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 intestine. 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 liters (saliva -1.5 liters, 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 intestines. 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 lesion lymphatic vessels intestines (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 clinical manifestations various types diarrhea.

Secretory diarrhea

Hypersecretion - most general 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 entry into the intestine osmotically active substances: 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 occurs when inflammatory diseases intestines: 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. Concept chronic diarrhea also includes systematically large 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. Association 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 where 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. When enough large sizes tumor and the absence of metastases to the liver, diarrhea may be at a certain stage of the development of the disease the only symptom of gradually increasing small intestinal obstruction. In patients with hyperthyroidism, the disease may also manifest itself in the form of prolonged diarrhea, while the symptoms of thyrotoxicosis ( constant feeling fever, irritability or weight loss, despite a good appetite, etc.) may fade 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 pancreas develops a deficiency of all pancreatic enzymes 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 diseases 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; absence of others probable 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. Organ examination abdominal cavity 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 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 disorders intestinal digestion. 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, anti bacterial preparations and symptomatic agents (adsorbents, astringents and coating agents).

Diet for diarrhea

For intestinal diseases accompanied by diarrhea, dietary food should help inhibit peristalsis, 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 are used, antimicrobial agents from the group of quinolones (nitroxoline, 5-nok), fluoroquinolones (tarivid, tsifran, etc.), sulfonamide drugs (biseptol, sulgin, phthalazole, etc.), nitrofuran derivatives (furadonin, furazolidone) 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 - combination drug, containing streptomycin, bacitracin, pectin, kaolin, sodium menadione and sodium citrate. The drug is prescribed 1 tablet 2-3 times a day. Average duration treatment - 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 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 normal microflora intestines: lactic acid, lactose, amino acids and fatty acids. These substances help restore 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, astringent and enveloping drugs. 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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Diarrhea (diarrhea ) is a condition in which a person has a fairly frequent or one-time bowel movement, during which a liquid stool is released. An adult healthy person excretes from 100 to 300 g of feces per day. Its amount varies depending on the amount of fiber contained in the food and the amount of remaining undigested substances and water. If the duration of the disease remains within two to three weeks, then in this case there is acute diarrhea . If a person has loose stools for more than three weeks, diarrhea becomes chronic form. At chronic diarrhea The patient also experiences systematically profuse stools. In this situation, the weight of feces will exceed 300 g per day. Diarrhea occurs when the water content in a person's stool increases dramatically - from 60 to 90%. If the absorption of nutrients from food is impaired, patients are diagnosed with polyfecal : An unusually large amount of feces is released, which consists of food debris that remains undigested. If intestinal motility is impaired, the stool will be very loose and frequent, but in general its weight will not exceed 300 g per day. That is, even in the case initial analysis characteristics of the course of diarrhea can be found out what is the cause of such a pathology and, therefore, facilitate the process of establishing a diagnosis and selecting subsequent therapy.

Diarrhea of ​​any kind is pathological process, in which there is a violation of the absorption of water and electrolytes in the intestines. In view of this, with diarrhea of ​​any kind, approximately the same picture is observed. Both the large and small intestine have a very high capacity for water absorption. So, every day a person consumes about two liters of liquid. In general, about seven liters of water enter the intestines, taking into account saliva , , intestinal And , . In this case, only 2% of the total volume of liquid is excreted with feces, the rest is absorbed directly in the intestine. If the amount of liquid in the stool changes even very slightly, the stool becomes too hard. If there is too much fluid in the colon, a person experiences diarrhea. This disease manifests itself due to disorders in the digestive process, problems with absorption, secretion and intestinal motility. In the case of diarrhea, the small and large intestine are perceived as a single physiological unit.

Types of diarrhea

At secretory diarrhea There is an increased secretion of electrolytes and water into the intestinal lumen. In more rare cases, the cause of this type of diarrhea is a decrease in the absorption functions of the intestine. Thus, secretory diarrhea occurs when cholera , Escherichiosis , salmonellosis . But sometimes a similar condition also occurs in patients with certain non-infectious pathologies. If a patient has this type of diarrhea, the osmotic pressure of the blood plasma is higher than the osmotic pressure of the feces. The patient produces watery and fairly abundant feces, their color is green. The causes of secretory diarrhea are the active process of secretion of sodium and water in the intestine. The occurrence of this process is provoked by bacterial toxins, enteropathogenic viruses, a number of drugs and other biologically active substances. Thus, secretory diarrhea can be provoked by long chain fatty acids And bile free acids , laxatives , which contain anthraglycosides , Castor oil .

