克罗恩病致回肠膀胱瘘1例

病例:患者,男性,43岁,因"腹痛、腹泻2月余"收治入院。患者入院前2个月起无明显诱因出现下腹隐痛,为阵发性,伴腹泻,最多达7～8次/d,为夹杂黏液的稀便,无恶心、呕吐,无发热。入院2 d后发现尿液内含有食物残渣和粪渣样物。否认结核病、疟疾史。查体:体温37℃,脉搏70次/min,呼吸18次/min,血压120/70 mm Hg(1 mm Hg=0.133 kPa);腹部平坦,全腹无压痛、肌紧张和反跳痛,未及腹部包块,移动性浊音阴性,肠鸣     

回肠末端巨大溃疡伴狭窄

回肠末端是小肠病变的好发部位,但多数疾病无诊断金标准,患者的症状、体征和实验室检查等缺乏特异性,给疾病的病因诊断和治疗带来了不小难度。本例患者病史长,以口腔、外阴和回肠末端溃疡为主要表现,先后并发不全性肠梗阻、消化道出血,经消化内科、消化外科、病理科、影像科等多学科协作诊治,最初考虑白塞病可能,最终诊断为CD,经积极治疗病情得以控制。     

克罗恩病患者用药变化10年回顾性分析

目的 总结空军军医大学西京医院消化内科克罗恩病（CD）患者10年的用药趋势变化。方法 回顾性分析2010—2019年10年间,西京医院IBD中心确诊CD患者的临床一般信息资料、患者用药情况,其中将CD患者根据用药时间段分为2010—2014年组与2015—2019年组,分别分析两组CD患者的一般情况和用药趋势,再根据患者性别和年龄（≤40岁和>40岁）进行亚组分析。结果 2015—2019年组与2010—2014年组分别纳入164和140例CD患者,2010—2014年组和2015—2019年组患者年龄和女性比例比较[（37.2±14.5）岁比（34.7±13.7）岁,30.0%(42/140)比40.9%(67/164)],差异均无统计学意义（P>0.05）。2015—2019年组免疫抑制剂和生物制剂使用率均高于2010—2014年组[50.6%(83/164)比32.1%(45/140)、52.4%(86/164)比23.6%(33/140)],差异均有统计学意义（χ2=10.566、χ2=26.421,P<0.001）。2010—2014年组和2015—2019...     

克罗恩病患者贫血因素分析及其临床意义

背景：我国克罗恩病（CD）的发病率日益增长,其伴随的疾病如贫血等正逐渐受到关注。目的：探讨CD患者贫血因素及其临床意义。方法：纳入2011年6月～2012年8月同济大学附属第十人民医院40例CD患者,比较不同蒙特利尔分型的患者之间血红蛋白（Hb）、血清铁、总铁结合力、叶酸、维生素B12水平,并分析克罗恩病活动指数（Ct）AI）、CRP水平与Hb、血清铁的相关性。结果：34例（85．0％）CD患者伴有贫血。不同蒙特利尔分型的CD患者之间Hb、血清铁、总铁结合力、叶酸水平无明显差异（P=0．2061,P=0．2449,P=0．8007,P=0．8804）,而维生素B12水平差异有统计学意义（P=0．0072）。CDAI、CRP与Hb、血清铁均呈负相关（P〈0．05）。结论：L1型和L3型CD患者存在维生素B12相关贫血。CD患者Hb、血清铁水平下降与疾病炎症活动度增加有一定关联。     

回肠末端淋巴滤泡增生症与慢性末端回肠炎的关系探讨

近年来随着结肠内镜技术的不断提高，对末端回肠疾病的认识更加深入，但回肠淋巴滤泡增生症与慢性末端回肠炎的关系仍不十分清楚。我院通过对二者临床表现、内镜下改变、病理学改变进行对比分析，探讨二者的关系及其病因和发病机制。     

