ulcerative colitis arthritis
Introduction
Introduction to ulcerative colitis arthritis "Enteropathicarthritis" refers to arthropathy associated with Crohn's disease or ulcerative colitis, which is caused by clinical and histological inflammation of the intestine, changes in intestinal permeability, and inflammation of the peripheral and axial joints. And so on. About 20% of cases have peripheral arthritis, and 10% to 15% of patients have axial axis arthritis. Peripheral joint disease is more common in people with extraintestinal syndrome (such as nodular erythema), and the incidence of men and women is equal. It can be affected at any age, but arthritis in adults usually occurs after inflammation of the intestine has actually occurred, as opposed to children. The ratio of male to female incidence is from 1.4:1 to 2.3:1. All age groups can develop the disease. It is more common in 20 to 50 years old. Generally, the onset is slow. A small number of patients can have a sudden onset of illness. The severity of the disease varies. The disease has repeated episodes. The trend, the onset factors are emotional, trauma, excessive fatigue, eating disorders and upper respiratory tract infections, systemic symptoms include anorexia, weight loss, normal or elevated body temperature, acute fever, pulse rate and dehydration. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: non-infectious Complications: blood in the stool, shock, peritonitis, rectal cancer, colon cancer
Cause
Causes of ulcerative colitis arthritis
Infection factor (25%):
The inflammatory changes of the colonic mucosa of this disease are similar to many infectious colitis, but no bacteria, viruses or fungi have been identified in this disease, and there is no evidence of infection between the population. Some people think that the disease is caused by dysentery. Caused by bacilli or lytic tissue, the long course of disease may also be caused by intestinal bacteria that are generally not pathogenic, and needs further confirmation.
Neurological factors (15%):
Some people think that cerebral cortical activity disorder can cause autonomic dysfunction, causing intestinal hyperactivity, intestinal vascular smooth muscle contraction, tissue ischemia, increased capillary permeability, thereby forming intestinal mucosal inflammation, erosion and ulcers. The factors may be secondary manifestations of recurrent episodes of the disease.
Genetic factors (15%):
It has been determined that the positive rate of HLA-B27 in patients with this disease is significantly higher than that in the control group, and the incidence of this disease is higher in many families.
Immunity factor (10%):
In recent years, important findings in the basics of immunology of this disease include: the presence of non-specific anti-colon antibodies in the serum of patients, among which antibodies against intestinal epithelial mucopolysaccharide antibodies and anti-E. coli polysaccharides have been identified in ulcerative colons. A 40kD organ-specific protein that binds to IgG is isolated from inflammatory lesions, supporting the disease as a strong evidence of autoimmune disease.
Allergic factors (15%):
Because a small number of patients are allergic to certain foods, after allergic or desensitization of foods, the condition is improved or healed, so it is suggested that the disease is caused by allergies.
The cause of ulcerative colitis in the elderly is the same as that of young people. The main reason may still be the abnormal immune response of the intestinal wall to different stimuli, as well as bacteria, viruses, protozoal infections, and genetic, mental, and metabolic factors. There are no specific etiological factors that confirm the association with the elderly, but recent studies suggest that there are three factors that may play a part in the disease before the onset, namely smoking, excessive consumption of refined sugars, low fiber and Fruit and vegetable intake is too low.
Pathogenesis
The pathogenesis of this disease is not yet clear and may be related to the following factors.
1. The study found that ulcerative colitis, Crohn's disease and ankylosing spondylitis have a family relationship, and all three diseases have a certain relationship with HLA-B27, but the penetrance rate is not high. The mucus secretion abnormality of intestinal mucosa is related to genetic quality.
2. All colitis colon tissue has 40kD organ-specific protein antigens that can bind to IgG, while the serum of Crohn's disease has only glycoprotein antibodies against small intestine or large intestine, and the patient's lymphocytes are in tissue culture. It can damage colonic epithelial cells. The serum of patients often contains one or several inhibitory factors of macrophage migration, often accompanied by immune diseases such as iridocyclitis, uveitis, nodular erythema, autoimmune Hemolysis anemia and systemic lupus erythematosus have replicated the experimental ulcerative colitis model by immunological methods. Therefore, the disease can be considered to be caused by autoimmune mechanisms.
3. The damaging effect of lysozyme Some people believe that the intestinal wall secretes excessive lysozyme.
4. Oxygen free radical damage The pathological process of this disease is affected by increased intra-intestinal pressure, enhanced sympathetic activity, and increased activity of endogenous vasoconstrictor, thus reducing intestinal blood flow or temporary ischemia. Reperfusion occurs, causing insufficient oxygen supply, especially in the intestinal jaundice oxidase, which can cause a large number of oxygen free radicals to form and damage the intestinal mucosa. At this time, the cell phospholipids release arachidonic acid products, especially Leukotriene B4 chemotaxis of neutrophils, which is rich in NADPH oxidase, can further form oxygen free radicals and aggravate intestinal mucosal damage.
