What is diarrheal syndrome and how does it manifest? Acute Diarrhea (Acute Diarrhea) Diarrhea Syndrome in Infectious Diseases

Diarrheal syndrome (diarrhea) - frequent loose stools with increased intestinal motility and changes in its characteristics. At the heart of diarrhea is the accelerated passage of the contents through the intestines, a slowdown in the absorption of fluid, as well as increased mucus formation.
An increase in bowel movements in a healthy newborn baby can be caused by:
- gross violations of the diet of a nursing mother;
- child starvation (hypogalactia, flat nipples, tight breasts);
- overheating;
- overfeeding;
- defects in care;
- intestinal dysbiosis.
A feature of the clinical picture is. the fact that the general condition of the child does not suffer, and after the elimination of the unfavorable factor, digestion and stool are almost always normalized.
Diarrheal syndrome in a newborn not always yavl. specific only for gastrointestinal diseases. The main reasons can be intestinal infections, a number of somatic diseases, metabolic, toxic, hormonal and other factors that lead to an inflammatory reaction from the gastrointestinal tract.

Acute diarrheal syndrome can occur a second time in various non-gastroenterological infectious and inflammatory diseases. These diseases most often include:
- otitis media;
- pneumonia;
- pyelonephritis;
- purulent-inflammatory diseases, including sepsis.
Possible and prolonged diarrhea - characterized by a persistently pronounced change in the consistency and volume of the stool, a violation of its composition and frequency, lasting more than 3 weeks. Long-term diarrhea should also include conditions in which intestinal disorders periodically appear. Their peculiarity is that they tend to heal within 3-4 weeks. The severity is different.
Most often, prolonged diarrhea is associated with non-infectious factors:
- malabsorption;
- maldigestion;
- hereditary metabolic disorders;
- primary immunodeficiencies (Di-Gheorghe syndrome, Wiskott-Aldrich syndrome);
endocrine system diseases (adrenogenital syndrome, salt-wasting form).
Malabsorption - hereditary pathology associated with impaired intestinal absorption of individual or several constituent parts of food (proteins, fats, carbohydrates, and electrolytes) with preserved enzymatic breakdown. In the neonatal period, it occurs when:
intestinal form of cystic fibrosis; intolerance to cow's milk proteins (allergy to cow's milk, lactic enteropathy, allergic enteritis).

SEASON 10

1)Hyper and hypovitaminosis D

Vitamin D- a group of biologically active substances. Vitamin D 3 is synthesized by ultraviolet rays in the skin and enters the human body with food. Vitamin D 2 can only be taken from food.

Hypovitaminosis: rickets develops. Avitaminosis D reduces the absorption of calcium and its release from the bones, which stimulates the synthesis of parathyroid hormone by the parathyroid glands. Secondary hyperparathyroidism develops and develops, contributing to the leaching of calcium from the bones and the excretion of phosphate in the urine.

Manifestations of rickets in children:

1. There is a slowed-down process of teething, closing of the fontanelle.

2. The flat bones of the skull with a flattening of the occiput are softened; in the region of the parietal and frontal tubercles, layers are formed ("square head", "Socrates' forehead").

3. The facial skull is deformed (saddle nose, high Gothic palate).

4. The lower limbs are crooked, the pelvis may be deformed ("flat pelvis").

5. The shape of the chest is changing ("chicken breast").

6. Sleep disturbances, sweating, irritability are observed.

Hypervitaminosis: an increase in the content of calcium in the blood, calcium is transferred from bone tissue to other organs and tissues, disrupting their functions. Its deposits are observed in the arteries, heart, liver, kidneys and lungs. The exchange is impaired, the fragility of the skeleton increases.

2)Acute rheumatic fever in children. Modern concepts of etiopathogenesis. Diagnostics. Therapy. Prevention.

ORL - it is a systemic disease of connective tissue with a predominant localization of lesions in the cardiovascular system (carditis, valvular heart disease), the development of articular (arthritis), skin (rheumatic nodules, annular erythema) and neurological (chorea) syndromes.

Etiology:β-hemolytic streptococcus group A

Clinical and diagnostic criteria for ARF:

I. Large (rheumatic clinical pentad):

1) rheumatic heart disease (mainly endomyocarditis);

2) polyarthritis (mainly of large joints, migratory in nature, without residual deformities, radiologically negative);

3) small chorea (hypotonic-hyperkinetic syndrome due to damage to the striatum of the subcortex of the brain);

4) rheumatic nodules (periarticular subcutaneous nodular seals);

5) anular erythema (ring-shaped redness of the skin of the trunk and proximal extremities).

1) clinical: fever, arthralgia;

2) laboratory and instrumental: a) laboratory (SRB, SK, DPA, SM, ASLO, ASGN); b) instrumental (increase in the PQ interval on the ECG)

Therapy: penicillins and NSAIDs; extencillin 2.4 million units 1 time in 3 weeks.

Acute diarrhea is watery loose stools with a frequency of more than 3 times a day, more than 200 r / mouth, or loose stools with blood more than 1 time a day. The duration of acute diarrhea does not exceed 14 days.

Surgical diseases of the abdominal organs,

Acute infectious diarrhea

Nosocomial infections

Non-surgical diseases,

Functional disorders of the gastrointestinal tract.

Acute surgical diseases include appendicitis, inflammation of the appendages, diverticulosis, perforation, nonspecific inflammatory bowel disease. For non-surgical diseases - systemic infection, malaria, typhoid fever, nonspecific inflammatory bowel disease, ischemic enterocolitis, drug intoxication, irritable bowel syndrome, endocrinopathy, radiation therapy.

Acute infectious diarrhea combines about 20 diseases of bacterial, viral, protozoal or helminths, and is the most common cause of acute diarrhea.

Enterotoxins do not cause structural changes in the intestinal mucosa.

If the pathogens produce only enterotoxin, then the disease proceeds according to the gastroenteric and gastritic variants, typical of foodborne toxicoinfection, the appointment of antimicrobial drugs in these patients is impractical. Some pathogens of infectious diarrhea produce cytotoxins that damage epithelial cells and cause inflammation.

The invasiveness of bacteria leads to inflammation in the submucous layer of the intestine, the formation of ulcers and erosions on the mucous membrane. Bacteria are able to enter the cytoplasm of epithelial cells, destroying them.

Traveler's diarrhea

Traveler's diarrhea (DP) - is considered a form of acute infectious diarrhea. Infection with it when traveling to the countries of Latin America, Africa, Asia and the Middle East is 30–54%, to the countries of Southern Europe - 10–20%, Canada, the countries of Northern Europe - less than 8%. Transmitted through raw fruits, vegetables, water, seafood, ice cream, unpasteurized milk; changes in the nature of nutrition, climatic characteristics of the country and stresses contribute to the development ... In 25-60% of cases of DP, the causative agent of the disease is toxigenic Escherichia coli.

Also distinguish:

Salmonella spp.,

Shigella spp.,

Klebsiella enterocolitica.

Staphylococcae cause acute infectious diarrhea by producing toxins in food that cause food poisoning.

Viruses cause acute infectious diarrhea in 10% of cases. It is difficult to establish the cause of acute infectious diarrhea even in a well-equipped laboratory.

The pathogenicity and virulence of the pathogen, the immunological reactivity of patients determine the severity of symptoms of acute infectious diarrhea. Reduced acidity of the stomach contents, a large number of microbial cells massively entering the gastrointestinal tract, and resistance of the pathogen to hydrochloric acid contribute to the occurrence of acute infectious diarrhea. In adults, acute infectious diarrhea rarely leads to severe, life-threatening complications.

