末端回肠炎在溃疡性结肠炎患者中有何临床意义？

我们认为末端回肠炎可能是非活动或轻度活动UC的一个主要结肠外表现，临床医生不能凭借末端回肠炎的表现排除UC的诊断。

来源：医学界消化频道（CCCF—IBD学习驿站出品）

翻译及评述：浙江中医药大学第一附属医院  郭梦舟 范一宏

背景：溃疡性结肠炎（UC）病变通常多局限于结肠。目前还没有关于轻度或不活跃UC患者末端回肠炎的研究报道。这篇前瞻性研究的目的就是为了阐明在内镜监测项目中的UC患者末端回肠炎的患病率及其临床意义。

方法：这项研究共纳入了72例UC患者及90例健康对照人群，分别进行了结肠镜筛查及。末端回肠炎（UC组及对照组）和结肠炎（UC组）的内镜及组织学特征按照标准化方式进行评估，对合并末端回肠炎及不合并末端回肠炎的UC患者进行比较分析（均有受试者详实的临床和内镜资料）。

结果：72例UC患者中16例（22%）合并末端回肠炎，90例非UC对照组中只有4例（4%）合并末端回肠炎（P＜0.001）。没有一个患者具有反流的特征。在UC患者中，末端回肠炎的存在呈现出与疾病严重程度正相关的趋势，但与回盲瓣的结肠侧受累存在明显相关性（P=0.02）。结肠镜检查前一周的酒精史也与末端回肠炎存在明显相关性（P=0.02）。其他资料没有显现出与UC患者末端回肠炎存在相关性。只有1例合并末端回肠炎的UC患者在随访中发展为克罗恩病。

结论：UC患者的末端回肠炎可能是非活动或轻度活动UC的一个主要结肠外表现，并不是由于反流造成的。

述评：

溃疡性结肠炎是一种主要累及结肠粘膜的炎症性疾病，少数可出现10 cm以内的“反流性回肠炎”。在非溃疡性结肠炎患者中，有许多潜在的原因造成回肠末端炎，包括CD、感染、缺血、药物毒性、肠道准备的影响。而在溃疡性结肠炎患者中，回肠末端炎的出现往往被认为是严重的广泛结肠炎导致反流所致，轻中度的回肠末端炎症的发生率、程度和炎症类型研究很少。假设反流性回肠炎是由炎症诱发的回盲瓣（ICV）功能失调，允许结肠内容物反流到远端回肠，故被推测回肠末端炎症是同结肠炎症相关。基于这一理论，炎症反应需要严重到足以引起ICV功能紊乱，因此，猜测回肠末端炎应该出现在严重溃疡性结肠炎（包括盲肠和回盲瓣区域）的患者。已有几篇关于反流性的回肠炎论文报导。然而，这些主要都是基于难治性溃疡性结肠炎进行手术切除的标本上发现的。轻度或不活跃UC与回肠末端炎的关系的研究很少。

本研究发现UC患者的末端回肠炎可能是非活动或轻度活动UC的一个主要结肠外表现，与反流、人口学特征、NSAID药物的使用、吸烟史、UC治疗药物的种类、肠道准备药物及肠道感染无关，且末端回肠炎的存在呈现出与疾病严重程度正相关的趋势。本研究报道的UC患者合并末端回肠炎的比例（22%）与Yamamota的报道（24%）相似，Yamamota也发现非反流性的UC合并末端回肠炎患者较不合并回肠炎患者呈现出更大的病变范围及更多的肠外表现，进一步支持了末端回肠炎是潜在的UC结肠外表现的假说，但Yamamota的纳入人群多为中至重度活动性UC（64%）。有趣的是，该研究发现末端回肠炎与结肠镜检查前一周的酒精史存在明显相关性，但因为样本量太少无法对酒精摄取量、频率及种类与回肠炎的关系进行进一步分析。基于以上分析，我们认为末端回肠炎可能是非活动或轻度活动UC的一个主要结肠外表现，临床医生不能凭借末端回肠炎的表现排除UC的诊断。当然，本研究仍存在许多局限性，如①样本量太少②纳入的UC局限，为轻度或非活动性，无法推广至所有UC患者③结肠镜检查前一周的酒精使用史与末端回肠炎的关系仍待进一步阐明。我们期待更大样本量的随机对照研究进一步论证本研究的观点。

Matthew J. Hamilton, et.al. Prospective Evaluation of Terminal Ileitis in a Surveillance Population of Patients with Ulcerative Colitis. Inflammatory Bowel Diseases 2016;22:2448–2455

Abstract

Background: Ulcerative colitis (UC) is a disease that is normally limited to involvement of the colon. Terminal ileitis in patients with UC with only inactive or mildly active disease has never been investigated. The aim of this prospective study was to determine the prevalence and significance of ileitis among patients with UC enrolled in an endoscopic surveillance program.

Methods: The study consisted of 72 patients with UC and 90 healthy controls who underwent surveillance and screening colonoscopy, respectively. The endoscopic and histologic features of the terminal ileum (both groups) and colon (UC group only) were evaluated in a standardized fashion. Extensive clinical and endoscopic information was obtained from the subjects, and these data were compared between patients with UC either with or without ileitis.

