2 English references Endometrial tuberculosis
3 disease code ICD:N74. 1*
4 Classification of Obstetric and Gynecological Diseases
5 disease overview Endometrial tuberculosis is often secondary to tuberculosis, renal tuberculosis, gastrointestinal tract, bone or joint tuberculosis, etc. Occasionally, it can also be part of systemic miliary tuberculosis. Infectious diseases of female reproductive organs caused by Mycobacterium tuberculosis often invade fallopian tubes first, and then gradually invade endometrium and ovary, rarely involving cervix, vulva and vulva.
Endometrial tuberculosis accounts for 50% ~ 60% of female genital tuberculosis. 80% ~ 90% of women of childbearing age aged 20 ~ 40 belong to this age group. It can also be seen in girls before puberty and elderly women after menopause.
symptom
(1) Severe patients often have emaciation, low fever, night sweats, fatigue and other systemic manifestations, and have a history of infertility and abnormal menstruation.
(2) The secretion of * * * is increased, among which, because the endometrium of endometrial tuberculosis is completely transformed into caseous granuloma-like tissue, serous and foul-smelling * * drainage may occur, such as purulent or purulent drainage and contact bleeding when cervical tuberculosis is combined.
(3) Abdominal pain. Among the patients with endometrial tuberculosis, 25% ~ 50% have different degrees of lower abdominal pain, which is characterized by long-term dull pain in the lower abdomen and aggravation before menstruation. If complicated with secondary purulent infection, obvious abdominal pain, fever and other symptoms similar to acute pelvic inflammatory disease may occur.
(4) Menstrual changes, manifested as menorrhagia in the early stage of the disease, and menorrhagia or even amenorrhea in the late stage due to endometrial atrophy.
6 disease description Endometrial tuberculosis is often secondary to tuberculosis, renal tuberculosis, gastrointestinal tract, bone or joint tuberculosis, and occasionally it can be a part of systemic miliary tuberculosis. Infectious diseases of female reproductive organs caused by Mycobacterium tuberculosis often invade fallopian tubes first, and then gradually invade endometrium and ovary, rarely involving cervix, vulva and vulva.
Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis, which seriously harms people's health. Since the founding of the People's Republic of China, China has attached great importance to the prevention and treatment of tuberculosis, which has been well controlled. However, since the mid-1980s, affected by HIV infection, multidrug-resistant tuberculosis and immigration, the global tuberculosis epidemic has picked up again, with an annual increase of about 6.5438+million tuberculosis patients and 3 million deaths from tuberculosis. In 2000, the fourth epidemiological sampling survey of tuberculosis in China showed that there were 4.6 million active tuberculosis patients in China, which indicated that the epidemic situation of tuberculosis in China was still quite severe, and the prevention and treatment of tuberculosis was facing new challenges. Due to the increase of tuberculosis patients, the number of female reproductive tract tuberculosis patients has also increased accordingly.
7 Symptoms and signs The clinical manifestations of female genital tuberculosis are very inconsistent. Many patients may have no symptoms, and severe cases may have the following manifestations:
1. Symptoms
(1) Severe patients often have emaciation, low fever, night sweats, fatigue and other systemic manifestations, and have a history of infertility and abnormal menstruation.
(2) The secretion of * * * is increased, among which, because the endometrium of endometrial tuberculosis is completely transformed into caseous granuloma-like tissue, serous and foul-smelling * * drainage may occur, such as purulent or purulent drainage and contact bleeding when cervical tuberculosis is combined.
(3) Abdominal pain. Among the patients with endometrial tuberculosis, 25% ~ 50% have different degrees of lower abdominal pain, which is characterized by long-term dull pain in the lower abdomen and aggravation before menstruation. If complicated with secondary purulent infection, obvious abdominal pain, fever and other symptoms similar to acute pelvic inflammatory disease may occur.
(4) Menstrual changes, manifested as menorrhagia in the early stage of the disease, and menorrhagia or even amenorrhea in the late stage due to endometrial atrophy.
