DYSENTERY

From Big Medical Encyclopedia

DYSENTERY (dysenteria; grech, dys-+ enteron a gut, intestines) — the infectious disease which is characterized by symptoms of intoxication of an organism, preferential functional and morphological damage of a large intestine, caused by bacteria from a genus of shigellas.

HISTORY

is known to D. since the most ancient times, the disease was familiar to Hippocrates who gave it the name. Detailed on that time (1 century AD) left the description of «a strained diarrhea» by Aretya, since then D. is constantly mentioned on pages of medical literature. D.'s epidemics in Europe are described in 6 century, and in 16 — 19 centuries it is told about D. in many historical descriptions.

Always accompanied wars, hunger and other social shocks. G. Dopter wrote that during all historical eras bacillar D. was a constant scourge of armies during wars, causing sometimes damages more awful, than fire of the enemy. Wars of the end of 19 century — the beginnings of 20 century are indicative in this respect. In the civil war in the USA (1861 — 1865) in four years D. ached apprx. 287 000 people from whom it died 9431, and incidence of so-called diarrhea made apprx. 1,5 million cases; at the same time died apprx. 35 thousand persons. It is obvious that among the last category of patients there was a considerable number of the suffering. D.'s incidence was bigger during other wars (tab. 1).

In the Great Patriotic War of a disease of D. in the Soviet troops, on T. E. Boldyrev (1955) materials, made 66,02% of all infectious diseases; from total number of diseases in field army — 48,7 5%, in rear troops — 51,25%.

The STATISTICS

is extended by D. globally and makes up to 75% of all intestinal infections which annually affect apprx. 500 million people and are, according to WHO data, a cause of death of nearly 5 million babies.

Incidence in the countries of Europe in 1959 — 1963, according to Kostshevsky and Stypulkovskaya-Misyurevich (J. Kostrzewski, H. Stypulkowska-Misiurewicz, 1968), varied ranging from 0,6 — 1,2 to 133,3 — 173,2 on 100 000 population.

In the USA apprx. 60% of the diseased it is the share of children aged from 1 up to 9 years [Lewis, Levenstayn (J. N. Levis, M. to S. Loewenstein), 1972].

In the majority of developing countries of D. remains to one of the leading causes of death among children. E.g., according to Gordon (J. E. Gordon, 1964), in El Salvador made a lethality from acute diarrhea among children under 4 years 60 on 100 children.

In developing countries D. caused by Fleksner's shigellas prevails, the lethality reaches 10 — 15%. At dysentery of Zonne prevailing in the developed countries, the lethality does not exceed 0,01 — 0,2%. In the late sixties in the countries of Central America epidemic of dysentery of Grigoriev flashed — Shigi, incidence made a cut in El Salvador 284 on 10 000 population, and a lethality — 35% [Reller (L. Century of Reller) with sotr., 1971].

In the USSR Fleksner's dysentery meets seldom, and Zonne's dysentery became the main etiol, a form of a disease. Level bacterial, D.'s confirmation reached 55%. More than 80% of patients are hospitalized.

The AETIOLOGY

Activators D. — bacteria of the sort Shigella of a tribe of Escherichieae of the Enterobacteriaceae family.

Shigellas — gram-negative bacteria from 2 to 4 microns long and from 0,5 to 0,8 microns wide, not having flagellums and the capsules which are not forming a dispute and a pigment, well painted aniline dyes. Activators D. well grow in aerobic conditions on simple mediums. Optimum temperature of growth 37 °, however, according to Slopek (St. Slopek, 1968), Zonne's shigellas are capable to breed at t ° from 10 ° to 45 °. Optimum reaction of the environment (pH) apprx. 7,2.

The bacteria which are constantly fermenting glucose and changeably the mannitol, dulcite, lactose, sucrose which are not forming to - you belong to the sort Shigella with a growth on Wednesdays with adonity, an inositol and salicin, not utilizing malonate, phenylalanine and citrate (on Christensen and Simmons's environments), not capable to liquefy to gelatin, to split urea and to form hydrogen sulfide, giving positive reaction with methyl red and negative reaction of Foges — Proskauera, the reducing nitrates not growing on the Wednesday about the KCN which are forming and not forming an indole. The main differential sign of shigellas — splitting of carbohydrates without gas generation. An exception some biochemical make, the options of shigellas Newcastle fermenting glucose with education to - you and gas (tab. 2).

Depending on enzymatic activity in relation to a mannitol and lactose of a shigella on the classification accepted in the USSR in 1962 are subdivided into 3 subgroups: not splitting a mannitol, splitting a mannitol, slowly splitting lactose, and on the International classification of 1958 — on 4 subgroups: subgroup And — S. dysenteria, subgroup In — S. flexneri, subgroup With — S. boydii, subgroup D — S. sonnei. The antigenic structure of shigellas differs in simplicity and is presented by generally somatic thermostable O-antigen.

On the classification accepted to the USSR, shigellas which are not splitting a mannitol are subdivided into 4 look and 10 serotypes. Each serotype has standard antigen on which it can be identified (tab. 2).

Shigellas of a type of Grigoriev — Shigi — the first of open activators D. — were for the first time described in Russia by A. V. Grigoriev in 1891; them epidemiol, the role at D. is proved to the Japanese scientists Shigoy (To. Shiga) in 1898. These bacteria are studied in 1900 it in detail. researcher W. Kruse. In 1903 H. Conradi found their ability to produce the exotoxin exerting negative impact on c. N of page, especially on its vegetative part.

Shigellas of a type of the Union — Schmitz are for the first time at the same time described in 1917 by the Russian scientist M. I. Shtutser and is mute. the scientist Schmitz (To. E. F. Schmitz).

In 1934 Lardzh (D. T. Large) and Sankaran (O. K. of Sankaran) found the bacteria reminding the described higher than two species of shigellas on enzymatic activity, but different from them serological. In 1943. A. Sachs added one more type to this group. In the USSR these activators are allocated and described by E. M. Novgorodska and soavt, in 1943 — 1948. In total 5 serotypes of shigellas of a type of Lardzha — A. Sachs (tab. 2) are described.

Also shigellas of a look «Provisional», subdivided on 3 independent serological isolated type (8, 9, 10) belong to subgroup of the shigellas which are not splitting a mannitol.

The shigellas splitting a mannitol are presented by the species of shigellas of Fleksner combining Fleksner's subspecies, Newcastle and Boyd. Shigellas of subspecies of Fleksner are for the first time studied and described in 1900 an amer. the scientist S. Fleksner and his pupils R. P. Strong and Musgrave (W. E. Musgrave) and in 1901 Cruz in Germany. Shigellas of these subspecies are subdivided into the serogroups having the general group antigens. Each serotype possesses standard antigen.

Shigellas of subspecies Newcastle were for the first time allocated in 1925 — 1929 in England by Clayton (F. N of Clayton) and Warren (S. N of Warren). In 1931 A. W. Downie with soavt, and in 1931 — 1938 J. S. Boyd was described by similar bacteria, serological identical, but differing on fermentation of a mannitol. J. S. Boyd showed that, despite some distinctions in enzymatic activity, microbes Newcastle, Denton — Manchester and Boyd-88 serological are identical.

Shigellas of subspecies of J. S. Boyd were for the first time found by the English scientist J. S. Boyd in 1932 — 1938. At us in the country their role in D.'s etiology was established by E. M. Novgorodskaya et al. (1943). It described serotypes of II, IV (1943) and VI (1945). Serotypes of these subspecies possess type-specific antigens.

Shigellas of a type of Zonne received the name in honor of the Danish scientist Zonne (S. Sonne) who in detail described in 1915 these activators D. serological differing from all known earlier and capable slowly to ferment lactose. Zonne's shigellas are inclined to dissociation and round, smooth colonys (S-form) and flat, rough give on solid nutrient mediums (R-form). It is established that R-forms are mutants of S-forms in which certain steps of biosynthesis of polysaccharide are blocked.

Serological Zonne's shigellas are isolated from other activators D.; two antigenic components characteristic of round and flat options are installed. Smooth and transitional options incorporate impurity of a R-component. Dominance of R-forms in cultures leads to spontaneous agglutination with all (or the majority) the dysenteric agglutinating serums.

For selection of S-forms the pseudotuberculous phage which has no strict specificity and lyses some types of enterobakteriya, including R-forms of shigellas of Zonne is used. Zonne's shigellas are subdivided for the purposes epidemiol, the analysis on enzymatic properties into 7 biotypes, and also in relation to standard phages, ability to produce colicines — specific antibiotic substances (see. Bakteriotsinogeniya ) and resistance to various antibiotics. In our country during the typing of shigellas of Zonne 64 fagotip are revealed (see. Lysotypy ). Typing of activators D. on ability to produce colicines is most applicable to Zonne's shigellas, shigellas Newcastle and to Boyd's shigellas which, by data I. V. Sheyna (1974), kolitsinogenna respectively in 60 — 90, 30—88 and 50% of cases.

Formation of toxins is studied by hl. obr. at shigellas of a type of Grigoriev — Shigi producing two types of toxins: thermolabile exotoxin and thermostable endotoksinony the Exotoxin formed by S-and R-forms of shigellas possesses the expressed neurotropic action, strikes blood vessels, especially vessels of gray matter of a head and spinal cord at experimental animals. Termostabilygy endotoxin, so-called enterotoxin, corresponds to O-antigen (a complex from polisakharidny, lipoid and protein connections), causes in experimental animals intestinal and other disturbances, such as a leukopenia, temperature increase, decrease in a glycogen in a liver and contents ascorbic to - you in adrenal glands, bleedings. Endotoxin is found in all representatives of a sort. The mechanism of pathogenic action of shigellas is caused by the endotoxin which is released at their death.

Also thermolabile endotoxin or a neurotoxin (the lipoproteidny part of O-antigen deprived of polysaccharides) reminding toxic action exotoxin of shigellas of a type of Grigoriev — Shigi is found in all shigellas. It is shown cytopathic! effect of a neurotoxin in culture of cells of HeLa and embryonal tissue of the person. Products of toxin in foodstuff (milk) Zonne's shigellas occur more intensively, than Fleksner's shigellas. Endotoxin of S-forms is more toxic, than R-forms.

Activators D. are characterized by unequal resistance to the environment. Grigoriev's shigellas — Shigi are least steady, Zonne's shigellas are steadiest. In water of open water sources of a shigella of Zonne survive to 48, Fleksnera — to 9 — 13 and Newcastle to — 16 days. In mains water of a shigella of Zonne and Newcastle survive up to 61 — 80 days (at the room temperature). In milk of a shigella of Grigoriev — Shigi keep viability at the room temperature 2 — 3 day, the Union — Schmitz — 3 — 5, Fleksnera — 2 — 6, Newcastle — 3 — 6, Zonne — 6 — 10 days. Especially long Zonne's shigellas in butter at storage in the refrigerator can remain (up to 6 — 8 months).

Activators D. are characterized by the expressed medicinal stability, especially Zonne's shigellas.

See also Schigella .

The EPIDEMIOLOGY

D.'s Epidemiology is defined by its polietiologichnost, polymorphism a wedge, manifestations, a mnogofaktornost of the fecal and oral mechanism of transfer, high stability of activators, twisted and a tipospetsifichnost of postinfectious immunity, a general susceptibility, especially high at children.

A source of an infection at D. is the sick person. Infection generally occurs from patients with lungs or the erased forms D., is more rare from convalescents and patients hron, forms D. Some consider that at D. caused by Fleksner's shigellas, a role of convalescents and patients hron forms as is higher than sources of an infection, than at Zonne's dysentery.

Formation hron is the most frequent, forms D. 2 — 3 years (29,5%) are celebrated at children in age groups of 1 — 2 years (23%). Patients a subwedge, forms D. make 2,6%.

Sick D.' importance of employees of the food enterprises is especially big epidemiol. At bacterial, inspections of these persons the vysevayemost of the activator D. reaches 0,2 — 1,2%. Sick D. is dangerous to people around from the first day of a disease when allocation of the activator to the environment happens most intensively, and 1 g of excrements can contain 104 — 106 shigellas; at an acute form D. the bakteriovydeleniye proceeds more often than 2 — 3 weeks.

