ࡱ> 5@ 0Wbjbj22 /`XX>>>>|j<Lz $L&L&L&L&L&L&L$ONRPTJLE @  JL>>L/#/#/# 6>R$L/# $L/#/#A#n|H"K ѕ?bI $LL0LIP!P@K>>>>PK  /#     JLJL$k"Esophagus - Mallory Weiss (Surical Recall) :   ,   ,        GE Junction        (               ).   ,  (20%)    Junction  5%   . : 1-15%    Upper GI.  :        "  .  :    (50%) -               50%    . *     ,      (   ADAM) :  ,  - ,    ()      (   ) : ,     :   Binge drinking  (  )        . :  (Lavage)    ! 90%   Electrocautery        .  :    -!      (     )       (      ) Leiomyoma      ,     .    :   Granular cell myoblastoma :     .    ( ):    ! ,  .  : ( )          !   .  -   :     CT  MRI      :     :   :   ,         " Thoracotomy + esophagotomy.   ():        !         "         . Esophagitis INFECTIOUS ESOPHAGITIS (MCCQE) o severe mucosal inflammation and ulceration (due to virus or fungus) o seen in diabetes, malignancy, and immunocompromised patients o symptoms: odynophagia, dysphagia o diagnosis: endoscopic visualization and biopsy o treatment: Candida (most common): nystatin swish and swallow, ketoconazole, fluconazole Herpes (second most common): often self-limiting, acyclovir CMV: IV gancyclovir CAUSTIC CHEMICAL INGESTION (First Principles of Gastroenterology) Strong acids or alkalis ingested accidentally or as a suicidal gesture cause marked esophagitis. Alkali tends to be more injurious to the esophageal mucosa than acid and produces liquefaction necrosis as well as thermal burns (due to heat release when the alkali is hydrated by gut secretions). Acids tend to produce superficial coagulation necrosis and eschar formation. Typically the patient develops: immediate chest pain and odynophagia. Oral burns also may produce local pain and drooling. There may be respiratory symptoms such as stridor, dyspnea and hoarseness if the airway is contaminated. Symptoms alone do not permit accurate prediction of the presence or absence of esophageal injury; therefore early diagnostic endoscopy should be considered in most patients. Clearly, endoscopy should not be performed if there is evidence of esophageal perforation. In the management of these patients, it is imperative to maintain: an adequate airway. Oral intake must be stopped and intravenous fluids administered. Empiric treatment: classically has involved antibiotics and corticosteroids, but