中国溃疡性结肠炎诊治规范的解析

溃疡性结肠炎(UC)在我国的发病率呈上升趋势,严重危害人民健康。迄今我国已发布4版UC诊断治疗规范,这些版本在涉及UC诊断治疗的各个方面均出现了较大的变化,体现了我国消化内科在UC诊治过程中对该病的理解不断深入、诊疗手段逐渐丰富方面,取得了长足的进步和发展,但我国UC的外科治疗与发达国家相比存在较大差距,包括手术指征、手术时机和术式规范等多个方面。本文从诊断标准、诊断内容、疗效标准和治疗建议等方面对我国UC诊治规范的演变进行解读分析,并针对我国UC的临床现状进行总结,对未来的发展趋势和工作方向进行展望。     

溃疡性结肠炎认识新视角

近年来随着对溃疡性结肠炎(UC)认识的深入、诊断技术的发展以及生物制剂等新药的研发与应用，各类共识指南对于UC的疾病评估、治疗方案和治疗目标等建议进行了调整与完善。本文从我国UC诊断现状、治疗目标的变化、生物制剂及传统药物的应用和急重症UC处理等方面对UC的诊治作一论述，以期对未来临床实践提供启发。     

溃疡性结肠炎癌变相关机制研究进展

炎症性肠病(inflammatory bowel disease, IBD)包括溃疡性结肠炎(ulcerative colitis, UC)的发病率在我国呈逐渐升高的趋势。随着诊治水平的进展，长病程的UC患者逐渐增多，发生结直肠癌(colorectal cancer, CRC)的风险明显增加。UC癌变的危险因素主要包括长病程、广泛肠段受累、累积炎症负担(cumulative inflammatory burden, CIB)、合并原发性硬化性胆管炎(primary sclerosing cholangitis, PSC)、CRC家族史等，其中炎症的反复发作是癌变的独立危险因素。结肠炎相关结直肠癌(colitis-associated colorectal cancer, CAC)与散发性CRC在癌变模式、发生机制、分子特征等方面均存在差异。本文将结合近年来的研究进展，详细阐述遗传和表观遗传的改变、氧化应激、异常免疫反应以及肠道菌群失调在炎癌转化中发挥的作用。基于危险因素对UC患者进行CAC风险分层，高危患者应进行更频繁的结肠镜监测以便早发现、早干预、早治疗。     

提高外科手术在溃疡性结肠炎治疗中的作用

溃疡性结肠炎(ulcerative colitis)是一种慢性、难治性疾病,我国溃疡性结肠炎的发病率近年呈上升趋势。约有20%～30%的溃疡性结肠炎患者需要接受外科手术治疗。适时、正确的手术治疗可以治愈溃疡性结肠炎,显著降低并发症与不良预后的发生率。然而我国对于溃疡性结肠炎的诊疗认知还存在一定的盲区,目前尚无规范性的炎症性肠病治疗体系和外科诊治指南,尚未在全国范围内开展溃疡性结肠炎的根治性手术—全结直肠切除回肠储袋肛管吻合术(IPAA术),国内炎症性肠病的手术比例不足5%。溃疡性结肠炎外科规范性治疗及外科技术发展水平远低于发达国家水平。因此,迫切需要提高各专业、各级医师对于溃疡性结肠炎诊治方案的知晓,制定IPAA手术技术规范,开展手术技术培训,弥补我国炎症性肠病诊治水平与发达国家的差距。     

溃疡性结肠炎的分期治疗

溃疡性结肠炎(ulcerative colitis,UC)是临床上常见的消化系统疑难病,治愈率低,易复发。研究证实,UC患者患结直肠癌、强迫症、恐慌症、抑郁症和焦虑症的概率较高,给生活带来了较大的困扰[1-2]。以往该病在北美和欧洲多见,近年来,我国UC的发病率呈上升趋势[3],但目前为止其确切的发病原因及机制尚不明确,因此治疗上只能控制急性发作,减缓疾病进程,减少并发症,使患者长期维持在缓解期,以提高生活质量,避免再次住院[4]。     

溃疡性结肠炎中西医结合诊疗指南(草案)

中国中西医结合学会消化系统疾病专业委员会于1992年山西临汾和2003年重庆全国中两医结合消化学术会议上分别制定了"慢性非特异性溃疡性结肠炎中西医结合诊断、辨证和疗效标准"[1]与"溃疡性结肠炎中西医结合诊治方案"[2].近年来,溃疡性结肠炎(Ulcerative colitis,UC)在国内外研究已经取得了一些重大进展[3～8],中华医学会消化病分会于2007年济南会议公布了"对我国炎症性肠病诊断和治疗规范的共识意见"[9].     

