Ulcerative colitis 3. Nonspecific ulcerative colitis

Treatment of nonspecific ulcerative colitis depends on the localization of the pathological process in the intestine, its extent, the severity of the attacks, and the presence of local and systemic complications.

The main goals of conservative therapy:

pain relief,
prevention of relapse of the disease,
preventing the progression of the pathological process.

Ulcerative colitis of the distal intestine: proctitis and proctosigmoiditis are treated on an outpatient basis, as they have a milder course. Patients with total and left-sided lesions of the colon are treated in a hospital setting, since they have more pronounced clinical manifestations and there are great organic changes.

Nutrition of the sick

The diet for ulcerative colitis should spare the intestines, help increase its regenerative abilities, eliminate fermentation and putrefactive processes, and also regulate metabolism.

Sample menu for ulcerative colitis:

Breakfast - rice or any other porridge with butter, steamed cutlet, tea;
Second breakfast - about forty grams of boiled meat and berry jelly;
Lunch - soup with meatballs, meat casserole, dried fruit compote;
Dinner - mashed potatoes with fish cutlet, tea;
Snack - baked apples.

Drug treatment

Treatment of ulcerative colitis of the intestine is carried out in three main directions:

preventing or stopping internal bleeding;
restoration of water-salt balance in the body;
cessation of pathogenic effects on the intestinal mucosa.

Phytotherapy

Infusions from medicinal herbs have a mild restorative effect: they envelop the damaged intestinal mucosa, heal wounds, and stop bleeding. Herbal infusions and decoctions can replenish fluid loss in the body and restore water and electrolyte balance.

The main components of medicinal herbal mixtures are:

The leaves and fruits of currants, raspberries and strawberries help the liver fight any acute inflammatory process in the body.
Dried blueberries cleanse the intestines of putrefactive microorganisms and help in the fight against cancer cells.
Nettle improves blood clotting, relieves inflammation, and cleanses the intestines of decay and putrefaction products.
Peppermint fights emotional lability, diarrhea, relieves inflammation and spasms, and has a pronounced antimicrobial effect.
Chamomile is a powerful herbal antibiotic that can also relieve spasms.
Yarrow stops diarrhea, has bactericidal properties and cleanses the intestines of pathogenic microorganisms.
St. John's wort stimulates motor activity intestines and has an anti-inflammatory effect.

These herbs are used to treat ulcerative colitis in the form of infusions and decoctions. They are combined into collections or brewed separately.

Dry raspberry leaves and branches are poured with boiling water and left for half an hour. Take one hundred milliliters four times a day before meals.
A collection of medicinal herbs is prepared as follows: mix a teaspoon of centaury grass, sage leaves and flowers pharmaceutical chamomile. Then pour a glass of boiling water and leave for thirty minutes. Drink one tablespoon every two hours. After three months, the intervals between doses of the infusion are lengthened. This treatment is harmless and can last for a long time.
Peppermint leaves are poured with boiling water and left for twenty minutes. Take a glass twenty minutes before meals. An equally effective remedy for colitis is an infusion of strawberry leaves, which is prepared in a similar way.
Fifty grams of fresh pomegranate seeds are boiled over low heat for half an hour, poured with a glass of water. Take two tablespoons twice a day. Pomegranate decoction is a fairly effective remedy for allergic colitis.
One hundred grams of yarrow herb is poured with a liter of boiling water and left for a day in a closed container. After straining, the infusion is boiled. Then add one tablespoon of alcohol and glycerin and stir well. Take thirty drops half an hour before meals for a month.
Mix equal quantities of sage, peppermint, chamomile, St. John's wort and cumin. This mixture is placed in a thermos, poured with boiling water and left overnight. Since next day, take the infusion regularly, half a glass three times a day for a month.

Folk remedies

One hundred grams of dried watermelon rinds are poured into two glasses of boiling water and taken one hundred milliliters six times a day.
Eight grams of propolis should be eaten daily to reduce the symptoms of colitis. It must be chewed for a long time on an empty stomach.
Squeeze the juice from onions and take one teaspoon three times a day. This folk remedy is very effective in the treatment of ulcerative colitis.
The whey obtained by squeezing feta cheese is recommended to be taken twice a day.
Cores walnuts eaten regularly for three months. Positive results will become noticeable within a month from the start of treatment.
How to cure ulcerative colitis using microenemas? For this, starch microenemas are shown, prepared by diluting five grams of starch in one hundred milliliters of cool water.
Microenemas made from honey and chamomile, which are pre-brewed with boiling water, are considered effective. One enema requires fifty milliliters of solution. The duration of treatment is eight procedures.
Viburnum berries are poured with boiling water and viburnum tea is drunk immediately before eating.

Ulcerative colitis – chronic inflammatory process on the mucous membrane of the colon, accompanied by the appearance of non-healing ulcers, areas of necrosis and bleeding. The disease occurs predominantly in adults and only in 10% of cases in children.

Causes of the disease

Although the exact etiology of the disease has not been established, genetic predisposition is believed to play a major role in the occurrence of the pathology. Several factors can trigger the development of ulcerative colitis:

infection – viruses, bacteria and fungi;
treatment with antibiotics and, as a consequence, the development of dysbiosis that they cause;
uncontrolled use of oral contraceptives, since estrogens can cause vascular microthrombosis;
smoking;
dietary errors - excess food consumption, rich in fats and carbohydrates;
inactive lifestyle, sedentary work;
constant psycho-emotional stress;
disruptions in the immune system and pathological reaction body to autoallergens.

What happens in the body with ulcerative colitis

The disease can occur in any part of the large intestine. But the rectum is always involved in a pathological erosive-ulcerative process, which then gradually spreads to other areas.

During an exacerbation, the intestinal mucosa thickens due to edema, and its folds are smoothed out. The network of capillaries is expanded, so even after the slightest mechanical impact bleeding may begin. As a result of the destruction of the mucous layer, ulcers form different sizes. Pseudopolyps appear - intact areas of the mucous membrane on which the glandular epithelium has grown. The intestinal lumen is often dilated and its length is shortened. With a pronounced chronic process, haustra are absent or smoothed out - ring-shaped protrusions of the intestinal walls.

In depth, the ulceration does not penetrate into the muscular layer, but can only slightly affect the submucosal layer. The process itself, without clear boundaries, gradually spreads and affects new healthy areas of the large intestine. With a weakened immune system, a secondary infection may occur.

Classification of ulcerative colitis

Depending on the location of the process, the disease has its own classification:

regional colitis - the pathology affects a small specific area of the colon, but over time it can increase in size and become more severe;
total colitis is an inflammation of the mucous membrane of the entire large intestine, which is very rare.

There are also several main forms of the disease:

left-sided colitis - the process is localized mainly in the descending and sigmoid intestine;
proctitis – inflammation of the rectal mucosa;
proctosigmoiditis - inflammation affects not only the mucous membrane of the rectum, but also the sigmoid.

Symptoms of the disease

The signs of the disease are somewhat different from the clinical manifestations of non-ulcerative colitis. They can be divided into general, specific and extraintestinal. Symptoms of ulcerative colitis from the side digestive system:

cramping pain in the abdomen localized predominantly on the left, which is difficult to relieve with medications;
diarrhea or unshaped chair mixed with mucus, blood or pus, worse at night or in the morning;
constipation that replaces diarrhea, which is caused by intestinal spasm;
bloating (flatulence);
frequent false urge to defecate (tenesmus), which occurs due to retention of feces above the area with inflammation;
spontaneous release of mucus, pus and blood (not during defecation) as a result of imperative (irresistible) urges.

General manifestations of the disease:

malaise, increased fatigue;
fever 37 – 390C;
decreased appetite and rapid weight loss;
dehydration.

Extraintestinal manifestations are concomitant pathologies that most often belong to the group of autoimmune diseases or have an idiopathic etiology. They may precede the manifestation of specific intestinal symptoms or appear after some time, sometimes even as complications. From the outside skin and mucous membranes:

nodular (nodular) erythema - inflammation of blood vessels and subcutaneous fat;
pyoderma gangrenosum – chronic ulcerative dermatitis, characterized by progressive skin necrosis;
aphthous stomatitis - inflammation of the oral mucosa with the formation of small ulcers - aphthous.

