Ulcerative-ColitisPPT课件

-,1,UlcerativeColitis,-,2,DefinitionChronicnonspecialinflammatorydiseasesoftherectumandcolonofunknownetiology.Thelesionislimitedinmucosaandsub-mucosaoflargeintestine.Clinicalfeaturesarediarrhea,mucusandbloodypurulentstool,abdominalpain.,-,3,Incidence,Theincidenceis70-150casesper100,000individuals.Incidenceamongwhitesisapproximately4timesthatofotherraces.3.Incidenceisslightlygreaterinfemalesthaninmales.,-,4,Pathophysiology,Inflammationbeginsintherectum,extendsproximallyacertaindistance.2.Acleardemarcationexistsbetweeninvolvedanduninvolvedmucosa,andnoskipareasarepresent.,-,5,Pathophysiology,3.Primarilyinvolvesthemucosaandthesubmucosa.4.Formationofcryptabscessesandmucosalulceration.5.Themucosatypicallyappearsgranularandfriable.6.Pseudopolypsform,inmoreseverecases.,-,6,Pathogenesis,1.TheetiologyofUCisunknown.2.Environmental,infectious,genetic,autoimmune,andhostfactorshavebeensuspected.Interactionsamongthesefactorsmaybemoreimportant.,-,7,Pathogenesis,3.Inflammatorymediators:Interleukin-1,Tumornecrosisfactoralpha(TNF-alpha).4.ThemostimportantriskfactorfordevelopingUCisapositivefamilyhistory.,-,8,Clinicalmanifestations,SymptomsBloodydiarrheaAbdominalpainandcrampingoccurinmoreseverecases.Rectalurgencyortenesmusreflectsreducedcomplianceoftheinflamedrectum.Systemicsymptoms,includinglow-gradefever,malaise,nausea,vomiting,sweats,andarthralgias.dehydration.,-,9,Symptoms,Recurrencesmayoccuremotionalstress,infectionsorotheracuteillnesses,pregnancy,dietaryindiscretions,useofcatharticsorantibiotics,withdrawalofanti-inflammatoryorsteroidmedications.,-,10,Symptoms,In10-20%ofcases,patientspresentwithextraintestinalmanifestations,includingarthritis,uveitis,orliverdisease.,-,11,Clinicalmanifestations,SignsFever,tachycardia,dehydration,andtoxicitymayoccur.Pallor.Signsoflocalizedperitonitis.Toxicmegacolonappearseptic-havehighfever;lethargy;chills;tachycardia;andincreasingabdominalpain,tenderness,anddistention.,-,12,ClinicalTyping,Severityofdiseasecanbedeterminedbyvariouscriteriaasfollow:1.ClinicalmanifestionsTheoriginalcriteriaofTrueloveandEdwardsaresimpleandeasytouse.MildLessthan4stoolsdaily,withorwithoutblood,withnosystemicdisturbanceandanormalerythrocytesedimentationrate(ERS);ModerateMorethan6stoolsdailybutwithminimalsystemicdisturbance;SevereMorethan6stoolsdailywithblood,withevidenceofsystemicdisturbanceasshownbyfever(37degreeformorethan2days),tachycardia(90times/min),anemia(Hb100g/L),oranERSofmorethan30mm/h.,-,13,ClinicalTyping,2.Clinicaltypying(1)Incipienttype:Thefirstattackofthedisease;(2)Chronicrecurrenttype:commoninclinical,stageofattackandremissionisalternation;(3)Chronicpersistenttype:Symptomsarepersistentandsometimesbecomesevereandacuteattack;(4)Acutefulminationform:acute,severe,toxicsymptomsofwholebodyareobvious,andwithtoxicmegacolon,perforationandseptic.,-,14,ClinicalTyping,3.RangeoflesionRectitis;proctosigmoiditis;lefthemicolitis(undersplenicflexureofcolon);extensiveorwholecolitis(lesionextendstomorethansplenicflexureofcolonorwholecolon).4.Stageofdiseasestageofattackandstageofremission.,-,15,LabStudiesandImagingStudies,BloodroutineexaminationAnemiaLeukocytosis,-,16,LabStudiesandImagingStudies,ThesedimentationrateSerumchemistryHypokalemia:theseverityofthediarrhea.Hypoalbuminemia:fromprotein-losingenteropathy.,-,17,LabStudiesandImagingStudies,Stoolexaminationsforfecalleukocytes,ovaandparasitestudies,bacterialpathogensculture,andClostridiumdifficiletiter.,-,18,LabStudiesandImagingStudies,Bariumenemamayrevealashortenedcolon,withlossofhaustrationsanddestructionofthemucosalpattern(ie,leadpipecolon).BEiscontraindicatedinpatientswithmoderatetoseverecolitis,asitrisksperforationorprecipitationofatoxicmegacolon.,-,19,-,20,LabStudiesandImagingStudies,CTscansandultrasoundbestfordemonstratingintraabdominalabscesses,mesentericinflammation,andfistulas.,-,21,LabStudiesandImagingStudies,Coloscopymakingthediagnosis;evaluatingtheextentandseverityofdisease;Themucosalsurfacebecomesirregularandfriable,bleedseasilywhentouched,andmayhavepseudopolyps.,-,22,-,23,-,24,-,25,-,26,Diagnosis,Casehistorypersistorrepeatdiarrheaandslime-bloodstool,abdominalpain,withorwithoutdifferentlevelsofwholebodysymptoms;TypicalX-rayorColonoscopythehistologicassessmentofrectalorcolonicbiopsyspecimens.,-,27,DifferentialDiagnosis,Irritablebowelsyndromediarrheaoftenalternateswithconstipation.Pseudomembranouscolitis(1)maybeahistoryofantibiotics;“membrane”maybeseenoncolonoscopy;difficulttoxindetectableinstools.