Chronic Enteritis - Treatment

In case of exacerbation of the disease, inpatient treatment and bed rest are recommended.

Treatment of chronic enteritis should be comprehensive, including agents that affect the etiologic and pathogenetic factors, as well as local and general manifestations of the disease. According to research, 84% of patients with chronic enteritis received a positive result from comprehensive treatment, including diet, enzyme and weak choleretic drugs, antibacterial, enveloping, astringent, adsorbing, neutralizing organic acids along with drugs that normalize the passage of contents through the intestine and reduce inflammatory processes in it when applied locally. Diarrhea, abdominal pain, bloating, rumbling stopped in patients, which in 52% of cases was combined with a decrease in the degree of colonization of the upper parts of the small intestine with microorganisms.

Therapeutic nutrition for chronic enteritis. An essential component of complex therapy is a mechanically, chemically and thermally gentle diet. Therapeutic nutrition has a positive effect on the main links in the pathogenesis of diarrhea: it reduces not only the increased osmotic pressure in the intestinal cavity, but also intestinal secretion, leading to the normalization of the passage of contents through the intestine.

At first, during an exacerbation, diets No. 4 and 4a are prescribed, which help eliminate inflammation, fermentation processes in the intestine, and normalize intestinal peristalsis. After 3-5 days, the patient is transferred to a full diet (No. 4b), rich in protein (up to 135 g), containing a normal amount of fats and carbohydrates (100-115 and 400-500 g, respectively). Exclude products containing coarse vegetable fiber (raw vegetables and fruits, rye bread, prunes, nuts, raisins), as well as rich dough, snack canned goods, smoked meats, spices, spicy and salty dishes, ice cream, whole milk, carbonated drinks, sinewy meat; pork, beef, mutton fat, legumes, beer, kvass, alcoholic beverages. Limit the use of table salt to 7-9 g per day, potatoes. The diet includes increased amounts of vitamins, microelements, calcium, iron, phosphorus, and lipotropic substances. The energy value of the diet is 3000-3500 kcal.

The diet of patients with chronic enteritis should include foods and dishes that help eliminate the inflammatory process and replenish the deficiency of substances necessary for the body. In case of exacerbation of the disease, soups on mucous decoctions of cereals and weak meat broth are recommended; mashed or well-boiled porridges in water with the addition of a small amount of butter from rice, semolina, buckwheat, oatmeal, pearl barley; boiled and mashed vegetables, except for white cabbage, turnips, legumes; homogenized vegetables and meat (baby food); lean and sinewy meats, fish in the form of quenelles, meatballs, steamed cutlets, meatballs, soufflé, pate, soft-boiled eggs, steamed omelettes, mild and low-fat cheese, fresh homemade cottage cheese, fresh yogurt (if tolerated), fresh sour cream for adding to dishes, yesterday's white bread, fruit jellies, mousses, kissels, compotes, baked non-acidic apples, juices containing tannins (from blueberries, bird cherry, black currants, pomegranate, dogwood, quince, pear), pastille, marmalade, marshmallow, non-acidic jam from soft non-weakening berries and fruits in small quantities. Fractional meals are recommended (5-6 times a day).

Diet No. 4b is prescribed for 4-6 weeks until the stool is completely normalized. Since it is physiological, it can be followed for a long time. During the period of remission, an "unstrained" version of the above diet No. 4c is indicated (the amount of protein is increased to 140-150 g), slightly expanding it: some vegetables and fruits are allowed up to 100-200 g per day: lettuce leaves, dill, parsley, ripe tomatoes without skin, soft pears (duchess), sweet apples, oranges and tangerines, blueberries, blueberries, raspberries, strawberries, wild strawberries.

Food is given boiled, baked or steamed.

Drug therapy for chronic enteritis is carried out taking into account the etiology and pathogenesis of the disease, the nature and severity of intestinal manifestations and changes in the general condition of the patient, and concomitant diseases.

