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A case review 28 months of diagnosis and treatment thinking-is it a treatment accident or an inevitable benefit?

A case review 28 months of diagnosis and treatment thinking-is it a treatment accident or an inevitable benefit?

  • Categories:Stomach healthy
  • Author:
  • Origin:
  • Time of issue:2020-12-03
  • Views:0

(Summary description)

A case review 28 months of diagnosis and treatment thinking-is it a treatment accident or an inevitable benefit?

(Summary description)

  • Categories:Stomach healthy
  • Author:
  • Origin:
  • Time of issue:2020-12-03
  • Views:0
Information

  Basic Information

  Surname First name: Wang X

  Gender: Female

  years Age: 57 years old

  民 Clan: Han

  Occupation: Retired cadre

  Introduction to medical history

  Main complaint: The patient developed upper abdominal discomfort with fullness and discomfort with acid reflux and belching two and a half years ago. Gastroscopy and pathological examination were performed outside the hospital, and he was diagnosed with Barrett's esophagus and gastric angle ulcer (A2) stage, Hp(+), in order to further understand the above The progress of the disease came to our hospital for treatment, followed by painless gastroscopy.

  History of present illness: The patient currently has no symptoms of discomfort. He reported that there was no obvious cause of upper abdomen discomfort 2 and a half years ago. After eating, it was accompanied by acid reflux, heartburn, and occasionally paroxysmal upper abdominal pain, which can be relieved after belching. 2016-12-02 Visited a local Grade A hospital in Guiyang, underwent gastroscopy and given relevant treatment. Since the onset, he has had no fever, no joint pain, rash, conjunctivitis, iritis, no cough, sputum, no genital and vulvar ulcers, good spirit, diet, and sleep, normal stools, and no significant changes in weight.

  Past history: past physical fitness, denying history of infectious diseases such as hepatitis, tuberculosis, malaria, and denying history of diabetes, cerebrovascular disease, and mental illness.

  Personal history: Native of Guiyang, living in Beijing for a long time, no history of smoking, drinking and other bad habits.

  Physical examination: T 36.5 ℃, P 70 beats/min, R 18 beats/min, BP 120/70 mmHg, BMI 126.8 KG/m2; acupuncture test was negative, and cardiopulmonary and abdominal examinations were normal.

  Treatment process

  2016-12-02 A third-class hospital in Guiyang

  Gastroscopy report tips:

  Esophagus: 18cm away from the incisor teeth, there is a orange-red tongue-shaped change. Take a biopsy and send it for medical examination;

  Stomach angle: Two depressions can be seen, about 0.1*0.1cm and 0.3*0.3cm, respectively, covered with thin white fur. Take 2 biopsies and send them for examination, soft;

  Pathological diagnosis:

  1. (Esophageal) squamous epithelial mucosa with gastric glands, some squamous epithelium with mild dysplasia; 2. (stomach angle) mucosa with severe chronic inflammation, active (++), Hp (+).

  2016-12-10 Preliminary diagnosis and treatment measures in the outer hospital:

  1. Barrett's esophagus; 2. Angle gastric ulcer (A2) stage, Hp(+); 3. Chronic non-atrophic gastritis. Treatment plan: 1. General treatment, pay attention to diet, avoid spicy;

  2. Barrett's esophagus, there is currently no effective treatment drug to control the symptoms of reflux, and the prokinetic drug cisapride is given symptomatic treatment;

  3. Hp eradication treatment was given the standard "bismuth quadruple" eradication program: esomeprazole 20 mg bid, amoxicillin 0.5 g bid, clarithromycin 0.25 g bid, and bismuth potassium citrate 0.3 g bid.

  Course of treatment: The patient complained for 2 weeks. During the treatment, he took regular medication for 2 weeks outside the hospital. The compliance was good, the symptoms of abdominal distension were slightly improved, and other symptoms did not improve significantly.

