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Nonspecific ulcer colitis

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Nonspecific ulcer colitis
Differential diagnosis with an illness Krone

Nonspecific ulcer colitis — a chronic disease of the inflammatory nature of an unspecified etiology with ulcer and destructive changes of a mucous membrane of a straight line and colon, is characterized by the progressing current and complications (narrowing, perforation, bleedings, sepsis, etc.).

Epidemiology
On a share of ulcer colitis, according to foreign the statistician, is the share from 4,9 to 10,9 of 10 000 inpatients, and in our country — 7 patients on 10 000 hospitalized. In countries of Western Europe the frequency of this disease fluctuates from 40 to 80 on 100 000 population. Women have ulcer colitis one and a half times more often than men.

Etiology and pathogeny
At different times allegedly viruses, bacteria, various cytoplasmatic toxins were considered as the reason of ulcer colitis. The autoimmune mechanism of forming of pathomorphologic changes connected with emergence of antibodies to a mucous membrane of the large intestine gaining antigenic properties is supposed.

It is allocated a number of constitutional features at patients with nonspecific ulcer colitis: decrease of the activity of system a hypophysis — adrenal glands and dominance of somatotropic and tiroidny reactions. The stimulation of a vagus nerve caused by a stress leading to release of acetylcholine causes disturbance of a vermicular movement of a large intestine and a hypoxia of an epithelium and submucosal layer, accumulation in them of lactic acid, deterioration in synthesis of slime. As a result resistance of a mucous membrane of a large intestine and food providing obligate microbic flora decreases. Thereof the hypoxia of kolonotsit, the accelerated exfoliating and the necrosis which is followed by emergence in blood of autoantigens to an epithelium of a large intestine develop. Then there is a generalization of process to all clinical manifestations characteristic of this disease.

Classification
Clinical options of ulcer colitis are various.

Approximate formulation of the diagnosis:
1. Nonspecific ulcer colitis, a recurrent current, moderately severe with defeat of a straight line and sigmoid department of a large intestine, an erosive and hemorrhagic form, a phase of the fading aggravation.
2. Nonspecific ulcer colitis, an acute form, quickly progressing current with total damage of a large intestine, toxic dilatation of a gut, a septicaemia.
3. Nonspecific ulcer colitis, mainly a proctosigmoiditis, an erosive and hemorrhagic form with a latent current, a remission phase.

Diagnosis
In typical cases diagnosis of nonspecific ulcer colitis does not present great difficulties. The disease is characterized by a frequent liquid chair with blood and slime, fervescence, a colicy pain in a stomach. At a rektoromanoskopiya edematous, easily vulnerable rectum comes to light. In a gut gleam a significant amount of blood and slime owing to diffusion bleeding of an intestinal wall. For statement of the correct diagnosis there is enough rektoromanoskopiya. Kolonofibroskopiya is carried out after subsiding of acute symptoms for the purpose of specification of extent of pathological process. At X-ray inspection of a large intestine (irrigoskopiya) define disappearance of haustrations, a thickening and roughness of a wall of a gut, narrowing of a gleam with suprastenotichesky expansion, polipovidny educations (pseudopolypuses), shortening of a gut. By means of X-ray inspection the extent of pathological process and its weight is estimated. At patients with the easy course of nonspecific ulcer colitis the listed above signs can be absent. At the long-term anamnesis and the progressing current a number of radiological symptoms can have much in common with a tumor of a large intestine (narrowing of a gleam, existence of defects of filling at a pseudo-polypose). In these cases endoscopic and histologic research is obligatory.

Laboratory researches already in mild cases allow to reveal a leukocytosis, increase of SOE. In process of progressing of an illness the deviation to the left, anemia appear.
At the heavy course of nonspecific ulcer colitis water and electrolytic frustration with dehydration, sharp weakness, disturbance of a muscle tone develop. In blood potassium concentration, calcium decreases, is more rare than sodium and chlorine.

In case of an acute onset of the illness clear symptoms of intoxication — high fever, tachycardia, weakness, a leukocytosis with considerable shift of a leukocytic formula, increase of level a1-and a2-globulins, immunoglobulins in blood serum are characteristic. Intoxication symptoms at the same time can often be a consequence of the septicaemia developing at decrease in barrier function patholologically of the changed large intestine.

The abdominal pain is not typical for nonspecific ulcer colitis. Severe pain demonstrates involvement in inflammatory process of a visceral layer of a peritoneum and can be a harbinger of perforation of a gut, especially if at the patient the toxic megacolon develops. This complication is characterized by continuous diarrhea, massive bleeding, a septicaemia. At a palpation of a loop of a large intestine of a pasty consistence because of sharp decrease in a tone, the palpation is followed by capotement. The stomach is blown up.

Classification of nonspecific ulcer colitis

1. Clinical characteristic

Clinical form

Current

Degree of activity

Severity

a) acute

a) quickly progressing

a) aggravation

a) easy

b) chronic

b) continuously recurrent

b) the fading aggravation

b) moderately severe

c) recurrent

c) remission

c) heavy

d) latent (erased)

 

 

2. Anatomic characteristic

Extent

Macroscopic characteristic

Microscopic characteristic

a) proctitis

a) erosive gemorragichssky colitis

a) dominance of destructively inflammatory process

b) proctosigmoiditis

b) ulcer destruktiviy colitis

b) reduction of inflammatory process with reparation elements

c) subtotal defeat

 

c) effects of inflammatory process

d) total defeat

 

 

3. Complications

Local

The general

a) perforation of a large intestine

e) consecutive intestinal infection

a) functional hypocorticoidism

b) intestinal bleeding

e) disappearance of a mucous membrane (full, partial) large intestine

b) septicaemia, sepsis

c) narrowing of a gut

g) toxic expansion
large intestine

c) arthritises, sacroileites

d) pseudo-polyposes

 

d) damages of skin, eye
e) nephrite, amyloidosis
e) phlebitis
g) dystrophy of a liver, other bodies

 

 

Massive bleedings at nonspecific ulcer colitis are observed seldom as large vessels usually are not damaged, but long blood losses quickly enough lead to development of a hypochromia iron deficiency anemia.

