Crohn's disease of the colon. Crohn's disease: causes, symptoms, diagnosis, treatment. Get treatment in Korea, Israel, Germany, USA

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The pathological process develops predominantly in the intestines, although all parts of the gastrointestinal tract can be affected, including the esophagus and oral cavity. Nonspecific immune inflammation extends to the entire thickness of the intestinal wall and is manifested by infiltration of leukocytes. In the mucous membrane in the infiltration zone, deep ulcers form, an abscess and fistulas develop, followed by scarring and narrowing of the intestinal lumen.

Causes

The reasons that trigger the development of the pathological process described above are still unknown. It is believed that in Crohn's disease the body produces antibodies to intestinal tissues. Heredity and smoking are identified as predisposing factors.

Symptoms

Intestinal manifestations include cramping, diarrhea, flatulence, fissures and inflammation in the anus. The patient is losing weight, he develops signs of hypovitaminosis, and metabolic disorders of varying severity. Extraintestinal signs also include anemia, aphthous stomatitis, arthritis, eye lesions (iritis, uveitis, episcleritis).

Complications

Crohn's disease It is dangerous not only for its manifestations, but also for the most severe complications: intestinal obstruction, perforation of the intestinal wall with the development, massive bleeding, internal and external fistulas, intestinal strictures, inflammatory infiltrates. All these complications can only be treated surgically.

What can you do

Both diagnosis and treatment of inflammatory bowel diseases should be carried out by a specialist or coloproctologist familiar with this pathology. Treatment of severe exacerbations is carried out only in a hospital. Treatment of mild forms of the disease should also be carried out under the supervision of a specialist. Therefore, if you suspect that you or your loved ones have Crohn's disease, you should immediately consult a doctor.

What can a doctor do?

To diagnose the disease and determine treatment tactics, the following is required: abdominal cavity; scatological research; irrigoscopy - serial radiography of the small intestine. Endoscopic research methods (colonoscopy, sigmoidoscopy) are the most informative in diagnosing Crohn's disease with damage to the colon, and a biopsy of a section of the intestine is often performed. The resulting material is sent for histological examination, based on the results of which an accurate diagnosis can be made.

In the absence of complications requiring surgical treatment, drug and diet therapy is carried out. The main groups of drugs for the treatment of Crohn's disease are glucocorticoids and 5-aminosalicylic acid preparations. A combination of these drugs is usually prescribed. In case of infection, antibiotics are used.

This disease affects the entire digestive tube: from the mouth to the anus. It usually begins in the ileum and then spreads to the rest of the gastrointestinal tract. Often the debut of Crohn's disease - acute ileitis (inflammation of the ileum) - is mistaken for appendicitis, since their symptoms are absolutely identical.

As a rule, people aged 20–40 years are affected, but often the disease begins in childhood. Men and women experience this pathology equally often.

Crohn's disease usually alternates between periods of exacerbation and remission, but a chronic continuous course is also common. The severity of the disease is determined not only by the severity of the current situation (attack), but also by complications affecting the intestines and other organs.

Causes of Crohn's disease

Why the disease occurs and what pathogenetic mechanisms underlie it is still unknown. Experts have no doubt that the root cause of Crohn's disease is autoimmune changes: a condition in which the body mistakes its own proteins for foreign ones and begins to actively destroy them with the help of immunoglobulins and immunocompetent cells. But the actual triggering factors remain unclear to this day. Blood relatives of patients with Crohn's disease are 10 times more likely to have Crohn's disease than the population average

There is an assumption that the reduced diversity of intestinal microflora (especially anaerobic strains) in patients (dysbiosis) plays a role in the development of the disease.

Symptoms of Crohn's disease

Depending on how widespread and active the inflammation is, the complex of symptoms may vary.

Inflammatory The (luminal) form of Crohn's disease does not develop significant symptoms for quite a long time. The process itself is localized in the intestinal submucosa and is not very active. At first, complaints are limited to vaguely expressed abdominal pain and general manifestations of inflammation:

• elevated temperature (usually about 37),
• headache,
• joint pain,
• in the blood test - leukocytosis and increased ESR.

At this stage, the disease is usually not diagnosed, and this may continue for many years.

As the inflammation spreads, other symptoms appear:

• paroxysmal abdominal pain,
• constant diarrhea,
• blood in stool;
• signs of digestive disorders: anemia, emaciation, decreased amount of protein in the blood plasma (hypoproteinemia), edema.

If the mucous membrane of the stomach or duodenum is involved in the pathological process, the symptoms begin to copy peptic ulcer disease, but standard methods of treating peptic ulcers are ineffective.

If the rectum is affected, long-term non-healing fissures and recurrent paraproctitis are diagnosed.

