潰瘍性結(jié)腸炎的內(nèi)科保守治療

潰瘍性結(jié)腸炎的內(nèi)科保守治療第1頁/共20頁潰瘍性結(jié)腸炎的藥物治療和預(yù)后第2頁/共20頁診斷與治療診斷：排除性、綜合性和完整性診斷治療：強(qiáng)調(diào)分型、分期、分度、分段的原則療效評定：緩解、有效、無效提倡多中心協(xié)作研究第3頁/共20頁TreatmentgoalsPotentialfuturetreatmentgoalsforulcerativecolitis

includesustainedclinicalremission,sustainedmucosal

healingwithareductionincolorectaldysplasiaandcancer,

andmaintainingnormalGIphysiology.Mesalaminetherapyissufficient

inapproximately50%ofpatients.Therearelimiteddatathat

azathioprinemightinduceandmaintainclinicalremission

andendoscopichealing.Infliximabiseffectiveforinduction

andmaintenanceofclinicalremissionandendoscopichealing.Dataonadalimumabandcertolizumabarelacking.CurrentDirectionsinIBDTherapy:WhatGoalsAreFeasibleWith

BiologicalModifiers?2008bytheAGAInstitute第4頁/共20頁SASP早在20世紀(jì)初期，斯堪的納維亞的風(fēng)濕病專家Suartg發(fā)現(xiàn)，水楊酸偶氮磺胺（SASP）的抗炎和抗菌特性可用于治療類風(fēng)濕性關(guān)節(jié)炎。1942年由DanaSvartz醫(yī)師首先將柳氮磺胺吡啶應(yīng)用于潰瘍性結(jié)腸炎（UC）的治療，取得了良好效果，成為UC治療的一個(gè)里程碑。自從SASP用作UC的維持治療后，復(fù)發(fā)率為原來的1/4，并大大改善了許多患者的生活質(zhì)量。經(jīng)過半個(gè)多世紀(jì)的實(shí)踐，SASP一直是UC患者廣泛應(yīng)用的藥物之一。但由于該藥口服耐藥性差，不良反應(yīng)多，通過開發(fā)研制了新劑型、改變給藥途徑等方法顯著提高了療效、減少了不良反應(yīng)。第5頁/共20頁氨基水楊酸制劑

第6頁/共20頁GCs

Intravenouscorticosteroidshavebeenestablishedas

themosteffectivefirst-linetreatmentforacutesevereUCsincethe

firsttrialofthistreatmentregimenwaspublishedin1974byTruelove

andJewell.Inthisstudy,36of49patients(73.5%)with

severeUCwerefoundtobeinremission5daysaftercommencing

intensiveintravenoustreatmentwithprednisolone60mg/day

(individeddoses).Theintroductionofintravenouscorticosteroid

treatmenthasledtoasubstantialdecreaseinthemorbidityand

mortalityassociatedwithacutesevereUC.Anumberofparenteralcorticosteroidshavebeentestedinthetreatment

ofsevereUC.TherewasnoobviousdifferencesintreatmentresponsebetweenthevarioussteroidsHowever,therewasnoevidencetosupportincreasingthecorticosteroiddosebeyond60mg/dayofmethylprednisolone

orequivalentTrueloveSC,JewellDP.Intensiveintravenousregimenforsevereattacksof

ulcerativecolitis.Lancet1974;1:1067–70.TurnerD,WalshCM,SteinhartAHetal.Responsetocorticosteroidsin

severeulcerativecolitis:asystematicreviewoftheliteratureandametaregression.ClinGastroenterolHepatol2007;5:103–110.第7頁/共20頁6MP/AZA

ArdizzoneS,MaconiG,RussoA,ImbesiV,ColomboE,

BianchiPorroG.Randomisedcontrolledtrialofazathioprineand

5-aminosalicylicacidfortreatmentofsteroiddependentulcerative

colitis.Gut2006;55:47–53.LeungY,PanaccioneR,HemmelgarnB,etal.Exposingthe

weaknesses:asystematicreviewofazathioprineefficacyinulcerative

colitis.DigDisSci2008;53:1455–1461.LewisJD,GelfandJM,TroxelAB,etal.Immunosuppressant

medicationsandmortalityininflammatoryboweldisease.AmJ

Gastroenterol2008;103:1428–1435.第8頁/共20頁IndicationsandContraindicationsforInfliximabTherapyinIBD第9頁/共20頁Otherbiotechnology

agents

第10頁/共20頁InfliximabRutgeertsP,SandbornWJ,FeaganBGetal.Infliximabfor

inductionandmaintenancetherapyforulcerativecolitis.NEnglJ

Med.2005;353:2462–2476.

