2015年 · 第35卷第04期

Achalasia is a neurogenic disorder of esophageal motility, accompanied by abnormal esophageal peristalsis and loss of low esophageal sphincter (LES) function. The incidence of achalasia is relatively low, and the annual incidence in western countries ranges from 0.5 to 1.2 per 100,000^[1,2]。 Esophageal motility examination is the gold standard for diagnosing achalasia, and high-resolution manometry (HRM) examination classifies patients with achalasia into three types (classical, pressurized and spastic). Recent studies have found that different subtypes of patients have different treatment effects^[3,4]。

H．pyloriThe high infection rate and susceptibility of gastroenterology has been one of the hot spots in gastroenterology research. More than 50% of the world's population is reported to be infectedH.pyloriOur countryH.pyloriThe infection rate is 40% ~60%^[1]。H.pyloriIt is not only an important pathogenic factor for the occurrence and development of some chronic upper digestive tract diseases, but also related to many diseases outside the digestive system, and its pathogenicity is related toH.pyloricytotoxin-associated gene A (cytotoxin-associated gene A,CagA), vacuolating cytotoxin A,VacA) of type IH.pyloriMore pathogenic. This study examined the coastal and mountainous residents in southern Fujian, ChinaH.pyloriThe results of the investigation of infection status and its genotype were analyzed.

Gastric cancer always occupies the first place in the incidence and mortality of malignant tumors of digestive tract^[1]。 China is a high incidence area of gastric cancer, and the actual number of cases accounts for more than 30% of the global number of cases^[1]。 In recent years, the research on hypoxia-inducible factor-1 α (HIF-1 α), which is widely expressed in tumor cells, has gradually become a hot spot. HIF-1 α changes a series of downstream genes controlled by HIF-1 α through its hypoxic response element (HRE^[2,3,4]。 Among them, 6-phospofructo-2-kinase/fructose-2,6-biphosphatase (PFKFB) is one of its controlled genes^[5,6,7]。 In this study, the expression of PFKFB3, PFKFB4 and HIF-1 α mRNA and protein in human gastric cancer tissues was detected, and the relationship between PFKFB3 and PFKFB4 and clinicopathological characteristics of gastric cancer and their significance were analyzed.

In recent years, the number of UC patients in China has been gradually increasing. UC patients often have recurrent attacks, which seriously affect the quality of life. At present, there is no drug that can cure it, and its treatment goal is to induce and maintain remission.

The liver plays an important role in regulating blood coagulation. Patients with liver cirrhosis due to various reasons will have decreased coagulation function. The classic explanation is that the liver synthesis of coagulation factors decreases (except factor VIII) during liver cirrhosis. At the same time, patients with liver cirrhosis are deficient in vitamin K, resulting in a decrease in vitamin K-dependent coagulation factor synthesis. Although the pathogenesis of alcoholic cirrhosis and hepatitis B (hereinafter referred to as hepatitis B) cirrhosis is different, it is currently believed that the abnormal coagulation function of both are related to liver injury.

IBD is a group of chronic inflammatory reactive intestinal diseases of unknown etiology and pathogenesis, including CD and UC. At present, the diagnosis of IBD mainly depends on clinical manifestations, endoscopy, imaging examination, histological examination and biochemical examination, and other causes of intestinal inflammatory reaction should be ruled out. However, for patients with overlapping characteristics of CD and UC and segmental and non-specific enteritis, its diagnosis and differential diagnosis are very difficult, so it is very important to find a method other than traditional diagnostic tools. The aberrant immune response of genetically susceptible hosts to microorganisms or endogenous antigens plays an important role in the pathogenesis of IBD. More and more antibodies and autoantibodies related to IBD against different microbial antigens have been discovered. These antibodies include anti-neutrophil cytoplasmic autoantibodies (ANCA), perinuclear ANCA, anti-Saccharomyces cerevisiae antibodies (anti-Saccharomyces cerevisiaeantibodies (ASCA), antibodies against goblet cells (GAB), antibodies against exocrine pancreas (PAB), antibody to islet cells of pancreas (ICA) They have certain application value in the diagnosis, differential diagnosis and risk prediction of complications of IBD^[1,2]。 This study further evaluated the clinical application value of six serological antibodies in 120 patients with IBD by combining detection.

Since the State Food and Drug Administration approved infliximab monoclonal antibody (IFX) for the treatment of CD in 2007, the drug has been in clinical use in my country for nearly 10 years. The Inflammatory Bowel Disease Group of the Gastroenterology Branch of the Chinese Medical Association formulated the recommended protocol and revised version of IFX for the treatment of CD in 2008 and 2011, respectively, to guide the standardized clinical medication. With the accumulation of experience in the application process, the current understanding of IFX has not only been limited to the grasp of indications and contraindications, but also extended to the standardization of use methods and the prevention of adverse events. For some hot issues that have gradually become prominent in the process of medication in recent years, such as the application of IFX in the early stage of disease, the combined application and advantages and disadvantages of immunosuppressants, and the application and precautions in special populations or states (hepatitis B, pregnancy and tumor patients), Chinese experts also have their own experiences. Therefore, on December 12, 2014, some domestic digestive disease experts discussed the hot issues of clinical application of IFX. The discussion opinions are summarized as follows.

