Ulcerative colitis lesions are mainly confined to the mucosa and submucosa of the colon and are predominantly ulcerative. The disease is more common in Europe and the United States. With the deepening of the understanding of the disease and the increasing improvement of diagnostic tools, the incidence of the disease in China has also increased significantly, and severe cases are often reported. In view of the recurrence, aggravation and persistence of the disease, and a certain rate of cancer, it is increasingly urgent to seek effective treatment.
I. Overview
Ulcerative colitis is a chronic nonspecific inflammatory disease of the rectum and colon, the etiology of which is not well understood. The lesions are mainly limited to the mucosa and submucosa of the large intestine. The clinical manifestations are diarrhea, mucopurulent stools, and abdominal pain. The disease varies in severity and has a chronic course with recurrent episodes. The disease can occur at any age, mostly between 20 and 40 years old, but also in children or the elderly. There is no significant difference in the incidence between men and women. The disease is less common in China than in Europe and the United States, and the disease is generally mild, but in recent years there has been a significant increase in the prevalence, and severe cases are often reported.
Pathology
1. The lesions are located in the large intestine and are distributed continuously and diffusely.
2. The lesions are confined to the mucosa and submucosa, and rarely invade the muscular layer.
Clinical manifestations
The disease starts slowly, with a few acute onset, and the course of the disease is a chronic one, showing alternating periods of exacerbation and remission, but there are some patients with gradually increasing symptoms. The clinical manifestations of the disease are related to the scope of the lesion, the disease type and the disease stage.
1.Digestive system performance
(1) Diarrhea.
(2) Mucus-purulent blood stool.
(3) Abdominal pain, most commonly left lower abdomen or lower abdominal paroxysmal pain.
(4) Other manifestations: abdominal distension, nausea, vomiting, loss of appetite, etc. If there is abdominal muscle tension, rebound pain and diminished bowel sounds, pay attention to toxic megacolon or intestinal perforation.
2.Systemic manifestations
(1) Hyperthermia: medium to heavy patients often have low to moderate fever during the active phase, such as the presence of hyperthermia mostly suggests comorbidity or acute explosive.
(2) Other manifestations: wasting, anemia, hypoproteinemia and electrolyte disorders, etc.
3.Extra-intestinal manifestations
(1) Peripheral arthritis, erythema nodosum, gangrenous pyoderma, anterior uveitis, recurrent oral ulcers, etc. The above diseases can be relieved or recovered after control or excision of ulcerative colitis.
(2) Sacroiliac arthritis, ankylosing spondylitis, primary sclerosing cholangitis and other diseases may coexist with ulcerative colitis, but they themselves are not related to the changes in ulcerative colitis.
IV. Clinical typing
1.Clinical types
(1) Primary: No previous history, first attack.
(2) Chronic relapsing type: clinically more common, mostly alternating periods of exacerbation and remission.
(3) Chronic persistent type: Patients have intensified symptoms over a period of time, even acute attacks.
(4) Acute fulminant type: less common. This type has an acute onset and is more severe, with more obvious systemic toxemia symptoms and possible complications such as toxic megacolon, intestinal perforation and sepsis.
2.Clinical severity
According to the clinical severity, it can be divided into mild, moderate and severe.
(1) Mild: diarrhea is less than 4 times, blood in stool is mild or absent, fever and rapid pulse are usually not present, and anemia is mild or absent. Blood sedimentation is usually normal.
(2) Severe: diarrhea of 6 times or more, with obvious mucopurulent and bloody stools, temperature above 37.5 degrees, and pulse above 90. Hemoglobin is low, below 10g, and hematocrit is above 30.
(3) Moderate: between mild and severe.
3.Level of lesion
4.Condition: According to the condition, it can be divided into active and remission stage.
