What Is the Effect of Alcohol on Ulcerative Colitis?

The ratio of male to female incidence is 1.4: 1 to 2.3: 1, which can occur in all age groups. It is more common in 20 to 50 years old. Generally, the onset is slow. A small number of patients can have rapid onset, different severity, and the disease has recurrent attacks. Trends, pathogenesis include emotional excitement, trauma, excessive fatigue, eating disorders, and upper respiratory tract infections. Systemic symptoms include anorexia, weight loss, normal or elevated body temperature, and fever, pulse rate, and dehydration in the acute phase.

Ulcerative colitis arthritis

"Enteropathic arthritis" refers to arthropathy associated with Crohn's disease or ulcerative colitis. These lesions are caused by clinical and histological inflammation of the intestinal tract, changes in intestinal permeability, and peripheral and axial joints. Inflammation and so on. About 20% of cases have peripheral arthritis, and 10% to 15% of patients have axial arthritis. Peripheral arthropathy is more common in people with extraintestinal syndromes (such as nodular erythema), with an equal incidence in men and women. It can be affected at any age, but arthritis in adults usually occurs after inflammation of the bowel actually occurs, and the opposite is true in children.

Ulcerative colitis arthritis symptoms and signs

1. The most common abdominal manifestations of ulcerative colitis in the digestive system are diarrhea and intestinal blood loss. Diarrhea is almost always present, and fever and weight loss are rare. Mucosa of ulcerative colitis is extensive and continuous, including superficial ulcers, edema Fragile and microabscess lesions are limited to the colonic mucosa. Although Crohn's disease is mainly affected by the terminal ileum and colon, the lesion can be seen throughout the gastrointestinal tract. This lesion is often ulcerative and distributed in small pieces. These lesions can be superficial, but are often transmural and granulomatous, of which aphthous ulcers, pseudopyloric metaplasia, and sarcomatoid granulomas have diagnostic value, and sometimes ulcerative colitis and Crohn's disease are difficult The difference; when the lesion is confined to the colon, histological manifestations will be helpful for differential diagnosis.

(1) Symptoms: The main symptoms are pus, blood, or mucus in the stool, which can alternate between diarrhea and constipation. Generally, diarrhea is 2 to 4 times a day. It is a paste-like soft stool mixed with blood and mucus. 30 times, bloody stools, paroxysmal colic cramps may appear in the abdomen, mostly confined to the left lower abdomen or lower abdomen, and there is a bowel movement after pain. Pain may be temporarily relieved after defecation, and upper abdominal discomfort may also occur. Nausea, vomiting, abdominal distension and lower back pain. In addition to tenderness in the abdomen, it can also be accompanied by abdominal muscle tension and hyperactive bowel sounds, which can touch the rigid tubular descending colon or sigmoid colon. Digital rectal examination often has tenderness and anal sphincter spasm.

(2) Clinical types:

The course of the disease can be divided into 4 types: A. Prototype; B. Chronic recurrence type: Most common, this type of lesion has a small range, mild symptoms, often has a remission period, but is easy to relapse; C. Chronic persistent type: Range of lesion Wide, symptoms last for more than six months; D. Acute irritability: This type is the least common, with rapid onset, severe systemic and local symptoms, and prone to major gastrointestinal bleeding and other complications, such as acute colonic dilatation, intestinal obstruction, and intestinal perforation. In addition to the initial hairstyle, the other three types can be transformed into each other.

According to the degree of the lesion, it is divided into light, medium and severe three degrees: A. Mild: Most common, only the distal part of the colon is involved, and the lesions are distributed in segments. Generally, the onset is slow, diarrhea is mild, and stool is less than 3 times a day. Feces are more formed, bloody, less pus and mucus, less bleeding, intermittent, may have mild abdominal pain, no systemic symptoms and signs, B. Severe: sudden onset, significant diarrhea (more than 6 times a day ), Blood in the stool, anemia, fever, tachycardia and weight loss, and even signs of toxemia such as dehydration and dehydration, leukopenia, accelerated erythrocyte sedimentation, hypoalbuminemia, persistent abdominal pain and bloating, C. Moderate: Between mild and severe, but there is no clear dividing line.

Lesion range: According to the lesion range of the affected colon, there may be proctitis, rectal sigmoiditis, right semicolitis, left semicolitis, regional colitis and pancolitis.

Complications: Frequently occur in patients with a long course and severe illness. The common complications are: A. Acute colonic dilatation and ulcer perforation. Acute irritability can spread to the colonic muscle layer, reduce the smooth muscle tension of the intestinal wall and cause colonic expansion. Dilated foundation can easily cause perforation of colonic ulcers and diffuse peritonitis, B. Anal fissure, anal fistula, rectal prolapse, rectal or perianal abscess, sciatic anal fossa abscess, rectal vaginal fistula, rectal anal fistula and colon small intestine fistula, C. During the acute active phase, major colonic bleeding may occur, D. Intestinal obstruction.

If complicated with hemorrhoids, blood in the stool can be aggravated.

2. Common skin lesions of the skin and mucous membranes include maculopapular rash, purpura, erythema polymorpha, aphthous ulcers, nodular erythema, and gangrenous pyoderma. Skin lesions often disappear with intestinal inflammation, and aphthous ulcers and nodes Erythematous erythema usually appears 24 hours after the acute onset of intestinal symptoms, and erythema polymorpha often occurs after the intestinal symptoms appear. Gangrene purulent disease is a recurrent skin ulcer. Bromine allergy, once the allergy occurs, the skin lesions can worsen or spread to the whole body, mostly distributed in the lower extremities and lower body. The onset usually starts with one or more pustules, and later forms and fuses into a larger ulcer. Sometimes Red nodules may appear first, and then develop into ulcers. The ulcers of pyoderma gangrenosum are usually multiple or systemic.

3. Joint disease manifestations: Of the 79 patients with active ulcerative colitis who have research reports, 49 (62%) have joint involvement, arthritis is oligoarticular, and most of them are asymmetric; Transient and migratory, both large and small joints can be affected, and lower limb joints are mainly involved; usually non-destructive, which usually resolves within 6 weeks, but recurrence is common, and canine finger (toe), tendon end disease, In particular, the inflammation of the Achilles tendon or plantar fascia attachment point can also involve the knee joint or other parts. Crohn's disease can occur with clubbing fingers, and periostitis is rare. In some cases, peripheral arthritis can turn into chronic, facet joints. And destructive damage to the hip joint has been reported.

Most cases of intestinal symptoms precede or appear at the same time, but joint symptoms may precede intestinal symptoms for several years. According to some data, in some spinal arthropathy, joint and tendon inflammation are the only clinical manifestations. The clinical symptoms of the disease are not obvious. The arthritic attack of ulcerative colitis is related to the occurrence of bowel disease. Surgical removal of the diseased part of the colon can relieve peripheral arthritis. In Crohn's disease, the colon is affected. Increased susceptibility to peripheral arthritis, but surgical removal of the diseased colon has little effect on joint disease.

Increased serum inflammatory markers (especially C-reactive protein), increased platelets, and hypochromic anemia are common laboratory manifestations. Synovial fluid analysis is non-specific, consistent with inflammatory arthritis, and the cell count is 1500 to 50,000. / mm3; culture negative, synovial biopsy is rarely reported, but found that in some patients with Crohn's disease, granulomatosis, ulcerative colitis and Crohn's disease may have a genetic basis, because they all appear in the same family, But there was no significant correlation with HLA antigen, and the frequency of HLA-B27 was in the normal range in patients with peripheral arthritis only.

(1) Peripheral arthritis: The prevalence of peripheral arthritis is about 10%, and the gender is similar. Joint swelling and pain usually occur after the onset of colitis and after colitis, and large joints such as the knee and ankle are involved. Joints, a small amount of fluid in the joint cavity, rarely involving more than 4 joints, but sometimes as many as 10 or more migratory joint pain, the incidence of children is similar to that of adults, and children with arthritis can appear in Prior to diarrhea, adults often have complications of inflammatory bowel disease, such as the formation of peritoneal abscesses and pseudomembrane polyps, ulcerative colitis often accompanied by nodular erythema, stomatitis, iridocyclitis, or gangrenous pustular disease, Onset of arthritis suddenly, often peaks within a day, half of it disappears within a month, usually improves within 6 weeks, and can last for several years. It is mainly seen in chronic intermittent or chronic persistent patients. Most arthritis occurs in the colon In the first year of inflammation, it can be relieved after colectomy, with little evidence of cartilage or bone destruction.

(2) Axillary joint involvement: Axillary joint involvement in ulcerative colitis and Crohn's disease is very similar, because it is often an occult disease, so it is difficult to estimate the true incidence of sacroiliitis. The incidence of arthritis is 10% to 20%, and spondylitis is 7% to 12%. The true incidence may be higher. Recently, 34 of 79 patients with ulcerative colitis were found to have ankylosing spondylitis (20 cases). ) And unspecified spinal arthritis (14 cases), men are three times more likely to develop these diseases than women.

Clinical manifestations are often indistinguishable from ankylosing spondylitis alone. Patients complain of inflammatory pain in the lower back, pain in the thoracic or cervical spine, pain in the hips, or chest pain. The characteristic clinical signs are restricted movement of the waist and neck, and reduced chest expansion. Small, may be combined with peripheral arthritis, the onset of central axis joint involvement and intestinal disease are not parallel, often the first occurrence of bowel disease; the course of central axis joint involvement is completely independent of the course of intestinal disease. Surgery cannot alter the course of any associated sacroiliitis or spondylitis.

The axial joint involvement and uncomplicated ankylosing spondylitis are difficult to distinguish on the X-ray. The frequency of asymmetric sacroiliitis may be higher than that of ankylosing spondylitis.

The correlation between iliac arthritis and spondylitis and HLA-B27 is less than that of ankylosing spondylitis without complications, which fluctuates between 50% and 60%. Although HLA-B27 has only iliac arthritis, Patients with ankylosing spondylitis that do not carry the HLA-B27 antigen have a lower risk of developing inflammatory bowel disease than patients with HLA-B27-positive ankylosing spondylitis, with Crohn's disease-like lesions on the intestinal biopsy Of patients with spinal arthropathy, the frequency of HLA-Bw62 is significantly higher, and the HLA-B27-B44 phenotype may make patients more prone to the common clinical manifestations of Crohn's disease and ankylosing spondylitis. Some people speculate that peripheral arthritis is an inflammatory bowel It is a manifestation of the disease, and the axial joint involvement is an inflammatory bowel disease-related disease.

Spondylitis: It usually occurs years before the onset of colitis symptoms. According to the British report, 6.4% of 234 non-selected cases have significant ankylosing spondylitis and 14% of asymptomatic sacroiliitis Conversely, ankylosing spondylitis is often complicated by occult colitis. The development of the condition is not related to the activity of ulcerative colitis, the degree of lesions, and the presence or absence of complications, but it has a significant correlation with the occurrence of uveitis. With the exception of cases of idiopathic ankylosing spondylitis, the ratio of men and women with colitis to spondylitis is 1.75: 1.

4. Other eyes may have conjunctivitis, irisitis, uveitis, etc., fatty liver, peribiliary inflammation, chronic active hepatitis, necrotic cirrhosis and sclerosing cholangitis may occur in the liver, kidney may occur, and pyelonephritis , Kidney stones and glomerulonephritis, but also iron deficiency anemia, autoimmune hemolysis, microangiopathic hemolysis and thromboembolism, etc. This disease can also be associated with Sjogren syndrome, systemic sclerosis, nodular Polyarteritis, rheumatoid arthritis, mixed connective tissue disease, systemic lupus erythematosus and other diseases overlap. Once it overlaps with other rheumatic diseases, the condition will quickly deteriorate. In addition, the disease can be combined with other autoimmune diseases such as multiple Sclerosis, idiopathic cholestatic cirrhosis, idiopathic Edison disease, autoimmune diabetes, etc. overlap.

5. Extra-intestinal and extra-articular characteristics Inflammatory bowel disease can manifest many skin, mucosal, serous, and ocular manifestations, of which skin damage is the most common, accounting for 10% to 25%, nodular erythema and intestinal diseases The activities are parallel and more likely to occur in patients with active peripheral arthritis, which may be a disease-related manifestation. Pyoderma gangrenosum is a more severe but rare extra-articular manifestation that is not related to intestinal and joint diseases. It may be a concurrent disease, and sometimes it may be complicated by leg ulcers and thrombophlebitis.

Ocular manifestations are often complicated by inflammatory bowel disease (3% to 11%), mainly anterior uveitis. Uveitis is usually acute, with asymmetric and transient symptoms, but often recurs. Not affected, but there may be chronic inflammation in the back of the eye. Granulomatous uveitis is rare, but may occur in Crohn's disease, acute anterior uveitis, and axial joint involvement is closely related to HLA-B27. Conjunctivitis And outer scleritis has also been reported.

Pericarditis is an uncommon complication, but secondary amyloidosis with major organ involvement is seen in Crohn's disease.

6. The most common clinical symptoms of ulcerative colitis in the elderly are bloody stools and bloody diarrhea. Zimmerman et al. Reported that diarrhea occurred more frequently in middle-aged and older patients aged 51 years and older than patients aged 21-30. Most scholars believe that the elderly The main clinical manifestations and course of ulcerative colitis are similar to those of young people. Zimmerman believes that the elderly with late-onset ulcerative colitis are relatively high, but this includes some recurrences before the age of 60 and delayed diagnosis leading to delayed treatment. Evans and Acheson found that the clinical manifestations of this disease are generally similar in the elderly to young people, but elderly ulcerative colitis may have a more sudden attack tendency than young people. There are 29 elderly patients with ulcerative colitis in a hospital. There are 13 cases of moderate to severe patients, a significantly higher proportion than young people with moderate to severe patients. The other difference is that the most common clinical symptom of the elderly is diarrhea, while the common symptom of young people is intestinal bleeding. The difference in clinical manifestations so far The reason is not clear, but it suggests that in elderly patients with long-term repeated diarrhea without blood in the stool, attention should be paid to ulcerative colon The existence of the disease can improve the understanding of the disease, which can avoid misdiagnosis and mistreatment. In addition, the elderly have lower disease recurrence and parenteral complications than young people, and systemic complications such as nodular erythema, arthritis, and uveitis. Pyoderma gangrenosum and stick-like fingers are very rare.

7. The clinical characteristics of ulcerative colitis in children include mucus and bloody stools, and lower abdominal cramps during defecation. According to the number of stools, abdominal cramps, fever, hemoglobin and albumin levels, the clinical points are mild, medium and severe, and mild onset is slow. No obvious diarrhea, usually 3 to 5 times a day, mixed with mucus and bloody stool. When it develops to medium and heavy, it can be increased to 10 to 30 times a day. Obvious bloody stool or mucus and bloody stool accompanied by slackness, Mir- Madjltssi reports that the incidence of pancolitis is higher in children, sometimes the lesions may spread to the distal end, and the risk of colectomy is greater than in adults. This type is more common in infants and young children, and abdominal pain is common in the left lower abdomen or lower abdomen. Most severe children have abdominal muscle tension and obvious abdominal distension. Sometimes the abdomen can also have diaphragmatic spasm or thickened sigmoid or descending colon. Gry-bosky recently reported that a group of 38 cases of ulcerative colitis less than 10 years old Children, although 71% of them have pancreatitis (diagnosed by endoscopy or X-ray), most of them are mild (53%) or medium (37%), with an average follow-up of 6 to 7 years, during which Only Two patients underwent a colectomy. With the improvement of medical methods, the support of intravenous nutrition, and the use of broad-spectrum antibiotics and immunosuppressants, people have gradually used colonoscopy to monitor their recurrence instead of prophylactic colectomy, which has led to colon resection Fewer children are undergoing surgery.

Systemic and parenteral manifestations: Children with inflammatory bowel disease often cause growth retardation and delayed sexual maturity. Children with prepubertal ulcerative colitis can have growth delays of 60% to 80%. Wrist radiographs show bone maturity Delay, joint pain, and arthritis are another important manifestation of children. Large joints such as knees, ankles, hips, etc. can be involved, and joint deformities rarely occur.

Examination, most children may not only have obvious discomfort and tenderness in the lesion, but may even touch the mass. Digital rectal examination may have anal sphincter spasm and rough rectal mucosa. In children with inflammatory bowel disease, weight loss One of the most important signs, 68% of ulcerative colitis reported an average decrease of 4.1 kg.

Delayed growth and sexual development is another clinical feature of pediatric inflammatory bowel disease. Many studies have shown that 6% to 8% of children with ulcerative colitis have delayed growth and sexual development. Iron deficiency anemia is common, and oral Aphtoid ulcers are also common. Inflammatory bowel diseases are common skin and mucosal lesions. The lesions are often multiple. The disease is aggravated during the active phase of the disease and recurrent. About 6% of children can develop renal calcification. In addition, renal complications include hydroureter, hydronephrosis, Or Crohn's disease pyelonephritis, which may be caused by inflammatory masses pressing the ureter or intestinal-bladder fistula. Rare renal insufficiency can be secondary to amyloidosis.

It has been reported in foreign countries that about 4% of children have liver and bile duct system lesions, and sclerosing cholangitis can occur. Except for children with ulcerative colitis, almost all of them have liver complications before obvious colon symptoms appear.

8. The impact of ulcerative colitis on conception. It was thought that the fertility rate of female patients with ulcerative colitis declined, but in recent years, most scholars believe that compared with normal people, the fertility rate of patients with ulcerative colitis has no effect, and Crohn The pregnancy rate of affected patients is affected, which may be related to many factors, such as conscious control of fertility when Crohn's disease affects the ovaries and fallopian tubes; fertility control under the advice of a doctor; abdominal pain leading to fear of sexual intercourse; decreased sexual desire, Accompanied by fever, diarrhea, and malnutrition can cause its fertility to decline, but drug treatment can make Crohn's disease active and return to normal fertility.

(1) The interaction between ulcerative colitis and pregnancy. There is a certain influence between pregnancy and ulcerative colitis. Relevant data show that about 1/3 of patients with inactive ulcerative colitis, or 2/3 of active patients In patients with ulcerative colitis, colitis can be aggravated during pregnancy or early after delivery. The exacerbation of colitis in patients with active ulcerative colitis mostly occurs in the first 1-3 months after pregnancy. About 10% of pregnant women Termination of pregnancy due to secondary and spontaneous abortion.

(2) Pregnancy occurs during the remission phase of ulcerative colitis. 25% to 52% of cases have more recurrence within the first 3 months of pregnancy, less recurrence in the postpartum period, higher spontaneous abortion, and severely prolonged disease. Common after induction of labor.

Pregnancy occurs during the active phase of ulcerative colitis, which exacerbates the symptoms of colon inflammation (30% to 100%), especially in the first three months of pregnancy, but a few cases can be improved.

Acute ulcerative colitis occurs during pregnancy. The first symptoms usually occur within the first 3 months of pregnancy. The condition during childbirth and its postpartum period is usually moderate or severe, with a mortality rate of 40% to 80%.

The impact of pregnancy on ulcerative colitis has not been systematically studied in China. It is generally believed that the extent of the disease, mobility and medical treatment will not affect the fertility of the patient. The vast majority of women will give birth to the fetus normally, but there are also data indicating that The premature and miscarriage rates of this disease are slightly higher than those of the normal population. Foreign studies suggest that patients with active disease can have aggravated pregnancy and puerperium. Therefore, the active disease should be delayed as much as possible, and it is best to stop during the remission period. Medications are used, or drugs are reduced to a minimum, and colitis is controlled for at least one year before becoming pregnant. Accordingly, strict contraception during active disease is recommended. However, pregnant women with inactive ulcerative colitis generally do not terminate their pregnancy.

