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DIAREEA CRONICA CONSTIPATIA CRONICA

DIAREEA CRONICA CONSTIPATIA CRONICA. DIAREEA. Scaun normal: 3/zi - 3/sapt; 100-200 g/zi. Diaree > 200 g scaun/zi; consistenta scazuta, numar mare scaune. Cantitate mare de scaun: secretie marita de anioni / absorbtie scazuta de electroliti. Mecanisme: osmotic, secretor, lezional.

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DIAREEA CRONICA CONSTIPATIA CRONICA

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  1. DIAREEA CRONICA CONSTIPATIA CRONICA

  2. DIAREEA • Scaun normal: 3/zi - 3/sapt; 100-200 g/zi. • Diaree > 200 g scaun/zi; consistenta scazuta, numar mare scaune. • Cantitate mare de scaun: secretie marita de anioni / absorbtie scazuta de electroliti. • Mecanisme: osmotic, secretor, lezional. • Diaree cu cantitate normala de scaun.

  3. MECANISM OSMOTIC • Laxative saline, lactuloza, orlistat, etc. • Deficienta dizaharidaze (lactaza etc). • Afectarea intestinului subtire (virala, Whipple, celiaca, mastocitoza, amiloidoza, ischemie, limfom).

  4. MECANISM OSMOTIC 2 • Scaderea suprafetei intestinale. • Insuficienta pancreatica. • Malabsorbtie saruri biliare (bacterii, Crohn)

  5. MECANISM SECRETORIU 1 • Laxative: bisacodil, ulei ricin. • Medicatii: colchicina, teofilina, diuretice, neuroleptice. • Toxine bacteriene: Vibrio, E. coli, Clostr. • Cauze hormonale: VIP (WaDrHkAcl), serotonina, calcitonina (MEN), gastrina (alergatori), glucagon, PG.

  6. MECANISM SECRETORIU 2 • Neuropatie vegetativa (DZ). Etilism. • Ciclu acizi biliari: postcolecistectomie, Crohn, proliferare bact. • Inflamatie mucoasa: colita limfocitara, colagenica. • Tulburari transport: adenom vilos, clorhidroree cong.

  7. MECANISM LEZIONAL 1 • Boli inflamatorii intestinale: BC, CU. Infectii active: • Virale (rotavirusuri, Norwalk). • Parazitare (Giardia, Cryptosporidium , Ciclospora, Entamoeba). • Bacteriene (E. coli, Shigella, Salmonella, Yersinia, Clostridium).

  8. MECANISM LEZIONAL 2 • Infectii cronice: Nematode, Entamoeba, Clostridium, Shigella, TBC. • Ischemie: ateroscleroza, vasculite. • Diverse: Behcet, iradiere, proctite, alergii proteine lapte, soia, gastroent. eoz.

  9. DIAREE CU CANTITATE NORMALA DE SCAUN • Sindrom de intestin iritabil. • Hipertiroidism. • Proctite infectioase, ulcerative. • Incontinenta fecala: fisuri anale / perianale, postoperatorii, hemoroizi, neuropatii, sclerodermie. • Fecaloame / tumori - falsa diaree.

  10. DIAREEA CRONICA • Diaree cronica > 3 – 4 saptamani. • AHC: boala celiaca, boala inflamatorie, pancreatita Factori de risc 1 • Viata personala, obiceiuri alimentare. • Calatorii, consum alimente / apa potential contaminate. • Profesie: contact potential germeni, toxine, radiatii.

  11. ANTECEDENTE / ISTORIC Factori de risc 2: • DZ, sclerodermie, boli endocrine, iradiere, ateroscleroza, etilism, boli psihice. • Interventii chirurgicale. • Tratamente cronice / recente. • Fenomene asociate: febra, dureri abd, variatii TA, AV, sangerari, incontinenta.

  12. EXAMEN FIZIC 1 • Stare generala, TA, AV, temp, pliu cutanat. • Tegumente , mucoase: icter, paloare, petesii / echimoze, ulceratii, noduli, cheilita, glosita. • Edeme, scadere ponderala. • Artrite, afectare neurologica, afectare CV, oftalmologica, pulmonara.

  13. EXAMEN FIZIC 2 • Palpare abdomen: hepatosplenomegalie, mase palpabile. • TR: hemoroizi, fisuri, tonus sfincter, aspect scaun etc.

  14. EVALUARE I • Tip diaree: volum mare / normal? • Volum normal – intestin iritabil. • Volum < 1 L/24 ore – diaree osmotica sau lezionala. • Volum > 1 L/24 ore – diaree secretorie. • Raspuns la oprire alimentatie: stop = osmotica; continua = lezionala.

  15. EVALUARE II • Steatoree. Numar leucocite. • Coproculturi. Examen coproparazitologic. • HLG, VSH, CRP. • Electroliti (Na, K, Ca etc) serici si fecali. pH fecal.

  16. EVALUARE III • Teste hepatice (TGO, TGP, bilirubina, GGT, F. Alc., albumine / proteine, TQ). • Fe, B12, folati, colesterol, T3, T4. • Sigmoido / colonoscopie + / - biopsii.

