潰瘍性結(jié)腸炎的診斷與鑒別診斷

1、潰瘍性結(jié)腸炎的診斷和鑒別診斷,Clinical Presentation,Intestinal Symptoms70% of patients with UC report >5 bowel movements during acute phases. The main reason for diarrhea is colonic inflammation, but bile acid and food malabsorpti

2、on secondary to inflammation in the terminal ileum or the proximal small bowel can contribute to this symptom. A history of surgical resections can be seminal in explaining symptoms. Acute phases of UC almost always pr

3、esent with bloody diarrhea (“hematochezia”). Active inflammatory anorectal lesions result in urgency of defecation and cramps around defecation (“tenesmus”). UC patients often complain of lower left quadrant pain. Extr

4、aintestinal Manifestations,Wafik El-Diery and David Metz, Section Editors．Diagnostics of Inflammatory Bowel Disease．Gastroenterology，2007;133:1670–1689．,腸外表現(xiàn)(Extraintestinal manifestations),腸外表現(xiàn)包括：皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性

5、膿皮病)關(guān)節(jié)損害(如外周關(guān)節(jié)炎、脊柱關(guān)節(jié)炎等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)血栓栓塞性疾病等。 Mendoza JL, Lana R, Taxonera C et al. Extraintestinal manifestations in inflammatory bowel disease: differences between Crohn’s disease

6、and ulcerative colitis. Med. Clin. (Barc.) 2005; 125: 297–300.,并發(fā)癥(Complications),并發(fā)癥包括：中毒性巨結(jié)腸 （toxic megacolon）腸穿孔下消化道大出血上皮內(nèi)瘤變和癌變錢家鳴, 等.潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí). 中華內(nèi)科雜志[J]. 2012，51(9): 694-697/Chow DK，Leong RW，Tsoi

7、KK, et a1．Long—term follow—up of ulcerative colitis in the Chinese population．Am J Gastroenterol，2009，104：647-654．,Serological markers,The two most widely studied serological markers in inflammatory bowel disease in rece

8、nt years have been p-ANCA and ASCA. The clinical utility of p-ANCA or ASCA testing in the diagnosis of inflammatory bowel disease, in patients with non-specific gastrointestinal symptoms, is limited because of the varyin

9、g seroprevalence of these antibodies in patients with inflammatory bowel disease and the inadequate sensitivity of the assays.Reese GE, Constantinides VA, Simillis C et al. Diagnostic precision of anti-Saccharomyces cer

10、evisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. Am J Gastroenterol. 2006 (Oct); 101 (10): 2410–22.,尿白蛋白,目的： 探討炎癥性腸病患者尿中白蛋白的臨床意義。方法：對臨床確診的32例IBD患者（UC 27例，CD 5 例 ) 在

11、疾病的不同時期，用免疫放射比濁法測定尿中白蛋白，并結(jié)合臨床 Harvey 和 Bradshaw 指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對照。結(jié)果：患者尿白蛋白活動期比緩解期明顯增高（0.002）， Harvey 和 Bradshaw 指數(shù)呈正相關(guān)（活動期 r=0.76, P<0.001；靜止期 r=0.73, P<0.001）?；颊吣蛑邪椎鞍酌黠@高于正常人（活動期 P<0.001, 緩解期, P<0.005）

12、。結(jié)論： 患者尿中白蛋白可作為判斷患者疾病活動情況的指標(biāo)。鄧長生. 炎癥性腸病患者尿白蛋白的臨床意義. 武漢大學(xué)學(xué)報. 2002， 23 (1)： 88-89.,Fecal markers,Calprotectin (FCP), a heterocomplex of S100A8 and S100A9, is a calcium-binding protein with antimicrobial protective proper

13、ties derived predominately from neutrophils, and to a lesser extent, from monocytes and reactive macrophages. It constitutes approximately 5% of the total protein and up to 60% of the cytosolic protein in human neutrophi

14、ls. As such, the fecal calprotectin concentration is proportional to the influx of neutrophils into the intestinal tract, a hallmark of active IBD.Lactoferrin is an iron-binding glycoprotein identified in the secretions

15、 overlying most mucosal surfaces that interact directly with external pathogens, including saliva, tears, vaginal secretions, feces, synovial fluid, and mammalian breast milk. It is a major component of the secondary gra

