DIAREE CRONIC~

DEFINI|IE:

> 3 scaune/zi, peste 4 s`pt.

> 300 g/zi

> 10 ml/kcorp/zi, > 3 s`pt

CONSISTEN|A:
 hidric`
 gr`sos
 alimente nedigerate
NOCTURN
PATOLOGIC: - mucus
- puroi
- s@nge
 DIFEREN|IAT~ DE:

I. INCONTINEN|~:
• SCAUN LICHID
• SCAUN SOLID = ANOMALIE SFINCTERIAN~:
 LEZIUNE PROPRIE
 NEURO MUSCULAR~

II. DISKEZIE
 DIAREE FUNC|IONAL~

1. ISTORIE LUNG~

2. ABSEN|A LEUCOCITELOR, S^NGELUI

3. ABSEN|A PIERDERII PONDERALE

4. APARI|IA EXCLUSIV DIURN~

 FALSE DIAREI

LA CONS TIP A| IE  S CAUN DUR + AP ~

 TU} EU RECTAL

INCONTINEN| ~  ANAMNEZ~ , TU} EU

 MANOMETRIE

TUMORI RECTALE  MUCUS , HEMATOCHEZIE

 RECTOS COP IE
 VALOARE SEMIOLOGIC~
ALTERAREA ST~RII CANCER, IBD
GENERALE
TUMORI, ADENOPATII CANCER, LIMFOM
ARTRITE IBD, WHIPPLE
ULCER G-D S. ZOLLINGER
EDEME S. MALABSORB|IE
FLUSH S. CARCINOID
HIPERPIGMENTARE ADDISON
ERITEM NODOS IBD
GU}E HIPERTIROIDIE, CANCER
NEUROPATIE DIABET, AMILOID
 DIAREE + DURERE
TIP ULCER S. ZOLLINGER
S. KOENIG STENOZ~:
- INFLAMATORIE
- TUMORAL~
PERIOMBILICAL~ ANGOR
LOCALIZAT~ S.I.I.
INFRAOMBILICAL
 FIZIOPATOLOGIE
• DIAREE MOTORIE
CAUZ~ SAU EFECT

• TRANSPORT ANORMAL DE FLUIDE

 SC~DEREA ABSORB|IEI - OSMOTIC~

 CRE}TEREA SECRE|IEI - SECRETORIE

 DIAREI MOTORII
RELA|IE INVERS~ T.T. - VOLUM SCAUN
([n absen\a leziunilor organice)

CARACTERE
1. SCAUN LICHID <1l/24 ore
2. SCAUN IMPERIOS, POSTPRANDIAL
3. RESTURI ALIMENTARE
4. TEST INDIGOCARMIN TT< 8H
5. INFLUEN|A ALITARII
 ETIOLOGIE
• CAUZE ORGANICE • CAUZE ENDOCRINE

- GASTRECTOMII - HIPERTIROIDIE

- COLECISTECTOMII - CANCER MEDULAR

- REZEC|II, BOLI - S. CARCINOID

• DISAUTONOMIE -
ILEALE
NERVOASE
- FISTULE
• IDIOPATICE
 FIZIOPATOLOGIA OSMOTIC~

SARCIN~ OSMOTIC~   DILU|IE  APA 

IZOTONIE  RETRORESORB|IA Na  
VOLUM   CRE}TEREA "GAP"

OSMOLARITATEASC - OSMOLARITATEAS < 20

(Na + K)X 2 (N = 220 mEg/l)

 ETIOLOGIE
1. EXOGENE:
 LAXATIVE: PEG, Mg, Na2PO4,
Na2SO3
 ANTIACIDE
 VARIA: - COLCHICIN~
- COLESTIRAMIN~
- NEOMICIN~
A 60-year-old woman with a family history of colon cancer and a history of adenomatous colorectal
polyps underwent surveillance colonoscopy

Ahmed S and Gunaratnam N. N Engl J Med 2003;349:1349

 ETIOLOGIE
2. ENDOGENE:
A) CONGENITALE:
- DEFICIT DE LACTAZ~
- ABSORB|IE  GLU., FRUCT.
- ALIPO
- LIMFANGIECTAZIE
- FIBROZ~ CHISTIC~
B) DOB^NDITE - S. MALABSORB|IE
A 50-year-old woman presented with a five-month history of fatigue, weakness, and diarrhea

