Chronic ulcerative colitis

　　The etiology of ulcerative colitis is still unknown. Although there are many theories, there is no definitive conclusion yet. The cause of bacteria has been excluded, and the cause of the virus does not seem to be the case, because the disease is not communicable, and the virus particles have not been confirmed. The serum lysosomes of Crohn's disease patients are elevated, while those of ulcerative colitis patients are normal.

　　1. Genetic factors:It may have a certain status, because Jewish people in white people are 2 to 4 times more than non-Jews, and non-white people are about 50% less than white people. In recent studies by Gilat et al. on the Jewish people in Tel Aviv, the incidence of ulcerative colitis was significantly reduced, at 3.8/100,000, while in Copenhagen, Denmark it was 7.3/100,000, in Oxford, England 7.3/100,000, and in Minnesota, USA 7.2/100,000. In addition, the ratio of women to men is only 0.8, while other reports are 1.3. It is obvious that geographical and racial differences affect the occurrence of this disease.

　　2. Psychological factors:It plays an important role in the progression of the disease, and it has now been clearly confirmed that there is no abnormal cause in ulcerative colitis patients compared to matched control cases. Moreover, pathological mental states such as depression or social distance that existed before the colon resection have significantly improved.

　　Some believe that ulcerative colitis is an autoimmune disease, with many patients having antibodies in their blood that cross-react with normal colonic epithelium and specific colonic bacterial lipopolysaccharide antigens. Moreover, lymphocytes cultured from the serum of patients with colitis can become cytotoxic to colonic epithelium. In addition, changes are found in the T and B lymphocyte populations of patients with colitis. However, it was later recognized that these abnormalities are not necessary for the occurrence of the disease but are the result of disease activity. In fact, Brandtzueg et al. clearly proved that there is no defect in the tissue level of immunoglobulin activity in the residual glands of ulcerative colitis patients, IgA transport is normal, and the IgG immune cell response is 5 times that of control patients. Therefore, it is possible that IgG plays a role in the chronic process of the disease, but is not related to the occurrence of the disease.

　　In summary, it is currently believed that the pathogenesis of inflammatory bowel disease is the result of the interaction of exogenous substances causing host reactions, genetic and immune influences. According to this view, chronic ulcerative colitis and Crohn's disease are different manifestations of a single disease process. Due to the allergic reaction of the host to exogenous antigens, once the intestinal immune response is initiated - perhaps this initiation is based on the period of microbial cloning in infancy - any injury that increases the permeability of the mucosa to these antigens may trigger an inflammatory response in the bowel wall. The type of antigen and other factors determine the nature of the inflammatory process, that is, the occurrence of Crohn's disease or ulcerative colitis.

　　Ulcerative colitis is a disease localized in the mucosa and submucosa of the colon. This is a distinct difference from the inflammatory changes in the bowel wall of Crohn's disease, where all layers of the bowel wall are involved in the granulomatous inflammatory process. However, the pathological changes seen in ulcerative colitis are non-specific and can also be seen in bacterial dysentery, amebic dysentery, and gonococcal colitis.

　　At the beginning of the lesion, there is infiltration of round cells and neutrophilic multinucleated cells in the Lieberkülin crypts of the mucosal basement, forming crypt abscesses. Under the light microscope, it is visible that the superficially stained epithelial cells are covered with vacuoles. In the electron microscope, mitochondria are swollen, intercellular spaces are widened, and rough endoplasmic reticulum is widened. As the lesion progresses, the crypt abscesses coalesce and the covering epithelium peels off, forming ulcers. Adjacent to the ulcers, there is relatively normal mucosa, but with edema, becoming a mucosal-like appearance and becoming very isolated between adjacent ulcers. The ulcer area is occupied by uncontrolled growth of collagen and granulation tissue, and it extends into the ulcers, but rarely penetrates the muscular layer. In acute ulcerative colitis and toxic megacolon, these lesions can penetrate the entire bowel wall, causing perforation. Fortunately, this type of lesion is not common, accounting for 15% and 3% respectively. The pathological changes provide a clear explanation for the clinical manifestations. There are almost more than 20 episodes of bloody stools almost every day. Because the mucosa, which is stripped and deformed, cannot absorb water and sodium, every intestinal peristalsis will squeeze out a large amount of blood from the exposed granulation tissue surface. The early X-ray manifestation of the disappearance of colonic pouches is due to the paralysis of the mucosal muscle layer, and the shortening and rigidity of the colon in barium enema is the result of scar formation after repeated injury.

