Invasive type of diarrhea. Osmotic diarrhea. Causes of osmotic diarrhea

In diarrhea, water can enter the intestinal lumen either by an osmotic mechanism (osmotic diarrhea) or as a result of active transport of ions into the intestinal lumen (secretory diarrhea) (Tables 5-2 and 5-3). Osmotic diarrhea occurs when non-absorbable substances, such as magnesium hydroxide or lactulose, enter the digestive tract, or when the absorption of certain substances, such as lactose, is impaired in patients with lactase deficiency. Any condition combined with malabsorption (pancreatic insufficiency, sprue, Crohn's disease) can cause overflow of the intestine with osmotically active substances and lead to diarrhea. Unlike secretory, osmotic diarrhea stops with fasting (Table 5-4). It is also accompanied by an “osmotic difference” in the electrolyte composition of the stool. With osmotic diarrhea, the concentration of electrolytes in the feces is significantly lower than the actual osmolality, since the main osmotic substances that contribute to the development of diarrhea are not electrolytes, but non-absorbable osmotically active substances. In secretory diarrhea, the main part of the osmotically active substances is electrolytes. It is necessary not only to understand the mechanisms of development of osmotic and secretory diarrhea, but also to know the mechanisms leading to the inhibition of these processes. Some types of diarrhea are only osmotic, for example due to the action of lactulose, or only secretory, for example in cholera. In most cases, both mechanisms are involved in the development of diarrhea. For example, when the mucous membrane of the small intestine is damaged, diarrhea is caused by osmotic components due to the development of malabsorption due to damage to brush border enzymes and the enterocytes themselves. But at the same time, there are also signs of secretory diarrhea due to damage to villous epithelial cells and a relative increase in the activity of secretory crypt cells. In addition, cytokines released during inflammation of the intestinal mucosa can stimulate secretory processes.

Table 5-1. causes of acute and chronic small intestinal infections

Acute infections

Bacteria:

Escherichia coli

Gonococci

Treponema pallidum

Clostridium difficile

Clostridium perfringens

Rotaviruses

Astroviruses

Aeromonas hydrophila caliciviruses

(including Norwalk virus)

Strongyloides stercoralis Others - much less common

Protozoa:

Giardia lamblia Criptosporidium Entamoeba histolytica

Chronic infections

Giardia lamblia Entamoeba histolytica Strongyloides stercoralis Dysbiosis of the small intestine Tropical sprue Yersinia enterocolitica

Table 5-2. classification of causes of osmotic diarrhea

I. Exogenous

A. Taking laxatives:

Mg(OH) 2; MgSO 4 ; Na 2 SO 4 (Glauber's or Carlsbad salt); Na 2 HPO 4 (neutral phosphate)

B. Taking antacids containing MgO and Mg(OH) 2

B. Diet errors, consumption of products containing sorbitol, mannitol and xylitol (sweets), use of chewing gum or food additives

D. Long-term use of medications: colchicine, cholestyramine, neomycin, para-aminosalicylic acid, lactulose

II. Endogenous A. Hereditary:

1. Specific diseases of malabsorption: deficiency of disaccharidases (lactase, sucrase-isomaltase, trehalase); malabsorption of glucose-galactose or fructose

2. General malabsorption: abetalipoproteinemia and hypobetalipoproteinemia; congenital lymphangiectasia; enterokinase deficiency; pancreatic insufficiency (cystic fibrosis or Shwachman syndrome) B. Acquired:

1. Specific malabsorption diseases; deficiency of disaccharidases after enteritis

(From: Yamada T, Alpers D.H., OwyangC., Powell D.W., Silverstein F.E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia: J.B. Lippincott, 1995: 820.)

A decrease in diarrhea during fasting is not necessarily a sign of “true” osmotic diarrhea. Most secretory diarrheas also have an osmotic component, so fasting only reduces the volume of feces. In addition, food intake increases the volume of gastrointestinal secretion, which also decreases during fasting. Moreover, in many secretory diarrheas, the normal absorption capacity of the small intestinal mucosa is reduced. Substances that enhance secretion not only stimulate secretory cells, but also inhibit absorptive cells. Diarrhea caused by bile acids is secretory, since bile acids increase the total secretion in the intestinal crypts. But fasting reduces such diarrhea because it reduces the secretion of bile acids.

Table 5-3. classification of causes of secretory diarrhea

(IMPAIRMENT OF ELECTROLYTE TRANSPORT)

I. Exogenous

A. Taking laxatives: phenolphthalein, bisacodyl, senna, aloe, castor oil and others

B. Taking other medications: diuretics (furosemide, thiazides); antiasthmatic (theophylline); cholinergic drugs (eye drops for glaucoma and bladder stimulants containing acetylcholine; cholinomimetics); drugs for the treatment of myasthenia gravis (cholinesterase inhibitors); cardiac drugs (quinine and quinidine); anti-gout drugs (colchicine); prostaglandins (misoprostol); di-5-aminosalicylic acid (azodisalicylate); gold preparations (can also cause colitis)

B. Toxins: metals (arsenic); vegetable (mushrooms, for example Amanita phalloides); organophosphates (insecticides and neurotoxins), toxins in seafood, contained in some fish and shellfish (mackerel, oysters); coffee, tea, cola (caffeine and other methylxanthine derivatives); ethanol

D. Bacterial toxins:

Staphylococcus aureus, Clostridium perfringens and botulinum, Bacillus cereus

D. Intestinal hypersensitivity (without structural disorders)

II. Endogenous

A. Hereditary: hereditary chloridorrhea (lack of Cl – /HCO 3 – exchange); hereditary Na + diarrhea (lack of Na + /H + exchange) B. Bacterial enterotoxins:

Vibrio cholerae; toxigenic Escherichia coli; Campylobacter jejuni; Yersinia enterocolitica; Klebsiella pneumoniae; Clostridium difficile: Staphylococcus aureus (toxic shock) B. Endogenous laxatives: bile acids; long chain fatty acids, especially hydroxylated G. Hormone-producing tumors: pancreatic cholera and ganglioneuroma syndrome (vasoactive intestinal peptide), medullary thyroid carcinoma (calcitonin and prostaglandins), mastocytoma (histamine), villous adenoma (unknown hormone)

(no: Yamada T., Alpers D.H., Owyang S., Powell D.W., Silverstein F.E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia: J.B. Lippincott, 1995: 821.)

Infectious diarrhea

Acute infectious diarrhea is one of the leading causes of death in the world. More than 4 million children under 5 years of age die from acute infectious diarrhea. In developed countries (USA) there are certain population groups that have an increased risk of intestinal infections (Table 5-5). Most cases of acute diarrhea are caused by bacteria or viruses, but the cause is often unknown. Some bacterial infections sometimes go away on their own without treatment and therefore go unrecognized. A comparative description of the causes most often contributing to diarrhea is given in Table. 5-6.

Table 5-4. osmotic and secretory diarrhea

(From: KellyW. N.. ed. Textbook of Internal Medicine. Philadelphia: J. B. Lippincott, 1989: 672.)

Diarrhea due to bacterial infections is accompanied by many symptoms, but based on their totality they can be fundamentally divided into two groups: inflammatory and non-inflammatory (Table 5-7). In noninflammatory diarrhea, microorganisms multiply in the intestines and/or produce toxins that cause “watery” diarrhea without bleeding. These enterotoxins stimulate secretion without damaging mucosal cells. In inflammatory diarrhea, microbes and/or their toxins damage the cells of the intestinal lining and cause inflammation. In this case, the stool is bloody, for example, with dysentery, and patients complain of general disorders, such as fever and abdominal pain.