  Hp initial treatment result: 4 weeks after drug withdrawal, the C-13 breath test was reviewed on 2017-02-15, the result: C-13 breath test (+), the initial treatment failed. The patient stated that during the initial treatment of the "bismuth quadruple" in 2016, he had obvious adverse reactions such as mouth pain, melena, and nausea, which caused the patient to fail to give active and standardized Hp remedial treatment after the initial treatment failed.

  "Individualized" remedial treatment measures:

  ◆ During 2017-2018, when the patient has obvious symptoms such as abdominal distension, abdominal pain, acid reflux, etc., oral mucosal protective agent-Relaisheng (polyprezinc granules) 75 mg bid.

  ◆ How to take: Periodic, intermittent oral.

  Course of treatment: When symptoms such as fullness and acid reflux appear, or when significant abdominal pain occurs due to irregular diet, start treatment, take regular oral administration for 3-4 weeks, and stop the drug for 4-6 weeks. As the symptoms of abdominal distension, abdominal pain, acid reflux and other symptoms improved significantly during the initial medication, and no obvious subjective discomfort was found, the medication was taken intermittently and regularly for 2 years according to the above-mentioned treatment course and plan.

  prognosis

  The patient reported that he knew that both gastric ulcer and Barrett's esophagus had potential cancer risk, and Hp was a class I carcinogen.

  The patient was diagnosed at the Gastroenterology Clinic of Peking University First Hospital 2 years after the diagnosis, 2018-12-18, and the C-13 breath test was reviewed and the gastroscope was reviewed to improve the relevant examinations.

  related inspection

  C-13 breath test: DOB value: -0.2 (normal)

  Blood routine: WBC 5.38×10^9/L, N% 44.4%, HGB 149.0g/L, PLT 315×10^9/L;

  Four items of coagulation: TT 17.9, PP 11.5;

  Biochemical examination: ALT 13.7, AST 17.5, TBIL 16.02, DBIL 4.57;

  Hp serum antibodies: UreA(+), UreB(+), CagA(+), VacA(+).

  Peking University Hospital treatment tips:

  1. Hp serum antibody is positive, C-13 breath test is negative, DOB value: -0.2 (normal).

  It was further confirmed that the patient had been infected with Hp, which has been completely eradicated.

  2. Gastric ulcer and Barrett's esophagus and other other needs to complete gastroscopy and further treatment.

  The patient complained that he was more psychologically anxious about conventional gastroscopy, and the appointment time for “painless gastroscopy” in the Outpatient Clinic of Peking University No. 1 Hospital was longer. Therefore, gastroscopy was not possible during this visit.

  Therefore, the patient went to our hospital (Beijing Tsinghua Chang Gung Memorial Hospital Affiliated to Tsinghua University) on July 10, 2019 for painless gastroscopy.

  Gastroscopy results:

  Esophagus: The mucous membrane is smooth and soft, pink, no erosions, ulcers and varicose veins, good peristalsis;

  Stomach angle: curved, smooth, with no abnormalities in the mucosa.

  Thinking and discussing

  Question 1: The above-mentioned patients have failed to adopt relevant guidelines and consensus-recommended remedial treatment measures since the initial treatment of Hp in 2017. The patient’s individual subjective willingness actively adopts Zinc granules) 75 mg bid" treatment. In the end, "It was accidentally discovered that Hp was successfully eradicated. Then, can Hp eradication by taking Relaisen alone? Can Relaisen be a new option for the Hp remedy quadruple program?

  Retrieving domestic and foreign literature, there is no clinical research and report on the application of mucosal protective agent-Relaisen (polyprezinc granules) alone in the treatment of Hp infection-related diseases. The commonly used treatment plan is combined with the conventional triple combination, and its safety and effectiveness have been fully verified.

  According to a large number of Japanese literature data, the combined application with conventional triple combination can significantly improve the eradication rate of patients, and it is well tolerated.

  At the same time, the results of research on the Chinese population show that the Hp eradication rate of Relaisen combined with triple therapy is significantly higher than that of conventional triple therapy.

