1, across the airwaves of medical dry – gastric perforation (peptic ulcer complications)
Inadvertently, from medical students have been practicing medicine for 10 years, busy, missed a lot of class reunions, junior high school, high school, but classmates, if something to ask, I will know everything, say everything, so much so that it has come to today, is a hotline for multiple circles of friends to seek medical advice.
Some people say that your classmates always do not come to class reunions, there are only two situations: one is that he died, the other he became a doctor. Check it out, what a cruel description, yet so true.
Weekends are sometimes shortened, and being disturbed is something that happens from time to time, and every doctor will calmly assume this, so don’t feel that your classmates are doctors and become indifferent, because, they are already used to it and will not shush a little cold you have for half a day, but with the implication of condemning you for not being sick. Your doctor friend won’t say, “Come to me for treatment, I’m sure you’ll be able to get rid of it.
Although only a few words, such as slapdash, but they must ask the key to the problem, your pile of descriptions, simply scattered sand, washed away by the sea without a trace.
Zhiguo is my middle and high school classmates, my hair good brothers, together with the food, together with the sleep, together with the trouble, the kind of dare to fight dare to rush all the way.
Last weekend, almost to bed, the phone rang, showing that he was.
”My dad can’t sleep because of stomach pain, what do you think about prescribing some medicine to eat first?” This is an old classmate, I have science how many times, or this routine. Which pain to eat what medicine. Well, I’d better ask him the most basic questions: “How long has our father been in pain, what time of day, where exactly, what is the pattern, and how can we relieve it?” I thought to myself that each symptom could be a different situation and I couldn’t take pain medication for granted.
”This time it’s been a week, it’s just below the rib cage, mainly pain at night, often waking up in pain, and sweating from the pain, and the medicine doesn’t work”
It’s been a week, how not to come to me earlier, I remember his father was originally a factory manager, very able to smoke and drink, before it seems to have a history of stomach ulcers, this situation preliminary judgment, there may be ulcer bleeding, or even gastric perforation.
”In this case, it is best to see in person, how do you not come to me during working hours? Now you can only go to a nearby hospital emergency room to see. Stabilize, to check a gastroscopy early”
”Not too much attention, always wanted to see you, did not take the time to come, this is not getting more and more serious” my brain is still racing, what are the big hospitals around his home, can now go to see.
”You live in the South City, right, then you go to Tiantan or Friendship Hospital to see an emergency.”
”so late, do not want to go, you first give me a little what pain relief measures, in two days and then go”
Pissed me off, the old schoolmate why so confused, before I have given him a lecture, plus the previous disease, once the stomach ulcer bleeding is not good to clean up.
”I advise you to go to the emergency room quickly to see, without seeing the person, I can not make a judgment, eat an antispasmodic, but also may not be effective.”
”Okay, then let’s go.”
The busy life, constantly pounding the inner waves of electricity, picks up this application, and receives another inquiry. Recently, my parents are in the flu and fever, my aunt’s intestinal polyps are about to be surgically removed, I can hear my phone calls coming and going, who let me be the university student who came out of our village, no matter what disease, I need to get the answer and the method of eradication here, it is easy to explain to the patients in front of me, and it is much more difficult to explain to my own parents. If you’re not careful, you’ll be accused of being ungrateful and hard-winged, and this is one thing that doesn’t help the count.
Fortunately, this time is a smooth transition.
Dragging a tired body, look at the table, 12:40 noon, in order to be able to end the clinic before 6:30, I tend to arrive at the clinic half an hour earlier, to facilitate the early start of work.
As I was walking, the phone rang, and it was Zhiguo.
I remembered the phone call from 3 days ago and asked, “How is our father doing?”
”Luckily we went to the hospital, my dad had a perforated stomach!”
My doctor friend was conflicted at this point, whether to be happy with the accuracy of the deduction, or to express calmness, or deep sympathy. “Is it better now?”
