Inflammatory bowel disease including ulcerative colitis and Crohn's disease
Recently, the ward has become tight. Spring is here, and the onset of ulcerative colitis and Crohn’s disease has come again. Many old patients have begun to get sick, and there are also some new ones.
Although Jingjing is young, she is a regular customer of our department. He comes to us to report almost every spring. With Jingjing admitted to the hospital, 1/3 of the patients in the department have inflammatory bowel disease (including ulcerative colon). Yan and Crohn’s disease). After the rounds, the director told us that during routine medical history discussions, we should discuss these two diseases, make a comparison, and sort out the treatments we can take.
In the process of clinical diagnosis, doctors need to continuously learn theoretically, while practicing and theoretically, it can increase the experience value of diagnosis skills. It’s like solving a case, what kind of disease is at stake, and keep practicing the doctor’s golden eyes.
If you recognize a disease, you may not be able to recognize it immediately in the clinical process. Sometimes the mastery of knowledge and the increase of skills are not positively correlated. Sometimes the diagnosis is like a mess, making people unable to start, and it is difficult to see where the thread originated. The doctor's mind must always be tightly assembled into an airtight net, constantly filtering the disease. the reason. If you want your network not to miss a diagnosis, you must continue to learn, learn, and learn again.
After the director said, we took out the yellowed textbooks that had been turned over a long time ago, and the notes from the study theory class.
Revisiting inflammatory bowel disease in medical textbooks
Ulcerative colitis is a chronic non-specific inflammatory disease of the colon and rectum whose etiology is not well understood. The lesions are limited to the large intestinal mucosa and submucosa. The lesions are mostly located in the sigmoid colon and rectum, but can also extend to the descending colon or even the entire colon. The course of the disease is long, often recurrent. This disease is seen at any age, but it is most common between 20 and 30 years old.
Crohn's disease is an inflammatory disease of the intestinal tract of unknown cause, which can occur in any part of the gastrointestinal tract, but it usually occurs in the terminal ileum and right colon. Both this disease and chronic nonspecific ulcerative colitis are collectively referred to as inflammatory bowel disease (IBD). The clinical manifestations of this disease are abdominal pain, diarrhea, intestinal obstruction, and extraintestinal manifestations such as fever and nutritional disorders. The course of the disease is often protracted, recurrent, and it is not easy to cure. This disease is also known as localized enteritis, localized ileitis, segmental enteritis and granulomatous enteritis.
The cause of inflammatory bowel disease is not clear. It is currently believed that the onset of inflammatory bowel disease is the result of the interaction of the host response caused by exogenous substances and the influence of genes and immunity.
For ulcerative colitis, genetic factors may have a certain status. Psychological factors play an important role in the deterioration of the disease. The original morbid spirit such as depression or social distance is significantly improved after colectomy. Some people think that ulcerative colitis is an autoimmune disease. According to this view, ulcerative colitis and Crohn's disease are different manifestations of a disease process.
Crohn's disease may be related to infection, heredity, humoral immunity and cellular immunity.
Crohn's disease is a proliferative disease that penetrates all layers of the intestinal wall and can invade the mesentery and local lymph nodes. The disease is limited to the small intestine (mainly the terminal ileum) and the colon. Both can be involved at the same time, often ileum and right colon disease. The lesions of this disease are distributed in segments, separated from the normal intestines, with clear boundaries, and are characterized by skip areas. The pathological changes are divided into acute inflammation period, ulcer formation period, stenosis period and fistula formation period (perforation period). In the acute stage, bowel wall edema and inflammation become the main cause; in the chronic stage, the bowel wall is thickened and stiff, and the affected bowel is tubular in shape, and its upper bowel is dilated. Typical lesions on the mucosal surface are:
Early superficial small ulcers, then longitudinal or transverse ulcers, longitudinal ulcers deep into the intestinal wall form a more typical fissure, distributed along the mesenteric side, the intestinal wall may have abscesses.
