溃疡性结肠炎的方方面面.ppt
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溃疡性结肠炎的方方面面.ppt
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溃疡性结肠炎,Introduction,IBD是一种病因尚不十分清楚的慢性非特异性肠道炎症,包括UC和CD。
其发病率呈逐年上升趋势,且多为青壮年发病,临床表现复杂,并发症严重,肠外表现多样,严重影响个人生活质量和社会生产力。
此外,因其有癌变的风险,备受广大医生的重视。
近年来在国内外IBD基础与临床研究高潮迭起,基础研究的成果直接指向临床治疗,取得了划时代的进展。
探讨和摸索适合国人的治疗方案以降低重症UC的并发症和死亡率显得十分重要。
Introduction,Ulcerativecolitisischaracterizedbymucosalinflammationofthecolon.Thepathologyisinflammatoryandthediseasecourseisrelapsingandremittingwithintermittentsymptomsofrectalbleedinganddiarrhea.Approximately25%ofpatientsdevelopachronicactiveorarapidlyfulminatediseasecourse.Chronicinflammationcanleadtodysplasiaandcancer.Approximately20%ofpatientsrequirecolectomywithileoanalpouchorstoma.VelayosFS,TerdimanJP,WalshJM.Effectof5-aminosalicylateuseoncolorectalcanceranddysplasiarisk:
asystematicreviewandmetaanalysisofobservationalstudies.AmJGastroenterol2005;100:
13451353.,Consensus,StangeEF,TravisSP,VermeireS,ReinischW,GeboesK,BarakauskieneA,etal.Europeanevidence-basedConsensusonthediagnosisandmanagementofulcerativecolitis:
definitionsanddiagnosis.JCrohnsColitis2008;2:
123.VanAsscheG,DignassA,PanesJ,eta1ThesecondEuropeanevidence-basedConsensusonthediagnosisandmanagementofulcerativecolitis:
DefinitionsanddiagnosisJCrohnsColitis,20104:
727MowatC,ColeA,WindsorA,AhmadT,ArnottI,DriscollR,etal.Guidelinesforthemanagementofinflammatoryboweldiseaseinadults.Gut2011;60:
571607.TurnerD,LevineA,EscherJC,GriffithsAM,RussellRK,DignassA,etal.Managementofpediatriculcerativecolitis:
ajointECCOandESPGHANevidence-basedconsensusguidelines.JPediatrGastroenterolNutr2012.TurnerD,TravisSP,GriffithsAM,RuemmeleFM,LevineA,BenchimolEI,etal.Consensusformanagingacutesevereulcerativecolitisinchildren:
asystematicreviewandjointstatementfromECCO,ESPGHAN,andthePortoIBDWorkingGroupofESPGHAN.AmJGastroenterol2011;106:
57488.,ManagementconsensusofinflammatoryboweldiseasefortheAsiaPacificregion2006,Abstract:
Atthepresenttherearenolarge-scaleepidemiologicdataoninflammatoryboweldisease(IBD)intheAsiaPacificregion,butseveralstudieshaveshownanincreasedincidenceandprevalenceofIBDinthisregion.ComparedtotheWest,thereappearstoexistatimelagphenomenon.WithregardtothetwomainformsofIBD,ulcerativecolitis(UC)ismoreprevalentthanCrohnsdisease(CD).Inadditiontogeographicdifferences,ethnicdifferenceshavebeenobservedinthemultiracialAsiancountries.Moreover,thegeneticbackgroundsaredifferentintheAsiancomparedtoWesternpatients.Forinstance,NOD2/CARD15variantshavenotbeenfoundinAsianCDpatients.Ingeneral,theclinicalcourseofIBDseemstobelesssevereintheAsiaPacificregionthaninWesterncountries.DiagnosisofIBDinthisregionposesspecialproblems.ThelackofagoldstandardforthediagnosisofIBD,andtheexistenceofavarietyofinfectiousenterocolitiswithsimilarmanifestationstothoseofIBDmakethedifferentialdiagnosisparticularlydifficult.Sofar,WesterndiagnosticcriteriahavebeenintroducedforthediagnosisofIBD.Astepwiseapproachtoexcludenon-IBDenterocolitisalsomustbeintroduced,andadefinitediagnosismustincludetypicalhistologicalfeatures.Insomepatients,followupandtherapeutictrialsmightbenecessarytoobtainadefinitivediagnosis.AbetterunderstandingofthepathogenesisofIBDwillallowthedevelopmentofbetterdiagnosticmarkers.ThemanagementofIBDalsoposessomespecialproblemsintheAsiaPacificRegion.ThereisoftenadelayinusingpropermedicationsforIBD,andalternativelocalremediesarestillwidelyused.WithacombinationofWesternguidelinesandregionalexperiences,similarprinciplescanbeusedforinductionandmaintenanceofremission.Astepwiseselectionofmedicationsisadvocateddependingontheextent,activityandseverityofthedisease