5. The pathogenesis of ulcerative colitis in the elderly is not as clear as that of young people. Recent studies suggest that there are three factors that may play a part in the disease before the onset, namely smoking, excessive consumption of refined sugars, Low fiber and too little intake of fruits and vegetables.
6. The pathogenesis of childhood ulcerative colitis is still not very clear. In recent years, some scholars have detected antibodies against autologous colonic epithelial cells from the serum of children. The antigenic substance is a mucopolysaccharide of colonic epithelial cells. The autoantigen-antibody reaction causes peripheral lymphocytes to damage the colon and rectal mucosal epithelial cells, causing inflammatory reactions such as congestion and ulceration. The child is growing and developing, the intestinal mucosal barrier is not fully developed, and the bacteria and antigenic substances can pass through the intestinal mucosal barrier. Mucosal lymphoid tissue is sensitized after contact, and as the child grows and develops, the intestinal mucosal barrier function becomes more perfect, and the contact is isolated, but in the case of food allergy, increased intestinal bacterial concentration, and intestinal fecal retention, or Intestinal bacteria can cause intestinal mucosal damage when contact with intestinal mucosa for too long. For example, lymphocytes remain highly sensitized. Enterobacterial antigens can cause allergic reactions through the intestinal mucosa and damage the tissues and organs containing the target antigen. Ulcerative colitis.
Food allergies and mental factors can cause intestinal mucosal allergy, mast cell degranulation reaction, colonic motor function and blood supply abnormalities caused by vagus nerve and sympathetic over-excitation, causing intestinal smooth muscle spasm, intestinal wall congestion, edema and even ulceration .
7. Pathology
Intestinal pathological changes involve the rectum and sigmoid colon, and can also extend to the descending colon and the entire colon.
(1) Mucosa: The degree of mucosal change depends on the degree of inflammation and the length of the disease. It can be divided into 5 stages:
1 early mucosal congestion, swelling, followed by goblet cell reduction, the damaged mucosa can further form crypt abscess and focal neutrophil infiltration due to bacterial infection, lymphocytes, plasma cells clustered with intestinal wall Lymphoid tissue hyperplasia may be an early immune response.
2 active period: mucosal capillaries are obviously congested, dilated, accompanied by intestinal wall hemorrhage, may have varying degrees of epithelial cell necrosis, the number of goblet cells is reduced, can disappear in severe cases, lymphocytes in the lamina propria, plasma cell aggregation, accompanied by Focal neutrophil infiltration in the crypt can form a crypt abscess with irregular mucosal contours, and the surface is covered with pus, blood and exfoliated epithelial cells.
3 Dissipation period: mucosal congestion, swelling, neutrophil and crypt abscess gradually disappear, epithelial cells re-growth, the number of goblet cells can return to normal, the number of lymphocytes in the lamina propria, plasma cells gradually decrease, along with the inflammatory process The disappearance can gradually become a focal infiltration.
4 Remission period: After the patient has 1-2 episodes, it will enter the remission period, sometimes it can be relieved. The sigmoidoscopy shows that the mucosa is close to normal, but the X-ray abnormality can exist continuously. There are different degrees of mucosal atrophy under the microscope. Sometimes There is only a single columnar epithelium with small and short crypts. In addition, there are few lymphocytes, focal infiltration of plasma cells, epithelial hyperplasia at the base of the crypt, and no reduction in goblet cells. .
5 quiescent period: Some patients showed persistent colitis with no obvious remission and deterioration. The mucositis of these patients was limited to the increased area of lamina propria lymphocytes and plasma cells. Occasionally, crypt abscess was found, and the epithelium may have a slight cup shape. The number of cells decreased and the number of lymphoid follicles in the mucosa increased.
(2) Muscle layer: Muscular layer abnormality is one of the common features of this disease. It is mainly characterized by shortening of colon, disappearance of colonic pouch, shortening of sigmoid colon length, thickening of colon wall, and narrowing of intestinal lumen. These changes are due to abnormal muscle layer. The nature of the abnormal muscle layer is smooth muscle contraction, not paralysis.
(3) Anus: The disease may have acute anal fissure, acute perianal or ischial anal abscess, and sometimes there may be low anal fistula and rectal vaginal fistula.
(4) Extraintestinal pathological changes: synovial biopsy of the joint showed microscopic synovial hyperplasia, fibroblast proliferation, vascular proliferation, synovial surface cellulose deposition, accompanied by neutrophils, lymphocytes and plasma cell infiltration Some parts have obvious cartilage erosion, and other organ system pathological changes are the same as Crohn's disease arthritis.
(5) The histopathological features of ulcerative colitis in the elderly are similar to those in young people. There may also be differences in some immune responses. Gebber and Ottc are found in the inflammatory area of disease activity, and the ulcer of colitis in the elderly. The cell/lymphocyte ratio is low, and this difference suggests that there may be some differences in immune responses between older adults and younger adults.
