Montreal classification of Crohn's disease. What do parents need to know about Crohn's disease in children? How long does it take to treat Crohn's disease?

The diagnosis must be confirmed:

endoscopic and morphological method; and/or

endoscopic and X-ray method.

If necessary, carry out the following additional research:

MRI, CT (diagnosis of fistulas, abscesses, infiltrates);

fistulography (in the presence of external fistulas);

capsule endoscopy (if a lesion is suspected small intestine and in the absence of strictures). It should be remembered that retention of the capsule in the intestine is observed in 13% of patientsxvi. Currently, in patients with CD, it is recommended to perform

X-ray studies (barium passage through the intestine, CT enterography) or MR enterography to assess the presence of small bowel stricturesxvii,xviii;

balloon enteroscopy (if damage to the small intestine is suspected).

The generally accepted ones are criteria for a reliable diagnosis of CD according to Lennard-Jones, including identification of six key signs of the diseasexix:

	Affects from oral cavity to anal				Fibrosis: strictures
		chronic	granulomatous		Lymphoid tissue(histology): aphthoid
	damage to the mucous membrane of the lips or cheeks;				ulcers or transmural lymphoid
	pyloroduodenal lesion, lesion				clusters
	small intestine, chronic perianal				Mucin (histology): normal content
	defeat				mucin in the area of ​​active inflammation
	Intermittent nature of the lesion				colon mucosa
	Transmural nature of the lesion: ulcers-				Presence of sarcoid granuloma
	cracks, abscesses, fistulas

The diagnosis of CD is considered reliable in the presence of any 3 signs or when a granuloma is detected in combination with any other sign.

Endoscopic criteria Diagnosis of CD are regional (intermittent) damage to the mucous membrane, the “cobblestone pavement” symptom (a combination of deep longitudinally oriented ulcers and transversely directed ulcers with islands of edematous hyperemic mucous membrane), linear ulcers (ulcers-fissures), aphthae, and in some cases strictures and the mouth of the fistula.

X-ray manifestations CDs include regional, intermittent lesions, strictures, cobblestones, fistulas, and interintestinal or intra-abdominal abscesses.

Morphological characteristics Bookmakers serve:

Deep slit-like ulcers penetrating into the submucosa or muscle layer;

Sarcoid granulomas (clusters of epithelioid histiocytes without foci of necrosis and giant cells), which are usually found in the wall of the resected area and only in 15-36% of cases - with a biopsy of the mucous membrane);

Focal (discrete) lymphoplasmacytic infiltration of the lamina propria of the mucous membrane;

Transmural inflammatory infiltration with lymphoid hyperplasia in all layers intestinal wall;

Lesion of the ileum with structural changes villous, mucoid or pseudopyloric crypt metaplasia and chronic active inflammation xx ;

Intermittent lesion - alternation of affected and healthy sections of the intestine (with

examination of the resected section of intestine).

Unlike UC, crypt abscesses rarely form in CD, and mucus secretion remains normal.

3.3. DIFFERENTIAL DIAGNOSIS Differential diagnosis BC is carried out fromxxi:

o campylobacteriosis; o yersiniosis;

o amoebiasis.

helminthic infestations;

antibiotic-associated intestinal lesions (Cl. difficile)xxii;

appendicitis;

endometriosis;

solitary rectal ulcer;

ischemic colitis;

actinomycosis;

radiation damage to the intestines;

irritable bowel syndrome.

4. CONSERVATIVE TREATMENT OF CROHN’S DISEASExxiii

4.1. PRINCIPLES OF THERAPY

Treatment options for CD include medications, surgery, psychosocial support and nutritional therapyxxiv.

Choosing the type of conservative or surgical treatment determined by the severity of the attack, the extent and localization of the gastrointestinal tract lesion, the presence of extraintestinal manifestations and intestinal

complications (stricture, abscess, infiltrate), duration of medical history, effectiveness and safety of previous therapy, as well as the risk of developing complications of CDxxv,xxvi.

The goals of therapy for CD are the induction of remission and its maintenance without constant use of corticosteroids, the prevention of complications of CD, the prevention of surgery, and if the process progresses and life-threatening complications develop, timely prescription of surgical treatment. Since surgical treatment does not lead to complete cure patients with CD, even with radical removal of all affected intestinal segments, anti-relapse therapy is necessary, which should be started no later than 2 weeks after surgeryxxvii.

Medicines, prescribed to patients with CD are conditionally divided into:

1. Agents for inducing remission: glucocorticosteroids (GCS) [systemic (prednisolone and methylprednisolone) and topical (budesonide)], Biological drugs: infliximab, adalimumab and certolizumab pegol, as well as antibiotics and 5-aminosalicylic acid (5-ASA).

2. Means for maintaining remission (anti-relapse drugs): 5-aminosalicylic acid and its derivatives, immunosuppressants [azathioprine (AZA), 6-mercaptopurine (6-MP) and methotrexate], infliximab, adalimumab and certolizumab pegol.

3. Auxiliary products for the prevention of disease complications and undesirable effects of medications (omeprazole, calcium, iron supplements, etc.).

It should be especially noted that GCS cannot be used as maintenance therapyxxviii.

4.2. CD of ILEOCECAL LOCALIZATION (terminal ileitis, ileocolitis). Light attack

First-line therapy consists of budesonide (9 mg/day for 8 weeks, then tapered by 3 mg/week until discontinuation) (LE: 2a, GR B)xxixxxx. Mesalazine may be prescribed

(4 g/day), however, although meta-analysis 3 major studies on the effectiveness of mesalazine

V dose of 4 g/day demonstrated a statistically significant superiority of the drug over placebo, these

the differences are not significant for clinical practice, since they amounted to only 18 points when assessed on the IABKxxxi scale. Thus, convincing evidence The use of 5-ASA drugs as first-line therapy has not been obtained.

