炎症性肠病内镜黏膜活检诊断方法

炎症性肠病内镜下以肠道黏膜糜烂、溃疡病变为特征，主要包括克罗恩病（CD）和溃疡性结肠炎（UC）。虽然一般根据内镜下形态特点可提供这2种疾病的诊断和鉴别诊断依据，但临床上一些不典型病例如IBD中间型病变（即所谓不确定性结肠炎）、肠道其他炎症、血管或肿瘤性病变也可表面为肠黏膜糜烂溃疡等病变，使鉴别诊断变得较为困难。[第一段]     

溃疡性结肠炎及克罗恩病的内镜活检病理特点分析

目的 总结溃疡性结肠炎（UC）及克罗恩病（CD）的病理形态学特点,为其诊断提供借鉴.方法 收集临床首次诊断并经病理科证实的UC患者180例、CD患者106例,资料包括年龄、性别及病变累及肠道的部位,并选用病理组织学标准对病变的黏膜结构改变、黏膜慢性炎症细胞浸润、黏膜急性炎症改变、黏膜上皮改变进行评价,比较两类患者间的差异.结果 和CD病例比较,UC病例出现黏膜结构紊乱的比例较高（P＜0.05）,出现局灶间断性炎症的比例较低（P＜0.05）,隐窝炎、隐窝脓肿及固有膜内中性粒细胞浸润发生率较高（P＜0.05）,表面上皮变扁或糜烂、黏液细胞减少的发生率较高.肉芽肿样小结、假幽门腺化生及裂隙状溃疡改变仅出现在CD病例.180例UC病例中90%（162例）病例病变部位局限于结肠.106例CD病例中28%（30例）病变部位局限于回盲部,56%（59例）病变累及到2个及以上不同部位.结论 肠镜活检病理诊断UC及CD是一个综合分析的过程.若病变局限于回盲部或胃肠道多部位累及,黏膜出现肉芽肿样小结、局灶间断性炎细胞浸润、假幽门腺化生等改变则倾向于CD诊断;若病变局限于结肠,黏膜出现弥漫一致性炎或明显的黏膜结构改变、黏膜上皮改变则倾向于UC诊断.     

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。     

活动期溃疡性结肠炎活检黏膜的组织学分级与临床分级和内镜分级的关系

目的 研究活动期溃疡性结肠炎(AUC)患者的活检黏膜的组织学分级与临床分级和内镜下分级的相互关系及其在疗效评价中的作用。方法 采用分级的方法来描述133例AUC患者的病理、临床和内镜特征，采用记分方法描述各临床表现，运用Spearman等级相关系数进行相关分析。结果133例．AUC的组织学分级为I级29例，Ⅱ级45例，Ⅲ级37例，Ⅳ级22例；临床分级为I级85例，Ⅱ级39例，Ⅲ级9例；肠镜分级为I级8例，Ⅱ级30例，Ⅲ级16例，Ⅳ级79例。组织学分级与血便程度(r=0．49，P=0．000)、排便次数(r=0．30，P=0．001)、血沉(r=0．42，P=0．000)、临床活动指数(r=0．56，P=0．000)、临床分级(r=0．52，P=0．000)、结肠镜分级(r=0．35，P=0．000)均有正相关性，与血清白蛋白(r=-0．31，P=0．000)有负相关性，而与血红蛋白(r=-0．13，P=0．125)无明显相关。轻中度患者经柳氮磺胺吡啶治疗6周后，在临床为完全缓解的68例中，组织学分级为0级仅19例，肠镜分级为0级仅16例，大部分患者仍有组织学与肠镜分级I级的改变。临床缓解和肠镜分级为0级的16例中，仍有7例组织学分级为I级。临床缓解、肠镜分级和组织学分级均为0级者仅有9例。结论．AUC患者的组织学分级和临床分级、内镜分级的分布有不一致性。组织学分级与血便的程度、大便的次数、血沉、临床活动指数、临床分级和肠镜分级之间有正相关性；与血清白蛋白呈负相关性。在疗效评价中，组织学分级优于肠镜分级，肠镜分级优于临床分级。     

