克罗恩病的临床多样性

目的：分析克罗恩病临床表现的多样性及误诊的主要原因，方法：对最近5年收治的30例患者的临床表现，内镜及实验室检查结果，结合文献报道，分析克罗恩病临床特点与误诊原因。结果：患者以青中年为主，女略多于男，病变侵犯胃肠道任一部位，呈节段性分布，常同时侵犯多个部位，结肠及小肠最多；腹痛与腹泻为主要的肠道症状，但尚有低热，消瘦，贫血及皮肤，关节与肝周等多系统症状。内镜有跳跃式分布的溃疡、息肉、狭窄或卵石样改变等破坏与增强病变并存在的特点，活检 肉芽肿检出率为30．8％。B超可探查出肠道并发症，误诊原因包括对本病认识不足；肠道病变多部位性，致使临床症状多样化；过于强调病理学检查及肉芽肿的诊断意义等。药物与手术治疗（16例）均收到积极疗效。结论：本病发病数明显增多，临床表现缺乏异性；内镜联合活检，加强临床与病理医师沟通是及时，正确诊断的关键。     

嗜酸性粒细胞性胃肠炎32例临床诊治分析

目的 分析嗜酸性粒细胞性胃肠炎(eosinophilic gastroenteritis,EG)的临床特点、内镜下表现、病理特点及诊治要点,以提高对该病的认识.方法 回顾性分析湖北医药学院附属太和医院消化内科2001年1月～2011年5月收治的32例EG患者临床资料,对病史、临床表现、实验室结果、内镜结果及治疗情况汇总分析.结果 32例患者黏膜型25例,浆膜型6例,黏膜-肌层混合型1例;患者多以腹痛为首发症状(84.38％);外周血和骨髓嗜酸粒细胞(ensinophils,EOS)计数明显增高(14.2％ ～49.5％ vs 12.5％ ～42.5％);镜下表现为黏膜充血水肿、糜烂、红斑,病变多分布在胃窦部、十二指肠和结肠;活检和腹水检测有大量EOS浸润;糖皮质激素治疗后患者症状缓解,复发用药亦有效.结论 EG多以腹痛起病,胃窦部、十二指肠、结肠为常见病变部位,内镜活检和腹水中见EOS浸润有助于明确诊断,糖皮质激素疗效好.     

肝脏肉芽肿

肝脏肉芽肿系多种病因引起的一种病理现象,肝活检的检出率一般为3～10％,其发病总数随肝活检次数增加而增多。本病的临床表现无特异性,视伴发病的情况而定,且其临床表现常为原发病所掩盖,故常不被作为独立的诊断。但如原发病的表现不突出,此时肝脏肉芽肿即有可能成为唯一的线索,从而使原发病的诊断得以确立。在某些情况下,原因不明的肝脏肉芽肿可有胆汁瘀积或肝细胞损害的临床及生化表现,在肝病的鉴别诊断中需加重视。有人称本病为肉芽肿性肝炎,Sherlock认为不妥,因其病变性质不是肝炎,且肝细胞功能不良罕见。     

26例腹型过敏性紫癜内镜表现及临床分析

目的总结腹型过敏性紫癜的临床表现、内镜特点及诊治要点。方法对我院26例腹型过敏性紫癜患者的临床特点、内镜下病变特点、病理组织学特点及治疗转归进行回顾性分析。结果腹型过敏性紫癜好发于中青年人,常合并上呼吸道感染等致敏因素,以腹痛、便血为主要临床表现;内镜检查病变可累及全消化道,但以十二指肠降部和空回肠发病多见且病变较重;及早诊治后恢复良好。结论中青年人发生腹痛、消化道出血并出现皮肤紫癜者,应尽早行胃肠镜等检查以明确诊断,确诊后应及时治疗,提高临床治愈率。     