From the organs of vision:

uveitis and chorioditis – a group of inflammatory diseases of the choroid;
episcleritis and conjunctivitis;
retrobulbar neuritis;
keratitis.

From the musculoskeletal system and bone tissue:

arthralgia – joint pain;
Ankylosing spondylitis is a form of arthritis that affects the joints of the spine;
sacroiliitis - inflammation in the sacroiliac joint of the spine;
osteoporosis – decreased bone density;
osteomalacia – softening of bone tissue due to insufficient mineralization and vitamin deficiency;
ischemic and aseptic necrosis - necrosis of bone areas.

Liver damage and bile ducts, as well as the pancreas:

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primary sclerosing cholangitis is inflammation of the bile ducts with sclerosis, which leads to stagnation of bile and disruption of normal liver function.

Rare extraintestinal symptoms are glomerulonephritis, vasculitis and myositis.

Complications of ulcerative colitis

If treatment is ineffective or the patient seeks help late, serious complications may develop:

severe bleeding, which poses a direct threat to life;
toxic intestinal dilatation - stretching of the intestinal walls due to spasm of the underlying sections, which causes stagnation of feces, mechanical intestinal obstruction and severe intoxication of the whole body;
perforation of the colon - a violation of the integrity of the wall and the entry of feces into the abdominal cavity (after which the occurrence of sepsis or peritonitis is likely);
stenosis (narrowing) of the lumen of the large intestine and intestinal obstruction;
cracks anus and hemorrhoids;
infiltrative bowel cancer;
addition of a secondary infection;
damage to internal organs - pancreatitis, pyelonephritis, urolithiasis, hepatitis, amyloidosis, pneumonia.

Extraintestinal symptoms may also be complications. They not only aggravate the course of the disease, but also provoke the development of new pathologies. Complications of the disease can be identified using a review x-ray organs abdominal cavity without use contrast agent.

Diagnosis of ulcerative colitis

A complete examination of the patient to diagnose ulcerative colitis of the intestine, in addition to questioning and examination, includes a number of instrumental and laboratory procedures. Instrumental diagnostic methods:

fibrocolonoscopy (sigmoidoscopy) - the main endoscopic examination of the intestine, which will reveal pathological processes occurring in the mucous membrane - hyperemia and edema, ulcers, hemorrhages, pseudopolyps, granularity, will help clarify which parts are affected;
irrigoscopy - an X-ray examination of the large intestine using a barium mixture, which shows the expansion or narrowing of the intestinal lumen, its shortening, smoothing of the haustra (the “water pipe” symptom), as well as the presence of polyps and ulcers on the mucous membrane;
Hydro MRI of the intestine is a modern, highly informative method based on double contrasting of the intestinal walls (simultaneous injection of a contrast agent intravenously and into the organ cavity), which will help determine the boundaries of the inflammatory process and detect extraintestinal pathologies, for example, fistulas, tumors, infiltrates;
Ultrasound reveals indirect symptoms of the disease - changes in the intestinal lumen and its walls.

Laboratory diagnostic methods:

clinical blood test (increased number of leukocytes and ESR, decreased level of hemoglobin and red blood cells);
biochemical blood test (increased levels of C-reactive protein and immunoglobulins);
biopsy - histological examination of tissue samples;
stool analysis for fecal calprotectin is a special marker for diagnosing intestinal diseases, which in ulcerative colitis can increase to 100 - 150;
coprogram (presence of occult blood, leukocytes and erythrocytes).

For differential diagnosis with other diseases accompanied by similar symptoms, the following is carried out:

bacteriological culture of stool (to exclude infectious diseases, for example, dysentery);
PCR analysis – identification of pathogens based on their genetic material in samples.

Treatment of ulcerative colitis

If the disease proceeds without complications, the symptoms are not pronounced, in which case outpatient observation is sufficient. Basic treatment for ulcerative colitis includes several groups medicines.

Preparations of 5-aminosalicylic acid (aminosalicylates). They have an anti-inflammatory effect and promote the regeneration of the intestinal mucosa. These include mesalazine and sulfasalazine. Medicines containing mesalazine are the most preferred for treatment because they have fewer side effects and can act on different areas colon.
Hormonal therapy (Dexamethasone, Prednisolone). These drugs are used in complex treatment when aminosalicylates do not have the desired effect or the patient has a pronounced reaction to them. allergic reaction. But they do not participate in the healing processes of the mucous layer, but only help cope with inflammation.
Biological drugs (immunosuppressants). In cases where the form of colitis is resistant (resistant) to the effects hormonal medications, it is advisable to prescribe Cyclosporine, Methotrexate, Mercaptopurine, Azathioprine, Humira, Remicade or Vedolizumab (Entyvio). They promote tissue healing and reduce symptoms of the disease.

When treating ulcerative colitis, especially its distal form, it is necessary to combine oral medications with rectal agents for local treatment - suppositories, solutions with systemic hormones or aminosalicylates for enema, with foam. Very often, this method turns out to be the most effective compared to therapy with exclusively tablet medications, since they act mainly in the right part of the large intestine and rarely reach the inflammation that is located in the rectum. When administered rectally, the drugs quickly and in the required dose reach the desired site of inflammation and, at the same time, practically do not enter the systemic bloodstream, which means that side effects will be mild or absent altogether.

In severe cases, as well as with rapid (lightning-fast) development of the pathology, urgent hospitalization in a hospital is necessary. In this case, preference is given to parenteral administration of corticosteroids. Only after a week can the patient be transferred to oral administration drugs, and aminosalicylates are not prescribed simultaneously with hormones, since they are weaker than hormones and reduce their therapeutic effect. This course of treatment lasts at least 3 months. Besides basic therapy, it is necessary to carry out symptomatic treatment with the following groups of drugs:

hemostatic agents (Aminocaproic acid, Dicynon, Tranexam) for periodic bleeding;
antispasmodics (No-shpa, Papaverine) to eliminate spasms and normalize intestinal motility;
antibiotics (Ceftriaxone, Ciprofloxacin) when a secondary infection occurs and complications develop;
vitamin D and calcium supplements to prevent osteoporosis;
probiotics to normalize intestinal flora and improve digestion.

Prescribing anti-diarrhea drugs is considered controversial issue, as it is believed that they can lead to toxic intestinal dilatation. Treatment folk remedies It is possible only with the permission and under the supervision of a doctor in order to avoid the development of complications. Surgical intervention for nonspecific ulcerative colitis is necessary in the following cases:

when the course of the disease does not respond to conservative therapy, especially in the hormone-resistant form;
if there is a hormonal dependence that arose during treatment;
in the presence of absolute contraindications or severe adverse reactions when taking medications;
if there are complications or severe course of the disease, total spread of the pathological process, which can lead to the development of colon cancer.

The essence of the operation is excision of the affected part of the large intestine and the formation of an ileostomy or sigmostoma, followed by intensive local treatment V postoperative period– the use of hormonal therapy and mesalazine drugs, as well as antiseptics, antibiotics and astringents.

Diet for ulcerative colitis

The main diet for patients with diseases of the digestive system during periods of severe dyspeptic symptoms (diarrhea, flatulence) is diet No. 4 (types 4a or 4b). Its goal is to spare the mucous membrane of the tract as much as possible, without injuring it mechanically and chemically, and also to prevent the processes of fermentation and decay. This diet lasts approximately 2 - 4 weeks, after which the patient can switch to table No. 4b, which is more complete and is quite suitable for nutrition during the period of remission. Basic Rules dietary nutrition in case of nonspecific ulcerative colitis:

food should be complete, high-calorie, balanced and rich in vitamins;
meals in small portions 6 times a day (for diarrhea - every 2 - 2.5 hours);
all dishes must be prepared only from steamed or boiled products;
consume foods rich in calcium and potassium more often;
the bulk of food should be eaten in the first half of the day;
last meal – no later than 19.00;
if one of the symptoms of the disease is diarrhea, then you need to limit or even temporarily eliminate the consumption of foods that can cause increased intestinal motility and excess secretion (milk, brown bread, raw vegetables and fruits);
if the disease is accompanied by flatulence, cabbage, fresh bread and legumes should be removed from the menu;
at frequent constipation include in the diet dairy products, buckwheat porridge, bran bread and raw vegetables - grated carrots, beets.

