practitioner under lock must understand the state that
is characterized by two ormorebasic features. For Treatment
presence of HZ only two signs, recorded during the twelve
weeks, not necessarily consecutive. is an important indication of the patient to replace the usual rhythm
bowel movement, disturbing the patient,
bringing him uncomfortable. The last is important because it must be remembered that a number of
healthy individuals revealed a rare rhythm of defecation, without delivering any inconvenience
man.
In the medical literature in recent years there has been a noticeable increase in interest
HZ. The reason is the significant spread of this disease
among the world's population, and Russia is no exception.
There is evidence that chronic constipation on land, on average suffer about 12% of adults
people.
Chronic constipation can result from exposure
very large number of etiological factors that have a point of its application
one common link in the pathogenesis - a violation of motor activity
gastrointestinal tract in general and the colon in particular.
Its formation can cause disturbances in any part of the system, which controls
motor activity of the intestine, causing the development of dyskinesia, which plays
leading role in the pathogenesis of constipation. It should be noted that both gipomotornaya,
and gipermotornaya dyskinesia, often even the last (20-25%) may lead to
HZ. Characteristically, as a whole with dyskinesia of the colon is disturbed the normal relationship between
anastaltic propulsion and motor activity.
With increased activity of spastic colon, hypertonicity, propulsive
activity is significantly reduced, while the proportion of segmented reductions
markedly increases, and causes constipation.
Total identify two basic forms of constipation: constipation, cause
which is the slow movement of the contents of the colon, and constipation,
associated with the violation function of the rectum and / or anal sphincter.
In addition, we differentiate functional and organic (mechanical), constipation, intestinal and extraintestinal
constipation, constipation in normal and expand the size of the large intestine
, primary, secondary, idiopathic, constipation, divided by
topographical principle, respectively, "functional units" thick
intestine, etc.
treatment of constipation each time is difficult for the clinician
problem since, unfortunately, patients often have long-term, in order of self-medication,
inconsistently and incorrectly take laxatives, enemas abuse.
problem of a doctor in every case - to bring the situation under control, assign resources,
best shown in the specific form of constipation, to convince the patient in need
change their habits, stereotype behavior. At its core,
treatment of constipation based on the principle of combination of basic, universal
recommendations (basic therapy) and treatment, which most shows at
certain pathogenic form of chronic constipation.
All laxatives are divided into groups according to their
basic mechanisms of action: money, causing the increase in fecal
masses means that increase the osmotic pressure; prokinetics; means
irritant; means having demulcent action on
intestinal contents.
Clearly, as basic assignments always
recommended an increase in fluid intake and foods containing high amount of dietary fiber
. Of particular significance these recommendations become
with simple constipation associated with nutritional factors, stagnation of the contents in
colon. Main line of treatment in this case is to normalize the power
patient appointment diet, enabling
propulsive activity of the colon. Patients were assigned to diet number 3, the food containing
fiber, including substances which increase the amount of fecal masses -
edible bran. It should be noted that today's commercially available ready-to-eat food
bran with different additions of mineral salts, vitamins,
medicinal herbs are added to the first dish, porridge, salads,
dairy products. taking food bran based on water absorption,
increase in gut contents and its softening. Besides
bran are excellent sorbent, particularly for cholesterol.
food Eating bran should start with one or two teaspoons 3 times a day, bringing
dose up to a tablespoon 3 times a day, picking up the number and multiplicity of techniques in
depending on the resulting effect. The good effect of increasing the content
intestine can be expected from receiving combined mixtures type "muesli",
dasgs divizita, mukofalka, methylcellulose, psyllium, calcium polikarbafila
. It should be noted that some patients, especially with chronic constipation
against irritable bowel syndrome, not tolerate products,
contain dietary fiber. In this case, the dasg of choice is precisely
mukofalk, which does not irritate the intestines. It may be recommended to patients
eating bran along with seaweed, flax seed, sugar beet,
corn, oats, barley, buckwheat cereals, raw vegetables and fasits (at least 200
g / day), especially shown receiving pasnes, apricots, bananas and apples.
good effect can be the use of meat containing a large number of
connective tissue, lactic acid products, dry white wines,
beer, kvas, fats, mostly of plant origin (olive,
corn oil). especially shown slag food load at gipomotornoy
dyskinesia intestine. To stimulate intestinal peristalsis advisable to drink
fasting 1-2 glasses of cold water or fasit juice with the addition of one tablespoon
xylitol or honey. It should be noted that a diet with gipermotornoy
dyskinesia of the colonmoregentle, low-fiber diet
(vegetables boiled, vegetable oils), and the introduction of food into the diet of bran
and other mixtures should start with small doses. HZ Treatment should always begin with
diet, and only when the ineffectiveness or inefficiency
to the appointment, above all, means increasing the volume of intestinal contents
, especially since the application of the latter to maintain a safe
normal stool for a long time. Currently, it is clear that
need to use laxatives category with HZ, when the
opportunities diet does not give the desired result.
