病 案
TCM Case:Dysentery1)
Mr Liu,4 years old,1st consultation on August 21th,2001
Main complaint:Paroxysmal abdominal pain accompanied by emesis and diarrhea for four days.
Medical History:The patient suddenly suffered from a high fever of 40.5℃ in the afternoon of August 18th.There was absence of sweating and abdominal discomfort.He vomited fluids and food six times that day.He had diarrhea for three days and stools were watery without pus and blood.He had taken antipyretics2) at home，but the fever did not resolve so he was taken to the children’s hospital for emergency treatment.The patient was diagnosed with bacillary dysentery after examining his stool.He received intravenous injection of hydrocortisone3) and tetracycline4) and went home with some medicine after the fever remitted the next day.At noon of the following day(19th of August)，his temperature rose to over 39℃ again.He had watery diarrhea containing mucus immediately following abdominal pain.He was taken to the hospital again for infusion，during which his abdominal pain aggravated intermittently.That afternoon the child had diarrhea over 20 times and maintained a temperature over 39℃.The symptoms were slightly relieved after he received another dose of hydrocortisone,atropine5) and tetracycline.He was admitted to the hospital for observation.
Physical Examination:Temperature:38.2℃；Pulse:100 bpm；blood pressure: 90 mmHg/60 mmHg(12 kPa/8 kPa).The child was alert but in low spirit.He was slightly undernourished.He had depressed eye sockets，wrinkled skin with poor elasticity，and no redness or swelling of the throat.The superficial lymph nodes were unpalpable.His neck was supple.No abnormal findings in the lungs.He had a regular heart beat，strong heart sounds，a little sunken and soft abdomen without obvious tenderness，unpalpable liver and spleen，active bowel sounds，redness of the anus，red tongue with a thin yellow coating and a thread and rapid pulse.
Blood Routine Test:WBC 13400/MM3,NEUTORPHIL6) 80%，lymphocyte 20%
Stool Routine Test:RBC 10-15/HF，Pyocytes all over the scope.
Diagnosis
TCM Diagnosis:Dysentery due to damp-heat retention
Western Medicine Diagnosis:Acute Dysentery
Treatment
Principles:
Clear heat and resolve toxins
Unblock the bowels and drain dampness
Acupuncture Point Combination:Shàngjùxū(ST 37),Tiānshū(ST 25),Qūchí(LI 11),Nèiguān(PC 6)，Zúsānlǐ(ST 36),Guānyuán(CV 4)
Manipulations:Insert the needle one cun perpendicularly at ST37 and stimulate to have a sensation radiating to the lower legs.Insert one cun perpendicularly at ST 25 and stimulate to have a sensation radiating to the lower abdomen.Insert one cun perpendicularly at LI 11 and PC 6 and stimulate to have a sensation radiating to the forearms.Apply the twirling，lifting and thrusting methods to purge all the points for one minute.Then apply the twirling method of even supplementation and drainage to ST 36 and CV 4 for one minute.
After one treatment，the abdominal pain and urgency with rectal heaviness resolved and after two treatments，the frequency of diarrhea decreased to two to three times a day.The patient was in better spirit and his appetite improved greatly.The body temperature reduced and all symptoms resolved.The patient received five more treatments to strengthen the body and consolidate the curative effect.
注释：
1）dysentery 痢疾
2）antipyretics 退热剂，退烧药
3）hydrocortisone氢化可的松，皮质醇
4）tetracycline四环素
5）atropine 阿托品
6）neutrophil 嗜中性粒细胞，中性白细胞
Case discussion of Gastroesophageal Reflux Disease（病案讨论：胃食管反流病）
In the Ward
Intern A:Good morning，Mrs.Zhang.How do you feel bad?
Patient:Well，I am suffering from swallowing difficulty which has been going on for about a week，and it started with just a little discomfort when I swallowed；I’d feel food gets to about here，then it would pause for just a minute and then go on.A couple of times since，however，food has gotten there and hasn’t gone through，and after a minute or two I’d spit up whatever I’d swallowed.That kind of condition scared me.
Intern A:Have you got any similar symptoms before?
