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How often should you have bowel movements?

Regarding the answer to the question? how often should you have stool? The opinions of professional gastroenterologists differ. And this is not surprising, since the frequency of stool depends on many factors. Some of them, for example age, diet, are easy to take into account. Others (individual characteristics of the body) are quite difficult to determine.

The normal frequency of stool varies over a fairly wide range. First of all, stool frequency depends on age. In newborns, stool 6-7 times a day is the norm, while in adults, such a frequency of stool clearly indicates pathology.

However, already in infancy, the frequency of stool strongly depends on the nature of the child’s nutrition. If the baby is breastfed, then the frequency of bowel movements should normally coincide with the number of feedings. In infants who are bottle-fed, stool, as a rule, occurs 1-2 times a day, and there is some tendency to constipation.

The frequency of stool in children over one year old is 1-4 times a day, and in children over three years old and in adults this figure varies within a very wide range: from 3-4 times a week to 3-4 times a day. Here, a lot depends on the nature of the diet (what is the table, so is the chair) and the individual characteristics of the body.

It is generally accepted that the ideal frequency of stool in children from three years of age and in adults is 1-2 times a day.

Having bowel movements 3-4 times a week in itself is not a pathology, but it requires a review of your diet (in such cases, doctors advise increasing the amount of plant-based foods containing dietary fiber in your diet).

The frequency of stool 3-4 times a day in adults and in children over three years of age is the norm if it is not associated with pathological changes in its consistency, color, etc., and is not accompanied by pain during defecation and/or other symptoms of discomfort .

A stool frequency of more than 3-4 times a day indicates pathology. Reason frequent bowel movements There may be various acute and chronic diseases that require adequate treatment.

Meanwhile, very often, instead of seeking qualified medical help and looking for the cause of the increase in stool frequency, patients independently prescribe a variety of antidiarrheal drugs, or are treated with folk remedies. In this way, time is lost, and, consequently, the chances of getting rid of the underlying disease.

Frequent bowel movements due to diarrhea (diarrhea). Symptoms and causes of diarrhea

Diarrhea is stool with a frequency of more than 2-3 times a day, with a pasty or liquid consistency. With diarrhea, stool contains an increased amount of liquid. If during normal stool the stool contains about 60% water, then with diarrhea its amount increases to 85-95%.

Often, in addition to increased frequency and liquid consistency, such symptoms diarrhea, such as a change in the color of stool and the presence of pathological inclusions (blood, mucus, undigested food debris).

Severe diarrhea also increases the volume of stool. Often the human body becomes dehydrated, which can lead to serious complications including death.

Acute infectious diarrhea is characterized by a sudden onset, the presence of general (fever, general malaise) and local (abdominal pain) symptoms, changes in the general blood test (leukocytosis in bacterial, and leukopenia in viral infection).

Infectious diarrhea is a highly contagious disease acquired through contaminated water and food. The “fly” factor is of great importance, so outbreaks of infection are typical for the warm season.

In many regions with hot climates - countries of Africa, Asia (excluding China), Latin America - infectious diarrhea ranks first in the structure of mortality. Children especially often get sick and die.

The period from infection to the appearance of the first signs of the disease depends on the pathogen and ranges from several hours (salmonellosis, staphylococcus) to 10 days (yersiniosis).

Some pathogens have their own “favorite” transmission routes. Thus, cholera spreads mainly through water, salmonellosis through eggs and poultry, and staphylococcal infection through milk and dairy products.

The clinical picture of many infectious diarrhea is quite characteristic; the diagnosis is confirmed by laboratory testing.

Attending doctor: infectious disease specialist

Frequent bowel movements due to bacterial diarrhea

Frequent, painful stools are the main symptom of dysentery.
The reason for frequent bowel movements during dysentery is damage to the large intestine. In some cases, the frequency of stools reaches 30 or more per day, so that the patient cannot count it.

Another characteristic sign of dysentery is changes in the nature of stool. Since the terminal sections of the intestinal wall are affected, the feces contain a large number of pathological inclusions visible to the naked eye (mucus, blood, pus).

In severe cases of dysentery, the symptom of “rectal spitting” occurs - extremely frequent stools with the release of a small amount of mucus mixed with pus and blood smears.

Damage to the large intestine is manifested by another characteristic sign of dysentery - tenesmus (frequent painful urge to empty the bowel).

The frequency of stool and the severity of other symptoms of diarrhea in acute dysentery correlate with the degree of general intoxication of the body (fever, weakness, headache, in some cases, confusion).

In the absence of adequate treatment, acute dysentery often becomes chronic, and bacterial carriage is common. The disease requires hospital treatment and long-term observation.

Cholera. Frequent bowel movements with secretory small intestinal diarrhea
If dysentery is a striking example of exudative type diarrhea, then cholera is a typical example of secretory diarrhea.

The frequency of stool in cholera varies and can be relatively small (3-10 times a day), however, a large volume of stool (in some cases up to 20 liters per day) quickly leads to dehydration of the body.

The onset of the disease is unusually acute, so that without emergency medical care, death can occur within the first hours or even minutes of the disease.

Sometimes the so-called “dry” or “fulminant” cholera occurs, when, due to the massive entry of water into the intestinal lumen, an increase in the concentration of potassium in the blood plasma occurs, leading to cardiac arrest. In such cases, diarrhea does not have time to develop.

In the initial stages of the disease, stools are fecal in nature, then become watery. A characteristic symptom of cholera is diarrhea in the form of rice water. In the absence of adequate therapy, the frequency of stool increases, and vomiting of watery contents may occur.

