Nonspecific ulcerative colitis. Crohn's disease. Ulcerative colitis. Treatment of nyak in children clinical guidelines

UDK 616.348-002.44-07-08

nonspecific ulcerative colitis: current approaches to diagnosis and treatment

S.R.Abdulkhakov1, R.A.Abdulkhakov2

1 chair general medical practice, 2 Department of Hospital Therapy

Gou VPO "Kazan State Medical University of Roszdrav", Kazan

Abstract. The article discusses the classification, clinical picture, approaches to diagnosis and modern standards treatment of nonspecific ulcerative colitis based on international and Russian recommendations. Criteria for assessing the severity of ulcerative colitis according to Truelove/Witts and the Mayo scale, recommended depending on the severity of the dose of 5-ASA and glucocorticosteroids, are given; indications for surgical treatment.

Keywords: nonspecific ulcerative colitis, assessment of activity and severity, treatment.

NoN-spEOiFiO uLOERATivE coLiTis: up-TO-DATE APPROACHES TO DIAGNOSTiOS AND TREATMENT

S.R. Abdoulkhakov1, R.A.Abdoulkhakov2

1 Department of General Medical Practice, 2 Department of Hospital Therapy,

^zan State Medical University, Kazan

abstract. The article deals with classification, clinic, approaches to diagnostics and modern standards of non-specific ulcerative colitis treatment, based on international and Russian recommendations. Criteria of assessment of severity stages of non-specific ulcerative colitis according to Truelove/Witts and Mayo score; 5-ASA and corticosteroids recommended doses depending on severity stages; and indications for surgical treatment are presented.

Key words: non-specific ulcerative colitis, assessment of activity and severity, treatment.

Nonspecific ulcerative colitis (NUC) is a chronic inflammatory disease of the colon, characterized by ulcerative-destructive changes in its mucosa.

The prevalence in the world is 50-230 cases per 100 thousand population. The epidemiology of NUC in Russia as a whole is unknown; the prevalence in the Moscow region is 22.3 cases per 100,000 population. The annual increase in UC patients in the world is 5-20 cases per 100,000 population. Epidemiological studies in the United States have shown that UC occurs 3-5 times more often in the white population than in African Americans, and in Jews - 3.5 times more often than in non-Jewish people. The disease occurs in all age groups, but the main incidence peak occurs in 20-40 years. Men and women get sick with the same frequency. In smokers, NUC occurs 2 times less frequently than in non-smokers. Mortality from inflammatory bowel diseases, including UC, is 6 cases per 1 million population in the world, and 17 cases per 1 million population in Russia. In Russia, in most cases, the diagnosis is made several years after the onset of the first clinical symptoms of the disease.

Classification

I. According to the clinical course:

Sharp form.

Fulminant (lightning) form.

Chronic form.

Recurrent (episodes of exacerbation lasting 4-12 weeks are replaced by periods of remission).

Continuous (clinical symptoms persist for more than 6 months).

II. By localization:

Distal colitis (proctitis, proctosigmoiditis).

Left-sided colitis (up to the level of the middle of the transverse colon).

Total colitis (in some cases with retrograde ileitis).

III. According to the severity of clinical manifestations (disease activity):

Light form.

Medium form.

Severe form.

IV. By response to steroid therapy1:

Steroid addiction.

Steroid resistance.

The severity of NUC exacerbation is assessed according to the criteria of Truelove and Witts (1955), supplemented by M.Kh. Levitan (Table 1).

In addition, the Mayo Clinic Severity Scoring System (Mayo Index) can be used.

Mayo index \u003d stool frequency + presence of rectal bleeding + endoscopy data + general medical opinion

Stool Frequency:

0 - stool frequency normal for this patient;

1 Important for deciding whether to add

immunosuppressive agents, biological agents, or surgical treatment.

Evaluation of the severity of UC

Signs Mild Moderate Severe

Stool frequency< 4 раз в сут >4 times a day > 6 times a day

Rectal bleeding Insignificant Pronounced Pronounced

Temperature Normal< 37,8°С >37.8°C for 2 days out of 4

Pulse rate Normal< 90 в мин >90 per min

Hemoglobin, g/l More than 111 105-111 Less than 105

ESR, mm/h Less than 20 20-30 More than 30

1 - stool frequency exceeds the usual by 1-2 in

2 - stool frequency exceeds the usual by 3-4 in

3 - stool frequency exceeds the usual by 5 or more per day.

Rectal bleeding:

0 - no visible blood;

1 - traces of blood in less than half of the bowel movements;

2 - visible blood in the stool in most bowel movements;

3 - predominant allocation of blood.

Endoscopic picture:

0 - normal mucous membrane (remission);

1 - mild degree (hyperemia, blurred vascular pattern, graininess of the mucous membrane);

2 - medium degree (severe hyperemia, lack of vascular pattern, granularity, erosion of the mucous membrane);

3 - severe (ulceration, spontaneous bleeding).

General clinical characteristics (based on the doctor's conclusion according to three criteria: the patient's daily reports of sensations in the abdomen, the patient's general well-being and the characteristics of the patient's objective status):

0 - norm (remission);

1 - easy form;

2 - moderate form;

3 - severe form.

Mayo index interpretation:

0-2 - remission/minimum disease activity;

3-5 - mild form of UC;

6-10 - moderate form of UC;

11-12 - severe form of UC.

Etiology and pathogenesis. The etiology of NUC is not fully known. In the pathogenesis of the disease, the significance of changes in immunological reactivity, dysbiotic changes, allergic reactions, genetic factors, and neuropsychiatric disorders is assumed.

There is a genetic predisposition to UC (familial cases of ulcerative colitis) and an association of UC with HLA histocompatibility complex antigens. Among the closest relatives, UC occurs 15 times more often than in the general population.

Pathological anatomy. Morphologically, inflammation of various parts of the colon is determined. The mucous membrane is hyperemic, edematous, ulcerated; ulcers of a rounded shape, various sizes. Microscopic changes are characterized by infiltration of the lamina propria by plasma cells, eosinophils, lymphocytes, mast cells, and neutrophils.

clinical picture. In the clinical picture, there are three leading syndromes associated with intestinal damage: stool disorders, hemorrhagic and pain syndromes (Table 2). The onset of the disease may be acute or gradual.

The main feature is multiple (in severe cases up to 20 times a day) watery stools mixed with blood, pus and mucus, combined with tenesmus and false urge to defecate. Often, only bloody mucus is excreted when the urge to defecate. Diarrhea is most pronounced when the right half of the large intestine is affected, where water and electrolytes are absorbed. In case of distribution inflammatory process in the proximal direction to a large part of the colon, the disease is accompanied by significant bleeding. In the initial period of the disease, which occurs in the form of proctosigmoiditis, constipation may occur, mainly due to spasm of the sigmoid colon. During remission, diarrhea may completely stop.

Pain in the abdomen - usually aching, less often - cramping. Localization of pain depends on the extent of the pathological process. Most often, this is the area of ​​​​the sigmoid, colon and rectum, less often - the paraumbilical or right iliac region. Typically, pain increases before a bowel movement and eases after a bowel movement. In many patients, the intensity of pain increases 30-90 minutes after eating. As the disease progresses, the connection between meals and abdominal pain is lost (i.e., the gastrocolytic reflex fades away, in which, after eating, there is increased peristalsis intestines).

Tenesmus - false urges with the release of blood, mucus and pus ("rectal spit") with little or no stool; are a sign of high activity of the inflammatory process in the rectum.

Constipation (usually associated with tenesmus) due to spastic contraction segment of the intestine above the lesion, typical for limited distal forms of UC.

Later join general symptoms: anorexia, nausea and vomiting, weakness, weight loss, fever, anemia.

The fulminant form is almost always characterized by a total lesion of the colon, the development of complications (toxic dilatation of the colon, perforation), in most cases it requires urgent surgical intervention. The disease begins acutely, within 1-2 days a pronounced clinical picture unfolds with a frequency of bloody stools more than 10 times a day, a decrease in hemoglobin level less than 60 g/l, an increase in ESR more than 30 mm/h.

Table 2 The frequency of intestinal symptoms at the onset of the disease and one year after the onset of the disease (according to M. Roth, V. Bernhartd, 2006)

Extraintestinal manifestations are detected in 10-20% of patients with UC, more often with total damage to the colon (Table 3).

Erythema nodosum and pyoderma gangrenosum are due to the presence of circulating immune complexes, bacterial antigens, and cryoproteins.

Aphthous stomatitis is observed in 10% of patients with UC, aphthae disappear as the activity of the underlying disease decreases.

Eye involvement - episcleritis, uveitis, conjunctivitis, keratitis, retrobulbar neuritis, choroiditis - occurs in 5-8% of cases.

Inflammatory lesions of the joints (sacroiliitis, arthritis, ankylosing spondylitis) can be combined with colitis or occur before the onset of the main symptoms.

Bone manifestations: osteoporosis, osteomalacia, ischemic and aseptic necrosis are complications of corticosteroid therapy.

All extraintestinal manifestations, with the exception of ankylosing spondylitis and hepatobiliary disease, disappear after coloproctectomy.

