潰瘍性結(jié)腸炎診治全集課件

Introduction

IBD是一種病因尚不十分清楚的慢性非特異性腸道炎癥，包括UC和CD

。其發(fā)病率呈逐年上升趨勢(shì)，且多為青壯年發(fā)病，臨床表現(xiàn)復(fù)雜，并發(fā)癥嚴(yán)重，腸外表現(xiàn)多樣，嚴(yán)重影響個(gè)人生活質(zhì)量和社會(huì)生產(chǎn)力。此外，因其有癌變的風(fēng)險(xiǎn)，備受廣大醫(yī)生的重視。近年來(lái)在國(guó)內(nèi)外IBD基礎(chǔ)與臨床研究高潮迭起，基礎(chǔ)研究的成果直接指向臨床治療，取得了劃時(shí)代的進(jìn)展。探討和摸索適合國(guó)人的治療方案以降低重癥UC的并發(fā)癥和死亡率顯得十分重要。Introduction

IBD是一種病因尚不十分清楚的慢Introduction

Ulcerativecolitisischaracterizedbymucosalinflammation

ofthecolon.Thepathologyisinflammatoryandthe

diseasecourseisrelapsingandremittingwithintermittent

symptomsofrectalbleedinganddiarrhea.Approximately

25%ofpatientsdevelopachronicactiveorarapidlyfulminate

diseasecourse.Chronicinflammationcanleadto

dysplasiaandcancer.Approximately20%ofpatientsrequire

colectomywithileoanalpouchorstoma.VelayosFS,TerdimanJP,WalshJM.Effectof5-aminosalicylate

useoncolorectalcanceranddysplasiarisk:asystematicreview

andmetaanalysisofobservationalstudies.AmJGastroenterol

2005;100:1345–1353.Introduction

UlcerativecolitConsensusStangeEF,TravisSP,VermeireS,ReinischW,GeboesK,BarakauskieneA,etal.Europeanevidence-basedConsensusonthediagnosisandmanagementofulcerativecolitis:definitionsanddiagnosis.JCrohnsColitis2008;2:1–23.VanAsscheG，DignassA，PanesJ，eta1．ThesecondEuropeanevidence-basedConsensusonthediagnosisandmanagementofulcerativecolitis：Definitionsanddiagnosis．JCrohnsColitis，2010·4：727．MowatC,ColeA,WindsorA,AhmadT,ArnottI,DriscollR,etal.Guidelinesforthemanagementofinflammatoryboweldiseaseinadults.Gut2011;60:571–607.TurnerD,LevineA,EscherJC,GriffithsAM,RussellRK,DignassA,etal.Managementofpediatriculcerativecolitis:ajointECCOandESPGHANevidence-basedconsensusguidelines.JPediatrGastroenterolNutr2012.TurnerD,TravisSP,GriffithsAM,RuemmeleFM,LevineA,BenchimolEI,etal.Consensusformanagingacutesevereulcerativecolitisinchildren:asystematicreviewandjointstatementfromECCO,ESPGHAN,andthePortoIBDWorkingGroupofESPGHAN.AmJGastroenterol2011;106:574–88.ConsensusStangeEF,TravisSP,Endoscopicscores(UCEIS)Cortisoneinulcerativecolitis.(4)初發(fā)病例如I臨床表現(xiàn)、結(jié)腸鏡及活檢組織學(xué)改變不典型者，暫不確診UC，應(yīng)予隨訪(follow-up)。TreatmentgoalsBackground&Aims:Thisretrospectivestudyanalyzedtheclinicalcharacteristicsofhospitalizedpatientswithulcerativecolitis(UC)inChina.常有流行病學(xué)特點(diǎn)(如不潔食物史或疫區(qū)接觸史)，急性起病常伴發(fā)熱和腹痛，具自限性(病程一般數(shù)天至1周，不超過(guò)6周)；慢性持續(xù)活動(dòng)或反復(fù)發(fā)作頻繁者，預(yù)后較差。FidderH．SchnitzlerF，RutgeertsP，eta1．Long—termsafetyofinflixjmabforthetreatmentofinflammatoryboweIdisease：asinglecentercohortstudy．Gut．2009，58(4)：50l-508．4．其他：腸結(jié)核、真菌性腸炎、抗生素相關(guān)性腸炎(包括假膜性腸炎)、缺血性結(jié)腸炎、放射性腸炎、嗜酸粒細(xì)胞性腸炎、過(guò)敏性紫癜、膠原性結(jié)腸炎、白塞病、結(jié)腸息肉病、結(jié)腸憩室炎以及人類(lèi)免疫缺陷病毒(HIV)感染合并的結(jié)腸病變應(yīng)與本病鑒別。IntheHTgroup,20.ExperienceofmaintenanceinfliximabtherapyforrefractoryulcerativecolitisfromsixcentersinEngland.BaronendoscopicscoresLoftusCG，LoftusEVJr，SandbornWJ．Cyclosporinforrefractoryulcerativecolitis．GUt．2003，52;172—173．ChinJGastroenterolHepatol.Gut1996;39:690-697.Managementconsensusofinflammatoryboweldiseasefor

