累及大肠的播散型组织胞浆菌病1例

1 临床资料 患者男,70岁,退休教师.因＂反复腹泻、发热8个月加重伴消瘦半年＂于2008年6月23日入院.2007年10月初,患者无明显诱因出现腹泻,黄色稀烂便,无脓血,量不多,3～4次/d;有轻微里急后重,伴少量黏液,无腹痛,体温37.5℃～38℃,双下肢水肿.     

以消化道症状为主的获得性免疫缺陷综合征

例1 患者男性,48岁,反复腹痛、腹泻1年,加重伴脓血便1个月.患者反复出现左下腹痛、腹泻1年,排便4～6次/d,水样便,无脓血,不发热.入院前1个月无明显诱因腹痛、腹泻加重,排黏液脓血便10次/d,间断发热,体温最高达39.2℃,体重下降约5 kg.     

小肠印戒细胞癌误诊为克罗恩病

患者男,52岁.因反复恶心、呕吐伴腹痛4个月余收入院.患者入院前4个月开始出现反复恶心、呕吐伴腹痛,呕吐物为胃内容物,同时停止排便,病程中无黑便、腹泻、黏液血便,无头晕、头痛,无口腔溃疡、发热、关节酸痛等.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

肾综合征出血热合并严重心脏并发症一例

患者男,43岁.入院前5 d无明显诱因地开始发热伴持续性头痛、腰痛、呕吐伴轻微腹痛、腹泻,在当地诊所疑为"急性胃肠炎"应用"丁胺卡那霉素"治疗2 d无效.     

临床研究的体会

黎介寿院士从医数十年,见证了中国外科的成长,并在临床工作和研究中为医疗事业进步作出了众多重要的贡献。本文中,笔者结合自己的从医以来在"肠功能障碍"、"快速康复外科"、"小肠移植"等诸多方向上令人瞩目的研究经历,深刻的探讨了医疗研究中发现和解决问题的态度和方法,对广大医生的临床实践有着重要的指导意义。     

Combination of Adult Intussusception and Intestinal Malrotation: An Unusual Presentation

Intussusception is familiar to pediatric surgeons but is rarely encountered by general surgeons. Adult intussusception is uncommon, accounting for less than 5% of intestinal obstructions, half of which are associated neoplasms. Intestinal malrotation is usually an incidental finding with unrelated disease on image studies, laparotomy or even autopsy. The major complications of intestinal malrotation are intestinal obstruction secondary to midgut volvulus, internal hernia, or adhesion band. The association of the two entities, which is named Waugh’s syndrome in infants, has rarely been reported in the literature. The association in adults is even rarer. We report an adult case with an unusual combination of malrotation and intussusception at exploration.     

Phasic study of intestinal homeostasis disruption in experimental intestinal obstruction

AIM: To investigate the phasic alteration of intestinal homeostasis in an experimental model of intestinal obstruction.METHODS: A rabbit model of intestinal obstruction was established by transforming parts of an infusion set into an in vivo pulled-type locking clamp and creating a uniform controllable loop obstruction in the mesenteric non-avascular zone 8 cm from the distal end of the ileum. The phasic alteration of intestinal homeostasis was studied after intestinal obstruction. The changes in goblet cells, intraepithelial lymphocytes, lamina propria lymphocytes, and intestinal epithelium were quantified from periodic acid-Schiff-stained sections. Ornithine decarboxylase (ODC) activity and serum citrulline levels were measured by high-performance liquid chromatography. Claudin 1 mRNA expression was examined by real-time polymerase chain reaction analysis. Intestinal microorganisms, wet/dry weight ratios, pH values, and endotoxin levels were determined at multiple points after intestinal obstruction. Furthermore, the number and ratio of CD3⁺, CD4⁺ and CD8⁺ T cells were determined by flow cytometry, and secretory IgA levels were measured with an enzyme-linked immunosorbent assay.RESULTS: A suitable controllable rabbit model of intestinal obstruction was established. Intestinal obstruction induced goblet cell damage and reduced cell number. Further indicators of epithelial cell damage were observed as reduced serum citrulline levels and claudin 1 gene expression, and a transient increase in ODC activity. In addition, the wet/dry weight ratio and pH of the intestinal lumen were also dramatically altered. The ratio of Bacillus bifidus and enterobacteria was reversed following intestinal obstruction. The number and area of Peyer’s patches first increased then sharply decreased after the intestinal obstruction, along with an alteration in the ratio of CD4/CD8⁺ T cells, driven by an increase in CD3⁺ and CD8⁺ T cells and a decrease in CD4⁺ T cells. The number of lamina propria lymphocytes also gradually decreased with prolonged obstruction.CONCLUSION: Intestinal obstruction can induce disruption of intestinal homeostasis.     

