Extraintestinal manifestations of Crohn's disease. Crohn's disease

Crohn's disease is a disease characterized by the occurrence of a granulomatous inflammatory process, as a result of which certain parts of the intestine may subsequently be affected. Crohn's disease, the symptoms of which we will consider in today's article, with this variant of the course mainly affects the small intestine (its final section). Any person, even a completely healthy person, can develop Crohn's disease, regardless of age and gender.

general description

As already noted, with Crohn’s disease, the development of the inflammatory process is relevant, and if we consider it globally, then not only the intestines suffer - almost the entire gastrointestinal tract system is affected, which, accordingly, gives reason to focus on complications, ranging from the oral cavity to anus. The difference between Crohn's disease and the similar course of ulcerative colitis is that it is accompanied by the involvement of each of the layers in the intestinal wall in the inflammatory process.

Mostly, the onset of inflammation is concentrated within the ileum, after which it spreads to various intestinal sections. The symptoms of the acute form of ileitis (this disease determines the inflammatory process in the ileum) are practically no different from the symptoms characteristic of acute appendicitis, and it is for this reason that patients are often operated on, determining the true diagnosis during the operation.

It should be noted that Crohn's disease is an extremely rare pathology. The onset of the disease, as a rule, occurs between 20 and 40 years of age, although the possibility of its manifestation in children cannot be ruled out. Statistics indicate that men are more susceptible to this disease.

Crohn's disease: causes

The causative agent of the disease we are considering has not yet been identified, although it is the infectious nature of Crohn's disease that is the main one in terms of considering its possible origin. This is explained by the effectiveness of treatment based on the use of antibacterial drugs.

Besides important role is also devoted to disorders immune system. The fact is that autoimmune processes, accompanied by the production of antibodies acting against their own tissues of the affected area (intestines), as well as an insufficiently effective protective function on the part of the immune system - all this serves as a serious background for the appearance and development of Crohn's disease.

The following options are also identified as factors predisposing to this disease:

• food allergies;
• the patient has previously had measles;
• mental overstrain, stress;
• predisposition at the level of heredity;
• smoking, presence of other bad habits.

Crohn's disease: symptoms

The main three symptoms characteristic of Crohn's disease are: diarrhea (its chronic course), abdominal pain and weight loss. Considering this disease as a whole, we note that given the possibility of it affecting any part of the gastrointestinal tract, the clinical manifestations characteristic of Crohn’s disease, in turn, can be more than multifaceted. As it becomes clear, it is the localization of the inflammatory process that determines the vast majority of concomitant illness Crohn's symptoms.

The general type of symptoms of this disease arise against the background of actual disorders in the functioning of the immune system, as well as against the background of intoxication. Accordingly, fever, general malaise and weakness can also be added to the symptoms noted above. Fever, in particular, is often provoked by purulent complications resulting from Crohn's disease itself; the temperature can reach 40°C.

Due to disturbances in the absorption of vitamins, nutrients, microelements and bile acids prolonged inflammation of the intestinal walls leads to the development of metabolic disorders, already noted weight loss and osteoporosis (which, in turn, is accompanied by the loss of characteristic bone tissue strength). In addition, cholesterol stones begin to form in the gallbladder.

Also, diarrhea, which was initially noted as one of the main symptoms, is accompanied by the appearance of blood in the stool. The stool, as can be assumed from the definition of the symptom, is liquid, and these symptoms are constant, reaching a frequency of about three to ten times a day. It is noteworthy that after defecation, abdominal pain becomes less intense.

Considering the nature of abdominal pain, you can notice that it is not intense, manifests itself in cramping patterns, in combination with such manifestations as bloating and heaviness. Often the localization of pain is concentrated in the area of ​​the right lower quadrant of the abdomen, which often leads to the mistaken association of pain with appendicitis.

The disease is also characterized by extraintestinal manifestations, which are determined by specific immunological disorders. Such manifestations include in particular:

• sacroiliitis - an inflammatory process in the sacroiliac joint, accompanied by severe pain concentrated in the sacral area;
• arthropathy – in in this case we are talking about an asymmetrical lesion affecting large types of joints, which, in turn, leads to the appearance of pain with a forced limitation of the patient’s mobility;
• skin rash(in particular, this includes pyoderma gangrenosum, erythema nodosum);
• the appearance of ulcerative formations in oral cavity;
• loss of vision;
• hepatitis;
• dermatitis;
• cholelithiasis, kidney stones;
• arthrosis, arthritis;
• inflammatory processes in the mucous membranes of the mouth, eyes, etc.

In addition to appendicitis, the disease is also difficult to distinguish from ulcerative colitis, intestinal tuberculosis, malignant type of lymphoma, infectious enterocolitis, which are also accompanied by symptoms of a similar type of manifestation.

It is noteworthy that about 30% of patients with symptoms characteristic of Crohn's disease also experience disorders of the anal area. These include, in particular, irritation of the anus and its swelling, rectal fissures, as a result of which the act of defecation itself may be accompanied by pain in combination with the release of mucus and blood.

Crohn's disease in children also implies certain features that characterize its course. Thus, children with this disease rapidly lose weight, they experience loss of appetite, often absolute. On the background associated with the disease developmental delay is also noted. One of the defining symptoms of Crohn's disease in children is an increase in temperature to significant levels, which is also often accompanied by pain in the joints.