theAsia–Pacificregion2006

Abstract:Atthepresenttherearenolarge-scaleepidemiologicdataoninflammatoryboweldisease(IBD)intheAsia–Pacificregion,butseveralstudieshaveshownanincreasedincidenceandprevalenceofIBDinthisregion.ComparedtotheWest,thereappearstoexistatimelagphenomenon.WithregardtothetwomainformsofIBD,ulcerativecolitis(UC)ismoreprevalentthanCrohn’sdisease(CD).Inadditiontogeographicdifferences,ethnicdifferenceshavebeenobservedinthemultiracialAsiancountries.Moreover,thegeneticbackgroundsaredifferentintheAsiancomparedtoWesternpatients.Forinstance,NOD2/CARD15variantshavenotbeenfoundinAsianCDpatients.Ingeneral,theclinicalcourseofIBDseemstobelesssevereintheAsia–PacificregionthaninWesterncountries.DiagnosisofIBDinthisregionposesspecialproblems.ThelackofagoldstandardforthediagnosisofIBD,andtheexistenceofavarietyofinfectiousenterocolitiswithsimilarmanifestationstothoseofIBDmakethedifferentialdiagnosisparticularlydifficult.Sofar,WesterndiagnosticcriteriahavebeenintroducedforthediagnosisofIBD.Astepwiseapproachtoexcludenon-IBDenterocolitisalsomustbeintroduced,andadefinitediagnosismustincludetypicalhistologicalfeatures.Insomepatients,followupandtherapeutictrialsmightbenecessarytoobtainadefinitivediagnosis.AbetterunderstandingofthepathogenesisofIBDwillallowthedevelopmentofbetterdiagnosticmarkers.ThemanagementofIBDalsoposessomespecialproblemsintheAsia–PacificRegion.ThereisoftenadelayinusingpropermedicationsforIBD,andalternativelocalremediesarestillwidelyused.WithacombinationofWesternguidelinesandregionalexperiences,similarprinciplescanbeusedforinductionandmaintenanceofremission.Astepwiseselectionofmedicationsisadvocateddependingontheextent,activityandseverityofthedisease.ComprehensiveandindividualizedapproachesaresuggestedfordifferentIBDpatients.DeeperunderstandingofdiseasepathogenesisandtheuniquecharacteristicsofIBDintheAsia–Pacificregion,combinedwithreasonableandpracticalguidelinesfordrugmanagementandthefutureuseofbiologicalagentswouldimprovethetherapeuticoutlookofIBDinthisregion.Endoscopicscores(UCEIS)ManaTheAsia-Pacificconsensusonulcerativecolitis2010

TheAsia-PacificconsensusonEuropeanevidence-basedconsensusonthediagnosis/managementofulcerativecolitis2008ThisdocumentsetsoutthecurrentEuropeanConsensusonthediagnosisandmanagementofUC,reachedbytheEuropeanCrohn'sandColitisOrganisation(ECCO)atameetingheldinBerlinon20thOctober2006.ECCOisaforumforspecialistsininflammatoryboweldiseasefrom23Europeancountries.LiketheinitialConsensusonthemanagementofCrohn'sdisease,thecurrentConsensusisgroupedintothreeparts:definitionsanddiagnosis;currentmanagement;andmanagementofspecialsituations.Thisfirstsectionconcernsaims,methodsanddefinitionsoftheConsensus,aswellasclassification,diagnosis,imagingandpathologyofUC.Thesecondsectiononcurrentmanagementincludestreatmentofactivedisease,maintenanceofmedically-inducedremissionandsurgeryofUC.Thethirdsectiononspecialsituationsincludespouchdisorders,cancersurveillance,pregnancy,paediatrics,psychosomatics,extra-intestinalmanifestationsandalternativetherapy.Europeanevidence-basedconsen2ndEuropeanevidence-basedconsensusonthediagnosis/managementofulcerativecolitis2012ThisdocumentupdatesthepreviousEuropeanConsensusonthediagnosisandmanagementofUC,andwasfinalisedbytheEuropeanCrohn'sandColitisOrganisation(ECCO)atameetingheldinDublininFebruary2011.ECCOisaforumforspecialistsininflammatoryboweldiseasefrom31Europeancountries.LiketheinitialConsensusonthediagnosisandmanagementofulcerativecolitis,6–8thisupdatedConsensusisgroupedintothreeparts:definitionsanddiagnosis;currentmanagement;andmanagementofspecialsituations.Previouslyincludedchaptersonpregnancyandpediatricsarenolongerincludedinthisguideline,asspecificECCOConsensusGuidelinesonReproductionandPregnancyandPediatricUC(togetherwithESPGHAN)coverthesetopicsextensively.2ndEuropeanevidence-basedcoBackground

潰瘍性結(jié)腸炎（UC）1859年由Wilks首先描述，1920年被醫(yī)學(xué)界公認(rèn)，我國(guó)于1956年首次報(bào)道?！短匕l(fā)性潰瘍性結(jié)腸炎診斷及治療標(biāo)準(zhǔn)（草案）》（1978年杭州）《潰瘍性結(jié)腸炎的診斷及療效標(biāo)準(zhǔn)》（1993年太原）《對(duì)潰瘍性結(jié)腸炎診斷治療規(guī)范的建議》（2000年杭州）《對(duì)我國(guó)炎癥性腸病診斷治療規(guī)范的共識(shí)意見(jiàn)》（2007年濟(jì)南）《炎癥性腸病診斷與治療的共識(shí)意見(jiàn)》（2012年廣州）從中可以看出每一次補(bǔ)充和修改都反映了我國(guó)對(duì)該病認(rèn)識(shí)的逐步提高，治療逐漸規(guī)范化。Background