2. Due to the severity and scope of the lesion, the signs change greatly. Abdominal examination: patients with mild symptoms such as endometrial tuberculosis can be found to be normal. When accompanied by peritoneal tuberculosis, the abdomen has tenderness, elasticity or ascites. When the encapsulated effusion is formed, an inactive cystic mass can be felt, which mostly adheres to the intestine and may have mild tenderness.
The cause of the disease is the spread of endometrial tuberculosis from tubal tuberculosis. After the incubation period, in the case of poor body resistance, mycobacterium tuberculosis mainly invades the endometrium, often involving the basal layer of the endometrium.
9 Pathophysiology Female genital tuberculosis first infects fallopian tubes, and then gradually spreads to endometrium, ovary and cervix. Because the endometrium falls off periodically, the focus of endometrial tuberculosis is discharged, and the lesions are mostly confined to the endometrium, scattered in miliary nodules in the early stage, and a few serious lesions invade the muscularis. The uterus is normal in size or slightly smaller, and there is no abnormality in appearance.
Tuberculous nodules can be seen under the microscope of the scraped endometrium, and caseous necrosis appears in severe cases. A typical tuberculosis nodule has 1 ~ 2 giant cells in the center, arranged in a horseshoe shape, surrounded by epithelioid cells, and a large number of lymphocytes and plasma cells infiltrated outside. Endometrial tuberculous nodules are characterized by the fact that the glands around tuberculous nodules are insensitive to ovarian hormones, which are characterized by persistent proliferation or insufficient secretion. Severe tuberculosis of the intima can cause caseous necrosis and superficial ulcer, which will lead to the destruction of most or all of the intima, thus forming scars, the loss of all functions of the intima and amenorrhea.
10 Diagnostic examination and diagnosis: Most patients with typical symptoms and signs have no difficulty in diagnosis, and most of them are easily missed or misdiagnosed because they have no obvious symptoms and signs. Some patients were diagnosed as endometrial tuberculosis only by diagnostic curettage because of infertility. The possibility of genital tuberculosis should be considered first if:
1. People with family history of tuberculosis, previous contact history with tuberculosis, or tuberculosis, pleurisy or intestinal tuberculosis.
2. Infertility due to oligomenorrhea or amenorrhea, with the following symptoms: abdominal pain or pelvic mass.
3. Unmarried women with a history of asexual contact who complain of low fever, night sweats, lower abdominal pain, irregular menstruation, thickened pelvic appendages and lumps should also think of this disease.
4. Chronic pelvic inflammatory disease can't be cured for a long time. Some scholars reported that among 52 cases of pelvic genital tuberculosis, 22 cases had a history of tuberculosis, accounting for only 42.3%. Therefore, those who have no history of tuberculosis cannot rule out genital tuberculosis, and elderly gynecological patients should carefully ask for examination and rule out tuberculosis.
Laboratory examination:
1. Unless there is mixed infection, the white blood cell count is generally not high, and lymphocytes may increase in the classified count. Erythrocyte sedimentation rate (ESR) can increase rapidly in active stage of pulmonary tuberculosis, but normal ESR can't rule out pulmonary tuberculosis.
2. Detection of Mycobacterium tuberculosis in blood or tissue by quantitative determination of polymerase chain reaction (PCR) can make rapid diagnosis of diseases. It is suggested that PCR is a rapid and sensitive method to detect the DNA of Mycobacterium tuberculosis in different tissues, but the course of disease should be considered when judging the results.
3. Determination of serum CA 125. The serum CA 125 level of patients with advanced abdominal tuberculosis increased significantly. Thakur et al reported that (200 1) 1 48-year-old female CT showed right ovarian mass with ascites, and the serum CA 125 value was as high as 1255U/ml (normal 0 ~ 35U/ml), and ovarian malignant tumor was to be diagnosed by laparotomy. Histopathological examination showed granuloma. After anti-tuberculosis treatment 1 month, the level of CA 125 decreased to 42U/ml. It is suggested that the possibility of tuberculosis should also be considered when the serum CA 125 value of patients with abdominal mass with or without ascites is abnormally increased. Laparoscopy combined with biopsy can make a definite diagnosis and avoid unnecessary exploratory laparotomy. The detection of serum CA 125 value can also be used to monitor the efficacy of anti-tuberculosis treatment.