At hyperexudative diarrhea sweating occurs plasma , mucus , blood into the intestinal lumen. This condition is typical for patients suffering from infectious and inflammatory bowel diseases ( shigellosis , salmonellosis , campylobacteriosis , clostridiosis ). Also, this type of diarrhea typically manifests itself in non-communicable diseases, such as nonspecific ulcerative colitis , . The osmotic pressure of blood plasma is higher than the osmotic pressure of feces.

The osmotic pressure of fecal matter is lower than the osmotic pressure of blood plasma. The stool is liquid, there is an admixture of pus, blood, and mucus.

At hyperosmolar diarrhea the patient has a malabsorption of certain nutrients in the small intestine. The body is noticeably disturbed metabolic processes. This type of diarrhea occurs with excessive use of saline laxatives. The osmotic pressure of fecal matter is higher than the osmotic pressure of blood plasma. This condition is characterized by loose and profuse stools, in which particles of undigested food are found.

At hyper- And hypokinetic diarrhea The patient has disturbances in the transit of intestinal contents. The cause of this condition is decreased or increased intestinal motility . Very often, this condition is typical for people suffering from irritable bowel syndrome, as well as for those who use too many laxatives and antacids. The osmotic pressure of fecal matter in this condition is the same as the osmotic pressure of blood plasma. The stool is not particularly abundant, with a liquid or mushy consistency. The last two types of diarrhea occur only in patients with non-infectious diseases.

Causes of diarrhea

The occurrence of diarrhea is influenced by the following phenomena: intestinal secretion , too much high pressure V intestinal cavity , intestinal exudation , violations in progress transportation intestinal contents . All these mechanisms have a certain connection, but a certain type of disease is characterized by the predominance of the corresponding type of disorder.

Symptoms of diarrhea

Acute diarrhea occurs with various types of infections, inflammation in the intestines and due to exposure to certain medications. As a rule, diarrhea occurs in combination with a number of other manifestations: it may be , bloating , stomach ache , weakness , feeling of chills , increase in body temperature .

Symptoms of an infectious type of disease are general malaise , manifestations , bad , vomit . Very often, the causes of diarrhea are poor quality food, as well as travel (the so-called tourist diarrhea occurs). The appearance of loose stools with elements of blood indicates the presence of damage in the intestinal mucosa. Their occurrence is provoked by some pathogenic microbes or with enteropathogenic properties. The patient's condition with this form of the disease is severe due to septic symptoms and pain in the abdominal area.

Also, manifestations of diarrhea can be caused by some medications. Level the body can be assessed already through examination of the patient. If there is a significant loss of electrolytes and water in the body, then dry skin is observed, a decrease in its turgor, and may also appear. hypotension . Due to noticeable calcium losses in the body, there may be a tendency to cramps .

In case of chronic diarrhea, that is, a disease lasting more than three weeks, the examination should first of all be aimed at finding out the reasons for its occurrence. The specialist examines the medical history and conducts all relevant stool examinations. During the diagnostic process, it is important to establish the duration of diarrhea, determine the volume of stool per day, the frequency and severity of intestinal motility, and weight fluctuations. If there is a disease of the small intestine, the stool will be bulky, watery or greasy. Colon diseases accompany frequent stool, however, it will be less abundant, containing pus, blood, and mucus. In cases of colon pathology, diarrhea will usually be accompanied by painful sensations in a stomach.

Diagnosis of diarrhea

During the diagnostic process, a routine physical examination is performed. In this case, the specialist carefully examines the condition of the patient’s bowel movements and conducts a proctological examination. If the patient's stool is found blood , There is , or , then we can assume that the patient has Crohn's disease . In the process of microscopic examination of stool, it is important to determine in it inflammatory cells, fat, the presence of eggs and protozoa.

Using the sigmoidoscopy method, it is possible to diagnose, pseudomembranous colitis . To establish a diagnosis of “acute diarrhea,” the doctor is guided primarily by the patient’s complaints, medical history, proctological examination, and physical examination. The laboratory performs macro- and microscopic examination of stool samples.

