肝脏穿刺ABC

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Liver Biopsy 肝穿 With a liver biopsy (BYE-op-see), the physician is able to examine a small piece of tissue from your liver for signs of damage or disease. This procedure involves using a special needle to remove tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. An x-ray could suggest that the liver is swollen. Looking at liver tissue itself is the best way to determine whether the liver is healthy. 通过肝脏穿刺活检医生可以根据一小块取样决定肝脏是否受损伤和生病. 过程就是用一个特殊针头将肝脏组织带出. 通常医生在发现肝脏工作不正常后, 如铜质, 酶标增高, 肝脏肿大, 特别是肝脏肿物, 常常会决定做肝穿来直接观察验证肝脏的健康情况. Preparation 准备 Before scheduling your biopsy, the physician will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those, like blood thinners, that affect blood clotting. One week before the surgery, you will have to stop taking aspirin, ibuprofen, and anticoagulants. You will also have a chest x-ray. 在安排做肝穿之前, 医生需要抽血验证病人的凝血状况正常. 此时病人需要告诉医生所有在服用的药物, 特别是会使血液变稀的药物, 如阿司匹林, 鲁苯酚等. 病人还需要照X光胸透. You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the surgery. Your physician will tell you whether to take your normal medications during the fasting period and may give you other special instructions. 做肝穿前8小时病人不能进食进水, 并且要最少提前一小时报到. 医生会告知病人是否需要空腹吃平时吃的药或其它注意事项. -------------------------------------------------------------------------------- Procedure 过程 Liver biopsy is considered minor surgery and is done at the hospital. The nurse will start an intravenous line to give you medication for the procedure. For the biopsy, you will lie on a hospital bed on your back or turned slightly to the left side, with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot. 肝穿属于小手术需要在医院里面完成. 进入操作室后护士通常会开始给病人换衣服并上上静脉点滴. 病人面朝上躺在床上, 有时医生会要求病人稍微向左躺, 把右手放在头上. 接下来医生会将病人的肝脏定位画好图标并在局部表皮注射些止痛剂. 之后医生会在病人右方肋骨架下方表皮划开一个小口, 将肝穿取样探针快速插入肝脏拉出(一般5-10秒钟)活检组织. 这叫皮下盲点取样. 有时医生需要取得肝脏内部某一个特定位置的组织, 如肿物, 溃疡侧需借助超声波来取样. 这叫皮下定位取样. You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel a dull pain. The entire procedure takes about 20 minutes. 在进针取样的几秒钟期间, 病人需要配合憋住呼吸不动以防止针头刺伤肺或胆囊. 进针出针的一刹那病人可能会感到一种迟钝的疼痛(不是尖锐刺痛, 通常会是酸痛). 整个过程大约需要20分钟. Two other methods of liver biopsy are also available. For a laparoscopic biopsy, the physician inserts a special tube called a laparoscope through an incision in the abdomen. The laparoscope sends images of the liver to a monitor. The physician watches the monitor and uses instruments in the laparoscope to remove tissue samples from one or more parts of the liver. Physicians use this type of biopsy when they need tissue samples from specific parts of the liver. 此外还有其它两种肝穿方法. 其一是应用腹腔镜取样, 即在病人腹腔上开一个小口把腹腔镜的蛇管插入腹部, 在电视荧光屏上看到肝脏取样. 医生一般利用此方法得取肝脏某一部位的活检. Transvenous biopsy involves inserting a tube called a catheter into a vein in the neck and guiding it to the liver. The physician puts a biopsy needle into the catheter and then into the liver. Physicians use this procedure when patients have blood-clotting problems or fluid in the abdomen. 另外一种是静脉血管介入取样. 把一个纤维导管从颈静脉放入到肝脏. 导管头上装上取样探针取样. 此方法广泛用于凝血不好, 腹水的病人. -------------------------------------------------------------------------------- Recovery 恢复 After the biopsy, the physician will put a bandage over the incision and have you lie on your right side, pressed against a towel, for at least 2 hours. The nurse will monitor your vital signs and level of pain. You may remain in the hospital for up to 24 hours after the surgery to recover from the sedative and to allow the medical staff to check you for complications before sending you home. 肝脏穿此后医生将皮下小口贴上并让病人向右方躺下并在破口处以毛巾卷压迫两小时. 护士将观察病人的血压, 呼吸, 心跳, 疼痛程度. 病人将在医院留观, 等待麻醉减退等, 有时可长达24小时之久. You will need to arrange to have someone take you home from the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain in bed (except to use the bathroom) for 8 to 12 hours, depending on your physician's instructions. Also, be sure not to exert yourself too much for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site, and you might have some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing. 如果没什么事情病人也可能让回家. 因为麻醉病人不能开车要家人送回. 回家后要卧床8-12小时. 接下来的一周也不能做剧烈运动或出力. 有的病人会一只感觉到疼痛, 但是疼痛不是肝脏, 通常是肌肉痛伴有放射感. 医生或许会让病人用止痛剂, 但是不要用阿司匹林, 鲁苯酚等造成血液稀释. Like any surgery, liver biopsy does have some risks, such as puncture of the lung or gallbladder, infection, bleeding, and pain, but these complications are rare. 和其它手术一样, 肝脏穿刺是有一点危险, 例如: 扎到肺, 胆囊, 感染, 流血, 疼痛等, 但是这些事情很少很少见. ******************************************************** 以前提过, 国外一个很好的肝脏科医生每年最少要亲自做150-200个肝穿已获得第一手资料. 我没做过, 但我想它比开胸, 开脑甚至内窥镜手术不会恐怖到哪里去. 所以下次医生建议您去做时不要害怕. 参考:National Digestive Diseases Information Clearinghouse

