Inflammatory Bowel Disease: Diagnostic and

Inflammatory Bowel Disease: Diagnostic and Therapeutic Modalities Hamdy M. Hussein and Eman MS. Muhammad General surgery and Histopathology Departments, Faculty of Medicine; Sohag University

ABSTRACT: Background: Inflammatory bowel disease (IBD) is chronic conditions of unknown origin that result from continuous or intermittent inflammation of a part of the intestinal wall. The main classic types of IBD are ulcerative colitis (UC), Crohn's disease (CD) and indeterminate colitis that cannot be classified accurately as UC or CD with pure colonic involvement. The aim of this study is to highlight this rare disease in our locality including; clinical feature, investigations, indication of surgical interference, operative procedures, histopathological examination, and postoperative complications. Patient and methods: Twenty nine patients were included in this study from January 2000 to May 2006. Histopathological examination proved to be UC in 18 patients and CD of the intestinal tract in 11 patients. Patients were subjected to history, tarinsclinical examination, and routine laboratory investigation, abdominal X-ray in an erect position, barium enema, intravenous urography, sigmoidoscopy and colonoscopy. Biopsy was taken, and CT and MRI were done in selected cases. All patients subjected to medical and/or surgical treatment according to their finding. Results: their mean age was 49.4±2.1 years (range 12 -65 ys). Female to male ratio was 2:1. The main clinical manifestations were abdominal pain in 27 patients (93.1%), bleeding per rectum in 14 patients (48.3%), mucus discharge in 10 patients (34.5%), and chronic diarrhea in 6 patients. Palpable abdominal mass was found in 3 patients. Extra-abdominal manifestations were loss of weight in 15 patients (51.7%), pallor in 11 patients (37.9%), lower limb edema in 7 patients and skin changes 4 patients. Twenty three patients (79.3%) were received medical treatment; 18 patients (62.1%) UC and 5 CD but the remaining 6 patients (20.7%) admitted to emergency department. Successful treatment with complete cure was achieved in 12 patients (41.4 %); 10 patients had UC and 2 CD while surgery was done in 17patients (58.6%); 9 patients had CD and 8 UC. Right hemicolectomy was done for 7 of them and limited resection anastomosis was performed in the other 2 patients. Total colectomy with terminal ileostomy was carried out in one patient and subtotal colectomy with ileorectal anastomsis in 7 patients. One patient presented with postoperative intestinal fistula and right hemicolectomy mas done. Three patients developed postoperative wound infection and one of them had burst abdomen. Conclusion: IBD is not rare in our locality and its treatment still remains the challenge despite growing knowledge about the disease, advances in medical treatment and surgical techniques. Proper assessment of IBD requires cooperation of gastroenterologists, radiologists, histopathologists and surgeons. Key words: Inflammatory bowel diseases, UC and CD.

SOHAG MEDICAL JOURNAL Vol.10 No.1 Jul.2006

Inflammatory Bowel Disease Hamdy M. Hussein et.al

INTRODUCTION: IBD continue to rise in lowincidence areas such as Southern Europe, Asia, and much of the developing world. The strongest environmental factors identified are cigarette smoking and appendectomy. Whether other factors such as diet, oral contraceptives, perinatal/childhood infections, or atypical mycobacterial infections play role in expression of IBD remains unclear. (1) A growing amount of evidence indicates that the intestinal flora plays a pathogenic role in IBD: hence, the use of anti-bacterial agents is usually carried out with either metronidazole or ciprofloxacin, or both. UC is an inflammatory destructive disease of the large intestine occurred usually in the rectum and lower part of the (2) colon as well as the entire colon.

