Crohn's disease code for mcb10 - causes and treatment. Nonspecific ulcerative colitis

Crohn's disease is a severe, disabling disease with a progressive course. In our country, it is still considered rare and remains the least studied disease of the gastrointestinal intestinal tract, especially for children.

What is Crohn's disease? Crohn's disease is a chronic immune-mediated inflammatory disease of the digestive tract. Nonspecific granulomatous inflammation can affect all parts of the gastrointestinal tract and involve other organs in the process. Wikipedia gives this definition. A characteristic lesion with ulceration can be in the oral cavity and rectum, but inflammation of the ileum (its terminal segment develops) more often prevails. ileitis) and colon.

Combined damage to the small and large intestines is called ileocolitis. In this case, the changes cover all layers of the intestinal wall, therefore, stenosing (narrowing of the intestine) and penetrating (penetration into an adjacent organ) complications are often formed.

For ten years of the disease, every second patient develops stricture or penetrating complications. The development of these complications is typical for men. Involvement of the ileum is more likely to develop strictures, and colon- penetrations. Treatment can stop the progression, but not the stricture or penetrating form.

The peak incidence occurs between 15 and 35 years of age. Taking into account the young age and early disability of patients, it is relevant to search for drugs that would most effectively eliminate the exacerbation and cause a long-term remission. The general ICD-10 code for Crohn's disease is K50 ( granulomatous enteritis), and the subheadings specify the localization - small intestine, large intestine, small and large intestine.

Pathogenesis

The disease is most likely the result of an altered mucosal immune response to an antigen that is innate. The intestinal immune system is normally regulated by the unchanged normal microflora, which is located on the surface of the mucosa and in the intestinal lumen. Violation of its composition entails the appearance of microbial antigens - autoantigens, which play the role of a trigger. Defects in the intestinal epithelium contribute to the development of the immune response.

Therefore, this disease is considered as an immunoinflammatory disease that has a chronic course, in which there is an excessive production of pro-inflammatory cytokines (interleukins, tumor necrosis factor and γ-interferon) and the influx of inflammatory cells into the mucosa. In this case, granulomatous inflammation occurs in the submucosal layer of the intestine and granulomas form (hence the name granulomatous colitis).

In the course of the disease, a large number of antibodies are produced that form circulating immune complexes with the antigen. Antibodies are considered the most specific for the disease. saccharomycetes(ASCA) - they are found in 83% of patients. Not only bacterial antigens of altered flora, but also food and industrial allergens can cause the synthesis of antibodies. Pathological changes in the intestines are not limited to the mucous membrane, but cover all layers of the intestinal wall, which causes serious consequences.

Classification

The most complete Montreal classification takes into account the age of patients, localization.

According to the age:

• up to 16 years;
• from 17 to 40;
• over 40 years old.

By localization:

• terminal ileitis;
• colon damage;
• colon damage and small intestine;
• lesions of the upper gastrointestinal tract;
• lesions of the upper gastrointestinal tract and terminal ileitis;
• lesions of the upper gastrointestinal tract, terminal ileitis and colitis.

According to clinical manifestations:

• inflammatory form (this is the form in which there is no stenosis and penetration);
• stenosing;
• penetrating;
• perianal (skin lesions in the anus, fistulas, ulcers, abscesses in this area).

By the nature of the flow:

• remission;
• easy flow;
• moderate;
• heavy.

Most often, Crohn's disease in adults has a typical localization - the process is limited to the terminal ileum and there is terminal ileitis of the intestine. An isolated lesion of the large intestine without involving the small intestine is called colitis and it occurs in 20-25% of cases. The rectum is involved in the process in 11-26%. In recent years, isolated terminal ileitis is less common, and most often in adults there is a combined inflammation of the small and large intestines - ileocolitis, which is detected in 40-55% of patients. The upper gastrointestinal tract is involved in the process in 5% of patients and includes any localization above the terminal ileum. Upper lesions very rarely occur in isolation, so there is a combined lesion of the stomach and colon, duodenum in addition to ileitis or colitis.

The stricture form is characterized by the appearance of a narrowing of the intestine, which is detected by X-ray and endoscopic methods of investigation. The penetrating form proceeds with the formation of intra-abdominal fistulas or abscesses. The perianal form may accompany any other forms. Crohn's disease.

To assess the activity and severity of the disease, an activity index (Best index) is used, which is calculated and expressed in points (from 0 to 700). If the score is less than 150, the disease is in remission. Light flow and minimal activity corresponds to 150-300 points, about moderate 300-450 points indicate, and the sum of 450 points indicates a severe course and high activity.

With low activity, weight loss is less than 10% per week, there is no fever, signs of dehydration and obstruction, C reactive protein(as a marker of inflammation) is normal. Moderate activity is accompanied by a weight loss of more than 10%, resistance to treatment is noted, C reactive protein is elevated, but there is no obstruction. With a high activity of BMI less than 18 kg / m2, there are signs of obstruction (or there is an abscess). Symptoms constantly recur despite intensive treatment.

The reasons

The causes of the disease remain unclear until the end, so there are several theories.

• The role of genetic factors. Genetic predisposition has been confirmed by many studies. There are 100 known genes that are associated with the development of this disease. It has been established that the CARD15 domain, which is located on the 16th chromosome, encodes the NOD2 protein and leads to an altered immune response, as well as changes in the permeability of the intestinal mucosa. It is often detected in patients and causes a severe course of the disease.
• Relationship with infection (infection theory). Errors in the diet are less important than infectious influences and, which play an important role in the development of the disease. Patients are characterized by a violation of the microbiocenosis of the large intestine - predominate mycobacteria, pseudomonas, yersinia, pathogenic Escherichia. Granulomas resembling foci are found in the intestinal tissue.
• An autoimmune nature of the disease is possible, but the exact cause of autoaggression is unknown.
• In the event of a disease, uncontrolled use is important medicines(contraceptives and antibiotics).
• The role of smoking. It should be noted that smokers develop this disease more often.
• Psycho-emotional stress is also considered as the cause of the manifestation and exacerbation of the disease.

Symptoms of Crohn's disease

Both in children and adults, different parts of the digestive tract can be affected, so the clinic depends on the localization of the process, as well as on the degree of inflammation activity. The disease has an undulating course, in which exacerbations and asymptomatic or asymptomatic remissions alternate. All symptoms of Crohn's disease in adults can be divided into intestinal and extraintestinal. As mentioned above, intestinal manifestations depend on the localization of the process and include pain, dyspeptic syndrome and malabsorption.

The pains are most often of a pressing nature, localized in any part of the abdomen, and their intensification after eating is characteristic. For many years, pain that appears paroxysmal may be the only manifestation of the disease. In this case, a mass formation can be determined in the abdomen. Acute attacks lead patients to the surgeon, they are operated on and thus the diagnosis is established. Patients have episodes of fever. An increase in temperature is not always accompanied by pain.

In addition to pain in adults, signs of intestinal inflammation are manifested by a change in stool. It is inflammation of the ileum that manifests itself, which is characteristic symptom with this localization. Loose stools are noted in almost 90% of patients, but most often the feces are soft and semi-formed. The frequency of stool is important in assessing the severity of the disease. When calculating the activity index, not only the frequency of stools during the week and the frequency of use of antidiarrheal drugs are taken into account, but also abdominal pain and its severity, general well-being, anal manifestations, fever, and the degree of weight loss.

Patients often have malabsorption, and it depends on the prevalence inflammatory process. The malabsorption is most pronounced if there is terminal ileitis or ileitis With colitis. Malabsorption syndrome is manifested by electrolyte disturbances and deficiency of: albumin, iron, ferritin, . Weight loss due to malabsorption is characteristic of this disease. Even in mild patients there is weight loss.

Often "unreasonable" in the opinion of the patient, weight loss is a symptom that makes him see a doctor. In combination with "incomprehensible" weight loss, anemia is often found in the patient, which is difficult to correct - this disease is typical. Thus, signs of terminal ileitis include abdominal pain, weight loss, and then chronic diarrhea.

For the defeat of the upper digestive tract, the presence of pain in the upper abdomen (in the epigastrium), nausea and vomiting is typical. But most often a disease with this localization of the process long time proceeds subclinically (without symptoms) and is detected during examination of the patient.

If we consider the symptoms of Crohn's disease of the colon, then this is the presence of blood in the feces and intestinal bleeding, although the latter also occur with a combined lesion of the final section of the small intestine and the colon. These symptoms may be associated with damage to the colonic mucosa, but most often with the presence of deep cracks that affect the submucosal layer of the intestinal wall. When the distal part of the large intestine is affected, patients experience tenesmus- false urges, in which bowel movement does not occur. When the end sections of the colon are affected, fistulas and abscesses are formed. The development of fistulas is a fairly common occurrence, and when a secondary infection is attached, abscesses or peritonitis. As one of the complications of fistulas and abscesses - secondary psoitis, including purulent (inflammation of the lumbar muscle). The patient develops pain in the iliac and inguinal region, increased pain when trying to straighten the leg. When the rectum is damaged, perianal complications are formed in the form of anal fissures, perianal abscesses, which are difficult to treat. At the same time, an admixture of pus appears in the feces.

In another group of patients, intestinal stenosis develops with partial obstruction. Stenosis is associated with inflammatory strictures. Therefore, along the course of the disease, forms are distinguished: penetrating (with the formation of fistulas) and stenosing (with the formation of stenosis). At a part of patients neither penetrations, nor the phenomena of a stenosis are noted. Clinical forms rarely change into one another - patients with fistulas do not develop intestinal strictures. This is due to the pathogenetic features of the disease. At the same time, there are cases of a combination of strictures and penetrations in one patient.

During an exacerbation of the disease, the most common acute arthropathy, sacroiliitis(inflammation of the sacroiliac joints), eye lesions ( episcleritis and uveitis), gangrenous. In 10% of cases, patients develop aphthae in the oral cavity.

Symptoms of Crohn's disease in children at the initial stage are nonspecific and do not make it possible to suspect this serious pathology. Subsequently, regardless of localization, the main symptoms are: chronic pain in the abdomen, fever, diarrhea with or without blood, weight loss, growth retardation and puberty in adolescence. All of these symptoms may be mild. Moreover, the well-being of the child may not correspond to the true picture of changes in the intestines.

If the ileum is affected, symptoms develop, maybe. With pathological changes in the rectum, the disease proceeds as acute paraproctitis. There may also be perianal manifestations in the form of itching, irritation of the anal area, cracks and fistulas. With the localization of the inflammatory process in the duodenum and stomach, the picture of the disease resembles chronic gastritis- Nausea, epigastric pain. Then weakness, fever, anemia and malnutrition join.

Any localization may be accompanied by extraintestinal symptoms: skin lesions, aphthous stomatitis, articular syndrome. Extraintestinal manifestations may also precede intestinal lesions. In children, extraintestinal manifestations occur less frequently than in adults.