Lubinski S and Hendrix T. N Engl J Med 2004;351:808

 DIAREE SECRETORIE
PATOGENIE: INCAPACITATEA DE ABSORB|IE
SAU/}I SECRE|IA ACTIV~ DE Na, K, Cl
= SCAUN IZOTONIC CU PLASMA

INFEC|IOASE: NONINFEC|IOASE
HOLERA  HORMONALE
 COLI  LAXATIVE
 PERFRINGENS  A. VILOASE
 CEREUS  MALABS. AC.
 AURIU BILIARI, GR~SIMI
 hemoragie

Modific`ri Protrombin` ↓ Dezhidratare

piele

1 Fracturi Acizi gra]i

edem
Vit. A Vit. K
Ca2+
1 Diaree
Atrofie Hipo- Pierdere
Osteoporoz` serinemie Vit. D
vilozitar` acizi gra]i

osteomalacie

Deficit Pierdere Pierdere a.a.

Denutri\ie glucide, minerale, Electroli\i
proteic calorii
vitamine

1
Ac. folic Vit. B12 Vit. B6 Vit. B2 Vit. B1 Fe

Insuficien\` Hipo-
pancreatic` pituitarism
anemie anemie anemie Glosit` anemie

Amenoree Polinevrit`
 DIAREI INFLAMATORII
I. LEZ. MINIME:
- BACTERII (EAEC)
- VIRUSURI (ROTA, NORWALK)
- PARAZI|I (GIARDIA, ASCARIS)
- MIXT (SPRUE TROPICAL)
- CITOSTATICE
- Rx TERAPIE
- COLIT~ COLAGEN
- GVHD
A 63-year-old woman was admitted to the hospital with vomiting and abdominal pain

Esser-Kochling B and Hirsch F. N Engl J Med 2005;352:e4

II. LEZIUNI MACROSCOPICE

- COLITA ULCEROAS~

- BOALA CROHN

- DIVERTICULITA

- COLITA ISCHEMIC~
 S. MALABSORBTIVE

DEF: INCAPACITATEA T. DIGESTIV DE A

TRANSPORTA CU V. NORMAL~ HRANA
{N COMPLEXITATEA EI SAU A
ORIC~RUI COMPONENT LUMEN-S^NGE,
LIMFA.
DIFERIT~ DE MALDIGESTIE
 TIPURI
ABSORB|IE DEFECTOAS~
-HIPER
-HIPO

- GLOBAL~
- SELECTIV~
 MECANISME
1. ACTIV~:
- NECESIT~ ENERGIE
- NECESIT~ TRANSPORTOR
- POATE FI INHIB. COMPETITIV
2. FACILITAT~:
- NECESIT~ TRANSPORTOR
- POATE FI INHIBAT~ COMP.
3. PASIV~: - CONFORM GRADIENTELOR
 ABSORB|IE

PE PRINCIPII:
• Fe, Ca, VIT. HIDROSOLUBILE, GR~SIMI 
JEJUN
• ZAHARURI  INTESTIN PROXIMAL }I MEDIU
• A. ACIZI  INTESTIN MEDIU
• VIT B12, S~RURI BILIARE  ILEON DISTAL
 PATOGENEZA STEATOREEI
1. DIGESTIE DEFICITAR~
2. ALTERAREA FORM~RII MICELIILOR
3. TRANSPORT ANORMAL:
a) RED. S. ABSORBTIVE: rezec\ii, fistule
b) ALTERAREA MUCOASEI: sprue, parazi\I
c) DEFICIT DE LIPOPROTEINE
d) BLOCAJ LIMFATIC:- limfoame
- meta
- TBC
 STEATOREE

6-14 g > 14g < 6g

FIZIOLOGIC
ABUNDENT~

ECHO
PANCREAS
DA NU ABD
BILAN|

ENDOSCOPIE,
BILAN| BIO JEJUN NU
DIAREE
SECRETORIE
OSMOTIC~ D-XYLOZ~
BILAN|
ENTEROSCOPIE

PATOLOGIE
N

PANCREAS
 hemoragie

Modific`ri Protrombin` ↓ Dezhidratare

piele

1 Fracturi Acizi gra]i

edem
Vit. A Vit. K
Ca2+
1 Diaree
Atrofie Hipo- Pierdere
Osteoporoz` serinemie Vit. D
vilozitar` acizi gra]i

osteomalacie

Deficit Pierdere Pierdere a.a.