The therapeutic effect (presence of clinical remission, IABC ≤ 150) should be assessed after 2-4 weeks. If there is remission during monotherapy with mesalazine, treatment is extended to 8 weeks. When inducing remission with budesonide, therapy is carried out according to the following regimen: 9 mg/day

V for 8 weeks, then decrease by 3 mg per week. Maintenance therapy is carried out with mesalazine 4 g/day ( UD 5, SR D)xxxii. In the absence of a therapeutic response, treatment is carried out as for a moderate attack of CD.

4.3. CD of ILEOCECAL LOCALIZATION (terminal ileitis, ileocolitis). Medium Attack

GCS therapy is indicated in combination with immunosuppressants: they are used to induce remission.

budesonide (9 mg/day) (LE 1a, GR A) or oral corticosteroids (prednisolone 1 mg/kg or methylprednisolone 0.8 mg/kg) (LE 1a, GR A)xxxiii. Application decision systemic GCS(not topical GCS

budesonide) is taken taking into account the severity systemic manifestations BK. Presence of extraintestinal manifestations and/or infiltrate abdominal cavity dictates the choice of systemic GCS. At the same time, immunosuppressants are prescribed: AZA (2 mg/kg), 6-MP (1.5 mg/kg), and in case of intolerance to thiopurines

<150) на фоне продолжения терапии иммуносупрессорами проводится снижение дозы ГКСuntil completely canceled: prednisolone - decrease by 5-10 mg per week, methylprednisolone - 4-8 mg per week, budesonide - take 9 mg / day for 8 weeks, then decrease by 3 mg per week.

The total duration of GCS therapy should not exceed 12 weeksxxxiv. Maintenance therapy with immunosuppressants is carried out for at least 4 years (LE 1a, SR A)xxxv,xxxvi.

(relapse 3-6 months after discontinuation of corticosteroids) biological therapy (infliximab, adalimumabxxxvii,xxxviii) or surgical treatment is indicated (LE 1b, SR A)xxxix.

Maintenance therapy after achieving remission with biological therapy is carried out with infliximab/adalimumab in combination with immunosuppressants xl, xli. The tactics of anti-relapse therapy after surgical treatment are described in “Section 5.5. Anti-relapse therapy after surgical treatment of CD."

4.4. BC COLON. Light attack.

Mild attacks of CD of the colon can be treated effectively with oral sulfasalazine 4 g or oral mesalazine 4 g (LE: 1b, GR A). The therapeutic effect is assessed after 2-4 weeks. When clinical remission is achieved (SABI ≤ 150), maintenance therapy is also carried out with sulfasalazine or mesalazine 4 g (at least 4 years)xlii. In the absence of a therapeutic response, treatment is carried out as for a moderate attack of CD (LE 1a,

CP B).

4.5. BC COLON. Medium attack.

Therapy with systemic corticosteroids in combination with immunosuppressants is indicated: prednisolone 1 mg/kg or methylprednisolone 0.8 mg/kg is used to induce remission (LE 1a, GR A)xliii. Simultaneously

immunosuppressants are prescribed: AZA (2 mg/kg), 6-MP (1.5 mg/kg), and in case of intolerance to thiopurines

– methotrexate (25 mg/week s.c. or i.m.). The effect of GCS therapy is assessed within 1-3 weeks. Therapy with a full dose of GCS should not be carried out for more than 1-3 weeks. Upon achieving clinical remission (IABC<150) на фоне продолжения терапии иммуносупрессорами проводится снижение дозы ГКСuntil completely canceled: prednisolone - decrease by 5-10 mg per week, methylprednisolone - 4-8 mg per week. The total duration of GCS therapy should not exceed 12 weeks. Maintenance therapy with immunosuppressants is carried out for at least 4 years (LE 1a, GR A)xlv.

In the absence of effect from corticosteroids or exacerbation of CD after discontinuation/reduction of the dose of steroids (hormone-dependent form) or ineffectiveness of immunosuppressive therapy

(relapse 3-6 months after discontinuation of corticosteroids) biological therapy (infliximab, adalimumab xlvi, xlvii) or surgical treatment (LE 1b, SR A) xlviii, xlix is ​​indicated.

Maintenance therapy after achieving remission with biological therapy is carried out with infliximab/adalimumab in combination with immunosuppressants. The tactics of anti-relapse therapy after surgical treatment are described in “Section 5.5. Anti-relapse therapy after surgical treatment of CD."

4.6. HEAVY ATTACK BC (any localization).

A severe attack of CD requires intensive anti-inflammatory therapy with systemic corticosteroids:

Intravenous administration of GCS: prednisolone 2 mg/kg/day (for example, 25 mg 4 times a day) for 7-10 days, followed by transition to oral administration of GCS (prednisolone 1 mg/kg body weight or methylprednisolone 8 mg/kg) . In the first 5-7 days, it is advisable to combine oral corticosteroids with additional intravenous administration of prednisolone 50 mg/day.

Prescription of immunosuppressants: AZA (2-2.5 mg/kg), 6-MP (1.5 mg/kg), and in case of intolerance to thiopurines - methotrexate (25 mg/week s.c. or i.m.).

Antibacterial therapy (EL5, SR D):

o 1st line - metronidazole 1.5 g/day + fluoroquinolones (ciprofloxacin, ofloxacin) IV 10-14 days;

o 2nd line - intravenous cephalosporins 7-10 dayslii,liii

Data obtained from systematic reviews and meta-analyses dictate the need for further research to assess the advisability of using antibiotics in the treatment of CDliv.

Infusion therapy: correction of protein-electrolyte imbalances, detoxification.

Correction of anemia (blood transfusions for anemia below 80 g/l, then therapy with iron supplements, preferably parenterally).

Enteral nutrition in malnourished patients.

When clinical remission is achieved, further treatment (maintenance therapy with immunosuppressants/biological therapy, dose reduction of oral corticosteroids) is carried out in the same way as for a moderate attack. If there is no effect from 7-10 days of IV GCS therapy, biological therapy (adalimumab/infliximab) or surgical treatment is indicated.