5-氨基水杨酸类药物有效预防炎症性肠病合并结直肠癌

在工业化国家，溃疡性结肠炎(UC)的发病率维持在0．005％-0.01％．其中以瑞典最高，英国和美国次之，我国的UC发病率较低。克罗恩病(CD)的发病率在过去30年内增加了6倍。现约为0．004％。尽管IBD合并的结直肠癌只占普通人群结直肠癌的1％～2％，但结直肠癌仍为IBD的严重并发症，是1／6 IBD患者的死亡原因^[1]。Eaden等^[2]对116项     

溃疡性结肠炎临床诊断指南

溃疡性结肠炎(UC)在西方较常见,而我国近来逐年增多,由此带来纷繁复杂的临床问题,引起了专业医生的高度重视。正确的诊断不仅是临床处理的第一要务,也是临床科研的首要条件。国外处理指南重在治疗,几经修改,不断补充完善;国内于1978年、1993年、2000年拟订的诊断标准与诊治规范建议(相当于诊断指南)对临床诊断具有指导意义,有必要认真复习,融汇贯通,以利规范行事,提高诊断水平。1国外UC诊断指南简介1·1西方沿用UC诊断标准西方国家现行诊断标准强调临床、内镜、影像、组织学与生化检查的综合诊断,但篇幅极小,组合不确切,鉴别诊断未重点涉…     

溃疡性结肠炎临床诊疗规范要点评介

本文根据溃疡性结肠炎（UC）最新共识,简介了UC的诊断标准和分度治疗方案,评述了UC药物治疗的安全性、终点指标、维持途径、癌变风险和手术适应症等,对临床UC诊治很有帮助。     

克罗恩病患者初次诊断时的贫血发生率及流行病学特征分析

<正>克罗恩病(CD)和溃疡性结肠炎(UC)是炎症性肠病(IBD)中的重要两种类型,我国以溃疡性结肠炎发病率较高,西方国家以克罗恩病发病率为高,我国克罗恩病发病率有超过溃疡性结肠炎的趋势~([1-3])。本文采用回顾性研究的方法,通过对10年245例克罗恩病患者临床资料的分析,脂在了解克罗恩病患者贫血率发生情况、流行临床特征及治疗方案变化趋势,为克罗恩病诊疗提供参考。1资料与方法     

Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database

OBJECTIVES: A continuous increase in the incidence of inflammatory bowel disease (IBD), Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC) has been suggested. Since Denmark provides excellent conditions for epidemiological research, we aimed to describe contemporary IBD incidence rates and patient characteristics in Copenhagen County and City. METHODS: All patients diagnosed with IBD during 2003-2005 were followed prospectively. Demographic and clinical characteristics, such as disease extent, extraintestinal manifestations, smoking habits, medical treatment, surgical interventions, cancer, and death, were registered. RESULTS: Five-hundred sixty-two patients were diagnosed with IBD, resulting in mean annual incidences of 8.6/10(5) for CD, 13.4/10(5) for UC, and 1.1/10(5) for IC. Time from onset to diagnosis was 8.3 months in CD and 4.5 months in UC patients. A family history of IBD, smoking, and extraintestinal manifestations was significantly more common in CD than in UC patients. Only 0.6% of UC patients had primary sclerosing cholangitis. In CD, old age at diagnosis was related to pure colonic disease, whereas children significantly more often had proximal and extensive involvement. Twelve percent of CD patients and 6% of UC patients underwent surgery during the year of diagnosis, significantly less than earlier reported. CONCLUSIONS: The incidence of IBD in Copenhagen increased noticeably during the last decades. Time from onset of symptoms until diagnosis decreased markedly, extent of CD was related to age at diagnosis, and the risk of surgery was low in UC.     