Continuing the conversation on laxatives for basic treatment of constipation and
features of the differentiated treatment of its various forms, especially when
lack of effectiveness of diet and funds, increasing the volume of intestinal contents
due to dietary fiber, you should go to reception facilities,
increasing osmotic pressure. Osmotic laxative effect caused
of osmotic forces contribute to fluid retention in the intestine, acting similarly
vlagosvyazyvayuschim ballast substances, as described above. However, these substances
there are some features that make their application in the HZ in the majority of
casesmoreeffective than monotherapy with ballast substances.
wide use now are preparations based on synthetic disaccharide
- lactulose. The mechanism of action of lactulose is based on its decay under the influence of
bacteria of the colon to organic acids, having
low molecular weight (lactic, acetic, butyric, and propionic). As a result,
on the one hand, there is acidification of the gut contents, on the other -
increase of osmotic pressure in the colon, water retention and increase
amount of content.
use of lactulose is now as if the second stage of treatment
HZ, rigid to therapy diet with high content of ballast substances
. especially shown the use of lactulose in patients with chronic liver disease
with the syndrome of portal hypertension associated with HZ,
in pediatric patients, the elderly, with HZ and diabetes mellitus have
pregnancy, renal failure, and constipation medication in patients
on bed rest and inactivity, neurogenic constipation. Lactulose helps
and proctogenic constipation, facilitating the act of defecation. lactulose preparations
available as a syasp or powder, which is usually used inside of 1-3
tablespoons per day (syasp) in the first half of the day or night. As a general asle,
optimal dose is chosen by the patient.
Promising Dasgs with the described (osmotic)
mechanism of action, butmoretime-consuming stable laxative effect,
include dasg macrogol 4000 - high molecular polymer, causing
increase of intestinal contents and softening due to the formation of additional
hydrogen bonds with water molecules. macrogol 4000 are assigned to
night of 1-2 sachets, dissolve in water. The advantage of dasgs based on
lactulose and macrogol 4000 is that these funds do not have
irritating effect on the intestinal wall and not addictive.
Data analysis of the literature on the comparative efficacy of cellulose, lactulose and macrogol 4000
patients with HZ showed that the greatest efficiency,
significantly differs macrogol 4000.
distinctive feature of modern therapy of pathological
conditions associated with impaired motor activity of the digestive system in general and
HZ in particular, is increasing the use of dasgs,
stimulating and regulating motor activity
various departments of the gastrointestinal tract, so-called prokinetics. These tools are rarely appointed
monotherapy HZ, but in the combined treatment can
significantly increase its effectiveness. especially shown when their appointment
gipomotornoy dyskinesia thick intestine.
Currently, the most common prokinetic
are dopamine antagonists (metoclopramide and domperidone).
Metoclopramide acts on D2-receptors, being also serotonin antagonist
receptors has a normalizing effect on the locomotor activity of the large intestine
, reinforcing it with oppression and braking in the amplification. dasg is given by
0,01 g 3 times a day for 15-20 minutes. before a meal for up to two weeks.
newer dasg of this group is domperidone which
mainly acts on the motility of the esophagus, stomach and duodenal ulcer
. However, the stimulating effect of domperidone on the system of bile,
especially when gipomotornoy dyskinesia of the gallbladder, often associated with HZ,
leads to successful treatment of chronic constipation on the background of cholestasis associated with
atony of the gallbladder. Domperidone is assigned to 0.01 g 3 times daily before meals inside
or under the tongue (lingual tablets).
morepronounced clinical effect in these types of constipation makes use of prokinetic combination with
cholagogue (allohol, Lioba) or preparations containing
henodeoksiholevuyu and ursodeoxycholic acid. These dasgs have a
pronounced stimulatory effect on motor activity of the colon due to
effect on its receptor apparatus.
A new and promising avenue for the correction of motor disorders
colon especially with irritable bowel syndrome with constipation
phenomena is the use of synthetic enkefalinergicheskih
opioid receptor agonists, dasgs and fedotozin trimebutin. Fedotozin,
being the k-receptor agonist, increases the pain threshold in the colon, removes the
a sense of bloating, fullness, a favorable effect as under hypokinetic and hyperkinetic forms
for violations of motor activity of the intestine.
Trimebutin interacts with m-, d-and k-receptors, enkephalins, having
normalizing effect on motility intestine. Trimebutin appoint 0,1 - 0,2
g 3 times daily before meals (3-4 weeks).
