2016年 · 第36卷第02期

Breast cancer metastasis involving esophagus is very rare, and there are few related reports at home and abroad, so it is easy to be misdiagnosed. This study analyzed the pathogenesis, diagnosis and treatment process of 4 patients with breast cancer metastasis involving esophagus diagnosed and treated by thoracic surgery, and reviewed the relevant literature to explore the general rule of this kind of disease and the choice of treatment methods, so as to provide reference for clinical diagnosis and treatment.

The gastrointestinal tract is one of the main lesions involved in patients with acquired immunodeficiency syndrome (AIDS). In recent years, the incidence of fungal esophagitis has been increasing year by year. Among its related factors, the proportion of fungal esophagitis in AIDS patients gradually increases due to the decline of their own immune function. The clinical symptoms of AIDS complicated by fungal esophagitis are atypical. In order to help clinical diagnosis and treatment, this study retrospectively analyzed the gastroscopy results of AIDS patients with digestive tract symptoms, which are reported as follows.

The incidence of colorectal tumors is increasing year by year, which is a serious threat to human health. Traditional surgery has great trauma, many complications and poor quality of life. In recent years, with the development of endoscopic minimally invasive technology, endoscopic mucosal resection (EMR) has been widely used in the treatment of colorectal tumors, and has achieved good curative effect. At present, there are few reports on endoscopic submucosal dissection (ESD) for the treatment of colorectal tumors. This study retrospectively analyzed and compared the clinical data of EMR and ESD in patients with colorectal precancerous lesions and early cancer, which is reported below.

A 79-year-old male was admitted to the hospital on 12 August 2010 due to sudden left abdominal pain for 2 h. The patient suffered from sudden persistent dull pain in the left abdomen 2 hours before admission, without alcoholism, trauma and other triggers, no radiation pain, vomiting stomach contents twice, relieving yellow paste stool twice, no relief of abdominal pain after defecation, no fear of cold, fever, chest tightness, chest pain, etc. The blood pressure was measured at 220/120 mmHg (1 mmHg =0.133 kPa) in the emergency department, and the blood pressure was lowered by intravenous nitroglycerin. The previous medical history is not special. Physical examination at admission: body temperature 36.5 ℃, pulse 80 beats/min, breathing 19 beats/min, blood pressure 143/83 mmHg, acute painful appearance, no cyanosis of the lips, no superficial lymph nodes, no special cardiopulmonary auscultation, full left middle and lower abdomen, local tenderness, rebound pain, seemingly palpable mass, liver and spleen subcostal unpalpable, negative mobile voiced sound, bowel sound 3 times/min. Blood routine showed a WBC count of 20.4×10⁹/L, neutrophil ratio was 0.928, Hb was 136 g/L, and PLT count was 161×10⁹/L, with a CRP of 9.4 mg/L. Fasting blood glucose was 9.23 mmol/L. Liver and kidney function, coagulation function, blood gas analysis, blood and urine amylase, tumor markers, etc. were all negative. CT showed a huge mass in the left middle abdomen, considering mesenteric malignancy (Figure 1)； Low-density lesions in the right liver, metastases waiting to be drained; Bilateral adrenal glands occupy space, and metastases are waiting to be drained. Abdominal pain was aggravated after 3 hours of conservative treatment, and blood was released once, with a dose of about 50 mL, accompanied by dizziness and sweating. The blood pressure was 120/68 mmHg again, the pulse was 80 beats/min, the abdominal muscles were tense, the tenderness and rebound pain were obvious, the palpation of the mass was not obvious, and the mobile voicing was suspected. 3 mL of non-coagulated blood was withdrawn by abdominal puncture. Blood routine reexamination showed WBC count of 16.8×10⁹/L, neutrophil ratio was 0.949, Hb was 111 g/L, and PLT count was 128×10⁹/L. CT reexamination showed that the left middle abdominal tumor rupture and bleeding were first considered; Multiple low-density lesions in the liver, metastases waiting to be drained; Bilateral adrenal glands occupy space, and metastases are waiting to be drained. Exploratory laparotomy was performed after consultation with the patient's family. A large amount of blood accumulation in the abdominal cavity was observed during the operation. The hematoma in the descending mesicolon was about 15 cm ×10 cm ×7 cm, with a rupture communicating with the abdominal cavity, with a total bleeding of 2 000 mL. A blood vessel in the descending mesicolon near the intestinal wall was ruptured with active bleeding. Ligation was performed to stop the bleeding. 800 mL of red blood cell suspension was transfused during the operation, and the blood pressure was stable. The liver did not reach the mass. Postoperative diagnosis of descending mesicolic vessel rupture and hemorrhage, liver and adrenal gland occupying mass is suspicious. After operation, symptomatic and supportive treatment such as anti-infection and infusion were given. The blood pressure was stable in the normal range, and there was no abdominal pain and blood in the stool. Postoperative enhanced MRI of epigastric abdomen showed that right hepatic hemangioma with small cyst was first considered; Bilateral lipid-containing nodular foci of the adrenal gland suggestive of adenoma. He was discharged 2 weeks later, and the discharge diagnosis was rupture and hemorrhage of descending mesocolic vessels; Acute peritonitis; Hepatic hemangioma with cyst; Bilateral adrenal adenoma suspected; Hypertension is suspicious. There was no discomfort at discharge follow-up, blood pressure was low, and the dose of antihypertensive drugs was reduced.