(6) Children with ulcerative colitis are similar to adult histopathological changes. Most of the lesions occur in the rectum and sigmoid colon. Sometimes they can spread up to the left colon, the transverse colon, or even the whole colon, and rarely involve the end of the ileum. The pathological changes are divided into two. Period, acute phase, first is mucosal congestion and edema, scattered in small superficial ulcers, with pus, blood and mucus, accompanied by lymphocytes, plasma cell infiltration, eosinophils and neutrophil infiltration, chronic phase The congestion and edema subsided, the ulcer healed, the mucous membrane regenerated, and a large number of new granulation tissue formed pseudopolyps, and eosinophil infiltration and degranulation were observed.
Prevention
Ulcerative colitis prevention
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
Ulcerative colitis inflammatory complications Complications, hemorrhagic shock, peritonitis, rectal cancer, colon cancer
Local complication
(1) a large amount of blood in the stool: blood in the stool is one of the common symptoms of ulcerative colitis. A large amount of blood in the stool refers to a large amount of bleeding in the intestine in a short period of time, accompanied by rapid pulse increase, decreased blood pressure and decreased hemoglobin. Blood transfusion therapy is needed to relieve the disease. Although the amount of blood in the stool is sometimes difficult to estimate accurately, it is an indicator to assess the severity of the disease. When there is fever, tachycardia, and decreased blood volume, hematocrit does not reflect the degree of anemia, causing bleeding, mainly due to ulcers. Involvement of blood vessels, in addition to low prothrombinemia is also an important cause, foreign statistics of 58 cases of colon resection due to bleeding, 37 cases of low prothrombinemia.
The literature reports that the incidence of massive bleeding is less than 5% (1.1% to 4.0%), more common in severe cases, secondary to lower gastrointestinal bleeding after ulcerative colitis is not uncommon in China, can lead to severe anemia after bleeding, acute bleeding 50% of patients have toxic megacolon. Therefore, when there is major bleeding in ulcerative colitis, the possibility of toxic megacolon should also be considered. Generally, the medical treatment can be effectively strengthened to stop bleeding, and the life-threatening person needs emergency surgery. surgery.
(2) Toxic megacolon: Toxic megacolon is a serious complication of ulcerative colitis, which occurs in patients with severe, fulminant, and total colitis. It is reported that the foreign incidence rate is 1.6% to 13.0%; It is rare in China, with a report of 2.6% and a mortality rate of 11% to 50%.
This is because severe inflammation affects the muscular layer of the colon and the intermuscular nerve plexus, which destroys the nerve and muscle regulation mechanism of the normal intestinal tract, resulting in low intestinal wall tension, paralysis of the segment, and accumulation of intestinal contents and gases, causing acute Colonic dilatation, thinning of the intestinal wall, various factors that promote the increase of intestinal pressure or decreased intestinal muscle tension can cause colonic expansion, involving the sigmoid colon and transverse colon. Because of the position of the transverse colon in the supine position, the gas is easy to accumulate. Therefore, the colon expands, the intestinal wall pressure increases, the bacteria and intestinal contents pass through the ulcer into the intestinal wall and blood flow, causing bacteremia and sepsis, and can also further expand the colon, vasculitis, intestinal muscle plexus or mucosa. The involvement of the lower plexus may be the cause of irreversible expansion.
Some drugs, such as anticholinergics (atropine, etc.) or opioids, can reduce intestinal muscle tone, inhibit bowel movements, can induce or aggravate toxic colonic dilatation, so should be used with caution, antidiarrheal agents (such as compound phenethyl Pyridines may be induced by the use of laxatives during intestinal preparation. In the case of barium enema (pre-enema preparation) or colonoscopy, insufflation and catheterization may interfere with blood supply or cause trauma, so heavy patients should not do the above. Examination, hypokalemia is also a common cause, but it may also be a spontaneous onset. Other causes of toxic megacolon include infection. The pathogens include Campylobacter jejuni, Shigella, Salmonella and Clostridium.
The clinical manifestation depends on the speed of occurrence, the degree of colon expansion, the degree of poisoning and the presence or absence of perforation. Patients often have different degrees of dehydration, fever, tachycardia, anemia, increased white blood cells, even shock, original diarrhea, blood in the stool. The symptoms of abdominal pain are sometimes relieved. Electrolyte disorders, anemia, hypoproteinemia and toxic neuropsychiatric symptoms can exist to varying degrees. Severe diarrhea, the number of bowel movements per day is more than 10 times, the condition deteriorates rapidly, and the symptoms of poisoning are obvious. There are abdominal distension, tenderness, rebound tenderness, weakened or disappeared bowel sounds, and obvious abdominal swelling. Especially when the transverse colon is dilated, there is often upper abdominal distension. The upper abdominal plain film shows widening of the intestinal lumen, the colonic bag disappears, etc., and the transverse colon diameter is up to 5 ~ 6cm or more, easy to have intestinal perforation and cause acute diffuse peritonitis, the clinical diagnostic criteria of toxic megacolon, need to meet the following points:
1 Abdominal plain film shows that the colon is obviously dilated, and the transverse diameter exceeds 5-6 cm.
2 At least 3 of the following manifestations: A. body temperature > 38.6 ° C; B. heart rate > 120 beats / min; C. significantly increased white blood cells; D. anemia.