1. Diagnosis The main diagnosis of this disease is chronic diarrhea, bloody stools, pus and mucus. There may be systemic symptoms or other systemic symptoms of different degrees, but no pathogens are found after multiple cultures, and combined with X-ray examination, sigmoid colon. Microscopy or fiber colonoscopy can make a diagnosis. For patients who have been identified as chronic ulcerative colitis, if they have arthritis and X-ray characteristics, they can be diagnosed as ulcerative colitis.

2. The diagnosis of senile ulcerative colitis is sometimes difficult, firstly because the disease is often not easily recognized by clinicians, secondly, it is easily confused with other senile intestinal diseases, and the elderly often suffer from a variety of diseases. The timely diagnosis of this disease is often delayed. For elderly patients with repeated diarrhea without blood in the stool, attention should also be paid to the existence of ulcerative colitis to avoid misdiagnosis and mistreatment, such as intestinal diverticulosis, colon cancer, and antibiotic-associated colitis. Aged granulomatous proctitis should be distinguished from this disease.

Treatment of ulcerative colitis arthritis

1. Common drugs and treatment methods for ulcerative colitis

(1) Commonly used drugs:

Sulfasalazine: Sulfasalazine has been used for many years to treat ulcerative colitis. Oral administration of 4 to 6 g / d, 64% to 77% of patients have good curative effect. After symptom relief, it is maintained at 2 g / d for at least 1 year, 89%. Patients can remain asymptomatic, and the efficacy is increased when the amount of sulfasalazine is large, but the side effects are also increased. After the sulfasalazine enters the colon, it is broken down by the intestinal bacteria azo reductase to mesalazine (5-aminosalicylic acid). And sulfapyridine, the former is an effective treatment part, and the latter is the main factor causing side effects. If only mesalazine is taken up by the upper digestive tract, and there is not enough medicine to reach the colon, it is difficult to have a curative effect. Mesalazine has been developed in recent years. New oral dosage forms such as Pentase, Ascol, Olsalazine, Poly-Mesalazine, Balsalazide, etc. Due to the absence of sulfadiazine, side effects are reduced. In recent years, many scholars have noted that topical administration can reduce side effects. For example, if sulfasalazine or mesalazine anal suppositories or enemas are used, the local drug concentration is increased and maintained for a longer time to improve the efficacy. There have been reports of local and systemic treatments that have a synergistic effect and can reduce sulfasalazine Dosage, its treatment mechanism and inhibition of the production of leukotrienes, prostaglandins, etc., can also inhibit the reaction of oxygen free radicals, etc., but there are rashes, granulocytopenia, liver and kidney damage and pancreatitis, etc., the incidence and dosage are positive Related.

4-Aminosalicylic acid (4-ASA): also known as PAS, is a primary anti-tuberculosis drug. It is dissolved in 100ml of water with 2g, and the enema is retained once a day. The effective rate for treatment for 8 weeks is 83%. Ginsberg et al. Reported 4-ASA Oral administration of 4 g was given daily, and after 12 weeks of treatment, 55% of patients had good results. The mechanism of 4-ASA for ulcerative colitis is unknown.

Adrenocortical hormone: can reduce capillary permeability, stabilize cells and lysosomal membranes, regulate immune function, reduce macrophages and neutrophils from entering the inflammation zone, and block leukotrienes, prostaglandins, thromboxane It can reduce the inflammatory response, and rapidly improve the clinical symptoms of ulcerative colitis. Generally, active ulcerative colitis takes prednisone (prednisone) 40 to 60 mg / d; if the condition is severe, the oral curative effect is not good, but intravenous Instillation of hydrocortisone succinate 200-300mg / d, or rectal infusion of 100mg of hydrocortisone succinate 100mg, is better than retention enema.

Long-term application of glucocorticoids is prone to side effects, so it should be gradually reduced after the symptoms have improved. After 2 to 3 months of discontinuation, the remission rate for ulcerative colitis is 55.7% to 88.2%. Long-term continuous application of glucocorticoid maintenance treatment It does not prevent recurrence. In recent years, some new corticosteroids such as budesonide (Tandocorbutolone) and cortisol (Tixocorto pivalate) have no systemic side effects. Enema is used to treat ulcerative colitis. Hormones, Fluticasone propionate (Fluticason propionate) is a fluorocorticosteroid with low systemic bioavailability after oral administration. It is not easily absorbed and most of it reaches the colon. It is administered orally at 5 mg each time 4 times a day for 4 weeks Its efficacy is slightly worse than prednisone due to the small dosage. If the dosage is increased, the efficacy is also improved, but there are few side effects. There are still glucocorticoid foams (Foam). Small doses of rectal injection and large doses of hydrocortisone are retained. Enemas have the same effect and are more convenient than enemas.

Immunosuppressive and immunomodulating agents: When glucocorticoid treatment is poor or cannot tolerate its side effects, azathioprine, cyclophosphamide, mercaptopurine, etc. can be used; methotrexate (methotrexate) has been used in recent years, Cyclosporin-A (Cyclosporin-A) 10mg / kg, sometimes good results, but these drugs have certain side effects, should be used with caution, there have been reports of penicillamine, levamisole, interferon, 7S- ball Protein, etc., have a certain effect.

Fish oil: It is a leukotriene synthesis inhibitor. Oral fish oil is an adjuvant treatment for mild, moderately active ulcerative colitis, and clinical improvement can be obtained. It has been reported that it can be treated with glucocorticoids and sulfasalazine simultaneously. , Supplemented with oral fish oil 5.4g / d, can improve the efficacy.

Metronidazole (Metridazole): It can inhibit intestinal anaerobic bacteria and reduce the symptoms of ulcerative colitis. In addition, metronidazole can affect the chemotaxis of leukocytes and certain immunosuppressive effects, and it has a certain effect on ulcerative colitis. Efficacy, but the large amount, longer time, prone to gastrointestinal reactions.

Saccharin: can stabilize the mast cell membrane, prevent degranulation, inhibit the release of histamine, serotonin, slow-reacting substances and other mediators, reduce the antigen-antibody response to the intestinal wall damage, 200mg / time, 3 times a day before meals; or 600mg retention enema, reported similar efficacy with prednisone 20mg.

Anti-infective drugs: For patients with concurrent infection, antibiotics should be targeted, but it should not be used as routine medicine, so as not to change the efficacy and response of sulfasalazine to patients.

Other drugs: A. Clonidine can inhibit the release of renin and some nerve mediators, orally at 0.15 0.225mg / time, 3 times / d, which is effective for ulcerative colitis, B. calcium channel blocker Such as verapamil (Isodamine), nifedipine (nifedipine), it has antidiarrheal, analgesic and secretion inhibition effects, cinnarizine 50mg, orally 4 times a day, also has good curative effect, C. West H2 receptor blockers such as mitidine (metimiguanide) and ranitidine, can reduce the inferior symptoms of ulcerative colitis by inhibiting the release of histamine from mast cells of the intestinal wall. D. chloroquine may slow the antigen response , Promote the normal function of intestinal epithelial cells, and can reduce the symptoms of ulcerative colitis. In addition, the free radical scavenger Oguin (superoxide dismutase), 5-lipoxygenase inhibitor Zileuton (A-64077), ketones Ketotifen can alleviate the symptoms of ulcerative colitis.

(2) Common treatment methods:

Traditional Chinese medicine treatment: Ulcerative colitis should belong to the categories of "diarrhea", "intestinal dysentery", and "resting dysentery" in Chinese medicine. The treatment is guided by the "overall concept" of combining traditional Chinese medicine with syndrome differentiation and western medicine. The treatment should be combined with supplementation, giving priority to eliminating evils, giving due attention to cultivating the soil, and strengthening the spleen and stomach, mainly for dampness and heat. Eliminating the evil should clear away heat and inflammation, and you can choose Coptis chinensis, Scutellaria baicalensis, Pulsatilla grandiflora, Portulaca oleracea, dandelion, and mischief. Coordinating the spleen and strengthening the dampness, Codonopsis, Astragalus, Poria, Yam, Lentils, Coix Seeds, Atractylodes, etc. can be added and subtracted according to the patient's specific symptoms. It has been reported that Shenling Baizhu Sanhe Lilian Decoction, Pulsatilla Hehuo The addition and subtraction of Puxialing Decoction or Tongxie Yaofang with Baitouweng Decoction have achieved good results in the treatment of ulcerative colitis.

Enema treatment with traditional Chinese medicine: A. The patients with hot and humid evidence are Huanggong 15g, Coptis chinensis 10g, Qinpi 10g, Baipiweng 30g, Baiji 15g, Baiji 15g, Pomegranate Peel 15g, B. Spleen deficiency dampness syndrome is 30g Astragalus, Coptis 10g, Scutellaria baicalensis 10g, purslane 30g, scutellariae 50g, gallbladder 5g, the first two are decocted 50 100ml, wait for cold, keep enema once every night before going to bed, half a month as a course of treatment, can also be used Xi class powder, berberine, Sophora flavescens, Yunnan Baiyao, those who retain enema.

It is also useful in the treatment of ulcerative colitis with traditional Chinese medicines such as Jiu Ning, Bu Pi Yi Chang Wan, Colitis Pill, etc. in combination with western medicine, and has achieved good results.

Nutritional treatment of ulcerative colitis: The incidence of dystrophy of ulcerative colitis is very high, so nutritional disorders should be comprehensively corrected in treatment. Nutritional treatment is based on pathology and basic psychological and physiological characteristics of patients. Nutrition to strengthen the body's resistance, promote tissue repair, nutritional therapy as a support and adjuvant treatment of ulcerative colitis, in recent years has gradually attracted people's attention, for patients with severe illness, can not eat during the active period or can not provide nutrition by diet Nutritional therapy has the advantages of symptom relief, improvement of body condition, enhancement of anabolic metabolism, improvement of immune function, etc. It is one of the means of treatment and has the same importance as medicine and surgery.

Nutritional therapy includes enteral and parenteral nutrition, and parenteral nutrition often uses synthetic amino acids, sugars, minerals, and vitamins for oral or nasal feeding. Parenteral nutrition is mainly used for patients who cannot eat, and can also be used during active periods. Or severe patients, or patients with complications and surgery.

A. Nutrition evaluation: Before nutrition treatment for patients with ulcerative colitis, nutrition evaluation is very important. It can comprehensively measure the nutritional status of the patient, take reasonable nutrition measures, and through the evaluation of nutritional status, we can understand the patient's disease status. An overview of food intake and nutrition utilization, so that the goals of nutrition therapy can be formulated. The goal of nutrition therapy is to provide and supplement and meet the nutritional needs of patients based on the treatment of basic gastrointestinal diseases such as inflammation or obstruction. The content can be carried out using a simpler subjective comprehensive assessment method (Table 2).

The patient's medical history and physical examination can indicate the need for nutritional support. Once malnutrition is diagnosed, a more accurate measurement of nutritional status is needed. The medical history can provide the speed and extent of weight loss and the quantity and quality of nutrition intake. Recent weight loss> 10% (during a 3-month period) is a sign of severe protein caloric malnutrition. In western countries, obesity is more common, and the percentage of weight loss may be more reliable than comparison with the ideal weight standard. Provide information on dietary characteristics, as well as changes in taste, chewing, swallowing, food allergies, drug and alcohol intake, and anorexia. Physical examination may reveal dry skin, scales and atrophy, muscle wasting, pitting edema, loss of muscle strength, and other factors. An experienced clinician getting a complete medical history and physical examination is perhaps the easiest and best way to assess nutrition.

B. Nutrition needs and implementation:

a. Nutritional requirements: The daily nutritional requirements of patients are generally calculated according to the condition and the age and weight of the patient, and vary depending on the condition. The supply of nutrition includes calories, amino acids, electrolytes and trace elements.

b. Heating energy substances: The heating energy substances are mainly glucose and fat. The caloric requirement should be based on maintaining the ideal body weight (IBW) and nitrogen balance. Generally, IBW can be maintained by giving 125.4 to 146.3 kJ / kg daily. 167kJ / kg can make a slight increase in body weight. When there are other high metabolic states, more calories are required. In order to provide sufficient calories, a high concentration (20% to 40%) glucose solution is often used, and 5% to 10 % Of glucose will make the liquid supply more than necessary. Hypertonic glucose will have high osmotic pressure, and in order to avoid local vascular irritation, it should be entered from the central vein. Insulin should be supplemented with sugar to avoid hyperglycemia and insulin consumption. Generally, 1U is given for every 4 to 20g of glucose (it can be started from about 10: 1, and then adjusted according to the blood sugar level). The human body's ability to use sugar is 0.5g / kg per hour. Under stress, the utilization rate of sugar decreases. Fat contains high calories (37.7kJ). Commonly used fat emulsions, in addition to providing heat, also provide essential amino acids that the body cannot synthesize. Fatty oxidation requires no amino acids to participate. Fat emulsions are isotonic fluids and can be passed through peripheral veins. Enter, It will not be excreted from urine and feces after being imported. Recently, medium-chain triacylglycerol-containing fat agents have been supplied. Medium-chain triacylglycerols are hydrolyzed into glycerol and medium-chain fatty acids in the human body. Fat particles of fat emulsions are generally similar in size to chylomicrons and have good stability. The usual dosage for adults is 1 to 2 g / kg per day. If used to prevent essential amino acid deficiency, it can be used 1 to 2 times a week. The body is under stress. Increased fat utilization.

c. Nitrogen supply materials: Nitrogen supply materials are mainly various compound amino acid solutions. The infused amino acid solution should meet the needs of amino acid and positive nitrogen balance. The daily supply of 1.0 to 1.5g / kg of protein can maintain the positive nitrogen balance of IBD patients. At present, the commonly used amino acid solution is configured according to the ratio of essential amino acids in the human body. The ratio of various compound amino acid solutions except all essential amino acids is preferably 1: 1 to 1: 3, and some amino acid solutions with adjusted formula are applicable. In liver failure, kidney failure and trauma cases.

d. Water and electrolyte: It is advisable to replenish 30ml / kg of fluid (approximately 100ml of water per 418kJ calories, ie 1ml / 4.81kJ per day). The amount of water for adults is based on 2000ml per day, and the volume of urine is 1000ml per day. Basically, there is no uniform electrolyte solution that can be used for all patients. The general supply is: potassium 30 40mmol / d, sodium 150mmol / d, phosphorus 20mmol / d, magnesium 10mmol / d. In principle, its supply can be adjusted in time according to the condition and serum biochemical test results. Potassium and sodium are the main electrolytes, but most patients with gastrointestinal diseases also need a certain amount of phosphorus and magnesium. Magnesium is a synergistic element necessary for the intermediate metabolism of many enzymes. When the magnesium deficiency is severe, the human body cannot mobilize calcium and stored potassium. The amount of magnesium required depends on the amount lost in the gastrointestinal tract and urine. Almost all patients have significantly decreased serum phosphorus after applying crystalline amino acid solution as a nutrient solution. Appropriate amount of phosphorus.

e. Trace elements: It is now clear that the essential trace elements of the human body are: iron, zinc, copper, manganese, chromium, molybdenum, fluorine, selenium, iodine, cobalt. In long-term therapy, the most common trace element deficiency is iron and zinc. , Copper, selenium and chromium, the lack of reasons is nothing more than reduced intake, absorption disorders, increased loss, reduced utilization, and excessive demand for high metabolic states.

f. Treatment implementation: determine the daily calories of the nutrition formula. The basic nitrogen requirement is: 104.6kJ / kg of calories, 0.15g / kg of nitrogen, 167.4-209.2kJ of calories under moderate stress, and the nitrogen amount> 0.4. g / kg, the ratio of calories to nitrogen is usually 627.6 753.1. If you use fat emulsion for heating, fat heating should be 1/3 of non-protein calories. Generally, the total calories and total nitrogen that are replenished on the day are determined according to the condition. Then calculate the specific dosages of various infusion nutritional components according to the planned fluid replacement volume and the specifications of the various nutritional preparations available.

C. Nutritional disorders of ulcerative colitis and its consequences Reasons for nutritional disorders: patients with ulcerative colitis have reduced eating due to abdominal pain, diarrhea, or reduced nutrient intake due to restricted diet, or have indigestion and malabsorption even when eating, and due to inflammation Ulcers, diarrhea, and other proteins, vitamins, water, electrolytes, and trace elements are lost, resulting in varying degrees of nutritional disorders. Patients with ulcerative colitis can experience multiple aspects of nutritional disorders, such as weight loss, hypoproteinemia, and anemia. Stunted growth, delayed maturity, lack of vitamins and trace elements, etc. Driscoll et al. Reported the incidence of nutritional disorders in ulcerative colitis.

At the same time, fever, increased nutritional requirements during infection, and the effects of some therapeutic drugs on nutrient absorption and utilization are also important reasons for nutritional disorders in ulcerative colitis. The specific reasons are as follows:

Reduced intake: patients with ulcerative colitis are sometimes accompanied by hypergastric-colonic reflexes, abdominal pain after eating, diarrhea, and relief of abdominal pain symptoms after defecation. To avoid this situation, reduce eating; or restrict diet due to good faith Decreased intake. Although many patients have rich nutrients in their diets, their nutritional requirements may not be sufficient. In recent years, literature has shown that anorexia can also be secondary to tumor necrosis caused by cachexia or intestinal inflammation. Factors, as well as gastrointestinal dysfunction and mechanical intestinal obstruction have contributed to anorexia, nausea, vomiting, abdominal pain and diarrhea. It can also lead to reduced intake of patients. In patients with severe clinical symptoms, fever and inflammation can cause patients with taste. Change or obvious anorexia, in the course of treatment of the disease, some drugs have adverse reactions to the gastrointestinal tract and thus reduce nutrient intake.

Malabsorption: Incomplete digestion of food due to reduction of digestive enzymes, or involvement of the ileum by lesions, such as back-filled ileitis, or biliary obstruction with biliary obstruction diseases such as sclerosing cholangitis, and short bowel syndrome, effective absorption Malabsorption caused by area reduction, etc. Malabsorption can be roughly divided into the following categories:

a. Pathological loss: such as severe inflammation, diarrhea, mucosal hemorrhage, excessive secretion, etc. causing loss of protein, water and electrolytes, vitamins and trace elements. 51Cr albumin and -antitrypsin clearance test confirmed the existence of the patient Protein-losing bowel disease, interruption of the enterohepatic circulation, active blood in the stool, vomiting, diarrhea or fistula discharge can cause gastrointestinal fluid and electrolyte loss. These factors also cause protein, blood, bile salts and trace elements from the gastrointestinal tract. The loss of the tract results in a deficiency of potassium, magnesium, and zinc. At this time, even if a sufficient amount of protein is ingested, the rate of protein loss from the gastrointestinal tract exceeds the ability of the liver to synthesize protein, and eventually low protein and malnutrition may still occur.

b. Need to increase: As fever, infection, and mucosal cell renewal accelerate, the need for nutrition increases.

Patients due to inflammation, fever, infection, stress, abscesses and fistula formation, increased basal metabolic rate, increased nutritional requirements, and the use of steroid corticosteroids accelerates protein catabolism, which promotes negative nitrogen balance in the human body. It has formed, but there are reports in the literature that among the causes of malnutrition, the increase in demand does not play a major role. The increase in demand is not due to chronic inflammation but to malnutrition.

c. The effects of therapeutic drugs on nutrient absorption and utilization: such as sulfasalazine reduces folic acid absorption, corticosteroids reduce calcium absorption and affect protein metabolism, cholestyramine (cholestyramine) reduces absorption of fats and fat-soluble vitamins , Antibiotics can cause vitamin K deficiency. When nutritional therapy is used and supplements are ignored, it is very easy to cause the lack of trace elements in the body.

d. Consequences of malnutrition: The occurrence of malnutrition can not only delay the recovery and healing of intestinal lesions, and further develop the disease; it may also delay the growth and development of young children or adolescent patients, and make metabolic effects related to vitamin D malabsorption. Osteopathy; or amenorrhea and fertility disorders in female patients; low immunity due to malnutrition, increased chances of infection, reduced tolerance, increased complications and mortality from surgery; various nutrition, In particular, the lack of protein makes the intestinal inflammation wounds and fistulas unsustainable; the patient's resistance decreases and the tolerance to blood loss decreases; folic acid malabsorption may be related to atypical hyperplasia of the colonic mucosa, which increases the risk of colon and rectal cancer .

