2017年 · 第37卷第07期

The digestive tract is the longest organ in the human body. Because of its tortuous shape and overlapping with each other, traditional examination methods can only observe the structure in the intestinal lumen, but can't show the structure outside the intestinal wall^[1]。 Many intestinal diseases can penetrate the intestinal wall and invade the lumen, so effective imaging examination is very important for the diagnosis and treatment of diseases. computer tomography enterography (CTE) has been widely used in intestinal diseases, especially small intestinal diseases, and its diagnostic value has been confirmed and recognized^[2,3]。 However, CTE is radiation dangerous and may not be the first choice for children and patients of childbearing age. With the development of MRI equipment and rapid scanning technology, magnetic resonance enterography (MRE) has been gradually applied to the examination of intestinal diseases. Through the comparative study of MRE and CTE, the diagnostic value of MRE for intestinal diseases was discussed.

IBS, as one of the common functional gastrointestinal diseases, is often characterized by recurrent abdominal pain, abdominal distension, abdominal discomfort and altered intestinal function^[1]Its etiology and pathogenesis are still unclear, and it is currently believed to be the result of a combination of factors^[2,3]。 In recent years, the role of stress in the pathogenesis of IBS has attracted increasing attention. Under stressful conditions, corticotropin releasing factor (CRF) can be released to cause changes in the structure and expression of intestinal tight junction-related proteins, which can change the permeability of intestinal epithelial cells, which plays an important role in the pathogenesis of IBS^[4,5]。

GERD is a common disease in gastroenterology, accounting for about 11% ~25% of gastroenterology outpatient clinics. Among them, GERD with typical symptoms such as heartburn and acid reflux accounts for 40% ~60%, and those with irritating dry cough, hoarseness, asthma, pharyngeal foreign body sensation and other symptoms account for about 70% ~90% of extraesophageal symptoms. They are often misdiagnosed as respiratory or throat diseases and delay the disease^[1]。 In recent years, due to the increase of stress and life pressure, the incidence of GERD with anxiety and depression has increased significantly.

Hypoalbuminemia is one of the common clinical symptoms, and its causes include hepatogenic, nephrogenic, tuberculous and neoplastic. In patients with hypoalbuminemia, the osmotic pressure of vascular colloids decreases, and multiple serous effusions occur, which can cause multiple edema throughout the body. The causes of hypoalbuminemia are varied, especially when there are fewer concomitant symptoms, causing difficulties in diagnosis. The medical records of a patient with difficult hypoalbuminemia admitted to Xi'an Xijing Gastroenterology Hospital were retrospectively analyzed to explore its diagnosis and treatment.

Case 1 was a 25-year-old female. The main reasons were intermittent fatigue, black tea urine for 16 months, periodic abdominal pain and low back pain for 14 months, abdominal pain, nausea and vomiting for 1 day. On February 8, 2011, he went to the Department of Gastroenterology, Hebei Provincial People's Hospital. Before admission, I had many abdominal pain, low back pain, reduced defecation and exhaust, accompanied by nausea, vomiting, general fatigue and discomfort, tachycardia, and black-tan urine. The triggers of attack were mostly menstrual cramps, fatigue, and upper respiratory tract infection. I went to many hospitals and was diagnosed as intestinal obstruction, which improved after symptomatic treatment. Hinterabdominal pain reappeared. Because the urine was orange-red, it turned dark red or burgundy red after exposure to the sun for 1 h, and it was suspected to be porphyria. Further investigation of intracellular zinc porphyrin was 4.8 μ g per g Hb, urinary porphyrin chologen (+) and uroporphyrin (-), and it was diagnosed as acute intermittent porphyria (AIP). Previous epilepsySeizure, respiratory muscle paralysis, ventilator support, intravenous drip of 50% glucose (300 g/d), and after remission, gonadotropin-releasing hormone analogues were given to control menstruation to avoid acute attacks. One day before this hospitalization, the patient developed fever without obvious trigger, with the highest body temperature of 37.7℃, chills, no chills, accompanied by general malaise, abdominal and low back pain, irritability, nausea, vomiting, and the vomit was stomach content. Physical examination: No photosensitive rash, no abnormalities in cardiopulmonary examination, tenderness under xiphoid process, no rebound pain, muscle tension, and normal intestinal sounds. Blood routine Hb was 101 g/L, electrolyte blood sodium was 123.7 mmol/L, urinary bilirubin (-), urinary biliogen (-), TBil was 22.3 μ mol/L, ALT was 48 U/L, AST was 72 U/L, and the diagnosis was AIP. Intravenous drip of 50% glucose (300 g/d) showed poor efficacy. Arginine heme (normosang) was applied at a dose of 4 mg·kg after patients were fully informed of risks such as drug allergy and informed consent was signed^－1• d^－1Dexamethasone was given before infusion to prevent allergic reaction for 4 days. The patient did not feel any discomfort during the infusion. After that, the patient's abdominal pain disappeared, and the symptoms such as general fatigue and discomfort gradually relieved. After discharge, I insisted on intramuscular injection of gonadotropin-releasing hormone analogues to control menstruation. After 3 months of follow-up, there was no obvious abdominal pain, holding breath and other discomfort, and I could live normally.

