Chronic enteritis: symptoms

Symptoms of chronic enteritis folding the w tsya symptom of the two that should be considered as a manifestation of the functional disorders associated with changes in the mucous membranes of the small intestine structure. One of them - local enteral syndrome - is caused by disruption of the processes of parietal (membrane) and cavitary digestion (maldigestion); the other - a common enteral syndrome - a violation of absorption of food ingredients (malabsorption), which causes disorders of all kinds of metabolism and changes the general state of the body.

For chronic enteritis of the 1st degree of severity, intestinal symptoms are characteristic, II - a combination of intestinal symptoms with a poorly expressed disturbance of metabolic processes, III severity - pronounced metabolic disorders with the appearance of often irreversible changes in internal organs. The symptomatology of chronic enteritis in its late stage does not actually differ from the symptoms of other diseases occurring with the syndrome of impaired absorption - gluten enteropathy, exudative hypoproteinemic enteropathy, Crohn's disease, Whipple's disease, etc. Therefore, it is necessary to carefully examine patients with chronic enteritis of grade III severity to exclude these diseases.

Local enteral syndrome. It is characterized by the following intestinal manifestations: flatulence, abdominal pain, mainly in its middle part, bloating (abdomen has the shape of a bell), loud rumbling, diarrhea, less frequent constipation, or alternation. At palpation, tenderness is noted in the middle part of the abdomen, as well as on the left and above the navel at the level of the XII thoracic - I lumbar vertebrae (Porges symptom), "splash noise" in the cecum area (Obraztsov's symptom). Cal has a clayey appearance, characterized by polypheal.

For the local enteral syndrome the following clinical symptoms are characteristic.

Stool disorders

For chronic enteritis the most typical is diarrhea, the frequency of stools varies from 4-6 to 20 times a day. Sometimes patients note the rapid urge to defecate immediately after eating, while the bowel movements are abundant, watery. Defecation can be accompanied by general weakness, trembling of hands, tachycardia, lowering of blood pressure.

The amount of feces with chronic enteritis is increased (polyphecal), feces are liquid or mushy, light yellow, contains pieces of undigested food, muscle fibers (creatorrhea). The presence of blood and mucus in the stool is uncharacteristic. When the fat content (steatorrhea) is large, the stool becomes gray, clayey, shiny, ointment. The predominance of putrefactive processes determines the fetid odor and alkaline reaction of the stool. When fermenting processes in the intestine, stooly masses are foamy, with bubbles of gas, have an acid reaction.

The appearance of diarrhea in chronic enteritis is due to:

• intestinal hypersecretion;
• increased osmotic pressure in the cavity of the small intestine;
• intestinal exudation;
• acceleration of passage of intestinal contents;
• inadequate absorption of bile acids in the small intestine.

With a mild and moderate form of chronic enteritis, diarrhea is mainly due to increased exudation, with a severe form of the disease - intestinal hypersecretion and an increase in osmotic pressure in the cavity of the small intestine.

The appearance of diarrhea in chronic enteritis is associated with intestinal hypersecretion, increased osmotic pressure in the cavity of the small intestine, impairment of its motor function, as a result of which the passage of intestinal contents accelerates, intestinal hyperexcession, and diarrhea predominant in patients with chronic enteritis of I and II severity increased exudation, III severity - more often intestinal hypersecretion and increased osmotic pressure in the intestinal cavity. Study of the pathogenesis of diarrhea at the molecular level, allowed to establish that the "brush" fringe mucosa of the small intestine are two enzymes possessing anionstimuliruemoy ATPase activity: Na ⁺, NPHS - ATPase and first Dedicated NaCl / HCO ^- - ATPase, apparently also involved in ensuring the active transfer of ions from cells into the lumen of the gut.

Flatulence

Flatulence is most pronounced in the second half of the day (at the height of intestinal digestion), accompanied by mild pain in the abdomen of a diffuse nature, which intensifies after eating and decrease after the efflux of gases and defecation. In flatulence, the abdomen increases in volume, the patient is prevented by the belt, the belt, and difficulty in breathing is felt. When percussion of the abdomen, common tympanitis is noted. Flatulence is often accompanied by pain in the heart, palpitations, sometimes with poxescular tachycardia. Often, flatulence increases after the intake of sweet milk and dishes containing it.

Stomach ache

Pain in the abdomen with chronic enteritis is not a leading symptom, but is observed quite often. They are localized around the navel (with a predominant lesion of the jejunum), in the right ileal region (with a predominant ileal lesion); often pain spreads all over the stomach.