At stenosing form, signs of cicatricial narrowing of the intestine and intestinal obstruction come to the fore:

• paroxysmal pain, usually in the right iliac (above the pelvic bone) region;
• vomit;
• swollen, rumbling, iridescent intestines;
• gas and stool retention;
• peristalsis of the abdomen noticeable upon examination.

The disease has a clear hereditary predisposition

Fistula(extraluminal) form is the most severe. The resulting fistulas between intestinal loops, intestines and neighboring organs (bladder, uterus) disrupt intestinal patency and the functions of neighboring organs. If the contents of the intestine enter the abdominal cavity through the formed fistula, peritonitis begins.

In addition to intestinal symptoms, Crohn's disease also has extraintestinal manifestations:

• arthritis,
• vasculitis,
• autoimmune hepatitis,
• episcleritis,
• aphthous stomatitis,
• erythema nodosum,
• pyoderma gangrenosum.

Due to chronic lack of nutrients and the resulting metabolic disorders, the following occur:

• osteoporosis;
• urolithiasis disease;
• calculous cholecystitis;
• anemia;
• disorders of the blood coagulation system;
• swelling.

Complications of Crohn's disease

Complications of Crohn's disease include:

• cicatricial stenosis (narrowing) of the intestine;
• external fistulas (enterocutaneous);
• internal fistulas (intestinal, enterovesical, rectovaginal);
• infiltrate of the abdominal cavity;
• interintestinal abscesses;
• anal fissures;
• paraproctitis;
• intestinal bleeding;
• intestinal perforation.

In addition, Crohn's disease increases the likelihood of developing colon cancer several times.

Diagnostics

Crohn's disease - causes, symptoms, treatment, dietary table

The main diagnostic criterion is characteristic microscopic changes in a biopsy (tissue sample) taken from the intestinal wall during endoscopy or during emergency surgery.

• the entire digestive tube from the mouth to the anus is affected;
• intermittent nature of the lesion (changed areas are adjacent to normal ones);
• transmural lesion (to the entire depth of the intestinal wall): deep ulcers, abscesses, fissures, fistulas;
• cicatricial narrowings;
• histologically (under a microscope) changes in the structure of the intestinal lymphoid tissue are detected;
• normal mucin content in the area of ​​active inflammation (determined by histology);
• histological signs of sarcoid granuloma - a special form of inflammation.

During endoscopy, the mucous membrane is changed in the form of a “cobblestone pavement”: a combination of longitudinal and transverse slit-like ulcers on the edematous surface; the changed areas are located on the seemingly intact mucosa.

A complete picture of the condition of the intestine - the presence of narrowings, infiltrates, fistulas - can be provided by MRI with contrast. If technically possible, capsule endoscopy is performed (the patient swallows a capsule with a video camera). If high-tech methods are not available, an abdominal x-ray with barium contrast is performed to confirm the diagnosis.

To determine the general condition of the body, clinical and biochemical blood and urine tests are performed. When analyzing stool, a test is performed for fecal calprotectin, a marker of an active inflammatory process in the intestines.

Treatment of Crohn's disease

Characteristic appearance of the intestinal mucosa and the most common sites of active pathological process

If with ulcerative colitis a complete recovery is possible, then with Crohn's disease the most a doctor can do for the patient is to help achieve remission and prolong it. Spontaneous (spontaneous) remission occurs in approximately 30% of cases, but its duration is unpredictable.

To interrupt the exacerbation, prescribe:

• systemic local glucocorticosteroids (hormonal anti-inflammatory drugs): prednisolone, methylprednisolone, budesonide;
• immunosuppressants (since the disease is caused by excessive activity of the immune system): azathioprine, 6-mercaptopurine, methotrexate;
• monoclonal antibodies to TNF-alpha (block a special biologically active substance that provokes immune inflammation): infliximab, adalimumab, certolizumab pegol.

All this time the patient adheres to dietary table No. 4.

After the patient goes into remission, the already mentioned immunosuppressants in the form of repeated courses or 5-aminosalicylic acid preparations (sulfasalazine, mesalazine) are recommended to prolong it. In addition, gastroprotectors (rebamipide) are prescribed - they reduce the permeability of the mucous membrane, the activity of inflammation and accelerate the recovery of damaged mucosa.

As an auxiliary therapy, agents are recommended that correct general changes in the body: iron supplements for anemia, calcium supplements for osteoporosis, agents that correct blood clotting, antidiarrheals, painkillers, and so on.

Bleeding, fistulas, abscesses, paraproctitis, and anal fissures caused by the disease require immediate surgical treatment. Most patients suffering from Crohn's disease are forced to undergo at least one operation related to this disease.

