RU2178986C1 - Method to predict ulcerative colitis in children - Google Patents

Abstract

FIELD: medicine, gastroenterology. SUBSTANCE: the method studies an echogenicity for the walls of cecum, ascending colon, cross-colon, descending colon, sigmoid flexure and rectum according to intensity values of a gray-colored scale and at 41-68% echogenicity values and slight wall thickening being about 3-4 mm the first degree of wall damage and minimal process activity are determined. At 27- 40% echogenicity values and wall thickening about 4-7 mm the second degree of wall damage and moderate process activity are established. At 15-26% echogenicity values and wall thickening about 8-10 mm the third degree of wall damage and pronounced process activity are detected at echogenicity norm being 41-68% and wall thickness being 2-3 mm. EFFECT: enhanced accuracy of prediction. 3 ex

Description

 The invention relates to medicine, namely to diagnosis, and can be used in gastroenterology in the diagnosis of ulcerative colitis in children.

 Currently, there is an increase in the incidence of chronic inflammatory diseases of the colon, a shift in the timing of the occurrence of pathological conditions to an earlier age, an aggravation of the course of diseases, the early formation of complications from adjacent organs and systems, an increase in the frequency of cases requiring surgical interventions. An intestinal disease such as ulcerative colitis has many clinical “masks”, which often complicates timely diagnosis, causes delayed treatment and thereby causes irreparable damage to the child’s health.

 Diagnosis of ulcerative colitis in children is not always simple, it is based on an anamnesis, data from clinical and laboratory studies, sigmoidoscopy, fibrocolonoscopy, and radiography of the colon.

 Sigmoidoscopy and fibrocolonoscopy [1] make it possible to assess the external condition of the mucous membrane: the presence of swelling, hyperemia, erosive and ulcerative defects, pseudo-polyps, and increased vulnerability. However, endoscopic diagnostic methods are available only to large and specialized clinics. The disadvantage of fibrocolonoscopy is the inability to assess the structural state of all layers of the wall of the colon, surrounding organs and tissues. In addition, such studies are often combined with the need for anesthetic management. The procedure is contraindicated in severe forms of ulcerative colitis with a pronounced degree of activity of the process due to the risk of perforation of the intestinal wall.

 An X-ray examination [2] of the colon wall by contrasting it with a barium suspension, and sometimes a barium suspension and air (double contrasting) allows us to establish a violation of motor-evacuation function, as well as morphological changes in the intestine (narrowing, kinks, changes in the relief of the mucous membrane, deformation, absence normal haustration, shortening and stiffness of the intestine). However, an X-ray examination for severe ulcerative colitis in order to avoid dangerous complications (perforation of the colon, its toxic dilatation, intestinal bleeding) is also contraindicated. The main negative point when using X-ray research methods is the high radiation load on the patient, and therefore repeated use of this method to dynamically monitor the course and prognosis of the disease is not valid.

Ultrasound examination of the colon [3] has several advantages compared to other methods, namely the absence of a harmful factor in the form of radiation exposure to the child’s body, allowing repeated studies without restrictions and monitor the dynamics of the disease. Sonography of the colon has not only high diagnostic accuracy, but also additional capabilities in the comprehensive diagnosis of ulcerative colitis in children. Currently, the following echographic signs characteristic of this disease are known:
1. Thickening of the intestinal wall.

 2. Violation of the lamination (layering) of the intestinal wall.

 3. Change in the inner contour of the wall in the form of erosive or ulcerative defects.

4. Reducing the height of the hustration up to its complete absence in places of localization of the inflammatory dystrophic process
5. Identification of polypous growths of the mucous layer.

 Almost all of the above sonographic signs characteristic of ulcerative colitis in children are subjective, as they are descriptive in nature, which affects the accuracy of diagnosis.

 For the prototype of the invention, a well-known method for diagnosing ulcerative colitis in children is selected, including conducting an echographic study and determining the wall thickness of the colon (see Yanitskaya M. Yu. Clinical and physiological criteria for an echographic study of the colon in children in normal and pathological conditions. Abstract. Dis. Candidate of Medical Sciences. - Arkhangelk, 1998, p. 7).

 The method is as follows.

