Recommended tactics for further examination.

Steatorrhea.

Patients with severe steatorrhea (excretion of fat in the stool more than 10 g per day) suffer from digestive or absorption disorders, according to Pannochka, an Internet publication for girls and women from 14 to 35 years old.. net Usually the diagnosis is made on the basis of several diagnostic procedures, such as a biopsy of the jejunal mucosa, a functional test of the pancreas according to Lundh, fluoroscopy of the small intestine to detect possible celiac disease, Crohn's disease, tumors, fistulas, stasis, blind loops, as well as tests to detect proliferation.

It is very important to remember that the excessive multiplication of bacteria in the small intestine can cause severe diarrhea, even in those patients in whom an X-ray examination did not reveal an obvious cause of stasis..

This happens especially often in the elderly.. Recently, breathing tests have appeared, which greatly simplified the diagnostic search.. It is believed that pathologically high levels of labeled CO2 after ingestion with liquid food containing 14 [C] -glycocholate, as well as increased hydrogen production with respiration after ingestion of some glucose or xylose indicate excessive bacterial proliferation..

However, the results of these tests only indicate a relationship between the amount of unabsorbed food substrates and the total mass of bacteria in the body.. Therefore, positive results are observed in patients after resection of the ileum or with accelerated passage of food through the small intestine.. False negative results occur when bacteria in the small intestine cannot metabolize the substrate.

If it is not possible to conduct a breath test, the excessive multiplication of bacteria in the small intestine is determined using the Schilling test for the absorption of vitamin B12. and then look at how the results of the Schilling test and the severity of steatorrhea were affected by trial treatment with broad-spectrum antimicrobial drugs such as metronidazole, trimethoprim (biseptol, bactrim) or tetracycline.

In cases where the results of these tests turn out to be normal or almost normal, it is advisable to prescribe a trial treatment with pancreatic enzymes, antibiotics; it is also recommended to prescribe the patient a diet devoid of vegetable protein.

Profuse secretory diarrhea.

The daily excretion of feces with a volume of more than 1 liter, which does not stop even during fasting, is usually attributed to the action of polypeptide-secreting tumors, secret administration of laxatives with irritating effect to patients or infection with enterotoxic bacteria.

With chronic diarrhea lasting more than 10 days, the latter is usually not taken into account. Nevertheless, we recently described five patients in whom the diagnosis was not detected despite a detailed examination for the secret intake of laxatives or the presence of polypeptide-secreting tumors.. In four of them, spontaneous remissions occurred 1.5-10 months after the onset of the disease.. The cause of diarrhea in this case has not been established, but we do not exclude the possibility of infection..

Secret reception of laxatives.

There are two ways to detect secret laxatives.. In the first case, biochemical analyzes of urine and feces are carried out for the detection of a drug. The presence of phenolphthalein can be determined by alkalinization of the stool or urine, which turns red. Bisokodil is detected by chromatography, and chemical analysis is used to identify anthracene derivatives (senna, cascara, dantron).

Magnesium and sulfates in feces can be found using chemical samples, and the high osmotic residue of fecal masses can be suspected of taking magnesium sulfate and lactulose. In our practice, there was a patient who took bath salts containing magnesium sulfate; the diagnosis was made in the study of intestinal lavage water. When diagnosing secret use of laxatives, the easiest way is to look at the patient's personal belongings: this saves time and effort.

One of our most recent studies was carried out on 27 patients with chronic diarrhea who were admitted to our department after, despite a thorough diagnostic examination in other hospitals, it was not possible to make a diagnosis. It turned out that at least 8 of these 27 patients secretly took laxatives or diuretics. Several of them underwent surgery (colectomy, pancreatectomy) for diarrhea. The doctor should always be alert when it comes to persistent diarrhea..

Even the most respectable and sincere-looking people can hide that they are taking a laxative.. Some people try to feign diarrhea by adding water or urine to their stool. It is easy to establish by the pathologically low osmolarity of fecal fluid. We found that normal fecal osmolarity is never below 260 mOsm / kg..

Polypeptide-secreting tumors.

If the patient does not take a laxative, the diarrhea is prolonged and has led to dehydration and hypokalemia, further research may be required to find a tumor that secretes substances that stimulate intestinal secretion. There are so many substances with the potential to increase intestinal secretion that it is simply impossible to develop methods for their determination in plasma for all of them..

However, it is important to send to the laboratory “plasma samples to determine the vasoactive intestinal polypeptide - gastrin and possibly calcitonin, as well as to measure the level of 5-hydroxyindoleacetic acid (5-HIAA) in the urine in order to rule out carcinoid syndrome. The results of these tests should be treated with caution and always repeated..

