Crohn's disease arthritis
Introduction
Introduction to Crohn's disease arthritis Crohnsdisease (CD) is a non-specific gastrointestinal granulomatous inflammatory disease of the gastrointestinal tract with pathological changes such as ulcers, granuloma, scar formation and arthritis, and ulcerative colon Inflammation is called inflammatory bowel disease (IBD), the disease can occur throughout the digestive tract, but mainly involving the terminal ileum and adjacent colon, the lesions are segmental distribution, clinical abdominal pain, diarrhea, abdominal mass, intestinal fistula, intestinal obstruction It is often accompanied by extra-intestinal manifestations such as fever, and the course of the disease is prolonged. The episodes of remission occur alternately. The severe cases are prolonged, often with various complications and poor prognosis. basic knowledge The proportion of illness: 0.002% Susceptible people: good for young adults Mode of infection: non-infectious Complications: intestinal obstruction, abdominal abscess, nodular erythema, arthritis, vasculitis
Cause
Crohn's disease arthritis
(1) Causes of the disease
The etiology of this disease is still unknown. There are bacterial, viral, fungal, protozoal and other infection theories; lymphatic obstruction and lymphocyte aggregation theory; inflammation and circulatory disorders theory, etc., are difficult to determine, it is now confirmed that most patients with HLA-1327 are positive. This indicates that genetic quality is the causative factor of this disease. In recent years, considering the diversity of pathological morphology, the chronic inflammatory characteristics of the disease, the presence of granuloma, multiple systemic injuries such as arthritis, skin damage and effective immunosuppressive treatment, The disorder of immune regulation is also an important cause of disease.
(two) pathogenesis
1. The pathogenesis of this disease is still not very clear. It is suggested that individuals carrying HL-B27 have common antigenicity between intestinal epithelial cells and intestinal anaerobic bacteria. This disease is similar to ulcerative colitis to anaerobic bacteria. The antigen is in an allergic state, and the bacteria as an antigen breaks through the defense barrier and invade the body, which can produce autoantibodies. At the same time, it can stimulate the immune system to produce sensitized lymphocytes. The autoantibody forms a self-antigen and antibody complex with the autoantigen, and activates the classic complement. Pathway, the result can cause an immune inflammatory response, sensitized lymphocytes produce lymphokine and other inflammatory mediators, and the autoantigen-antibody complex activates the inflammatory mediators released by the complement system, damaging mucosal tissues and other tissues, resulting in disease.
2. Pathology The disease is a proliferative disease that penetrates the whole layer of the intestinal wall and invades the mesenteric and regional lymph nodes. In the acute inflammatory phase, the terminal ileal wall is edematous, hyperemia, purple-red, and the serosal layer has fibrinous exudate. The mesentery is swollen, congested and swollen. In the chronic phase, the intestinal wall is thickened by fibrous tissue hyperplasia, tough, narrow in the intestine, more common in the terminal ileum, thickening of the mesentery and surrounding adipose tissue, collecting lymph nodes and mesenteric lymph nodes. Swelling, and varying degrees of intestinal obstruction, the upper segment of the intestine is dilated. This disease is usually distributed in a typical segment. The boundary between the affected intestine and the normal intestine is clear, there is a gap in the jumping zone, and the typical changes in the intestinal mucosa are :1 Ulcer: There are multiple longitudinal fissures and various irregular ulcers. The mucosa is normal between the ulcers. The longitudinal ulcers are distributed along the mesentery. It is an early manifestation and occurs in the small intestine. The depth of the ulcer varies, but it generally invades the pulp. Under the membrane, 2 pebbles nodules: small island-like protrusions formed by submucosal edema and cell infiltration, which occur in the vicinity of the longitudinal ulcer of the small intestine. Dimensionalization and scar tissue contraction caused by limited dense inflammatory polyps, 3 granuloma: composed of epithelial cells, sometimes accompanied by Langham cells, no cheese stove, no acid-fast bacilli, it is different from intestinal tuberculosis, granuloma It is an inflammatory infiltration composed of monocytes, lymphocytes and plasma cells, and the latter is the main one. The granuloma is usually located under the mucosa, and can also be located in any part of the intestinal wall, mesenteric, local lymph nodes and liver. It is called granulomatous enteritis, 4 fistula: When the ulcer gradually expands, it can penetrate the serosa and the nearby intestinal fistula to form a traffic fistula, which can communicate with each other between the intestine and the intestine.
