Inflammatory bowel disease (IBD) is an idiopathic inflammatory disease of the intestine involving the ileum, rectum, and colon. Clinical manifestations include diarrhea, abdominal pain, and even bloody stools. The disease includes ulcerative colitis (UC) and Crohn’s disease (CD). Ulcerative colitis is a continuous inflammation of the mucosal and submucosal layers of the colon, usually involving the rectum first and gradually spreading to the whole colon, while Crohn’s disease can involve the whole GI tract and is a discontinuous inflammation of the whole layer, most often involving the terminal ileum, colon and perianal area.
Common sites: ileum, rectum, colon
Common causes: related to environmental, genetic, infectious and immune factors
Common symptoms: diarrhea, abdominal pain, bloody stools
Etiology: The etiology and pathogenesis are not yet fully understood. It is known that the inflammatory response caused by the abnormal response of the immune system of the intestinal mucosa plays an important role in the pathogenesis of IBD and is thought to be caused by the interaction of multiple factors, mainly including environmental, genetic, infectious and immune factors.
Clinical manifestations: The onset of the disease is generally slow, with a few acute cases. The severity of the disease varies. It is prone to recurrent attacks, and the triggers of attacks include mental stimulation, excessive fatigue, eating disorders, secondary infections, etc.
I. Abdominal symptoms
1, diarrhea: bloody diarrhea is the most important symptom of UC, feces containing blood, pus and mucus. Mild 2-4 times a day, serious up to 10-30 times, bloody watery; CD diarrhea is a common symptom, most daily stools 2-6 times, paste or watery, generally no pus or mucus, compared with UC, the amount of blood in the stool is small, less fresh blood color.
2, abdominal pain: UC is often confined to the left lower abdomen or lower abdomen paroxysmal spasmodic colic, pain can be followed by bowel movements, pain temporarily relieved after defecation. The vast majority of CD have abdominal pain, the nature of more vague pain, paroxysmal aggravation or recurrent, part of the right lower abdomen is more common, and terminal ileal lesions, followed by periumbilical or total abdominal pain.
3, posterior urgency: due to rectal inflammatory stimulation.
4, abdominal mass: part of CD can appear abdominal mass, the right lower abdomen and periumbilical area is common, due to intestinal adhesions, intestinal wall and mesenteric thickening, mesenteric lymph node enlargement, internal fistula formation and intra-abdominal abscess can cause abdominal mass.
Second, systemic symptoms
1, anemia: often mild anemia, acute outbreak of the disease due to massive bleeding, resulting in severe anemia.
2, fever: acute severe patients have fever with systemic toxemia symptoms, 1/3 CD patients can have moderate fever or low fever, intermittent, caused by active intestinal inflammation and toxin absorption after tissue destruction.
3, malnutrition: due to intestinal absorption disorders and excessive consumption, often cause patients wasting, anemia, hypoproteinemia and other manifestations. Younger patients are accompanied by growth retardation.
Examination
1.Hematological examination
Hemoglobin and plasma protein: normal or mildly decreased in light cases, mild or moderate decrease in medium and heavy cases, or even severe anemia and hypoprotein edema; decreased Hb can be attributed to chronic inflammatory bleeding and protein loss, iron and other hematopoietic material deficiency or malabsorption, especially ileal lesions in Crohn’s disease, which are prone to vitamin and mineral absorption disorders and chronic inflammation-related bone marrow hematopoietic inhibition. In addition, insufficient erythropoietin secretion plays an important role in the development of anemia in inflammatory bowel disease, despite normal renal function.
White blood cell count: Most patients have a normal count. In a few severe cases, it can be as high as 30×10/L. Sometimes, neutrophils are the main cause, and in severe cases, the nucleus of neutrophils may shift to the left and there are toxic granules.
Platelet count: Platelet count can be elevated in patients with ulcerative colitis and Crohn’s disease relapse. Platelet counts greater than 400×10/L are more common in patients with heavy ulcerative colitis than in those with mild or moderate ulcerative colitis.
2.Fecal examination
Routine fecal examination: the naked eye view is most common with paste-like mucus-purulent blood stool, very little fecal matter in severe cases, a few patients with mainly bloody stool, accompanied by a small amount of mucus or no mucus. Microscopic examination reveals a large number of erythrocytes, leukocytes, and also eosinophils, and a large number of multinucleated macrophages are commonly seen in stool smears during acute attacks.
