Enteritis

Enteritis - an inflammatory disease of the mucous membrane of the small intestine.

Enteritis acute. In acute enteritis, the stomach (gastroenteritis) and the large intestine (gastroenterocolitis) are also often involved in the pathological process.

Etiology, pathogenesis. There are acute enteritis: 1) infectious and viral origin (with a clinical picture of severe enteritis, cholera, typhoid, salmonella, sometimes influenza, etc.) occur; 2) alimentary (caused by overeating with the reception of a large number of acute or too rough food, irritating the mucous membrane of spices, strong alcoholic beverages); 3) toxic (poisoning with arsenic compounds, sulemoma and other poisons, poisoning with mushrooms - pale toadstool, fly agarics, false honey agarics, other toxic substances of non-bacterial nature that can be contained in food products - stone fruit, some fish products - liver burbot, pike, Caviar of mackerel, etc.); 4) allergic (with idiosyncrasy to some food products-strawberries, eggs, crabs, etc. or allergic reaction to medications - preparations of iodine, bromine, certain sulfonamides, antibiotics, etc.).

Pathogenesis is caused either by the direct action of the pathological origin on the mucosa of the small intestine, or by its hematogenous drift (microbes, toxins) into the intestinal vessels, and then by the damaging effect when the mucosa is secreted into the intestinal lumen or due to autoimmune mechanisms. Predicting moments to the emergence of acute gastroenteritis are cold drinking, general cooling of the body, polyhypovitaminosis, abuse of foods rich in coarse fiber, and other factors.

Symptoms, course. The disease can begin with local symptoms - nausea, vomiting, diarrhea, pronounced rumbling in the abdomen, sometimes spasmodic pain. Then they are joined by weakness, general malaise, cold sweat, fever (the temperature can reach 38-39 degrees C and above), the phenomena of general intoxication, the symptoms of vascular collapse. In other cases, the general symptoms appear first, and after a while (from half an hour to several hours) they are joined by signs of an inflammatory defeat of the small intestine. When palpation of the abdomen, tenderness is observed in the epigastric region, sometimes severe rumbling during palpation of the cecum. There is a moderate, less pronounced leukocytosis, an increase in ESR.

Differential diagnosis of noninfectious enteritis is primarily carried out with acute intestinal infections (cholera, typhoid, food intoxication), as well as with common infectious and viral diseases that can occur with enteritis syndrome. Of great importance is the epidemiological anamnesis. Bacteriological study of feces often allows the isolation of a pathogenic pathogen (with infectious acute enteritis). Detailed analysis of the patient facilitates differential diagnosis of alimentary, toxic, allergic enteritis.

In light and medium-heavy cases, the disease ends in recovery after a few days. Heavy forms can be complicated by intestinal bleeding, necrosis and perforation of the small intestine. With toxic and allergic enteritis, there may be concomitant lesions of other organs - the heart, liver, kidneys, etc.

Treatment. Patients with severe enteritis, as well as enteritis of toxic origin (the further course of which is difficult to determine in the first hours of the disease is difficult) must be hospitalized. Patients with infectious enteritis are hospitalized in infectious hospitals. In all cases of acute enteritis in order to remove toxins from the gastrointestinal tract, the stomach is washed (by the eondovy or bezprocedov method) with a weak solution of sodium hydrogencarbonate, the laxative is given inside (30 ml of castor oil or 25 g of magnesium sulfate in 100 ml of water). In the first 12-24 hours, hunger is prescribed, an abundant drink is recommended (boiled water, unsweetened tea). At the expressed general intoxication appoint p / to or in / in drip infusions of an isotonic solution of sodium of a chloride or 5% of a solution of glucose, kordiamin, sulfokamfokain, caffeine. Inside prescribe preparations of digestive enzymes (abomin, festal, etc.), and in the future with the goal of normalizing the intestinal flora - en-teroseptol, intestopan or colibacterin, bifudimbak-terin, bifikol, lactobacterin. From the 2nd day of the disease, patients are allowed low-fat broth, mashed porridge in water, crackers; In the following days the diet is expanded.

Prevention of acute enteritis is strict adherence to the rules of personal hygiene, eating only carefully washed fruits and vegetables, and rational nutrition. To prevent toxic enteritis from food, products that can have toxic effects on the body (unknown fungi, etc.) are excluded from food.

The enteritis is chronic. Etiology: 1) systematic nutritional deficiencies, abuse of spicy food and spicy condiments, dietless meals; 2) alcoholism, especially the reception of strong alcoholic beverages and their surrogates; 3) production intoxication in violation of safety procedures and chronic poisoning with lead, mercury, phosphorus, arsenic, etc. compounds; Domestic intoxications, in particular medicinal (in case of abuse of salt laxatives, long uncontrolled use of broad-spectrum antibiotics, capable of causing intestinal dysbacteriosis, etc.) and endogenous (with uremia); 4) food allergy; 5) parasitic infestations (giardiasis, etc.), some intestinal helminthiases; 6) radiation damage (production in case of violation of safety procedures and as a result of radiation treatment of malignant neoplasms of the abdomen); 7) "accompanying" enteritis with prolonged gastritis with secretory gastric insufficiency, chronic pancreatitis, colitis.