潰瘍性結(jié)腸炎（UC）1859年由Wil第九屆中華消化病學(xué)分會(huì)炎癥性腸病學(xué)組成員名單

名譽(yù)組長(zhǎng)：歐陽(yáng)欽

組長(zhǎng)：胡品津

副組長(zhǎng)：錢(qián)家嗚夏冰吳開(kāi)春冉志華

秘書(shū)：王玉芳高翔

核心成員：胡品津歐陽(yáng)欽鄭家駒錢(qián)家嗚夏冰

吳開(kāi)春冉志華劉占舉鐘捷吳小平

陳旻湖胡仁偉

組員：歐陽(yáng)欽鄭家駒鄧長(zhǎng)生劉新光胡品津

錢(qián)家鳴夏冰吳開(kāi)春李俊霞呂愈敏

顧芳劉玉蘭王曉娣韓英朱峰

冉志華劉占舉鄭萍鐘捷龐智

曹茜陳旻湖智發(fā)朝姜泊張亞歷

鐘英強(qiáng)沙衛(wèi)紅胡仁偉王玉芳甘華田

鄒開(kāi)芳吳小平繆應(yīng)蕾江學(xué)良于成功

梅俏王承黨郭長(zhǎng)存盧雪峰高翔

霍麗娟第九屆中華消化病學(xué)分會(huì)炎癥性腸病學(xué)組成員名單

名譽(yù)組長(zhǎng)：歐UlcerativecolitisinChina:Retrospectiveanalysisof3100

hospitalizedpatientsBackground&Aims:Thisretrospectivestudyanalyzedtheclinicalcharacteristicsofhospitalizedpatientswithulcerativecolitis(UC)inChina.Methods:Atotalof3100hospitalizedpatientswithUCadmittedto23hospitalsinChinafrom1990to2003wereretrospectivelyinvestigatedandtheirclinicalcharacteristicswereanalyzed.Results:Amale/femaleratioof1.34/1.00wasfoundinthe3100patients,whohadanaverageageof4415.1yearsatdiagnosis.Ofthepatients,2972(95.9%)hadactiveUC.ActiveUCwasmildin35.4%ofthe2972patients,moderatein42.9%andseverein21.7%.Ofthe2726patientswithadescriptionoftheirlesionextent,14.8%hadproctitis,26.4%hadproctosigmoiditis,25.0%hadleft-sidedcolitis,6.3%hadextensivecolitis,25.8%hadpancolitisand1.7%hadregionalcolitis.ThepredominantcomplaintsofthepatientswithUCwerebloodydiarrhea(48.2%),abdominalpain(67.3%)andmucusstools(58.4%).Amongthesepatients,13.6%hadextraintestinalmanifestationsand9.6%hadrelatedcomplications.Adifferentialdiagnosiswasdifficulttomake,astherewere19varietiesofthedisease;infectiousenterocolitishadamisdiagnosisrateof22.9%beforeadmission.ThemainmedicationsforUCinChinawereaminosalicylates(66.8%)andsteroids(42.8%).Only94(3%)ofthepatientsrequiredcolectomyandonly19(0.6%)diedofUC.Conclusions:ComparedwithUCinWesterncountries,ulcerativecolitisinChinahassomedifferencesinclinicalcharacteristics.Therefore,afurtherpopulation-basedepidemiologicalstudyisrequiredtodeterminetheprevalenceandincidenceratesofUCinChina.OuyangQ．APDW2004ChineseIBDworkinggroup．JGastroenterolHepatol.2007．UlcerativecolitisinChina:REpidemiolgyTheincidenceofUCrangedfrom1.0to2.0per100000personyears.TheprevalenceofUChasrangedfrom4.0to44.3per100000.Inarecentstudy,thespeculatedprevalencewas11.6/100000inChina.ComparedtotimetrendsintheWest,thereappearstobeatimelagphenomenoninvolvingincidenceandandprevalenceofIBDwithregardtotheAsianexperience.OuyangQ,TandonR,GohKLetal.Managementconsensusof

