Objective To explore the method of correctly judging intestinal dysfunction of ischemic bowel disease and the important clinical significance of timely treatment, as well as the application skills of traditional Chinese medicine. Methods 19 patients with intestinal dysfunction of ischemic bowel disease were diagnosed by colonoscopy, imaging examination and CT examination. And basically take symptomatic conservative treatment combined with traditional Chinese medicine. Among them, Chinese medicine particularly emphasizes the method of promoting blood circulation and stopping bleeding. Results 19 cases achieved good results. Among them, 1 case was caused by radiotherapy of gynecological tumor. After 1.5 years, colon perforation and gangrene occurred due to ischemic colitis. Partial intestinal resection and end-to-end anastomosis were performed, and intestinal fistula was caused by perforation again 9 days after operation, and he died 56 days later. Other patients were not followed up regularly. Conclusion It is of great clinical significance to master the correct judgment method and deal with the intestinal dysfunction of ischemic bowel disease in time. Avoiding emergency operation and blind hemostasis are the key to reduce complications. At the same time, we should pay attention to the method of removing blood stasis, and the method of promoting blood circulation and stopping bleeding is indeed a major method of treating intestinal dysfunction of ischemic bowel disease in traditional Chinese medicine, which is worthy of clinical reference.
Ischemic bowel disease; Diagnosis; Integrated traditional Chinese and western medicine treatment
Ischemic colitis (ic) is the most common type of gastrointestinal ischemic injury in the elderly, accounting for about 60% of intestinal ischemia and 3% ~ 9% of acute lower gastrointestinal bleeding in the elderly. Its clinical manifestations are reversible colonic lesions (submucosal or intramural bleeding), transient colitis, chronic ulcerative colitis, stenosis, gangrene and explosive diffuse enteritis [1 ~ 4]. When ischemic bowel disease occurs, patients may have a variety of clinical manifestations of intestinal dysfunction in addition to typical symptoms such as abdominal pain and bloody stool due to intestinal wall ischemia. Correct judgment and timely treatment of intestinal dysfunction is of great clinical significance for the treatment of ischemic bowel disease. The experience of diagnosis and treatment of 9 patients with ischemic bowel disease in recent two years (July 2002 to August 2004)/kloc-0 was reported as follows.
1 Clinical manifestations of ischemic bowel disease and intestinal dysfunction
No matter what causes intestinal ischemia, its clinical manifestations are similar. Although there are no special symptoms and signs, it still has its own characteristics and has certain value for diagnosis. The most common manifestation is sudden spasmodic pain in the left lower abdomen, accompanied by obvious defecation. In the next 24 hours, the blood in the stool is bright red or dark red, and the blood is mixed evenly. The amount of bleeding is not large, and blood transfusion is rarely needed, otherwise other diagnosis should be considered. Intestinal ischemia leads to intestinal dysfunction, which can cause nausea, vomiting, belching, abdominal distension, diarrhea and other symptoms. 19 patients, abdominal pain due to ischemic bowel disease 19 patients, bloody stool 17 patients, nausea and vomiting due to intestinal dysfunction in 4 patients, abdominal distension in 5 patients, diarrhea in 4 patients and constipation in 2 patients.
2 colonoscopy
It is of diagnostic significance, especially in the period of hematochezia, and emergency endoscopy is the key to early diagnosis. It can also determine the scope and staging of the lesion, and obtain histological examination, which is helpful for differential diagnosis with other inflammatory bowel diseases and colon cancer. According to the duration and severity of colonic ischemia, IC2 is generally divided into non-gangrenous and gangrenous. Among them, non-gangrene can be divided into transient and chronic. Transient disease becomes transient ischemia, involving mucosa and submucosa, which is characterized by mucosal congestion, edema, ecchymosis, submucosal bleeding, dark red mucosa, disappearance of vascular network and partial mucosal necrosis, followed by mucosal shedding, ulcer formation, annular, vertical, serpentine and scattered ulcer erosion. The border of subacute ulcer is clear, which can be as long as 3 ~ 4 cm and as wide as 1 ~ 2 cm. The surrounding mucosa is edema and congestion, which needs dynamic observation. 19 IC patients, non-gangrenous IC 14 cases, including transient IC 1 1 case and chronic IC 3 cases. There were 4 cases of gangrene: severe ischemia or mesenteric artery thrombosis was seen, and the intestinal mucosal lesion was full-wall necrosis, forming deep longitudinal ulcer (perforation 1 case without microscopic examination).
3 Radiological examination
3. 1 plain abdominal film 19 cases, 16 cases showed early localized spasm, followed by pneumatosis in the intestinal cavity, segmental expansion and disappearance of the diseased enterocolon bag, but there was no specificity; 7 cases showed transverse ridge similar to small intestine Creutzfeldt-Jakob fold, which was one of the characteristic X-ray signs of this disease. 1 case has free gas, which is considered as severe perforation of ischemic bowel disease.
