Ulcerative colitis is a chronic nonspecific inflammatory disease of the colon and rectum whose etiology is not well understood and whose lesions are confined 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.
The cause of ulcerative colitis is still unknown. Genetic factors may have some place. Psychological factors have an important place in disease progression, and the pre-existing pathological psychosis such as depression or social distance improves significantly after colectomy. It is thought that ulcerative colitis is an autoimmune disease.
It is now believed that the pathogenesis of inflammatory bowel disease is the result of the interaction of exogenous substances causing a host response, genetic and immune influences. According to this insight, ulcerative colitis and clonorchiasis are different manifestations of one disease process.
Clinical manifestations
The initial presentation of ulcerative colitis can take many forms. Bloody diarrhea is the most common early symptom. Other symptoms include, in order, abdominal pain, blood in the stool, weight loss, urgency, and vomiting. Occasionally, the main manifestations are arthritis, iridocyclitis, liver dysfunction, and skin lesions. Fever is a relatively uncommon sign, and the disease presents as a chronic, hypermalignant process in most patients and as an acute, catastrophic outbreak in a minority of patients (approximately 15%). These patients present with frequent bloody stools, up to 30 times/day, and high fever and abdominal pain.
Signs are directly related to the stage and clinical presentation of the disease. Patients often have weight loss and pallor, and tenderness is often present in the colonic region on abdominal examination during the active phase of the disease. There may be signs of acute abdomen with fever and decreased bowel sounds, especially in acute attacks or fulminant cases. In toxic megacolon, abdominal distention, fever and signs of acute abdomen may be present. Due to frequent diarrhea, the perianal skin may be abraded and exfoliated. Perianal inflammation such as fissures or fistulas may also occur, although the latter is more common in Crohn’s disease. Rectal finger examination is painful. Examination of the skin, mucous membranes, tongue, joints, and eyes is extremely important.
Diagnosis
The diagnosis of the disease is based on the following clinical manifestations and auxiliary examinations.
1.Clinical manifestations
Except for a few patients with rapid onset, the disease usually starts slowly and varies in severity. The symptoms are mainly diarrhea, with feces containing blood, pus and mucus, often accompanied by paroxysmal colonic spasmodic pain, and shortness of breath, which can be relieved after defecation.
Patients with the mild form have mild symptoms, with less than 5 diarrheas per day.
In severe cases, diarrhea is more than 5 times a day, with watery or bloody stools, severe abdominal pain, fever, temperature over 38.5°C, and pulse rate greater than 90 beats/min.
Fulminant diarrhea is less common. The onset of the disease is rapid, with a large amount of diarrhea and frequent blood in the stool. The body temperature can rise up to 40℃, and in severe cases, systemic symptoms of toxicity may appear. If the disease is prolonged, wasting, anemia, nutritional disorders, and weakness may occur. Some patients have extra-intestinal manifestations, such as erythema nodosum, iritis, chronic active hepatitis and small peribiliary ductitis.
2.Auxiliary examination
The diagnosis mainly relies on fiberoptic colonoscopy, because 90% to 95% of patients have rectal and sigmoid colon involvement, so in fact the diagnosis can be clearly made by fiberoptic sigmoidoscopy. The microscopy reveals a congested, edematous mucosa that is brittle and bleeds easily. In progressive cases, ulcers surrounded by raised granulation tissue and edematous mucosa may be seen, resembling polyps, or may be referred to as pseudopolyposis. In chronic progressive cases, the lumen of the rectum and sigmoid colon can be significantly reduced. To clarify the extent of the lesion, it is better to perform a full colonoscopy with multiple biopsies to differentiate it from clonal colitis.
Dual contrast gas-barium enema is also a useful diagnostic test, especially in determining the extent and severity of lesions. In a barium enema, loss of colonic pouching, wall irregularities, pseudo-polyp formation, and thinning and stiffening of the intestinal lumen may be seen. Although barium enema examination is valuable, the examination should be performed with caution and avoid bowel cleansing preparations, as it can worsen colitis. A liquid diet given for 3 days before the examination is sufficient in cases without diarrhea. Barium enema is contraindicated in cases with abdominal signs, and an abdominal radiograph should be performed to look for signs of toxic megacolon, dilated colon, and subdiaphragmatic free gas.
Complications
1. Toxic colonic dilatation
It occurs in the acute active phase, with an incidence of about 2%. It is due to the inflammation of the colon muscle layer and the intermuscular plexus, so that the intestinal wall is hypotonic and is paralyzed in stages, resulting in a large accumulation of intestinal contents and gas, which causes acute colon dilatation and thinning of the intestinal wall, and the lesions are mostly found in the sigmoid colon or transverse colon. Causes include hypokalemia, barium enema, use of anticholinergic drugs or opioids, etc. The clinical manifestations are rapid deterioration, obvious symptoms of toxicity, with abdominal distension, pressure pain, rebound pain, diminished or absent bowel sounds, and increased white blood cell count. x-ray abdominal plain film shows widening of the intestinal lumen and disappearance of the colonic pouch. Intestinal perforation is easily complicated. High death rate.
2.Intestinal perforation
The incidence is about 1.8%. It occurs mostly on the basis of toxic colonic dilatation, causing diffuse peritonitis and free gas under the diaphragm.