”That day went to Friendship Hospital, and later went to Tiantan Hospital, lined up the film, blood tests, the doctor said there is no problem, but eat the medicine or pain, and then went to the Union Hospital, the Union to see the small doctor can not take, asked a senior physician to guide, finally diagnosed clearly, is a gastric perforation, immediately did open surgery, as if 1.5 centimeters large, through surgery Stitched up ……”
I was walking quickly towards the clinic, unable to listen to his careful description, but in my mind, the process of this treatment, has been clear over the side of the movie.
Just listen to Zhiguo said: or the doctors of the Union have a level, the first two doctors did not see much.
The people always remember the scene of being cured and diagnosed clearly, but do not understand the process of observation and diagnosis before. I need to do justice to the first two hospitals. “In fact, it is true that the level of Concordia is very high, but we can not bury the credit of the first two hospitals” “They did not diagnose it?!” “When you arrived at the Xiehe, did you give all the previous tests and inferences to the doctors at the Xiehe” “Yes, yes” “Unlucky doctors look at the head of the disease, lucky doctors look at the tail of the disease, diagnosis and treatment is a process, this inference, as well as the presence of disease and performance, is gradually clear, perhaps, at that time there was no perforation, just ulcer pain, and later perforated stomach contents to the abdominal cavity, it was quickly caught, so the process and records of the previous diagnosis and treatment, is also very important, perhaps you stay in the first two hospitals for more time, diagnosis and treatment is also the same”
”Oh, then I understand, I was too anxious, always thinking about getting my father better quickly”
Patients often only ask about the results, regardless of the process, and the constant science, need to allow patients to give themselves and the doctor a time, not to see what you can guess the symptoms of the disease, and not to use any medicine, you can immediately return to the magic.
I also want to take the opportunity to say “look, face to face treatment is still very important, right, if you can see the scene, as well as abdominal touch and examination, as opposed to just talking on the phone is not the same, so the health of our parents must pay attention to”.
”Yes, my dad was scared to death this time, I must pay attention to it in the future, see when you have time, I’ll take my dad to your place to have some Chinese medicine to adjust”
I hope what I told him this time, he can pay attention to.
For our father this disease, the first and most important thing is that I repeatedly stressed with you and the elderly, he smoked and drank alcohol for so many years, now he must quit, which is a stomach ulcer, the potential main cause of gastric perforation, as well as irregular life, he is a factory manager, work hard, after retirement, to eat more light and fresh vegetables, can no longer smoke and alcohol stimulation.
”Yes, yes, yes, this time, I’ll talk to him properly”
”In addition, the main cause of gastric perforation is peptic ulcer, and the cause of ulcer formation is likely to be H. pylori infection, and so on the condition of stability, to check a gastroscopy, do not say that you do not want to do, who has nothing to do willing to do, the key is that he is very necessary to assess the state of the most important”
Already walked to the door of the clinic, the patient saw that I had walked in the door, hailing the book into my hand. Had to stop and say: wait a moment, I have not yet opened the clinic. But they still guarded me unrelentingly.
”Zhiguo, I immediately clinic, for gastric ulcer and perforation of the most important measures, I just told you those two, followed by, is the recent light diet, relaxed mood, after a while to come to me to see, I talk to the old man himself”
”Okay, you are busy, the doctor is busy”
From time to time, I feel that my studio is seamlessly connected, there is always no respite, quite a few things are constantly stacked up, just like the medical record book stacked on my consultation table, dense, just like a stone pressed on my body.
The fast pace, constantly combing mood, in fact, this state, is also a cause of peptic ulcer.
I took a deep breath and pressed the call system to ask #1 to visit the A255 clinic ……
2, guard your stool (ulcer bleeding is also common)
No. 1 just sat down, the door was knocked open by nurse Tengjuan, Dr. Li, let this one at the door look at it first, I see that he is not in a good condition, just vomited at the door, seems to have blood.
I quickly helped the patient get into bed and lie down, then went to the door and looked at the scene, housekeeping had already packed up the vomit. Performed abdominal palpation and there was significant epigastric pressure pain.
Tengjuan, take his blood pressure quickly. Where is the family? What diseases did he have before?
The couple who had been next to him replied: He is in good health, but he loves to stay up late and seems to have a stomach ulcer.
Have you had any discomfort recently?
