Digenesis of the digestive tract

Digenesis of the digestive tract - functional diseases, manifested by a violation of the tone and peristalsis of the digestive organs, having smooth muscles (esophagus, stomach, bile ducts, intestines).

Dyskinesia of the esophagus is manifested in the form of its atony and paralysis, spastic dyskinesia (esophagospasm), inadequacy of the pharyngeal and esophageal and cardiac sphincters.

Atony and paralysis of the esophagus are caused by a violation of its innervation and are observed in lesions as central (with head injuries, brain hemorrhages, brain tumors, poliomyelitis, etc.) and the peripheral nervous system (defeat of the vagus nerve, neural plexuses of the esophagus), and Also the muscular membrane of the esophagus (systemic scleroderma, myasthenia, etc.).

Symptoms of atony and paralysis of the esophagus are masked in most cases by manifestations of the underlying disease. The atony of the esophagus is manifested by dysphagia, which occurs when eating dry and poorly chewed food, as well as eating while lying down. Atony of the pharyngeal esophageal sphincter, swallowing is difficult and there is a choking due to ingestion of the esophagus into the respiratory tract. The diagnosis is established on the basis of the characteristic clinical symptoms, the data of targeted X-ray study, esophagothicography.

Treatment - anticholinergic and anticholinesterase drugs. With secondary atony of the esophagus, treatment of the underlying disease.

Insufficiency of the cardiac sphincter occurs with axial hernia of the esophageal opening of the diaphragm, damage to the cardiac sphincter due to surgical intervention in systemic scleroderma, as well as as a result of dyskinesia of the esophagus and stomach (functional cardia failure).

Characterized by belching, regurgitation of gastric contents after heavy meals, with the torso tilted and lying down. The diagnosis is made on the basis of complaints of frequent, sometimes painful belching and regurgitation (especially when the torso is tilted) and the data of the radiographic examination, which, in addition to the patient's vertical position, is also in a horizontal position, which allows us to detect the flow of the contrasting barium suspension from the stomach into the esophagus, and It is often possible to establish the presence of a hernia of the esophageal opening of the diaphragm. Ezofagotonokymografiya allows to determine the presence and degree of decrease in the tone of the cardiac sphincter. With the help of esophagusfibroskopii and pH-metry, indirectly confirm the presence of cardiac insufficiency, revealing the transfer of gastric contents into the esophagus (gastroesophageal reflux). Due to the systematic ingress of active gastric juice into the esophagus, reflux-eeophagitis, peptic ulcer and then peptic stricture of the esophagus often develop.

Treatment. Patients should be advised to avoid those positions in which the cardiac sphincter function is inadequate, ie, gastroesophageal reflux occurs. Contraindicated physical exercises, all kinds of work related to the strain of the abdominal press, the torso of the body. Sleep is recommended with a high raised head. If there is a peptic complication, therapy with antacid and astringent agents.

Dyskinesia of the esophagus spastic (esophagospasm). Distinguish primary esophagospasm, which is a consequence of cortical violations of the regulation of esophagus, and secondary (reflex and symptomatic) that occurs with esophagitis, ulcer and cholelithiasis, etc., or in diseases accompanied by general convulsive syndrome (epilepsy, etc.). Prolonged severe esophagospasm leads to a sharp hypertrophy of the muscular wall of the esophagus.

Typical inconstant dysphagia, sometimes of a paradoxical nature: arising from the intake of liquid and absent from the ingestion of dense and mushy food. Often there is a chest pain associated with swallowing, but in some cases resembling a coronary. The diagnosis is confirmed by X-ray examination; When swallowing contrast slurries, various spastic deformities of the esophagus are revealed. The course can be long. Complications are the formation of true diverticula of the esophagus (see), axial hernia of the esophageal aperture of the diaphragm.

Differential diagnosis is carried out with the initial stages of achalasia of the cardia. The main significance is the x-ray study, which establishes the normal patency of the cardia, a gas bubble of the stomach is clearly revealed. Esophagofibroscopy can exclude esophagus cancer and other organic lesions, often with secondary esophagospasm.

Treatment for secondary esophagospasm in the first place should be directed to the treatment of the underlying disease. Recommended regular frequent (4-6 times a day) fractional nutrition, mechanically and thermally sparing diet. In all cases, prescribe antispasmodic, cholinolytic and sedative drugs.

Dyskinesia of the stomach is manifested by acute atony, chronic hypotension and gastroptosis, hypertensive dyskinesia, pneumatosis.