　　Most ulcerative colitis involves the rectum, but if the lesion is limited to the rectum, it can be called ulcerative proctitis. It is still unknown why some cases have lesions limited to the rectum, while others involve the entire colon. Most inflammation extends towards the proximal end, involving the left colon, with about 1/3 of patients having the entire colon involved, known as pancolitis. In 10% of pancolitis patients, the last few centimeters of the ileum also have ulcers, known as retrograde ileitis. The lesions in ulcerative colitis are always adjacent, rarely segmental or skip distribution. The factors determining the severity and stage of the disease are not clear, and it may be related to the scope of immune disorders. There is evidence that prostaglandins may play an important role in the acute exacerbation of the disease, but unfortunately, there are no reports on the good effects of prostaglandin synthase inhibitors such as indomethacin.

　　1. Toxic megacolon occurs during the acute active phase, with an incidence of about 2%. It is due to inflammation involving the muscular layer and intermuscular plexus of the colon, resulting in low colonic wall tension, stage-wise paralysis, and a large accumulation of intestinal contents and gas, leading to acute colonic dilatation, thinning of the intestinal wall, and lesions mainly seen in the sigmoid colon or transverse colon. Triggers include hypokalemia, barium enema, use of anticholinergic drugs or opiate drugs, etc. Clinical manifestations include rapid deterioration of the condition, marked toxic symptoms, accompanied by abdominal distension, tenderness, rebound pain, decreased or absent bowel sounds, and leukocytosis. X-ray abdominal flat film shows widened intestinal lumen and disappearance of haustra. It is prone to complications such as intestinal perforation and has a high mortality rate.

　　2. The incidence of intestinal perforation is about 1.8%. It often occurs on the basis of toxic megacolon, causing diffuse peritonitis and free gas under the diaphragm.

　　3. Massive hemorrhage refers to bleeding that requires blood transfusion, with an incidence of 1.1% to 4.0%. In addition to bleeding due to ulcer involvement of blood vessels, low prothrombinemia is also an important cause.

　　4. The incidence of polyps in this disease is 9.7% to 39%. These polyps are often referred to as pseudopolyps. Some are classified into mucosal prolapse type, inflammatory polyp type, and adenomatous polyp type. The polyps are more common in the rectum, and some believe that the descending colon and sigmoid colon are the most common, decreasing upwards. The outcome can disappear with the resolution of inflammation, be destroyed with the formation of ulcers, persist for a long time, or become malignant. Malignancy mainly originates from adenomatous polyps.

　　5. The incidence of malignancy varies, with some studies suggesting it is several times higher than in those without colitis. It is more common in patients with colitis involving the entire colon, onset in childhood, and a history of more than 10 years.

　　6. The lesions of concurrent enteritis mainly occur in the distal ileum, manifested as periumbilical or right lower quadrant pain, watery stools, and fatty stools, which accelerate the progression of systemic failure in patients.

　　7. Common complications related to autoimmune reactions include:

　　(1) Arthritis: The incidence of arthritis in ulcerative colitis is about 11.5%, usually occurring in the severe stage of colitis. It is more common for large joints to be affected, and often only a single joint is involved. There is joint swelling and synovial effusion, but no damage to the bone and joint. There are no serological changes related to rheumatoid disease. It often coexists with specific ocular and skin complications.

　　(2) Skin and mucosal lesions: nodular erythema is common, with an incidence rate of 4.7% to 6.2%. Other conditions include multiple abscesses, localized abscesses, necrotizing fasciitis, erythema multiforme, etc. Oral mucosal refractory ulcers are also not uncommon, and sometimes present as thrush, with poor treatment response.