Always feel pain in the stomach, yesterday also drink?
What kind of work does he do? Is work stressful?
Blood pressure 90/60, Tengjuan answered first –
What is the usual blood pressure, and I could not wait for her answer.
Seeing that I was asking in a hurry, his family members were also a little nervous, usually slightly hypertensive.
How are your stools these days?
It seems like the stool is rather dark in color. This morning the pain was so bad that I came here ……
These answers all point to one disease, a bleeding stomach ulcer.
Your loved one needs to be hospitalized for observation and treatment, while quickly issuing a hospitalization order and briefly explaining the condition: it may be bleeding from a peptic ulcer, admit quickly for observation. Tell Tengjuan to accompany them to the hospitalization department
Immediately at the same time called the nurse on duty in the inpatient department, so that the doctor on duty to draw attention to the preparation of arrangements for emergency gastroscopy, and to prepare for various diagnostic and treatment measures for gastric bleeding ……
The patient finished dry stool, but quickly had a bowel movement, which may suggest that the patient was bleeding acutely. Thinking of this, I was uneasy and made another call to the nurse on duty in the ward, telling them to remember to observe the stool, and looking at their distant figure, I thought of the previous scene.
2.Watching your stool –
The doctor’s duty is to watch over your health, and for the change of your patient’s condition, nothing is more important than a mountain. Every day in the clinic, we are watching over the patient, expecting the patient’s condition to improve, and also expecting our efforts to receive good results.
I still remember in 2003 in the emergency department of the China-Japan Friendship Hospital internship, nervous busy, unknowingly to noon, a patient with abdominal pain was brought into the emergency room with a painful look, put down the box lunch is hurriedly eaten, we quickly followed the teacher into the work state.
The patient had a history of duodenal ulcer and had a sudden reoccurrence today. He used to have tarry stools and now the abdominal pain was obvious and he also seemed to have a feeling of stool. So, we asked the patient to defecate first and then asked us to look at the stool afterwards. The family was told to inform us to come and see him immediately after the bowel movement. The patient was a little hesitant, and I was impressed by the touching look behind the hesitation.
For the next 2 minutes, and 3 minutes, we waited, eating hurriedly while waiting for news of the patient’s bowel movement. At that time, I don’t know what it was like to eat a box lunch while anxiously waiting for the patient’s stool. The scenario that is difficult to imagine in daily life did not seem to occur, and we did not notice the situation of stool in daily life, but were very concerned that we could make important judgments about the patient’s condition based on the stool, and this information was important whether we were eating or not.
Just as a mouthful of rice ball that was about to be swallowed crossed the esophagus while another part was still being chewed, the family member came running and told us – the patient had a bowel movement!
While chewing, while quickly running towards the patient, no, more accurately the patient’s stool, the scenario that only the doctor, for the patient’s point of view, must endure and bear, which is important for the diagnosis, because you are a doctor.
Sure enough, the patient was a typical tarry stool, while the thin paste-like stool could be seen emitting a dark red sheen, clearly telling us that the GI tract had bled and was continuing, forgetting all gastric sensations, and under the leadership of our teacher, we quickly took measures to stop the bleeding and proceeded to the next specific treatment. From that moment on, my heart crossed over from medical student to the important step of a doctor – a doctor, who has to watch over the stool for the patient – and watch over the health of the patient.
Now that I am out on my own, the stools of constipated patients, irritable bowel patients, and patients with ulcerative colitis in the outpatient clinic are all topics of great concern to me as a gastroenterologist, and this information is vital to the doctor’s judgment and care for the patient, which is reflected in every word.
Each time, I am eagerly waiting for information about the stool of the patient, the constipated hope for more stool, the irritable bowel hope to control some stool, ulcerative colitis hope to reduce some mucus. Careful questioning of the bowel movements is also very helpful in determining the discriminatory prescription. For example, whether the stool is dry or not can determine whether there is fire in the body; and whether the stool is dry all the time, or whether it is just dry at the beginning and loose later, which is another scenario, has the factor of spleen deficiency; whether the non-dry stool is easily expelled is a way to determine whether there is spleen qi deficiency and unfavorable propulsion (poor intestinal peristaltic function); whether the expelled stool can be easily washed away by water, this detail of inquiry is an important basis for determining dampness This is an important basis for determining factors such as stagnation.
