Johnson D J, Tonnesen A S
Department of Surgery, University of Texas Medical School, Houston.
Gastroenterol Clin North Am. 1988 Jun;17(2):419-31.
When a patient presents with sepsis and no clear etiology, the abdomen can hide a focus of infection and must be considered in the course of the evaluation (Fig. 1). There are certain groups of patients who do not exhibit the usual signs and symptoms of intra-abdominal infection and therefore constitute the population at risk for occult abdominal sepsis. These patients, for one reason or another, have an unreliable history or physical exam. Once intra-abdominal infection is suspected, certain basic laboratory and radiographic evaluations should be undertaken. Treatment delays are not tolerated and the performance of diagnostic tests when a laparotomy appears inevitable is not indicated. CT of the abdomen should not be used as a screening exam and should be reserved for those cases potentially having an infected fluid collection. If a thorough evaluation of the abdomen reveals a possible source, a measured medical and surgical approach can be undertaken, depending on the etiology. If no source is found, the question of a diagnostic laparotomy arises in certain cases (Fig. 2). This procedure should be reserved for those patients having some type of underlying abdominal surgery or pathology. Without a previous history of abdominal surgery or pathology, and with no other clinical evidence of intra-abdominal infection, a nondirected laparotomy can be safely performed when organ failure is not present but usually will not reveal a treatable lesion. Multiple organ failure may indicate the presence of a hidden abdominal source of infection; however, the window for successful surgical intervention may have already passed. Multiple organ failure does not mandate laparotomy when there is no clinical or radiographic basis for suspecting an abdominal source of infection. This is especially true if an alternative source of sepsis has been defined.
当患者出现脓毒症且病因不明时，腹部可能隐藏着感染病灶，在评估过程中必须加以考虑（图1）。有某些患者群体未表现出腹腔内感染的常见体征和症状，因此构成了隐匿性腹部脓毒症的高危人群。这些患者由于某种原因，病史或体格检查结果不可靠。一旦怀疑有腹腔内感染，应进行某些基本的实验室和影像学评估。不容许治疗延误，当开腹手术似乎不可避免时，进行诊断性检查并无必要。腹部CT不应作为筛查检查，应仅用于那些可能有感染性积液的病例。如果对腹部进行全面评估后发现可能的感染源，可根据病因采取适度的内科和外科治疗方法。如果未发现感染源，在某些情况下会出现是否进行诊断性开腹手术的问题（图2）。该手术应仅用于那些有某种腹部手术史或病理情况的患者。没有腹部手术史或病理情况，且无其他腹腔内感染的临床证据时，在不存在器官衰竭的情况下可安全地进行非定向开腹手术，但通常不会发现可治疗的病变。多器官功能衰竭可能表明存在隐匿的腹部感染源；然而，成功进行手术干预的时机可能已经错过。当没有临床或影像学依据怀疑腹部是感染源时，多器官功能衰竭并不一定需要进行开腹手术。如果已确定脓毒症的其他来源，情况尤其如此。