Acute atony of the stomach - the paresis of the muscles of his stitch, which arises as a result of direct damage to the innervating nerves of the nervous formations, and reflexively. The disease is rare, can be observed with myocardial infarction, peritonitis, pneumonia, with thrombosis of the stomach vessels, sometimes - against the background of long-term stenosis of the pylorus, with some severe infectious diseases (typhoid fever, etc.); In surgical practice - with a trauma to the stomach, injury of the spinal cord, in the postoperative period and the patient's withdrawal from anesthesia.

Characterized by a feeling of heaviness, overflow in the epigastric region, the urge to vomit (vomiting with a lot of greenish liquid), hiccups, dull raspirayuschaya pain in the pit of the stomach. Symptomatic rapidly increases, complications occur (violations of the blood supply to the stomach wall, rupture of the stomach). When examined, a significant, rapidly increasing swelling in the epigastric region is determined; When percussion over it, a wide zone of tympanic sound is defined, which extends beyond the median line to the right. Gastric probe is freely introduced into the stomach, while a very large quantity of liquid contents is evacuated and temporary relief comes.

Treatment. Gastric probing is carried out with a one-stage extraction of all the accumulated contents in the stomach, followed by a permanent drainage (using a probe or catheter in the esophagus and stomach through the lower nasal passage) until the stomach tone is restored. At the same time, intensive treatment of the underlying disease is performed, against which there was an acute expansion of the stomach. To combat dehydration, a large amount of isotonic sodium chloride solution and 5% glucose solution is injected intravenously drip. To increase the tone and stimulation of the peristalsis of the stomach, carbachol (1 ml of a 0.01% solution of SC), acetylidine (1-2 ml of 0.2% solution of SC, can be repeated 2-3 times at intervals of 20-30 minutes) , Anticholin-esterase preparations (proserin, etc.), as well as strychnine (1 ml of 1% solution 2-3 times a day). Do not take medicines and food inside. Narcotic analgesics and anticholinergics are contraindicated.

Chronic hypotension of the stomach and gastroptosis are usually combined. There are three degrees of gastroptosis a. At 1 degree, the small curvature is determined by 2-3 cm above l. Biiliaca, at the II degree-at the level and at the third degree-below it. There are also total gastroptosis and partial, i.e., anthropyloroptosis. Gastroptosis is more common in women usually aged 15-45 years and older.

Etiology, pathogenesis. Congenital gastroptosis is primarily due to constitutional asthenia: an excessively long mesentery of the large intestine? Which, sinking, pulls the gastric and ligamentous ligament and pulls a large curvature of the stomach, causing gastroptosis. The omission of the anthropyloric part of the stomach leads to an inflection of the initial part of the duodenum, which further disturbs the evacuation from the stomach and can cause pain. Acquired gastroptosis is observed with a sharp weakening of the muscles of the abdominal wall due to significant weight loss, after childbirth, removal of ascitic fluid or large tumors of the abdominal cavity. It is explained by the stretching of the ligamentous apparatus that fixes the position of the stomach. In most cases, antropiloroptosis is combined with lengthening and hypotension of the stomach; Total gastroptosis is observed only when the diaphragm is simultaneously lowered (due to emphysema of the lungs, massive pleural effusion, etc.), which moves down the bottom of the stomach.

Symptoms, course. In most cases gastroptosis of 1 and 2 degrees is asymptomatic. There are fewer complaints of a feeling of heaviness, raspiraniya, fullness in the epigastric region, especially after a plentiful meal; Dull aching pain in epigastrium is facilitated in the lying position of the patient and is explained by the stretching of the ligament fixing the ligaments. Sometimes cardialgia is noted. Some patients experience short-term abdominal pain during running or jumping, which itself passes, nausea, and a decrease in appetite. Constipation is often observed. The combination of gastroptosis with ptosis of other organs (liver, kidneys, etc.) can give additional symptoms. Patients with constitutional gastroptosis often present a large number of neurotic complaints. When examining a patient with gastroptosis, the pendulous abdomen attracts attention, while when it is pulled upward the pain often decreases or disappears. The omission of the pylorus and the large curvature of the stomach can be determined palpation. The diagnosis is confirmed by X-ray examination. In gastric juice is frequent achlorhydria.