In outpatient clinics, it is rare to observe the stool in person, but careful questioning, trying to communicate sincerely, looking for clues from just a few words, reproducing the stool scene, can provide ideas for the next step of judgment, whether from the perspective of Chinese medicine, or Western medicine, more information, there will be a more accurate grasp.
Watching is an attitude and responsibility, the doctor for the patient to watch the stool, watch not only the patient’s information, but also for the patient to watch is a healthy expectation.
3, ulcer is to digest yourself (definition)
No. 1 finally saw a bus driver, Master Xiao, from the phone to the emergency room, to the clinic, this is the third peptic ulcer of the day. Only the degree is different, Zhiguo’s father is a peptic ulcer resulting in gastric perforation, just now the emergency is a peptic ulcer caused by gastric bleeding, these are the two main complications of gastrointestinal peptic ulcer is also a peptic ulcer serious to a certain degree resulting in bleeding or even rupture of the ulcer surface. And Master Xiao is mainly ulcer, not to the extent of perforation and bleeding.
When it comes to peptic ulcers, they actually include ulcers of the esophagus, stomach and duodenum. They can also occur in other areas in contact with acidic gastric juices, including the anastomosis and adjacent intestinal loops after gastrointestinal anastomosis, and Meckel’s diverticulum.
Doctor, so what is the difference between erythema, erosion and ulcer in some places as written on my gastroscopy?
Ulcers are different from vesicles because the lesions are beyond the mucosal muscle layer.
Erythema is only caused by the irritation of inflammation. You can consider erythema to be the least severe, followed by vesicles and then ulcers.
The reason why your disease is called peptic ulcer is that its occurrence should be related to gastric acid and pepsin. It is caused by the damage factors of the gastric mucosa (H. pylori, gastric acid and NSAIDs, etc.) being greater than the defense factors (gastric mucosal barrier, mucus, mucosal blood flow, cell renewal and prostaglandins, etc.).
It is the destruction of the gastric mucosa and the gastric acid produced by the stomach that starts digesting its own muscles that causes this.
As you can see, the stage A1 marked on the gastroscope is the ongoing phase of the ulcer, if it is stage H, it is the healing phase, past progressive, and if it is stage S, it is the scarring phase, past complete. It seems not too serious at the moment, no need to worry.
3. Pain on an empty stomach is a characteristic (symptom) of peptic ulcers
Then this pain is produced by your own digestion, right?
Yes, your pain is mainly before meals, right? Wouldn’t it be relieved if you eat something?
Yes, doctor, in any case, I can’t be hungry and I have to bring something with me at all times.
Well, pain on an empty stomach is characteristic of peptic ulcers. This is caused by the fact that when you eat, stomach acid mixes with food and reduces the irritation of the ulcer, and if you are too full, it is also painful, and that has to do with the stretched stomach wall. In short, for your disease, you can’t fast and you can’t be too full, you can only eat less and more.
4.Cause of the disease
Stomach acid can digest itself? Yes, we usually eat meat, also eat some tripe and so on, right. These are meat, stomach acid can digest them, of course, can also digest their own meat, but normal people have a gastric mucosal barrier, the stomach acid blocked. If the gastric mucous membrane barrier is attacked and destroyed, then it is likely to digest itself, and an ulcer will form over time. There are many reasons why the gastric mucosa is attacked, and it is clear that it is caused by the infection of Helicobacter pylori, as well as the use of non-steroidal anti-inflammatory drugs, and some anticoagulant drugs, as well as work strain, tension, and irregular diet.
Master Xiao is a typical peptic ulcer-prone group, and more than half of the peptic ulcer patients in my clinic are bus drivers, who travel long distances for a long time, eat irregularly, and are also stressed and strained.
Just like the description of “The Doctor’s Meal”: always talking about work while eating, as well as suffering criticism while eating, is also a high cause of peptic ulcer.
5. Diagnosis
So, am I sure about this disease?