2-3 days before the examination, foods that promote gas formation in the intestine are excluded from nutrition. 12 and 2 hours before the study, the patient cleanses the intestines with an enema. The intestines are contrasted with a 5% glucose solution with a temperature of 36-37 ^o C. Then they conduct a study and evaluate the anatomical and functional features of the colon: determine the diameter of the intestine, wall thickness, evenness of the wall, the nature of Tauration, assess the lamination of the intestinal wall. As a result, the diagnosis of ulcerative colitis is based on:
wall thickening from 3 to 10 mm;
violations of wall lamination;
violation of the internal contour of the wall in the form of erosive or ulcerative defects;
reducing the height of the hustration up to its complete absence in places of localization of the inflammatory-dystrophic process.

 The known method allows to diagnose ulcerative colitis by an objective criterion - the thickness of the intestinal wall, which plays a paramount role in the differential diagnosis of ulcerative colitis from other inflammatory (chronic or acute) diseases of the colon, as the magnitude of the thickening of the wall is directly proportional to the severity of the inflammatory-destructive process, flowing in the wall of the intestine. However, this unique, objective criterion is interpreted differently according to the literature. So according to Sapozhnikov V.G. [4] the wall thickness for the disease should be from 5 to 9 mm. From 3 to 10 mm according to Yanitskaya M. Yu. [5], from 5 to 7 mm according to Limberg V. [6]. In our opinion, such a variety of data reduces the accuracy of diagnosis of ulcerative colitis. In this regard, the development of new ultrasonic objective signs of the diagnosis of ulcerative colitis in children is relevant.

 Nonspecific ulcerative colitis is an inflammatory and destructive lesion of the colon, which has a chronic course with frequent relapses and often severe complications. Of particular importance is the choice of treatment tactics, which should correspond to the activity of ongoing processes. The known method does not allow to judge the activity of ulcerative colitis.

 The task of the invention is to increase the accuracy of diagnosis by obtaining new information about the degree of damage to the colon wall and the activity of the inflammatory process and providing the possibility of correction of treatment and prognosis of the course of the disease.

 The problem is solved in that in the known method for the diagnosis of ulcerative colitis in children, including conducting an echographic examination and determining the thickness of the intestinal wall to determine the activity of the process, the echogenicity of the walls of the blind, ascending, transverse colon, descending, sigmoid and rectum is studied according to the intensity values gray scales, with echogenicity values from 41 to 68% and a slight thickening of the walls from 3 to 4 mm, determine the first degree of damage to the wall and the minimum active the process, with an echogenicity value of 27 - 40% and a wall thickening of 4 to 7 mm, the second degree of intestinal wall damage and moderate activity of the process, with an echogenicity value of 15 to 26% and a wall thickening of 8 to 10 mm, the third degree of wall damage is determined intestines and pronounced activity of the process, with a norm of echogenicity of 41-68% and a wall thickness of 2 to 3 mm.

 The authors propose for the first time to evaluate the activity of the course of ulcerative colitis by the degree of damage to the colon wall, using a new echographic sign - echogenicity of the intestinal wall in combination with the known echographic sign of intestinal wall thickness.

 The invention meets the criterion of "novelty", since patent information research has not identified materials that discredit the novelty of the invention.

 The invention meets the criterion of "inventive step", since no solutions having features matching the distinguishing features of the present invention have been identified.

 The proposed method allows to obtain the following positive effect.

 The method allows for the first time to diagnose the activity of the inflammatory and destructive process in ulcerative colitis by obtaining new objective information, namely, the degree of damage to the colon wall according to a new diagnostic feature - echogenicity of the intestinal wall in combination with the well-known sign - intestinal wall thickness. The degree of damage to the walls of the intestine indicates the activity of ulcerative colitis, which makes it possible to predict the course of the disease, as well as timely correction of therapy.

 Possessing all the positive qualities of ultrasound, the proposed method allows for dynamic monitoring of the patient, and new data allow us to identify in advance the chronicity of the process, long before the appearance of clinical endoscopic and radiological data.

 In modern ultrasound devices, echogenicity, that is, the degree of reflected energy, is determined on a gray scale in a range of shades, from black to white. The scale is available in each ultrasound device and contains from 8 to 64 shades (on average 16 - 32). Considering that the visual perception is different for everyone and for the objectification of a new diagnostic sign - the degree of echogenicity of the colon wall - the authors translated the sonographic image of a separate section of the intestinal wall into a digital value in percentage terms in accordance with the gray scale. The results were processed using a computer program.

 Research was conducted at the Nizhny Novgorod Research Institute of Pediatric Gastroenterology. The authors examined 17 children aged 3 to 15 years with a diagnosis of ulcerative colitis. The duration of the disease is from 1 year to 11 years. The control group consisted of 96 children aged 3 to 15 years, without clinical and medical history and laboratory indications of impaired colon activity.