Patient：For the last thirty years，I’ve always had kind of an acid stomach for which I took over-the -counter antiacids.I’ve also experienced reflux at times.I’d go to bed at night and I’d be lying there，and all of a sudden I’d wake up with this rush of stomach contents coming back up my esophagus.And there have been a couple of times when it scared me because I’d really aspirated some of this stuff，and it would wake me up with this wheezing in my chest until I’d get that stuff cleared.It gets into my bronchi，and my bronchi shut down.The reflux has gotten worse over the last few months，and then once it got to that swallowing problem，then I thought，you know，this could be something bad.（30年来，我一直有些胃痛，就自己去买点非处方的制酸药。另外，还经常反胃，当我上床睡觉时，有时会突然觉得反胃而惊醒。有好几次我还将这些呕吐物吸入气管，我因此惊醒过来非得不停地咳嗽才能把这些东西吐出来。因为呕吐物进入我的支气管，造成了支气管闭塞。而且这几个月里，反流变得越来越严重，现在又觉得呼吸困难了，我不得不怀疑自己是不是得了什么恶性疾病。）
Intern A：Let me ask you a little bit more about the swallowing problem that developed recently.Did you notice that with anything you would swallow，or were there certain foods that seemed more problematic？（接下来再说一下近来吞咽困难这种情况的发展。你吃任何事物都会噎住吗？什么类型的食物会加重你的症状？）
Patient:In the mornings，when I drank coffee，I didn’t seem to have a problem.And very often，at lunch，I wouldn’t have much of a problem.The problems seem to occur more in the evenings，but most particularly if I was drinking something cold；a glass of ice tea with dinner，or a glass of cold water seemed to trigger it and make it really difficult to swallow.
Intern A：OK，now if you experienced it sticking and then you regurgitate it，could you come back and eat some more after that，or were you pretty well finished at that point？（你将哽住的食物吐出来以后，能否再吃点东西？或是吐完之后就正常了？）
Patient：Pretty frequently，once the bolus of food came up above wherever I was cut off，and the contents of my stomach were on the other side of that narrow spot and came through that narrow spot，I could sit down and finish a dinner，and it wouldn’t really take me any longer time than normal.It was almost like if I ate for two or three minutes，it tightened up，and then I felt that I was going to throw up，and I left the table，and threw up，I couldn’t come back to the table in three or four minutes and finish the dinner in the normal 20 or 30 minutes it would take to eat dinner.So it wasn’t like I had to divide everything into microscopic little bites just to make it happen.I really didn’t feel any nausea with regurgitation；it was just a mechanical thing.Once it started，it started，then it was over，and there wasn’t any kind of a churning，sick indigestion sort of deal；there wasn’t any nausea associated with it.（经常是这样的，一大口食物先到某个地方下不去了，然而一旦它们进入胃之后，我就能坐下来继续吃饭，也不比吃一顿正常晚餐花更多时间。比方说，我有时吃饭吃了两三分钟后，突然感到胃不舒服了，然后就去呕吐，吐完也就三四分钟的时间，再继续吃饭，整个过程也不过二三十分钟的时间，所以我倒不是每次都得一小口一小口地吃东西。实际上，我都不觉得恶心，这种呕吐纯粹是机械性的，来得快，去得也快，也没有其他消化不良的症状，一点也不觉得恶心。）
Intern A：Now you mentioned that for a number of years you’d been having some acid indigestion，reflux，heartburn，that sort of thing，and you were describing these nocturnal episodes.How often would you experience this at night？（你觉得反酸、反流、胃灼痛已经有几年了，而且你提到的这些基本都是夜间发生的。那么，这种情况出现得有多频繁呢？）
Patient:Two or three times a year.Most recently，it had happened two or three times a month.
Intern A:More frequently than you had experienced it before.
Patient:Shortly after that，the trouble with swallowing began.
Intern A:Did you experience heartburn during the day?
Patient：Somewhat，but it was for the most part pretty manageable；I’d eat a couple of Tums（碳酸钙）or Rolaids（碳酸二羟铝钠）and it would go away.
Intern A:Have you been somebody that would carry antiacids with you，have them in your desk，or whatever?
Patient:Oh，yeah，I’ve pretty much lived with them.
