六种肠道消化溃疡性疾病的内镜鉴别诊断

2019-07-08 李明松 CCMTV消化频道

结肠镜检查中,肠道溃疡性病变常见,包括回肠末端溃疡、回盲瓣溃疡和盲肠溃疡和结肠溃疡。常见的相关疾病有感染性肠炎、克罗恩病、溃疡性结肠炎、肠结核、肠型淋巴瘤、白塞病、缺血性肠炎和肠癌等。这些疾病虽然结肠镜下均以肠道溃疡为主,但其特点各不相同。今天我们就回顾学习一下临床容易混淆的克罗恩病、溃疡性结肠炎、肠结核、肠型淋巴瘤、白塞病、缺血性肠炎的结肠镜下特点及其病理学特征。

结肠镜检查中,肠道溃疡性病变常见,包括回肠末端溃疡、回盲瓣溃疡和盲肠溃疡和结肠溃疡。常见的相关疾病有感染性肠炎、克罗恩病溃疡性结肠炎、肠结核、肠型淋巴瘤、白塞病、缺血性肠炎和肠癌等。这些疾病虽然结肠镜下均以肠道溃疡为主,但其特点各不相同。今天我们就回顾学习一下临床容易混淆的克罗恩病溃疡性结肠炎、肠结核、肠型淋巴瘤、白塞病、缺血性肠炎的结肠镜下特点及其病理学特征。

01
克罗恩病

消化道症状明显,以腹痛及腹泻为主要表现,常有肠外表现。结肠镜下见病变呈节段性分布,典型形态为葡行性溃疡,沿肠系膜侧纵行分布,溃疡深大,边界清晰,有厚白苔,反复发作者可有卵石征。病理学为肠壁全层炎症(见下图1)。


图1  克罗恩病,结肠镜下溃疡及活检结果

02
溃疡性结肠炎

以腹痛及黏液血便为主要表现,病变呈弥漫性,主要侵犯直肠及乙状结肠,常有肠外表现。内镜下可见黏膜脆性增加,有广泛分布的细小糜烂灶及浅表溃疡(见图2)。


图2  克罗恩病,结肠镜下溃疡及活检结果

03
肠结核

常有肠外结核病史,多有结核中毒症状。结肠镜见溃疡好发于回盲部,溃疡深大,呈环形分布,溃疡周边增殖明显。病理见干酪样坏死(见图3)。


图3  肠结核,结肠镜及活检结果

04
肠型淋巴瘤

临床上以发热和贫血为常见表现。内镜下见溃疡多发于回盲部,溃疡孤立而深大,表面常覆污苔,周边增值反应明显。病理学见淋巴瘤细胞浸润(见图4)。


图4  肠型淋巴瘤,结肠镜及活检结果

05
肠型白塞病

起病隐匿,临床上以发热为常见表现,常伴有肠外表现,针刺试验阳性,免疫学检查常有异常。结肠镜下见溃疡多发于回盲部,溃疡孤立而深大,溃疡面常覆白苔,周边无明显增殖反应。病理学见中央小动脉栓塞性坏死(见图5)。


图5  肠型白塞病,结肠镜及活检结果

06
缺血性肠炎

以腹痛及血便为主要表现。常有高血压病或心血管疾病。腹部血管多普勒超声检查可见肠系膜血管供血不足。肠镜可见病变呈节段性分布,病变部分与正常肠段分界清楚,肠道呈弥漫性糜烂及溃疡(见图6)。


图6  呈节段性分布的弥漫性黏膜糜烂及溃疡

肠道溃疡性疾病发生机理各不相同,治疗各异,甚至完全相反。如克罗恩病和白塞病的发生与免疫功能过激相关,相应的治疗原则是抑制患者的免疫功能,但肠结核和肠型淋巴瘤则与免疫功能较低相关,相应的治疗原则是增强患者的免疫功能。如果未确诊就贸然进行治疗,则治疗方向可能完全相反,势必会导致病情恶化。

值得注意的是,虽然肠道溃疡性疾病各有其镜下的特点,但许多病例并不典型,即使多次结肠镜检查及活检有时也不能确诊。尤其是克罗恩病、肠结核、白塞病和肠型淋巴瘤这4种疾病,有时鉴别诊断非常困难,其确诊不仅需要结肠镜检查及活检,有时还需要结合肠外表现及特殊的实验室检查,甚至实验性治疗。

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    2020-08-18 1238d654m87暂无昵称

    0

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    2020-05-21 nymo
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    2019-07-10 184****9840

    学习了,谢谢分享。

    0

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    2019-07-09 phoebeyan520

    学习了

    0

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    2019-07-08 329523732

    不错

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