Dysentery, name of disease. See Fang Jisheng. Before the Song Dynasty, there were names such as diarrhea, red and white fever, heat benefit, dysentery, dysentery and stagnation. "Medical Theory" Volume III: "Diarrhea is damp-heat, or due to eating damp-heat or feeling damp-heat gas, it accumulates in the gastrointestinal tract, which is blocked by evil, and the spleen and stomach function is abnormal, so the diet is increasingly stagnant, turning into turbidity, sticking to the gastrointestinal tract, and the operation of the machine is beneficial to the disadvantages, and qi stagnation is a fire, which is mixed with damp-heat gas to become evil and attack ... Later generations clearly pointed out that dysentery is mostly caused by unclean diet and feels the poison of the epidemic. However, the red, white and sticky freeze caused by dysentery, "Medical Principles and Limen" said: "Red blood is injured and belongs to the small intestine; White people are injured in qi and belong to the large intestine. " "Ming Yi Zhang Zhi": "Dampness and heat accumulate, blood dryness is red, and qi dryness is white. "Clinically, it is appropriate to clear away heat and promote diuresis, cool blood and detoxify, and eliminate stagnation. In addition to strengthening the body resistance, the pathogen with excess qi deficiency should also promote blood circulation and regulate qi. This so-called "promoting blood circulation will heal itself, regulating qi will eliminate itself", and deficiency syndrome should replenish qi, warm yang and astringent essence. Dysentery can be divided into many kinds. According to the different causes and symptoms (including the severity and course of symptoms and the color of dysentery), there are roughly summer dysentery, damp-heat dysentery, wind dysentery, epidemic dysentery, gas dysentery, toxic dysentery, heat dysentery, cold dysentery, mouth dysentery, chronic dysentery, rest dysentery, strange dysentery, red dysentery, white dysentery, red dysentery and five-color dysentery.
Bacillary dysentery is a common disease, which can occur all year round, but the incidence rate is high in summer and autumn. People of all ages can be infected, and the incidence rate of children is higher than that of adults, especially children aged 1-4. In the case of poor sanitation and bad hygiene habits, it is easy to be popular. The incidence of bacillary dysentery in China is also very high. Early treatment of bacillary dysentery is effective; 3-4 days after onset, the curative effect is poor. If the treatment is not thorough or appropriate, it is easy to turn into chronic dysentery, which is difficult to cure. Poisonous dysentery is serious and the mortality rate is high.
1 etiology
Shigella dysenteriae belongs to the genus Shigella, and Gram staining is negative. According to different bacterial antigens, it can be divided into four groups: Shigella, Freund's, Borrelia and Sonnerella. This genus has a strong viability in the external environment, among which Sonnetobacter is the strongest and Shigella is the weakest. Exposure to the sun for half an hour can cause death, 60℃ 10 minutes can cause death, and 100℃ can cause immediate death. General disinfectants such as Lysol, bleaching powder, bromogeramine and peracetic acid can inactivate it.
2 epidemiology
Dysentery can occur all year round, but the incidence rate is high in summer and autumn. Dysentery patients and carriers are the sources of infection, while mild and chronic dysentery and healthy carriers are easily overlooked. The main route of transmission is fecal and oral infection, and children with poor hygiene habits are prone to this disease. Chronic bacillary dysentery in children is latent, atypical and persistent, and it is not easy to be found, so it is easy to be prevalent among children. People's immunity is not lasting after being infected, and it can recur. Cold, fatigue, improper diet, lack of nutrition, intestinal flora imbalance and other factors can reduce the resistance to this disease.
3 Pathogenesis
The main lesion of this disease is suppurative inflammation at the end of colon or ileum, because the endogenous and exogenous toxins produced by Shigella dysenteriae damage the intestinal mucosa, and multinucleated cells infiltrate the lesion site, forming abscess or ulcer. The local mesenteric lymph nodes were congested and swollen. The main pathological change of toxic bacillary dysentery is the increase of systemic arterial wall permeability, which makes the tissues around the vascular wall edema seriously and the internal organs (such as brain, liver, kidney and adrenal gland) edema.
4 Clinical manifestations
The clinical manifestations of bacillary dysentery are abdominal pain, diarrhea, acute diarrhea, purulent bloody stool and systemic poisoning. Infants do not respond strongly to infection and have a slow onset. At first, the stool was mostly indigestion-like loose stool, and the course of the disease was easy to delay. Children over 3 years old have an acute onset, with fever, diarrhea and abdominal pain as the main symptoms, and may have convulsions and vomiting. People infected with Shigella or Freund's disease are more serious and prone to toxic dysentery, which is more common in children aged 3-7. Infants who are artificially fed are weak and prone to complications.
