内科学 课件 ibd的诊治展--王晓艳.pptVIP

炎症性肠病的诊治进展 湘雅三医院消化内科 王晓艳 教授 Case 1 ID/CC: A 21-year-old male presents with abdominal pain for 3 years. HPI: He also complain of diarrhea, fistula, weight loss, stricture and was admitted to hospital for 7 times. One year before he was diagnosed as Crohn’s Disease(A2, L3, B2p). PE: VS: fever (T:38.3), thin and pale (secondary to anemia); Heart and lung are normal; abdomen soft with right lower quadrant tenderness, visible peristalsis; Perianal fistula. Labs: ESR and CRP elevated. Blood routing, LFT, SPS are normal. Imaging: Colonoscope examination: Crohn’s Disease? Pathological examination: chronic inflamation in mucose and submucosa. Case 1 Case 1 Record of management: 1 year agao, 5-ASA( 1 year) and corticosteroids (2 Mon.) were used, which can relieve the symptom. While after withdraw corticosteroids, the fever and abdominal pain became worse. 4 months ago, IFX and azathioprine were used for the patient, and his symptoms had been relieved for 15 days to 20 days after IFX injection, then all the symptom will be worsen. Now he found the visible peristalsis occasionally, and the fistula haven’t be improved. Question: What’s the further treatment for this patient? Can we draw a conclusion that the fistula hasn’t response to IFX? And how to cure the fistula? Can we use IFX every 2-3 weeks after IFX inducing treatment? If it can be done, could the patient get better effect after giving IFX every 2-3 weeks. UC的临床诊断 诊断要点：腹泻、便血≥6周，结肠镜检查发现至少一项特征性改变（粘膜易脆、点状出血、弥漫性炎性溃疡）钡餐检查发现同样征象。活检标本有特征性改变。 排除表其他原因：结肠CD、缺血性肠病、放射性肠炎慢性血吸虫、阿米巴等 拟诊+排除其他原因+肠粘膜活检或手术切除标本病理学检查有典型表现，可确诊 评估肠外表现及并发症：关节、皮肤、眼和肝脏等 UC的临床分型 1）初发型：指无既往史、首次发作。 2）慢性复发型：发作与缓解期交替出现。 3）慢性持续型：症状持续存在，间以症状加重的急性发作。 4）急性爆发型：症状严重，每日血便10次以上，办全身中毒症状，可有中毒性巨结肠、穿孔及脓毒血症。 UC的病变范围 UC的活动性 UC的活动性的严重程度 UC的自然史与外科手术指征 首次发作UC约10%手术25年UC30%手术 手术指针： 1）绝对指征：大出血、穿孔、癌变及高度疑癌变者 2）相对指征：1）积极内科治疗无效的重度UC，伴中毒性巨结肠、静脉用药无效者；内科治疗疗效欠佳和（或）药物不良反应已严重影响生存质量者 CD