D. Total parenteral nutrition (TPN):

a. Overview: TPN refers to the process of intravenously injecting all kinds of nutrients required by a patient completely without the gastrointestinal tract. Amino acids, glucose, various inorganic salts, trace elements and vitamins are input from the vein, and fatty milk, TPN is given. It is used in patients with ulcerative colitis, mainly by improving nutrition, intestinal rest, and promoting the disease into remission. It has a good effect on rapidly alleviating diarrhea of severe ulcerative colitis, improving the general condition and restoring the body's positive nitrogen balance. In patients with ulcerative colitis who are hospitalized due to aggravated conditions, protein energy malnutrition can reach up to 50%, often including multiple nutrients such as vitamins, minerals, and trace elements. At this time, simply supplement fluid and electrolytes. Treatment is far from meeting the nutritional needs of the body. Certain forms of nutritional supportive therapies must be given, including total intestinal rest therapy and complete parenteral nutritional therapy. Intensive nutritional supportive therapy is not just to ensure nutritional supply, it is more important. What's more, its therapeutic effect on ulcerative colitis, avoiding oral ingestion can reduce diarrhea and relieve abdominal pain; Intestinal and pancreatic secretion decreased, and significantly reduced the number of intestinal bacteria; reduce or eliminate damage and irritation effect of food on inflammatory factors mucosa, promote healing and regeneration of mucosal injury.

b. The main purpose of applying TPN: to control acute inflammation and relieve symptoms; to treat complications such as intestinal obstruction and intestinal fistula; to improve nutritional status and promote the development and normal growth of patients; as a perioperative treatment to reduce Surgical mortality and postoperative complications improve the success rate of surgery; maintain nutrition for patients with extensive lesions or short bowels.

c. The main indications of TPN: those who cannot take food orally, such as those with intestinal obstruction, intestinal fistula, acute attack of the disease, who need to rest completely after the operation of the gastrointestinal tract; Gut enteral nutrition and parenteral nutrition, as well as patients with surgical treatment combined with malnutrition, who need a lot of nutrition before and after surgery, including patients with severe or worsening ulcerative colitis, or those who are ineffective for medical treatment and need surgical treatment, before surgery Must first correct nutrition and metabolic disorders.

d. Note: Because the nutrient solution infused by TPN therapy is hypertonic, the average daily solute input can be as high as 25% to 80%. Therefore, it must be infused at a uniform rate within 24 hours to avoid exceeding the patient's water. The maximum metabolic capacity of sugars, amino acids, vitamins and minerals, to ensure that patients can most effectively assimilate these nutrients. Due to the hypertonicity of the solution (1800 2400mmol / L), it should be passed through large blood vessels (such as the superior vena cava). ) Infusion, the intravenous nutrient solution is gradually increased to a tolerable level after infusion (such as 2000-2500ml / d), which is equivalent to the above-mentioned 30ml / kg body weight of liquid requirements, and about 100ml of water can be consumed for each 418kJ calories supplement (1ml / kcal) standard supplementary liquid volume. In general, the ratio of non-protein calories (ie, calories from sugars or fats) to nitrogen (g) is recommended to be 150: 1 to meet the best nitrogen utilization. And obtain the positive nitrogen balance. For example, in the adult central intravenous infusion of TPN solution, the following three solutions can be prepared, dripped separately, and finally mixed into the body through a Y-shaped tube: amino acid solution plus inorganic salts and trace elements; emulsified fat plus fat-soluble vitamins, Every 1000m l 200ml 20% fat emulsion can be input in the TPN solution at the same time; the hypertonic glucose solution is added with water-soluble vitamins, and the ratio of non-protein thermal energy to nitrogen in the mixed solution should be in the range of 627 836kJ (150 200kcal): 1g nitrogen. At least 2000ml per day. For long-term use of TPN, the amount of trace elements and vitamins must be sufficient to prevent its deficiency. Those who cannot enter emulsified fat every day should enter it once a week to prevent the lack of essential fatty acids. Some nutrient solutions have been prepared. Qi inorganic salts and vitamins, but some are incomplete or insufficient, pay attention to supplement.

E. Partial parenteral nutrition: In contrast to TPN therapy, a partial nutritional support therapy by infusion of the above solution via a intravenous route (either peripheral or central vein) is called partial transgastric Parenteral nutrition therapy, the so-called PPN therapy, or maintenance parenteral nutrition (MPN), PPN for many patients with gastrointestinal diseases, especially only for a short period (<2 weeks) Therapists are particularly suitable and can obtain better results. Therefore, PPN may have a wider indication for a variety of medical diseases, including digestive diseases.

a. Central venous TPN therapy: refers to the infusion of hypertonic glucose, amino acids, fatty milk, and other nutrients through a central vein (usually the subclavian vein) infusion. The concentration of infused sugar is 10% to 25%. , Even up to 50%.

b. Peripheral intravenous amino acid solution infusion therapy, also known as protein-saving nutrition therapy, refers to mixing isotonic amino acid concentration (3% or 5%) with other sugar-free liquids, vitamins, minerals and trace elements. Peripheral intravenous infusion treatment method, this treatment method can generally provide 1674-2510kJ / d and some micronutrients, although this therapy can allow some patients to retain lean body mass (or fat-free meat) ), But it does not meet its energy needs. This therapy generally does not meet the needs of patients with gastrointestinal diseases. With the development of isotonic fat emulsions, high-nutrition solutions can be infused through peripheral veins. TPN therapy is a treatment of intravenous infusion after mixing amino acid solution with 5% -7.55% glucose, electrolytes and vitamins with fat milk. This treatment can provide 5858-8368kJ / d of calories. The main source of calories is fat. Although this treatment cannot maintain a positive balance of calories and protein for a long time, it can provide some supportive treatment for patients with mild nutritional deficiencies. As mentioned earlier, this therapy It is suitable for short-term (1 to 2 weeks) treatment. It avoids the risk of certain complications caused by central venous intubation, but patients must have good peripheral veins and be able to tolerate a certain volume of fluid that must be infused. A solution with a concentration of 600 to 700 mmol / L, a solution with a concentration higher than this osmotic pressure, can stimulate and damage the surrounding veins, causing sclerosis and phlebitis.

The TPN solution may be between 1200 and 12200 mmol / L. In order to achieve the best ratio of non-protein calories to grams of nitrogen and the osmotic pressure of the infusion solution below 700 mmol / L, a glucose solution must be used at the same time. With fat emulsion, 10% fat emulsion (280mmol / L; 20% intralipid is 350mmol / L) can dilute hypertonic glucose solution, and may form a protective film in the vein. After the solution is prepared by using the traditional "Y" tube connection , Its osmotic pressure is close to the tolerance range of peripheral veins, and peripheral vein infusion should be provided at the same time, vitamins, minerals and trace elements should be provided at the same time. Currently, commercially available trace element injections (Andami), Vitalipid Vitalipida and Soluvit are commercial preparations for intravenous infusion during parenteral nutrition therapy, containing various trace elements, fat-soluble (4 types) and water-soluble (9 types) vitamins, respectively. Each one is added to a certain amount of solution every day, which can meet the daily needs of normal adults. In addition, when intravenous nutrition, hypophosphatemia is often prone to occur.

F. Transition from parenteral nutrition to enteral nutrition (EN): The effect of TPN on ulcerative colitis is uncertain, there are many complications, strict management requirements, and higher costs, while EN has fewer complications and management It is highly safe, its nutritional elements meet physiological requirements, and the drug is cheap, which is convenient for widespread use in ordinary wards and families. Therefore, TPN is only used as a backing when EN is truly contraindicated, or when the nutritional needs of patients cannot be met by EN alone. The recovery of digestive tract function should be transitioned to EN as soon as possible. Recent studies have found that after long-term application of parenteral nutrition support, the intestinal mucosa has atrophy, intestinal morphology and function are abnormal, which may be accompanied by biliary dysfunction, and may also damage And the immune system, simply inputting high concentrations of large amounts of amino acids is harmful to the liver. Therefore, enteral nutrition is valued.

Enteral nutrition (EN) therapy refers to a supportive treatment method of supplementing nutrients by oral feeding or tube feeding. Although EN therapy may not be as effective as TPN therapy in promoting gastrointestinal rest, it is effective for ulcerative colitis. For patients, they can still obtain the same satisfactory results as TPN therapy, and have the advantages of more physiological requirements, more safety and lower cost. The biggest feature of EN therapy is to maintain the normal continuity of gastrointestinal function, which can prevent Intestinal mucosal atrophy that may occur with intravenous nutrition therapy is beneficial to maintaining and improving the barrier and immune function of the intestinal mucosa, maintaining the normal distribution and balance of the intestinal flora, maintaining the balance of various intestinal and important hormones in the body, thereby promoting The recovery of intestinal lesions and functions, as well as the nutritional status of the whole body, with the various nutritional preparations used in EN therapy, and the improvement and commercialization of tube feeding catheters, the application of EN therapy has become increasingly widespread. At present, it is commercially available for clinical use. Enteral nutrition preparations (enteral nutrition meals), there are polymer diets (such as anoxin, vegan, and full energy, etc.), suitable for most gastrointestinal tract Patients who can be normal or close to normal), pre-digestion meals or elemental meals, etc. In clinical application, it should be based on the patient's age, nutrient requirements, different disease states and gastrointestinal functions, and the physical Chemical properties (such as osmotic pressure) are appropriately selected and applied. When polyvinyl chloride (PVC) catheters are used, they can be left in the body for about 10 days, while polyvinyl chloride (PUR) catheters can be left longer (up to 6 months). ), Long-term TPN, the gastrointestinal function declines, so the transition from TPN to enteral nutrition must be carried out gradually, otherwise, it will inevitably increase the burden on the intestinal tract and is not conducive to recovery, its progress can be roughly divided into four stages: a. Parenteral Combination of nutrition with tube feeding; b. Tube feeding alone; c. Tube feeding combined with oral feeding; d. Normal diet.

G. Complete gastrointestinal nutrition:

a. Concept: Complete gastrointestinal nutrition (TEN) refers to the complete fasting of natural foods, input of digested nutrient solution, so that it is completely absorbed in the proximal small intestine, and the distal small intestine is rested, thereby gradually reducing symptoms. A nutritional treatment method. In recent years, people have paid more attention to the research and application of enteral nutrition close to the physiological state. This nutrition fully exerts the body's ability to digest, absorb, transport and transform nutrients, and processes it to ensure the body. The stable environment can improve the body's immune function, overcome the intestinal flora shift, and avoid cholestasis of the hepatobiliary system. At present, enteral nutrition support has been widely used internationally, especially in economically developed countries, it is more widely used.

b. Indications: In cases with mild lesions, or when the condition is severe, TPN is used to alleviate the condition, and the small intestine function should be transitioned to TEN to continue to supply nutrition after proper recovery; oral food intake is not sufficient to meet needs, such as the gastrointestinal tract When the function allows and can tolerate, enteral nutrition should be considered first.

c. Contraindications: multiple intestinal perforations, high-output intestinal fistula (especially those with high positions), mechanical intestinal obstruction; after extensive resection of the small intestine, TPN should be used for 4 to 6 weeks, and gradually increased enteral nutrition will be used in the future.

d.TEN diet preparation and usage: At present, there are a variety of commercial meals at home and abroad, including non-element meals and element meals. The so-called element meals are also called chemically prepared meals, which are powders that put various nutrients together according to a certain formula. After adding water, it can form a suspension, or it can be made into a suspension to avoid contamination during preparation. There are also powders and fat emulsions, which have little residual content and can be absorbed in the upper small intestine without digestion or slight hydrolysis. The elemental diet contains ammonia as a source of nitrogen, which can cause diarrhea. Before using it, you should understand the composition and preparation method of any diet. The nutritional elements of the compound can be weighed according to the required concentration. Warm water (60 70 ) ) To a certain volume, stir well.

Meals can be taken orally or tube-fed, such as nasal tubes, oral gastrointestinal tubes, nasal duodenal tubes, nasal jejunal tubes, and most commonly used silicone tubes with an outer diameter of 1 to 2 mm, which can be administered at one time or intermittently, or continuously. It is clinically considered that the continuous instillation of the dietary concentration should be isotonic (10%) at the beginning, and the rate should be slow (40-60ml / h), and then increase by 25ml / h every day until the amount of liquid can meet the needs, and then increase daily Concentration 5% until it can be tolerated and can meet nutritional requirements. In general treatment, dietary elimination of milk, dairy products or other lactose-containing foods may help alleviate symptoms of patients with lactose intolerance. Patients, their symptoms can be significantly improved when their fat intake is reduced to less than 60-70g / d. For patients with abdominal cramps and diarrhea, reducing the intake of fiber-containing food may also relieve the symptoms. Occasionally, diarrhea and abdominal pain may occur or worsen when the oral formula diet is started. If an isotonic formula diet is adopted at the beginning, the permeability of the formula diet will be gradually gradually increased in the future. speed Infusion, these adverse reactions may be avoided. The principle of oral rehydration is to take advantage of the existence of a sodium-glucose cotransporter in the small intestinal epithelial bristles to stimulate the absorption of sodium and water, because glucose can promote sodium absorption (through active transport). It also promotes the absorption of water. In the case of diarrheal diseases, this transport mechanism is still retained, thus providing the basis for oral sodium and water replacement therapy.

e. Complications and prevention: Complications of tube feeding include three aspects: mechanical aspects: such as pneumothorax, pneumonia, lung abscess caused by feeding tube mistakenly entering the respiratory tract, and damage to nose, throat, and esophageal mucosa, so attention should be paid to the operation. Gastrointestinal aspects: such as nausea, vomiting, diarrhea, etc., need to adjust the drip rate or concentration, and work accordingly; Metabolic aspects: such as hyperglycemia, hypoglycemia, hyperkalemia, hypokalemia, etc., metabolism and nutrition should be closely monitored In terms of changes, in general, TEN has fewer complications, high management safety, nutritional elements that meet physiological requirements, and low cost, which is convenient for widespread use in wards and families. There are contraindications to the use of TEN, or the nutritional needs of patients cannot be left alone. When EN is satisfied, TPN can be used. Once the patient's digestive tract function is restored, TPN quickly transitions to TEN.

H. Dietary treatment principles: The principles of dietary treatment for ulcerative colitis mainly include the following points:

a. Meal can be given to elements without protein during acute attacks to avoid allergic reactions. In severe cases, fasting should be used and total parenteral nutrition should be used.

b. The condition after remission is mostly chronic. Dietary treatment is very important. A sufficient amount of heat energy, high-quality protein, inorganic salts and vitamins should be provided, and irritating foods should be avoided. The diet should be self-liquid, semi-liquid and gradually transition to soft rice and ordinary rice.

c. Patients are mostly deficient in folic acid, vitamins A, B6, B12, D, K, calcium, iron, protein and other nutrients. If they do not cause allergic reactions, they need to be given gradually based on blood biochemical tests and specific conditions.

d. Patients should pay attention to which foods or foods they eat can aggravate the condition, so as to avoid such foods to reduce symptoms, and to check for allergies caused by foods through allergy tests to avoid as much as possible.

Maintenance therapy for ulcerative colitis

A. Duration of maintenance treatment: The duration of maintenance treatment is inconclusive. Studies in early Dissanayake and Truelove (1973) have suggested that mesalazine maintenance therapy in patients with ulcerative colitis should continue indefinitely, but recently Ardizzone et al. A randomized study conducted by Ren (1996) found that patients who sustained mesalazine maintenance therapy for more than 2 years had no greater risk of relapse than those who continued mesalazine treatment if they continued to receive placebo. 1997 Canadian International Gastroenterology Academic Conference discussed the pathogenesis, diagnosis and treatment of inflammatory bowel disease through the regression analysis of 19 active-stage and 16 remission-stage treatment studies, and reached some consensus. In principle, active-stage treatment should not be less. At 4 weeks, the remission period was treated for at least 6 months. Some foreign scholars applied mesalazine 1g enema to treat left ulcerative colitis. After 1 year of follow-up, 3 of 12 patients in the treatment group relapsed and 11 of 13 in the placebo group. Recurrence. According to our experience, the duration of maintenance treatment should generally not be less than 1 year. As for patients with severe illness or recurrent attacks, it is recommended to use it for a long time. Maintenance, but due to poor patient compliance, unaffordable economic conditions, insufficient understanding of physicians, and many drug side effects, maintenance treatment is not well implemented in China, especially long-term (> 1 year) maintenance treatment has not caused Attention, which leads to repeated illness, and the duration of maintenance treatment in domestic patients is generally too short, which is the main cause of relapse.

B. Case selection for maintenance treatment:

a. Patients with first-onset hair: After achieving clinical complete remission after treatment, the drug can be discontinued for observation and maintenance treatment will not be maintained temporarily. If recurrence occurs, maintenance treatment is required.

b. Chronic recurrent patients: This type of lesion emphasizes the importance of maintenance treatment. After the acute attack is controlled, maintenance treatment must be performed. According to our statistics, ulcerative colitis in China is mainly of chronic recurrent type. (Accounting for 52.6%), 92.7% of the lesions are in the left half of the colon (70.2% of rectal sigmoiditis or proctitis, and 22.5% of left colonitis), and most patients (75.5%) have a disease course of less than 5 years. Treatment is expected to reduce recurrence.

c. Postoperative patients: Severe foreign patients undergo multiple colectomy after corticosteroids and cyclosporine treatment is ineffective, and a short course of maintenance treatment is continued after operation. At present, some domestic surgical operations for severe ulcerative colitis More conservative, only left or right hemicolectomy, these patients must be given maintenance treatment, if recurrence, according to the severity of the disease treatment method of treatment, ineffective those who need surgery again.

C. Drug choices for maintenance therapy:

a. The effect of no maintenance treatment of corticosteroids should be gradually reduced after the symptoms are relieved, and transition to aminosalicylic acid maintenance as much as possible.

However, the following matters should be paid attention to during the reduction: After the effect of the application of corticosteroids, the reduction should be maintained for a period of time according to the type and degree of the lesion. The principle is to slowly and gradually reduce, if the condition is stable, reduce 2.5 to 7 to 10 days. 5mg, or 2 mg to 4 weeks, 5 mg. After 20 mg per day, the reduction should be slow and reduced to a certain amount. It is necessary to maintain the dose for a period of time. The size of the maintenance dose and the length of the medication should be based on the condition and response of the patient. The difference is that the minimum maintenance amount can reach the ideal dose below 10mg / d. Some patients with recurrent attacks are easily relapsed once they are reduced to a small dose. When the recurrence decreases, the amount of corticosteroids should quickly return to the original therapeutic dose.

b. Mesalazine: Sulfasalazine is recommended for maintenance therapy with a relatively small dose (2g / d). Mesalazine local maintenance therapy (enema, foam therapy, gel) is effective for left colon disease and side effects occur. The rate is low and may be more effective for patients than oral mesalazine.

Although the new formulation of mesalazine is better tolerated, it can also cause rare and severe allergic reactions, such as pneumonia, pericarditis, and interstitial nephritis. Some patients can also develop allergic colitis, which is manifested as taking Symptoms of diarrhea worsened after mesalin.