Ways of distribution. The fecal and oral mechanism of transmission of infection at D. is carried out with participation of various spreading factors. The activator D. is allocated from an organism of the patient or the carrier with contents of intestines and can get on various objects in their environment. At the same time D.'s distribution happens contact and household, water or food in the ways, and also through flies.

The contact and household way of distribution of D. involves infection as at direct contact with the sick person (e.g., at care of it), and through various objects of use contaminated by allocations of sick (carrier): ware, door handles, switches, vessels, brushes for cleaning of clothes etc. Finally D.'s infection at a kontaktnobytovy way of transmission of infection occurs through the hands anyway contaminated by allocations of the patient; the activator is transferred by the contaminated hands either to foodstuff, or to ware.

The contact and household way of infection of adults was more often observed in the centers of D. caused by Grigoriev's shigellas — Shigi. According to experiences on volunteers in the USA, Grigoriev's bacteria — Shigi are most virulent (the infecting dose for adults 10 1 microbic cells), a little to a lesser extent — Fleksner's shigellas of the most widespread subtype 2a (the infecting dose 10 2 ) and least — Zonne's shigellas (the infecting dose 10 7 ).

At a contact and household way of transfer is more often observed in the form of sporadic cases, is more rare than group («gnezdny») diseases. The flash in the absence of measures of prevention flows is usually long. Infection of people in these cases happens not in one step; diseases accrue gradually and are connected, as a rule, with different sources. In organized collectives, in particular in child care facilities, at early detection and hospitalization of patients the contact and household way of distribution of D. is not of great importance and becomes dangerous at serious violations a dignity. - a gigabyte. governed, especially in catering services.

The waterway of distribution of D. is characterized by acute rise (flash or epidemic) and rather bystry falling of incidence, however at the same time there is «tail» of epidemic due to incomplete implementation protivoepid, died. D.'s incidence at infection of mains water can be considerable and be registered among the population provided with water of this water supply system. Pollution by the activator D. of a well can cause also bystry rise in incidence, edges, as a rule, arises among the persons using water from this well. Infection of water of open reservoirs can be long due to constant penetration of sewage into them. In these cases D.'s incidence gets hron, character though in summertime (a season of bathing) rises in incidence can be observed. Thus, D.'s incidence at the waterway of distribution (the centralized water supply) is characterized more often by explosive development, covering the population using the general source of water supply and at elimination of a source of infection quickly falls down.

The food way of distribution of D. quite often gains paramount value. At the same time foodstuff can be infected with hands of slovenly sick (carriers), workers of food objects and flies.

Many foodstuff at optimal heating environments is rather favorable environment for reproduction of the activator D. In D.'s distribution foodstuff which is not exposed to heat treatment before the use are important: milk and dairy products, salads, vinaigrettes, jellies, pastes, vegetables, fruit, berries, etc.

D.'s flashes a food origin have explosive character if in retail chain stores, in a public catering or in child care facility milk, sour cream, cottage cheese, creams, etc. is infected.

Infection of products and at favorable heating environments reproduction of the activator D. in them causes emergence of the flash proceeding clinically and epidemiologically as food toxicoinfection (see. Toxicoinfections food ). Such manifestations of D. are inherent usually in Zonne's dysentery and are connected, apparently, with a massive dose of infection as a result of intensive reproduction of the activator in products.

Infection of the foodstuff used by narrow group of people usually causes rather small incidence, edges takes place at a contact and household way of transfer. If infection of products was single, then in some cases origins of these diseases can be and are not revealed.

The role of flies in D.'s distribution is estimated by various researchers unequally. One authors give it, a factor crucial importance in definition of seasonality of. (L. V. Gromashevsky, 1947), others completely deny a role of flies in transfer D. Tak, E. M. Novgorodskaya (1957) observed in one of the cities of the Leningrad region the increased incidence at total destruction of flies. Such extreme point of view is hardly well-founded as it is proved that the activator D. is capable to keep within 2 — 3 days viability in intestines or on a body surface of a fly, and access of flies both to sewage, and to foodstuff can play a part in D.

Sezonnost's distribution. From time to time years D. is distributed unevenly. In the winter about 15% of annual incidence, in the spring — 12%, in the summer — 31%, in the fall — 42% are registered that reflects the value of separate ways of transfer changing within a year.

Cases of pollution of water of economic and drinking water supply systems as emergencies can arise in the winter and in the spring more often; respectively and the group diseases connected with infection of water usually are registered at this time. Increase in incidence during the summer period is defined both by change of character of food, and the increasing opportunities of disturbance a gigabyte. rules of preparation, storage and implementation of foodstuff. Gain value and such accessory factors as the use of the contaminated berries, vegetables and fruit, and also bathing in the contaminated reservoirs.

The PATHOGENY

the Mechanism of development patol, process at D. is difficult and insufficiently studied.

Infection at D. occurs only through a mouth. Depending on a functional state went. - kish. a path, local and general immunity, and also a dose of the activator there can be a following: in one cases under influence went. - kish. juice (salt to - that, a lysozyme and other factors) the activator perishes in an upper part went. - kish. path; in others — passes through intestines and it is allocated to the environment, without causing at the same time noticeable response from a macroorganism; in the third, in response to implementation process with a clinical picture D develops in an organism of shigellas patol. According to H. N. Sirotinina and E. A. Brodskoy (1955), shigellas within a day (sometimes longer) can be in a stomach, at the same time part of them breaks up, releasing endotoxin, the survived bacteria move ahead in a small intestine where can be late up to several days and even to breed, and then move ahead in underlying departments of intestines.

At sharply reduced body resistance and massive doses of infection short-term bacteremia, edges, according to most of authors can be observed, has no essential pathogenetic value. Only at D. caused by Grigoriev's shigellas — Shigi, especially at children, to bacteremia possesses an essential role in a pathogeny of a disease. The main role in D.'s pathogeny belongs to toxins of the activator which are soaked up and cause the first displays of a disease: fever, fever, etc. All shigellas contain endotoxin, and Grigoriev's type — Shigi produces as well ekzotoksinony Toxins in an organism work doubly: directly influence a mucous membrane went. - kish. a path and on nerve terminations, vessels and receptors of a mucous membrane, and the soaked-up toxins exert impact on various parts of the nervous system and internals.

Development of easy, especially gastroenterokolitichesky forms D., at which even the most careful bacterial. a research the calla does not allow 'to allocate activators, most likely speaks also toxaemia (see), the ground mass of bacteria arising at destruction. Involvement from the first days of a disease in patol, process and a small bowel is explained by a toxaemia what points the acute capillary plethora which is found in a mucous membrane, disturbance of its motive, vsasyvatelny and digestive functions to. About same also detection of endotoxin in blood serum of patients from the first days of a disease and its allocation with urine testifies.

The toxins which got to blood, according to L. S. Bibinova (1932), I. V. Davydovsky (1956) and others, is allocated not only kidneys, but also through a mucous membrane of a large intestine, at the same time first of all the neurovascular device of intestines suffers, and changes in a mucous membrane develop for the second time. A certain role in D.'s pathogeny, obviously, is played also by an allergic factor. According to A. A. Koltypina (1936), V. D. Timakov (1949), V. O. Mokhnach (1957), etc., all patol, process in a large intestine develops after preliminary it sensitization (see). A. F. Blyuger et al. (1972) also revealed an autoserotherapy to tissue of intestines — to the body which is preferential involved in patol, process. H. N. Sirotinin and E. A. Brodskaya (1959) consider that D. is not a typical allergic disease, and comprises only separate components of an allergy.

M. V. Voyno-Yasenetsky (from 1962 to 1973), H. Ogava with sotr. (1964, 1966), I. K. Musabayev (1975), etc. the conducting significance in D.'s pathogeny is attached to an intracellular invasion of shigellas. However V. I. Pokrovsky and N. B. Shalygina (1973), A. V. Tsinzirling et al. (1973), A. F. Kolesnikov et al. (1975), etc. is considered that there are no sufficient bases to attach to intra epithelial reproduction of shigellas major importance in D.'s pathogeny of the person. Obviously, some authors are right [Shiga (To. Shiga), 1898; E. Letterer, 1949, etc.] which assigned a leading role in D.'s pathogeny to toxins (see).

Along with immediate (organotropic) effect on a number of bodies endotoxins D. cause the general exchange disturbances in an organism: block oxidizing reactions, break water-salt, carbohydrate, protein metabolism, cause polyhypovitaminoses (due to the increased need of an organism of patients for vitamins) and the phenomena of dysbacteriosis, lead to change of structure and quantity of microelements, reduce the content of sodium and potassium in the acute period of a disease.

These disturbances can be considered as nonspecific reaction of an organism to influence of toxin. From a macroorganism in response to implementation of shigellas complex specific and nonspecific defense reactions which in most cases lead to bystry recovery develop. However sometimes process accepts a long current, and in some cases passes in hron, a form.

Pathogeny hron. Is even more difficult that is caused by existence of a large number of the reasons which disturb involution of acute process, part of them takes place and at acute D. K to their number carry a premorbidal condition of a macroorganism, functional inferiority went. - kish. a path, lowered immunobiol, reactivity and emergence of the raised sensitization of an organism to a number of allergens, late begun and wrong treatment of patients, disturbance by patients of a feeding schedule in the period of early reconvalescence. Formation hron. Can be caused also by ability of shigellas to form L - for-we with the lowered virulence and pathogenicity. All this interferes with manifestation fiziol, protective mechanisms and leads to acute D.'s transition to chronic.

According to N. I. Ragoza (1949), A. F. Bilibina (1958, 1959), B. M. Domrachev (1966), I. B. Sepia (1963), etc., at hron. Of the phenomenon of intoxication play a secondary role, and on the first place the progressing disturbances of vsasyvatelny and digestive functions act went. - kish. path.

PATHOLOGICAL ANATOMY

Fig. 1. Microdrug of a mucous membrane of a large intestine at a dysenteric endocolitis: focal defeats and leukocytic infiltration are expressed (it is specified by shooters); X 40.
Fig. 2. Microdrug of a mucous membrane of a large intestine at dysentery: on the site of deep destruction of a mucous membrane the solid film is visible (it is designated in black color) from the breaking-up polymorphonuclear leukocytes (it is specified by shooters). Coloring according to Goldman; x 55.

Characteristic of D. morfol, changes arise in distal departments of a digestive tract. In development of dysenteric colitis it is possible to allocate two main types of inflammatory reaction: diffuse catarral and focal is purulent - a necrotic inflammation of a mucous membrane. The catarrh is characterized by a hyperemia, swelling of a mucous membrane and sometimes hemorrhages (tsvetn. fig. 1,7 and 8) and the strengthened production of slime scyphoid cells. The epithelial cover remains whole, leukocytic infiltration, as a rule, is absent. In certain places where the mucous membrane is partially destroyed, many polymorphonuclear leukocytes (fig. 1) collect, and production of slime, on the contrary, is suppressed. Such centers of an inflammation can be small and rare, distinguishable only under a microscope, or deep, occupying considerable sites of a mucous membrane. Inflammatory exudate quite often forms filmy imposings (fig. 2) over the injured mucous membrane — gentle, grayish, quite thick yellow-white. It is accepted to call these imposings fibrinous, however fibrin they contain a little, and hl consist. obr. from the breaking-up polymorphonuclear leukocytes, slime and the remains of the destroyed fabric. After removal (or rejection) films on their place there are superficial ulcerations of the irregular angular shape.

At acute dysenteric colitis of disturbance of an integrity of fabrics and accumulations of polymorphonuclear leukocytes are limited to limits of actually mucous membrane. In a submucosa only expansion of blood vessels with migration of polymorphonuclear leukocytes is usually observed, and also arises more, less expressed hypostasis, sometimes with hemorrhages. At especially severe forms of the colitis called diphtheritic (tsvetn. fig. 3), on extensive sites a mucous membrane almost completely is absent, the submucosa is very strongly thickened and penetrated by dense network of fibers of fibrin with plentiful hemorrhages.

