Inflammatory bowel disease including ulcerative colitis and Crohn’s disease?
Recently the ward started to be tight, spring is here and it is the onset season of ulcerative colitis and Crohn’s disease again, many old patients started to develop, and some new patients.
Although Jing Jing is not very old, she is a regular customer of our department, and she reports to us almost every spring. With the admission of Jing Jing, 1/3 of the patients in the department are inflammatory bowel disease (including ulcerative colitis and Crohn’s disease), and the director said to us at the end of the room visit that the routine chart discussion would be to discuss these two diseases, make a comparison, and sort out the treatment we can take The director said to us at the end of the consultation that we should discuss the two diseases, make a comparison, and sort out the treatment we can take.
Doctors in the process of clinical evidence, need to continue to learn the theory, practice while theory, can make the diagnostic skills grow experience value. It’s like solving a case, what kind of disease is at work, and constantly practicing the doctor’s eyes.
The acquisition of knowledge and the growth of skills are sometimes not positively correlated. Diagnosis is sometimes like a mess, so people can’t start and can’t see where the threads originate.
Where, the doctor’s mind must always be taut strings combined into an impermeable net, constantly filtering the cause of the disease. To make their own net does not leak diagnosis, we must constantly learn, learn, learn again.
After the director said that, we took out the textbooks that had been yellowed long ago, and but the notes from the study theory class.
Revisiting inflammatory bowel disease in medical textbooks
Ulcerative colitis is a chronic non-specific inflammatory disease of the colon and rectum whose etiology is not well understood, with lesions limited to the mucosa and submucosa of the large intestine. The lesions are mostly located in the sigmoid colon and rectum, but may also extend to the descending colon or even the entire colon. The course of the disease is long and often recurrent. The disease is seen at any age, but is most common between the ages of 20 and 30.
Crohn’s disease, on the other hand, is an inflammatory disease of the intestine of unknown origin that can occur anywhere in the gastrointestinal tract, but is more likely to occur in the terminal ileum and the right hemicolectum. The disease and chronic nonspecific ulcerative colitis are collectively referred to as inflammatory bowel disease (IBD). The clinical manifestations of this disease are abdominal pain, diarrhea, and intestinal obstruction, accompanied by fever, nutritional disorders, and other extraintestinal manifestations. The course of the disease is prolonged, recurrent and not easily curable. The disease is also known as limited enteritis, limited ileitis, segmental enteritis and granulomatous enteritis.
The etiology of inflammatory bowel disease is not well understood. It is currently believed that the pathogenesis of inflammatory bowel disease is the result of an interaction between exogenous substances causing a host response, genetic and immune influences.
In ulcerative colitis, genetic factors may have a place. Psychological factors have an important place in disease progression, with pre-existing pathological psychosis such as depression or social distance improving significantly after colectomy. It is thought that ulcerative colitis is an autoimmune disease. According to this insight, ulcerative colitis and Crohn’s disease are different manifestations of one disease process.
In contrast, Crohn’s disease may have some relationship with infection, genetics, humoral immunity and cellular immunity.
Crohn’s disease is a proliferative lesion that penetrates all layers of the intestinal wall, invading the mesentery and local lymph nodes, with lesions confined to the small intestine (mainly the terminal ileum) and the colon, both of which can be involved at the same time, often as ileal and right hemicolectomy lesions. The lesions are segmental in distribution, with clear boundaries between normal intestinal segments, and are characterized by a skip area. The pathological changes are divided into acute inflammatory phase, ulcer formation phase, stricture phase, and fistula formation phase (perforation phase). The acute phase is characterized by edema and inflammation of the intestinal wall; in the chronic phase, the intestinal wall is thickened and stiffened, and the affected intestine has a tubular shape with dilatation of the upper intestine. Typical lesions on the mucosal surface are:
1. ulcers
Early shallow small ulcers, later into longitudinal or transverse ulcers, longitudinal ulcers deep into the intestinal wall that form a more typical cleavage groove, distributed along the mesenteric side, the intestinal wall may have abscesses.
2. Pebble nodules
Due to the submucosal edema and cellular infiltration of the formation of small islands of protrusion, coupled with the contraction of fibrosis and scarring after ulcer healing, the mucosal surface resembles pebbles.
3. Granuloma
There is no caseous change, which is different from tuberculosis.