Denutri\ie glucide, minerale, Electroli\i
proteic calorii
vitamine

1
Ac. folic Vit. B12 Vit. B6 Vit. B2 Vit. B1 Fe

Insuficien\` Hipo-
pancreatic` pituitarism
anemie anemie anemie Glosit` anemie

Amenoree Polinevrit`
 CLINICA
1. SIMPTOME SPECIFICE DEFICITELOR
SAU MALABSORB|IEI GENERALE
2. SCAUN
3. DISTENSIE ABDOMINAL~
4. CRAMPE
5. GREA|~
6. ANOREXIE
 DIAGNOSTIC

I. STABILIREA MALABSORB|IEI
A) DOZAREA LIPIDELOR
B) CA = (GD-GF)/GD X 100 N>94%
C) IZOTOPI IBI
D) PROTEINE MARCATE N<5%
E) D XYLOZ~
 DIAGNOSTIC
II. DEFINIREA DEFICITELOR NUTRI|IONALE
III. DG. ETIOLOGIC:
1. ANAMNEZA
2. EX. FIZIC
3. TESTE:
- Rx: - nespecific
- specific: - fistule
- obstruc\ii
- diverticuli
4. BIOPSIE
 ANATOMIE PATOLOGIC~

1. ENTERIT~ RADIC~: - ACUT

- CRONIC
2. LIMFANGIECTAZIA
3. SCLERODERMIA
4. HIPO γGLOBULINEMIA
5. PARAZI|I
 CLASIFICARE

I. LEZIUNI MUCOASE:
- SPRUE
- SPRUE TROPICAL
- DERMATITA HERPETIFORM~
- COLAGENOZE
- HIPO γGLOBULINEMIA
II. LEZIUNI PARIETALE:
1. CONGENITALE:
- I. SCURT
- LIMFANGIECTAZIA
2. DOB^NDITE:
- B. CROHN
- LIMFOAME
- AMILOID
- INSUF. ARTERIAL~
- RxT
- OBSTRUC|IE LIMFATIC~
III. INFEC|II:
1. ENTERITE ACUTE
2. PARAZI|I
3. TBC
4. WIPPLE
5. STAZA:
a) ANATOMIC
b) FUNC|IONAL
IV. L. BIOCHIMICE:

1. ALACTAZIE

2. A  LIPOPROTEINEMIE

3. AN  LIPOPROTEINEMIE

4. S. ZOLLINGER

5. MACROAMILAZEMIA
V. BOLI EXTRADIGESTIVE
A) ENDOCRINOPATII:
- tiroid`
- paratiroid`
- diabet
- Addison
B) TUMORI:
- renale
- s. carcinoid
 SPRUE CELIAC
(ENTEROPATIA GLUTEMIC~)

BAZ~ GENETIC~:
 1:300 Irlanda
 1:2000 alte zone
 grup sanguin "O"
 femei x 2 B
• FACTORI EXOGENI :
- GLIADINA - frac\iune solubil` [n alcool.
• FACTORI IMUNI:
- Ag HLA cl II DQ3
- Ac antigliadin`
- Ac antiendomisium
- Ac antireticulin`
 ANATOMIE PATOLOGIC~

1. Alterarea microcitelor

2. Pierderea vililor

3. Infiltrat limfocitar [n lamina

4. Cre]terea nr. mitoze

 FIZIOPATOLOGIE

1. REDUCEREA SUPRAFE|EI ABSORPTIVE

2. SC~DEREA ENZIMELOR
 CLINICA
1. V^RSTA DE DEBUT
2. SCAUN
3. MANIFEST~RI GENERALE:
- ASTENIE
- INAPETEN|~
- SL~BIRE
4. G-I: - DIAREE 90%
- ABDOMEN DESTINS 75%
- ABDOMEN DUREROS 50%
5. SECUNDARE MALABSORB|IEI
 MANIFEST~RI SPECIALE

1. MODIFICAREA AMPRENTELOR

2. FEBR~

3. SPLENOMEGALIE

4. TROMBOCITOPENIE
 DIAGNOSTIC DIFEREN|IAL

1. BOLI FUNC|IONALE

2. S. MALDIGESTIE

3. S. MALABSORB|IE
 Diagnosticul diferential al atrofiei
viloase
• Giardia
• Sprue colagenic
• Enterita radica
• B.Whipple
• Tuberculoz
• Gastroenterita eozinofilica
• Limfoame
• S.Zollinger Ellison
 DIAGNOSTIC POZITIV