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三、肝脏活体组织穿刺术



（一）术前准备



1.患者术前应检查出凝血时间、血小板计数、凝血酶原时间，如有异常需暂缓执行，待纠正后再行穿刺，必要时测血型并备血待用。



2.术前三天肌注维素素K3 4mg每日1次，并口服钙剂及维生素C。



3.向患者解释穿刺目的，练习屏气方法（在深吸气后呼气末屏气片刻）。有咳嗽者，术前1小时给服可待因0.03，情绪紧张者于术前半小时给小量镇静剂。



4.用品准备：无菌肝穿刺包、多头腹带、小沙袋、消毒手套、1～2％普鲁卡因、生理盐水、标本固定液等。



（二）操作方法



1.体位 患者取仰卧稍向左倾，其右侧应尽量靠近床沿，背部垫一薄枕，先铺好腹带，右臂上举置脑后。



2.穿刺部位 通常选腋前线第八肋间或腋中线第九肋间为穿刺点。



3.操作步骤



皮肤常规消毒，铺无菌洞巾(包括套管和针芯)沿肋骨上缘刺入穿刺点0.5～1.0cm后，拔出针芯，连接乳胶管，管之另一端接20ml注射器，内盛3～5ml无菌生理盐水，助手持注射器并抽吸注射器成负压状态，嘱患者在深吸气后呼气末屏气片刻，此时迅速将针直线方向进入肝脏，并立刻退出（此动作一般在1秒钟左右完成），穿刺针绝不能在肝内搅动，穿刺深度不超过6cm。将针头内的肝组织注入盛福尔马林液瓶内送检。穿刺部位盖无菌纱布，用多头腹带包扎，再压上小沙袋。



分叶针切取法：用特制分叶穿刺针（由套管、针芯及分叶针芯三部分组成，后者较套管长2cm），先将套管及针芯装妥后，穿透皮肤，刺入约0.5～1.0cm，快速拔出针芯置入分叶针芯，将分叶针芯推进至后端标志线，此时分叶刺芯前端恰与套管前端平齐，嘱病人深吸入旋转360°，然后再将套管推入2cm，使两者前端又平齐，随之迅速将两者一起拔出，此时患者方可重新呼吸，全部操作应在15秒内完成。拔针后的处理同抽吸法。