The severity of the disease in travelers' diarrhea is determined to a large extent by emotional experiences due to the violation of the traveler's plans. The prognosis is serious in patients in the high-risk group, which include children under 5 years old, people over 60 years old, people with impaired immunity: abusers, taking corticosteroids, having undergone chemotherapy or radiation therapy, suffering from systemic diseases, acquired immunodeficiency syndrome.

Symptoms of acute infectious diarrhea can range from frequent bloody diarrhea with severe abdominal pain and dehydration to relatively easily tolerated mild watery diarrhea. Most sporadic cases of acute infectious diarrhea last no more than 3–6 days.

Symptoms of Acute Infectious Diarrhea

Symptoms of acute infectious diarrhea, depending on the severity, are subdivided: acute profuse diarrhea: watery, bloody, bloody; dehydration: mild, moderate, severe; intoxication: moderate, severe, shock; abdominal pain: tenesmus, cramping pain, acute abdomen; fever: subfebrile (37.5 ° C), febrile (38 ° C); nausea / vomiting: mild, severe.

For coccal infections and salmonellosis, a shorter incubation period is characteristic. Bacterial acute infectious diarrhea is accompanied by severe intoxication, a significant deterioration in the general condition of the patient, dehydration, headache, fever up to 38–39 ° C, nausea, and vomiting. With a widespread infection, symptoms of muscle irritation, muscle and bone-joint pain may appear.

Bacterial acute diarrhea is always accompanied by painful tenesmus (urge to defecate) and cramping severe pain in the abdomen, and with dysentery leads to bloody stools. Men may develop Reiter's syndrome: arthritis - inflammation of the joints, conjunctivitis - inflammation of the conjunctiva of the eyes, urethritis - inflammation of the urethra.

From the characteristics of the course, several of the most typical variants of viral or bacterial acute infectious diarrhea are distinguished. Infection with E. cole leads to watery diarrhea without clinically significant dehydration (dehydration): watery stools 4–8 times a day, low-grade fever for no more than 2 days, unexpressed abdominal pain and vomiting lasting no more than 2 days, painless feeling of the abdomen.

A watery OID with clinically significant dehydration requires first exclusion of cholera. It is distinguished by a sudden onset, has a profuse character, is accompanied by severe dehydration, the absence of fever and abdominal pain, the feeling of the abdomen does not cause pain, convulsions may develop.

The duration of the disease does not exceed 4–5 days. The algorithm for managing such patients: in cases where a patient with diarrhea has "anxiety symptoms" - temperature over 38.5 "C, feces mixed with blood, severe vomiting, symptoms of dehydration, the patient is prescribed a bacteriological examination of feces, determination of toxin (if diarrhea arose while taking antibiotics), sigmoidoscopy and specific therapy, depending on the changes identified. In the absence of such symptoms, therapy includes symptomatic remedies; in the absence of improvement within 48 hours, an examination is necessary.

Gastroenteritis

From the group of acute infectious diarrhea, the most common gastroenteric variant develops with foodborne infections (PTI), bacterial OIDs with a secretory mechanism for the development of diarrheal syndrome, viral gastroenteritis, cryptosporidiosis and giardiosis (giardiasis).

The article uses materials from open sources:

Chapter 1. Infectious diarrheal diseases

Surgical diseases of the abdominal organs,

Acute infectious diarrhea

Nosocomial infections

Non-surgical diseases,

Functional disorders of the gastrointestinal tract.

Acute surgical diseases include appendicitis, inflammation of the appendages, diverticulosis, bowel perforation, nonspecific inflammatory bowel disease. For non-surgical diseases - systemic infection, malaria, typhoid fever, nonspecific inflammatory bowel disease, ischemic enterocolitis, drug intoxication, irritable bowel syndrome, endocrinopathy, radiation therapy.

Acute infectious diarrhea combines about 20 diseases of bacterial, viral, protozoal or helminths, and is the most common cause of acute diarrhea.

In bacterial infections, diarrhea is associated with the production of enterotoxins, which, through the activation of natural intracellular mechanisms, increase the secretion of fluid and electrolytes into the intestinal lumen, which leads to the development of dehydration. Enterotoxins do not cause structural changes in the intestinal mucosa. If the pathogens produce only enterotoxin, then the disease proceeds according to the gastroenteric and gastritic variants, typical of foodborne toxicoinfection, the appointment of antimicrobial drugs in these patients is impractical. Some pathogens of infectious diarrhea produce cytotoxins that damage epithelial cells and cause inflammation.

Traveler's diarrhea (DP) is considered a form of acute infectious diarrhea. Infection with it when traveling to the countries of Latin America, Africa, Asia and the Middle East is 30–54%, to the countries of Southern Europe - 10–20%, Canada, the countries of Northern Europe - less than 8%. Transmitted through raw fruits, vegetables, water, seafood, ice cream, unpasteurized milk; changes in the nature of nutrition, climatic characteristics of the country and stresses contribute to the development ... In 25-60% of cases of DP, the causative agent of the disease is toxigenic Escherichia coli. Also distinguish:

Salmonella spp.,

Shigella spp.,

Klebsiella enterocolitica.

Staphylococcae cause acute infectious diarrhea by producing toxins in food that cause food poisoning.

Viruses cause acute infectious diarrhea in 10% of cases. It is difficult to establish the cause of acute infectious diarrhea even in a well-equipped laboratory.

The severity of the disease in travelers' diarrhea is determined to a large extent by emotional experiences due to the violation of the traveler's plans. The prognosis is serious in patients in the high-risk group, which include children under 5 years old, people over 60 years old, people with impaired immunity: alcohol abusers, taking corticosteroids, having undergone chemotherapy or radiation therapy, suffering from systemic diseases, acquired immunodeficiency syndrome.

Acute infectious diarrhea of bacterial origin is more severe and more unfavorable than viral due to damage to the mucous membrane by enterotoxins. The incubation period for acute infectious diarrhea ranges from 6-8 hours to 3 days. For coccal infections and salmonellosis, a shorter incubation period is characteristic. Bacterial acute infectious diarrhea is accompanied by severe intoxication, a significant deterioration in the general condition of the patient, dehydration, headache, fever up to 38–39 ° C, nausea, and vomiting. With a widespread infection, symptoms of muscle irritation, muscle and bone-joint pain may appear.

Often cause bloody salmonella stools, Escherichia coli, dysentery shigella. At the onset of the disease - watery diarrhea, after 1–2 days, frequent small bowel movements (10–30 times a day), consisting of blood, mucus and pus; abdominal pain, tenesmus - false urge to defecate, febrile - high body temperature, fever, slight dehydration (dehydration), pain on palpation of the abdomen, hemolytic uremic syndrome - blood breakdown and increased blood urea levels, sepsis. A watery OID with clinically significant dehydration requires first exclusion of cholera. It is distinguished by a sudden onset, has a profuse character, is accompanied by severe dehydration, the absence of fever and abdominal pain, the feeling of the abdomen does not cause pain, convulsions may develop.