V. Laboratory and other tests
1, stool examination Active phase is most common with paste-like mucus, pus and blood stool, microscopic examination has a large number of red blood cells, pus cells, the number of changes often associated with the disease condition. A large number of multinucleated macrophages are often seen in the smear. Patients with ulcerative colitis may have a positive fecal occult blood test. To avoid a false positive fecal occult blood test due to oral iron or diet, anti-human hemoglobin antibodies with high specificity can be used for the test. Stool pathogenic examination helps to rule out various infectious colitis. Easily confused pathogens include Mycobacterium dysenteriae, Mycobacterium tuberculosis, Campylobacter jejuni, Salmonella, and Jaranis flagellata, followed by Amoeba, Clostridium difficile, Chlamydia trachomatis, cytomegalovirus, venereal lymphogranuloma virus, herpes simplex virus, Norwalk virus, Histoplasma, bacillus, Cryptococcus, and Yersinia pestis, etc.
2, blood sedimentation (ESR) ulcerative colitis patients in the active phase, ESR is often elevated, mostly mild or moderate increase, common in more severe cases. However, ESR does not reflect the severity of the disease.
3, white blood cell count Most patients have a normal white blood cell count, but in the acute active phase, there may be a mild increase in moderate and heavy patients, and in severe cases there are neutrophilic granules.
4.Hemoglobin 50% to 60% of patients may have varying degrees of hypochromic anemia.
5, C-reactive protein (CRP) normal plasma only trace C-reactive protein, but mild inflammation can also lead to abnormal synthesis and secretion of protein by hepatocytes, therefore, CRP can distinguish between functional and inflammatory bowel disease. Impairment of 16h
CRP may be elevated before other inflammatory proteins, whereas fibrinogen and serum mucin are elevated 24 to 48 h later. In Crohn’s patients, CRP is higher than in patients with ulcerative colitis, suggesting a different acute response phase. when IBD is active, CRP reflects the patient’s clinical status. CRP is often consistently elevated in patients requiring surgical treatment; in patients with more severe disease, if CRP is high, the response to treatment is slow. The test is simple, easy, inexpensive, and more suitable for use in primary hospitals.
6.Immunological examination It is generally believed that immunological indicators can help to judge the activity of the disease, but the significance to confirm the diagnosis of the disease is limited. In the active stage, IgG, IgA and IgM in the serum may be increased and the T/B ratio decreases. In patients with Crohn’s disease and some ulcerative colitis, the ratio of interleukin-1 (IL-1) to interleukin-1 receptor (IL-1R) is higher than in normal subjects and patients with other inflammatory conditions. IL-1 levels are increased in the tissues of inflammatory bowel disease and their levels are proportional to the activity of the lesion. It has been shown that macrophages are highly active in inflammatory bowel disease and secrete TNF-α, and the measurement of TNF is important for understanding the extent and activity of lesions in patients with IBD.
Other auxiliary examinations.
1. X-ray examination X-ray examination has always been an important method for the diagnosis of ulcerative colitis, and even after the application of colonoscopy, it still has unique value in the diagnosis and differential diagnosis of ulcerative colitis.
(1) abdominal plain film: abdominal plain film is rarely used to diagnose ulcerative colitis in clinical practice, and its most important value lies in the diagnosis of toxic megacolon. The X-ray shows that the transverse diameter of the colon exceeds 137.5 px, the outline may be irregular, and the “fingerprint” sign may appear.
(2) Barium enema: Barium enema is one of the main diagnostic tools for ulcerative colitis, but X-ray examination is not very helpful for the diagnosis of mild or early cases. X-ray mainly shows the following.
(1) coarse and disorganized mucosal folds or fine granular changes, which is described as “snowflake dots”, i.e. the X-ray shows that the intestinal canal is filled with small and dense barium dots.
②Multiple shallow niche shadows or small filling defects.
(iii) Shortening of the intestinal canal and disappearance of the colonic pouch in a tubular shape. In the initial stage, spasmodic contraction of the intestinal wall, increased colonic pockets, thickened and disorganized mucosal folds, and jagged protrusions of varying sizes on the edges of the intestinal wall when ulcers are formed, and fine granular changes in the rectum and sigmoid colon are seen. In the later stage, the fibrous tissue of the intestinal wall is proliferated, resulting in the disappearance of the colonic pouch, hardening of the wall, narrowing of the intestinal lumen, shortening of the intestinal canal, and a watery tube shape. When there is pseudo-polyps formation, multiple round defects in the intestinal lumen are seen.