Crohn's disease: complications

Late diagnosis of the disease, as well as its long course (and treatment, accordingly) can lead to the development of a number of complications. Let's highlight their main options:

• Intestinal obstruction.This complication is a type-specific sign, especially when it comes to damage to the small intestine area. In this case, the intestinal lumen undergoes significant narrowing, as a result of which adequate passage of food is disrupted. As a rule, absolute obstruction of the lumen of the area under consideration does not occur, and therefore the possibility of implementing conservative expectant therapy measures when prescribing hormonal drugs, antispasmodics, and antibacterial drugs is not excluded. Meanwhile, the lack of effectiveness in treatment, along with the required positive dynamics of the development of the process, leads to the need for an operation in which the part of the intestine that has undergone narrowing is subject to removal.
• Perforation to free abdominal cavity. Due to an actual violation of the tightness in the intestinal wall due to deep ulcerative lesions, contents are poured into the abdominal cavity, which occurs in combination with inflammation in this area (that is, peritonitis). This process requires immediate surgical intervention.
• Infiltration followed by the formation of an abscess in the abdominal cavity. This complication is relevant against the background of its previous version. Activation protective functions, characteristic of the peritoneum, leads to a peculiar delimitation of the area of ​​inflammation, in which an infiltrate is formed (a conglomerate based on inflamed tissue), which, in turn, has an abscess (i.e. purulent contents). This type of complication requires the implementation of drug therapy, and if it is not effective, it again requires surgical intervention.
• Bleeding. In this case, we are talking about intestinal bleeding, which, however, occurs much less frequently as a complication in the case of the disease in question (than in comparison with the same ulcerative colitis), but they also cannot be excluded. This option requires the prescription of drug hemostatic therapy, and it is usually quite effective in its implementation.
• Toxic dilatation. This complication implies a pronounced expansion noted in a certain area of ​​the intestine. This complication also appears rarely, and its development is provoked by therapy using antidiarrheal drugs, as well as colonoscopy and irrigoscopy. The use of antibacterial and anti-inflammatory drugs in this situation provides, along with a temporary stop in food intake, the possibility of eliminating the current condition for the patient.
• Anal fissures, paraproctitis, fistulas. These complications often accompany the onset of the disease. They mean the appearance of ulcers in the area of ​​the mucous membrane of the anal canal at the transition to the skin surrounding it. The formation of fistula tracts occurs against the background of a breakthrough of purulent formations in the area of ​​fatty peri-rectal tissue. Correction of this type of complication involves an operation in which the corresponding area is excised, which also implies the need for the use of drug therapy.

Diagnosis

Diagnosis of the disease in the event of the appearance of characteristic symptoms is made using several basic studies, these include the following:

• Endoscopy. This method involves inserting directly into the intestine an instrument equipped with a light source and a video camera, a flexible tube used to examine the mucous membrane in the area of ​​the colon and rectum.
• X-ray. The implementation of the techniques is carried out in combination with the use of a contrast agent, on the basis of which it is possible to detect areas of narrowing, granulomas and other types of neoplasms in the area small intestine.
• Biopsy of the intestinal mucosa. Tissue is taken for subsequent histological examination during a colonoscopy procedure. Subsequently, in laboratory conditions, an analysis is carried out of the changes that have occurred in the mucosa.
• Laboratory research. This includes a standard (general) blood test, a biochemical blood test, and a urine and stool test. In addition, an immunological blood test is also performed, in its expanded version.

Treatment of Crohn's disease

Considering the fact that the disease, as we noted earlier, exposes the entire gastrointestinal tract system to corresponding damage, the treatment of Crohn's disease is predominantly medicinal and complex. As for surgical intervention, it is applicable only in the case of the complications listed above, as a result of which appropriate correction of the conditions is ensured.

The disease itself is incurable, but despite this, its treatment should not only not be excluded for this reason, but, on the contrary, should be permanent and consistent, due to which support for a consistently normal level of the patient’s quality of life can be ensured.

It should also be borne in mind that the lack of treatment for this disease determines a very unfavorable prognosis for it, as a result of which serious complications develop, which, in turn, can affect not only the intestinal area in terms of discomfort and unpleasant manifestations, but in general pose a serious danger for the life of a sick person.

For the disease in question mandatory a diet is prescribed based on the inclusion of high-calorie foods with a significant amount of vitamins and protein in their composition. At the same time, some restrictions are introduced regarding the consumption of vegetable coarse fiber products and fats, as a result of which intestinal irritation occurs.

In general, nutrition should be balanced, because Crohn's disease does not exclude vitamin deficiency and anemia as concomitant conditions, which occurs due to poor absorption of food. Alcohol consumption is excluded; in general, lifestyle should be significantly adjusted in favor of the criteria that define it as healthy.

An exacerbation of Crohn's disease implies the need for antibacterial therapy; the duration of taking drugs can be about 6 weeks. Damage to the colon determines the greatest effectiveness in treatment when using antibiotics.

If symptoms appear that indicate the possible relevance of Crohn's disease, you should contact a gastroenterologist.

What is Crohn's disease is an inflammatory process characterized by granulomatous lesions of various segments of the digestive system.

Foci of inflammation can be located in any part of the gastrointestinal tract - from the oral cavity to the anal canal. However, most often the disease is localized in the intestinal lumen - in one or more fragments of the small or large intestine, turning it into a bed for granulomas.

According to statistics, this disease occurs much more often in men than in women. At the same time, the first signs of the disease, as a rule, appear at a fairly young age - 20-40 years.

Causes

Why does Crohn's disease occur and what is it? The exact reason for the development of this disease not installed. Experts point to some factors that can provoke the occurrence of Crohn's disease.

According to the first hypothesis, the pathogenesis of Crohn's disease is caused by bacteria and viruses. The second hypothesis interprets pathogenesis as the provocation of an abnormal systemic immune response by a food antigen. According to the third assumption, experts believe that the pathogenesis lies in autoantigens located on the intestinal wall. Because of antibacterial treatment gives positive results, it is believed that the cause of this disease lies precisely in the infectious theory.

The main risk factors influencing the development of the disease in adults include the following:

1. Genetic predisposition. This disease is often detected in siblings or twins. In approximately 19% of cases, the pathology is diagnosed in blood relatives.
2. Immunological factors. Since sequential organ damage is observed in Crohn's disease, scientists put forward a hypothesis regarding the autoimmune nature of the pathology.
3. Infectious diseases. The role of these factors has not yet been reliably confirmed, however, there are hypotheses regarding viral or bacterial nature diseases.

