溃疡性结肠炎诊治全集课件.pptx

1、Introduction Introduction n IBDIBD是一是一种种病因病因尚尚不十分不十分清清楚的慢性非特楚的慢性非特异异性性肠肠道炎症，包括道炎症，包括UCUC和和CDCD 。n 其其发发病率呈逐年上升病率呈逐年上升趋势趋势，且多，且多为青壮为青壮年年发发病，病，临临床表床表现复杂现复杂，并发并发症症严严重，重，肠肠外表外表现现多多样样，严严重影重影响个响个人生活人生活质质量和社量和社会会生生产产力。力。n 此外，因其有癌此外，因其有癌变变的的风险风险，备备受广大受广大医医生的重生的重视视。n 近年来在国内外近年来在国内外IBDIBD基础与临床研究高潮迭起，基础研究的成果直接指

2、向临基础与临床研究高潮迭起，基础研究的成果直接指向临床治疗，取得了划时代的进展。床治疗，取得了划时代的进展。n 探讨和摸索适合国人的治疗方案以降低重症探讨和摸索适合国人的治疗方案以降低重症UCUC的并发症和死亡率显得十分的并发症和死亡率显得十分重要。重要。Introduction n Ulcerative colitis is characterized by mucosal inflammation of the colon.n The pathology is inflammatory and the disease course is relapsing and remitting wi

3、th intermittent symptoms of rectal bleeding and diarrhea.n Approximately 25%of patients develop a chronic active or a rapidly fulminate disease course.n Chronic inflammation can lead to dysplasia and cancer.n Approximately 20%of patients require colectomy with ileoanal pouch or stoma.n Velayos FS,Te

4、rdiman JP,Walsh JM.Effect of 5-aminosalicylate use on colorectal cancer and dysplasia risk:a systematic review and metaanalysis of observational studies.Am J Gastroenterol 2005;100:13451353.ConsensusConsensusn Stange EF,Travis SP,Vermeire S,Reinisch W,Geboes K,Barakauskiene A,et al.European evidence

5、-based Consensus on the diagnosis and management of ulcerative colitis:definitions and diagnosis.J Crohns Colitis 2008;2:123.n Van Assche G，Dignass A，Panes J，et a1The second European evidence-based Consensus on the diagnosis and management of ulcerative colitis：Definitions and diagnosisJ Crohns Coli

6、tis，20104：7 27n Mowat C,Cole A,Windsor A,Ahmad T,Arnott I,Driscoll R,et al.Guidelines for the management of inflammatory bowel disease in adults.Gut 2011;60:571607.n Turner D,Levine A,Escher JC,Griffiths AM,Russell RK,Dignass A,et al.Management of pediatric ulcerative colitis:a joint ECCO and ESPGHA

7、N evidence-based consensus guidelines.J Pediatr Gastroenterol Nutr 2012.n Turner D,Travis SP,Griffiths AM,Ruemmele FM,Levine A,Benchimol EI,et al.Consensus for managing acute severe ulcerative colitis in children:a systematic review and joint statement from ECCO,ESPGHAN,and the Porto IBD Working Gro

8、up of ESPGHAN.Am J Gastroenterol 2011;106:57488.Endoscopic scores(UCEIS)Cortisone in ulcerative colitis.(4)初发病例如I临床表现、结肠镜及活检组织学改变不典型者，暂不确诊UC，应予随访(follow-up)。Treatment goalsBackground&Aims:This retrospective study analyzed the clinical characteristics of hospitalized patients with ulcerative colitis(

9、UC)in China.常有流行病学特点(如不洁食物史或疫区接触史)，急性起病常伴发热和腹痛，具自限性(病程一般数天至1周，不超过6周)；慢性持续活动或反复发作频繁者，预后较差。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-5084其他：肠结核、真菌性肠炎、抗生素相关性肠炎(包括假膜性肠炎)、缺血性结肠炎、放射性肠炎、

10、嗜酸粒细胞性肠炎、过敏性紫癜、胶原性结肠炎、白塞病、结肠息肉病、结肠憩室炎以及人类免疫缺陷病毒(HIV)感染合并的结肠病变应与本病鉴别。In the HT group,20.Experience of maintenance infliximab therapy for refractory ulcerative colitis from six centers in England.Baron endoscopic scoresLoftus CG，Loftus EV Jr，Sandborn WJCyclosporin for refractory ulcerative colitisGUt2

