临床带教与英文查房 | 消化科（二）

小白老师说：Bedside teaching is seen as one of the most important modalities in teaching a variety of skills for the medical profession, which greatly improves certain clinical diagnostic skills in medical students and residents. 

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临床带教和英文查房的内容很受欢迎，很多朋友留言希望能有语音。小白老师特意录了音频，方便大家跟读学习。

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II. In the Ward在病房

Attending Physician: Mr. White, this is our Chief Physician, Professor Smith, who concerns with your illness very much.

主治医师：White 先生，这是我们的主任，Smith 教授，他特意来给你看病。

Chief Physician: How are you feeling now?

主任医师：现在感觉好吗?

Patient: Not good.

病人：不太好。

Chief Physician: Have you any fever, cough or coughing up blood?

主任医师：有发热、咳嗽或咯血吗?

Patient: Never.

病人：从来没有。

Chief physician: May I have an examination for you? It will take a few minutes.

主任医师：我能检查一下你吗，这将占用你几分钟时间。

Patient: Of course.

病人：当然可以。

After examination. 检查后。

Chief Physician: Thank you for your cooperation.

主任医师：谢谢你的配合。

Patient：Not at all.

病人：不客气。

III. In the Doctor's Office 在医生办公室

Chief Physician: This 48-year-old man was seen at this hospital after having recurrent episodes of acute and subacute gastrointestinal bleeding on many occasions over a period of almost three years, but endoscopic and imaging studies were unrevealing. Now we have the problem, where is the most probable bleeding site of the patient? Dr. Grey, I'd like to invite you to answer my question.

主任医师：该 48 岁男性因 3 年内多次反复急性及亚急性胃肠道出血入院，但内镜与影像学检查均未发现病因。现在我们面临的问题是病人的出血点最可能在哪里? Grey 医生，我想请你来回答问题。

Intern：Really sorry. I have no idea. It is quite puzzling for me.

实习医师：很抱歉我不太会。这个病例让我很费解。

Digestive System Diseases

Chief physician: Dr. Clark, what is your opinion?

主任医师：Clark 医生，你的意见呢？

Resident: This patient had gastrointestinal bleeding with melena, which is defined as the passage of black or tarry stools containing blood that has been presented in the gastrointestinal tract for at least 14 hours. The finding of melena suggests that the site of bleeding is in the upper gastrointestinal tract or small intestine. Bleeding in the ascending colon can cause melena, but usually bleeding in the colon will result in the passage of maroon-colored stools, or in the case of rectal bleeding, red stools or blood. The normal results of the upper and lower endoscopic examinations also suggest that the small bowel is the likely source of this patient’s bleeding.

住院医师：由于粪便在肠胃道中持续存在 14 小时以上才会出现黑便或柏油样便，该病人胃肠道出血伴有黑便，提示出血点是在上消化道或小肠。升结肠出血亦可引起黑便，但通常结肠出血可引起褐色便，直肠出血可引起血便和鲜血。该病人上消化道和小消化道内镜检查结果正常也提示小肠出血的可能性最大。

Chief Physician: I quite agree with you. Gastrointestinal bleeding is one of the most common reasons for consultation with a gastroenterologist in a hospital setting. Usually, a diagnosis can be made with an endoscopic evaluation of the upper gastrointestinal tract (esophagus, stomach, duodenum) and the lower gastrointestinal tract (rectum, colon, and distal small intestine). Often, the problem that is identified can be treated by a variety of endoscopic techniques. Only 3 to 5 percent of patients have a site of bleeding in the small intestine. Such problems cannot be diagnosed, or treated by routine endoscopic means.

主任医师：我非常同意你的意见。临床中，胃肠道出血是消化科的常见疾病。通常根据内镜检查即可做出上消化道和下消化道的鉴别诊断，而这些问题常可通过各种内镜技术解决。小肠出血只占胃肠道出血病人的 3%~5%，因而并不能依靠常规内镜解决本病的诊断和治疗。

Cause of  Acute GI Bleeding

Intern: Bleeding in the small bowel is quite unusual. What is the cause? 

实习医师：既然小肠出血很少见，那原因是什么呢？

Chief Physician: A good question. The types of lesions that cause bleeding in the small bowel are similar to those found in other areas of the gastrointestinal tract. They include vascular abnormalities, ulcers and inflammatory lesions, neoplasm, and other Jess common lesions. Finding and treating them, however, is much more difficult than with more proximal and more distal lesions. To this case, which cause do you think is the most probable?

主任医师：你问得好。引起小肠出血的原因与其他胃肠道出血的病因类似，包括血管异常、溃疡及炎症、赘生物及其他少见的损害。然而，小肠出血的诊断和治疗要比胃肠道近段及远段出血困难。对于这个病例来说，你认为那种情况最有可能？

Intern: May be inflammatory lesions.

实习医师：可能是炎性病变。

Chief Physician: Ulcers and other inflammatory lesions of the small bowel can cause either brisk or slow blood loss in the gastrointestinal tract. Patients with Crohn's disease, the most common of these conditions, present with either rapid or slow blood loss. 

