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8/17/2019 Diareea Cronica 2016
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DIAREEACRONICA
CONSTIPATIA
CRONICA
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Medicaţie prokinetică
• Metoclopramid cp 10 mg cp!"i#
• Motili$m %Domperidona& cp 10 mg cp!"i#
• I'$tin ! De'ridat %Trime'$tina& cp 100 mg(
00 mg) 00mg!"i#
• Pro*taglandine + Mi*opro*tol#
Agoni*ti *erotonina,
• -elmac %Tega*erod& cp . mg / cp!"i#
• Re*olor %Pr$caloprid& cp 1mg( / mg!"i#
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aati2e o*motice ! de 2ol$m
• act$lo"ă *irop 13 + 43 ml %apro 10 + 0 g
• aati2e *aline, Mg# S$l5at Mg 13 + 0 g!"i#
Citrat Mg 130 + 00 ml!"i# 6idroid Mg 0 + .0
ml!"i#
• Sor'itol 13 + 0 ml 1 + /!"i#
•
7ortran* %Macrogol 8 NaSo4 8 NaCl etc& 1 plic !1 l apa / 9 4 plic$ri#
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aati2e o*motice ! de 2ol$m
• 7orla %Macrogol 9 polietilenglicol& plic 10 g
+ 4 plic$ri!"i#
• P$rgola cp ! Planta'en plic %I*pag:$la +
*eminţe de p*;lla&( 1 cp!"i *a$ 1 +
plic$ri!"i#
• P*;lli$m /(3 + 0 g!"i#
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aati2e emoliente ! cli*me
• S$po"itoare de glicerina %/ + g& 1!"i#
•
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aati2e iritati2e
• D$lcola %=i*acod;l& cp 3 mg 3 9/0 mg!"i#
•
Tia*en %Senna( Reg$la& cp 10 mg 1 + cp!"i#
• D$lcopic %Pico*$l5at de natri$& *ol$ţie 10 + /0
picat$ri#
• Colc:icina 0(3 + 1 mg !"i#
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Noi laati2e
• inaclotid />0 mcg!"i# Agoni*t g$anilat
cicla"a + cre*te *ecretia de clor *i 'icar'onat
in l$men#
•$'ipro*tone /4 mcg!"i# Acti2ator al
canalelor de clor( cre*te *ecretia de lic:id
intral$minal#
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Medicatie anti*pa*tică !
anti'alonare• Papa2erină cp 100 mg cp!"i#• No9*pa %Drota2erina& cp 40 mg + . cp !"i#
• Colo*pa*min( D$*patalin %Me'e2erina& cp
100 mg + 4 cp!"i#• Spa*momen %Otiloni$m 'romid& cp 40 mg /
+ cp!"i#
• Meteo*pa*m;l %al2erina 8 dimeticona& 1 cp !"i#
• Dimeticona ! *imeticon 19 / cp /9 !"i
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Medicaţie antidiareică
• Normi %Ri5aimina& cp /00 mg + . cp!"i#
• Erce5$r;l %Ni5$roa"id& cp /00 mg 4 cp!"i#
• 7$ra"olidon cp 100 mg 4 cp!"i#
• Sapro*an %Clorc:inaldol& cp 100 mg + .cp!"i#
• Cipro5loacina cp 300 mg / cp!"i#
• Metronida"ol cp /30 mg + . cp!"i#
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Medicaţie antidiareică /•
operamid %Imodi$m& cp / mg / mg /9 4!"i#Opioid minor#
• Dio*mectita %Smecta& plic g( 1 plic / + 4 !"i#
Argila c$ e5ect ad*or'ant#• Car'$ne medicinal + / + 4 g!"i#
• Racecadotril %6idra*ec& + 100 mg !"i#
=locant al canalelor de clor#• Pro'iotice, E$'iotic cp cp !"i# -ir5o* 1 plic ! "i#
Erce5lora / cp !"i# ine / cp ! "i# Enterol
%Sacc:arom;ce* 'o$lardii& cp* /30 mg 4 cp*!"i#•
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Date generale• Sca$n normal, !"i 9 !*apt) 1009/00 g!"i#
Dietă 'ogată ?n 5i're *ca$n normal @ 400 ml !
