湘西地区炎症性肠病的流行病学特点研究

摘 要 目的:收集七年间湘西地区炎症性肠病(inflammatory boweldisease,IBD)患者的临床资料,对其进行回顾性分析及探讨流行病学特点,为进一步总结本地区炎症性肠病的诊断和治疗提供依据。 方法:收集湘西州人民医院 2012 年 1 月-2019 年 1 月间确诊为炎症性肠病患
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  摘 要

  
  目的:收集七年间湘西地区炎症性肠病(inflammatory boweldisease,IBD)患者的临床资料,对其进行回顾性分析及探讨流行病学特点,为进一步总结本地区炎症性肠病的诊断和治疗提供依据。
  
  方法:收集湘西州人民医院 2012 年 1 月-2019 年 1 月间确诊为炎症性肠病患者的临床资料,其中包括溃疡性结肠炎(Ulcerative Colitis,UC)和克罗恩病(Crohn's Disease,CD),并对两种疾病的临床特点进行分析。

湘西地区炎症性肠病的流行病学特点研究

  
  结果:
  
  1、人群特征:我院 2012 年 1 月至 2019 年 1 月期间确诊炎症性肠病住院人数为 71 例,其中溃疡性结肠炎 47 例,克罗恩病 24 例。
  
  溃疡性结肠炎男女比为 1.04:1,克罗恩病男性多于女性(3.8:1),炎症性肠病发病年龄为 13~78 岁不等,两病的性别差异有统计学意义(χ2= 5.253,P=0.022)。湘西地区炎症性肠病患者民族有苗族、汉族、土家族,其中苗族、土家族占比例最高(均为 38.0%),其次为汉族(23.9%)。溃疡性结肠炎平均年龄为 43.3+13.2,克罗恩病平均年龄为 36.1+16.1,两组平均年龄单独比较后差异无统计学意义(t=,1.736,P=0.192,P>0.05)。溃疡性结肠炎患者七年间发病人数大致无变化,克罗恩病患者有增加趋势,炎症性肠病总体发病人数无明显增加。2012 年-2018 年炎症性肠病粗发病率在 0.196/10-0.550/10 万之间波动,2012 年-2018 溃疡性结肠炎粗发病率为 0.078/10-0.392/10 万之间波动,2013 年-2018 克罗恩病粗发病率为 0.078/10-0.265/10 万,有逐渐上升趋势。
  
  2、肠道手术史:溃疡性结肠炎肠道手术史 3 例(6.4%),克罗恩病肠道手术史 7 例(29.2%),克罗恩病组:溃疡性结肠炎组为 2.3:1,克罗恩病 组肠道手术率高于 溃疡性结肠炎组,差异有统计学意义(χ2=6.851,p<0.005)。
  
  3、临床表现及并发症:溃疡性结肠炎临床表现主要为腹痛、粘液脓血便、里急后重为主,克罗恩病临床表现主要为腹痛、腹泻、体重减轻。两组症状单独比较后发现腹痛、腹胀、里急后重、发热差异无统计学意义(P>0.05)。血便、腹泻、体重减轻差异有统计学意义(P<0.05)。克罗恩病组并发症较溃疡性结肠炎组多,两组比较有统计学意义(χ2=14.724,P<0.05)。
  
  4、实验室指标:溃疡性结肠炎组:女性溃疡性结肠炎患者 HGB为( 100.5±8.3) g /L,男性为( 104.4±13.7) g /L,男性女性血红蛋白比较,差异无统计学意义( t=1.262,P>0.05)。克罗恩病组:女性克罗恩病患者 HGB 为( 91.0±0.00) g /L,男性为( 104.4±14.8) g /L,男性女性血红蛋白比较,差异有统计学意义( t=34.6,P<0.05)。溃疡性结肠炎组疾病活动度评分与红细胞沉降率呈正相关(r=0.500,P<0.05),与血红蛋白(r=-0.159 ,P<0.05)、白蛋白(r=-0.324,P<0.05)呈负相关。与 C 反应蛋白及白细胞无相关性(P>0.05)。克罗恩病组疾病活动度评分与 C 反应蛋白( r=0.237,P<0.05)、红细胞沉降率(r=0.348 ,P<0.05)呈正相关 ,与白蛋白(r=- 0.187,P<0.05))呈负相关 ,与血红蛋白、白细胞无相关性( P>0.05)。克罗恩病组炎症指标 CRP 较溃疡性结肠炎组升高,差异有统计学意义(t=49.548,P<0.05)。
  
