Chronic inflammatory bowel pathology

2021-01-27 12:00 AM

Because there are no specific criteria, diagnosis should be based on the overall clinical symptoms and the following investigations.

Outline

Chronic inflammatory bowel diseases usually include two main diseases:

Recto-colite hémorragique or ulcerative colitis as called by British American authors. Crohn's disease or inflammatory bowel disease in each region.

Both have the following characteristics:

A chronic inflammatory condition in the gut.

Common in teenagers and young people.

Prolonged progression, increasing with decreasing but never spontaneous healing.

The etiology is not known.

There is no radical medical treatment.

Treatment with anti-inflammatory drugs, corticosteroids, and immunosuppressants was not consistently effective.

Crohn's disease

Pathogenesis and pathogenesis mechanism

Damage to the intestine results from an uncontrolled activation of the immune system of the mucosa.

Infectious and genetic factors are also involved in pathogenesis.

Clinical symptoms

Common symptoms:

Abdominal pain: common, has a variable position, often cramping pain along the colon frame, sometimes with Koenig syndrome.

Diarrheal, sometimes open or bloody, the frequency of change.

During exacerbations there is often weakness, loss of appetite, weight loss, and mild fever

Some of the most common clinical manifestations can be isolated:

Prolonged diarrheal with fever.

Pseudo-appendic syndrome (damage to the right ileum or ileum-colon): Right pelvic pain is not clear, limited plaque in the right iliac fossa. Dysentery syndrome.

The syndrome resembles a functional colon disease.

Severe acute colitis: Massive diarrheal, often bloody, severe abdominal pain all over the abdomen, bloating. The whole body has a fever, a rapid heart rate, and fatigue. Laboratory tests: anaemia, decreased blood albumin.

Lesions in the anus - perineal region:

Valid diagnostic suggestion. Scratches (fissure) and an anal-rectal ulcer.

Anal canal fibrotic stenosis, sometimes very severe stenosis.

Abscesses and fistula, may have complications with bladder or genital probe complications

Symptoms outside of digestion:

Osteoarthritis: Arthritis: ankylosing spondylitis, pelvic arthritis. Skin, mucous membranes: Erythema nodosum, purulent skin gangrene, erythema multiforme.

Eyes: Uveitis, corneal ulcer.

Hepatobiliary: Fatty liver, chronic hepatitis, granulomatous hepatitis, gallbladder stone

Progression and complications

Progression: The disease progresses in waves; 90% of the progressions can be controlled with corticosteroid therapy. In the bad case, exacerbations are getting thicker.

Symptoms:

Intestinal obstruction: The intestinal lumen is narrow due to inflammation and progressive fibrosis.

Detect and abscess in the abdomen.

Gastrointestinal bleeding.

Diagnosis of Crohn's disease

Because there are no specific criteria, diagnosis should be based on the overall clinical symptoms and the following investigations.

Biological:

Fecal culture and parasitic testing to rule out bacterial runoff.

During exacerbations with leucocytosis, the rate of blood sedimentation increases.

Reduced ferritin, decreased albumin, mixed anaemia (lack of substance and inflammation), thrombocytosis.

Specific tests for malabsorption syndrome.

Endoscopic:

It is a basic test for diagnosis, and helps to evaluate the extent of damage: 70-80% have colon lesions, 20-30% have only lesions in the small intestine.

Superficial lesions such as congestion, mucosal oedema, ulcerative or vertical ulcer. Lesions progress deeply such as deep ulcers, scarring (ulcerative scarring, pseudo-polyps, narrowing ..). There are healing spaces between the pathological mucosa.

Histology:

Buffer oedema, lymphocytic infiltrates, ulcers and large cell epidermal granulomas do not have pea necrosis.

Polling images:

Contrast colonoscopy: useful in cases of incomplete endoscopy or in which probes are not detected by endoscopy. Radiological signs include ulcerative lesions, paedomorphic polyps forming a paved pattern, stoma, narrowing of the loops, typical cases of narrowing of multiple spaces separated by dilated healthy bowel segments.

Abdominal computed tomography: in case of abdominal mass or suspicion of pus incineration.

Treatment of Crohn's disease

Medications treat:

Salicylic derivatives:

Sulfasalazine: The most classic drug in this group, made up of sulphapyridine, bound to salicylic acid 5 amino acid (5 ASA), less absorbed in the small intestine, when entering the colon will be broken down by bacteria to release 5 ASA.

Sulfasalazine is only effective in case of damage to the colon or anise - colon, can be used in progression, not effective in maintaining the retreat period.

Mesalamine is a Sulphapyridine-free Salicylic derivative and is better tolerated.

Other drugs: Asacol, olsalazine, balsalazide:

Mechanism of action: inhibition of T cell growth, antigen presentation to T cells and antibody production by B cells in addition to an anti-inflammatory effect through inhibition of cyclo-oxygenase reduces production of prostaglandins.

Corticoid:

As an important means of treatment during exacerbations.

Prednisolone dose 1 mg / kg / ng for 3 to 7 weeks, then reduce dose stepwise every 10 mg to 1/2 dose, then reduce every 5 mg per week for the full 12 week course.