嗜酸性粒细胞性胃肠炎14例临床分析

目的分析嗜酸性粒细胞胃肠炎(eosinophilic gastroenteritis,EG)的临床特点、诊断要点、治疗和预后。方法对14例诊断为嗜酸粒细胞性胃肠炎患者的病史、临床表现、实验室检查、内镜检查、病理结果、治疗及随访情况进行回顾性临床分析。结果 14例EG患者中,10例病变范围涉及黏膜层,1例病变范围涉及肌层,3例病变范围涉及浆膜层。所有患者均出现不同程度的胃肠道症状,内镜下黏膜活检或手术活检均证实胃肠道组织有较多量嗜酸性粒细胞浸润。给予糖皮质激素类治疗的9例患者,1～2周后症状得到明显缓解,且嗜酸性粒细胞数逐渐下降至正常水平。14例患者均预后良好。结论嗜酸性粒细胞性胃肠炎是临床上较为少见的一种疾病,病因和发病机制尚不十分明确。内镜或手术取到活体组织中提示较多嗜酸性粒细胞浸润是确诊的关键。糖皮质激素是主要的治疗药物。该疾病预后良好。     

以肠道症状为首发临床表现的白血病18例临床分析

目的分析以肠道症状为首发临床表现的白血病患者的临床特点,以提高对该病的认识。方法回顾性分析北京协和医院18例以腹部症状就诊的白血病患者临床资料,分析其临床特点。结果肠道为主要首发临床表现的症状以腹痛(88.9%)、发热(72.2%)和消化道出血(72.2%)多见,实验室检查可表现为血常规异常、血沉和超敏C反应蛋白升高(80%),约1/2患者(44.4%)出现凝血酶原时间(prothrombin time,PT)延长,33.3%患者乳酸脱氢酶(lactate dehydrogenase,LDH)异常升高。病变部位以结肠病变最常见(33.3%),其次是回肠(11.1%),多表现为肠壁增厚。内镜下可见溃疡性病变、溃疡浸润性肿块。结论以消化系统症状就诊的患者出现血液系统异常及LDH异常升高,及早做骨髓穿刺活检是诊断关键。     

35例原发性恶性胃淋巴瘤临床特点分析

原发性恶性胃淋巴瘤（PMGL）临床表现缺乏特异性，内镜和上消化道钡餐检查确诊率低。目的：了解PMGL的临床特点，以期早期诊断，早期治疗，改善预后。方法：回顾性分析上海仁济医院2000年9月～2006年2月收治的PMGL病例的病史资料。结果：共35例PMGL患者人选。主要消化道症状为上腹痛，伴全身症状者较少。内镜下溃疡型、弥漫浸润型和结节肿块型病变分别占67．7％、22．6％和9．7％，病变主要位于胃窦和胃体。内镜活检病理检查确诊率为54．5％。35例PMGL术后病理诊断均为B细胞性非霍奇金淋巴瘤，其中黏膜相关淋巴组织（MALT）淋巴瘤5例，弥漫性大B细胞淋巴瘤（DLBCL）26例，DLBCL合并MALT淋巴瘤（DLBCML）4例。患者预后与肿瘤病理类型、临床分期和血清乳酸脱氢酶（LDH）水平有关（P〈0．05）。术后3年生存率为81．8％。结论：PMGL患者局部表现严重而全身状况良好。内镜下病变大、范围广且多部位侵犯。多点取材或“挖洞式”活检可提高内镜诊断率。治疗方案的选择应根据肿瘤病理类型、临床分期和是否存在幽门螺杆菌感染而定。     

变应性肉芽肿性血管炎误诊2例分析

目的总结变应性肉芽肿性血管炎(Churg-Strauss syndrome,CSS)的诊治经验及误诊原因。方法回顾性分析近年来本院收治诊断的2例被误诊的CSS患者的临床表现、发病机制、影像学表现、诊断和治疗的特点。结果 2例患者中1例被误诊为难治性哮喘,1例被误诊肺结核,提示CSS患者的临床表现早期可能与相关疾病很多相似之处,容易漏诊、误诊而延误诊治。结论临床医师对本病的认识不足是误诊的主要原因,提高对本病的认识程度,熟悉其病理生理,临床特点,影像学特征是减少误诊的关键。     

