Crohn's disease: life goes on. Crohn's disease

Once again about "terminal ileitis" or a post of gratitude to competent and honest endoscopists.
A young girl is coming today. Pain under the right rib, appeared after food poisoning in the south of Russia. Spasmolytics help. The work is responsible, there were troubles in the family. No anemia, no malabsorption, no extraintestinal manifestations. Calprotectin and C-reactive protein are normal, stones and cholecystitis are absent. No changes in stool, articular or skin manifestations. But no: for some reason they do a colonoscopy for her: they prepare her for research with phosphates and, of course, they find three erosions in the ileum. Immediately diagnosed with "Crohn's disease" and appointed mesalazine with the words: "does not help, come for hormones." Then everything is typical: Kronportal, reading stories from the Internet about how people die from Crohn's disease, and hence the natural increase in functional pain. On the Internet, everyone in unison advises to run for video capsule endoscopy. And if such a girl came to an endoscopist who is too lazy to take an anamnesis (and strictly speaking, the endoscopist is not obliged to do this in detail), she would now go with a capsule in healthy gut, where a couple of erosions would also be found. But the girl came to Ekaterina Ivanova, who did not mechanically do her job, but advised to first talk with a gastroenterologist. Result: in high spirits, the girl leaves to meet New Year without an unfounded diagnosis of "Crohn's disease".
Is it worth panicking because of three erosions in the ileum? NO!

1. Single erosion of the intestinal mucosa - possible side effect bowel preparations with sodium phosphate. It is for this reason that it is generally better not to use them if IBD is suspected: such a colonoscopy will not add clarity to the diagnosis. In 2011, a targeted study of mucosal inflammatory changes caused by preparation for colonoscopy (PMID: 21547879) was carried out: 634 patients without significant clinical and laboratory signs Crohn's disease, not taking NSAIDs and not having heart or kidney failure drinking Polyethylene glycol, sodium picosulfate or sodium phosphate. 3.4% of those taking Sodium Phosphate and 3.5% of those taking Picosulfate had hyperemia and/or erosion. When prepared with polyethylene glycol, these changes were present in only one patient out of 284 (0.35%).

2. Single erosions in the ileum rarely "end" a real illness Crohn's - progressive deep inflammation intestinal wall. This year, the Mayo Clinic tracked the five-year fate of 108 patients with histologically confirmed inflammation of the terminal section. ileum(PMID: 29064015). Colonoscopy was performed either because of abdominal pain and chronic diarrhea (85% of patients), or because of thickening of the intestinal wall on ultrasound/MRI/CT, ​​or in connection with iron deficiency anemia, in general, not out of "curiosity". Only five (five out of a hundred and eight, Carl!) people with discovered "acute ileitis" later developed typical disease Krona (on average, over 3 years). At the same time, neither the initial deviations in the analyzes, nor whether there were erosions / edema of the mucous membrane, and not only changes during the biopsy, did not affect the "fate" of patients. In patients with true Crohn's disease, narrowing of the intestinal lumen was more often initially found on ultrasound / MRI / CT - and this seems to be the only way to predict the outcome of the changes found in the ileum, because even the wall thickness did not allow distinguishing a patient with a future "deployed" Crohn's disease from those whose inflammation arose by chance and does not matter.

3. Videocapsule endoscopy “just like that” is not necessary: ​​it is a difficult to interpret and expensive diagnostic method. American Guide The 2017 Gastroenterology Association recommends against this study if diarrhea and abdominal pain are the only manifestations of suspected "Crohn's disease" (PMID: 28063287). Why? Yes, because, at normal level fecal calprotectin and C-reactive protein anyway, we can't find anything. They began to guess about this back in 2003: Israeli doctors (PMID: 12929066) gave capsules to 20 patients with chronic pain in the abdomen, which had no deviations in the analyzes and changes during colonoscopy, ultrasound, etc. In 14, nothing was found, and in six, changes in the small intestine could not explain the symptoms (all sorts of hemangiomas and venectasias). Later, this pattern: no anemia/inflammatory markers - the capsule most likely will not show anything, has been repeatedly confirmed, most clearly in the 2011 study (PMID: 21925046). Changes in the small intestine were "found" in 66.7% of people with abdominal pain and an increase in C-reactive protein / calprotectin and only in 21.4% of patients with normal values these indicators. And among those who, in addition to abdominal pain, also had diarrhea, but also did not have increased indicators of inflammation, the video capsule study showed nothing at all: no signs of Crohn's disease / tumors / celiac disease were found in any patient.

