溃疡性结肠炎的诊断与治疗.ppt

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1、溃疡性结肠炎的诊断与治疗,临床症状,常见：腹痛、发热(38C)、腹泻、血便、消瘦。肠外表现：关节炎、口腔溃疡、强直性脊柱炎（HLA-B27）、微型硬化性胆 管炎。,内镜检查及X线检查,内镜检查表现：中毒性巨结肠是内镜绝对 禁忌症钡剂灌肠：铅管征、毛刺样改变、粘膜颗 粒粗糙,Endoscopic features of active ulcerative colitisFigure 4-1.Endoscopic features of active ulcerative colitis.Findings include diffusely erythematous,edematous,and g

2、ranular mucosa with areas of submucosal hemorrhage and,when severe,frank mucopurulent exudate.Inflammation invariably begins in the rectum and extends proximally for varying extents.The chronicity of the process is suggested by the loss of colonic haustrations;otherwise,the endoscopic picture is non

3、specific and could be consistent with acute infectious colitis,chronic ulcerative or Crohns colitis,or any number of other specific causes of colitis.A,Mild distal ulcerative colitis with diffuse erythema and friability well demarcated from the normal mucosa more proximally is depicted.B,This exampl

4、e shows moderately severe ulcerative colitis with irregular,inflamed,ulcerated mucosa and a patchy exudate.,Ulcerative colitis in remissionFigure 4-2.Ulcerative colitis in remission.The normal vascular pattern is absent and a white scar indicates the site of a previous ulcer.,Severe ulcerative colit

5、isFigure 4-3.Severe ulcerative colitis.The mucosa shows extensive ulceration and diffuse thickening with an inflammatory infiltrate.In contrast to Crohns colitis,the ulceration lacks depth.,Chronic ulcerative colitisFigure 4-5.Chronic ulcerative colitis.In long-standing ulcerative colitis,the mucosa

6、 has an atrophic and scarred appearance with a blunted vascular pattern.Pseudopolyps are often present.,Severe ulcerative colitis with pseudopolypsFigure 4-4.Severe ulcerative colitis with pseudopolyps.In addition to severe mucosal ulceration and inflammation,chronic ulcerative colitis is often asso

7、ciated with the formation of pseudopolyps,which represent islands of regenerating mucosa and exuberant inflammation amidst diffuse mucosal destruction.Pseudopolyps have no malignant potential.,Resected colon from patient with ulcerative colitisFigure 4-8.Gross pathologic specimen of resected colon f

8、rom a patient with severe ulcerative colitis.Inflammation is diffuse and continuous,involving the mucosa and extending from the rectum without interruption to the ascending colon.,Severe ulcerative colitisFigure 4-6.Radiographic appearance of severe ulcerative colitis.This single-contrast barium ene

9、ma demonstrates the typical ragged and ulcerative appearance of the mucosa in active ulcerative colitis.Characteristic collar-button or undermining ulcers are seen.In general,barium enema and colonoscopy should be avoided in fulminant ulcerative colitis because of the possibility of precipitating to

10、xic megacolon.,Chronic ulcerative colitisFigure 4-7.Radiographic appearance of chronic ulcerative colitis.Long-standing chronic ulcerative colitis,as shown in this single-contrast barium enema,is characterized by shortening and straightening of the colon with loss of haustrations,resulting in the ap

11、pearance of a featureless tube.No ulcerations are seen.,其他辅助检查,血沉、白细胞计数（10.0X109）、血白蛋白、电解质,临床分型,初发型、慢性复发型、慢性持续型、急性暴发型,鉴别诊断,感染性肠病：菌痢、阿米巴肠炎药物性肠炎：伪膜性肠炎痔疮、结直肠癌克隆病,UC和CD的病理鉴别要点,+始终有+常有+偶有 无,评估溃疡性结肠炎严重性的标准,并发症,肠穿孔：左半结肠（乙状结肠多见）肠出血：多见于慢性重型溃结伴溃疡，糜 烂，炎性息肉，如果出血 则有手术指征中毒性巨结肠：多见于暴发性溃结和全结肠炎，因病变侵及肌层，横结肠直径可达结直肠癌,轻度

12、溃结的处理,可选用柳氮磺胺吡啶（SASP）制剂，每日34g，p o；5-氨基水杨酸（5-ASA）制剂。远段结肠者可SASP栓剂0.51g，每日2次；氢化可的松琥珀酸钠盐灌肠液100200mg，每晚1次保留灌肠，或用相当剂量的5-ASA制剂灌肠，亦可用中药保留灌肠治疗。,中度溃结的处理,可用上述剂量水杨酸类制剂治疗，反应不佳者适当加量或改服皮质类固醇激素，常用强的松3040mg/d，分次口服。,重度溃结的处理,如患者尚未用过口服类固醇激素，可口服强的松龙40-60mg/d，观察7-10天，亦可直接静脉给药；已使用激素者，静滴注氢化考的松300mg/d或甲基强的松龙40mg/d；未用类固醇激素者亦