淋巴瘤的胸部病变

淋巴增生性肺病变中,淋巴瘤为最主要病变,包括原发性肺淋巴瘤与全身淋巴瘤的肺侵犯。现就本病的发病与病理、临床表现、诊治原则等作一简介。     

如何通过内镜活检提高大肠淋巴瘤的诊断水平

大肠淋巴瘤临床表现并无特异性,肠镜检查虽多能发现黏膜病变,但由于组织病理学上多有明显的炎症背景,与炎症浸润的淋巴细胞难以区分。肠镜下溃疡病变为淋巴瘤的常见表现,但由于内镜活检取材局限,常常误诊为克罗恩病或肠结核,不易获得明确诊断。本文从肠道淋巴瘤发生的病理学基础入手,介绍了肠道淋巴瘤内镜下的常见表现和临床诊断线索,强调可疑病变需要大块黏膜剥离活检,借助淋巴瘤的单克隆起源特性,通过病理形态和免疫组化的结合,正确诊断肠道淋巴瘤,从而提高内镜诊断大肠淋巴瘤的水平。     

Transabdominal bowel sonography for the detection of intestinal complications in Crohn's disease

Background—The course ofCrohn's disease is characterised by the occurrence of intestinalcomplications such as strictures, intra-abdominal fistulas, orabscesses. Standard diagnostic procedures may fail to show thesecomplications, in particular fistulas.
Aims—To test the value oftransabdominal bowel sonography (TABS) for the detection of intestinalcomplications in Crohn's disease.
Methods—TABS was prospectivelyperformed in 213 patients with Crohn's disease in a university basedinflammatory bowel disease referral centre. Thirty three underwentresective bowel surgery and were included in this study. The accuracyof TABS to detect strictures, intra-abdominal fistulas, or abscesseswas compared with surgical and pathological findings.
Results—TABS was able to identifystrictures in 22/22 patients and to exclude it in 10/11 patients (100%sensitivity, 91% specificity). Fistulas were correctly identified in20/23 patients and excluded in 9/10 patients (87% sensitivity, 90%specificity). Intra-abdominal abscesses were correctly detected in 9/9patients and excluded in 22/24 patients (100% sensitivity, 92% specificity).
Conclusions—In experienced handsTABS is an accurate method for the detection of intestinalcomplications in Crohn's disease. TABS is thus recommended as aprimary investigative method for evaluation of severe Crohn's disease.

Keywords:Crohn's disease complications; fistula; stricture; abscess; bowel sonography

     

Clinical features of patients with negative results from traditional diagnostic work-up and Crohn's disease findings from capsule endoscopy

INTRODUCTION: Capsule endoscopy (CE) can detect Crohn's disease in patients with suggestive symptoms but with negative results from the traditional diagnostic work-up (ileocolonoscopy and small bowel follow-through). The objective of this study was to determine which clinical features predict the diagnosis of Crohn's disease by CE in this subgroup of patients. MATERIAL AND METHODS: Twenty-three patients (7 men, 16 women; mean age: 40+/-15 y) with negative results from conventional imaging techniques were prospectively included in the study because of suspicion of Crohn's disease (long-standing abdominal pain and/or diarrhea and at least one of the following symptoms: anemia, weight loss, long-standing fever, perianal disease, extraintestinal manifestations typical of inflammatory bowel disease, elevated inflammatory parameters, or family history of inflammatory bowel disease). RESULTS: CE diagnosed Crohn's disease in 6 patients (26%). Crohn's disease diagnosis was more frequent in patients with a combination of anemia and elevated inflammatory parameters than in patients without this combination (57% vs. 12.5%; P=0.04). The only statistically significant association between an inflammatory parameter and Crohn's disease was an increased platelet count. CONCLUSIONS: CE is a useful tool for the diagnosis of subtle small bowel Crohn's disease. The diagnostic yield of CE in patients with suspicion of Crohn's disease but negative results from the traditional diagnostic work-up is significantly higher in patients with anemia and increased platelet count than in patients without this combination of clinical features.     