Fig. 1 — 6. A mucous membrane of a large intestine at various forms of dysentery: fig. 1 — an acute endocolitis (folds of a mucous membrane are thickened, hyperemic, with hemorrhages); fig. 2 — excess regeneration of a mucous membrane with polipovidny growths (are specified by shooters); fig. 3 — diphtheritic colitis (the wall of a gut and a fold of a mucous membrane are thickened, covered with fibrinous imposings); fig. 4 — scarring of a mucous membrane after the postponed dysentery (a mucous membrane of an atrofichn, with a smoothed skladchatost); fig. 5 — ulcer colitis (the mucous membrane which bulked up with a smoothed skladchatost and multiple small ulcerations — are specified by shooters); fig. 6 an endocolitis (kataralno - a hemorrhagic form) at toxic dysentery (folds of a mucous membrane are thickened and sharply hyperemic).
Fig. 7 — 10. Microdrugs of a wall of a large intestine at dysentery: fig. 7 — a plethora (it is specified by shooters) a mucous membrane and a submucosa' intestines in the first days of a disease; fig. 8 — plentiful diffusion leukocytic infiltrate of a mucous membrane (1), hypostasis and a plethora (2) submucosas; fig. 9 — superficial necroses (are specified by shooters) a mucous membrane with transition to a solitary follicle (1); to fig. 10 — the ulcer form of dysentery — is visible an ulcer surface (1) against the background of which the remained islands of a mucous membrane act (2).

At favorable disease inflammatory process in a mucous membrane of a large intestine abates. Its small damages are epithelized, but in the field of more serious defects the mucous membrane a nek-swarm time remains to lower. Formation of ulcers is characteristic of prolonged heavy colitis (tsvetn. fig. 5, 9 and 10), quite often numerous and large. Edges of such ulcers of a podryta. At extensive ulcers of their edge merge with each other. However dysenteric ulcers are not deep, extend within a submucosal layer and contrary to typroid extremely seldom lead to perforation. For the same reason scarring of ulcers (tsvetn. 304, fig. 4) seldom causes narrowing of a gleam of a gut. The wrong (excess) regeneration of the injured mucous membrane with its polypostural growths is sometimes observed (tsvetn. fig. 2).

At a long and recurrent current of D. in a large intestine can be found different in prescription and on weight of change. The exacerbation of an infection is shown by strengthening of Qatar and emergence of the new centers of an inflammation, often on site former, napr, at the edges of ulcers.

The fabric changes inherent in bacterial D. are most sharply expressed in the direct, sigmoid and descending guts, but not less heavy they can be and in other departments of intestines, sometimes occupying even terminal sites of a small bowel. Defeats, as a rule, have local character and often alternate with a little changed sites of a mucous membrane; most strongly tops of folds suffer.

Expressiveness and some morfol, features of damage of intestines allow to distinguish the following main forms of dysenteric colitis.

The endocolitis is shown by swelling and a hyperemia of the mucous membrane of a large intestine which is quite often covered with slime and muddy or putreform liquid. At a research through rektoskop and on openings of change of a mucous membrane are represented widespread and quite homogeneous, it is possible to distinguish small hemorrhages and erosion only here and there (a catarral and hemorrhagic form — tsvetn. fig. 6) or to notice insignificant filmy exudative imposings. Degree of manifestation of an endocolitis happens different — from easy swelling and pink coloring of a mucous membrane of direct and sigmoid guts to sharply expressed Qatar taking all large intestine.

At an endocolitis at small children with strongly developed limf, the device sometimes over a mucosal surface of a cover the large solitary follicles bordered with a narrow corbel of a hyperemia clearly act. However to isolate such colitis, calling it follicular, there are no bases especially as at D. (contrary to salmonelloses) lymphoid formations of intestines in itself in patol, process are not involved.

Fibrinous, or purulent, colitis along with pronounced diffusion Qatar is characterized by the massive, but easily removed yellow-white filmy imposings covering the damaged sites of a mucous membrane.

Fig. 3. Microdrug of a large intestine at diphtheritic colitis: loss of fibrin in a submucosal layer of a large intestine (fibers of black color, are specified by shooters). Coloring according to Goldman of X 40.

Diphtheritic colitis (tsvetn. fig. 3) differs in a sharp thickening, consolidation and bloody coloring of all wall of a large intestine. At the same time the mucosal surface of a cover seems uneven and covered with dirty greenish-gray or brownish-gray dim imposings owing to loss of fibrin in the most intestinal wall (fig. 3) which is almost deprived of an epithelial cover.

Gangrenous colitis — especially dangerous form; the wall of a large intestine is painted in dark brown, almost black color, is fetid and is easily torn. Such defeats of a gut at D. meet very seldom and, obviously, are result of the joined mephitic gangrene.

Ulcer colitis (tsvetn. fig. 5, 9 and 10) is characteristic for long heavy. Ulcers, the arising hl. obr. in distal departments of a large intestine, heal slowly, quite often remaining also after attenuation of a dysenteric infection (post-dysenteric colitis).

The specified damages of a large intestine at D. quite often consider not separate forms, and stages of development of the dysenteric colitis which is beginning Qatar and which is coming to an end with formation of ulcers. However such sequence is not obligatory at all. At sick D., the called Fleksner and Zonne's shigellas, changes of a large intestine are usually limited to simple Qatar with small hardly noticeable ochazhka of destructive changes of a mucous membrane.

In submucosal and intermuscular neuroplexes of a large intestine degenerative changes of neurons are found; they are considered the reason for the slowed-down regeneration of dysenteric ulcers.

In other bodies at D. the dystrophic changes explained as disturbance of food (especially at a long disease), and action of the bacterial products and other toxicants getting through the injured mucous membrane of a gut are found.

Fig. 4. Microdrug of a large intestine of a monkey, sick dysentery: in epithelial cells of a mucous membrane shigellas are visible (are specified by shooters).

With the advent of chemotherapeutic drugs of the directed action deaths and severe forms of colitis in general almost do not meet. By means of methods morfol, researches (immunohistochemical, electronic and microscopic, etc.) it was succeeded to obtain the new data important for understanding patol, anatomy and a pathogeny of a dysenteric infection. So, in an experiment ability of shigellas to parasitizing in epithelial cells of intestines (fig. 4) was established. At the same time the cover cells struck with shigellas are found only in the centers of a purulent inflammation and are absent in sites of simple Qatar. In process of reproduction of microbes epithelial cells collapse and exfoliated. In the small pieces of fabric received by a biopsy at endocolites at the person, ochazhka of an inflammation with shigellas in an epithelium come across seldom.

IMMUNITY

Features of a dysenteric infection (tendency to transition in hron, a form, a frequent recurrence) promoted that the question of existence of immunity at this disease long time remained disputable.

A wedge, and experimental observations P. K. Likhtorovich, etc. (1956), N. A. Yakhnina (1958), S. Honjo with sotr. (1967), etc. confirm emergence of postinfectious specific immunity (see) lasting from 1 — 3 month till 1 year.

Till 60th questions of specific immunity at D. were considered only in connection with function of reticuloendothelial and mesenchymal systems of an organism. The big material testimonial of increase was saved up during a disease of maintenance of serumal antibodies (agglutinins, pretsipitin, fixators, hemagglutinins) and preventive activity of blood serum, data on accumulation in blood serum of sick D. of bacteriolysins are obtained. However it is established that the level of antibodies does not define degree of immunity of an organism to the subsequent infection and in some cases does not correspond to weight of a disease.

At D. along with humoral cellular defense reaction amplifies. According to M. V. Voyno-Yasenetsky (1963), etc., capture and digestion of shigellas in a mucous membrane of intestines generally carry out polymorphonuclear leukocytes. Ut (A. Takeuchi, 1968) and sotr. believe that also mononukleara — fabric macrophages and histiocytes participate in this process, ideas of local immunity at D. became More specific, the Prevailing majority of works on this question is carried out on keratokonjyunktivalny model (at a Guinea pig).

According to Formal (S. Formal, 1966) and sotr. and Yu. A. Béla (1970), local immunity has generally cellular and fabric character. Other probable mechanism of local immunity at D. is immunity of epithelial cells. D. G. Manolov and G. V. Kosturkov (1967) consider that the mechanism of local immunity consists in emergence of more resistant population of epithelial cells with the acquired properties of antibacterial protection. According to V. I. Bakhutashvili (1968), in population of cells selection of naturally steady clones is possible.

Is among diseases at which extremely important role is played by factors of nonspecific protection of a macroorganism. This situation is established as a result of numerous a wedge. - epidemiol, observations.

The diseases proceeding with diarrhea, in particular D. most often meet and hard proceed at the persons receiving defective food. In experiences on monkeys and small animals the role of a proteinaceous and vitamin deficiency for a disease of is shown.

The problem of protective functions of a mucous membrane has great theoretical and practical value went. - kish. path. V. I. Pokrovsky, etc. (1972); B. A. Godovanny, etc. (1973); Etc. (1975) showed to M. I. Semashko in an experiment dependence between a condition of an intestinal wall and a susceptibility of an organism to infection with dysenteric microbes. One of mechanisms of decrease in resistance of an organism to activators D. at damages or diseases of intestines was found out — a susceptibility to the small doses of the activator which are not causing normal a disease in healthy individuals.

To nonspecific fiziol, elements of protection of an organism at D. as well as at other infectious diseases, mechanisms of destruction and release of toxic substances of a bacterial cell belong.

The CLINICAL PICTURE

On a wedge, to D.'s current subdivide on acute and chronic, and also a bacteriocarrier. Acute D. lasts from several days to 3 months D. lasting more than 3 months is regarded as chronic.

Duration of an incubation interval 2 — 3 days, seldom drags on up to 7 days. At receipt in an organism of a massive dose of the activator these terms can be reduced till several o'clock.

Features of disease are caused by a type of the activator, a condition of a macroorganism and depend on character and starting date of treatment.

Separate etiol, options D. have a wedge, features. So, D. caused by Grigoriev's shigellas — Shigi, proceeds very hard, with intensive diarrhea with impurity in excrements of the slime, blood and pus expressed by dehydration, high septic fever, bacteremia, a leukocytosis of blood more often., Fleksnera called by shigellas, is characterized by bigger expressiveness of a kolitichesky syndrome, bigger intensity of focal damages of a mucous membrane of intestines. Cases, Zonne called by shigellas, proceed in the form of a gastroenterocolitis, with more expressed right-hand colitis more often. However at all etiol, options D. lungs and the erased forms of a disease meet.

Acute D. has four a wedge, forms: kolitichesky, gastroenterokolitichesky, hypertoxical and erased. The first two forms on weight of a current are subdivided on easy, moderately severe and heavy. The hypertoxical form always proceeds hard, and erased differs in very easy current.

Hron. Has two a wedge, forms: recurrent and continuous.

The bacteriocarrier probably represents the most frequent option of infectious process of D. U of the majority of carriers at gistol, a research of biopsy material of a mucous membrane of intestines and immunol, researches signs of infectious process in this connection this form of a carriage is designated sometimes as subclinical are found.

Acute dysentery

the Kolitichesky form

the Easy current is characterized typical, though insufficiently outlined a wedge, a picture, with insignificant intoxication and a slight kolitichesky syndrome (the scanty speeded-up chair, it is frequent with impurity of slime and blood, tenesmus, pains in the bottom of a stomach). If symptoms of intoxication are difficult to be established clinically, then functional and morfol, changes of a large intestine come to light at this form clearly.

The disease begins suddenly more often. Patients have moderate pains which are localized in the bottom of a stomach, is preferential in the field of a sigmoid gut which precede the act of defecation, and after it quite often there are nagging pains in a rectum — tenesmus (see). Frequency of a chair from 3 — 5 to 10 times a day, excrements of fecal character, contain impurity of slime, and sometimes and blood. Body temperature, as a rule, normal or subfebrile. Patients complain of insignificant weakness, a loss of appetite. Symptoms of defeat of cardiovascular system at this form of acute D. are, as a rule, not expressed. In peripheral blood at 1/3 patients — a moderate leukocytosis with shift of a formula to the left. At rektoromanoskopiya (see) more often the catarrh of a mucous membrane, sometimes dot hemorrhages is found and erosion are more rare. The reparation of the specified changes comes by the end of the 2nd, the beginning of the 3rd week of a disease.