Analyzes and diagnostics

• Clinical studies include blood and urine tests. In the clinical analysis of blood in patients, an increase in ESR (erythrocyte sedimentation rate) is noted, and leukocytosis.
• Biochemical blood tests. Biochemical analyzes reveal a violation of the composition of electrolytes, microelement deficiencies (iron, calcium, zinc, magnesium). There is a decrease in total protein (mainly albumin), a deficiency of essential amino acids, a decrease in the level of fat-soluble vitamins and B vitamins. All these indicators reflect malnutrition. Against the background of inflammation in the intestine occurs dysproteinemia, increase seromucoid, C-reactive protein (CRP), sialic acids. CRP in this disease can have a wide range of values, in connection with which multiple analyzes are made in dynamics, which helps to evaluate the effectiveness of treatment. Its decrease indicates the effectiveness of treatment, and constantly increased performance about its inefficiency. The predictive value of CRP is also known - with high rates, there is an increased frequency of relapse in the next 2 years. At the onset of the disease, renal and hepatic parameters are evaluated.
• Analysis of feces for leukocytes, worm eggs, occult blood and clostridium toxins. The coprogram reflects the digestibility of food. Specific markers of intestinal inflammation - lactoferrin and calprotectin in feces. Calprotectin is a calcium- and zinc-binding protein that is considered the most important fecal marker of intestinal inflammation. It is a sensitive laboratory marker of inflammation and is superior in informativeness to other markers of inflammation - C reactive protein and ESR. Its highest concentration is detected at high activity with a stool frequency of 8-10 times a day. Its concentration in feces is 6 times higher than in the blood.
• The main diagnostic method is endoscopic examination. Colonoscopy - examination of the intestinal mucosa - allows you to identify the level and extent of lesions, determine the degree of activity by the presence of aphthoid ulcers and cracks (slit ulcerative lesions), which extend to all layers of the intestinal wall, the "cobblestone" relief, fissural ulcers. Aphthoid ulcers are the earliest endoscopic sign of the disease. The appearance of ulcers is preceded by swelling and redness of the intestinal mucosa. Ulcers are found on the unchanged mucosa, in which the vascular pattern is preserved. They can be located separately or in groups and there is a tendency to merge. Confluent ulcers form into slit-like ulcers and may develop into deep fissure ulcers. Endoscopic examination is not always possible to carry out to the distal ileum, where the lesion is most often localized. It is also difficult to determine the localization, since the unevenness of the lesion is characteristic - the alternation of altered areas and unchanged ones. The length of lesions varies from 4 cm to 1 m.
• Since Crohn's disease affects any part of the digestive tract, patients need to esophagogastroduodenoscopy. Lesions of the stomach and duodenum are rare in this pathology, however, the diagnostic search for changes in the stomach in the early stages is important, since they have an unfavorable prognosis. Very often with lesions of the stomach occur, crayfish and (less commonly). EGDS in patients revealed aphthoid ulcers (single, multiple), located chaotically and tending to merge. As in the intestines, slit-like ulcerations and "cobblestones" appear in the later stages. Strictures are most often localized in the final part of the esophagus and in the stomach (its antrum).
• Histological examination of biopsy specimens is mandatory and is the final diagnosis. In the tissues, infiltration by lymphocytes and foci of proliferation of lymphoid tissue are detected, and fibrosis of all layers of the intestinal wall is also noted. Lymphocytes accumulate in the mucosa, forming lymphoid follicles and granulomas - a characteristic sign of the disease. Granulomas in the submucosal layer are a reliable histological criterion for the disease.
• Ultrasound is performed as an initial screening examination.
• CT scan. She evaluates the condition of the intestinal wall.
• Magnetic resonance imaging best method for inspection small intestine and definitions of fistulas, abscesses, and stenosis. This method is preferred computed tomography because the diagnostic accuracy is higher and there is no patient exposure.
• Immunological research. In patients, an increase in the level of antibodies is detected - more often these are immunoglobulins G1 and G2. In addition, an increase in the level of inflammatory cytokines - TNF-a, interleukins -1, -6, -8, -12 is detected. TNF-α is the most active inflammatory cytokine and its increase is considered to be key to the development of the disease.
• A test is being carried out for Crohn's disease- determination of immunological markers of antibodies to saccharomycetes (ASCA). They are the main marker of this disease and are detected with a frequency of 60% -80%. Antibodies are represented by IgG or IgA classes. High ASCA titers are associated with the risk of such complications as strictures and fistulas. Thus, a positive analysis is associated with a high risk of surgery.
• The second important test is a genetic examination (NOD2 gene). There are three gene variants associated with an increased risk of the disease. Detection of mutations in the NOD2 and DLG5 genes does not confirm the diagnosis, but indicates the risk of developing the disease.

Crohn's disease treatment

How to treat Crohn's disease? To date, this disease cannot be cured by any methods. The use of medical or surgical treatment makes it possible to achieve remission, maintain it for a long time, prevent exacerbations and provide patients with an acceptable quality of life. Treatment of ileitis is aimed at reducing inflammation and antigenic response, normalizing the intestinal microflora, improving microcirculation, correcting deficient conditions (protein and vitamin deficiency).

In the treatment are used:

• Diet therapy.
• Medical treatment.
• Surgery.

Drugs remain the mainstay of treatment today for mild forms. 5-amino salicylic acid . With a mild form, 2-4 g per day is prescribed. However, their value as monotherapy is limited, since drugs only in high doses cause remission with minimal or moderate disease activity. Since aminosalicylates are considered as ineffective agents, some authors advise the use of topical steroids () at a dose of 9 mg per day even in mild forms.

With moderate severity, aminosalicylates can be used, but in an increased dose - up to 6 g per day. In parallel, topical corticosteroids are necessarily prescribed, or their dose is increased if they were used at the first stage. is the drug of choice for this disease, since it is absorbed from the gastrointestinal tract in a minimal amount and has practically no systemic effect compared to hydrocortisone or prednisolone and it has no side effects. The microgranular form of the drug in high concentrations is released in the ileum and colon, so it is effective in terminal Ileite and ileocolitis moderate course.

When treating a severe form, the dose of budesonide is doubled and the patient should take 18 mg per day. Systemic corticosteroids are prescribed at a dose of 1 mg per kg of body weight, and the dose of immunosuppressants is also increased. Action azathioprine and methotrexate occurs slowly, improvement occurs noticeably and only after 3-4 weeks. To get the maximum effect, you need time - at least 4-6 months, so this group of drugs is not used in acute conditions. They are necessary in the treatment of chronic sluggish forms. Such patients are shown the appointment of biological drugs - antibodies to tumor necrosis factor (TNF). infliximab, adalimumab). The use of infliximab is indicated for patients with penetrating form. It is prescribed intravenously, once a week: from the beginning of treatment, in the second and sixth weeks. Then, to maintain remission, they are administered every 2 months. Immunobiological therapy neutralizes the tumor necrosis factor and changes the reactivity of the patient's immune system. These drugs are well studied and give good results in adults.

When treating patients with a disease of any severity, it is important to activate the "useful" microflora by prescribing. The method of transplantation of fecal microbiota is also used, which is effective in Crohn's disease in 60% of cases. This can be done by introducing faeces healthy donor into the patient's intestines using an enema, a colonoscope, or through the upper gastrointestinal tract with a nasogastric tube. The latter route of administration is often manifested by nausea, vomiting and diarrhea. Rectal method administration is preferred. During colonoscopy, the fecal substrate is brought to the terminal part of the caecum and dosed distributed along the walls of the colon. After the introduction of the material, the patient must keep it for 4 hours. Transplantation of fecal microbiota contributes to its restoration in the patient, and patients achieve remission after one or two procedures.

In addition to the basic treatment, symptomatic therapy is prescribed to correct deficient conditions (fat-soluble vitamins, iron, folic acid and vitamin B12), extraintestinal manifestations, malabsorption. Enzymes, enterosorbents, antidiarrheal drugs are prescribed.

Anti-relapse treatment after achieving remission may be different. For many, and in small doses are ineffective, at a dose of 6 mg it also does not maintain remission during the year. and 6-mercaptopurine effective for maintenance therapy, but they cannot be used continuously due to a large number adverse reactions. Some authors recommend for mild to moderate severity, basic treatment until remission is achieved and to resume it only when an exacerbation occurs.

Crohn's disease treatment folk remedies can only be used as an addition to basic treatment. With diarrhea, a decoction of oak bark, pomegranate peels, alder seedlings can be used. Inflammation in the intestines and swelling help to eliminate decoctions of chamomile, sage, yarrow mint leaves and calendula. Onion peel is also used as an anti-inflammatory agent. Of course, these herbs do not have a specific effect on the process, which is confirmed by reviews of the treatment of folk remedies, but they bring relief to the patient.

The Crohn's Disease Forum reaffirms the need drug treatment as soon as the diagnosis is established. Some point out that for some time they were treated with non-traditional methods, and in the end, precious time was lost. Many write that it is a permanent drug, as well as a diet. The forum discusses the cause of exacerbations and their frequency. Predicting the frequency of flare-ups is difficult, but quitting smoking, dieting, being stress-free, and having a positive emotional attitude are all important. In most cases, it is possible to stop the process with drugs, since in half of the patients the disease is mild, so intermittent treatment is carried out. Patients with moderate or severe course take the treatment constantly. Many talk about the fact that they had to agree to the operation. Unfortunately, the operation does not solve the problem radically, because it does not eliminate the disease. However, almost everyone believes and instills this confidence in others - life with Crohn's disease is possible, even when you have to constantly take medications.

The doctors

Medications

• Salicylic acid derivatives:, Asakol, .
• Steroid drugs.
• Cytostatics:, Mercaptopurine native, .
• Biological preparations:,.

Procedures and operations

Surgical interventions are a reserve for the treatment of forms that are complicated and resistant to drug therapy. The operation may be required when:

• massive bleeding;
• severe stenosis, complicated intestinal obstruction;
• toxic dilatation of the intestine;
• the formation of fistulas (external or internal);
• purulent complications.

In 40-55% of patients there is a need surgical intervention. It should be noted that surgical treatment does not eliminate the disease and 55% of patients experience relapses after surgery.

Crohn's disease in children

For a long time it was believed that this disease only occurs in adults, but a large number of studies indicate that Crohn's disease begins as early as childhood. But since children have nonspecific manifestations, detectability this disease very low in children. Most often, children aged 7 years and older are sick, and the peak incidence coincides with adolescence. In boys, the disease is more common.

In children, this pathology is more difficult to diagnose, and difficulties are associated with the limited use of invasive methods in them ( colonoscopy, gastroscopy, ). The younger the child, the more difficult it is to perform the necessary research. The period before the diagnosis usually takes several years, since in children the disease at first manifests itself with uncharacteristic symptoms (periodic fever, anemia, pale skin, stunting, poor weight gain), which are not associated with the intestines.

If pains appear, they are not pronounced and unstable, without vomiting and diarrhea, do not disturb children and do not give parents reason to consult a doctor. In children, the disease develops slowly, starting with non-specific symptoms - growth retardation and sexual development may be an early sign. Then appear intestinal symptoms that resemble symptoms proctitis or . Children often have a combined lesion of the small and large intestine - ileocolitis. Compared to adults, they are more likely to experience pain, fever, and weight loss.

In different age groups, certain symptoms may predominate. Before the age of 1 year, the most common symptoms are: blood in the stool, the development of diarrhea, indigestion, weight loss and growth retardation. At the age of 1-3 years leading initial symptoms are: violation of weight and height indicators. Then there are pains in the abdomen and diarrhea, the admixture of blood in the feces is not observed in milestones of sick children.

In the group of children from 3 to 7 years, abdominal pain and diarrhea predominate, almost all of them have an admixture of blood. In children of this age, extraintestinal manifestations and damage to the area around the anus are most common. At 7-10 years of age, growth retardation, weight loss and abdominal pain come to the fore. At the age of 10-15 years, the same symptoms plus asthenic syndrome, which is most often noted. Diarrhea and the appearance of blood in the stool is observed in half of the patients. A feature of this group of children is the rare development of delay. At 15-17 years of age, abdominal pain and weight loss are most characteristic. At this age, extraintestinal manifestations and perianal lesions rarely develop. Growth retardation is not typical.