Meanwhile, there are no inflammatory changes in the intestines, so the general symptoms of cholera are symptoms of dehydration: thirst, dry skin and visible mucous membranes (in severe cases, wrinkling of the skin of the hands - “washerwoman’s hands”), hoarseness (up to complete aphonia), decreased blood pressure, increased heart rate, increased muscle tone (with severe dehydration - cramps).

Often a symptom of cholera is a decrease in body temperature (34.5 – 36.0).
Today, thanks to advances in medicine, cholera has been excluded from the list of especially dangerous infections, and is extremely rare in our region.

Diarrhea of ​​mixed origin. Symptoms of salmonellosis
Frequent stools are a constant sign of salmonellosis, and the frequency ranges from 3-5 times a day in mild forms affecting the upper gastrointestinal tract, to 10 or more times in cases of infection spreading to the terminal parts of the intestine.

Diarrhea due to salmonellosis has a mixed genesis (secretory and exudative). The predominance of one or another mechanism depends both on the strain of the pathogen and on the characteristics of the patient’s body.

Sometimes the disease has a cholera-like course and is complicated by severe dehydration.

A diagnostically significant sign of salmonellosis is the green tint of stool (from dirty green to emerald). The stool is usually foamy, with lumps of mucus. However, with cholera-like diarrhea, stool in the form of rice water is possible. In cases where the infectious process covers all parts of the intestine, including the large intestine, streaks of blood appear in typically “salmonella” feces.

Another distinctive symptom of salmonellosis is pain in the so-called salmonellosis triangle: in the epigastrium (under the stomach), in the navel, right iliac region (to the right of the navel from below).

Acute salmonellosis is characterized by pronounced signs of intoxication: severe fever (up to 39-40 degrees), repeated vomiting, coated tongue, headache, adynamia. In severe cases, generalization of the process is possible (sepsis, typhoid-like forms).

Just like dysentery, acute salmonellosis is prone to becoming chronic, so careful treatment and long-term observation are required.

Frequent bowel movements due to food poisoning
Food poisoning (toxicoinfections) is a group of acute diseases of the gastrointestinal tract caused by consumption of foods containing bacterial toxins.

The cause of the disease in this case is not the bacteria themselves, but their toxins produced outside the human body. Most of these toxins are heat labile and are inactivated by heating. However, the toxin produced by Staphylococcus aureus can survive boiling for 20 minutes to 2 hours.

Most often, foodborne illnesses occur when eating low-quality foods containing high amounts of protein. Staphylococcus most often multiplies in dairy products and creams, clostridia and proteus - in meat and fish products.

Foodborne toxic infections have a group explosive nature, when in a short period (about two hours) all participants in the outbreak (sometimes dozens of people) fall ill.

Diarrhea of ​​secretory origin is an integral symptom of food poisoning, which usually occurs as acute gastroenteritis (damage to the stomach and small intestine). Stool with toxic infections is watery, foamy, without pathological inclusions. With severe diarrhea, dehydration may occur, leading to the development of hypovolemic shock.

Frequent bowel movements (up to 10 times a day) are accompanied by symptoms characteristic of food poisoning, such as nausea and vomiting (most often repeated, sometimes uncontrollable). Signs of general intoxication of the body are often observed: fever, headache, weakness.

The duration of the disease is 1-3 days. However, in some cases, the lack of timely assistance leads to death.

Diarrhea in children. Frequent bowel movements due to exposure to pathogenic E. coli
Escherichia coli is a bacterium that normally inhabits the human intestine. However, some varieties of this microorganism can cause severe intestinal damage in children - the so-called escherichiosis.

The disease most often affects infants under one year of age. Escherichia coli in children causes diarrhea of ​​mixed origin (secretory and exudative), but the leading symptom is dehydration, which is extremely dangerous for the child’s body.

Frequent stools with escherchiosis in children, as a rule, have a bright yellow color and spattering stool. In the case of a cholera-like course, the stool becomes watery and takes on the character of rice water. Diarrhea is often accompanied by repeated vomiting or regurgitation.

Symptoms of diarrhea caused by E. coli depend on the type of pathogen. In addition to cholera-like esherchiosis, there are forms similar to dysentery and salmonellosis. In such cases, signs of general intoxication of the body are more pronounced; there may be pathological inclusions in the form of mucus and blood in the stool.

Pathogenic E. coli can cause serious complications in children of the first year of life, especially newborns, in the form of generalization of the process (blood poisoning). Then the symptoms of diarrhea are joined by signs of infectious-toxic shock (drop in pressure, tachycardia, oliguria) and symptoms of damage to internal organs (kidneys, brain, liver), caused by the formation of metastatic purulent foci.

Therefore, Escherchiosis in children, as a rule, is treated in a hospital under the constant supervision of specialists.

Frequent bowel movements due to viral diarrhea. Symptoms of rotavirus infection in children and adults

Today, several groups of viruses are known that can cause diarrhea in children and adults (rotaviruses, adenoviruses, astroviruses, Norfolk virus, etc.).

In the Russian Federation, rotavirus infection is the most common, with a pronounced winter-autumn seasonality. Sometimes the disease begins as an acute respiratory viral infection, and then symptoms of diarrhea are added with a stool frequency of 4-15 times a day. The stool is light-colored and watery in consistency.

Like other viral diarrheas, rotavirus infection in children and adults is accompanied by severe fever and severe vomiting. The course of the disease is severe or moderate, but complications are rare (the disease goes away in 4-5 days). In young children, diarrhea can lead to dehydration.