Pathogenesis. The most studied mechanisms of the development of the disease are: 1) the direct chronic damaging effect of the etiological factor on the wall of the small intestine (toxic, irritating); 2) long-term dysbacteriosis, accompanied by irritation and toxic effects of products of abnormal digestion of nutrients under the influence of enzymes of unusual intestinal flora (organic acids, aldehydes, indole, scatol, methane, hydrogen sulphide, etc.), and bacterial toxins on the mucosa of the intestinal wall; 3) immunological mechanisms. In some cases, lean (jejunite) or ileum (ileitis) gut is predominantly affected.

Symptoms, course. Pain (if present) is usually blunt, rarely spasmodic, localized in the near-buccal region; Here, soreness is often noted during palpation of the abdomen and strong pressure (somewhat to the left and above the navel, a symptom of Porges), tenderness along the mesentery of the small intestine (in the direction from the navel to the right sacroiliac joint - the Sternberg symptom). Pain with a concussion of the body, walking can be a sign of perivistercite. Rumbling and splashing during palpation of the cecum is an important sign of enteritis (Obraztsov's symptom).

The syndrome of intestinal dyspepsia is manifested by low-frequency dyspepsia complaints: sensation of pressure, bursting and swelling of the abdomen, especially after eating, nausea, rumbling, transfusion in the abdomen, etc., which result from a violation of digestion of nutrients in the intestines, acceleration of their passage through the small intestine, As well as violations of absorption in the intestine. Sometimes with severe enteritis, shortly after eating, weakness, dizziness and other common phenomena resembling a dumping syndrome occur.

Enteritis coprologic syndrome: frequent (up to 15-20 times a day) mushy, with undigested food particles, but without visible mucus, often fetid, with gas bubbles stools. Typical polyphecal: the total amount of fecal matter per day can reach 1.5-2 kg. Sometimes there is a sudden urge to defecate soon after eating, and after defecation there is a sharp weakness, accompanied by a cold sweat, trembling of hands (ejonal diarrhea). In mild cases and in the absence of concomitant colitis, diarrhea may be absent and even constipation may be observed. Typical intolerance of milk: after its intake, increased flatulence, diarrhea. Exacerbation of the disease causes the reception of spicy foods that contain a large amount of fats and carbohydrates, overeating. Often there is a peculiar yellowish (golden) color of feces due to the presence of unreduced bilirubin and a large amount of fat, giving the calves a clayey appearance. At microscopic examination: a large number of undigested food residues (lenteria), drops of neutral fat (steatorrhea), droplets, lumps and crystals of fatty acids and insoluble soaps, muscle fibers (kitarinorea), free extracellular starch (amylorea), a large amount of mucus, evenly mixed With feces.

The syndrome of insufficiency of absorption is manifested by a gradual decrease in the body weight of the patient (in severe cases up to cachexia), general weakness, malaise, decreased efficiency. In the blood, hypoproteinemia, gopocholesterolemia, the sugar curve is usually flattened.

The study of the sugar profile in the application of differentiated carbohydrate loads allows to determine mainly the violation of cavity digestion of carbohydrates (with starch loading), parietal digestion (with sucrose load) and absorption processes (with glucose load). A sample with d-xylose (low blood levels of pentose 2 h after ingestion of d-xylose inside and decreased excretion of urine in the urine) confirms a malabsorption. Anemia is iron deficient, in some cases B12-deficient, but often has a mixed character, with a normal color index.

Often the phenomenon of hypovitaminosis (vitamins B1, B2, B6, B12, D, K, A, biotin, folic acid); Their manifestation can be dry skin, angular stomatitis, hair loss, brittle nails, polyneuritis, twilight vision disorders, etc.

In the blood, the concentration of a number of ions, especially Ca, decreases, in severe cases, pathological brittleness of bones and other signs of hypoparathyroidism occur. Gipofizarnaya insufficiency manifests itself in vaguely pronounced phenomena of diabetes insipidus (polydipsia, polyuria in combination with hypoisostenuria), adrenal - poorly pronounced addisonism (hyperpigmentation of the skin, especially the areas of the skin folds of the palms, oral mucosa, and arterial and muscular hypotension). Violation of the sexual glands in men is manifested by impotence, in women with amenorrhea.

With severe enteritis, there are dystrophic changes in the heart muscle, liver, kidneys and other organs.

X-ray in case of chronic enteritis is most often determined by the accelerated passage of barium suspension in the small intestine and its uneven accumulation in various loops of the intestine; Often visible thickened swollen folds of the mucous membrane, in severe cases, their smoothing due to the process of atrophy.

