2018年 · 第38卷第04期

Over half of the world's population is infectedH.pyloriThe majority of adultsH.pyloriInfection is acquired in childhood, mostly in early childhood, and it is generally difficult to spontaneously clear after infection, resulting in lifelong infection. Children have their own characteristics in growth and development, immune response and drug metabolism, so inH.pyloriThere are some differences between children and adults in the epidemiological characteristics, pathogenesis, disease spectrum and clinical management of infection. Children compared to adultsH.pyloriLow probability of developing serious illness after infection; There are few types of drugs to choose from, and the tolerance to adverse drug reactions is low;H.pyloriThe rate of reinfection after eradication is high. In addition, young children are not excludedH.pyloriInfection may have potential benefits to its immune balance. These childrenH.pyloriThe characteristics and standardized management of infections require the joint attention of pediatricians and gastroenterologists.

InH.pyloriBefore its discovery, it was believed that the stomach was sterile because the high acid environment in the stomach prevented bacteria from colonizing it untilH.pyloriOnly when it was discovered was this idea broken. With the development of high-throughput sequencing technology in recent years, people have gradually found that gastric internal sequencingH.pyloriThere are other bacterial colonizations.H.pyloriInfection can affect the gastrointestinal flora by altering the biological, mechanical, and mucosal immune barriers of the gastrointestinal tract. Therefore,H.pyloriIn addition to the role of its own virulence factors, the imbalance of gastrointestinal flora induced by infection may also participate in the occurrence and development of disease. At the same time, gastrointestinal flora may also play a role in the development of diseaseH.pyloriImpact on colonization and pathogenesis of the gastric mucosa.

acute primary epiploic appendagitis (APEA) is one of the causes of clinical acute abdomen. With the improvement of understanding of this disease and the widespread application of imaging, especially CT, its incidence has increased in recent years. APEA is a benign self-limiting disease with ischemic infarction caused by intestinal lipid blood supply disorder. Its clinical manifestations are often similar to peritonitis, diverticulitis, appendicitis, panniculitis and ovarian lesions. Some cases are difficult to differentiate and easy to misdiagnose^[1,2,3,4]。 The disease has characteristic CT imaging findings, and recognition of its imaging features is helpful for diagnosis and treatment. This study retrospectively analyzed the medical records of 15 patients with APEA, aiming to summarize the CT imaging features of APEA and its clinical application value.

Radiotherapy is an important treatment for pelvic malignant tumors, but it can also cause serious effects on tissues and organs adjacent to target organs. The incidence of chronic radiation proctitis (CRP) can reach 20%, usually within a few months to several years after the end of radiotherapy. CRP patients often show bright red bloody stool with or without tenesmus, urgency to defecate, diarrhea, mucous stool, rectal pain^[1]The most common clinical symptom is rectal bleeding, which can be accompanied by symptoms of iron deficiency anemia. CRP is due to endarteritis obliterans, submucosal tissue fibrosis, and neocapillary dilatation^[2]。 At present, there is no standard treatment plan for CRP bleeding. The common treatment plan is mainly topical corticosteroids, formaldehyde solution, sulfasalazine and sucralfate enema, but the treatment effect is not good. Studies have shown that fecal bypass surgery is not effective in the treatment of CRP refractory hemorrhage, and has a high complication rate and mortality rate^[3]。 Current studies have shown that argon plasma coagulation (APC) is an effective treatment for CRP hemorrhage, and may be effective for other symptoms of CRP^[4]。 APC transmits high-frequency current through ionized argon gas, which produces non-contact osmotic coagulation to the mucosa to stop bleeding. Its therapeutic advantage is that the contact surface with the mucosa is uniform, and the coagulation depth (0.5~3.0 mm) can be limited, thus minimizing the risk of perforation, stenosis and fistula. This study attempted to treat CRP hemorrhage with APC and is reported below.

