本文選題：炎癥性腸病　切入點：潰瘍性結(jié)腸炎　出處：《昆明醫(yī)科大學》2014年碩士論文　論文類型：學位論文

【摘要】：第一部分：489例炎癥性腸病患者臨床特點的研究——基于醫(yī)院的回顧性研究 目的 分析近10年我院住住院的IBD患者包括UC和CD患者的臨床資料,了解我院10年內(nèi)IBD的臨床流行病學特征變化趨勢,指導臨床診治。 方法 選取2004-2013年在昆明醫(yī)科大學第一附屬醫(yī)院住院的確診IBD患者作為研究對象,統(tǒng)計分析患者的一般信息(性別、年齡等)、病程、臨床類型、分期、分度、結(jié)腸鏡檢查、癌變情況、病理資料以及治療情況(治療的主要藥物、用藥途徑)、腸外表現(xiàn)和并發(fā)癥,回顧分析這些患者的臨床特點和診治現(xiàn)狀；按照入院時間將IBD患者A、B兩組：A組(2004-2008年),B組(2009-2013年)；再將A、B兩組按照疾病種類分為4個亞組,1組為UC患者(A1和B1組),2組為CD患者(A2和B2組),對這4組患者的臨床特征的變化趨勢進行比較分析。 結(jié)果 1.IBD患者總計489例,男性293例,女性196例,男女比例1.49：1。UC和CD患者分別有425例和64例,其中男性患者250例和43例,女性患者175例和21例,男女比例為1.43：1和2.05：1。UC患者年齡在4-72歲之間,中位年齡44歲,UC患者在30-39歲年齡段最多。CD患者年齡在12-75歲之間,中位年齡38歲,40-49歲年齡段最多。 2.在過去的10年中,A組為65.9478X104,B組為95.3908X10-4,增長了1.45倍。A1組和A2組,UC：CD=10.9：1,平均入院構(gòu)成比分別為60.7717X104和5.5669X10-4；B1組和B2組,UC:CD=5.65:1,平均入院比分別為95.7717X10-4和14.3934X10-4。CD增長速度較UC快。 3.425例UC中病程在3周至30年之間,平均3.8年；64例CD患者病程在半年至13年之間,平均3.7年。病程均以少于2年最多見。 4.UC患者99.1%處于活動期,僅0.9%處于緩解期；20.2%輕度,41.6%中度,38.2%重度；19.5%直腸型,44.7%左半結(jié)腸型,35.8%廣泛結(jié)腸型；25.9%初發(fā)型,74.1%慢性復發(fā)型。CD患者98.4%處于活動期,1.6%處于緩解；輕度68.2%,中度30.2%,重度1.6%；狹窄型7.8%,穿通型4.7%,非狹窄非穿通型87.5%；回腸末端型32.8%,結(jié)腸型51.6%,回結(jié)腸型15.6%,無上消化道型。 5.395例UC患者接受腸鏡檢查,其中96.2%黏膜充血水腫、92.4%糜爛或潰瘍、30.1%膿性滲出、21.3%黏膜顆粒狀84例、19.7%假性息肉和黏膜橋、7.8%腸腔狹窄；282例UC患者腸鏡或手術(shù)后行病理檢查,病理可見95.8%有炎性細胞浸潤、33.0%有隱窩炎或隱窩膿腫、8.5%肉芽組織增生、4.6%不典型增生,2.1%管狀腺瘤或腺瘤樣增生。56例CD患者接受結(jié)腸鏡或膠囊內(nèi)鏡檢查,92.9%黏膜充血水腫、85.7%黏膜糜爛或潰瘍、14.3%裂隙狀潰瘍、27.9%炎性假息肉10例、5.4%瘺管3例、12.5%腸腔狹窄或腸管變形、8.9%鵝卵石樣改變,未見不典型增生或腺瘤樣增生病例：47例患者行病理學檢查,97.9%淋巴細胞聚集、29.7%全壁炎、25.5%.非干酪樣肉芽腫、29.8%裂隙狀潰瘍。 6.UC患者中有11.1%出現(xiàn)腸外表現(xiàn),其中脂肪肝4.23%、膽石癥3.53%,關(guān)節(jié)炎1.9%、0.7%口腔潰瘍、0.7%皮疹；3.1%并發(fā)癥,其中有2.1%管狀腺瘤或腺瘤樣增生、0.9%消化道大出血。CD患者中有6.3%出現(xiàn)腸外表現(xiàn),其中4.7%口腔潰瘍、1.6%虹膜炎；17.2%出現(xiàn)并發(fā)癥,9.3%腸管狹窄、4.7%瘺管、1.6%肛周膿腫、1.6%急性穿孔。 7.UC治療藥物以氨基水楊酸制劑為主,部分聯(lián)合使用糖皮質(zhì)激素、免疫抑制劑。23.8%單獨使用氨基水楊酸制劑全身或局部治療；58.3%使用氨基水楊酸制劑和激素全身或局部治療；有16.7%使用免疫制劑治療。425例UC患者中40.4%臨床緩解,59.1%有效,0.5%無效；轉(zhuǎn)外科手術(shù)治療5例,4例病情緩解,1例因感染死亡。 8.CD主要使用氨基水楊酸制劑、糖皮質(zhì)激素和免疫抑制劑治療。64例CD患者39.1%臨床緩解,59.3%治療有效,1例因其他原因死亡；有10.9%患者接受手術(shù)治療。 9.A、B組UC患者在性別、年齡有統(tǒng)計學差異(P0.05)；A、B組的病程長短、病情分期、病情程度、病變累及部位、腸外癥狀及并發(fā)癥無差異(P0.05)。 10.A、B組CD患者在性別、確診年齡、平均年齡、疾病行為和并發(fā)癥有差異(P0.05)；A、B組的病程長短、病情分期、病情程度、病變累及部位和腸外癥狀無統(tǒng)計學差異(P0.05)。 結(jié)論 1.IBD住院患者人數(shù)逐年增加,入院構(gòu)成比亦逐漸增加,CD的增長尤為顯著。 2.UC和CD患者的中位年齡分別為44歲和38歲,分別以30-39歲和40-49歲年齡段最多見,均晚于西方國家。 3.UC和CD男女患病比例分別為1.43：1和2.05：1,男性明顯高于女性。且近5年的IBD男性患者增多明顯,女性患者比例相對下降。 4.UC和CD病程均以少于2年的最常見。 5.UC住院患者大多處于活動期,以中重度為主,疾病類型以慢性復發(fā)型為主,受累部位左半結(jié)腸型所占比例最大；CD住院患者絕大部分患為活動期,以為輕中度為主,受累部位以結(jié)腸型居多,疾病行為以非狹窄非穿通型為主。近5年的IBD患者病程長短、病情分期、病情程度、病變累及部位等方面總體上較前無明顯變化。UC和CD的腸外表現(xiàn)和并發(fā)癥總體發(fā)生率較低。 6.IBD臨床表現(xiàn)多樣性,腸鏡檢查和病理學組織檢查是目前確診的重要手段,本研究中病例中雖暫無癌變病例,但已發(fā)現(xiàn)不典型增生和腺瘤樣增生病例,需加強其內(nèi)鏡監(jiān)測,進一步完善隨訪制度,提高早期癌變的發(fā)現(xiàn)率。 7.UC和CD內(nèi)科藥物治療效果佳,外科手術(shù)率較國內(nèi)外報道低。 第二部分：硫唑嘌呤治療炎癥性腸病的研究 目的 觀察我院IBD患者使用AZA的療效及安全性。 方法 收集活動性IBD患者,開始予AZA及糖皮質(zhì)激素治療,激素撤離后以AZA維持治療,隨訪監(jiān)測第12、24、48、96周的臨床療效,內(nèi)鏡下黏膜愈合程度及不良反應(yīng)。 結(jié)果 1.納入研究的IBD患者共80例,60例UC,20例CD。UC共60例,完成96周隨訪30例,完成48周隨訪40例,完成24周隨訪50例,完成12周隨訪52例,退出2例(因自行停藥退出),12例失訪；CD共20例,完成96周隨訪6例,完成48周隨訪12例,完成24周18例,完成12周隨訪12例,失訪2例。 2.AZA治療UC12周、24周、48周、96周的總有效率分別是84.7%、83.3%、80%、86.7%；緩解率分別是11.5%、20.8%、55%、53.4%。AZA治療滿12周30例停用激素,激素撤停率為65.4%。