Scientific journal
European Journal of Natural History
ISSN 2073-4972
ИФ РИНЦ = 0,301

NONSPECIFIC ULCERATIVE COLITIS IN COMBINATION WITH RHEUMATOID ARTHRITIS

Toleuova A.S. 1 Beysenbekova Z.A. 1 Tayzhanova D.Z. 1
1 Karaganda State Medical University

Introduction. Rheumatoid arthritis, in the structure of rheumatologic diseases, consists about the 10 % and is one of the most widespread inflammatory joint diseases. According to different authors mention [1] joints damage often meets at nonspecific ulcerative colitis, but a separate combination of rheumatoid arthritis and nonspecific ulcerative colitis is rare. In our clinical case of the patient with long-term rheumatoid arthritis with the expressed joints deformation and full disability were observed and in the subsequent at the patient nonspecific ulcerative colitis with its complications developed.

Case description. Patient N. is 66 years old, hospitalized in the surgery department of № 1 city hospital of the Karaganda city from 23.09.2013 till 09.10.2013 with the following diagnosis:

Nonspecific Ulcerative Colitis. Sigmoid colon phlegmon. Diffuse purulent peritonitis.

IHD. MI (2000, 2008). Aortic atherosclerosis. Arterial hypertension III degree, risk 4. Chronic Heart Failure I degree, Functional Class I.

Rheumatoid arthritis. Seropositive, late stage, I stage of activity, with systemic manifestations (rheumatoid nodules and arthropathy). Functional Damage III degree.

Anemia I degree, on the background of rheumatoid arthritis and gastrointestinal pathology. DIC syndrome, IV stage.

Complaints: abdominal pains, meteorism, nausea, repeated vomiting with the gastric contents, liquid stool, dryness in a mouth, weakness.

Anamnesis morbi: Within the last 8 years she noted pains at first in knee joints with gradual transition to ankle joints. There were rheumatoid small nodules around the 4 years ago. Because of joint pains incidentally, she accepted nonsteroid anti-inflammatory drugs. The last deterioration within a day when for no apparent reason began abdominal pains. At once she didn’t ask for medical care, in dynamics pain began to grow. She accepted laxatives, without positive effect. Due to her condition deteriorated, she called «ambulance» and was hospitalized in the surgical department of the 1st city hospital.

Other anamnestic data: In 1996 she had a cholecystectomy. In 2000 and 2008 she had myocardial infarction. Within 10 years she suffered from arterial hypertension her BP was 180/110 mm Hg. She accepted hypotensive drugs by situation.

The Allergic anamnesis isn’t burdened.

Objective data: patient condition is heavy, because of pain and intoxication syndromes, and accompanying pathology. Her consciousness is adequate. Integuments are usually colored. Peripheral lymph nodes aren’t increased. The thorax is correct form, participates in the breath act. On auscultation in the lungs is listened rigid breath on all fields, crepitations aren’t present. The respiratory rate is 19 per min. Heart sounds are muffled, rhythm is correct. BP is 140/90 mm Hg, pulse is satisfactory properties, 90 beats per min. The tongue is dryish, has a white cover. The abdomen has the correct form, is evenly blown up. There is a postoperative scar without inflammation signs in epigastria. On palpation abdomen is painfulness. On percussion: tympanic sound, the peristaltic movement is weakened in all departments. The Blumberg’s symptom is positive. The liver isn’t increased. The spleen isn’t palpated. Gases don’t leave. The stool is absent. Pasternatsky symptom is negative from both sides. Urination is free, painless.

Perrectum: The perianal area isn’t changed. The tonus of a sphincter is kept. Rectum walls overhang isn’t present. On glove excrement traces is usually colored.

Laboratory diagnostic tests: in blood – leukocytosis, ESR acceleration; in urine analyses – a moderate proteinuria; in coagulogram PTI is decreased (60 %), soluble fibrin monomer complexes are positive; in biochemical analyses – without changes; histologically intestines biopsy research showed – sharp erosive and ulcerative colitis with vessel thrombosis; on ECG – a sinus rhythm, HR is 80 per minute, electric axis is deviated to the left.

Treatment: In clinic the patient received conservative treatment. On the conservative therapy background, abdominal pains are remained. There were peritonitis symptoms. She was operated. Intra operatively was found sigmoid colon phlegmon. It was made: left hemicolonectomy, with one opening colostomy, sanitation and drainage of an abdominal cavity.

In the postoperative period the patient was in reanimation department, received the appointed treatment: tramadol 2,0 IM, № 3; ceftriaxone 1,0×3 times per day IV, № 4; glucose 5 % – 400,0, № 4; 0,9 % physiological saline solution – 1200 l, № 4; 1 % morphine solution – 1,0 IV, № 3, metrogyl 500 – 100,0 IV, № 4, dimedrol 1,0×1 per day IM, № 3; ketotop 2,0 IM, № 1; prednisolonum 60,0 IV, № 4; humulin 4 UN IV; clexane 0,4 PC № 4, hemotransfusion 209,0 ml, № 122012110042061, 290,0 ml, № 122062110044152.

After condition stabilization the patient is transferred to surgical department where continued to receive the appointed treatment: 0.9 % physiological saline solution – 800,0 IV, № 11; xefocam 2,0 IM, № 8; Glucose solution 5 % – 500 + potassium chloride 7,4 % – 20,0 + insulin 4UN IV, № 7; Amiclav 1,2×3 times per day IM, № 11; metrogyl 100×2 times per day IV, № 10; fraxiparine 0,4 PC, № 11, morphine 1,0 IM, № 2; fercayl 2,0 IM, № 11, tramadol 2,0 IM, № 3, nexium 40 mg, № 3; Prednisolonum 60,0 mg IV, № 9, bandagings, colostoma care.

The postoperative period proceeded hard, due to accompanying pathology.

On the 6th day of the postoperative period the control drainage is removed. Postoperative wound without inflammation signs, healing by primary tension. Seams are removed. Colostoma functions. The patient independently eats, stool is regular through colostoma.

Patient’s condition at the moment of the hospital leaving: She is in a satisfactory condition on the further out-patient management.

Discussion. Further treatment of this patient, first of all, is connected with reconstructive operation. Use of immunosupressive therapy before new operation can call infectious complications. Only after the recovery operation, it is possible to speak about treatment, both nonspecific ulcer colitis, and rheumatoid arthritis.

According to some authors [2, 3] it is possible to use the following scheme of treatment: (sulfasalazine 4–6 g per day, mesalazine 3–4,8 g per day) – per os and mesalazine 2–4 g per day per rectum or corticosteroids – Prednisolonum 20–30 mg per day or a hydrocortisone 125–250 mg per day in the form of enemas. In the absence of effect Prednisolonum 1 mg on 1 kg per day in combination with rectal introduction of corticosteroids and mesalazine (Prednisolonum 20–30 mg per day or hydrocortisone 125–250 mg or mesalazine 2–4 g per day).

Conclusions. Thus, treatment of this patient remains in discussion and depends, first of all, from the patient’s condition during the postoperative period, from the progression of nonspecific ulcerative colitis and rheumatoid arthritis.