4. Fistula and abscess
Fissures in the intestinal wall are essentially penetrating ulcers that cause adhesions and abscesses between the intestinal canal and the intestinal canal, the intestinal canal and organs or tissues (such as the bladder, vagina, mesenteric or retroperitoneal tissues, etc.), and form internal fistulae. If the lesion penetrates the intestinal wall and passes outside the body through the abdominal wall or perianal tissues, an external fistula is formed.
Both of these diseases are inflammatory bowel diseases, and both are clinically common, according to the textbook, and the lecturer at the time had a table for comparison. I wrote it down in my notebook.
When I memorized this part by rote, I let these words, dead crawl in the brain gutter, walking very carefully, for fear of shaking my head, I would shake a key word down or potential brain gutter, when needed but like a dish in the teeth, dead picked out.
After 10 years of pro-licensing, you will be deeply touched by the contents of these records, especially every spring and autumn when Jingjing comes.
And Jingjing became friends because of her brashness, only to find out later that she is a typical woman, showing her tenderness is simply fleeting.
Growing up in a single-parent family, Jingjing is very independent and also has a tendency to be anxious to varying degrees, and the hidden inferiority complex and sensitivity behind her big feminism is also reflected in the gradual communication.
The initial visit to the clinic was for blood in the stool, which is the main and most initial manifestation of ulcerative colitis. Jingjing thought it was an attack of hemorrhoids, so she ignored it, but she didn’t expect it to get worse and worse, and at most, she would have more than 20 bloody stools a day. The actual fact is that you can’t get a lot more than a couple of days, so you have to go to the hospital to see what’s going on.
The first thing you need to do is to go to the anorectal department and think that it is a matter of hemorrhoids. After the anorectal examination, it is true that there are hemorrhoids, but they do not cause bloody stools and mucus so many times a day, so Dr. Zhou of the anorectal department referred Jingjing to our gastroenterology department and wrote “ulcerative colitis” on the referral form. “Crohn’s disease” with two big question marks.
From the typical symptoms of Jingjing, it should be an inflammatory bowel disease, but it is not certain whether it is ulcerative colitis or Crohn’s disease. Jing Jing had symptoms, abdominal pain in the lower right abdomen, fever at times, diarrhea with bloody stools and mucus, all of which are present in ulcerative colitis and Crohn’s disease, so there was no way to identify her by her symptoms.
She had an abdominal examination, and she also had pressure pain, but she did not feel the abdominal mass that is characteristic of Crohn’s disease, so it was not easy to judge.
At the second follow-up, I said to her, “Jingjing, your case should be inflammatory bowel disease, there are two types of this disease, ulcerative colitis and Crohn’s disease, we need to give you a colonoscopy to make a clear diagnosis.
Jingjing readily agreed, so I gave her a checklist for the colonoscopy.
Before Jing Jing did the colonoscopy, I made an explanation with Dr. Song that Crohn’s disease was unlikely, and that it should be ulcerative colitis, but we still had to be careful because if it was Crohn’s disease, the ulcers were deeper, and a bad colonoscopy could lead to intestinal perforation.
Old Song is still very reliable, in order to be cautious, before the colonoscopy, we gave her a full gastrointestinal barium meal, combined with the results of the barium meal, we further analyzed the situation, that it is safe to do colonoscopy, so, the day of the colonoscopy.
The results of the colonoscopy were soon available: under the picture, the ulcers were shallow and continuous, not one by one, and there were normal ones between the ulcers, so Dr. Song’s conclusion was: ulcerative colitis.
Combining the diagnosis of ulcerative colitis and Crohn’s disease, we thought about and ruled out each of them.
In fact, the most core diagnosis was already seen from the colonoscopy.
In Jingjing’s case, I carefully matched the diagnosis of Crohn’s disease, with the aim of using the method of exclusion to determine that it was ulcerative colitis and not Crohn’s disease.
The main gastrointestinal manifestations of Crohn’s disease are.
(1) Abdominal pain Located in the right lower abdomen or around the umbilicus, spasmodic pain, intermittent episodes, with bowel sounds, aggravated after meals, relieved after defecation. If the abdominal pain persists and the pressure pain is obvious, it suggests that the inflammation has spread to the peritoneum or the abdominal cavity and formed an abscess. Severe pain throughout the abdomen and abdominal muscle tension may be due to acute perforation of the diseased intestinal segment.
