I. Overview
Pediatric ulcerative colitis (UC), or ulcerative colon, is a nonspecific, chronic inflammatory disease of the colonic mucosa and submucosa whose cause is unknown. It often begins in the left hemocolon and may progress in a continuous manner to the proximal colon and even to the whole colon, with a few cases involving the terminal ileum. The incidence is low in pediatric patients and occurs mainly in adolescents and school-age children. The clinical symptoms vary in severity and may alternate between remission and flare-ups with colonic symptoms only or with systemic symptoms.
Etiology
The etiology of this disease is not clear, but it is an inflammatory disease that occurs mainly in the colonic mucosa, with ulceration and erosion of the colonic mucosa as the main pathological changes. There is a consensus that both immune factors and genetic factors are present in the development of this disease, while various other factors are mostly predisposing factors.
There may be various causes as follows.
1, autoimmune causes
Pediatric ulcerative colitis is often complicated by autoimmune hemolysis, rheumatoid arthritis, lupus erythematosus, Hashimoto’s disease, iritis, etc., and is effectively treated with adrenocorticosteroids or other immunosuppressive drugs, so it is considered that the disease may be an autoimmune disease.
2. Infectious causes
Some children are effectively treated with antibiotics.
3.Dietary allergy causes
Certain foods can cause the recurrence of the lesions, and the removal of these diets can make the disease remit.
4.Hereditary causes
15% to 30% of the patients’ families have the disease.
5.Mental factors
Some children are found to have anxiety, nervousness, paranoia and autonomic disorders.
Clinical manifestations
The onset of the disease is mostly slow, and the course of the disease can be continuous, often with alternating periods of attack and remission. 10% of patients have acute attacks, with rapid development of the disease, obvious symptoms of systemic toxicity, frequent complications, and high mortality rate, and the disease can suddenly intensify during the remission period.
1.Digestive system symptoms
Initially dilute stool, 4-6 times / day, progressive aggravation of mucus blood stool and pus. Acute onset is bloody stools with abdominal pain, vomiting, fever and other toxic symptoms of the disease.
2, systemic symptoms
In mild cases, it is often not obvious, but in severe cases, there may be fever, water-electrolyte disorders; children with prolonged diarrhea, blood in the stool, loss of appetite, increased heart rate, weakness, depression, and in time, anemia and malnutrition, etc., about 3% of patients show emotional instability, such as depression, anxiety, insomnia, etc.; severe cases can also be accompanied by growth disorders, delayed puberty, and some children with mental, psychological and emotional Some children have mental, psychological and emotional abnormalities.
3.Extra-intestinal symptoms
The disease is associated with arthritis in 25% of children, mainly in the limbs and spine, and joint symptoms sometimes occur before diarrhea. 10% of children have skin lesions, such as erythema nodosum and gangrenous pyoderma. 2% of children may have retinitis and oral ulcers.
Four, examination
1.Barium enema examination
It is a method mainly used to diagnose colon lesions, i.e., inserting an anal tube from the anus, filling it with barium and then examining it by X-ray to diagnose colon tumors, polyps, inflammation, tuberculosis, intestinal obstruction and other lesions.
2.Electron colonoscopy
It is a simple and easy examination method, which can find the masses in high position that cannot be felt by rectal finger examination, and take tissue biopsy of suspicious lesions to clarify the nature. It is often used to examine intestinal inflammation, ulcers, polyps, tumors, lesions caused by parasites and unexplained diarrhea. It is important for the prevention and early detection of intestinal lesions.
V. Diagnosis
1.Diagnostic criteria
At present, the Lennard-Jones criteria are often used internationally, and the Diagnostic Criteria and Efficacy Criteria of Ulcerative Colitis formulated by the 1993 Taiyuan National Symposium on Chronic Non-infectious Intestinal Diseases are used domestically, both of which emphasize exclusionary diagnosis, endoscopic and histological features.
(1) Lennard-Jones criteria A person with clinical manifestations of ulcerative colitis meeting the following criteria suggests the diagnosis of this disease.
①The following diseases must be excluded first: infectious colitis, ischemic colitis, radiation colitis, isolated colonic ulcer, Crohn’s disease
(2) The following conditions must be included: biopsy showing diffuse mucosal inflammation without granuloma formation; endoscopic or barium enema finding that inflammation involves the rectum and part or all of the colon, with lesions starting in the rectum and progressing continuously and retrogradely from distal to proximal ends.