New types of corticosteroids: Fluticasone propionate, tixocortol pivalate, beclomethasone dipropionate, and budesonide, these drugs have the advantage of having a greater affinity for corticosteroid receptors than conventional corticosteroids, while increasing first-time hepatic metabolism. less systemic side effects.

In particular, Budesonide is often used in crohn's disease, drug released in the ileum and main effect on the terminal ileum and right colon, with a dose of 6-9mg / ng.

Immunosuppressants:

Azathioprine: Most effective, especially in Corticoid-dependent patients or to maintain remission, also effective in the treatment of intestinal - skin or anal - episiotomy fistula.

The effect is slow, symptoms begin to improve after 3 months.

Side effects: Myelosuppression, acute pancreatitis, acute hepatitis, gastrointestinal intolerance and allergic reactions.

Methotrexate is also effective in corticoid-dependent or non-respondent forms of Azathioprine, whose effects appear as early as the first month.

Artificial nurturing:

As a good treatment in exacerbations, parenteral or intestinal nourishment brings high recovery rates and corticosteroids.

Other treatments:

Antibiotic:

Metronidazole works well in anal - episiotomy lesions.

Ciprofloxacin (Ciflox) is just as effective.

Recently clarithromycin has also been shown to be a useful means in Crohn's disease.

Immunity:

Monoclonal antibodies against tumour necrosis factor type ((Anti-TNF () and Interleukin 10 (IL 10) have shown encouraging results in many studies: INFLIXIMAB.

Indications and treatment strategies for Crohn's disease:

Mild or moderate progression:

Mesalamine 4g / day.

Sulfasalazine 3 - 4 g / day, only in the colon.

Metronidazole 10-20 mg / kg / day or Ciprofloxacin 1g / day.

Budesonide 9 mg / day in the ileum (right colon

Exacerbation worsening or treatment failure described above.

Prednisolone 1 mg / kg / day.

If it fails, systemic corticosteroids 1 mg / kg / ng

Severe progression:

Systemic corticosteroids 1 mg / kg / day.

Nourishes the entire intestinal appearance in severe malnutrition ± antibiotics.

If that fails, Cyclosporine TM or surgery.

Treatment to maintain remission:

Mesalazine 2 - 4 g / day.

If that fails, Azathioprine.

Corticoid dependent or chronic progressive form:

Azathioprine.

If that fails, Methotrexate.

If all else fails, surgery or low dose corticoid (<10mg / ng). Corticosteroids.

Nourishes the intestinal or intestinal tract

N If failed, Methotrexate, Cyclosporine.

IL 10 or Anti-TNF.

Postoperative recurrence prevention:

Mesalazine 2-3 g / day 

Bleeding colorectal inflammation

Whole disease

N understands possibility role of genetic factors. Immune system activation plays an important role. The role of infectious factors is not clear.

Pathology

Localization: Mainly in the rectum and more or less in the colon, more rarely, damage to the entire colon (pancolite).

Clinical

Conventional form:

Inflammation of the rectum - mild - moderate enlarged colon.

 

Bloody mucus bowel movements, sometimes there is no stool, with potting, sometimes constipation. The whole condition changed little and the physical examination found nothing.

Rectal examination reveals stone-paved mucosa and gloved blood. This body has no biological change.

Diagnosis is based on:

Elimination of infectious and parasitic colitis is based on fecal culture and parasitic testing, which should be done in the first wave of progression.

Colonoscopy: lesions of the rectum and colon are homogeneous, with clear upper limit, the rest of the colon and the end of the ileum are normal. Red mucous membranes, stone slabs, bleed spontaneously or on contact, usually without ulcers.

Biopsy of the entire colon frame, both diseased and healthy mucosa.

Out-of-digestion manifestations:

Joint: Pain or inflammation of the joint, affecting mainly the large joints of the limbs,

Skin: The most common is erythema nodosum. Eyes: sclera, iritis and uveitis.

Joint, eye, and skin lesions often progress in parallel with intestinal damage.

Progression and complications

Progression: The disease progresses in waves with no symptoms between episodes.

Symptoms:

Colon dilatation, or large toxic colon: seen in severe progression.

Perforation: Often obscured by Corticoid.

Diffuse bleeding.

The risk of colon carcinoma is increased in case of inflammation of the entire colon.

Treatment of bleeding colitis

Internally medical treatment:

Mainly relied on long-term anti-inflammatory drugs.

Salazosulfapyridine (Salazopyrine) and derivatives such as Pentasa, Rowasa and Dipentum, used in mild forms or for maintenance therapy, comes in the form of an enema.

Corticosteroids: During moderate to severe episodes, beware of side effects with prolonged use.

Minimize fibers used in progression

Surgical treatment:

Point:

Severe progression after failure of a short, strong course of medical treatment.

Complications of perforation or diffuse bleeding.

In the case of severe cancer or dysplasia.

In chronic forms, continuous failure to respond to medical treatment causes depression.

Surgical methods of treatment:

Colon-rectectomy with ileostomy.

Colon-rectectomy with ileo-anus connection.

Colonectomy with ileorectal connection.