PONOSA (diarrhea, singular; synonym diarrhea) — the speeded-up bowel emptying with allocation liquefied, and regarding cases and plentiful excrements.
Due to the specific features of function of intestines justification of quantitative criteria of P. is difficult. Normal at most of people the chair happens, as a rule, 1 — 2 time a day. Average daily weight calla (see) makes usually 100 — 200 g, water content in it 60 — 80%. At P. the chair is usually more often than 2 times a day, daily quantity the calla exceeds 200 g, water content in it increases to 95%. In some cases it is possible to speak about P. in the presence of liquid, plentiful excrements and at more rare chair — two-and even single.
Items can arise at diseases intestines (see), and also at defeats of other bodies and systems which are followed by disturbance of motor and secretory function of intestines. Carry to P. arising at diseases of intestines: infectious P. — caused by intestinal viruses (enteroviral diseases, etc.) and bacteria (dysentery, salmonellosis, cholera, tuberculosis of intestines, etc.), parasitic P. — caused by helminths, protozoa, fungi; The Item at nonspecific inflammatory diseases of intestines (hron, enterita, hron, colitis, nonspecific ulcer colitis, a disease Krone, ischemic colitis, a diverticulitis of intestines, etc.); The Item at tumors of intestines (hl. obr. large intestine); Diskineticheskiye P. (neurogenic); The item at the inborn and genetically caused intestinal enzymopathies (disakharidazny insufficiency, a Gee's disease, etc.) J post-resection P. — the enterectomies arising later, and also at patients with an eyunoilealny anastomosis when from digestion the considerable site of a small bowel is switched off; toxic P. — at poisoning with salts of heavy metals, poisonous mushrooms, etc., and also P. at uraemia; medicamentous P. — caused by antibiotics of a broad spectrum of activity, iron preparations, Rauwolfias, foxgloves, cytostatics, laxative; allergic P. — at food allergy. The items arising at diseases of other bodies and systems subdivide on: gastrogenic P. — at gastritises with secretory insufficiency, a postgast-rorezektsionny syndrome, a carcinoma of the stomach; pankreatogenny P. — at pancreatitis, tumors of a pancreas, a mucoviscidosis, Zollinger's syndrome — Ellisona; hepatogenous P. — at cirrhosis, hepatitis; endocrine P. — at an addisonovy disease, a thyrotoxicosis, a diabetes mellitus, etc.; metabolic P. — at an amyloidosis, hypovitaminoses, etc.; The Item at general diseases (e.g., at a scleroderma).
Items arise at disturbance of normal ratios between secretion of liquid in intestines and it absorption (see), at acceleration of advance of contents on intestines. Main pathogenetic mechanisms P. following: disturbance of osmotic processes in intestines, strengthening of intestinal secretion, braking of active transport of ions through cellular membranes in intestines, increase in permeability of an intestinal wall, disorder of motor function of intestines. According to these mechanisms conditionally allocate various pathogenetic types P.: osmotic diarrhea, secretory diarrhea; The Items caused by a torkhmozheniye of active transport of ions through cellular membranes in intestines; The Items caused by increase in permeability of an intestinal wall; The Item at disturbance of intestinal motility. More often P. are caused by several pathogenetic mechanisms.
Osmotic diarrhea develops owing to increase in osmolarity of intestinal contents at intake of substances which badly or at all are not soaked up in intestines (e.g., laxatives), and also at disturbances of digestion (a syndrome of a maldigestiya) and absorptions (see. Malabsorption syndrome ). E.g., at deficit of lactase lactose is not split in a small bowel, molecules of this disaccharide collect in a cavity of a gut and in its distal departments are exposed to bacterial hydrolysis with education organic to - t that leads to increase in osmolarity of intestinal contents and thereof to braking of absorption of water, increase in total amount and a liquid part of excrements.
Secretory diarrhea results from stimulation of active secretion of ions of electrolytes epithelial cells of intestines with the subsequent secretion of water. A classical example of secretory diarrhea is cholera (see), at a cut epithelial cells of intestinal crypts intensively cosecrete ions of sodium, potassium and bicarbonate. The secretory effect of cholera exotoxin (choleragen) is mediated through system of cyclic adenosinemono-phosphates. Intestinal secretion is stimulated also by enterotoxins of nek-ry causative agents of intestinal infections, dilithocholic bilious to - you, fat to - you and a number of medicines, including laxatives. Vigorously some digestivny hormones, in particular the vasoactive intestinal polypeptide (VIP) excite intestinal secretion.