Medium-weight current. Characteristic symptoms of a disease are expressed more accurately. Usually sharply or after a short prodromal stage which is characterized by an indisposition, weakness, chilling, feeling of discomfort in a stomach characteristic symptoms of a disease appear.

First of all there are abdominal pains which have skhvatkoobrazny character and are localized preferential in the left ileal area. Along with pains or a bit later desires to defecation appear. Gradually the volume of fecal masses decreases and they become scanty, there is an impurity of slime and blood, but the frequency of defecations increases. At the height of a disease of an excrement can lose fecal character and have an appearance of a so-called rectal spittle, i.e. consist of scanty amount of slime with blood. Defecation is followed by painful tenesmus, false desires to defecation are very frequent. Impurity of blood in excrements of patients of acute D. is usually insignificant by quantity and is in them in the form of blood points or streaks. Frequency of a chair fluctuates from 10 — 15 to 25 times a day. Along with dysfunction of intestines, and sometimes and preceding it, the headache develops, at the most part of patients body temperature increases: to a thicket to 38 — 39 °, is more rare to subfebrile figures. Duration of the feverish period at most of patients at treatment does not exceed 2 — 3 days, without treatment can proceed more. At the height of a disease increase of weakness, an adynamia is characteristic. Patients often become irritable, dizzinesses and even short-term faints can be observed. Pulse is speeded up. Maximum by the ABP it is lowered. The size of pulse pressure decreases.

In peripheral blood increase in neutrophilic leukocytes with clear shift of a formula is noted to the left.

The main trouble to patients is given by colicy pains which at most of them proceed 3 — 4 days and seldom have constant character. More often they are localized in the bottom of a stomach, in half of cases — is preferential in the left ileal area, and at 1/3 persons have diffuse character; sometimes there are pains of atypical localization — in epigastric or umbilikalny areas. The meteorism is quite often noted. Frequency of a chair within a day to 10 — 20 times is observed at a half of patients, St. 20 times — almost at 1/3 patients. Without patol, impurity of an excrement meet very seldom, with impurity of slime is much more often, impurity not only slime, but also blood is typical.

At a palpation of a stomach at the vast majority of patients the condensed, painful sigmoid gut comes to light. At a rektoromanoskopiya — signs of the expressed catarrh, against the background of to-rogo are quite often visible focal changes — hemorrhages, erosion or ulcers.

At a research of a functional condition of intestines by fiziol. loadings mono - di - and polysaccharides disturbances of the digesting, vsasyvatelny and motor functions of a small intestine come to light. It is established (an intravital biopsy) that the mucous membrane of upper parts of a jejunum is in a condition of an easy catarrh, moderately expressed phenomena of dystrophy of its epithelium, serous hypostasis, hemorrhages, cellular infiltration of a stroma, hypersecretion of slime are noted. Quite often also symptoms of gastritis come to light. Changes of a small intestine and a stomach are according to weight, duration of disease and meet especially often at tendency to a long current. At the patients who transferred a medium-weight form of acute D. at a favorable outcome full functional and morfol, recovery of intestines can drag on up to 2 — 3 months.

The heavy current is characterized typical a wedge, a picture with the expressed intoxication and a kolitichesky syndrome.

The disease, as a rule, begins violently, patients complain of strong colicy pains in a stomach, very frequent liquid chair, excrements scanty, slizistokrovyanisty, sometimes with impurity of pus. Weakness, high temperature, quite often nausea and vomiting, dehydration is noted. Clearly changes from cardiovascular system come to light: tachycardia, short wind, the ABP sharply decreases, sometimes arises collapse (see). At the height of a disease weakness, apathy, frustration of a dream develops. Quite often severe headache, spasms, sometimes hiccups.

There can be mental disorders. More often they are defined by various extents of devocalization reaching sometimes depth of a sopor (see. Devocalization ). At involution of symptoms of devocalization there can be psychosensorial frustration, delirious episodes (see. Delirious syndrome ), gipnagogichesky hallucinations (see. Hallucinations ). Most longer various manifestations of an adynamy keep (see. Asthenic syndrome ).

From peripheral blood — the expressed leukocytosis (more than 12 000 — 15 000). An absolute and relative neutrocytosis, a sharp deviation to the left up to young forms. Quite often toxic granularity of neutrophils is registered. ROE is accelerated. At a rektoromanoskopiya more often (but not always) destructive changes of a mucous membrane in the form of erosion and ulcers prevail. The disease lasts up to 6 and more weeks.

At the persons who transferred a severe form of acute D., terms funkts, and morfol. recovery of intestines can be late up to 3 — 4 months.

The Gastroenterokolitichesky form

the Incubation interval usually short — 6 — 8 hours that is connected with massiveness of a dose of the microbes getting to an organism.

The disease often proceeds as food toxicoinfection (see. Toxicoinfections food ), it is characterized by the acute beginning. The prevailing syndrome — the gastroenteritis which is followed by high fever and intoxication. The disease begins with vomiting more often, and then the profuse diarrhea joins. Excrements are watery, plentiful. Patients are disturbed by pains on all stomach. Rapid current, but short. By the end of the first — the beginning of second day in excrements impurity of slime and blood appears. Excrements decrease in volume and take a form of typically dysenteric.

Weight of disease, as well as at a kolitichesky form, is defined first of all by degree of intoxication of an organism, expressiveness of symptoms of defeat of cardiovascular and digestive systems.

A hypertoxical form

Into the forefront symptoms act as cutting intoxications (see). At the patient the Meningeal syndrome, coma, a collapse can develop. Symptoms of defeat went. - kish. a path join later. Disease, as a rule, very heavy.

The erased form differs insignificant or short-term a wedge, manifestations. The picture of a disease is exhausted by one or several slight symptoms: a kashitseobrazny chair, mild pains in a stomach, consolidation and morbidity of a sigmoid gut at a palpation, the changes of a mucous membrane of a gut revealed at a rektoromanoskopiya.

Chronic dysentery

Acute D. in 2 — 5% of cases can accept hron, a current. The factors promoting acute D.'s transition in hron, a form, the previous diseases of bodies of the alimentary system are; decrease in immunoreactive properties of a macroorganism; the accompanying diseases among which protozoan and helminthic invasions are on the first place; untimely and wrong treatment both in the acute period, and in the period of reconvalescence; wrong diet. Hron. Proceeds in the form of two forms: recurrent and continuous.

The recurrent form meets considerably more often than continuous. It is characterized by the fact that after the postponed acute D. in 2 — 5 months of imaginary wellbeing there is a palindromia.

During this period at patients the speeded-up chair, excrements kashitseobrazny with considerable impurity of slime is noted, and it is frequent also blood. The abdominal pains connected with walking, jolting and even a postural change of a body prevail. Existence of tenezm and false desires is characteristic. At a palpation restrictedly mobile sigmoid gut, but also the painful and condensed caecum is defined not only condensed, infiltrirovanny, painful. Dysfunction of intestines has resistant character, the period of remission can not come a long time.

The resistant and recurrent nature of diarrhea has in the basis not only deep defeat of all went. - kish. a path, but also involvement in patol, process of other digestive organs — a pancreas and bodies of gepatobiliarny system, than also speaks existence at sick complaints to rumbling, abdominal distention, feeling of discomfort, a loss of appetite, intolerance of separate types of food (e.g., dairy products), extreme sensitivity to disturbance of food. These extensive defeats lead to sharp disturbances of processes of digestion and absorption. But at the same time defeat of distal department of intestines always remains prevailing.

During the interrecurrent period a condition of patients satisfactory, working capacity remains, but there is a functional insufficiency of intestines. It is shown by an unstable chair, disturbance of digestive and vsasyvatelny function. Short-term dysfunctions of intestines arise after plentiful spicy food. There is a bad portability of some products (the milk, products rich with rough cellulose or fermenting, spices). It is long the sensation of discomfort in a stomach keeps.

Patients hron. Are irritable, emotionally labilna, are inclined to neurotic reactions. Increase of a chair can be also caused raised physical. loading, strong emotions.

Continuous form. The main feature of this form — lack of the periods of remission. At the same time continuous progressing of a disease and an aggravation of symptoms of the patient takes place. Symptoms of intoxication at patients hron. Are usually expressed poorly, during aggravations their high temperature, signs of cardiovascular insufficiency is not observed.

The bacteriocarrier

the Bacteriocarrier is characterized by absence of any dysfunction of intestines both during inspection, and in preceding it 1 — 3 month in the presence of allocation of activators with a stake.

COMPLICATIONS

At big acute and hron. Can be observed various complications influencing as a wedge, displays of a disease, and its outcome. At D. caused by Zonne's shigellas, complications meet less than at D. caused by Fleksner's shigellas and especially Shigi.

A rare, but the most terrible complication is peritonitis (see). Peritonitis at sick D. is characterized by slow increase of intoxication, absence or weak expressiveness of painful symptoms and a local muscle tension of an abdominal wall. Characteristic symptoms of peritonitis (abdominal distention, a muscle tension of an abdominal wall, symptoms of irritation of a peritoneum, nausea, vomiting, a hiccups, etc.) clearly are expressed only in late terms of development of a complication.

Persistent ponosa, enterospasms can serve as premises for development of invagination of intestines (see. Impassability of intestines ). According to V. P. Arsenyev (1936), invagination at D. was observed in 0,5% of cases. I. K. Musabayev and T. 3. Abubakirov (1973) is specified that invagination in some cases is allowed independently and owing to this fact it is diagnosed considerably less than meets.

Much more often acute D.'s patients have cracks and erosion anus (see), loss of a mucous membrane of a rectum (see. Prolapse of the rectum ) and aggravation hemorrhoids (see).

At sick D. such complications as polyarthritises, nephrites, iridocyclites, polyneurites, toxic hepatitises are described.

Disturbance of a biocenosis of intestines which is quite often aggravated with purpose of antibacterial drugs is characteristic of acute D. and can lead to development of intestinal dysbacteriosis (see).

The DIAGNOSIS

the Diagnosis is made on the basis a wedge. - epidemiol, the laboratory researches given taking into account results.

The anamnesis, detection of the sequence of emergence and interrelation of various symptoms of a disease, establishment of an opportunity and the nature of contact of this patient with another, earlier hurting D., or the persons having any dysfunction of intestines are of great importance. Such characteristic symptoms of D. as the colicy pains in a stomach connected with the act of defecation the speeded-up chair, excrements containing impurity of slime and blood existence of tenezm are not always accurately expressed, intensity of these symptoms depends on weight and the period of a disease. At a palpation of a stomach along with the spazmirovanny and limited in mobility painful sigmoid gut also other departments of an infiltrirovanny large intestine can be palpated.

Essential help at diagnosis of D. is given by laboratory and tool data, especially at atypical and a subwedge, forms of a disease.

In diagnosis of a disease results bacterial are of great importance. researches of excrements, of smaller value detection of a specific antigen in urine of patients and antibodies in blood serum is.

A part in D.'s diagnosis is played by a skin allergy test with dizenteriny. The drug of 0,1 ml is administered strictly vnutrikozhno and results of reaction are considered in 24 hours.

From tool methods of a research gained the greatest recognition rektoromanoskopiya (see), edges helps with diagnosis and differential diagnosis. If D.'s diagnosis does not raise doubts, the rektoromanoskopichesky research can be not conducted.

