哪个工作岗位在美国最受尊重?Harris民意调查最近发布了2016年美国最具声望职业的排名,医生位居榜首。每十个美国人中有九个认为医生是具有声望的职业,年老一辈尤其认为如此。Harris民意调查始于1
大家都知道怀孕时容易得痔疮。现在全面开放二孩政策,孕期得“痔”的顾虑就更为常见了。有些妈妈第一次怀孕时已经得过痔疮,苦不堪言,心有余悸。再次怀孕实在是顾虑多多!直接关系到大家子孙后代的事情,还是要引起重视!平日里大家所说的“痔疮”是大众化语言,而医学上称之为“痔”。痔是人体正常的生理组织。就跟每个人都有鼻子耳朵眼睛一样,每个人都有痔。痔,在正常人体中起的作用是与括约肌一起,共同起到封闭肛门的作用,避免肛门失禁。只是在多种因素作用下,痔的支持结构出现松弛,导致痔下移,最终脱出肛门,并伴有血管的扩张,这才出现相关症状。孕期痔产生的三大原因孕期出现痔,大多在第三孕期。主要是因为胎儿压迫盆腔的血管,包括动脉和静脉,引起血液回流障碍,血管扩张。怀孕时出现痔,除了压迫血管,原因还有:便秘、用力排便。孕期痔的症状可仅表现为皮赘。常见出血,脱出。还有:肛门瘙痒,排便不尽感。孕期痔的预防患者可从以下几个方面预防。除非痔脱出很严重,符合一般痔的手术切除指征,否则一般情况下,不建议在怀孕前预防性切除没有症状、不影响生活的痔:(一)避免便秘,也就是说保持大便通畅,最好每天一次。(二)软化大便。要做到这一点,可以多喝水,多吃带叶子的青菜、水果,避免酸辣,适当活动。(三)养成良好的排便习惯,不要用力排便,不要在上洗手间的时候看书、看ipad、看手机。孕期痔的治疗从概述中可以知道,痔是人体正常的生理组织,所以,除非有明确的手术指征(手术指征请搜索本公众号既往文章),医生一般不建议手术切除痔。一旦出现痔,根据情况,处理不一样,原则是尽量避免手术。因为孕早期会担心麻药、手术影响胎儿发育,孕后期会担心导致早产。(一)如果只是简单出血,没有脱出,就可以软化大便,不要用力排便,往往就可以自行好转。(二)如果效果不佳,可以坐浴。如何坐浴,请在本公众号中搜索“坐浴”即可获得相关文章(在公众号内回复关键词即可搜索)。(三)如果有痔脱出肛门外,尽早用手还纳(就是把痔塞回去)。以免进一步恶化,造成嵌顿。还纳后建议尽快躺下,左侧卧位。次日不管有没有再出现脱出,也建议常规坐浴。(四)如果痔脱出,自己不能还纳,这时候就要尽早就医了。到医院,找专科医生,医生会帮忙还纳,以及进一步处理(局部消肿等)。(五)如果痔脱出时间较长,嵌顿严重无法还纳,甚至已经出现坏死,应该及时手术。孕期痔的鉴别诊断其实应该先说这个!孕期出现痔的相关症状,跟非孕妇一样,也要注意排除息肉、直肠癌、肛裂、憩室等等可能,才能确诊。临床上有孕妇怀孕后便血,开始以为是痔,自行治疗,后来到才发现直肠癌的。所以,建议大家,有相关症状,还是尽早到医院就医。痔本事不会影响胎儿发育,但如果延误治疗,或者误诊,可能会带来灾难性的后果。请大家直接关注“练磊医生”微信公众号,以获得更多的胃肠保健、胃肠疾病治疗知识,并可与练医生互动,排疑解惑。
老王今年刚满60岁,准备退休,开始享受天伦之乐。他身体健朗,行动自如,谈吐清晰。平时身体也是没有什么毛病,连感冒发烧等小病也都很少,这辈子基本没有生过什么大病,更别说去过医院了。老王也比较好抽烟、喝酒这一口,平时吃的也是大鱼大肉,基本没有什么忌口的,可谓是“五毒俱全”,但从来没有到医院体检过,虽然老王的单位每年都会组织体检的。又是一年体检时,单位又组织了一次体检,老王一如既往地不愿意去参加体检。但是家里人认为老王年纪大了,做个体检看看身体是否有不适,早期发现问题能够早期治疗,就算没有问题也可以图个心安。在家人积极地劝说下,老王终于参加了单位组织的体检。很多东西表面看起来很好,其实不然,身体也是一样。这一体检后,发现老王的左肺部有一个2.5cm的“结节”,也就是肺里面长了个瘤子。老王在当地医院做了CT检查,明确“结节”性质。由于经济原因,并没有选择做全身PET-CT检查,只做了肺部的增强CT,诊断为“肺癌”,在完善了相关的检查之后,老王在当地医院进行了左肺癌根治术,手术后病理提示肺部的肿物是“中分化腺癌”,并有肺门淋巴结转移,术后进行了多个疗程的化疗。故事到这里,并没有结束……肺癌手术后3个月左右,老王突然好几天没有排便,逐渐出现恶心、腹胀,到最后出现肚子痛得厉害,呈阵发性绞痛。老王这时候到了当地医院急诊,查腹部CT提示:低位结肠梗阻;乙状结肠肠壁增厚,肠腔狭窄,结肠癌待排。经过放胃管、灌肠等一系列保守治疗后,腹部仍然越来越涨,这才转诊到了中山六院。在完善了相关的检查后,行剖腹探查术,发现乙状结肠巨大肿物,侵出肠壁,造成了肿瘤在腹腔里面的播散。主刀医生为老王施行了乙状结肠癌切除。因为肠梗阻导致肠腔积聚了大量的粪便,术中灌洗干净肠道,才把肠管接了回去,还做了“回肠末端造口术”来保护结肠的吻合口。术后病理最终提示为肠癌。结合患者之前的肺癌病史以及会诊肺部手术病理切片,医院最终确诊老王是乙状结肠癌合并肺转移。至此才发现,肺癌的罪魁祸首原来是肠癌!从该病例可以看出,肠癌的临床表现也可以是千变万化的。有时候肠癌的发现并不是一开始首先发现原发的肠癌,而是通过其他途径发现继发的转移病灶或其他部位的不适。那么肠癌是如何转移的呢?肠癌的转移途径局部浸润淋巴途径血行途径种植播散局部浸润结直肠癌首先直接先肠壁深层浸润性生长,向肠壁纵轴浸润发生较晚。估计癌肿浸润肠壁需要1.5~2年时间。在结直肠癌中,主要以肿瘤在肠道深层浸润的层次来评估浸润的范围,当肿瘤突破浆膜层时,也可浸润到临近器官,如子宫、膀胱、输尿管等。淋巴途径结直肠癌都主要经淋巴结转移:结肠癌首先到结肠壁和结肠旁淋巴结,再到肠系膜血管周围和肠系膜血管根部淋巴结;上段直肠癌向上沿直肠上动脉、肠系膜下动脉及腹主动脉周围淋巴结转移,下段直肠癌向上方和侧方转移为主。血行途径结肠癌血行转移多见于肝,其次为肺、骨等;直肠癌侵入静脉后沿门静脉转移至肝;也可由髂静脉转移至肺、骨和脑等。种植播散结肠癌脱落的癌细胞可以在腹膜种植转移;直肠癌种植转移的机会较小,上段直肠癌可发生种植转移。老王的肺癌即是肠癌的肿瘤细胞通过血行途径转移到肺部,从而导致肺部肿瘤的发生。如下图:从老王的病例中可以看出:一、晚期肠癌可以没有肠道症状,更别说早期肠癌了!可见进行肠镜筛查有多重要!二、在确诊肺癌的时候,尽管没有肠道相关症状出现时,多留一个心眼,怀疑是不是有肠癌是很有帮助的。有肠道相关症状时更应该引起重视,此举有可能避免漏诊肠癌这个导致肺癌的罪魁祸首。做个肠镜就能发现问题。在出现肺转移的时候,肠癌已经可以说属于晚期了。但如果及早发现,老王也不至于后来出现肠梗阻、腹腔播散、需要造口两次手术了。请大家直接关注“练磊医生”微信公众号,以获得更多的胃肠保健、胃肠疾病治疗知识,并可与练医生互动,排疑解惑。
