超声内镜在肠道溃疡性病变的诊断及鉴别诊断价值

发布时间：2018-05-11 11:33

本文选题：超声内镜 + 肠道溃疡　；参考：《南方医科大学》2014年硕士论文

【摘要】：研究背景与目的近年来随着国内内镜检查开展范围的扩大,具有腹痛、腹泻、便血等腹部症状的患者接受内镜检查的比率越来越高,可早期发现肠道病变诸如肠道溃疡,从而及早得到有效的治疗。肠道溃疡可由多种疾病导致,可通过各种方法确诊或排除。但仍有部分疾病因各方面表现相似之处较多而难以相互鉴别,其中克罗恩病、肠道淋巴瘤、肠道结核有较大的鉴别难度。克罗恩病(Crohn's disease, CD)是一种病因尚未完全清楚的慢性非特异肠道炎性疾病,近年来在我国已成为消化系统的常见病。该病临床特点为：全肠道累及,病程呈发作与缓解交替,并可有多种肠外并发症。常见于青少年。内镜下表现为节段性、非对称性分布的粘膜炎症,可有纵行或阿弗他溃疡,溃疡间粘膜可呈正常表现或呈鹅卵石样增生,亦可见瘘管、脓肿、肠狭窄等并发症。因该病临床表现的多样化,现仍未确定诊断金标准,需结合各种临床资料才能确诊,故该病在我国诊治率较低。原发性肠道淋巴瘤(Lymphoma, L)起源于肠壁粘膜下层的淋巴组织,可向肠腔内破溃形成肠道溃疡,肠壁周围淋巴结肿大,以及形成局部肿块。亦可出现全身转移,造成发热、消瘦、盗汗等全身症状甚至恶病质。结直肠是原发性胃肠道淋巴瘤较罕见的发病部位。本病内镜下的溃疡型多表现为大小不等、形状不规则的多发溃疡,部位不定,缺乏特异性。钳夹活检则难以取到病变组织,且多数结直肠淋巴瘤患者的初期症状无典型性且多为轻度,体征不明显,因此在临床上更容易漏诊误诊。我国的结核病(Tuberculosis, TB)患病人数目前为世界第二位。该病以青壮年多见,女性多于男性。肠结核绝大部分继发于肺结核,好发于回盲部。分为3种类型：溃疡型、增殖型及混合型。其内镜下最具特征的表现为环形溃疡,回盲部多发；但病变处于早期时溃疡较小以及后期融合为巨大溃疡后无法辨认其是否呈环形,且溃疡之间粘膜正常。症状上患者可有腹痛、腹泻及结核全身中毒症状。以上均容易与克罗恩病互相误诊。常用的各种辅助检查特异性均较低。怀疑肠结核后,一般需进行较长时间的诊断性抗结核治疗后复查内镜视溃疡愈合情况判定是否为肠结核。其诊断耗时较长。综上所述,克罗恩病、结直肠淋巴瘤、肠道结核三病因起病缓慢一般难以得到较有鉴别意义的病史；症状上均有腹痛、便血、消瘦、营养不良,亦可有发热；体征上无明显差别,都有腹部压痛、腹块等,克罗恩病与肠道结核均可出现瘘管、腹腔脓肿等并发症；各项辅助检查特异性均不高。再加上有使用英孚利昔单抗治疗的克罗恩病患者继发结核病、淋巴瘤的报道,导致三病的鉴别诊断成为内镜医师的重点难题之一。目前内镜检查成为肠道溃疡的常规检查手段。但内镜仅可对病变消化道的粘膜表面进行检查,探明溃疡大小及分布。而三病的内镜下表现常不典型,尤其是早期患者,常仅仅表现为非特异的单发或多发溃疡；克罗恩病及肠道结核常多发于回盲部；都可有肠狭窄、梗阻等并发症；另外克罗恩病、肠道结核因具有特异性的非干酪样及干酪样肉芽肿病理活检检出率低、结直肠淋巴瘤因病变较深深挖活检难度较大且需要冒一定的穿孔风险,三病内镜下钳夹活检结果多为粘膜非特异性炎症,故内镜下活检难以提供较好的三病早期鉴别诊断价值,使三病的早期鉴别诊断难度较大。三病的治疗方法从原则上即各不相同,一旦误诊必然导致误治,其冗长的诊断周期及相应的诊断成本可对患者及其家庭造成生理、心理及经济上的重大负担。故三病的早期诊断可从多方面极大改善患者的生存质量。超声技术已有数十年的应用历史。体表超声对增厚的肠壁、肠外肿大淋巴结、腹水以及肠腔狭窄有很好的探查效果,在肛周进行检查尚可探查瘘管和脓肿等肠外并发症。