(2) National Symposium on Chronic Non-infectious Intestinal Diseases Criteria
(1) Clinical manifestations Not only are there persistent or recurrent mucus and blood stools, abdominal pain, with varying degrees of systemic symptoms, but also the few patients who have only constipation without bloody stools should not be neglected, and extraintestinal manifestations such as joints, eyes, mouth, liver and spleen should be noted in past history and physical examination.
The mucosa has multiple shallow ulcers with congestion and edema, most of the lesions start from the rectum and are diffusely distributed; the mucosa is rough and finely granular, the mucosal vessels are blurred, brittle and bleeding, or with purulent secretions; pseudopolyps are seen, and the colonic pouch is often blunt or disappears.
Histological examination of mucosal biopsy shows inflammatory reaction, while erosion, ulceration, crypt abscess, abnormal arrangement of glands, reduction of cupped cells and epithelial changes are often seen.
④Barium enema examination Mucosal coarse disorganization and/or fine-grained changes; multiple shallow niche shadows or small filling defects; shortening of the intestinal canal and disappearance of the colonic pouch may be tubular.
(5) Surgical resection or pathologic anatomy Visual or histologic features of ulcerative colitis may be seen.
(3) Diagnosis after exclusion of related diseases On the basis of exclusion of infectious colitis such as bacillary dysentery, amebic dysentery, chronic schistosomiasis, intestinal tuberculosis and Crohn’s disease, ischemic colitis, and radiation colitis.
It can be diagnosed according to the following criteria.
①The disease can be diagnosed based on clinical manifestations, one of the colonoscopy and/or mucosal biopsy.
②The disease can be diagnosed based on clinical manifestations and one of the barium enemas.
③The disease can be diagnosed if the clinical manifestations are atypical but there are typical colonoscopy manifestations or barium enema examination typical changes. (4) Those with typical clinical symptoms or typical past history, but no typical changes on colonoscopy or barium enema, should be classified as “suspected” for follow-up.
2.Main clinical characteristics
The most common symptom is recurrent colitis, which is characterized by bloody diarrhea, fever, and abdominal pain during acute attacks, and children with pallor, anemia, malnutrition, and delayed puberty.
3.Main auxiliary examination
Barium enema and electronic colonoscopy are valuable diagnostic and differential diagnostic methods.
Differential diagnosis
1.Chronic bacteriophageal dysentery
Often have a history of acute bacterial dysentery, antibacterial treatment is effective, stool culture can be isolated bacillus dysenteriae, colonoscopy to take mucus pus blood culture, the positive rate is high.
2.Chronic amoebic dysentery
The lesion mainly invades the right colon, but also can involve the left colon, the colon ulcer is deeper, the edge is submerged, the mucosa between the ulcer is mostly normal, the fecal examination can find the lysoamebic trophozoites or encapsulation, the anti-amebic treatment is effective.
3.Crohn’s disease
The lesion mainly invades the end of the ileum, the whole gastrointestinal tract is damaged, abdominal pain is mostly located in the right lower abdomen or around the umbilicus, the urgency is rare, the stool is often without mucus and pus and blood, abdominal mass, fistula formation, the anus and perirectal lesions are more common, barium X-ray imaging can be seen at the end of the ileum with linear signs, e-colon examination is mostly normal, if the rectum is involved, the mucosa of the lesion is seen to be pebble-like elevation, there are round longitudinal ulcers, the lesion is segmentally distributed. The lesion is segmentally distributed.
4.Colon cancer
Colonoscopy is valuable for differential diagnosis, and biopsy can confirm the diagnosis.
5.Easy bowel irritation syndrome
With systemic neurosis, mucus but no pus and blood in stool, no evidence of organic lesion on colonoscopy.
VII. Complications
1.Intestinal complications
(1) Acute fulminant ulcerative colitis Acute colonic dilatation and ulcer perforation, lower gastrointestinal bleeding, colonic pseudo-polyps in multiple, variable size, sometimes cobblestone-like, colonic stenosis mostly in rectum and transverse colon, also seen in other parts.
(2) toxic megacolon a serious complication, the incidence of 1.6% to 2.5%, the death rate of 13% to 50%, mostly seen in acute fulminant and heavy patients, the cause is mostly related to taking too much anticholinergic drugs, low potassium, barium enema, colon lesions are extensive and serious, involving the intestinal muscular layer and intermuscular plexus, so that the intestinal canal dilatation can not be contracted, the diameter of the intestinal cavity can be more than 10 cm, toxic symptoms The symptoms of toxicity are obvious, with abdominal distension, abdominal pressure pain, rebound pain, diminished or absent bowel sounds, significantly elevated leukocytes, enlarged colon and disappearance of colonic pouch in X-ray plain film, and ischemia and necrosis due to intestinal expansion, resulting in acute intestinal perforation.