In short, as long as conditions permit, mesalazine drugs are used as much as possible, and local or systemic application of mesalazine is effective in maintaining the relief of ulcerative colitis. Only less than 10% of patients cannot tolerate mesalazine.

c. Sulfasalazine: Sulfasalazine also has a good effect on reducing recurrence. It has been reported that its efficacy is similar to that of mesalazine preparations, but mesalazine preparations are better tolerated. Sulfasalazine alone is used to maintain remission. Effective, its effectiveness depends on its dose, the effect of 3 to 4g / d is better than 2g / d, but the larger the dose, the more side effects, the poorer the tolerance, the relapse rate and the maintenance dose, the course of treatment Related to the condition, long-term medication must regularly monitor liver and kidney function.

d. Immunosuppressive agents: Most patients with ulcerative colitis are effective on mesalazine and short-term hormone therapy. If patients are not effective on drug therapy, they should undergo colectomy, because if immunosuppressive therapy is applied for a long time, the probability of future surgical treatment will decrease And, over time, the risk of colon cancer increases.

Purine antimetabolites: Purine antimetabolites are the most commonly used immunosuppressive agents in the clinic. There is currently no RCT to evaluate thiopurine. Therefore, there is very little clinical evidence to support purine antimetabolites as maintenance therapy. However, in Patients who have not responded to mesalazine and hormone therapy can still choose purine antimetabolites.

Methotrexate: Currently only one RCT has evaluated the effect of methotrexate on chronic active colitis. Oren divided 67 patients who had been treated with hormones or immunosuppressants for 4-12 months. Methotrexate was administered orally at 12.5 mg / kg) and the control group. After 9 months, it was found that there was no significant difference between the two groups in terms of remission rate, time required to obtain remission, and relapse rate after remission.

Therefore, except for controlled studies, methotrexate should not be used as a drug to induce remission or maintenance therapy, and the effect of methotrexate doses greater than 12.5 mg / kg should be further studied in the future.

Cyclosporine: The results of several small-scale RCTs and a large-scale case observation suggest that cyclosporine can induce remission of severe colitis, and to date patients who have been treated with intravenous cyclosporine have not received oral cyclosporine to maintain In a randomized controlled study of treatment, due to renal toxicity damage, oral cyclosporine should not be> 5 mg / (kg · d). At present, cyclosporine has not been used as a maintenance treatment.

Inframed: randomized controlled trials have failed to find effective in inductive remission or maintenance of ulcerative colitis due to inframed, as only in experimental studies.

In summary, in cases of steroid-ineffective or dependent cases, the immunosuppressant azathioprine can be used for maintenance therapy in remission. Although azathioprine treatment for ulcerative colitis is not as good as Crohn's disease, a recent survey confirmed The drug has been widely used by gastrointestinal doctors in the UK. Azathioprine or thiopurine can be used as a combination when hormone-dependent patients need to reduce the dose of hormones. It can also be used for patients who cannot use aminosalicylate for long-term maintenance therapy. It can also be used for maintenance treatment of those who have failed hormone therapy. The immunomodulators azathioprine and thiopurine have also been shown to have a preventive effect.

D. Administration route of maintenance therapy:

a. Distal colitis: Patients with distal ulcerative colitis can use local therapy to maintain and consolidate the efficacy. Foreign experience reports indicate that enema treatment with mesalazine preparations every other day is an economical and effective therapy. However, long-term use of enema treatment is still difficult. Therefore, as long as the patient can cooperate, the application of anal suppositories may be a feasible alternative method. Oral sulfasalazine (2 ~ 4g / d) can also maintain the relief effect. Topical corticosteroids have not been shown to be effective in maintaining remission of distal colitis.

b. Generalized colitis: If the patient is a patient with generalized ulcerative colitis, most studies have confirmed that the application of oral mesalazine therapy can have a good maintenance effect, and sulfasalazine also has a curative effect of reducing recurrence. However, the adverse effects of mesalazine preparations were significantly reduced, especially the gastrointestinal side effects were reduced. The optimal maintenance dose of mesalazine was 2 g / d. In addition to olosalazine, other mesalazine preparations or willows Neither sulfasalazine formulations have been shown to have a significant dose effect.

In short, the disease requires maintenance treatment. After treatment in the acute episode, the clinical symptoms improve or disappear, and the drug used in the acute phase gradually decreases until a minimum maintenance amount is found. During the remission period, a small amount of drug is used for a longer period (1 year). The above-mentioned) maintenance treatment should pay attention to the adverse reactions of the drug at this stage. There are many adverse reactions of corticosteroids and sulfasalazine, and it should be transitioned to mesalazine preparations as much as possible. For patients who need long-term application of hormone therapy, observe adverse reactions. At the same time, the amount of hormones should be reduced as much as possible, or other drugs should be used instead of hormones. Adverse reactions of sulfasalazine can be caused by patients' allergy or poisoning. The latter is more common and often associated with larger doses (> 4g / d) Or it may be related to the slow acetylation of the liver, which may gradually improve after stopping the drug and switching to mesalazine.

Surgical treatment of ulcerative colitis: According to our statistics, out of 10218 domestic patients with ulcerative colitis, the treatment of 6859 patients was described. Only 87 patients were treated surgically (1.3%). There are two: one is that domestic severe patients are less common than in Europe and the United States and other countries; the other is that domestic colleagues are very conservative in surgical treatment and do not think that ulcerative colitis is a curable disease. Colectomy plus ileal-anal storage bag anastomosis Surgery is an important alternative to medical treatment for chronic active or refractory colon disease. 20% to 30% of patients with ulcerative colitis have failed drug treatment or had complications and require surgery.

A. Indications for surgery: The condition of ulcerative colitis is complex and changeable. There is no unified standard for the timing and indication of surgery. Generally, the choice of indications abroad is broader and stricter in China. However, in recent years, with the maturity of surgical technology With the improvement of the effect, the domestic surgical indications are gradually relaxed. The following cases should be performed: a. Perforation or suspected perforation of the colon, b. A large amount of bloody stool, c. Toxic megacolon, d. Severe severe cases , Medical treatment is not effective for 5 to 7 days, and the condition deteriorates sharply. E. Chronic recurrent episodes, medical treatment is ineffective, and it is difficult to maintain normal life and work. F. In colonic cases, the colon has formed a fibrous narrow tube and lost function. G. Local comorbidities, such as obstruction, stenosis, intestinal fistula, etc., h. Cancerous or suspected cancerous changes, i. Severe parenteral comorbidities, such as arthritis, skin and mucosal lesions, conjunctivitis, sclerosing cholangitis Etc. Resection of the diseased colon is of great value in relieving and controlling bowel symptoms. J. Juvenile patients with growth and development disorders.

B. Preoperative preparation: Patients with ulcerative colitis should be fully prepared before surgery. In addition to the general preoperative preparation, there are two issues that should be paid special attention to. First, nutritional problems. Patients with ulcerative colitis have increased disease recurrence and nutrition. Insufficient intake, digestive tract malabsorption, and malnutrition are often associated with it. Therefore, adequate nutritional support should be given before surgery. Generally, parenteral nutrition and / or enteral nutrition can be selected. The second is the application of anti-inflammatory drugs. Patients with acute stage surgery At this time, anti-inflammatory drugs such as sulfasalazine, mesalazine, and hormones should be used before surgery to control the symptoms and facilitate the operation. However, long-term application of hormones will have many side effects and is not good for surgery. Therefore, an appropriate dose should be selected. And treatment course, generally choose the minimum dose, the time is 1 to 2 weeks is appropriate.

C. Surgical methods and choices: The radical operation of ulcerative colitis is mainly a total colectomy followed by an ileostomy. The operation can be performed in one or two stages. The second stage is to remove the colon and perform an ileostomy to retain the rectum. Later, the rectum is removed in stages, and the mortality rate of selective surgery is about 3%. Most patients can maintain good health after surgery and generally do not relapse. If only a subtotal colectomy is performed, the residual intestinal segment of 12% of patients will Continue bleeding.

When the patient is critically ill, such as toxic intestinal dilatation, multiple stages of surgery are used. When the inflammation around the rectum is severe and it is not easy to separate satisfactorily, this method is also used. It is worth noting that the choice of surgery still needs Decisions are made based on the condition of the patient, the nature and extent of the lesion, and the same operation should not be forced on different patients and in different situations.

Total colectomy and ileal-anal anastomosis are used to treat this disease, avoiding the shortcomings of ileal ostomy. This operation is characterized by peeling the rectal mucosa and submucosa, retaining its muscle layer and intestinal canal, and making the end of the ileum into a pouch shape. Suture the muscular layer at the dentate line of the anal canal, so that the patient can get the effect of total colectomy and defecation through the anus. The patient can have incontinence during a period of time after surgery, which will gradually improve over time. Patients younger than 50 years of age have better surgical results than those who are older. For the problems left after acute surgery, they can be further treated after the general condition improves.

a. Emergency surgery: Emergency surgery is mainly applicable to the following cases: severe fulminant cases, especially with systemic symptoms such as high fever, sweating, tachycardia, decreased blood pressure, etc., when vital signs are at risk; acute bowel perforation; repeated massive bleeding Ineffective medical treatment; toxic intestinal dilatation.

The purpose is to control the deterioration of the disease and save lives. Such patients are seriously ill and have poor general conditions. Therefore, the operation should be simple and effective. The methods available are: major colon resection, ileum and sigmoid ostomy; ileal ostomy and transverse colon Or sigmoid colostomy, suitable for patients with toxic megacolon who can not tolerate major resection of the colon; ileal ostomy ostomy, suitable for those who cannot perform the above two operations due to systemic or local reasons, after emergency surgery, wait for the patient's condition Stable. After general improvement, elective radical surgery should be performed.

b. Selective surgery is suitable for the following cases: the medical treatment of active lesions is not effective, in the following cases: continuous disease severely affects the quality of life, and is not alleviated by traditional and active medical treatment; the condition is not controlled by hormone therapy And hormones have large side effects and cannot be tolerated; although the condition can be controlled, but large doses of corticosteroids are maintained, and the risk of side effects is greater; adolescent patients, disease activity, unsatisfactory control by active medical treatment, and affect growth Developmental patients; late-stage complications of this disease, such as colon cancer; extracolonic complications, colonic biopsy with highly dysplasia, flat mucosa with low-grade dysplasia, and lumpy lesions with low-grade dysplasia or colonoscopy failure The narrow one who passed.

The purpose is to completely cure ulcerative colitis. The following surgical methods are available: sigmoid colorectomy, anorectal anastomosis; total colorectal resection, ileostomy; total colorectal resection, ileal pouch stoma; total colonectomy , Rectal anastomosis; total colorectal resection, ileal anastomosis (IAA); total colorectal resection, ileal pouch anal anastomosis (IPAA).

e. Postoperative treatment should pay attention to the following points: continue to provide nutritional support, and choose deep vein catheterization for parenteral nutrition. If jejunostomy has been performed during the operation, early enteral nutrition can be performed; for those with ileal stoma, The stoma should be opened as early as possible with a suitable ostomy bag. The ostomy bag should be transparent, easy to observe the blood flow of the stoma mucosa and the color of the excreted intestinal fluid, record the amount of excretion, and strengthen the care of the skin around the stoma. In order to reduce the secretion of digestive juice and reduce diarrhea, somatostatin drugs such as octreotide (shanning) and somatostatin (statin) can be used to significantly reduce the incidence of anastomotic fistulas. Drainage tube should be removed after 7-9 days; regular anal dilation, twice a day for 3 months to prevent anastomotic stenosis; for those who have not removed all diseased intestinal tubes, sulfasalazine or mesalazine should be continued after surgery And other anti-inflammatory drugs, but generally need not be applied after IPAA.

f. Surgical complications and prevention: Patients with ulcerative colitis have an elective mortality rate of 1%, but surgical complications can reach 30% to 57.7%. Common complications include pelvic infection and anastomotic fistula, anastomotic stenosis, and a storage bag. Inflammation, anal fistula, ileal vaginal fistula, sexual dysfunction, kidney stones, etc.

g. Pelvic infection and anastomotic fistula: It is the most serious complication after surgery. Once it occurs, for IAA and IPAA, it usually means that the operation fails, and ileal stoma may eventually need to be performed. Therefore, great care must be taken to prevent and prevent it. The key is to ensure the blood flow of the ileum during the operation, without tension and proper suture. In addition, the preserved muscle sheaths should not be too long and too tight to avoid fluid accumulation between the intestinal walls of the muscle sheaths. For high-risk patients, temporary ileal stoma should be performed. The application of Shanning and other drugs also plays a certain role. Drainage must be kept unobstructed. Do not remove it prematurely. After anastomotic fistula occurs, fasting should be given. Drainage should be adequate. Shanning and parenteral nutrition should be applied. Ileostomy.

Pouchitis (cystitis): It is a non-specific inflammation of the ileum storage cavity, and it is the most common long-term complication of ileal cystic anal anastomosis after ulcerative colitis. This unexplainable inflammation may occur within 5 years and recurrence is associated with 2/3 of the patients. Although people often use fecal silt to explain the cause of cystitis, between the two groups of patients with and without cystitis, There are no differences in the concentrations of bacteria, bile acids and short-chain fatty acids, and the complex interrelationships between immune-susceptible mucosa, fecal deposition, and bacterial clumps deserve further study. The length of the intestinal canal in some types of storage bags can also be related to pouchitis.

With the passage of time after the establishment of the storage bag, the colonic metaplastic changes in the small intestinal mucosa in the bag can occur, which not only affects epithelial cells, but also involves goblet cells, which are almost always accompanied by an increase in the number of lymphocytes and plasma cells. Acute pouchitis has a high incidence, and often brings many symptoms that bother patients, such as diarrhea and bleeding. There are fashions that can be accompanied by fever and some parenteral symptoms. This pouchitis generally occurs almost exclusively due to ulcers Patients undergoing surgery for ulcerative colitis and perinuclear anti-neutrophil cytoplasmic antibodies, that is, PANCA-positive patients; in addition, patients with ulcerative colitis with primary sclerosing cholangitis also Has a high risk of pouchitis. Among ulcerative colitis patients who undergo ileoanal pouch surgery, this complication may occur in 20% to 30% of patients, and 8% to 12% may Become a patient with chronic pouchitis.

Most patients with acute pouchitis have a good response to antibiotics, especially metronidazole and ciprofloxacin. Some patients may require longer-term antibiotic treatment, and some patients who are resistant to treatment may be applying At the same time, antibiotics need to be combined with mesalazine or glucocorticosteroids; some patients can only be controlled after azathioprine. If the drug does not heal for a long time, you need to remove the storage bag to eliminate the symptoms. If Crohn The disease was misdiagnosed as ulcerative colitis, and about 50% of patients who underwent a bag-anal anastomosis needed a bag resection.

2. Treatment of severe ulcerative colitis

(1) Selection and application of corticosteroids: For patients with severe left semicolitis or generalized colitis, hormone therapy is essential, and most of these patients require hospitalization.

Management of patients who have not used oral steroids: Prednisone (prednisolone) can be taken orally at 40 to 60 mg / d, observed for 7 to 10 days, or directly administered intravenously. ACTH (120 U / d) ), The effect is better than hydrocortisone, prednisolone, methylprednisolone (methylprednisolone) or dexamethasone and other drugs, the symptoms can be significantly improved within 48 hours, once the symptoms are controlled, you can start Decreasing the dose of hormone, it is best to perform rectal endoscopy to monitor the change of disease activity to guide hormone therapy. If the symptoms are not relieved within 7 to 10 days, choose cyclosporine or surgery according to the condition.

Treatment of patients with poor efficacy after taking oral steroid hormones: intravenous hormone therapy is listed as the first choice, and hydrocortisone 300 mg / d (100 mg, 3 times / d) or methylprednisolone 48 mg / d (16 mg) should be administered intravenously. , 3 times / d), prednisolone 30mg, 2 times / d, both can be selected, the increase of the dose does not increase the efficacy, generally within 48 hours, the symptoms have improved, once the symptoms are controlled, you can start to decrease the hormone Dose, but must monitor changes in disease activity to guide hormonal therapy, while infusion of hormones with mesalazine may not be more effective, but with mesalazine or hydrocortisone enema can help anal symptoms improve.

Efficacy prediction indicators: A recent study re-evaluated some of the indicators used to predict the 3-day efficacy of intravenous glucocorticoids in the treatment of severe colitis. The results showed that among these patients with severe ulcerative colitis, It is predicted that up to 85% of patients who need to undergo colectomy are predicted to have diarrhea more than 8 times within 24 hours, or diarrhea 4 to 5 times within 24 hours, but C-reactive protein> 45mg / L. According to these indicators, The patient makes the decision to administer cyclosporine intravenously or perform a colectomy.

Outcome: Some patients have not improved after the above treatment. Those who suspect perforation should undergo colectomy within 72 hours, because the mortality rate of perforation can reach 50%. For the symptoms of poisoning disappeared, bleeding stopped, abdominal pain and diarrhea relieved, and those who can gradually eat, Change to oral prednisone (same intravenous dose). Patients with stable disease should gradually reduce the dose. For those who have no symptoms of poisoning but watery stools or bloody stools persist, consider continuing treatment for another week or two, not exceeding 2 For weeks, those who still do not improve should undergo colectomy in time. Those who reported no improvement after 7 to 10 hours of hormone therapy can also consider surgical treatment or the use of immunomodulator cyclosporine to induce remission in 1/3 to 2/3 of patients. Colectomy was avoided for at least six months.

Application of cyclosporine: Intravenous steroid hormones are not effective after 7 to 10 days. Cyclosporine intravenous infusion of 2 to 4 mg / kg per day can be considered. Due to drug immunosuppressive effects, renal toxicity and other adverse reactions, blood concentration should be strictly monitored. Therefore, considering the monitoring conditions of the hospital, it is advocated to use in a few medical centers, and when deciding whether to extend medical treatment, the effectiveness of surgical treatment and the excellent results it produces must be considered.

Cyclosporine intravenous drip is now considered as a measure of transition before surgery. Cyclosporine intravenous drip 4 mg / kg has been used in foreign countries, and 59.8% (39/67) has achieved remission, eliminating the need for patients to undergo surgery under extremely severe conditions. However, 6 of them relapsed after discontinuation of the drug, and finally received surgical treatment; the other 28 were treated with colectomy, with a total short-term effective rate of 44%. The current epidemic is cyclosporine-induced remission, followed by immunosuppression. Agents such as azathioprine maintenance treatment, through this therapy, more than half of patients can avoid colectomy for a long time, even if avoiding colectomy for a short period of time, it is also beneficial for some patients, so that they have time to consider choosing surgery Surgery is another non-emergency option.

(2) Application of heparin drugs: foreign reports (accumulatively reported about 1,000 cases), treatment by intravenous or subcutaneous injection of unseparated heparin, the clinical condition of patients has significantly improved, because the blood of patients with ulcerative colitis is in a hypercoagulable state The incidence of thrombosis is significantly increased. We use nebulized inhaled heparin to avoid the inconvenience caused by long-term injection. At the same time, heparin enters the lungs and is taken up by endothelial cells, which is gradually released, which can prolong the drug t1 / 2 and maintain Sustained and effective blood concentration is safe, convenient, and effective. Due to the anticoagulant, antithrombotic, and anti-inflammatory effects of heparin, blood in the stool is often the first symptom to be relieved.

The indications for the application of heparin drugs must be strictly selected. The following conditions can be used: Patients with active ulcerative colitis with significant hypercoagulability after testing (such as platelets); Hormone-dependent or resistant refractory ulcers Patients with colitis; early DIC.

(3) Application of antibiotics: When using hormones intravenously, adding antibiotics has no therapeutic value, but it is recommended to use broad-spectrum antibiotics for those with peritoneal irritation, high fever, and increased white blood cells, such as third-generation cephalosporin antibiotics plus metronidazole The direct role of antibiotics in the treatment of severe ulcerative colitis is unclear, but some cases can help improve symptoms.

