2018年 · 第38卷第05期

Medical care is different from other industries because it involves the life safety of individuals. According to the law, its behavior must comply with industry norms, and the consensus guidelines for disease diagnosis and treatment can be regarded as the basis of industry norms. With the progress of medicine, new therapeutic drugs and diagnostic technologies are constantly emerging. These drugs and technologies must be applied reasonably and standardizedly in clinical practice, and at the same time, they need to be consistent with the existing evidence-based medical evidence. Consensus guidelines are the best bridge between evidence-based medical evidence and clinical practice^[1]。 In the development of consensus guidelines^[2,3,4,5,6]Delphi method is one of the important methods in the formulation of consensus guidelines for evidence-based clinical practice. This method was developed by Olaf Helmer and Theodore J. Gordon in the 1940s, using anonymous methods to extensively solicit experts' opinions through several rounds of questionnaires. After repeated information exchange and feedback correction, the opinions of experts gradually tend to be consistent. Finally, according to the comprehensive opinions of experts, it is a quantitative and qualitative prediction and evaluation method to evaluate the evaluation objects. In developing procedures, the most important thing is to raise clinical questions that are important and of clinical need, called PICO questions. P is a participant (patient or a specific condition), I is an intervention (intervention), C is a comparison (comparison), and O is an outcome (outcome). The PICO issue directly influences and guides the entire consensus guidance development process. Of course, in the process of formulating consensus guidelines, in addition to considering the important and influential international research evidence, it is also necessary to closely combine China's disease epidemiological characteristics, genetic background, health economics, drug supply, living habits, etc., so as to better implement and implement it.

Since my country began to recognize IBD in 1956, consensus opinions on the diagnosis and treatment of IBD in China were formulated in 1978, 1993, 2001, 2007 and 2012 respectively. The promulgation and promotion of these consensus opinions have greatly standardized the clinical diagnosis and treatment of IBD in China and improved the treatment level. Epidemiological data in China show that the standardized incidence rate of IBD in Daqing, Heilongjiang Province is 1.77/100,000, and that in Zhongshan, Guangdong Province is 3.14/100,000^[1,2]。 It is not difficult to see that IBD is still a rare disease in China, but the number of patients seeking IBD has been increasing rapidly in the past 20 years^[3]。 At the same time, with the deepening of understanding of IBD, clinical and basic research in China has become more standardized and standardized, so more and more Chinese disease population data can be used to formulate consensus guidelines. In view of this, the IBD group is learning from the latest foreign consensus [4,5,6,7], combined with the domestic research results and actual situation, the consensus opinions on the diagnosis and treatment of IBD in my country in 2012^[8]It was revised to make the new consensus opinion more reflective of current progress, more in-depth and comprehensive in content, and more clinical guidance value.

UC is a continuous, reflux, and non-specific chronic intestinal inflammatory disease involving the colonic mucosa and submucosa. The etiology is unclear and there is no cure for the time being. The incidence of UC in China is increasing year by year, and its diagnosis and treatment methods are constantly being updated. In 2018, the IBD Group of the Gastroenterology Branch of the Chinese Medical Association summarized the latest research results, guidelines and consensus at home and abroad, combined with the actual situation in China, and followed the standardized procedures to make consensus opinions on the diagnosis and treatment of IBD in 2012^[1](hereinafter referred to as the 2012 Consensus) was revised. Consensus Opinions on Diagnosis and Treatment of Inflammatory Bowel Disease (Beijing, 2018)^[2](hereinafter referred to as the 2018 consensus), interpret the differences between the old and new consensus in 2018 and 2012, as well as the updated key points of UC diagnosis and treatment, in order to deepen clinicians' understanding of the new consensus and improve the diagnosis and treatment level of UC.

In 2017, the IBD Group of the Gastroenterology Branch of the Chinese Medical Association launched a new round of updating the consensus opinions on IBD diagnosis and treatment. By drawing on the latest relevant consensus at home and abroad, combining the relevant research results and actual situation in China, the consensus opinions on IBD diagnosis and treatment (2018, Beijing)^[1](hereinafter referred to as the 2018 Consensus) There are many revisions in the diagnosis and treatment of CD. In order to enable readers to better understand the changes of the old and new consensus, the updates on CD diagnosis and treatment in the 2018 consensus are explained in detail.