Rotavirus infection in adults can cause unusually severe pain, so patients are often admitted to the hospital with a diagnosis of “acute abdomen.”

There are primary and secondary malabsorption. Unlike secondary malabsorption, which arose as a complication of a disease, primary malabsorption is characterized by a congenital malabsorption of certain substances. Therefore, primary malabsorption manifests itself and is diagnosed in childhood.

Malabsorption syndrome in children is manifested by a pronounced lag in development (physical and mental), and requires urgent compensatory measures.

The attending physician for malabsorption syndrome: therapist (pediatrician), gastroenterologist.

Frequent bowel movements due to exocrine pancreatic insufficiency

Frequent bowel movements (3-4 times a day) with exocrine pancreatic insufficiency are caused by a lack of production of enzymes necessary for the breakdown of fats, proteins and carbohydrates.

The reserve capacity of the pancreas is quite large (10% of healthy acini can provide normal enzyme production), however, malabsorption syndrome occurs in 30% of patients with chronic pancreatitis. This is the main cause of malabsorption syndrome in pancreatic diseases.

Much less common is malabsorption syndrome caused by pancreatic cancer. Exocrine pancreatic insufficiency in this case indicates the terminal stage of the disease.

Sometimes malabsorption syndrome is caused by damage to the pancreas due to cystic fibrosis (severe hereditary genetic pathology accompanied by gross disturbances in the activity of the exocrine glands).

Frequent bowel movements in diseases of the liver and biliary tract

Frequent bowel movements in diseases of the liver and biliary tract can be caused by a lack of production of bile acids necessary for the breakdown of fats, or a violation of the flow of bile into the duodenum (cholestasis). The stool becomes acholic (pale) and acquires an oily sheen.

With cholestasis, the normal metabolism of fat-soluble vitamins A, K, E and D is disrupted, which is manifested by the clinical manifestations of corresponding vitamin deficiencies (impaired twilight vision, bleeding, pathological fragility of bones).

In addition, cholestasis syndrome is characterized by symptoms of obstructive jaundice (yellowness of the skin and sclera, itching, dark urine).

Among diseases of the liver and biliary tract leading to malabsorption syndrome, the most common are viral and alcoholic hepatitis, liver cirrhosis, compression of the common bile duct by a pancreatic tumor, and cholelithiasis.

Often, frequent bowel movements are observed after removal of the gallbladder. In this case, the metabolism of bile acids is disrupted due to the lack of a reservoir for their storage.

Frequent bowel movements with celiac disease

Celiac disease is a hereditary disease characterized by congenital deficiency of enzymes that break down gliadin (a fraction of the gluten protein contained in cereals). Uncleaved gliadin triggers an autoimmune reaction, ultimately leading to disruption of parietal digestion and absorption of various substances in the small intestine.

Clinical symptoms of celiac disease in children appear during the period when the child begins to be fed cereal products (porridge, bread, cookies), that is, at the end of the first – beginning of the second half of life.

Diarrhea in celiac disease is characterized by an increased volume of feces, and other symptoms of malabsorption (anemia, edema) quickly appear. The child loses weight and lags behind in development.

When symptoms of celiac disease appear in children, a strict diet is necessary with the exclusion of grains containing gluten (wheat, rye, barley, oats, etc.), additional examination and treatment.

Frequent bowel movements in ulcerative colitis and Crohn's disease

Nonspecific ulcerative colitis and Crohn's disease are chronic inflammatory bowel diseases that occur with exacerbations and remissions. The origin of these pathologies still remains unclear; a hereditary predisposition and connection with the nature of nutrition have been proven (rough plant foods with a large amount of dietary fiber have a preventive effect).

Stool frequency in nonspecific ulcerative colitis and Crohn's disease is an indicator of the activity of the process. In mild and moderate cases, stool occurs 4-6 times a day, and in severe cases it reaches 10-20 times a day or more.

Symptoms of diarrhea in ulcerative colitis and Crohn's disease include a significant increase in the daily weight of feces, a large number of pathological inclusions in the stool (blood, mucus, pus). In the case of ulcerative colitis, there may be profuse intestinal bleeding.

Abdominal pain is more typical for Crohn's disease, but also occurs with ulcerative colitis. A characteristic symptom of Crohn's disease is also dense infiltrates palpated in the right iliac region.

These chronic intestinal diseases often occur with fever and weight loss, and anemia often develops.

Approximately 60% of patients with ulcerative colitis and Crohn's disease experience extraintestinal manifestations, such as arthritis, lesions of the choroid of the eyes, skin (erythema nodosum, pyoderma gangrenosum), and liver (sclerosing cholangitis). It is characteristic that sometimes extraintestinal lesions precede the development of chronic intestinal inflammation.

These diseases in the acute stage require inpatient treatment in a specialized gastroenterology department.

Frequent bowel movements due to colon and rectal cancer

Today, colon and rectal cancer is the second most common cancer among men (after bronchial cancer) and the third most common among women (after cervical cancer and breast cancer).

Frequent bowel movements may be the first and only symptom of colon and rectal cancer. It appears even when there are no signs characteristic of cancer, such as weight loss, anemia, or increased ESR.

Diarrhea in patients with colorectal cancer is paradoxical (persistent constipation followed by diarrhea), since it is caused by a narrowing of the segment of the intestine affected by the tumor.

Another characteristic symptom of diarrhea in case of colon and rectal cancer is that in the stool, as a rule, pathological inclusions are visible to the naked eye - blood, mucus, pus. However, there are cases when blood in the stool can only be determined by laboratory methods.

