Hypokinetic diarrhea. Diarrhea (diarrhea)

- a polyetiological pathological condition in which for 3-6 or more weeks there is an increase in the act of defecation up to 2-3 or more times a day with the discharge of an unformed stool. May be accompanied by tenesmus, bloating, rumbling, abdominal pain, imperative urges and the presence of pathological impurities in feces. Chronic diarrhea is diagnosed taking into account complaints, anamnesis, examination data, contrast radiological methods, colonoscopy (possibly with a biopsy), stool tests and other diagnostic methods. Treatment - diet, symptomatic and pathogenetic drug therapy.

General information

Chronic diarrhea is a symptom complex, manifested by an increase in the frequency of bowel movements with the discharge of insufficiently formed feces. Chronic diarrhea occurs in infectious and non-infectious lesions of the intestine, some diseases of the upper digestive tract, other organs and systems, as well as in chronic intoxication and conditions caused by psycho-emotional disorders. The prevalence is unknown due to the lack of generalized statistical data on the frequency of chronic diarrhea in various diseases and pathological conditions. Treatment is carried out by specialists in the field of gastroenterology, proctology and other branches of medicine.

Causes

There are several mechanisms for the development of diarrhea: hypersecretory, hyperosmotic, hyperkinetic and hyperexudative. With hypersecretory diarrhea, more intense than normal secretion of water and electrolytes into the intestinal lumen is observed. Secretion can be passive or active. Chronic diarrhea as a result of an increase in passive secretion is detected with an increase in hydrostatic pressure due to right ventricular heart failure, some diseases of the lymphatic system and systemic diseases accompanied by damage to the lymphatic vessels of this anatomical region (Whipple's disease, amyloidosis, lymphoma, lymphangiectasias). The cause of chronic diarrhea with intense active secretion can be some fatty acids, bile acids, toxins secreted by pathogenic microorganisms (V. cholerae, Escherichia coli, Staphylococcus aureus), laxatives and peptide hormones (serotonin, glucagon, vasointestinal peptide).

Hyperosmotic chronic diarrhea develops with disorders of digestion and absorption. nutrients in various parts of the gastrointestinal tract. This type of chronic diarrhea can be provoked by pathology of the pancreas (tumor, chronic pancreatitis), obstructive jaundice, a decrease in the duration of contact of intestinal contents with the wall of the small intestine (a condition after removal of a part of the small intestine, the presence of an anastomosis or interintestinal fistula), congenital and acquired malabsorption disorders (syndrome malabsorption).

Hyperkinetic chronic diarrhea occurs as a result of excessive neurogenic, hormonal or pharmacological stimulation of intestinal motor activity. Neurogenic stimulation is seen in irritable bowel syndrome, functional chronic diarrhea, and diabetic enteropathy. Hormonal stimulation is seen in thyrotoxicosis, Addison's disease, and neuroendocrine neoplasias. Pharmacological stimulation is noted when taking certain laxatives. The latter mechanism is more common in acute rather than chronic diarrhea, as patients adjust the dose of the drug after the onset of diarrhea. However, some patients abuse laxatives secretly from the doctor or even contrary to his recommendations, so this cause of diarrhea should be excluded during the differential diagnosis.

Hyperexudative chronic diarrhea is caused by inflammation of the intestinal wall and increased release of exudate into the intestinal lumen. Chronic diarrhea with increased exudation is observed in inflammatory bowel diseases (ulcerative colitis, Crohn's disease), chronic infections (actinomycosis, tuberculosis, syphilis), enteropathy, coronary bowel disease, polyps and malignant neoplasms of the colon. Usually chronic diarrhea develops as a result of a combination of several or all of the above mechanisms.

Symptoms of chronic diarrhea

The main signs of this pathology are 2-3 or more acts of defecation during the day and the discharge of insufficiently formed (watery, liquid or mushy) feces. Opinions of experts on the duration of diarrhea differ. Some researchers believe that stool disorders that persist for 3 weeks are enough to make a diagnosis of "chronic diarrhea", others indicate numbers of 4-6 or more weeks. Along with the listed symptoms, patients may experience abdominal pain, rumbling, flatulence, tenesmus, imperative urges and pathological impurities in the fecal masses.