超声对该三病最具鉴别意义之处在于能够探查患者的肠壁层次改变。因三病病理在病变早期已各不相同,故可通过其肠壁声像改变对三病做出鉴别诊断。克罗恩病病理主要表现为肠壁全层增厚,粘膜下层增厚明显,此系管壁炎症引起的一系列改变,包括水肿、淋巴管血管扩张、淋巴细胞聚集,这些改变可造成粘膜下层回声较正常粘膜下层稍低以及层次间界线稍许模糊但依旧可辨；结直肠淋巴瘤病变起源于粘膜下层,早期亦为粘膜下层增厚,但其病情进展较快,沿肠壁长轴侵犯,且其实质细胞密度较高,中间间质细胞含量少,故其声像可表现为层次模糊甚至消失,病变呈弥漫的低回声且因其为低度恶性肿瘤,具有一定侵袭性,故病变常可突破肠壁并侵犯周围组织；肠道结核病变起源于粘膜层淋巴组织,粘膜层炎症导致的水肿、增生渗出使其声像表现为粘膜层增厚,粘膜下层可因炎症导致疤痕形成而闭锁,以及因粘膜层的挤压而变窄及声像上显示模糊,由于其炎症较为局限,层次一般清晰可辨。但体表超声因易受干扰、操作要求高,国内较少依靠体表超声诊断三病。超声内镜(Endoscopic ultrasonography, EUS)融合了超声及内镜的特点,在内镜下观察消化道管壁粘膜病变的同时,可对消化道管壁及管壁外病变进行实时超声扫描,有效避免了腹壁脂肪、肠腔空气的干扰,且可对肠壁层次病变更加近距离的观察,得到更准确的信息。但目前在我国超声内镜开展范围较小,关于超声内镜诊断克罗恩病、结直肠淋巴瘤、肠道结核管壁病变的数据均较少。鉴于以上研究背景,本次研究回顾了最近5年内南方医院消化内镜中心351例疑似克罗恩病、结直肠淋巴瘤、肠道结核所致肠道溃疡的内镜、超声内镜及临床资料,总结三病超声内镜下诊断标准,并计算其诊断率等数据,探讨超声内镜对克罗恩病、结直肠淋巴瘤、肠道结核三病的诊断及鉴别诊断价值。患者资料和检查方法 1、临床资料：2008年1月-2013年6月,于广州南方医院消化内镜中心所检查内镜下发现肠道溃疡者,经各种方法排除除克罗恩病、肠道淋巴瘤、肠道结核的其它疾病,剩余者行肠道超声内镜检查,最后经各种方法确诊,且临床数据完整者共351例。确诊方法为试验性治疗、活检病理、手术病理、大块黏膜剥离活检、淋巴结切除活检及B超引导下淋巴结穿刺活检。 2、检查方法及术前准备：超声内镜于电子结肠镜检查后即刻或1周内进行。每位患者检查前均签署超声肠镜检查知情同意书,患者为左侧卧位,根据需要变换体位。在病灶处及病灶周围进行超声内镜扫描。根据病灶的不同情况分别采用脱气水充盈法、直接接触法或水囊法+脱气水充盈法对病灶进行扫描。每例行超声内镜检查时间10～30mim所有患者检查时及检查后除偶见轻度腹痛外未见其它并发症发生； 3、图像评阅：由南方医院消化内镜中心资深超声内镜医师对内镜图像及超声下图像结果进行评阅,仔细观察管壁及其旁组织结构影像变化并记录：管壁全层厚度、主要增厚层次、病变回声高低、各层次边界是否清晰、有无探及粘膜下层内直径大于2mm的脉管结构、病变是否突破管壁、有无探及窦道、瘘管、脓肿、管壁旁肿大淋巴结以及淋巴结是否融合；同一患者不同节段的病灶以病变最重处的数据计入。结果 1、克罗恩病的超声内镜表现：病变处管壁以粘膜下层增厚为主,各层次结构清晰可辨,部分边界模糊；病变回声较正常粘膜下层回声稍低；共214例克罗恩病患者、无结直肠淋巴瘤患者及肠道结核患者符合该表现,在各组所占比例分别为90.7%、0%、0%；克罗恩病组与结直肠淋巴瘤组(χ2=194.846,P0.001)、克罗恩病组与肠道结核组(χ2=150.891,P0.001)比较均有差异；克罗恩病组符合比例明显高于其它2组； 