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NONINFECTIOUS INFLAMMATORY DISEASES OF INTESTINES NONSPECIFIC ULCER COLITIS
This chronic disease of an unknown etiology affects distal department of a large intestine, extending in the proximal direction to various length; in certain cases all large intestine is involved in process. Diffusion inflammatory reaction is characterized by neutrophylic infiltrates and abscesses in crypts. Inflammatory process seldom goes beyond a mucous membrane. Nonspecific ulcer colitis differs in it from an illness Krone.
Epidemiology. Ulcer colitis rather often occurs among Jewish people and is rare at Blacks and east people. For the unclear reason the majority of cases are the share of Europe and North America. The increased incidence among the immediate family at patients, at the persons suffering from an ankylosing spondylitis at HLA-B27 histocompatibility antigens carriers is noted.
Clinical manifestations. About 15% of patients get sick aged till 20 flyings. Symptoms of ulcer colitis can appear even at the newborn, but nevertheless in most cases the illness begins not earlier than the prepubertal period. The leading display of an illness — chronic diarrhea with release of fresh blood, imperative desires, tenesmus, pristupoobrazny pains in the lower half of a stomach, especially before defecation. At most of patients the illness develops gradually, against long ponos there comes the anorexia leading to loss of body weight. In some cases the illness develops violently, within several days against high fever there are peritonitis and even perforation of intestines. At long process, especially in combination with bad digestion of nutrients, the growth inhibition and developments of the child is noted. At teenage girls periods sometimes stop. Sick children often skip classes at school, their activity at lessons and out of school is reduced.
By the time of establishment of the diagnosis usually there are already symptoms of a chronic disease. Morbidity of a stomach at a palpation is noted, especially on the course of the left half of a large intestine, rumbling of intestines is heard. The stomach is increased in sizes, manual rectal research is painful. In Calais fresh blood, accumulations of leukocytes and slime are defined. Proctal cracks are possible, but perianal fistulas and abscesses meet less than at an illness Krone.
Abenteric displays of colitis at children are not so frequent as at adults, but nevertheless symptoms of arthritis are noted in 10% of cases. Mainly large joints — humeral, elbow, knee, coxofemoral are surprised. At inspection morbidity, puffiness, reddening and local increase of tolerance are defined. Occasionally small joints of hands and legs are involved in process. At patients with colitis the spondylitis occurs more often than at persons without damage of intestines, but at children this communication is traced seldom. Usually, though not always, exacerbations of arthritis arise in parallel with exacerbations of ulcer colitis, and the insignificant intestinal symptomatology can be combined with a severe damage of joints. The knotty erythema which is shown accurately outlined, painful, towering red elements takes place approximately at 5% of patients, mainly in the period of an exacerbation of colitis. Very rare complication of colitis is the gangrenous pyoderma, i.e. necrotic damage of skin. As rather rare and late complication it is possible to consider an inflammation of an iris of the eye of an eye (iritis). It is characterized by pains, a conjunctiva hyperemia, existence of cells in an anterior chamber of an eye, deposits in a cornea and developments of stagnation in an iris. The accompanying hepatitis which is also infrequently observed at children is shown by a hyperbilirubinemia of the mixed type, and also increase and consolidation of a liver. Unlike other abenteric displays of ulcer colitis activity of hepatitis does not match exacerbations of colitis. At the heavy course of colitis approximately at 10% of patients the thickening of trailer phalanxes of fingers in the form of drum sticks is noted. Owing to big losses of protein there are peripheral hypostases; besides, phlebitis and hemolitic anemia are possible, but in pediatric practice these complications meet seldom.
At a state assessment the special attention should be paid to the psychological status. Though emotional frustration, povidimy, are not an etiological factor and do not make direct impact on disease, they undoubtedly aggravate clinical symptomatology. The correct assessment of mentality of the patient and his parents allows the doctor to give them moral support.