11、003，52;172173Chin J Gastroenterol Hepatol.Gut 1996;39:690-697.Management consensus of inflammatory bowel disease forManagement consensus of inflammatory bowel disease forthe AsiaPacific regionthe AsiaPacific region 2006 2006nAbstract:At the present there are no large-scale epidemiologic data on infl

12、ammatory bowel disease(IBD)in the AsiaPacific region,but several studies have shown an increased incidence and prevalence of IBD in this region.nCompared to the West,there appears to exist a time lag phenomenon.With regard to the two main forms of IBD,ulcerative colitis(UC)is more prevalent than Cro

13、hns disease(CD).In addition to geographic differences,ethnic differences have been observed in the multiracial Asian countries.Moreover,the genetic backgrounds are different in the Asian compared to Western patients.For instance,NOD2/CARD15 variants have not been found in Asian CD patients.nIn gener

14、al,the clinical course of IBD seems to be less severe in the AsiaPacific region than in Western countries.nDiagnosis of IBD in this region poses special problems.The lack of a gold standard for the diagnosis of IBD,and the existence of a variety of infectious enterocolitis with similar manifestation

15、s to those of IBD make the differential diagnosis particularly difficult.So far,nWestern diagnostic criteria have been introduced for the diagnosis of IBD.A stepwise approach to exclude non-IBD enterocolitis also must be introduced,and a definite diagnosis must include typical histological features.

16、In some patients,follow up and therapeutic trials might be necessary to obtain a definitive diagnosis.A better understanding of the pathogenesis of IBD will allow the development of better diagnostic markers.nThe management of IBD also poses some special problems in the AsiaPacific Region.There is o

17、ften a delay in using proper medications for IBD,and alternative local remedies are still widely used.With a combination ofWestern guidelines and regional experiences,similar principles can be used for induction and maintenance of remission.A stepwise selection of medications is advocated depending

18、on the extent,activity and severity of the disease.Comprehensive and individualized approaches are suggested for different IBD patients.nDeeper understanding of disease pathogenesis and the unique characteristics of IBD in the AsiaPacific region,combined with reasonable and practical guidelines for

19、drug management and the future use of biological agents would improve the therapeutic outlook of IBD in this region.The Asia-Pacific consensus on ulcerative colitis 2010European evidence-based consensus on the diagnosisEuropean evidence-based consensus on the diagnosis/management of ulcerative colit

20、is 2008/management of ulcerative colitis 2008n This document sets out the current European Consensus on the diagnosis andmanagement of UC,reached by the European Crohns and Colitis Organisation(ECCO)at a meeting held in Berlin on 20th October 2006.n ECCO is a forum for specialists in inflammatory bo

21、wel disease from 23 European countries.n Like the initial Consensus on the management of Crohns disease,the current Consensus is grouped into three parts:definitions and diagnosis;current management;and management of special situations.n This first section concerns aims,methods and definitions of th

22、e Consensus,as well as classification,diagnosis,imaging and pathology of UC.n The second section on current management includes treatment of active disease,maintenance ofmedically-induced remission and surgery of UC.n The third section on special situations includes pouch disorders,cancer surveillan

23、ce,pregnancy,paediatrics,psychosomatics,extra-intestinal manifestations and alternative therapy.2nd European evidence-based consensus on the diagn2nd European evidence-based consensus on the diagnosis/management of ulcerative colitis 2012osis/management of ulcerative colitis 2012n This document upda

24、tes the previous European Consensus on the diagnosis and management of UC,and was finalised by the European Crohns and Colitis Organisation(ECCO)at a meeting held in Dublin in February 2011.n ECCO is a forum for specialists in inflammatory bowel disease from 31 European countries.n Like the initial

25、Consensus on the diagnosis and management of ulcerative colitis,68 this updated Consensus is grouped into three parts:definitions and diagnosis;current management;and management of special situations.n Previously included chapters on pregnancy and pediatrics are no longer included in this guideline,

26、as specific ECCO Consensus Guidelines on Reproduction and Pregnancy and Pediatric UC(together with ESPGHAN)cover these topics extensively.Backgroundn 溃疡性结肠炎（UC）1859年由Wilks首先描述，1920年被医学界公认，我国于1956年首次报道。n 特发性溃疡性结肠炎诊断及治疗标准（草案）（1978年杭州）n 溃疡性结肠炎的诊断及疗效标准（1993年太原）n 对溃疡性结肠炎诊断治疗规范的建议（2000年杭州）n 对我国炎症性肠病诊断治疗规范

