TNF―α和IL―6及IL―11在小儿急性肠套叠中测定及临床意义

【摘 要】目的：测定血清肿瘤坏死因子-α（TNF-α）和白介素-6（IL-6）及白介素-11（IL-11）在小儿急性肠套叠中的浓度变化，探讨TNF-α和IL-6及IL-11浓度变化在急性肠套叠发病中的作用及其临床意义。方法：选择25例小儿急性肠套叠患儿和19例对照组健康儿童，采用双抗体夹心酶联免疫吸附试验（ELISA）检测治疗测肠套叠组术前、术后及对照组血清中TNF-α和IL-6及IL-11的浓度变化。结果：对照组血清TNF-α和IL-6及IL-11分别（42.67±12.34） pg/ml，（6.23±2.48） pg/ml，（13.25±5.34） pg/ml；小儿急性肠套叠灌肠复位前血清TNF-α和IL-6及IL-11分别为（283.1±145.36）pg/ml，（55.92±17.39） pg/ml，（53.69±18.33） pg/ml；灌肠复位成功后24小时TNF-α和IL-6及IL-11分别为（129.73±87.99）pg/ml、（18.64±6.93）pg/ml，（25.61±7.38）pg/ml，差异有统计学意义。且复位成功后TNF-α和IL-6及IL-11持续增高与复发密切相关。结论：TNF-α和IL-6及IL-11在小儿急性肠套叠发生发展中起着重要的作用，对于急性肠套叠的辅助诊断及判断愈后有着重要的意义。

【关键词】急性肠套叠；血清肿瘤坏死因子-α；白介素-6；白介素-11（IL-11）

婴幼儿时期最常见的急腹症就是小儿急性肠套叠，其发病率位居小儿外科急性肠梗阻的首位，严重威胁婴幼儿身体健康，虽然很多学者对其发病机理做了大量的研究工作，也取得了很大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进展，但具体机制仍不明了。我们应用ELISA法测神经母细胞瘤患者血清内的NF-α和IL-6及IL-11表达情况，分析三者在肠套叠的发生和发展中的作用，以便为预防肠套叠的发生和复发提供一定的理论依据和途径。

1 资料与方法

1.1一般资料 随机收集我院儿科2008年10月至2009年6月具有典型临床表现且经彩超诊断确诊的小儿急性肠套叠25例，分别于灌肠复位前、复位后24小时（h）抽取外周静脉血2ml置于非抗凝管中。同时选择健康对照组19例，无个人家庭过敏性疾病及其他变态反应性疾病史，空腹抽取外周静脉血2ml。所有标本分别测定其血清中的TNF-α和IL-6及IL-11浓度。

1.2方法

用双抗体夹心酶联免疫吸附实验（ELISA）具体步骤严格依ELISA试剂盒产品说明书步骤进行。将50μl的TNF-α和IL-6及IL-11标准品稀释液加入预包被的酶标板上，反复作标准品对倍稀释建立标准曲线。加入100 μl标本于待测孔，混匀，37℃温育120m in，洗涤；每孔中加入第一抗体工作液50ul，混匀，37℃温育60 m in，洗涤；每孔加入酶标抗体工作液100ul，混匀，37℃温育60 m in，洗涤；每孔中加入底物工作液100ul，37℃避光温育10min；然后每孔加入终止液50μl，在492nm处测吸光值（OD），通过标准曲线计算标本中人TNF-α和IL-6及IL-11浓度。

1.3 统计学方法 结果采用SPSS13.0统计软件进行数据分析， 实验数据以均数均数±标准差（ ±s），组间比较采用t检验和方差分析。检验水准为α=0.05。

2 结果

2.1肠套叠患儿灌肠复位治疗前、后和对照组TNF-α和IL-6及IL-11水平变化肠套叠患儿和正常对照组血清相比TNF-α和IL-6及IL-11明显增高，组间比较差异有统计学意义。术前血清TNF-α和IL-6及IL-11浓度随明显高于术后者组，组间差异有统计学意义P

2.2 肠套叠患儿复发和TNF-α和IL-6及IL-11水平的关系

在灌肠复位成功25例肠套叠患儿中，有5例24小时TNF-α持续高浓度，其中复发4例，复发率为80%； TNF-α降低的20例中复发2例，未复发18例，复发率仅为10%。有6例24小时IL-6持续高浓度，其中复发4例，复发率为66.67%；IL-6降低的119例中复发2例，未复发17例，复发率仅为10.53%。有3例24小时IL-11持续高浓度，其中复发2例，复发率为66.67%； IL-11降低的22例中复发3例，未复发19例，复发率仅为13.64%。

3 讨论

小儿急性肠套叠的发病原因比较复杂，与小儿年龄、性别、病毒感染、机体的免疫状态、饮食结构及习惯的改变等都有密切关系，但是具体机制尚不清楚。胃肠的正常协调运动有赖于神经、免疫、内分泌等因素组成的发杂网络的联合调节。而肠套叠是肠管痉挛和舒张失调为病理生理基础的胃肠运动功能紊乱性疾病，其中胃肠道炎症和免疫反应在肠套叠的形成中起着重要的作用。作为人体内最大的淋巴器官，肠道局部的免疫炎症反应机制复杂。当局部产生炎症反应时免疫细胞及由免疫细胞分泌的各种细胞因子、炎症介质影响肠道平滑肌功能，改变胃肠运动状态进而诱导肠套叠的发生。

肿瘤坏死因子-α（TNF-α）是由脂多糖刺激单核-巨噬细胞分泌的一种内源性致热原蛋白质。TNF-α不仅诱导发热反应，同时是具有诱导多种生物活性的炎性细胞因子，诱发肿瘤的发生且还可致肿瘤坏死的作用，在炎症与肿瘤的发生发展中具有重要作用。TNF-a具有强烈的刺激收缩肠道平滑肌，诱导多种炎症介质释放，引起肠道炎症和高反应性等作用。研究表明TNF-α可以通过Nox2， MAPKs， NF-κB等通路促进其表达[5]，当给予其COX-2抑制剂时，起作用减弱。白介素是由活化的淋巴细胞和单核巨噬细胞及某些基质细胞分泌的在炎症反应、免疫调节中起到十分重要作用的的多功能、高活性小分子多肽类物质，其功能是在细胞间传递信息，刺激T和B淋巴细胞活化、增殖、分化。白细胞数量较多，其中IL-6和IL-11极为重要，在细胞因子网络中发挥着多种效应，同样也调节着TNF-a和前列腺素等炎性因子的释放[6-7]。为了确定TNF-α和IL-6及IL-11在急性肠套叠变化，我们应用ELISA检测了肠套叠组术前、术后及对照组血清中TNF-α和IL-6及IL-11的浓度变化。结果发现与对照组比，急性肠套叠患儿灌肠复位前TNF-α和IL-6及IL-11明显升高，复位后急剧下降，组间比较差异有统计学意义（P

总的来说TNF-α和IL-6及IL-11表达水平与小儿急性肠套叠的发生、发展关系密切，为预防急性肠套叠的的复发提供实验依据，指导临床。但是由于本组研究收集的病例数量有限，且小儿急性肠套叠发病机理复杂，TNF-α和IL-6及IL-11在急性肠套叠的具体作用机制和临床上应用仍有待进一步研究。

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