Bacillary dysentery can be divided into acute, persistent and chronic bacillary dysentery according to the course of disease, and its clinical manifestations are as follows:
(1) Acute bacillary dysentery can be divided into four types according to clinical manifestations, namely, common type, mild type, severe type and toxic type.
① Ordinary type: acute onset, body temperature 39℃ -40℃, accompanied by nausea, vomiting, abdominal pain and diarrhea. Stool 10- 20 times a day. At first, it is loose stool or watery diarrhea, then it is purulent, and the tenderness of the left lower abdomen is accompanied by hyperactivity of bowel sounds, which is obvious after the emergency. If treated in time, it will be cured within a few days.
② Mild: Compared with common systemic toxic blood symptoms and intestinal symptoms, acute diarrhea, severe diarrhea and other symptoms are not obvious and are easily misdiagnosed as enteritis or colitis.
③ Severe type: high fever, vomiting, abdominal pain and acute diarrhea. Severe cases have purulent bloody stools, which can reach dozens of times a day. Severe cases have symptoms of dehydration and acidosis.
④ Poisoning type: This type is more common in children aged 3-7 years. The onset is urgent, and the body temperature rises rapidly to 40℃ 0-4 1℃, accompanied by symptoms such as headache, chills, convulsions or circulatory disorders. This disease often has no symptoms of upper respiratory tract infection. Gastrointestinal symptoms are not serious, and most of them occur 6- 12 hours after convulsion. Poisoning type is mainly manifested as shock type with peripheral circulation failure; The brain type with brain edema and increased intracranial pressure is mainly mixed respiratory and circulatory failure.
A. Shock type: In the early stage, the child's face was pale, his mouth was blue, his limbs were cold, his toenails were pale, his heart rate was accelerated, and his breathing was accelerated. With the development of the disease, the complexion turns gray, referring to the cyanosis of nails, lips and skin, the heart rate is more than 160 times per minute, the heart sound is dull, the pulse is weak, and the consciousness is unclear. Late stage with heart failure, shock lung, DIC (disseminated intravascular coagulation) and so on.
B. brain type: more common in preschool children, relatively rare in infants and school-age children. At first, the child was conscious, suddenly convulsed, his limbs convulsed and his eyes turned over. Severe cases appear repeatedly. At first, consciousness is still clear after each convulsion, and then gradually becomes dull, irritable or sleepy until coma. The child's face is gray. The higher the body temperature, the grayer the face and the more serious the neurological symptoms. Brain edema and encephalopathy can cause respiratory failure, so treatment is difficult. Therefore, if the child's face is pale, his heart rate is slow, and he has repeated convulsions, they are all signs of increased intracranial pressure, which should be actively dealt with to prevent respiratory failure.
When bacillary dysentery has brain edema, the change of fundus is not obvious, so it can not be used to judge whether there is brain edema.
C. mixed type: brain type and shock type coexist, and the condition is serious.
(2) The course of protracted bacillary dysentery is between 2 weeks and 2 months, which is the reason for the persistence of acute bacillary dysentery. Patients often have no symptoms of high fever, abdominal pain or poisoning, but only abdominal discomfort, poor appetite, frequent defecation, and sometimes purulent stool and mucus appear alternately. The positive rate of stool culture was lower than that in acute stage.
(3) The course of chronic bacillary dysentery is more than 2 months. Due to delayed treatment in the acute phase, or due to physical weakness, malnutrition, rickets, parasites, anemia and other complications. It may also be caused by drug-resistant strains. Except for diarrhea, other symptoms are atypical. A long course of disease may lead to emaciation, fatigue and mild anemia.
5 check
The total number of white blood cells and neutrophils in acute patients increases, and some nuclei may shift to the left, while those in chronic patients may have anemia. Microscopic examination of stool in typical patients shows a large number of pus cells, red blood cells and phagocytes, while atypical patients only see a small number of white blood cells. Choosing purulent blood is easy to get positive results. X-ray and sigmoidoscopy can be used for the examination and differential diagnosis of chronic bacillary dysentery.
