课件：溃疡性结肠炎的内科保守治疗.ppt

溃疡性结肠炎的药物治疗和预后,诊断与治疗,诊断：排除性、综合性和完整性诊断 治疗：强调分型、分期、分度、分段的原则 疗效评定：缓解、有效、无效 提倡多中心协作研究,Treatment goals,Potential future treatment goals for ulcerative colitis include sustained clinical remission, sustained mucosal healing with a reduction in colorectal dysplasia and cancer, and maintaining normal GI physiology. Mesalamine therapy is sufficient in approximately 50% of patients. There are limited data that azathioprine might induce and maintain clinical remission and endoscopic healing. Infliximab is effective for induction and maintenance of clinical remission and endoscopic healing. Data on adalimumab and certolizumab are lacking. Current Directions in IBD Therapy: What Goals Are Feasible With Biological Modifiers? 2008 by the AGA Institute,SASP,早在20世纪初期，斯堪的纳维亚的风湿病专家Suartg发现，水杨酸偶氮磺胺（SASP）的抗炎和抗菌特性可用于治疗类风湿性关节炎。1942年由Dana Svartz 医师首先将柳氮磺胺吡啶应用于溃疡性结肠炎（UC）的治疗，取得了良好效果，成为UC治疗的一个里程碑。自从SASP用作UC的维持治疗后，复发率为原来的1/4，并大大改善了许多患者的生活质量。经过半个多世纪的实践，SASP一直是UC患者广泛应用的药物之一。但由于该药口服耐药性差，不良反应多，通过开发研制了新剂型、改变给药途径等方法显著提高了疗效、减少了不良反应。,氨基水杨酸制剂,GCs,Intravenous corticosteroids have been established as the most eff ective fi rst-line treatment for acute severe UC since the first trial of this treatment regimen was published in 1974 by Truelove and Jewell . In this study, 36 of 49 patients (73.5 % ) with severe UC were found to be in remission 5 days aft er commencing intensive intravenous treatment with prednisolone 60 mg / day (in divided doses). The introduction of intravenous corticosteroid treatment has led to a substantial decrease in the morbidity and mortality associated with acute severe UC . A number of parenteral corticosteroids have been tested in the treatment of severe UC . There was no obvious differences in treatment response between the various steroids However, there was no evidence to support increasing the corticosteroid dose beyond 60 mg / day of methylprednisolone or equivalent Truelove SC , Jewell DP . Intensive intravenous regimen for severe attacks of ulcerative colitis . Lancet 1974 ; 1 : 1067 70 . Turner D , Walsh CM , Steinhart AH et al. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a metaregression. Clin Gastroenterol Hepatol 2007 ; 5 : 103 110 .,6MP/AZA,Ardizzone S, Maconi G, Russo A, Imbesi V, Colombo E, Bianchi Porro G. Randomised controlled trial of azathioprine and 5-aminosalicylic acid for treatment of steroid dependent ulcerative colitis. Gut 2006; 55: 4753. Leung Y, Panaccione R, Hemmelgarn B, et al. Exposing the weaknesses: a systematic review of azathioprine efficacy in ulcerative colitis. Dig Dis Sci 2008;53:14551461. Lewis JD, Gelfand JM, Troxel AB, et al. Immunosuppressant medications and mortality in inflammatory bowel disease. Am J Gastroenterol 2008;103:14281435.,Indications and Contraindications for Infliximab Therapy in IBD,Other biotechnology agents,Infliximab,Rutgeerts P, Sandborn WJ, Feagan BG et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005; 353: 24622476. Rutgeerts P, Colombel JF, Reinisch W, et al. Infliximab induces and maintains mucosal healing in patients with active ulcerative colitis: the ACT trial experience. Gut 2005;54(Suppl VII):A58. Reinisch W, Sandborn WJ, Rutgeerts P, et al. Infliximab treatment for ulcerative colitis: comparable clinical response, clinical remission, and mucosal healing in patients with disease duration = 3 years. Gastroenterology 2008;134(Suppl 1):A495. Fidder HSchnitzler F， Rutgeerts P ，et a1 Longterm safety of inflixjmab for the treatment of inflammatory boweI disease：a single center cohort studyGut2009，58(4)：50l-508 Rutgeerts P, Vermeire S，Van Assehe GBiological therapies for inflammatory bowel diseasB Gastroenterology. 