临床医学英语

Chapter1Patient-PhysicianInteraction第一章医患沟通

Thepatient-physicianinteractionproceedsthroughmanyphasesofclinicalreasoning

anddecisionmaking.医患沟通在临床诊断和治疗决策的许多阶段中进行着。The

interactionbeginswithanelucidationofcomplaintsorconcerns,followedbyinquiriesor

evaluationtoaddresstheseconcernsinincreasinglypreciseways.这种沟通开始于病人诉说

或所关注问题，然后通过询问、评估不断精确地确定这些问题。Theprocesscommonly

requiresacarefulhistoryorphysicalexamination,orderingofdiagnostictests,integrationof

clinicalfindingswiththetestresults,understandingoftherisksandbenefitsofthepossible

coursesofaction,andcarefulconsultationwiththepatientandfamilytodevelopfuture

plans.这个过程通常需要细致的病史询问和体格检查，进行诊断性化验，综合临床发现和化

验结果，理解分析拟行治疗过程中的风险和疗效，并与病人及家属反复磋商以形成治疗方

案Physiciansincreasinglycancallonagrowingliteratureofevidence-basedmedicineto

guidetheprocesssothatbenefitismaximized,whilerespectingindividualvariations

amongdifferentpatients.医生们越来越容易查阅不断增长的循证医学文献来指导这个过程，

使得疗效最大化，但要考虑到不同病人中个体差异是存在的。

Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtodiagnosisand

therapyshouldnotbeequatedwithucookbook^^medicine越来越多的可用于指导临床诊断

与治疗的随机试验资料不应变成“烹调书”医学。Evidenceandtheguidelinesthatarederived

fromitemphasizeprovenapproachesforpatientswithspecificcharacteristics.因为随机试验

获得的现象和思路是着重于特征性病人的求证过程。Substantialclinicaljudgmentis

requiredtodeterminewhethertheevidenceandguidelinesapplytoindividualpatientsand

torecognizetheoccasional.实际的临床判断需要确定这些现象和思路能否应用于某个病人

个体，并能找出例外。Evenmorejudgmentisrequiredinthemanysituationsinwhich

evidenceisabsentorinconclusive,许多情况下，临床表现缺乏或不典型，需要考虑更多的判

断。Evidencealsomustbetemperedbypatients9preferences,althoughitisaphysician's

responsibilitytoemphasizewhenpresentingalternativeoptionstothepatient.病人还会根

据自己的倾向调节着临床症状，但医生有责任通过选择性问题搞清事实。Theadherenceofa

patienttoaspecificregimenislikelytobeenhancedifthepatientalsounderstandsthe

rationaleandevidencebehindtherecommendedoption.假如病人也懂得医生问题的基本原

理和表现，有特殊生活方式病人的固执容易被强化。

Tocareforapatientasanindividual,thephysicianmustunderstandthepatientasa

person.为了把病人作为一个个体进行治疗，医生必须理解病人是一个人（不是一群人）。

Thisfundamentalpreceptofdoctoringincludesanunderstandingofthepatienfssocial

situation,familyissues,financialconcerns,andpreferencesfordifferenttypesofcareand

outcomes,rangingfrommaximumprolongationoflifetothereliefofpainandsuffering.这

个最基本的行医原则包括了解病人的社会地位，家庭问题，资金状况以及对不同治疗方法、

不同治疗结果的选择，从最大限度地延长生命到临时缓解疼痛和折磨。Ifthephysiciandoes

notappreciateandaddresstheseissues,thescienceofmedicinecannotbeapplied

appropriately,andeventhemostknowledgeablephysicianfailstoachieveappropriate

outcomes.假如医生没有正确理解和定位这个问题，医学就不可能恰当地应用于临床，甚至

一个知识最渊博的医生也不能取得理想的治疗结果。

Evenasphysiciansbecomeincreasinglyawareofnewdiscoveries,patientscanobtain

theirowninformationfromavarietyofsources,someofwhichareofquestionablereliability.