Table 5-5. high-risk groups for infectious diarrhea

Recent travel

Returnees from developing countries

Peace Corps workers

Users of water from natural sources

"Unusual" food

Seafood and shellfish, especially raw

Eating in restaurants, especially fast food

Banquets and picnics

Homosexuals, prostitutes, drug addicts

"Gay Gut Syndrome"

Nannies, housewives

Contact with children (more often suffer from intestinal infections)

Secondary contact with sick family members

Institution related

Patients of psychiatric clinics

Home call nurses

Patients in hospitals

(From: Yamada T, Alpers D. H., Owyang S., Powell D. yv., Silverstein F. E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia: J. B. Lippincott, 1995: 825.)

Table 5-6. epidemiology of intestinal pathogens

A high percentage is observed in adults and children hospitalized for diarrhea in winter (overall percentage for the entire human population: 12.5% ​​in the United States; 5-19% in developing countries.)

(no: Yamada T., Alpers D. H., Owyang C., Powell D. W., Silverstein F. E., eds. Textbook of Gastroenterology, 1sted. Philadelphia: J. B. Lippincott, 1991: 1448.)

Secretion stimulants

Secretagogues are substances that stimulate the secretion of electrolytes and water in the intestines. They can be endogenous, such as cytokines, bile acids, hormones from neuroendocrine tumors, enterotoxins from pathogenic microorganisms in the intestine, or exogenous, such as castor oil or a foodborne pathogen.

Neuroendocrine. Pancreatic cholera is a severe watery diarrhea associated with hypokalemia and achlorhydria caused by a non-β cell tumor of the pancreas that produces vasoactive intestinal polypeptide (VIPoma). Vasoactive intestinal polypeptide stimulates the secretion of water and electrolytes by acting on specific receptors in the intestinal epithelium, activating adenylate cyclase and increasing cAMP levels. This diarrhea is purely secretory. Many patients lose more than 3 liters of water per day, and in some cases - up to 20 liters. Due to the inhibitory effect of VIP on gastric secretion, patients develop hypochlorhydria, and due to increased loss of potassium in the stool, hypokalemia. Hyperglycemia and hypercalcemia are also common. Often such patients have facial redness due to the direct effect of VIP on vascular tone. About 5% of VIPomas are combined with tumors of other endocrine cells, which is a sign of multiple endocrine neoplasia syndrome type 1 (MEN-1).

Table 5-7. two main clinical syndromes in acute diarrhea

* Some microorganisms are capable of disseminating from the intestine, causing systemic, intestinal, febrile syndromes (Salmonella typhi, other salmonella, Yersinia)

(From: KellyW. N.. ed. Textbook of Internal Medicine. Philadelphia: J. B. Lippincott, 1989: 555.)

Gastrinoma or Zollinger-Ellison syndrome is the first neuroendocrine tumor described and is the most common. In 90% of patients, this tumor causes a peptic ulcer that is refractory to treatment. Chronic secretory diarrhea is observed in 30% of patients. The mechanism of diarrhea is not entirely clear, but, apparently, gastrin stimulates only gastric secretion and does not affect intestinal secretion, such as VIP. The pH in the small intestine decreases, which leads to irritation of its proximal parts with hydrochloric acid. At the same time, pancreatic enzymes are inactivated and bile salts precipitate. 30% of patients with gastrinoma have MEN-1 syndrome. Gastrinoma is usually localized in the pancreas, but can also be in the duodenum. Most gastrinomas become malignant by the time they are diagnosed. Previously, the main causes of death in gastrinomas were acute complications of peptic ulcer in the form of perforations and bleeding, but now, due to early diagnosis and treatment, the main cause of death is gastrinoma metastasis.

Diarrhea also occurs as a consequence of medullary thyroid carcinoma, which may be the only tumor, but may also be associated with MEN-II syndrome. Diarrhea is a common manifestation of increased secretion of calcitonin and other peptides. In such cases, it is associated with increased intestinal secretion, as well as increased intestinal motility. Not all neuroendocrine tumors produce secretagogues that cause severe secretory diarrhea; some substances cause only mild diarrhea. Endocrine causes of diarrhea are presented in table. 5-8.

Bacterial toxins. Toxins produced by bacteria that cause an increase in intestinal secretions are called enterotoxins. The classic enterotoxin is cholera toxin. It binds to C,-6el, which increases the level of cAMP in the cell and increases the secretion of chlorides. In severe cases of cholera diarrhea, fluid secretion reaches 10 liters per day, and if untreated, dehydration can be fatal. Cholera is a type of infection whose pathogenesis is associated with microbial colonization in the intestine and toxin production. Other microorganisms, such as Shigella, not only produce enterotoxin, but also cause damage to the epithelial cells of the intestinal mucosa. The third type of bacteria exhibits pathogenicity, primarily through invasion into the mucous membrane (Table 5-9). Escherichia coli is not usually a pathogenic microorganism, but some strains are exceptionally pathogenic. Enterotoxigenic Escherichia coli are not invasive, but the toxin they produce causes severe diarrhea. It can be deadly, especially in children. This pathogen is a common cause of diarrhea in people traveling, particularly to developing countries, causing the so-called “Montezuma's revenge” syndrome. Enterotoxins are also produced by Clostridium difficile, Staphylococcus aureus, Campylobacter jejuni, Yersinia enterocolitica, and the enterohemorrhagic strain Escherichia coli 0157:H7, which caused the deaths of several children in the United States in 1993. Many of the bacterial toxins (especially Clostridium difficile, Escherichia coli 0157:H7) are cytotoxic and directly cause damage to the intestinal mucosa.

Table 5-8. neurohumoral substances that stimulate secretion

(From: KelleyW. N., ed. Textbook of Internal Medicine. Philadelphia: J. B. Lippincott, 1989: 673.)

Table 5-9. symptoms of infectious diarrhea and pathophysiological

MECHANISMS OF THEIR DEVELOPMENT

(no: Yamada T, Alpers D N., Owyang C., Powell D. W., Silverstein F. E., eds. Textbook of Gastroenterology, 1sted. Philadelphia: J. B. Lippincott, 1991: 745.)

Foodborne illness is caused by the ingestion of contaminated food into the gastrointestinal tract. Diarrhea develops within a few hours, as does nausea and vomiting. Bacterial toxins can accumulate in foods (Bacillus cereus, Staphylococcus aureus, Clostridium botulinum) or be released in the intestines (Clostridium pertringens, Esherichia coli 0157:H7) (Table 5-10).

Other reasons. Many substances, such as bile acids and long-chain free fatty acids, that are not absorbed in the small intestine can promote fluid secretion in the colon, leading to diarrhea. The mechanism of this type of secretion is not fully understood, but appears to be mediated by the release of inflammatory mediators. Ileal resection and some small bowel diseases (Crohn's disease) can cause diarrhea due to malabsorption of bile acids and free fatty acids, which stimulate fluid secretion in the colon. In mild cases, only the absorption of bile acids is impaired. In more severe cases (for example, resection of 100 cm of the terminal ileum), loss of bile acids and their salts occurs, which impairs the digestion and absorption of fatty acids. When they enter the colon, they cause diarrhea. Therefore, there is a “100 cm rule”: removal of less than 100 cm of the terminal ileum causes diarrhea due to impaired absorption of bile acids, and resection of more than 100 cm increases diarrhea due to incomplete digestion of fatty acids. In other forms of steatorrhea, such as pancreatic insufficiency, unabsorbed triglycerides reach the colon, where they are hydrolyzed by microorganisms to fatty acids that cause diarrhea. Thus, castor oil contains ricinoleic acid, which actively promotes an intestinal reaction in the form of diarrhea.

In some cases, secretory diarrhea has no apparent cause and may be associated with an overdose of laxatives. In this case, the patient’s condition can be severe, he may lose weight, and the frequency of stools reaches 10-20 times a day with a large volume. Drugs commonly used as laxatives (phenolphthalein, senna preparations, aloe) in large doses stimulate the development of secretory diarrhea. If, after careful questioning and examination of the patient, the cause of diarrhea is not established, a diagnosis of “chronic diarrhea” is often made when the stool volume is less than 700 ml per day and “pseudopancreatic cholera syndrome” when the stool volume is more than 700 ml per day.