Particular oncological vigilance should be shown in relation to patients in whom the described symptoms first appeared in old age. The risk group also includes patients with a family history of colorectal cancer: patients who were previously treated for ulcerative colitis or Crohn's disease. It should be noted that colon polyposis is a precancerous condition, and the development of chronic paradoxical diarrhea in such patients can be a serious symptom of oncological pathology.

In such cases, a thorough examination should be carried out, including digital examination, quantitative determination of carcinoembryonic antigen, endoscopic diagnosis with mandatory targeted biopsy, and, if necessary, irrigoscopy.

Such an examination will make it possible to detect the disease at earlier stages and save the patient’s life.

Attending doctor: oncologist.

Frequent bowel movements with diarrhea of ​​hyperkinetic origin

Frequent bowel movements with hyperthyroidism

Frequent bowel movements can be an early sign of hyperthyroidism (occurs in 25% of patients in the early stages of the disease). At one time, doctors excluded the diagnosis of diffuse toxic goiter if the patient did not have daily bowel movements.

Diarrhea, together with such a constant symptom of early hyperthyroidism as severe emotional lability, often becomes the basis for a diagnosis of a functional bowel disorder (irritable bowel syndrome).

The mechanism for the occurrence of frequent bowel movements with increased thyroid function is due to the stimulating effect of thyroid hormones on intestinal motility. The time it takes for chyme to pass through the gastrointestinal tract in patients with symptoms of hyperthyroidism is reduced by two and a half times.

In the case of a detailed clinical picture of the disease with such specific symptoms as exophthalmos, enlargement of the thyroid gland, severe tachycardia, etc., making a diagnosis does not cause difficulties.

In the initial stages of hyperthyroidism, in controversial cases, additional laboratory tests are required to determine the level of thyroid hormones.

Attending doctor: endocrinologist

Frequent bowel movements due to functional diarrhea (irritable bowel syndrome)

Functional diarrhea is the most common cause of frequent bowel movements. According to some data, every 6 out of 10 cases of chronic diarrhea are functionally determined.

Very often, such patients are given a vague diagnosis of “chronic spastic colitis.” Often they are treated for years for non-existent chronic pancreatitis or dysbiosis, prescribing unjustified treatment with enzyme preparations or antibiotics.

Functional diarrhea is one of the variants of the course of irritable bowel syndrome. This syndrome is defined as a functional disease (that is, a disease that is not based on general or local organic pathology), characterized by severe pain, usually decreasing after defecation, flatulence, a feeling of incomplete bowel movement or an imperative urge to defecate.

Different variants of the course of irritable bowel syndrome are characterized by different symptoms of impaired stool frequency: constipation, frequent bowel movements, or alternating constipation with diarrhea.

Functional diarrhea, as well as other variants of irritable bowel syndrome, is characterized by the absence of so-called anxiety symptoms - fever, unmotivated weight loss, increased ESR, anemia - indicating the presence of severe organic pathology.

In the complete absence of objective indicators indicating a serious organic lesion, attention is drawn to the abundance of various subjective complaints. Patients feel pain in the joints, sacrum and spine, and are tormented by paroxysmal migraine-type headaches. In addition, patients with functional diarrhea complain of a feeling of a lump in the throat, the inability to sleep on the left side, a feeling of lack of air, etc.

With functional diarrhea, there is a slight increase in stool frequency (up to 2-4 times a day); there are no pathological impurities (blood, mucus, pus) in the stool. A characteristic sign of this type of diarrhea is the urge to defecate most often appear in the morning and in the first half of the day.

Among patients with irritable bowel syndrome, the vast majority are women in the age category of 30-40 years. The disease can last for years without significant dynamics towards improvement or worsening. The long course of the disease affects the neuropsychic status of patients (phobias and depression may occur), which increases the symptoms of irritable bowel disease - a so-called vicious circle is formed.

Attending doctor: gastroenterologist, neurologist.

Before use, you should consult a specialist.

General concept of diarrhea

Diarrhea is a disorder of intestinal function, which manifests itself in increased frequency of stools with a change in its consistency and quality. Diarrhea occurs with a variety of diseases of the gastrointestinal tract.

The following main factors are noted in the mechanism of their development: increased motility of the small or large intestine with increased frequency and intensification of peristaltic waves and acceleration of the entire intestinal passage, decreased absorption of water in the large intestine with increased secretion into the intestinal lumen of intercellular fluid or inflammatory exudate.

The nature of diarrhea usually makes it possible to determine the location of the intestinal lesion - large or small. However, such a division is not always possible, since many diseases, especially of an infectious nature, affect all parts of the gastrointestinal tract. Then they say that the disease proceeds as acute gastroenterocolitis, which indicates the involvement of the stomach, small intestine, and large intestine in the pathological process.

Clinical characteristics of enteric diarrhea

Enteritis

With the primary localization of the lesion in the small intestine (with enteritis), diarrhea can be of varying frequency, but the bowel movements are always copious, mushy or liquid, foamy, their reaction is acidic, there are usually remnants of undigested food substances - lumps of starch, muscle and plant fibers, saponified fats and fatty acid crystals. If such stool is present, they speak of enteric diarrhea.

Chronic enteritis can develop as a secondary disease against the background of other diseases of the digestive and other systems, for example after gastrectomy, chronic pancreatitis, hepatitis, liver cirrhosis, renal failure, various skin diseases (psoriasis, eczema).

