Inflammatory bowel disease and associated uveitis

Introduction to inflammatory bowel disease and its associated uveitis Inflammatory bowel disease (IBD) includes two types of ulcerative colitis (ulcerativecolitis) and Crohn's disease (Crohn's disease), both of which can cause or combine diseases such as uveitis and arthritis. basic knowledge The proportion of illness: 0.002% Susceptible people: no special people Mode of infection: non-infectious Complications: pancreatitis pulmonary vasculitis myocarditis pericarditis prostatitis kidney stones amyloidosis thrombophlebitis anemia

Inflammatory bowel disease and its associated uveitis etiology

(1) Causes of the disease

The cause is unknown, presumably related to a variety of factors, which may include infection, autoimmunity, mental factors and toxic factors.

1. Infectious factors Because the pathological changes and clinical manifestations of this disease are very similar to dysentery, it is considered to be chronic dysentery; other bacteria or viruses have been suspected, but they have not been fully confirmed. Mitchell's use of Crohn's disease patients to transfer intestinal tissue to animals can cause Similar to Crohn's disease, it has been suggested that the factor of this metastasis may be a virus or a variant of the bacterium.

2. Immune factors Some people have reported that the disease is due to food allergies, such as milk or other proteins. The condition of this food has been improved. Some people have found that the serum of this patient has anti-colon antibodies, so it is considered to be an autoimmune disease. It was proved that other antibodies such as RF, ANA existed, and the immune complex was found to be high, the antigenic nature was unknown, and the antibody was IgG. Pedmann proved that the patient had cytotoxic lymphocytes in the blood circulation, and the cells were surgically removed after the colon. Then disappeared, Shorter et al. pointed out that IgM binds to this cell and proves that this cell cross-reacts with colon cells and intestinal bacterial antigens, which can be explained by the fact that the patient destroys the normal mucosal barrier when the blood is insufficient or traumatic. Sensitization of intestinal microbial antigens, normal human immune factors can inhibit this hypersensitivity reaction, when the patient is unable to inhibit this inflammatory response, it can be re-activated by the new bacteria or intestinal mucosa periodically stimulated Severe cases may be associated with multiple arthritis and rash, which is considered to be a chronic collagen disease. Caused by the autoimmune response.

3. Mental factors The disease is caused by emotional or traumatic symptoms of the patient or the disease is worsened. Some people think that neuropsychiatric factors may be one of the causes of this disease. The cerebral cortical activity disorder can be caused by the dysfunction of the autonomic nervous system. The smooth muscles of the intestines and their blood vessels form erosions and ulcers of the colonic mucosa.

4. The immune gene Asguith studied HLA in patients with IBD and found that HLA-A11 and HLA-B7 increased; Nahir found that HLA-A2, HLA-BW35 and HLA-BW40 increased, and there was no significant difference with the normal control group, but with AS HLA-B27 is an increase in IBD patients with ankle arthritis, indicating that the disease may be related to immune genes.

(two) pathogenesis

It is unclear that when the colonic inflammatory activity is active, the uveal and scleral vascular basement membranes bind to intestinal bacterial antigens or mucosal antigens. This antigen binding to the basement membrane causes periodic activity due to the action of cytotoxic lymphocytes that bind IgM. It can cause complementation and attract inflammatory cells and inflammation. It has been found that several factors are associated with uveitis in patients with inflammatory bowel disease:

1 Intestinal lesions: When the intestinal lesions are still, the possibility of uveitis is reduced, but the possibility of uveitis increases when the intestinal lesions are active.

2 Ankle arthritis: In patients with ankle arthritis, the possibility of uveitis is significantly increased. It is reported that in 25 patients with ankle arthritis, the incidence of iridocyclitis is as high as 52. %, but in 119 patients with no arthritis, only 3.4% of people developed uveitis.

3 The age of the patient: Patients in the 20-39 age group are prone to uveitis.

4 nodular erythema and oral ulcers: patients with nodular erythema and oral ulcers are prone to uveitis.

Inflammatory bowel disease and its associated uveitis prevention

The timely and correct treatment of inflammatory bowel disease can partially prevent the occurrence of ocular complications.