Complications of UC: toxic dilatation of the colon, perforation, profuse bleeding, strictures, malignancy, sepsis, thrombosis and thromboembolism.

Toxic dilatation of the colon is an acute expansion of the colon, predominantly descending and transverse, with an increase in pressure in its lumen. Clinically characterized by a sharp and progressive deterioration of the patient's condition: hyperthermia, rapidly increasing weakness, abdominal pain, frequent loose stools with copious discharge of blood, pus, tachycardia, arterial hypotension, bloating, and weakening/absence of bowel sounds on auscultation. Against the background of steroid therapy, clinical symptoms may be erased. The diagnosis is confirmed with

Plain radiography of the abdominal organs. Depending on the diameter of the large intestine,

3 degrees of toxic dilatation:

I degree - the diameter of the intestine is less than 8 cm;

II degree - intestine diameter 8-14 cm;

III degree - the diameter of the intestine is more than 14 cm.

Perforation usually develops against the background of toxic dilatation of the colon and is diagnosed by the presence of free gas in the abdominal cavity during x-ray examination. Characteristic symptoms - abdominal pain, bloating, palpation tenderness, symptoms of peritoneal irritation - can be erased while taking steroid drugs.

Thrombosis and thromboembolism are a manifestation of the high activity of the inflammatory process and develop against the background of hypercoagulation. Most often, thrombosis of the superficial or deep veins of the lower leg or iliofemoral thrombosis is observed. The presence of recurrent thromboembolism is an indication for colectomy.

Diagnostics

Endoscopic examination (colonoscopy) with biopsy is the main method to confirm the diagnosis, assess the degree of activity of the inflammatory process, establish the extent of the process, and monitor the effectiveness of treatment. NUC is characterized by the absence of a vascular pattern, granularity, hyperemia and edema of the mucous membrane, the presence of contact bleeding and / or erosions and ulcers. Histological examination of biopsy specimens is carried out in order to confirm the diagnosis: signs of nonspecific immune inflammation are revealed, which, however, are not pathognomonic for UC.

In the remission phase, endoscopic changes may be completely absent.

In severe exacerbations, colonoscopy is not always possible due to the risk of complications.

When conducting an endoscopic examination, the activity of the inflammatory process in UC is assessed (Table 4, Fig. 1).

X-ray examination(irrigoscopy, irrigography) allows you to establish the length of the process according to characteristic features: smoothness or absence of gaustra (symptom of the "water pipe"), shortening of the colon; it is possible to identify barium depots corresponding to ulcerative defects, pseudopolyps, strictures (Fig. 2).

Symptoms At the onset of the disease, % After 1 year, %

Intestinal bleeding 80 100

Diarrhea 52 85

Abdominal pain 47 35

anal fissures 4 4

Anal fistulas 0 0

Table 3

Symptoms Frequency 5-20% Frequency below 5%

Associated with the activity of the inflammatory process in the intestine Aphthous stomatitis. Nodular erythema. Arthritis. Eye damage. Thrombosis, thromboembolism Pyoderma gangrenosum

Not associated with the activity of the inflammatory process in the intestine Sacroiliitis. Psoriasis Ankylosing spondylitis. Rheumatoid arthritis. Sclerosing cholangitis. Cholangiogenic carcinoma. Amyloidosis

Consequences of malabsorption, inflammation, etc. Steatohepatitis. Osteoporosis. Anemia. Cholelithiasis

UC activity according to endoscopic examination

Activity

Sign minimal (I degree) moderate (II degree) high (III degree)

Hyperemia Diffuse Diffuse Diffuse

Graininess No Yes Pronounced

Edema Yes - -

Vascular pattern Absent Absent Absent

Bleeding Petechial hemorrhages Contact, moderate Spontaneous, severe

Erosions Single Multiple Multiple with ulceration

Ulcers None Single Multiple

Fibrin No Yes Abundant

Pus (in the lumen and on the walls) No No or a small amount Much

Rice. 1. Endoscopic picture in UC (a - minimal, b - moderate, c - high activity)

Rice. 2. X-ray picture in NUC (symptom of "water pipe")

Bacteriological examination of feces is carried out in order to exclude infectious colitis.

Laboratory research methods are important for establishing the severity of NUC. In addition, with a long course of the disease due to diarrhea, hyponatremia, hypochloremia, hypoalbuminemia develop, weight loss progresses; anemia is often observed. Severe forms of the disease are characterized by an increase in ESR, the presence of leukocytosis.

Differential Diagnosis

Nonspecific ulcerative colitis is differentiated primarily from infectious lesions of the intestine, ischemic colitis, Crohn's disease.

In differential diagnosis with infectious pathology, microbiological examination of feces is of paramount importance.

Ischemic colitis. characteristic elderly age sick, typical radiological signs(symptom of "finger impressions", pseudodiverticulum), detection of hemosiderin-containing macrophages in histological examination of biopsy specimens of the colon mucosa.

The greatest difficulties may arise when distinguishing between nonspecific ulcerative colitis and Crohn's disease (granulomatous colitis) with localization in the large intestine (Table 5).

Differential diagnosis of ulcerative colitis and Crohn's disease

Signs of UC Crohn's disease

Clinical: Bloody diarrhea 90-100% 50%

Tumor-like masses in the abdominal cavity Very rare Often

Perianal localization Does not happen 30-50%

Colonoscopy: Presence of proctitis 100% 50%

Histology: Spread Mucosa Transmural

Cellular infiltrates Polymorphonuclear Lymphocytic

Glands Disturbed Normal

Decreased goblet cells Often when the process is active Absent

Granulomas Absent Have diagnostic value

X-ray: Distribution Expressed Localized

Symmetry Yes No

Ulcers Superficial Deep

Strictures Very rare Common

Fistulas Never Often

Treatment. Diet

Various diet options are prescribed that slow down intestinal transit (4, 4a, 4b), rich in protein with fat restriction.

The goals of UC treatment are induction and maintenance of clinical and endoscopic remission, improvement of the patient's quality of life, prevention of relapses and prevention of complications.

Medical therapy

Currently, the doctor has a fairly large arsenal of drugs that are effective in the treatment of patients with chronic inflammatory bowel diseases. The choice of drugs and method of treatment depends on the following characteristics of the disease in a particular patient:

1. Prevalence (localization) of the pathological process in the intestine.

2. The severity of the exacerbation (mild, moderate, severe), which does not always correlate with the prevalence of the inflammatory process. Determining the severity of the disease is necessary, first of all, to resolve the issue of the need for hospitalization of the patient and the appointment of hormone therapy.

3. The effectiveness of previously used drugs (with a previous exacerbation and before the start of the prescribed therapy).

4. The presence of complications.

Basic in the treatment of NUC are two groups of drugs:

Preparations of 5-aminosalicylic acid (sulfasalazine, mesalazine).

Glucocorticosteroids (GCS).

Preparations of 5-aminosalicylic acid (5-ASA)

Before the advent of mesalazine, the drug of choice in the treatment of patients with UC was sulfasalazine, administered in clinical practice in the early 40s. After entering the large intestine, about 75% of sulfasalazine is cleaved into two components by the action of bacterial azoreductases - 5-aminosalicylic acid and the sulfonamide component sulfapyridine. Late 70s - early

80s it has been shown that sulfapyridine has no intrinsic anti-inflammatory activity. Most of the side effects when taking sulfasalazine are associated precisely with the systemic action of sulfapyridine and they are observed most often in individuals with genetically determined "slow" acetylation in the liver of sulfapyridine to N-acetylsulfapyridine. The frequency of side effects when using sulfasalazine (nausea, vomiting, itching, dizziness, headache, allergic reactions, etc.) reaches, according to some reports, 55%, averaging 20-25%. These effects are often dose-dependent, therefore, it is recommended to stop taking sulfasalazine for 1-2 weeks, followed by the resumption of taking the drug at a dose of 0.125-0.25 g / day, gradually increasing the dose by 0.125 g / week until a maintenance dose of 2 g / day is reached. serious side effects(agranulocytosis, leukopenia, impotence) when using sulfasalazine are observed in 12-15% of patients. After it was found that the only active anti-inflammatory component of sulfasalazine is 5-aminosalicylic acid (5-ASA), further prospects in the development of an effective drug for the treatment of chronic inflammatory bowel diseases were associated with it.

Preparations of "pure" 5-ASA are represented by three groups of pharmacological agents. The first of these is mesalazine (salofalk, pentasa, mesacol), in which 5-ASA is enclosed in various chemical composition shells that gradually dissolve in the gastrointestinal tract In another 5-ASA preparation, olsalazine, two 5-ASA molecules are connected by an azo bond, the destruction of which occurs under the action of colonic microorganisms. Preparations of the third group consist of 5-ASA and an inert non-absorbable conductor; the release of 5-ASA also occurs under the action of the intestinal microflora. Nevertheless, despite the existence of a number of 5-ASA preparations, mesalazine preparations form the basis of drug therapy for UC.

