克罗恩病合并肠瘘273例临床特征与预后分析
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摘要
目的分析克罗恩病(CD)合并肠瘘病人的临床特征及预后状况。方法回顾性分析2001年1月至2015年6月南京大学医学院附属金陵医院就诊的CD合并肠瘘的273例病人资料,分析其临床特征、肠瘘特点、临床用药方案及预后转归。结果 273例病人中,男女比为2.5:1;起病年龄为29(22,40)岁;确诊年龄为31(25,42)岁;起病至确诊的间隔时间为22(8,31)个月;最常见的首发症状分别为腹痛(78.0%)、腹泻(28.9%)及发热(26.0%);确诊时最常见的发病部位为末端回肠(56.8%);确诊时最常见的发病性质为穿透性病变(54.9%),其次为狭窄(42.1%)、无狭窄无穿孔(2.9%)及肛周病变(19.0%)。共并发肠瘘442例次,其中肠外瘘有327例次(73.9%),最常见的类型为回结肠吻合口瘘124例次(28.1%),肠内瘘有115例次(26.1%),其中肠膀胱瘘38例次(8.6%)。肠内(91.9%)及肠外(72.9%)营养联合柳氮磺胺吡啶(57.9%)及雷公藤多苷(48.0%)是治疗此类病人的最为常用的方法;共有227例(83.1%)病人行抗感染治疗,β-内酰胺类(77.6%)及硝基咪唑类(56.0%)是最常用药物。所有入选病人共接受外科手术625例次,确诊后1、3及5年的累积手术率分别为34.4%、59.0%及63.0%。共有9例(3.3%)病人在随访期间死亡,确诊后1、3、10年的累积存活率分别为98.5%、97.8%和96.7%。结论与西方及其他亚洲国家文献资料相比,该中心CD合并肠瘘病人在性别比、发病部位、手术率及死亡率等方面均存在一定差异,尚须继续进一步随访及深入研究。
ObjectiveTo analyze the clinical characteristics and prognosis of Crohn's patients with gastrointestinal fistulas.MethodsThe data of 273 patients with gastrointestinal fistulas who were registered in GI Fistula Center, Department of Surgery, Jinling Hospital from January 2001 to June 2015 were retrospectively reviewed and the clinical features,characteristics of gastrointestinal fistulas, medication plan and outcome of the patients were analyzed.ResultsThe ratio of male to female was 2.5:1.The mean onset age was 29(22,40)years. The mean diagnosis age was 31(25,42)years. The averageage between onset to diagnosis was22(8,31)months. The most common initial symptoms were abdominal pain(78.0%), diarrhea(28.9%) and fever(26.0%). The most common lesion locations were terminal ileum(56.8%). The most common behavior of disease were penetrating(54.9%), followed by stricturing(42.1%), inflammatory(2.9%) and perianal disease(19.0%). 442 patients developed GI, including intestinal cutaneous fistulas(73.9%) and intestinal fistulas(26.1%).The most type of intestinal cutaneousfistulas were ileocecal anastomotic fistula.The most type of intestinal fistulas were entero-vesical fistulas. Enteral nutrition(91.9%) and parenteralnutrition(72.9%) combined with sulfasalazine(57.9%) and tripterygium glycosides(48.0%) were the most commonly used drugs. A total of 227(83.1%)patientsreceived antibiotics due to infectious complications. Β-lactam(77.6%) and nitroimidazoles(56.0%) were the most common antibi-otics. All the patients had received 625 cases of operations. The cumulative operative rates of 1 year, 3 years and 5 years after diagnosis were 34.4%, 59.0%and 63.0%. 9(3.3%)patients died during the research.The cumulative survival rates were 98.5%, 97.8%,and 96.7% at 1 year, 3 years and 10 years after diagnosis.ConclusionCompared with the literature of western and other Asian countries, there are some differences in sex ratio, lesion locations, operative rates and mortality ratesamong Crohn's disease patients with GI fistula. Further followup and in-depth study are needed.
ObjectiveTo analyze the clinical characteristics and prognosis of Crohn's patients with gastrointestinal fistulas.MethodsThe data of 273 patients with gastrointestinal fistulas who were registered in GI Fistula Center, Department of Surgery, Jinling Hospital from January 2001 to June 2015 were retrospectively reviewed and the clinical features,characteristics of gastrointestinal fistulas, medication plan and outcome of the patients were analyzed.ResultsThe ratio of male to female was 2.5:1.The mean onset age was 29(22,40)years. The mean diagnosis age was 31(25,42)years. The averageage between onset to diagnosis was22(8,31)months. The most common initial symptoms were abdominal pain(78.0%), diarrhea(28.9%) and fever(26.0%). The most common lesion locations were terminal ileum(56.8%). The most common behavior of disease were penetrating(54.9%), followed by stricturing(42.1%), inflammatory(2.9%) and perianal disease(19.0%). 442 patients developed GI, including intestinal cutaneous fistulas(73.9%) and intestinal fistulas(26.1%).The most type of intestinal cutaneousfistulas were ileocecal anastomotic fistula.The most type of intestinal fistulas were entero-vesical fistulas. Enteral nutrition(91.9%) and parenteralnutrition(72.9%) combined with sulfasalazine(57.9%) and tripterygium glycosides(48.0%) were the most commonly used drugs. A total of 227(83.1%)patientsreceived antibiotics due to infectious complications. Β-lactam(77.6%) and nitroimidazoles(56.0%) were the most common antibi-otics. All the patients had received 625 cases of operations. The cumulative operative rates of 1 year, 3 years and 5 years after diagnosis were 34.4%, 59.0%and 63.0%. 9(3.3%)patients died during the research.The cumulative survival rates were 98.5%, 97.8%,and 96.7% at 1 year, 3 years and 10 years after diagnosis.ConclusionCompared with the literature of western and other Asian countries, there are some differences in sex ratio, lesion locations, operative rates and mortality ratesamong Crohn's disease patients with GI fistula. Further followup and in-depth study are needed.