2、结直肠淋巴瘤的超声内镜表现：病变处管壁层次消失而无法判断增厚层次,各层次结构消失；病变回声呈均质弥漫低回声；共3例克罗恩病患者、48例结直肠淋巴瘤患者、4例肠道结核患者符合本表现,在各组所占比例分别为1.3%、81.4%、11.4%；结直肠淋巴瘤组与克罗恩病组(χ2=211.702,P0.001)、结直肠淋巴瘤组与肠道结核组(χ2=43.460,P0.001)比较均有显著性差异；结直肠淋巴瘤组符合比例明显高于其它2组 3、肠道结核的超声内镜表现：病变处管壁以粘膜层增厚为主,粘膜下层变窄、模糊,或未见明显增厚,各层次间界限清晰可辨；病变呈稍高或高回声；4例克罗恩病患者、2例结直肠淋巴瘤患者、25例肠道结核患者符合该表现,所占比例为1.7%、3.4%、71.4%；肠道结核组与克罗恩病组(x2=155.103,P0.001)、肠道结核组与结直肠淋巴瘤组(χ2=49.673,P0.001)比较均有显著性差异；肠道结核组符合比例明显高于其它2组。 4、本研究中超声内镜对克罗恩病诊断符合率、敏感性、特异性分别为91.5%,90.7%,93.0%；对结直肠淋巴瘤诊断符合率、敏感性、特异性分别为95.2%,81.4%,97.9%；对肠道结核诊断符合率、敏感性、特异性分别为94.5%,71.4%,97.5%。结论 1.克罗恩病、结直肠淋巴瘤、肠道结核三病的超声内镜表现有较大差异性： 1)克罗恩病的超声内镜表现：病变处管壁以粘膜下层增厚为主,各层次结构清晰可辨,部分边界模糊；病变回声较正常粘膜下层回声稍低； 2)结直肠淋巴瘤的超声内镜表现：病变处管壁层次消失而无法判断增厚层次,各层次间界限模糊不清,部分层次结构消失；病变回声呈均质弥漫低回声； 3)肠道结核的超声内镜表现：病变处管壁以粘膜层增厚为主,粘膜下层变窄、模糊,或未见明显增厚,各层次间界限清晰可辨；病变呈稍高回声； 2、超声内镜可清晰显示管壁病变及管壁外并发症,包括瘘管、窦道、脓肿、腹水等； 3、本研究中超声内镜对三病的诊断符合率均达到90%以上；超声内镜对克罗恩病、结直肠淋巴瘤、肠道结核鉴别诊断有较高价值,可对病变进行较准确的术前评估,为外科治疗提供有价值的信息；有效缩短诊断周期及成本,使患者早期接受正确的治疗。
[Abstract]:Research background and purpose
In recent years, with the expansion of the scope of domestic endoscopy, the rate of endoscopy in patients with abdominal pain, diarrhea, and blood pressure is getting higher and higher, and early detection of intestinal lesions, such as intestinal ulcers, can be effectively treated. Intestinal ulcer can be caused by a variety of diseases and can be confirmed or excluded by various methods. However, there are still some diseases that are difficult to identify with each other because of the many similarities in each aspect. There are more difficult identification of Crohn's disease, intestinal lymphoma and intestinal tuberculosis.