As for the mechanism of action of 5-ASA preparations, most studies are devoted to the study

the effect of these drugs on the metabolism of arachidonic acid and the suppression of cyclooxygenase activity. However, given that non-steroidal anti-inflammatory drugs, which are based on the inhibition of cyclooxygenase, do not affect the course of the inflammatory process in the intestine, this mechanism can hardly be considered the leading one. At the same time, both sulfasalazine and “pure” 5-ASA preparations have been shown to increase the local concentration of prostaglandins, which are known to have a cytoprotective effect. Among other possible mechanisms of action, the influence of 5-ASA on the production of immunoglobulins, interferons, pro-inflammatory cytokines, suppression of the activity of oxygen free radicals, a decrease in increased cell permeability, etc.

Currently, mesalazine preparations are available in the form of 3 dosage forms: tablets, suppositories and microclysters.

Topical application of 5-ASA preparations

Topical treatment is indicated in the case of distal colitis (proctitis, proctosigmoiditis or left-sided colitis) and as part of a combination therapy for advanced colitis (given that the inflammatory process in UC always affects the distal intestine).

Placebo controlled clinical trials have shown high efficiency mesalazine in the form of enemas at a dose of 1-4 g / day and rectal suppositories at a dose of 0.5-1.5 g / day in inducing remission in patients with left-sided colitis, proctosigmoiditis and proctitis with mild and moderate severity of the disease. The clinical effect of the rectal method of drug administration in the treatment of left-sided lesions is almost always higher than with oral administration, the maximum effect is achieved with the combined use of oral and rectal forms of mesalazine. Foam is distributed in the rectum and sigmoid colon, suppositories - only in the rectum. With the introduction of 5-ASA in an enema, 20-30% of the total dose is absorbed and has a systemic effect, most of the drug has a local effect.

Salofalk in enemas of 2 and 4 g (30 and 60 ml) is used to treat left-sided forms of ulcerative colitis. Enemas containing 2 g of salofalk (30 ml) can be prescribed for mild and moderate forms of ulcerative colitis, especially in cases where the lesion is limited to the rectum and sigmoid colon. The contents of the enema are administered daily in the evening before bedtime [enemas of 60 ml (4 g) can be used in two doses: the second portion of the enema is administered after emptying the bowels from the first, or the next day in the morning].

In a comparison of different treatment options for distal colitis, rectal mesalazine was found to be comparable to, and in some reports even better than, corticosteroid enemas and oral mesalazine. Meta-analysis clinical research showed that rectal mesalazine was more effective in inducing remission in left-sided lesions compared to rectal steroids.

Interestingly, the use of 5-ASA enemas provides a significant therapeutic effect even in the treatment of patients resistant to previous oral administration.

treatment with sulfasalazine, systemic and topical corticosteroids.

With regard to maintenance therapy with topical forms of mesalazine, it has been shown that more frequent use of drugs (suppositories 2 times a day or enemas daily) leads to a lower frequency of recurrence compared with less frequent use of drugs (suppositories 1 time per day or enemas 1 time in 2- 3 days) . Oral administration of 5-ASA preparations Placebo-controlled studies have shown high efficacy of mesalazine at a dose of 1.6-4.8 g/day in inducing remission in patients with mild to moderate UC. The results of meta-analyses confirm the presence of a dose-dependence with oral mesalazine. The effectiveness of mesalazine at a dose of 0.8-4.0 g / day and sulfasalazine at a dose of 4-6 g / day is approximately the same, however, when using the latter, a significantly greater number of side effects are observed. In mild and moderate forms, the average dose of sulfasalazine is 4-6 g / day, mesalazine - 2-4 g / day. After achieving the effect, a gradual decrease in the dose of the drug is recommended. Research shows that high doses mesalazine, used in the exacerbation phase, in some cases is almost equivalent in effectiveness to glucocorticoids. However, high doses of 5-ASA preparations are recommended to be used for no more than 8-12 weeks.

The maximum effect of therapy can be achieved with a combination of oral and local forms mesa lazina.

In the case of long-term use, the appointment of mesalazine is preferable compared to sulfasalazine due to fewer side effects. Side effects when taking mesalazine Side effects are quite rare. Cases of toxic hepatitis, pancreatitis, pericarditis, interstitial nephritis. However, the observations of Hanauer et al. (1997) for patients taking mesalazine at various doses up to 7.2 g / day for up to 5.2 years, did not reveal any unwanted effects regarding kidney function. In a small number of patients, adverse events have been described in the form of increased diarrhea and abdominal pain, which are commonly associated with hypersensitivity to 5-ASA.

The use of mesalazine in children With an exacerbation of the disease, depending on the severity of the disease and the age of the child, the recommended doses of mesalazine are 30-50 mg / kg of body weight per day for 3 doses. In case of inflammation limited to the left half of the large intestine, it is possible to use local dosage forms (suppositories, enemas). For the prevention of relapses, depending on age, mesalazine is prescribed at a dose of 15-30 mg / kg of body weight per day for 2 doses. If the child weighs over 40 kg, the usual adult dose of mesalazine is prescribed. official recommendations for treatment infants and children early age no, due to insufficient experience with mesalazine in this age group. Age under 2 years is considered a contraindication to taking mesalazine.

Mesalazine use during pregnancy and lactation

Pregnancy is not a contraindication to the use of mesalazine. Moreover, in many works

it is recommended to continue therapy with NUC without reducing the dose of mesalazine during pregnancy. The use of 5-ASA preparations during lactation is also considered safe, since only a small amount of the drug passes into milk.

Glucocorticosteroids

The effect of glucocorticosteroids (GCS) may be associated with systemic (i.v., oral or rectal administration of prednisolone, hydrocortisone) or local (non-systemic) action (rectal or oral administration of budesonide). Glucocorticoids are used in severe UC or in case of ineffectiveness of previous therapy with 5-ASA drugs. The drugs of choice are prednisolone and its methylated analogues. The most effective dose of prednisolone is 1 mg / kg per day, however, in severe cases, higher (up to 1.5-2 mg / kg per day) doses of prednisolone can be used for 5-7 days, followed by a dose reduction to 1 mg / day. kg In the case of an acute attack of UC, short courses (7 days) of intravenous steroids (prednisolone 240-360 mg/day or hydrocortisone succinate 400-500 mg/day) are effective. Reducing the dose of hormonal drugs begins when clinical improvement is achieved (on average, after 2-3 weeks of therapy).

Systemic action of glucocorticosteroids

Given that, under physiological conditions, plasma cortisol levels are highest between 6 a.m. and 8 a.m., large dose Glucocorticoids are recommended to be taken in the morning. Morning oral administration at a dose of 40 mg is comparable in effectiveness to 4 times daily intake of separate doses of 10 mg In cases of disease refractory to hormone therapy, it may be effective to divide the daily dose into a higher morning dose (2/3 of the daily dose) and lower evening (1/3 daily dose). Oral administration of prednisolone begins with doses of 40-60 mg per day (until remission is achieved, usually from 2 weeks to 1 month) with a gradual decrease to 5 mg and subsequent withdrawal during therapy with mesalazine drugs.

Hydrocortisone is applied rectally (in microclysters) or intravenously. With ulcerative proctitis or proctosigmoiditis, the administration of hydrocortisone in microclysters, 125 mg 1-2 times a day, is effective. In severe cases, parenteral administration of hydrocortisone in daily doses of 300-500 mg is used.

Indications for intravenous administration of corticosteroids are severe UC and refractoriness to oral corticosteroids, since patients with UC often have impaired absorption and metabolism of orally taken corticosteroids. For example, individuals with severe UC have a smaller peak plasma concentration of corticosteroids and a slower decrease after a single dose of 40 mg of prednisolone compared with healthy volunteers. Intravenous administration leads to the same level of GCS in plasma as in healthy individuals. Intravenous use of corticosteroids for 5 days leads to the achievement of clinical remission in 55-60% of patients with severe exacerbation of ulcerative colitis.

In the event that parenteral use of GCS for 7-10 days does not lead to the achievement of clinical remission, it is recommended to raise the question of the advisability of surgical treatment.

Recently, much attention has been paid to new generation glucocorticoids (fluticasone

propionate, beclomethasone dipropionate, budesonide), the local activity of which is significantly higher than that of methylprednisolone. In addition, as a result of rapid metabolism during the first passage through the liver, the severity of their side effects due to systemic action is significantly lower than that of hormones commonly used in practice. The most studied among them is budesonide. Thus, the affinity for GCS receptors in budesonide is 195 times higher than that of methylprednisolone. Only 2% of the accepted dose of the drug circulates in the systemic circulation, more than 95% of the drug binds to tissues. Currently, budesonide is recommended for inclusion in regimens for the treatment of inflammatory bowel disease.

Oral glucocorticosteroids with non-systemic action

Comparative studies using budesonide 10 mg/day and prednisolone 40 mg/day showed comparable efficacy; the difference in the two groups of patients was only in fewer side effects when taking budesonide.

Local therapy with glucocorticosteroids (systemic effect)

Hydrocortisone, prednisolone, methylprednisolone and others steroid drugs, administered rectally in the form of enemas or suppositories, are absorbed as well as the drug taken per os, and, accordingly, can be the cause of all side effects characteristic of systemic GCS.

