Crohn's disease

Crohn's disease has various names, used synonymously: granulomatous enteritis, transmural ileitis, regional enteritis, terminal ileitis. They indicate the localization of bowel damage.

This is a serious disease caused by immuno-dependent granulomatous inflammation of the gastrointestinal tract. It affects not only the thick or small intestine, but also the oral cavity. The predominant localization of changes in 2/3 of the cases is in the final department of the ileum and the large intestine, so in practice the name Ileocolitis was fixed.

Together with ulcerative colitis according to ICD-10 is included in the class "Noninfectious enteritis and colitis" with code K 50. Additionally it is subdivided into clinical forms depending on localization and a group of unspecified lesions.

The first described the pathology of American gastroenterologist B. Crohn in 1932.He was able to trace and group the characteristic symptomatology by the example of 18 cases from his observations.

Prevalence of

Crohn's disease is diagnosed in both adults and children. Most of the cases were found in the north of the European continent, in the USA, Canada. In Asia and Africa, the incidence is much lower.

Every year, 2-3 primary cases per 1,000 population are identified, 10-15 cases per 100,000 children. Assume 2 age "peak" incidence: first in 15-35 years, then in 60 and older. Men are ill almost twice as often as women.

There is an ethnic connection: the frequency of detection in Ashkenazi Jews is 6 times higher than the average

. The causes of

The causes of Crohn's disease are still a mystery to scientists. There is a connection with some factors, which allows talking about the inheritance of the disease, infectious infection, changes in immunity. Let us give theoretical proofs of different directions.

Heredity

The disease spreads among homozygous twins, siblings, in 17% of relatives. The connection with Bekhterev's disease( ankylosing spondylitis) was revealed. The presence of the mutating CARD15 gene in the body of patients, which is responsible for the activation of the synthesis of the capsid enzyme, is proved.

It is involved in the production of specific protein components that create receptor susceptible areas in cells for infectious agents. Of the known 34 variants of gene modifications, 25 are directly capable of causing Crohn's disease.

Infectious infection

The effect of the infection has not been fully proven. There are scientific works, especially highlighting the role of the viral and bacterial nature of the disease. The most specific paratuberculous bacterium( MAP) has been detected. Evidence should be identified in future studies.

Immunological factor

The systemic nature of organ damage in granulomatous ileocolitis causes suspicion of an autoimmune process. But so far there is no connection with human leukocyte antigens.

Patients in the blood can be assessed increase in the number of T-lymphocytes, the presence of antibodies to Escherichia coli, fat and polysaccharide compounds, milk protein. Even isolated some immune complexes.

While known violations are attributed to secondary. For the proof, the identified chain is missing: a specific antigen in the intestine or blood that would cause activation of T-lymphocytes, stimulate cellular macrophages, fibroblasts to produce antibodies and typical allergic reactions associated with the allergic reaction( cytokines, prostaglandins).

Anatomical changes

Most often, changes in Crohn's disease are found in the terminal( terminal) section of the ileum and the initial areas of the large intestine. The sites of inflammation have segmental division with clear boundaries. The wall of the intestine thickens. Due to this, the lumen is narrowed. The diameter of the upper portion is enlarged.

On the mucosa, multiple ulcers are seen in the form of longitudinal and transverse slits or cracks. Such an anatomical surface is called a "cobblestone pavement" because of the abundance of hillocks. A pattern of perforation of the muscular layer is possible with the formation of abscesses and fistulous passages inside the peritoneum.

Fistulas bind to intestinal loops, penetrate into the bladder, in women to the uterus and vagina, come out on the skin of the abdomen. Histological examination reveals inflammatory infiltration into the whole intestine. Here, lymphocytes, eosinophils, and plasma cells accumulate.

In the photo, the sign of Crohn's disease - granuloma from epithelioid and giant multinucleate cells, recorded with microscopy of biopsy gut

The result of chronic inflammation is the formation of scars from connective tissue, stenosis of the intestinal lumen. With Crohn's disease, lymph nodes are affected. Their tissue is filled with epithelioid granulomas and elements of inflammation.