AZA治療滿48周有40例使用AZA,4例復發(fā)共4次,復發(fā)率為10%；治療滿96周的有30例,12例復發(fā),復發(fā)率40%。內(nèi)鏡下的黏膜愈合率用藥后48周、96周為70.0%、66.7%。 3.AZA治療CD12周、24周、48周、96周的有效率分別是80%、88.9%、100%、100%；緩解率70%、77.8%、75%、66.7%。AZA治療滿12周16例停用激素,激素撤停率為88.9%。AZA治療滿48周12例,2例復發(fā),復發(fā)率為16.7%；滿96周6例,1例復發(fā),復發(fā)率為16.7%。用藥后48周,有8例腸鏡結(jié)果顯示正常,2例輕度,2例中度,黏膜愈合率為66.7%;用藥后96周,有6例腸鏡下黏膜正常,黏膜愈合率為100%。 4.UC患者使用AZA治療12周、24周較用藥前ESR、CRP、WBC計數(shù)均無統(tǒng)計學意義(P0.05),Truelove和Witts UC分度對比有統(tǒng)計學意義(P0.05)；用藥48周后較用藥前的ESR、CRP和Sutherland評分、內(nèi)鏡Mayo評分、Truelove和Witts UC分度有統(tǒng)計學意義(P0.05)；用藥96周后較用藥前Sutherland評分、Truelove和Witts UC分度比較有統(tǒng)計學意義(P0.05)。 5.UC患者使用不同劑量的AZA治療,2mg/kg組與1mg/kg在WBC、ESR、CRP和Sutherland評分、內(nèi)鏡下黏膜愈合Mayo評分、臨床治療反應(yīng)對比均無統(tǒng)計學意義(p0.05)。 6.CD患者使用AZA治療12周后較用藥前ESR、CRP、WBC、HCT、Hb、CDAI評分均無統(tǒng)計學意義(P0.05)；用藥24周后較用藥前ESR、CRP有統(tǒng)計學意義(P0.05), WBC、HCT、Hb、CDAI評分均無統(tǒng)計學意義(P0.05)；用藥48周后較用藥前ESR, CDAI評分、內(nèi)鏡下嚴重度分級(CGSCD)有統(tǒng)計學意義(P0.05), CRP、WBC計數(shù)、HCT、Hb無統(tǒng)計學意義(P0.05)；比較用藥前和用藥96周后的ESR、CRP、HCT、Hb、CDAI評分和內(nèi)鏡下嚴重度分級均有統(tǒng)計學意義(P0.05)。 7.80例IBD患者,總計有26例發(fā)生不良反應(yīng),其中20例UC,6例CD。2例CD患者因骨髓抑制停藥。 結(jié)論 1.AZA對UC患者的長期維持緩解及激素撤停率有明顯效果。 2.1mg/(kg.d)、2mg/(kg.d) AZA治療UC,療效并無明顯差異。 3.CD患者使用AZA可有效維持撤離激素后的長程緩解,減少復發(fā)率、減少激素的用量。 4.AZA能夠明顯改善UC和CD患者的黏膜愈合程度。 5.AZA用于IBD的不良反應(yīng)發(fā)生率較高,但嚴重不良反應(yīng)發(fā)生率低。
[Abstract]:The first part: the research on 489 cases of patients with inflammatory bowel disease clinical characteristics: Based on the retrospective study of the hospital
objective
Analysis of the past 10 years in our hospital in hospital patients with IBD including UC and CD in patients with clinical data, to understand the epidemiological and clinical characteristics of trends in our hospital within 10 years of IBD, clinical diagnosis and treatment guidance.
Method
Selected in the First Affiliated Hospital of Kunming Medical University 2004-2013 years diagnosed IBD patients as the research object, statistical analysis of patients with general information (gender, age), duration, clinical type, staging, grading, colonoscopy, cancer, pathological data and treatment (mainly drug treatment, medicine), extra intestinal manifestations retrospective analysis of clinical features and complications, and the diagnosis and treatment of these patients; patients with IBD A according to the time of admission, B two groups: A group (2004-2008), B group (2009-2013 years); then A, B two groups according to the types of diseases were divided into 4 subgroups, 1 patients (UC group A1 and B1 group), 2 patients with CD (A2 group and B2 group), compare the variation trend of the clinical characteristics of these 4 groups of patients.
Result
A total of 489 cases of 1.IBD patients, male 293 cases, female 196 cases, male to female ratio of 1.49:1.UC and CD were 425 cases and 64 cases, including 250 cases of male patients and female patients with 43 cases, 175 cases and 21 cases, male to female ratio of 1.43:1 and 2.05:1.UC in patients aged 4-72 years old, the median age was 44 years. UC patients 30-39 years of age in most.CD patients aged 12-75 years old, the median age was 38 years, 40-49 years of age the most.
