Patient She Mou, female, 79 years old, hospitalization number: 93234. At the beginning of June 2016, the patient had stool changes without obvious inducement. The stool became thinner and occasionally had blood in the stool. At first, he thought he was hemorrhoids and was ignored. At the beginning of November 2017, the patient felt that his condition was worse than before, and he went to the First Affiliated Hospital of Guangdong Pharmaceutical University. A colonoscopy was performed and a colorectal mass was found. A biopsy was taken. The pathology showed that the sigmoid colon was 35 cm from the anus. Polypoid structure, glandular hyperplasia, a small amount of papillary structure can be seen, glandular epithelial cells have mild atypia, and interstitial lymphocytes and plasma cells are infiltrated. The rectum is 12-16cm away from the anus. Part of the intestinal mucosal tissue for examination is polypoid, the glands are adenomatous hyperplasia, and some are densely small glands. A small amount of papillary and sieve-like structures can be seen, and the glandular epithelial cells are severely atypia. Proliferation of interstitial fibrous tissue. Immunohistochemical findings: Tubular-villous adenoma of sigmoid colon; Tubular-villous adenoma of rectum cancer.
The patient is very old, and both the patient himself and his family members refuse to undergo postoperative adjuvant chemotherapy and require the use of Chinese medicine. Engraved diagnosis: the patient is in good spirits, poor appetite, painful mouth, normal sleep, sticky stool, burning sensation in the anus, dark tongue, yellow greasy coating, tortuous purple veins under the tongue, and slippery pulse string. The patient had a history of hypertension for 5 years and was hospitalized for cerebral infarction. Combining the patient's preoperative, postoperative and past medical history, a prescription and pill treatment were prescribed.
The prescription is as follows: 150 grams of raw rehmannia, 100 grams of white peony root, 100 grams of coptis, 150 grams of gecko, 100 grams of scutellaria baicalensis, 150 grams of coix seed, 100 grams of dandelion, 100 grams of Patriniaceae, 100 grams of raw rhubarb, 100 grams of turmeric, scorpion 100 grams, 100 centipedes, 100 grams of leech, 100 grams of raw atractylodes, 100 grams of agrimony, 100 grams of woody, 100 grams of angelica, 100 grams of Alisma, 150 grams of ebony, 100 grams of silkworm, 100 grams of fried chicken gold , 100 grams of dried tangerine peel, 100 grams of Amomum, 100 grams of Codonopsis, 100 grams of Poria, 100 grams of Pueraria, 150 grams of Chinese yam, 150 grams of cornus, 150 grams of dried licorice, the above medicines are made into water pills, 12 grams each time, each Three times a day.
On April 10, 2018, the patient returned to the hospital for review. CT of the entire abdomen showed that there was a postoperative change of rectal cancer and no recurrence of the anastomosis was found. There was no local thickening of the colon in the pelvic cavity, and no expansion of the adjacent intestinal cavity. Multiple calcifications in the liver and small cysts in both kidneys. The general condition of the patient is fair, no complaints, obvious discomfort, good mental and physical strength, stable blood pressure, quick mental response, clear thinking, and require continued treatment with prescription pills.
Note: The initial pathogenesis of rectal cancer usually includes excessive dampness and heat, then dampness and heat are mixed together, and dampness and heat, phlegm and blood stasis, which gather together to form cancer, and the spleen and kidney are insufficient throughout the whole process. Therefore, in terms of treatment, clearing heat and removing dampness, dispelling blood stasis and dissipating masses are the main treatment methods, and the main treatment is the symptoms, supplemented by strengthening the spleen and kidney, and adjusting the prescription according to the changes of the etiology and pathogenesis. The use of insect medicine in the prescription can enhance the effectiveness of searching for clearing the collaterals, removing blood stasis and dispelling congestion. At the same time, incorporating insect medicine into the pill has stronger activity and can further improve the efficacy.
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