Damage to the mucous membrane (desquamation of villous cells and inflammation)

Table 5-10. main causes of gastroenteritis due to food

POISONING

(From: Centers for Disease Control. Food-borne disease outbreaks, annual summary, 1982. Atlanta: Centers for Disease Control, 1986; St. ME. Water-related disease outbreaks, 1985 MMWR CDC Surveillance Summary 1988; 37 (55-2 ); Yamada T., Alpers D. H., Owyand C., Polvell D. W., Silverstein F. E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia: J. B. Lippincott, 1995: 1609.)

The mucous membrane of the small intestine consists of villi and crypts (Fig. 5-9). Crypt cambial cells are the source of enterocytes and other specialized epithelial cells that, upon differentiation, migrate along the crypt-villus axis. As they move along the villi, the cells age and slough off. In humans, such migration of enterocytes takes about 3-5 days. The cells of the villi are predominantly absorptive, and the cells of the crypts are secreting, therefore, when the villi are damaged or lost, the remaining cells are stored only in the crypts, thus , secretion begins to overall prevail over absorption, which leads to the development of secretory diarrhea. Due to damage to the mucous membrane, the absorption of nutrients from food is impaired, so unabsorbed substances also cause osmotic diarrhea. With inflammation (some infections, ulcerative colitis, disease Crohn's) enterocytes are damaged, which stimulates secretion, in addition, it is stimulated by inflammatory mediators such as prostaglandins E1 and E2, hydroxyeicosotetraenoic and hydroxyperoxyeicosotetraenoic acids. Ischemia of the small or large intestine, the effect of radiation also lead to damage and death of the epithelium, which is often accompanied by bloody stool (ischemic or radiation colitis). The term "colitis" in this case is not entirely accurate, since the main mechanism of damage here is vascular disorders, and not inflammation. The causes of damage to the intestinal mucosa are given in table. 5-11.

Rice. 5-9. Diagram of the relationship between the villus-crypt and the small intestine of an adult mouse. At the base of each villi there are from 6 to 14 crypts (fewer in the proximal sections and more in the distal). In the lower parts of the crypts there are 40-50 cells with an average proliferation cycle time of 26 hours and 20-30 non-proliferating Napet cells. Cambial (fixed) cells have maximum proliferative activity. Cells from this place migrate both towards the villi and towards the base of the crypts to Paneth cells. The upper sections of the crypts contain proliferating cells that migrate to the villi. 275 cells approach the base of the villus from each crypt. The cells migrate to the tip of the villus, where they are then desquamated. (From: Yamada T., Alpcrs D.H., Owyang S., Powell D.W., Silverstein F.E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia: J.B. Lippincott, 1995:562.)

Diarrhea is an episode of abnormally loose or frequent stools. It can be considered chronic if it lasts more than 2 weeks. Diarrhea is considered the fifth most common symptom in general practice. Patients may use the word “diarrhea” when calling, but often they simply mean frequent bowel movements.

Diarrhea is defined as a situation with more than three loose stools per day and a weight of more than 200-250 g per day; acute diarrhea: duration< 14 дней, хроническая диарея: длительность >14 days. Feces contain 60-90% water. For residents of Western countries, the typical stool weight per day is 100-200 g in adults and 10 g/kg body weight in children, depending on the amount of indigestible fiber (mainly carbohydrates) consumed. Diarrhea is characterized by a stool weight of >200 g per day. Often, by diarrhea, patients mean the appearance of liquid stool consistency. With increased fiber consumption, the stool becomes more voluminous, but remains formed, which is not regarded by patients as diarrhea.

Complications and complications can occur with diarrhea of ​​any origin. Loss of fluid is possible with the development of dehydration, deficiency of electrolytes (Na, K, Mg, Ct) and even vascular collapse. In severe diarrhea (eg, cholera) in young, old, and malnourished patients, collapse can develop rapidly. Loss of HCO 3 may be accompanied by metabolic acidosis. With severe and prolonged diarrhea and excess mucus in the stool, hypokalemia may occur. Hypomagnesemia with prolonged diarrhea can cause tetany.

The term "diarrhea" is used when stool loses its normal consistency. Usually there is also an increase in its weight (in men more than 235 g/day, in women more than 175 g/day) and frequency (> 2 bowel movements per day).

Causes of diarrhea

Common reasons:

• acute infectious gastroenteritis, for example rotavirus infection, campylobacteriosis, food intoxication;
• taking antibiotics (and side effects of other drugs);
• diverticulitis;
• overflowing diarrhea with constipation (especially in the elderly).

Possible reasons:

• lactose intolerance;
• chronic infection: amoebiasis, giardiasis, hookworm;
• intestinal neoplasia;
• inflammatory bowel diseases;
• alcohol abuse;
• infantile diarrhea;
• celiac disease (1 case in 300).

Rare reasons:

• appendicitis;
• laxative abuse;
• thyrotoxicosis;
• malabsorption syndrome, for example, with celiac disease;
• allergic reaction;
• ovarian cancer.

Acute diarrhea:

Chronic diarrhea:

Causes of chronic diarrhea may include:

• Usually organic diseases, such as inflammatory bowel disease (ulcerative colitis, Crohn's disease)
• Poor digestion/impaired resorption (short bowel syndrome)
• Tumors (eg, neuroendocrine tumors)
• Pancreatic insufficiency.

Normally, 99% of the water entering the lumen with ingested liquids and digestive secretions is absorbed in the small and large intestines - the total liquid load reaches 9-10 l/day. Even a small decrease (by 1%) in intestinal absorption or increase in secretion leads to a significant increase in the water content in the lumen and the development of diarrhea.

There are a number of causes of diarrhea. In most cases, several basic mechanisms are involved in the development of diarrhea: increased osmotic load, increased secretion, and decreased time/area of ​​contact with the absorptive surface. In many cases, not one, but two or three mechanisms play a role. In inflammatory bowel diseases, diarrhea occurs due to damage to the mucosa, exudation and the production of various prosecretory substances and bacterial toxins that disrupt the functions of enterocytes.

Increased secretion. If the secretion of electrolytes and water in the intestines exceeds the absorption capacity, diarrhea develops. The reasons for increased secretion are infections, impaired absorption of fats, the influence of certain drugs and various prosecretory substances of endogenous and exogenous origin.

Infections (eg, gastroenteritis) are the most common causes of secretory diarrhea. Infections combined with food poisoning are the most common causes of acute diarrhea (duration< 4 дней). Большинство энтеротоксинов блокируют Na + -H + обменник, играющий важную роль в абсорбции воды в тонкой и толстой кишках.

Unabsorbed fat and bile acids stimulate secretion in the colon, causing diarrhea.

Drugs may stimulate intestinal secretions directly (eg, quinidine, quinine, colchicine, anthraquinone laxatives, castor oil, prostaglandins) or indirectly by inhibiting fat absorption (eg, orlistat).

Various endocrine tumors produce prosecretory substances; These include VIPomas (produce vasoactive intestinal peptide), gastrinomas (gastrin), mastocytosis (histamine), medullary thyroid cancer (calcitonin and prostaglandins), and carcinoid. Some of these mediators (in particular, prostaglandins, serotonin and similar substances) also increase peristalsis of the small and/or large intestine.

Reducing the time/area of ​​contact with the suction surface. Accelerated intestinal transit and reduced surface area lead to impaired fluid absorption and diarrhea. The main reasons are resection or anastomosis of the small or large intestine, gastric resection, inflammatory bowel diseases.

Other causes are microscopic colitis, celiac sprue.

Stimulation of the activity of intestinal smooth muscle cells under the influence of drugs or humoral agents (prostaglandins, serotonin) also accelerates transit.

