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本期为普外科疾病的开篇第一讲，普外科(Department of General Surgery)因此手术为重要法子医治肝脏、胆道、胰腺、胃肠、肛肠、血管疾病、甲状腺和乳房的肿瘤及外伤等其它疾病的临床学科，是外科体系最大的专科。本期重要会商急性胰腺炎和阑尾炎这两种常见急腹症。
急性胰腺炎是多种病因致使胰酶在胰腺内被激活后引发胰腺组织本身消化、水肿、出血乃至坏死的炎症反响。临床以急性上腹痛、恶心、吐逆、发烧和血胰酶增高档为特色。
急性阑尾炎是外科常见疾病，居各类急腹症的首位。转移性右下腹痛及阑尾点压痛、反跳痛为其常见临床表示，可是急性阑尾炎的病情变革多端。多为延续伴阵发性加重的右下腹痛、恶心、吐逆，大都病人白细胞和嗜中性粒细胞计数增高。右下腹阑尾区（麦氏点）压痛，则是该病首要体征。
案例阐发
Case 1：A 50-year-old HIV-positive man presents to his primary care physician with a 1-day history of nausea and vomiting. He also has severe epigastric pain radiating to the back. Review of the patient’s medical history reveals that he is taking the reverse transcriptase inhibitor didanosine. Laboratory testing reveals at amylase level five times higher than normal and a lipase level six times than normal.
案例1：50岁AIDS患者主诉恶心吐逆1天，同时伴随紧张背部放射痛。患者今朝正在服用地达诺新医治，实行室查抄显示淀粉酶高于正常值5倍，脂肪酶高于正常6倍。
1. What is the most likely diagnosis?
Acute pancreatitis.
急性胰腺炎
诊断特色：中上腹痛苦悲伤+腰背部放射痛+血尿淀粉酶/脂肪酶显著升高
2. What are the top three conditions to consider in the differential diagnosis?
a. Cholelithiasis: refers to the presence of gallstones in the gallbladder that can obstruct the cystic duct. This obstruction can lead to biliary colic (more prolonged, constant pain due to infla妹妹ation of the gallbladder)
b. Intestinal obstruction: often presents with abdominal pain, nausea, and vomiting but also with changes in bowel habits.
c. Acute coronary syndrome: should be considered in patients 50 years of age or older with abdominal pain and associated risk factors.
重要辨别诊断（腹痛辨别）
a. 胆石症：有结石病史，胆绞痛特色（短期内频频呈现，与进食油腻食品相干），向肩背部放射
b. 肠阻塞：有腹痛、恶心吐逆，多伴随排便习气扭转
c. 急性冠脉综合征：多见于50岁以上，有血汗管伤害身分，多为雷同胃疼表示
3. Why
is this condition more co妹妹on in patients with HIV infection?
Patients with HIV and/or AIDS are susceptible to infection with organism such as cytomegalovirus, and cryptosporidium, all of which can cause pancreatitis.
引发缘由：HIV传染者常见大小胞病毒、隐胞子菌传染，都可引发胰腺炎；HIV医治药物如地达诺新也能引发急性胰腺炎（题干中患者有服用）。
4. What is the appropriate treatment for this condition?
Most cases (85-90%) are self-limited and resolve within 4-7 days of the start of treatment. Typical treatment for acute pancreatitis includes avoiding oral intake, aggressive intravenous fluid resuscitation, pain control, and possibly nasogastric tube placement to decrease gastric secretions in the stomach. Antibiotics are not reco妹妹ended in uncomplicated pancreatitis but may be of use in severe, necrotizing pancreatitis.
医治办法：此类胰腺炎多为自限性，或医治4-7天可以治愈。经典医治包含禁食、大量补液、止痛、鼻饲管以削减胃酸排泄。抗生素除紧张坏死型胰腺炎外一般
不举荐利用。
Case 2: A 25-year-old woman presents to her physician with a 3-day history of crampy abdominal pain that started in the epigastrium. She also reports nausea, low-grade fever and loss of appetite. She denies changes in urination or bowel habits, dysuria, or recent sick contacts. Her last menstrual period was 2 weeks ago. Relevant laboratory findings are as follows:
WBC count: 13,000/妹妹3
β-HCG: negative
Urinalysis: Negative for blood, WBCs, leukocyte esterase, and protein
案例2：25岁女性主诉3天上腹部痉挛样痛苦悲伤，同时伴随吐逆、低热和纳差。否定排尿及排便习气扭转，无少尿或近期与病患接触史。末次月经为2周之前，实行室查抄：
白细胞13,000/妹妹3, β-HCG阴性，尿检无异样
1. What is the most likely diagnosis?
Appendicitis
急性阑尾炎
诊断：右下腹压痛反跳痛+吐逆低热+血白细胞升高，其他查抄一般无异样。
2. What other conditions should be considered in the differential diagnosis of a 25-year-old female with abdominal pain?
a. Genitourinary: ruptured
Graafian follicle, ectopic pregnancy, pelvic infla妹妹atory disease, and ovarian torsion
b. Gastrointestinal: Crohn disease, peptic ulcer
c. Renal: Urinary tract infection, cystitis
重要辨别诊断：
a. 生殖体系：异位怀胎（尿检可解除），卵泡决裂、卵巢囊肿蒂改变（急性爆发、激烈痛苦悲伤）
b. 消化体系：克隆病（排便习气扭转可解除）、胃溃疡（多有病史）
c. 泌尿体系：泌尿体系传染（多有尿路传染特性、尿通例异样），膀胱炎
3. What is the pathophysiology of this condition?
Obstruction is often implicated as the cause of appendicitis but is not required for disease progression. The appendiceal lumen may become obstructed by a fecalith, mucosal secretions, lymphoid hyperplasia or an infection process resulting in a distended appendix, elevated intraluminal pressure, and subsequent arterial insufficiency and tissue death.
病理心理表示：阻塞是最多见诱因，多见于粪石、粘性排泄物、淋凑趣增生；其次是传染，致使阑尾扩大、腔内压力升高，终极至供血不足、组织坏死。
4. What is the appropriate treatment for this condition?
Surgery is the preferred treatment, along with supportive intravenous fluids and empiric antibiotics (in case of rupture). The gold standard for diagnosis is CT scan of the abdomen with contrast.
医治：手术医治首选。辅以补液和履历性抗生素医治（避免阑尾决裂），诊断金尺度为腹部CT扫描。（下图可见阑尾结石致密影）
辞汇鳞爪
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