6 Diagnosis and differential diagnosis
In the epidemic season, acute diarrhea should be considered if you have a history of contact with dysentery or unclean diet, and have symptoms such as fever, mucus pus and bloody stool. In summer and autumn, those with sudden high fever, convulsions, pale face, chills in limbs and rapid pulse should consider toxic bacillary dysentery. The disease has symptoms of vomiting and abdominal pain, but if the patient has severe vomiting and persistent severe abdominal pain, other intestinal and parenteral diseases should be ruled out first to prevent misdiagnosis. Attention should be paid to distinguish it from the following diseases:
① Pathogenic Escherichia coli enteritis mostly occurs in children under 2 years old, and the incidence rate is high in 5-8 months. There may be mucus in the feces, fishy smell, thin like egg drop soup, and a lot of stool, which is easy to cause dehydration and acidosis. Microscopic examination can have white blood cells and pus cells, and fecal bacterial culture can make a diagnosis.
② Salmonella enteritis often occurs in families or groups, and vomiting is more common. Fecal mucus is more than pus, and it is often green jelly-like. Acute diarrhea rarely occurs, and it can be diagnosed by fecal bacterial culture.
③ Viral diarrhea is more common in children under 2 years old. Acute onset, accompanied by symptoms of upper respiratory tract infection, watery stool or egg drop soup, a small amount of mucus, no foul smell. Fecal bacteria culture is negative, and immunoelectron microscopy, enzyme-linked immunosorbent assay, polyacrylamide gel electrophoresis and virus isolation are helpful for the diagnosis of diseases.
④ Amoebic dysentery is more common in South China, especially in older children. The onset is slow, and the number of stools is more, but it is not urgent and then heavy. There is blood and mucus in stool, like purple jam. Fresh fecal mucus can be found by microscopic examination.
⑥ Acute attack of hemorrhagic enteritis, with symptoms such as abdominal pain, abdominal distension and vomiting. The stool is bloody and watery, and shock often occurs in the later stage. Fecal culture is negative, and X-ray examination is helpful for the diagnosis of the disease.
⑥ The epidemic season of Japanese encephalitis is the same as toxic dysentery. Toxic dysentery is similar when it lacks intestinal symptoms. Cerebrospinal fluid examination is helpful for the diagnosis of Japanese encephalitis. The diagnosis of toxic dysentery can be confirmed by warm saline enema and objective examination or culture.
⑦ Cholera and paracholera come from epidemic areas in the epidemic season, and they have a history of eating aquatic products, acute vomiting and diarrhea, and the amount of water is large, showing rice-washing water samples. Bacterial culture in feces is helpful for diagnosis.
⑧ Purulent bloody stool may appear in intestinal tuberculosis, which is similar to bacillary dysentery, but the onset is slow, with a history of tuberculosis, low fever and night sweats in the afternoon, and the tuberculin test is positive; Fecal culture is helpful for diagnosis.
7 treatment
(1) Treatment of common acute dysentery
① Routine treatment: Children should stay in bed, be isolated and take disinfection measures. The diet is mainly liquid or semi-liquid food, and children with vomiting and abdominal distension can fast for a short time.
② Antibiotic treatment: oral flugualic acid, gentamicin, berberine and compound sulfamethoxazole can be used. The course of treatment is 7- 10 days.
③ Adsorption therapy: Smecta can be given. Smecta has a strong adsorption effect on bacteria and toxins, can inhibit the growth of bacteria, and can also combine and interact with mucin to strengthen the intestinal mucosal barrier.
④ Microecological therapy: preparations containing Bifidobacterium can be used. By combining with intestinal cat membrane epithelial cells, it plays a protective role, inhibits bacterial invasion and maintains intestinal microecological balance.
⑥ rehydration therapy: determine the method and amount of rehydration according to dehydration.
(2) Treatment of chronic dysentery
① The commonly used drugs and doses of antibiotics are the same as those of acute bacillary dysentery, but the course of treatment is longer. Intermittent therapy can be used, with medication for 7- 10 days, rest for 4 days, further treatment for 4 days, rest for 4 days, and repetition for 4 days, with a total course of treatment of 3-4 weeks. It can also be treated by enema with berberine or garlic mixture. However, it should be noted that long-term use of antibiotics will cause intestinal flora imbalance. When stool culture turns negative and purulent blood disappears, it is necessary to switch to traditional Chinese medicine, vitamins, microecological agents and smecta.
② Diet therapy: Besides antibacterial therapy, we should also pay attention to improving the nutritional status of patients with chronic bacillary dysentery.
(3) Treating toxic dysentery
① Improve microcirculation: Atropine drugs can be used to relieve vasospasm and prevent shock. Dilate blood vessels with dopamine, phentolamine, isoproterenol, etc. Chlorpromazine, a hibernating drug, has the effects of calming and reducing basal metabolism by inhibiting receptors on blood vessel walls, dilating microvessels and improving microcirculation. Use glucocorticoid and hydrocortisone to relieve inflammation, brain edema and poisoning symptoms.