For chronic diarrhea in the pathology of the small intestine, abundant fatty or watery stools are characteristic. With damage to the large intestine, the volume of stool decreases, and the number of bowel movements increases, impurities of pus, mucus and blood are often found in the feces. Colonic chronic diarrhea is often accompanied by pain (with the exception of functional diarrhea), pain is usually not observed with small bowel diarrhea. In chronic diarrhea resulting from diseases of the lower sections of the large intestine (with proctitis and rectosigmoiditis of various etiologies), the stool is even more meager, and defecation is even more frequent than with colitis. Patients are worried about false urges.

The remaining symptoms are determined by the underlying disease that caused the development of chronic diarrhea. With colorectal cancer, weakness, fatigue, loss of appetite, and weight loss are observed. Perhaps the development of intestinal obstruction or perforation of the intestine. On late stages cancer intoxication, hyperthermia and cachexia are noted. Inflammatory bowel diseases accompanied by chronic diarrhea are characterized by hyperthermia of varying severity (depending on the severity of the disease) and extraintestinal manifestations: arthralgia, stomatitis, etc. In endocrine and neuroendocrine disorders, signs of hormonal regulation disorders are observed.

Diagnostics

Since chronic diarrhea is not an independent disease, but a manifestation of other pathological conditions, the main goal of diagnosis is to identify the causes of diarrhea. During the examination, the doctor collects an anamnesis, finding out the features of the symptoms and determining the level of damage (small intestinal or colonic diarrhea, diseases of the rectum). When conducting an objective examination of a patient with chronic diarrhea, a specialist draws attention to the presence of bloating, soreness, abdominal asymmetry, endocrinologist, if there are signs of uremia, a consultation with a nephrologist, etc.

Treatment of chronic diarrhea

Treatment of chronic diarrhea can be pathogenetic and symptomatic. The plan of pathogenetic treatment is made taking into account the identified pathology, it is possible to use conservative (drug and non-drug) and surgical techniques. Patients with chronic diarrhea are prescribed a special diet that excludes the use of foods that stimulate motility, fermentation processes and gas formation. Steamed mashed dishes are recommended.

If necessary, antibacterial therapy is carried out using agents that do not cause the development of dysbacteriosis (nifuroxazide, tiliquinol). In chronic diarrhea against the background of dysbacteriosis, probiotics are used. Apply symptomatic means of adsorbing, enveloping and astringent action. For the regulation of motility, loperamide is prescribed, less often - octreotide and calcium antagonists. The prognosis is determined by the cause of chronic diarrhea.

For citation: Parfenov A.I. DIARRHEA // BC. 1998. No. 7. S. 6

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

The etiology and pathogenetic mechanisms of secretory, osmotic, dyskinetic and exudative diarrhea are considered. Algorithms are proposed to identify the disease that caused acute or chronic diarrhea. A scheme for the treatment of 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 stools should be 1 time per day, in the morning, is far from always true. Defecation is subject to considerable variability and numerous extraneous influences. This bowel function varies greatly with age, influenced by individual physiological, dietary, social and cultural factors. At healthy people stool frequency can vary from 3 times a day to 3 times a week, and only changes in the volume and consistency of the stool, as well as the admixture of blood, pus, or undigested food residue, indicate illness.

Definition

The stool mass of healthy adults ranges from 100 to 300 g/day, depending on the amount of fiber in the diet and the volume of water and undigested substances remaining in it. Diarrhea - frequent or single bowel movements with the release of liquid feces. Diarrhea can be acute if its duration does not exceed 2-3 weeks, and chronic if liquid stool lasts more than 3 weeks. The concept of chronic diarrhea also includes systematically abundant stools, the mass of which exceeds 300 g / day. However, in people who eat foods rich in plant fibers, this mass of stool 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 stool, consisting of undigested food debris. In case of violations of the motor function of the intestine, the stool can be frequent and liquid, but its daily amount may not exceed 200 - 300 g. Thus, already an initial analysis of the features of diarrhea makes it possible to establish the cause of the increase in the amount of feces and can facilitate the diagnosis and choice of treatment.