Most often, Crohn's disease affects the part of the intestine that is located near the large intestine. Although there are cases of localization of lesions in all parts of the digestive tract. With this disease, the entire mucous membrane of the affected area is covered with abscesses and ulcers.

Symptoms of Crohn's disease

Since this disease can affect any organ of the gastrointestinal tract, the symptoms will be completely different. Experts divide the symptoms of Crohn's disease into:

• are common;
• local (depending on the location of the lesion);
• extraintestinal disorders.

The first type of symptoms includes increased body temperature, fever, malaise (signs of an inflammatory process). If the temperature rises to very high levels (40 degrees), this indicates purulent complications of the disease. Loss of body weight is due to the fact that the inflamed organs of the gastrointestinal tract do not absorb all the nutrients necessary for the body.

To local symptoms Crohn's diseases include the following:

• regular diarrhea, it is caused by the inability to absorb nutrients in the intestines; in severe cases, rotting processes develop;
• frequently recurring pain in the abdominal area, it is similar to, occurs due to damage to the intestinal mucosa and constant irritation of nerve endings;
• infiltration (abnormal leakage of substances) and abscesses;
• perforation of the intestinal walls;
• intestinal obstruction;
• with the development of perforated fistulas and ulcers, the patient experiences bleeding.

Extraintestinal disorders are more associated with immune disorders that affect the entire body. For example, damage to large joints (pain, limited mobility), inflammation of the sacroiliac area, blurred vision, skin rash.

Chronic form

In the picture of symptoms of the chronic form of Crohn's disease, signs of intoxication come to the fore: weakness, malaise, increased fatigue, low-grade body temperature, loss of appetite and body weight, pain in large joints. Over time, regular diarrhea, bloating and significant weight loss are added.

When the large intestine is damaged, stools become more frequent and may contain blood. In some cases, in the right iliac region or in the central parts of the abdomen, a tight-elastic mobile formation is palpated during palpation. The phalanges of the fingers take on the appearance of drumsticks.

Typically, the chronic form of Crohn's disease occurs with exacerbations and long-term remissions, causing severe consequences in the form of appearance anal fissures, ulcers, internal and external fistulas, massive intestinal bleeding, partial or complete intestinal obstruction, sepsis. The resulting infiltrates can cause complications, causing the development of cancerous tumors and subsequent disability. With the progressive course of the disease, there is an unfavorable prognosis for the patient’s life.

Diagnostics

Before you can figure out how to treat Crohn's disease, it's important to get a proper diagnosis. Therefore, to exclude other pathologies that have similar symptoms, an instrumental examination is prescribed.

The following methods are commonly used:

1. Colonoscopy. Such a study allows you to visualize the inner surface of the intestine.
2. Irrigography. Provides the opportunity to see partial lesions intestines, narrowing of its lumen, intestinal relief, ulcerations or ulcers, thickening of the walls and decreased activity.
3. Ultrasound. It can be used to assess the diameter of intestinal loops and the presence of free fluid in the abdominal cavity.
4. CT scan. This is done if Crohn’s disease is complicated by diseases of other organs, and establish accurate diagnosis difficult. MRI allows you to study in more detail the condition of the intestine, the degree of its damage, the presence of fistulas, narrowing of the passage of the small or large intestines, and enlarged lymph nodes.
5. Endoscopic examination. It is mandatory; it is used to both visually confirm the diagnosis and take a piece of tissue for subsequent examination under a microscope.

Laboratory methods, including blood and stool tests, are required to rule out infectious intestinal diseases.

Treatment of Crohn's disease

When Crohn's disease is diagnosed, the main treatment regimen consists of using drug therapy aimed at localizing and reducing inflammation in the intestine, reducing the frequency and duration of exacerbations, as well as maintaining a state of stable remission, that is, anti-relapse treatment.

Severe cases may require more strong drugs, complex treatment, and periods of exacerbations - surgical intervention. The choice of treatment method depends on the severity of Crohn's disease, the dominant symptoms, general condition patient's health.

Drug therapy

There is currently no universal treatment for Crohn's disease, but therapy using one or more drugs is aimed at early treatment disease and relief of its symptoms.

Most common medicines are:

• salicylates (5-ASA) - sulfasalazine, mesalazine, Pentasa;
• topical hormones – budenofalk;
• glucocorticoids - prednisolone, methylprednisolone;
• immunosuppressants - azathioprine, methotrexate, 6-mercaptopurine;
• tumor necrosis factor blockers - adalimumab, infliximab, golimumab, etanercept, certolizumab pegol.
• integrin receptor blockers: Vedolizumab.

Also actively used:

• antibiotic treatment: ciprofloxacin, metronidazole and new antibiotic rifaximin;
• (VSL#3, live donor fecal transplant);
• vitamin D.;
• hyperbaric chambers (oxygen treatment);
• in severe cases, intestinal transplantation from a donor.

For more common and complex cases of Crohn's disease, surgery may be indicated. Sometimes, with the development of serious complications of the disease, such as bleeding, acute intestinal obstruction or intestinal perforation, emergency surgical interventions have to be performed.

Other less urgent indications for surgery include abscess formation, intestinal fistulas(pathological reports various departments gastrointestinal tract), severe forms perianal lesion, lack of effect of conservative treatment.

Diet

During remission of the disease, patients are advised to follow a strict diet so as not to provoke an exacerbation of the inflammatory process in the intestinal wall. The diet should be balanced, contain a large amount of protein and vitamins, and fats should be limited. The diet for Crohn's disease is not very strict, the main thing in it is careful attitude to the intestines.

1. Drink enough fluids;
2. Limit consumption of flour and baked goods;
3. Eat small portions 5-6 times a day;
4. Give preference to low-fat products;
5. Avoid eating spicy foods and alcohol;
6. Take multivitamin complexes.

The diet for Crohn's disease limits the consumption of heavy, rough foods that irritate the intestinal mucosa, as well as fats and milk. Easily digestible and easily digestible food is recommended, with limited use fermented milk products, gentle on the gastrointestinal tract. It is extremely important that the diet for Crohn's disease is balanced, since anemia and vitamin deficiencies are common with this disease due to poor absorption of food.