(2) Diarrhea is caused by inflammatory exudation, increased peristalsis and secondary malabsorption of the diseased intestinal segment. It starts as intermittent episodes and later becomes persistent paste-like stools without pus, blood or mucus. If the lesion involves the lower part of the colon or rectum, there may be mucus and blood stools and a feeling of urgency.
(3) Abdominal masses are most common in the right lower abdomen and around the umbilicus and are caused by intestinal adhesions, thickening of the intestinal wall and mesentery, enlarged mesenteric lymph nodes, internal fistula or local abscess formation.
(4) Fistula formation is one of the clinical features of Crohn’s disease. The fistula is formed by a transmural inflammatory lesion that penetrates the entire intestinal wall to the extraintestinal tissues or organs. Internal fistulae may lead to other intestinal segments, mesentery, bladder, ureter, and retroperitoneum of the vagina. External fistulas lead to the abdominal wall or perianal skin.
(5) Perianorectal lesions A few patients have perianal and perirectal fistulae, abscess formation, anal fissures and other lesions.
From Jingjing’s symptoms: having the first three, which are also manifestations of ulcerative colitis, for the last two Crohn’s disease specific manifestations, did not appear in our clinic.
The systemic symptoms of Crohn’s disease are: (1) Fever Fever is caused by intestinal inflammatory activity or secondary infection, often intermittent hypothermia or moderate fever, a few flaccid fever, which can be accompanied by toxemia.
(2) Nutritional disorders due to loss of appetite, chronic diarrhea and chronic wasting diseases, anemia, hypoproteinemia, vitamin deficiency, calcium deficiency, osteoporosis, etc.
(3) Disorders of water, electrolyte and acid-base balance during acute attacks.
These conditions, instead of appearing in Jingjing, are reflected in the inpatients with Crohn’s disease. Zhang Jianguo, in bed 15, has been febrile since he was admitted to the hospital, and has also had a toxic shock, and is particularly weak due to long-term diarrhea, and currently weighs only 40kg.
In the same room, bed 16, Tong Aimin, was also referred from the anorectal department for ulcerative colitis. in fact, not only the anorectal department referred me patients, but also the ophthalmology department would refer me patients with bowel disease. bed 17, Kang Jie was referred from the ophthalmology department, and some patients with Crohn’s disease had iridocyclitis and uveitis, and the internal correlation of such immune diseases also made the clinicians stumped until later It was not until later that they knew what was going on.
After years of clinical practice, some diseases still require constant review of textbooks, so that progress from theory to practice and then from practice to theory is an upward spiral.
The complexity of the doctor lies in considering all the symptoms and possible conditions of inflammatory bowel disease. Those that appear and those that do not appear have to be analyzed.
Going through the diagnoses of ulcerative colitis and Crohn’s disease from this medical record of Jing Jing made me feel like I was back in my college days, with the difference of experiencing the different complexities that real patients exhibit.
Jing Jing’s diagnosis was very clear and the purpose of hospitalization was to develop the best plan for us.
The treatment was mainly medical conservative and surgical resection. The judgment is based on the severity of the disease. Of course, the first thing we consider is the internal treatment.
Before the internal treatment, we should evaluate based on the main symptoms and colonoscopic manifestations, using the current internationally accepted scale, called: (Sutherland Disease Activity Index)
Main symptoms and intestinal mucosal lesion activity index Ulcerative colitis main symptoms and intestinal mucosal lesion activity index
An assessment of the severity of the disease is helpful in helping patients to recognize their disease and in assessing the effectiveness of treatment. Because each person’s condition is different, it is like people going down the stairs, some on the 8th step and some on the 3rd step.
Doctors are like health assistants, and people who are on the 8th floor and go to the 5th step through our treatment is a good thing, while patients who are on the 3rd step are better off going down the stairs completely. As to whether they will go back up the next year
floor, it is also different for each person. We hope that through the respective advantages of Chinese and Western medicine, patients with inflammatory bowel disease can go downstairs smoothly without rebound. This requires the joint creation of patients and doctors.
If the 10th floor is the worst situation for inflammatory bowel disease, then Jingjing is basically hovering on the 3rd-5th floor, Tong Aimin in the same room in bed 16 is probably on the 7th floor, Kang Jie in bed 17 belongs to the 6th floor, the toughest bed 15 Zhang Jianguo should be on the 8th-9th floor, and the same interventions, are not all able to let each patient down the same floor, the conclusion is also negative, the same measures under the joint intervention of Chinese and Western medicine. It is possible that some down three floors, some down 5 floors; is not the more serious the more bad downstairs, also not necessarily, some can be from 8 floors down to 2 floors, some from 6 floors to 4 floors is good, so the diagnosis and treatment of disease is also a doctor-patient common cultivation fate and creation.
