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反复烧心表现的食管裂孔疝病例治疗

2018-10-08 王伯军 王伯军大夫谈消化

患者高龄,反复烧心10个月,以晚上睡觉时发作,胃镜、胸部CT示食管裂孔疝。食管裂孔疝是怎么一回事?该如何治疗?

患者高龄,反复烧心10个月,以晚上睡觉时发作,镜、胸部CT示食管裂孔疝。食管裂孔疝是怎么一回事?该如何治疗?

病例

患者男,81岁,烧心10个月。患者一到晚上睡觉的时候,感觉“烧得慌”,用手去揉肚子能稍微好受一些,有时候会反酸水,有时候会打嗝,打嗝能感觉好受一些。过去有冠心病史。

胃镜检查:反流性食管炎、贲门溃疡、慢性浅表性胃炎伴糜烂、食管裂孔疝?十二指肠球部隆起性病变

超声胃镜:十二指肠球部隆起,肝脏外压

胸部CT:肺气肿,心包积液、食管裂孔疝

上腹B超、心电图无异常

患者陆续吃了枸橼酸莫沙比利片、奥美拉唑肠溶胶囊、刺五加片和胃复春片,到现在也没见好转。

分析

详细阅读患者的病历资料,结合患者的症状、胃镜、胸部CT等检查,可明确诊断:食管裂孔疝、反流性食管炎、贲门溃疡、慢性浅表性胃炎伴糜烂。

患者烧心症状主要是由于食管裂孔疝引起,并并发食管炎和贲门溃疡。

胸腔与腹腔之间有一个分隔,叫横膈,其上有一个孔,食管穿过这个孔连接腹腔中的胃,当这个孔扩大的时候,胃的一部分就会通过这个孔进入到胸腔内,这就是“食管裂孔疝”。

食管裂孔疝的原因:
1)食管发育不全。
2)食管裂孔部位结构削弱。
3)长期腹腔压力增高,如妊娠、慢性咳嗽、习惯性便秘等。
4)手术后裂孔疝。
5)创伤性裂孔疝。

因食管裂孔疝,使食管与胃连接角度发生改变,胃内的胃液容易反流到食管内,刺激损伤食管黏膜,并引起患者烧心、食管或和贲门炎症糜烂溃疡等。

因此,其主要表现为烧心、反酸,还可以发生上腹饱胀、嗳气、疼痛等症。

由于夜间处于平卧,更容易反酸,并导致食管损伤,尤其睡前进食会刺激胃酸分泌,加重夜间酸反流。

由于经常反酸,酸对食管黏膜的慢性损伤,容易诱发食管癌,食管裂孔疝是目前公认的食管癌的癌前疾病。

食管裂孔疝,由于解剖结构已发生改变,目前没有药物能纠正食管裂孔疝,大多数主张药物控制其症状,并修复食管、贲门炎症,以防止其发生并发症。症状严重者外科或胃镜下手术治疗,但手术后发复率较高。由于胃的部分疝入胸腔,若疝入的胃较多,患者进入食后胃部鼓胀可压迫周围心肺、纵隔,可产生气急、心悸、咳嗽、发绀等症状,则必须手术治疗。如患者突发剧烈上腹痛伴呕吐,完全不能吞咽或同时发生大出血,提示食管裂孔疝发生急性嵌顿,需紧急外科手术。

治疗方面,首先要改变生活方式,这相当重要,是治疗的基础。不要吃过甜、酸、油腻食物,不要吃蕃茄、番薯、咖啡、茶等等,少量多餐进食,汤水一次不能喝多,睡前3小时禁食禁水。进食后不要弯腰,床头的脚抬高15厘米使床板呈30度角倾斜。

药物主要是抑制胃酸分泌,促进食管、胃蠕动,防止胃酸反流。

治疗建议

1.雷贝拉唑片20mg,早晚餐前半小时口服,莫沙比利片5mg每日3次饭前半小时口服,铝碳酸镁片2粒每日3次饭后2小时嚼碎服,以抑酸、护胃、促食管胃动力。

该患者过去用过奥美拉唑没效,可能患者属质子泵抑制剂快代谢者。

质子泵抑制剂主要通过肝内CYP2C19途径代谢,根据其代谢强弱,分:强代谢型者、弱代谢者,强代谢型者使用这些质子泵抑制剂效果比较差。

奥美拉唑更依赖CYP2C19代谢途径,而雷贝拉唑依赖较少,因此雷贝拉唑对各患者疗效差别不大。该患者用奥美拉唑无效改用雷贝拉唑可有效。

2.服药2个月,复查胃镜观察贲门溃疡是否愈合。

3.贲门溃疡愈合后减少雷贝拉唑剂量,以最小剂量(最小剂量是10mg)控制患者的症状,需长期口服。

如果改变生活方式后,患者症状能明显改善,只偶尔烧心,则可以按需口服,即只烧心时服药一次。

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    2018-11-10 青山颖钰

    学习了

    0

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    2018-10-10 zhouqu_8
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    2018-10-08 医者仁心5538

    学习了

    0

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13岁女童,因“茶色尿5个月”入院,患儿无过敏性紫癜病史,肾活检病理显示IgA沉积在系膜基质,诊断为IgA肾病明确。IgA肾病多见于年长儿和青年,对于反复发作的肉眼血尿,伴或不伴蛋白尿的患者,诊断不明确者,通过肾活检明确诊断具有积极意义。对病变轻微和严重者应分别采用何种治疗方案?对儿童的治疗有哪些注意事项?详见以下病例——

面部反复红斑伴瘙痒 不规则使用“皮康王”悲剧了

45岁男性患者,10年前不明原因反复出现面部红斑,伴瘙痒,持续数天后可自行消退。3年前,患者于出现面部红斑后持续不规则使用“皮康王”,起初疗效好,后来用药效果差,红斑持续不退。湿疹、颜面再发性皮炎、类固醇皮炎、面部难辨认癣、红斑狼疮还是皮肌炎?以下病例告诉我们,医务工作者对患者的用药常识指导或具有重要意义。

患儿反复肝功能异常,你考虑到这个病因了吗?

小广8岁,偶然体检发现肝酶升高,ALT126U/L,AST113U/L,其他脏器生化大体正常。找当地儿科医生解读,开了点护肝药,定期复查,转氨酶可以稍下降,但容易反复。

反复晕厥1周,什么情况?

该患者男性,45岁,近一周来反复发作 3 次晕厥,发作前均有剧烈咳嗽,轻度胸闷,晕倒后伴有大量出汗,面色苍白,约 1 分钟左右神志转清,无抽搐,无大小便失禁,就诊当地医院检查头 CT可见右侧颞叶囊肿,其余未见明显异常,为进一步诊治转来我院。发病 1 周以来患者神清、语利,饮食、活动正常。既往体健,抽烟 20 年。

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