內(nèi)科學(xué)大課及巡檢：潰瘍性結(jié)腸炎英語

1、Increased stool Increased stool frequency frequency HematocheziaHematochezia( (便血便血) ) Abdominal Abdominal pain pain 36/F C.C. Abdominal pain and Hemafecia 4 months; Fever and Bloody Purulent Stool 1 month. 2015-02 Abdominal Pain and Hemafecia Pain VAS 2 Remission after defecation(排便) Hemafecia 5/da

2、y Vinous(深紅色) blood on formed stool Simultaneous Phenomenon Without fever, nausea, vomiting or tenesmus(里急后重), ect. Q. Take into consideration 36/F Abdominal Pain and Hemafecia Diarrhea Passage of abnormally liquid or unformed stools at an increased frequency. Stool liquidity Daily stool weight 300g

3、/d Frequency 3/d Acute if 2 weeks, persistent if 2 to 4 weeks, and chronic if 4 weeks in duration. Hematochezia Passage of bright red or maroon（栗色） blood from the rectum. Related symptom: Anemia Acute：palpitation心悸, dizziness, perspire流汗, Chronic：fatigue UGIB or LGIB? UpperLower Past Medical History

4、 peptic ulcer, hepatic , biliary , pancreatic lower abdominal pain/mass Signs before Bleedingupper abd. discomfort nausea mid and lower abd discomfort defecation desire Bleeding Mannerhematemesis （嘔血） with tarry stool （柏油樣 便） Hematochezia without Hematemesis Characteristic and Shape of Stool tarry s

5、tool loose or in shape, no blood clot dark or fresh red stool loose usually may have clot Increased stool frequency, Hematochezia and Abdominal pain Differential Diagnosis DiverticulosisDiverticulosis Diverticulum：Sac-like protrusion of the colonic wall Age-dependent, Aspirin and NSAIDs Absence of d

6、iverticulitis: Painless hematochezia AngiodysplasiaAngiodysplasia Dilated, tortuous submucosal vessels Endothelial cells, lack smooth muscle Increases with age GI bleeding Episodic and self-limited Typhoid Typhoid feverfever Salmonella（沙門氏菌） Abdominal pain, fever, and chills Relative bradycardia, ro

7、se spots Hepatosplenomegaly, intestinal bleeding, and perforation Leukopenia Shigella infection 細菌性痢疾 Fever 30 to 40 percent Abdominal pain 70 to 93 percent Mucoid diarrhea 70 to 85 percent Bloody diarrhea 35 to 55 percent Watery diarrhea 30 to 40 percent Vomiting 35 percent Stool culture Intestinal

8、 Intestinal EntamoebaEntamoeba HistolyticaHistolytica AmebiasisAmebiasis Asymptomatic Mild diarrhea severe dysentery, producing abdominal pain and bloody stools to fulminant amebic colitis Stool microscopy, Antigen testing, Serology, Molecular methods. TuberculousTuberculous E Enteritisnteritis Nons

9、pecific chronic abdominal pain Anorexia（厭食）, fatigue, fever, night sweats, weight loss, diarrhea, constipation（便秘）, or blood in the stool Colonoscopic: circumferential ulcers Endarteritis obliterans（閉塞性動脈內(nèi)膜炎）（閉塞性動脈內(nèi)膜炎） Histopathology: Granulomas: be large and confluent, with caseation necrosis Ische

10、mic colitisIschemic colitis Older adults: relative hypotension, heart failure, and arrhythmias Young patients: hypercoagulable state Abdominal pain, diarrhea, and passage of bright red blood per rectum Colonoscopy, CT, MRA Inflammatory Bowel Disease Colon Colon CancerCancer Rare in younger individua

11、ls Bleeding: low-grade and recurrent Bright red blood: left-sided lesions Maroon blood or melena: right-sided lesions Change in bowel habits, Iron deficiency anemia. Colonoscopy, Barium enema Gastrointestinal Gastrointestinal lymphomaslymphomas IPSID associated lymphoma: abdominal pain, chronic diar

12、rhea, malabsorption, severe weight loss, clubbing, and ankle edema. Enteropathy-associated T cell lymphoma (EATL): acute bleeding, obstruction, or perforation Non-IPSID lymphomas: more nonspecific presentation Colonoscopy with biopsy Back to the case 2015-05 Fever and Blood Purulent stool Abdominal

13、Pain VAS 9-10 Blood Purelent Stool 10-20/day Mushy Fever Continued Tmax 40 Blood Rt.: WBC Diagnosis: Bacterial Infection Rx: Levofloxacin(左氧氟沙星), Cephalosporins(頭孢類) Effect: Improved VAS 7 7-10/day, Mushy 2015-06-18 Manifestation Persist HGB 90 g/L ESR 74 mm/h hsCRP 165mg/L Diagnosis: Infection Rx.:

14、 Vancomycin(萬古霉素) Parenteral Nutrition Effect: No remission 2015-06-26 PUMCH Emergency Department Blood Rt.: WBC 7.79x109/L, NUET% 68.4%, HGB 51g/L, PLT 521x109/L Stool Rt.: RBC whole/HPF, WBC whole/HPF Stool OB(+) Alb 19g/L, ESR 84mm/h, hsCRP 23.12mg/L Diagnosis: Infection Rx.: Ceftazidime(頭孢他啶), M

15、etronidazole(甲硝唑) Effect T 37.0 VAS 4 Blood volume of hemafecia 2015-07-02 PUMCH WT -6kg, VV 400-500ml/day Past Medical History (-) Personal History (-) Family Medical History: Mother HTN, DM P.E. T 36.5 HR 111/min R 20/min BP 90/60mmHg Abdominal tenderness, especially LLQ, rebound tenderness (-) An

16、kle edema Q. Take into consideration 36/F Abdominal Pain, Blood Purulent Stool, Fever LLQ Abdominal Tenderness, Ankle Edema Differentiate Diagnosis Infection Cytomegalovirus, CMV Clostridium Difficile Colitis(難辨梭菌感染性腸炎) Intestinal Tuberculosis Typhus Abdominalis Disorder of Immune System Inflammatio

17、n Bowel Disease, IBD Tumor Lymphomas Q. Examination taken into consideration Differentiate Diagnosis Colonoscopy Biopsy Laboratory Examination PCT, G-Test, Widals Test, Stool T.SPOT-TB Clostridium Difficile Toxin Test Parasite Micrography 2015-07-03 Colonoscopy Sigmoid colon and Descending colon inv

18、olved Appearance: Hyperemia, Mucosal edema, Longitudinal ulcers, Pus, Bleeding Spot. 2015-07-03 Colonoscopy Appearance: Sigmoid colon and Descending colon involved Hyperemia, Mucosal edema, Longitudinal ulcers, Pus, Bleeding Spot Biopsy: Superficial Chronic Inflammation, Crypt Abscesses, Architectur

19、al Distortion NO Lymphoma Sign Differentiate Diagnosis PCT, G-Test (-) Widals test (-) Stool T.SPOT-TB (-) CMV-DNA 7th ed. 2002:2039. www.CCFA.or. Accessed July 29, 2005. Ulcerative Colitis: Defining Extent of Disease Ulcerative proctitis (rectum only) E1 Left-sided Colitis (extends to splenic flexu

20、re) E2 Extensive Colitis (beyond splenic flexure) E3 Adapted from Orangio GR. Surgical Therapy for IBD. In: Stein SH, Rood RP, eds. Inflammatory Bowel Disease. Philadelphia, PA: Lippincott-Raven; 1999:155(Fig 10). Accessed July 29, 2005. Disease Disease SeveritySeverity MildModerateSevere stools per

21、 dayfour or fewerfrequent loose, bloody stools (4 per day) frequent loose bloody stools (6 per day) HR90100100 HCT（%）normal30-4030 Weight loss（%）01010 Temperaturenormal37.5C37.5C ESR(mm/h)2020-3030 Alb（g/dL）normal3-3.53 Mild Granular mucosa Edematous Loss of normal vascular pattern Images courtesy o

22、f R. Cohen MD. Modified from Sutherland LR, et al. Gastroenterology. 1987;92:1894. Endoscopic Severity Index for UC Coarsely granular Small ulcerations Friable Moderate Frank ulcerations Spontaneous hemorrhage Severe PseudopolyposisMucosal Tag Ulcerative Colitis (remission) Histology Features of UC

23、Quiescent Crypt distortion No active inflammation Active Crypt distortion Inflammation infiltrates Crypt abscesses Images courtesy of John Hart, MD. Strategy for Treatment of IBD Surgery/Bi ologics Immunosuppre ssor Corticosteroids Aminosalicylates(5-ASA)氨基氨基 水楊酸鹽水楊酸鹽 Severe Moderate Mild Medication

24、 Back to the case Extent & Severity Stool 7-10/day HR 111/min HCT 21% Weight Loss 12% T 36.5 ESR 84mm/h Alb 19g/L Colonoscopy: Left-side Colitis (E2) MildModerateSevere stools per dayfour or fewerfrequent loose, bloody stools (4 per day) frequent loose bloody stools (6 per day) HR90100100 HCT（%）norm

25、al30-4030 Weight loss（%）01010 temperaturenormal37.5C37.5C ESR(mm/h)2020-3030 Alb（g/dL）normal3-3.53 Treatment of Severe UC Aminosalicylates(5-ASA) Corticosteroids Immunosuppressive Surgery/Biologics Mesalamine(美沙拉秦) 1000mg qid Hydrocortisone(氫化可的松) 150mg q12h Omeprazole(奧美拉唑), Fortum(復(fù)達欣) Prognosis 2015-07-06 Remmission of ankle edema and hemafecia 2015-07-08 Fever, Tmax 38, Else dicto Infection? Virus, Opportunistic Infection