  17. DIAREE CU VOLUM NORMAL • Evaluare anorectala. • Volum scaun. • Sindrom intestin iritabil.

  18. DIAREE OSMOTICA • Ac anti gliadina / endomisium, anti TTG. • IS – biopsii, culturi, Rx, EDS (dd), capsula endoscopica. • ERCP, CT abd., ecoendoscopie. • Teste secretii exocrine, trat. enzime pancreatice. • Teste respiratorii subst. marcate (C14 trioleina). Test D – xiloza. • Test Schilling diferite variante.

  19. DIAREE PRIN LEZIUNI DE MUCOASA • Test D – xiloza. • IS – biopsii, culturi, Rx, EDS (dd), caps. • Irigografie, inclusiv cu dublu contrast. • Colonoscopie + biopsii. • CT, RM abdominal. • Angiografie.

  20. DIAREE SECRETORIE • Volum scaun cu sau fara alimente. • pH scaun N (acid diaree osmotica) electroliti scaun ( diaree osmotica) • Colonoscopie + biopsie. • Dozari hormonale: gastrina, VIP, calcitonina, serotonina etc. • CT abd. Ecoendoscopie.

  21. TESTE NEGATIVE / DIAREEA CONTINUA! • Abuz de laxative. • Autoclisme. • Reluarea anamnezei si a examenului fizic. • Extinderea investigatiilor. • Falsa diaree. Probleme psihice. • ?

  22. COMPLICATII • Deshidratare. • Malabsorbtie. • Spitalizari. • Tratamente / diete costisitoare. • Interventii chirurgicale. • Pierderea capacitatii de munca / zile de concediu medical. • Costuri personale / sociale..

  23. TRATAMENT • Tratament etiologic. • Restrictii alimentare. • Tratament antibiotic local (Rifamixina 200 mg x 3- 6/zi) / general - antibiograma. • Tratament probiotice – Biotics, Enterol.

  24. TRATAMENT • Tratamente simptomatice: antidiareice opioide (loperamid 2 mg x 2- 3/zi), argile (diosmectita 3 g x 2- 3/zi). • Racecadotril 100 mg x 3 / zi - blocant • Tratamentul complicatiilor.

  25. CONSTIPATIE CRONICA • Definitie: < 3 scaune / saptamana. • Cea mai frecventa acuza digestiva. • Cauze: obstructie mecanica, boli neurologice / musculare, boli endocrine / metabolice, medicatii, idiopatice.

  26. OBSTRUCTIE MECANICA COLON • Cancer colorectal. • Boala inflamatorie intestinala. • Stricturi colonice / anale. • Corpi straini intrarectali. • Hemoroizi, fisuri anale. • Endometrioza.

  27. BOLI NEUROLOGICE / MUSCULARE • Neuropatie periferica si vegetativa. • Sindrom de coada de cal. Leziuni mieloradiculare. Neurofibromatoza. • Sclerodermie, DM/PM. B. Parkinson • Boala Chagas. Boala Hirschprung. • Amiloidoza. Distrofii musculare. • Pseudoobstructie intest. Scleroza mult.

  28. BOLI ENDOCRINE / METABOLICE • Diabet zaharat. Hipotiroidie. • Feocromocitom. Insuf. hipofizara. • Glucagonom. • Porfirie. • Hipopotasemie. Hipercalcemie

  29. MEDICATII • Opioide. Anticolinergice. Antidepresive. • Neuroleptice. Antiparkinsoniene. • Anticonvulsive. Antihipertensive. • Suplimente Fe / Ca. Antiacide cu Al. • Sulfat de Ba. • Intoxicatii metale grele (Pb, As, Hg).

  30. IDIOPATICE • Intestin iritabil. • Megacolon, dolicocolon. • Prolaps rectal. • Dissinergie rectosfincteriana.

  31. ANTECEDENTE ISTORIC • Antecedente familiale. • Durata / aparitie. • Boli / medicatii concomitente / recente. • Simptome / semne concomitente: genitourinare, cutanate, CV, etc. • Scaun ?

  32. EXAMEN FIZIC • Evidentiere cauze digestive / nondigestive. • Palpare mase abdominale, hepatice etc. • TR, tonus sfincter, aspect scaun. • Prolaps mucoasa rectala, fisuri. • Examen ginecologic.

  33. EXAMENE DE LABORATOR • Scaun. • HLG, VSH. • Teste tiroidiene. • Ca. • Porfirine. • Teste autoimunitate. • etc

  34. EXPLORARI • Sigmoidoscopie, colonoscopie + biopsii. • Irigografie. • Manometrie anorectala. • Defecografie. • CT, RM.

  35. COMPLICATII • Hemoroizi. • Prolaps mucoasa. • Sangerari. • Fisuri anale. • Obstructie, perforatii.

  36. TRATAMENT • Exercitiu fizic. Aport fibre 20 – 30 g / zi. • Aport adecvat lichide. • Crestere volum scaun (psyllium, metilceluloza) macrogol – Forlax. • Lubrifiante (ulei parafina).

  37. TRATAMENT • Laxative osmotice (lactuloza 5 – 10 g x 1 – 3 / zi). Solutii PEG - Fortrans . • Lubiprostone inh. – canale Cl. • Laxative emoliente – docusate.

  38. TRATAMENT 2 • Laxative iritante (senna – Regulax, Rixative). • Prokinetice: tegaserod (serotonina) - 2-6 mg x 2 / zi, trimebutine 100 mg x 3 /zi, PG, colchicina. • Clisme. Supozitoare. • Tratament chirurgical.

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