试验性抗结核治疗鉴别肠结核与克罗恩病的临床与内镜分析

CHnical and endoscopic evaluation of anti-tuberculosis trial for differentiation between intestinal tuberculosis and Crohn＇s disease

目的探讨试验性抗结核治疗鉴别诊断肠结核与克罗恩病的评估标准及合适的判断时间点。方法回顾分析接受试验性抗结核治疗且最后得以确诊的28例肠结核（ITB）和11例克罗恩病（CD）患者在治疗过程中临床表现及肠镜下的改变。结果2组患者基线时较特异的临床特征包括活动性肺结核、PPD强阳性、肛瘘或肛周脓肿等差异均无统计学意义。抗结核治疗后2组临床症状均有改善，但3个月后ITB组无好转率为0，CD组为27．3％（P=0．004）。抗结核治疗3个月及6个月，ITB组活动性溃疡消失率＋明显好转率分别为90．9％（20／22）＋9．1％（2／22）及100％（28／28）＋0；结节样病变消失率＋明显好转率为58．8％（10／17）＋41．2％（7／17）及76．5％（13／17）＋23．5％（4／17）。而CD组在各时点活动性溃疡、结节样病变均无明显好转（P均〈0．01）。结论ITB和CD的鉴别因缺乏特异性指标，部分鉴别困难的病例仍需采用试验性抗结核治疗。试验性抗结核治疗后3个月，回结肠镜复查见活动性溃疡及结节样病变消失或明显好转，伴临床症状痊愈或明显好转可评定为试验治疗有效。

Objective To investigate the evaluation standard and proper time point of anti-tuberculosis trial for differential diagnosis between intestinal tuberculosis （ITB） and Crohn＇s disease （CD）. Methods Clinical data and endoscopic changes of 28 patients with confirmed ITB and Ⅱ with confirmed CD, who underwent anti-tuberculosis trail, were retrospectively analyzed. Results No significant difference could be found in clinical characteristics of ITB and CD patients on baseline, such as active pulmonary tuberculosis, strong positive skin test and anal fistula/perianal abscess. Clinical symptoms were relieved in beth groups right after anti-tuberculosis treatment. After 3 months of treatment, the no-improvement rate in ITB group was O, whereas that of CD group was 27. 3% （P =0. 004）. The disappearance rate plus improvement rate of ulcer in ITB group was 90. 9% （20/22） plus 9. 1% （2/22） and 100% （28/28） plus 0 at 3 and 6 months of treatment, respectively. The disappearance rate plus improvement rate of nodular lesion was 58. 8% （10/17） plus 41.2% （7/17） and 76. 5% （13/17） plus 23.5% （4/17）, respectively. There was no obvious improvement of active ulcer or nodular transformation in CD group at any time point （P 〈 0.01 ）. Conclusion With deficiency of special index for differential diagnosis of ITB and CD, some cases hard to differentiate still have to accept anti-tuberculosis treatment. Three months of anti-tuberculosis treatment is a proper time point to evaluate the efficacy. Disappearance of active ulcer and nodular transformation, together with cure or obvious improvement in clinic are taken as effective for treatment trail.