潰瘍性結(jié)腸炎的診斷與鑒別診斷課件

ClinicalPresentationIntestinalSymptoms70%ofpatientswithUCreport>5bowelmovementsduringacutephases.Themainreason

fordiarrheaiscolonicinflammation,butbileacidand

foodmalabsorptionsecondarytoinflammationinthe

terminalileumortheproximalsmallbowelcancontribute

tothissymptom.Ahistoryofsurgicalresectionscan

beseminalinexplainingsymptoms.AcutephasesofUC

almostalwayspresentwithbloodydiarrhea(“hematochezia”).Activeinflammatoryanorectallesions

resultinurgencyofdefecationandcrampsarounddefecation

(“tenesmus”).UCpatientsoftencomplainof

lowerleftquadrantpain.ExtraintestinalManifestationsWafikEl-DieryandDavidMetz,SectionEditors．DiagnosticsofInflammatoryBowelDisease．Gastroenterology，2007;133:1670–1689．ClinicalPresentationIntestina腸外表現(xiàn)(Extraintestinal

manifestations)腸外表現(xiàn)包括：皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)關(guān)節(jié)損害(如外周關(guān)節(jié)炎、脊柱關(guān)節(jié)炎等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

Crohn’sdiseaseandulcerativecolitis.Med.Clin.(Barc.)2005;125:

297–300.腸外表現(xiàn)(Extraintestinalmanifesta(B)Moderateinflammationwithreducedhaustration.糞便檢出病原體可確診。ScandJGastroenterol.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.(1)具有上述典型臨床表現(xiàn)者為I臨床疑診(spicious)，安排進(jìn)一步檢查；并發(fā)癥(Complications)黏膜活檢組織學(xué)檢查ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).并發(fā)癥(Complications)并發(fā)癥包括：中毒性巨結(jié)腸（toxicmegacolon）腸穿孔下消化道大出血上皮內(nèi)瘤變和癌變錢家鳴,等.潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).中華內(nèi)科雜志[J].2012，51(9):694-697/ChowDK，LeongRW，TsoiKK,eta1．Long—termfollow—up

ofulcerativecolitisintheChinesepopulation．AmJ

Gastroenterol，2009，104：647-654．(B)Moderateinflammationwithsmall-bowelcapsuleendoscopy(SBCE).Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.NikolausS，SchreiberS．Diagnosticsofinflammatoryboweldisease．Gastroenterology，2007，133：1670—1689．ReeseGE,ConstantinidesVA,SimillisCetal.Diagnosticcriteria眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)并發(fā)癥(Complications)并發(fā)癥(Complications)皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)患者尿中白蛋白明顯高于正常人（活動(dòng)期P<0.Differentiatediagnosis結(jié)論：患者尿中白蛋白可作為判斷患者疾病活動(dòng)情況的指標(biāo)。宜注明為活動(dòng)期或緩解期。Serologicalmarkers

Thetwomostwidelystudiedserologicalmarkersin

inflammatoryboweldiseaseinrecentyearshavebeen

p-ANCAandASCA.Theclinicalutilityofp-ANCAorASCA

testinginthediagnosisofinflammatoryboweldisease,in

patientswithnon-specificgastrointestinalsymptoms,is

limitedbecauseofthevaryingseroprevalenceofthese

antibodiesinpatientswithinflammatoryboweldiseaseand

theinadequatesensitivityoftheassays.ReeseGE,ConstantinidesVA,SimillisCetal.Diagnosticprecision