Symptoms Chronic enteritis is manifested by moderate pain in the umbilical region, which, when exacerbated, intensifies in the afternoon, subside with the appearance of a loud rumbling. Patients note bloating and a feeling of fullness. The frequency of stool is usually 3–6 times a day, in severe cases it can reach 15 times a day. The stool is typical: stool is abundant, light yellow in color, without any admixture of blood, mucus or pus. With prolonged or severe course of chronic enteritis, symptoms of impaired absorption of substances necessary for the body are observed.

Malabsorption occurs because dystrophic changes develop in the mucous membrane, intestinal cells cease to perform their functions, and as a result, the body ceases to receive sufficient amounts of proteins, carbohydrates, fats, minerals, microelements, and vitamins.

The patient gradually develops exhaustion, weight loss, and swelling, most often of the lower extremities. All types of metabolism (protein, fat, carbohydrate, mineral) are disrupted. Characteristic signs of hypovitaminosis, iron and B 12 deficiency anemia, osteoporosis, dystrophy of internal organs, including the liver, myocardium.

There is a decreased content of potassium, calcium, magnesium, iron, and protein in the blood. A scatological examination of stool reveals undigested fats, fiber, large amounts of mucus and leukocytes. Dysbacteriosis is very often detected. X-ray examination determines the acceleration or deceleration of the passage of barium from the stomach through the small intestine, changes in the relief of the mucous membrane, and spasms of certain areas.

Enteroviral diarrhea

Among infectious diarrhea, diarrhea of ​​a viral nature has recently come to the fore. In children, the causative agent of acute enteritis is rotavirus, in adults it is more often the Norwolk virus. The onset of the disease is acute, diarrhea is preceded by nausea, and in severe cases, vomiting. General infectious manifestations (headaches, fever, muscle pain) are mild. Abdominal pain is not typical for viral enteritis. At first, the stool has a mushy fecal character, but then it becomes more and more liquid and watery. This happens because swelling and inflammation of the small intestine caused by the virus lead to impaired secretion and reabsorption of water rich in sodium and potassium salts. The fluid lost with diarrhea contains little protein, but a lot of these valuable salts. Fluid losses can be up to 1 liter per hour.

The colon does not suffer during viral diarrhea, so no leukocytes are detected in the stool. The main reason requiring immediate treatment is the threatening loss of fluid and salts. Viral diarrhea lasts 1–3 days in adults, 2 times longer in children, so it is necessary to immediately begin replacing lost fluid.

Gastric achylia

Enteric diarrhea often develops with gastritis with reduced secretion. With gastric achylia (lack of hydrochloric acid and digestive enzymes in the gastric juice), there may be several causes of diarrhea. Firstly, due to the lack of gastric digestion, undigested food remains in large quantities, especially during rapid gastric emptying, enter the intestine and cause increased peristalsis. Secondly, insufficient preliminary digestion of food in the stomach leads to the development of fermentation and putrefactive processes in the small intestine. Thirdly, with insufficient secretion of hydrochloric acid, disturbances in the secretory function of the pancreas develop, which leads to the formation of “fatty” diarrhea.

Clinical characteristics of colitic diarrhea

If the process involves predominantly the large intestine, stool with diarrhea is of a different nature. At first it has the usual consistency, but always with an admixture of mucus, visible to the eye. With the further development of the disease, the stool becomes increasingly scanty, an admixture of blood may appear, and a painful urge to defecate is usually noted - tenesmus, which occurs due to spasm of the large intestine. Sometimes the stool takes on the character of “rectal spit” - only a lump of mucus with pus or blood is released.

Dysentery

A typical example of colitic diarrhea is the well-known infectious disease dysentery. The causative agent is a bacterium of the genus Shigella. The source of infection is a sick person and a bacteria carrier. Infection occurs when food, water, or objects are contaminated directly by hands or flies. Dysenteric microbes are localized mainly in the large intestine, causing inflammation, superficial erosions and ulcers.

Symptoms The incubation period lasts from 1 to 7 days (usually 2–3 days). The disease begins acutely, with an increase in body temperature, chills, a feeling of heat, weakness, and loss of appetite. Then abdominal pain appears, initially dull, spread throughout the abdomen, later it becomes more acute, cramping. By location - lower abdomen, more often on the left, less often on the right. The pain usually intensifies before defecation. Tenesmus occurs, and false urges to descend appear. When palpating the abdomen, spasm and soreness of the colon are noted, more pronounced in the area of ​​the sigmoid colon, which is palpated in the form of a thick tourniquet. The stool is typical colitic, its frequency ranges from 2–3 times a day in mild forms of the disease to 15–20 in severe cases. The duration of the disease ranges from 1–2 to 8–9 days.

Chronic colitis

Colitic stool is also observed in chronic colitis. Chronic colitis is inflammatory, dystrophic and atrophic changes in the colon mucosa, which are accompanied by its motor and secretory disorders. Often the cause of chronic colitis is untreated dysentery and other infectious diseases. However, we cannot exclude the influence of poor nutrition, exposure to toxic substances (lead, arsenic, mercury), medications with long-term uncontrolled use of antibiotics and laxatives. A significant role in the formation and development of the disease is played by the pathology of other parts of the gastrointestinal tract (pancreatitis, gastritis).