16、nules of polymorphonuclear neutrophils and is shown to be a primary factor in the acute inflammatory response. In the intestinal lumen, fecal lactoferrin levels quickly increase with the influx of neutrophils during infl

17、ammation.Sugi and colleagues investigated lactoferrin, polymorphonuclear neutrophil (PMN) elastase, and lysozyme together with myeloperoxidase in fecal material and whole-gut lavage fluid from IBD patients.Langhorst J,

18、 Elsenbruch S, Mueller T et al. Comparison of 4 neutrophil-derived proteins in feces as indicators of disease activity in ulcerative colitis. Inflamm. Bowel Dis. 2005; 11: 1085–91.,鋇劑灌腸,,檢查所見的主要改變?yōu)椋?1)黏膜粗亂和(或)顆粒樣改變；(2)

19、腸管邊緣呈鋸齒狀或毛刺樣，腸壁有多發(fā)性小充盈缺損；(3)腸管短縮，袋囊消失呈鉛管樣。,CT,,Ulcerative colitis with backwash ileitis. Axial CT enterographic sections show continuous involvement of the large bowel (white arrrows) and backwash ileitis (black arrow i

20、n b).Elsayes KM，AI—Hawary MM，Jagdish J，et a1．CT enterography：principles，trends，and interpretation of findings．Radiographics，2010，30：1955—1970．,結(jié)腸鏡檢查,,Danese S，F(xiàn)iocehi C．Ulcerative colitis．N Engl J Med，2011．365：1713 1725

21、．,結(jié)腸鏡檢查并活組織檢查(后文簡稱活檢)是UC診斷的主要依據(jù)。結(jié)腸鏡下UC病變多從直腸開始，呈連續(xù)性、彌漫性分布，表現(xiàn)為：(1)黏膜血管紋理模糊、紊亂或消失，黏膜充血、水腫、質(zhì)脆、自發(fā)或接觸出血和膿性分泌物附著，亦常見黏膜粗糙、呈細(xì)顆粒狀；(2)病變明顯處可見彌漫性、多發(fā)性糜爛或潰瘍；(3)可見結(jié)腸袋變淺、變鈍或消失以及假息肉、橋黏膜等。,Typical endoscopic findings,,(A) UC with mil

22、d inflammation and reduced haustration, vascular transparency is missing. (B) Moderate inflammation with reduced haustration. The mucosa is edematous, covered with fibrin, and shows multiple erosions.(C) Severe inflamm

23、ation with inflammatory narrowing of the lumen through pseudopolyps.,放大內(nèi)鏡 (Confocal microscopy),,內(nèi)鏡下黏膜染色技術(shù)能提高內(nèi)鏡對黏膜病變的識別能力，結(jié)合放大內(nèi)鏡技術(shù)，通過對黏膜微細(xì)結(jié)構(gòu)的觀察和病變特征的判別，有助UC診斷，姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附1 16例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：11

24、6—118．,small-bowel capsule endoscopy (SBCE).,Crohn’s disease and ulcerative colitis are lifelong diseases. Both diseases are marked by frequent relapses and patients often undergo repeated investigationsto define the ext

25、ent of the disease, assess the severity of relapse, or identify complications. Whereas ulcerative colitis is a chronic inflammatory condition causing diffuse and continuous mucosal inflammation of the colon, Crohn’s dis

26、ease is a heterogeneous entity comprised of several different phenotypes,but can affect the entire gastrointestinal tract.The use of capsule endoscopy as a filter for push?and?pull enteroscopy (PPE) is occasionally nec

27、essary in patients with established ulcerative colitis when the diagnosis is questioned, especially before surgery. Capsule endoscopy can also direct the choice of route of PPE.,SBCE,,Subtle lesions as seen at small-bow

28、el capsule endoscopyBourreille A，Ignjatovic A，Aabakken L，et a1．Role of small—bowel endoscopy in the management of patients with inflammatory bowel disease：an international OMED-ECCO consensus．Endoscopy，2009，41：618—637．,

