Objective:To analyze the incidence, occurrence time and risk factors of cholestasis in the elderly patients after long-term jejunal feeding, and to construct a risk prediction model for cholestasis in the elderly patients after long-term jejunal feeding.Methods:Clinical data of 84 the elderly patients over 65 years of age who were hospitalized in the Second Medical Center of PLA General Hospital from July 2019 to July 2022 and underwent jejunal nutrition tube insertion more than 2 weeks after surgery were retrospectively collected. The patients were divided into two groups according to whether cholestasis occurred. The incidence of cholestasis was analyzed. In addition, univariate and multivariate analysis of related risk factors was carried out to construct the corresponding risk prediction model, and the prediction performance and clinical applicability of the model were further evaluated.Results:A total of 84 patients were included in the study, of which 38 patients developed cholestasis, with an incidence rate of 45.2%. The median time of tube feeding was 556.5 days. Multivariate analysis showed that: Uric acid, endotracheal intubation, history of heart failure, history of Alzheimer′s disease and history of diabetes were independent risk factors for cholestasis in the elderly patients after long-term feeding in jejunal tubes. The concordance index of COX risk prediction model established based on the above risk factors was 0.78. The Calibration curve and decision curve analysis showed that the model had good predictive performance and clinical applicability.Conclusion:The elderly patients are prone to cholestasis after jejunal tube feeding for a long time. Uric acid, tracheal intubation, history of heart failure, history of Alzheimer′s disease and history of diabetes are independent risk factors for cholestasis after jejunal tube feeding for a long time.

目的:观察胃苏颗粒联合四联疗法对幽门螺杆菌(Hp)阳性慢性萎缩性胃炎(CAG)患者血清胃肠激素和胃黏膜氧化酶-2(COX-2)、核转录因子-κB(NF-κB)表达的影响.方法:选取2017年7月～2019年6月期间中国人民解放军总医院第二医学中心消化内科收治的Hp阳性CAG患者120例,根据信封抽签法将患者分为观察组(60例,胃苏颗粒联合四联疗法)、对照组(60例,四联疗法),均治疗2周.观察两组疗效、Hp根除率、胃肠激素和胃黏膜COX-2、NF-κB表达,观察两组治疗方案的药物安全性.结果:观察组的临床总有效率和Hp根除率均高于对照组(P＜0.05).观察组治疗2周后胃泌素(GAS)、胃动素(MTL)水平低于对照组,胃泌素-17(G-17)水平高于对照组(P＜0.05).观察组治疗后3个月的胃黏膜COX-2、NF-κB表达低于对照组(P＜0.05).两组不良反应发生率对比无差异(P＞0.05).结论:Hp阳性CAG患者采用四联疗法联合胃苏颗粒治疗,可有效控制患者胃肠激素水平,降低胃黏膜COX-2、NF-κB表达,疗效确切,且不良反应发生风险较低.

With the innovation and speedy development of digestive endoscope diagnosis and treatment technology, endoscopists need higher expertise level, so the standardized training of endoscopists has become an urgent problem to be solved. At present, there are different endoscopic training modes at home and abroad. According to the characteristics of endoscopic training, we use advanced digestive endoscope simulation training system combined with problem-based learning and case-based learning teaching methods to explore the formation of digestive endoscope step-by-step advanced training mode. This paper summarizes the application of digestive endoscopic simulation system in different endoscopic training modes and comprehensively introduces the application of segmented advanced teaching mode in digestive endoscopic training.