g ! "i#
•Inte*tin *$'tire > + colon 1 + *ca$n 0(/ #
• Ileon terminal rol de re"er2or#
• Inte*tin *$'ţire + MMC comple motor
migrator 4 min$te ! .09>0 min$te#• Po*tprandial 9 contracţii nereg$late( mai
lente( amplit$dine mică#
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Date generale
• Colon a*cendent *i tran*2er* rol re"er2or +
tran"it 13 ore ! colon de*cendent rol
tran*port + ore#
• Colon + contracţii 5a"ice c$ rol de ame*tecare
3 ! "i) contracţii tonice#
• Po*tprandial 9 creterea contracţiilor 5a"ice *i
tonice pentr$ / ore#
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C$loarea *ca$n$l$i
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Con*tipatie
• De5initie, B *ca$ne ! *aptamana#
•Cea mai 5rec2enta ac$"a dige*ti2a 1/ + 1>pop$laţie generală#
• 7!= /!1#
• Ca$"e, >0 5ara ca$"a decela'ila( o'*tr$ctiemecanica( 'oli ne$rologice ! m$*c$lare( 'oli
endocrine ! meta'olice( medicatii#
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Criterii Roma con*tipatie cronica
• /!. criterii#
• E5ort de5ecatie 1 ! 4 oca"ii#
•
Sca$ne d$re 1 ! 4 oca"ii#• Sen"atie de e2ac$are incompleta 1 ! 4 oca"ii#
• Mane2re man$ale pentr$ 5acilitarea *ca$nelor
1 ! 4 oca"ii#• Sen"atie de o'*tr$ctie anorectala 1 ! 4
oca"ii#
•
Mai p$tin de *ca$ne pe *aptamana#
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O'*tr$ctie mecanica colon
• Cancer colorectal#
• =oala in5lamatorie inte*tinala#
•
Strict$ri colonice ! anale#• Corpi *traini intrarectali#
• 6emoroi"i( 5i*$ri anale#
•
Endometrio"a#
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=oli endocrine ! meta'olice
• Dia'et "a:arat#
• 6ipotiroidie#
• 7eocromocitom#
• In*$5icienta :ipo5i"ara#
• Fl$cagonom#
• Por5irie#
• 6ipopota*emie# 6ipercalcemie
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Medicatii ! di2er*e
• Opioide# Anticolinergice# Antidepre*i2e#
• Ne$roleptice# Antiparkin*oniene#
•
Anticon2$l*i2e# Anti:iperten*i2e#• S$plimente 7e ! Ca# Antiacide c$ Al#
• S$l5at de =a#
Di2er*e
• Intoicatii metale grele %P'( A*( 6g
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Antecedente ! i*toric
• Antecedente 5amiliale#
• D$rata ! aparitie#
•
=oli ! medicatii concomitente ! recente#• Simptome ! *emne concomitente,
genito$rinare( c$tanate( CG( etc#
•
Sca$n H
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Atentie
• Con*tipatie 8
•
Scadere in gre$tate#• Sca$n c$ *ange#
• Anemie#
•
Gar*ta @ 30 ani#
• Colono*copie
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Eamen 5i"ic
• E2identiere ca$"e dige*ti2e ! nondige*ti2e#
• Eaminare a'domen( torace( ganglioni etc#
• TR( ton$* *5incter( a*pect *ca$n#
• Prolap* m$coa*a rectala( 5i*$ri#
•
Eamen ginecologic ! $rologic#
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Eamene de la'orator
• Sca$n#
• 6F( GS6( CRP#
•
Te*te tiroidiene#• Na( J( Ca#
• Por5irine#
•Te*te :epatice *i pancreatice#
• Te*te a$toim$nitate#
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Eplorari
• Sigmoido*copie( colono*copie 8 'iop*ii#• Irigogra5ie#
• Timp de tran"it colonic + admini*trare orala(
e2ac$are @ K0 la 3 "ile( 5ara laati2e• Ecogra5ie a'dominala#
• Manometrie anorectala#
• De5ecogra5ie# Te*t e2ac$are 'alona*#
• CT( RM#
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Gariante
• Anemie( *ca$n c$ *ange( pierdere ponderala +neopla*m ( 'oala in5lamatorie inte*tinala#
