溃疡性结肠炎的诊断与鉴别诊断ppt课件

1、Clinical PresentationClinical Presentationn Intestinal SymptomsIntestinal Symptomsn 70% of patients with UC report 5 bowel movements during acute phas70% of patients with UC report 5 bowel movements during acute phases. es. n The main reason for diarrhea is colonic inflammation, but bile acid and Th

2、e main reason for diarrhea is colonic inflammation, but bile acid and food malabsorption secondary to inflammation in the terminal ileum or tfood malabsorption secondary to inflammation in the terminal ileum or the proximal small bowel can contribute to this symptom. he proximal small bowel can cont

3、ribute to this symptom. n A history of surgical resections can be seminal in explaining symptoms. A history of surgical resections can be seminal in explaining symptoms. n Acute phases of UC almost always present with bloody diarrhea (“hemaAcute phases of UC almost always present with bloody diarrhe

4、a (“hematocheziatochezia). ). n Active inflammatory anorectal lesions result in urgency of defecation anActive inflammatory anorectal lesions result in urgency of defecation and cramps around defecation (“tenesmusd cramps around defecation (“tenesmus). UC patients often complai). UC patients often c

5、omplain of lower left quadrant pain. n of lower left quadrant pain. n Extraintestinal ManifestationsExtraintestinal ManifestationsWafik El-Diery and David Metz, Section EditorsDiagnostics of Inflammatory Bowel DiseaseGastroenterology，2007;133:16701689肠外表现肠外表现(Extraintestinal manifestations)(Extraint

6、estinal manifestations)n 肠外表现包括：n 皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)n 关节损害(如外周关节炎、脊柱关节炎等)n 眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、n 肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)n 血栓栓塞性疾病等。n Mendoza JL, Lana R, Taxonera C et al. Extraintestinal manifestations in inflammatory bowel disease: differences between Crohns disease and ulcerative coliti

7、s. Med. Clin. (Barc.) 2005; 125: 297300.并发症并发症(Complications)(Complications)n 并发症包括：n 中毒性巨结肠 toxic megacolonn 肠穿孔n 下消化道大出血n 上皮内瘤变和癌变n 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. 2021，51(9): 694-697/n Chow DK，Leong RW，Tsoi KK, et a1Longterm followup of ulcerative colitis in the Chinese populationAm J Gast

8、roenterol，2021，104：647-654Serological markersSerological markersn 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 n

9、on-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.n Reese GE, Constantinides VA, Simillis C et al. Diagnostic precision of anti-Saccharomyces cerevisiae

10、antibodies and perinuclear antineutrophil cytoplasmic antibodies in inflammatory bowel disease. Am J Gastroenterol. 2006 (Oct); 101 (10): 241022.尿白蛋白尿白蛋白n 目的： 讨论炎症性肠病患者尿中白蛋白的临床意义。n 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 指数进展综合分析，选取25例安康人为正常对照。n 结果：患者尿白蛋白活动期

11、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。n 结论： 患者尿中白蛋白可作为判别患者疾病活动情况的目的。n 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 markersFecal markersn Calprotectin (FCP), a heterocomplex of S100A8 and S100A9, is a calcium-bin

12、ding 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 calprote

13、ctin concentration is proportional to the influx of neutrophils into the intestinal tract, a hallmark of active IBD.n Lactoferrin is an iron-binding glycoprotein identified in the secretions overlying most mucosal surfaces that interact directly with external pathogens, including saliva, tears, vagi

14、nal 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 inf

15、lux of neutrophils during inflammation.n 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.n Langhorst J, Elsenbruch S, Mueller T et al. Comparison of 4

16、neutrophil-derived proteins in feces as indicators of disease activity in ulcerative colitis. Inflamm. Bowel Dis. 2005; 11: 108591.钡剂灌肠钡剂灌肠n 检查所见的主要改动为：n (1)黏膜粗乱和(或)颗粒样改动；n (2)肠管边缘呈锯齿状或毛刺样，肠壁有多发性小充盈缺损；n (3)肠管短缩，袋囊消逝呈铅管样。CTCTUlcerative colitis with backwash ileitis. Axial CT enterographic sections sh