4.7. CD WITH PERIANAL LESIONS

Perianal manifestations of CD often require surgical treatment and are therefore discussed in Section 5.5, “Surgical Treatment of Perianal CD.”

4.8. CD of the SMALL INTESTINE (except for terminal ileitis).

For a mild attack, mesalazine 4 g/day is indicated, and the same dose is continued as maintenance therapy for at least 2 years (LE: 2b, GR B). Preference should be given to drugs with a coating that ensures the creation of a sufficient concentration of mesalazine in the affected area (ethylcellulose coating).

Medium Attack requires systemic hormonal therapy in combination with immunosuppressants: prednisolone 1 mg/kg or methylprednisolone 0.8 mg/kg (LE 1a, GR A) are prescribed in combination with immunosuppressants: AZA (2-2.5 mg/kg), 6- MP (1.5 mg/kg), and in case of intolerance to thiopurines - methotrexate (25 mg/week s.c. or i.m.). If there is an infiltrate of the abdominal cavity, antibiotics are prescribed: metronidazole intravenously + fluoroquinolones (mainly) parenterally for 10–14 days (LE 1a, SR A).lv. If necessary, nutritional support (enteral nutrition) is prescribed.

When remission is achieved, maintenance therapy is carried out with immunosuppressants for at least 4 yearslvi. The ineffectiveness of GCS therapy or the development of hormonal dependence is an indication for the prescription of biological therapy: infliximab/adalimumab.

Treatment of a severe attack is described in section 4.6, but nutritional support (enteral nutrition) is essential.

4.9. SELECTED ASPECTS OF THERAPY

When carrying out hormonal therapy, a gradual reduction in the dose of steroids until complete withdrawal is strictly necessary. The total duration of hormonal therapy should not exceed 12 weeks. During GCS therapy, concomitant use of calcium supplements, vitamin D (prevention of osteoporosis), proton pump inhibitors, and control of blood glucose levels are indicated.

When prescribing immunosuppressants (AZA, 6-MP, methotrexate), it should be remembered that their effect, due to the therapeutic concentration of the drug in the body, develops, on average, within 3 months for thiopurines and 1 month for methotrexate. During therapy, monthly monitoring of leukocyte levels is recommended.

Before carrying out biological (anti-cytokine) therapy, it is mandatory to consult a TB doctor and screen for tuberculosis (quantiferon test, and if this is not possible, the Mantoux test, Diaskin test). Strict adherence to the dosage and schedule of administration of lix is ​​mandatory. Irregular administration of biological drugs increases the risk of allergic reactions and treatment failure.

Therapy with infliximab (Remicade) is carried out at a starting dose of 5 mg/kg and includes an induction course of three infusions according to the “0-2-6” scheme, i.e. with the second administration of the drug after 2 weeks and the third administration 6 weeks after the first infusion. Infusions as part of further maintenance therapy are carried out every 8 weeks. In some patients, it may be necessary to increase the dose to 10 mg/kg and reduce the duration of administration to 6 weeks to achieve effect.

An induction course of adalimumab (Humira) includes a 160 mg subcutaneous dose followed by an 80 mg dose 2 weeks later. Further administrations (as part of maintenance therapy) are carried out from 4 weeks from the start of treatment, 40 mg subcutaneously every 2 weeks.

To be more effective, biological (anticytokine) therapy must be combined with immunosuppressive (azathioprine) therapy. Carrying out surgery during therapy with immunosuppressants and biological drugs, as a rule, does not require a change in anti-relapse therapy.

Prevention of opportunistic infectionslxi

TO Risk factors for the development of opportunistic infections include:

Medications: azathioprine, intravenous hormone therapy 2 mg/kg or orally more than 20 mg per day for more than 2 weeks, biological therapy;

Age over 50 years;

Related diseases: chronic diseases lungs, alcoholism, organic

brain diseases, diabetes.

In accordance with the European consensus on the prevention, diagnosis and treatment of opportunistic infections in IBD, such patients are subject to mandatory vaccine prophylaxis. The required minimum of vaccination is:

Recombinant HBV vaccine;

Polyvalent inactivated pneumococcal vaccine;

Trivalent inactivated influenza virus vaccine.

For women under 26 years of age, in the absence of the virus at the time of screening, vaccination against the human papillomavirus is recommended.

5. SURGICAL TREATMENT OF CROHN'S DISEASE

Most patients with CD undergo at least one surgical intervention on the gastrointestinal tract during their lifetime. The inability to achieve a radical cure in patients with CD often leads to repeated resections, increasing the risk of short bowel syndrome. Modern tactics of surgical treatment of CD are aimed at performing limited resections, and, if possible, organ-preserving interventions (stricturoplasty, stricture dilatation) lxii.

5.1. INDICATIONS FOR SURGICAL TREATMENT OF CD

Indications for surgical intervention in CD include acute and chronic complications, as well as ineffectiveness conservative therapy and delayed physical developmentlxiii. 5.1.1. Acute complications of CD include intestinal bleeding, intestinal perforation and toxic dilatation of the colon.

At intestinal bleeding Emergency surgical intervention is indicated when it is impossible to stabilize the patient’s hemodynamics, despite red blood cell transfusions and intensive hemostatic therapy lxiv. Intestinal bleeding is diagnosed when there is a loss of more than 100 ml of blood/day according to objective laboratory methods (scintigraphy, determination of hemoglobin in stool using the hemoglobin cyanide method) or when the volume of stool with a visually detectable admixture of blood is more than 800 ml/day. In such cases, resection of the affected area of ​​the intestine is performed (with or without anastomosis) with mandatory intraoperative enteroscopic or colonoscopy.lxv

Small bowel perforation into the free abdominal cavity is a fairly rare complication and usually occurs either distal or proximal to the bowel with the presence of a stricture. If threatening symptoms are detected (peritoneal symptoms, free gas in the abdominal cavity according to survey R-graphy), emergency surgical intervention is indicated, which in such a situation may be limited to resection of the affected area with the formation of an anastomosis or stoma lxvi. In case of emergency surgery, formation of a primary anastomosis without protection using a double-barreled ileostomy should be avoided.