3.2 barium enema, especially double contrast examination of colon, is of great significance to the diagnosis of this disease. In acute phase 17 cases, all showed characteristic polypoid filling defect, which was called "finger pressure sign" or "pseudotumor sign". Intestinal spasm and acute sign of splenic flexure are also common in the early stage. 1 case barium imaging of intestinal wall is specific, indicating that necrosis has reached the muscular layer. 1 case not perforated.
3.3 CT 19 cases and 13 cases were examined by CT in the middle and late stage of the lesion, which could clearly show the changes of annular thickening, stenosis, dilated pneumatosis, gas in portal vein and free gas in abdominal cavity, mesenteric artery embolism and so on, which was of great significance for diagnosis.
Treatment of intestinal dysfunction in ischemic bowel disease
The treatment of intestinal dysfunction caused by ischemic bowel disease should focus on the treatment of primary disease. Such as positive correction of shock, fasting, intravenous hypernutrition, full rest of the intestine, and broad-spectrum antibiotics. When the heart function is normal, digitalis, vasopressin and other drugs that cause mesenteric vasoconstriction should be stopped as much as possible. Severe intestinal dysfunction is not only not conducive to the recovery of ischemic lesions, but also aggravates ischemia, and even causes complications such as water-electrolyte disorder, protein-deficient colon disease and colon perforation. Therefore, active symptomatic treatment should be given, such as intestinal tube exhaust decompression for flatulence patients and nasal feeding tube exhaust decompression; Patients with nausea and vomiting were given antiemetic drugs and gastrointestinal motility drugs; Diarrhea patients were given intestinal mucosal protective agents such as smecta and bismuth carbonate. Spasmodic agents such as atropine and anisodamine, and opioid drugs such as phenylephrine and loperamide can reduce intestinal peristalsis and increase the reabsorption of salt and water, thus reducing the number of defecation and relieving abdominal pain. However, due to the possibility of inducing intestinal paralysis and intestinal perforation, some drugs should be carefully selected in practical work. Glucocorticoid is not helpful to the recovery of ischemic lesions, and may promote intestinal perforation, so it is not recommended. Most patients with non-gangrene can be improved within 1 week after the above treatment. If diarrhea, bleeding or obvious obstructive symptoms persist, surgery is generally needed.
5 Chinese medicine treatment
The main symptoms of patients are abdominal pain, bloody stool, accompanied by nausea, vomiting, anorexia, abdominal distension, diarrhea, pale or purple tongue, deep or late pulse, or knot instead. Because of old age and infirmity, the deficiency of middle qi leads to blood stasis for a long time, which makes the intestinal pulse stagnate, leading to blood not following menstruation, blood overflowing from the pulse and blood in the stool; Qi stagnation and blood stasis lead to abdominal pain and bloating; Cardinal Zhong Jiao is not suitable, so it causes nausea, vomiting and anorexia. The tongue is dull or purple, and the pulse is dull or slow, which is also the manifestation of qi deficiency and blood stasis. Therefore, this disease mainly belongs to the syndrome of deficiency of vital qi and blood stasis blocking collaterals in traditional Chinese medicine. Therefore, the Buyanghuanwu decoction of Yilin Gaicuo was selected, and Sophora japonica and Platycladus orientalis were added to replenish qi and nourish blood, promote blood circulation and stop bleeding. The main prescriptions are Radix Astragali 60g, Radix Angelicae Sinensis 10g, Radix Paeoniae Rubra 10g, Rhizoma Chuanxiong 6g, Flos Carthami 6g, Semen Persicae 6g, Flos Sophorae Immaturus 12g, and Folium Platycladi 10g. According to the different characteristics of syndrome differentiation, drugs such as cattail pollen can be added as appropriate to promote blood circulation and remove blood stasis; Removing blood stasis and relieving pain, such as frankincense, myrrh, corydalis tuber, etc. Drugs for removing blood stasis, such as Rhizoma Sparganii and Rhizoma Curcumae.
6 discussion
6. 1 etiology
6. 1. 1 Vascular diseases The pathological changes of blood vessels themselves are the main pathological basis of intestinal ischemia. (1) Atherosclerosis (15 cases): Due to the narrowing of vascular lumen and poor blood flow, the blood supply in the corresponding parts decreased. (2) Embolization (8 cases): under the conditions of hypertensive heart disease, rheumatic heart disease, infective endocarditis, myocardial infarction, atrial fibrillation, traumatic fracture and long-term bed rest. Because the trunk of superior mesenteric artery is large in diameter and inclined to abdominal aorta, it is easy to accept emboli from the heart and embolism occurs. Its incidence accounts for about 50% of acute intestinal infarction. (3) Systemic vascular disease (1 case of polyarteritis nodosa): It is also one of the local manifestations. Such as polyarteritis nodosa, systemic lupus erythematosus and other immune system diseases, intestinal arterioles are involved, resulting in poor blood supply to the corresponding intestines and ischemic changes.