2. in the past 10 years, A 65.9478X104 group, B group was 95.3908X10-4, increased 1.45 times in.A1 group and A2 group, UC:CD=10.9:1, 60.7717X104 and 5.5669X10-4 accounted for the average hospitalization; B1 group and B2 group, UC:CD=5.65:1, the average admission ratios were 95.7717X10-4 and 14.3934X10-4.CD grew faster than UC.
In 3.425 cases of UC disease in 3 to 30 years, an average of 3.8 years; 64 cases of CD patients in the first half of the year to 13 years, average 3.7 years. The course in less than 2 years the most.
99.1% 4.UC patients in the active stage, only 0.9% remained in remission; 20.2% mild, 41.6% moderate and 38.2% severe, 19.5%; type 44.7% left colon rectum, colon, 35.8% wide type; early 25.9% hair, 74.1% chronic relapsing.CD patients, 98.4% in the active stage, 1.6% in remission; 68.2% mild, 30.2% moderate and severe. 1.6%; Stenosis type 7.8%, perforating type 4.7%, type 87.5% non penetrating non stenosis; ileal colonic type 51.6%, type 32.8%, type 15.6%, ileocolon, digestive tract.
5.395 cases of UC patients received colonoscopy, 96.2% of which 92.4% mucosal congestion and edema, erosion or ulcer, 30.1% purulent exudation, 21.3% mucosa granular in 84 cases, 19.7% pseudopolyps and mucosal bridge, 7.8% lumen stenosis; 282 cases of UC patients underwent colonoscopy or surgical pathology, pathology showed 95.8% inflammatory cell infiltration, 33% cryptitis or crypt abscess, 8.5% granulation tissue hyperplasia, 4.6% atypical hyperplasia, 2.1% tubular adenoma or adenomatoid hyperplasia of.56 CD patients received colonoscopy and capsule endoscopy, 92.9% mucosal edema, 85.7% mucosa erosion or ulcer, 14.3% fractured ulcer, 10 cases of 27.9% inflammatory pseudopolyps, 3 cases of 5.4% fistula. 12.5% lumen stenosis or bowel deformation, 8.9% cobblestone like change, no dysplasia or adenomatous hyperplasia cases: 47 cases of patients with pathological examination, 97.9% lymphocyte aggregation, 29.7% wall inflammation, 25.5. Non caseous granuloma, 29.8% crack Lyriform ulcer.
With 6.UC there were 11.1% extra intestinal manifestations, including fatty liver 4.23%, 3.53% cholelithiasis, arthritis 1.9%, 0.7% oral ulcers, 0.7% rash; 3.1% complications, including 2.1% tubular adenoma or adenomatous hyperplasia, 0.9% gastrointestinal bleeding in patients with.CD 6.3% had extra intestinal manifestations, including 4.7% oral ulcers, 1.6% iritis; 17.2% had complications, 9.3% stricture, 4.7% fistula, 1.6% perianal abscess, acute perforation in 1.6%.
7.UC therapeutics to aminosalicylates, part of the joint use of corticosteroids and immunosuppressive agents used alone.23.8% aminosalicylates systemic or topical therapy; 58.3% amino acid preparations and hormone systemic or local therapy; 16.7% of the use of immune agents for the treatment of.425 patients with UC in remission, 40.4% clinical and 59.1% effective, 0.5% ineffective; surgical surgical treatment of 5 cases, 4 cases of remission, 1 cases died of infection.
8.CD the main use of aminosalicylates, alleviate the glucocorticoid and immunosuppressive treatment of.64 patients with CD 39.1% clinical, 59.3% effective treatment, 1 cases of death due to other reasons; 10.9% patients received surgical treatment.
