2015年 · 第35卷第12期

acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is one of the most common clinical critical emergencies. In 2009, Chinese Journal of Internal Medicine, Chinese Journal of Digestive Medicine and Chinese Journal of Digestive Endoscopy organized experts from gastroenterology, digestive endoscopy, general surgery and critical medicine to conduct many special discussions in Hangzhou, and jointly formulated and promulgated the Guidelines for the Diagnosis and Treatment of Acute Non-varicose Upper Gastrointestinal Bleeding (2009, Hangzhou)^[1]This guideline has played a very good guiding role in the clinical diagnosis and treatment of ANVUGIB in my country. In the past five years, with the rapid development of technology in various disciplines, new progress has been made in the diagnosis and treatment of ANVUGIB. The guidelines promulgated in 2009 can no longer fully meet the needs of current clinical practice. Therefore, Chinese Journal of Internal Medicine, Chinese Journal of Medicine, Chinese Journal of Digestion, Chinese Journal of Digestive Endoscopy and the Digestive Endoscopy Branch of Chinese Medical Association organized experts in related fields again in November 2015, and revised the guidelines promulgated in 2009 as follows in combination with evidence-based medicine at home and abroad in recent years and with reference to updated foreign guidelines.

cholestasis refers to the pathological state of bile formation, secretion and excretion disorders caused by various reasons inside and outside the liver. Bile cannot flow into the duodenum normally and enters the blood. Clinically, it can be manifested as itching, fatigue, deepening urine color and jaundice. In the early stage, it is often asymptomatic and only manifests as elevated serum ALP and GGT levels. After the disease progresses, hyperbilirubinemia can occur, and in severe cases, liver failure or even death^[1]。 Hepatobiliary diseases with cholestasis as the main manifestation of liver lesions for various reasons are collectively called cholestatic liver disease, and cholestasis itself will further aggravate liver damage. Cholestatic liver disease can be divided into intrahepatic cholestasis and extrahepatic cholestasis according to the location of occurrence. If cholestasis lasts for more than 6 months, it is called chronic cholestasis^[2]。 This consensus focuses on intrahepatic cholestatic liver disease.

Japan and other countries have applied serum pepsinogen (PG) detection for general screening and early diagnosis of gastric cancer^[1]。 Large-scale long-term studies in Japan have shown that the sensitivity and specificity of PG for the diagnosis of gastric cancer are higher when serum PGⅠ ≤70 μ g/L and pepsinogen ratio (PGR; PGⅠ/PGⅡ) ≤3.0 as the boundary values^[1,2,3]。 Because human serum PG levels are influenced by ethnic and dietary factors, serum PG varies greatly in different ethnic groups and regions, and the definition standards of serum PG abnormalities are also very different in different countries. In China, serum PGⅠ ≤60 μ g/L and PGR ≤6.0 were used as the screening margin for high incidence areas of gastric cancer, and their sensitivity and specificity were high^[4]。 Studies have shown that serum gastrin 17 levels are reduced in patients with atrophic antral gastritis and elevated in patients with gastric cancer^[5,6]Therefore, it can be used as a serum marker for both, but its screening boundary has not been determined at home and abroad. Serum PG and gastrin-17 alone or in combination have been reported for screening gastric cancer and precancerous lesions^[5,7]But at present, there are few large sample and longitudinal studies on serology in China. In this study, the serum levels of PG and gastrin-17 in patients with gastric cancer in Shanxi Province were detected. The purpose of this study was to investigate the value of the Japanese standard PGⅠ ≤70 μ g/L, PGR ≤3.0 and the recommended PGⅠ ≤60 μ g/L, PGR ≤6.0 in Chinese literature, and the detection of gastrin-17 in gastric cancer screening.

TNM stage of tumor is the most important prognostic factor for gastric cancer, but the prognosis of patients with the same stage is not the same. Therefore, it is necessary to find a new index for early diagnosis and prognostic evaluation of gastric cancer. The Dickkopf family includes Dickkopf-1, Dickkopf-2, Dickkopf-3, and Dickkopf-4, and also includes Dickkopf L1/Soggy similar to Dickkopf-3^[1]。 Dickkopf-1 is a secreted protein, which plays an important role in cell replication and proliferation during embryonic development, and can inhibit the activation of Wnt signaling pathway^[2]。 Studies have found that Dickkopf-1 can be overexpressed in certain tumors, such as hepatoblastic carcinoma, nephroblastic carcinoma, breast cancer, prostate cancer, lung cancer, esophageal cancer and liver cancer, etc., so it can be used as a serological marker for early diagnosis of tumors^[3,4,5]。 In this study, the expression of Dickkopf-1 in gastric cancer specimens was detected to explore the relationship between Dickkopf-1 and clinical pathology of tumor patients, and its value in judging prognosis.