（三）术后处理



1.穿刺后绝对卧床休息24小时，术后2小时内，每15～30分钟测血压、脉搏一次，如无变化，改为每小时一次，共6次。若发现血压下降、出冷汗、右胸痛、呼吸困难等出血或气胸征象，应给输血、止血、抽气等处理。



2.酌情继续用维生素K3三天。



（四）适应证



凡肝脏疾患通过临床、实验或其他辅助检查无法明确诊断者，包括



1.肝功能检查异常，性质不明者



2.肝功能检查正常，但症状、体征明显者。



3.不明原因的肝大，门脉高压或黄疸



4.疑有肝脏肿瘤、肝炎及肝硬变、脂肪肝、肝结核、肝淀粉样变性、血吸虫病等。



（五）禁忌证



1.有出血倾向



2.大量腹水或重度黄疸



3.肝缩小或肝浊音界叩不清



4.凝为肝包虫病或肝血管瘤



5.严重贫血或一般情况差者



6.右侧胸腔积液或其他脏器有急性疾患者。



[附注]



同肝脓肿穿刺时，应选用特制的长针头，于压痛最明显、局部有水肿处或经超声定位的穿刺点进入，待抽到脓液后，固定穿刺针，嘱患者维持浅表呼吸，继续抽取脓液直至抽尽，标本根据需要送检，腔内可注入抗生素。若未获得结果应将穿刺针退至皮下，再改变方向穿刺，不得在肝内搅动穿刺针，在抽脓过程中因脓液太稠堵塞针头，抽吸不畅时，可用无菌生理盐水冲洗后再抽吸。



四、腹腔穿刺术



（一）术前准备



1.详细询问病史、体格检查和超声波检查确定腹腔内有积液。



2.术前测血压、脉搏、腹围、并嘱患者将尿排空。



3.器械与药物无菌腹穿包、手套、多头腹带、火棉胶、橡皮围裙（或油布）、盛水容器、送检器皿、皮尺、胶布、1～2％普鲁卡因等。



（二）操作方法



1.体位 患者多取半位，面向椅背,两手交叉抱臂,置于椅背,头枕臂上,使肋间隙增宽;不能坐起者,可采取半卧位,兴趣起患侧上臂(图13-1-1 13-1-2)



2.穿刺部位 选择叩诊实音、呼吸音消失的部位作为穿刺点，一般常选腋后线与肩胛下角线之间第7～9肋间；或采用超声波检查所定之点。



3.操作步骤



（1）穿刺部位常规消毒，术者带无菌手套，铺洞巾，用1～2％普鲁卡因逐层麻醉至腹膜臂壁层，当针尖有落空感并回抽有腹水时拔出针头。



（2）检查腹腔穿刺针是否通畅，连接乳胶管，以血管钳夹紧，从穿刺点进针，有落空感时即达腹腔（一般仅1.5～2.0cm），放开血管钳腹水即可流出。若系诊断性穿刺，抽出少量腹水作检查之用即可拔出；若为治疗放液，一般最多不超过5000ml，放液速度不可过快。



（3）放液完毕，拔出针头，复盖无菌纱布，测腹围，若穿刺孔有腹液渗出，可涂火棉胶封闭创口，然后用多头腹带包扎。



（三）术后处理



病人仰卧休息，复查血压、脉搏、测定腹水量。



（四）适应证



1.腹水原因不明，或疑有内出血者。



2.大量腹水引起难以忍受的呼吸困难及腹胀者。



3.需腹腔内注药或腹水浓缩再输入者。



（五）禁忌证



1.有肝昏迷前驱症状者



2.疑有粘连性结核性腹膜炎、卵巢肿瘤、包虫病等。



（六）注意事项



1.腹水量多者，穿刺针应自穿刺点附近斜行刺入皮下，后将穿刺针在穿刺点处与腹壁呈垂直方向刺入腹腔，以防止腹水自穿刺点漏出。



2.初次放腹水者，不宜放液过快，放液中逐渐缩紧腹部的多头腹带，以防腹压骤减。



3.见肉眼血性腹水时，留标本后应停止放液

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不做,医生与病人是否就很难作出正确判断,及有效正确冶序?