inflammatoryboweldiseasefortheAsia-Pacificregion.J

Gastroenterol.Hepatol.2006;21:1772–82.Lennrd-JonesJE.IncidenceofinfammatoryboweldiseaseacrossEurope:isthereadifferencebetweennorthandsouth?.Gut1996;39:690-697.EpidemiolgyTheincidenceofUCEtiologyandPathogenesis目前對(duì)IBD病因和發(fā)病機(jī)制的認(rèn)識(shí)可概括為：環(huán)境因素作用于遺傳易感者，在腸道菌群叢的參與下，啟動(dòng)了腸道免疫系統(tǒng)及非免疫系統(tǒng)，最終導(dǎo)致免疫反應(yīng)和炎癥過(guò)程。可能是由于抗原的持續(xù)刺激或（及）免疫調(diào)節(jié)紊亂，這種免疫炎癥反應(yīng)表現(xiàn)為過(guò)度亢進(jìn)或難于自限。BaumgartDC,CardingSR.Inflammatoryboweldisease:causeandimmunobiology.Lancet2007;369:1627–1640.BrownSJ，MayerI．Theimmuneresponseininflammatoryboweldisease．AmJGastroenterol，2007，102：2058—2069．BernsteinCN，ShanahanF．Disordersofamodernlifestylelreconcilingtheepidemiologyofinflammatoryboweldiseases．Gut，2008，57：1185-1191．EtiologyandPathogenesis目前對(duì)IB菌群失調(diào)IBD患者腸遭細(xì)菌存在菌群失調(diào)，正常細(xì)菌數(shù)量減少，而致病菌、條件致病菌數(shù)量明顯增多。Duchmann等發(fā)現(xiàn)。正常人對(duì)其體內(nèi)腸道菌群及抗原物質(zhì)耐受，而IBD患者腸黏膜免疫細(xì)胞對(duì)失調(diào)的腸道菌群及抗原物質(zhì)失去了耐受。這一發(fā)現(xiàn)證實(shí)了IBD患者腸道菌群及抗原物質(zhì)能誘導(dǎo)腸黏膜異常免疫反應(yīng)。Frank等發(fā)現(xiàn)IBD患者腸道菌群中擬桿菌、厚壁菌類(lèi)減少，而變形桿菌及放線菌等增多。由于在腸道內(nèi)，擬桿菌、厚壁菌是主要的裂解食物纖維產(chǎn)生丁酸鹽和其他短鏈脂肪酸的細(xì)菌，這些細(xì)菌數(shù)量減少，導(dǎo)致維持腸上皮細(xì)胞生長(zhǎng)和代謝的丁酸鹽和其他短鏈脂肪酸等營(yíng)養(yǎng)物質(zhì)減少。同時(shí)。潰瘍性結(jié)腸炎患者腸道內(nèi)產(chǎn)硫化氫的細(xì)菌增多，硫化氫具有抑制丁酸鹽和其他短鏈脂肪酸等營(yíng)養(yǎng)物質(zhì)生存．及直接影響腸上皮細(xì)胞新陳代謝的功能。上述細(xì)菌菌群失調(diào)導(dǎo)致腸上皮細(xì)胞營(yíng)養(yǎng)缺乏，影響了腸黏膜屏障功能。DuchmannR。KaiserI，HermannE，eta1．Toleranceexiststowardsresidentintestinalflorabutisbrokeninactiveinflammatoryboweldisease(IBD)．ClinExpImmunol，1995．102：448—455．FrankDN，StAmandAL，F(xiàn)eldmanRA，eta1．Molecularphylogeneticcharacterizationofmicrobialcommunityimbalancesinhumaninflammatoryboweldiseases．ProcNatlAcadSciUSA，2007，104：13780—13785．菌群失調(diào)IBD患者腸遭細(xì)菌存在菌群失調(diào)，正常細(xì)菌數(shù)量減少，而FamilyhistoryKitahoraetal.foundastrongfamilialoccurrenceinUCamongJapanesepatients.InaKoreanstudy,asimilarfamilialaggregationwasalsoreported.KitahoraT,UtsunomiyaT,YokotaA.EpidemiologicalstudyofulcerativecolitisinJapan:incidenceandfamilialoccurrence.TheEpidemiologyGroupoftheResearchCommitteeofInflammatoryBowelDiseaseinJapan.J.Gastroenterol.1995;30(Suppl.8):5–8.ParkER,YangSK,MyungSJetal.FamilialoccurrenceofulcerativecolitisinKorea.KoreanJ.Gastroenterol.2000;36:770–4.FamilyhistoryKitahoraetal.RiskfactorsObjectiveToscreentheriskfactorsofinflammatoryboweldisease(IBD)bycaseinvestigation．Methords72determinedIBDpatientsand72pairedhealthysubjectsweresurveyedwithanorganizedinventorycomprisingofrelevantitemstoIBD．COXregressionmethodwasusedtoscreenthestatisticallysignificantriskfactorsforIBD．ResultsCOXregressionindicatedthestatisticalsignificanceinstress．milkandfriedfoodovertheotherpostulatedriskfactorsforIBD．ConclusionStress，milkandfriedfoodarethepotentialriskfactorsforIBD．KaichunWuetal.Investigationontheriskfactorsofinflammatoryboweldisease：Apairedstudyof72cases.ChinJGastroenterolHepatol.2006,15(2):161-162RiskfactorsObjectiveToscreeProtectivefactorsAstudyfromJapanfoundaprotectiveeffectofsmokingforUC.Nametal.foundthatappendectomywasprotectiveagainstUCintheirgroupofKoreanpatients.Acase-controlstudyofulcerativecolitisinrelationtodietaryandotherfactorsinJapan.TheEpidemiologyGroupoftheResearchCommitteeofInflammatoryBowelDiseaseinJapan.JGastroenterol.1995;30(Suppl.8):9–12.NamSW,YangSK,JungHYetal.Appendectomyandtheriskofdevelopingulcerativecolitis:resultsaftercontrolofsmokingfactor.KoreanJ.Gastroenterol.1998;32:55–60.VleggaarFP,LutgensMW,ClaessenMM.Reviewarticle:the

relevanceofsurveillanceendoscopyinlong-lastinginflammatory

boweldisease.Aliment.Pharmacol.Ther.2007;26(Suppl.2):