Inflammatory bowel disease and its associated uveitis complications Complications Pancreatitis Pulmonary vasculitis Myocarditis Pericarditis Prostatitis Kidney stones Amyloidosis Thrombophlebitis Anemia

Inflammatory bowel disease can also cause or be associated with other pathologies, such as hepatobiliary disease, tubal blockage, pancreatitis, pulmonary vasculitis, fibrotic alveolitis, myocarditis, pericarditis, prostatitis, kidney stones, amyloidosis, sputum Finger (toe), thrombophlebitis, etc., due to intestinal lesions caused by absorption and nutritional disorders, it can also cause non-specific manifestations such as anemia, weight loss.

Inflammatory bowel disease and its associated symptoms of uveitis common symptoms peripheral vascular reduction constipation unilateral fundus appears ... nausea diarrhea abdominal mass

1. Gastrointestinal lesions Ulcerative colitis is characterized by diffuse superficial mucosal ulcers, which are typically clinically manifested as spastic pain in the lower left abdomen, recurrent mucus or pus and bloody stools, or as diarrhea or watery stools. Dehydration, electrolyte imbalance, toxic megacolon, fever, loss of appetite, weight loss, anemia, etc., long-term chronic ulcerative colitis, especially in children, is prone to colon cancer.

Crohn's disease is characterized by the appearance of non-caseous necrotizing granuloma, which is typically clinically characterized by lower right abdominal cramps, accompanied by diarrhea or constipation, often with nausea, vomiting, right lower abdominal mass, fever, weight loss, anemia, etc. Performance, individual patients may have intestinal stenosis, abdominal abscess, psoas abscess, perianal fistula, perianal abscess and other complications.

2. Eye lesions 1.9% to 23.9% of patients with inflammatory bowel disease have ocular damage, mainly manifested as uveitis, scleral inflammation, scleritis and keratitis, in addition to eyelid inflammatory pseudotumor. Posterior optic neuritis and so on.

(1) uveitis: uveitis is the most common ocular lesion in inflammatory bowel disease. It is reported that up to 17% of patients with inflammatory bowel disease develop uveitis, and another report has occurred in patients with ulcerative colitis. Uveitis accounts for about 14%, and Crohn's disease accounts for about 8% of uveitis. Uveitis usually occurs after intestinal lesions, but in a few patients can also occur before intestinal lesions, uveitis Often involved in both eyes, but the inflammation of both eyes usually occurs successively and alternately.

Although inflammatory bowel disease can be associated with various types of uveitis, previous uveitis is the most common, Crohn's disease is more prone to anterior uveitis than ulcerative colitis, and the anterior uveitis associated with both diseases is mainly It is characterized by acute non-granulomatous inflammation, but granulomatous inflammation can also occur, especially in patients with Crohn's disease.

The anterior uveitis associated with this disease can be acute inflammation or chronic inflammation; severe redness, eye pain, photophobia, and tearing can occur, and significant ciliary congestion is found in the examination, and a large number of anterior chamber inflammatory cells and obvious The anterior chamber is flashing, or even a large amount of cellulose-like exudation and anterior chamber empyema appear in the anterior chamber. In these patients with severe inflammation, cystoid macular edema may also occur; it may also be occult, showing mild to moderate morbidity. Anterior uveitis, dusty or medium-sized KP, anterior chamber inflammatory cells ( ), anterior chamber glimmer ( ); can also be expressed as granulomatous anterior uveitis, emergence of sheep fat KP, iris Koeppe With Bussuca nodules, these patients are prone to post-iris adhesions.

Iris ciliary inflammatory disease is the most common type of inflammatory bowel disease associated with uveitis, accounting for 85%, mainly as chronic non-granulomatous iridocyclitis, occult disease, long duration, also reported In uveitis with inflammatory bowel disease, 60% manifest as acute non-granulomatous iridocyclitis, typically as follows:

1 patients usually have obvious eye pain, photophobia, headache and other symptoms.

2 obvious ciliary congestion.

3 The anterior chamber is prone to a large amount of fibrinous exudation, and the anterior chamber is flashing.

4 prone to anterior chamber empyema, empyema in the corner.

5KP is slightly larger and has a tendency to blend.

6 iris nodules are rare.

7 is prone to post-iris adhesion.

8 inflammation is prone to recurrence.

9 sensitive to glucocorticoids.

