Diarrhea syndrome. Secretory diarrhea Etiology and pathogenesis of diarrhea

Chronic diarrhea is a pathological process that is a sign of serious diseases of the digestive system.

Intestinal upset can last for several weeks, accompanied by flatulence, abdominal pain, and cramps.

For chronic diarrhea, treatment should be aimed not only at reducing its manifestations, but also at the underlying disease. In addition to drug therapy, patients are prescribed a special diet.

Etiology of chronic diarrhea

Chronic diarrhea can last for more than a month. If you do not find out the reasons that caused diarrhea in time, serious complications will develop that will lead to disruption of the functioning of all body systems.

Persistent diarrhea causes dehydration, loss of nutrients and essential electrolytes.

The causes of chronic diarrhea are varied and are divided into two large groups: infectious and non-infectious. In some cases, the cause of the disease may remain unknown.

The most common nature of the disease is infectious. There are gastrointestinal lesions caused by E. coli, salmonella and other pathogenic microbes and helminths. In addition, diarrhea in adults and children can develop after infection with viruses.

Infectious causes of chronic diarrhea:

• infection with protozoa and fungi - cryptosporidium, dysenteric amoeba, cyclospora, microsporidia, lamblia;
• bacterial infections - aeromonas, E. coli, salmonella, campylobacter;
• viral infection - rotavirus (stomach flu).

Chronic diarrhea of ​​a non-infectious form occurs due to poisoning with chemicals (alcohol, drugs, poisons), pathologies of the digestive system and prolonged stress.

The main causes of non-infectious diarrhea:

• acute and chronic pancreatitis;
• cystic fibrosis of the pancreas;
• colitis;
• proctitis;
• uncontrolled use of antibacterial drugs;
• pathology of the thyroid gland;
• excessive consumption of sweeteners;
• benign and malignant tumors;
• insufficient absorption of bile acids;
• impaired blood supply to the intestines;
• diverticulitis;
• Crohn's disease.

In addition to the reasons listed, chronic diarrhea can develop in people suffering from intolerance to gluten, a protein found in cereals.

In order for intestinal function to be restored, in this situation it is enough to exclude baked goods made from wheat and oatmeal from the diet.

Symptoms of pathology

The main symptom of chronic diarrhea is frequent loose bowel movements. During the day, the patient can visit the toilet more than 5 times.

Intestinal upset is often accompanied by pain, cramping, increased gas formation and mucus in the stool.

If diarrhea is caused by pathology of the small intestine, then defecation will occur with fatty, liquid stool.

If you have a disease of the large intestine, the volume of bowel movements will decrease, but the urge to go to the toilet will occur more often. The stool may contain impurities of pus, blood and mucous secretions.

Unlike diarrhea due to diseases of the small intestine, colonic disorder is accompanied by pain.

During inflammatory processes in the lower intestines (proctitis, colitis), patients experience frequent false urges to defecate.

Other observable signs are determined by the underlying disease that caused the onset of chronic diarrhea. Patients with colorectal cancer experience weakness, fatigue, and gradually lose weight.

Chronic diarrhea can give way to intestinal obstruction, and in severe cases, rupture of the intestinal wall develops.

In the later stages of development of cancer pathology, the patient is exposed to severe intoxication, cachexia and hyperthermia occur.

Inflammations that occur in the gastrointestinal tract and cause chronic diarrhea are characterized by hyperthermia of varying severity and other extraintestinal symptoms: stomatitis, arthralgia, and so on.

With neuroendocrine and endocrine pathologies of the intestine in sick people, hormonal disturbances can be noticed.

If diarrhea lasts, you should consult a doctor, especially if the pathology is accompanied by severe pain and blood in the stool.

If treatment is not started in time, the patient will develop dehydration, nausea, vomiting, fever and muscle cramps.

Due to nutritional deficiencies, the patient will become underweight. Only a doctor can determine the exact cause of the disease that caused chronic diarrhea based on the results of the examination.

Diagnosis of chronic bowel disorder

The doctor makes a diagnosis based on a conversation with the patient, in which he finds out the manifestations of the disease - how long the diarrhea lasts, whether there is pain and cramps, bloating and asymmetry of the abdomen, etc.

Then laboratory tests are prescribed, the results of which can determine how to treat diarrhea.

In chronic diarrhea, the most important indicators of the body are:

• complete blood count;
• serum calcium concentration;
• concentration of B vitamins;
• amount of iron;
• determination of the functioning of the thyroid gland and liver;
• screening for celiac disease.

Depending on the underlying cause that caused chronic diarrhea, patients are prescribed additional examinations to confirm or clarify the diagnosis and prescribe the correct treatment regimen.

The doctor may prescribe:

• ultrasound examination of the abdominal organs;
• X-ray examination of the abdominal cavity;
• colonoscopy with collection of intestinal tissue for biopsy.

Since chronic diarrhea is not an independent disease, but a symptom of a pathology of internal organs, the main goal of diagnosis is to identify the main cause of diarrhea.

Based on the results of the examination, the gastroenterologist will determine what diseases affect the small or large intestine.

Microbiological analysis of stool helps determine the presence of an inflammatory process in the intestines and the type of pathogenic organisms.

A scatological examination of patients with chronic diarrhea reveals amilorrhea, steatorrhea, and creatorrhea.

During irrigoscopy for cancerous tumors and polyps, all sorts of filling defects are found.

With the help of sigmoidoscopy and colonoscopy, it is possible to examine the intestinal wall, the presence and appearance of ulcerations, polyps and other neoplasms.

If there is a special need, during the examination the specialist collects tissue samples for biopsy.

If you suspect a hormonal imbalance or thyroid pathology, consult an endocrinologist; if you have uremia, consult a urologist.

Pathology treatment regimen

To cure chronic diarrhea or reduce its manifestations, you need to undergo all the necessary examinations and find out the cause of the unpleasant symptom.

The therapeutic regimen includes antibacterial drugs, probiotics and adsorbents. During treatment, patients must follow a special diet.

Antibacterial drugs are prescribed to kill microorganisms that cause chronic diarrhea. During treatment, patients are prescribed antimicrobial and antiseptic agents.

The drug contains dodecyl sulfate and tiliquinol. The course of taking Entoban lasts 6–10 days, 4–6 capsules per day.

The next product, Mexaform, contains kaolin, streptomycin, sodium citrate and pectin. The drug is prescribed 1 tablet three times a day for a week.

The Depental-M suspension, which contains metronidazole and furazolidone, also has bactericidal properties. Take 1 scoop after each meal for 5 days.

Intestinal disorders of various natures can be effectively corrected with the help of probiotics.

The drug Baktisubtil contains cultures of beneficial microbes needed by the intestines and calcium carbonate. The product should be taken twice for 10 days, 1 capsule.

After a course of antibiotics, patients are prescribed Enterol, Linex and Bificol to restore the natural ratio of microorganisms in the intestines.

Taking these medications should continue for at least one month. Hilak-Forte drops, which contain waste products of lactobacilli, can reduce the proliferation of pathogenic bacteria.

Smecta is used as an enveloping absorbent for the treatment of chronic diarrhea.

Kaopectate solution has similar properties. The drug binds and removes toxic substances and harmful microbes from the intestines.

For treatment to be successful, patients must follow a diet. Proper nutrition will compensate for the lack of nutrients in the body and help normalize natural intestinal motility.

For quotation: Parfenov A.I. DIARRHEA // Breast cancer. 1998. No. 7. P. 6

The etiology and pathogenetic mechanisms of secretory, osmotic, dyskinetic and exudative diarrhea are considered. Algorithms have been proposed to identify the disease that caused acute or chronic diarrhea. A treatment regimen for diarrhea is recommended depending on the predominant pathogenetic mechanism.

The etiology and pathogenetic mechanisms of secretory, osmotic, dyskinetic and exudative diarrhea are considered. Algorithms have been proposed to identify the disease that caused acute or chronic diarrhea. A treatment regimen for diarrhea is recommended depending on the predominant pathogenetic mechanism.

The paper deals with the etiology and pathogenetic mechanisms of secretory, osmotic, dyskinetic, and exudative diarrhea, proposes algorithms to detect a disease underlying acute or chronic diarrhea, recommends a treatment regimen for diarrhea in relation to a prevalent pathogenetic mechanism.

A.I. Parfenov - Doctor of Medical Sciences, Head. Department of Pathology of the Small Intestine, Central Research Institute of Gastroenterology

A.I.Parfenov, MD, Head, Department of Small Bowel Pathology, Central Research Institute of Gastroenterology

Introduction

The traditional idea that the normal frequency of bowel movements should be once a day, in the morning, is not always true. Defecation is subject to considerable variability and numerous extraneous influences. This bowel function varies greatly with age and is influenced by individual physiological, dietary, social and cultural factors. In healthy people, the frequency of stool can vary from 3 times a day to 3 times a week, and only changes in the volume and consistency of stool, as well as the admixture of blood, pus or undigested food, indicate illness.

Definition

The stool weight of healthy adults ranges from 100 to 300 g/day, depending on the amount of fiber in food and the volume of water and undigested substances remaining in it. Diarrhea is frequent or single bowel movement with the release of liquid feces. Diarrhea can be acute if its duration does not exceed 2-3 weeks, and chronic if loose stools continue for more than 3 weeks. The concept of chronic diarrhea also includes systematically profuse stools, the weight of which exceeds 300 g/day. However, for people who eat foods rich in plant fiber, this stool weight may be normal. Watery diarrhea occurs when the amount of water in the stool increases from 60 to 70%. In patients with impaired absorption of nutrients, polyfecal matter predominates, i.e. an unusually large amount of feces consisting of undigested food debris. In case of disturbances of intestinal motor function, stool may be frequent and liquid, but its daily amount may not exceed 200 - 300 g. Thus, an initial analysis of the characteristics of diarrhea makes it possible to establish the cause of the increase in the amount of feces and can facilitate diagnosis and the choice of treatment method.

Pathophysiology of diarrhea

Diarrhea is a clinical manifestation of impaired absorption of water and electrolytes in the intestine. The pathogenesis of diarrhea of ​​various etiologies has much in common. The ability of the small and large intestines to absorb water and electrolytes is enormous. Every day a person receives about 2 liters of water from food. The volume of endogenous fluid entering the intestinal cavity as part of digestive secretions reaches an average of 7 l (saliva - 1.5 l, gastric juice - 2.5 l, bile - 0.5 l, pancreatic juice - 1.5 l, intestinal juice - 1 l). Of the total amount of liquid, the volume of which reaches 9 liters, only 100 - 200 ml, i.e. about 2% is excreted in feces, the rest of the water is absorbed in the intestine. Most of the liquid (70 - 80%) is absorbed in the small intestine. From 1 to 2 liters of water enters the colon during the day, 70% of it is absorbed, and only 100 - 150 ml is lost in feces. Even minor changes in the amount of liquid in the stool lead to a change in its consistency (unformed or harder than normal).
Table 1. Pathogenesis of diarrhea

Transport (absorption and secretion) of water in the intestine depends on the transport of electrolytes. Water and electrolytes are absorbed and secreted by enterocytes and colonocytes. The villous epithelium ensures the absorption of sodium, chlorine and water ions. Their secretion occurs in the crypt epithelium. During the day, 800 mmol of sodium, 100 mmol of potassium and 700 mmol of chlorine enter the intestines with food and juices. Water absorption is a passive secondary process associated with the transport of ions, primarily sodium. Some substances, such as glucose and amino acids, stimulate the absorption of ions and water. In the small intestine, passive transport of water and ions predominates, which is due to the high permeability of enterocyte membranes. Absorption of water and ions occurs through the intercellular spaces. In the ileum and colon, sodium is absorbed through an energy-dependent mechanism, i.e. actively. This mechanism ensures the transport of sodium against the chemical concentration gradient, the negative electrical charge of the mucous membrane, and in some cases against the flow of fluid. Active sodium transport is stimulated by d-hexoses and some amino acids. In this case, the transport mechanism involves a common brush border transporter for glucose, amino acid and sodium.
Table 2. Medicines that cause diarrhea

The final retention of sodium and water occurs in the colon. Up to 70% of sodium entering the colon is absorbed. Active transport of sodium is carried out in the colon electrogenically using a sodium pump or a combination of sodium with a hydrogen ion, chlorine or bicarbonate. Sodium, actively absorbed from the lumen of the colon into the paracellular water channels, increases the osmotic pressure in them, and consequently, the hydrostatic pressure in them. An increase in hydrostatic pressure causes absorption of water through the low-permeability membrane of capillaries into the blood plasma. So, water is absorbed passively, following sodium. The colon can absorb up to 5 liters of water per day. If more fluid enters it, diarrhea appears. Such disorders arise due to disorders of digestion, absorption, secretion and intestinal motility. In this case, the small and large intestine must be considered as a single physiological unit.