Intern A：What about the newer heartburn remedies，like Pepcid or Tagamet，these kinds of things？Have you tried those？（你试过一些新疗法吗？比如法莫替丁或西咪替丁？）
Patient：I’d taken Tagamet as a prescription drug several years ago，and just because it was a prescription drug，and hassle of keeping up with it，I’d gotten away from it.I was real glad when they became over-the-counter medications.I’d take them occasionally，and I really felt pretty good when I was taking them，but I was scared to take one twice a day，everyday，forever，without seeing somebody.That’s why I wanted to see a physician who specialized in this stuff to figure out what it was I needed to do.I didn’t know if I could use those on a long-term basis.（几年前我曾经吃过西咪替丁，但因为这是处方药，且疗效还存在争议，后来我就不用了。后来我很高兴能看到它成了非处方药，因此有时候我会吃一点，感觉效果挺好的。但我可不想没看过医生就一直每天吃2次药，因为我不知道这个药是不是能长期吃。所以，我来看一下专业医生，咨询一下这个该怎么办。）
Intern A:Now，your general health otherwise had been OK?
Patient:Otherwise，my health has been pretty good.
Intern A:No major illnesses?(https://www.daowen.com)
Patient:No.
Intern A:Any history in your family of any digestive problems or symptoms of this type，heartburn，etc.?
Patient:No.
Intern A：You don’t do any heavy lifting or straining，anything like that？（你有没有经常提重物或做需要力气的工作）
Patient:No.
Intern A:What about tobacco?Are you a smoker，or have you ever been a smoker?
Patient:Light to moderate.
Intern A:Tell me about your smoking history.
Patient:For a number of years,fairly moderate to heavy,and then as it became less and less socially tolerable，I cut way back.Several years ago when I was in a fairly high-pressure setting，and smoking quite a bit，I really could tell that it was bothering me.So I really pretty much quit，but I still kind of enjoy that habit.At this point，I probably smoke less than two packs a week.
Intern A：During the past few weeks or months，have you experienced any change in bowel habits？Have you had any black stools，anything that might indicate internal bleeding or anything like that？（在过去的几个月或几周里，大便习惯有没有改变？有没有出现黑便之类消化道出血的症状？）
Patient:No，nothing like that.
Intern A:How about weight loss?Have you lost any weight since this problem started，or has your weight been pretty much the same?
Patient:For the most part，it’s been pretty much the same.My weight’s varied within 10~12kg over the last several months，and I did kind of have a weight gain，but it came off pretty easily.
Intern A:OK，tell me a little bit about your diet，and whether you’ve identified any foods that are more likely to be associated with heartburn.
Patient：Interesting enough，the things that people would very often consider automatic triggers for heartburn are not automatic triggers for heartburn for me.Mexican food may or may not trigger it；Italian food may or may not trigger it.Garlic and onions don’t seem to be anything that really trigger it，but whole milk products，at times，seem to give me an acidy feeling；or if I’ve eaten what to me seems like a lot of highly refined starchy products，like white bread or pastas or something like that.Large amounts of that can become kind of sour-tasting pretty quick，so it’s really not necessarily food-specific.（很有趣，会让我感受到胃灼痛的食物与别人不太一样。墨西哥菜和意大利菜都还行，有时会感觉到胃灼痛，有时感受不到胃灼痛。我吃大蒜和洋葱后从来不会觉得难受，但全奶制品经常会让我觉得有酸味感；或者我吃了很多精炼淀粉类食品如白面包、生面团之类的也会有这种感觉。只要这些东西别吃太多，我也不需要去特别改变我的饮食。）
In the Doctor’s Office
Chief Resident:Last Saturday we received a patient who has the problem of swallowing difficulty.It the day that Professor Wang makes routine ward round in our department.We expect we’ll have a definite conclusion for this difficult case with the help of Professor Wang’s guide.
Chief Physician:I’m told that Dr.Guan’s team is in charge of this case.Who can give me a brief introduction of the case?
Attending Physician:OK，Dr.Shi，can you tell me the case history now?