Classical example of P. caused by braking of active transport of ions through cellular membranes in intestines is inborn hloridoreya, caused by genetic defect of absorption of ions of chlorine in an ileal gut. Braking of active transport of ions is the cornerstone also of P. at the acquired malabsorption bilious and fat to - t. E.g., at the patients who transferred an ileectomy absorption bilious to - t owing to reduction of the soaking-up surface of intestines decreases; under the influence of colibacilli there is deconjugation bilious to - t which thereof lose ability actively to be transported through intestinal membranes that leads to strengthening them in a gleam of intestines and thereof to braking of absorption of water.
Increase in permeability of an intestinal wall is observed at P. at patients salmonelloses (see), and also at influence bilious to - t on an intestinal wall (e.g., at disturbance of enterogepatichesky circulation bilious to - t after an ileectomy).
Disorders of motor function of intestines are characteristic of the most part of patients with the Item. As a rule, at P. accelerated promotion of intestinal contents that is caused in most cases not by strengthening of motor function of intestines as was considered earlier, and easing of motility, especially in distal departments of a large intestine. In the conditions of an intestinal hypokinesia of kcal passively moves on a large intestine, without encountering resistance, a cut usually render the segmenting movements of a gut mixing contents and creating a fecal column (see. Intestines, physiology ). Quite often easing of motility occurs for the second time at increase in secretory processes in intestines, at malabsorptions. Sometimes P. can be caused by strengthening of propulsive intestinal motility. Such mechanism plays the leading role in P.'s genesis at a carcinoid syndrome (see. Carcinoid ), diskineziya of intestines (neurogenic P.), in some cases diabetic diarrhea, at P. because of vagisection. At nek-ry patients with P. disturbances of motility not in all departments of intestines are same. Sometimes decrease in motor activity of a sigmoid colon is followed by the raised kont-raktilnost of a rectum. The system of nervous and humoral control of motor activity of intestines is quite difficult. Sympathetic nerves preferential brake, and parasympathetic excite reductions of intestines. In intestines there are also not adrenergic brake and nekholinergi-chesky stimulating receptors. A number of hormones exerts preferential stimulating impact on motility of intestines (cholecystokinin, gastrin, a cortisone, Aldosteronum, angiotensin, etc.), a row — brake (a glucagon, secretin, adrenaline, noradrenaline, oxytocin). In P.'s genesis the large role is played by reflex impacts on motility of intestines. E.g., irritation of receptors stomach (see) causes strengthening of motility of intestines. This gastrointestinal (gastroceccal) reflex quite often gets the reason of desires on a chair after food.
On the mechanism of development distinguish from true P. false, or «locking», P. which are a version locks (see). These P. result from irritant action of the stagnating fecal masses on a mucous membrane of a large intestine. The large amount of slime which is allocated at the same time is led to fluidifying by a calla and to emergence after a delay of a chair of the scanty liquid or semi-issued excrements.
On a wedge, to P.'s current divide on acute and chronic. The standard criterion of reference of P. to acute or chronic does not exist. Century of X. Vasilenko, E. A. Beyul, A. V. Frolkis and some other Soviet clinical physicians consider chronic P. proceeding more than two months. Golgeynger (S. E. Golgeinger, 1977), Matsesh and Phillips (J. W. Matseshe, S. F. Phillips, 1978) suggest to consider chronic P. proceeding more than 2 weeks, and also recuring P.