Etiology and pathogenesis

In table 1 The main types of diarrhea and the pathogenetic mechanisms underlying them are shown. Four mechanisms are involved in the pathogenesis of diarrhea: intestinal hypersecretion, increased osmotic pressure in the intestinal cavity, impaired transit of intestinal contents and intestinal hyperexudation. The mechanisms of diarrhea are closely related, however, each disease is characterized by a predominant type of ion transport disorder. This explains the features of the clinical manifestations of various types of diarrhea.

Secretory diarrhea

Secretory diarrhea develops due to increased active secretion of sodium and water into the intestinal lumen. The main activators of this process are bacterial toxins (for example, cholera endotoxin), enteropathogenic viruses, some drugs and biological active substances. A typical example of secretory diarrhea is diarrhea due to cholera. The secretory effect is mediated by the mediator 3"-5"-AMP. Cholera endotoxin and many other substances increase the activity of adenyl cyclase in the intestinal wall with the formation of cAMP. As a result, the volume of secreted water and electrolytes increases. This secretes a large amount of sodium.
Table 3. Principles of treatment for different types of chronic diarrhea

Secretory diarrhea is also caused by free bile acids and long-chain fatty acids, secretin, vasoactive peptide, prostaglandins, serotonin and calcitonin, as well as laxatives containing anthroglycosides (senna leaf, buckthorn bark, rhubarb) and castor oil.
The secretory form is characterized by painless, profuse watery diarrhea (usually more than 1 liter). If there is a malabsorption of bile acids or poor contractile function of the gallbladder, the feces usually become bright yellow or green in color. The osmolar pressure of intestinal contents during secretory diarrhea is significantly lower than the osmolar pressure of blood plasma.

Hyperosmolar diarrhea

Hyperosmolar diarrhea develops due to an increase in the osmotic pressure of the chyme. An increase in osmotic pressure in the intestinal cavity is observed with disaccharidase deficiency (for example, with lactose intolerance), with malabsorption syndrome, with an increased intake of osmotically active substances into the intestine (salt laxatives containing magnesium and phosphorus ions, antacids, sorbitol, etc.).
With hyperosmolar diarrhea, the stool is profuse (polyfecal matter) and may contain a large amount of semi-digested food residue (steatorrhea, creatorrhoea, etc.). Its osmotic pressure is higher than the osmotic pressure of blood plasma.

Hyper- and hypokinetic diarrhea

An important factor in the development of diarrhea is disruption of the transit of intestinal contents. Laxatives and antacids containing magnesium salts contribute to an increase in the transit rate. An increase and decrease in intestinal motor activity is especially often observed in patients with neurogenic diarrhea and irritable bowel syndrome. With hyper- and hypokinetic diarrhea, the stool is liquid or pasty, not abundant. The osmotic pressure of intestinal contents approximately corresponds to the osmotic pressure of blood plasma.

Hyperexudative diarrhea

Hyperexudative diarrhea occurs due to the “dumping” of water and electrolytes into the intestinal lumen through the damaged mucous membrane and is accompanied by the exudation of protein into the intestinal lumen. This type of diarrhea is observed in inflammatory bowel diseases: Crohn's disease and ulcerative colitis, intestinal tuberculosis, salmonellosis, dysentery and other acute intestinal infections. Hyperexudative diarrhea can also be observed with malignant neoplasms and ischemic intestinal diseases. With hyperexudative diarrhea, the stool is liquid, often with blood and pus. The osmotic pressure of feces is often higher than the osmotic pressure of blood plasma.

Clinical features of diarrhea

There are acute and chronic diarrhea.
Acute diarrhea. Diarrhea is considered acute when its duration does not exceed 2 to 3 weeks and there is no history of similar episodes. Its causes include infections, inflammatory processes in the intestines and medications. Acute infectious diarrhea is characterized by general malaise, fever, lack of appetite, and sometimes vomiting. It is often possible to establish a connection with the consumption of poor quality food and travel (tourist diarrhea). Features of the clinical picture depend on the type of causative agent of acute intestinal infection. Thus, vomiting is more typical for foodborne infections caused by staphylococci, and almost never occurs in patients with salmonellosis and dysentery. Bloody, loose stools indicate damage to the intestinal mucosa by pathogenic microbes such as Shigella Flexner and Sonne, Campylobacter jejuni or E. coli with enteropathogenic properties. Acute bloody diarrhea may be the first manifestation of ulcerative colitis and Crohn's disease. In the acute form, the patient's condition is serious due to intoxication and abdominal pain.

Many medications cause diarrhea. In table 2 lists the main drugs that can cause diarrhea. In pseudomembranous colitis, which develops as a result of antibiotic therapy, a severe form of diarrhea occurs, characterized by sudden, severe watery diarrhea, sometimes with a small amount of blood in the stool, as well as high fever. In other cases, diarrhea does not worsen the general condition and stops after stopping the medication.
Examination of the patient allows you to assess the degree of dehydration. With a significant loss of water and electrolytes, the skin becomes dry, its turgor decreases, and tachycardia and hypotension are observed. Due to large losses of calcium, there is a tendency to cramps, which may be preceded by the “muscle roller” symptom observed when pinching or hitting the biceps brachii muscle. Along with the usual physical examination, it is necessary to examine the patient’s stool and conduct a proctological examination. The presence of blood in the stool, anal fissure, paraproctitis or fistulous tract gives reason to assume that the patient has Crohn's disease. During stool microscopy, it is of great importance to identify inflammatory cells, fat, protozoa and worm eggs.
Sigmoidoscopy allows you to make a diagnosis of ulcerative colitis (bleeding, easily vulnerable mucous membrane, often with erosive-ulcerative changes), dysentery (erosive proctosigmoiditis), as well as pseudomembranous colitis based on the detection of characteristic dense fibrinous deposits in the form of plaques. The absence of plaques does not yet exclude the possibility of this complication of antibacterial therapy, since pathological changes can be localized in the proximal parts of the colon.

Treatment

Diarrhea is not a disease, but a symptom. Therefore, for etiological or pathogenetic treatment, nosological diagnosis is necessary. In table 3 diseases with similar mechanisms of diarrhea are listed and principles of treatment for each type of diarrhea are outlined. As can be seen from table 3 , the treatment of diarrhea has some features depending on its pathogenesis. Some therapeutic approaches are common to each of the 4 types of diarrhea. These include diet, prescription of antibacterial drugs and symptomatic agents (adsorbents, astringents and enveloping substances).

Diet

For intestinal diseases accompanied by diarrhea, nutrition should help inhibit peristalsis and reduce the secretion of water and electrolytes into the intestinal lumen. The set of products in composition and quantity of nutrients must correspond to the enzymatic capabilities of the pathologically altered small intestine. In this regard, with diarrhea, the principle of mechanical and chemical sparing is always observed to a greater or lesser extent, depending on the severity of the process. During the acute period of diarrhea, foods that enhance the motor-evacuation and secretory functions of the intestine are excluded. Diet No. 4b almost completely meets these requirements. It is prescribed during periods of exacerbation of diarrhea. A physiological diet with a limitation of table salt to 8 - 10 g/day, a moderate limitation of mechanical and chemical irritants of the gastrointestinal tract, the exclusion of foods that increase diarrhea, fermentation and putrefaction in the intestines, as well as strong stimulants of gastric secretion. All dishes are steamed and eaten pureed.

Antibacterial drugs

Bacterial preparations

Some bacterial drugs can be prescribed for diarrhea of ​​various origins as an alternative therapy. These include bactisubtil, linex and enterol.
Bactisubtil is a bacterial culture IP-5832 in the form of spores with the addition of calcium carbonate, white clay, titanium oxide and gelatin. For acute diarrhea, the drug is prescribed 1 capsule 3-6 times a day; in severe cases, the dose can be increased to 10 capsules per day. For chronic diarrhea, bactisubtil is prescribed 1 capsule 2 - 3 times a day. The drug should be taken 1 hour before meals.
Enterol contains a lyophilized culture of Saecharamyces doulardii. The drug is prescribed 1 - 2 capsules 2 - 4 times a day, the course of treatment is 3 - 5 days. Enterol is especially effective for diarrhea that develops after antibiotic therapy.
Other bacterial drugs (bifidumbacterin, bificol, lactobacterin, linex, acylact, normaflor) are usually prescribed after a course of antibacterial therapy. The course of treatment with bacterial drugs can last up to 1 - 2 months.
Hilak-forte is a sterile concentrate of metabolic products of normal intestinal microflora: lactic acid, lactose, amino acids and fatty acids. These substances help restore the biological environment of the intestine, necessary for the existence of normal microflora, and suppress the growth of pathogenic bacteria.
Hilak-forte is prescribed 40-60 drops 3 times a day. After 2 weeks, the dose of the drug is reduced to 20-30 drops 3 times a day and treatment is continued for another 2 weeks.

Symptomatic remedies

This group includes adsorbents that neutralize organic acids, astringents and coating agents. These include smecta, attapulgite, tannacomp.
Smecta contains dioctahedral smectite - a substance of natural origin that has pronounced adsorbing properties and has a protective effect on the intestinal mucosa. Being a stabilizer of the mucous barrier and having enveloping properties, smecta protects the mucous membrane from toxins and microorganisms. Prescribed 3 g (1 sachet) 3 times a day 15 - 20 minutes before meals in the form of a mash (the contents of the sachet are dissolved in 50 ml of water). Given the pronounced adsorbing properties of the drug, smecta should be taken separately from other drugs.
Attapulgite is a natural purified aluminum-magnesium silicate in colloidal form. Attapulgite has a high ability to adsorb pathogenic pathogens and bind toxic substances, thereby helping to normalize the intestinal flora. The drug is not absorbed from the gastrointestinal tract and is used for acute diarrhea of ​​various origins. The initial dose for adults is 4 tablets, then after each stool another 2 tablets. The maximum daily dose is 14 tablets. The tablets should be swallowed without chewing, with liquid. The duration of treatment with attapulgite should not exceed 2 days. The drug interferes with the absorption of simultaneously prescribed drugs, in particular antibiotics and antispasmodics, so the interval between taking attapulgite and other drugs should be several hours.
Tannacomp- combination drug. It contains tannin albuminate (0.5 g) and ethacridine lactate (0.05 g). Tannin albuminate (tannic acid combined with protein) has astringent and anti-inflammatory properties. Ethacridine lactate - antibacterial and antispastic. Tannacomp is used for the prevention and treatment of diarrhea of ​​various origins. To prevent diarrhea among tourists, the drug is prescribed in 1 tablet. twice a day, for treatment - 1 tablet. 4 times a day. Treatment ends with the cessation of diarrhea. For chronic diarrhea, the drug is prescribed in 2 tablets. 3 times a day for 5 days.
Calcium polycarbophil used as a symptomatic remedy for non-infectious diarrhea. The drug is prescribed 2 capsules per day for 8 weeks.
To treat hologenic diarrhea caused by bile acids, ion exchange resins - cholestyramine, vazazan, questran - are successfully used.
Cholestyramine Prescribe 4 g 2 - 3 times a day for 5 - 7 days.