Intern A：OK.Zhang，female，45 years old，was admitted to this hospital because of dysphagia for about one week.The symptom often occurred in the evenings，especially when the patient was drinking something cold like a glass of cold water or ice tea.The patient also had acid indigestion，reflux，heartburn for about thirty years and antiacids were effective for those symptoms.The patient didn’t have significant weight loss or any change of bowel habits in the past few weeks or months but she had a smoking history for quite a long time.Nothing special in her family history.On admission，the patient’s vital signs were normal.The routine lab tests were within the normal ranges.The ECG and chest radiograph showed no special abnormality.So much for the case.（病人因为吞咽困难1周而入院。这一症状通常发生在晚上，特别是会在病人喝冷水或冰茶的时候发生。该病人还有长达30年的消化不良、反流、胃灼痛等症状，服用制酸剂有效。在过去的一段时间里，病人未出现明显体重减轻和任何排便习惯的改变。家族史无异常，但是她有相当长时间的吸烟史。入院时，病人的主要生命体征正常。常规实验室检查结果在正常范围内，心电图和胸片报告未显示异常。汇报完毕。）
Chief Physician:Good，but I still have some questions about the patient.What about the frequency of the symptoms of acid indigestion,reflux,heartburn?
Intern A:Two or three times a year.Most recently，it had happened two or three times in a month.
Chief Physician：The symptoms seem to be aggravating.En，Dr.Shi，about dysphagia，have you noticed any difference between solid foods versus liquids？Was there a difference as regards to the types of food that would stick and the patient had to regurgitate it？（症状看起来正在加重。嗯，史医生，关于吞咽困难，你是否注意到在固态食物和液态食物之间存在差异？是否存在病人根本无法下咽以至于不得不全部吐出某类食物？）
Intern A:Sorry，professor.I didn’t pay attention to it.
Chief Physician:It doesn’t matter.Dr.Guan，why we should find out the difference?
Attending Physician：Dysphagia of liquids is a signal of esophageal movement disorder and the dysphagia of solid foods may caused by organic block.（对液体食物吞咽困难提示可能为食管运动障碍，对固体食物吞咽困难则可能是器质性阻塞引起的。）
Chief Physician:Right.Dr.Shi，it is very important to make the differentiation of the diagnosis.
Intern A:OK，I will remember it.
Chief Physician:I’d like invite you to answer my question，Dr.Zhu.Do you know what is Barrett’s esophagus?
Resident A：Barrett’s esophagus is a gastrointestinal disorder in which the lining of the esophagus is damaged by stomach acid that leaks backward.It can cause heartburn and increased risk of esophageal cancer.（Barrett食管是一种胃肠道的异常，表现为食管内皮受到胃酸破坏。它可以导致患食管癌的风险上升，也能导致胃灼痛等症状的出现。）
In the Doctor’s Office
Chief Physician:Have you done the upper gastrointestinal endoscopy of the patient?
Resident A:Well，we did it yesterday and got some findings on that.
Chief Physician:What findings?
Resident A：The esophagus comes down here and disappears behind the heart in this diagram，and into the stomach here.Normally the junction between the esophagus and stomach is below the diaphragm.So we really found evidence of three things：first of all，there’s a small hiatal hernia，which means that this upper part of the stomach actually passes up through the diaphragm.（食管从这里下去并从心脏后方进入胃。一般来说，食管和胃的连接处在隔膜下。这里我们找到了3点问题：第一点，这儿有个小的食管裂孔疝，事实上这意味着部分胃的上部穿过了隔膜。）
Chief Physician:What happens with a hiatal hernia?
Resident A：Under normal circumstances，the esophagus enters the stomach sort of at an angle.But here it is protruded up into the chest，straightening the angle out and making it a little easier for things to come back up into the esophagus.（在正常环境下，食管进入胃处有一个角；但现在这部分突入了胸腔，使得角度变直，胃内容物更容易进入食管。）
Chief Physician:Good，what are the next two findings?