Treatment. With gastroptosis of I-II degree, which proceeds asymptomatically, physical exercises are recommended, exercises aimed at strengthening the abdominal press. At a gastroptosis of III degree appoint special courses of medical physical culture, massage of a stomach, hydrotherapy. In all cases, frequent fractional nutrition of high-calorie and easily digestible food is shown, especially in case of rapid weight loss. To increase appetite - bitterness, small doses of [4-6 units of ED) insulin 20 minutes prior to eating p / c and other appetite-stimulating agents; With achilias prescribed gastric juice and its substitutes. Anabolic hormones (methandrostenolone 0,005 g 1-2 times a day before meals), strychnine and arsenic preparations (duplex - 1 ml 1-2 times a day) are also recommended. It is necessary to eliminate constipation with dietary measures and laxatives. In severe cases of gastroptosis associated with a sharp flabbiness of the anterior abdominal wall, it is recommended to lie for 1-1.5 hours after eating and prescribe a medical bandage; It is imposed in the position of the patient lying down.

Prevention of gastroptosis and hypotension of the stomach is the correct physical education of children and adolescents. Of great importance is the strengthening of the abdominal wall in women during pregnancy and in the first months after childbirth, the use of therapeutic gymnastics.

Hypertensive dyskinesia of the stomach is characterized by an increase in its tone and impairment of peristalsis by spastic type. It is observed as against the background of common diseases manifested by the spastic condition of the musculature (tetanus, lead intoxication, etc.), and as a result of reflex changes in the peristalsis of the stomach (with peptic ulcer of the stomach, pylorus, with cholelithiasis, etc.). Sometimes it is a consequence of a hysterical neurosis or a temporary increase in the tone of the stomach under the influence of emotions, mental stress. Limited (local, local) hypertension and spasm of the muscular wall of the stomach are usually reflex (local spasm of great curvature in the peptic ulcer of the small curvature of the stomach, pylorospasm with ulcer pylorus or duodenal bulb). Gastric tetany can be a consequence and one of the manifestations of insufficiency of parathyroid glands and hypocalcemia. Smoking intensifies spasmic contractions of the stomach. Significant hypersecretion and hyperacidity of the stomach contribute to increased spasm of the pylorus.

Symptoms, course. Hypertonic dyskinesia is asymptomatic or manifests as pain in the epigastric region, often ulcerative. With pilorospazme there is a tendency to vomiting. In the X-ray study, the size of the stomach (in cases of total hypertension) is small, it has the shape of a horn. The contrast mass is retained for a long time in the upper parts of the stomach, takes the form of a broadened wedge with a vertex directed distally. With pilorospasm, the progress of the contrast mass through the pylorus is difficult and occurs in small sporadic portions; In the phase of decompensated pylorospasm and pyloric stenosis, the stomach is enlarged, its peristalsis is weakened. Long-term pylorospasm can lead to the formation of organic pyloric stenosis.

Treatment. With neurogenic and psychogenic hypertensive dyskinesia of the stomach, a gentle fractional diet is recommended according to the type of antiulcer, the mode of work and rest, sedatives, tranquilizers, anticholinergic drugs (atropine, platyphylline, metacin, etc.) and spasmolytic (papaverine, no-shpa, etc.) , Heat on the epigastric region.

Pneumosis of the stomach - increased content in the stomach of the air. It can occur as a result of an organic disease (with hernia of the esophageal opening of the diaphragm, lesion of the diaphragmatic nerve, left dome of the diaphragm, etc.), but more often - in violation of higher nervous activity, hysterical psychosis (neurogenic aerophagia, nervous belching).

Symptoms, course. Feeling of heaviness, pressure, overflow in the epigastrium and frequent strong eructation, sometimes so loud that it prevents the appearance of patients with pneumatosis of the stomach in public places. Due to the high standing of the left dome of the diaphragm, cardialgia can be observed (it is relieved after belching, sensing the stomach, intensifying after a plentiful meal). With percussion and radiological examination, a large gastric gas bubble is found.

Differential diagnosis with axial hernia of the esophagus of the diaphragm and cardioesophageal cancer is carried out by means of radiological and gastroscopic examination.

Treatment of pneumatosis of the stomach of a functional origin is carried out by means of general restorative therapy, sedatives and tranquilizers, therapeutic exercises. In a number of cases, hypnosis and acupuncture help. Patients are recommended frequent fractional meals, forbidden carbonated drinks.

Dyskinesia of the biliary tract - functional disorders of the tone and motility of the gallbladder and biliary tract. Distinguish hypertonic hyperkinetic, characterized by the hypertonic state of the gallbladder (usually in combination with the hypertonic sphincters of Lutkens and Oddi), and hypotonic-hypokinetic, which is characterized by a hypotonic state of the gall bladder and sphincter of Oddi. More common in women. Hypertonically-hyperkinetic dyskinesia of the thicket is detected at a younger age, and hypotonic-hypokinetic in asthenics and in individuals older than 40 years.