Motor regulators

Loperamide hydrochloride is widely used to treat diarrhea, which reduces intestinal tone and motility, apparently due to binding to opiate receptors. Unlike other opioids, loperamide does not produce central opiate-like effects, including blockade of small intestinal propulsion. The antidiarrheal effect of the drug is realized through the m-opiate receptors of the enterin system. There is evidence that direct interaction with enteric opiate receptors alters epithelial cell function by reducing secretion and improving absorption. The antisecretory effect is accompanied by a decrease in intestinal motor function. For acute diarrhea, the initial dose of loperamide is 2 capsules, then 1 (0.002 g) capsule is prescribed after each bowel movement; in the case of loose stools - until the number of bowel movements is reduced to 1 - 2 per day. The maximum daily dose for adults is 8 capsules. If normal stool appears and there are no bowel movements within 12 hours, treatment with loperamide should be discontinued. Possible side effects: dry mouth, abdominal pain, bloating, nausea, vomiting, constipation, weakness, drowsiness, dizziness and headache. Contraindications: ulcerative colitis, pseudomembranous colitis, acute dysentery. Loperamide should be prescribed with extreme caution to patients with impaired liver function.
Currently, a search is underway for drugs that affect the processes of absorption and secretion in the intestine. Somatostatin has these properties. This hormone increases the rate of absorption of water and electrolytes, reduces the concentration of vasoactive intestinal peptides in the blood and reduces the frequency of bowel movements and fecal weight.
Octreotide- a synthetic analogue of somatostatin - can be successfully used for severe forms of secretory and osmotic diarrhea of ​​various origins; it is prescribed 100 mcg subcutaneously 3 times a day.
For diarrhea of ​​various origins, calcium antagonists - verapamil and riodipine - can be used.
In some cases, treatment can last several weeks or even months. In cases of diarrhea after intestinal resection or colon hyperkinesia, treatment is continued until 3 - 4

In pra-k-ti-ke ga-st-ro-en-te-ro-lo-ga di-a-reya is one of the most widespread sym-pto-mov , which can be a sign of many different personal conditions. From the point of view of the existing di-ag-no-sti-che-skih cr-te-ri-ev di-a-reya - pa-to-lo-gi- a Czech condition, which under-ra-zu-me-va-et from both the form of the ka-la and the cha-s-to- you de-fe-ka-tion. First of all, this is the study of stool (more than 3 times per day), in addition, you de-le-liquid feces masses (water or porridge) with a volume of more than 200 ml.

They make a spicy and chronic di-a-ray. Symptoms of acute di-a-rei can manifest themselves from a few days to 4 weeks. In most cases, episodes of acute di-a-rhea are associated with a virus, ba-k-te-ri-al or pa-ra-zi-tar-noy in-va-zi-ey. With chronic di-a-ree, the sim-pto-we are on blue-yes for more than 4 weeks.

For-bo-le-va-niya or-ga-nov pi-sche-va-re-niya, as a rule, with skoy di-a-re-ey. These include: at-ro-fi-che-ga-st-ri-you with a sub-wife of se-k-re-tor-function of the stomach- ka, according to stga-st-ro-re-zek-tsi-on-nye and po-stva-go-mi-che-dis-structures, chronic pan-crea- a-tit with an external-not-se-to-re-tor-no-to-s-that-accuracy under-the-same-lu-daughter-le-zy, bi-li-ar -nye di-s-functions and according to-stho-le-tsi-ste-to-mi-che-sky syn-drome, chron-ni-che-skie for-bo-le-va-nia ne -che-ni, pa-to-lo-gia of the small intestine, so-pro-in-well-da-yu-sha-ya-sha-vi-ti-em sin-dro-ma mal- absorption, ba-k-te-ri-al-naya con-ta-mi-na-tion of the small intestine, ulcerative-venous colitis and Cro-n's disease, opu -ho-li thin and thick intestines, ishe-mi-che-sky and pseudo-mem-b-ra-nos-ny ko-li-you, func-ci-o-nal- ny for-bo-le-va-niya k-shech-ni-ka, mountain-mo-nal-but-a-k-tiv opu-ho-ho-li-lu-doch-no-ki-shech- no-go tra-k-ta (gastrointestinal tract).

Is it possible that you are pa-to-ge-ne-ti-che-skih va-ri-an-ta di-a-rei.

• Se-k-re-tor-naya di-a-reya, equipped with direct sti-mu-la-tsi-ey se-k-re-tion of water and electricity in pro- gut light. This type of di-a-rei ha-ra-k-te-ri-zu-et-sya with frequent liquid stool with a volume of more than 1000 ml per day. It occurs primarily with ba-k-te-ri-al-noy and viral infection (ho-le-ra, sal- mo-nell-lez, ro-ta-vi-rus-naya and HIV-infection), as well as with hor-mo-nal-active tumors - apu- do-mah (ga-st-ri-no-ma, VI-Po-ma, kar-tsi-no-id).
• Os-mo-ti-che-skaya di-a-rea is connected with the os-mo-ti-che-da-v-le-niya in the po-lo-s-ti-guts, which leads to the release of water into the light of the intestine. The volume of liquid fecal masses ranges from 500 to 1000 ml per day. Os-mo-ti-che-skaya di-a-reya has me-s-with-chro-no-che-sky pan-crea-a-ti-te with external-not-se-to-re- tor-no-to-with-that-accuracy, fer-men-to-pa-ti-yah, glut-te-no-voy en-te-ro-pa-tii, bo-lez- no Whip-p-la, dem-ping-sin-dro-me, ba-k-te-ri-al-noy kon-ta-mi-na-tion of the small intestine, with-me-ne- Institute of os-mo-ti-che-weak-tel-nyh.
• Ex-su-da-tiv-naya di-a-reya connected with ex-su-da-qi-ey in the lumen of the intestines of blood, mucus, pus on the background of non-vo-pa-li-tel-nyh from -me-ne-niy mucus-stay shell-ki. The volume of liquid feces is 200-500 ml per day. This type of di-a-rei develops with an ulcer-venous co-li-te, bo-lez-ni Kro-na, ishe-mi-che-sk and pseudo-meme -b-ra-noz-nom-ko-li-those, opu-ho-lyah of the colon-stay intestines, radiant co-li-tahs, dysbacteriosis, di-ver-ti-ku-le-ze fat guts with di-ver-ti-ku-li-tom.
• Mo-tor-naya di-a-reya ha-ra-k-te-ri-zu-et-xia us-ko-re-ni-eat the transit of a food bolus on the background of a non-active engine -noy function of the intestines. As a matter of fact, with this form of di-a-rei there is no indication: the volume of liquid fecal masses for per day is no more than 200-300 ml. Motor-tor-di-a-reya ti-pich-na for sin-dro-ma raz-dra-zhen-no-go k-shech-ni-ka (IBS), functional-ci-o-nal-noy di-a-rei, intestinal dysbiosis, from-me-cha-et-sya in patients with va-go-to-mia.

So-s-that-precisely, the hro-ni-che-skaya di-a-reya is a clinical sign of syn-dro-ma mal-ab- sorption. This term has been used for many years in foreign countries. Syn-d-rum mal-ab-sorption ha-ra-k-te-ri-zu-et-sya dis-organization of all-sy-va-niya in the small intestine pi-ta- bodily substances and on-the-line metabolic processes. In the basis of the development of this syn-dro-ma there are not only mor-pho-lo-gi-che-s-me-nots of mucus shells -ki of the small intestine, but also on the enzymatic systems of the gastrointestinal tract, the motor function of the intestine, and so on -the same dis-structure of special-purpose transport-mechanisms.

In the father-che-st-ven-noy cli-che-great-to-ti-ke, the term “chro-ni-che-en-te-rit” is more often used " One gi-s-s-s-s-s-s-s-study of the majority of such chronically ill patients the inflammation is not revealed.

Malabsorption syndrome can be caused by any of the layers of the wall of the small intestine. Absorption disorders can be cha-s-tich-ny (absorption of certain nutrients is difficult) or general (difficulty-not-absorbing). sorption of all products per-re-va-ri-va-niya food).

Are there primary and secondary malabsorption? Primary mal-absorption is based on enzymes, which are subsequently caused by changes construction of ab-sor-btiv-no-go epi-te-lia (glu-te-no-va-disease, un-per-re-no-si-most di-sa-ha-ri- dov, kol-la-ge-no-vaya sprue, tro-pi-che-skaya sprue).

Secondary malabsorption is caused by damage to various layers of the walls of the small intestine, as well as other organs -new (illness of Whip-p-la, Kro-na, chronic en-te-rit, intestinal re-section, pa-to-logia under-the-lu -daughter-le-zy, re-section of the stomach, from-ra-in-le-nia, radiation-induced-injuries, ami-lo- and-doses, infectious and viral-related conditions, im-mu-but-de-fi-cytic conditions) .

Let us remind you about the functional morphology of the small intestine. It consists of four shells: mucus, under mucus, muscle and grey.

The mucus shell forms spiral or circular folds, due to which the suction the surface increases by 2-3 times. In addition, the circular dis-position of the folds is capable of re-me-shi-va-nu-hi-mu- sa and keep him in the ob-ra-zu-yu-shah-shahs. There are a lot of mucus on the top. They are in front of you with your own plate, covered with a column of epi-te -li-eat, bo-ka-lo-vid-us cells, one-layer-nym epi-te-li-em, 90% of it -in-la-yut en-te-ro-tsi-you with a precise CHIC-po-lo-living-ka-em-coy, shaped-by-van-mi-k -ro-vor-sin-ka-mi. On the top-no-sti ka-zh-do-go en-te-ro-tsi-ta dis-po-lo-zhe-but 1500-2000 mi-k-ro-vor-si-nok, co- then increase the entire surface of the intestine by 30-40 times (up to 200 m2). The alkali ka-em is characterized by the high activity of an alkali phosphate. Among the epi-te-lya there are a large number of cells.

The crypts are based on single cells with large eo-zi-no-fil-mi gra-nu-la-mi . These are the cells of Pa-ne-ta, the na-mi-na-yu-schy aci-nar-nye cells under the same-lu-daughter-le-zy. There is evidence that the cells of Pa-ne-ta should com-pen-si-ro-set the ek-zo-k-rin-function under the same -daughter-noy-le-zy (so-hold-zhat trip-syn, fo-s-fo-li-pa-zu, in-gi-bi-tor trip-si-na). In addition, the cells of Pa-ne-ta co-hold li-zo-tsim, im-mu-nog-lo-bu-lin A, i.e. you perform a ba-k-te-ri-cide function.

Epi-te-li-al-nye cells, on-the-covering parts of the intestines, occupied with drink-e-ro-you plaque-ka- we are different in structure and function; they are called mem-b-ra-noz-ny-mi cells (M-cells). Mi-k-ro-vor-si-nok on them is small, the activity of enzymes is lower. M-cells grab and trans-port-ti-ru-yet an-ti-genes from the intestinal lining to the lymphoid tissue neither. In addition, there are many en-do-k-rin cells in the small intestine.

