Chronic enteritis: diagnosis

Laboratory and instrumental data

• The general analysis of a blood: iron deficiency hypochromic enough is quite often revealed, In _12- deficient hyperchromic or polyfactorial anemia.
• General urine analysis: without significant changes. With the development of hypothalamic-pituitary insufficiency and the syndrome of diabetes insipidus, the density of urine decreases. With a severe course of chronic enteritis, a small proteinuria, a microhematuria, is possible; with putrefactive dyspepsia of the intestine - increased allocation of the indicator.
• Biochemical analysis of blood: a decrease in the blood levels of total protein, albumin, calcium, sodium, iron; often - hypoglycemia; when developing reactive hepatitis, an increase in bilirubin, alanine aminotransferase, cholesterol.
• The content of hormones in the blood: with hypothyroidism - a decrease in the content of thyroxine, triiodothyronine; with hypokorticism, a decrease in the level of cortisol; hypothalamic-pituitary insufficiency - a decrease in the content of somatotropin, gonadotropins, thyrotropin, corticotropin; with hypofunction of the sexual glands - a decrease in the content of sexual hormones in the blood.
• Coprologic analysis: chronic enteritis is characterized by the following changes in feces (coprocytes):
  • polyphecal (the amount of feces increased to 300 g or more per day);
  • stool color is straw-yellow or greenish-yellow;
  • there are pieces of undigested food;
  • mucus (in a small amount);
  • steatorrhea (in large quantities, fatty acids and soaps are determined - the intestinal type of steatorrhoea);
  • Creatorrhea (in the stool undigested muscle fibers are determined);
  • amylorea (undigested starch);
  • gas bubbles, foam feces with fermentation dyspepsia;
  • acid reaction of feces (pH below 5.5) indicates a violation of digestion of carbohydrates;
  • increased release of fecal enterokinase and alkaline phosphatase.
  • Bacteriological examination of feces reveals a dysbacteriosis.
• Research of the functional capacity of the intestine:
  • Investigation of the intestinal absorption function.

Absorptive capacity of the intestine is assessed by the speed and amount of appearance in the blood, saliva, urine and stool of various substances taken orally inserted into the 12-colon through the probe. The most common sample is D-xylose. D-xylose is taken orally in an amount of 5 g, then it is determined to be excreted in the urine for 5 hours. In chronic enteritis, the excretion of D-xylose in the urine is reduced (normally 30% of the total D-xylose ingested is secreted).

To exclude the influence of the kidneys on the results of the test, it is advisable to determine the level of D-xylose in the blood 60 and 120 minutes after taking 25 g of D-xylose inside. Normally, the content of D-xylose in the blood after 60 minutes is 0.15 ± 0.03 g / l, after 120 minutes - 0.11 + 0.02 g / l.

With chronic enteritis, these indicators are reduced.

A test with D-xylose makes it possible to evaluate the functional capacity of the predominantly proximal part of the small intestine.

A sample with lactose is used to diagnose the breakdown of splitting and absorption of lactose. Normally, after ingestion of 50 grams of lactose, blood glucose levels increase by at least 20% compared to its original value. Glucose is formed after lactose is digested with lac gas. In chronic enteritis, splitting and absorption of lactose is disturbed, and an increase in glucose level is less than 20% compared to the baseline level.

The sample with potassium iodide is a simple indicative test for judging the state of the intestinal absorption function, in particular, the absorption of salts.

The patient takes inside 0.25 g of potassium iodide, then determine the time of appearance of iodine in the saliva by reaction with 10% starch solution (when iodine saliva turns blue when starch is added). Normally iodine appears in saliva no later than 6-12 minutes, with chronic enteritis and impaired absorption of the small intestine this time increases.

Sample with calcium chloride. The patient takes inside 20 ml of a 5% solution of calcium chloride, then after 2 hours the calcium content in the blood is determined. With normal suction function, the level of calcium in the blood increases, with chronic enteritis virtually unchanged.

A sample loaded with albumin labeled with ¹¹ I. The sample allows evaluation of the absorption of proteins in the small intestine. When malabsorption in the small intestine is observed, a flat curve of radioactivity of the blood, a decrease in the release of ¹¹ I in the urine and an increase in excretion with feces.

Probe van de Camera is used to study the absorption of fats. The patient is prescribed a diet containing 50-100 g of fat, then determine the fat content in the daily feces. In healthy people, the loss of fat with feces for a day does not exceed 5-7 g. If there is a violation of fat absorption, the amount of fat released from the feces per day can be 10 g or more.