Etiology, pathogenesis. Dyskinesia of the biliary tract is primarily caused by a violation of neurohumoral regulation, occurs with neurosis, diencephalic syndrome, solaritis, endocrine-hormonal disorders (with hypo- and hyperthyroidism, menopause, insufficient function of the ovaries, adrenals and other endocrine glands). The hypertonic-hyperkinetic form arises reflexively (with ulcer disease, colitis, appendicitis, adnexitis, etc.), if the development of the gastrointestinal hormone (cholecystokinin-pancreosimin) is compromised by the mucosa of the duodenum with atrophic duodenitis and other diseases. Asthenic conditions caused by severe infectious diseases, viral hepatitis, avitaminosis, malnutrition, various endogenous and exogenous intoxications can also lead to the development of biliary dyskinesia. With a pronounced asthenic constitution, a sedentary lifestyle, an irrational diet with very large intervals between meals, a hypotonic-hypokinetic form of dyskinesia is relatively common. Frequent, but irregular meals, excessive craving for sharp meals, the systematic use of spices irritating the mucous membrane of the digestive tract, predispose to the emergence of hypertonic hyperkinetic dyskinesia of the biliary tract. Organic lesions of the biliary system (cholecystitis, cholangitis, cholelithiasis, etc.), parasitic, helminthic digestive tract invasions often occur with pronounced symptoms of dyskinesia of the gallbladder and bile ducts.

Symptoms, course. Hypertonic hyperkinetic dyskinesia of the biliary tract proceeds with paroxysmal pain in the right hypochondrium of the aching or cramping character resembling colic attacks during cholelithiasis. The occurrence of seizures is facilitated by unrest, significant neuropsychic load, negative emotions, in women exacerbations may be associated with the menstrual cycle. Pain can be irradiated to the right shoulder blade, the right shoulder, sometimes to the heart area, accompanied by general vegetative reactions - sharp sweating, pallor, nausea, sometimes headache, palpitation, etc. Painful seizures last from several minutes to several days; Stupid pressing and aching pain in the right hypochondrium can persist for weeks, sometimes intensifying or fading. During a period of pain, the stomach is not tense. Jaundice, febrile reaction, leukocytosis and increased ESR after an attack is not observed.

Hypotonic-hypokinetic form of dyskinesia is manifested mainly by low-intensity pain in the right hypochondrium, often prolonged. With palpation, there is a slight soreness in the gallbladder.

The diagnosis is confirmed by multi-stage chromodiagnostic duodenal sounding; When the hypertonic hyperkinetic form of dyskinesia II phase (closed sphincter of Oddi) can be lengthened, the IV phase (contractions of the gallbladder) is shortened. In the hypotonic hypokinetic form of dyskinesia, the II phase may be absent (the sphincter of Oddi is constantly in a relaxed state), the IV phase is delayed and elongated; Often a bubble reflex can be obtained only by introducing a sufficiently strong stimulus (cholecystokinin-pancreosimin). Oral cholecysto- and intravenous cholegraphy, echography, in more diagnostic cases, computed tomography, confirm the functional nature of the disease. Hypertonically-hyperkinetic form with the help of serial radiography determines the accelerated and strong contraction of the gallbladder after the introduction of the stimulant (two egg yolks), with a hypotonic-hypokinetic form a gallbladder of large dimensions, in some cases - it is omitted and reduced sluggishly. The hypotonic state of the sphincter of Oddi is sometimes revealed during X-ray examination of the duodenum (flowing contrast mass through the relaxed sphincter of Oddi into the common bile duct). Radioisotope cholecystography has recently begun to be used.

The course is usually prolonged with periods of exacerbation (often caused by emotional stress, alimentary disorders) and remission. Over time, however, in the gallbladder and ducts, an inflammatory process may occur or gallstones may form.

Treatment. Regulation of diet, correct alternation of labor and rest, normalization of sleep and other functions of the central nervous system (sedatives, tranquilizers, physiotherapy procedures). Hypertensive hyperkinetic form during the exacerbation shows diet No. 5, 5a and 2 - magnesium (with restriction of mechanical and chemical food irritants, fats), spasmolytic and anticholinergic agents, thermal physiotherapy procedures, mineral water of low mineralization (Slavic and Smirnovka, Essentuki No. 4 and 20, narzan, etc. usually in hot form fractional, 5-6 meals a day for 1/3 - 1/2 cup).