Differential diagnosis. Basic reasons of chronic inflammatory damages of intestines are various in different regions, but nevertheless among them win first place an infection (tab. 12-9). Therefore before making the diagnosis "nonspecific ulcer colitis", it is necessary to carry out careful identification of contacts with infectious patients and microbiological researches. Among infectious agents who can cause chronic colitis with release of blood and pus it is necessary to call Shigella, Salmonella, Yersinia enterocolitica, Campylobacter jejuni and Entamoeba histolytica.
Table 12-9. Chronic inflammatory diseases of intestines
The colitis caused by Campylobacter jejuni Tuberculosis
Tsitomegalovirusny colitis Amoebic dysentery the Trichuriasis Other diseases, mainly at children:
Necrotic coloenteritis the Coloenteritis at an illness of Girshprunga "Allergic" colitis At patients of any age:
Nonspecific ulcer colitis Illness Krone Anaphylactoid purpura Gemolitiko-uremichesky syndrome
Pseudomembranous (connected with reception of antibiotics) colitis the Eoziiofilny gastroenteritis
Ulcer colitis seldom arises at babies, but in this age group the colitis caused by intolerance of food proteins, in particular proteins of cow's milk is possible; besides, colitis can complicate disease of Girshprunga. The illness Krone differs in an accurate segmentarnost of defeat, frequent involvement in process of a small bowel, distribution of granulematozny inflammatory reaction to all layers of an intestinal wall. Intestinal frustration can be the first manifestation of anaphylactoid purpura or a gemolitiko-uraemic syndrome, but further it is possible to observe also other signs of a widespread vasculitis. To pseudomembranous colitis, which: has a typical endoscopic picture, treatment by antibiotics usually precedes.
Diagnosis. It is clinically possible to define that damage of intestines of inflammatory character takes place, but only the subsequent laboratory research allows to make the correct diagnosis. When carrying out bacteriological researches it is necessary to consider possible contacts. In case of suspicion on amoebic dysentery it is necessary to carry out serological, and also koprologichesky researches. Increase of level of serumal antibodies is possible at long infection of Yersinia enterocolitica, Campylobacter jejuni and some types of salmonellas. If antibiotikozavisimy colitis is suspected, then it is necessary to identify Clostridium difficile enterotoxin.
Nonspecific ulcer colitis has characteristic endoscopic signs: diffusion inflammatory changes are localized in direct and distal department of a large intestine; the mucous membrane is inflamed, a zernist and is extremely easily vulnerable; ulcers at children are visible seldom. For inflammatory reaction at nonspecific ulcer colitis are inherent an infiltration polymorphonuclear leukocytes and abscesses in crypts. At the beginning of a disease the X-ray pattern is not changed, but further at an irrigoskopiya diffusion defeat of distal department of a large intestine is visible; process can extend in the proximal direction, taking sometimes all small bowel. It should be noted that any of these radiological and endoscopic morphological features not patognomonichen for nonspecific ulcer colitis.
Treatment. The existing methods do not relieve the patient of nonspecific ulcer colitis, but allow to reduce activity of inflammatory process and to prevent recurrence.
Especially important role is played by psychotherapeutic actions. The child and his parents should open (moderately their understanding) the disease nature. Any dietary restrictions are not necessary on condition of the good and balanced nutrition. Some patients have a food nedostatochost) owing to inability to acquire necessary quantity of food. In such cases transition to completely parenteral food allows to recover exclusively effectively body weight * the patient though in intestines it directly does not influence inflammatory process. Free it is necessary to convince that о® has to lead full-fledged life. This patients are not recommended to appoint the drugs regulating mood and stimulating appetite.
The controlled tests which are carried out on adults with at l of a fasalazin showed that at long reception it reduces probability of aggravations even if treatment is begun through; flying after developing of a disease is a lot of. In dozv 0,5 g / (15 kg-days) (at most 4 g) it has almost no side effect; anorexia or nausea can be removed if to accept drug in a dosage form with an intestinal covering. During the neurosinging or reaction of hypersensitivity drug withdrawal is required. With long reception of Sulfasalazinum connect reversible toxic impact on seed plants with development of an oligospermatism and sterility. Nevertheless patients with firmly proved nonspecific ulcer colitis have to is long and regularly to accept this drug.
