黑热病致下消化道大出血一例

患者男 ,2 1岁 ,因头晕 ,胸闷、心悸、腹痛、腹泻 2周于2 0 0 0年 2月 2 3日以病毒性心肌炎收住内科。入院时体检无异常体征 ,肝脾肋下未触及。血常规 :血红蛋白 10 0 ｇ/Ｌ,红细胞 3.73× 10 12 /Ｌ ,白细胞 6 .4× 10 9/Ｌ ,血小板 88×10 9/Ｌ ,心电图、胸部Ｘ片均正常 ,Ｂ超示肝脾肿大。入院第2天始不规则发热 ,体温波动于 37.7～ 39.5°Ｃ ,表现为骤升骤降 ,发热前无寒战 ,热退时出汗。给予抗菌药物及对症治疗 ,效欠佳。 1周后 ,以肝脾肿大原因待查转入传染科。追问病史 ,患者自幼生活在原籍 ,无外地居住史 ,无疫水接触史 ,无宠物饲养…     

大剂量立止血治疗老年人急性消化道大出血

近年来，应用立止血治疗消化道出血，疗效基本得到肯定。对于急性消化道大出血的老年患者，我们采用短期内大剂量使用立止血，疗效尤为显著。现将我们近２年来应用立止血治疗老年人消化道大出血的结果报道如下。１对象与方法１．１治疗对象老年患者３６例，年龄６０～７５...     

术中内镜检查诊断原因不明下消化道大出血

近11年来,我院胃镜室配合普外科在剖腹手术中紧急内镜检查5例原因不明的便血患者,全部诊断明确并抢救成功,现总结报告如下。 1.一般资料:男3例,女2例,年龄16～67岁,均因大量便血内科治疗无效紧急剖腹探查,有4例因便血曾作过胃镜和结肠镜检查,均未明确出血部位和病因。 2.检查方法:剖腹探查术时经肛门入路检查3例,经空肠切口入路检查2例。     

克罗恩病并发急性下消化道大出血13例临床分析

目的 探讨克罗恩病(CD)并发急性下消化道大出血患者的临床特点及疾病转归.方法 收集1998年1月至2007年12月收治的CD并发急性下消化道大出血患者13例,对其临床及随访资料进行回顾性分析.结果 收治确诊的CD患者共230例,其中发生急性下消化道大出血者13例,占5.6%.13例患者中男女之比为3.3:1,其中4例以急性下消化道大出血为首发症状,10例病变累及小肠,能明确出血部位者8例(小肠出血4例,吻合口出血2例,结肠出血2例).13例首次大出血后,接受手术治疗4例,无死亡;接受内科保守治疗9例,死亡3例.随访10例,随访期6～94个月内,再发大出血8例,因再发大出血需手术2例,死亡1例.再发大出血而能继续存活的所有7例患者均以反复出血为惟一或主要临床表现,且病变均累及小肠.结论 部分CD患者可并发急性下消化道大出血,其诊断和治疗均存在一定困难,应引起临床医师的重视.     

结肠息肉致下消化道大出血一例

患女，68岁。因鲜血便一天就诊。患当日上午10时左右无明显诱因突然出现鲜血便，至下午4时就诊时共解鲜血便5次，每状量约150～200ml，均为鲜红色，有少量血块伴有轻度头晕及心慌，无恶心呕吐，无腹痛发热等。既往体健。     

消化道大出血金属钛夹治疗与外科手术治疗的效价比较

目的通过观察金属钛夹及外科手术对消化道大出血的治疗效果及治疗费用，探讨内镜下金属钛夹治疗急性消化道大出血的临床应用价值及经济学价值。方法钛夹止血组（A组）采用经内镜对出血病灶放置金属钛夹止血；外科手术组（B组）采用“病灶切除术或胃大部切除术”。结果金属钛夹治疗组止血率100．0％，并发症发生率为0，平均住院时间17．82天，平均总住院费用5698．76元；外科手术治疗组止血率100．0％，术后并发症发生率42．86％，平均住院时间23．65天，平均总住院费用15831．56元。结论金属钛夹治疗消化道大出血具有止血效果确切、操作安全、简便、无并发症，费用低等优点，具有良好的效价比。     

经内镜下金属钛夹治疗急性消化道大出血——附25例分析

急性消化道出血为临床常见急症,原因包括溃疡病、息肉、癌肿,静脉曲张、内镜治疗并发症等。如何使大出血患,特别是年老不能耐受手术,在短期内迅速止血,以降低急诊手术率及死亡率?我们从1998年5月至目前成功地在内镜下用钛夹治疗消化道急性出血的患25例,取得了满意的效果。现将报道如下。     

下消化道大出血患者的内镜诊治

下消化道大出血易导致血液动力学改变 ,呈现出血性休克 ,临床处理比较棘手。我科自１９７８年２月～１９９８年２月 ,急诊收治下消化道大出血６３例 ,现分析如下。１．一般资料 :本组６３例中 ,男性４４例 ,女性１９例 ,年龄１９～７６岁 ,中位年龄４９岁。患者均为急诊入院 ,出血时间最短１ｈ ,最长２４ｈ。均排出大量暗红色血便 ,其中４例排出大量鲜红血便伴血块 ,便血量均超过１０００ｍｌ。所有患者入院时均表现为脉率＞１００次／ｍｉｎ ,搏动减弱。４１例血压低于９０／６０ｍｍＨｇ,最低为６０／０ｍｍＨｇ。均有不同程度贫血 ,血红…     