  5、临床表型、病变部位及严重程度:溃疡性结肠炎初发型为 28例,复发型为 19 例。病变范围按蒙特利尔分型:以左半结肠型(E2)为主。以轻中度为主。克罗恩病组按蒙特利尔分型,17-40 岁(A2)患者数最多,病变部位以结肠型(L2)及回结肠型(L3)最多见,病变行为以非狭窄非穿透型(B1)为主,严重程度以及轻度活动期为主。
  
  6、肠镜及病理表现:肠镜表现炎症性肠病主要有黏膜充血水肿、糜烂、溃疡为主,克罗恩病肠镜下可见特征性铺路石结节改变。溃疡性结肠炎组病理主要表现为急性或慢性性炎性细胞浸润、黏膜慢性炎、糜烂、隐窝脓肿形成、腺体增生,克罗恩病组主要病理表现为黏膜慢性炎、糜烂、炎性细胞浸润、隐窝脓肿形成、溃疡形成。
  
  7、治疗:71 例炎症性肠病溃疡性结肠炎组及克罗恩病组主要以氨基水杨酸治疗为主,其次是激素。
  
  8、随访:随访溃疡性结肠炎患者 47 例,失访 10 例,死亡 1 例。
  
  克罗恩病患者 24 例,失访 6 例,死亡 1 例,死于穿孔后感染。溃疡性结肠炎组院外使用美沙拉嗪、美沙拉嗪+激素、中药为主,无患者使用免疫抑制剂。克罗恩病组患者,院外使用美沙拉嗪为主,少部分其中使用激素、硫唑嘌呤、手术、中药治疗。溃疡性结肠炎患者依从率43.2%;克罗恩病患者依从率 41.2%。54 例随访炎症性肠病患者中,缓解稳定期 11 例(20.4%),有效好转 33 例(61.1%),加重恶化10 例(18.5%)。依从性与预后转归有相关性(χ2=10.688,P=0.01)。
  
  结论:
  
  1、湘西地区溃疡性结肠炎患者七年间发病人数大致无变化,克罗恩病发病人数有增加趋势,湘西地区炎症性肠病粗发病率呈较低水平,明显低于沿海发达地区。
  
  2、溃疡性结肠炎以轻中度活动期多见,左半结肠受累为主;克罗恩病活动性以轻度为主,受累病变部位以回结肠型和结肠型为主。
  
  3、美沙拉嗪是湘西地区治疗炎症性肠病使用率最高的药物,克罗恩病患者手术率明显高于溃疡性结肠炎,炎症性肠病患者治疗依从性差,患者的依从性影响患者的预后转归。
  
  关键词: 炎症性肠病,溃疡性结肠炎,克罗恩病,临床特点。
  

  ABSTRACT

  
  Objective: The clinical data of patients with inflammatory bowel disease (IBD) in the western Hunan area during seven years were collected, retrospectively analyzed and discussed the epidemiological characteristics, providing a basis for further summarizing the diagnosis and treatment of inflammatory bowel disease in this area.
  
  Methods: Collect clinical data of patients diagnosed with inflammatory bowel disease from January 2012 to January 2019 in Xiangxi People's Hospital, including Ulcerative Colitis (UC) and Crohn's Disease (CD),And analyze the clinical characteristics of the two diseases.
  