Colon perforation It is extremely rare in CD. The operation of choice is subtotal resection of the colon with the formation of an ileostomy.

Toxic dilatation of the colon is a rare complication of CD and is an expansion of the colon up to 6.0 cm or more, not associated with obstruction, with symptoms of intoxication. Risk factors for toxic dilatation include hypokalemia, hypomagnesemia, bowel preparation for colonoscopy with osmotic laxatives, and

antidiarrheal drugs. The development of toxic dilation is indicated by a sudden reduction in the frequency of stools against the background of existing diarrhea, bloating, as well as a sudden decrease or disappearance of pain and an increase in symptoms of intoxication (an increase in tachycardia, a decrease in blood pressure). The operation of choice is subtotal resection of the colon with single-barrel ileostomy.

5.1.2. Chronic complications include strictures, abdominal infiltration, internal or external intestinal fistulas, and the presence of neoplasia lxviii.

5.1.3. Ineffectiveness of conservative therapy and delayed physical development

The ineffectiveness of conservative therapy is evidenced by the presence of hormonal dependence and resistance (see Section 2.2. Classification of CD). A manifestation of inadequate drug therapy is also delayed physical development, most often occurring when the upper gastrointestinal tract is affected.

5.2. SURGICAL TREATMENT OF CD OF THE SMALL INTESTINE AND ILEOCECAL ZONE

Approximately 1/3 of all patients with CD have such localization and are often complicated

formation of stricture of the ileum or ileocecal valve. The operation of choice is resection of the ileocecal region with the formation of ileo-ascendoanastomosis lxix,lxx.

If a stricture is detected after the first course conservative treatment(i.e., the use of GCS), resection of the affected area of ​​the intestine is indicated as the first stage of treatment, and not a repeated course of conservative (hormonal) therapy.

In the presence of active CD with the formation of an abdominal abscess, antibiotics are required, as well as drainage of the abscess or resection of the affected area. Drainage can be carried out surgically or, in specialized centers and with sufficient qualifications, by percutaneous drainage. The latter option can only be used in the absence of stricture of the affected area, which determines the need for resection of the affected area.

In the presence of short strictures of the jejunum or ileum, including anastomotic strictures after a previous resection, an alternative to resection is strictureplasty, which avoids extensive resections of the small intestine. This intervention is possible if the length of the stricture is no more than 10 cm. Contraindications to strictureplasty are the presence of infiltrate, abscess, malignant formations in the intestinal wall, or active bleeding and severe inflammation of the affected area.

In the absence of infiltrate and abscess, it is preferable to perform laparoscopic surgery on the small intestine and ileocecal area lxxi, lxxii.

The simultaneous formation of two anastomoses does not lead to an increase in the incidence of postoperative complications and the incidence of disease relapse lxxiii. The preferred technique for forming an anastomosis on the small intestine is the application of a hardware anastomosis of the “side-by-side” type, which reduces the likelihood of its failure lxxiv and the subsequent development of a stricture.

5.3. SURGICAL TREATMENT OF CD OF THE COLON

Limited damage to the colon in CD (less than a third of the colon) does not require

colectomy. In this case, you can limit yourself resection of the affected segment with the formation of intestinal anastomosis within healthy tissueslxxv,lxxvi. If there is a lesion in the ascending

in the colon, the proximal resection border should be located at the level of the middle colon vessels, preserving the latter. Right hemicolectomy is indicated when irreversible inflammatory processes in the ascending and/or transverse colon. In this situation, it is also possible to perform an extended right hemicolectomy. In case of left-sided lesion, resection of the left parts is performed with the formation of a colorectal anastomosis, and in case of involvement in inflammatory process It is also possible to form an ascendorectal anastomosis in the transverse colon.

For extended CD of the colon with severe clinical manifestations, the operation of choice is subtotal resection of the colon with a single-barrel ileostomy. It is possible not to resect the distal part of the colon, provided that there is no significant inflammation in it, and bring it to the anterior abdominal wall in the form of a single-barreled sigmostoma, or immerse the sutured end under the pelvic peritoneum.

An alternative operation is colproctectomy with the formation of a terminal single-barrel ileostomy. This intervention is performed only in patients with severe activity of the inflammatory process in the rectum or severe perianal manifestations, since it makes further restoration of anal bowel movement impossible. At the same time, if possible, abdominoperineal extirpation should be avoided due to the extremely low repair capabilities and the risk of the formation of extensive perineal wounds, which subsequently take a long time to heal by secondary intention, which disables patients and limits their social activity.

In the absence of severe clinical manifestations in patients with total damage to the colon with minimal activity of inflammatory changes in the rectum, adequate function of holding intestinal contents and the absence of perianal lesions, the operation of choice is colectomy with formation ileo-rectal anastomosis lxxvii.

Possibility of formation of ileo-anal reservoir anastomosis (IARA) in CD of the colon is controversial due to the high incidence of complications and frequent indications for removal of the reservoir. At the same time, the average life expectancy of patients after the formation of an IRA without a permanent ileostomy reaches 10 years, which is important for young, able-bodied patients lxxviii. The main problems threatening a patient with IARA due to Crohn's disease are the development of perianal lesions and Crohn's disease of the small intestinal reservoir.

Operation “switching off” tranchitis of intestinal contents through the colon by forming a double-barreled ileostomy or colostomy is indicated only in extremely malnourished patients and in pregnant women. This type of surgical treatment is temporary. Considering that in UC, disabling passage through the colon is not effective, it is necessary to carry out an accurate differential diagnosis between CD of the colon and UC.

