Chronic non-ulcerative colitis - Diagnosis

Laboratory and instrumental data

• General blood test, urine test and blood biochemistry test showed no significant changes.
• Coprological analysis. Stool analysis includes microscopy, chemical examination (determination of the content of ammonia, organic acids, protein [using the Triboulet reaction], fat, fiber, starch in the daily amount of feces), and bacteriological examination.

Based on the results of the coprological examination, the following coprological syndromes can be distinguished:

• increased motility of the colon. The amount of feces is increased, the feces are mushy or liquid in consistency, light brown or yellow in color, the reaction is slightly acidic or neutral, there is a lot of intracellular starch, digested fiber, iodophilic flora;
• slowing of colon motility. The amount of feces is reduced, the consistency is hard ("sheep feces"), the smell is putrid, the reaction is alkaline, the remains of undigested food are in normal quantities;
• increased motility of the large and small intestines. The amount of feces is increased, the consistency is liquid, the color is greenish, the reaction is alkaline, there are many undigested muscle fibers, neutral starch, extra- and intracellular starch, cellulose, iodophilic flora;
• fermentation dyspepsia syndrome. The amount of feces is increased, the feces are of a mushy consistency, foamy, yellow in color, sour smell, the reaction is sharply acidic, there is a lot of starch, digestible fiber, iodophilic flora, the amount of organic acids is increased (20-40 mmol/l), an insignificant amount of soaps and fatty acids;
• putrefactive dyspepsia syndrome. The amount of feces is increased, the feces are liquid or mushy, dark brown in color, the smell is putrid, the reaction is sharply alkaline, the amount of protein and ammonia is sharply increased (the amount of ammonia is 10-14 mmol/l), a significant amount of digestible fiber;
• coprological signs of exacerbation of colitis. Triboulet test (for soluble protein) is positive, the number of leukocytes in the feces is increased, there are many cells of desquamated epithelium;
• ileocecal syndrome. Stool is not formed, smells sharply sour or like rancid oil, color is golden yellow, there is a large amount of undigested fiber, a small amount of altered muscle fibers and broken down fat, a small amount of leukocytes, mucus;
• coli-distal syndrome. The stool is not formed, there is a lot of mucus, it lies superficially, there are a lot of leukocytes and epithelial cells.

A study of the bacterial flora reveals dysbacteriosis: a decrease in the number of bifidobacteria, lactobacilli, an increase in the number of hemolytic and lactose-negative Escherichia, pathogenic staphylococcus, Proteus, and hemolytic streptococcus .

• Endoscopic examination of the large intestine (rectoscopy, colonoscopy) reveals inflammatory changes in the mucous membrane, erosion, increased or decreased vascular pattern, atrophy - with a long-term inflammatory process.

Colonoscopy also verifies the diagnosis of segmental colitis in the corresponding section of the large intestine.

The diagnosis of chronic colitis is also confirmed by histological examination of biopsy specimens. This method is especially important in the differential diagnosis of chronic colitis and colon cancer.

• X-ray examination of the large intestine (irrigoscopy) - in chronic colitis, asymmetric haustration, hypo- or hypermotor dyskinesia, smoothing of the mucous membrane relief, and uneven filling of the large intestine with barium are revealed.

Depending on the severity of clinical and laboratory data, three degrees of severity of chronic colitis are distinguished.

Mild chronic colitis has the following characteristic features:

• the clinical picture is dominated by mildly expressed “intestinal” symptoms (minor pain in the abdomen of a diffuse nature or in the lower sections, bloating, a feeling of incomplete bowel movement, unstable stool, discomfort in the rectum);
• psychoneurotic symptoms are expressed (they sometimes come to the fore);
• the general condition of the patients does not suffer significantly;
• palpation pain in the large intestine is noted;
• coprological examination does not reveal any significant changes;
• Endoscopy reveals a picture of catarrhal inflammation against the background of swelling of the mucous membrane; sometimes hemorrhages and slight vulnerability of the mucous membrane are detected.

Chronic colitis of moderate severity is characterized by a more persistent and recurrent course. This form of chronic colitis is characterized by:

• severe intestinal complaints (almost constant pain throughout the abdomen, heaviness in the lower abdomen, bloating, rumbling, pouring, a feeling of distension, loose stools, often alternating constipation and diarrhea);
• significantly expressed asthenoneurotic syndrome;
• weight loss during an exacerbation of the disease;
• bloating, pain on palpation of all parts of the colon, rumbling and splashing in the area of the cecum;
• typical coprological syndromes (poorly digested muscle fibers, soaps, fat, fatty acids, mucus, leukocytes, positive Triboulet reaction for protein are found in the feces);
• significantly pronounced inflammatory changes in the mucous membrane of the large intestine, revealed during endoscopic examination.