A. I Parfenov. Crohn's disease: on the 80th anniversary of its description. Therapeutic archive, 2013.

Contents of the article: classList.toggle()">toggle

Crohn's disease of the colon is a chronic inflammatory disease in which there is a narrowing of the affected areas (stenosis), the formation of fistulous canals between the intestinal cavity and other organs. The lesion can occur in several areas of the colon at once.

Diagnosis of the disease is carried out by a gastroenterologist or therapist based on the results of a survey, laboratory (blood, urine, stool tests) or instrumental studies (X-ray, endoscopy, computed tomography, ultrasound, esophagogastroduodenoscopy, colonography). Therapeutic tactics for Crohn's disease depend on the severity of the clinical manifestations.

Causes

There are several predisposing factors for the development of the disease:

Symptoms of Crohn's Disease

Clinical manifestations of the disease are determined by the localization and speed of development of the disease (gradual or acute onset).

General manifestations are divided depending on their connection with the intestines:

• Intestinal symptoms:
  • Diarrhea: rare and abundant or frequent and scanty, with admixtures of mucus and blood;
  • Abdominal pain of varying intensity (dull or sharp);
• Extraintestinal symptoms:
  • High temperature (37-39º C);
  • Weight reduction;
  • Fatigue, weakness;
  • Anemia;
  • Development of cholelithiasis;
• Damage to various organs:
  • Joints (inflammatory processes, periodic pain);
  • Skin (the occurrence of difficult-to-heal wounds);
  • Gum (appearance of ulcers on the mucous membrane);
  • Eye (vision impairment);
  • Liver (development of jaundice - discoloration of the skin color and whites of the eyes in a yellow tint);
  • Kidneys (change in urine color and change in frequency of urination).

The course of Crohn's disease of the colon is often accompanied by remissions (reduction of symptoms), the duration of which reaches several years.

Treatment

Treatments are determined by the severity of Crohn's disease.

In case of exacerbation, the patient should be provided with a state of rest.

Salofalk is taken orally with water, 3-4 grams per day for several months. During treatment, the dose is gradually reduced upon the onset of remission.

1. For severe manifestations of Crohn's disease a complex of medications is additionally prescribed.

• Hormonal agents help reduce the activity of the inflammatory process. Prednisolone is taken orally or intravenously at 40-60 milligrams per day for a period of 1-4 weeks with a gradual reduction in dose by milligrams per week. Budesonide is used in an amount of 9 milligrams per day.
• Immunosuppressants help suppress the immune system involved in the development of Crohn's disease due to hereditary defects.

Methotrexate is used intramuscularly at 25 mg per week for 3 months. Side effects include nausea, diarrhea, leukopenia, anemia, and teratogenicity.

Infliximab - administered intravenously at 5-10 mg per kilogram of weight. Side effects include headache and respiratory infections.

• Antibacterial drugs help suppress the development of unwanted infectious processes in the colon. Metronidazole is used at a dose of 10-20 milligrams per kilogram of body weight in 3 doses per day for a period determined by the doctor.

1. In extremely severe forms of the disease surgical treatment is performed - resection (removal of the affected area of ​​the colon), together with antibacterial and anti-inflammatory therapy.

The prognosis for treatment of Crohn's disease of the colon depends on a complex of factors:

Carrying out complex therapy for the disease can significantly improve the patient’s condition, but Crohn’s disease has a high tendency to relapse.

There is practically no long-term improvement in the health of patients. At a minimum, relapse occurs once every 20 years.

Most often, patient death occurs due to operations or complications.

Complications

• Formation of intestinal narrowings and fistulas between the walls, intestines and other internal organs;

The mortality rate in patients with Crohn's disease is 2 times higher than in healthy people

Development of abscesses (cavities with purulent contents) in the intestinal area;

• Urolithiasis disease;
• The appearance of bleeding;
• Anemia;
• Development (difficulty in moving contents);
• The appearance of perforations (violation of the integrity of the intestinal walls);

Diet

With low activity of Crohn's disease of the colon, the patient is prescribed diet No. 4 according to Pevzner.

Authorized Products:

Forbidden food:

• Natural milk;
• Fatty animal products (smoked products, poultry, fish);
• Raw, fried, hard-boiled eggs;
• Turnips, cabbage, radishes, cucumbers and radishes;
• Spicy, smoked, salty cheeses;
• Horseradish, fatty and hot sauces, pepper, mustard;
• Kvass, soda, grape juice.

During the active course of the disease, patients are also prescribed intravenous amino acid nutrition.

In addition to the above food products, during the active course of the disease, the following products are prohibited:

• Biscuit;
• Pasta;
• Dietary sausages;
• Cookie;
• Fish.

Additionally, foods containing easily digestible proteins and fats are introduced into the patients’ diet..