An anal fissure is a tear in the opening of the anus that can cause pain, itching, and bleeding.肛裂,就是肛门开口处裂开,引起疼痛、瘙痒、出血。Anal fissures are common in infants but less so in older children. They occur in adults of all ages. The pain, which can be quite severe, usually occurs during and after a bowel movement. The most common cause of anal fissures is constipation, but diarrhea can be a cause as well. Anal fissures often result from a cycle in which you have pain as a result of constipation, avoid having a bowel movement, and thus worsen the constipation. Treatment involves changing your diet to eliminate diarrhea or constipation, or topical medications to help heal the tear. However, some people need surgery to treat an anal fissure. Anal fissures are not associated with cancer, but you should always talk to your doctor if you have bleeding with a bowel movement.肛裂在婴幼儿较为常见,成年人相对少见。肛裂可以在任何年龄段发生。疼痛通常比较剧烈,一般在排便时或排便后出现。肛裂最常见的病因是便秘,但腹泻也可以引起肛裂。肛裂常常形成恶性循环:便秘导致肛裂,患者因为肛裂疼痛避免排便,又加重便秘。治疗包括改变饮食,避免腹泻或便秘,或局部药物治疗加速肛裂愈合。SYMPTOMS AND DIAGNOSIS症状以及诊断The most common symptoms are pain when having a bowel movement and blood on the toilet tissue. Acute anal fissures usually get better quickly. A chronic fissure, which can be more difficult to treat, is one that has lasted more than 6 weeks.最常见的症状时排便时疼痛、擦拭有血。急性肛裂一般恢复较快。慢性肛裂治疗相对困难,一般持续6周以上。A doctor can usually easily see if you have an anal fissure. To make the diagnosis, he or she might use an instrument called an anoscope to examine the anal canal.医生进行体格检查很容易发现肛裂。确诊需要使用肛门镜检查肛管。CAUSES病因Constipation can cause the skin of the anus to tear. When that happens, the pain of a bowel movement can cause spasms in the anal sphincter muscle. This in turn means that less blood flows to the area, making it more difficult for the fissure to heal. The pain can also cause people to resist having a bowel movement, which worsens the constipation. Other causes include diarrhea and Crohn disease.便秘可以导致肛周皮肤裂开。一旦发生,疼痛可使肛门括约肌痉挛,导致肛门周围血运减少,肛裂愈合更慢。疼痛也可能使患者避免排便,加重便秘。其他原因包括腹泻、克罗恩病。If you have anal pain for more than 10 days, you should see a doctor to rule out an infection, a complication of inflammatory bowel disease, a hemorrhoidal condition, or anal cancer.如果疼痛持续超过10天,应该咨询医生,排除感染、炎症性肠病、痔、肛管癌等。