消化系統(tǒng)疾病30胃腸道中英文12a校abdominal effusion unterer

ClinicofSmallAnimalLudwigilianUniversityofAbdominaleffusionHeart,liverorneosia?StefanUntererDiplomateECVIMClinicofSmallAnimalLudwigilianUniversityofOverviewabdominal腹部滲出的綜Recognition Classification Pathophysiology病理生理problem-orientedapproach問題導(dǎo)向式方symptomatictherapy對(duì)癥治識(shí)historyofabdominaldistention腹部膨脹的病DD:organomegaly,tumor,adipositas,distendedbladder,pregnancy, 胱擴(kuò)張，懷孕，physicalexamination體格檢severeeffusionundulationmildeffusion:?slippery“feelingonoftennot識(shí)-rays:lossof DD:tumor,peritonitiswithouteffusion,鑒別診斷：腫瘤，無滲出的腹膜炎，惡病ltraybestmethodtoidentifyeffusionsmallamountstendtoaccumulate少量的滲出易積聚在局craniallyto 頭betweenliverlobes肝葉之識(shí) edcasesstandingpatient,lineaalba,umbilicalrelativelysafecomplicationsrare)并發(fā)癥（很少見bleedingduetocoagulopathybleedingduetoorgan iatrogenicinfection醫(yī) Initialdiagnostic初步診斷步firstheartmurmur,arrhythmia,muffledheartsounds,congestedjugularveinsright-心雜音，心率不齊，心音不清，頸靜脈充右心衰Jaundiceliver肝衰，膽管破裂或阻Initialdiagnostic初步診斷步firstFeverinfl toryLymphadenopathy 病malignantInitialdiagnostic初步診斷步effusion ysisforTransudate漏出modifiedFoto:Prof.J.Foto:Prof.J.Blood血Chyle乳糜Urine尿Bile膽分 漏出 滲出protein(g/dl)spec.grav. nucleatedcell

<<<mesothelial間皮細(xì)

2,5–1.015-1000-hocytes混雜淋

>>>中性粒細(xì)病理生理decreasedoncoticpressure increasedhydrostaticpressureportal pre-post-

bloodflow!血液流increasedvascularpermeabilitydecreasedlymphaticdrainage淋 Blood

分manyeffusionsseembloody(e.g.許多滲出物是帶血的（如滲出液PCVusually<5

PCV通常PCV>10%(oratleast?ofperipheralPCV>10%（或者至少達(dá)到1/4的外周血液distinguishingiatrogeniccontamination?fresh“bloodbyiatrogenicorganaspiration分Chylemilky,cloudytriglycerideseffusion>Urineyelloweffusioncreatinine/potassiumeffusion>肌酐/鉀Bilecogniac-colouredeffusionCasesignalement特GermanShepherdDog5months5maleintacthistory病

Casewithownersince6weeks主人飼養(yǎng)6picky weight lethargicforafewdistendedabdomenforafewCasephysicalexamination體格檢QARrectaltemp.38.2°C直腸溫度HR80bpm心率pinkmucousmembranesRR28/minCachecticundulatingabdomenCaseinitial n ysisabdominalultrasound腹部BthoracicradsCaseinitial n ysisabdominalultrasound腹部BthoracicradsCasefluid ysismacroscopic:slightlyred,clearprotein:1.4g/dl1.4spec. ：nucleatedcellcount:200cells/μlcytologylowcellularitymixedcellularmpopulation,erythrocytes,mesothelialcells,lymphocytes,non-degeneratedneutrophils 的中性粒細(xì)胞混Caseinterpretation:puretransudate歸類：?jiǎn)渭兊穆┏鰈owcellularity,lowproteinApre-hepaticportalhypertensionA：肝前性門脈高disturbeddrainagefromportalveins門脈系統(tǒng)紊connectionportalveinwithartery(hepaticarteryportovenousfistula)門靜脈與動(dòng)脈（肝動(dòng)脈-門靜脈瘺BhypalbuminemiaB：低蛋白血Casepre-hepaticportalhypertension肝前門靜脈高disturbeddrainagefromportalconnectionbetweenportalveinand n漏出液的診斷計(jì)nextalbumin-/totalproteinmeasurement白蛋白-/總蛋白計(jì)albuminmajorcomponentofoncotic白蛋白是膠體滲透壓的主要成albumin<1.5 effusion白蛋白<1.5 滲albumindecreased,but>1.5白蛋白下降，但1.5hypalbuminemiaprobablynotsolereasonforfurtherdiagnostictests n漏出液的診斷計(jì)Hpalbuineiarenalloss?urinedipstick;better:UP/C尿液試紙條；最好是尿蛋白/肌酐比dipstickinprecise:dilutedurine尿液試紙 確：稀釋尿液UP/C>1consistentwithincreased尿蛋白/肌酐1提示丟失增UP/Cmostly>5,ifsignificant尿蛋白/肌酐>5提示明顯的蛋白 n漏出液的診斷計(jì)Hypalbuminemia低蛋白血decreasedproduction?liverenzymeactivities;better:bile檢測(cè)肝酶活性；最好是膽汁酸測(cè)liverenzymeactivitieswithsign.liverdiseasenotalwayselevated(livercirrhosis,neosia,chronic肝酶活性是一個(gè)指標(biāo)，一些肝臟疾病并不能很好地被評(píng)（肝硬化，腫瘤，慢性肝炎post-prandialbileacidsmoresensitivethan餐后膽汁酸測(cè)試比禁食下測(cè)試更敏 n漏出液的診斷計(jì)Hpalbuineiaintestinalloss?excludeliverandkidneys;better:intestinal排除肝臟腎臟原因；最好做腸道活組織檢noeasylabtestforprotein-loosing(α1-antitrypsinonlyin對(duì)于蛋白丟失性腸病沒有簡(jiǎn)易 檢測(cè)方法（只 有抗胰蛋白酶endoscopicbiopsiesmostly大多數(shù)情況下內(nèi)窺鏡活檢是足夠 n漏出液的診斷計(jì)Hypalbuminemia低蛋白血othercausesrarelyleadtosevereVasculitis Malnourishmentreferencex5.5–7.45–0.35–x150–x5–x0.04–x1–x0–segmentedx3–x0–x0–reference0-16-0-AP00-0-cholines2280-0-0-0-0-refrence90–0-bile0–3.1–0.27–48–25–3.3–32–3.33–0-referenceP0.71–99-143-K3.9–total2.4–11-0.7–UrineUrinereferencecollection收集方--5.5-+--------+-spec.1.015–Erys2–Caseabdominalultrasound腹部Bliverappearsverysmall,ratherlivermarginsappearirregularbecauseofsevereeffusiononlycautiousCaseHypalbuminemiaportalhypertensionhypalbuminemiapresent,butdoesnotex severeabdominaleffusioneffusionhypalbuminemiaandportalhypertensionCasediagnosis:juvenilelivercirrhosisModifiedcharactriedslightlyhigherproteincontent(>2.5lowcell蛋白質(zhì)含量更高一些2.5?mostcommoncauseformod.引 的常見原congestiveright-sidedheartfailure充血性右心衰liverdisease肝臟疾 siaModified?ed=cllen deuy tmn.apositive

