2018年 · 第38卷第09期

In 2007, Chinese Journal of Digestion organized some domestic experts from gastroenterology, surgery, radiology and nuclear medicine to formulate the "Recommended Procedure for Diagnosis and Treatment of Unexplained gastrointestinal bleeding (OGIB) (Nanjing, March 2007)"^[1]It has promoted domestic research on OGIB and improved its diagnosis and treatment level. At that time, OGIB was defined as persistent or recurrent gastrointestinal bleeding for which routine digestive endoscopy (including upper gastrointestinal endoscopy to examine the esophagus to the descending duodenum and colonoscopy from the anorectum to the ileocecal valve) and routine X-ray barium examination did not determine the cause. In 2012, the Chinese Journal of Digestion once again organized experts to revise the recommended process, and added small intestine CT as an examination method to the definition of OGIB^[2]。 In 2015, in the domestic "Guidelines for the Diagnosis and Treatment of Acute Non-varicose Upper Gastrointestinal Bleeding (Nanchang, 2015)", OGIB was still defined as "persistent or recurrent gastrointestinal bleeding whose cause cannot be determined by routine endoscopy (including gastroscopy and colonoscopy)"^[3]。

With the change of social operation and lifestyle, the digestive health problems associated with mental stress and behavior change gradually increase^[1,2,3,4]。 In the clinical practice of gastroenterology, the so-called "refractory" diseases are often encountered, that is, according to the existing diagnosis and treatment norms, the inherent diagnosis and treatment thinking and commonly used drugs of gastroenterology are applied. Although sufficient courses of treatment are achieved, the ideal curative effect can still not be obtained. In response to these clinical challenges, more and more gastroenterologists are trying to apply central nervous system drugs to improve efficacy^[5,6,7,8]。 Many clinical research results also show that the application of central nervous system drugs can indeed help to improve the efficacy^[6,7,8]。 However, there are many studies that show that its efficacy is not better than that of placebo^[9,10]。 The inconsistent (or even opposite) findings of these studies suggest that digestive diseases related to psychosomatic factors may be a class of diseases with very "heterogeneous" characteristics, or there may be more detailed factors affecting the efficacy of central nervous system drugs^[11,12]。 Therefore, it is a hot and difficult point in the treatment of difficult diseases in digestive specialty to explore how to use central nervous system drugs accurately and improve the curative effect of "refractory" digestive diseases^[13]。

A single biomedical model confined to finding disease attributions and treatments has encountered great challenges from clinical practice. The confusions and challenges encountered in the clinical practice of gastroenterology under the biomedical model mainly include three aspects: ① the so-called "functional" symptoms that can be explained by organic diseases cannot be found; ② Symptoms that are difficult to explain and obtain therapeutic effect with the primary organic disease itself or its activity degree; ③ Emotional and physical symptoms induced by iatrogenic stress in gastroenterology. Now we mainly discuss how gastroenterologists can recognize and face these challenges. On the basis of fully accepting the contribution of mature science and technology to medicine, how to get out of the limitations of a single biomedical model, better understand and practice the holistic medical model of mind and body, solve the clinical gastroenterology problems that biomedicine can't solve yet, and establish a brand-new gastroenterology discipline system that integrates mind and body including biomedicine.

Disease perception and disease behavior are an important component of functional gastrointestinal disorders (FGID), and the aim is to introduce this concept to gastroenterologist clinicians, as well as preliminary methods of clinical evaluation and intervention.

Primary duodenal adenocarcinoma is a malignant tumor originating from the glandular epithelium of the duodenal mucosa, excluding tumors in the Vater's ampulla, the lower common bile duct, and the head of the pancreas. The overall prevalence of primary duodenal adenocarcinoma is low, accounting for less than 1% of all gastrointestinal malignant tumors and 30% ~45% of all small intestinal malignant tumors, but its incidence tends to increase year by year^[1]。 There are few literature reports on primary duodenal adenocarcinoma, which is difficult to diagnose early, and is prone to misdiagnosis and misdiagnosis. Current literature reports on treatment modalities, survival and prognostic factors of primary duodenal adenocarcinoma^[2,3]Not consistent. In this study, the clinical data of 99 patients with primary duodenal adenocarcinoma were collected and analyzed to provide clinical basis for the diagnosis, treatment and prognosis evaluation of this disease.