Types of Crohn's disease according to the classification according to the main characteristics of

The classification of Crohn's disease has been repeatedly changed. The specialists tried to group the pathology each time by a certain type of symptoms.

First, the names of the inflammations depending on the location:

• gastro-duodenal form - indicates damage to the stomach and duodenum;
• Crohn's disease of the small intestine is divided into ileitis( inflammation of the ileum) and ileoileitis( iliac and lean);
• Crohn's disease of the colon - represents a delineated lesion of only the large intestine;
• ileocolitis is a form indicating a simultaneous process in the ileum and large intestine.

In the 1976 classification, the following are additionally identified:

• jejunitis - isolated lesion of jejunum;
• anal area inflammation.

Enterocolitis is a joint inflammation of the entire intestine, granulomatous colitis - a lesion within the large intestine, panregional - Crohn's disease with lesions of the entire gastrointestinal tract.

In 1982, Soviet scientists V. Fedorov and M. Levitan proposed to simplify the classification:

• enteritis,
• enterocolitis,
• colitis.

The latest modification was adopted by a specialized European society in 2005.It combined the age of patients, the form of the disease, the localization of inflammation. The textual variant is replaced by the coding of signs of Crohn's disease.

The age of primary diagnosis is noted: for children under 16 years old - A1, further to A3

Pathology forms are encoded as code B:

• B1 - inflammatory without complications, possibly with fistula or abscess, transition to anal area;
• B2 - stenosing, confirmed by inspection, it is possible to attach a perianal fistula or abscess;
• B3 - penetrating, the clinic is dominated by intraperitoneal fistulas.

The severity of the current is estimated by points in the calculation of activity. They consist of a seven-day observation of the patient, accounting for the frequency of diarrhea, abdominal pain, extraintestinal symptoms, fistula or anal fissure, fever above 37.8, patient weight, general well-being, dose of drugs, determination of infiltrate in the peritoneal cavity, hematocrit in the analysisblood.

The score indicates the severity of the patient:

• 150-220 - light;
• 220-450 - moderate;
• over 450 - high;
• is less than 150 - is considered a remission.

According to this system, the recurrence of symptoms with a set of scores greater than 150 is accepted for exacerbation, and relapse cases include the resumption of symptoms after surgical treatment of Crohn's disease, confirmed by laboratory diagnostics and instrumental methods.

Symptoms of

Symptoms of Crohn's disease in adults and children are very diverse. There is no single evidence complex of clinical signs. Patients turn to different specialists, where they treat the symptoms.

About aphthous stomatitis - to the dentist, to the therapist with incomprehensible pains in the abdomen, to the surgeon-proctologist with a lesion in the anal passage( fistula, cracks, abscessing).There are intestinal and extraintestinal symptoms. It depends on the localization of the process, the severity of the flow, the frequency of relapses, the form of inflammation.

Intestinal signs include:

• long-term diarrhea( considered chronic if continuing for more than 6 weeks);
• abdominal pain - worse after eating;
• nausea, vomiting;
• flatulence;
• weight loss - initially supported by a refusal to eat because of fear of the appearance of pain, then - a syndrome of malabsorption of food against a common process.

Pain can be masked for acute appendicitis if localized in the iliac region to the right

Symptoms of general condition:

• lack of appetite;
• increased fatigue, constant fatigue;
• rise in temperature of undulating character.

Fistulous form is manifested: non-healing anal fissures, fistulas of the rectum. The correct diagnosis is made after unsuccessful use of medicines and surgical intervention for another reason.

Symptoms of Crohn's disease of the colon are often accompanied by high body temperature. To defeat the small intestine indicates a sharp weight loss of the patient, impaired absorption of proteins, fats and carbohydrates, loss of vitamins( especially A, D, B12) with signs of hypovitaminosis, severe steatorrhea( fatty stool).