 Ultrasound examination of the colon was carried out in real time on the apparatus "Aloka 680", "Scanner 250" using sector and convex sensors with a frequency of 3.5 and 5 MHz. For colonic echography, the method of hydrocolonoechography proposed by M. Yanitskaya was used, as well as an ultrasound examination without preliminary staining of the intestine.

 Studies have shown that, depending on the duration of ulcerative colitis in children, a sign of increased echogenicity of the intestinal wall occurs with a disease duration of 5 years or more in 100% of cases, 4 years in 50% of cases, 3 years in 25% of cases, with the duration of the disease less than 3 years is not observed.

Based on the data on the severity of the echogenicity of the intestinal wall and its thickness, one can judge about three degrees of damage to the colon wall and the activity of the process:
1 degree of damage to the intestinal wall: echogenicity from 41 to 68% and a thickening of the intestinal wall from 3 to 4 mm corresponds to the minimum activity of the inflammatory-destructive process;
2 degree of damage to the intestinal wall: echogenicity from 27 to 40% and thickening of the wall from 4 to 7 mm corresponds to moderate activity of the process;
3 degree of damage to the intestinal wall: echogenicity of 15-26%, wall thickening from 8 to 10 mm corresponds to the pronounced activity of the process.

 A histological examination of biopsy and surgical preparations of the colon, along with signs of the degree of the process, revealed chronic changes: fibrosis of the mucous membrane of the intestinal wall with coarse-fibrous connective tissue, with the complete absence of crypts, with only integumentary epithelium, sclerosis and submucosal lipomatosis.

 The method is as follows.

In order to remove or displace gas from the study area 2-3 days before the study, products that promote gas formation in the intestine are excluded, multienzyme preparations (festal, panzinorm) are prescribed. 12 and 2 hours before the study, patients cleanse the intestines with enemas. In order to contrast the intestine, transrectal filling is carried out with physiological saline with a temperature of 36 ^o C, in the amount of 80 - 100% of the age volume of the cleansing enema until a subjective feeling of filling appears. To diagnose the activity of ulcerative colitis, the echogenicity of the colon wall, as well as all known ultrasound signs, are determined. During the study, the echogenicity of the wall and its thickness is determined simultaneously. The blind, ascending, transverse colon, descending, sigmoid and rectum are examined, echogenicity is determined by the gray scale intensity values and with an echogenicity value of 41 - 68% and a slight wall thickening of 3 to 4 mm, the first degree of colon bowel wall lesion is determined and the minimum activity of the inflammatory-destructive process, with echogenicity of 27–40% and thickening of walls from 4 to 7 mm, determines the second degree of damage to the wall and moderate activity of the process, with echogenicity of 15–26% and thickening of st APIS from 8 to 10 mm define a third degree of damage of the intestinal wall expressed and the degree of process activity, at a rate of echogenicity 41 - 68% and a wall thickness of 2 - 3 mm.

 Examples of specific performance are given in the form of extracts from medical records.

 Extract from the medical history N 1624.

 Ivshina Aleksandra Vladimirovna, 13 years old, was at the Research Institute of Pediatric Gastroenterology in the 2nd GEO from 09/03/98 to 12/25/98.

 Diagnosis: Chronic nonspecific ulcerative colitis, total, moderate, activity 2 - 3 degrees, recurrent course. Colon pseudopolyposis. Colonization of the ileum.

 Severe anemia, hypochromic, mixed etiology.

On admission: complaints of weakness, loss of appetite. Liquid stool up to 6 times a day, mixed with blood. The survey:
General blood test from 09/03/98: ESR 15 mm / h, HB - 87 g / l, er. - 2.7 • 10 ¹² / l, color indicator - 0.7, white blood cells - 4.0 • 10 ⁹ / l, ret.cl. - 2%, p - 5%, s - 37%, lim - 33%, m - 22%, b - 1%, thrombus - 104% ₀ = 280.8 • 10 ⁹ / l, micro-N-macrocytes, pronounced poikilocytosis, hypochromia, erythrocytes with vaoculation, tsn 3+, Ht 27%, conv. = 2'-3'50 '', Ret - 122% ₀ (2 gr. = 2.5%, 3 gr. = 9%, 4 gr. = 9%, 5 gr. = 79%), blood group Av (2) Rh + (put).

 Urinalysis: from 04.09.98 without pathology.

 Coproscopy from 09.09.98: feces liquefied, soap 0.5+ digested fiber with starch included 1+ mucus with red blood cells and white blood cells 1+ deuterium 2.5+ white blood cells and red blood cells in large quantities, helminth eggs and giardia were not found.