Symptoms The main signs of chronic colitis, in addition to typical colitis, are dull, aching, cramping pain in different parts of the abdomen, sometimes without clear localization; they are always more intense after eating and weaken after defecation and the release of gas. The pain may intensify when walking, shaking, or after cleansing enemas. Patients complain of rumbling, flatulence, bloating, a feeling of incomplete bowel movement, and after eating there may be a urge to defecate. Diarrhea occurs up to 5–6 times a day, and there are streaks of mucus or blood in the stool. Pain in the anus may occur due to inflammation of the mucous membrane of the rectum and sigmoid colon. When palpating the abdomen, pain is determined along the course of the large intestine, alternating its spasmodic and dilated areas. The course of the disease is undulating: deterioration is replaced by temporary remission.

Examination of the colon during irrigation and colonoscopy allows an accurate diagnosis of chronic colitis. It is imperative to perform sigmoidoscopy - examination of the rectal mucosa with a rectoscope. If necessary, during a colonoscopy, a biopsy of the colon mucosa is taken for examination under a microscope.

A special place among diseases of the large intestine is occupied by nonspecific ulcerative colitis and Crohn's disease, which are also accompanied by specific colitic diarrhea. Nonspecific ulcerative colitis is a chronic disease of the colon with the development of ulcers in the mucous membrane and hemorrhages against the background of widespread inflammation.

The causes of ulcerative colitis are unknown, but exacerbations are provoked by physical overexertion and stressful situations. Women get sick more often. Damage to the intestine can be total - along its entire length or only in a separate area (segmental). Involvement of the rectum in the pathological process occurs almost constantly.

Patients are usually worried about a triad of complaints: diarrhea, bleeding from stool, and abdominal pain. However, the stool is typical colitic, sometimes there is an admixture of pus in the stool.

General well-being is significantly affected: loss of appetite, apathy, weight loss, temperature rises to 37.5–40 °C. The disease can be very severe, accompanied by bleeding from ulcers, perforation of the intestinal wall, peritonitis, tumors, sepsis, and degeneration of internal organs. The course of the disease is long-term and requires constant maintenance therapy.

During sigmoidoscopy and colonoscopy (endoscopic examination of the mucous membrane of the colon), swelling, redness and increased bleeding of the mucous membrane of the rectum and other parts of the colon, ulcers and pseudopolyps are detected. A mucosal biopsy confirms the diagnosis. During irrigoscopy, in advanced cases, the colon looks like a “water pipe.” Blood tests show nonspecific signs of inflammation - an increase in the number of leukocytes, an acceleration of ESR, a decrease in hemoglobin (anemia).

Crohn's disease

Crohn's disease is a specific inflammation of the intestinal wall with clear boundaries of the affected areas. The cause of the disease is also unknown. Specific inflammation is accompanied by ulceration, disintegration of the tissue of the intestinal wall, with scarring of which the intestinal lumen narrows. The painful process affects not only the mucous membrane, but also all layers of the intestinal wall, manifesting itself in the form of deep slit-shaped ulcers or cracks. The affected areas of the intestine may be located at a distance from each other - the so-called “kangaroo jumping”. Rarely, parts of the gastrointestinal tract above the intestines - the stomach, esophagus - become inflamed.

Symptoms Crohn's disease is characterized by a long-term chronic course. Patients usually complain of constant pain in various places of the abdomen, diarrhea with the passage of semi-liquid stools with a small admixture of blood and mucus, bloating and rumbling in the abdomen, weight loss, and joint pain. When the final part of the small intestine is affected (terminal ileitis), pain appears in the right iliac region, vomiting, and fever, which often leads to surgery due to suspicion of acute appendicitis. Narrowing of the lumen of the small intestine can lead to obstruction. Other complications include perforation of the intestine at the site of ulcer formation, followed by the formation of an abscess in the abdominal cavity, fistulas, and rarely peritonitis. During colonoscopy, all parts of the colon and the final part of the small intestine are necessarily examined, with a mandatory biopsy of the changed areas. A biopsy confirms the diagnosis.

Clinical characteristics of gastroenterocolitic diarrhea

When both the small and large intestines, and sometimes the stomach, are involved in the pathological process, total damage to the entire gastrointestinal tract develops - gastroenterocolitis.

With gastroenterocolitis or enterocolitis, diarrhea is of a mixed nature - feces can be copious, but mixed with mucus, less often - blood or pus.

Foodborne illnesses

A typical example of gastroenterocolitis is food poisoning. This is a group of diseases that occur when microbial agents and (or) their toxins enter the body along with food. The disease typically has an acute onset, a rapid course, symptoms of general intoxication and damage to the digestive organs. The cause of foodborne toxic infections can be a variety of bacteria: salmonella, shigella, escherichia, streptococci, spore anaerobes, spore aerobes, halophilic vibrios, staphylococcal enterotoxins types A, B, C, D, E.

The source of infection is a sick person or bacteria carrier, as well as sick animals and bacteria excretors. Microbes get on food products, mainly those that are not cooked. For example, staphylococci can multiply in milk and dairy products and release specific toxins. At the same time, the appearance and smell of the product is no different from the usual one. Often the disease can be associated with the consumption of cakes and pastries with milk or butter cream, cottage cheese. Other bacteria more often contaminate meat pates, canned fish in oil, vegetable dishes, and salads. The disease can occur in both sporadic cases and outbreaks. The incidence is recorded throughout the year, but increases slightly in warm weather.

Symptoms The incubation period is short - up to several hours, which allows us to think about the absorption of toxins already in the stomach. Chills, increased body temperature, nausea, repeated vomiting, and cramping abdominal pain, mainly in the iliac and periumbilical regions, are noted. Then comes frequent loose stools, sometimes mixed with mucus. There is no blood or pus in the stool due to food poisoning. Phenomena of general intoxication are observed: dizziness, headache, weakness, loss of appetite. The skin and visible mucous membranes are dry. The tongue is also dry, covered with a gray-white coating. The diagnosis of foodborne infectious poisoning is made on the basis of the clinical picture, epidemiological history and laboratory tests. The results of bacteriological examination of feces, vomit, and gastric lavage are of decisive importance.