Operation

If diet, lifestyle changes, drug therapy and other methods are ineffective, the patient is recommended to undergo surgical treatment. About half of all patients with Crohn's disease experience at least one surgical intervention, during which doctors remove the damaged section of intestine.

Unfortunately, surgery cannot completely eliminate Crohn's disease, as is possible, for example, with ulcerative colitis. Even if a large segment of intestine is removed during surgery, the disease may reappear. In this regard, some experts recommend postponing the operation as long as possible. This tactic allows you to reduce the number of operations that a person will have to undergo.

Complications

Crohn's disease can be accompanied by complications such as:

1. Intestinal bleeding.
2. Perforation (violation of the integrity of the intestinal wall).
3. Urolithiasis disease.
4. The occurrence of abscesses (ulcers) in the intestines.
5. Development of intestinal obstruction (impaired movement of intestinal contents through the intestines).
6. Formation of fistulas (normally absent channels) and strictures (narrowings) of the intestine.

If the fistula develops inside the abdominal cavity, food entering the intestines may bypass the areas responsible for the absorption of nutrients and also enter organs such as the bladder or vagina. The development of a fistula is a serious complication, since it involves high risk suppuration and abscess formation. Left unattended, this condition can become a threat to the patient's life.

Forecast for life

The mortality rate for Crohn's disease is 2 times higher compared to the mortality rate among the healthy population. Most reasons fatal outcome are associated with complications and surgical operations for them.

The disease has a relapsing course and almost all patients experience at least one relapse within 20 years. This requires constant dynamic monitoring of the patient to adjust therapy and identify complications of the disease.

The prognosis for life varies significantly and is determined individually. The course of Crohn's disease can be asymptomatic (if the lesion is localized only in the anus in older people) or be extremely severe.

The acute form of Crohn's disease is observed less frequently. As a rule, at the same time pathological process localized in the terminal segment of the ileum. Characteristic clinical signs of the acute form of Crohn's disease are:

• increasing pain in the right lower quadrant of the abdomen;
• nausea, vomiting;
• diarrhea, often mixed with blood;
• flatulence;
• increased body temperature, often with chills;
• thickened, painful terminal segment of the ileum;
• leukocytosis, increased ESR.

Chronic form of Crohn's disease

The chronic form of Crohn's disease is the most common. Its manifestations vary depending on the location of the inflammatory process.

Small intestinal localization

The clinical symptoms of this form can be divided into a group of general and local symptoms.

General symptoms are caused by intoxication and malabsorption syndrome and include: weakness, malaise, decreased performance, increased body temperature to subfebrile, weight loss, edema (due to loss of protein), hypovitaminosis (bleeding gums, cracks in the corners of the mouth, pellagross dermatitis, deterioration of twilight vision), pain in bones and joints (depletion of calcium salts), trophic disorders (dry skin, hair loss, brittle nails), adrenal insufficiency (skin pigmentation, hypotension), thyroid gland(lethargy, puffiness of the face), gonads (menstrual irregularities, impotence), parathyroid glands (tetany, osteomalacia, bone fractures), pituitary gland (polyuria with low density urine, thirst).

Local symptoms:

1. Periodic, and later constant dull pain (with damage to the duodenum - in the right epigastric region, jejunum - in the left upper and middle part of the abdomen, ileum - in the right lower quadrant of the abdomen).
2. The stool is semi-liquid, liquid, foamy, sometimes mixed with mucus and blood.
3. With intestinal stenosis - signs of partial intestinal obstruction (cramping pain, nausea, vomiting, gas and stool retention).
4. On palpation of the abdomen - pain and tumor-like formation in the terminal part of the ileum; if other parts are affected - pain in the umbilical region.
5. Formation of internal fistulas opening into the abdominal cavity (interloop, between the ileum and cecum, bile and bladder), and external ones, opening into the lumbar and groin areas.
6. Intestinal bleeding (melena) is possible.

Taking into account the above-described symptoms, it is advisable to distinguish four main types of regional enteritis(Walfish, 1992):

• inflammatory - characterized by pain in the right lower quadrant of the abdomen and tenderness on palpation of this area (especially the ileum terminale), which, with severe symptoms, resembles acute appendicitis;
• obstructive - develops with intestinal stenosis, symptoms of recurrent partial obstruction appear with severe spastic pain in the abdomen, bloating, constipation and vomiting;
• diffuse jejunoileitis- characterized by pain in the right iliac region, pain on palpation in the periumbilical and right iliac region; sometimes with symptoms of partial intestinal obstruction; a decrease in body weight and even severe exhaustion gradually develops;
• abdominal fistulas and abscesses- usually found on late stages illnesses accompanied by fever, abdominal pain, and general exhaustion. Fistulas can be entero-intestinal, entero-vesical, entero-retroperitoneal, enterocutaneous.

Localization in the colon (granulomatous colitis)

Main clinical symptoms:

1. Abdominal pain of a cramping nature that occurs after eating and before defecation. Constant pain during movements and bending of the body is also possible (due to the development of the adhesive process). The pain is localized along the large intestine (in the lateral and lower abdomen).
2. Severe diarrhea (loose or pasty stools up to 10-12 times a day mixed with blood). Some patients have a strong urge to defecate at night or in the morning.
3. Pale, dry skin, decreased turgor and elasticity.
4. When examining the abdomen, a decrease in muscle tone of the anterior abdominal wall is revealed; palpation along the colon is accompanied by significant pain. The sigmoid colon is most often determined in the form of a tourniquet, which is explained by infiltration of its wall.
5. 80% of patients have anal fissures. Features that distinguish them from ordinary cracks: different localization, often multiple in nature, significantly less pain, laxity of granulations, absence of rigid cicatricial edges, sphincter spasm.
6. During a digital examination, if the walls of the anal canal are involved in the process, edematous tissue is palpated, and a decrease in sphincter tone can often be determined. After the finger is removed, there is a gaping of the anus and leakage of intestinal contents, usually of a purulent-bloody nature. In the presence of cracks and fistulas, especially with extensive purulent ischiorectal leaks, complete destruction of the pulp fibers is possible.
7. Important diagnostic sign- fistulas associated with the intestines and infiltrates of the abdominal cavity. Rectal fistulas in Crohn's disease, even with long-term existence, are rarely accompanied by scarring and are most often surrounded by infiltrated tissues with polypoid-shaped, infiltrated mucous membrane in the area of ​​the internal opening and flaccid “lip-like protruding” granulations around the external opening.