In the treatment, the same drugs and approaches are used as in adults:

• Children are shown special nutrition - therapeutic mixtures ( modular). This is a complete blend based on casein protein. The fat composition of Modulen is represented by easily digestible fats (corn oil, medium chain triglycerides, milk fat), and the content Omega 3 and Omega 6 gives an anti-inflammatory effect. It is an immunomodulatory product, as it is enriched with growth factor, which is involved in immune regulation and reduces inflammation in the intestines. The mixture can be used as a supplement to a child's diet or as a sole source of nutrition. Total enteral nutrition promotes remission, it is especially indicated in moderate to severe cases, but should also be used in children with mild forms. Modulen powder is convenient to use, since the mixture is quickly prepared by simply dissolving it in boiled water.
• 5-ASA preparations for mild disease.
• Glucocorticosteroid drugs are prescribed for 5-ASA failure, as well as for patients with lesions of the upper digestive tract to the jejunum and extraintestinal symptoms. These drugs are prescribed to achieve remission and are not recommended for maintenance treatment.
• Cytostatics are used in patients in whom hormone treatment does not show a sufficient effect. They are also prescribed with a decrease in the dose of hormones. used to maintain remission in children at risk of adverse outcome. With the ineffectiveness of Azatiprine, they switch to reception.
• The experience of using monoclonal antibody preparations of tumor necrosis factor blockers in children is small when compared with adults. Of the immunobiological drugs, adalimumab (drug ) and infliximab (drug ) are registered. Adalimumab are human monoclonal antibodies that selectively bind to tumor necrosis factor and neutralize its effects. These drugs are used to achieve and maintain remission in chronic active inflammatory, steroid-refractory, perianal fistulizing and severe progressive fulminant colitis. In developed countries, there is a trend towards early biologic therapy. It should be noted that it is successful in 2/3 of patients.
• Antibacterial therapy, including or, is prescribed to patients with perianal fistulas.
• Probiotics.

Diet for Crohn's disease

For patients with this disease, a violation of the nutritional status is characteristic, which is manifested by a lack of weight, metabolic disorders due to a deficiency of protein, macro- and microelements. Therefore, nutrition plays a big role in metabolism, the course of the disease and the processes of growth and development, if it concerns a child. Improper nutrition exacerbates the deficiency of trace elements, and the use of products that irritate the intestinal mucosa or cause sensitization (allergization) lead to an exacerbation of the process. Therefore, diet therapy is one of the components of complex treatment for intestinal diseases.

The generally recognized diet that is used for exacerbation of this disease is. Food is boiled, steamed and given in a pureed form - that is, mechanical sparing is important. Eating small and frequent. The protein content increases by 20%, with a reduced content of carbohydrates and fats. Protein in the diet is represented by fish, eggs, meat. Considering that damage to the small intestine causes a violation of the digestion and absorption of fats, the use of fatty foods (mayonnaise, cream, butter, ice cream, fried foods) causes increased diarrhea and the appearance of steatorrhea, fatty stools. Carbohydrates also cause diarrhea and bloating.

With an exacerbation and severe course of the disease, foods with coarse fiber are excluded - mainly vegetables and some fruits: cabbage, legumes, radishes, radishes, cucumbers, swedes, tomatoes, beets, mushrooms in any form, turnips, plums. Many patients notice that when restricting foods with coarse dietary fiber, pain decreases. It is unacceptable to use spicy seasonings: horseradish, mustard, onion, pepper, vinegar, mayonnaise, ketchup, garlic. Pickled vegetables, smoked meats, carbonated drinks, canned food, duck and goose meat, cabbage soup, okroshka, dairy products are excluded.

Obvious allergens are prohibited: citrus fruits, strawberries, raspberries, red apples, tomatoes, chocolate, coffee. With active terminal ileitis, products containing oxalic acid are excluded: sorrel, parsley, rhubarb, spinach.

This is due to the fact that patients have impaired fat absorption, unabsorbed fats bind calcium in the intestinal lumen, and excess oxalic acid is absorbed into the blood, which ultimately leads to the formation of oxalate kidney stones. A diet with severe exacerbation should spare the intestines as much as possible, therefore elemental mixtures and even parenteral nutrition are prescribed. AT pediatric practice a mixture of Modulin is used.

After the exacerbation is eliminated, the diet expands and the patients are transferred to. When compiling a menu for a week, you need to take into account the allowed foods and dishes: soups on a not strong broth and decoctions of vegetables, dishes from lean beef and chicken ( steam cutlets, meatballs, soufflé), dishes from boiled lean fish, boiled cereals, compotes, jelly from berries with tannins (blueberries, pomegranates, pears, quince), pomegranate juice and chokeberry.

In the future, after stopping diarrhea, the task is to exclude from the diet foods that increase digestive disorders and diarrhea. To do this, the patient must keep a food diary in which to note the nature of the stool and the body's reaction to a particular product. The expansion of the diet is carried out gradually - every day or every other day one new product is introduced - boiled zucchini, carrots, bananas, pear pulp without peel. If a product causes loose stools, it is excluded. Excessive sugar consumption is one of the reasons that contributes to the exacerbation of Crohn's disease, so simple carbohydrates are limited. However, during the period of remission, jam, marmalade, marshmallows, meringue cookies can be introduced into the diet, but in limited quantities.

Correction of iron deficiency is provided meat products. Taking drugs orally is undesirable, given their irritating effect on the mucosa of the gastrointestinal tract. If there is a need for iron preparations, then they are prescribed intravenously or intramuscularly. The patient should take folic acid preparations for the entire period of admission, as well as courses of vitamins A, E, D, calcium with vitamin D, zinc.

Prevention

In view of the fact that the cause of the disease is not completely clear, specific prevention has not been developed. It is important for the patient to achieve long-term remissions and have as few exacerbations as possible. In this regard, each patient should:

• Regularly undergo examination and follow the recommendations of the doctor.
• Change your lifestyle and eliminate bad habits. Limiting smoking allows you to quickly achieve remission.
• Change your diet and stick to your diet. Milk, fatty foods, coarse fiber vegetables cause diarrhea, so they should be excluded from the diet. The same applies to drinks containing caffeine- they also stimulate peristalsis and increase diarrhea. Carbonated drinks that increase gas formation are excluded. Fruits, vegetables, whole grains, can be consumed boiled or stewed. In addition, there may be foods that cause an increase in symptoms in a particular patient, and these are also excluded.
• Drink plenty of fluids.
• Additionally, take vitamin and mineral complexes.
• Deal with stresses that exacerbate or significantly increase the symptoms of the disease. To reduce stress will help playing sports, the use of techniques aimed at relaxation or communication with a psychologist.
• To increase the level of knowledge about the disease, which will help to correctly follow the doctor's recommendations for treatment and dietary nutrition.

Consequences and complications

Among the complications and consequences can be identified:

• Stenosis with the development of complete and partial.
• Penetrations.
• Perianal lesions in the form of abscesses, fissures and fistulas. Difficult to heal and constantly recurring lesions of the sphincter eventually lead to a violation of its function and fecal incontinence.
• Abscesses abdominal cavity.
• Psoitis- inflammation of the lumbar muscle.
• Perforation with development peritonitis.
• Internal and external fistulas. These are artificially arising passages - external (between the intestine and the surface of the body) and internal (between the intestine and adjacent organs of the abdominal cavity).
• Crack anus. The patient has pain during defecation.
• Weight loss due to dietary restrictions and malabsorption of food.
• An increased risk of developing colon cancer. The development of this oncological disease is possible 8-10 years after an inflammatory lesion of the large intestine over a large area. There is also a risk of developing cancer of the small intestine and anus.
• Rare complications include bleeding and toxic bowel dilatation.

Forecast

Since there is currently no effective treatment of this disease, as well as after surgery, relapses develop, Crohn's disease in adults often leads to disability and creates restrictions in the life of patients.

It is known that the earlier the disease debuts, the more aggressive the course. Early onset in adults is the development of the disease before the age of 40. If this disease is detected in children, then they initially belong to a high-risk group for a severe course. The prognosis is affected by the severity of the disease, which is determined by the presence of complications. Involvement of the upper gastrointestinal tract proceeds with the development of a stricturing and penetrating form. This causes the need for frequent hospitalization and surgical interventions. An unfavorable prognostic sign is the combination of any localization of the disease with perianal fistulas, which leads to the patient's disability. In addition to the above, unfavorable prognostic signs include a widespread lesion of the small intestine, two or more resections of it, deep and extended ulcers of the large intestine, as well as stereo- and dodependence.

The prognosis of life in Crohn's disease is relatively favorable. The life expectancy of these patients does not differ significantly from the duration of other individuals, provided that recommendations for the treatment and prevention of relapses are followed, however, the quality of life of patients is significantly reduced. Of course, the prognosis of life is aggravated with the development of complications:, bowel perforation, exhaustion and crayfish. Also, the prognosis is unfavorable in the fulminant form.

List of sources

• Adler G. Crohn's disease and ulcerative colitis. - M.: Geotar Med., 2001. - 527 p.
• Khalif I.L., Loranskaya I.D. Inflammatory bowel disease (ulcerative colitis and Crohn's disease): clinic, diagnosis and treatment. - M.: Miklosh, 2004. - 88 p.
• Ardatskaya M.D., Arutyunyan E.E., Minushkin O.N. Evaluation of the effectiveness of 5-ASA preparations and the tactics of choosing the treatment of nonspecific ulcerative colitis according to the content of volatile fatty acids in feces and blood serum // Russian Journal of Gastroenterology, Hepatology, Coloproctology - 2001. - No. 6. - P. 65-70.
• Belousova E.A. Ulcerative colitis and Crohn's disease. - Tver: LLC Triada Publishing House, 2002. - 128 p.
• Aruin L.I., Kapuller L.L., Isakov V.A. Morphological diagnostics diseases of the stomach and intestines. - M.: Triada-X, 1998. - 496 p.

Excludes: with Crohn's disease of colon (K50.8)

Crohn's disease [regional enteritis]:

• colon
• colon
• rectum

Excludes: with Crohn's disease of small intestine (K50.8)

Crohn's disease of the small and large intestine

Crohn's disease NOS

Regional enteritis NOS

In Russia, the International Classification of Diseases of the 10th revision (ICD-10) is adopted as a single regulatory document for accounting for morbidity, reasons for the population to contact medical institutions of all departments, and causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. №170

The publication of a new revision (ICD-11) is planned by WHO in 2017 2018.

With amendments and additions by WHO.

Processing and translation of changes © mkb-10.com

Crohn's disease code for mcb10 - causes and treatment

Crohn's disease, microbial code 10, is chronic and difficult to diagnose. As for the treatment of this disease, it should be selected at a professional level.

Causes of the disease

Crohn's disease is diagnosed in various age groups, although people aged 20 to 40 years are most susceptible to this disease. In the event that the disease affects the child's body, it proceeds in a more severe stage, but as for recovery, but with the right treatment, the chance of recovery is very high.

Disease affecting the intestines

Basically, Crohn's disease is diagnosed if a person has a violation of the immune system, leads an unhealthy lifestyle, or a person does not eat properly. In addition, many experts agree that the pathogenic flora can be the cause of the disease. It is because of various bacteria and viruses that inflammatory processes occur in the human body, which mainly manifest themselves in the large or small intestine.

Also, a genetic predisposition may be the cause of the development of this disease.