Osmotic diarrhea occurs when consuming large amounts of non-absorbable or slowly absorbed substances, either normally or due to malabsorption. The first group of substances includes sorbitol (included in drugs that do not contain sugar, sweets and some fruits), fructose (included in lemonade, various fruits, honey), magnesium salts (antacids, laxatives), as well as poorly absorbed anions, such as sulfates, phosphates or citrates.

Unabsorbed substances are osmotically active and therefore fix water in the intestinal lumen. In table This mechanism is illustrated by the example of a simulation experiment. After taking, for example, 150 mmol of a non-absorbable substance (in this case, polyethylene glycol - PEG) dissolved in 250 ml of water (PEG concentration = 600 mmol/l), osmotic secretion of water into the duodenum begins, the volume of its contents increases to 750 ml (PEG concentration decreases to 200 mmol/l). Osmolality reached the plasma level (290 mOsmol/L), 90 mOsmol/L of which is provided by Na +, K + ions, as well as accompanying anions (ions are secreted into the intestinal lumen along chemical gradients). The volume of contents in the middle section of the small intestine increases to 1000 ml (PEG concentration decreases to 150 mmol/L, and ions entering the lumen provide an osmolality of 140 mOsmol/L). Given the active absorption, especially of Na + ions (plus anions), in the ileum and colon (higher epithelial density compared to the jejunum), the osmolality provided by the ions is reduced to 90 and 40 mOsmol/L, respectively. The major cation in stool is K+ (most of the Na+ is absorbed in the ileum and colon). So, after taking 150 mmol of PEG dissolved in 250 ml of water, the stool volume will be 600 ml. In the absence of ion absorption in the ileum and colon (for example, after resection or in the presence of corresponding diseases), the volume of stool can reach 1000 ml. (For this reason, PEG is given before a colonoscopy to cleanse the colon.)

In case of malabsorption of carbohydrates, insufficient absorption of Na + in the upper part of the small intestine (reduced cotransport of Na + with glucose and galactose) leads to insufficient absorption of water. The osmotic activity of unabsorbed carbohydrates causes additional secretion of water. Colon bacteria are capable of metabolizing up to 80 g/day (divided into four meals) of unabsorbed carbohydrates into organic acids, which can act as a source of energy and are absorbed together with water in the colon. Only excessive gas formation (flatulence) indicates a malabsorption of carbohydrates. However, if less than 80 g of carbohydrates are absorbed per day (i.e. less than 1/4 of the daily value) or if the intestinal flora is suppressed by antibiotics, diarrhea occurs.

Secretory diarrhea (in the narrow sense) occurs when the intestinal mucosa begins to secrete Ch ions. Inside the cells of the mucous membrane, Ch ions accumulate actively due to the work of transporters located in the basolateral membrane and cotransporting 1 Na + ion, 1 K + ion and 2 Ch ions. Ch ions are then secreted via Ch channels in the luminal membrane. With an increase in the intracellular concentration of cAMP, these channels open more often. cAMP is formed in large quantities in the presence of certain laxatives and bacterial toxins (Clostridium difficile, Vibrio cholerae). Cholera toxin causes massive diarrhea (up to 1000 ml/h), which can quickly become life-threatening due to loss of water, K + ions and HCO 3 - (hypovolemic shock, hypokalemia, non-respiratory acidosis).

Excessive production of VIP by pancreatic islet cell tumors also leads to an increase in the concentration of cAMP in mucosal cells, which leads to massive life-threatening diarrhea - pancreatic "cholera", or watery diarrhea syndrome.

After resection of the ileum or part of the colon, diarrhea occurs for several reasons. Bile salts, normally absorbed in the ileum, accelerate the passage of colon contents (insufficient water absorption). In addition, unabsorbed bile salts are dehydroxylated by colonic bacteria. The resulting salt metabolites stimulate the secretion of NaCl and H 2 O in the colon. Finally, along with the resected segments of the intestine, the ability to actively absorb Na + is lost.

Screening for diarrhea

Examination methods

Basic: for persistent diarrhea - stool analysis, CBC. Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP), thyroid function assessment, endomysium and gliadin antibodies, fecal calprotectin.

Additional: general urinalysis (UU), assessment (liver function, sigmoidoscopy followed by irrigoscopy, colonoscopy, analysis for CA-125.

Auxiliary: tests for malabsorption.

Clarify what the patient means when he talks about diarrhea. Patients may come in simply because of a slight change in their usual bowel movements or their increased frequency with formed feces.

Giardiasis appears to be much more common than previously thought, and the pathogen can be difficult to isolate from stool samples. If the characteristic clinical picture (an attack of ongoing diarrhea with fat inclusions, accompanied by anorexia, nausea and bloating, occurring shortly after travel), empirical treatment is justified.

IBS rarely causes nighttime diarrhea.

Patients with gastroenteritis should improve steadily after a few days of illness, but symptoms may persist for up to 10 days - warn the patient about this.

Don't be mistaken when diagnosing overflow diarrhea in the elderly. The only way to make this diagnosis is a rectal examination.

It is necessary to ask about foreign travel and type of activity - this data can help in making a diagnosis and prescribing treatment.

Weight loss with chronic diarrhea is highly likely to indicate a serious pathology.

In young people who are healthy in all other organ systems, a diagnosis of IBS is possible after minimal research, but beware that this is the first time we make such a diagnosis in middle-aged or elderly patients. Serious pathology is often disguised as IBS.

Carefully assess for signs of dehydration in children and the elderly with diarrhea - if present, hospitalization is necessary.

An initial telephone consultation is often sufficient in cases of acute diarrhea, however, in cases of persistent (non-colicky) abdominal pain, it is necessary to examine the patient to exclude acute surgical pathology.

Remember that acute diarrhea in older adults can cause or worsen kidney failure, especially if they are taking angiotensin-converting enzyme (ACE) inhibitors. Discontinue these medications during treatment and ensure the adequacy of rehydration therapy.

Anamnesis

Stool protocol (consistency, appearance, quantity, frequency, dynamics, pain), medications, foods, previous episodes of diarrhea, long-distance travel.

A history of the present illness helps clarify the duration and severity of diarrhea, the circumstances under which it began (travel, certain foods, a “suspicious” water source), medications taken (including any antibiotics in the previous 3 months), presence of abdominal pain or vomiting, frequency and time of defecation, changes in the nature of stool, as well as accompanying changes in appetite, body weight, the presence of urgent urges to defecate, tenesmus. The fact of simultaneous occurrence of diarrhea in persons who were in contact with the patient is established.

Assessing the state of various systems helps to detect other signs of diseases occurring with diarrhea, including arthralgia, “hot flashes” (with carcinoid, VIPoma, mastocytosis); chronic abdominal pain and manifestations of gastrointestinal bleeding (with ulcerative colitis, tumors).

A history of previous diseases helps to identify risk factors for the development of diarrhea (indications of the presence of inflammatory bowel disease, irritable bowel syndrome, HIV infection, previous surgical interventions on the abdominal organs (resection, anastomosis of the stomach and intestines, pancreatic resection). It is necessary to clarify the family and epidemiological anamnesis, which helps to establish the fact of the simultaneous development of diarrhea in persons who were in contact with the patient.

Laboratory data: blood picture (anemia? leukocytosis? eosinophilia?), increased ESR? electrolyte imbalance (due to fluid loss), iron (iron deficiency is often observed in celiac disease), elevated transaminases? Have your thyroid function parameters changed?

Stool analysis: total 3 x with bacteriological examination (primarily Clostridium difficile, Yersinien, Campylobacter, with a negative result of Clostridium perfringens, Klebsiella oxytoca, Salmonella spp. after/during the period of antibiosis), occult blood test (Haemoccult)

Endoscopy: primarily in case of anemia and/or a positive Haemoccult test result, as well as in case of chronic diarrhea (tissue test in patients with immunosuppression due to CMV infection).