A sample loaded with labeled ¹¹ I lipids. The patient takes either sunflower oil or trioleate glycerol labeled with ¹¹ I; then the radioactivity of blood, urine, feces is determined. When the absorption of lipids in the intestine is impaired, the radioactivity of blood and urine decreases, but the radioactivity of the feces increases.

Hydrogen test. The essence of the test is to determine hydrogen in the exhaled air. Hydrogen is formed normally in the colon as a result of the vital activity of the flora, absorbed into the blood and secreted by the lungs. If the digestion and absorption of disaccharides (lactose, lactulose) in the small intestine are disturbed, they enter the large intestine, are broken down by bacteria, a large amount of hydrogen is formed and, consequently, the amount of it in the exhaled air sharply increases.

• Investigation of the excretory function of the small intestine.

The study of excretory function of the intestine is very important, especially with exudative hypoproteinemic enteropathy. The simplest test, which allows to determine the isolation of a protein, is the Tribula test. It is that to 6 ml of 10% emulsion of stool is added the same amount of saturated solution of mercuric chloride. With increased protein secretion, the solution is clarified above the precipitate after agitation of the solution and settling it at room temperature.

More accurate methods for determining the excretory function of the intestine is the electrophoregram of the stool to determine the soluble protein, as well as the radionuclide method (intravenous administration of human serum albumin labeled with ¹¹ I, followed by determination of the radioactivity of blood plasma, intestinal juice and stool).

• Investigation of the motor function of the intestine.

To study the motor function of the intestine, a radiotelemetric method is used (using radionuclides and endoradiosonde); introduction into the intestine of radioactive substances that are not absorbed in the intestine, Bengal pink, labeled with ³¹ I and others, followed by a study of their progression through the intestine.

An accessible method for assessing the motor activity of the intestine is to determine the passage of the radiopaque substance of barium sulfate. Normally, barium fills the jejunum in 25-30 minutes, the ileum - after 3-4 hours, fills the entire large intestine after 34 hours, complete emptying of the colon occurs 48-72 hours.

In chronic enteritis, the motor function of the small intestine is usually strengthened.

• Study of the digestive function of the small intestine.

To investigate the digestive function of the small intestine, the activity of enterotnase and alkaline phosphatase in intestinal juice, feces and mucous membrane of the small intestine is determined . Normally, the content of enterokinase in duodenal contents is 48-225 units / ml, alkaline phosphatase - 10-45 U / ml. With chronic enteritis, these values are significantly reduced.

About parietal digestion is judged on the basis of the definition of intestinal digestive enzymes in washings from the biopsy of the small intestinal mucosa after removal from the surface of intestinal juice and sequential desorption of the biopsy.

Pristenochnoe digestion in chronic enteritis is disrupted.

• X-ray examination: when X-rays of the small intestine are determined characteristic for chronic enteritis:
  • the mucosal relief is unevenly thickened, deformed, the folds are smoothed;
  • accumulation of fluid and gas due to impaired absorption function (with severe enteritis form);
  • increased motility of the small intestine (with a severe degree of enteritis, there may be a decrease in the motility of the small intestine).
• Endoscopic examination of the small intestine mucosa: 12-colon can be examined with a fibrogastroduodenoscope, examination of the remaining parts of the small intestine with the help of an intestinal fibroscope. A flexible intestinal endoscope allows you to examine both the proximal and distal parts of the small intestine. However, the study is technically difficult and to some extent burdensome for the patient.

With chronic enteritis (especially in the period of exacerbation), the mucous membrane of the small intestine is focal or diffuse giperemirovana, edematous, the vessels are injected, the folds are broad, thickened, sometimes deformed. With long-term chronic enteritis, the mucous membrane is pale, atrophic, its folds are thinned, smoothened.

In case of doubt, a biopsy of the mucosa is performed to confirm the diagnosis of chronic enteritis and exclude other diseases of the small intestine . Chronic enteritis is characterized by inflammatory-dystrophic changes in the mucous membrane of the small intestine, phenomena of atrophy of varying severity.

Differential diagnosis

Differentiation of forms of chronic enteritis depending on the localization of small intestine damage

It is of great clinical interest to determine the localization of the primary lesion of the lean or ileum in chronic enteritis.

