Diareea cronica

CONF. MANUC MIRCEA

CLINICA GASTROENTEROOGIE SI HEPATOLOGIE INSTITUTUL FUNDENI BUCURESTI

DEFINITIE/ EPIDEMIOLOGIE
Prezenta unor scaune de consistenta scazuta, timp de peste 4 saptamani Peste 3 saune / 24 ore 3-5% din populatia generala adulta

fiziopatologie
Poate fi divizata in
Diareee apoasa (fecale lichidiene)
Diaree osmotica Diaree scretorie Diaree functionala

Diaree grasoasa (malabsorbtie) Diaree inflamatorie (sange, puroi) . Exista si forme de overlapping

Diareea apoasa caracteristici

1. diareea secretorie
Diurna si nocturna Nelegata de ingesta de alimente Cantitate semnificative (> 1000 ml/zi) Osmolaritate joasa (gap fecal osmotic < 50 mOsm per kg)

2. diaree osmotica
Diurna si nocturna legata de ingesta de alimente (se opreste la post) Osmolaritate crescuta (gap fecal osmotic > 125 mOsm per kg)

3. diaree functionala
Exclusiv diurna Diminueaza la post alimentar Volume mici de scaun (< 350 ml.) Prezenta hipermotilitatii intestinale

Diareea grasoasa caracteristici

Scaune grasoase , cu miros caracteristic, albicioase, lipicioase, Pot fi alimente nedigerate steatoree Scadere ponderala Meteorism, borborigme

Diaree prin leziuni

Produse patologice in scaun sange, mucus, puroi Semne generale de infectie/inflamatie

1. Diaree secretorie etiologie

Alcoholism Enterotoxine bacteriene (e.g., cholera Malabsorptia acizilor biliari diareea epidemica secretorie Sindroame congenitale Boala Crohn ileala la debut Tulburari endocrine (e.g., hipertiroidia) Medicamente Colita microscopica (limfocitara si colagena) tumori neuroendocrine (e.g., gastrinom, vipom, carcinoid, mastocitoza sistemica) Laxative non-osmotice (e.g., senna, docusate sodium) Postoperator (e.g., cholecistectomia, gastrectomia, vagotomia, reazectii intestinale) Vasculite

Diaree functionala etiologie

Intestinul iritabil Sd de diaree functionala

Diaree osmotica etiologie

sindroame de malabsorptie de carbohidrati (e.g., intoleranta la lactoza, fructoza) Boala celiaca Laxative osmotice si antiacide (e.g., magnesium, phosphate, sulfate) Consumul de mannitol, sorbitol, xylitol

Diaree grasoasa etiologie

1. malabsorbtie 2. maldigestie

Diaree grasoasa etiologie

1. sindroame de malabsorbtie
Amyloidoza Malabsorptia de carbohidrati severa (e.g., intoleranta la lactose) Celiac sprue Gastric bypass Afectare a fluxului limfatic (e.g., limfoame, insuf card congestiva) Medicamente (e.g., Xenical) Mesenteric ischemia Parazitoze non-invazive (e.g., Giardia) Diaree post rezectii intestinale Sd de hiperproliferare bacteriana (> 105 bacteria per mL) Boala Whipple (Tropheryma whippelii)

Diaree grasoasa etiologie

2. sindroame de maldigestie
Insuficienta pancreatica exocrina Afectare hepatobiliara severa Depletia de acizi biliari intralumenal Anomalii de evacuare gastrica

Diareea prin leziuni (inflamatorie sau exudativa)

IBD (boala Crohn sau RCUH) diverticulita jejunoileita ulcerativa Enterite/colite infectioase
Clostridium difficile (colita pseudomembranoasa) Bacterii entero-invazive (e.g., tuberculoza, yersinioza) Infectii parazitare (e.g., Entamoeba hystolytica) Infectii virale (e.g., cytomegalovirus, herpes simplex virus)

Neoplazii (carcinom, limfom, adenom vilos Colita/ enterita radica

Management diagnostic
1. istoric 2. examen clinic 3. diagnostic biologic 4. imagistica 5. histopatologia

1. istoric
intelegerea termenului de diaree de catre pacient Intereseaza
Istoric familial de IBD, boala celiaca, neoplazie, Istoric personal de chirurgie digestiva Istoric de calatorie in Orient, Africa Consum de medicamente recent/cronic Simptome generale nespecifice febra, scadere ponderala, anemie Caracteristicile scaunelor
Volumul, frecventa , aparitia nocturna, prezenta alimentelor nedigerate, a produselor patologice, etc

2. Examen clinic
Date aditionale care pot orienta asupra etiologiei

Deficitul ponderal Paloare tegumentara Adenopatii prezente Manifestarile extracolonice din IBD (artrite, iridociclite) Manifestari clinice de hipertiroidism Dermatita herpetiforma bola celiaca Examinare abdominala = durere, borborigme, cicatrici, etc, Prezenta leziunilor anale / oerianale.

