Inflammatory bowel disease of Digestive Disease Branch of Chinese medical association cooperation groupInflammatory bowel disease (IBD) is a
Inflammatory bowel disease of Digestive Disease Branch of Chinese medical association cooperation group
Inflammatory bowel disease (IBD) is a kind of unknown etiology of chronic non-specific inflammatory bowel disease, including ulcerative colitis and Crohn's disease (UC) (CD). The former is a kind of chronic inflammation disease mainly involving the colon mucosa and submucosa, since the scope of the distal colon, retrograde to proximal, even involving the whole colon and terminal ileum, showed a continuous distribution, the main clinical manifestations are diarrhea, abdominal pain and purulent stool. The latter is a chronic granulomatous inflammation, lesions can be parts of the gastrointestinal tract, the distal ileum and proximal colon, showed transmural inflammation, showed segmental distribution of non symmetry, and the main clinical manifestations were abdominal pain, diarrhea, anal fistula, disease etc.. Both can be combined with varying degrees of systemic symptoms. In 2006, since the establishment of the national IBD cooperation group, we have discussed the recommendations of the diagnosis and treatment guidelines in combination with the guidelines of foreign countries, and emphasized that the diagnosis and treatment norms should be advanced, scientific, practical and universal. According to the principle of evidence-based medicine, extensive search for evidence-based data, amended is critical, but China's current clinical data of high quality is not much, and for a vast country of these data is also very difficult to achieve by all the guidance effect, so in the discussion part except the citation data, more reference foreign countries have guidelines for the diagnosis and treatment and to solicit the opinions of experts, the criterion of diagnosis and treatment were further modified to form consensus draft. Report in Ji'nan in May this year, the Seventh National Academic Conference on digestive diseases finalized, are now announced as follows, for domestic reference. In the future, it is necessary to strengthen the collection of evidence based information, and modify the application in a timely manner, and constantly improve and update the contents of the specification, so that it can be further refined, strengthen the practicality and guidance.
Part 1 diagnostic and therapeutic criteria
1 clinical manifestations: persistent or recurrent episodes of diarrhea, mucus, pus and blood stool with systemic symptoms of abdominal pain, tenesmus and different degree. The course of disease is more than 4 to 6 weeks. Can have joint, skin, eyes, mouth and liver and gallbladder and other intestinal manifestations. 2 colonoscopy: lesions from the rectum, a continuous, diffuse distribution. FINDINGS: the mucosal vascular fuzzy texture, disordered or disappeared, hyperemia, edema, hemorrhage, brittle and purulent secretion, also common mucosal rough, with fine granule; the lesion was visible diffuse and multiple erosion or ulcer; the remission in patients with colonic pouch visible shallowing, or blunt disappear, pseudopolyps and bridge shaped mucosa.
3 barium enema examination: the main changes are as follows. The mucosa of chaos and (or) coarse granular changes; the intestinal serrated edges or burrs, the intestinal wall has multiple small filling defects; the bowel shortening, a lead pipe bag away. 4. The histological examination of the mucosa showed that there were different manifestations in active and remission stage. Activity: the lamina propria with diffuse chronic inflammatory cells, neutrophils, eosinophils infiltration; the crypt had acute inflammatory cell infiltration, especially between the epithelial cells of neutrophil infiltration and crypt inflammation, even crypt abscess formation, abscess can burst into the crypt epithelium membrane; the visible, goblet cells decreased; superficial mucosal erosion, ulcer formation and proliferation of granulation tissue. Remission: neutrophils disappeared, chronic inflammatory cells decreased; the crypt size, irregular shape, arranged in disorder; the glandular epithelium and muscularis mucosa gap widened; the Paneth cell metaplasia.
5 the pathological examination of the resected specimen showed that the UC features were observed in meat and histology.
In the exclusion of bacterial dysentery, amebic dysentery, chronic schistosomiasis, intestinal tuberculosis and other infectious colitis and colon CD, ischemic colitis, ulcerative colitis and other diseases on the basis, according to the following criteria. With the typical clinical manifestations were clinically suspected, for further examination. At the same time with the above first, 2, any of the 3 items, can be diagnosed as the disease. If combined with fourth or fifth of the pathological examination of the characteristics of the performance, it can be diagnosed. The primary cases, clinical manifestations and endoscopic changes are not typical, not to diagnose UC, but should be followed up for 3 to 6 months, to observe the attack. The colonoscopy found mild chronic rectosigmoid colitis is not the same as UC, should observe the condition changes, to find the cause.