中国人群克罗恩病患者贫血的发生率及临床特点分析

 目的 调查中国人群克罗恩病(CD)患者初次诊断时的贫血发生率及特征,探讨引起贫血的可能原因及危险因素。方法 纳入2003年1月至2012年5月于中山大学附属第一医院住院及门诊就诊的CD患者441例。分析确诊为CD患者首次就诊时贫血的发生率、严重程度及类型,并对其中资料齐全的122例患者进行多因素logistic回归分析,以探讨CD患者贫血发生的可能危险因素。结果 64.4%(284/441) 患者达到贫血标准,其中,轻度贫血占69.0%(196/284),中度贫血占28.9%(82/284),重度贫血占2.1%(6/284);贫血类型以小细胞低色素性贫血为主（43.7%,124/284）。多因素logistic回归分析提示,校正的克罗恩病疾病活动指数(CDAI)偏高(OR=1.007,95%CI 1.002~1.013)、血小板计数增加 (OR=1.007,95%CI 1.001~1.012)、红细胞沉降率增加(OR=1.024,95%CI 1.000~1.048)、穿透型(OR=16.925,95%CI 2.626~108.626)或狭窄型(OR=6.717,95%CI 1.583~28.507)、确诊年龄大(OR=1.065,95%CI 1.012~1.121)及体重指数（BMI）偏低(OR=0.769,95%CI 0.633~0.935)均可能增加CD患者发生贫血的风险。结论 贫血是CD常见并发症。炎症活动、穿透型或狭窄型疾病行为、确诊年龄大、BMI低均为CD患者贫血的危险因素。     

NOD2/CARD15基因多态性与克罗恩病患者相关性研究

目的NOD2/CARD15基因是人类的第一个克罗恩病(CD)易感基因,其间的3个单核苷酸多态性(SNPs)与白种人CD有显著性相关,但与日本人无关。本研究旨在证实这3个SNPs是否与浙江地区人群的CD易感性有关。方法血样来自浙江地区32例CD患者,110例溃疡性结肠炎患者及292例健康对照者。通过PCRSSP方法直接检测野生型及NOD2/CARD15基因的3个多态性(Arg702Trp,Gly908Arg,Leu1007fsinsC)。结果没有发现1例CD患者纯合子或杂合子的SNPs突变,同样在溃疡性结肠炎患者和健康人中也未能检测到。结论本研究表明一些存在于特定人群的CD易感基因可能在其他人群中不存在,白种人CD患者相关的易感基因NOD2/CARD15常见的3个SNPs与浙江地区CD人群无关。     

炎症性肠病的病因与发病机制

炎症性肠病(inflammatory bowel disease,IBD)是一组病因未明的慢性肠道炎症性疾病,指慢性非特异性溃疡性结肠炎(ulcerative colitis,UC)和克罗恩病(Crohns disease,CD)。大约10％的结肠炎症尚不能区别是CD抑或UC,在西方国家称为不明确的结肠炎(indeterminate colitis)。随访研究可发现这些患者大多数发展成为UC。迄今,IBD的病因不明,目前认为是由多因素相互作用所致,主要包括环境、免疫以及遗传等因素。发病机制的假设是感染、饮食等环境因素作用于遗传易感的人群,使之肠免疫反应过度亢进导致肠粘膜损伤,但目前还不清楚这种过度亢进的免疫反应是特异的抗原     

克罗恩病治疗新目标：黏膜愈合

一直以来,传统治疗大多无法达到黏膜愈合的目标,生物制剂的应用改变了这一观念.黏膜愈合与克罗恩病的临床复发率以及手术率的减少存在一定的关系.黏膜愈合已逐渐成为克罗恩病药物治疗的临床研究以及日常临床实践的客观指标.早期积极的药物治疗可取得更好的临床疗效和更高的黏膜愈合率这一事实正逐渐得到认同.促进并维持黏膜愈合可能有助于改变克罗恩病的自然病程.     

回肠末端炎的临床、内镜、病理学及病因学探讨

目的：研究回肠末端炎的临床、内镜、病理学及超微结构、细菌学改变的特点及病因学。材料与方法：全部病例均行内镜及病理学检查，１５例作细菌学检查，７例作电镜检查。结果：１．本病的临床表现无特异性（Ｐ＞０．０５）；易与结肠疾病并存但又不同于小肠疾病。２．本病的内镜下改变与病理学改变一致。３．本病多有回盲瓣舒缩功能异常（Ｐ＜０．０１）。４．病灶处杯状细胞增多，吸收细胞变性或坏死。５．本病有细菌失衡：保护性细菌减少，且回盲瓣内外细菌改变一致（Ｐ＞０．０５）。结论：本文分析了本病临床、内镜、病理学的变化特点。推测本病可能与感染和免疫反应有关。同时指出，结肠－－回肠反流在本病发生中的重要作用．     

