Hospital therapy. Diseases of the digestive tract. Colon diseases. Nonspecific ulcerative colitis (lecture notes)

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Hospital therapy. Diseases of the digestive tract. Colon diseases. Nonspecific ulcerative colitis (lecture notes)

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LECTURE No. 14. Diseases of the digestive tract. Diseases of the colon. Nonspecific ulcerative colitis

Nonspecific ulcerative colitis is an inflammatory disease that affects the mucous membrane of the colon with ulcerative-destructive changes, which has a chronic relapsing course, often accompanied by the development of life-threatening complications.

Etiology and pathogenesis. Nonspecific ulcerative colitis is an idiopathic disease. The reasons for its occurrence are not known.

Of the many theories explaining the origin of the disease (infectious, enzymatic, allergic, immune, neurogenic, etc.), the infectious theory is of greatest interest, but attempts to isolate the pathogen from the contents of the colon were unsuccessful.

The pathological process in chronic ulcerative colitis begins in the rectum and spreads in the proximal direction, capturing the overlying parts of the colon.

Inflammation can be limited to the rectum (proctitis), rectum and sigmoid (proctosigmoiditis), spread to the entire left section (left-sided colitis), or affect the entire colon (total colitis).

In functional terms, the length of the colon in nonspecific colitis is reduced by about 1/3. In the study of pathological material revealed diffuse inflammation of the mucous membrane of the colon (pronounced swelling and plethora, thickening of the folds).

Ulcers of various sizes are formed in the mucosa, having an irregular shape, the bottom of which is located in the mucous membrane, less often in the submucosal layer, in the muscular and serous membranes.

Morphologically, in the initial period, an infiltrate in the lamina propria of the mucous membrane is determined, consisting of lymphocytes with an admixture of polymorphonuclear leukocytes, dilation of blood vessels and swelling of the endothelium of these vessels. Violation of microcirculation is accompanied by the development of hypoxia, which exacerbates the violations of the structure and function of the mucosal epithelium. The stage of pronounced clinical manifestations is accompanied by leukocyte infiltration of the surface layer of the epithelium, the development of cryptitis, in which accumulations of neutrophils occur in the lumen of the crypts. The distal parts of the crypts are obliterated, crypt abscesses appear, in the formation of which an important role is played by impaired maturation of epitheliocytes. With necrosis of the epithelium lining the crypts, crypt abscesses open, ulcers form.

During the period of remission, the mucous membrane is restored, but its atrophy, deformation of the crypts, and uneven thickening of the lamina propria remain.

Classification (Yu. V. Baltaitis et al., 1986).

Clinical characteristic.

1. Clinical form:

1) acute;

2) chronic.

2. Current:

1) rapidly progressing;

2) continuously relapsing;

3) recurrent;

4) latent.

3. Degree of activity:

1) exacerbation;

2) fading exacerbation;

3) remission.

4. Severity:

1) light;

2) moderate;

3) heavy.

Anatomical characteristic.

1. Macroscopic characteristic:

1) proctitis:

2) proctosigmoiditis;

3) subtotal lesion;

4) total defeat.

2. Microscopic characteristic:

1) the predominance of destructive-inflammatory processes;

2) reduction of inflammatory processes with elements of reparation;

3) consequences of the inflammatory process. Complications.

1. Local:

1) intestinal bleeding;

2) perforation of the colon;

3) narrowing of the colon;

4) pseudopolyposis;

5) secondary intestinal infection;

6) disappearance of the mucous membrane;

7) toxic dilatation of the colon;

8) malignancy.

2. General:

1) functional hypocorticism;

2) sepsis;

3) systemic manifestations - arthritis, sacroiliitis, skin lesions, iritis, amyloidosis, phlebitis, sclerosing cholangitis, liver dystrophy.

clinical picture. The clinical picture of ulcerative colitis is polymorphic and depends on the severity of the course and severity of the process. The course of the inflammatory process, often considered chronic, in some cases becomes acute. The extent of damage to the colon may also vary. Nonspecific ulcerative colitis is characterized by 3 leading symptoms: discharge of scarlet blood during bowel movements, intestinal dysfunction and abdominal pain.

