内镜对炎症性肠病临床处理的诊断价值.ppt

,Company Logo,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,内镜对,IBD,临床处理的诊断价值,Significance of,Follow-up,with,Endoscope for,Management of,IBD,Company Logo,My Talk Can Begin with,普通内镜（,white light endoscopy,WLE,）,色素内镜（,Chromoendoscpy,）,虚拟色素（,NBI,I-Scan,FICE,）,超声内镜（,endoscpic ultrasonography,EUS,）,共焦内镜（,confocal laser endomicroscpoy,CLE,）,Company Logo,Or,with,1.Challenge:Incidence&Prevalenc-Endoscopic Diagnosis,2.Distinguishing IBD From Other Disorders,UC and CD,3.Assessment of Extent and Severity,4.Assessment of Response and Prediction of Relapse,5.Surveillance,:,Dysplasia and Colorectal Cancer,Company Logo,The Earliest Report of symptom,Reports of manifestations of IBD(Crohns Disease?)have been reported as early as 850 AD when King Alfred,Englands Darling,suffered from an illness which caused pain on eating,discomfort,and much embarrassment.This affliction plagued the King from the age of 20,without remission.At the time the illness was thought to be due to witchcraft,or a punishment for the Kings infidelities.In retrospect,however,the illness was probably Crohns Disease from todays knowledge,.,Company Logo,The Earliest Medical Article,An article was published in the British Medical Journal of 1913 by T.Kennedy Dalziel,who reported treating 13 patients who had suffered from intestinal obstruction.On autopsy he found that all 13 patients had inflamed gut,especially in the jejunal,ileal and colonic areas.On examining the inflamed bowel more closely,the transmural inflammation that is characteristic of the disease was clearly seen.,IBD:,From:Inflam Bowel Dis 2009:1232,(a),(b),(b),Company Logo,UC 176,篇,3053,例,CD 356,篇,3703,例,1989-2008,年,（文献,572,篇）,我国医学文献报道的,IBD,病例数,“,万方期刊库,”,“,中国期刊网,”,“,中国科技期刊数据库,”,“,中国生物学文摘数据库,”,等,Company Logo,我国医学文献报道的,IBD,病例数,1989-2008,我国医学文献报道的溃疡性结肠炎病例数,Company Logo,我国医学文献报道的,IBD,病例数,1989-2008,我国医学文献报道的克罗恩病例数,Company Logo,中文文献,IBD,误诊数据与类别,误诊定义与分类,A,类误诊,入院诊断其它病并已治疗，出院诊断,IBD,，或称“漏诊,”,B,类误诊,入院诊断,IBD,并已治疗，出院诊断其它病，或称“错诊,”,（,1989-2008,年，,572,篇）,Company Logo,中文文献炎症性肠病的误诊分类统计,UC,（,3053,例）,A,类,912,例（,29.9%,）,B,类,221,例（,7.2%,）,总计,1133,例（,37.1%,）,CD,（,3073,例）,A,类,1801,例（,48.6%,）,B,类,627,例（,16.9%,）,总计,1828,例（,76.5%,）,来自,1989-2008,中文期刊,572,篇文献（,UC176,篇,CD,356,篇）,Company