ofanti-Saccharomycescerevisiaeantibodiesandperinuclear

antineutrophilcytoplasmicantibodiesininflammatorybowel

disease.AmJGastroenterol.2006(Oct);101(10):2410–22.small-bowelcapsuleendoscopy尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。結(jié)果：患者尿白蛋白活動(dòng)期比緩解期明顯增高（0.002），Harvey和Bradshaw指數(shù)呈正相關(guān)（活動(dòng)期r=0.76,P<0.001；靜止期r=0.73,P<0.001）?；颊吣蛑邪椎鞍酌黠@高于正常人（活動(dòng)期P<0.001,緩解期,P<0.005）。結(jié)論：患者尿中白蛋白可作為判斷患者疾病活動(dòng)情況的指標(biāo)。鄧長(zhǎng)生.炎癥性腸病患者尿白蛋白的臨床意義.武漢大學(xué)學(xué)報(bào).2002，23(1)：88-89.尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。FecalmarkersCalprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.Itconstitutesapproximately5%ofthetotalproteinandupto60%ofthecytosolicproteininhumanneutrophils.Assuch,thefecalcalprotectinconcentrationisproportionaltotheinfluxofneutrophilsintotheintestinaltract,ahallmarkofactiveIBD.Lactoferrinisaniron-bindingglycoproteinidentifiedinthesecretionsoverlyingmostmucosalsurfacesthatinteractdirectlywithexternalpathogens,includingsaliva,tears,vaginalsecretions,feces,synovialfluid,andmammalianbreastmilk.Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.Intheintestinallumen,fecallactoferrinlevelsquicklyincreasewiththeinfluxofneutrophilsduringinflammation.Sugiandcolleaguesinvestigatedlactoferrin,polymorphonuclearneutrophil(PMN)elastase,andlysozymetogetherwithmyeloperoxidaseinfecalmaterialandwhole-gutlavagefluidfromIBDpatients.LanghorstJ,ElsenbruchS,MuellerTetal.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.Inflamm.BowelDis.2005;11:1085–91.FecalmarkersCalprotectin(FCP鋇劑灌腸檢查所見的主要改變?yōu)椋?1)黏膜粗亂和(或)顆粒樣改變；(2)腸管邊緣呈鋸齒狀或毛刺樣，腸壁有多發(fā)性小充盈缺損；(3)腸管短縮，袋囊消失呈鉛管樣。鋇劑灌腸檢查所見的主要改變?yōu)椋篊TUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．結(jié)腸鏡檢查并活組織檢查(后文簡(jiǎn)稱活檢)是UC診斷的主要依據(jù)。結(jié)腸鏡下UC病變多從直腸開始，呈連續(xù)性、彌漫性分布，表現(xiàn)為：(1)黏膜血管紋理模糊、紊亂或消失，黏膜充血、水腫、質(zhì)脆、自發(fā)或接觸出血和膿性分泌物附著，亦常見黏膜粗糙、呈細(xì)顆粒狀；(2)病變明顯處可見彌漫性、多發(fā)性糜爛或潰瘍；(3)可見結(jié)腸袋變淺、變鈍或消失以及假息肉、橋黏膜等。結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．UlceraTypicalendoscopicfindings

(A)UCwithmildinflammationandreducedhaustration,vasculartransparencyis

missing.(B)Moderateinflammationwithreducedhaustration.Themucosaisedematous,coveredwithfibrin,andshowsmultipleerosions.(C)

Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.Typicalendoscopicfindings(A放大內(nèi)鏡(Confocalmicroscopy)

內(nèi)鏡下黏膜染色技術(shù)能提高內(nèi)鏡對(duì)黏膜病變的識(shí)別能力，結(jié)合放大內(nèi)鏡技術(shù)，通過對(duì)黏膜微細(xì)結(jié)構(gòu)的觀察和病變特征的判別，有助UC診斷，姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附116例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：116—118．放大內(nèi)鏡(Confocalmicroscopy)內(nèi)鏡下small-bowelcapsuleendoscopy(SBCE).

