中西医结合内外并治重症溃疡性结肠炎达黏膜愈合1例
One Case of Integrated Traditional Chinese and Western Medicine in the Treatment of Severe Ulcerative Colitis to Achieve Mucosal Healing
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1.天津中医药大学第一附属医院消化科/国家中医针灸临床医学研究中心,天津 300193
2.天津中医药大学, 天津 301617
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庞连晶, 周正华, 宋杰林. 中西医结合内外并治重症溃疡性结肠炎达黏膜愈合1例[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43053332&Fpath=home&index=0
PANG Lianjing, ZHOU Zhenghua, SONG Jielin. One Case of Integrated Traditional Chinese and Western Medicine in the Treatment of Severe Ulcerative Colitis to Achieve Mucosal Healing[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43053332&Fpath=home&index=0
庞连晶, 周正华, 宋杰林. 中西医结合内外并治重症溃疡性结肠炎达黏膜愈合1例[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43053332&Fpath=home&index=0 DOI:
PANG Lianjing, ZHOU Zhenghua, SONG Jielin. One Case of Integrated Traditional Chinese and Western Medicine in the Treatment of Severe Ulcerative Colitis to Achieve Mucosal Healing[DB/OL].(2023-10-26)[2023-11-05].http://cccl-tcm.cacm.org.cn/thesisDetails?columnId=43053332&Fpath=home&index=0 DOI:
患者王某某,女,34岁,主因“黏液脓血便间作8月余,加重2周”于2018年12月19日由我科门诊以“溃疡性结肠炎”收住院。患者自发病以来多次就诊于当地医院,经西医治疗症状好转,后仍反复发作,严重影响患者生活质量,为求中医药治疗慕名就诊于我科。四诊信息:患者神清,黏液脓血便,脓液较多,4~6次/日,甚至10余次,时左下腹痛,疼痛呈撕裂痛,感寒时加重,消瘦,纳少,寐差,舌暗苔黄腻,脉滑数。西医诊断 溃疡性结肠炎(慢性复发型 E3 活动期 重度)中医诊断 大瘕泄,脾虚湿热、浊毒阻络证。干预措施 西医治以抗炎、激素诱导缓解、调节肠道菌群、补液平衡电解质等基础上,中医药治疗依据“整体辨证,局部辨病”的诊疗模式,将全身用药与局部青赤散灌肠相结合,发挥中医药优势与特色。疗效转归 患者未再发黏液脓血便,体重增加,达到临床缓解和黏膜愈合的治疗目标,生活质量得到改善。
Medical history summary:Wang, female, 34 years old,On December 19, 2018,she was admitted to the outpatient department of our department is admitted to the ward of our department with "ulcerative colitis" mainly because of "faecal mucus and Hematochezia for more than 8 months and aggravated for 2 weeks". Since the onset of the disease, the patient has visited the local hospital for many times.After the treatment of western medicine, the symptoms have improved, but the recurrence still occurs, which seriously affects the quality of life of the patient, in order to seek traditional Chinese medicine treatment, he went to our department.Diagnostic information:The patient with ventilation was conscious, Faecal mucus and Hematochezia, with a lot of pus, 4~6 times a day, or even more than 10 times, Sometimes left lower quadrant pain, pain in the form of tearing pain, aggravated by cold, weight loss, poor appetite, Insomnia.Her tongue was dark red with yellow and greasy coating, and the pulse felt slippery.,Western medicine Diagnosis, acute severe ulcerative colitis,TCM Diagnosis, dysentery, spleen deficiency damp-heat, obstruction of turbid toxic.,Treatment, Western medicine treatment is based on anti-inflammatory, hormone-induced remission, regulation of intestinal flora, and electrolyte balance. Traditional Chinese medicine treatment is based on the diagnosis and treatment model of "overall syndrome differentiation and partial disease differentiation", combining systemic medication with local Qingchi san enema, and giving full play to the advantages and characteristics of traditional Chinese medicine.,Efficacy outcome, The patient no longer had faecal mucus and Hematochezia, gained weight, achieved the therapeutic goals of clinical remission and mucosal healing, and improved the quality of life.
溃疡性结肠炎整体辨证局部辨病青赤散
ulcerative colitisoverall dialecticslocalized diseaseqingchi san
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