With aspiration biopsy from the upper parts of the jejunum inflammatory and dystrophic changes in the mucosa, a decrease in the size of villi, a flattening of the cells of the superficial epithelium of the mucosa and its brush rim, in severe stages, the development of sclerotic changes.

The course of chronic enteritis progresses gradually or violently, in rare cases (especially under the influence of treatment and a strictly sustained diet) there is a regression of the symptoms of the disease.

In the differential diagnosis, first of all, it is necessary to exclude alimentary dyspepsia, which arise due to systematic irrational nutrition (fermentation, putrefaction, fat). In these cases, special studies do not show disturbances in absorption by the intestinal wall, aspiration biopsy shows no inflammatory changes in the intestinal mucosa, and transfer of the patient to a rational diet without additional medical measures usually quickly eliminates pathological symptoms and normalizes bowel function. In cases of severe enteritis, differential diagnosis with sprue should be performed. A comparatively rare form of enteritis is the regional enteritis (Crohn's disease), which occurs most often with a predominant ileal lesion, a febrile condition, hyper-alpha (two) and gamma globulinemia, a progressive course. The possibility of congenital enzyme-deficient enteropathies (gluten, disaccharidase, etc.) should be excluded first of all by the appointment of the appropriate diet, as well as by probes with loads of various disaccharides, gliadin, etc.

Treatment during an exacerbation is spent in a hospital. Assign a diet number 4-4a, b, c. The food ration should contain a sufficient amount of protein (130-150 g) mainly of animal origin (veal, low-fat beef or chicken, fish, eggs, cottage cheese) and easily assimilated fats (100-110 g). Exclude refractory fats of animal origin (mutton, pig); During the exacerbation of the process, the amount of fat is temporarily reduced to 60-70 g. The amount of carbohydrates in the daily diet is normal - as with mild and moderate exercise (about 500-450 g), but restrict foods containing high amounts of fiber. The latter is achieved in addition to selecting products, careful mechanical processing of food (mashed vegetables and fruits, mashed potatoes). With diarrhea, prunes, figs, cabbage, grapes, black bread, freshly baked flour products, nuts, fermented beverages, beer, kvass are excluded from the food ration. The regime of frequent (5-6 times a day) fractional nutrition; All food is taken in a warm form. During the exacerbation of the process, food is prescribed mechanically sparing - in the form of mucous broths, soups, mashed cereals, mashed potatoes, steam cutlets, soufflings, etc. With diarrhea a good effect is the systematic intake of acidophilic milk (100-200 grams 3-4 Once a day) and unsweetened juices and fruit jelly and berries containing tannic substances (blueberries, black currants, pomegranates, pears, etc.). At the phenomena of vitamin deficiency, vitamins are prescribed, primarily B1, B2, B6, B12, folic acid, vitamin A, with hemorrhagic phenomena - vitamin K (vikasol). Particularly useful are complex vitamin preparations: pangexavit, decamewith, undevit, and others.

Antibiotics of a wide range of actions for chronic enteritis do not find great application because of the dysbacteriosis danger. More often appoint kolibakterin, bifidumbakterin, bifikol and especially derivatives of oxyquinoline: enteroseptol, intestopan, meksaform, meksazu. Preparations of digestive enzymes (gastric juice and similar medicinal affinities, pancreatin, festal, cholenzym, abonine, etc.) are indicated with a predominant violation of intestinal intestinal digestion.

During the period of exacerbation of the process, especially accompanied by diarrhea, the oral administration of astringent and enveloping agents (bismuth nitrate basic, tanalbine, thebalb, decoctions of the rhizome or roots of the serpentine, blood-grouses, paws - 4,0-15,0: 200,0 or infusions of tansy flowers , Herbs of St. John's wort, cones of alder, etc. - 10,0- 30,0: 200,0 for 1 tablespoon 5-6 times a day).

In case of severe enteritis with the phenomena of insufficiency of absorption, intravenously infusion of plasma, protein hydrolysates (aminopeptide, casein hydrolyzate, aminocrovin, etc.) is prescribed -1 l / day; In more light cases they are injected through the nitragastral probe drip. It is useful to prescribe anabolic steroid hormones (methandrostenolone 0.005-0.01 g 1-2 times per day orally or retabolil 0.025-0.05 g once every 1-3 weeks w / m). Treatment of concomitant anemia see Anemia.

Of the physiotherapeutic procedures, warming compresses, paraffin applications, ozocerite, diathermy, inductothermy, etc. are most effective. Spa treatment in the sanatoriums of Zhepeznovodsk, Essentuki, Pyatigorsk, Mirgorod, Borjomi. In severe cases of chronic enteritis, employment of patients and transfer to disability is shown.

Prevention is to prevent the effects of those factors that can cause chronic enteritis. It is necessary timely treatment of acute and subacute enteritis and clinical examination of patients with chronic enteritis with a chain of prevention of recurrence of the disease and the occurrence of possible complications.