Isolation of blood (from streaks on the surface of feces to 300 ml or more) during defecation is the first sign of the disease. In the acute form of the disease, blood is secreted by a jet, which leads to a decrease in blood pressure up to the development of collapse and hemorrhagic shock.

Intestinal dysfunction manifests itself in the form of complaints of repeated unstable stools, which is the result of extensive damage to the mucous membrane and a decrease in the absorption of water and salts. Most often, diarrhea occurs with severe ulcerative colitis. However, diarrhea is not a reliable indicator of the severity of the process. The severity of diarrhea in combination with the presence of red blood in the stool matters. In a significant number of patients with ulcerative colitis, blood and mucus are periodically found on the surface of the formed feces, which is often mistakenly regarded as a manifestation of hemorrhoids.

Patients complain of pain in the lower abdomen of a cramping or persistent nature, which is more often localized in the hypogastrium or the left iliac region, increases before the act of defecation and disappears after it. Tenesmus is often noted. When the submucosal, muscular and serous layers of the intestine are involved in the process, pain increases; palpation of the abdomen appears defense of the muscles of the anterior abdominal wall.

The mild course of nonspecific ulcerative colitis is characterized by a satisfactory condition of patients. Pain in the abdomen is moderate and short-term. The chair is decorated, speeded up, up to 2-3 times a day. Blood and mucus are found in the stool. The process is localized within the rectum and sigmoid colon. The clinical course is recurrent. The effect of treatment with salazopreparations is satisfactory. Relapses occur no more than 2 times a year. Remissions can be long (more than 2-3 years).

The moderate course of the disease is diagnosed if the patient has diarrhea. The chair is frequent (up to 6-8 times a day), in each portion an admixture of blood and mucus is visible. Cramping pains in the abdomen are more intense. There are intermittent fever with a rise in body temperature up to 38 ° C, intense general weakness. There may also be extraintestinal manifestations of the disease (arthritis, uveitis, erythema nodosum). The course is continuously recurrent, the effect of salazopreparations is unstable, hormones are prescribed during exacerbations.

The severe form of the disease is characterized by an acute onset. A total lesion of the large intestine rapidly develops with the spread of the pathological process deep into the intestinal wall. The patient's condition deteriorates sharply. The clinic is characterized by a sudden onset, high fever, profuse diarrhea up to 24 times a day, profuse intestinal bleeding, and a rapid increase in dehydration. Tachycardia appears, blood pressure decreases, extraintestinal manifestations of nonspecific ulcerative colitis increase. Conservative treatment is not always effective, and emergency surgery is often required.

Diagnosis and differential diagnosis. In clinical blood tests in mild forms of the disease, slight neutrophilic leukocytosis, an increase in ESR, and red blood counts are not changed. As the severity of the course increases and the duration of exacerbation increases, anemia of mixed origin occurs (B₁₂-deficient and iron-deficient), increased ESR.

In the biochemical analysis of blood in moderate and severe forms, dysproteinemia, hypoalbuminemia, hypergammaglobulinemia, electrolyte imbalance, and acid-base state are noted. In the general analysis of urine, changes appear only when complications arise in the form of nephrotic syndrome against the background of amyloidosis, when characteristic changes in urine tests are noted - proteinuria, "dead" urinary sediment, there is also an increase in the blood and the level of creatinine, urea.

The main role in the diagnosis is acquired by endoscopic examination with targeted biopsy, since in nonspecific ulcerative colitis, the colon mucosa is primarily affected. The rectum is always involved in the pathological process, i.e., erosive and ulcerative changes are detected during endoscopy immediately behind the anal sphincter during sigmoidoscopy. In ulcerative colitis, the rectosigmoid bend is not always possible to overcome due to severe spasm. An attempt to hold the tube of the proctoscope is accompanied by severe pain. In this situation, the proctoscope should be inserted to a depth of no more than 12-15 cm.

Colonoscopy during a severe exacerbation of nonspecific ulcerative colitis is not safe to carry out. It should be used at high risk of malignancy. It should be noted the high information content of sigmoidoscopy.

