刘启泉治疗溃疡性结肠炎缓解期病案
Case of Ulcerative Colitis in Remission
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1.河北中医学院第一附属医院脾胃病科,河北 石家庄 050000
2.河北省中医院脾胃病科,河北 石家庄 050000
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郭浩林, 刘启泉. 刘启泉治疗溃疡性结肠炎缓解期病案[DB/OL].(2023-03-18)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=35601632&Fpath=home&index=0
GUO Haolin, LIU Qiquan. Case of Ulcerative Colitis in Remission[DB/OL].(2023-03-18)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=35601632&Fpath=home&index=0
郭浩林, 刘启泉. 刘启泉治疗溃疡性结肠炎缓解期病案[DB/OL].(2023-03-18)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=35601632&Fpath=home&index=0 DOI:
GUO Haolin, LIU Qiquan. Case of Ulcerative Colitis in Remission[DB/OL].(2023-03-18)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=35601632&Fpath=home&index=0 DOI:
病史摘要,2,李某,男性,83岁,农民,患者14年前无明显诱因出现大便不成形伴次数增多,5年前症状加重出现黏液脓血便,2016年6月27日电子肠镜检查:回盲部(近阑尾窝处)及升结肠起始部肠壁散在多处点状黏膜缺损,浅凹陷,覆薄苔,质韧,钳取出血不多;所见横、降、乙状结肠光整,肠腔通畅,未见具体新生物;直肠黏膜光整、柔软,未见明显异常;病理:回盲部活检:黏膜慢性炎伴糜烂。经治疗后症状缓解,欲求中医调治。四诊信息:通过望闻问切四诊信息获知,患者神清,精神稍差,形体偏瘦,面色黄,对答流利,大便稀溏,2次/日,无脓血便,偶有黏液,左下腹稍有隐痛,稍有乏力,无胃疼、胃胀,无烧心、反酸,纳寐尚可。舌红,苔微黄腻少津。脉滑略数,按之无力。否认食物、药物过敏史,体格检查、实验室检查未见明显异常。患者处于溃疡性结肠炎缓解期,现以小剂量美沙拉嗪口服,1次1片(0.5 g),1日3次,但症状缓解不明显,易反复发作,十分痛苦。刘教授在“脾虚湿盛,湿热蕴结”乃贯穿UC始终的主病机前提下,明确病变阶段,在健运脾胃,清热化湿的基础上随证治之。减轻患者临床症状,减少发作频次,改善镜下病理结果,取得了很好的疗效,为今后消化系统疾病的治疗提供新的借鉴与参考。中医诊断 久痢(脾虚湿热证)西医诊断 溃疡性结肠炎干预措施 中药汤剂口服疗效转归 经中药干预治疗后,患者诉黏液稀便等症状消失,体力和精神状态也有明显改善,复查电子肠镜,镜下肉眼判断,黏膜炎症较前减轻,肉眼观察已无明显活动性炎症表现,继续予中药巩固。
Summary of case history, Li, male, 83 years old, farmer, 14 years ago ,In the absence of obvious inducement, the patient had unformed stool with increased frequency, and the symptoms were aggravated 5 years ago with Mucopurulent bloody stool appeared.June 27, 2016 electronic colonoscopyshows that The ileocecal region (near the appendiceal fossa) and the intestinal wall at the beginning of the ascending colon were scattered with punctate mucosal defects, shallow depressions, covered with thin moss, tough, and not much blood in the forceps.The transverse, descending and sigmoid colon were smooth and the intestinal lumen was unobstructed. No specific new organisms were observed. The rectal mucosa was smooth and soft, with no obvious abnormalities; pathologyshows that Backblind biopsies,mucosal chronic inflammation with erosion. After treatment, the symptoms are relieved and he wanted to be treated by traditional Chinese medicine. Current main disease: loose stools, 2 times per day, no pus and blood stool, occasionally mucus, slightly hidden pain in the left lower abdomen. The history of food and drug allergies was denied, and the physical examination and laboratory examination showed no obvious abnormalities. The patient was in the remission period of ulcerative colitis, Now, mesalazine is taken orally at a low dose, one tablet (0.5 g) once, three times a day, but the symptom is not relieved obviously, repeated attacks, very painful. Professor Liu thinks that spleen deficiency withdampness and heat accumulated is the main pathogenesis throughout UC, clarified the lesion stage and treated it on the basis of invigorating the spleen and stomach, clearing heat and dampness.Reduce the clinical sign and symptom of patients, reduce the attack frequency, improve the pathological results under the microscope, and achieve good curative effect, which provides a new reference for the treatment of digestive system diseases in the future.,TCM diagnosis, Long dysentery (Splenic deficiency with dampness and heat),Western medicine diagnosis, Ulcerative colitis,Therapeutic methods, Traditional Chinese medicine decoction oral,Clinical outcomes, After the intervention of traditional Chinese medicine, the symptoms such as mucus thinning and stool disappeared, and his physical and mental state were also improved significantly. Under the microscope, the inflammation of the mucosa was less than before, and there was no obvious active inflammation by visual observation, so the patient was continued to consolidate with traditional Chinese medicine.
便溏久痢溃疡性结肠炎病案举隅
Loose stoolProtracted dysenteryUlcerative colitisMedical record
王志坤,李博林,刘启泉,等.刘启泉教授治疗溃疡性结肠炎经验[J].中华中医药杂志,2013,28(12):3589-3591.
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