Blood biochemistry from 09/04/98: total protein 74 g / l, albumin 52.3%, α ₁ -4.2%, α ₂ -11%, β-15%, γ-17.5%, A / G coefficient . - 1.09, ALAT - 0.041 μmol / L, ACAT - 0.073 μmol / L, total bilirubin 4.4 μmol / L, free bilirubin - 4.4 μmol / L, potassium 4.01 mmol / L, sodium 134.2 mmol / L, calcium 2.29 mmol / L, iron 6.4 μmol / L, zinc 8.87 μmol / L, amylase 24.4 g / L, sugar 3.22 mmol / L, residual nitrogen 3.22 mmol / l, glutathione reduced 1056.6 μmol / l, alkaline phosphatase 0.92 μkat / l, cholesterol 4.31 μmol / l, prothrombin index 100%.

 Blood for sterility from 09.16.98: no bacteria growth was detected in blood cultures. Analysis of feces for dysentery, typhoid-paratyphoid group, enteropathogenic Escherichia coli from 08.09.98 N 338-34 - negative.

 Fibrocolonoscopy from 10.09.98. Anus area - at 12 o'clock pronounced "watchdog tubercle" granulation. The device was inserted into the ileum by 17-20 cm. In this area, its lumen was widened, folds were expressed, the mucous membrane was pale pink, the vascular pattern was distinct but rarefied. Inflammatory-destructive changes in the mucosa in this department were not detected. The Bauginev damper yawns, its mouth is oriented to the ascending section. The lumen of the colon can be traced, presented in the form of a hose, the gut is shortened, physiological bends and sphincters do not differentiate, there is no haustration, no folds are detected (horseshoe gut). In all parts of the colon, a pronounced degree of activity of the inflammatory and destructive process is determined: - pronounced edema and hyperemia of the mucous membrane (vessels are not visible), - a large number of large irregularly shaped ulcer defects with abundant imposition of fibrin, - a large number of pseudo-polyps, - vulnerability and contact bleeding mucous membrane mild.

 Conclusion: ulcerative colitis, total, degree of activity of 2-3. Pseudopolyposis. Insufficiency of the butterfly valve. Signs of colonization in the ileum.

 Morphological conclusion of 09/10/98. The ileum is a chronic diffuse slano, active subatrophic ileitis, erosive, fibrosis of the own plate of the mucous membrane. Ascending - ulcerative colitis, activity of the 2nd degree, reorganization of the cryptal apparatus of the intestine, pseudopolyposis, dysplasia of the integumentary and cryptal epithelium of the 1st degree. Rectosigmoid transition - nonspecific ulcerative colitis, activity of 2–3 degrees, ulcerative defects, fibrosis of the lamina propria mucosa. Pseudopolyposis. Lymphofollicular hyperplasia. Pronounced productive vasculitis. Dysplasia of the epithelium of the 2nd degree.

 Irrigoscopy from 12/01/98. The contrast medium is not evenly distributed throughout the gut. The colon is shortened. The haustration is smoothed, the gut is rigid. In the lumen of the intestine, filling defects (pseudopolyposis). Pronounced reflux of ileum contrast agent, ileum loops are expanded in volume, the walls are rigid. Emptying is not complete - a contrast in the right intestines. The relief of the mucosa in the transverse colon and the descending section does not differentiate.

 Conclusion: X-ray picture of ulcerative colitis with signs of pseudopolyposis, colonization of the ileum and cicatricial changes.

 In order to identify the degree of damage to the colon wall and the activity of the inflammatory-destructive process, an ultrasound examination of the colon was conducted on 09/14/98.

 Rectum: diameter 42 mm, wall 5 mm, uneven, layering is not determined, echogenicity 46% of the intensity of the gray scale. Sigmoid colon: diameter 37 mm, wall 6 mm, uneven, layering is not determined, the haustration is not visualized. The descending intestine: diameter - 28 mm, wall 5 mm, uneven, layering is not determined, echogenicity 31% - gray scale intensity, no gaustration. Transverse-colonic: diameter 28 mm, wall 4 mm, uneven, layering is not determined, echogenicity is 28% of the intensity of the gray scale, gaustration is not determined. Ascending intestine: diameter 28 mm, wall 3 mm, uneven, layered fuzzy, echogenicity - 33% of the intensity of the gray scale. The cecum: diameter 32 mm, the wall is uneven, the layering is fuzzy, echogenicity is 42% of the gray scale intensity.