Blood loss is rarely the only manifestation of Crohn's disease, especially over a period of almost three years, as in the current case. Isolated ulcers in the small bowel, either idiopathic or due to nonsteroidal anti-inflammatory drugs, tend to be associated with slow blood loss. 

Although this patient's initial episode of bleeding occurred while he was taking a nonsteroidal anti-inflammatory drug, subsequent episodes were apparently spontaneous. Ischemic ulcers can cause acute bleeding, which is typically associated with pain, as this patient had these ulcers, however, would be unlikely to recur over a long interval in an otherwise healthy patient. 

Other rare disorders, such as the Zollinger - Ellison syndrome and vasculitis, can cause blood loss from ulcerations in the small bowel. This patient had no other findings that suggested either of these disorders.

主任医师：小肠溃疡及其他炎性损害能引起急性或慢性胃肠道出血。此症最常见为克罗恩病，可表现为急性或慢性失血。但克罗恩病很少仅以出血为主要表现，在病史长达 3 年（如本病例）的病例中尤其如此。原发性与非甾体抗炎药物所致孤立性小肠溃疡都会引起慢性失血。虽然本病例最初出血恰发生在服用非甾体抗炎药期间，但随后反复出血均属自发性。缺血性溃疡可以引起急性出血，甚至有典型的腹痛，本病例就有腹痛表现；但其他方面健康的病人中这种溃疡不会在间隔很长时期后再复发。其他类型的疾病，如 Zollinger -Ellison综合征与血管炎也能引起小肠溃疡出血，但本病例未发现此类病症。

Crohn's disease（克罗恩病）

Resident: I have learned that vascular abnormalities are the most common causes of bleeding in the small intestine. Are they responsible for the case?

住院医师：我知道血管异常是小肠出血最常见的原因，这个病例是否就是这个病因?

Chief physician: Vascular lesions, including telangiectasia, Dieulafoy's lesion, aortoenteric fistula, are responsible for 70 to 80 percent of cases. They can affect the small bowel. But in this case, there is no evidence of these syndromes in this patient.

主任医师：血管病变包括毛细血管扩张、Dieulafoy 损害、主动脉肠瘘，可以引起 70%～80% 的小肠出血，可以影响到小肠。但在这个病例中，无这些病症损害的依据。

Intern : Excuse me, what is the Dieulafoy's lesion?

实习医师：不好意思，老师，请问什么是 Dieulafoy 损害?

Attending physician: Dieulafoy's lesion, also known as caliber-persistent artery, classically occurs in the proximal portion of the stomach, but has also been reported throughout the bowel. Its appearance is that of a larger-than-usual artery found in close proximity to the mucosal surface. There is often a pinpoint ulcer that causes the bleeding. This lesion can easily be missed on endoscopic examination if it is not bleeding at the time of the study. Repeated endoscopy and a little luck are needed to find this small bleeding site and to treat it.

主治医师：Dieulafoy 损害也称为恒径动脉，通常出现在胃近端，但也可发生于全肠道。表现为近黏膜表面出现大于正常的动脉。常有引起其出血的微小溃疡。这种微小损伤不出血时，易在内镜检查中被漏诊。多次内镜检查，加上点运气，可能会发现此类出血点并予以治疗。

Dieulafoy's lesion（Dieulafoy 损害）

Chief Physician：Really a good instruction. Tumors of the small bowel are the common cause in persons between 30 and 50 years of age. Benign and malignant primary tumors, as well as metastatic tumors, can be found throughout the small intestine. They account for only 5 percent of all tumors in the gastrointestinal tract and for 5 to 10 percent of cases of small-bowel bleeding. Benign tumors are more common than malignant ones, and they tend to cause more abundant bleeding. 

Leiomyoma and leiomyosarcoma are the most common tumors associated with episodes of severe bleeding. These tumors are submucosal, but they often have a mucosal ulcer that causes bleeding. 

Other lesions, for example, adenomatous polyps, adenocarcinoma, lymphoma, polyps associated with syndromes, such as the Peutz - Jeghers syndrome or familial polyposis, other gastrointestinal stromal tumors, and carcinoid tumors, tend to cause a more gradual blood loss than this patient had. 

A variety of malignant tumors can metastasize to the small intestine. The most common are melanoma and breast cancer. Others include renal-cell cancer, Kaposi's sarcoma, colon cancer, and ovarian cancer. This patient has no history of a malignant tumor, and imaging studies did not show evidence of either a primary tumor in the abdomen, or a metastatic lesion in the small intestine.