Distribution of bleeding gastrointestinal angioectasias in a Western population

AIM: To define which segments of the gastrointestinal tract are most likely to yield angioectasias for ablative therapy.METHODS: A retrospective chart review was performed for patients treated in the Louisiana State University Health Sciences Center Gastroenterology clinics between the dates of July 1, 2007 and October 1, 2010. The selection of cases for review was initiated by use of our electronic medical record to identify all patients with a diagnosis of angioectasia, angiodysplasia, or arteriovenous malformation. Of these cases, chart reviews identified patients who had a complete evaluation of their gastrointestinal tract as defined by at least one upper endoscopy, colonoscopy and small bowel capsule endoscopy within the past three years. Patients without evidence of overt gastrointestinal bleeding or iron deficiency anemia associated with intestinal angioectasias were classified as asymptomatic and excluded from this analysis. Thirty-five patients with confirmed, bleeding intestinal angioectasias who had undergone complete endoscopic evaluation of the gastrointestinal tract were included in the final analysis.RESULTS: A total of 127 cases were reviewed. Sixty-six were excluded during subsequent screening due to lack of complete small bowel evaluation and/or lack of documentation of overt bleeding or iron deficiency anemia. The 61 remaining cases were carefully examined with independent review of endoscopic images as well as complete capsule endoscopy videos. This analysis excluded 26 additional cases due to insufficient records/images for review, incomplete capsule examination, poor capsule visualization or lack of confirmation of typical angioectasias by the principal investigator on independent review. Thirty-five cases met criteria for final analysis. All study patients were age 50 years or older and 13 patients (37.1%) had chronic kidney disease stage 3 or higher. Twenty of 35 patients were taking aspirin (81 mg or 325 mg), clopidogrel, and/or warfarin, with 8/20 on combination therapy. The number and location of angioectasis was documented for each case. Lesions were then classified into the following segments of the gastrointestinal tract: esophagus, stomach, duodenum, jejunum, ileum, right colon and left colon. The location of lesions within the small bowel observed by capsule endoscopy was generally defined by percentage of total small bowel transit time with times of 0%-9%, 10%-39%, and 40%-100% corresponding to the duodenum, jejunum and ileum, respectively. Independent review of complete capsule studies allowed for deviation from this guideline if capsule passage was delayed in one or more segments. In addition, the location and number of angioectasias observed in the small bowel was further modified or confirmed by subsequent device-assisted enteroscopy (DAE) performed in the 83% of cases. In our study population, angioectasias were most commonly found in the jejunum (80%) followed by the duodenum (51%), stomach (22.8%), and right colon (11.4%). Only two patients were found to have angioectasias in the ileum (5.7%). Twenty-one patients (60%) had angioectasias in more than one location.CONCLUSION: Patients being considered for endoscopic ablation of symptomatic angioectasias should undergo push enteroscopy or anterograde DAE and re-inspection of the right colon.     

肠道菌群与1型糖尿病的关系

1型糖尿病发病机制与遗传因素、环境因素及自身免疫因素均有关,是在遗传因素基础上,由环境因素启动,以T淋巴细胞介导的胰岛β细胞进行性损伤为主要特征的自身免疫性疾病.肠道菌群作为环境因素与1型糖尿病发生有直接关系,可通过改变肠壁通透性和宿主免疫系统影响发病.肠道菌群、宿主免疫及1型糖尿病三者之间存在相互联系,研究肠道菌群可为1型糖尿病的预防和治疗提供线索.     

隐源性多灶性溃疡性狭窄性小肠炎

隐源性多灶性溃疡性狭窄性小肠炎(CMUSE)是一种以小肠多部位狭窄和多灶性浅溃疡为特点的小肠疾病,主要的临床表现为慢性或复发性肠梗阻。溃疡一般较浅,位于黏膜层和黏膜下层。纤维性狭窄部位较短(一般1~2 cm),相互间隔较紧凑(多为2~10 cm),无瘘管形成。外科手术治疗后复发率高,糖皮质激素可有效防止再次手术,多数患者成为激素依赖状态。     

Safety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre

BACKGROUND: Comparisons between safety and efficacy of home parenteral nutrition and of intestinal transplantation for treatment of chronic intestinal failure derived from observational studies. AIMS: To present the 16-year experience of home parenteral nutrition by the Chronic Intestinal Failure Centre of Bologna University. PATIENTS: A total of 40 adult patients were enrolled between 1986 and 2001. METHODS: Safety indices: survival and cause of death, catheter-related bloodstream infection, deep vein thrombosis, liver disease. Efficacy indices: nutritional and rehabilitation status, quality of life (SF36 instrument), re-hospitalisation rate. Statistics: Kaplan-Maier analysis and Cox model for survival probability and risk factors; logistic regression for catheter-related bloodstream infection risk factors. RESULTS: Survival rates at 1, 3 and 5 years were 97, 82 and 67% respectively. Survival was higher in patients < or = 40 years. One death was home parenteral nutrition-related. Incidence of catheter-related bloodstream infection: 0.30/year home parenteral nutrition, was lower in patients treated by a specialized nursing protocol. Incidence of deep vein thrombosis was 0.05/year home parenteral nutrition. Hepatosteatosis occurred in 55%. Body weight remained stable or increased in 80%. Rehabilitation was total or partial in 74%. Re-hospitalisation rate was 0.70/year home parenteral nutrition. Quality of life scored significantly lower than in healthy populations in six out of eight domains. CONCLUSIONS: Home parenteral nutrition is a safe and efficacious therapy for chronic intestinal failure. Survival compares favourably with survival after intestinal transplantation.     

老年人粪性结肠梗阻与穿孔诊治的体会

目的 分析老年人粪性结肠梗阻与穿孔的临床特征，以提高诊治水平。方法 对1994年1月至2003年12月收治的22例老年粪性结肠梗阻与6例粪性结肠穿孔患者资料进行回顾性分析。结果 粪性结肠梗阻22例，6例分别以肠梗阻、结肠占位病变行手术治疗，16例行保守治疗，均痊愈。粪性结肠穿孔6例，分别以结肠恶性肿瘤穿孔、肠绞窄行手术治疗，穿孔部位多见于直-乙状结肠交界处，2例因感染性休克、多器官功能衰竭死亡。结论 粪性结肠梗阻患者经保守治疗多能缓解症状。粪性结肠穿孔比较罕见，缺乏特异性临床表现，误诊率和病死率高，应积极行手术治疗，切除病变肠段、行Hartmann造瘘术为首选。