溃疡性结肠炎的诊断与鉴别诊断课件

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肠外表现(Extraintestinal

manifestations)肠外表现包括：皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)关节损害(如外周关节炎、脊柱关节炎等)眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

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

297–300.肠外表现(Extraintestinalmanifesta(B)Moderateinflammationwithreducedhaustration.粪便检出病原体可确诊。ScandJGastroenterol.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.(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；并发症(Complications)黏膜活检组织学检查ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).并发症(Complications)并发症包括：中毒性巨结肠（toxicmegacolon）肠穿孔下消化道大出血上皮内瘤变和癌变钱家鸣,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].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眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)并发症(Complications)并发症(Complications)皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)患者尿中白蛋白明显高于正常人（活动期P<0.Differentiatediagnosis结论：患者尿中白蛋白可作为判断患者疾病活动情况的指标。宜注明为活动期或缓解期。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：探讨炎症性肠病患者尿中白蛋白的临床意义。方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。结果：患者尿白蛋白活动期比缓解期明显增高（0.002），Harvey和Bradshaw指数呈正相关（活动期r=0.76,P<0.001；静止期r=0.73,P<0.001）。患者尿中白蛋白明显高于正常人（活动期P<0.001,缓解期,P<0.005）。结论：患者尿中白蛋白可作为判断患者疾病活动情况的指标。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.尿白蛋白

目的：探讨炎症性肠病患者尿中白蛋白的临床意义。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钡剂灌肠检查所见的主要改变为：(1)黏膜粗乱和(或)颗粒样改变；(2)肠管边缘呈锯齿状或毛刺样，肠壁有多发性小充盈缺损；(3)肠管短缩，袋囊消失呈铅管样。钡剂灌肠检查所见的主要改变为：CTUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback结肠镜检查DaneseS，FiocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要依据。结肠镜下UC病变多从直肠开始，呈连续性、弥漫性分布，表现为：(1)黏膜血管纹理模糊、紊乱或消失，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；(2)病变明显处可见弥漫性、多发性糜烂或溃疡；(3)可见结肠袋变浅、变钝或消失以及假息肉、桥黏膜等。结肠镜检查DaneseS，FiocehiC．UlceraTypicalendoscopicfindings

(A)UCwithmildinflammationandreducedhaustration,vasculartransparencyis

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

Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.Typicalendoscopicfindings(A放大内镜(Confocalmicroscopy)

内镜下黏膜染色技术能提高内镜对黏膜病变的识别能力，结合放大内镜技术，通过对黏膜微细结构的观察和病变特征的判别，有助UC诊断，姜泊，等．放大内镜结合黏膜染色技术诊断溃疡性结肠炎附116例放大内镜形态分析．现代消化及介入诊疗，2005，10：116—118．放大内镜(Confocalmicroscopy)内镜下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黏膜活检组织学检查

组织学可见以下主要改变。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，乃至形成隐窝脓肿；(2)隐窝结构改变：隐窝大小、形态不规则，排列紊乱，杯状细胞减少等；(3)可见黏膜表面糜烂，浅溃疡形成和肉芽组织增生。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失，慢性炎性细胞浸润减少；(3)隐窝结构改变：隐窝结构改变可加重，如隐窝减少、萎缩，可见潘氏细胞化生(结肠脾曲以远)。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变，结合临床，可报告符合UC病理改变。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。RileySA,ManiV,GoodmanMJ,etal.Microscopicactivityinulcerativecolitis:whatdoesitmean?Gut.1991;32:174–178.黏膜活检组织学检查

组织学可见以下主要改变。RileySMicroscopicfindingsinbiopsies

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

disease．Gastroenterology，2007，133：1670—1689．Microscopicfindingsinbiopsi诊断要点

在排除其他疾病基础上，可按下列要点诊断：(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；(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)；(3)如再加上上述黏膜活检和(或)手术切除标本组织病理学特征者，可以确诊(definite)；(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)。Lennard-JonesJE.Classificationofinflammatoryboweldisease.ScandJGastroenterol.Suppl.1989;170:2–6;discussion16–19.诊断要点

在排除其他疾病基础上，可按下列要点诊断：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鉴别诊断

1．急性感染性肠炎：各种细菌感染，如志贺菌、空肠弯曲菌、沙门菌、产气单孢菌、大肠埃希菌、耶尔森菌等。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)；抗菌药物治疗有效；粪便检出病原体可确诊。2．阿米巴肠病3．肠道血吸虫病4．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、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。鉴别诊断