What foods should not be consumed during an acute process and what is allowed during remission:

exclude from the menu foods rich in fiber (raw vegetables), as well as fatty, fried, salty and spicy foods, all spices, seasonings, canned food and alcoholic drinks;
sweets (chocolate, candies), fast food products (chips, popcorn, crackers) and carbonated drinks are also prohibited;
consume milk and dairy products infrequently and carefully;
fish, lean meat, soups, cereals, potatoes and boiled eggs (or steam omelet) are allowed;
As desserts, you can use fruit jelly, curd soufflé, and for drinks - jelly, tea, rosehip and blueberry decoctions, as well as cocoa in water.

Disease prognosis

Knowing exactly what ulcerative colitis is and how to treat it, we can say with confidence that the prognosis of the disease is quite favorable. The pathological process is curable thanks to modern methods of therapy. Most patients experience complete remission, and only 10% of cases retain mild clinical symptoms.

Nonspecific ulcerative colitis - long-term ongoing inflammatory disease intestines.

The peak incidence of ulcerative colitis occurs in the age period from 20 to 40 years. The disease occurs slightly more often in men than in women (1.4:1), and in urban residents more often than in rural areas.

Among the factors contributing to the development of the disease, one should primarily mention hereditary predisposition. In relatives of patients, the risk of developing it is 10 times higher than in the entire population.

If both parents suffer from ulcerative colitis, the risk of developing it in a child by age 20 increases to 52%.

Factors that prevent the occurrence of ulcerative colitis include smoking. Smokers have a lower risk of developing the disease than non-smokers or people who have stopped smoking. A convincing explanation for the protective effect of smoking in ulcerative colitis has not yet been given. It is assumed that smoking reduces blood flow in the rectal mucosa, resulting in a decrease in the production of inflammatory agents.

Manifestations of nonspecific ulcerative colitis

The picture of nonspecific ulcerative colitis depends on the prevalence of the disease and the severity of inflammation.

The leading symptoms are bleeding from the rectum and loose stool. The frequency of stools is on average 4 to 6 times a day. At severe course it reaches up to 10-20 times a day or more. The volume of feces is usually small. In some cases, during bowel movements, only blood and pus mixed with mucus are released.

Sometimes patients complain of a false urge to defecate and a feeling of incomplete bowel movement. Unlike patients with functional intestinal disorders, stool in patients with ulcerative colitis also occurs at night.

Some patients, especially those with rectal involvement, may experience constipation. Their occurrence is most often explained by a painful spasm of the rectum.

Approximately 50% of patients experience abdominal pain.

Almost 60% of patients have extraintestinal manifestations - various lesions of the joints, eyes, skin, oral cavity, and liver.

In some cases, these lesions may precede the onset of intestinal symptoms.

The diagnosis of ulcerative colitis is based on the results of x-ray, endoscopic and histological examinations.

Complications

Complications of nonspecific ulcerative colitis are:

intestinal bleeding;
rupture of the intestinal wall;
formation of fistulas and abscesses;
narrowing of the intestinal lumen and development in long-term period colorectal cancer.

Treatment of ulcerative colitis

Patients with exacerbation of nonspecific ulcerative colitis are subject to hospitalization, preferably in a specialized gastroenterological or coloproctological department. In severe cases, patients are temporarily prescribed feeding through a tube.

The main drugs used to treat ulcerative colitis remain corticosteroids and 5-aminosalicylic acid preparations.

Corticosteroids are used for severe and moderate disease.

Prednisolone is prescribed at 60 mg/day. 4-6 weeks after achieving remission of the disease, the dose of the drug is reduced over 8 weeks (by 5-10 mg per week) until a maintenance dose is established (10-15 mg per week) or until prednisolone is completely discontinued with a transition to taking 5-aminosalicylic acid. acids.

For isolated ulcerative proctitis or proctosigmoiditis, 100 mg of hydrocortisone is prescribed morning and evening in enemas or in the form of foam. In very severe cases, hydrocortisone is administered intravenously (100 mg/day) for 10-14 days.

Topical corticosteroid medications include beclomethasone dipropionate, budesonide, and fluticasone dipropionate.

An important place in the treatment of ulcerative colitis is occupied by sulfasalazine and 5-aminosalicylic acid preparations (mesalazine). Sulfasalazine (3-4 g/day) is used less and less due to its significant frequency and severity side effects. For proctitis and proctosigmoiditis, they are prescribed in suppositories (1.5 g/day) or enemas (4 g).

For common forms of the disease, 5-aminosalicylic acid preparations are used in tablets (1.5-3 g) in combination with glucocorticoids. After achieving clinical and laboratory remission, mesalazine is used for long-term maintenance therapy to prevent exacerbations of the disease.

For exacerbations of ulcerative colitis that are resistant to corticosteroid therapy, the use of cyclosporine, which is usually prescribed at a dose of 4 mg/kg intravenously or 10 mg/kg, may be effective. Cyclosporine should be used with great caution due to its toxicity and high incidence of side effects.

An alternative in the treatment of resistant forms of ulcerative colitis may also be the administration of azathioprine (1-2 mg/kg per day) or methotrexate (15-25 mg/week intramuscularly). When using methotrexate, you also have to take into account its high toxicity.

Absolute indications for surgery for nonspecific ulcerative colitis are rupture of the intestinal wall, massive bleeding or the occurrence of colorectal cancer.

Relative indications for surgery are the development of toxic colitis, as well as the ineffectiveness of conservative therapy, especially in the formation of severe pseudopolyposis.

Forecast

Modern treatment methods are effective in 85% of patients with mild or moderate ulcerative colitis. Most patients achieve complete remission. Moderate clinical manifestations persist in 10% of patients.

The long-term prognosis is characterized by an increased risk of colon cancer. The diagnosis is based on colonoscopy findings. Treatment involves the appointment of 5-aminosalicylic acid, corticosteroids, immunomodulators, anticytokine drugs, antibiotics, and in some cases, surgery.

Causes of Ulcerative Colitis

Unknown. It is believed that the cause may be various bacteria, viruses or their metabolic products.

Pathomorphology. The surface of the ulcers is covered with fibrin or purulent contents. The intestinal wall thickens, the intestine narrows, and shortens. When ulcers heal, pseudopolyps are formed, which can lead to the development of carcinoma colon.

Pathophysiology

UC usually begins with damage to the rectum. The process may remain localized at this level (ulcerative proctitis) or spread proximally, sometimes affecting the entire colon. In rare cases, colitis involves a large part of the colon from the very beginning.

Inflammation within UC affects the mucous membrane and submucosal layer, characterized by the presence of a clear boundary between healthy and affected tissue. The muscle layer is affected only in severe cases. In the early stages, the mucous membrane is erythematous, the surface is covered with small granules, is easily vulnerable, the normal vascular pattern disappears, and scattered hemorrhagic elements are often detected. For severe forms characterized by large ulcerations of the mucous membrane with copious purulent discharge. Islands of relatively intact or inflamed hyperplastic mucosa (pseudopolyps) protrude above the ulcerated surface. The formation of fistulas and abscesses is not observed.

Toxic, or fulminant, colitis is observed with transmural spread of the ulcerative process. Over the course of several hours or days, the colon loses its ability to maintain tone and begins to expand.

The term "toxic megacolon" can be misleading because... inflammation with intoxication and complications can occur without the development of obvious megacolon (a sign of the latter is an increase in the diameter of the transverse colon > 6 cm during an exacerbation). Toxic colitis - emergency, which usually develops spontaneously with very severe colitis, but can be triggered by taking opioids or antidiarrheal drugs with anticholinergic action. This condition carries the risk of colon perforation, which significantly increases the likelihood of death.

Classification of ulcerative colitis

Ulcerative colitis is classified:

By clinical course- typical and fulmicant; chronic form (recurrent and continuous);
localization - distal (proctitis, proctosigmoiditis); left-sided (to the middle of the transverse colon); subtotal; total (pancolitis); total with reflux ileitis (against the background of total colitis, the area is involved in the process ileum);
severity of clinical manifestations.

