内科学教学课件：溃疡性结肠炎英语

IncreasedstoolfrequencyHematochezia(便血)

Abdominalpain36/FC.C.

Abdominal

painand

Hemafecia

4

months;

Fever

and

BloodyPurulentStool

1

month.2015-02

Abdominal

Pain

and

HemafeciaPainVAS

2Remission

after

defecation(排便)Hemafecia5/dayVinous(深红色)

blood

on

formed

stoolSimultaneousPhenomenonWithout

fever,

nausea,

vomiting

or

tenesmus(里急后重),

ect.Q.

Takeintoconsideration…36/F

Abdominal

Pain

and

HemafeciaDiarrheaPassageofabnormallyliquidorunformedstoolsatanincreasedfrequency.StoolliquidityDailystoolweight>300g/dFrequency>3/dAcuteif＜2weeks,persistentif2to4weeks,andchronicif＞4weeksinduration.HematocheziaPassageofbrightredormaroon（栗色）

bloodfromtherectum.Relatedsymptom:AnemiaAcute：palpitation心悸,dizziness,perspire流汗,Chronic：fatigueUGIBorLGIB?

UpperLowerPastMedicalHistorypepticulcer,hepatic,biliary,pancreaticlowerabdominalpain/massSignsbeforeBleedingupperabd.discomfortnauseamidandlowerabddiscomfortdefecationdesireBleedingMannerhematemesis（呕血）withtarrystool（柏油样便）HematocheziawithoutHematemesisCharacteristicandShapeofStooltarrystoollooseorinshape,nobloodclotdarkorfreshredstoollooseusuallymayhaveclotIncreasedstoolfrequency,HematocheziaandAbdominalpain

DifferentialDiagnosisDiverticulosis

Diverticulum：Sac-likeprotrusionofthecolonicwallAge-dependent,

AspirinandNSAIDsAbsenceofdiverticulitis:PainlesshematocheziaAngiodysplasiaDilated,tortuoussubmucosalvesselsEndothelialcells,

lacksmoothmuscleIncreaseswithageGIbleedingEpisodicandself-limitedTyphoidfeverSalmonella（沙门氏菌）Abdominalpain,fever,andchillsRelativebradycardia,"rosespots"Hepatosplenomegaly,intestinalbleeding,andperforationLeukopeniaShigellainfection细菌性痢疾Fever–30to40percentAbdominalpain–70to93percentMucoiddiarrhea–70to85percentBloodydiarrhea–35to55percentWaterydiarrhea–30to40percentVomiting–35percentStoolcultureIntestinalEntamoebaHistolyticaAmebiasisAsymptomaticMilddiarrhea→

severedysentery,producingabdominalpainandbloodystoolstofulminantamebiccolitisStoolmicroscopy,Antigentesting,Serology,Molecularmethods.TuberculousEnteritis

Nonspecificchronicabdominalpain

Anorexia（厌食）,fatigue,fever,nightsweats,weightloss,diarrhea,constipation（便秘）,orbloodinthestoolColonoscopic:circumferentialulcersEndarteritisobliterans（闭塞性动脉内膜炎）Histopathology:Granulomas:belargeandconfluent,withcaseationnecrosisIschemiccolitisOlderadults:relativehypotension,heartfailure,andarrhythmiasYoungpatients:hypercoagulablestateAbdominalpain,diarrhea,andpassageofbrightredbloodperrectumColonoscopy,CT,MRAInflammatoryBowelDiseaseColonCancerRareinyoungerindividualsBleeding:low-gradeandrecurrentBrightredblood:left-sidedlesionsMaroonbloodormelena:right-sidedlesionsChangeinbowelhabits,Irondeficiencyanemia.Colonoscopy,BariumenemaGastrointestinallymphomasIPSIDassociatedlymphoma:abdominalpain,chronicdiarrhea,malabsorption,severeweightloss,clubbing,andankleedema.Enteropathy-associatedTcelllymphoma(EATL):acutebleeding,obstruction,orperforationNon-IPSIDlymphomas:morenonspecificpresentationColonoscopywithbiopsyBacktothecase…2015-05

Fever

and

Blood

Purulent

stoolAbdominal

PainVAS

9-10Blood

Purelent

Stool10-20/dayMushyFeverContinuedTmax

40℃BloodRt.:WBC↑Diagnosis:Bacterial

InfectionRx:Levofloxacin(左氧氟沙星),

Cephalosporins(头孢类)Effect:ImprovedVAS77-10/day,Mushy2015-06-18

Manifestation

PersistHGB

90

g/LESR

74

mm/hhsCRP

165mg/LDiagnosis:InfectionRx.:Vancomycin(万古霉素)Parenteral

NutritionEffect:Noremission2015-06-26PUMCHEmergencyDepartmentBloodRt.:WBC7.79x10^9/L,NUET%68.4%,HGB51g/L,PLT521x10^9/LStoolRt.:RBCwhole/HPF,WBCwhole/HPFStoolOB(+)Alb19g/L,ESR84mm/h,hsCRP23.12mg/LDiagnosis:InfectionRx.:Ceftazidime(头孢他啶),

Metronidazole(甲硝唑)EffectT

37.0℃VAS

4Blood

volume

of

hemafecia

↓2015-07-02PUMCHWT

-6kg,

VV

400-500ml/dayPast

Medical

History

(-)Personal

History

(-)Family

Medical

History:Mother

–

HTN,

DMP.E.T

36.5℃

HR

111/min

R

20/min

BP

90/60mmHgAbdominal

tenderness,

especially

LLQ,

rebound

tenderness

(-)Ankle

edema

Q.Takeintoconsideration…36/FAbdominal

Pain,

Blood

Purulent

Stool,

FeverLLQ

Abdominal

Tenderness,AnkleEdemaDifferentiate

DiagnosisInfectionCytomegalovirus,

CMVClostridiumDifficileColitis(难辨梭菌感染性肠炎)IntestinalTuberculosisTyphusAbdominalisDisorder

of

Immune

SystemInflammation

Bowel

Disease,

IBDTumorLymphomasQ.