目的:观察老年胆总管结石患者经内镜逆行胰胆管造影术(ERCP)治疗后,炎性因子、免疫功能的变化,并分析术后并发胰腺炎的危险因素.方法:纳入2015年3月～2021年5月期间来我院接受治疗的老年胆总管结石患者250例,均接受ERCP治疗,观察治疗前后炎性因子、免疫功能的变化,记录两组一次性取石成功率、术中出血量、手术时间、住院时间及术后并发症发生率.采用多因素Logistic回归分析术后并发胰腺炎的危险因素.结果:本次研究纳入的患者一次性取石成功率为96.80％(242/250),术中出血量(16.57±1.34)ml,手术时间(46.38±5.19)min,住院时间(8.82±1.35)d.术后并发症发生率12.80％(32/250).治疗后,患者的CD3+、CD4+、CD4+/CD8+较治疗前升高,CD8+较治疗前下降(P＜0.05).治疗后,患者的血清白介素-6(IL-6)、C反应蛋白(CRP)和肿瘤坏死因子-α(TNF-α)水平较治疗前下降(P＜0.05).按照ERCP术后是否并发胰腺炎进行分组,其中26例发生胰腺炎的患者纳为并发组,未并发胰腺炎的224例纳为未并发组.单因素分析结果显示,ERCP术后并发胰腺炎与胰管显影、性别、胆总管结石病史、体质量指数(BMI)、Oddi括约肌功能障碍(SOD)病史、ERCP手术时间、多次插管、胰腺炎病史、导丝进入胰管、阻塞性黄疸有关(P＜0.05).多因素Logistic回归分析结果显示:SOD病史、性别为女、BMI≥30 kg/m2、胰腺炎病史、ERCP手术时间≥60 min、多次插管、胰管显影是ERCP术后并发胰腺炎的危险因素(P＜0.05).结论:ERCP治疗老年胆总管结石患者,疗效显著,术中出血量少,患者术后恢复较快,但患者术后有一定的并发症发生,主要以胰腺炎为主.且术后并发胰腺炎的危险因素较多,可采取适当措施改进操作环节,减少术后胰腺炎的发生.

功能性胃肠病是一组根据胃肠道症状分类的疾病,其症状产生主要与脑-肠轴功能异常、动力紊乱、内脏高敏感、黏膜和免疫功能的改变、肠道菌群的改变、中枢神经系统处理功能异常相关,在老年患者中发病率较高.单用常规药物治疗该病多难以缓解症状,辅以中枢神经调节剂则可明显改善症状.然而老年人多存在共病状态,因此在应用中枢神经调节剂时,应注意药物种类、剂量和药物间相互作用,避免毒副作用.本文主要对中枢神经调节剂在老年功能性胃肠病患者中对不同转运蛋白和受体的调节机制和作用、临床应用及副反应进行综述,以期对老年功能性胃肠病患者应用中枢神经调节剂提供参考依据.

功能性胃肠病的症状跟情绪密切相关.如果在生活不顺心、工作压力大或者发脾气之后,出现了消化不良、腹胀、便秘、腹泻、腹痛等一系列消化道症状,就要考虑这些不适其实是胃肠道在“闹情绪”.那么,这类患者要吃调节情绪的药物吗?

胃和食管的连接部有个结构叫贲门,是胃的入口,贲门的作用就像是一个可开可闭的阀门:没有进食的时候,贲门处于关闭状态,这样即使人在倒立的时候,胃里的胃酸和食物也不会倒流回食管;当这个阀门功能失常无法紧闭时,胃就像一个没盖的醋瓶,平躺或腹腔压力大时,胃酸很容易反流到食管甚至口腔,出现反酸、烧心等一系列胃食管反流症状. 因此,从增强“阀门”功能的角度来看,改善反流可以从降低胃腔或腹腔压力做起,采用保持食管直立等方法,尽量避免会让胃酸反流加重或复发的生活习惯.