3. Probele biologice
Testele hematologice si biologice uzuale
hemograma, VSH, fibrinogen, albumina, AST/ALT, ionograma, glicemie , hormoni tiroidieni , sideremie, creatinina, colesterol,

Testare enteropatie glutenica

ac. Antiendomisiium, ac anti transglutaminaza A, ac antigliadina indicatii:
diareea cronica inexplicabila, anemia feripriva scaderea ponderala, infertilitatea, aminotransferaze crescute fara motiv

3. Probele biologice (II)

Examen de scaun
leucocite, FOBT, coprocultura, ex. coproparazitologic, Masurare scaun din 24 ore, Calprotectina fecala daca se suspecteaza IBD Testare Cl Difficile
daca diaree in context consum Ab, intraspitalicesc, consum IPP

Testare malabsorbtie (dozare acizi grasi in scaun sau coloratie Sudan) pH-metrie fecala , dozare electroliti fecali

4. Diagnosticul endoscopic
Colonoscopia Enteroscopia Videocapsula
Evaluare leziuni de tract digestiv inferior Se pot preleva biopsii pt diagnostic histopatologic (eg. IBD, colita microscopica, boala celiaca)

Algoritm de evaluare a pacientilor cu diaree cronica

Algoritm de evaluare a pacientilor cu diaree cronica (II)

Intestinul iritabil
Criterii ROMA III
Durere abdominala sau discomfort recurente, ce apar cel putin 3 zile/sapt in ultimele 3 luni, asociate cu 2 sau mai multe din situatiile: 1. ameliorare dupa defecatie 2. simptomatologia asociata cu o modificare in frecventa emisiei scaunului 3. simptomatologie asociata cu o modificare in aspectul scaunului
*criterii indeplinite in ultimele 3 luni, cu un debut al simptomelor de cel putin 6 luni inaintea diagnosticului. **Discomfortul este definit ca un simptom negativ non-dureros. In cercetarea fiziopatologica si in trialurile clinice se considera necesara prezenta simptomatologiei cel putin 2 zile/saptamana.

Subtipurile de SII

Constipatie (SII-C) Fecale tari > 25% Scaune apoase < 25%

Diaree (SII-D) Scaune moi > 25%

Mixed (SII-M)
Alternare Scaune tari > 25%

Neclasificabil

Scaune tari < 25%

Scaune moi > 25%

Tulburari de tranzit
Diareea
Urgenta la defecatie Scaunele moi, apoase (tip 6,7 Bristol) Incontinenta anala Uneori induse de ingesta de alimente

Alternanta constipatie/diaree Constipatia

Pasajul unui scaun dur (tip 1,2 Bristol) Tensiunea la emisia scunului Evacuarea incompleta

Scala scaunelor Bristol

Tip: 1 bile separate de marimea nucilor (scibale), ce se elimina cu dificultate 2 ca un carnat dar zgrunturos 3 ca un carnat dar cu fisuri in suprafata 4 ca un carnat sau un sarpe , neted si moale 5 mai multe fragmente moi, cu margini nete, care se elimina usor 6 bucati cu margini zdrentuite, scaun cu aspect spongios, poros 7 scaun apos, fara elemente solide

Strategia de diagnostic
Prima grija este excluderea unei afectiuni organice ? investigatii costisitor
Symptom based criteria mai util

Strategia de diagnostic
Identificarea siptomelor importante si selectarea simptomului dominant
Durere abdominala sau discomfort Diareea Constipatia Meteorismul abdominal

Atentie la conditii alarmante bazate pe

Istoricul personal sau familial Datele clinice Datele de laborator

Daca se considera necesar se efectueaza teste specifice pentru a exclude o boala organica diagnosticul pozitiv de SII Se initiaza un tratament empiric pentru SII, bazat pe simptomatologia clinica Follow-up in 4-6 saptamani si se evalueaza raspunsul terapeutic

Conditii alarmante (stegulete rosii)

Scaderea ponderala Anemia Hemoragia digestiva inferioara Test pozitiv hemoccult Mase abdominale palpabile sau adenopatii Istoric de calatorie in orient sau tari in curs de dezvoltare Istoric personal sau familial de BIC , boala celiaca, cancer colonic, cancer de ovar Varsta peste 50 ani (60 ani) Debutul tardiv al simptomatologiei Semne clinice de infectie investigatiile sunt obligatorii pentru excluderea sau confirmarea unei boli organice

Boala inflamatorie intestinala

Entitati:
Boala Crohn ileala/ colonica RCUH Colita nedeterminata

Diagnostic pozitiv
Examen endoscopic (EDI, EDS, enteroscopie/videocapsula) Examen histopatologic -

Colita microscopica
Entitate subdiagnosticata ( 10% din diareile cronice ?) Caracteristici
Diaree intermitenta, de tip secretor, Pacienti varstnici de obicei Caracter diurn si nocturn Nu se opreste la post

etiologie necunoscuta
Asociat frecvent cu istoric de consum cronic de AINS

Colonoscopic mucoasa apare normala Histopatologic 2 entitati

colita limfocitara (infiltrat limfocitic in lamina propria) Colita colagenica (strat de colagen subepitelial crescut peste 10 mm)

Enteropatia glutenica
Persoane tinere, sex F predominant, eventual istoric familial, sau istoric personal de diaree in copilarie anemie feripriva, scadere ponderala
tablolul clasic poate lipsi frecvent (diaree apoasa, a. feripriva fara diaree, infertilitate, etc.)