For the treatment of chronic enteritis with increased infection of the upper gastrointestinal tract, with concomitant focal infections (tonsillitis, cystitis, pyelitis, etc.), antibacterial drugs are prescribed (for example, tetracycline 250 mg 4 times a day for 5-8 days, chloramphenicol 0.5 g 4 times a day, erythromycin 200,000 IU 3 times a day for 5-7 days, etc.). For anaerobic flora, lincomycin hydrochloride, clindamycin and metronidazole are effective - 7-10-day courses, in severe cases - repeated weekly courses every 6 weeks. Sulfanilamide preparations (phthalazole, sulgin, biseptol, etazol) and nitrofuran series agents (furazolidone, furazoline 0.1 g 4 times a day for 5-10 days) are also recommended. Oxyquinoline series preparations with antibacterial and antiprotozoal activity, in particular intetrix, enteroseptol, have a beneficial effect. It has been proven that oxyquinoline derivatives should not be prescribed for diseases of the optic nerve, peripheral nervous system, liver, kidneys, and iodine intolerance. Treatment with these drugs should be carried out in short courses and only under the supervision of a physician. In recent years, due to fear of side effects, they have become rarely used; intetrix is used more often, since the methylated derivatives included in its structure reduce its toxicity.

For the treatment of chronic enteritis associated with giardiasis, metronidazole is recommended - 0.25 g 3 times a day for 2-3 weeks or 2.0 g per day for 3 days.

In case of infection of the upper gastrointestinal tract with microorganisms resistant to sulfonamides and antibiotics, or with Proteus, as well as in case of a combination of chronic enteritis with inflammatory diseases of the genitourinary system, nevigramon is prescribed (0.5-1.0 g 4 times a day for 7-14 days). Detection of pathogenic fungi (especially in case of candidiasis) requires the prescription of nystatin or levorin at 500,000 IU 3-4 times a day for 10-14 days. If campylobacter is isolated during stool culture, then erythromycin, gentamicin, as well as tetracycline, intetrix, or furazolidone are indicated.

In case of combination of chronic enteritis with chronic cholecystitis against the background of hypo- and achlorhydria, a good effect can be obtained from nicodine, which has a bactericidal, bacteriostatic and choleretic effect. The drug is recommended to be taken 1.0 g 4 times a day after meals, taking into account the amide nicotinic acid contained in the drug, for 10-14 days. If necessary, 2-3 courses are carried out with a 10-day break.

After using antibacterial drugs, bacterial drugs are prescribed - bifidumbacterin and bificol 5 doses 2 times a day, colibacterin and lactobacterin 3 doses 3 times a day. Thanks to such consistent use of these drugs, it is possible to achieve a more stable clinical effect. This is also facilitated by the gradual withdrawal of bacterial drugs. In this case, the phenomena of dysbacteriosis disappear, the intestinal microflora is normalized.

To influence one of the important intestinal manifestations of the disease - diarrhea, antidiarrheal agents are prescribed, the arsenal of which continues to expand. An effective antidiarrheal agent is loperamide (imodium), prescribed 1 drop per 2 kg of body weight 3 times a day or 1 capsule 2-3 times a day. The drug is well tolerated with long-term use; it inhibits propulsive peristalsis, enhances non-propulsive contractions, increases the tone of the intestinal sphincters, slows down the passage, inhibits the secretion of water and electrolytes, stimulates fluid absorption. Reasek has a pronounced antidiarrheal effect (1-2 tablets or 30-40 drops 3 times a day).

Astringents and adsorbents (bismuth nitrate, dermatol, tannalbin, chalk, white clay, smecta) have not lost their importance, including those of plant origin (alder cones, oak bark, pomegranate peels, rhizome of burnet, snakeroot, cinquefoil, tansy flowers, St. John's wort, sorrel, plantain, knotweed, sage, marshmallow root, comfrey, black currant, bird cherry, blueberry) in the form of decoctions and infusions. Agents that inhibit intestinal motor function have a fixing and antispasmodic property: opium tincture, codeine, atropine, metacin, belladonna extract, platifillin, papaverine, no-shpa in normal therapeutic doses.

