# 心肌梗死误诊胆囊炎一例及如何减少心梗漏诊率 **URL:** \ **Category:** 🥼实践与临床\ **Tags:** 心血管科cardiology, 胆心综合征, 心肌梗死, 误诊\ **Created:** [2024 年1 月 17 日 05:35 UTC](http://forum.beginner.center/t/topic/691 "2024-01-17T05:35:22Z")\ **Posts on this page:** 2\ **Page:** 1
**Author:** ![doggie](http://forum.beginner.center/user_avatar/forum.beginner.center/doggie/32/550_2.png) [@doggie](http://forum.beginner.center/u/doggie)\ **Post date:** [2024 年1 月 17 日 05:35 UTC](http://forum.beginner.center/t/topic/691/1 "2024-01-17T05:35:22Z")
# 心肌梗死误诊胆囊炎一例 近期本组收入急性心肌梗死患者一例（中年男性），最早患者以右上腹疼痛入院，普外按急性胆囊炎治疗，后夜间发作左胸及背部疼痛，请心内科会诊，心电图异常，急查心肌酶升高，再问有冠心病史，最终转入我心内科治疗，进一步完善辅助检查，确认为急性心肌梗死 后续分析本病例，主任指出鉴别[胆心综合征](https://forum.beginner.center/t/topic/690)和急性心梗，查阅相关材料，发现胆心综合征很容易误诊为心梗，因为[胆心反射](https://forum.beginner.center/t/topic/692)的存在（还有其他学说\[1\]），胆囊发病时会表现出心梗类似症状，故常常误诊为心梗，误诊率高达一半以上\[2\]。 但是个人认为，胆囊炎当成心梗处理，胆囊炎处理不及时问题不大，要是心梗当成胆囊炎处理，心梗处理不及时可就要命了，很可惜并没有找到把心梗误诊成胆系疾病的文章。不过我找到一些其他案例\[3\]，比如心梗被误诊成消化道疾病、呼吸系统疾病等 ![image](https://forum.beginner.center/images/transparent.png) # 如何减少心梗漏诊率 心梗漏诊后果非常严重，毕竟宝贵的治疗窗口只有12h，结合这些案例以及老师的讲解，总结如下经验，抛砖引玉，望各位补充 ![如何减少心梗漏诊率 (2)](https://forum.beginner.center/images/transparent.png) https://viewer.diagrams.net/?tags=%7B%7D&highlight=0000ff&edit=_blank&layers=1&nav=1&title=%E5%A6%82%E4%BD%95%E5%87%8F%E5%B0%91%E5%BF%83%E6%A2%97%E6%BC%8F%E8%AF%8A%E7%8E%87.drawio#R7Vxdc6M4Fv01VM0%2BOAVIgPQINu6e2d6p2ere6elHYhPb08RkMPmaX79XVwKELdskDnbs6bzECCEJdKRzdHWvLDK8ffpQJHfz%2F%2BTTNLNce%2FpkkZHlug53XPgnUp5VSsCITJkVi6lKaxI%2BL%2F5OVaKtUu8X03TVyljmeVYu7tqJk3y5TCdlKy0pivyxne0mz9q13iWzdCPh8yTJNlO%2FLqblXKYyN2jSP6aL2byq2fG5vHObVJnVm6zmyTR%2F1JJIbJFhkeel%2FHX7NEwz8fWq7%2FL15%2Bev2afv%2Fodf%2Frv6K%2Flf9O8vv%2F4%2BkIWNX%2FJI%2FQpFuizftmjVuw9Jdq%2B%2Bl%2BX6GVQS3eRQF7x0%2Bay%2BpP%2FXfV7dGKywn0PI4NI7AEvU3IdfM%2FwfuxYfWTyw4rEVMYuNrdi3%2BNBithVziwUWG1kxs0LfYo4hs2oHvJBsiipVdkXdKrfI75fTVLyjDbfn5W0GPx34%2BWdals8Kj8l9mUNSXpTzfJYvk%2BxTnt%2BpfKJ0lc0R1%2BlyGgrcwfV1lk%2B%2By6TxIstUHXCl8jO4WpVF%2Fr2GliigxonInCXXaRYlk%2B8zbOgwz%2FICbi3zZSqKmgJW1bs0jYub1Khj1yuIrPL7YpLuyKfGbpkUs3RXeb7MJ9qnDSMFrA9pfpuWxTNkUPOEfWW7rnqmSLOkXDy0h1%2BiRvGsfrQu7bd8gUirsuQ3NytomwZl%2BKFV2iQhwM1gjz79HKc3jvfl8Sv58DAKycflaOByA9rX4LS%2FR9qAM0LKAD0NmNCTxfMf4vkrr7r8VmMLLkZPratndWXskn6xYfyMhJix8NqOVxgauD694jQgPqPAHp7ryRIU8UASgCygHucedQmhXrsC2WxV5ttjh7AfUHkFVIIDodLqxh19tquV%2BnCPqRVFFgut2LNCaoUcU0ZWaIsUIKeQWXEgeIh5gq4Ys6KxuAWkFQ3VU5AN8gBFhSOkK6C0IWYOxV2Rh1hhJPKEIXIbZIZafJVH1K5VKsqJkBGBHV2tQKBG%2BE0dzBWFTatF%2FVy0MaLYWCjJwexQD0eSDbA2oFEiyFRlDsTXbBLxLXmkVYjZwlhrnS%2Fem8kULj6GaG9o8Vg9xcc7%2BFgA%2BHG%2BKNPPdwmi6REkZhvfOvcCTqJZlqxWCsN7iPVliH5IizJ9sjpQmePbrXlnUAnZx0Y9Op5Km2vKkdk9wZgaYOwJWEJHQg%2BFLsomirJphN3PsM%2FwRxT%2FUEwHTXV%2BR8VUwWSvZHoX%2Bsj4Cl4noHkCU2Iq2Au0lxLkmUHxREALXibNB%2FZVQClpzWneO1Lqu75FC4m%2BFQH5RBokgb6oSBTMHQkA6twJdMclcwNnekhuXEBYAHksHowRs6IcOXXa1Y%2BaEiVJDjFFm17FytXd2YyaSLFYoQA8fJxpLfTEZShLHiOB7ygQ180gAdTjfHNOn%2Be31%2Fer%2FYzbwrcYPePkdpEJXHxMs4e0XEwSAy8n2WK2hIsJQD0tzAMHqlwsZ3DlN1dfcKACg%2FXI116brx1m4OvAwNeO0xdhB0b0QrtC1JQAy9DTupsJOEn9BVgVwo00sOGO0p1KJtZPeUIvCpFKUYiFSi8KkVg%2FTlE2IowBYKATVRVMYYzjLB65QtzFKB5ZcHGCblAjQiGE8k2EuMSAENoXQJh5YSInmAD7kyhBH5J%2Fmn47bM37ZnRczQ5717juyXTfhgnFJW2bCWX8imt%2FrF3p25lMjF%2FQYG3bD%2B4fmvFQkJozdkVpoxptm7I2s9rvXTZWLVyDXDhCu4hcuCDzwjwr6RXIEWhUCDYX5aJmzeHIp4KCbbFH0WFe%2FqHBFFII7ajBerOZVHhfW8tCVzJU%2Fgxtc5vGs0sTPzTYr30ctyftYzYJHzzlv8aO%2FrQo%2F6hmc%2Fj9rZEXcNUICnHRgw19l27ott4%2Fggnd2MhutseXmYQ%2BCYZs98%2FG3CYQDtNgFqobt4vpVEIhXS3%2BTq6xPNFLd4Jc8K29yPJGdb9tDJHaw0A9bNX7%2BnqPbofsLqp0aeVOUG1WvSOmNL6SycByiE35CGP4BOPRmM87lrx%2Fs21vY18L68Gok1Xt1Tpn60js1mfb5QZdI7XAQGq8J7lh%2FMSGBf0pWG7Lyrm%2B1%2F9u8fYR03mR8vaOBWtw8da1Tc%2BuA69eB58dUbK9RMlY20JBDiNKVTJvlVnZX%2FufWR1ns2svkBkN49f8OWxz%2Fx9Hqjpb3D06WlXPcsA5%2B604xKet0eEcNuL6H1TmXWglVzRjzmltOMfSNp5pwX5UbePQk2iZV6zY36v%2B6WylPelS3%2Bm2Jrzwtb5E%2B64Z1eN%2B25viwBlVlUxcU6FHWB3%2BMzRM9%2B28k4qY6uO%2FqWHm7Abh%2FmgD4rT3pg5cRxxhqWDamqr9MzaNL%2Biayx3NrVjzHApjdPhAryA%2B1nxKanel2oFpwyv53SuegJxa8bgn3aOofp%2Bz4nG7Kp6DTT6HdbRpe%2BMyV4ru3k0MPwjaumbwntxEzS9lkKwXqF1Mo8mc8dC9icNGk8nv8cINMBKBu4aVQ8ibLheOMKrMXjQiJipAN9FQiy4anbV1hZ3cuuKazV0i8otrXx3jvpgM97LR3FUrPG5xD%2FNwjKDmSiAyfBxEIZd%2B6CO0hOki0kc3doz14jISbYiVoss8w5A0UJmirtpBvvIRbvzQZZD2ddFEfcMiZYg%2BNRiHJl2eIwefkmLU24hxCzr5Na%2Bj6VQYIm0MObZBsNbOcjqI%2FL5ARP1TCtZGpH7T7uwTrLpc1dTriQQr6RoYf1pvHHNkAcehCMMVlnecqWhRMSGjkRzGngp%2B4WpPP8SRHFHx4yJYmO5lYRi17Y3HwbunYWLaz9Iii9Sk2EzAhrM6rvNimhaDiXRCDrG04qfBQE%2F%2Fl2U%2BvaMmmA4oakJO5KTvVnZiW8OnvCWfckQYtpziIxk7TSrXXPRIqcOLYwza4jKIOm64R9wKRLS28l2RgNeeggJFLDfSGxtpt2QkToDxXxTz6AWOKuIcHewO2hcBDch6yJNtUDH%2BUQnIYLY8O0Y62RELO45OOAIjbXGa8b0rb23hsh4wJ99hw2%2BmS1m0ow9OWBTJs5ZNsUkP0y01Tbf13CVPiwiUluWbUXLnyZtbrG8ab7rVtmDFm%2B5hvFlFKrULZWuRSf2xKj3pbvZb2HbPZmLaIsqOJJVN6%2BpagVzocN67d03ZmjHqDGTwljWP3PCS1guy0%2Blno7Obs2s2rReaWUWdUKevpnyFnma3LlCyVYnd%2BoeUtnQXhRwezN%2Bbwly3k5nMZKYzcILeBKYpZLo%2BsKkOrq9D4HENEtnKPUz8wCh7aU5iFA1eeBSUAhFrB86jtStCaxSPKzOZnhlPd%2BI%2BLl7qg5RqM5lEQVSdn2SrzFw%2F5KGO%2Bq839X2x6IiiFpZDUq2h1g4N2O%2Bl%2Fx6WKrTLYUqm0PtX2FvhsjmLU84%2BzZGmJP4%2F * * * 1. 秦玲, 王立波, 谷兰梨树县中医院内科. 胆心综合征发生机制的研究进展[J]. 临床肝胆病杂志, 2002(4): 197-198. 2. 杨士贤, 吴铁镛, 刘晓刚. 胆心综合征220例误诊文献分析[J]. 解放军医药杂志, 2015, 27(6): 63-65. 3. 樊燕琴, 刘宏, 王媛. 老年冠心病漏诊和误诊临床分析[J]. 实用老年医学, 2011, 25(3): 236-238+242. ---
**Author:** ![doggie](http://forum.beginner.center/user_avatar/forum.beginner.center/doggie/32/550_2.png) [@doggie](http://forum.beginner.center/u/doggie)\ **Post date:** [2024 年1 月 21 日 05:51 UTC](http://forum.beginner.center/t/topic/691/2 "2024-01-21T05:51:31Z")
以下内容来自雷哥 @星期天的萨莉亚 任何疾病的诊断都是病史症状体征辅助检查结合，很多时候追问病史以及发病诱因就会有明显提示 胆囊炎作为外科急腹症，特点就是诱因明确，通常由进食油腻引发，且患者常有胆石病史；而心梗的本质是血（氧）供需不平衡，ami的诱因通常是受寒、情绪激动、剧烈活动这些加重心肌耗氧/引起冠脉血流不足的行为，与进食关系不大 症状上两者虽然都有疼痛，但还是西外经典题目：内外科急腹症鉴别——胆囊炎典型症状是右上腹绞痛，痛有定处（解剖变异除外），可放射至右肩胛，如炎症波及浆膜层则在下压腹壁时可刺激到壁层腹膜，出现经典的Murphy征阳性；ami疼痛表现各异，经典就是胸骨后（而非心前区）压榨样疼痛，可放射至左肩胛及左上肢内侧，但也有很多不典型的，比如下壁梗以剑突下不适、打嗝等消化道症状来诉，这时候心电图和心损的重要性就体现出来了，急诊来的眉毛以下膝盖以上疼的病人不管三七二十一都拉图，高危人群直接拉图抽血一起开，毕竟现在心梗的诊断标准1+1里面心损是必需条件 胆心综合征和心梗鉴别起来其实很容易，病史通常就直接提示了，还有就是胆心综合征的表现是慢心率甚至停搏（迷走神经牵张的结果），这个慢心律应当是窦律为主，窦房结功能是没有问题的；部分右冠闭塞的心梗也会出现慢心率，但心电图可以看到房室阻滞、逸搏等表现，因为窦房结和房室结由右冠供血，右冠闭塞时它们的功能是不好的