Dg pozitiv
Testarea serologica Biopsia de jejun atrofie vilozitara , teliocite intraepitelial

Diareea post medicamentoasa

Mecanism osmotic
Citrati, phosphati, sulfati de magnesium (laxarive osmotice, antiacide) -alcoholi glucidici (e.g., mannitol, sorbitol, xylitol) Antiaritmice (e.g., quinine) Antibiotice (e.g., amoxicillin/clavulanate Antineoplastice (Biguanide,) Calcitonina Glicozide cardiace (e.g., digitalis) Colchicine AINS (pot contribui si la diaree prin leziuni) Prostaglandine (e.g., misoprostol Ticlopidine Prokinetice = eg. macrolide - erythromycin) , Metoclopramid, motilium, Laxaive stimulante (e.g., bisacodyl , senna) Acarbose Aminoglycozide Orlistat (Xenical) Ticlopidine Antibiotice (e.g., amoxicillin, cephalosporine, clindamycina, fluoroquinolone, Antineoplastice, Imunosupresante, terapia imunologica, IPP

Mecanism secretor

Hipermotilitate

Malabsorptie

Colita pseudomembranoasa (Clostridium difficile)

Infectii cronice
Etiologie
Bacteri: Aeromonas, Campylobacter, C. difficile, Plesiomonas, Yersinia. Paraziti: Cryptosporidium, Cyclospora, Entamoeba, Giardia, Microsporida, Strongyloides. Giardia, Agenti neidentificati diareea Brainerd (diaree scretorie epidemica)
Dg. Pozitiv
Istoric sugestiv teste serologice, testare antigene fecale, coprocultura, ex. coproprazitlogic Colonoscopie (ocazional) leziuni nespecifice

Common Causes of Chronic Diarrhea (1)

Diagnosis Celiac disease Clinical findings Chronic malabsorptive diarrhea, fatigue, iron deficiency anemia, weight loss, dermatitis herpetiformis, family history Tests Immunoglobulin A antiendomysium and antitissue transglutaminase antibodies most accurate; duodenal biopsy is definitive

Clostridium difficileinfection

Often florid inflammatory diarrhea with weight loss Recent history of antibiotic use, evidence of colitis, fever May not resolve with discontinuation of antibiotics

Fecal leukocyte level; enzyme immunoassay that detects toxins A and B; positive fecal toxin assay; sigmoidoscopy demonstrating pseudomembranes
Elimination of offending agent; always consider laxative abuse

Drug-induced diarrhea

Osmotic (e.g., magnesium, phosphates, sulfates, sorbitol), hypermotility (stimulant laxatives), or malabsorption (e.g., acarbose [Precose], orlistat [Xenical]) Secretory diarrhea or increased motility (hyperthyroidism)

Endocrine diarrhea

Thyroid-stimulating hormone level, serum peptide concentrations, urinary

Giardiasis Infectious enteritis or colitis (diarrhea not associated with C. difficile): bacterial gastroenteritis, viral gastroenteritis, amebic dysentery Inflammatory bowel disease: Crohn disease, ulcerative colitis

Excess gas, steatorrhea (malabsorption) Inflammatory diarrhea, nausea, vomiting, fever, abdominal pain History of travel, camping, infectious contacts, or day care attendance

Giardia fecal antigen test Fecal leukocyte level, elevated erythrocyte sedimentation rate Cultures or stained fecal smears for specific organisms are more definitive

Bloody inflammatory diarrhea, abdominal pain, nausea, vomiting, loss of appetite, family history, eye findings (e.g., episcleritis), perianal fistulae, fever, tenesmus, rectal bleeding, weight loss Stool mucus, crampy abdominal pain, altered bowel habits, watery functional diarrhea after meals, exacerbated by emotional stress or eating More common in women History of vascular disease; pain associated with eating

Complete blood count, fecal leukocyte level, erythrocyte sedimentation rate, fecal calprotectin level Characteristic intestinal ulcerations on colonoscopy All laboratory test results are normal Increased fiber intake, exercise, dietary modification should be recommended Colonoscopy, abdominal arteriography Colon biopsy

Irritable bowel syndrome

Ischemic colitis

Microscopic colitis

Watery, secretory diarrhea affecting older persons

Nonsteroidal anti-inflammatory drug association possible