溃疡性结肠炎的诊断与治疗

溃疡性结肠炎的诊断与治疗

临床症状常见：腹痛、发热(<38˚C)、腹泻、血便、 消瘦。肠外表现：关节炎、口腔溃疡、强直性脊柱 炎（HLA-B27）、微型硬化性胆 管炎。内镜检查及X线检查内镜检查表现：中毒性巨结肠是内镜绝对 禁忌症钡剂灌肠：铅管征、毛刺样改变、粘膜颗 粒粗糙Endoscopicfeaturesofactiveulcerativecolitis

Figure4-1.Endoscopicfeaturesofactiveulcerativecolitis.Findingsincludediffuselyerythematous,edematous,andgranularmucosawithareasofsubmucosalhemorrhageand,whensevere,frankmucopurulentexudate.Inflammationinvariablybeginsintherectumandextendsproximallyforvaryingextents.Thechronicityoftheprocessissuggestedbythelossofcolonichaustrations;otherwise,theendoscopicpictureisnonspecificandcouldbeconsistentwithacuteinfectiouscolitis,chroniculcerativeorCrohn`scolitis,oranynumberofotherspecificcausesofcolitis.A,Milddistalulcerativecolitiswithdiffuseerythemaandfriabilitywelldemarcatedfromthenormalmucosamoreproximallyisdepicted.B,Thisexampleshowsmoderatelysevereulcerativecolitiswithirregular,inflamed,ulceratedmucosaandapatchyexudate.Ulcerativecolitisinremission

Figure4-2.Ulcerativecolitisinremission.Thenormalvascularpatternisabsentandawhitescarindicatesthesiteofapreviousulcer.

Severeulcerativecolitis

Figure4-3.Severeulcerativecolitis.Themucosashowsextensiveulcerationanddiffusethickeningwithaninflammatoryinfiltrate.IncontrasttoCrohn`scolitis,theulcerationlacksdepth.

Chroniculcerativecolitis

Figure4-5.Chroniculcerativecolitis.Inlong-standingulcerativecolitis,themucosahasanatrophicandscarredappearancewithabluntedvascularpattern.Pseudopolypsareoftenpresent.

Severeulcerativecolitiswithpseudopolyps

Figure4-4.Severeulcerativecolitiswithpseudopolyps.Inadditiontoseveremucosalulcerationandinflammation,chroniculcerativecolitisisoftenassociatedwiththeformationofpseudopolyps,whichrepresentislandsofregeneratingmucosaandexuberantinflammationamidstdiffusemucosaldestruction.Pseudopolypshavenomalignantpotential.

Severeulcerativecolitis

Figure4-6.Radiographicappearanceofsevereulcerativecolitis.Thissingle-contrastbariumenemademonstratesthetypicalraggedandulcerativeappearanceofthemucosainactiveulcerativecolitis.Characteristiccollar-buttonorunderminingulcersareseen.Ingeneral,bariumenemaandcolonoscopyshouldbeavoidedinfulminantulcerativecolitisbecauseofthepossibilityofprecipitatingtoxicmegacolon.

Chroniculcerativecolitis

Figure4-7.Radiographicappearanceofchroniculcerativecolitis.Long-standingchroniculcerativecolitis,asshowninthissingle-contrastbariumenema,ischaracterizedbyshorteningandstraighteningofthecolonwithlossofhaustrations,resultingintheappearanceofafeaturelesstube.Noulcerationsareseen.

其他辅助检查血沉、白细胞计数（>10.0X109／Ｌ）、血白蛋白、电解质临床分型初发型、慢性复发型、慢性持续型、急性暴发型鉴别诊断感染性肠病：菌痢、阿米巴肠炎药物性肠炎：伪膜性肠炎痔疮、结直肠癌克隆病鉴别要点UCCD病变连续性++－穿壁性累及+/－+++集合淋巴小结－+++隐窝脓肿++++肉芽肿结节－++窦道/瘘管－+++直肠病变++++/－口疮样溃疡或线性溃疡－+++铺路石样改变－++粘膜脆性+++++粘膜脆性+++++UC和CD的病理鉴别要点+++始终有++常有+偶有－无指标轻症重症暴发1、大便（次数/天）<46-10>102、大便中带血间歇性经常持续3、体温(°C)正常>37.5>37.54、脉搏(次/分)<90>90>905、血红蛋白正常<正常值的75%需输血6、血沉(mm/hr)≤30>30>307、结肠放射学表现无充气,肠壁水肿扩张8、体征无腹部压痛腹部胀满、压痛评估溃疡性结肠炎严重性的标准

并发症肠穿孔：左半结肠（乙状结肠多见）肠出血：多见于慢性重型溃结伴溃疡，糜 烂，炎性息肉，如果出血２～３ Ｌ／ｄ则有手术指征中毒性巨结肠：多见于暴发性溃结和全结 肠炎，因病变侵及肌层，横结 肠直径可达６ｃｍ结直肠癌轻度溃结的处理可选用柳氮磺胺吡啶（SASP）制剂，每日3~4g，po；5-氨基水杨酸（5-ASA）制剂。远段结肠者可SASP栓剂0.5~1g，每日2次；氢化可的松琥珀酸钠盐灌肠液100~200mg，每晚1次保留灌肠，或用相当剂量的5-ASA制剂灌肠，亦可用中药保留灌肠治疗。中度溃结的处理可用上述剂量水杨酸类制剂治疗，反应不佳者适当加量或改服皮质类固醇激素，常用强的松30~40mg/d，分次口服。重度溃结的处理①如患者尚未用过口服类固醇激素，可口服强的松龙40-60mg/d，观察7-10天，亦可直接静脉给药；已使用激素者，静滴注氢化考的松300mg/d或甲基强的松龙40mg/d；未用类固醇激素者亦可使用促肾上腺皮质激素（ACTH）120mg/d，静滴。②应用抗生素控制肠道继发感染，如氨苄青霉素、硝基咪唑及喹诺酮类制剂。

重度溃结的治疗③应使患者卧床休息，适当输液、补充电解质，以防水盐水平衡紊乱。④便血量大、Hb<90g/L和持续出血不止者应考虑输血。⑤营养不良、病情较重者可用要素饮食，病情严重者应予肠外营养。重度溃结的治疗⑥静脉类固醇激素使用7～10天后无效者可考虑环孢素每日2～4mg/kg静脉滴注；⑦如上述药物疗效不佳，应及时内、外科会诊，确定结肠切除手术的时机和方式。⑧慎用解痉剂及止泻剂，以避免诱发中毒性巨结肠。⑨密切监测患者生命体征及腹部体征变化，尽早发现和处理并发症。缓解期溃结的处理症状缓解后，应继续维持治疗，但至少应维持1年，近年主张长期维持。一般认为类固醇激素无维持治疗效果，在症状缓解后应逐渐减量，尽可能过渡到用SASP维持治疗