炎症性肠病课件

Inflammatory Bowel Disease,SUN JIANYONG DEPARTMENT OF GASTRPENTEROLOGY, ZHONGSHAN HOSPITAL, FUDAN UNIVERSITY,Inflammatory Bowel Disease (IBD),Crohns Disease (CD) Ulcerative Colitis (UC) Uncertain Colitis,Epidemiology,Rate higher in northern climates and the developed world Equal incidence between men and women Peak incidence CD 15-35 years by far the commonest UC usually diagnosed prior to 30 years Aggregation in families 25 % of patients with CD 20 % of patients with UC Smoking reduces risk of UC but increases risk of CD,Etiology and Pathogenesis,Etiology and Pathogenesis,Genetic easy to infect,Environmental factors,Fungus in intestines,Immune and non-immune system of intestines,Immunological reaction and inflammation,Environmental factors,IBD is more prevalent in developed countries and more common in white-collar workers Risk of UC Negative: Breast feeding, appendectomy, smoking Positive: “Western diet” , left-handedness, depression Risk of CD Smoking, second-hand smoke,Genetic factors,High Family incidence, but low with spouse Concordance for CD in twins Mutations of Gene Polygene disease and heterogenetical disease,Infected factors,Mycobacterium paratuberculosis Paramyxovirus Measles virus Helicobacter species,Immune factors,Abnormal immune response to auto-intestinal normal fungus Abnormal function of T cells CD Typical T-helper 1 (Th1) (cell-mediated) reaction UC Atypical T-helper 2 (Th2) (humoral) reaction Non-immunological cells: epithelial cell, vascular endothelial cell Immune cytokines and medium ROMs, NO,Ulcerative colitis is a continuous inflammation and ulceration of the colon and rectum and typically involves only the innermost lining or mucosa, with no segments of normal tissue. Crohns disease is a chronic, relapsing, focal, asymmetric, transmural inflammation of the gut anywhere between the mouth and the anus, but is predominantly seen in the terminal ileum and/or colon.,Definitions,Pathology,Histopathology of UC,Begin within the rectum and extend a variable adjacent level 25% rectum 2550% rectum and sigmoid or descending colon One third extend adjacent to splenic flexure or involve the entire colon A few involve the terminal ileum Diffuse, continuous, superficial and not-focal inflammation Submucosa or mucosa,Histopathology of UC,Active phase of inflammation: Acute inflammation cells accumulate and invade the crypts Progressive changes: Degeneration or necrosis of the crypt epithelium Crypt abscesses Shallow ulcerations extending to the lamina proprius Rarely and severe changes: Toxic megacolon and spontaneous perforation,Histopathology of UC,Chronic changes: Distorted crypt architecture of colon Transformed, disorganized, and loss of gland Loss of cupped cells Loss and disappearance of haustrations, so much as straitness Thicking of the smooth muscle Malignant tumor,Pathology of UC,Histopathology of CD,Involves any segment or combination of segments from the mouth to anus. Most commonly terminal ileum and right colon 20 per involve exclusively the colon 1520 per limited to the small bowel 50 per Both 10 per involve the stomach and duodenum and usually with more distal disease focal, discontinuous, asymmetric, transmural inflammation All layer of mucosa, submucosa, muscle, serosa,Histopathology of CD,Minute aphthoid,Linear ulceration,Isolating normal islands of mucosa,Cobblestone appearance,Extend deep throughout the layers of the bowel wall,Fissula, and fistula into the mesentery or organ,Histopathology of CD,Acute and chronic inflammatory cells invades isolated or contiguous single crypts (including producing crypt abscess) with normal adjacent glands Transmural Inflammatory changes: thickening of the bowel wall and narrowing of the lumen Fibrotic changes (healing): Permanent focal stricture Non-caseating granulomas (20%),Crohn ileitis,Clinical manifestations,Clinical manifestations of UC,Gastroenterology: Diarrhea: most commonly,rectal