Sometimes the disease manifests itself only as a sluggish ulcer of the anal canal with frequent transition to the skin.

Fistulas can be internal (interintestinal, enterovesical, gastrointestinal, etc.) and external, emanating from various parts of the digestive tract. The cause of fistula formation is a transmural inflammatory process involving the serous layer, which causes the formation of adhesions between nearby organs. Since in the case of inflammation there is usually ulceration in the form of ulcer-cracks that penetrate deeply into the intestinal wall, and sometimes beyond its limits, it is in this place that penetrations are formed with the development of internal or external fistulas.

Abdominal infiltrates are stationary, painful formations, usually fixed to the posterior or anterior abdominal wall. The most typical localization of the infiltrate is in the right iliac region, often in the area of ​​the scar after appendectomy. Due to the frequent breakthrough of pus into the surrounding tissue and the transition of the inflammatory process to surrounding tissues, the clinical picture is supplemented by symptoms of psoas syndrome.

Depending on the location of the pathological process, ileocolitis, colitis, and anal form are distinguished. The process can involve one or several sections of the intestine (single- or multifocal lesion) and proceed as an ulcerative, sclerotic or fistulous variant.

Combined damage to the small and large intestine

This form of Crohn's disease is manifested by a combination of symptoms inherent in terminal ileitis and symptoms of damage to the colon. G. A. Grigorieva (1994) indicates that when the pathological process is localized in the ileum and right parts of the colon, pain in the right half of the abdomen and low-grade body temperature predominate; Some patients experience symptoms of malabsorption. With diffuse damage to the colon in combination with damage terminal department ileum in clinical picture the symptoms of total colitis dominate.

The clinical picture of Crohn's disease with the localization of the pathological process in the esophagus, stomach, duodenum in the initial stages resembles the clinic, respectively, of chronic esophagitis, chronic gastritis, duodenitis. In case of damage to the stomach and duodenum clinical manifestations may be similar to the clinic peptic ulcer stomach and duodenum (ulcer-like syndrome), and there is often an admixture of blood in the vomit. As the disease progresses, weakness, low-grade body temperature, weight loss, and anemia occur.

Crohn's disease is chronic illness inflammatory in nature, which is accompanied by damage to the gastrointestinal tract. It has an unclear etiology and a fairly severe course with frequent relapses during periods of exacerbation. This pathology can affect any part of the digestive system - from the mouth to the rectum.

This problem can occur at any age and is diagnosed in both children and adults. Crohn's disease is always accompanied by a transmural inflammatory process that affects all layers of tissue of the digestive system. This pathology has many similar manifestations to ulcerative colitis, which complicates its diagnosis.

In Crohn's disease, symptoms most often appear in the small intestine (70% of cases). Only in 25% of patients pathological processes develop in the colon, and in 5% - in the stomach, anus or other parts of the digestive system.

This problem is equally common throughout the world, but is most common in northern America and Europe. Most people first learn about Crohn's disease between the ages of 15 and 35. Despite this, it also occurs in children. Crohn's disease also recurs after age 60. Representatives of the Caucasian race are more susceptible to this pathology than the Negroid and Asian races. Ashkenazi Jews are 6 times more likely to suffer from Crohn's disease than other ethnic groups. It has also been found that men are more susceptible to this problem than women (in a proportional ratio of 1.8:1).

The history of the disease suggests that it became known to the public in 1932. It was first described by a group of American scientists. They saw similarities in the symptoms and features of the course of Crohn's disease in 18 patients. At this time, as well as later, the cause that leads to the appearance of this pathology was not fully established.

It has been established that the immune system plays a significant role in the development of Crohn's disease. There is a disruption in its operation, which leads to an attack own body. Food entering the gastrointestinal tract useful material, bacteria that make up the normal microflora become foreign agents. As a result, in Crohn's disease there is an increased production of leukocytes - white blood cells. They accumulate on the walls of the digestive system, causing an inflammatory process.

Several causes of Crohn's disease have been proposed:

• genetic factors. It has been found that signs of Crohn's disease are most often observed in two identical twins or siblings. Also, approximately 15% of patients have relatives who also suffer from this disease. There are about 34 known gene mutations that can lead to Crohn's disease;
• negative impact of infections. Certain experiments were carried out on rats, which confirmed the development of Crohn's disease in them against the background negative influence certain pathogenic microorganisms. It is assumed that the same processes are observed in people. There are suggestions that pseudotuberculosis bacteria can cause this pathology;
• immunological processes. Because of systemic damage organism, one can suspect the autoimmune nature of Crohn's disease. Patients often have antibodies to coli, lipopolysaccharides, cow's milk protein. Also, when examining blood, a fairly high number of T-lymphocytes can be noted.

Also, some experts are of the opinion that the appearance of Crohn’s disease is promoted by smoking, alcohol abuse, unfavorable environmental conditions, and taking certain medications(even oral contraceptives).

What pathological changes are observed in Crohn's disease?

Macroscopic changes that are observed during the development of Crohn's disease have general character. They are mainly studied on surgical or sectional material. If the intestine is damaged, there is no significant decrease in its length. This is more common in ulcerative colitis. A distinctive feature of Crohn's disease is a decrease in the diameter of the intestine in some areas. The serous membrane at this time is full-blooded, cloudy, with small granulomas.