The distance shall be reflected in record of results of a rektoromanoskopiya, on a cut it was succeeded to enter a tube of a rektoskop, the tone of a gut and color of a mucous membrane is noted, focal changes in it are listed and described, availability of slime on walls and in a gleam of a gut is noted. The description of all examined departments of a large intestine, including an anus is obligatory. The nature of changes of a mucous membrane or absence them shall be fixed in the conclusion.

the Rektoromanoskopichesky picture at dysentery (fig. 1 and 2 — a type of a mucous membrane of various sites of a sigmoid gut is normal — it is given for comparison). Fig. 3. Erosive proctosigmoiditis: erosion (1) and deposits of slime (2) on a top of a fold kataralno the changed mucous membrane. Fig. 4. Kataralno - a mucous proctosigmoiditis: the hyperemia (1) of a mucous membrane and adjournment of slime (2) are expressed. Fig. 5. Catarral and hemorrhagic proctosigmoiditis: hemorrhages of a mucous membrane (are specified by shooters). Fig. 6. Erosive proctosigmoiditis: erosion of a mucous membrane (are specified by shooters). Fig. 7. Ulcer proctosigmoiditis: a mucous membrane ulcers (are specified by shooters). Fig. 8. Erosive sigmoiditis: 1 — accumulation of pus; 2 — erosion (the arrow specified erozivno the changed outside sphincter of an anus).

At macroscopic survey and assessment of a condition of a mucous membrane of a direct and sigmoid gut at D. distinguish catarral, catarral and mucous, catarral and hemorrhagic, erosive, ulcer, erosive and ulcer sigmoidites and a proctosigmoiditis (tsvetn. rice. And, 3 — 8).

The listed forms meet unequal frequency and in various combinations, and the mucous membrane sigmoid, a rectum and an anus on the nature of changes can be various at the same patient. At acute D. changes of a mucous membrane are noted from an onset of the illness and reach a maximum to 2 — to the 4th day of a disease.

The wedge, acute D.'s symptoms disappear to 7 — to the 10th day of a disease, the macroscopic changes of a mucous membrane revealed at a rektoromanoskopiya remain more long time, and at microscopic examination of biopsy material of a mucous membrane patol, changes remain to 3 — 4 weeks from an onset of the illness and more.

The negative take, especially single laboratory or tool research at patients with characteristic a wedge, a picture, cannot form the basis for failure from the diagnosis acute to.

Diagnosis hron. Put on the basis of data on the acute D. postponed within the last two years, characteristic abdominal pains, the speeded-up kashitseobrazny chair with patol, impurity, existence of a sigmoid gut, positive takes, condensed, often painful with limited mobility, bacterial, researches a calla and serol, researches.

At the same time negative takes of separate laboratory researches in the presence a wedge, data as well as at acute D., cannot form the basis for a rejection of the diagnosis hron.

For the purpose of confirmation a wedge, the diagnosis hron. Shall be used all laboratory and tool methods which found application at diagnosis of acute forms of this disease.

At patients hron. Of change from a mucous membrane of a large intestine have polymorphic character. During an aggravation the rektoromanoskopichesky picture reminds the changes characteristic of acute D. Odnako at attentive survey intensity of changes on various sites is not identical. Alternation of a bright hyperemia with more pale sites of a mucous membrane on which the expanded vascular network clearly is visible is possible. The mucous membrane is in these parts thinned, dim, easily vulnerable. At gistol, a research the expressed dystrophy of an epithelium is found. During subsiding of the acute phenomena the mucous membrane looks less edematous and more dim, than during the same period at acute D.

Laboratory diagnosis

Laboratory diagnosis of D. is carried out bacterial., immunol, and koprol. by methods. The basic is bacterial, a method of identification of the activator allocated from excrements, the emetic mass and rinsing waters of a stomach, a contaminated water and foodstuff cadaveric a mat of rial.

Excrements (1 — 2 g) take a wooden or glass rod from the vessel or a diaper, including lumps of pus and slime (but not blood), or directly from a rectum a cotton plug or a rectal tube. Excrements at patients collect prior to etiotropic treatment. The best results are yielded by crops of material directly at a bed of the patient. At impossibility of immediate crops of an excrement place in test tubes with the preserving solution in the ratio 1:3 — 1:4. As preservative apply glyceric mix, buffer solution of phosphate salts (pH 8,0), etc. The emetic mass and rinsing waters of a stomach, the remains of foodstuff, pieces of bodies of a corpse collect in sterile jars with a capacity of 200 — 250 ml. Material in tin containers is delivered in bacterial. laboratory, and at impossibility of bystry delivery place in the refrigerator (no more than for days).

First day of a research. Crops is made in two cups with differential and diagnostic circles of Ploskirev (see. Ploskireva Wednesday ) and Endo (see. Endo Wednesday ) or Levina (see. Levina Wednesday ) with levomycetinum (25 mkg/ml) or synthomycin (50 mkg/ml) for increase in a vysevayemost and in parallel in the ratio 1: 5 increases a vysevayemost of shigellas of Zonne by the selenitovy environment of enrichment, edge. At crops of emetic masses and rinsing waters use the selenitovy environment of double concentration and provide a ratio of an inoculum to the environment 1:1. All crops incubate at t ° 37 ° 18 — 20 hour.

Second day. Look through cups with crops (tsvetn. fig. B., 9) and suspicious colonies sift on Russell's circle (see. Russell Wednesday ) or on a slanted column with urea (lactose, glucose and urea). Activators D. grow in a type of round, gentle, colourless, transparent colonies to dia. 1 — 2 mm; colonies of shigellas of Zonne more dense, large, sometimes rather turbid, with the cut-up edges. From the selenitovy environment make seeding on Ploskirev's circle. All crops incubate at t ° 37 ° 18 — 20 hour.

Fig. 9 — 14. Laboratory diagnosis on differential and diagnostic environments: fig. 9 — growth of shigellas of Zonne (light colonies) on Petri dishes (and — on Ploskirev's circle — on Levin's circle); fig. 10 — 14 — Wednesday an agar with lactose, glucose and urea, the indicator — mix of water blue of dye with rosolic acid: fig. 10 — without crops — is given Wednesday for comparison; fig. 11 — splitting of urea with a growth of Bact. proteus (Wednesday gets a reddish-orange shade); fig. 12 — splitting of glucose to acid (the column of the environment becomes blue) — suspicion on growth of the causative agent of dysentery; fig. 13 — splitting of glucose to acid and gas — growth of Bact. coli; fig. 14 — splitting of lactose and glucose (Wednesday becomes blue) — growth of bacteria, suspicious on the causative agent of dysentery (Zonne's shigella).

Third day. The cultures which are marked out the day before identify on morphology, biochemical (tsvetn. fig. B, 10 — 14). and serol, properties in an agglutination test on glass with the adsorbed serums and are given after that the preliminary answer. Study cultures of the gram-negative sporeless sticks which are not splitting lactose and urea, splitting glucose to - you. Consider that Zonne's shigellas are capable to ferment lactose to - you (on second day and later), and some options of shigellas Newcastle split glucose with education to - you and gas. For final identification of culture sow on Giss's circles with carbohydrates: sucrose, a maltose, xylose, pectine sugar, rhamnose and polyatomic alcohol, a mannitol and dulcite (see. Gissa of the environment ), on a column from 0,2% an agar for definition of mobility, Kligler's circle for definition of ability to form hydrogen sulfide, on a slanted beef-extract agar for further studying of enzymatic and colicinogenic properties of culture, Christensen's circle, acetate, Simmons, with amino acids — ornithine, a lysine and phenylalanine. Splitting of amino acids to an indole comes to light on discoloration of the piece of paper impregnated with Ehrlich's reactant (see. Ehrlich reaction ) and placed under a stopper in a test tube with crops on a beef-extract broth.

Look through cups with resowings from the selenitovy environment and select suspicious colonies. Crops incubate at t ° 37 ° 18 — 20 hour.

Fourth day. Note changes of carbohydrate circles of Giss — a long «motley» line; formation of an indole and hydrogen sulfide, formation of alkali and to - you on Christensen's circle (crops is maintained up to 2 days), decarboxylation of amino acids (up to 4 days), growth on the acetate environment and Simmons's citrate (up to 7 days). At cultures, biochemical which properties correspond to shigellas establish an antigenic formula by means of repeated agglutination on glass and issue the final answer about results of a research. In addition study sensitivity to a polyvalent dysenteric bacteriophage and put keratokonjyunktivalny test on Guinea pigs. The majority of svezhevydelenny dysenteric bacteria on the second - third day causes a specific keratoconjunctivitis.

For epidemiol, the analysis of incidence of D. carry out studying of a number of enzymatic properties of the shigellas of Zonne which are not differentiated serol, methods and abilities to a kolitsinogeniya (see. Bakteriotsinogeniya ). Zonne's shigellas on ability to split rhamnose and xylose are subdivided on 4 (I, II, III, IV), and on ability to ferment rhamnose, xylose and a maltose — on 7 biochemical, types — Ia, Ib, IIig, IIe, IIId, IIIc, IVf (tab. 3).

Shigellas Newcastle depending on the nature of splitting of glucose, a mannitol and dulcite are subdivided according to Edwards and Ewing (P. R. Edwards, W. H. Ewing, 1962) on 7 biochemical, types (tab. 4).

Apply a method of fluorescent antibodies to the accelerated D.'s diagnosis (see. Immunofluorescence ).

At diagnosis apply also immunol, the reactions based on detection of antibodies to the activator. Specific antibodies in blood serum of the patient at acute D. find with 5 — the 8th day of a disease with the subsequent increase of their contents to 15 — to the 20th day. The most reliable results receive during the studying of pair blood sera of the patients taken twice for the purpose of identification of dynamics of an antiserum capacity. For D.'s diagnosis it is possible to use sensitive and specific reaction of passive hemagglutinations (see) with erythrocyte diagnosticums from Zonne and Fleksner's shigellas; Hemagglutinins are found in blood serum of sick D. within 3 months. The caption 1 is diagnostic: 200.

Koprol. researches are suitable for D.'s diagnosis only as an additional method and are an indicator patol, changes in intestines. These researches provide macro - and microscopic studying of excrements. At macroscopic studying pay attention to availability of tyazhy slime of purulent character and impurity of blood. Under a microscope in mucous lumps accumulations of the neutrophils which often already underwent a degeneration, eosinophils and macrophages are visible.

Results of laboratory researches shall be estimated in a complex and be compared surely with data a wedge, and epidemiol, inspections.

The differential diagnosis

the Differential diagnosis of D. should be carried out with the following diseases: food toxicoinfections, first of all salmonellezny etiology, cholera, poisoning with mushrooms and salts of heavy metals, viral diarrhea, acute appendicitis, new growths of a large intestine, thrombosis of mezenterialny vessels, impassability of intestines, amebiasis, balanthidiasis, nonspecific ulcer colitis, tubercular coloenteritis.

Food toxicoinfections in most cases begin so sharply that patients specify not only day, but also hour of an onset of the illness. In the anamnesis connection of a disease with consumption of this or that product (however the similar instruction always shall be regarded with the known care), the group nature of a disease, a short incubation interval is quite often established. Emergence in patients of nausea, vomiting, a plentiful watery chair of green or brown color with a fetid smell first of all force to think of food toxicoinfection of a salmonellezny etiology. The chair at a salmonellosis remains plentiful throughout all acute period of a disease, and at D. in the course of a disease the volume of fecal masses decreases, but the frequency of defecations increases. Sick D. have a sigmoid gut of a spazmirovan, is painful, limited mobility, at patients with food toxicoinfections morbidity is most often localized in epigastric area and around a navel. More expressed leukocytosis with band shift up to emergence of young forms is characteristic of food toxicoinfections.

At a rektoromanoskopiya at patients with food toxicoinfections easy catarral process or single dot hemorrhages can come to light, but the mucous membrane is much more often remains not changed (see. Salmonelloses , Toxicoinfections food ).

Crucial importance in differential diagnosis of these diseases results have bacterial, researches.

From additional laboratory tests during the carrying out the differential diagnosis can beat reaction of indirect hemagglutination and a skin allergy test are used.