Radiologic imaging especially of the small bowel plays an important role in the diagnosis and management of patients with inflammatory bowel disease by small bowel follow through is still the mainstays in small bowel imaging. However, abdominal CT or MRI, are overall comparable with regard to the sensitivity and specificity in detecting intestinal pathologies and have already replaced the (3) conventional techniques. Endoscopy plays an integral role in the diagnosis, management, (4) and surveillance of IBD. Diagnosis of UC and CD relies heavily on pathologic interpretation of biopsy and resection specimens. (5) A summary of the classic microscopic features of UC and CD is noted by Odze (6):

Ulcerative Colitis

Crohn's Disease

Diffuse, continuous disease Segmental disease Rectal involvement Variable rectal involvement Disease worse distally Variable disease severity No fissures Fissures, sinus, fistula No transmural aggregates Transmural lymphoid aggregates No ileal involvement (exception: "backwash")Ileal involvement --------------------------------Upper GI involvement No granulomas Granulomas Histopathological grading of chronic UC was based on inflammation severity, ulceration, hyperplasia, and area of inflammatory involvement, as described previously. (7) The histopathological variables of colorectal CD are transmural inflammation, transmural granuloma, perineural chronic inflammation or a combination of the three. (8)

The great diversity of symptoms within UC and CD suggests distinct underlying pathogenetic mechanisms. It is hoped that a better understanding of the environmental, genetic, and immunological mechanisms that produce UC and CD will lead to improved therapy for IBD. (9) The pharmacologic management of IBD is based on the 2



location, extent, and severity of the pathologic process within the GI tract. (10) Corticosteroids are a mainstay in the treatment of inflammatory bowel disease. Consistently improve moderate to severe active UC and CD, although they are ineffective in the maintenance of remission in either illness Alternative therapies include 5-aminosalicylic acid (5ASA), mesalamine (pentasa), immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab). (11) Operative excision provides symptomatic relief and long-term benefit. (12, 13, 14) The majority of patients treated with CD will need at least one surgical intervention.(15) The most common indications for surgical interference are intestinal obstruction, septic complications and failure of medical treatment. In any given patient one or more indication may be present. (16) The aim of this study is to highlight this rare disease in our locality including clinical feature, investigations, indication of surgical interference, operative procedures, histopathological examination, and postoperative complications.

corticosteroids either systemic or local, 5-aminosalicylic acid (5-ASA), mesalamine (pentasa), and azathoprim and / or surgical treatment according to their finding. Medical treatment was continued up to 1 or 1/2 years. Surgical treatment was performed through abdominal exploration and resection of affected lesions up to total colectomy. Histopathological examination was done for all excised specimens. RESULTS: Twenty nine patients were included in this study; their mean age was 49.4 ± 2.1 years (range 1265 ys). Female to male ratio was 2:1 Histopathological examination of specimens was taken from patients through endoscopy preoperative or postoperative specimen was proved to be UC in 18 patients (62.1%) and CD in 11 patients (37.9%). Clinical features: The main clinical manife-stations were abdominal pain in 27patients (93.1%), bleeding per rectum in 14 patients (48.3%), mucus discharge in 10 patients (34.5%), and chronic diarrhea in 6 patients (20.7%). Seven patients presented with acute abdomen while the other 20 patients presented with chronic abdominal troubles. Abdominal pain was the commonest symptom and varied from discomfort to sever colic. History of chronic diarrhea was found in 7 patients (24.1%). Palpable abdominal mass was found in 3 patients (10.3%), one of them was a child with intussusception, the two patients of middle age who having right iliac fossa mass suspected to be intestinal TB The extra-abdominal manifestations were loss of weight in 15 patients (51.7%), pallor in 11 patients (37.9%), lower limb edema in

PATIENTS AND METHODS: Twenty nine patients admitted to department of surgery, Sohag Faculty of medicine South Valley University from Januory 2000 to Bay 2006. Patients were subjected to history, clinical examination, routine laboratory investigation, abdominal X-ray in erect position, barium enema, intravenous urography, sigmoidoscopy, colonoscopy and biopsy was taken from any pathological lesion for histopathological examination; (figure;1& 2), and CT, MRI were done in selected cases. All patients subjected to medical in form of 3



7patients (24.1%) and skin changes 4 patients (13.8%); (Table:1).

respond to medical treatment, while 8 patients 44.4 %( 8/18); or 34.8% (8/23) failed medical treatment with persistent endoscopic finding or development of pseudopolyps with histopathological dysplasia. Two patients 40% (2/5); or 18.1 %( 2/11) with CD had complete improvement on medical treatment.