3, haemorrhage
The incidence is 1.1% to 4.0% for those who have to be treated with blood transfusion due to heavy bleeding. In addition to bleeding due to ulcer involvement of blood vessels, hypoprothrombinemia is also an important cause.
4.Polyp
The complication rate of polyps in this disease is 9.7%～39%, often called this kind of polyps as pseudopolyps. It can be divided into mucosal prolapse type, inflammatory polyp type, and adenomatous polyp type. It is believed that polyps are most frequent in the rectum, and some believe that they are most frequent in the descending colon and sigmoid colon, and decrease in the upward order. They can disappear with the healing of inflammation, be destroyed with the formation of ulcers, remain for a long time or become cancerous. The carcinoma is mainly from adenomatous polyp type.
5.Carcinoma
The incidence is reported inconsistently, with some studies suggesting that it is many times higher than that of those without colitis. It is more common in those with colitis involving the whole colon, those with early onset of disease and those with a history of more than 10 years.
6. Small bowel inflammation
Complicated small bowel inflammation is mainly in the distal ileum and manifests as peribulbar or right lower abdominal pain, watery stools and fatty stools, which accelerates the progress of systemic failure in patients.
7. Complications related to autoimmune reactions
The common ones are: arthritis? The complication rate of arthritis in ulcerative colitis is about 11.5%, which is characterized by complications in the severe stage of enterocolitis lesions. Large joints are more commonly involved, often as a single joint lesion. Swollen joints and synovial effusion without damage to the bony joints. There are no rheumatic serological changes. It is often associated with ocular and skin-specific complications. Skin mucosal lesions? Erythema nodosum is common, with an incidence of 4.7% to 6.2%. Others, such as multiple abscesses, limited abscesses, pustular gangrene, and erythema multiforme, are common. Intractable ulcers of the oral mucosa are also uncommon, sometimes as thrush, and are poorly treated. Eye lesions? There are iritis, iridocyclitis, uveitis, and corneal ulcers. The former is the most common, with an incidence of 5% to 10%.
Treatment
In patients with fulminant and severe disease, surgical treatment will be considered in cases where medical treatment is not effective.
1.Internal medicine treatment
(1) Bed rest and systemic supportive therapy? including fluid and electrolyte balance, especially potassium supplementation, and those with low blood potassium should be corrected. At the same time, we should pay attention to protein supplementation, improve the general nutritional status, and give total extra-gastrointestinal nutritional support if necessary. Those with anemia can be given blood transfusion, and milk and dairy products should be avoided as much as possible when gastrointestinal intake.
(2) Drug treatment?
(1) Salicylic acid preparations of salazosulfapyridine are the main therapeutic drugs, such as Edisha and mesalazine.
②Corticosteroids are commonly used as prednisone or dexamethasone, but it is not believed that long-term hormone maintenance can prevent recurrence. The value of applying hormone therapy during acute attacks is certain, but there is still disagreement whether hormone should be used continuously during the chronic period, and because it has certain side effects, most of them do not advocate long-term use.
(iii) The value of immunosuppressants in ulcerative colitis is still doubtful. Rosenberg et al. reported that azathioprine did not control the disease when it worsened, while it helped to reduce the use of corticosteroids in chronic cases.
④ Herbal treatment of diarrheal ulcerative colitis can be treated with Chinese herbal medicine, which is more effective. Attention should also be paid to diet as well as lifestyle habits.
2.Surgical treatment
20% to 30% of patients with severe ulcerative colitis eventually undergo surgery
(1) Indications for surgery? The indications for emergency surgery are.
(1)Massive, uncontrollable bleeding;
(2) Toxic megacolon with adjacent or definite perforation, or toxic megacolon that has failed to respond to treatment for several hours rather than days;
(iii) fulminant acute ulcerative colitis that does not respond to steroid hormone therapy, i.e., no improvement after 4 to 5 days of treatment;
④Obstruction due to stricture;
⑤Suspected or confirmed colon cancer;
(6) Refractory ulcerative colitis with recurrent worsening, chronic persistent symptoms, malnutrition, weakness, inability to work, and inability to participate in normal social activities and sexual life;
(7) When the dose of steroid hormones is reduced, the disease deteriorates, so that the hormone therapy cannot be stopped for months or even years;
(8) When children suffer from chronic colitis that affects their growth and development;
(9) Surgery may be effective for severe extracolonic manifestations such as arthritis, gangrenous sepsis, or biliary and liver disease.
(2) Surgical options? There are currently four surgical options available for ulcerative colitis.
① Total colorectal resection and ileostomy;
②Total colectomy and ileorectal anastomosis;
(iii) Controlled ileostomy;
④Total colorectal resection and ileal pouch anastomosis.
There is no effective long-term prevention or treatment method. Among the existing four types of surgery, total colorectal resection and ileal pouch anastomosis is the more reasonable and optional method.
Prevention
1, pay attention to the combination of work and rest, not too much exertion; 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, should generally eat soft, easily digestible, nutritious and sufficient heat food. It is advisable to have a small number of meals and supplement with multivitamins. Do not eat raw, cold, greasy and multi-fiber food.
4, pay attention to food hygiene, to avoid intestinal infection induced or aggravated the disease. Avoid smoking, alcohol, spicy food, milk and dairy products.
5, usually to maintain a relaxed mood, avoid mental stimulation, lift a variety of mental stress.