Intestinal dysbiosis

In addition to food toxic infections, mixed diarrhea accompanies many other conditions and diseases of both the digestive system and other organs and systems. Often, diarrhea can be a consequence of intestinal dysbiosis. Dysbacteriosis is a disturbance in the composition of the intestinal microflora that normally populates it, and the proliferation of microbes that are normally absent. Dysbacteriosis can develop independently or accompany diseases of the gastrointestinal tract, in particular the colon. The cause of its occurrence may be disturbances in the digestion of food due to various diseases of the digestive system (gastritis with reduced secretion, pancreatitis, enterocolitis), uncontrolled or long-term use of antibiotics that suppress the growth of normal intestinal flora, and decreased immunity.

In a healthy person, the intestines are dominated by lactobacilli, anaerobic streptococci, Escherichia coli, and enterococci. They have pronounced antagonistic activity against pathogenic microorganisms entering the intestinal cavity from the external environment. With dysbiosis, both the ratio of intestinal flora and its ability to suppress the growth of pathogenic microbes are disrupted. Putrefactive and fermentative bacteria, fungi of the genus Candida develop abundantly, and pathogenic strains of Escherichia coli appear.

Patients complain of decreased appetite, unpleasant taste and odor from the mouth, nausea, bloating, diarrhea, lethargy, and general malaise. The frequency of stool varies from 2-3 times to 5-7 times a day, feces are abundant, have an unpleasant putrefactive odor, and an admixture of mucus is present. Sometimes there is an alternation of diarrhea and constipation - the so-called unstable stool. An increase in temperature to 37–38 °C is less common. With a prolonged course of the disease, hypovitaminosis, especially group B, can develop.

Clinical characteristics of diarrhea of ​​toxic-allergic origin

The intestines, like other organs, can be damaged by various allergic conditions. At the same time, allergic diarrhea develops. As a rule, their occurrence is associated with the consumption of certain types of food, the sensitivity to which is specifically increased. Very often, allergies appear in response to the entry of crayfish, strawberries, citrus fruits, greenhouse vegetables, milk, eggs and many other products into the gastrointestinal tract.

Diarrhea due to allergies is mixed, with remnants of undigested food and mucus found in the stool.

When stool microscopy, you can find a large number of cells specific for allergic reactions - eosinophils. Often, diarrhea coincides in time of appearance with other manifestations of allergies - Quincke's edema, allergic conjunctivitis, urticaria.

In such cases, the diagnosis is made on the basis of allergic skin manifestations and repeated coincidence of diarrhea with the intake of certain nutrients.

In the treatment of allergic diarrhea, antihistamines are of greatest importance - diphenhydramine, suprastin, tavegil in an age-appropriate dosage.

Toxic diarrhea can be associated with acute or chronic poisoning with various poisons (mercury, arsenic) and waste products of the body (endotoxins). The latter is most clearly manifested in uremia - the final stage of renal failure. It occurs in the stage of decompensation of chronic renal diseases - glomerulonephritis, pyelonephritis, renal amyloidosis. Self-poisoning of the body with nitrogenous wastes occurs (products of the breakdown of proteins, the excretion of which is significantly impaired in renal failure).

Diarrhea with uremia occurs up to 2-3 times a day, feces are foul-smelling and dark in color. The abdomen is swollen, symptoms of flatulence are pronounced, there may be frequent vomiting, regurgitation, the tongue is covered with a gray coating, and the smell of ammonia is clearly felt from the mouth. Treatment of such diarrhea is symptomatic; a significant improvement in the condition can only be associated with the removal of toxins using the artificial kidney apparatus.

Acute arsenic poisoning occurs as a typical gastroenteritis with vomiting, abdominal pain, profuse diarrhea and severe dehydration. However, there is a dry throat (despite drooling), as well as cramps in the calf muscles, which should immediately alert you to poisoning. Lethal outcome (death of the patient) occurs within 1–2 days due to toxic shock symptoms.

Chronic arsenic poisoning occurs more smoothly in the gastrointestinal tract, but diarrhea is still present.

These are accompanied by changes in the skin and mucous membranes, anemia, paralysis, and exhaustion. The diagnosis of arsenic poisoning is easily confirmed by chemical analysis of hair and nails. In acute cases, the diagnosis can be confirmed by the green color of the vomit and the smell of garlic.

Acute mercury poisoning occurs with frequent, black-colored stools, often mixed with blood. At first, such diarrhea is typical only when mercury is ingested through the mouth; later, specific colitis associated with the excretion of mercury through the intestinal wall occurs. Detection of mercury in blood and urine is of great value for correct diagnosis. Treatment of such poisonings should be carried out only in a hospital setting.

Many medications, in addition to antibiotics, can cause diarrhea. Diarrhea often occurs when laxatives are abused, paradoxically as it may seem. The possibility of drug-induced diarrhea should be considered in all unclear cases.

Toxic diarrhea can also occur with chronic nicotine poisoning.

Clinical characteristics of diarrhea in endocrine diseases

Diarrhea due to endocrine diseases is classified into a special group. They are believed to reflect disruption of hormonal regulation of intestinal function.