(2)X-rayexamination:edematous,shaggyoutline.(3)Histology:Similartoacuteischemiccolitisbutmayshow“summit”lesionsoffibropurulentexudate.,-,28,Ischemiccolitis(1)Clincal:olderagegroups;vasculardisease;suddenonset,oftenpain;(2)Radiology:thumbprinting;(3)Histology:mucosalnecrosis;ballooningofcapillaries;redbloodcellcongestion;hemosiderinandfibrosis(chronicdisease).,-,29,InfectivecolitisManifestations:suddentonsetusual;identifiablesourcewithothercases;painmaypredominate;pathogenspresentinstool.(2)Radiology:usuallynormal.(3)Histology:cryptarchitectureusuallynormal.Edema,superficalneutrophilinfiltrate,cryptabscesses.,-,30,DifferentialDiagnosisofUCandCDClinicalRadiologyUCBloodydiarrheaExtendsproximallyfromrectum;finemucosalulcerationCDPerianallesionscommon;Segmentaldisease;frankbleedinglessstrictures,fissure,ulcers,frequentthanUCfistulas,-,31,EndoscopicDifferentiationBetweenUCandCD,UCCDDistributionDiffuseinflammationextendingfreduentskipfromrectumlesionsInflammationDiffuse,withmuscosalFocalandasymmetric,cobblestoning,granularityorfriabilitygranularity.AndfriabilitylesscommonUlcerationSmallulcersinadiffuselyAphthoidulcers;linear/serpiginousinflamedmucosa;RaggedulcerationmucosaoftennormalulcersinseverediseaseColoniclumenOftennarrowedinlong-Stricturescommonstandingchronicdisease;stricturesveryrare,-,32,Complications,PerforationandtoxicmegacolonThemostdreadedcomplicationsofUC.Themortalityrateis50%ifperforationoccurs.Toxicmegacoloncanbeprecipitatedbyantidiarrhealagents,hypokalemia,narcotics,cathartics,andenemas,includingbariumenemas.,-,33,Perforationandtoxicmegacolon,Thebestmethodofdiagnosingtoxicmegacolonisthroughtheuseofplainfilms.Thetransversecolonisdilated,usuallymorethan8cm.Anythingmorethan6cmisconsideredtobeabnormal.Acolectomyisrequiredifnoimprovementoccurswithin24-48hours.,-,34,Complications,StricturesUsuallyarebenignbutcanleadtoobstruction.FistulasandabscessesSeeninabout20%ofpatientswithUC.Fistulatypesincludeenterovesicalenteroentericenteromesentericenterocutaneousrectovaginalperianal.,-,35,Complications,PerianalcomplicationsOccurin90%ofpatientswithCD.MassivehemorrhageOccursinfewerthan1%ofpatients.CancerUCcarriesa10-to30-foldincreaseindevelopmentofcarcinomaofthecolon.Riskincreaseswithextentanddurationofthedisease.,-,36,Complications,Extraintestinalcomplications1.ArthritisPeripheralarthritis,usuallymigratoryandmonoarticular.2.Ankylosingspondylitisisassociatedwithhumanleukocyteantigen-B27(HLA-B27).3.Episcleritispresentswithburningeyesandscleralinjection.4.Iritiswhichpresentsasanacutepainfulredeyewithphotophobiaandconjunctivalinjection.,-,37,Treatment,EmergencyDepartmentCareInitiatesupportivecarewith(1)bowelrest,(2)nasogastricsuction,and(3)intravenous(IV)fluidscontainingelectrolytes.Medication1.Agentsforsymptomatictreatment(1)loperamideandthecombinationofatropineinmilddiseasetoreducethenumberofbowelmovementsandtorelieverectalurgency.,-,38,Agentsforsymptomatictreatment,(2)Theanticholinergicagentrelieveintestinalspasms.Antidiarrhealandanticholinergicmedicationsmustbeavoidedinacuteseverediseasebecausetheymayprecipitatetoxicmegacolon.Avoidthelong-termuseofnarcoticsforpain.(3)Anironsupplementbeaddedwhensignificantrectalbleedingispresent.,-,39,Treatment,2.Salicylazosulfapyridine(SASP)Itisthefirstselectivedrugforthisdisease.Thelargepartofdrugreachcolonanddecompositionbybacteriumincolonandbecomes5-aminosalicylicacid(5-ASA)andsulfadiazine.Usage:1g/timesfor4times,after3-4weeks,thesymptomsrelieveanddecreasethedosefor3-4weeksand2g/dmaintainfor1-2years.Badeffects:WBCandRBCdecreasemesalamzine,Olsalazineare5-ASA.,-,40,Treatment,3.GlucocorticoidItisbetterforstageofacuteattack.Thebasicmechanismisnonspecialantii