Pathogenic examination: The purpose of pathogenic examination of inflammatory bowel disease is to exclude infectious colitis, which is an important step in the diagnosis of this disease.
3.Blood sedimentation (ESR) examination
ESR is generally seen to increase during the active phase of inflammatory bowel disease, and ESR can generally reflect the activity of the disease. The average ESR in patients in remission is 18mm/h, 43mm/h in mildly active patients, 62mm/h in moderately active patients, and 83mm/h in severely active patients, according to foreign reports.ESR changes reflect changes in the concentration of certain proteins in the serum during the active phase of the disease. ESR changes when serum concentrations of certain proteins, especially gamma-globulin, fibrinogen and Y-globulin, and hematocrit, are altered. Because of the long half-life of serum proteins associated with ESR, if clinical symptoms improve quickly, ESR often decreases only a few days after clinical symptoms have resolved.
IV. Differential diagnosis
The main means of diagnosing inflammatory bowel disease include history taking, physical examination, laboratory tests, imaging, endoscopy and histocytological features.
1.Chronic bacterial dysentery
Often have a history of acute bacterial dysentery, fecal examination can isolate Bacillus dysenteriae, colonoscopy to take mucopurulent secretions culture has a high positive rate, antibacterial treatment is effective.
2.Amoebic enteritis
Mainly invade the right colon, but also can involve the left colon, colon ulcers deeper, the edge of the subterranean, ulcers between the mucosa is more normal, fecal examination can find more amoeba trophozoites encapsulation, anti-amoebic treatment is effective.
3.Schistosomiasis
History of exposure to epidemic water, often with hepatosplenomegaly, fecal examination can be found schistosome eggs, hatching trichurias positive. Proctoscopy in the acute stage can be seen in the mucosa yellow-brown particles, biopsy mucosal pressure or histopathological examination can be found schistosome eggs.
4.Colorectal cancer
It can be seen after middle age, and the mass can be palpated by rectal finger examination.
5.Irritable bowel syndrome (IBS)
Mucus but no pus and blood in stool, normal microscopic examination or only a small amount of white blood cells, no evidence of organic lesion on colonoscopy.
6.Other
Intestinal tuberculosis: intestinal tuberculosis lesions mainly involve the ileocecal region, sometimes involving the adjacent colon, but not in a segmental distribution; fistulas and perianorectal lesions are rare; positive tuberculin test.
Malignant lymphoma of small intestine: primary malignant lymphoma of small intestine is often confined to the small intestine and/or adjacent mesenteric lymph nodes for a long period of time; in some patients, the tumor may have a multifocal distribution; the diagnosis of Crohn’s disease is facilitated by the simultaneous involvement of small intestine and colon, segmental distribution, fissure ulceration, cobblestone sign, fistula formation, etc. on X-ray; if the examination reveals extensive invasion in one intestinal segment, large indentation marks or filling defects, the diagnosis of Crohn’s disease is favorable. The diagnosis of malignant lymphoma of the small intestine is supported by the obvious thickening of the intestinal wall and enlarged abdominal lymph nodes on B ultrasound or CT examination, and surgical exploration can be performed if necessary.
V. Treatment
1.General treatment
Emphasize diet and nutritional supplementation, and give high nutrition and less residue diet. Give folic acid, B12 and other vitamins and trace elements as appropriate. If necessary, anticholinergics or antidiarrheal drugs can be given for abdominal pain and diarrhea, and broad-spectrum antibiotics can be given by intravenous route for combined infections.
2.Drug treatment
Aminosalicylic acid preparation: SASP is effective in controlling the activity of light and medium-sized patients, mainly for those whose lesions are confined to the colon.
Glucocorticoid: the most effective drug to control the activity of the disease, applicable to the active stage of the disease. Aminosalicylic acid preparations or immunosuppressants can be added for active cases.
Immunosuppressant: For patients with poor effect of glucocorticoid treatment or glucocorticoid-dependent chronic active patients, the addition of such drugs can reduce the dosage of glucocorticoids or even stop using them.
3.Surgical treatment
Indications for surgery: Complicated complete intestinal obstruction, fistula and abscess formation, acute perforation or uncontrollable massive bleeding.