A 37-year-old male was admitted to the hospital in February 2016 due to aggravation of abdominal pain for 3 months with abdominal distension for 1 month. The patient developed abdominal pain without obvious trigger 3 months ago, which was dull periumbilical pain, without acid reflux, heartburn, nausea, vomiting, diarrhea, constipation, and intermittent abdominal pain. The abdominal pain can be relieved after application of omeprazole and other drugs. The patient's abdominal pain worsened 1 month ago, which was paroxysmal severe pain in the upper abdomen and periumbilical area, accompanied by obvious abdominal distension, sweating, no nausea, vomiting, and exhaustion and defecation. He went to a local hospital and underwent gastroscopy to show a columnar bulge in the cardia with surface erosion. Biopsy pathology showed chronic inflammation of the mucosa and gastric antrum mucosa congestion. He was diagnosed as chronic non-atrophic gastritis and cardia erosion. After being treated with omeprazole, his abdominal pain was relieved. He came to Qingdao University Affiliated Hospital for further diagnosis and treatment. Physical examination showed obvious periumbilical tenderness, no rebound pain and muscle tension, and active intestinal sounds, 7~8 times/min. Other physical examinations showed no obvious abnormalities. Abdominal pain was relieved after pantoprazole treatment. The abdominal enhanced CT examination showed that the local intestinal wall of the right lower abdominal ileum showed a long strip of fat density shadow, the surrounding wall was obviously thickened and enhanced, and the adjacent intestinal tube showed concentric circular changes, seeFigure 1AndFigure 2。 Diagnosis of terminal ileal lipoma with possible intussusception.

A 26-year-old female was admitted to the hospital on December 30, 2012 due to intermittent upper abdominal pain for more than half a year. Six months ago, the patient developed pain and discomfort in the upper abdomen without obvious trigger, which lasted for about 5 minutes each time, and could be relieved by itself, aggravated when hungry, and relieved after eating. With acid reflux, heartburn, no hematemesis, melena, abdominal distension and diarrhea. On December 22, 2012, the patient underwent gastroscopy in an external hospital, which revealed gastric stromal tumor with submucosal lesions of the gastric angle, and endoscopic ultrasound revealed submucosal mass occupation and lipoma of the gastric angle. No special treatment was performed. The patient was admitted to the hospital for further diagnosis and treatment with gastric bulge lesions. The patient was previously in good health and no abnormalities were found in the physical examination.