4. If calprotectin is normal, and nothing significant is found during ileocolonoscopy, there is no point in examining the small intestine: the Scots in 2011 compared the level of calprotectin with the results of a video capsule study in 70 patients (PMID: 21269246). With a normal level of calprotectin (less than 50 µg/g), no changes were found in the small intestine in any patient. No inflammation has been found and in people with mild increased level calprotectin: 50 to 100 mcg/g. Here, at a level of more than 100 μg / g, almost every second (42.8%) video capsule revealed changes corresponding to Crohn's disease. A 2016 systematic review (PMID: 27415156) confirmed that when the level of calprotectin is less than 50 µg/g, the probability of "finding" in a video capsule study does not exceed 8.2%.
That's all discussed with my morning patient. They agreed that she would spend the money set aside for the video capsule on going to a restaurant with her husband and a subscription to a fitness center. Well, or for a colonoscopy of relatives after 50 years, which Badma Bashankaev reminds us of, it seems, every day (and he does it right)

Crohn's disease type inflammatory disease bowel disease (IBD), in which the lining of your digestive tract becomes inflamed, causing severe diarrhea and abdominal pain. Inflammation often penetrates deep into the layers of damaged tissue. How non-specific ulcerative colitis More common (IBD), Crohn's disease can be both painful and debilitating, and can sometimes lead to a life-threatening complication.

As long as Crohn's disease is considered incurable, existing methods treatments can significantly reduce the signs and symptoms of Crohn's disease and even induce long-term remission. Thanks to this treatment, most people suffering from this disease are able to lead a normal life.

Steps

Recognizing symptoms and confirming the diagnosis

Recognize the symptoms and signs of Crohn's disease. The symptoms of this disease are similar to a whole host of other intestinal pathologies, such as ulcerative colitis and irritable bowel syndrome. Symptoms may come and go and range from mild discomfort to severe pain. At different people they will be different, depending on which part of the intestine is affected. A few of the most common symptoms include:

• diarrhea. The inflammation found in Crohn's disease causes cells in affected areas of the intestine to secrete a large number of water and salt. Due to the fact that the large intestine cannot completely absorb this liquid, diarrhea begins.
• abdominal pain and muscle spasm. Inflammation and ulceration can cause the intestinal walls to swell and eventually thicken with scar tissue. This interferes with the normal flow of your intestinal contents through your digestive tract and can lead to pain and muscle spasm.
• Blood in the stool. Food moving along digestive tract, can cause the inflamed walls to bleed, or the gut can bleed on its own.
• Ulcers. Crohn's disease begins as small, scattered sores on the surface of the intestine. Ultimately, these wounds can become large ulcers that penetrate deep into, and sometimes through, the walls of the intestine.
• Weight loss and loss of appetite. Stomach pain, muscle spasm, and inflammation of the intestinal wall can all affect your appetite and your ability to digest food and absorb nutrients.
• Fistula or abscess. Inflammation from Crohn's disease can migrate through the intestinal wall to related bodies, such as bladder or vagina, creating a connecting channel called a fistula. Inflammation can also lead to an abscess: a swollen, pus-filled sore.

1. Recognizing the less common symptoms of Crohn's disease. In addition to the above, people with this condition may experience other, less common side effects such as: joint pain, constipation and swelling of the gums.

   When should you see a doctor? Call your doctor as soon as you experience any of the following symptoms:

   • Feeling weak or fast and weak pulse.
   • Severe pain in the stomach.
   • Unexplained fever or chills that persist for more than two days.
   • Repetitive vomiting.
   • Blood in the stool.
   • Ongoing bouts of diarrhea that are not controlled by over-the-counter medications (OTRs).