To improve the digestion process, enzyme preparations are recommended: pancreatin (0.5-1.0 g 3-4 times a day), abomin (0.2 g 3 times a day), panzinorm-forte (1-2 dragees 3 times a day), festal (1 tablet 3-4 times a day), digitalistal (1 tablet 3-4 times a day), pancurmen (1-2 dragees 3 times a day), mezim-forte, triferment, etc. Enzyme preparations should be taken before or during meals for 1-2 months (repeat courses are indicated if necessary). If a patient with chronic enteritis with reduced gastric secretory function takes enzymes, there is no need to take diluted hydrochloric acid or gastric juice. The exception is patients with achlorhydria, who take these drugs for a long time and note their beneficial effect on well-being and stool character. The normalization of cavity digestion is also facilitated by drugs (liobil) containing bile acids.

In case of a tendency to constipation, gradual introduction of dietary fiber into the diet is recommended. The prescription of laxatives should be approached with great caution. Saline laxatives are contraindicated in chronic enteritis.

In case of severe flatulence, herbal carminatives (chamomile flowers, mint leaves, valerian root, dill seeds, parsley, caraway, calamus rhizome, oregano, centaury, hyssop) are prescribed in the form of an infusion or decoction, as well as carbolene.

In case of simultaneous damage to the small and large intestines, especially the lower section of the latter, treatment is carried out with microclysters with protargol, Shostakovsky's balm, fish oil, chamomile decoction and antipyrine, eucalyptus decoction, etc. in combination with suppositories with belladonna extract, novocaine, xeroform, dermatol, chamomile, etc.

Thermal procedures on the abdominal area: warming, semi-alcoholic compresses, poultices; applications of paraffin, ozokerite; diathermy, non-erythemal doses of quartz, etc., relieve abdominal pain, reduce the frequency of stool.

Transduodenal and rectal bowel lavage should be approached with caution and strictly differentiated to avoid increased abdominal pain and diarrhea. They can be recommended only to patients with a mild course of the disease without signs of intestinal irritation, in whom its atony prevails.

To eliminate changes in the general condition of patients and metabolic disorders, replacement therapy is indicated. To compensate for vitamin deficiency, vitamins B1 and B6 are prescribed parenterally for 4-5 weeks at 50 mg, PP - 10-30 mg, C - 100 mg. Parenteral administration of vitamin B12 is recommended - 100-200 mcg not only for hyperchromic anemia, but also in combination with fat-soluble vitamins for steatorrhea. It is suggested to administer B12 and C on the 1st day, B6 on the 2nd, B1 and PP on the 3rd, riboflavin orally at 0.02 g, folic acid at 0.003 g 3 times a day, vitamin A at 3300 IU 2 times a day.

Courses of parenteral administration of vitamins are carried out 2-3 times a year; between them, multivitamin preparations are prescribed in a therapeutic dose (1 tablet 3 times a day).

In chronic enteritis accompanied by protein deficiency, along with diet, it is recommended to administer parenteral plasma, serum (150-200 ml), protein hydrolysates and amino acid mixtures (aminopeptide, aminokrovin, aminazol, polyamine, alvesin, etc.) 250 ml for 20 days in combination with anabolic hormones: nerobol 0.005 g 2-3 times a day, methylandrostenediol (0.01 g 2-3 times a day), nerobolil, retabolil (2 ml once every 7-10 days for 3-4 weeks), as well as fat mixtures (interlipid). Simultaneous administration of anabolic drugs with amino acids increases the effectiveness of therapy for patients with chronic enteritis.

