部队合理用药系列讲座（3） 炎症性肠病临床合理用药

炎症性肠病（IBD）是一种病因尚不明确的慢性非特异性肠道炎症性疾病,包括溃疡性结肠炎（UC）和克罗恩病（CD）。     

炎症性肠病研究新进展

炎症性肠病（IBD）指溃疡性结肠炎（UC）和克罗恩病（CD）,该二种病均以慢性过程、自动复发、病因未明为其特征.西方国家发病率较高,国内发病有上升趋势,为此,中华医学会消化学会于1978（杭州）、1993（太原）和2000（成都）分别召开了炎症性肠病专项研讨会,对其病因、诊断和治疗的规范进行了讨论.     

微生物感染与炎症性肠病相关流行病学及临床研究进展

炎症性肠病（IBD）包括溃疡性结肠炎（UC）和克罗恩病（CD）,近年来发病率呈上升趋势。虽然发病机制尚不明确,但已知肠道黏膜免疫系统异常是该病发病的重要因素,微生物感染因素在其发生和发展中亦起着一定作用。虽然尚未找到某一特异微生物病原感染与IBD有恒定关系,     

细菌与炎症性肠病

炎症性肠病（IBD）是一种病因尚不明确的慢性非特异性肠道炎症性疾病，包括溃疡性结肠炎（UC）和克罗恩病（CD）。此病可能的病因有由基因决定的宿主易患性、肠道细菌的作用、自身免疫、环境因素等。肠道细菌的感染因素作为一种主要病因，虽尚未被证实，但已有许多研究表明，细菌是IBD的促发因素。近年的研究表明，     

炎症性肠病的MRI进展

炎症性肠病(inflammatory bowel disease,IBD)主要包括2种慢性肠道疾病,即溃疡性结肠炎(ulcerative colitis,UC)和克罗恩病(Crohn's disease,CD)[1].MRI可采用多平面、多参数、多序列成像方式,除可显示解剖学信息以外还能提供功能学参数,从而能更全面地诊断和评价IBD[1-2].另外,由于其检查无创、无电离辐射,十分适合作为IBD患者长期随访手段.本文就IBD的MRI研究进展进行综述.     

53例初诊儿童炎症性肠病临床分析

目的探讨儿童炎症性肠病(IBD)初诊临床特点,提高对儿童IBD的认识。方法回顾性分析2005年1月至2015年10月于中国医科大学附属盛京医院儿科初诊,并确诊为IBD的53例患儿的临床资料,包括临床表现、实验室检查、影像学、内窥镜和病理组织学结果,以及治疗方案。结果 IBD患儿的临床表现主要以腹痛、腹泻、便血、发热为主。其中,溃疡性结肠炎(UC)患儿较克罗恩病(CD)患儿更易出现腹泻及便血症状(P<0.05),而CD患儿腹痛症状更为明显(P<0.05),同时更易出现肠外表现,34.0%患儿出现生长发育和营养障碍,84.9%患儿存在不同程度的精神状态改变。实验室检查结果以炎症性指标(如白细胞、C-反应蛋白、血沉)升高为主,UC和CD患儿的血清白蛋白比较,差异有统计学意义(P<0.05)。UC和CD患儿,内镜及病理表现明显不同,MRE同时观察到肠壁强化和瘘管及肿块的形成。51例单纯药物治疗,2例联合手术治疗。其中,13例患儿应用了英夫利昔单抗(IFX)治疗,诱导缓解迅速,身高、体质量有所增长。结论对临床出现腹痛、腹泻、便血、发热以及营养状态不佳的患儿,要警惕IBD的发生;需结合生化、影像学、内镜、病理进行综合诊断;MRE无创、无辐射,值得推广;中重度患者,IFX可以迅速缓解病情,促进生长发育。     

炎性肠病相关骨质疏松的影像学研究进展

骨质疏松症（OP）是炎性肠病（IBD）病人最常见的肠道外表现之一。双能X线吸收测量仪、CT、MRI以及定量超声等影像方法可以评估IBD病人的骨量、骨结构、骨髓脂肪以及骨强度变化,对IBD的诊断治疗及预后评估具有重要意义。就IBD相关OP的发病机制、影像学研究进展及其临床应用予以综述。     

MRI小肠成像在克罗恩病诊断中的应用进展

克罗恩病(CD)是慢性炎症性肠道疾病。MRI小肠成像技术在临床上已应用多年,能清晰反映肠壁和肠腔外的病灶,结合一些新技术、新方法能更全面反映炎性肠病的部位、范围和性质,对CD诊断起重要作用。本文就目前临床上常用的MRI小肠成像技术在CD中的应用进行综述。     

