克罗恩病与肠结核的鉴别诊断研究

Study of Differential Diagnosis Between Crohn′s Disease and Intestinal Tuberculosis

目的对比研究克罗恩病(Crohn′s disease,CD)与肠结核(intestinal tuberculosis,ITB)的临床、实验室检查、内镜及病理特点,为两者的鉴别诊断提供依据。方法回顾性分析作者医院2016-01/2020-09月收治的34例CD及46例ITB患者的临床表现、实验室检查结果、内镜特征及病理特点等资料。结果与ITB相比,CD患者男性多见,好发于年轻人,城市人口高发,确诊时间长(P<0.05),而ITB肠外结核病史比例更高(P<0.05)。CD患者肠梗阻、肛周病变、肠外表现多于ITB患者,而ITB患者盗汗、腹水多于CD患者(P<0.05)。CD患者核周型抗中性粒细胞胞浆抗体(perinuclear anti-neutrophil cytoplasmic antibody,pANCA)、抗酿酒酵母抗体(perinuclear anti-neutrophil cytoplasmic antibody,ASCA)阳性率明显高于ITB患者(P<0.05),CD患者结核菌杆菌纯蛋白衍化物(purified protein derivative,PPD)阳性率、结核感染干扰素释放试验(interferon gamma release assays,IGRAs)阳性率、胸片/胸部电子计算机断层扫描(computed tomography,CT)异常比例均低于ITB患者(P<0.05)。CD患者纵向溃疡、鹅卵石征、节段性病变、病变≥4个节段、累及直肠、黏膜桥形成更加多见(P<0.05),而ITB患者环形溃疡、回盲瓣固定开放检出比例更高(P<0.05)。CD患者病理组织学检查神经节细胞增生、裂隙样溃疡、多部位炎症细胞浸润、隐窝结构破坏、淋巴细胞聚集/淋巴小结、非干酪样肉芽肿更加多见(P<0.05),而干酪样肉芽肿、组织抗酸染色阳性仅在ITB患者检出,且检出比例不高。结论CD与ITB临床鉴别诊断困难,综合分析临床、实验室检查、内镜及病理特点等资料做出判断,可提高诊断准确率。构建鉴别诊断模型是值得研究的一个方向。

Objective To compare the clinical,laboratory inspective,endoscopic and pathological features,between Crohn′s disease(CD)and intestinal tuberculosis(ITB),so as to provide the bases for differential diagnosis of the two.Methods A total of 34 CD patients and 46 ITB patients who were treated in author′s hospital from January 2016 to September 2020 were retrospectively analyzed,including the clinical symptoms,laboratory inspective results,endoscopic features and pathological characteristics of these patients.Results Compared with ITB patients,CD patients were more common in males,more frequently in young people,higher incidence among urban population and longer diagnosis time(P<0.05),while the proportion of parenteral tuberculosis of ITB patients were higher(P<0.05).Intestinal obstruction,perianal lesions and extraintestinal manifestations in CD patients were more than those in ITB patients,while night sweat and ascites in ITB patients were more than those in CD patients(P<0.05).The positive rates of perinuclear antineutrophil cytoplasmic antibody(pANCA)and perinuclear anti-neutrophil cytoplasmic antibody(ASCA)in CD patients were significantly higher than those in ITB patients(P<0.05).The positive rates of purified protein derivative(PPD)and interferon gamma release assays(IGRAs),abnormal rate of chest film/chest computed tomography(CT)in CD patients were lower than those in ITB patients(P<0.05).Longitudinal ulcer,cobblestone sign,segmental lesions,lesions≥4 segments,involving rectum and mucosal bridge formation were more common among CD patients(P<0.05),while annular ulcer,fixed and open ileocecal valve were more common among ITB patients(P<0.05).In CD patients,ganglion cell proliferation,fissure like ulcer,multiple inflammatory cell infiltration,crypt structure destruction,lymphocyte aggregation/lymph nodes and non caseous granuloma were more common(P<0.05),while caseous granuloma and positive tissue acid fast staining were only detected in ITB patients,and the check out rate was not high.Conclusion The clinical differential diagnosis between CD and ITB is difficult.Comprehensive analysis of clinical,laboratory inspective,endoscopic and pathological features can improve the diagnostic accuracy.Constructing differential diagnosis model is a direction worthy of research.