27、的共识意见（2007年济南）n 炎症性肠病诊断与治疗的共识意见（2012年广州）n 从中可以看出每一次补充和修改都反映了我国对该病认识的逐步提高，治疗逐渐规范化。第九届中华消化病学分会炎症性肠病学组成员名单 n 名誉组长：欧阳钦n 组长：胡品津n 副组长：钱家呜 夏 冰 吴开春 冉志华n 秘书：王玉芳 高 翔n 核心成员：胡品津 欧阳钦 郑家驹 钱家呜 夏 冰吴开春 冉志华 刘占举 钟 捷 吴小平陈旻湖 胡仁伟n 组员：欧阳钦 郑家驹 邓长生 刘新光 胡品津钱家鸣 夏 冰 吴开春 李俊霞 吕愈敏顾 芳 刘玉兰 王晓娣 韩 英 朱 峰冉志华 刘占举 郑 萍 钟 捷 庞 智曹 茜 陈旻湖 智发朝

28、姜 泊 张亚历钟英强 沙卫红胡仁伟 王玉芳 甘华田邹开芳 吴小平 缪应蕾 江学良 于成功梅 俏 王承党 郭长存 卢雪峰 高 翔霍丽娟Ulcerative colitis in China:Retrospective analysis of 3100Ulcerative colitis in China:Retrospective analysis of 3100hospitalized patientshospitalized patientsnBackground&Aims:Background&Aims:This retrospective study analyzed the clini

29、cal characteristics of hospitalized patients with ulcerative This retrospective study analyzed the clinical characteristics of hospitalized patients with ulcerative colitis(UC)in China.colitis(UC)in China.nMethods:Methods:A total of 3100 hospitalized patients with UC admitted to 23 hospitals in Chin

30、a from A total of 3100 hospitalized patients with UC admitted to 23 hospitals in China from 1990 to 20031990 to 2003 were retrosp were retrospectively investigated and their clinical characteristics were analyzed.ectively investigated and their clinical characteristics were analyzed.nResults:Results

31、:A male/female ratio of 1.34/1.00 was found in the 3100 patients,who had an average age of 44 15.1 years at A male/female ratio of 1.34/1.00 was found in the 3100 patients,who had an average age of 44 15.1 years at diagnosis.Of the patients,2972(95.9%)had active UC.Active UC was mild in 35.4%of the

32、2972 patients,moderate in diagnosis.Of the patients,2972(95.9%)had active UC.Active UC was mild in 35.4%of the 2972 patients,moderate in 42.9%and severe in 21.7%.Of the 2726 patients with a description of their lesion extent,14.8%had proctitis,26.4%ha42.9%and severe in 21.7%.Of the 2726 patients wit

33、h a description of their lesion extent,14.8%had proctitis,26.4%had proctosigmoiditis,25.0%had left-sided colitis,6.3%had extensive colitis,25.8%had pancolitis and 1.7%had regiond proctosigmoiditis,25.0%had left-sided colitis,6.3%had extensive colitis,25.8%had pancolitis and 1.7%had regional colitis.

34、The predominant complaints of the patients with UC were bloody diarrhea(48.2%),abdominal pain(67.3%)anal colitis.The predominant complaints of the patients with UC were bloody diarrhea(48.2%),abdominal pain(67.3%)and mucus stools(58.4%).Among these patients,13.6%had extraintestinal manifestations an

35、d 9.6%had related complicd mucus stools(58.4%).Among these patients,13.6%had extraintestinal manifestations and 9.6%had related complications.A differential diagnosis was difficult to make,as there were 19 varieties of the disease;infectious enterocolitis hations.A differential diagnosis was difficu

36、lt to make,as there were 19 varieties of the disease;infectious enterocolitis had a misdiagnosis rate of 22.9%before admission.The main medications for UC in China were aminosalicylates(66.8%ad a misdiagnosis rate of 22.9%before admission.The main medications for UC in China were aminosalicylates(66

37、.8%)and steroids(42.8%).Only 94(3%)of the patients required colectomy and only 19(0.6%)died of UC.)and steroids(42.8%).Only 94(3%)of the patients required colectomy and only 19(0.6%)died of UC.nConclusions:Conclusions:Compared with UC in Western countries,ulcerative colitis in China has some differe

38、nces in clinical characCompared with UC in Western countries,ulcerative colitis in China has some differences in clinical characteristics.Therefore,a further population-based epidemiological study is required to determine the prevalence and incidteristics.Therefore,a further population-based epidemi

39、ological study is required to determine the prevalence and incidence rates of UC inence rates of UC in C Chinahina.Ouyang QAPDW 2004 Chinese IBD working groupJ Gastroenterol Hepatol.2007EpidemiolgyEpidemiolgyn The incidence of UC ranged from 1.0 to 2.0 per 100 000 person years.The prevalence of UC h

