【作者】 杨艳；

【导师】 余保平；

【作者基本信息】 武汉大学 ， 临床医学（八年制）， 2016， 博士

【摘要】 目的：小肠疾病是消化系统临床常见的疑难疾病之一,青少年发生小肠疾病,可严重影响患者的生长发育,因此,小肠疾病的早期诊断对疾病的治疗有很大指导意义。人体小肠长达5-7米,远离肛门、口腔,并在体内形成肠襻,常规内镜难以达到深部小肠,双气囊小肠镜通过气囊的辅助,可以到达深部小肠,完成全小肠的检查,对小肠疾病的诊断意义重大。本文旨在通过分析疑有小肠疾病并行小肠镜检查的青少年人群的病例资料,对其临床表现进行分析整理,结合患者出院临床诊断和随访结果,初步了解青少年人群小肠疾病的临床表现特点及常见病因,探讨双气囊小肠镜对青少年小肠疾病的诊断价值。方法：收集武汉大学人民医院从2007年9月-2015年3月期间所有怀疑小肠疾病并在该院消化内镜中心行双气囊电子小肠镜检查的患者,共纳入28岁及28岁以内的青少年患者共计59例,并按年龄分为少儿组和青年组,分析和比较两组患者的临床症状表现、致病病因及双气囊小肠镜诊断结果。结果：1、按年龄分组：少儿组共计18例,其中男性16例、女性2例,年龄12-17岁,平均15.6±1.4岁；青年组共计41例,其中男性36例、女性5例,年龄18-28岁,平均23.5±3.0岁；两组在性别分布上无统计学差异(x2=0.014,P=0.905)。2、临床表现：青少年患者小肠疾病多以便血(33.9%)、黑便(27.1%)、腹痛(20.3%)等消化道症状为临床表现；其中少儿组依次以黑便(27.8%)便血(22.2%)、腹痛(22.2%)为临床症状就诊；青少年患者小肠疾病依次以便血(39.0%)、黑便(26.8%)、腹痛(19.5%)等消化道症状为临床表现；两组在就诊症状分布上无统计学差异(x2=2.536,P=0.864)。3、消化道出血：42例青少年患者有消化道出血症状,29例(69.0%)为急性出血,其中13例(44.8%)急性出血患者有既往出血史;13例(30.9%)为慢性出血,最常见病因分别为小肠憩室9例(32.0%)、克罗恩病5例(38.5%)；12例少儿患者有消化道出血症状,其中8例为急性出血,4例为慢性出血,最常见病因分别为小肠憩室5例(62.5%)、克罗恩病2例(50%)；30例青年患者有消化道出血症状,21例为急性出血,9例为慢性出血,最常见病因分别为重复畸形5例(23.8%)、克罗恩病3例(33.3%)；两组患者在急慢性出血表现无统计学差异(x2=0.045,P=0.833)。4、腹痛：18例青少年患者有腹痛症状,慢性腹痛11例(61.1%),最常见病因为克罗恩病9例(50%)；其中7例少儿患者有腹痛症状,4例(57.1%)为慢性腹痛,最常见病因为克罗恩病4例(57.1%)；11例青年患者有腹痛症状,7例(63.6%)为慢性腹痛,最常见病因为克罗恩病5例(45.5%),两组患者在病程表现上无统计学差异(x2=0.076,P=0.783)。5、小肠镜检查情况：在收集的病例中,完成全小肠检查的共计12人,全小肠检查完成率为20.3%,其中少儿组2人,全小肠检查率为11.1%,成人组共计10人,全小肠检查完成率为24.4%,两组全小肠检查完成率无统计学差异(P=0.415)。双气囊小肠镜检查对胃肠道病变检出率为78.0%,小肠病变检出率为74.6%,其中少儿组总病变检出率为83.3%,青年组总病变检出率为75.6%；少儿组消化道出血患者病变检出率为91.7%,青年组消化道出血患者病变检出率为70.0%；少儿组腹痛患者病变检出率为71.4%,青年组腹痛患者病变检出率为81.8%；各组病变检出率均无统计学差异(P=0.276-1.000)。在疾病种类上,少儿组和青年组病变种类分布无统计学差异(P=0.725),所有检出小肠病变类别依次为炎性改变(45.5%)、肠道畸形(38.6%)、血管病变(6.8%)、息肉(4.5%)、肿瘤(2.3%)和其他疾病(2.3%)。病变部位上,少儿组和青年组病变部位分布无统计学差异(P=0.250),青少年小肠病变好发部位依次为回肠、空肠、十二指肠。6、与其他检查比较：双气囊小肠镜与CT/CTE(7例)诊断一致性较差,与胶囊内镜(4例)诊断一致性较好,与DSA(2例)相比诊断一致性好,诊断一致性Kappa值分别为0,0.5,1.0。7、安全性：双气囊小肠镜应用于诊断青少年小肠疾病安全性较高,两组患者均未出现严重并发症,仅术后有一过性高淀粉酶血症,少儿组、青年组发生率分别为5.6%、9.8%,青少年总发生率为8.5%,两组术后高淀粉酶血症发生率无统计学差异(P=0.580)。结论：青少年小肠疾病多好发于男性,临床表现不具有特异性,多以消化道出血和腹痛为临床表现,小肠肠道畸形和克罗恩病患者多以消化道出血为首发症状；小肠克罗恩病患者还可出现慢性腹痛等临床表现。青少年小肠病变以性改变和肠道畸形为主,其中以回肠最易受累。双气囊小肠镜对青少年小肠疾病检出率较高,安全性较好,是临床诊断少年儿童等特殊人群小肠疾病的有效手段。更多还原

【Abstract】 Objective:Small bowel diseases are one of the most puzzling digestive diseases. Small bowel diseases can seriously stunt the growth and development of teenagers. Therefore, early diagnosis of small bowel disease is of great importance for the treatment of the diseases. Human small intestine is about 5-7 meters in length, tortuous and far away from both ends of the digestive tract, which makes it difficult for conventional endoscopy to achieve the lesions in the small bowel. Whereas, double-balloon enteroscopy assisted with two balloons can achieve a great insertion depth, complete pan-intestine examination, rendering it useful for the diagnosis of small bowel disorders. This paper aims to get a preliminary understanding of the clinical manifestations of small bowel diseases in children and youths and their potentional common causes, and also to explore the value of double-balloon enteroscopy in detecting small bowel diseases, by analyzing the case files of teenagers who were suspected with small bowel disease and underwent a double-balloon enteroscopy and combining with the clinical diagnosis of patients discharged from