13岁男孩间断性腹痛腹胀伴乏力和大量腹水

Intermittent abdominal pain and abdominal distension with fatigue and massive ascites in a 13-year-old boy

摘要:

患儿男性，13岁，因间断腹痛1年伴大量腹水入院。入院后结核菌素试验检查示（3+），腹水检查呈黄色，有核细胞数634×109/L，多核0.178，单核0.822，蛋白定性阳性，为渗出液，考虑结核感染。经异烟肼和利福平联合抗结核感染及对症支持治疗后症状未缓解。腹部平扫及增强CT检查提示病变位于横结肠左侧管壁，腹膜不均匀增厚，强化呈不均匀性；肠镜病理活检提示黏膜内见印戒样细胞，免疫组化标记提示Syn（-），CgA（-），CD56（-），CK（pan）（+），CDX-2（+），CK20（+），Muc-1（+），Ki-67（+，约80%）；PET-CT提示横结肠近脾曲团块状氟脱氧葡萄糖（FDG）代谢异常增高，标准摄取值（SUV）最大值9.9，为高活性病变，结合病史符合恶性肿瘤代谢改变。转外科手术诊治，术中探查：大量腹水，肿块位于结肠肝区，侵及浆膜至组织周围，质硬，肠腔狭窄，肠系膜上血管周围及胃结肠韧带可及多枚肿大淋巴结，大网膜、腹壁、盆腔见多发转移结节。术后病理与结肠镜活检病理结果一致：横结肠低分化黏液腺癌，部分为印戒细胞癌。综上，患儿诊断为结肠印戒细胞癌伴腹膜转移、结核感染。因此，当患儿出现顽固性腹痛、不明原因的肠梗阻、大量难治性腹水等情况时，应警惕恶性肿瘤的可能，及早行腹部CT平扫加增强检查，必要时行肠镜检查。

Abstract:

A 13-year-old boy was admitted due to intermittent abdominal pain for one year with massive ascites. The purifed protein derivative (PPD) test after admission yielded positive results (3+), and ascites examination revealed a yellow color. There were 634×10⁹ nucleated cells/L in the ascites, among which 82.2% were mononuclear cells and 17.8% were multinuclear cells. The Rivalta test yielded a positive result and revealed that the ascites was exudate, suggesting the possibility of tuberculosis infection. The symptoms were not relieved after isoniazid-rifampicin antituberculosis therapy and symptomatic/supportive treatment. Plain CT scan of the abdomen and contrast-enhanced CT showed that the lesion was located at the left wall of the transverse colon, with uneven thickening of the peritoneum and heterogeneous enhancement. Colonoscopic biopsy found signet ring cells in the mucosa and immunohistochemical examination revealed Syn (-), CgA (-), CD56 (-), CK(pan) (+), CDX-2 (+), CK20 (+), Muc-1 (+) and Ki-67 (+, about 80%). PET-CT scan showed an abnormal increase in fluorodeoxyglucose metabolism, which was shown as a mass near the splenic flexure of the transverse colon, with a maximum standard uptake value of 9.9, indicating a highly active lesion; this was consistent with the metabolic changes of malignant tumors. Surgical operation was performed and intraoperative exploration revealed massive ascites, a hard mass located at the hepatic flexure of the colon, involvement of the serous coat and surrounding tissues, stenosis of the bowel, lymph node enlargement around the superior mesenteric vessels and the gastrocolic ligament, and multiple metastatic nodules in the greater omentum, the abdominal wall and the pelvic cavity. The results of postoperative pathology were consistent with those of colonoscopic biopsy, i.e., poorly differentiated mucinous adenocarcinoma of the transverse colon and partly signet-ring cell carcinoma. Therefore, the boy was diagnosed with colon signet-ring cell carcinoma with peritoneal metastasis and tuberculosis infection. When a child is suffering from intractable abdominal pain, unexplained intestinal obstruction and massive intractable ascites, the possibility of malignancy should be considered. Abdominal plain CT scan as well as contrast-enhanced CT scan should be performed as early as possible, and enteroscopy should be performed when necessary.