溃疡性结肠炎的内科保守治疗

溃疡性结肠炎的内科保守治疗第1页/共20页溃疡性结肠炎的药物治疗和预后第2页/共20页诊断与治疗诊断：排除性、综合性和完整性诊断治疗：强调分型、分期、分度、分段的原则疗效评定：缓解、有效、无效提倡多中心协作研究第3页/共20页TreatmentgoalsPotentialfuturetreatmentgoalsforulcerativecolitis

includesustainedclinicalremission,sustainedmucosal

healingwithareductionincolorectaldysplasiaandcancer,

andmaintainingnormalGIphysiology.Mesalaminetherapyissufficient

inapproximately50%ofpatients.Therearelimiteddatathat

azathioprinemightinduceandmaintainclinicalremission

andendoscopichealing.Infliximabiseffectiveforinduction

andmaintenanceofclinicalremissionandendoscopichealing.Dataonadalimumabandcertolizumabarelacking.CurrentDirectionsinIBDTherapy:WhatGoalsAreFeasibleWith

BiologicalModifiers?2008bytheAGAInstitute第4页/共20页SASP早在20世纪初期，斯堪的纳维亚的风湿病专家Suartg发现，水杨酸偶氮磺胺（SASP）的抗炎和抗菌特性可用于治疗类风湿性关节炎。1942年由DanaSvartz医师首先将柳氮磺胺吡啶应用于溃疡性结肠炎（UC）的治疗，取得了良好效果，成为UC治疗的一个里程碑。自从SASP用作UC的维持治疗后，复发率为原来的1/4，并大大改善了许多患者的生活质量。经过半个多世纪的实践，SASP一直是UC患者广泛应用的药物之一。但由于该药口服耐药性差，不良反应多，通过开发研制了新剂型、改变给药途径等方法显著提高了疗效、减少了不良反应。第5页/共20页氨基水杨酸制剂

第6页/共20页GCs

Intravenouscorticosteroidshavebeenestablishedas

themosteffectivefirst-linetreatmentforacutesevereUCsincethe

firsttrialofthistreatmentregimenwaspublishedin1974byTruelove

andJewell.Inthisstudy,36of49patients(73.5%)with

severeUCwerefoundtobeinremission5daysaftercommencing

intensiveintravenoustreatmentwithprednisolone60mg/day

(individeddoses).Theintroductionofintravenouscorticosteroid

treatmenthasledtoasubstantialdecreaseinthemorbidityand

mortalityassociatedwithacutesevereUC.Anumberofparenteralcorticosteroidshavebeentestedinthetreatment

ofsevereUC.TherewasnoobviousdifferencesintreatmentresponsebetweenthevarioussteroidsHowever,therewasnoevidencetosupportincreasingthecorticosteroiddosebeyond60mg/dayofmethylprednisolone

orequivalentTrueloveSC,JewellDP.Intensiveintravenousregimenforsevereattacksof

ulcerativecolitis.Lancet1974;1:1067–70.TurnerD,WalshCM,SteinhartAHetal.Responsetocorticosteroidsin

severeulcerativecolitis:asystematicreviewoftheliteratureandametaregression.ClinGastroenterolHepatol2007;5:103–110.第7页/共20页6MP/AZA

ArdizzoneS,MaconiG,RussoA,ImbesiV,ColomboE,

BianchiPorroG.Randomisedcontrolledtrialofazathioprineand

5-aminosalicylicacidfortreatmentofsteroiddependentulcerative

colitis.Gut2006;55:47–53.LeungY,PanaccioneR,HemmelgarnB,etal.Exposingthe

weaknesses:asystematicreviewofazathioprineefficacyinulcerative

colitis.DigDisSci2008;53:1455–1461.LewisJD,GelfandJM,TroxelAB,etal.Immunosuppressant

medicationsandmortalityininflammatoryboweldisease.AmJ

Gastroenterol2008;103:1428–1435.第8页/共20页IndicationsandContraindicationsforInfliximabTherapyinIBD第9页/共20页Otherbiotechnology

agents

第10页/共20页InfliximabRutgeertsP,SandbornWJ,FeaganBGetal.Infliximabfor

inductionandmaintenancetherapyforulcerativecolitis.NEnglJ

Med.2005;353:2462–2476.