Two, diagnostic content
A complete diagnosis should include the type of disease, severity, disease stage, extent of disease, and complications.
1 clinical types: can be divided into chronic relapsing, chronic persistent, fulminant and primary. No past history, onset to first attack; fulminant refers to severe symptoms, daily bloody stool 1O times, with systemic poisoning symptoms, with toxic megacolon, intestinal perforation, sepsis and other complications. In addition to fulminant type, each type can be transformed into each other.
2 clinical severity: mild, moderate and severe. Patients: mild diarrhea 4 times a day, no or slight hematochezia, fever, anemia or pulse rate, erythrocyte sedimentation rate normal. Severe diarrhea: more than 6 times a day, with clear mucus and blood stool, body temperature of 37.5 degrees, the pulse of > > 9O / min, hemoglobin (Hb) < 100 g / L, erythrocyte sedimentation rate > 30 mm / 1 h, with the Truelove index in Annex 1. Moderate: between mild and severe. Annex 1 Truelove and Witts UC indexing
3 disease stage: can be divided into active and remission period. South - erland disease activity index (DAD), also known as Mayo index, is relatively simple and practical, see table L. Chronic active or refractory UC refers to the failure to induce or maintain remission, usually with glucocorticoid resistance or
. The former refers to the amount of prednisolone applied for 4 weeks without remission for 3 months, the recurrence of prednisolone reduced to 10 mg / D is unable to control the attack or after withdrawal.
Table 1 Sutherland disease activity index
Note: the sum of the total < 2 is divided into symptom remission; from 3 to 5 is divided into mild activity; from 6 to 10 is divided into moderate activity; from 11 to
4 lesions: into the rectum, rectosigmoid colon, left colon (spleen, colon (Qu Yiyuan) wide, nearly the whole colon and splenic flexure).
5 intestinal manifestations and complications: the outside may have joints, skin, eyes, liver and gallbladder system involvement; complications can be bleeding, perforation, toxic megacolon and canceration.
Three, differential diagnosis
1 acute infectious colitis: a variety of bacterial infections, such as dysentery bacillus, Salmonella, Escherichia coli, Campylobacter jejuni and other bacteria, Jerson. Acute onset of fever, abdominal pain is more obvious, peripheral blood platelet does not increase, stool examination can be isolated from pathogenic bacteria, antibiotic treatment has good effect, usually in 4 weeks.
2: amebic enteritis disease mainly affects the right colon, also involving the left colon, colonic ulcer is deep, the edge of stealth, mostly between normal mucosa ulcer. Stool or colonoscopy from ulcer exudate examination found Entamoeba histolytica trophozoites or cysts. Serum anti amoebic antibody positive. Anti amoebic treatment.
3: a history of water contact of schistosomiasis, often with hepatosplenomegaly, stool examination can be found in schistosome eggs, hatching miracidium positive colonoscopy in the acute phase of visible mucosal brown granules, pathological examination or biopsy of mucosa pressed schistosome eggs. Immunological tests also help identify.
4: differential diagnosis of Crohn's disease described below.
5 colorectal cancer: more common in the middle age, the rectal examination can often touch the mass, colonoscopy and barium enema examination of the value of differential diagnosis, biopsy can be diagnosed. It should be noted that UC can also cause colon cancer.
6 irritable bowel syndrome: feces mucus but no pus, microscopic examination of normal colonoscopy without evidence of organic disease.
7 others: other infectious enteritis (such as intestinal tuberculosis, fungal enteritis, hemorrhagic enteritis, antibiotic associated colitis), ischemic colitis, radiation enteritis, allergic purpura, collagenous colitis, Behcet's disease, colon polyps, and colonic diverticulitis HIV infected with this disease should be differentiated from colitis. In addition, special attention should be paid to the symptoms of the lower gastrointestinal tract colonoscopy examination found that the light straight, sigmoid colitis and UC can not be the same, you need to carefully check the cause of the disease observed.
Four, diagnostic steps
The clinical manifestations of suspected UC, recommend the following diagnostic procedures.
1 in the history of attention to the course of disease: diarrhea abdominal pain in more than 4 to more than 6 weeks, should pay special attention to the recent history of intestinal infection, antibiotics and non steroidal anti-inflammatory drugs (NSAID) and other drug use, smoking cessation and stress factors.
2 training and stool: not less than 3 times, according to epidemiological characteristics do the relevant checks except amebic dysentery, schistosomiasis etc..
3 colonoscopy and biopsy: critically ill patients or patients with fulminant type can be delayed or only for direct, sigmoidoscopy.