蛋白组织学研究在炎症性肠病中的应用

炎症性肠病（inflammatory bowel disease,IBD）是一组病因未明的慢性非特异性肠道炎症性疾病．目前大多数学者将其归结为自身免疫性疾病,包括溃疡性结肠炎（Ulcerative colitis,UC）和克罗恩病（Crohn’s disease．CD）。两者发病的基本病理过程相似,但其发病部位及临床表现不全相同,前者常自远端结肠开始发病,逆行向近端发展。严重时甚至累及全结肠及末端回肠,主要累及肠黏膜及黏膜下层,属于慢性非特异性结肠炎;后者可累及胃肠道各部位,但以末端回肠及其邻近结肠受累最为常见,     

大小肠双充盈法多层螺旋CT肠道成像对炎症性肠病的诊断价值

目的总结炎症性肠病(IBD)在大小肠双充盈法多层螺旋CT(MSCT)肠道成像中的影像表现,评价该成像方法对IBD的诊断价值。资料与方法回顾性分析42例克罗恩病(CD)和10例溃疡性结肠炎(UC)患者的CT资料,均采用大小肠双充盈法MSCT肠道成像,评价肠管扩张程度和病变显示情况。结果 52例患者中,回肠扩张最佳10例(19.23%),扩张良好42例(80.77%);空肠扩张良好21例(40.38%),扩张欠佳31例(59.62%);大肠评价范围全面50例(96.15%),回盲部显示良好52例(100.00%)。42例CD患者中,仅小肠受累20例(47.62%),大小肠同时受累22例(52.38%)。9例UC仅累及结肠,1例累及全结肠及末端回肠。52例患者的MSCT表现显示明确,其中肠壁增厚及异常强化52例;肠腔狭窄28例,肠系膜血管增多46例,肠系膜淋巴结肿大27例,肠管周围蜂窝织炎10例,不全小肠梗阻4例,脓肿或炎性肿块7例,腹腔内瘘3例,肛周病变12例;浆膜腔积液15例,骶髂关节炎13例,泌尿系及胆系结石18例,肝脾肿大9例。结论大小肠双充盈法MSCT肠道成像不但能较好地同时显示小肠和大肠自身的肠壁病变,而且能明确显示肠外病变及并发症,可以明显提高IBD病变的定位及定性准确率。     

Value of sonography in the diagnosis and follow-up of patients with cryptogenic inflammatory bowel diseases in current practice: review of a 10-year experience in a community hospital

Inflammatory bowel diseases (IBD) are chronic inflammatory diseases of the bowel that are of unknown etiology. These diseases either progress with intermittent flare-ups interrupted by periods of remission or on a chronic active progressive mode. IBDs include Crohn disease (CD) and ulcerative colitis (UC). Clinical and imaging diagnosis often is challenging, hence explaining the frequent time delay between onset of disease and initiation of therapy. Clinical evaluation is characterized by three consecutive steps: consider a diagnosis of IBD; exclude other causes of inflammatory bowel disease; differentiate CD from UC since a definitive curative surgical treatment is available for UC. US is non-invasive, widely available, easy to perform, and relatively inexpensive and thus represents a significant advance in the evaluation of these three steps. The role of US in the evaluation of patients with suspected IBD will be reviewed.     

Inflammatory chronic disease of the colon: how to image

Inflammatory bowel disease, including Crohn's disease and UC, is a chronic disorder of the gastrointestinal tract. The inflammatory process in UC is confined to the mucosa and submucosa and it involves only the colon. In contrast, in Crohn's disease the inflammation process extends through the bowel wall layers and it can involve any part of gastrointestinal tract. Moreover, inflammatory bowel disease of the colon may be associated with complications, such as toxic megacolon, fulminant colitis, acute bleeding, fistulas and abscesses. Radiographic imaging studies are useful for the diagnosis of inflammatory bowel disease, and may be used to assess the extent and severity of disease, rule out complications, and monitor the response to therapy. The double-contrast barium study is a valuable technique for diagnosing inflammatory bowel disease colonic alterations, even in patients with early mucosal abnormalities. The earliest finding of UC is characterized by a fine granular appeareance of the colonic mucosa, usually involving the rectosigmoid junction. In chronic UC double-contrast enema may reveal marked colonic shortening with tubular narrowing of the bowel and loss of haustration. The earliest radiographics findings of Crohn's disease are represented by aphthous ulcers. As disease progresses, aphthous ulcers may enlarge and coalesce to form stellate or linear areas of ulceration. In advanced Crohn's disease, transmural ulceration may lead to the development of fissures, sinus tracts, fistulas, and abscesses. Cross sectional studies such as computed tomography, magnetic resonance imaging and sometimes ultrasound, are useful alternative tools not only in the assessment of bowel wall abnormalities, but also for the assessment of extraluminal alterations in patients with advanced disease.     