Standard diet No. 4 is prescribed when body temperature decreases to normal, abdominal pain and diarrhea are eliminated.

All patients are prescribed vitamins A, K, D, E, B12, and folic acid due to the lack of their natural intake in the body with food in case of intestinal damage.

Crohn's disease in children

Crohn's disease of the colon can develop in children at any age. Children over 13 years of age are most often affected.

Features of clinical symptoms in children:

The basics of diagnosis and treatment of the disease in children and adults are the same.

During pregnancy

The favorable outcome during pregnancy is directly related to the severity of the disease.

With a mild form of the disease, in 80% of cases no complications occur, with an active form - only in 50%.

There are a number of complications of Crohn's disease of the colon that occur during pregnancy:

• Spontaneous miscarriage (the risk increases by 2 times with the active form of the disease);
• Fetal hypotrophy;
• Premature birth (with an active form of the disease, the risk increases by 3.5 times);
• The need for a caesarean section arises.

Exacerbations of Crohn's disease in pregnant women do not occur more often than in the normal state.

The most common exacerbations of the disease are:

• After abortion or childbirth;
• In the first trimester of pregnancy;
• When stopping treatment if pregnancy occurs.

If Crohn's disease was in remission at conception, then in 2/3 of pregnant women it remains inactive.

Similarly, if pregnancy occurs during the active phase of the disease, this disease state will persist or worsen in 2/3 of women.

In general, the prognosis is favorable in the case of the inactive phase of Crohn's disease at conception and pregnancy.

It is worth remembering that during pregnancy, diagnosis and treatment of Crohn's disease of the colon should be carried out with caution under the strict supervision of a specialist.

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Crohn's disease of the small intestine (K50.0)

Gastroenterology

general information

Short description

Crohn's disease- a chronic relapsing disease with transmural granulomatous inflammation and destructive changes in the mucous membrane. Crohn's disease is characterized by segmental lesions of the gastrointestinal tract and the presence of systemic manifestations.
The localization of inflammation and the form of the disease determine special approaches to its diagnosis and treatment.

Note

1. Crohn's disease (regional enteritis):

Duodenum;

Ileum;

Jejunum;

2. Crohn's disease (ileitis):

Regional;

Terminal.

Classification

In accordance with the Montreal classification, there are three main phenotypic characteristics Crohn's disease:
- age of the patient;
- localization of the pathological process;
- the nature of the disease.

By process localization:
- terminal ileum - 30-35% (see "Crohn's disease of the small intestine" - K50.0);

Ileocecal region - 40% (see "Crohn's disease of the small intestine" - K50.0);

Large intestine (including rectum) - 20%, only anorectal area - 2-3% (see. " Crohn's disease of the colon" - K50.1);

Small intestine - 5% (see "Crohn's disease of the small intestine" - K50.0);

Other localizations (esophagus, stomach) - 5% (see "Other types of Crohn's disease" - K50.8);

Rare localizations (oral cavity, lips, tongue) in combination with intestinal damage (see "Other types of Crohn's disease" - K50.8);
- simultaneous damage to the large and small intestines (see "Other types of Crohn's disease" - K50.8).

Figure 1. Terminal ileitis

Fig 2. Granulomatous ileocolitis

Fig 3. Colon damage

Fig 4. Inflammation in the stomach, esophagus, oral cavity and anorectal area in combination with intestinal damage

According to the length of the inflammatory process:

Limited or local process (less than 100 cm);

Common process (more than 100 cm).

According to the form of the disease (according to the Vienna classfification 1998):

Fistula-forming form;

Stricture-forming form;

Inflammatory-infiltrative form.

Vienna classification of Crohn's disease (1998) with Montreal modification (2005) recommended by the European Society for the Study of Crohn's Disease and Ulcerative Colitis (ECCO) and is based on the identification of different variants of Crohn's disease depending on the location of the inflammatory process, the phenotype of the disease and the age of the patients.

1. Age of the patient- is the age when the diagnosis of Crohn's disease was first definitively established radiographically, endoscopically, histologically or surgically:
- A1- 16 years or younger;
- A2- 17-40 years old;
- A3- over 40 years old.

2. Localization of the inflammatory process- the entire involved segment(s) of the gastrointestinal tract is assessed at any time before the first resection. Minimal Involvement: Any aphthous lesion or ulceration. Insufficient hyperemia and swelling of the mucous membrane.

Classification by location requires examination of both the small and large intestines:
- L1 - terminal ileitis- the disease is limited to the ileum (lower third of the small intestine) with or without penetration into the cecum;
- L2 - colitis- any location in the colon between the cecum and rectum without involving the small intestine or upper gastrointestinal tract;
- L3 - ileocolitis- terminal lesions with or without involvement of the cecum, and any location between the ascending colon and the rectum:
-L4- upper gastrointestinal tract - proximal to the terminal ileum (excluding the oral cavity), regardless of additional involvement of the terminal ileum or colon.