甚至，当医生越来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，

当然，某些信息是不可靠的。Theincreasinguseofalternativeandcomplementarytherapies

isanexampleofpatients9frequentdissatisfactionwithprescribedmedicaltherapy•替代疗法

和辅助疗法的应用不断增加就是病人对常规疗法经常不满意的一个例子。Physiciansshould

keepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyif

suchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayrelied

ontosubstituteforprovenapproaches医生对未证实的疗法应该保持开放的思想，但是，如

果这些疗法具有任何程度的潜在风险，都必须细致地告知病人，包括可能需要用已证实的

常规疗法去替代的风险。Itiscrucialforthephysiciantohaveanopendialoguewiththe

patientandfamilyregardingthefullrangeofoptionsthateithermayconsider对医生来说，

对病人及家属开诚布公地介绍所有能考虑的治疗选择，是极及关键的。

Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedand

extensivesystemofmedicalcareandpubichealth.医生不是生存在真空中的，而是复杂而庞

大的医疗和公共健康体系中的一部分。Inpremoderntimesandeventodayinsome

developingcountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemost

importantwaystopromotehealthandreducedisease.在未发达时代，甚至当今在一些发展

中国家，基本卫生、清洁饮用水和最低营养保障是促进健康减少疾病的最重要措施。In

developedcountries,theadoptionofhealthylifestyles,includingbetterdietandappropriate

exercise,arecornerstonestoreducingtheepidemicsofobesity,coronarydisease,and

diabetes.而在发达国家中，健康的生活方式包括合理饮食和适当锻炼，是减少肥胖、冠心病

和糖尿病盛行的基础。Publichealthinterventionstoprovideimmunizationsandtoreduce

injuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemore

healthbenefitthannearlyanyotherimaginablehealthintervention.公共健康干预如进行疫

苗接种、减少损伤、减少吸烟、减少吸毒、减少酗酒等措施共同产生的健康效果几乎比可

想象的任何其它健康干预措施都要好。

Chapter5ClinicalPreventiveServices第五章临床预防服务

Clinicalpreventiveservicesincludecounseling,immunization,screeningtests,and

reductionofthesusceptibilitytodiseasebyinterventionssuchastherapeuticlifestyle

changesandpharmacotherapy.临床预防服务包括对疾病的咨询、防疫、筛查以及通过治疗

性的生活习惯改变和药物治疗来减少易感性。Preventiveserviceoftenareclassifiedas

primary,secondary,ortertiary.临床预防服务常分为一级预防、二级预防和三级预防。

Primarypreventionisdirectedtowardpreventingdiseaseorinjurybeforeitdevelops,

whereassecondarypreventiondealswithearlydetectionandtreatmenttoimpedethe

progressofovertdisease.一级预防是直接针对疾病或损伤发生前的预防，而二级预防是解决

疾病或损伤发生后的早期发现和早期治疗，以防止临床疾病的进一步发展。Incontrast,

tertiarypreventionreferstorehabilitativeactivitiesaftertheonsetofdiseasetominimize

complicationsanddisability.对比之下，三级预防是指疾病发生后的康复治疗，以减少并发

症和病残。Becauseofconsiderableoverlap,distinguishingamongthesephasesofprevention

maybeconfusing.因为（三级预防之间）有相当大的交叉，这些预防阶段的区分可能有些

混淆。Detectingandtreatinghypertensioncouldbeconsideredsecondarypreventionof

hypertensivecardiovasculardiseasebutprimarypreventionofheartfailureandstroke.发

现和治疗高血压可以认为是对高血压性心血管疾病的二级预防，但也可是对心力衰竭和中

风的一级预防。Preventionmaybeperceivedbestalongacontinuumfrommodificationof

predisposingfactors,topreventingadisease,toavoidingprematuredeathanddisability•长

期一贯地减少易感因素可能是防止疾病、避免早死早残最好的预防。Thesoonerthe

prevention,themorelikelyunnecessaryillness,disability,andprematuredeathcanbe

avoided.预防得越早，越不易发生不必要的疾病，病残和早死就能够避免。Increasing

emphasishasbeenplacedonpreventingriskfactorsthemselves.越来越多的重点已经集中到

对危险因素本身的预防。Thetermprimordialpreventionhasbeenintroducedforthis

concept.术语…根源预防(病因预防)已经引进了这个概念。

Indiscriminatescreeningforriskfactorsordiseasewithoutadequateadviceand

follow-upservesnousefulpurpose.没有引导和随访的毫无选择地远离危险因素或疾病是没

有实用价值的预防。Theperiodichealthexaminationhasevolvedfromanannual,

broad-based,uniformprotocoltoanapproachthattargetstheprevention,detection,and

treatmentofspecificdiseasesorriskfactorsforparticularage,gender,andethnicgroupsat