If you carefully examine the affected areas, you can find deep ulcers with smooth edges that resemble knife cuts. These lesions are in most cases localized along the intestinal axis. In Crohn's disease, intact but swollen areas of the mucous membrane usually remain between the ulcers. Perforation of the affected areas is often observed, which provokes the formation of intra-abdominal abscesses and fistulas. In this case, the latter sometimes connect to intestinal loops and other organs. It mainly affects the bladder, skin, and in women the uterus and vagina.

There are cases of the development of Crohn's disease when it affects the intestine segmentally. Then a narrowing of its lumen occurs in an area from 5 to 15 cm, and no pathological processes develop above and below this zone. This manifestation of Crohn’s disease (photos confirm this) is called “suitcase handle” in the medical literature. Sometimes such narrowed areas are quite long, and the walls themselves are significantly thickened. This pathological condition more typical for the small intestine. Its distinctive feature is the alternation of unchanged areas with affected areas.

If Crohn's disease is present, diagnosis is made to separate it from ulcerative colitis. A feature of the first pathological condition is damage to all layers of the intestinal wall, which is not typical for the second. Also, with Crohn's disease, uneven infiltration of the mucous membrane is observed. The following cells predominate in the affected areas: lymphocytes, plasma cells, segmented lymphocytes, eosinophils. Crohn's disease is also characterized by the presence of granulomas, but they are found in only half of patients. Usually they are placed separately and are not grouped into several pieces.

Because Crohn's disease is chronic, the inflamed tissue begins to scar over time. This leads to stenosis of the intestinal lumen. Also, this pathological condition is almost always accompanied by damage to the lymph nodes.

When Crohn's disease affects the colon, the symptoms will differ if the pathological process is localized in another part of the digestive system. But there are some signs that are present in the majority of patients:

• chronic diarrhea. With Crohn's disease, it can last a very long time - more than 6 weeks. With diarrhea, the number of bowel movements per day reaches 10 times. A person visits the toilet after every meal and at night. At the same time, there is almost always no blood in the discharge or it appears inconsistently;
• abdominal pain of different localization. With Crohn's disease, there are often sensations that are characteristic of acute appendicitis. Pain mainly manifests itself in the umbilical or iliac region of the abdomen. Uncomfortable sensations are present all the time. The pain is dull and has a spastic, bursting character;

• rapid loss of body weight. This is due to impaired absorption of food from the intestines;
• weakness, fatigue, loss of ability to work;
• a significant increase in body temperature, which has a wave-like character;
• lack of appetite;
• nausea accompanied by vomiting;

• bloating;
• the presence of anal fissures that do not heal for a long time;
• frequent occurrence of rectal fistulas. This condition often delays the diagnosis of Crohn's disease;
• There is an increase in abdominal pain after the next meal, after stressful situations.

Secondary manifestations of Crohn's disease

Against the background of developing disorders in Crohn's disease and the corresponding lifestyle of a person leads to the appearance of other symptoms:

• eye damage, which occurs in 4-5% of patients. Against the background of the underlying pathology, conjunctivitis, uveitis, keratitis, scleritis, iridocyclitis and others develop;
• skin damage is observed. As a result, erythema nodosum, pyoderma gangrenosum, and angiitis develop. The oral mucosa is also often affected, leading to aphthous stomatitis. Deep cracks and ulcers may appear on the lips themselves;

• joints are often affected, which provokes the development of monoarthritis, ankylosing spondylitis, sacroiliitis;
• liver damage occurs as a complication from the underlying disease and as a consequence of drug treatment. As a result, chronic hepatitis develops, turning into cirrhosis, fatty hepatosis, cholelithiasis, sclerosing cholangitis;
• kidney damage is accompanied urolithiasis, amyloidosis, glomerulonephritis;

• through damage to the intestinal wall leads to the development of intraperitoneal abscesses, adhesions, and fistulas;
• the presence of a chronic inflammatory process, tissue scarring is fraught with the appearance of intestinal obstruction;
• the presence of ulcers in tissues provokes damage to small and large vessels. This leads to bleeding into the intestinal lumen;
• the presence of fistulas in the bladder or uterus provokes inflammation and infection of these organs, and the removal of air or feces through them.

Classification of Crohn's disease

Depending on location inflammatory processes in the digestive system, there is the following classification of Crohn's disease:

• ileocolitis. Characterized by damage to the ileum and colon. Other parts of the gastrointestinal tract are functioning well;
• gastroduodenal form. With its development, pathological changes occur in the stomach and duodenum;
• ileitis Negative changes in the ileum are observed. All other parts of the gastrointestinal tract remain healthy;
• jejunoileitis. Damage to the ileum and small intestine is observed;
• development of Crohn's disease with damage to the colon.

Diagnosis of Crohn's disease

Diagnosis of Crohn's disease includes a large number of studies different types, which allow you to determine the condition of a sick person:

• general analysis blood. Allows you to determine a decrease in hemoglobin, which indicates anemia. This occurs due to significant blood loss due to the lesion blood vessels in the intestines in Crohn's disease. Leukocytosis with band shift is also observed, elevated ESR. These symptoms appear against the background of the development of the inflammatory process and intoxication. Hypoalbuminemia and electrolyte disturbances with progression of Crohn's disease;
• general urine analysis. Indicated for identifying complications of the urinary system;

• stool test for the presence hidden blood. It is carried out to determine bleeding in the digestive tract;
• coprogram. It is a stool analysis that allows you to determine undigested food particles and fat;
• stool analysis to exclude the infectious nature of Crohn's disease. Special bacteriological tests are carried out to determine salmonella, tubercle bacilli, dysentery amoeba, and various helminths;
• examination of stool for the level of calprotectin (a protein produced by cells of the intestinal mucosa). The result of the analysis for Crohn's disease is a significant amount of this substance, which greatly exceeds the norm. The level of calprotectin also increases with ulcerative colitis, cancer, and infectious lesions of the digestive tract;

• endoscopy with biopsy. The entire colon and terminal ileum are examined because this disease affects most of the digestive system. A positive biopsy result is possible when multiple biopsies are taken from different parts intestines;
• video capsule endoscopy. An endocapsule is used to examine the small intestine;

• X-ray of the abdominal cavity. In Crohn's disease, this examination allows you to determine the swelling of intestinal loops;
• X-ray examination of the digestive tract with a contrast agent. Allows you to determine the location of damage and their nature;
• computed tomography, ultrasound. Indicated for determining complications of Crohn's disease - intraperitoneal abscesses, assessing the condition of the kidneys, biliary tract, pancreas and other organs;
• histological examination of the mucous membrane of the gastrointestinal tract. Sometimes sarcoid granulomas are found, which are the main symptom of Crohn's disease.