hospital and follow-up results.Methods:All patients suspected with small bowel disorders who visited the endoscopic center and underwent double-balloon enteroscopy in Renmin Hospital of Wuhan University from September 2007 to March 2015 were collected. In total,59 patients younger than 28-year-old were included. According to age,59 included patients were divided into the Children Group and the Youth Group. The clinical symptoms, the potential causes of the two groups and the results of double-balloon enteroscopy were analyzed and compared.Results:1.Groups:All the included patients suspectedd with small bowel disorders who visited the endoscopic center and underwent double-balloon enteroscopy in Renmin Hospital of Wuhan University from September 2007 to March 2015 were divided into the Children Group and the Youth Group:There were a total of 18 cases in the Children Group, including 16 males and 2 females, aged 12-17 years, the mean ages were 15.6±1.4 years; There were a total of 41 cases in the Youth Group, including 36 males and 5 females, aged 18-28 years, mean ages were 23.5±3.0 years; There was no significant difference between the two groups (x2=0.014, P=0.905) in the gender distribution.2. Clinical manifestations:Overall, the patients with small bowel disorders complained mostly of hematochezia (33.9%), melena (27.1%), abdominal pain (20.3%); whereas the Children Group complained mostly of melena (27.8%), hematochezia (22.2%), abdominal pain (22.2%); the Youth Group complained mostly of hematochezia (39.0%), melena (26.8%), abdominal pain (19.5%); There was no significant difference (x2=2.536, P=0.864) between the two groups in the symptoms distribution.3. Obscure gastrointestinal bleeding:There was a total of 42 patients who complained of obscure gastrointestinal bleeding,29 cases (69.0%) presented with acute hemorrhage, of which 13 cases (44.8%) with acute hemorrhage had a previous history of bleeding, the other 13 cases (30.9%) presented with chronic bleeding, in which the most common causes were intestinal diverticulum in 9 cases (32.0%), Crohn’s disease in 5 cases (38.5%), respectively; 12 patients in the Children Group complained of gastrointestinal bleeding, in which 8 cases presented with acute hemorrhage and 4 cases presented with chronic bleeding. The most common causes were intestinal diverticulum in 5 cases (62.5%), Crohn’s disease in 2 cases (50%), respectively; 30 cases of the young patients complained of gastrointestinal bleeding, including 21 cases presenting with acute hemorrhage and 9 cases presented with chronic bleeding. The most common causes were enteric duplication in 5 cases (23.8%), Crohn’s disease in 3 cases (33.3%), respectively; There was no significant difference (x2=0.045, P=0.833) between the two groups in the course distribution.4. Abdominal pain:A total of 18 patients complained of abdominal pain,11 presented with chronic abdominal pain. Overall, the most common cause of abdominal pain was Crohn’s disease in 9 cases (50%); 7 patients were children who complained of abdominal pain, and 4 cases were children with chronic abdominal pain. The most common cause of abdominal pain in children was Crohn’s disease in 4 cases (57.1%); 11 young patients were with abdominal pain, and 7 patients