Your disease disease is certain. For medical diagnosis, there is no most definite, only more definite.
By using multiple clues to determine the whole thing, it is like solving a case and finding grounds everywhere.
An inference from the history of the disease that your occupation is a high prevalence group for peptic ulcers.
from the symptoms, with a typical predominance of pain before meals.
Most importantly, based on the gastroscopy, it is a very clear peptic ulcer.
6.Treatment
Master Xiao, how many shifts do you drive a day now? Can you eat on time?
No, our route is too long, so what can I do?
All peptic ulcer diseases are treated by eliminating the cause of the disease first. If you can’t eliminate the cause, we have to strengthen the medication.
What symptoms do you have now?
The most uncomfortable is stomach pain, a burst, especially before eating, but it will be better after eating, but also uncomfortable after eating.
Do you have any acidity and heartburn?
I had it before, but less recently.
Well, usually like to eat hot, or like to eat cold food.
I can’t eat cold food, but I feel uncomfortable when I do?
Does your stomach rise? Is there any gas?
My stomach is often bloated and I have fewer farts.
Yes, you sit and drive all day long, so you get bloated easily.
No, it’s always thin, sometimes several times a day.
Peptic ulcers are often the evidence of “Huangqi Jianzhong Tang” in Chinese medicine, which is true, about half of the peptic ulcers can be treated with Huangqi Jianzhong Tang. The main TCM evidence type is the spleen and stomach deficiency cold.
This is verified by looking at Master Xiao’s tongue and pulse, which is red with a thin white coating and a sunken pulse.
Master Xiao, the diagnosis of your disease is clear and belongs to the active stage of peptic ulcer.
According to H. pylori monitoring, your previous infection has been killed, so this cause has been eliminated, and the ulcer that has not healed will recover after these 2 months of acid suppression treatment.
At present, acid reflux and heartburn are not obvious, which means that stomach acid secretion is not vigorous. Moreover, the most important treatment of western medicine has been treated for a period of time, and it is recommended to treat mainly with tonics now.
Okay, I will listen to you.
The main effect of the prescription is to strengthen the spleen and benefit the stomach.
Roasted Astragalus 30g Radix Codonopsis 10 Poria 15 Gui Zhi 10
White peony 20, dry ginger 6, Huanglian 6, Wu Zhuyu 2
Citrus Aurantium 12, Fried Atractylodes 15, Lotus Leaf 10, Sandy Seed 6
Radix Bletillae 10 Radix Glycyrrhiza glabra 10
Ginger 10 Jujube 10 Caramelized sugar 20g
Huang Qi Jian Zhong Tang contains Huang Qi, Gui Zhi, Bai Shao, Ginger, Jujube and Caramel Sugar, which is the most important part of the prescription to strengthen the spleen, benefit the stomach and promote the repairing ability of the stomach and intestines.
The combination of Huanglian Wujiao can effectively and reasonably inhibit stomach acid and reduce the damage it can do to itself. It is the most important auxiliary medicine pair.
And fried Atractylodes, Citrus aurantium, Lotus leaf and Sandy seed as adjuvants can help to strengthen the spleen and regulate Qi, promote gastrointestinal dynamics and facilitate its own repair.
Bletilla is an important binder in Chinese medicine, forming a protective film on the stomach, similar to applying a layer of glue to an ulcer. As an enabling medicine, together with licorice, it harmonizes the relationship of the individual drugs and facilitates its own repair.
In short, after eliminating the cause and treating the symptoms, after a month, it should recover.
Doctor, you do not say, I can not eliminate the cause of the disease.
Master Xiao, don’t worry, the three major causes of peptic ulcer (H. pylori infection, NSAIDs and other drugs that damage the gastric mucosa, and strenuous running), you currently only account for 1/3 and the last cause, just pay more attention. I will prescribe medicine for you to promote recovery and eliminate the effects.
Symptomatic treatment with herbs is sufficient. According to a number of our studies and clinical observations, peptic ulcers often appear as abdominal distension, abdominal pain.
