Ulcerative colitis in children
Introduction
Introduction to pediatric ulcerative colitis Ulcerative colitis (ulcerativecolitis UC), referred to as ulceration, has not yet fully elucidated the cause. It is mainly a chronic non-specific inflammatory disease invading the colonic mucosa, often starting from the left colon, and progressing gradually to the proximal colon and even the whole colon in a continuous manner. The clinical symptoms vary in severity, and there may be a combination of remission and seizures. Patients may have only colon symptoms or systemic symptoms. basic knowledge The proportion of illness: 0.015% Susceptible people: children Mode of infection: non-infectious Complications: lower gastrointestinal bleeding fatty liver malnutrition kidney stones
Cause
Causes of pediatric ulcerative colitis
Autoimmune causes:
Ulcerative colitis often complicated by autoimmune hemolysis, rheumatoid arthritis, lupus erythematosus, Hashimoto's disease, iritis, etc., and is effective with adrenocortical hormone drugs or other immunosuppressive agents, so considering this disease may be a self Immune disease.
Cause of infection:
Clinically, some children are found to have anxiety, nervousness, suspiciousness and autonomic nervous disorder performance. Psychotherapy can receive certain effects. Some children with infection are treated with antibiotics.
Causes of eating allergies and genetic causes:
Some foods can cause the disease to recur, and the removal of these diets can alleviate the condition, and 15% to 30% of the families with genetic causes have a disease.
Pathogenesis
1. Pathogenesis:
(1) Immunity factors: This disease is often complicated by rheumatoid arthritis, systemic lupus erythematosus and other autoimmune diseases. Many studies have shown that its pathogenesis is closely related to immune factors.
1 humoral immunity: immunoglobulins in patients with this disease are often elevated, IgM is significantly increased, IgG and IgA are also increased in serum and intestinal mucosal interstitial and glandular cavities, and a variety of non-specific anti-antigens can be found in serum. Colon antibody.
2 Cellular immunity: The number and ratio of T lymphocytes in the peripheral blood of patients with this disease, lymphocyte conversion rate, leukocyte and phagocytic cell migration blocking test were all decreased, indicating that the occurrence of this disease is related to the decline of cellular immune function.
3 immune complex: the patient's colonic mucosa intrinsic membrane with IgG, complement and fibrinogen deposition of immune complexes.
(2) Genetic factors: an important factor in the pathogenesis of this disease, the main basis is:
1 Family aggregation phenomenon: Compared with the general population, patients with ulcerative colitis have a higher family incidence rate and family aggregation, and 5% to 15% of relatives also have this disease.
2 The incidence of monozygotic twins is higher than that of twins.
3 The first-degree relatives (parents, children, siblings) of the patients had a higher incidence, but the incidence of their spouses and neighbors who were in contact with them was not high, suggesting that the disease was not contagious.
4 The incidence rate is racially different, the incidence rate of white is higher, the incidence of black people is only 1/3 of that of whites, and Jews are 3 to 5 times higher than non-Jews.
5 is often accompanied by some known genetic immune diseases.
The genetic mechanism of this disease is generally considered to be not only a dominant gene, but also a simple recessive gene, but may be a genetic model of "multiple loci single disease".
(3) Infectious factors: Most patients have a history of intestinal infection before the onset of the disease. However, over the years, repeated studies have failed to find microbiological evidence of infection, failed to cultivate pathogenic bacteria, and most of the antibiotic treatments are ineffective, so it is considered to be infected. Although the factors have a certain relationship with the disease, they may be only predisposing factors.
(4) Mental factors: have a certain relationship with the onset of this disease, mental disorders can cause autonomic dysfunction, resulting in intestinal dysfunction, smooth muscle spasm, vasoconstriction, increased capillary permeability and other pathological changes, ultimately leading to Intestinal wall inflammation and ulcer formation, clinically visible in some patients with anxiety, nervousness, and suspicious, the use of psychotherapy can receive certain effects.