Examination

taken

intoconsideration…Differentiate

Diagnosis⭐️ColonoscopyBiopsyLaboratory

ExaminationPCT,

G-Test,Widal’s

Test,Stool

T.SPOT-TBClostridiumDifficileToxin

TestParasite

Micrography2015-07-03ColonoscopySigmoidcolon

andDescendingcolon

involvedAppearance:Hyperemia,Mucosaledema,Longitudinalulcers,Pus,Bleeding

Spot.2015-07-03ColonoscopyAppearance:Sigmoidcolon

andDescendingcolon

involvedHyperemia,Mucosaledema,Longitudinalulcers,Pus,Bleeding

SpotBiopsy:SuperficialChronicInflammation,CryptAbscesses,ArchitecturalDistortionNO

Lymphoma

SignDifferentiateDiagnosisPCT,

G-Test

(-)Widal'stest

(-)Stool

T.SPOT-TB

(-)

CMV-DNA

&

CMV-IgM

(-)ClostridiumDifficileToxin

Test

(-)Stool

Parasite

Test

(-)Q.Diagnosis?UlcerativeColitisNormalIntestinevs.

IntestineWithIBDNormalbowel:controlledinflammationNormally:inflammationIsdown-regulatedIBD:failuretodown-regulateinflammationChronicuncontrolledinflammation=IBDEnvironmentaltriggers(medicationsinfections,diet?)InflamedbowelNormalbowel:controlledinflammationFarrellJJ,SandsBE.Etiologyandpathogenesisofinflammatoryboweldisease.InCohenRD,ed.InflammatoryBowelDisease:DiagnosisandTherapeutics.2003,HumanaPressInc,Totowa,NJ.ClinicalManifestationof

UlcerativeColitisDiarrhea,typicallybloodyandwithmucus（黏液脓血便）AbdominalpainandtendernessLossofappetiteandweightFeverFatigueUrgencyforbowelmovementChildren:growthanddevelopmentalfailureJewellDP.UlcerativeColitis.In:FeldmanM,FriedmanLS,SleisengerMH,eds.Sleisenger&Fordtran’sGastrointestinalandLiverDisease.Philadelphia,PA:Saunders;7thed.2002:2039.www.CCFA.or.AccessedJuly29,2005.UlcerativeColitis:

DefiningExtentofDiseaseUlcerativeproctitis(rectumonly)E1Left-sidedColitis(extendstosplenicflexure)E2ExtensiveColitis(beyondsplenicflexure)E3AdaptedfromOrangioGR.SurgicalTherapyforIBD.In:SteinSH,RoodRP,eds.InflammatoryBowelDisease.Philadelphia,PA:Lippincott-Raven;1999:155(Fig10).AccessedJuly29,2005.DiseaseSeverityMildModerateSeverestoolsperdayfourorfewerfrequentloose,bloodystools(>4perday)frequentloosebloodystools(≥6perday)HR＜90＜100＞100HCT（%）normal30-40＜30Weightloss（%）0＜10＞10Temperaturenormal＜37.5ºC≥37.5ºCESR(mm/h)＜2020-30＞30Alb（g/dL）normal3-3.5＜3MildGranularmucosaEdematousLossofnormalvascularpatternImagescourtesyofR.CohenMD.ModifiedfromSutherlandLR,etal.Gastroenterology.1987;92:1894.EndoscopicSeverity

IndexforUCCoarselygranularSmallulcerationsFriableModerateFrankulcerationsSpontaneoushemorrhageSeverePseudopolyposisMucosalTagUlcerativeColitis(remission)HistologyFeaturesofUCQuiescent

CryptdistortionNoactiveinflammationActive

CryptdistortionInflammationinfiltratesCryptabscessesImagescourtesyofJohnHart,MD.StrategyforTreatmentofIBDSurgery/BiologicsImmunosuppressorCorticosteroidsAminosalicylates(5-ASA)氨基水杨酸盐

SevereModerateMildMedicationBacktothecase…Extent

&

SeverityStool

7-10/dayHR

111/minHCT

21%Weight

Loss

12%T36.5℃ESR

84mm/hAlb

19g/LColonoscopy:Left-side

Colitis

(E2)MildModerateSeverestoolsperdayfourorfewerfrequentloose,bloodystools(>4perday)frequentloosebloodystools(≥6perday)HR＜90＜100＞100HCT（%）normal30-40＜30Weightloss（%）0＜10＞10temperaturenormal＜37.5ºC≥37.5ºCESR(mm/h)＜2020-30＞30Alb（g/dL）normal3-3.5＜3Treatment

of

Severe

UCAminosalicylates(5-ASA)CorticosteroidsImmunosuppressiveSurgery/BiologicsMesalamine(美沙拉秦)

1000mgqidHydrocortisone(氢化可的松)150mgq12h

Omeprazole(奥美拉唑),Fortum(复达欣)Prognosis2015-07-06 Remmission

of

ankle

edema

and

hemafecia2015-07-08

Fever,

Tmax

38℃,

Else

dicto