Metabolic changes during syn-dro-me mal-absorption include metabolic disorders: whiteness (according to -te-rya mass-sy te-la, gi-po-pro-te-i-not-miya, gi-po-al-bu-mi-ne-miya, father-but-as-tsi-ti-che -sky syn-drome, di-s-ba-lance con-cen-t-ra-tion ami-no-kis-lot in the blood-sy-mouth, high-high-po- te-rya white with ka-lom - kre-a-to-reya), coal-le-water-no-go (on-ru-she-nie hydro-li-za and all-sy-va -niya ug-le-vo-dov, hy-pog-li-ke-miya, flat gli-ke-mi-che-che-curves, from-precise image -nie in the ki-shech-ni-ke or-ga-ni-che-skih ki-s-lot) and lipid-no-go (by-hu-de-nie, reduction of co-der -zha-niya li-pi-dov in the blood, st-a-to-rhea due to the increased content of fatty acids in the stool- lot and soap). Closely related to all fat absorption of Ca ++, Mg ++ and vitamin D. Reduction of all sy-va-niya Ca ++ and Mg ++ equip-layer-in-le-but with-ra-zo-va-ni-em non-soluble calcium-e-outs and magic -no-e-soaps put-and-mo-de-st-viya of these salts with non-ab-sor-bi-ro-van-ny-mi in the intestine fat-ny-mi ki-s-lo-ta-mi. De-fi-cit vi-ta-mi-na D can be explained by its dis-solution in non-absorbed fats.

With malabsorption, there are symptoms associated with the de-fi-ci-t of elec-t-ro-li-tov, mi-k-ro-ele-men- tov, vi-ta-mi-nov. It may be possible to develop a plus-rig-lan-du-lar-naya inaccuracy (gi-po-fi-zar-but-over-in-Chech-ni -ko-vaya, po-lov-vye dis-structures, decrease in the function of the thyroid gland). On the contrary, the functional for-bo-le-va-nia of the intestines never co-occur exchanging us on-ru-she-ni-i-mi, the general condition of pain-but-doesn’t suffer. One-on-one new diagnosis -rei) - always very responsive and serious for-da-cha, tre-bu-yu-sh-cha-is-kly-che-niya or-ga-ni-che -skaya pa-to-logia of the intestines, in-fek-tsi-on-nyh and gli-st-st-for-bo-le-va-ny. In the differential-fe-ren-tsi-al-noy di-ag-no-sti-ke, you should use the so-called “sympto-we are worried” -gi" (the-te-re-weight, whether-ho-rad-ka, blood in the stool, an-mia, severe family history of cancer thick guts, le-che-nie an-ti-bio-ti-ka-mi). Su-sche-st-vu-yut di-ag-no-sti-che-cry-the-rii, po-z-vo-la-yu-shchie diff-fe-ren-ci-ro-vat IBS and or-ga-ni-che-skie for-bo-le-va-nia of the gastrointestinal tract:

• short anamnesis for-bo-le-va-niya (less than 2 years);
• po-sto-yan-naya di-a-reya;
• di-a-ray at night;
• spicy na-cha-lo di-a-rei;
• according to the body mass (5 kg or more);
• accelerated rate of settling of eri-t-ro-tsi-tov;
• low level of he-mo-glo-bi-on blood;
• low level of al-bu-mi-na blood;
• positive test for laxatives in the urine;
• po-li-fe-ka-lia;
• pa-to-logia found in the bio-pta-those intestines;
• pa-to-lo-gi-ya, discovered during re-k-to-ro-ma-no-sco-pii.

Sov-re-men-naya di-ag-no-sti-ka for-bo-le-va-niy or-ga-nov pi-sche-va-re-niya, as-so-ci-i-ro- baths with di-a-re-ey, s-ta-precisely complex and in- cludes some cli-no big ne -re-chen la-bo-ra-tor-nyh and in-st-ru-men-tal-nyh methods.

First of all, this is a general clinical analysis of blood and urine, co-pro-lo-gi-che-che-study, bio-chi-mi- Czech blood analysis (total protein and protein fractions, glucose, blood lipids, electrolytes, serum -ro-precise-le-zo, pe-che-night tests, pan-crea-a-ti-che-enzymes), ECG, mi-k-ro-bio-lo -gi-che-study-to-va-nie ka-la for the elimination of infection-tsi-on-go ge-not-for-di-a-rei, op- re-de-le-nie ela-sta-zy-1 in ka-le. To assess the function of the stomach, pH is measured. Rent-ge-no-lo-gi-che-study-includes-study-of-lud-ka and pass-sazh ba-ria in tone -koy gut-ke, if not-about-ho-di-mo-sti - ir-ri-go-sko-piyu.

The standard di-ag-no-sti-ki for diarrhea includes ultrasound of the organ-ga-nov of the pi-sche-va-re-niya (liver, bi-li-ar-tract, sub- zhe-lu-doch-naya zhe-le-za, intestine). With chronic di-a-ree, eso-fa-go-ga-st-ro-du-o-de-no-sco-pia with bio-psy from no-s-ho-dya-from-de-la two-on-d-tsa-ti-per-st-intestines or pro-xi-small-but-go from-de-la then -shchee intestines for gi-s-to-lo-gi-che-sko-go-study-to-va-niya, ka-che-st-ven-no-go op-re-de-le- niya ak-tiv-no-sti fer-men-ta la-k-ta-zy in bio-pta-te, ba-k-te-rio-lo-gi-che-s-sle-do- va-niya (for di-ag-no-sti-ki ba-k-te-ri-al-noy kon-ta-mi-na-tion of the small intestine); to eliminate pa-to-lo-gia of the colon - co-lo-no-skopia with os-mo-t-rum ter-minal-no-go from- de la small intestine. In recent years, to assess the status of the intestine (especially the small intestine), Xia research with the help of video-cap-sul.

Re-breathing water test using gas from-precise ba-k-te-ri-al growth (ba-k-te-ri-al-nu-con-ta-mi-na-tion) in the small intestine, fer -men-to-pa-tii, motor function of the small intestine.

Currently, a breathable carbon test with the C 13 isotope has been used to assess the functionality -th state of the ge-pa-to-tsi-tov, external-not-se-to-re-tor-function of the sub-gland-gland, identifying enzymes, ba-k-te-ri-al-noy con-ta-mi-na-tion of the small intestine and motor function of the gastrointestinal tract. In difficult di-ag-no-sti-che-s-cases, to exclude im-mu-no-de-fi-cit conditions, they give an assessment to im-mun-no-go sta-tu-sa pain-no-go (main sub-po-pu-la-tions im-mu-no-com-pe-tent- ny cells, im-mu-nog-lo-bu-li-ny in the blood-sy-mouth). To assess the place im-mu-ni-te-ta in the per-fu-for-those small intestines op-re-de-la-ut acute-phase proteins, al-bu-min, α-1-an-ti-tryp-syn, se-k-re-tor-ny im-mu-nog-lo-bu-lin A. Standard me -the-house, recommended by WHO for assessing the pro-no-tsa-e-mo-sti of the intestinal bar-e-ra, is -x-im-mu-no-enzyme-method with a load of oval-bu-mi-nom chicken-egg.

In di-ag-no-sti-ke glu-te-no-voy en-te-ro-pa-tii, po-mi-mo gi-s-to-lo-gi-che-sko-go is-sle -do-va-niya bio-pta-ta mucus-stay small intestine, no-about-ho-di-mo op-re-de-le-nie in the sy-mouth-ke -vi an-ti-tel to gli-a-di-nu, tissue-non-howling trans-glu-ta-mi-na-ze and definition of an-ti-en-do-mi-zi-al-nyh ans -ti-tel.

Assessment of the motor function of the intestine, based on the rent-ge-no-lo-gi-che-study, can -but pro-in-dit and with the help of radio -koy Ts 99 (skin-ti-gra-fia of the stomach, thin and thick intestines).

Le-che-nie khro-ni-che-sko-go di-a-rey-no-go sin-dro-ma at za-bo-le-va-ni-yah or-ga-nov pi-sche-va -re-niya must be comprehensive, provide norm-ma-li-za-tion of well-t-ri-tiv-no-go (tro-fo-lo- gi-che-sko-go) sta-tu-sa pa-tsi-en-ta and development of adapt-ta-tsi-on-no-com-pen-sa-tor-processes , which helps to improve the quality of life.

The first and leading must be the di-e-to-te-ra-pii. Therapeutic nutrition during di-a-ray turns on the standard di-e-e-you, if not-about-ho-di-mo- sti - eli-mi-na-tsi-on-nyh di-et and mixture for en-te-ral-no-go pi-ta-niya.

Va-ri-ant standard di-e-you ha-ra-k-te-ri-zu-et-sya with-high-with-holding-no-bel-ka ( 110-120 g), physiological norm of fat (90 g) and carbon-le-water (300-350 g), vi-ta-mi-nov and mineral substances in the su-exact ra-tsi-o-not. The energy value is 2500-2600 kcal. Pre-dus-ma-t-ri-va-et-sya ku-li-nar-naya ob-ra-bot-ka pro-du-k-tov, po-z-vo-la-yu-shchaya ma- k-si-little-but spare the mucus of the small intestine and slow down the movement of the food. The food is fractional, it is used to pro-du-k-you with a rough cell-chat, milk, can-serves, spicy and salty dishes, alcoholic drinks.

Eli-mi-na-tsi-on-nye di-e-e-you under-ra-zu-me-va-yut the use of milk at the la-k-pelvic not-to -with-that-precision-no-sti, on-the-knowing without-glu-te-new-howling di-e-e-you and the-exclusion of pro-du-to-tov, so- holding “hidden” gluten (con-serves, sausages from de-lia, kvass, gin, pro-du-to-you with gluten-so-der -zha-schi-mi sta-bi-li-za-to-ra-mi) with glu-te-no-howl en-te-ro-pa-tiya.

The meaning of mixtures for the en-te-ral-no-go pi-ta-niya pa-tsi-en-there with the cli-che-ski-mi manifestations-le-ni- I-mi sin-dro-ma mal-ab-sorption, with de-fi-tsi-tom mass-sy te-la not-about-ho-di-mo in all cases, when The standard di-e-toy fails to provide good support. They use standard, semi-element, modular, im-mo-du-li-ru-yu-yu and special ones -al-nye me-ta-bo-li-che-skie mixtures for the correction of me-ta-bo-li-che-skih na-ru-she-niy, as al-ter-na- ti-va le-kar-st-ven-nym pre-pa-ra-tam (Nu-t-ri-zon, Kli-nu-t-ren, Ber-la-min Mo-du-lyar, Uni-pit , Pep-ta-men, etc.).

For the correction of exchanges, in a number of cases they are used for-me-s-tel-te-ra-piya, including re-hydr-ra-ta-tsi-on solutions (Re-hydr-ron, Ga-st-ro-lit, Glu- ko-sa-lan, etc.), pa-ren-te-ral introduction of proteins, amino-acid mixtures in combination with ana -bo-li-che-ski-mi ste-ro-i-da-mi (Re-ta-bo-lil), glu-ko-zy, elek-t-ro-li-tov, vi-ta-mi -new group B, as-kor-bi-no-howl ki-s-lo-you, pre-pa-ra-tov same-le-za.

