_Joysun kuijie or intestinal tuberculosis

Abdominal pain, diarrhea-ulcerative colitis? Peking Union Medical College Hospital fee guides

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Introduction to medical records patients, female, 23 years old, because of the "abdominal pain one and a half years, diarrhea, increased 3 months" in May 2000 admission.

Patients in December 1998, recurrent pain, and eating qizhou, bowels, can alleviate. Local hospital is General and gynecological examination was normal. Abdominal pain in March 1999, fecal earlier 2 ~ 3 times/day, yellow fever, even consciously. Repeatedly visiting the local hospital, check your blood count, then General and abdominal ultrasound are OK, after treatment of abdominal pain. In March 2000, following the aggravation of tourism, stool 5 ~ 8 times/day, yellow light water, sometimes with pus, abdominal pain, and fever (not measuring body temperature). The outer Court questioning blood properly, erythrocyte sedimentation rate (ESR) to 67mm/h. Colonoscopy shows patients ileum and colon mucous congestion, edema rough sheet ulcer, Ulcer of maximum diameter 1cm, surface adhesion, Pyogenic excretions and have a large number of soybean major inflammatory polypoid hyperplastic changes. Pathologic findings, ileal mucosa are polypoid, stromal edema, a large number of patients, plasma cells and lymphocytes in neutrophil inflammatory exudate, ulcer surface and necrotic tissue. Pathological diagnosis to chronic ulcer "colon". Press the "severe ulcerative colitis" give patients sulfasalazine (SASP), prednisone (20mg, 3 times/day), succinate hydrocortisone (100 mg) treatment of 2 months, 2-4 times the stool/day, no fever, ESR for 2mm/h. Discharged to continue prednisone (20mg, 3 times/day) for the treatment of patients with treatment, it is invalid to consciously stop drugs, use of Chinese herbal medicine, disease increased again. Diagnosis and treatment of income I further. Almost 4 months of weight loss 23kg. History, personal history, menstrual history, family history of marriage, no special. Hospital check-up, the result is that the body temperature 38.8 ° c, pulse 96 times/min, 20 times/min, pressure 90/40mmHg. Patient weight, superficial lymph node untouched. Heart and lung (-). Abdominal tenderness soft, qizhou, no rebound pain, liver, spleen and ribs, mobility voiced sound (de), bowel sounds. Double leg swelling. Admission diagnosis: ulcerative colitis. The diagnosis is clear of ulcerative colitis? why treatment effect poor? patients to "abdominal pain, diarrhea," as the main symptoms, recurrent, but has increasing trend. Stool to dilute waters, sometimes with pus, with fever, diarrhoea characteristics meet the exudative diarrhea, you need to consider is the infectious inflammatory or non-specific inflammation. The outer Court of colonoscopy and histopathologic diagnosis with ulcerative colitis, basic clear. Patients with SASP, corticosteroids after oral administration and enema betterto, normal body temperature, diarrhea, ESR decrease. But the recent case of repeated, high fever, weight decrease, the main considerations and irregular, patients treated with their own drug withdrawal. In addition, patients with long-term high-dose glucocorticoid therapy, you need to watch out for secondary intestinal infection. Once intermittent fever patients admitted to hospital, temperature up to 39 ° c, diarrhea 3 ~ 6 times/day, a small amount of mucus, dilute it with pus, accompanied by abdominal pain. Routine inspection results: white blood cell (WBC) 12.2 × 109/L, granulocyte (GR) 76.6% hemoglobin (Hb) for 96g/L, platelet (Plt) 346 × 109/L. Urine results are normal. It is the regular result: WBC 8 ~ lot/power vision, RBC is 0 ~ lot/power vision, occult blood (OB) (+); then Sudan Ⅲ dyeing (-). We develop, we look for acid-fast bacilli (-a) × 3 times. Blood culture (-). Patients with serum albumin (ALB) 23g/L, potassium 2.6 mmol/L, blood calcium 1.7 mmol/L. ESR for 50mm/h. Protein electrophoresis, quantitative normal immunoglobulin. CD4 T cell subsets: 22.3% (28% to 58%), CD8 39.3% (19% ~ 45%), CD3 60.4% (61% ~ 85%), CD4/CD8 0.6 (0.9 ~ 2.0). Antinuclear antibodies (ANA), double-stranded DNA (dsDNA) autoantibodies, extractable nuclear antigen (ENA) antibody, antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), cardiolipin (ACL) antibodies, anti-La antibody (anti-Sjogren syndrome Antigen B antibody) (-). Hepatitis b five, HCV antibody and HIV antibodies are (-). Chest x-ray