Although the disease is mainly caused by digestive tract diseases, there are often other organ system damage. Mesothelial tissue biopsy specimens show mesothelial cell proliferation, lymphocytic infiltration and multiple non-necrotic epithelial granuloma.
Prevention
Crohn's disease prevention of arthritis
1. Eliminate and reduce or avoid the disease factors, improve the living environment, improve the development of good habits, prevent infection, pay attention to food hygiene, and rational diet.
2. Pay attention to exercise, increase the body's ability to resist disease, do not fatigue, excessive consumption, quit smoking and alcohol.
3. Early detection and early diagnosis and early treatment, establish confidence in the fight against disease, adhere to treatment.
Complication
Crohn's disease arthritis complications Complications, intestinal obstruction, abdominal abscess, nodular erythema angiitis
Local complications include sinus or fistula, infection around the rectum, intestinal obstruction, intestinal perforation, abdominal abscess, etc.; systemic complications include arthritis, nodular erythema, vasculitis and so on.
Symptom
Crohn's disease arthritis symptoms common symptoms joint pain nausea spotted papules burnt heart corneal ulcer joint effusion anal fissure perianal cyst sound hoarse and urgency
The disease mainly occurs in young and middle-aged, and is more common in 15 to 35 years old. The elderly are mainly affected by colon, and the ileocecal lesions account for more than 50%. The lesions are limited to 10% of the colon, and the colon and small intestine are affected. More than 30%, the onset is slow.
1. Digestive system abdominal pain is the most common symptom. The pain is mostly located in the umbilical cord and the right lower abdomen. It is mild colic or discomfort before the stool. It can be relieved after the stool. The diarrhea is usually 3 to 6 times a day due to bile acid, water and fat. Absorption obstacles, so the stool is semi-liquid, when the lesions involve the colon, there may be fecal incontinence, the performance is urgent and heavy, in the later stages of the disease can be licked and mass.
If the lesion occurs in the mouth and epiglottis, there will be aphthous ulcers, and the oral mucosa may also have paving stone changes. For example, involving vocal cords, hoarseness may occur, and oral lesions often occur simultaneously with intestinal Crohn's disease.
Esophageal involvement mainly manifests as swallowing pain, sternal pain, heartburn, stomach and duodenal involvement may cause upper abdominal pain, nausea, vomiting, etc., and may also be complicated by pyloric obstruction.
Hepatobiliary lesions are more common in peribiliary inflammation and hepatic steatosis, followed by necrotizing cirrhosis, hilar fibrosis and chronic active hepatitis, few liver abscesses, portal phlebitis, amyloidosis and granulomatous hepatitis.
Intestinal complications include: 1 intestinal obstruction: caused by fibrosis of the intestinal segment, scar formation and inflammatory edema, about 25% of patients; 2 fistula formation: the incidence of internal hemorrhoids in the small intestine is high, Most of the external hemorrhoids occurred after surgery; 3 perianal lesions: perianal inflammation, anal fissure, anal fistula, perianal ulcer, perianal abscess, etc.; 4 gastrointestinal bleeding: small intestinal lesions are mostly occult blood, colon lesions or extensive Small bowel lesions are mainly bloody stools, a few cases may have major bleeding; 5 intestinal perforation: rare; 6 toxic megacolon: patients may have a large number of diarrhea, nausea, vomiting, abdominal pain, abdominal distension, toxemia, etc.; 7 cancer and pseudo Polyps: About 1% of patients can have colon cancer; 8 malabsorption syndrome: the most common is fat, fat-soluble vitamins and vitamin B12 malabsorption, but also protein, electrolyte, folic acid, calcium, magnesium, zinc and other malabsorption The main causes of malabsorption are distal ileal dysfunction, bile salt malabsorption, and excessive bacterial growth in the small intestine, resulting in bile salt decomposition.
2. Skin nodular erythema is a common skin lesion of the disease, usually parallel to the activity of the disease, mainly distributed in the extension of the lower extremities, and some can form ulcers.
