临床医学英语

Chapter 1 Patient-Physician Interaction 第一章医患沟通The patient-physician interaction proceeds through many phases of clinical reasoning and decision making. 医患沟通在临床诊断和治疗决策的许多阶段中进行着。

The interaction begins with an elucidation of complaints or concerns, followed by inquiries or evaluation to address these concerns in increasingly precise ways.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。

The process commonly requires a careful history or physical examination, ordering of diagnostic tests, integration of clinical findings with the test results, understanding of the risks and benefits of the possible courses of action, and careful consultation with the patient and family to develop future 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Physicians increasingly can call on a growing literature of evidence-based medicine to guide the process so that benefit is maximized,while respecting individual variations among different patients.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。

The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” 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。

Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics.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。

Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize the occasional. 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。

Even more judgment is required in the many situations in which evidence is absent or inconclusive.许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。

Evidence also must be tempered by patients’ preferences, although it is a physician’s responsibility to emphasize when presenting alternative options to the patient. 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。

The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.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。

To care for a patient as an individual, the physician must understand the patient as a 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）。

This fundamental precept of doctoring includes an understanding of the patient’s s ocial situation, family issues,financial concerns, and preferences for different types of care and outcomes, ranging from maximum prolongation of life to the relief of pain and suffering. 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。

If the physician does not appreciate and address these issues, the science of medicine cannot be applied appropriately, and even the most knowledgeable physician fails to achieve appropriate 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。

Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variety of sources, some of which are of questionable reliability.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。

The increasing use of alternative and complementary therapies is an example of patients’ frequent dissatisfaction with prescribed medical therapy.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。

Physicians should keep an open mind regarding unproven options but must advise their patients carefully if such options may carry any degree of potential risks, including the risk that they may relied on to substitute for proven approaches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。

It is crucial for the physician to have an open dialogue with the patient and family regarding the full range of options that either may consider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。

The physician does not exist in a vacuum but rather as part of a complicated and extensive system of medical care and pubic health.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。

In premodern times and even today in some developing countries, basic hygiene, clean water, and adequate nutrition have been the most important ways to promote health and reduce disease.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 developed countries, the adoption of healthy lifestyles, including better diet and appropriate exercise, are cornorstones to reducing the epidemics of obesity, coronary disease, 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。

Public health interventions to provide immunizations and to reduce injuries and the use of tobacco, illicit drugs, and excess alcohol collectively can produce more health benefit than nearly any other imaginable health intervention.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。

Chapter 5 Clinical Preventive Services 第五章临床预防服务Clinical preventive services include counseling, immunization, screening tests, and reduction of the susceptibility to disease by interventions such as therapeutic lifestyle changes and pharmacotherapy.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。

Preventive service often are classified as primary, secondary, or tertiary. 临床预防服务常分为一级预防、二级预防和三级预防。

Primary prevention is directed toward preventing disease or injury before it develops, whereas secondary prevention deals with early detection and treatment to impede the progress of overt disease.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。

In contrast, tertiary prevention refers to rehabilitative activities after the onset of disease to minimize complications and disability.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。

Because of considerable overlap, distinguishing among these phases of prevention may be confusing. 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。

Detecting and treating hypertension could be considered secondary prevention of hypertensive cardiovascular disease but primary prevention of heart failure and stroke. 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。

Prevention may be perceived best along a continuum from modification of predisposing factors, to preventing a disease, to avoiding premature death and disability.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。

The sooner the prevention, the more likely unnecessary illness, disability, and premature death can be 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 emphasis has been placed on preventing risk factors themselves.越来越多的重点已经集中到对危险因素本身的预防。

The term primordial prevention has been introduced for this concept.术语---根源预防（病因预防）已经引进了这个概念。

Indiscriminate screening for risk factors or disease without adequate advice and follow-up serves no useful purpose.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。

The periodic health examination has evolved from an annual, broad-based, uniform protocol to an approach that targets the prevention, detection, and treatment of specific diseases or risk factors for particular age, gender, and ethnic groups at appropriate intervals. 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 recommendations by the U.S. Preventive Services Task Force are based on systematic evidence reviews that distinguish procedures likely to prove effective and to have substantially more benefit than harm.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。

Changes in the health care system and the development of national guidelines for management of disease are likely to draw greater attention to health promotion, disease prevention, and the interface of physician-based medical care with the public health care 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。