(2) Dilatation and acid correction: According to the principle that the infusion speed is fast first and then slow, salt is first followed by sugar, and potassium is supplemented in urine.
③ Respiratory failure: take oxygen, keep the respiratory tract unobstructed, use respiratory stimulants, and give tracheal intubation or artificial respiration to the critically ill.
④ Alleviating brain edema: The dehydrating agent mannitol should be used in time, and dexamethasone should be added by intravenous injection or rapid intravenous drip.
⑤ Control infection: do drug sensitivity test in time and use antibiotics reasonably. Before the drug sensitivity results come out, intravenous injection of voronone drugs, such as ciprofloxacin, is generally the first choice, but such drugs may affect the skeletal development of young children, and the course of treatment should not be too long, usually 5-7 days. Cephalosporins such as cefoperazone and cefotaxime are also commonly used to control infection.
⑥ Cooling: Rapiline, paracetamol and naproxen can be used to cool down, or cold saline enema or physical cooling.
Drug resistance of Shigella dysenteriae
The drug resistance factor (R factor) in the cytoplasm of Shigella dysenteriae can make it produce enzyme system that destroys antibacterial drugs and produce drug resistance. R factor can spread between different strains, even between different flora, resulting in the spread of drug resistance, resulting in more drug-resistant strains.
In recent years, with the wide application and even abuse of antibiotics, the drug resistance of Shigella dysenteriae has increased year by year, and some sensitive strains have also become drug-resistant strains, which have different degrees of drug resistance to commonly used antibiotics (compound methoxazole, chloramphenicol, pipemidic acid, ampicillin and norfloxacin), which brings difficulties to treatment.
Overview of TCM research on dysentery
Traditional Chinese medicine believes that this disease is mostly caused by external damp-heat poison gas, internal injury, cold diet and damage to spleen, stomach and viscera, and belongs to the category of "intestinal obstruction and dysentery". "Su Wen? Taiyin Yangming said, "If you don't eat well, you will live well from time to time ... and you will have diarrhea for a long time. "Zheng Zhi Bu" pointed out: "If the intestine is open, it means that damp-heat accumulates in the intestine, that is, dysentery also exists, so dysentery is caused by dampness, heat and food accumulation". In treatment, we should adopt the method of syndrome differentiation and treatment. " "Jing Yue Quan Shu" says: "To treat dysentery, it is most important to observe the deficiency and excess and distinguish between cold and heat, which has the greatest relationship with this diarrhea. If the four are unknown, it is easy to kill people. "So cold and heat deficiency is the first syndrome differentiation of this disease. Clinical symptoms should be differentiated according to abdominal pain, urgency and diarrhea, and combined with tongue pulse, which can usually be divided into 6 types. The key points of syndrome differentiation and treatment principles of each type are as follows.
(1) damp-heat type
Abdominal pain, red and white purulent blood due to dysentery, yellow and greasy fur and slippery pulse are the key points of syndrome differentiation. The pathogenesis is that the pathogen of damp-heat invades the stomach and intestines, qi and blood are blocked, and it hurts if you don't move, so abdominal pain is acute inside and then severe; Dampness and heat stagnate in the large intestine, and the meridians are damaged, so diarrhea is red, white and pus; The yellow greasy fur and slippery pulse are signs of damp heat. Treatment should be clearing away heat and promoting diuresis, regulating qi and promoting blood circulation. You can add or subtract 15g of Radix Paeoniae Alba and Flos Lonicerae, 9g of Radix Angelicae Sinensis, Radix et Rhizoma Rhei, Scutellariae Radix and Coptidis Rhizoma, 5g of Areca catechu, Radix Aucklandiae, Ramulus Cinnamomi and Glycyrrhrizae Radix. Sanguisorba officinalis, peach kernel and peony bark are added for blood heat and phlegm stagnation.
(2) Cold-dampness type
The main points of this syndrome are abdominal pain, aversion to temperature, diarrhea with more white and less red or pure white freezing. The pathogenesis is that the pathogen of cold and dampness invades the gastrointestinal tract, the qi and blood stagnate, and the fu-organs are unfavorable, so the abdominal pain is full, and the internal urgency is severe; It is caused by cold evil, so I like warmth; When the evil of cold and dampness interferes with the large intestine and the meridians are damaged, the diarrhea is white or frozen; Pale tongue, white greasy fur and slow pulse are signs of cold and dampness. The treatment principle should be warming, cold and dampness, activating qi and promoting blood circulation. Add and subtract Ling Wei Tang Can: Rhizoma Atractylodis, Cortex Magnolia Officinalis, Pericarpium Citri Tangerinae, Poria, Radix Angelicae Sinensis each 65438±00g, Ramulus Cinnamomi, Rhizoma Zingiberis Preparata, Radix Aucklandiae, and Fructus Aurantii Immaturus each 3g. If the weather is very cold, increase the amount of dried ginger.