bleeding and passage of mucopus Abdominal pain:located in left lower and down abdomen Other symptom: anorexia, nausea, vomit Physical examination: abdominal tenderness,rebound tenderness Systemic symptom: Moderate and severe patients Fever,fatigue, anemia, dehydration,Clinical classification of UC,Clinical types: First outbreak Chronic relapse Chronic continuance Acute out-break Severity of disease: Mild Moderate Severe Pathological range: Stages of disease: Active stage and catabatic stage,Ulcerative Colitis: Disease Presentation,Experimental investigation of UC,Blood: HB WBC ESR CRP albumin Stool: Mucopurulent bleeding stool Exclude dysentery, salmonella, ameba, schistosome Autoantibody examination P-ANCA (+) anti-Saccharomyces cerevisiae (ASCA)(-),Colonoscopy investigation of UC,Colonoscopy Distributed diffusely and continuously Absence of the mucosal vascular pattern, Fine granularity of the mucosa, hemorrhage, exudation of mucopus Diffused erosion and superficial ulceration Pseudopolyps, bridged mucosa, loss and disappearance of haustrations, so much as straitness Microscopy mucosa, submucosa inflammation cells invade Acute stage:erosion,ulceration, cryptitis and crypt abscess Chronic stage: disorganized structure of crypt and loss of cupped cells,UC by Endoscopy,Radiography investigation of UC,Radiography Disorder and (or) fine granularity of the mucosa multi-superficial ulceration Coarse edge of mucosa and bur, niche Round and ovi-round thumb-printing (pseudopolyps) Loss and disapperance of haustrations, so much as straitness, tubular-appearing “lead pipe” Severe and out-break patients are forbidden,UC by barium enema,Clinical manifestations of UC,Complication: Toxic megacolon Malignant tumor Other complication: bleeding, perforation, ileus,Toxic megacolon,Clinical manifestations of CD,Gastroenterology: Abdominal pain: most commonly, located in down-right and around bellybutton, aggravated after dinner Diarrhea: commonly, usually without rectal bleeding and passage of mucopus Mass: 1020%, usually located in right lower and around bellybutton Fistula formation: inner- and outer- fistula Pathological changes around rectum and anus: fistula,abscess,split Systemic symptom:(more and obvious) Fever:common,mild and moderate fever Innutrition:fatigue, anemia, hypoalbumin,Experimental investigation of CD,Blood: HB WBC ESR CRP albumin Stool: OB(+) Autoantibody examination anti-Saccharomyces cerevisiae (ASCA)(+),Colonoscopy investigation of CD,Colonoscopy Distributed focally, discontinuously, asymmetrically Linear ulceration, Isolating normal islands of mucosa Cobblestone appearance Fissula, and fistula into the mesentery or organ Pseudopolyps, focal stricture, straitness of bowl Microscopy All layer of mucosa, submucosa, muscle, serosa Lymphocyte invade and linear ulceration Non-caseating granulomas organized structure of crypt and cupped cells,Crohns on colonoscopy,Linear ulcer Moderately Severely ulcerated ulcerated,Radiography investigation of CD,Radiography (GI and BE) Distributed focally, discontinuously Disorder of the mucosa Linear ulceration Cobblestone appearance Pseudopolyps Straitness and fistula “Jumping sign” and “Lining sign”,Crohns by barium enema,Crohns colitis & stricture Close-up of stricture,*,Clinical manifestations of CD,Complication: Ileus: most commonly Celiac abscess Absorbing badness Perforation and bleeding Toxic megacolon, rarely Malignant tumor Other complication: gall-stone, urine-stone, fatty liver,Diagnosis and Differential diagnosis,Diagnosis of UC,Chronic diarrhea, rectal bleeding and passage of mucopus, abdominal pain, diverse extents of systemic symptom At least one important changes of coloscopy or BE and biopsy Exclude other diseases Atypical clinical presentation but have typical changes of coloscopy or BE and biopsy also can be diagnosised Typical clinical presentation but have atypical changes of coloscopy or BE and biopsy should be d