膿(nong)(nong)(nong)(nong)液積聚在(zai)一(yi)側或兩(liang)(liang)側的(de)(de)(de)(de)膈(ge)(ge)(ge)肌(ji)下(xia)(xia)、橫結腸及其系膜的(de)(de)(de)(de)間隙(xi)內者,通稱膈(ge)(ge)(ge)下(xia)(xia)膿(nong)(nong)(nong)(nong)腫(zhong)。膈(ge)(ge)(ge)下(xia)(xia)膿(nong)(nong)(nong)(nong)腫(zhong)可發生(sheng)在(zai)一(yi)個或兩(liang)(liang)個以上的(de)(de)(de)(de)間隙(xi)。其常(chang)繼發于(yu)臟器(qi)穿(chuan)(chuan)孔(kong)、炎(yan)(yan)(yan)癥等腹(fu)(fu)(fu)膜炎(yan)(yan)(yan)的(de)(de)(de)(de)并發癥。患者發生(sheng)膈(ge)(ge)(ge)下(xia)(xia)膿(nong)(nong)(nong)(nong)腫(zhong)時,應(ying)及時治(zhi)(zhi)療(liao),治(zhi)(zhi)療(liao)效(xiao)果好。急性(xing)腹(fu)(fu)(fu)膜炎(yan)(yan)(yan)或腹(fu)(fu)(fu)腔內臟器(qi)的(de)(de)(de)(de)炎(yan)(yan)(yan)性(xing)疾(ji)病經治(zhi)(zhi)療(liao)好轉后(hou)(hou),或腹(fu)(fu)(fu)部(bu)手術(shu)數日后(hou)(hou)出現發熱、腹(fu)(fu)(fu)痛者,均應(ying)想到本病,并作(zuo)進(jin)一(yi)步(bu)檢(jian)查。X線透(tou)視可見(jian)患側膈(ge)(ge)(ge)肌(ji)升高,隨(sui)呼吸(xi)活(huo)動(dong)度受限或消失,肋膈(ge)(ge)(ge)角模糊,積液。X線片顯示(shi)胸膜反應(ying)、胸腔積液、肺下(xia)(xia)葉部(bu)分不(bu)張等;膈(ge)(ge)(ge)下(xia)(xia)可見(jian)占位陰(yin)影。左(zuo)膈(ge)(ge)(ge)下(xia)(xia)膿(nong)(nong)(nong)(nong)腫(zhong),胃底可受壓下(xia)(xia)降移位;膿(nong)(nong)(nong)(nong)腫(zhong)含氣(qi)者可有(you)液氣(qi)平面。B超檢(jian)查或CT檢(jian)查對膈(ge)(ge)(ge)下(xia)(xia)膿(nong)(nong)(nong)(nong)腫(zhong)的(de)(de)(de)(de)診斷(duan)及鑒別診斷(duan)幫(bang)助(zhu)(zhu)較(jiao)大。特(te)別是(shi)在(zai)B超指引下(xia)(xia)行診斷(duan)性(xing)穿(chuan)(chuan)刺(ci),不(bu)僅可幫(bang)助(zhu)(zhu)定性(xing)診斷(duan),而且對于(yu)小的(de)(de)(de)(de)膿(nong)(nong)(nong)(nong)腫(zhong)可在(zai)吸(xi)膿(nong)(nong)(nong)(nong)后(hou)(hou)注入抗生(sheng)素進(jin)行治(zhi)(zhi)療(liao)。需(xu)要提出的(de)(de)(de)(de)是(shi),穿(chuan)(chuan)刺(ci)陰(yin)性(xing)者不(bu)能排除(chu)有(you)膿(nong)(nong)(nong)(nong)腫(zhong)的(de)(de)(de)(de)可能。
膈(ge)下(xia)(xia)膿(nong)腫(zhong)一旦形(xing)成,可(ke)出現(xian)明顯的(de)全身及局部癥狀(zhuang)。具體表(biao)現(xian):1、全身癥狀(zhuang):發(fa)熱(re),初為弛張熱(re),膿(nong)腫(zhong)形(xing)成以后持(chi)續高熱(re),也可(ke)為中等程度的(de)持(chi)續發(fa)熱(re)。脈率(lv)增(zeng)(zeng)快(kuai),舌苔厚膩。逐漸(jian)出現(xian)乏力、衰弱、盜汗、厭食、消(xiao)瘦(shou)、白(bai)細胞計數升高、中性粒細胞比(bi)例(li)增(zeng)(zeng)加;2、局部癥狀(zhuang):膿(nong)腫(zhong)部位(wei)可(ke)有(you)(you)持(chi)續鈍痛(tong),深呼吸時(shi)加重。疼痛(tong)常位(wei)于(yu)近中線的(de)肋緣下(xia)(xia)或(huo)(huo)劍突(tu)下(xia)(xia)。膿(nong)腫(zhong)位(wei)于(yu)肝下(xia)(xia)靠(kao)后方可(ke)有(you)(you)腎區痛(tong),有(you)(you)時(shi)可(ke)牽涉到肩、頸部。膿(nong)腫(zhong)刺激膈(ge)肌(ji)可(ke)引起呃逆。膈(ge)下(xia)(xia)感染可(ke)通過淋(lin)巴系統(tong)引起胸(xiong)(xiong)(xiong)膜、肺反應(ying),出現(xian)胸(xiong)(xiong)(xiong)水、咳嗽、胸(xiong)(xiong)(xiong)痛(tong)。