Pathophysiology of diarrhea

Diarrhea is a clinical manifestation of malabsorption of water and electrolytes in the intestine. The pathogenesis of diarrhea of ​​various etiologies has much in common. The capacity of the small and large intestines to absorb water and electrolytes is enormous. Every day with food a person receives about 2 liters of water. 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 liters, bile - 0.5 liters, pancreatic juice - 1.5 liters, 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 the feces, the rest of the water is absorbed in the intestines. Most of the liquid (70 - 80%) is absorbed in the small intestine. During the day, from 1 to 2 liters of water enters the large intestine, 70% of it is absorbed, and only 100 - 150 ml is lost with feces. Even slight changes in the amount of fluid in the stool lead to a change in its consistency (unformed or harder than normal).
Table 1. Diarrhea pathogenesis

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 epithelium of the villi ensures the absorption of sodium, chlorine and water ions. In the epithelium of the crypts, their secretion occurs. For a day with food and juices, 800 mmol of sodium, 100 mmol of potassium and 700 mmol of chlorine enter the intestine. Water suction is 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. Passive transport of water and ions predominates in the small intestine, which is due to the high permeability of enterocyte membranes. The absorption of water and ions occurs through the intercellular spaces. In the ileum and large intestine, sodium is absorbed through an energy-dependent mechanism, i.e. actively. This mechanism ensures the transport of sodium against a chemical concentration gradient, negative electric charge mucous membrane, 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 carrier across the brush border for glucose, amino acid, and sodium.
Table 2. Medications that cause diarrhea

The final retention of sodium and water occurs in the large intestine. Up to 70% of the sodium entering the colon is absorbed. Active transport of sodium is carried out in the large intestine by electrogenic means using a sodium pump or a combination of sodium with a hydrogen ion, chlorine or bicarbonate. Sodium, actively absorbed from the lumen of the large intestine 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-permeable capillary membrane into the blood plasma. So, water is absorbed passively, following sodium. The large intestine can absorb up to 5 liters of water per day. If it enters large quantity liquid, diarrhea occurs. Such disorders occur due to disorders of digestion, absorption, secretion and intestinal motility. In this case, the small and large intestines 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 clinical manifestations various types 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 biologically active substances. A typical example of secretory diarrhea is cholera diarrhea. The secretory effect is mediated by the mediator 3"-5"-AMP. Cholera endotoxin and many other substances increase the activity of adenylcyclase in the intestinal wall with the formation of cAMP. As a result, the volume of secreted water and electrolytes increases. At the same time, a large amount of sodium is secreted.
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 antroglycosides (senna leaf, buckthorn bark, rhubarb) and castor oil.
The secretory form is characterized by painless, profuse watery diarrhea (usually more than 1 L). When malabsorption of bile acids or poor contraction of the gallbladder, feces usually become bright yellow or green in color. The osmolar pressure of intestinal contents in 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 impaired absorption syndrome, with increased intake of osmotically active substances into the intestine (salt laxatives containing magnesium and phosphorus ions, antacids, sorbitol, etc.).
With hyperosmolar diarrhea, stools are plentiful (polyfecal matter) and may contain a large amount of remnants of semi-digested food (steatorrhea, creatorrhea, 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 a violation of the transit of intestinal contents. An increase in the rate of transit is facilitated by laxatives and antacids containing magnesium salts. An increase and decrease in motor activity of the intestine is especially often observed in patients with neurogenic diarrhea and irritable bowel syndrome. With hyper- and hypokinetic diarrhea, the stool is liquid or mushy, not abundant. The osmotic pressure of the intestinal contents approximately corresponds to the osmotic pressure of the blood plasma.

Hyperexudative diarrhea

Hyperexudative diarrhea occurs due to the "dump" of water and electrolytes into the intestinal lumen through the damaged mucous membrane and accompanies protein exudation 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 in malignant neoplasms and ischemic bowel diseases. With hyperexudative diarrhea, the stool is liquid, often with blood and pus. The osmotic pressure of faeces is often higher than the osmotic pressure of blood plasma.

Clinical features of diarrhea

Distinguish between 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 such episodes. Its causes are infections, inflammatory processes in the intestines and taking 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 use of poor-quality food and travel (diarrhea of ​​tourists). Features of the clinical picture depend on the type of causative agent of acute intestinal infection. Thus, vomiting is more typical for food poisoning caused by staphylococci, and almost never occurs in patients with salmonellosis and dysentery. Bloody liquid stool indicates 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 severe due to intoxication and abdominal pain.