  Result:
  
  1. Population characteristics: The number of inpatients diagnosed with inflammatory bowel disease in our hospital from January 2012 to January 2019 was 71, including 47 cases of ulcerative colitis and 24 cases of Crohn's disease. Ulcerative colitis has a male to female ratio of 1.04: 1,Crohn's disease has more males than females (3.8: 1), and the age of onset of inflammatory bowel disease ranges from 13 to 78 years. = 5.253,P = 0.022). The ethnic groups of patients with inflammatory bowel disease in western Hunan include Miao, Han and Tujia, of which Miao and Tujia account for the highest proportion (both 38.0%), followed by Han (23.9%). The average age of ulcerative colitis was 43.3+13.2, and the average age of Crohn's disease was 36.1+16.1. There was no significant difference in the average age of the two groups (t =, 1.736, P =0.192, P> 0.05). The number of patients with ulcerative colitis has remained unchanged for seven years. Crohn's disease patients have an increasing trend, and the overall number of patients with inflammatory bowel disease has not increased significantly. The crude incidence rate of inflammatory bowel disease fluctuated between 0.196/10million-0.550 / 10million between 2012 and 2018, and the crude incidence rate of ulcerative colitis fluctuated between 0.078/10million-0.392 /10million between 2012 and 2018 The crude incidence rate of Crohn's disease fromyear to 2018 is 0.078/10million-0.265/10 million, which is gradually increasing.
  
  2. Intestinal surgery history: 3 cases (6.4%) of intestinal surgery history of ulcerative colitis, 7 cases (29.2%) of intestinal surgery history of Crohn's disease, Crohn's disease group: 2.3 in ulcerative colitis group :
  
  1. The rate of intestinal surgery in Crohn's disease group is higher than that in ulcerative colitis group, the difference is statistically significant (χ 2= 6.851, p <0.005).
  
  3. Clinical manifestations and complications: The clinical manifestations of ulcerative colitis are mainly abdominal pain, mucous pus and bloody stools, and tenesmus. The clinical manifestations of Crohn's disease are mainly abdominal pain, diarrhea and weight loss.After comparing the symptoms of the two groups alone, there was no statistically significant difference in abdominal pain, bloating, tenesmus,and fever (P> 0.05). The differences in bloody stools, diarrhea and weight loss were statistically significant (P <0.05). Crohn's disease group had more complications than ulcerative colitis group, and the two groups were statistically significant (χ2 = 14.724, P <0.05).
  
  4. Laboratory index: ulcerative colitis group: female patients with ulcerative colitis HGB is (100.5 ± 8.3) g / L, male is (104.4 ± 13.7) g / L,male and female hemoglobin, the difference is not statistically significant (t = 1.262, P> 0.05). Crohn's disease group: Female Crohn's disease patients with HGB (91.0 ± 0.00) g / L, males (104.4 ± 14.8) g / L, male and female hemoglobin, the difference was statistically significant (t =34.6, P <0.05). The disease activity score of the ulcerative colitis group was positively correlated with the erythrocyte sedimentation rate (r = 0.500, P <0.05), hemoglobin (r = -0.159, P <0.05), albumin (r = -0.324, P <0.05) It is negatively correlated. No correlation with C-reactive protein and leukocytes (P> 0.05). Crohn's disease activity score was positively correlated with C-reactive protein (r = 0.237, P <0.05), erythrocyte sedimentation rate (r = 0.348, P <0.05), and albumin (r = -0.187, P <0.05) )) There is a negative correlation, no correlation with hemoglobin and white blood cells (P> 0.05). The inflammation index CRP in the Crohn's disease group was higher than that in the ulcerative colitis group,and the difference was statistically significant (t = 49.548, P <0.05).
  
  5. Clinical phenotype, lesion location and severity: ulcerative colitis has 28 cases of initial onset and 19 cases of recurrent type. The range of lesions is classified according to Montreal: the main type is the left colon (E2). Mainly light to moderate. The Crohn's disease group is classified according to Montreal. The number of patients aged 17-40 years (A2) is the largest. The lesions are most common in the colon type (L2) and ileococcal type (L3). ) Mainly, severity and light activity period.
  
  6. Colonoscopy and pathological manifestations: Colonoscopy showed inflammatory bowel disease mainly including mucosal congestion and edema, erosion, and ulcers. Crohn's disease showed characteristic changes in paving stones nodules under colonoscopy. Thepathological manifestations of the ulcerative colitis group are mainly acute or chronic inflammatory cell infiltration, chronic mucosal inflammation, erosion, crypt abscess formation, and gland hyperplasia.The main pathological manifestations of the Crohn's disease group arechronic mucosal inflammation, erosion, and inflammation Cell infiltration, crypt abscess formation, and ulcer formation.
  
