迫在眉睫的膽囊破裂的紅旗

12評論

Ultrasound and subtle lab findings may convince you to admit that patient with RUQ pain.

一世當您的居民詢問她是否可以向您提出案例時,T的另一個忙碌的一天。患者是一名49歲的女性,為腹痛呈現給ed。患者說,三天前,她突然出現了一係列的曇花一現,大約一個小時的糟糕是糟糕的,然後逐漸得到了大約三個小時。今天它重複,但更嚴重,10分,10分,並輻射到右上象限。它已經存在超過10個小時,並不更好。她說她嘔吐一次,並沒有寒意,但不認為她發燒了。她大約一個小時前服用了布洛芬的痛苦,並指出它並沒有真正幫助。她否認了任何其他投訴。

對於她的體力考試,您的居民票據“穩定”生命體征雖然久經飛機隻采取一次。脈衝是97,血壓為93/61,呼吸為22,溫度為98.9。她被描述為肥胖的右上象限的溫柔和一個正墨菲的標誌,但不是其他積極的發現。


廣告

在分類中的PA在一個半個小時半前訂購了實驗室,它們已經導致並顯示了以下內容:WBC 5.7,血紅蛋白12.3,化學和LFTS全麵限製。您的居民為您帶來了以下圖像,她用自己的床位超聲圖保存。她告訴你她的計劃,“這看起來像沒有真正的紅旗的簡單膽結石。我們可以用氫化氫化酮送她的家,並安排正式的超聲波和外科谘詢作為門診?“

問:您是否簽署了居民的管理計劃?圖像顯示什麼?


廣告

不要在這個計劃上簽字!在我們到達圖像之前,這裏有多個紅旗。首先,疼痛的持續時間:持續超過六小時的推定膽道疼痛是膽囊炎,直到依據否則,所以在此表明正式的成像(參見更多臨床珍珠和陷阱的EM 1分鍾谘詢膽囊炎)。第二個紅旗是生命體征:97的脈衝在100歲以下,但在高端的高端和93/61的血壓可能在49歲的肥胖女性中,93/61的血壓可能在9/10的49歲的肥胖女性中可能不正常疼痛,22的呼吸也不是98.9的溫度,在布洛芬可能代表發燒後的每小時,特別是在患有寒冷的患者中。

第三個紅旗是體檢:一個正墨菲的標誌是考試發現,這已在膽囊炎,而不是膽道絞痛中描述。

更多的:


廣告

實驗室正在令人放心,但是你注意到沒有報告差異?這個患者實際上有22條樂隊。如果訂購一個,請始終等待差異的結果。正常的白數通常是放心,但在可能的感染的設置中,差異包括嚴重的敗血症。重要的是要意識到沒有單一的實驗室值優於50%對膽囊炎敏感,而且不常見的所有實驗室都是正常的。

The images show two transabdominal views of the gallbladder. The first shows a large gallstone with posterior shadowing that is possibly impacted in the gallbladder neck. To the right side of the image, near the gallbladder fundus, there is also shadowing but no evidence of stones. This could be due to an air collection from gallbladder rupture (see labeled ultrasound below). The second image above focuses on this area and shows a non-descript area with shadowing that is probably free air, consistent with a perforated gallbladder from cholecystitis.

