小児 回腸末端炎の鑑別？

TERMINAL ILEITIS Making the diagnosis: pathologic diagnosis - granuloma is most specific finding (present in 50% biopsies) Rule out: infection acute bacterial infection - Campylobacter, Yersinia, Salmonella, Shigella, gonococcal proctitis, Chlamydia, ETEC, C. difficile, Aeromonas hydrophila chronic bacterial infection - Whipple's disease, TB enterocolitis case report of colonic tuberculosis mimicking Crohn's disease can be found in BMC Gastroenterology 2002 May 13;2:10 Bartonella henselae infection reported in 1 case (Lancet 2000 Oct 7;356(9237):1245), commentary can be found in Lancet 2001 Jun 16;357(9272):1974 amebiasis histoplasmosis (case presentation can be found in N Engl J Med 2005 Feb 3;352(5):489, correction can be found in N Engl J Med 2005 Apr 21;352(16):1731) immunocompromised - TB, Cryptosporidium, HSV, CMV, Isospora belli, MAI, GC, Chlamydia ulcerative colitis, collagenous colitis, microscopic colitis, irritable bowel syndrome, amebiasis, giardiasis, intestinal lymphoma, cancer of ileum or colon, carcinoid tumors, celiac sprue, mesenteric adenitis, diverticulitis, acute appendicitis, polyarteritis nodosa, radiation enteritis, fungal infections (Histoplasma, Actinomyces), alpha chain disease, endometriosis, "gay bowel syndrome", ischemic colitis, eosinophilic gastroenteritis for pneumaturia - bladder cancer, actinic lesions, trauma, xanthogranulomatous pyelonephritis 10-15% colitis of indeterminate origin (can not be distinguished from ulcerative colitis) Testing to consider: useful blood tests may include CBC, chemistries, liver function tests plain abdominal x-ray important if intestinal obstruction suspected, and may be useful to estimate extent and severity of Crohn's colitis small bowel follow-through (SBFT) better than small bowel enteroclysis (SBE) for determining extent of small bowel disease barium swallow may be useful to evaluate upper gastrointestinal tract, ultrasound or CT useful to assess for complications, especially abscesses or masses colonoscopy with biopsy (or surgical biopsy) necessary for definitive diagnosis Blood tests: blood test abnormalities may include electrolyte abnormalities, decreased magnesium, decreased calcium hypoalbuminemia iron deficiency, B12 and folate deficiency leukocytosis, anemia increased erythrocyte sedimentation rate (ESR) normal screening laboratory results may not rule out inflammatory bowel disease based on inception cohort study 526 children with newly diagnosed inflammatory bowel disease from 18 US/Canadian centers prospectively included in registry laboratory tests investigated were hemoglobin level, platelet count, albumin level and erythrocyte sedimentation rate screening tests often normal 26% had normal erythrocyte sedimentation rate, including 18% with moderate/severe disease 32% had normal hemoglobin levels 50% had normal platelet counts 60% had normal albumin levels all 4 values screened normal in 54% with mild ulcerative colitis 21% with mild Crohn's disease 4.3% with moderate/severe ulcerative colitis 3.8% with moderate/severe Crohn's disease Reference - Pediatrics 2007 Jun;119(6):1113 anti-Saccharomyces cerevisiae antibodies (ASCA) or perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) can diagnose but not rule out inflammatory bowel disease (IBD) (level 1 [likely reliable] evidence) based on systematic review of diagnostic cohort studies 60 studies evaluated included 3,841 patients with ulcerative colitis, 4,019 patients with Crohn's disease, and 3,748 controls results reported here for distinguishing IBD (ulcerative colitis or Crohn's disease) from controls positive pANCA in meta-analysis of 27 studies with 6,117 patients 32.8% sensitivity 97.1% specificity positive likelihood ratio 9.842 negative likelihood ratio 0.674 positive ASCA IgA in meta-analysis of 3 studies with 1,651 patients 31.4% sensitivity 96% specificity positive likelihood ratio 6.103 negative likelihood ratio 0.717 presence of ASCA had in meta-analysis of 13 studies with 4,097 patients 39.7% sensitivity 92.5% specificity positive likelihood ratio 4.281 negative likelihood ratio 0.698 presence of pANCA or ASCA IgA or ASCA in meta-analysis of 5 studies with 839 patients 62.6% sensitivity 92.6% specificity positive likelihood ratio 8.777 negative likelihood ratio 0.393 Reference - Am J Gastroenterol 2006 Oct;101(10):2410