40、as ranged from 4.0 to 44.3 per 100 000.n In a recent study,the speculated prevalence was 11.6/100 000 in China.n Compared to time trends in the West,there appears to be a time lag phenomenon involving incidence and and prevalence of IBD with regard to the Asian experience.n Ouyang Q,Tandon R,Goh KL

41、et al.Management consensus of inflammatory bowel disease for the Asia-Pacific region.J Gastroenterol.Hepatol.2006;21:177282.n Lennrd-Jones JE.Incidence of infammatory bowel disease across Europe:is there a difference between north and south?.Gut 1996;39:690-697.Etiology and PathogenesisEtiology and

42、Pathogenesisn 目前对IBD病因和发病机制的认识可概括为：n 环境因素作用于遗传易感者，在肠道菌群丛的参与下，启动了肠道免疫系统及非免疫系统，最终导致免疫反应和炎症过程。n 可能是由于抗原的持续刺激或（及）免疫调节紊乱，这种免疫炎症反应表现为过度亢进或难于自限。n Baumgart DC,Carding SR.Inflammatory bowel disease:cause and immunobiology.Lancet 2007;369:16271640.n Brown SJ，Mayer IThe immune response in inflammatory bowel di

43、seaseAm J Gastroenterol，2007，102：20582069n Bernstein CN，Shanahan FDisorders of a modern lifestylel reconciling the epidemiology of inflammatory bowel diseasesGut，2008，57：1185-1191菌群失菌群失调调n IBD患者肠遭细菌存在菌群失调，正常细菌数量减少，而致病菌、条件致病菌数量明显增多。n Duchmann等 发现。正常人对其体内肠道菌群及抗原物质耐受，而IBD患者肠黏膜免疫细胞对失调的肠道菌群及抗原物质失去了耐受。这一发

44、现证实了IBD患者肠道菌群及抗原物质能诱导肠黏膜异常免疫反应。n Frank等 发现IBD患者肠道菌群中拟杆菌、厚壁菌类减少，而变形杆菌及放线菌等增多。由于在肠道内，拟杆菌、厚壁菌是主要的裂解食物纤维产生丁酸盐和其他短链脂肪酸的细菌，这些细菌数量减少，导致维持肠上皮细胞生长和代谢的丁酸盐和其他短链脂肪酸等营养物质减少。同时。溃疡性结肠炎患者肠道内产硫化氢的细菌增多，硫化氢具有抑制丁酸盐和其他短链脂肪酸等营养物质生存及直接影响肠上皮细胞新陈代谢的功能。n 上述细菌菌群失调导致肠上皮细胞营养缺乏，影响了肠黏膜屏障功能。n Duchmann R。Kaiser I，Hermann E，et a1Tol

45、erance exists towards resident intestinal flora but is broken in active inflammatory bowel disease(IBD)Clin Exp Immunol，1995102：448455n Frank DN，St Amand AL，Feldman RA，et a1Molecularphylogenetic characterization of microbial community imbalances in human inflammatory bowel diseasesProc Natl Acad Sci

46、 USA，2007，104：1378013785Family historyFamily historyn Kitahora et al.found a strong familial occurrence in UC among Japanese patients.In a Korean study,a similar familial aggregation was also reported.n Kitahora T,Utsunomiya T,Yokota A.Epidemiological study of ulcerative colitis in Japan:incidence a

47、nd familial occurrence.The Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan.J.Gastroenterol.1995;30(Suppl.8):58.n Park ER,Yang SK,Myung SJ et al.Familial occurrence of ulcerative colitis in Korea.Korean J.Gastroenterol.2000;36:7704.R Risk factorsisk factorsn Object

48、ive To screen the risk factors of inflammatory bowel disease(IBD)by case investigationn Methords 72 determined IBD patients and 72 paired healthy subjects were surveyed with an organized inventory comprising of relevant items to IBDCOX regression method was used to screen the statistically significa

49、nt risk factors for IBDn Results COX regression indicated the statistical significance in stressmilk and fried food over the other postulated risk factorsfor IBDn Conclusion Stress，milk and fried food are the potential risk factors for IBDn Kaichun Wu et al.Investigation on the risk factors of infla

50、mmatory bowel disease：A paired study of 72 cases.Chin J Gastroenterol Hepatol.2006,15(2):161-162Protective factorsProtective factorsn A study from Japan found a protective effect of smoking for UC.Nam et al.found that appendectomy was protective against UC in their group of Korean patients.n A case-