Asian Case Reports in Oncology 亚洲肿瘤科病例报告, 2012, 1, 1-3 http://dx.doi.org/10.12677/acrpo.2012.11001 Published Online July 2012 (http://www.hanspub.org/journal/acrpo) Gigantic Appendiceal Mucocele: A Case Report and Analysis of Diagnosis and Treatment Zhanwei Wang, Pengfei Wang, Zengrong Jia, Xiuling Wu, Shaoliang Han* Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou Email: *slhan88@yahoo.com.cn Received: Jul. 4th, 2012; revised: Jul. 18th, 2012; accepted: Jul. 23rd, 2012 Abstract: A 63-year old female complained of right lower abdominal mass for 3 months, and she was admitted to hos- pital with a diagnosis colon tumor. On physical examination, an abdominal mass was found in her right quadrant, sized in 13 cm × 8 cm × 6 cm, hard, movable with clear margin. Laboratory examination revealed that Hb 12.4 g/L, CEA 5.4 μg/L, CA125 24.4 U/mL, CA153 U/mL and CA19-9 < 2.0 U/mL. A cord-like cystic mass in right abdominal cavity, primitive impression of gastrointestinal tumor, was detected by ultrasound examination, and CT scan demonstrated that a cystic occupation in right pelvic cavity, and exophytic tumor at cecum was found by fibrocolonoscopy. An exploratory laparotomy underwent by epidural anesthesia, a sausage-like tumor with size of 15 cm × 8 cm × 5 cm was seen at right abdominal cavity, and a diagnosis of appendiceal mucocele was made by intraoperative frozen pathological examination, then an appendectomy was performed, ad the patient recovered smoothly after operation and discharged on the 4th op- eration day. Keywords: Appendix; Mucocele; Surgery 巨大阑尾黏液囊肿:一例报道与诊疗分析 王战伟,王鹏飞,贾曾荣,吴秀玲,韩少良* 温州医学院附属第一医院普外科,温州 Email: *slhan88@yahoo.com.cn 收稿日期:2012 年7月4日;修回日期:2012 年7月18 日;录用日期:2012 年7月23 日 摘 要:患者女,63 岁,主诉右下腹部肿块3个月,门诊以结肠肿物收入院。查体在右下腹部触及13 cm × 8 cm × 6 cm 大小包块、质硬、活动、边界欠清。实验室检查:Hb 12.4 g/L、CEA 5.4 μg/L、CA125 24.4 U/mL、CA153 9.6 U/mL及CA19-9 < 2.0 U/mL。B超检查示下腹部条索状囊性包块(首先考虑肠道来源);腹部 CT扫描示盆腔 右侧囊性占位性病变;结肠镜检查示回盲部外压性肿物。连硬麻醉下行剖腹探查,术中见右下腹部有一个15 cm × 8 cm × 5 cm腊肠样囊性肿物。术中冰冻病理组织学检查诊断为阑尾黏液囊肿。故决定行阑尾切除术,术后第 4天痊愈出院。 关键词:阑尾;黏液囊肿;手术 1. 引言 女性,63 岁。主诉右下腹部肿块3个月,伴下腹 部隐痛,门诊以结肠肿物收入院。入院体检:一般情 况好,腹平坦,腹壁柔软,右下腹部触及约13 cm × 8 cm × 6 cm 大小包块、质硬、活动、轻压痛、无反跳 痛,边界欠清,麦氏点无压痛。实验室检查:Hb12.4 g/L、CEA5.4 μg/L、CA125 24.4 U/mL、CA153 9.6 U/mL 及CA19-9 < 2.0 U/mL。B超检查提示下腹部条索状囊 *通讯作者。 