2. Get tested to confirm the diagnosis. If your doctor suspects you have Crohn's disease, he/she may refer you to a gastroenterologist (specialist in digestive system) to pass various surveys. They may include:

   • Blood analysis. Your doctor may suggest that you donate blood for anemia, which is a common side effect of Crohn's disease (due to blood loss).
   • Colonoscopy. This test allows the doctor to view your entire colon with a thin, flexible tube with a light and a camera on the tip. Using the camera, the doctor will be able to identify any inflammation, bleeding, or ulcers on the walls of the colon.
   • Flexible sigmoidoscopy. In this procedure, a doctor uses a thin, flexible tube to examine the two lower segments of your colon.
   • Barium enema. This diagnostic method allows you to examine the colon using x-rays. Before analysis, barium, a contrast dye, is injected into your colon with an enema.
   • x-ray small intestine. This analysis allows you to examine the part of the small intestine that was not visible during colonoscopy.
   • Computed tomography (CT). Sometimes you may need CT scan, which is a more advanced x-ray method that diagnoses in more detail than a standard x-ray. This test looks at the entire bowel and tissues outside of it, which cannot be seen with other tests.
   • capsule endoscopy. If you have symptoms suggestive of Crohn's disease and routine tests show nothing, the doctor may perform a capsule endoscopy.

   Adequate methods of treatment

   1. Ask your doctor about medical methods treatment. Many different medications are used to control the symptoms of Crohn's disease. The type of treatment that is right for you will depend on the specifics of your case and the severity of your symptoms. Some common drug treatments include:

      • Anti-inflammatory drugs. These drugs are often the first step in treating inflammatory bowel disease. Including sulfasalazine (Azulfidine), which is useful mainly for colonic disease, and mesalamine (Azacol, Rovaza), which will help prevent recurrence of Crohn's disease after surgical intervention or corticosteroids.
      • Immunosuppressants. These drugs also reduce inflammation, but they are designed to suppress the immune response, not to treat the inflammation itself. These include azathioprine (Imuran), mercoptopurine (Purenetol), infliximab (Remicade), adalimumab (Humira), certolizimab pegol (Cimisia), methotrixate (Rheumatrix), cyclosporine (Neoral, Sandammun), and natalizumab (Tysabri).
      • Antibiotics. They are able to cure fistulas and abscesses in people with Crohn's disease. Such as metronidazole (Flegyl) and ciprofloxacin (Cipro).
      • Antidiarrheal drugs. Crohn's disease patients suffering from chronic diarrhea often respond well to the antidiarrheal drug loperamide. Loperamide is sold in pharmacies as Immodium, it can be purchased without a prescription.
      • Substances that increase the secretion of bile acids. Patients with chronic form diseases of the ileum or after its resection (the part at the end of the small intestine) may not absorb bile acid, which can lead to secretory diarrhea in the colon. Cholestyramine or colestipol may be suitable for these patients.
      • Other medicines. Some medications used to treat Korn's disease include steroids, suppressants immune system, fiber, mild laxatives, pain relievers, iron supplements, vitamins B12, calcium and vitamin D.

   2. Follow your doctor's recommendations regarding diet and nutrition. It is impossible to say with certainty that the food you eat actually causes inflammation of the intestine. But certain products may worsen the condition (especially during a flare-up), while others may significantly alleviate symptoms and prevent future flare-ups.

   3. Alcohol has an intense effect on the course of Crohn's disease. Therefore, it is recommended even Everyday life Reduce or eliminate your intake to reduce symptoms of Crohn's disease.
   4. Regular exercise and maintenance healthy diet help to cope with stress.
   5. If you live in a city or industrial developed country are at risk of developing Crohn's disease.
   6. Although Caucasians have the most high probability get sick, yet the disease can affect any ethnic group.
   7. Keep a food journal that will record your diet, which will help you keep track of foods that are bad for you, and try to eliminate them (for each patient is different).
   8. Stay close to your healthcare provider and donate blood regularly to check for by-effect from medications taken.
   9. Take only drugs prescribed by your doctor or gastroenterologist.
   10. If you smoke, your risk of getting Crohn's disease will increase.
   11. Crohn's disease can occur at any age, but younger people are more susceptible to it.

   Warnings

   • Do not use non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, and others), or naproxen (Aliv). They may make your condition worse.
   • Check with your doctor before taking any, even mild laxatives, because even over-the-counter ones can be harmful to your intestines.
   • Use antidiarrheal drugs with caution and after consulting a doctor because they increase the risk of toxic megacolon, a life-threatening form of inflammation of the colon.