2. Pebble nodules
The small island protrusions formed by submucosal edema and cell infiltration, coupled with fibrosis and scar contraction after the ulcer healed, make the mucosal surface look like a pebble.
No cheese-like change, different from tuberculosis.
4. Fistulas and abscesses
The fissure of the intestinal wall is essentially a penetrating ulcer, causing adhesions and abscesses between the intestine and the intestine, the intestine and the organs or tissues (such as the bladder, vagina, mesenteric or retroperitoneal tissue, etc.), and the formation of internal fistulas. If the lesion penetrates the intestinal wall, through the abdominal wall or the tissues around the anus, it leads to the body, forming an external fistula.
Both of these diseases belong to inflammatory bowel disease, and both are common clinical diseases. According to the textbook records, the teacher at that time also listed a table for comparison. I wrote it down in my notebook.
Differentiation of ulcerative colitis and colonic Crohn disease
Slowly or suddenly
Tenesmus and heavy pus and blood in the stool
Symptoms of poisoning
Recurrent abdominal pain
Chronic abdominal pain
Distribution of lesions
Starting at the distal end of the colon, the lesion continues to the proximal end, generally not invading the small intestine
It is segmental, multiple, involving more ileum and right colon, less invading rectum
Rough granular, shallow ulcers, pseudopolyps
Cobblestone-like, slit-like ulcer
Rarely, seen in late
More common, can appear early
Mucosa diffuse hyperemia, edema, easy to touch bleeding, coarse particles, shallow ulcers, pseudo polyps
Scattered deep ulcers, normal mucosa between lesions
Full thickness of intestinal wall
Inflammatory cell infiltration
Disperse fissure longitudinal ulcer
Destruction of glands
Decrease and disappear
Atypical hyperplasia of epithelial cells
I had to memorize the content of this part by rote, just to let these words crawl in my head, and walk carefully. I was afraid of shaking my head, then I would shake a certain key word or potentially in my head. , When needed, it is like a dish in the teeth, unable to pick it out.
After 10 years of clinical experience, I will feel deeply about the contents of these records, especially when Jingjing comes every spring and autumn.
I became friends with Jingjing because of her boldness, and later discovered that she was a typical female man, and showing her gentleness was fleeting.
Since she was a single-parent family, Jingjing is very independent and tends to be anxious to varying degrees. The hidden inferiority and sensitivity behind the feminism are also reflected in the gradual communication.
I first came to the clinic because of blood in the stool, which is also the main initial manifestation of ulcerative colitis. Jingjing thought it was an attack of hemorrhoids, so she ignored it. She didn't expect to get worse and worse. At most, she would pull more than 20 bloody stools a day. Jingjing couldn't hold it anymore, so she went to the hospital to see what happened.
Jingjing went to the anorectal department first, thinking it was about hemorrhoids. After a digital examination in the anorectal department, he did have hemorrhoids, but it did not cause bloody stool and mucus so many times a day, so the doctor Zhou of the anorectal department took Jing Jing was referred to our Gastroenterology Department, and wrote "ulcerative colitis" and "Crohn's disease" on the referral form and also put two big question marks.
From Jingjing’s typical symptoms, it should be an inflammatory bowel disease, but it is still uncertain whether it is ulcerative colitis or Crohn’s disease. Jingjing’s symptoms include abdominal pain in the right lower quadrant, fever, diarrhea, bloody stools, and mucus. These symptoms are found in ulcerative colitis and Crohn’s disease, so they cannot be distinguished by symptoms.
I performed an abdominal examination on her, but there was also tenderness. I didn’t feel the peculiar Crohn’s disease and it was not easy to judge. In fact, I felt it, and I was not sure. It was only on the multiple choice questions of judgment. Crohn's disease is approaching.
At the second visit, I said to her, Jingjing, your condition should be inflammatory bowel disease. There are two types of this disease, ulcerative colitis and Crohn’s disease. We need to give you a colonoscopy. Make a clear diagnosis.