.ComprehensiveandindividualizedapproachesaresuggestedfordifferentIBDpatients.DeeperunderstandingofdiseasepathogenesisandtheuniquecharacteristicsofIBDintheAsiaPacificregion,combinedwithreasonableandpracticalguidelinesfordrugmanagementandthefutureuseofbiologicalagentswouldimprovethetherapeuticoutlookofIBDinthisregion.,TheAsia-Pacificconsensusonulcerativecolitis2010,Europeanevidence-basedconsensusonthediagnosis/managementofulcerativecolitis2008,ThisdocumentsetsoutthecurrentEuropeanConsensusonthediagnosisandmanagementofUC,reachedbytheEuropeanCrohnsandColitisOrganisation(ECCO)atameetingheldinBerlinon20thOctober2006.ECCOisaforumforspecialistsininflammatoryboweldiseasefrom23Europeancountries.LiketheinitialConsensusonthemanagementofCrohnsdisease,thecurrentConsensusisgroupedintothreeparts:
definitionsanddiagnosis;currentmanagement;andmanagementofspecialsituations.Thisfirstsectionconcernsaims,methodsanddefinitionsoftheConsensus,aswellasclassification,diagnosis,imagingandpathologyofUC.Thesecondsectiononcurrentmanagementincludestreatmentofactivedisease,maintenanceofmedically-inducedremissionandsurgeryofUC.Thethirdsectiononspecialsituationsincludespouchdisorders,cancersurveillance,pregnancy,paediatrics,psychosomatics,extra-intestinalmanifestationsandalternativetherapy.,2ndEuropeanevidence-basedconsensusonthediagnosis/managementofulcerativecolitis2012,ThisdocumentupdatesthepreviousEuropeanConsensusonthediagnosisandmanagementofUC,andwasfinalisedbytheEuropeanCrohnsandColitisOrganisation(ECCO)atameetingheldinDublininFebruary2011.ECCOisaforumforspecialistsininflammatoryboweldiseasefrom31Europeancountries.LiketheinitialConsensusonthediagnosisandmanagementofulcerativecolitis,68thisupdatedConsensusisgroupedintothreeparts:
definitionsanddiagnosis;currentmanagement;andmanagementofspecialsituations.Previouslyincludedchaptersonpregnancyandpediatricsarenolongerincludedinthisguideline,asspecificECCOConsensusGuidelinesonReproductionandPregnancyandPediatricUC(togetherwithESPGHAN)coverthesetopicsextensively.,Background,溃疡性结肠炎(UC)1859年由Wilks首先描述,1920年被医学界公认,我国于1956年首次报道。
特发性溃疡性结肠炎诊断及治疗标准(草案)(1978年杭州)溃疡性结肠炎的诊断及疗效标准(1993年太原)对溃疡性结肠炎诊断治疗规范的建议(2000年杭州)对我国炎症性肠病诊断治疗规范的共识意见(2007年济南)炎症性肠病诊断与治疗的共识意见(2012年广州)从中可以看出每一次补充和修改都反映了我国对该病认识的逐步提高,治疗逐渐规范化。
第九届中华消化病学分会炎症性肠病学组成员名单,名誉组长:
欧阳钦组长:
胡品津副组长:
钱家呜夏冰吴开春冉志华秘书:
王玉芳高翔核心成员:
胡品津欧阳钦郑家驹钱家呜夏冰吴开春冉志华刘占举钟捷吴小平陈旻湖胡仁伟组员:
欧阳钦郑家驹邓长生刘新光胡品津钱家鸣夏冰吴开春李俊霞吕愈敏顾芳刘玉兰王晓娣韩英朱峰冉志华刘占举郑萍钟捷庞智曹茜陈旻湖智发朝姜泊张亚历钟英强沙卫红胡仁伟王玉芳甘华田邹开芳吴小平缪应蕾江学良于成功梅俏王承党郭长存卢雪峰高翔霍丽娟,UlcerativecolitisinChina:
Retrospectiveanalysisof3100hospitalizedpatients,Backgroundinfectiousenterocolitishadamisdiagnosisrateof22.9%beforeadmission.ThemainmedicationsforUCinChinawereaminosalicylates(66.8%)andsteroids(42.8%).Only94(3%)ofthepatientsrequiredcolectomyandonly19(0.6%)diedofUC.Conclusions:
ComparedwithUCinWesterncountries,ulcerativecolitisinChinahassomedifferencesinclinicalcharacteristics.Therefore,afurtherpopulation-basedepidemiologicalstudyisrequiredtodeterminetheprevalenceandincidenceratesofUCinChina.,OuyangQAPDW2004ChineseIBDworkinggroupJGastroenterolHepatol.2007,Epidemiolgy,TheincidenceofUCrangedfrom1.0to2.0per100000personyears.TheprevalenceofUChasrangedfrom4.0to44.3per100000.Inarecentstudy,thespeculatedprevalencewas11.6/100000inChina.ComparedtotimetrendsintheWest,thereappearstobeatimelagphenomenoninvolvingincidenceandandprevalenceofIBDwithregardtotheAsianexperience.OuyangQ,TandonR,GohKLetal.ManagementconsensusofinflammatoryboweldiseasefortheAsia-Pacificregion.JGastroenterol.Hepatol.2006;21:
177282.Lennrd-JonesJE.IncidenceofinfammatoryboweldiseaseacrossEurope:
isthereadifferencebetweennorthandsouth?
