杨志一《胃病研究》的学术思想初探

近代医家杨志一,名佩贤,江西吉安人,早年卒业于上海中医专门学校,曾任《医界春秋》编辑部主任,江西省中医药研究所临床主任。其所著《胃病研究》一书,于1937年出版,为胃病专著。书中较全面地阐述了胃的生理病理、发病原因、预防治疗、饮食调护等,书中还收录了先哲治疗胃病的经验及作者临证实录,对现今临床及教学具有一定指导意义和学术参考价值。

2011 update on esophageal achalasia

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes.The most favorable outcome is predicted for patients receiving treatment for type Ⅱ achalasia (achalasia with compression).Patients with typeⅠ(classic achalasia) and type Ⅲ achalasia (spastic achalasia) experience a less favorable outcome.Second,the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD).Although the follow-up period was not long enough to reach a convincing conclusion,it merits the continued use of PD as a generally available technique in gastroenterology.Third,the novelendoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia,but it requires increased experience and cautious evaluation.Despite all this good news,the bottom line is a real break-through from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.

Does gastric atrophy exist in children?

Several clinical reports confirmed that gastric atrophy is a pathology not only limited to adult patients. In pediatrics, it is most olden described in association with a H pylori infection but this bacteria does not seem to be the only etiological factor of this preneoplastic state in children. The frequency of gastric atrophy and intestinal metaplasia in children are unknown because they are not systematically sought during upper gastrointestinal endoscopy. The lack of specific histological classification of children＇s gastropathies makes their diagnosis difficult for pathologists. Based on our knowledge to date, we think that it is necessary to describe, in detail, the natural course of this lesion during childhood. A close and prolonged clinical and endoscopic follow-up is important for children with gastric atrophy.

Effectiveness of infliximab after adalimumab failure in Crohn's disease

AIM:To evaluate the effectiveness of infliximab as a second-line therapy in Crohn's disease patients after adalimumab failure. METHODS:A historical cohort study in a community-based gastroenterology practice evaluated Crohn's disease patients treated with infliximab (induction plus maintenance) after adalimumab failure. Patients were identified using a large Spanish database (ENEIDA). RESULTS:We included 15 Crohn's disease patients who received infliximab after adalimumab failure. Five patients discontinued adalimumab due to loss of response, 3 due to adverse events and 7 due to partial response. After infliximab therapy was started, all patients who had interrupted adalimumab due to loss of efficacy regained response. All patients who discontinued adalimumab due to adverse events responded to infliximab and maintained this response; one of these patients had an uneventful course on infliximab, but 2 developed adverse events. None of the 7 patients who interrupted adalimumab due to partial response reached remission with infliximab. CONCLUSION:Switching from adalimumab to infliximab may be useful in patients who develop adverse effects or loss of response, however, the benefit of infliximab in primary nonresponders was not established.

CLINICAL APPLICATION OF NEIGUAN (内关 PC 6) IN THE TREATMENT OF DISORDERS OF THE DIGESTIVE SYSTEM——THE RELATED RESEARCH PROGRESS

In the present paper, the authors review recent situations of clinical application of Neiguan (PC 6内关), etc. in the treatment of disorders of the digestive system and its related research progresses. In clinical practice, Neiguan (PC 6) is usually selected as one of the main acupoints to treat gastrointestinal reactions induced by ① nausea and vomiting, ② hiccup, ③ gastrointestinal dyskinesia, ④ gastritis, and ⑤ intra-gastric examination, cesarean section, etc. Concerning experimental studies, the effects of Neiguan (PC 6), etc. on ① gastric electrical activities, ② gastrointestinal motion, ③ gastrointestinal hormone secretion, and ④ gastric mucosal structure were observed. Results indicated that Neiguan (PC 6) is an important and effective acupoint for treatment of gastrointestinal disorders in clinic. Stimulation of Neiguan (PC 6) induced favorable regulation of both the peripheral nervous system and central nervous system, and changes of the gastrointestinal hormone secretion may contribute to its effects in treating various disorders.

Esophageal epithelial surface in patients with gastroesophageal reflux disease:An electron microscopic study

A/M： To investigate the intercellular spaces between the most superficially located esophageal epithelial cells in patients with gastroesophageal reflux disease （GERD）. METHODS： Eighteen patients with erosive esophagitis, 10 patients with non-erosive reflux disease （NERD）, and 18 normal asymptomatic volunteers were enrolled. Biopsy specimens were obtained from the lower esophageal mucosa without ulcer or erosion. Scanning electron microscopy was employed to investigate the tightness of the superficial cellular attachment. RESULTS： The intercellular space between the most superficially located epithelial cells in patients with erosive esophagitis or NERD was not different from that in asymptomatic healthy individuals. CONCLUSION： Widened luminal intercellular spaces of esophageal superficial epithelium are not responsible for the induction of reflux symptoms in patients with GERD.