Crohn’sdiseaseandulcerativecolitisarelifelong

diseases.Bothdiseasesaremarkedbyfrequentrelapsesandpatientsoftenundergorepeatedinvestigationstodefinetheextentofthedisease,assesstheseverityofrelapse,oridentifycomplications.Whereasulcerativecolitisisachronicinflammatoryconditioncausingdiffuseandcontinuousmucosalinflammationofthecolon,Crohn’sdiseaseisaheterogeneousentitycomprisedofseveraldifferentphenotypes,butcanaffecttheentiregastrointestinaltract.Theuseofcapsuleendoscopyasafilterforpush?and?pullenteroscopy(PPE)isoccasionallynecessaryinpatientswithestablishedulcerativecolitiswhenthediagnosisisquestioned,especiallybeforesurgery.CapsuleendoscopycanalsodirectthechoiceofrouteofPPE.small-bowelcapsuleendoscopySBCE

Subtlelesionsasseenatsmall-bowelcapsuleendoscopyBourreilleA，IgnjatovicA，AabakkenL，eta1．Roleofsmall—bowelendoscopyinthemanagementofpatientswithinflammatoryboweldisease：aninternationalOMED-ECCOconsensus．Endoscopy，2009，41：618—637．SBCESubtlelesionsasseenat黏膜活檢組織學(xué)檢查

組織學(xué)可見以下主要改變?；顒?dòng)期：(1)固有膜內(nèi)彌漫性急慢性炎性細(xì)胞浸潤(rùn)，包括中性粒細(xì)胞、淋巴細(xì)胞、漿細(xì)胞和嗜酸粒細(xì)胞等，尤其是上皮細(xì)胞間中性粒細(xì)胞浸潤(rùn)及隱窩炎，乃至形成隱窩膿腫；(2)隱窩結(jié)構(gòu)改變：隱窩大小、形態(tài)不規(guī)則，排列紊亂，杯狀細(xì)胞減少等；(3)可見黏膜表面糜爛，淺潰瘍形成和肉芽組織增生。緩解期：(1)黏膜糜爛或潰瘍愈合；(2)固有膜內(nèi)中性粒細(xì)胞浸潤(rùn)減少或消失，慢性炎性細(xì)胞浸潤(rùn)減少；(3)隱窩結(jié)構(gòu)改變：隱窩結(jié)構(gòu)改變可加重，如隱窩減少、萎縮，可見潘氏細(xì)胞化生(結(jié)腸脾曲以遠(yuǎn))。UC活檢標(biāo)本的病理診斷：活檢病變符合上述活動(dòng)期或緩解期改變，結(jié)合臨床，可報(bào)告符合UC病理改變。宜注明為活動(dòng)期或緩解期。如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。RileySA,ManiV,GoodmanMJ,etal.Microscopicactivityinulcerativecolitis:whatdoesitmean?Gut.1991;32:174–178.黏膜活檢組織學(xué)檢查

組織學(xué)可見以下主要改變。RileySMicroscopicfindingsinbiopsies

(D,E)CryptabscessinUC.(F)Pseudopolypformation.L,lymphfollicle.NikolausS，SchreiberS．Diagnosticsofinflammatorybowel

disease．Gastroenterology，2007，133：1670—1689．Microscopicfindingsinbiopsi診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：(1)具有上述典型臨床表現(xiàn)者為I臨床疑診(spicious)，安排進(jìn)一步檢查；(2)同時(shí)具備上述結(jié)腸鏡和(或)放射影像特征者，可臨床擬診(probable)；(3)如再加上上述黏膜活檢和(或)手術(shù)切除標(biāo)本組織病理學(xué)特征者，可以確診(definite)；(4)初發(fā)病例如I臨床表現(xiàn)、結(jié)腸鏡及活檢組織學(xué)改變不典型者，暫不確診UC，應(yīng)予隨訪(follow-up)。Lennard-JonesJE.Classificationofinflammatoryboweldisease.ScandJGastroenterol.Suppl.1989;170:2–6;discussion16–19.診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：LennDiagnosticcriteria

VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.ModifiedMendeloffcriteriapluskeypointsoftheLennard-Jonescriteria,commonlyusedcriteria,arepresentedhere.MyrenJ,BouchierIA,WatkinsonG,SoftleyA,ClampSE,deDombalFT.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.Afurtherreporton3175cases.ScandJGastroenterol.Suppl.1988;144:11–19.Diagnosticcriteria

Variousd鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎曲菌、沙門菌、產(chǎn)氣單孢菌、大腸埃希菌、耶爾森菌等。常有流行病學(xué)特點(diǎn)(如不潔食物史或疫區(qū)接觸史)，急性起病常伴發(fā)熱和腹痛，具自限性(病程一般數(shù)天至1周，不超過6周)；抗菌藥物治療有效；糞便檢出病原體可確診。2．阿米巴腸病3．腸道血吸蟲病4．其他：腸結(jié)核、真菌性腸炎、抗生素相關(guān)性腸炎(包括假膜性腸炎)、缺血性結(jié)腸炎、放射性腸炎、嗜酸粒細(xì)胞性腸炎、過敏性紫癜、膠原性結(jié)腸炎、白塞病、結(jié)腸息肉病、結(jié)腸憩室炎以及人類免疫缺陷病毒(HIV)感染合并的結(jié)腸病變應(yīng)與本病鑒別。鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。IntestinalSymptoms001,緩解期,P<0.姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附116例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：116—118．潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).組織學(xué)可見以下主要改變。(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).腸外表現(xiàn)(Extraintestinalmanifestations)肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)Activeinflammatoryanorectallesionsresultinurgencyofdefecationandcrampsarounddefecation(“tenesmus”).Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.組織學(xué)可見以下主要改變。Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.(F)Pseudopolypformation.Differentiatediagnosis

方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5Differentiatediagnosis

夏冰，等.缺血性結(jié)腸炎與潰瘍性結(jié)腸炎的臨床鑒別診斷.胃腸病學(xué).2010，15(11)：681-683.Differentiatediagnosis

夏冰，等.InternationalStudyGroupforBehcet’sdisease.Criteriaforthe

diagnosisofBehcet’sdisease.Lancet1990;335:1078–1080.

InternationalStudyGroupfor感謝您的觀看！感謝您的觀看！Sugiandcolleaguesinvestigatedlactoferrin,polymorphonuclearneutrophil(PMN)elastase,andlysozymetogetherwithmyeloperoxidaseinfecalmaterialandwhole-gutlavagefluidfromIBDpatients.方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.SerologicalmarkersVariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。)2005;125:297–300.并發(fā)癥(Complications)TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.2010，15(11)：681-683.MicroscopicfindingsinbiopsiesBothdiseasesaremarkedbyfrequentrelapsesandpatientsoftenundergorepeatedinvestigationstodefinetheextentofthedisease,assesstheseverityofrelapse,oridentifycomplications.腸外表現(xiàn)(Extraintestinal

manifestations)腸外表現(xiàn)包括：皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)關(guān)節(jié)損害(如外周關(guān)節(jié)炎、脊柱關(guān)節(jié)炎等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

Crohn’sdiseaseandulcerativecolitis.Med.Clin.(Barc.)2005;125:

297–300.Sugiandcolleaguesinvestigat并發(fā)癥(Complications)并發(fā)癥包括：中毒性巨結(jié)腸（toxicmegacolon）腸穿孔下消化道大出血上皮內(nèi)瘤變和癌變錢家鳴,等.潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).中華內(nèi)科雜志[J].2012，51(9):694-697/ChowDK，LeongRW，TsoiKK,eta1．Long—termfollow—up

ofulcerativecolitisintheChinesepopulation．AmJ

Gastroenterol，2009，104：647-654．并發(fā)癥(Complications)并發(fā)癥包括：CTUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．結(jié)腸鏡檢查并活組織檢查(后文簡(jiǎn)稱活檢)是UC診斷的主要依據(jù)。結(jié)腸鏡下UC病變多從直腸開始，呈連續(xù)性、彌漫性分布，表現(xiàn)為：(1)黏膜血管紋理模糊、紊亂或消失，黏膜充血、水腫、質(zhì)脆、自發(fā)或接觸出血和膿性分泌物附著，亦常見黏膜粗糙、呈細(xì)顆粒狀；(2)病變明顯處可見彌漫性、多發(fā)性糜爛或潰瘍；(3)可見結(jié)腸袋變淺、變鈍或消失以及假息肉、橋黏膜等。結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．UlceraDiagnosticcriteria

VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.ModifiedMendeloffcriteriapluskeypointsoftheLennard-Jonescriteria,commonlyusedcriteria,arepresentedhere.MyrenJ,BouchierIA,WatkinsonG,SoftleyA,ClampSE,deDombalFT.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.Afurtherreporton3175cases.ScandJGastroenterol.Suppl.1988;144:11–19.Diagnosticcriteria

VariousdInternationalStudyGroupforBehcet’sdisease.Criteriaforthe

diagnosisofBehcet’sdisease.Lancet1990;335:1078–1080.

InternationalStudyGroupforClinicalPresentationIntestinalSymptoms70%ofpatientswithUCreport>5bowelmovementsduringacutephases.Themainreason

fordiarrheaiscolonicinflammation,butbileacidand

foodmalabsorptionsecondarytoinflammationinthe

terminalileumortheproximalsmallbowelcancontribute

tothissymptom.Ahistoryofsurgicalresectionscan

beseminalinexplainingsymptoms.AcutephasesofUC

almostalwayspresentwithbloodydiarrhea(“hematochezia”).Activeinflammatoryanorectallesions

resultinurgencyofdefecationandcrampsarounddefecation

(“tenesmus”).UCpatientsoftencomplainof

lowerleftquadrantpain.ExtraintestinalManifestationsWafikEl-DieryandDavidMetz,SectionEditors．DiagnosticsofInflammatoryBowelDisease．Gastroenterology，2007;133:1670–1689．ClinicalPresentationIntestina腸外表現(xiàn)(Extraintestinal

manifestations)腸外表現(xiàn)包括：皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)關(guān)節(jié)損害(如外周關(guān)節(jié)炎、脊柱關(guān)節(jié)炎等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

Crohn’sdiseaseandulcerativecolitis.Med.Clin.(Barc.)2005;125:

297–300.腸外表現(xiàn)(Extraintestinalmanifesta(B)Moderateinflammationwithreducedhaustration.糞便檢出病原體可確診。ScandJGastroenterol.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.(1)具有上述典型臨床表現(xiàn)者為I臨床疑診(spicious)，安排進(jìn)一步檢查；并發(fā)癥(Complications)黏膜活檢組織學(xué)檢查ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).并發(fā)癥(Complications)并發(fā)癥包括：中毒性巨結(jié)腸（toxicmegacolon）腸穿孔下消化道大出血上皮內(nèi)瘤變和癌變錢家鳴,等.潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).中華內(nèi)科雜志[J].2012，51(9):694-697/ChowDK，LeongRW，TsoiKK,eta1．Long—termfollow—up

ofulcerativecolitisintheChinesepopulation．AmJ

Gastroenterol，2009，104：647-654．(B)Moderateinflammationwithsmall-bowelcapsuleendoscopy(SBCE).Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.NikolausS，SchreiberS．Diagnosticsofinflammatoryboweldisease．Gastroenterology，2007，133：1670—1689．ReeseGE,ConstantinidesVA,SimillisCetal.Diagnosticcriteria眼部病變(如虹膜炎、鞏膜炎、葡萄膜炎等)、皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)并發(fā)癥(Complications)并發(fā)癥(Complications)皮膚黏膜表現(xiàn)(如口腔潰瘍、結(jié)節(jié)性紅斑和壞疽性膿皮病)患者尿中白蛋白明顯高于正常人（活動(dòng)期P<0.Differentiatediagnosis結(jié)論：患者尿中白蛋白可作為判斷患者疾病活動(dòng)情況的指標(biāo)。宜注明為活動(dòng)期或緩解期。Serologicalmarkers

