内科学-结肠炎课件

ULCERATIVECOLITISDEFINITIONUlcerativecolitisisachronicdiseasecharacterizedbyinflammationofthemucosaandsubmucosaofthelargeintestine.Themainclinicalmanifestationsincludediarrhea,abdominalpain.Theincidenceandprevalenceofthediseasevarygreatlywithgeographiclocation.

EPIDEMIOLOGY

RatesarehighestinnorthernclimatesandinwelldevelopedareasoftheworldBimodalagedistribution15-40and50-80Males>FemalesTendstoruninfamiliesETIOLOGYTheetiologyofulcerativecolitisremainsunknown.InfectivefactorsNoorganismhasbeenreproduciblydemonstratedtoberesponsibleforthedisease,AlthoughitischaracterizedbyaninflammatoryreactionthatcausedbyanknownmicrobiologicpathogenssuchasShigella.GeneticfactorsApproximately10%~20%ofpatientswithulcerativecolitishavefirst-degreerelativeswhoalsohavethesamedisease.CD:NOD2/CARD15genemutationNF-kB

ETIOLOGYImmunologicalfactorsClearevidenceexistsfortheactivationoftheimmuneresponseinulcerativecolitis.Threemajorhypothesisastotheantigenictriggersinulcerativecolitishavebeenpostulated.

☆

Microbialpathogens

☆Dietaryantigenorusuallynonpathogenic

microbialagent

☆autoimmunetheory:Oneantibodyagainsta40-KDproteinthathasbeenidentifiedas

tropomysin.Inflammation

Neutrophils,lymphocytes,mastcells,NKInflammatorycytokines:IL,TNF,IFN-r

leukotrieneB4(LTB4)

superoxideandotherreactiveoxygenspecies(ROS)PATHOLOGYUlcerativecolitisinvolvesprimarilythemucosaofthecolon.Theinflammationusuallybeginsintherectum,andmayextendproximallyinthecolonforvariabledistance.Macroscopicfeaturesofpathologicspecimensinulcerativecolitisdependontheseverityanddurationofthedisease.PATHOLOGYInactiveulcerativecolitis,

☆mucusdepletionandmucosaledema;☆Plasmacells,neutrophils,lymphocytes,andeosinophils

infiltraion;

☆vascularcongestion;

☆

Superficalulcerations;

☆Cryptabscesses.PATHOLOGYInchronicdisease,themucosalosesitsnormalfoldsandbecomesflat.Inflammatorypolypsorpseudopolypsmaybepresent.Inquiescentulcerativecolitis,theinflammationislessintensethaninactivedisease.Thenumberofcryptsisreducedandoftenbranched.PATHOLOGYThehistologicchangesinulcerativecolitisarenonspecific,butthechronicityanddistributionpatternarecharacteristic.

HistologicevaluationofrectalbiopsymaybehelpfulindifferentiatingulcerativecolitisfromCrohn’sdisease.CLINICALFEATURESSymptomsandsigns

☆Diarrhea☆Abdominalpain☆Others:anorexia,nausea,vomiting

☆Signs:generalizedtendernesslocalizedtenderness,with“rebound”bowelsoundCLINICALFEATURESSystemicmanifestations

☆Fever☆Fatigue☆Weightloss

☆Anemia

☆HypoproteinemiaCLINICALFEATURESExtracolonicmanifestations

☆Skin:pyoderma,

gangrenosumanderythema

nodosum☆Joints:Arthritis☆Liver:Sclerosing

cholangitis☆Eyes:episcleritis,iritis

CLINICALFEATURESClinicaltypes

☆Initialattack

☆Chronicrelapse☆Chroniccontinuance

☆AcutefulminateThedegreeofseverity

☆Mild

☆Moderate☆SevereMildDiseaseIntermittentrectalbleedingwithmucusMilddiarrhea(<4smallstools/day)Mildcrampyabdominalpain

TenesmusandperiodsofconstipationModerateDiseaseFrequentloose,bloodystools(<6/day)MildanemianotrequiringtransfusionsAbdominalpainthatisnotsevereLowgradefeverUsuallyabletomaintainadequatenutritionSevereDiseaseFrequentloosestools(>6/day)SeverecrampsFeverupto37.5°Bleedingoftennecessitatestransfusion

