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摘要: 结肠憩室炎是一种十分常见的胃肠道疾病,可为急性或慢性病程。本文报道1例慢性结肠憩室炎患者的诊疗经过。该患者临床表现不典型,影像学检查示占位性病变可能性大,PET/CT示代谢增高灶,急性期结肠镜检查可见黏膜隆起、病理回报为炎症,但仍需与结直肠癌、炎症性肠病进行鉴别。综合考虑后予以随访观察的建议,并最终明确诊断。该患者的诊治经过体现了循证医学在疾病诊断与治疗中的重要意义。Abstract: Colonic diverticulitis is a common gastrointestinal disease which can be acute or chronic in course. In this paper we report the management of a patient with chronic colonic diverticulitis. The patient had an atypical clinical presentation, whose imaging showed a high likelihood of occupying lesions. PET/CT showed hypermetabolism focus and colonoscopy saw mucosal thickening, pathological return of inflammation in the acute phase, which were difficult in differential diagnosis with colorectal cancer and inflammatory bowel disease. After comprehensive consideration, follow-up observation was recommended and the diagnosis was finally clarified. The management of this patient demonstrates the importance of evidence-based medicine in the diagnosis and treatment of diseases.中国医学科学院北京协和医院消化内科 杨红教授结肠憩室炎反复或慢性持续发作导致的炎症反应、肉芽组织增生与部分CRC患者的表现存在很大程度的相似之处,加上临床症状缺乏特异性,导致二者的鉴别诊断存在一定困难,影响后续治疗决策的制订。该患者为老年女性、慢性病程,外院检查无法除外乙状结肠占位性病变,此次住院评估后考虑乙状结肠病灶暂无恶变证据,嘱患者定期随访。在为期1年的随访过程中患者肠壁增厚、乙状结肠隆起明显好转,结肠憩室炎得以明确诊断。循证医学引入中国已有20余年并得到了广泛应用,其核心思想是予以患者关照和尊重,将循证医学融入日常的临床工作中无疑会为患者带来便利。在综合最佳证据、明确证据可信度与权衡获益及风险后,基于循证医学证据对该患者的病情作出个体化评估,有助于明确诊断思路并厘清后续治疗方法、避免有创操作,为患者提供最优的诊疗路径。作者贡献:于子清负责收集资料、撰写论文;吴斌、唐晓妍负责审阅论文;杨红负责修订论文。利益冲突:所有作者均声明不存在利益冲突
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表 1 不同检查方式对结肠憩室炎诊断价值比较
第一作者(年份) 检查方式 样本(n) Se(%, 95% CI) Sp(%, 95% CI) LR+(95% CI) LR-(95% CI) Qaseem等[6],Balk等[7](2022年) CT 684 94(97~97) 99(90~99.9) 78.4(8.7~706.6) 0.06(0.03~0.13) Laméris等[8](2008年) 超声 630 92(80~97) 90(82~95) 9.6(5.0~18.6) 0.09(0.04~0.23) Andeweg等[9](2014年),Liljegren等[10](2007年) CT 684 95(91~97) 96(90~100) 30.62(16.07~58.36) 0.10(0.07~0.15) Andeweg等[9](2014年) 超声 698 90(76~98) 90(86~94) 12.83(7.42~22.19) 0.12(0.08~0.17) Andeweg等[9](2014年) MRI 57 98 70~78 4.40(1.30~14.96) 0.03(0.004~0.20) Se:灵敏度;Sp:特异度;LR+:阳性似然比;LR-:阴性似然比 表 2 结肠憩室炎患者后续罹患CRC的风险
第一作者(年份) 样本(n) 结肠憩室炎发生癌前病变的风险(OR) 结肠憩室炎发生CRC的风险(%,95% CI) 单纯性结肠憩室炎发生CRC的风险(%,95% CI) 复杂性结肠憩室炎发生CRC的风险(%,95% CI) 复杂性/单纯性憩室炎发生CRC的风险比较(RR,95% CI) Qaseem等[13],Balk等[14](2022年) 1721/2635 0.62 - - - - Koo等[15](2020年) 31 741 - 1.67(1.24~2.14) 1.22(0.63~1.97) 6.14(3.20~9.82) 5.033(3.714~7.930) Sharma等[16](2014年) 1970 - 1.6(0.9~2.8) 0.7(0.3~1.4) 10.8(5.2~21.0) - de Vries等[17](2014年) 2490 - - 1.16(0.72~1.9) - - CRC: 结直肠癌;-:无相关数据 -
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