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Abstract: Proctitis is a lesion involving the mucosa and submucosa of the rectum. This 25-year-old young male presented to our hospital with mucopurulent stools, increased and unformed stools, and pain in the left lower abdomen, which was confirmed to be proctitis after examination. The patient was first given fasting and nutritional support, and medication was preferred after the condition improved, which eventually resulted in good treatment and control of inflammation.
Basic information】Male, 25 years old
Disease Type】Proctitis
Hospital】Hegang City People’s Hospital
Time of consultation】June 2016
【Treatment plan】Water fasting + medication (compound amino acid injection (18AA-II) + glucose sodium chloride injection + blood transfusion therapy + human albumin + mesalachin suppository)
【Treatment cycle】 Hospitalization for 10 days
Treatment effect】Proctitis was controlled, mucus-purulent-blood stool and anal drop sensation disappeared
I. Initial consultation
The patient, male, 25 years old, complained of mucopurulent stool six months ago, due to busy work, no treatment was given. The stool specimen examination showed elevated levels of erythrocytes and leukocytes, and the finger sleeve exited with pus and blood during anal finger examination. After the outpatient examination, the patient was recommended to be hospitalized according to his condition.
II. Treatment history
After hospitalization, we further improved the relevant examinations. The blood routine indicated that the red blood cells and hemoglobin decreased significantly and reached the indication of blood transfusion; the biochemical routine showed that the albumin was lower than 28g, suggesting that the patient was anemic and malnourished; the colonoscopy indicated that the rectal mucosa was congested, edematous and eroded, with white moss on the surface. Considering that the patient was in the active stage of ulcerative proctitis in the classification of proctitis, the patient was advised to fast from water and given compound amino acid injection (18AA-II) and glucose sodium chloride injection intravenously to replenish body fluids as well as nutritional support treatment, and then given blood transfusion treatment to correct anemia and human albumin infusion to treat hypoproteinemia.
After 2 days, the patient’s mental status improved significantly, and the symptoms of malaise and dizziness were reduced, and the routine blood tests indicated mild anemia and protein was close to normal. At this time, the patient could start to eat liquid food, and at the same time, Mesalachin suppository was given to be inserted into the anus to treat rectal inflammation.
III. Treatment effect
The patient’s condition improved after 2 days of symptomatic treatment with blood transfusion, fasting, rehydration and nutritional support, and the symptoms of malaise and dizziness were reduced; after the condition stabilized, the patient was further treated for ulcerative enteritis, and was hospitalized for about 10 days. The patient expressed that he was satisfied with the treatment effect.
IV. Notes
We are glad that the patient’s proctitis symptoms have been relieved, but we also need to advise the patient that he should pay attention to the combination of work and rest, maintain sufficient sleep, and also carry out some activities, but not too strenuous, such as slow walking, tai chi and other sports; pay attention to emotional control in life, do not be too depressed, family members should try to comfort the patient, encourage the patient, face the disease with a healthy attitude; diet should pay attention to hygiene, eat nutritious, easy to digest Eat nutritious, easily digestible food, such as lean meat, fish, etc., eat less or do not eat cold, spicy food, dairy products are also to eat less, so as not to increase the burden on the intestines.
V. Personal insight
The patient had symptoms of mucopurulent stool six months ago, but because of her busy schedule and mild symptoms, she did not give any treatment and let the disease develop until her condition worsened and affected her life before she came to the clinic, where she was already in a negative state such as anemia and malnutrition, which made treatment more difficult and increased the expenses for treating the disease, which shows the importance of timely diagnosis and treatment. However, the patient was able to follow the doctor’s instructions to do things during treatment, and his companion was able to care for the patient according to the instructions of the medical staff, and continued to adhere to outpatient treatment after discharge from the hospital in accordance with the doctor’s instructions, and eventually achieved satisfactory results.