(5) Allergic factors: Some patients are allergic to certain foods, such as milk, lemon, potato, wheat, tomatoes, etc., often cause recurrence when eating such foods, and the condition can be improved after fasting such foods. Some patients have eosinophilia in the blood circulation and diseased tissues, and some plasma cells secrete IgE and the number of plasma cells and histamine content increase. These phenomena suggest that some patients have type I allergic reaction.
2. Pathological changes:
The basic pathological changes are the same as those in adults. The colonic mucosa is extensively hyperemic, edematous, and oozing is the pathological basis of blood diarrhea. It is more serious than adults. The initial lesions only affect the rectum, the sigmoid colon, and gradually spread to the proximal colon, eventually spreading to the whole colon. Severe ileum can also be affected within 20cm of the end of the ileum. The lesion mainly occurs in the colonic mucosa. Early intestinal mucosal congestion, edema, loss of normal blood vessel distribution, increased fragility, secondary mucosal abscess after secondary infection, mucosa after rupture The surface forms shallow ulcers, followed by ulcer fusion, enlargement to form large irregular ulcers, decreased glands, mucosal atrophy, a few serious cases invade the muscular layer and serosal layer, and a part of the ulcers healed to form scars, resulting in intestinal stenosis and shortening Can cause incomplete intestinal obstruction, part of the ulcer is surrounded by fibrous tissue to form polypoid changes, called pseudopolyps, mucosal dysplasia, on the basis of canceration.
Prevention
Pediatric ulcerative colitis prevention
At present, there is no specific measure to prevent this disease. It should be a reasonable diet, good eating habits, enhance physical fitness, promote physical and mental health, avoid mental stress, prevent nutritional deficiencies and gastrointestinal infectious diseases.
Complication
Pediatric ulcerative colitis complications Complications lower gastrointestinal bleeding fatty liver dystrophy kidney stones
Intestinal complications
(1) acute fulminant ulcer colitis: acute colonic dilatation and ulcer perforation; lower gastrointestinal bleeding, colon pseudopolyps, multiple, varying in size, sometimes cobblestone-like, colonic stenosis more common in the rectum and transverse colon, Can also be found in other parts.
(2) toxic megacolon: is a serious complication, the incidence rate is 1.6% to 2.5%, and the mortality rate is 13% to 50%. It is more common in acute fulminant and severe patients. Multi-anticholinergic drugs, low potassium, barium enema, colon lesions are extensive and serious, involving the intestinal muscle layer and intermuscular nerve plexus, so that the intestine can not be contracted, the diameter of the intestine can reach more than 10cm, the symptoms of poisoning are obvious, abdominal distension, abdominal Tenderness, rebound tenderness, weakening or disappearance of bowel sounds, markedly elevated white blood cells, X-ray plain film showing colonic enlargement, colonic bag shape disappearing, due to intestinal dilatation, ischemia and necrosis can occur, causing acute intestinal perforation (acute intestinal Perforation).
(3) Intestinal perforation: and rectal bleeding: the incidence rate is about 1%, and the mortality rate is 40% to 50%. The reasons are:
1 occurs on the basis of toxic megacolon expansion,
2 chronic stenosis occurs.
3 high pressure barium enema induced.
(4) polyp (polyp): for late complications, the incidence rate of 9.7% to 39%, caused by inflammation, usually colon pseudopolyps (pseudo-polyp).
(5) Cancer (canceration): cancer can occur in the late stage, the incidence rate is 5% to 10%. The lesions mainly occur in severe patients. The lesions involve the whole colon and patients with long course of disease. The cancer is less in children, and the longer the course is cancerous. The higher the tendency, the cancer rate in the first 10 years after onset is about 3%, and the annual increase is 0.5% to 1.0%, and the second 10 years can reach 10% to 20%. Therefore, the child should have a colonoscopy once a year. Check, late complications have anal infection, anal fistula and so on.