appropriateintervals.定期体检逐渐从一年一度的、全面的、统一的规定项目改进成以恰当

的周期对特定年龄、性别和种群的特殊疾病或危险因素有目的地预防、发现和治疗。Current

recommendationsbytheU.S.PreventiveServicesTaskForcearebasedonsystematic

evidencereviewsthatdistinguishprocedureslikelytoproveeffectiveandtohave

substantiallymorebenefitthanharm.美国预防服务特别局的最近建议是基于全面的回顾性

研究，这些研究选出了易于证明有效、确实是利大于弊的预防措施。

Changesinthehealthcaresystemandthedevelopmentofnationalguidelinesfor

managementofdiseasearelikelytodrawgreaterattentiontohealthpromotion,disease

prevention,andtheinterfaceofphysician-basedmedicalcarewiththepublichealthcare

system.卫生保健系统的改进和国家疾病控制政策的完善使人们更重视健康促进、疾病预防，

以及接受医疗人员为主的公共卫生系统的保健服务。Physiciansshouldconsidereach

disorderintermsofthepotentialforprevention,includingthepossibilityofadverseeffects

andcost・effectiveness.医生应该以有无需要预防的角度考虑每一种疾病，包括可能发生的副

作用和付出代价是否值得。Aconceptusefulforclinicaldecisionmakingisthenumberof

patientsneededtotreattopreventoneadverseevent,whichisbasedonabsoluterisk

reduction.一个对临床决策有用的理念是需要治疗的病人数量决定一个不利因素是否要预

防，这是基于绝对风险的下降。Thisnumberisbasedonefficacyandiscalculatedasthe

reciprocalofthedifferenceineventratesbetweencontrolandtreatmentgroupsfora

specifiedperiod.这个数量是以效能为基础的，是对特定时期内对照组和治疗组之间发生率

差异的倒数进行的统计。

Ampleevidenceconnectsidentifiableandoftenpreventablefactorstothemorbidityand

mortalityassociatedwithmajorhealthproblems.大量的试验证据找出了可确认的又常可预

防的与主要健康问题相关的发病和死亡因素。Abouthalfofalldeaths,morbidity,and

disabilitycanbeattributedtosuchnongeneticfactors.约一半死亡、发病和病残与这些非遗

传性因素有关.Manylifestylechangesbenefitmultiplesystemsanddisorders.许多生活习惯

改变有利于多个系统和紊乱的改善。Cigarettesmokinghasbeenestimatedtocontributeto

oneinfivedeathsintheUnitedStates;dietaryhabitsmayaffecttheoccurrenceof

cardiovasculardisease,diabetes,osteoporosis,andcancer.美国五分之一的死亡估计与吸烟

有关，饮食习惯可能影响心血管疾病，糖尿病、骨质疏松症和癌症的发生。Otherimportant

personalbehaviorfactorsinfluencinghealthincludephysicalactivity,alcoholintake,illicit