Symptoms and signs of ulcerative colitis

Bloody diarrhea of varying severity and duration is followed by periods of absence of symptoms. As a rule, the attack begins unexpectedly, with the appearance of an urgent urge to defecate, mild cramping pain in the lower abdomen, and blood and mucus in the stool. In some cases, symptoms of exacerbation develop due to infection (amoebiasis, shigellosis).

At ulcerative lesion In the rectosigmoid region, the stool is normal or dense and dry, but during bowel movements or between episodes of bowel movement there is mucus discharge with blood and leukocytes. There are no systemic manifestations, or they are mild.

With a more proximal spread of the ulcerative process, the stool becomes unformed (frequency > 10 per day, often with severe cramping pain and painful tenesmus that continues at night. The stool may be watery, contain mucus, or consist entirely of blood and pus.
Toxic, or fulminant, colitis manifests with sudden appearance severe diarrhea, fever up to 40 ° C (104 ° F), abdominal pain, signs of peritonitis (in particular, the phenomenon of “rebound pain”), severe intoxication.

Systemic manifestations that are most characteristic of widespread colitis include general weakness, fever, anemia, anorexia, and weight loss. Extraintestinal symptoms (especially joint and skin damage) are very characteristic of forms of the disease with pronounced systemic manifestations.

Proctitis is more common than total colitis. When the rectum is involved in the process, the patient complains of constipation and tenesmus.

Extraintestinal manifestations of UC associated with the activity of colitis - peripheral arthropathy, erythema nodosum, episcleritis, aphthous stomatitis, pyoderma gangrenosum, anterior uveitis; not associated with colitis - sacroiliitis, ankylosing spondylitis, primary sclerosing cholangitis; rare manifestations - pericarditis, amyloidosis.

Diagnosis of ulcerative colitis

Microbiological examination and microscopy of stool (to exclude infectious pathology).
Sigmoidoscopy with biopsy.

Endoscopic examination reveals swelling, inflammatory infiltration, muco-bloody effusion and contact bleeding. In severe cases, erosions and ulcers are found, the bottom of which is covered with pus.

Beginning of the disease. The presence of a disease can be suspected typical symptoms, especially in combination with extraintestinal manifestations and when indicating previous similar attacks. Ulcerative colitis must be differentiated from Crohn's disease, but more importantly - from other forms of acute colitis (in particular, infectious, ischemic in the elderly).

In each case, a stool culture test for pathogenic intestinal microflora, it is also necessary to exclude the presence of Entamoeba histolytica in fresh stool samples. If medical history (epidemiological situation, travel) gives reason to suspect amebiasis, it is necessary to carry out histological and serological research. Indications of previous antibiotic use or hospital stay necessitate evaluation of stool for the presence of Clostridium difficile toxins. Patients at risk should be tested for HIV infection, gonorrhea, herpes virus infection, chlamydia and amoebiasis. Women may develop colitis induced oral contraceptive mi; As a rule, it resolves on its own after stopping the medication.

It is necessary to perform sigmoidoscopy, because This study allows you to confirm the presence of colitis, and take mucus and feces for cultural and microscopic examination, as well as material for histological examination from the affected areas. Although endoscopy and biopsy may not provide diagnostic information ( Various types colitis have similar features), yet acute self-limiting infectious colitis can usually be distinguished from ulcerative colitis and Crohn's disease. Severe perianal lesions, the absence of inflammation in the rectum, bleeding, and the asymmetrical or segmental nature of the lesions of the colon are more in favor of the presence of Crohn's disease than ulcerative colitis. The need for colonoscopy arises in isolated cases when inflammation extends proximal to the level of reaching the sigmoidoscope.

Laboratory tests are carried out to exclude anemia, hypoalbuminemia, and electrolyte metabolism disorders. Liver tests should be assessed; increased activity alkaline phosphatase and angleamyl transpeptidase may indicate the presence of primary sclerosing cholangitis. The presence of antibodies to Saccharomyces cerevisiae is relatively specific for Crohn's disease. However, these studies do not reliably distinguish between UC and CD and are not recommended for use in daily practice. It is also possible to have leukocytosis, thrombocytosis and increased acute phase parameters (ESR, C-reactive protein).

At X-ray examination Pathological changes can be detected, but it is difficult to make an accurate diagnosis. An X-ray of the abdominal cavity reveals swelling of the mucous membrane, smoothness of the haustra and the absence of formed feces in the affected colon. With irrigoscopy, changes are revealed more clearly, ulcerations can also be detected, but the study cannot be carried out in the acute phase of the disease. After several years of illness, a shortened, rigid colon with mucosal atrophy or the presence of pseudopolyps may be detected. X-ray signs The “thumbprint” and segmental nature of the lesion is more characteristic of ischemic colitis or Crohn's disease.

Fulminant course. In case of severe exacerbation, a more in-depth examination is necessary. X-rays are taken; The images may reveal signs of megacolon - accumulation of gas in the lumen of an extended segment of the intestine, which is in a paralytic state as a result of the loss of the ability of smooth muscle cells to maintain tone. Colonoscopy and irrigoscopy should be avoided due to the risk of perforation. It is necessary to obtain the result of a general blood test with an assessment of ESR, tests for electrolytes, prothrombin time, partial thromboplastin time, blood group and Rh factor.

The patient's condition should be closely monitored for signs of developing peritonitis or perforation. Assessment of hepatic dullness using percussion allows us to identify the first clinical sign free perforation - the disappearance of dullness, especially in patients receiving high doses of corticosteroids, but “erases” the symptoms of peritoneal irritation. Every 1-2 days, an x-ray of the abdominal cavity is performed to monitor the condition of the dilated area of the intestine and identify free or intramural gas.

Course and prognosis of ulcerative colitis

Ulcerative colitis is a chronic, lifelong inflammatory disease in which the immune system (which normally fights infections) attacks your colon, causing ulcers and bleeding from the lining of the colon. Symptoms usually occur during periods of exacerbation (we call them “attacks” of the disease) and can persist for months and sometimes years. These exacerbations may occur differently in different patients and may be accompanied by abdominal pain, diarrhea, including blood, nausea, vomiting and/or weight loss. This leads to a decrease in quality of life, frequent visits to the doctor and hospitalizations, and in some patients it becomes an indication for removal of the colon due to worsening of the disease. Most patients experience about two exacerbations of the disease within 5 years, but in some patients the disease may progress differently. In many untreated patients, UC tends to progress over time. Exacerbations occur more frequently and become more severe, increasing the likelihood of hospitalization and even surgery to remove the colon (colectomy). In addition, if left untreated, UC patients have an increased risk of developing colon cancer over time.

After establishing a diagnosis, so that exacerbations occur less frequently and are easier, it is recommended to immediately prescribe treatment. Due to the development of new drugs, the likelihood of worsening the disease is now less than it was a couple of decades ago. These treatments also reduced the need to remove the colon (colectomy) and may have reduced the risk of colon cancer. It is important to understand that UC persists throughout life and medications cannot cure it, but are extremely effective in controlling the disease.

Ulcerative colitis is a chronic inflammatory disease characterized by repeated acute exacerbations followed by periods of remission. Previous population-based studies have shown that without treatment, these patients have an increased risk of colorectal cancer (CRC) and mortality, although this risk has decreased in recent decades due to the successful use of immunosuppressants and biological therapies. Uncontrollable pathological process can spread throughout the colon, leading to systemic manifestations that may require colectomy.

The course of the disease depending on the extent of the lesion

Depending on the extent of the lesion, ulcerative colitis is divided into ulcerative proctitis, left-sided colitis and widespread (total) colitis. The Montreal classification includes the extent of the lesion, severity of symptoms (number of bowel movements per day) and signs systemic disease(erythrocyte sedimentation rate, temperature, hemoglobin). Determining the severity of the disease and the extent of the lesion is convenient for prognosis. Ulcerative proctitis is the most common form of the disease (30-60%), and left-sided (10-40%) and widespread colitis (10-35%) are less common. The risk of proximal disease spread is estimated to be 10-20% over 5 years, rising to 30% over 10 years.