there is no good evidence documenting the efficacy of this approach. Prognosis: Patients who survive the acute phase of the injury are at risk of developing strictures because of the intense collagen deposition associated with healing. This often requires repeated esophageal dilation to maintain luminal patency. Lye-induced (NaOH, KOH) injury increases the risk of developing squamous cell carcinoma of the esophagus. Typically there is a 30- to 50-year lag time before the development of cancer. For this reason any patient with previous lye injury and new esophageal symptoms should be promptly investigated. The extent of the risk is such that periodic endoscopic surveillance is not indicated. PILL-INDUCED ESOPHAGITIS (First Principles of Gastroenterology): A large number of oral agents can cause localized esophageal injury: The antibiotic doxycycline and the anticholinergic emepronium bromide are two of the most common culprits. NSAIDs drugs and slow-release forms of potassium chloride are also frequently implicated. History: Patients with this type of injury typically take their medication with a small amount of water and then immediately lie down to go to bed. They may then wake up several hours later with severe retrosternal chest pain and odynophagia. Capsules and tablets are notorious for being transported through the esophagus quite poorly unless adequate amounts of fluid are ingested at the same time. This is an important point to remember in counseling all patients who take medicines at bedtime. Rarely, the medication becomes lodged and causes a deep esophageal ulcer with perforation. More commonly the ulceration is superficial and heals in a few weeks. Late stricture formation may occur. Patients with esophageal motility disorders are particularly prone to this complication. Radiation-Induced Esophagitis (First Principles of Gastroenterology): When included in the field of irradiation the esophagus becomes inflamed in up to 80% of patients receiving therapeutic radiation for cancer. The risk of esophagitis is greater if there is concomitant chemotherapy. The patients typically develop chest pain, dysphagia and odynophagia shortly after the initiation of therapy. Z\fjr  8 * . @ L N T V X b d j z ̿zqhhbbh\h\bh\ h_H  h[Y_H hZ_H o(hlZ_H o( hl_H h[YZ_H o( h?d_H h?d5Z\_H o(h?dh?d5Z\_H o(h?dZ_H o(h?dh?dZ_H o(h5>*Z\_H o(hh5>*\jhUmHnHuhhCJ aJ hh5>*CJ \aJ $\ z b V J$ & F A$gdb $A$gdb $A$^gd- $A$gd- $A$gd ` $A$gd66 $A$gd[Y $A$gd?dTW , . 