Pseudomembranous colitis

　　Pseudomembranous colitis is caused by toxins produced by the following two bacterial populations.

　　1, Clostridium difficile
　　Clostridium difficile is an important pathogenic cause of antibiotic-associated pseudomembranous colitis. This bacterium is a resident bacterium in the human body, existing in the intestines of normal people. In patients who have not received antibiotic treatment, the number of Clostridium difficile only accounts for % of anaerobic bacteria.2% to3%, the toxins produced by bacteria are few, even not producing toxins harmful to humans. The detection rate of Clostridium difficile in the population is5% to13%, normally these bacteria mutually restrict each other, cannot reproduce in large quantities, and will not cause disease. Long-term use of large amounts of antibiotics can inhibit the growth of various bacteria in the intestines, while antibiotic-resistant Clostridium difficile quickly reproduces. The amount of Clostridium difficile in the stool can reach up to % of anaerobic bacteria.10% to20%, generates a large amount of exotoxins, causing necrosis of the mucosa, exudative inflammation with pseudomembrane formation, and this exotoxin can be found almost in all stools of pseudomembranous colitis.

　　2Hemolytic resistant Staphylococcus aureus
　　After the use of a large amount of broad-spectrum antibiotics (such as terramycin, chloramphenicol, tetracycline, ampicillin, cefamycin, etc.), various bacterial flora including Escherichia coli are suppressed. Resistant Staphylococcus aureus then multiply and produce exotoxins, leading to the occurrence of pseudomembranous enteritis. Gram staining of the patient's feces can reveal large clusters of cocci. Pseudomembranous enteritis can also occur in animals if the toxins produced by these bacteria are injected.

　　Severe pseudomembranous enteritis can lead to irreversible shock, rapid dehydration, and acidosis; or complications such as toxic megacolon, colon perforation, or peritonitis; or acute intestinal obstruction, hypoproteinemia, and polyarticular arthritis, etc.

　　Pseudomembranous enteritis usually occurs during the process of antibiotic use after tumor, chronic消耗性疾病, and major surgery. Most cases have an acute onset and rapid progression, with the earliest onset occurring a few hours after starting medication, but it can also occur after discontinuing medication3weeks. There are approximately20% of patients develop after discontinuing antibiotics2to10days after onset.

　　1Fever
　　10% to20% of patients have fever and elevated white blood cells. Mild patients often have moderate fever, while severe patients may have high fever.

　　2Diarrhea
　　Diarrhea is an outstanding symptom of the disease. Due to the mucosal inflammation and the stimulation of exotoxins, which damage the absorption function of the affected intestinal tract, it affects the absorption of intestinal contents, causing an increase in water and sodium secreted by the intestinal wall into the intestinal lumen, leading to a large accumulation of intestinal fluid and causing diarrhea. The degree of diarrhea depends on the number of bacteria, the strength of their virulence, and the patient's resistance.

　　3Abdominal pain, abdominal distension
　　Under the stimulation of inflammation and intestinal fluid toxins, the intestinal tract presents spastic contractions, causing varying degrees of abdominal pain, which can be very severe and accompanied by early increased bowel sounds. After the intestinal peristalsis function is disturbed, it cannot effectively empty the accumulated fluid and gas in the intestines, leading to abdominal distension. Severe cases may have typical symptoms of toxic megacolon.

　　4Toxemia and shock
　　Late manifestations in severe patients. After absorbing a large amount of toxins, there is a significant decrease in appetite, fever, tachycardia, mental depression, delirium, poor orientation, and disturbance of consciousness, which eventually leads to liver and renal insufficiency and irreversible shock.

　　To prevent pseudomembranous enteritis, strict control of antibiotic indications should be exercised in clinical practice to prevent misuse. The prophylactic use of antibiotics should be strictly controlled. Clindamycin is a drug that has activity against Staphylococcus aureus and anaerobic Bacteroides fragilis, but it is generally not recommended to use clindamycin and lincomycin unless other drugs are ineffective or not available. Ampicillin is also prone to cause pseudomembranous enteritis, and attention should be paid to its clinical use.
　　The clinicians should closely observe the complications of antibiotic use, identify and diagnose them early to avoid delaying treatment. If patients develop diarrhea, they should discontinue medication promptly for fecal examination, and if necessary, repeat sigmoidoscopy. This is especially true for patients with clinical suspicion of pseudomembranous colitis or those with unexplained fever after major intestinal surgery.