  On the basis of the above research, a large number of in vitro antibacterial studies have also been carried out in China (1)

  Experimental result: Concentration of Relaisheng completely inhibiting the growth of Hp:

  0.04mmol/mL, 0.03mmol/mL, 0.02mmol/mL, 0.01mmol/mL, 0.005mmol/mL, 0.0025mmol/mL;

  In vitro antibacterial study (2)

  Experimental method: agar dilution method

  test results:

  clinical strains: 2 strains MIC: 0.001 mmol/mL, 5 strains MIC: 0.0025 mmol/mL;

  Hp International Standard Strain (11637): MIC: 0.001 mmol/mL.

  Water and HCL as a solvent have the same dissolving ability for the effective antibacterial ingredients of Relaisen

  Its related mechanism:

  Two important components in Polyprezinc can significantly inhibit the activity of urease:

  1. Zinc ion replacement modification effect:

  Zinc can make the nickel ion in the urease molecule undergo a substitution reaction, change the conformation of the urease, thereby inhibiting its enzyme activity:

  2. Another important component, carnosine, is a two peptide unit composed of alanine and histidine. Histidine can effectively regulate the accurate insertion of zinc ions into the active site of the zymogen, and replace it with nickel ions. This residue Conformational changes can make urease lose nearly 98% of its enzyme activity.

  Question 2: From February 2017 to October 2019, the above patient took Relaisen regularly and intermittently. The patient did not experience subjective discomfort. In December 2018, the relevant biochemical examination was completed, but no liver or kidney was found. There are abnormal phenomena in related safety indicators. So, can the conventional dose of Relaisen 75 mg bid be taken for a long time? After the 14 days of the Hp eradication program, can the treatment time of the mucosal protective agent be appropriately extended? That is, taking Relaisen alone for 4-8 weeks?

  Retrieved a Japanese literature report that for patients with chronic liver disease who had been taking polyprezinc for more than 3 years, there was no significant adverse reaction during the follow-up period.

  Therefore, except for patients with severe liver and kidney failure. The conventional dose of Relaisheng is 75 mg bid, which has no accumulation and toxicity for long-term use, and its safety is good.

  Question 3: The above patients were diagnosed with Barrett's esophagus and gastric ulcer (A2) in 2016, and took Relaisen regularly and intermittently. The gastroscopy report of our hospital (Tsinghua Chang Gung Memorial Hospital, Tsinghua University) in 2019 showed: "The esophageal mucosa is smooth and soft It was pink, no erosions, ulcers and varicose veins were seen, and the peristalsis was good; the stomach angle was curved and smooth, and the mucous membrane was not abnormal.” During the period, except for regular and intermittent administration of regular doses of Relaisant, no other intervention measures were taken. So, is Barrett's esophagus and gastric ulcer (A2) an accident of treatment, or is it an inevitable benefit?

  Barrett's esophagus is covered with abnormal columnar epithelium at the lower end, and is closely related to reflux esophagitis, and there is a possibility of adenocarcinoma. The current treatment measures and goals are to relieve and eliminate symptoms, reverse the esophageal columnar epithelium to squamous epithelium, prevent and treat complications, and reduce the incidence of esophageal adenocarcinoma.

  Retrieving domestic and foreign literature about polyprezinc and esophageal injury, the relevant reports are as follows:

  Research has shown that the benefits of Polyprene on esophageal injury are based on its anti-inflammatory, anti-oxidant, anti-fibrotic, and protective and repair mucosal damage effects.

  At the same time, the results of an endoscopic and pathological analysis of 127 cases of gastric angle ulcers showed that 36 of them were pathologically confirmed as malignant ulcers, with a carcinogenesis rate of 27.6%. Gastric angle ulcers had a higher carcinogenesis rate and were related to Hp infection. .

  The obvious improvement of the gastric ulcer in the above cases is closely related to the eradication of the patient's Hp and the repair of the mucosal structure.

  Case experience

  The follow-up time of the above cases is relatively long, and the patients themselves have a strong subjective willingness to take Relaisen, and their treatment benefits are significant. However, the treatment is a retrospective report of a single case, and its related mechanisms need to be further explored and discussed in subsequent related studies. verification.

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