Spring in Ukraine turned out to be politically turbulent. Even the outburst of "patriotism" in connection with the dispatch of Savchenko to Ukraine speaks of the growth of political instability and the deepening of the crisis at the top, political ferment in the regions of present-day Ukraine.

It remained in the shadow of Transcarpathia, where the regional council in April adopted an appeal to the president, the Verkhovna Rada and the prime minister demanding that the region be recognized as a “special self-governing territory” in accordance with the results of the referendum on December 30, 1991, when 78.6% of the voters of Transcarpathia voted for autonomy . The deputies of the Regional Council also reminded the central authorities that in January 1992 the Transcarpathian Regional Council adopted an appeal to the Verkhovna Rada to introduce appropriate amendments and additions to the Constitution of Ukraine, the essence of which is that Transcarpathia, remaining "an integral part of Ukraine", "independently resolves issues, within its competence” within the framework of autonomy.

If a quarter of a century has passed since Ukraine gained independence, and Transcarpathians again and again turn to the topic of autonomy, then there are good reasons for that. The fact is that the Rusyns living today in Transcarpathia, Eastern Slovakia, Serbian Vojvodina, southeastern Poland, Hungary and northwestern Romania are not Ukrainians, as Kiev sees it, but a special East Slavic people. In Poland, Russia, Slovakia, the Czech Republic, Serbia and Croatia, they are recognized as an ethnic minority.

The UN Committee on the Elimination of Racial Discrimination in 2008 recommended that Ukraine consider recognizing the Rusyns as a national minority. But Kyiv, which is busy building the Ukrainian nation “with fire and sword” “from the Xiang to the Pamirs”, has no time to consider the recommendations of the UN and the appeals of the Transcarpathian Regional Council.

In May, in Budapest, and in Ukraine, the question of the autonomy of the Hungarians in Transcarpathia was raised.

Collected more than 25 thousand signatures a petition to the president on the creation of a special development region "Slobozhanshchina" in the Kharkiv region. It is this number that is necessary for the head of state to consider the appeal. Kharkiv residents propose to adopt a law providing for the transfer to the region of a number of powers of the center, including the right to independent foreign economic activity. The goal is to resume the former cooperation of Kharkov industrial giants with Russian partners. A "special status" of the region is proposed, essentially meaning its autonomy, albeit in a primary form. On May 26, a march of supporters of this idea took place in the center of Kyiv.

The reunification of Crimea with Russia, the emergence of the proclaimed republics of Donbass, strangled by force of arms, the fires of the Inquisition and arrests, but the unbroken movement for the federalization of the country in Odessa, Nikolaev, Kherson, Dnepropetrovsk and Zaporozhye, and now the initiatives of Transcarpathia and Kharkiv region make us once again look at how viable or on the contrary, Ukraine is a doomed state formation.

The territory of modern Ukraine consists of several regions that are seriously different from each other in terms of ethnic, socio-cultural and civilizational features. Eastern Ukraine, that is, everything that lies east of the Dnieper, from Chernigov to Sea of ​​Azov, represents a territory with a predominance of the Russian ethnic group and the Orthodox Ukrainian population (after Ukrainization). This region is historically, culturally, ethnically and religiously closely connected with Russia and is an organic part of the Russian world. Here, in the fire of the national liberation struggle, the independent Donbass was born, and in Kharkov, seized by the noose of the Kyiv punishers, the grapes of anger ripen again.

The central part of Ukraine from Chernihiv towards Odessa, which includes Kyiv, is a region where Ukrainians are ethnically dominated and Ukrainian language with the simultaneous advantage of Orthodoxy. But Orthodoxy itself became heterogeneous. The activities of schismatics from the "Kyiv Patriarchate" who turned their shoulders ruling regime influences the mindset of the population. Nevertheless, this part of Ukraine still remains culturally close to Eastern Ukraine.