hepatic sinusoidal obstruction syndrome (HSOS) is an intrahepatic sinus portal hypertension, which has many similarities in clinical manifestations and signs with Budd-Chiari syndrome, decompensated cirrhosis and acute hepatitis, which brings difficulties in the diagnosis and treatment of HSOS. This study retrospectively analyzed the clinical data of 22 patients with HSOS and summarized their clinical characteristics, aiming to improve the understanding of the disease and find an effective diagnosis and treatment plan.

neuroendocrine neoplasm (NEN) is a group of heterogeneous tumors originating from peptidergic neurons and neuroendocrine cells, among which gastroenteropancreatic-neuroendocrine neoplasm (GEP-NEN) is the most common type of NEN, accounting for about 65% to 75% of all NEN^[1]。 Epidemiological surveys in several countries and regions showed that the incidence of GEP-NEN showed a steady upward trend^[2,3,4]。 The understanding and research of GEP-NEN in China is relatively lagging behind, and the tumor registry system has not covered all provinces, municipalities and autonomous regions in China, especially in the western region, there is a lack of authoritative epidemiological data^[5]。 At present, there are very few reports of this disease in Yunnan Province, and the related incidence and diagnosis and treatment status are still rarely reported. The purpose of this study was to obtain epidemiological data on the incidence, diagnosis and treatment of GEP-NEN in Yunnan Province, establish an open database of GEP-NEN in Yunnan Province, improve clinicians' understanding and diagnosis and treatment level of this kind of disease, improve the prognosis of patients, and provide data for the national epidemiological study of GEP-NEN.

Gastroenterology Branch of Chinese Medical AssociationH.pylori/Peptic Ulcer Group in the 5th NationalH.pyloriOn the occasion of the first year of the Infection Treatment Consensus Conference, it was held in Guangzhou in January 2018H.pyloriThematic sessions. The contents mainly include summarizing the work of the school group, the 5th nationalH.pyloriInfection Management Consensus Report^[1](hereinafter referred to as the fifthH.pyloriConsensus) Answering and discussing questions raised in the lecture, eradicatingH.pyloriNegative effects, emphasis on eradicatingH.pyloriPrevention of gastric cancer andH.pyloriSeveral research advances (H.pyloriWith gastrointestinal microecology, childrenH.pyloriInfection management guidelines/consensus, etc.).

Porphyria is a kind of disease caused by the abnormality of some enzymes in the process of hemoglobin synthesis, which hinders the synthesis of heme, and causes the excessive accumulation and secretion of porphyrin and porphyrin precursors that are not converted into heme in the body. Because the disease is relatively rare, its clinical manifestations are diverse, intermittent, gradual and occult, which brings certain difficulties to clinical diagnosis and is easy to misdiagnose and misdiagnose. This paper analyzes the diagnosis and treatment process of a case of erythropoietic protoporphyria (EPP) diagnosed only after the disease progressed to esophagogastric vein rupture and hemorrhage of liver cirrhosis in the Department of Hepatobiliary Medicine of Fuzhou General Hospital of the People's Liberation Army, summarizes the lessons of delayed diagnosis, discusses the diagnostic thinking of rare diseases and improves the clinical diagnosis level of difficult diseases.