IBD药物治疗进展

引言:炎症性肠病(inflammatory bowel disease,IBD)是一组病因尚未完全清楚的慢性、非特异性肠道炎症性疾病,包括溃疡性结肠炎( ulcerative colitis,UC)和克罗恩病(Crohn's disease,CD).IBD在西方国家相当常见,但近20年来,随着人们生活方式的改变和诊断水平的提高,IBD的发病率在我国逐年上升.UC主要累及结肠黏膜和黏膜下层,范围从远段结肠开始,可逆向近段发展,可累及全结肠和末端结肠,呈连续性分布.     

炎症性肠病患者肠黏膜白细胞分化抗原-14的表达及意义

目的: 探讨炎症性肠病患者肠黏膜CD14的表达及与该病的关系.方法: 收集活动性溃疡性结肠炎(ulcerative colitis, UC)患者25例及克罗恩病(Crohn's disease, CD)患者15例;20例对照来自于非炎症性肠病患者手术切除的正常结肠组织(肠镜及肠黏膜病理组织学检查结果均正常).炎症性肠病的临床诊断均依据于常规影像学、内镜学及组织学标准.采用免疫组织化学方法检测肠黏膜组织中CD14表达量.结果: 肠黏膜固有层单个核细胞表达CD14.UC患者CD14阳性细胞百分数高于CD患者,但二者差异无统计学意义(P>0.05);UC患者较正常对照有显著性差异(t=4.404, P<0.01),CD患者较正常对照亦见显著性差异(t=3.324,P<0.01).CD14的表达与疾病活动度(diseaseactivity index, DAI)相关, UC组轻、中、重度比较有显著性差异(F=56.709, P<0.01);CD组轻、中、重度比较亦有显著性差异(F=12.880, P<0.01).结论: CD14参与了炎症性肠病的发病过程, 其表达强度反映了该病的程度.     

炎症性肠病诊断和鉴别诊断中的难点以及中国面临的问题

炎症性肠病的诊断是排他性诊断,需要鉴别肠结核、肠淋巴瘤、感染性肠病等。其确诊还需结合临床表现、内 镜下表现、影像学和病理组织学进行综合分析,而对于治疗过程中病情的判断则影响着治疗的选择。如何判断溃疡 性结肠炎合并机会性感染,抑或鉴别克罗恩病的纤维性狭窄和炎症性狭窄等皆是临床中经常碰到的难题。     

炎症性肠病患者肠黏膜炎症和非炎症组织CD27的激活表达

目的比较炎症性肠病患者肠黏膜炎症组织、非炎症组织及正常对照者肠黏膜CD27激活表达的差异,探讨CD27激活表达在炎症性肠病发病中的意义。方法共纳入32例克罗恩病患者、41例溃疡性结肠炎患者及40例正常对照者。分别应用West-ern blot试验和SYBR-green real time PCR方法分析炎症性肠病患者肠黏膜炎症组织、非炎症组织及正常对照者肠黏膜CD27蛋白及其mRNA的表达。数据处理使用GraphPad Prism 5软件。结果克罗恩病和溃疡性结肠炎患者肠黏膜炎症组织CD27蛋白及其mRNA表达均显著高于非炎症组织及正常对照组织(P均0.01);克罗恩病患者肠黏膜非炎症组织CD27蛋白及其mRNA表达显著高于正常对照组织(P=0.000);溃疡性结肠炎患者肠黏膜非炎症组织CD27蛋白表达显著高于正常对照组织(P=0.000)。结论炎症性肠病患者肠黏膜组织中存在CD27的激活表达,这种激活效应不仅出现在内镜表现为炎症性肠病的炎症组织中,甚至出现在炎症性肠病患者内镜表现为正常的肠黏膜中,CD27的激活表达是炎症性肠病发病的早期事件。     

克罗恩病的典型内镜表现

大肠的溃疡性病变常见的有以下几种：溃疡性结肠炎、克罗恩病、肠结核、肠道淋巴瘤、肠道Behcet’S病(白塞病)等，其内镜下的表现非常复杂，除溃疡性结肠炎内镜下有一定的特征形态，诊断比较容易外(请参阅本刊上一期专家读片内容，所列照片均为溃疡性结肠炎的典型内镜形态)，其它肠道溃疡性病变的诊断往往较为困难。     

