<Chief
Complain> The 48-year-old
man was admitted on April 4, 2001 because of shortness of
breath for one day and recurrent VT transferred from local
hospital.
<Brief
History> This 48 year-old
man had history of hypertension without regular medical
control. He suffered from sudden onset of chest tightness,
shortness of breath and cold sweating on March 3, 2001. He was
sent to a local hospital where ECG revealed ST segment
elevation over V2-V5. Elevated cardiac enzyme was also noticed
(CK: 3227, CK-MB: 112, LDH: 3406). He was admitted to CCU
under the impression of AMI, anterior wall, Killip II. No
thrombolytic therapy was given because the golden hour passed.
The cardiac enzyme returned to normal value gradually under IV
NTG and heparin treatment. However, recurrent wide QRS-complex
tachycardia developed despite antiarrhythmic agents including
lidocaine, amiodarone and procainamide use. He was then
transferred to our hospital on April 4,
2001.
Emergent
coronary angiography revealed CAD, 1-V-D. PTCA to LAD was
performed smoothly. Recurrent VT happened during ICU stay
despite adjustment of anti-arrhythmic agent. An episode of Vf
with consciousness loss occurred on April 20, 2001. EP study
on the same day revealed multiple(more than 6) sustained
monomorphic VTs and no SVT. Procainamide was prescribed and
intermittent DC shock was performed. He was intubated again on
April 22 because of acute lung edema. Heart transplantation
was suggested for frequent VT and poor cardiac reserve.
On June 4, 2001
morning, he complained of right side chest pain. No cold
sweating, dyspnea or fever was noted. Local tenderness over
right chest and right upper quadrant were also found. Chest
X-ray did not reveal new pulmonary lesion. The pain was
migratory and shifted to right lower quadrant in the
afternoon. His appetite was as usual though no stool passage
for two days.
On examination, the
abdomen was soft. Bowel sound was hypoactive. RLL tenderness
was noted. No rebound tenderness or peritoneal sign was found
at that time.
The results of
laboratory and radiographic studies were as following:
1.CBC/DC:
|
WBC |
RBC |
Hb |
Hct |
PLT |
|
/ul |
M/ul |
G/dL |
% |
K/ul |
90-05-29 |
9520 |
3.35 |
10.1 |
30.9 |
361 |
90-06-01 |
11140 |
3.6 |
10.6 |
33.4 |
417 |
90-06-04 |
21930 |
3.95 |
12.0 |
36.0 |
489 |
90-06-06 |
19010 |
3.02 |
9.0 |
2.6 |
329 |
2.BCS+e
|
BUN |
Cre |
Na |
K |
Cl |
Amyla |
Lipas |
GOT |
T-Bil |
|
Mg/dL |
Mg/dL |
mmol/L |
Mmol/L |
Mmol/L |
U/L |
U/L |
U/L |
mg/dL |
90-05-29 |
24.4 |
1.52 |
132.3 |
3.78 |
106 |
|
|
|
|
90-06-01 |
22.3 |
1.37 |
132.5 |
4.02 |
101 |
|
|
|
|
90-06-04 |
|
|
131.4 |
3.72 |
|
|
|
|
|
90-06-05 |
28.2 |
2.17 |
130.3 |
4.1 |
99 |
59 |
16 |
30 |
0.85 |
3. Abdominal CT
scan: <Figur1,Figure2>
<病案討論> 本病人因反覆性心室速動(Ventricular
Tachycardia)入院接受治療。病人最近罹患前壁急性心肌梗塞,Killip
II,經心導管檢查,發現為左前降枝冠心症(CAD,1-V-D,LAD),雖經冠狀動脈擴張術,病人仍復發心室速動,並曾併發心室顫動(ventricular
fibrillation),接受氣管插管及電擊治療。病人同時接受多種抗心率不整藥物治療,包括:amiodarone、phenytoin、lidocaine等,並準備接受接受心臟移植。
病人於加護病房治療期間出現右側胸痛,疼痛並轉移至右上腹部及右下腹部,此外病人長期即患有慢性便秘問題。身體檢查發現病人體溫升高,右上及右下腹部輕微壓痛,莫非氏徵候(Murphy’s
sign)不明顯,但並無反彈性壓痛或腹膜炎徵候。
血液檢查發現白血球增高,肝功檢查:GOT及Bil-T正常,Amylase及Lipase亦正常。因懷疑腹腔內感染存在,故安排腹部超音波檢查,發現膽囊壁雖未水腫增厚(3mm),但膽囊明顯擴大,而且病患出現輕微超音波下的莫非氏徵候,因此安排腹部電腦斷層檢查。檢查結果發現,膽囊明顯擴大,同時附近軟組織有發炎現象(dirty
fat
plane around the gall bladder),並未發現膽結石。因此診斷為「無結石性膽囊炎」(acalculous
cholecystitis),病人接受開刀治療,施行膽囊切除術。術中發現為壞死性膽囊炎(gangrenous
cholecystitis with
empyema)。手術採全身麻醉進行,術中並未發生心室過速或顫動狀況,術後病患復原狀況良好,感染徵候消失。病理檢查發現膽囊壁已出現壞死性變化(gangrenous
change)。
|