With the continuous development of endoscopic technology, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) has become a common method for the treatment of common bile duct calculi. For larger diameter stones, lithotripsy is often required. In recent years, it has been believed that endoscopic papillary large balloon dilation (EPLBD) after EST can eliminate the need for mechanical lithotripsy when treating large stones or multiple stones. At present, there are still no clear operating guidelines for EPLBD, and its indications, safety and long-term prognosis are still not completely clear. This study reviewed the efficacy of EPLBD in the treatment of choledocholithiasis, and evaluated its efficacy, safety and long-term prognosis.

bacterial liver abscesses (BLA) are secondary infectious diseases when bacteria enter the liver through various routes, and the liver parenchyma undergoes inflammatory reaction, necrosis and then abscesses are formed. Pathogenic bacteria can directly enter the liver through biliary tract, portal vein, hepatic artery and open wound, or can directly spread from tissue infection foci near the liver. BLA mostly has no typical clinical manifestations, and the acute inflammatory reaction phase is often masked by the primary disease. This disease is often acute and progresses rapidly, and is easy to complicate with sepsis and liver function damage. The clinical characteristics of 66 patients with BLA in West China Hospital of Sichuan University were retrospectively analyzed, aiming to improve the understanding of this disease, improve the early diagnosis rate and select the appropriate treatment plan.

Colorectal cancer is a common malignant tumor in China. With the social and economic development of our country, people's life, diet, environment and other changes, the incidence of colorectal cancer has an obvious trend of increasing. colorectal adenoma (CRA) is the main precancerous disease of colorectal cancer, and timely treatment of precancerous disease is the key to prevent and treat colorectal cancer. The prognosis of early colorectal cancer treatment is good, but early colorectal cancer mostly has no obvious clinical symptoms. Early diagnosis of precancerous diseases and colorectal cancer requires screening of a large number of asymptomatic people. How to choose a convenient, effective and economical screening method becomes the key. In this study, the results of fecal occult blood combined with colonoscopy screening for colorectal cancer were analyzed as follows.

An 18-year-old female was admitted to the hospital on 23-Sep-2013 due to upper abdominal distension for 6 months. Physical examination showed no obvious abnormalities. Gastroscopy showed a mucosal bulge near the dentate line of the gastric fundus, about 3.0 cm ×4.0 cm in size, with a smooth surface and the same color as the surrounding mucosa (Figure 1), no obvious resistance was felt through gastroscopy through the cardia. Endoscopic ultrasound showed that the hierarchical structure of the gastric wall was clear and complete. The lesions originated from the submucosa, with clear boundaries, and uniform moderately high echoes were seen inside. The section size was 3.4 cm ×2.4 cm (Figure 2)。 Second-stage enhanced CT examination of the stomach showed a nodular low-density shadow outside the gastric cavity near the dentate line of the gastric fundus, with a diameter of about 3.8 cm (Figure 3), the enhanced scan edge is slightly enhanced. After endoscopic labeling of the lesions, submucosal injection was performed, and the mucosa on the surface of the tumor was peeled off to expose the submucosal lesions. The lesions were still soft to touch, and the surface was wrapped by fibrous membrane. After incision, coffee-colored viscous liquid flowed out. After sufficient drainage and lavage, part of the cyst wall was removed and sent for pathological examination, and the cyst cavity was opened (Figure 4), the operation was smooth, and he was discharged 7 days after the operation. The pathological diagnosis was gastric submucosal cystic lymphangioma; HE staining showed that the dilated lymphatic vessels were cystic, and a few glandular components and smooth muscle tissue hyperplasia were seen; The results of immunohistochemistry were desmin, CD31, CD34, cytokeratin (CK) 20, Ki67,H.pylorinegative, specific lymphatic endothelial marker D2-40 (Figure 5), CK7 positive. Gastroscopy was reexamined 5 months after operation, and no recurrence was observed (Figure 6)。

A 63-year-old female was admitted to the hospital on February 9, 2015 due to middle and upper abdominal colic for 2 months. The pain was mainly under the xiphoid process, obvious after meals, and occasionally accompanied by abdominal distension and belching. There was no abnormality in physical examination and laboratory examination at admission. Under ultrasound gastroscopy, the focus originated from a hypoechoic mass of muscularis propria 1.2 cm ×1.0 cm, and the posterior adventitia was clear and intact, suggesting a fundus stromal tumor. Endoscopic mucosal dissection was performed under general anesthesia. A broad base bulge was seen on the small curved side of the anterior wall of the gastric fundus, which was marked, submucosal injection and partial incision with HOOK knife. No tumor was exposed. After full-thickness incision and suction, tumor-like tissue adhered to the gastric wall and hepatoduodenal ligament. Free liver lobes were seen in the left front and free duodenum was seen in the right back. The tumor was dissected with IT knife, and the perforated site was sutured with titanium clip and nylon rope. SeeFigure 1。 After operation, he was fasted, gastrointestinal decompression, and strengthened acid suppression, anti-inflammatory and hemostatic support treatment. After 3 days, he was extubated and fed, and was discharged after 1 week. Postoperative pathology showed liver tissue and fibrous tissue in tumor-like tissue. Immunohistochemical staining showed positive cytokeratin (CK) 19 (catheter), CK8/CK18 and hepatocyte antibody. Combined with clinical consideration, it was ectopic liver of hepatoduodenal ligament. SeeFigure 2。