17、ow 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，2021，30：19551970结肠镜检查结肠镜检查Danese S，Fiocehi CUlcerative colitisN Engl J Med，2021365：

18、1713 1725n 结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要根据。n 结肠镜下UC病变多从直肠开场，呈延续性、弥漫性分布，表现为：n (1)黏膜血管纹理模糊、紊乱或消逝，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；n (2)病变明显处可见弥漫性、多发性糜烂或溃疡；n (3)可见结肠袋变浅、变钝或消逝以及假息肉、桥黏膜等。Typical endoscopic findingsTypical endoscopic findingsn n (A) UC with mild inflammation and reduced haustration,

19、 vascular transparency is missing. n (B) Moderate inflammation with reduced haustration. The mucosa is edematous, covered with fibrin, and shows multiple erosions.n (C) Severe inflammation with inflammatory narrowing of the lumen through pseudopolyps.放大放大内镜内镜 (Confocal microscopy)(Confocal microscop

20、y)n n 内镜下黏膜染色技术能提高内镜对黏膜病变的识别才干，结合放大内镜技术，经过对黏膜微细构造的察看和病变特征的判别，有助UC诊断，n 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例放大内镜形状分析现代消化及介入诊疗，2005，10：116118small-bowel capsule endoscopy (SBCE).small-bowel capsule endoscopy (SBCE).n Crohns disease and ulcerative colitis are lifelong diseases. Both diseases are marked by fre

21、quent relapses and patients often undergo repeated investigationsto define the extent of the disease, assess the severity of relapse, or identify complications. nWhereas ulcerative colitis is a chronic inflammatory condition causing diffuse and continuous mucosal inflammation of the colon, Crohns di

22、sease is a heterogeneous entity comprised of several different phenotypes,but can affect the entire gastrointestinal tract.nThe use of capsule endoscopy as a filter for pushandpull enteroscopy (PPE) is occasionally necessary in patients with established ulcerative colitis when the diagnosis is quest

23、ioned, especially before surgery.n Capsule endoscopy can also direct the choice of route of PPE.SBCESBCEn n Subtle lesions as seen at small-bowel capsule endoscopyn Bourreille A，Ignjatovic A，Aabakken L，et a1Role of smallbowel endoscopy in the management of patients with inflammatory bowel disease：an

24、 international OMED-ECCO consensusEndoscopy，2021，41：618637黏膜活检组织学检查n 组织学可见以下主要改动。n 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，乃至构成隐窝脓肿；(2)隐窝构造改动：隐窝大小、形状不规那么，陈列紊乱，杯状细胞减少等；(3)可见黏膜外表糜烂，浅溃疡构成和肉芽组织增生。n 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逝，慢性炎性细胞浸润减少；(3)隐窝构造改动：隐窝构造改动可加重，如隐窝减少、萎缩，可

25、见潘氏细胞化生(结肠脾曲以远)。n 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动，结合临床，可报告符合UC病理改动。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 biopsiesMicroscopic findings in biopsiesn n (D, E) Cr

26、ypt abscess in UC. (F) Pseudopolyp formation. L, lymph follicle.n Nikolaus S，Schreiber SDiagnostics of inflammatory bowel diseaseGastroenterology，2007，133：16701689诊断要点n 在排除其他疾病根底上，可按以下要点诊断：n (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；n (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)；n (3)如再加上上述黏膜活检和(或)手术切除标本组

27、织病理学特征者，可以确诊(definite)；n (4)初发病例如I临床表现、结肠镜及活检组织学改动不典型者，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 criterian Various diagnostic classifications of IBD are available, including Mendeloffs

28、 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.n Modified Mendeloff criteria plus key points of the Lennard-Jones criteria, commonly used criteria, are presented here.n Myren J, Bouchier IA, Watkinson G, Softley A, Clamp SE, de Dombal FT. The OMGE multinational inflammatory bowel disease survey 19761986. A further report on 3175 cases. Scand J Gas