3 There must be one of the following symptoms of poisoning: A. disturbance of consciousness; B. lowering of blood pressure; C. dehydration and/or electrolyte imbalance.
For the first time patients with short course of disease, rectal examination should be performed to observe the presence or absence of ulcerative colitis. The examination above the rectum has certain risks and should be avoided. The use of glucocorticoids may mask the symptoms of colonic dilatation. Neglected, attention should be paid to the timing of surgery. Delayed surgery may increase the mortality rate, and the prognosis of this complication is poor.
(3) intestinal perforation: mostly serious complications of toxic colonic expansion, due to its rapid expansion, thinning of the intestinal wall, blood circulation disorders, acute intestinal perforation caused by ischemic necrosis, can also be seen in severe patients, the incidence of foreign reports 2.5% ~ 3.5%, mostly occurred in the left colon, causing diffuse peritonitis, free perforation of megacolon is extremely rare, severe shock, peritonitis and sepsis are the main causes of death, the application of corticosteroids is an important factor in the induction of this complication Factors, at the same time, due to the use of corticosteroids, often the clinical symptoms are atypical, X-ray abdominal plain film examination found the underarm free gas, therefore, should be particularly vigilant.
(4) polyps: the polyps rate of this disease is 10% to 40%, called this polyp is a pseudopolyposis, the so-called pseudo polyps are due to a large number of late, new granulation tissue hyperplasia, normal mucosal tissue edema, resulting in normal The surface of the mucosa protrudes to form polyps. This polyp is pathologically an inflammatory polyp. Dikes and Caunsell are further divided into mucosal drooping type, inflammatory polyp type, adenomatous polyp type, mostly inflammatory polyps, more common in In patients with long-term ulcerative colitis, the location is related to the extent of inflammation. The predileous part of the polyp is in the rectum. Some people think that the descending colon and sigmoid colon are the most common, and the upper part is decreased in turn, and some can disappear with colonic inflammation. Some adenomatous polyps can be caused by inflammation. Sexual polyps are directly derived from normal mucosa, and are more common in patients with long-term ulcerative colitis. The incidence is 3 to 5 times higher than that of the general population. Generally, they are associated with different degrees of dysplasia, such as mild dysplasia. Can be re-examined according to routine colonoscopy for 1 year; moderate dysplasia as precancerous lesions, followed up; if severe dysplasia, confirmed by re-examination, it is recommended surgery In addition, once the adenoma is found, special attention should be paid to the whole colon examination to see if there are multiple adenomas and accompanying cancers. Due to the popularity of electrocoagulation, those who have the possibility of removal can be removed by colonoscopy. After the disease, because the cancer is mainly from adenoma type polyps.
Polyp outcomes can be mainly: 1 part disappears with the healing of inflammation; 2 destroys with the formation of ulcers; 3 long-term retention; 4 cancerous.
(5) Carcinogenesis: It has been recognized that ulcerative colitis is complicated by knots. The chance of rectal cancer is higher than that of the same age group and the same sex group. The reason is still unclear, the intrinsic defects of the mucosa or long-term chronic inflammation. The result may be the most important cause, and the environment, nutrition and genetics may also be important factors. From the molecular biology point of view, the evolution of ulcerative colitis to colon cancer is the oncogene and inhibition in colonic epithelial cells. Accumulation process of oncogene complex mutations.
It is generally believed that the trend of cancer is related to the length of the disease and the anatomical extent of colitis. After 15 to 20 years of disease, the risk of cancer increases by about 1% per year. The risk of colon cancer occurs in patients with total colitis and those with a disease duration of more than 10 years. It is 10 to 20 times higher than the general population. Western countries report that the incidence of rectal cancer is 3% to 5%, and some are as high as 10%.
Carcinogenesis is more common in lesions involving the entire colon. Infants with a onset and history of more than 10 years are more common. Chronic persistent colon cancer is more common. The age of seizures has also been considered an important factor, but studies in recent years have shown that these factors may be Does not increase the risk of colon cancer, Deroede reports that the child's medical history is more than 10 years, 20% of the following 10 years of cancer, children are generally more colonic involvement, adult patients are mostly located in the distal colon, regardless of the child or In adults, the risk of colon cancer may be the same. Cancer can also occur on the basis of pseudopolyps, mainly from adenomatous polyps, but some patients do not have polyps in their colon cancer.