For diagnostic purposes, microbiological examination and microscopy of feces in the dark field of view are performed. Traveler's diarrhea appears 2-3 days after the start of the trip. In 80% of patients, stool frequency is 3-5 times a day, in 20% - b or more times. In 50-60% of cases, fever and abdominal pain occur, blood in the stool is noted only in 10% of patients. The duration of the disease does not exceed 4–5 days. The algorithm for managing such patients: in cases where a patient with diarrhea has "anxiety symptoms" - temperature over 38.5 "C, feces mixed with blood, severe vomiting, symptoms of dehydration, the patient is prescribed a bacteriological examination of feces, determination of toxin (if diarrhea arose while taking antibiotics), sigmoidoscopy and specific therapy, depending on the changes identified. In the absence of such symptoms, therapy includes symptomatic remedies; in the absence of improvement within 48 hours, an examination is necessary.

Gastroenteritis is one of the most frequent variants of the course of acute infectious diarrhea. Difficulty in the differential diagnosis of this variant of the course of the disease lies in the fact that in some cases it develops in conditions not associated with infection - acute appendicitis. From the group of acute infectious diarrhea, the most common gastroenteric variant develops with foodborne infections (PTI), bacterial OIDs with a secretory mechanism for the development of diarrheal syndrome, viral gastroenteritis, cryptosporidiosis and giardiosis (giardiasis).

Etiological and clinical-epidemic characteristics of food toxicoinfections.

Bacillus cereus is a diarrheal toxin. The incubation period is 10-16 hours; symptoms - spastic abdominal pain, nausea, watery diarrhea, stops on its own; the duration of the disease - 24–48 hours; food connection - meat, stews, gravies, sauces; treatment - pathogenetic, antibacterial agents.

Bacillus cereus. The incubation period is 1-6 hours; symptoms - sudden onset with nausea and vomiting, diarrhea may develop; the duration of the disease is 24 hours; in case of violation of the rules for storing cooked products (meat, rice); pathogenetic treatment, antibiotic therapy is not indicated. These are actually two different diseases caused by the same pathogen.

Clostridium perfringens toxin. The incubation period is 8-16 hours; symptoms - spastic abdominal pain, nausea, watery diarrhea, fever is uncommon; the duration of the disease is 24–48 hours; food connection - meat, poultry, sauces, dried foods and convenience foods; treatment - antibiotic therapy is not indicated.

Enterotoxigenic E. cole. The incubation period is 1-3 days; symptoms - watery diarrhea, abdominal pain, possible vomiting; the duration of the disease is 3–7 days; therapy - pathogenetic therapy, antibiotic therapy in severe cases.

Staphylococcus aureus (producing enterotoxin); the incubation period is 1–6 hours, the onset is sudden with severe nausea and vomiting, abdominal cramping, diarrhea and fever are not typical; the duration of the disease is 24–48 hours, occurs when the rules for storing cooked products (meat, potatoes, salads, eggs, cakes, pastries with cream) are violated; treatment - pathogenetic therapy, antibiotic therapy is indicated in severe cases.

Salmonella spp. The incubation period is 1 - 3 days, manifested by fever, vomiting, diarrhea, abdominal cramping, depending on the course; the duration of the illness is 4–7 days or more, the relationship with food - contaminated eggs and poultry meat, unpasteurized milk, juice, cheese, raw vegetables; pathogenetic therapy, antibiotic therapy is indicated in severe cases.

Food toxicoinfections have the shortest incubation period, due to the entry into the body of not only the pathogen, but also its enterotoxin. With IPT, the duration of the incubation period is 6-12 hours, no more than 24 hours. A longer incubation period (16-72 hours or more) is observed with salmonellosis, shigellosis, campylobacteriosis, yersiniosis, escherichiosis.

Viral gastroenteritis - causes and clinical picture and epidemic characteristics.

Noroviruses are a Norwalk-like virus. The incubation period is 24–48 hours; symptoms - nausea, vomiting, watery diarrhea, fever is uncommon; duration - 24-60 hours; connection with food - insufficiently thermally processed shellfish, salads, sandwiches; pathogenetic therapy.

Rotaviruses; incubation period 1-3 days; symptoms - vomiting, loose, watery stools, sub-febrile / febrile fever, more often in young children, the elderly; the duration of the disease is 4–8 days; develops when eating contaminated foods (salads, fruits); pathogenetic therapy.

Other viruses (astoroviruses, adenoviruses, etc.); incubation period 10–70 h; symptoms - nausea, vomiting, diarrhea, weakness, abdominal pain, headache, fever; the duration of the disease is 2–9 days; occurs when using contaminated marine products; pathogenetic therapy.

Acute viral gastroenteritis is accompanied by severe nausea and vomiting, fever, the general condition of the patient suffers. Viral diarrhea in children may be accompanied by catarrhal symptoms from the BtepxHHX respiratory tract, conjunctivitis. The duration is rarely more than 3 days; it must be differentiated from acute food intoxication.

Causes and clinical and epidemiological characteristics of protozoal diarrheal diseases.

Cryptosporidium parvum. The incubation period is on average 7 days (2-28 days); symptoms - abdominal cramping, watery, diarrhea, sometimes vomiting, fever, possibly recurrent course; food contact: contaminated water, herbs, fruits, unpasteurized milk; in severe cases, paromomycin for 7 days.

Cyclospora caetanensis. The incubation period is 1-11 days; clinical symptoms - weakness, prolonged diarrhea, frequent relapses, possibly a protracted course of the disease up to several months; connection with contaminated water, fruits; pathogenetic therapy, trimethoprimsulfamethoxazole for 7 days.

Giardia intestinalis. The incubation period is 1–4 weeks; symptoms - acute or chronic sluggish diarrhea, flatulence; duration of illness - weeks; contact with contaminated food and water; pathogenetic therapy, according to the indications of metronidazole.

Entamoeba histolytica. The incubation period is from 2-3 days to 1-4 weeks; symptoms - prolonged development of the disease, stool mixed with blood, cramping abdominal pain; the duration of the disease - months; contamination through contaminated water and food; pathogenetic therapy, metronidazole.

Acute giardiasis is widespread and causes the development of acute enterocolitis with severe diarrhea. The prognosis of the disease is extremely unfavorable.

There are also other special forms of acute infectious diarrhea: diarrhea in homosexual men; diarrhea in HIV-infected people; antibiotic-associated diarrhea; syndrome of overgrowth of bacteria in the small intestine.

After antibiotic therapy, acute diarrhea occurs in 2-26% of patients (clindamycin, lincomycin, ampicillin, penicillin, cephalosporins, tetracycline, erythromycin). Clostridium difficile is considered the immediate causative factor, but it is isolated in only 15%. Clinical manifestations range from mild diarrhea to severe pseudomembranous colitis. Antibiotic-associated diarrhea is characterized by profuse watery stools a few days (up to a month) after antibiotics are prescribed; cramping abdominal pain, better after stool.

With fever, leukocytosis, the presence of leukocytes in the feces, pseudomembranous colitis should be assumed. After the abolition of antibiotics, the symptomatology quickly disappears in antibiotic-associated colitis, but with pseudomembranous colitis it persists, the frequency of stool continues to increase, and dehydration develops, in especially severe cases, toxic expansion and perforation of the colon develop, very rarely a fulminant course resembling cholera develops. Metronidazole therapy, with bacteriological confirmation, use vancomycin 125 mg orally 4 times a day for 7-1Q days, metronidazole 500 mg orally 2 times a day. The relief of symptoms in antibiotic-associated colitis is facilitated by the appointment of enterol and hilaka-forte. Probiotics are also effective: bifiform, colibacterin, bificol, which are prescribed with a stool frequency 3-4 times a day, 2 doses 3 times a day for 3 weeks.