(3) Selective angiography of superior mesenteric or submesenteric arteries: angiography can visualize tiny vessels at the lesion site, which can provide a strong help for the diagnosis of this disease. Typically, the arterial images of the intestinal wall are interrupted, narrowed and dilated, while the venous images show high intensity staining in the early stage, and the capillary images show moderate intensity staining.
2.Colonoscopy
Colonoscopy is a very important diagnostic and differential diagnostic method for ulcerative colitis. Generally speaking, the whole colon and the end of the ileum should be examined to directly observe the changes in the intestinal mucosa, take biopsies, and determine the extent.
Generally, the microscopy reveals blurred, disturbed or absent texture of mucosal vessels, congestion, edema, bleeding, friability and adhesion of thick secretions, and the roughness of the mucosa is seen in the form of fine granules. In chronic lesions, pseudopolyps and bridging mucosa are seen, and the colonic band becomes shallow, blunt, or even disappears. Colonoscopic mucosal biopsies reveal diffuse chronic inflammatory cell infiltration, surface erosions, ulcers, crypt abscesses, etc. in the active phase. Chronic manifestations are generally disorganization of the crypt structure, reduction of cupular cells and chemosis of loop phagocytes.
VI. Diagnosis
If the patient has persistent or recurrent episodes of diarrhea and mucopurulent stools, abdominal pain, urgency, with (or without) various degrees of systemic symptoms, and on the basis of exclusion of acute self-limiting colitis, amebic dysentery, chronic schistosomiasis, intestinal tuberculosis and other infectious colitis, colonic Crohn’s disease, ischemic enteritis, radiation enteritis, etc., and at least one of the important changes on colonoscopy and histological findings on mucosal biopsy mentioned above This disease can be diagnosed.
Differential diagnosis
1, Crohn’s disease is a chronic inflammatory disease through the wall, which usually occurs in young adults, but the first onset can be seen at any age. More than half of the patients have lesions involving multiple parts of the gastrointestinal tract, from the esophagus to the anus.
2, irritable bowel syndrome The onset of the disease is related to mental and psychological disorders, often abdominal pain, bloating, abdominal tinnitus, alternating constipation and diarrhea, accompanied by symptoms of generalized neurosis. There is mucus but no pus and blood in the stool, a few white blood cells are occasionally seen on microscopic examination, and there is no organic lesion on colonoscopy and other examinations.
Rectal colorectal cancer is mostly seen in middle-aged people and above. A mass can often be palpated during rectal cancer finger examination, and the fecal occult blood test is often positive. Colonoscopy and barium enema examination are valuable for differential diagnosis, but must be distinguished from ulcerative colitis cancer.
4, chronic amoebic dysentery lesions often involve both ends of the large intestine, namely the rectum, sigmoid colon and cecum, ascending colon. The ulcer is usually deeper, the edge is submerged, the mucosa between the ulcer and the ulcer is mostly normal, the fecal examination can find the trophozoite or encapsulation of lysed tissue amoeba, and the positive rate is high when the exudate from the ulcer surface or the edge of the ulcer is taken by colonoscopy to find amoeba; anti-amoebic treatment is effective.
5, colonic schistosomiasis History of exposure to schistosomal epidemic water, often with hepatosplenomegaly, chronic phase of the rectum can have granuloma-like hyperplasia, may have a malignant tendency; fecal examination can be found schistosome eggs, hatching trichurias positive results. Proctoscopy in the acute stage can be seen in the mucosa with yellow-brown particles, biopsy mucosal pressure or histopathological examination can be found schistosome eggs.
6, chronic bacterial dysentery Generally have a history of acute dysentery, repeated fresh stool culture can isolate Bacillus dysenteriae, antibiotic treatment is effective.
7, ischemic colitis Most commonly seen in the elderly, caused by arteriosclerosis, sudden onset, lower abdominal pain with vomiting, bloody diarrhea, fever, increased white blood cells after 24-48h. In mild cases, the process is reversible and can be cured after l-2 weeks to 1-6 months; in severe cases, intestinal necrosis, perforation and peritonitis occur. On barium enema X-ray, finger indentation sign, pseudotumor, jagged changes in the intestinal wall and fusiform stenosis of the intestinal canal are seen. Endoscopically, dark purple elevation caused by submucosal hemorrhage, peeling bleeding and ulceration of the mucosa can be seen, which is clearly demarcated from the normal mucosa. The lesions are mostly in the splenic flexure of the colon.