Combination of localizations:
- L1+L4;
- L2+L4;
- L3+L4.

3. Phenotype (form) of the disease:

-Inflammatory form (B1)- inflammatory nature of the disease, which has never been complicated. May be combined with perianal Crohn's disease (with perianal fistula or abscess).

- Stenosing or stricturing form (B2)- narrowing of the intestinal wall by X-ray examination, endoscopy or surgical and histological methods, with prestenotic dilatation or symptoms of obstruction. May be combined with perianal Crohn's disease (perianal fistula or abscess).

- Penetrating or fistulous form (B3)- the occurrence of intra-abdominal fistulas, inflammatory mass and/or abscess at any time during the course of the disease, excluding postoperative intra-abdominal complications. May be combined with perianal Crohn's disease (with perianal fistula or abscess). If the patient has both a stricture and fistulas, the diagnosis indicates the fistula form.

4. Classification by activity (severity) of the disease: assessed by calculating the Crohn's Disease Activity Index, the Best Index (CDAI). Within 7 days, the frequency of loose and mushy stools is determined; stomach ache; general well-being; the presence of extraintestinal manifestations, fistulas, anal fissure, fever above 37.8 C; body weight, taking antidiarrheal drugs; the presence of infiltrate in the abdominal cavity and hematocrit level.

Crohn's Disease Activity Index according to Best (CDAI)

Exacerbation- resumption of clinical symptoms of the disease, CDAI more than 150 points.
Relapse- resumption of clinical symptoms, laboratory and instrumental signs of exacerbation after surgery.

Etiology and pathogenesis

The etiological factor of Crohn's disease has not been established.
There are suggestions that Crohn's disease is a consequence of an abnormal innate immune response of the mucous membrane to some antigen in a genetically susceptible organism. Blood relatives suffering from some kind of inflammatory bowel disease are identified in 20% of patients with Crohn's disease.
Trigger suspected Trigger - trigger, provoking substance or factor
the role of viruses or bacteria. The role of nutritional sensitization or a commensal microbe that is non-pathogenic under normal conditions is allowed A commensal is an organism that lives in close relationship with other organisms that differ from it, without causing them any harm or benefit.
causing an abnormal immune response.
According to the third hypothesis, autoantigens expressed on the intestinal epithelium play the role of a trigger.

Thus, Crohn's disease appears to be a chronic immunoinflammatory disease in which a T-helper type 1 response with excessive production of IL-12 and interferon-γ predominates. There is increased synthesis of proinflammatory cytokines, including IL-1beta, IL-6, IL-8, IL-16, and TNF-alpha, accompanying the influx of nonspecific inflammatory cells into the mucosa.

Epidemiology

Age: mostly young

Sex ratio(m/f): 0.9

Crohn's disease occurs at varying rates depending on the country, ranging from 4 to 146 cases per 100,000 population. According to average estimates, from 4 to 7 new cases of the disease per 100,000 population are detected annually.

Most often the disease is registered in people aged 15-30 years. In approximately 20-30% of patients, Crohn's disease manifests itself before the age of 20 years. In 18% of patients the disease is diagnosed at the age of 20-39 years and in 13% of patients over the age of 40 years. Recently, there has been a tendency towards an increase in the manifestation of the disease at a later age (55-60 years).

There are clearly defined relationships between the age of patients and the localization of the inflammatory process:
- at a young age, combined lesions of the ileum and colon are most common;
- in elderly patients, isolated lesions of the colon are more often diagnosed.

Crohn's disease affects women somewhat more often: the ratio of affected men to women is approximately 1:1.1.

Risk factors and groups

1. Smoking is a proven predisposing factor in the development of Crohn's disease. Smokers get sick 4 times more often than non-smokers. Quitting smoking reduces the likelihood of relapse after surgery.

2. There are very good reasons to believe that genetic predisposition is extremely important.
3. The role of other risk factors (diet errors, infectious diseases, dysbacteriosis, uncontrolled use of certain medications) is discussed.

Clinical picture

Clinical diagnostic criteria

Abdominal pain, diarrhea, melena, fever, weight loss, bloating, stool and gas retention, weight loss, anorexia, nausea, vomiting, dyspepsia, fatigue, depression, anxiety, growth retardation in children

Symptoms, course

The disease has a multifaceted clinical picture, which can be represented by almost any gastroenterological symptom.
The clinical picture depends on the location of the lesion and the depth of pathological changes in the intestinal wall, and is also determined by the severity of the development of the pathological process and the form of the disease.