Colon cancer in patients with ulcerative colitis is mostly in the stationary phase of the disease. Because of the tendency to treat bleeding or diarrhea as recurrence of colitis, the clinical symptoms of ulcerative colitis and colorectal cancer overlap, so it is clear that the diagnosis of cancer is late. On the basis of ulcerative colitis, the tumor may have a polyp, nodular or plaque-like appearance, may be flat, and small in size, even if experienced endoscopy and radiologists are often difficult to diagnose, ulcers Intestinal stenosis is rare in colitis, but it can be combined with tumor infiltration.
The clinical symptoms of active ulcerative colitis sometimes overlap with the clinical symptoms of ulcerative rectal cancer, which delays the diagnosis of cancer in patients. Some reports that during the exploratory laparotomy, more than 60% of these cases have lymph nodes and distant cancer. Swelling metastasis, therefore, early diagnosis is very important.
Colorectal cancer occurs in ulcerative colitis, and the prognosis of colon cancer occurs when there is no colitis, and the degree of malignancy is also high. It has the following characteristics: 1 is a cancer that secretes mucus; 2 is a primary cancer. 3 can be evenly seen in any intestinal segment of the colon, ulcerative colitis with rectal or sigmoid colon cancer is only about 1/4, while common colon cancer 70% to 80% occurs in the rectum, sigmoid colon; 4 gross morphology of cancer is mostly Diffuse invasive cancer; early cancer is mostly coarse particles, low papillary irregular bulge, or even uneven.
Ulcerative colitis, such as dysplasia, especially severe dysplasia, should be considered as precancerous lesions, and histologically atypical hyperplasia, 50% can be combined with colon cancer, 1983 by 10 diseases The morphological study group of inflammatory bowel disease composed of scientific experts put forward the classification evaluation and criteria for dysplasia, and divided it into negative, unclear or positive, and further classified unclear dysplasia (may be negative) Or may be positive), while the dysplasia positive is mild and severe, it is impossible to determine how long it takes to develop from severe dysplasia to cancer, but the development of dysplasia may be quite slow; at a certain time Within the lesion, the lesion can be relatively stable, sometimes with a tendency to resolve itself; this pathological change is not irreversible.
In inflammatory bowel disease, metaplasia and dysplasia of the ulcerated marginal epithelium and inflammatory polyps are precancerous, and the severity is related to the risk of cancer. For extensive colitis, the course lasts for more than 10 years, or Patients with left colitis who have been active for more than 20 years should undergo endoscopy every year. If the mucosa is normal, each biopsy is 10 cm apart. When suspicious lesions such as mucosal bulge and ulcer plaque are found, biopsy should be added. And for cell smear histological examination, due to the infiltration characteristics of cancer, sometimes endoscopy may fail for submucosal tumors, and various grades of definitive dysplasia are found to be indications for colon resection.
The characteristics of cancerous ulcerative colitis are summarized as follows: 1 The age of onset is earlier than that of the general population, 2 is usually distributed evenly in various parts of the colon, but has a tendency to distribute more proximally, only about 1/4 occurs in the rectum, sigmoid colon, and For multi-centered, 3 pathological types are colloidal carcinoma, poorly differentiated carcinoma, and infiltrating type, such as leather-like intestine thickening, resulting in stenosis and benign are difficult to distinguish, higher than the general colon cancer malignancy, poor prognosis.
Therefore, the course of disease for more than 10 years, chronic recurrent episodes, especially chronic persistent patients, such as abdominal pain, bleeding, anemia and hypoproteinemia, should pay attention to cancer, timely, regular colonoscopy or sputum irrigation is still the most Valuable examination, multiple biopsies during microscopy, finding cancer or precancerous lesions are of great benefit to diagnosis. Riddell has proposed various treatments for dysplasia, which has limited promotion due to difficulties in judgment. The Morson dysplasia classification scheme is still used.
(6) Intestinal stenosis: In some patients who underwent barium enema or colonoscopy, colonic stenosis may be seen, the incidence rate is 6% to 10%, which occurs in a wide range of lesions and lasts for 5 to 25 years. Patients, more common in the left colon, sigmoid colon or rectum, causing stenosis, often not due to fibrous tissue hyperplasia, but due to the formation of inflammatory polyps, mucosal muscle layer thickening, obstruction of the intestinal lumen.
Clinically, there are generally no symptoms. Abdominal colic may be an important sign. In severe cases, it may cause partial intestinal obstruction. In the case of intestinal stenosis in ulcerative colitis, be alert to the tumor, identify its benign, malignant, and obvious colonic stenosis. Colonic spasm, narrowed and disappeared after intravenous glucagon, colonoscopy sometimes difficult to rely on biopsy and cytology to rule out deep invasive cancer, if there is any doubt about the diagnosis of colon cancer, should consider colectomy The possibility, if the tumor can be ruled out, the expansion of the water capsule can eliminate the stenosis without surgery; if it can not be ruled out, surgical resection is required. Sometimes, the stenosis in the inflammatory activity stage can be caused by intestinal fistula, which is alleviated by inflammation control.