 Conclusion: Echographic signs of chronic ulcerative colitis, total, moderate activity, 2 degree of damage to the colon wall.

 Treatment: table N 4 (dairy-free), sulfasalazine, salofalk in enemas, prednisone 30 mg / day, essentials, polyphepan, microclysters with vinylin, infusion therapy in the detoxification and correction of metabolic disorders mode, transfusion of freshly frozen plasma, ferrum-lek, vitamin therapy.

 Extract from the medical history N 1724.

 Kartomysheva Ekaterina Gennadievna, 10 years old (date of birth September 17, 89), was at the Research Institute of Pediatric Gastroenterology in the 2nd department from September 13, 1999 to November 1, 1999.

 Diagnosis: Nonspecific ulcerative colitis, total, severe severity, activity 3 degrees, fulminant onset with early manifestation of signs of chronicity with extraintestinal manifestations in the form of reactive hepatitis, reactive pancreatitis.

 Severe anemia, normochromic, mixed etiology.

 Associated intestinal dysbiosis.

 Functional cardiopathy (mitral valve prolapse 1 degree without regurgitation).

 Upon receipt, the condition is serious. Complaints of weakness, headache, dizziness, stool more than 20 times a day with an admixture of blood.

The survey was conducted: General blood test from 09/14/99: ESR - 27 mm / h, HB - 72 g / l, Er. 2.9 • 10 ¹² / l, color indicator - 0.9, lake. - 4.0 • 10 ⁹ / l, Rt - 1% ₀ , n - 1%, s - 52%, lim. - 33%, m - 10%, eo - 3%, platelets - 96% = 384.0 • 10 ⁹ / l; blood group Ab (2) Rh + (gender).

 General analysis of urine from 09/14/99: quantity 100 ml, density 1026, color yellow, pH 5.0, white blood cells 1-3 / r, red blood cells 1-2 / r, large amounts of oxalates, large amounts of mucus. Coproscopy from 09/14/99 unchanged muscle fibers 1+, drops of fatty acids 0.5+, digested fiber with vk / cell. a significant amount of starch, detritus 2+, mucus, white blood cells and red blood cells.

 A blood test for hepatitis markers from 10.21.99 - negative.

Blood biochemistry from 09.16.99: total protein - 68.9 g / l, albumin - 54.2%, α ₁ -4.6%, α ₂ -12.1%, β-9.9%, γ-19 , 2%., ALAT - 0.038 mmol / ls, ASAT - 0.078 mmol / ls, cholesterol - 6.43 mmol / l, total bilirubin. - 8.4 μm / l, free. - 8.4 μM / l, thymol sample - 4.4 units, alkaline phosphatase - 3.11 μkat / l, prothrombin index - 97%, restored glutathione - 1196.3 μM / l, residual nitrogen - 27.5 mm / l, urea - 4.26 mmol / L, sugar - 4.26 mmol / L, potassium - 3.86 mmol / L, sodium - 126.2 mmol / L, calcium - 2.13 mmol / L, phosphorus - 1.48 mM / L, zinc - 9.94 μM / L, copper - 11.64 μM / L, iron - 7.67 μM / L.

 Feces for dysbiosis from 09.16.99. - decompensated dysbacteriosis, caused by a deficiency of bifidumbacteria, the presence of hemolytic E. coli with reduced enzymatic properties, an increased content of protea.

 Analysis of feces for dysentery, typhoid-paratyphoid group, enteropathogenic E. coli from 13.09.99 N 883-84 - neg.

 Ultrasound of the abdominal cavity from 09/17/99. Liver: +1 cm from under the costal arch, dimensions of the right lobe 111 mm, left 55 mm, the contours are even, the capsule is not thickened, the echostructure is homogeneous, uneven, possibly due to cholestasis, the vessels are not changed, their walls are strengthened, portal vein 10 mm. Gall bladder: normal shape, the walls are even, the ducts are not dilated. Pancreas: dimensions: head - 10 mm, body - 9 mm, tail - 18 mm, the contours are even, the echostructure is uniform, not sharply strengthened, the duct is not expanded. Spleen: dimensions 91/41 mm, contours are even, uniform, homogeneous, splenic vein 5 mm. Kidneys: normal position, mobility is normal, sizes are not enlarged, parenchyma is uniform, PLC is not deformed.

 Conclusion: Diffuse changes in the liver (signs of cholestasis). Compaction of the pancreas.