In the presence epidemiol, indications it is necessary to exclude the cholera clinically different from D. lack of abdominal pains, characteristic plentiful, watery inodorous excrements which in typical cases take a form of «rice water». Quickly, sometimes within several hours, dehydration of an organism (the pointed features, the sunk-down eyes, «cholera points», dim scleras, disturbance of turgor of skin, «beef-steak hand») develops. Accession of vomiting is characteristic after the beginning of a diarrhea. Body temperature is seldom subfebrile, is more often normal or subnormal. In peripheral blood a leukocytosis (25 000 — 40 000 in 1 mkl), increase in quantity of erythrocytes up to 6 — 8 million in 1 mkl, signs of a pachemia (see. Cholera ).

At recognition of poisonings with mushrooms and salts of heavy metals carefully collected anamnesis is essential. Damage of a liver and a nervous system, and also hemolysis of erythrocytes that is not present at acute D. (see is characteristic of poisoning with mushrooms. Mushrooms, poisonings ). At patients with poisoning with salts of heavy metals, except colicy pains in a stomach, repeated vomiting and bloody stools, the sharp xerostomia, bradycardia, spasms, damage of kidneys comes to light (see. Food poisonings ).

At an acute appendicitis pains in the right ileal area are localized more clearly, there are symptoms of irritation of a peritoneum and a protective muscle tension of a stomach, but the frequency and character of a chair usually do not change, though false desires can take place (see. Appendicitis ).

At the differential diagnosis of D. it is necessary to remember that at fibrinferment of arteries of a mesentery of pain appear suddenly, quickly accrue and have constant character. In the liquefied excrements impurity of blood often is noted, but false desires, tenesmus are absent, there is no slime or it is not enough. Patients with thrombosis in the anamnesis have instructions on different diseases of cardiovascular system more often: general atherosclerosis, stenocardia, myocardial infarction, etc. Gradually symptoms of intestinal impassability and peritonitis develop.

Invagination of intestines can resemble acute D. existence of abdominal pains and a mucosanguineous chair in the beginning. Invagination differs in quickly progressing deterioration in the general state, change of colicy pains by constants, a delay of a chair and gases, abdominal distention, tension of an abdominal wall, a gaping of an ampoule of a rectum at a manual research from acute D. (see. Impassability of intestines ).

The amebiasis is more widespread in areas with hot climate, has no character epid, flashes, is characterized by a long incubation interval (from a week to several months). At an amebiasis of the phenomenon of intoxication are expressed poorly or are absent. Standard temperature, is more rare subfebrile. The chair to 5 — 15 times a day, has fecal character with impurity of transparent vitreous slime, edges is often impregnated with blood and sometimes reminds «crimson jelly». At a rektoromanoskopiya against the background of not changed mucous membrane the ulcers with the subdug edges containing necrotic masses and surrounded with a corbel of a hyperemia come to light. In a koprogramma eosinophils, macrophages, Sharko's crystals — Leyden are specific. Detection in Calais of a big vegetative form of an amoeba with fagotsitirovanny erythrocytes solves the diagnosis (see. Amebiasis ).

The balanthidiasis is characterized by slower progressing course of a disease which is followed by profuse ponosa, bystry emaciation, anemia. The chair is plentiful, foamy, with considerable impurity of blood, 6 — 10 and more times a day. The pain syndrome is more often localized in the field of the expanded humming caecum. Disease is wavy, inclined to transition to chronic. At a rektoromanoskopiya the ulcers covered with white friable, filmy imposings which usually easily are removed are found.

Make crops for detection of balantidiya a calla on Pavlova's circle. It is better to take away material for crops at a rektoromanoskopiya from a mucous membrane near the centers of defeat (see. Balanthidiasis ).

A precursory symptom of an intestinal schistosomatosis, about the Crimea usually it is necessary to differentiate D., dermatitis is. Later the expressed fever is observed, in blood the quantity of eosinophils increases, in lungs eosinophilic infiltrates can be defined. In 6 — 8 weeks patients have a speeded-up chair which is followed by tenesmus and containing impurity of slime and blood. In later period of a disease the prolapse of the rectum, formation of fistulas can be observed, to develop cirrhosis. At a rektoromanoskopiya on a hyperemic mucous membrane shistosomatozny hillocks, papillomas can come to light. For diagnosis of intestinal schistosomatosis (see) the anamnesis (a wide spread occurance on the African continent) and datas of laboratory (a research of native smears, and also use of a method of sedimentation and a larvoskopiya) is important epidemiol.

Viral diarrhea proceeds usually with an enteritichesky chair; excrements are plentiful, watery, yellow color, foamy, it is frequent with a pungent smell, without patol, impurity. Pains are more often localized in an upper half of a stomach, abdominal murmur is characteristic, a cut amplifies at a palpation. At a rektoromanoskopiya focal changes of a mucous membrane of a large intestine are absent. According to V. P. Mashilov (1973), the existence of a hyperemia and granularity on a mucous membrane of a soft palate observed at patients with viral diarrhea is important for the differential diagnosis (see. Diarrhea virus ).

Differential diagnosis hron. Should be carried out with hron, a post-dysenteric coloenteritis, colitis of a tubercular etiology, with nonspecific ulcer colitis, new growths, polipozy a large intestine and from helminthosis mi.

Patients hron, a post-dysenteric coloenteritis have instructions on the postponed acute D. V a wedge, to a picture the phenomena of dyspepsia or dyskinesia and only for the second time — inflammations prevail. Surely take place accompanying hron, diseases of bodies of the alimentary system (a stomach, a pancreas, a small bowel, a liver and biliary tract) in various combinations. At repeated bacterial, researches a calla the activator is not found. Post-dysenteric hron, colitis represents as if rezidualno the residual phenomena acute or hron.

D. U of patients with a tubercular coloenteritis in the anamnesis often is available a disease of tuberculosis of other bodies. Gradual development, constant abdominal pains, meteorism, subfebrile temperature is characteristic of disease. At a palpation of a stomach changes preferential come to light from a caecum. The anemia, skin tests applied at tuberculosis is characteristic, are positive (see. Enteritis, coloenteritis ).

The gradual beginning with the advent of feeling of discomfort, abdominal distention, the aching pains and weakness is characteristic of nonspecific ulcer colitis. An important sign is emergence of impurity of fresh blood at the issued chair. Frustration of a chair can join a little later, excrements have kashitseobrazny character more often and contain impurity of slime and pus. Temperature is often increased, emaciation progresses. Hypochromia or normokhromny anemia is observed. At a rektoromanoskopiya the expressed hypostasis, the increased vulnerability of a mucous membrane throughout, multiple erosion and ulcers, purulent exudate is found. At rentgenol, a research rigidity of a gut, an illegibility and a crenation of contours, disappearance gaustr comes to light (see. Ulcer nonspecific colitis ).

At an exception of a malignant new growth of a large intestine correctly collected anamnesis is important, in Krom quite often there are instructions on emergence of impurity of blood at the issued chair. Symptoms of a disease develop slowly more often: the amount of blood and slime in a chair increases, constant dull aches in a stomach develop, the feeling of discomfort increases, weakness, a weight loss joins. During the early period of a disease it is possible to reveal only separate symptoms and only at purposeful careful inquiry. Changes of a leukocytic formula, the accelerated ROE are possible. At the slightest suspicion on blastomatous process needs to be carried out manual, rektoromanoskopichesky, kolonfibroskopichesky and rentgenol, researches (see. Intestines, tumors ).

Impurity of blood in Calais can take place also at a polypose of intestines and hemorrhoids.

TREATMENT

the Complex of actions for treatment of patients of acute D. consists of the following main components: the mode to lay down. the food, germicides, means having specific and nonspecific effect on immunol, system, means which use leads to desintoxication and recovery of a homeostasis, and also release of an organism of the patient from the activator and recovery of the broken functions of a number of bodies, and first of all the alimentary system.

The choice of means, duration of their use and practical implementation of the principles of therapy in the course of treatment of the patient are defined by a form of a disease and severity of its current. For patients subclinical the erased and easy form of acute D. allows active behavior, walks. Sick with a hypertoxical and heavy current of acute D. the high bed rest and careful leaving is necessary.

To lay down. food is an obligatory component of treatment of all patients of acute D. with the expressed dysfunction went. - kish. path.

In the acute period of D. purpose of a table No. 46 is recommended to most of patients (except cases of hard proceeding gastroenterokolitichesky and hypertoxical form) (see. Clinical nutrition ). Terms of use of a diet are strictly individual and are defined by a state and health of the patient. Usually at patients with an easy current of acute D. expansion of a diet can be begun with 4 —-go day of a disease. For all patients in the period of reconvalescence it is necessary to exclude use of the products irritating a mucous membrane went. - kish. a path and causing hypersecretion (spices, alcoholic beverages).

With hard proceeding gastroenterokolitichesky form of acute D. it is reasonable to patient to appoint in the first days drink (tea, a fruit drink, etc.), and then a table No. 4.

In view of the fact that diets of a diet No. 4, full-fledged on content of proteins, fats and carbohydrates, do not contain fiziol, norms of vitamins, their additional introduction in the raised doses is necessary.

Along with to lay down. food for normalization of a functional state went. - kish. a path use of the drugs containing a number of the substances and enzymes produced by bodies of the alimentary system is of great importance (amylase, a lipase, protease, pepsin, trypsin, cathepsine, a tselunaza, bilious to - you, secretin, Pancreatinum). Fermental drugs accept during food or right after it. They are often combined with the derivatives 8 oxyquinolines promoting maintenance of balance of an indestinal flora. For the purpose of the prevention of a possible intestinal dysbiosis or recovery of normal flora use of bacteritic drugs of type is justified kolibakterin (see), bifidumbacterium (see) and a bifikola which accept for 1/2 — 1 hour to food on 1 — 2 and more doses. Purpose of eubiotichesky means (means of selective effect) is especially important when it is long antibiotics of a broad spectrum of activity are applied.

In view of existence not only functional disturbances of a stomach and intestines, but also destructive changes of an epithelium of the last, appointment in the acute period of the pharmaceuticals strengthening reparative processes of a mucous membrane of intestines and stimulating nonspecific immunity is proved. Purpose of pentoxyl, methyluracil (methacil) is for this purpose recommended. Additional positive property of the last is ability to reduce side effects of antibiotics, especially tetracycline row. Use of the pharmaceuticals normalizing motor evakuatornuyu function of intestines and possessing spasmolytic action is proved (atropine, Nospanum, etc.).

It is very important disintoxication therapy (see) in the acute period of a disease (except for cases of easily proceeding D.). Intensity of therapy depends on degree of intoxication. If in mild cases of rather plentiful drink, then in heavier intravenous administration of complex isotonic salt solutions and 5% of solution of glucose equally, with a total amount of 1,5 — 2 l in days is required. At the expressed intoxication in addition apply Haemodesum on 100 — 150 ml and a blood plasma on 100 — 150 ml intravenously repeatedly. In the most hard cases appoint glucocorticoids.

At most expressed intoxication (a hypertoxical form of acute D.) when manifestations of cardiovascular insufficiency accept the menacing character, the complex of an intensive care for the purpose of desintoxication and recovery of a hemodynamics is carried out. In these cases along with carrying out a regidratation intravenously enter Polyglucinum to 1 l, a hydrocortisone in a dose of 125 mg repeatedly to 500 mg per day, in need of a current of 2 — 3 days. Together with salt solutions administration intravenously of 5% of solution of a hydrochloride of ephedrine of 1 — 2 ml, and also 1 ml of 1% of solution of Phethanolum is justified. If it is not possible to achieve stable indicators of the ABP, then in addition intramusculary enter 0,5% oil solution of cortexone of acetate on 1 — 2 ml repeatedly. Use of strophanthin and Korglykonum is at the same time shown.

At a gastroenterokolitichesky form of acute D. weight of a condition of the patient substantially is defined by the disturbances of a water salt metabolism caused by generally excess losses of water and electrolytes with an emetic masses and excrements. As dehydration, as a rule, does not exceed 3 — 5% of body weight, are limited to introduction of 2 — 3 l (volume of alleged losses) of complex isotonic salt solutions — trisol, kvartasol, Ringera. In case of the continuing losses of water and salts the corresponding corrective therapy is carried out by injection of the specified solutions.

Antibacterial therapy shall be performed strictly differentially with the maximum restriction of prescription of antibiotics of a broad spectrum of activity.