4 barium enema examination: can be used as appropriate, severe patients are not recommended.
5 routine laboratory tests: such as blood, plasma protein, erythrocyte sedimentation rate, C reactive protein, plain abdominal radiograph, ultrasound is helpful to determine the severity and activity of disease. The unit also has the condition for fecal calprotectin and lactoferrin detection, understand the inflammatory activity.
Five, diagnosis example
Ulcerative colitis in primary, moderate, active, straight sigmoid colon involvement.
Six, curative effect standard
1 complete remission: clinical symptoms disappeared, colonoscopy examination showed normal mucosa.
2 effective: the clinical symptoms disappeared, and the colonoscopic examination showed mild mucosal inflammation or false polyp formation.
3 invalid: after treatment, the clinical symptoms, endoscopic and pathological examination results did not improve.
1 clinical manifestations: recurrent chronic onset, lower right abdomen or periumbilical abdominal pain and diarrhea with abdominal mass, intestinal obstruction, intestinal fistula, anal lesions and recurrent oral ulcers, and fever, anemia, weight loss, growth retardation and other symptoms. Yang
Sex family history helps diagnose.
2 imaging examination: gastrointestinal barium contrast barium enema, if necessary. There were multiple, skip lesions, showed segmental inflammation with stiff, narrow, slit like ulcer, fistula, pseudopolyps and cobblestone like change etc.. Abdominal ultrasound, CT, MRI can show the thickening of the intestinal wall, abdominal or pelvic abscess, mass, etc..
3 colonoscopy: colonoscopy should be the terminal ileum. The segmental and non symmetry of the longitudinal or mucosal inflammation, aphthous ulcer, cobblestone like change, a narrowing of the lumen and intestinal wall stiffness. Capsule endoscopy is of great significance in the detection of small intestinal lesions, especially early lesions. Double balloon enteroscopy preferable biopsy diagnosis. If you have symptoms of upper gastrointestinal tract, endoscopy should be performed. Endoscopic ultrasonography is helpful in determining the extent and depth of abdominal mass or abscess.
4 histological examination: endoscopic biopsy should include inflammatory and non inflammatory areas, to determine whether the segmental distribution of inflammation; each lesion site take at least 2 tissues. The lesion is a typical change: non caseating granuloma; the aphthous ulcer; the fissure ulcer; the intrinsic membrane of chronic inflammatory cell infiltration, the bottom and submucosal lymphoid aggregates; the submucosa widened; the lymphatic dilatation; the ganglion; the crypt structure is mostly normal, goblet cells do not reduce. 5 specimens: visible bowel localized lesions, segmental lesions, cobblestone appearance, lumen stenosis, intestinal wall stiffness and other characteristics, in addition to the above microscopic lesions, lesions of intestine more visible tramural inflammation, intestinal edema, fibrosis and mesenteric fat wrapping and other changes, bureau of the Ministry of lymph node it can also have granuloma formation. In the exclusion of intestinal tuberculosis, amebic dysentery, Jerson bacteria infection chronic intestinal infection, intestinal lymphoma, diverticulitis, ischemic colitis, Behcet's disease and UC basis, according to the following criteria. The above-mentioned clinical manifestations were clinically suspected, for further examination. At the same time with the above first, 2, 3 characteristics, the clinical diagnosis of the disease can be diagnosed. If coupled with the pathological examination on fourth or fifth, and other non caseating granulomas was found a typical performance with or without granulomas above three typical histological changes, can be confirmed that clinical diagnosis, pathological diagnosis. The exclusion of these diseases, but also according to the WHO (WHO), 6 were diagnosed with the clinical diagnosis of X-ray and endoscopic and pathologic recommendations, see Annex 2, but because these conditions are difficult to meet the clinical diagnostic criteria, the application is limited. The primary cases, clinical and imaging or endoscopy and biopsy diagnosis is difficult to change, should be followed up for 3 ~ 6 months. As is the case with intestinal tuberculosis should be confused by intestinal tuberculosis diagnostic treatment for 4 ~ 8 weeks, observed. Ulcerative colitis diagnosis project Annex 2 WHO recommended: clinical, X-ray and endoscopic biopsy specimens.
Note: 1, with the second and the third is suspected; one plus four, five and six three can be confirmed; have the 4th items, plus 1, the second and the third of the three and two can be confirmed
Two, diagnostic content
After the establishment of CD diagnosis, the diagnosis should include the clinical type, severity (mobility, Yan Zhongdu), the scope of the lesion, the extra intestinal manifestations and complications.