To detect a polypeptide-secreting tumor, it is also advisable to use other research methods (angiography, lymphoangiography, echography), and intestinal perfusion can be used to confirm violations of intestinal secretion.. When looking for the causes of profuse diarrhea caused by Ellison-Zollinger syndrome, another practical observation may be helpful: diarrhea stops with constant suction of stomach contents.

At present, it is advisable to investigate the level of polypeptides in the blood only after the presence of profuse secretory diarrhea has been confirmed by measuring the mass of the stool and the secret intake of laxatives has been excluded..

Scanty (less than 500 ml) diarrhea without signs of steatorrhea.

These are the most common cases of diarrhea.. Although mild to scanty diarrhea may indicate a colon disease, nearly all of the above conditions are associated with mild diarrhea in milder cases..

Except in cases of Crohn's disease, ulcerative colitis, or pseudomembranous colitis, colonoscopy does not have significant advantages over double contrast colonic contrast in the search for causes of diarrhea..

In many patients with diarrhea, a biopsy of the mucous membrane of the rectum or colon shows an increase in the number of leukocytes. In the absence of other histological signs, leukocyte infiltration indicates only nonspecific irritation of the colon (fatty or bile acids, laxatives, etc.). ) and therefore cannot be considered an unconditional sign of the inflammatory process in the large intestine.

If the diagnosis is doubtful, one can try to prescribe a trial treatment with salazosulfapyridine, and the appointment of steroids for diagnostic purposes is meaningless, since they nonspecifically increase the absorption of salts and water and therefore cure diarrhea of \u200b\u200balmost any etiology.

In a recent study, the author and co-workers used a trial of cholestyramine treatment in two patients with diarrhea and urgency. As a result, it was found that these patients, apparently, had an accelerated flow of bile acids into the large intestine and increased sensitivity to them..

Irritable bowel syndrome.

In many patients, scanty diarrhea without steatorrhea is a manifestation of irritable bowel syndrome.. The diagnosis of this disease can be made on the basis of a thorough history and the absence of pathology on clinical examination and standard laboratory tests..

If the patient looks healthy, does not notice a decrease in body weight, anemia, accelerated ESR, but there are repeated episodes of diarrhea, usually accompanied by abdominal pain, possibly alternating with constipation, then the diagnosis of irritable bowel syndrome is very likely. Interestingly, irritable bowel syndrome with diarrhea is more common in men than in women..

Manning et al. conducted a continuous examination of 109 patients in gastroenterological and surgical clinics. The following symptoms have helped differentiate patients with irritable bowel syndrome from those with organic diseases: bloating, pain relief during bowel movements, and easier and more frequent bowel movements with pain.

Irritable bowel syndrome is also characterized by a feeling of incomplete emptying, urge to the bottom and discharge of mucus.. The disadvantages of the study include a small number of patients with organic diseases of the large intestine, due to this, the symptoms, taken for the "

Intolerance to certain types of food.

A recent study found that approximately 2/3 of patients with diarrhea attributable to irritable bowel may have food intolerances.; symptoms of the disease recurred with the introduction of these foods into the diet.

Thus, food intolerances are much more likely to cause mild diarrhea than previously thought.. The best studied food intolerance is due to lactase deficiency, with the amount of unabsorbed dietary lactose exceeding the absorption capacity in the colon.

In most people, lactase production decreases soon after weaning.; in some individuals, consumption of dairy products can cause mild diarrhea. Moreover, after suffering nonspecific gastroenteritis, they may re-develop relative lactose intolerance..

Lactase deficiency can be detected simply: by testing for lactose tolerance when taken orally, or by determining the evolution of hydrogen with respiration when loaded with lactose. Increased intake of non-starch polysaccharides for weight loss can increase the carbohydrate content of the large intestine and cause diarrhea in those with hypersensitivity.

One of my coworkers examined a slim man whose stool consisted almost entirely of undigested bran.. Cases of diarrhea due to excessive consumption of sorbitol, a poorly absorbable sweetener used in the manufacture of chewing gum and confectionery for diabetics, have been reported.

Anal sphincter dysfunction.

Patients with diarrhea often have urge to lower urge and stool incontinence, although they hide this.. If the doctor does not know these symptoms and the patient does not have stool mass, a complex and not always necessary examination may be required.. A fairly accurate objective indicator of the normal function of the anal sphincter in patients with diarrhea is the measurement of fluid leakage when 1500 ml of saline is injected into the rectum.

medbe. ru.