PPARγ：一个IBD治疗的新靶点

脂质过氧化物酶体增殖物激活受体(PPAR)属于核受体家族。PPARγ配体通过PPARγ依赖或PPARγ不依赖的途径,在调节肠道炎症中起重要作用,有可能成为炎症性肠病的新治疗靶点。其作用机制尚不完全明确,报道较少。     

Accuracy of fecal calprotectin for the prediction of endoscopic activity in patients with inflammatory bowel disease

BackgroundFecal calprotectin is a noninvasive marker of inflammatory bowel disease.AimTo evaluate the accuracy of calprotectin for prediction of endoscopic activity in inflammatory bowel disease.MethodsOne-hundred patients were prospectively included. Quantum Blue^® (Bühlmann) kits were used to determine calprotectin. Endoscopic activity was calculated. Various serum markers (platelets, leukocytes, C-reactive protein, and albumin) were recorded.ResultsCalprotectin was higher in patients with endoscopic activity than in those without activity: in ulcerative colitis, with the low- (29 ± 14 vs. 301 ± 174, p < 0.001) and high- (99 ± 727 vs. 617 ± 801, p < 0.001); and in Crohn’s disease, with the low- (29 ± 59 vs. 124 ± 268, p < 0.01) and high-range kit (99 ± 37 vs. 287 ± 607, p < 0.01). Serological marker concentrations did not vary with endoscopic activity. The area under the ROC curve of calprotectin for the prediction of endoscopic activity was 0.9 in ulcerative colitis and 0.8 in Crohn’s disease. The best cut-off points for the detection of activity in ulcerative colitis were 50 for the low- (sensitivity 85%, specificity 79%) and 102 for the high- (sensitivity 85%, specificity 79%); in Crohn’s disease, 54 for the low- (sensitivity 71%, specificity 75%) and 122 for the high-range kit (sensitivity 71%, specificity 75%).ConclusionsFecal calprotectin concentration has good diagnostic accuracy for the detection of endoscopic activity in inflammatory bowel disease and performs better in ulcerative colitis than in Crohn’s disease.     

Obesity and novel management of inflammatory bowel disease

Obesity is prevalent within the inflammatory bowel disease(IBD) population,particularly in newly developed countries.Several epidemiological studies have suggested that 15%-40% of IBD patients are obese,and there is a potential role of obesity in the pathogenesis of IBD.The dysfunction of mesenteric fat worsens the inflammatory course of Crohn’s disease and may induce formation of strictures or fistulas.Furthermore,obesity may affect the disease course or treatment response of IBD.Given the incr...     

Anemia at the time of diagnosis of inflammatory bowel disease: Prevalence and associated factors in adolescent and adult patients

BackgroundThe prevalence, characteristic and determinants of anemia, at the time of inflammatory bowel disease (IBD) diagnosis have yet to be fully elucidated.MethodsRetrospective cross-sectional study. Analytical data and disease characteristics obtained upon diagnosis of 1278 IBD patients [Crohn’s disease/ulcerative colitis (CD/UC): 718/560] were collected.ResultsAnemia was present in 41.2% of patients at diagnosis (47% and 33.8% of CD and UC patients, respectively; p < 0.001), being severe in 5.5%. Iron deficiency anemia represented 69.6% of cases, with no differences between CD and UC. Female sex was the strongest risk factor for anemia in both CD and UC (OR 7.11; 95%CI 4.18–12.10 and 6.55; 95%CI 3.39–12.63, respectively), followed by elevated (≥2 mg/dL) C-reactive protein (OR 4.08; 95%CI 2.39–6.97 and 4.58; 95%CI 2.26–9.27, respectively). Current smoking was a risk factor for anemia in CD (OR 2.23; 95%CI 1.24–4.02), but a protective one in UC (OR 0.36; 95%CI 0.14–0.92). A penetrating CD behavior increased the risk of anemia (OR 3.34; 95%CI 1.36–8.21); in UC, anemia increased with disease extension (E2 + E3) (OR 1.80; 95%CI 1.13–2.86).ConclusionsFemale sex and disease activity are major determinants of anemia at IBD diagnosis. Anemia is associated with disease behavior in CD and with disease extension in UC.     