Physical examination. It is necessary to assess water balance and hydration status. It is important to conduct a full examination with a particularly careful assessment of the abdomen and digital examination of the rectum to assess the integrity of the sphincter and test for occult blood.

Symptoms and signs of diarrhea

Certain signs indicate the presence of organic pathology or severe disease with diarrhea:

• blood or pus;
• fever;
• signs of dehydration;
• chronic diarrhea;
• weight loss.

Interpretation of results. Acute watery diarrhea in an initially healthy person is more likely to be of infectious origin, especially during travel, travel, consumption of poor-quality products, or in the development of outbreaks with the spread of infection from a single source.

Acute bloody diarrhea in combination with or without hemodynamic disorders in an initially healthy person gives reason to suspect an infection with enteroinvasive bacteria. Bleeding from a diverticulum or ischemic colitis also causes acute bloody diarrhea. If repeated episodes of bloody diarrhea occur in younger patients, inflammatory bowel disease should be excluded.

In the absence of laxatives and structural changes in the gastrointestinal tract, diarrhea with a large volume of stool (>1 l/day) is highly likely to indicate the presence of endocrine pathology. The presence of fat droplets in the stool, especially during weight loss, indicates the presence of malabsorption.

Diarrhea that naturally develops after eating a certain type of food (for example, fatty food) indicates the presence of intolerance to certain food components. With recent use of antibiotics, antibiotic-associated diarrhea should be suspected, incl. colitis associated with Clostridium difficile infection.

The nature of the clinical manifestations may indicate damage to a specific part of the intestine. As a rule, with diseases of the small intestine, the stool is bulky, watery, or mixed with fat. In diseases of the colon, stool is frequent, sometimes in small portions, may contain an admixture of blood, mucus, pus and be accompanied by discomfort in the abdomen. In irritable bowel syndrome (IBS), abdominal discomfort is relieved after bowel movements and is associated with loose and/or frequent bowel movements. However, these symptoms alone do not distinguish IBS from other diseases. Patients with IBS or inflammatory changes in the rectal mucosa often experience an urgency to defecate, tenesmus, and frequent stools.

Extraintestinal manifestations that help determine the nature of the pathology include skin changes and hot flashes (with mastocytosis), thyroid nodules, murmurs characteristic of damage to the right side of the heart (with carcinoid), lymphadenopathy (with lymphoma, AIDS), arthritis.

Survey. For acute diarrhea (duration< 4 дней), как правило, нет необходимости в специальном обследовании. Исключение составляют пациенты, у которых определяются признаки дегидратации, кровь в стуле, лихорадка, интенсивная боль, гипотензия, симптомы выраженной интоксикации, в особенности пациенты детского, подросткового и пожилого, старческого возраста. Таким больным необходимо провести общий анализ крови, исследовать содержание электролитов, азота мочевины и креатинина в крови. Необходимо провести микроскопический анализ кала, включая оценку содержания лейкоцитов, культуральное исследование кала и -при недавнем применении антибиотиков -исследовать содержание токсинов С. difficile в кале.

If a definite diagnosis cannot be established, and the presence of steatorrhea is determined using Sudan staining, a quantitative assessment of fat loss in feces is carried out and then the condition of the small intestine is examined using enteroclysis or CT enterography (to assess anatomical changes) and endoscopic biopsy (to assess the condition of the mucosa) . If pathology of the small intestine is not identified, in the presence of “unexplained” steatorrhea, the structure and function of the pancreas is assessed. In some cases, capsule endoscopy can detect changes not detected by other methods (mainly Crohn's disease and enteropathy associated with taking NSAIDs).

A stool characteristic such as osmotic “failure”, which is calculated as 290-2" (Na concentration in feces + K concentration in feces), indicates whether the diarrhea is secretory or osmotic in nature. Osmotic “failure”< 50 мэкв/л указывает, что диарея носит характер секреторной; большее значение указывает на осмотический характер. При осмотической диарее необходимо заподозрить скрытый прием Mg-содержащих слабительных (определяемый по содержанию Mg в кале) или мальабсорбцию углеводов (диагностируемую с помощью водородного дыхательного теста, исследования активности лак-тазы и пересмотра диеты).

For secretory diarrhea of ​​unspecified origin, an examination is necessary to exclude endocrine pathology (in particular, a study of the content of gastrin, calcitonin, vasoactive intestinal peptide in the serum, histamine, 5-hydroxyindoleacetic acid in the urine). It is necessary to carefully evaluate the symptoms to identify signs of diseases of the thyroid gland and adrenal glands. The possibility of taking laxatives should be considered; it can be turned off by examining the stool for laxatives.

Treatment of diarrhea

• Administration of electrolyte solutions to correct dehydration.
• For diarrhea without blood and the absence of general signs of intoxication, antidiarrheal drugs may be prescribed.
• Cancel provoking substances or pause their use:
  • foods (tube feeding), avoid, for example, poorly absorbed carbohydrates (fructose, sorbitol). The frequency of diarrhea can be influenced by changing the composition of the tube diet (for example, the amount of carbohydrates, fats and osmolarity level), it is better to use formulations with low osmolarity and ballast substances. Continuous feeding (pumping) may reduce diarrhea.
  • medications (laxatives, prokinetics, antibiotics): if clinically necessary, take a break or discontinue and monitor the course of the disease.
• Symptomatic therapy:
  • replenishment of fluids and electrolytes, sometimes taking glucocorticoid solutions
  • if there is a threat of malnutrition, initiate concomitant parenteral nutrition if indicated
  • sometimes taking antidiarrheals: loperamide (initially 2-4 mg), anticholinergics or opioids, caution: risk of paralytic ileus.
• Antibiotic therapy, such as for severe Clostridium difficile infection or other confirmed bacterial diarrhea.

In case of severe diarrhea, it is necessary to replace losses of water and electrolytes to avoid dehydration, salt metabolism disorders and acidosis. As a rule, parenteral administration of plasma substitutes containing NaCl, KCL, and glucose is indicated. The introduction of acid-neutralizing salts (Na lactate, acetate, HCO 3) is indicated when the content of HC03 in the serum< 15 мэкв/л. При нетяжелой диарее и отсутствии сильной рвоты можно проводить пероральную регидратацию глюкозо-солевыми растворами. В случаях, когда требуется массивное возмещение потерь воды и электролитов (например, при холере), растворы для регидратации назначают одновременно внутрь и парентерально.

Diarrhea is only a single symptom. The underlying disease is treated, but often it is necessary to resort to symptomatic remedies. Diarrhea is reduced by oral administration of loperamide, diphenoxylate, codeine phosphate, and tincture of opium with camphor.

Since taking antidiarrheal drugs may worsen the course of colitis associated with C. difficile infection and increase the likelihood of developing hemolytic-uremic syndrome due to infection with Shiga toxin-producing Escherichia coli, these drugs should not be prescribed for diarrhea mixed with blood of unspecified origin. Indications for the use of antidiarrheals should be limited to cases of watery diarrhea without signs of general intoxication. However, there is no convincing evidence that taking antidiarrheal drugs lengthens the period of elimination of pathogenic bacteria.

Diarrhea (diarrhea ) is a condition in which a person has a fairly frequent or one-time bowel movement, during which a liquid stool is released. An adult healthy person excretes from 100 to 300 g of feces per day. Its amount varies depending on the amount of fiber contained in the food and the amount of remaining undigested substances and water. If the duration of the disease remains within two to three weeks, then in this case there is acute diarrhea . If a person has loose stools for more than three weeks, diarrhea becomes chronic. At chronic diarrhea The patient also experiences systematically profuse stools. In this situation, the weight of feces will exceed 300 g per day. Diarrhea occurs when the water content in a person's stool increases dramatically - from 60 to 90%. If the absorption of nutrients from food is impaired, patients are diagnosed with polyfecal : An unusually large amount of feces is released, which consists of food debris that remains undigested. If intestinal motility is impaired, the stool will be very loose and frequent, but in general its weight will not exceed 300 g per day. That is, even in the case of an initial analysis of the characteristics of the course of diarrhea, it is possible to find out what the cause of such a pathology is and, therefore, facilitate the process of establishing a diagnosis and selecting subsequent therapy.