A 51-year-old male was admitted to the gastroenterology department on January 31, 2014 due to blood in the stool for 8 days, about 2 500 g, accompanied by cold sweat. In September 2013, the patient was seen for chest pain. At that time, the enhanced CT of the chest in the outer hospital showed a lobulated soft tissue density mass near the right hilar, with a diameter of 3.7 cm, with less smooth edges, uneven internal density and enhancement, small nodules about 1.5 cm in diameter in the upper lobe of the right lung, and enlarged lymph nodes (4R/L, 10R) in the mediastinum, right group 4 lymph nodes, left group 4 lymph nodes, and right group 10 lymph nodes (4R/L, 10R) in the hilar.Figure 1)。 Puncture pathology showed non-small cell lung cancer with poor cell differentiation, and the pathological type could not be further defined (Figure 2)。 Immunohistochemical staining showed anti-cytokeratin monoclonal antibody AE1/AE3 (+), cytokeratin (CK) 7 (+), cluster of differentiation antigen (CD) 68 monoclonal antibody KP-1 (+ / -), tumor suppressor geneP63 (+ / -), CK5/6 (-), CK10/13 (-), monoclonal antibody to human alveolar surfactant PE10 (-), novel aspartic proteinase A (Napsin A) (-), intestinal epithelium-specific geneCDX2 (-), synaptophysin (-), CD117 (-), thyroid transcription factor-1 (TTF-1) (-). The clinical stage was T3N3M0, stage IIIB. Simultaneous chemotherapy and radiotherapy were performed in the external hospital. Docetaxel + cisplatin (TP) regimen chemotherapy was administered on 27 November and 31 December 2013, with docetaxel 120 mg intravenous drip on Day 1 and cisplatin 40 mg intravenous drip daily on Days 1 to 3. The radiotherapy regimen was to take the visible lesion of the right lung and the area of 1.5 cm around it as the planned target area, and the tumor irradiation dose was 60 Gy, which was completed in 30 sessions (6 weeks). The patient experienced grade IV myelosuppression during treatment and recovered after treatment. Chest CT reexamination on 17 Feb 2014 showed partial remission (Figure 3)。 Blood routine after this admission, WBC count was 4.80×10⁹/L, neutrophils were 0.736, and RBC count was 2.09×10¹²/L, Hb was 65 g/L, PLT count was 119×10⁹/L. Activated partial thromboplastin time was 22.5 s, PT was 11.6 s, INR was 0.98, thrombin time was 17.60 s, fibrinogen was 1.5 g/L, fibrin degradation products were 2.7 μ g/mL, and D-dimer quantification was 0.84 mg/L. Gastroscopy revealed superficial gastritis. Colonoscopy showed a large amount of old dark red bloody fluid deposition in the intestinal lumen, and no active bleeding foci and obvious proliferative lesions were found in the intestinal segment. Capsule endoscopy showed suspected submucosal protuberance in the middle and lower segments of jejunum, and possible stromal tumor. Abdominal CT enhancement showed increased mesenteric density in the left upper abdomen and enlarged lymph nodes. Pelvic CT enhancement showed that the structure of the right lower abdominal ileocecal region was unclear, the terminal ileal intestinal canal was dilated, and the intestinal wall was abnormally enhanced locally; Ileocecal mesangial density slightly increased with peripheral lymph nodes; Colorectal effusion. Digital subtraction angiography was negative.