RutgeertsP,ColombelJF,ReinischW,etal.Infliximabinducesandmaintainsmucosalhealinginpatientswithactiveulcerativecolitis:theACTtrialexperience.Gut2005;54(SupplVII):A58.ReinischW,SandbornWJ,RutgeertsP,etal.Infliximabtreatmentforulcerativecolitis:comparableclinicalresponse,clinicalremission,andmucosalhealinginpatientswithdiseaseduration<3yearsvs>=3years.Gastroenterology2008;134(Suppl1):A495.FidderH．SchnitzlerF，RutgeertsP

，eta1．Long—termsafetyofinflixjmabforthetreatmentofinflammatoryboweIdisease：asinglecentercohortstudy．Gut．2009，58(4)：50l-508．RutgeertsP,VermeireS，VanAsseheG．BiologicaltherapiesforinflammatoryboweldiseasBGastroenterology.2009，136：l182·1197．第11页/共20页DietandnutritionPatientsshouldbeofferedanormaldietorenteral

nutritionunlesssuchadietisnottoleratedTPNisnoteffectiveasprimarytherapy.TPN

shouldbeconsideredonlyinmalnourishedpatientswhocannot

tolerateoralintakeorenteralnutrition.WrightR,TrueloveSC.Acontrolledtherapeutictrialofvariousdietsin

ulcerativecolitis.BrMedJ1965;2:138–41.GassullMA,AbadA,CabreE,Gonzalez-HuixF,GineJJ,DolzC.

Enteralnutritionininflammatoryboweldisease.Gut1986;27

(Suppl.1):76–80.Gonzalez-HuixF,Fernandez-BanaresF,Esteve-ComasMetal.Enteral

versusparenteralnutritionasadjuncttherapyinacuteulcerativecolitis.

AmJGastroenterol1993;88:227–32.第12页/共20页Dietandnutrition

UC患者因摄入不足，肠道吸收障碍，能量消耗及丢失增加常导致营养风险(nutritionalrisk)，故积液营养支持(nutritionalsupport)不仅能改善患者的营养状况，一些营养成分，包括谷氨酰胺、w-3多不饱和脂肪酸及微生态制剂还具有调节炎症反应、改善患者肠道免疫屏障的功能、改善疾病的活动作用，有助于病变恢复，避免手术。张澍田，等.营养治疗对溃疡性结肠炎肠道免疫屏障的疗效.胃肠病学和肝病学[J].2009，18(1)：83-86.RazackR，SeidnerDL．Nutritionininflammatoryboweldisease．CurrOpinGastroenterol，2007,23(4)：400-405．第13页/共20页Diet,nutritionandprobiotics

Patientsshouldbeofferedanormaldietorenteral

nutritionunlesssuchadietisnottolerated.TPNisnoteffectiveasprimarytherapy.TPN

shouldbeconsideredonlyinmalnourishedpatientswhocannot

tolerateoralintakeorenteralnutrition.WrightR,TrueloveSC.Acontrolledtherapeutictrialofvariousdietsin

ulcerativecolitis.BrMedJ1965;2:138–41.GassullMA,AbadA,CabreE,Gonzalez-HuixF,GineJJ,DolzC.

Enteralnutritionininflammatoryboweldisease.Gut1986;27

(Suppl.1):76–80.Gonzalez-HuixF,Fernandez-BanaresF,Esteve-ComasMetal.Enteral

versusparenteralnutritionasadjuncttherapyinacuteulcerativecolitis.

AmJGastroenterol1993;88:227–32.ShermanPM，Ossajc，Johnson—HenryK．Unraveling

mechanismsofactionofprobioties．NutrClinPract，2009，24：10—14．第14页/共20页Antibiotics

Routineuseofantibioticsisnotrecommended.Severaltrialshaveshownthattheuseofantibioticsin

additiontocorticosteroidsdoesnotleadtoadditionalbenefitsover

corticosteroidtreatmentalone.Itshouldbenotedthatantibioticsareindicatedin

patientswhodevelopsignsofsepsis.Similarly,antibiotics,eithermetronidazole

orvancomycinareindicatedinpatientswithconcurrent

C.difficileinfection.GuslandiM．Antibioticsforinflammatoryboweldisease：dotheywork?EurJGastroenterolHepatol，2005，17：145-147．PerencevichM,BurakoffR.Useofantibioticsinthetreatmentof

inflammatoryboweldisease.InflammBowelDis.2006;12:

651–64.TorunerM,LoftusEVJr,HarmsenWSetal.Riskfactorsfor

opportunisticinfectionsinpatientswithinflammatorybowel

disease.Gastroenterology2008;134:929–36.第15页/共20页其他

白细胞洗涤技术(Leukocytapheresis，LCAP)干细胞移植疗法(Autologousstemcelltransplantation)基因疗法钱家鸣，等.白细胞分离法治疗炎症性肠病.中华消化杂志.2005.25(9)：575—576.钱家鸣，等.造血干细胞移植与炎症性肠病.中华内科杂志.2005.44(1)：65—67.周黎，等.炎症性肠病的基因治疗.胃肠病学.2006.11(7)：439—441.第16页/共20页禁忌

抗胆碱能药麻醉剂其他第17页/共20页预后（Prognostic）本病呈慢性过程，大部分患者反复发作，轻度及长期缓解者预后较好。急性爆发型、有并发症及年龄超过60岁者预后不良。慢性持续活动或反复发作频繁者，预后较差。病程漫长者癌变危险性增加，应注意随