Crohn’s disease (CD) is an inflammatory bowel disease with a fistula and constriction that has a chronic course.
There is a disease at any age, but more often in young people, and in smokers 4 times more often than in non-smokers, there is also a connection with taking oral contraceptives. The prevalence of the disease is 30–35 per 100,000 population,
A certain role in the development mechanism belongs to the impaired immune response of the organism to the influence of various factors. Disruption of the immune response may be genetically determined. Until the end of the cause of BC is unknown. Predisposing causes include infection (viruses, atypical mycobacteria), tissue cytotoxins, impaired cellular immunity, food allergens, a diet high in refined sugar. But these factors can not explain the wave-like course of the disease, improvements that continue for 5 years.
In most cases of Crohn’s disease, the terminal, terminal ileum and proximal (proximal) parts of the colon are affected, but damage to all parts of the gastrointestinal tract is possible. The theory of the immune mechanism of Crohn’s disease development suggests that frequent extra-intestinal manifestations (arthritis, periholangitis) are of autoimmune origin, moreover, treatment with glucocorticoids and azathioprine is effective due to their immunodepressive action. Crohn’s sufferers sometimes detect antibodies to intestinal cells, bacterial and viral antigens, Escherichia coli and the IgM class measles virus, polysaccharides, etc.
The disease begins with terminal inflammation of the ileum, the extent of the lesion may be different: from 3-4 cm to 1 m and more connective tissue. Regional lymph nodes are enlarged. In the affected area, areas of unchanged mucous membrane alternate with deep slit-like ulcers penetrating into the submucous and muscular layers. Fistulas, abscesses and narrowing of the intestine are also formed here. Between the affected and healthy areas there is a clear boundary. The process of suppuration and ulceration of lymphoid follicles, the degeneration of granulomas is completed.
With exacerbation of Crohn’s disease, symptoms are noted, depending on the localization of the pathological process:
- pain, usually colicky, especially in the lower abdomen, often aggravated after eating due to obstruction (blockage);
- weight loss;
- lack of appetite;
Symptoms of Crohn’s disease, independent of the localization process:
- most patients have the main symptoms – fever, diarrhea, abdominal pain, weight loss. Abdominal pains resemble those of acute appendicitis;
- fever, anorexia (loss of appetite), weakness, lethargy, fatigue are typical for the active phase of the disease;
- weight loss associated with anorexia without diarrhea and abdominal pain;
- The clinic is associated with the localization and development of complications, the activity of the process.
For enteric localization:
1) exacerbation of Crohn’s disease is sometimes accompanied by the formation of aphthous ulcers, but they are not characteristic of the granulomatous process;
2) difficult to heal post-bar (zalukovichnye) duodenal ulcers are formed;
3) colicky abdominal pain with systemic manifestations and local tenderness on palpation;
4) a violation of absorption develops rarely, with a common process in the distal ileum develops a deficiency of vitamin B12;
5) when palpating, a tumor-like formation in the right iliac region is determined, and other localization is possible.
Crohn’s disease with the localization process in the colon:
1) severe diarrhea manifests itself as a semi-liquid stool up to 10–12 times a day, bloody stools are possible with affection of the descending and sigmoid intestines; sharp urge to defecate at night or in the morning;
2) pains are colicky, occur after eating and before stool, may be constant, aggravated by movements, bowel movements, cleansing enema (commissural pains) in the lower and lateral sections of the abdomen;
3) when palpation is determined by the pain of the affected parts of the colon;
4) the rectum in Crohn’s disease, in contrast to the perional zone, is rarely involved in the pathological process;
5) systemic granulomatous colitis is possible.
manifestations (arthralgia, ankylosing spondylarthritis, erythema nodosum, pyoderma, conjunctivitis);
6) rectal bleeding in patients with CD require the exclusion of colon cancer;
7) unlike ulcerative colitis, toxic dilatation of the colon is very rare in Crohn’s disease.
Perianal (near the anus) localization of Crohn’s disease:
1) is more common in patients with primary concomitant localization of CD in the distal (distal) section of the small and proximal (middle) section of the colon;
2) is characterized by polypous skin lesions, systemic manifestations of Crohn’s disease in this localization are absent;
3) anal (anus) and rectal (rectal) contractions may occur, leading to constipation. Extraintestinal manifestations develop in 15% of patients, more often with colonic localization.
Extra-intestinal manifestations associated with the activity of the process: aphthous ulcers of the oral mucosa and tongue, erythema nodosum, “drumsticks”, eye damage – conjunctivitis, keratitis, uveitis, arthritis – large joints are affected, necro-pyoderma, that is, skin lesions .
Non-intrinsic manifestations not related to the activity of the process, spondylitis – inflammation of cartilage, cholecystolythiase – cholelithiasis, ankylosing sacroiliitis, liver disease (fatty degeneration, primary sclerosing cholangitis), kidney damage (stones, hydronephrosis, oxalic nephropathy,) I’m drawing) bones), malnutrition, systemic amyloidosis.
If nutrition is impaired, it leads to a deficiency of vitamin B, potassium and magnesium, vitamin B12, folic acid and zinc, which exacerbates the symptoms of general weakness, besides it is manifested by dermatitis and a perversion of taste due to iron and nicotinic acid deficiency.
The complications of Crohn’s disease requiring immediate surgical treatment are intestinal obstruction, internal and external intestinal fistulas, abscesses, and intestinal perforation.