Investigations: Plain abdominal X-ray showed multiple air fluid levels in 2 patients with intestinal obstruction. Abdominal ultrasound revealed intra-abdominal collection of fluid in 4 patients and abdominal masses in 3 patients. Barium enema is carried out in 7 patients with loss of hustration in 5 patients and 2 with filing defect and CT in 3 patients to exclude other intraabdominal lesion, Sigmoidoscopy, colonoscopy and biopsy reveal:

Indications of surgical interference: Urgent surgery was done for 6 patients (20.7%); peritonitis (4patients) and intestinal obstruction (2patients). Elective abdominal exploration was done in 11 patients (37.9%); palpable abdominal mass (3 patients), and 8 patients failed medical treatment with persistent endoscopic finding or development of pseudopolyps with histopathological dysplasia;(Table: 2).

Histopathological results: (figure: 7, 8, 9,10.11 A+B); examination of serial sections of the submitted endoscopic biopsy specimens revealed that 18 patients had UC; and 11 patients had chronic non specific inflammation (CD). In 18 patients with UC after follow up for outcome of medical treatment, 4 patients had persistent endoscopic picture and 4 patients developed pseudopolyps with histopathological dysplasia where surgical colectomy was indicated.

Operative findings and anatomical distribution of the lesions: The intestinal masses were ranging from 2-5 cm. In diameter, firm in consistency were detected in 5 patients. Thickening of the ileum and mesentery and enlarged regional lymph nodes were found in 2 patients; (figure: 3, 4,5), right hepatic flexure in 2 patients thickening of terminal ileum in one patients. Peritonitis due to perforation of the ileum was found in 4 patients; 2 patients with single perforation and 2 with multiple perforations. The terminal ileum was the commonest site of involvement in our study; (Table: 3). Right paramedian exploration was done in 9 patients; right hemicolectomy was done for 7 of them; (figure: 6) and limited resection anastomosis was performed in the other 2 patients, (Table: 4). Middle line or left

Medical treatment: Twenty three patients (79.3%) were received medical treatment; 18 patients (62.1%) with UC and 5 with CD but the remaining 6 patients (20.7%) admitted to emergency department (4 peritonitis and 2intestinal obstruction). As regard to complete cure with maintenance therapy were achieved in 12 patients 52.2 % (12/23). Failed medical treatment was 11 patients 47.8 % (12/23). Ten patients with ulcerative colitis 55.6% ( 10/18); or 43.5% (10/23) will 4

Inflammatory Bowel Disease


Hamdy M. Hussein et.al

paramedian in which total colectomy with terminal ileostomy in one patient pad bod genero; condition and subtotal colectomy with ileorectal anastomsis in 7 patients where the rectal mucosa is free in 5 patients and 2 patients with mild rectal UC treated with local cortisone and mesalamine (pentasa). We prescribed salazopyrine and metronidazole therapy to our patients for 4 postoperative weeks.

One patient presented with postoperative intestinal fistula, with failure of limited resection, and then right hemicolectomy was done. Sixteen patients showed smooth postoperative course without anastomotic leakage. However 3 patients were operated on for peritonitis which subsequently developed postoperative wound infection, 2 patients were treated conservatively, while the remaining one had burst abdomen and require surgical repainer; (Table: 5).