Logo,溃疡性结肠炎误诊病种统计,-A,类,来自,1989-2008,我国,176,篇,UC,相关医学文献报道,Company Logo,溃疡性结肠炎误诊病种统计,-,B,类,来自,1989-2008,我国,176,篇,UC,相关医学文献报道,Company Logo,来自,1989-2008,我国,356,篇,CD,相关医学文献报道,克罗恩病误诊病种统计,-,A,类,Company Logo,来自,1989-2008,我国,356,篇,CD,相关医学文献报道,克罗恩病误诊病种统计,-B,类,Company Logo,中文文献炎症性肠病的误诊分类统计,UC,（,3053,例）,A,类,912,例（,29.9%,）,B,类,221,例（,7.2%,）,总计,1133,例（,37.1%,）,CD,（,3073,例）,A,类,1801,例（,48.6%,）,B,类,627,例（,16.9%,）,总计,1828,例（,76.5%,）,来自,1989-2008,中文期刊,572,篇文献（,UC176,篇,CD,356,篇）,Company Logo,挑战诊治,IBD,的消化专科医师的问题,你们医院内镜检查有会诊制度吗？,您是否亲自您的患者作内镜检查？,您肠镜检查时是否常规插入会肠？,肠粘膜损伤患者您如何进行活检？,您是否经常与病理医师读片讨论？,您怎样对您的患者进行内镜随访？,Company Logo,挑战诊治,IBD,的消化专科医师的问题,确定诊断,IBD,的“金”标准,内镜图像,特征性肠粘膜损害,病理依据,特征性组织学描述,Company Logo,内镜检查和活检病理的目的,确定,IBD,的诊断、确定,CD,或,UC,提供粘膜损害的严重程度依据,活动指数,提供评估病变的范围（,UC;CD?,）,追踪和判断治疗效果，指导修改治疗方案,提供梗阻、癌变的形态学依据,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,Journal of Crohn and Colitis,）,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,（,2006,）,（,Journal of Crohn and Colitis,）,（,2010;4:7-27,）,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease.The British Society of Gastroenterology,（,J Clin Pathol 1997;50:93-105,）,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease.The British Society of Gastroenterology,Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease.The British Society of Gastroenterology,Company Logo,ECCO Statement 3F(2010),Focal(discontinuous)chronic(lymphocytes and plasma cells)inflammation and patchy chronic inflammation,focal crypt irregularity(discontinuous crypt distortion),and granulomas(not related to crypt injury)are the generally accepted microscopic features that permit a diagnosis of CD EL2,RGB.The same features and,in addition,an irregular villous architecture,can be used for analysis of endoscopic biopsy samples from the ileum.If the ileitis is in continuity with colitis,the diagnostic value of this feature should be used with caution EL2,RG B.,Travis SM,er al.Gut 20,10,gt81950A 10/01/06,Company Logo,2010,年,ECCO,关于,CD,病理,特征的声明,与会专家一致认为，,CD,的特征性病理组织学特征有：局灶性（,focal or discontinuous,）慢性炎症（非连续性、粘膜浸润以淋巴细胞和浆细为主）和斑片状慢性炎症（,patchy chronic inflammation,）、局灶性隐窝不规则（非连续性隐窝不规则）和肉芽肿（与隐窝损害无关）等,EL5,RG D,。内镜下回肠活检标本病理特征除此以外，绒毛结构不规则也作为诊断参考依据。