Copyright © 2012 Hanspub 1 巨大阑尾黏液囊肿:一例报道与诊疗分析 性包块(首先考虑肠道来源)(图1(a));腹部 CT 扫描提 示盆腔右侧囊性占位性病变(图1(b));电子纤维结肠 镜检查提示回盲部外压性肿物(图1(c))。 2011 年3月25日在连续硬脊膜外阻滞麻醉下行 剖腹探查,术中见右下腹部有一个腊肠样囊性肿物, 大小 15 cm × 8 cm × 5 cm,张力高,近端与盲肠壁相 延续,回盲部完整,结肠带消失于囊肿根部。术中冰 冻病理组织学检查见阑尾壁略带白色、其腔内充满白 色胶冻样物质,诊断为阑尾黏液囊肿(图1(d))。鉴于 上述探查,决定行阑尾切除术。术后病理检查报告为 阑尾黏液囊肿伴囊壁肉芽肿反应(图1(e))。患者于术 后第 4天痊愈出院,15个月后随访无异常。 2. 讨论 阑尾黏液囊肿是阑尾呈囊状扩张并腔内有黏液 积聚的一类少见疾病。本病病因尚不清楚,有学者认 为是由阑尾近端梗阻造成,也有认为本病是阑尾的新 生肿物[1-3]。本病在阑尾切除术中的发现率为 0.07%~ 0.3%[1,2],女性多见,男女比例为 1:3。主要症状和体 征有腹痛和腹部包块。本病诊断方法主要依靠超声检 查和 CT扫描,但在术前难以明确诊断。B超表现为 右下腹阑尾区边界清晰的椭圆形或囊袋状肿物,壁 薄、光滑或不光滑,多数呈椭圆形,腔内积满液性暗 区,内部无血流信号。CT 扫描示右侧髂窝区紧邻回 盲部的囊性病灶,呈圆形或椭圆形、或管状,囊壁光 整,厚薄均匀。可伴有点状、条状及弧形钙化,边界 清晰,内容物均为均匀水样密度。本病例影像学检查 符合上述表现。 本病应与下列疾病鉴别:1) 阑尾脓肿。临床症状 较典型,压痛明显,血白细胞计数增高。脓肿壁厚, 增强扫描可见明显环形强化,周围呈炎性浸润改变, 肠系膜脂肪密度增高或消失。2) 右侧卵巢囊肿。多发 生在子宫旁附件区,囊壁无钙化。3) 阑尾黏液性囊腺 癌。右下腹髂窝区不均质肿块,内有囊性低密度影, 边缘不规则,周围脂肪层模糊,可侵犯盲肠,增强扫 描肿块呈不均质强化,有时可见壁结节。 3. 结论 手术是治疗阑尾黏液囊肿的惟一方法,手术方式 选择应遵循 1) 如囊肿较小,位于阑尾中部或尖端, Figure 1. A cord-like cystic mass in right abdominal cavity, primitive impression of gastrointestinal tumor, was detected by ultrasound ex- amination (a); and CT scan demonstrated that a cystic occupation in right pelvic cavity (b); and Exophytic tumor at cecum was found by fibrocolonoscopy (c); A sausage-like tumor with size of 15 cm × 8 cm × 5 cm was found at right abdominal cavity (d); The postoperative di- agnosis was appendiceal mucocele with granulomatous tissue at wall (e) 图1. (a) B 超检查提示下腹部条索状囊性包块(箭头);(b) 腹部 CT 扫描提示盆腔右侧囊性占位性病变(箭头);(c) 电子纤维结肠镜检查提示 回盲部外压性肿物(箭头);(d) 术中见一个腊肠样囊性肿物,大小 15 cm × 8 cm × 5 cm,张力高;(e) 术后病理检查报告为阑尾黏液囊肿伴 囊壁肉芽肿反应 Copyright © 2012 Hanspub 2 巨大阑尾黏液囊肿:一例报道与诊疗分析 可行常规阑尾切除术,术后送病理检查;2) 囊肿较大, 但活动性较好,粘连轻者可行回盲部切除术;3) 囊肿 较大、粘连重或造成肠梗阻等并发症,应行右半结肠 切除术,不应强行分离粘连,以免导致囊肿破裂,引 起腹腔内种植;4) 对于术中确诊或怀疑恶变者,可行 快速冰冻病理检查,如果证实为恶性肿瘤,则行根治 性右半结肠切除术;5) 对于囊肿已破裂或分离时破 裂,有引起腹腔假性粘液瘤的可能,必须尽量清除腹 腔脏器表面黏附的胶冻物,关腹前可采用氟脲嘧啶冲 洗腹腔[1-3]。 参考文献 (References) [1] J. Long, F. Yang, C. Jin, et al. Mucocele of the appendix. Diges- tive Surgery, 2009, 26(2): 115-116. [2] M. Gentile, V. Guarino, F. Mosella, et al. Giant mucocele of the appendix. Case report and review of the literature. Annali Ital- iani Chirurgia, 2008, 79(4): 293-297. [3] M. Pitiakoudis, A. K. Tsaroucha, K. Mimidis, et al. Mucocele of the appendix: A report of five cases. Techniques in Coloproctol- ogy, 2004, 8(2): 109-112. Copyright © 2012 Hanspub 3 |