Other diseases that must be distinguished include intestinal tuberculosis, pseudomembranous enteritis, radiation enteritis, colonic polyposis, colonic diverticulum, etc.
Eight, Chinese medicine on the evidence and treatment of ulcerative colitis
(a) etiology and pathogenesis
1, feeling external evil
2, injury by diet
3, emotional and mental disorders
4.Weakness of spleen and stomach
5.Spleen and kidney Yang deficiency
(B) Identification and treatment
1.Dampness and heat within the evidence
(1) manifestations: pain in the abdomen, blood in the stool with pus, or red and white sticky jelly, burning in the anus, shortness of breath, body heat, stomach froth, foul-smelling stools, short and red urine, yellow and greasy tongue coating, slippery pulse.
(2) Treatment: Clearing heat and relieving dampness.
(3)Remedies: Radix Puerariae Scutellariae Tang plus or minus (Radix Puerariae Scutellariae Pill + Sophora Jiao Pill) for those with food stagnation, add Baohe Pill. For those with superficial evidence, Huo Xiang Zheng Qi San. If dampness is more important than heat, use San Ren Tang and Stomach Ling Tang plus or minus (Xiang Lian Tablet + Ping Gastric San). If heat is more important than dampness, add or subtract Baitou Weng Tang (Xianglian Tablet + Ge Gen Scutellaria Pill + Clear Heat and Dampness Punch).
2.Cold and damp stagnation evidence
(1) Manifestations: abdominal pain and constriction, warmth and pressure, loose stools, with red and white mucus jelly, more white and less red, or pure white mucus jelly, shortness of breath, lack of taste, lack of food and drink, fullness and thirst, heavy and sleepy limbs, clear and long urine, pale tongue, white and greasy moss, moist and slow pulse.
(2) Treatment: Warming the middle and dispersing cold, harmonizing Qi and Blood.
(3) Remedy: Stomach Ling Tang with addition and subtraction (Huo Xiang Zheng Qi San + Ping Stomach San).
3.Qi stagnation and blood stasis evidence
(1) Manifestations: abdominal distention with intestinal tinnitus or abdominal stabbing pain, pain with a fixed location, refusal to press, unpleasant diarrhea, dull complexion, belching with little food, distention and fullness in the chest, abdominal lumps or lumps, skin nail fault, blood in the stool, purple tongue or petechiae, petechiae, stringent and astringent pulse.
(2) Treatment; resolving blood stasis and promoting circulation, regulating qi and relieving pain.
(3) Remedy: Shao Abdominal Expulsion of Blood Stasis with Addition and Reduction. (Shao Abdominal Expelling Blood Stasis Oral Liquid). Stool with red and white sticky jelly, can be combined with Xianglian tablets. For dark red stools with blood, add Panax ginseng powder. If the abdomen is full and distended, add Shen Xiang Shu Qi Wan. If the lump is hard, take Soft and Firm Punch. For those who do not feel like eating or drinking and are tired, add Baohe Pill + Sijunzi Pill.
4.Spleen and kidney deficiency
(1) Manifestations: prolonged diarrhea, thin diarrhea with white jelly, cold form and limbs, little breath and lazy speech, hidden pain in the abdomen, warmth and pressure, abdominal distension and intestinal tinnitus, diarrhea on the fifth night, reduced food and dullness, soreness and weakness of the waist and knees, aggravated by cold, pale tongue, white fur, sunken and thin pulse.
(2) Treatment: warming the spleen and kidney, astringent bowel to stop diarrhea.
(3)Remedies: Renhangsheng Tang with addition and subtraction: (Annexe Rizhong Wan + Sishen Wan) For prolonged diarrhea with prolapse, add Zhong Zhong Yi Qi Wan. For mucus and blood in stool, with urgency, add Angelica Bitter Ginseng Pill.