presented with chronic abdominal pain. The most common cause of abdominal pain in young patients was Crohn’s disease in 5 cases (45.5%). There was no significant difference (x2=0.076, P=0.783) between two groups inn the course distribution..5. Double-balloon enteroscopy:In all the cases, there were a total of 12 patients who completed a whole small intestine examination, with a completion rate of 20.3%, including 2 children and 10 youths. The completion rate of the whole small intestine in children and youths was 11.1% and 24.4%, respectively. There was no significant difference (P=0.415) between the two groups in the completion rate. The detection rate of double-balloon enteroscopy was 78.0% for gastrointestinal lesions and 74.6% for small bowel lesions.In the Children Group, the total lesion detection rate was 83.3%, while in the Youth Group, the total lesion detection rate was 75.6%. In patients with obscure gastrointestinal bleeding in the Children Group, the lesion detection rate was 91.7%, while in the youth group, the rate was 70.0%. The lesion detection rate in children with abdominal pain was 71.4%, while in youth, the rate was 81.8%; There was no significant difference (P=0.276-1.000) in lesion detection rate between the two groups. There was no significance (P=0.725) between the Children and the Youth groups in the distribution of types of lesions. The most common lesion detected in the small intestine was inflammatory changes (45.5%), followed by intestinal malformations (38.6%), vascular disease (6.8%), polyps (4.5%), cancer (2.3%) and others (2.3%). There was no significance (P=0.250)between the Children and the Youth Groups in the location distribution of the lesions detected, ileum being the most commonly involved, followed by the jejunum and the duodenum.6. Comparison with other examinations:When compared with other examinations, there was a poor diagnostic consistency between double-balloon enteroscopy and CT/CTE (7 cases), a moderate diagnostic consistency between double-balloon eneteroscoy and capsule endoscopy (n=4), a high diagnosis consistency between double-balloon eneteroscoy and DSA (2 cases), with the Kappa values being 0,0.5,1.0, respectively.7. Safety:Double-balloon enteroscopy was a safe way to diagnose small intestinal diseases. Apart from a transient hyperamylasemia, there were no serious complications in the two groups, and the complication rate was 5.6%,9.8%, respectively, and a pooled complication rate of 8.5%.Conclusion:Small intestinal diseases occured mainly in men, and the clinical manifestations in children and young people are not specific, mostly presented with gastrointestinal bleeding and abdominal pain. Most teenagers with small intestinal malformations and Crohn’s disease presented with gastrointestinal bleeding as the first symptom, while patients with Crohn’s disease might be accompanied with other symptoms such as chronic abdominal pain. Inflammatory changes and small intestinal malformation most commonly occurred in teenagers, with ileum being the most likely site involved. Double balloon enteroscopy boast a higher diagnostic yield and safety for detecting small intestinal diseases in teenagers, which makes it an effective means in the diagnosis of small intestinal disease.更多还原