激素在潰瘍性結(jié)腸炎的應(yīng)用

1、The Clinical Application of Corticosteroids in Ulcerative Colitis,rui nan Wang,Two parts,The introduction of Ulcerative colitisThe clinical application of Corticosteroids in Ulcerative colitis,Ulcerative coliti

2、s,Definition:Chronic non-specific colitisInflammation of the mucosa and submucosa of the large intestine,Features:,diarrhea with feces containing mucus, pus and blood, abdominal pain and tenesmus; and recurre

3、nce is commonMostly seen in 20-50 years of age, and in EuropeLess common in China,,,,,Infection,Environmental factors,Genetic susceptible,,Immune & inflammatory system,,,Etiology and pathogenesis,,Location: rectum

4、 and sigmoid colon, then descending, transverse or pan-colon, even terminal ileumMucosa diffused inflammation with edema, congestion and local bleedings.,Pathology,,,Infiltration of lymphocytes, plasma cells, eosinophil

5、ic cells and neutrophilic cells in mucosaCryptic abscess and superficial ulcersInflammatory polyps or pseudopolyps;,,,UC,UC,Cryptic abscess in UC,,Clinical Manifestations,,Symptoms: diarrhea abdominal pain, others :

6、tenesmus, anorexia, nausea and vomiting Signs: tenderness in the left hypogastrium and rebound tenderness,Manifestations of digestive system,Systemic manifestations,fever,tachycardia,Anemia, malnutrition, volume depleti

7、on, disturbance in acid-basebalance and hypoalbuminemia in advanced patients,Extra-intestinal manifestations,erythema nodosum, arthritis, ankylosing spondylitis, iritis，episcleritis, conjunctivitis, ulcers of oral mucosa

8、, chronic active hepatitis and so on.,erythema nodosum,,,A.course classificationinitial typechronic relapse typechronic permanent type acute and fulminant type,,Clinical classification,UC,B.Extent classification

9、 (1) mild type (2) moderate type (3)severe type,Classification,,UC,C.range classificationProctitis or proctosigmoiditis:40-50%Left-sided or intermediate colitis :30-40%Pancolitis:20% D.period c

10、lassificationActive phaseAlleviative phase,Classification,,UC,,UC,endoscopic examination,Diseased mucosa: hyperemic and edematous, blood vessels not clear-cut, mucosa erosions and multiple shallow ulcers; rough, fragi

11、le, bleeding easily granular, pus; pseudopolyps seen,Mucosa irregularity, saw-tooth like, loss of haustrations, shortening of colon and pseudopolyps formationContraindicated in fulminant type,UC,Barium enema,typical sy

12、mptoms+one of endoscopic appearances and biopsy (or one of x-ray barium enema signs)+elimination of other alike disease Notice:1.symptoms are not typical,while endoscopic appearances are typical-diagnosis 2.symptoms ar

13、e typical, while endoscopic appearances are not typical-suspect,Diagnosis,Treatment,General treatment,Drug treatment,Sulfasalazine,Corticosteroids,Immune inhibitor,,,,,First choice,Severe patients,Surgical therapy,,,,Ind

14、ications: abscess formation, canceration, perforation, fistula, mega-colon and refractory colitis, failure of medical therapy etc,Second part,The clinical application of Corticosteroids in Ulcerative colitis,Finding,CO

15、RTISONE IN ULCERATIVE COLITIS FINAL REPORT ON A THERAPEUTIC TRIAL,BRITISH MEDICAL JOURNAL On OCTOBER 29 1955,S. C. TRUELOVE, M.D., M.R.C.P. AND L. J. WITTS, M.D., F.R.C.P.,Conclusion,the patients receiving cortisone en

16、joyed a clear-cut advantage over the patients on a dummy preparation. About two out of every five patients on cortisone therapy were in clinical remission at the end of six weeks' treatment, compared with less than

17、one out of every six patients receiving the inert therapy.,,Among the patients treated with cortisone those in their first attack have fared somewhat better than those in relapse.,How to decide the dose of Corticost

18、eroids,,The American Journal of GASTROENTEROLOGY,Ulcerative Colitis Practice Guidelines in Adults,by American College of Gastroenterology Practic Parameters Committee,Ulcerative Colitis Practice Guidelines in Adults,O

19、ral prednisone shows a dose response effect between 20 and 60 mg per day , with 60 mg per day modestly more effective than 40 mg per day but at the expense of greater side-effects .,Ulcerative Colitis Practice Guidelines

20、 in Adults,No randomized trials have studied Corticosteroids taper schedules; most recommendations have advised 40 – 60 mg per day until significant clinical improvement occurs and then a dose taper of 5 – 10 mg weekly

21、until a daily dose of 20 mg is reached. At this point tapering generally proceeds at 2.5 mg per week.,,The therapeutic plan is determined by the Patients condition and preferences,severe and fulminant type,For patients

22、 who suffer from severe and fulminant type of UC ：intravenous injection Corticosteroids is First choice , recommend dosage hydrocortisone 300mg or meprednisone 60mg。,mild and moderate type with largely lesion,For mild a

23、nd moderate patient, First choice oral Sulfasalazine ，while it is not effective，recommend oral prednisone 20～60 mg/d,mild and moderate type with Distal lesion,Corticosteroids topical therapies,Effect of topical administr

24、ation of budesonide and tranditional corticosteroids on active distal ulcerative colitis or proctitis,Shang hai Jiao tong University School of Medicine,Research from,Conclusion,The effects of budesonide and traditional c

25、orticosteroids on active distal Ulcerative colitis or Proctitis are similar.However, budesonide maybe Preferable to traditional corticosteroids ,since its inhibitory effect on Plasma cortisol level is lower than traditi

26、onal corticosteroids.,adverse effects,Such as cushingoid features, emotional and psychiatric disturbances, infections, glaucoma.Complicationsinclude gastroduodenal mucosal injury, impaired wound healing, and metabolic

27、bone disease.,steroid-dependency,Although short term control of symptoms can be achieved with steroid treatment, followed by recurrence during alleviating dose or stopping administration． this pattern of drug response，kn

28、own as steroid-dependency．,The therapeutic plan for steroid-dependency,Azathioprine 2-2.5mg/kg*dCyclosporin therapy for severe ulcerative colitisInfliximab ——could not only maintain the clinical remission in UC patie

29、nts，but also decrease the colon resection rate for patients with moderate to severe refractory UC,Else therapies,intestinal stem cells antibiotics If failure of medical therapy ，the Surgical therapy should be taken.,,T