Diarrhea is caused by many drugs. In table. 2 the main drugs that can cause diarrhea. Pseudomembranous colitis following antibiotic therapy is a severe form of diarrhea characterized by sudden severe watery diarrhea, sometimes with some blood in the stool, and high fever. In other cases, diarrhea does not worsen the general condition and stops after the drug is discontinued.
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, tachycardia and hypotension are observed. Due to the large loss of calcium, there is a tendency to convulsions, which may be preceded by a symptom of a "muscle roller" observed when pinching or hitting the biceps of the shoulder. Along with the usual physical examination, it is imperative to examine the patient's feces and conduct a proctological examination. The presence of blood in the feces, anal fissure, paraproctitis or fistulous tract suggests that the patient has Crohn's disease. On microscopy of feces great importance has the identification of inflammatory cells, fat, protozoa and eggs of worms in it.
Sigmoidoscopy allows the diagnosis of ulcerative colitis (bleeding, easily vulnerable mucous membrane, often with erosive and ulcerative changes), dysentery (erosive proctosigmoiditis), and pseudomembranous colitis based on the detection of characteristic dense fibrinous deposits in the form of plaques. The absence of plaques does not exclude the possibility of this complication of antibiotic therapy, since pathological changes can be localized in the proximal colon.

Treatment

Diarrhea is not a disease, but a symptom. Therefore, nosological diagnostics is necessary for etiological or pathogenetic treatment. In table. 3 lists diseases with similar mechanisms of diarrhea and outlines the principles of treatment for each type of diarrhea. As seen from tab. 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, the appointment of antibacterial drugs and symptomatic agents (adsorbents, astringents and enveloping substances).

Diet

In bowel diseases accompanied by diarrhea, nutrition should help to inhibit peristalsis, reduce the secretion of water and electrolytes into the intestinal lumen. A set of products in terms of composition and quantity of nutrients should 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. In 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 the period of exacerbation of diarrhea. Restricted physiological diet table salt up to 8 - 10 g / day, moderate limitation of mechanical and chemical irritants of the gastrointestinal tract, with the exception of products 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 preparations can be prescribed for diarrhea of ​​various origins as an alternative therapy. These include bactisubtil, lineks and enterol.
Baktisubtil is a culture of bacteria IP-5832 in the form of spores with the addition of calcium carbonate, white clay, titanium oxide and gelatin. In 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. In chronic diarrhea, bactisubtil is prescribed 1 capsule 2 to 3 times a day. The drug should be taken 1 hour before meals.
Enterol contains a freeze-dried 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 in diarrhea that developed after antibiotic therapy.
Other bacterial preparations (bifidumbacterin, bifikol, lactobacterin, linex, acilact, normaflor) are usually prescribed after a course of antibiotic therapy. The course of treatment with bacterial preparations 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 contribute to the restoration of the biological environment of the intestine, necessary for the existence of normal microflora, and inhibit the growth of pathogenic bacteria.
Hilak-forte appoint 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 enveloping preparations. These include smecta, attapulgite, and tannacomp.
Smecta contains dioctahedral smectite - a substance of natural origin, which 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. Assigned to 3 g (1 sachet) 3 times a day for 15 - 20 minutes before meals in the form of a mash (the contents of the sachet is dissolved in 50 ml of water). Given the pronounced adsorbing properties of the drug, smectite 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 contributing to the normalization of 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. Tablets should be swallowed without chewing, drinking liquid. The duration of treatment with attapulgitis should not exceed 2 days. The drug disrupts the absorption of concomitantly prescribed drugs, in particular antibiotics and antispasmodics, so the interval between taking attapulgite and other medicines should be several hours.
Tannacomp- combination drug. It contains tannin albuminate (0.5 g) and ethacridine lactate (0.05 g). Tannin albuminate (tannic acid bound to 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. For the prevention of tourist diarrhea, the drug is prescribed in 1 table. twice a day, for treatment - 1 tab. 4 times a day. Treatment ends with the cessation of diarrhea. In chronic diarrhea, the drug is prescribed in 2 tablets. 3 times a day for 5 days.
Polycarbophil calcium used as a symptomatic agent for non-infectious diarrhea. The drug is prescribed 2 capsules a day for 8 weeks.
For the treatment of hologenic diarrhea caused by bile acids, ion-exchange resins - cholestyramine, vazazan, questran are successfully used.
Cholestyramine appoint 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 bowel propulsion. The antidiarrheal effect of the drug is realized through the m-opiate receptors of the enteric system. There is evidence that direct interaction with small intestinal opiate receptors alters epithelial cell function, decreasing secretion and improving absorption. The antisecretory effect is accompanied by a decrease in the motor function of the intestine. In acute diarrhea, the initial dose of loperamide is 2 capsules, then 1 (0.002 g) capsule is prescribed after each act of defecation; in the case of loose stools - until the number of defecation acts is reduced to 1 - 2 per day. The maximum daily dose for adults is 8 capsules. With the appearance of a normal stool and the absence of acts of defecation 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. With extreme caution, loperamide should be prescribed 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 defecation, fecal mass.
Octreotide- a synthetic analogue of somatostatin - can be successfully used in severe secretory and osmotic diarrhea of ​​various origins, it is prescribed 100 mcg subcutaneously 3 times a day.
With 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 resection of the intestine or hyperkinesia of the colon, treatment is continued up to 3-4

