SPRU (English. sprue) — the peculiar progressing enteritis proceeding with a diarrhea, disturbance of absorption in intestines, heavy dystrophy, anemia of preferential folic and scarce type, disturbances of activity of hemadens, loss by an organism of calcium.
The description of separate cases of S. occurs in references of 17 — 18 centuries. For the first time the disease was described by P. Munson in 1879. At the end of 19 century there was a term «tropical to a spr» since this disease was revealed at the persons coming from the countries with a temperate climate to the tropical countries for rather long time; more often military personnel, workers foreigners got sick; the indigenous people of the tropical countries was ill less often, and the disease at them usually proceeded in a latent form.
The etiology and a pathogeny
Tropical S. represents hron. enteritis inf. the nature, caused by a persistention in a small bowel of enteropathogenic flora (see. Enteritis ). The specific activator is not allocated. As a rule, at crops of excrements from tropical S.'s patients it is sowed bore a stake ko species of pathogenic microbes, is more often from the class Klebsiella pneumoniae, is more rare — from the class Escherichia coli, etc. About inf. to the nature of a disease also messages on its epidemics (e.g., in India and Burma testify during World War II). Areas, endemic on tropical S.'s incidence, in India, in Cuba, in Puerto Rico, Venezuela, Colombia, Vietnam, Sri Lanka, on the Philippine islands, etc. are known. In the USSR tropical S. was described for the first time by A. N. Kryukov in 1922, and in 1927 it gave the detailed description of anemia at this disease.
Already in early works on S. the polietiologichnost of the disease provoked by an infection, a role of a hypovitaminosis in its development, influence of insufficiency in food of proteins at excess of carbohydrates was assumed. From the second half of 20 century the different forms of enteritis proceeding with disturbance of absorption designate the term «not tropical to a spr», among to-rykh the main place borrows Gee's disease (see) — hron. the disease of children's age caused by genetic insufficiency of the enzymes participating in digestion of gluten — one of the main parts of protein of cereals (wheat, barley, rye). Not tropical S. can arise at inborn deficit of immunoglobulin A. At the same time immunity is broken local (in intestines) that can lead to the fermentative dyspepsia soon accepting peculiar features of tropical S. Vozmozhno, this mechanism plays the main role and at so-called European S. Odnim from the factors leading to disturbance of absorption and S.'s development as a result of injury of a mucous membrane of intestines can appear a protozoan infection. Carry to not tropical S. also the enterita at children arising in connection with intolerance of cow's milk; the enterita developing after an ileectomy at a disease Krone (see. Krone disease ); the heavy enterita connected with insufficiency of a pancreas, with pathology of a liver. Disturbance of absorption can be caused by an ulcerative enteritis of any origin, including arising at treatment by cytostatics owing to necrotic changes of a mucous membrane went. - kish. path (necrotic enteropathy). Not tropical S.'s symptom complex can be also developed at to a lymphosarcoma (see) mesenteric limf, nodes or mucous membrane of a small bowel. At the same time positive takes of the diet reducing fermentative processes in intestines can be regarded as the proof of Page. As a rule, the corresponding dietotherapy liquidates a diarrhea for some time and at a lymphosarcoma. Patients put on weight, the picture of a hypovitaminosis completely disappears that can imitate recovery, a cut actually concerns only S. K to a picture C. can give the tumoral process in a small bowel developing not from an adenoid tissue, e.g. carcinoid (see).
In a basis pathogeny practically all heavy symptoms of a disease the syndrome of disturbance of absorption lies (see Malabsorption a syndrome). At S. absorption of fat, glucose, vitamin A, then other vitamins, amino acids, calcium, enzymes, carbohydrates very much is early broken, deficit of protein appears. Anemia is caused by quickly increasing deficit folic acid (see), the reason to-rogo is not quite clear; at the same time can take place and deficit of iron (is more often at a Gee's disease at children). Deficit folic to - you lead to the megaloblastny transformation of a hemopoiesis which is characterized by disturbance of synthesis of DNA and cellular division at rather kept synthesis of hemoglobin. As a result anemia has preferential macrocytic character, is frequent with the raised (unreliable) color indicator, a moderate macrocytosis and an anisocytosis of erythrocytes (page of m. Gemogramma ). In marrow megaloblasts meet. The disease a long time can not be followed by signs of B12 - scarce anemia (see. Pernicious anemia ), but at the persistent not treated tropical S. striking all small bowel also B12 - scarce anemia develops. At not tropical S. usually deficit of B12 vitamin is absent (its stocks in an organism provide a hemopoiesis within several years).
