Documente Academic
Documente Profesional
Documente Cultură
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
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
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 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)
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%
Mixed (SII-M)
Alternare Scaune tari > 25%
Neclasificabil
Tulburari de tranzit
Diareea
Urgenta la defecatie Scaunele moi, apoase (tip 6,7 Bristol) Incontinenta anala Uneori induse de ingesta de alimente
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
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
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
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
Mecanism secretor
Hipermotilitate
Malabsorptie
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
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
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
Ischemic colitis
Microscopic colitis