Jing Jing can go from the 5th floor to the 1st floor, but once a year go upstairs, Zhang Jianguo can only go down to the 3rd floor, and then to constantly support him, and Kang Jie hospital after the basic are on the 1st floor, from time to time on the 2nd floor, Tong Aimin downstairs and then no relapse.
For Zhang Jianguo on the highest floor, the measures we took included all the internal medicine means that could be used. It was also a collection of treatment options for inflammatory bowel disease.
First of all, bed rest and systemic supportive therapy including fluid and electrolyte balance, especially potassium supplementation. Old Zhang also developed hypokalemia who, fortunately, was corrected in time. Nutritional supplementation was done by reducing the intake of milk in case of normal diet.
Drug medication for Lao Zhang We used almost all the current drugs ① Salicylic acid preparations of salazosulfapyridine are the main therapeutic drugs, such as Addisha and Mesalazine. Since the symptoms were not relieved after a period of use, we started to use hormones ②Dermal
Mass steroids commonly used drugs for prednisone or dexamethasone, with the use of greatly relieved, the old Zhang daughter-in-law was very happy, said, this drug can not be used regularly with the review of relevant studies, I told them that at present do not think that long-term hormone
maintenance can prevent recurrence. Only during acute attacks can hydrocortisone or dexamethasone be used intravenously, and hydrocortisone in saline can be used nightly as a retention enema.
The value of hormone therapy during acute attacks is certain, but there is still disagreement whether hormones should be used continuously during the chronic period, because after all, they are hormones and most of them are not recommended for long-term use because they have certain side effects.
There are also times when immunosuppressants are recommended, but Zhang did not use them because this treatment is also uncertain and its value in ulcerative colitis is still doubtful.
The entire course of treatment for Lao Zhang used oral herbal tonics, and because he was also hospitalized several times, he could almost judge for himself what interventions to use. After five hospitalizations, two used herbal enemas and tonics orally, one used mesalazine orally and enemas, and two others, including this one, used hormone therapy. ④ Chinese herbal medicine for diarrhea-type ulcerative colitis is more effective. It needs to be combined with the specific situation. Attention should also be paid to diet as well as lifestyle habits.
Old Zhang also deeply experienced the side effects due to the repeated use of hormone and salicylic acid preparations, and hoped to solve the problem with Chinese medicine. As a modern doctor of Chinese and Western medicine cooperation, we more objectively explored the different advantages of Chinese and Western medicine in the treatment process.
Some
Some patients can use herbal medicine and recover completely, some patients must use mesalazine or even hormones to relieve their symptoms, while some of them use mesalazine and hormones to no avail and end up using herbal medicine for effective treatment, specifically
Which patient with which therapy is better, we are also in continuous research. But old Zhang, in each attack with a different method. The general order is, when a patient comes, we first use the soup orally, if the oral medicine is taken for three
day remission 50% improvement.
Then it is OK, or depending on the situation, we can add tonics and proprietary Chinese medicine enemas. If the herbal medicine is not good for three days, add salicylic acid preparation such as mesalazine orally, and whether to enema depends on the specific situation. If the salicylic acid preparation is not good, then
If the disease is still aggravated, it is necessary to use hormones in time for symptom control, generally speaking, this is the most powerful move.
But not absolutely not, in the case of increasingly heavy, you need to promptly and decisively use a full amount of hormone treatment. If the hormones are still not under control, then we will go back to TCM again.
For the selection of TCM tonics for inflammatory bowel disease, we use the principle of evidence-based treatment. Symptomatic targeted treatment is performed based on the assessment of the disease and the status of TCM.
Jing
When Jing first attacked, the TCM practitioner considered that it belonged to the evidence of damp-heat in the large intestine, and the method chosen was: clearing heat and drying dampness, regulating Qi and moving blood. We used the classical Chinese medicine formula: Paeonia lactiflora soup (Paeonia lactiflora, Scutellaria baicalensis, Huanglian, Rhubarb, Betel nut, Angelica sinensis, Mu
As there was more pus and blood in the stool, Baishu, Zizhu and Diyu were added to cool the blood and stop the dysentery; on the third day when there was more white jelly and mucus in the stool, Cang Zhu and Coix Seed were added to strengthen the spleen and dry dampness.