Crohn's disease (CD) is a chronic nonspecific enteric inflammatory disease, which has not been fully understood. In recent years, it has become a common disease in the digestive system in our country. The clinical characteristics of this disease are all intestinal involvement, the course of the disease is alternating with remission, and there are many kinds of extra intestinal complications. The mucosal inflammation of the segmental and asymmetrical distribution of mucous membrane may have longitudinal or aphthous ulcers, the mucous membrane of the ulcers can show normal or cobblestone like hyperplasia, and the complications such as fistula, abscess, and intestinal stenosis. The diagnostic gold standard is still unconfirmed because of the diversity of clinical manifestations of the disease. It is necessary to combine various clinical data to confirm the diagnosis. Therefore, the disease is in our country. The rate of diagnosis and treatment is low.
Primary intestinal lymphoma (Lymphoma, L) originates from the lymphatic tissue of the submucosa of the intestinal wall, which can break into the intestinal cavity to form the intestinal ulcer, the lymph nodes around the intestinal wall are enlarged, and the local mass is formed. The whole body metastases can also occur, causing fever, emaciation, night sweating and even cachexia. The colorectal is a primary gastrointestinal lymphoma. The ulcerative type in the endoscopy of this disease is characterized by different sizes, irregular shapes of ulcers, indeterminate locations and lack of specificity. The biopsy of the clamp is difficult to take the pathological tissue, and the initial symptoms of most cases of colorectal lymphoma are not typical and light, and the signs are not obvious, so it is more likely to be missed clinically. Misdiagnosis.
The number of Tuberculosis (TB) in China is currently the second most common disease in the world. The disease is more common in young adults and more women than men. The vast majority of intestinal tuberculosis secondary to tuberculosis in the ileocecal region. It is divided into 3 types: ulcerative, proliferating and mixed types. In the early stage of the disease, the ulcer is small and the later fusion can not be identified if the ulcer is ring-shaped, and the mucous membrane between the ulcers is normal. The symptomatic patients can have abdominal pain, diarrhea and the symptoms of tuberculosis systemic poisoning. All of these are easily misdiagnosed with Krohn's disease. In general, it is necessary to conduct a long time of diagnostic tuberculosis treatment to check whether the endoscopic ulcer healing is intestinal tuberculosis.
To sum up, the three causes of Crohn's disease, colorectal lymphoma, and intestinal tuberculosis are generally difficult to have a more differential history of disease; symptoms include abdominal pain, blood, emaciation, malnutrition, and fever; there are no obvious differences in physical signs, abdominal pain, abdominal mass, Crohn's disease and intestinal tuberculosis, and abdominal cavity, abdominal cavity, and abdominal cavity. Complications such as abscess and other complications; the specificity of all the auxiliary examinations was not high. In addition to the secondary tuberculosis of the patients with Crohn's disease treated with infliximab, a report of lymphoma, which led to the differential diagnosis of three diseases became one of the key problems of endoscopes.
Endoscopy has become a routine examination for intestinal ulcers. However, endoscopy can only examine the mucosal surface of the digestive tract and detect the size and distribution of the ulcer. The endoscopic findings of three diseases are often untypical, especially in early patients, which are often characterized by nonspecific single or multiple ulcers; Crohn's disease and intestinal tuberculosis often occur frequently. In the ileocecal part, there are complications such as intestinal stenosis and obstruction; in addition, Crohn's disease and intestinal tuberculosis are low in the detection rate of pathological biopsy of non cheese like and caseous granuloma. Colorectal lymphoma is more difficult to biopsy because of a deeper lesion and requires a certain risk of perforation. The results of biopsy under three endoscopy are mostly sticky. Non specific inflammation of the membrane, therefore, the endoscopic biopsy is difficult to provide a good value for the early differential diagnosis of three diseases, making the early differential diagnosis of the three disease difficult. The treatment methods of three diseases are different in principle. Once the misdiagnosis inevitably leads to mistaken treatment, the long diagnosis cycle and the diagnosis cost of the phase should cause the physiology of the patients and their families. The early diagnosis of three diseases can greatly improve the quality of life of patients.