1．急性感染性肠炎：各种细菌感染，如志贺菌、空肠弯方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。IntestinalSymptoms001,缓解期,P<0.姜泊，等．放大内镜结合黏膜染色技术诊断溃疡性结肠炎附116例放大内镜形态分析．现代消化及介入诊疗，2005，10：116—118．溃疡性结肠炎合并中毒性巨结肠六例及文献复习.组织学可见以下主要改变。(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).肠外表现(Extraintestinalmanifestations)肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)Activeinflammatoryanorectallesionsresultinurgencyofdefecationandcrampsarounddefecation(“tenesmus”).Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.组织学可见以下主要改变。Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.(F)Pseudopolypformation.Differentiatediagnosis

方法：对临床确诊的32例IBD患者（UC27例，CD5Differentiatediagnosis

夏冰，等.缺血性结肠炎与溃疡性结肠炎的临床鉴别诊断.胃肠病学.2010，15(11)：681-683.Differentiatediagnosis

夏冰，等.InternationalStudyGroupforBehcet’sdisease.Criteriaforthe

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

InternationalStudyGroupfor感谢您的观看！感谢您的观看！Sugiandcolleaguesinvestigatedlactoferrin,polymorphonuclearneutrophil(PMN)elastase,andlysozymetogetherwithmyeloperoxidaseinfecalmaterialandwhole-gutlavagefluidfromIBDpatients.方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。如有隐窝上皮异型增生(上皮内瘤变)或癌变，应予注明。Itisamajorcomponentofthesecondarygranulesofpolymorphonuclearneutrophilsandisshowntobeaprimaryfactorintheacuteinflammatoryresponse.SerologicalmarkersVariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.如有隐窝上皮异型增生(上皮内瘤变)或癌变，应予注明。)2005;125:297–300.并发症(Complications)TheOMGEmultinationalinflammatoryboweldiseasesurvey1976–1986.(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.2010，15(11)：681-683.MicroscopicfindingsinbiopsiesBothdiseasesaremarkedbyfrequentrelapsesandpatientsoftenundergorepeatedinvestigationstodefinetheextentofthedisease,assesstheseverityofrelapse,oridentifycomplications.肠外表现(Extraintestinal

manifestations)肠外表现包括：皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)关节损害(如外周关节炎、脊柱关节炎等)眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

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

297–300.Sugiandcolleaguesinvestigat并发症(Complications)并发症包括：中毒性巨结肠（toxicmegacolon）肠穿孔下消化道大出血上皮内瘤变和癌变钱家鸣,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].2012，51(9):694-697/ChowDK，LeongRW，TsoiKK,eta1．Long—termfollow—up

ofulcerativecolitisintheChinesepopulation．AmJ

Gastroenterol，2009，104：647-654．并发症(Complications)并发症包括：CTUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback结肠镜检查DaneseS，FiocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要依据。结肠镜下UC病变多从直肠开始，呈连续性、弥漫性分布，表现为：(1)黏膜血管纹理模糊、紊乱或消失，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；(2)病变明显处可见弥漫性、多发性糜烂或溃疡；(3)可见结肠袋变浅、变钝或消失以及假息肉、桥黏膜等。结肠镜检查DaneseS，FiocehiC．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肠外表现(Extraintestinal

manifestations)肠外表现包括：皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)关节损害(如外周关节炎、脊柱关节炎等)眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)血栓栓塞性疾病等。

MendozaJL,LanaR,TaxoneraCetal.Extraintestinal

manifestationsininflammatoryboweldisease:differencesbetween

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

297–300.肠外表现(Extraintestinalmanifesta(B)Moderateinflammationwithreducedhaustration.粪便检出病原体可确诊。ScandJGastroenterol.Comparisonof4neutrophil-derivedproteinsinfecesasindicatorsofdiseaseactivityinulcerativecolitis.肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)Calprotectin(FCP),aheterocomplexofS100A8andS100A9,isacalcium-bindingproteinwithantimicrobialprotectivepropertiesderivedpredominatelyfromneutrophils,andtoalesserextent,frommonocytesandreactivemacrophages.(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；并发症(Complications)黏膜活检组织学检查ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．VariousdiagnosticclassificationsofIBDareavailable,includingMendeloff’scriteria,theLennard-Jonescriteria,theinternationalmulticentrescoringsystemoftheOrganizationMondialedeGastroenterologie(OMGE),andthediagnosticcriteriaofJapaneseResearchSocietyonIBD.方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).并发症(Complications)并发症包括：中毒性巨结肠（toxicmegacolon）肠穿孔下消化道大出血上皮内瘤变和癌变钱家鸣,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].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眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)并发症(Complications)并发症(Complications)皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)患者尿中白蛋白明显高于正常人（活动期P<0.Differentiatediagnosis结论：患者尿中白蛋白可作为判断患者疾病活动情况的指标。宜注明为活动期或缓解期。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：探讨炎症性肠病患者尿中白蛋白的临床意义。方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。结果：患者尿白蛋白活动期比缓解期明显增高（0.002），Harvey和Bradshaw指数呈正相关（活动期r=0.76,P<0.001；静止期r=0.73,P<0.001）。患者尿中白蛋白明显高于正常人（活动期P<0.001,缓解期,P<0.005）。结论：患者尿中白蛋白可作为判断患者疾病活动情况的指标。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.尿白蛋白