Jingjing readily agreed, so I gave her a colonoscopy checklist.
Before Jingjing’s colonoscopy, Dr. Song and I explained that Crohn’s disease is unlikely, it should be ulcerative colitis, but be careful, because if it’s Crohn’s disease, the ulcer is deeper. Poor colonoscopy may lead to bowel perforation.
Lao Song is still very reliable. To be cautious, we prescribed a full digestive tract barium meal for her before the colonoscopy. Combined with the results of the barium meal, we further analyzed the situation and thought it was safe to do colonoscopy. So, choose a date. Had colonoscopy.
Soon the results of colonoscopy were obtained: under the picture, the ulcers were shallow and continuous, rather than one by one, and there were normal ulcers between them. Therefore, Dr. Song concluded: ulcerative colitis.
Combined with the diagnosis of ulcerative colitis and Crohn's disease, we considered and ruled out one by one.
In fact, the most core diagnosis has been seen from colonoscopy.
Regarding Jingjing's situation, I carefully checked the diagnosis of Crohn's disease. The purpose was to use the method of exclusion to determine that it was ulcerative colitis, not Crohn's disease.
The digestive system manifestations of Crohn's disease mainly include:
(1) Abdominal pain is located in the right lower abdomen or around the umbilical cord. It presents spasmodic pain, with intermittent attacks, accompanied by bowel irritation. If the abdominal pain persists and the tenderness is obvious, it indicates that the inflammation spreads to the peritoneum or the abdominal cavity and forms an abscess. Panic pain and tight abdominal muscles may be caused by acute perforation of the diseased intestine.
(2) Diarrhea is caused by inflammation and exudation of the diseased intestine, increased peristalsis, and secondary malabsorption. Intermittent seizures started at the beginning, and persistent mushy stools without pus, blood or mucus in the later stage. If the disease involves the lower part of the colon or rectum, there may be mucus, bloody stools and tenesmus.
(3) Abdominal masses are more common in the right lower abdomen and around the umbilical cord. They are caused by intestinal adhesions, thickening of the intestinal wall and mesentery, enlarged mesenteric lymph nodes, internal fistulas or local abscess formation.
(4) Fistula formation is one of the clinical features of Crohn's disease. Transmural inflammatory lesions penetrate the entire thickness of the intestinal wall to extraintestinal tissues or organs, forming a fistula. Internal fistula can lead to other intestines, mesenteric, bladder, ureter, vagina and retroperitoneum. The external fistula leads to the abdominal wall or perianal skin.
(5) Perirectal lesions A few patients have lesions such as fistulas, abscess formation, and anal fissures around the anus and rectum.
From the perspective of Jingjing's symptoms: having the first three items, which are also the manifestations of ulcerative colitis, the last two specific manifestations of Crohn's disease did not appear in our diagnosis and treatment.
The systemic symptoms of Crohn's disease are: (1) Fever. Fever is caused by intestinal inflammatory activity or secondary infection. It is usually intermittent low-grade or moderate-grade fever, and a few have flaccid fever, which may be accompanied by toxemia.
(2) Nutritional disorders: Weight loss, anemia, hypoproteinemia, vitamin deficiency, calcium deficiency, osteoporosis, etc. caused by loss of appetite, chronic diarrhea and chronic wasting diseases.
(3) Water, electrolyte, and acid-base balance are disturbed during acute attack.
These conditions did not appear in Jingjing, but were reflected in the Crohn’s disease hospitalized patient. Zhang Jianguo, 15-bed, has been feverish since he was admitted to the hospital, and once had a toxemic shock due to prolonged diarrhea. , The body is particularly weak, the current weight is only 40kg.