Antral exfoliative cytology for the detection of Helicobacter pylori in the stomach

AIM: To evaluate the efficacy of antral exfoliative cytology method in the diagnosis of Helicobacter pylori (H pylori)infection in the stomach.METHODS: Fifty patients were submitted to upper digestivetract endoscopy due to complaints of dyspepsia. Thematerial for exfoliative cytology was obtained by extensive brushing of the gastric antral mucosa and Papanicolaou stain was used to identify the bacteria. The authors also performed gastric biopsies to collect material for urease tests and histologic studies, with hematoxylin-eosin and fucsin stains in order to identify the microorganism. The gold standard used to detect the presence of H pylori was an analysis of the combined results from the gastric biopsies by urease test and histological method. RESULTS: Antral exfoliative cytology method exhibited 90.3% sensitivity, 66.6% specificity, accuracy of 81.6%, positive predictive value of 82.3% and negative predictive value of 80.0%, in this population with a prevalence of 63.3%.CONCLUSION: Antral exfoliative cytology was demonstrated to be a sensitive, accurate and easy to perform method for investigating H pylori infection in the stomach.

Association of the p73 Gene G4C14-to-A4T14 Polymorphism with Increased Gastric Cancer Risk in a Northwestern Chinese Population

OBJECTIVE To evaluate the p73 gene G4C14-to-A4T14 double nucleotide polymorphism with both increased gastric cancer(GC) risk and different histological subtypes of GC in a northwestern Chinese population. METHODS Genotyping of the polymorphism of the p73 gene was conducted with PCR-CTPP. RESULTS All 385 GC patients including 305 diffuse-type and 80 intestinal-type cases and 412 healthy controls were investigated.The frequencies of p73 AT/AT,AT/GC,and GC/GC genotypes were 28.1%,47.1%,and 24.8% in the controls,and were 22.0%,45.0%,and 33.0% in GC cases respectively;the GC/GC homozygote frequency was higher in GC cases,mainly in diffuse type compared to the controls with OR=1.71(1.16～2.51) and 1.87 (95%CI,1.24～2.81) respectively.The results showed that carriers of the p73 G4A GC/GC homozygote had a 1.71-time higher risk of GC,especially of the diffuse-type GC compared to the controls. The carriers of the AT/GC heterozygote also had a slightly increased risk of GC cancer,mainly on intestinal-type GC.This is the first report that the p73 G4A double-nucleotide polymorphism is associated with an increased risk of diffuse-type gastric cancer. CONCLUTION The p73 G4A GC/GC genotype is associated with an increased risk of gastric cancer,especially of the GC diffuse-type.

Severity of gastroesophageal reflux disease influences daytime somnolence: A clinical study of 134 patients underwent upper panendoscopy

AIM: To asses the relationship between severity of gastroesophageal refluxe disease and Epworth sleepiness scale as an indicator of daytime somnolence. METHODS: One hundred and thirty-four patients underwent an upper panendoscopy as indicated by the typical reflux symptoms and were also investigated with regard to somnolence. Sleepiness was evaluated by Epworth Sleepiness Scale, which was compared to the severity of endoscopic findings (Savary-Miller/modified by Siewert). Patients with psychiatric disorders or being on sedato-hypnotics as well as shift workers were excluded from the study. The relationship between the severity of the reflux disease and daytime somnolence was analyzed with the help of multivariate regression analysis. RESULTS: A positive tendency was found between the severity of the reflux disease and the corresponding Epworth Sleepiness Scale. In the case of the more severe type-Savary-Miller Ⅲ- at least a mild hypersomnia was found. For this group daytime somnolence was significantly higher than in the case of the non-erosive type of Gastroesophageal Reflux Disease representing the mildest stage of reflux disease. CONCLUSION: The severity of Gastroesophageal Reflux Disease influences daytime somnolence.

Training gastroenterology fellows to perform gastric polypectomy using a novel ex vivo model

AIM:To evaluate the effect of hands-on training of gastroenterology fellows in gastric polypectomy using an ex vivo simulator.METHODS:Eight gastroenterology fellows at Mackay Memorial Hospital,Taipei were evaluated in gastricpolypectomy techniques using a pig stomach with artificial polyps created by a rubber band ligation device.The performance of four second year(year-2)fellows who had undergone one year of clinical training was compared with that of four f irst year(year-1)fellows both before and after a 4-h workshop using the ex vivo simulator.The workshop allowed for hands-on train-ing in the removal of multiple artif icial polyps and the placement of hemoclips at the excision site.Evaluation included observation of technical skills,procedure time,and the fellows' conf idence scale.RESULTS:One week after the workshop,the year-1 fellows were re-evaluated and had significantly im-proved mean performance scores(from 17.9 ± 1.8 to 22.5 ± 0.7),conf idence scale(from 4.5 ± 1.0 to 7.8 ± 0.5)and procedure time(from 615.0 ± 57.4 s to 357.5 ± 85.0 s)compared with their baseline performance.After 4 h of training using the ex vivo simulator,the skills of the year-1 fellows were statistically similar to those of the year-2 fellows.CONCLUSION:Use of this ex vivo simulator significantly improved the endoscopic gastric polypectomy skills of gastroenterology fellows who had not had previous clinical training in gastric polypectomy.