Symptoms of Crohn's disease

During the period of the disease, a person has a partial lesion of the gastrointestinal tract. In most cases, patients are diagnosed with lesions of the small intestine or combined. In this case, patients show the following symptoms:

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• erosion is diagnosed, which can be of various forms;
• ulcers appear, which can be of different depths;
• there is a narrowing of the intestine, as well as its segmentation;
• a channel is formed between organs and tissues;
• there is lymphatic edema;
• there are pains in the abdomen, which can manifest themselves different intensity, from almost imperceptible aching, to sharp and cutting;
• diarrhea appears, which can be expressed to varying degrees depending on the degree of damage;
• in the process of loose stools, blood impurities can be observed, which can also appear in varying amounts depending on the degree of damage;
• the patient also has general weakness and fatigue;
• with a severe degree of the disease, weight loss occurs, which can be quite significant;
• body temperature rises;
• in some cases, inflammation of the vascular or mucous membrane of the eye is diagnosed;
• various kinds of redness may occur on the skin;
• observed muscle pain, as well as pain in the joints;
• blood vessels may become inflamed;
• there is a violation of blood clotting, resulting in the formation of blood clots.

Depending on the degree of activity of the inflammatory process in medical practice, the symptoms that indicate this differ. The degree of activity is mild, moderate or severe.

In the event that the disease is in a mild stage, then the patient has diarrhea, which in frequency does not exceed four times a day, the pulse is within normal limits, but the body temperature rises to 37.5 degrees. Also, the patient may have blood impurities in the process of going to the toilet.

Type of bowel in Crohn's disease

The average degree is mainly distinguished by symptoms such as bloody stools, diarrhea more than six times a day, and increased heart rate. In this case, the disease can be dangerous because various complications can occur.

As for the severe degree of the disease, in this case, the frequency of diarrhea increases in the patient, which can exceed more than ten times a day, blood impurities in the feces increase, body temperature rises to 38 degrees, and the pulse quickens.

Diagnosis of Crohn's disease

When in medical institution a patient comes in with symptoms of Crohn's disease, the first thing the doctor should do is discuss with the patient all his complaints. Particular attention is paid to the characteristics and quantity of the stool.

After the conversation, the doctor proceeds to examine the patient in the process, which can be seen an increase in the abdomen. Also, the doctor pays close attention to the skin, in the event that symptoms of eye diseases are observed, it is recommended to consult an ophthalmologist, if signs of the disease are detected on human skin, then this problem is solved by a dermatologist.

Probing the abdomen is also given Special attention, as this can reveal areas of increased sensitivity and soreness. Then the appropriate tests are already prescribed, which include general, immunological and biochemical analysis blood.

Palpation of the abdomen will help identify areas of pain

In order to diagnose Crohn's disease microbial 10, a doctor prescribes an X-ray and endoscopic examination together with a biopsy. In the process of research, the inflammatory process is diagnosed and it turns out how many areas are affected.

Among other things, the presence of leukocytes in the feces is also an indicator of the inflammatory process.

Despite all this, the main study in the detection of Crohn's disease is considered an X-ray examination. As for endoscopic studies, they can also confirm or refute the presence of the disease. A biopsy is necessary in order to be able to distinguish Crohn's disease from ulcerative colitis, as well as to identify acute colitis, dysplasia, or malignancy in time.

Crohn's disease treatment

In order to get rid of such an insidious disease as Crohn's disease, it is necessary, first of all, when the first symptoms appear, to seek a qualified medical care, and after confirming the diagnosis, clearly follow all the recommendations of the doctor.

In addition, it is necessary to clearly monitor your lifestyle, and, if possible, eliminate stress, since it is they who can cause the development of the disease and the occurrence of relapses. It is also necessary to completely abandon bad habits such as smoking and drinking alcohol.

The choice of treatment method, as well as the appointment of drugs, depends entirely on the severity of the disease, the presence of complications and the nature of the lesion. All drugs are selected in each case according to an individual scheme. During treatment, the patient must be under strict control medical workers who will monitor the dynamics.

Medications are prescribed individually, in addition, it is necessary to adjust the diet

In the event that a patient is diagnosed with a narrowing of the intestine or purulent complications, then in this case the only way out is to perform an operation. Surgical treatment is also chosen if the medical method was ineffective.

In the event that the diagnosis of the disease is carried out on time and the patient has easy stage diseases, then in this case derivatives of aminosalicylic acid are prescribed, in some cases they are supplemented with metronidazole.

If the pills prescribed by the doctor do not help, then they will be replaced with others.

With moderate severity of the disease, prednisone is prescribed, as well as when an abscess is detected, antibiotic therapy with open or percutaneous drainage is also prescribed. When all of the above methods are ineffective in the treatment of Crohn's disease, the patient is recommended to use more serious drugs. This occurs if the symptoms worsen, fever appears, as well as frequent vomiting. In this case, the patient may even develop intestinal obstruction. If there is a risk of complications or death, then an emergency operation is performed.

In the process of treating the disease, the patient must necessarily follow a strict diet, which will help eliminate the possibility of thermal, chemical or mechanical irritation of the gastrointestinal tract. All food taken should be heated to a temperature of at least 18 degrees. It is necessary to take food in small portions about 6 times during the day. If there is an exacerbation of the disease, it is recommended to completely refuse food for two days.

Complications of Crohn's disease

In the event that Crohn's disease is not diagnosed in time and complex treatment, then this disease can lead to the development of the following complications:

• fistulas may form, which in most cases are accompanied by purulent processes. In this case, surgical treatment is used to get rid of the disease;
• abscesses occur in soft tissues, mainly these are purulent inflammations around the intestinal structures, which are removed only by the surgical method;
• massive bleeding, which can lead to severe cases, as well as death or shock;
• the occurrence of peritonitis is also a rather serious complication that can lead to severe intoxication of the body. With the development of peritonitis, also in advanced cases, this can be fatal. This turn of events is characterized heat, acute abdominal pain.
• vasculitis is also one of the complications of Crohn's disease, during which inflammation of small vessels occurs.

In order to completely get rid of Crohn's disease, you must strictly follow all the doctor's recommendations. Basically, when you follow all the rules and take medicines, you feel better after a few weeks.

After the patient gets rid of this disease, it is necessary to systematically conduct an examination, since a relapse can occur after a fairly long period of time. As for deaths, they occur if the patient develops complications.

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Nonspecific ulcerative colitis. Crohn's disease in children

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)

Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan

general information

Short description

Approved by the Expert Commission

Protocol name: Nonspecific ulcerative colitis. Crohn's disease in children.

Abbreviations used in the protocol

Protocol development date: 2014

Users of the protocol are pediatricians of hospitals and polyclinics, pediatric gastroenterologists, general practitioners, paramedics of emergency medical services.

Classification

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations carried out at the outpatient level:

Additional diagnostic examinations performed at the outpatient level:

The minimum list of examinations that must be carried out when referring to planned hospitalization:

The main (mandatory) diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out):

Additional diagnostic examinations performed at the inpatient level (in case of emergency hospitalization, diagnostic examinations are performed that were not performed at the outpatient level):

Diagnostic criteria for CD and UC:

Indications for expert advice:

Crohn's disease

K50. Crohn's disease (regional enteritis).

Etiology and pathogenesis

Pathomorphology

Microscopically, Crohn's disease is characterized by spread of inflammatory infiltrate to all layers of the intestinal wall(transmural nature of inflammation). At the same time, in most cases, the architectonics of the crypts and the usual number of goblet cells are preserved. However, in the mucous membrane of the edge of the ulcers, the structure of the crypts is disturbed, and the goblet cells almost completely disappear, which makes these changes similar to those in NUC (Table 66-2).

in the mucosa and submucosa

membrane and superficial parts of the submucosa

chronic course diseases

Another characteristic sign of inflammation in Crohn's disease is uneven density of the infiltrate of the lamina propria of the intestinal mucosa. Lymphocytes predominate in the infiltrate, plasma cells are found in a smaller amount; eosinophils and segmented leukocytes are single. Crohn's disease is characterized by the presence of granulomas, but they are rarely found on microscopic examination. They resemble the granulomas of sarcoidosis, which is why they are called sarcoid. Typical granulomas are isolated and do not form large conglomerates. They consist of epithelioid and giant cells of the Pirogov-Langhans type, surrounded by a belt of lymphocytes, do not have clear boundaries, and a fibrous rim, characteristic of sarcoidosis, does not form around them. Unlike tuberculous granulomas, they do not have a zone of cheesy necrosis.

Crohn's disease

Crohn's disease is a chronic transmural inflammatory disease of the gastrointestinal tract that usually affects the distal ileum and colon, but can occur at any level of the gastrointestinal tract. Symptoms of the disease include diarrhea and abdominal pain. Abscesses, internal and external fistulas, intestinal obstruction may develop.

Crohn's disease - intestinal pathology

Since this disease can be localized in any part of the gastrointestinal tract, there is a certain classification to differentiate the forms of the disease. So, with ileocolitis, the ileum and large intestine are mainly affected. In the gastroduodenal form - the stomach and duodenum 12. Ileitis occurs in the ileum. With jejunoileitis, the small intestine and ileum are damaged. In Crohn's disease of the colon, other parts of the gastrointestinal tract are not affected.

Extraintestinal symptoms, especially arthritis, may appear. Diagnosis of Crohn's disease is established by colonoscopy and radiopaque studies with barium. Treatment consists of 5-ASA, glucocorticoids, immunomodulators, anticytokines, antibiotics, and often surgery is required.

ICD-10 code

ICD defines Crohn's disease as an inflammation of the gastrointestinal tract of unknown origin, which is characterized by damage to individual segments, a recurrent course, the appearance of ulcerative formations, which in some cases may be accompanied by complications. The disease can affect the small and large intestine together or separately. The frequency of the disease is approximately twenty-five cases per hundred thousand of the population. In this case, the most common form of the disease is a mixed form, when both the large and small intestines are affected at once. Risk factors for the development of the disease include genetic predisposition, chronic intestinal pathologies. In macroscopic examination, ulcerations and granulomatous growths are distinguished, in microscopic examination - swelling in the damaged area and hyperplasia of the submucosal lymph follicles. Stages of development of the disease:

• acute stage. It is characterized by acute diarrhea, emaciation, pain in the right side of the abdomen.
• Subacute stage. It is characterized by an increase in the number of ulcerative formations, the appearance of granulomas, and the development of intestinal stenosis. The pain syndrome in this case has a cramping character.
• chronic stage. It is characterized by the further development of the disease and the occurrence of complications.

ICD-10 code

Causes of Crohn's disease

The causes of Crohn's disease are currently not fully understood. There are suggestions that this disease can be inherited, and can also be triggered by infectious pathologies and immunological factors.

How does Crohn's disease develop?

Crohn's disease begins with inflammation of the crypts and abscesses that progress to small focal aphthoid ulcers. These mucosal lesions may develop into deep longitudinal and transverse ulcers with preceding mucosal edema, forming characteristic cobblestone bowel changes.

The spread of transmural inflammation leads to lymphedema and thickening of the intestinal wall and mesentery. The adipose tissue of the mesentery usually extends to the serosal surface of the intestine. The lymph nodes of the mesentery are often enlarged. Extensive inflammation can lead to hypertrophy of the muscle layer, fibrosis, and the formation of narrowing, which can cause intestinal obstruction. Characterized by abscess formation and fistula formation with adjacent structures, including other bowel loops, bladder or t. psoas; they may even open onto the anterior or lateral walls of the abdomen. Regardless of the intra-abdominal activity of the process, the formation of perianal fistulas and abscesses occurs in 1/4-1/3 cases; these complications are often the most unfavorable aspects.

Noncaseating granulomas can develop in the lymph nodes, on the peritoneum, in the liver and affect all layers of the intestinal wall. The pathognomonic sign is the detection of granulomas, however, Crohn's disease in 50% of patients is not characterized by the presence of granulomas. Their presence, most likely, is not associated with the clinical course.

