内镜对炎症性肠病临床处理的诊断价值

,内镜对IBD临床处理的诊断价值,Significance of Follow-up with Endoscope for Management of IBD,,Company Logo,My Talk Can Begin with,普通内镜（white light endoscopy, WLE）色素内镜（Chromoendoscpy）虚拟色素（NBI, I-Scan, FICE）超声内镜（endoscpic ultrasonography, EUS）共焦内镜（confocal laser endomicroscpoy, CLE）,,Company Logo,Or, with,1. Challenge: Incidence & Prevalenc-Endoscopic Diagnosis2. Distinguishing IBD From Other Disorders, UC and CD3. Assessment of Extent and Severity4. Assessment of Response and Prediction of Relapse5. Surveillance: Dysplasia and Colorectal Cancer,,Company Logo,The Earliest Report of symptom,Reports of manifestations of IBD (Crohns Disease?) have been reported as early as 850 AD when King Alfred, Englands Darling, suffered from an illness which caused pain on eating, discomfort, and much embarrassment. This affliction plagued the King from the age of 20, without remission. At the time the illness was thought to be due to witchcraft, or a punishment for the Kings infidelities. In retrospect, however, the illness was probably Crohns Disease from todays knowledge.,,Company Logo,The Earliest Medical Article,An article was published in the British Medical Journal of 1913 by T. Kennedy Dalziel, who reported treating 13 patients who had suffered from intestinal obstruction. On autopsy he found that all 13 patients had inflamed gut, especially in the jejunal, ileal and colonic areas. On examining the inflamed bowel more closely, the transmural inflammation that is characteristic of the disease was clearly seen.,IBD:,From: Inflam Bowel Dis 2009: 1232,(a),(b),(b),,Company Logo,UC 176篇3053例,CD 356篇3703例,1989-2008年（文献572篇）,我国医学文献报道的IBD病例数,“万方期刊库”,“中国期刊网”,“中国科技期刊数据库”,“中国生物学文摘数据库”等,,Company Logo,我国医学文献报道的IBD病例数,1989-2008我国医学文献报道的溃疡性结肠炎病例数,,Company Logo,我国医学文献报道的IBD病例数,1989-2008我国医学文献报道的克罗恩病例数,,Company Logo,中文文献IBD 误诊数据与类别,误诊定义与分类 A类误诊 入院诊断其它病并已治疗，出院诊断IBD，或称“漏诊” B类误诊 入院诊断IBD并已治疗，出院诊断其它病，或称“错诊”,,（1989-2008年，572篇）,,Company Logo,中文文献炎症性肠病的误诊分类统计,UC （3053例）A 类 912例（29.9%）B 类 221例（ 7.2%）总计 1133例（37.1%）,CD （3073例） A 类 1801例（48.6%） B 类 627例（16.9%） 总计 1828例（76.5%）,,来自1989-2008中文期刊572篇文献（UC176篇 CD 356篇）,,Company Logo,溃疡性结肠炎误诊病种统计-A类,来自1989-2008我国176篇UC相关医学文献报道,,Company Logo,溃疡性结肠炎误诊病种统计-B类,来自1989-2008我国176篇UC相关医学文献报道,,Company Logo,来自1989-2008我国356篇CD相关医学文献报道,克罗恩病误诊病种统计-A类,,Company Logo,来自1989-2008我国356篇CD相关医学文献报道,克罗恩病误诊病种统计-B类,,Company Logo,中文文献炎症性肠病的误诊分类统计,UC （3053例）A 类 912例（29.9%）B 类 221例（ 7.2%）总计 1133例（37.1%）,CD （3073例） A 类 1801例（48.6%） B 类 627例（16.9%） 总计 1828例（76.5%）,,来自1989-2008中文期刊572篇文献（UC176篇 CD 356篇）,,Company Logo,挑战诊治IBD的消化专科医师的问题,你们医院内镜检查有会诊制度吗 ？ 您是否亲自您的患者作内镜检查 ？ 您肠镜检查时是否常规插入会肠 ？ 肠粘膜损伤患者您如何进行活检 ？ 您是否经常与病理医师读片讨论 ？ 您怎样对您的患者进行内镜随访 ？,,Company Logo,挑战诊治IBD的消化专科医师的问题,确定诊断IBD的“金”标准 内镜图像特征性肠粘膜损害 病理依据特征性组织学描述,,Company Logo,内镜检查和活检病理的目的,确定IBD的诊断、确定CD或UC提供粘膜损害的严重程度依据 活动指数提供评估病变的范围（UC; CD?）