The extent of the lesion is a major determinant of disease spread throughout the intestine, which may reflect disease activity and worsen disease outcome. In patients with ulcerative proctitis, the disease transforms into widespread colitis with a frequency of 14% within 10 years from the date of diagnosis. According to the Norwegian IBSEN study, with left-sided colitis, the incidence of spread of the affected area was higher - 28%. Independent factors predicting proximal disease extension include young age at diagnosis and primary sclerosing cholangitis (PSC) in a prospective study of 420 patients. The average time to transformation of proctitis into left-sided or widespread colitis in this study was 5.25 years.

Expected frequency of exacerbations of the disease

Most patients with UC experience at least 2 exacerbations within 5 years, but less than 1 exacerbation per year on average. In approximately half of the patients included in the Norwegian IBSEN study, the exacerbation at which the diagnosis was made was also the most severe, and in 1/3 subsequent relapses were of the same frequency as the first. Patients with a younger age at diagnosis generally experienced exacerbations more often. Patients who were diagnosed after age 50 were found to have fewer exacerbations and were less likely to undergo colectomy. These patterns were also confirmed in the multicenter IBD study of the European Commission.

Long-term complications

The progression of UC can lead to the formation of benign strictures of the colon due to hypertrophy and irreversible contraction of the muscular layer of the mucosa, which actually separates from the submucosal layer. These strictures cause serious difficulties, since in their presence it is impossible to completely exclude a hidden malignant process in the area of narrowing, and therefore they become an indication for surgery. In addition, when long term In UC, the number of neuroglial cells decreases, which leads to impaired motility and persistent diarrhea, despite the healing of the mucous membrane detected by endoscopy, as well as impaired sensitivity of the rectum, accompanied by urgency and incontinence associated with inhibition of the reservoir function of the rectum. These changes may persist even after the mucosa has healed, which may explain why some patients continue to experience symptoms even in the absence of active inflammation.

Risk of Colectomy

Colectomy is an intervention that leads to healing from UC and significantly improves general state health, but for some patients, living with an ostomy or J-pouch can be extremely difficult. About 50% of colectomies for UC are performed according to urgent indications. Colectomy has not been shown to reduce mortality, but undue refusal of timely surgery increases the incidence of postoperative complications and mortality. The rate of colectomy has decreased in recent years: two independent studies have shown that the annual rate of colectomy for UC has decreased from 9% in 1962-1987. up to 6% in 2003-2005 This decrease appears to be due to more widespread use azathioprine/mercaptopurine recently. In a recently published European Commission IBD study, the mean colectomy rate for UC was 8.7% at 10-year follow-up. Differences in colectomy rates between northern (10.4%) and southern centers (3.9%) suggest that the disease is more severe in patients living in colder and sterile regions. Colectomies are performed in more than 90% of cases in patients with widespread and severe resistant colitis. As might be expected from the fact that most severe exacerbations develop early in the disease, about 2/3 of colectomies are performed in the first 2 years after diagnosis. The presence of widespread colitis at diagnosis was an independent predictor of colectomy over 10 years in the IBSEN study. The risk of colectomy in patients with widespread colitis is 4 times higher than in patients with ulcerative proctitis. However, the same study showed that patients with proximal colonic inflammation had a higher risk of colectomy than those with widespread colitis at diagnosis. In general, patients are more young (<30 лет), больные с распространенным колитом, скоростью оседания эритроцитов >30 mm/h and the presence of indications for corticosteroid therapy at the time of diagnosis are 15 times more likely to undergo colectomy.

The presence of systemic symptoms, such as weight loss and fever secondary to widespread colitis, further increases the risk of colectomy. At the same time, these factors do not affect the risk of exacerbation, which indicates that a severe attack of the disease fundamentally affects the outcome of the disease. A small proportion of patients with widespread colitis and systemic manifestations who managed to avoid colectomy during timely drug therapy had fewer exacerbations than patients without systemic symptoms (data from the IBSEN study and the Copenhagen cohort study). Epidemiologically identified patterns were confirmed and endoscopic examination: healing of the mucous membrane 1 year after the start of treatment in patients with widespread colitis with systemic symptoms predicted a good response to drug therapy.

Colorectal cancer

Inflammation of the colon mucosa and its damage by reactive oxygen species can lead to genetic changes and malignant growth. According to an analysis of the Belgian national registry, CRC in patients with UC in 73% develops in the area affected by colitis. Non-selective observation in the general population patients indicates that the cumulative incidence of CRC is 0.4 and 1.1% over 10 and 20 years, respectively.The overall risk of CRC in patients was comparable to the background risk of CRC in the general population, as shown by meta-regression analysis in the same study. the incidence of CRC in other studies was higher and reached 10-20% after 10-20 years from the onset of the disease, but mainly increased in patients with total colitis observed in specialized centers. More high frequency The occurrence of CRC was observed in patients with a longer duration of the disease, concomitant PSC and in those in whom the disease began at an early age. At the same time, in a Belgian study, greater age at diagnosis was identified as an independent risk factor for CRC, which developed quite early, up to 8 years from diagnosis. Advanced colitis, male gender, and young age at diagnosis were also factors associated with increased mortality in UC patients with CRC. The incidence of CRC in patients with UC has decreased in recent decades and in 1999-2008. was only 1/3 of that in 1979-1988, probably due to the successful use of biological drugs and immunosuppressants. The IBSEN study also confirmed existing evidence that CRC does not significantly increase mortality in UC compared with the general population. Currently, the prognosis for patients with UC is the same as in the general population: 5-year survival is about 50%. According to a meta-analysis that included 1932 patients with UC, taking 5-aminosalicylic acid (5-ASA) helps reduce the risk of colorectal cancer. The role of 5-ASA in the chemoprevention of CRC in UC, given the decreasing incidence of cancer, may not be as great as previously thought. In patients with UC with concomitant PSC, when the risk of CRC is significantly increased, taking ursodeoxycholic acid, which reduces the level of secondary bile acids, which are carcinogens that increase the risk of CRC, especially in the right parts of the colon, can be considered promising. However, 2010 guidelines recommended against the use of ursodeoxycholic acid as chemoprophylaxis for CRC, based on results from a prospective follow-up study showing that patients taking high doses of ursodeoxycholic acid had an increased incidence of dysplasia and CRC.

Screening for colorectal cancer in patients with UC is recommended to be carried out 8-10 years after the onset of total colitis and after 15 years in patients with left-sided colitis. Patients with ulcerative proctitis do not require additional monitoring. The frequency of further observation is determined by risk factors. A study based on the Belgian national registry showed that the time to development of colorectal cancer was independently influenced by: age at the onset of IBD and duration of IBD. Greater age at diagnosis of IBD predisposed to more rapid development CRR. A significant number of cases of colorectal cancer detection simultaneously with the first confirmation of ulcerative colitis in this study indicates the need for a more cautious approach to monitoring older patients. In patients with UC and PSC, the risk of CRC is increased by 3 times compared to individuals suffering from UC only. In this group of patients, the cumulative incidence of colorectal cancer was 33 and 40%, respectively, 20 and 30 years after diagnosis. In patients with UC with concomitant PSC, screening colonoscopy is recommended annually from the time of diagnosis. Patients newly diagnosed with PSC should undergo colonoscopy to identify possible concomitant UC. In addition, the risk increases 2-3 times in patients with UC who have close relatives who suffered from colorectal cancer. If a relative develops cancer before the age of 50, the risk of a patient with UC increases by 9 times. Chromoendoscopy has been shown to be superior to traditional colonoscopy with biopsies of random mucosal sites in identifying areas of dysplasia. Confocal laser endomicroscopy increases the frequency of detection of dysplasia foci by 2.5 times compared with chromoendoscopy and by 4.75 times compared with traditional colonoscopy with random biopsy.

The mortality rate of patients with UC is not increased compared to the general population. Some increase in mortality is found in patients over 60 years of age with concomitant diseases who underwent emergency colectomy.