Diarrhea of ​​any kind is a pathological process in which the absorption of water and electrolytes in the intestine is impaired. In view of this, with diarrhea of ​​any kind, approximately the same picture is observed. Both the large and small intestine have a very high capacity for water absorption. So, every day a person consumes about two liters of liquid. In general, about seven liters of water enter the intestines, taking into account saliva , , intestinal And , . In this case, only 2% of the total volume of liquid is excreted with feces, the rest is absorbed directly in the intestine. If the amount of liquid in the stool changes even very slightly, the stool becomes too hard. If there is too much fluid in the colon, a person experiences diarrhea. This disease manifests itself due to disorders in the digestive process, problems with absorption, secretion and intestinal motility. In the case of diarrhea, the small and large intestine are perceived as a single physiological unit.

Types of diarrhea

At secretory diarrhea There is an increased secretion of electrolytes and water into the intestinal lumen. In more rare cases, the cause of this type of diarrhea is a decrease in the absorption functions of the intestine. Thus, secretory diarrhea occurs when cholera , Escherichiosis , salmonellosis . But sometimes a similar condition also occurs in patients with certain non-infectious pathologies. If a patient has this type of diarrhea, the osmotic pressure of the blood plasma is higher than the osmotic pressure of the feces. The patient produces watery and fairly abundant feces, their color is green. The causes of secretory diarrhea are the active process of secretion of sodium and water in the intestine. The occurrence of this process is provoked by bacterial toxins, enteropathogenic viruses, a number of drugs and other biologically active substances. Thus, secretory diarrhea can be provoked by long chain fatty acids And bile free acids , laxatives , which contain anthraglycosides , Castor oil .

At hyperexudative diarrhea sweating occurs plasma , mucus , blood into the intestinal lumen. This condition is typical for patients suffering from infectious and inflammatory bowel diseases ( shigellosis , salmonellosis , campylobacteriosis , clostridiosis ). Also, this type of diarrhea typically manifests itself in non-communicable diseases, such as nonspecific ulcerative colitis , lymphoma , Crohn's disease . The osmotic pressure of blood plasma is higher than the osmotic pressure of feces.

The osmotic pressure of fecal matter is lower than the osmotic pressure of blood plasma. The stool is liquid, there is an admixture of pus, blood, and mucus.

At hyperosmolar diarrhea the patient has a malabsorption of certain nutrients in the small intestine. Metabolic processes in the body are noticeably disrupted. This type of diarrhea occurs with excessive use of saline laxatives. The osmotic pressure of fecal matter is higher than the osmotic pressure of blood plasma. This condition is characterized by loose and profuse stools, in which particles of undigested food are found.

At hyper- And hypokinetic diarrhea The patient has disturbances in the transit of intestinal contents. The cause of this condition is decreased or increased intestinal motility . Very often, this condition is typical for people suffering from irritable bowel syndrome, as well as for those who use too many laxatives and antacids. The osmotic pressure of fecal matter in this condition is the same as the osmotic pressure of blood plasma. The stool is not particularly abundant, with a liquid or mushy consistency. The last two types of diarrhea occur only in patients with non-infectious diseases.

Causes of diarrhea

The occurrence of diarrhea is influenced by the following phenomena: intestinal secretion , too much high pressure V intestinal cavity , intestinal exudation , violations in progress transportation intestinal contents . All these mechanisms have a certain connection, but a certain type of disease is characterized by the predominance of the corresponding type of disorder.

Symptoms of diarrhea

Acute diarrhea occurs with various types of infections, inflammation in the intestines and due to exposure to certain medications. As a rule, diarrhea occurs in combination with a number of other manifestations: it may be , bloating , stomach ache , weakness , feeling of chills , increase in body temperature .

Symptoms of an infectious type of disease are general malaise , manifestations , bad , vomit . Very often, the causes of diarrhea are poor quality food, as well as travel (the so-called tourist diarrhea occurs). The appearance of loose stools with elements of blood indicates the presence of damage in the intestinal mucosa. Their occurrence is provoked by some pathogenic microbes or with enteropathogenic properties. The patient's condition with this form of the disease is severe due to septic symptoms and pain in the abdominal area.

Some medications can also cause diarrhea. Level the body can be assessed already through examination of the patient. If there is a significant loss of electrolytes and water in the body, then dry skin is observed, a decrease in its turgor, and may also appear. hypotension . Due to noticeable calcium losses in the body, there may be a tendency to cramps .

In case of chronic diarrhea, that is, a disease lasting more than three weeks, the examination should first of all be aimed at finding out the reasons for its occurrence. The specialist examines the medical history and conducts all relevant stool examinations. During the diagnostic process, it is important to establish the duration of diarrhea, determine the volume of stool per day, the frequency and severity of intestinal motility, and weight fluctuations. If there is a disease of the small intestine, the stool will be bulky, watery or greasy. Colon diseases are accompanied by frequent stools, but they will be less abundant, containing pus, blood, and mucus. With pathology of the colon, diarrhea, as a rule, will be accompanied by pain in the abdomen.

Diagnosis of diarrhea

During the diagnostic process, a routine physical examination is performed. In this case, the specialist carefully examines the condition of the patient’s bowel movements and conducts a proctological examination. If the patient's stool is found blood , There is , or , then we can assume that the patient has Crohn's disease . In the process of microscopic examination of stool, it is important to determine in it inflammatory cells, fat, the presence of eggs and protozoa.

Using the sigmoidoscopy method, it is possible to diagnose, pseudomembranous colitis . To establish a diagnosis of “acute diarrhea,” the doctor is guided primarily by the patient’s complaints, medical history, proctological examination, and physical examination. The laboratory performs macro- and microscopic examination of stool samples.

If, during the process of establishing a diagnosis, it turns out that there is no inflammation in the intestines, then, most likely, diarrhea in this case will be associated with malabsorption. In some cases, the occurrence of acute diarrhea is provoked by enteroviruses. If viral enteritis is suspected, the doctor must make sure whether the symptoms and manifestations of this condition coincide. Thus, with viral enteritis, there is no blood and inflammatory cells in the stool, antibacterial therapy is ineffective during the treatment process, and the patient can recover spontaneously. The specialist must note all the described features during the differential diagnosis of various types of intestinal diseases.

In the process of diagnosing chronic diarrhea, first of all, it is determined whether there is a connection between the occurrence of diarrhea and infections or inflammations. To do this, stool tests are carried out - microscopic , bacteriological , sigmoidoscopy . Also, to exclude inflammation, the pathogenetic mechanism of diarrhea should be determined. Often, a period of time on a specific diet for diarrhea helps to establish the correct diagnosis.

Treatment of diarrhea

Some approaches to treating diarrhea are common to all four types of the disease. Thus, symptomatic medications and drugs with antibacterial action are equally effective. First of all, changes in eating style are practiced. So, a diet for diarrhea involves consuming foods that help inhibit peristalsis and reduce the secretion of water and electrolytes. At the same time, it is important to exclude those products whose properties suggest an increase in the motor-evacuation and secretory functions of the intestine.

Treatment of diarrhea includes administration antibacterial drugs , which are designed to restore intestinal eubiosis. Patients with acute diarrhea should take antibiotics , antimicrobial And sulfonamides drugs , antiseptics . The most preferred treatment for diarrhea is one that does not disturb the balance of intestinal microflora.

