炎症性肠病诊断与治疗的共识意见(2018年，北京)溃疡性结肠炎部分解读

2018年5月,中华消化杂志在线发表了中华医学会消化病学分会炎症性肠病学组制订的《炎症性肠病诊断与治疗的共识意见(2018年,北京)》,该共识意见在2012年共识意见的基础上对炎症性肠病的诊治进展进行了更新与完善,为医务人员规范诊治炎症性肠病提供了更新、更全面的依据。本文主要对共识意见中溃疡性结肠炎的诊断和治疗部分进行解读,以期加深临床医师对新共识的认识与理解,提高溃疡性结肠炎的诊治水平。     

克罗恩病的诊断思路及鉴别诊断要点(连载四)

克罗恩病[Crohn(CD)病]可发生在从口腔到肛门整个消化道的任何部位,常有并发症及肠外表现,临床表现复杂多样,误诊情况极为普遍,为提高对本病的认识,减少误诊,通过复习有关资料,结合自己有限的临床体会,提出诊断思路,分析误诊原因,与几个极易混淆的疾病重点进行鉴别。     

炎症性肠病妊娠期管理的专家共识意见

炎症性肠病大多于中青年发病, 会面临生育问题, 故加强妊娠前咨询、优化妊娠期管理可改善不良妊娠结局, 提高患者生命质量。本共识基于循证医学依据和Delphi方法, 在妊娠前指导和管理、妊娠期管理、分娩方式、哺乳期管理和婴儿疫苗接种共5个方面达成初步共识, 为临床工作提供指导。     

克罗恩病的鉴别诊断

临床上大多CD的肠镜不典型,与其他疾病的肠镜表现互相重叠,其鉴别诊断极为困难。其中CD与肠结核（ITB）的鉴别尤为困难又特别重要,因二者的治疗完全不同。CD与ITB有相同的好发部位和临床表现,有各自的典型肠镜表现,但不典型的病变内镜几乎无法区别时,则主要依靠病理和肠外表现等综合分析。另一个容易误诊为CD的是肠淋巴瘤,误诊最主要原因是一次活检病理往往不能发现淋巴瘤,这与活检取材及病理阅片经验有关。所以,多次多部位活检及仔细病理阅片（必要时免疫组织化学、基因重排或原位杂交）是避免淋巴瘤误诊漏诊的关键。此外,发现病变不符合典型CD表现时还应想到肠白塞病、非甾体类消炎药所致药物性肠病及其他少见原因肠病的可能,通过反复活检病理、结合各自的临床特点大都可以予以鉴别。     

炎症性肠病的内镜诊断探讨

目的：探讨炎症性肠病的内镜诊断的方法和思路，并就内镜对它的诊断价值予以评估。方法：回顾本院近5年来住院治疗的确诊（包括在上级医院确诊）的28例炎症性肠病病例的内镜诊断资料并复习有关文献。结果：内镜对炎症性肠病中溃疡性结肠炎和克罗恩病的诊断准确性分别为80％和50％。结论：内镜及活检是炎症性肠病不可或缺的诊断手段．但是对炎症性肠病表现只有相对的特异性。内镜追踪观察是提高确诊率和了解病情进展的主要手段。     

炎症性肠病－－炎症性肠病的病理诊断与鉴别诊断

1　克隆病 (Crohn’sdisease ,CD )克隆病病变主要累及回肠末端和近段结肠 ,其次为远段结肠、近端回肠和空肠等处 ,直肠常不受累。另外还可以累及消化管的任何部位。统计分析提示 ,约 40 %的病例病变仅累及小肠 ,3 0 %病变限于结肠 ,3 0 %的病例病变同时见于小肠和结肠。典型的病例病变呈节段性 ,故又有局限性肠炎之称。1 1　大体检查　肠管局限性病变 ,跳跃式损害 ,病变之间为正常肠壁。最早、最明显的损害是细小而边界清楚的黏膜溃疡 ,称为“阿弗他”溃疡 (或鹅口疮样溃疡 ) ,常呈多灶性分布 ,这是在黏膜淋巴小结上形成的溃疡。以后随着…     