　　(3) Ocular lesions: include iritis, iridocyclitis, uveitis, corneal ulcer, etc. The former is the most common, with an incidence rate of about 5% to 10%.

　　8. Other complications include colonic stricture, anal abscess, fistula, anemia, liver damage, and kidney damage. In addition, there are myocarditis, thrombotic vasculitis, pancreatic atrophy, and endocrine disorders, etc.

　　The initial manifestations of ulcerative colitis can take many forms. Bloody diarrhea is the most common early symptom, followed by other symptoms such as abdominal pain, hematochezia, weight loss, tenesmus, vomiting, etc. Occasionally, arthritis, iridocyclitis, liver dysfunction, and skin lesions may be the main manifestations, and fever is relatively uncommon. In most patients, the disease presents as a chronic, low-malignant condition, while in a few patients (about 15%) it presents as an acute, catastrophic outbreak process. These patients present with frequent bloody stools, up to 30 times per day, and high fever, abdominal pain, therefore, the clinical manifestations of the disease are very broad, ranging from mild diarrhea to fulminant, life-threatening outcomes in a short period of time, which require immediate treatment.

　　The signs and symptoms are directly related to the stage and clinical manifestations of the disease. Patients often have weight loss and pale complexion. During the active phase of the disease, abdominal examination often shows tenderness in the colon area. There may be signs of acute abdomen, accompanied by fever and reduced bowel sounds, especially in acute attacks or fulminant cases. In cases of toxic megacolon, there may be abdominal distension, fever, and signs of acute abdomen. Due to frequent diarrhea, the perianal skin may be chafed, peeled, and may also develop perianal inflammation such as anal fissure or fistula, although the latter is more common in Crohn's disease. Rectal examination is always painful, and in cases with perianal inflammation, the examination should be gentle. Examination of the skin, mucosa, tongue, joints, and eyes is extremely important because if there are lesions in these areas, the cause of diarrhea may be ulcerative colitis.

　　Chronic ulcerative colitis is a disease that exists worldwide, but it is more common in Western countries. Its incidence ranges from 5 to 12 per 100,000, and its prevalence is 50 to 150 per 100,000. Women are slightly more than men. The age of onset shows a bimodal distribution, with the first peak at 15 to 30 years old, and the second peak at 50 to 70 years old, with the first peak being more common. Up to 15% to 40% of patients have a family history of chronic ulcerative colitis or Crohn's disease. In the United States, Jewish patients are more than non-Jewish patients, but Jewish patients in Israel are fewer. China has no comprehensive statistics on this disease, but based on clinical observations, it is not rare and shows an increasing trend. In terms of prevention, it is necessary to actively engage in aerobic exercise and enhance immunity.

　　一、结肠镜所见

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　　Chronic ulcerative colitis requires which laboratory tests to be done

　　1, Colonoscopy findings

　　1, Multiple superficial ulcers of the mucosa, accompanied by congestion, edema, and the lesions mostly start from the rectum and are widely distributed.

　　2, Rough mucosa呈细颗状, mucosal blood vessels are blurred, fragile and prone to bleeding, or accompanied by purulent and bloody secretions.

　　3, Visible pseudopolyps, the colon pouches often become blunt or disappear.

　　1, Rough mucosa or fine granular changes.

　　2, Multiple superficial fissures or small filling defects.

　　3, Shortening of the intestinal tract, disappearance of the colon pouches, and the lower part呈管状.

　　4, Surgical resection or pathological anatomy can be seen in the characteristics of macroscopic or histological ulcerative colitis

　　Honeysuckle and sweet potato porridge:Sweet potato, rice, honeysuckle, ginger. Sweet potatoes can be cut into small pieces or ground into fine powder, added with honeysuckle (the amount should be adjusted according to the severity of clinical symptoms), ginger, and cooked into rice or porridge as usual. Eat three meals a day, adhere to it, and eat at least 3^4 months before gradually achieving effects. Sweet potatoes contain a large amount of dietary fiber, which can enhance peristalsis. The large amount of vitamin E contained in them participates in the synthesis of collagen, which can promote the healing of the ulcer surface, and the large amount of beta-carotene has a good protective effect on the epithelial tissue. Adding honeysuckle to sweet potato porridge will undoubtedly enhance the antibacterial and anti-inflammatory effects, combined with the stomach-soothing effect of ginger. Abdominal distension and abdominal pain symptoms can be alleviated.

