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史××,男,61岁,教师,病案号160915。1994年7月16日入院。患者1993年3月因恶心、呕吐、腹胀、腹痛以急性胃肠炎收住消化科。后出现明显的肠梗阻症状和体征,转外科手术治疗。手术中发现回肠末端距回盲部30cm处肠管僵硬狭窄,切除肠管约35cm,术后病理诊断为克隆氏病。出院后反复出现不完全性肠梗阻,且右下腹包块逐渐增大,有明显压痛。内科先后给予强的松每日60mg,柳氮磺胺吡啶每日4g,雷公藤等治疗(患者对雷公藤过敏)。包块增至10×15cm,压痛明显,固定不动,边界不清。钡灌肠钡剂在近回盲部处受阻,回盲部未显示。全消化道钡餐透视示回肠末段狭窄,近端回肠扩张。
History × ×, male, 61 years old, teacher, medical record number 160,915. July 16, 1994 admitted. Patients in March 1993 due to nausea, vomiting, abdominal distension, abdominal pain with acute gastroenteritis admitted to the Department of Gastroenterology. Obvious symptoms and signs of intestinal obstruction after surgery turned to surgery. Surgical findings ileum 30 cm away from the ileum at the end of stiff bowel stricture, resection of the intestine about 35cm, postoperative pathological diagnosis of Crohn’s disease. Recurrent incomplete intestinal obstruction after discharge, and the right lower quadrant mass gradually increased, there was significant tenderness. Internal medicine has given prednisone daily 60mg, sulfasalazine daily 4g, Tripterygium treatment (patients with tripterygium allergy). Mass increased to 10 × 15cm, tenderness, fixed, the border is not clear. Barium enema barium near the Ministry of ileocecal obstruction, ileocecal Department did not show. Full digestive barium meal showed distal ileal stenosis, proximal ileal dilatation.