潰瘍性結(jié)腸炎的診斷與治療

潰瘍性結(jié)腸炎的診斷與治療

臨床癥狀常見：腹痛、發(fā)熱(<38?C)、腹瀉、血便、 消瘦。腸外表現(xiàn)：關(guān)節(jié)炎、口腔潰瘍、強(qiáng)直性脊柱 炎（HLA-B27）、微型硬化性膽 管炎。內(nèi)鏡檢查及X線檢查內(nèi)鏡檢查表現(xiàn)：中毒性巨結(jié)腸是內(nèi)鏡絕對 禁忌癥鋇劑灌腸：鉛管征、毛刺樣改變、粘膜顆 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.

其他輔助檢查血沉、白細(xì)胞計(jì)數(shù)（>10.0X109／Ｌ）、血白蛋白、電解質(zhì)臨床分型初發(fā)型、慢性復(fù)發(fā)型、慢性持續(xù)型、急性暴發(fā)型鑒別診斷感染性腸病：菌痢、阿米巴腸炎藥物性腸炎：偽膜性腸炎痔瘡、結(jié)直腸癌克隆病鑒別要點(diǎn)UCCD病變連續(xù)性++－穿壁性累及+/－+++集合淋巴小結(jié)－+++隱窩膿腫++++肉芽腫結(jié)節(jié)－++竇道/瘺管－+++直腸病變++++/－口瘡樣潰瘍或線性潰瘍－+++鋪路石樣改變－++粘膜脆性+++++粘膜脆性+++++UC和CD的病理鑒別要點(diǎn)+++始終有++常有+偶有－無指標(biāo)輕癥重癥暴發(fā)1、大便（次數(shù)/天）<46-10>102、大便中帶血間歇性經(jīng)常持續(xù)3、體溫(°C)正常>37.5>37.54、脈搏(次/分)<90>90>905、血紅蛋白正常<正常值的75%需輸血6、血沉(mm/hr)≤30>30>307、結(jié)腸放射學(xué)表現(xiàn)無充氣,腸壁水腫擴(kuò)張8、體征無腹部壓痛腹部脹滿、壓痛評估潰瘍性結(jié)腸炎嚴(yán)重性的標(biāo)準(zhǔn)

并發(fā)癥腸穿孔：左半結(jié)腸（乙狀結(jié)腸多見）腸出血：多見于慢性重型潰結(jié)伴潰瘍，糜 爛，炎性息肉，如果出血２～３ Ｌ／ｄ則有手術(shù)指征中毒性巨結(jié)腸：多見于暴發(fā)性潰結(jié)和全結(jié) 腸炎，因病變侵及肌層，橫結(jié) 腸直徑可達(dá)６ｃｍ結(jié)直腸癌輕度潰結(jié)的處理可選用柳氮磺胺吡啶（SASP）制劑，每日3~4g，po；5-氨基水楊酸（5-ASA）制劑。遠(yuǎn)段結(jié)腸者可SASP栓劑0.5~1g，每日2次；氫化可的松琥珀酸鈉鹽灌腸液100~200mg，每晚1次保留灌腸，或用相當(dāng)劑量的5-ASA制劑灌腸，亦可用中藥保留灌腸治療。中度潰結(jié)的處理可用上述劑量水楊酸類制劑治療，反應(yīng)不佳者適當(dāng)加量或改服皮質(zhì)類固醇激素，常用強(qiáng)的松30~40mg/d，分次口服。重度潰結(jié)的處理①如患者尚未用過口服類固醇激素，可口服強(qiáng)的松龍40-60mg/d，觀察7-10天，亦可直接靜脈給藥；已使用激素者，靜滴注氫化考的松300mg/d或甲基強(qiáng)的松龍40mg/d；未用類固醇激素者亦可使用促腎上腺皮質(zhì)激素（ACTH）120mg/d，靜滴。②應(yīng)用抗生素控制腸道繼發(fā)感染，如氨芐青霉素、硝基咪唑及喹諾酮類制劑。

重度潰結(jié)的治療③應(yīng)使患者臥床休息，適當(dāng)輸液、補(bǔ)充電解質(zhì)，以防水鹽水平衡紊亂。④便血量大、Hb<90g/L和持續(xù)出血不止者應(yīng)考慮輸血。⑤營養(yǎng)不良、病情較重者可用要素飲食，病情嚴(yán)重者應(yīng)予腸外營養(yǎng)。重度潰結(jié)的治療⑥靜脈類固醇激素使用7～10天后無效者可考慮環(huán)孢素每日2～4mg/kg靜脈滴注；⑦如上述藥物療效不佳，應(yīng)及時(shí)內(nèi)、外科會(huì)診，確定結(jié)腸切除手術(shù)的時(shí)機(jī)和方式。⑧慎用解痙劑及止瀉劑，以避免誘發(fā)中毒性巨結(jié)腸。⑨密切監(jiān)測患者生命體征及腹部體征變化，盡早發(fā)現(xiàn)和處理并發(fā)癥。緩解期潰結(jié)的處理癥狀緩解后，應(yīng)繼續(xù)維持治療，但至少應(yīng)維持1年，近年主張長期維持。一般認(rèn)為類固醇激素?zé)o維持治療效果，在癥狀緩解后應(yīng)逐漸減量，盡可能過渡到用SASP維持治療