 75 bpm,
respiratory rate 18 per minutes and blood pressure 120/80
mmHg. The conjunctivae were not pale or injected and sclera
was icteric. Pupils were isocoric and throat was not injected.
The neck was supple without lymphadenopathy. The jugular veins
were not distended. Lung sounds were symmetric and clear.
Rapid heart beat without audible murmurs were observed.
Abdomen was soft, but mildly distended. Liver and spleen were
impalpable below the costal margin. Tenderness was detected
over the right upper quadrant. Bowel sounds were normoactive.
No knocking tenderness was observed at the flank. The
extremities were freely movable without pitting edema or
ecchymosis.
 Laboratory:
1. CBC and differential count:
| |
WBC |
RBC |
Hb |
Plt |
Hct |
MCV |
Band |
Neu |
Baso |
Eos |
Mon |
Lym |
| |
/μl |
M/μl |
g/dl |
K/μl |
% |
fL |
% |
% |
% |
% |
% |
% |
| ER |
15920 |
4.06 |
12.5 |
206 |
36.2 |
91.4 |
0.4 |
91.8 |
0.4 |
0 |
1.3 |
6.1 |
| Day1 |
8590 |
3.74 |
11.3 |
181 |
33.5 |
89.6 |
0 |
84.8 |
0.1 |
1.3 |
7.7 |
6.1 |
| Day3 |
6010 |
3.6 |
11.9 |
188 |
32.2 |
89.4 |
0 |
71.5 |
0.7 |
2 |
7 |
18.8 |
| Day7 |
5420 |
3.8 |
11.6 |
166 |
34.1 |
89.7 |
0 |
73.0 |
0.3 |
1.4 |
7.6 |
17.7 |
| Day9 |
5580 |
3.96 |
12.1 |
183 |
36.2 |
91.4 |
0 |
66.8 |
1.4 |
4.2 |
6.6 |
21 |
2. Biochemistry:
| |
A/G |
BilT/D |
ALP |
AST |
ALT |
r-GT |
BUN |
Cre |
Na |
K |
Ca |
|
|
g/dl |
mg/dl |
U/L |
U/L |
U/L |
U/L |
mg/dl |
mg/dl |
mM |
mM |
mM |
| ER |
|
5.7/3.0 |
341 |
190 |
374 |
182 |
6.2 |
0.7 |
140 |
4.7 |
2.23 |
| Day1 |
4.0/ |
4.7/3.6 |
310 |
220 |
434 |
216 |
7.2 |
0.7 |
|
|
|
| Day2 |
|
4.4/2.6 |
322 |
144 |
365 |
153 |
|
|
|
|
|
| Day3 |
4.0/ |
2.2/1.5 |
306 |
118 |
359 |
161 |
7.4 |
0.7 |
|
|
|
| Day7 |
3.4/ |
2.0/1.6 |
242 |
36 |
69 |
159 |
4.9 |
0.7 |
134 |
4.8 |
2.3 |
| Day9 |
|
1.2/1.0 |
238 |
22 |
49 |
152 |
|
|
|
|
|
| |
Amylase |
Lipase |
LDH |
TG |
Glucose |
| |
U/L |
U/L |
mg/dl |
mg/dl |
mg/dl |
| ER |
726 |
4029 |
|
|
|
| Day1 |
374 |
1588 |
256 |
117 |
89 |
| Day2 |
91 |
278 |
|
|
|
| Day3 |
<46 |
89 |
|
|
|
| Day7 |
<46 |
46 |
|
|
|
3. Urinalysis:
| |
Outlook |
PH |
Pro |
Sugar |
KB |
OB |
Bil |
Urobil |
RBC |
WBC |
Epi |
| ER |
Y,C |
6.0 |
- |
- |
- |
+/- |
2+ |
1.0 |
4-6 |
0-1 |
2-4 |
4. PT (ER): 12.4/12.8; PTT: 43.1/35.8
5. ABG: (Room air)
| |
PH |
PaCO2 |
PaO2 |
BE |
HCO3 |
SaO2 |
| ER |
7.4 |
35.3 |
108.1 |
-2.6 |
21.2 |
98.1% |
6. Blood culture (ER): Escherichia
coli (II/II)
7. Hepatitis markers: HBsAg (-); Anti-HBs (+); Anti-HCV (-)
Course and Treatment:
At ER,
empirical antibiotic treatment with cefoxitin 1gm IV q8h was
prescribed for possible biliary tree infection after blood
culture. Under the impression of acute pancreatitis, NPO with
iv fluid supplement and analgesia with meperidine were given.
Abdominal sonography (Figure 1)
and CT (Figure 2)
revealed GB stones and dilated biliary tree with distal CBD
stone. The pancreatic parenchyma was slightly heterogeneous
without surrounding fluid accumulation. The pain and fever
subsided gradually after treatment. She received endoscopic
retrograde cholangiopancreatography (ERCP) on day 3 and
several brown stones were extracted after endoscopic
papillectomy (EPT) (Figure
3
). Antibiotic was kept for 2 weeks because of
Escherichia coli sepsis. Patient was discharged later and
received laparoscopic cholecystectomy after 1 month.
病例分析:
本病例為一位中年女性產生上腹部疼痛多日，雖經就醫後症狀仍未改善，隨後出現黃疸及發燒現象，而轉來教學醫院急診處，經檢查發現有急性胰臟炎及膽道感染症，超音波及電腦斷層發現病患有膽囊結石及總膽管結石，造成阻塞性黃疸，並產生胰臟炎。對於膽道感染症給予適當的抗生素治療，並密切追蹤其效果及黃疸之變化，考量是否需作緊急之膽汁引流術。而胰臟炎之治療，在禁食及給予適當輸液下，並適時給予不影響Oddi括約肌的meperidine止痛，病患之症狀逐漸獲得改善，於第三日時接受內視鏡逆行性膽胰攝影術，發現有許多總膽管結石，經內視鏡乳頭切開術後，取出若干黃棕色膽道結石。病患術後不再有發燒及腹部疼痛現象，肝功能指數逐漸恢復正常，在完成兩週之抗生素療程後順利出院，一個月後病患順利接受腹腔鏡切除膽囊。
急性胰臟炎典型症狀為上腹部疼痛並有轉移至背部現象，疼痛可能在彎腰時才稍微緩解，劇烈時常合併嘔吐或腹脹現象。常見造成急性胰臟炎的原因有：酒精、膽管結石、高三酸甘油脂症、ERCP、藥物等等。多數的胰臟炎患者在支持性療法下，進食數日即可改善，但仍有少數重度胰臟炎會產生許多併發症，造成多重器官衰竭。
膽管結石是造成膽管炎之常見原因，膽管結石多發生在有膽囊結石之患者，其成分多為膽固醇或混合石，另外一類為色素結石，會發生在有慢性溶血疾病或有膽道異常疾病患者身上。膽管炎典型症狀為Charcot's
triad，包括發燒畏寒、右上腹痛及黃疸。非化膿性膽管炎在適當抗生素治療下可獲得改善，而化膿性膽管炎若無合併引流膽汁之適當治療，可能導致敗血症而死亡。因此密切觀察病人，一旦膽管炎無法以抗生素控制，必須以內視鏡方法自十二指腸乳頭作引流術或是經皮作膽管引流術，才可減少其死亡率。
因為膽囊結石仍有百分之十到十五的機會會掉到總膽管內，因此以內視鏡取出總膽管結石後，若病患膽囊內有結石時，可建議病患切除膽囊避免後患無窮。
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Case Discussion
繼續教育考題