Systematic evaluation of the causes of chronic watery diarrhea with functional characteristics

BACKGROUND Causes of chronic watery diarrhea are multiple. There is not definite scientific evidence about AND AIMS: which are the recommended explorations to be performed in the diagnostic workup of patients with functional diarrhea. The aim was to assess prospectively the presence of gluten-sensitive enteropathy, bile acid malabsorption, and sugar malabsorption in consecutive patients with chronic watery diarrhea of obscure origin fulfilling Rome II criteria of functional disease. METHODS: A total of 62 patients with chronic watery diarrhea, defined as more than 3 loose or liquid bowel movements a day for at least 4 wk and a stool weight >200 g/day were included. The following tests were performed: (a) HLA-DQ2/DQ8 genotyping, and if positive, endoscopic biopsies from distal duodenum were obtained, and intestinal damage assessed; (b) SeHCAT (Se-homotaurocholate) abdominal retention test; (c) small bowel follow-through; and (d) hydrogen breath test (lactose, fructose + sorbitol). Gluten- or sugar-free diet, or cholestyramine was administered according to results. Functional disease was diagnosed if all tests performed were normal or if either there was no response to specific therapy or diarrhea relapsed during a 12-month follow-up. RESULTS: Bile acid malabsorption was considered to be the cause of diarrhea in 28 (45.2%) patients, sugar malabsorption in 10 (16.1%), gluten-sensitive enteropathy in 10 (16.1%), and both bile acid and sugar malabsorption in 2 patients. Twelve (19.4%) patients remained without a specific diagnosis and were considered as functional bowel disease. Diarrhea stopped in the 50 patients after specific treatment, decreasing the daily stool number from 5.4 +/- 0.3 to 1.5 +/- 0.1 (P < 0.0005), without relapse after the 12-months follow-up. CONCLUSIONS: The diagnosis of functional disease in patients with chronic watery diarrhea should be performed with caution since in most cases there is an organic cause that justifies diarrhea.     

Intestinal spirochetosis and chronic watery diarrhea: clinical and histological response to treatment and long-term follow up

BACKGROUND: The clinical significance of intestinal spirochetosis is uncertain, therefore the aim of the present paper was to assess the prevalence of histological intestinal spirochetosis in patients with and without chronic watery diarrhea and to evaluate its clinical relevance. METHODS: A prospective diagnostic work-up of intestinal spirochetosis was made on biopsy samples taken from patients with chronic watery diarrhea submitted between 1994 and 2004 (1174 colonoscopies with multiple biopsies). Three other positive cases identified from routine endoscopic biopsies also were reviewed. In addition, samples from 100 asymptomatic control patients and a random sample of another 104 colonic specimens were reviewed for intestinal spirochetosis. The diagnosis was established by light and electron microscopy. Polymerase chain reaction (PCR) amplification of the 16S ribosomal RNA and reduced nicotinamide adenine dinucleotide (NADH) oxidase genes of the intestinal spirochetes Brachyspira aalborgi and Brachyspira pilosicoli was performed on tissue biopsies of the 11 positive patients. After diagnosis, treatment with penicillin benzatine (PB) or metronidazole was offered to all symptomatic patients and they were followed for a mean of 45.4 months (range: 37-113 months). RESULTS: Eight patients with chronic watery diarrhea were positive for intestinal spirochetosis. Intestinal spirochetosis was not diagnosed in the controls. Histological resolution of the infection paralleled clinical recovery in six patients (following metronidazole treatment in three). Most patients showed mild, non-specific colonic inflammation. Invasion by the spirochetes was not demonstrated by electron microscopy. Brachyspira aalborgi and B. pilosicoli each were identified by PCR in two cases. CONCLUSIONS: Histological intestinal spirochetosis appears to be relatively uncommon in Catalonia (Spain) compared to previous reports from other countries, but was identified in patients (0.7%) with chronic watery diarrhea. Sustained clinical recovery after spontaneous or drug-induced spirochetal disappearance in these individuals suggests that intestinal spirochetosis may play a pathogenic role in chronic watery diarrhea. Treatment with metronidazole is advisable in patients with persistent symptoms.     