47–52.ProtectivefactorsAstudyfromClinicalPresentationIntestinalSymptoms70%ofpatientswithUCreport>5bowelmovementsduringacutephases.Themainreason

fordiarrheaiscolonicinflammation,butbileacidand

foodmalabsorptionsecondarytoinflammationinthe

terminalileumortheproximalsmallbowelcancontribute

tothissymptom.Ahistoryofsurgicalresectionscan

beseminalinexplainingsymptoms.AcutephasesofUC

almostalwayspresentwithbloodydiarrhea(“hematochezia”).Activeinflammatoryanorectallesions

resultinurgencyofdefecationandcrampsarounddefecation

(“tenesmus”).UCpatientsoftencomplainof

lowerleftquadrantpain.ExtraintestinalManifestationsWafikEl-DieryandDavidMetz,SectionEditors．DiagnosticsofInflammatoryBowelDisease．Gastroenterology，2007;133:1670–1689．ClinicalPresentationIntestina腸外表現(xiàn)(Extraintestinal

manifestations)腸外表現(xiàn)包括：皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)關(guān)節(jié)損害(如外周關(guān)節(jié)炎、脊柱關(guān)節(jié)炎等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

Crohn’sdiseaseandulcerativecolitis.Med.Clin.(Barc.)2005;125:

297–300.腸外表現(xiàn)(Extraintestinalmanifesta巨細(xì)胞病毒(CMV)屬皰疹病毒科B屬雙鏈DNA病毒，近年隨著IBD與CMV研究的深入，發(fā)現(xiàn)CMV在IBD的發(fā)生和疾病進(jìn)展中起一定作用，且對(duì)IBD的臨床診治亦有一定指導(dǎo)價(jià)值。LawranceIC,MurrayK,HallA,SungJJ,LeongR.Introduction《對(duì)潰瘍性結(jié)腸炎診斷治療規(guī)范的建議》（2000年杭州）0%hadleft-sidedcolitis,6.StangeEF，TravisSP，VermeireS，etal，Europeanevidence-basedConsensusonthediagnosisandmanagementofulcerativecolitis：definitionsanddiagnosis．JCrohnsColitis，2008，2：1—23．結(jié)果：患者尿白蛋白活動(dòng)期比緩解期明顯增高（0.AnderssonP,SoderholrnJD.Infliximabasrescuetherapyinseveretomoderatelysevereulcerativecolitis:arandomized,placebo-controlledstudy.借鑒風(fēng)濕免疫性疾病(如類(lèi)風(fēng)濕關(guān)節(jié)炎)的治療和腫瘤化療的理念與實(shí)踐經(jīng)驗(yàn)，目前強(qiáng)調(diào)靶向治療、早期治療、長(zhǎng)期規(guī)律維持和客觀評(píng)估療效，特別是黏膜愈合度、疾病活動(dòng)度以及復(fù)發(fā)情況等；同時(shí)收集腸易激綜合征(IBS)患者及無(wú)腸道疾患的健康人群各60例為對(duì)照.Gastroenterology.RazackR，SeidnerDL．Nutritionininflammatoryboweldisease．CurrOpinGastroenterol，2007,23(4)：400-405．Thesecondsectiononcurrentmanagementincludestreatmentofactivedisease,maintenanceofmedically-inducedremissionandsurgeryofUC.BMJ1955;2:1041–1048.并發(fā)癥(Complications)并發(fā)癥包括：中毒性巨結(jié)腸（toxicmegacolon）腸穿孔下消化道大出血上皮內(nèi)瘤變和癌變錢(qián)家鳴,等.潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).中華內(nèi)科雜志[J].2012，51(9):694-697/ChowDK，LeongRW，TsoiKK,eta1．Long—termfollow—up

ofulcerativecolitisintheChinesepopulation．AmJ

Gastroenterol，2009，104：647-654．巨細(xì)胞病毒(CMV)屬皰疹病毒科B屬雙鏈DNA病毒，近年隨著Serologicalmarkers

Thetwomostwidelystudiedserologicalmarkersin

inflammatoryboweldiseaseinrecentyearshavebeen

p-ANCAandASCA.Theclinicalutilityofp-ANCAorASCA

testinginthediagnosisofinflammatoryboweldisease,in

patientswithnon-specificgastrointestinalsymptoms,is

limitedbecauseofthevaryingseroprevalenceofthese

antibodiesinpatientswithinflammatoryboweldiseaseand

theinadequatesensitivityoftheassays.LawranceIC,MurrayK,HallA,SungJJ,LeongR.Aprospective

comparativestudyofASCAandpANCAinChineseandCaucasian

IBDpatients.Am.J.Gastroenterol.2004;99:2186–94ReeseGE,ConstantinidesVA,SimillisCetal.Diagnosticprecision

ofanti-Saccharomycescerevisiaeantibodiesandperinuclear

antineutrophilcytoplasmicantibodiesininflammatorybowel

disease.AmJGastroenterol.2006(Oct);101(10):2410–22.BossuytX．Serologicmarkersininflammatofyboweldisease．C1in