For the growth of pa-to-gene micro-flora in the upper parts of the small intestine on-know -cha-yut-sya an-ti-ba-k-te-ri-al-nye pre-pa-ra-you shi-ro-ko-go spec-t-ra dey-st-via - sul-fa-ni-la-mi-dy (Bi-sep-tol, Fta-la-zol, Ko-t-ri-mo- k-sa-zol), about-from-water ni-t-ro-fu-ra-nov (Fu-ra-gin, Fu-ra-zo-li-don), hi-no-lo-ny (Ni-t-ro-xo-lin), fluoro-hi-no-lo-ny (Dig-ran) in average te-ra-singing doses in the same 5-7 days. For po-da-v-le-niya ro-s-ta ana-e-rob-nyh ba-k-te-riy use me-t-ro-ni-da-zol 0.5 d 3 times a day for 7-10 days. Effective intestinal an-ti-sep-ti-ki, having a wide spectrum of action: In-te-t-rix 1 each cap-su-le 3 times a day - 7-10 days, Er-se-fu-ril 200 mg 4 times a day - 7 days.

According to this, at the present time, for the de-con-ta-mi-na-tion of the small intestine, pre-pa-ra is used -you, about-la-da-yu-shchie pro-bi-o-ti-che-skim dey-st-vi-em: En-te-rol 1 cap-su-le 2 times a day during the for 14 days, Ba-k-ti-sub-til 1 cap-su-le 2-3 times a day for 3-4 weeks, as well as pre-pa-ra-you on the basis of the sen-noy pa-loch-ki (Spo-ro-ba-k-te-rin, Bio-spo-rin, Ba-k-tis-po-rin).

After-le pro-ve-de-niya an-ti-ba-k-te-ri-al-noy te-ra-pii ef-fe-k-tiv-but use-zo-va-nie pre- bi-o-ti-kov (Hi-lak for-te - 40-60 drops 3 times a day for 2-4 weeks; Du-fa-lak in pre-bi-o-ti- Czech dosage 5-10 ml per day for 1 month) for restoration of normal microflora of the intestine -Nika. For the same purpose, we know the pre-pa-ra-you about the bi-o-ti-che-go-go-st-viya (Li-nex, Bi-fi-dum-ba -k-te-rin for-te, Pro-bi-for, Bi-fi-form, Aci-lact, Ko-li-ba-k-te-rin in the middle te-ra-pev-ti-che -skih do-zakhs in the same mi-ni-mum 4 weeks), as well as syn-bi-o-ti-che-skie bio-com-p-le-k-sy (Nor-mof -lo-rin L, Nor-mof-lo-rin B, Nor-mof-lo-rin D) cur-sa-mi for 2-4 weeks.

One of the probiotics widely used in clinical practice is Linex, a combination drug that contains three types of bacteria: Bifidobacterium infantis v. liberorum, Lactobacillus acidophilus and nontoxigenic lactic acid streptococcus group D Streptococcus faecium. Linex meets modern requirements: it contains a complex of living microorganisms that play an important role in maintaining the intestinal biocenosis; all three strains of Linex bacteria are resistant to the aggressive environment of the stomach, which allows them to easily reach all parts of the intestine without losing their biological activity. The use of Linex is safe in any age group of patients. The microbial components of Linex are highly resistant, which makes it possible to take the drug simultaneously with antibiotics and chemotherapeutic agents. Adults and children over 12 years of age are prescribed 2 capsules 3 times a day after meals. The course of treatment depends on the causes of dysbiotic disorders. There are no cases of side effects or overdose of Linex in the literature.

In le-che-nii an-ti-bio-ti-ko-as-so-tsi-i-ro-van-noy di-a-rei and pseudo-do-mem-b-ra-noz-no-go ko-li-ta pre-pa-ra-ta-mi you-bo-ra yav-la-yut-sya van-ko-mi-cin, me-t-ro-ni-da-zol, En-te- roll. Pa-tsi-en-there with the pain Whip-p-la na-know-cha-yut te-t-ra-tsi-k-lin at a dose of 1-2 g per day, Bi-sep -tol - 6 mg/kg body weight for 5-9 months with gradually decreasing doses.

In-gi-bi-to-ry k-shech-noy mo-to-ri-ki and se-k-re-tion na-know-cha-yut ko-rot-ki-mi kur-sa-mi or, as required, in cases of acute di-a-rei, with IBS.

Since ancient times, doctors have used opium when di-a-ray-nom sin-dro-me. At the present time, lo-pe-ra-mid (Imo-di-um) is used to reduce the frequency of stool and gi -per-se-to-re-tion of mucus in the intestine - 1-2 drops-su-le 1-4 times a day until the end -small-but-go chair or from-sut-st-via de-fe-ka-tion more than 12 hours. Along with the lo-pe-ra-mi-house, to the re-gu -la-to-ram mo-to-ri-ki ki-shech-ni-ka from-no-syat pla-ti-fil-lin, hyoscine butyl bromide (Bu-s-ko-pan), dro-ta-ve -rin (No-spa), which is known to be 40-80 mg 3 times a day, Meteo-spaz-mil (1-2 drops 3 times per day). With the mountains-mo-nal-but-active opu-ho-lyakh good-ro-shim an-ti-di-a-rey-ef-fe-k-tom ob-la-da-yut ana- lo-gi gor-mo-na so-ma-to-sta-ti-na (Ok-t-re-o-tid, San-do-sta-tin).

Knitting, about-la-ki-va-yu-yu-sti-va-st-va sor-bi-ru-yut liquid, from-to-or-ga-no-che-ki-s-lot, then-k-si-nov. These include the pre-pa-ra-you, containing white clay, ta-nin, vi-s-mut; Ne-oin-te-sto-pan, Tan-na-comp (about-la-da-yu-shchiy knitting, about-in-la-ki-va-yu-shim and an-ti-ba -to-te-ri-al-nym de-st-vi-em), Al-ma-gel, Sme-to-ta, which-ry-know-cha-yut for 5-7 days.

In the Kli-ni-che-pra-k-ti-ke, for this purpose they use le-kar-st-ven-plants: cher-ni-ku, che -re-mu-hu, zve-ro-fight, ko-ru du-ba, ol-ho-vye shish-ki, ko-zhu-ru of the fruits of the gra-na-ta in the view from-va- ditch

En-te-ro-sor-ben-you pre-pyat-st-vu-yut influence of ba-k-te-ri-al-nyh and viral agents, then-k-si-nov, osus-sche-st -in-la-yut qi-to-pro-tek-tion. These include Sme-to-tu, En-te-ros-gel, Po-li-fe-pan, Filter-room-STI, Ne-oin-te-sto-pan, which are known tea on Wednesday for 10-14 days, in-ter-va-lah between pi-e-ma-mi pi-schi. With ho-le-gen-noy di-a-ree ef-fe-k-tiv-ny Ho-le-sti-ra-min, Bi-lig-nin.

Enzyme pre-pa-ra-you na-know-cha-yut for op-ti-mi-za-tion of processes on-lo-st-no-go p-sche-va-re-niya. When la-k-pelvis is not-to-s-accurately in children, they use the enzyme La-k-ta-za Baby-bi (1 cap-su -lu with every smoky food for children under the age of 1 year; for children up to 7 years - 2-5 capsuls with food, co-der- thirsty mo-lo-ko). Adult-lym pa-tsi-en-there re-ko-men-du-yut eli-mi-na-tsi-on-nu-di-e-tu (with the use of a mo-lo- ka). When selecting enzyme pre-pa-ra-tov, co-holding pan-crea-a-tin, it is not-about-ho-di-mo from-yes-presenting respect for the medium-st-you, ha-ra-to-te-ri-zu-yu-sh-sha-you-with-k-keep-with-any-li-pa-zy, and also pay attention to the form you-pu-s-ka (mi-ni-mi-k-ro-spheres, established -viyu zhe-lu-doch-no-go so-ka) (Cre-on, Pan-tsi-t-rat). Su-precise do-for-enzyme pre-pa-ra-tov in le-che-nii syn-dro-ma mal-absorption should be 30,000- 150,000 units (in terms of maintenance of the li-groove).

Glu-ko-kor-ti-ko-ste-ro-id-nye pre-pa-ra-you used for severe and moderate forms of gluten en-te-ro-pathy (with average at the same degree of severity 20-30 mg when switching to pre-nizolon, for severe forms - 50-70 mg in the same - 2 weeks with a gradual reduction in dosage to full from me).

In this way, di-a-reya can be a sign of many for-bo-le-va-niy or-ga-nov pi-sche-va-re-niya. Ade-k-vat-nye di-ag-no-sti-che-me-ro-pri-ya-tiya at di-a-ray-nom syn-dro-me po-z-vo-la-yut vra -chu-to-mean opt-ti-mal-kom-p-lex-noe, etio-trop-noe and pa-to-ge-ne-ti-che-le-che-nie.

Literature

I. D. Lo-ran-skaya, Doctor of Medical Sciences, Professor
RMA-PO, Moscow

Diarrhea (diarrhea) - frequent or single bowel movement with the release of liquid feces.

Why does diarrhea occur?

Any diarrhea is a clinical manifestation of impaired absorption of water and electrolytes in the intestines. Therefore, the pathogenesis of diarrhea of ​​various etiologies has much in common. The ability of the small and large intestines to absorb water and electrolytes is enormous.

Every day a person consumes about 2 liters of water with food. The volume of endogenous fluid entering the intestinal cavity as part of digestive secretions reaches an average of 7 l (saliva - 1.5 l, gastric juice - 2.5 l, bile - 0.5 l, pancreatic juice - 1.5 l, intestinal juice - 1 l). Of the total amount of liquid, the volume of which reaches 9 liters, only 100-200 ml, i.e. about 2% is excreted in feces, the rest of the water is absorbed in the intestine. Most of the liquid (70-80%) is absorbed in the small intestine. From 1 to 2 liters of water enters the colon during the day, 90% of it is absorbed, and only 100-150 ml are lost in feces. Even slight changes in the amount of fluid in the stool lead to loose or harder-than-normal stool.

I. Secretory diarrhea (increased secretion of water and electrolytes into the intestinal lumen).

1.1. Passive secretion

1.1.1. Increased hydrostatic pressure due to damage to the intestinal lymphatic vessels (lymphangiectasia, lymphoma, amyloidosis, Whipple's disease)

1.1.2. Increased hydrostatic pressure due to right ventricular failure

1.2. Active secretion

1.2.1. Secretory agents associated with activation of the adenylate cyclase - cAMP system

1.2.1.1. Bile acids

1.2.1.2. Long chain fatty acids

1.2.1.3. Bacterial enterotoxins (cholera, E. coli)

1.2.2. Secretory agents associated with other intracellular second messengers

1.2.2.1. Laxatives (bisacodyl, phenolphthalein, castor oil).

1.2.2.2. VIP, glucagon, prostaglandins, serotonin, calcitonin, substance P.

1.2.2.3. Bacterial toxins (staphylococcus, Clostridium perfringens, etc.).

II. Hyperosmolar diarrhea (reduced absorption of water and electrolytes).

2.1. Digestion and absorption disorders

2.1.1. Absorption disorders (celiac enteropathy, small intestinal ischemia, congenital absorption defects)

2.1.2. Membrane digestion disorders (disaccharidase deficiency, etc.)

2.1.3. Cavitary digestive disorders

2.1.3.1. Pancreatic enzyme deficiency (chronic pancreatitis, pancreatic cancer)

2.1.3.2. Bile salt deficiency (obstructive jaundice, disease and ileal resection)

2.2. Insufficient contact time of chyme with the intestinal wall

2.2.1. Small bowel resection

2.2.2. Entero-enteroanastomosis and intestinal fistula (Crohn's disease) III. Hyper- and hypokinetic diarrhea (increased or slowed rate of transit of intestinal contents). 3.1. Increased rate of transit of chyme through the intestines

3.1.1. Neurogenic stimulation (irritable bowel syndrome, diabetic enteropathy)

3.1.2. Hormonal stimulation (serotonin, prostaglandins, secretin, pancreozymin)

3.1.3. Pharmacological stimulation (anthroquinone laxatives, isophenine, phenolphthalein)

3.2. Slow transit speed

3.2.1. Scleroderma (combined with small intestinal bacterial syndrome)

3.2.2. Blind loop syndrome

IV. Exudative diarrhea (“discharge” of water and electrolytes into the intestinal lumen).

4.1.Inflammatory bowel diseases (Crohn's disease, ulcerative colitis)

4.2. Intestinal infections with cytotoxic effects (dysentery, salmonellosis)

4.3. Ischemic disease of the small and large intestine

4.4. Protein-losing enteropathies.

Mechanism of development of diarrhea

Four mechanisms are involved in the pathogenesis of diarrhea: intestinal hypersecretion, increased osmotic pressure in the intestinal cavity, impaired transit of intestinal contents and intestinal hyperexudation.