29、黏膜活檢組織學(xué)檢查,組織學(xué)可見以下主要改變?；顒悠冢?1)固有膜內(nèi)彌漫性急慢性炎性細(xì)胞浸潤，包括中性粒細(xì)胞、淋巴細(xì)胞、漿細(xì)胞和嗜酸粒細(xì)胞等，尤其是上皮細(xì)胞間中性粒細(xì)胞浸潤及隱窩炎，乃至形成隱窩膿腫；(2)隱窩結(jié)構(gòu)改變：隱窩大小、形態(tài)不規(guī)則，排列紊亂，杯狀細(xì)胞減少等；(3)可見黏膜表面糜爛，淺潰瘍形成和肉芽組織增生。緩解期：(1)黏膜糜爛或潰瘍愈合；(2)固有膜內(nèi)中性粒細(xì)胞浸潤減少或消失，慢性炎性細(xì)胞浸潤減少；(3)隱窩結(jié)構(gòu)改變：隱窩

30、結(jié)構(gòu)改變可加重，如隱窩減少、萎縮，可見潘氏細(xì)胞化生(結(jié)腸脾曲以遠(yuǎn))。UC活檢標(biāo)本的病理診斷：活檢病變符合上述活動期或緩解期改變，結(jié)合臨床，可報告符合UC病理改變。宜注明為活動期或緩解期。如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。,Riley SA, Mani V, Goodman MJ, et al. Microscopic activity in ulcerative colitis: what does it mean?

31、 Gut. 1991;32:174–178.,Microscopic findings in biopsies,,(D, E) Crypt abscess in UC. (F) Pseudopolyp formation. L, lymph follicle.Nikolaus S，Schreiber S．Diagnostics of inflammatory bowel disease．Gastroenterology，2007，13

32、3：1670—1689．,診斷要點(diǎn),在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：(1)具有上述典型臨床表現(xiàn)者為I臨床疑診 (spicious)，安排進(jìn)一步檢查；(2)同時具備上述結(jié)腸鏡和(或)放射影像特征者，可臨床擬診 (probable)；(3)如再加上上述黏膜活檢和(或)手術(shù)切除標(biāo)本組織病理學(xué)特征者，可以確診(definite)；(4)初發(fā)病例如I臨床表現(xiàn)、結(jié)腸鏡及活檢組織學(xué)改變不典型者，暫不確診UC，應(yīng)予隨訪(follow-u

33、p)。,Lennard-Jones JE. Classification of inflammatory bowel disease. Scand J Gastroenterol. Suppl. 1989; 170: 2–6;discussion 16–19.,Diagnostic criteria,Various diagnostic classifications of IBD are available, including M

34、endeloff’s criteria, the Lennard-Jones criteria, the international multicentre scoring system of the Organization Mondiale de Gastroenterologie (OMGE), and the diagnostic criteria of Japanese Research Society on IBD.Mod

35、ified Mendeloff criteria plus key points of the Lennard-Jones criteria, commonly used criteria, are presented here.Myren J, Bouchier IA, Watkinson G, Softley A, Clamp SE, de Dombal FT. The OMGE multinational inflammator

36、y bowel disease survey 1976–1986. A further report on 3175 cases. Scand J Gastroenterol. Suppl. 1988; 144: 11–19.,鑒別診斷,1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎曲菌、沙門菌、產(chǎn)氣單孢菌、大腸埃希菌、耶爾森菌等。常有流行病學(xué)特點(diǎn)(如不潔食物史或疫區(qū)接觸史)，急性起病常伴發(fā)熱和腹痛，具自限性(病程一般數(shù)天至1周，不

37、超過6周)；抗菌藥物治療有效；糞便檢出病原體可確診。2．阿米巴腸病3．腸道血吸蟲病4．其他：腸結(jié)核、真菌性腸炎、抗生素相關(guān)性腸炎(包括假膜性腸炎)、缺血性結(jié)腸炎、放射性腸炎、嗜酸粒細(xì)胞性腸炎、過敏性紫癜、膠原性結(jié)腸炎、白塞病、結(jié)腸息肉病、結(jié)腸憩室炎以及人類免疫缺陷病毒(HIV)感染合并的結(jié)腸病變應(yīng)與本病鑒別。,Differentiate diagnosis,,Differentiate diagnosis,,夏冰，等. 缺血性結(jié)腸