　　1, Medical treatment

　　The outcome of acute recurrence of ulcerative colitis mainly depends on the severity of the disease, manifested as systemic symptoms, and is unrelated to the duration of the disease and the extent of the lesion, except for ulcerative proctitis which is not considered.

　　Medical treatment should include four aspects:

　　1, Bed rest and general supportive treatment:Including fluid and electrolyte balance, especially potassium supplementation, hypokalemia should be corrected. At the same time, attention should be paid to protein supplementation, improvement of overall nutritional status, and parenteral nutrition support may be provided when necessary. Anemia can be treated with blood transfusion, and milk and dairy products should be avoided as much as possible during gastrointestinal intake.

　　2, Sulfasalazine (Azulfidine, SASP):Initially, 0.25g oral administration 4 times a day, then increased to 1g oral administration 4 times a day, and after the effect is achieved, it can be changed to 1g 3 times a day or 0.5g 4 times a day. Metronidazole 0.2g can also be administered 3 times a day, and after 3 weeks, it can be changed to 0.2g metronidazole suppository 2 times a day for rectal administration, and then changed to 0.2g once a day for rectal administration, and it should be continued for 3 to 6 months.

　　3. Corticosteroids:The usual dose is prednisone 5-10mg, three times a day, and the dose is reduced after 1-2 weeks, reducing 5mg per week until the final dose is 5mg once a day or 2.5mg twice a day as a maintenance dose. Or dexamethasone 0.75-1.5mg, three times a day, similarly reduced to 0.75mg once a day or 0.375mg twice a day as maintenance, but it is currently not considered that long-term hormone maintenance can prevent recurrence. In the acute recurrence period, hydrocortisone 100-300mg or dexamethasone 10-30mg can also be administered intravenously, as well as 100mg of hydrocortisone added to 60ml of normal saline for retention enema every night. The value of hormone treatment in the acute attack period is certain, but whether to continue using hormones in the chronic period is still controversial, as it has certain side effects, so most do not advocate long-term use. In addition to corticosteroids, ACTH 20-40U can also be used intravenously.

　　4. Immunosuppressants:Its value in ulcerative colitis is still questionable. According to reports by Rosenberg et al., azathioprine (azathioprine) has no effect on controlling the disease during disease progression, but it helps to reduce the use of corticosteroids in chronic cases.

　　In addition to the above treatment measures, for cases with severe diarrhea and nocturnal diarrhea, anticholinesterase drugs or a combination of phenethylpiperidine (Stop Diarrhea) can be administered, but opium-based drugs such as codeine and tincture of camphor should be avoided, as they may induce acute colonic dilation.

　　Second, surgical treatment

　　About 20% to 30% of ulcerative colitis patients will eventually need surgical treatment. In the past, surgery was the last resort for solving the disease after various internal medical treatments had failed, and the patients were also in a state of severe malnutrition and weakness due to acute or chronic diseases. Now, it is more advocated to perform surgery earlier, and this change in treatment attitude is due to the fact that there are several surgical options available and the results are good.

　　1. Indications for surgery:Indications for emergency surgery include: (1) Large, uncontrollable bleeding; (2) Toxic megacolon with impending or definite perforation, or toxic megacolon that does not respond to treatment for several hours rather than several days; (3) Fulminant acute ulcerative colitis that does not respond to corticosteroid hormone treatment, that is, there is no improvement after 4-5 days of treatment; (4) Obstruction caused by stricture; (5) Suspected or confirmed colon cancer. In addition, several non-emergency conditions should be considered for surgery, such as: (6) Refractory chronic ulcerative colitis refers to recurrent exacerbations, chronic persistent symptoms, malnutrition, weakness, inability to work, inability to participate in normal social activities and sexual life; (7) The disease worsens when the dose of corticosteroid hormones is reduced, resulting in the inability to stop hormone treatment for several months or even years, which is an indication for colon resection surgery; (8) Children with chronic colitis that affects their growth and development; (9) Severe extracolonic manifestations such as arthritis, gangrenous pyoderma, or biliary liver diseases may be effective for surgery.