A small number of studies comparing rectally administered 5-ASA with rectal hydrocortisone 100-175 mg/day or prednisolone 20-30 mg/day have shown similar clinical efficacy of these treatment options in patients with active ulcerative proctitis and proctosigmoiditis. However, this meta-analysis showed the advantage of rectally administered mesalazine preparations over rectal steroids in inducing remission of UC.

The effectiveness of local glucocorticoid therapy depends on the depth of penetration of the drug and the duration of its stay in the intestinal lumen. Studies have shown that when GCS is administered in the form of enemas, the drug enters the sigmoid colon and reaches the distal parts of the descending colon, and when favorable conditions- splenic angle. The depth of penetration of the drug depends on the volume of the enema. However, when using large volume enemas, patients are often unable to hold them for a long time. The introduction of GCS in the form of rectal foam contributes to the retention of the drug in the intestine and thus makes it possible to reduce the dose of the administered drug.

Thus, short courses of rectally administered corticosteroids (prednisolone 20-40 mg/day, hydrocortisone 100-250 mg/day, etc.) are effective in the treatment of distal ulcerative colitis of any severity, but they are not recommended to be used continuously due to the possibility of side effects. .

Rectal glucocorticosteroids (local action)

Placebo-controlled studies have shown that rectal (in the form of enemas) administration of budesonide at a dose of 2-8 mg / day leads to clinical improvement in patients with mild to moderate

severity and left-sided lesion of the colon. It turned out that enemas containing 2 mg of budesonide have the same positive effect on the clinical and endoscopic picture of the disease as enemas containing 4 g of 5-ASA.

Side effects associated with taking systemically active corticosteroids include a moon-shaped face, acne, infectious complications, ecchymosis, hypertension, hirsutism, etc. complications - in 3-5% of patients. The incidence of diabetes mellitus, requiring the appointment of hypoglycemic drugs, in persons taking GCS for a long time is 2.23 times higher than the average in the population.

Depending on the response to steroid therapy, the following conditions are distinguished: steroid resistance and steroid dependence.

Steroid resistance - lack of effect of adequate therapy, including prednisolone 0.75 mg / kg / day for 4 weeks, infusion therapy(erythromass, protein solutions, etc.), if necessary - broad-spectrum antibiotics.

Steroid dependence: 1) the impossibility of reducing the dose of steroids to less than 10 mg / day (in terms of prednisolone) within 3 months from the start of GCS therapy without exacerbation of the disease; 2) the presence of a relapse of the disease within 3 months after the abolition of GCS.

Immunosuppressants (azathioprine, metatrexate, cyclosporine) in the treatment of UC are reserve drugs. Indications for their appointment are steroid dependence and steroid resistance.

Azathioprine is used in UC as monotherapy for steroid-resistant and steroid-dependent forms of the disease; as an anti-relapse treatment in patients with frequent exacerbations during maintenance therapy with 5-ASA drugs; in case of activation of inflammation with a decrease in the dose of hormones. The recommended dose of azathioprine is 2 mg/kg per day (no more than 150 mg). Therapeutic effect - after 12 weeks; duration of treatment - at least 12 months. In the absence of side effects, it can be used for a long time as maintenance therapy at a minimum dose of 50 mg / day.

Metatrexate is used in steroid-resistant forms of UC; 25 mg intramuscularly is prescribed once a week for 2 weeks, then the dose can be reduced to 7.5-15 mg. Time expected therapeutic effect- 3-4 weeks, duration of the active phase - 12-16 weeks, duration of the maintenance phase -

12-16 weeks (dose 7.5 mg per week). Currently, the use of metatrexate in UC is recommended only in the absence of effect or inability to prescribe azathioprine.

Cyclosporine is effective in fulminant course and severe exacerbation of UC, administered intravenously at a dose of 2-3 mg/kg per day for 5-7 days. Causes remission in 50% of steroid-resistant patients.

The effectiveness of aminosalicylates is assessed on the 14-21st day of therapy, corticosteroids - on the 7-21st day, azathioprine - after 2-3 months.

biological therapy inflammatory bowel disease

Infliximab (Remicade) is an anti-cytokine drug of biological origin, which

is a chimeric human-mouse monoclonal antibody (!d G) to the pro-inflammatory cytokine - tumor necrosis factor alpha (TNF-a). Infliximab is 75% human and 25% mouse protein. Thanks to the variable "mouse" fragment, a high affinity of antibodies to TNF-a and the ability of infliximab to neutralize the effect of the cytokine are ensured. The "human" component of antibodies provides low immunogenicity of the chimeric molecule.

TNF-a exists in the body in a soluble form, and is also partially fixed on the membranes of immunocompetent cells. In this regard, a significant advantage of infliximab is its ability to neutralize both forms of TNF-a.

The clinical efficacy of infliximab is associated with its anti-inflammatory and immunomodulatory effects on the intestinal mucosa; however, there is no suppression of the systemic immune response. After intravenous administration infliximab long time circulates in the blood, which allows you to enter it once every 4-8 weeks. It is known that patients with UC have elevated serum concentrations of TNF-a, which decrease during disease remission.

Indications for the appointment of infliximab in UC (since 2006) are moderate and severe forms of the disease (Mayo index - from 6 to 12) with ineffectiveness, intolerance to standard therapy or the presence of contraindications to its implementation. Infliximab (Remicade) for UC is recommended to be administered every 8 weeks after induction therapy (induction scheme - 0, 2, 6 weeks).

Maintenance therapy and maintenance of remission

The recurrence rate of ulcerative colitis after discontinuation of oral therapy or topical treatment with sulfasalazine or "pure" 5-ASA preparations reaches 74% within a year. The frequency of recurrence after discontinuation of local treatment is even higher in patients with distal colitis.

It is reliably shown that glucocorticoids do not prevent the recurrence of ulcerative colitis. The effectiveness of 5-ASA preparations in preventing relapses is considered unequivocally proven, with doses ranging from 0.75 to 4 g per day equally effective in maintaining remission. Currently, patients with UC are recommended to carry out long-term maintenance therapy with possibly lower doses of sulfasalazine (2 g/day) or mesalazine (1-1.5 g/day). The use of mesalazine as maintenance therapy is preferred due to fewer side effects compared to sulfasalazine. Enemas and oral preparations can be equally successful in prolonging remission; in the case of a distal lesion, topical 5-ASA preparations can be limited. For example, for the prevention of recurrence of ulcerative colitis, limited to damage to the rectum, the use of salofalk suppositories 250 mg 3 times a day is usually sufficient.

Long-term use (up to 2 years) of a maintenance dose of mesalazine, as a rule, ensures the maintenance of stable remission; on the contrary, in patients with a remission that persists for a year while taking the drug, when transferred to placebo, relapses are observed in 55%

cases over the next 6 months. With continued maintenance therapy, the recurrence rate over the same period is only 12%. In addition, regular use of mesalazine reduces the risk of colorectal carcinoma, which is significantly more common in ulcerative colitis and Crohn's disease. On the background long-term use mesalazine, the incidence of carcinomas becomes comparable to the average in the population. That is why the question of stopping maintenance therapy after 1-2 years in the absence of relapses should be decided in each case individually.

T a b l e 6 Doses of drugs recommended in the treatment of ulcerative colitis

* It is recommended to reduce the dose of prednisolone by 10 mg/week to a dose of 30 mg, and then reduce by 5 mg weekly to a dose of 10 mg/day, etc., with a dose of 20 mg/day recommended for a month. After achieving remission, GCS should be canceled; cancellation of GCS - while taking mesalazine.

There is no unequivocal opinion on the advisability of using antidiarrheal drugs in patients with UC; some authors do not recommend their appointment due to the possibility of developing toxic dilatation of the colon and an insignificant therapeutic effect.

As part of the treatment of UC, correction of dysbiotic disorders is carried out. Additional treatments for UC also include hyperbaric oxygenation (HBO), plasmapheresis, and hemosorption.

Distal UC

Mild form - mesalazine 1-2 g / day rectally in the form of suppositories or enemas.

Moderate form - mesalazine rectally (2-4 g / day in the form of enemas or suppositories) or corticosteroids (prednisolone 20-30 mg / day or hydrocortisone 125 mg / day) in the form of enemas. With proctitis, the introduction of steroids in suppositories is indicated.

With the ineffectiveness of local therapy - a combination of aminosalicylates (sulfasalazine, mesalazine)

2-3 g / day orally with their rectal administration or corticosteroids in the form of enemas.

Severe form - oral prednisolone 0.5-1 mg / kg body weight per day in combination with rectal corticosteroids (prednisolone - 20-30 mg / day or hydrocortisone 125 mg / day).

Left sided UC

Mild form - aminosalicylates (sulfasalazine 3-4 g/day, mesalazine 2-3 g/day) orally and mesalazine

2-4 g / day rectally.