Treatment of ulcerative colitis

Modern therapy of mild and moderate ulcerative colitis

Once the severity has been assessed and excluded infectious nature diseases, therapy for mild and moderate UC is determined by the extent of the lesion, which is determined by colonoscopy. The goal of treatment is to control active inflammation and maintain the achieved remission. Treatment active disease usually consists of a combination of topical and/or oral 5-ASA and corticosteroids. In the long term, maintenance therapy aims to reduce the duration of corticosteroid use due to its side effects (eg, infections and osteoporosis) and includes long-term use of 5-ASA, often with the addition of azathioprine. Regardless of drug choice, disease control is critical to reducing the overall risk of CRC in patients with a long history of the disease by reducing prolonged severe inflammation.

Mild to moderate active proctitis

The basis for the induction and maintenance of remission in mild and moderate UC is the use of 5-ASA drugs, which apparently act through the activation of nuclear receptors affecting inflammation, cell proliferation, apoptosis and metabolism epithelial cells colon. With active proctitis, treatment is directed directly to the rectum: in this situation, suppositories with mesalazine, according to a meta-analysis that compared the two dosage forms(oral and local), turned out to be more effective than taking the drug orally, and made it possible to achieve remission after 2 weeks. This drug is usually prescribed at a dose of 500 mg 2 times a day or 1 g/day and is considered to be safe, easily tolerated and effective in patients with active proctitis and distal colitis. The choice of local therapy depends on the extent of the lesion. The suppositories act for 10-15 cm, the foam reaches 15-20 cm, and the enema allows you to deliver the medicine to the left bend. Disadvantages of treatment include bloating and leakage of medication, which can lead to non-compliance with the treatment regimen. Local corticosteroids are also used to accelerate the induction of remission, but they are ineffective in maintaining it. At the same time, in left-sided colitis, topical steroids demonstrate efficacy comparable to systemic corticosteroids, with less suppression of cortisol levels. A complete response often cannot be achieved with local therapy alone. In this case, oral mesalazine is added to treatment, which has been shown to achieve faster and more complete relief of intestinal symptoms than with oral or rectal-only medications.

Mild to moderate distal active colitis

As with the lack of effectiveness of treatment for active proctitis, combination therapy increases the likelihood of achieving remission to a greater extent than monotherapy. The combination of enemas and oral mesalazine resulted in remission in 64% of patients compared with 43% receiving oral mesalazine and placebo enemas in a randomized, double-blind trial. At the same time, a dose-dependent effect is observed for oral therapy with 5-ASA. The ASCEND III study (a study to confirm comparable effectiveness) showed that of 389 patients receiving mesalazine extended release, when taking 4.8 g / day, treatment was effective in 70%, while when taking 2.4 g / day day the effect was observed in 66%. However, significantly more patients achieved clinical remission at weeks 3 and 6 of therapy when receiving 4.8 g rather than 2.4 g. In the ASCEND I study, comparing 4.8 and 2.4 g of the drug with a delayed release of mesalazine, statistically significant differences were found in the subgroup of patients with moderate active colitis: the effectiveness of treatment was 72 and 57%, respectively. Considering the relationship between side effects and therapeutic response, in patients with moderate forms of the disease it is preferable to prescribe high doses of the drug.

In general, 5-ASA preparations are affordable and easily tolerated. However, some patients experience varying degrees of nausea, vomiting, dyspepsia, and anorexia, which reduces compliance. More severe reactions include pancreatitis, hepatotoxicity, bone marrow suppression, interstitial nephritis and anemia. In addition, 5-ASA, namely sulfasala-1ine, can have an effect on the structure of spermatozoa, which disappears after the end of administration. In 1-2% of patients, 5-ASA therapy can worsen the course of UC and should be discontinued.

Mild to moderate widespread colitis

Patients with active inflammation extending beyond the distal colon should initially be treated with oral 5-ASA. It has been shown that taking 4.8 g of mesalazine per day reduces the time to normalization of stool frequency and the disappearance of blood impurities compared with a dose of 2.4 g. A decrease in symptoms by the 2nd week was observed in 73 and 61% of patients, respectively. In addition, symptomatic relief by day 14 of therapy predicts continued remission an additional 2 weeks later, making day 14 the point at which intensification of therapy should be considered. Oral prednisolone should be added to treatment if symptoms are not relieved by oral 5-ASA alone. Based on an acceptable ratio between the therapeutic effect and possible side effects, a dose of 20 to 60 mg is traditionally recommended. The relative risk of developing opportunistic infections with long-term use of corticosteroids is higher in patients over 50 years of age, so steroids are used with caution in them. Although randomized trials of different steroid tapering regimens have not been conducted, a slow tapering of 5 mg per week to 15-20 mg/day is usually recommended once symptoms have improved.

Inclusion of budesonide (Cortiment) in treatment regimens

Budesonide, which has minimal corticosteroid activity due to extensive first-pass hepatic metabolism, is now available as an alternative to prednisolone. Budesonide (Cortiment) is a sustained-release enteric-coated tablet that dissolves in the terminal ileum and is approved for the treatment of mild to moderate advanced UC. In a randomized comparison of the drug at a dose of 6 and 9 mg with mesalazine and placebo, the remission rate at week 8 was 17.9, 13.2 and 12.1%, respectively, with a placebo efficacy of 7.4%. Budesonide 9 mg was more effective than placebo in achieving clinical remission in patients with active mild to moderate UC. Since this drug does have side effects of traditional corticosteroids, the duration of its use should ideally be limited to 8 weeks.

Maintaining remission

Further therapy for remission of UC is determined by the extent of the lesion. Azathioprine or mercaptopurine may be used to overcome hormonal dependence or in patients with an insufficient response to aminosalicylates monotherapy. When compared within a randomized clinical trial 2 mg/kg azathioprine and 3.2 g mesalazine in hormone-dependent UC patients achieved clinical remission in 53% versus 21%, respectively. Side effects include depression of bone marrow function (primary leukopenia), abnormal liver function tests, and intolerance reactions such as fever, rash, myalgia, or arthralgia. Before prescribing these drugs, thiopurine methyltransferase genotype analysis should be performed as this allows dose selection and identification of patients at risk for possible drug toxicity. Long-term severe inflammation is a proven risk factor for neoplasia. The importance of mucosal healing should be emphasized, as this outcome of treatment not only reduces the risk of cancer, but also, as shown in a prospective study, reduces the risk of colectomy and further use of steroids.

Modern therapy of moderate and severe ulcerative colitis

Symptoms of UC result from inflammation of the large intestine, which consists of the colon and rectum. Most symptoms of UC are caused by inflammation of the rectum. The severity of your symptoms and some additional information can help you determine which therapy is right for you. For example, patients with 4 or more bowel movements per day or other manifestations such as fever or anemia are classified as having moderate to severe active colitis. Your current symptoms allow you to determine exactly the severity of the disease.

Your treatment will include a remission induction period, during which we will try to suppress inflammatory activity so you get better, and a second remission maintenance period, which aims to maintain your health and prevent future flare-ups. As a chronic disease, UC requires ongoing treatment in order to fully control the disease and avoid the low but possible risk of colorectal cancer.

For moderate UC, the most commonly used class of drugs is aminosalicylates. Aminosalicylates are a group of non-immune suppressive drugs that act locally on the intestinal wall to reduce inflammation. These drugs presented in various forms, are capable of inducing and maintaining remission of this form of UC and can be prescribed in combination with other treatments for more severe UC. To increase effectiveness, they are prescribed both orally and rectally. These drugs are extremely safe, but 3% of people may experience intolerance and even worsening diarrhea after starting to take them. There is also a very small risk of kidney failure, which periodic blood tests to assess kidney function can help rule out.

Most patients with moderate to severe UC require corticosteroids. Steroids are extremely effective and quick fix induction of remission, used mainly because of the speed of response to treatment. When taken short-term, they are generally safe, but we try in every possible way to reduce the duration of their use due to the danger of side effects with long-term use and quickly reduce the dose. Topical steroids in the form of a foam or enema may be used to treat the rectum and lower colon. The most common side effects of short-term steroid therapy are sleep disturbances, weight gain, anxiety, acne, and mood changes. Steroids are not suitable for maintaining remission. New type steroids - budesonide (Kortiment*) - acts predominantly locally, in the colon, and has fewer side effects than prednisolone, so it can be useful in the treatment of less severe forms of the disease.