Postoperative complications: Table (1): Main clinical features Main clinical features Abdominal pain Loss of weight Bleeding per rectum Pallor Mucus discharge Lower limb edema Chronic diarrhea Skin changes Peritonitis Abdominal mass Intestinal obstruction

No. of patients

percentage

27 15 14 11 10 7 6 4 4 3 2

93.1% 51.7% 48.3% 37.9% 34.5% 24.1% 20.7% 13.8% 13.8% 10.3% 6.9%

Table (2): Indications of surgical interference Indications of surgical interference Persistent endoscopic finding after medical treatment UC Rectal lesions(pseudopolyp&/ or ulcers)on top of UC Peritonitis Abdominal mass Intestinal obstruction

5

No. of patients

% (17)

% (29)

4 4 4 3 2

23.5% 23.5% 23.5% 17.6% 11.8%

13.8% 13.8% 13.8% 10.3% 6.9%




Table (3): Operative findings and site of lesions Operative findings & site of lesions

No. of patients

% (17)

% (29)

4

23.5%

13.8%

4

23.5%

13.8%

intestinal mass Terminal ileum Right hepatic flexure Ileocaecal (intussusception)

5 2 2 1

29.4% 11.8% 11.8% 5.9%

17.2% 6.9% 6.9% 3.4%

Perforation of terminal ileum: Multiple Single

4 2 2

23.5% 11.8% 11.8%

13.8% 6.9% 6.9%

Colonic lesions(pseudopolyp and/or ulcers)UC rectal lesions(pseudopolyp&/ or ulcers)UC

Table (4): Operative procedure: Type of procedure

No. of patients

% (17)

% (29)

Subtotal colectomy with ileorectal anastomosis Total colectomy with terminal ileostomy

7 1

41.2% 5.9%

24.1% 3.4%

Right hemicolectomy for: Multiple perforations of terminal ileum Terminal ileal masses Right hepatic flexure mass Ileocaecal intussusception Limited resection anastomosis for: Ileal lesions (single perforation)

7 2 2 2 1 2

41.2% 11.8% 11.8% 11.8% 5.9% 11.8%

24.1% 6.9% 6.9% 6.9% 3.4% 6.9%

Table (5): Postoperative complication Complication Intestinal leakage Wound infection: Burst abdomen

No. of patients

% (17%)

Percentage (29)

1 (3) 1

5.9% (17.6%) 5.9%

3.4% (10.3%) 3.4%

6



(Fig: 1): Endoscopic picture of sever UC

(Fig: 2): Endoscopic picture of Mild UC

(Fig: 3): multiple adhesions with CD

(Fig: 4): Thickened mesentery with enlarged LNs

7



(Fig: 6): microscopic picture of

(Fig: 5): Operative specimen of

mild ulcerative colitis showing inflammatory cells invading the mucosa in colonic mucosa X200.

RT hemicolectomy for CD

(Fig: 8): microscopic picture of severe UC showing moderate dysplasia in the colonic mucosa X200.

(Fig: 7): microscopic picture of severe ulcerative colitis showing crypt abscess in colonic mucosa X200.

(Fig: 9- B): microscopic picture of CD

(Fig: 9-A): microscopic picture of CD showing chronic inflammation in the whole thickness of the wall and ulceration in mucosa X100.

showing chronic inflammation in the whole thickness of the wall and fissuring in intestinal wall X100.

8



DISCUSSION IBD are chronic conditions of unknown origin that result from continuous or intermittent inflammation of a part of the intestinal wall. UC is an inflammatory destructive disease of the large intestine occurred usually in the rectum and lower part of the colon as well as the entire colon. CD and UC represent clinicopathologic entities that traditionally have been diagnosed on the basis of a combination of clinical, radiologic, endoscopic, and histologic findings. The hallmark of IBD is chronic, uncontrolled inflam(17) mation of the intestinal mucosa , which can affect any part of the gastrointestinal tract. Diagnosis is based on the presence of architectural distortion and/or acute inflammatory cells, moreover; IBD inflammation is not down-regulated in which the mucosal immune system remains chronically activated, and the intestine remains (18, 19, 20) chronically inflamed. Kelly and Wolff stated that the incidence of CD is increasing while others have found it to be constant. (12) Also they found that both sexes are equally affected and the peak age of onset is between the 2nd and 3rd decades. In our study 12 patients were encountered in the 5th and 6th decades, but male to female ratio is 1:2. The diagnosis of IBD is sometimes difficult. The cardinal symptom of UC is bloody diarrhea. The clinical characteristics of CD are more heterogeneous, and many patients remain incorrectly diagnosed. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/bloating, anemia and diarrhea. (21) This was support the result in our series as regard main clinical presentations.