Treatment of the disease

Treatment of Crohn's disease involves eliminating the inflammatory process in the intestines, which allows achieving stable remission. Also, therapy for this disease is based on the prevention of complications and exacerbations.

Treatment of this pathology is predominantly conservative, carried out by a gastroenterologist and proctologist. TO surgical intervention resorted only in cases where there is a risk of death.

Drug treatment involves the use of the following drugs:

• salicylates. They are used both in the form of tablets and in the form of rectal suspensions, suppositories, foams. These drugs are not very effective for Crohn's disease, so they are used only for mild form pathological changes in organism;
• topical hormones. Used if there is low disease activity, which manifests itself only in the ileocecal area;
• glucocorticoids. Used to eliminate acute manifestations diseases. Long-term use of glucocorticoids can provoke hormone dependence, so they are prescribed for a short period;

• immunosuppressants. Used as maintenance therapy;
• genetic engineering biological drugs. Antibodies to TNF-alpha and many others are used;
• antibiotics are used to eliminate bacterial infections. The most commonly used drugs are wide range actions that can overcome abscesses and other negative processes in the body;
• symptomatic treatment involves the use of antidiarrheal, analgesic, and hemostatic agents.

On this moment there are many practices alternative ways treatment. These include the use of probiotics, enzymes and other drugs. They practice treatment with stem cells, eggs of pig worms, plasmapheresis, etc. These techniques are used as experimental ones and have not found wide application.

Surgery

Surgery for Crohn's disease is indicated in the presence of complications, but it does not get rid of the problem. The main task of the surgeon is to remove the segment of intestine that represents great danger for a person. At the same time, other areas are not subject to surgical intervention. Surgeons try to leave as few connections as possible between intestinal segments. If there are narrowings, conventional removal of pathological areas will not lead to positive result. This disorder is most easily corrected using stricturoplasty.

If the problem exclusively affects the last part of the small intestine or the cecum, then surgery is the best treatment. During this operation, the problem area is removed. After this, a suture is placed at the junction of the small intestine and the large intestine. In some cases, this operation can be performed with a minimum number of incisions, which allows the rehabilitation period to be minimized.

Also, fistulas that cannot be eliminated conservatively are subject to surgical treatment. In this case, colostomy is often used when open end the intestines are brought out onto the abdominal wall. This phenomenon is most often temporary. A permanent colostomy is resorted to only when the large intestine has been completely removed due to severe inflammatory processes.

Prognosis for Crohn's disease

In Crohn's syndrome, the prognosis depends on many factors. First of all, the patient’s lifestyle, age and other factors matter. In children this pathology characterized by a blurred picture and the presence of a large number of extraintestinal manifestations. Their prognosis is usually unfavorable, especially without a correct diagnosis, which is often very difficult.

Crohn's disease is relapsing. All patients experience an outbreak of the disease at least once every 20 years. To reduce intensity negative manifestations, you need to be constantly monitored by a doctor, undergo preventive treatment and adhere to a certain lifestyle:

• a special diet is prescribed. The patient is strictly forbidden to eat fatty meat, fish, whole milk, cheese, some vegetables (cabbage, cucumbers, radishes, turnips), hot and spicy sauces, and carbonated drinks. A person’s diet may include dry bread and other baked goods, lean meat and fish, doctor’s sausage, soft-boiled eggs, all cereals and pasta;
• regular use vitamin complexes throughout life, which were prescribed by the attending physician;
• avoidance of stress, normal work and rest hours, sufficient sleep;
• light daily physical activity;
• complete cessation of bad habits - smoking and drinking alcohol.

If you follow all the doctor’s recommendations, you can significantly increase your quality of life. Despite this, the mortality rate among patients with this disease is 2 times higher than that observed among other people. To a large extent, this disappointing prognosis is associated with complications of surgical treatment, which is necessary for such patients.

Crohn's disease is an inflammatory bowel disease (IBD) in which the lining of the digestive tract becomes inflamed, causing severe diarrhea and abdominal pain. Inflammation often penetrates deep into the layers damaged tissue. Like ulcerative colitis, a more common IBD, Crohn's disease can be painful and debilitating and sometimes lead to life-threatening complications. Crohn's disease is incurable, but existing methods treatments can significantly reduce its symptoms and even induce long-term remission. With this treatment, most people with this condition are able to lead a normal life.

Steps

Part 1

Recognizing symptoms and confirming diagnosis

Recognize the symptoms of Crohn's disease. The symptoms of this disease are similar to a number of other intestinal pathologies, such as ulcerative colitis and irritable bowel syndrome. Symptoms may come and go and range from mild to severe. U different people they will be different depending on which part of the intestine is affected. Here are some of the most common symptoms of Crohn's disease:

• Diarrhea. The inflammation that occurs in Crohn's disease causes cells in the affected areas of the intestines to release large amounts of water and salt. Because the colon cannot completely absorb this fluid, diarrhea begins.
• Abdominal pain and muscle spasms. Inflammation and ulceration can cause the intestinal walls to swell and, over time, thicken as scar tissue forms. This interferes with the normal movement of intestinal contents through the digestive tract and can cause pain and muscle spasms.
• Blood in the stool. Food moving through the digestive tract can cause inflamed walls to bleed, or the intestine may bleed on its own.
• Ulcers. Crohn's disease begins with small, scattered sores on the surface of the intestinal wall. Eventually, these wounds can become large ulcers that penetrate deep into, and sometimes through, the intestinal wall.
• Weight loss and loss of appetite. Abdominal pain, muscle cramps and inflammation of the intestinal wall can all affect your appetite and ability to digest food and absorb nutrients.
• Fistula or abscess. Inflammation caused by Crohn's disease can spread through the intestinal wall to adjacent organs such as the bladder or vagina, creating a connecting passage (fistula). Inflammation can also lead to the formation of an abscess, a swollen, pus-filled damaged area.