 Given the serious condition at admission, the appointment of fibrocolonoscopy and irrigoscopy was contraindicated, therefore, in order to determine the degree of damage to the colon wall and the activity of the inflammatory-destructive process, an echographic study of the colon was performed without preparing and contrasting the colon.

 Ultrasound examination of the colon from 09.15.99.

 Rectum: diameter 43 mm, wall 4 mm, uneven (bumpy), fuzzy layering, echogenicity 34% of the gray scale intensity. In the area of the rectosigmoid transition, a narrowing of the intestinal lumen to 8 mm, 4 cm long is visualized, the internal and external contours at the site of narrowing are uneven, the wall is thickened to 11 mm, its echogenicity is 16% of the gray scale intensity. Sigmoid colon: diameter 28 mm, wall thickened to 8 mm, inner contour uneven (bumpy) - pseudopolyposis, multiple ulcerative defects from 4 to 11 mm, layering not determined, echogenicity 30% of the gray scale intensity, gaustration is not visualized. The descending intestine: diameter 33 mm, the wall thickened to 5 mm, uneven - erosive-ulcerative defects, pseudopolyposis, layering is not determined, echogenicity is 32% of the gray scale intensity, the haustration is not visualized. The transverse intestine: diameter 29 mm, the wall thickened to 5 mm, the inner contour uneven - erosive-ulcerative defects, pseudopolyposis, layering is not determined, wall echogenicity is 34% of the gray scale intensity, gaustration is not determined. Ascending intestine: diameter 39 mm, wall 4 mm, uneven - erosive changes, pseudopolyposis, layering is not determined, echogenicity is 35% of the gray scale intensity, gaustration is not visualized. The cecum: diameter 42 mm, wall 4 mm, uneven (possibly due to pseudopolyposis), layering is not determined, echogenicity is 48% of the gray scale intensity. The ileum: (examined 15 cm in the distal section), diameter 27 mm, wall 3 mm, layering fuzzy, internal and external contours smooth, echogenicity - 81% of the intensity of the gray scale. Conclusion: Echographic signs of chronic inflammatory disease of the colon - ulcerative colitis, total, with pronounced activity of the process, 3 degree of damage to the intestinal wall, pseudopoliposis. Stenosis of rectosigmoid transition.

 Based on the data obtained by ultrasound examination of the colon, a correction of the therapy was carried out, as a result of which the girl's condition improved, and there was an opportunity for further examination.

 Fibrocolonoscopy from 09/20/99 there is no pathological area of the anus, digital examination - rigidity of the walls of the rectum. The device is inserted into the rectum. Further implementation is impossible due to a funnel-shaped narrowing of the intestine at the site of the rectosigmoid transition. Insufflation of air does not give an effect, attempts to conduct the apparatus are painful, the mucous membrane bleeds contact. In the rectum, the mucosa is edematous, hyperemic, vessels are not visible, ulcerative and erosive defects.

 Conclusion: ulcerative colitis, grade 3 activity (proctitis), pseudopolyposis, stenosis of the colon in the area of rectosigmoid transition.

 Morphological examination of the colon (according to fibrocolonoscopy with biopsy material) from 09/20/99. Rectum: the integumentary epithelium is intensely infiltrated, mainly by eosinophilic granulocytes, the cryptal layer is narrowed, deformed, destroyed crypts. Own plate fibrosed, intensely infiltrated, mainly by eosinophilic granulocytes, areas of capillary stasis.

 Conclusion: active ulcerative colitis.

 Irrigoscopy from 09.30.99. The sharply accelerated filling of the colon is noteworthy. From the first portions of the introduced contrast, a section of narrowing up to 3 cm in length is determined in the zone of rectosigmoid transition. The colon is shortened, rigid, physiological bends are smoothed. The gaustration is smoothed, multiple filling defects (pseudopolyposis). A contrast cast into the ileum is visible. The ileum loops are dilated. After emptying, a sharply changed relief is visible - pseudopolyposis. Symptom of free movement of fluid in the intestines.

 Conclusion: X-ray picture of severe ulcerative colitis with pseudopolyposis, stenosis of the rectosigmoid transition.

 Treatment: table No. 4, dairy-free, budesomide, sulfasalazine, infusion therapy in the detoxification and correction of metabolic disorders, essentials, panangin, folic acid, linex, nicodine, multivitamins, mesim-forte, suprastin, intetrix, enemas with vinylin.

 Due to the ineffectiveness of the massive conservative complex therapy and pronounced echographic signs of chronicity - irreversible sclerotic changes in the colon wall with stenosis, confirmed by morphological examination, the girl underwent surgical treatment: colectomy, ileostomy.