The endoscopic picture depends on the form of the disease. With a mild form, edematous dull mucous membrane, thick whitish overlays of mucus on the walls of the intestine, and slight contact bleeding are visible. The vascular pattern of the submucosal layer is not visually determined. In the moderate course of the disease, hyperemia and edema of the mucous membrane, severe contact bleeding, hemorrhages, erosions and irregularly shaped ulcers, thick overlays of mucus on the walls of the intestine are revealed. In a severe course of the disease, the mucous membrane of the colon is destroyed over a considerable extent. A granular, bleeding inner surface, extensive areas of ulceration with fibrinous deposits, pseudopolyps of various sizes and shapes, pus and blood in the intestinal lumen are found. Contraindications for colonoscopy and sigmoidoscopy are severe forms of ulcerative colitis in the acute stage of the disease.

X-ray examination allows you to determine the extent of the lesion; clarify the diagnosis in case of insufficiently convincing endoscopy data; differential diagnosis with Crohn's disease, diverticular disease, ischemic colitis; timely detect signs of malignancy. Plain radiographs can reveal shortening of the intestine, lack of haustration, toxic dilatation, free gas under the dome of the diaphragm during perforation.

Irrigoscopy should be carried out with great care. It can provoke a deterioration in the patient's condition. In some cases, the preparation of the patient for barium enema with enemas and laxatives has to be replaced with a special diet prescribed 2 days before the study. In some cases, the use of a contrast enema can accelerate perforation or cause toxic dilatation of the colon. Therefore, irrigoscopy is performed after the subsidence of acute phenomena. This method reveals unevenness and "graininess" of the mucosa, thickening of the intestinal wall, ulceration, pseudopolyposis, lack of haustration. Differential diagnosis of nonspecific ulcerative colitis is carried out primarily with acute intestinal infections.

In the presence of an epidemic of intestinal infections, the diagnosis is easily established. But even in the case of sporadic morbidity in acute intestinal infections, the colitis syndrome flows without relapses, while ulcerative colitis has a relapsing course. The most accurate methods for identifying acute intestinal infection include bacteriological and serological.

Often, ulcerative colitis is differentiated from Crohn's disease. In typical cases, Crohn's disease differs from nonspecific colitis in the absence of damage to the rectum, frequent involvement of the ileum in the pathological process, and segmental lesions of the intestinal wall. The definitive diagnosis can be made by detecting Crohn's disease-specific lymphoid granulomas in biopsy specimens. With granulomatous colitis, paraproctitis and pararectal fistulas are detected more often than with nonspecific ulcerative colitis.

In some cases, it becomes necessary to distinguish between ulcerative colitis and intestinal tuberculosis. For intestinal tuberculosis, a certain localization of the process is characteristic (ileum, ileocecal region), segmental intestinal damage. But sometimes with intestinal tuberculosis, the rectum and the entire large intestine are affected. The colonoscopic picture of intestinal tuberculosis is characterized by the presence of ulcers with raised edges filled with grayish contents. Tuberculous ulcers tend to spread in a transverse direction and leave behind short scars in which ulcers reappear. With nonspecific ulcerative colitis, scars do not form at the site of former ulcers.

In elderly and senile patients, ulcerative colitis should be differentiated from ischemic colitis. The latter is characterized by intense, paroxysmal pain in the abdomen 20-30 minutes after eating, while in ulcerative colitis pain occurs before the act of defecation. The most important radiological sign is the "thumbprint" symptom. The endoscopic picture of ischemic colitis is characterized by sharply defined boundaries of the lesion, submucosal hemorrhages, cyanotic pseudopolypous formations protruding into the intestinal lumen. Histological examination reveals hemosiderin-containing cells and fibrosis. The absence of contact bleeding at the time of the biopsy is also more indicative of ischemic colitis.

