70岁以上确诊为克罗恩病患者的疾病自然史： 一项基于人群的队列研究

来源：医学界消化频道

翻译：林江   上海中医药大学附属龙华医院消化科

Marhurin Fumery，et al.  Inflamm Bowel Dis 2016;0:1-10

前言：与年轻发病者相比，老年发病（确诊时年龄>60岁）的克罗恩病（CD）患者的预后似乎较好。本研究的目的是比较EPIMAD人群注册研究中确诊时年龄≥70岁CD患者和年龄介于60-70岁CD患者的疾病自然史。

方法：从1988年1月至2006年12月共有370例老年发病的CD患者被确认。其中188例（63%）在确诊时年龄≥70岁。记录患者被确诊时的临床表现、病变部位和疾病行为，以及随访中的疾病自然史、手术和用药情况。确诊时年龄≥70岁者，随访时间的中位数为4.5年（1.1；8.3）。确诊时年龄介于60-70岁者，随访时间的中位数是7.8年（3.3；12.1）。

结果：确诊时年龄≥70岁者的发病率为2.3/100,000，而确诊时年龄介于60-70岁者的发病率为2.6/100,000。确诊时年龄≥70岁组中男性的比例低于60-70岁组（31% vs 45%，P=0.006）。两组确诊时的临床表现是相似的。无论是在确诊时还是在随访结束时，单纯结肠病变（L2）均在≥70岁组中更为常见，与60-70岁组相比分别为73% vs 57%（P=0.004）和70% vs 47%（P<0.0001）。病变范围扩大（从L1或L2进展到L3）在两组间无显著性差异（HR=2.0[0.9；4.5]，P=0.09）。无论是在确诊时还是在随访结束时，两组最常见的疾病行为是炎症，分别为75% vs 80%（P=0.43）和69% vs 70%（P=0.55）。两组在使用5-氨基水杨酸（P=0.72）、口服糖皮质激素（P=0.83）和抗肿瘤坏死因子（P=0.37）等方面均无显著性差异。然而在≥70岁组中免疫抑制剂的使用率明显低于60-69岁组（HR=2.1[1.3;3.5]，P=0.003）。两组实施外科手术的几率是相似的（P=0.72）。确诊时的肠外表现与疾病进展为B2或B3（HR=7.2[1.0;7.0]，P=0.045）、免疫抑制剂（HR=2.9[1.4;6.0]，P=0.006）和糖皮质激素（HR=3.3[1.8;6.1]，P<0.0001）的使用显著相关。

结论：70岁以上确诊为CD患者的疾病自然史的特点是病情轻，较少发生病变范围扩大，B2或B3的发生率低。在确定治疗方案时应将此考虑在内。

Abstract

Introduction:Elderly onset (.60 yrs at diagnosis) Crohn’s disease (CD) seems to be associated with a better outcome than when diagnosed earlier in life. The aim of this study was to compare the natural history of patients with CD older than 70 years at diagnosis with that of elderly patients diagnosed between 60 and 70 years in the EPIMAD population-based registry. Methods:Three hundred seventy patients with elderly onset CD diagnosed between January 1988 and December 2006 were identified. Among them, 188 (63%) were older than 70 years at diagnosis ($70 yrs). Clinical presentation, disease location, and behavior at diagnosis and also natural history, surgery needs, and drug exposure were recorded, with a median follow-up of 4.5 years (1.1; 8.3) in CD diagnosed after 70 years and of 7.8 years (3.3; 12.1) in CD diagnosed between 60 and 70 years, respectively. Results:CD incidence in elderly patients diagnosed$70 years was 2.3/100,000 inhabitants, compared with 2.6/100,000 in elderly patients diagnosed below the age of 70 (60–69 yrs). The proportion of males was lower in patients$70 years than in patients aged 60 to 69 (31% versus 45%,P?0.006). Clinical presentation

at diagnosis was similar in both groups. Pure colonic location (L2) was more frequent among patients.70 years both at diagnosis (73% versus 57%,P?0.004) and maximal follow-up (70% versus 47%,P,0.0001). Disease extension (from L1 or L2 to L3) was not significantly different among patients.70 years and patients aged 60 to 69 years (hazard ratio [HR]?2.0 [0.9; 4.5] for 60 to 69 yrs,P?0.09). The most frequent behavior in the 2 groups was inflammatory, both at diagnosis (75% versus 80%,P?0.43) and at maximal follow-up (69% versus 70%,P?0.55). There was no significant difference in patients.70 years compared

with patients aged 60 to 69 years regardingtreatment with 5-aminosalicylic acid (P?0.72), oral corticosteroids (P?0.83), and anti–tumor necrosis factor therapies (P?0.37). However, the use of immunosuppressants was significantly less frequent in patients.70 years (HR?2.1 [1.3; 3.5] for 60 to 69 yrs,P?0.003). Risk of surgery was similar in both groups (P?0.72). Extraintestinal manifestations at diagnosis were significantly associated with an evolution to complicated behavior (HR ?2.7 [1.0; 7.0],P?0.045), immunosuppressant treatment (HR?2.9 [1.4; 6.0],P?0.006), and corticosteroid use (HR?3.3 [1.8; 6.1],P,0.0001). Conclusions:The natural history of CD in elderly patients diagnosed over the age of 70 is mild with low disease extension and complicated behavior. This needs to be taken into account when establishing therapeutic strategies.

作者简介：

林江，医学博士，主任医师，上海中医药大学附属龙华医院消化科主任，博士生导师。中国医师协会中西医结合学会消化病分会常务委员，中国医师协会肛肠医师分会委员，中华中医药学会脾胃病分会委员，上海中西医结合学会消化病分会副主任委员，上海中医药学会脾胃病分会常务委员。

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