主任医师：说得很好。小肠肿瘤是小肠出血的第二常见原因；在 30～50 岁病人中最常见。全小肠均可发生良性或恶性原发性肿瘤及转移性肿瘤。此类肿瘤在胃肠道肿瘤中只占 5%，在小肠出血疾病中占 5%～10%。良性肿瘤比恶性肿瘤常见，且出血引起的出血量更多。平滑肌瘤和平滑肌肉瘤是引起严重出血的最常见肿瘤。此类肿瘤位于黏膜下层，但常引起出血黏膜溃疡。其他病变会引起的渐进性出血，比本例病人更典型，比如腺瘤样息肉、腺癌、淋巴瘤、与 Peutz-Jeghers 综合征相关的息肉、家族性息肉、其他胃肠道基间质瘤及类癌瘤等。多种恶性肿瘤可以转移至小肠。最常见是黑色素瘤和乳癌，其他的还包括肾细胞癌、卡波济肉瘤、结肠癌与卵巢癌。本病例无恶性肿瘤史，影像学未检出腹部原发肿瘤或小肠转移性损害。

Small Intenstine Cancer

Attending physician：Professor Smith, small-bowel diverticula, like colonic diverticula, occur at the site of perforating blood vessels and cause bleeding. Do you think it can be the reason of the bleeding in this case?

主治医师：Smith 教授，小肠憩室像结肠憩室一样，一般发生在血管穿孔处并引起出血，您认为这可能是导致这位病人出血的原因吗?

Chief physician: Meckel's diverticulum, a remnant of the vitelline duct located in the distal ileum, is the most common cause of small-bowel bleeding in patients under the age of 25 years. Ectopic gastric tissue in the diverticulum causes ulceration and acute gastrointestinal bleeding. 

Occasionally, Meckel's diverticulum can cause intussusception that is associated with bleeding. There have also been case reports of inverted Meckel's diverticulum and of angiectasis and submucosal tumors within the diverticulum that caused bleeding. In addition to bleeding, pain can be one of the presenting symptoms. This patient is older than most patients who have Meckel's diverticulum, but we can not exclude the possibility.

主任医师：Meckel 憩室位于回肠远端卵黄管残余中，是 25 岁以下病人小肠出血最常见的病因。憩室中的异位胃组织可引起溃疡和急性胃肠道出血。偶尔也可引起伴有出血的肠套叠。此外，倒置 Meckel 憩室及憩室内血管扩张和黏膜下肿瘤也可引起出血。除出血以外，疼痛也是表现之一。本病例年龄超过一般Meckel 憩室病人的年龄，但是我们不能排除也有这个可能性。

Meckel's diverticulum

Resident: In the case, we had not any special findings in the result of endoscopy and CT. What shall we do next?

住院医师：在这个病例里，我们通过内镜和 CT 没有找到任何特别的结果，那下一步我们应该怎么办呢？

Chief physician: Diagnosing small-bowel bleeding is always challenging. Flat and vascular lesions, which are the most common cause, may be especially difficult to find. Three-dimensional lesions, such as ulcers and tumors, are more likely to be found on conventional studies such as small-bowel radiography, enteroclysis, or CT. 

These studies provide a diagnosis in about 5 to 10 percent of cases of small-bowel bleeding. Angiography has a success rate of about 50 percent if there is active bleeding at a rate of 0.5 ml pw minute and about 25 Percent if there is no active bleeding. Technetium-99 m scanning is approximately 75 percent accurate for the diagnosis of Meckel's diverticulum. 

Endoscopic studies provide an opportunity for both diagnosis and therapy if the lesion can be found. Between 60 and 70 percent of bleeding small-bowel lesions are within the reach of a standard endoscope. "Push" enteroscopy with a specially designed enteroscopy allows examination of the entire jejunum, but often not the I ileum. Intraoperative enteroscopy is the most invasive but the most accurate approach for this problem, with diagnostic rates of 75 to 80 percent. 

There have been a few case reports of laparoscope-assisted enteroscopy to evaluate small-bowel bleeding. Wireless-video-capsule endoscopy is a promising technique for direct visualization of the small bowel. It provides a diagnosis in 50 to 60 percent of the cases. We can take the examination. I think it is the time to finish the discussion.

主任医师：诊断小肠出血颇具难度。特别难发现扁平血管病变，这是引起小肠出血的最常见原因。诸如溃疡、肿瘤之类的立体损害易被小肠平片、小肠造影和 CT 常规检查发现。这些检查的小肠出血病例诊断率为5%～10%。血管造影术诊断率，在有每分钟 0.5ml 速度的出血时为 50%，而在无活动性出血时只有 25%。锝-99m 扫描术 Meckel 憩室的确诊率约为 75%。若内镜检查能找到病变，诊断与治疗可同时进行。标准内镜检查范围通常覆盖小肠出血 60%～70% 病变。装有特别设计的 “推进式” 肠镜可检查全空肠，但不能检查回肠。水中肠镜检查侵入最大，但最准确，诊断率高达 75%～80%。已有少数病例报道，通过腹腔镜协助肠镜检查评价小肠出血。无线——视频——胶囊内镜检查是一种可以直视小肠的技术，可诊断 50%～60% 的病例。我们可以做这个检查。我认为我们的讨论可以到此结束了。

Capsule Endoscopy

Attending Physician: OK, that's all for the case today. Much thanks to Professor Smith. Thanks for everybody's attention !

主治医师：好的，今天的查房结束。感谢 Smith 教授和大家的参与。

未完待续。。。

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