If, during the process of establishing a diagnosis, it turns out that there is no inflammation in the intestines, then, most likely, diarrhea in this case will be associated with malabsorption. In some cases, the occurrence of acute diarrhea is provoked by enteroviruses. If viral enteritis is suspected, the doctor must make sure whether the symptoms and manifestations of this condition coincide. Thus, with viral enteritis, there is no blood and inflammatory cells in the stool, antibacterial therapy is ineffective during the treatment process, and the patient can recover spontaneously. The specialist must note all the described features during the differential diagnosis of various types of intestinal diseases.

In the process of diagnosing chronic diarrhea, first of all, it is determined whether there is a connection between the occurrence of diarrhea and infections or inflammations. To do this, stool tests are carried out - microscopic , bacteriological , sigmoidoscopy . Also, to exclude inflammation, the pathogenetic mechanism of diarrhea should be determined. Often, a period of time on a specific diet for diarrhea helps to establish the correct diagnosis.

Treatment of diarrhea

Some approaches to treating diarrhea are common to all four types of the disease. So, it works equally effectively, symptomatic medicines and drugs with antibacterial action. First of all, changes in eating style are practiced. So, a diet for diarrhea involves consuming foods that inhibit peristalsis and reduce the secretion of water and electrolytes. At the same time, it is important to exclude those products whose properties suggest an increase in motor-evacuation and secretory functions intestines.

Treatment of diarrhea includes administration antibacterial drugs , which are designed to restore intestinal eubiosis. Patients with acute diarrhea should take antibiotics , antimicrobial And sulfonamides drugs , antiseptics . The most preferred treatment for diarrhea is those that do not upset the balance of intestinal microflora.

An alternative medicine for diarrhea is bacterial drugs , the course of treatment of which lasts up to two months. Used as symptomatic agents adsorbents , which neutralize organic acids and also prescribe astringents And enveloping facilities.

Diarrhea is also treated with the help of drugs that regulate motility and reduce intestinal tone. And to eliminate the state of dehydration of the body it is used rehydration . If the patient is diagnosed acute condition, then rehydration is carried out orally; in rare cases, crystalloid polyionic solutions are infused intravenously for rehydration.

The doctors

Medicines

Intestinal suffering is usually represented by two opposing types - diarrhea And . Moreover, the first one causes a lot of trouble, because of which it is impossible to even leave the house. Usually, (the official name of diarrhea) is a malaise that is expressed by frequent and very loose, watery stools. She is, of course, unpleasant. But most importantly, it can be an indicator of a fairly serious disease caused by intestinal infections or food poisoning.

The main danger - as its consequence - dehydration , because of which the patient may even die. Of course, at the first signs of diarrhea, you need to consult a doctor and make a correct diagnosis. The specialist will prescribe treatment in accordance with the characteristics of your body, but, perhaps, the main thing for all patients remains severe.

Both with the treatment prescribed by the doctor and at the first signs of diarrhea, even before going to the hospital, you should drink as much mineral water as possible without carbon, fruit juice, any juice and other liquid. The exception is dairy products and coffee.

How to get rid of diarrhea?

Along with drug treatment (if the infectious nature of the disease or food poisoning is identified), it is not only possible, but also necessary to resort to folk remedies. For example, for hundreds of years now people have been getting rid of diarrhea in the following way: chicken stomach cut off the yellow shell, wash it well and dry it, then crush it with a wooden masher or rolling pin to a powder. Take this powder 1 tbsp. spoon - adults, and 1/2 tbsp. spoon - children. Drink plenty of water. Apply once a day.

Even easier to use potato starch : 1 tbsp. dilute a spoon in a cooled glass boiled water and have a drink. Adults can resort to another fairly simple recipe: dilute 1 teaspoon of salt in less than half a glass of vodka and consume immediately.

At home, it’s quite easy to prepare another version of the drug: cut a raw onion crosswise (not at the root) and put it in a glass of hot tea (not strong, without sugar). Insist this way onion 10 minutes, then drink.

A solution prepared from two components also helps well - cinnamon and red capsicum pepper . Possessing excellent astringent properties, such decoction It also helps remove it from the body gases.

Very common among people are decoctions from the walls, infused in alcohol for 2-3 days, and from the peel grenade, brewed with boiling water. Berries mixed with honey can also help - viburnum, cranberry swamp And of course, rice or, more precisely, rice congee (1:7 - ratio of cereals to cold water, boil until half-baked). Just use unbroken rice.