When gipermotornoy dyskinesia (spastic phenomena)
shown along with the application of hyoscine butylbromide trimebutinom, otiloniya bromide,
pinaveriya bromide, homeopathic remedy - spaskuprelya.
possible reception and traditional antispasmodics (drotaverine, papaverine). A very good effect in
constipation with spastic component gives warm oil enema in the amount of 150-200
r. functional constipation justified combination with prokinetic eubiotics
(means normalizing the bacterial flora of the intestines).
In the presence of pathogens is particularly shown in the appointment of erythromycin, which besides
antibacterial action and has a stimulating effect on motor activity
colon. The mechanism of stimulating effect of erythromycin and other macrolides
is to stimulate the motilin receptor latest,
neyropeptidnogo hormone involved in regulation of gastrointestinal motility
tract.
At the low efficiency of the above-mentioned therapy as
involuntary measures should be the appointment of adequately matched laxatives
of inhibiting the absorption of water from the intestines and stimulates secretion by
chemical stimulation of chemoreceptor organs mucosal thick
intestine. This is especially herbal dasgs in the
which includes antraglikozidy (preparations of leaves and fasits of Senna, Saburo, root
rhubarb zhostera fasit, bark buckthorn, castor oil) as well as synthetic chemicals
(Bisacodyl, sodium pikosulfat) and saline laxatives.
Some of these dasgs are able to soak,
metabolized by the liver and excreted in the bile. The main mechanisms
action of these laxatives are effective in accelerating the advancement
contents of the intestine due to increase peristalsis and fluid in
feces.
most popular laxatives of this group are
anthranoids (sennosidy) related to long-known plants.
should remember that the vegetable origin of products containing antraglikozidy,
has no tangible benefits, no obvious flaws and is often used in
as false advertising. Moderate , indicated, in adequate doses
supplementation on anthranoids not accompanied?? Firmed
side effects. However, with continuous, excessive use of sennosidov in
colon mucosa irritation develops cancer, melanosis, and
to some reports, the degeneration of nerve endings, leading to the development of inert
intestine, may also receive and water-electrolyte imbalance because
disorders of sodium and water absorption in the colon, liver and kidneys.
However, there is an opposite opinion, that at normal dosages
these phenomena do not occur, and the hypothesis about the defeat of the autonomic nervous system of the large intestine
chronic administration of these funds appears to be incorrect. Neuropathy is
colon - this is the reason of the mobility impaired gut and thus cause
laxatives, rather than their consequence.
Typically, dasgs containing Senna (leaves or fasits),
taken 1 time a day, and defecation occurs within 8-12 hours
course of treatment with these dasgs should not exceed 2 weeks. Synthetic laxative Bisacodyl
appointed for 2-3 pills a day, or one candle rectal sodium
pikosulfat - with 5-15 drops per day. Phenolphthalein is not currently used
.
It is worth reiterating that moderate use of laxatives
the group with HZ, especially when basic therapy
gives an unsatisfactory effect, or for rapid clinical effect in its early
clearly shown and should be applied. Particularly indicated in these funds
gipomotornom, "senile" constipation.
Saline laxatives (sodium and magnesium sulfate, Carlsbad and
Morshinska laxative salt) is currently used for the treatment of HZ
limited.
emollient, facilitating the transit of intestinal contents
of the colon due to the lubricating effect (Vaseline, olive,
almond oil), the action begins at the level of the small intestine after 4-5 hours reception,
causing branch chair, close to normal. Emollient
possess both hydrophobic and hydrophilic properties, hold water, increasing
amount of feces, and softening of the contents of the colon facilitates
process emptying and relieves the painful symptoms of constipation. Particularly shown
use emollient for rectal forms of constipation, contact
laxatives can be given in the form of candles (candles with glycerin, candles Bisacodyl),
mikroklizm (combined dasg norgalaks containing
carboxymethylcellulose, glycerin and docusate sodium), but the application of the latest
should not be prolonged because of the possibility of irritation of the rectum.
enemiasis with HZ should be limited to periodic
single application. Especially shown in patients with habitual constipation alternating
water-oil enema (volume 300-400 mL) with cleaning (once a week) with a view to restoring
reduced or lost reflexes. Good effect on the functional constipation
provides physiotherapy, acupuncture, psychotherapy. When
existence of an internal prolapse rectal mucosa, even in the early stages (when
lung vain attempts) should be used surgical technique.
In any case, treatment of chronic constipation
requires an individual approach, an accurate diagnosis causes constipation, and substitution
pathogenic, integrated, staged treatment of long-term use of laxatives
especially irritating, is not allowed.
The article was published in the journal
Pharmaceutical Bulletin