2. Extraintestinal complications
(1) joint involvement: about 25% of joint involvement in ulcerative colitis, manifested as non-teratogenic migratory acute arthritis, such as swelling and pain; at the same time, it can be one or more joints, each joint can be Invasion, but more common in the knee, ankle and wrist.
(2) skin damage: more common, severe active ulcerative colitis about 15% have skin damage, nodular erythema is more common, and no scar after the recovery; gangrenous pyoderma is ulcerative damage, common in The trunk is scarred after the healing, and the incidence is 5% to 10% during the active period of the disease, but it can be cured.
(3) Eye: The incidence of scleral inflammation, recurrent iritis and uveitis is about 5%.
(4) massive hemorrhage: the incidence rate is 1.1% to 4.0%, the cause is ulceration involving large blood vessels, and hypoprothrombinemia.
(5) Others: advanced fatty liver, sclerosing cholangitis, chronic hepatitis; also prone to anemia, malnutrition, kidney stones.
Symptom
Ulcerative symptoms of colitis in children Common symptoms Abdominal distension, abdominal pain, loss of appetite, fatigue, nausea, colonic swell, colonic bag, half a month, disappearance, anxiety, abdominal muscle tension, constipation
Most of the onset is slow, the course of disease can be persistent, often with the attack period and the remission period alternate, the onset of acute illness accounts for 5%, the disease develops rapidly, the symptoms of systemic poisoning are obvious, the complications are common, the mortality rate is high, and the disease can be relieved during the remission period. Sudden increase, mental stimulation, fatigue, intestinal inflammation, eating disorders are often the predisposing factors of this disease.
1. Digestive system performance
(1) Diarrhea: The degree of diarrhea varies, and the lightness is 3 to 4 times per day, or diarrhea and constipation alternate. The severe defecation is frequent, and it can be taken once every 1-2 hours. 4 to 6 times / d, progressive exacerbation, excretion of mucus and blood, bloody stools, watery stools, loose stools and pus, especially mucus and bloody stools have almost become the necessary symptoms of all active patients in this disease, common urgency and heavy, acute cases Beginning with bloody stools with abdominal pain, vomiting, fever and other symptoms of poisoning.
(2) Abdominal pain (abdominal pain): patients with mild and remission period may have no abdominal pain, abdominal pain is generally mild, moderate, often limited to the left lower abdomen or lower abdomen, may also involve the whole abdomen, there is pain - constipation - post-surgical relief .
(3) Other symptoms: often have abdominal distension, severe cases of loss of appetite, nausea, vomiting and other symptoms.
(4) Signs: In addition to mild tenderness in the left lower abdomen, there are no other signs, and those with severe and violent bloating may have abdominal distension, abdominal muscle tension, abdominal tenderness or rebound tenderness, and some patients may touch the sputum or thickening of the intestinal wall. The sigmoid colon or descending colon.
2. Whole body performance:
Light is often not obvious, severe cases may have fever, water and electrolyte disorders; sick children due to long-term diarrhea, blood in the stool, loss of appetite, increased heart rate, weakness, mental dysfunction, long-term anemia and malnutrition, about 3% Patients with emotional instability, such as depression, anxiety, insomnia, etc.; severe cases may also be accompanied by growth and development disorders, delayed development of puberty, some children with mental, psychological and emotional abnormalities.
3. Clinical classification:
(1) According to the course of disease: according to clinical manifestations and processes can be divided into the following 4 types:
1 initial hair: symptoms vary, no history of ulcerative colitis, can be converted to chronic relapsing or chronic persistent.
2 Chronic recurrence type: mild symptoms, more common in clinical, the length of remission after treatment is different, typical ulcerative colitis lesions at the time of onset; mild mucosal congestion and edema in the remission period, some children can be converted into chronic Continuous type.
3 Chronic persistent type: After the onset, there are persistent diarrhea, intermittent bloody stools, abdominal pain and systemic symptoms, which last for several weeks to several years, during which there may be an acute attack.