6. 1.2 Hematological diseases In the case of polycythemia vera, thrombocytosis, long-term oral contraceptives, severe ICD infection, chemotherapy and radiotherapy, the blood is in a hypercoagulable state, which is easy to form thrombus or embolus and block intestinal blood vessels. 19 patients, 1 patients received radiotherapy for gynecological tumors, 1.5 years later, ischemic colitis occurred.
6. 1.3 Insufficient blood flow can cause intestinal ischemia, leading to ischemic enteritis, such as decreased cardiac output caused by coronary heart disease, valvular heart disease or arrhythmia, and insufficient perfusion of peripheral blood vessels during hypotensive shock. In particular, digitalis drugs, α -adrenergic agonists or β -adrenergic agonists can be used as exogenous stimuli to further reduce intestinal blood flow and induce or aggravate ischemic bowel disease. 48660.6886868866 1
6. 1.4 Other diseases such as superior mesenteric artery compression, intestinal vascular malformation, intestinal and abdominal malignant tumor, intestinal obstruction, acute pancreatitis, etc. It can also lead to ischemic bowel disease. Acute pancreatitis is a common clinical disease, and the incidence of its complications is about 20%. Vascular complications are not uncommon. 19 patients, 2 cases belong to ischemic bowel disease caused by acute pancreatitis invading intestinal artery and vein.
6.2 Diagnosis Because the symptoms of ischemic bowel disease are not specific, it is difficult to make an early diagnosis according to the clinical manifestations [3]. People with basic pathological changes of ischemic enteritis, such as persistent or sudden abdominal pain, should think of the possibility of ischemic enteritis when there is no special examination, such as positive occult blood in gastrointestinal secretions or hematochezia, and elevated white blood cells in peripheral blood, which is helpful for diagnosis. If there are signs of severe abdominal pain, acute abdomen or shock, be alert to the possibility of intestinal perforation. Emergency endoscopy is of diagnostic significance, especially bloody stool, which is the key to early diagnosis. It can also determine the scope and staging of the lesion, and obtain histological examination, which is helpful for differential diagnosis with other inflammatory bowel diseases and colon cancer. Precautions for endoscopic examination: (1) gangrene should be considered if there is persistent abdominal pain, bloody stool and peritoneal irritation, and microscopic examination is a contraindication; (2) It is strictly forbidden to slide the mirror blindly, pull it, take off the ring, etc. It will aggravate bleeding and even puncture; (3) When the air pressure under colonoscopy exceeds 3.9kPa(30mmHg), the intestinal wall will become thinner and the blood flow will decrease, which will aggravate colon ischemia. If CO2 gas is injected, blood vessels will expand, which is beneficial to the blood supply of colon. (4) Submucosal hemorrhage is usually absorbed quickly or replaced by ulcer, so endoscopic examination within 72 hours after onset is very important. If necessary, serology, CT, angiography, color Doppler and endoscopy are feasible for those suspected of the disease. Color Doppler examination is a noninvasive and relatively sensitive examination method. Some scholars [4] examined 24 cases of ischemic bowel disease with color Doppler. By measuring the thickness of intestinal wall and blood flow of intestinal artery, it was found that the sensitivity, specificity and positive predictive value of diagnosing ischemic bowel disease were 82%, 92% and 865,438 0% respectively. Therefore, color Doppler ultrasound is of great significance for early diagnosis and prognosis monitoring of ischemic bowel disease. The determination of special gas in intestinal cavity is also helpful to the diagnosis of the disease. This disease is mainly differentiated from ulcerative colitis, Crohn's disease of colon and colon cancer [5 ~ 9].
6.3 General treatment includes gastrointestinal decompression, intravenous rehydration to maintain water-electrolyte balance, blood transfusion and the use of broad-spectrum antibiotics. Once acute mesenteric ischemia is diagnosed, papaverine should be diluted to 65,438 0.0 mg/ml with physiological saline immediately, and infused through superior mesenteric artery at a speed of 30 ~ 60 mg/h with infusion pump. For non-occlusive mesenteric ischemia, papaverine infusion lasts for 24 hours, and whether to stop taking the drug should be decided according to the relief of vasospasm, which is generally 24 hours, but it can also be extended to 60 hours. Glucocorticoid does not help the recovery of ischemic lesions, and may promote intestinal perforation. Not recommended. If intestinal gangrene and intestinal perforation are suspected, laparotomy should be performed. Some cases can be treated by mesenteric artery replacement [10].