The syndrome of bacterial overgrowth in the small intestine develops when it is colonized by the flora of the oral cavity or colon and is manifested by inflammation and malabsorption syndrome. The diagnosis is assisted by sowing an aspirate from the small intestine with the isolation of a culture of the pathogen. Patients with malabsorption syndrome require an appropriate diet, pre- and probiotics, and sometimes antibiotics.

It is necessary to differentiate acute infectious diarrhea with acute non-infectious diseases of therapeutic, surgical, gynecological origin. Crohn's disease, ulcerative colitis with fulminant course can occur with the development of acute bloody diarrhea, the distinctive symptoms of these diseases are indications of therapy with corticosteroids or sulfonamides for Crohn's disease and ulcerative colitis, absence of epidemiological anamnesis, acute dyspepsia against the background of symptoms of systemic connective disease sepsis.

Diarrhea caused by ischemia of the colon occurs in elderly patients with poor circulation in the abdominal aorta. Ischemia leads to erosive-hemorrhagic lesions of the mucosa. Bloody diarrhea with ischemic colitis can reach the degree of severe bleeding.

Irritable bowel syndrome (IRS) can occur with diarrhea. Functional disease involves abdominal pain and discomfort that resolves after a bowel movement and is accompanied by changes in stool frequency and consistency for at least 12 weeks over the past year. Functional diarrhea is characterized by frequent, as a rule, more than 2-3 times a day, emptying of the intestine with the release of liquid or mushy feces. The diagnosis of functional diarrhea is made by excluding organic pathology and secondary functional disorders. Clinical signs of functional diarrhea: absence of it at night, stool after breakfast, urge to defecate. In the treatment of TFR with diarrhea, drugs are used that slow down peristalsis and secretion in the intestine - loperamide, pinaverium, as well as antacids, adsorbents; recently, combined drugs have been used - imodium-plus, containing loperamide hydrochloride 2 mg and simethicone 125 mg. The first eliminates increased peristalsis, the second - flatulence. Acute diarrhea during chemotherapy or radiation therapy is a serious complication of malignant neoplasm: patients receive loperamide in some cases. - antibacterial drugs.

The main complications of acute infectious diarrhea: infectious toxic shock; dehydration; hemolytic uremic syndrome; acute nausea or vomiting leading to Mallory-Weiss syndrome; colon perforation and the development of peritonitis; Reiter's syndrome; reactive arthritis.

With the gastroenteric form of acute infectious diarrhea, patients are not prescribed antibiotic therapy, the first direction is rehydration, for the purpose of rapid and adequate replenishment of water-electrolyte disturbances.

For oral rehydration (with dehydration of I and II degrees), glucose-electrolyte solutions, oral rehydration salt, oralit, rehydron, citroglucosolan are used. The simplest oral rehydration saline solution can be prepared in the following way: dissolve half a teaspoon of table salt (2.5 g), 6 tsp. sugar (30 g) in 1 liter of drinking water. For parenteral rehydration, polyionic solutions are used (with rehydration of III-IV degrees) trisol, acesol, chlosal, quartosol, lactosol. For hyperkalemia, crystalloid disol solution is used.

The criteria for the effectiveness of rehydration therapy are improving the patient's well-being, stabilizing blood pressure, normalizing the pulse, stopping vomiting, restoring urine output, and normalizing blood viscosity.

Colloidal solutions are administered only with persistent circulatory failure.

If the volume of excreted urine begins to prevail over the volume of bowel movements in the last 6-12 hours, then you can switch to oral rehydration.

It is prescribed for exudative diarrhea, antibiotic therapy and for severe forms of acute infectious diarrhea; antibiotic therapy is also indicated for children under 3 years of age, elderly people, patients with immunosuppression, diabetes mellitus, liver cirrhosis, chronic renal failure. The choice of the drug before the verification of the pathogen is based on specific symptoms and epidemiological information. Antibiotics in typical cases of watery acute infectious diarrhea are undesirable until the pathogen is isolated. For bloody acute infectious diarrhea, empiric antibiotic therapy is used as early as possible.

For travelers' diarrhea, the selection of the optimal antibiotic regimen may be facilitated by information on the antibiotic susceptibility of local dominant strains. With bloody DP, the appointment of atropine, loperamide, which slow down passage through the intestines due to mucosal damage, is categorically contraindicated.

Cause-directed - etiotropic, therapy for the most common forms of acute infectious diarrhea of a bacterial cause:

The drugs of choice are drugs from the group of fluoroquinolones - ciprofloxacin (ciprolet) in average therapeutic doses of 5–7 days. The third-generation cephalosporins are used as second-choice drugs. Nitrofurans are prescribed for the treatment of mild forms of acute infectious diarrhea in Russia.

The clinical efficacy of antibacterial drugs is assessed within 48 hours from the moment of their appointment; efficiency criteria: a decrease in the frequency of bowel movements, a decrease in blood, mucus, pus in the stool, a decrease in temperature. Irrational use of antimicrobial drugs can lead to dysbiosis with increased colonization of the intestinal mucosa by opportunistic bacteria and fungi, the formation of a long-term carriage of Salmonella spp., Clostridium difficile.

With recurrent diarrhea of protozoal origin, confirm the diagnosis.

Symptomatic therapy:

Antispasmodics;

Enzyme preparations (mezim-forte, festal, cre-on) during early recovery in general therapeutic doses of 7-10 days;

With flatulence, espumisan 40 mg in capsules or emulsions after each meal;

During the recovery period, probiotics are prescribed - bion 3, 1 tablet per day, linex 2 capsules 3 times a day, bifidumbacterin-forte 5 doses 3 times a day; the course of treatment is 7-10 days. Probiotics are not used for severe diarrhea, they are not combined with antimicrobial drugs;

Enterol (prebiotic) containing the non-pathogenic yeast Saccha-romyces boulardii, which suppresses the growth of opportunistic and pathogenic flora in the gastrointestinal tract, is shown to sanitize the body from pathogens of acute infectious diarrhea. For mild acute infectious diarrhea, it replaces antimicrobial drugs; appoint 2-4 capsules per day in two doses for 5-10 days;

Imodium is used with caution, which, by suppressing intestinal motility, can aggravate the course of diseases caused by invasive enteropathogenic strains. If you suspect food toxicoinfection, it is necessary in the first 6-12 hours (no later than 24 hours) to rinse the stomach to clean wash water, followed by the intake of enterosorbents (polyphepan, polysorb, carbolong) in the first 2-3 days of the disease. Polyphepan is prescribed in 1 tbsp. l. 3 times a day, stirring in water. Smecta is prescribed 1 sachet 3-4 times a day. Usually 3-5 days - the duration of the intake of enterosorbents.

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Diarrhea syndrome

Diarrhea is one of the most common syndromes in medical practice that accompanies many diseases. Almost every day, doctors of all specialties with varying frequency are faced with complaints of patients with diarrhea, looking for effective ways to solve this problem. There are many definitions of the concept of "diarrhea", but their main meaning boils down to the following: diarrhea (diarrhea) is a frequent (usually more than 2-3 times a day) discharge of liquid feces. There are several mechanisms for the development of diarrhea (Fig. 1). In some cases, chyme passes through the intestine too quickly due to increased peristalsis (wave-like contraction of the walls). In others, liquefaction of intestinal contents occurs due to impaired absorption of water in the large intestine or the release of inflammatory fluid into the intestinal lumen. It is known that the secretion of liquid feces is usually associated with an increase in bowel movements, but it must be remembered that diarrhea is not always characterized by an increase in stool frequency, a single stool of a thinner consistency can also be considered a manifestation of diarrhea. That is why it should be noted that the hallmark of diarrhea is more than normal, the water content in feces (up to 60-80% and higher).