4 acute fulminant: the proportion of this type of adolescents is significantly higher than that of adults, acute onset, severe systemic and local symptoms, high fever, diarrhea and a large number of bloody stools, can cause anemia, dehydration and electrolyte imbalance, hypoproteinemia, nutrition Poor, and prone to toxic colonic dilatation, intestinal perforation and peritonitis.
(2) According to the condition: according to the severity of the disease can be divided into the following 3 degrees:
1 Mild: Most common, mild digestive symptoms, systemic symptoms are not obvious.
2 Moderate: Between mild and severe, the digestive system is more severe and has mild systemic symptoms.
3 severe: obvious systemic symptoms, obvious digestive system symptoms, more common complications, more cancerous opportunities, most patients with chronic disease, 10% of patients with acute attacks, can be repeated after treatment symptoms are relieved.
4. Extraintestinal symptoms:
25% of the sick children may be associated with arthritis, mainly limbs and spine, joint symptoms sometimes occur before diarrhea, 10% of the sick children develop skin lesions, such as nodular erythema, gangrenous pyoderma, etc., 2% With retinitis, oral ulcers, etc., clinical chronic diarrhea, mucus or bloody stools, the following checks should be done when suspected of this disease:
1 Multiple fecal routine examinations and fecal cultures to find enteric pathogens such as Shigella bacilli, smear to find amebic trophozoites, and to exclude schistosomiasis and intestinal diseases according to the characteristics of the epidemic areas.
2 sigmoid colonoscopy or colonoscopy and mucosal biopsy.
3 barium enema examination, while excluding other diseases of the intestines.
Examine
Examination of pediatric ulcerative colitis
Barium enema and sigmoid colonoscopy are valuable diagnostic and differential diagnostic methods.
First, barium enema examination:
It is mainly used to diagnose colonic lesions by inserting an anal canal from the anus, injecting a tincture and then X-raying to diagnose colonic tumors, polyps, inflammation, tuberculosis, intestinal obstruction and other diseases.
Second, sigmoidoscopy:
It is a simple and easy method of examination, which can find a high-grade mass that cannot be touched by the rectal examination. At the same time, a biopsy is performed on the suspected lesion to confirm the nature.
Therefore, sigmoidoscopy can be used for diagnosis and as a therapeutic instrument, which is of great significance for prevention and early detection of rectal and sigmoid colon cancer.
Sigmoidoscopy is used to examine inflammation of the rectum and sigmoid colon, ulcers, polyps, tumors, parasitic lesions, and unexplained diarrhea. It can be used to take live tissue specimens during inspection.
Diagnosis
Diagnosis and diagnosis of ulcerative colitis in children
diagnosis
1. Diagnostic criteria
At present, the Lennard-Jones standard is commonly used internationally, and the Diagnostic Criteria and Efficacy Criteria for Ulcerative Colitis developed by the 1993 Taiyuan National Symposium on Chronic Non-infectious Intestinal Diseases in China, both emphasize exclusionary diagnosis. Endoscopic and histological features.
(1) Lennard-Jones standard: Patients with clinical manifestations of ulcerative colitis, which meet the following criteria suggest the diagnosis of this disease.
1 First, the following diseases must be excluded:
A. Infective colitis, according to microbiological examination.
B. Ischemic colitis, according to the predisposing factors, lesion distribution characteristics and histological examination.
C. Radioactive colitis, according to medical history.
D. Isolated colonic ulcer, based on lesion location and histological features.
E. Crohns disease, small bowel lesions according to X-ray examination, anal lesions found on physical examination, and granulomas on biopsy.
2 must include the following conditions:
A. Biopsy revealed diffuse mucosal inflammation without granuloma formation.
B. Endoscopic or barium enema examination revealed that inflammation affects the rectum and part or the whole colon. The lesion begins in the rectum and continuously develops retrogradely from the distal end to the proximal end.