The south of Ukraine, or Novorossia, stretches from the Donbass in the east to the Danube Delta in the west. The region is inhabited by Ukrainians and Russians, interspersed with Bulgarians, Greeks, Armenians and other peoples. Novorossiya is almost entirely Orthodox. However, in Lately the factor of Islam, moreover, with elements of fundamentalism, is asserting itself more and more loudly.

The Majlis, dug in in Genichesk, with the good will of Kyiv and with the money of Ankara, resettles the extremist-minded part here Crimean Tatars. The joint plans of Kyiv, Ankara and the Mejlis include the creation of a Crimean Tatar autonomy on the territory of the Kherson region. Kyiv is counting on special relationship with Ankara, while the Erdogan regime still cherishes the illusion of turning the Black Sea into a “Turkish puddle”, as in the days of the greatness of the Porte.

Western Ukraine is notable for its heterogeneity. Volyn with a predominance of Uniates in socio-cultural terms belongs to the Catholic sector Central Europe. Similar situation in Galicia and Transcarpathia, although there are differences: Volyn is historically connected with Poland, Galicia and Transcarpathia - with the Austro-Hungarian Empire. The Rusyns of Transcarpathia showed amazing stubbornness in the struggle for the preservation of Orthodoxy. In the Bessarabia, Ukrainians and Russians mix with Moldavians and Romanians.

Even a cursory glance at the religious, cultural and ethnic situation in Ukraine allows us to see that at least three civilizations have met here - Orthodox Slavic (Eurasian), which is increasingly called the Russian World, Western (Euro-Atlantic) and Islamic.

The question arises: how viable is a state formation, cobbled together not only on a multinational, but also on a polycivilizational basis? In Switzerland, for example, five peoples live, two confessions met here, but the state turned out to be prosperous.

The federal structure, three official and one partially official languages ​​help out. Although everyday friction is probably nowhere to be avoided, they do not define the Swiss example of achieving unity through diversity.

In Ukraine, the opposite is true - an aggressive nationalist minority, living by the standards of wild nationalism, growing into Nazism, is trying to dress the whole country in the “one-building” of the OUN-UPA, relying on bayonets. The obvious truth, discovered by Napoleon, has been forgotten: a bayonet is convenient for everyone, except for one thing - you can’t sit on it for a long time.

It can be seen that, at the level of intuition, still guessing about the precariousness of the created structure of power, the regime from time to time tries to invent additional "clamps" for it. The latest "achievement" in this field is the policy of "decommunization". The idea was to rally the heterogeneous elements of a loose society in the "fight against the communist legacy." Several months of "titanic effort" Verkhovna Rada and local authorities to rename everything "red" led to the fact that the law of negation of negation began to operate.

The logic of the development of events turned out to be such that it is necessary to move from the erasure of the past to the destruction of the present, created in the past. It's about first of all, in fact, about Ukraine as we know it. Ukraine is the brainchild of two of the greatest figures Soviet period our history - Lenin and Stalin. Thanks to the first, it gained statehood and became the second most important federal republic of the USSR, while receiving the current South-East, which never belonged to it. Thanks to the second, Ukraine entered the international arena, becoming a founder of the UN, and again grew territorially - Galicia, Northern Bukovina and Transcarpathia.

If we have abandoned the names of Lenin and his associates, we must go to the end and abandon their heritage - modern Ukraine. Consequently, the slogan of the moment should be Kyiv's demand for the entry of Ukraine in parts into the composition of those states where they were before Lenin and Stalin. If there are none today, then you need to turn to their successors. It seems that in this case, the peoples of Ukraine would support "decommunization" with both soul and heart. And without this, instead of a “clip”, it turned out, like that non-commissioned officer's widow, who flogged herself. The society, and indeed the whole world, once again became convinced of the dense cavernousness and obscurantism of the Kyiv regime.

Deprived of the slightest signs of rationality and common sense, Kyiv's policy has become the main subjective cause of the disintegration of the state taking place before our eyes, the objective prerequisites for which were laid in its organizational and structural foundations. If nothing changes in the Kyiv regime’s policy of “decommunization” and rejection of the past as part of historical Russia, the disintegration of Ukraine will only accelerate, and the point of no return will soon be passed. Moreover, and it is difficult to doubt this, knowing the history of the country and its peoples, most of Ukraine will turn towards the Russian world - to his home. The crown will finally take root.