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病历摘要 男性,37岁。因腹泻、腹痛、间隙发热1年余,反复血便1个月于1985年9月25日入院。1年前开始腹泻,4～5次/日,黄色水样便,伴腹部疼痛不适,发热,体温37.8～39℃,盗汗、消瘦、服异菸肼月余疗效不显,月前排黑便,钡灌肠检查未见异常,两天后解暗红色糊状便,1～3次/日。9月 24日排血便3次,来我院就医,行乙状结肠镜检,插入15cm,见肠粘膜充血,无脓血及溃疡。经输血、止血治疗后仍反复血便。
Medical record summary Male, 37 years old. Due to diarrhea, abdominal pain, fever in the gap for more than one year, repeated bloody stools were admitted to hospital on September 25, 1985. 1 year ago began to diarrhea, 4 to 5 times / day, yellow watery stools, accompanied by abdominal pain, discomfort, fever, body temperature 37.8 ~ 39 °C, night sweats, weight loss, after the treatment of isoniazid and other effects are not significant, months before the black No abnormality was observed in barium enema examination. After two days, dark red paste was resolved, 1 to 3 times per day. On September 24th, the patient was discharged 3 times and came to our hospital for medical treatment. He underwent sigmoidoscopy and was inserted 15cm. The intestinal mucosa was congested without pus and blood. After blood transfusion and hemostasis treatment, blood was still repeated.