Magnetic resonance imaging of inflammatory bowel disease: evaluation in a rabbit model

PURPOSE: To correlate intestinal contrast enhancement and wall thickening with the degree of inflammation in an experimental model of inflammatory bowel disease. MATERIALS and METHODS: Inflammatory bowel disease was elicited in 39 New Zealand White rabbits by rectal instillation of 2,4,6-trinitrobenzene sulphonic acid (TNBA). Magnetic resonance imaging (MRI) was used to determine bowel wall thickness and intestinal contrast enhancement after the administration of 0.1 mmol/kg of gadodiamide intravenously. MR measurements were compared with the complete histopathologic analysis. RESULTS: MR measurements of bowel wall thickness correlated well with histopathologic measurements in vitro (r = 0.85, P < 0.0001) and with histopathologic evidence of chronic inflammatory bowel disease (P < 0.02). Chronic inflammation was characterized by increased intestinal contrast enhancement (137 +/- 25%) when compared to normal bowel (86 +/- 7%, P = 0.04). CONCLUSION: Contrast-enhanced MRI accurately reflects inflammatory bowel disease in the rabbit model.     

Magnetic resonance enterography in Crohn's disease: Standard and advanced techniques

Crohn's disease (CD) is a chronic autoimmune disorder that affects mainly young people. The clinical management is based on the Crohn's Disease Activity Index and especially on biologic parameters with or without additional endoscopic and imaging procedures, such as barium and computed tomography examinations. Recently, magnetic resonance (MR) imaging has been a promising diagnostic radiologic technique with lack of ionizing radiation, enabling superior tissue contrast resolution due to new pulse-sequence developments. Therefore, MR enterography has the potential to become the modality of choice for imaging the small bowel in CD patients.     

Usefulness of MR Imaging for Diseases of the Small Intestine: Comparison with CT

Objective

To evaluate the usefulness of MR imaging for diseases of the small intestine, emphasizing a comparison with CT.

Materials and Methods

Thirty-four patients who underwent both CT and MR imaging using FLASH 2D and HASTE sequences were analyzed. All patients had various small bowel diseases with variable association of peritoneal lesions. We compared the detectabilities of CT and MR imaging using different MR pulse sequences. The capability for analyzing the characteristics of small intestinal disease was also compared.

Results

MR imaging was nearly equal to CT for detecting intraluminal or peritoneal masses, lesions in the bowel and mesentery, and small bowel obstruction, but was definitely inferior for detecting omental lesions. The most successful MR imaging sequence was HASTE for demonstrating bowel wall thickening, coronal FLASH 2D for mesenteric lesions, and axial FLASH 2D for omental lesions. MR imaging yielded greater information than CT in six of 12 inflammatory bowel diseases, while it was equal to CT in six of seven neoplasms and inferior in five of seven mesenteric ischemia. In determining the primary causes of 15 intestinal obstructions, MR imaging was correct in 11 (73%) and CT in nine (60%) patients.

Conclusion

MR imaging can serve as an alternative diagnostic tool for patients with suspected inflammatory bowel disease, small intestinal neoplasm or obstruction.     

Magnetic Resonance in the study of the small bowel

Magnetic resonance (MR) of the small bowel is a field of application which for many years received little attention, being limited to advanced and selected research centres whose studies had no real clinical impact. Even after the first two publications in 1985, it was not until 1998 and the following years that a decisive improvement in scientific research articles was observed. This was largely due to the need for progressive development of adequate technologies, in particular fast imaging. Although the major technological problems have now been resolved, the optimisation of the study protocol is still under evaluation. In this regard there are two main methodological approaches: 1) "MR follow-through" following administration of an oral contrast medium; 2) "MR enteroclysis", following administration of contrast medium through a nasojejunal tube. Several contrast media are currently available for small bowel study, and they are classified according to signal intensity into positive, negative or biphasic. Biphasic agents are those most commonly used for both MR follow-through and MR enteroclysis. The major clinical indication for a study of the small bowel with MR is the evaluation of chronic inflammatory disease (Crohn's disease). Considerable experience has been obtained over the past years, with the consequent introduction of MR in routine clinical practice in many centres worldwide. Other potential clinical indications, at the moment to be considered work-in-progress, are the evaluation of malabsorption syndromes (and among them, celiac disease) and assessment of neoplastic diseases.     