All of the listed surgical interventions can be safely performed using laparoscopic technologieslxxix.

If a short stricture of the colon is detected, it is possible to perform

endoscopic dilatation lxxx, however, this manipulation is associated with a higher risk of disease relapse compared to resection of the affected area of ​​the intestine lxxxi, lxxxii. Execution

Stricturoplasty for colonic strictures is not recommended.

5.4. SURGICAL TREATMENT OF CD INVOLVING THE UPPER GASTROINTESTINAL TRACT

Involvement of the intestinal area proximal to the terminal ileum in the inflammatory process often leads to the formation of multiple strictures and interintestinal fistulas, which leads to an unfavorable prognosis for CD. Surgical treatment can include the formation of a bypass anastomosis, stricturoplasty and resection of the affected area. It is necessary to resort to the formation of a bypass small intestinal anastomosis only in exceptional cases due to the high risk of developing bacterial overgrowth syndrome in the disconnected part of the small intestine and malignancy. Extensive resections contribute to the formation of short small bowel syndromelxxxiii. In the presence of single or multiple

for non-extended strictures, the operation of choice may be stricturoplasty in various variantslxxxiv.

Strictures of the gastroduodenal zone (usually the duodenum) are amenable to balloon dilatation. Stricturoplasty is also effective.

5.5. TREATMENT OF CD WITH PERIANAL LESIONSlxxxv

Perianal manifestations develop in 26-54% of patients suffering from CD1xxxvi,lxxxvii, and are more common when the colon is affected. The most accurate diagnostic methods are MRI of the pelvis, local examination under anesthesia and, in a specialized center, ultrasound with a rectal probe. Fistulography is less accurate than MRI in diagnosing perianal fistulas.

The purpose of the examination for perianal manifestations of CD is, first of all, to exclude an acute purulent process in the pararectal area, requiring urgent surgical treatment.

The approach to surgery in the perianal area should be individual for each patientlxxxviii,lxxxix.

Perianal manifestations in CD exclude the possibility of using salicylates to maintain remission and require the use of immunosuppressants (azathioprine, 6-mecarptopurine,

methotrexate) and/or biological drugs (infliximab, adalimumab) in standard doses. Perianal manifestations of CD also require the administration of metronidazole 0.75 g/day and/or ciprofloxacin 1 g/dayxc. Antibiotics are prescribed for a long time (up to 6 months or until side effects appear). Local use of steroid drugs and aminosalicylates for pararectal fistulas is ineffective. It is effective to add metronidazole to therapy in the form of suppositories and ointments.

Subject to availability cracks anal canal Surgical intervention is not recommended, and preference is given to the above-described conservative therapy.

Simple fistulas that are not accompanied by any symptoms do not require surgery. Dynamic observation is indicated against the background of the above-described conservative therapy. If symptoms are present, it is possible to eliminate the fistula using a fistulotomyxci or its adequate drainage by installing latex seton drains. The indication for the installation of setons in most cases is the involvement of part of the sphincter in the fistulous tract. In the absence of inflammation of the rectal mucosa, it is possible to perform a reduction of the rectal mucomuscular flap with plastic surgery of the internal fistula xcii.

Treatment of complex fistulas includes the installation of latex seton drains in combination with aggressive drug therapy. Given the high effectiveness of biological therapy with proper drainage of complex fistulas, early administration of infliximab or adalimumab is justified. However, complex perianal fistulas, which with a high frequency lead to the development purulent complications, are often an indication for cutting off passage through the colon by forming a double-barreled ileostomy.

Rectovaginal fistulas in most cases they require surgical intervention. Only in certain situations, in the presence of a low fistula between the rectum and the vestibule of the vagina, only conservative treatment is possible. In other cases, surgical treatment under the cover of an ileostomy is indicated. In the presence of active rectal damage, adequate anti-inflammatory therapy before surgery increases the effectiveness of the intervention.

The most unfavorable factor that increases the likelihood of a permanent ileostomy or colostomy is the presence of a stricture inferior ampullary rectum or anal canal stenosis. In most cases, these complications require proctectomy or abdominoperineal extirpation of the rectum. In some situations, in the absence of active inflammation in the overlying parts of the intestine, stricture formation is possible.

5.5. ANTI-RECURRENCE THERAPY AFTER SURGICAL TREATMENT OF CD

Even with complete removal of all macroscopically changed parts of the intestine, surgical intervention does not lead to complete healing: within 5 years clinically

significant relapse is observed in 28-45% of patients, and within 10 years - in 36-61%, which dictates

the need to continue anti-relapse therapy after surgery for CDxciii,xciv. TO

factors that significantly increase the risk postoperative relapse, include: smoking, history of two or more bowel resections, history of extensive small bowel resections (>50 cm), perianal lesions, penetrating phenotype xcv.

Depending on the combination of risk factors, as well as on the effectiveness of previously administered anti-relapse therapy, patients after surgery should be stratified into groups with different risks of postoperative relapse. In the group at low risk of CD recurrence, it is advisable to prescribe mesalazine (4 g) or sulfasalazine (4 g). Patients at intermediate risk are candidates for therapy with azathioprine (2.5 mg/kg/day) or 6-mercaptopurine (1.5 mg/kg/day)xcvi. For patients with a high risk of relapse, it is advisable to begin a course of biological therapy with anti-TNF drugs (infliximab, adalimumab, certolizumab pegol) even before a control endoscopic examination.

Anti-relapse therapy is recommended to begin 2 weeks after surgery. After 6-12 months, all operated patients with CD are advised to undergo a follow-up examination, primarily endoscopic. If it is impossible to visualize the anastomosis area, the presence or absence of relapse should be determined based on a combination of X-ray examination data (usually CT) and non-invasive markers of inflammation - C-reactive protein, fecal calprotectin, etc.