• 6epatomegalie( adenopatii( ma*e palpa'ile
a'dominale + neopla*m#• Modi5icari piele( 5anere( intoleranta la 5rig(
ca*tig ponderal + :ipotiroidie#
• =alonare( e2ac$are incompleta( di*pep*ie(*imptome $rinare + *indrom de inte*tin
irita'il#
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Con*tipatie 1
• 7emeie 33 ani#
• Con*tipatie @ 4 l$ni( accent$ata progre*i2#
• Ca*tig ponderal . kg# Piele $*cata( a*pra#
• Edeme gam'iere# 7atiga'ilitate#
• AG 33!min#
• Goce rag$*ita# entoare in 2or'ire#
• In2e*tigatii( diagno*tic( tratamentH
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Con*tipatie /
• =ar'at 44 ani# A*tenie( 5atiga'ilitate#
• Con*tipatie de aproimati2 / l$ni#
•
D$reri a'dominale intermitentepredominant in 5o*a iliaca dreapta#
• 6g' 10(/ g!dl#
•
Endo*copie dige*ti2a *$perioara +normala#
• In2e*tigatii( diagno*tic( tratamentH
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Con*tipatie
• 7emeie 3. ani#
• Anietate# Con*tipatie de 3 l$ni#
•
A5e'rila( 5ara pierdere ponderala#• T$*e$ rectal normal#
• Colono*copie normala#
•
Te*te de la'orator + normale#• In2e*tigatii( diagno*tic( tratamentH
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Con*tipatie cronica
Lamada* 6and'ook o5 Fa*troenterolog; /01
Tran"it colonicManometrie ano rectala
De5ecogra5ie
Te*t ep$l"ie 'alona*
Normal
Te*t terape$tic
E2al$are
p*i:ologica
Tran"it
lent
Prokinetice(
laati2e(
*ecretoare#C:ir$rgie
Manometrie
anormalaA5ectare
*en*# rect
=io5eed'ack
Antrenamentpel2in
Modi5icari
*tr$ct$rale
C:ir$rgie
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Complicatii
• 6emoroi"i#
• Prolap* m$coa*a#
•
Sangerari#• 7i*$ri anale#
• 7a2ori"area aparitiei :erniilor#
•
Di2ertic$li( di2ertic$lite#• O'*tr$ctie( per5oratii#
• Melano*i* coli d$pa laati2e#
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Tratament
• Eerciti$ 5i"ic# Antrenament pel2in#
• Aport 5i're 13 + 0 g ! "i#
•
Aport adec2at lic:ide#• Relaare# =io5eed'ack#
• S$po"itoare glicerina#
•Cre*tere 2ol$m *ca$n %p*;lli$m(metilcel$lo"a& macrogol + 7orla#
• $'ri5iante %$lei para5ina
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Tratament
• aati2e o*motice %lact$lo"a 3 + 10 g 1 +
! "i Sol$tii macrogol 9 7ortran* #
• $'ipro*tone#
•
inaclotid
• aati2e emoliente + doc$*ate#
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Tratament /
• aati2e iritante %*enna
•
Prokinetice, Tega*erod ( Trime'$tine 100mg !"i( pro*taglandine( colc:icina#
•
Cli*me#
• Tratament c:ir$rgical#
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Diaree
• Diaree @ /00 + //3 ml!g *ca$n!"i) con*i*tenta*ca"$ta( n$mar mare *ca$ne# Cantitate mare
de *ca$n, *ecretie marita de anioni ! a'*or'tie
*ca"$ta de electroliti#• Mecani*me, o*motic( *ecretor( le"ional#
• Diaree c$ cantitate normala de *ca$n#
• Diaree cronică / + pop$laţie generală#• 7!= /!1#
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Mecani*m o*motic
•aati2e *aline, *ar$ri Mg( etc#
• Car'o:idrati nere*or'a'ili, lact$lo"a(
*or'itol( polietilenglicol#
•Orli*tat + in:i'itor lipa"a#
• Acar'o"a + mala'*or'tie gl$cide#
• De5icienta di"a:arida"e %lacta"a etc
• A5ectarea inte*tin$l$i *$'tire %2irala(Q:ipple( celiaca( ma*tocito"a( amiloido"a(
i*c:emie( lim5om
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Mecani*m o*motic /
• Scaderea *$pra5etei inte*tinale#
• In*$5icienţă pancreatică#
•