0 z J R T V h HJXżżul`lh- 5Z\_H o(h- Z_H o(h- >*Z_H o(h `h `>*Z_H o( h `_H h `6>*Z]_H o(h `6Z]_H o(h `>*Z_H o( h `Z_H h `Z_H o(h `h `Z_H o( h?d>*_H h?d>*Z_H o(jh66UZmHnHu h?d_H h?dZ_H o(#>@JLNPΫyk]L h_.CJZ_H aJnHo(tHh_.CJ_H aJnHtHhrCJ_H aJnHtH hrCJZ_H aJnHo(tH&hr5CJZ\_H aJnHo(tHhrZ_H nHo(tHhb_H nHo(tHh- _H nHo(tHhbZ_H nHo(tHhb_H nHtH hb_H hbZ_H o(h- >*Z_H o(h- Z_H o( h- _H @LPx>t> $A$gd_$ & F A$gd_$ & F A$gd3 $A$gd3$ & FA$gd3 $A$gd_. $A$gd4 $A$gdr$ & F A$gdb Pvx<>Xfrt̸~lUAU0 h%h3CJ_H aJnHtH&h%h_.CJZ_H aJnHo(tH,h%h35CJZ\_H aJnHo(tH#h%h3CJ_H aJnHo(tH#h%h3CJZ_H aJnHtH&h%h3CJZ_H aJnHo(tH&h%h35CJ\_H aJnHtH&h_h_.CJZ_H aJnHo(tHh_.Z_H nHo(tH h4CJZ_H aJnHo(tH)h_.5>*CJZ\_H aJnHo(tH>`HJxzűvvdS>űS)h_h35CJ\_H aJnHo(tH h_CJZ_H aJnHo(tH#h_h3CJZ_H aJnHtH#h_h3CJ_H aJnHo(tH#h_h3CJ_H aJnHo(tH,h_h35CJZ\_H aJnHo(tH&h_h3CJZ_H aJnHo(tH)h_h3>*CJZ_H aJnHo(tH#h%h3CJ_H aJnHo(tH&h%h3CJZ_H aJnHo(tH(4 .0n 7$8$H$gd#X $A$gd_.$ & F pA$gdgm$ & F pA$gd3$ & F A$gd3$ & F A$gd3 $A$gd3$ & F  A$gd3$ & F A$gd_ &(2 BDb"ٶٶǡُٶ{i{W{i{W#h_hgmCJ_H aJnHo(tH#h_hgmCJZ_H aJnHtH&h_hgmCJZ_H aJnHo(tH#h_h3CJZ_H aJnHtH)h_h3>*CJZ_H aJnHo(tH h_h3CJ_H aJnHtH#h_h3CJ_H aJnHo(tH&h_h3CJZ_H aJnHo(tH#h_h66CJ_H aJnHo(tH ,.0^ln|&ntxxxbbbO:)h_ha5>*CJOJPJQJ\^J%hHDha5>*CJOJQJ\^J*h_h#X5CJOJPJQJ\^JaJ-h_h#X5>*CJOJPJQJ\^JaJ$h_h#XCJOJPJQJ^JaJ!h4h#X5>*CJPJ\aJhah#X5>*PJ\)h_.5>*CJZ\_H aJnHo(tH)hr5>*CJZ\_H aJnHo(tH)h#Xh#X5>*CJ\_H aJnHtHxRld+y^ h & FgdHDgdHD & FgdHDgdagd$ 7$8$H$^gd#X 7$8$H$gd#Xcdj*+0xy]^к{a{aT;{{{{{0h_ha>*B*CJOJPJQJ^JaJphh_hHDCJPJaJ3h_ha5B*CJOJPJQJ\^JaJph-h_hHDB*CJOJPJQJ^JaJph-h_haB*CJOJPJQJ^JaJph!h4ha5>*CJPJ\aJ*h4h40J6CJOJQJ]^JaJ3h4h456>*CJOJPJQJ\]^JaJ)h456>*CJOJPJQJ\]^J  gh/:?N йййЬЬйВВЬyВlйS1h_hHDB*CJOJPJQJ^J_H aJphh_haCJPJaJ0h_hHD>*B*CJOJPJQJ^JaJph3h_ha5B*CJOJPJQJ\^JaJphh_hHDCJPJaJ-h_hHDB*CJOJPJQJ^JaJph-h_haB*CJOJPJQJ^JaJph0h_ha>*B*CJOJPJQJ^JaJph  !""U"""#a#R%%%q&s&&H''P_PPgd66 & Fgd66gd`/gd4gda hh^h`hgdHD & FgdHDgdHD & FgdHD !!!"""","-"."R"S"δs[E6h4h4CJPJ_H aJ*h4h40J6CJOJQJ]^JaJ/h4h456>*CJOJQJ\]^JaJ%h456>*CJOJQJ\]^J+hHDha56>*CJOJQJ\]^J/h_hHD56>*CJOJQJ\]^JaJh_haCJPJaJh_hHDCJPJaJ-h_haB*CJOJPJQJ^JaJph3h_ha5B*CJOJPJQJ\^JaJph S"T"U"y"""""""""""## ###?