1 clinical types: reference to the main clinical manifestations of disease type. According to the classification of disease behavior in the 2005 World Congress of Gastroenterology (CD) in Montreal, it can be divided into three types: stenosis, perforating and non stenotic non penetrating (inflammatory response). Each type can be crossed or transformed into each other.
2 severity: severity and activity were associated with the severity of CD, often in combination. The severity of CD can refer to the clinical manifestations, no systemic symptoms, abdominal tenderness, block and obstruction were mild; obvious abdominal pain, diarrhea and systemic symptoms and complications were severe; between the moderate. CD activity index (CDAI) can correctly estimate the disease and evaluate the clinical efficacy of Harvey and Bradshow standard (simplified CDAI) is more simple and practical, see table 2.
Table 2 simplified calculation of activity index for Crohn's disease
Item scores general conditions of abdominal pain, abdominal pain, abdominal pain, arthritis, arthritis, nodular
0: good; 1: a little worse; the poor: the poor; the poor; 4: 3: poor
0: No; 1: light; in the middle; 3: heavy: 2
Dilute stool 1 times a day to record 1 points
0: No; 1: 2: 3 suspected; determination; with tenderness
Erythema, pyoderma gangrenosum, aphthous each symptom record 1 points
Fissure ulcer, fistula and abscess), new
Note: < 4 for remission; 5 ~ 8 for moderate activity period; more than 9 were divided into severe activity period
In addition to exacerbation and remission stage CD chronic active clinical conventional or refractory CD to induce or maintain remission failure, the same definition as the UC. Best's CDAI method is widely used in clinical and scientific research in the world, see Annex 3. According to 8 variables such as abdominal pain, diarrhea, abdominal mass, through the observation of the score of 1 weeks, multiplied by the weight of the provisions, to obtain their scores, and then calculate the integral. CDAI< 150 for the remission period, > for the active period of 150 ~ 219 between mild, moderate to, > 450 for severe.
Appendix 3 Best Crohn's disease activity index calculation method
Thinning times (1 weeks)
Abdominal pain duration (1 weeks total, 0 to 3)
General (1 weeks total.O ~ 4)
Extra intestinal manifestations and complications (1 item 1)
Opioid antidiarrheals (0, 1)
Abdominal mass (suspicious 2 points; positive for 5 points)
Hematocrit value (normal: 47, female: 42)
100 x (1 body weight)
Sum of scores
Note: the score is multiplied by the weight, the score value, the sum of the 8 scores for the total score.
Crohn's disease activity index < 150 for remission, > for the active period: between 150 ~ 220 was mild, from 221 to 45O was moderate, > 450 was severe. Hematocrit may refer to the Chinese standard: male 42, female 37.
3 pathological changes: the location of the lesion and the scope of the reference image and endoscopic findings, can be divided into small intestinal type, colon type. In addition, if other parts of the digestive tract are involved, it shall also be indicated. The range of involvement was > 100 cm was widespread.
4 the extraintestinal manifestations and complications: a mouth, eyes, joints, skin, urinary and hepatobiliary system involvement can be parenteral complications; intestinal obstruction, fistula, abscess or inflammatory mass, hemorrhage and intestinal perforation.
Three, differential diagnosis
Identification of 1.CD and intestinal tuberculosis: the first diagnosis of CD should be the elimination of intestinal tuberculosis. Intestinal tuberculosis in patients with previous or existing intestinal tuberculosis history, clinical manifestations of intestinal fistula, abdominal abscess and less anal lesions, endoscopic lesion segment was not obvious, as the ulcer is rampant, superficial and irregular. The histopathological features in differential diagnosis of the most valuable, the intestinal wall and mesenteric lymph nodes in large and dense and the fusion of caseous granuloma and acid fast bacilli staining is characteristic of intestinal tuberculosis, see Appendix 4. Antituberculous therapy should not be performed in addition to intestinal tuberculosis. Also for bacterial culture, serum antibody detection of Mycobacterium tuberculosis DNA tuberculosis or using specific primers for detection of PCR in.
Appendix 4 differential diagnosis of Crohn's disease and intestinal tuberculosis
The clinical features such as intestinal fistula, intestinal wall or organ abscess, perianal disease, activity of blood in the stool, intestinal perforation and other complications or recurrence after resection of lesions, should consider the CD.
