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Lecture notes, cheat sheets
Hospital therapy. Diseases of the digestive tract. Intestinal diseases. Crohn's disease (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 13. Diseases of the digestive tract. Diseases of the intestines. Crohn's disease Crohn's disease is a chronic bowel disease with systemic manifestations; the morphological basis of which is granulomatous autoimmune inflammation of the gastrointestinal tract. Etiology and pathogenesis. The etiology and pathogenesis of the disease have not been sufficiently studied. The most popular are the infectious and immune concepts of the occurrence of the disease. In recent years, reports have appeared on the etiological role of microorganisms of the genus Yersinia. However, it is difficult to determine whether these microbial agents are pathogens or commensals. At the same time, changes in the intestinal microflora play an important role in the pathogenesis of the disease. Typically, a decrease in bifidum-type bacteria with a simultaneous increase in enterobacteria with signs of pathogenicity. Autoimmune mechanisms play a role in the development of the disease. In Crohn's disease, autoantibodies (IgC, IgM) appear against intestinal tissues. The morphological substrate of the disease is an autoimmune inflammatory process that occurs initially in the submucosal layer, spreads to the entire thickness of the intestinal wall and is characterized by the presence of granulomatous infiltrates followed by ulceration of the mucous membrane, the development of abscesses and fistulas that heal with the formation of scars and narrowing of the intestinal lumen. With an increase in the duration of the disease, the extent of the lesion increases and symptoms of extraintestinal disorders appear. Classification. Classification (F.I. Komarov, A.I. Kazanov, 1992). 1) Course: acute; chronic. 2) Characteristics of the process: lesion within the small intestine; lesion within the ileocecal region; lesion within the colon. 3) Complications: narrowing of the intestine; toxic dilatation of the colon; fistulas; amyloidosis; nephrolithiasis, cholelithiasis; AT12-deficiency anemia. clinical picture. The clinical picture of Crohn's disease is characterized by significant diversity, which is determined by the localization and extent of the pathological process in the intestine, the form of the disease and the addition of complications. The onset of the disease can be acute, when the disease progresses from the very beginning, and chronic, when the disease begins gradually. In the first case, the diagnosis is often made during laparotomy performed for suspected appendicitis, or intestinal obstruction that developed for no apparent reason in young people. At the same time, a hyperemic area of the small intestine, enlarged lymph nodes of the mesenteric root, characteristic of Crohn's disease, are found. Patients complain of pain in the abdomen without a specific localization, loosening of the stool without visible pathological impurities, weight loss, low-grade body temperature. An objective study pays attention to the pallor of the skin, which correlates with the severity of anemia, swelling in the legs due to impaired absorption and protein metabolism. On palpation of the abdomen, flatulence and rumbling are noted. When the process is localized in the large intestine, alternating constipation with diarrhea, cramping abdominal pain, liquid or semi-formed stools containing an admixture of blood are noted. When the upper gastrointestinal tract is affected, symptoms resembling chronic esophagitis, chronic gastritis, and chronic duodenitis occur. There may be pain behind the sternum during the passage of food through the esophagus, night and "hungry" pain in the epigastrium, pain on palpation in the pyloroduodenal zone. During physical examination of the patient, pallor of the skin, subfebrile condition, body weight deficiency are determined, palpation reveals spasmodic bowel loops, pain in the paraumbilical zone, in the right iliac region. In Crohn's disease, extraintestinal signs of the disease are noted: aphthous stomatitis, phlegmon and fistulas of the oral cavity, arthritis, resembling rheumatoid arthritis in the clinic, with characteristic symptoms of symmetrical lesions of small joints, stiffness in the morning. Typical changes in the eyes: iritis, iridocyclitis, maculopathy. The skin may develop erythema nodosa and pyoderma gangrenosum. Diarrhea is characterized by an increase in the frequency of stools up to 10 times a day or more, polyfecal matter. The volume of the stool is determined by the anatomical localization of the process: with damage to the proximal small intestine, the volume of feces is much larger than with damage to the distal parts. Weight loss is noted in all patients. Diagnosis and differential diagnosis. A clinical blood test during an exacerbation reveals leukocytosis, anemia, and an increase in ESR. Changes in the general urine analysis appear in severe forms, characterized by the addition of renal amyloidosis (proteinuria). A biochemical blood test reveals hypoproteinemia, hypoalbuminemia, an increase in α-globulins, a decrease in the content of iron, vitamin B12, folic acid, zinc, magnesium and potassium. The data of scatological examination allow to indirectly assess the level of the lesion. In the coprogram with small intestinal localization of the process, polyfecal matter, steatorrhea, creatorrhoea are found; with the colon - an admixture of mucus, leukocytes, erythrocytes. X-ray diagnostics allows you to establish the localization and prevalence of the pathological process in the intestine. Areas of the affected intestine alternate with areas of the unchanged intestine. The altered loops become rigid, the picture is mosaic with small filling defects and with the penetration of contrast beyond the intestinal wall in the form of pockets. The intestine in the affected area acquires the character of finely fringed, with the formation of pseudodiverticula. The contractile capacity of the intestinal wall is reduced or completely lost, the evacuation of barium slows down. An uneven narrowing of the intestinal lumen is observed, as a result, it becomes so narrow that it takes on the form of a lace. Above the zone of narrowing, the intestine expands. Endoscopic diagnosis is of decisive importance in the verification of the diagnosis. For Crohn's disease, the most characteristic is the change in the antrum of the stomach and the initial section of the duodenum. Endoscopically, it is possible to detect a circular narrowing of the antrum, resembling tumor stenosis. The initial period of Crohn's disease