膿(nong)腫(zhong)穿破到胸(xiong)(xiong)(xiong)腔發(fa)生(sheng)膿(nong)胸(xiong)(xiong)(xiong)。近年由于(yu)大量應(ying)用(yong)抗生(sheng)素,局部癥狀(zhuang)多不典型。嚴重時(shi)出現(xian)局部皮膚凹陷(xian)性水腫(zhong),皮膚溫度升高。患側胸(xiong)(xiong)(xiong)部下(xia)(xia)方呼吸音減(jian)弱或(huo)(huo)消(xiao)失醫`學教育網搜集整理。右(you)膈(ge)下(xia)(xia)膿(nong)腫(zhong)可(ke)使肝濁(zhuo)音界擴大。約有(you)(you)10%-25%的(de)膿(nong)腔內含有(you)(you)氣體。
膈(ge)(ge)(ge)下(xia)(xia)(xia)膿(nong)(nong)腫(zhong)(zhong)的(de)(de)病(bing)(bing)理(li)特點(dian)為:病(bing)(bing)人平臥時膈(ge)(ge)(ge)下(xia)(xia)(xia)部位最低,急(ji)性(xing)腹(fu)膜(mo)炎(yan)(yan)(yan)時腹(fu)腔(qiang)內的(de)(de)膿(nong)(nong)液(ye)易(yi)積(ji)聚此處。細菌亦可(ke)(ke)由門靜脈(mo)和淋(lin)巴系統到達(da)膈(ge)(ge)(ge)下(xia)(xia)(xia)。約70%急(ji)性(xing)腹(fu)膜(mo)炎(yan)(yan)(yan)的(de)(de)病(bing)(bing)人經手術或(huo)藥物治(zhi)療(liao)后(hou),腹(fu)腔(qiang)內的(de)(de)膿(nong)(nong)液(ye)可(ke)(ke)被完全吸(xi)(xi)收;30%的(de)(de)病(bing)(bing)人發生局限性(xing)膿(nong)(nong)腫(zhong)(zhong)。膿(nong)(nong)腫(zhong)(zhong)的(de)(de)位置與原發病(bing)(bing)有關。十(shi)二指(zhi)腸潰瘍(yang)穿孔、膽管化膿(nong)(nong)性(xing)疾病(bing)(bing)、闌尾(wei)炎(yan)(yan)(yan)穿孔,膿(nong)(nong)液(ye)常(chang)發生在右膈(ge)(ge)(ge)下(xia)(xia)(xia);胃(wei)穿孔、脾切除術后(hou)感(gan)染,膿(nong)(nong)腫(zhong)(zhong)常(chang)發生在左膈(ge)(ge)(ge)下(xia)(xia)(xia)。小的(de)(de)膈(ge)(ge)(ge)下(xia)(xia)(xia)膿(nong)(nong)腫(zhong)(zhong)經非(fei)手術治(zhi)療(liao)可(ke)(ke)被吸(xi)(xi)收。較大(da)的(de)(de)膿(nong)(nong)腫(zhong)(zhong),可(ke)(ke)因長期感(gan)染使身體消耗以至衰竭,死亡率甚(shen)高。膈(ge)(ge)(ge)下(xia)(xia)(xia)感(gan)染可(ke)(ke)引(yin)起反(fan)應性(xing)胸腔(qiang)積(ji)液(ye),或(huo)經淋(lin)巴途(tu)徑蔓延到胸腔(qiang)引(yin)起胸膜(mo)炎(yan)(yan)(yan);亦可(ke)(ke)穿入(ru)胸腔(qiang)引(yin)起膿(nong)(nong)胸;個別的(de)(de)可(ke)(ke)穿透結腸形成內瘺而(er)(er)“自(zi)家”引(yin)流;也有因膿(nong)(nong)腫(zhong)(zhong)腐蝕消化道管壁而(er)(er)引(yin)起消化道反(fan)復出血(xue)(xue)、腸瘺或(huo)胃(wei)瘺者(zhe)。如病(bing)(bing)人的(de)(de)身體抵抗力(li)低下(xia)(xia)(xia),就可(ke)(ke)能發生膿(nong)(nong)毒(du)血(xue)(xue)癥。
在(zai)治(zhi)(zhi)療(liao)(liao)方面,切(qie)開引(yin)流(liu)排膿是外(wai)科(ke)治(zhi)(zhi)療(liao)(liao)的基本原則。同(tong)時可采用(yong)(yong)中(zhong)醫中(zhong)藥(yao)、理療(liao)(liao)等治(zhi)(zhi)療(liao)(liao)加強治(zhi)(zhi)療(liao)(liao)效果。早期膿腫尚未(wei)形成,應采用(yong)(yong)非手術治(zhi)(zhi)療(liao)(liao),以抗(kang)生素和中(zhong)藥(yao)控制感染為主(zhu);晚期膿腫已經形成,除個別采用(yong)(yong)穿刺抽膿,膿腔內注入(ru)抗(kang)生素并服中(zhong)藥(yao)外(wai),絕大多數病例應手術切(qie)開引(yin)流(liu)。如治(zhi)(zhi)療(liao)(liao)延誤,膿腫可能會穿破至腹腔、胸(xiong)腔或結(jie)腸等。