目的：探讨炎症性肠病患者尿中白蛋白的临床意义。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钡剂灌肠检查所见的主要改变为：(1)黏膜粗乱和(或)颗粒样改变；(2)肠管边缘呈锯齿状或毛刺样，肠壁有多发性小充盈缺损；(3)肠管短缩，袋囊消失呈铅管样。钡剂灌肠检查所见的主要改变为：CTUlcerativecolitiswithbackwashileitis.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).ElsayesKM，AI—HawaryMM，JagdishJ，eta1．CTenterography：principles，trends，andinterpretationoffindings．Radiographics，2010，30：1955—1970．CTUlcerativecolitiswithback结肠镜检查DaneseS，FiocehiC．Ulcerativecolitis．NEnglJMed，2011．365：17131725．结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要依据。结肠镜下UC病变多从直肠开始，呈连续性、弥漫性分布，表现为：(1)黏膜血管纹理模糊、紊乱或消失，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；(2)病变明显处可见弥漫性、多发性糜烂或溃疡；(3)可见结肠袋变浅、变钝或消失以及假息肉、桥黏膜等。结肠镜检查DaneseS，FiocehiC．UlceraTypicalendoscopicfindings

(A)UCwithmildinflammationandreducedhaustration,vasculartransparencyis

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

Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.Typicalendoscopicfindings(A放大内镜(Confocalmicroscopy)

内镜下黏膜染色技术能提高内镜对黏膜病变的识别能力，结合放大内镜技术，通过对黏膜微细结构的观察和病变特征的判别，有助UC诊断，姜泊，等．放大内镜结合黏膜染色技术诊断溃疡性结肠炎附116例放大内镜形态分析．现代消化及介入诊疗，2005，10：116—118．放大内镜(Confocalmicroscopy)内镜下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黏膜活检组织学检查

组织学可见以下主要改变。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，乃至形成隐窝脓肿；(2)隐窝结构改变：隐窝大小、形态不规则，排列紊乱，杯状细胞减少等；(3)可见黏膜表面糜烂，浅溃疡形成和肉芽组织增生。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失，慢性炎性细胞浸润减少；(3)隐窝结构改变：隐窝结构改变可加重，如隐窝减少、萎缩，可见潘氏细胞化生(结肠脾曲以远)。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变，结合临床，可报告符合UC病理改变。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。RileySA,ManiV,GoodmanMJ,etal.Microscopicactivityinulcerativecolitis:whatdoesitmean?Gut.1991;32:174–178.黏膜活检组织学检查

组织学可见以下主要改变。RileySMicroscopicfindingsinbiopsies

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

disease．Gastroenterology，2007，133：1670—1689．Microscopicfindingsinbiopsi诊断要点

在排除其他疾病基础上，可按下列要点诊断：(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；(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)；(3)如再加上上述黏膜活检和(或)手术切除标本组织病理学特征者，可以确诊(definite)；(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)。Lennard-JonesJE.Classificationofinflammatoryboweldisease.ScandJGastroenterol.Suppl.1989;170:2–6;discussion16–19.诊断要点

在排除其他疾病基础上，可按下列要点诊断：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鉴别诊断

1．急性感染性肠炎：各种细菌感染，如志贺菌、空肠弯曲菌、沙门菌、产气单孢菌、大肠埃希菌、耶尔森菌等。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)；抗菌药物治疗有效；粪便检出病原体可确诊。2．阿米巴肠病3．肠道血吸虫病4．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、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。鉴别诊断

1．急性感染性肠炎：各种细菌感染，如志贺菌、空肠弯方法：对临床确诊的32例IBD患者（UC27例，CD5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指数进行综合分析，选取25例健康人为正常对照。IntestinalSymptoms001,缓解期,P<0.姜泊，等．放大内镜结合黏膜染色技术诊断溃疡性结肠炎附116例放大内镜形态分析．现代消化及介入诊疗，2005，10：116—118．溃疡性结肠炎合并中毒性巨结肠六例及文献复习.组织学可见以下主要改变。(C)Severeinflammationwithinflammatorynarrowingofthelumenthroughpseudopolyps.AxialCTenterographicsectionsshowcontinuousinvolvementofthelargebowel(whitearrrows)andbackwashileitis(blackarrowinb).肠外表现(Extraintestinalmanifestations)肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)Activeinflammatoryanorectallesionsresultinu