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摘要: 目的 急腹症是急诊常见急症，延迟诊断，甚至误诊可能影响预后。本文通过回顾性分析重症急腹症延迟诊断情况，并分析原因，力图提高急诊医师对重症急腹症的诊治效率。方法 回顾性分析北京协和医院急诊抢救室2020年1月—2020年12月期间重症急腹症病例，采集患者一般资料，起病时间及诊疗情况等资料，比较及时诊断组与延迟诊断组差异。结果 纳入统计的4269例患者中，以重症急腹症及相关诊断入抢救室的患者248例，其中入室诊断与出室诊断不一致者46例(包括最终诊断不清6例)，入室后及时诊断者24例，延迟诊断者16例，延迟确诊疾病主要诊断为缺血性肠病7例，糖尿病酮症酸中毒(DKA)5例，急性心肌梗死4例。两组患者性别差异无统计学意义，及时诊断组年龄为(58.54±9.05)岁，延迟诊断组(67.44±10.22)岁，差异有统计学意义(P＜0.01)；与及时诊断组比较，延迟诊断组在糖尿病(OR=0.47，95%CI：027~0.80)，卧床(OR=0.117，95%CI：0.02~0.674)、年龄(OR=0.091，95%CI：0.02~0.41)，起病超过6 h(OR=15.4，95%CI：3.089~76.776)，夜间就诊(OR=0.152，95%CI：0.037~0.617)，首诊非三甲医院(OR=0.227，95%CI：0.059~0.882)，≥2个科室会诊(OR=5.343，95%CI：1.35~21.14)等方面差异有统计学意义；及时诊断24例中，错误的初始诊断包括消化道穿孔5例、急性胰腺炎5例、急性阑尾炎4例、肠梗阻4例、泌尿系结石3例、胆系感染3例，延迟诊断16例病例中，错误的初始诊断包括急性胰腺炎6例，急性胆囊炎4例，消化道穿孔2例，自发性腹膜炎2例，肠梗阻2例。结论 重症急腹症被延迟诊断的影响因素较多，与患者基本状态、就诊时机、就诊方式相关，缺血性肠病、DKA及急性心肌梗死为最常见的重症急腹症延迟诊断病因，应引起急诊医生的高度重视。Abstract: Objective Acute abdomen is a common emergency disease in emergency department. Delayed diagnosis and even misdiagnosis may affect prognosis. Our research attempts to improve the efficiency of emergency physicians in the diagnosis and treatment of severe acute abdomen by retrospectively analyzing the reasons of the delayed diagnosis.Methods From January 2020 to December 2020, the cases of severe acute abdomen in the emergency department of our hospital were retrospectively analyzed, the general data of patients, onset time and diagnosis and treatment were collected, and the differences between the timely diagnosis group and the delayed diagnosis group were compared.Results Among the 4269 patients included in the statistics, 248 patients were admitted to the emergency room with severe acute abdomen and related diagnoses, of which 46 patients were not consistent with the out of room diagnosis, and 6 patients were not diagnosed clearly. After admission, 24 cases were diagnosed in time, 16 cases were delayed in diagnosis. The main delayed diagnosis diseases were ischemic bowel disease (7 cases), diabetes ketoacidosis (DKA) (5 cases), and acute myocardial infarction (4 cases). There was no significant difference in gender between the two groups. In terms of average age, the timely diagnosis group was(58.54±9.05) years old, and the delayed diagnosis group was(67.44±10.22) years old, and the difference was significant(P < 0.01). Compared with the timely diagnosis group, the delayed diagnosis group had significant differences in diabetes(OR=0.158, 95%CI: 0.038-0.648), bedridden(OR=0.117, 95%CI: 0.02-0.674), age ≥ 65 years(OR=0.091, 95%CI: 0.02-0.41), onset time to visit > 6 hours(OR=15.4, 95%CI: 3.089-76.776), visit at night(OR=0.152, 95%CI: 0.037-0.617), first visit to non-tertiary hospitals(OR=0.227, 95%CI: 0.059-0.882), less than 2 departments consultation(OR=5.343, 95%CI: 1.35-21.14). Among the 24 cases diagnosed in time, the wrong initial diagnosis included 5 cases of gastrointestinal perforation, 5 cases of acute pancreatitis, 4 cases of acute appendicitis, 4 cases of intestinal obstruction, 3 cases of urinary calculi, and 3 cases of biliary infection. Among the 16 cases diagnosed late, the wrong initial diagnosis included 6 cases of acute pancreatitis, 4 cases of acute cholecystitis, 2 cases of gastrointestinal.Conclusion There were many factors of delayed diagnosis of severe acute abdomen, which are related to the patient's basic conditions, time of seeking medical treatment, and methods of medical treatment. Ischemic bowel disease, DKA and acute myocardial infarction were the most common causes of delayed diagnosis of severe acute abdomen. It should arouse the attention of emergency physicians.
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Key words:
- emergency /
- acute abdomen /
- delayed diagnosis /
- misdiagnosis
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表 1 比较患者一般资料及与诊断相关因素
例(%) 特征 及时诊断组 延迟诊断组 OR(95%CI) P 年龄/岁 58.54±9.05 67.44±10.22 0.006 女性 12(50.0) 9(56.3) 1.286(0.361~4.584) 0.698 糖尿病 5(20.8) 10(62.5) 0.158(0.038~0.648) 0.008 卧床 2(8.3) 7(43.8) 0.117(0.02~0.674) 0.009 年龄≥65岁 4(16.7) 11(68.8) 0.091(0.02~0.41) 0.001 起病到来诊时间/h < 6 21(87.5) 5(31.3) ≥6 3(12.5) 11(68.8) 15.4(3.089~76.776) 0.000 诊疗因素 夜间就诊 6(25.0) 11(68.8) 0.152(0.037~0.617) 0.006 首诊非三甲医院 8(33.3) 11(68.8) 0.227(0.059~0.882) 0.028 ≥2个科室会诊 17(70.8) 5(31.3) 5.343(1.35~21.14) 0.014 
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表 2 及时诊断情况
例 初步诊断 病例数 及时确诊 病例数 消化道穿孔 5 肠坏死 3 肝破裂 1 主动脉夹层 1 急性胰腺炎 5 DKA 3 心肌梗死 1 主动脉夹层 1 急性阑尾炎 4 输卵管妊娠 2 急性憩室炎 2 肠梗阻 4 消化道穿孔 2 缺血性肠病 2 泌尿系结石 3 主动脉夹层 2 肾囊肿破裂 1 胆系感染 3 消化道出血 2 肝破裂 1
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表 3 延迟诊断情况
例 初步诊断 病例数 延迟确诊 病例数 急性胰腺炎 6 DKA 4 缺血性肠病 2 急性胆囊炎 4 心肌梗死 3 缺血性肠病 1 消化道穿孔 2 心肌梗死 1 DKA 1 自发性腹膜炎 2 缺血性肠病 2 肠梗阻 2 缺血性肠病 2
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| 引用本文: |
刘安雷, 刘洋, 杨惊, 等. 急诊重症急腹症延迟诊断原因分析[J]. 临床急诊杂志, 2022, 23(12): 807-811. doi: 10.13201/j.issn.1009-5918.2022.12.001
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| Citation: |
LIU Anlei, LIU Yang, YANG Jing, et al. Reasons for delayed diagnosis of severe acute abdomen in emergency department[J]. J Clin Emerg, 2022, 23(12): 807-811. doi: 10.13201/j.issn.1009-5918.2022.12.001
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