(4) Nutrition support and symptomatic treatment:

Monitor vital signs: closely monitor patients' vital signs and abdominal signs, and detect and manage complications early.

Bed rest, proper infusion, electrolyte supplementation, waterproofing, electrolyte balance disorder.

If the blood volume in the stool is large, those with hemoglobin (Hb) below 90g / L and persistent bleeding should consider transfusion.

Malnutrition, the more severe illness can use the element diet, the severe illness should be given parental nutrition (TPN).

Although parenteral nutrition has no direct therapeutic effect on ulcerative colitis, it is beneficial for maintaining a complete rest in the intestine, improving nutrition, and correcting water and electrolyte disorders. If it can be tolerated, early recovery of a slag-free diet is also important. At present, the general tendency, For patients with severe colitis, conventional parenteral nutrition therapy is routinely given. The results of controlled studies have not proven the benefits of TPN, and even think that due to TPN therapy, intestinal cells in the colon may be stopped from supplying their metabolism and repair. Essential short-chain fatty acids, but TPN is still necessary as a nutritional adjuvant treatment in patients with severe ulcerative colitis.

Symptomatic treatment: those who have had megacolon should be decompressed through the nasogastric tube, and the anal canal can also have decompression effect. Changing position can help to expel colon gas. Antidiarrheal, sedative and anticholinergic drugs can induce megacolon or intestinal obstruction The possibility should be avoided.

Surgical treatment: If the above-mentioned drugs are not effective, or when toxic megacolon is combined, the surgical consultation should be performed in time to determine the timing and method of colectomy surgery.

When medical treatments such as corticosteroids or cyclosporine are ineffective, only high-energy nutrition in the vein is available for a short period of time (1 to 2 months), and seize the opportunity for total colectomy and ileostomy. Young people should keep the rectum 7-8cm in preparation An ileo-rectal anastomosis is performed after the disease is stationary; those who are older than 50 years, especially for more than 10 years of disease, who have atypical hyperplasia on colonoscopy should resection the rectum as a permanent ileostomy. Ulcerative colitis Heals after the colon.

The operation should be radical. Those who retain inflammation in the rectum can be perfused with hydrocortisone. After remission, use Pentasa anal suppository, 1 g 2 times / d, and then change it 1 time / d or once every other day. After the inflammation is completely eliminated, a retro-rectal anastomosis is performed.

Many surgeons in foreign countries are currently inclined to perform three-step surgery, that is, first to perform a colectomy to seal the remaining short rectal stump; then establish an ileoanal pouch and a temporary ileal stoma Surgery; finally closed the fistula.

In short, although the treatment of severe ulcerative colitis is clinically difficult, different measures can be taken according to different situations, and most patients can obtain remission.

3. Treatment of distal ulcerative colitis The lesions involving 30 to 40 cm of the distal colon are called distal ulcerative colitis, also known as straight sigmoid colitis, and have bloody stools. Mild to moderate patients generally have no systemic symptoms or mild.

Treatment of mild-to-moderate distal colitis: For patients with proctitis or distal colitis, oral or topical treatments are generally effective, and the treatment plan depends to some extent on the patient Choices (such as whether you are willing to take oral medication, whether it can adapt to local administration, or how economically affordable it is).

(1) Aminosalicylic acid drugs: Mesalazine preparations commonly used are:

Topical agents: Mesalazine anal suppository or local enema. The method is simple and practical. Because the local drug concentration is high and maintained for a long time, the effect is significantly improved, and systemic adverse reactions are reduced. Mesalazine enema is used to treat ulcerative colitis. Compared with sulfadiazine and sulfadiazine, it was found that 75% of patients with mesalazine or sulfadiazine enema had clinical and sigmoidoscopy improvements, while the response rate in the sulfadiazine group was only 35%. We used mesalazine 4g enema for 10 patients with mild-to-moderate left ulcerative colitis. The clinical and colonoscopy improvement rate is 90%, and the histological remission rate is 80%. Its efficacy is higher than hydrocortisone. The enema drugs are generally only 20% is absorbed in the colon, excreted from the urine after acetylation, and the dosage of anal medication is small (500mg), which can be 2 to 3 times / d, and usually has a good effect on ulcerative proctitis.

The unique waxy carrier method of mesalazine suppository can improve the stability of the drug. The suppository is convenient to use and administered several times a day to ensure the sustained high concentration of local drug release from the terminal colon. 0.2 to 1.0 g / d. Colitis and proctitis work well.

Oral preparation: Mesalazine is well absorbed after oral administration, and is excreted in the urine from 52% to 93%. The disadvantage is that the concentration of the drug in the colon is low. By changing the new release method of the drug, the concentration of mesalazine in the colon can be increased. To achieve a good therapeutic purpose.

Mesalazine (Asacol) is a slow-release form of mesalazine covered with acrylic-based resin, which dissolves at pH> 6, which can release mesalazine in the terminal ileum and colon. This drug works well. Fewer adverse reactions.

Pentasa is another slow-release form of mesalazine capsules, which can be released in the small intestine or terminal ileum according to pH and time in a translucent coating of Ethylcellulose, in local or oral form Mesalazine capsules are called Mesalamine in the United States, but the same-acting preparation is called Mesalazine in Europe.

Olsalazine, if two mesalazine molecules are connected by a diazo bond, when the drug reaches the colon, bacterial diazo reductase is required to break down the diazo bond to decompose mesalazine, so the drug The drug concentration is high in the colon and the effect is definite.

The above-mentioned various mesalin preparations are often used with azosalicylic acid, which has the same molecular structure as the azosalicylic acid applied in European and American countries in recent years.

For patients with mild to moderate distal ulcerative colitis, local treatment should be preferred. Its advantages are fast onset and no need to take multiple oral medications. The choice of local treatment depends on the patient and the extent of the disease. For active distal lesions, mesalazine preparations can achieve at least the same efficacy as corticosteroids. For patients with left semicolitis, enema therapy is the best choice, because the drug solution can diffuse directly Rectal foam may be more easily tolerated by patients than the enema method (which can reach the spleen curvature) in the colon. It can reach 15-20cm in the anus. However, it should be noted that the local insertion of hard tubes may cause damage during administration. Use 1g Mesalazine is the lowest effective dose, but increasing the dose to less than 4g, there is no obvious difference in dose effect. Anal suppositories are effective dosage forms for treating proctitis, and the drug can reach the rectal sigmoid area further (10cm in the anus). ), If the patient's condition allows, mesalazine suppository, anal plug 500mg, 2 times / d, 1 time at night before bedtime, and 1 time after emptying stool in the morning, 1 time The number can be completely relieved within 2 to 4 weeks, and those who have only partial remission after 4 weeks of treatment can continue treatment for 4 to 6 weeks, and can still be completely relieved. A few who still do not respond can be replaced with mesalan enema, such as mesal 1 to 4 g of sodium oxazine per night can completely relieve the disease in more than 80% of patients, and a few patients are still ineffective. The extent of the disease should be re-evaluated, and oral mesalazine preparations can be considered, such as oxasalazine sodium 0.5 g. 3 to 4 times per day, taken immediately after meals. Some patients may achieve better results when combined with oral and topical therapy. Traditional sulfasalazine has many adverse reactions. When used for the treatment of this disease, it is best to use suppositories. Or an enema method, such as sulfasalazine 2 to 4 g in an enema, and the enema is kept before going to bed every night for 15 to 30 days, which can alleviate the disease and reduce adverse reactions in 70% to 80% of patients.

(2) Adrenal corticosteroids: After 4 to 6 weeks of treatment with aminosalicylic acid drugs, those who are intolerant or allergic to mesalazine should be treated with adrenal corticosteroids, such as hydrocortisone (100mg / d) Keep the enema, and do not use it for more than 3 weeks at a time. There are already many new glucocorticoid dosage forms abroad, such as the rapidly metabolizing tixocortol pivalate enema, which is better than traditional corticosteroids and has few systemic adverse reactions. Budesonide (Benesonide, trade name Entocort) is also used to retain the enema. It has a very high first-pass effect, so it has almost no systemic effect. When a 2 mg dose is used, it can be equivalent to 20-30 mg. The effect of prednisone (or 100 mg hydrocortisone), repeated treatment with budesonide enema does not have the adverse effect of inhibiting the body's hypothalamus-pituitary-adrenal axis, so long-term use of budesonide has Good safety. Its standard dose is 9mg. Increasing it to 15mg does not increase the efficacy. It also has the effect of inhibiting the adrenal cortex. In the morning, the concentration of plasma cortisol is reduced, and the dose is 18mg. Adverse reactions increased, but still lower than systemic medication. In addition, another topically applied adrenocortical foam, rectal hydrocortisone foam suppository, has also been used to treat this disease. A 5ml rectal injection and hydrocortisone The effect of 100mg enema is the same, and it is more convenient than the enema, which does not affect the patient's daily life. Therefore, it provides another treatment method for patients with this disease. The above drug treatments can quickly alleviate the disease, but it is easy to relapse when the drug is stopped. It is also advisable to treat cortisone by oral or intravenous treatment in severe cases, and it should be reduced in time once remission.

4. Treatment of refractory distal colitis If the patient's distal active colitis is treated with topical mesalazine or corticosteroid preparations, or combined with oral aminosalicylic acid or sulfasalazine preparations for up to 4 If it is not effective for ~ 6 weeks, such patients should be classified as "refractory distal colitis", and the administration time can be appropriately extended for further treatment and observation or other drugs for treatment. Prostatitis patients with ineffective salsaqin have a curative effect on corticosteroid enemas, or have no effect on corticosteroid enemas, and are effective on mesalazine preparations. Another method that is worth considering is the combined use of mesalasa in enema Qin and corticosteroids, Mulder et al. Reported that the use of beclomethasone dipropionate (also known as beclomethason dipropionate) 3mg and mesalazine 1g combined with enema had a better effect on some resistant lesions.

(1) Whether cyclosporin is used for enema is still controversial. The results of enema treatment with nicotine tartrate solution showed that the enema was first administered at a dose of 3mg / d for 1 week, and then at 6mg / d. Dose enema for 3 weeks, some of the patients with mild-to-moderate active left ulcerative colitis who did not respond to the first-line effect achieved clinical improvement.

(2) Maintenance therapy: Domestic patients with first-onset can be discontinued after treatment is relieved, and those who have slow response to treatment, insensitivity to conventional treatment or relapse within a few weeks of treatment should be maintained. Mesalazine suppositories once per night It is the most effective plan for maintaining remission. There are also those who maintain remission once every other day or even 3 to 4 days. 54% to 80% can maintain remission for 1 year. However, due to the inconvenience of enema maintenance treatment, many patients prefer oral medication. Maintain remission, sulfasalazine 4g / d is more effective than 2g / d, but low doses can improve patient compliance and reduce side effects, and generally do not use thiopurine or azathioprine maintenance treatment, unless the patient is ineffective for hormones or for hormones rely.

(3) Surgical treatment: Unless severe complications occur or cancer is suspected, surgical treatment is rarely used.

(4) Treatment of left hemicolitis and pancolitis: those with inflammation involving the spleen curvature of the colon are referred to as left colitis, those with more than hepatic curvature are called total colitis, because the extent of the lesion exceeds the area accessible by local therapy (such as Descending colon-spleen flexure), generally need to be treated with oral medication or combined with local medication.

5. Treatment of mild-to-moderate patients

(1) Aminosalicylic acid drugs: Traditional therapy is still oral sulfasalazine with a large dose (4-6g / d), and about 80% of patients can achieve complete clinical relief or obvious within 4 weeks. Improvement; about half of patients can achieve remission of endoscopic performance. If the patient's financial conditions permit, or adverse reactions to sulfasalazine treatment or poor efficacy, can be treated with mesalazine preparations, or oral The combination of mesalazine and topical mesalazine preparations has fewer adverse reactions, and the anal symptoms may be relieved quickly with local treatment. Once relieved, oral medication should be halved and maintained. Local treatment can be interrupted. Patients at risk of relapse can use enema 2 times per week to maintain remission in combination with oral drugs, but no randomized study has been concluded. A controlled study with placebo shows that oral salicylic acid can be more effective when it exceeds 2 g / d. To control the onset of mild and moderate ulcerative colitis, it is generally believed that aminosalicylic acid has a dose-responsive effect within a dose of 3.8 g / d, and the effect of increasing the dose is not significant. Increase, and adverse reactions may increase, but the relationship between dose-response needs to be proved in various cases, oxasalazine sodium capsules, salsalazine, ossalazine, or Eudragit-S or ethyl Cellulose-encapsulated mesalazine (Pentasa) can also achieve the same efficacy as sulfasalazine, but with fewer adverse reactions, especially in patients who are allergic to sulfasalazine Sex.

(2) Corticosteroids: Patients who have failed to treat oral aminosalicylate (with or without local therapy) or whose symptoms are complex and need to be controlled in time can be treated with oral corticosteroids, usually oral prednisolone In the case of pineal therapy, when the dosage is 20 60mg / d, the curative effect is related to the dosage. When the dosage is 60mg / d, the effect is improved than 40mg / d, but the adverse reactions are correspondingly increased. Therefore, a dose reduction scheme is often used. Generally, first use a dose of 40 to 60 mg / d to improve symptoms, and then decrease by 5 to 10 mg per week until 20 mg per day, and then can decrease by 2.5 mg per week, but the scientific nature of the commonly used programs is still lacking random trials to prove.

The oral corticosteroids are intolerable or have many adverse reactions. Try the topical corticosteroid preparations in the table below (Table 5).

(3) Immunosuppressants: Azathioprine (1.5-2.5mg / kg) can be used in patients who are ineffective in hormone therapy and do not urgently need to use intravenous hormone preparations, or those who cannot use hormone therapy, but azathioprine has a slower effect. Sometimes it does not work well until 3 to 6 months after administration. Controlled drug withdrawal trials have shown that azathioprine is also effective for maintenance therapy. Retrospective studies have shown that thiopurine (6-mercaptopurine) has a long-term remission effect. Important value.

6. The treatment of severe patients is ineffective for oral prednisone, oral salicylates, or local treatment, or severe patients with symptoms of poisoning, should be treated with intravenous corticosteroid infusion for 7 to 10 days, if not effective , It should be considered as a total colectomy or intravenous cyclosporine therapy (1 ~ 4mg / kg). For those with peritoneal irritation, high fever, and increased white blood cells, a broad-spectrum antibiotic is recommended, such as the third-generation cephalosporin antibiotic plus Metronidazole, etc., should also closely monitor vital signs, strengthen nutritional support and symptomatic treatment.

7. Treatment of Complications The early complications of ulcerative colitis include water and electrolyte disturbances, a large amount of blood in the stool, toxic colonic dilatation, sepsis, and intestinal flora imbalance. Intestinal fistula, intestinal obstruction, canceration, etc. may occur in the later stage, with severe complications. Symptoms are generally seen in severe patients and are an important cause of death from ulcerative colitis. The following are the principles of diagnosis and treatment of several major complications.

(1) Toxic intestinal dilatation: Early detection of this complication should be noticed. Patients with abdominal gas, less bowel sounds, and hypokalemia, especially when accompanied by systemic toxicity symptoms (such as fever 38.6 , heart rate 120 times / min, increased white blood cells, etc.) or conscious disturbance, it is necessary to consider this possibility. Hypokalemia or the application of anticholinergic or containing opioid antidiarrheals can induce toxic intestinal dilatation. In severe patients, for To reduce intestinal load, fasting is usually required. Due to the frequent occurrence of diarrhea, patients often have dehydration and electrolyte disturbances. At this time, water, electrolytes, especially potassium supplements should be given in time. For severe ulcerative colitis, the above-mentioned should be used with caution Laxatives or anticholinergic drugs, in order to avoid toxic intestinal dilatation. The place where intestinal dilatation occurs is mostly in the transverse colon. Because gas is easy to accumulate there, you should pay close attention to it. On abdominal flat films, such as the transverse diameter of the intestine> 6cm Prompt intestinal dilatation.

The medical treatment measures for toxic intestinal dilatation are: Immediate fasting and active gastrointestinal decompression to reduce gas in the intestine; Large infusions to correct water and electrolyte disorders; due to low potassium, alkalosis may also be caused, so A large amount of potassium, chlorine plasma supplementation, intravenously given fast-acting corticosteroids, such as hydrocortisone succinate, 300mg / d, although corticosteroids help reduce inflammation and poisoning reactions, control poisoning symptoms in more than 50% of patients, However, patients may have already been treated with corticosteroids, and the use of large doses can increase the infection rate of wounds and concurrent sepsis. Therefore, it is necessary to emphasize the problem of the dosage of corticosteroids and prevent the occurrence of adrenal cortical crisis at any time. In the case, it is necessary to add broad-spectrum antibiotics, including the treatment of anaerobic bacteria and aerobic gram-negative bacteria. Apply intravenous nutrition therapy to improve the overall nutritional status of the patient. The above measures should be applied for 24 to 28 hours. If the condition does not improve, Consider surgical treatment in a timely manner.

(2) Intestinal perforation: Severe patients with acute onset of abdominal pain accompanied by obvious abdominal wall tenderness, muscle tension and rebound pain should consider this possibility. Plain abdominal radiographs show free gas under the diaphragm or diagnostic puncture to extract purulent When liquid is used, the diagnosis can be definitely confirmed. Intensive patients should not undergo detailed colonoscopy or barium enema examination in order to avoid perforation. After intestinal perforation occurs, it should be surgically treated.

(3) Massive bleeding: The criterion for massive bleeding is a rapid increase in heart rate (120 beats / min), accompanied by a decrease in blood pressure (90 / 60mmHg). At this time, blood volume, infusion, and blood transfusion should be actively supplemented to maintain effective circulating blood. Volume, generally 24 to 48 hours of blood transfusion of 1200 ~ 1600ml, and patients still have continuous active bleeding, surgery should be considered to stop bleeding.

(4) Polyps: Inflammatory polyps generally do not need to be removed, unless the naked eye can not be distinguished from real adenomas. Once adenoma polyps are confirmed, they should be removed during colonoscopy. For patients with colitis The relationship between adenomas and colon cancer is particularly important, and careful attention must be paid to the presence of other adenomas or cancers in the colon of these patients.

(5) Colorectal cancer: patients with severe or total colitis, especially with a course of more than 10 years, should be treated with prophylactic colectomy when endoscopic multiple follow-up biopsy confirms atypical hyperplasia. This method seems to be a radical method. It is suitable for young patients with a wide range of lesions, because such patients will undergo long-term endoscopic monitoring if they do not undergo surgical treatment. However, patients are often reluctant to undergo this surgical treatment, especially for mild colonic symptoms or drugs This is especially true for those with less adverse reactions to treatment. Some scholars believe that about 1/3 to 2/3 of the patients with severe atypical hyperplasia have invasive cancer and should be treated for total colonectomy in time; those with mild atypical hyperplasia About 10% have cancer and can also be used for colon resection; less than 3% of patients with suspicious atypical hyperplasia have cancer. Colonoscopy and multi-site biopsy should be reviewed every 3 to 6 months; chronic without atypical hyperplasia Patients with ulcerative colitis should also undergo colonoscopy once a year. If the cancer is clinically suspected, despite repeated negative colonoscopy biopsies, a colectomy should be performed immediately.