　　The diagnosis of pseudomembranous colitis relies not only on clinical manifestations but also on laboratory tests and auxiliary examinations, which are indispensable means. The commonly used examinations are as follows:

　　1Blood routine and blood biochemical examination
　　Visible electrolyte disorder, often with hypokalemia, hyponatremia, etc.; hypoalbuminemia, serum albumin should be lower than3％; the white blood cell count can be as high as20×109/L and above, and mainly neutrophils.

　　2X-ray examination
　　Abdominal X-ray film shows no special findings, can show intestinal paralysis or intestinal loop dilation, and visible liquid level. Due to colon edema, thumbprint marks may appear, and spontaneous megacolon may occur occasionally. Barium enema X-ray shows no special changes in early or mild patients; in late and severe cases, colonic peristalsis may be faster, mucosa thickening, intestinal spasm, mucosal ulceration, etc. Barium enema can often worsen the condition and is generally not recommended.

　　3Stool examination
　　The stool is smeared and examined under a microscope. If Gram-positive bacilli and their spores are found, it will be very helpful for clinical judgment. Subsequent step-by-step bacterial culture can be performed to check for the presence of a large number of Gram-positive bacteria.

　　4Bacteriological examination
　　90% of cases can culture Clostridium difficile from the stool at the time of onset. When sending for testing, in order to reduce contact with air, it is necessary to take at least more than the container capacity of fresh stool, together with the container, placed in a capped and sealed wide-mouth bottle, in2Send for testing within 0 minutes.

　　5Colonoscopy
　　Pseudomembranous colitis may simultaneously involve the colon, especially the sigmoid colon, which can be examined by colonoscopy. The typical manifestation is red and swollen mucosa with plaques or confluent pseudomembranes. Biopsy shows acute inflammation of the mucosa, with necrotic epithelium, fibrin, inflammatory bacteria, etc. in the pseudomembrane.

　　6Ultrasound diagnosis
　　Ultrasound can detect local intestinal wall pseudomembrane, mucosal and submucosal edema causing severe thickening, narrowing or disappearance of the intestinal lumen. Careful examination can find a pseudorenal sign resembling intestinal tuberculosis or tumor in the lower right abdomen. Good-quality ultrasound diagnostic instruments can also accurately distinguish the layers related to the lesions. In addition, ultrasound diagnosis can detect complications such as ascites associated with the disease.

　　7CT diagnosis
　　The CT findings are not specific, and occasionally, low attenuation of thickened intestinal wall can be found.

　　Mild pseudomembranous colitis patients can have light diet, eat easily digestible semi-liquid food, and at the same time, they can eat yogurt containing beneficial flora. In severe cases or those with severe nausea and vomiting, fasting is required, and parenteral nutrition is provided, and the diet is gradually restored after the symptoms are relieved.

　　The goal of treating pseudomembranous colitis is to eliminate bacteria, eliminate or weaken the effects of bacterial toxins, support the normal intestinal flora, and improve the symptoms of the digestive tract in the whole body and abdomen. The specific treatment methods are as follows:

　　1. Treatment of the cause
　　Very important, the clinical use of drugs should be strictly controlled according to the indications, and the changes in the gastrointestinal tract should be closely observed for the extensive use of broad-spectrum antibiotics. In case of suspected or confirmed diagnosis of the disease, the use of antibiotics should be discontinued immediately. After discontinuing antibiotics, it is beneficial for the growth of other intestinal bacteria, especially aerobic bacteria, to inhibit the growth of anaerobic bacteria, and to restore the normal intestinal environment.

　　Δεύτερη, χρήση αντιβιοτικών
　　Πριν από την αποκάλυψη των αποτελεσμάτων της καλλιέργειας των κόπρανων και των δοκιμών ευαισθησίας στα φάρμακα, πρέπει να αλλάξετε τον αντιβιοτικό, μπορεί να χρησιμοποιηθεί ο στενός αντιβιοτικός που είναι σκοπός.

