Page 30 of 73 ILLNESS KRONE
Illness Krone — the transmural segmented defeat taking one or several sites of a digestive tract on all its extent — from a mouth to an anus, however most often it is localized in distal part of an ileal gut and a large intestine. Morphologically this inflammatory process is characterized by existence of not curdled granulomas and defeat of local lymphatic educations. The tendency to formation of fistulas between loops of intestines or between intestines and adjacent bodies (an uric path, skin) is observed. In the bioptata taken at the beginning of a disease, granulomas can be absent, and changes of a mucous membrane remind changes at nonspecific ulcer colitis. An illness Krone and ulcer colitis — main types of a "nonspecific" inflammation of intestines; this term is often used for designation of each of the specified diseases.
In the last decade in Western Europe and North America growth of number of cases of an illness Krone is noted. Its etiology is unknown, however is established that it rather often occurs at Jewish people, at close relatives of the patient, at patients with an ankylosing spondylitis, at HLA-B27 histocompatibility antigens carriers.
Clinical signs. In 18 — 30% of cases an illness the Krone begins aged till 20 flyings, mainly in the prepubertal and pubertal period. At early children's age the disease arises extremely seldom. The beginning is usually hardly noticeable, the correct diagnosis manages to be made in many months after emergence of the first symptoms. In the beginning there are colicy pains in a stomach, then — diarrhea. Unlike nonspecific ulcer colitis every second case of an illness
The krone is first shown by vpekishechny symptoms: fever, lack of appetite, growth inhibition, general weakness, joint pains. If at the teenager the long indisposition, especially in combination with fever is noted, and also growth is slowed down, it is necessary to think of an illness Krone. Carry chronic perianal fistulas which force to assume this illness to early symptoms even if there are no other intestinal signs.
Further exacerbations of an illness Krone at children are followed by ponosa and abdominal pains. At defeat of a small bowel of pain are localized in paraumbilical area or in the right lower quadrant of a stomach, but are not limited to its lower half, as at ulcer colitis. Allocation of fecal masses less rough and with smaller tenesmus, than at ulcer colitis (except for cases of defeat of distal segments of a gut).
The illness Krone differs from ulcer colitis also in the fact that blood is present at fecal masses less often, however some patients can have very strong intestinal bleeding.
Abenteric displays of an illness Krone same as at ulcer colitis, but meet more often. In one research arthritis (as a rule, large joints) is noted at 18% of children with an illness Krone. Among rare manifestations it is necessary to mention a knotty erythema, an iritis, hepatitis and phlebitis; their activity changes parallel to an aggravation and subsiding of intestinal symptoms. Much more often than at ulcer colitis, fingers get a form of drum sticks (approximately from one third of patients with an illness Krone).
Diagnosis. The correct assessment of a clinical picture allows to diagnose inflammatory damage of intestines. The diagnosis is confirmed by datas of laboratory: in an active phase of a disease of SOE it is raised approximately at 75% of patients; level of hemoglobin and seralbumin is reduced approximately at one third of patients.
Having suspected an inflammatory disease and having excluded a specific infection, it is necessary to conduct X-ray contrast research of a small and large intestine to define the struck segment. The illness Krone is characterized by the wrong relief of a mucous membrane, is frequent in the form of "cobblestone road", a thickening of walls of intestines and interintestinal fistulas; but nevertheless the main diagnostic criterion is the defeat segmentarnost. To study details of a structure of a small bowel, it is reasonable to enter contrast weight directly in duodenal or into a large intestine through a probe and to use a method of a double contrast study.
In bioptata of a mucous membrane of a rectum typical granulomas are found even if macroscopic signs of segmented defeat are absent. As defeat is often localized in proximal part of a large intestine, at a sigmoidoskopiya it is possible to obtain negative data, and only a kolonoskopiya which allows to examine a large intestine throughout, gives the chance to define borders of the inflamed segment.
Differential diagnosis. Basic reasons of inflammatory diseases of a large intestine are listed in tab. 12-8. Krone those infectious diseases at which the distal department of a small bowel is surprised, namely iyersinioz, meeting quite often, and tuberculosis (in North America meets seldom) are most similar to an illness. Defeats of a small bowel at an iyersinioza and anaphylactoid purpura radiological are similar to changes at an illness Krone. An illness the Krone differs from ulcer colitis in a process segmentarnost (at ulcer colitis defeat diffusion and is limited only to a large intestine).
Treatment. The Krone is not present effective methods of conservative treatment of an illness. Unlike treatment of ulcer colitis surgical intervention is carried out less often and does not cure patients. According to literature, more than 90% of the patients who underwent surgical treatment within the next 30 years had a recurrence of a disease.
As medicines have at best palliative effect, the important role is got by psychotherapeutic methods of influence. The child and his relatives need to explain essence of a disease and its most unpleasant signs. The doctor has to inspire in the patient that he can lead full-fledged life as far as it is possible; around the child it is necessary to create such atmosphere in which he would not feel like the disabled person. For example, it is recommended to encourage physical exercises though at the same time it is necessary to avoid excessive tension.
Food has to be full; the stimulators of appetite and means regulating mood, apparently, are ineffective. The tests which are carried out in recent years allowed to develop some principles of medicinal treatment. Prednisonum is shown in an acute stage of a disease. At defeat of a small bowel it is given in a dose 1 — 2 mg/(kg-days) (at most 60 mg) during 6 weeks, and then the dose is gradually reduced during the subsequent 4 — 8 weeks. If attempt to reduce a dose causes process strengthening, then drug should be used in bigger quantity and is longer. Prednisonum reception every other day is, as a rule, insufficient for remission maintenance. In some hard cases addition of Azathioprinum [2 mg / (kg of days)] allow to lower a dose of steroids, however it is impossible to apply it more than 1 year; at treatment by Azathioprinum it is necessary to control constantly number of leukocytes in blood and a leukocytic formula. Sulfasalazinum has no such positive effect, as at nonspecific ulcer colitis. According to the available data, purpose of Sulfasalazinum in a dose of 0,5 g / (15 kg-days) (to 4 g/days) in general is justified, but it does not extend terms of remission and does not exponentiate action of corticosteroids.
Owing to the high frequency of recurrence and, in some cases, a severe defeat of a small bowel an illness Krone treat by surgical methods less than ulcer colitis. Recurrence arises less often when delete all large intestine and operation perform against the minimum activity of process. According to vital testimonies of the patient operate at massive bleeding, perforation of a gut, impassability; at children with an illness Krone such complications arise seldom. Usually it is necessary to resort to bowel resection when the illness negatively influences growth and puberty of the child. Though the palindromia, apparently, is inevitable, the resection often gives the chance to the patient some time normally to raise and return to normal life. The decision on carrying out operation needs to be made taking into account expressiveness and duration of a growth inhibition and development, age of the patient and his growth potential, and also the relation of the patient and his parents to an illness. The preference has to be given to limited bowel resection in the period of the minimum activity of process and a satisfactory condition of food of the patient.
Forecast. The Krone is characteristic of an illness irregular change of the periods of remission and an aggravation. In many cases localization of the inflammatory center remains to a constant; recurrence of defeat on the new place usually arises after operation. Owing to the natural course of inflammatory process in the center cicatricial fabric which can cause impassability of intestines develops. Obstructive changes are almost inevitable at defeat of an ileal gut, however it should be noted that they appear only in one-two decades after the beginning of a disease. At persons, it is long having an illness Krone, the frequency of cancer of intestines increases, but nevertheless it is lower, than at nonspecific ulcer colitis.