In chronic enteritis, the following types of abdominal pain are possible:

• spastic;
• due to flatulence;
• mesenteric;
• the effect of ganglionitis;
• mixed nature.

Spastic pains are caused by spastic contractions of the small intestine and are paroxysmal, localized around the navel.

Pain due to flatulence - usually of a permanent nature, is associated with bowel gas inflations and decrease after gas scavenging and defecation.

Mesenteric pains are caused by the development of nonspecific mezadenitis. These pains are permanent in nature, are not related to food, are not stopped by anticholinergics, spasmolytic, do not disappear after defecation and othoevdzheniya gases. Pain is located along the mesentery of the small intestine in the direction: the right iliac region - the navel region - the left hypochondrium. When involved in the inflammatory process of mesentery of the small intestine manifests palpation pain in the following points:

• the point of Perges is on the left and above the navel at the level of the XII thoracic and I lumbar vertebra;
• Sternberg points - 1 - in the ileocecal region, 2 - above the navel at the level II of the lumbar vertebra.

In addition, with the development of mesoadenitis appears a cross symptom of Sternberg. The procedure for determining the symptom is as follows. With the help of deep sliding palpation the right hand probes the cecum and pushes it outward and somewhat downward. Without releasing the right hand, with your left hand, feel the right iliac region medial to the displaced cecum. With inflammation of the mesenteric lymph nodes there is a clear soreness. If the pain is caused by inflammation of the cecum, then there is no pain from it.

Pain due to ganglionitis. With chronic enteritis, it is possible to involve the autonomic nervous system in the pathological process of ganglia. In this case, the pains are of a peculiar burning nature, they are permanent, they do not decrease after defecation and otaozhpeniya gases, as well as after the use of antispasmodics.

Pain of a mixed nature is due to a combination of causes that cause abdominal pain. Most often this is a combination of spasmodic pains and pain caused by flatulence.

Characteristic local manifestations of chronic enteritis are rumbling in the abdomen, intolerance to sweet milk, which is manifested by flatulence, diarrhea after taking milk and dishes containing it. This is due either to allergy to milk, or a deficiency in the intestine of lactase (congenital or acquired) that breaks down the milk sugar - lactose.

At objective research of the patient it is possible to reveal following characteristic displays of a local enteric symptomatology:

• bloated tongue gray-white bloom;
• bloating, mainly in the central areas (with pronounced meteorism) or zapping in different parts of the abdomen (with severe diarrhea).

VP Obraztsov pointed out in his lectures the following characteristic signs of chronic enteritis:

• loud rumbling at a palpation of a cecum that is caused by receipt of liquid contents of a thin intestine in a blind gut; especially this is expressed in the failure of the ileocecal valve. Normally, the cecum does not grumble at palpation, because the contents in it are thick enough;
• rumbling at palpation of the terminal segment of the ileum;
• spastic contractions of the terminal segment of the ileum.

General enteral syndrome. It is characterized primarily by disorders of protein metabolism, with which other metabolic shifts and changes in a number of organs and systems, for example, endocrine, hematopoietic, hepatobiliary, can be related.

The general enteral syndrome develops with moderate and severe forms of the disease and is caused by the development of malodigest syndromes (digestive disorders in the small intestine) and malabsorption (impaired absorption capacity of the intestine).

Patients complain of general weakness, malaise, decreased performance, irritability, poor appetite, memory impairment, headaches, dizziness. Many patients develop functional dumping syndrome (typical for enteritis with a predominant ileal lesion). It is that after eating food, especially rich in carbohydrates, due to the rapid passage of food through the intestines, rapid absorption of carbohydrates and irritation of the insular apparatus, there are phenomena of hyperinsulinism: sweating, trembling of hands, palpitations.

Patients with chronic enteritis dry, flaky, pale or grayish skin, turgor and elasticity of it are reduced, pigment spots on the face, neck, dull, brittle nails, sometimes as "hourglasses", easily dropping hair. The tongue with the impressions of the teeth along the edges, sometimes crimson-red, cracked, papillae atrophied ("lacquered tongue").

In connection with malabsorption syndromes and malvdigestii violations of all types of metabolism develop.