Physicians should consider each disorder in terms of the potential for prevention, including the possibility of adverse effects and cost-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。

A concept useful for clinical decision making is the number of patients needed to treat to prevent one adverse event, which is based on absolute risk 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。

This number is based on efficacy and is calculated as the reciprocal of the difference in event rates between control and treatment groups for a specified period.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。

Ample evidence connects identifiable and often preventable factors to the morbidity and mortality associated with major health problems.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。

About half of all deaths, morbidity, and disability can be attributed to such nongenetic factors.约一半死亡、发病和病残与这些非遗传性因素有关.Many lifestyle changes benefit multiple systems and disorders.许多生活习惯改变有利于多个系统和紊乱的改善。

Cigarette smoking has been estimated to contribute to one in five deaths in the United States; dietary habits may affect the occurrence of cardiovascular disease, diabetes, osteoporosis, and cancer.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。

Other important personal behavior factors influencing health include physical activity, alcohol intake, illicit drug use, sexual practices, and exposure to environmental toxins.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。

The identification of informative DNA polymorphisms (e.g., single nucleotide polymorphisms) and further elucidation of
candidate genes allow for detection of susceptible individuals and possible institution of measures to prevent the expression of these harmful genetic traits.携带信息DNA多态性（例如，单核苷酸多态性）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。

Several common misconceptions impede preventive health care.好几种错误观念妨碍了预防保健。

Many believe that diseases with a strong heritable component cannot be altered, but susceptibility to disease often requires the interaction of multiple genes and environmental factors for expression.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。

In addition, chronic diseases are multifactorial, so other factors can be changed to compensate for an elevated genetic risk.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。

Although gene therapy holds much promise, preventive measures currently offer the best possibilities for limiting gene expression and avoiding disease.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。

The notion that prevention is less useful in older persons excludes many who would benefit most from prevention because elderly patients generally have a greater absolute risk of disease and have been shown to adhere and respond favorably to preventive measures.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, life expectancy frequently is underestimated in the elderly; individuals who reach age 75 now can expect to live an average of 11 more years.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。

Chapter 8 Why Geriatric Patients Are Different 第八章老年病人的特殊性
Older patients differ from young or middle-aged adults with the same disease in many ways, one of which is the frequent occurrence of comorbidities and of subclinical disease.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。

As a function of the high prevalence of disease, comorbidity (or the co-occurrence of two or more diseases in the same individual) is also common. 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。

Of people age 65 and older, 50% have two or more chronic disease, and these diseases can confer additive risk of adverse outcomes, such as mortality. 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。

In some patients, cognitive impairment may mask the symptoms of important conditions. 在一些病人中，认知损害可以掩盖重要病情的症状。

Treatment for one disease may affect another adversely, as in the use of aspirin to prevent stroke in individuals with a history of peptic ulcer disease.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。

The risk for becoming disabled or dependent also increases with the number of diseases present.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。

Specific pairs of diseases can increase synergistically the risk of disability. 特殊的成对疾病可以协同增加病残的风险。

Arthritis and heart disease coexist in 18% of older adults; although the odds of developing disability are increased by three-fold to four-fold with either disease alone, the risk of disability increases 14-fold if both are present. 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。

A second way in which older adults differ from younger adults is the
greater likelihood that their diseases present with nonspecific symptoms and signs. 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。

Pneumonia and stroke may present with nonspecific changes in mentation as the primary symptom. 肺炎和中风时可出现非特异性意识变化作为主要症状Similarly, the frequency of silent myocardial infarction increases with increasing age, as does the proportion of patients who present with a change in mental status, dizziness, or weakness rather than typical chest pain.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。

As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally would be considered in middle-aged adults.因此，老年病人的诊断应考虑更广泛的疾病谱，要超过通常对中年病人所考虑的范围。

A third condition that is found primarily in older adults is frailty, frailty is thought to be a wasting syndrome that presents with multiple symptoms and signs, including reduced muscle mass, weight loss, weakness, poor exercise tolerance, slowed motor performance, and low physical activity. 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。

Some estimates indicate that the full syndrome is found in 7% of community-dwelling people age 65 and older, and in 25%of community-dwelling people age 85 and older. 一些人估计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 institutionalized older adults also are frail.许多老人院里的老人也是衰弱的。