#`#a#h#εkTkkT:kkT3h_h`/5B*CJOJPJQJ\^JaJph-h_h66B*CJOJPJQJ^JaJph3h_ha5B*CJOJPJQJ\^JaJph-h_haB*CJOJPJQJ^JaJph0h_h`/>*B*CJOJPJQJ^JaJph0h_h66>*B*CJOJPJQJ^JaJph0h_ha>*B*CJOJPJQJ^JaJph h#Xha"h4h4CJPJZ_H aJo(h#j#Q%R%w%%%%%%&p&q&s&&&&&&ѫ{cM>h4h4CJPJ_H aJ*h4h40J6CJOJQJ]^JaJ/h4h456>*CJOJQJ\]^JaJ"h45;>*CJOJQJ\^J(h66ha5;>*CJOJQJ\^Jh#XhaPJh_haCJPJaJ0h_ha>*B*CJOJPJQJ^JaJph-h_haB*CJOJPJQJ^JaJph-h_h66B*CJOJPJQJ^JaJph&&&G'H'''(PP^P_PPPPPPPP̵̵̵̳̦|jR<*h4h40J6CJOJQJ]^JaJ/h4h456>*CJOJQJ\]^JaJ"h45;>*CJOJQJ\^J(hahHD5;>*CJOJQJ\^J)h#Xha5>*CJ\_H aJnHtHh_haCJPJaJU-h_h66B*CJOJPJQJ^JaJph-h_haB*CJOJPJQJ^JaJphh4h4CJaJ"h4h4CJPJZ_H aJo( This can be a serious problem in such patients, who are already often severely malnourished. Late stricture formation is a well-recognized complication. Esophagitis Associated with Immune-Mediated Disease (First Principles of Gastroenterology): Rarely, esophagitis can occur in association with Crohn's disease or Behet's syndrome. The typical lesion is scattered aphthous-type ulcerations, although severe transmural involvement with stricture formation can occur. The esophagus can also be severely involved in pemphigoid, in pemphigus and in epidermolysis bullosa. Esophagitis occurs in as many as one-third of patients who develop chronic graft-versus-host disease after bone marrow transplantation. The typical lesion is a generalized epithelial desquamation of the upper and middle esophagus. There may be associated ring-like narrowings or strictures due to submucosal fibrosis. A nonspecific esophageal motor disorder may also develop and result in superimposed reflux esophagitis because of poor esophageal clearing. Sarcoidosis and eosinophilic gastroenteritis are two other immune-mediated diseases that (rarely) cause esophageal inflammation.  INCLUDEPICTURE "http://a248.e.akamai.net/7/248/430/20031120121622/www.mercksource.com/ppdocs/us/cns/content/adam/images/ency/fullsize/18145.jpg" \* MERGEFORMATINET  The mucosal laceration of the Mallory-Weiss tear is probably better classified as a disorder of the stomach, because in most cases the laceration starts at the GE junction and extends down into the stomach. These patients present with hematemesis or melena following a bout of retching or vomiting. The bleeding usually stops spontaneously and only supportive therapy is required. If bleeding persists, endoscopically