病例：心塞！做个ERCP怎么阴囊都变大了？

2018-02-05 佚名医学界消化肝病频道

fuhua.W

四川大学华西医院研究员/ 助理研究员

ERCP一般指经内镜逆行性胰胆管造影

ERCP一般指经内镜逆行性胰胆管造影

病例介绍

患者，男，35岁，间歇性上腹痛伴巩膜黄染、小便发黄2月余，腹痛加重伴恶心、呕吐一天入院。

体格检查：心率110-120 次/分，皮肤巩膜黄染，体温及血压正常。右上腹压痛，无反跳痛及肌紧张。

实验室检查

TB：4.3 mg/dL (正常为 0–0.3 mg/dL) ；

ALP：372 IU/L (正常为 36–92 IU/L)；

腹部超声：胆囊内多发小结石，胆总管扩张（16 mm），胆总管末端可见结石。

诊疗经过

ERCP：导丝引导下胆总管插管并行括约肌切开，将结石取出并行胆道引流。

几小时后，患者出现阴囊疼痛、肿大，且向其腹部及大腿部放射。患者无发热，生命体征平稳。查体可见其阴囊是正常体积的3-4倍，表面皮肤无红斑或坏死，但触诊时阴囊及周围皮肤有捻发音。

阴囊超声检查示：阴囊内可见气体存在，无任何液体；腹平片示：阴囊软组织影增大，其内可见气体存在。

腹部及盆腔CT示：腹部及会阴部软组织可见广泛的皮下气肿，阴囊气肿、后腹膜气肿、纵隔气肿等。后腹膜气肿主要存在于十二指肠周围及右侧腹部，提示十二指肠穿孔；但未见渗出。

诊断为腹膜后十二指肠穿孔，密切观察患者病情并给予禁食、补液及抗生素等保守治疗，患者病情稳定，逐步改为流质饮食，患者可耐受，后症状改善出院。

讨论

ERCP是诊断和治疗胆胰管疾病的常用手段，其安全性高，并发症较少（发生率为5-10%）。ERCP的常见并发症为胰腺炎、出血、胆管炎、内脏穿孔等，其中内脏穿孔较为少见，发生率＜1%。ERCP所致的内脏穿孔多为十二指肠穿孔，可导致肠内气体及内容物漏入腹腔。

十二指肠穿孔是ERCP罕见却严重的并发症，其严重程度由穿孔的位置及类型决定。

医源性十二指肠穿孔分类

1.十二指肠内侧或外侧壁损伤穿孔；内镜对肠道的直接损伤，可致大量十二指肠内容物漏入腹腔，后果严重，常需早期手术干预治疗，诊断延迟可导致较高的死亡率。

2.十二指肠降部周围穿孔，常发生在内镜下乳头括约肌切开术术中；根据严重程度的不同可选择手术或保守治疗。

3.胆管远端穿孔，常发生在导丝或网篮插入时；这种穿孔常常很小，大多保守治疗即可。

4.由于微小穿孔导致气体漏入后腹膜，可保守治疗。

这个分类的顺序与疾病的严重程度密切相关，有助于预测患者是应早期手术干预还是保守治疗。

十二指肠穿孔有各种临床表现，可无症状或发生全腹性腹膜炎和脓毒症，常见症状为恶心、呕吐、发热、腹痛、腹胀等。少数情况下，十二指肠穿孔可因肠内气体漏入腹腔导致皮下气肿，极少数情况下可致阴囊气肿。

当空气漏入腹膜后间隙时，常向上通过膈肌裂孔引发纵膈气肿，也可沿筋膜平面及颈部皮下组织扩散，导致皮下气肿。少数情况下，进入腹膜后间隙的气体可沿筋膜平面下行至阴囊，导致阴囊气肿。

阴囊气肿较临床罕见，分为原发性及继发性两种。原发性阴囊气肿主要由阴囊壁或阴囊内容物产生的气体导致，继发性阴囊气肿是由其它部位产生的气体扩散至阴囊所致。此例患者即为因ERCP中发生十二指肠穿孔导致的继发性阴囊气肿。

专家点评

ERCP后穿孔首发症状为阴囊气肿，实为罕见。睾丸由腹膜后下降至阴囊时，腹膜随之下降，成为睾丸鞘膜。包绕睾丸副睾的鞘膜为鞘膜脏层，其外尚有一层为鞘膜壁层。随睾丸下降的鞘突则在出生后完全闭合成为条索状物。若鞘突完全未闭合，腹腔内液体（气体）可沿其未闭合的管腔流至睾丸固有鞘膜两层间，造成睾丸鞘膜积液（积气），一般鞘膜积液常见。此例十二指肠穿孔明确，因合并鞘未闭，过多的十二指肠气体由穿孔处到后腹膜，再下行至阴囊，造成阴囊积气。

该例患者穿孔处无渗出，考虑穿孔不大，但造成如此广泛的腹膜后积气和皮下气肿，应该与过度注气有关，为避免这种情况，操作中应少注气、使用CO2可能有帮助。

点评专家：

王林恒主任

◆北京中医药大学东方医院消化内镜诊疗中心主任兼消化内科副主任

◆北京中西医结合学会消化内镜学专业委员会副主任委员兼秘书长、青年委员会主任委员

◆北京医学会消化病学分会胰胆学组副组长

◆北京中西医结合肿瘤外科专业委员会常务委

◆中国中西医结合学会消化内镜学专业委员会秘书长

◆中国医师协会中西医结合医师分会消化病学专家委员会常委

◆中华医学会消化病学分会影像学组委员

◆中华医学会消化内镜学分会NOTES学组委员

◆ 擅长消化内镜微创治疗消化道疾病：出血、狭窄、异物、早癌等，尤其ERCP治疗胆胰疾病方面，颇具造诣

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2019-02-01 124dbf38m16暂无昵称

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2018-10-31 vera_1210

#阴囊#

36 0
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2018-02-10 天山医者

谢谢分享

57 0
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2018-02-10 天山医者

学习了

50 0
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2018-02-06 明月清辉

谢谢分享.学习了

48 0
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2018-02-06 龙胆草

学习谢谢分享

51 0
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2018-02-06 1dd8c52fm63(暂无匿称)

了解了解.学习学习

23 0
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2018-02-06 121832a9m88暂无昵称

了解了

28 0
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2018-02-06 秀红

了解了

24 0
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2018-02-06 yjs木玉

好好好好好好好好

26 0