Secretory type of diarrhea

Diarrhea (diarrhea) is a condition in which the volume of stool exceeds the usual value. Its consistency is soft watery, with a frequency of more than three times a day. The mechanism of diarrhea is a combination of an increase in fluid entering the intestinal lumen and a decrease in its absorption.

Secretory diarrhea is characterized by an increased output of water and electrolytes. The consequences of secretory diarrhea are:

• loss of bicarbonate (acidosis);
• loss of potassium (hypokalemia);
• violation of electrolyte metabolism;
• malabsorption (malabsorption in the small intestine).

A significant loss of sodium is a complex violation of intracellular regulation and leads to the penetration of bacterial toxins.

What diseases cause secretory diarrhea

Secretory diarrhea develops with various infections of the gastrointestinal tract. These include enteroviruses, cholera. It also occurs on the background of taking various medications. These are antibiotics, laxatives, antacids, anticoagulants, drugs for the treatment of arrhythmias. The use of biologically active additives, sugar substitutes, as well as irritable bowel syndrome, when the functions of peristalsis and intestinal motility are impaired, contributes to secretory diarrhea. Diarrhea occurs with diseases:

• cholera;
• diseases in violation of the absorption of fatty and bile acids (Crohn's disease);
• diseases caused by staphylococcal infection;
• dysfunction of the liver, kidneys or pancreas.

Secretory diarrhea symptoms

Symptoms of secretory diarrhea are:

• frequent, watery and liquid odorless stools;
• the presence in the feces of undigested food residues;
• mild intoxication of the body;
• lack of spastic pain;
• an increase in body temperature from 37.2 ° C to 37.8 ° C;
• lack of false urges to empty;
• electrolyte imbalance.

Differential diagnosis of secretory diarrhea

The main diagnostic information is the examination and examination of the patient's feces. Its consistency, color indicates one or another pathological conditions. An examination by the attending physician and an analysis of all the patient's complaints and these symptoms complete the overall picture of the disease.

Secretory diarrhea treatment

For the treatment of secretory diarrhea, after receiving the results of the studies, a diet is prescribed. More often than not, this is an elimination diet. Within three weeks, foods in all forms that can cause allergic reactions should be excluded from your diet. Antibacterial drugs are prescribed. These include Enterol, Furazalidon, Intetrix. At the same time, treatment is carried out with bacterial preparations, for example, Hilak-forte, Baktisubtil, Bifidumbacterin. Both astringents and enveloping intestinal walls are used, medicines: Smecta, Attapulgite.

Secretory diarrhea in children

For a child with secretory diarrhea, proper nutrition is of great importance in treatment. The diet should consist of dairy and plant products. For infants, it is preferable breast-feeding. For formula-fed babies, choose an adapted lactose-free formula. After a year, give the child acidophilus milk, kefir. In the baby's diet should be a sufficient amount of vitamins, proteins, carbohydrates and fats. Use dairy biologically active nutritional supplements with Lysozyme, Lactobacterin, or a drug that contains both of these components. Cook porridge on vegetable broths.