The patient, a 32-year-old female, was married. She was admitted to the First Affiliated Hospital of Suzhou University on December 12, 2016 because she "found a mass in her right lower abdomen for 2 years and increased for nearly 2 months". In the past 2 months, the patient had repeated nausea and vomiting with weight loss, but no improvement was seen after symptomatic treatment. There were two previous cesarean sections in 2012 and 2014, and no special medical history. Physical examination at admission: body temperature 37.0 ℃, pulse 79 beats/min, respiratory rate 18 beats/min, blood pressure 110/80 mmHg (1 mmHg =0.133 kPa); A mass can be palpable in the right lower abdomen, about 10 cm ×9 cm in size, hard in texture, without tenderness, with clear borders and can be pushed; The liver and spleen were not palpable under the costs, the mobile voiced sound was negative, and the intestinal sound was normal. Blood routine showed a white blood cell count of 4.8×10⁹/L, with a red blood cell count of 4.8×10¹²/L, hemoglobin was 141 g/L, and platelet count was 212×10⁹/L. There were no abnormalities in urine routine and tumor markers CA19-9, CA125, carcinoembryonic antigen and alpha-fetoprotein. The full set of biochemistry examinations showed an ALT of 177.2 U/L, an AST of 68.8 U/L and a potassium ion of 3.32 mmol/L. Abdominal ultrasonography showed a substantial mass in the middle and lower abdomen, approximately 139 mm ×71 mm ×157 mm in size (digestive tract origin?). Abdominal CT examination showed that the abdominal cavity occupied a huge space, with a size of approximately 16.7 cm ×7.8 cm. Considering the possibility of myxoma (Figure 1)。 Clinical diagnosis: The abdominal cavity is huge and occupies space, the nature of which is to be determined. He was transferred to the general surgery department for operation. During the operation, a huge round solid tumor in the abdominal cavity was seen, with a size of about 18 cm ×15 cm ×10 cm, with an intact envelope and a close relationship with the small mesenteric. The mass seemed to originate from the retroperitoneal cavity, with the upper boundary reaching below the pancreas, invading and squeezing the horizontal segment of the duodenum, resulting in obvious dilatation of the proximal intestinal canal and the lower boundary reaching the level of iliac blood vessels. Combined with the preoperative medical history, physical signs and imaging findings, the intraoperative diagnosis was a huge retroperitoneal tumor with mesenteric and duodenal invasion. Gross pathological examination showed that the abdominal cavity occupied a huge space, and a mass was visible to the naked eye, about 18 cm ×13 cm ×9 cm in size, with a suspected intestinal mucosa attached to the surface, about 7 cm ×7 cm ×1 cm in size, and the cut surface was gray-white and partially gray-red. Another section of intestinal tube specimen, about 23 cm ×2 cm ×2 cm in size, showed local intestinal mucosal congestion and edema by incision. Exploration revealed 2 suspected lymph node-like tissues with a diameter of 0.5 cm. Examination under light microscope revealed (abdominal cavity) spindle cell tumor (Figure 2)。 Immunohistochemical examination showed that β-catenin was positive, and tumor cells CD117 (small focus weakly positive), Ki-67 (5%), CD34, DOG-1, desmin, smooth muscle actin (SMA), S100 and Syn were all negative. Genetic testing not detectedc-kitand platelet-derived growth factor receptor alpha,PDGFRA) gene exon mutations. The postoperative pathological diagnosis was mesenteric fibromatosis (MF).

A 28-year-old female was admitted to the hospital on January 7, 2015 due to "recurrent upper abdominal pain for 1 year and recurrence for 7 days". One year ago, the patient had repeated persistent upper abdominal pain without obvious trigger, and blood and urine amylase were significantly increased. Ultrasound and CT examination showed pancreatic swelling and exudation, and the diagnosis was acute pancreatitis (mild), which occurred 7 times before admission. No drinking habits. magnetic resonance cholangiopancreatography (MRCP) examination at the third attack showed that cholecystitis was considered and gallbladder mud-like stones were possible. The diagnosis was acute attack of chronic calculous cholecystitis and acute biliary pancreatitis. Laparoscopic cholecystectomy was performed in a local hospital. endoscopic retrograde cholangiopancreatography (ERCP) showed no dilatation of the common bile duct, no calculi, and submucosal bulging lesions of the duodenal papilla. Two duodenoscopy examinations were performed in two hospitals in Shanghai, respectively, and it was reported that the submucosal occupation of the descending duodenal bulb was possible, and the huge diverticulum of the descending duodenum was reported. Physical examination at admission showed clear consciousness, no yellowing stain on the sclera, no swelling of superficial lymph nodes, no special lung and heart, flat and soft abdomen, mild tenderness in the upper abdomen, no rebound pain, and no mass. Laboratory examination: GGT 165 U/L, blood amylase 104 U/L, urinary amylase, blood lipase, IgG4, AST, ALT, ALP, bilirubin, blood lipid and other indexes were normal. Ultrasonography: After cholecystectomy, the intrahepatic and extrahepatic bile ducts did not dilate, and no obvious abnormalities in the pancreas were observed. Enhanced CT examination of the pancreas revealed edema in the duodenal papillary area and mild sulcus pancreatitis. Endoscopic ultrasound showed that there was a webbed membrane between the medial wall and the lateral wall of the descending duodenum, the rear of the webbed membrane was the blind end, the front of the webbed membrane was communicated with the distal end of the descending duodenum, and the duodenal papilla was located on the lateral side of the webbed membrane; The pancreatic echo was slightly lower, the pancreatic duct was not dilated, and the common bile duct was not calculated. Double air-barium angiography showed diverticular changes in the descending duodenum; CT coronal reconstruction showed an intraluminal diverticulum in the descending duodenum with a longitudinal depth of about 5 cm, accompanied by edema of the inner wall of the duodenum (duodenal papillary area) (Figure 1)。 Endoscopic endoduodenal diverticular diaphragmotomy was performed with the informed consent of the patient. Olympus 260J gastroscope was used with a transparent cap at the front end. The diaphragm was longitudinally incised along the inner side of the diaphragm with a hook knife and IT2 knife, and the nipple was carefully avoided until the blind end of the diverticulum was completely open without barrier (Figure 2)。 The patient developed melena (4 times/d) on the third day after surgery, without hematemesis, abdominal pain, etc. The monitoring of vital signs was stable, and the hemoglobin dropped to 1.0 g/L. He was discharged after fasting, acid suppression, hemostasis and fluid rehydration. Endoscopy 2 months after surgery showed disappearance of intraluminal diverticulum in the descending duodenum and patency of intestinal lumen. There was no recurrence of abdominal pain or pancreatitis after 2 years of follow-up.