2009，136：l 1821197,2019/8/20,11,可编辑,Diet and nutrition,Patients should be offered a normal diet or enteral nutrition unless such a diet is not tolerated TPN is not effective as primary therapy. TPN should be considered only in malnourished patients who cannot tolerate oral intake or enteral nutrition. Wright R , Truelove SC . A controlled therapeutic trial of various diets in ulcerative colitis . Br Med J 1965 ; 2 : 138 41 . Gassull MA, Abad A, Cabre E, Gonzalez-Huix F, Gine JJ, Dolz C. Enteral nutrition in inflammatory bowel disease. Gut 1986; 27 (Suppl. 1): 7680. Gonzalez-Huix F , Fernandez-Banares F , Esteve-Comas M et al. Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis . Am J Gastroenterol 1993 ; 88 : 227 32 .,Diet and nutrition,UC患者因摄入不足，肠道吸收障碍，能量消耗及丢失增加常导致营养风险 (nutritional risk)，故积液营养支持 (nutritional support)不仅能改善患者的营养状况，一些营养成分，包括谷氨酰胺、w-3多不饱和脂肪酸及微生态制剂还具有调节炎症反应、改善患者肠道免疫屏障的功能、改善疾病的活动作用，有助于病变恢复，避免手术。 张澍田，等. 营养治疗对溃疡性结肠炎肠道免疫屏障的疗效. 胃肠病学和肝病学J. 2009，18 (1)： 83-86. Razack R，Seidner DLNutrition in inflammatory bowel diseaseCurr Opin Gastroenterol，2007, 23(4)：400-405,Diet, nutrition and probiotics,Patients should be offered a normal diet or enteral nutrition unless such a diet is not tolerated. TPN is not effective as primary therapy. TPN should be considered only in malnourished patients who cannot tolerate oral intake or enteral nutrition. Wright R , Truelove SC . A controlled therapeutic trial of various diets in ulcerative colitis . Br Med J 1965 ; 2 : 138 41 . Gassull MA, Abad A, Cabre E, Gonzalez-Huix F, Gine JJ, Dolz C. Enteral nutrition in inflammatory bowel disease. Gut 1986; 27 (Suppl. 1): 7680. Gonzalez-Huix F , Fernandez-Banares F , Esteve-Comas M et al. Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis . Am J Gastroenterol 1993 ; 88 : 227 32 . Sherman PM，Ossa jc，JohnsonHenry KUnraveling mechanisms of action of probiotiesNutr Clin Pract，2009，24：1014,Antibiotics,Routine use of antibiotics is not recommended. Several trials have shown that the use of antibiotics in addition to corticosteroids does not lead to additional benefi ts over corticosteroid treatment alone. It should be noted that antibiotics are indicated in patients who develop signs of sepsis. Similarly, antibiotics, either metronidazole or vancomycin are indicated in patients with concurrent C. difficile infection. Guslandi MAntibiotics for inflammatory bowel disease：do theywork? Eur J Gastroenterol Hepatol，2005，17：145-147 Perencevich M, Burakoff R. Use of antibiotics in the treatment of inflammatory bowel disease. Inflamm Bowel Dis. 2006; 12: 65164. Toruner M, Loftus EV Jr, Harmsen WS et al. Risk factors for opportunistic infections in patients with inflammatory bowel disease. Gastroenterology 2008; 134: 92936.,其他,白细胞洗涤技术 (Leukocytapheresis，LCAP) 干细胞移植疗法 (Autologous stem cell transplantation) 基因疗法 钱家鸣，等. 白细胞分离法治疗炎症性肠病. 中华消化杂志. 2005. 25(9)：575576. 钱家鸣，等. 造血干细胞移植与炎症性肠病. 中华内科杂志. 2005. 44(1)：6567. 周黎 ，等. 炎症性肠病的基因治疗. 胃肠病学. 2006. 11(7)：439441.,禁忌,抗胆碱能药 麻醉剂 其他,预后 （Prognostic）,本病呈慢性过程，大部分患者反复发作，轻度及长期缓解者预后较好。 急性爆发型、有并发症及年龄超过60岁者预后不良。 慢性持续活动或反复发作频繁者，预后较差。 病程漫长者癌变危险性增加，应注意随访。 Je