Coupled with the other organ tuberculosis, blood adenosine deaminase (ADA) activity increased, should consider the intestinal tuberculosis. Pathological biopsy of CD can be seen as non caseous granuloma, fissure ulcer and lymphocyte aggregation. Bowel wall lesions of intestinal tuberculosis can be diagnosed as having a cheesy appearance
Submucosa, dead. Identification of patients with difficulty in the treatment of tuberculosis. There are surgical indications for surgical exploration, in addition to resection of pathological changes in the intestinal segment, but also take a number of mesenteric lymph nodes for pathological examination.
Differential diagnosis of 2.CD and Behcet's disease: diagnostic criteria recommended international research group of Behcet's disease. The recurrent oral ulcer in the past 12 months, the incidence of not less than 3257 ~ 6 times; the recurrent genital ulcer; the eye; the skin lesions; the skin prick test positive (sterile puncture needle into the forearm, 24 ~ 48 h > 2 mm aseptic erythematous nodules or pustules). Diagnosis need to add two other characteristics.
3 other differential disorders include: ischemic colitis, microscopic colitis, radioactive enteritis, bypass enteritis, drug-induced bowel disease (such as NASID), eosinophilic enteritis, malignant lymphoma and cancer. For some diseases that are difficult to identify with CD, close follow-up should be observed.
Identification of 4.UC and CD: UC and CD are not difficult to differentiate according to clinical manifestations, endoscopic and histological features. The former is clinical colonic diarrhea, often a bloody, stomatitis and abdominal block is rare; the latter is not diarrhea, often have abdominal pain and nutritional disorders, stomatitis, abdominal mass and anal lesions are common. Endoscopic and imaging, the former for rectal involvement, diffuse and superficial colitis; the latter in the ileum or colon rare lesions showed segmental transmural and non symmetry, the typical cobblestone visible changes, longitudinal ulcer and fissure etc.. Histologically, the diffuse mucosal or submucosal inflammation, with superficial submucosal erosion and ulcer; the latter granulomatous inflammation, showed segmental distribution or focal crypt structure change, proximal colon on characteristics. For inflammatory bowel disease are difficult to distinguish between UC and CD, a clinical diagnosis of type IBD (type unclassified IBDU) to observe the condition changes. The diagnosis of indeterminate colitis (indeterminate eoli - tis, IC) is often used in the absence of pathological examination. Neutrophil cytoplasmic antibody (ANCA) and Saccharomyces cerevisiae antibody (ASCA) detection can help to identify the two.
Four, diagnostic steps
The following diagnostic procedures are recommended for clinical suspicion of CD.
1: pay attention to the course of disease, history of abdominal pain, diarrhea in 4 ~ 6 weeks or more, should pay special attention to the history of tuberculosis, nosocomial infection, antibiotics and NSAID, medication history, smoking and stress factors, should also pay attention to the growth and nutritional status. Except for 2 of intestinal tuberculosis: chest X-ray, tuberculin (PPD) skin test and serum PPD antibody detection.
3 colonoscopy should enter the terminal ileum; small intestine air barium double contrast principle shall be conducted; endoscopy, capsule endoscopy and double balloon enteroscopy can be chosen.
4 abdominal ultrasound or CT, MRI examination for the diagnosis of intestinal wall and intestinal complications.
5 routine laboratory examination: stool and necessary etiological examination, blood routine, electrolytes, plasma protein, erythrocyte sedimentation rate, C reactive protein, abdominal plain film etc.. The unit also has the condition for fecal calprotectin and lactoferrin and A1 antitrypsin examination.
6 biopsy: pathological intestinal biopsy is helpful for diagnosis, should be more biopsy, if necessary, multiple biopsies.
Five, diagnosis example
CD, stenosis, moderate, active, involvement of the colon, perianal abscess.
Six, curative effect standard
1 clinical remission: after treatment, the clinical symptoms disappeared, and the X-ray or colonoscopy examination showed that the inflammatory reaction tended to be stable, or CDAI< 15O.
2 effective: after treatment, clinical symptoms, X-ray or colonoscopy inflammation reduced, or CDAI reduction of more than 7O.
3 invalid: after treatment, clinical symptoms, X-ray, endoscopy and pathology did not improve, or CDAI> 15O, to reduce the above indicators (such as CDAI increased by more than 7O for deterioration or recurrence).
The second part of the treatment recommendations
First, the principle of UC treatment
1 determine the diagnosis of UC: from the national conditions, emphasizing the various assignable cause serious exclusion of colitis; suspected cases according to UC treatment, further follow-up, but not recommended to glucocorticoid.