4. The positive tuberculin test indicates that there has been tuberculosis infection, and its diagnostic significance is not significant. If it is strongly positive, it means that there are active lesions in the body, but it cannot explain the location of the lesions. Negative results cannot rule out tuberculosis.
5. Mycobacterium tuberculosis culture and animal inoculation, blood collection, endometrial curettage, cervical secretion, uterine cavity secretion, pelvic mass puncture fluid or pelvic encapsulated effusion, etc. Culture, and check the positive results after 2 months. Or these substances are inoculated under the abdominal wall of guinea pigs. If tuberculosis is found in lymph nodes around the inoculation site, the diagnosis can be made after 6-8 weeks of anatomical examination. If the result is positive, further drug sensitivity test can be done to guide clinical treatment.
Blood culture (taking 6 ~ 8 ml menstrual blood on 1 day) can avoid the transmission of tuberculosis caused by curettage, but the positive rate is lower than that of endometrial bacteriology. It is generally advocated that histological examination, bacterial culture and animal inoculation can improve the positive diagnosis rate. This method has certain technical requirements, takes a long time and is difficult to popularize and use.
Other auxiliary inspections:
1. Pathological examination shows that those who see miliary nodules or cheese-like substances in the pelvic cavity must generally have diagnostic curettage. Infertility and suspicious patients should also take endometrium for pathological examination. Diagnosis and curettage should be performed within 1.2 hours after menstrual cramps, so the lesions are more obvious. When curettage, we should pay attention to scraping the endometrium on both sides of the uterine horn, because most of the endometrial tuberculosis comes from the fallopian tube, so that the lesions first appear on both sides of the uterine cavity. All the scraped tissues should be sent for pathological examination, and it is best to slice them continuously and systematically to avoid missed diagnosis. If typical tuberculosis nodules are found in the section, a diagnosis can be made. Patients with endometrial inflammatory granuloma should be highly suspicious of endometrial tuberculosis. There is no tuberculosis focus, but there is a giant cell system (macrophages have a strong phagocytosis and killing effect on mycobacterium tuberculosis), so the existence of tuberculosis cannot be denied. Suspicious patients need to be reviewed every 2 ~ 3 months. If the endometrial examination is negative for three times, it can be considered that there is no endometrial tuberculosis. Because curettage may cause the spread of tuberculosis, anti-tuberculosis drugs should be used for preventive treatment before and after operation. Other lesions, such as cervix and vulva. It is also necessary to pass histopathological examination to make a definite diagnosis.
2. X-ray inspection
(1) Chest X-ray: X-ray examination of gastrointestinal system and urinary system can be done when necessary to find the primary lesion. However, when many patients find genital tuberculosis, the primary focus has often healed without leaving any trace, so negative X-ray can't rule out pelvic tuberculosis.
(2) Abdominal X-ray film: If isolated calcified lesions are displayed, pelvic lymph node tuberculosis is suggested.
(3) Hysterosalpingography: Hysterosalpingography has certain value in the diagnosis of genital tuberculosis. Its development features are as follows:
① Uterine cavity: different shapes, with different degrees of stenosis or deformation, and serrated edges, if there is no history of curettage or abortion.
② There are many strictures in the lumen of fallopian tube, which are typically beaded or tiny and hard.
③ Endometrial tuberculosis: interstitial, parauterine lymphatic vessels or blood vessels should be considered when the contrast agent enters the uterine wall.
④ Obstruction between ampulla and isthmus of fallopian tube, accompanied by perfusion obstacle of iodized oil into fallopian tube interstitial.
⑤ It is equivalent to fallopian tubes, ovaries and pelvic lymph nodes: mostly scattered in millet-shaped bright spots and shadows.
Calcified lesions.
Iodized oil hysterosalpingography may bring tuberculosis or cheese-like substances into the pelvic cavity, and even cause the spread of the disease, which is life-threatening. The indications should be strictly controlled. When there is pus or other diseases in the fallopian tube, angiography should not be performed. Anti-tuberculosis drugs should be given before and after angiography to prevent the disease from getting worse. The suitable time for radiography is within 2 ~ 3 days after cleaning.