In an active stage of an illness corticosteroids give the greatest effect. In mild cases when process is localized only in distal department of intestines, the hydrocortisone or Prednisolonum enter in enemas (it is necessary to enter slowly 100 mg - a hydrocortisone or its equivalents before going to bed during 6 weeks. new half of a course daily, and then every other day). If within 10 days of such treatment the condition of the patient does not improve or worsens, add Prednisonum orally. At average and heavy disease, and also at resistance to treatment enemas Prednisonum appoint 1 — 2 mg/(kg-days) (the maximum dose of 60 mg/days) in a dose. At a fulminant current the condition of the patient happens such heavy that he cannot take medicine through a mouth. In such cases the hydrocortisone in the corresponding dose is entered intravenously. Having begun a course of treatment with hormones, the doctor has to continue it 3 — 4 months. at first in a full dose during 6 weeks, then reducing it by 5 mg/days every week. Changes of a shape of a face and the eels arising against corticosteroid therapy are hard perceived by young patients. Treatment by corticosteroids can be complicated by development of a cataract, increase of arterial pressure and a growth inhibition. Prednisolonum reception every other day allows to avoid suppression of functions of adrenal glands, but the therapeutic effectiveness of drug at the same time decreases.
For treatment of ulcer colitis also other drugs, but without a little noticeable result were used. At a number of patients improvement of a state after purpose of a kromoglikat of sodium orally in high doses was noted. With the purpose to reduce activity of process by smaller doses of hormones Prednisolonum applied in combination with Azathioprinum.
This disease treat by also surgical method: carry out a total resection of a large intestine. The colectomy is carried out according to the emergency indications (perforation of a gut or its threat, massive bleeding), and also at development of a carcinoma in the struck gut. The long course of colitis exhausting the patient, especially the growth inhibition and insufficiency of food which developed against unsuccessful intensive medicamentous care serves frequent the indication to an operative measure. Very complex challenge rises before the doctor if the diagnosis of active colitis is made to the child in 10 flyings after an onset of the illness. In such cases the probability of development of a carcinoma of a gut therefore most of authors recommend a colectomy, especially at a rapid current when the illness affects considerable part of a gut is high. With the purpose to distinguish a tumor at an early stage recommend 2 times to carry out a kolonoskopiya in a year and to take a large number of bioptat.
In pediatric practice as the first stage carry out a subtotal colectomy, leaving a rectum stump. Such resection is less traumatic, well influences the general condition of the patient, gives the chance to choose optimum time for the second stage of operation. Though after the first stage the condition of the patient considerably improves, in the remained rectum stump active process inevitably remains. At the second stage the stump is deleted. Preliminary messages indicate the positive takes received when imposing an anastomosis at which delete only the affected mucous membrane thanks to what integrity of a gut and its ability to hold kcal remain. If after a colectomy integrity of a gut does not manage to be kept, then impose a constant to ileosty or create the holding pocket according to Koch. In the latter case positive takes are received (the patient can easily empty artificially created reservoir and not resort to the help of a kalopriyemnik).
Forecast. In most cases the illness which arose in the childhood proceeds very actively and affects considerable part of a large intestine. Sometimes the illness progresses so quickly that perforation of intestines happens before the correct diagnosis is made. The usual current is characterized by the periods of aggravations which come behind the remission periods caused by medicinal therapy. Serious complication — profuse, life-threatening bleeding, but as the most terrible complication it is necessary to recognize a toxic megacolon which indicates a possibility of perforation. Nonspecific ulcer colitis is a precancerous disease; the risk of a malignancy in the first 10 years makes only 3%, and increases in the subsequent for 20% each 10 years.