10 Most patients have good visual acuity.

The posterior segment of the eye can manifest as multiple types of posterior uveitis, such as choroiditis, chorioretinitis, neuroretinitis, retinal vasculitis, optic discitis, intermediate uveitis, total uveitis, etc., in front of and behind In patients with segmental involvement, granulomatous total uveitis is more common. In the above posterior uveitis, choroiditis is a common change in the posterior segment of the inflammatory bowel disease, often manifested as bilateral posterior poles. Focal yellow-white choroidal infiltration, 1/8~1/2 optic disc diameter, blurred edge of active period, fusion phenomenon, pigmentation and choroidal scar, fluorescein fundus angiography showed early masking fluorescence, late staining, As the disease progresses, the boundary of the lesion becomes clearer.

Retinal vascular involvement is manifested by vascular embolization or occlusion and vasculitis. The former can occur alone in the absence of other retinopathy, while the latter often manifests as unilateral or bilateral asymmetrical occlusive arteritis or Phlebitis, clinical examination can be found in retinal edema (caused by diffuse leakage of capillaries), cotton plaque, vascular sheath, vascular occlusion, retinal hemorrhage, vitreous hemorrhage, intravitreal inflammatory cells and opacity.

Compared with ulcerative colitis, Crohn's disease is more likely to cause optic neuropathy, which may involve unilateral or bilateral involvement; it may be an inflammatory lesion or ischemic lesion; it may be optic discitis or a ball. Posterior optic neuritis; without any sequelae, can also cause optic atrophy and permanent visual field defects.

In patients with posterior segment of the eye caused by inflammatory bowel disease, serous retinal detachment is prone to occur, and in some patients, cystoid edema may also occur.

Uveitis generally occurs after intestinal lesions, that is, the average age at which inflammatory bowel disease occurs is less than the average age at which uveitis occurs, but in a small number of patients, uveitis can occur before or during intestinal disease. At the same time.

(2) Scleritis or scleral inflammation: Scleral involvement is another common ocular lesion of inflammatory bowel disease. Women are prone to such ocular lesions, which can be manifested as acute scleral inflammation and acute scleritis. Two types, the sclera of the outer layer of inflammation and unilateral, may also involve bilateral, may be nodular inflammation, but also diffuse inflammation, scleral inflammation and intestinal disease activity is closely related, it is almost Found in Crohn's disease, often occurs several years after the occurrence of intestinal lesions, prone to patients with arthritis and other systemic changes (such as anemia, skin lesions, oral ulcers, hepatobiliary diseases), scleritis in the inflammatory bowel The incidence rate of patients with diseases is 2.06% to 9.67%, which can be nodular, necrotizing or diffuse. Scleritis can be repeated. In severe cases, scleral softening or perforation may occur, and uveitis and scleritis are often caused. It is also more common in patients with arthritis and other systemic diseases, mostly in the case of intestinal disease deterioration.

(3) Conjunctivitis: Conjunctivitis is also a common ocular manifestation of inflammatory bowel disease, which can be accompanied by uveitis, keratitis and keratitis.

(4) corneal lesions: relatively rare, with or without scleritis, can be expressed in two types, one is epithelial or epithelial gray-white point infiltration, and the other is epithelial or anterior stromal layer Infiltrating, lesions appear in the peripheral cornea, severe cases can cause corneal ulcers.

(5) Others: Orbital inflammatory pseudotumor is a rare eye lesion, which is more common in women; others may have extraocular muscle paralysis, eyelid inflammation, and cellulitis.

3. Arthritis is a common manifestation of inflammatory bowel disease, mainly in two types, one is peripheral arthritis and the other is ankle arthritis and spondylitis.

Peripheral arthritis usually occurs half a year to several years after intestinal lesions. In a small number of patients, arthritis can occur before or at the same time as intestinal lesions. Arthritis is more acute, manifesting as single arthritis or less joint type joints. Inflammation, any joint can be affected, but the knee and ankle joints are the most common. Arthritis often manifests as joint swelling and pain, which can be migratory. The inflammation usually lasts for 1 to 2 months, and the minority can last for more than 1 year. There is no permanent joint damage, arthritis and intestinal lesions are closely related, and more common in patients with other systemic diseases (such as skin lesions, oral ulcers, uveitis, etc.), in ulcerative colitis Patients, patients with colon involvement are more likely to develop arthritis than those with rectal involvement. In patients with Crohn's disease, those with colonic involvement are more likely to develop arthritis than those with small bowel.