13、可使用促肾上腺皮质激素（ACTH）120mg/d，静滴。应用抗生素控制肠道继发感染，如氨苄青霉素、硝基咪唑及喹诺酮类制剂。,重度溃结的治疗,应使患者卧床休息，适当输液、补充电解质，以防水盐水平衡紊乱。便血量大、Hb90g/L和持续出血不止者应考虑输血。营养不良、病情较重者可用要素饮食，病情严重者应予肠外营养。,重度溃结的治疗,静脉类固醇激素使用710天后无效者可考虑环孢素每日24mg/kg静脉滴注；如上述药物疗效不佳，应及时内、外科会诊，确定结肠切除手术的时机和方式。慎用解痉剂及止泻剂，以避免诱发中毒性巨结肠。密切监测患者生命体征及腹部体征变化，尽早发现和处理并发症。,缓解期溃结的处理,症状缓

14、解后，应继续维持治疗，但至少应维持1年，近年主张长期维持。一般认为类固醇激素无维持治疗效果，在症状缓解后应逐渐减量，尽可能过渡到用SASP维持治疗。,外科手术治疗,绝对指征：大出血、穿孔、明确或高度怀疑癌肿及组织学检查发现重度异型增生或肿块性损害轻、中度异型增生。相对指征：重度UC伴中毒性巨结肠、静脉用药无效者；内科治疗症状顽固、体能下降、对类固醇激素耐药或依赖者；UC合并坏疽性脓皮病、溶血性贫血等肠外并发症者。,溃结疗效标准,完全缓解：临床症状消失，结肠镜检查发现粘膜大致正常。有效：临床症状基本消失，结肠镜检查发现粘膜轻度炎症或假息肉形成。无效：经治疗后临床症状、内镜及病理检查结果均无改善。

15、,炎症性肠病的现代药物治疗,SASP是传统的广泛应用于治疗IBD的药物。SASP治疗UC已有多年。口服4-6g/d，可使64-77%患者获良好的效果。症状缓解后，以2g/d维持治疗至少1年，89%患者可保持无症状。口服SASP后，约13-42%可出现不良反应，且与用药剂量呈正相关，,*包括巨红细胞症、变性血红蛋白及Heing抗体水平升高。*有红细胞G-6-PD缺乏患者，同样可发生溶血。,SASP的不良反应,5-ASA常用的制剂,美沙拉嗪（Asacol）为外罩丙烯酸碱树酯缓慢释放形式的5-ASA。在pH6时溶解。可使5-ASA在末端回肠及结肠中释放。此药作用好，不良反应少。潘太沙（Pentasa

16、）为另一缓慢释放形式的5-ASA胶囊。在乙基纤维素半透明包衣的微球中，能根据pH及时间，在小肠或末端回肠中释放。局部或口服形式的5-ASA胶囊，在美国称为Mesalamine，但相同制剂在欧洲叫做Mesalagine。偶氮水杨酸（Olsalagine）用重氮键连接两个5-ASA分子。药物到达结肠时，需通过细菌的重氮还原酶，破坏重氮键后分解出5-ASA。因此该药在结肠中药物浓度很高，疗效确切。,GCS治疗UC和CD的指征,常用免疫抑制剂,硫唑嘌呤（AZT）目前该药主要应用于CD的治疗。一般剂量范围为2mg-4mg/Kg/d，可有效防止CD的复发。尤其对结肠性CD病，肛门和腹部瘘管以及肠切除术后的

17、维持治疗，具有良好的效果。,常用的免疫抑制剂,甲氨喋呤（MTX）:为叶酸合成抑制剂，其分子结构同IL-1相似，能干扰IL-1的炎症过程。用MTX25mg静脉注射，每周1次。同时对难治性UC，亦有较好的疗效。且作用较AZT为快。,免疫抑制剂的不良反应,包括白细胞、血小板减少症；胃肠道反应有恶心、呕吐等；少数可发生胰腺炎,对感染敏感性增加。常见不良反应有皮疹、发热、肝功能、肾功能异常等。长期应用有引起皮肤肿瘤和恶性淋巴瘤的报道。虽无致畸胎的报道，但孕妇禁用。,抗生素,甲硝唑400mg每天2次，对回肠结肠炎和结肠炎患者，同SASP一样有效。最近提倡甲硝唑治疗CD合适剂量是10mg-20mg/Kg/d。,辅助治疗方法,肠道微生态的治疗:米雅BM,培菲康,乐托尔等肠道外营养支持治疗,谢谢,