8. Treatment of ulcerative colitis in the elderly The treatment characteristics of ulcerative colitis in the elderly should pay attention to maintaining nutritional balance. The treatment of ulcerative colitis in the elderly is similar to the treatment of ulcerative colitis in general, and the treatment is roughly the same as in young people. Prednisone and sulfasalazine are used for maintenance treatment, and new mesalazine preparations should be used as much as possible to reduce adverse drug reactions. The dosage should be determined according to the weight and severity of the elderly. Generally, prednisone is 20 to 40 mg per day. Salazine 1 4g / d, the recommended maintenance dose is 1 2g / d; salazolidine 1g each time, 2 times / d, the maintenance dose of sulfasalazine is 1 2g / d, glucocorticoid and Immunosuppressants are not contraindications for the elderly, but they should be used with caution to avoid their side effects. Attention should be paid to common concomitant diseases such as diabetes, heart disease, hypertension, osteoporosis, etc. The use of sulfa Depression, glucocorticoids can easily cause fractures, and the rate of glucocorticoids used in the elderly in ulcerative colitis is high. Woolrich study found that elderly ulcerative colitis requires oral prednisone 58%, 30% for intravenous injection, 29% for young people taking oral prednisone, and 11% for intravenous injection. Zimmerman also believes that elderly patients need glucocorticoid therapy, remember that the application of corticosteroids is more likely to induce some elderly people Sexual complications, such as heart failure, high blood pressure, diabetes or osteoporosis, therefore, hormones should not be applied to elderly patients if their condition is not allowed for a long time, otherwise there will be adverse consequences. Since the patient's condition is more dangerous, emergency surgery is needed. Mortality can be as high as 50%, and sometimes intestinal perforation complications are hidden and difficult to detect.

9. The treatment of children with ulcerative colitis is to control gastrointestinal symptoms, alleviate extraintestinal symptoms (such as joint pain and joint discomfort, etc.), restore children to the optimal nutritional state (growth line, weight gain), and improve children The nutritional status and reduction of complications, as in the treatment of ulcerative colitis in adults, emphasize that the program should be formulated according to the severity of the disease, the location of the intestinal lesions, the scope and the parenteral complications. The treatment includes general treatment (general treatment Including bed rest, reasonable diet, iron supplements, zinc, correction of water and electrolyte acid-base disorders, enhanced supportive therapy and symptomatic treatment, etc.), medicine and surgical treatment.

(1) Drug treatment: For children with mild active ulcerative colitis, oral sulfasalazine or mesalazine is usually effective. Corticosteroids or mesalazine can also be used for enema treatment at night, and the use of corticosteroid foam suppositories is recommended. Because of its ease of use and no rectal dilatation, sulfasalazine can be started from a small dose of 25 mg / (kg · d) and gradually increased in volume, which can reduce the side effects of SAPS. The initial sulfasalazine dose was 25 to 40 mg / (kg · D), if necessary, it can be increased to 50 70mg / (kg · d). Those who are not responding or allergic to sulfasalazine can be treated with mesalazine. Adverse effects of sulfasalazine in children Yes: headache, gastrointestinal discomfort (especially nausea), allergic reactions including rash, hemolytic anemia, liver toxicity, neutrophil and thrombocytopenia, and even exacerbation of bloody diarrhea, Chinese medicine and traditional Chinese medicine have ulcerative colitis Some treatment effects, and no adverse reactions, some people use fresh white radish juice 80 ~ 100ml to retain the enema, once / d, the effect is better for light young children, 400ml chrysanthemum extract, instillation in the sigmoid colon for more than 2h, 1 0 days is a course of treatment, and the total effective rate is 90%.

Moderate to severe ulcerative colitis is treated with glucocorticoids and can be administered orally or intravenously. The remission rate varies according to the severity of the disease. Generally, about 56% of the severe cases can be relieved, and at least 92% of the mild cases can be relieved. For abdominal cramps Severe, diarrhea, more blood in the stool, children with anemia and hypoproteinemia with moderate to severe ulcerative colitis can take prednisone or intravenous methylprednisolone hydrocortisone at a dose of 1.0 to 2.0 mg / (kg · D), in order to reduce gastrointestinal tract movements, restrict dietary intake, give intravenous high nutrition, at the same time give albumin 1g / (kg · d) and fresh blood, and correct water, electrolytes (potassium, calcium, magnesium), acid Disorders of alkali balance. Although corticosteroid treatment can temporarily relieve the condition to reduce clinical symptoms, it can cause adverse reactions such as intestinal perforation, infection, osteoporosis, and growth retardation. In order to avoid this adverse reaction, hormone separation can be used. Day treatment plan, the maintenance treatment of corticosteroids, should be gradually reduced after abdominal cramps pain relieved and bloody stool disappeared, 2.5 to 5 mg every 1 to 2 weeks, some people recommend a plan to gradually reduce the next day, Nisson 40-50mg once every other day, a single dose in the morning, can maintain the relief of the disease, without affecting growth and development, new corticosteroid preparations (such as Budesonide) have the first rapid effect of passing through the liver, on the hypothalamus-pituitary- The adrenal axis has basically no inhibitory effect and is beneficial for reducing hormone-induced growth arrest in children.

70% of children with hormone-dependent or refractory ulcerative colitis can be treated with immunosuppressants. Generally, azathioprine 2mg / (kg · d) or thiopurine dose is 1.0 1.5mg / (kg · d). Cyclosporine (Cyclosporine) for children with severe refractory ulcerative colitis, whether oral or parenteral administration, 60% to 70% of children can improve symptoms after 7 to 10 days of medication, the incidence of side effects is low, but The recurrence rate is high, and the adverse reactions of this drug include hypertension, tremor, hirsutism, and epileptic seizures.

It should be noted that children with ulcerative colitis may be vulnerable to co-infection due to decreased resistance and the use of hormones and other immunosuppressants. Cryboski recorded that children with exacerbated inflammatory bowel disease had difficulty identifying clostridial toxin The frequency is 16% higher than expected. Oral vancomycin or metronidazole 25 to 30 mg / (kg · d), clinical response occurs within 3 to 6 days, and toxin disappears within 7 to 10 days. Many pediatric gastroenterologists recommend moderate -Children with severe inflammatory bowel disease should be treated with vancomycin 0.5 to 2.0 g / d for 10 to 14 days, or metronidazole 20 mg / (kg · d) (maximum 1.5 g / d).

(2) Surgical treatment: The surgical treatment of ulcerative colitis in children should be timely to reduce the occurrence of complications. The surgical indications include refractory ulcerative colitis, refractory weight loss, toxic megacolon, bleeding, perforation, etc. Some studies have shown that the continuous dosage of prednisone reaches 10mg per day will affect growth. Therefore, once the acute symptoms of childhood patients are controlled, the effect of corticosteroids is not good. Considering the growth and development of children, surgical treatment should be considered.

Surgery method: One-stage total colon and rectal resection, but this operation is very traumatic. In recent years, rectal mucosal exfoliation and total colectomy are used. Fecal storage bag, this surgical method is an ideal method to promote the establishment of defecation reflex and restore the self-control function of defecation. The second phase is colectomy, which is suitable for children with extreme failure or severe poisoning. After the condition is stable and improved, other operations are performed. Infants and young children are only resected for partial colonic lesions. For the improved Soave surgery, when there are severe colonic or sigmoid colonic lesions, it is usually suitable for total colonectomy and ileal-rectal anastomosis.

10. Treatment of ulcerative colitis in pregnant women The treatment of inflammatory bowel disease in pregnant women is similar to that of ordinary adults. Glucocorticoids, sulfasalazine, 5-SAS and other treatments can be applied during pregnancy.

The application of sulfasalazine is generally safe for mothers and infants. Some people worry that sulfa drugs will compete with albumin through the placental barrier and unbound bilirubin, which will increase the incidence of neonatal jaundice. However, Studies have shown that the binding sites of sulfadiazine and bilirubin on albumin are different. Only when a high concentration of sulfadiazine appears in the blood can the binding of bilirubin and albumin be prevented. Therefore, the therapeutic dose of sulfadiazine and 5 -SAS is still safe, but it may affect the absorption of folic acid. Therefore, appropriate amount of folic acid should be supplemented at the same time, 1 mg each time, 2 times per day. Glucocorticoids can generally be safely used during pregnancy and lactation. In the treatment of ulcerative colitis, immunosuppressive agents can also be applied. The application of azathioprine and thiopurine can cause fetal weight loss, but the newborn is generally healthy. The indications should be strictly controlled when applying immunosuppressive drugs. Although There have been no reports of any adverse reactions of azathioprine to the fetus, but such immunosuppressants may cause fetal aberrations, so they are not recommended for use during pregnancy.

Among antibiotics, ampicillin (ampicillin) and cephalosporins are known to be safe during pregnancy. Vancomycin has not been reported to be toxic to the fetus. Animal experiments have shown that metronidazole has carcinogenic and teratogenic effects. The medicine can pass through the placenta and enter the breast. It has been reported that craniofacial abnormalities occur in infants after treatment with metronidazole during the first 3 months of pregnancy in pregnant women with amoebiasis. Therefore, it is best to avoid pregnant and lactating women. Use the medicine.

The surgical indications for ulcerative colitis are also applicable to pregnant women, but surgery will bring danger to pregnant women and fetuses, and increase postoperative complications. Therefore, contraception should be performed during the active period of the disease.

Since ulcerative colitis is a chronic disease, its symptom relief is not the only indicator of curative effect. It must be examined by sigmoidoscopy and X-ray to determine the efficacy.

(1) General treatment: bed rest during acute attacks and severe cases. General cases should also pay attention to the combination of work and rest. If the patient develops nervousness and emotional tension, clozazol (Limening) and phenobarbital ( Lumina), Diazepam (Diazepam), etc. The diet is based on the principles of softness, easy digestion, rich nutrition, and sufficient calories. It is advisable to eat less and eat more, and supplement various vitamins. Give a residue-free semi-liquid diet, avoid cold drinks, fruits, fiber-rich vegetables and other irritating foods, and avoid milk and dairy products.

(2) Symptomatic treatment: For patients with abdominal pain and diarrhea, atropine, bromoproline (probencin), anisodamine, etc. must be used with caution. Large doses can cause acute colonic dilatation, except for severe diarrhea. Antiperistal drugs such as compound acetophenidine can be used with caution. Anesthetics should be used as little as possible. For anemia patients, a small number of blood transfusions can be given. Iron supplements can be injected intramuscularly when the oral intolerance is not tolerated. Patients with acute attacks often have severe water. Electrolyte disorders, especially hypokalemia, should be corrected. When the diarrhea is severe, the colonic mucosa absorbs sodium, but it also secretes the same amount of potassium to be excreted with feces, which can cause severe hypokalemia, so it should be corrected according to the blood potassium level. When the disease is active for a long time, showing weight loss or severe illness, with hypoalbuminemia, toxemia, intestinal obstruction, intestinal fistula or short bowel syndrome caused by large and small bowel resection before and after surgery, it can be given intravenously. nutrition.

(3) Systemic treatment: Glucocorticoids and sulfasalazine are currently the most effective drugs for controlling the symptoms of this disease, and sometimes they can quickly relieve joint symptoms.

Glucocorticoids: ACTH and hydrocortisone are effective drugs to induce relief of symptoms. They are suitable for severe cases. ACTH is 20 to 40 U per day. It is added to 500 ml of 5% glucose solution by intravenous drip, which is finished in about 8 hours, or with emulsion 80. 100U subcutaneous injection, hydrocortisone 100-300mg per day, added to 5% glucose solution 500ml to relieve intravenous drip, or oral prednisone or prednisone 20-80mg per day. After achieving the desired effect, the dose can be gradually reduced or Switch to prednisone and other oral drugs for maintenance, and then gradually reduce or even stop the drug within 1 to 3 months depending on the condition.

In order to avoid side effects caused by systemic application of hormones, those whose lesions are limited to the rectum and sigmoid colon can be administered topically. Usually, 100 mg of sodium succinate hydrocortisone or 25 mg of prednisolone are added to 100 ml of physiological saline and slowly dripped. Rectal, once a night, or retain anal lavage, 1 to 2 times / d.

Anti-infective drugs: sulfasalazine is the first choice. This drug can reduce and alleviate the onset of the disease. It is taken 4 to 6 g per day during the onset period and divided into 4 oral doses. If the condition improves after several weeks of use, it can be reduced to 3 to 4 g per day. Continued medication for 1 to 2 months. After remission, the dose was changed to 2 g per day for 1 year. Side effects of this medicine include nausea, vomiting, headache, and occasionally granulocytopenia and rash.

immunosuppressants: those who are allergic to sulfasalazine or dissatisfied with the treatment, can be replaced with methotrexate or azathioprine, or chloroquine or hydroxychloroquine.

Surgical treatment: Complicated canceration, intestinal perforation, abscess and fistula formation, refractory pancolitis or toxic colonic openings, and those who are not effective in medical treatment can be treated with surgery, generally using ileostomy or total colectomy.

Ulcerative colitis arthritis diet care

Eat high-energy, low-fat, low-residue foods.

Preventive care of ulcerative colitis arthritis

1. Eliminate and reduce or avoid the incidence factors, improve the living environment space, improve the development of good living habits, prevent infection, pay attention to diet hygiene, and reasonable dietary allocation.

2. Pay attention to exercise, increase the body's ability to resist disease, do not over fatigue, over consumption, quit smoking and alcohol.

3. Early detection, early diagnosis and early treatment, build confidence to overcome the disease, and adhere to treatment.

Pathological causes of ulcerative colitis arthritis

1. Infectious factors The inflammatory changes of the colonic mucosa of this disease are similar to many infectious colitis, but bacteria, viruses or fungi have not been identified in this disease, and there is no evidence of infection among the population. Some people think that this disease The disease is caused by dysentery bacillus or histolytic amoeba. The long course may also be caused by intestinal bacteria that are generally non-pathogenic and need further confirmation.

2. Psycho-nervous factors Some people think that cerebral cortical dysfunction can cause autonomic dysfunction, cause intestinal hyperactivity, intestinal vascular smooth muscle spasm and contraction, tissue ischemia, increased capillary permeability, and thus intestinal mucosal inflammation, erosion and ulcers. At present, it is generally believed that this factor may be a secondary manifestation of the disease due to repeated attacks.

3. Genetic factors have confirmed that the positive rate of HLA-B27 in patients with this disease is significantly higher than that in the control group. In many families, the incidence of this disease is higher.

4.Immunological factors In recent years, important findings in the immunological basis of this disease include: non-specific anti-colon antibodies in the serum of patients, of which anti-mucopolysaccharide antibodies against intestinal epithelium and antibodies against E. coli polysaccharide components have been identified, Isolation of 40kD organ-specific proteins that can bind to IgG in ulcerative colitis tissues supports strong evidence that the disease is an autoimmune disease.

5. Allergy Doctrine Because a small number of patients are allergic to a certain food, after excluding food allergy or desensitization, the condition is improved or cured, so some people suggest that the disease is caused by allergies.

The cause of ulcerative colitis in the elderly is the same as in young people, and it is still not very clear. The main reason may be the abnormal immune response of the intestinal wall to different stimuli, and it is also related to bacterial, viral, and protozoal infections, as well as genetic, mental, and metabolic factors. There are no specific etiology factors related to the elderly, but recent research suggests that three factors may play a part in the occurrence of the disease before the onset of smoking, excessive consumption of refined sugars, low fiber and Too little fruit and vegetables.

The cause of childhood ulcerative colitis is still not very clear. Most people think that it is closely related to immune dysfunction, infection, mental and genetic factors. Among them, autoimmune dysfunction has attracted much attention and the role of inflammatory mediators has also been valued. important topic.

Studies in Western Europe and other countries suggest that genetic factors also have a certain effect on the occurrence of ulcerative colitis. Relatives of 5% to 15% of children with this disease have the incidence of HLA-B11 and B7 in tissue-associated antigens (HLA). Increased, the detection rate of lymphocyte antibodies in children's blood was as high as 51%, indicating that the weakened immune function may be affected by genetic factors.

Diagnosis of ulcerative colitis arthritis

1. Except for senile ulcerative colitis, other types of this disease should be distinguished from the following diseases.

(1) Chronic bacterial dysentery: there is a clear history of acute bacterial dysentery, and pus, red blood cells and phagocytic cells can be routinely found in stool, and in exudates taken from stool, rectal swab or rectal sigmoidoscopy, Can be isolated from dysenteriae.

(2) Chronic amoebic dysentery: The lesion is mainly the proximal colon, the edge of the ulcer is latent, the colonic mucosa between the ulcers is normal, and the amoebic cyst or trophozoite can be found in the feces. Anti-amoeba treatment is effective.

(3) Schistosomiasis: The patient has a history of contact with the epidemic water in the endemic area. The stool test was positive for schistosomiasis eggs and hatching hairy clams. Rectal sigmoidoscopy showed yellow particles and other lesions under the mucosa. Rectal mucosal biopsy can find the eggs. Liver, splenomegaly, and eosinophilia in the blood and other clinical manifestations improved after anti-schistosomiasis treatment.

(4) X-ray examination of colon cancer shows tumor lesions with filling defects and destruction of mucosal folds. Rectal sigmoidoscopy can detect cancer and biopsy can find cancer cells, but it must be noted that some patients with ulcerative colitis also Can be complicated by colon cancer.

(5) Colon allergy: There may be a lot of mucus in the stool, but no pus and blood, no organic lesions on X-ray examination or sigmoidoscopy. In addition to intestinal symptoms, patients often have headaches, lack of energy, and anxiety. Neurosis symptoms such as insomnia.

(6) Crohn's disease: It can occur in any part of the digestive tract from the esophagus to the anus, but it is more common in the small intestine and colon. The domestic findings are mainly limited to the small intestine or the cecum and ascending colon. The clinical manifestations and ulcerative Colitis is similar.

2. Identification of senile ulcerative colitis. If there is blood in the stool in the elderly, it must first be distinguished from colorectal cancer or ischemic colitis. The clinical manifestations of many intestinal diseases are similar to those of inflammatory bowel disease in the elderly, so early diagnosis is difficult. Although the clinical manifestations of ischemic enteritis are similar to inflammatory bowel disease, they often have the characteristics of self-limiting and low recurrence rate. The acute stage of inflammatory bowel disease is similar to that of diverticulitis. The basis for its identification is the secondary clinical course and Histological examination.

In addition, inflammatory bowel disease needs to be distinguished from infectious enteritis, autoimmune enteritis, radiation enteritis, and tumors.

This disease must first be distinguished from colon cancer. Due to the overlap of ulcerative colitis symptoms and colon cancer, this disease may be more prone to a misdiagnosis tendency, especially when both are present at the same time, endoscopic examinations should be performed regularly and repeated Block biopsy to confirm the diagnosis.

Ulcerative colitis needs to be differentially diagnosed with common intestinal diverticulosis in the elderly, because the two have many similar clinical manifestations, which can include abdominal pain, diarrhea, abdominal mass, and rectal bleeding and internal fistula. Diverticulopathy often occurs intermittently. Relatively serious, X-ray barium enema and fiber colonoscopy for intestinal diverticulum can usually be distinguished. Because some elderly people have diverticulosis, attention should be paid to the coexistence of the two.

Elderly ulcerative colitis still needs to be distinguished from antibiotic-associated colitis, including pseudomembranous colitis. Among the 15 patients described by Rod-dis, one clinical symptom is a large number of watery diarrhea with mucosal debris discharged and intestinal Hemorrhage, barium enema X-ray was non-specific, sigmoidoscopy showed reddening of the mucosa, exactly like ulcerative colitis, Huang Min and other reports of 30 cases of antibiotic-associated colitis, all medical records are suffering from a variety of chronic diseases Elderly people, after stopping antibiotics, most of the symptoms improve rapidly and the prognosis is good, which can be distinguished from senile ulcerative colitis.

There is also a variant form of ulcerative colitis in senile ulcerative colitis, known as senile granulomatous proctitis. The clinical symptoms of this disease are relatively mild, and the prognosis is generally good. The response to topical application of corticosteroids is very effective.

Examination of ulcerative colitis arthritis

1. Blood routine and erythrocyte anemia are low pigmented small cell anemia. During the active phase of the disease, neutrophils increase and erythrocyte sedimentation increases.