There is no doubt that the mechanisms of diarrhea are closely related, however, each disease is characterized by a predominant type of ion transport disorder. This explains the features of the clinical manifestations of various types of diarrhea.

Secretory diarrhea

Hypersecretion is the most common mechanism in the pathogenesis of diarrhea in all diseases of the small intestine. It occurs as a result of the fact that the secretion of water into the intestinal lumen prevails over absorption. Watery diarrhea occurs when the amount of water in the stool increases from 60 to 90%.

The main activators of secretion are bacterial toxins (for example, in cholera), enteropathogenic viruses, some drugs and biological active substances. Secretory diarrhea is also caused by biochemical processes in the intestine associated with the vital activity of microorganisms: the formation of free bile acids with a decrease in the proportion of conjugated bile acids involved in the absorption of lipids, and as a result, the accumulation of long-chain fatty acids in the intestinal cavity. Some gastrointestinal hormones (secretin, vasoactive peptide), prostaglandins, serotonin and calcitonin, as well as laxatives containing anthroglycosides (senna leaf, buckthorn bark, rhubarb) and castor oil also have the ability to increase the secretion of sodium and water into the intestinal lumen.

If the absorption of bile acids is impaired or the contractile function of the gallbladder is poor, the feces usually become bright yellow or green in color.

Secretory diarrhea is characterized by large, watery stools (usually more than 1 liter) that are not accompanied by pain. The osmolar pressure of intestinal contents during secretory diarrhea is significantly lower than the osmolar pressure of blood plasma.

Hyperosmolar diarrhea

Hyperosmolar diarrhea develops due to an increase in the osmotic pressure of the chyme. In this case, water and substances dissolved in it remain in the intestinal lumen.

An increase in osmotic pressure in the intestinal cavity is observed:

a) with disaccharidase deficiency (for example, with hypolactasia),

b) with malabsorption syndrome,

c) with increased intake of osmotically active substances into the intestines: saline laxatives containing magnesium and phosphorus ions, antacids, sorbitol, etc.

With hyperosmolar diarrhea, the stool is unformed, abundant, with a large amount of undigested food debris and is not accompanied by pain. The osmotic pressure of intestinal contents is significantly higher than the osmolar pressure of blood plasma.

Hyper- and hypokinetic diarrhea

The cause of hyper- and hypokinetic diarrhea is a violation of the transit of intestinal contents.

An increase in the transit rate is facilitated by laxatives and antacids containing magnesium salts, as well as biologically active substances, for example, secretin, pancreozymin, gastrin, prostaglandins and serotonin.

The duration of transit increases in patients with scleroderma, in the presence of a blind loop in patients with enteronto-neroanastomoses. In these cases, both a violation of the transit rate and bacterial contamination of the small intestine are observed. It develops as a result of the spread of bacteria from the large intestine to the small intestine. An increase and decrease in intestinal motor activity is especially often observed in patients with irritable bowel syndrome.

With hyper- and hypokinetic diarrhea, stool is frequent and liquid, but the daily amount does not exceed 200-300 g; its appearance is preceded by cramping pain in the abdomen. The osmotic pressure of intestinal contents approximately corresponds to the osmotic pressure of blood plasma.

Exudative diarrhea

Exudative diarrhea occurs due to the “discharge” of water and electrolytes into the intestinal lumen through the damaged mucous membrane and is accompanied by the exudation of protein into the intestinal lumen.

This type of diarrhea is observed in inflammatory bowel diseases: Crohn's disease and ulcerative colitis, intestinal tuberculosis, salmonellosis, dysentery and other acute intestinal infections. Exudative diarrhea can also be observed with malignant diseases and ischemic intestinal disease.

With exudative diarrhea, the stool is liquid, often with blood and pus; Abdominal pain appears after stool. The osmotic pressure of feces is often higher than the osmotic pressure of blood plasma.

Thus, the pathogenesis of diarrhea is complex and involves many factors. However, their role in different diseases is different. In patients with intestinal infections, diarrhea is associated with hypersecretion of water and electrolytes due to the fact that bacterial toxins increase the activity of adenylate cyclase in the intestinal wall with the formation of cyclic AMP. In case of celiac enteropathy, the primary role is played by hyperosmotic factors caused by impaired digestion and absorption of nutrients in the small intestine. In patients who have undergone extensive resection of the small intestine, a secretory factor, which develops as a result of disruption of the enterohepatic circulation of bile acids and bacterial contamination of the small intestine, is important in the pathogenesis of diarrhea.

Clinical features of different types of diarrhea

The clinical features of diarrhea largely depend on its cause, duration, severity and location of intestinal damage.

There are acute and chronic diarrhea.

Diarrhea is considered chronic if it lasts more than 3 weeks. The concept of chronic diarrhea also includes systematically profuse stools, the weight of which exceeds 300 g/day. However, for people who eat foods rich in plant fiber, this stool weight may be normal.

One of the causes of chronic diarrhea may be the abuse of laxatives, including their secret use. The connection of diarrhea with systemic diseases is also often established on the basis of anamnestic information. Diarrhea in patients with diabetes, other endocrinopathies and scleroderma is usually easily explained by the underlying disease, if it has already been established. Difficulties arise in those rare cases when diarrhea is the first manifestation of a systemic disease or dominates the clinical picture. Thus, in patients with carcinoid syndrome, the disease may manifest itself as episodes of profuse watery diarrhea. If the tumor is large enough and there are no metastases to the liver, diarrhea may be the only symptom of gradually increasing small intestinal obstruction at a certain stage in the development of the disease. In patients with hyperthyroidism, the disease can also manifest itself in the form of prolonged diarrhea, while the symptoms of thyrotoxicosis (constant feeling of heat, irritability or weight loss, despite a good appetite, etc.) may recede into the background and not attract the attention of the patient himself.

The cause of chronic diarrhea in patients who have undergone vagotomy, resection of the stomach or intestines with the formation of a blind loop, is bacterial contamination of the small intestine. This phenomenon is also often observed in patients with diabetes and scleroderma due to impaired motor function of the small intestine. In some patients, diarrhea improves if they eliminate foods to which they have a reduced tolerance. A classic example is the transition to a hypolactose diet in patients with hypolactasia.

In patients with chronic alcoholism and frequent relapses of chronic pancreatitis, as well as after surgical removal of the pancreas, a deficiency of all pancreatic enzymes develops and, as a result, diarrhea with steatorrhea. Crohn's disease localized in the ileum or its resection leads to disruption of the enterohepatic circulation of bile acids. This also results in diarrhea and steatorrhea. The stool of these patients is usually profuse, foul-smelling, with floating fat. Ulcerative colitis usually presents with bloody diarrhea. Tenesmus and a small amount of diarrhea suggest that the pathological process is limited to the distal colon. The presence of a rectal fissure and paraproctitis in the past also suggests Crohn's disease. Extraintestinal manifestations such as arthritis or skin lesions may be present in ulcerative colitis and Crohn's disease.

Colon and rectal tumors may also present with diarrhea; the absence of other plausible causes in older patients and the presence of bleeding further supports this assumption.

Irritable bowel syndrome is usually observed in younger patients, often chronic in time, patients actively seek medical help, exacerbations are often worsened by stress, stools are usually frequent, after every meal, scanty and never contain blood. Weight loss in these patients, if it occurs, is also associated with stress.

Physical examination of patients with chronic diarrhea is important to assess the degree of dehydration and determine the relationship with systemic diseases.

For example, tachycardia may be a manifestation of latent hyperthyroidism, cardiac murmurs characteristic of pulmonary artery or tricuspid valve stenosis may be a consequence of carcinoid syndrome, and the presence of isolated or peripheral neuropathy may be a manifestation of diabetes. Scleroderma can be suspected based on characteristic facial features and changes in the skin of the hands. The presence of food intolerance in patients with chronic diarrhea may be a consequence of primary or secondary disaccharidase deficiency. Examination of the abdominal organs may reveal signs of Crohn's disease in the form of a palpable infiltrate. Diseases of the perianal zone serve as confirmation of this. As with acute diarrhea, stool examination and evaluation of sigmoidoscopy findings should be part of the physical examination.

Diagnosis, differential diagnosis of diarrhea

Diarrhea is a symptom of many diseases and determining its causes should be based primarily on anamnesis, physical examination and macro- and microscopic examination of stool.

Some forms of acute diarrhea can be caused by enteroviruses. Characteristic features of viral enteritis are:

a) absence of blood and inflammatory cells in the stool,

b) the ability to spontaneously recover and

c) lack of effect from antibacterial therapy. The listed features should be taken into account in the differential diagnosis between infectious and non-infectious inflammatory bowel diseases.

You should pay attention to the consistency of the mouth guard, smell, volume, presence of blood, pus, mucus, or fat in it. Sometimes the connection between chronic diarrhea and malabsorption can be established by history and physical examination. In diseases of the small intestine, the stool is bulky, watery or fatty. With diseases of the colon, stool is frequent, but less abundant and may contain blood, pus and mucus. Unlike enterogenous, diarrhea associated with colon pathology is in most cases accompanied by abdominal pain. With diseases of the rectum, the latter becomes more sensitive to stretching and stool becomes frequent and scanty, tenesmus and false urges to defecate appear. Microscopic examination of feces can detect signs of inflammation - accumulations of leukocytes and desquamated epithelium, characteristic of inflammatory diseases of an infectious or other nature. A scatological examination makes it possible to identify excess fat (steatorrhea), muscle fibers (creatorrhoea) and lumps of starch (amilorrhea), indicating intestinal digestive disorders. The detection of eggs of worms, lamblia and amoebas is also of great importance. It is necessary to pay attention to the pH of the stool, which is normally above 6.0. A decrease in pH occurs as a result of bacterial fermentation of unabsorbed carbohydrates and proteins. An increase in stool pH usually occurs due to laxative abuse and is detected by phenolphthalein, which turns pink.

Diet changes often help make the diagnosis. For example, a good therapeutic effect observed after transferring a patient to an alactose diet makes it possible to establish a diagnosis of hypolactasia without conducting a large number of invasive diagnostic studies.

How to treat diarrhea

Diarrhea is a symptom. Therefore, for etiological or pathogenetic treatment, nosological diagnosis is necessary.

A number of therapeutic approaches are common to each of the 4 types of diarrhea. These include diet, antibacterial drugs and symptomatic agents (adsorbents, astringents and enveloping substances).

