INTESTINE Vol.16 No.3(1)

特集名 クローン病のTherapeutic Strategy ─ mucosal healingは治療のゴールか
題名 [総論]クローン病治療に当たっての各画像診断法(modality)の意義 ─ 治療方針決定と治療効果判定
発刊年月 2012年 05月
著者 久松 理一 慶應義塾大学医学部消化器内科
著者 緒方 晴彦 慶應義塾大学病院内視鏡センター
【 要旨 】 生物学的製剤の登場によりクローン病治療のストラテジー,治療目標が大きく変化している.もっとも重要な点は,クローン病について腸管機能障害をきたす進行性の疾患ととらえ,早期治療介入により長期予後を改善させようとすることである.具体的な治療目標として注目されているのが“粘膜治癒”という概念であり,これは臨床症状の改善だけでなく内視鏡所見における潰瘍病変の治癒を目標としている.しかし“粘膜治癒”の取り扱いについては議論の余地が残されている.バルーン小腸内視鏡やカプセル内視鏡の開発により小腸の微細病変の観察も可能となったが,その取り扱いについては定まっていない.CTやMRIなどのcross sectional imagingの解像度の進歩により,腸管外病変のみならず粘膜病変自体の評価もこれらのモダリティーで可能となってきているが,“粘膜治癒”の評価が可能かどうかは今後の課題である.このように,実臨床の現場ではクローン病の活動性や粘膜治癒をどのように客観的に評価するのかは定まっておらず,今まさに議論が始まったばかりである.クローン病の長期予後の改善のためには適切な時期に適切な治療を行うことが重要であり,そのためにはさまざまなモダリティーの特徴を知り活用する必要がある.
Theme Therapeutic strategy for Crohn's disease -- Should mucosal healing be a final goal?
Title Role of endoscopy and imaging study in management of Crohn's disease
Author Tadakazu Hisamatsu Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University
Author Haruhiko Ogata Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University
[ Summary ] The development of biologics has dramatically changed the strategies used for Crohn's disease therapeutics. Because of this, the goals of treatment have been changed. Crohn's disease should be considered to be a progressive disease which causes "disabilities". Therefore, it is important to improve the long-term prognoses for patients with this disease by employing early therapeutic interventions with agents such as biologics. The term "mucosal healing" is highlighted as being the new goal we should strive to achieve. The term "Mucosal healing" indicates not only symptomatic improvements, but also endoscopically induced healing of ulcerations and inflammation. This is a very attractive concept, however it is necessary to discuss how we judge its implementation in daily clinical practice. Balloon endoscopy and capsule endoscopy can detect minute changes on mucosal surfaces. However, we do not know how we should best assess information obtained. The dramatic progress of cross sectional imaging such as CTs and MRIs, has made it possible to detect mucosal lesions as well as intestinal complications such as fistulas or abscesses. It has become a new task to define whether cross sectional imaging can assess "mucosal healing". Thus, it has not yet been established how we should assess "disease activity" or "mucosal healing" in practicalterms. We should be aware of the characteristics of individual modalities and use them properly improve the long-term prognosis for Crohn's disease. Investigations into the use of these new tools are in their infancy.