The pathological anatomy
Tropical S. is characterized by education aft on a mucous membrane of the cheeks, a pharynx and language which are exposed further to an ulceration. Language at the same time becomes red, «varnished». At gistol. a research in it reveal a picture glossitis (see). In a mucous membrane of a stomach — the expressed atrophy of the main glands and a psevdopilorichesky metaplasia. The mucous membrane of a small bowel is thinned, its fibers are shortened (a subtotal atrophy), crypts are a little deepened. According to Ueli (M. of S. Whely) et al. (1971), in an epithelium of crypts it is noted megalotsitoz, the hypertrophy of endocrine cells is observed. Enterocytes are a little flattened, have various sizes and the form, activity of enzymes in them is reduced. At electronic microscopic examination in enterocytes a large number of lysosomes, drops of lipids, shortening and depression of microvillis comes to light. The basal membrane of a mucous membrane is unevenly thickened, in it small drops of lipids come to light that Schenk (E. A. Schenk) and soavt. (1965) consider pathognomonic for tropical Page. Own plate of a mucous membrane of a small bowel is edematous, moderately an infiltrirovana lymphocytes, plasmocytes, macrophages and eosinophils. Due to binding fat to-tami calcium at S. there are disturbances of mineral metabolism leading to osteoporosis (see). Changes of internals are similar to their changes at to a pellagra (see), and marrow — with changes at pernicious anemia (see).
At not tropical S. there comes the subtotal and total atrophy of fibers and sharp lengthening of crypts of a mucous membrane of a small bowel. Enterocytes take the cubic form and contain many RNA; activity of all enzymes in them is reduced. With the help autoradiography (see) increase in number of cells in a phase of synthesis of DNA comes to light that demonstrates the strengthened proliferation of an epithelium. At electronic microscopic examination sharp shortening, a thickening and deformation of microvillis, damage of terminal network and expansion of an endoplasmic reticulum are established. A characteristic sign is increase in maintenance of interepithelial lymphocytes. Own plate of a mucous membrane of a small bowel plentifully infiltrirovana preferential plasmocytes. Also macrophages meet high activity of lizosomalny enzymes. The number of the cells synthesizing A, M, G immunoglobulins is considerably increased.
In some cases the atrophy of fibers of a mucous membrane and adjournment in subepitelialyyuy parts of own plate of the eosinophilic material having an appearance of a hyalin is noted. Electronic microscopically in it collagenic fibers (so-called collagenic S.) are found.
The clinical picture
the Clinical picture is identical to all forms C. The disease begins sharply, temperature increases. Patients complain of a frequent chair, foamy kcal (in the analysis a calla already to early terms of a disease — a steatorrhea, undigested muscle fibers), fervescence, pains, rumbling, splash in a stomach, its swelling. Early appetite vanishes, there is a weakness, the lose of weight is noted. Then process accepts hron. the current, progresses disturbance of absorption, exhaustion accrues (see. Cachexia ); there are protein-free hypostases (see. Swelled ). Loss of calcium leads to emergence of convulsive twitchings of muscles, in far come cases there are signs of not diabetes mellitus (see. Diabetes not sugar ), an amenorrhea, the adrenal insufficiency which is expressed in decrease in the ABP and a xanthopathy. Invagination of a small bowel in connection with its atrophy and a hyperperistalsis is possible.