2 to master the principles of good grading, staging, treatment segment: as shown in the diagnostic criteria, classification refers to the severity of the disease, using different drugs and different treatment methods; staging refers to the disease is divided into acute and remission stage, active stage to control inflammation and relieve symptoms as the main target, remission should continue to maintain remission relapse prevention treatment; to determine the lesion segment to choose different methods of drug delivery, distal colitis can use local treatment, extensive colitis or extraintestinal manifestations in systemic therapy. Please refer to annex 5. The principle and method of treatment of ulcerative proctitis and distal colitis, local treatment is more important than oral medication.
Appendix 5 UC and CD treatment options
Classification of distal segment UC wide UC CD
Mild rectal administration or oral administration of 5-ASA
5 ASA; rectal administration GCS
Moderate rectal administration or oral administration of 5-ASA
5 ASA; rectal administration GCS
Severe oral or intravenous oral or intravenous
GCS rectal administration of GCS vein
Administration of GCS to CsA
Intractable oral or intravenous oral or intravenous
Administration of GCS to GCS plus
Add Aza or 6-MP Aza or 6-MP
Oral or rectal oral 5-ASA
Administration of 5 ASA orally Aza
Oral Aza or 6-MP or 6-MP
Oral 5 ASA, metronidazole
Oral Bud or ciprofloxacin
Oral GCS (Bud)
Aza or 6-MP
Oral or intravenous administration of GCS;
Subcutaneous or intravenous administration of MTX
Intravenous administration of infliximab
Intravenous administration of infliximab
Oral 5-ASA, metronidazole,
Aza or 6-MP
Oral antibiotics, Aza or
6-MP, intravenous infliximab
Note: 5-ASA: GCS: aminosalicylic acid; glucocorticoid; Aza: azathioprine;
6-MP:6- mercatopurine; cyclosporine A; CsA: Bud: MTX: Budesonide; methotrexate
3 reference to the course of disease and past treatment to determine the treatment of drugs, methods and course of treatment, as early as possible to control seizures, prevent recurrence.
4 pay attention to the complications of the disease in order to estimate the prognosis, determine the treatment end point, and choose the internal and surgical treatment. Pay attention to adverse reactions during drug treatment, adjust treatment at any time.
5 to determine the general situation in order to assess the prognosis and quality of life.
6 the principle of comprehensive and individualized treatment, including nutrition, support, psychology and symptomatic treatment; internal and surgical consultation to determine the limits of medical treatment and further treatment.
Two, medical treatment
The goal of treatment is to control the inflammation and relieve the symptoms as soon as possible.
(-) treatment of active phase
1 mild UC: can be used sulfasalazine (SASP) preparation, daily 3 ~ 4 g, sub El service; or with a considerable amount of one amino acid (5 ASA). SASP 1 g is equivalent to mesalazine with a g of 0.4 g, which is equivalent to mesalazine with mesalazine of about 0.36 g, and Oshala's equivalent of mesalazine to g of 1 g, at a rate of $1. The distribution of lesions in the distal colon can agree with the SASP or 5-ASA suppository 0.5 ~ 1 g, 2 times daily; 5-ASA enema 1 ~ 2 g or hydrocortisone sodium succinate enema
10O ~ 200 mg, 1 night retention enema; conditions available budesonide 2 mg retention enema, 1 times every night; or by Retention Enema with traditional Chinese medicine.
2: the moderate UC dose available aminosalicylates therapy, nonresponders or take appropriate dosage of glucocorticoid, commonly used prednisone 3O ~ 40 mg / D orally.
3 severe UC: severe UC lesions in a wide range of general conditions, the rapid development of disease changes, must be dealt with in time, the amount of medication, the treatment is as follows. The patients had not used oral corticosteroids, oral prednisone or prednisolone 4O ~ 60 mg / D, was 7 ~ 10 d, can be directly used for intravenous administration; corticosteroids, intravenous hydrocortisone should be 300 mg / D or methylprednisolone 48 mg / d. The application of parenteral broad-spectrum antibiotics to control the intestinal infection, such as nitro imidazole, quinolone agents, ampicillin or cephalosporins. Patients should rest in bed, appropriate infusion, electrolyte supplement. The amount of blood, Hb< 90 g / L and continuous bleeding should be considered blood transfusion. The malnutrition, serious illness available elements of diet, serious illness should be parenteral nutrition. The intravenous corticosteroid use 7 ~ 10 d can be considered invalid after CSA for 2 ~ 4 mg• kg • D intravenous infusion of 7 ~ 10 d; the inhibitory effect of drugs, immune renal toxicity and other adverse reactions, should be strictly monitoring the blood concentration. Therefore, comprehensive consideration of hospital monitoring conditions based on the proposition of the method in a medical center; refractory UC can also consider other immunosuppressants such as azathioprine, mercaptopurine (Aza) 6- (6-MP), dosage and usage of CD, or reference Pharmacopoeia and textbooks. The above treatment is invalid when conditions allow unit
Leukocyte ablation therapy. The above poor efficacy, should be timely and surgical consultation, determine the timing and method of colon resection. We used antispastic and antidiarrhoeal, to avoid induced toxic megacolon. The close monitoring of patients
Changes of vital signs and abdominal signs, early detection and treatment of complications.