下消化道大出血的诊断分析

下消化道大出血是消化内科常见的急重症，有时因病因诊断非常困难而影响到治疗和预后，已成为消化科医生非常重视的疾病。2001—2008年，我科收治下消化道大出血患者100例。现将其诊断方法和结果报告如下。     

血管造影及介入治疗在消化道大出血中的应用价值

目的探讨血管造影及介入治疗在消化道大出血中的诊断和治疗价值。方法对58例消化道大出血病人进行血管造影检查，对有阳性发现的病例行药物灌注或栓塞治疗。结果58例动脉造影阳性发现率74．1％。其中27例行栓塞治疗，16例行药物灌注，均成功止血。结论血管造影为消化道大出血的有效检查方法，介入治疗为止血的重要手段之一。     

Treatment of locally recurrent rectal cancer

PURPOSE: This study was designed to analyze the outcome for patients with isolated local recurrence after radical treatment of rectal cancer and to identify predictors of curative resection. METHODS: The medical records of 87 patients who developed isolated local recurrence after curative radical surgery for primary rectal cancer were retrospectively reviewed. Survival rates from the time of recurrence were calculated using the Kaplan-Meier method. Tumor stage and histology, patient characteristics, and treatment variables were analyzed using logistic regression to identify predictors of curative surgery. RESULTS: Symptomatic treatment alone or chemotherapy and/or radiation therapy was provided to 23 patients (26 percent), and surgical exploration was performed in 64 patients. In 22 patients (25 percent), the tumor was considered unresectable at surgery (n=13) or was resected for palliation with gross or microscopic positive margins (n=9). In 42 patients (48 percent), curative-intent resection was performed. The only independent predictors of resectability were younger age at diagnosis, earlier stage of the primary tumor, and initial treatment by sphincter-saving procedure. There was no difference in survival between patients who had no surgery and those who had palliative surgery. The estimated five-year survival rate for patients who had curative-intent resection was better than for those who had no surgery or palliative surgery (35vs. 7 percent;P=0.01). Of the 42 patients who underwent curative-intent resection, 14 (33 percent) developed a second recurrence at a mean of 15±11 months after reoperation. Twenty-five percent of patients developed major complications. CONCLUSIONS: Salvage surgery for locally recurrent rectal cancer may be helpful in a selected group of patients. The stage and treatment of the primary tumor may help to identify patients with the best chance for curative-intent resection.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

上消化道溃疡急性穿孔96例保守治疗的体会

目的总结上消化道溃疡急性穿孔保守治疗的体会。方法对2008-01～2009-12接受保守治疗的上消化道溃疡急性穿孔患者96例的临床资料进行回顾性分析。结果全组96例上消化道溃疡急性穿孔患者全部治愈,无出现腹腔脓肿、再穿孔和死亡病例。随访半年,预后良好84例,复发10例,死亡2例。结论对于上消化道溃疡急性穿孔的治疗,在严格掌握适应证的前提下对患者采取保守治疗,可以取得满意效果。     

Neoadjuvant radiation and chemotherapy in rectal cancer does not increase postoperative complications

Background and aims Neoadjuvant radiation and chemotherapy in rectal cancer reduces local recurrences and increases the rate of conservative sphincter surgery. However, an increase in postoperative morbidity and mortality has also been observed. This study analyzed the operative difficulty and postoperative complications in patients with this treatment.Patients and methods Retrospective review of 103 patients with rectal cancer, divided into two groups: group A, 53 patients undergoing preoperative radiotherapy with 45 Gy combined with chemotherapy, and group B, 50 patients with rectal cancer who received surgery after diagnosis. Both groups were homogeneous. The two groups were compared for both technical difficulty, using intraoperative data and rate of complications.Results There were no statistically significant differences between the two groups with regard to intraoperative or postoperative data. In group A there were 20 complications in 17 patients (32%) and in group B 22 complications in 19 patients (38%). The rates of perineal wound infection were similar. The percentage of anastomotic leaks was higher in group A. A greater number of anterior resections was performed in group A.Conclusion Preoperative radiation and chemotherapy in rectal cancer does not increase postoperative complications and increases the rate of sphincter-preserving surgery.An invited commentary on this paper is available at     

Lower gastrointestinal bleeding in the elderly

Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.     

Can we increase the chance of sphincter saving surgery in rectal cancer with neoadjuvant treatments: lessons from a systematic review of recent randomized trials

Purpose

A common hypothesis is that neo-adjuvant treatment in rectal cancer, is able to increase sphincter saving surgery. This review studies data relevant to this question.

Study selection

A total of 17 randomized trials were analysed.