A5ectarea cicl$l$i aci"ilor 'iliari %'acterii(Cro:n( re"ecţii ileale
• Mala'*or'tie ! *teatoree#
•
=oli in5lamatorii inte*tinale#
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Mecani*m *ecretori$ 1
• aati2e, 'i*acodil( $lei ricin#
• Medicatii, colc:icina( teo5ilina( di$retice(
ne$roleptice#
• Toine 'acteriene, Gi'rio( E# coli(
Clo*tridi$m#
• Con*$m cronic de alcool#
• Ca$"e :ormonale, GIP %QaDr:kAcl&(
*erotonina( calcitonina %MEN&( ga*trina
%alergatori&( gl$cagon( PF#
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Mecani*m *ecretori$ /
• Ne$ropatie 2egetati2a %D-
• A5ectarea cicl$l$i aci"ilor 'iliari,
po*tcoleci*tectomie( Cro:n( proli5erare'acteriana#
• In5lamatie m$coa*a, colita lim5ocitara(
colagenica#• T$l'$rari tran*port, adenom 2ilo*(
clor:idroree congenitala#
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Mecani*m le"ional 1•
=oli in5lamatorii inte*tinale, 'oala Cro:n(colita $lceroa*a 'oli in5lamatorii
inte*tinale#
• I*c:emie, atero*clero"a( 2a*c$lite#
•
Di2er*e, 'oala =e:cet( iradiere( proctite(alergii proteine lapte( *oia( ga*troenterită
eo"ino5ilică#
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Mecani*m le"ional /
In5ectii!para"ito"e,
• Girale %rota2ir$*$ri( Noralk
• =acteriene %E# coli( S:igella( Salmonella(
Ler*inia( Clo*tridi$m( T=C
• Para"itare %Fiardia( Cr;pto*poridi$m (
Ciclo*pora( Entamoe'a
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Diaree c$ cantitate normala de *ca$n
• Sindrom de inte*tin irita'il#
• 6ipertiroidi*m#
• Proctite in5ectioa*e( $lcerati2e#
• Incontinenta 5ecala, 5i*$ri anale !
perianale( po*toperatorii( :emoroi"i(
ne$ropatii( *clerodermie#• 7ecaloame ! t$mori 9 5al*a diaree#
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Diareea cronica
• Diaree ac$ta B / *aptamani#
• Diaree per*i*tenta / + 4 *aptamani#
• Diaree cronica @ 4 *aptamani# De o'icei
nein5ecţioa*ă
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E2al$are
• A6C, 'oala celiaca( 'oala in5lamatorie
inte*tinală( pancreatită#
• APP, D-( *clerodermie( 'oli endocrine(
iradiere( atero*clero"a( etili*m( 'oli p*i:ice(
in5ectii( 6IG# Inter2entii c:ir$rgicale#
•
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E2al$are
7actori de ri*c• Giata per*onala( o'icei$ri alimentare#
• Pro5e*ie ! calatorii 9 con*$m alimente ! apa
potential contaminate ( contact toine(germeni( radiatii#
• Tratamente cronice ! recente#
• 7enomene a*ociate, 5e'ra( d$reri a'd( 2ariatii
TA( AG( *angerari( incontinenta( er$ptii(
paloare( edeme#
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Eamen 5i"ic 1
•
Stare generala( TA( AG( temp( pli$ c$tanat#•
• Ma*e a'dominale palpa'ile#
• 6epatomegalie 8! 9 *plenomegalie#
• TR, :emoroi"i( 5i*$ri( colectii perianale( ton$**5incter( a*pect *ca$n#
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Eamen 5i"ic /
• Teg$mente ( m$coa*e, icter( paloare(pete*ii ! ec:imo"e( $lceratii( nod$li( c:eilita(
glo*ita#
• Edeme( *cadere ponderala( :ipocrati*m
digital#
• A5ectare ne$rologica %:TA( p$pile&(
cardiaca( p$lmonara( o5talmologica
%iridociclita( con$ncti2ita&( a5ectare
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Eamene de la'orator•
6F( GS6( CRP#• Te*te :epatice %TFO( TFP( 'ilir$'ina( FFT( 7#
Alc( al'$mine ! proteine( T
•Electroliti *erici *i 5ecali#
• 7e( =1/( 5olati( cole*terol( T( T4#
• ASCA( ANCA( ac antiendomi*i$m( anti tTF#
E d l ' t !