(7) rectal and perianal lesions: local complications of ulcerative colitis include hernia, anal fissure, perianal or sciatic anal abscess, rectal vaginal fistula and rectal prolapse, etc., in patients with severe diarrhea, these complications Most likely to occur, anal fissure can be improved when colon inflammation is controlled. Abscess around the rectum and rectal fistula can be healed after an abscess incision or fistula fenestration. 10% of patients with rectal prolapse often With long-term diarrhea in the active period of ulcerative colitis, there are more cases of total colitis, which is related to the severity of diarrhea. Perianal lesions are found in about 20% of patients, such as anal fistula and perianal abscess, which are far less common than Crohn's disease. Abscess often requires conservative surgical treatment, such as drainage, and severe cases sometimes require total colon resection.
2. Systemic complications
(1) Liver lesions: 15% of ulcerative colitis has different degrees of liver dysfunction, but only 2% to 5% of patients have lesions, and peribiliary inflammation accounts for 50% to 70% of hepatobiliary lesions. Lymphocytic inflammation, most liver function is normal, and biopsy shows inflammation around the bile duct, recurrent bile stasis, a few cases of ascending cholangitis, primary sclerosing cholanagitis (PSC) is due to intrahepatic and extrahepatic Inflammatory biliary fibrosis and sclerosing damage, causing bile duct obstruction and repeated inflammatory episodes, manifested as biliary stasis jaundice and itching, upper abdominal pain, liver and spleen, etc., about 10% ulcerative colitis with PSC, 50% ~ 70% PSC patients have inflammatory bowel disease, some patients have inflammatory bowel disease after PSC, which increases the difficulty of diagnosis. The branched bile duct branch can be determined by ERCP. Corticosteroid application can inhibit inflammation. Antibiotic application can treat retrograde Infection, a small number can be complicated by biliary cirrhosis and cholangiocarcinoma.
(2) Arthritis: The rate of arthritis associated with ulcerative colitis is about 11.5%. It is characterized by more complicated stages of enteritis and is more common in large joints, and often is a single joint lesion, joint swelling, synovium There is no damage to the effusion, no changes in the bones and joints, no serological changes in rheumatism, and often coincide with ocular and skin-specific complications.
(3) skin damage: nodular erythema is more common in the acute phase of colitis, the incidence rate is 4.7% ~ 6.2%, can have arthritis at the same time, more common in women, gangrenous pyoderma has not been reported in China, oral mucosa intractability Ulcers are not uncommon, sometimes thrush, and the treatment is not effective.
(4) Eye disease: there are iritis, iridocyclitis, uveitis, corneal ulcer, etc., the former is the most, seen in 5% to 10% of patients, ulcerative colitis is more common than Crohn's disease, more with Severe colitis, arthritis, skin lesions, oral aphthous ulcers, etc., also disappear with colitis control, iritis can threaten patients' vision.
(5) thromboembolic complications: about 5% of cases, can occur in the abdominal cavity, lungs, brain and other parts of the body, or manifested as migratory thrombophlebitis, more common in women, and more with disease activity Sexually related, may cause a hypercoagulable state due to ulcerative colitis, increased platelets and II, V, VIII and other factors, can disappear after colon resection, severe cases may be caused by DIC, vasculitis can still lead to Multiple organ ischemic infarction, in addition, ulcerative colitis can occur hypercoagulable state, combined with thrombosis and thromboembolism, can also have thrombocytosis, arteritis.
(6) Growth retardation: About 15% of ulcerative colitis, patients with short, thin, adolescent patients with secondary sexual deficiencies, mainly related to malnutrition, disease consumption and other factors.
(7) enterocolitis: the pathogenesis of concurrent enteritis is mainly in the distal part of the ileum, which is characterized by umbilical or right lower abdominal pain, watery stool and fat stool, which accelerates the patient's systemic failure.
(8) Complications caused by drug treatment itself: such as azathioprine, sputum inhibiting bone marrow, causing thrombocytopenia, occasionally causing drug-induced pancreatitis; sulfasalazine complicated by acute pancreatitis; corticosteroids complicated with sepsis, Peptic ulcers, diabetes, and cataracts should also be taken seriously.
3. The incidence of toxic megacolon in elderly patients with delayed ulcerative colitis is higher than that in elderly patients with early-onset ulcerative colitis; the incidence of tumor is related to the course of disease. The longer the course of disease, the higher the risk of concurrent tumors. .
4. Growth and sexual development delay is another clinical feature of pediatric inflammatory bowel disease. Many studies have shown that 6% to 8% of children with ulcerative colitis have delayed growth and sexual development, common iron deficiency anemia, oral Aphtoid Ulcer is also a common skin mucosal lesion of inflammatory bowel disease. The lesions are often multiple, which is aggravated during the active period of the disease. Repeated attacks occur. About 6% of children may have renal calcification. In addition, renal complications include ureteral hydrops and renal hoarding. Water, or Crohn's disease, pyelonephritis, may be caused by inflammation of the ureter or intestinal-bladder fistula, and rare renal insufficiency may be secondary to amyloidosis.