Even with a visually unchanged mucous, a sigmoidoscopy is performed with a biopsy. Radiographically to the acute stage of Crohn’s disease in the affected segment of the terminal ileum, there is an accumulation of mucus and a rapid movement of the contrasting mass to the ascending colon, the bowel tone is altered (alternation of spasm and hypotension of the affected area). One can see a characteristic change in the relief of the spruce membrane for the inflammatory process: thickening and deformation of the folds, sometimes – an increase in lymphatic follicles in the form of filling defects up to 0.5 cm in diameter, spasm of the cecum. Ulceration is characterized by the accumulation of barium suspension and edema of the mucous membrane around. The tone of the intestine in the area of the lesion is reduced; there are many small (0.2–0.3 cm) filling defects in the relief. Due to excessive accumulation of mucus in the intestinal lumen, its shadow is low-intensity, the relief of the mucous membrane is smoothed. During the formation of stenosis, the affected segment of the intestine is shortened, straightened and narrowed. The folds of the mucous membrane acquire a longitudinal direction, smoothed, converge; roundish filling defects up to 1 cm in diameter (“cobblestone pavement”) are determined on the mucosa. With a pronounced narrowing of the intestine (up to 0.2 cm) and fistulas (up to 0.1 cm), probe enterography is an informative method, with high sensitivity and specificity. Ultrasound in the detection of this pathology was less informative.
The adhesive deformation of the loops of the small intestine as a complication of Crohn’s disease is well visualized when the small intestine is contrasted with the Entero-Vue preparation, which provides a differentiated image of the layered loops.
Diagnosis of relapse of Crohn’s disease after surgical treatment for 3-5 years revealed the progression of the pathological process near the ileotrans-verzoanastomosis. Treatment is prescribed in accordance with the X-ray picture. The positive dynamics of the clinical state and the normalization of the x-ray picture of the affected area serve as criteria for the correct diagnosis of the disease.
In the absence of rectal bleeding, an irrigoscopy is indicated in patients, but it must be preceded by a rectosigmoscopy. Irrigoscopy does not exclude radiological examination of the small intestine. Blood tests show anemia due to iron deficiency and sometimes vitamin B12 and folic acid, ESR increased, thrombocytosis, hypoalbuminemia. Antibodies to Yersinia, indicating the possible role of Yersinia in the onset of Crohn’s disease, are determined. It is necessary to conduct a study of feces for the presence of protozoa and clostridia – Cl. Difficile.
A targeted biopsy is taken from the sites of inflammation. Even in the absence of endoscopic signs of inflammation, granulomas are characteristic of the rectum, but chronic inflammatory indurations are most often detected.
Mandatory research in the presence of bleeding and uninformative X-ray examination of the small and large intestine is a colonoscopy with multiple biopsies. Crohn’s disease is characterized by: edema of the submucous layer, the absence of vascular pattern, small aphthous ulcers in the infiltrative phase of the process with the subsequent formation of deep slit-like cracks, narrowing of the intestine, changing the mucous membrane-like relief.
In case of obstruction associated with contractions, laparoscopy is performed. In the early stage of the disease in laparotomy, the terminal portion of the ileum looks hyperemic, loosened, and the mesentery and mesenteric lymph nodes are compacted and have a reddish tint.
The main signs of the process activity:
1) clinical – anorexia, weight loss, weakness, fever, tachycardia;
2) laboratory signs of activity – hypoalbuminemia, severe anemia, increased ESR, C-reactive protein, thrombocytosis;
3) X-ray signs of activity – ulcers, fistulas, mucous of the “cobblestone” type;
4) endoscopic and histological signs of activity – visible ulcer, granulomas;
5) Ultrasound signs – a thickening of the intestinal loops, inflammatory infiltration, abscess.
If the joined symptoms are different from the previous ones, then the following examinations should be performed – kidney and urinary tract, an overview of the abdominal cavity, an ultrasound scan to detect gallstones, kidneys.
When duodenal localization of the process, the doctor needs to exclude tuberculosis and sarcoidosis using a biopsy from the edge of a long-existing ulcer and chest x-ray examination; in case of localization of the process in the small intestine, it is necessary to exclude lymphoma, adenocarcinoma, yersiniosis ileitis, cel-cue, Behcet’s disease, contractions caused by the use of nonsteroidal anti-inflammatory drugs; in case of colonic localization of Crohn’s disease, a differential diagnosis is performed with ulcerative, ischemic, radiation and infectious colitis, carcinoma, and benign ulcer. In the presence of diarrhea, it is necessary to exclude ulcerative, pseudomembranous, infectious and ischemic colitis by performing a stool culture, endoscopy with a biopsy. Isolated diarrhea, the cause of which remains unclear after colon examinations, requires an x-ray examination of the small intestine, its biopsy and aspirate culture.
When detecting tumor formations in the right iliac region, it is necessary to exclude a tumor, appendicular abscess or tuberculosis, for which ultrasound and serological studies, sometimes laparoscopy, are used. Rectal and perianal ulcerations are most often manifestations of Crohn’s disease, but may be associated with cancer, Hodgkin’s disease, Behcet’s disease, herpes simplex, cytomegalovirus, tuberculosis, syphilis.
With Crohn’s disease, the risk of developing cancer is significantly lower than with ulcerative colitis. Malignanization exposed areas of the affected colon, less often – ileum. Risk factors for malignancy are a long-term course and a large amount of damage.