chronic ulcerative colitis
Introduction
Introduction to chronic ulcerative colitis Ulcerative colitis is a kind of knot, diffuse inflammation of the rectal mucosa. Its clinical features are unexplained, good and bad diarrhea. It is difficult to imagine such a destructive disease but there is no determinable cause or a specific internal medicine. treatment method. Although the removal of all the lesions of the knot, rectum can completely cure the disease; but the price will be the possibility of a lifelong abdominal ileostomy. basic knowledge The proportion of sickness: 0.2% Susceptible people: no specific population Mode of infection: non-infectious Complications: bloating, peritonitis, abdominal pain, nodular erythema, swelling, abscess, polymorphous erythema, thrush, anemia, myocarditis
Cause
Causes of chronic ulcerative colitis
The etiology of ulcerative colitis is still unknown. Although there are many kinds of theories, there is no certain conclusion yet. The cause of the bacteria has been ruled out. The cause of the virus is not like, because the disease is not contagious, and the virus particles have not been confirmed. Patients with Crohn's disease have elevated serum lysosomes and are normal in patients with ulcerative colitis.
Genetic factors may have a certain status, because whites are 2 to 4 times more likely to be Jewish than non-Jews, while non-whites are about 50% less than whites. Recently, Gilat et al. reported on ulcerative colitis in the Jewish study of Traviev. The incidence rate was significantly reduced to 3.8/100,000, compared with 7.3/100,000 in Copenhagen, Denmark, 7.3/100,000 in Oxford, England, and 7.2/100,000 in Minnesota, USA. In addition, the ratio of women to men was only 0.8, while other reports were 1.3. Obviously geographical and ethnic differences affect the occurrence of this disease.
Psychological factors play an important role in the deterioration of the disease. It is now clear that patients with ulcerative colitis have no abnormal cause compared with the matched control cases. Furthermore, the existing pathological spirit such as depression or social distance is significantly improved after colectomy. .
It is considered that ulcerative colitis is an autoimmune disease. Many patients have antibodies that cross-react with normal colonic epithelium and specific intestinal bacterial lipopolysaccharide antigen. Furthermore, lymphocytes can be cultured by serum of patients with colitis. It becomes cytotoxic to the colonic epithelium, and changes are found in the T and B lymphocyte populations of patients with colitis, but it is later recognized that these abnormalities are not necessary for the occurrence of the disease, but are the result of disease activity, in fact, Brandtzueg et al. It is clearly demonstrated that tissue immunoglobulin activity in residual glands of patients with ulcerative colitis is defective, IgA transport is normal, and IgG immune cell response is five times that of control patients. Therefore, it is possible that IgG has a chronic process in the disease. Role, but not related to the occurrence of the disease.
In conclusion, it is currently believed that the pathogenesis of inflammatory bowel disease is the result of interaction between foreign substances causing host reactions, genes and immune effects. According to this insight, chronic ulcerative colitis and Crohn's disease are different manifestations of a disease process. Because the host is allergic to the antigen of the foreign substance, once the immune activation of the intestine is established - perhaps this initiation is established during the period of microbial cloning in infancy - any increase in mucosal damage to the permeability of these antigens may induce the intestine The inflammatory response of the wall, the type of antigen and other factors determine the nature of the inflammatory process, ie, Crohn's disease or ulcerative colitis.
Ulcerative colitis is a disease confined to the colonic mucosa and submucosa, which is distinct from the inflammatory changes in the intestinal wall of colonic cloning, which is affected by various layers of the intestinal wall during granulomatous inflammatory processes. The pathological changes seen in ulcerative colitis are non-specific and can also be seen in bacterial dysentery, amoebic dysentery and gonococcal colitis.