IBD is a group of chronic nonspecific intestinal inflammatory diseases of unknown etiology, including CD and UC^[1]。 Although the etiology and pathogenesis of the disease are not clear, it is generally believed that the disease is the result of the interaction of immune, genetic, environmental and intestinal microbes. IBD tends to occur in young people, with diverse clinical manifestations. The heterogeneity of symptoms among different patients is obvious and lacks specificity. Common symptoms include gastrointestinal symptoms such as abdominal pain, diarrhea, and bloody stools. Some patients also have systemic symptoms such as weight loss, fever, anemia, and fatigue, as well as extraintestinal manifestations such as oral ulcer, perianal lesions (perianal abscess, anal fistula, etc.), and primary sclerosing cholangitis. Although the above clinical features are not specific, the combination of several manifestations may be a valid clue for the diagnosis of CD, so the diagnosis of CD depends on clinical symptoms, endoscopic, imaging, pathological findings, and excludes other diseases with similar symptoms (intestinal tuberculosis, lymphoma, etc.). In recent years, the incidence of IBD in China has been increasing, which needs to be paid enough attention to. In this study, the clinical data of hospitalized patients with IBD were retrospectively analyzed, which can provide clinical basis for the diagnosis and treatment of IBD.

IBD, which includes UC and CD, is a chronic non-specific intestinal inflammatory disease with unknown cause and pathogenesis. IBD patients in remission often have IBS-like symptoms such as abdominal pain and abnormal defecation, which not only seriously affect the patient's mental health and quality of life, but also may lead to changes in treatment plans, resulting in adverse drug reactions and increased treatment costs. During external stimulation, excitatory neurotransmitters such as substance P, calcitonin gene-related peptide (CGRP), nerve growth factor, serotonin, etc. in the colon and spinal cord are released, which act on the corresponding nerve end receptors, resulting in visceral hypersensitivity; Visceral hypersensitivity runs throughout IBD, and the pain threshold for rectal dilatation decreases and the visceral sensory score increases in IBD patients in remission. Patients with IBD in remission with IBS-like symptoms have reduced intestinal epithelial cell-to-cell tight junction proteins zonula occludens-1 (ZO-1) and α-catenin (α-catenin), and increased intestinal permeability, which can make pathogenic bacteria, toxins and antigens in the intestinal lumen penetrate into the intestinal mucosa; In addition, the number of intraepithelial lymphocytes and the expression level of the pro-inflammatory factor TNF-α in colon tissue were elevated. The pathogenesis of IBS-like symptoms is associated with increased intestinal permeability, low-grade inflammation of the intestinal mucosa, and visceral hypersensitivity^[1]。 There is intestinal dysbiosis in IBD and IBS patients, and the role of intestinal dysbiosis in the development of IBS-like symptoms in IBD patients is unclear. The purpose of this study was to investigate the effects of fecal filtrate from UC patients and dextran sulfate sodium (DSS) -induced colitis mice on intestinal inflammation, intestinal ZO-1 and visceral sensitivity in normal mice, and to investigate the effects of fecal filtrate from UC patients on IBS-like symptoms of UC in remission.

IBS is a common recurrent functional gastrointestinal disease with unclear etiology and pathogenesis. Diarrhea type IBS is the main disease in China. Studies show that intestinal dysbiosis is closely related to IBS^[1]。 Intestinal cleansing is an essential procedure before colonoscopy in gastroenterology department, but there are few studies on the influence of intestinal cleansing on disease symptoms and bacterial flora. This study intends to conduct a preliminary discussion on this problem, aiming at providing clues for intestinal cleansing as an adjuvant treatment for IBS.

The disease course of autoimmune hepatitis (AIH) is prolonged and difficult to cure. Evaluating the progression of liver fibrosis and cirrhosis during long-term follow-up of patients is the key to adjust the treatment and improve the prognosis. Although liver puncture biopsy is the gold standard for evaluating liver fibrosis, it is an invasive operation, and it is not easy for patients to accept dynamic monitoring of liver lesion progression by multiple liver punctures. There is still a lack of valid and non-invasive tools that can dynamically assess the progression of liver fibrosis in patients with AIH. The transient elastography detector FibroTouch is based on ultrasound examination, and the degree of liver fibrosis is determined by using low frequency elastic shear wave to measure liver stiffness (LSM)^[1]It has the advantages of non-invasive, rapid, quantifiable and reproducible, and its value in the follow-up of hepatitis B and fatty liver is gradually recognized. Liver biopsy removed only 1/50 000 of liver tissue, whereas FibroTouch measurement representsTable 1/500 liver tissue, which has important advantages in the quantitative assessment of liver fibrosis^[2]。 The purpose of this study was to evaluate the value of FibroTouch in the diagnosis of liver fibrosis in patients with AIH and its influencing factors.