Thetwomostwidelystudiedserologicalmarkersin

inflammatoryboweldiseaseinrecentyearshavebeen

p-ANCAandASCA.Theclinicalutilityofp-ANCAorASCA

testinginthediagnosisofinflammatoryboweldisease,in

patientswithnon-specificgastrointestinalsymptoms,is

limitedbecauseofthevaryingseroprevalenceofthese

antibodiesinpatientswithinflammatoryboweldiseaseand

theinadequatesensitivityoftheassays.ReeseGE,ConstantinidesVA,SimillisCetal.Diagnosticprecision

ofanti-Saccharomycescerevisiaeantibodiesandperinuclear

antineutrophilcytoplasmicantibodiesininflammatorybowel

disease.AmJGastroenterol.2006(Oct);101(10):2410–22.small-bowelcapsuleendoscopy尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。結(jié)果：患者尿白蛋白活動(dòng)期比緩解期明顯增高（0.002），Harvey和Bradshaw指數(shù)呈正相關(guān)（活動(dòng)期r=0.76,P<0.001；靜止期r=0.73,P<0.001）。患者尿中白蛋白明顯高于正常人（活動(dòng)期P<0.001,緩解期,P<0.005）。結(jié)論：患者尿中白蛋白可作為判斷患者疾病活動(dòng)情況的指標(biāo)。鄧長(zhǎng)生.炎癥性腸病患者尿白蛋白的臨床意義.武漢大學(xué)學(xué)報(bào).2002，23(1)：88-89.尿白蛋白

目的：探討炎癥性腸病患者尿中白蛋白的臨床意義。FecalmarkersCalprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.Itconstitutesapproximately5%ofthetotalproteinandupto60%ofthecytosolicproteininhumanneutrophils.Assuch,thefecalcalprotectinconcentrationisproportionaltotheinfluxofneutrophilsintotheintestinaltract,ahallmarkofactiveIBD.Lactoferrinisaniron-bindingglycoproteinidentifiedinthesecretionsoverlyingmostmucosalsurfacesthatinteractdirectlywithexternalpathogens,includingsaliva,tears,vaginalsecretions,feces,synovialfluid,andmammalianbreastmilk.Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.Intheintestinallumen,fecallactoferrinlevelsquicklyincreasewiththeinfluxofneutrophilsduringinflammation.Sugiandcolleaguesinvestigatedlactoferrin,polymorphonuclearneutrophil(PMN)elastase,andlysozymetogetherwithmyeloperoxidaseinfecalmaterialandwhole-gutlavagefluidfromIBDpatients.LanghorstJ,ElsenbruchS,MuellerTetal.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.Inflamm.BowelDis.2005;11:1085–91.FecalmarkersCalprotectin(FCP鋇劑灌腸檢查所見的主要改變?yōu)椋?1)黏膜粗亂和(或)顆粒樣改變；(2)腸管邊緣呈鋸齒狀或毛刺樣，腸壁有多發(fā)性小充盈缺損；(3)腸管短縮，袋囊消失呈鉛管樣。鋇劑灌腸檢查所見的主要改變?yōu)椋篊TUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．結(jié)腸鏡檢查并活組織檢查(后文簡(jiǎn)稱活檢)是UC診斷的主要依據(jù)。結(jié)腸鏡下UC病變多從直腸開始，呈連續(xù)性、彌漫性分布，表現(xiàn)為：(1)黏膜血管紋理模糊、紊亂或消失，黏膜充血、水腫、質(zhì)脆、自發(fā)或接觸出血和膿性分泌物附著，亦常見黏膜粗糙、呈細(xì)顆粒狀；(2)病變明顯處可見彌漫性、多發(fā)性糜爛或潰瘍；(3)可見結(jié)腸袋變淺、變鈍或消失以及假息肉、橋黏膜等。結(jié)腸鏡檢查DaneseS，F(xiàn)iocehiC．UlceraTypicalendoscopicfindings