1. Recognize the less common symptoms of Crohn's disease. In addition to the above symptoms, people with this condition may experience other, less common side effects such as joint pain, constipation and swollen gums.

   Know when to see a doctor. Contact us immediately medical care if you notice any of the following symptoms:

   • lightheadedness or rapid and weak pulse;
   • severe stomach pain;
   • unexplained fever or chills lasting more than one or two days;
   • repeated vomiting;
   • blood in stool;
   • ongoing bouts of diarrhea that cannot be controlled with over-the-counter medications.

2. Get tested to confirm your diagnosis. If your doctor suspects you have Crohn's disease, he or she may refer you to a gastroenterologist (digestive system specialist) for various tests. These may include:

   • Blood analysis. Your doctor may suggest you have blood tests to check for anemia, which is a common side effect of Crohn's disease (due to blood loss).
   • Colonoscopy. This test will allow your doctor to look at your entire colon using a thin, flexible tube with a light and a camera on the tip. Using the camera, the doctor will be able to identify any inflammation, bleeding or ulcers on the walls of the colon.
   • Flexible sigmoidoscopy. In this procedure, the doctor, armed with a thin flexible tube, examines two lower segment your colon.
   • Barium enema. This diagnostic method allows you to examine the colon using x-rays. Before the examination, barium, a contrast dye, is injected into the intestine using an enema.
   • X-ray of the small intestine. This test allows you to examine the part of the small intestine that was not visible during a colonoscopy.
   • Computed tomography (CT). Sometimes you may need a CT scan, which is more advanced X-ray method, diagnosing in more detail than a standard x-ray. In this case, the specialist can examine the entire intestine and tissues outside it, which cannot be seen using other examinations.
   • Capsule endoscopy. If you have symptoms that suggest Crohn's disease and routine tests don't show anything, your doctor may perform a capsule endoscopy.

   Part 2

   Available Treatments

   1. Ask your doctor about medicinal methods treatment. To control the symptoms of Crohn's disease, many different medicines. The type of medication that is right for you will depend on the specifics of your case and the severity of your symptoms. Here are some of them that are used most often:

      • Anti-inflammatory drugs. These drugs are often the first step in treatment inflammatory disease intestines. These include sulfasalazine, which is useful primarily for colon disease, mesalazine (Salofalk, Pentasa), which helps prevent recurrence of Crohn's disease after surgery, and corticosteroids.
      • Immunosuppressants. These drugs also reduce inflammation, but they are designed to suppress the immune response rather than treat inflammation directly. These include azathioprine (Imuran), mercaptopurine (Puri-Netol), infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), methotrexate (Metoject), cyclosporine ( "Sandimmune Neoral", "Ekoral"), and natalizumab ("Tysabri").
      • Antibiotics. They can heal fistulas and abscesses in people with Crohn's disease. These include metronidazole and ciprofloxacin.
      • Antidiarrheal drugs. Patients with Crohn's disease who suffer from chronic diarrhea often respond well to antidiarrheal drugs such as loperamide. Loperamide (Imodium, Lopedium) is available without a prescription.
      • Substances that enhance the secretion of bile acid. Patients with chronic form diseases of the ileum (lower part of the small intestine) or after its resection may not absorb bile acid, which can lead to secretory diarrhea in the colon. These patients may benefit from a bile acid sequestrant drug such as cholestyramine or colestipol.
      • Other medicines. Medicines prescribed for specific symptoms of Crohn's disease also include steroids, immune system suppressants, fiber, laxatives, pain relievers, iron, vitamin B12, calcium, and vitamin D.

   2. Follow your doctor's recommendations regarding diet and nutrition. There is no hard evidence that the food you eat directly causes intestinal inflammation. However, certain foods and drinks can make the condition worse (especially during a flare-up), while others can significantly relieve symptoms and prevent future flare-ups.

      Make changes to your lifestyle. Although Crohn's disease has no cure, you can minimize symptoms and live a normal life life to the fullest following the recommendations of the attending physician and adhering to healthy image life.

      Learn about your surgical options. If diet, lifestyle changes, medications and other treatments do not relieve your symptoms, your doctor may recommend surgery to remove the damaged part of the intestine, close fistulas, or remove scar tissue. There are three main types of surgery for Crohn's disease:

      Try to alleviate symptoms with herbal medicine. Plants such as licorice, asparagus racemosus (shatavari), and others may be beneficial for Crohn's disease.

   • Seek information about your condition and join a support group if possible.
   • Don't miss doctor's appointments and donate blood regularly to detect problems in a timely manner. side effects medications taken.
   • If you have a close relative - a parent, child, brother or sister - with Crohn's disease, you are at risk.
   • Alcohol significantly affects the course of Crohn's disease. Therefore, it is recommended to reduce its use to a minimum or eliminate it completely to reduce symptoms.
   • If you smoke, your risk of Crohn's disease increases.
   • Take only those medications prescribed by your physician or gastroenterologist.
   • Crohn's disease can occur at any age, but young people are more susceptible to it.
   • If you live in a city or industrial area, your risk of Crohn's disease is higher.
   • Regular exercise and healthy eating will do you good.
   • Although Caucasians have the highest likelihood of getting the disease, the disease can affect any ethnic group.
   • Keep a food diary and write down everything you eat every day. This will help identify foods that increase symptoms and eliminate them from the diet (this will be different for each patient).