Diarrhea can be provoked by taking medications (antibiotics, antineoplastic drugs, antihypertensive drugs, antidepressants, antiarrhythmics, oral hypoglycemic drugs, cholesterol-lowering drugs, magnesium-containing antacids, etc.); inflammatory or ischemic bowel disease; dietary habits (consumption of excessive amounts of coffee, beer, coarse fiber), food allergens; inflammatory processes in the small pelvis, etc. Sometimes diarrhea is associated with emotional stress or unhealthy diet. In children, diarrhea may be caused by a diet that contains too much fat or fruit juices. In adults suffering from lactase deficiency, the cause of diarrhea is a deficiency of an enzyme necessary for the hydrolysis of milk sugar (lactose); diarrhea usually occurs after consuming dairy products. People with chronic diarrhea often have food intolerances. A classic example is celiac disease, a disease with a complex pathogenesis, which consists in intolerance to the gliadin contained in cereals.

Hereditary predisposition also plays a role in the development of diarrhea associated with inflammatory bowel diseases such as Crohn's disease and ulcerative colitis, or diarrhea in bowel cancer. The diarrheal syndrome can be caused by the operations carried out by the patients (resections of the stomach and intestines, cholecystectomy), intoxication with mercury and arsenic compounds, as well as diabetes mellitus, tuberculosis and intestinal amyloidosis. The so-called travelers' diarrhea is distinguished into a separate form. This condition is understood as three or more cases of unformed stool per day when changing the place of permanent residence. All known intestinal pathogens can be causative agents of travelers' diarrhea, depending on their prevalence in specific geographic regions.

There are several types of diarrhea (Table 1): secretory, accompanied by increased secretion of sodium and water into the intestinal lumen, - when exposed to infectious enterotoxins, the presence of tumors secreting polypeptide hormones, taking laxatives and other drugs; hyperosmolar, which occurs in diseases accompanied by malabsorption syndrome; hyperkinetic, due to increased intestinal peristalsis, which is characteristic of patients with irritable bowel syndrome, thyrotoxicosis. Exudative diarrhea is characterized by a loss of protein into the intestinal lumen along with inflammatory exudate and is detected in dysentery, salmonellosis, ulcerative colitis and Crohn's disease.

The following physiological mechanisms of diarrhea development are known:

- increased secretion of electrolytes and water by the intestinal epithelium, causing massive fluid loss;

- a decrease in the absorption of electrolytes and nutrients from the intestinal lumen, which develops as a result of damage to the brush border of the epithelium of the large or small intestine;

- an increase in the osmolarity of intestinal contents due to a deficiency of saccharolytic enzymes and lactose intolerance;

- violation of the motor activity of the intestine.

Clinic

Diarrhea in malabsorption syndrome is usually characterized by an increase in stool volume (polyfecal), feces have a mushy or watery consistency, often acquire an unpleasant odor and, in the presence of steatorrhea, is poorly washed off the walls of the toilet bowl. If the synthesis of bile acids is disturbed or if it is difficult for them to enter the intestine (cholestasis), the stool becomes acholic and acquires a greasy sheen. With lactase deficiency, diarrhea appears after drinking milk and dairy products and is accompanied by rumbling and cramping abdominal pain. Pain in the upper abdomen, radiating to the lumbar region or acquiring a shingles character, accompany diarrhea in the presence of chronic pancreatitis. In children and adolescents (particularly those with celiac disease), malabsorption syndrome leads to stunted growth and infantilism. A decrease in protein levels, especially pronounced with exudative enteropathy, causes edema. With exudative diarrhea, stool is loose, often bloody and pus-filled. The osmotic pressure of feces often exceeds the osmotic pressure of blood plasma.

Deterioration of the absorption of iron and vitamin B12 is the cause of the development of anemia. Patients with malabsorption syndrome often complain of general weakness, fatigue, and decreased performance. Many patients with malabsorption syndrome have clinical signs of deficiency of various vitamins: B 1 (neuropathy, ophthalmoplegia, paresthesia, psychosis), B 2 (glossitis and angular stomatitis, apathy, ataxia), B 6 (sideroblastic anemia, neuropathy), D (pain in bones, tetany), K (increased bleeding, subcutaneous hemorrhage), A (follicular hyperkeratosis, twilight vision disorders), nicotinic acid (pellagra), ascorbic acid (delayed wound healing, bruising), etc. With prolonged and severe course of malabsorption syndrome cachexia progresses, symptoms of polyglandular insufficiency (adrenal glands, gonads), muscle atrophy, mental disorders join.

A sudden onset of violent diarrhea with frequent stools, tenesmus, first of all, gives reason to suspect acute intestinal infections. Acute infectious diarrhea is characterized by general malaise, fever, lack of appetite, and sometimes vomiting. There is often a connection with the use of poor quality food and travel (traveler's diarrhea). Bloody loose stools indicate damage to the intestinal mucosa by pathogenic microbes such as Shigella Flexner and Sonne, Campylobacter jejuni or Escherichia 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 septic symptoms and abdominal pain. 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 seizures. In diseases of the small intestine, stools are bulky, watery or oily. In colon disease, stools are frequent but less profuse and may contain blood, pus, and mucus. In contrast to enterogenic diarrhea associated with pathology of the colon, in most cases accompanied by abdominal pain. Diseases of the rectum increase its sensitivity to stretching, and the stool becomes frequent and scanty, tenesmus and false urge to defecate appear.

Pain sensations with lesions of the small intestine are always localized in the umbilical region. The defeat of the proximal colon is accompanied by pain most often in the right iliac region, with intensification after eating. With damage to the distal colon, pain is localized in the left iliac region with irradiation to the sacrum, significantly weakening after defecation or passing gas. In some cases, diarrhea alternates with constipation - more often with functional disorders, abuse of laxatives, with colon cancer, with chronic (habitual) constipation, when, due to prolonged stay of feces in the intestine, there is an increased formation of mucus with periodic discharge of liquid feces (constipated diarrhea) ... In some cases, acute onset diarrhea may be due to changes in the diet or intake of irritating bowel agents, including laxatives, or is the first sign of chronic nonspecific bowel disease and its functional disorders. Often, the clarification of the time of day at which the patient develops diarrhea has a differential diagnostic value. Nocturnal diarrhea is almost always organic, while diarrhea during the morning and afternoon hours may be functional.

A separate group of diarrhea is made up of intestinal dyspepsia, which occurs as a result of indigestion in violation of the diet and a sharp change in diet. Distinguish between fermentation, putrefactive and soapy (fatty) dyspepsia. With dyspepsia, there is no general intoxication, how they differ from food toxicoinfections. Fermentation dyspepsia is characterized by flatulence, sour foamy stools containing a large number of starch grains and iodophilic microorganisms. Foul-smelling, putrefactive alkaline stools with undigested muscle fibers are observed with putrefactive dyspepsia. Fat indigestion is recognized by the presence of fat in the stool, needles of fatty acids, and soaps.

Allergic diarrhea occurs as an acute enterocolitis. Their distinctive feature is the external manifestations of allergies (Quincke's edema, urticaria, toxicoderma). Sometimes they proceed according to the type of abdominal purpura (as in Shenlein-Henoch disease) and with symptoms of intestinal obstruction. Alimentary (milk, eggs, chocolate, strawberries, etc.) and medication (antibiotics) allergic diseases occurring with diarrheal syndrome are distinguished.