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Eamene de la'orator !
eplorari• Te*t Sc:illing 8 2ariante#
• Te*te re*piratorii gl$co"a ! lacto"a marcate#
• Do"are *ecreţii pancreatice#
• Sigmoido ! colono*copie 8 ! 9 'iop*ii#
• =iop*ii inte*tinale# C$lt$ri inte*tinale#
•
CT ! RM a'dominal#• ERCP#
• Angiogra5ie a'dominală#
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E2al$are *ca$n
• Steatoree 8!9 %@ . 9 g gra*imi ! *ca$n /4 oreCalprotectină 5ecală# 6emoragii oc$lte#
• Coproc$lt$ri# Eamen copropara"itologic#
• p6 5ecal acid + mala'*or'tie gl$cide#
• O*molaritate *ca$n />0 mo*m %o*molaritate
*er& 9 / U %Na 8 J 5ecale Di5erenţă @ 30 + 1/3
mo*m diaree o*motică)
B 30 diaree de alte ca$"e 9 *ecretorie#
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E2al$are *ca$n
• Tip diaree, 2ol$m mare ! normalH• Gol$m normal + inte*tin irita'il#
• Gol$m B 1 !/4 ore + diaree o*motica *a$
le"ionala#• Gol$m @ 1 !/4 ore + diaree *ecretorie#
• Ra*p$n* la oprire alimentatie, *top diaree
o*motica) contin$a diareea *ecretorie#
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Diaree cronica
•
In5ectioa*a ! nein5ectioa*aH• Ca$"e in5lamatorii ! le"ionaleH Sca$n c$
*ange( anemie + colono*copie( 'iop*ii( c$lt$ri#
•
Steatoree ! alte elemente de mala'*or'tie +te*te pancreatice *i inte*tinale %'iop*ie( c$lt$ri(
imagi*tica( endo*copie
•
D$reri in5l$entate de *ca$n( 2ol$m normal +inte*tin irita'il#
• Medicatie ! laati2e ! t$l'$rari alimentatie#
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Diaree ac$tă
Nein5ecţioa*ă + tratament adec2at#
In5ecţioa*ă,
• Reec:ili'rare :idroeletrolitică
• Agenţi antidiareici
•
Coproc$lt$ri( tratament anti'iotic#
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Diaree cronică 1
• 7emeie 4 ani#
• Diaree *ang:inolenta @ . *aptamani#
• 6g' >(3 g!dl# CRP 1/mg!l %N 0 93 GS6
3 mm !:#
• Calprotectina 5ecala cre*c$ta#
• Ce te*t recomandatiH
• Ce diagno*tic *$*pectatiH Ce tratamentH
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Diaree cronica /
• =ar'at 3 ani( con*$mator cronic alcool#
• Scadere ponderala 10 kg ! l$ni#
•
Diaree @ / l$ni# Sca$ne 5rec2ente(cantitate mare#
• Ec:imo"e la tra$mati*me $*oare#
•
D$reri a'dominale de eta *$perior#• D$reri o*oa*e( :ipotro5ie m$*c$lara#
• Te*te( diagno*tic( tratamentH
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Diaree cronica
• 7emeie 4 ani#
• Diaree l$ni#
• Scadere ponderala#
• Colono*copie normala#
• Anticorpi anti tTF tip IgA inten* po"iti2i#
•
Ce in2e*tigatii recomandatiH• Ce tratament recomandati c$ ce
*$*pici$ne de diagno*ticH
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Diaree cronica 4
• 7emeie . ani#
• Diaree intermitenta @ 1 an#
•
7ara *cadere ponderala#• D$reri pre*ca$n( ameliorate d$pă(
*en"aţie de5ecaţie incompletă#
•
Colono*copie 8 'iop*ii normale#• In2e*tigatii( diagno*tic( tratamentH
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Te*te negati2e ! diareea contin$a
• Rel$area anamne"ei *i a eamen$l$i 5i"ic#
• Medicatii c$ e5ect laati2, Colc:icina(
e5l$nomid( Orli*tat#
• Etinderea in2e*tigatiilor#
• A'$" de laati2e nerec$no*c$t# A$tocli*me#
• 7al*a diaree# Pro'leme p*i:ice#
• H
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Complicatii
• De*:idratare#
• Mala'*or'tie#
• Spitali"ari#
• Tratamente ! diete co*ti*itoare#
• Inter2entii c:ir$rgicale#
•
Pierderea capacitatii de m$nca ! "ile deconcedi$ medical#
• Co*t$ri per*onale ! *ociale#
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Tratament
• Tratament etiologic#
• Re*trictii alimentare, gl$ten( lacto"a#
• Inloc$irea medicatiei care pro2oaca
diareea#
• Tratament anti'iotic local ! general 9
anti'iograma#
• Tratament pro'iotice + =iotic*( Enterol(
-ir5o* etc#
• Anti*pa*tice#
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CONC