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Illness Krone

Table of contents
Illness Krone
Clinical picture, illness forms, pathology
Endoscopy
Treatment

The illness Krone (a granulematozny ileitis) — a chronic inflammatory disease of the autoimmune nature, is characterized by a stenosis of intestinal segments, formation of fistulas and abenteric manifestations (arthritises, a knotty erythema, damages of eyes, etc.).
The Granulematozny inflammation of terminal department of an ileal gut is for the first time described by V. Crohn in 1932. Further it was established that the terminal ileitis is only one of illness forms Krone.

Epidemiology
Prevalence of a disease in the countries of Europe 25 — 27 on 100 000 people. Approximately at 90% of patients pathological process is localized in the typical place, at the others — in other departments thin or in a large intestine.

Etiology and pathogeny
The illness etiology Krone is still not known. Now again the role of viruses, bacteria and products of their life activity in an etiopathogenesis of granulematozny inflammatory process is discussed. Pathological process arises in a submucosal layer of a gut where the inflammatory infiltrates having an appearance of granulomas are formed. Granulomas consist of accumulations of lymphocytes in which center it is possible to find single colossal cells like Langkhans. Unlike tubercular granulomas at an illness Krone the centers of a caseous necrosis are never formed.

Infiltration extends both to a mucous membrane, and to a serous layer of an intestinal wall. As a result the intestinal wall becomes dense, the mucous membrane gets an uneven relief, on its surface the multiple erosion and ulcers like cracks penetrating all intestinal wall are formed. Sometimes ulcers perforate that leads to forming of interintestinal fistulas. Cicatricial changes of a wall can lead to narrowing of a gleam of a gut, development of intestinal impassability.

Classification
Clinically distinguish acute to chronic forms. Anatomic characteristic:
a) defeat is limited to a small bowel;
b) the ileocecal area is struck; c) defeat is limited to a large intestine;
d) segments of a small and large intestine are struck;
e) the combined damage of intestines with other bodies (a stomach, a gullet).

Complications: narrowing of a gut, toxic megacolon, fistulas, amyloidosis, nephrolithiasis, cholelithiasis, B12-scarce anemia.

Approximate formulation of the diagnosis:
1. An illness Krone with defeat of a segment of an ileal gut, the chronic, recurrent form complicated by narrowing of a small bowel with partial enteric obstruction, B12-scarce anemia.
2. An illness Krone with defeat of ileocecal area and sigmoid department of a large intestine, the acute form complicated by a toxic megacolon.

 

Preliminary diagnosis
Patients with an acute form have diseases and with localization of process in terminal department of an ileal gut the correct diagnosis is usually established during the laparotomy which is carried out concerning an expected acute appendicitis. On operation find a dense hyperemic site of a gut, the increased lymph nodes of a root of a mesentery that allows to diagnose an illness Krone and existence of complications (perforation, abscess, a stenosis). In other cases the correct diagnosis is established, as a rule, several years later after the first clinical manifestations.
The clinical picture is more often characterized by an uncertain abdominal pain, ease of a chair, weight loss, an indisposition. Symptoms of intestinal impassability are usually expressed slightly. At patients appear the abdominal pain amplifying at an active peristaltics, loud rumbling and transfusion in a stomach. The peristaltics of a small bowel at concussion of a front abdominal wall or palpation of intestines is sometimes visible.

Fervescence, leukocytosis, increase of SOE are characteristic. These symptoms are signs of an active phase of an illness. Inflammatory infiltrates or intestinal conglomerates in a stomach can develop in this period at patients, is more often in the right ileal area.
In process of progressing of an illness Krone patients have system complications: knotty erythema, gangrenous pyoderma, ulcerations of perianal area, iridocyclites, keratitis and conjunctivitis. Acute arthritises, an ankylosing spondylitis are frequent.

Reveal clear symptoms of the broken absorption: weight loss, frustration of a trophicity (change of nails, hair, mucous membranes). At most of patients the content of iron, protein in blood serum is lowered, anemia, osteoporosis are noted.