Damage to the upper gastrointestinal tract(Crohn's disease of the esophagus, stomach and duodenum) can be isolated, but is more often combined with the involvement of distal intestinal segments in the pathological process. 50% of patients with Crohn's disease show histological signs of focal Helicobacter pylori-unassociated gastritis, while less than 5% of them have gastroduodenal symptoms.
The clinical picture is often similar to a peptic ulcer. Possible symptoms: epigastric pain, nausea, vomiting after eating. The distal part of the antrum and various parts of the duodenum are usually affected.

With a more severe course of the disease, signs of acute inflammation appear: night sweats, significant weight loss, fever, increased levels of inflammatory markers in the blood (ESR, C-reactive protein).
With a slowly progressive course of the disease, the first clinical symptoms are extraintestinal manifestations, for which patients are observed by doctors of other specialties.

Stricturing form the disease often develops with small intestinal or ileocecal localization of the lesion. Symptoms: attacks of abdominal pain, mainly in the right iliac region; unstable stool. Pain can have varying degrees of intensity: be episodic or frequent.
This form is less characterized by extraintestinal obstructions: attacks of pain accompanied by vomiting, bloating, loud rumbling, “transfusion” with retention of stool and gases. In some cases, at the height of pain and increased peristalsis of a swollen intestinal loop, rumbling is heard, after which the swelling decreases and there is often loose stool (Koenig's symptom). When palpating the abdomen, it is sometimes possible to detect an infiltrate in the abdominal cavity. Diagnosis is usually made by X-ray or during laparotomy for suspected acute appendicitis.

Penetrating form The disease is characterized by the formation of fistulas or abscesses. Open intra-abdominal perforation is rare. Intra- or extra-abdominal abscesses form in 20% of patients. More common are intra-abdominal abscesses, which can be located in the mesentery or between the loops of the intestine. Extra-abdominal abscesses occur in the retroperitoneum and in the abdominal wall.

Various combinations of clinical and laboratory data are used to assess disease severity. Such calculations are mainly for research purposes and are difficult for everyday use.
It is most possible to assess the severity of the disease based on the patient’s complaints, and based on the impact of the disease on the patient’s daily functions, relevant physical examination data (fever, body weight), and the presence of altered laboratory results (anemia, hypoalbuminemia).

A generally accepted method for assessing the severity of the disease is to calculate the Crohn's Disease Activity Index - CDAI (see section "Classification"). Determining the parameters used to calculate the index for a week usually allows the attending physician to assess the course of the disease as remission (less than 150 points), mild (150-220 points), moderately severe (220-350 points), severe (350-475 points) or extremely severe (more than 475 points).

Extraintestinal manifestations

In Crohn's disease, many organs and systems are involved in the pathological process with the development of the following conditions:

Eyes: conjunctivitis, keratitis, uveitis;

Oral cavity: aphthous stomatitis;

Joints: monoarthritis, ankylosing spondylitis;

Skin: erythema nodosum, angiitis, pyoderma gangrenosum;

Liver-biliary tract: fatty liver, sclerosing cholangitis, cholelithiasis, cirrhosis, cholangiocarcinoma;

Kidneys: nephrolithiasis, pyelonephritis, cystitis, hydronephrosis, renal amyloidosis;

Bowel: Colitis increases the likelihood of developing colon carcinoma.

Diagnostics

Diagnosis of Crohn's disease is based on clinical symptoms, laboratory, endoscopic, radiological and histological signs.

Mandatory instrumental studies:
- fibrogastroscopy with examination of H. pylori Helicobacter pylori (traditionally spelled Helicobacter pylori) is a spiral-shaped gram-negative bacterium that infects various areas of the stomach and duodenum.
in case of erosive and ulcerative lesions of the mucous membrane of the stomach and duodenum, taking gastrobiopsy specimens;
- histological examination of biopsy specimens;
- ileocolonoscopy with inspection of the terminal ileum;
- morphological examination of a biopsy specimen (remains the “gold standard” of diagnosis, although it is not always possible to make an unambiguous diagnosis during a histological examination of biopsy specimens. Probably, with the widespread introduction of calprotectin determination into everyday practice, the value of a morphological examination will be reconsidered);

Ultrasound of the abdominal cavity and pelvis;
- irrigoscopy;
- enterography.

Additional Research
One time:
- CT or MRI of the abdominal cavity;
- fluoroscopy of the stomach;
- hydro-MRI;
- laparoscopy.

According to the practical recommendations of the American College of Radiology 2011 (ACR Appropriateness Criteria® Crohn disease.), the priority of types of radiation diagnostics is different in different groups of patients, at different stages of the disease in terms of effectiveness/safety ratio.