A 26-year-old male developed dull pain in the middle and upper abdomen on August 2, 2014, which worsened after eating, without acid reflux, nausea, vomiting, and then increased the frequency of defecation, 2 to 4 times/d, which was brown inshaped paste stool, without fever, tenesmus, etc. The gastroscopy in an external hospital showed "erosive gastritis with bile reflux", and the abdominal pain did not improve after omeprazole. On August 6th, I had a fever, and my body temperature fluctuated from 39.0 to 40.2℃, accompanied by chills, chills, and middle and lower abdominal pain after diarrhea. I was transferred to many hospitals, but my symptoms did not improve when I was given cephalosporins, tinidazole and azithromycin. WBC count fluctuates from (6.2~3.6) ×10⁹/L, the neutrophil count fluctuated from (0.6 to 0.2) ×10⁹/L, Hb decreased from 134 g/L to 94 g/L, IFN-γ release assay (+). Colonoscopy showed irregular protuberance and erosion of the ileocecal valve and the end of the ileum, and the formation of an apical ulcer with white coating (Figure 1)。 Biopsy pathological examination showed ileocecal ulcer with necrotic tissue. The patient developed a perianal abscess after transcolonoscopy. The patient was given intravenous infusion of gatifloxacin + ornidazole from September 12 to October 6. The patient's body temperature and abdominal pain improved. After stopping antibiotics for 2 days, the body temperature rose to 37.5℃, and the body temperature was normal after re-infusion. Considering that the intestinal lesions of the patient did not exclude intestinal tuberculosis, the patient was given diagnostic antituberculosis treatment with isoniazid, rifampicin and pyrazinamide for 1 month from September 17, and the patient's symptoms did not change. The outpatient blood routine WBC count on October 8 was 2.48×10⁹/L with a neutrophil count of 0.22×10⁹/L, Hb was 83 g/L, PLT count was 129×10⁹/L, with an ESR of 115 mm/1 h and a hypersensitive CRP of 24.38 mg/L. IBD antibody profile: anti-Saccharomyces cerevisiae antibody-IgG 23 RU/mL, (normal reference value<20 RU/mL) Yu negative. Tuberculin spot test was negative and CEA negative. There were no abnormalities in chest CT, and abdominopelvic enhanced CT + small intestine reconstruction showed abnormal changes in the ileocecal and terminal ileal walls, and multiple lymph nodes in the surrounding mesentery. Mesalazine 1 g, 4 times/d, compound digestive enzyme capsules and glutamine sodium gualanate granules were given for symptomatic treatment, but the effect was not good. On October 12, the patient suffered from fever, abdominal pain and diarrhea again, with the same symptoms as before, and was hospitalized on October 16, 2014. Since the onset of the disease, the patient's consciousness is clear, the spirit is slightly poor, the food intake has dropped to 1/3 of the original, the defecation is as mentioned above, and the body weight has been reduced by 10 kg from the onset to admission. The patient smoked for 7 years, 15 cigarettes/d, and occasionally consumed alcohol. The admission temperature was 38.2 ℃, the heart rate was 116 beats/min, the appearance of anemia, the superficial lymph nodes of the whole body were not enlarged, the right lower abdomen and middle and lower abdomen were tender and rebound pain, and the liver and spleen were not reached. At the lithotomy position of the anus, an oval skin ulcer with a diameter of about 1.2 cm ×1.0 cm can be seen at about 8 o'clock, and the surface is covered with white pus. A soft bulge with a length of about 2 cm can be palpable at the corresponding position in the anus, with tenderness.