Chem2006：52：171一181．Serologicalmarkers

ThetwomoSerumproteins

目的應(yīng)用蛋白質(zhì)組學(xué)尋找潰瘍性結(jié)腸炎(UC)血清差異蛋白，初步探索UC可能的生物標(biāo)志物。方法收集UC患者30例和健康對(duì)照者30名的血清標(biāo)本，雙向凝膠電泳(2-DE)分離等量混合血清的蛋白質(zhì)，運(yùn)用圖像分析軟件進(jìn)行比較和分析，識(shí)別差異表達(dá)蛋白質(zhì)。應(yīng)用基質(zhì)輔助激光解吸／電離飛行時(shí)間質(zhì)譜(MAI，DI-TOF-MS)鑒定部分差異蛋白質(zhì)點(diǎn)。結(jié)果UC組和對(duì)照組之間年齡、體重指數(shù)、吸煙情況和飲滔量的差異均無(wú)統(tǒng)計(jì)學(xué)意義(P值均>o．05)。初步篩選出UC患者與健康對(duì)照者存在明顯差異的39個(gè)蛋白點(diǎn)，選擇其中9個(gè)點(diǎn)。經(jīng)質(zhì)譜分析發(fā)現(xiàn)觸珠蛋白，熱休克轉(zhuǎn)錄因子2，受體酪氨酸激酶、醛脫氫酶、載脂蛋白c一Ⅲ、中心粒旁物質(zhì)l在UC患者中表達(dá)水平升高，角蛋白1，細(xì)絲蛋白A結(jié)合蛋白1、肌球蛋白3在UC患者中表達(dá)水平降低。結(jié)論采用蛋白質(zhì)組學(xué)2-DE和質(zhì)譜技術(shù)，篩選并鑒定出與UC相關(guān)的9個(gè)血清蛋白質(zhì)，為提供新的UC生物學(xué)行為研究分子標(biāo)志物奠定基礎(chǔ)。繆應(yīng)雷，等.潰瘍性結(jié)腸炎血清差異蛋白的篩選研究.中華消化雜志.2010,30(12):898-901.Serumproteins

目的應(yīng)用蛋白質(zhì)組學(xué)尋找潰瘍性尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。結(jié)果：患者尿白蛋白活動(dòng)期比緩解期明顯增高（0.002），Harvey和Bradshaw指數(shù)呈正相關(guān)（活動(dòng)期r=0.76,P<0.001；靜止期r=0.73,P<0.001）。患者尿中白蛋白明顯高于正常人（活動(dòng)期P<0.001,緩解期,P<0.005）。結(jié)論：患者尿中白蛋白可作為判斷患者疾病活動(dòng)情況的指標(biāo)。鄧長(zhǎng)生.炎癥性腸病患者尿白蛋白的臨床意義.武漢大學(xué)學(xué)報(bào).2002，23(1)：88-89.尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。巨細(xì)胞病毒(CMV)巨細(xì)胞病毒(CMV)屬皰疹病毒科B屬雙鏈DNA病毒，近年隨著IBD與CMV研究的深入，發(fā)現(xiàn)CMV在IBD的發(fā)生和疾病進(jìn)展中起一定作用，且對(duì)IBD的臨床診治亦有一定指導(dǎo)價(jià)值。Pfau等發(fā)現(xiàn)CMV更易感染肉芽組織生長(zhǎng)細(xì)胞．CMV對(duì)炎癥的趨向性使IBD患者感染CMV的風(fēng)險(xiǎn)增加。結(jié)腸活檢組織的炎癥和潰瘍部位可見(jiàn)CMV包涵體,且研究發(fā)現(xiàn)生長(zhǎng)旺盛的細(xì)胞如肉芽組織或潰瘍深部．更易發(fā)現(xiàn)CMV感染．推測(cè)CMV可通過(guò)單核細(xì)胞到達(dá)炎癥黏膜．并可在黏膜內(nèi)增殖．且對(duì)炎癥黏膜具有特殊親和力。CMV急性感染可顯著提高血清和腸道自然殺傷細(xì)胞、白細(xì)胞介素(IL)．6、TNF-a、IFN．1水平．提示CMV感染可改變黏膜免疫．提高宿主對(duì)炎癥的易感性．CMV感染可激活原癌基因、激酶、轉(zhuǎn)錄因子致腫瘤發(fā)生。可能是IBD患者結(jié)直腸癌發(fā)病率較高的原因之一例。MatsuokaK,1waoY，MoriT，eta1．Cytomegalovirusisfrequentlyreactivatedanddisappearswithoutantiviralagentsinulcerativecolitispatients．AmJGastroenterol，2007，102：331-337．巨細(xì)胞病毒(CMV)巨細(xì)胞病毒(CMV)屬皰疹病毒科B屬雙鏈難辨梭狀芽孢桿菌（Clostridiumdifficile）目的通過(guò)對(duì)炎癥性腸病(IBD)患者糞便中難辨梭狀芽孢桿菌(Cd)的檢測(cè),了解IBD患者中該菌的感染情況及其與IBD的關(guān)系.方法收集2009年12月至2011年1月上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院消化科確診的IBD患者130例,包括潰瘍性結(jié)腸炎(UC)患者60例及克羅恩病(CD)患者70例.同時(shí)收集腸易激綜合征(IBS)患者及無(wú)腸道疾患的健康人群各60例為對(duì)照.通過(guò)聚合酶鏈反應(yīng)(PCR)和Cd毒素快速測(cè)試試劑盒(CDTK)方法對(duì)糞便樣本中毒素A、毒素B基因進(jìn)行檢測(cè),采用SPSS軟件進(jìn)行統(tǒng)計(jì)分析.結(jié)果納入研究的130例IBD患者中,Cd感染者16例(12.3％),其中UC10例(16.7％),CD6例(8.6％)；對(duì)照組中未發(fā)現(xiàn)Cd感染者(x2=15.779,P=0.000).處于活動(dòng)期的IBD患者Cd感染率顯著高于非活動(dòng)期患者(x2=10.092,P=0.001).結(jié)腸型CD患者的感染率為4/14,顯著高于其他類(lèi)型的CD患者(x2=13.125,P=0.001).輕度UC患者Cd感染率為4.5％、中度為14.3％、重度為6/17(x2=6.667,P=0.037)；輕度CD患者的Cd感染率為0％、中度為4.2％、重度為5/16,感染率隨疾病嚴(yán)重程度的上升而增高(x2=13.907,P=0.000).使用廣譜抗生素的患者與未使用者其Cd感染率差異無(wú)統(tǒng)計(jì)學(xué)意義(x2=1.414,p=0.378);免疫抑制劑與廣譜抗生素同時(shí)使用者和單用廣譜抗生素者Cd感染率差異亦無(wú)統(tǒng)計(jì)學(xué)意義(x2=0.330,P=0.962).結(jié)論IBD患者中存在著一定的Cd感染率,尤其是處于疾病活動(dòng)期的患者,感染率隨IBD疾病嚴(yán)重程度的上升而增高.袁耀宗，等.

