内科学炎症性肠病(英文)

1、Inflammatory Bowel Disease (IBD),Introduction,IBD is an idiopathic and chronic intestinal inflammation. It embraces two similar, but distinct, pathological conditions: ulcerative colitis (UC) Crohns disease (CD) There are many overlapping clinical, radiological, endoscopic, and histological characteristics, but equally, there are clear differences in the distribution and depth of inflammation within the gastrointestinal tract (GI).,CD is a transmural process that may affect any part of the GI, w

2、hereas in uncomplicated UC, inflammation is confined to the colonic mucosa. In cases of IBD that are difficult to distinguish, specialised investigations are available. For example, some cases of UC are ANCA-positive and expression of CD44v6 and v3 epitopes (抗原决定基) in crypt epithelial cells.,Epidemiology of IBD,UC has an incidence of 11/100,000 in U.S. CD has an incidence of 7/100,000. Variations are seen with: Race - in the USA, white people are 3 times more susceptible to UC, and 5 times more

3、susceptible to CD, than are black people Sex - approximately the same Age - peaks between 15 - 30 and between 60 - 80 years,Geography: common in developed communities of N. America, S. Africa, Australasia and W. Europe less common in Japan and S. and E. Europe rare in rest of Asia, Africa and S. America Genetics: Monozygotic(单卵的) concordance in CD HLA-DR2 is associated with a ANCA positive form of UC familial aggregations. increased incidence of HLA-B27 in patients with IBD and ankylosing spondy

4、litis (强直性脊椎炎). greater prevalence in Ashkenazi Jews (德系犹太 人),Smoking: CD is 3-4x more common in smokers than non-smokers UC is uncommon in smokers Oral contraceptive pill may predispose to development of CD Appendicectomy may have a protective effect.,Epidemiology of IBD,Ulcerative colitis (UC),UC is a chronic disease of unknown etiology in which a part or the whole of the mucosa of the large bowel becomes diffusely inflamed and may ulcerate, as a result of which the patient suffers from diarrh

5、oea which may be bloody. It is characterised by exacerbations and remissions. The highest incidence of this disease is in adulthood, although it may occur in childhood.,Etiology,The cause of UC is unknown But infective, genetic, immunological, dietary, and psychological factors have all been implicated.,Etiopathogenesis,Environment,Heredity,Infection,Clean environment Smoking, diet,polygenic disease：CARD15/NOD2(16),OCTN(5),GLD5(10) genetic heterogeneity,Microorganism Normal intestine flora,Immun

6、e factor,Immune tolerance depletion,Abnormal immune response to normal antigen,Inflammation,IBD,Pathological features,UC primarily affects the mucosa and the submucosa, with inflammatory cell infiltrate, crypt abscess and ulcer formation. Goblet cells are few in number and frequently depleted of mucus. Pseudopolyps, the mucosa is friable(脆的) and bleeding easily on contact. Continuous lesions. The rectosigmoid is most commonly involved with 50% of patients having total colonic involvement. Chroni

7、c disease causes shortening and thickening of the bowel wall with haustral loss.,Histology,Mucosal inflammation Proportioned Crypt abscesses Continuous lesions,Continuous polymorphonuclear infiltration, limited to the mucosa, crypt abscesses, goblet cell mass reduced,Localization of UC,50% of cases presented UC extending up to the left flexure of the colon,Clinical features,UC may be fulminant, chronic, or relapsing. The patient may present dehydrated and/or toxic.,Symptoms-intestinal,Diarrhea,

8、Bloody/mucoid stool Abdominal pain: in the left iliac fossa and cramping that usually subsides after a bowel movement; Abdominal sounds: borborygmus, a gurgling or splashing sound heard over the intestine Tenesmus (里急后重) Nausea and vomiting,Symptoms- extraintestinal,Fever Anemia Weight loss Loss of appetite Fatigue Arthralgia or arthritis Eye involvement: uveitis(葡萄膜炎) Erythema nodosum In fulminating disease the presentation may be of abdominal distension, catastrophic diarrhoea, fever and colla

9、pse (虚脱),Signs,pallor, dehydration, mouth ulcers, abdominal tenderness Signs of toxic dilatation or perforation,Clinical classification,临床类型 (Type) 严重程度 (Severity) 病变范围 (Lesion extent ) 病情分期 (Stage),临床类型（ Type ）,Classification of Severity of UC,病变范围,直肠炎 直乙结肠炎 左半结肠炎(脾曲以远) 广泛结肠炎（脾曲以近） 全结肠炎,病情分期,活动期或缓解期 Sourtherland 疾病活动指数（DAI）,也称Mayo指数。慢性活动性或顽固性UC指诱导或维持缓解治疗失败，通常为皮质激素抵抗或依赖的病例。前者指泼尼松龙足量应用4周不缓解，后者为泼尼松龙减量至10mg/d即无法控制发作或者停药后3月复发者。 Sourtherland DAI 项目 记 分 0 1 2 3 腹泻：正常 超过正常12次/天 超过正常34次/天 超过 正常5次/天 便血：无 少许 明显 以血为主 粘膜表现：正常 轻度易脆 中度易脆 重度易脆伴渗出 医师评估病情：正常 轻 中 重 注：总分之和2分症状缓解；35分轻度活动；610分中度活动；1112分重度活动,Complications,Massive colonic haemorrhage: 3% Toxic megacolon: 5% Colon stricture formation - rare Fistula formation - rare Perforation of the colon Increased risk of malignancy - lymphoma, carcinoma,Investigations,FBC - anaemia; leukocytosis ESR - increased; correlates with active disease CRP - raised; but less so than in CD Biochemistry - in active disease, biochemical abno

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