3. Laparoscopy is more valuable than other methods in the diagnosis of female early pelvic tuberculosis. Laparoscopic examination is feasible for patients with negative endometrial histopathology and bacteriology. Microscopically observe whether there are miliary nodules on the serosal surface of uterus and fallopian tube, whether there are membranous adhesions around fallopian tube, and whether there are masses in fallopian tube and ovary. At the same time, the suspected pathological tissue can be biopsied and the fluid in the posterior vault can be taken for tuberculosis culture. Palmer et al. examined 99 patients with suspected genital tuberculosis by laparoscopy, of which 10 was diagnosed. Because the appearance of fallopian tube is not clear, intestinal perforation is easy to occur when there is intestinal adhesion, so the operation should be carried out by experienced doctors. Do not use it for patients with extensive abdominal adhesion.
4. Hysteroscopy hysteroscopy can directly find the focus of endometrial tuberculosis, and biopsy can be taken for pathological examination under direct vision, but it is possible to spread tuberculosis. The severe adhesion and deformation of uterine cavity caused by tuberculosis destruction can hinder the observation effect, which is difficult to distinguish from traumatic intrauterine adhesion and should not be the first choice. If hysteroscopic diagnosis is needed, whether there is active tuberculosis should be ruled out before microscopic examination and anti-tuberculosis treatment should be carried out. Hysteroscopy showed that the endometrium was hyperemia and redness due to inflammatory reaction, and the focus was yellow-white or grayish-yellow. Mildly diseased endometrium is uneven, and miliary white nodules can be attached to the surface; When the lesion is serious, the endometrium is destroyed by tuberculosis, which leads to intrauterine adhesions and irregular shapes. The uterine cavity can be filled with messy and fragile polypoid protrusions, and the scar tissue is hard, even forming stony calcified foci, which is difficult to expand and separate.
1 1 Differential diagnosis Endometrial pathological examination can differentiate the following diseases and make a definite diagnosis:
1. Odor serous leucorrhea can appear in caseous granuloma of endometrial carcinoma, and endometrial carcinoma should be excluded.
2. Cervical cancer can be differentiated from cervical tuberculosis by cervical curettage and biopsy.
3. Nonspecific pelvic inflammatory disease has a history of fertility, abortion, intrauterine device, gonorrhea or acute pelvic inflammatory disease. The most common clinical manifestations are menorrhagia and amenorrhea. Most patients with pelvic tuberculosis are infertile, with decreased menstrual flow and even amenorrhea. Pelvic examination can palpate nodules or masses.
4. The clinical manifestations of pelvic endometriosis are similar, such as infertility, menstrual disorder, low fever, pelvic adhesion, thickening and nodules. However, endometriosis has obvious dysmenorrhea and generally has more menstrual flow. Diagnostic curettage and hysterosalpingography are helpful to make a definite diagnosis.
12 treatment plan 1. General treatment enhances the body's resistance and immunity, which is helpful for treatment. Patients with active pulmonary tuberculosis should stay in bed for at least 3 months. When the illness is under control, you can do some light work, but you need to pay attention to the combination of work and rest, strengthen nutrition, participate in sports activities properly, and strengthen your physique.
2. Drug treatment The application of anti-tuberculosis drugs is an important measure to treat tuberculosis.
(1) Commonly used anti-tuberculosis drugs: The ideal anti-tuberculosis drugs have sterilization, disinfection or strong bacteriostatic effects, with low toxicity, few adverse reactions, low price, convenient use and sufficient drug sources; After oral administration or injection, the drug can reach an effective concentration in the blood and penetrate into phagocytes, abdominal cavity or cerebrospinal fluid, with rapid and lasting curative effect.
At present, commonly used anti-tuberculosis drugs are divided into four categories: ① drugs with similar effects on bacteria inside and outside cells, such as rifampicin, isoniazid, ethionine and cycloserine; ? ② Extracellular effects are dominant, such as streptomycin, kanamycin, capreomycin and violomycin; ③ those with dominant intracellular action, such as pyrazinamide; ④ Antibacterial drugs, such as sodium p-aminosalicylate, ethambutol and thiosemicarbazone.