A 46-year-old female was found to have an abdominal mass for more than 3 years. Three years ago, the patient found a right lower abdominal mass, about 3 cm ×3 cm, without significant enlargement, nausea, vomiting, abdominal distension, abdominal pain, changes in defecation habits, abdominal tenderness, and abdominal rebound pain during physical examination. Positron emission computed tomography showed the possibility of low-grade malignant neoplastic lesions in the right lower abdominal appendix. Laboratory tests showed no obvious abnormalities. Ultrasound examination showed that the appendix tip was obviously expanded, the size was 3.2 cm ×3.1 cm, the density was relatively uniform, the edge was smooth, and the boundary with the surrounding organs was still clear. Laparoscopic appendectomy was performed. During the operation, the appendix was located in the posterior position of the cecum, about 10 cm long, and a solid tumor of 3 cm ×3 cm ×3 cm was seen at the tip of the appendix, which was hard in texture and adhered to the surrounding area. The root of the appendix was normal. Postoperative pathological examination showed that the resected appendix was 11.2 cm long, and a gray-white mass was found at the tip of the appendix, 4.5 cm ×3.0 cm ×2.0 cm in size, with envelope, gray-white braided section, solid, medium texture, and no obvious appendix cavity was found (Figure 1)； Among the tumor cells, spindle cells are the main ones, and the boundary with the surrounding tissues is unclear, and the arrangement is varied (Figure 2), the cell boundary is unclear, eosinophilic, the nucleus is oval or short fusiform, a few nuclei are enlarged in volume, deeply stained, mitotic images are rare, no necrosis and bleeding are seen, tumor cells fill the appendix cavity, there are fewer blood vessels in the interstitium, and more plasma cells and lymphocyte infiltration are seen; S-100 protein positive (Figure 3), vimentin positive, CD117 negative, CD34 negative, smooth muscle actin negative, desmin negative, Ki-67 proliferation index 3%.

A 106-year-old female was admitted to the hospital with the main complaint of "repeated hematemesis and melena for more than half a month". No prior special medical disorders. On the morning of October 27, 2013, the patient developed diarrhea, defecated bloody stool (about 300 mL) and vomited bloody stomach contents (about 200 mL), so he went to the gastroenterology department of another hospital (tertiary class A hospital) for diagnosis and treatment. Gastroscopy showed acute upper gastrointestinal hemorrhage (Forrest type III), duodenal ulcer (stage A1), cardia tear and hemorrhage. At that time, the coagulation function test showed that fibrinogen (Fib) was basically normal. Later, he was injected with hemagglutinase from Agkistrodon acutus for hemostatic treatment. On November 12, 2013, he was transferred to Guangdong Provincial Hospital of Traditional Chinese Medicine. On the first day of admission, he was given hemagglutinase of white-eyebrown snake venom 2 kU/d for hemostatic treatment, and was combined with intravenous pumping of PPI for acid suppression and fluid rehydration support treatment. Reexamination of coagulation function on the night of admission showed that Fib was 0.24 g/L, PT was prolonged, and D-dimer was 2 130 mg/L. Intermittent cryoprecipitation (cryoprecipitation, plasma cryoprecipitate contains factor VIII and Fib, can treat patients with bleeding due to lack of factor VIII and Fib or hemophilia patients), fresh frozen plasma and Fib lyophilized powder for supplementary treatment to correct hypofibemia and improve coagulation dysfunction. After supplementary therapy, Fib increased slowly to a maximum of 1.37 g/L, and the gastrointestinal bleeding was controlled, but once the infusion of cryoprecipitate, fresh frozen plasma and Fib lyophilized powder was stopped, Fib decreased to 0.53 g/L. With the decline of Fib, the patient experienced melena again, and Hb also progressively decreased, suggesting repeated upper gastrointestinal bleeding. During this period, the patient's platelets were always normal or normal low, so the possibility of disseminated intravascular coagulation (DIC) was excluded. Due to poor control of gastrointestinal bleeding, the patient's condition deteriorated once, and complications such as pulmonary infection and cardiac insufficiency occurred during hospitalization. He was intermittently given ceftriaxone sodium, imipenem cilastatin sodium, piperacillin sodium and tazobactam sodium for anti-infective treatment, and diuresis and anti-heart failure treatment. After withdrawal of hemagglutinase from white-brown snake venom, Fib began to rise significantly without supplementation of cryoprecipitate, fresh frozen plasma and Fib lyophilized powder. On the third day after withdrawal, the coagulation function was completely normal, and Fib was 2.04 g/L. The patient's upper gastrointestinal bleeding stopped, complications were controlled, and then he was cured and discharged.