At a bacteriocarrier the first stage in treatment are the actions directed to normalization of functional disturbances of an organism, and first of all from a stomach, a liver, a pancreas and also appointment immunobiol, the drugs influencing specific resistance of patients. If do not achieve success after this stage, use of etiotropic drugs is possible. Specific tactics of their use is strictly individualized as the uniform standard scheme of treatment of bacillicarriers is not offered.

Purpose of antibacterial drugs is not shown to patients with easily proceeding acute D. V these cases causal treatment, especially with use of antibiotics of a broad spectrum of activity, renders negative effect (longer bakteriovydeleniye and terms of normalization of function of intestines). Use of antibiotics shall be limited to cases of heavy and partially medium-weight current.

From antibiotics of a broad spectrum of activity in acute D.'s treatment drugs of a tetracycline row (a hydrochloride of tetracycline, Vitacyclinum, Morphocyclinum, a hydrochloride of metacycline) are on the first place. Treatment continues 5 — 7 days. It is reasonable to combine tetracycline drugs with low solubility streptocides (Ftalazolum, sulfaguanidine).

Along with tetracycline according to the same indications apply ampicillin. Use for treatment of patients of acute D. of levomycetinum is inexpedient in view of high resistance of shigellas to it. Kanamycinum, without having advantages in comparison with other antibiotics, often causes an aggravation of a coloenteritis.

Use of derivatives of nitrofuran as drugs is most widely recommended, the Crimea effective impact on shigellas at the minimum negative influence on function of intestines of the patient is peculiar. From these drugs most often apply furasolidone.

At purpose of derivatives 8 oxyquinolines (Enteroseptolum, Mexasum, Intestopanum, etc.) first of all use their eubiotichesky, but not antishigellezny action. More effective is use Mexasums and Mexaformum.

For impact on the general specific resistance of an organism use to lay down. dysenteric vaccine of Chernokhvostov vnutrikozhno, and also number of drugs of nonspecific action (Prodigiosanum, aloe, plasma transfusion or whole blood). However use them is justified at acute D. at patients with expressed areaktivnostyo the patient. In an initial stage of a disease at its usual current there is no need to use the drugs causing an aggravation of process.

In the period of reconvalescence at slow subsiding of inflammatory process in a mucous membrane of intestines use of the knitting anti-inflammatory drugs is shown (infusion of a camomile inside and in microclysters, infusion of alder cones and a St. John's Wort inside, microclysters from oil of a sea-buckthorn, a dogrose, Shostakovsky's balm, etc.). At the ended inflammatory process, but a long spasm of a large intestine physiotherapeutic procedures are shown (UVCh, to lay down. enemas from 0,25 — 0,5% of solution of novocaine, the general heat baths, paraffin applications on skin of a stomach etc.).

At the expressed asthenic condition of patients use of small tranquilizers, drugs of a valerian, a belladonna is proved. The general gigabyte is important. patient care, being in a serious condition.

Treatment hron. Carry out according to the general principles of therapy of patients of acute D.: stopping of the acute phenomena, providing the maximum shchazheniye went. - kish. path, measure for normalization of function of intestines and treatment of associated diseases, stimulation of the general and specific protective forces of an organism of the patient.

The FORECAST

the Forecast in most cases favorable, but at severe forms of the disease caused by Grigoriev's activator — Shigi, can be serious.

PREVENTION

D.'s Prevention is provided with all-sanitary measures for improvement of settlements, supply of the population high-quality water and foodstuff and carrying out a dignity. - a gleam, works among the population, increase a dignity. cultures.

Due to the big role of foodstuff, especially milk, in transfer of activators D. the strengthened control over the implementation of rules of collecting milk, its processing, transportation and implementation is necessary. Special attention shall be paid to observance of the mode of pasteurization. In the summer for the purpose of prevention of flashes of D. of a «milk» origin in preschool institutions and summer camps it is necessary to process in addition thermally before the use milk and cottage cheese. This measure is justified also in a public catering. The close check behind preparation, storage and terms of implementation of foodstuff is obligatory.

It is important to provide efficient a dignity. - a gleam, work among the population on the prevention of the use for drink of water of doubtful quality without heat treatment and bathing in the contaminated reservoirs. Providing milk-processing and other food enterprises with a decontaminated water remains the most important problem of prevention D.

Epidemiol, danger of undetected patients among the persons who are engaged in production, storage, transportation and implementation of food stuffs, and also equated to them is especially big and demands strengthening of supervision of them, increase in level their dignity. cultures. It is recommended to carry out systematically bacterial, researches on sanitary and indicative microflora of washouts from hands of the working and working surfaces at the food enterprises, in preschool institutions and other objects. This work is conducted taking into account a sanitarnotekhnichesky state and degree potential epid, dangers of separate food and other objects. Detection of sanitary and indicative flora in washouts from hands and from various surfaces, unsatisfactory a dignity. a condition of the enterprise form the basis for measures of administrative influence, targeting a dignity. about, carrying out mass bacterial, inspections of collective. Sudden departures of medics on food objects for the purpose of sampling of foodstuff, washouts from hands and working surfaces are effective. This work is intensively carried out at the milk-processing enterprises, milk kitchens, catering establishments, preschool institutions, etc.

The persons arriving on the food enterprises pass single bacterial, inspection. At allocation of the activator D. to work they are not allowed and direct to treatment.

At D.'s emergence in epid, the center carry out a complex protivoepid, actions. The attention of medical staff goes for early active identification of patients and their treatment. Early rational therapy reduces number hron, forms D., number of bacillicarriers.

A wedge, indications for hospitalization of the patient are severe and medium-weight forms of acute intestinal diseases, acute intestinal diseases at the faces which are sharply weakened by associated diseases.

On epidemiol, to indications sick D. and bacillicarriers from among employees of the food enterprises and to them equated are without fail hospitalized. Hospitalization is obligatory and when observance protivoepid. the mode at the place of residence of the patient is impossible (see. Isolation of infectious patients ).

The patients who had acute intestinal diseases without bacteriological the confirmed diagnosis, treated in-tse or houses, write out not earlier than in three days after a wedge, recovery, normalization of a chair and temperature. Under the same conditions of the persons directly related to production of food stuffs, their storage, transportation and implementation and equated to them, surely subject control single bacterial, to inspection, a cut carry out not earlier than in two days after the end of treatment. Write out them only at a negative take of inspection.

The patients who transferred D. confirmed bacteriological, treated in-tse or houses, prescribe not earlier than in three days after normalization of a chair and temperature and obligatory single control bacterial, the examination conducted not earlier than after two days after the end of treatment. To all persons, busy production, storage, transportation and implementation of food stuffs, and also equated to them under these conditions carry out double bacterial, inspection.

At hron. An extract is made after subsiding of an aggravation, disappearance of toxicosis, a rack (within 10 days) normalization of a chair and a negative take single bacterial, the examination conducted not earlier than in two days upon termination of treatment.

The persons who are engaged in production, storage, transportation and implementation of food stuffs, and also equated to them are allowed to work on the certificate of the doctor of a hospital of recovery without additional bacterial. inspections. If the activator D. is found more than 3 months after the postponed disease in these persons, then the solution of a consultation (the infectiologist, the therapist, the epidemiologist) they as patients hron, are transferred by a form D. to the work which is not connected with food stuffs.

After an extract convalescents shall be under observation of the doctor office of infectious diseases (see) policlinics. For the persons suffering hron. And allocating the activator, and also bacillicarriers is established dispensary observation for 3 months with monthly survey and bacterial, inspection. In the same terms persons at whom the long time is observed an unstable chair are inspected. Employees of the food enterprises and equated to them, transferred acute D., are observed 3 months, and transferred hron. — month with monthly bacterial, inspection. After this term and full a wedge, recovery these persons can be allowed to work in the specialty.

After hospitalization of the patient in the apartment (hostel) it is carried out disinfection (see). If the patient is left at home, it is isolated at observance strict protivoepid, the mode, including the current disinfection. The persons surrounding the patient are instructed about rules of care of the infectious patient, observance of isolation mode and personal hygiene.

During the developing of acute intestinal diseases in child care facilities and among employees of the food enterprises and persons equated to them it is carried out obligatory epidemiol. inspection. In other cases need epidemiol, inspections is defined by the epidemiologist.

The important place in fight against D. belongs epidemiol, to the analysis of incidence which allows to reveal ways and spreading factors of activators D. and to take effective preventive measures. For this purpose in a dignity. - epid, stations schematic maps of supply of separate objects of the serviced territory by various foodstuff, first of all milk, and also schemes of distribution of products of the milk-processing enterprises located in the serviced territory shall be developed. On each type of products several reference points (objects) are selected. Similarly by means of control sites with the isolated water supply (a separate water supply system, wells, artesian wells, imported water, etc.) the possibility for an exception or confirmation of a role of a water factor is created. Comparison of territorial distribution of D. to schemes of water supply and schematic maps of distribution of foodstuff allows to establish in short terms (or to exclude) this or that factor of transmission of infection at rise in sporadic incidence and at flashes of. During the leaving of the patient at home in the center the current disinfection is carried out.

Specific prevention (creation of active immunity by means of vaccines or passive — by means of serums or gamma-globulin) is in a stage of further development.

According to Du Pont (H. L. Du Pont) with sotr. (1970, 1972) and V. V. Sergeyev (1974), the live enteral vaccine from streptomitsinzavisimy mutants of shigellas of Fleksner is perspective; it was a little reactogenic, rather effective.

Dysentery at children

Among activators D. at children Zonne's shigellas prevail, Fleksner's shigellas are found much less often and it is single other types.

The main symptoms of D. at children — the general intoxication and frustration from outside went. - kish. a path (abdominal pains, liquid excrements with impurity of slime, blood, tenesmus, etc.). Degree of manifestation of symptoms varies and defines forms of a disease, various on weight.

At children distinguish the same forms of a current of D., as at adults.

Acute dysentery. The easy current is characterized by the acute beginning with temperature increase to 37,5 — 38 °, edges sticks to 1 — 2 day, vomiting, a thicket single. A chair to 3 — 8 times a day. Excrements usually do not lose fecal character, can be plentiful with impurity of slime and greens, blood is absent more often. Tenesmus are poorly expressed, the sigmoid gut is a little painful, the anus is pliable.

Quite often at this form D. of the phenomenon of the general intoxication are absent. Against the background of standard temperature at the child appears liquid or kashitseobrazny to kcal, a thicket without patol, impurity, a chair of 1 — 3 time a day. The most constant symptom is morbidity spastic of the reduced sigmoid gut, edges is palpated in the form of a dense tyazh. Intestinal frustration in such cases usually take for disturbance in a feeding schedule of the child. Further emergence of repeated cases of children and positive takes reveal bacterial, inspections sick. These patients represent serious epidemiol, danger in children's collectives.

The medium-weight current is followed by the expressed phenomena of intoxication and changes from outside went. - kish. path. Temperature increases to 38 — 39 ° and keeps within 1 — 2 days, up to 3 days more rare. The general state worsens. Repeated vomiting is observed, colicy pains in a stomach and tenesmus appear. The stomach is blown moderately up: the sigmoid gut spastic is reduced and painful; rumbling on the course of a large intestine.

The anus is pliable, the phenomena of a sphincteritis are noted. Excrements are liquid, contain a large amount of slime, greens, and in half of cases — blood. Frequency of a chair can reach 8 — 15 times a day. Morbidity at a palpation in the right ileal area is quite often noted that dictates need of an exception of an acute appendicitis.