Advanced multimodality imaging of inflammatory bowel disease in 2015: An update

The diagnosis and effective management of inflammatory bowel disease (IBD) requires a combination clinical, endoscopic, histological, biological, and imaging data. While endoscopy and biopsy remains the gold standard for diagnosis of IBD, imaging plays a central role in the assessment of extra mural disease, in disease surveillance and in the assessment of response to medical treatments, which are often expensive. Imaging is also vital in the detection and diagnosis of disease related complications, both acute and chronic. In this review, we will describe, with illustrative images, the imaging features of IBD in adults, with emphasis on up-to-date imaging techniques focusing predominantly on cross sectional imaging and new magnetic resonance imaging techniques.     

MR imaging of crohn disease: Use of perflubron as a gastrointestinal contrast agent

This study was undertaken to evaluate the use of perflubron (perfluorooctylbromide) as an oral contrast agent for magnetic resonance (MR) imaging of patients with Crohn disease. MR examinations were performed before and after perflubron administration in 12 patients with documented Crohn disease. Glucagon was administered intramuscularly before the post-perflubron examinations. Each patient also underwent abdominal computed tomography within 48 hours of MR imaging. The imaging studies were analyzed for effectiveness of bowel marking with oral contrast agent, clarity of bowel wall visualization, and presence of bowel wall thickening and extraluminal manifestations of Crohn disease such as abscess or fistula formation. Analysis of the imaging studies showed effective marking of the bowel with perflubron and improved bowel wall visualization on postcontrast MR images. Detection of bowel wall thickening and extraluminal complications of Crohn disease was not significantly improved on postcontrast MR images. The authors conclude that perflubron administration effectively marked the bowel and increased the clarity of bowel wall visualization but did not significantly increase the detection of abnormalities related to Crohn disease in the study population.     

MR imaging of the small bowel in Crohn's disease

MR and CT techniques optimized for small bowel imaging are playing an increasing role in the evaluation of small bowel disorders. Several studies have shown the advantage of these techniques over tradition barium fluoroscopic examinations secondary to improvements in spatial and temporal resolution combined with improved bowel distending agents. The preference of MR vs. CT has been geographical and based on expertise and public policy. With the increasing awareness of radiation exposure, there has been a more global interest in implementing techniques that either reduce or eliminate radiation exposure [Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84]. This is especially important in patients with chronic diseases such as inflammatory bowel disease who may require multiple studies over a lifetime or in studies that require sequential imaging time points such as in assessment of gastrointestinal motility [Froehlich JM, Patak MA, von Weymarn C, Juli CF, Zollikofer CL, Wentz KU. Small bowel motility assessment with magnetic resonance imaging. J Magn Reson Imaging 2005;21:370–75]. A recent study showed that certain subgroups of patients with Crohn's disease may be exposed to higher doses of radiation; those diagnosed at an early age, those with upper tract inflammation, penetrating disease, requirement of intravenous steroids, infliximab or multiple surgeries [Desmond AN, O’Regan K, Curran C, et al. Crohn's disease: factors associated with exposure to high levels of diagnostic radiation. Gut 2008;57:1524–29]. Therefore it has been suggested that techniques that can reduce or eliminate radiation exposure should be considered for imaging [Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84]. Owing to the excellent softtissue contrast, direct multiplanar imaging capabilities, new ultrafast breath-holding pulse sequences, lack of ionizing radiation and availability of a variety of oral contrast agents, MR is well suited to play a critical role in the imaging of small bowel disorders. In this article we will review the technical issues related to the performance of MR enterography and enteroclysis and discuss the role and controversies of using MR in the assessment of inflammatory bowel disease.     

Bowel disease: prospective comparison of CT and 1.5-T pre- and postcontrast MR imaging with T1-weighted fat-suppressed and breath-hold FLASH sequences.

The potential of new high-field-strength magnetic resonance (MR) imaging sequences to evaluate bowel disease was investigated and compared with computed tomographic (CT) studies. Thirty-two patients were studied, 14 with known or suspected gastrointestinal tumors and 18 with known or suspected bowel inflammatory conditions. T1-weighted fat-suppressed spin-echo and breath-hold FLASH (fast low-angle shot) images were obtained before and after intravenous injection of 0.1 mmol/kg gadopentetate dimeglumine. Pathologic confirmation was obtained by biopsy (n = 18), surgical excision (n = 8), or endoscopy (n = 6). CT and MR images were analyzed separately in a prospective fashion and reviewed by consensus. Information from CT and MR images was comparable in cases of confirmed bowel neoplasia. CT scans had better spatial resolution, while fat-suppressed gadolinium-enhanced MR images had better contrast resolution. In the 18 cases of bowel inflammation, CT scans showed concentric wall thickening in 16, while MR images showed concentric wall thickening in 14 and increased contrast enhancement in 17. Contrast enhancement was better appreciated on fat-suppressed images than on FLASH images. The results suggest that MR imaging may play a role in the evaluation of bowel disease.