Frailty is a state of decreased reserve and increased vulnerability to all kinds of stress, from acute infection or injury to hospitalization, and may identify individuals who cannot tolerate invasive therapies. 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。

The syndrome of frailty is associated with high risk of falls, needs for hospitalization, disability, and mortality. 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。

There is early evidence that a core component of frailty is sarcopenia, or loss of muscle mass associated with aging, which occurs in 13 to 24% of persons age 65 to 70 and in 60% of persons age 80 and older. 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。

It is likely that dysregulation of multiple physiologic systems, including inflammation, hormonal status, and glucose metabolism, underlies the syndrome, with resulting decreased ability to maintain homeostasis in the face of stress. （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Subclinical disease (e.g., atherosclerosis), end-stage chronic disease (e.g., heart failure), or a combination of comorbid diseases may precipitate the syndrome. 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。

Evidence from randomized, controlled trials shows that resistance exercise, with or without nutritional supplements, and home-based physical therapy can increase lean body mass and strength in even the frailest older adults. 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。

This evidence suggests that earlier stages of frailty may be remediable, although end-stage frailty likely presages death.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, cognitive impairment increases in prominence as people age. 第四，人们变老时认知损害显著增加。

Cognitive impairment is a risk factor for a wide range of adverse
outcomes, including falls, immobilization, dependency, institutionalization, and mortality. 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Cognitive impairment complicates diagnosis and requires additional care giving to ensure safety.
认知损害使诊断复杂，为保证安全需要更多的照料。

Finally, a serious and common outcome of chronic diseases of aging is physical disability, defined as having difficulty or being dependent on others for the conduct of essential or personally meaningful activities of life, from basic self-care (e.g., bathing or toileting) to tasks required to live independently (e.g., shopping, preparing meals, or paying bills) to a full range of activities considered to be productive and/or personally meaningful.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。

Of older adults, 40% report difficulty with tasks requiring mobility, and difficulty with mobility predicts the future development of difficulty in instrumental activities of daily living (IADL; household management tasks) and activities of daily living (ADL; basic self-care tasks). 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。

In persons age 65 and other, difficulty with IADL is reported by 20%, and difficulty with ADL is reported by 11%; for both, the prevalence increases with age.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People who have difficulty with tasks of IADL and ADL are at high risk of becoming dependent.
IADL和ADL困难的人处于生活不能自理演变的高风险中。

Of persons older than age 65, 5% reside in nursing homes, largely as a result of dependency in IADL and/or ADL secondary to severe disease. 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, woman live more years with disability, whereas men who become similarly disabled are more likely to die at a younger age.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。

Although physical disability is primarily a result of chronic diseases and geriatric conditions, its onset and severity are modified by other factors, including treatments that control the underlying diseases, physical activity, nutrition, and smoking.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。

Many intervention trials indicate that disability can be prevented or its severity decreased; one trial showed improvements in functioning with resistance and aerobic exercise in older adults with osteoarthritis of the knee.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。

21 Occult and Obscure Gastrointestinal Bleeding隐匿性和来源不明性胃肠道出血
Occult bleeding is defined as the detection of asymptomatic blood loss from the gastrointestinal tract, generally by routine fecal occult blood testing (FOBT) or the presence of iron deficiency anemia.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。

Obscure gastrointestinal bleeding is defined as bleeding of unknown origin that persists or recurs after a negative initial endoscopic evaluation of both the upper and lower gastrointestinal tracts.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。

Both of these entities may be presentations of recurrent or chronic bleeding.两者都可能表现为反复的或慢性的出血。

The initial approach to evidence of occult gastrointestinal blood loss should be endoscopic evaluation.对隐匿性胃肠道出血，应该使用内窥镜进行早期检查。

In the setting of an isolated positive FOBT, colonoscopy is indicated as the first test.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。

The yield of colonoscopy in these patients is approximately 2% for cancer and 30% for one or more colonic polyps.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。

The initial approach to a patient with iron deficiency anemia depends on the presence of symptoms referable to either the upper or lower gastrointestinal tract.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。

Regardless of the findings on the initial upper or lower endoscopic examination, all patients should have both upper and lower endoscopy because the complementary endoscopic examination has a yield of 6% even if the first one was positive.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。

