祸不单行:为何肝脓肿“青睐”糖尿病患者?

2018-05-28 闵红杰 江苏省人民医院感染病科 江苏省人民医院感染病科

肝脓肿是细菌、真菌等病原体侵入肝脏引起的化脓性感染。若不积极治疗,可以引起败血症、感染性休克,甚至脓肿破入腹腔引起腹膜炎,病死率可高达10%~30%。

导读:患者,女,56岁,因持续高热伴后背疼痛就诊于当地医院,给予抗感染治疗一周,体温无下降,并逐渐出现乏力、纳差、恶心、呕吐等症状,因病情加重到我院就诊,经过详细询问病史,血液、CT、B超等细致检查,发现血白细胞明显升高、肝功异常、血糖明显升高,肝脏上有低回声/低密度病灶存在。既往糖尿病史3年。最终确诊为肝脓肿、糖尿病,经过积极抗感染及对症、穿刺引流等综合治疗,患者病情逐渐控制,体温恢复正常,脓肿缩小。

什么是肝脓肿?

肝脓肿是细菌、真菌等病原体侵入肝脏引起的化脓性感染。若不积极治疗,可以引起败血症、感染性休克,甚至脓肿破入腹腔引起腹膜炎,病死率可高达10%~30%。

细菌性肝脓肿有哪些表现?

细菌性肝脓肿多无典型临床表现,急性炎症期常被原发病所掩盖。本病一般起病较急,由于肝脏血运丰富,一旦发生化脓性感染后,大量毒素进入血循环,引起全身脓毒性反应。主要临床表现如下:

1.寒战和高热:多为最早症状,也是最常见的症状。病人在发病初期骤感寒战,继而高热,发热多呈弛张型,体温在38~40℃,最高可达41℃,往往伴大量出汗,脉率增快,一天可数次,反复发作。

2.肝区疼痛:炎症引起肝脏肿大,导致肝包膜急性膨胀,肝区出现持续性钝痛。出现的时间可在其他症状出现之前或之后发生,亦可与其他症状同时出现。疼痛剧烈者常提示单发性脓肿。脓肿早期为持续钝痛,后期常为锐利剧痛。随呼吸加重者常提示肝膈顶部脓肿。有时疼痛可向右肩放射,左肝脓肿也可向左肩放射。

3.乏力、食欲不振、恶心和呕吐:由于伴有全身性毒性反应及持续消耗,乏力、食欲差、恶心和呕吐等消化道症状较为常见。少数病人在短期内表现精神萎靡等较严重病态,也有少数病人出现腹泻、腹胀或较顽固性的呃逆等症状。

4.体征:肝区压痛和肝大最常见;右下胸部和肝区有叩击痛;有时出现右侧反应性胸膜炎或胸腔积液;如脓肿位于肝表面,其相应部位的肋间皮肤呈红肿、饱满、触痛及凹陷性水肿;如脓肿位于右下部,常见有右季肋部或右上腹部饱满,甚至可见局限性隆起,常能触及肿大的肝脏或波动性肿块,并有明显的触痛和腹肌紧张等;左肝脓肿时,上述体征则局限在剑突下。晚期病人可出现腹水,这可能是由于门静脉炎以及周围脓肿的压迫影响门静脉循环及肝功能受损伤以及长期消耗致营养不良和低蛋白所致。继发于胆道梗阻的病人,都伴有黄疸。其他原因的化脓性肝脓肿,一旦出现黄疸,则表示病情严重,预后不良。

以上为典型的肝脓肿表现,需要指出的是,由于目前诊疗技术的进步,抗菌药物的早期应用,上述典型表现已不多见。

为什么糖尿病患者易得肝脓肿?

糖尿病是引发细菌性感染的重要危险因素之一,这与糖尿病患者自身免疫力低下、高血糖促进细菌生长繁殖以及糖尿病患者多有肾脏、神经、心脏和肝脏等脏器功能损害有关。研究发现长期高血糖,使吞噬细胞的趋化作用、吞噬作用以及杀菌功能受损。糖尿病患者合并细菌性肝脓肿,因其常合并血管和神经病变,机体疼痛敏感性下降,局部症状、体征不典型,加之多伴有其他系统疾患,易掩盖细菌性肝脓肿病情,早期容易漏诊。对持续发热久治不缓解者应警惕细菌性肝脓肿,行腹部超声检查。糖尿病并发肝脓肿的患者治疗应有效控制血糖,防止继发感染。对于体积较大、脓腔液化、凝血功能正常、心功能可耐受穿刺的患者应及时行肝脓肿穿刺置管引流术,同时选择针对性的抗菌药物进行治疗控制感染。

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    2018-06-12 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

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    2018-05-30 hunizi009
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    2018-05-28 131****1460

    学习了受益匪浅

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