2. Stool: There are blood, pus and mucus in stool. Stool culture and incubation are free of pathogens of specific colitis such as dysentery bacillus, lysohistamine ameba, schistosomiasis eggs and hairy pupae.

3. Biochemical examination Due to the increase of factor VII activity, the production of thromboplastin can be accelerated, which can lead to a high blood coagulation state, and the number of platelets can be significantly increased. In severe cases, serum albumin is reduced, and a1 and a2 globulin are significantly increased. In the remission period, a2 globulin increases, which is often a signal of recurrence of the disease. If the globulin decreases during the onset of the disease, it often indicates a poor prognosis, and severe patients may have obvious water and electrolyte disorders, and hypokalemia may occur.

4. Immunological examination of rheumatoid factor is negative, but when overlapping with other rheumatoid diseases such as rheumatoid arthritis, rheumatoid factor, LE cells, antinuclear antibodies or other autoantibodies can be positive, IgG can be normal, or can be Decrease; IgA can be increased or decreased. About half of the patients' E-rosette formation decreased, PHA test decreased, and HLA-B27 was positive.

5. Pediatric ulcerative colitis laboratory examinations include routine stool and culture and complete blood routines. During the active phase of pediatric ulcerative colitis, increased erythrocyte sedimentation, increased white blood cells, decreased serum albumin, and significantly increased globulin, The decrease of -globulin, the decrease of immunoglobulin IgE, the decrease of the number of T cells and T cell subpopulations, suggest that the presence of immune complexes in the diseased part of the child, and acute phase reactants (erythrocyte sedimentation, C-reactive protein, serum mucin-like levels) 90% of children with Crohn's disease are elevated, while ulcerative colitis is relatively rare. During the active phase of inflammatory bowel disease, polymorphonuclear cells can be seen to accumulate in the intestinal segment of inflammation.

1. X-ray examination of the barium enema showed that the affected colonic colon bag became shallow and disappeared, and the edges were smooth or rough. Most shallow ulcers can show a lot of fine burr-like protrusions on the edge of the intestine, and larger ulcers can cause the edge of the colon to appear. A series of small ulcers of similar size and shaped like ulcers at the bottom of the buttocks, but rare, often with disordered mucosal arrangement, varying thickness or obscurity, and deeper ulcers can also appear. There is a small circle of translucent mucosa around this ulcer. Edema, fine spotted barium in the center, which is the small pimple where the ulcer is located. The double contrast shows that the ulcer is clearer. Most small ulcers can lose the normal smooth thin line state of the colon edge, and appear rough and uneven, like a layer of fine wrinkles. Paper, the small protruding part is the shadow, the larger ulcers can form a row of light-permeable small diverticulum-like protrusions outside the intestinal cavity, viewed from the front in a high-density disc shape, with a thin circle around the barium Translucent edema area.

The chronic phase is mainly a granulocytic change of colonic mucosal hyperplasia, which is accompanied by ulcers. Barium filling images show that the intestinal canal is rough or uneven, with small papillary protrusions of different shades, and the size of the protrusions is generally 2 to 3 mm, as if A small layer of stones was laid on the inner edge of the intestinal wall, and the mucosa after barium removal appeared to be a disorder of the mucosa, with most polypoid filling defects of varying sizes, like red beans.

Chronic advanced cases are mainly manifested by intestinal wall fibrosis. In the barium enema, no matter the filling image or mucosal image, the contour of the narrow intestine is smooth and stiff, and the intestinal cavity is not well dilated or contracted. If the intestinal cavity is inflated or inflated, it cannot expand.

Peripheral arthritis X-ray examination is normal or mild to moderate osteoporosis, periostitis, bone erosion and cartilage destruction are occasionally seen, joint ankylosis is rare, and ankylosing spondylitis X-ray findings are shown in the first section of this chapter.

2. Sigmoidoscopy during the acute phase of the mucosa was diffuse congestion, edema, bleeding, erosion and fine-grained, and there were most ulcers of irregular shape and size, varying degrees of depth, covered with yellow-white or bloody exudates, advanced patients Intestinal wall thickening, intestinal cavity narrowing, pseudopolyps formation, non-specific inflammatory lesions and fibrous scars can be seen on the biopsy, while erosion, crypt abscess, abnormal glandular arrangement, and epithelial changes can be seen.

3. Colonoscopy and X-ray examination of pediatric ulcerative colitis:

(1) Colonoscopy: In most cases, colonoscopy and biopsy are needed. The type, location, and extent of the lesion can be determined based on direct observation and biopsy results. When children are anxious about rectal microscopy, sedatives can be used. Domestic experience of 283 infants and young children with endoscopy. The test is relatively safe. The diagnostic accuracy of ulcerative colitis is 83.3%. Early endoscopy is characterized by the disappearance of intestinal mucosal blood vessel texture, and the mucosa manifests as congestion, edema, erosion, and small. Ulcer formation, or rough mucosa, fragile and easy to bleed, mucosal thickening in the later stage, pseudopolyps formation, large ulcers and stenosis in the intestinal wall, but it should be distinguished from Crohn's disease colonoscopy, Crohn's disease in children Segmental thickening of the intestinal wall was seen under endoscopy, and the early mucosal lesions were multiple, with clear boundaries, raised erythema, and gradually became aphthous superficial ulcers, single or multiple vertical ulcers. Formation of segments, skipping bowel stenosis and mucosal pebbles, sometimes difficult to distinguish from ulcerative colitis, but if fistula and anal fissure are seen, it is helpful for the diagnosis of Crohn's disease.

(2) X-ray examination: X-rays can generally show small serrated protrusions on the edge of the intestinal sac in the early stage of ulcerative colitis, disappearance of the intestinal sac in the later stage, and deformation of the intestinal tract. Double contrast of barium can show changes in the microstructure of the mucosa and superficial ulcers. When severe ulcer activity, you should be alert to the possibility of barium enema to induce colonic dilatation and perforation. It is necessary to pay attention to identify with Crohn's disease. Foreign pediatric gastroenterologists advocate the use of upper gastrointestinal X-ray examination for children with inflammatory bowel disease. The first observation of the stomach, duodenum, and then the small intestine, colon will help determine the extent of the disease, distinguish between ulcerative colitis and Crohn's disease. X-rays of Crohn's disease show irregular intestinal thickening of the intestinal mucosa. Cobblestone-like changes, or enlarged colonic bags, multiple longitudinal or fissure ulcers, asymmetric intestinal stenosis, intestinal wall stiffness, or fistula formation.

4. Examination of ulcerative colitis in pregnant women General diagnostic measures for ulcerative colitis are applicable to pregnant patients, but X-ray examinations should be minimized. If pregnancy is considered in order to develop a treatment plan, sigmoid colon should be safely implemented Microscopy, but a total colonoscopy is contraindicated. Proctoscopy is only considered when necessary, especially in the third month of pregnancy.

Complications of ulcerative colitis arthritis

Local complications

(1) A large amount of blood in the stool: Blood in the stool is one of the common symptoms of ulcerative colitis. A large amount of blood in the stool refers to a large amount of bleeding in the intestine in a short period of time, accompanied by a rapid pulse, decreased blood pressure, and decreased hemoglobin. Those who need blood transfusion to relieve the condition Although the amount of blood in the stool is sometimes difficult to estimate accurately, it is an indicator for assessing the severity of the disease. When there is fever, tachycardia, and blood volume decline, the hematocrit cannot reflect the degree of anemia and the cause of bleeding, mainly due to ulcers Involving blood vessels, in addition to hypothrombinemia is also an important cause. Some people abroad have reported that in 58 cases of colectomy due to bleeding, 37 cases had hypothrombinemia.

The literature reports that the incidence of massive bleeding is less than 5% (1.1% to 4.0%), which is more common in severe cases. Lower gastrointestinal bleeding secondary to ulcerative colitis is not uncommon in China, and bleeding can cause severe anemia and acute bleeding. 50% of patients have toxic megacolon. Therefore, when ulcerative colitis is bleeding, the possibility of toxic megacolon should also be considered. Generally, active intensive medical treatment can stop bleeding, and life-threatening patients need emergency surgery. surgery.

(2) Toxic megacolon: Toxic megacolon is a serious complication of ulcerative colitis, which mostly occurs in patients with severe, fulminant, and total colitis. According to reports, the incidence rate abroad is 1.6% to 13.0%; It is rare in China, with a report of 2.6%, and the mortality rate can reach 11% to 50%.

This is because severe inflammation spreads to the colonic muscularis and intermuscular plexus, disrupting the normal intestinal nervous and muscle regulatory mechanism, resulting in low bowel wall tension, paralysis of the segments, and large accumulation of intestinal contents and gas, which causes acute The colon expands and the intestinal wall becomes thinner. Various factors that promote the increase in the pressure of the intestinal cavity or the decrease in intestinal muscle tension can cause the colon to expand, involving the sigmoid colon and the transverse colon. Because the transverse colon is positioned forward in the supine position, gas is easily accumulated. Therefore, colon expansion, intestinal wall pressure increase, bacteria and intestinal contents enter the intestinal wall and blood flow through ulcers, causing bacteremia and sepsis, and can further expand the colon, vasculitis, intestinal plexus or mucosa The involvement of the lower plexus may be the cause of irreversible expansion.

Some drugs, such as anticholinergics (atropine, etc.) or opioids, can reduce intestinal muscle tone, inhibit bowel movements, and induce or aggravate toxic colonic dilatation. Therefore, antidiarrheal agents (such as compound fendiphen) ) And the use of laxatives during intestinal preparation may be induced. During barium enema (and preparation before enema) or gastroscopy, gas injection and catheter operation can interfere with blood flow or cause trauma, so heavy patients should not do the above. Examination, hypokalemia is also a common cause, but it may also be spontaneous. Other causes of toxic megacolon include infections. The pathogens include Campylobacter jejuni, Shigella, Salmonella, and Clostridium.

The clinical manifestations depend on the rate of occurrence, the degree of colonic expansion, the degree of poisoning, and the presence or absence of perforation. Patients often have varying degrees of dehydration, fever, tachycardia, anemia, increased white blood cells, and even shock. Original diarrhea, blood in the stool Sometimes, the symptoms of abdominal pain are alleviated. Electrolyte disorders, anemia, hypoproteinemia, and toxic neuropsychiatric symptoms can exist to varying degrees. Severe diarrhea, stools as many as 10 times a day, the condition rapidly deteriorates, symptoms of poisoning are obvious, accompanied by Abdominal distension, tenderness, rebound pain, weakening or disappearance of bowel sounds, and obvious abdominal distension, especially when the transverse colon expands, often with abdominal distension, wide abdominal cavity can be seen on the plain film, colon bag disappears, etc., the diameter of the transverse colon reaches 5 Above 6cm, it is easy to be complicated by intestinal perforation and cause acute diffuse peritonitis. The clinical diagnostic criteria of toxic megacolon need to meet the following points:

Plain film of the abdomen showed obvious expansion of the colon, and the transverse diameter exceeded 5-6cm.

There are at least three of the following manifestations: A. body temperature> 38.6 ° C; B. heart rate> 120 beats / min; C. significantly increased white blood cells; D. anemia.

There must be one of the following symptoms of poisoning: A. disturbance of consciousness; B. decreased blood pressure; C. dehydration and / or electrolyte disturbance.

For first-time patients with a short course of treatment, rectal microscopy should be performed to observe local signs of ulcerative colitis. Examination above the rectum is a certain risk and should be avoided. The use of glucocorticosteroids may cover the symptoms of colonic expansion and make the diagnosis. Ignored, care should be taken in choosing the timing of surgery, delaying surgery may increase mortality, and the prognosis of this complication is poor.

(3) Intestinal perforation: Most of them are serious complications of toxic colonic dilatation. Due to its rapid expansion, intestinal wall thinning, blood circulation disorders, and ischemic necrosis, acute intestinal perforation can also be seen in severe patients. The incidence is reported abroad. 2.5% to 3.5%, mostly in the left hemicolon, causing diffuse peritonitis, free perforation of the megacolon is extremely rare, severe cases of shock, peritonitis and sepsis are the main causes of death, the application of corticosteroids is an important cause of this complication At the same time, due to the use of corticosteroids, clinical symptoms are often atypical, X-ray abdominal plain film examination only found the free gas under the diaphragm, therefore, special caution should be taken.

(4) Polyps: The concurrency rate of polyps in this disease is 10% to 40%. This kind of polyps is called pseudopolyps. The so-called pseudopolyps are due to a large number of late stage, new granulation tissue hyperplasia, normal mucosal tissue edema, which is normal. The mucosal surface protrudes to form a polyp. This polyp is pathologically an inflammatory polyp. Dikes and Caunsell are further divided into a mucosal droop type, an inflammatory polyp type, and an adenoma-like polyp type. Most of the inflammatory polyp type are found in In patients with long-term ulcerative colitis, the site is related to the inflammation area. The most common site of polyps is in the rectum. It is also believed that the descending colon and sigmoid colon are the most common, and they decrease in order. Part of them can disappear with colon inflammation. Sexual polyps are transformed, and some are directly derived from normal mucosa. They are also more common in patients with long-term ulcerative colitis. The incidence is 3 to 5 times higher than that of the general population. They are usually accompanied by varying degrees of dysplasia, such as mild dysplasia. Can be re-examined as a routine colonoscopy for about one year; moderate dysplasia is considered as a precancerous lesion and should be followed up; if severe dysplasia is confirmed by re-examination, surgery is recommended In addition, once adenomas are found, special attention should be paid to whole colon examination to observe the existence of multiple adenomas and accompanying cancers. Due to the popularity of electrocoagulation, all patients who are likely to be removed can be removed by colonoscopy. After the disease, because the cancer mainly comes from adenoma-type polyps.

The main outcomes of polyps are: part of it disappears with the healing of inflammation; is destroyed with the formation of ulcers; persists for a long time; cancerous.

(5) Carcinogenesis: It is currently recognized that ulcerative colitis is complicated by the incidence of rectal cancer. The chance of rectal cancer is higher than that of the general population of the same age and gender group. The reason is still not clear. The internal defect of the mucosa or from chronic chronic inflammation. The result may be the most important inducement, and the environment, nutrition and genetics may also be important factors. From the perspective of molecular biology, the evolution of ulcerative colitis to colon cancer is an oncogene and suppressive factor in colon epithelial cells. Cumulative process of oncogene complex mutations.

It is generally believed that the trend of canceration is related to the duration of the disease and the anatomy of colitis. After 15 to 20 years of disease, the risk of canceration increases by about 1% per year. For patients with pancreatitis and those with a disease duration of more than 10 years, the risk of colon cancer 10 to 20 times higher than the general population. Western countries report that the incidence of rectal cancer is 3% to 5%, and some are as high as 10%.

Cancer is more common in lesions that affect the entire colon, with young onset and a history of more than 10 years. Chronic and persistent colon cancer is common, and the age of onset has been considered an important factor. However, research in recent years has shown that these factors may Does not increase the risk of colon cancer. Deroede reports that children with a medical history of more than 10 years, and 20% of them will become cancerous in the next 10 years. Children are generally affected by the entire colon. Adults are mostly located in the distal colon. In adults, the risk of colon cancer may be the same. Cancer can also occur on the basis of pseudopolyps, mainly from adenoma-like polyps, but some patients do not have polyps in their colon cancer sites.

Patients with ulcerative colitis often develop colon cancer during the quiescent period of the disease. Because bleeding or diarrhea is easily regarded as a recurrence of colitis, the clinical symptoms of ulcerative colitis and colorectal cancer overlap, so the diagnosis of cancer is mostly advanced. The tumors that occur on the basis of ulcerative colitis can have a polyp, nodular or spot-like appearance, may be flat and small in size, and even experienced endoscopy and radiologists are often difficult to diagnose. Ulcers Intestinal stenosis of rare colitis is rare, but it can be accompanied by tumor infiltration.

The clinical symptoms of active ulcerative colitis sometimes overlap with the clinical symptoms of ulcerative rectal cancer. As a result, the diagnosis of cancer has been postponed. In some cases, lymph nodes and distant cancers have been reported in more than 60% of these cases during laparotomy. Swelling metastasis, therefore, early diagnosis is important.

Colorectal cancer that occurs in ulcerative colitis has a worse prognosis and higher malignancy than colon cancer that does not occur in colitis. It has the following characteristics: mostly mucus-secreting cancer; mostly primary cancer can be seen uniformly in any intestinal segment of the colon, ulcerative colitis complicated with rectal or sigmoid colon cancer is only about 1/4, and 70% to 80% of common colon cancer occurs in the rectum and sigmoid colon; Diffuse infiltrating cancer; early cancers are mostly coarse particles, low papillary irregular bulges, or even uneven.

Ulcerative colitis with atypical hyperplasia, especially severe dysplasia, should be regarded as a precancerous lesion, and it must be histologically atypical hyperplasia. 50% of them can be associated with colon cancer at the same time. The morphological research group of inflammatory bowel disease composed of scientific experts proposed classification and evaluation of dysplasia, and classified it into negative, ambiguity or positive, and further classified dysplasia (possibly negative). (Or may be positive), and at the same time, the atypical hyperplasia positive is divided into mild and severe, and it is impossible to determine how much time it takes to develop from severe atypical hyperplasia to cancer, but the development process of atypical hyperplasia may be quite slow; at a certain time Within, the lesions can be relatively stable and sometimes even have a tendency to resolve on their own; this pathological change is not irreversible.

In inflammatory bowel disease, metaplasia and atypical hyperplasia of the ulcer edge epithelium and inflammatory polyps are precancerous states, the severity of which is related to the risk of cancer. For extensive colitis, the duration of the disease lasts more than 10 years, or Patients with left colitis who have been active for more than 20 years should undergo endoscopic examinations every year. If the mucosa is normal, each biopsy should be separated by 10 cm. When suspicious lesions are found, such as mucosal bulges, ulcerative plaques, etc., additional biopsy should be performed. For histological examination of cell smears, due to the infiltrating characteristics of cancer, sometimes endoscopic examinations of submucosal tumors may fail. It is found that definitive developmental abnormalities of various grades are an indication of colon resection.

The cancerous characteristics of ulcerative colitis can be summarized as follows: the age of onset is earlier than the general population, it is usually evenly distributed in various parts of the colon, but has a tendency of more proximal distribution, only about 1/4 occurs in the rectum, sigmoid colon, and can be It is polycentric. The pathological type is gelatinous cancer, and there are many poorly differentiated cancers, which are invasive, such as thickening of the leather-like intestine, and the narrowness caused by benign is not easy to distinguish from benign ones. It has higher malignancy and poor prognosis than general colon cancer.

Therefore, for more than 10 years, chronic recurrent episodes, especially chronic persistent patients, if exacerbation of abdominal pain, bleeding, anemia and hypoalbuminemia, etc., should pay attention to the possibility of canceration. In time, regular colonoscopy or barium irrigation examination is still the most Valuable examinations, multiple biopsies during microscopy, and looking for cancerous or precancerous lesions are very helpful for diagnosis. Riddell has proposed various treatments for dysplasia. Due to difficult judgments, its promotion has been limited. Most authors so far The Morson dysplasia classification scheme is still used.

(6) Intestinal stenosis: In some patients undergoing barium enema examination or colonoscopy, colonic stenosis may be seen, with an incidence rate of 6% to 10%, which mostly occurs in a wide range of lesions and lasts for 5 to 25 years. Of the patients, the site is more common in the left semicolon, sigmoid colon or rectum. The cause of stenosis is often not due to fibrous tissue hyperplasia, but due to the formation of inflammatory polyps, thickening of the mucosal muscular layer, and obstruction of the intestinal cavity.