As a result of a vitamin deficiency of group B stomatitis, a glossitis (nipples of language of an atrofichna, its surface is hyperemic) develop, there are cracks on mucous membranes of an oral cavity, a gullet, is observed gastritis (see). The recurrent aphthous stomatitis at a Gee's disease which is clinically poorly shown is described.
In the absence of treatment the cachexia progresses, anemia becomes expressed; unlike other enterit process spontaneously does not calm down, and accrues irrespective of the initial reason. Crucial importance belongs to fermentative to a diarrhea (see); its elimination leads to bystry disappearance of other symptoms of S.
the Diagnosis establish a wedge, pictures (a long fermentative diarrhea, objectively registered enteritis) on the basis. It is necessary to establish the main reason for a diarrhea therefore carry out repeated bacterial. researches, a biopsy of a mucous membrane of a small bowel, a koproskopiya, a careful palpation of a stomach for the purpose of identification of tumoral processes in limf, nodes. Diagnosis is helped by determination of content folic to - you with blood serum and erythrocytes (at S. it is lowered). As establishment of the diagnosis takes place along with treatment, it is necessary repeated, after elimination of a diarrhea, a research of an abdominal cavity for an exception of a lymphosarcoma — roentgenoscopy went. - kish. a path, a computer tomography (see. Tomography computer ), a limfoangiografiya (see. Limfografiya ), kolonoskopiya (see). Wedge, recovery, increase in weight on 15 — 20 kg are not a reliable sign of lack of a lymphosarcoma of intestines.
Against the background of the corresponding diet (an exception of food of carbohydrates, milk, kefir, preserved foods) is appointed by antibiotics, among to-rykh the most effective drugs of a tetracycline row, and also astringents are: drugs of bismuth, calcium carbonate (1 — 2 powder on 0,5 g 2 — 3 times a day), crude ovalbumin (3 — 5 proteins a day), infusion from garnet crusts. At deficit folic to - you it is appointed but 5 mg a day (if necessary the dose can be increased), at deficit of B12 vitamin — an injection of B12 vitamin on 60 — 100 mkg daily within 20 — 30 days.
At exhaustion, protein-free hypostases it is kapelno reasonable to enter intravenously albumine. At loss of electrolytes use of solutions of potassium, sodium intravenously (kapelno) or inside is necessary. At a giiovolemiya and disturbance of absorption of glucose effectively slow intravenous drop administration of 5% of solution of glucose (500 — 1000 ml). The amount of the liquid entered to the patient shall correspond to its loss.
the Forecast at timely correct therapy favorable if the disease is not connected with tumoral process in an abdominal cavity.
Bibliography: Beyul E. A. and Ekisenina N. I. Chronic colitis and enterita, page 3, M., 1975; E to and with e N and - N and N. I. and d river. Gee's disease of adults, Owls. medical, No. 10, page 86, 1980, bibliogr.; Kassirsky I. A. and Plotnikov H. H. Diseases of tropical countries, page 414, M., 1964, bibliogr.; Hooks And. H. Anemia at a spra, the Medical thought of Uzbekistan, No. 1, page 28, 1927, bibliogr.; Chanarin I. The megaloblastic anaemias, Oxford — Edinburgh, 1969; Klipstein F. A. Tropical sprue in travelers and expatriates living abroad, Gastroenterology, v. 80, p. 590, 1981, bib-liogr.; Mathan M., Mathan V. I. a. Baker S. J. An electron-microscopic study of jejunal mucosal morphology in control subjects and in patients with tropical sprue in southern India, ibid., v. 68, p. 17, 1975; M o r s o n V. of C. a. Dawson I. M. P. Gastrointestinal pathology, Oxford a. o., 1972; Scott B. B. Diagnosing gluten intolerance, Lancet, v. 1, p. 891, 1981; Spezielle pathologische Anatomie, hrsg. v. W. Doerr u. a., Bd 2, T. 2, S. 127, B. u. a., 1976; Webster A. D. B. a. o. Coeliac disease with severe hypo-gammaglobulinaemia, Gut, v. 22, p. 153, 1981.
A. I. Vorobyov, M. D. Brilliant; L. I. Aruin (stalemate. An.).