Chastot of a chair at P. can be various — from single with plentiful not properly executed excrements to repeated (several tens of times a day). Excrements watery or kashitseobrazny. What more expressed P., that more electrolytic structure the calla approaches structure of a blood plasma. At heavy acute P. with considerable loss of water and electrolytes (cholera, heavy P. of various genesis children) for a short time term can have signs dehydration of an organism (see), oligemiya (see) with a pachemia, heavy quite often develops collapse (see). The wedge, P.'s symptomatology substantially depends on preferential localization patol, process in a small or large intestine; in this regard distinguish enteral and kolitichesky Items. At enteral P. the chair usually is not more often than 4 — 6 times a day, an excrement plentiful, often contain the visible remains of undigested food, is characteristic steatorrhea (see). Pains of the aching character are localized, as a rule, in a navel. At kolitichesky P. the chair can be very frequent (to 10 and more times a day), excrements usually scanty, sometimes with impurity of blood. Are characteristic tenesmus (see), the colicy pains which are localized more often in lower parts of a stomach. Enteral P. depending on localization patol, process in proximal or distal departments of a small bowel also have the features. So, at defeat of proximal department of a small bowel (e.g., at jejunites) the major pathogenetic factor of P. is accumulation in a gleam of intestines not absorbed fatty acids (see) that leads to development of «fat diarrhea»: a chair usually infrequent (1 — 3 time a day), excrements plentiful, kashitseobrazny, a clay look. At defeat of distal department of a small bowel (ileitises, a state after an ileectomy) the major pathogenetic factor of P. is disturbance of absorption bile acids (see). At the same time so-called bilious diarrhea develops: a chair to 6 — 8 times a day, an excrement watery, foamy. Loss of sodium with a stake is more considerable at P. caused by defeat of distal department of a small bowel.
Functional (Diskinetichesky, neurogenic) P. meet at women of young and middle age more often. They are quite often connected with psychogenic factors, are often observed in the mornings, never happen at night, are not followed by polyexcrements. Functional P. usually do not cause a lose of weight (weight) of a body, often accompanies them cancerophobia (see).
The symptom allowing to suspect a tumor of a large intestine is emergence in persons of middle and advanced age of the causeless P. lasting more than 2 weeks. Availability of blood in Calais, the patient is characteristic loses flesh, it has a feeling sick.
P.'s complications are connected with development of dehydration of an organism at heavy acute P. and the disturbances of intestinal absorption leading patients to exhaustion. Items can be complicated by various anorectal frustration, in particular an incontience a calla (see. Enkoprez ), at Krom are reduced intra intestinal pressure in the field of rectal sphincters and ability to hold liquid in a rectum. At long P. even of the noninfectious nature develops dysbacteriosis (see) various degree of manifestation.
First of all find out the nature of the basic disease which caused the Item. At suspicion on kolitichesky P. conduct a koprologichesky research (see. Kal ), manual rectal research (see), rektoromanoskopiya (see), rentgenol. a research of a large intestine (see. Irrigoskopiya ), at indications kolonoskopiya (see), a biopsy of a mucous membrane of a small and large intestine (see. Biopsy ). At enteral P. define daily quantity a calla, conduct a koprologichesky research, the tolerance test to lactose, a research of vsasyvatelny function of a small bowel by test with D-xylose, tracer techniques (see. Intestines, methods of a research ).
Treatment is directed to elimination of the reason which caused the Item. Along with carrying out causal treatment appoint the means operating on separate patofiziol, mechanisms P. At heavy acute P. make up of a fluid loss and electrolytes (see. Infusional therapy ), at infectious or toxic P. appoint antibacterial drugs, the adsorbing means (see). At chronic P.' treatment appoint fermental drugs (see) — Pancreatinum, abomin, Cholenzymum, panzinorm, festal, etc., high doses of the adsorbents and other means increasing viscosity of intestinal contents (calcium carbonate, a kaolin, drugs of bismuth, in particular, Dermatolum). At acute and chronic P. drugs of a lignin (Polyphepanum, Biligninums) which are well adsorbing bilious to - you are shown, to a bacterium. Effective remedy, hl. obr. at bilious diarrhea, is holestiramin, connecting bilious to - you. At P. with the increased motility of a large intestine, in the presence of imperative desires (e.g., at diskineziya of intestines) Platyphyllinum, atropine, drugs of a belladonna, ephedrine, alkaloids of an ergot (ergotal, dihydroergotamine) are shown. At dysbacteriosis (see) short courses (5 — 7 days) derivatives 8 oxyquinolines (Intestopanum, Mexasum, etc.), the hardly adsorbed streptocides (sulfaguanidine, etc.), derivatives of nitrofuran (furasolidone, furadonin), bacteritic drugs are appointed (bifikol, kolibakterin, etc.). In hard cases carry out correction of exchange frustration. The diet is defined by character of a basic disease (see. clinical nutrition ). Apply also broths of medicinal plants: rhizomes with roots of a burnet, fruits of a bird cherry and bilberry, compound fruits of an alder, a grass of a St. John's Wort, a rhizome of a coil. At an incontience a calla for increase in ability of a rectum to hold liquid carry out its perfusions by isotonic solution of sodium chloride.