In some patients with UC, another group of drugs that suppress the immune system, thiopurines, may also be effective. These drugs, which include azathioprine (Imuran® or Azasan) and mercaptopurine (Purinegol), are prescribed to help you stop taking steroids and avoid them in the future. Thiopurines are taken orally once a day. Their mechanism of action is not fully understood, although we know that they suppress the growth of white blood cells, which play a key role in the development of inflammation. Common but preventable side effects include a decrease in the number of white cells in the blood, which recovers when the drug is stopped and should be monitored with periodic blood tests. Some side effects depend on how a particular patient's body processes the medicine. Fortunately, you can understand how this happens using simple analysis blood before starting treatment. Rarer effects include infections and a small increase in the incidence of non-melanomatous skin cancer and lymphoma. This risk can be reduced by getting vaccinated against influenza and pneumonia and limiting exposure sunlight and having an annual checkup with a dermatologist. The risk of lymphoma is extremely small, but slightly increased compared to the general population. It increases with the duration of taking the drug and with the age of the patient, but is eliminated when therapy is stopped.

Another type of treatment is biological therapy, the use of anti-TNF drugs. They are antibodies to TNF, a mediator of inflammation. Because these are protein drugs, they must be administered intravenously or subcutaneously. There are currently three anti-TNF drugs approved for the treatment of UC in the United States, including infliximab (Remicade), adalimumab (Humira), and golimumab (Simponi). This therapy is extremely effective for this form of UC and becomes even more effective when combined with thiopurines. Side effects include a slightly increased risk of infection and, rarely, allergic reactions to treatment, which may also indicate loss of response. To protect patients from these reactions, we screen patients for tuberculosis and hepatitis B and vaccinate them against influenza and pneumonia before starting treatment.

A recent addition to our arsenal is vedolizumab (Entyvio), which is also an intravenous biologic but works by inhibiting the migration of white blood cells from the bloodstream into the intestine. Because of this specific mechanism of action, the use of vedolizumab represents a more targeted and fairly safe approach to the treatment of UC, although it does not significantly increase the risk of nasopharyngeal infections. Vedolizumab can be used for both induction and maintenance of remission.

In some cases, severe UC may require hospitalization, during which intravenous therapy is administered to achieve remission. A small proportion of patients have to perform surgery. Surgery for severe UC involves removing the entire colon and rectum. With the removal of the colon, a person is cured of UC. In most patients, it is possible to form a “new” rectum from the small intestine - a J-shaped reservoir.

Moderate active UC is characterized by the presence of four or more bowel movements per day with minimal overall impact of the disease on the body, while with severe UC, frequent, more than 6 times a day, bloody stools are combined with general changes body (fever, tachycardia, anemia or increased erythrocyte sedimentation rate).

The main goal of therapy is to induce remission, after which treatment is selected to prevent further use of steroids. In general, the choice of maintenance therapy is determined by which drug was required to induce remission. A more stringent criterion effective therapy One approach that is increasingly being used is endoscopic remission (mucosal healing), which reduces the need for corticosteroids, hospitalization, the risk of colectomy and cancer, and increases the chances of sustained clinical remission.

At lung treatment and moderate active UC, they initially prefer to prescribe aminosalicylates due to the convenience of selecting their dose and high safety. Sulfasalazine and daily dose 4-6 g is an effective and inexpensive means of inducing and maintaining remission, but more often leads to side effects. Mesalazine, olsalazine and balsalazide have the same proven effectiveness in inducing and maintaining remission in moderate-severe UC. Their effect is further enhanced by prescribing a dose of 4.8 g/day and simultaneous administration of the drug locally into the rectum in the form of suppositories or enemas. Intolerance to mesalazine is rare, in contrast to sulfasalazine, for which it is very common.

Many patients with moderately active UC and patients with severe UC must be prescribed treatments that affect the immune system. In patients with aminosalicylate failure or hormonal dependence, thiopurines may be effective, but their slow onset of action makes them unsuitable for inducing remission and therefore usually requires concomitant administration of steroids or anti-TNF agents. The use of thiopurines in UC does not have a qualitative evidence base; Thus, it is unclear whether they should be prescribed together with aminosalicylates or as monotherapy.

Under the action of the enzyme thiopurine methyltransferase, thiopurines are converted into 6-thioguanine and 6-methylmercaptopurine. The latter may cause an increase in liver enzyme levels. Achieving remission is due to the action of 6-thioguanine, but this same metabolite leads to suppression of bone marrow function in patients with low thiopurine methyltransferase activity in the presence of high levels of 6-thioguanine. In patients with normal thiopurine methyltransferase activity, the dose is selected based on body weight at the rate of 2-3 mg/kg azathioprine and 1-1.5 mg/kg mercaptopurine.

Currently a quality indicator medical care is to assess the activity of thiopurine methyltransferase before starting treatment with thiopurines. Lack of enzyme activity (0.3% of the population) is a contraindication to therapy. Patients with intermediate disease activity (11%) should initially receive a low dose of the drug (25-50 mg) and increase it gradually (25-50 mg/week), while patients with normal enzyme activity can begin treatment immediately with the full dose . Bone marrow function and changes in liver enzyme levels should be monitored. We also recommend periodic analysis of thiopurine metabolite levels to optimize therapy, although these studies are not included in the standards of care. Increases in liver enzymes and bone marrow depression are dose-related side effects, while for intolerance reactions such as fever, rash, arthralgia and myalgia, a different thiopurine is usually sufficient. There is still a 50% chance of cross-reaction. A common side effect of this class of drugs is pancreatitis, which requires permanent discontinuation of thiopurine therapy. In addition, taking thiopurines increases the risk of non-melanoma skin cancer, infections, including serious ones, and lymphoma.

Anti-TNF therapy is an effective treatment option for patients with moderate to severe active UC, patients with hormone-dependent and hormone-resistant disease, and patients with ineffectiveness or intolerance to aminosalicylates or thiopurines. Infliximab, adalimumab and golimumab are approved for use in the United States to induce and maintain remission of UC. The likelihood of inducing and maintaining remission, as well as healing of the mucous membrane, increases with simultaneous use anti-TNF drugs and thiopurines. Combination therapy also helps to reduce immunogenicity (the formation of antibodies to the drug) and increase the residual level of anti-TNF drug in the blood. Such data were obtained using infliximab/adalimumab in combination with azathioprine in UC, but recent studies indicate the advisability of prescribing methotrexate, which should be preferred in patients with increased risk lymphoma (men under 30 and over 50 years old). Data on combination therapy with golimumab are still accumulating.

Secondary loss of response to anti-TNF therapy has been well studied. If it occurs, infections and the possibility of accelerated elimination of the drug due to the formation of antibodies to it should be excluded. Test kits for infliximab and adalimumab are available on the market. serum levels and antibodies to drugs. In patients who have previously responded to anti-TNF therapy but then develop antibodies to the drug and the drug itself is not detectable in the serum, it is reasonable to prescribe a different anti-TNF drug. Recently, treatment tactics have been changing: we are trying to control not only the symptoms of the disease, but also endoscopic activity in order to prevent exacerbations and the development of colonic dysplasia, but a clear scheme for such monitoring has not yet been developed. At the same time, the use of fecal calprotectin for non-invasive monitoring of disease activity has received deserved attention.

Vedolizumab, an α 4 β 7 integrin inhibitor, is effective in inducing and maintaining remission in moderate to severe active UC, regardless of whether the patient has previously received anti-TNF drugs. Available data indicate its high safety, low immunogenicity and high sustained response rates.

Patients with fulminant UC or patients with severe UC and intolerance/ineffectiveness of induction of remission with maximum doses oral steroids, oral and topical aminosalicylates, and anti-TNF drugs require hospitalization and intravenous hormonal therapy. If remission is not achieved after 3 days of intravenous steroid treatment, there is an increased likelihood that further use will not be effective. In this situation, additional therapy with infliximab or calcineurin inhibitors should be considered.