The affected segment of the intestine is clearly delimited from the normal intestine ("zone of silence"); hence the name - regional enteritis. Crohn's disease in about 35% of cases affects only the ileum (ileitis); in 45% - the ileum and large intestine (ileocolitis) are involved in the process with a primary lesion of the right flank of the large intestine; in about 20% of cases, only the large intestine is affected (granulomatous colitis) and in most cases, unlike ulcerative colitis (UC), the rectum is not always affected. Sometimes the entire small intestine is involved (jejunoileitis). Very rarely affects the stomach, duodenum or esophagus. In the absence of surgical intervention, the disease usually does not spread to areas of the small intestine that were not involved in the process at the initial diagnosis.

There is an increased risk of developing cancer in the affected areas of the small intestine. Patients with colon involvement have a long-term risk of developing colorectal cancer, similar to ulcerative colitis, depending on the extent and duration of the disease.

Symptoms of Crohn's disease

Crohn's disease is characterized by the initial symptoms of chronic diarrhea with abdominal pain, fever, anorexia, and weight loss. The abdomen is painful and palpation can determine the mass formation or tension. Significant rectal bleeding is uncommon, with the exception of an isolated lesion of the colon, which can also be observed in ulcerative colitis. Some patients develop acute abdomen, which simulates acute appendicitis or intestinal obstruction. Approximately 1/3 of patients have perianal lesions (especially fissures), which are sometimes the main manifestations or even the cause of complaints. In children, extraintestinal manifestations often predominate over gastrointestinal symptoms; arthritis, unexplained fever, anemia, or growth retardation may be the main manifestations of the disease, and abdominal pain or diarrhea may be absent.

If Crohn's disease recurs, then its symptoms change. Pain is the main symptom and occurs with a normal relapse. In patients with severe exacerbation or abscess formation, pain on palpation, protective tension, peritoneal symptoms and signs of general intoxication are noted. Sites of intestinal stenosis can cause intestinal obstruction with characteristic colicky pain, bloating, stool retention, and vomiting. The adhesive process after previous surgical interventions can also cause intestinal obstruction, which begins acutely, without fever, pain and malaise, characteristic of obstruction during exacerbation. The formation of a vesico-intestinal fistula can cause air bubbles to appear in the urine (pneumuria). Free perforation into the abdominal cavity is uncommon.

Chronic Crohn's disease causes a variety of general symptoms, including fever, weight loss, weight loss, and extraintestinal manifestations.

Crohn's disease according to the Vienna classification is divided into three main forms: (1) primarily inflammatory, which after several years of the course of the disease usually becomes either (2) stenotic or obstructive, or (3) primary penetrating or fistulous. These various clinical forms define different approaches to treatment. Some genetic studies suggest a molecular basis for this classification.

Crohn's disease and pregnancy

Crohn's disease and pregnancy are treated differently by different specialists. Some of them argue that Crohn's disease does not have a significant impact on the course of pregnancy, the birth process and the fetus, except in cases of exacerbation of the disease during this period. But still, most experts believe that pregnancy can have a negative impact on the development of the disease, since the enlarged uterus puts pressure on the intestinal sections, and the level of endogenous cortisol also increases, which drops rapidly after childbirth. The prognosis of the disease also depends on whether the pregnancy occurred during remission or exacerbation. If the disease proceeds without complications, this usually does not affect the course of pregnancy. In severe cases, Crohn's disease can provoke the risk of miscarriage, and can also pose a threat to the life of the fetus during childbirth. Complications during the birth process occur most often if the disease occurs or worsens during pregnancy. It is not easy to identify an exacerbation of the disease during pregnancy, since the clinical picture practically does not change. In cases of intestinal obstruction, intestinal stenosis, fistula formation, a negative effect on the course of pregnancy occurs even during the period of remission of the disease. With a persistent weakening of the symptoms of the disease, pregnancy in the presence of Crohn's disease is acceptable, while its exacerbation is a contraindication for conception.

Where does it hurt?

Crohn's disease and ulcerative colitis

Crohn's disease and ulcerative colitis are presumably associated with hereditary predisposition, as well as with exposure to the gastrointestinal tract of infectious agents. The main difference between these diseases is that in ulcerative colitis, usually only the large intestine is vulnerable, while in Crohn's disease, various parts of the gastrointestinal tract are affected. The lesion in ulcerative colitis is usually concentrated in any one segment of the colon. In Crohn's disease, the affected area may cover multiple areas of the intestinal region. Symptoms of Crohn's disease and ulcerative colitis are very similar to each other, and it is far from always possible to distinguish them with accuracy. A biopsy is usually ordered to differentiate between the two diseases. Common signs of these pathologies are diarrhea and temperature reaction of the body, pain in the abdomen, deterioration or complete lack of appetite, weight loss, general weakness. Nausea and vomiting, joint pain may also be present. It should be noted that similar symptoms can also be observed in other pathologies of the gastrointestinal tract, so qualified diagnosis is extremely important to establish the correct diagnosis.

Why is Crohn's disease dangerous?

In order not to delay treatment and timely seek help from a specialist, the patient needs to know why Crohn's disease is dangerous:

1. With the progressive course of the disease, the number of segments of intestinal damage increases.
2. Re-development of the disease due to surgical intervention (lesion of the proximal intestine).
3. The formation of fistulas in the rectum and other parts of the digestive tract.
4. Development of extraintestinal pathologies (erythema, pyoderma, episcleritis, uveitis, ankylosing spondylitis).
5. bowel obstruction.
6. risk of adenocarcinoma.
7. Perforation of the colon, development of intestinal bleeding.
8. Colon expansion.
9. Lack of absorption of nutrients in the small intestine.

Diagnosis of Crohn's disease

Crohn's disease should be suspected in patients with symptoms of inflammation or obstruction, in patients without visible symptoms from the gastrointestinal tract, but with perianal abscesses, as well as unexplained signs of arthritis, nodular erythema, fever, anemia, or (in a child) stunted growth. A family history also strengthens the suspicion of Crohn's disease. Similar Crohn's disease symptoms and signs (eg, abdominal pain, diarrhea) may be due to other gastrointestinal disorders. Crohn's disease is differentiated from ulcerative colitis; diagnosis can be difficult in 20% of cases in which Crohn's disease is limited to the colon. However, since the treatment of these diseases is similar, such a distinction is only important when considering indications for surgical treatment or empirical therapy.

Patients with symptoms of an acute abdomen (for the first time or relapse) require direct and lateral abdominal radiography and abdominal CT. These studies can detect obstruction or other possible reasons acute abdomen (eg, appendicitis). Ultrasound allows a better assessment of gynecological pathology in women with pain in the lower abdomen and pelvis.

If the initial manifestations of the disease are not so acute, examination of the upper GI tract and small intestine with pinpoint radiography of the terminal ileum is preferable to CT. Gastrointestinal examinations are diagnostic if they show abrupt narrowing (producing a "string sign") or separation of bowel loops. If the findings are questionable, superficial aphthous and linear ulcers can be detected by enteroclysm or video capsule enteroscopy. Barium enema can be used if colonic symptoms predominate (eg, diarrhoea), which may show barium reflux into the terminal ileum with valve insufficiency, tuberosity, rigidity, wall thickening, and narrowing of the lumen. Similar radiographic findings are seen in caecal cancer, ileal carcinoid, lymphosarcoma, systemic vasculitis, radiation enteritis, ileocecal tuberculosis, and amoebic granuloma.

In atypical cases (eg, predominant diarrhea with minimal pain), Crohn's disease is diagnosed similarly to ulcerative colitis, with colonoscopy (including biopsy, pathogen testing). intestinal microflora and, if possible, visualization of the terminal ileum). Upper GI endoscopy may reveal gastric and duodenal involvement even in the absence of upper GI symptoms.

It is necessary to perform laboratory tests to diagnose anemia, hypoalbuminemia and electrolyte imbalance. Liver function tests should be performed; elevated levels of alkaline phosphatase and y-glutamyl transpeptidase suggest the possible development of primary sclerosing cholangitis. Leukocytosis or increased levels of acute phase reagents (eg, ESR, CRP) are nonspecific, but periodic monitoring can be used to monitor disease activity.

Perinuclear antineutrophil cytoplasmic antibodies are present in % of patients with ulcerative colitis and in only 5-20% of patients with the disease. Crohn's disease is characterized by the presence of aHiw-Saccharomyces cerevisiae antibodies. However, these tests do not reliably differentiate between the two diseases. They are of some value in cases of "uncertain colitis" and are not recommended for routine diagnosis.

Algorithm for diagnosing Crohn's disease

Diagnosis of Crohn's disease is carried out by X-ray and endoscopy, which allow to assess the state of the gastrointestinal tract. When analyzing feces, the presence of leukocytes in it is determined. The presence of leukocytes in the feces indicates an inflammatory process of the intestinal walls. If loose stools appear during the disease, it is examined for the presence of infectious agents, helminth eggs and clostridia. When diagnosing Crohn's disease, the irrigoscopy method is used - an x-ray of the colon with the introduction of a contrast agent (an aqueous solution of barium sulfate with tannin). Two or three days before the start of the examination, the patient is recommended a special diet, the day before - ingestion of castor oil (about thirty grams). In the evening, they put an enema and do not eat until the end of the procedure. X-ray examination of the passage of barium is carried out in order to assess the evacuation capacity of the large intestine and its interaction with other organs. The method of intubation enterography allows you to examine the small intestine by introducing barium into it with a nasogastric tube. After x-rays, scintigraphy can be performed to differentiate between inflammatory and non-inflammatory processes. This method allows you to study the activity of the gastrointestinal tract and is based on the fact that the patient takes food labeled with a radioactive isotope, after which, using special equipment, the process of its movement along the digestive tract is monitored. As part of a comprehensive diagnosis, a blood test, feces, and an immunogram are also carried out.

Tests for Crohn's disease

A blood test for Crohn's disease shows an increase in the erythrocyte sedimentation rate, disturbances in the water-salt balance, low level protein in blood plasma, lack of folic acid, vitamins B12 and D. Coprological examination reveals an increased content of fatty acids and salts, the presence of a large amount of undigested starch in the feces, and an increased nitrogen content in feces. Carrying out fibrogastroscopy allows you to detect lesions in the upper parts of the gastrointestinal tract. During sigmoidoscopy, pathological changes in the rectum are detected. With endoscopy at the initial stage of the disease, aphthous erosive formations are visible, mucus containing pus is present on the intestinal walls.

x-ray

When diagnosing Crohn's disease, X-ray is quite important, since it can be used to accurately determine the location of the inflammatory process. Of particular importance is radiography when examining the small intestine, since it is the only way to study it. Before starting the procedure, the patient ingests a barium-containing liquid, which can also be introduced through the rectum (barium enema). On x-ray, fluid is identified by white color, which allows you to see ulcerative formations, narrowing of the intestine, etc. If such a study turned out to be ineffective, other types of x-rays are additionally prescribed.

Colonoscopy

Colonoscopy is sufficient to diagnose Crohn's disease. great importance. Colonoscopy for Crohn's disease provides the most complete picture of the condition of the large intestine. It helps to identify the presence of ulcerative formations, foci of inflammation and bleeding. Probing the colon allows you to explore it completely - from the caecum to the rectum. Usually the procedure is performed without prior anesthesia. Local anesthesia is done in cases where a pronounced pain syndrome is localized in the anus, as well as in severe processes that disrupt the functioning of the small intestine, the formation of adhesions in the abdominal cavity. The procedure is performed in the supine position with the introduction of a special device (colonoscope) through the anus into the rectum. Two days before the colonoscopy, the patient is shown a slag-free diet, the day before, and also on the day of the procedure, food should consist only of liquid (broths, teas). Castor oil intake is also shown the day before the study. Two tablespoons of oil are dissolved in about half a glass of kefir and taken orally, which helps to completely cleanse the colon. In the morning, before the procedure, one or two more enemas are put - until the intestines are completely cleansed and water is released from it.