Kelly and Wolff reported that two main intestinal complications develop from these lesions; obstruction and perforation producing symptoms of obstruction or localized perforation with fistula, (12) in our study peritonitis detected in 4 patient (13.8%) but intestinal obstruction in 2 patients (6.9 %). Extra-abdominal manifestations were encountered in 30% of their series. Mucocutaneous lesions as skin tags, ulcers, fissures, abscesses, fistulas or stenosis are commonly associated and can precede gastrointestinal symptoms, thereby alerting the clinician to the diagnosis of IBD before the onset of gastrointestinal symptoms. (22, 23) In our study skin changes were detected in 4 patients (13.8%). MRI can be valuable in distinguishing CD from UC in uncertain cases by assessing the sparing of the distal ileum and the continuity of colonic involvement. Moreover, MRI can provide important information if endoscopy is incomplete. (24) In our study CT is enquired in 3 patients and MRI in one patient. But the main investigations plain X-ray in acute intestinal obstructions, sonography in diagnosis of collection, barium meal in diagnosis of stricture or distant lesion our cases. Endoscopy plays an integral role in the diagnosis, management, and surveillance of IBD. A finding of flat low-grade dysphasia during UC surveillance is a strong predictor of progression to advanced neoplasia.(25) Early colectomy should be recommended for such patients. The risk of colorectal cancer is significantly increased 8 years after diagnosis of pancolitis. Thus, regular surveillance by colonoscopy with 9



random biopsies is recommended.(26) In our study colonoscopic finding and histopathological finding represents the main diagnostic procedure for UC. Moreover signs of persistent inflammation with medical treatment were detected and pre-malignant change in pseudopolys was found in histopathological examination in 8 patients as mild to moderate dysplasia in the intestinal mucosa. Drug therapy is not the only choice for UC treatment and medical management should be as a comprehensive whole. (Pentasa mesolamina) is the newer 5aminosalicylates remain the first agents of choice to treat mild to moderate disease and often are effective at high doses as maintenance therapies. More commonly used in treating Crohn's ileitis because release more 5-ASA into the small intestine. It can also be used for treating mild to moderate UC. Sulfasalazine and corticosteroids are often required to treat more moderate to severe disease activity, although approxi-mately one-third of patients become steroid-dependent after a steroidinduced remission. Corticosteroids have proven ineffective in maintaining remission and side effects resulting from prolonged exposure preclude their long-term use. (19, 27) In our study medical treatment is successful in 12 patients (41.4 %); 10 patients with UC responding to medical treatment on clinical and endoscopic follow up. As regard to CD only 2 patients were responding to medical treatment. Despite the existence of multiple therapies, the medical treatment of these diseases often has proven insufficient and surgery is frequently required. Surgery is required in many patients with IBD

at some point in their disease. In patients with ulcerative colitis, surgery is potentially curative whereas recurrence of CD following surgery is a common occurrence. Surgery is usually reserved for the management of complications or failure of medical treatment in CD. (13) In our study surgery was done in 8 patients with UC due to failure of medical treatment and persistent endoscopic finding with development of pseudopolyps and the delecdom dysplasia in histopathological examination. In CD surgery was done for complicated cases; peritonitis in 4 patients, intestinal obstruction in 2 patients. Druker sated that surgical procedure doesn’t have a demonstrable effect on the natural history of the disease, so surgical procedures are designed to treat complications of the disease rather than to cure or to reduce the recurrence. (10) Also in our study surgery was directed for removing intestinal obstruction in 2 patients and peritonitis in 4 patients. Kelly and Wolff stated that 70% of patients with CD undergo surgery for this disease, (12) also agreed by result our study 81.8 % (9/11patients). Kelly and Wolff, and Michelassi and Block found that the common indications for surgical interference in CD are intestinal obstruction, septic complications, fistula formation, gastrointestinal bleeding and failure of medical treatment; this also, support our results. (12, 16) Michelassai and Block found that a palpable abdominal mass occurred in 20 to 25% of patients underwent surgery for CD of the terminal ileum. (16) The presence of the mass reflects severity and complexity which eventually terminates as phlegmon or frank 01