For young people and children with suspected Crohn's disease, MRI is preferable. In adult patients, if suspected, along with MRI, CT with contrast is acceptable as a priority method (both types have the same rating).

During exacerbation of the disease in children and young people, the ratings of MRI and CT with contrast are the same and are the highest of all radiological methods. In adult patients with exacerbation of Crohn's disease, MRI is less appropriate than contrast-enhanced CT.

For the observation of young people or children with an already established diagnosis and stable, mild symptoms of the disease, MRI is considered as the method that best suits the objectives. Contrast-enhanced CT and ultrasound are similarly rated and may be equally appropriate, although they are inferior to MRI.
For routine follow-up of stable adult patients with mild symptoms, contrast-enhanced abdominal CT is slightly preferable to MRI and significantly superior to CXR and ultrasound.

Consultations with specialists are required: a proctologist, in women - a gynecologist, and in the presence of extraintestinal manifestations - an ophthalmologist.

Laboratory diagnostics

Mandatory laboratory tests:
- complete blood count, platelets, Ht, Hb (if the test deviates from the norm, repeat once every 10 days);
- feces for eggs of worms and protozoa for differential diagnosis;
- stool test for Cl toxin. difficile for differential diagnosis and diagnosis of complications of Crohn's disease;
- culture of stool for bacterial flora to diagnose bacterial overgrowth syndrome;
- C-reactive protein, as a marker of inflammation and/or exacerbation;
- RNGA RNHA - indirect hemagglutination reaction - is used to determine the concentration of virus-neutralizing antibodies in blood serum and swabs from the mucous membrane of the respiratory tract
for typhoid-paratyphoid group;
- albumin (malnutrition);
- a general urine test to diagnose kidney damage.

Additional laboratory tests:
- vitamin B12 to determine the causes of possible anemia;
- folic acid to determine the causes of possible anemia;

Determination of the level of perinuclear antineutrophil cytoplasmic antibodies (pANCA) for differential diagnosis with ulcerative colitis;
- determination of the level of antibodies to Saccharomyces cerevisiae (ASCA) to confirm the diagnosis and differential diagnosis with ulcerative colitis;

Determination of calprotectin in feces - a specific protein as a marker of inflammation and oncological processes in the intestine;
- fibrinogen, factor V, factor VIII, antithrombin III, as markers of hypercoagulation characteristic of Crohn's disease.

Note. Laboratory data may vary significantly:
- in the process of exacerbation;
- for forms of varying severity;
- with different localization of the process.

Differential diagnosis

Differentiated from any lesions of the small/cecal intestine, ileocecal zone.

Complications

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Treatment

The choice of treatment is determined by the location and severity of the disease.

Diet

To prevent intestinal obstruction, patients are advised to avoid foods rich in insoluble fiber that are difficult to digest (raw vegetables, roasted corn, seeds and nuts). This obstruction may be due to a narrowing or stricture caused by inflammation in the small intestine.
No other dietary restrictions are recommended, although patients are generally advised to avoid any foods that aggravate their condition. In addition, the diet is used to correct protein and micronutrient deficiencies.

Activity
The goal of therapy for Crohn's disease is to allow patients to maintain a normal lifestyle without restrictions. Patients with osteoporosis due to treatment with systemic corticosteroids should exercise caution when moving and avoid certain sports to minimize the risk of fractures.

Moderate and severe exacerbation:
- prednisolone orally 40-60 mg/day (on average for 7-28 days until symptoms disappear), then gradual withdrawal (5-10 mg per week) or budesonide orally 9 mg/day (mainly if the ileocecal area is affected);
- for abscesses - antibacterial therapy and drainage of the abscess;
- infliximab intravenously slowly once 5 mg/day;
- azathioprine orally 2.5 mg/kg per day;
- methotrexate subcutaneously or intramuscularly 25 mg per week.

Severe or fulminant forms:
- when diagnosing an abscess - drainage; daily carrying out a set of laboratory tests, a plain X-ray of the abdominal cavity for early diagnosis of complications;
- prednisolone equivalent intravenously 40-60 mg/day (gradually reducing the dose by 5-10 mg per week until a daily dose of 20 mg is reached, then by 2.5-5 mg per week until complete withdrawal);
- parenteral nutrition and other resuscitation measures in the appropriate department (blood transfusions, administration of fluids, electrolytes);
- broad-spectrum antibiotics;
- if there is no effect from intravenous corticosteroids, intravenous cyclosporine is indicated;
- infliximab intravenously slowly once 5 mg/kg;
- after 5 days, the indications for emergency surgery are determined.

With these forms, the patient must be hospitalized.