 Morphological study (postoperative material from a rectosigmoid transition) from 10.11.99. The presented material determines the morphological picture characteristic of ulcerative colitis with the presence of crypt abscesses, erosion and ulcers with severe fibrosis.

 Extract from the medical history N 578.

 Zinoviev Igor Andreevich, 6 years old (11/16/92), was at the Research Institute of Pediatric Gastroenterology in the 2nd GEO from 03.16.99 to 1.06.99.

 Diagnosis: Nonspecific ulcerative colitis, total, degree of activity 0-1, recurrent course, mild severity. Reactive hepatitis. Asthenoneurotic syndrome.

Upon receipt of a complaint about a mushy stool 2 to 3 times a day periodically with an admixture of blood. Survey conducted:
General blood test from 03/17/99 - without pathology.

 General urine analysis dated 03/17/99: 30 ml, yellow, protein and sugar negative, pH 6.0, squamous epithelium 1 / p, transitional epithelium 1-2 / p, white blood cells 1-3 / p, red blood cells altered 1 / r, mucus a small amount.

 Coproscopy from 03/17/99 cal is framed, muscle fibers treason. 0.5+, overcooked fiber with inclusions of starch 0.5+, detritus 3.5+, mucus a significant amount, a significant number of leukocytes and red blood cells.

Blood biochemistry from 03.22.99: total protein - 70.3 g / l, albumin - 52.1%, α ₁ -4.7%, α ₂ -10.1%, β-9.2%, γ-23 , 9%, A / G coefficient. - 1.09, reduced glutathione - 1295.9 μM / L, alkaline phosphatase - 9.27 μkat / L, cholesterol - 3.1 mmol / L, total bilirubin - 1.0 μM / L, free - 1.0 μM / L, ALAT - 0.697 μM / L, ASAT - 0.278 μM / L, prothrombin index - 92%, potassium - 4.11 mm / L, sodium - 133.9 mm / L, iron - 8.56 μM / L, zinc - 8.41 μM / l, sugar - 3.49 mmol / l; blood amylase - 18.8 hl / h, urine - 39.4.

 Analysis of feces for dysentery, typhoid-paratyphoid group, enteropathogenic E. coli from 16.03.99 N 327-28 - negative.

 Analysis of feces for dysbiosis from 03/19/99: dysbiosis due to hemolytic Escherichia.

 ECG from 03.19.99 without features. Ultrasound of the abdominal cavity from 03.25.99 Liver: dimensions of the right lobe - 116 mm, left lobe - 48 mm, echogenicity is not sharply increased, the echostructure is heterogeneous, the portal vein is 9 mm, the walls of the vessels are strengthened. Gall bladder: dimensions increased 62/36 mm, the walls are even, the echogenicity of bile is increased, the ducts are not dilated. Pancreas: head size - 9 mm, body 14 - mm, tail - 10 mm, the contours are even, homogeneous, the duct is not expanded. Spleen: dimensions 87/22 mm, smooth contours, homogeneous, uniform, splenic vein - 5 mm. Kidneys: the position is normal, the dimensions are not enlarged, the contours are even, the parenchyma is uniform, the PLC is not deformed.

 Conclusion: Signs of reactive changes in the liver. Hypotension of the gallbladder.

 Fibrocolonoscopy from 04/05/99. Anus region without features. The apparatus was carried out 20 cm into the ileum: the mucous membrane is not changed, the vascular pattern is clear, the Baugin's valve is gaping, its mucosa is hyperemic, edematous. Blind and ascending: the haustration is smoothed, the mucous membrane is loose, the vascular pattern is traced, submucous hemorrhages are found. Transverse: the haustration is smoothed, the mucous edema, the vascular pattern is not visible. Descending: the tauration is smoothed, the vascular pattern is not visible, single erosion. Sigmoid: the haustration is slightly smoothed, the mucous edematous, loose, vascular pattern is slightly changed, the physiological bends are not changed. Direct: mucous edematous, shiny, vascular pattern can be traced, there is no contact bleeding. Conclusion: ulcerative colitis, total, activity 0 - 1. Bauginitis.