(3) Type of epidemic virus
The key points of syndrome differentiation are sudden onset, abdominal pain, severe or severe fever, restlessness, red tongue, Huang Gan coating and slippery pulse. Pathogenesis is the evil of epidemic poison, which hurts people the fastest, so the onset is sudden, the epidemic poison burns the intestines, consumes qi and blood, and damages the meridians, so diarrhea is bright purple. The gas of epidemic poison is more than the evil of damp heat, so the abdominal pain is worse after acute; Poison is abundant in the stomach, which helps heat and hurts body fluids, so it is strong and thirsty; Red tongue, yellow and dry fur, and slippery pulse are the signs of excessive internal heat. The treatment should be to clear away heat, cool blood and detoxify. Pulsatilla decoction: Pulsatilla chinensis, Lonicera japonica and Paeonia lactiflora each 3 abalone, Cortex Fraxini and Sanguisorba each 15g, Rhizoma Coptidis 3g and Cortex Phellodendri 6g. Rhinoceros horn and antelope horn are added for dizziness and convulsion. This type needs symptomatic treatment with western medicine to alleviate the urgent need.
(4) Yin deficiency type
This disease is seen in patients with chronic dysentery and body fluid injury. The key points of syndrome differentiation are sticky pus with blood under dysentery, empty sitting without responsibility, red tongue with little fur. The pathogenesis is pathogenic colon and insufficient yin and blood, so the pus and blood under dysentery are thick; Insufficient camp yin, so it is strange to sit empty; Red tongue with little fur and rapid pulse are symptoms of yin-blood deficiency. Treatment should be nourishing yin and clearing heat, promoting blood circulation and relieving pain. Modified Huanglian Ejiao Decoction and Podan: Huanglian and Mume each 6g, Scutellaria baicalensis, Ejiao and Angelica each 10g, Radix Paeoniae Alba and Sanguisorba charcoal each 15g. If diarrhea is excessive, you should sit in the void and blame, and add halloysitum rubrum, Yu Yu Liang and Ginseng.
(5) deficiency-cold type
The main points of this syndrome are thin or white frozen diarrhea, lack of food, fatigue, backache and cold limbs or slippage. The pathogenesis is spleen deficiency with cold, and cold and dampness stay in the intestine, so the diarrhea is thin and white and frozen; The spleen and stomach are weak, so eating less is easy to get tired and the limbs are not warm; Long-term kidney, kidney yang deficiency and failure, the door is not solid, so the waist is sour and afraid of cold, and can't help but slip; A pale tongue with white fur and a deep and thin pulse are all signs of deficiency and cold. The principle of treatment should be to warm and tonify the spleen and kidney, and to strengthen the body. Taohua Decoction and Zhenren Yangzang Decoction: Halloysitum rubrum 15g, Yuliang, Radix Paeoniae Alba, Radix Aconiti Lateralis Preparata, Zingiberis Rhizoma 3g, Atractylodis Rhizoma 10g, and terminalia chebula 6g. If you have dysentery and proctoptosis for a long time, you can use Buzhong Yiqi Decoction.
(6) dysentery type
Most patients with this disease have a history of dysentery. The focus of syndrome differentiation is to stop the onset and not recover all the year round. The pathogenesis is chronic diarrhea, lack of positive energy and evil love, mixed cold and heat, and disharmony of gastrointestinal conduction, so lingering is difficult to heal, and it stops and continues; Damp-heat lingering, the root of the disease has not been removed, so it is caused by exogenous evil or improper diet. Causing abdominal pain, sticky or red stool, and not greasy fur. Pulse condition is damp and hot, and vital qi is weak. The principle of treatment should be warming the middle warmer, clearing the intestines, regulating qi and relieving depression. Lilian decoction: Ginseng, Atractylodes macrocephala, Radix Aucklandiae each10g, dried ginger, Fructus Aurantii Immaturus, Glycyrrhrizae Radix each 5g, and Coptidis Rhizoma 6g. In addition, acupuncture can also be used for treatment. Acupoints such as Quchi, Hegu, Zusanli, Shangxiajuxu, Shenque, Xiawan, Shu Tian, Dachangshu and Pishu are often selected according to the illness.