Schmidt Carsten, Bachmann Oliver, Baumgart Daniel C, Goetz Martin, Drvarov Oliver, Kucharzik Torsten F, Kühbacher Tanja, Langhorst Jost, Maul Jochen, Mohl Wolfgang, Mudter Jonas, Repp Michael, Sturm Andreas, Witzemann Dieter, Atreya Raja
Medizinische Klinik II, Klinikum Fulda gAG, Fulda, Germany.
Medizinische Fakultät der Friedrich-Schiller-Universität Jena, Germany.
Z Gastroenterol. 2021 Oct;59(10):1091-1109. doi: 10.1055/a-1504-9782. Epub 2021 Jul 20.
The complete and reliable documentation of endoscopic findings make up the crucial foundation for the treatment of patients with inflammatory bowel diseases such as Crohn´s disease and ulcerative colitis. These findings are, on the one hand, a prerequisite for therapeutic decisions and, on the other hand, important as a tool for assessing the response to ongoing treatments. Endoscopic reports should, therefore, be recorded according to standardized criteria to ensure that the findings of different endoscopists can be adequately compared and that changes in the course of the disease can be traced back. In consideration of these necessities, fifteen members of the Imaging Working Group of the German Kompetenznetz Darmerkrankungen have created a position paper proposing a structure and specifications for the documentation of endoscopic exams. In addition to the formal report structure, the recommendations address a large number of attributes of acute and chronic inflammatory alterations as well as endoscopically detectable complications, which are explained in detail and illustrated using exemplary images. In addition, more frequently used endoscopic activity indices are presented and their use in everyday clinical practice is discussed.
对炎症性肠病（如克罗恩病和溃疡性结肠炎）患者进行治疗的关键基础是完整且可靠的内镜检查结果记录。一方面，这些结果是治疗决策的前提条件；另一方面，作为评估正在进行的治疗反应的工具也很重要。因此，内镜报告应按照标准化标准记录，以确保不同内镜医师的检查结果能够得到充分比较，并且能够追溯疾病进程中的变化。考虑到这些必要性，德国胃肠疾病能力网络成像工作组的15名成员撰写了一篇立场文件，提出了内镜检查记录的结构和规范。除了正式的报告结构外，这些建议还涉及大量急性和慢性炎症改变以及内镜可检测并发症的特征，并通过示例图像进行了详细解释和说明。此外，还介绍了更常用的内镜活动指数，并讨论了它们在日常临床实践中的应用。