  7. Treatment: 71 cases of inflammatory bowel disease ulcerative colitis group and Crohn's disease group are mainly treated with aminosalicylic acid, followed by hormones.
  
  8. Follow-up: 47 patients with ulcerative colitis were followed up,10 were lost to follow-up, and 1 died. There were 24 patients with Crohn's disease, 6 were lost to follow-up, 1 died, and died of infection after perforation. In the ulcerative colitis group, mesalazine, mesalazine +hormone, and Chinese medicine were mainly used outside the hospital,and no patients used immunosuppressants. Patients in the Crohn's disease group mainly use mesalazine outside the hospital, and a small part of them use hormones, azathioprine, surgery, and traditional Chinese medicine. The compliance rate of patients with ulcerative colitis was 43.2%; the compliance rate of patients with Crohn's disease was 41.2%.Among the 54 patients with follow-up inflammatory bowel disease, 11 patients (20.4%) in the remission stable period, 33 patients (61.1%)improved effectively, and 10 patients (18.5%) worsened. There was a correlation between compliance and prognosis (χ2= 10.688, P = 0.01).
  
  Conclusion:
  
  1. The number of patients with ulcerative colitis in Xiangxi area has not changed in the past seven years, and the number of Crohn's disease has increased. The crude incidence of inflammatory bowel disease in Xiangxi area is at a low level, which is significantly lower than that in coastal developed areas.
  
  2. Ulcerative colitis is more common in mild-to-moderate active period, and the left half of the colon is mainly involved; the activity of Crohn's disease is mainly mild, and the affected lesions are mainly ileum type and colon type.
  
  3. Mesalazine is the drug with the highest rate of treatment for inflammatory bowel disease in western Hunan. The operation rate of patients with Crohn's disease is significantly higher than that of ulcerative colitis. The treatment compliance of patients with inflammatory boweldisease is poor. The compliance of patients affects the patient's compliance. Outcome of prognosis.
  
  Key words: inflammatory bowel disease, ulcerative colitis, Crohn's disease, clinical feature。
  

  前言
  

  炎 症 性 肠 病 (flammatory bowel disease,IBD) 包 括 克 罗 恩 病 (Crohn’sDisease,CD)和溃疡性结肠炎(Ulcerative colitis,UC),是一种病因、发病机制未明的非特异性慢性肠道炎症性疾病[1]。国内外研究考虑炎症性肠病的发病与遗传、肠道微生态、生活环境及地域、免疫等方面的因素有关。溃疡性结肠炎临床表现主要为腹痛、腹泻、黏液脓血便等,溃疡性结肠炎在肠镜下以连续性、弥漫性的结直肠粘膜充血水肿、糜烂、溃疡多见。克罗恩病以腹痛、消瘦、腹泻和不同程度的全身症状为主要临床症状,其主要累及回肠末端及邻近肠段,克罗恩病在肠镜下多为非连续性病变,典型的镜下改变为非连续性糜烂、铺路石样改变以及裂隙性溃疡,肉芽肿为其典型的病理表现[2]。克罗恩病和溃疡性结肠炎临床表现多样,包括腹痛、腹泻等消化系统症状,发热等全身症状,眼等肠外表现,以及中毒性巨结肠、上皮内瘤变、下消化道大出血、肛周病变等多种并发症,具有终生不愈、病程中反复发作、发作时病情复杂等特点,病情严重时可危及患者生命[3]。
  
  炎症性肠病病程长,易复发,具有癌变倾向,严重影响到患者的生活质量[4]。近年来炎症性肠病发病率逐年增高,并且有低龄化的趋势[5]。
  
  溃疡性结肠炎发病率明显高于克罗恩病[6]。第一个发病高峰为 20-30 岁[7-8], 第二个发病高峰为 70-80 岁。 但是有研究表明溃疡性结肠炎可以发生在任何年龄[9]。克罗恩病是一种病因未明的消化道非特异性炎症, 好发于 20-30 岁青壮年, 大量研究表明儿童和老年都可以发病[10-11], 但男性常好发[12]。
  