A 52-year-old male was admitted to the hospital due to fatigue, anorexia and yellow urine for 7 d. Since the disease, the appetite has decreased significantly, and there is no abdominal pain, diarrhea, nausea, vomiting, chest tightness, shortness of breath, etc. Outpatient liver function: TBil was 33.7 μ mol/L, DBil was 17.9 μ mol/L, ALT was 73 U/L and AST was 249 U/L. Had a cholecystectomy 10 years ago and has a history of hepatitis E. He was admitted to the hospital with chronic liver disease on 27 November 2014. Physical examination: temperature 36.8 ℃, pulse 77 beats/min, breathing 19 beats/min, blood pressure 115/75 mmHg (1 mmHg =0.133 kPa). The skin and sclera were slightly yellowed, the superficial lymph nodes were not swollen, and there was no spider nevus or liver palm in the whole body. The breathing sounds of both lungs were clear, and dry and wet rales were not heard. The heart rhythm was uniform, and no pathological murmur was heard. The whole abdomen was flat and soft, there were no varicose veins in the abdominal wall, no tenderness and rebound pain in the whole abdomen, positive percussion pain in the liver area, no subcostal reach of the liver and spleen, negative Murphy's sign, negative mobile voiced sound, no hyperactivity of intestinal sound, and no edema in both lower limbs. Upper abdominal CT showed that the tail of the pancreas was 1.2 cm in diameter, and the density was equal to that of the pancreas on plain scan. The enhancement of the arterial phase was lower than that of the pancreas, showing uneven enhancement, and the enhancement was uniform in the portal phase, and the density was equal to that of the pancreas (Figure 1)。 MRI showed a rounded lesion with a diameter of 1.2 cm in the tail of the pancreas, T₁The weighted image showed uniform low signal, T₂The weighted image and diffusion-weighted imaging showed high signal, and the apparent diffusion coefficient showed low signal. The signal was similar to that of the main spleen in all scan sequences, with non-uniform enhancement in the arterial phase and uniform enhancement in the portal phase (Figure 2)。 AFP and CEA were normal, CA19-9 was 49.4 U/mL (reference range 0-39 U/mL), and enolase was 21.1 μ g/L (reference range 0-12.5 μ g/L). After admission, he was given compound glycyrrhizin, adenosylmethionine butanedisulfonate, and ursodeoxycholic acid to protect the liver, reduce yellow and choleretic treatment. On December 22, 2014, he underwent laparoscopic pancreatic tail tumor + splenectomy under general anesthesia. Postoperative pathology reported ectopic spleen in the pancreatic tail.