Crohn's disease of the mouth: an indicator of intestinal involvement.

Nineteen patients with clinical evidence of oral Crohn's disease but no intestinal symptoms were studied. Oral lesions in all patients were shown histologically to have lymphoedema with or without chronic granulomas consistent with Crohn's disease. Seven patients (37%) had demonstrable intestinal disease on rectal biopsy and four of these had abnormal bowel radiology. All seven had evidence of nutritional deficiency. Patients with clinical features suggesting oral Crohn's disease may have evidence of Crohn's disease in the intestine, although this may not be clinically apparent.     

Small intestinal bacterial overgrowth mimicking acute flare as a pitfall in patients with Crohn's Disease

Background  

Small intestinal bacterial overgrowth (SIBO) is characterized by excessive proliferation of colonic bacterial species in the small bowel. Potential causes of SIBO include fistulae, strictures or motility disturbances. Hence, patients with Crohn's Disease (CD) are especially predisposed to develop SIBO. As result, CD patients may experience malabsorption and report symptoms such as weight loss, watery diarrhea, meteorism, flatulence and abdominal pain, mimicking acute flare in these patients.     

Influence of intestinal transit time on azo-reduction of salicylazosulphapyridine (Salazopyrin).

During a normal and an accelerated intestinal transit, in seven healthy volunteers, the recoveries of salicylazosulphapyridine (SASP) and its split products sulphapyridine (SP) and 5-aminosalicylic acid (5-ASA) were determined in urine and faeces. The azo-reduction of SASP and consequently the recovery of 5-ASA in the faeces was found to be substantially decreased during an accelerated intestinal transit. In addition, in 18 patients with inflammatory disease of the colon during maintenance therapy of SASP it could be demonstrated that the serum SP levels were related to the diarrhoeal state and did not correlate with disease activity. As recent studies have reported that 5-ASA is possibly the active therapeutic moiety of SASP, the ineffectiveness of SASP therapy in patients with active colitis may be ascribed to the reduced azo reduction of SASP as the result of profuse diarrhoea.     

Is Ileoscopy With Biopsy Worthwhile in Patients Presenting With Symptoms of Inflammatory Bowel Disease?

Objective : To assess the value of adding ileoscopy with biopsy to colonoscopy, hence increasing the indications for ileoscopy in patients presenting with symptoms of inflammatory bowel disease. Methods : Two hundred fifty-seven patients with persistent diarrhea and 43 patients with sporadic colonic polyps were studied prospectively. The final diagnosis based on clinical and follow-up data, the histology of multiple ileal biopsies, and endoscopic findings were analyzed. Results : Endoscopic lesions of the terminal ileum were found in 123 of 300 patients. In the 43 patients with colonic polyps, no ileal lesions were seen. Ileal disease without colonic involvement was present in 44 of 123 patients. Microscopic lesions of the ileum were present in 125 of 300, or in 125 of 257 (49%) with symptoms of diarrhea. Two of these had a normal endoscopy. Thirteen patients had a diffuse colitis and 11 had a predominantly left-sided colitis, both originally suggestive of ulcerative colitis. Crohn's disease was diagnosed in 88 patients and infectious disease in 17. Ileal biopsies were essential for the diagnosis in 15 patients and were contributive in 53. Granulomas, solitary giant cells, pseudopyloric gland metaplasia, eosinophils, and a disturbed villous architecture were the most important lesions observed in Crohn's disease and were contributive for this diagnosis. Conclusions : Ileoscopy with biopsy is useful in carefully selected patients presenting with symptoms of inflammatory bowel disease. The main indications are diagnosis of isolated ileal disease in the presence of a normal colon and differential diagnosis in patients with pancolitis and predominantly left-sided colitis. Multiple biopsy specimens show definite pathology in almost half of the patients.     