難辨梭狀芽孢桿菌與炎癥性腸病關(guān)系的初步研究.中華消化雜志.2012，32(4)：88-89.難辨梭狀芽孢桿菌（ClostridiumdifficilFecalmarkersCalprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.Itconstitutesapproximately5%ofthetotalproteinandupto60%ofthecytosolicproteininhumanneutrophils.Assuch,thefecalcalprotectinconcentrationisproportionaltotheinfluxofneutrophilsintotheintestinaltract,ahallmarkofactiveIBD.Lactoferrinisaniron-bindingglycoproteinidentifiedinthesecretionsoverlyingmostmucosalsurfacesthatinteractdirectlywithexternalpathogens,includingsaliva,tears,vaginalsecretions,feces,synovialfluid,andmammalianbreastmilk.Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.Intheintestinallumen,fecallactoferrinlevelsquicklyincreasewiththeinfluxofneutrophilsduringinflammation.Sugiandcolleaguesinvestigatedlactoferrin,polymorphonuclearneutrophil(PMN)elastase,andlysozymetogetherwithmyeloperoxidaseinfecalmaterialandwhole-gutlavagefluidfromIBDpatients.LanghorstJ,ElsenbruchS,MuellerTetal.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.Inflamm.BowelDis.2005;11:1085–91.FecalmarkersCalprotectin(FCPFecalmarkers

JuddTA，DayAS，LembergDA，eta1．Updateoffecalmarkersofinflammationininflammatoryboweldisease．JGastroenterolHepat01．2011，26：1493—1499．Fecalmarkers

JuddTA，DayAS，LFecalmarkers

Fecalmarkers

鋇劑灌腸檢查所見(jiàn)的主要改變?yōu)椋?1)黏膜粗亂和(或)顆粒樣改變；(2)腸管邊緣呈鋸齒狀或毛刺樣，腸壁有多發(fā)性小充盈缺損；(3)腸管短縮，袋囊消失呈鉛管樣。鋇劑灌腸檢查所見(jiàn)的主要改變?yōu)椋篊TUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．結(jié)腸鏡檢查并活組織檢查(后文簡(jiǎn)稱活檢)是UC診斷的主要依據(jù)。結(jié)腸鏡下UC病變多從直腸開(kāi)始，呈連續(xù)性、彌漫性分布，表現(xiàn)為：(1)黏膜血管紋理模糊、紊亂或消失，黏膜充血、水腫、質(zhì)脆、自發(fā)或接觸出血和膿性分泌物附著，亦常見(jiàn)黏膜粗糙、呈細(xì)顆粒狀；(2)病變明顯處可見(jiàn)彌漫性、多發(fā)性糜爛或潰瘍；(3)可見(jiàn)結(jié)腸袋變淺、變鈍或消失以及假息肉、橋黏膜等。結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．UlceraTypicalendoscopicfindings

(A)UCwithmildinflammationandreducedhaustration,vasculartransparencyis

missing.(B)Moderateinflammationwithreducedhaustration.Themucosaisedematous,coveredwithfibrin,andshowsmultipleerosions.(C)

Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.Typicalendoscopicfindings(A放大內(nèi)鏡(Confocalmicroscopy)

內(nèi)鏡下黏膜染色技術(shù)能提高內(nèi)鏡對(duì)黏膜病變的識(shí)別能力，結(jié)合放大內(nèi)鏡技術(shù)，通過(guò)對(duì)黏膜微細(xì)結(jié)構(gòu)的觀察和病變特征的判別，有助UC診斷，姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附116例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：116—118．放大內(nèi)鏡(Confocalmicroscopy)內(nèi)鏡下small-bowelcapsuleendoscopy(SBCE).

Crohn’sdiseaseandulcerativecolitisarelifelong

diseases.Bothdiseasesaremarkedbyfrequentrelapsesandpatientsoftenundergorepeatedinvestigationstodefinetheextentofthedisease,assesstheseverityofrelapse,oridentifycomplications.Whereasulcerativecolitisisachronicinflammatoryconditioncausingdiffuseandcontinuousmucosalinflammationofthecolon,Crohn’sdiseaseisaheterogeneousentitycomprisedofseveraldifferentphenotypes,butcanaffecttheentiregastrointestinaltract.Theuseofcapsuleendoscopyasafilterforpush?and?pullenteroscopy(PPE)isoccasionallynecessaryinpatientswithestablishedulcerativecolitiswhenthediagnosisisquestioned,especiallybeforesurgery.CapsuleendoscopycanalsodirectthechoiceofrouteofPPE.small-bowelcapsuleendoscopySBCE

Subtlelesionsasseenatsmall-bowelcapsuleendoscopyBourreilleA，IgnjatovicA，AabakkenL，eta1．Roleofsmall—bowelendoscopyinthemanagementofpatientswithinflammatoryboweldisease：aninternationalOMED-ECCOconsensus．Endoscopy，2009，41：618—637．SBCESubtlelesionsasseenat黏膜活檢組織學(xué)檢查

組織學(xué)可見(jiàn)以下主要改變。活動(dòng)期：(1)固有膜內(nèi)彌漫性急慢性炎性細(xì)胞浸潤(rùn)，包括中性粒細(xì)胞、淋巴細(xì)胞、漿細(xì)胞和嗜酸粒細(xì)胞等，尤其是上皮細(xì)胞間中性粒細(xì)胞浸潤(rùn)及隱窩炎，乃至形成隱窩膿腫；(2)隱窩結(jié)構(gòu)改變：隱窩大小、形態(tài)不規(guī)則，排列紊亂，杯狀細(xì)胞減少等；(3)可見(jiàn)黏膜表面糜爛，淺潰瘍形成和肉芽組織增生。緩解期：(1)黏膜糜爛或潰瘍愈合；(2)固有膜內(nèi)中性粒細(xì)胞浸潤(rùn)減少或消失，慢性炎性細(xì)胞浸潤(rùn)減少；(3)隱窩結(jié)構(gòu)改變：隱窩結(jié)構(gòu)改變可加重，如隱窩減少、萎縮，可見(jiàn)潘氏細(xì)胞化生(結(jié)腸脾曲以遠(yuǎn))。UC活檢標(biāo)本的病理診斷：活檢病變符合上述活動(dòng)期或緩解期改變，結(jié)合臨床，可報(bào)告符合UC病理改變。宜注明為活動(dòng)期或緩解期。如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。RileySA,ManiV,GoodmanMJ,etal.Microscopicactivityinulcerativecolitis:whatdoesitmean?Gut.1991;32:174–178.黏膜活檢組織學(xué)檢查

組織學(xué)可見(jiàn)以下主要改變。RileySMicroscopicfindingsinbiopsies

(D,E)CryptabscessinUC.(F)Pseudopolypformation.L,lymphfollicle.NikolausS，SchreiberS．Diagnosticsofinflammatorybowel

disease．Gastroenterology，2007，133：1670—1689．Microscopicfindingsinbiopsi診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：(1)具有上述典型臨床表現(xiàn)者為I臨床疑診(spicious)，安排進(jìn)一步檢查；(2)同時(shí)具備上述結(jié)腸鏡和(或)放射影像特征者，可臨床擬診(probable)；(3)如再加上上述黏膜活檢和(或)手術(shù)切除標(biāo)本組織病理學(xué)特征者，可以確診(definite)；(4)初發(fā)病例如I臨床表現(xiàn)、結(jié)腸鏡及活檢組織學(xué)改變不典型者，暫不確診UC，應(yīng)予隨訪(follow-up)。Lennard-JonesJE.Classificationofinflammatoryboweldisease.ScandJGastroenterol.Suppl.1989;170:2–6;discussion16–19.診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：LennDiagnosticcriteria

VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.ModifiedMendeloffcriteriapluskeypointsoftheLennard-Jonescriteria,commonlyusedcriteria,arepresentedhere.MyrenJ,BouchierIA,WatkinsonG,SoftleyA,ClampSE,deDombalFT.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.Afurtherreporton3175cases.ScandJGastroenterol.Suppl.1988;144:11–19.Diagnosticcriteria

Variousd鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎曲菌、沙門(mén)菌、產(chǎn)氣單孢菌、大腸埃希菌、耶爾森菌等。常有流行病學(xué)特點(diǎn)(如不潔食物史或疫區(qū)接觸史)，急性起病常伴發(fā)熱和腹痛，具自限性(病程一般數(shù)天至1周，不超過(guò)6周)；抗菌藥物治療有效；糞便檢出病原體可確診。2．阿米巴腸病3．腸道血吸蟲(chóng)病4．其他：腸結(jié)核、真菌性腸炎、抗生素相關(guān)性腸炎(包括假膜性腸炎)、缺血性結(jié)腸炎、放射性腸炎、嗜酸粒細(xì)胞性腸炎、過(guò)敏性紫癜、膠原性結(jié)腸炎、白塞病、結(jié)腸息肉病、結(jié)腸憩室炎以及人類(lèi)免疫缺陷病毒(HIV)感染合并的結(jié)腸病變應(yīng)與本病鑒別。鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎Differentiatediagnosis

Differentiatediagnosis

Differentiatediagnosis

夏冰，等.缺血性結(jié)腸炎與潰瘍性結(jié)腸炎的臨床鑒別診斷.胃腸病學(xué).2010，15(11)：681-683.Differentiatediagnosis

夏冰，等.InternationalStudyGroupforBehcet’sdisease.Criteriaforthe

diagnosisofBehcet’sdisease.Lancet1990;335:1078–1