The human digestive tract is divided into upper digestive tract and lower digestive tract with Treitz ligament as the boundary. Lower digestive tract bleeding refers to bleeding originating from the distal end of Treitz ligament, which can be caused by a variety of diseases. Patients have no obvious symptoms when the amount of bleeding is small, and when the amount of bleeding is large, they may have bloody stool, peripheral circulatory system failure, etc., and even lead to death in severe cases. The annual incidence of lower gastrointestinal bleeding in adult hospitalization is (21-87) /100,000^[1]。 Although the research on lower gastrointestinal bleeding has gradually increased in recent years, there are still few large sample studies on lower gastrointestinal bleeding in China. The clinical characteristics and associated risk factors of 255 patients with lower gastrointestinal hemorrhage were retrospectively analyzed in this study, which are reported below.

idiopathic mesenteric phlebosclerosis (IMP) is a rare type of ischemic colitis with low incidence. It is easy to be misdiagnosed and misdiagnosed because of the non-specificity of clinical manifestations and laboratory tests. Clinicians need to strengthen their understanding of this disease^[1,2,3,4,5]。 In this study, the clinical data of 7 patients with IMP were retrospectively analyzed, and the diagnostic value of CT and endoscopy in IMP was discussed in combination with relevant literature.

autoimmune pancreatitis (AIP) is a rare chronic inflammatory autoimmune disease of the pancreas, which is characterized by fibrosis caused by infiltration of pancreatic plasma cells, diffuse or focal pancreatic enlargement and irregular pancreatic duct stenosis, increased serum immunoglobulin G (IgG) 4 levels, and significant efficacy of steroid hormones^[1]。 If AIP involves the pancreatic tail and compresses the splenic vein, causing obstruction of blood return, it can lead to left-side portal hypertension (LSPH), also known as regional portal hypertension (RPH). LSPH is a type of extrahepatic portal hypertension, accounting for only about 5% of patients with portal hypertension^[2]Its etiology is mainly divided into pancreatogenic and non-pancreatogenic lesions, with pancreatogenic lesions as the main lesions. At present, there are few reports on LSPH caused by AIP. This study reported the clinical characteristics and experience of diagnosis and treatment of 2 patients diagnosed with AIP combined with LSPH, and reviewed the relevant literature to improve the clinical understanding of this disease.

UC is a class of chronic intestinal inflammatory diseases, and commonly used therapeutic drugs include immunosuppressants and biologics. The inflammation of UC itself and the application of immunosuppressive drugs may lead to an increased risk of developing tumors, and the treatment of UC and tumor recurrence often interact with each other, so the treatment of such patients is a clinic thorny problem. The medical records of a patient with UC complicated with thyroid cancer diagnosed and treated in Peking Union Medical College Hospital were analyzed, and the treatment situation was discussed.

The 18-year-old male was admitted to Shenyang Tenth People's Hospital on July 13, 2017 due to "chest pain, choking after eating, accompanied by fever for 20 days". Twenty days before admission, the patient had chest pain, choking after eating, accompanied by fever without obvious triggers. The highest body temperature was 39.1℃, which occurred more in the afternoon and at night, night sweats at night, no chest tightness, shortness of breath, no choking after eating, no cough or expectoration. On June 28, 2017, I visited the local hospital. Chest CT examination showed that there were soft tissue nodules in the mediastinum, about 4.3 cm ×3.0 cm in size; Blood routine showed a white blood cell count of 11.9×10⁹/L, the local hospital considered that the infection caused changes in chest CT and blood routine, and gave levofloxacin and cephalosporin antibiotics anti-infective treatment for 2 weeks, but the symptoms were not significantly relieved. Because his cousin suffers from tuberculosis, the patient has a history of contact, and the purified protein derivative of tuberculin (PPD) test found in the local tuberculosis prevention and control institute showed a strong positive result. Therefore, considering the possibility of mediastinal lymph node tuberculosis, the initial treatment plan: isoniazid, rifampicin, pyrazinamide and ethambutol was given for 1 week of anti-tuberculosis treatment. After the symptoms improved slightly, he was transferred to Shenyang No.10 People's Hospital for further treatment on July 13, 2017. After admission, the anti-tuberculosis treatment plan was suspended, and relevant examinations were improved. Chest CT examination showed that the thorax was symmetrical and normal in shape; Small nodules were seen in the basal segment of the lower lobe of the right lung, with clear boundaries, and the trachea and main bronchi were unobstructed; Multiple enlarged lymph node shadows in the mediastinum, the larger one is located under the tracheal carina, the size is about 2.6 cm ×3.5 cm, the CT value is about 33 HU, and patchy low-density shadows can be seen in the center, and the surrounding structures such as the esophagus are compressed, and the local boundaries are unclear; There was no thickening of the bilateral pleura, no fluid density shadow in the pleural cavity, no bone destruction in the thoracic bones, and no abnormal changes in the soft tissue of the chest wall. The patient refused enhanced CT examination. On July 14, 2017, the ESR was 17 mm/1 h, and the tuberculosis antibody was negative. There were no abnormalities in blood routine, urine routine, fecal routine, coagulation function, liver function, hepatitis B virus complete set, syphilis and human immunodeficiency virus antibody. On July 15, 2017, T cell enzyme-linked immune sport assay (T-SPOT) was positive, and no bacterial growth was observed in sputum culture and multiple sputum acid-fast bacilli. On July 18, 2017, a gastroscopic examination in the Department of Gastroenterology showed that a deep ulcer was seen on the posterior wall of the esophagus about 30 cm away from the incisors, about 2.0 cm ×3.0 cm in size, with a white coating in the center and a bulge in the surrounding mucosa. After inflation, a fistula-like change was seen in the center of the ulcer, and no bubbles and secretions were seen (Figure 1)； No significant changes were observed in the stomach and duodenum. Two pieces of tissue were taken and sent for pathological examination, which showed ulcerative lesions. Five other pieces of tissue were detected by real-time fluorescence quantitative nucleic acid amplification detection technology (Gene X-pert MTB/RIF) for rifampicin resistance, which showed that Mycobacterium tuberculosis (Mycobacterium tuberculosis, MTB) infected and rifampicin resistant. On 20 Jul 2017, bronchoscopy showed chronic inflammation of the trachea and chronic inflammation of the bronchi, and tuberculosis of the left common and right common bronchi was not excluded. No MTB growth was observed in the bronchoscopic lavage fluid and the rapid culture of TB 960.