Gangrenous pyoderma is a deep, necrotizing ulcerative skin lesion with obvious pain. It is located in the anterior region of the lower extremity, often accompanied by systemic symptoms. The lesion is single, but it can also be multiple or extensive. The lesion can develop into the deep and cause osteomyelitis. Other skin lesions include eczema, maculopapular rash, erythema, urticaria and erythema multiforme.
3. Arthritis
(1) Peripheral arthritis: 10% to 20% of patients with Crohn's disease develop peripheral arthritis, which is the most common extraintestinal manifestation of Crohn's disease, and is mainly seen in patients with colon involvement, which involve joint ulcers. Goent colitis, subacute asymmetrical oligoarthritis, the most common involvement of the knee joint, followed by the ankle joint, again for the shoulder joint, wrist joint, elbow joint, metacarpophalangeal joint, small joints and small joints susceptible to the lower limbs Joints are more susceptible to joints in the upper extremities. Arthritis often does not leave deformities, but can cause joint pain, tenderness, and sometimes associated with joint effusion. Joint symptoms usually last for weeks or even more than a month.
(2) spondylitis: 1% to 25% of patients can develop ankylosing spondylitis, using strict criteria to determine about 5%, most patients with ankle joint symptoms are not obvious, joint radiological findings found in arthritis More than 3 times more than symptomatic sacroarthritis, spondylitis can occur before, after or at the same time as intestinal lesions, and is not parallel with intestinal disease activity. Spontaneitis can not be relieved by controlling intestinal symptoms. Some patients may The occurrence of clubbing, especially in the upper part of the small intestine, is more common, and the incidence of internal hemorrhoids and malabsorption is also higher.
4. Urinary tract urinary tract calculi are common complications of Crohn's disease, more common in colon resection and ileostomy, which may be due to severe diarrhea or ileal fistula to lose a large amount of secretions, urine concentration, causing Urine pH is reduced, and urate stones are formed, and bile salt absorption disorder causes excessive absorption of oxalate in the small intestine, which is also the cause of urinary calculi. In addition, obstructive hydronephrosis, perirenal abscess and renal amyloid Symptoms and intestinal fistula formation lead to urinary tract lesions, etc., can also cause urinary tract stones.
5. Other patients may have different degrees of fever, some patients may have blepharitis, conjunctivitis, keratitis, corneal ulcer and scleritis, etc., eye performance generally occurs in the acute deterioration of intestinal lesions, when the disease is relieved Disappeared, but recurrent, in addition, patients with bed rest, toxemia, surgery, increased production of thromboplastin and thrombocytosis, can cause venous thrombosis, and occasionally extensive arterial thrombosis.
Examine
Examination of Crohn's disease arthritis
1. Blood routine and erythrocyte sedimentation due to blood loss or bone marrow suppression, as well as malabsorption of folic acid or vitamin B12, can cause anemia, varying degrees of leukocytosis and erythrocyte sedimentation rate, which can reflect the activity and inflammation of the lesion.
2. Biochemical examination of serum 2 globulin increased, diarrhea is common in patients with low potassium, hypomagnesemia, hypocalcemia is caused by extensive intestinal mucosal involvement and vitamin D malabsorption, hypoproteinemia is due to protein Leaking out, duodenal juice test glycine and taurine content increased, suggesting that end ileum lesions are extensive, serum lysozyme can reflect the degree of inflammation of active granuloma, its normal value is 5mg / L, the disease is in 10mg/L or more, can be used to judge the activity of the disease and observe the therapeutic effect. Extensive small bowel resection has abnormal iodine-povidone test (I-PVP) (normal human fecal excretion rate <1.5%), relapsed iodine-glycerol The oleate test (I-triolein) is abnormal.
3. Immunological examination of rheumatoid factor, lupus cells were negative, HLA-B27 positive patients prone to peripheral arthritis or ankylosing spondylitis, serum IgA showed good prognosis.