Colonic ulcerative lesions are mostly difficult and complicated diseases, which need to be differentiated from tuberculosis, IBD, lymphoma, Behcet's disease, infectious bowel disease, etc. clinically; Especially in patients with lung shadows found by imaging examination and abnormal laboratory tests of tuberculosis, it is extremely difficult to distinguish between colonic ulcerative lesions and intestinal tuberculosis. Systemic vasculitis is a group of diseases with inflammation and destruction of blood vessels as the main pathological changes. It can occultly involve many organs in the whole body, and the main manifestations are ischemia, bleeding and inflammation of the organs belonging to it^[1]。 Systemic vasculitis often involves the skin, kidney, lung, nervous system, etc. Its clinical manifestations are complex and diverse, without specificity, and it is difficult to diagnose early. Xi' an Xijing Hospital once treated a patient with multiple organ injuries such as lung shadows, colon ulcers and skin nodules. Combined with multiple CT examinations, pathological biopsy (hereinafter referred to as biopsy), colonoscopy, anti-tuberculosis diagnostic treatment and other multidisciplinary discussions, tuberculosis was finally ruled out, systemic vasculitis was considered, and it was improved after glucocorticoid treatment. The diagnosis and treatment of this patient are discussed comprehensively, aiming at improving clinicians' understanding of this disease, so as to make a clear diagnosis as soon as possible, treat it in time and improve the prognosis in the future.

IBD is a chronic non-specific recurrent intestinal disease involved by genetics, environment, infection, intestinal microorganisms and immunity, including UC, CD and undefined enteritis. Its main clinical manifestations are abdominal pain, diarrhea, mucus, pus and bloody stool. Studies have shown that offspring of patients with UC and CD have a 2-to 13-fold higher risk of developing IBD than the general population^[1]。 The peak incidence of IBD is young people, which overlaps with the reproductive age. Therefore, fertility problems are very important in the management of IBD patients, but at present, there is less attention to fertility problems of male IBD patients. A survey study showed that UC patients expressed the desire to have children more strongly than CD patients, CD patients hesitated at a higher rate, and considered the safety of drugs when preparing for pregnancy and maintaining remission more than those who did not receive treatment^[2]。 Infertility is defined as a couple of childbearing age living together for 1 year and failing to conceive without any contraceptive measures. The incidence of infertility in men with IBD is difficult to determine, but research has begun to focus on this aspect. Some studies suggest that more than half of male IBD patients have different degrees of fertility decline, accounting for 8% to 17% of the general population^[3]。 A recent multicenter cross-sectional study found lower sperm quality in CD patients compared to those with UC^[4]。 The degree of disease activity, nutritional status, drugs, surgery, ethanol abuse, smoking, psychological factors, etc. all affect the fertility of male IBD patients. In addition, related studies have shown that colorectal surgery required during the course of UC patients may be associated with sexual dysfunction^[5]。 Therefore, the influence of IBD on fertility of male patients will be reviewed from the aspects of IBD treatment drugs and surgery.

IBD is a group of chronic nonspecific inflammatory bowel diseases of unknown etiology, including UC and CD. Because IBD can involve multiple systems, its clinical manifestations are diverse, but the division of domestic hospitals is becoming more and more detailed, and difficult and complicated diseases involving multiple disciplines are easy to become the "three no cares" zone. In this context, a multi-disciplinary team (MDT) diagnosis and treatment model for complex diseases similar to IBD has emerged. For example, the University of Texas Anderson Cancer Center in the United States divided the whole center into 12 MDT groups, and patients can be assigned to different MDT groups for diagnosis and treatment according to individual characteristics, and a large number of high-level scientific research projects have been spawned. In addition, to increase the emphasis on MDT, the National Cancer Institute (NCI) accredited MDT-eligible Cancer centers as designated "Comprehensive Cancer Research Centers."^[1]。 China's MDT model started late, and its application in the field of IBD still needs to be improved in many aspects, especially in the integration into scientific research. Combined with the scientific research of MDT carried out by Guangdong Provincial People's Hospital and the experience of peers at home and abroad, several key "clinical-scientific research" problems that need to be solved in MDT in IBD field are discussed.

A 65-year-old male was admitted to the Department of Gastroenterology, Beijing Shijitan Hospital on June 9, 2015 due to "intermittent lower limb swelling for 10 years, aggravated with abdominal distension for more than 3 months". Ten years ago, the patient began to intermittently develop symmetric depressed edema of both lower limbs. He was diagnosed with hypoalbuminemia, which was not paid attention to and treated. Three months ago, he reappeared edema of both lower limbs, accompanied by abdominal distension and anorexia. He visited the local hospital many times, suggesting hypoalbuminemia and massive ascites. He was given symptomatic treatment such as diuresis and albumin supplementation, and his symptoms were slightly improved. After improving the relevant examinations, he considered the possibility of abdominal lymphatic fistula and abdominal infection at the same time. After symptomatic treatment such as anti-infection, albumin supplementation and diuresis, he was improved and discharged. After discharge, abdominal distension aggravated again, abdominal circumference increased, and low fever was repeatedly seen.