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DIAREEA CRONICA CONSTIPATIA CRONICA

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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. - PowerPoint PPT Presentation
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DIAREEA CRONICA CONSTIPATIA CRONICA
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Page 1: DIAREEA CRONICA  CONSTIPATIA CRONICA

DIAREEA CRONICA

CONSTIPATIA CRONICA

Page 2: 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.

• Diaree cu cantitate normala de scaun.

Page 3: DIAREEA CRONICA  CONSTIPATIA CRONICA

MECANISM OSMOTIC

• Laxative saline, lactuloza, orlistat, etc.

• Deficienta dizaharidaze (lactaza etc).

• Afectarea intestinului subtire (virala, Whipple, celiaca, mastocitoza, amiloidoza, ischemie, limfom).

Page 4: DIAREEA CRONICA  CONSTIPATIA CRONICA

MECANISM OSMOTIC 2

• Scaderea suprafetei intestinale.

• Insuficienta pancreatica.

• Malabsorbtie saruri biliare (bacterii, Crohn)

Page 5: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 6: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 7: DIAREEA CRONICA  CONSTIPATIA CRONICA

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).

Page 8: DIAREEA CRONICA  CONSTIPATIA CRONICA

MECANISM LEZIONAL 2

• Infectii cronice: Nematode, Entamoeba, Clostridium, Shigella, TBC.

• Ischemie: ateroscleroza, vasculite.

• Diverse: Behcet, iradiere, proctite, alergii proteine lapte, soia, gastroent. eoz.

Page 9: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 10: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 11: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 12: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 13: DIAREEA CRONICA  CONSTIPATIA CRONICA

EXAMEN FIZIC 2

• Palpare abdomen: hepatosplenomegalie, mase palpabile.

• TR: hemoroizi, fisuri, tonus sfincter, aspect scaun etc.

Page 14: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 15: DIAREEA CRONICA  CONSTIPATIA CRONICA

EVALUARE II

• Steatoree. Numar leucocite.

• Coproculturi. Examen coproparazitologic.

• HLG, VSH, CRP.

• Electroliti (Na, K, Ca etc) serici si fecali. pH fecal.

Page 16: DIAREEA CRONICA  CONSTIPATIA CRONICA

EVALUARE III

• Teste hepatice (TGO, TGP, bilirubina, GGT, F. Alc., albumine / proteine, TQ).

• Fe, B12, folati, colesterol, T3, T4.

• Sigmoido / colonoscopie + / - biopsii.

Page 17: DIAREEA CRONICA  CONSTIPATIA CRONICA

DIAREE CU VOLUM NORMAL

• Evaluare anorectala.

• Volum scaun.

• Sindrom intestin iritabil.

Page 18: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 19: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 20: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 21: DIAREEA CRONICA  CONSTIPATIA CRONICA

TESTE NEGATIVE / DIAREEA CONTINUA!

• Abuz de laxative.

• Autoclisme.

• Reluarea anamnezei si a examenului fizic.

• Extinderea investigatiilor.

• Falsa diaree. Probleme psihice.

• ?

Page 22: DIAREEA CRONICA  CONSTIPATIA CRONICA

COMPLICATII

• Deshidratare.

• Malabsorbtie.

• Spitalizari.

• Tratamente / diete costisitoare.

• Interventii chirurgicale.

• Pierderea capacitatii de munca / zile de concediu medical.

• Costuri personale / sociale..

Page 23: DIAREEA CRONICA  CONSTIPATIA CRONICA

TRATAMENT• Tratament etiologic.

• Restrictii alimentare.

• Tratament antibiotic local (Rifamixina 200 mg x 3- 6/zi) / general - antibiograma.

• Tratament probiotice – Biotics, Enterol.

Page 24: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 25: DIAREEA CRONICA  CONSTIPATIA CRONICA

CONSTIPATIE CRONICA

• Definitie: < 3 scaune / saptamana.

• Cea mai frecventa acuza digestiva.

• Cauze: obstructie mecanica, boli neurologice / musculare, boli endocrine / metabolice, medicatii, idiopatice.

Page 26: DIAREEA CRONICA  CONSTIPATIA CRONICA

OBSTRUCTIE MECANICA COLON

• Cancer colorectal.

• Boala inflamatorie intestinala.

• Stricturi colonice / anale.

• Corpi straini intrarectali.

• Hemoroizi, fisuri anale.

• Endometrioza.

Page 27: DIAREEA CRONICA  CONSTIPATIA CRONICA

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.

Page 28: DIAREEA CRONICA  CONSTIPATIA CRONICA

BOLI ENDOCRINE / METABOLICE

• Diabet zaharat. Hipotiroidie.

• Feocromocitom. Insuf. hipofizara.

• Glucagonom.

• Porfirie.

• Hipopotasemie. Hipercalcemie

Page 29: DIAREEA CRONICA  CONSTIPATIA CRONICA

MEDICATII

• Opioide. Anticolinergice. Antidepresive.

• Neuroleptice. Antiparkinsoniene.

• Anticonvulsive. Antihipertensive.

• Suplimente Fe / Ca. Antiacide cu Al.

• Sulfat de Ba.

• Intoxicatii metale grele (Pb, As, Hg).

Page 30: DIAREEA CRONICA  CONSTIPATIA CRONICA

IDIOPATICE

• Intestin iritabil.

• Megacolon, dolicocolon.

• Prolaps rectal.

• Dissinergie rectosfincteriana.

Page 31: DIAREEA CRONICA  CONSTIPATIA CRONICA

ANTECEDENTE ISTORIC

• Antecedente familiale.

• Durata / aparitie.

• Boli / medicatii concomitente / recente.

• Simptome / semne concomitente: genitourinare, cutanate, CV, etc.

• Scaun ?

Page 32: DIAREEA CRONICA  CONSTIPATIA CRONICA

EXAMEN FIZIC

• Evidentiere cauze digestive / nondigestive.

• Palpare mase abdominale, hepatice etc.

• TR, tonus sfincter, aspect scaun.

• Prolaps mucoasa rectala, fisuri.

• Examen ginecologic.

Page 33: DIAREEA CRONICA  CONSTIPATIA CRONICA

EXAMENE DE LABORATOR

• Scaun.

• HLG, VSH.

• Teste tiroidiene.

• Ca.

• Porfirine.

• Teste autoimunitate.

• etc

Page 34: DIAREEA CRONICA  CONSTIPATIA CRONICA

EXPLORARI

• Sigmoidoscopie, colonoscopie + biopsii.

• Irigografie.

• Manometrie anorectala.

• Defecografie.

• CT, RM.

Page 35: DIAREEA CRONICA  CONSTIPATIA CRONICA

COMPLICATII

• Hemoroizi.

• Prolaps mucoasa.

• Sangerari.

• Fisuri anale.

• Obstructie, perforatii.

Page 36: DIAREEA CRONICA  CONSTIPATIA CRONICA

TRATAMENT• Exercitiu fizic. Aport fibre 20 – 30 g / zi.

• Aport adecvat lichide.

• Crestere volum scaun (psyllium, metilceluloza) macrogol – Forlax.

• Lubrifiante (ulei parafina).

Page 37: DIAREEA CRONICA  CONSTIPATIA CRONICA

TRATAMENT

• Laxative osmotice (lactuloza 5 – 10 g x 1 – 3 / zi). Solutii PEG - Fortrans .

• Lubiprostone inh. – canale Cl.

• Laxative emoliente – docusate.

Page 38: DIAREEA CRONICA  CONSTIPATIA CRONICA

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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