　　2, Surgical selection:Currently, there are four surgical options for chronic ulcerative colitis. Each has its own advantages and disadvantages, so a strict indication is required. Only reasonable selection can achieve the best results.

　　(1) Total resection of the colorectum and ileostomy: This is the oldest and most thorough surgery, with no concern for recurrence or cancer transformation, and no need for medication after surgery. The postoperative complications are relatively few, and the surgery can be completed in one stage. However, the permanent ileostomy brings inconvenience to the patient's life, mental suffering, and physical torment, which is undoubtedly the surgery that patients are least willing to accept. Therefore, this method should be limited to patients who need rectal resection due to low rectal cancer; patients with anal diseases or a history of anal surgery; those who have previously undergone small bowel resection or are suspected of having Crohn's disease and are not suitable for pelvic ileal pouch surgery.

　　(2) Total colectomy and ileorectal anastomosis: This is a controversial surgery because it retains the diseased rectum, which poses a risk of disease recurrence and cancer transformation. However, this operation is simple, avoids permanent ileostomy, and has few complications. Therefore, before the emergence of Koch ileostomy and ileal pouch anal anastomosis, this was the only method that could avoid permanent ileostomy. Those who advocate for this method believe that it can at least allow patients to suffer less from ileostomy for several years, and this surgery is mainly suitable for patients with no rectal lesions. Patients with cancer or dysplasia in the colon or rectum, those with rectal fibrosis that cannot be expanded, those with perianal diseases, and those who cannot follow up regularly after surgery are not suitable for this operation.

　　(3) Controllable ileostomy: Koch first proposed the construction of a storage bag and a nipple valve using the distal ileum before ileostomy to achieve the purpose of controlling defecation. This is a relatively complex surgery with a high incidence of complications, especially related to the nipple valve, such as fistula formation, nipple valve slippage, necrosis, and valve prolapse. Among them, nipple valve slippage is the most common and also the most difficult to deal with. Although many improvements have been made to reduce their occurrence, they cannot be eliminated. Theoretically, the status of Koch ileal pouch is more restricted. Generally, patients who wish to avoid ileostomy should choose pelvic ileal pouch surgery; if the patient has previously undergone total colectomy or is not suitable for pelvic ileal pouch surgery due to low rectal cancer or anal dysfunction, then Koch ileal pouch surgery can be chosen. However, those who have previously undergone small bowel resection surgery or have Crohn's disease in the small bowel are contraindicated for Koch ileal pouch surgery.

　　(4) Total colorectal resection and ileal pouch-anal anastomosis (IPAA): This surgery is mainly indicated for cases of chronic ulcerative colitis that are unresponsive to medical treatment, with continuous extraintestinal manifestations, persistent slight bleeding, stricture, or severe mucosal metaplasia. Cases with cancer located above the middle segment of the rectum and without metastasis are also suitable for this surgery. Under acute conditions, this surgery should never be performed. Additionally, during emergency colon resection, it is not necessary to remove the rectum, especially in young patients; if the clinical situation requires, the rectum should be preserved, and a proximal rectal resection can be performed later, followed by the removal of the distal rectal mucosa and ileal pouch-anal anastomosis.

　　The ileal pouch-anal anastomosis can be roughly divided into three categories: double ileal pouches, including J-type, improved J-type, and lateral ileal pouch; three ileal pouches (S-shaped ileal pouch); and four ileal pouches (W-shaped ileal pouch). Each type of ileal pouch has its own advantages and disadvantages.