It is reported in foreign countries that about 4% of children have liver and biliary tract lesions, and sclerosing cholangitis can occur. Except for children with ulcerative colitis, almost all liver complications have occurred before the obvious symptoms of colon.
Symptom
Symptoms of ulcerative colitis arthritis Common symptoms Nausea and vomiting Dehydration Watery skin rashes, bloody anorexia, fever, collapse, colonic expansion, colonic bag, half moon, disappearance
The ratio of male to female incidence is from 1.4:1 to 2.3:1. All age groups can develop the disease. It is more common in 20 to 50 years old. Generally, the onset is slow. A small number of patients can have a sudden onset of illness. The severity of the disease varies. The disease has repeated episodes. The trend, the onset factors are emotional, trauma, excessive fatigue, eating disorders and upper respiratory tract infections, systemic symptoms include anorexia, weight loss, normal or elevated body temperature, acute fever, pulse rate and dehydration.
1. Digestive system performance
The most common abdominal manifestations of ulcerative colitis are diarrhea and intestinal blood loss. Diarrhea is almost always present, while fever and weight loss are rare. Ulcerative colitis mucosa is extensive and continuous, including superficial ulcers, edema, fragility and microscopic Abscess lesions are confined to the colonic mucosa. Although Crohn's disease is mainly affected by the ileum end and colon, the lesions can be found in the entire gastrointestinal tract. This lesion is often ulcerative and has a small blocky distribution. These lesions can be shallow. Table, but often transmural and granulomatous, of which aphthous ulcer, pseudo-pyloric metaplasia and sarcomatoid granuloma have diagnostic value, sometimes ulcerative colitis and Crohn's disease are difficult to distinguish; lesions are limited In the colon, histological performance will facilitate differential diagnosis.
2. Skin mucosa performance
Common skin lesions include maculopapular rash, purpura, polymorphous erythema, aphthous ulcer, nodular erythema and gangrenous pyoderma. Skin lesions often disappear with intestinal inflammation, and aphthous ulcers and nodular erythema usually Intestinal symptoms appear 24 hours after an acute attack, polymorphic erythema often occurs after the appearance of intestinal symptoms, gangrenous pyoderma is a recurrent skin ulcer, this skin lesion is easy to be allergic to iodine and bromine, once it appears Allergies, skin lesions can be exacerbated or spread to the whole body, mostly distributed in the lower limbs and lower body, the attack usually begins with one or more pustules, which later form and fuse into larger ulcers, sometimes appearing first Red nodules, then developed into ulcers, ulcers of gangrenous pyoderma are generally multiple, but also systemic.
3. Joint lesions
Of the 79 patients with active ulcerative colitis reported, 49 (62%) had joint involvement, arthritis was less articulated, and mostly asymmetrical; often transient and migratory Sexual, large and small joints can be affected, the lower extremity joints are mainly affected; usually non-destructive, more than 6 weeks of remission, but recurrence is common, there may be dachshund finger (toe), tendon end disease, especially Achilles tendon or Inflammation of the point of attachment of the plantar fascia may also involve the knee joint or other parts. Crohn's disease may have clubbing, and periostitis is rare. In some cases, peripheral arthritis may turn chronic, and the joints and hips may be damaged. Sexual damage has been reported.
4. Other
Eyes may have conjunctivitis, iritis, uveitis, liver, fatty liver, bile duct inflammation, chronic active hepatitis, necrotizing cirrhosis and sclerosing cholangitis, kidney can occur, pyelonephritis, kidney stones And glomerulonephritis, there may also be iron deficiency anemia, autoimmune hemolysis, microvascular hemolysis and thromboembolism, etc., this disease can also be associated with Sjogren's syndrome, systemic sclerosis, nodular polyarteritis Rheumatoid arthritis, mixed connective tissue disease, systemic lupus erythematosus and other diseases overlap, and once it overlaps with other rheumatism, the condition deteriorates rapidly. In addition, the disease can be combined with other autoimmune diseases such as multiple sclerosis. Idiopathic cholestasis cirrhosis, idiopathic Edison disease, autoimmune diabetes, etc. overlap.
5. Characteristics of extraintestinal and extra-articular
Inflammatory bowel disease can occur in many skin, mucous membrane, serosa and eye manifestations, of which skin damage is the most common, accounting for 10% to 25%, nodular erythema and intestinal disease activities are parallel, and in the active periphery Arthritis patients are more likely to appear, may be a disease-related manifestation, gangrenous pyoderma is a more serious but rare extra-articular manifestation, not related to intestinal and joint diseases, may be a concurrent disease, sometimes It is also possible to have leg ulcers and thrombophlebitis.