Progression of inflammatory bowel disease in China

The epidemiology and phenotype of inflammatory bowel disease (IBD) in the Chinese population is not well-known. We performed a comprehensive search of the Chinese biomedical literature database from 1989 to 2007 using the following key words: inflammatory bowel disease (IBD), ulcerative colitis (UC), Crohn's disease (CD). The investigation of hospitalized IBD patients from 1990 to 2003 was also carried out in 23 medical centers of 11 cities over China. There are some notable epidemiological and phenotypical differences between Chinese IBD and Caucasian IBD, including a lack of familial clustering, male predominance, a relatively later onset of the illness with no second peak age occurrence after 50 years old, a milder clinical course, less extra-intestinal manifestations and complications, and less fistulous and peri-anal complications in Chinese CD. The data indicate an increased incidence of IBD in China with many complicated clinical problems, which offers potential opportunities to study the disease prospectively and identify the etiological factors, leading also to the better management of this disease in China.     

Guidelines for the management of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder characterized by a relapsing and remitting course. The quality of life can decreases significantly during exacerbations of the disease. The incidence and prevalence of UC in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Various medical and surgical therapies are currently used for the management of UC. However, many challenging issues exist and sometimes these lead to differences in practice between clinicians. Therefore, Inflammatory Bowel Diseases (IBD) Study Group of Korean Association for the Study of Intestinal Diseases (KASID) set out the Korean guidelines for the management of UC. These guidelines are made by the adaptation using several foreign guidelines and encompass treatment of active colitis, maintenance of remission and indication for surgery in UC. The specific recommendations are presented with the quality of evidence. These are the first Korean treatment guidelines for UC and will be revised with new evidences on treatment of UC.     

Surgery for inflammatory bowel disease in the era of laparoscopy

During the course of inflammatory bowel disease (IBD), surgery may be needed. Approximately 20% of patients with ulcerative colitis (UC) will require surgery, whereas up to 80% of Crohn’s disease (CD) patients will undergo an operation during their lifetime. For UC patients requiring surgery, total proctocolectomy and ileoanal pouch anastomosis (IPAA) is the operation of choice as it provides a permanent cure and good quality of life. Nevertheless a permanent stoma is a good option in selected patients, especially the elderly. Minimally invasive surgery has replaced the conventional open approach in many specialized centres worldwide. Laparoscopic colectomy and restorative IPAA is rapidly becoming the standard of care in the treatment of UC requiring surgery, whilst laparoscopic ileo-cecal resection is already the new gold standard in the treatment of complicated CD of terminal ileum. Short term advantages of laparoscopic surgery includes faster recovery time and reduced requirement for analgesics. It is, however, in the long term that minimally invasive surgery has demonstrated its superiority over the open approach. A better cosmesis, a reduced number of incisional hernias and fewer adhesions are the long term advantages of laparoscopy in IBD surgery. A reduction in abdominal adhesions is of great benefit when a second operation is needed in CD and this influences positively the pregnancy rate in young women undergoing restorative IPAA. In developing the therapeutic plan for IBD patients it should be recognized that the surgical approach to the abdomen has changed and that surgical treatment of complicated IBD can be safely performed with a true minimally invasive approach with great patient satisfaction.     

An analysis of an inflammatory bowel disease practice in an urban community hospital.

OBJECTIVES: To review an individual community gastroenterologist's experience with inflammatory bowel disease (IBD). The aspects studied were distribution of disease, need for hospital admission, immunosuppressants, systemic steroids, and surgery and its indications. The incidence of cancer was also reviewed. PATIENTS AND METHODS: The charts of all IBD patients (n=373) seen between 1993 and 1996 by an individual gastroenterologist in an urban community hospital were reviewed for the aforementioned information. Patients seen during this period may have been diagnosed with IBD before or during the period of 1993 to 1996. RESULTS: Of the 373 patients, 219 had Crohn's disease (CD) and 154 had ulcerative colitis (UC). The most common age of onset for both groups was 20 to 29 years. Distal UC and distal Crohn's colitis patients rarely required surgery, hospitalization, systemic steroids or immunosuppressants. Eighty per cent of patients with small bowel CD and 51% of those with ileocolonic CD required at least one operation. Of the UC patients, 10.4% required surgery. Of the UC patients undergoing surveillance for cancer, none developed cancer but one developed significant dysplasia. CONCLUSIONS: In both CD and UC the site of the inflammation plays a major role in determining the need for hospitalization, surgery, systemic steroids and immunosuppressants. Distal UC, the most common form of UC in this group of patients, is a very benign disease. Of all forms of IBD, small bowel CD had the greatest need for hospitalization, surgery and systemic steroids.     