druguse,sexualpractices,andexposuretoenvironmentaltoxins,其它影响健康的重要个人

行为因素有锻炼、饮酒、吸毒、性行为以及环境毒物的接触。Theidentificationofinformative

DNApolymorphisms(eg,singlenucleotidepolymorphisms)andfurtherelucidationof

candidategenesallowfordetectionofsusceptibleindividualsandpossibleinstitutionof

measurestopreventtheexpressionoftheseharmfulgenetictraits,携带信息DNA多态性（例

如，单核昔酸多态性）的认识和候选基因的进一步阐明允许我们发现易感人群和可能采取

的措施，以预防这些有害基因特性的表达。

Severalcommonmisconceptionsimpedepreventivehealthcare.好几种错误观念妨碍了

预防保健。Manybelievethatdiseaseswithastrongheritablecomponentcannotbealtered,

butsusceptibilitytodiseaseoftenrequirestheinteractionofmultiplegenesand

environmentalfactorsforexpression.许多人认为有很强遗传性的疾病是无法改变的，但是对

疾病的易感性经常需要多种基因和环境因素的相互作用才能表达。Inaddition,chronic

diseasesaremultifactorial,sootherfactorscanbechangedtocompensateforanelevated

geneticrisk.另外，慢性疾病是多因素的，所以，可以改变其它因素来弥补高基因风险。

Althoughgenetherapyholdsmuchpromise,preventivemeasurescurrentlyofferthebest

possibilitiesforlimitinggeneexpressionandavoidingdisease.虽然基因疗法有着很大的希

望，但目前的最有可能提供的预防措施是限制基因表达来避免疾病。Thenotionthat

preventionislessusefulinolderpersonsexcludesmanywhowouldbenefitmostfrom

preventionbecauseelderlypatientsgenerallyhaveagreaterabsoluteriskofdiseaseand

havebeenshowntoadhereandrespondfavorablytopreventivemeasures•对老年人预防无

用的观念排除了在预防上本应极为受益的许多人，因为老年病人一般有更高患病风险，并

且一直对预防措施极为支持、反应积极。Also,lifeexpectancyfrequentlyisunderestimatedin

theelderly;individualswhoreachage75nowcanexpecttoliveanaverageof11moreyears.

并且，老年人的预期寿命经常是低估的，现在将到75岁的老人可以预期平均再活11年多。

Chapter8WhyGeriatricPatientsAreDifferent第八章老年病人的特殊性

Olderpatientsdifferfromyoungormiddle-agedadultswiththesamediseaseinmany

ways,oneofwhichisthefrequentoccurrenceofcomorbiditiesandofsubclinicaldisease.同

样的疾病，老年病人在许多方面与青中年病人是有区别的，其中之一是并存病多、亚临床

疾病多。Asafunctionofthehighprevalenceofdisease,comorbidity（ortheco-occurrenceof

twoormorediseasesinthesameindividual）isalsocommon.作为高发疾病的结果，并存病

（两个或更多的疾病在同一个体同时发生）也是常见的。Ofpeopleage65andolder,50%

havetwoormorechronicdisease,andthesediseasescanconferadditiveriskofadverse

outcomes,suchasmortality.65岁以上的老年人中，50%患有两种以上的慢性疾病，这些疾

病能够增加不良预后的风险，如死亡的风险。Insomepatients,cognitiveimpairmentmay

maskthesymptomsofimportantconditions.在一些病人中，认知损害可以掩盖重要病情的

症状。Treatmentforonediseasemayaffectanotheradversely,asintheuseofaspirinto

preventstrokeinindividualswithahistoryofpepticulcerdisease.对一种疾病的治疗可能会

加重另一种疾病，例如，对有消化性溃疡病史的病人使用阿斯匹林预防中风。Theriskfor

becomingdisabledordependentalsoincreaseswiththenumberofdiseasespresent•病残或生

活不能自理的发生率也随着并存的疾病数而增高。

Specificpairsofdiseasescanincreasesynergisticallytheriskofdisability.特殊的成对

疾病可以协同增加病残的风险。Arthritisandheartdiseasecoexistin18%ofolderadults;

althoughtheoddsofdevelopingdisabilityareincreasedbythree-foldtofour-foldwitheither