Diarrhea during pregnancy

Diarrhea occurs quite often when . There are a number of reasons for this condition to occur in pregnant women. So, sometimes diarrhea occurs due to diseases of the intestines or the gastrointestinal tract as a whole. In some cases, the cause of diarrhea in pregnant women is common ailments. However, during pregnancy, a woman’s body becomes especially susceptible to various infections, so diarrhea can provoke infectious diseases, local poisoning. Thus, pregnant women have a high sensitivity to toxins. However, diarrhea can also be caused by disruptions in work nervous system, and the presence of worms, and insufficient production of enzymes in the body. Often the cause of diarrhea is becoming pregnant.

In some cases, diarrhea may not pose a danger to a woman, performing the function of a kind of cleansing of the body before the upcoming childbirth . However, the causes of diarrhea should be closely monitored. After all, if this condition arose due to food or other poisoning, then it is very dangerous for both the unborn child and the woman.

During pregnancy, treatment of diarrhea should be carried out only under the close supervision of a doctor, who will definitely take into account all individual aspects. At the same time, the specialist adjusts the patient’s nutrition, prescribing her a special diet. It is very important for the expectant mother to constantly observe drinking regime, drinking enough fluid, because dehydration is an undesirable condition for the fetus and mother.

Diet, nutrition for diarrhea

List of sources

• Ivashkin V.T., Sheptulin A.A., Sklyanskaya O.A. Diarrhea syndrome - M.: GEOTAR-MED, 2002.
• Guide to gastroenterology: in three volumes / Ed. F.I. Komarov and A.L. Grebneva. T.Z.-M.: Medicine.-1996.
• Belousova E.A., Zlatkina A.R. Diarrhea syndrome in the practice of a gastroenterologist: pathophysiology and differentiated approach to treatment. - 2008.
• Treatment of diarrhea. - A textbook for doctors and other categories of senior health workers. - WHO, 2006.

Diarrhea (diarrhea) is a pathological condition of the body, which is not an independent disease and, as a rule, acts only as a syndrome. Diarrhea is accompanied by frequent bowel movements (watery stools), as well as abdominal pain.

For a healthy adult, it is considered normal to excrete 100-300 g of feces per day, depending on the food consumed and lifestyle. The appearance of defecation disorder may indicate the presence of various diseases. In some countries with low levels of economic development, diarrhea reaches pandemic proportions and causes death among infants. In countries with normal economic development, diarrhea does not have such frightening consequences and is quite easily eliminated. The mechanism of development of diarrhea involves impaired absorption of water and electrolytes in the intestine and in most cases occurs due to general intoxication of the body.

Etiology and pathogenesis of diarrhea

Severe intoxication of the body contributes to increased secretion of water with sodium ions into the intestinal lumen, which in turn contributes to the dilution of stool.

Such reactions in the intestinal lumen contribute to the accumulation of water in it, which leads to the appearance of loose stools. This form of diarrhea is extremely rare in the modern world, but if the necessary measures to dehydrate the body are not taken in time, death from hypovolemic shock is possible. This type of diarrhea is characterized by the appearance of liquid, light stool with mucus and blood clots.

Classification of diarrhea (diarrhea)

Acute diarrhea

Acute diarrhea, quite severe, develops after pathogenic microorganisms enter the body of a healthy person due to the consumption of food and water contaminated with microorganisms (fecal-oral route). The causative agents of this form of diarrhea are:

• viruses (adenoviruses, rotaviruses, enteroviruses);
• bacteria (salmonella, E. coli, Vibrio cholerae, dysentery bacteria);
• protozoa (dysenteric amoeba, Giardia).

The severity of the disease depends on the pathogen itself, the number of microorganisms that have penetrated the gastrointestinal tract, as well as the human body’s ability to immune defense.

Traveler's diarrhea

There is also traveler's diarrhea, which often develops in the first two weeks in people who have left their region; it lasts about 7 days. The cause of such dyspeptic disorders may be changes in diet, climate, water quality and stress.

Chronic diarrhea

Chronic diarrhea is a symptom of many gastrointestinal diseases. Chronic pancreatitis is characterized by girdle pain in the upper abdomen radiating to the left half chest. The pain is accompanied by bloating, steatorrhea, foul-smelling stools, as well as nausea and vomiting that does not bring relief. Exacerbations of the disease appear after consuming fatty, spicy, smoked foods and alcohol.