Extraintestinal signs of

The course of the disease is characterized by the involvement of various organs and systems in the pathological process. How the inflammation is transmitted from the intestine is unknown.

In the oral cavity, aphthous stomatitis is detected with painful bleeding ulcers, pain when eating

. Eyes react with a disease of the membranes: conjunctivitis, uveitis, keratitis. Defeat of the joints is characterized by inflammation of one( monoarthritis) with pain, redness, swelling, ankylosing spondylitis of the spine with severe soreness with body movements, development of stiffness.

Liver dystrophy is formed in the liver, later cirrhosis, sclerosing cholangitis develops in the bile ducts, bile stasis causes the formation of stones( cholelithiasis), later the outcome of a malignant tumor is cholangiocarcinoma. For the tissues of the kidneys and urinary tract, typical manifestations are: cystitis, chronic pyelonephritis, kidney stone disease, amyloidosis, hydronephrosis.

Manifestations of varying degrees of activity of the

process In practice, doctors use to determine the degree of activity of the process by combining the signs of the disease.

For an easy degree is characteristic:

• diarrhea is not more than four times a day;
• rare presence of blood in the stool;
• temperature not higher than 37.5 degrees;
• is the normal pulse.

In case of moderate activity:

• , diarrhea is repeated more than six times a day;
• in the stool is constantly present blood;
• mild tachycardia( pulse 90);
• complications are likely.

Severe degree differs:

• expressed diarrhea, stool more than 10 times a day;
• massive release of blood with feces;
• temperature within 38 degrees;
• tachycardia is greater than 90 per minute;
• adjunct complications.

Hyperthermia - one of the signs of the acute process

Symptoms in children

Symptoms in children for a long time do not allow you to put the right diagnosis and prescribe the best treatment for Crohn's disease. The clinical picture is worn out, mildly expressed, diarrhea impermanent, first signs of extraintestinal symptoms. Cases of child diseases are severe, accompanied by numerous complications.

Parents and attending physicians are advised to pay attention to the following symptoms:

• abdominal pain - the child is of a different nature from strong cramping, to stupid, aching;
• nausea, vomiting - are observed with lesions of the gastric mucosa;
• bloating;
• diarrhea - the more intense, the higher the prevalence of inflammation of the intestine, the feces are possible blood clots, impurities of pus and mucus, fat film, the color of the stools becomes lighter;
• lacks appetite, weight decreases;
• defines an unclear elevated temperature;
• in a blood test with good nutrition find a lower hemoglobin value;
• in adolescent girls cease monthly;
• in half of the cases of inflammation occurs in the ileo-ophthalmic zone, the symptoms are manifested in the form of an "acute abdomen", an urgent observation of the surgeon is required;
• extraintestinal symptoms do not differ from manifestations in adult patients( stomatitis, congestion in the biliary tract, perianal abscess, fissures and fistulas of the anus, joint pain).

What are the consequences that require surgery?

The most pronounced negative manifestations complicating Crohn's disease and requiring surgical intervention. These include the formation of fistulous passages from the intestine into the bladder, the uterus in women with infection, the release of stool and air from the bladder, the vagina.

Perforation( perforation) of the intestinal wall with development of abscesses in the abdominal cavity, severe peritonitis, external and internal fistulas, adhesions, cicatricial changes. There is a chronic inflammatory process accompanied by massive scarring of the lumen of the intestine, this is the cause of intestinal obstruction.

Ulcers on the mucous membrane damage the vessels, causing massive internal bleeding. It is possible to form a megacolon with intoxication phenomena.

The formation of various fistulous passages of the anorectal zone

is schematically shown. For the correct diagnosis, exclude intestinal diseases of different etiologies. First of all, it is necessary to identify chronic infectious diseases, distinguish Crohn's disease from ulcerative colitis, congenital anomalies in children and hereditary pathology.