Drug-induced diarrhea, like food diarrhea, does not always have an allergic pathogenesis: they can occur as a result of individual intolerance. In such cases, there are no allergic manifestations and the clinic of enterocolitis.

Neurogenic diarrhea has an acute transient nature; it occurs in emotionally unstable people. Diarrhea is one of the manifestations of acute poisoning with arsenic (green vomit with the smell of garlic), mercury (mercury stomatitis and gingivitis, acute renal failure), poisonous mushrooms (history).

Chronic diarrhea occurs mainly in chronic diseases of the digestive system. Chronic colitis can be a consequence of dysentery infection, protozoal invasions, chronic intoxication. Other causes of chronic diarrhea include helminthiasis, sprue, intestinal lipodystrophy, intestinal amyloidosis (often combined with nephrotic syndrome), terminal ileitis (Crohn's disease), chronic intestinal infections (tuberculosis, actinomycosis, syphilis), ulcerative colitis, polyposis and colon cancer intestines, carcinoid of the small intestine, uremic diarrhea, pellagra, gastric and pancreatic achilia, endocrinopathy (Addison's disease, thyrotoxicosis).

Diagnostics

Along with the usual physical examination (Fig. 2), it is imperative to examine the patient's feces and conduct a proctological examination. The presence of blood in the stool, anal fissure, paraproctitis or fistulous tract suggests that the patient has Crohn's disease.

To confirm the viral nature of the disease, use:

- methods based on the detection of the virus and its antigens (electron and immunoelectronic microscopy of feces, ELISA, RIA, MFA);

- methods for detecting viral RNA (molecular probe method - PCR and hybridization, electrophoresis of RNA in polyacrylamide gel or agarose);

- methods for detecting antibodies to rotavirus (ELISA, RSK, RTGA, RNGA, etc.).

Sigmoidoscopy allows you to diagnose ulcerative colitis (bleeding, easily vulnerable mucous membrane, often with erosive and ulcerative changes), dysentery (erosive proctosigmoiditis), and pseudomembranous colitis (dense fibrinous plaque in the form of plaques).

Once inflammatory diseases have been ruled out, an attempt should be made to determine the predominant pathogenetic mechanism of chronic diarrhea. To do this, you should set the mass or volume of feces per day. In the absence of polyfecal matter, hyperkinetic diarrhea is most likely, and with a large volume of feces, secretory or osmolar type of diarrhea. If excess fat and increased osmolarity are found in the stool, it should be osmolar diarrhea associated with impaired intestinal digestion and absorption. In the absence of steatorrhea and hyperosmolarity of feces, the patient is diagnosed with a secretory type of diarrhea that is not associated with a bacterial infection. It is also necessary to keep in mind the possibility of abuse of laxatives.

In a laboratory study, in patients with malabsorption syndrome, a decrease in the content of albumin, cholesterol, iron, calcium, magnesium, vitamin A, and folic acid is often detected in the blood.

Stool examination plays an important role in the diagnosis and differential diagnosis of malabsorption syndrome. First of all, the total mass of feces excreted by the patient during the day is specified. To do this, it is necessary to measure the daily amount of feces, collecting it for at least 3 days. Malabsorption syndrome is characterized by a significant mass of feces (usually more than 500 g per day), which decreases with starvation. Stool microscopy (coproscopy) is very important for the differential diagnosis of gastroenterological diseases (Table 2). At the same time, attention is paid to the presence of muscle fibers (creatorrhea), neutral fat (steatorrhea) and starch (amilorrhea) and determine the daily loss of fat with feces. With disorders of digestion and absorption in the small intestine, the pH of the stool may change. So, in case of impaired digestion of carbohydrates, the pH values shift to the acidic side (< 6,0).

The assessment of the absorption function of the small intestine is carried out using the D-xylose test, etc. More accurate data on the absorption processes in the small intestine can be obtained using its perfusion study. Increased loss of protein through the intestine (with Whipple's disease, malignant lymphoma, radiation enteropathy) is detected when using a test with albumin labeled with a chromium isotope. If malabsorption syndrome is suspected, an X-ray examination of the small intestine is performed, revealing its typical signs (fragmentation of a suspension column of barium sulfate, thickening and coarsening of the folds of the mucous membrane). Sometimes X-ray examination helps to recognize the diseases that caused the development of malabsorption (multiple diverticula, small bowel lymphoma, intestinal pseudo-obstruction syndrome in systemic scleroderma, etc.).

Endoscopic examination of the small intestine with biopsy from its proximal sections and subsequent histological and histochemical examination makes it possible to diagnose diseases such as Whipple's disease, small bowel lymphoma, eosinophilic gastroenteritis, celiac disease, amyloidosis.

To diagnose bacterial overgrowth syndrome, hydrogen breath tests are currently used, which are carried out with lactulose or glucose. The diagnosis of bacterial overgrowth syndrome is also confirmed by inoculation of the duodenal aspirate and the subsequent detection of an increased content of microorganisms in it.

To diagnose the underlying disease that caused the development of malabsorption syndrome, additional research methods are used. So, if there is a suspicion of exocrine pancreatic insufficiency, in addition to determining the daily loss of fat with feces, a secretin-pancreozymin test is performed, the content of chymotrypsin and elastase-1 in feces is assessed, etc. The diagnosis of pancreatitis is confirmed by ultrasound examination of the abdominal organs, endoscopic retrograde cholangiopancreatography.

To recognize lactase deficiency, an additional test is carried out with a load of lactose. The patient takes 50 g of lactose orally, after which the blood glucose level is determined. The occurrence of dyspeptic disorders, as well as the absence of an increase in blood glucose after lactose loading, confirm the diagnosis of lactase deficiency. An increase in the titer of antibodies to gliadin is a specific diagnostic test for detecting celiac disease. If systemic mastocytosis is suspected, the level of histamine in the blood and the excretion of its metabolites in the urine are determined.

Treatment

In the treatment of diarrhea, the main focus should be on the treatment of the disease that caused the diarrhea. For example, in acute infectious diarrhea, the main role is given to rehydration therapy and antibiotic therapy. In diarrhea due to ulcerative colitis and Crohn's disease, 5-ASA drugs and / or glucocorticosteroids play a major role. With fermentopathies - a diet that excludes foods that the patient can not tolerate.

In intestinal diseases accompanied by diarrhea, dietary nutrition should help inhibit peristalsis, reduce the secretion of water and electrolytes into the intestinal lumen. The set of products should correspond in composition and amount of nutrients to the enzymatic capabilities of the pathologically altered small intestine. In this regard, in case of diarrhea, the principle of mechanical and chemical sparing of the small and large intestine must be observed. In the acute period of diarrhea, foods that enhance the motor-evacuation and secretory function of the intestines, provoking flatulence, are largely excluded from the diet: raw vegetables and fruits, legumes, nuts, raisins, milk, spices, fried foods, rye bread, pastry products , canned foods, spicy and salty dishes and seasonings, carbonated drinks, fatty meats and fish, cold dishes and drinks, beet juice, etc.

Antibiotic therapy is prescribed to restore intestinal eubiosis. In acute diarrhea of bacterial etiology, with a pronounced infectious and inflammatory process in the intestine, antibiotics, antimicrobial drugs from the groups of quinolones (nitroxaline, 5-nok), fluoroquinolones (tarivid, cyfran, etc.), sulfonamide drugs (biseptol, phthalazole, etc.) , derivatives of nitrofurans (furadonin, furazolidone) and intestinal antiseptics. Preference is given to drugs that do not disturb the balance of the microbial flora in the intestine - antiseptics (intetrix, ercefuril, enterosediv). With candidiasis, antifungal drugs are prescribed - nystatin, levorin. In the treatment of protozoal intestinal infections, metronidazole and tinidazole are used. For helminthic invasions, anthelmintics are used - fenasal, vermox, etc.