At the beginning of the lesion, the mucosal basal Lieberkülin crypt has round cells and neutral multinucleated cells infiltrating, forming a crypt abscess. Under the light microscope, the covered epithelial cells are stained shallowly and vacuoles are formed. In the electron microscope, mitochondrial swelling and cell gap widening are observed. As well as the widening of the internal pulp network, as the lesion progresses, the crypt abscess combines and covers the epithelium to fall off, forming an ulcer. The adjacent ulcer has a relatively normal mucosa, but there is edema, which becomes a meat-like appearance, between adjacent ulcers. It becomes very isolated, the ulcer area is occupied by the indulgent growth of collagen and granulation tissue, and it penetrates into the ulcer, but rarely penetrates the muscular layer. In the case of fulminant ulcerative colitis and toxic megacolon, these lesions can penetrate the whole Intestinal wall, leading to perforation, fortunately, this type of lesions are rare, accounting for 15% and 3%, respectively, pathological changes provide a clear explanation for clinical manifestations, almost 20 times more bloody stools per day, because of intestinal wall stripping The obviously deformed mucosa can no longer absorb water and sodium. Every time the peristalsis moves out a large amount of blood from the exposed granulation tissue surface, the early X-ray shows that the colonic bag disappears. Paralysis muscularis mucosa, therefore, barium enema and colonic shortening was stiff tubular chimney injury is the result of repeated scarring.
Most ulcerative colitis affects the rectum, but if the lesion is confined to the rectum, it can be called ulcerative proctitis. It is not known why the lesions in some cases are confined to the rectum, while others are affected by the entire colon. Most of the inflammation is near. End expansion, invading the left colon, about one-third of patients with the entire colon involvement, known as total colitis, in 10% of patients with total colitis, the end of the ileum also has ulcers, called anti-hydraulic ileitis, ulcerative In colitis, the lesions are adjacent and rarely distributed in segments or jumps. The factors that determine the severity and duration of the disease are unclear. These factors may be related to the extent of the immune disorder. There is evidence that prostaglandins may be present. It has an important role in the acute onset of the disease, and unfortunately there have been no reports of good effects on prostaglandin synthetase inhibitors such as indomethacin.
Prevention
Chronic ulcerative colitis prevention
Chronic ulcerative colitis is a disease that is common all over the world, but it is more common in Western countries. Its incidence rate is 5 to 12/100,000, the prevalence rate is 50 to 150/100,000, and women are slightly more than men. It has a double-peak distribution, the first peak is between 15 and 30 years old, the second peak is between 50 and 70 years old, and the first peak is more common. In 15% to 40% of patients, there is chronic ulcerative colon. Family history of inflammation or Crohn's disease, there are more Jewish patients than non-Jews in the United States, but there are fewer Jews in Israel who suffer from this disease. There is no comprehensive statistics on this disease in China, but in terms of clinical cases. It is not uncommon, and there is an increasing trend. In the prevention of this disease, aerobic exercise should be actively carried out to improve self-immunity.
Complication
Chronic ulcerative colitis complications Complications, abdominal distension, peritonitis, abdominal pain, nodular erythema, swelling, abscess, polymorphous erythema, thrush, anemia, myocarditis
(1) toxic colonic expansion occurs in the acute active phase, the incidence rate is about 2%, because the inflammation affects the muscular layer of the colon and the intermuscular nerve plexus, and the intestinal wall tension is low, showing stage palsy, and the intestinal contents and gas accumulate. , causing acute colonic dilatation, thinning of the intestinal wall, lesions are more common in the sigmoid colon or transverse colon, induced by hypokalemia, barium enema, anticholinergic drugs or opioids, clinical manifestations of rapid deterioration of the disease, symptoms of poisoning Obviously, with abdominal distension, tenderness, rebound tenderness, weakening or disappearance of bowel sounds, leukocytosis, X-ray abdominal plain film showing widening of the intestine, disappearance of the colonic bag, etc., easy to be accompanied by intestinal perforation, high mortality.
(2) The incidence of intestinal perforation is about 1.8%, which occurs on the basis of toxic colonic expansion, causing diffuse peritonitis and the presence of free gas under the armpit.
(3) Major bleeding: It is pointed out that the blood volume is large and the blood transfusion is treated. The incidence rate is 1.1% to 4.0%. In addition to the bleeding caused by ulceration, low prothrombinemia is also an important cause.