Perianal lesion:
- metronidazole orally 10-20 mg/kg per day for 2-3 months;
- metronidazole orally 10-20 mg/kg per day + ciprofloxacin orally 500 mg 2 times a day for 2-3 months;
- infliximab IV slowly 5 mg/kg, repeated infusions after 2-6 weeks.

Maintenance therapy
After surgery for Crohn's disease, aminosalicylates (more than 3 g/day), azathioprine or 6-mercaptopurine are used to prevent relapse. After using corticosteroids in the acute phase of the disease, you should switch to maintenance therapy with azathioprine or 6-mercaptopurine (the result of treatment can be assessed after 3-4 months).

Surgery

Due to the development of complications, approximately 60% of patients require surgical treatment.

For Crohn's disease, surgical treatment does not cure patients. Over the past decades, a concept has emerged according to which surgical methods are used only to treat complications that are not subject to conservative therapy. This is due to the frequent development of severe manifestations of short bowel syndrome in patients after extensive radical removal of various parts of the intestine.

Absolute indications for surgical treatment are intestinal perforation, intestinal bleeding, toxic megacolon, involvement in

Urinary tract process.
Relative indications: fistulas, chronic partial intestinal obstruction, abscess formation of infiltrate in the abdominal cavity.

Forecast

Adults

Crohn's disease is characterized by periodic remissions and exacerbations. The recurrence rate within 10 years is 90%, and the cumulative probability of situations requiring surgical treatment over 10 years is approximately 38%.
According to available data, about 80% of patients who are in remission for 1 year will remain in remission for subsequent years. Patients with active disease in the current year have a 70% chance of having clinical disease activity in the next year.

Independent risk factors for surgery:
- localization in the terminal ileum;
- formation of fistulas and strictures.

Surgery for Crohn's disease is usually performed for complications (stricture, stenosis, obstruction, fistula, bleeding or abscess). It should be borne in mind that relapse of the disease, even after surgery, is high, including at the site of surgical anastomosis.

Recurrences of perianal fistulas after medical or surgical treatment are observed in 59-82% of cases. In one study, one year after surgery for Crohn's disease, 20-37% of patients had symptoms suggestive of relapse, and endoscopic evidence of recurrent ileal inflammation in 48-93% of cases.

In general, the quality of life of patients with Crohn's disease tends to be lower than that of patients with ulcerative colitis.
Data show that in individuals with involvement of the entire colon, the risk of developing a malignant tumor is equal to that of individuals with ulcerative colitis. In most patients with Crohn's disease localized to the small intestine, the risk of colorectal cancer is reduced.
In the future, the risk of developing bowel cancer in patients with Crohn's disease may increase due to the development of effective therapy and, accordingly, longer survival of these patients.

Children

Although Crohn's disease can have a significant impact on a child or teenager's life, with appropriate treatment and support the prognosis is good and the risk of death is extremely low.
Severe Crohn's disease can lead to prolonged hospitalization, multiple surgical procedures, growth retardation, malnutrition, delayed sexual development, and poor quality of life.

Hospitalization

In cases of severe Crohn's disease and/or the development of complications, patients are hospitalized in a therapeutic (gastroenterological) or surgical hospital. All patients are subject to dispensary observation.

Prevention

Prevention has not been developed.
To prevent repeated exacerbations and complications of the disease, careful medical supervision of patients and the patient’s compliance with the appropriate instructions of the attending physician (conducting anti-relapse therapy, routine examinations) are recommended.
The key to the success of preventive measures is largely the degree of trust the patient has in his attending physician.

Information

Sources and literature

1. Ivashkin V.T., Lapina T.L. Gastroenterology. National leadership. Scientific and practical publication, 2008
   1. p.478
2. "Diagnostic Accuracy of Point-of-Care Fecal Calprotectin and Immunochemical Occult Blood Tests for Diagnosis of Organic Bowel Disease in Primary Care...", "Clinical Chemistry", vol. 58 no. 6, June 2012
   1. Liselotte Kok, Sjoerd G. Elias, Ben J.M. Witteman, Jelle G. Goedhard, Jean W.M. Muris, Karel G.M. Moons and Niek J. de Wit
3. ACR Appropriateness Criteria® Crohn disease. . Reston (VA): American College of Radiology (ACR); 2011
   1. Fidler JL, Rosen MP, Blake MA, Baker ME, Cash BD, Charron M, Greene FL, Hindman NM, Jones B, Katz DS, Lalani T, Miller FH, Small WC, Sudakoff GS, Tulchinsky M, Yaghmai V, Yee J
4. Dorofeev A.E., Crohn's disease: classification, diagnosis and treatment, "News of Medicine and Pharmacy", No. 5 (356), 2011
5. http://emedicine.medscape.com
6. wikipedia.org (Wikipedia)
   1. http://ru.wikipedia.org/wiki/Crohn's disease

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