Bloody diarrhea, accompanied by abdominal pain, anemia and hyperthermia, joint pain, may be a sign of ulcerative colitis, pseudomembranous colitis, Crohn's disease, and intestinal tumors. Tarry diarrhea indicates bleeding from the upper gastrointestinal tract.

The diagnosis of “functional diarrhea” in irritable bowel syndrome is made if infectious etiology and all other causes are excluded. possible diseases. This condition can develop at a young age and manifest itself against the background depressive states and stress experienced. Clinically manifested by pain, bloating, rumbling and abnormal stool type pseudodiarrhea (fast stool, stool consistency is formed).

Clinical features of diarrhea

It is enough to simply identify the signs of diarrhea yourself. Clinically it manifests itself sharp pain in the stomach and intestines, frequent (more than 3 times a day) loose, watery stools, sometimes accompanied by vomiting or nausea. Features of the clinical manifestations of diarrhea depend on the etiological factors and the disease that provoked this syndrome. At severe forms diarrhea caused by infectious and viral pathogens, febrile phenomena (hyperthermia, chills, convulsions) may occur. Patients also note weakness and deterioration in general condition.

Diagnosis of diarrhea

There are many nosological entities that can manifest themselves through this syndrome, which is a hindering factor for differential diagnosis. A detailed survey of the patient will help narrow the range of suspected diseases, among which the root cause will be determined.

Diarrhea is a sign of malabsorption

Analysis of the consistency of stool and the frequency of bowel movements in most cases makes it possible to determine the level of damage. For example, polyfecalation (copious stool) with pasty, foamy or liquid masses that are poorly washed off the walls of the toilet, have a clayey or sour odor and are repeated 1-2 times a day, is a sign of enteral diarrhea and indicates malabsorption syndrome in the patient.

Enteral diarrhea

Confirmation of enteral diarrhea is a decrease in the severity of diarrhea when abstaining from food. Diarrhea with copious, watery discharge that continues during fasting may indicate increased intestinal secretion or the patient’s hidden use of laxatives.

Colon lesions

Lesions of the colon are characterized by stool 4-6 times a day with a small amount of feces (often mixed with blood), while the patient complains of abdominal pain and tenesmus. Very often, the urge to defecate can result in the separation not of feces, but of lumps of mucus, sometimes mixed with blood. When the anal sphincter is damaged, patients report fecal incontinence. A variant of such dysfunction may be the appearance of fecal particles on the underwear, instead of the expected release of gases, observed with malignant neoplasms rectum.

Inflammatory diseases

A clinical sign of inflammatory bowel diseases, infectious diarrhea, ischemic colitis, diverticulitis, and malignant tumors may be hematochezia (the presence of blood in the stool). In this case, the functional nature of diarrhea is excluded. Also, an admixture of mucus may appear in the stool, for example, with villous adenoma of the colon and with colitis, but this phenomenon may also be accompanied by irritable bowel syndrome, so differential diagnosis is very important.

The presence of undigested food particles in the stool indicates acceleration of the transit of contents in the small and large intestines and is not significant for differentiation.

The timing of the onset of diarrhea is very important clinically. Dyspeptic disorders caused by organic disease, can occur at any time of the day, including at night. Irritable bowel syndrome, which is a functional dysfunction manifested by diarrhea in the morning (usually after breakfast).

Differential diagnosis

To carry out a correct differential diagnosis, it is very important to take into account the presence of other symptoms accompanying intestinal dysfunction.

1. Pain projected in the umbilical region is a sign of pathology small intestine.
2. Painful sensations in the right iliac region usually indicate pathological processes in terminal department ileum or cecum.
3. Lesions of the sigmoid colon are characterized by cramping pain that intensifies during defecation.
4. Changes in the rectum may be indicated by pain that intensifies after defecation and radiates to the sacrum.
5. With pancreatic cancer and chronic pancreatitis, girdle pain in the upper abdomen is often observed.
6. Fever is a common symptom of infectious diarrhea, which also occurs with inflammatory changes in the intestine (ulcerative colitis, Crohn's disease), malignant tumors, diverticulitis.
7. Weight loss is not typical for irritable bowel syndrome and functional diarrhea, but may be a sign of colorectal cancer, chronic inflammatory bowel disease or malabsorption syndrome.
8. With chronic adrenal insufficiency there is a risk of developing hyperpigmentation skin and hypotension.
9. The presence of systemic signs of damage (erythema nodosum, arthritis, primary sclerosing cholangitis, iridocyclitis) facilitate the differentiation of Crohn's disease and ulcerative colitis; periodic facial hyperemia suggests the presence of carcinoid syndrome in the patient.
10. Zollinger-Edison syndrome is characterized by a combination of persistent diarrhea and frequent relapses of gastroduodenal ulcers.