Ultrasound has a history of decades of application. Body surface ultrasound has a good effect on the thickening of the intestinal wall, enlarged lymph nodes outside the intestine, ascites and the stenosis of the intestinal cavity. It is possible to detect the external complications such as fistula and abscess in the perianal examination. The most differential significance of ultrasound to the three diseases is to detect the changes of the intestinal wall level of the patients. The pathology of three disease is different at the early stage of the lesion, so the differential diagnosis of three disease can be made through the changes in the sound image of the intestinal wall. The pathology of Crohn's disease is mainly the thickening of the whole layer of the intestinal wall, the thickening of the submucosa, and a series of changes caused by the inflammation of the wall of the tube, including edema, vasodilatation of the lymphatic tube, and lymphocyte aggregation. These changes can be made. The submucosa echo is slightly lower than that of the normal submucosa, and the boundary line is a little blurred. The lesion of colorectal lymphoma originates from the submucosa and is thickened at the early stage of the mucous membrane. However, the disease progresses rapidly, along the long axis of the intestinal wall, and its parenchyma cell density is high, and the intermediate stromal cell content is less, so its sound image is low. It can be expressed as a fuzzy or even disappearing level, with a diffuse low echo and a low malignancy with a certain invasive, so the lesion often breaks through the intestinal wall and invades the surrounding tissue; the intestinal tuberculosis lesions originate from the mucosa of the mucosa, the edema caused by mucous membrane inflammation, and the proliferation and exudation of the mucous membrane as the thickening of the mucous membrane. The submucosa can be locked in the formation of inflammation, narrowing and blurred on the sound image because of the extrusion of the mucous membrane. Because the inflammation is limited, the level is clear and distinguishable. However, the body surface ultrasound is easily disturbed, the operation is high, and the three disease is diagnosed less by the body surface ultrasound.
Endoscopic ultrasonography (EUS), which combines the characteristics of ultrasound and endoscopy, can be used to observe the mucosal lesions of the digestive canal wall under endoscopy, and can perform real-time ultrasonic scanning on the wall of the digestive tract and extramial lesions, effectively avoiding the abdominal wall fat, the interference of the air in the intestine, and the more close observation of the intestinal wall lesion. More accurate information is obtained. However, there is a small range of endoscopic ultrasonography in our country. There are few data on the diagnosis of Krohn's disease, colorectal lymphoma and intestinal tuberculosis tube wall lesions. In view of the above research background, this study reviewed 351 cases of suspected Krohn's disease and colorectal cancer in the digestive endoscopy center of southern hospital in the last 5 years. Endoscopy, endoscopic ultrasonography, and clinical data of intestinal ulcers caused by intestinal tuberculosis were used to summarize the diagnostic criteria of three diseases under ultrasonic endoscopy and to calculate the diagnostic rate. The value of endoscopic ultrasonography in the diagnosis and differential diagnosis of Crohn's, colorectal lymphoma and three diseases of intestinal tuberculosis was discussed.
Patient data and methods of examination
1, clinical data: in June -2013, January 2008, in the digestive endoscopy center of Guangzhou Nanfang Hospital, the patients with intestinal ulcer were detected by endoscopy. The other diseases were eliminated by various methods, including Crohn's disease, intestinal lymphoma and intestinal tuberculosis. The remaining patients were examined by intestinal endoscopic ultrasonography, and 351 cases were confirmed by various methods, and the total clinical data were complete. The diagnostic methods were experimental treatment, biopsy pathology, surgical pathology, large lump dissection biopsy, lymph node biopsy and lymph node biopsy under B-ultrasound guidance.
2, examination method and preoperative preparation: endoscopic ultrasonography was performed immediately after electronic colonoscopy or within 1 weeks. Each patient signed an informed consent book of ultrasonic colonoscopy before examination. The patient was a left lateral position, and the body position was changed according to the need. The ultrasound endoscopy was performed at the lesion and around the lesion. The focus was scanned by air water filling, direct contact or water bursa and degassing water filling, and every routine endoscopy time was 10 ~ 30mim for all patients and no other complications were found except for mild abdominal pain.