(4) polyps The polyps rate of this disease is 9.7% to 39%, often called this polyp is a pseudopolyposis, some people are divided into mucosal drooping type, inflammatory polyp type, adenomatous polyp type, polyps The part is in the rectum. Some people think that the descending colon and the sigmoid colon are the most, and the upward direction is reduced. The outcome can disappear with the healing of the inflammation, and it will be destroyed with the formation of the ulcer. It will persist or become cancerous. The cancer is mainly from the adenocarcinoma polyp.
(5) Carcinogenesis: The incidence rate is different. Some studies think that it is many times higher than those without colitis. It is more common in colitis lesions involving the whole colon, and the onset and medical history are more than 10 years.
(6) enterocolitis: the pathogenesis of complicated 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.
(7) Common complications associated with autoimmune reactions are:
1 arthritis: ulcerative colitis with an arthritis rate of about 11.5%, which is characterized by more frequent stages of enteritis lesions, more common in large joint involvement, and often a single joint lesion, joint swelling, synovial effusion There is no damage to the bones and joints, no serological changes in rheumatism, and often coincide with eye and skin specific complications.
2 skin mucosal lesions: nodular erythema is more common, the incidence is 4.7% ~ 6.2%, other such as multiple abscess, localized abscess, pustular gangrene, polymorphous erythema, etc., oral mucosal refractory ulcer is not uncommon Sometimes it is thrush, and the treatment is not effective.
3 eye lesions: there are iritis, iris ciliary body, uveitis, corneal ulcer, etc., the former is the most, the incidence rate is about 5% to 10%.
(8) Other complications: colonic stenosis, anal abscess, fistula, anemia, liver damage and kidney damage, in addition, there are also myocarditis, embolic vasculitis, pancreatic atrophy and endocrine disorders.
Symptom
Chronic ulcerative colitis symptoms Common symptoms Abdominal pain Diarrhea Abdominal bloating Congestion pale pale bowel sound polyps Anal fissure urgency and heavy blood in the stool
The initial manifestations of ulcerative colitis can take many forms. Bloody diarrhea is the most common early symptom. Other symptoms include abdominal pain, blood in the stool, weight loss, urgency, vomiting, etc., occasionally mainly arthritis, iridocyclitis, Liver dysfunction and skin lesions, fever is relatively an uncommon sign. In most patients, the disease is chronic, low-grade, acute in a few patients (about 15%), the process of catastrophic outbreaks, These patients present with frequent bloody stools, up to 30 times/d, and high fever and abdominal pain. Therefore, the clinical manifestations of this disease are extremely broad, ranging from mild diarrheal diseases to fulminant, short-term life-threatening outcomes. Treat immediately.
Signs are directly related to the disease and clinical manifestations. Patients often have weight loss and pale complexion. The colon is often tender during abdominal examination during the active period of the disease. There may be signs of acute abdomen with fever and reduced bowel sounds. Or violent cases are particularly obvious, toxic megacolon may have abdominal distension, fever and acute abdomen signs, due to frequent diarrhea, perianal skin may have bruises, exfoliation, but also perianal inflammation such as anal fissure or anal fistula, although The latter is more common in Crohn's disease. The rectal examination is always painful. In cases with perianal inflammation, the examination should be gentle, and the examination of the skin, mucous membranes, tongue, joints and eyes is extremely important because there are The lesion is present, then the cause of diarrhea may be ulcerative colitis.
Examine
Examination of chronic ulcerative colitis
1. Seen by colonoscopy
1 mucosa has multiple superficial ulcers, accompanied by congestion, edema, and most of the lesions start from the rectum and are diffusely distributed.
2 The mucosa is rough and fine, the mucosal blood vessels are blurred, brittle and easy to bleed, or with pus and bloody secretions.
3 visible polyps, colonic bags tend to become dull or disappear.
2. Mucosal biopsy
Histological examination showed an inflammatory response, accompanied by erosions, ulcers, crypt abscesses, abnormal glandular arrangement, reduction of goblet cells and epithelial changes.
3. See the tincture enema
1 mucosa is rough or has fine particle changes.
2 multiple shallow sputum or small filling defects.