目的 分析急性肠系膜上动脉栓塞(ASMAE)患者的血管基础病变CT影像,为及早筛查易患人群提供依据.方法 回顾性分析解放军总医院2008年1月-2013年12月确诊ASMAE并有腹部增强CT及在发病2年内曾在本院做过腹部CT平扫检查患者的CT资料.随机抽取同期住院并行腹部CT平扫+增强检查的40例非缺血性肠病患者作为对照.借鉴冠脉钙化积分方法评估肠系膜上动脉(SMA)及其开口上下各3 cm段腹主动脉钙化积分,借助Volume软件测定非钙化体积,从钙化及非钙化角度了解ASMAE的肠道动脉血管基础病变.结果 病例组目标段腹主动脉总平均钙化积分高于对照组,差异无统计学意义(P=0.361).病例组以块状钙化和环周钙化为主,而对照组以点状或条形钙化为主,病例组更严重的钙化程度与对照组比较,差异有统计学意义(P ＜0.001).病例组钙化斑块分布于SMA开口水平以上者、目标段腹主动脉非钙化体积均高于对照组(P =0.046、0.031),SMA开口部直径小于对照组(P ＜0.001).结论 腹主动脉更严重的环周型及块状钙化、位于SMA开口水平以上的钙化斑块、更大的非钙化负荷及SMA开口部位非钙化病变导致的管腔狭窄是ASMAE的血管基础病变,临床医师应加以重视.

Objective To investigate the correlation of the serum levels of intestinal fatty acid binding protein (I-FABP) and D-lactate (D-Lac) with ischemic time and intestinal mucosa injury in rats with acute mesenteric ischemia. Methods A total of 60 rats were randomly and equally divided into 6 groups, that is, sham-operation group and 5 mesenteric ischemia groups according to mesenteric artery occluded for 30, 60, 90, 120 and 150 min respectively. Their serum levels of I-FABP and D-Lac were determined by ELISA. The content of I-FABP in the damaged intestinal mucosa was measured by immunohistochemical assay. Histopathological analysis was performed in the injured intestinal mucosa to evaluate the score of injury. The correlation of serum levels of I-FABP and D-Lac with tissue injury was analyzed. Results The serum I-FABP level was significantly increased from 30 min after ischemia, and reached a peak at 90 min [(1741.37±184.12)mg/L], and the cells positive to I-FABP accounted for 72.5%(P<0.05). The serum level of D-Lac was significantly increased from 60 min after ischemia and showed a time-dependent manner (P<0.05). The score of injury was also increased with the extent of ischemic time. Spearman’s rank correlation non-parameter test indicated that the serum level of D-Lac was positively correlated with intestinal mucosa injury (r=1), but that of I-FABP had no such correlation (r=0.6). Conclusions Serum I-FABP is increased at the early stage of acute mesenteric ischemia, and then after reaching peak, decreased with the elapse of ischemic time. Serum D-Lac is obviously increased at the late stage, and might be used to predict the severity of intestinal ischemic injury.

Objective To investigate whether Arginine-Glycin-Aspartic acid (RGD) could enhance Oxymatrine liposomes (OXYL) theraputic effect on CCl 4-induced hepatic fibrosis in rat.Methods CCl 4-induced hepatic fibrosis model was constructed based on rats.Different formulations of oxymatrine were established in this study,i.e.RGD-OXYL and OXYL.Animals were diveded into five groups,which was control group,CCl 4-induced hepatic fibrosis group,OXYL group,RGD-OXYL group and RGD-Liposomes control group.To evaluate the anti-fibrotic effect,levels of alkaline phosphatase,hepatic histopathology (HE and Masson staining) were detected.Moreover,fibrosis-related gene expression of matrix metallopeptidase-2 (MMP-2),tissue inhibitor of metalloproteinases-1 (TIMP-1) were determined via semiquantitative polymerase chain reaction.Results Oxymatrine can attenuate CCl 4-induced hepatic fibrosis,as defined by reducing serum alkaline phosphatase (344.47 ± 27.52 vs 550.69 ± 43.78,P 0.05),attenuating liver injury and improving collagen deposits (2.36% ± 0.09% vs 7.70% ± 0.60%,P 0.05) and down regulating fibrosis-related gene expression,i.e.,MMP-2,TIMP-1 (P 0.05).RGD could enhance the therapeutic effect of OM in terms of serum alkaline phosphatase (272.51 ± 19.55 vs 344.47 ±27.52,P 0.05),liver injury,collagen deposits (0.26% ± 0.09% vs 2.36% ± 0.09%,P 0.05) and down regulating fibrosis-related gene expression,i.e.,MMP-2,TIMP-1 (P 0.05).Conclusion OXYL could attenuate CCL4-induced hepatic fibrosis and inhibit fibrosis-related gene expression.RGD could enhance theraputic effect.of OXYL.