The 46-year-old female was admitted to the Department of Oncology, Drum Tower Hospital affiliated to Nanjing University School of Medicine in March 2017. She had a history of hypertension and type 2 diabetes, and had no family history of tumor. Take "Beijing Antihypertensive Zero" to control blood pressure, and the control is acceptable; Metformin was taken to control blood sugar, and the control was unknown. In December 2015, he underwent right ovariectomy in a local hospital due to ovarian occupation. The postoperative pathology showed Krukenberg tumor, and the pathology also considered Krukenberg tumor after consultation with other hospitals. Gastrointestinal endoscopy, total abdominal CT examination and positron emission tomography-computed tomography (PET-CT) did not show any obvious abnormalities, and the primary lesion was never found. During the first chemotherapy, the gastrointestinal reaction was severe and intolerable, so chemotherapy was abandoned. After visiting the Drum Tower Hospital affiliated to Nanjing University School of Medicine, gastroscopy in gastroenterology department found that the small curved side of the lower part of the stomach body had a straight diameter<1 cm white lightly depressed lesion (FIG. 1A), pathological examination of biopsy showed signet ring cell carcinoma, laboratory examination showed that tumor markers carcinoembryonic antigen, alpha-fetoprotein, CA125, carbohydrate antigen 72-4, carbohydrate antigen 242, CA19-9 were all within the normal range, and blood routine, liver function and renal function tests were basically normal. narrow band imaging-magnifying endoscopy (NBI-ME) examination showed that the boundary line of the lesion existed, the microglandular structure disappeared, and abnormal microvessels (FIG. 1B)。 endoscopic submucosal dissection (ESD) was performed to completely excise the lesion. The postoperative pathology showed that gastric signet ring cell carcinoma, the carcinoma tissue infiltrated the superficial layer of mucosal lamina propria (stage T1a), and the lesion extent was about 0.9 cm ×0.4 cm (FIG. 2A)。 The macroscopic classification was type IIC. There was no invasion of cancerous tissue in the vessels, no residual tumor tissue in the lateral and basal margin of the specimen, and the surrounding gastric mucosa showed mild chronic non-atrophic gastritis. Immunohistochemical staining of intragastric lesions revealed cytokeratin 7 (−), cytokeratin 20 (+ + +), villin (−), mucin 2 (−), mucin 5AC (+,Figure 2B), mucin 6 (−), tail homeobox transcription factor 2 (−), cytokeratin (+), proliferating cell nuclear antigen 67 (about 8%, +), ovarian tumor immunohistochemical staining revealed mucin 2 (−), mucin 5AC (+,Figure 2C), mucin 6 (-), considering that gastric lesions are homologous to ovarian tumors. This patient did not undergo any treatment for nearly 2 years after ovarian surgery to admission to our hospital, and his primary tumor did not progress and there was no obvious evidence of metastasis in other sites.

IBD refers to a group of non-specific intestinal inflammation of unknown etiology, including UC and CD, which are pathologically manifested as intestinal mucosal inflammation. The etiology and pathogenesis of this disease are not fully understood, but may be related to immune, genetic, infective, psychological factors and so on. In recent years, the incidence of IBD has gradually increased, accompanied by psychological diseases such as anxiety and depression. Brain functional imaging technology is an important means of psychological research. Electroencephalogram, event-related potential, magnetoencephalogram, positron emission tomography, single photon emission computed tomography, functional magnetic resonance imaging and functional infrared imaging, etc., through the measurement of electromagnetism, metabolism, blood flow, oxygen consumption and neuronal activity of human brain, the relationship between psychological factors and IBD-related mechanisms was studied. The research progress of IBD and psychological factors is summarized as follows.

IBS is one of the most common functional gastrointestinal disorders (FGID) in clinical practice. Latest diagnostic criteria for IBS Rome IV criteria^[1]It is defined as recurrent abdominal pain with symptoms that have occurred for at least 6 months and have occurred at least once a week on average in the last 3 months, and at least 2 of the following conditions are met: ① related to defecation; ② With changes in the frequency of defecation; ③ With changes in fecal traits. According to the main abnormal bowel habits of patients, IBS can be subdivided into constipation-predominant irritable bowel syndrome (IBS-C), diarrhea-predominant irritable bowel syndrome (IBS-D), irritable bowel syndrome with mixed bowel habits (IBS-M) and undefined-irritable bowel syndrome (IBS-U).