applied hemostasis or surgical intervention may be necessary. First Principles of Gastroenterology: The Basis of Disease and an Approach to Management, one of the leading books in the field. PPPUQQBR TTTTTT=U>UVVV!WWWgd ` [$\$gd ` $A$gd$gda $A$gda^gdHD & FgdHDgd4 $A$gdHDPPPP.Q5QAQIQ RRR#R+R@RRRTTTTTT9U:U;UU~sh`\`T`\jh66UhjhUhh5>*\h_haCJaJ#h_haCJZ_H aJnHtH,h_ha5>*CJZ\_H aJnHtH3h_hHD5B*CJOJPJQJ\^JaJph-h_hHDB*CJOJPJQJ^JaJph h#Xh4"h4h4CJPJZ_H aJo(h4h4CJPJ_H aJ>UVVVV!WJWyWWWWWWλhh5>*\h$hlh `h `CJOJQJ^JaJ$h `0J6CJOJQJ]^JaJ"h `h `0J6OJQJ]^Jh `B*OJQJ^Jph!h `h `B*OJQJ^Jph WWWWWgdagd `-&P 1:pS. A!"##$%(2vXDdt  S PA &18145Mallory-Weiss tearRW\ S4:WDFW\ S4:JFIFddDucky(!Adobed i9'Wo     $$''$$53335;;;;;;;;;;  %% ## ((%%((22022;;;;;;;;;;@"1 0!"24@#3PA5$B  !1AQa"2 qrBRb#30т@ᒲSsPC$4`cDd5!1 0@QaqA"2PBb!1AQaq 0@P P!&*Q.E}&'2b܎@ 7#BJ LA"fwhUqI[db˗OGGD_K<טK߅Q٨6 `(6 `(6 3SbKIw@WIЉ*IeSI!AEzc};Is6WZ!c?P"PPH2vdGBWw,_9I,YutyuB]GjjLH1ZP]_V61gA~NVYyHe󦕖h/P7 ql[Q?޹ʸY$M>ڠCcq'MM3L;WYWb!xs~sM9bX05X6U4-ZT{~/Ӟ֩oAfZh0*̝}w_kv')Zrx_Jh"IfDڦni4/ZTg}/J[ ̪ތCWޝizcێz|@TQ^n]2o_o˲/'h:D[0J:J:"[T:z!4%B.$s |hq "kD),۹9mAbLp|Y {>yQPzj^,hv'jZJ链q[WIv̘hF5'Ic^к|y<=>N~So2srn~GI4 __~z'׉MC~O-lM&'Sm^羅N[en^ccX3E$U)Row(nmUS?O" jS)-U8Y3cmcudf^羅sV›N۵Fid+&r"^ժf.dF)궛r4Rz<7]<WE*/G hVHbHG2Gxsl毪 l92Zs/,708Y r=AGQlgʺAvvC&bƑ6W{^$A,9X̴BD:fc:+%:q[)/pai)U giBF-Nίp-TgD*"tZb:GOWAXZahUVXZahUW;(܋Qm!E-֖kbvճ9.ʘ d!A!HtA!HtA! LHs"C; poa{OSڠe)%h;ts;;uxKppg,Sǧ8mq< =|t>2N/.4x<,]s`x0z`:5\/*A0p9gVu $tg9yL54rxyFt4/0_ rH^^q,>@瑯 0ώ3u>yƯy9`y>kGԾj9d^ FkRӀ::0zƕċ'ΣqN'Kxa$ q^')::)S0Hn ψ8ON1׀_f -FS3Lʍ[_N85\,Ӏ>.ׇϧ sIc4΢0Cd_T5Μzi#%(H  8s^QK!\6)׏8IHmpF7<YKry\$CBεδ"gv<&9տƄnwaȭE+y#>Lycϓ|ǟ&<1ɏ>Lycϓ|ǟ&<1ɏ#$7ўq^Mq}]16@Ȣ놚וUZj6-kuM!l<SZf].cigq$?'MdCҸ\1zzvvOyfŜ1FB@t/DOOM? dhO@A=AC#ZBAxZY'KI4>\~:k>,xhsF!c>:b@ kojv@ؙ}p Ǐ\nXއ{OZ5IcH)+n]|Xc8p3 iQG5>׎PدUTjW@VȖ"N= N0iz lW iMi𾘺UTlOhD|CS|.DyC**cXO &Y%f!0ڲ$23&kxX /V u=^S?cj}xVMmC݂$v0Lb8>dI7}w4V˔-Eh3f⦘}Y$bHC5>~8t΁^ ;$}Li,,i']Ɛm4m&, N5[U:LAqfP1 0؊|f:Řͮ/f$$ J#K§FI+Z(ҕQ^ը9=+Sw* 2bȮ鞙u o\W̓菗 EKgqҘ(OŽ~TPp5JrX)ۗpuijO ,I`ZN5d"HXe'Ir<e;m]°x$[U[8_CS۝}YUo\G˃G֯6-:5*Ԉ8$1T*RFXsª>ʬkȑI WAKRJPK3#,"h:N. V>p!y7 =f"fǼhwFn̐T嶗o~͛3ݑb66mV$T_"Qf6Nݧ0; ^,$d.IVlh:gs\ΥӨI͇鏖+ep[YvʒmI DY#}hb(6ڵVco6NĐQ\ s•I*_&Nd%YbU +S%W:%B "\fDkD}6owŞXlnV3Ṻ"micr%V9nPaۚ[v&LI!]w AuW)4$kr`E6dBt52V^ծ:tCf\Ќ +{lI9]V=MaJ,WWM Ovc,u+vjɷLT!hF4d=N"=u4F. HZ'b~ݷV+;nX֫:GguxY3ظ*KZ]0&C٨hlC&aOqC,`(54Aur6NQjf}Ӟ2ԟOZieXFyY -M.eKX`6]>͖(,ԉL\I4i=T#JMtmKʺdnG=u=J.ZKFԸ,"G$ WߑmȚߗI)ZkM sj rԍn 7b$O[ڧڹ$Fնks-^̗e٥&qsmN-Y6MOojbڮBTT$Mc*>URiZ6OjuuH}r]C/ {:]kמh֓pڗn=ꔆ}´RMAwX. >#Q4]bkKTZ7ylފ y4!c󏗀5.