课件：溃疡性结肠炎的诊断与鉴别诊断.ppt

溃疡性结肠炎的诊断和鉴别诊断,Clinical Presentation,Intestinal Symptoms 70% of patients with UC report 5 bowel movements during acute phases. The main reason for diarrhea is colonic inflammation, but bile acid and food malabsorption 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 present 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. Extraintestinal Manifestations,Wafik El-Diery and David Metz, Section EditorsDiagnostics of Inflammatory Bowel DiseaseGastroenterology，2007;133:16701689,肠外表现(Extraintestinal manifestations),肠外表现包括： 皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病) 关节损害(如外周关节炎、脊柱关节炎等) 眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、 肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等) 血栓栓塞性疾病等。 Mendoza JL, Lana R, Taxonera C et al. Extraintestinal manifestations in inflammatory bowel disease: differences between Crohns disease and ulcerative colitis. Med. Clin. (Barc.) 2005; 125: 297300.,并发症(Complications),并发症包括： 中毒性巨结肠 （toxic megacolon） 肠穿孔 下消化道大出血 上皮内瘤变和癌变 钱家鸣, 等.溃疡性结肠炎合并中毒性巨结肠六例及文献复习. 中华内科杂志J. 2012，51(9): 694-697/ Chow DK，Leong RW，Tsoi KK, et a1Longterm followup of ulcerative colitis in the Chinese populationAm J Gastroenterol，2009，104：647-654,Serological markers,The two most widely studied serological markers in inflammatory bowel disease in recent 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 varying 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 cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. Am J Gastroenterol. 2006 (Oct); 101 (10): 241022.,尿白蛋白,目的： 探讨炎症性肠病患者尿中白蛋白的临床意义。 方法：对临床确诊的32例IBD患者（UC 27例，CD 5 例 ) 在疾病的不同时期，用免疫放射比浊法测定尿中白蛋白，并结合临床 Harvey 和 Bradshaw 指数进行综合分析，选取25例健康人为正常对照。 结果：患者尿白蛋白活动期比缓解期明显增高（0.002）， Harvey 和 Bradshaw 指数呈正相关（活动期 r=0.76, P0.001；静止期 r=0.73, P0.001）。患者尿中白蛋白明显高于正常人（活动期 P0.001, 缓解期, P0.005）。 结论： 患者尿中白蛋白可作为判断患者疾病活动情况的指标。 邓长生. 炎症性肠病患者尿白蛋白的临床意义. 武汉大学学报. 2002， 23 (1)： 88-89.,Fecal markers,Calprotectin (FCP), a heterocomplex of S100A8 and S100A9, is a calcium-binding protein with antimicrobial protective properties 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 neutrophils. 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 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 granules 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 inflammation. 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, 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: 108591.,钡剂灌肠,检查所见的主要改变为： (1)黏膜粗乱和(或)颗粒样改变； (2)肠管边缘呈锯齿状或毛刺样，肠壁有多发性小充盈缺损； (3)肠管短缩，袋囊消失呈铅管样。,CT,Ulcerative colitis with backwash ileitis. Axial CT enterographic sections show continuous involvement of the large bowel (white arrrows) and backwash ileitis (black arrow in b). Elsayes KM，AIHawary MM，Jagdish J，et a1CT enterography：principles，trends，and interpretation of findingsRadiographics，2010，30：19551970,结肠镜检查,Danese S，Fiocehi CUlcerative colitisN Engl J Med，2011365：1713 1725,结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要依据。 结肠镜下UC病变多从直肠开始，呈连续性、弥漫性分布，表现为： (1)黏膜血管纹理模糊、紊乱或消失，黏膜充血、水肿、质脆、自发或接触出血和脓性分泌物附着，亦常见黏膜粗糙、呈细颗粒状； (2)病变明显处可见弥漫性、多发性糜烂或溃疡； (3)可见结肠袋变浅、变钝或消失以及假息肉、桥黏膜等。,Typical endoscopic findings,(A) UC with mild 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 inflammation with inflammatory narrowing of the lumen through pseudopolyps.,放大内镜 (Confocal microscopy),内镜下黏膜染色技术能提高内镜对黏膜病变的识别能力，结合放大内镜技术，通过对黏膜微细结构的观察和病变特征的判别，有助UC诊断， 姜泊，等放大内镜结合黏膜染色技术诊断溃疡性结肠炎附1 16例放大内镜形态分析现代消化及介入诊疗，2005，10：116118,2019/4/20,13,可编辑,small-bowel capsule endoscopy (SBCE).,Crohns disease and ulcerative colitis are lifelong diseases. Both diseases are marked by frequent relapses and patients often undergo repeated investigationsto define the extent 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, Crohns disease 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 pushandpull enteroscopy (PPE) is occasionally necessary 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-bowel capsule endoscopy Bourreille A，Ignjatovic A，Aabakken L，et a1Role of smallbowel endoscopy in the management of patients with inflammatory bowel disease：an international OMED-ECCO consensusEndoscopy，2009，41：618637,黏膜活检组织学检查,组织学可见以下主要改变。 活动期：(1)固有膜内弥漫性急慢性炎性细胞浸润，包括中性粒细胞、淋巴细胞、浆细胞和嗜酸粒细胞等，尤其是上皮细胞间中性粒细胞浸润及隐窝炎，乃至形成隐窝脓肿；(2)隐窝结构改变：隐窝大小、形态不规则，排列紊乱，杯状细胞减少等；(3)可见黏膜表面糜烂，浅溃疡形成和肉芽组织增生。 缓解期：(1)黏膜糜烂或溃疡愈合；(2)固有膜内中性粒细胞浸润减少或消失，慢性炎性细胞浸润减少；(3)隐窝结构改变：隐窝结构改变可加重，如隐窝减少、萎缩，可见潘氏细胞化生(结肠脾曲以远)。 UC活检标本的病理诊断：活检病变符合上述活动期或缓解期改变，结合临床，可报告符合UC病理改变。宜注明为活动期或缓解期。如有隐窝上皮异型增生(上皮内瘤变)或癌变，应予注明。,Riley SA, Mani V, Goodman MJ, et al. Microscopic activity in ulcerative colitis: what does it mean? Gut. 1991;32:174178.,Microscopic findings in biopsies,(D, E) Crypt abscess in UC. (F) Pseudopolyp formation. L, lymph follicle. Nikolaus S，Schreiber SDiagnostics of inflammatory bowel diseaseGastroenterology，2007，133：16701689,诊断要点,在排除其他疾病基础上，可按下列要点诊断： (1)具有上述典型临床表现者为I临床疑诊 (spicious)，安排进一步检查； (2)同时具备上述结肠镜和(或)放射影像特征者，可临床拟诊 (probable)； (3)如再加上上述黏膜活检和(或)手术切除标本组织病理学特征者，可以确诊(definite)； (4)初发病例如I临床表现、结肠镜及活检组织学改变不典型者，暂不确诊UC，应予随访(follow-up)。,Lennard-Jones JE. Classification of inflammatory bowel disease. Scand J Gastroenterol. Suppl. 1989; 170: 26;discussion 1619.,Diagnostic criteria,Various diagnostic classifications of IBD are available, including Mendeloffs 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. Modified Mendeloff cr