  炎症性肠病具有明显的区域性,不同国家、不同种族以及不同地区的发生率不同。炎症性肠病既往被称为“西方疾病”,在欧美等发达国家发病率较高,约为2‰;在亚洲和拉丁美洲的发病率较低,为 0.1‰~1‰[13];近几年,炎症性肠病的发病率随着包括发展中国家经济的发展在亚洲国家呈逐渐上升之势,但在西方发达国家炎症性肠病的发病率逐渐趋向于稳定,表明炎症性肠病的发病率与经济发展水平密切相关。有研究提示随着我国经济的发展,我国炎症性肠病的发病率达到 11.6/10 万,呈逐年上升的趋势,严重影响患者的生活质量和增加社会负担[14]。
  
  炎症性肠病在我国已成为了消化系统的常见病。但诊断仍十分困难,至今仍缺乏金标准,目前主要结合其临床表现、实验室检查结果、影像学相关检查、内镜下表现和组织病理学表现进行综合分析,在排外其他疾病的基础上作出诊断,容易造成误诊,因此对该病的临床特征的科学认识非常重要。
  
  且国内外研究[15-19]表明炎症性肠病发病率和患病率存在地区差异,城市地区高于农村,欧美等发达国家高于发展中国家,经济发达地区高于经济落后地区。
  
  而本研究的湘西地区是经济落后山区,大部分人居住在农村,且湘西自治州人民医院为湘西地区唯一西医三甲医院,具有诊治炎症性肠病的能力和水平,故对湘西地区炎症性肠病患者临床资料进行回顾性分析,总结以经济欠发达的农村、少数民族为主的湘西地区炎症性肠病患者的发病特点、临床表现、内镜病理表现、治疗方案等,为以后更好的诊治本地区炎症性肠病患者提供依据。
  
  第一章:资料与方法。
  
  1.1 、研究对象:

  
  选取 2012 年 1 月—2019 年 1 月于我院收治首次确诊住院、以炎症性肠病或溃疡性结肠炎或克罗恩病为主要诊断的患者,对其资料进行回顾性分析,患者现病史、个人史、个人资料、手术史及肠镜等资料完整。溃疡性结肠炎和克罗恩病共 71 例,溃疡性结肠炎 47 例,其中男性 24 例,女性 23 例。克罗恩病 24 例,其中男性 19 例,女性 5 例。
  
  1.1.1、 纳入标准:
  

  经临床表现、结肠镜检查、锁剂灌肠检查、粘膜组织或手术切除标本病理诊断证实为溃疡性结肠炎或克罗恩病的病例,符合 2018 年《炎症型肠病诊断与治疗的共识意见(2018 年?北京)》的诊断标准[3]。临床相关资料基本完整。
  
  1.1.2、 排除标准:
  

  ①不符合纳入标准,并行结核菌素试验、胸部 X 线、粪培养等检查排除急性感染性肠炎、肠结核、人类免疫缺陷病毒 (HIV) 相关肠炎、白塞病等感染性肠炎。
  
  ②除外临床资料不全、诊断不明确、联系方式不全、无法完成数据收集及进行院外随访的患者。
  
  1.2、 研究方法:
  
  病例、数据收集:于我院病案系统选时间段为 2012 年 1 月至 2019 年 1 月住院诊断为炎症性肠病、克罗恩病、溃疡性结肠炎的病历。收集入组病历一般资料(性别、患病平均年龄、民族、病程、肠道手术史等)、临床表现、实验室检查结果、镜下及病理表现(以近期外院检查结果及首次我院的检查结果为准)、病变范围、治疗情况、院外随访情况、临床类型(按照蒙特利尔表型分类法进行分型)、病情严重程度(根据改良 Truelove 和 Witts 疾病严重程度分型和 Best CDAI计算法进行评分)、住院期间治疗方案、院外治疗依从性、治疗方案、是否复发及预后转归等(具体疾病活动评分及蒙特利分型见 2018 年炎症性肠病诊断与治疗共识意见)。
  