外科谘詢要求提供確認的CT掃描(如下所示)。注意尖皺的液,還有流體收集到後肝和右腎的側向,以及自由空氣前和內側到膽囊。

患者接受了IV氨苄青黴素/蘇溝抗腸,並急於於手術室。幸運的是,她做得很好,隨後在術後手術診所,而不是在膿血休克或升上的膽管炎診所。


珍珠和陷阱:膽囊和魯克超聲波

  1. 了解您的限製:超聲可能有助於澄清通過徹底曆史和體檢引發的結果。正確使用時,它可以大大提高診斷準確性和幫助指導患者管理,特別是對於不穩定患者的時間關鍵診斷和治療。它還可以減少CT掃描的使用,從而最小化輻射曝光。但是,您需要考慮您的技能水平並了解您的局限性。當不確定時,命令正式的學習。如果您的部門擁有ED專用超聲機,它應考慮實施ED管理和放射學批準的質量改進計劃。
  2. 找到膽囊:在左側躺在患者並通過定位下肝邊緣可以幫助。
  3. 超聲墨菲的標誌:要檢查超聲靜脈炎的超聲波墨跡的標誌,請將超聲探頭放在右上象限的最大溫柔點。如果探頭在膽囊眼底上放置直接壓力,你有一個積極的超聲墨菲的標誌。如果患者在考試前接受鴉片劑,可能會偶爾發生錯誤的否定。
  4. 膽囊牆:膽囊炎的一個跡象是一個加厚的膽囊牆。正常的膽囊壁可以高達3mm厚。膽囊炎可能導致膽囊壁增厚的最常見條件包括肝炎,低惡蛋白血症,腫瘤,增生性膽囊增生症,腺瘤菌症和CHF。在沒有腹水的情況下,存在終生液體,也支持急性膽囊炎的診斷。如果存在臨床不確定性,則可以進行核膽掃描(HIDA或DESIDA掃描)。
  5. 常見的膽管:擴張的常見膽管是急性膽囊炎的另一個跡象。正常的膽總管內徑應小於4mm,但可能更高,高達10mm,後膽囊切除術。此外,老年患者的直徑可能更高,每年壽命達1毫米。
  6. 膽囊內容:尋找一個擴張膽囊,石頭的證據, and for sludge. Gallstones should be mobile, unless they are impacted in the gallbladder neck, and should cast an acoustic shadow. If all stones are mobile in a patient who remains symptomatic, consider that they may be a red herring and not the true cause of the patient’s pain. Remember that approximately 15% of adults have asymptomatic gallstones. If there are no sonographic signs of cholecystitis, but a gallstone is impacted (non-mobile) in the gallbladder neck, be suspicious for early cholecystitis and consider admission, additional imaging, or at least next-day follow-up. Always also consider early cholecystitis when pain lasts for more than six hours, even when the ultrasound is normal except for the presence of a stone. Uncomplicated gallstone attacks usually should only last a few hours. Make sure to explain this to patients if you for some reason decide to send them home with opiates. Attacks lasting longer than that may be something more serious.
  7. Pitfalls:不要錯過隱藏在膽囊頸部的一個障礙膽結石。它有時會很難看到。此外,不要被偶然的“紅鯡魚”膽結石偽造出來。如前所述,許多人有多年的膽結石,無症狀,所以如果一切都不臨床,那麼看看別人導致腹部,側翼或肋骨疼痛。一些實例包括主動脈瘤,Fitz-hugh-curtis綜合征,高闌尾炎,Pe,腎結石和肺炎。最後,不要錯過一個AAA,即使它也是偶然的,因為你沒有尋找它。超聲波技術看。主動脈並不是那麼遙遠,應該在50歲以上的任何人常規檢查腹部超聲的任何人。篩選拯救生命!

關於作者

緊急超聲部分編輯器Pregerson博士管理免費在線EM超聲圖像庫。他是緊急醫學的作者1分鍾谘詢Pocketbook和A到Z口袋應急藥典和抗生素指南(可提供Emresource.org.)和Tarascon急救部門快速參考指南(tarascon.com.)。

12評論

  1. 琳達補助金on

    一世have had upper right quadrant pain on and off for years.
    the past year its been bad, but not always when I eat, it can start just with excise, or movements.
    我在自己旁邊,我在9/22/17中的貓掃描也是一個超聲,8/2018的MRI展示了膽囊最小的擴張。疼痛幾乎就像一個痙攣從3到10到10。然後離開並回來。
    一世also had a gallbladder empty study which they said was ok……Any suggestions? I am desperate

  2. 一世had pain basically below the breast bone varying levels of pain and not related to eating. Varying levels of pain extending to the right and earlier in the piece to the left just below the ribs and finally in my back on the right side where the right lung would be. I had this pain for 12 months and was treated for IBS which my symptoms did not support.

    除去膽囊,最初在不能被移除的膽管中的石頭,但似乎根據後續血液測試的結果看起來是自我的。

    No more chronic and repeated pain.. Seems that the US an CT can’t see the issue but after I receive pathology results this week I am going to request a re-read of the CT so that the doctors learn and can hopefully pinpoint the issue for other patients.