(two) treatment in remission
In addition to the initial cases, mild symptoms of patients with chronic colitis after complete remission can be stopped, all patients should continue to maintain treatment after complete remission. The duration of maintenance therapy is inconclusive, and 6 months after remission should be maintained. It has been recognized that glucocorticoids do not maintain the therapeutic effect, and should be gradually reduced after the remission of symptoms, the transition to 5-ASA maintenance therapy. The maintenance treatment dose of SASP is generally controlled half of the attack, with 2 ~ 3 g / D, and oral folic acid. Can also be used to induce remission of the same dose of 5-ASA drugs. 6-MP or Aza may be used for the maintenance of the above drugs or the dependence on glucocorticoids.
(three) other treatment
5-ASA and immunosuppressive agents should be considered as a new biological therapeutic agent, such as anti tumor necrosis factor A (TNF-a) monoclonal antibody. Probiotics maintenance therapy. Have anti-inflammatory, anti diarrhea, mucosal protection, suppression of the immune response to drugs of traditional Chinese medicine, as an important part of replacement therapy, but the syndrome differentiation, proper selection, a variety of traditional Chinese medicine enema has certain curative effect preparation, but further according to the modern medical science principle. Attention should be paid to the education of patients in order to improve the treatment compliance, early identification of the disease and regular follow-up.
Three, surgical treatment
1 absolute indications: bleeding, perforation, clear or highly suspected cancer and histological findings of severe dysplasia or mass lesions of mild and moderate dysplasia.
2 relative indications: severe UC with toxic megacolon, intravenous medication ineffective; medical treatment of intractable symptoms, physical decline, in refractory cases of glucocorticoid resistance or dependence, replacement therapy; UC patients with pyoderma gangrenosum, hemolytic anemia and other parenteral complications.
Four, cancer monitoring
Of course 8 ~ 10 years of extensive colitis, ulcerative colitis and whole course of 3O ~ 40 years left colitis, proctosigmoiditis patients, UC patients with primary sclerosing cholangitis, should monitor colonoscopy with at least 2 years, 1 times, and multi site biopsy. To find the histological examination with dysplasia, more should be closely followed up for severe dysplasia confirmed by surgical treatment.
First, the principle of CD treatment
The goal of 1.CD therapy is to induce and maintain remission, prevent complications and improve the quality of life of patients with UC.
2 during the active period, the choice of the induction remission therapy is mainly based on the activity of the disease, the severity of the disease, the location of the lesion and the response and tolerance to the treatment. Treatment must be maintained during remission to prevent recurrence. Complications should be treated in time.
3 compared with UC, CD has the following characteristics: the severity of disease and the judgment of activity is not as clear as UC, the clinical remission is not consistent with the recovery of intestinal diseases, the treatment effect is not as good as UC, and the disease is complicated and changeable. Therefore, we must pay more attention to the observation and analysis of the disease, but also emphasize the principle of individualized treatment.
4 although a considerable number of patients with CD ultimately avoid surgical treatment, but the recurrence rate of CD is high, so the basic treatment of CD is still a medical treatment. The value and risk of surgery, as well as the extent of surgery, should be carefully evaluated during CD treatment in order to perform the most effective surgery at the right time.
5 all CD patients must quit smoking. Pay attention to the comprehensive application of nutritional support, symptomatic and psychological treatment.
6 patients with severe symptoms should be using the nutritional therapy, can drink with elemental diet or total parenteral nutrition induced remission, to help.
Two, medical treatment
The principle of CD treatment was similar to that of UC, and the treatment was slightly different. 5-ASA drugs should be selected according to the location of the lesion, the role of less than UC, immunosuppressive agents, antibiotics and biological treatment agents are more common, refer to annex 5.