Hb<100g/L,ESR>30mm/hMaysufferrapidweightlossleadingtoapoornutritionalstateCOMLICATIONToxicmegacolonCarcinomaoftherectumandcolonOthers:massivebleeding,perforation,strictureCOMPLICATIONLABORATORYFINDINGSBlood:anemia,leukocytosis,ESR↑,CRP↑,

hypoalbuminemiaStool:noidentifiablepathogenicbacteria,noparasitesAntibodis:p-ANCA,ASCALABORATORYFINDINGSColonscopy

☆Lossofthefinevascularpattern

☆A

geanularappearance☆Superficalulcerations☆Mucopus

☆PostinflammatorypolypsCOLONSCOPYCOLONSCOPYCOLONSCOPYCOLONSCOPYCOLONSCOPYCOLONSCOPYLABORATORYFINDINGSRadiography

☆Collar-buttonulcers☆Nodular/filiform

☆Granularityofmucosa☆Disappearofthehastralmarkings

RADIOGRAPHYRADIOGRAPHYDIAGNOSISThediagnosisofulcerativecolitisisbasedonclinicalfeatures,laboratorytests,and

endoscopicandhistologicfeatures.

HowUCisDiagnosedClinicalhistoryPhysicalexaminationLabtestsEndoscopy(Colonoscopy)X-rayTissuebiopsy(Pathology)DIFFERENTIALDIAGNOSISInfectiouscolitisCrohn’sdiseaseColoncancerIrritablebowelsyndromeIschemiccolitisRadiationcolitisDiverticulitisDIFFERENTIALDIAGNOSIS

ulcerativecolitisCrohn’sdiseaseSiteRectumalwaysAnysegmentofthecolononlygastrointestinaltractPatternContinuousSkipDiarrheaBloodyUsuallynonbloodyFistulaNoYesEndoscopic

Erythema,friable,Aphthoidulcers,deepfindingssuperficialulcerationsulcersHistologicCryptabscessGranulomas(30%)featuresTREATMENTGeneraltherapy

☆Nutrition☆Antidiarrhealmedications☆AntibioticsDrugtherapy

☆Sulfalazine(SASP)☆5-aminosalicylic(5-ASA)

☆Corticosteroids☆ImmunosuppressiveagentsTREATMENTSurgicaltreatment☆Emergentoperation☆SelectiveoperationFuturetherapy5-ASAInduceremissionsinmild-moderateUCMaintainremissionsinmild-moderateUCMaintainremissionsinCDaftermedicaltreatmentSurgicalresections5-ASABenefits

RisksWell-toleratedRareallergies/FewsideeffectssideeffectsRelativelyinexpensiveNothelpfulinseverediseaseOralorRectalNothelpfulSafeforallages&aftersteroidspregnancyCorticosteroidsPrednisone,Hydrocortisone,

Budesonide,Medrol,Decadron,

Cortenema,Cortifoam,ACTHAdministeredbypill,IVorenemaInduceremissionsinUCNomaintenancedenefitsCortcosteroidsBenefits

Risks●Inducesremissions●Nolong-termbenefits●Quickfix●Numeroussideeffects●InexpensiveCushingoidchanges●OralorrectalHypertensionDiabetesOsteoporosis

GrowthretardationAntibioticsFlagyl(Metronidazole),Ciprofloxacin,

Ampicillin,etc.IntravenoustotreatseverecolitisorinfectionssuchasabscessAntibioticsBenefits

Risks●Mild-moderateCD●NoteffectiveinUC●Fistulaandperi-analCD●

Flagyl●ReducerecurrenceNeuropathyAftersurgery(?)Coatedtongue

Yeastinfections

●CiprofloxacinYeastinfections

TendoninjuryImmune-ModulatorsLong-term(maintenance)treatmentsPrimarilyforpatientsunabletogetoffSteroidsRequirescontinuousmonitoringofbloodtestsImmune-Modulators

Imuran&6-MP

Benefits

Risks●Steroid-sparing●Canlowerbloodcountsandimmunity●Long-term●Requireslong-termMaintenancemonitoring●Relatively●

OccaionalallergiesInexpensivefever,pancreatitisCyclosporine

Benefits

Risks●EffectiveinsevereUC●Kidneydamage●EffectiveinCD?●Incresedinfections●Worksrapidly●Seizures●Hypertension●Tumors?UC:Indicatiosfo