A 26-year-old male was admitted to the hospital on 11 April 2013 due to abdominal pain for half a year and aggravated for 3 days. Six months ago, the patient developed abdominal pain without obvious trigger, showing paroxysmal colic, mainly around the umbilicus, obvious at night, often starting at 3 o'clock in the middle of the night, lasting for 3~4 hours and slightly relieved, without hematemesis, melena, fever, amaurosis, syncope, and no stopping anal exhaust and defecation. The local hospital considered it to be a stomach disease, and the abdominal pain was not significantly relieved after taking stomach medicine (specifics unknown). Three days before admission, the patient's abdominal pain progressively worsened and radiated to the back of the waist. It could be slightly improved when the knee was bent. He defecated bright red soft stool twice, with moderate amount, accompanied by sweating, no nausea, vomiting, no fever, no acid reflux, belching, and no anal stopping exhaustion and defecation, so he came to the hospital for treatment. CT examination showed consideration of middle and lower abdominal intussusception with incomplete obstruction. Plain X-ray of the abdomen showed incomplete intestinal obstruction. Physical examination at admission: body temperature 37℃, clear consciousness, normal spirit, no yellowing stain of skin and sclera, superficial lymph nodes not swollen, normal cardiopulmonary function, flat abdomen, no subcostal reach of liver and spleen, no tenderness in gallbladder area, negative Murphy's sign, whole abdominal tenderness, no rebound pain, oblique 8 cm ×7 cm mass palpable in the right lower abdomen, sausage-shaped, fixed, tenderness, no rebound pain, clear boundary, negative tremor sound, negative mobile voiced sound, and intestinal sound of 6~8 times/min. Routine blood RBC count was 4.10×10¹²/L with a PLT count of 188×10⁹/L with a WBC count of 13.85×10⁹/L, Hb was 117 g/L, and neutrophils accounted for 0.91. Liver function: 33.5 g/L for albumin, 9 mmol/L for glucose, 1 μ mol/L for IBil, 143 μ mol/L for uric acid and normal electrolytes. Tumor markers CA19-9, CEA, CA125, AFP, cancer antigen 15-3 and cancer antigen 72-4 were all in the normal range. The initial diagnosis was intussusception and incomplete intestinal obstruction. Exploratory laparotomy was performed on the night of admission. During the operation, there was no ascites in the abdominal cavity, no obvious metastatic implant nodules in the mesentery, etc. The lesion was located about 100 cm from the proximal end of the ileocecal region, and the small intestine showed intussusception changes, which was intussusception of the small intestine. The proximal small intestine was mildly dilated with a little intestinal fluid, and the distal small intestine was dark brown fluid. Intraoperative diagnosis was incomplete intestinal obstruction, intussusception and intestinal duplication malformation. Partial resection of the small intestine was performed. Postoperatively, the specimen was cut to see a cord in the small intestine, about 8.0 cm ×1.5 cm in size, ulcer formation on the mucosal surface, and serous surface on the dorsal surface with yellow fat-like tissue. Postoperative pathology showed intestinal duplication of "small intestine" with ectopic pancreas and erosion (Figure 1)。 The patient recovered well after surgery.

H．pyloriThe global infection rate in natural populations has exceeded 50%^[1]。 Epidemiology has confirmed that,H.pyloriInfection is closely related to a variety of upper gastrointestinal diseases, such as gastritis, peptic ulcer, gastric cancer and gastric MALT lymphoma. The study found that,H.pyloriInfection can also increase the risk of other diseases, such as coronary atherosclerotic heart disease (hereinafter referred to as coronary heart disease) and end-stage kidney disease. In recent years, withH.pyloriThe increase in antibiotic resistance,H.pyloriThe eradication rate showed a downward trend. Therefore, the treatment plan should be reasonably selected according to the drug resistance situation. InH.pyloriPPI has been widely used in eradication treatment schemes. Now we mainly introduce PPI in eradicationH.pyloriThe role played in.

PPI passes through H acting on parietal cells^＋K^＋-ATPase blocks the last pathway of acid secretion, strongly and effectively inhibits gastric acid secretion, and is widely used in the treatment and eradication of various acid-related diseases (peptic ulcer, GERD, upper gastrointestinal bleeding, Zollinger-Ellison syndrome, corrosive esophagitis)H.pyloriOne of the important drugs used in combination with infection^[1]。 Commonly used PPIs include esomeprazole, omeprazole, lansoprazole, pantoprazole, rabeprazole, ilaprazole, etc. Among them, esomeprazole has an efficient and stable acid suppression effect, and is widely used in clinical practice. It has become one of the drugs with the largest prescription volume of PPI in the world.

autoimmune liver disease is a group of liver damage mediated by immune response. According to clinical manifestations, biochemical tests, imaging examinations and histopathological characteristics, it can be divided into autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). Clinically, when a patient has the clinical, serological and histological features of any of the above two diseases at the same time or at different stages of the disease course, it is referred to as overlap syndrome (OS). In recent years, with the deepening of the understanding of autoimmune diseases and the advancement of examination methods, in addition to the above-mentioned overlapping patterns, the phenomenon of autoimmune liver disease combined with other extrahepatic autoimmune diseases has been more and more reported. However, there is still a lack of systematic understanding of this phenomenon, so the latest research progress of this phenomenon is reviewed.