Treatment. The absence of a single etiological factor and the complexity of the pathogenesis of nonspecific ulcerative colitis make the treatment of this disease difficult. Drugs that have anti-inflammatory and antibacterial effects are used: salazopyridazine, sulfasalazine, salazodimethoxin, salofalk. Sulfasalazine taken orally, with the participation of intestinal microflora, breaks down into 5-aminosalicylic acid and sulfapyridine. Unabsorbed sulfapyridine inhibits the growth of anaerobic microflora in the intestine, including clostridia and bacteriodes. And thanks to 5-aminosalicylic acid, the drug not only causes changes in the intestinal microflora, but also modulates immune reactions and blocks mediators of the inflammatory process. The drug is prescribed at a dose of 2-6 g per day for the entire period of active inflammation. When the colitic syndrome subsides, the dose of sulfasalazine is reduced gradually, bringing it to maintenance (on average 1-1,5 tablets per day).

The appointment of 5-aminosalicylic acid derivatives (salofalk, mesacol, salosan, tidikol) is the basic method and can be used as monotherapy for mild and moderate forms of ulcerative colitis.

The treatment is carried out against the background of diet therapy with the exception of dairy products, in the presence of a balanced content of proteins, fats, carbohydrates and vitamins in the diet. It is advisable to exclude fresh fruits, vegetables, canned food. Food should be mechanically and chemically gentle. Feed fractional 4-5 times a day. Vitamin imbalance disrupts the process of absorption of microelements and is compensated by the appointment of complex preparations in tablets ("Duovit", "Oligovit", "Unicap").

In severe diarrheal syndrome in persons with mild and moderate course of the disease, the appointment of sandostatin is indicated, which inhibits the synthesis of gastrointestinal hormones and biogenic amines (vasoactive intestinal peptide, gastrin, serotonin), the production of which is sharply increased in ulcerative colitis and Crohn's disease. And also the drug reduces secretion and improves absorption in the intestine, inhibits visceral blood flow and reduces motility. When using sandostatin (within 7 days at a dose of 0,1 mg 2 times, subcutaneously), diarrhea decreases, tenesmus practically disappears, and blood excretion with feces decreases.

In a severe form of nonspecific ulcerative colitis, treatment is carried out against the background of parenteral nutrition. The protein content of these preparations should be approximately 1,5-2,0 g/kg of body weight. Corticosteroids, which are administered parenterally, are a pathogenetic treatment for a severe form of the disease: during the first day, prednisone is administered intravenously at intervals of 12 hours (90-120 mg or more), in the next 5 days - intramuscularly, gradually reducing the dose. With a positive effect, they switch to oral medication (prednisolone 40 mg per day).

Long-term administration of hormones during a period of stable remission is not advisable.

In patients with a severe course of the disease, a positive effect of hyperbaric oxygenation (HBO) was noted. The use of a course of HBO (7-10 procedures) during the period of remission can reduce the frequency of relapses.

Indications for emergency surgical treatment: intestinal perforation, toxic dilatation, profuse intestinal bleeding, malignancy.

In the moderate form of the course of nonspecific ulcerative ulcer, a strict diet is required with a restriction of fiber, dairy products and a high protein content. Prednisolone is administered orally at an initial dose of 20-40 mg per day. Treatment can be supplemented with sulfasalazine and its analogues, which are taken orally or administered in microclysters and suppositories into the rectum. The initial dose of sulfasalazine is 1 g per day, then it is increased to 4-6 g.

As an auxiliary method of treatment, decoctions of herbs with anti-inflammatory and hemostatic effects (burnet root, nettle leaf, lichen, gray alder cones, licorice root) can be used, herbal medicine often allows you to reduce the dose of salazopreparations, prolong remission.

Prognosis and prevention. In severe cases and the presence of systemic and local complications, the prognosis is serious. The patients are completely unable to work. In mild and moderate forms of the disease, the prognosis for life is favorable. Patients need to be transferred to light work.

During the period of remission, maintenance treatment with salazopreparations, bacterial agents, psychotherapy, and diet therapy is recommended. Patients suffering from nonspecific ulcerative colitis for a long time (more than 5-7 years) should be assigned to the risk group for the occurrence of bowel cancer and put on dispensary records. These patients are shown once a year colonoscopy with targeted biopsy.

Author: Mostovaya O.S.

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