9.A, B group of UC patients in gender, age had significant difference (P0.05); A B group, the duration of disease, disease stage, severity of disease, lesion site, no difference in extraintestinal symptoms and complications (P0.05).
10.A, B group of CD patients in gender, age of diagnosis, average age, illness behavior and complications difference (P0.05); A B group, the duration of disease, disease stage, severity of disease, no significant difference between the involved area and extraintestinal symptoms (P0.05).
conclusion
The number of hospitalized patients with 1.IBD increased year by year, admission proportion has increased gradually, CD growth is particularly significant.
The median age of 2.UC and CD were respectively 44 and 38, respectively in 30-39 and 40-49 years old age the most common than western countries.
3.UC and CD of male and female prevalence ratio were 1.43:1 and 2.05:1, the male was higher than female. Male IBD patients and nearly 5 years increased significantly, the proportion of female patients with relative decline.
4.UC and CD are the most common disease in less than 2 years.
Most of 5.UC patients in the active stage, with moderate to severe disease, type of chronic recurrent type, the affected area of left colon type accounted for the largest proportion of hospitalized patients suffering from CD; most of the active phase and that mild to moderate, the affected area in the colon than that in non stenosis disease behavior nonpenetrated type. For nearly 5 years. The course of disease in patients with IBD disease stage, length, severity, overall extraintestinal manifestations and complications involved area on the whole is no obvious changes of.UC and CD showed a low incidence rate.
6.IBD has a variety of clinical manifestations, histological examination and pathological examination is an important means of diagnosis, patients in this study although no cancer cases, it has been found that the atypical hyperplasia and adenomatous hyperplasia cases, the need to strengthen its endoscopic monitoring, to further improve the follow-up system, improve the detection rate of early cancer.
Therapeutic effect of 7.UC and CD medical, surgical rates reported at home and abroad.
The second part: the study of azathioprine in the treatment of inflammatory bowel disease
objective
To observe the efficacy and safety of IBD patients in our hospital using AZA.
Method
The collection of active IBD patients administered with AZA and glucocorticoid therapy, hormone withdrawal after AZA maintenance treatment, clinical follow-up in 12,24,48,96 weeks, healing of mucosa and adverse reaction under endoscope.
Result
1. patients with IBD, a total of 80 cases, 60 cases of UC, 20 cases of CD.UC total of 60 patients completed 96 weeks of follow-up 30 patients completed 48 weeks of follow-up of 40 cases, 50 cases were followed up for 24 weeks to complete, completed 12 weeks of follow-up of 52 cases, 2 cases of exit (due to stop the drug withdrawal), 12 cases were lost CD; a total of 20 patients completed 96 weeks of follow-up 6 patients completed 48 weeks of follow-up of 12 cases, 18 cases completed 24 weeks, 12 weeks follow-up in 12 cases, 2 cases were lost.