.Gut1996;39:
690-697.,EtiologyandPathogenesis,目前对IBD病因和发病机制的认识可概括为:
环境因素作用于遗传易感者,在肠道菌群丛的参与下,启动了肠道免疫系统及非免疫系统,最终导致免疫反应和炎症过程。
可能是由于抗原的持续刺激或(及)免疫调节紊乱,这种免疫炎症反应表现为过度亢进或难于自限。
BaumgartDC,CardingSR.Inflammatoryboweldisease:
causeandimmunobiology.Lancet2007;369:
16271640.BrownSJ,MayerITheimmuneresponseininflammatoryboweldiseaseAmJGastroenterol,2007,102:
20582069BernsteinCN,ShanahanFDisordersofamodernlifestylelreconcilingtheepidemiologyofinflammatoryboweldiseasesGut,2008,57:
1185-1191,菌群失调,IBD患者肠遭细菌存在菌群失调,正常细菌数量减少,而致病菌、条件致病菌数量明显增多。
Duchmann等发现。
正常人对其体内肠道菌群及抗原物质耐受,而IBD患者肠黏膜免疫细胞对失调的肠道菌群及抗原物质失去了耐受。
这一发现证实了IBD患者肠道菌群及抗原物质能诱导肠黏膜异常免疫反应。
Frank等发现IBD患者肠道菌群中拟杆菌、厚壁菌类减少,而变形杆菌及放线菌等增多。
由于在肠道内,拟杆菌、厚壁菌是主要的裂解食物纤维产生丁酸盐和其他短链脂肪酸的细菌,这些细菌数量减少,导致维持肠上皮细胞生长和代谢的丁酸盐和其他短链脂肪酸等营养物质减少。
同时。
溃疡性结肠炎患者肠道内产硫化氢的细菌增多,硫化氢具有抑制丁酸盐和其他短链脂肪酸等营养物质生存及直接影响肠上皮细胞新陈代谢的功能。
上述细菌菌群失调导致肠上皮细胞营养缺乏,影响了肠黏膜屏障功能。
DuchmannR。
KaiserI,HermannE,eta1Toleranceexiststowardsresidentintestinalflorabutisbrokeninactiveinflammatoryboweldisease(IBD)ClinExpImmunol,1995102:
448455FrankDN,StAmandAL,FeldmanRA,eta1MolecularphylogeneticcharacterizationofmicrobialcommunityimbalancesinhumaninflammatoryboweldiseasesProcNatlAcadSciUSA,2007,104:
1378013785,Familyhistory,Kitahoraetal.foundastrongfamilialoccurrenceinUCamongJapanesepatients.InaKoreanstudy,asimilarfamilialaggregationwasalsoreported.KitahoraT,UtsunomiyaT,YokotaA.EpidemiologicalstudyofulcerativecolitisinJapan:
incidenceandfamilialoccurrence.TheEpidemiologyGroupoftheResearchCommitteeofInflammatoryBowelDiseaseinJapan.J.Gastroenterol.1995;30(Suppl.8):
58.ParkER,YangSK,MyungSJetal.FamilialoccurrenceofulcerativecolitisinKorea.KoreanJ.Gastroenterol.2000;36:
7704.,Riskfactors,ObjectiveToscreentheriskfactorsofinflammatoryboweldisease(IBD)bycaseinvestigationMethords72determinedIBDpatientsand72pairedhealthysubjectsweresurveyedwithanorganizedinventorycomprisingofrelevant
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