(A)UCwithmildinflammationandreducedhaustration,vasculartransparencyis

missing.(B)Moderateinflammationwithreducedhaustration.Themucosaisedematous,coveredwithfibrin,andshowsmultipleerosions.(C)

Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.Typicalendoscopicfindings(A放大內(nèi)鏡(Confocalmicroscopy)

內(nèi)鏡下黏膜染色技術(shù)能提高內(nèi)鏡對(duì)黏膜病變的識(shí)別能力，結(jié)合放大內(nèi)鏡技術(shù)，通過對(duì)黏膜微細(xì)結(jié)構(gòu)的觀察和病變特征的判別，有助UC診斷，姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附116例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：116—118．放大內(nèi)鏡(Confocalmicroscopy)內(nèi)鏡下small-bowelcapsuleendoscopy(SBCE).

Crohn’sdiseaseandulcerativecolitisarelifelong

diseases.Bothdiseasesaremarkedbyfrequentrelapsesandpatientsoftenundergorepeatedinvestigationstodefinetheextentofthedisease,assesstheseverityofrelapse,oridentifycomplications.Whereasulcerativecolitisisachronicinflammatoryconditioncausingdiffuseandcontinuousmucosalinflammationofthecolon,Crohn’sdiseaseisaheterogeneousentitycomprisedofseveraldifferentphenotypes,butcanaffecttheentiregastrointestinaltract.Theuseofcapsuleendoscopyasafilterforpush?and?pullenteroscopy(PPE)isoccasionallynecessaryinpatientswithestablishedulcerativecolitiswhenthediagnosisisquestioned,especiallybeforesurgery.CapsuleendoscopycanalsodirectthechoiceofrouteofPPE.small-bowelcapsuleendoscopySBCE

Subtlelesionsasseenatsmall-bowelcapsuleendoscopyBourreilleA，IgnjatovicA，AabakkenL，eta1．Roleofsmall—bowelendoscopyinthemanagementofpatientswithinflammatoryboweldisease：aninternationalOMED-ECCOconsensus．Endoscopy，2009，41：618—637．SBCESubtlelesionsasseenat黏膜活檢組織學(xué)檢查

組織學(xué)可見以下主要改變?；顒?dòng)期：(1)固有膜內(nèi)彌漫性急慢性炎性細(xì)胞浸潤(rùn)，包括中性粒細(xì)胞、淋巴細(xì)胞、漿細(xì)胞和嗜酸粒細(xì)胞等，尤其是上皮細(xì)胞間中性粒細(xì)胞浸潤(rùn)及隱窩炎，乃至形成隱窩膿腫；(2)隱窩結(jié)構(gòu)改變：隱窩大小、形態(tài)不規(guī)則，排列紊亂，杯狀細(xì)胞減少等；(3)可見黏膜表面糜爛，淺潰瘍形成和肉芽組織增生。緩解期：(1)黏膜糜爛或潰瘍愈合；(2)固有膜內(nèi)中性粒細(xì)胞浸潤(rùn)減少或消失，慢性炎性細(xì)胞浸潤(rùn)減少；(3)隱窩結(jié)構(gòu)改變：隱窩結(jié)構(gòu)改變可加重，如隱窩減少、萎縮，可見潘氏細(xì)胞化生(結(jié)腸脾曲以遠(yuǎn))。UC活檢標(biāo)本的病理診斷：活檢病變符合上述活動(dòng)期或緩解期改變，結(jié)合臨床，可報(bào)告符合UC病理改變。宜注明為活動(dòng)期或緩解期。如有隱窩上皮異型增生(上皮內(nèi)瘤變)或癌變，應(yīng)予注明。RileySA,ManiV,GoodmanMJ,etal.Microscopicactivityinulcerativecolitis:whatdoesitmean?Gut.1991;32:174–178.黏膜活檢組織學(xué)檢查