In hypotonic-hypokinetic dyskinesia, diet No. 5, 15 or 3, psychomotor stimulants and analeptics (strychnine preparations, caffeine, etc.), exercise therapy and physiotherapeutic tonic agents, repeated duodenal soundings, closed tumeses, course treatment with mineral water of high mineralization type Essentuki No. 17, Arzni, Batalinskaya and others; Water is prescribed in a cold or slightly heated form for 200-250 ml 2-3 times a day for 30-90 minutes before meals. Surgical treatment is not indicated. With reflex dyskinesia of the biliary tract, the treatment of the underlying disease is of major importance.

Prevention of dyskinesia of the biliary tract is to maintain a rational regime and the nature of nutrition, normalize the work and rest regime, systematically engage in physical education, eliminate stressful situations at work and at home, and timely treatment of neurotic disorders.

Dyskinesia of the intestine includes intestinal bowel and reflex disorders, which are observed both in organic diseases of the digestive system (peptic ulcer, cholecystitis, cholelithiasis, appendicitis, anus fissure, etc.), and in the defeat of other organs and systems (urolithiasis, adnexitis and etc.).

Etiology, pathogenesis. Neurogenic dyskinesia of the intestine, as a rule, is accompanied by other manifestations of a general neurosis, but they are leading in the clinical picture of the disease. The contributing factors are mental overstrain (well-known "bear illness" - diarrhea in the course of disturbances), family, domestic or industrial conflicts, especially in combination with erratic and irrational food (hasty food, consumption of too hot, acute or rough food, etc.). Functional character has the so-called Achilles diarrhea with atrophic gastritis with secretory gastric insufficiency. In this case, there is an acceleration of peristalsis due to irritation of the intestinal mucosa with undigested food mass. Functional intestinal disorders can be a consequence of endocrine disorders (with thyrotoxicosis - diarrhea, with thyroid function deficiency-intestinal atony and constipation). Finally, functional bowel disorders can accompany diseases of the central and peripheral nervous system (parkinsonism, syringomyelia, tumors and spinal cord injuries, etc.).

Symptoms, course. The total dyskinesia of the intestine is manifested by a disorder in the stool-chronic constipation or diarrhea, with no pathological impurities (mucus, blood, etc.) in the feces, sensations of rumbling, transfusion in the abdomen or heaviness, sometimes deterioration in appetite, and an unpleasant taste in the mouth. X-ray examination reveals an accelerated or delayed passage of barium mass over the intestine. With recto-and colonoscopy (as well as biopsy) morphological changes in the mucous membrane of the large intestine are not detected.

Dyskinesia duodenal ulcer and duodenostasis often accompany ulcerative and cholelithiasis; Clinical symptoms are pain in the epigastric area of ​​a spastic character, a feeling of pressure or overflow in the epigastric region, nausea, attacks of vomiting. X-ray examination of the duodenum determines the long-term retention of the barium suspension in it (over 40 s), the alternation of spasms and expansions of various parts of the intestine, the throwing of contrast mass into the more proximal parts of the intestine, and the stomach.

Dyskinesia of the small intestine is manifested by spastic pain in the abdomen, diarrhea or the appearance of a semi-fluid stool, rumbling and a feeling of transfusion in the abdomen.

Dyskinesia of the large intestine can occur after dysentery. Violations of the motor function of the colon manifest spasm or atony. There may be either diarrhea - functional diarrhea (in this case, unlike colitis, stool masses usually do not contain mucus and blood), or constipation. In the latter case, there is no independent chair from several days to 1-2 weeks. A special clinical form of motor secretory disorders of the colon is colic mucosa, in which there are attacks of pain in the abdomen, accompanied by the excretion of feces with a significant amount of mucus usually in the form of tapes or films. When microscopic examination is often found a large number of eosinophils and crystals of Charcot-Leiden.

Differential diagnosis is carried out with enteritis, enterocolitis; Confirmation of the functional nature of the disease is the appearance or intensification of intestinal dysfunction under the influence of emotions, mental disorders, the presence of signs of general neurosis, other diseases often accompanied by intestinal disorders, the appearance of unchanged intestinal mucosa in duodeno- and colonoscopy, the absence of mucosal changes in the histological examination of biopsy specimens Different parts of the intestinal mucosa. The cause of persistent constipation may be organic lesions of the intestine: tumors, adhesions in the abdominal cavity, and abnormalities of the colon (megacolon), which is confirmed by irrigoscopy and endoscopic examination of the colon.

Treatment. Regulation of the regime and the nature of nutrition, lifestyle, physical education, sedatives and tranquilizers. With spastic dyskinesia of the intestine, cholinolytic agents are prescribed in small courses (2-3 weeks). With hypotonic dyskinesia self-massage of the abdomen, exercise therapy, restorative therapy helps.