abscess. In our series 3 patients (27.3%) had palpable abdominal mass and 2 patients with mass detected during exploration. Terminal ileum was the commonest involved site with lesions; in our series (7/ 11) about 64%. This agreed by result of Michelassi and Block they found that the terminal ileum was the primary site of involvement in 40-50% of cases.(16) The different surgical procedures for treatment of CD include bypass, resection with primary anastomosis or staged procedures, stricturoplasty and permanent stoma as a last resort (10, 16), Kelly and Wolff stated that most surgeons advise excision rather than bypass to avoid its complications, (12 which in agreement with our series; 9 patients (81.8 %) operated upon had resection anastomosis and right hemicolectomy.. Laparoscopic total abdominal colectomy is technically challenging and requires a team approach but offers patients significant benefit in length of stay and surgical recovery. This operation can be effectively used with minimal morbidity in difficult, ill patients requiring urgent surgery. (28) In our study all surgery were performed by open technique due to lack of laparoscopic expertise. CONCLUSION: IBD is not rare disease and its treatment still remains the challenge despite growing knowledge about the disease, advances in medical treatment and surgical techniques. Indications and optimal timing for surgery are the mainstays of good outcome and are as important as the quality of medical therapy and surgery. Surgery continues to have a major role in the management of IBD

because it may save the patient's life, eliminate the long-term risk of cancer, and most important, abolish the disease. Finally proper assessment of IBD requires cooperation of gastroenterologists, radiologists, histopathologists and surgeons. REFERENCE: 1-Loftus EV, Clinical Epidemiology of Inflammatory Bowel Disease: Incidence, Prevalence, and Environmental Influences. Gastroenterology, 2004; 126(6)120417. 2-Guslandi M, Antibiotics for inflammatory bowel disease: do they work? Eur J Gastroenterol Hepatol. 2005, 17(2):145-7. 3-Schreyer AG, Seitz J, Feuerbach S, et al. Modern imaging using computer tomography and magnetic resonance imaging for inflammatory bowel disease (IBD) AU1. Inflamm Bowel Dis. 2004; 10 (1):45-54. 4-Hommes DW, van Deventer SJ Endoscopy in inflammatory bowel diseases. Gastroenterol. 2004; 126 (6):1561-73. 5-Geboes K. Crohn's disease, ulcerative colitis or indeterminate colitis, how important is it to differentiate? Acta Gastroenterol Belg. 2001; 64: 197-200. 6-Odze R: Diagnostic Problems and Advances in Inflammatory Bowel Disease. Mod Pathol. 2003; 16:347358. 7-Mahler,M., Bristol,I.J., Leiter-,E.H.,et al: Differential susceptibility of inbred mouse strains to dextran sulfate sodium-induced colitis. Am J Physiol. 1998; 274: G544–G551. 8-Warren BF: Classic pathology of ulcerative colitis and Crohn’s disease. J Clin Gastroenterol. 2004; 38: S33-S35. 9- Abreu MT: The pathogenesis of inflammatory bowel disease:

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‫‪Inflammatory Bowel Disease‬‬ ‫‪Hamdy M. Hussein et.al‬‬

