以腹痛为首发症状的自身免疫性肝炎伴胸腺瘤误诊分析并文献复习

Abdominal Pain as the Initial Symptom of Autoimmune Hepatitis with Thymoma,a Misdiagnosed Case Report and Literature Review

目的探讨自身免疫性肝炎(AIH)的临床特征。方法回顾分析自身免疫性肝炎并胸腺瘤1例的临床资料。结果本例因腹痛13 d入院,先后误诊为胃肠痉挛、胃炎、腹膜炎,予相应治疗症状无明显改善。无长期大量饮酒和长期服用肝损伤药物史。入院后行腹部超声检查示:肝实质回声弥漫性增粗,脾大,腹腔积液。查肝功能及乙型肝炎、丙型肝炎、戊型肝炎相关检查均正常;抗核抗体(ANA)1∶1000阳性(颗粒),抗线粒体抗体、抗平滑肌抗体均阴性。肝脏活检示:部分肝细胞增生及肿胀,可见小胆管结构,汇管区纤维组织增生伴慢性炎细胞浸润。根据AIH诊断评分系统诊断为AIH。肺部CT扫描示左前上纵隔结节,考虑胸腺瘤可能性大。予免疫抑制剂治疗后症状迅速缓解,随访3个月,腹痛症状完全消失。胸腺瘤拟进一步行外科治疗。结论临床遇合并肝硬化且常规治疗方法不能改善腹痛症状的患者,应考虑到AIH的可能,及时行血清免疫学、血清自身抗体检查及肝脏活检,以减少误诊误治。

Objective To investigate the clinical features and experience about the autoimmune hepatitis （AIH）. Methods A retrospective analysis of a misdiagnosed case with autoimmune hepatitis was carried out. Results The patient suffered from abdominal pain for 13 days, and had been misdiagnosed as stomach cramps, gastritis, peritonitis, after treatment to relieve pain failed. No previous history of long-term heavy alcohol consumption and long-term liver damaging medication were recorded. The abdominal ultrasound showed solid echo diffuse thickening of liver, splenomegaly and ascites. Liver func-tion, hepatitis B, hepatitis C and hepatitis E virus related examinations were normal. Antinuclear antibody （ ANA） test was positive（1∶ 1000, particles）, anti-mitochondrial antibody （ AMA） test was negative, and anti-smooth muscle antibodies （ ASMA） test was negative. Liver biopsy showed partial liver cell proliferation and cloudy swelling, small bile duct structure, and periportal fibrosis with chronic inflammatory cell infiltration. According to AIH diagnostic scoring system, the patient was diagnosed with autoimmune hepatitis. The lung CT scan showed pulmonary nodules on the anterior mediastinum, and the pos-sibility of a large thymoma was suspected. The pain was relieved after immunosuppressant. The abdominal symptoms disap-peared completely in the 3-month-follow-up. Thymoma may need further surgical treatment. Conclusion If the conventional treatment does not relieve the abdominal pain in hepatic cirrhosis patients, autoimmune hepatitis should be considered and Im-munologic test, antisubstance and liver biopsy should be taken to prevent misdiagnosis.