2.AZA for UC12 weeks, 24 weeks, 48 weeks, 96 weeks, the total effective rate is 84.7%, 83.3%, 80%, 86.7%; the remission rate were 11.5%, 20.8%, 55%, 12 weeks of 53.4%.AZA treatment with 30 cases of steroid and steroid withdrawal rate of 65.4%.AZA after 48 week in 40 cases with AZA, 4 cases a total of 4 times of recurrence, the recurrence rate was 10%; for the full 96 weeks of the 30 cases, 12 cases of recurrence, the recurrence rate of 40%. endoscopic mucosal healing rate of 48 weeks after medication for 96 weeks, 70%, 66.7%.
3.AZA for CD12 weeks, 24 weeks, 48 weeks, 96 weeks were 80%, 88.9%, 100%, 100%; 77.8%, response rate was 70%, 75%, 12 weeks of 66.7%.AZA treatment with 16 cases of steroid and steroid withdrawal rate of 88.9%.AZA after 48 weeks in 12 cases, 2 cases of recurrence, the recurrence rate was 16.7%; over 96 weeks in 6 cases, 1 cases of recurrence, the recurrence rate was 48 weeks after 16.7%. treatment, 8 cases showed normal colonoscopy, 2 cases of mild, 2 moderate cases, mucosal healing rate was 66.7%; 96 weeks after treatment, 6 cases of normal mucosa under endoscopy, mucosal healing rate was 100%.
12 weeks of treatment with AZA in patients with 4.UC, 24 weeks after medication, ESR, CRP, WBC were not statistically significant (P0.05), there was statistical significance in Truelove and Witts UC (P0.05); contrast index after 48 weeks of treatment compared with before treatment ESR, CRP and Sutherland score, endoscopic Mayo score was statistically significant, and Truelove the Witts UC index (P0.05); after 96 weeks of treatment compared with before treatment Sutherland score, Truelove and Witts UC index were statistically significant (P0.05).
AZA 5.UC patients treated with different doses of the 2mg/kg group and the 1mg/kg in WBC, ESR, CRP and Sutherland score, Mayo score and endoscopic mucosal healing, clinical effect comparison was not statistically significant (P0.05).
12 weeks of treatment with AZA in patients with 6.CD after ESR compared with before treatment, CRP, WBC, HCT, Hb, CDAI scores were not statistically significant (P0.05); after 24 weeks of treatment compared with before treatment ESR and CRP had statistical significance (P0.05), WBC, HCT, Hb, CDAI scores were not statistically significant (P0.05); after 48 weeks of treatment compared with before treatment ESR, CDAI score, severity of endoscopic (CGSCD) had statistical significance (P0.05), CRP, HCT, WBC count, Hb had no statistical significance (P0.05); compared with before treatment and after 96 weeks of treatment, ESR, CRP, HCT, Hb, CDAI score and endoscopic the severity grading had statistical significance (P0.05).
7.80 cases of IBD patients, a total of 26 cases of adverse reactions, including 20 cases of UC, 6 cases of CD.2 CD patients with bone marrow suppression withdrawal.
conclusion
1.AZA of UC patients to maintain long-term remission and steroid withdrawal rate have obvious effect.
2.1mg/ (kg.d), 2mg/ (kg.d) AZA in the treatment of UC, no significant difference in efficacy.
The use of AZA can effectively maintain the evacuation after long term hormone remission 3.CD patients, reduce the recurrence rate, reduce the amount of hormones.
4.AZA can significantly improve UC and CD patients, healing of mucosa.
5.AZA for the adverse reaction rate of IBD is higher, but the occurrence of severe adverse reaction rate is low.