The heavy current meets seldom. Weight of a state is more often caused by the phenomena of intoxication. The rough beginning, temperature increase to 40 ° above, repeated vomiting is characteristic. The child faints, kloniko-tonic spasms develop. Meningoentsefalitichesky symptoms can be observed. Dullness of cardiac sounds, falling of the ABP, a cold snap of extremities is noted. Pulse is frequent, weak filling. There is cyanosis of extremities and a nasolabial triangle, «mramornost» of skin. Emphysema of lungs and a toxic asthma is observed. Breath becomes superficial and frequent. At repeated vomiting and the speeded-up chair symptoms of an eksikoz can appear: decrease in turgor of fabrics, elasticity of skin, polydipsia and moderate dryness of integuments and visible mucous membranes, retraction of a big fontanel. In an onset of the illness the chair can be absent, and then mistakenly make the diagnosis of meningitis or food intoxication. And only in several hours there is a frequent chair, more than 10 — 15 times a day, excrements with impurity of a large amount of muddy slime and greens, a bowl with streaks of blood. However and at these forms of an excrement seldom lose fecal character.

The phenomena of intoxication accrue usually to 3 — to the 5th day from the beginning of a disease — the chair becomes frequent, vomiting amplifies, temperature increases again and the general condition of the child worsens.

In cases of accession of associated diseases at D. toxicosis with eksikozy at children of early age can arise also at medium-weight and even at an easy form D.

In the second half of 20 century the quantity of severe forms of D. sharply decreased, easy forms of a disease prevail. Respectively also the lethality decreased, edges makes the tenth shares of percent among children.

At the same time clear dependence of weight of an initial syndrome on ways of transfer of activators is noted. Unlike a contact way of infection, the short incubation interval is characteristic of a food way of transfer. The disease begins violently, with high temperature, repeated vomiting and defeat of a nervous system in the form of excitement or an adynamia. Short-term spasms can be noted. Happens much more often the pain syndrome with localization in the right ileal area is expressed. Frustration of a chair at the same time is late.

The current and D.'s outcome at children depend on age, immunobiol, states and from terms of the beginning of complex therapy, including also the period of reconvalescence.

At favorable disease the chair is normalized in 5 — 10 days from an initiation of treatment.

Chronic dysentery. Hron. Is observed at children with lowered immunobiol, reactivity, having associated diseases. Especially often forms when the acute respiratory viral infection and complications joins D., with it connected. It promotes an aggravation of intestinal symptoms, repeated seeding of shigellas and tightening of the period of reconvalescence. Untimely therapy is also the reason of formation of chronic D.

Hron. Is clinically characterized by a continuous or recurrent current, but with insignificant the wedge, manifestations quite often proceeds. At patients at the general satisfactory condition and a thicket a normal chair the spazmirovanny and painful sigmoid gut is defined, and at endoscopy diffusion inflammatory changes of catarral and follicular or catarral and erosive character come to light.

At establishment of the diagnosis hron. Needs to exclude reinfection. Besides, the unstable chair after the postponed D. can be result of dysbacteriosis and disturbance of enzymatic activity went. - kish. path.

Diagnosis

The diagnosis presents special difficulties in cases of insufficiently expressed kolitichesky syndrome.

At children of early age of D. differentiate with intestinal if - the infection caused by pathogenic strains of escherichias, a salmonellosis, staphylococcal enterita and coloenterites, viral diarrhea, invagination, appendicitis.

Special difficulties are presented by differential diagnosis of D. with the syndromes which are followed by disturbance of intestinal absorption at children of early age at such diseases as Gee's disease (see), mucoviscidosis (see), disakharidazny insufficiency (see. Malabsorption syndrome ), an exudative enteropathy (see. Enteropathy exudative ). In these cases the big role in establishment of the diagnosis belongs to special laboratory methods of a research. Results of datas of laboratory need to be estimated only in combination with a wedge. - epidemiol. indicators.

Treatment

The philosophy of treatment of D. is complex use of therapeutic means and staging taking into account age, the general condition of the child, weight and a phase of infectious process; correct organization of the medical and guarding mode and food. Performing treatment, including also the period of reconvalescence, provides an absolute recovery and prevention of formation hron, forms of a disease.

At development of toxicosis in the baby do a break in feeding on 4 — 8 hours depending on weight of toxicosis with purpose of plentiful drink. Then appoint the dosed feeding — on 10 — 20 ml of the decanted breast milk or acid mixes (kefir) every 2 hour.

In the next days the volume of food is added on 100 — 200 ml a day, respectively increasing intervals between feedings. In these cases to 6 — to the 7th day of treatment the child already receives food on structure, volume and caloric content according to the age.

The special place is allocated to disintoxication therapy — administration of plasma, glucose, Neocompensanum, Haemodesum. Ways of administration of the specified drugs (struyno, kapelno) depend on D.'s weight and the nature of toxicosis. At easy forms to the patient appoint the usual food corresponding to its age. For decrease in a hyperthermia intramuscular introduction of 0,1 ml/kg of 4% of solution of pyramidon or 0,1 ml for a year of life of 50% of solution of analginum is shown.

During the developing of kloniko-tonic spasms — intramusculary 1 ml for 1 year of life of 25% of solution of magnesium sulfate. At sharp excitement and spasms apply lytic mixes. Disturbances of cordial activity are the indication for purpose of strophanthin, Korglykonum and cocarboxylase. At the expressed toxicosis use of adrenal hormones within 5 — 7 days with gradual reduction of a daily dose in an age dosage is shown (each 1 — 2 day for 30 — 50%). At the same time appoint in 5 — 10% solution of acetate or potassium chloride — 20 — 40 ml a day.

Children of the first year have lives in the presence of toxicosis with eksikozy it is necessary to carry out rehydration therapy taking into account indicators of water mineral metabolism and acid-base equilibrium.

Apply various himiopreparata and antibiotics to D.'s treatment: furasolidone, Phthazinum, Biseptolum, ampicillin, etc.

The repeated course of treatment is shown by antibiotics only in cases of emergence of a recurrence and at repeated seeding of shigellas.

For the purpose of the prevention of development of dysbacteriosis and long allocation of shigellas use biol, drugs — kolibakterin, bifidumbacterium or a bifikol is shown. It is necessary to appoint a complex of vitamins, especially With and groups B. Ozokerite on area of a stomach is widely applied.

The system of treatment of children of early age includes stay of the child after the postponed D. in sanatorium department for convalescents. Duration of stay in department for convalescents depends on a condition of the child and averages 2 — 4 weeks.

The patients suffering hron, a form D. after hospitalization are transferred to sanatorium department where they are before permanent normalization of a chair and an increase of weight.

Forecast

At timely treatment forecast favorable. Accession of intercurrent diseases, especially an acute respiratory viral infection, can bring to a long current with transition in hron, a form D. and a long bakteriovydeleniye.

Prevention

The same main preventive actions, as at D. at adults. At the same time there are also some features.

Identification of patients in preschool institutions is provided with careful control of a chair and its frequency at children. Children with dysfunction of intestines or with patol, impurity in a chair (slime, pus, blood) are isolated. Reception of children in preschool institution after the postponed disease or absence within 5 and more days is allowed only in the presence of the reference from the doctor.

The children of younger age who are visiting and not visiting preschool institutions prescribe after the postponed D. not earlier than in three days after normalization of a chair and temperature, and also single negative bacterial. the examination conducted not earlier than in two days after the end of treatment.

The children visiting preschool institutions, and the children from specialized sanatoria who are written out from-tsy or treated at home are allowed in collectives after a wedge, recovery. Behind them within 1 month observation for the purpose of timely detection of possible disorder of function of intestines is established.

Children from orphanages and boarding schools are allowed in collectives after recovery, but within 2 months are not allowed to watch on catering department.

The children who transferred an aggravation hron. are allowed in children's collective in the presence of a normal chair within 5 days, a top general condition and standard temperature.

FEATURES of EPIDEMIOLOGY AND PREVENTION of DYSENTERY IN TROOPS

Actions for D.'s prevention are defined on the basis of studying of the reasons of incidence of D. among staff of troops and the civilian population, living conditions of military unit, data of inspection of new replenishment, workers of food warehouses, bakeries, kitchens, dining rooms, objects of water handling, etc. Usually the plan relating to all services providing holding preventive actions (room and operational, food, medical, etc.) who is approved as the commander of a part (garrison) is formed. Are provided in it: 1) actions for improvement and dignity. to the maintenance of kitchens, dining rooms, buffets, soldier's tea, food warehouses, vegetable storehouses, bakeries; 2) control of observance dignity. - a gigabyte. requirements during the processing of products and cooking, and also behind washing of the dining room and tea-things; 3) systematic bacterial, a research on colibacillus of washouts from kitchen ware and other objects of kitchen, table, dishwashing, and also from hands of constant workers of food and a kitchen dress; 4) control of observance by staff of requirements of personal and public hygiene and of creation of appropriate conditions for performance gigabyte. governed; 5) actions for providing parts with enough high-quality water, and also for its transportation and storage; 6) control of cleaning of the territory and holding actions for the prevention of breeding of flies and fight against them.

For the purpose of the prevention of a drift of D. in a body the arriving replenishment and the military personnel who is returned from business trips and also the military personnel of a stock arriving to retraining are exposed to medical inspection for identification of sick D. among them, colitis and coloenterites and being ill in the past. The revealed patients are isolated and treated, and having intestinal infections in the last 6 months registered and subjected to comprehensive examination.

At medical survey of recruits of the medical commission of military registration and enlistment offices also conduct comprehensive examination of all having acute intestinal diseases.

The employees going to work connected with food and water supply, the diseases of intestinal infectious diseases which do not have in the anamnesis (is confirmed by the reference of the epidemiologist of SES), allow to work only after medical inspection and in the presence of three negative takes bacterial. the researches conducted at an interval of two days. Behind all persons working at objects of food and water supply systematic medical observation is conducted, a cut includes medical examinations (weekly) and bacterial, inspections on D., tifo-paratyphoid and salmonellezny diseases (in the letneosenny period — monthly, in the rest of the time of year — not less once a quarter).

In D.'s prevention very effectively active carrying out lechebnoozdorovitelny work among having intestinal infectious diseases. Within month after an extract from hospital behind them dispensary observation with obligatory monthly medical examination and bacterial, inspection would be established. Comprehensive planned examination is conducted not less than two times a year: in the spring — at the end of the winter period of training and in the fall — after the summer period of training of troops. The obtained data on the state of health are entered in the medical book of inspected.

The workers of food and water supply who had intestinal infections after an extract from hospital are not allowed to work within 1 month. For this period they shall be directed to the work which is not connected with food and water supply and to be under medical observation. Throughout this term they are exposed to the medical inspection including triple bacterial. a research of excrements (for one each 10 days), single koprologichesky and final survey by the infectiologist on 28 — the 30th day. In the absence of pathology these persons are allowed to work in the specialty, however are subject to dispensary observation within 6 months. At an exacerbation of a disease or detection at one of bacterial, inspections of the activator D. of these persons hospitalize again and treat. After an extract they are not allowed to the main work by 1 more months, during to-rogo conduct examination again. The persons which were returned after the postponed D. to former work remain under medical observation within 6 months and once a month are exposed bacterial, to inspection.

All actions for D.'s prevention in troops are effective only if they are carried out in a complex and during the whole year.


Tables

Table 1. Incidence of dysentery in warring armies during various wars

Table 2. Main diagnostic biochemical properties of representatives of the sort shigella

Symbols: + splitting in 24 hours; (+) splitting in 48 hours and later; — splitting is absent;   &±nbsp; various reactions (splitting is or not depending on a biotype or a serotype)


  • Some biotypes Newcastle are capable to split glucose to

acid and gas. ** An exception — the serotype 13 decarboxylizing ornithine.


Table 3. Biochemical typing of shigellas to a zone on ability to split rhamnose, xylose and a maltose

Symbols: + splitting to - you (in brackets terms of splitting of carbohydrates in days are specified;; — splitting is absent.



Table 4. Biochemical typing of shigellas of subspecies Newcastle on ability to split carbohydrates

Symbols: + splitting during 24 hours; (+) splitting during 48 hours and later; — splitting is absent.




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V. I. Pokrovsky, H. D. Yushchuk; A. G. Avanesova (ped.), V. I. Agafonov (soldier.), M. V. Voyno-Yasenetsky (stalemate. An.), Yu. P. Solodovnikov (medical Art., epid., profit.), M. V. Turchinskaya (lab., etiol.), G. K. Ushakov (psikhiat.).

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