4. X-ray examination of the site of the disease is more common in the terminal ileum, early due to submucosal inflammation and edema, X-ray examination showed intestinal mucosal folds thickened, flattened and disappeared, the diseased bowel morphology is fixed, but the intestine is generally not significantly narrow, other The intestines may have sub-sections, diastolic and other functional changes. Due to increased secretion, the expectorants are often scattered and patchy. With the development of the lesions, the submucosa may have a large number of granulation tissue hyperplasia, and the mucosal folds may appear as pebble-like or polypoid filling. Defect, after the ulcer is formed, the outline of the intestine is often jagged or spiked. This is where the shadow is often fixed, the shape of the intestine is often fixed, and the local peristalsis disappears. Because the intestinal wall is thickened, the intestinal spacing can be widened. A large amount of fibrosis can occur, and when the intestinal lumen is obviously narrow, the X-ray shows that the intestinal lumen is linear and irregular, the mucosal folds disappear, and the length of the stenosis varies from 1 to 2 cm to a longer range, and it can be intermittently multiple. Sometimes see X-ray findings of mechanical intestinal obstruction, but mostly incomplete intestinal obstruction.
Localized enteritis is less common in colons, and occurs in the right colon, especially in the cecum. It is often accompanied by lesions at the end of the ileum. When the colon is violated, it can occur in multiple segments and involve the left side. In the colon, the early manifestation is colonic motility, the signs of stimulation are obvious, the expectorant is not easy to fill, the intestinal lumen is narrow in the chronic phase, the bowel is shallow or disappears, mostly one side, but sometimes it can be symmetrical, the edge of the intestine can be There are papillary rugged protrusions or longitudinal ulcers.
In addition to changes in the small intestine and colon, multiple peripheral arthritis can occur, but no changes in joint erosion can occur on the X-ray. X-ray changes in ankle arthritis are associated with ankylosing spondylitis. Acheson (1960) found that Of the 742 cases of Crohn's disease, 2.3% had ankylosing spondylitis.
5. Endoscopy fiberoptic colonoscopy can be found in small and initial lesions, biopsy can be used to obtain a definitive diagnosis, endoscopy can be seen: 1 ulcer; 2 mucosa in paving stone shape; 3 congestion, edema; 4 bag shape changes, stenosis, There are two types of intestinal wall ulcers: one is a small ulcer, which is more common in the early stage; the other is a larger round, oval or slit ulcer, and a typical granuloma can be found at the biopsy of the lesion. Non-specific inflammatory sigmoidoscopy is only valuable for rectal and sigmoid lesions. Some patients with granuloma, esophagus, stomach, duodenum and jejunal lesions can be used for fiber endoscopy.
Diagnosis
Diagnosis and diagnosis of Crohn's disease arthritis
Clinically, patients with chronic diarrhea, abdominal pain, fever, anemia, weight loss, abdominal mass, anal lesions and hypoproteinemia should be considered. Combined with X-ray examination, endoscopy and biopsy, the diagnosis can be confirmed. .
Differential diagnosis
1. Acute appendicitis Acute appendicitis has fever, right lower quadrant pain and other symptoms, similar to this disease, but the effect of antibiotic treatment is good, and the disease responds well to glucocorticoid therapy, biopsy can help diagnose.
2. Acute hemorrhagic enteritis has abdominal pain, diarrhea, blood in the stool and local tenderness, but Crohn's disease is mostly chronic, often repeated, acute hemorrhagic enteritis rarely recurs, in addition, X-ray and endoscopy results are also Not the same.
3. Most ulcerative colitis is diffusely invading the colon and rectum, which is a superficial inflammation of the intestinal mucosa. It is rare to have proliferative changes, intestinal wall hypertrophy, stenosis, fistula formation and anal lesions are rare. For atypical cases, the two are more Difficult to identify, and occasionally two diseases can also exist at the same time.
4. The age of onset of ischemic enteritis is about 80% in the age of 50 years old. There is a history of cardiovascular disease, the onset is sudden, the disease develops rapidly, and often forms a narrowing. The affected intestines are mostly spleen, transverse colon and descending colon, and barium enema. Checks often have a "thumb pattern".
5. Intestinal tuberculosis is similar to Crohn's disease in clinical symptoms and predilection sites. The typical X-ray signs of intestinal tuberculosis can be seen as annular or banded ulcers at right angles to the long axis of the intestine and due to scar formation around the ulcer. Characteristic stenosis, no pebbles and jumping areas, patients with difficulty in identification can be tested for anti-tuberculosis treatment.
