Abdominal pain without incentive, gastroscope showing gastric stones... This cause cannot be ignored!

It is only for medical professionals to read and refer to the cause of the investigation, and the most afraid of seeing "no obvious abnormality"
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Intestinal flora imbalance is a disease caused by changes in the type, quantity, proportion, location transfer and physiology of intestinal flora, mainly manifested as diarrhea, abdominal pain, abdominal distension, bowel sounds, and may be accompanied by nausea, vomiting, fever, etc.
In severe cases, shock manifestations such as rapid pulse and drop in blood pressure may occur
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The author received a special case of intestinal flora imbalance some time ago, and I would like to share it with you to avoid detours in the treatment of similar diseases in the future
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Case review: Unexplained abdominal pain, abdominal distension.
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The patient was a middle-aged woman who complained of "abdominal pain for 1 day
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" and was admitted to the hospital on 2021/11/4
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The patient began to have abdominal pain symptoms without obvious incentives 1 day ago, located in the upper abdomen, with paroxysmal attacks, dull pain and discomfort, accompanied by acid regurgitation, heartburn, nausea, vomiting, abdominal distension, and self-reported that the vomit was acid and decomposing gastric juice, without defecation and gas.
Stopped and reduced, no chills, fever, chest tightness, chest pain, dysphagia, dysphagia and other discomforts, came to our hospital for treatment, the emergency department admitted our department with "abdominal pain pending investigation"
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Past history: Half a month ago, she was admitted to the pain department of our hospital because of lumbar disc herniation, and she was treated with “ibuprofen and Jinwugutong”.
She visited our outpatient department because of abdominal distension one week ago, and was recommended to be hospitalized.
History of blood pressure, diabetes, coronary heart disease, tuberculosis, hepatitis, denial of major surgery, trauma, blood transfusion and blood donation, drug and food allergy history, and vaccination history
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Physical examination: body temperature: 36.
3°C, pulse: 86 beats/min, respiration: 17 beats/min, blood pressure: 130/85mmHg, body weight: 65kg, no pathological murmur was heard in the auscultation area of ​​each heart valve, breath sounds in both lungs were clear, No obvious dry or wet rales were heard, the abdominal wall was soft, tenderness under the xiphoid process and right abdomen, no rebound tenderness, no palpation of the liver and spleen under the ribs, Murphy's sign was negative, no percussion pain in the liver and kidney area, moving dullness was negative, bowel movements were negative.
The sound was 4 times/min, and there was no swelling in both lower extremities
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(2021-10-26, our hospital) CT tips of the upper abdomen: 1.
The gallbladder volume is reduced and the wall is thickened.
Consider the postprandial gallbladder, and cholecystitis is not excluded; 2.
The intrahepatic bile duct is dilated; the appendix has increased density and gas accumulation; 3.
, Uterine calcification
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(2021-10-28, our hospital) MRI of the lumbar spine: 1.
Mild herniation of the lumbar 5/sacral 1 intervertebral disc; 2.
Degeneration of the lumbar spine, lumbosacral transitional vertebrae, and the formation of Schmöller's nodules in the lumbar 2 and 4 vertebrae 3, lumbar 5 vertebral hemangioma; part of the interspinous ligament edema
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Preliminary diagnosis: 1.
Abdominal pain to be investigated; (1.
1, acute gastritis? 1.
2, acute cholecystitis?) 2.
Lumbar disc herniation
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Perfect examination, most afraid of seeing "no obvious abnormality" after admission, complete blood routine, coagulation four items, liver and kidney function, electrolytes have no obvious abnormality, blood glucose: 6.
23mmol/L (random); all four immune items are negative
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Further gastroscopy (Figure 1) suggested: 1.
Gastric lithotripsy; 2.
Erythematous exudative gastritis with erosion
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3.
Submucosal bulge of the descending part of the duodenum
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(Regular re-examination or further examination is recommended) Figure 1.
The results of gastroscopy have no cause for abdominal pain, and gastroscopy shows gastric calculi.
These key information are linked together.
Do you already know the diagnosis of the patient? Don't worry, let's look down.
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The patient was given oral 5% sodium bicarbonate injection 1000ml and Coca-Cola alternately for 2 consecutive days after gastroscopic lithotripsy, and was given omeprazole, aluminum Magnesium carbonate chewable tablets and Simo decoction oral liquid were used to suppress acid, protect gastric mucosa, and promote gastrointestinal motility.
During the treatment, the patient developed obvious symptoms of diarrhea
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After the above treatment, the patient's symptoms of abdominal pain were relieved, but the symptoms of abdominal distension and anorexia were aggravated, and the abdominal distension was mainly above the abdomen
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The patients were successively given mosapride, digestive enzymes, simethicone, bifidobacteria quadruple viable bacteria tablets, metoclopramide and other drugs to promote gastrointestinal motility, promote digestion, reduce swelling, adjust intestinal flora and traditional Chinese medicine.