如出现回肠炎症与结肠炎症连续一起时，上述标准应用时需慎重,EL2,RG B,Travis SPL,er al.Gut 20,10,gt81950A 10/01/06,J Clin Pathol 2002;55:955-960,J Clin Pathol 2002;55:955-960,“,Using a full colonoscopic biopsy series,rather than a single rectal biopsy,produced the largest diagnostic improvement.,”,Company Logo,单中心临床小组的经验：,2009.1.,2010.9.,Company Logo,6,个图像,哪个诊断为,CD,或,UC,？,Company Logo,以一患者为例,女性，,75,岁，腹泻、腹痛、粘液血便,2,周入院,发病前进食过海鲜，但没有集体发病。腹痛、腹泻水样便,1,天就诊。静脉左旋氧氟沙星,2,天。腹泻腹痛无好转，出现粘液脓血便，,3-6,次,/,日，,30-10ml/,次，无里急后重，无发热。既往无炎症性肠病史,体检肠鸣音,6-8,次,/,日，腹部无压痛。其余体征正常,全结肠镜：溃疡性结肠炎（重症），附内镜照片,Company Logo,炎症性肠病入、出院诊断变化分析,病例数,35,，男性,21,例，女性,14,例，年龄,275,岁,来自消化内科、肾内科、内分泌、老年病学科、肛肠外科、急诊,入院诊断非,IBD,并已治疗，最终确诊为,IBD,入院前诊断,IBD,并开始按,IBD,治疗，最终部分确诊为非,IBD,时间自,2009,年,1,月,-2010,年,6,月,（新华医院,2009.1-20010.6,）,Company Logo,IBD,患者入、出院诊断变化统计,(,漏诊,),（新华医院,2009.1-20010.6,）,Company Logo,IBD,患者入、出院诊断变化统计,（新华医院,2009.1-20010.6,）,Company Logo,IBD,患者入院出院诊断变化统计,（新华医院,2009.1-20010.6,）,Company Logo,误诊病例最后诊断疾病分类,疾病名称 例数,(,n,=24),感染性胃肠炎,(,包括,AAD 4,例,)11,肠结核,3,CD,合并肠结核,3,缺血性肠病,2,回肠淋巴滤泡增生,2,阿司匹林肠道损伤,2,白塞病,1,干燥综合症,1,Company Logo,病例,-6,诊断,CD,、风湿病肠粘膜损害,男性，,73,岁，河南郑州人。,2,年前因低热、粘液脓血便伴里急后重一个月、糖尿病史,6,年，在当地医院住院经内镜检查发现升结肠,2,处圆形下凹溃疡，直径约,15-20,毫米，内附黄厚苔，边缘规则，充血水肿。病理慢性炎症，提示,CD,可能。开始使用,5-ASA,，,4,周后低热无好转，来上海某三级医院住院。由于溃疡不典型，查全部风湿病指标阴性，诊为风湿病肠粘膜损害，开始用强的松（,3,周后逐渐减、停药）和硫唑嘌呤。体温降至正常粘液脓血便消失后回郑州。,2,个月后再次发热，大便粘液、气急并加重。超声发现右侧中等量胸水住院，胸膜活检病理找到结核结节。,CT,显示两肺上中结核灶。,RFP+INH+PZ,抗痨,2,周体温进一步增高，怀疑,RFP,药物热，停用。转上海肺科医院住院抗痨,3,周仍中等到高热，少量粘液脓血便血。经会诊后，复查肠镜。,Company Logo,病例,-7,诊断为克罗恩病,男性，,62,岁，嘉兴人。便秘,2,年，加重并出现腹胀、腹痛,5,天，,2012,年,2,月,10,日当地医院急诊，腹部平片提示大肠梗阻、,CT,平片升结肠扩张住院。经禁食、胃肠减压症状和体征好转。通便后肠镜检查诊断为,CD,。小肠钡剂造影正常，,BE,造影见结肠扩张，铅管样。全部风湿病指标（包括,ASCA,、,ANCA,）阴性。口服,5-ASA,，便秘和腹胀仍间断出现，依赖通便药，但体重恢复。,2012-5-16,新华医院肠镜复查结果附后。,Company Logo,内镜复查：个人经验、一孔之见,急性发病、疑似急性感染性肠炎者，,12,周,慢性病变，肠道毁损不典型者，停药,3,个月,治疗无效，立即复查，更改治疗，,36,个月,可疑出现并发症，为外科治疗，立即复查,肠道手术后,6-12,个月,Company Logo,提镜临床学科之间会诊交流,消化内科,影像科,急诊外科,小儿普外科,病理科,检验科,肛肠外科,Company Logo,需要排除的疾病或并发症,感染性疾病：机会性如,CMV,感染、艰难梭菌、大肠杆菌感染、抗生素相关性腹泻,(AAD),、阿米巴等,特殊感染：肠结核、,CD,合并肠结核、,UC,合并肠结核、其它分支杆菌感染,风湿病：干燥综合症、白塞病、血清阴性血管炎、系统性红斑狼疮、韦格纳肉芽肿,胃肠淋巴瘤,缺血性肠病,非甾体类抗炎药胃肠道损伤,Company Logo,国外诊治炎症性肠病医生的素质,必须是一个训练有素的消化专科,senior doctor,，在具备,IBD,诊治资质的综合性医院工作多年,必须具备熟练的内镜操作技能（尤其是肠镜以及内镜下治疗技术）,必须把自己当成患者的家属，提供各种联系方式，任何时候患者都可以向您联系,必须使患者和家属掌握,IBD,的知识，使他们的知识水平与您一样，就是没有诊治经验,建立自己的患者档案数据库，用作规范随访,必须利用网络资源，不断更新,IBD,诊治知识,THANKS !,