  3. Amber Henleyon

    一世have ha gallbladder stones for over three months now. I only found out two months ago, because I had been having chronic diarrhea everyday for a month. And had 5-8 episodes that day. My abdomen was super tight, and my liver enzymes were elivated.
    所以他們做了超聲波,看到了石頭和汙泥。他們承認了我,讓我液體過夜,然後放棄了我,告訴我我應該找到一個外科醫生。

    我終於找到了一個,從那以後一直到了呃,因為我的右上腹疼痛讓我哭泣,但他們隻是一直說它隻是石頭,而且我應該看看器官被刪除。

    一世’ve been having servere pain, chills and diarrhea daily. I feel a stabbing pain under my ribs that runs down my right flank burning, and even got so disoriented, I almost fell and fainted several times at the doctor’s.. I’m scared, and my appointment isn’t for 11 days to even get examined for surgery. I also have a MRSA skin infection that my doctor’s refuse to treat for over a year. I don’t know what to do.
    有小費嗎?我的膽囊可以泄漏嗎?

    • 我讀這個嗎?你的醫生不會對待你的MRSA?你需要一位新醫生。他們為你工作,而不是另外一輪!

    • Hi AMBER, you MUST read “The Liver and Gallbladder Miracle Cleanse” by ANDREAS MORITZ / the title literally speaks for itself, and the REVELATION will amaze you I’m sure, like it has for me. Started reading the book end-2019; and started my journey January 2020 – I do very much recommend reading the book for yourself, and not rely on 2nd hand download. There are many “testimonies ” on the internet; sure I’ve listened, but one will find the exact information in this book. I can chat about this all day long…

  4. 如果有的話,您對消化係統的對消化係統有何影響,如果有的話?
    不是醫生,但已被告知我確實有石頭,這是在無關的脊椎MRI上撿到的。
    My right side in tender to touch right below rib.

  5. 一世have had chronic diarrhea for around 7 months now. Some days I got 2-3 times and other 10 times . I got into my gi dr but it was when this whole COVID thing started and non emergent procedures were cancelled. One day I started having pains in my chest that keep coming back. I went to the Ed when it went on for about 2 hours because I have a history of coronary artery disease and it scared me. They ran all kinds of tests and had a stress test that all were fine. Pains have continued. My gi did an endoscopy scope down into my stomach with no findings. I had a gall bladder ultrasound with no findings except a possible kidney issue. Gi decided to try me on nitroglycerin to see if it is esophageal spasms but that is not working either. I feel tired all the time and still have pain. Family history of gallbladder disease. I don’t know what I should do. I’m in pain while writing this.

  6. Sylviane Bloss.on

    一世’m veryyy discouraged at the medical care in emergency rooms I’m 69 and finally went to ER for after five days constant on and off upper right side,, had no fever, blood pressure 135/83,, no chills just horrible pain and nausea,, doctor never examined me, just ordered labs and ultrasound, comes back in room an hour later says allll is well,what the heck!! I asked him to please do catscan because I have brain tumor and was told several years ago I have a growth also on my liver, I explain to the doctor that my stools had turned yellow within a week that is not normal so I thought it was my gallbladder he insisted that it was not the gallbladder never said anything else they did the CAT scan and within 15 minutes they came in my room and told me I was fine,, they had the clipboard ready to zoom me out of the hospital room like I said I’m 69-year-old female with brain tumor and I have another tumor in my left long as well they treated me and shoved me out!! My son drove me home and I am still at home suffering not knowing what to do

  7. 凱倫埃文斯on

    善良的上帝謝天謝地,我不住在你們所有人都是我們的nhs絕對夢幻般的我的心來向你們所有人都祈禱我祈禱你們所有人都會很快放心你的痛苦xx

  8. 我是一個29歲的女性。一年前被診斷出患有膽結石,因為我在腹部的右上方疼痛真的很痛苦,所以我去緊急照顧,他們把我送到了聲像劇。所以我做了,他們發現了2個膽結石。幾個月後,我沒有與膽囊有關的任何疼痛,所以我認為手術可能不是必要的,因為我不再感到疼痛了。現在快進一個月前。我幾乎每天都在休息。感覺就像被困的氣體。有時它有時它有時它隻是一個不適。有些日子已經有一段時間了,但今天的日子我一整天都在休息。這是一個痛苦,我右邊乳房上方有更多的乳房,有時在我的右側腋窩附近。 I’m scared and don’t know if I should go to ER or just to see if it pain goes away. I don’t have fever or chills or vomiting. My stools have started to change color but I’m also on medication for H. Pylori so I don’t know if it could be that. I’m sick and tired of feeling this pain everyday and im afraid that my gallbladder will burst. What do you think I should do ?

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