 Morphological examination (according to fibrocolonoscopy with biopsy material). Baugin's flap: the surface epithelium is sharply flattened, microerosion areas are determined, the cryptal layer is narrowed, the crypts are enlarged, deformed, and contain segmented leukocytes in the lumen. Own plate of the mucous membrane is intensely infiltrated. Sigmoid: the surface epithelium is sharply thinned, subepithelial edema is determined, the cryptal layer is narrowed, there are deformed crypts. Own plate of the mucous membrane is unevenly infiltrated. Direct: integumentary epithelium is sharply flattened, microerosion is determined. The cryptal layer is narrowed. Own plate of the mucous membrane is full-blooded, edematous, a lymphoid follicle with an enlightened center is determined.

 Conclusion: ulcerative colitis with moderate activity.

 Irrigoscopy from 04/16/99. Accelerated filling with contrast of the entire colon: the right and left sections were tightly contrasted, and the transverse colon was weakly contrasted. The hustle is smoothed in all departments. Single filling defects in the lower third of the descending department. Severe insufficiency of the bougain damper (leakage of contrast into the ileum), the ileum approaches the colon in volume. Evacuation function is weakened (the entire colon and ileum are contrasted).

 Conclusion: X-ray signs of ulcerative colitis. Ileita. Severe insufficiency of the bugin damper.

In order to identify the degree of damage to the colon wall and determine the activity of the inflammatory-destructive process, the following was carried out:
Ultrasound examination of the colon from 1.03.99.

 Rectum: diameter 34 mm, wall 4 mm, uneven, layered fuzzy, echogenicity 61% of the intensity of the gray scale. Sigmoid colon: diameter 29 mm, wall 6 mm, uneven, layering is not determined, echogenicity is 67% of the gray scale intensity, the haustration is not visualized. The descending intestine: diameter 25 mm, wall 5 mm, uneven, erosive defects, lamination is not determined, echogenicity is 65% of the gray scale intensity, the haustration is sharply reduced. Transverse intestine: diameter 22 mm, wall 4 mm, uneven, layered fuzzy, echogenicity 58% of the gray scale intensity, haustration reduced. Ascending intestine: diameter 32 mm, wall 3 mm, uneven, layered fuzzy, echogenicity 60% of the intensity of the gray scale, haustration reduced. The cecum: diameter 34 mm, wall 3 mm, uneven, layered fuzzy, echogenicity 62% of the intensity of the gray scale. The ileum: failed to visualize.

 Conclusion: echographic signs of chronic inflammatory disease of the colon - ulcerative colitis, minimal activity of the process with predominant severity in the descending and sigmoid colon, 1 degree of damage to the colon wall.

 Treatment: table No. 4, sulfasalazan, trental, folic acid, clarithin, bifidumbacterin, festal, essentials, heptral, nicodine, multivitamins.

 Literature.

 1. Lenyushkin A.I. Children's coloproctology. - M .: Medicine, 1990. - 352 p. , from. 230.

 2. Zedgenidze G.A. Clinical radiology (manual). T. 2: X-ray diagnosis of diseases of the digestive system. - M.: Medicine, 1983. -424 p., P. 198 (p. 197-203).

 3. Seitz K. Inflammatory Bowel Diseases. Sonographic Diagnostics. Department of internal Medicine Kreiskrankenhaus Sigmaringen (Germany). 1994 .-- 78 pages, p. 38.

 4. Sapozhnikov V.G. Sonography of the stomach and intestines in children. Vitebsk, Republic of Belarus 1994, 43 p., P. 40.

 5. Yanitskaya M.Yu. Clinical and physiological criteria for ultrasound examination of the colon in children are normal and pathological. Abstract. dis. Cand. honey. sciences. - Arkhangelsk, 1998, p. 23.

 6. Limberg B. Diagnosis of Acute Ulcerative Colitis and Colonic crohn's Disease by Colonic sonography. J. Clin. Ultrasound - 1989, -vol. 17, - p. 25-31, p. 25.

Claims (1)

 A method for diagnosing ulcerative colitis in children, including conducting an echographic study and determining the wall thickness of the colon, characterized in that to determine the activity of the process, the echogenicity of the walls of the cecum, ascending, transverse colon, descending, sigmoid and rectum is examined according to the intensity of the gray scale and with values of echogenicity of 41-68% and a slight thickening of the wall from 3 to 4 mm, the first degree of damage to the wall and the minimum activity of the process are determined, at echogenicity of 27-40% and thickening of the wall from 4 to 7 mm determine the second degree of damage to the intestinal wall and moderate activity of the process, with values of echogenicity from 15 to 26% and thickening of the wall from 8 to 10 mm determine the third degree of damage to the intestinal wall and pronounced activity process, with an echogenicity rate of 41-68% and a wall thickness of 2 to 3 mm.