肠结核与克罗恩病的临床鉴别及肠黏膜结核分枝杆菌聚合酶链反应检测的意义

目的总结肠结核与克罗恩病临床症状、内镜、病理表现的差异及肠黏膜组织结核分枝杆菌聚合酶链反应（polymerasechain reaction for Mycobacterium tuberculosis,TB-PCR）对二者鉴别诊断的意义。方法回顾分析1994年1月-2006年2月于我院确诊的42例肠结核和60例克罗恩病病例,记录患者的临床、内镜、病理表现特点及肠黏膜TB-PCR检测结果。结果克罗恩病患者临床表现为消化道出血者占56.9%（33/58）,较肠结核（16.1%,5/31）多见（P〈0.001）;29.3%克罗恩病患者有肠外表现（口腔溃疡、皮疹、关节痛、肛周病变）,而肠结核患者未见;内镜下克罗恩病表现为纵行/裂隙样溃疡（44.9%,22/49）、卵石征（28.6%,14/49）、节段性病变（51.0%,25/49）多于肠结核（7.7%、3.9%、0）（P值分别为0.001、0.011、0.000）;克罗恩病患者肠黏膜组织病理表现为淋巴细胞聚集占34%（18/53）,小血管炎占26.4%（14/53）,明显较肠结核多见（0%、3.8%）（P值分别为0.001、0.016）。82.4%（14/17）的肠结核患者试验性抗结核1-2周症状改善,而5例克罗恩病患者试验性抗结核治疗4-8周均无效。肠黏膜组织TB-PCR检测阳性率肠结核组为11.5%（3/26）;与CD组（14.3%,3/21）比较无显著差异（P〉0.5）。结论肠结核与克罗恩病鉴别需结合临床表现、内镜、影像学表现综合判断;肠黏膜TB-PCR对肠结核与CD鉴别诊断的意义有限;试验性抗结核治疗及内镜随访仍是鉴别肠结核与克罗恩病的有效方法。

Clinical features, differential diagnosis and intestinal mucosal TB-PCR for intestinal tuberculosis and Crohn's disease

Objective To analyze the difference of clinical,endoscopic and pathological features between intestinal tuberculosis（ITB） and Crohn＇s disease （CD）,and to evaluate the significance of tissue polymerase chain reaction for Mycobacterium tuberculosis（TB-PCR） assay for the differential diagnosis.Methods One hundred and two cases diagnosed as intestinal tuberculosis（42） and CD（60） from Jan.1994 to Dec.2006 were reviewed.The clinical manifestation,endoscopic,histopathological findings,and the result of intestinal mucosal TB-PCR were analyzed.Results Hematochezia was more frequently seen in CD patients（56.9%,33/58） than that in ITB（16.1%,5/31,P〈0.001）.Extraintestinal manifestations such as oral ulcer,skin rash,arthralgia and peri-anal diseases,were seen in 29.3% CD patients compared with none in ITB.Under the endoscope,CD appeared as longitudinal/fissure-like ulcers for 44.9%（22/49）,cobblestone mucosa 28.6%（14/49）,and segmental lesion 51.0%（25/49）,significantly higher than those in ITB（7.7%,3.9%,0,P=0.001,0.011,0.000 respectively）.As for histopathological findings,lymphoid aggregation（34%,18/53） and microvasculitis（26.4%,14/53） were more common in CD compared with ITB（0,3.8%,P=0.001,0.016 respectively）.82.4%（14/17）ITB patients got symptom improved after 1～2 weeks empirical antituberculous therapy compared with no effect in 5 CD patients after 4～8 weeks antituberculous therapy.There was no significant difference in the assay of intestinal mucosal TB-PCR between ITB group（11.5%,3/26） and CD group（14.3%,3/21） （P〉0.5）.Conclusion We need to take account the clinical features,endoscope,radiological and histological findings to diagnose ITB or CD,and the significance of intestinal mucosal TB-PCR assay is limited for diffeventially diagnosing ITB and CD.For those cases difficult to differentiation,empirical antituberculous therapy and follow-up colonoscopy are necessary.