At patients with nonspecific ulcer colitis abenteric manifestations of an illness are possible: damages of skin, eye, joints and backbone.

Differential diagnosis
First of all, it is necessary to carry out the differential diagnosis with acute dysentery. Due to the need of observance of the anti-epidemic mode quite often the patient before establishment of the correct diagnosis is inspected in infectious department. Dysentery is excluded on the basis of negative crops a calla and blood analyses on antigens of dysenteric bacteria. The endoscopic picture inherent to ulcer colitis (see above), is not characteristic of dysentery at which, as a rule, are available only a hyperemia, erosion and hemorrhages. It is important also that the antibacterial therapy giving fast effect at dysentery at nonspecific ulcer colitis either is inefficient or leads to progressing of an illness.

Differential and diagnostic difficulties arise at an illness Krone with localization in a straight line and a colon. At ulcer colitis unlike granulematozny there are no defeats of a perianal zone (fistulas, cracks), inflammatory process in a gut begins with a mucous membrane and from the very beginning is followed by bleedings, there is no relief like "cobblestone road", slit-like ulcers. At histologic research of biopsy or operational material in a podslieisty layer there are no typical epithelioid granulomas with Pirogov's cells characteristic of an illness Krone — Langkhansa.

Extremely important value has the differential diagnosis with endofitno the growing tumors of a large intestine (cancer, a lymphoma), a diffusion family polipoz in which recognition have crucial importance a kolonofibroskopiya with a multiple repeated biopsy of affected areas of a gut.
Locks and releases of blood with a stake are characteristic of ischemic damage of a large intestine pain in the left half of a stomach. As differential and diagnostic criteria can serve vascular noise over belly department of an aorta, lack of symptoms of intoxication and diarrhea.

Treatment, prevention of recurrence, forecast
Treatment at nonspecific ulcer colitis is in many respects similar to that at an illness Krone therefore lower only features of pathogenetic therapy will be stated by sulfanamide and corticosteroid drugs.

Sulfasalazinum is effective at treatment of easy and moderately severe forms of ulcer colitis. The usual therapeutic dose of 3 g/days can be increased in the absence of effect to 6 — 8 g a day. Drug is appointed for a period of up to 4 weeks, then the dose is reduced to supporting (1,5 — 0,5 g a day) and her patient receives usually long time for the purpose of the prevention of palindromias. Use of Sulfasalazinum is limited by side effects, especially at its long appointment. The headache, skin rashes, a leukopenia and the dispepsichesky phenomena (nausea, loss of appetite) concern to them. At left-side localization of ulcer colitis the part of the drug can be administered in the form of the microclysters containing from 1,5 to 3 g of Sulfasalazinum. Enemas are appointed daily to night.
Salazopyridazinum has similar therapeutic effect in a dose of 2 g/days. Appoint it in this dose for 3 — 4 weeks, then consistently reduce a dose to 1,5 — 0,5 g a day within the next month.

Corticosteroids belong to reserve drugs at nonspecific ulcer colitis. Apply a hydrocortisone and Prednisolonum or their analogs. Appoint these drugs the patient who by means of Sulfasalazinum did not possible to interrupt an acute phase of an illness, and also at a heavy current with nonspecific ulcer colitis. Prednisolonum is appointed on 40 mg a day within a month in case of a heavy current, at less heavy current the dose can be reduced twice, but in a combination with introduction at the same time of a hydrocortisone in a microclyster on 125 PIECES once a day.

It is reasonable to appoint a hydrocortisone also during decrease in hormonal therapy for the prevention of a withdrawal.

At simultaneous use of Sulfasalazinum and Prednisolonum it is necessary to follow the rule: in process of Prednisolonum dose decline gradually to increase Sulfasalazinum dose which in the period of an optimum dose of hormonal drug has to be 1,5 — 2 g.

Sick with anemia appoint iron preparations (ferrum Lek, Ferroplexum, Conferonum, etc.), vitamin B and on 200 mkg every other day and folic acid on 5 mg/days. Duration of a course is 30 days.
At nonspecific ulcer colitis apply also all complex of the symptomatic therapy used at chronic enterita and an illness Krone to elimination of disturbances of motility, absorption and other functions of intestines.

As indications to an urgent operative measure serve perforation of a gut, the septic state connected with acute toxic dilatation of a large intestine and also profuse bleeding.

Patients with inefficient conservative treatment in case of a heavy current with nonspecific ulcer colitis need the delayed operative measure, at repeated massive bleedings.

As the relative indication to surgical treatment (to a resection of a large intestine within healthy fabrics) serves the progressing recurrent course of ulcer colitis, despite complex medicamentous therapy.

Patients with nonspecific ulcer colitis need dynamic supervision of the gastroenterologist of policlinic. At easy disease working capacity has to be significantly limited (hard physical work and the work connected with the raised psychological loadings is contraindicated). At more severe forms patients are disabled.

For the purpose of prevention of recurrence all patients have to consult once in a quarter the gastroenterologist to carry out correction of medicamentous therapy. Patients, it is long having nonspecific ulcer colitis, treat group of the increased risk concerning oncological diseases of intestines. Therefore during remission they need to appoint annually control endoscopic and X-ray inspections of a large intestine.



 
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