Effectiveness and safety of vedolizumab for maintenance treatment in inflammatory bowel disease—The Israeli real world experience

Introduction

Several real-world experience (RWE) studies with vedolizumab (VDZ) for induction of remission in inflammatory bowel diseases (IBD) have been published; however, long-term RWE data is scarce.

Dysplasia and colorectal cancer surveillance in inflammatory bowel disease

Introduction: Inflammatory bowel disease (IBD) patients are at an increased risk of developing colorectal cancer (CRC), a devastating complication of which intestinal dysplasia is the precursor. Considerable progress has been made to determine CRC risk in IBD, identification & management of dysplasia and preventative methods. Traditionally, surveillance colonoscopies with random colonic biopsies was used. However recent data suggests that chromoendoscopy is a better method of surveillance. Using 5-aminosalicylic acid agents primarily for chemoprevention is an ongoing debate however, when prescribed along with other strategies to control inflammation, their use is considered of benefit. This review presents current understanding of risk factors of neoplasia focusing on dysplasia and preventive strategies.

Areas covered: PubMed search was done using key words to assess current evidence. Along with genetics, risk factors, strategies that modify the risk of dysplasia, and CRC in IBD are discussed in detail.

Expert commentary: The role of our strategies in modifying CRC risk needs further assessment. Future research should aim to fill knowledge gaps such as high quality evidence for Chromoendoscopy and development of molecular markers for dysplasia detection. Our ultimate goal would be to eliminate CRC and is possible by better understanding of key pathogenic mechanisms in IBD.     

炎症性肠病相关性肝病的研究进展

炎症性肠病(inflammatory bowel disease,IBD)是一种累及回肠、结肠、直肠的特发性炎症性疾病,本病主要包括溃疡性结肠炎(ulcerative colitis,UC)和克罗恩病(Crohn’s disease,CD)。除常见的消化道症状外,研究发现IBD合并肝脏疾病较为常见,是IBD常见的肠外表现之一,其严重影响IBD的预后与转归。本文就IBD相关性肝病的分类和总结作一概述,以期为IBD及其肝脏病变的临床诊疗提供参考。     

Patient preferences for inflammatory bowel disease treatment objectives

BackgroundThere is currently little evidence about what treatment objectives most interest patients with inflammatory bowel disease (IBD).AimsTo determine patient preferences regarding IBD treatment objectives, specially the attributes they value most and the symptoms to be controlled as a priority.MethodsProspective, observational, anonymous study conducted in 117 outpatients with Crohn’s disease or ulcerative colitis.ResultsThe most important treatment objectives from the patients’ perspective were: improving quality of life (40.2% of patients), and completely resolving symptoms (33.3%). Only 12.8% of patients indicated having a completely normal colonoscopy as a preferred objective. The symptoms the patients considered to be most important when prioritizing their control were: abdominal pain (23.1% of patients), and bowel movement urgency (17.1%). The preferred treatment objectives were similar for Crohn’s disease and ulcerative colitis patients.ConclusionsImproving quality of life and completely controlling symptoms are the priority treatment objectives for IBD patients, with abdominal pain being the most important symptom. Conversely, therapeutic objective target goals proposed by physicians, such as healing the mucosal lesions, are not a priority for most patients. This indicates that there are discrepancies between patient and physician expectations, which should be taken into account if a patient-centered care model is to be implemented.     