(I) treatment of active period
1 colonic type CD: divided into mild, moderate and severe. Mild: oral adequate SASP or 5 ASA as initial treatment, the use of UC treatment. Conditional oral budesonide 9 mg / d. Moderate: corticosteroids were used as initial treatment with moderate UC. Also available with budesonide, infection with antibiotics, such as ciprofloxacin 500 ~ 1000 mg / D
(1O ~ 20 mg• kg • d) or metronidazole from 800 to 1200 mg / d. Not recommended for a 5 ASA. Severe: the first use of corticosteroids, the use of the same treatment with severe UC. Patients with early recurrence, hormone therapy, or hormone dependence should be treated with Aza l_5
2.5 mg• kg • d 1 or 6-MP = 1.5 mg• kg • D a. Those who cannot tolerate methotrexate (MTX) can be changed to 15 ~ 25 mg / week by intramuscular injection, or reference Pharmacopoeia and textbooks. This kind of medicine takes effect slowly, there is the risk of serious adverse reactions such as bone marrow suppression. The drug treatment is invalid or not tolerated with surgical treatment to assess conditions can use infliximab (infliximab) 5 - 10 mg / kg, the general static control seizures
Intravenous drip 3 times, also refer to the relevant literature.
2 colonic type CD: divided into mild, moderate and severe.
Light, moderate: can choose 5-ASA or SASP, SASP effective but more adverse reactions. Corticosteroids may be used at the beginning of treatment. Distal lesions can be supplemented with local treatment, drug and dose with UC.
Severe drug selection with severe colonic type CD.
3 small intestinal CD: divided into mild, moderate and severe.
Mild: ileal lesions can be controlled by adequate release of 5-ASA; extensive small bowel CD nutrition treatment as the main treatment.
Moderate and severe: the use of Glucocorticoid (budesonide best) and antibiotics, with Aza or 6-MP recommended, can not be tolerated can be changed to MTX. Nutritional support therapy as an important adjuvant treatment. The treatment fails, consider infliximab
4 other cases involving the stomach and duodenum: treatment with intestinal type CD, with a proton pump inhibitor; anal lesions, such as anal fistula when antibiotics as first-line therapy, Aza, 6-MP, infliximab has good effect on the activity of the disease, or with abscess, fistula and subcutaneous catheter; other parts form with the treatment of moderate and severe induction regimen is the same, can also be considered infliximab and surgical treatment, the specific program required It differs from man to man.
(two) treatment in remission
Stress smoking cessation. The first drug treatment achieved remission, 5-ASA can maintain remission, the same drug dosage and remission induction dose; frequent recurrence and serious illness in the use of glucocorticoid induced remission, should be added with Aza or 6-MP, Aza or 6-MP and continue to maintain remission in remission, intolerance can use small doses of MTX the use of infliximab induced remission; continue to maintain the recommended regular use of relief, but with other drugs such as immunosuppressive agents combined use. The above maintenance remission treatment time and UC the same, generally 3 to 5 years or even longer.
(three) other treatment
Based on the research progress of pathogenesis, there are a variety of immunosuppressive drugs, especially new biological therapeutic agents. Probiotics maintenance therapy. Have anti-inflammatory, anti diarrhea, mucosal protection, suppression of the immune response to drugs of traditional Chinese medicine, as an important part of replacement therapy, can be appropriately selected, syndrome differentiation, but the need for further scientific summary according to the principle of modern medicine. Attention should be paid to the education of patients in order to improve the treatment compliance, early identification of the disease and regular follow-up.
Three. Surgical treatment of CD and prevention of postoperative recurrence
(I) indication of operation
Surgical treatment is the final choice of CD treatment, which is suitable for the patients who have active medical treatment, but the condition is life-threatening or seriously affect the quality of life, and has complications (perforation, obstruction, abdominal abscess, etc.).
(two) prevention of postoperative recurrence
The recurrence rate of CD lesions after bowel resection is quite high. All patients were treated with medication to prevent recurrence. General selection of 5-ASA. Although it is effective, but the long-term use of antibiotics. High risk patients with relapse can be considered using Aza or 6-MP. Recommended use of preventive medicine in 2 weeks after the start, the duration of not less than 2 years. Looking for effective measures to prevent recurrence is still the focus of today's research.
Four, cancer monitoring
Intestinal CD inflammation may be associated with cancer, but does not occur in the colon; colon cancer risk of CD and UC were similar, the same monitoring method. Special statement: in this consensus opinion, the dosage of drugs and the course of treatment were cited in some foreign countries, and the Chinese should be especially careful in their use. It is recommended to accumulate experience to prevent the occurrence of adverse drug reactions.