Assessment of the prevalence of infection with Helicobacter pylori in patients with inflammatory bowel disease

OBJECTIVE: To determine the prevalence of Helicobacter pylori in patients with inflammatory bowel disease (IBD) and compare this to the prevalence in a control population with non-organic bowel symptoms, and to investigate the effect of sulphasalazine and other 5-aminosalicylic acid (5-ASA) drugs on the prevalence of H. pylori in IBD patients. DESIGN: Prospective, controlled trial. SETTING: Gastroenterology out-patient department, City General Hospital, North Staffordshire Hospitals NHS Trust, Stoke-on-Trent. PARTICIPANTS: The population comprised 51 patients with ulcerative colitis, 42 patients with Crohn's disease and 40 patients with irritable bowel syndrome as controls. Patients with X-ray- and/or biopsy-proven disease were eligible to be entered into the study. INTERVENTIONS: Subjects filled in a detailed questionnaire, were assessed for seropositivity of H. pylori and underwent a C13 urea breath test (UBT). MAIN OUTCOME MEASURES: Seropositivity for H. pylori and a positive C13 UBT result. RESULTS: A quarter of the irritable bowel syndrome controls were seropositive for H. pylori. Of the ulcerative colitis patients, 21.6% were currently H. pylori-positive on C13 UBT; 17.6% of the ulcerative colitis patients who had been previously treated with sulphasalazine were positive while 23.1% of the ulcerative colitis patients who had been treated with a non-sulphasalazine 5-ASA drug were positive. Of the Crohn's patients, 11.9% were currently H. pylori-positive; 3.6% of the Crohn's patients who had been previously treated with sulphasalazine were positive while 12.5% of the Crohn's patients who had been treated with a non-sulphasalazine 5-ASA drug were positive. CONCLUSIONS: Patients with IBD and Crohn's disease in particular were less likely to be H. pylori-positive than controls. Sulphasalazine treatment further decreased the prevalence of H. pylori, although the reduced prevalence of H. pylori in IBD patients could not be accounted for by this alone.     

Usefulness of colonoscopy with biopsy in the evaluation of patients with chronic diarrhea

OBJECTIVE: Patients referred for chronic diarrhea frequently undergo endoscopic evaluation. There are limited data on the role for colonoscopy with biopsy and ileoscopy for patients with chronic diarrhea. METHODS: We reviewed the charts of 228 patients with chronic diarrhea evaluated by colonoscopy between November 1995 and March 1998. Chronic diarrhea was defined as loose, frequent bowel movements for a minimum of 4 wk. Patients were excluded if biopsies were not performed in normal colons, if they had undergone previous bowel surgery, a history of inflammatory bowel disease, HIV, or an inadequate colonoscopy. RESULTS: One hundred sixty-eight patients were included in the analysis, of whom 142 (85%) had ileoscopy. Colonoscopy and biopsy yielded a specific histological diagnosis in 52 (31%) patients. These included Crohn's disease (9), ulcerative colitis (7), lymphocytic colitis (10), collagenous colitis (3), ischemic colitis (3), infectious colitis (6), and miscellaneous diseases (14). Ileoscopy yielded significant findings in 3% of patients (four with Crohn's disease and one with infection). CONCLUSIONS: Colonoscopy and biopsy is useful in the investigation of patients with chronic diarrhea yielding a histological diagnosis in 31% of patients without a previous diagnosis. Ileoscopy complemented colonoscopy findings in a minority of patients with chronic diarrhea and was essential for a diagnosis in only two patients.