Salvage therapy to induce remission with calcineurin inhibitors (tacrolimus or cyclosporine) avoids colectomy in 82% of patients with severe hormone-resistant colitis. After achieving remission, patients continue maintenance therapy with thiopurines or anti-TNF drugs. When switching from one immunosuppressant to another, careful monitoring of possible infectious complications is required. We recently described the use of calcineuron inhibitors to induce remission followed by maintenance therapy with vedolizumab. Within 10 years from the diagnosis of UC, colectomy is performed in a total of 10-17% of patients, and among patients hospitalized for severe UC, urgent colectomy is necessary in 27% of cases. The “gold standard” of surgery is multi-stage surgical treatment with the formation of an ileoanal pouch anastomosis (IAPA) using a hardware or manual method.

Nonspecific ulcerative colitis is one of the most mysterious gastroenterological diseases. The exact reasons for its development have not yet been determined, but effective treatment methods that can maximize the quality of life of a chronic patient have already been developed.

With nonspecific ulcerative colitis, the mucous membrane of the large intestine suffers. It becomes inflamed, causing the patient severe pain. Unlike viral or infectious diseases, when the pathogen enters the body from the outside, UC is an autoimmune pathology. It originates inside the body, with a certain failure of the immune system, the exact nature of which has not yet been determined. Accordingly, it is not possible to develop preventive measures that 100% guarantee protection against UC. There are only theories that allow us to talk about risk factors:

Genetic. Statistics have revealed that the disease has a family predisposition.
Infectious. Some experts suggest that UC occurs as a result of the body's reaction to the action of certain bacteria, which under normal conditions are non-pathogenic (safe). What exactly contributes to the modification of bacteria into pathogenic ones is not yet clear.
Immune. According to this theory, with UC there is an allergic reaction to certain components in the composition. food products. During this reaction, the mucous membrane produces a special antigen that comes into “confrontation” with the natural intestinal microflora.
Emotional. A less common theory is that UC develops against the background of prolonged deep stress.

The diagnosis of “nonspecific ulcerative colitis” is rapidly becoming younger. More than 70% of cases, according to statistics from the last twenty years, are teenagers and people under 30 years of age. Pensioners suffer from ulcerative colitis much less frequently. According to the latest statistics, the incidence is 1 case in approximately 14 thousand people.

Is it possible to be cured for good?

This question worries many who hear their diagnosis for the first time. Unfortunately, no doctor who calls himself a professional can guarantee a cure. The fact is that UC is a chronic disease, which means that the disease can only be “healed”, but not completely eliminated. Colitis has a cyclical course, that is, relapses (periods of exacerbation) alternate with months of stagnation, when the disease hardly manifests itself. The goal of therapy for UC is to delay the onset of relapse as much as possible, and when it occurs, to reduce the severity of symptoms.

Some patients, upon learning their diagnosis, panic, believing that they will have to spend the rest of their lives on a strict diet. Meanwhile, the emotional state of the patient is an important factor determining the success of therapy. Therefore, under no circumstances should you give up. Strict restrictions in nutrition are necessary only during the acute phase of the disease; during periods of remission, the diet is much softer.

Treatment options

Search effective techniques Treatments for UC have been ongoing since the 80s of the last century. Currently, the best results have been achieved with an integrated approach to therapy, combining different treatment methods:

taking medications;
diet;
psycho-emotional correction.

Surgical treatment of UC is also practiced, but in recent years there has been a tendency to replace surgical therapy with conservative therapy.

The treatment plan is developed based on the individual characteristics of the body (gender, age, presence of other chronic illnesses etc.). General treatment for ulcerative colitis has long proven ineffective. Therefore, before prescribing certain drugs or surgical intervention the patient must undergo a lengthy examination.

If a complete cure is not possible, therapy for ulcerative colitis sets itself the following tasks:

reduction of disease symptoms;
relapse prevention;
improving quality of life.

Video - Nonspecific ulcerative colitis: symptoms and treatment

Drug therapy for UC

The main group of drugs prescribed for the treatment of ulcerative colitis are anti-inflammatory drugs. Their goal is to stop the inflammatory process in the mucous membranes of the large intestine.

Glucocorticoids(Prednisolone, Hydrocortisone, Methylprednisolone). A group of medications that were the first to be used to reduce inflammation of the rectum. The greatest effectiveness of glucocorticoids is observed in the treatment of left-sided forms of UC. Previously, these medications were used in the form of enemas; in recent years, a special medicinal product—rectal foam—has become widespread. Glucocorticoid therapy demonstrates good results for moderate and severe forms of UC. The duration of the course is often no more than 10 days, then the question of the advisability of replacing glucocorticoids with drugs of another group is considered.
Sulfasalazine. This drug originally developed to combat bacterial infections. He showed high efficiency in the treatment of mild and moderate forms of inflammation of the rectal mucosa. Prescribed in the form of enemas or suppositories. The main disadvantage of this drug in the treatment of ulcerative colitis is the abundance of side effects even with a small overdose. Patients develop diarrhea, nausea, weakness, and severe abdominal pain. Therefore, a adjusted dosage is the main key to successful treatment with sulfasalazine.
Medicines group 5-ASK(aminosalicylic acid) - Mesacol, Mezavant, Kansalazine, Salofalk, etc. The effectiveness of UC therapy with these drugs is similar to that of sulfasalazine, but, unlike the latter, 5-ASA is less toxic to the body. Used as the main medicine for mild and moderate forms of colitis. May be prescribed in addition to glucocorticoid drugs.

Analysis of the effectiveness of a particular anti-inflammatory drug is carried out within a week from the moment of administration. If stabilization of the patient's condition is not observed, the drug is replaced with another.

Reducing mucosal inflammation is the main, but not the only task that a UC treatment plan should solve. In addition to anti-inflammatory drugs, your doctor may prescribe medications from the following groups:

Depending on the form of the disease and individual sensitivity to individual drugs a gastroenterologist can prescribe all of the above-described drugs, as well as drugs from groups 1-2.

When is surgery needed?

Currently, surgical intervention is prescribed in 10-15% of all cases of UC. At the beginning of the 2000s, this figure was at least twice as high. Surgery is recommended in extreme cases when conservative treatment has failed and the patient's condition is deteriorating. Against the background of UC, a malignant intestinal tumor (colorectal cancer) can develop. Then the operation is necessary to save the patient’s life, and not to improve its quality.

The following types of surgical intervention are currently practiced:

The choice of one or another surgical intervention technique, as in the case of conservative treatment, depends on the patient’s condition and the presence of concomitant diseases.

Features of the diet for UC

Nutrition for ulcerative colitis requires strict control of balance nutrients in consumed products. Exceeding the norm of carbohydrates or fats during remission can lead to relapse. Therefore, visits to a nutritionist who will adjust the menu within different cycles illnesses are a must.

In case of UC, it is recommended to completely remove foods containing coarse fiber or milk protein from the diet. Flour increases intestinal peristalsis, which in case of inflammation of the mucous membranes is fraught with sharp, paroxysmal pain. As for the ban on dairy products, it is due to the body’s increased sensitivity to the protein contained in them. If in healthy people the allergy to this protein is suppressed by the immune system, then in UC the body cannot cope with this task. Also prohibited are sweets with a high lactose content (chocolate, candies, various syrups, etc.). Consumption of vegetables and fruits during an exacerbation should be kept to a minimum. Baked apples and pears are allowed only in stable remission; it is better to exclude citrus fruits altogether.

The basis of the diet of a patient with nonspecific colitis during the acute phase should be porridge and broth. Meat and fish are allowed only boiled or steamed, without crust. As a side dish, in addition to porridge, soft-consistency mashed potatoes are recommended. Eggs are also allowed, but only in the form of a steam omelet.

The main principle of forming a menu during the period of remission is to assess the body’s reaction to the addition of a particular product. Diet correction is carried out only under the supervision of a gastroenterologist.

A properly selected treatment regimen for ulcerative colitis and adherence to a diet ensure stable, long-term remission, in which dietary restrictions are kept to a minimum. The example of thousands of patients has shown that with nonspecific ulcerative colitis you can lead a bright, fulfilling life, the quality of which depends primarily on the desire to comply with the treatment plan.