組織學(xué)可見以下主要改變。RileySMicroscopicfindingsinbiopsies

(D,E)CryptabscessinUC.(F)Pseudopolypformation.L,lymphfollicle.NikolausS，SchreiberS．Diagnosticsofinflammatorybowel

disease．Gastroenterology，2007，133：1670—1689．Microscopicfindingsinbiopsi診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：(1)具有上述典型臨床表現(xiàn)者為I臨床疑診(spicious)，安排進(jìn)一步檢查；(2)同時(shí)具備上述結(jié)腸鏡和(或)放射影像特征者，可臨床擬診(probable)；(3)如再加上上述黏膜活檢和(或)手術(shù)切除標(biāo)本組織病理學(xué)特征者，可以確診(definite)；(4)初發(fā)病例如I臨床表現(xiàn)、結(jié)腸鏡及活檢組織學(xué)改變不典型者，暫不確診UC，應(yīng)予隨訪(follow-up)。Lennard-JonesJE.Classificationofinflammatoryboweldisease.ScandJGastroenterol.Suppl.1989;170:2–6;discussion16–19.診斷要點(diǎn)

在排除其他疾病基礎(chǔ)上，可按下列要點(diǎn)診斷：LennDiagnosticcriteria

VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.ModifiedMendeloffcriteriapluskeypointsoftheLennard-Jonescriteria,commonlyusedcriteria,arepresentedhere.MyrenJ,BouchierIA,WatkinsonG,SoftleyA,ClampSE,deDombalFT.TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.Afurtherreporton3175cases.ScandJGastroenterol.Suppl.1988;144:11–19.Diagnosticcriteria

Variousd鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎曲菌、沙門菌、產(chǎn)氣單孢菌、大腸埃希菌、耶爾森菌等。常有流行病學(xué)特點(diǎn)(如不潔食物史或疫區(qū)接觸史)，急性起病常伴發(fā)熱和腹痛，具自限性(病程一般數(shù)天至1周，不超過6周)；抗菌藥物治療有效；糞便檢出病原體可確診。2．阿米巴腸病3．腸道血吸蟲病4．其他：腸結(jié)核、真菌性腸炎、抗生素相關(guān)性腸炎(包括假膜性腸炎)、缺血性結(jié)腸炎、放射性腸炎、嗜酸粒細(xì)胞性腸炎、過敏性紫癜、膠原性結(jié)腸炎、白塞病、結(jié)腸息肉病、結(jié)腸憩室炎以及人類免疫缺陷病毒(HIV)感染合并的結(jié)腸病變應(yīng)與本病鑒別。鑒別診斷

1．急性感染性腸炎：各種細(xì)菌感染，如志賀菌、空腸彎方法：對(duì)臨床確診的32例IBD患者（UC27例，CD5例)在疾病的不同時(shí)期，用免疫放射比濁法測(cè)定尿中白蛋白，并結(jié)合臨床Harvey和Bradshaw指數(shù)進(jìn)行綜合分析，選取25例健康人為正常對(duì)照。IntestinalSymptoms001,緩解期,P<0.姜泊，等．放大內(nèi)鏡結(jié)合黏膜染色技術(shù)診斷潰瘍性結(jié)腸炎附116例放大內(nèi)鏡形態(tài)分析．現(xiàn)代消化及介入診療，2005，10：116—118．潰瘍性結(jié)腸炎合并中毒性巨結(jié)腸六例及文獻(xiàn)復(fù)習(xí).組織學(xué)可見以下主要改變。(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).腸外表現(xiàn)(Extraintestinalmanifestations)肝膽疾病(如脂肪肝、原發(fā)性硬化性膽管炎、膽石癥等)Activeinflammatoryanorectallesionsresultinu