diseasealone,theriskofdisabilityincreases14-foldifbotharepresent.18%的老年人同时患

有关节炎和心脏病，虽然每个疾病可以增加3~4倍的病残率，但两个疾病同时存在，可使

病残率提高到14倍。Asecondwayinwhicholderadultsdifferfromyoungeradultsisthe

greaterlikelihoodthattheirdiseasespresentwithnonspecificsymptomsandsigns.老年与

青中年的第二个差异是更容易出现非典型的症状和体症。Pneumoniaandstrokemay

presentwithnonspecificchangesinmentationastheprimarysymptom.肺炎和中风时可出

现非特异性意识变化作为主要症状Similarly,thefrequencyofsilentmyocardialinfarction

increaseswithincreasingage,asdoestheproportionofpatientswhopresentwithachange

inmentalstatus,dizziness,orweaknessratherthantypicalchestpain•同样地，隐匿性心肌梗

塞发生频度随着年龄的增大而增加，这些病人相应地频发精神状态改变、眩晕、虚弱而不

是典型的胸痛症状。Asaresult,thediagnosticevaluationofgeriatricpatientsmustconsider

awiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults•因

此，老年病人的诊断应考虑更广泛的疾病胃，要超过通常对中年病人所考虑的范围。

Athirdconditionthatisfoundprimarilyinolderadultsisfrailty,frailtyisthoughttobe

awastingsyndromethatpresentswithmultiplesymptomsandsigns,includingreduced

musclemass,weightloss,weakness,poorexercisetolerance,slowedmotorperformance,and

lowphysicalactivity.主要出现在老年人的第三个情况是衰弱，衰弱被认为属于衰竭综合症，

它有许多症状和体征，包括肌肉萎缩、体重下降、虚弱、运动耐受差、动作慢、身体活动

少。Someestimatesindicatethatthefullsyndromeisfoundin7%ofcommunity-dwelling

peopleage65andolder,andin25%ofcommunity-dwellingpeopleage85andolder.——些人

估计7%的65岁以上社区老人和25%的85岁以上社区老人这些症状全部出现。Many

institutionalizedolderadultsalsoarefrail.许多老人院里的老人也是衰弱的。Frailtyisastate

ofdecreasedreserveandincreasedvulnerabilitytoallkindsofstress,fromacuteinfectionor

injurytohospitalization,andmayidentifyindividualswhocannottolerateinvasivetherapies.

衰弱是对各种压力耐受下降、易于损害的一种状态，从急性感染、损伤到住院治疗，都可

以发现一些老人不能耐受侵入性诊疗措施。Thesyndromeoffrailtyisassociatedwithhigh

riskoffalls,needsforhospitalization,disability,andmortality.衰弱症状与高病倒率、高住

院率、高病残率、高死亡率是密切相关的。Thereisearlyevidencethatacorecomponentof

frailtyissarcopenia,orlossofmusclemassassociatedwithaging,whichoccursin13to24%

ofpersonsage65to70andin60%ofpersonsage80andolder.衰弱早期征象中的一个主要

变化是肌减少症,或者说随年龄增长的肌肉减少,它发生在13〜24%的65~70岁的老人,60%

的80岁以上的老人。Itislikelythatdysregulationofmultiplephysiologicsystems,including

inflammation,hormonalstatus,andglucosemetabolism,underliesthesyndrome,with

resultingdecreasedabilitytomaintainhomeostasisinthefaceofstress.（衰弱时）多种生理

系统易于失调，包括炎症反应、激素调节、葡萄糖代谢，在症状的背后，伴随的结果是在

压力面前保持内环境稳定的能力下降Subclinicaldisease（e.g.,atherosclerosis）,end-stage

chronicdisease（e.g.,heartfailure）,oracombinationofcomorbiddiseasesmayprecipitate

thesyndrome.亚临床疾病（如动脉粥样硬化），晚期慢性疾病（如心力衰竭），或多种疾病并

存可共同形成症状。Evidencefromrandomized,controlledtrialsshowsthatresistance

exercise,withorwithoutnutritionalsupplements,andhome-basedphysicaltherapycan

increaseleanbodymassandstrengthineventhefrailestolderadults.随机对照试验的结果

显示无论有无营养支持和家庭运动疗法，即使是最虚弱的老年人，对抗运动能够增加瘦弱

躯体的质量和力量。Thisevidencesuggeststhatearlierstagesoffrailtymayberemediable,

althoughend-stagefrailtylikelypresagesdeath.这个结果提示早期衰弱是可挽回的，尽管末

期衰弱常预示着死亡。

Fourth,cognitiveimpairmentincreasesinprominenceaspeopleage.第四，人彳门变老时

认知损害显著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverse

outcomes,includingfalls,immobilization,dependency,institutionalization,andmortality.

认知损害是大量不良预后的风险因子，包括摔倒、活动能力下降、生活不能自理、需住老

人院护理、死亡Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcare

givingtoensuresafety.