Streptomycin, isoniazid and sodium p-aminosalicylate are called first-line drugs; Other drugs are called second-line drugs. First-line drugs are generally used in clinic. When first-line drugs produce drug-resistant strains or patients can't tolerate toxic reactions, 1 ~ 2 second-line drugs can be used.
(2) Chemotherapy plan: Understanding the mechanism of anti-tuberculosis drugs and combining the side effects of drugs are important basis for choosing combined chemotherapy plan.
① Long-term standard chemotherapy: triple therapy of streptomycin (SM), isoniazid (INH) and sodium p-aminosalicylate (PAS), with a course of 1.5 ~ 2 years. The cure standard is focus absorption, stability and no recurrence. However, due to the long course of treatment, some patients no longer insist on regular medication because of the disappearance of symptoms, resulting in incomplete treatment, which is often the reason for inducing drug-resistant mutants.
The treatment plan is to use streptomycin (SM), isoniazid (INH) and sodium p-aminosalicylate (PAS) every day for the first two months, then use isoniazid (INH) and sodium p-aminosalicylate (PAS) 10 month, or use streptomycin (SM) and isoniazid (INH) for two months. Isoniazid (INH) and sodium p-aminosalicylate (PAS) were used daily, and isoniazid (INH) and sodium p-aminosalicylate (PAS) were used for 7 months (2hp/3s 2hp/7HP).
1977 Sutherland summarized the drug treatment experience of 566 cases of genital tuberculosis in the past 25 years (195 1 ~ 1975). The drugs used include streptomycin (SM), sodium p-aminosalicylate (PAS), isoniazid (INH), EMB and rifampicin (RFP). These drugs were combined into seven different treatment schemes, and the conclusion was that streptomycin (SM), isoniazid (PAS) and sodium p-aminosalicylate were the best among 206 cases. The specific drugs were streptomycin (SM) 1g/d, intramuscular injection *** 120 days, isoniazid (INH) 100g/d, sodium p-aminosalicylate (PAS)300mg/d, * * *1d.
② Short-term plan: Since 1970s, scholars at home and abroad have studied the short-term plan of anti-tuberculosis drugs. Compared with the long-term standard scheme, it is proved that reducing the time and dosage of medication can also achieve the curative effect. In recent years, short-term chemotherapy is the first choice to achieve the purpose of high curative effect, low toxicity and low price.
A. short-term treatment requirements:
A. it must contain two or more fungicides.
B is based on isoniazid (INH) and rifampicin (RFP) and runs through the whole treatment process.
C. no bacteriostatic agent is added except ethambutol (EMB). When EMB is controlled, the course of treatment should be 9 months.
B. The treatment options are:
A. Take streptomycin (SM), isoniazid (INH), rifampicin (RFP) and pyrazinamide (PZA) orally every day for the first two months, and then take isoniazid (INH), rifampicin (RFP) and ethambutol (EMB) orally every day for four months.
B. Streptomycin (SM), isoniazid (INH), rifampicin (RFP) and pyrazinamide (PZA) were given daily for two months, and then isoniazid (INH), rifampicin (RFP) and ethambutol (EMB) were taken orally three times a week for six months.
C. Give streptomycin (SM), isoniazid (INH) and rifampicin (RFP) every day for two months, then give streptomycin (SM), isoniazid (INH) and rifampicin (RFP) twice a week for two months, and then give streptomycin (SM) and isoniazid (INH) twice a week for five months (2
D. Streptomycin (SM), isoniazid (INH), rifampicin (RFP) and pyrazinamide (PZA) were given daily for 2 months, and then thiosemicarbazone (T) and isoniazid (INH) were given for 4-6 months (2 times/4th-6th time).
(3) the principle of anti-tuberculosis drugs:
① Early medication: In the early tuberculosis focus, the metabolism of Mycobacterium tuberculosis is vigorous, the local blood supply is abundant, and drugs are easy to kill bacteria.
② Combination medication: In addition to preventive medication, it is best to combine medication, in order to achieve the synergistic effect of various drugs and reduce drug resistance.