The 16th bed in the same room, Tong Aimin, also had ulcerative colitis transferred from the anorectal department. In fact, not only the anorectal department referred me to patients, but the ophthalmology department also referred me to patients with enteropathy. The 17-bed Kang Jie was transferred from the ophthalmology department. Some patients with Crohn’s disease have iridocyclitis and uveitis. The internal correlation of such immune diseases also made clinicians surprised. I knew what was going on.
After many years of clinical diagnosis, some diseases still need to constantly read textbooks. This way, from theory to practice, and then from practice to theory is a spiraling process of progress.
The complexity of the doctor is to consider all the symptoms and possible conditions of inflammatory bowel disease. Whatever appears, what does not appear must be analyzed.
From this medical record of Jingjing, looking through the diagnosis of ulcerative colitis and Crohn's disease, it seems that I have returned to the college days. The difference is that I experience the different complexity shown by real patients.
Jingjing's diagnosis is very clear, and the purpose of hospitalization is to make the best plan.
The treatment methods are mainly medical conservative and surgical resection. The basis for judgment is the severity of the condition. Of course, the first thing we consider is medical treatment.
Before medical treatment, we should evaluate the main symptoms and colonoscopy, using the current internationally accepted scale, called: (Sutherland Disease Activity Index)
Main symptoms and intestinal mucosal disease activity index Main symptoms of ulcerative colitis and intestinal mucosal disease activity index
Pus and blood in stool
Severe brittleness with exudation
Physician's condition assessment
Note: A total score of <2 is divided into symptom relief; 3 to 5 is divided into mild activity; 6 to 10 is divided into moderate activity; 11 to 12 is divided into severe activity.
The assessment of the severity of the disease can help patients understand their own disease and also help evaluate the efficacy. Because everyone’s condition is different, just like people going downstairs, some are on the 8th step, and some are on the 3rd step. Doctors are like health assistants. For people on the 8th floor, if they go to the fifth step through our treatment, it is a good thing, and for patients on the third step, it is best to go downstairs completely. As for whether they will go upstairs again in the second year, everyone is different. We hope that through the advantages of Chinese and Western medicine, patients with inflammatory bowel disease can go downstairs steadily and not rebound. This requires the common good of patients and doctors.
If the 10th floor is the worst situation with inflammatory bowel disease, Jingjing basically lingers on the 3-5 floors. The 16-bed Tong Aimin in the same room is probably on the 7th floor, and the 17-bed Kangjie belongs to the 6th floor. The difficult 15-bed Zhang Jianguo should be on the 8th-9th floors, and the same intervention measures, can every patient go to the same floor, the conclusion is also negative, under the joint intervention of Chinese and Western medicine, the same measures may also have The lower three floors, some lower 5 floors; the more serious, the worse it is to go downstairs, not necessarily, some can go from the 8th floor to the 2nd floor, and some from the 6th floor to the 4th floor are good. Therefore, diagnosis and treatment of diseases is also a kind of fate and good fortune that doctors and patients share.
Jingjing can go from the 5th floor to the 1st floor, but goes upstairs once a year. Zhang Jianguo can only go down to the 3rd floor, and then he has to continue to support him. The Kang Jiehui courtyard is basically on the 1st floor, sometimes on the 2nd floor. Tong Aimin never relapsed after going downstairs.
For Zhang Jianguo on the highest floor, the measures we took included all available medical methods. This is also a collection of treatment options for inflammatory bowel disease.
The first is bed rest and systemic support treatment, including fluid and electrolyte balance, especially potassium supplementation. Lao Zhang also suffered from hypokalemia, but fortunately, he corrected it in time. When nutritional supplements, if you eat a normal diet, reduce your milk intake.