追踪和判断治疗效果，指导修改治疗方案提供梗阻、癌变的形态学依据,（2006）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（Journal of Crohn and Colitis）,（2006）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（2006）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（2006）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（Journal of Crohn and Colitis）,（2010;4:7-27）,（2006）,（Journal of Crohn and Colitis）,（2010;4:7-27）,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease. The British Society of Gastroenterology,（J Clin Pathol 1997;50:93-105）,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease. The British Society of Gastroenterology,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease. The British Society of Gastroenterology,,Company Logo,ECCO Statement 3F (2010),Focal (discontinuous) chronic (lymphocytes and plasma cells) inflammation and patchy chronic inflammation, focal crypt irregularity (discontinuous crypt distortion), and granulomas (not related to crypt injury) are the generally accepted microscopic features that permit a diagnosis of CD EL2, RGB. The same features and, in addition, an irregular villous architecture, can be used for analysis of endoscopic biopsy samples from the ileum. If the ileitis is in continuity with colitis, the diagnostic value of this feature should be used with caution EL2, RG B.,Travis SM, er al. Gut 2010 gt81950A 10/01/06,,Company Logo,2010年ECCO关于CD病理特征的声明,与会专家一致认为，CD 的特征性病理组织学特征有：局灶性（focal or discontinuous）慢性炎症（非连续性、粘膜浸润以淋巴细胞和浆细为主）和斑片状慢性炎症（patchy chronic inflammation）、局灶性隐窝不规则（非连续性隐窝不规则）和肉芽肿（与隐窝损害无关）等 EL5, RG D。内镜下回肠活检标本病理特征除此以外，绒毛结构不规则也作为诊断参考依据。如出现回肠炎症与结肠炎症连续一起时，上述标准应用时需慎重EL2, RG B,Travis SPL, er al. Gut 2010 gt81950A 10/01/06,J Clin Pathol 2002;55:955-960,J Clin Pathol 2002;55:955-960,“Using a full colonoscopic biopsy series, rather than a single rectal biopsy, produced the largest diagnostic improvement.”,,Company Logo,单中心临床小组的经验：2009.1. 2010.9.,,Company Logo,6个图像, 哪个诊断为CD或UC？,,Company Logo,以一患者为例,女性，75岁，腹泻、腹痛、粘液血便2周入院 发病前进食过海鲜，但没有集体发病。腹痛、腹泻水样便1天就诊。静脉左旋氧氟沙星2天。腹泻腹痛无好转，出现粘液脓血便，3-6次/日，30-10ml/次，无里急后重，无发热。既往无炎症性肠病史 体检肠鸣音6-8次/日，腹部无压痛。其余体征正常 全结肠镜：溃疡性结肠炎（重症），附内镜照片,,Company Logo,炎症性肠病入、出院诊断变化分析,病例数35，男性21例，女性14例，年龄275岁来自消化内科、肾内科、内分泌、老年病学科、肛肠外科、急诊入院诊断非IBD并已治疗，最终确诊为IBD入院前诊断IBD并开始按IBD治疗，最终部分确诊为非IBD时间自2009年1月-2010年6月,（新华医院 2009.1-20010.6）,,Company Logo,IBD患者入、出院诊断变化统计(漏诊),（新华医院 2009.1-20010.6）,,Company Logo,IBD患者入、出院诊断变化统计,（新华医院 2009.1-20010.6）,,Company Logo,IBD患者入院出院诊断变化统计,（新华医院 2009.1-20010.6）,,Company Logo,误诊病例最后诊断疾病分类,疾病名称 例数 (n=24)感染性胃肠炎 (包括AAD 4例) 11肠结核 3CD合并肠结核 3缺血性肠病 2回肠淋巴滤泡增生 2阿司匹林肠道损伤 2白塞病 1干燥综合症 1,,Company Logo,病例-6 诊断CD、风湿病肠粘膜损害,男性，73岁，河南郑州人。2年前因低热、粘液脓血便伴里急后重一个月、糖尿病史6年，在当地医院住院经内镜检查发现升结肠2处圆形下凹溃疡，直径约15-20毫米，内附黄厚苔，边缘规则，充血水肿。病理慢性炎症，提示CD可能。开始使用5-ASA，4周后低热无好转，来上海某三级医院住院。由于溃疡不典型，查全部风湿病指标阴性，诊为风湿病肠粘膜损害，开始用强的松（3周后逐渐减、停药）和硫唑嘌呤。体温降至正常粘液脓血便消失后回郑州。 2个月后再次发热，大便粘液、气急并加重。超声发现右侧中等量胸水住院，胸膜活检病理找到结核结节。CT显示两肺上中结核灶。RFP+INH+PZ抗痨2周体温进一步增高，怀疑RFP药物热，停用。转上海肺科医院住院抗痨3周仍中等到高热，少量粘液脓血便血。经会诊后，复查肠镜。,,Company Logo,病例-7 诊断为克罗恩病,男性，62岁，嘉兴人。便秘2年，加重并出现腹胀、腹痛5天，2012年2月10日当地医院急诊，腹部平片提示大肠梗阻、CT平片升结肠扩张住院。经禁食、胃肠减压症状和体征好转。通便后肠镜检查诊断