Disorders of protein metabolism

Disorders of protein metabolism are manifested by the following symptoms:

• progressive weight loss;
• muscle atrophy, decreased muscle strength;
• hypoproteinemia (the content of total protein and albumin in the blood is sharply reduced), with a pronounced fall in the blood protein develop hypoproteinemic edema;

The causes of violations of protein metabolism in chronic enteritis are:

• decrease in activity in the mucosa of the small intestine of enzymes involved in the hydrolysis of proteins (glycine-leucine dipeptidase, etc. Peptidohydrolase, enterokinase and other enzymes);
• impaired absorption of amino acids;
• syndrome of exudative enteropathy with increased loss of protein in the lumen of the gastrointestinal tract.

Disorders of fat metabolism

The small intestine plays an important role in the metabolism of lipids: it produces cholesterol, triglycerides, fat absorption, transport of exogenous triglycerides (neutral fats) in the form of chylomicrons, endogenous low-density lipoproteins. Part of the lipids is excreted with feces.

The disorders of fat metabolism have the following characteristic symptoms:

• decrease in body weight, disappearance of subcutaneous fat;
• steatorrhea (increased secretion of fats with feces);
• a change in the lipid spectrum of blood serum (lowering the content of cholesterol, phospholipids, triglycerides).

The main causes of lipid metabolism disorders:

• decrease in activity in the jejunum of lipase, which provides the initial stages of hydrolysis of triglycerides;
• violation of digestion and absorption of fat.

Disorders of carbohydrate metabolism

Disturbances in the metabolism of carbohydrates in chronic enteritis are observed less frequently than disruption of protein and lipid metabolism, are much less expressed and are manifested by the following symptomatology:

• fermenting intestinal dyspepsia (bloating, rumbling, transfusion, severe flatulence, diarrhea). These symptoms are caused by fermentation of absorbed carbohydrates under the influence of intestinal flora;
• the tendency to decrease the blood glucose, expressed hypoglycemic manifestations are not often observed;
• intolerance to milk (due to deficiency of lactase enzyme);
• a flat glycemic curve after loading with glucose.

The causes of the metabolism of carbohydrates are:

• decrease in the activity of enzymes that break down carbohydrates: lactase deficiency (in 70-85% of patients), saccharase (in 45-50%), maltase (in 55% of patients), as well as pancreatic a-amylase and y- produced by enterocytes;
• malabsorption of carbohydrates in the small intestine.

Disorders of mineral metabolism

Disturbances in mineral metabolism are extremely characteristic of the pronounced malabsorption syndrome.

Hypocalcemia develops in 87% of patients with a disease duration of more than 10 years. The main manifestations of calcium deficiency:

• reduction of calcium in the blood;
• increased neuromuscular excitability (convulsions of the arms and legs, torso, muscle pains, positive symptom of the tail) - convulsive contraction of the facial muscles and the corresponding half of the face when the tragus is tapped in the place of the exit of the facial nerve, the positive symptom of Tissot is in the cuff of the tonometer, superimposed on the shoulder area, air is injected, and when a pressure exceeds systolic blood pressure, a convulsive contraction of the hand occurs in the form of a "midwifery hand");
• osteoporosis (with severe course of malabsorption syndrome).

The main reason for the development of calcium deficiency is a violation of its absorption in the intestine.

Disturbance of metabolism of other electrolytes, trace elements and water-salt metabolism. In connection with the violation of the absorption function of the intestine in patients with chronic enteritis, there is a tendency to decrease the sodium and potassium content in the plasma, as well as to a decrease in the blood levels of magnesium, phosphorus, trace elements: manganese, copper, lead, chromium, strontium, vanadium.

The water-salt balance undergoes certain changes, which is due to the development of secondary hyperaldosteronism as a compensatory-adaptive reaction of the organism in response to a decrease in sodium reabsorption in the intestine and loss of sodium and water in diarrhea. Violation of the water-salt balance is manifested by weakness, pain in the muscles, decreased muscle tone, nausea, vomiting, extrasystolic arrhythmia, lowering of blood pressure.

Of great clinical importance is iron deficiency, which is caused by a violation of iron absorption and has the following manifestations:

• iron-deficiency hypochromic anemia;
• dry skin and mucous membranes;
• Dysphagia due to atrophic changes in the mucosa of the esophagus;
• changes in nails (nails lose their natural shine, become brittle, a spoon-like depression - koylonihia appears on the surface of the nail);
• fragility and hair loss;
• perversion of taste and smell;
• atrophic changes in the gastric mucosa, a decrease in the secretory function of the stomach;
• decrease in the iron content in the blood.

Violations of the exchange of vitamins

The phenomena of polyhypovitaminosis of different degree of severity take place practically in all patients with severe and moderate severity of chronic enteritis.