We have almost exhausted all the current drugs for Lao Zhang's medications. ①Sulfasalazine salicylic acid preparations are the main therapeutic drugs, such as Edissa and Mesalazine. After using it for a period of time, the symptoms did not alleviate, so we started to use hormones. The commonly used corticosteroids are prednisone or dexamethasone. After using it, it is greatly relieved. The old wife Zhang is very happy and said, can this drug I used it frequently and checked relevant research. I told them that at present, I don't think long-term hormone maintenance can prevent recurrence. Hydrocortisone or dexamethasone can be used intravenously only in the acute attack period, and hydrocortisone is added to normal saline every night as a retention enema. The value of hormone therapy in the acute attack period is certain. However, there is still disagreement as to whether hormones should be used continuously in the chronic phase, because they are hormones after all. Because of their side effects, most do not advocate long-term use.
Sometimes it is recommended to use 3 immunosuppressive agents, but Lao Zhang did not use it, because this treatment is not certain, and its value in ulcerative colitis is still questionable.
During Lao Zhang's treatment, he used Chinese herbal decoctions orally. Since Lao Zhang was hospitalized many times, he could almost judge what intervention measures to use. I stayed in the hospital five times. Two times used Chinese medicine enema and oral decoction, once used mesalazine orally and enema, and two times including this time, used hormone therapy. ④The effect of traditional Chinese medicine on diarrhea-type ulcerative colitis is ideal. Need to combine specific circumstances. At the same time, attention should be paid to diet and living habits.
Since Lao Zhang has used hormones and salicylic acid preparations many times, he has also deeply experienced the side effects and hoped to use Chinese medicine to solve the problem. As modern doctors cooperating with Chinese and Western medicine, we have more objectively explored the different advantages of Chinese and Western medicine in the treatment process.
Some patients can use traditional Chinese medicine to fully recover. Some patients must use mesalazine or even hormones to relieve symptoms. Some patients use mesalazine and hormones to no avail. In the end, the treatment with traditional Chinese medicine is effective. What kind of treatment is better, we are also constantly studying. But Lao Zhang uses a different method every time he gets sick. The general order is that when a patient comes, we first take the decoction orally. If the relief is improved by 50% after 3 days, then it is fine, or depending on the situation, add decoction and Chinese patent medicine enema. If the traditional Chinese medicine is not good for three days, add salicylic acid preparations such as mesalazine orally, and whether to enema depends on the specific situation. If the salicylic acid preparation is not good, the disease is still getting worse. It is necessary to use hormones in time to control the symptoms. Generally speaking, this is the most powerful trick. This trick should be the last method. Due to the side effects of hormones, we use them with caution, but not absolutely. In the increasingly serious situation, we need to use adequate hormone therapy in time and decisively. If we still can't control it after using hormones, at this time, we will return to Chinese medicine decoction again.
For the selection of traditional Chinese medicine decoctions for inflammatory bowel disease, we use the principle of syndrome differentiation and treatment. According to the assessment of the condition and the status of Chinese medicine, targeted treatment will be carried out.
When Jingjing first started, Chinese medicine thought it belonged to the syndrome of damp-heat in the large intestine, and the method of choice was: clearing away heat and dampness, regulating qi and promoting blood circulation. Classic traditional Chinese medicine prescriptions are used: peony soup (peony, scutellaria, coptis, rhubarb, betel nut, angelica, woody, cinnamon, and licorice) due to more pus and blood in the stool, add pulsatilla, purple beads, and Diyu to cool blood to stop dysentery; On the third day, those who have white cold stool and more mucus, add atractylodes japonicus and coccineae for invigorating the spleen and dampness
One week later, stool pus and blood were reduced, and spleen-qi weakness appeared. We adjusted the prescription in time: to invigorate the spleen and nourish qi, reduce dampness and relieve diarrhea. The classic prescription Shenlingbaizhu San (Ginseng, Poria, Atractylodes, Platycodon, Chinese Yam, White Lentil, Amomum villosum, Coix Seed, Lotus Seed Meat, Licorice) was selected.