认知损害使诊断复杂，为保证安全需要更多的照料。

Finally,aseriousandcommonoutcomeofchronicdiseasesofagingisphysicaldisability,

definedashavingdifficultyorbeingdependentonothersfortheconductofessentialor

personallymeaningfulactivitiesoflife,frombasicself-care(e.g.,bathingortoileting)to

tasksrequiredtoliveindependently(eg,shopping,preparingmeals,orpayingbills)toafull

rangeofactivitiesconsideredtobeproductiveand/orpersonallymeaningful.最后，老年人慢

性疾病严重又常见的结果是身体能力丧失，描述为个人最基本的或必须的日常活动有困难

或不得不依靠别人帮助指导，从基本的自理(如洗澡或如厕)到独立生活需要的各种任务

(如购物、做饭、支付各种账单)，到具有集体和/或个人意义的所有活动。Ofolderadults,

40%reportdifficultywithtasksrequiringmobility,anddifficultywithmobilitypredictsthe

futuredevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;household

managementtasks)andactivitiesofdailyliving(ADL;basicself-caretasks).在老年人中，

40%对需要运动的任务有困难，运动困难提示将来开展日常工具锻炼(IADL；家务自理项

目)和目常锻炼(ADL；基本自理项目)的困难。Inpersonsage65andother,difficultywith

IADLisreportedby20%,anddifficultywithADLisreportedby11%;forboth,the

prevalenceincreaseswithage.大于65岁的老人或其它人，IADL困难报导为20%,ADL困

难报导为11%；随年龄增加两个都困难成为普遍现象Peoplewhohavedifficultywithtasks

ofIADLandADLareathighriskofbecomingdependent.

IADL和ADL困难的人处于生活不能自理演变的高风险中。Ofpersonsolderthanage65,

5%resideinnursinghomes,largelyasaresultofdependencyinIADLand/orADL

§00)11(1217toseveredisease.大于65岁的老人中，5%住在疗养院里，大多数是严重疾病后

依赖IADL和ADL的结果。Generally,womanlivemoreyearswithdisability,whereasmen

whobecomesimilarlydisabledaremorelikelytodieatayoungerage.一般来说，同样的能力

丧失，男性常死得更年轻，女性比男性能多活几年。Althoughphysicaldisabilityisprimarily

aresultofchronicdiseasesandgeriatricconditions,itsonsetandseverityaremodifiedby

otherfactors,includingtreatmentsthatcontroltheunderlyingdiseases,physicalactivity,

nutrition,andsmoking.虽然身体能力丧失是慢性疾病和年老状态的一个主要结果，它的发

生和严重程度被其它因素影响着，包括基础疾病的治疗和控制、身体锻炼、营养和吸烟。

Manyinterventiontrialsindicatethatdisabilitycanbepreventedoritsseveritydecreased;

onetrialshowedimprovementsinfunctioningwithresistanceandaerobicexerciseinolder

adultswithosteoarthritisoftheknee.许多干预试验揭示能力丧失可预防或减轻；一个试验显

示膝骨关节炎老年人用对抗运动和有氧运动改善了功能。

21OccultandObscureGastrointestinalBleeding隐匿性和来源不明性胃肠道出血

Occultbleedingisdefinedasthedetectionofasymptomaticbloodlossfromthe

gastrointestinaltract,generallybyroutinefecaloccultbloodtesting(FOBT)orthepresence