1. AMELIORARE:

- CLINIC~: 1-14 zile

- ANAT-PAT: 14-180 zile

2. RECIDIV~
 COMPLICA|II

1. LIMFOAME

2. CANCERE:

 ESOFAG

 OROFARINGE

 S^N
 TRATMENT
• Sunt interzise graul,orzul,secara

• Sunt permise orezul porumbul sorgul ovazul

• Surse de amidon care pot fi folosite
hrisca,mei,arorut,cartof,tapioca
• Nuci,alune,floarea soarelui
An Assessment Plan for a Patient with Poorly Responsive Celiac Disease

Green P and Cellier C. N Engl J Med 2007;357:1731-1743

 DEFICITUL DE
DIZAHARIDAZE
• AMIDON - amilopectine
• GLICOGEN - amilaza

AMILAZA 1,4:  MALTOZ~

 MALTOTRIOZ~
 DIZAHARIDAZE

• MALTAZ~

• SUCRAZ~

• LACTAZ~

 DEXTRINAZ~
 DISTRIBU|IA

• {N TIMP (L III)

• ANATOMIC~
 DEFICIT

1. PRIMAR

2. SECUNDAR:

a) aport excesiv

b) rezec\ii

c) b. intestinal`
 FIZIOPATOLOGIE
DEFICIT LACTAZ~

HIDROLIZ~ DEFICITAR~

CRE}TE PO FERMENTA|IE
-crampe
-diaree AC. ORGANICI
-grea\`
DIAREE
 DIAGNOSTIC

1. CLINIC
2. BIOLOGIC
3. HISTOCHIMIC
4. COPROLOGIC
5. Rx
6. RESPIRATOR
 BOALA WHIPPLE
• Boala rara , proteiforma caracterizata prin
diaree, slabire artralgii.
• Trophi =hrana
• eryma = bariera
• whipplei
 GERMENELE
• Se transmite fecal- oral
• Se cultiva pe celule sau mediu cu amino-acizi
• Are And de< 1 megabaza
• Se recunosc 2 specii
ANATOMIE PATOLOGICA
 Patogenie
• HLA-B 27 / imunosupresie
• Invadeaza macrofagele care sufera apoptoza ,
permitand diseminarea
 EVOLUTIE STADIALA
• PRODROMAL - ARTRITE
- artralgii
• STARE DUPA 6 ANI - BARBATI 90%
- SLABIRE 93%
- DIAREE 80%
- ARTRITE 70%
- ADENOPATII 40%
- MELANODERMIE 50%
 Diagnostic

Anemie,leucocitoza±eozinofilie,trombopenie
Reactanti de faza acuta
Mucoasa duodenala
galbena,mitoasa/eritematoasa,eroziuni,fri
abila
Coloratia PAS
Aspect trilamelar al peretelui microbian
Colorare imunochimica
 TRATAMENT
• Tetraciclina
• Sulfamethoxazol-trimetoprim 800/1602
• Streptomicina 1g/zi+ penicilina 1,6 milU/zi
+ ceftriaxon 2g/zi
 Initial Treatment and Subsequent Relapse in Whipple's Disease

Fenollar F et al. N Engl J Med 2007;356:55-66

 GASTROENTEROPATIA
EXUDATIV~
• DEFINI|IE: Sindrom caracterizat prin pierderi
anormale de proteine.
• CLINIC: DIAREE + EDEME + DURERI
• BIOLOGIC:
- clearance 1AT > 12mg/24 ore
- albumin` marcat` (Tc, Cr)
 ETIOLOGIE
I. CAUZE CE CRESC PRESIUNEA INTERSTI|IAL~
1. Limfangiectazia congenital`
2. Obstruc\ia mezenteric`:
a) TBC
b) sarcoidoz`
c) limfoame
d) fibroz` retroperitoneal`
3. Cre]terea PVC:
a) pericardit` constrictiv`
b) insuficien\` cardiac`
II. BOLI CU ULCERA|II:
a) gastrite sau enterite erozive
b) neoplazii
c) b. Crohn
II. BOLI F~R~ ULCERA|II:
a) Menetrier
b) Whipple
c) alergice
d) gastroenterite eozinofile
e) sprue
f) SLE