ح}iZP[JO-գmlfŖ`ձQ:L|Ϟ>z\=s|Ϟ>z\=riJ.;==5E5Υz6pmP,e9~\ i+Q~G*U5-Xɷm{tU+K6&%mK,ME5{yEVtmMK<0A|koTo?))_}n/K8FhP6-sMzczcǕ1yi|?tnp5 $[Dj5Qmx(@0@X>9Z)dODF1 tY{aę,>ѴK`.SnsN`3Al?KI 4 =@`>e ^RRlD*^*}+Nʦ//cq\Uq*\.>"U[d,w[wmw͆닄tʐ&ێ!<ײGY?٬Ook'5[-dfY?٬Ook'5[-dfY?٬Ook'5[!ou)\˥b,XtW|R/d01^unʃsjX{¿ُZ'GRI2h(zWG#ŔEs|Ʈ2?}ҭ} ي'h\XΙ{]*z[ RGbNE~u<9^l:a|g͟@B3wWv 2H [;[!?оn!;#џM-YՆg!ZN#s4MaD95$\'T28S5 >)󇲾 G:{3?!O'qa,')5 YlvIIW;+ XYPQ0BPJV:zW}̳UdӀOYǸ8B2RH ~2v7qӫ:} +bvIp4fiGO.u\4鵏* #7$G#GR׆(_ڀ%k{)iy8FED\T`kaaph &Zvg/WՈtmsMcRl❴7l BO?}?!DC鯶q1:FU$zEE_g:~+]%y>[IFC eCUXƲ<v  |ٛJ|5n~ o/p>LHzs7a_$=|8\0&#|6FE('ĸn@̰OI6 ~/61$„8'1u>d1c_e8ը)?b_^Vy15p8|(#>@8aRc|?%ךXgnXTλ.N%_rEZW&<ж=yd(ζ9/GX[$AOj>2RO8ŠmW" eC%0n:W&?fONG?ؗh!ps^&S~ +v[]Z27P`?FEǝZݞݹo>\ o<}T>w7 {ò69Rʸ,˓ 'V8P#+PύaXJ~8+yĿ>MQ~$׳IԜoaDwѕ[IcZ,1w#K%&V|х9B|yȽxO;gm<:iT+_ă<(z8elyS@,VG1W E,VoxUnUb=w;Im,_!xqZY7VGb_ &Y{F^z0U*Т1PƂ}D9F+Tdscz}1gmxaLXe8‰n8b莢x׺l :&ۋo04 jil!D;\\4Ywqx+O>Ȯ:A88M|\bb_ђK1>׺vBݱprnn=0xE޳^Mg~u!G35VoG|y0 q?εSFsU֟USrWjb{ 'n?^v`{L4?k2F{.;'|Zs^1ԧ":_cVQkϐ#VR>H> ; W+ŒO+CR>I޺ ^ m0,3J%`Oh{ޣ[\VΖvw!t "d|hc+Y\3sjnbBkĊ=R)ދ]X ۍҡWl3l4(}:­Xt_ $NUeYV]cɇ_`!oz{4Mv\tC3I|y p=U~33K NC6nfM 5\wQ(KIު&l^oD ŕiĻdOiuyfw^sXy]B8}#R n>k駔*F@ |u'o9jMėΎcZI*=D{f`99驧-{b)W1At @ ۵{Xr_`1Mzj:1+KtuW] c"Wް5/*=xQ\͹> a{ݮenvB7<'9D᩿sį(ጟ} ɹ%y'?lbƿwڳ 1EVg _V ·Rڐl3 !ly^IwF]ټE(A$`i #l4JV׵4r(4 ⽝Xʠʣ$q'݇87*`4OO¦ feYZwSV#+kp_,v;i5"¤~i}LQ$eW4Ž'C/MHS&0yׅ/#ʾ\eˢ aXaX0ODT_b1>j" [Jo ybWԺP띱zbiP=U F}è+yh *}bmDqMmLK36Zl(Jp beWΆHTj,jW$~g.#Q<" 8^Gn+KͯL}}֡WʱBa[cdxUGxi)`ÈCդ6Xr|֠ʛ`Ne[d٤}lFDlpF ,ru6xcX"q龦/r*./"Ǯ?:%xmt6>i4"uFr槪67ncCx֡hAEvM\W&V5nUч< 66yRX)H4$!fGt,aA[P]>ki#PF%#&bzqupUQj [!;6릆U2׎twg$aO*J7: qK3kJ#GG]Mm.FA‘Jb[RI=.&FXep|fU >X!cYW<=5/; YIȏTTH~1Ae#5=UvNʵ-I:]unU^z$sf(Tt O:t[W mA:x˭hQcQױx/'E]oڢY4d`,Bjn )q$1A|J.KyʓMbi pK0ZyD7TCF_9gHVЮ>Usoe&Wɇjv (ٯ6ݓQp5z.3*qV5uXT%xeԖMRUmgpZӇU"fuZy I `<{K#X+ G2jh74бcvljw+%EtK\DA&E8kbҦڀu{ E8o@aj_`3G ԍ6ӛm;|N0'4o=ιcFEy3,P?fI:d:ti8c_AXLh/)Շ]@;b}uø;xLF9W&" e[8W_bԤp*o6"RHLNRE_I?&x^(7Yݙt:$QE+"w@>jչNI4,B8clT2jѫf*M\HFPsH IkzYc"dVkSM)cSBuSy2lmnG }sbo2R3?FX.\IoSFDhbFLS!;][-$%MդV=Ƴ- RıQe7jq}mT4 .