For P.'s prevention the rational diet, observance of rules of personal hygiene is recommended. At the outbreaks of intestinal infections timely carrying out epidemiol, actions is necessary. Early detection and treatment of diseases of the digestive system is of great importance. It is necessary to explain a possibility of harmful effects of abuse of laxative and other medicines.
Ponosa at children
the Diseases which are followed by P. are high on the list at children after defeats of a respiratory organs. In developing countries of P. stand on the 1st place among causes of death of children of the first 5 years of life, and in the developed countries — on 4 — the 5th place. P. at children of the first three years of life are especially frequent. It is connected with low acidity and secretory activity of a gastric juice, frequent developing of dysbacteriosis, inability (or reduced ability) to development of secretory and humoral antibodys. The oroimmunity to a number of intestinal infections received vnutriutrobno is supported with existence of specific antibodies in female breast milk only to 3 — 6-month age. P.'s emergence is promoted rickets (see), exudative and catarral diathesis (see), acute respiratory viral diseases (see), overheating of an organism (see), disturbance water salt metabolism (see), early transfer of children into artificial feeding (see. Feeding of children ).
Quantitative criteria of P. (frequency of a chair, volume of excrements, water content in them) at children of preschool and school age same, as well as at adults. For babies of P. it is diagnosed at increase of a chair of St. 4 times a day.
Infectious ponosa. The most frequent reason of P. children — intestinal infections with food, water, contact and household, and at newborns and have a transplacental way infections. Causative agents of intestinal infections at children of chest age more often are enteropathogenic and enterotoxigenic escherichias, a company - and adenoviruses, are more rare staphylococcus, salmonellas, klebsiyella, a tsitrobakter, etc. At children years apprx. 50% of diarrheas are more senior are caused by shigellas.
Wedge, infectious P.' picture at children is caused by more frequent in comparison with adults development of syndromes of neurotoxicosis (see. Toxic syndrome ) — a hyperthermia, a convulsive, encephalitic syndrome or infectious and toxic shock which can be complicated by a fluid lungs and a brain, a renal failure. At P. at children more often than at adults, develops eksikoz (see. Dehydration of an organism, at children ). Losses of potassium with excrements and urine gradually bring to hypopotassemias (see), considerably aggravating weight of a state. At children at cholera and other intestinal infections, activators to-rykh contain the Ent-plasmids causing ability to produce toxins identical to choleragen, it is rather more loss of potassium with excrements, and — it is less loss of sodium, than at adult patients. P.'s weight and character of excrements depend on an etiology of a disease, properties of the activator (its virulence, invasive and adhesive properties, etc.), massivenesses of infection, age of the child, his premorbidal background, associated diseases. Expressiveness of inflammatory process in intestines varies from catarral to ulcer necrotic go. Perforation of ulcers (staphylococcal, yersinia coloenterites) is possible that it leads to development of peritonitis and interintestinal abscesses. Localization of inflammatory process depends on an etiology of a disease and age of the child; widespread damage of a small and large intestine is characteristic of babies. Separate activators (salmonellas, iyersiniya, and newborns have escherichias) can get into a submucosa of a wall of a gut, into mesenteric limf, nodes, and then a hematogenous way to various bodies, causing generalized forms of a disease.
At most of children with infectious P. recovery occurs on 1 — the 2nd week from an onset of the illness. Recovery can be unstable — palindromias or a long bakteriovydeleniye are possible. The most often long and hron, infectious P.' forms are observed at early children's age, and also at children with the burdened premorbidal background. After infectious P. postinfectious coloenterites can be created (see Enteritis, a coloenteritis) and colitis (see). At severe forms of a disease, untimely and inadequate therapy of the patient can die in the first days of a disease. In a late stage of a disease lethal outcomes are result of development toksiko-dystrophic or toksiko-septi-cheskikh syndromes.