Results: Sixteen of 72 patients with UC (22%) had ileitis compared to only 4 of 90 (4%) of the non-UC controls (P , 0.001). None of the patients had features of backwash. Among patients with UC, the presence of ileitis showed a trend towards correlation with extent of disease, but a significant association with involvement of the colonic side of the ileocecal valve (P ¼ 0.02) was noted. Alcohol use in the week before the colonoscopy was also significant (P ¼ 0.02). There were no other features that were significantly related to ileitis in the patients with UC. Only one UC case with ileitis developed Crohn’s disease on follow-up.

Conclusions: Ileitis in patients with UC may represent a primary extracolonic manifestation of UC in patients with inactive or mild disease and is not due to backwash.

参考文献

1. Dilauro S, Crum-Cianflone NF. Ileitis: when it is not Crohn’s disease. Curr Gastroenterol Rep. 2010;12:249–258.

2. Goldstein N, Dulai M. Contemporary morphologic definition of backwash ileitis in ulcerative colitis and features that distinguish it from Crohn disease. Am J Clin Pathol. 2006;126:365–376.

3. Guindi M, Riddell RH. Indeterminate colitis. J Clin Pathol. 2004;57:1233–1244.

4. Glotzer DJ, Gardner RC, Goldman H, et al. Comparative features and course of ulcerative and granulomatous colitis. N Engl J Med. 1970;282:582–587.

5. Lumb G, Protheroe RH. Ulcerative colitis; a pathologic study of 152 surgical specimens. Gastroenterology. 1958;34:381–407.

6. McCready FJ, Bargen JA, Dockerty MB, et al. Involvement of the ileum in chronic ulcerative colitis. N Engl J Med. 1949;240:119–127.

7. Saltzstein SL, Rosenberg BF. Ulcerative colitis of the ileum, and regional enteritis of the colon. A comparative histopathologic study. Am J Clin Pathol. 1963;40:610–623.

8. Haskell H, Andrews CW Jr, Reddy SI, et al. Pathologic features and clinical significance of “backwash” ileitis in ulcerative colitis. Am J Surg Pathol. 2005;29:1472–1481.

9. Leighton JA, Shen B, Baron TH, et al. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. 2006;63:558–565.

10. Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005;353:2462–2476.

11. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546–557.

12. Yamamoto T, Maruyama Y, Umegae S, et al. Mucosal inflammation in the terminal ileum of ulcerative colitis patients: endoscopic findings and cytokine profiles. Dig Liver Dis. 2008;40:253–259.

13. McHugh JB, Appelman HD, McKenna BJ. The diagnostic value of endoscopic terminal ileum biopsies. Am J Gastroenterol. 2007;102:1084–1089.

14. Arrossi AV, Kariv Y, Bronner MP, et al. Backwash ileitis does not affect pouch outcome in patients with ulcerative colitis with restorative proctocolectomy. Clin Gastroenterol Hepatol. 2011;9:981–988.

15. Lin J, McKenna BJ, Appelman HD. Morphologic findings in upper gastrointestinal biopsies of patients with ulcerative colitis: a controlled study. Am J Surg Pathol. 2010;34:1672–1677.

16. Valdez R, Appelman HD, Bronner MP, et al. Diffuse duodenitis associated with ulcerative colitis. Am J Surg Pathol. 2000;24:1407–1413.

17. Knobler H, Ligumsky M, Okon E, et al. Pouch ileitis—recurrence of the inflammatory bowel disease in the ileal reservoir. Am J Gastroenterol. 1986;81:199–201.

18. Bode C, Bode JC. Effect of alcohol consumption on the gut. Best Pract Res Clin Gastroenterol. 2003;17:575–592.

19. Bode JC, Bode C, Heidelbach R, et al. Jejunal microflora in patients with chronic alcohol abuse. Hepatogastroenterology. 1984;31:30–34.

20. Beck IT, Dinda PK. Acute exposure of small intestine to ethanol: effects on morphology and function. Dig Dis Sci. 1981;26:817–838.

21. Bjarnason I, Peters TJ, Wise RJ. The leaky gut of alcoholism: possible route of entry for toxic compounds. Lancet. 1984;1:179–182.

22. Lengeling RW, Mitros FA, Brennan JA, et al. Ulcerative ileitis encountered at ileo-colonoscopy: likely role of nonsteroidal agents. Clin Gastroenterol Hepatol. 2003;1:160–169.

23. Rejchrt S, Bures J, Siroky M, et al. A prospective, observational study of colonic mucosal abnormalities associated with orally administered sodium phosphate for colon cleansing before colonoscopy. Gastrointest Endosc. 2004;59:651–654.

作者简介：

郭梦舟，医学硕士，浙江中医药大学第一附属医院，住院医师，毕业于复旦大学上海医学院，曾获第十二届挑战杯大学生课外学术科技作品竞赛全国三等奖及江西省三好学生、复旦大学优秀毕业生等荣誉称号，以第一作者发表SCI论文2篇，中文核心综述一篇。

范一宏，浙江中医药大学附属第一医院消化科工作，医学硕士，主任医师、硕士生导师

中华医学会消化病分会炎症性肠病学组组员、中华医学会消化病分会心身疾病学组组员，中华医学会浙江省分会消化病分会委员，中华医学会浙江省分会炎症性肠病学组副组长，中国中西医结合学会大肠肛门病专业委员会炎症性肠病专家组委员，浙江省新世纪151第三层次人才，《世界华人消化杂志》编委。

研究方向：炎症性肠病和功能性胃肠病基础和临床研究。主持国基金、省基金各一项，完成省基金一项。

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