An alternative medicine for diarrhea is bacterial drugs , the course of treatment of which lasts up to two months. Used as symptomatic agents adsorbents , which neutralize organic acids and also prescribe astringents And enveloping facilities.

Diarrhea is also treated with the help of drugs that regulate motility and reduce intestinal tone. And to eliminate the state of dehydration of the body it is used rehydration . If the patient is diagnosed with an acute condition, then rehydration is carried out orally; in rare cases, crystalloid polyionic solutions are infused intravenously for rehydration.

The doctors

Medicines

Intestinal suffering is usually represented by two opposing types - diarrhea And . Moreover, the first one causes a lot of trouble, because of which it is impossible to even leave the house. Usually, (the official name of diarrhea) is a malaise that is expressed by frequent and very loose, watery stools. She is, of course, unpleasant. But most importantly, it can be an indicator of a fairly serious disease caused by intestinal infections or food poisoning.

The main danger - as its consequence - dehydration , because of which the patient may even die. Of course, at the first signs of diarrhea, you need to consult a doctor and make a correct diagnosis. The specialist will prescribe treatment in accordance with the characteristics of your body, but, perhaps, the main thing for all patients remains severe.

Both with the treatment prescribed by the doctor and at the first signs of diarrhea, even before going to the hospital, you should drink as much mineral water as possible without carbon, fruit juice, any juice and other liquid. The exception is dairy products and coffee.

How to get rid of diarrhea?

Along with drug treatment (if the infectious nature of the disease or food poisoning is identified), it is not only possible, but also necessary to resort to folk remedies. For example, for hundreds of years now people have been getting rid of diarrhea in the following way: chicken stomach cut off the yellow shell, wash it well and dry it, then crush it with a wooden masher or rolling pin to a powder. Take this powder 1 tbsp. spoon - adults, and 1/2 tbsp. spoon - children. Drink plenty of water. Apply once a day.

Even easier to use potato starch : 1 tbsp. Dilute a spoon in a glass of cooled boiled water and drink. Adults can resort to another fairly simple recipe: dilute 1 teaspoon of salt in less than half a glass of vodka and consume immediately.

At home, it’s quite easy to prepare another version of the drug: cut a raw onion crosswise (not at the root) and put it in a glass of hot tea (not strong, without sugar). Insist this way onion 10 minutes, then drink.

A solution prepared from two components also helps well - cinnamon and red capsicum pepper . Possessing excellent astringent properties, such decoction It also helps remove it from the body gases.

Very common among people are decoctions from the walls, infused in alcohol for 2-3 days, and from the peel grenade, brewed with boiling water. Berries mixed with honey can also help - viburnum, cranberry swamp And of course, rice or, more precisely, rice congee (1:7 - ratio of cereal and cold water, boil until half-baked). Just use unbroken rice.

Diarrhea during pregnancy

Diarrhea occurs quite often when . There are a number of reasons for this condition to occur in pregnant women. So, sometimes diarrhea occurs due to diseases of the intestines or the gastrointestinal tract as a whole. In some cases, the cause of diarrhea in pregnant women is common ailments. However, during pregnancy, a woman’s body becomes especially susceptible to various infections, so infectious diseases and local poisoning can provoke diarrhea. Thus, pregnant women have a high sensitivity to toxins. However, the cause of diarrhea can be disturbances in the functioning of the nervous system, the presence of worms, and insufficient production of enzymes in the body. Often the cause of diarrhea is becoming pregnant.

In some cases, diarrhea may not pose a danger to a woman, performing the function of a kind of cleansing of the body before the upcoming childbirth . However, the causes of diarrhea should be closely monitored. After all, if this condition arose due to food or other poisoning, then it is very dangerous for both the unborn child and the woman.

During pregnancy, treatment of diarrhea should be carried out only under the close supervision of a doctor, who will definitely take into account all individual aspects. At the same time, the specialist adjusts the patient’s nutrition, prescribing her a special diet. For the expectant mother, it is very important to constantly maintain a drinking regime, consuming a sufficient amount of liquid, because dehydration is an undesirable condition for the fetus and mother.

Diarrhea is a condition in which the weight of stool and the number of bowel movements increase. Diarrhea can lead to disturbances in water-salt balance. Based on the type and mechanism, there are four types of diarrhea: secretory, osmotic, mixed and invasive. Invasive diarrhea or intestinal hyperexudation is caused by certain pathogens in the intestinal walls, where the permeability of cell membranes is increased.

Pathological processes are localized in the large intestine and are manifested by certain symptoms:

• frequent stools with blood and mucus;
• a small amount of stool (rectal spit);
• disturbances in the water-electrolyte balance do not appear;
• severe and frequent intoxication;
• pain is localized in the lower abdomen;
• tenesmus - frequent and unsuccessful urge to defecate;

Secretory diarrhea or intestinal hypersecretion occurs due to bacterial exotoxins. It is caused by a violation of the transport of electrolytes. The process is localized in the small intestine. Characteristic symptoms are:

• frequent, watery, sometimes greenish loose stools;
• the presence of undigested food residues in the stool;
• pain and spasms are not felt;
• slight increase in temperature;
• absence of false urge to defecate;
• imbalance of electrolytes.

Osmotic diarrhea occurs against the background of active substances in the intestines that retain fluid due to a lack of enzymes, as well as in the presence of an inflammatory process. This condition is also facilitated by taking laxatives, which contain poorly adsorbed negatively charged ions.

Osmotic diarrhea symptoms

Typical symptoms of osmotic diarrhea include:

• slight increase in stool volume;
• foamy stool with remnants of undigested food;
• increased body temperature;
• slight dehydration;
• moderate painful spasms.

Osmotic diarrhea treatment

Treatment of osmotic diarrhea begins with prescribing the right diet. A number of foods do not need to be consumed. These include:

• stimulating intestinal motility - fresh vegetables, black bread;
• stimulating reflex peristalsis - coffee, spicy and spicy dishes;
• containing osmotically active components - chips, nuts, salty soups;
• disaccharides - sweet carbonated drinks, milk;
• fatty foods containing many enzymes - honey

Authorized products include:

• white bread crackers;
• soups with light vegetable, fish or meat broth;
• low-fat cottage cheese;
• rice porridge with water;
• baked apples;

Even a completely healthy person can be lactose intolerant. This is more common in regions where there are no long-standing dairy traditions. Such people can only eat light cottage cheese in small quantities.

Registration solutions are used in drug therapy to treat osmotic diarrhea. These are Regidron, Codeine phosphate, Imodium or Loperamide. Antibacterial therapy is prescribed. They use Biseptol, Bactrim. If an infection is detected, the doctor will prescribe a course of antibiotics. Eubiotics are widely used. These are drugs with broad antifungal and antibacterial action. They are usually used for five to seven days, but in some cases longer treatment is possible. After an infection, diarrhea may persist for some time. Reasons that may contribute to this include:

• lactose deficiency;
• exacerbation of early diseases - Crohn's disease, ulcerative colitis;

Osmotic diarrhea is a pathological intestinal disorder, which is accompanied by an increased number of bowel movements and changes in the structure of stool. The osmotic type differs from other varieties in that it is characterized by permanent disruption of the functioning of the gastrointestinal tract.

Types of diarrhea

In medical practice, there are four types of diarrheal disorders:

1. Secretory diarrhea.
2. Osmotic.
3. Mixed.
4. Invasive.

Having an understanding of the origin and pathogenesis of intestinal disorders, it is possible to identify the cause of the osmotic type of diarrhea and eliminate it, rather than treating symptoms without a positive result.

An invasive type of diarrhea is accompanied by active damage to the colon by pathogenic microorganisms. In this case, the signs of the disease disappear after taking antibacterial drugs.

The appearance is due to toxic damage to the body by bacterial waste products. In this case, treatment consists of replenishing the balance of electrolytes and influencing the pathogen.