Table 5.5. Endoscopic activity scale for postoperative relapse of Crohn's disease according to

Rutgeertsxcviii

	Definition
	No signs of inflammation
	≤5 aphthous ulcers
	>5 aphthous ulcers with normal mucous membrane between them or extended
	areas of healthy mucosa between more severe ulcerations or
	lesions limited to the ileocolic anastomosis.
	Diffuse aphthous ileitis with diffusely inflamed mucous membrane
	Diffuse inflammation with large ulcers, cobblestones and/or narrowing
	lumen.

In the absence of signs of inflammation or detection of minimal (i1 on the Rutgeerts scale) inflammatory changes, therapy should be continued. The presence of more pronounced inflammatory changes (i2-i4) indicates the ineffectiveness of the therapy and should serve as an indication for intensifying therapy: adding immunosuppressants in patients who have not previously received them or conducting biological therapy with adalimumabxcix or infliximabc in patients on maintenance therapy with azathioprine/6 - mercaptopurine. In the future, regardless of the nature of the disease and the clinical manifestation of CD, control tests should be performed at least once every 1-3 years. endoscopic examination, following the same algorithm for choosing an anti-relapse drug (Figure 1)ci.

Figure 1. Algorithm for preventing postoperative relapse of Crohn's disease

Assessing the risk of postoperative recurrence of Crohn's disease:

Penetrating phenotype

Perianal lesions

History of two or more bowel resections

History of resection of an extended segment of the small intestine (>50 cm)

Low risk	Medium risk	High risk
Mesalazine or abstain	AZA or 6-MP in combination with	Infliximab / Adalimumab
from therapy	metronidazole
Control endoscopic examination in 6-12 months
No relapse	No relapse	No relapse
Colonoscopy in 1-3 years	Colonoscopy in 1-3 years	Colonoscopy in 1-3 years
Relapse	Relapse	Relapse
AZA/6-MP or	AZA/6-MP or	change of biological
infliximab/adalimumab	infliximab/adalimumab	drug or optimization
		infliximab/adalimumab

6. FORECAST

Crohn's disease is characterized by progressive damage to the intestines. At the time of diagnosis, complications (strictures, fistulas) are found in only 10-20% of patients, while within 10 years similar complications develop in >90% of patients. Within 10 years, surgery due to complications and/or failure of conservative therapy is performed in half of patients with CD, and 35-60% develop a relapse of the disease within 10 years after surgery. Hormonal dependence in CD has been detected at least once in 30% of patients for 10 years.

Prognostically unfavorable factors with CD are smoking, the onset of the disease in childhood, perianal lesions, penetrating disease phenotype and widespread small bowel disease.

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Severe intestinal pathology (usually at the border of the terminal zone of the ileum and the initial part of the colon) with an unknown cause is. The treatment is complex and continues throughout the patient’s life. Chronic disease is expressed in specific granulomatous inflammation, when nodules from accumulations of lymphocytes, eosinophils, and epithelioid cells form in the wall and nearby lymph nodes.

The consequences cause the formation of purulent abscesses, rough scars, narrowing of the lumen, rupture (penetration) of the intestine, massive bleeding. Fistula tracts connect the intestine with bladder, other loops, in women with a vagina, extend to the skin of the abdomen.

The onset of the disease is adolescence, continues into adulthood. At successful therapy gives long-term remissions. The loss of part of the intestinal surface contributes to impaired absorption and peristalsis, a deficiency of necessary nutrients, so organs and systems suffer. Extraintestinal forms affect the eyes, skin, and oral cavity. Patients turn to doctors of various specialties with the first symptoms. To diagnose, you need to undergo a serious examination.

The clinical picture of Crohn's disease consists of signs of enteritis or colitis (inflammatory process in the small and large intestines). When the etiology of the disease is unknown, doctors are forced to use an approved standard protocol for treatment as a guideline. It contains a list of mandatory medications, symptomatic medications, dosages for children and adults in the acute period and for maintenance use.

Specialists are developing new medications, but they are only allowed to be used after clinical trials have been conducted and reliable positive results have been obtained.

To tasks healing process includes:

• relief of acute inflammation;
• pain relief for severe pain;
• normalization of stool through diet and stopping diarrhea;
• removal of toxic substances that accumulate due to tissue breakdown;
• compensation for deficiency of vitamins, protein, microelements;
• restoration of organ function;
• support of the remission stage and prevention of exacerbations;
• combating complications.

The level of modern medical knowledge about pathology does not allow the disease to be completely cured, but considerable experience has been accumulated in counteracting destruction with the help of different groups medicines. Their purpose depends on the form of the disease and the severity of the course. When choosing a product, specialists use a scheme for determining the biological activity of the process in points.

Crohn's disease can be treated with monotherapy (one drug) and the combined effects of several drugs. From drug groups to different periods diseases apply:

• salicylic acid derivatives;
• corticosteroid hormones;
• blockers of hyperactive immune response;
• antibiotics.

Alternative treatments are being developed. Among them:

• plasmasorption and plasmapheresis;
• using the hyperbaric oxygenation method (the patient is placed in a chamber with high concentration oxygen);
• introducing your own stem cells or a drug from donors (Polychrome);
• creation of marijuana-based medicines;
• homeopathic remedies;
• genetically modified bacteria.

Some drugs are used in other areas of medicine. For example, Naltrexone is used in narcology to eliminate dependence on opiates and alcohol, but is capable of blocking nerve endings involved in the inflammatory process. Therefore, it has a supporting effect in complex therapy.

Medicines for mild illness

IN mild degree activity of the process, the use of salicylates (Sulfasalazine, Salofalk, Melasazin, Budenofalk, Pentaxa, Mesacol, Salozinal) is most indicated. The drugs are taken orally, in rectal suppositories, are prepared in the form of a suspension. Proved to be effective against inflammation in the ileum and colon. Tablets differ in dosage and degree of absorption.