inspection results (2 June 2000) shows a double lung texture thick, double lung in the leaf blade. Abdominal ultrasound indicated in spleen and thick. By "giving patients with ulcerative colitis" fasting, intravenous nutrition and SASP (4g/d) treatment. June 5, due to the large number of patients withWith pus will increase with succinate hydrocortisone (200mg/d, infusion), at the same time be cefotaxime, metronidazole or ciprofloxacin, anti-infective treatment, symptoms no mitigation. The outer Court colonoscopy microtome after pathology consultation results in: (terminal ileum and colon) inflammatory exudate and colonic mucosa is mild or severe acute and chronic inflammation. "" The formal treatment of ulcerative colitis, and you should also consider what reasons? because of poor patients in General, do not immediately after admission review colonoscopy, according to the outer Court, consideration of all inspection results of ulcerative colitis colon basic expressly diagnoses. In accordance with active Ulcerative colitis for fasting, parenteral nutrition, SASP and plenty of glucocorticoid therapy, should be alert for the possibility of intestinal infections. But will they find, and acid-resistant bacteria are not blood culture found evidence of infection. Chest radiograph prompts double lung in the spot on tablets, should be alert to the possibility of pulmonary infections. Given the experience of antibacterial therapy, no apparent effect. Consider patients have the following possibilities: ① diagnosis is clear, including ulcerative colitis diagnosis is clear, is there a lymphoma, tuberculosis, Vasculitis, possibility, after several disease involving the cecum, colon, rarely with full, and the outer Court colonoscopy performance and pathological examination do not match. ② with infection, patients an immunodepressed subjects, with the exception of bacterial infection, whether or not to merge with TB, fungi, viruses and other pathogens. ③ on glucocorticoid resistance, this is not a good explanation of patients admitted to hospital the corticosteroid treatment before. 12 June 2000, patients with blood, with pus is 14 times, decrease blood pressure, deactivate the SASP. The next day the temperature 40 ℃ exposal doses increase, suffocating,. Check the arterial blood gas (nasal cannula oxygen 5L/min): pH 7.439, arterial oxygen partial pressure (PaO2) 60.5 mmHg, arterial carbon dioxide partial pressure (PaCO2) 31.9mmHg, HCO3 21.2 mmol/L. Chest x-ray inspection shows double lung miliary-like change. Tuberculin purified protein derivative (PPD) test (-). Line diagnostic abdominal paracentesis, extract yellowish ascites 2ml, ascites acid-fast stain (+). Diagnosis of Miliary Tuberculosis, tuberculous peritonitis, isoniazid, rifampicin, pyrazinamide streptomycin, quadruple anti-TB treatment. June 22, in patients with jaundice, total bilirubin to 2.7mg/dl, deactivate rifampin and pyrazinamide. Give ETHAMBUTOL, Streptomycin and levofloxacin in anti-tuberculosis treatment. Patients since June 16, normal body temperature, the gradual reduction of hormone-July 28, deactivate. At the same time strengthening the parenteral nutrition, blood transfusion, etc support treatment. During hospitalization sexual decline in patients with Hb, minimum 26g/L, after a blood transfusion is 80 g/L. Anti-TB therapy in patients with normal body temperature, diarrhea markedly, 1 ~ 2 times/day, volume 100 ~ 200ml/d, Brown paste it. July 11, review the chest more markedly. The diagnosis of pulmonary tuberculosis tuberculous peritonitis and specifically, whether the intestinal lesions from tuberculosis infection due? 24 July, after the fever, patients with cold temperature 39.2 ° c, no coughing, night sweats, stool 1 ~ 2 times/day. July 27, review the chest diseases significantly increased. The whole digestive tract angiography: ileum accumulated gas expansion, the last paragraph of mucosal damage the ileum, the edge see Burr, cecum filling, the ascending colon and transverse colon wall stiffness, colon bag disappeared, with ulcerative colitis. Patients on 31 July the colonoscopy results (Figure 1): the last paragraph of the ileocecal from ileocecal valve 10cm Department mucosal hyperemia swelling, powder in lymph follicular hypertrophy. Ileocecal valve mucosal thickening, CHF edema deformation, powder in inflammatory polyps. Cecum to transverse colon mucosal hyperemia edema, more inflammatory polyps and mucosal bridge. Sigmoid colon and rectum sheet CHF edema, scattered