Probiotics are prescribed for diarrhea of various origins. Probiotics are preparations from living microorganisms and substances of microbial origin, which, when administered naturally, have a positive effect on the physiological, biochemical and immune responses of the host organism by optimizing its microbial ecological system. Preparations from live bacteria have a probiotic effect, antagonistic activity against a number of pathogenic and opportunistic microbes due to the production of acids, antibiotic substances, secrete various enzymes and vitamins that take part in the digestive activity of the gastrointestinal tract, metabolic processes, and also contribute to the restoration of natural protective factors of the body.

Probiotics can contain both a monoculture and a combination of several types of microorganisms. In the latter case, such drugs are referred to as symbiotics.

The following drugs are most often used (doses for adults are indicated):

- bifidumbacterin - 5 doses 3 times a day; course - 15-20 days, up to 2 months;

- bifidumbacterin forte - 15-25 doses per day in one dose, preferably before bedtime, along with liquid or pasty food at room temperature; course - 10-25 days;

- bifilis - 5 doses 2 times a day; course - 14-15 days; in severe cases - 5 doses 3 times a day for 1 week, then 5 doses 2 times a day for 15-20 days;

- lactobacterin - 5 doses 2 times a day (a tablet contains 1 dose, an ampoule - 3-5 doses, a bottle - 5 doses) with milk or lactic acid products; course - 10-25 days;

- acylact - 5-10 doses per day (in a tablet - 1 dose, in a bottle - 5 doses, in a candle - 1 dose); course - 10 days or more;

- Acipol - 5 doses 2 times a day (4-10 doses a day); course - 2-4 weeks;

- bilaminolact - 5 tablets 3 times a day; course - 10 days;

- colibacterin - 6-12 doses per day (ampoule contains 2-5 doses; tablet - 1 dose); course - from 3 weeks, depending on the severity of the disease. It should be borne in mind that the use of the drug is contraindicated in atrophic changes in the intestinal mucosa and ulcerative colitis (E. coli lipopolysaccharide stimulates local defense factors, which can ultimately lead to a negative effect on immunocompetent cells);

- bificol - 5-10 doses per day; restrictions - like colibacterin;

- bifiform - 2 capsules (possibly up to 4 capsules) per day;

- bioflor (bio-cocktail H K) - 2 tablespoons 3 times a day; course - 1-2 months (with acute intestinal infections - 5-7 days);

- linex - 2 capsules 3 times a day; course 3-5 days;

- bactisubtil - 1 capsule 4 times a day; course - 4-6 days;

- biosporin - 2 doses 3 times a day; course - 7-10 days;

- bactisporin - 1 dose 2 times a day; course - 10-20 days;

- sporobacterin - 1-2 doses 2 times a day; course 10-20 days;

- enterol - 1-2 capsules (sachets) 1-2 times a day; course 5 days.

Despite the fairly widespread use, bacterial preparations based on living microorganisms are not always highly effective. Perhaps this is due to the rapid elimination of strains introduced into an aggressive environment due to the high tolerance of the immune system to its own microflora. Their high cost also limits their use. The solution to the problems of dysbiosis correction can consist in the development and introduction into clinical practice of fundamentally new drugs created on the basis of components of microbial cells or their metabolites - metabolic-type probiotics. Such probiotics have a positive effect on the physiological functions and biochemical reactions of the host organism either directly - by interfering with the metabolic activity of cells of the corresponding organs and tissues, or indirectly - through the regulation of the functioning of biofilms on the mucous membranes of the macroorganism.

This group of medicines is represented by the drugs Khilak and Khilak forte in drops for oral administration. The composition of the preparations includes an optimized set of metabolic activity products of the normal intestinal microflora: lactic acid, amino acids, short-chain fatty acids, lactose.

Khilak is a composition of metabolites of the probiotic strain of lactobacilli ( Lactobacillushelveticus). Hilak forte contains metabolites of 4 bacteria: in addition to lactobacilli ( Lactobacillusacidophilus, Lactobacillushelveticus), the preparation contains colibacillus metabolites ( Escherichiacoli) and fecal streptococcus ( Streptococcusfaecalis). 1 ml of preparations corresponds to the biosynthetic potential of 100 billion microorganisms.

The acids that make up the preparations, as well as lactose, which is further converted to lactic, acetic acid and carbon dioxide, provide the pH values of the medium in the intestinal lumen within the physiological norm, which is the first prerequisite for the existence of a normal microflora. As a result, the colonization resistance of the intestine increases. At the same time, of course, metabolic inhibition of the growth of opportunistic microorganisms is also important.

Against the background of the acceleration of the development of normal intestinal symbionts under the influence of the drugs hilak and hilak forte, the physiological functions of the digestive tract are improved. Under their influence, destroyed goblet cells that produce protective mucus are restored, the activity of cellular enteral enzymes increases, the loss of water and electrolytes decreases, resulting in a pronounced antidiarrheal effect.

Khilak and Khilak forte are the "building blocks" for normal bacterial strains of the colon. An increase in the “survival rate” in the intestine of probiotics containing live bacteria was noted when combined with the preparations Khilak and Khilak Forte.

Unlike preparations containing live microorganisms, hilak and hilak forte are not destroyed by antibiotics, the acidic environment of the stomach and oxygen. Therefore, they can be prescribed as a means of preventing intestinal dysbiosis simultaneously with antibiotics, sulfonamides, during radiation therapy. Probiotic treatment is usually accompanied by prebiotics.

Prebiotics are drugs or biologically active additives of non-microbial origin that can have a positive effect on the body through selective stimulation of the growth or metabolic activity of normal intestinal microflora. This group includes drugs belonging to various pharmacotherapeutic groups, but with a general effect - the ability to stimulate the growth of normal intestinal microflora. The most effective prebiotic is lactulose (dufalac, normaze). Lactulose promotes a decrease in the pH of the contents of the colon, a decrease in the pool of putrefactive bacteria and the reproduction of bifidobacteria and lactobacilli. It should be borne in mind that lactulose has a laxative effect. In addition, pectin is referred to as prebiotics.

Synbiotics are drugs or dietary supplements obtained as a result of a rational combination of probiotics and prebiotics. As a rule, these are dietary supplements enriched with one or more strains of representatives of the genera Lactobacillus and / or Bifidobacterium.

Sometimes in the domestic literature you can find the definition of "eubiotics". This term is currently used to characterize the ability of a particular drug, mainly with antibacterial properties, to influence mainly the pathogenic and opportunistic microflora, without inhibiting the intestinal bifido- and lactoflora, and not to designate any group drugs.

The principles of the pathogenetic treatment of diarrhea are presented in table. 3.

Rehydration is carried out in order to eliminate dehydration and associated electrolyte and acid-base disorders. In acute intestinal infections, rehydration should be carried out by the oral route, only about 10% of patients require intravenous infusions. For intravenous rehydration, polyionic crystalloid solutions are used: trisol, rehydron, acesol. Colloidal solutions (rheopolyglucin, etc.) are used for detoxification in the absence of dehydration.

