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Chinese PLA General Hospital

Medical Records

Outpatient No.: Y222222

Aug. 7, 2017 8:49

Discharge Record

Patient, , Female, 28 years old, admitted to Rehabilitation ward of gastroenterology department on July 25, 2017 due to “difficulty in swallowing for nearly 9 months and aggravated with food reflux for 6 months.” The patient discharged on Aug. 7, 2017 with the length of stay for 13 days.

Condition at admission: The patient admitted to our hospital due to “difficulty in swallowing for nearly 9 months and aggravated with food reflux for 6 months.” The patient was difficulty in swallowing in November 2016 without obvious cause, especially after eating solid food. No food reflux, no sour regurgitation and heartburn, no substernal pain, no nausea and vomiting, no abdominal distension and pain, no chest distress and shortness of breath. She received the treatment from Peking University People's Hospital on Dec. 26, 2016 and received gastroscopy, the results showed that: the esophageal mucosa is smooth. No brown area found under NBI. Distance between toothed portion and incisor was 40 cm. Distal esophagus showed chrysanthemum pattern. Cardiac orifice had a sign of breaking. The cardiac orifice didn’t show loose when reversing it; piebaldness can be found on mucosa of fundus of stomach. Mucus had been counted and showed yellow green; piebaldness can be found on gastric mucosa. Piebaldness can be found on incisura mucosa of gastric angle. Piebaldness can be found on mucosa of antrum of stomach; pattern of sprinkling salt can be found behind the duodenal bulb. The diagnosis was: achalasia of cardia? Chronic Superficial Gastritis, duodenitis at descending part of duodenum. The patient received pathological examination and immumohistochemical staining results showed: antrum of stomach Hp (-). The patient was suggested receiving operation for treatment, but the patient refused. The hospital gave her medicines orally taken to promote relaxation of smooth muscle tissue (details unknown). Since the patient was difficulty in swallowing, she didn’t take it regularly, so the symptom of difficulty in swallowing aggravated in the recent half year and accompanied with food reflex. Vomitus were almost mucus with food she taken, at the same time, she felt sour regurgitation and heartburn, substernal pain as well as abdominal distension. No abdominal pain. She sought for treatment from Peking University People's Hospital on the early July 2017, and the abdominal ultrasound examination showed: no abnormity in liver, gallbladder, pancreas, spleen and both kidneys. The examination of upper gastrointestinal contrast showed: Barium passed the esophagus slowly and beaking narrow can be found at lower esophagus, with widest section of 5 cm. The diagnosis was: possible achalasia of cardia, please combine with clinical examination. To further treat the illness, the patient has been transferred to our hospital, and admitted by Outpatient department by “achalasia of cardia” to our department. The patient is in good spirit at present, with normal physical strength and appetite. She is still suffering from difficulty in swallowing, but with normal sleeping. She lost weight for about 5 kg in the recent half year and has regular bowel movements for 2-3 days/time and normal micturition. She admitted to our hospital for further examination and treatment.

Diagnosis at admission: achalasia of cardia.

Chinese PLA General Hospital

Medical Records

Outpatient No.: Y2865835

Treatment process during hospitalization: The patient completed all relevant examinations after admission and received POME operation on July 28, 2017: lift right shoulder of the patient to enlarge the cavity of esophagus. There is troubled liquor inside and clean it. No obvious circuity in the cavity, no ring, half-moon-shaped or diverticulum, with smooth mucous membrane on the surface. No granular hyperplasia, erosion or anabrosis etc. Texture of blood vessels is clear, cardia of stomach is closed, with resistance for endoscope to pass. The distance between dentate line to incisor is 40 cm. Inject methylthionine chloride epinephrine normal saline solution under the mucosa at 30 cm away from the incisor. Make an incision of reversed T on the mucosa with lance-shaped knife and peel while injecting, to build a tunnel under the mucosa to 2 cm away under the cardia of stomach. The end of the tunnel is 42 cm away from the incisor. Make a full-thickness resection of muscularis propria at 35 cm away from the incisor with lance-shaped knife to the place 1 cm under the cardia of stomach. During building the tunnel and peeling, lance-shaped knife and electric coagulation forceps are used to treat the exposed vessels, without obvious errhysis. Withdraw the endoscope for observation, cardia of stomach is loose than before and there is a mucosal injury with length of 1.2 cm at the cardia of stomach. No mucosa perforations found through the observation in the tunnel and spray fibrin glue in the tunnel. After suction of air and imbibition, 6 titanium clips are used to fully close the wound entrance. After suction of air, withdraw the endoscope and give anti-inflammatory treatment, expectant treatment to inhibit acid after the operation. The patient is in stable condition and asks for discharge later. After being approval by the director, the patient is allowed to discharge.

Condition at discharge: The patient is in good spirit and no special discomfort after eating liquid food. No chest pain, breathe hard or fever etc.. Physical examination: vital signs of the patient are normal, no dry or wet rale heard at both lungs, with regular heart rate of 82 times/ min.. The abdomen is soft, no pressing pain and the borborygmus is normal, no edema of lower extremity.

Diagnosis at discharge: achalasia of cardia

Medical orders at discharge: 1. Continue to eat liquid food for a week and then can eat semiliquid food gradually. Avoid eating stimulating food or dry and hard food. Avoid aggravating activities or long trip. 2. Esomeprazole Magnesium Enteric-coated Tablets 20 mg, 2 times per day, Polaprezine Granules 75 mg, 2 times per day. 3. Reexamine gastroscope, gastrointestinal dynamic PH monitoring, gastrointestinal dynamic monitoring, upper gastrointestinal contrast examination after 3 months. 4. See a doctor when feel discomfort.

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