Anabolic steroids should not be used for a long time, as they have some androgenic properties, and nerobol, in addition, suppresses the production of monoglyceride lipase in the small intestine. It is noted that prednisolone stimulates the production of this enzyme and neutralizes the negative effect of nerobol on it, and also reduces the flow of plasma proteins into the intestine. However, steroid hormones in chronic enteritis are indicated only in severe cases with pronounced hypoproteinemia associated with the syndrome of hypercatabolic exudative enteropathy, which is more common in other severe diseases of the small intestine. They are recommended in cases where there is a clear clinical picture of adrenal cortex insufficiency, confirmed by special studies, in particular, the determination of 17-OCS in urine and blood. In addition, corticosteroid therapy is advisable for patients with a pronounced allergic component that is not relieved by the prescription of antihistamines.

Functional insufficiency of the endocrine system organs is closely conditioned by protein deficiency in the body and often disappears or decreases as it is eliminated. Only in severe cases, occurring with pronounced endocrine disorders, is it necessary to prescribe special hormonal drugs: thyroidin for thyroid gland insufficiency (0.1 g 2-3 times a day), parathyroidin for parathyroid gland insufficiency (0.5-0.1 ml intramuscularly), adiurecrin for pituitary gland insufficiency (0.03-0.05 g 2-3 times a day, inhaled through the nose).

To eliminate mineral deficiency and correct water-electrolyte imbalances in moderate disease (decrease in serum calcium to 4.0-4.3 mEq/l, potassium to 3.0-3.5 mEq/l with unchanged sodium content and normal acid-base balance), 20-30 ml of panangin, 2000-3000 mg of calcium gluconate in 5% glucose solution or isotonic sodium chloride solution - 250-500 ml are administered intravenously by drip. Electrolyte solutions are administered 4-5 times a week for 25-30 days.

In severe cases of the disease (calcium levels below 2.0 mEq/l, potassium levels below 3 mEq/l, hyponatremia, hypomagnesemia, acid-base imbalances), the correction of water-electrolyte imbalances is approached differentially. However, such pronounced water-electrolyte imbalances are more often observed in other severe diseases of the small intestine.

In case of anemia or iron deficiency without anemia, iron preparations are taken orally after meals - ferroplex, ferrocal 2 tablets 3 times a day or gemostimulin 1 tablet 3 times a day; in case of severe iron deficiency anemia, they are administered parenterally: ferrum-lek, ectofer 2 ml intramuscularly every other day - 10-15 injections. Iron preparations should be taken for a long time - even after the hemoglobin content has normalized. To avoid diarrhea, the dose can be reduced.

For macrocytic anemia, vitamin B12 is administered intramuscularly at 500 mcg weekly for 3-4 weeks.

In chronic enteritis caused by immunodeficiency, agents that eliminate dysbacteriosis against the background of blood transfusions and the introduction of gamma globulin provide a good therapeutic effect and also contribute to the normalization of absorption (according to the results of the D-xylose test) and the disappearance of steatorrhea.

For eosinophilic enteritis, drugs that affect allergic reactions are prescribed; for radiation enteritis, corticosteroids, sulfasalazine, salicylates, broad-spectrum antibiotics, and cholestyramine are prescribed.

Mineral waters for chronic enteritis in the absence of diarrhea should be taken with caution, warm, without gas, no more than 1/4-1/3 glass per dose. Only low-mineralized waters can be recommended: Slavyanovskaya, Smirnovskaya, Essuntuki No. 4, Izhevskaya, Narzan, etc. The time of taking mineral water depends on the state of the acid-secreting function of the stomach: with low acidity - 15-20 minutes, with normal - 40-45 minutes, with high - 1 hour 30 minutes before meals.

The prognosis depends on the frequency of relapse, the severity of changes in the general condition and the degree of involvement of a number of organs and systems in the pathological process. The disease is long-term, the course is recurrent. With early diagnosis, timely administration of etiological and pathogenetic treatment, recovery is possible with restoration of the structure of the small intestinal mucosa. In severe progressive course, accompanied by frequent exacerbations, exhaustion, anemia, endocrine, vitamin, mineral deficiency and dystrophic changes in internal organs, a fatal outcome may occur. However, according to a number of authors, this is rare. Some doctors emphasize that chronic enteritis is characterized by a benign course and a favorable prognosis.

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