Moderate form - aminosalicylates (sulfasalazine 4-6 g / day, mesalazine - 3-4.8 g / day) orally and mesalazine 2-4 g / day rectally or corticosteroids (prednisolone 20-30 mg / day or hydrocortisone 125-250 mg / day) in the form of enemas.

With absence clinical effect- prednisolone 1 mg/kg of body weight per day orally in combination with rectal administration of corticosteroids and mesalazine (prednisolone - 20-30 mg / day or hydrocortisone - 125-250 mg / day, or mesalazine - 2-4 g / day) .

Severe form - prednisolone 1-1.5 mg/kg body weight per day IV and mesalazine 2-4 g/day rectally or corticosteroids (prednisolone 20-30 mg/day or hydrocortisone 125-250 mg/day) in the form of enemas .

Total NUC

Mild form - aminosalicylates (sulfasalazine

3-4 g / day, mesalazine - 2-3 g / day) orally and mesalazine 2-4 g rectally or corticosteroids (prednisolone 20-30 mg / day or hydrocortisone 125 mg / day) in the form of enemas.

Moderate form - prednisolone 1-1.5 mg/kg of body weight per day.

Severe form - intravenous prednisolone 160 mg / day or metipred 500 mg or hydrocortisone / m 500 mg / day (125 mg 4 times) 5-7 days, then prednisolone 1.5-

2 mg/kg body weight per day orally (but not more than 100 mg per day).

In case of inefficiency conservative therapy surgical treatment is carried out.

Indications for surgical treatment

Reasonable clinical signs suspected bowel perforation;

not amenable to purposeful complex therapy toxic dilatation of the colon;

Rare cases profuse intestinal bleeding;

Lack of effect of adequate conservative treatment:

Hormonal resistance and hormonal dependence;

Ineffectiveness or severe side effects when taking immunosuppressants (azathioprine, methotrexate, cyclosporine);

The constant threat of the development of complications of hormonal therapy (osteoporosis, steroid diabetes, arterial hypertension, infectious complications);

The development of persistent strictures with symptoms of partial intestinal obstruction;

Cancer on the background of a chronic inflammatory process.

The most preferred operation is proctocolectomy with preservation of the natural anus.

The prognosis for NUC is determined by the severity of the disease itself, the presence of complications requiring surgical intervention, as well as a high risk of developing colon cancer.

The risk of malignancy in NUC is determined by 4 main factors:

Duration of the disease (more than 8 years with total colitis, more than 15 years with left-sided colitis);

Drug Dose

Exacerbation of the disease Glucocorticosteroids 60 mg ^ 0 mg ^ 10 mg *

Sulfasalazine E-4 g/day

5-ASA 2-4 g/day

5-ASA in enemas 1-2 g/day

5-ASA in suppositories 500 mg 2 times a day

Prevention of recurrence Sulfasalazine 2 g/day

5-ASA 1.5 g/day

5-ASA in enemas 1 g/day

The prevalence of the inflammatory process (total colitis) and the severity of the disease;

Age of first exacerbation (under 30 years old);

Combination with primary sclerosing cholangitis.

Risk of carcinoma formation in UC

Duration over 10 years 2%

disease (probability 20 years 9%

development of carcinoma) 30 years 19%

Prevalence of pro-Proctitis *1.7

process (increased risk for Left-sided colitis *2.8

population) Total colitis *14.8

Cancer in NUC can develop in any area

large intestine; for the most part they are solitary and are localized in the distal sections. However, 10-25% of patients may have two or more carcinomas at the same time.

In non-operated patients with pancolitis after 20 years in 12-15% of cases, colon carcinoma develops. Histologically, carcinomas against the background of UC are most often represented by adenocarcinomas.

With a duration of UC disease of 10 years or more in the case of left-sided colitis and 8 years or more with a total lesion, an annual or 1 time in 2 years colonoscopy is recommended for the prevention of colon cancer (with taking 3-4 biopsies every 10-15 cm of the intestine, as well as from all macroscopically suspicious areas).

The presence of signs of severe dysplasia is an indication for preventive colectomy. When dysplasia is detected mild degree a follow-up study after 3 months with histological verification is recommended. In case of confirmation of low-grade dysplasia, colectomy is recommended, in the absence of a colonoscopy after a year. In the case of histological changes, when the presence of dysplasia is doubtful, it is recommended to repeat colonoscopy after a year, in the absence of dysplastic changes - after 1-2 years.

The possibility of chemoprevention of colorectal cancer in patients with UC has been proven: long-term (over 5-10 years) administration of mesalazine at a dose of at least

1.2 g/day resulted in an 81% reduction in the risk of developing cancer (compared to patients who did not take mesalazine). At lower doses, as well as when taking

2 g sulfasalazine per day, the effect was significantly lower. Individuals with UC and primary sclerosing cholangitis have an increased risk of developing colorectal cancer compared to patients with UC without cholangitis. Administration of ursodeoxycholic acid preparations at a dose

13-15 mg/kg per day leads to a significant reduction in the risk of developing carcinomas in these patients.

LITERATURE

1. Adler, G. Crohn's disease and ulcerative colitis / G. Adler; per. with him. A.A. Sheptulina.-M.: GEOTAR-MED, 2001.-500 p.

2. Belousova, E.A. Ulcerative colitis and Crohn's disease / E.A. Belousova.-M.: Triada, 2002.-130 p.

3. Goigoriev, P.Ya. Reference guide to gastroenterology / P.Ya.Grigoriev, E.P.Yakovenko.-M.: Med. inform. agency, 1997.-480 p.

4. Goigoryeva, G.A. Nonspecific ulcerative colitis and Crohn's disease: diagnosis and treatment of complicated forms / G.A. Grigorieva, N.Yu. Meshalkina, I.B. Repina // Clinical perspectives of gastroenterology, hepatology.-2002.- No. 5.-C.34- 39.

5. Masevich, Ts.G. Modern pharmacotherapy of chronic inflammatory bowel diseases / Ts.G.Masevich,

S.I. Sitkin // Aqua Vitae.-2001.-No. 1.-S. 37-41.

6. Rumyantsev, V. G. Local therapy of distal forms of ulcerative colitis / V. G. Rumyantsev, V. A. Rogozina, V. A. Osina // Consilium-medicum.-2002.-T. 4, no. 1.

7. Sitkin, S.I. Mesalazine in the treatment of inflammatory bowel disease. Pharmacokinetics and clinical efficacy / S.I. Sitkin // Gastroenterology of St. Petersburg.-2002.-№ 1.-S. 15.

8. Khalif, I.L. Inflammatory bowel disease (nonspecific ulcerative colitis and Crohn's disease): clinic, diagnosis and treatment / I.L. Khalif, I.D. Loranskaya.-M.: Miklosh, 2004.-88 p.

9. Shifrin, O.S. Modern approaches to the treatment of patients with nonspecific ulcerative colitis / O.S. Shifrin // Consilium-medicum.-2002.-T. 4, No. 6.-S.24-29.

10 Hanauer, S.B. Renal safety of long-term mesalamine therapy in inflammatory bowel disease (IBD) / S. B. Hanauer, C. Verst-Brasch, G. Regalli // Gastroenterology.-1997.-Vol. 112.-A991.

11. Inflammatory Bowel Disease: From Bench to Bedside / ed. by S.R.Targan, F.Shanahan, L.C.Karp.- 2nd ed.-Kluwer Academic Publishers, 2003.-904 p.

12. Lamers, C. Comparative study of the topically acting glucocorticoid budesonide and 5-ASA enema therapy in proctitis and proctosigmoiditis / C. Lamers, J. Meijer, L. Engels // Gastroenterology.-1991.-Vol. 100.-A223.

13. Lofberg, R. Oral budesonide versus prednisolone in apationts with active extensive and left-sided ulcerative colitis / R.Lofberg, A.Danielsson, O.Suhr // Gastroenterology.- 1996.-Vol. 110.-p. 1713-1718.

14. Marshall, J.K. Rectal corticosteroids versus alternative treatments in ulcerative colitis: a meta-analysis / J.K. Marshall, E.J. Irvine // Gut.-1997.- Vol. 40.-p. 775-781.

15. Murch, S.H. Location of tumor necrosis factor alpha by immunohistochemistry in chronic inflammatory bowel disease / S.H.Murch // Gut.-1993.-Vol. 34(12).-P.1705-1709.

16. Sutherland, L.R. Sulfasalazine revisited: a meta-analysis of 5-aminosalicylic in the treatment of ulcerative colitis / L.R.Sutherland, G.R.May, E.A.Shaffer // Ann. Intern. Med.- 1993.-Vol. 118.-P.540-549.

17. Sutherland, L.R. Alternatives to sulfasalazine: a meta-analysis of 5-ASA in the treatment of ulcerative colitis / L.R.Sutherland,

D.E. Roth, P.L. Beck // Inflam. Bowel. Dis.-1997.-Vol. 3.-P.5-78.