Diet for diarrhea

For intestinal diseases accompanied by diarrhea, dietary nutrition should help inhibit peristalsis and reduce the secretion of water and electrolytes into the intestinal lumen. The set of products must correspond in composition and quantity of nutrients to the enzymatic capabilities of the pathologically altered small intestine. In this regard, with diarrhea, the principle of mechanical and chemical sparing is always observed to a greater or lesser extent, depending on the severity of the process. During the acute period of diarrhea, food products that enhance the motor-evacuation and secretory function of the intestine are largely excluded from the diet. Diet No. 4b almost completely meets these requirements. It is prescribed during periods of exacerbation of diarrhea.

Diet 4c. Prescribed for intestinal diseases during remission.

The diet is similar to 46, but all dishes are given in uncut form. Baking in the oven is allowed. Additionally, ripe tomatoes, leafy lettuce with sour cream, sweet varieties of berries and fruits in raw form 100-200 g are allowed.

Antibacterial drugs for diarrhea

Antibacterial therapy is prescribed to restore intestinal eubiosis. For acute diarrhea of ​​bacterial etiology, antibiotics, antimicrobial agents from the group of quinolones (nitroxoline, 5-nok), fluoroquinolones (tarivid, tsifran, etc.), sulfonamide drugs (biseptol, sulgin, phthalazol, etc.), nitrofuran derivatives (furadonin, furazolidone, etc.) are used ) and antiseptics. Preference is given to drugs that do not disturb the balance of microbial flora in the intestine. These include intetrix, ersefuril.

For intestinal amebiasis, 4 capsules per day are prescribed; course of treatment - 10 days.

Ersefuril contains 0.2 g of nifuroxazide in one capsule. The drug is prescribed for acute diarrhea, 1 capsule 4 times a day. The course of treatment should not exceed 7 days.

Enterosediv is a combination drug containing streptomycin, bacitracin, pectin, kaolin, sodium menadione and sodium citrate. The drug is prescribed 1 tablet 2-3 times a day. The average duration of treatment is 7 days.

Dependal-M is available in tablets and suspensions. One tablet contains furazolidone (0.1) and metronidazole (0.3). The suspension also includes pectin and kaolin. Dependal-M is prescribed 1 tablet (or 4 teaspoons of suspension) 3 times a day. In most patients with acute diarrhea, the effect of treatment is observed after 1-2 days, treatment continues for 2-5 days.

Bacterial preparations for diarrhea

Some bacterial drugs can be prescribed for diarrhea of ​​various origins as an alternative therapy. These include bactisubtil, linex, bifiform and enterol.

Bactisubtil is a bacterial culture IP-5832 in the form of spores, calcium carbonate, white clay, titanium oxide and gelatin. For acute diarrhea, the drug is prescribed 1 capsule 3-6 times a day; in severe cases, the dose can be increased to 10 capsules per day. For chronic diarrhea, bactisubtil is prescribed 1 capsule 2-3 times a day. The drug should be taken 1 hour before meals.

Enterol contains a lyophilized culture of Saecharamyces doulardii.

The drug is prescribed 1-2 capsules 2-4 times a day. The course of treatment is 3-5 days.

Enterol is especially effective for diarrhea that develops after antibiotic therapy.

Other bacterial drugs (bifidumbacterin, bifiform, lactobacterin, linex, acylact, normaflor) are usually prescribed after a course of antibacterial therapy. The course of bacterial treatment can last up to 1-2 months.

Hilak-forte is a sterile concentrate of metabolic products of normal intestinal microflora: lactic acid, lactose, amino acids and fatty acids. These substances help restore the biological environment in the intestine, necessary for the existence of normal microflora, and suppress the growth of pathogenic bacteria.

Hilak-forte is prescribed 40-60 drops 3 times a day. The course of treatment lasts 2-4 weeks.

Symptomatic remedies for diarrhea

This group includes adsorbents that neutralize organic acids, astringents and coating agents. These include smecta, neointestopan; tannacomp and polyphepan.

Smecta contains dioctahedral smectite, a substance of natural origin that has pronounced adsorbing properties and a protective effect on the intestinal mucosa. Being a stabilizer of the mucous barrier and having enveloping properties, smecta protects the mucous membrane from toxins and microorganisms. Prescribed 3 g (1 sachet) 3 times a day 15-20 minutes before meals in the form of a mash, dissolving the contents of the sachet in 50 ml of water. Given the pronounced adsorbing properties of the drug, smecta should be taken separately from other drugs.

Neointestopan is a natural purified aluminum-magnesium silicate in colloidal form (attapulgite). Neointestopan has a high ability to adsorb pathogenic pathogens and bind toxic substances, thereby promoting the normalization of intestinal flora. Attapulgite is not absorbed from the gastrointestinal tract and is used for acute diarrhea of ​​various origins. The initial dose for adults is 4 tablets, then after each stool another 2 tablets. The maximum daily dose is 14 tablets. The tablets should be swallowed without chewing, with liquid. The duration of treatment with neointestopan should not exceed 2 days.

The drug interferes with the absorption of concomitantly prescribed drugs, in particular. antibiotics and antispasmodics, therefore the time interval between taking neointestopan and other medications should be several hours.

Tannacomp is a combination drug. It contains tannin albuminate 0.5 g and ethacridine lactate 0.05 g. Tannin albuminate (tannic acid combined with protein) has an astringent and anti-inflammatory effect. Ethacridine lactate has antibacterial and antispastic effects. Tannacomp is used for the prevention and treatment of diarrhea of ​​various origins. To prevent diarrhea among tourists, the drug is prescribed 1 tablet twice a day. For treatment - 1 tablet 4 times a day. The course of treatment ends with the cessation of diarrhea. For the treatment of chronic diarrhea, the drug is prescribed 2 tablets 3 times a day for 5 days.

Calcium polycarbophil is used as a symptomatic remedy for non-infectious diarrhea. The drug is prescribed 2 capsules per day for 8 weeks.

To treat hologenic diarrhea caused by bile acids, bilignin and ion exchange resins - cholestyramine - are successfully used.

Polyphepan is taken orally, 1 tablespoon 3 times a day, 30-40 minutes before meals, after mixing in 1 glass of water. The course of treatment is 5-7 days or more.

Cholestyramine (vazazan, questran) is prescribed 1 teaspoon 2-3 times a day for 5-7 days or more.

Motor regulators in diarrhea

Imodium is widely used to treat diarrhea, which reduces intestinal tone and motility, apparently due to binding to opiate receptors. Unlike other opioids, loperamide lacks central opiate-like effects, including blockade of small intestinal propulsion. The antidiarrheal effect of the drug is aimed at opiate receptors of the enterin system. There is evidence that direct interaction with enteric opiate receptors alters epithelial cell function by reducing secretion and improving absorption. The antisecretory effect is accompanied by a decrease in intestinal motor function due to blockade of opiate receptors.

Imodium for acute diarrhea is prescribed 2 capsules (4 mg) or lingual tablets (on the tongue), then 1 capsule (2 mg) or tablet is prescribed after each act of defecation in case of loose stools until the number of bowel movements is reduced to 1-2 per day . The maximum daily dose for adults is 8 capsules daily. If normal stool appears and there are no bowel movements within 12 hours, treatment with Imodium should be discontinued.

Somatostatin has a powerful antidiarrheal (antisecretory) effect.

Sandostatin (octreotide), a synthetic analogue of somatostatin, can be effective for refractory diarrhea in patients with malabsorption syndrome of various etiologies. It is an inhibitor of the synthesis of active secretory agents, including peptides and serotonin, and helps to reduce secretion and motor activity. Octreotide is available in ampoules of 0.05 mg. The drug is administered subcutaneously at an initial dose of 0.1 mg 3 times a day. If diarrhea does not subside after 5-7 days, the dose of the drug should be increased by 1.5-2 times.

Rehydration for diarrhea

The purpose of rehydration is to eliminate dehydration and associated disturbances in electrolyte metabolism and acid-base balance. In acute intestinal infections, rehydration should be carried out orally and only 5-15% of patients require intravenous therapy.

For intravenous rehydration, polyionic crystalloid solutions are used: trisol, quartasol, chlosol, acesol. They are much more effective than saline solution, 5% glucose solution and Ringer's solution. Colloidal solutions (hemodez, rheopolyglucin) are used for detoxification in the absence of dehydration.

Water-electrolyte solutions are administered for severe acute diarrhea at a rate of 70-90 ml/min in a volume of 60-120 ml/kg, for moderate severity of the disease - 60-80 ml/min in a volume of 55-75 ml/kg.

For cholera, the optimal rate of intravenous infusion can reach 70-120 ml/min, and the volume of infusion is determined by body weight and the degree of dehydration. For shigellosis, the volumetric rate of administration of polyionic crystalloid solutions is 50-60 ml/min.

With a low rate and smaller volume of rehydration therapy, dehydration may increase, hemodynamic failure progresses, and pulmonary edema, pneumonia, disseminated intravascular coagulation syndrome, and anuria develop.

For oral rehydration therapy, glucosalan, rehydron and other glucose-electrolyte solutions are used. They are administered at a rate of 1 - 1.5 l/hour in the same quantities as for intravenous rehydration.

Rehydration therapy is the mainstay of treatment for acute diarrheal infections.

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MINISTRY OF HEALTH OF THE RF

STAVROPOL STATE MEDICAL

ACADEMY

CHRONIC DIARRHEA SYNDROME

IN THE PRACTICE OF A THERAPIST

Stavropol, 2003

Chief Consultant – Head of the Department of Physical Education Therapy,

Doctor of Medical Sciences, Professor

Compiled by: Ph.D., Associate Professor

Assistant

Reviewers: Head. Department of PVB, Faculty of Medicine

Candidate of Medical Sciences, Associate Professor

Candidate of Medical Sciences, Associate Professor of the Department of Therapeutics

RELEVANCE

Internists and general practitioners often see patients suffering from diarrhea. It can be the leading clinical syndrome in many diseases of the gastrointestinal tract. In the diagnosis and treatment of these diseases (especially at the outpatient stage), many mistakes are still made, which determines the relevance of this problem at the present time.

DEFINITION.

Under diarrhea(diarrhea) understand frequent (more than 2-3 times a day) bowel movement with the release of liquid or mushy feces in quantities exceeding 300 grams with a normal diet.

This definition requires some additions and clarifications. Sometimes daily single loose stools can be a variant of diarrhea. On the other hand, stool 3-4 times a day, in which the feces remain formed, is not regarded as diarrhea. Thus, the most important sign of diarrhea should be a higher than normal water content in the stool, which during diarrhea increases to 85–95% (with the norm being 60–75%).

PATHOMORPHOLOGICAL MECHANISMS OF DIARRHEA

Diarrhea is a clinical manifestation of impaired absorption of water and electrolytes in the intestine.

Normally, the intestines of a healthy person receive about 9 liters of fluid daily, of which 2 liters are food products, the rest is represented by endogenous fluids that enter the intestinal cavity as part of digestive secretions (saliva -1.5 liters, pancreatic juice - 1.5 liters, gastric juice – 2.5 liters, bile – 0.5 liters, intestinal juice – 1 liter).

Most of these fluids (70-80%) are absorbed in the small intestine. A significantly smaller part (1-2 liters) enters the large intestine, where 90% is also absorbed and only 100-150 ml is lost in feces.

Absorption of water from the intestinal lumen is carried out in the small intestine by enterocytes (mature cells at the tips of the villi), in the large intestine - by colonocytes. This process depends on the transport of electrolytes. In the small intestine, passive transport of water and sodium, chlorine, and bicarbonate ions predominates, which is due to the high permeability of enterocyte membranes. In the ileum and colon, electrolytes are absorbed through an energy-dependent mechanism, while water flows passively to collect the electrolytes.