Results

Since 1976, the rate of sphincter saving surgery increased from 20% to 75%. In none of the 17 trials it was possible to demonstrate a significant benefit of the neo-adjuvant regimens on the rate of sphincter saving surgery. There was a reduction in the risk of 5-year local recurrence partly due to these neo-adjuvant treatments. These neo-adjuvant regimens had no significant impact on the overall 5-year survival.

Conclusions

None of the neo-adjuvant treatments tested was able to demonstrate an increase in the rate of sphincter saving surgery. The improvement in conservative surgery is mainly due to technical changes in surgery. Organ preservation after complete clinical response appears as an interesting hypothesis to test.     

Short-term preoperative radiotherapy is a safe approach for treatment of locally advanced rectal cancer

Background and aims The Swedish Rectal Cancer Trial (SRCT) demonstrated that a short term regimen of high-dose preoperative radiotherapy (5×5 Gy) not only reduces the risk of local recurrence but also improves overall survival rate. An increase in postoperative mortality and morbidity has also been observed, however. We therefore evaluated early postoperative complications in patients treated with neoadjuvant radiotherapy for locally advanced rectal adenocarcinoma.Patients/methods Between 2000 and 2004, 85 patients with locally advanced rectal tumors were treated in our institution. Preoperative staging was based on CT scan and, in several cases, on endorectal ultrasonography. They were 55 men and 30 women, with a median age of 68 years. They were retrospectively divided into two groups: Group A, which included 40 patients undergoing preoperative radiotherapy (25 Gy in five fractions) followed by surgery within 1 week, and Group B, which included 45 patients with rectal cancer receiving surgery immediately after diagnosis. Both groups were homogeneous regarding age, gender and preoperative stage of the disease. The two groups were compared for both technical difficulties during operation and rate of postoperative complications.Results/findings No postoperative deaths were recorded in either group. Low anterior resection with total mesorectal excision was performed in all group A patients, whereas eight patients in group B underwent abdominoperineal resection (P<0.05). Diverting stoma was performed in seven patients of group A and it was closed 3–6 months later on every occasion. Postoperative morbidity was not statistically significant between the two groups (40 vs 39%). The rate of postoperative hemorrhage, pelvic or abdominal wound infection, acute urinary infection, and delayed ileus was similar. The percentage of major anastomotic leak was also equivalent (5 vs 6.6%).Interpretation/conclusion Short-term preoperative radiotherapy does not increase the rate of postoperative complications and is a safe therapeutic adjunct for the treatment of locally advanced rectal cancer.     

Decision-making in rectal cancer surgery

PURPOSE: Although rectal cancer is common in the United States, there is significant variation in management and outcome of this disease. The aim of this study is to measure the amount of variability that exists in the way colorectal surgeons investigate and manage patients with rectal cancer. METHODS: A detailed questionnaire covering preoperative assessment, operative technique, and follow-up of primary rectal cancer was sent to all colorectal surgeons associated with colorectal residency programs throughout North America. RESULTS: One hundred ten responses were obtained (response rate, 71 percent). Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of endorectal ultrasound and carcinoembryonic antigen and the postoperative use of endorectal ultrasound. There was also broad agreement about the use of adjuvant therapy and radical resection for a poorly differentiated uT2,N0 cancer, the use of total mesorectal excision for a mid rectal cancer, and for the choice of loop ileostomy if diversion is necessary. Two-thirds of the surgeons used adjuvant therapy and radical resection for a uT3,N0 cancer and preferred a follow-up schedule of three monthly visits for two years with six monthly visits for the next three years. Opinion was divided (<63 percent agreement) on the use of a preoperative liver scan, the approach to a moderately differentiated uT2,N0 cancer, the use of rectal irrigation before resection, the timing of colonoscopy in a patient with stenosing rectal cancer, and the frequency of postoperative colonoscopies. CONCLUSIONS: There is considerable variation in the management of low rectal cancer advocated by colorectal surgeon educators. For each histologic and pathologic stage, opinion is divided about which operation is best. Careful outcomes analysis is required to clarify the situation.Presented at the meeting of the Ohio Valley Society of Colon and Rectal Surgeons, Columbus, Ohio, June 7, 1997.     

Local excision of rectal cancer

A review of 282 patients with carcinoma of the rectum treated by local excision suggests that some patients are best managed and perhaps preferably managed by local means.In situ cancer is treated adequately by local excision regardless of size or grade. Well-differentiated lesions, particularly those less than 3 cm in diameter, probably are managed best by local excision. Moderately or poorly differentiated lesions, regardless of size, probably are managed best by radical techniques until more information is available to document results with local excision.     

直肠癌诊疗模式转变的研究进展

直肠癌是普外科常见的疾病之一,居恶性肿瘤发病率及病死率前三位。近年来,随着临床研究和诊断技术的发展,发现距离肛门12 cm内的直肠癌与上段结直肠癌的解剖学、疾病发展、诊疗手段及治疗效果均有明显差异。直肠癌概念已经重新定义为传统中的中低位直肠癌,即距离肛门12 cm内的直肠癌。该文就直肠癌的诊疗模式发生变化的一些临床研究进行综述。