Deficiency of vitamin C is manifested by increased bleeding gums, nosebleeds, the appearance on the skin of hemorrhagic rash (with severe vitamin C deficiency) due to pronounced capillary permeability.

Deficiency of vitamin B ₁₂ and folic acid is manifested by a picture of B ₁₂ (folic) -deficiency anemia, the characteristic symptoms of which are:

• hyperchromatic macrocytic anemia;
• the appearance in the leukocyte formula of hypersegmented neutrophils;
• atrophic gastritis and lack of free hydrochloric acid in gastric juice;
• defeat of the nervous system in the form of funicular myelosis.

Deficiency of vitamin PP (nicotinic acid) is characterized by skin pigmentation of open areas of the body, dermatitis, taste disorder, tingling sensation and reddening of the tongue with smoothing of its papillae (polished "crimson" tongue); with severe vitamin PP deficiency, it is possible to develop dementia (with prolonged deficiency) and increase diarrhea.

Deficiency of vitamin A is manifested by dry skin, worsening of evening and night vision ("night blindness").

Deficiency of vitamin B _{1 is} characterized by a sensation of burning and tingling in the legs, "crawling", weakness in the legs, a decrease in tendon reflexes (polyneuropathy syndrome).

When vitamin B ₂ deficiency develops angular stomatitis ("seizures" in the corners of the mouth), cheilitis (inflammation of the red border of the lips), dermatitis in the wings of the nose, nasolabial folds.

Deficiency of fat-soluble vitamin K leads to a decrease in the synthesis of prothrombin and bleeding phenomena.

With a deficiency of vitamin D, calcium absorption in the intestine is impaired, which leads to hypocalcemia.

Dysfunction of endocrine glands

Endocrine changes of varying severity are observed in 35-40% of patients with chronic enteritis, mainly with moderate and severe forms of the disease. As a rule, there are clinico-laboratory or only laboratory signs of lesion of several endocrine glands, less often - of any one gland.

Hypothalamic-pituitary insufficiency is manifested by weakness, loss of appetite, thirst, frequent urination, increased cachexia, arterial hypotension, marked pallor of the skin, atrophy of the genital organs, and a sharp decrease in their function.

Hypofunction of the thyroid gland is manifested by puffiness of the face, chilliness, dry skin, memory loss, constipation, hoarseness, bradycardia, hair loss, decreased blood levels of thyroxine, triiodothyronine.

With hypofunction of the adrenal cortex, skin pigmentation appears, body weight decreases, arterial hapotension, hypoglycemia, hyponatremia, hypochloraemia develop, blood levels of cortisol decrease.

Characteristic is the development of gonadal hypofunction.

The defeat of endocrine glands promotes aggravation of anemia in patients with chronic enteritis.

The symptomatology of endocrine diseases is detailed in the relevant section of this manual.

Defeat of other digestive organs

With prolonged and severe chronic enteritis, other organs of the digestive system are attacked - chronic gastritis, reactive hepatitis, chronic pancreatitis, aggravating the course of chronic enteritis.

Degrees of severity of clinical course

Depending on the severity of local and general enteral syndrome, three degrees of severity of chronic enteritis are distinguished.

• Light form (I degree) is characterized by the prevalence of local intestinal symptoms, increased fatigue and a slight loss of body weight (up to 5 kg).
• At an average severity of the disease (grade II), there is a more pronounced weight loss in conditions of adequate nutrition (up to 10 kg), general disorders become more pronounced (trophic disorders, electrolyte shifts), although they do not dominate the clinical picture.
• For severe (grade III), progressive weight loss, dystrophic changes in the skin, nails, hair, symptoms of hypovitaminosis, pain in the calf muscles, bones, hypoproteinemia, anemia, hypotension, edema, menstrual cycle in women, and sexual weakness in men are characteristic.

The mild forms of chronic enteritis are characterized by a latent monotonous course, a recurrent and continuously recurring course is present in the middle and severe forms. Latent flow occurs in secondary forms of chronic enteritis, which has developed in connection with other chronic diseases of the digestive system. Monotonous flow is characterized by scarcity, episodic appearance of enteric symptoms without a tendency to increase. Recurrent flow occurs with a clear alternation of periods of exacerbation and remission, vivid clinical manifestations of the disease in the period of exacerbation, the frequency of the latter no more than 3 times a year. Continuously relapsing current differs from short-duration recurring light intervals (on average from 2 to 4 weeks) between periods of improvement and deterioration, the absence of complete elimination of clinical symptoms of the disease.

[1], [2], [3], [4], [5], [6], [7], [8], [9]