Read more about methods of detecting the disease and differential diagnosis of Crohn's disease in this article.

Treatment of

How to treat Crohn's disease in a specific case becomes clear only after a complete examination of the patient. Bed rest is recommended during an exacerbation period. In the absence of complications, the treatment of Crohn's disease is carried out with drugs of different directions. The goal is to suppress and limit inflammation.

Diet

Nutrition for Crohn's disease should compensate for the loss of absorption function of the intestine, do not irritate the gastrointestinal tract, have a low allergenicity. Therefore, categorically prohibited:

• sharp, fried meat and fish dishes;
• canned food;
• legumes and fresh vegetables;
• grapes;
• pearl barley and corn groats;
• milk soups, cheese;
• alcohol, coffee, carbonated water;
• chocolate;
• ice cream.

It is recommended to cook food only in boiled form, steamed, stew. The menu includes:

• low-fat soups from meat, fish;
• mashed potatoes;
• porridge buckwheat, oatmeal, rice in a grated form;
• sour-milk products, if there is no severe diarrhea;
• steam cutlets, meatballs, casseroles;
• dishes from boiled chicken;
• were jammed.

The patient should be fed "by the clock", at least 6 times a day. It is obligatory to use up to 2 liters of liquid to compensate for losses with diarrhea. There are recommendations for two "hungry" days of release per week, but not all experts agree with them. The group of salicylates - representatives - Sulfasalazine, Mesalazine. They are used in tablets and for local treatment in the form of rectal suppositories, suspension, foam.

The drug is recommended for monotherapy with a mild course of the disease, minimal activity of inflammation.

. General antibiotics - Ciprofloxacin, Rifaximin, Metronidazole, Clotrimazole are used in combination with other agents. Group of glucocorticoids - Prednisolone, Methylprednisolone is used in combinations, has a supporting value.

In severe cases, intravenously and intramuscularly. On the effectiveness of wound healing is inferior to other means. Often gives complications in the form of hormone-dependent conditions. With ileocolitis with low and moderate activity, Budesonide is indicated, a hormonal preparation with less negative properties than glucocorticoids.

Immunosuppressants - are not suitable for monotherapy, Azathioprine, 6-mercaptopurine, Methotrexate are used. Modern genetically engineered drugs are based on human antibodies or from animal blood to the tumor necrosis factor alpha.

Presented by Infliximab, Adalimumab, Golimumab, Etanercept, Certolizumab Pegol. The drug Vedolizimab - has the property of blocking intestinal receptors. As symptomatic treatment are used:

• enterosorbents;
• enzymatic agents;
• probiotics;
• vitamins;
• with severe anemia use iron preparations.

There are works on the effective use of alternative methods:

• hyperbaric oxygenation( saturation of the body with oxygen in special chambers);
• plasmapheresis and plasmosorption;
• own( autologous) stem cells;
• preparation from donor stem cells - Polychrome;
• preparations based on marijuana;
• vaccine;
• genetically modified bacteria.

The main use of Naltrexone is the treatment of alcohol and opiate dependence, according to some scientists, opioid receptors are involved in the inflammatory process, so their blockade promotes bowel healing.

Surgical treatment of

. Statistics show that up to 60% of patients in 10 years of illness need surgery,for the development of complications and unsuccessful conservative therapy. It is important to consider that the operation does not lead to recovery. Up to 45% of patients in the next 5 years need to re-surgical intervention. For information about the prognosis for patients with Crohn's disease, see this article.

The volume of surgery is usually associated with resection( removal) of the affected part of the intestine, the elimination of fistulous strokes. Some specialized clinics perform graft transplantation from the donor.

The complexity of diagnosis and therapy of Crohn's disease, ulcerative colitis( NJC) and other diseases, according to experts, require the establishment of centers in regional cities. This will allow to observe patients, to develop an individual approach to treatment, to expand the possibilities of therapy.