  随访内容、随访方式及工具:于 2019 年 10 月 1 日-2019 年 12 月 31 日时间段用医院医师办公室电话对符合本次研究纳入标准的炎症性肠病患者进行电话随访。告知患者随访的目的,在取得患者的同意的情况下,详细询问患者院外治疗情况并记录,记录其有无规律按照医嘱用药、药物的名称、用药时间(是否持续用药)病程中是否出现腹痛、大便次数增多、粘液以及脓血便等复发症状。
  
  患者院外依从情况分类:将在随访过程中(规律复查、规律用药)遵从医生医嘱的患者视为依从,在随访过程中不遵医嘱、不规律用药及不规律复查的患者视为不依从。
  
  流行病学分析:以湘西自治州常住人口为研究的基础人群,收集 2012 年 1月至 2019 年 1 月住院诊断为炎症性肠病、溃疡性结肠炎、克罗恩病的患者,包括既往确诊的病例。由湘西自治州统计局提供本地区 2012 年-2018 年的人口学资料。用发病率、患病率公式计算出湘西地区近七年每年的粗发病率、粗患病率。
  
  用以下公式进行炎症性肠病、溃疡性结肠炎、克罗恩的 2012 年至 2018 年每一年的粗发病率及粗患病率计算。(k=100%,1000‰,10000/万或 100000/10 万)。
  
  粗发病率 =一定时期某人群中新病例数&pide;同期暴露人口数×k
  
  粗患病率 =特定时期某人群中某病新旧病例数&pide;同期观察人口数×k
  

  【由于本篇文章为硕士论文,如需全文请点击底部下载全文链接】

  
  1.3 统计学方法:
  
  第二章 结果
  

  2.1 、炎症性肠病基线资料对比
  2.2、 临床表现及并发症
  2.3 、既往史、异地居住史
  2.4、 溃疡性结肠炎和克罗恩病的实验室指标比较
  2.5、 疾病严重程度分型、疾病活动度评分 ( Harvey-Bradshow index HBI)与实验室指标相关性
  2.6、 临床类型、病变部位
  2.7、 肠镜表现
  2.8 、病理表现
  2.9 、治疗方案
  2.10、 溃疡性结肠炎及克罗恩病患者随访情况
  
  第三章:讨论
  
  3.1、 人口统计学和一般资料特点
  3.2 、临床特征
  3.3 、炎症性肠病内镜下特征及病理特征
  3.4 、炎症性肠病治疗方案及随访

  结论

  总 结

  我国是一个人口大国,与其他国家和地区有着不同种族、地域、经济文化背景,国内外研究表明炎症性肠病发病率、患病率因地域不同、民族不同、经济水平等有关,因此我国一直进行的炎症性肠病患者的群体数据研究具有重要社会学经济学意义。

  湘西自治州人民医院为湘西地区唯一西医三甲医院,具有诊治 IBD 的能力和水平。本研究纳入在我院确诊为炎症性肠病且信息完善的炎症性肠病患者,可能还有少数未入我院就诊的湘西地区的炎症性肠病患者,本研究仅能粗略总结湘西地区炎症性肠病的临床特征,尚不能完全代表整个湘西地区,所以需要大样本全覆盖进一步研究。

  炎症性肠病终生不愈,病程长且病情复杂,治疗上复杂且须患者长期配合,且目前在诊断上仍困难,需结合临床表现、肠镜、实验室检查、影像学检查等综合诊断,故在炎症性肠病临床诊治上建议消化内科与外科、营养科、医学影像学科、病理科、内镜室等多学科协作。对于炎症性肠病治疗上需做到个体化治疗和提高患者依从性,有助于提高疾病的治愈率和降低复发率等。

  参考文献

作者单位:吉首大学 原文出处:张彩凤. 湘西地区71例炎症性肠病临床特征分析[D].吉首大学,2020. 点击下载全文 转载请注明来源。原文地址:http://www.lw54.com/html/zhlw/20210129/8379266.html   

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