Let's consider the definition of osmotic diarrhea. It is characterized as a continuous disorder in the gastrointestinal tract, accompanied by disruption of digestive processes and colon motility. The intestines become unable to fully perform their functions, which leads to the accumulation of water and sodium in it, diluting the stool and irritating the mucous membrane. Quite often, symptoms of osmotic diarrhea occur against the background of various pathological processes in the digestive system, such as diseases of the intestines, gall bladder, and pancreas in a chronic form.

Causes

There are quite a few factors that can affect the occurrence of osmotic diarrhea. In most cases, it occurs as a result of an infectious lesion of the body, for example, with enterovirus or rotavirus. However, diarrhea can also appear against the background of other prerequisites:

1. Chronic pancreatitis quite often leads to stool disorders. Moreover, in this case, prolonged constipation is replaced by no less prolonged diarrhea. The osmotic type of diarrhea is a concomitant symptom of pancreatitis and occurs as a result of a lack of enzymes and bile acids. The food eaten is poorly digested and quickly enters the intestines in the form of coarse fibers. Deficiency of pancreatic enzymes is also observed in cancer of the pancreas and gall bladder, as well as in obstructive jaundice.

2. Another cause of osmotic diarrhea is hereditary fermentopathy. Children often suffer from intolerance to foods such as lactose and gluten. Such pathologies are accompanied by colic, restlessness, pain in the abdomen and upset stool. Diagnosis is usually not difficult. Disaccharide deficiency occurs as a consequence of impaired production of lactose and sucrose. Without disaccharides, these substances are not absorbed by the small intestine. Carbohydrates that have not undergone the breakdown process are excreted through the large intestine and cause osmotic diarrhea.

3. Another type of fermentopathy is hypolactasia. In this case, diarrhea occurs after consuming fermented milk and dairy products. After a couple of hours, the patient begins to feel flatulence, rumbling, and pain. Feces become liquid, voluminous and foamy. This condition is dangerous due to the possibility of developing water-electrolyte imbalance. The only way to treat hypolactasia is to follow a special diet.

4. Another cause of diarrhea is surgical operations performed on one of the parts of the intestine, for example, anastomoses or resections. After such an intervention, there is a high risk of disruption of osmosis. This is explained by the shortening of the period of contact of digested products with the intestinal wall that has undergone resection. Nutrients do not have enough time to be fully absorbed. Against this background, polyfecal syndrome develops, when food remains that have not had time to be digested are excreted with the feces.

5. Long-term use of laxatives in excess of prescribed dosages can also cause the development of pathology.

Symptoms

The following symptoms are characteristic of osmotic diarrhea:

1. Increased stool output and increased visits to the toilet.
2. Pain in the area of ​​the large intestine.
3. Discomfort that occurs due to bloating.
4. Liquefaction of stool, its watery contents. In pathology caused by bacterial infection, the secreted masses acquire a greenish color.
5. Body temperature rises as the body responds to an irritant.
6. Dehydration due to prolonged diarrhea, accompanied by thirst, dry skin and mucous membranes.

If the symptoms of osmotic diarrhea do not go away for quite a long time, and the patient feels a worsening of the condition, you should consult a doctor.

Diagnostics

At the initial stage of examining the patient, the doctor conducts a physical examination. In addition, a detailed medical history is collected to clarify the contents of stool and a proctological examination is performed. If there are blood impurities in the stool, as well as if an anal fissure, fistulous tract or paraproctitis is detected, we can talk about Crohn's disease.

Microscopic examination reveals the presence of mast cells, protozoa and worm eggs in the contents of feces. When performing sigmoidoscopy, it is possible to diagnose dysentery, ulcerative or pseudomembranous colitis. Laboratory diagnostic methods are based on macro- and microscopic examination of a stool sample.

If the diagnosis shows the absence of an inflammatory process, we can conclude that diarrhea is the result of impaired absorption. Acute diarrhea can be caused by enteroviruses, so a blood test is performed to check for the presence of these microorganisms.

When diagnosing osmotic diarrhea, it is necessary to find out whether there is a connection between this symptom and an infectious or inflammatory disease. For this purpose, various stool studies are carried out, including bacteriological, microscopic and sigmoidoscopy. To exclude inflammation as a factor in the occurrence of diarrhea, the pathogenetic mechanism is determined. In some cases, for correct diagnosis, a diet is prescribed for some time.

Treatment of osmotic diarrhea

Treatment of the disease involves two directions: elimination of symptoms and treatment of the cause of the pathology. At the initial stage, the patient is rehydrated. If the patient’s condition is not characterized as severe, the drinking regime can be adjusted, thereby compensating for the lost volume. Rehydration involves drinking small amounts of water frequently every 10-15 minutes. In more complex cases, the patient should be monitored in an inpatient setting. There the patient will be given IV drips with glucose, saline and Ringer's solution.

Antibiotics

After eliminating dehydration, antibacterial drugs are prescribed. If an intestinal infection is detected, Bactrim, Biseptol and other drugs from the sulfonamide group are prescribed. Another popular drug for the treatment of intestinal infectious diseases is Nifuroxazide. This drug is an antimicrobial agent that has an antiseptic effect. The disadvantage of antibacterial therapy is the suppression of not only pathogenic microflora, but also healthy bacteria in the intestine.

Probiotics

During antibacterial therapy or after its completion, probiotics are also prescribed. These drugs restore the balance of intestinal microflora and promote its normal functioning. Such drugs include Linex, Acipol, Biogaya, Enterozermina, Lactofiltrum, etc. These drugs will help avoid diarrhea caused by taking antibiotics, without causing any harm to the body.

Medicines to slow down peristalsis

Subsequently, symptomatic treatment begins, consisting of taking drugs that can slow down intestinal motility. The following drugs are most often prescribed for osmotic diarrhea to stop it:

1. "Loperamide". Peristalsis slows down as a result of the drug binding to receptors in the mucous membrane of the colon and inhibiting the production of acetylcholine. The drug is produced in the form of capsules for oral administration. The most commonly prescribed regimen is to take one capsule after each pathogenic bowel movement. A very popular analogue of Loperamide is Imodium.

2. “Codeine phosphate.” Prescribed for the treatment of various syndromes, including cough, pain and diarrhea. The drug is taken in short courses and in small dosages. The treatment regimen for Codeine Phosphate should be determined by the attending physician.

Medical nutrition

None of the proposed methods of therapy will give a positive result in the presence of signs of osmotic diarrhea, unless the patient begins to follow a special therapeutic diet. It is a gentle, dietary diet that will help restore normal functioning of the intestines and stomach.

When preparing the right diet, the following recommendations should be taken into account:

• Soups must be vegetarian.
• Cereals must be boiled in water.
• Instead of bread, you should eat crackers.
• Tea should be drunk without adding sugar.
• You can eat baked apples.
• Meat is only allowed in lean varieties and in strictly limited quantities.

It is necessary to follow the diet for several weeks, even after intestinal motility is completely restored.

Complications and consequences

If timely measures are not taken to treat osmotic diarrhea, the following complications may develop:

1. Mild, moderate and severe dehydration. This condition is calculated based on the patient's percentage of weight loss. At the first stage of dehydration, the loss of body weight is about three percent, at the second it reaches 4-6 percent, and at the third more than seven percent. In addition, a significant loss of fluid and electrolytes can provoke the development of kidney failure and other pathologies of these organs.
2. Septic or hypovolemic shock.
3. Metabolic acidosis.
4. Hypokalemia.
5. Continuous diarrhea.
6. Convulsive syndrome, accompanied by loss of consciousness and falling into a coma.
7. Intestinal bleeding.

To avoid the unpleasant consequences of osmotic diarrhea, it is necessary to promptly contact a specialist and carry out both symptomatic and treatment aimed at eliminating the cause of the pathology.