Characteristic radiological signs are sites of narrowing of a gut with a clear boundary of defeat, so-called symptoms of a cord or the suitcase handle. They alternate with the normal loops having an expanded gleam. The relief of a mucous membrane in a zone of narrowing is sharply changed, has the cellular drawing which is formed owing to zatek of a baric suspension in deep narrow ulcers. Extent patholologically of the changed sites of a gut varies from several centimeters to ten centimeters.

At endoscopic research the main attention is paid to an ileocecal zone and a terminal site of an ileal gut up to 50 cm long. In typical cases the mucous membrane of a gut is sharply edematous, thickened, with rough folds, is ulcerated, easily vulnerable, with numerous hemorrhages.

Verification of the diagnosis, differential diagnosis
Histologic research of bioptat the Krone as sarkoidopodobny granulomas with Langkhans's cells are located in a submucosal layer in most cases does not allow to receive pathognomonic symptoms of an illness, its sites do not get in bioptat. Therefore characteristic histologic symptoms of an illness can be found only at research of the site of a gut resected during operation.

At identification at the patient of symptoms of an illness Krone and detection at it of changes, suspicious on granulematozny process, it is necessary to exclude a number of diseases with segmented defeat of a small bowel. The tubercular ileotyphlitis, a lymphoma of a small bowel, a lymphogranulomatosis, a divertuculosis, polyposes, a nodal lymphoid hyperplasia concern to them. Besides, differentiation with the diseases having a similar clinical picture is quite often necessary (iyersinioz, ulcer colitis, amoebic dysentery, bacterial dysentery, acute appeiditsit, an ischemic abdominal syndrome, chronic enteritis).

The changes of a relief of a small bowel reminding those at granulematozny enteritis can appear at patients with a chronic circulatory unefficiency in system of an upper mesenteric artery. Similarity is given also by some other symptoms: diarrhea, abdominal pain, weight loss. Serve as the main distinctive features of a syndrome of chronic insufficiency of mezenterialny blood circulation vascular noise over a navel, accurate communication of a pain syndrome with meal. In difficult cases differential and diagnostic questions are resolved during the selection angiography (mezenterikografiya).
For determination of activity of an illness Krone the following index is offered.

Index of activity of an illness Krone

1.

Number of defecations by not properly executed chair in a week

h2-

2.

Intensity of an abdominal pain within a week (0 —
there is no pain, 1 — the slight pain 2 expressed 3 — severe pain)

h5-

3.

Health within a week (0 — good, 1 — satisfactory, 2 — bad, 3 — very bad, 4 — insufferably bad

h7-

4.

Body weight ___ kg, standard body weight ___ kg
1 - Body weight / Standard body weight

h100-

5.

Stomach tension at a palpation (0 — no, 2 — it is doubtful, 5 — is)

h10-

6.

Need for a symptomatic treatment of diarrhea (0 — no, 1 — is)

h30-

7.

Hematocrit. A difference between available and normal (men — 47, women — 42)

h6-

8.

Other symptoms of an illness Krone:
Joint pain, arthritises
Iritis, uveitis
Knotty erythema
Pyoderma
Aphthous stomatitis
Proctal fistula, pararectal abscess
Fistulas and abscesses of other localization
Body temperature is above 37,5 °C within a week
Sum of positive symptoms

h20 -

 

Total index of activity

-

Notes. 1. Patients with the resected intestines have an increase of a chair to 3 times a day and a symptomatic treatment of diarrhea holestiraminy is not taken into account.
2. A technique of calculation of points in subitem 1 — 3: daily data are fixed by the patient for a week, summed up and the result is multiplied by coefficient.
3. In subitems 4 and 7 both positive, and negative takes are taken into account.
Activity index at healthy - 0, at small activity it less than 150, at big activity more than 150.



 
"Diseases of the operated stomach   Illness heavy and - chains and a lymphoma of a small bowel"