3, image review: a senior endoscope doctor of the southern hospital's digestive endoscopy was reviewed by a senior endoscope doctor for the image of endoscopy and ultrasound. The changes of the wall and its adjacent tissue images were carefully observed and recorded: the thickness of the wall of the tube, the main thickness of the thickening, the high and low echo of the lesion, the clarity of the boundary of each level, the submucosa and the submucosa. The internal diameter of the vascular structure is greater than 2mm. Whether the lesion breaks through the wall of the tube, the sinus, the fistula, the abscess, the lymph nodes adjacent to the wall of the tube and the fusion of the lymph nodes; the lesions of the same patient's segments are included in the data of the most serious lesions.
Result
1, the ultrasonic endoscopy of Crohn's disease: the wall of the lesion was thickened mainly by the submucosa, the structure of each level was clear and the partial boundary was blurred, and the echo of the lesion was slightly lower than that of the normal submucosa; a total of 214 cases of Crohn's disease, non colorectal lymphoma and intestinal nucleation patients were in accordance with this manifestation, and the proportion of the patients in each group was the same. 90.7%, 0%, 0%, Crohn's disease group and Colorectal Lymphoma Group (x 2=194.846, P0.001), Crohn's disease group and intestinal tuberculosis group (x 2=150.891, P0.001) were different, and the proportion of Crohn's disease group was significantly higher than that of other 2 groups.
2, the endoscopic ultrasonography of colorectal lymphoma: the disappearance of the wall level in the lesion and the disappearance of the thickening level and the disappearance of the layers; the echo was homogeneous and diffuse hypoechoic; 3 cases of Crohn's disease, 48 cases of colorectal lymphoma and 4 cases of intestinal tuberculosis were conformed to this performance, and the proportion in each group was 1.3%, 81.4%, 11, respectively. .4%, colorectal lymphoma group and Crohn's disease group (x 2=211.702, P0.001), colorectal lymphoma group and intestinal tuberculosis group (x 2=43.460, P0.001) were significantly different, the proportion of colorectal lymphoma group was significantly higher than the other 2 groups.
3, the endoscopic ultrasonography of intestinal tuberculosis: the wall of the lesion was thickened mainly with the thickening of the mucous layer, the submucosa narrowed, blurred, or no obvious thickening, and the boundaries were clearly distinguishable; the lesions were slightly higher or hyperechoic; 4 cases of Crohn's disease, 2 cases of colorectal lymphoma and 25 cases of intestinal tuberculosis were conformed to this performance, the proportion accounted for 1.7%. 3.4%, 71.4%, the intestinal tuberculosis group and the Crohn's disease group (x2=155.103, P0.001), the intestinal tuberculosis group and the Colorectal Lymphoma Group (x 2=49.673, P0.001) were significantly different, the proportion of intestinal tuberculosis group was significantly higher than the other 2 groups.
4, the diagnostic coincidence rate, sensitivity, specificity of endoscopic ultrasonography to Crohn's disease were 91.5%, 90.7%, 93%, and the diagnostic coincidence rate, sensitivity and specificity of colorectal lymphoma were 95.2%, 81.4%, 97.9%, respectively, and the diagnostic coincidence rate of intestinal tuberculosis, sensitivity and specificity were 94.5%, 71.4%, 97.5%., respectively.
conclusion
1. there were great differences in endoscopic ultrasonography in Crohn's disease, colorectal lymphoma, and intestinal tuberculosis three diseases.
1) the ultrasonic endoscopy of Crohn's disease: the wall of the lesions was thickened mainly by the submucosa, the structure of each level was clear and the partial boundary was blurred, and the echo of the lesion was slightly lower than the echo of the normal submucosa.
2) endoscopic ultrasonography of colorectal lymphoma: the layer of the wall of the lesions disappeared and the thickening level could not be judged. The boundaries between the various levels were blurred, some of the layers disappeared, and the echoes were homogeneous and diffuse hypoechoic.
3) endoscopic ultrasonography of intestinal tuberculosis: the wall of the lesion was thickened with the thickening of the mucous layer, the submucosa narrowed, blurred, or no obvious thickening, and the boundaries between the various levels were clearly distinguishable.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R445.1;R574

【参考文献】