Ζh.jѧµ7Xg¶rK Τ6tGw![dno?oMJgy))6ަ*L^8*Gk*dXXC3&*κyasQ~guh/h0=&z$M7q,ptx:RG ϕnFp`XcI aʷv:n_FBUTak[~t1ǝC:Fì GE mί“)>گ“)>گ“)>گ“)>گ“)>گ“)>گ“)>گ“)>ک#aFOyMC\wM ^@: 6ERonn6邏)@xg_?R~Ŏ U Tb]VKC-k5ʂN(wf'cv!;v|C_!kuTIK6h!5 3y7H:Ř'jK4O(lֹ?bEtW+[xnTZF6ϪqmԱ#NuDċY-}WZwo N6TfúX^EE.u"(N ,EsXf92a04!pX_?SРBk KgBT?}4y1 DSr!9eGla :ba:OqIL}љa^}1W,IB > Ov?ׄ']y:0 \<ҵ5F:tD{&Eu..4^J[՟s or55bƞxG XGEߘțGT~AD~x]-=O\0\>m]3 G,} FR7-똜T`IbUP ۸#K+DI :N?:T-fgknR݊sM<]Xn]c]fCG3<(\";OQʧYQ'm8>"@}4v`5yބuѥܵu_E10{߸JQ1y:3Ĥ^%-).18C̗P6^ #!ɧ2CqD) g\WQh}U,1*~W޸[ p9q\QQfŧX1ĵ}@_so2JjǼqL蟓 IW?ւH˼A9\WBK: }/͔ZV(uv29vj+`w6QزνT[!W?i6 7ӏx 5ZM+~Cpvߙ@d. y%FD2KN7:{]4I}wnS7/`7mb@,i6 :8ah K6" bL0`kw")4I [ʡ1hmflgW&[ Dvǣozׯ^zׯ^zA!U]C׸ڵ#/BS|Cl44^a3R醴X~SAĠ)Ϙ@/94|˟2E)gR},'G%&-37r.%ߧ ]z:7G,u]YS nKw!GQYSڼ P#(TDZ:*.pAFqD;_ߒF3 N, Xݞ(2hzEYK ;Jt?\/ +pG~2`((GvY)HW05#X]ܪ Y(:SKn`^mꩨ<{6 @rg@b1_*/ElXtЛL@:;Qm#H3:p)\gyd -YwȂo\l6Dk"л`PKQWT d+֭b:nAQ . J;ӵ):{C SO'x!*CUX4f8@T"E%Ǣۑ`<<aK䕦Ʒ1ݑ)\J#UcYnQ|BNg/ PXG%gX9lP %t<%v.7]LB\UIsua(%8[0}[jRŊ[. lϵR *fXPXSv'@ڱ3.QL;f)iȍJT6ҳ7NF{ELldFʕDꯖ]Fkp>\A $te8J::W 2*pH 0 yk*`츗{`b磣}^QsUԙ)K.Ŀf9pEBh{?a= DqnvC`,4Z]O@=5)#GJE56c~m ĢVԄcf cywQ'+g?etaY18"OЙSo'AYT'5(_0> K!\Ml`s+],e<GAkXDdE'MP / F?&= vt/9QJ" ">8Xklr.~c`S٘,cPih}5;̞&@~Yym\KPFYEH,320m4FM庼 "܂Ds, CυÒ\j ^9 /Y Wylo?VLP_hbAOaprR%9)\zF2u |y ]#4 DQ\OAӱDTI"ԔES|Fh "'Ӄp{L]zv&p$ F7^1ohVeX~uWox92u>\.]BB1vk>bNcRnq{O2ZMdp((DO k3 u ~yKwBucqC bt)]!j=WI|LQ-l|'.j[jִ~sKוԍ wau?Vma( YV̩@߷X唃2#Pe9 ?d :mYbm-;=C`P<`ޛ9~^rp;KgE*b[fM|#_ōuVnh,n;Ev#ޙkeNXH<23v([Qb`fGO.|9 >a`->KnbX{ݦ{-z,`*hFg'v$\OQ) ׮ʧ2:7^)9XP@;{%A̶? y+U-5 =~{#u{1vy˃"/`.9Z{ !U͔6.6 t;Cov99Y"<J˷+~`Vk)u-c)LKȽʉw@`ur"QgCahi:wO_pMtwҥX9#in88_9C#aWXY̿z4s)C3==w_-;+]XU)HXjjbĦ`? !} Eg%e pYg\P|^ߙP[s- |űeSnUEZ..RX׉fUa}V` |1PwJM$Yp{*0!wrLF`Ɩpf3Gȼf-"сET-7lbf/DM [1pȼ0?|5Wel!%a“D:ɑ>i5:[t)kWD鏞倦9nc2,~BfE5yxO,uNFqYS"d[I/Ժb[YGK MbM1>`L x=MJRDzAUP 2WK7 'X*T(c3pFr|{<*ΰ BK,x4VH Pkn]$8n 7$ S7P%4#je.P!",ū ޲Ƣ"bX{`ڻs8#Ц_A@ACH 8>fID__uG& Ou43} nj#dro_~?YlDw 8fƳ3wx }^` jnAH-5u9{# ৸--$# ]'YMi~y]ȹYx=sIu>X99䘬(b[!aڶ l`:-eɜALN* b8:!bkhZ#Gkp[ޔ(] DΒ$7Văap5ÝZ[qA6 ixO|CYڳ vaˮLt ;rHx5٣Aa]uRF֊7o aڲ'Q%aIR* gHﶜJP|busTP`\CQ Ί\2IgIճzd$V@Xrm( Z;[KQ0 ;-7FpQ|.fG{2E-o\xFYm-GIE0vXq.Fh /24}2#E%u̝͞'n֎َ@26ug=03恸,lz!Ϡ5=X ؕ)eLãDꫲ [q1ZAl,'u4йB&US:'d{|UCvF}\`l(JwI0ںu/vcxY'.OR)4T8VW~y%[k5tD(is;@mxǐW)z:C+_޸F|_xM@fNy {P^LqR/&bXaԝP6-/ U-Ya`=?)z8D)fX˹A,(:c;{7:?5f8^9BH(8@s6rDD ꌴvs-N KB{LKUR-6qm_wc?-{_=n|͌js`buDuN~Ut(Y2 0%ZG/:eOL*ԡ-|0 Ɋc,rm%"4pof-vx1Öm(xlXۋuTc1{и"PzO3q,VECX P(ʡ֌:˃ 91)ȅk !W0Ïi_4B7 xM0셰UO! 캍:ͻ&Boppމs\pćV&]5+/F!