炎症性肠病－－炎症性肠病的内镜诊断

结肠克罗恩病与溃疡性结肠炎同属非特异性炎症性肠病 ,二者在病因、临床表现和治疗上有一些共同之处。克罗恩病可发生于胃肠道任何部位 ,虽可发生在结肠 ,但小肠和胃、盲肠的病变更为多见。本病在欧美发病率高 ,东方国家较为少见。1980年北京协和医院等北京四家大医院对手术和病理确诊的14 5例克罗恩病分析的结果表明 ,本病单纯分布于结肠者仅占全部病例的 7 6% ,而合并小肠病变者近半数 ,尤其病变好发于回盲肠。溃疡性结肠炎在西方国家多见 ,北欧和北美的年发病率为 2 / 10万～ 10 / 10万人群 ,高发年龄在 3 0～ 60岁 ,女性略高于男性 ,我…     

克罗恩病的诊断及鉴别诊断

目的研究克罗恩病（Crohn病）的发病规律、诊断和鉴别诊断。方法对有完整资料的56例Crohn病的临床、x线气钡双重对比造影影像学、结肠镜及病理资料进行回顾性研究。结果56例Crohn病间歇性腹泻51例,右下腹痛53例,累及远端小肠44例,升结肠26例,横结肠6例,溃疡56例,“阿弗他”溃疡20例,裂隙状溃疡54例,局灶性、节段性溃疡44例,病变间由正常肠黏膜相隔,鹅卵石征34例,瘘管或窦道5例,“脂肪外套”4例,肠壁全层炎细胞浸润50例,水铅管样肠腔狭窄8例,非干酪性肉芽肿12例。结论Crohn病发病具有一定的规律性,上述病变中的任何一条都不是特异性诊断指标,其诊断和鉴别诊断应结合临床、x线气钡双重对比造影及内窥镜检查等综合性指标。     

炎症性肠病的影像学诊断

炎症性肠病（inflammatory bowel disease,IBD）是一种病因不明的慢性非特异性肠道炎症性疾病,包括克罗恩病（Crohn’s disease,CD）和溃疡性结肠炎（ulcerative colitis,UC）。影像学检查是诊断IBD的重要手段,目前主要包括X线钡剂检查和CT、MRI,其不仅可确诊IBD、鉴别CD与UC,还能评价病变的累及范围和严重程度；判断有无肠外并发症．并对临床疗效进行随访。     

炎症性肠病－－炎症性肠病的临床表现、诊断及鉴别诊断

炎症性肠病 (inflammatoryboweldisease ,IBD)是一组病因不明的慢性、反复发作性肠道非特异炎症性疾病 ,包含了两个独立的疾病 ,溃疡性结肠炎 (ulcerativecolitis ,UC)和克罗恩病(Crohndisease ,CD) ,二者在临床表现、诊断、鉴别诊断方面各有特点。1　IBD的临床表现1 1　腹泻与血便　UC患者活动期多是黏液脓血便 ,重症可致大出血 ,轻症大便每日数次 ,重症可达 10余次以上。缓解期便次减少 ,无脓血或排便正常。CD患者常有糊状便 ,每日数次 ,常无脓血 ,如直肠受累或急性发作时可有便血。1 2　腹痛　两者均有腹痛 ,UC病变多累及直肠、乙…     