TREATMENT治疗Home and over-the-counter treatments include sitting in a warm bath; treating constipation with a high-fiber diet, a fiber supplement, and plenty of liquids; and nonprescription ointments including petroleum jelly, 5% lidocaine or 2.5% lidocaine plus 2.5% prilocaine, zinc oxide, or 1% hydrocortisone cream.家用、非处方药物治疗温水坐浴,高纤维饮食治疗便秘,纤维素添加剂,大量饮水。非处方药膏包括凡士林胶、5%利多卡因、或2.5%加2.5%丙胺卡因、氧化锌、或1%氢化可的松软膏。A second line of treatment may be prescription-strength topical ointments containing medications such as nitroglycerin, diltiazem, or nifedipine to relax the sphincter muscles.二线药物可采用处方局部药膏,包括硝酸甘油、地尔硫卓、或尼福地平来松弛括约肌。Another treatment option is surgery, usually done in an outpatient setting. One type of surgery involves injecting botulinum toxin into the anal sphincter. Another kind of surgery involves an operation to cut a small portion of the internal anal sphincter. This improves blood flow to the tear and reduces spasm. Surgery does not heal the tear but is usually successful in preventing anal fissures from recurring.另一种治疗方法是手术,一般可以在门诊进行。一种手术方式是局部注射肉毒素进入括约肌。另一种是切断部分内括约肌。这些手术可以改善肛裂的血运,减轻痉挛。手术本身不是使肛裂愈合,但常常可以有效地预防肛裂复发。请大家直接关注“练磊医生”微信公众号,以获得更多的胃肠保健、胃肠疾病治疗知识,并可与练医生互动,排疑解惑。
放疗,也叫放射治疗,是采用高能量的射线来杀死肿瘤细胞或使肿瘤缩小的治疗手段。什么时候采用放疗?手术前(新辅助治疗):如果肿瘤较大,在做手术前使用放疗可以使肿瘤缩小,也可以减少直肠癌局部复发。放疗常与化
2014年《Gut》发表了《克罗恩病肛瘘诊治指南》。克罗恩病肛瘘专家共识小组就克罗恩病肛瘘分类与评分、诊断、治疗和手术管理等四个方面制定了指南,是基于当前最佳的临床证据。2015年中国中西医结合学会炎症性肠病专家组翻译成中文,发表在《中华胃肠外科杂志》,为国内临床医生提供参考。2016年本人在南京军区总医院主办的IBD论坛就此指南进行了解读。解读幻灯通过此平台与大家共享。欢迎提出宝贵意见!接受批评指正,共同学习进步(可加我个人微信:leilianmd)。请大家直接关注“练磊医生”微信公众号,以获得更多的胃肠保健、胃肠疾病治疗知识,并可与练医生互动,排疑解惑。本文系练磊医生授权好大夫在线(www.haodf.com)发布,未经授权请勿转载。
克罗恩病(CD)的肛裂分两种类型:一、原发性肛裂与克罗恩病无关,并且其病损处外观和一般的肛裂并无差异,具有典型的特征:浅溃疡、位于正中线、从齿状线下延伸至肛管外缘。通常对以下治疗有效:坐浴、麻醉药和激
得了克罗恩病,又患了“痔疮”,怎么办?首先要区分到底是“痔”还是“皮赘”。克罗恩病患者更常见的是肛门周围出现皮赘,有时与痔难于区分,因此应找医生仔细检查,分清楚是痔还是皮赘。皮赘的大小、形状、性质各异
The colon, the lower part of the digestive system, processes waste products and prepares feces (stoo
A hernia develops when a weakness that forms in the abdominal wall enables part of the intestine (bowel) or another organ to protrude through it. Among the most common are umbilical hernias that occur at the navel and inguinal hernias that are seen in the groin area. There are 2 types of inguinal hernia, indirect and direct, that may look similar but have different locations of the protruding intestine. Incisional hernias occur where an incision has been made in the abdominal wall for an operation.当腹壁出现薄弱,肠子或其他内脏经过薄弱的部位突出,就形成“疝”。最常见是脐疝以及腹股沟疝。腹股沟疝有两种:斜疝和直疝。两者看起来很类似,但突出的部位不同。切口疝是腹部手术后在切口部位出现的疝。