Crohn's disease

In the event that a person has signs of a severe intestinal disorder, one should not self-medicate in the hope that the unpleasant symptoms will disappear on their own, but should immediately contact a specialist in order to conduct the necessary diagnostic study. After all, such manifestations can hide quite terrible pathologies of the gastrointestinal tract, one of which is Crohn's disease.

It almost always develops according to a chronic type and is very difficult to diagnose and treat, especially when time is lost and the disease begins to progress. In addition, Crohn's disease has many varieties. Their most accurate classification can be found in ICD 10, under code 50. All manifestations of this pathology are collected there, which gives the specialist the opportunity to determine the most accurate diagnosis and prescribe adequate treatment.

A distinctive feature of Crohn's disease is that not only the sections of the large intestine are affected by the inflammatory process, but the entire digestive tract, including the stomach, esophagus and anus. This creates certain difficulties both in identifying the form of the disease and in prescribing drug therapy. In addition, with it, pathological changes occur in all layers of the walls. digestive organs and not just in their mucous membranes.

The symptomatology of this disease often resembles an acute appendicitis, which is fraught for the patient with the fact that a real diagnosis can only be made during an operation to remove the appendix. Due to the difficulty exact definition of this inflammatory pathology, physicians usually use the method of differential diagnosis, which allows to determine the form of the developing disease with the greatest accuracy.

Classification of Crohn's disease

This disease has several forms. This classification of Crohn's disease is based on the localization of pathological phenomena in the digestive tract:

• Ileocolitis. It is the most common type of this disease, the inflammation process in which the colon and ileum are affected;
• Ileitis. With this form of Crohn's disease, pathological changes occur only in the ileum;
• Gastroduodenitis. It is less common than other types and is characterized by the fact that the stomach is mostly prone to inflammation.

Of all the varieties, the gastroduodenal form of development of this pathology, localized in the stomach, should be distinguished. Although it is very rare (no more than 5% of all manifestations of this disease), it brings the patient the greatest problems. They are due to the fact that ulcers located in the main digestive organ are quite difficult to diagnose and very often the cause of their appearance is attributed not to Crohn's disease, but to other inflammatory diseases of the stomach. This, accordingly, leads to the fact that the start of adequate treatment is postponed indefinitely.

Symptoms with this localization of Crohn's disease for the most part correspond to a stomach ulcer ( severe pain in the epigastrium, vomiting with spotting, weight loss). With this form, treatment should be carried out with drugs that block gastric secretion.

Crohn's disease - causes of the disease

Although it is believed that people aged 20 to 40 are susceptible to Crohn's disease, it occurs, although quite rarely, in children of all age groups. In them, the manifestations of the pathology are usually more severe than in adults, but there is a greater chance for a complete recovery.

Despite the fact that the etiology of Crohn's disease is still unclear, numerous studies have identified a group of children most susceptible to it. For the most part, it can be attributed to those who have a hereditary factor. It can be called the main cause of the development of this pathology in the gastrointestinal tract at an early age.

If one of the parents or close relatives suffered from this or similar pathologies of the digestive organs, then the child has an increased percentage of the likelihood of developing Crohn's disease. The following causes also influence the occurrence of the disease:

• violations of the body's immune system, when it ceases to recognize its own cells of the body and fights against them;
• negative impact external factors such as various infections, unhealthy lifestyle and unhealthy diet.

Parents of children whose lives are affected by these factors should be extra vigilant for any symptoms that may signal the development of Crohn's disease in the child.

Symptoms of Crohn's disease

Clinical picture of this inflammatory disease is quite diverse. It usually starts gradually. If you ignore the alarming symptoms and do not start timely treatment, Crohn's disease will take a chronic form, almost untreatable.

The main clinical symptom in children, which occurs in the very first place, is diarrhea with very frequent (up to 10 times a day) urge to defecate. There is always bloody discharge in the stool.

Another obligatory sign of this pathology, which is present in both children and adults, is abdominal pain. In the initial stage of Crohn's disease, they are hardly noticeable and completely unrelated to food intake. Strengthening of the pain syndrome occurs as the pathology develops, when during the meal or the process of defecation it becomes cramping. The most advanced stages of Crohn's disease are characterized in children by their greatest intensity and bloating.

This disease also has general physiological symptoms. These include fever, fever, weight loss, significant weight loss and general weakness. For children with a history of this pathology of the gastrointestinal tract, growth retardation, as well as sexual development, is also characteristic.

Crohn's disease can also be accompanied by extraintestinal manifestations, the most characteristic of which for this disease will be vascular disorders, stomatitis, and allergies.

In the case when the pathological process is localized in the rectum, children will have lesions in the biliary system, liver and joints. Also, for some unknown reason, rashes on the skin may occur. And in the case of localization of inflammation in the small intestine, extraintestinal manifestations of Crohn's disease become hydronephrosis and urolithiasis disease. In addition, the active stage of the disease sometimes causes aphthous ulcers to appear in the patient's oral cavity.

Pregnancy planning and Crohn's disease

Due to the fact that this pathology affects patients at a fairly young age, many patients are most concerned about the compatibility of this disease with pregnancy. Moreover, there is practically no decrease in fertility in women with this disease.

Although many modern doctors categorically prohibit the bearing of a child and childbirth with Crohn's disease, studies by Western experts show that during the period of remission, these processes proceed without any special pathologies. The chance of having healthy offspring in women whose gastrointestinal tract is affected by this serious illness is no less than that of the rest, but subject to a stable remission.

The biggest problem during pregnancy is differential diagnosis necessary for Crohn's disease. The reason for this is that X-ray examination of the intestine cannot be performed, and colonoscopy and sigmoidoscopy are difficult due to the displacement of the uterus of the colon.

The childbearing process should occur during a stable remission and due to the fact that the degree of activity of the inflammatory process occurring in the digestive organs has a significant effect on the occurrence of pregnancy complications. At active form Crohn's disease increases the risk of fetal malnutrition, spontaneous miscarriage and premature birth.

Many are also concerned about the question of how pregnancy affects the course of Crohn's disease. Here we can definitely say that in the case when the bearing of the child falls on the period of remission, it will remain throughout the pregnancy. Therefore, it is so important for a woman with this pathology, before she decides to have a child, to consult a specialist and undergo a full course of treatment.

This gives very high chances of both getting pregnant normally and giving birth to a healthy baby. Even if an exacerbation occurs during the first months of gestation, the specialist will prescribe such medications that are not a contraindication and will not harm the body of the pregnant woman, as well as the unborn child.

The process of childbirth in patients with Crohn's disease is most often carried out by caesarean section. This method is necessary even if the pregnancy proceeded throughout its entire length without any pathological changes, since this disease causes cicatricial changes and perianal lesions in the perineum.

Crohn's disease according to ICD-10

The International Classification of Diseases is a single normative document designed both to take into account the causes of various diseases and the mortality caused by them. For such an inflammatory pathology as Crohn's disease, code 50 is assigned in ICD 10. Under it, you can find any kind of this disease.

This inflammatory pathology is classified in this regulatory document according to the following codes:

• K50.0 Beneath it in ICD 10 is a variety of Crohn's disease, which is localized in the small intestine;
• Under code 50.1, this type of this pathology is presented, in which inflammatory lesions occur in the large intestine;
• K50.9 classifies the unspecified form of this pathology.

But under code 50.8, all other varieties of Crohn's disease are collected, among which are granulomatous enteritis, intestinal granuloma, as well as inflammation of the digestive tract, which results in the formation of fistulas on the inner surface of the digestive organs

The exact causes of all 10 varieties of Crohn's disease classified in the ICD are still unknown, so even with the slightest manifestation of gastrointestinal disorders, you should immediately consult a specialist. Thanks to timely diagnosis, it is possible to identify the pathology with the greatest accuracy, presumably determine the cause of its occurrence and begin timely treatment.

Crohn's disease, unspecified

Definition and background[edit]

Crohn's disease is a chronic inflammatory process that can occur in any part of the gastrointestinal tract, from the esophagus to the rectum. Inflammation mainly captures the submucosal layer, but can spread to all layers of the intestinal wall. The distal ileum and colon are most commonly affected.

Etiology and pathogenesis[edit]

Clinical manifestations[edit]

Crohn's disease is distinguished not only by great morphological, but also by clinical diversity. Clinical manifestations vary widely depending on the location and extent of the lesion, the stage of the disease, and the presence or absence of complications. In the clinical picture of Crohn's disease, one can distinguish local and general symptoms, as well as extraintestinal manifestations of the disease.

Local symptoms - abdominal pain, diarrhea, bleeding - are caused by damage to the gastrointestinal tract. As local complications of Crohn's disease, anal and perianal lesions (fistulas of the rectum, abscesses in pararectal tissue, anal fissures), strictures of various parts of the intestine, infiltrates and abscesses in the abdominal cavity, external and internal fistulas are considered. Complications associated with the pathological process in the intestine also include toxic dilatation of the colon, perforation and massive intestinal bleeding. Complications of Crohn's disease are due to the transmural nature of the lesion of the intestinal wall and anal canal.

Abdominal pain, a classic symptom of Crohn's disease, occurs in 85-90% of patients. Recurrent pain in the lower right quadrant of the abdomen is characteristic, and it can simulate a picture of acute appendicitis or intestinal obstruction. At the same time, many patients may not have sharp pain, and the main manifestations of the disease are a feeling of discomfort, heaviness in the abdomen, bloating, and cramping pains of moderate intensity, aggravated by a violation of the diet.

Diarrhea is noted by 90% of patients. When only the small intestine is involved in the process, the stool frequency ranges from 2 to 5 times, and with enterocolitis from 3 to 10 times a day. The consistency of feces is more mushy than liquid.

General symptoms in Crohn's disease, they arise due to an inflammatory process in the intestine or immunopathological reactions. These include fever, weakness, weight loss.

Crohn's disease, unspecified: Diagnosis[edit]

1) In the anamnesis, there is a delay in physical development, bouts of fever, abdominal pain. Diarrhea is less common than in ulcerative colitis. Systemic manifestations of the disease include arthritis, erythema nodosum, uveitis, and aphthous stomatitis.

2) Physical examination reveals emaciation, abdominal tenderness, and abdominal mass; with digital rectal examination - anal fissures and pararectal fistulas, blood and mucus in the discharge from the rectum.

3) Laboratory and instrumental research include fecal analysis; general analysis blood; determination of the levels of serum proteins, electrolytes, iron, folic acid and serum iron-binding capacity; sigmoidoscopy, irrigoscopy, radiography of the upper gastrointestinal tract.

2) Anemia, leukocytosis with a shift to the left, thrombocytosis, increased ESR are noted.

3) Tuberculin skin test is negative.

4) Serum iron and folic acid levels are reduced, serum iron-binding capacity is increased.

5) Sometimes the level of serum albumin is reduced.

6) Irrigoscopy, radiography of the upper gastrointestinal tract and sigmoidoscopy allow diagnosing a lesion of the gastrointestinal tract.

7) 30% of patients have a severe delay in physical development, although malabsorption occurs in less than 5% of cases. Apparently, developmental delay is due to insufficient intake of calories and high activity of the inflammatory process.

8) Periods of exacerbations and remissions are typical.

9) Possible malabsorption of vitamin B 12, which is detected using the Schilling test.

Differential diagnosis[edit]

Crohn's disease, unspecified: Treatment[edit]

2) In ileitis, corticosteroids are the treatment of choice; sulfasalazine is ineffective. If corticosteroids cause severe side effects or steroid dependence develops, azathioprine and mercaptopurine are used.