For premenopausal women, a positive FOBT requires full evaluation, as does iron deficiency anemia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。

Barium radiographs of the upper and lower gastrointestinal tract have limited utility in the setting of occult bleeding because of their inability to biopsy or treat lesions that are identified.隐匿性出血时，上、下消化道的钡剂造影应用有限，因为它们不能活检或治疗发现的病损。

The evaluation of obscure gastrointestinal bleeding is often frustrating原因不明性胃肠道出血的诊断常常令人沮丧。

Angiodysplasia is the most common cause in most recent series.血管发育畸形是最近病例统计中最常见的病因。

Initial endoscopic examination should focus on any symptoms reported by the patient.首次内窥镜检查要关注病人诉说的任何症状。

Potential causative agents, such as NSAIDs and aspirin, should be discontinued. 能成为潜在病因的药物，如非甾体类抗炎镇痛药和阿斯匹林，都应该停用。

Disorders associated with bleeding, such as hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), inflammatory bowel disease, or a bleeding diathesis should be considered.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、或出血性体质应该加以考虑。

A repeat endoscopic evaluation may be appropriate, because approximately one third of cases reveal a cause of bleeding overlooked during the initial 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。

When upper endoscopy and colonoscopy are both unrevealing, evaluation of the small bowel is indicated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。

Radiographic evaluation of the small bowel is noninvasive but relatively insensitive, with a less than 6% yield from small bowel follow-through and a 10 to 21% yield from enteroclysis.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。

By comparison, the diagnostic yield of endoscopic enteroscopy of the small bowel in obscure gastrointestinal bleeding is 38 to 75%.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%。

Traditional videoendoscopes can evaluate only the proximal small bowel (≤150cm), whereas longer scopes, which are passed though the entire small bowel and then withdrawn while visualizing the mucosa (sonde enteroscopy), are limited in their ability
to visualize the entire mucosa and cannot be used to perform diagnostic or therapeutic maneuvers.传统的电视内窥镜只能检查近端小肠(≤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。

When endoscopic evaluation does not detect the cause of blood loss, radiographic procedures such as scintigraphy and angiography should be considered.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。

Provocative angiography using heparin or thrombolytic agents has been suggested by some authorities, but this approach has the potential risk of precipitating major bleeding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。

In the face of continued blood loss and no identified etiology, intraoperative endoscopy may provide simultaneous diagnosis and therapy.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。

During the procedure, the surgeon plicates the bowel over the endoscope.操作时，外科医生把小肠套到内窥镜上。

As the scope is withdrawn, endoscopic findings can be identified for surgical resection or treatment.内镜退出时，内镜的发现可以决定是外科切除或保守治疗。

The yield of this procedure exceeds 70%.这个措施70%以上有结果。

In some clinical situations, the site of bleeding cannot be identified, and the patient requires long-term transfusion therapy.某些临床病例，出血部位无法找到，病人而要长期输血治疗。

A new device for visualizing the entire gastrointestinal mucosa consists of a small camera in an ingestable capsule that transmits images to receivers attached to the patient’s abdomen and mapped to identify the location of the image.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。

The diagnostic yield of capsule enteroscopy is not yet clear, but this approach may potentially visualize segments of the small bowel that were previously inaccessible.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。

No therapeutic maneuvers are possible with the device.但这个装置不可能有任何治疗性操作。

Chapter 23 Diabetic Nephropathy 第二十三章糖尿病肾病End-stage renal disease (ESRD) from diabetic nephropathy is a major cause of morbidity and mortality, particularly in patients with type 1 diabetes, affecting 30 to 35% of patients in the United States.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 nephropathy is about one half as frequent in type 2 diabetics (partially due to a shortened life expectancy), type 2 diabetes still makes up the vast majority of diabetic patients seeking therapy for ESRD.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 is the leading cause of ESRD in the United states, accounting for more than one third of 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。

Details are less clear in patients with type 2 diabetes, but the natural history of diabetic nephropathy in type 1 diabetes is well described.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。

The period immediately following diagnosis is best characterized by glomerular hyperfiltration.紧接诊断后的一段时期以肾小球超滤最具有特征。

During this time, there is renal hypertrophy, increased renal blood flow, increased glomerular volume, and an increased transglomerular pressure gradient, all contributing to。