Enzymes, probiotics are prescribed as therapeutic therapy. If conditionally pathogenic microflora is found in the feces, the use of special bacteriophages is prescribed. Herbal decoctions of St. John's wort, eucalyptus, sage are also prescribed. Lingonberries, yarrow, plantain. To increase the activity of the gastrointestinal tract, cabbage juice, nettle decoction, lemon balm or string are used. Additionally, a course of vitamin therapy is prescribed. These are complexes: Mystic, Hyper, Nutrimax, Passilat. Enterosorbents are prescribed - activated carbon, Atapulgite and antisecretory drugs - Loperamide or Somatostin. Antidiarrheal drugs are prescribed to children infrequently, only in the case of a chronic form of diseases, inflammation of the liver or short bowel syndrome. In the case of an acute episode, rapid hydration with an electrolyte solution with glucose for four to six hours is prescribed.

To collect anamnesis, you need to use the data:

• what medications have been used recently, including antibiotics;
• the presence of diseases in the child: past infections, relapses of severe infections;
• whether the diet was violated;
• whether there were trips to third world countries;
• whether the child attends a childcare facility;
• what foods have you recently used;
• having pets at home.

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, cramps.

In 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 the causes of diarrhea are not found out in time, then serious complications will develop that will lead to disruption of the work of all body systems.

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

The causes of chronic diarrhea are diverse 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 lesions of the gastrointestinal tract caused by intestinal stick, salmonella and other pathogenic microbes and helminths. In addition, diarrhea in adults and children can develop after exposure to viruses.

Infectious causes of chronic diarrhea:

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

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

The main causes of non-infectious diarrhea are:

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

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

In order for the function of the intestine to be restored, in this situation it is enough to exclude from the diet bakery products made from wheat and oatmeal.

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, spasms, increased gas formation and an admixture of mucus in the feces.

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

With 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 feces may contain impurities of pus, blood and mucous secretions.

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

In inflammatory processes in the lower intestines (proctitis, colitis), patients experience frequent false urge to empty.

Other observed 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 be replaced by intestinal obstruction, in severe cases, a rupture of the intestinal wall develops.

In the later stages of the development of cancer pathology, the patient is subjected to severe intoxication, he has cachexia and hyperthermia.

For inflammation occurring in the gastrointestinal tract and causing chronic diarrhea, hyperthermia of varying severity and other extraintestinal symptoms are characteristic: stomatitis, arthralgia, and so on.

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

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

If treatment is not started on 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 established 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 the diarrhea lasts, whether there is pain and cramps, bloating and asymmetry of the abdomen, and so on.

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

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

• complete blood count;
• serum calcium concentration;
• concentration of B vitamins;
• the 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, additional examinations are prescribed for patients 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 taking 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 underlying 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 feces helps to determine the presence of an inflammatory process in the intestine and the type of pathogenic organisms.

Coprological examination of patients with chronic diarrhea reveals amylorrhea, steatorrhea, and creatorrhoea.

During irrigoscopy with cancerous tumors and polyps, all kinds of filling defects are found.

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

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

If you suspect a violation of the hormonal background and pathology of the thyroid gland, you need to consult an endocrinologist, with uremia - a urologist.

The scheme of treatment of pathology

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 destroy the microorganisms that caused 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 remedy Mexaform contains kaolin, streptomycin, sodium citrate and pectin. The drug is prescribed 1 tablet three times a day for a week.

Suspension Depental-M, which includes metronidazole and furazolidone, also has bactericidal properties. Take it 1 scoop after each meal for 5 days.

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

The drug Bactisubtil contains cultures of beneficial microbes needed by the intestines, and calcium carbonate. The remedy should be taken within 10 days twice in 1 capsule.

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

These medications should be taken for at least one month. Drops of Hilak-Forte, which contain waste products of lactobacilli, can reduce the reproduction 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 the natural motility of the intestines.

Diarrhea(diarrhea) - rapid, repeated loose stools. Diarrhea is usually accompanied by pain, rumbling in the abdomen, flatulence, tenesmus. Diarrhea is a symptom of many infectious diseases and inflammatory processes of the intestine, dysbacteriosis, and neurogenic disorders. That's why importance in the prevention of complications plays the diagnosis and treatment of the underlying disease. The loss of a large amount of fluid during profuse diarrhea leads to a violation of the water-salt balance and can cause heart and kidney failure.

General information

Diarrhea is called a single or frequent bowel movement with liquid stools. Diarrhea is a symptom that signals a malabsorption of water and electrolytes in the intestine. Normally, the amount of feces excreted per day by an adult varies between 100-300 grams, depending on the characteristics of the diet (the amount of vegetable fiber consumed, poorly digestible substances, liquids). In the case of increased intestinal motility, the stool may become more frequent and thin, but its amount remains within the normal range. When the amount of fluid in the stool increases to 60-90%, then they talk about diarrhea.