3 The bowel is shortened, and the colonic bag disappears.
4. Surgical resection or pathological anatomy can be seen in the characteristics of macroscopic or histological ulcerative colitis.
Diagnosis
Diagnosis and diagnosis of chronic ulcerative colitis
diagnosis
Diagnosing mainly depends on fiberoptic colonoscopy, because about 90% to 95% of patients with rectal and sigmoid colon involvement, so in fact, through fiber sigmoidoscopy has been able to confirm the diagnosis, microscopic examination can see congestion, edema of the mucosa, brittle Easy to hemorrhage, ulcers can be seen in progressive cases, surrounded by raised granulation tissue and edema of the mucous membrane, looks like polypoid, or can be called pseudopolyposis, in the chronic progressive cases, the rectum and sigmoid cavity can be significantly reduced, In order to clarify the extent of the lesion, a colonoscopy was used for the whole colon examination, and multiple biopsy was performed at the same time to identify with colon colitis.
Gastroenterology double contrast angiography is also a useful diagnostic test, especially to determine the extent and severity of the lesion. In the sputum angiography, the colonic shape disappears, the intestinal wall is irregular, the pseudopolyposis and the intestinal cavity change. Fine, stiff, although the sputum examination is valuable, but should be cautious when checking, to avoid preparation for intestinal cleansing, because it can make colitis worse, no diarrhea case can be given 3d juice before the diet, there are abdominal signs The case should not be used as a barium enema examination, but should be used as a plain X-ray film to observe the presence or absence of toxic megacolon, colonic expansion and signs of free gas under the arm.
Due to the chronic long-term course of the disease and its high malignant rate, it is advisable to have an annual angiographic examination or a fiberoptic colonoscopy every 6 months for cases with a history of more than 10 years.
Differential diagnosis
Chronic bacterial dysentery
There is often a history of acute bacterial dysentery, antibacterial therapy is effective, and dysentery bacilli are isolated and isolated from fecal culture. The rate of mucus purulent secretion culture during colonoscopy is higher.
2. Chronic amoebic dysentery
The lesion mainly invades the right colon, and may also involve the left colon. The colon ulcer is deep, the margin is deep, the mucosa is normal, and the amoebic trophozoites or cysts can be found in the secretions taken from the feces or colonoscopy. Ba treatment is effective.
3. Schistosomiasis
In the epidemic area, there is a history of contact with infected water. The fecal examination shows that the schistosomiasis eggs are positive for hatching, and the rectal microscopic examination shows that the rectal mucosa has yellow-brown granules in the acute phase. The biopsy tablets or histopathological examination show that the schistosomiasis eggs are often accompanied by liver. splenomegaly.
4. Irritable bowel syndrome
Feces have mucus but no pus and blood. There may be alternating constipation and diarrhea, often accompanied by abdominal pain, abdominal distension, bowel sounds and systemic neurosis. Various examinations have no obvious quality lesions, and symptoms are closely related to mood and mental status.
5. Colon cancer
More common in middle-aged, anal examination can often touch the mass, fecal occult blood Changyangsheng, X-ray tincture fiber colonoscopy, differential diagnosis value.
It is worth noting that the disease is easy to be confused with chronic bacillary dysentery. Both are chronic pus and bloody stools. The colonoscopy is chronic inflammation. Especially for the intestinal mucosa, it is easy to bleed, the gland is abnormally arranged and the crypt is abscess. The barium enema is not found. Colonic pouch changes and other specific lesions, only chronic inflammation or "burr or jagged" shadow is more easily misdiagnosed, the author has 16 cases of chronic pus and blood, colonoscopy reported as "chronic colitis", sputum enema showed "burr or jagged "Shadow, diagnosed as ulcerative colitis, found that 6 cases of chronic bacteria, are multiple (3 ~ 6 times) enhanced pine stimulation (or prednisone before stool culture 3 days, 40mg daily) The stool culture of the dysentery bacillus should be taken as a warning, other need to identify: intestinal tuberculosis, ischemic colitis, pseudomembranous colitis, radiation enteritis, colon polyposis, colonic diverticulitis.