6. The most common clinical symptoms of ulcerative colitis in the elderly are bloody stools and bloody diarrhea. Zimmerman et al reported that the number of diarrhea in patients aged 51 and older is higher than that in patients aged 21 to 30, and the clinical symptoms last for a long time. Most scholars believe that the elderly The main clinical manifestations and course of ulcerative colitis are similar to those of young people. Zimmerman believes that older patients with delayed ulcerative colitis have higher puberty, but this includes some cases of recurrence before the age of 60 and delayed diagnosis leading to delay in treatment. Evans and Acheson found that the clinical manifestations of this disease are similar in the elderly and young people, but older ulcerative colitis can have a more sudden onset of seizures than in young people, 29 elderly patients with ulcerative colitis in a hospital Among the 13 patients with moderate to severe disease, the proportion of moderate to severe patients was significantly higher than that of young people. The other difference was that the most common clinical symptom of the elderly was diarrhea, and the common symptom of young people was intestinal bleeding. The reason is not clear, but it suggests that for elderly patients with long-term repeated diarrhea without blood in the stool, attention should be paid to ulcerative colon. The existence of the disease, to improve the understanding of the disease, can avoid misdiagnosis and mistreatment, in addition, the elderly and young people have lower disease recurrence and extraintestinal complications, systemic complications such as nodular erythema, arthritis, uveitis Gangrenous pyoderma and stick-like fingers are very rare.
7. Children with ulcerative colitis
Clinical features include mucus and blood, as well as lower abdominal cramps during defecation, according to the frequency of stool, abdominal cramps, fever, hemoglobin and albumin levels, clinical grades of light, medium and heavy, mild onset slow, no obvious diarrhea, general daily stool 3 to 5 times, the stool is mixed with mucus and bloody stools. When it is developed to medium and heavy, it can be increased to 10 to 30 times a day. The obvious blood sample is thin or the mucus blood is accompanied by the urgency. Mir-Madjltssi reports that the child has full colitis. The incidence is high, sometimes the lesion may extend to the distal end, the risk of colectomy is greater than that of adult patients. This type is more common in infants and young children, abdominal pain is common in the lower left abdomen or lower abdomen, and severely ill children have abdominal muscles. Tension and obvious bloating, and sometimes the sigmoid or descending colon of the abdominal muscles or the thickened intestinal wall, recently reported by Gry-bosky, a group of 38 children with ulcerative colitis less than 10 years old, although 71% of them People with total colitis (by endoscopy or X-ray diagnosis), but most of the patients are mild (53%) or moderate (37%), with an average follow-up of 6 to 7 years, during which only 2 patients underwent colectomy Operation With the improvement of medical means, the support of intravenous nutrition, the application of broad-spectrum antibiotics and immunosuppressive agents, people gradually use colonoscopy to monitor their recurrence instead of preventive colectomy, making fewer and fewer children undergoing colectomy in recent years. .
Systemic and parenteral manifestations: inflammatory bowel disease in children often causes growth retardation and delayed sexual maturity. Children with pre-pubertal ulcerative colitis have a growth delay of 60% to 80%, and the wrist shows skeletal maturity. Delay, joint pain, and arthritis are another important manifestations of children. They can affect large joints such as knees, ankles, hips, etc., and joint deformation rarely occurs.
At the time of physical examination, most of the children may have aggravation and tenderness in addition to the lesions, and may even touch the mass. In the rectal examination, there may be an anal sphincter spasm and a rectal mucosa with coarse graininess. In children with inflammatory bowel disease, weight loss It is one of the most important signs, and it has been reported that 68% of ulcerative colitis falls by an average of 4.1 kg.
Delayed growth and sexual development is another clinical feature of pediatric inflammatory bowel disease. Many studies have shown that 6% to 8% of children with ulcerative colitis have delayed growth and sexual development, common iron deficiency anemia, oral Aphtoid ulcer Common mucosal lesions of inflammatory bowel disease, lesions often appear multiple, increased in the active period of the disease, repeated attacks, about 6% of children, can occur renal calcification, in addition to renal complications including ureteral hydrops, hydronephrosis, Or Crohn's disease pyelonephritis, the cause may be due to inflammation of the ureter or intestinal-bladder fistula, rare renal insufficiency may be secondary to amyloidosis.
It is reported in foreign countries that about 4% of children have liver and biliary tract lesions, and sclerosing cholangitis can occur. Except for children with ulcerative colitis, almost all liver complications have occurred before the obvious symptoms of colon.
8.
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(2)25%52%3
(30%100%)3
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1
Examine
1. Blood routine and blood sedimentation
2.
3. Biochemical inspection
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4. Immunological examination
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5.
-IgETT(C)90%
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7.
8.X
9.
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Diagnosis
Diagnostic criteria
1.XX
2.
Differential diagnosis
1.
(1)
(2)
(3)
(4)X
(5)X
(6)
2.
X
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