UDC 616.36-004-06-07-08

DIAGNOSTICS AND TREATMENT OF COMPLICATIONS OF LIVER CIRRHOSIS. MANAGEMENT OF PATIENTS WITH EDEMATE-ASCITIS SYNDROME

I.A. Gimaletdinova

Clinical Hospital of the Ministry of Internal Affairs for the Republic of Tatarstan, Kazan

Abstract: The clinical picture of liver cirrhosis is largely determined by the development of complications: edematous-ascitic syndrome, hepatic encephalopathy, bleeding from varicose veins of the esophagus, etc. This article discusses approaches to the management of patients with edematous-ascitic syndrome in cirrhosis

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2010 (Order No. 239)

Ulcerative colitis, unspecified (K51.9)

general information

Short description

(NUC) is a chronic inflammatory disease of the colon, characterized by ulcerative-necrotic changes in the mucous membrane, which is localized mainly in its distal sections. Changes initially occur in the rectum, then spread sequentially in the proximal direction and in about 10% of cases capture the entire colon.

Crohn's disease- non-specific primary chronic, granulomatous inflammatory disease involving all layers of the intestinal wall in the process, characterized by intermittent (segmental) lesions of various parts of the gastrointestinal tract. The consequence of transmural inflammation is the formation of fistulas and abscesses.

Protocol"Nonspecific ulcerative colitis. Crohn's disease. Ulcerative colitis"

ICD-10 codes: K 50; K 51

K50.0 Crohn's disease small intestine

K50.1 Crohn's disease of colon

K50.8 Other varieties of Crohn's disease

K51.0 Ulcerative (chronic) enterocolitis

K51.2 Ulcerative (chronic) proctitis

K51.3 Ulcerative (chronic) rectosigmoiditis

Classification

Classification(depending on the location of the lesion)

Nonspecific ulcerative colitis:

1. By localization: distal colitis (proctitis, proctosigmoiditis), left-sided colitis (damage to the splenic flexure), subtotal colitis, total colitis, total colitis with retrograde ileitis.

2. By form: acute (1 attack), fulminant (fulminant course - fever, hemorrhages, left-sided or total colitis with complications: toxic megacolon, perforations); chronic relapsing; chronic continuous. Chronic form - clinical symptoms over 6 months.

3. By phase: exacerbations, remissions.

4. Downstream (severity):

4.1 Lung: stools up to 4 times a day with a slight admixture of blood, fever and tachycardia are absent, moderate anemia, ESR is not higher than 30 mm/h, complications and extraintestinal manifestations are not typical.

4.2 Moderate: stool 4 to 8 times a day with clots or bright red blood, subfebrile temperature, tachycardia over 90 bpm, anemia 1-2 tbsp., ESR within 30 mm/hour, weight loss up to 10%, complications are not typical, there may be extraintestinal manifestations.

4.3 Severe: stool more than 8 times a day with blood loss over 100 ml, febrile temperature, anemia of 2-3 degrees, ESR over 30 mm/h, severe tachycardia, weight loss over 10%, complications and extraintestinal manifestations are typical.

Diagnostics

Diagnostic criteria for CD and UC

Complaints and anamnesis
Crohn's disease - diarrhea, pain in the right iliac region, perianal complications, fever, extraintestinal manifestations (Ankylosing spondylitis, arthritis, skin lesions), internal fistulas, weight loss.

Nonspecific ulcerative colitis - bleeding from the rectum, frequent bowel movements, constant urge to defecate, stools mainly at night, abdominal pain mainly in the left iliac region, tenesmus.

Physical examination: deficiency of body weight, symptoms of intoxication, polyhypovitaminosis; pain on palpation of the abdomen mainly in the right and left iliac regions.

Laboratory research: accelerated ESR, leukocytosis, thrombocytosis, anemia, hypoproteinemia, hypoalbuminemia, CRP, an increase in alpha-2 globulins, reticulocytosis.

Instrumental Research: colonoscopy, sigmoidoscopy - the presence of transverse ulcers, aphthae, limited areas of hyperemia, edema in the form of " geographical map”, fistulas with localization in any part of the gastrointestinal tract.

Contrast radiography with barium - rigidity of the intestinal wall and its fringed outlines, strictures, abscesses, tumor-like conglomerates, fistulous passages, uneven narrowing of the intestinal lumen up to the "lace" symptom.
With NUC: granulation (granularity) of the mucosa, erosion and ulcers, jagged contours, wrinkling.

Histology (by agreement with parents) - edema and infiltration of lymphoid and plasma cells of the submucosal layer, hyperplasia of lymphoid follicles and Peyer's patches, granulomas. With the progression of the disease, suppuration, ulceration of lymphoid follicles, the spread of infiltration to all layers of the intestinal wall, hyaline degeneration of granulomas.

Ultrasound - thickening of the wall, decrease in echogenicity, anechoic thickening of the intestinal wall, narrowing of the lumen, weakening of peristalsis, segmental disappearance of haustra, abscesses.

Indications for expert advice:

Dentist;

Physiotherapist;

Surgeon (by indications).

List of main diagnostic measures:

1. Complete blood count (6 parameters).

2. Examination of feces for occult blood.

3. Coprogram.

4. Esophagogastroduodenoscopy.

5. Sigmoidoscopy.

6. Colonoscopy.

7. Contrast radiography with barium.

8. Histological examination of the biopsy.

9. Determination of total protein.

10. Determination of protein fractions.

11. Coagulogram.

12. Dentist.

14. Physiotherapist.

15. Surgeon (according to indications).

Additional diagnostic studies:

1. Determination of bilirubin.

2. Determination of cholesterol.

3. Determination of glucose.

4. Definition of ALT, AST.

5. Determination of C-reactive protein.

6. X-ray of the stomach.

7. Ultrasound of the abdominal organs.

8. Determination of iron.

9. Colonoscopy.

Differential Diagnosis

Medical tourism

Get treatment in Korea, Israel, Germany, USA

Medical tourism

Get advice on medical tourism

Treatment

Treatment tactics

Purpose of treatment:

Ensuring remission;

Prevention of complications.

Non-drug treatment

Medical treatment

In the treatment of UC and CD, the effectiveness of 5-aminosalicylic acid, glucocorticoids and cytostatics has been proven.

Basic therapy consists in prescribing 5-aminosalicylic acid preparations. Use mesalazine at a dose of 2-4 g / day. mainly in tablet form or sulfasalazine (2-8 g / day, always in combination with folic acid 5 mg / day). Mesalazine is preferred as it is less toxic and has fewer side effects.

In the presence of perianal lesions in the complex medical measures include metronidazole at a dose of 1-1.5 g / day.
Additional drugs(antibiotics, prebiotics, enzymes, etc.) are prescribed according to indications.
Once remission is achieved, patients should receive maintenance therapy with mesalazine or sulfasalazine 2 g/day for at least 2 years.

In case of intolerance to 5-aminosalicylic acid preparations, prednisolone (10-30 mg every other day) is used. Azathioprine is prescribed as maintenance therapy to patients in whom remission has been achieved with its use (50 mg / day).

Preventive actions:

Prevention of bleeding;

fistula prevention;

Prevention of the formation of strictures;

Prevention of purulent-infectious complications;

Prevention of the development of deficient conditions (anemia, polyhypovitaminosis).

Further management: patients with UC and CD are subject to dispensary observation with a mandatory annual visit to the doctor and sigmoidoscopy with targeted biopsy of the rectal mucosa in order to identify the degree of inflammation and dysplasia. Colonofibroscopy with multiple targeted biopsy is performed for total colitis that has existed for more than 10 years. Blood tests and liver function tests are done annually. In remission, patients with UC and CD are prescribed salofalk 0.5 x 2 r for life. in the day or sulfasalazine 1 g x 2 p. in d.

List of essential medicines:

1. Mesalazine 250 mg, 500 mg, tab.

2. Sulfasalazine 500 mg, tab.

3. Prednisolone 0.05, tab.

4. Metronidazole 250 mg, tab.

List of additional medicines:

1. Azathioprine 50 mg tab.

2. Thiamine bromide 5%, 1.0

3. Pyridoxine hydrochloride 5%, 1.0

4. Aevit, caps.

5. Aktiferrin, syrup, drops, tablets

6. Methyluracil, 0.25 tab., suppositories 0.5

7. Duphalac, syrup

8. Dicynon, solution 12.5%, 2.0 ml, tab. 0.250

9. Epsilon-aminocaproic acid, solution 5%, 100 ml

Treatment effectiveness indicators: disappearance of pathological impurities in the feces, relief of abdominal pain, normalization of stool, regression of systemic manifestations.

Hospitalization

Indications for hospitalization (planned):

1. For the first time established diagnosis NJK and BK.

2. Exacerbation of the disease (moderate and severe course, laboratory signs of process activity, the presence of systemic manifestations).

3. The presence of complications and the risk of developing the activity of the process.

The required amount of research before planned hospitalization:

Complete blood count (6 indicators);

total protein and fractions, SRB;

Coagulogram;

Sigmoidoscopy, irrigoscopy or colonoscopy;

Fibrogastroduodenoscopy.