　　①The S-shaped ileal pouch-anal anastomosis is the earliest pelvic ileal pouch surgery, proposed by Parks and Nicholls in 1978. Initially, they used 30 cm of distal ileum to fold into three segments, and later improved to use 50 cm long ileum divided into three segments of 15 cm and a 5 cm output tube. The result was that 50% required catheterization for emptying, and ileal pouchitis was the most common complication. Many scholars pointed out that an overly large storage pouch and an excessively long output tube were two main reasons for retention and ileal pouchitis. Therefore, it is currently recommended to use three segments of 10 to 12 cm ileum to form the storage pouch, and the length of the output tube should be 2 to 4 cm.

　　②The J-shaped storage pouch-anal anastomosis, advocated by Utsunomiya in 1980, has the advantage of good emptying and less retention. Two segments of the intestine with opposite directions of peristalsis can enhance the storage function. The storage pouch is composed of two segments of 12 to 15 cm long distal ileum, and then the top of the ileal pouch is pulled down to form an end-to-side anastomosis with the anal canal.

　　③The improved J-shaped ileal pouch-anal anastomosis, designed by Balcos, is a modification of the J-shaped ileal pouch. It involves cutting off the back of the original J-shaped pouch, pulling down the distal segment to form an end-to-end ileal-anal anastomosis with an antiperistaltic direction, and the length of the output tube should not exceed 4 cm. This surgery combines the advantages of the J-shaped pouch, correcting the major drawback of the J-shaped pouch by changing the end-to-side anastomosis to an end-to-end anastomosis.

　　④The side-to-side ileal pouch-anal anastomosis, proposed by Peck in 1980 as another type of double ileal pouch surgery, is performed in two stages. The first stage involves an end-to-end ileal-anal anastomosis, followed by the creation of an ileostomy at 30 to 40 cm distal to the ileum. After 3 to 6 months, the ileostomy is closed, and the proximal ileum is pulled down into the pelvic cavity to form a side-to-side anastomosis with the distal ileum, completing the ileal pouch formation. Theoretically, both segments of the ileum are in a counterclockwise peristalsis, resulting in less retention and having all the advantages of the J-shaped pouch without its disadvantages. However, in practice, the second stage surgery is extremely difficult, and both stages are major surgeries, so Peck himself has abandoned this surgery.

　　The W-shaped ileal pouch-anal anastomosis involves folding, cutting, and forming a large cavity with four segments of 12cm long distal ileum, then pulling it down to make an end-to-side anastomosis with the anal canal. This operation is time-consuming and difficult in operation, but due to the large cavity formed, the storage function is relatively good. Nicholls and Pezim (1985) reported 104 cases of IPAA, comparing the functional outcomes of J-shaped, S-shaped, and W-shaped ileal pouches after surgery, including normal defecation, spontaneous defecation, and capacity as the three major indicators. The results showed that all three indicators were the best with the W-shaped ileal pouch. Keighley et al. (1989) reported 65 cases of IPAA, mainly comparing the complications and functional outcomes of J-shaped and W-shaped ileal pouches after surgery, and concluded that there was no difference between the two ileal pouches. Wexner (1989) reported 114 cases, mainly S-shaped ileal pouches, with an average follow-up of 5 years. The overall efficacy included spontaneous evacuation 92%, emptying when awake 91%, nocturnal continence 76%, one case of frequent incontinence during the day, three cases of frequent incontinence at night, a total failure rate of 8%, and 87% returning to work after surgery. Silva et al. (1991) reported 88 cases of IPAA, comparing the results of J-shaped, S-shaped, and W-shaped procedures, with the W-shaped being the best and the S-shaped being the worst. Recently, Gratz and Pemberton (1993) reported the experience of 1400 cases of IPAA at the Mayo Clinic in the United States, mainly J-shaped ileal pouches, with only 2 postoperative deaths, one due to perforation of a gastric ulcer caused by hormones, and the other due to pulmonary embolism. In the long term, 95% of patients were satisfied with the surgery, but the control of defecation was not perfect. Some patients still have fecal incontinence, and in addition, up to one-third of patients have pouchitis, and there is currently no effective long-term prevention or treatment method, so further research is needed to solve this problem. However, among the existing four types of operations, total colectomy and ileal pouch-anal anastomosis is a relatively reasonable and selectable method.