Resident A：The second thing that we found was that the lining of the esophagus shows evidence of injury.There are what we call erosions that are superficial ulcers，which are direct results from acid getting up into the esophagus where it doesn’t belong to，producing injury and ulceration.And the third thing that we found was，and we had suspected this was because of the history of swallowing difficulty，that as a result of the acid bum，scar tissues have developed over the years，producing a narrowing of the channel.It has lost its compliance so that anything that has any bulk to it at least runs the risk of getting stuck there for a few seconds for perhaps longer.And I think that explains why she were having the swallowing difficulty.（第二点，我们发现食管内膜有受损征象，我们称之为浅表溃疡。这种溃疡是因为胃酸进入了不应进入的食管所直接导致的。第三点，瘢痕组织数年来持续发展，导致了食管梗阻。结合病人的病史，我们考虑这是胃酸过多的结果。食管失去了其顺应性，故而任何体积较大的东西在此处可能都会停滞几秒或更长时间。我想这就是病人吞咽困难的原因。）
Resident B：Chief Physician，is the hiatal hernia a chicken or an egg？Did the hiatal hernia let the stomach creep through the hole，or did the stomach force its way through the diaphragm？（主任医师，食管裂孔疝是病因还是结果？是食管裂孔疝导致胃内容物穿过了孔，还是因为胃自身穿过了横膈？）
Chief Physician：The patient can get this condition without having a hiatal hernia，so there’s more than just the hernia，but we see it commonly together.Now there are a number of things that normally prevent acid from getting up into the esophagus.The body has natural defense mechanisms to prevent that from happening.One may be this normal anatomy，but there are many others.Perhaps the major one is what we call the lower esophageal sphincter，which is sort of the valve-like mechanism that normally keeps the door shut.It opens up for swallowing to let the food through，while tightens up again to keep the stomach contents in the stomach.For reasons that we don’t understand，this sphincter mechanism might become dysfunctional.Either，it simply becomes weak or lax，which is probably what’s happened in your situation；or in other individuals，we know from researchers that the sphincter for whatever reason just opens up for periods of several seconds，a sort of inappropriate relaxation.I suspect the sphincter valve of the patient，for whatever reason，has gotten weak，and consequently there’s no barrier against acid reflux.（即便没有食管裂孔疝，也可导致这种症状，所以不只是疝的问题。然而，我们发现这两者常常一起发生。机体内本身具有防止胃内容物反流到食管的机制，即自然防御机制。其中一个自然防御机制便是解剖学特征，当然还有其他机制。最主要的自然防御机制就是我们所说的下食管括约肌——它有点像一个经常保持关闭的活瓣。当吞咽时，它会打开让食物通过，然后关闭以使胃内容物留在胃内。在某些情况下，括约肌功能可能会出现原因不明的功能异常，可能是过松或者过紧，或者其他情况。研究发现，种种原因所造成的括约肌不恰当的放松，可使其打开超过了几秒钟。我考虑这个病人正是括约肌出于某种原因而变得松弛，故而失去了抑制胃酸反流的屏障。）
Resident B:I am clearer now.
Attending Physician:How about the treatment of the patient，Dr.Xi?
Intern B：I think we should give the patient reasonable drugs to reduce the acid secrete as proton pump inhibitors.（我认为应该给予病人合理的药物治疗来减少胃酸分泌，比如质子泵抑制剂。）
Attending Physician:Your advice is right，but according to the result of endoscopy，before we give the patient any drugs，we should go ahead and dilate the stricture，to open things up，and then we sent the patient home on some medication to reduce the acid.
Chief Physician：I agree with you，Dr.Guan.Acid is the major player here，and we started on a drug that is representative of a class that we call proton pump inhibitors，and they’re the most potent drugs that we have to reduce acid.They reduce acid secretion in the stomach by about 80%，all but keeping acid out of the stomach，keeping the acid level low so there’s less acid to come back up.In most situations，this is very helpful.And we did that for two reasons：one is to relieve the symptoms，secondly to promote healing，and hopefully minimize the chances that this scar tissue is going to tighten up again.The other thing we have to do in managing this problem，in addition to reducing the acid is collectively known as lifestyle modifications.We’d better give the patient a little informational brochure about reflux，and other things like sensible eating habits，not eating within a couple of hours of lying down，discontinuing smoking，avoid straining and heavy lifting，that sort of things.All right，I think it is the time to finish the discussion.（我同意你的意见，管医生。胃酸是主要的病因。制酸药中，代表性的有质子泵抑制剂，这是最为有效的制酸药。它可以抑制80%的胃酸分泌，保持在低水平，因而可以减少胃酸反流。在大多数情况下，这很有效。而且我们这样做有2个好处：一是可以改善症状；二是可以促进健康，且有希望使瘢痕组织再次恢复紧致。另外须以改变生活方式来降低胃酸分泌。我们可给予病人关于胃酸反流的知识手册，手册内知识包括诸如良好的饮食习惯、戒烟、减少重物抬举和过度用力等。好了，我认为我们的讨论可以到此结束了。）
Attending Physician:OK，that’s all for the case today.Much thanks to Chief Physician Wang.Thank you for everybody’s attention!
Doctors:Thank you.