The 58-year-old male was admitted to the hospital on December 1, 2014 due to repeated abdominal distension for more than 2 months. The patient went to a local hospital for abdominal distension more than 2 months before admission, and the peripheral blood PLT count was checked at 60×10⁹/L, Yu is normal. ALT 51 U/L, AST 81 U/L, GGT 175 U/L, ALP 270 U/L, DBil 37.8 μ mol/L, IBil 15.0 μ mol/L. There were no abnormalities in AFP and coagulation function. Upper abdominal CT scan + enhancement showed insignificant enhancement of liver and spleen parenchyma, uneven decrease of liver density, splenomegaly, and moderate volume of peritoneal effusion. The local hospital gave treatment such as liver protection, antiyellowing and diuresis, but the patient's abdominal distension progressively aggravated, so he was transferred to Drum Tower Hospital affiliated to Nanjing University School of Medicine. The patient was in good health and had no history of diabetes, heart disease, kidney disease, hepatitis, tuberculosis, etc., no history of long-term drinking, no history of taking special drugs, no history of exposure to chemical poisons, no history of trauma and surgery.

In the United States, obesity already accounts for nearly 40% of the total population, 20% of cancer patients are linked to obesity, and obesity has been a cause of death in about 14% of men and 20% of women with cancer in the past 25 years. It has been reported that extremely obese people have high overall mortality and short disease-free survival. Increasing physical activity and reducing body weight can reduce the risk of cancer and improve the quality of life of cancer patients. As a risk factor for digestive tract cancer, obesity is caused by a number of factors, namely, visceral fat accumulation, insulin and insulin-like growth factor (IGF), leptin and adiponectin, inflammatory cytokines, and immune response^[1]。

gastric antral vascular ectasia (GAVE) is the disease of Rider et al.^[1]A rare lesion of unknown origin confined to the gastric antrum, proposed in 1953, was first described in an endoscopic biopsy of an elderly woman with occult gastrointestinal hemorrhage. 1984, by Jabbari et al.^[2]According to the endoscopic manifestations, that is, the erythema or red dot-like lesions in the gastric antrum are linear or diffuse, which is vividly called "watermelon stomach". The etiology of GAVE is complex and the diagnostic criteria are unclear. The research progress of its etiology, pathological anatomy, diagnosis and treatment is reviewed.

Liver fibrosis is the process of chronic liver injury caused by various etiologies and then developing into cirrhosis. Early diagnosis and dynamic monitoring of the degree of liver fibrosis are the key to prevent various chronic liver diseases from developing into cirrhosis and end-stage liver diseases. At present, the diagnosis of liver fibrosis mainly relies on serological tests, imaging examinations and liver biopsy. Serological detection mainly includes components of extracellular matrix synthesis and degradation or related enzymes, such as hyaluronic acid, type III procollagen amino terminal peptide, type IV collagen, laminin, etc. However, there is no specific sensitive index that can reflect liver fibrosis. Imaging tests such as routine ultrasound are valuable in the assessment of liver fibrosis and can diagnose liver fibrosis and cirrhosis^[1,2]However, it is still difficult to judge the stage of liver fibrosis, especially early cirrhosis. Liver biopsy can accurately reflect the tissue lesions and fibrosis degree of chronic hepatitis, and is the gold standard for clinical diagnosis of liver fibrosis and cirrhosis. However, because it is invasive and potentially risky, it is not easy to be accepted by patients, so it cannot be used for dynamic observation and follow-up, nor is it suitable for large sample epidemiological investigation. The application of elastic ultrasound technique provides powerful technical support for clinical non-invasive assessment of liver fibrosis^[3]。 Because of its advantages of non-invasive, painless, quick, convenient, easy to operate and good repeatability, it has been widely recognized, and has been used in chronic liver diseases with various etiologies such as hepatitis B, hepatitis C, non-alcoholic fatty liver disease, alcoholic fatty liver disease, etc^[4,5,6,7,8]。 At present, there are many kinds of ultrasound elastography technologies, and the examination operation has developed from only ultrasound physicians to gastroenterologists, physicians and even technicians in physical examination centers. However, it is easy to lead to different detection values, inaccurate evaluation of fibrosis degree, and sometimes even unexplained situations. In order to avoid the above situation, the following aspects should be paid attention to.

IBS is a common functional gastrointestinal disease. Most IBS patients have worsening postprandial symptoms, and about 2/3 of IBS patients have one or more food intolerances. The most common intolerant foods are often rich in carbohydrates such as lactose, fructose, fructans and polyols^[1]。 The common feature of this type of carbohydrate is that it is not easy to be absorbed by the human body and can aggravate digestive tract symptoms. Such difficult-to-absorb short-chain carbohydrate include fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (fermentable oligo-, Di-and Mono-Saccharides and polyols, FODMAP)^[2]。 In recent years, the influence of FODMAP diet on IBS symptoms has attracted much attention of scholars.