At present, the pathogenesis of IBS is still unclear. Scholars generally believe that IBS is caused by various factors such as intestinal flora imbalance, psychological changes, enhanced visceral sensitivity, impaired intestinal barrier function and changes in immune function. The composition of the intestinal flora is altered in IBS patients compared to healthy people. The basic basis of probiotic treatment of IBS is: ① the number of intestinal probiotics in IBS patients decreases; ②The intestinal probiotic activity of IBS patients is reduced; ③ Intestinal microecology plays an important role in gastrointestinal function and disease occurrence^[1]。 Although clinically applied probiotic preparations can effectively alleviate the symptoms of IBS patients, the specific mechanism is still unclear. Now, the mechanism of probiotic adjuvant treatment of IBS is reviewed from the general situation of probiotics and their protection of intestinal mucosal barrier function, regulation of intestinal immune function, regulation of visceral hypersensitivity and motility disorder, regulation of brain-intestinal axis, regulation of bipolar disorder, and regulation of small intestinal microecology.

Acute pancreatitis is an inflammatory reaction in which pancreatic tissue digests itself due to abnormal activation of pancreatic enzymes, resulting in pancreatic edema, bleeding and even necrosis. The incidence of acute pancreatitis is (13~45) /100,000^[1]About 15% of the patients progressed to severe acute pancreatitis (SAP) with many complications and high mortality^[2]。 In the past, portal vein thrombosis (PVT) was considered a relatively rare local complication of SAP. In recent years, with the increase of diagnosis and treatment level and understanding of this disease, its detection rate has also increased year by year. The study found that the incidence of PVT in SAP patients was 16%, while the incidence of PVT in acute necrotizing pancreatitis (ANP) patients was 50%^[3]。 PVT can cause ascites, intraabdominal hypertension, esophageal and gastric varices and even bleeding^[4]However, it is easy to ignore in the early stage, and most of them are discovered in the later stage due to other symptoms. However, at this time, the treatment is difficult, the prognosis is poor, and the mortality rate is high. Early prevention of PVT can reduce the occurrence of complications and reduce the mortality rate in the later stage. Although both domestic and foreign guidelines recommend the use of anticoagulants such as low relative molecular weight heparin to prevent thrombosis in hospitalized patients with higher risk of thrombosis^[5,6]However, there is no consensus on whether patients with SAP or ANP prone to PVT need to use anticoagulants such as low relative molecular weight heparin. The formation mechanism and prevention strategy of concurrent PVT in SAP are emphasized.