The situation of Lao Zhang's attack was similar to Jingjing, so he also used Shaoyao Decoction for treatment. In these few hospitalizations, he was treated with Shaoyao Decoction twice. The subsequent treatment was different from Jingjing because Lao Zhang was too old. , The spleen and kidney yang deficiency syndrome appears. For this condition, we use the method of warming yang to dispel cold, strengthening the spleen and invigorating the kidney. Recipe: Fuzi Lizhong Decoction (aconite, ginseng, dried ginger, atractylodes, licorice) addition and subtraction. Lao Zhang's yang deficiency was very obvious. At that time, the prescriptions also added bone fat and nutmeg to warm the spleen and kidney.
Tong Aimin's temper is relatively big, and he still loves sulking. It belongs to liver depression and spleen deficiency. We chose the treatment method for him during the remission period: soothing the liver, regulating qi, and invigorating the spleen. Recipe: the main prescriptions for pain and diarrhea (Chenpi, Atractylodes macrocephala, peony, Fangfeng) addition and subtraction.
Kang Jie is a typical mixed syndrome of cold and heat. It requires warming yang to invigorate the spleen, clearing heat and eliminating dampness, and calming cold and heat. Recipe: ebony pill (black plum meat, coptis, cork, ginseng, angelica, aconite, cassia twig, Sichuan pepper, dried ginger, asarum) addition and subtraction.
For patients with hematochezia that still has no effect after the use of hormones, we generally think that it is a syndrome of flaming heat and toxins. The treatment method: clearing away heat and detoxifying, cooling blood to stop dysentery. Recipe: Pulsatilla decoction (Pulsatilla, Coptis, Phellodendron, Qinpi) addition and subtraction.
Traditional Chinese medicine enema is generally used in the recovery period, mainly with Shenlingbaizhu, or Shuangliaohoufengsan and Kangfuxin liquid retention enema are used.
After these treatments, if the recurrence is still repeated, it is about to enter the surgical procedure. 20% to 30% of patients with severe ulcerative colitis will eventually undergo surgery
How to judge whether there is surgery or not depends on whether there are indications for surgery. Indications for emergency surgery are: ① massive and uncontrollable bleeding; ② toxic megacolon with adjacent or clear perforation, or those who have failed treatment for several hours rather than days; ③ fulminant acute ulcerative Colitis is ineffective to steroid therapy, that is, those who do not improve after 4 to 5 days of treatment; ④ Obstruction due to stenosis; ⑤ Suspected or confirmed colon cancer; ⑥ Intractable ulcerative colitis recurrent and worsening, chronic persistent symptoms , Malnutrition, weakness, unable to work, unable to participate in normal social activities and sexual life; ⑦when the dose of steroid hormones is reduced, the disease worsens, so that hormone therapy cannot be stopped for several months or even years; ⑧children suffer from chronic colitis and affect them During growth and development; ⑨Severe extracolonic manifestations such as arthritis, pyoderma gangrenosum, or biliary liver disease and other operations may be effective.
If it is not the above situation, we try to choose medical treatment. If the above situation occurs, we will contact the doctor of gastrointestinal surgery for consultation and evaluation. We also need to inform and discuss with the patient for multi-angle treatment.
The onset of inflammatory bowel disease has seasonality and incentives, so we can take some measures to prevent it. In fact, sometimes it is impossible to prevent it, but it may be reliable to reduce the attack.
1. Pay attention to the combination of work and rest, not to be too tired, not to worry about anger and excessive tension; patients with violent, acute and severe chronic types should stay in bed.
2. Pay attention to clothing, keep warm and cold; proper physical exercise to enhance physical fitness.
3. Generally, you should eat soft, digestible, nutritious and sufficient calorie food. It is advisable to eat a small amount of meals and add a variety of vitamins. Do not eat raw, cold, greasy and high-fiber foods.
4. Pay attention to food hygiene and avoid intestinal infections to induce or aggravate the disease. Avoid tobacco and alcohol, spicy food, milk and dairy products.
5. Always keep a good mood, avoid mental stimulation, and relieve all kinds of mental stress.