頸靜脈陽性搏siitolaf頸靜脈反射陽dtModifiedpericardialmuffledheartsounds心音不?poundingpulses脈搏沉?rounded“onthoracicrads胸片上心臟呈圓ECGelectricalternans電交ModifiedpericardialModifiedpericardialModifiedtricuspid systolicheartmurmur心臟收縮期雜loudestonrightthorax聽診右側(cè)心音definitivediagnosiswithecho確診需要超tricuspid閉鎖不rightatrium右心房擴(kuò)dilatedliver肝靜脈擴(kuò)Modifiedtricuspid systolicheartmurmur心臟收縮期雜loudestonrightthorax聽診右側(cè)心音definitivediagnosiswithecho確診需要超tricuspid閉鎖不rightatrium右心房擴(kuò)dilatedliver肝靜脈擴(kuò)ModifiedCardiomyopathysoftheartsounds心音疲poss.systolicheartmurmur有時(shí)會(huì)有收縮期雜weakpulses脈搏poss.enlargedheartshapeonthoracic有時(shí)在胸部放射片上會(huì)顯示心影增definitivediagnosiswithecho確診需心臟超enlargedventricularandatrialdimensions心房、心室diminishedcontractility收縮力下Modifiedliverintra-hepaticportalhypertensioncompressionofliversinusoids pronetoeffusionbysaltandwater(activationofrenin-tensine-aldosterone水鹽潴留也可能形成滲（腎素-血管緊張素-醛固酮系統(tǒng)的激活Modifiedliverifposthepaticportalhypertension(esp.byheartfailure)excludedascauseformod.transudate&liverenzymeactivity/functionparameters如果是肝后門靜脈高壓（如心衰）造成性指標(biāo)可能正hepatic

，肝酶ModifiedliverCAUTION:注eveninpost-hepaticcongestion(e.g.right-sidedheartfailure)liverenzymeacitivitiescanbeincreaseddueto即使是肝后性阻塞（如右心衰竭）病例中，肝酶活性也可能會(huì)為缺氧而升fordefinitivediagnosis,therapy,andprognosisliverbiopsy肝臟活檢對(duì)于確診、治療、預(yù)后判斷都很重ModifiedNeo siaafterexclusionpost-hepaticportalhypertensionliver在排除了肝后門靜脈高壓和肝臟疾病之occult siamost隱蔽的腫瘤可能性最obstructionofcapillaries堵塞毛細(xì)血secondary tion炎癥繼ModifiedNeo siainmostpatientsno sticcellson大部分病例中，細(xì)胞學(xué)檢查時(shí)看不到腫瘤細(xì)reactivemesothelialcellscouldbeconfused sticcellsCAUTION!反應(yīng)性間皮細(xì)胞可能與腫瘤細(xì) 注意ultrasoundusefulforidentificationofabdominal B超對(duì)于識(shí)別腹部腫瘤很有advanceddiagnosticimaging:CT,Modifiednodiagnosisafterinitialdiagnosticlaparotomy+biopsies(liver,mesentery,lymphnodes,GItract,anyabnormaltissue)活組織檢查（肝臟，腸系膜， ，胃腸道，任何腹腔組織+measureportalvein測(cè)量門靜脈壓+mesentericvenoportogramclassification

滲出highproteincontent(>2.5蛋白含量高2.5highnuclearcellcount(>7000有核細(xì)胞數(shù)量多7000neutrophilseffusion>滲出液中的中性粒細(xì)胞>血液中initialdecision初步定Septic敗血滲出septiceffusion敗血癥性滲細(xì)mostlyneutrophils主要是中性細(xì) intracellularbacteria胞內(nèi)細(xì)CAUTIONpatientsrecieving接受抗生素治療的患lessneutrophils中性粒細(xì)胞減-oronlymildlydegenerated沒有或僅輕度的細(xì)bacteria滲出septiceffusion敗血癥性滲perforatedGItract胃腸道穿foreign 異hematogenicdissemination血液散rupturedintraabdominalabscess腹腔內(nèi)膿腫破Iatrogenic醫(yī)源septic敗血癥性滲出需要開腹