5, Yin and blood deficiency evidence
(1) Manifestations: dry stools, or the ambassador starts with hard stools, followed by loose stools, with mucus jelly or fresh blood, low fever in the afternoon, vague pain in the abdomen, dizziness, insomnia and night sweats, irritability, fatigue, red tongue with little coating, thin pulse.
(2) Treatment: Nourishing Yin and clearing heat, strengthening the spleen and stopping diarrhea.
(3) Formula: Huanglian Agaricus Tang combined with Artemisia annua and turtle nail soup plus reduction (Shengvei Drink + Doulian Wan).
(2) The formula is based on the following formula If the stools are dry and loose, alternating with poor appetite, Ginseng Ling Bai Zhu Wan. In case of low fever in the afternoon, add Di Bone Bark, Bai Wei and Shu Di Huang. For insomnia and dreaminess, add fried jujube seeds, Salvia miltiorrhiza, and nightshade. If the stool is slippery, add red stone resin. If the dysentery is red and white and sticky, add white flowering snake’s tongue grass, septoria, wild chrysanthemum.
6, food stagnation gastrointestinal evidence
(1) manifestations: abdominal pain and intestinal tinnitus, thick stool or fecal water mixed down, or mixed with undigested food, foul odor such as defeated eggs, diarrhea pain reduction, chest and epigastric distension, stuffiness, belching and swallowing acid, do not think about eating, moss turbid or thick and greasy, pulse string slippery.
(2) Treatment; eliminating food and inducing stagnation.
(3)Remedies: Baohe Wan plus or minus. If the food stagnation is heavy, add fried Citrus aurantium. In case of cold food stagnation with white greasy coating and sluggish pulse, add ginger.
7. Liver depression and spleen deficiency
(1) Manifestations: abdominal pain and diarrhea, pain decreases after diarrhea, thin stools, more mucus, sometimes with pus and blood, aggravated by emotional changes, abdominal cramps, dullness or pain in both hypochondria, irritability or depression, chest and epigastric fullness, red tongue, thin white or thin yellow coating, string pulse.
(2) Treatment: Drain the liver and strengthen the spleen.
(3) Remedy: Combine the essential formula for pain and diarrhea with Si-wei-san plus or minus (Shu-Hi Wan + Liu Junzi Wan). For food stagnation, add Baohe Wan. For heavier spleen deficiency and more frequent diarrhea, add Tonic Zhong Yi Qi Pill. For depressed mood and dullness, add Dai Dai Hua and Rose Flower. For burning in the anus and shortness of breath, add Ge Gen Scutellaria Pill.
8.Spleen deficiency and dampness trapped evidence
(1) Manifestations: loose stools with pus and blood, mucus, lingering diarrhea, vague abdominal pain, withered face, fatigue, abdominal distension, poor appetite, heavy and sleepy limbs, pale tongue with white greasy coating, slow pulse.
(2) Treatment: Strengthening the spleen, resolving dampness, regulating Qi and harmonizing the middle.
(3) Remedy: Ginseng Ling Bai Zhu San plus or minus (Xiang Sha Liu Jun Zi Wan). Add Sophora Pill for obvious pus-blood stools. If the abdominal distension is severe due to food stagnation, add Baohe Pill. For dampness and heat, with yellow tongue coating, add Ge Gen Scutellaria Pill.
(C) Treatment points
1.Treatment principle: the principle of combining overall and local treatment.
2, treatment should pay attention to the problems: mainly to dredge, cautious use of astringent and astringent drugs; taking into account the flow of qi and qi; cautious use of bitter cold drugs; regulate qi and activate blood, try not to use drugs that break qi; protection of stomach qi.
(IV) Local treatment
1. Methods.
(1) Local treatment should be chosen for diseased intestinal segments below 60 cm from the anus.
(2) Heat-clearing and detoxifying drugs: Huanglian, Scutellaria baicalensis, Huangbai, Rhubarb, Baichauang, Dandelion, Fructus sabdarii, Horsetail, Bitter ginseng, etc.
(3) Astringent and astringent medicine: Wu Bei Zi, Shi Yuan Pi, Huxiang Zi.