(3) Colon perforation and rectal hemorrhage The incidence is about 1%, and the morbidity and mortality rate is 40% to 50%, due to.
(1) occurring on the basis of toxic megacolon dilatation ;
(ii) occurring in chronic stenosis;
(3) induced by high-pressure barium enema.
(4) Polyp as a late complication, the incidence of 9.7% to 39%, caused by inflammation, usually colon pseudopolyp.
(5) Carcinoma can occur in the late stage, the incidence of 5% to 10%, mainly in heavy patients, lesions involving the whole colon and patients with a long course of disease, carcinoma in children cases less, the longer the course of the disease, the higher the tendency of carcinoma, the first 10 years after the onset of cancer rate of about 3%, after the annual increase of 0.5% to 1.0%, the second 10 years up to 10% to 20%, so children should be 1 year to perform The late complications include perianal infections, anal fistula, etc.
2, extra-intestinal complications
(1) Joint involvement About 25% of the joints in ulcerative colitis are involved, manifesting as non-deformable wandering acute arthritis, such as swelling, pain; simultaneous involvement can be one or more joints, all joints can be invaded, but the knee, ankle and wrist joints are more common.
(2) Skin damage More common, about 15% of severe active ulcerative colitis has skin damage, erythema nodosum is more common, and does not leave scar after healing; gangrenous pyoderma is ulcerative damage, commonly in the trunk, and leaves scar after healing, in the active phase of the disease, its incidence is 5% to 10%, but can be cured.
(3) Eye The incidence of outer scleral inflammation, recurrent iritis and uveitis is about 5%.
(4) Hemorrhage The incidence is 1.1% to 4.0%, which occurs due to bleeding from ulcers involving large blood vessels and hypoprothrombinemia.
(5) Other late complications may include fatty liver, sclerosing cholangitis, chronic hepatitis; also prone to anemia, malnutrition, and kidney stones.
VIII. Treatment
1. Non-surgical treatment
(1) Diet therapy In the acute stage, correct water-electrolyte disorders, improve anemia and hypoproteinemia, if necessary, give parenteral nutrition fasting, so that the intestine rests, after the symptoms improve, you can give elements of diet. In the remission period, a protein- and carbohydrate-rich diet with easy digestion and less fiber should be given.
(2) Drug therapy Sulfa: For mild or moderate patients. For those who are prone to relapse after discontinuation, small doses of long-term maintenance therapy can be used; Immunosuppressants: When the treatment of hormones and sulfonamides is not good, the immunosuppressant 6-mercaptopurine can be considered. Metronidazole: can inhibit intestinal anaerobic bacteria, and has immunosuppressive, affect leukocyte chemotaxis and other effects. This drug can significantly reduce the symptoms of post-rash and is effective in patients with perianal disease and fistulas. Antibiotics: available for those with secondary infection; give antispasmodic, analgesic, antidiarrheal; supportive treatment: maintain nutrition, correct water-electrolyte disorders, improve anemia and hypoproteinemia. If necessary, parenteral nutrition therapy can be given to rest the intestine, and elemental diet can be given after symptoms improve; hormones: hormones can relieve symptoms. Biologic therapy: the above treatments cannot control the symptoms and are needed when the disease recurs. Infliximab is commonly used in children.
2.Surgical treatment
(1) Indications Long-term symptomatic treatment, symptoms are not relieved. Severely affect growth and development; in the process of symptomatic treatment, the occurrence of comorbidities, such as colonic stenosis, colonic perforation, hemorrhage and toxic megacolon must be operated urgently.
(2) Surgical methods Different surgical methods should be selected according to the age of the child, the length of the disease, the degree of lesion, the mildness, severity, slowing and urgency of the symptoms, such as subtotal colectomy, total colectomy, permanent enterostomy, etc.
IX. Prognosis
The cause of the disease is unknown and there is no special treatment, the course of the disease is long, there are several remissions and relapses, so it is not easy to completely cure. In mild cases, the disease can be in long-term remission after symptomatic treatment. In severe cases, the prognosis is poor.
X. Prevention
There is no definite measure to prevent the disease, but a reasonable diet and good eating habits should be taken; to enhance physical fitness, promote physical and mental health, avoid mental stress, prevent nutritional deficiency and infectious diseases of the gastrointestinal tract, etc.; regular physical examination: to achieve early detection, early diagnosis and early treatment; good follow-up: to prevent deterioration of the disease.