3) For fistula use metronidazole, 250 mg orally 3 times a day.

4) Antidiarrheals (deodorized tincture of opium, diphenoxylate, loperamide) are recommended only for chronic Crohn's disease, which occurs with diarrhea and tenesmus.

5) With a delay in physical development, nutrition with elemental mixtures is indicated.

6) If corticosteroids are ineffective, in the prepubertal period, total parenteral nutrition is prescribed to accelerate physical and sexual development.

7) Psychiatric consultation helps the patient and family to adapt to a chronic disabling disease.

8) Indications for surgery

b) intestinal obstruction;

c) extensive damage to the anus or rectum, not amenable to conservative treatment;

d) severe delay in physical development (the operation is performed if it is possible to remove the affected area of ​​the intestine).

In table. 10.7 is given Comparative characteristics nonspecific ulcerative colitis and Crohn's disease.

Crohn's disease- non-specific inflammatory lesion of various parts of the gastrointestinal tract of unknown etiology, characterized by segmentation, recurrent course with the formation of inflammatory infiltrates and deep longitudinal ulcers, often accompanied by complications. Depending on the affected part of the gastrointestinal tract, small intestine, large intestine and mixed forms of the disease are distinguished. Frequency. 25-27 cases per 100,000 population. Small intestinal form - 25% of cases, large intestine form - 25%, mixed form - 50%. In the small intestine, the most common localization (90%) is the terminal ileum, which explains the outdated name of this disease - terminal ileitis. Dominant age. The first peak of incidence is 12-30 years, the second is about 50 years.

Code by international classification ICD-10 diseases:

The reasons

Risk factors. genetic factors. Approximately 17% of cases of Crohn's disease are detected among the patient's immediate family (first degree of relationship). Propensity to develop inflammatory diseases intestine (Crohn's disease and ulcerative colitis) determine the loci 12p13.2, 12q24.1, 7q22 and 3p21.2. Chronic inflammatory bowel disease. Ileocecal valve insufficiency. Dysbacteriosis.

Pathomorphology. Significant thickening of the affected intestinal wall with transmural inflammation. A multiplicity of lesions is characteristic (focal granulomas, deep tortuous or linear ulcerations), separated from each other at a great distance. In this regard, the spread of the disease is figuratively compared with jumping kangaroos. Macroscopically: the appearance of "cobblestone pavement" - areas of normal mucous membranes are replaced by ulcerations and granulomatous growths. Microscopically.. In the affected area, edema and hyperplasia of lymphatic follicles in the submucosa.. Proliferation of reticuloendothelial and lymphoid elements.. Granulomas consisting of giant and epithelioid cells. Enlarged, dull on the cut mesenteric The lymph nodes. Secondary strictures with scarring, fistula formation is possible.

Symptoms (signs)

Clinical picture

General manifestations for all forms of Crohn's disease. anorexia) .. Fistulas of the rectum and other lesions of the anorectal region (abscesses, strictures) are characteristic of a long course of the disease .. Extraintestinal manifestations: erythema nodosum and pyoderma, episcleritis, uveitis, ankylosing spondylitis, arthritis (5%).

Small bowel form.. Abdominal pain, similar to appendicular, not decreasing after defecation (the stool is usually liquid) and aggravated after eating.. Malabsorption syndrome (weight loss, anemia, growth retardation in children, hypoproteinemia, edema) .. Obstructive intestinal obstruction (in a third of cases) .. Intestinal bleeding (20%), rarely massive.

Colonic form .. Admixture of blood and purulent mucus in the stool .. Pain throughout the abdomen, often associated with the act of defecation .. Constipation (16.6%) .. Lesions of the anorectal region (40%) .. intestinal, and for segmental — extraintestinal manifestations of the disease.

Mixed form .. Pain in the right side of the abdomen, similar to appendicular .. Intestinal obstruction occurs more often than in other forms.

Associated pathology. Viral gastroenteritis. Arthritis. Erythema nodosum and pyoderma. Episcleritis, uveitis. Sclerosing cholangitis.

Pregnancy not contraindicated in patients with mild to moderate Crohn's disease.

Clinical stages(characterized by periods of exacerbations and remissions). Acute .. Diarrhea, weight loss, dull pains in the abdomen (often in its right half) come first. Subacute .. The number of ulcerative lesions increases, granulomas form, segmental stenosis of the intestine occurs .. In this regard, the pains are cramping in nature .. Symptoms of intestinal obstruction are possible. Chronic .. It is characterized by the further spread of the sclerotic process in the intestinal wall and the development of complications.

Diagnostics

Laboratory diagnostics(non-specific). Blood test: anemia, increased ESR, hypoproteinemia, electrolyte disturbances, low folic acid, vitamins B 12 and D. A coprological study in violation of digestion and absorption reveals steatorrhea, amylorrhea and creatorrhea. Steatorrhea of ​​the intestinal type (the predominance of fatty acids and their salts) is characteristic of Crohn's disease in the small intestine or mixed form.

Special Studies

FEGDS .. Allows you to identify lesions of the upper gastrointestinal tract. Localization of the process in the stomach is 1-1.5% of all cases of Crohn's disease .. The most characteristic is an isolated lesion of the antrum of the stomach or a combined lesion of the stomach and the initial section of the duodenum .. Often the stomach is involved in the process in the terminal stage of intestinal damage.

Sigmoidoscopy allows you to detect changes in the rectum involved in the pathological process (50% of cases).

Colonoscopy allows you to examine the mucous membrane of the entire large and terminal ileum, determine the localization of the process, the size of the lesion, diagnose or exclude strictures, timely recognize the recurrence of the disease in patients who underwent surgery; conduct a targeted biopsy of the mucous membrane in any part of the large and terminal ileum .. From the pus of postoperative abscesses, intestinal flora is most often sown: Escherichia coli, Bacteroides fragilis, enterococci .. The initial period of the disease is characterized by poor endoscopic data: dull mucous membrane; against its background, erosions of the aphthae type are visible, surrounded by whitish granulations, in the lumen of the intestine and on the walls - purulent mucus. For the same stage, the formation of fistulas is characteristic. With a decrease in the activity of the process, scars form at the site of ulcers - cracks, which leads to the formation of stenosis.

The most complete x-ray picture can be obtained only with a comprehensive examination (with tight or semi-tight filling of the intestine with a barium suspension and with double contrasting). malignant tumor of the antrum of the stomach.. Main signs... Segmentation of the lesion... "Symptom of the cord"... Wavy or uneven contour of the intestine... into the fiber.

Selective angiography of the mesenteric vessels - along with changes in the intramural vascular network, a change in the mesenteric part of the vessels is noted.

Ultrasound provides the following possibilities.. Determine the prevalence of the process in the intestine.. Measure the thickness of the intestinal wall in the affected area.. Follow the dynamics of the process.. Study the state of other organs of the digestive system.. Monitor the effectiveness of treatment.

CT can detect abscesses along the course of fistulas and extensive pararectal lesions.

Treatment

TREATMENT

Mode. In the period of exacerbations - stationary, in the stage of remission - outpatient.

Diet. During the period of exacerbation of the disease, a mechanically and chemically sparing diet is prescribed with a high content of proteins, vitamins, with the exception of milk in case of its intolerance and a limited amount of coarse vegetable fiber, especially when the intestinal sections are narrowed (diet No. 4, then No. 4b). Calorie content of food can be increased by liquid nutrient solutions, protein preparations containing whole protein and devoid of lactose and vegetable fiber, special diets that include hydrolyzed protein, also devoid of lactose and fiber. In case of strictures or repeated obstructions, coarse and gas-producing foods should be avoided. At various forms diarrhea, it is necessary to increase the amount of vegetable fiber, limit the intake of fats.

Lead tactics. Influence on the reactivity of the organism. Reduced allergic and inflammatory reactions. Elimination of infection and intoxication. Regulation of metabolic and enzymatic disorders. Correction of malabsorption syndrome in severe lesions of the small intestine. Diet therapy and vitamin therapy.

Surgery.

Indications for a planned operation. Lack of effect from long-term conservative therapy in severe cases of the process and frequent relapses diseases .. Bowel strictures, accompanied by partial intestinal obstruction, gradually approaching (despite conservative treatment) to complete obstruction.. The development of cancer on the background of Crohn's disease.

Indications for urgent surgery.. Recurrent and progressive profuse bleeding.. Acute toxic dilatation of the colon, not amenable to conservative therapy.. Perforation of intestinal ulcers, development of abscesses, fistulas and peritonitis.

Types of surgical interventions .. In the acute period of terminal ileitis, appendectomy is recommended .. With significant involvement of the caecum, ileocecal resection is performed .. Usually, the postoperative course is smooth; if fistulas occur, they often come from the affected intestine than from the stump of the removed process. Treatment of fistulas is not successful without sanation of surrounding abscesses. Operations are divided into palliative, radical and reconstructive-restorative.. Palliative (off operations) - the imposition of a double-barreled ileo- or colostomy in an extremely serious condition of the patient or intraperitoneal infiltrates, expansion of strictures using a Foley catheter .. Radical - resection of a segment of the small intestine, segmental or subtotal resection of the colon, colectomy, colproctectomy, as well as plastic surgery with cicatricial strictures of small extent .. Reconstructive and restorative operations.

Treatment of lesions of the anorectal region. With the development of perianal abscesses, it is necessary to perform their opening and drainage. Fistulas of the rectum and anal fissures require surgical treatment if they are multiple, or if they are severe. clinical course.. Indications for surgical treatment of the pathology of the perianal region should be as limited as possible, because. wounds in such patients heal very slowly, the percentage of recurrence of the disease is high.

Drug therapy

There is no specific therapy. Symptomatic treatment: diphenyltropine 2.5-5 mg, loperamide 2-4 mg or codeine 15-30 mg orally up to 4 r / day - to relieve cramping pain and diarrhea.

Sulfanilamide preparations. The action develops within 4-6 weeks. with damage to the descending colon and rectum - per rectum 1.5 g / day in 3 divided doses.

GC - at acute forms diseases, severe relapses and moderate forms resistant to other drugs .. Prednisolone 20-40 mg / day. When remission is achieved, the dose is gradually reduced to 10-20 mg / day by the end of the 4th week of treatment. The duration of the course of treatment is up to 2 months. If oral administration is not possible, hydrocortisone is first administered at a dose of 50 mg 2 r / day iv or 4 r / day IM, then prednisolone 40-60 mg / day is prescribed after 5-7 days inside .. With total damage to the colon, enemas with hydrocortisone are used at 125 mg per 200 ml of water 2 r / day (morning and night), then as the effect is achieved - 1 r / day, then every other day. With left-sided localization of the lesion, the daily dose of hydrocortisone is reduced to 75-100 mg, and with damage to the rectum and sigmoid colon - up to 50 mg.

Metronidazole 250 mg 3 r / day for no more than 8 weeks - in the presence of pararectal abscesses or fistulas of the rectum.

Cyanocobalamin parenterally - with lesions of the ileum.

For maintenance therapy - mesalazine, methotrexate, azathioprine or mercaptopurine (prolong remission).

Alternative drugs. Broad-spectrum antibiotics that target gram-negative and anaerobic organisms are most effective for complications (eg, abscess or fistula). Instead of sulfasalazine - salazodimethoxine.

Observation. Dynamic observation, control examination every 3-6 months with a stable patient condition (Hb content, ESR, body weight, pain syndrome, diarrhea, systemic manifestations). Control colonoscopy with biopsy of suspicious areas of the mucous membrane. Annually - biochemical blood test, liver tests, proteinogram. Determination of the content of vitamin B12 in the small intestine form of the disease or after resection of a segment of the small intestine.