消化道出血(gastrointestinal bleeding GIB)是老年人消化道常见疾病之一,出血源于消化道的任何位置[12].根据出血量的不同,可以分为显性出血和隐性出血;根据解剖位置的不同,可以分为上消化道出血(UGIB)、下消化道出血(LGIB)和全消化道出血(TGIB).我们对老年GIB患者临床特征以及治疗上的特点进行了综述.

炎症性肠病(inflammatory bowel disease,IBD)包括溃疡性结肠炎( ulcerative colitis,UC)和克罗恩病(Crohn's disease,CD),是一种病因和发病机制尚未完全明了的慢性肠道炎性疾病,其发病率在全世界范围内逐年上升.我国报道的IBD病例也逐年增多,近十年来,有关的临床报道及系统分析研究表明IBD病例数量上升了约3.1倍,其中UC的患病率为11.6/10万,CD的患病率为1.38/10万[1].目前认为其发病机制主要是环境因素作用于遗传易感者,在肠道菌群参与下,启动了肠道免疫和非免疫系统,导致免疫和炎性反应过程,可能由于免疫调节紊乱,这种免疫炎性反应表现为过度亢进和难于自限。

Objective To observe and evaluate the clinical effects of thymosin α1 on gastrointestinal carcinoma in elderly patients.Methods Ninety-six aged patients with gastrointestinal carcinoma in the General Hospital of PLA,who had received chemotherapy,were randomly divided into two groups(n=48 for each group): control group and treatment group.Patients in the treatment group received thymosin α1 by subcutaneous injection in a dose of 1.6mg,the treatment was given once every other day and the whole course lasted for 8 weeks;while patients in the control group received physiological saline solution in the same amount only instead of thymosin.For the patients in both groups,the activities of peripheral blood T cell subsets,such as CD4+,CD4+/CD8+ and natural killer(NK),were measured by flow cytometry before the treatment and in the 2nd,4th,8th week of chemotherapy.The life quality of every patient was evaluated by Karnofsky scores at the same time.Results After the treatment,the Karnofsky scores in the treatment group were much higher than that in the control group(P<0.05).In the trcatment group,the activities of CD4+,CD4+/CD8+ and NK cell were significantly higher after treatment than those before treatment(P<0.05).The immunity indexes(CD4+,CD4+/CD8+) of the treatment group were also much higher than those of the control group(P<0.05).Conclusion Thymosin α1 can improve the immunological function and the life quality of the aged patients with gastrointestinal carcinoma.It also can be used as an adjunctive drug for the gastrointestinal carcinoma in aged patients.

随着非甾体类抗炎药(NSAIDs)治疗和预防疾病的种类和范围不断增加,应用NSAIDs的患者越来越多;然而,NSAIDs的不良反应,特别是其引起严重的NSAIDs相关性胃肠黏膜损伤,常是导致患者不得不停药的原因.在国外,NSAIDs的不良反应占所有报道的药物不良反应的25%～30%.

正常情况下,胰腺分泌的消化酶通过胰管流入十二指肠,被十二指肠液和胆汁激活后才能发挥消化作用.如果在某种病理情况下胰液被十二指肠液或胆汁激活后,又反流到胰腺内,就可导致胰腺的自身消化而引起急性胰腺炎(acute pancreatitis,AP).凡能引起胰液大量分泌的情况均可成为急性胰腺炎的诱因.常见的原因为暴饮暴食,特别是高蛋白、高脂肪饮食和大量饮酒,使胰腺大量分泌消化酶,还促进胆汁、胃液和肠液的分泌增加,导致十二指肠内压力增高,胰管和胆管共同开口段的压力增高,极易引起胰液反流,发生急性胰腺炎.另外,慢性胆囊炎和胆石症也是常见原因之一.