A week later, the stool pus and blood decreased, there was a spleen qi weakness evidence, we promptly adjusted the prescription: strengthen the spleen and benefit qi, resolve dampness and stop diarrhea. The classical formula Ginseng, Poria, Atractylodes, Radix Platycodon, Yam, White Lentil, Sandy Nut, Coix Seed, Lotus Pulp, Licorice was used.
Old
Zhang just had an attack similar to Jing Jing’s, so he was also treated with Paeoniae Tang, which was used for several admissions, and twice he got better with Paeoniae Tang.
In this case, we used the method of warming Yang and dispelling cold, strengthening the spleen and tonifying the kidney to treat. The formula: Radix et Rhizoma (Radix et Rhizoma, Ginseng, Ginger, Rhizoma Atractylodis Macrocephalae, Glycyrrhiza Glabra) with reduction. Old Zhang’s Yang deficiency was so obvious that he also added tonic
The formula also added tonic bone fat and nutmeg to warm the spleen and kidney.
Tong Aimin’s temper was rather strong, and he was always angry, which belonged to liver depression and spleen deficiency. The formula: Painful Diarrhea Essential Formula (Chen Pi, Atractylodes Macrocephala, Paeonia lactiflora, Fengshui) plus or minus.
Kang Jie has a typical cold-heat syndrome. The formula: Wu Mei Wan (Wu Mei Pill, Huang Lian, Huang Bai, Ginseng, Radix Angelicae Sinensis, Radix Codonopsis Pilosulae, Gui Zhi, Sichuan Pepper, Dry Ginger, Hsiang Xin) plus or minus.
For patients with episodes of blood in the stool that still have no effect after the use of hormones, we generally consider it to be a case of incandescence of heat and toxicity. Treatment: Clearing heat and detoxifying the blood to stop dysentery.
Chinese herbal enema treatment is usually used in the recovery period, with Ginseng and Atractylodes as the mainstay, or with double ingredients of Throat and Wind San and Rehabilitative New Liquid to retain the enema.
After these treatments, still recurring, it is necessary to enter the surgical procedure, 20% to 30% of patients with severe ulcerative colitis eventually surgical treatment
How to determine whether to operate depends on whether there are indications for surgery. The indications for emergency surgery are: (1) massive, uncontrollable bleeding; (2) toxic megacolon with near or definite perforation, or toxic megacolon that fails to respond to treatment in hours rather than days; (3) fulminant acute ulcerative colitis that fails to respond to steroid hormone therapy, i.e., no improvement after 4 to 5 days of treatment; (4) obstruction due to stricture; (5) suspected or confirmed colon cancer; (6) refractory ulcerative colitis (6) refractory ulcerative colitis with recurrent worsening, chronic persistent symptoms, malnutrition, weakness, inability to work, and inability to participate in normal social and sexual activities; (7) worsening of the disease when the steroid hormone dose is reduced so that hormone therapy cannot be stopped for months or even years; (8) children with chronic colitis that affects their growth and development; (9) severe extracolonic manifestations such as arthritis, gangrenous sepsis, or biliary and hepatic diseases, etc. If it is not one of the above, we try to treat it as much as possible.
If it is not one of the above, we try to opt for internal medicine treatment. If it occurs we contact a gastroenterologist for a consultation and evaluation, and also to inform the patient about the discussion for a multifaceted treatment.
The attack of inflammatory bowel disease has seasonal and causative factors, so we can take some measures to prevent it, in fact, sometimes it is impossible to prevent it, but it is still reliable to reduce the possibility of attack.
1. pay attention to the combination of work and rest, not too much exertion, not to mention anxiety and anger and excessive tension; fulminant, acute attacks and severe chronic type patients, should be bed rest.
2. Pay attention to clothing, keep warm and cold; appropriate physical exercise to enhance physical fitness.
3. Generally, eat soft, easily digestible, nutritious and adequate caloric food. A small number of meals and multivitamins are recommended. Do not eat raw, cold, greasy and fibrous food.
4. Pay attention to food hygiene to avoid intestinal infection triggering or aggravating the disease. Avoid smoking, alcohol, spicy food, milk and dairy products.
5. Usually keep a relaxed mood, avoid mental stimulation, and release all kinds of mental stress.