Symptomatic agents - adsorbents that neutralize organic acids, astringents, coating agents (tannacomp, polyphepan). Smecta preparation, which includes natural aluminum and magnesium silicate, also belongs to adsorbents. Smecta has a positive effect on the intestinal mucosa, increasing the thickness of the mucin layer, increasing the viscosity of mucin and decreasing its solubility. Smecta provides this cytoprotective effect and increases resistance to damaging factors. In addition, smecta actively binds rotaviruses and bacterial toxins of Escherichia coli, and also reduces the secretion of water and electrolytes, and normalizes the permeability of the mucous membrane. The daily dose of the drug for adults is 9 g; intestinal obstruction is a contraindication.

The regulators of intestinal motility include loperamide (imodium), which, accumulating in the smooth muscle structures and nerve plexuses of the intestinal wall, reduces intestinal tone and motility due to binding to opiate receptors. By increasing the intestinal transit time, the absorption of water and electrolytes increases, and the duration of the action of immunoglobulins, which play a protective role, also increases. The antisecretory effect is also accompanied by a decrease in the motor function of the intestine. In the treatment of acute diarrhea, Imodium is prescribed at a dose of 4 mg at a time and then 2 mg after each act of defecation (the maximum dose is up to 16 mg / day). When treating patients with functional diarrhea, the daily dose of the drug is selected individually and averages 4 mg in adults. This drug is the treatment of choice for the treatment of acute diarrhea and irritable bowel syndrome with diarrhea. A powerful antidiarrheal and antisecretory effect is exerted by somatostatin (octreotide), a synthetic analogue of the hormone somatostatin. In the treatment of diarrhea, it is possible to prescribe other groups of drugs: enzyme agents, antispasmodics, antiallergic drugs, anabolic steroids, etc.

Bibliography

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Is a polyetiological syndrome that accompanies the course of a number of infectious and non-infectious diseases, characterized by frequent loose stools. With acute diarrhea, the stool becomes abundant, watery or mushy, it may contain impurities of undigested food, mucus; its frequency is more than three times a day. To determine the causes of the disorder, they collect complaints and anamnesis, a general analysis of blood and feces, a bacterial culture of feces, as well as instrumental studies: colonoscopy and irrigoscopy. Treatment includes diet therapy, the appointment of antibacterial drugs, antidiarrheals, eubiotics, and rehydration therapy.

ICD-10

A09 Diarrhea and gastroenteritis of suspected infectious origin

General information

Causes

Acute diarrhea can develop under the influence of many etiofactors against the background of various pathological processes. The main causes of this condition are infectious agents, toxins, medication, ischemic or inflammatory bowel disease, as well as acute diseases of the pelvic organs. In developed countries, acute diarrhea most often occurs against the background of a viral infection, the causative agents of which are rotaviruses and adenoviruses. In addition to viruses, the development of the syndrome can be provoked by strains of various bacteria that produce enterotoxins, for example, Salmonella, E. coli, Shigella, Campylobacter, and so on. In some cases, the cause of diarrhea is the simplest microorganisms (lamblia, blastocysts and others) and intestinal helminths (causative agents of strongyloidiasis, schistosomiasis and angiostrongylosis).

Acute diarrhea sometimes occurs while taking various medications, as a side effect of their action on the body. The occurrence of diarrhea can be associated with treatment with antibiotics, magnesium-containing agents, antiserotonin drugs, digitalis, anticoagulants, and chenodeoxycholic acid. In addition, acute diarrhea occurs with an overdose and misuse of laxatives, while stool disorder can develop both immediately after taking a certain drug, and with an increase in its dosage.

The hypokinetic form of diarrhea is observed in cecum syndrome or scleroderma, when the transit of intestinal contents is disturbed. As a result, bacterial overgrowth is noted, against the background of which fat malabsorption and increased mucus production in the intestine progresses. A symptom of hypokinetic acute diarrhea is loose, foul-smelling stools with undigested fats.

Acute diarrhea is often accompanied by general, nonspecific intestinal symptoms such as abdominal pain, fever, nausea, and vomiting. Also, with frequent heavy stools, symptoms of dehydration can be observed in the form of dry skin, lowering blood pressure and tachycardia. In addition, there may be impurities in the feces that are characteristic of the defeat of a certain part of the intestine. For example, acute diarrhea caused by damage to the small intestine is accompanied by undigested food debris in the stool. At the same time, the stool often has a greenish tint and gives off an unpleasant odor. With the development of a pathological process in the large intestine, spotting and an increased amount of mucus may be noted.

Diagnostics

An important factor that allows you to determine the nature of acute diarrhea is a complete collection of complaints and anamnesis. In this case, it is important for the patient to find out the frequency and consistency of the stool, the presence of various impurities or blood in the feces. Symptoms such as abdominal pain, vomiting, dry skin and high fever indicate the severity of the pathological process. These clinical manifestations require either an infectious disease doctor or a proctologist to promptly prescribe appropriate therapy. When talking with a patient, the specialist clarifies what drugs he has been taking recently, since this factor can also lead to the development of acute diarrhea. The diagnostic criterion for acute diarrhea is the appearance of loose stools more than 3 times a day with the duration of intestinal disorders not exceeding three weeks.

Laboratory tests such as complete blood counts and stool tests are used to diagnose acute diarrhea. These studies allow to confirm the inflammatory genesis of the process. In particular, the coprogram determines the concentration of leukocytes and erythrocytes, which makes it possible to differentiate between inflammatory and non-inflammatory diarrhea. In the absence of signs of inflammation, fecal culture is not performed. If a large number of leukocytes and erythrocytes are found in the stool, a microbiological study of feces is mandatory. This method allows you to identify the pathogenic bacteria that caused the development of acute diarrhea. However, in some cases, microbiological examination of feces does not give a result, since other factors cause diarrhea.

From instrumental methods to establish the cause of acute diarrhea, colonoscopy is used. This study makes it possible to identify inflammatory changes in the intestinal mucosa, as well as the presence of ulcers and erosions of the intestinal wall. Intestinal endoscopy can diagnose colitis, Crohn's disease, diverticulitis, and other conditions that could cause acute diarrhea. An informative instrumental research method is contrast radiography of the intestine (irrigoscopy). This technique makes it possible to determine the speed of passage through the intestine and to suspect inflammatory changes in the mucous membrane.

Treating acute diarrhea

Regardless of the cause of the upset stool, all patients are prescribed a special diet, eubiotics, as well as astringents and adsorbents. The diarrhea diet is used to reduce intestinal motility and reduce the secretion of fluid into the intestinal lumen. It is very important to exclude foods that can irritate and damage the mucous membrane.

With severe loss of fluid and electrolytes in the feces, rehydration therapy is performed. With a mild degree of dehydration, oral therapy is prescribed - special saline solutions. In severe forms of diarrhea, there is a significant loss of fluid and electrolytes. In such cases, parenteral rehydration therapy is used, which involves intravenous administration of balanced saline solutions. Antibacterial drugs are prescribed only when the diarrhea syndrome is caused by pathogenic bacteria. In this case, the duration of the course of antibiotic therapy can vary from several days to a month.

In the treatment of acute diarrhea, agents that inhibit intestinal motility play an important role. They reduce the secretion of fluid into the intestinal lumen, thereby slowing down smooth muscle contractions. Loperamide is an effective antidiarrheal drug, but it is not recommended for the inflammatory genesis of diarrhea. It is also imperative to use eubiotics to restore normal intestinal flora.

Forecast and prevention

To prevent acute diarrhea, it is necessary to follow the rules of personal hygiene and store food correctly. In addition, meat, fish and eggs must be thoroughly cooked. With timely complex treatment, the prognosis for this pathological condition is favorable.