This disease should belong to the category of "blood syndrome" in traditional Chinese medicine, which is caused by deficiency of blood stasis, blood stasis blocking, blood not following the meridian and overflowing outside the pulse. In the characteristic theory of blood syndrome in TCM, Miao Xiyong's "Three Essential Methods for Treating Hematemesis" and Tang Rongchuan's "Four Essential Methods for Treating Blood" pay special attention to promoting blood circulation and removing blood stasis. Miao Xiyong's "Notes on Early Awakening and Zhai Medicine: Hematemesis" in Ming Dynasty emphasized the important role of promoting blood circulation, nourishing liver and lowering qi in treating hematemesis, and put forward three main methods for treating hematemesis: promoting blood circulation without stopping bleeding, nourishing liver without cutting liver, and lowering qi without lowering fire. From a historical point of view, this is a new development in the treatment of hemorrhagic diseases, which has the nature of supplementing its shortcomings. We must treat these three pairs of therapies dialectically according to the condition: activating blood circulation to stop bleeding, nourishing liver and cutting liver, and reducing qi and reducing fire. In Qing Dynasty, Tang Rongchuan put forward four methods to treat blood: stopping bleeding, removing blood stasis, calming blood and tonifying deficiency. Therefore, hemostasis is not the first priority in the treatment of blood syndrome. Therefore, the method of removing blood stasis is indeed an outline for the treatment of intestinal dysfunction of ischemic bowel disease, which is worthy of clinical reference.
19 patients have achieved good results through the combination of traditional Chinese and western medicine. Among them, 1 case was caused by radiotherapy of gynecological tumor. After 1.5 years, colon perforation and gangrene occurred due to ischemic colitis. Partial intestinal resection and end-to-end anastomosis were performed, and intestinal fistula was caused by perforation again 9 days after operation, and he died 56 days later. Other patients were not followed up regularly.
refer to
1 Jiang Xueliang, Pan Borong, Ma Jingyun, etc. Gastroenterology at the turn of the century-review and prospect. World chinese journal of digestology, 2000, August:11-1176.
Cao Tao, Zhu Meizhong, Zhang Taichang, et al. Ischemic colitis 17 cases. New Journal of Gastroenterology, 1996, 4: 348.
3 Pan Xiuzhen. Research progress of ischemic bowel disease. New Journal of Gastroenterology,1994,2 (special issue 2): 16.
4 Farrell jj, Friedman L. Gastrointestinal bleeding in the elderly. Clinical gastroenterology, North America, 2000, 29: 1-36.
5 levels, Meng, and so on. Endoscopic and clinical study of ischemic colitis. Chinese Journal of Digestion, 1998, 15: 26 1-263.
6 Zhang Taichang, Cao Tao, Li Yajun, et al. Clinical features and diagnostic methods of ischemic colitis. Chinese Journal of Digestion, 1998, 15: 268-27 1.
7 Liu. Significance of color Doppler ultrasound in detecting inferior mesenteric artery. Chinese journal of ultrasound in medicine, 200 1, 17: 36-38.
Chen Zhenhua and Shao Xianyu. X-ray and colonoscopy of ulcerative colitis. World chinese journal of digestology, 2000, 8: 335-336.
9 Wei Shi, Zhao Cong, Qiu Xiong, et al. Ischemic enteritis in middle-aged and elderly people. China Journal of Digestive Endoscopy, 2000, 17: 336-338.
10, Bao, Qujinhe, etc. Single channel characteristics of calcium ion in mesenteric artery resistance vascular smooth muscle and the effect of sodium nitroprusside. World chinese journal of digestology, 200 1, 9: 55-58.
Authors: 300 150 Tianjin, Department of Gastroenterology, Second Affiliated Hospital of Tianjin College of Traditional Chinese Medicine.
(Editor: zhangyan)
References:
ischemic bowel disease
Ischemic bowel disease is a disease that eventually leads to infarction due to ischemia and hypoxia of intestinal wall. This disease is more common in elderly patients with arteriosclerosis and cardiac insufficiency. The lesions mostly occurred in the segment centered on the splenic flexure of colon. The direct cause of colon ischemia is mesenteric artery and vein, especially the occlusion and stenosis of superior mesenteric artery caused by atherosclerosis or thrombosis. Heart failure and shock cause blood pressure reduction, and local intestinal blood supply deficiency may also be the cause.
At the early stage of the lesion, bleeding and edema appeared in the intestinal mucosa and submucosa, and the mucosa was dark red. With the progress of the disease course and the aggravation of the disease, superficial mucosa necrosis and ulcer formation. In severe cases, the whole intestinal wall is necrotic (transmural infarction), which even causes intestinal wall rupture, peritonitis and shock to death. Patients with small infarct size may not be able to penetrate the intestinal wall and local fibrosis may occur. Intestinal stenosis can be caused by scar formation after self-healing of the lesion.