In this case, Western medicine generally uses gastrointestinal dynamics and anticholinergic drugs to relieve spasm, while this is the strength of Chinese medicine “strengthening spleen and regulating qi”, which can enhance gastrointestinal dynamics, relieve spasm and relieve symptoms by strengthening spleen and regulating qi.
At the same time, for active ulcers, we need to use drugs that reduce the acidity in the stomach: there are two main categories according to the route of action. Drugs that neutralize gastric acid, such as aluminum hydroxide, magnesium oxide, compound gastric soothing, and Lodestone stomach. Drugs that inhibit gastric acid secretion, mainly referring to H2 receptor blockers and proton pump inhibitors.
The lightest power to neutralize gastric acid, H2 receptor blocker is the commonly used famotidine, various kinds of titin such as ranitidine belong to the medium power, while the proton pump inhibitor PPI is the strongest acid suppressant.
For you, we should prefer the strongest acid suppressant for 2 weeks and then gradually bring down the power and switch to the titin class.
I will prescribe you two weeks of rabeprazole 20mg a capsule first, take one every morning 30 minutes before meal on an empty stomach for two weeks, after two weeks, I will switch you to ranitidine 10mg a capsule, take one every morning 30 minutes after meal on an empty stomach for two weeks.
At the same time take soup 30 minutes after meals, you come to the clinic two weeks later to give feedback, to change your Western medicine and adjust the prescription of Chinese medicine.
Master Xiao heard that he would be well in a month, so he went out happily.
Master Xiao just went out, Teng Juan pushed the door open again, with a patient in a hospital gown, I guessed that No. 2 is the inpatient consultation, the condition allows activity, so, come to the outpatient clinic.
I’m asking, “Tengjuan, how is that patient doing, did you send him to the ward?
The blood bank has already prepared blood, so it should be possible to turn the situation into a success.
I breathed a long sigh of relief and went back to the patient in front of me.
The patient’s main problem is coronary artery disease, high blood lipids, and unstable angina. These do not matter, the use of coronary expansion, lipid-lowering and anti-platelet drugs can be, the most damaging is that the patient has a peptic ulcer, and must use anti-platelet drugs are non-steroidal anti-inflammatory drugs such as aspirin, is a contraindication to peptic ulcers.
The use of aspirin can be anti-platelet coagulation, which can effectively avoid infarction of blood stagnation in blood vessels and avoid myocardial infarction, but why not use it is because it brings an increased risk of peptic ulcers after use. The most serious is that without aspirin, myocardial infarction, or brain infarction stroke, with aspirin, peptic ulcer bleeding shock.
I read the patient’s gastroscopy and pathology report, which showed that the ulcer was not very large.
Have you had acid reflux and heartburn recently?
Some, very little. When did you start taking aspirin before when it was more severe? Has there been any change after taking it?
It’s just that after taking aspirin for a while, I had stomach pain and acidity, and sometimes heartburn.
Well, your disease in gastroenterology should be NSAID-related ulcer, and you need to use gastric mucosal protector and acid suppressant at the same time to prevent further expansion of the ulcer, and the use of acid suppressant should be relatively longer, and the treatment should be properly maintained even after the ulcer heals.
According to your condition, enteric aspirin should be used first to reduce the irritation to the gastric mucosa.
Then add potassium citrate 0.3g twice daily and famotidine 10mg twice daily, both on an empty stomach before meals, and expect to take them for at least two months – three months.
After two months, depending on the situation, herbs can be added to protect the gastric mucosa.
This morning evil had the door, each one is peptic ulcer.
I sighed deeply as I wrote the consultation notes. The contradictions encountered in the clinic can be seen everywhere, and the balance between using and not using requires more thinking, and for the diagnosis and treatment of different peptic ulcers, there is still a need to open up the road in every mountain and build bridges in every water. Of course, more is to promote the science and try to make people not to form ulcers.
How not to form ulcers, of course, is to avoid the causes.
Don’t stay up late, don’t stress and work hard
Don’t eat casually, pay attention to hygiene and don’t form H. pylori infection
Don’t eat and use NSAIDs correctly
Preventive measures include regular medical check-ups and consultation with a doctor.
All this is necessary to guard the health of the stomach.