Generally, there are no symptoms in the clinic. Abdominal colic may be an important sign. In severe cases, it can cause partial bowel obstruction. When intestinal stenosis occurs in ulcerative colitis, be aware of the tumor and identify its benign and malignant. Obvious colonic stenosis can occasionally be caused by Colonic spasm, narrowing disappears after intravenous glucagon injection, colonoscopy is sometimes difficult to exclude deep invasive cancer by biopsy and cytology. If there is any doubt about the diagnosis of colon cancer, colonectomy should be considered If the tumor can be ruled out, sac expansion can eliminate stenosis without surgery; if it cannot be ruled out, surgical resection is required. Sometimes, the stenosis at the stage of inflammatory activity can be caused by intestinal spasm, which is reduced with inflammation control.

(7) Rectal and perianal lesions: Local complications of ulcerative colitis include hemorrhoids, anal fissures, perianal or sciatic anal fossa abscess, rectal vaginal fistula, and rectal prolapse. These complications are severe in patients with severe diarrhea. It is most likely to occur. Anal fissure can be improved when colon inflammation is controlled. Perirectal abscesses and rectal fistulas can heal only after abscess incision and drainage or fistula openings. Hemorrhoids account for 10% of patients. Rectal prolapse often occurs. Cases of chronic diarrhea associated with ulcerative colitis during active phase are more common with colitis, which is related to the severity of diarrhea. Perianal lesions are seen in about 20% of patients, such as anal fistula and perianal abscess, which are far less common than Crohn's disease. Abscesses often require conservative surgical treatment, such as drainage, and severe cases sometimes require total colectomy.

2. Systemic complications

(1) Liver lesions: 15% of ulcerative colitis has abnormal liver function to varying degrees, but only 2% to 5% of patients have lesions. Peribiliary inflammation accounts for 50% to 70% of hepatobiliary lesions, which is the portal area. Lymphocytic inflammation, most liver functions are normal, and inflammation around the bile ducts during biopsy, recurrent bile stasis, and a few have ascending cholangitis. Primary sclerosing cholanagitis (PSC) is caused by the liver Biliary duct inflammatory fibrosis and sclerotic damage, causing bile duct obstruction and recurrent inflammation, manifested as cholestatic jaundice and pruritus, epigastric pain, hepatosplenomegaly, etc. About 10% of ulcerative colitis complicated with PSC, 50% 70% of PSC patients have inflammatory bowel disease, and some patients have inflammatory bowel disease after PSC, which increases the difficulty of diagnosis. The branched bile duct branch can be determined by ERCP. Corticosteroid application can inhibit inflammation and antibiotic application can treat retrograde disease. Infection, a few can be complicated by biliary cirrhosis and bile duct cancer.

(2) Arthritis: The rate of ulcerative colitis complicated by arthritis is about 11.5%, which is characterized by the concurrent occurrence of severe enteritis lesions, which are more common in large joints, and often single joint disease, joint swelling, synovium Fluid accumulation, no damage to bones and joints, no serological changes in rheumatism, and often coexist with eye- and skin-specific complications.

(3) Skin lesions: Nodular erythema is more common in the acute phase of colitis, with an incidence of 4.7% to 6.2%. It can also have arthritis, which is more common in women. Gangrene purulent disease has not been reported in China, and the oral mucosa is refractory. Ulcers are also not uncommon, sometimes as thrush, with poor treatment results.

(4) Ocular diseases: iritis, iridocyclitis, uveitis, corneal ulcers, etc., the former is the most, seen in 5% to 10% of patients, ulcerative colitis is more common than Crohn's disease, more associated with Severe colitis, arthritis, skin lesions, oral aphthous ulcers, etc. also disappear with the control of colitis, and iris can threaten patients' vision.

(5) Thromboembolic complications: accounting for about 5% of cases, which can occur in the abdominal cavity, lungs, brain and other parts of the body, or manifested as migratory thrombophlebitis, more common in women, and more often related to disease activity Sexually related, it may be caused by the formation of a hypercoagulable state in ulcerative colitis. Platelets and factors such as , , and increase. They can disappear after colon resection. In severe cases, it can be caused by DIC. Multiple organ ischemic infarction. In addition, ulcerative colitis may appear hypercoagulable, with thrombosis and thromboembolism, thrombocytosis, and arteritis.

(6) Growth retardation: It is seen in more than 15% of ulcerative colitis. The patient is short, thin, and lack of secondary sexual characteristics in adolescents. It is mainly related to malnutrition and disease consumption.

(7) Enterocolitis: The lesions complicated by enterocolitis are mainly in the distal ileum, manifested as umbilical or right lower abdominal pain, watery stools and fatty stools, which accelerates the progress of patients with systemic failure.

(8) Complications brought by drug treatment itself: such as azathioprine and thiopurine inhibit bone marrow, cause thrombocytopenia, and occasionally cause drug-induced pancreatitis; sulfasalazine complicated by acute pancreatitis; corticosteroids complicated by sepsis, Peptic ulcers, diabetes and cataracts should also be taken seriously.

3. The incidence of toxic megacolon in elderly patients with late-onset ulcerative colitis is higher than in elderly patients with early-onset ulcerative colitis; the incidence of tumors is related to the course of disease, the longer the course of disease, the higher the risk of concurrent tumors .

4. Delayed growth and sexual development is another clinical feature of pediatric inflammatory bowel disease. Many studies have shown that 6% to 8% of children with ulcerative colitis have delayed growth and sexual development. Common iron deficiency anemia, oral Aphtoid Ulcers are also common skin and mucosal lesions of inflammatory bowel disease. The lesions are often multiple. The disease is aggravated during the active phase of the disease and recurrent. About 6% of children can have renal calcification. In addition, renal complications include hydroureteric effusion and pyelonephrosis. Water, or Crohn's disease pyelonephritis, may be caused by inflammatory masses pressing the ureter or bowel-bladder fistula. Rare renal insufficiency can be secondary to amyloidosis.

Prognosis of ulcerative colitis arthritis

According to foreign data, the course of most (about 80%) patients with ulcerative colitis presents with repeated intermittent episodes, and the remission time varies widely, ranging from weeks to years, with the course of 10% to 15% of patients Chronic and persistent, while the remaining few patients have severe seizures and require emergency colectomy. Very few patients have only one episode. According to a study in Copenhagen, Denmark, adults over 18 years of age About 1% of patients no longer relapse after onset. According to the author's statistics, among 10218 Chinese patients with ulcerative colitis, the initial type accounted for 34.8%, the chronic recurrent type accounted for 52.6%, and the chronic persistent type accounted for 10.7%. Acute fulminant type accounts for 1.9%. The above data shows that ulcerative colitis is mainly of chronic recurrent type, both at home and abroad. Therefore, ulcerative colitis is a disease characterized by continuous recurrence and remission. It is characterized by acute non-infectious inflammation of the colorectal mucosa. The rectal mucosa is always involved. Fusion inflammation and superficial ulcers extend from the edge of the anus to the proximal end. The patient can be Enteritis, colitis left (proximal splenic flexure less boundaries), extensive colitis (including transverse) or pancolitis.

At any point in the course of the disease, 50% of the patients are asymptomatic, 30% have mild symptoms, and 20% have moderate to severe symptoms. Many patients can achieve complete long-term remission, but the probability of relapse for two years is only 20%. Less than 5% of patients do not relapse in 10 years, and the recurrence site is generally in the area of previous colon lesions.

The extent of colonic inflammation during ulcerative colitis determines the severity and course of the disease to a certain extent, that is, patients with colitis with generalized or total colitis are more severe than those with more limited lesions, which may be needed in the future. There is also a relatively large proportion of colectomy treatments, as found in the Danish study mentioned above. Among those with pancreatitis at the time of onset, about 1/3 of the patients had colectomy treatment in the first year of the disease. Among the patients with more limited lesions, less than 8% of the patients underwent the above-mentioned surgical treatment. However, once the first year has passed after the onset of disease, the disease course of patients with different disease ranges is basically similar. However, because of the short course of disease in Chinese patients, the bowel There were few external complications, and only 1.3% of the patients had surgery.

There is no large case statistics report on the malignant rate of ulcerative colitis in China. Foreign reports suggest that the course of disease is more than 8 years, and the range of lesions is close to the sigmoid colon. These are the two main factors that increase the risk of colon and rectal cancer. At the same time, they have primary sclerosis. Chronic cholangitis also increases this risk. Regular screening (1 to 2 years) for bowel abnormalities through colonoscopy is the only feasible way to monitor tumors. Before entering the monitoring process, patients must know the end point of this process. Such as surgery.

In patients with chronic recurrent ulcerative colitis, the risk of colorectal cancer is increased, and the risk of colon cancer is highest in generalized or pancreatic colitis, but only in patients with a disease course of more than 10 years (every year (Approximately 0.5% to 1%) is only valued. If cancer occurs, it can occur in all parts of the colon, and may be multiple cancers. In patients with colitis who have chronically passed after adolescence, the cancer The risk is also high, but it does not necessarily become an independent risk factor.

The risk of cancer is not increased in patients with proctitis, and the risk of left hemicolitis is very small, but the conclusions of various studies are inconsistent. Most of the relevant studies currently conducted are from the data of hospitalized patients. In the population, ulcerative colitis is relatively uncommon and the incidence of cancer is relatively low. Therefore, it is difficult to carry out population research. It may take at least 20 years of follow-up to obtain certain prospective research conclusions.

So far, although there are many reports on the results of monitoring programs for the prevention of colon and rectal cancer in patients with ulcerative colitis, they are all non-randomized studies. At present, the most practical can be recommended for patients with ulcerative colitis The decision of whether to perform a colonectomy should be based on the results of a colonoscopy once a year to determine whether there is an atypical hyperplasia. However, it should be noted that the colonoscopy should be performed as soon as possible without clinical recurrence. Multi-site biopsy at 10 cm intervals, and colonoscopy every 2 years may reduce the cost, but there is a risk of reducing the chance of early detection of positive cancer. Any theoretically feasible monitoring plan should be combined with the patient's Consider compliance.

The U.S. "inflammatory inflammatory bowel disease dysplasia morphology research group" has developed and published diagnostic criteria for dysplasia, including low or high limits, as a more stringent diagnostic criteria for dysplasia for clinical reference applications. The cost of this surveillance program to diagnose precancerous lesions or cancer itself is about $ 93,000 in the United States. In other cases, the cost of colony screening for individuals with a high risk of colon and rectal cancer using flexible sigmoidoscopy Equivalently, if the diagnosis of atypical hyperplasia is established, patients with low or high levels should undergo colectomy in a timely manner, but it should be emphasized that the positive neobiological atypical hyperplasia must first be caused by inflammation or repair. Identification of atypical regeneration to confirm a pathologically correct and strict diagnosis of atypical hyperplasia. If a reliable diagnosis of atypical hyperplasia has been established, it is not necessary to repeat the inspection again before making a decision on whether to undergo surgery, but When the biopsy report is "not sure" atypical hyperplasia, it should be repeated by a professional gastroenterologist or After repeated symptoms of colonoscopy, further confirm the diagnosis, confirmed atypical hyperplasia refers to the authority of the gastrointestinal pathologist reviewing the slice certainly, rather than repeat monitoring checks to reaffirm dysplasia sites.

The disease can be relieved and relapsed many times, but because most cases are mild, it can be relieved by medical treatment for a long time, return to work, fulminant symptoms, complications or age over 60 years, the prognosis is poor.

If a clear diagnosis can be made and actively treated in the early stages of the disease, the prognosis of senile ulcerative colitis is relatively optimistic. In fact, severe ulcerative colitis is dangerous for patients of any age. , A group of 269 patients (20% of patients were 60 years of age or older) showed that after 10 years of follow-up, 28% of the patients needed surgery, 28% of patients with lesions clearly located in the rectum, 22% had Extensive colonic disease. In patients with extensive colonic disease (10 years or more), the risk of colorectal cancer is found to increase. Subsequently, the risk of cancer in this disease increases by about 20% every 10 years. A colorectal cancer study of 35 patients with ulcerative colitis showed that the 5-year survival rate of the cancer was 33.5%, and the median age for diagnosis of cancer was 45 to 49 years. Because ulcerative colitis patients are always observed regularly Under follow-up, the early diagnosis of malignant lesions may be earlier than the general population, and the prognosis is relatively good.

Pathogenesis of ulcerative colitis arthritis

1. The study found that ulcerative colitis, Crohn's disease, and ankylosing spondylitis have family relationships, and all three diseases have a certain relationship with HLA-B27, but the penetrance rate is not high. The data in recent years prove that The abnormal mucus secretion of the intestinal mucosa is related to hereditary qualities.

2. All colitis colonic tissues contain 40kD organ-specific protein antigens that can bind to IgG. Crohn's disease serum contains only glycoprotein antibodies against the small or large intestine. Patients' lymphocytes are in tissue culture. Can damage colonic epithelial cells. Patients' serum often contains one or more factors that inhibit macrophage migration, often accompanied by immune diseases such as iridocyclitis, uveitis, nodular erythema, and autoimmunity. Hemolytic anemia and systemic lupus erythematosus, etc., have been used to reproduce experimental ulcerative colitis models using immunological methods. Therefore, the disease can be considered to be caused by autoimmune mechanisms.

3. Destructive effects of lysozyme Some people think that the intestinal wall secretes too much lysozyme.

4. Oxygen free radical damage The pathological process of this disease is affected by factors such as increased intestinal pressure, increased sympathetic nerve activity, and increased endogenous programmed vasoconstrictive substance activity, thus reducing intestinal blood flow, or after temporary ischemia Reperfusion occurs, causing insufficient oxygen supply, especially under the action of intestinal xanthine oxidase, etc., which can lead to the formation of a large number of oxygen free radicals and damage the intestinal mucosa. At this time, cell phospholipids release arachidonic acid products, especially Leukotriene B4 chemotactic neutrophils, which are rich in NADPH oxidase, can further form oxygen free radicals and aggravate intestinal mucosal damage.

5. The pathogenesis of ulcerative colitis in the elderly is the same as in young people, and it is not very clear so far. Recent research suggests that there are three factors that may play a part in the occurrence of the disease before the onset of smoking, namely excessive consumption of refined sugars. Low in fiber and low intake of fruits and vegetables.

6. The pathogenesis of ulcerative colitis in children is still not very clear. In recent years, some scholars have found antibodies against autocolonic epithelial cells from the serum of children. The antigenic substance is a mucopolysaccharide of colonic epithelial cells. The autoantigen-antibody reaction causes peripheral lymphocytes to damage colon and rectal mucosal epithelial cells, causing inflammatory reactions such as hyperemia and ulcers. Children are in the period of growth and development, and the intestinal mucosal barrier is not fully developed. Bacteria and antigenic substances can pass through the intestinal mucosal barrier and The mucosal layer is sensitized after contact with lymphoid tissues. With the completion of children's growth and development, the function of the intestinal mucosal barrier is becoming better and better. This contact is isolated, but in the case of food allergies, increased intestinal bacterial concentrations, and intestinal fecal retention, etc., or Intestinal bacteria can cause damage to the intestinal mucosa when the contact time is too long. If the lymphocytes remain highly sensitized, enterobacterial antigens can cause allergic reactions through the intestinal mucosa and cause damage to tissues and organs containing the target antigen. Ulcerative colitis.

The role of inflammatory mediators in the occurrence of ulcerative colitis is another important topic in foreign research in recent years. Some people believe that ulcerative colitis and inflammatory mediators, such as metabolites of arachidonic acid, cell activating factors and oxygen free radicals It is related to the increase. In addition, neuropeptides, substance P, and vasoactive intestinal peptide are also related to a certain part of the pathogenesis of ulcerative colitis inflammation.

Food allergies and mental factors can cause intestinal wall mucosa allergies, increased mast cell degranulation reactions, and abnormal colonic motor function and blood supply caused by vagal and sympathetic nerve overstimulation, causing intestinal smooth muscle spasm, intestinal wall congestion, edema and even ulcer formation .

7. Pathology Intestinal pathological changes affect the rectum and sigmoid colon, and can also extend to the descending colon and the entire colon.

(1) Mucosa: The degree of mucosal change depends on the degree of inflammation and the length of the disease. Generally, it can be divided into 5 stages:

Early mucosal hyperemia and swelling, followed by reduction of goblet cells. The damaged mucosa can further form crypt abscesses and focal neutrophil infiltration due to bacterial infection. Lymphocytes and plasma cells are distributed in clusters with intestinal walls. Hyperplasia of lymphoid tissue may be an early immune response.

Active phase: The mucosal capillaries are markedly congested and dilated, with intestinal wall hemorrhage, there may be varying degrees of epithelial cell necrosis, goblet cells decrease, and they can disappear in severe cases, lymphocytes and plasma cells in the lamina propria aggregate, accompanied by Focal neutrophil infiltration in the crypts can form crypt abscesses, irregular mucosal contours, and surfaces covered with pus, blood, and exfoliated epithelial cells.

Dissipation period: mucosal hyperemia, swelling reduced, neutrophils and crypt abscesses gradually disappear, epithelial cells regenerate, goblet cells can return to normal, lymphocytes and plasma cells in lamina propria gradually decrease, along with the inflammatory process Disappearance can gradually become focal infiltration.

Remission period: The patient enters the remission period after 1-2 episodes of seizures. Sometimes the remission can be sustained. The sigmoidoscopy shows that the mucosa is close to normal, but the X-ray abnormality persists. There are different degrees of mucosal atrophy under the microscope. Sometimes There is only a single layer of columnar epithelium, and there are small and short crypts. In addition, there are few lymphocytes. The plasma cells are focally infiltrated. Epithelial hyperplasia can be found at the base of the crypt, but the goblet cells are not significantly reduced. .

Quiet period: Some patients show persistent colitis with no obvious remission and worsening. The mucositis of these patients is limited to the part where the propria layer lymphocytes and plasma cells increase, occasionally crypt abscesses may be seen, and the epithelium may have mild goblet shape. The number of cells decreases and the number of lymphoid follicles in the mucosa increases.

(2) Muscle layer: Muscle layer abnormality is one of the common features of this disease, mainly manifested by shortening the colon, disappearing of the colonic bag, shortening the length of the sigmoid colon, thickening of the colon wall, and narrowing of the intestinal cavity. These changes are due to muscular layer abnormalities Caused by the abnormal nature of the muscular layer is the contraction of smooth muscles, not spasms.

(3) Anus: This disease may have acute anal fissure, acute perianal or sciatic anal fossa abscess, and sometimes there are low anal fistula and rectal vaginal fistula.

(4) Pathological changes outside the intestinal tract: joint synovial biopsy, showing synovial hyperplasia, fibroblast proliferation, angiogenesis, microvascular deposition on the synovial surface with neutrophil, lymphocyte and plasma cell infiltration under the microscope Some areas have obvious cartilage erosion, and other organ system pathological changes are the same as Crohn's disease arthritis.

(5) The histopathological characteristics of ulcerative colitis in the elderly are roughly similar to those in young people, and there may be some differences in the immune response between them. Gebber and Ottc found in the inflammatory area of the disease activity. The low cell / lymphocyte ratio suggests that there may be some differences in immune responses between older and younger people.

(6) Children's ulcerative colitis is basically similar to the histopathological changes of adults. Most of the lesions occur in the rectum and sigmoid colon, and can sometimes spread upward to the left semicolon, transverse colon, and even the entire colon, rarely involving the terminal ileum. The pathological changes are divided into two Phase, acute phase, first of all, mucosal congestion and edema, scattered superficial ulcers, pus, blood and mucus, with lymphocytes, plasma cell infiltration, and eosinophil and neutrophil infiltration, chronic phase Congestive edema subsided, ulcers healed, mucosal regeneration, a large number of new granulation tissue formed pseudopolyps, and eosinophil infiltration and degranulation were seen.