③ Drugs with the same mechanism, such as streptomycin (sm) and kanamycin, should not be given at the same time.
④ Choose drugs with both intracellular and extracellular effects, such as isoniazid (INH), rifampicin (RFP) and ethambutol (EMB).
⑤ Use drugs that are not affected by the environment where tuberculosis is located: for example, streptomycin (SM) works in alkaline environment, but does not work in acidic environment; Pyrazinamide (PZA) plays a role in acidic environment.
⑥ Adverse reactions of anti-tuberculosis drugs to the same organ should be considered: such as rifampicin (RFP), isoniazid (INH) and ethionine all have effects on liver function, and serum alanine aminotransferase should be detected when combined.
⑦ Regular medication: drug withdrawal is the main cause of treatment failure, which can make bacteria unable to be completely eliminated or even relapse, resulting in drug resistance.
8 Appropriate dosage: Excessive dosage will increase side effects; The dosage is too small to achieve the therapeutic effect.
⑨ Whole course medication: The duration of treatment is closely related to the recurrence rate. Sticking to reasonable medication throughout the course can reduce the recurrence rate.
⑩ Drugs with strong bactericidal power and high safety should be selected, such as isoniazid (INH) and rifampicin (RFP), which have high curative effect and are not affected by various conditions; The germicidal efficacy of streptomycin (SM) and pyrazinamide (PZA) is affected by tuberculosis environment, and the curative effect is poor.
(4) immunotherapy: In the course of tuberculosis, T cell-mediated immune response and type I hypersensitivity can be induced. Tuberculosis patients are in a state of immune disorder, cellular immune function is low, while humoral immune function is enhanced, resulting in a serious imbalance of immune function. The response of anti-tuberculosis drugs is slow, and the curative effect of anti-tuberculosis drugs alone is often poor. Therefore, adjuvant immunomodulators can adjust the cellular immune function of the body in time, improve the cure rate and reduce the recurrence rate. Commonly used immunomodulators for tuberculosis are:
① Freeze-dried BCG: Freeze-dried BCG (PNS) is the pyrogallol ethanol extract of BCG, which contains 10 kinds of immune active components such as BCG polysaccharide and nucleic acid, and has the functions of improving cellular immune function and nucleic acid phagocytosis, restoring T cell function, increasing H2O2 release and killing suicide-damaged cells. Commonly used freeze-dried BCG (PNS) 1mg intramuscular injection twice a week. Combined isoniazid (INH), streptomycin (SM) and rifampicin (RFP) as short-term chemotherapy for active pulmonary tuberculosis.
② Mycobacterium vaccae: Mycobacterium vaccae: The mechanism of Mycobacterium vaccae is to increase the level of NO and H2O2 produced by macrophages to kill Mycobacterium tuberculosis and inhibit allergic reaction. Mycobacterium bovis vaccine is injected into deep muscle every 3 ~ 4 weeks 1 time, 0. 1 ~ 0.5 mg, * * 6 times, and combined with anti-tuberculosis drugs to treat newly-treated and refractory pulmonary tuberculosis can shorten the chemotherapy course of newly-treated pulmonary tuberculosis and improve the therapeutic effect of refractory pulmonary tuberculosis.
(3) Levamisole (LMS): Levamisole is beneficial to the treatment of tuberculosis patients, but it has no obvious effect on the normal body by activating immunocompetent cells, promoting lymphocyte transformation to produce more active substances and enhancing the phagocytic function of reticuloendothelial system. Levamisole, as an immunomodulator, has attracted more and more clinical attention in the treatment of some refractory diseases. Levamisole (LMS) is generally used in combination with chemotherapy drugs to assist in the treatment of primary pulmonary tuberculosis. Usage: 1.50 mg/d, three times a week, chemotherapy every day for three months.
④ Interferon -γ (γIFN-γ): It can activate macrophages to produce NO, thus inhibiting or killing mycobacteria. The clinical symptoms of pulmonary tuberculosis patients who failed to respond to conventional anti-tuberculosis drugs chemotherapy can be relieved by adding interferon-γ. 25 ~ 50μ g/m2, subcutaneous injection, 2 ~ 3 times a week. As an adjuvant drug, the dose of refractory disseminated mycobacterial infection is 50 ~ 100μ g/m2, at least three times a week. Adverse reactions include fever, chills, fatigue and headache, but mild reactions are rare.