SYMPTOMS症状The first symptom of a hernia is usually a small bulging under the skin that is generally painless but may produce discomfort and get larger during strenuous activities or coughing. At this stage, the hernia is reducible because its contents (bowel) can be pushed back into the abdomen. However, if the hernia grows, it may become incarcerated (unable to be pushed back). If blood stops flowing through an incarcerated bowel, this results in strangulation, which is accompanied by pain, often with nausea, vomiting, or constipation.最开始的症状是皮下凸起,没有疼痛,但在活动剧烈或咳嗽时可以增大,产生疼痛。在这个阶段,疝还是可以回复的,也就是疝的内容物可以回到腹腔。但是,随着疝的发展,可能会出现嵌顿(无法回纳)。如果血液无法进入嵌顿的肠管,会导致绞窄,出现疼痛、恶心、呕吐或便秘。RISK FACTORS危险因素 Family history of hernia 疝的家族史 Being male 男性 Obesity 肥胖 Pregnancy 妊娠 Weight lifting, coughing, straining during bowel movement 举重、咳嗽、排便费力 Cystic fibrosis and chronic lung infections 囊性纤维化以及慢性肺炎 Previous abdominal surgery 既往腹部手术史COMPLICATIONS并发症A hernia may result in entrapment of other organs (such as the bladder or colon) or nerves, producing constipation or problems with urination or sexual function. A strangulated hernia is a surgical emergency because part of the bowel may become necrotic (dead), resulting in life-threatening peritonitis (inflammation of the abdominal cavity) needing surgical removal of part of the bowel. If you have a hernia and significant abdominal pain, pain over the hernia, or nausea or vomiting, you should seek medical care immediately.疝可能累及其他器官(如膀胱或结肠)或神经,导致便秘、排尿功能或性功能障碍。绞窄性疝是外科急症,因为肠子会坏死,导致腹膜炎(腹腔里面的炎症),危及生命,需要手术切除部分肠管。如果疝伴有明显腹痛、疝疼痛、恶心、呕吐,应该及时就医。TREATMENT治疗Initial treatment of a minor hernia includes avoiding heavy lifting and strenuous exercises and, sometimes, wearing a support (truss or girdle). It used to be thought that all hernias should be repaired. However, recent evidence suggests that repair should be performed only if significant discomfort or pain is associated with the hernia. 小的疝的初始治疗包括避免举重、用力、或运动,有时可以佩戴支持物。既往认为所有的疝都应该修补。但最新的证据显示只有当疝伴有明显的不适或疼痛时才需要进行修补。The operation to repair a hernia is called a herniorrhaphy (closing the gap in muscles). When the gap is large, a plastic mesh may be used for reinforcement of muscles of the abdominal wall. Use of mesh reduces the risk of the hernia recurring, but the mesh material can become infected. In some cases, hernia repairs may be performed laparoscopically (through small skin incisions using a fiberoptic tube with a camera and small instruments), although this approach has not been shown to be better than traditional open operations.手术修补疝的方法叫疝修补术。当缺损比较大,可以采用补片加强肌肉的薄弱区域。使用补片可以减少复发,但补片可能会感染。某些情况下,疝修补术可以通过腹腔镜(通过皮肤的小切口以及带有摄像头的纤维软管、微型器械)来操作,但没有证据显示腹腔镜比传统手术有优势。请大家直接关注“练磊医生”微信公众号,以获得更多的胃肠保健、胃肠疾病治疗知识,并可与练医生互动,排疑解惑。