More than 30 years ago, when Warren and Marshall isolated and cultured a spiral, slightly anaerobic microorganism from the gastric antrum mucosa of gastritis patients, they may not have expected that this bacteria, which helped them win the 2005 Nobel Prize in Physiology and Medicine, was enough to subvert human understanding of some traditional diseases. Over the years, by trying to use powerful acid suppressants and antimicrobial drugs toH. pyloriKill them all, cure most peptic ulcers, chronic gastritis, indigestion and early gastric MALT lymphoma, and even take the most important step on the road to preventing gastric adenocarcinoma. 2015H. pyloriThe launch of the Kyoto Global Consensus Report on Gastritis is a final wordH. pyloriPositive gastritis is directly defined as an infectious disease, written into the international classification of diseases (ICD-11), and passed a new consensus that detectedH. pyloriAll positive patients should receive eradication therapy^[1]This is a decision that has not yet been written into the Maastricht Consensus, which has always led the world. But it seems that medical workers should thinkH. pyloriThis bacterium, which has a global adult infection rate of no less than 50%, has been observed by humans under a microscope for only more than 30 years, and may have existed in humans for at least 60,000 years. Some scholars have long proposed that,H. pyloriPerhaps it is a member of the normal bacterial flora that parasites in the human body and plays some positive role.

autoimmune hepatitis (AIH) is a chronic progressive autoimmune liver disease of unknown etiology, mostly in women, characterized by hyperimmunoglobulinemia, presence of autoantibodies in serum, and liver boundary laminitis. If left untreated, AIH can progress to cirrhosis, liver failure, and even death. In 2015, the consensus on the diagnosis and treatment of AIH clearly stated that for AIH patients, the combination treatment regimen of prednisone (dragon) and azathioprine is generally recommended preferentially. The initial dose of prednisone (dragon) is 30-40 mg/d, and the dose is gradually reduced to 10-15 mg/d within 4 weeks; Azathioprine was maintained at a dose of 50 mg/d^[1]。 Clinically, the vast majority of patients with AIH are effective in treatment, manifested by disappearance of clinical symptoms and biochemical remission (complete return of ALT, AST and IgG to normal), and histological remission [disappearance of liver inflammatory reaction or only mild inflammatory reaction, histological activity index (HAI) ≤4]; However, 10% ~15% of patients responded poorly to standardized therapy^[1,2,3]。 Because AIH is rare and has high heterogeneity, the diagnosis and treatment of AIH patients with unsatisfactory response to treatment is a difficult problem in clinical work at present. The progress in the diagnosis and treatment of patients with AIH unsatisfactory response to standardized treatment is reviewed to help clinicians make rational decisions.

Hepatocellular carcinoma is the most common liver malignant tumor originating from liver cells, accounting for more than 90% of liver malignant tumors^[1]。 Different from other tumors, the occurrence and development of most hepatocellular carcinoma follow the development process of chronic liver injury → liver fibrosis → cirrhosis → hepatocellular carcinoma caused by various etiologies. This also brings great challenges to the treatment of hepatocellular carcinoma, that is, how to actively treat hepatocellular carcinoma patients with cirrhosis on the premise of ensuring the liver reserve function. The assessment of liver function has always troubled the majority of medical staff, and the establishment of an efficient liver function assessment and grading system suitable for hepatocellular carcinoma patients has also aroused the strong interest of researchers. Based on the new liver function assessment classification, albumin-bilirubin (ALBI) model, the new advances in liver function assessment of hepatocellular carcinoma are reviewed.

IBD is a chronic nonspecific disease involving the gastrointestinal tract, including UC and CD, and unidentified intermediate intestinal inflammatory response lesions overlapping UC and CD^[1]。 In recent years, with the increasing incidence of IBD in developing countries, IBD has become a research hotspot, but the understanding of its etiology and pathogenesis is still not perfect^[2]。 At present, IBD is a disease of intestinal inflammatory response mediated by abnormal immune response of intestinal immune system to intestinal microbial antigen, and involved by environmental and genetic factors. infliximab (IFX) is a human-mouse chimeric IgG1 monoclonal antibody, which can specifically bind to TNF-α, thereby activating antibody-dependent cytotoxic pathway and complement-dependent cytotoxic pathway, inhibiting the immune damage and inflammatory response caused by TNF-α from the root cause, promoting intestinal mucosal repair, prolonging the survival time of patients and improving the quality of life of patients. However, 25% to 40% of IBD patients will experience drug unresponse during IFX treatment, including primary unresponse, secondary unresponse, and reuse unresponse after drug discontinuation. About 10% of IBD patients have to discontinue medication every year due to unresponse^[3]。 The possible mechanisms and coping strategies of IFX failure are reviewed.