is characterized by poor endoscopic data: a dull mucous membrane, against which erosions of the aphthae type are visible, surrounded by whitish granulations. The vascular pattern is absent or smoothed out. In the lumen of the intestine and on its walls, purulent mucus is determined. In clinical remission, the described changes may disappear completely. As the disease progresses, the mucosa becomes unevenly thickened, has a whitish color, and large superficial or deep fissure ulcers are noted. The intestinal lumen narrows, making it difficult to advance the colonoscope. Colonoscopy makes it possible to perform a targeted biopsy of the mucous membrane in any part of the colon and in the terminal ileum. In Crohn's disease, the pathological process begins in the submucosal layer, so the biopsy should be performed in such a way that a portion of the submucosal layer enters the biopsy material. In connection with the above, in 54% of cases the morphological substrate of the disease is not detected. It is necessary to differentiate Crohn's disease from nonspecific ulcerative colitis, gastrointestinal tuberculosis, ischemic colitis, Whipple's disease, diverticular disease, pseudomembranous colitis, lymphogranulomatosis, primary small intestinal amyloidosis, chronic enteritis. Common to all of these diseases are the syndrome of intestinal dyspepsia and some systemic lesions. However, ulcerative colitis is characterized by a change in the distal parts of the colon with the obligatory involvement of the rectum and sigmoid in the process. In nonspecific ulcerative colitis, there is no segmentation of the lesion; less often than in Crohn's disease, systemic manifestations are determined, and malabsorption syndrome is less pronounced. However, the most accurate diagnosis of Crohn's disease is confirmed by endoscopy with targeted biopsy. Gastrointestinal form of tuberculosis is distinguished from Crohn's disease by frequent localization in the ileum, endoscopic findings that allow the detection of ulcers with raised, exfoliated edges filled with grayish contents. Such ulcers heal with the formation of a short scar, which is not observed in Crohn's disease. In the elderly, there is a need to differentiate Crohn's disease and ischemic colitis. For the latter, attacks of intense pain in the abdomen after eating are typical, irrigoscopically detectable colitis changes in the splenic flexure, descending and sigmoid colon. The most important radiographic sign of ischemic colitis is the "thumbprint" symptom. Endoscopic and morphological examination reveals typical for ischemic colitis hemosiderin-containing cells and fibrosis in the biopsy material. The diagnosis of lymphogranulomatosis and primary intestinal amyloidosis is made on the basis of histological examination. In the first case, Berezovsky-Sternberg cells are found in the biopsy specimen from the mesenteric lymph node, in the second case, there are deposits of amyloid in the rectal mucosa. Treatment. A mechanically and chemically gentle diet with a high content of proteins, vitamins, microelements is prescribed, with the exclusion of milk if it is intolerant, and the limitation of coarse plant fiber. The use of liquid enteral hydrolysates is indicated. Salazopreparations and corticosteroids form the basis of pathogenetic drug therapy. The daily dose of drugs is 3-6 g. With the localization of the pathological process in the large intestine, the activity of sulfasalazine exceeds the activity of prednisolone. In the absence of the effect of the use of sulfasalazine, with lesions predominantly of the small intestine and pronounced signs of immune inflammation, as well as in the presence of systemic manifestations of the disease, the use of corticosteroids is indicated. The effect of their use is noted in the first 8 weeks from the start of treatment. Prednisolone is prescribed according to the following scheme: at the height of an exacerbation, 60 mg per day, then the dose is gradually reduced and, by the 6-10th week, is adjusted to a maintenance dose of 5-10 mg per day. Upon reaching clinical remission, the drug is gradually canceled. If remission is not achieved, treatment with prednisolone is continued on an outpatient basis until 52 weeks. In severe course of the disease, in case of complications in the form of torpid current rectovaginal, skin-enteric, enteroenteric fistulas, the appointment of 6-mercaptopurine orally at 0,05 g 2-3 times a day is indicated for 10-day courses with an interval of 3 days until clinical remission is achieved . Subsequently, they switch to taking maintenance doses of the drug during the year. The dose of 6-mercaptopurine in this case is 75 mg per day. The effect of treatment with immunosuppressants can be determined no earlier than after 3-4 months. Widespread use in the treatment of Crohn's disease was found by metronidazole, the main indications for which are perianal fistulas and fissures, the lack of effect of salazopreparations and glucocorticoids, as well as relapses of the disease after proctectomy. The drug is prescribed at a dose of 500-1000 mg per day. The duration of the continuous course should not exceed 4 weeks. Symptomatic therapy of Crohn's disease is reduced to the appointment of short courses (2-3 days each) of antidiarrheal drugs (imodium, loperamide). Doses are selected individually according to the clinical effect. Do not prescribe antidiarrheals for a long time (more than 5 days). Due to the presence of malabsorption syndrome in Crohn's disease, enzyme preparations that do not contain bile acids (pancreatin, mesimforte, solizim, somilase) are used in a dose of 2 to 6 tablets with each meal. According to the indications, anemia and hypoalbuminemia are corrected by prescribing iron preparations (parenterally) and administering Alvezin, protein hydrolysers, aminopeptide, aminoblood. Assign multivitamins in pills, Essentiale in capsules. Treatment of dysbacteriosis is carried out according to general rules. Prognosis and prevention. With Crohn's disease, the prognosis for life with timely diagnosis and effective follow-up is favorable, but for work it is uncertain. In patients with severe disease, in the presence of complications and systemic manifestations, disability group I or II is established. Crohn's disease is a precancerous disease. The patient needs to be familiarized in detail with the features of the course of the disease and warned about possible complications, describing their clinical manifestations in an accessible form. Author: Mostovaya O.S. >> Forward: Diseases of the digestive tract. Diseases of the colon. Nonspecific ulcerative colitis
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