炎症性肠病发生消化道狭窄的临床特点分析

目的探讨住院炎症性肠病(inflammatory bowel disease,IBD)患者发生消化道狭窄的临床特点。方法纳入2010年1月至2018年12月在中国人民解放军总医院第七医学中心住院诊治的IBD患者,对发生消化道狭窄患者的诊治过程和随访情况进行回顾性分析。结果发生消化道狭窄患者118例(23.14%),其中克罗恩病(Crohn’s disease,CD)、溃疡性结肠炎(ulcerative colitis,UC)和IBD类型待定(IBD unclassified,IBDU)的消化道狭窄发生率分别为59.02%、6.67%和34.25%,三者比较,差异有统计学意义(P<0.001)。病程0~10年的消化道狭窄发生率为25.06%,而病程>10年的发生率为14.29%,二者比较,差异有统计学意义(χ2=4.880,P=0.027)。发生消化道狭窄患者中,33.90%(40例)的患者经单纯药物治疗有效;55.93%(66例)的患者予以外科手术治疗,术后并发症发生率为18.46%(12例),10.61%(7例)的患者予以再次手术治疗。27.12%(32例)的患者予以内镜下治疗,内镜治疗有效率为81.25%(26例),18.75%(6例)的患者经内镜治疗无效后行外科手术治疗,内镜治疗术后并发症发生率为3.13%(1例)。结论消化道狭窄是IBD的严重并发症之一,CD的消化道狭窄发生率显著高于UC。有效的内科药物及营养治疗可降低消化道狭窄发生率、手术率。内镜治疗消化道狭窄具有较高的有效性、安全性,可有效避免外科手术的发生。     

Characterization of inflammatory bowel disease in elderly patients: A review of epidemiology,current practices and outcomes of current management strategies

The authors review and summarize the current literature regarding the epidemiology, clinical presentation and management of inflammatory bowel disease (IBD) in elderly patients.Among elderly patients, the incidence of ulcerative colitis (UC) is higher than that of Crohn disease (CD). Elderly patients with a new diagnosis of UC are more likely to be male and have left-sided colitis. Elderly patients with a new diagnosis of CD are more likely to be female and have colonic disease. Conversely, increasing age at diagnosis has been associated with a lower likelihood of having any of a family history of IBD, perianal disease in CD and extraintestinal manifestations. Although response to drug therapies appears to be similar in elderly patients and younger individuals, the elderly are more likely to receive 5-aminosalicylic acid agents, and less likely to receive immunomodulators and biologics. Corticosteroid use in the elderly is comparable with use in younger individuals. The rates of surgical intervention appear to be lower for elderly CD patients but not elderly UC patients. Elderly individuals with UC are more likely to need urgent colectomy, which is associated with an increased mortality rate. Elective surgery is associated with similar outcomes among the elderly and young patients with IBD. Therefore, the use of immunomodulators and biologics, and earlier consideration of elective surgery for medically refractory disease in elderly patients with IBD, should be emphasized and further evaluated to prevent complications of chronic corticosteroid(s) use and to prevent emergency surgery.     

Clinical study of the relationship between inflammatory bowel diseases and colorectal neoplasms

OBJECTIVE: To investigate the incidence of colorectal cancer in inflammatory bowel disease (IBD) patients and its risk factors. METHODS: Data on 513 patients in the last 10 years from Ruijin Hospital were collected. Their medical histories were put in database and analyzed including their socio‐demographic features, pathogenetic conditions, diagnostic methods, possible related risk factors, treatment and outcome. RESULTS: Among the 513 were 242 with ulcerative colitis (UC), among whom four patients developed cancers and four had precancerous lesions. None of the 271 CD patients developed cancer. The incidence of both cancer and precancerosis in the UC patients was 1.65%. Through multifactorial logistic regression analysis, loss of weight, other disease complications and frequent relapses were proved to be the most probable risk factors. CONCLUSION: The incidence of IBD has kept on rising in recent years. Clinically, UC patients have more probability of developing colorectal cancer than CD patients. The main risk factors of developing colorectal cancer in UC patients are frequent relapses, weight loss and other complications.