Histology of the terminal ileum in coeliac disease

Background: The histological lesion of gluten sensitivity primarily affects the proximal small bowel. The purpose of this study was to assess whether there were features of gluten‐sensitive enteropathy in biopsies taken from the terminal ileum during colonoscopy/ileoscopy. Specific and sensitive abnormalities might facilitate diagnosis of coeliac disease in patients undergoing colonoscopy as their initial procedure or help select those who should proceed to upper gastrointestinal endoscopy and duodenal biopsy. Methods: Terminal ileal biopsies, taken from 30 patients with duodenal villous atrophy consistent with coeliac disease and from 60 control patients with no evidence of coeliac or inflammatory bowel disease, were reviewed blindly and compared. Biopsies were assessed for the presence or absence of villous atrophy and crypt hyperplasia, and counts were made of intraepithelial lymphocytes (IELs). Results: One patient only, in the coeliac group, had partial villous atrophy with crypt hyperplasia in the terminal ileum. IEL counts were significantly higher (P?Conclusions: Coeliac disease may affect the entire small bowel. Increased IEL density in the terminal ileum is associated with duodenal VA and should prompt a search for coeliac disease by serology and duodenal biopsy. Conversely, a normal IEL count does not allow the exclusion of coeliac disease with confidence.     

Elevated basal intestinal mucosal cytokine levels in asymptomatic first-degree relatives of patients with Crohn's disease

AIM To determine levels of cytokines in colonic mucosa of asymptomatic first degree relatives of Crohn's disease patients.METHODS Cytokines (Interleukin (IL) 1-Beta,IL-2, IL-6 and IL-8) were measured using ELISA in biopsy samples of normal looking colonic mucosa of first degree relatives of Crohn's disease patients (n = 9) and from normal controls (n=10) with no family history of Crohn's disease.RESULTS Asymptomatic first degree relatives of patients with Crohn's disease had significantly higher levels of basal intestinal mucosal cytokines (IL-2, IL-6 and IL-8) than normal controls. Whether these increased cytokine levels serve as phenotypic markers for a genetic predisposition to developing Crohn's disease later on, or whether they indicate early (preclinical) damage has yet to be further defined.CONCLUSION Asymptomatic first degree relatives of Crohn's disease patients have higher levels of cytokines in their normal-looking intestinal mucosa compared to normal controls.This supports the hypothesis that increased cytokines may be a cause or an early event in the inflammatory cascade of Crohn's disease and are not merely a result of the inflammatory process.     

Diverticulitis of the terminal ileum

In the past two decades, several reports have documented inflammatory changes in acquired diverticula of the terminal ileum and their associated complications, namely, perforation, intestinal obstruction, gastrointestinal hemorrhage, and fistulization. A comprehensive review revealed 28 cases of diverticulitis of the terminal ileum documented in the world medical literature. Only one case of internal fistula (ileovesical) has been reported previously. This report describes another patient with diverticulitis of the terminal ileum with associated perforation and jejunoileal fistula and reviews the world literature.     

慢性重型肝炎患者中性粒细胞超微结构的改变

目的观察慢性重型肝炎患者中性粒细胞超微结构的改变及其意义。方法采用透射电镜对１５例慢性重型肝炎患者中性粒细胞超微结构进行观察，并以１５例正常人为对照。结果慢性重型肝炎患者中性粒细胞有明显异常，表现为胞浆稀疏，吞噬空泡，细胞器及细胞颗粒明显减少，线粒体水肿、空化、退变，细胞核浓缩等，病情严重及继发严重感染者尤著。结论观察中性粒细胞的超微结构变化对判断慢性重型肝炎患者防御细菌感染能力以及肝衰竭程度有一定的参考价值。     

Decreased expression of serotonin in the jejunum and increased numbers of mast cells in the terminal ileum in patients with irritable bowel syndrome

AIM： To investigate if there are changes in serotonin （5-HT） levels, enterochromaffin （EC） cells and mast cells in small intestinal mucosa of patients with irritable bowel syndrome （IBS）. METHODS： Diarrhea-predominant （IBS-D, n = 20）, or constipation-predominant （IBS-C, n = 18） IBS patients and healthy controls （n = 20） underwent colonoscopy and peroral small intestinal endoscopy, and mucosal samples were obtained at the descending part of the duodenum, proximal end of jejunum and terminal ileum. High-performance liquid chromatographyelectrochemistry and immunohistochemical methods were used to detect 5-HT content, EC cells and mast cells. RESULTS： （1） There were no differences in the number and distribution of EC cells between IBS patients and the normal group. （2） The mucosal 5-HT contents at the duodenum, jejunum and ileum in IBS-C patients were 182 ± 90, 122 ± 54, 61 ± 35 ng/mg protein, respectively, which were all lower than those in the normal group （256 ± 84, 188 ± 91, and 93 ± 45 ng/ mg protein, respectively）, with a significant difference at the jejunum （P 〈 0.05）. There were no differences in the small intestinal mucosal 5-HT contents between IBS-D patients and the normal group. The mucosal 5-HT contents at the duodenum were significantly higher than those at the ileum in the three groups （P 〈 0.001）. （3） The numbers of mast cells in patients with IBS-C and IBS-D at the ileum were 38.7 ± 9.4 and 35.8 ± 5.5/highpower field （hpf）, respectively, which were significantly more than that in the normal group （29.8 ± 4.4/hpf） （P 〈 0.001）. There was no significant difference in the numbers of mast cells at the other two parts between IBS patients and the normal group. The numbers of mast cells in IBS-C, IBS-D, and normal groups were all significantly higher at the ileum （38.7 ± 9.4, 35.8 ± 5.5, 29.8 ±4.4/hpf, respectively） than at the duodenum （19.6± 4.7, 18.5 ± 6.3, 19.2 ±3.3/hpf, respectively, P 〈 0.001）. CONCLUSIO     