The 47-year-old female was seen in early March 2014 due to abdominal distension for more than 5 months. More than 5 months ago, the patient had obvious abdominal distension in the right lower abdomen and middle abdomen, and sometimes a raised mass could be palpable, resembling an intestinal type; Aggravated after eating. I have taken mosapride and other drugs for treatment, but I feel that the effect is not good. The previous patient had polymyositis and pulmonary fibrosis for 10 years and was taking prednisone for a long time. The current dose is 20 mg/d, instantaneously, and azathioprine 5 mg, twice/d. No history of peptic ulcer, gastrointestinal tumor, etc. Wastness, BMI 17.0 kg/m²There is no special abnormality. There were no abnormalities in blood routine, fecal routine, biochemical indexes and tumor markers. On August 28, 2014, colonoscopy showed that the mucosa of the transverse colon was thin and translucent, which was a diffuse change. When the intestinal lumen contracted, the mucosal surface of the annular fold showed multiple hemispherical cyst-like changes, and the mucosal bulge caused the intestinal lumen to be narrowed. The scope was not continued (Figure 1、Figure 2)； Diffuse pneumocystosis of the colon was diagnosed. Gastroscopy revealed chronic superficial antral gastritis (grade II). Abdominal CT examination showed that the intestinal walls of transverse colon and ascending colon showed cystic-like light-transmitting areas of different sizes, distributed in clusters (Figure 3)。 Lung CT examination half a month before this visit showed that multiple stripes parallel to the pleura were seen under the peripheral pleura of the lower lobes of both lungs, and irregular stripes were seen in the lower fields of both lungs (Figure 4)。 Follow-up medical history, the patient had undergone colonoscopy 6 years ago and showed no obvious abnormalities in whole colon. Oral Clostridium butyricum live bacteria tablets and mosapride were given for symptomatic treatment, but the effect was not good. After treatment with traditional Chinese medicine such as eliminating accumulation, dehumidifying and dispelling heat, the symptoms improved.

At present, there is still a lack of effective treatment for acute pancreatitis (AP), and recent research results have constantly questioned some prevention and treatment strategies of severe acute pancreatitis (SAP). ① Inhibit pancreatic juice secretion and reduce pancreatic necrosis: In AP, acinar cells are apoptotic or necrotic, intracellular enzymogen granules are reduced, and pancreatic exocrine function has been inhibited. At this time, it is difficult to prevent the progression of SAP or improve its outcome by continuing to inhibit pancreatic exocrine function. ② Organ support: Organ failure is mainly related to excessive inflammatory damage. Compared with actively controlling inflammatory response, although organ support can make some patients get through difficulties, the treatment strategy is in a relatively passive position, and the treatment cost is high. There is nothing to do about subsequent infection. ③ Application of antibiotics: The initial stage of AP is a chemical inflammatory injury, and the preventive use of antibiotics cannot reduce the incidence of pancreatic necrosis and infection. Antibiotics are very important in the treatment of pancreatic infection, but the final success or failure still depends on the body's immune state.

autoimmune pancreatitis (AIP) is a special type of chronic pancreatitis, developed by Yoshida et al.^[1]First proposed in 1995. AIP is often characterized by obstructive jaundice, emaciation, fatigue, abdominal discomfort as the first symptoms, and is characterized by diffuse or segmental pancreatic enlargement, irregular pancreatic duct stenosis, elevated serum IgG4 level, and significant curative effect of glucocorticoids^[2]。 In 2011, the international consensus on diagnostic criteria for AIP classified AIP into type I and type II based on histopathological characteristics. Type I is related to IgG4, usually with characteristic elevated serum IgG4 levels and other IgG4-related diseases; Type Ⅱ is associated with epithelial granulocyte injury^[3]。 At present, Type I is the main prevalence in Asia, accounting for more than 96%, while in Europe and America, Type I is the main prevalence (80%).

Contrast-enhanced ultrasound technology refers to the imaging technology that makes use of the obviously different echo characteristics and significant acoustic impedance differences of human tissues after intravenous pellet bolus injection of ultrasound contrast agent to highlight the lesions from the surrounding tissues. contrast-enhanced endoscopic ultrasonography (CE-EUS) is developed into the field of endoscopic ultrasonography. CE-EUS can develop and imaging in the way closest to the lesion, reducing the interference of abdominal wall tissue and air, and is more accurate than transabdominal ultrasound, CT, MRI and other examination methods in some disease diagnosis^[1,2]。 In addition, it has the advantages of non-radiation, non-invasiveness, simple operation and wide application. Therefore, the clinical application of CE-EUS has attracted more and more attention. This paper expounds the research progress of CE-EUS in the aspects of ultrasound contrast agent, image analysis software and indication.