‫‪SOHAG MEDICAL JOURNAL‬‬ ‫‪Vol.10 No.1 Jul.2006‬‬

‫اإليجاز العربى‬ ‫د‪.‬حمدى محمد حسيه ود‪.‬إيمان ُمحمد صالح الديهُ محمد‬ ‫قسم الغراؽخ العبنخ ِالجبصّلّعي–كليخ الطت ‪ -‬عبنعخ سَّبط‬ ‫رعزجر انراض الزُبثبد االنعبء نى االنراض الهزنًهٍ ِالًبرغهٍ هى االلزُبثهبد الهزنًهٍ الهز هر ح‬ ‫ثغههزء نههى عههما اغنعههبء فيههر نعرِ ههخ اغسههجبةا ِ نههى رَههم ريّا ُههب الهعرِ ههخ نههرض ر رؽههبد ال ّلههّو‬ ‫ِنرض كرِيز‪ِ ,‬كبو الغرض نى الجؾش إل بء الضّء لهٓ َه ٌ االنهراض الًهبر ح هٓ نًط زًهب نهى ه‬ ‫ر اسههخ اال ههراض االسبسههيخ للهههرض ِكهه ل الخؾّفههبد اله زلخههخ ِرِا ههٓ الزههم الغراؽههٓ ِ رقههٍ‬ ‫اله زلخخ ِ الخؾص الجبصّلّعي ل يسغخ ِالهضب خبد ثعم العهليبد الغراؽيخا‬ ‫ِقم اشزهلذ َ ٌ الم اسخ لٓ ‪ 29‬نريض ٓ الخزرح نى يًبير ‪ 2111‬ؽزهٓ نهبيّ ‪2116‬ا ِرجهيى نهى ؾهص‬ ‫اغيسغخ او ‪ 08‬نريض يعبيّو نى نرض ر رؽبد ال ّلّو ِ‪ 00‬نريض يعبيّو نى نرض كرِيزا‬ ‫ِقههم ضههي عهيههي الهراههٓ لم اسههخ الزههب يف الهراههٓ ِالخؾههص اوكليًي ههٓ التههبن ِك ه ل للخؾّفههبد‬ ‫الهعهليخ الرِريًيخ ِاغشعبد ال عبريخ ِ فهجغخ الجهب يّل لل ّلهّو ِ ؾهص الغُهبو الجهّلٓ ثبلاهجغٍ ِاغشهعخ‬ ‫الزليخزيّييخ لغهيي الهرآ ِثهًظب ال ّلّو ِالهسهز يم ِر ه يًهخ نهى ه الهًظهب نهى اغيسهغخ الغيهر‬ ‫جيعيخ ِقم رم ه رشعخ ن طعيخ ِرشعخ ييى نغًب يسٓ ٓ ثعض الؾبالد الضرِ يخا‬ ‫ِقههم ضههي عهيههي الهراههٓ للعهه ط الههمِاوٓ رِ الغراؽههٓ رِ ك َهههب نعههب ؽسههت يزيغههخ ؾههص االيسههغخ‬ ‫ِاالسزغبثخ للع ط المِاوٓ اِ يزيغخ االسز تبف الغراؽٓ العبع ٓ ثعض الؾبالدا‬ ‫ِقم كبيذ يزبوظ الجؾش كبلزبلٓ‪:‬‬ ‫كههبو نزّسههر هههر الهههريض ‪4‬ا‪ 49‬ههبل ِرراِؽههذ ا هههب َم نههب ثههيى ‪ 65 -02‬بنههب ِكبيههذ يسههجخ االيههبس‬ ‫لل كّ ‪0:2‬‬ ‫ِكبيذ اال راض االكضر شيّ ب آآلل ثبلجطى ثب ز ف ر عبرُب ٓ ‪ 27‬نريض ‪ِ %9330‬يزيه رنهّْ نهى‬ ‫الترط ٓ ‪ 04‬نهريض ‪ِ %4833‬ا هراواد ن ب يهخ نهى التهرط هٓ ‪ 01‬نراهٓ ‪ِ %3435‬اسهُب‬ ‫نهههزنى هههٓ ‪ 6‬نراهههٓ ثيًههههب رهضلهههذ اال هههراض الغيهههر نعّيهههخ هههٓ فهههّ ح هههماو هههٓ الهههّوو هههٓ ‪05‬‬ ‫نههريض‪ِ %5037‬شههؾّة اِ ههر رل ههٓ ‪ 00‬نههريض ‪ ِ %3739‬رههّ ل ثبلسههبقيى السههخلييى ههٓ ‪ 7‬نراههٓ‬ ‫ِنظبَر ثبلغلم ٓ ‪ 4‬نرآا‬ ‫ِقم ضي ص رخ ِ ترِو نريض‪ %7933‬للعه ط ثبالرِيهخ ‪ 08 ,‬نهريض ثز رؽهبد ال ّلهّو ِ ‪5‬نراهٓ‬ ‫ثهرض كرِيز ِار السزخ الجهبقيى نسزتهخٓ الطهّا (‪ )%2137‬ال هراض الزُهبة ثريزهّيٓ ؽهبر هٓ ‪4‬‬ ‫نرآ ِ ايسمار نعّْ ؽبر ٓ نريضيىا‬ ‫ِقههم اسههزغبة للعهه ط الههمِاوٓ ‪ 02‬نههريض‪01( %4034‬نههريض ر رؽههبد ال ّلههّو ِاصًههبو نههى نراههٓ‬ ‫كرِيز) ٓ ؽيى رم اللغّء للع ط الغراؽهٓ هٓ ‪ 07‬نهريض ‪ِ %5836‬كهبو الزهم الغراؽهٓ لهٓ الًؾهّ‬ ‫الزبلٓ‪ :‬إسزئاب الغزء االيهى نى ال ّلّو ٓ ‪ 7‬نراهٓ يعهبيّو نهى نهرض كرِيهز ِاسزئاهب عهزء هٓ‬ ‫االنعبء ٓ إصًيى نهى يعبيّو نى يخس الهرض هٓ ؽهيى رهم العه ط الغراؽهٓ هٓ ؽهبالد ر رؽهبد ال ّلهّو‬ ‫لٓ الًؾّ الزبلٓ‪:‬‬ ‫اسزئاب كلٓ لل ّلّو ِالهسز يم ني زؾخ شرط إفطًب يخ ل نعبء المقي خ ٓ ؽبلخ ِاؽمحا ِاسزئاب فيهر‬ ‫كبن لل ّلّو ٓ ‪ 7‬نرآ ني رّفي االنعبء المقي خ ني الهسز يما‬ ‫ِلم رؾمس ِ يهبد هٓ عهيهي ؽهبالد الم اسهخ هٓ ؽهيى رعهرض ‪ 4‬نراهٓ لهضهب خبد هٓ فهّ ح يبسهّ‬ ‫انعبوٓ ٓ نريض ِاؽهم ِقهم اعريهذ لهٍ هليهخ اسزئاهب للغهزء االيههى نهى ال ّلهّو ِص صهخ نراهٓ هٓ‬ ‫فّ ح رلّس ثبلغرػ ِيزظ ٓ اؽمَم زؼ ثغما الجطى ِاعريذ لٍ هليخ اف ػ عراؽٓا‬ ‫ِيسههز لص نههى َ ه ح الم اسههخ رو رنههراض إلزُبثههبد اغنعههبء ليسههذ ثههبلهرض الًههبر ههٓ نًط زًههب ِنههبوا‬ ‫عُم يهض رؾميب لٓ الرفم نى الزطّ اد الؾميضٍ ٓ الزت يص ِ الع ط المِاوٓ ِالغراؽهٓا ِارضهؼ‬ ‫ايضب رو الز ييم السليم لهرآ إلزُبثبد اغنعبء يؾزبط لزظب ر عُّر ريق جٓ نز بن نهى ر جهبء الغُهبو‬ ‫الُضهٓ ِاالشعخ ِالزؾلي الجبصّلّعٓ ل يسغخ ِالغراؽييىا‬ ‫‪03‬‬



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