Information

Sources and literature

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 239 of 04/07/2010)
   1. 1. Guido Adler. Crohn's disease and ulcerative colitis. M., "Geotar - honey", 2001. 2. Management of ulcerative colitis. Society of Surgery of the alimentay tract. 2001. 3. American College of Radiology. Imaging recommendations for patients with Crohn's disease. 2001. 4. Clinical guidelines for practicing physicians. M, 2002. 5. Practical gastroenterology for a pediatrician, M.Yu. Denisov, M., 2004 6. Diseases of older children, a guide for physicians, R.R. Shilyaev et al., M, 2002 7. Practical gastroenterology for a pediatrician, V.N. Preobrazhensky, Almaty, 1999

Information

List of developers:

1. Head of the Department of Gastroenterology, RCCH "Aksay", F.T. Kipshakbaeva.

2. Assistant of the Department of Children's Diseases KazNMU named after. S.D. Asfendiyarova, Ph.D., S.V. Choi.

Download: Google Play Store | AppStore

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website cannot and should not replace an in-person medical consultation. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
• The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the state of the patient's body.
• The MedElement website is an information and reference resource only. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
• The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

Residents of megacities, due to the current environmental situation and in connection with urbanization, are more likely to various diseases both at young and old age. Today we will discuss the health risks of non-specific ulcerative colitis, the treatment of which is still little studied.

Why does this disease appear?

Non-specific ulcerative colitis of the intestine is a pathological condition in which the mucosal lining of the large intestine is affected. Ulcers form on the surface.

Such a disease is not provoked by infectious or bacteriological pathogens. It is not transmitted from a sick person to a healthy one.

On a note! Bleeding from the rectum may indicate the progression of intestinal nonspecific colitis. This serious reason for immediate medical attention.

Most often, the described pathology affects people who have crossed the 60-year mark. But as medical practice shows, even at a young age, in particular, up to 30 years, colitis can be diagnosed.

Among the causes that provoke the disease of nonspecific ulcerative colitis include:

• genetic predisposition;
• violation of the intestinal microflora;
• gene mutations;
• infections in the organs of the digestive tract of unknown etiology;
• unbalanced diet;
• frequent experience of stressful situations;
• uncontrolled intake of a number of anti-inflammatory drugs, as well as oral contraceptives.

Symptoms of pathology

Nonspecific ulcerative colitis in children of various age categories, including adolescents, progresses in 8-15% of cases. But in infants, according to statistics, it practically does not appear.

To date, the causes of this disease have not been reliably studied. Symptoms and treatment of non-specific ulcerative colitis in children and adults are the same.

Important! The described pathological condition is among the chronic. With treatment, you can achieve a stable remission, which, under the influence of certain factors, is replaced by an acute form.

How to recognize nonspecific ulcerative colitis? Symptoms of this pathology are conditionally divided into two categories:

• intestinal;
• extraintestinal.

• diarrhea with blood impurities;
• pain sensations of varying intensity in the abdomen;
• an increase in the temperature of the human body to subfebrile levels;
• a sharp decrease in body weight;
• pathological weakness;
• loss of appetite;
• dizziness;
• false urge to defecate;
• flatulence;
• fecal incontinence.

As for extraintestinal symptoms, it manifests itself extremely rarely, in about 10-20% of clinical cases. Extraintestinal signs include:

• inflammatory processes in the articular and bone tissue;
• defeat skin, mucous membrane of the eye, oral cavity;
• increased blood pressure;
• tachycardia.

On a note! primary symptom progression of nonspecific ulcerative colitis is considered the presence of blood impurities in the products of defecation. In this case, you should immediately contact a specialized doctor and undergo an examination.

When diagnosing ulcerative nonspecific colitis, specialized doctors first of all determine the severity of the disease, in particular, the progression of ulcerative processes.

Treatment is almost always complex and includes:

• diet therapy;
• taking medications;
• surgical intervention.

It is important to diagnose nonspecific ulcerative colitis in a timely manner. The diet will help the patient feel better and relieve symptoms. In addition, the process of progression of pathology slows down.

When the disease goes into the acute stage, a person suffering from intestinal nonspecific colitis, it is necessary to completely refuse food intake. These days it is allowed to drink only filtered water without gas.

When the disease enters the phase of stable remission, the patient must adhere to a dietary diet. Taboo is placed on fatty foods, preference should be given to products with a high concentration of protein.

In parallel with the diet, the patient is prescribed pharmacological preparations:

• vitamins;
• anti-inflammatory nonsteroidal;
• antibiotics.

On a note! You cannot self-medicate. In each particular case, based on clinical picture ulcerative colitis, a suitable drug is selected individually for the patient.

Specialists resort to surgical intervention only in extreme cases when conservative treatment did not give any positive results. In addition, the following factors are considered direct indications for surgery:

• malignant processes in the intestine;
• perforation of the intestinal walls;
• intestinal obstruction;
• abscesses;
• bleeding of profuse type;
• the presence of toxic megacolon.

Alternative treatments

Some doctors advise patients suffering from ulcerative colitis, in addition to taking pharmacological agents and adherence to a diet, apply for the treatment of traditional medicine.

Microclysters, which are made on the basis of sea buckthorn oil extract and rose hips, are considered very effective. It is only necessary to first enlist the support of the attending physician. Also, to relieve symptoms and improve well-being, take decoctions of burnet.

Important! In no case should you abandon drug therapy in favor of alternative treatment.

Although the prevalence of ulcerative colitis is not high, there is a regular increase in cases. Over the past 4 decades, the number of people with this disease as a percentage of healthy people increased more than 6 times.

Let's define terms. Ulcerative colitis is a chronic disease of the large intestine with immune inflammation of the mucosa. Only the large intestine is affected, while the rectum is limited to inflammation of the mucous membrane.

Exacerbation or recurrence of the disease - the occurrence of symptoms in remission.

In non-specific ulcerative colitis clinical guidelines are reduced to the fact that in order to treat the disease, surgical intervention, drug treatment, psychological support patient and diet.

The severity of relapse determines the choice of a specific method of therapy. The following factors also influence:

the length of the affected area of ​​the intestine; duration of history; existing extraintestinal manifestations; the risk of complications; the effectiveness of previous therapy.

To assess the severity of recurrence, various parameters are used, including the Mayo index.

The Mayo index is equal to the frequency of stool + the presence of rectal bleeding + endoscopic examination data + the general opinion of the doctor. All these parameters are indicated in numerical form - each digital code indicates a certain degree of severity.

Ulcerative colitis in children: types, symptoms and treatment

Babies get sick with ulcerative colitis quite rarely (15 people out of 100), but in last years such cases have increased. At the same time, in half of them the disease has a chronic form and is treated for a sufficiently long period of time.

Ulcerative colitis in children of different ages is a special form of disease of the colon mucosa. With it, purulent and erosive blood inflammations of unknown origin appear in the indicated organ and interfere with the normal functioning of the gastrointestinal tract. As a result, particles of such formations can come out with the feces of a child. Together with them, complications of a local nature or covering the entire body are possible.

Varieties of ulcerative colitis in children

There are several varieties of this disease:

Non-specific. Spastic. Crohn's disease. Colon irritation. Undifferentiated.

The first type of the disease does not have a clear location and can manifest itself throughout the mucous membrane of the colon. It should be noted that in children under 2 years of age, ulcerative colitis is more common among boys, and at an older age it is more common among girls. At the same time, it is very dangerous for both the former and the latter, and the course of the disease is usually moderate or severe.

The spastic appearance is manifested by the presence of dry feces in small quantities with spotting, gas and spasmodic pain in the abdomen. It can be cured by eating right. Considered the most mild form diseases.

The third variety can be localized in several places. In this case, wounds-cracks appear, the walls of the large intestine become thicker, pain is felt in the abdomen on the right. After a tissue study, the disease is identified by the resulting granulomas.

For ulcerative colitis with irritation of the large intestine in a child, frequent fecal excretions (up to 6 times a day), accompanied by painful sensations, are characteristic. At the same time, food does not have time to be completely digested. First there is a bowel movement in a large volume, and then - little by little. At the first sign of this type of illness, you should seek help from a specialist in order to avoid serious consequences and prevent it from becoming chronic.

The last type of the disease combines those colitis that are difficult to attribute to any other group according to the results of the tests (1 out of 10 cases). Its symptoms are similar to various of those described above, so it should be treated with sparing drugs, individually selecting them.

Factors that provoke ulcerative colitis in a child

Scientists are still studying the etiology of this disease, but cannot come to a consensus. To date, it is believed that the factors provoking ulcerative colitis are:

Decreased immunity. Improper nutrition. Availability various infections in the body (dysentery bacillus, salmonella, SARS, chickenpox, etc.). Taking certain medications for inflammation. Psychic trauma. Transmission of the disease by genes (the risk of getting sick increases fivefold).

Each of these reasons is a possible factor that can provoke the development of the disease.

The main symptoms of ulcerative colitis in children

Depending on what symptoms are manifested by ulcerative colitis of the intestine in children, the treatment of a certain type of disease is prescribed. In a child, the disease usually progresses rapidly, therefore, in order to avoid surgical intervention, it is necessary to see the first signs of the disease without wasting time to contact a specialist. That is why it is very important to know how this disease in one case or another, in order to be able to diagnose it as soon as possible and start treating it, preventing it from flowing into a chronic form and the occurrence of various complications.