in inflammatory polyps, sigmoid colon visible a superficial ulcer 1.5cm× 0.8 cm. Colonoscopy diagnosis: Chronic Ulcerative colitis, fall of ileitis; ileocecal has no tuberculosis other than violations of the question. Colonoscope biopsy: (terminal ileum and ileocecal valve, liver Qu), intestinal tuberculosis find acid-fast bacilli acid-fast stain. Figure 12000 July 31 (hospital) colonoscopy results, visible in the last paragraph of the ileocecal swelling, mucosal hyperemia in lymph follicular hypertrophy. Ileocecal valve mucosal thickening, CHF edema deformation, powder in inflammatory polyps. Transverse colon mucosal hyperemia edema, more inflammatory polyps and mucosal bridge. Figure 22002 5 July (discharge follow-up) colonoscopy results, visible ileal mucosa multiple end of lymph follicular hypertrophy, no erosion, ulcer. Ileocecal properly. Colon Polyps in the finger, polyp mucosa looks for the rest of the colon and rectum submucosal vascular texture clear, plicae finishing, not patients, erosion or ulcers. Clearly, in patients with intestinal tuberculosis diagnosis treated as treatment. Anti-TB treatment review chest shows double lung diffused shadow spots, upper lungs in leaf blade. Adjustment of anti-TB treatment, beginning on 1 January 8 to Wei-Ning (isoniazid-rifampicin mixture) 3 tablets/day (equivalent to isoniazid, rifampicin 0.3g/d 0.45 g/d) treatment, but because the bile Red-Increased to 9 August deactivated. August 7, patient blood urea nitrogen as 49 mg/dl, the dl for 3.2mg/creatinine, deactivate streptomycin. August 18, patients with serum creatinine recovery to 1 mg/dl, plus use of Streptomycin (0.75 g/times, intramuscular, next time). 23 August 2000 patients discharged because of economic reasons requirement. Discharge time still afternoon low heat, temperature peak 37.5 ℃ ~ 38 degrees centigrade. No coughing, phlegm, yellow mushy stools 1 ~ 2 times/day. It is normal practice occult blood (+); Hb as 3.2g/dl. Discharged to continue anti-TB treatment, outpatient follow-up. Discharge diagnosis: whole body disseminated tuberculosis (Miliary Tuberculosis, tuberculous peritonitis, intestinal tuberculosis), ulcerative colitis (remission). TB Diagnostics, treatment of tuberculosis, whether in the case of repeated prompts ulcerative colitis activities? patients in case of repeated again, mainly characterized by fever, no respiratory symptoms, abdominal pain, diarrhoea or worse. But the chest radiograph tip progression, ileum, colonic mucosal biopsy slices are found acid-fast bacilli, confirmed the diagnosis of intestinal tuberculosis. The enhanced anti-TB therapy in patients with getting better. Our analysis of the illness repeatedly is tuberculosis yet to be effectively controlled. In intestinal lesions, colonoscopy performance and gastrointestinal radiography see are in line with the characteristics of ulcerative colitis, ulcerative colitis diagnosis is clear, as seen through a remission of ulcerative colitis. In view of the patients in anti-TB drug use is not suitable for liver and kidney damage, plus use SASP maintenance treatment. Follow-up in July 2002, the patient is generally good, with no discomfort. Review the colonoscopy (D3 map 2) as shown in the last paragraph of the mucous membrane of the ileum is visible more lymph follicular hypertrophy, no erosion, ulcer. Ileocecal normal, colonic mucosa in the finger polyps, polyp mucosa looks for the rest of the colon and rectum submucosal vascular texture clear, plicae finishing, not patients, erosion or ulcers. Colonoscopy diagnosis: intestinal tuberculosis treatment, the lesions heal; ulcerative colitis, colon, remission. Patients from the onset is accompanied by intestinal tuberculosis? atypical intestinal inflammatory bowel disease and differential diagnosis in clinical practice is difficult. It is difficult to detect, patient allowed to choose 5-aminosalicylic acid class preparation for treatment or diagnosis of first choice for treatment of tuberculosis. When the patient weight, you must use corticosteroids should be comprehensive inspection, except for the possibility of merging TB, and medication to closely monitor the TB infection or secondary to TB spread. From the entire course of guess, when onset in patients with intestinal lesions of the Foundation is ulcerative colitis, was treated and inflammation under control, but because of the long high-dose glucocorticoid, secondary to the whole body disseminated tuberculosis. Responsible editor Sun Hing