(4) Blood cooling and hemostatic drugs: Diyu, Sophora, Cynthia, Dampi, Red peony, Blood dried, Panax ginseng, Yunnan Baiyao, Rhubarb charcoal, Salvia, Phellodendron, etc.
(5) Astringent medicine for sores and muscles: hyacinth, pearl, catechu, hematoxylin, nux vomica, amber, ice chips, alum, etc.
(6) Tin-like dispersion, Yunnan Baiyao.
2.Treatment route
(1) The most commonly used is reserved enema.
Enema solution configuration: the selected drug plus three times the amount of water, soak for about an hour, boil for an hour, the liquid will be concentrated and put into a clean container, generally speaking, 100 degrees sterilization for 30 minutes can be set aside. Decoct to 250ml per dose.
Operation method: Connect a 50ml syringe or enema tube to the infusion tube for enema and inject the medicine directly into the colon.
Drug retention time: The longer the time, the better, preferably until the next morning.
Temperature of the drug solution: about 38 degrees. However, the drug temperature can be 34-37 degrees for patients with damp-heat accumulation; 37-40 degrees for patients with a weak spleen and stomach; and slightly higher for the elderly.
Course of treatment: Generally speaking, one month is a course of treatment, once a night irrigation, generally speaking 1-2 weeks can be relieved. After the condition is stabilized, it can be infused once every other day, and the treatment can last for about six months after going.
Prescription: Dampness and heat within the evidence: Baitou weng Tang chemistry: Baitou weng, septoria, raw rhubarb, ground elm, Huanglian gram, scutellaria, Qin Pi, horsetail, tin class San. Spleen and kidney Yang deficiency, cold and dampness stagnation, liver depression and spleen deficiency: Astragalus membranaceus, Atractylodes macrocephala, Radix et Rhizoma Polygonati, Rhizoma Red Vine, Radix et Rhizoma Dioscorea, Radix et Rhizoma Serpentis, Fried Atractylodes Macrocephala, Radix et Rhizoma Chai Hu, Radix Codonopsis pilosula. Deficiency of Yin and Blood: Angelica sinensis, Radix et Rhizoma Dioscoreae, Radix rehmanniae, Radix et Rhizoma lingzhi, Radix et Rhizoma cypress, Radix et Rhizoma botrytis, Radix et Rhizoma acaciae, Radix et Rhizoma pseudostellariae, Radix et Rhizoma peony, Radix et Rhizoma tinctoria. Spleen deficiency and dampness: Radix Codonopsis pilosulae, Rhizoma Atractylodis Macrocephalae, Rhizoma Atractylodis, Rhizoma Atractylodis, Rhizoma Polygonati, Rhizoma Lotus, Pericarpium Citri Reticulatae, Poria, Radix Paeoniae Alba, Radix Glycyrrhiza Uralensis. Horsetail, tin-like powder.
(2) Rectal drip method: The medicine is dripped into the inside of the colon through the rectum at a uniform rate so that the medicine reaches the disease damage.
(3) Rectal aerosol method: After the rectal infusion of medicinal solution, the intestinal cavity is injected with gas so that the medicinal solution can be evenly distributed on the surface of the colonic mucosa, thus providing a therapeutic effect. Applicable to a wide range of colonic inflammation, especially multiple foci above the sigmoid colon.
(4) suppository therapy: the drug is made into a suppository directly into the rectum, the drug dissolved only the mucosa can be absorbed, so as to play a therapeutic role. It is suitable for patients with lesions in the rectal area.
(5) Enteroscopic drug delivery method: Generally, sigmoidoscopy, fiberoptic colonoscopy and proctoscopy are used to coat or spray the drug or linger the lesion in the colon. Enteroscopic drug delivery can be used alone or in combination with other methods. It is suitable for patients with more severe bleeding mucosal ulcers.
(E) Foods to be avoided
(1) Irritating foods: chili, pepper, wine, coffee.
(2) greasy, coarse fiber, flatulent food: fried food, peanuts, celery, leek, milk, soy products.
(3) cold, laxative, slippery food: pears, bananas. Sesame, walnut, duck, mulberry, bitter melon, honey, gum, sea cucumber, wolfberry.