Differential diagnosis of chronic enteritis and intestinal tuberculosis

Tuberculosis of the intestine can be diagnosed on the basis of the following symptoms:

• the presence in the anamnesis of indications on the transferred tubercular process;
• primary lesion of the ileocecal section (ileotiflit);
• characteristic palyutory changes in the terminal segment of the iliac and cecum - soreness, compaction, tuberosity and poor mobility of these parts of the intestine;
• prolonged fever, accompanied by sweating, especially at night;
• palpatory tenderness in the projection of the mesentery root and an increase in mesenteric lymph nodes, defined on the left above the navel and in the right ileal region;
• positive tuberculin tests;
• positive reaction to latent blood in the feces and the definition of mycobacteria in feces;
• detection of calcified mesenteric lymph nodes during X-ray examination;
• detection in the anus of tuberculous ulcers, which do not tend to healing;
• detection of intestinal ulceration of the mucous membrane, cicatricial stenoses, sometimes defects in the filling of the caecum, a narrow ulcerated terminal ileum, pathological shortening in the region of the blind and ascending gut with X-ray examination;
• detection of colon ulcers ulcers oval or rounded, pseudopolyps;
• detection in biopsy specimens of the intestinal mucosa of mycobacterium tuberculosis and epithelioid granulomas with giant Pirogov-Langhans cells;
• detection of increased mesenteric lymph nodes in ultrasound, as well as the symptom of the affected hollow organ - an ultrasound image of an oval or rounded shape with anehogennaya periphery and echogenic center; the peripheral part reflects the pathologically altered intestinal wall, the echogenic center - the contents and folds of the mucosa.

Differential diagnosis of chronic enteritis and amyloidosis of the intestine

Amyloidosis of the intestine is characterized by the following features:

• presence of symptoms of the underlying disease that causes the development of amyloidosis (tuberculosis, bronchiectasis, rheumatoid arthritis, recurrent disease, etc.).
• persistent, often profuse diarrhea, not amenable to active treatment with diet, antibacterial, astringent, adsorptive agents;
• involvement in the pathological process of other organs - the liver, spleen, kidneys, pancreas, heart;
• elevated blood levels of a ₂ - and y-globulins;
• significant increase in ESR;
• positive test Bengolvda (absorption of more than 60% of the injected into the vein of Congo red paint);
• the detection of amyloid in biopsies of gums, skinny, 12-finger and rectum.

Differential diagnosis of chronic enteritis and ileitis in Crohn's disease

For ileitis in Crohn's disease, the following symptoms are characteristic:

• systemic manifestations (erythema nodosum, eye damage in the form of episcleritis, uveitis, keratitis, iritis, polyarthritis with lesion of large joints, renal damage);
• aphthous ulcers of the oral and linguistic mucosa;
• colicky pains in the right side of the abdomen, local palpation pain and probing of tumor-like formation in the right ileal region;
• a mushy, liquid or watery stool;
• absence of polyphecal and steatorrhea (in contrast to chronic enteritis);
• when X-ray examination of the small intestine (barium is advisable to inject through the probe for a bundle of Treits), strictures, fistulas, pseudodiverticles, ulcers of the mucous membrane of various sizes, narrowing (a symptom of the cord), shortening of the altered segments of the intestine are revealed;
• with laparoscopy, the terminal segment of the ileum looks hyperemic, loosened, the mesentery and lymph nodes are compacted, have a reddish hue.

Differential diagnosis of chronic enteritis and enzyme enteropathy

The most often it is necessary to differentiate chronic enteritis with gluten and disaccharidic enteropathy.

In differential diagnostics with gluten enteropathy, the main emphasis is placed on improving the condition and disappearing diarrhea after applying the gluten-free diet, detecting circulating gluten antibodies in the blood, positive test with gliadin load (rapid increase in glutamine levels after oral administration of 350 mg gliadin per 1 kg body weight ); long, beginning with childhood, anamnesis of the disease.

In the diagnosis of disaccharidic enteropathy, emphasis is placed on indications of milk intolerance, sucrose and the decrease or disappearance of enteric symptoms (diarrhea, flatulence) after exclusion from the diet of milk and containing milk and sucrose products.

Diagnosis of chronic enteritis is established based on anamnesis (the presence of an etiological factor), clinical picture, examination data, as well as laboratory and instrumental studies. In the clinical picture, the combination of intestinal symptoms with the syndrome of impaired absorption is of particular importance.

[1], [2], [3], [4], [5], [6], [7]