Sodium chlorine and bicarbonates penetrate into the paracellular spaces, increasing the osmotic and hydrostatic pressure in them, which ensures the absorption of water through the low-permeability membrane of the capillaries into the blood plasma.

CHRONIC DIARRHEA

Diarrhea is considered chronic if it lasts for more than 3 weeks, the only exception being infectious diseases, which can sometimes continue for a long time, but end in recovery.

ETIOLOGY.

Chronic diarrhea is a symptom of many diseases. Most often it is observed when:

· some diseases of the liver and biliary tract, accompanied by cholestasis, intestinal fermentopathies (deficiency of enterokinase, prolidase, malabsorption of glucose - galactose, sucrose - isomaltase, lactase deficiency, celiac enteropathy, endemic sprue),

tropical sprue

Whipple's disease

eosinophilic gastroeneritis,

systemic mastocytosis,

· exudative enteropathy,

intestinal amyloidosis, immunodeficiency syndromes (variable unclassified immunodeficiency, IgA deficiency),

lymphomas of the small intestine,

malabsorption syndrome,

exocrine pancreatic insufficiency,

post-gastroresection syndrome,

with radiation damage to the intestines,

Inflammatory bowel diseases (UC, Crohn's),

· hormonally active tumors, tuberculosis and intestinal cancer, endocrine diseases,

· irritable bowel syndrome.

Determining its causes should be based primarily on data from the anamnesis, physical examination and macro- and microscopic examination of stool. In this case, pay attention to the consistency of stool, its smell, volume, the presence of blood, pus, mucus or fat in it.

GENERAL PRINCIPLES OF DIAGNOSTICS AND DIFFERENTIAL DIAGNOSTICS .

When collecting anamnesis, attention is paid to the duration of diarrhea, the characteristics of its onset, the volume of stool during the day, the connection of diarrhea with abdominal pain or flatulence, the presence of blood in the stool, the frequency and severity of intestinal peristalsis, and changes in body weight.

Copious stool (polyfeces) with a frequency of 1-2 times a day and the release of mushy, foamy or greasy feces, poorly flushed from the toilet, with a sour or putrid odor is usually a manifestation of enteral diarrhea and indicates malabsorption syndrome. This conclusion is confirmed by a decrease in the severity of diarrhea during fasting.

Diarrhea with copious watery stools, which persists during fasting, indicates increased intestinal secretion or the use of laxatives hidden by patients.

Stool 4-6 times a day and more often with a small amount of feces (often mixed with blood), accompanied by cramping pain in the lower abdomen and tenesmus, is characteristic of damage to the colon. In this case, frequent urges to defecate may result in the release of lumps of mucus, sometimes mixed with blood, rather than feces. Incontinence of patients with feces may indicate damage to the anal sphincter.

The presence of blood in the stool is most often detected in infectious diarrhea, inflammatory bowel diseases, diverticulitis, ischemic colitis, malignant tumors and, as a rule, excludes the functional nature of diarrhea (irritable bowel syndrome - IBS).

An admixture of mucus in the feces appears with colitis, villous adenoma of the colon, but can also be observed with IBS.

The presence of undigested food particles indicates accelerated transit of contents through the small and large intestines.

Many patients have clinical signs of deficiency of various vitamins: B1 (paresthesia), B2 (glossitis and angular stomatitis), D (bone pain, tetany), K (increased bleeding) and other vitamins. With a long and severe course of malabsorption syndrome, cachexia progresses, symptoms of polyglandular insufficiency (adrenal glands, gonads), muscle atrophy, and mental disorders are added.

The clinical manifestations of malabsorption syndrome, its diagnosis and treatment may have certain features due to the specific disease that caused its development. This requires a separate consideration of the most common diseases occurring with malabsorption syndrome.

Postgastroresection syndrome.

In the early period after gastrectomy, diarrhea is observed in almost 40% of patients. After the adaptation phase, which lasts several weeks, the frequency of stool disorders decreases significantly, although it persists with dumping syndrome c. within 14-20%. The incidence of diarrhea was lowest (3.8%) after selective proximal vagotomy.

The main reason for the development of diarrhea in diseases of the operated stomach is the too rapid entry of stomach contents with osmotically active food components into the upper parts of the small intestine. Due to the rapid passage of chyme through the intestines, the processes of digestion and absorption (primarily fats) are disrupted and steatorrhea occurs. An additional factor contributing to the occurrence of diarrhea may be the syndrome of excessive proliferation of bacteria, which occurs in conditions of a sharp decrease in the secretion of hydrochloric acid after gastric surgery.

Exocrine pancreatic insufficiency.

Diarrhea with exocrine pancreatic insufficiency is the result of decreased production by the pancreas of enzymes involved in the digestion and absorption of fats (lipase, colipase, phospholipase A), proteins (trypsin, chymotrypsin, elastase, carboxypeptidase) and carbohydrates (amylase). In general, the reserve functionality of the pancreas is very high, which only results in a decrease in enzyme production (for example, lipase by 90%). Diarrhea caused by exocrine pancreatic insufficiency occurs most often in patients with chronic pancreatitis, but can also occur in patients with cystic fibrosis and pancreatic cancer.

Diseases of the liver and biliary tract

Diarrhea due to diseases of the liver and biliary tract occurs in cases where the synthesis of bile acids is disrupted or for one reason or another | do not enter the intestine (i.e., in the presence of cholestasis). In this case, the stool becomes acholic, acquires a greasy sheen, and upon microscopic examination, fatty acids and soaps are revealed. Steatorrhea in patients with cholestasis is accompanied by impaired absorption of vitamins A, K, D, as well as calcium, which can lead to twilight vision disorders, the development of hemorrhagic syndrome, osteoporosis and pathological bone fractures. In cholestasis syndrome, diarrhea is combined with symptoms such as dark urine, jaundice, itching, xanthoma formation and xanthelasm. The causes of cholestasis are varied. Intrahepatic hepatocellular cholestasis is observed in viral and alcoholic hepatitis and cirrhosis of the liver, drug-induced hepatopathy. Hepatocanalicular and ductular (biliary) intrahepatic cholestasis can be observed in bile duct atresia, Caraly's disease, primary biliary cirrhosis and primary sclerosing cholangitis. Often in clinical practice, extrahepatic cholestasis occurs due to compression of the common bile duct by stones, tumors of the pancreas or papilla of Vater (duodenal papilla), or cholangiocarcinoma.

Short bowel syndrome.

Short bowel syndrome is a complex of pathophysiological and clinical disorders that occur in the body after resection of the small intestine. As is known, the small intestine has a large reserve of absorption surface, therefore, severe absorption disorders after its resection develop either with very large sizes of the resected area (more than 50% of the entire small intestine), or with resection of small in size, but functionally very important parts of it (thus, loss of the jejunum is tolerated more commonly than loss of the ileum). According to other data, pronounced clinical manifestations associated with short bowel syndrome develop only if a section of the small intestine less than 120 cm in length is preserved, which corresponds to the loss of more than 75% of the entire small intestine. Diseases that necessitate resection of the small intestine are most often thrombosis and embolism of mesenteric vessels, complicated forms of Crohn's disease, and traumatic intestinal injuries.

Functional short bowel syndrome is spoken of in cases where the total length of the small intestine remains sufficient, but the teaching part of it turns out to be excluded from the process of normal passage of the contents. This situation can arise, for example, in the presence of intestinal fistulas.

The clinical picture of short bowel syndrome is caused by diarrhea (stools, as a rule, have a watery consistency or contain a lot of neutral fat), weight loss, and manifestations of hypovitaminosis. Impaired absorption of vitamin B12 in the ileum contributes to the development of B12 deficiency anemia. Lack of B vitamins (B1, B2, B6) in the body leads to polyneuropathy. The consequence of steatorrhea and decreased absorption of fat-soluble vitamins can be disorders such as hypocalcemia and pathological bone fractures, twilight vision disorder, and blood clotting disorders.

Intensinal fermentopathies

Intestinal fermentopathies are a fairly large group of hereditary or acquired disorders that are characterized by a decrease in the activity of certain intestinal enzymes involved in the digestion and absorption of nutrients in the intestine.

Intestinal fermentopathies include, in particular, a deficiency of the transport protein that exchanges chlorides for bicarbonates, as a result of which the absorption of chlorides in the intestine is impaired and the so-called congenital chloridorrhea develops. Deficiency of enterokinase (enteropeptidase) leads to impaired digestion and absorption of proteins, loss of body weight and hypoproteinemic edema. Prolidase deficiency causes decreased absorption of proline, which can cause bone demineralization and impaired collagen metabolism.

Disturbances in the synthesis of enzymes involved in the digestion and absorption of carbohydrates are of important clinical significance. This is due to the fact that carbohydrates cover the body's basic calorie needs.

The group of these enzymopathies includes, in particular, congenital glucose-galactose malabsorption syndrome. This disease, inherited in an autosomal recessive manner, is associated with the absence of a glucose cotransporter in the apical membrane of the enterocyte, resulting in the occurrence of acidic diarrhea with a high glucose content (mellitorrhea). Treatment of patients consists of eliminating starch, lactose and sucrose from the diet and including fructose, the only carbohydrate whose absorption is not impaired in this syndrome.

Sucrase-isomaltase deficiency is also a congenital disease, inherited in an autosomal recessive manner and occurs only in childhood. The disease manifests itself when children begin to include sucrose or starch in their diet.

Diarrhea is usually very severe, accompanied by clinical signs of malabsorption syndrome, and sometimes dehydration. In middle school-age children, sucrose assimilation improves, and by adulthood, the symptoms of the disease almost completely disappear.

Deficiency of trehalase, which breaks down the carbohydrate trehalose found in mushrooms, can cause diarrhea after eating dishes made from mushrooms. The disease is a rare syndrome, although some authors believe that in reality it is more widespread.

The most common type of intestinal fermentopathies is lactase deficiency. Lactase breaks down milk sugar (lactose) into. glucose and galactose. Its deficiency leads to high osmolarity of intestinal contents, created by undigested lactose, and the occurrence of diarrhea. Absolute lactase deficiency, i.e. the inability to digest milk immediately after the birth of a child, is very rare. As a rule, primary lactose intolerance (hypolactasia) develops later (at the age of 1-2 years), often in adolescence or even in adults. There are significant ethnic differences in the prevalence of this disease. Thus, in Europeans and the white population of the USA, lactase deficiency is detected in 5-30% of cases, while its frequency among representatives of the black race of the USA, as well as residents of Africa, Asia, and Mediterranean countries increases to 70-90%. Secondary lactase deficiency develops against the background of other diseases, such as chronic pancreatitis.

The clinical picture of lactase deficiency is characterized by the appearance of cramping abdominal pain, rumbling and diarrhea after drinking milk or dairy products. At the same time, products with natural fermentation of lactose (for example, yogurt) are absorbed quite normally by some patients. In a number of patients, clinical symptoms occur only when drinking a large amount of milk (more than 2 glasses), while a smaller volume of milk does not cause any discomfort in them. On the contrary, in other patients, dyspeptic disorders appear after a short time, even after taking a few sips of milk.

The diagnosis of lactase deficiency is often made on the basis of medical history (often empirically established by the patients themselves). If necessary, an additional lactose load test is performed. The patient takes 50 g of lactose orally, after which the glucose level in the blood is determined. The occurrence of dyspeptic disorders, as well as the absence of an increase in blood glucose after a lactose load, confirms the diagnosis of lactase deficiency. The hydrogen breath test provides valuable diagnostic information. An increase in the concentration of hydrogen in the exhaled air after taking lactose indicates a violation of its absorption in the small intestine and breakdown by bacteria in the colon.