RutgeertsP,ColombelJF,ReinischW,etal.Infliximabinducesandmaintainsmucosalhealinginpatientswithactiveulcerativecolitis:theACTtrialexperience.Gut2005;54(SupplVII):A58.ReinischW,SandbornWJ,RutgeertsP,etal.Infliximabtreatmentforulcerativecolitis:comparableclinicalresponse,clinicalremission,andmucosalhealinginpatientswithdiseaseduration<3yearsvs>=3years.Gastroenterology2008;134(Suppl1):A495.FidderH．SchnitzlerF，RutgeertsP

，eta1．Long—termsafetyofinflixjmabforthetreatmentofinflammatoryboweIdisease：asinglecentercohortstudy．Gut．2009，58(4)：50l-508．RutgeertsP,VermeireS，VanAsseheG．BiologicaltherapiesforinflammatoryboweldiseasBGastroenterology.2009，136：l182·1197．第11頁/共20頁DietandnutritionPatientsshouldbeofferedanormaldietorenteral

nutritionunlesssuchadietisnottoleratedTPNisnoteffectiveasprimarytherapy.TPN

shouldbeconsideredonlyinmalnourishedpatientswhocannot

tolerateoralintakeorenteralnutrition.WrightR,TrueloveSC.Acontrolledtherapeutictrialofvariousdietsin

ulcerativecolitis.BrMedJ1965;2:138–41.GassullMA,AbadA,CabreE,Gonzalez-HuixF,GineJJ,DolzC.

Enteralnutritionininflammatoryboweldisease.Gut1986;27

(Suppl.1):76–80.Gonzalez-HuixF,Fernandez-BanaresF,Esteve-ComasMetal.Enteral

versusparenteralnutritionasadjuncttherapyinacuteulcerativecolitis.

AmJGastroenterol1993;88:227–32.第12頁/共20頁Dietandnutrition

UC患者因攝入不足，腸道吸收障礙，能量消耗及丟失增加常導(dǎo)致營養(yǎng)風(fēng)險(xiǎn)(nutritionalrisk)，故積液營養(yǎng)支持(nutritionalsupport)不僅能改善患者的營養(yǎng)狀況，一些營養(yǎng)成分，包括谷氨酰胺、w-3多不飽和脂肪酸及微生態(tài)制劑還具有調(diào)節(jié)炎癥反應(yīng)、改善患者腸道免疫屏障的功能、改善疾病的活動(dòng)作用，有助于病變恢復(fù)，避免手術(shù)。張澍田，等.營養(yǎng)治療對潰瘍性結(jié)腸炎腸道免疫屏障的療效.胃腸病學(xué)和肝病學(xué)[J].2009，18(1)：83-86.RazackR，SeidnerDL．Nutritionininflammatoryboweldisease．CurrOpinGastroenterol，2007,23(4)：400-405．第13頁/共20頁Diet,nutritionandprobiotics

Patientsshouldbeofferedanormaldietorenteral

nutritionunlesssuchadietisnottolerated.TPNisnoteffectiveasprimarytherapy.TPN

shouldbeconsideredonlyinmalnourishedpatientswhocannot

tolerateoralintakeorenteralnutrition.WrightR,TrueloveSC.Acontrolledtherapeutictrialofvariousdietsin

ulcerativecolitis.BrMedJ1965;2:138–41.GassullMA,AbadA,CabreE,Gonzalez-HuixF,GineJJ,DolzC.

Enteralnutritionininflammatoryboweldisease.Gut1986;27

(Suppl.1):76–80.Gonzalez-HuixF,Fernandez-BanaresF,Esteve-ComasMetal.Enteral

versusparenteralnutritionasadjuncttherapyinacuteulcerativecolitis.

AmJGastroenterol1993;88:227–32.ShermanPM，Ossajc，Johnson—HenryK．Unraveling

mechanismsofactionofprobioties．NutrClinPract，2009，24：10—14．第14頁/共20頁Antibiotics

Routineuseofantibioticsisnotrecommended.Severaltrialshaveshownthattheuseofantibioticsin

additiontocorticosteroidsdoesnotleadtoadditionalbenefitsover

corticosteroidtreatmentalone.Itshouldbenotedthatantibioticsareindicatedin

patientswhodevelopsignsofsepsis.Similarly,antibiotics,eithermetronidazole

orvancomycinareindicatedinpatientswithconcurrent

C.difficileinfection.GuslandiM．Antibioticsforinflammatoryboweldisease：dotheywork?EurJGastroenterolHepatol，2005，17：145-147．PerencevichM,BurakoffR.Useofantibioticsinthetreatmentof

inflammatoryboweldisease.InflammBowelDis.2006;12:

651–64.TorunerM,LoftusEVJr,HarmsenWSetal.Riskfactorsfor

opportunisticinfectionsinpatientswithinflammatorybowel

disease.Gastroenterology2008;134:929–36.第15頁/共20頁其他

白細(xì)胞洗滌技術(shù)(Leukocytapheresis，LCAP)干細(xì)胞移植療法(Autologousstemcelltransplantation)基因療法錢家鳴，等.白細(xì)胞分離法治療炎癥性腸病.中華消化雜志.2005.25(9)：575—576.錢家鳴，等.造血干細(xì)胞移植與炎癥性腸病.中華內(nèi)科雜志.2005.44(1)：65—67.周黎，等.炎癥性腸病的基因治療.胃腸病學(xué).2006.11(7)：439—441.第16頁/共20頁禁忌

抗膽堿能藥麻醉劑其他第17頁/共20頁預(yù)后（Prognostic）本病呈慢性過程，大部分患者反復(fù)發(fā)作，輕度及長期緩解者預(yù)后較好。急性爆發(fā)型、有并發(fā)癥及年齡超過60歲者預(yù)后不良。慢性持續(xù)活動(dòng)或反復(fù)發(fā)作頻繁者，預(yù)后較差。病程漫長者癌變危險(xiǎn)性增加，應(yīng)注意隨