Urotensin II levels in patients with inflammatory bowel disease

BACKGROUNDPatients with inflammatory bowel disease (IBD) are associated with increased cardiovascular risk and have increased overall cardiovascular burden. On the other hand, urotensin II (UII) is one of the most potent vascular constrictors with immunomodulatory effect that is connected with a number of different cardiometabolic disorders as well. Furthermore, patients with ulcerative colitis have shown increased expression of urotensin II receptor in comparison to healthy controls. Since the features of IBD includes chronic inflammation and endothelial dysfunction as well, it is plausible to assume that there is connection between increased cardiac risk in IBD and UII.AIMTo determine serum UII levels in patients with IBD and to compare them to control subjects, as well as investigate possible associations with relevant clinical and biochemical parameters.METHODSThis cross sectional study consecutively enrolled 50 adult IBD patients (26 with Crohn’s disease and 24 with ulcerative colitis) and 50 age and gender matched controls. Clinical assessment was performed by the same experienced gastroenterologist according to the latest guidelines. Ulcerative Colitis Endoscopic Index of Severity and Simple Endoscopic Score for Crohn’s Disease were used for endoscopic evaluation. Serum levels of UII were determined using the enzyme immunoassay kit for human UII, according to the manufacturer’s instructions.RESULTSIBD patients have significantly higher concentrations of UII when compared to control subjects (7.57 ± 1.41 vs 1.98 ± 0.69 ng/mL, P < 0.001), while there were no significant differences between Crohn’s disease and ulcerative colitis patients (7.49 ± 1.42 vs 7.65 ± 1.41 ng/mL, P = 0.689). There was a significant positive correlation between serum UII levels and high sensitivity C reactive peptide levels (r = 0.491, P < 0.001) and a significant negative correlation between serum UII levels and total proteins (r = -0.306, P = 0.032). Additionally, there was a significant positive correlation between serum UII levels with both systolic (r = 0.387, P = 0.005) and diastolic (r = 0.352, P = 0.012) blood pressure. Moreover, serum UII levels had a significant positive correlation with Ulcerative Colitis Endoscopic Index of Severity (r = 0.425, P = 0.048) and Simple Endoscopic Score for Crohn’s Disease (r = 0.466, P = 0.028) scores. Multiple linear regression analysis showed that serum UII levels retained significant association with high sensitivity C reactive peptide (β ± standard error, 0.262 ± 0.076, P < 0.001) and systolic blood pressure (0.040 ± 0.017, P = 0.030).CONCLUSIONIt is possible that UII is involved in the complex pathophysiology of cardiovascular complications in IBD patients, and its purpose should be investigated in further studies.     

Recent results of laparoscopic surgery in inflammatory bowel disease

Inflammatory bowel diseases are an ideal indication for the laparoscopic surgical approach as they are basically benign diseases not requiring lymphadenectomy and extended mesenteric excision;well-established surgical procedures are available for the conventional approach.Inflammatory alterations and fragility of the bowel and mesentery,however,may demand a high level of laparoscopic experience.A broad spectrum of operations from the rather easy enterostomy formation for anal Crohn’s disease(CD)to restorati...     

Evolving role of endoscopy in inflammatory bowel disease: Going beyond diagnosis

Inflammatory bowel disease, encompassing Crohn’s disease (CD) and ulcerative colitis, are chronic immune-mediated inflammatory bowel diseases (IBD) that primarily affect the gastrointestinal tract with periods of activity and remission. Large body of evidence exist to strengthen the prognostic role of endoscopic evaluation for both disease activity and severity and it remains the gold standard for the assessment of mucosal healing. Mucosal healing has been associated with improved clinical outcomes with prolonged remission, decreased hospitalization, IBD-related surgeries and colorectal cancer risk. Therefore, endoscopic objectives in IBD have been incorporated as part of standard care. With the known increased risk of colorectal cancer in IBD, although prevention strategies continue to develop, regular surveillance for early detection of neoplasia continue to be paramount in IBD patients’ care. It is thanks to evolving technology and visualization techniques that surveillance strategies are continuously advancing. Therapeutic endoscopic options in IBD have also been expanding, from surgery sparing therapies such as balloon dilation of fibrostenotic strictures in CD to endoscopic mucosal resection of neoplastic lesions. In this review article, we discuss the current evidence on the use of endoscopy as part of standard of care of IBD, its role in surveillance of neoplasia, and the role of interventional endoscopic therapies.