The main symptoms of ulcerative colitis of the colon in children are:

Diarrhea (stools up to 6-10 times a day) or constipation. Blood discharge from the anus and in the stool. Feces do not have clear forms, come out with mucus or purulent secretions. Constant general fatigue of the child. drastic loss body weight. Significant decrease in appetite. Colic in the stomach. Pain in the abdomen or around the navel. Dysbacteriosis.

During the frequent urge to defecate, only liquid with mucus and blood comes out. Due to frequent bowel movements, irritation, itching, cracks appear in the anus. As a result of a decrease in the number of bifidobacteria in the intestine, the work of other internal organs.

One of the symptoms of ulcerative colitis of the intestine in children of different ages is pale skin of the face with bruises under the eyes. It loses its healthy appearance, acquiring a grayish-greenish tone. Rashes appear, sometimes dermatitis, in severe forms of the disease, abscesses may occur. When listening to the heart, arrhythmia is palpable.

When an ultrasound of the internal organs is prescribed, with this disease, an increase in the liver or spleen may be observed. The gallbladder and ducts are affected.

Symptoms of nonspecific ulcerative colitis in young children can be expressed, in addition to these manifestations, also:

Stomatitis. Urticaria. High body temperature (about 38 ° C). conjunctivitis. Redness of the iris. Aches and pains in the joints.

Due to the disease, children may experience a delay in sexual and physical development.

As soon as any of the above symptoms of ulcerative colitis in children have been noticed, it is necessary to immediately consult a doctor for the appointment of treatment. In no case should you self-medicate, because, firstly, an accurate diagnosis is necessary, and secondly, some types of ulcerative colitis in children can develop at lightning speed and even lead to death.

Diagnosis of ulcerative colitis in a child

Diagnosis of ulcerative colitis by a specialist occurs through communication with the patient's parents, identifying complaints. This is followed by the assignment:

General blood test. Studies of feces. Abdominal ultrasound. Sounding. biopsies. Colonoscopy. Sigmoidoscopy. Sigmoscopy. Irrigography (X-ray of the colon).

In a clinical blood test, there is a reduced hemoglobin, an increase in the total number of leukocytes and stab cells, and an increase in the erythrocyte sedimentation rate in the patient's blood. In feces, an increase in the number of leukocytes and erythrocytes, mucus, undigested food is detected.

Treatment and prevention of ulcerative colitis in children

Treatment of ulcerative colitis of the intestine in children is prescribed by a doctor after identifying the reasons why the disease could occur. The disease can be treated in two ways:

In the first case, the baby is prescribed drug therapy with 5-aminosalicylic acid to reduce the inflammatory process in the mucosa (for example, Sulfasalazine), immunosuppressants (Azathioprine). They are available both in tablets and in the form of suppositories. If their impact is not enough, clinical recommendations for ulcerative colitis in children will be glucocorticoid agents ("Prednisolone"), designed to lower local immunity, due to which the body's antibodies will stop responding to the rectal mucosa. If there are contraindications to hormonal drugs, children can rarely be prescribed drugs from the group of cytostatics ("Azathioprine"). The dosage and period of use of these drugs is determined by the doctor in individually and depends both on the age of the child and on the complexity of the form of the disease.

Surgery for nonspecific ulcerative colitis in children as a treatment is possible if the disease worsens too quickly and the drugs do not have the desired effect. In this case, the part of the intestine in which inflammation has occurred is removed, which makes it possible for the child to resume normal eating, and sometimes becomes a vital necessity.

Stick to the required diet medical nutrition. Provide the child with a drink in the form of non-carbonated mineral water and herbal medicinal infusions and decoctions.

In addition to the diet (food should be as high-calorie as possible), it is important to minimize physical activity for the child, not to overcool the young body. It is also necessary to protect as much as possible from possible infectious diseases, mental stress and overwork. The doctor may also prescribe vitamins, iron-containing preparations, Smecta, and dietary supplements in addition to therapy.

Prevention of ulcerative colitis in a child is to maintain proper nutrition, complete cure from a variety of infectious diseases, exclusion of contact with carriers of infections. Hardening and charging will also help eliminate the disease. Get exercise and stay healthy!

Ulcerative colitis is a fairly serious inflammatory bowel disease. This is due to the severity of the course, a large number of complications and frequent cases of death. Left untreated, the disease can lead to malignancy. With nonspecific ulcerative colitis, the doctor's clinical recommendations should be followed as strictly as possible in order to prevent the development of complications.

Classification of ulcerative colitis

Ulcerative colitis is distinguished by the nature of the course, localization, severity of manifestations and response to therapy.

According to the course of the disease, there are:

• sharp and chronic form;
• fulminant, in other words lightning fast;
• recurrent, when the stages of exacerbation are replaced by stages of remission. Periods can last from one to three months;
• continuous when symptoms persist for more than six months.

The severity of the disease can be mild, moderate and severe. It depends on many factors, such as the severity of the current stage, the presence or absence of complications, the response to the treatment, and so on.

Depending on the type of ulcerative colitis, clinical recommendations will differ. Treatment is prescribed by the doctor on an individual basis.

Nonspecific colitis is a relapsing form of the disease, as the stages of exacerbation are replaced by remissions. Symptoms of ulcerative colitis in adults during an exacerbation may differ depending on the lesion and the intensity of the ongoing process.

If the rectum is affected, bleeding from anus, pain in the lower abdomen, false urges. When the colon is affected, diarrhea is noted, and the stool itself contains blood. In addition, there is a pronounced cramping pain on the left, the patient has a decrease in appetite and diarrhea, which leads to a sharp weight loss.

If intestinal lesions are global, there are severe pain in the abdomen, copious diarrhea with bleeding. This can lead to dehydration or orthostatic shock due to sharp decline pressure. But the greatest danger is the fulminant form of the disease, since there is a risk of rupture of the intestinal wall or a toxic increase in the intestine itself.

In addition to the above, some patients have other extraintestinal symptoms;

• stomatitis;
• skin rashes;
• eye inflammatory diseases;
• joint damage, bone softness;
• diseases of the biliary system and kidneys.

For the diagnosis of nonspecific ulcerative colitis, the recommendations of doctors are as follows:

1. Colonoscopy is a study of the lumen of the colon and internal walls, including a biopsy of the affected area.
2. Irrigoscopy is an x-ray examination with the addition of barium, which reveals ulcers, changes in the size of the intestine, narrowing of the lumen, and so on.
3. Computed tomography - gives complete picture intestinal conditions.
4. Coprogram, blood and stool tests.

In ulcerative colitis, national treatment recommendations depend on many factors, such as the site of the lesion, the severity of the stage, and the presence of complications. First of all, conservative treatment is prescribed, the purpose of which is to stop the development of the disease and prevent reappearance. Mild forms of colitis are treated on an outpatient basis, in more severe cases - in a hospital. Medicines fall into two categories:

1. anti-inflammatory drugs, immunosuppressants and steroids;
2. ancillary medications that are prescribed on an individual basis.

In addition to medicines, nutrition of the patient is of great importance. It is necessary to follow a strict diet aimed at sparing the effect on the intestines. At the same time, food should be high-calorie and rich in proteins. Raw fruits and vegetables, alcohol, fried fatty foods should be excluded.

Watch videos about ulcerative and ulcerative colitis.

In cases where conservative treatment fails or serious complications occur, for non-specific ulcerative colitis, national recommendations focus on the need for surgical intervention.

In the most severe forms of the disease, when the lesion is too large, we are talking about the complete removal of the colon. As a result, the operated patient remains disabled, because he loses the ability to anal defecation. Therefore, surgical treatment is prescribed only in the most extreme cases.

Ulcerative colitis in children requires a more serious approach to diagnosis and treatment. This is due to the difficulties in making a diagnosis, more severe and aggressive forms of the course.

For ulcerative colitis in children, clinical recommendations for treatment are more serious, and the recovery process may take more than one year. First of all, drug therapy is carried out in order to translate the disease into a milder form and achieve a remission stage. At the same time, it is very important to follow a diet, limit physical activity, avoid stress, overwork and infectious diseases.

Bleeding leads to protein deficiency in the body, so you need to use more fish, cape, chicken, eggs. If the child fully complied with all the doctor's prescriptions, then his body weight should begin to increase. This indicates the success of therapy.

In addition to broad-spectrum medications, local therapy is prescribed. wound healing agents, it allows to alleviate the patient's condition. In addition, nutritional supplements, herbal remedies and homeopathy can be prescribed.

If conservative treatment does not help or serious complications develop, the doctor prescribes surgery.

In the treatment of nonspecific ulcerative colitis in children, the doctor's clinical recommendations should be followed with all responsibility. Since the disease is very severe, the entire course of therapy takes from several months to several years under the constant supervision of an experienced gastroenterologist. It is necessary to achieve full understanding between the doctor, parents and the child, then it is possible to recover without the consequences of ulcerative colitis or the disease goes into remission for a long time.

Share your experience of treating bowel disease - ulcerative colitis in