For example, Mesalazine is produced in a soluble coating. Absorbed 15-30% in the ileum, the rest goes into large intestine. Salofalk is good for maintenance therapy in the remission phase. Budenofalk is not recommended for treatment of patients with lesions in the stomach, initial parts of the small intestine, eyes, joints, or skin.

Budesonide is used from the group of corticosteroids. From others hormonal drugs has the least negative properties.

Drugs for severe Crohn's disease

Is it possible to cure Crohn's disease in moderate to severe form? Gastroenterologists answer positively, but clarify: “Not to cure forever, but to reduce exacerbations.” There are strong drugs available for complex impact for pathology.

Corticosteroids are hormones of the adrenal cortex, known for their powerful anti-inflammatory effect. Used in tablets or injections. Daily dose controlled by the doctor, it is reduced gradually as the patient’s condition improves and switches to minimal maintenance.

The most commonly used are Prednisolone, Methylprednisolone, Budesonide. If the lower regional sections of the intestine are affected, it is administered in microenemas twice a day. The drugs are included in standard combinations with salicylates and antibacterial agents. The result of treatment improves when prescribing Prednisolone with Metronidazole or Sulfasalazine. Replacement with Mesalazine in small doses is carried out when the activity of inflammation decreases.

Immunosuppressants - suppress the hyperreaction; they are not used as a single drug. To this day, doctors disagree about the advisability of its use. Azathioprine, Methotrexate, and 6-mercaptopurine are commonly used. On the one hand, there are observations on the healing of fistula tracts in the severe stage of Crohn's disease, on the other hand, the drugs cause pronounced negative disturbances (leukopenia, inflammation of the pancreas). Installed increased risk transformation of granulomatous changes into a malignant tumor.

Antibiotics are prescribed in cases of purulent complications, secondary infection, and detection of painful infiltrates in the peritoneal cavity. Drugs used wide range actions (Ciprofloxacin, Rifaximin), a group of semisynthetic penicillins (Ampicillin, Pentrexil). The duration of a course of antibiotic therapy for Crohn's disease should not exceed 10-14 days due to the danger of severe dysbiosis.

To enhance the effect, antibiotics are combined with antibacterial agents: Clotrimazole, Metronidazole. Effective in localizing inflammation in the rectum and around the anus.

A group of genetically engineered drugs is made from human or animal blood antibodies to tumor necrosis factor alpha. Representatives: Infliximab, Adalimumab, Golimumab, Etanercept. Vedolizimab blocks intestinal receptors that support inflammation. The treatment dose of Infliximab is divided into 3 parts. It is administered intravenously in a dilution of saline. solution. The second time after 2 weeks, the third time after 4 weeks. Scientists believe that the drug is able to simulate the correct immune response.

Additional and maintenance therapy products

In the treatment of Crohn's disease in adults and children, it is impossible to do without symptomatic drugs. To relieve symptoms use:

1. Painkillers - not all drugs that relieve spasmodic contractions of the intestines are suitable for this purpose. For example, such popular means, as Imodium and Diphenoxylate against the background of diarrhea increase the pressure inside the intestine, which promotes perforation. They are used if necessary under the supervision of a physician in a hospital setting. Almagel is allowed if there are no signs of obstruction.
2. Enterosorbents help remove tissue breakdown products and waste from the intestines. Prescribe Polysorb, Smecta, Enterosgel.
3. Enzymes - compensating for irritation of the pancreas, normalize digestion, Panzinorm, Mexase, Festal are indicated. For extensive lesions (removal of the ileum), cholestyramine, which binds fatty acids, is used.
4. Multivitamins - a patient with impaired absorption in the intestine experiences vitamin deficiency. Everyone is important fat soluble vitamins(A, D, E), B12 and folic acid.
5. The lack of microelements is covered with calcium, zinc, and magnesium preparations.
6. Probiotics are recommended to support intestinal flora, responsible for food processing, absorption, regional immunity.
7. When hemoglobin and red blood cells fall, signs iron deficiency anemia Iron supplements are indicated.
8. Convulsive syndrome and severe diarrhea are eliminated by taking Loperamide 4 times a day before meals.

The withdrawal of medications is carried out gradually, at a slow pace. The patient remains on the minimum maintenance dosage for several months or years. This depends on residual regional changes and the degree of digestive disturbance. Gastroenterologists have found that complete withdrawal of drugs leads to exacerbations after 6-12 months.

As inter-relapse therapy, it is possible to use 5-ASA, Metronidazole (if it does not cause taste distortion and neuropathy), Infliximab (every 2 months), Azathioprine. To avoid the negative effects of drugs, monthly monitoring is carried out using blood tests.

Patients with Crohn's disease require constant dietary nutrition. It differs during periods of exacerbation and remission. Refusal of restrictions causes a new exacerbation with more severe symptoms. According to Pevzner’s classification, the choice at different stages of the disease varies within the options of table No. 4 (a, b, c, d).

Nutrition Goals:

• providing the body sufficient quantity proteins, fats and carbohydrates, calorie content, vitamin composition, taking into account constant losses;
• maximum sparing of inflamed areas of the intestine;
• elimination of products containing irritating substances that promote fermentation and bloating.

• frequent feeding with small portions and intervals of 3 hours;
• avoiding overeating or prolonged hunger;
• creating conditions for eating food warm; hot and cold dishes are equally harmful;
• drinking plenty of water from 2.5 liters during the inter-relapse period, up to 3.5 liters with frequent diarrhea;
• prohibition of spicy and fatty foods, sauces, whole milk, fresh vegetables and fruits (only boiled compotes are allowed), fried meat and fish.

In case of severe condition of the patient, parenteral nutrition is used intravenously. special drugs, making up the necessary calorie requirements. If swallowing is impaired, the nutritional mixture is administered through a nasogastric tube. A slag-free diet is indicated in preparation for surgery, in patients with intestinal fistulas, obstruction, and in childhood.

When the temperature, pain, and diarrhea decrease, a gradual transition to diet No. 4c will be required.