365例炎症性肠病、缺血性肠炎临床与病理诊断分析

目的探讨炎症性肠病、缺血性肠炎临床与病理诊断的符合率及临床特点,提高临床诊断水平。方法回顾性分析365例符合中华医学会消化病分会制定的炎症性肠病诊断治疗规范标准,临床诊断的溃疡性结肠炎(UC)270例、克罗恩病(CD)55例、缺血性肠炎40例,对其与病理诊断的符合率,发病年龄,临床特征,肠外合并症进行分析。结果3种疾病临床诊断与病理诊断的总符合率252/365(83.6%),UC组符合率最高为99.3%(268/270);CD和缺血性肠炎组分别为40.0%(22/55)和37.5%(15/40),显著低于UC组(P<0.001)。发病平均年龄:UC组(30.5±15.2)岁;CD组(24.5±13.4)岁;缺血性肠炎组(62.9±20.5)岁,缺血性肠炎组显著偏高(P<0.001)。腹痛、腹泻、便血的出现率:UC组88.2%(238/270)、98.2%(265/270)、27.0%(73/270);CD组65.5%(36/55)、10.9%(6/55)、12.7%(7/55);缺血性肠炎组100%(40/40)、20.0%(8/40)、95.0%(38/40)。UC组腹痛、腹泻发生率较高,而缺血性肠炎组便血的发生率较高。肠管外合并症的出现率和种类:UC组34.1%(92/270)、26种肠管外合并症;CD组36.4%(20/55)、20种肠管外合并发症;缺血性肠炎组35.0%(14/40)、6种肠管外合并症。结论CD和缺血性肠炎的病理诊断符合率不高,应提高病理诊断的准确率。发病年龄、临床症状、肠管外合并症对炎症性肠病与缺血性肠炎的诊断有重要的参考价值。     

Fecal markers in the management of inflammatory bowel disease

Inflammatory bowel disease (IBD) is characterized by periods of symptomatic remission and relapse. Diagnosis and assessment of IBD are based on clinical evaluation, serum parameters, radiology, and endoscopy. Fecal markers have emerged as new diagnostic tools to detect and monitor intestinal inflammation. Fecal calprotectin (FC) and lactoferrin (FL) were identified decades ago as potentially revolutionary markers for IBD. Following these discoveries numerous additional markers, including S100A12, M2-PK, metalloproteinases, hemoglobin, myeloperoxidase, lysozyme, polymorphonuclear elastase, neopterin, and nitric oxide, have also been suggested as novel markers of IBD. But only FC and FL are used for the management of clinical IBD patients. The objective of this review is to introduce the clinical applications of fecal markers in the diagnosis, monitoring and prediction of outcomes of inflammatory bowel disease.     

Molecular diagnosis and classification of inflammatory bowel disease

Introduction: Traditional diagnosis and classification of inflammatory bowel diseases (IBDs) have been based on clinical evaluation, laboratory testing, endoscopy, imaging, and histological examinations. With the advancement of medical technology, an increasing number of molecular surrogates are playing a key role in diagnosis, differential diagnosis, assessment of disease activity, prediction of clinical course, and therapeutic response of IBD.

Areas covered: The authors review roles of both existing and emerging surrogates including genetic, serological, histologic, and fecal markers in diagnosis and classification of IBD. Comparisons in advantages and disadvantages of different markers have also been discussed. In addition, this review underscores controversial and unclear aspects which need further study.

Expert commentary: IBD is characteristic of chronicity, relapse-remission and destructiveness. It is of great importance for clinicians to make an accurate diagnosis and classification. Current and new molecular markers perform well with acceptable sensitivity and specificity. The use of molecular markers in clinical practice needs to be further explored and then generalized. More work is warranted to identify novel useful markers and elucidate how to apply them together with current markers in clinical settings.     

炎症性肠病回盲部溃疡内镜下特征性表现与鉴别诊断

目的观察回盲部溃疡性病变黏膜特征性改变,初步诊断和鉴别诊断,为临床诊断提供有力依据。方法收集该院自2008年1月-2014年12月行结肠镜检查诊断为炎症性肠病性溃疡43例,观察溃疡特点及黏膜特征性改变。结果回盲部溃疡性病变内镜下特征性表现主要分为3种:溃疡表浅斑片地图状、溃疡较深不规则,沟槽状和回盲瓣瓣口受累变形伴假息肉形成。结果显示以上3种内镜下特征性改变,在单项及两组构成比方面,溃疡性结肠炎(UC)患者和克罗恩病(CD)患者比较,差异有统计学意义(P0.01),可以作为根据其作出初步的鉴别诊断。结论 CD、UC均缺乏诊断的金标准,诊断需结合临床、内镜和组织病理学表现进行综合分析并随访观察,但有一定的特征性表现及规律可循。所以在组织病理学没有充分证据的情况下,观察病变的内镜下特征性表现就显得尤为重要,可能会对临床诊断提供有力的依据。降低此类病变在诊断上的盲目性,提高回盲部溃疡性病变病因确诊率。     