`DO9*Yk.&|.R NpWj(͵sW1V,f†y3^cI.ɓTF4Ɓ=qh! 3Ω[ʳ`9ڋSN\.F?NrQyè5YqNo vv4K'0oG+KqFQ9(5qee~&RpP4h/f6PX-&ݶkF~ jP7k(n՝*ÔϥHttvr% 8o;'(1 YC/eY$nSJ.0fcU9+~<"xm[4a,@QmZA2;ův{5Nx3Z/M x; &t ¸Axź"5uC4Ʊ VP.+AfmUb ]gh?ej˜`%ΆDc')aXl,HLJgx _[ +,jE]hj\1e [jp\K낵zN[|ńD t0cM[7a%]7.;#:q+S2-1xxeG vb7MN"~1p IO*15ȼTpˠ;iKB1r.DuSt5ܐVPFT.JD" ǘ`,4]Ƈ&Дѥ'Q2̈YQKZ&Fqp2 nFM0 zLMW-V%VYtԎuLM yDSNF`C8NԠ$,ЩU@a2S+"Bc_ϕQfwڶEUS:$ %ĤZ[pg'#мl\Qn8tCJ%1mY)F" !]h-xFWcj0ʄ*`=PÿI1'aҭI(^09S|bRx&ru]IkK9:+ {K> x@s~Ϡf^yGf 2uT vK(ك,vUqfc!< P٧QZ ՟P J%YKYX? DK+Iكp'A1Ktf 4n1PQSikWy KLN@Z˅:%eoA4n6U]a.*/27suk1čsjS!> c{C6uҷuS?f ЃkI@Elؑ`>,,,,+ʪ1GV[?ĢQqyh+WXg j1l]@=ڝڝڝڝڝڝڝڝڝڝڝڝڝڝڌ]J("[jSeݲh}2U8: l.7[N.#+vYVx4l^m[!000000000000000 0 0 0 00000 0 0 00 0 00 0 0 00 0 0 0 0 0 0 0p000000000000@00p@0p@ 0p@ 0p@0p@0p@0@0p@0@0@0p@ 0p@ 0@ 0@ 0@0@ 0@ 0@0@0p@0@0@ 0@ 0p@ 0@0p@0@0@0p@0p0@0@0p@0p@0p@0p@0p0p 0@0p@ 0p@ 0p@ 0p@0p@0p00p00000000000.CR l  Uqs_B >!O9000mO900@mO900@O900O900O900Oy0 0O90 0Oy0 0@cOy0 0Oy0 0Oy0 0Oy0 0Oy0 0Oy00@@dOy00Oy00Oy0 0Oy00@HOy00Oy00Oy0 0Oy0 0@cOy0 0Oy0 0Oy00O900@O900L@0@0@0 0T> P S"h#&P>UW !#$%&-.PWW",/WC8@z(  N  3    3 @. TTTT"` B S  ?xb| TP[g@pilltrauma>U%.359:de} "&,135>BFMPXY]_ny03<>WZ#%*,OP_aq   BCMOhj349:NQYZ\juw~$&=>OQVWfitu!#./1<?KMZ\gj  6 > R ^ ` k W b f l  % ' .    +7GRT_.5AIu} #+89@BMKUku*+6:@ .OPwy03WX$%OP  BC9:vwPQhituLMij 78}~  6 D R ^ J O GJ33333333333333 x   QMj   OPgi   UUss<>Niva c- R^Wd *D> ;6 VA(vx5 ZP.Al4N,@gR68[NvKT~qUJUnoi~Th^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh  ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh| | ^| `OJQJo(hHhLL^L`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh| | ^| `OJQJo(hHhLL^L`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH VA(c- noRWd qUNvKTi~ZP.Ax54N> ;                                                                                                                      _x%_.`/3HD@HS[Y `?d hgmc66#4l$#X5Na7- br@wlێvv@{@ PPPP4@P@UnknownGz Times New Roman5Symbol3& z ArialG  MS Mincho-3 fg?5 z Courier New;Wingdings"qh1|f|f v2v2!24 3Q H ?5N Esophagus - NivaNiva@         Oh+'0p  , 8 DPX`hEsophagus - osopNivaaguivaivaNormaluNivalu12aMicrosoft Word 10.0@Ff@@γv՜.+,0 hp|  AAA2 Esophagus - Title  !"#$%&'()*+,-./023456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FvߕData 1vX1Table^5QWordDocument/`SummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q