幽门螺杆菌感染对胃粘膜超微结构的影响

目的研究幽门螺杆菌（Ｈｐ）感染及其根除前后胃粘膜超微结构的变化．方法Ｈｐ感染患者１０例经三联疗法２８ｄ．Ｈｐ阴转７例于停药１月后及治疗前内镜下取胃窦粘膜，经切片染色后分别行透射电镜及扫描电镜观察．结果透射电镜显示，Ｈｐ聚集处上皮细胞微绒毛变短、减少或消失，细胞呈毛刺状或外突形成分枝状，细胞膜内侧粘液颗粒聚集，细胞破裂，释放粘液颗粒．扫描电镜下Ｈｐ横卧于微绒毛表面或垂直镶嵌在微绒毛里．应用三联疗法（德诺１２０ｍｇ＋四环素０２５ｇ＋呋喃唑酮１０ｍｇ，４次／ｄ）治疗２８ｄ，停药１月后７例Ｈｐ根除．电镜显示Ｈｐ消失，粘膜细胞变性逆转，上皮细胞及微绒毛结构恢复正常．结论Ｈｐ引起的胃粘膜超微结构损害在根除Ｈｐ后有改善及恢复     

克罗恩病和肠结核的组织病理学研究

目的：明确克罗恩病和肠结核的组织病理学特征，找出异同点。方法：利用手术切除的肠结核和克罗恩病理标本，观察其组织病理学特征并比较。结果：克罗恩病的特征为裂隙性溃疡、非干酪样坏死性肉芽肿、肿膜下层增宽；肠结核的特征为干酪样坏死、粘膜下层闭锁，肉芽肿融合，组织切片有许多相似之处，如微肉芽肿，全层炎症等，结论：典型的肠结核和克罗恩病易于鉴别，但二者组织病理学的相似性，给部分病例的鉴别诊断带来困难。     

Usefulness of magnifying endoscopic evaluation of the terminal ileum for a patient with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

The gastrointestinal tract is one of the common targets of acute graft-versus-host disease (GVHD), but accurate diagnosis is difficult because of the nonspecific nature of complicated diseases and the lack of diagnostic findings by conventional endoscopy. Recently, a magnifying endoscope has been developed and used for examining microstructures of the mucosa. Herein, we report the first use of a magnifying endoscope for a patient with gastrointestinal (GI) GVHD. Magnified endoscopic findings of atrophic and coalescent villi of the terminal ileum reflect histological findings of GVHD. Magnifying endoscopy of the terminal ileum may be useful for early detection and follow-up of GI GVHD.     

Why does Crohn's disease usually occur in terminal ileum?

Crohn's disease can affect any part of the gastrointestinal tract, but terminal ileum is the most frequent localization. The reason why Crohn's disease is primarily located in the distal part of the ileum remains unexplained.In this article it has been attempted to provide a compelling explanation why Crohn's disease usually occurs in terminal ileum. Recent data indicate that some individuals are genetically predisposed to develop ileal Crohn's disease. Two genetic alterations, the polymorphism of Caspase Associated Recruitment Domain (CARD15) and Carcinoembryonic Antigen-related Cell Adhesion Molecule 6 (CEACM6), favour the colonization of terminal ileum by entero adherent-invasive Escherichia coli (AIEC). The adhesion of these bacteria to epithelial intestinal cells depends on Carcinoembryonic Antigen-related Cell Adhesion Molecule 6 expression in ileal epithelial cells and on the reduced ileal defensins expressed in a CARD15 dependent manner. Genetic defects in Authophagy-related 16-like gene (ATG16L1) and Immunity-related Guanosine Triphospatase (IRGM) recently found in ileal CD patients lead to a reduction of bacterial killing by macrophages and consequent continuous immunological upstimulation, cytokine secretion, chronic inflammation of the ileum and tissue injury. On the basis of all these data Crohn's disease of the ileum seems to be a subset of the disease mainly genetically determined.