ofirondeficiencyanemia.隐匿性出血指的是无症状性胃肠道出血，一般通过常规的大便隐

血试验(FOBT)或存在着缺铁性贫血而发现。Obscuregastrointestinalbleedingisdefined

asbleedingofunknownoriginthatpersistsorrecursafteranegativeinitialendoscopic

evaluationofboththeupperandlowergastrointestinaltracts.来源不明性胃肠出血是指首次

上、下消化管内窥镜检查都阴性、原发部位不明的持续性或反复性出血。Bothoftheseentities

maybepresentationsofrecurrentorchronicbleeding.两者都可能表现为反复的或慢性的出

血。

Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbe

endoscopicevaluation.对隐匿性胃肠道出血，应该使用内窥镜进行早期检查。Inthesettingof

anisolatedpositiveFOBT,colonoscopyisindicatedasthefirsttest.只有单纯大便隐血试验阳

性的情况下，结肠镜作为首选的检查方法是适合的。Theyieldofcolonoscopyinthese

patientsisapproximately2%forcancerand30%foroneormorecolonicpolyps•这些病人

结肠镜的结果大约2%是癌症，30%是单发或多发的结肠息肉。

Theinitialapproachtoapatientwithirondeficiencyanemiadependsonthepresenceof

symptomsreferabletoeithertheupperorlowergastrointestinaltract.缺铁性贫血病人的早

期检查方法要根据存在的症状是与上消化道相关还是与下消化道相关而决定。Regardlessof

thefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhave

bothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasa

yieldof6%evenifthefirstonewaspositive.无论首次上消化道或下消化道内窥镜检查会有

何发现，所有病人两个检查都应该做，因为互补的内窥镜检查有6%的再发现，即使第一个

检查是阳性的。Forpremenopausalwomen,apositiveFOBTrequiresfullevaluation,asdoes

irondeficiencyanemia对绝经前妇女，大便隐血试验阳性需要全面分析,缺铁性贫血也一样。

Bariumradiographsoftheupperandlowergastrointestinaltracthavelimitedutilityinthe

settingofoccultbleedingbecauseoftheirinabilitytobiopsyortreatlesionsthatare

identified.隐匿性出血时，上、下消化道的钢剂造影应用有限，因为它们不能活检或治疗发

现的病损。

Theevaluationofobscuregastrointestinalbleedingisoftenfrustrating原因不明性胃肠

道出血的诊断常常令人沮丧。Angiodysplasiaisthemostcommoncauseinmostrecentseries.

血管发育畸形是最近病例统计中最常见的病因。Initialendoscopicexaminationshouldfocus

onanysymptomsreportedbythepatient.首次内窥镜检查要关注病人诉说的任何症状。

Potentialcausativeagents,suchasNSAIDsandaspirin,shouldbediscontinued.能成为潜在

病因的药物，如非留体类抗炎镇痛药和阿斯匹林，都应该停用。Disordersassociatedwith

bleeding,suchashereditaryhemorrhagictelangiectasia(Osler-Weber-Rendusyndrome),

inflammatoryboweldisease,orableedingdiathesisshouldbeconsidered.伴有出血的疾病，

像遗传性出血性毛细血管扩张症(Osler-Weber・Rendu综合症)、炎性肠疾病、或出血性体

质应该力口以考虑。Arepeatendoscopicevaluationmaybeappropriate,because

approximatelyonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitial

endoscopy,内窥镜重复检查可能是需要的，因为接近三分之一病例查出了首次内窥镜漏掉的

出血病原灶。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthe

smallbowelisindicated当上消化道内窥镜和结肠镜均无发现时，应该对小肠进行检查。

Radiographicevaluationofthesmallbowelisnoninvasivebutrelativelyinsensitive,witha

lessthan6%yieldfromsmallbowelfollow-throughanda10to21%yieldfromenteroclysis.