【學位授予單位】：昆明醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R574

【參考文獻】

相關(guān)期刊論文 前9條

1 鄒開芳;楊杰;丁炎波;;炎癥性腸病內(nèi)鏡診斷標準及評估[J];臨床消化病雜志;2006年03期

2 ;An analysis of 10218 ulcerative colitis cases in China[J];World Journal of Gastroenterology;2002年01期

3 Abdullah S.AI-Ghamdi;Ibrahim A.AI-Mofleh;Rashed S.AIRashed;Saleh M.AI-Amri;Abdulrahman M.Aljebreen;Reda EI-Badawi;Arthur C.Isnani;;Epidemiology and outcome of Crohn's disease in a teaching hospital in Riyadh[J];World Journal of Gastroenterology;2004年09期

4 Gert De Hertogh;Jeroen Aerssens;Karen P Geboes;Karel Geboes;;Evidence for the involvement of infectious agents in the pathogenesis of Crohn's disease[J];World Journal of Gastroenterology;2008年06期

5 Juan Luis Mendoza;Raquel Lana;Manuel Díaz-Rubio;;Mycobacterium avium subspecies paratuberculosis and its relationship with Crohn's disease[J];World Journal of Gastroenterology;2009年04期

6 Francesca Fava;Silvio Danese;;Intestinal microbiota in inflammatory bowel disease:Friend of foe?[J];World Journal of Gastroenterology;2011年05期

7 冉志華;;炎癥性腸病診斷與治療的共識意見(2012年·廣州)克羅恩病診斷的部分解讀[J];胃腸病學;2012年12期

8 朱維銘;;炎癥性腸病的手術(shù)時機[J];胃腸病學;2012年12期

9 Pascal Frei;Luc Biedermann;Ole Haagen Nielsen;Gerhard Rogler;;Use of thiopurines in inflammatory bowel disease[J];World Journal of Gastroenterology;2013年07期

，

本文編號：1633833