(2) National Symposium on Chronic Non-infectious Enteric Diseases (Taiyuan, 1993):
1 clinical manifestations: not only persistent or recurrent mucus bloody stools, abdominal pain, with varying degrees of systemic symptoms, and should not ignore a small number of patients with constipation and no bloody stools, pay attention to joints, eyes, oral cavity in past history and physical examination , extrahepatic manifestations such as liver and spleen.
2 colonoscopy see:
A. There are multiple superficial ulcers in the mucosa, accompanied by congestion and edema. Most of the lesions start from the rectum and are diffusely distributed.
B. The mucosa is rough and fine-grained, the mucosal blood vessels are blurred, the fragility is easy to bleed, or the purulent secretion is attached.
C. Visible pseudopolyps, colonic bags tend to become dull or disappear.
3 mucosal biopsy: histological examination showed an inflammatory reaction, and often showed erosion, ulcer, crypt abscess, abnormal gland arrangement, goblet cell reduction and epithelial changes.
4 barium enema examination:
A. The mucous membrane is rough and/or has fine particle changes.
B. Multiple shallow shadows or small filling defects.
C. The bowel is shortened, and the colonic bag disappears to be tubular.
5 surgical resection or pathological anatomy: visible macroscopic or histological ulcerative colitis characteristics.
(3) Diagnosis after exclusion of related diseases: on the basis of exclusion of bacterial dysentery, amoebic dysentery, chronic schistosomiasis, intestinal tuberculosis and other infectious colitis and Crohn's disease, ischemic colitis, and radiation colitis Can be diagnosed according to the following criteria:
1 According to clinical manifestations, one of the colonoscopy and / or mucosal biopsy can diagnose the disease.
2 According to the clinical manifestations and one of the barium enema can diagnose the disease.
3 clinical manifestations are atypical and typical colonoscopy findings or typical changes in barium enema examination, can diagnose the disease.
4 clinical manifestations of typical symptoms or typical past history, and the current colonoscopy or barium enema examination has no typical changes, should be listed as "suspicious" follow-up.
2. Main clinical features
The most common symptoms are recurrent colitis, which is characterized by bloody diarrhea, fever, abdominal pain, pale skin, anemia, malnutrition, delayed puberty, and clinical ulcerative colitis and bacterial dysentery. , amoebic enteritis, intestinal tuberculosis, localized colitis (Crohns disease), colon tumor differentiation.
3. Main auxiliary inspection
Barium enema and sigmoid colonoscopy are valuable diagnostic and differential diagnostic methods.
Differential diagnosis
1. Chronic bacillary dysentery: often has a history of acute bacterial sputum disease, antibacterial treatment is effective, fecal culture can be isolated from dysentery bacilli, mucus pus and blood culture during colonoscopy, the positive rate is higher.
2. Chronic amebic dysentery: The lesion mainly invades the right colon, but also the left colon. The colon ulcer is deep, the edge is sneak, the mucosa between the ulcers is normal, and the stool can be found in the stool. Miba trophozoites or cysts are effective against amebic treatment.
3. Crohns disease: The lesion mainly invades the end of the ileum. The abdominal pain is mostly located in the right lower abdomen or the umbilical cord. It is rare after the urgency. The stool often has no mucus and pus and blood. The abdominal mass and the fistula are formed. The lesions around the anus and rectum are more common. X-ray barium angiography showed a line-like sign at the end of the ileum. The sigmoid colon examination was normal. If the rectum was involved, the mucosa of the lesion showed a pebbly-like bulge, and there was a round longitudinal ulcer with a segmental distribution.
4. Colon cancer: more common in middle-aged, rectal examination can touch the mass, colonoscopy is valuable for differential diagnosis, biopsy can confirm the diagnosis.
5. Irritable bowel syndrome: with systemic neurosis, mucus in the stool but no pus and no evidence of organic lesions in colonoscopy.