The incidence of ankle arthritis and spondylitis is similar to that of peripheral arthritis. The clinical manifestations are similar to those of ankylosing spondylitis. The progression is not related to intestinal lesions. Patients with such arthritis Mostly HLA-B27 antigen positive, prone to uveitis, especially prone to acute non-granulomatous anterior uveitis.

4. Other changes

(1) Skin lesions: The skin lesions caused by inflammatory bowel diseases are mainly manifested in two types, one is nodular erythema and the other is gangrenous pyoderma. These skin lesions are mainly caused by small blood vessels. Caused by vasculitis.

(2) Oral ulcers: This disease can also cause oral ulcers, but the incidence is low, about 4.9%, showing painful oral ulcers.

Examination of inflammatory bowel disease and its associated uveitis

1. Stool routine examination to determine whether there is mixed blood, pus and mucus, and pay attention to stool characteristics.

2. Blood routine and electrolyte examination to determine whether there is electrolyte imbalance and anemia.

Histopathology is different in various enteritis manifestations.

1. Ulcerative colitis lesions involving the rectum and sigmoid colon, can also extend to the entire colon, early intestinal mucosal edema, congestion, hemorrhage, first form a shallow small ulcer, and then merge into a large ulcer, the surface has inflammatory exudate; ulcer There are cell infiltration at the margins, with lymphocytes and plasma cells as the majority, and a large number of neutrophils can be seen in the secondary infection.

2. Granulomatous ileocolitis (Crohn's disease) Most involving the terminal ileum, the basic lesion is granuloma, in the acute stage of intestinal wall edema congestion, veins and telangiectasia, serosal fibrinous exudation; in the chronic phase of the submucosa There are a large number of granulomatous hyperplasia and lymphoid tissue hyperplasia, lymphocyte and plasma cell infiltration, macrophages, fibrosis or calcification, but no cheese-like necrosis.

3. Ankle X-ray examination excludes inflammation.

4. Eye slit lamp examination and fundus examination can confirm the anterior uveal lesion, and the fundus examination can confirm the choroid and fundus lesions.

Diagnosis and diagnosis of inflammatory bowel disease and its associated uveitis

diagnosis

Various enteritis can be based on the specific manifestations of feces, jejunal biopsy results and cell granules demonstrating PAS-positive, and other specific enteritis should be excluded at the time of diagnosis.

Differential diagnosis

1. Intestinal Behcet disease Intestinal Behcet disease mainly manifests as superficial ulcer of the intestine, abdominal pain, diarrhea and even pus and bloody stools, prone to oral ulcers, arthritis, thrombotic vasculitis, pleomorphic skin lesions, genitals Ulcers, etc., the main manifestations of the eye are uveitis, retinitis and retinal vasculitis, which can also occur in inflammatory bowel disease, but the incidence of oral ulcers in Behcet disease is high, and easy to cause genital ulcers, Its typical uveitis and retinal vasculitis are different from anterior uveitis of inflammatory bowel disease, and many patients have positive skin allergic reaction tests, which are helpful for the identification of the two, and it is difficult to identify. At the time, endoscopy, biopsy and X-ray examination are feasible to confirm the diagnosis.

2. Intestinal tuberculosis intestinal tuberculosis can cause uveitis, but this inflammation is mostly granulomatous inflammation, choroidal granuloma can occur when choroidal involvement, exudative retinitis can occur in the retina, a wide range of retinitis and retinal vein Peripheral inflammation, which is different from non-granulomatous anterior uveitis caused by inflammatory bowel disease. In addition, although intestinal tuberculosis can affect any part of the gastrointestinal tract, it rarely affects the colon, and histological examination reveals caseous necrosis. Granuloma, granuloma has a tendency to fuse, lymphocyte ring can be seen around, ulcerative colitis does not show granuloma changes, Crohn disease can cause granulomatosis, but the incidence is low, and all are non-case-like necrotic granulation Swelling, biopsy and acid-fast staining, tuberculin test, chest X-ray examination, etc. all help to identify.

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