(5) Treatment of drug-resistant tuberculosis: The result of drug resistance must be short-term treatment failure or long-term recurrence. Generally, Mycobacterium tuberculosis has monophasic cross resistance to streptomycin (SM), kanamycin and erythromycin, that is, Mycobacterium tuberculosis resistant to streptomycin (SM) is sensitive to kanamycin and erythromycin, while resistant to kanamycin, it is also resistant to streptomycin (SM), but sensitive to erythromycin, and resistant to both erythromycin. Streptomycin (SM), kanamycin and erythromycin should be given in turn in clinic.
The initial drug resistance of newly treated patients is not common, generally less than 2%, mainly resistant to isoniazid (INH) and/or streptomycin (SM), and rarely resistant to rifampicin (RFP), pyrazinamide (PZA) or ethambutol (EMB). It is best to do culture and drug sensitivity before taking medicine, so as to adjust the treatment plan according to the results and ensure that at least 2 ~ 3 drugs are sensitive. If the patient has primary drug resistance, the treatment time must be extended to achieve the treatment goal. When primary resistance to INH and/or streptomycin (SM) is suspected, isoniazid (INH), rifampicin (RFP), pyrazinamide (PZA) and ethambutol (EMB) should be selected in the strengthening stage, and rifampicin (RFP) and ethambutol (EMB) should be used in the consolidation stage. Secondary drug resistance is the biggest and most difficult form of drug resistance. Generally, it is caused by improper combination of drugs, insufficient drug dosage, irregular drug use, interruption of treatment or premature withdrawal of drugs. When secondary drug resistance is suspected, culture and drug sensitivity must be done before choosing chemotherapy regimen. If resistant to isoniazid (INH), rifampicin (RFP), pyrazinamide (PZA) and ethambutol (EMB), 4-5 kinds of bacteria-sensitive drugs should be used in the strengthening period, and at least 3 kinds of drugs should be used in the consolidation period, with a total course of treatment of 24 months. In order to prevent further drug resistance, short-term treatment is necessary.
3. Surgical therapy
(1) surgical indications:
① The symptoms of tubal ovarian abscess were relieved after drug treatment, but the lump did not disappear, and the patient felt the symptoms relapse.
(2) Drug therapy is ineffective, resulting in tuberculous abscess.
③ A large amount of encapsulated effusion was formed.
④ The endometrium was extensively destroyed, and anti-tuberculosis drugs were ineffective.
⑤ For patients with tuberculous peritonitis complicated with ascites, surgical treatment combined with drug therapy is beneficial to the recovery of peritoneal tuberculosis.
(2) Operation method and scope: The operation scope should be determined according to the age and lesion scope. Because most of the patients are women of childbearing age, we should also consider preserving the ovarian function of the patients when surgery is needed. If the patient requests to preserve menstruation, the uterus can be preserved according to the healing of endometrial tuberculosis lesions. Hysterectomy is feasible for those who have formed a large mass between fallopian tube and ovary and cannot be separated. Pelvic tuberculosis leads to multiple adhesions, which are so extensive and dense that it is difficult to operate separately. If you do it reluctantly, it may cause unnecessary harm. In case of the above situation, the operator should stop the operation in time, and the postoperative tuberculosis will last for 3 ~ 6 months, and a second operation will be performed if necessary.
(3) preoperative and postoperative medication: general patients have used 1 course of chemotherapy before operation. If you do bilateral appendectomy, besides tuberculosis in other organs, you still need regular drug treatment, generally only about 1 month after operation. If the preoperative diagnosis is unknown, and the tuberculosis focus is found during the operation, and the focus is cleared and drained smoothly, 4 ~ 5g of streptomycin (SM) can be intraperitoneally infused during the operation, and conventional anti-tuberculosis treatment can be performed after the operation.