Very important factor The differential diagnosis of diarrhea is the correct and clear collection of anamnesis from the patient. In most cases, these phenomena occur after errors in nutrition or ignoring hygienic principles.

Very often, diarrhea is provoked by taking medications (antibacterial, antiarrhythmic, antitumor drugs, some antidepressants and tranquilizers).

To clarify the diagnosis, the patient undergoes a series of additional research(laboratory tests, ultrasound, endoscopic examinations, sometimes a radiograph is shown).

Treatment of diarrhea

Treatment of diarrhea requires consideration individual characteristics each disease, but there are still a number of therapeutic measures that are applicable for any form of diarrhea.

Diet

The first thing you need to start with is diet. Nutrition should help reduce the secretion of electrolytes and water into the intestinal lumen, as well as slow down peristalsis. The main principle of the diet for diarrhea is the use of a mechanically and chemically gentle diet. Patients with diarrhea are usually prescribed a diet that meets this requirement, number 46, most often this diet is used during an exacerbation.

Antibacterial drugs

If it was possible to establish that etiological factor the appearance of diarrhea is a bacterial pathogen, patients are prescribed antibacterial agents. For acute forms of diarrhea, antibacterial drugs and antimicrobial agents from the group of quinolones, fluoroquinolones, nitrofuran derivatives, sulfonamide drugs, and antiseptics are used. It is best to use products that do not disturb the balance of intestinal microflora. As an alternative therapy, bacterial preparations (Linex, Enterol, Bifi-form) are used. After graduation antibacterial treatment Patients are advised to continue taking bacterial agents.

Symptomatic treatment

Treatment of diarrhea does not exclude symptomatic treatment- binders, adsorbents, neutralizing organic acids, enveloping agents(tannacomp, smecta, polyphepan).

To regulate motility, loperamide (Imodium) is prescribed, which reduces intestinal tone.

To normalize the acid-base balance and eliminate electrolyte imbalances, rehydration therapy is carried out. In the presence of acute intestinal infections rehydration is carried out orally, in severe conditions of the patient - intravenous drip infusion.

Prevention of diarrhea

The basic principles of preventing diarrhea are familiar to every person since childhood - personal hygiene, cleaning and processing of food, careful monitoring of the diet. But the main thing when symptoms of diarrhea appear is to seek medical help, especially if it lasts more than 3 days. Qualified health care will prevent and eliminate unwanted complications.

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. She can be the host clinical syndrome for 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 one-time loose stool may 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 tips of the villi), in the large intestine - 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 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, pay attention 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, frequency and severity intestinal peristalsis, 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. Wherein frequent urge defecation may result in the release not of feces, but of lumps of mucus, sometimes mixed with blood. 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) are added, muscle atrophy, mental disorders.

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 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 bacterial overgrowth syndrome, which occurs in conditions sharp decline 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 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 cause disorders twilight vision, development 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 with atresia bile ducts, Caraly's disease, primary biliary cirrhosis and primary sclerosing cholangitis. Often in clinical practice Extrahepatic cholestasis occurs, caused by compression of the common bile duct by stones, tumors of the pancreas or papilla of Vater ( duodenal papilla), 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 (so, loss jejunum generally tolerated than loss of 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. Consequence of steatorrhea and decreased absorption fat-soluble vitamins There may 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 associated with congenital diseases, is 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. In prevalence of this disease there are significant ethnic differences. 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 lactose fermentation (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 problems in them discomfort. 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.

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. Except 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 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 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 occurring in the gastrointestinal tract and causing chronic diarrhea are characterized by hyperthermia varying degrees severity and other extraintestinal symptoms: stomatitis, arthralgia, and so on.

With neuroendocrine and endocrine pathologies intestines in sick people, hormonal disturbances can be noticed.

In case of prolonged diarrhea, you should consult a doctor, especially if the pathology is accompanied 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. The exact cause of the disease that caused chronic diarrhea can only be determined by a doctor 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 does diarrhea last, is there any pain syndrome 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 pathology internal organs, then 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 fill the lack of nutrients in the body and help normalize natural intestinal motility.