阵发性睡眠性血红蛋白尿并发缺血性肠病临床特点分析

Clinical characteristics of paroxysmal nocturnal hemoglobinuria (PNH) complicated with ischemic bowel disease

阵发性睡眠性血红蛋白尿症(paroxysmal nocturnal hemoglobinuria,PNH)是一种罕见的获得性造血干细胞疾病。PNH胃肠道受累非常少见。本研究旨在总结和分析PNH并发缺血性肠病的临床特点。收集并总结自2010年1月至2020年12月在北京协和医院诊断的6例PNH并发缺血性肠病患者的临床资料。发现PNH并发缺血性肠病好发于青中年,中位发病年龄为31岁,男性多见。疾病多呈慢性反复发作,表现为腹痛(5/6)、消化道出血(5/6)。实验室检查可见全血细胞减少,网织红细胞百分比增高,血清乳酸脱氢酶、D-二聚体、C-反应蛋白等指标明显增高,多伴有胆红素水平增高。疾病好发于小肠,可同时累及结肠,单纯结肠病变相对少见,病变呈多节段性分布。腹部CT检查可见肠壁增厚并毛糙或渗出(6/6),肠系膜密度增高或呈"梳状征"(4/6),多数患者存在胆汁淤积或胆囊结石(5/6)。内镜下表现为不规则浅溃疡,环腔分布(5/6),病变界限分明,黏膜肿胀(6/6)。病理活检表现为黏膜慢性炎性改变。治疗上激素治疗联合抗凝治疗效果优于单纯激素治疗。PNH并发缺血性肠病与典型的缺血性肠炎表现有所不同,青中年、小肠受累、多发节段性病变多见,且伴有提示血管内溶血的实验室检查证据,早期识别和诊断,给予积极的激素联合抗凝治疗效果较为理想。

Paroxysmal nocturnal hemoglobinuria(PNH)is a rare acquired hematopoietic stem cell disease.Gastrointestinal involvement is rarely seen in PNH.This study aims to analyze the clinical features in PNH patients complicated with ischemic bowel disease.Clinical date of 6 patients were collected at Peking Union Medical College Hospital from January 2010 to December 2020.The clinical manifestations,laboratory tests,imaging,endoscopic,and histopathological features and treatment were analyzed.Five in 6 patients were men,with a median age of 31 years old at onset.Most of disease course were recurrent episodes of chronic disease,with abdominal pain(5/6)and gastrointestinal bleeding(5/6).Laboratory examinations showed pancytopenia,reticulocytosis,elevated serum lactate dehydrogenase,high D-dimer and C-reactive protein levels in all patients.Multiple segments of small intestine were the most commonly involved and colon was also affected.Abdominal CT scan showed thickening and roughness or exudation of the intestinal wall(6/6),increased mesenteric density or“comb sign”(4/6),and cholestasis or gallbladder stones(5/6).Endoscopic manifestations included irregular shallow ulcers in the annular cavity(5/6),swelling mucosa with well-defined margins(6/6).Pathological biopsy revealed chronic inflammation of mucosa.The efficacy of steroids combined with anticoagulant therapy was better than that of steroids alone.Ischemic bowel disease in PNH patients is different from typical ischemic enteritis.Young patients,involvement of intestine with multiple segments are common characteristics.The anticoagulant is an essential agent for these patients.