　　Τρίτη, υποστήριξη της κανονικής πληθυσμιακής ομάδας
　　Επειδή η απώλεια της αντοχής της colonization της Clostridium difficile είναι μια σημαντική αιτία της παθογενετικής της παθογονικής εντεροκολλίτιδας, θεωρητικά μπορεί να χρησιμοποιηθεί η μεθόδος της ανακατασκευής της κανονικής πληθυσμιακής ομάδας για τη θεραπεία.
　　1、Φαρμακευτική θεραπεία: Υδρολύση της γαλακτόζης, Βιταμίνη C, Φολικό οξύ, Συμπλήρωμα Βιταμινών Β12、Ασπαρτάτη και άλλα μπορούν να προωθήσουν τη αναπαραγωγή των κανονικών βασιλικών αλληλεπιδράσεων στο εντέρο; Λακτόζη, μέλι, μαλτοζή και άλλα μπορούν να προωθήσουν τη αναπαραγωγή των E. coli.
　　2、Χρήση υγιούς κοπράνων: Η υγιής κοιλιά του εντέρου περιέχει κανονικές βακτηριακές κοινότητες κοπράνων ως δωρητή, η θεραπεία της παθογονικής εντεροκολλίτιδας με τον τρόπο της εντερικής σφίξεως μπορεί να επιτύχει καλή επίδραση.

　　Τέταρτη, θεραπεία για τα συμπτώματα και την υποστήριξη του οργανισμού
　　1、Αντιμετώπιση της σοκ και της τοξαιμίας: Συμπληρώνετε τον όγκο αίματος και δίνετε πλήρη αίμα, πλάσμα ή αλβουμίνη, ενισχύετε την αντοχή και την ικανότητα αντιμετώπισης του σοκ. Η θεραπεία της τοξαιμίας μπορεί να χρησιμοποιηθεί για σύντομο χρονικό διάστημα. Κορτικοστεροειδή για να επιτύχετε την μείωση της τοξαιμίας, ευνοεί την διορθώσεις του σοκ. Είναι απαραίτητο να χρησιμοποιηθούν σε μεγάλη δόση και μακροχρόνως. Η χαμηλή πίεση αίματος μπορεί να χρησιμοποιηθεί για την αμινοκυανίνη, την φαινυλαινίνη και άλλα φαρμακευτικά.
　　2、Καθαρισμός της διαταραχής του νερού και των ηλεκτρολυτών και της διαταραχής της οξέως-αλκαλικής ισορροπίας: Η διάρροια μπορεί να προκαλέσει αφυδάτωση,一般是等渗性脱水，应根据生化检查和尿量补充丢失的水和钾、钠盐。使用碱性药物纠正酸中毒。单纯以静脉补充液体常难以补足血容量，肠道尚有正常黏膜可以吸收水分时，可以通过口服途径补充葡萄糖盐水，葡萄糖在被吸收的同时作为载体将钠离子吸收，有利于补充钠的丢失和酸碱平衡的恢复。
　　3、Εξωτερική τροφοδότηση του εντέρου (PN): Η θεραπεία αυτής της νόσου έχει σοβαρές διάρροιες, επηρεάζει την πρόσληψη τροφής κατά τη διάρκεια της πορείας της νόσου, η πορεία της νόσου είναι μακρά, και συχνά οδηγεί σε αρνητικό ισοζύγιο αζώτου. Επομένως, η θεραπεία PN μπορεί να ενισχύσει την ικανότητα του οργανισμού να αντιμετωπίζει την ασθένεια, να επιταχύνει τη αποκατάσταση των ιστών.
　　4、Τεραπεία της βασικής νόσου: Κατά τη διάρκεια της θεραπείας, πρέπει να δίνετε προσοχή στη θεραπεία της βασικής νόσου, να διορθώνετε την καρδιακή ανεπάρκεια, να βελτιώνετε τη λειτουργία του ήπατος και άλλα.

　　Πέμπτη, χειρουργική θεραπεία
　　Σε περιπτώσεις όπου η θεραπεία χωρίς χειρουργική επέμβαση δεν βελτιώνει την πορεία της νόσου, η υποψία για νεκρωση του εντέρου, διάτρηση του εντέρου ή την ανάπτυξη τερατομεγάλου παχέος εντέρου κατά τη διάρκεια της θεραπείας μπορεί να ενεργήσει ενεργά για χειρουργική εξετάση ενώ διορθώνει την αCIDΟσις και συμπληρώνει τον όγκο αίματος.