Traditional methods

Doctors have an extremely negative attitude towards popular advice in the treatment of Crohn's disease. The unusual nature of intestinal inflammation should set the patient up for careful use of herbal remedies, medicinal herbs with your illness. Herbal decoctions, indicated for ordinary chronic colitis and enteritis, are strictly prohibited in case of intestinal damage by granulomatous inflammation.

Among the recommendations traditional medicine There are decoctions of marshmallow root, celandine, chamomile, and yarrow for oral administration and enemas. The plant composition causes even more allergies digestive tract, does not support, but destroys the achieved treatment results. Therefore, doctors are categorically against additional load complicating therapy.

Exercise therapy to help therapy

Some websites claim that it is safe to exercise if you have Crohn's disease. Apparently, the authors present what they want as a rule, but they themselves are far from therapy. Let us remind you that any sport requires not just moving, but achieving improved results. Only healthy people can withstand the stress of competition. Even chess players reach nervous breakdowns.

Any stress (not necessarily physical) contributes to the failure of the achieved treatment result and leads to an exacerbation of Crohn's disease with pain and diarrhea. Therefore, we will focus on practical exercises physical therapy and consider options for exercise therapy that are possible at home.

The fact of improvement is not disputed immune system under light loads. This can be a long walk fresh air, classes in the pool.

A feature of gymnastic techniques for the intestines is the obligatory lying position.

Important! By measuring the indicator intra-abdominal pressure in a lying person, it was found that the organs from the abdominal cavity move upward, the intestines are freed from compression and all parts of the large intestine are at the same level. This improves blood microcirculation and normalizes stool.

For patients with Crohn's disease during an acute condition, any exercise is strictly contraindicated; strict bed rest is recommended.

During remission, doctors suggest doing yoga. It involves mastering breathing practices, the possibility of mental relaxation, and performing exercises at a slow pace.

Classes should begin under the supervision of a specialist. Having learned the basic asanas, the patient can practice at home. The patient needs exercises to eliminate gas formation and relieve tension in the abdominal cavity. Their regular implementation gives a healing effect.

Duration and effectiveness of treatment

Treatment acute stage anti-inflammatory drug complex lasts 2-3 months, followed by maintenance therapy. The specific period depends on the choice of drug and the patient’s condition. For example, corticosteroids cannot be used for a long time; the negative effect is the appearance of osteoporosis, diabetes mellitus, hypertension, intestinal bleeding.

Antibiotic therapy is allowed for no longer than two weeks. In severe cases, 2 drugs with different directions of action are prescribed to enhance the effect. Other medications are used in a minimal dose for several months or years. Replacement with drugs of the same group is carried out.

The best positive outcome of treatment is the achievement of long-term remission, when exacerbations occur 1-2 times every 20 years. Doctors note that, unfortunately, relapses occur more often in 50-78% of cases. Carrying out surgical removal irreversibly changed area of ​​the intestine - a way to extend the inter-relapse period. 65% of patients require re-intervention in the next 5 years.

How long does it take to treat Crohn's disease?

Patients have to undergo treatment for the rest of their lives. Doses and medications are changed, but the threat of exacerbation is not removed. The main cause of death of the disease is emergency conditions caused by ulcers breaking into the abdominal cavity, peritonitis, bleeding. The risk of degeneration into a malignant tumor increases sharply.

Is it possible to completely cure the disease?

The disease cannot yet be cured. Doctors insist that patients follow a healthy regimen, stop smoking, complete refusal from alcohol. If patients do not want to take care of their health, the frequency of relapses increases almost 3 times. And lethal outcomes are 3.5-4.8 times.

The undulating course of the disease alternates between exacerbations and remissions. In mild and moderate forms, patients do not experience signs of pathology for several months and years.

In what situations is inpatient or surgical treatment necessary?

Treatment of the patient in the hospital begins with conservative treatment if severe general symptoms intoxication, high fever, chills, vomiting, fluid loss with frequent diarrhea. Hospitalization is necessary for symptoms of irritation abdominal wall(peritonitis), acute bleeding, palpation identification of areas of compaction.

Patients are prescribed parenteral nutrition, intravenous administration medications. If the severity of the condition cannot be eliminated within 5-7 days, then surgical intervention is suggested. It is estimated that up to 60% of patients require surgery. If the patient refuses, it is necessary to operate later for health reasons. But the result will be worse due to more severe damage to the immune system.

There are absolute indications (without surgery a person will die) and relative ones, when the patient can be prepared and operated on as planned. The absolute ones include:

• rupture of the intestinal wall with release of contents into the abdominal cavity, fecal peritonitis;
• intestinal obstruction caused by scars;
• acute bleeding from vessels involved in the inflammatory process;
• formation of fistula tracts in urinary tract, vagina, uterus.

Under general anesthesia the surgeon, after opening the abdominal cavity (laparotomy), ligates the bleeding vessel, removes (resects) the non-viable section of the intestine with the connection of the above and underlying loops, fistula tracts. The peritoneal cavity is washed with an antiseptic, drainage tubes are left in it to remove fluid, and the wound is sutured.

Relative indications are:

• ineffective course of full-fledged conservative therapy;
• partial intestinal obstruction;
• signs of damage to joints, eyes, skin that cannot be treated with therapeutic methods.

Surgeons routinely perform:

• opening and drainage of abscesses;
• resection of individual segments of the intestine;
• plastic surgery of constrictions;
• application of bypass anastomoses, removal of the stoma on the skin of the abdomen.

After surgery, in addition to wound care, the patient receives the full range of conservative therapy. It is necessary to note that in case of Blood disease, surgery cannot completely cure the patient. The causes of the disease remain, so it is only possible to delay complications and eliminate life-threatening situations.

The methods used in the treatment of Crohn's disease give the patient hope for possible relief from painful symptoms for a long time. Great value has the correct implementation of doctor’s recommendations, participation in therapeutic measures.