小肠X线检查是非侵入性的，但相对不灵敏，小肠全片不到6%有发现，小肠造影10〜21%

有结果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelin

obscuregastrointestinalbleedingis38to75%.相比较，对来源不明性胃肠道出血小肠内窥镜

的诊断结果是38〜75%。Traditionalvideoendoscopescanevaluateonlytheproximalsmall

bowel(W150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallboweland

thenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirability

tovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeutic

maneuvers.传统的电视内窥镜只能检查近端小肠（这150cm）,然而能通过整个小肠边退边看

肠粘膜的更长内镜，也不能看到整个肠粘膜，不能作为常规的诊断或治疗手段。

Whenendoscopicevaluationdoesnotdetectthecauseofbloodloss,radiographic

proceduressuchasscintigraphyandangiographyshouldbeconsidered•当内窥镜检查不能

发现出血病因，像闪烁造影和血管造影等影像学手段应该考虑。Provocativeangiography

usingheparinorthrombolyticagentshasbeensuggestedbysomeauthorities,butthis

approachhasthepotentialriskofprecipitatingmajorbleeding虽然使用肝素或溶栓药的刺

激性血管造影被某些专家推荐，但这种方法有促发大出血的潜在风险。Inthefaceof

continuedbloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovide

simultaneousdiagnosisandtherapy.碰到进行性出血又诊断不明，术中应用肠镜可以同时进

行诊断和治疗。Duringtheprocedure,thesurgeonplicatesthebowelovertheendoscope.操

作时，外科医生把小肠套到内窥镜上。Asthescopeiswithdrawn,endoscopicfindingscanbe

identifiedforsurgicalresectionortreatment.内镜退出时，内镜的发现可以决定是外科切除

或保守治疗。Theyieldofthisprocedureexceeds70%.这个措施70%以上有结果。Insome

clinicalsituations,thesiteofbleedingcannotbeidentiHed,andthepatientrequires

1011g・termtransfusiontherapy,某些临床病例，出血部位无法找到，病人而要长期输血治疗。

Anewdeviceforvisualizingtheentiregastrointestinalmucosaconsistsofasmall

camerainaningestablecapsulethattransmitsimagestoreceiversattachedtothepatienfs

abdomenandmappedtoidentifythelocationoftheimage.一种新的装置能显示全部胃肠粘

膜，这种装置由一颗装有小型摄像机并并能咽下的胶囊组成，它将（数字）影像信号传到

附着在病人腹部的接收器，并绘制出图像来识别影像的位置。Thediagnosticyieldofcapsule

enteroscopyisnotyetclear,butthisapproachmaypotentiallyvisualizesegmentsofthe

smallbowelthatwerepreviouslyinaccessible.胶囊小肠镜的诊断效率现在还不清楚，但是，

这种方法可能显示出以前难以接近的小肠肠管。Notherapeuticmaneuversarepossiblewith

thedevice.但这个装置不可能有任何治疗性操作。

Chapter23DiabeticNephropathy第二十三章糖尿病肾病

End-stagerenaldisease（ESRD）fromdiabeticnephropathyisamajorcauseof

morbidityandmortality,particularlyinpatientswithtype1diabetes,affecting30to35%of

patientsintheUnitedStates.由糖尿病性肾病所发展的晚期肾病（EARD）是人类患病和死

亡的一个主要原因，特别是患有1型糖尿病的病人，在美国涉及30~35%的病人。Although

nephropathyisaboutonehalfasfrequentintype2diabetics（partiallyduetoashortened

lifeexpectancy）,type2diabetesstillmakesupthevastmajorityofdiabeticpatientsseeking

therapyforESRD,尽管2型糖尿病的肾病发生率大约是1型的一半（部分原因为预期寿命

缩短），但2型糖尿病仍然是需要治疗晚期肾病的糖尿病病人的绝大多数。Overall,diabetes

istheleadingcauseofESRDintheUnitedstates,accountingformorethanonethirdof

cases.总的来说，糖尿病是美国晚期肾病的首要病因，占三分之一以上。

Detailsarelessdearinpatientswithtype2diabetes,butthenaturalhistoryofdiabetic

nephropathyintype1diabetesiswelldescribed.2型糖尿病病人的演变细节不是很清楚，但

1型糖尿病肾病的自然病程已有充分的描述。Theperiodimmediatelyfollowingdiagnosisis

bestcharacterizedbyglomerularhyperfiltration.紧接诊断后的一段时期以肾小球超滤最具

有特征。Duringthistime,thereisrenalhypertrophy,increasedrenalbloodflow,increased

glomerularvolume,andanincreasedtransglomerularpressuregradient,allcontributingto

ariseinGFR.在这段时间中，有肾脏肥大、肾血流增加、肾小球容积增大和肾小球两端的

压力梯度增加，这些都与肾小球滤过率升高有关。Importantly,thesechangesdependatleast

inpartonhyperglycemia,astheyarediminishedbyintensivediabetestreatment.重要的是，

这些变化至少部分是依靠高血糖，因为通过有力的糖尿病治疗它们会消失。Threeto5years

afterdiagnosis,earlyglomerularlesionsappear,characterizedbythickeningofglomerular

basementmembranes,mesangialmatrixexpansion,andarteriolosclerosis•诊断后的3~5年，

早期的肾小球损害出现，以肾小球基底膜增厚、系膜基底扩张和小动脉硬化为特征。Albumin

excretionremainslowduringearlyglomerularchanges;however,aspathologicchanges

mount,theglomerulilosetheirfunctionalintegrity,resultinginglomerlarfiltrationdefects

andincreasedglomerularpermeability在肾小球变化的早期，白蛋白排泄仍然较低，但是，

随着病理变化加重，肾小球失去完善的功能，引起肾小球滤过的缺陷，肾小球渗透性增加。

Althoughresultsofroutinetestsofrenalfunction(creatini