There are acute diarrhea (lasting no more than 2-3 weeks) and chronic. In addition, the concept of chronic diarrhea includes a tendency to periodically plentiful stools (more than 300 grams per day). Patients suffering from malabsorption of various nutrients have a tendency to polyfaeces: the excretion of large amounts of stool containing undigested food debris.

Causes of diarrhea

With severe intoxication in the intestine, excessive secretion of water with sodium ions into its lumen occurs, which helps to thin the stool. Secretory diarrhea develops with intestinal infections (cholera, enteroviruses), taking certain medications and dietary supplements. Osmolar diarrhea occurs with malabsorption syndrome, insufficiency of sugar digestion, excessive consumption of osmotically active substances (laxative salts, sorbitol, antacids, etc.). The mechanism of development of diarrhea in such cases is associated with an increase in osmotic pressure in the intestinal lumen and diffusion of fluid along the osmotic gradient.

A significant factor contributing to the development of diarrhea is a violation of intestinal motility (hypokinetic and hyperkinetic diarrhea) and, as a result, a change in the rate of transit of intestinal contents. Strengthening of motility is facilitated by laxatives, magnesium salts. Motor function disorders (weakening and strengthening of peristalsis) occur with the development of irritable bowel syndrome. In this case, they talk about functional diarrhea.

Inflammation of the intestinal wall is the cause of the exudation of protein, electrolytes and water into the intestinal lumen through the damaged mucosa. Exudative diarrhea accompanies enteritis, enterocolitis of various etiologies, intestinal tuberculosis, acute intestinal infections (salmonellosis, dysentery). Often with this type of diarrhea in the stool there is blood, pus.

Diarrhea may develop as a result of taking medications: laxatives, antacids containing magnesium salts, certain groups of antibiotics (ampicillin, lincomycin, cephalosporins, clindamycin), antiarrhythmic drugs (quindiline, propranol), digitalis preparations, potassium salts, artificial sugars (sorbitol, mannitol) , cholestyramine, chenodeoxycholic acid, sulfonamides, anticoagulants.

Classification

There are the following types of diarrhea: infectious (with dysentery, salmonellosis, amoebiasis, food poisoning and entroviruses), alimentary (associated with violations in the diet or allergic reaction on food), dyspeptic (accompanies digestive disorders associated with insufficiency of the secretory functions of organs digestive system: liver, pancreas, stomach; as well as with insufficient secretion of enzymes in the small intestine), toxic (with arsenic or mercury poisoning, uremia), drug (caused by taking drugs, drug dysbacteriosis), neurogenic (with changes in motor skills due to impaired nervous regulation associated with psycho-emotional experiences).

Clinical features of diarrhea

In clinical practice, acute and chronic diarrhea are distinguished.

Acute diarrhea

chronic diarrhea

Diarrhea that lasts more than 3 weeks is considered chronic. It can be the result of various pathologies, the identification of which is the main task for determining treatment tactics. Information about the causes of chronic diarrhea can be provided by the history data associated with clinical symptoms and syndromes, physical examination.

Particular attention is paid to the nature of the stool: the frequency of defecation, daily dynamics, volume, consistency, color, the presence of impurities in the feces (blood, mucus, fat). When questioned, the presence or absence of concomitant symptoms is revealed: tenesmus (false urge to defecate), abdominal pain, flatulence, nausea, vomiting.

Pathologies of the small intestine are manifested by abundant watery or fatty stools. For diseases of the large intestine, less abundant stools are characteristic, streaks of pus or blood, mucus may be noted in the feces. Most often, diarrhea with lesions of the large intestine is accompanied by pain in the abdomen. Diseases of the rectum are manifested by frequent scanty stools as a result of increased sensitivity to stretching of the intestinal walls, tenesmus.

Diagnosis of diarrhea

Acute diarrhea, as a rule, is characterized by a very pronounced loss of fluid and electrolytes in the feces. On examination and physical examination of the patient, signs of dehydration are noted: dryness and decreased skin turgor, increased heart rate and decreased blood pressure. With a pronounced calcium deficiency, the symptom of a "muscle roller" becomes positive, there may be convulsions.