Severe form of chronic colitis is characterized by the addition of clinical signs of involvement of the small intestine in the pathological process (enteric syndrome), which actually determines the severity of the disease. Severe form of chronic colitis is characterized by:

• prolonged diarrhea, bloating, feeling of fullness in the abdomen;
• clinical manifestations of malabsorption syndrome (weight loss, trophic disorders - hair loss, dry skin, brittle nails, etc. symptoms;
• pronounced bloating and palpable pain in the entire abdomen or mainly in the umbilical region;
• coprological analysis reveals pronounced changes characteristic of damage to the large and small intestines (liquid consistency of feces, yellow or greenish-yellow color of feces, a lot of undigested muscle fibers, neutral fat, fatty acids, extracellular starch, digestible fiber, desquamated epithelium, a large number of leukocytes, a sharply positive Triboulet reaction);
• sharply expressed inflammatory changes and atrophy of the mucous membrane of the large intestine, duodenum and jejunum during endoscopic examination, erosions are often detected.

Differential diagnosis

Differential diagnosis of chronic non-ulcerative colitis and intestinal tuberculosis.

The main characteristic symptoms of intestinal tuberculosis are:

• tuberculosis intoxication syndrome (general weakness, malaise, weight loss, subfebrile body temperature, profuse sweating, especially at night, loss of appetite);
• constant abdominal pain, most often in the right iliac and umbilical region; with the development of tuberculous mesadenitis, pain is localized to the left of the cecum, as well as to the left and below the navel along the mesentery of the small intestine;
• dense, painful thickening of the walls of the cecum, determined by palpation of the cecum and the terminal section of the ileum; sometimes a dense tumor-like formation is determined in the right iliac region;
• tenesmus and false urge to defecate when the rectum is affected; ulcers that are not prone to healing may be found in the anus or on the intestinal mucosa;
• ulcerations of the mucous membrane, cicatricial stenosis, and dyskinetic phenomena are revealed during colonoscopy and X-ray examination of the large intestine;
• characteristic picture of the tuberculosis process in histological examination of biopsy specimens of colon ulcers (epithelioid granulomas with multinucleated giant Pirogov-Langhans cells and caseation);
• presence of occult blood and soluble protein in the feces (positive Triboulet reaction);
• strongly positive tuberculin tests;
• pronounced pulmonary signs of tuberculosis;
• hypochromic anemia, leukopenia with relative lymphocytosis, increased ESR.

Differential diagnosis of chronic non-ulcerative colitis and colon cancer.

In the initial, early period of colon cancer, there are usually no characteristic symptoms, the cancer most often proceeds asymptomatically and is usually discovered accidentally during a routine examination, colonoscopy, rectoscopy, digital rectal examination. These studies are usually undertaken for some other disease or chronic colitis, which the patient has suffered from for many years.

Later, the so-called "general intoxication syndrome" develops, manifested by increasing general weakness, loss of appetite, weight loss, heaviness after eating, vague abdominal pain, rumbling and bloating, unstable stool. These symptoms are highly suspicious for colon cancer, especially if there is anemia, increased ESR, mucus and blood in the stool, pain during defecation.

Symptoms of colon cancer depend on the location of the tumor.

Cancer of the right half of the colon has the following characteristic manifestations:

• intestinal bleeding (clinically expressed or hidden) and hapochromic anemia;
• constant pain in the right half of the abdomen;
• a palpable, nodular, dense tumor in the region of the cecum or ascending transverse colon;
• absence of symptoms of intestinal obstruction (the contents of the right half of the large intestine are quite liquid and pass well through the narrowed section of the intestine).

Cancer of the left half of the colon has the following characteristic symptoms:

• cramping abdominal pain, alternating diarrhea and constipation;
• limited swelling of the left half of the abdomen, visible intestinal peristalsis;
• picture of partial intestinal obstruction (due to pronounced annular narrowing of the intestinal lumen);
• palpable nodular tumor in the left half of the colon;
• Rectal cancer is easily detected by digital examination;
• the release of blood with feces (in the form of ichor or streaks), mucus and pus (usually when a tumor in the rectum disintegrates);
• pain in the anus and difficulty defecating (with a rectal tumor);
• persistently positive reaction to occult blood in feces.

Rectal and sigmoid colon tumors are easily detected by rectoscopy, and transverse colon and right half of the large intestine - by colonoscopy. During the examination, biopsies are taken from all areas suspicious for cancer (at least 3-4 pieces) for histological confirmation of the cancer diagnosis.

An important method for diagnosing colon cancer is irrigoscopy (i.e. X-ray examination of the colon with filling it with a contrast agent - barium sulfate suspension - using an enema). Colon cancer is manifested by a filling defect, uneven contours of this defect, and often by a ring-shaped narrowing of the intestinal lumen at the site of the tumor.

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