儿童重症克罗恩病2例并文献复习

目的:探讨儿童克罗恩病(Crohn′s,CD)的临床特点及诊断和治疗,以提高儿童CD的诊断、治疗水平,减少急重型病例的误漏诊。方法:回顾我院2007年经内镜、手术和病理证实的2例儿童重症CD,并结合近期文献进行分析。结果:2例儿童重症CD均并发肠道多发穿孔,行外科病变肠段切除。并经儿内科治疗后缓解出院,目前仍在随访。结论:儿童CD早期诊断极为困难,易误漏诊。内镜加组织学是诊断CD的金标准,胃肠道直接显影对于明确儿童肠道炎症的部位、范围和类型极为重要。除皮质类固醇、氨基水杨酸类药物治疗外,可选用免疫调节制剂治疗。肠穿孔是炎症性肠病最主要的并发症和儿童CD主要的死亡原因。     

经腹肠道超声诊断小肠克罗恩病并发症

目的 评估经腹肠道超声（TBUS）诊断小肠克罗恩病（SBCD）并发症的价值。方法 回顾性分析25例确诊SBCD患者10年42例次超声检查,包括活动期26例次（活动期组）、缓解期16例次（缓解期组）的声像图特征,观察超声评估病变活动度结果与Harvey-Bradshaw指数（HBI）的一致性。结果 TBUS与HBI评估病变活动度的一致性较高（Kappa=0.897）。瘘、脓肿、炎性包块均见于活动期组;活动期组狭窄、爬行脂肪征、淋巴结炎、腹腔积液等发生率均明显高于缓解期组（P均<0.05）,肠壁及爬行脂肪厚度明显大于缓解期组（P均<0.01）。42例次超声检查中,15例次见肠管狭窄,8例次见瘘;31例次病变肠壁周围脂肪组织炎性增生,20例次见多发肠系膜淋巴结炎;腹腔积液16例次,腹部包块9例次,其中5例次伴脓肿,穿孔1例次,炎性息肉8例次,憩室形成3例次。结论 TBUS能准确显示SBCD腹部并发症,可作为评估SBCD并发症的常规影像学检查手段。     

Treatment of inflammatory bowel disease by leukocytapheresis

Studies about leukocytapheresis have emerged with the need of search for alternatives to conventional treatment in inflammatory bowel diseases (IBD). Leukocytapheresis is a novel non-pharmacologic approach for active ulcerative colitis (UC) and Crohn’s disease (CD), in which leukocytes are mechanically removed from the circulatory system. Patients with active IBD treated with leukocytapheresis using a Cellsorba E column between 2012 and 2015, were enrolled in Turkey. In our experience, the results of leukocytapheresis therapy in 6 patients with CD and 20 patients with active UC were overviewed. Leukocytapheresis (10 sessions for remission induction therapy, 6 sessions for maintenance therapy) was applied to the patients with their concomitant medications. Intensive leukocytapheresis (≥4 leukocytapheresis sessions within the first 2 weeks) was used in 30% patients with active severe UC. The overall clinical remission rate in patients with UC was 80%, and the mucosal healing rate was 65%. Patients were followed for an average of 24 months. It was observed that clinical remission has continued in 65% of patients with UC. Mild relapse was observed in 3 patients with UC during follow up period. In 5 patients with CD significant clinical remission was achieved except only one patient. Surgical needs were disappeared in 3 patients with obstructive type Crohn’s disease. Adverse events were seen in only 4.3% of 416 sessions. Any concomitant medications did not increase the incidence of adverse events. Our results indicate that leukocytapheresis is efficacious in improving remission rates with excellent tolerability and safety in patients with IBD.