After treatment with Lizhong Decoction, the clinical symptoms were not relieved, and the abdominal distension after oral administration of simethicone powder could be relieved for a short time
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Physician thinking: After routine treatment, the patient's clinical symptoms are not satisfactory, and there should be other problems, rheumatism and immune disease? Gut flora imbalance? Stomach stone into the small intestine causing small bowel obstruction? Therefore, the medical history was further inquired in detail: the patient had intermittent symptoms of upper abdominal distention and discomfort in the past six months, and the symptoms were aggravated in the standing position and after eating, and the symptoms were relieved in the supine position.
The abdomen was flat in the supine position.
drum sound
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During hospitalization, the above symptoms showed progressive aggravation (the frequency and severity of the attacks were all aggravated).
Considering the possibility of the patient's condition aggravated by the use of drugs during the hospitalization, it is urgent to adjust the treatment direction
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Therefore, tests such as antinuclear combination, vasculitis-related antibodies, immunoglobulin and complement determination, erythrocyte sedimentation rate, and colonoscopy should be further improved
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The results showed no abnormality, and colonoscopy was shown in Figure 2
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Figure 2 The results of colonoscopy were discussed in the department, and the condition was finally determined! There is no abnormality in the examination of the patient, why there is still abdominal distension, and the patient has diarrhea symptoms after oral administration of sodium bicarbonate and successfully completed the intestinal preparation work, indicating that the entire intestinal tract is unobstructed, and it can be ruled out that some gastric stones enter the small intestine and cause small intestinal obstruction.
What should be done? What about diagnosis and treatment? For further treatment, the department will discuss difficult cases: 1.
The patient has completed gastroscope and colonoscopy examinations, and no positive lesions that cause the patient's clinical symptoms have been found, and the initial location of the lesions is in the small intestine; 2.
After oral administration of simethicone powder Abdominal distension can be relieved for a short time, combined with the obvious drum sound when percussion, indicating that abdominal distension is related to the increase of gas in the gastrointestinal tract, and the intestinal flora may be disordered; There should be people who exacerbate the disease, and omeprazole can induce aggravation of dysbacteriosis due to its inhibitory effect on gastric acid
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Based on the above conditions, it is considered that the bacterial overgrowth in the small intestine may be the cause
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Treatment: Discontinue omeprazole, add amoxicillin-clavulanate potassium 468.
75mg, 4 times a day for oral treatment, after adjusting the treatment plan, the patient's symptoms gradually relieved, the treatment is effective, support the current diagnosis, and take the medicine after the disease is relieved.
Drug discharge
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▎Recognize bacterial overgrowth in the small intestine: bacterial overgrowth in the small intestine refers to the overgrowth of bacteria in the small intestine caused by an abnormal increase in the number of bacteria in the small intestine and/or changes in the type of flora in the small intestine, which can manifest as nutrient malabsorption, abdominal distension, abdominal pain and other symptoms
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Pathogenesis: Small intestinal bacterial overgrowth is currently believed to be mainly associated with small intestinal motility disorders, abnormal intestinal anatomy, gastric acid deficiency, liver disease, pancreatic disease, decreased bile acid secretion, and immunoglobulin deficiency
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Diagnostic methods: small intestinal fluid bacterial culture, CO2 breath test, hydrogen breath test, lactulose hydrogen breath test combined with radionuclide tracer technology, aminobenzoic acid urinary excretion rate assay, serum non-tuberculous bile acid assay, etc.
However, due to various factors, there is a high false negative rate
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At present, the hydrogen breath test is the most widely used because of its simplicity, non-invasiveness and low cost
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However, it is believed that with the continuous deepening and development of related research, new progress will be made in the understanding of the pathogenesis of small intestinal bacterial overgrowth, and new ideas for diagnosis will be provided
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The main treatment is to use antibiotics and live bacteria preparations to adjust the intestinal flora.
Antibiotics can be used: rifaximin, amoxicillin and clavulanic acid, ciprofloxacin, doxycycline, metronidazole, neomycin, Fluloxacin, tetracycline, sulfamethoxazole,
etc.

The general course of treatment is 7-10 days.
If symptoms recur after treatment, the treatment can be repeated
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Summary of experience: Although gastric stones are found in gastroscopy, there is a possibility of intestinal obstruction caused by stones, but the disease still needs to be carefully analyzed, taking into account the possibility of abdominal distension caused by other diseases; omeprazole is currently a commonly used drug in gastroenterology and even many related departments.
The application of the drug should strictly follow the indications of the drug to avoid unnecessary pain caused by the misuse of the drug
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References: [1] Zheng Xia, Dai Ning.
The pathogenesis and diagnosis of bacterial overgrowth in the small intestine [J].
Gastroenterology.
2012, 17(8): 499-502.
[2] Zhou Jing, Li Ya , Cai Lingshan, et al.
The relationship between inflammatory bowel disease and small intestinal bacterial overgrowth [J].
Parenteral and enteral nutrition [J].
2019, 26(6): 341-345.
[3] Tang Shuai, Wan Jun, Zhang Ru, et al.
Research progress on diseases related to bacterial overgrowth in the small intestine [J].
Journal of the People’s Liberation Army Medical College [J].
2019, 40(2): 190-192.
[4] Lin Sanren, Qian Jiaming, Zhou Liya, et al.
Digestion Advanced Course of Internal Medicine [M].
People's Military Medical Press.
2014, 3:54-60.