With diarrhea, the patient's stool is always carefully examined, in addition, it is desirable to carry out a proctological examination. Identification of an anal fissure, fistula, paraproctitis may suggest the presence of Crohn's disease. With any diarrhea, a comprehensive study of the digestive tract is performed. Instrumental endoscopic techniques (gastroscopy, colonoscopy, irrigoscopy, sigmoidoscopy) allow you to examine the inner walls of the upper gastrointestinal tract and large intestine, detect mucosal damage, inflammation, neoplasms, bleeding ulcers, etc.

Microscopy of feces reveals a high content of leukocytes and epithelial cells in it, which indicates the presence of inflammation of the mucous membrane of the digestive tract. The detected excess of fatty acids is a consequence of malabsorption of fats. Together with the rest muscle fibers and high starch content in the feces, steatorrhea is a sign of malabsorption syndrome. Fermentation processes due to the development of dysbacteriosis contribute to a change in the normal acid-base balance in the intestine. To identify such disorders, intestinal pH is measured (normally 6.0).

Persistent diarrhea in combination with excessive gastric secretion is characterized by Zollinger-Ellison syndrome (ulcerogenic adenoma of the pancreas). In addition, prolonged secretory diarrhea may be the result of the development of hormone-producing tumors (for example, vipoma). Laboratory blood tests are aimed at identifying signs of an inflammatory process, biochemical markers of liver and pancreas dysfunction, hormonal disorders that can be causes of chronic diarrhea.

Treatment of diarrhea

Diarrhea is a symptom of many diseases, therefore, in the choice of medical tactics, the main role is played by the identification and treatment of the underlying pathology. Depending on the type of diarrhea, the patient is referred for treatment to a gastroenterologist, an infectious disease specialist, or a proctologist. It is imperative to apply for medical care if there is diarrhea lasting more than 4 days, or streaks of blood or mucus are noticeable in the stool. In addition, symptoms that should not be ignored are: tarry stools, abdominal pain, fever. If there are signs of diarrhea and there is a possibility of food poisoning, it is also necessary to consult a doctor as soon as possible.

Treatment for diarrhea depends on the type of diarrhea. And includes the following components: diet food, antibacterial therapy, pathogenetic treatment (correction of malabsorption in case of enzyme deficiencies, reduction of gastric secretion, drugs that normalize intestinal motility, etc.), treatment of the effects of prolonged diarrhea (rehydration, restoration of electrolyte balance).

With diarrhea in diet introduce products that help reduce peristalsis, reduce the secretion of water into the intestinal lumen. In addition, the underlying pathology that caused diarrhea is taken into account. Diet components should correspond to the functional state of digestion. Products that promote the secretion of hydrochloric acid and increase the rate of evacuation of food from the intestines are excluded from the diet for the duration of acute diarrhea.

Antibiotic therapy for diarrhea is prescribed to suppress the pathological flora and restore normal eubiosis in the intestine. With infectious diarrhea, broad-spectrum antibiotics, quinolones, sulfonamides, nitrofurans are prescribed. The drugs of choice for intestinal infections are drugs that do not adversely affect the intestinal microbiocenosis (combined drugs, nifuroxazide). Sometimes, with diarrhea of ​​various origins, eubiotics may be prescribed. However, more often such treatment is prescribed after the signs of diarrhea subside to normalize the intestinal flora (eliminate dysbacteriosis).

As symptomatic agents, adsorbents are used, enveloping and astringent agents that neutralize organic acids. To regulate intestinal motility, loperamide is used, in addition, acting directly on the opiate receptors of the small intestine, reducing the secretory function of enterocytes and improving absorption. A pronounced antidiarrheal effect is exerted by somatostatin, which affects the secretory function.

In infectious diarrhea, drugs that reduce intestinal motility are not used. Loss of fluid and electrolytes with prolonged and profuse diarrhea requires rehydration measures. Most patients are prescribed oral rehydration, but in 5-15% of cases there is a need for intravenous administration of electrolyte solutions.

Prevention of diarrhea

Diarrhea prevention includes body hygiene and nutrition. Washing hands before eating, thoroughly washing raw vegetables and fruits, and properly cooking food all contribute to avoiding food poisoning And intestinal infections. In addition, it is worth remembering the need to avoid drinking raw water, unfamiliar and suspicious food, food products that can cause an allergic reaction.