Noninfectious ponosa. Acute P. of a noninfectious etiology can be caused by disturbances of food, irrational selection of food ingredients at reduced secretory activity of glands went. - kish. path and change of its motility. At children of the first year of life in such cases develops simple or toxic dyspepsia (see), at children 1 years — enterita are more senior. Poisonings with salts of heavy metals, poisonous mushrooms, pharmaceuticals, inflammatory diseases of abdominal organs (appendicitis, peritonitis, etc.), diseases of kidneys in stages of uraemia, endocrine diseases (thyrotoxicosis) can be the reason of P. proceeding as a gastroenteritis or a coloenteritis.
Chronic P. of a noninfectious etiology can be manifestation inborn or acquired enzymopathies (see), followed by disturbance digestion (see) and absorptions of various food ingredients in a small bowel (see. Malabsorption syndrome ), including various carbohydrates, fat and protein. Adjoins this group of diseases Gee's disease (see), connected with inborn lack of the enzymes deaminizing peptides of gliadine (the protein which is contained in cereals). P.'s strengthening at introduction to food of substances, absorption is characteristic of enzymopathies to-rykh it is broken, deficit of weight at the kept appetite, the standard temperature of a body, the expressed positive effect from strict observance of a diet (P.'s termination, an increase in weight). Treats the hereditary diseases which are often followed by P. also mucoviscidosis (see). At most of children at this disease of change from intestines are combined with damage of lungs. Also P. is chronic at ulcer nonspecific colitis (see), diseases Krone (see. Krone disease ), etc.
Principles of treatment. Treatment is directed to elimination of the reason which caused P. by means of an adequate diet, recovery of water and mineral, vitamin and proteinaceous balance, performing disintoxication and replacement therapy. At infectious P. antibacterial therapy taking into account sensitivity of the activator and pharmacokinetics of the used drug is of great importance. Recovery of water and mineral balance is reached by introduction inside and intravenously crystalloid and colloid solutions. The volume and composition of the entered solutions are defined by weight of an eksikoz and its look. At sick children of the first year of life daily water requirement makes from 140 to 220 ml/kg, children from 1 year to 3 years have 120 — 160 ml/kg, 3 years — 60 — 100 ml/kg are more senior. The ratio of colloid and crystalloid solutions is defined by extent of change of an oskhmolyarnost of blood and a hypovolemia, more often it is 1:2 or 1:3. From colloid solutions dry or native plasma, albumine, blood-substituting liquids is used (Neocompensanum, Polyglucinum, Haemodesum, etc.). As crystalloid solutions solution of glucose, isotonic solution of sodium chloride, Ringer's solution, etc. use 5 — 10%. At children under 3 years not less than 1/3 volumes of the entered solutions solution of glucose shall make 5 — 10%. Correction is at the same time carried out acid-base equilibrium (see). Elimination of deficit of potassium is carried out after recovery of volume of the circulating blood and a diuresis. The average daily need for potassium and sodium at children under 3 years makes 1 — 2 mmol/kg, at heavy P. the daily need for potassium — 3 mmol/kg, in sodium — to 5 mmol/kg. Intravenous administrations are carried out in the drop way.
Disintoxication therapy (see) it is carried out by means of the funds allocated for the binding and bystreyshy removal from an organism of products of microbic disintegration and disturbances of cellular exchange (adsorbing means, Haemodesum, Neocompensanum, plasma, gamma-globulin, etc.).
Clinical nutrition is important (see. clinical nutrition, children ). Food shall contain complete proteins, to be mechanically and chemically sparing that is reached by the choice of digestible products and the corresponding culinary processing. Vegetables and meat are recommended to be steamed. Restriction of volume and fractional introduction of food is shown only in the acute period of a disease. At children of the first year of life ideal food is breast milk (see). In process of decrease in intoxication the diet is quickly expanded, the volume of food is increased to age norm. At P. connected with food allergy, enzymopathies (disakharidazny insufficiency, etc.), the products which are allergens or which are not had by this patient are excluded from a diet. The same pharmaceuticals, as at adults are applied to P.'s treatment at children. For elimination dysbacteriosis (see) appoint bacteritic drugs, including bifidumbacterium, especially effective at treatment of newborns and children of the first year of life, bifikol, etc.
P.'s prevention at children includes strict observance of a diet and water relationships according to age of the child, the prevention of overheating, performance a gigabyte. requirements during the cooking and its storage.
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A. V. Frolkis; H. V. Borotymtsevna (ped.)