引文
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[25]Weterman IT,Biemond I,Pena AS.Mortality and causes of death in Crohn's disease.Review of 50 years'experience in Leiden University Hospital[J].Gut,1990,31(12):1387-1390.
[2]Xavier RJ,Podolsky DK.Unravelling the pathogenesis of inflammatory bowel disease[J].Nature,2007,448(7152):427-434.
[3]Caprilli R,Gassull MA,Escher JC,et al.European evidence based consensus on the diagnosis and management of Crohn's disease:special situations[J].Gut,2006,55(suppl 1):i36-58.
[4]Van Assche G,Dignass A,Reinisch W,et al.The second European evidence-based Consensus on the diagnosis and management of Crohn's disease:Special situations[J].J Crohns Colitis2010,4(1):63-101.
[5]闫冬升,任建安,韩刚,等.肠内营养治疗CD并发管状外瘘探讨[J].中国实用外科杂志,2013,33(1):73-76.
[6]Bernstein CN,Fried M,Krabshuis JH,et al.World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010[J].Inflamm Bowel Dis,2010,16(1)112-124.
[7]Satsangi J,Silverberg MS,Vermeire S,et al.The Montreal classification of inflammatory bowel disease:controversies,consensus and implications[J].Gut,2006,55(6):749-753.
[8]Ye BD,Yang SK,Cho YK,et al.Clinical features and long-term prognosis of Crohn's disease in Korea[J].Scand J Gastroenterol2010,45(10):1178-1185.
[9]Yao T,Matsui T,Hiwatashi N.Crohn's disease in Japan:diagnostic criteria and epidemiology[J].Dis Colon Rectum,2000,43S85-593.
[10]Vind I,Riis L,Jess T,et al.Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County,2003-2005:a population-based study from the Danish Crohn colitis database[J].Am J Gastroenterol2006,101(16):1274-1282.
[11]Bernstein CN,Wajda A,Svenson LW,et al.The epidemiology of inflammatory bowel disease in Canada:a population-based study[J].Am J Gastroenterol,2006,101(7):1559-1568.
[12]Yang SK,Yun S,Kim JH,et al.Epidemiology of inflammatory bowel disease in the Songpa-Kangdong district,Seoul,Korea1986-2005:a KASID study[J].Inflamm Bowel Dis,2008,14(4):542-549.
[13]Leong RW,Lau JY,Sung JJ.The epidemiology and phenotype of Crohn's disease in the Chinese population[J].Inflamm Bowel Dis,2004,10(5):646-651.
[14]Bernell O,Lapidus A,Hellers G.Risk factors for surgery and postoperative recurrence in Crohn's disease[J].Ann Surg,2000,231(1):38-45.
[15]Tao QS,Ren JA,Li JS.Triptolide suppresses IL-1beta-induced chemokine and stromelysin-1 gene expression in human colonic subepithelial myofibroblasts[J].Acta Pharmacol Sin,2007,28(1):81-88.
[16]Ren J,Tao Q,Wang X,et al.Efficacy of T2 in active Crohn's disease:a prospective study report[J].Dig Dis Sci,2007,52(8):1790-1797.
[17]Zachos M,Tondeur M,Griffiths AM.Enteral nutritional therapy for induction of remission in Crohn's disease[J].Cochrane Database Syst Rev,2007(1):CD000542.
[18]Malchow H,Ewe K,Brandes JW,et al.European Cooperative Crohn's Disease Study(ECCDS):results of drug treatment[J].Gastroenterology,1984,86(2):249-266.
[19]Evaluation of drug treatment in mild hypertension:VA-NHLBIfeasibility trial.Plan and preliminary results of a two-year feasibility trial for a multicenter intervention study to evaluate the benefits versus the disadvantages of treating mild hypertension.Prepared for the Veterans Administration-National Heart,Lung,and Blood Institute Study Group for Evaluating Treatment in Mild Hypertension[J].Ann N Y Acad Sci,1978,304:267-292.
[20]Nielsen OH,Rogler G,Hahnloser D,et al.Diagnosis and management of fistulizing Crohn's disease[J].Nat Clin Pract Gastroenterol Hepatol,2009,6(2):92-106.
[21]Prantera C,Berto E,Scribano ML,et al.Use of antibiotics in the treatment of active Crohn's disease:experience with metronidazole and ciprofloxacin[J].Ital J Gastroenterol Hepatol,1998,30(6):602-606.
[22]Jakobovits J,Schuster MM.Metronidazole therapy for Crohn's disease and associated fistulae[J].Am J Gastroenterol,1984,79(7):533-540.
[23]Oriuchi T,Hiwatashi N,Kinouchi Y,et al.Clinical course and longterm prognosis of Japanese patients with Crohn's disease:predictive factors,rates of operation,and mortality[J].J Gastroenterol,2003,38(10):942-953.
[24]Solberg IC,Vatn MH,Hoie O,et al.Clinical course in Crohn's disease:results of a Norwegian population-based ten-year follow-up study[J].Clin Gastroenterol Hepatol,2007,5(12):1430-1438.
[25]Weterman IT,Biemond I,Pena AS.Mortality and causes of death in Crohn's disease.Review of 50 years'experience in Leiden University Hospital[J].Gut,1990,31(12):1387-1390.