Complications. Progression of the disease - an increase in existing and the appearance of new areas of intestinal damage. Relapse of the disease after surgical treatment (often there is a lesion of the proximal intestine). Fistulas are found in 15% of patients: rectum and anal canal, intestinal-vaginal, intestinal-vesical, inter-intestinal and external, emanating from various parts of the gastrointestinal tract. Extraintestinal lesions occur in 10% of cases (erythema nodosum and pyoderma, episcleritis, uveitis, ankylosing spondylitis). Bowel obstruction occurs in about 25% of cases. Widespread involvement of the colon increases the risk of developing adenocarcinoma. Colon perforation and profuse intestinal bleeding. Formation in the abdominal cavity of infiltrates of different localization. Acute toxic dilatation of the colon. Crohn's disease can lead to malabsorption due to mucosal injury, multiple strictures with bacterial overgrowth, or multiple bowel resections.

Forecast. Due to the protracted progressive course of the disease, the prognosis is often unfavorable. The disease leads to disability in younger patients, and disability is noted 2 times more often in women than in men. The long-term prognosis of Crohn's disease is favorable when the process is localized in the colon.

Prevention. Regular medical supervision. With a persistent frequency of relapses - a preventive anti-relapse course of treatment.

Synonyms. Granulomatous colitis. Granulomatous enteritis. Intestinal granuloma. Crohn's proctocolitis. Terminal ileitis. Regional colitis. Regional ileitis

ICD-10. K50 Crohn's disease [regional enteritis]

Crohn's disease, microbial code 10, is chronic and difficult to diagnose. As for the treatment of this disease, it should be selected at a professional level.

Collapse

Crohn's disease is diagnosed in various age groups, although people aged 20 to 40 years are most susceptible to this disease. In the event that the disease affects the child's body, it proceeds in a more severe stage, but as for recovery, but with the right treatment, the chance of recovery is very high.

Disease affecting the intestines

Basically, Crohn's disease is diagnosed if a person has a violation of the immune system, leads an unhealthy lifestyle, or a person does not eat properly. In addition, many experts agree that the pathogenic flora can be the cause of the disease. It is because of various bacteria and viruses that inflammatory processes occur in the human body, which mainly manifest themselves in the large or small intestine.

Also, a genetic predisposition may be the cause of the development of this disease.

During the period of the disease, a person has a partial lesion of the gastrointestinal tract. In most cases, patients are diagnosed with lesions of the small intestine or combined. In this case, patients show the following symptoms:

• erosion is diagnosed, which can be of various forms;
• ulcers appear, which can be of different depths;
• there is a narrowing of the intestine, as well as its segmentation;
• a channel is formed between organs and tissues;
• there is lymphatic edema;
• there are pains in the abdomen, which can manifest themselves of varying intensity, from almost imperceptible aching to sharp and cutting;
• diarrhea appears, which can be expressed to varying degrees depending on the degree of damage;
• in the process of loose stools, blood impurities can be observed, which can also appear in varying amounts depending on the degree of damage;
• the patient also has general weakness and fatigue;
• with a severe degree of the disease, weight loss occurs, which can be quite significant;
• body temperature rises;
• in some cases, inflammation of the vascular or mucous membrane of the eye is diagnosed;
• various kinds of redness may occur on the skin;
• observed muscle pain, as well as pain in the joints;
• blood vessels may become inflamed;
• there is a violation of blood clotting, resulting in the formation of blood clots.

Depending on the degree of activity of the inflammatory process in medical practice, the symptoms that indicate this differ. The degree of activity is mild, moderate or severe.

In the event that the disease is in a mild stage, then the patient has diarrhea, which in frequency does not exceed four times a day, the pulse is within normal limits, but the body temperature rises to 37.5 degrees. Also, the patient may have impurities in the process of going to the toilet.

Type of bowel in Crohn's disease

The average degree is mainly distinguished by symptoms such as bloody stools, diarrhea more than six times a day, and increased heart rate. In this case, the disease can be dangerous because various complications can occur.

As for the severe degree of the disease, in this case, the frequency of diarrhea increases in the patient, which can exceed more than ten times a day, blood impurities in the feces increase, body temperature rises to 38 degrees, and the pulse quickens.

When a patient comes to a hospital with symptoms of Crohn's disease, the doctor should first discuss with the patient all his complaints. Particular attention is paid to the characteristics and quantity of the stool.

After the conversation, the doctor proceeds to examine the patient in the process, which can be seen an increase in the abdomen. Also, the doctor pays close attention to the skin, in the event that symptoms of eye diseases are observed, it is recommended to consult an ophthalmologist, if signs of the disease are detected on human skin, then this problem is solved by a dermatologist.

Probing the abdomen is also given special attention, since it is possible to identify areas of increased sensitivity and pain. Then, appropriate tests are already prescribed, which include a general, immunological and biochemical blood test.

Palpation of the abdomen will help identify areas of pain

In order to diagnose Crohn's disease microbial 10, a doctor prescribes an X-ray and endoscopic examination together with a biopsy. In the process of research, the inflammatory process is diagnosed and it turns out how many areas are affected.

Among other things, the presence of leukocytes in the feces is also an indicator of the inflammatory process.

Despite all this, the main study in the detection of Crohn's disease is considered an X-ray examination. As for endoscopic studies, they can also confirm or refute the presence of the disease. A biopsy is necessary in order to be able to distinguish Crohn's disease from ulcerative colitis, as well as to identify acute colitis, dysplasia, or malignancy in time.

In order to get rid of such an insidious disease as Crohn's disease, it is necessary first of all to seek qualified medical help when the first symptoms appear, and after confirming the diagnosis, clearly follow all the doctor's recommendations.

In addition, it is necessary to clearly monitor your lifestyle, and, if possible, eliminate stress, since it is they who can cause the development of the disease and the occurrence of relapses. It is also necessary to completely abandon bad habits, such as smoking and drinking alcoholic beverages.

The choice of treatment method, as well as the appointment of drugs, depends entirely on the severity of the disease, the presence of complications and the nature of the lesion. All drugs are selected in each case according to an individual scheme. During treatment, the patient must be under the strict supervision of medical professionals who will monitor the dynamics.

Medications are prescribed individually, in addition, it is necessary to adjust the diet

In the event that a patient is diagnosed with a narrowing of the intestine or purulent complications, then in this case the only way out is to perform an operation. Surgical treatment is also chosen if the medical method was ineffective.

In the event that the diagnosis of the disease is carried out on time and the patient has a mild stage of the disease, then in this case derivatives of aminosalicylic acid are prescribed, in some cases they are supplemented with metronidazole.

If the pills prescribed by the doctor do not help, then they will be replaced with others.

With moderate severity of the disease, prednisone is prescribed, as well as when an abscess is detected, antibiotic therapy with open or percutaneous drainage is also prescribed. When all of the above methods are ineffective in the treatment of Crohn's disease, the patient is recommended to use more serious drugs. This occurs if the symptoms worsen, fever appears, as well as frequent vomiting. In this case, the patient may even develop intestinal obstruction. If there is a risk of complications or death, then an emergency operation is performed.

In the process of treating the disease, the patient must necessarily comply with strict rules, which will help eliminate the possibility of thermal, chemical or mechanical irritation of the gastrointestinal tract. All food taken should be heated to a temperature of at least 18 degrees. It is necessary to take food in small portions about 6 times during the day. If there is an exacerbation of the disease, it is recommended to completely refuse food for two days.

Complications of Crohn's disease

In the event that Crohn's disease is not diagnosed in time and complex treatment is not started, then this ailment can lead to the development of the following complications:

• fistulas may form, which in most cases are accompanied by purulent processes. In this case, surgical treatment is used to get rid of the disease;
• abscesses occur in soft tissues, mainly purulent inflammations around the intestinal structures, which are removed only by the surgical method;
• massive bleeding, which can lead to severe cases, as well as death or shock;
• the occurrence of peritonitis is also a rather serious complication that can lead to severe intoxication of the body. With the development of peritonitis, also in advanced cases, this can be fatal. Such a development of events is characterized by high fever, acute pain in the abdomen.
• vasculitis is also one of the complications of Crohn's disease, during which inflammation of small vessels occurs.

In order to completely get rid of Crohn's disease, you must strictly follow all the doctor's recommendations. Basically, when you follow all the rules and take medicines, you feel better after a few weeks.

After the patient gets rid of this disease, it is necessary to systematically conduct an examination, since a relapse can occur after a fairly long period of time. As for deaths, they occur if the patient develops complications.

12326 0

Crohn's disease- chronic recurrent segmental inflammatory lesion of the gastrointestinal tract of unclear etiology with the development of local and systemic complications.

ICD-10 CODE
K50. Crohn's disease (regional enteritis).

Etiology and pathogenesis

The main etiological factor in Crohn's disease, supporters of the infectious theory consider Mycobacterium paratuberculosis and the measles virus. The commonality of the clinical picture of Crohn's disease and intestinal tuberculosis, as well as the presence of granulomas, do not exclude the tuberculous etiology of this disease. At the same time, the absence of Mycobacterium tuberculosis in granulomas, unsuccessful experiments of infection guinea pigs, a negative Mantoux test and unsuccessful attempts at anti-tuberculosis treatment are indicative of the non-tuberculous nature of Crohn's disease.

Proponents of the viral etiology of Crohn's disease believe that the measles virus can cause vascular disorders in the intestinal wall, which determine the originality of the clinical picture of the disease. However, with the help of modern virological studies in Crohn's disease, it is not possible to detect the measles virus in intestinal tissues. One of the arguments in favor of the infectious etiology of Crohn's disease is the positive effect of antibiotic treatment. However, it is now clear that for a patient to develop chronic inflammation characteristic of Crohn's disease, a genetic predisposition is necessary, which determines the development of defects in the intestinal immune system.

Pathomorphology

Ulcers are usually oriented along or across the axis of the intestine, have even, uncut edges, and the areas of edematous mucous membrane remaining between them give the surface of the intestine a resemblance to a cobblestone pavement. A segmental lesion of the colon is noted with a narrowing of the lumen with a length of 5-15 cm (“suitcase handle”); above and below this zone, the intestinal wall is not changed. Sometimes the narrowed areas have a large length and a thickened wall, which makes them look like a hose; often they are located in the small intestine. It is characterized by the presence of several lesions separated by an unchanged mucous membrane.. In table. 66-1 shows the differential diagnostic signs of macroscopic changes characteristic of Crohn's disease and UC.

Table 66-1. Macroscopic differences between Crohn's disease and ulcerative colitis

Table 66-2. Microscopic changes in the colon wall in nonspecific ulcerative colitis and Crohn's disease

Features of the flow

Isolated damage to the small intestine is observed in 25-30% of cases of Crohn's disease, ileocolitis - in 40-50%, isolated damage to the large intestine - in 15-25% of patients.

Among patients with Crohn's disease with lesions of the small intestine the terminal segment of the ileum is involved in the process in almost 90%. Nearly 2/3 of patients with Crohn's disease are affected by the large intestine. Despite the fact that inflammation in the rectum in Crohn's disease is found in 11-20% of patients, anorectal lesions (anal fissures, fistulas, abscesses) are much more common - in 30-40% of cases. In Crohn's disease, the esophagus, stomach, and duodenum are rarely affected (3-5% of patients).

Epidemiology

Classification

• enteritis;
• enterocolitis;
• colitis.

• light;
• medium heavy;
• heavy.

• intestinal obstruction;
• infiltrates and abscesses of the abdominal cavity;
• intestinal fistulas (external and internal);
• perforation in the free abdominal cavity;
• intestinal bleeding;
• toxic megacolon.

Table 66-3. Scheme for determining the index of Crohn's disease activity

G.I. Vorobyov