Complications 13 Endometrium is caseous tissue or abscess which can form uterine cavity; Some patients complicated with amenorrhea; The vast majority of patients with genital tuberculosis are complicated with infertility.
14 Prognosis and prevention Prognosis: Endometrial tuberculosis is one of the main causes of infertility. Due to the serious damage of tuberculosis to fallopian tubes, there is little chance of getting a normal pregnancy after applying enough anti-tuberculosis drugs. According to the pregnancy rate of more than 700 patients, only 3 1 case (0.44%) was normal pregnancy, 25 cases were tubal pregnancy1case, and 67 cases were aborted after chemotherapy. If patients with genital tuberculosis need to give birth, artificial assisted pregnancy can be used. Pregnancy should be avoided during the active period of tuberculosis. Foreign D@@@@esopo and Springett reported that the disease was followed up for more than 5 years after treatment, and the recurrence risk rate was lower than 1‰, so pregnancy can only be achieved if the disease is stable for more than 5 years.
Prevention: Endometrial tuberculosis is mostly secondary infection, and the primary focus is tuberculosis. Therefore, active prevention and treatment of tuberculosis is of great significance to the prevention of genital tuberculosis. Its preventive measures are the same as tuberculosis. In addition to strengthening publicity and education on tuberculosis prevention, health care for children and adolescents should also be strengthened. Newborns weighing more than 2200g can be inoculated with BCG vaccine 24 hours after birth and replanted within 3 months if necessary. Babies of adolescent girls with negative tuberculin test after 3 months should be vaccinated with BCG. Pregnancy should be avoided during active pulmonary tuberculosis. In addition, there may be tuberculosis in the secretions and menstrual blood of patients with genital tuberculosis, so isolation should be strengthened to avoid infection.
15 Epidemiology Endometrial tuberculosis accounts for 50% ~ 60% of female genital tuberculosis. 80% ~ 90% of women of childbearing age aged 20 ~ 40 belong to this age group. It can also be seen in girls before puberty and elderly women after menopause.
It is reported that the onset age tends to be delayed. The average age of onset increased from 28.2 years in the 1950s to 38.9 years in the 1970s. Patients over 40 years old accounted for 6.5% in 1950s, rose to 16.7% in 1960s, and rose to 43.3% in 1970s. The incidence of female genital tuberculosis after menopause is about 65438 0%. Many cases of endometrial tuberculosis over 80 years old were reported, and the oldest patient was 88 years old.
16 especially suggests that active prevention and treatment of tuberculosis is of great significance to the prevention of genital tuberculosis. Its preventive measures are the same as tuberculosis. In addition to strengthening publicity and education on tuberculosis prevention, health care for children and adolescents should also be strengthened. Newborns weighing more than 2200g can be inoculated with BCG vaccine 24 hours after birth and replanted within 3 months if necessary. Babies of adolescent girls with negative tuberculin test after 3 months should be vaccinated with BCG. Pregnancy should be avoided during active pulmonary tuberculosis. In addition, there may be tuberculosis in the secretions and menstrual blood of patients with genital tuberculosis, so isolation should be strengthened to avoid infection.
The acupoint for treating endometrial tuberculosis is located at 1 ~ 2 inches. Straight stab 1 ~ 1.5 inch, with heavy feeling locally. Note: Patients with tuberculosis and ulcer and pregnant women are prohibited. Moxibustion: moxibustion is acceptable. Moxibustion 5 ~ ...
Hand deficiency refers to numbness, fatigue, cholera vomiting and diarrhea, fever in the chest, epilepsy, nosebleeds, endometritis and so on. Alias: yin deficiency of hand (classic acupuncture), yin deficiency. ...
Shaoyin refers to numbness, fatigue, cholera vomiting and diarrhea, chest fever, epilepsy, nosebleeds, endometritis and so on. Alias: yin deficiency of hand (classic acupuncture), yin deficiency. ...
Shoulder dysfunctional uterine bleeding, mammary gland hyperplasia, delayed delivery, postpartum blood halo, cervical lymph node tuberculosis, stroke hemiplegia, stiff neck, shoulder and back pain, hypertension, stroke, neurasthenia. ...
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