Thyrotoxicosis

Diarrhea occurs especially often with thyrotoxicosis, which is observed in diseases of the thyroid gland and is characterized by a high level of thyroid hormones (thyroid hormones) in the blood. Thyrotoxicosis is often observed in diffuse toxic and nodular goiter, toxic adenoma, and in various inflammatory processes in the gland - thyroiditis. Women get sick 10 times more often than men; they are most susceptible to these diseases between the ages of 20 and 50 years.

The causes of this pathology can be both immunity disorders due to infection, and mental trauma in individuals with a hereditary predisposition to damage to the thyroid gland, when antibodies that are aggressive to it are formed in the body.

Symptoms The main manifestations are usually an enlarged thyroid gland - goiter, as well as bulging eyes and palpitations. However, the disease can develop even when the size of the gland is normal. Tearfulness, nervousness, and insomnia appear. The appetite is very good, patients eat a lot, but at the same time lose up to 10–15 kg in weight per month.

Diarrhea is associated with increased intestinal motor function; usually food digestion is not impaired, but there may be an increased secretion of fats. The skin is moist and warm. The so-called angry look is characteristic (the palpebral slits are wide open, the eyes shine, the eyes blink rarely), pain appears in the eyeballs. Muscle weakness and fatigue develop, and patients cannot tolerate high ambient temperatures.

With typical manifestations of an enlarged thyroid gland, diagnosis is not difficult. If the size of the gland is normal, it is necessary to study its function (using radioactive iodine) and determine the level of thyroid hormones in the blood.

Hypoparathyroidism

Insufficiency of the parathyroid glands (hypoparathyroidism) is also sometimes accompanied by diarrhea, which is associated with increased excitability of the autonomic nervous system with low calcium levels in the blood.

There are also periodic diarrhea in diabetes mellitus, and they can be caused both by a specific diabetic diet (large amounts of fat and fiber, fruits and vegetables), and by the reduced enzyme-forming function of the pancreas, which is often noted in diabetes.

Diarrhea is one of the frequently observed symptoms of chronic adrenal insufficiency (Addison's disease), and complaints of gastrointestinal dysfunction often prevail in such patients. Adrenal insufficiency occurs when the adrenal cortex is damaged by Mycobacterium tuberculosis, as well as autoantibodies in the autoimmune form of the disease. As a result, the production of all cortical hormones - glucocorticoids, mineralocorticoids and androgens - decreases.

Symptoms Patients complain of fatigue, muscle weakness, weight loss, apathy, decreased or loss of appetite, and loss of interest in life. Weight loss usually correlates closely with loss of appetite and severity of gastrointestinal dysfunction. In addition to “fatty” diarrhea, peptic ulcers of the stomach and duodenum, gastritis with reduced secretion may occur.

In addition, one of the early symptoms of chronic adrenal insufficiency is persistently low blood pressure. Systolic pressure never exceeds 110 mmHg. Art., and diastolic - 70 mm Hg. Art. Addison's disease is characterized by dizziness, rapid heartbeat, and progressive weakness. A typical symptom is darkening of the skin and mucous membranes (hyperpigmentation).

In the skin, there is an increased deposition of the pigment melanin, which is responsible for the dark color of the epidermis. Areas of the body that are constantly exposed to friction by clothing darken especially strongly.

With chronic adrenal insufficiency, there is a decrease in sexual function in both men and women. In men, impotence develops; in women, the ability to bear children is impaired (spontaneous miscarriages, pregnancy pathology).

Half of patients with adrenal insufficiency have mental disorders - from mild to persistent and progressive. Apathy or irritability are common, and as the disease progresses, negativism and lack of initiative increase.

Clinical characteristics of neurogenic diarrhea

Neurogenic diarrhea is caused by a violation of the nervous regulation of the motor and secretory functions of the intestine. They can occur in the form of acute attacks under the influence of negative emotions (excitement, fear) or obsessions, which is popularly called “bear disease.” It is also possible that specific intestinal manifestations may occur against the background of general neuroticism of the body. The latter are characterized by a lack of dependence on the quality and composition of food. There may be paradoxical improvements from varied and even rough foods and deterioration while following a strict gentle diet.

Treatment of diarrhea

Treatment of enteric diarrhea using traditional methods

Chronic enteritis

It is very important to start treatment of chronic enteritis on time and prevent the development of malabsorption syndrome. The main role in therapy belongs to a strict diet. Patients with exacerbation of enteritis should eat food at least 5–7 times a day at regular intervals. All food should be served warm and pureed. It is necessary to limit the amount of animal fats. It is preferable to give vegetables and fruits in the form of puree.

Patients are advised to eat lean varieties of beef, veal, chicken, fish, eggs and cottage cheese, slimy soups, and pureed porridges. It is necessary to completely exclude milk, brown bread, carbonated drinks, prunes, grapes, cabbage, nuts, and freshly baked flour products. If dysbacteriosis is detected, biological drugs (colibacterin, bificol, bifidum-bacterin) should be taken. If a disorder of protein metabolism develops, treatment in a hospital is required with the administration of protein preparations, B vitamins, and ascorbic acid by injection. Astringents (kaolin, bismuth preparations, tanalbin) are used against frequent heavy diarrhea. For anemia, iron supplements, vitamin B 12, and folic acid are indicated.

Enteroviral diarrhea

The liquid is administered at an approximate rate of 1.5 liters per liter of stool (for children - 110 ml per kilogram of weight), however, only normalization of the condition is a sufficient criterion. Use saline solutions for rehydration: rehydron, oratil.

Gastric achylia

Diarrhea caused by gastritis with reduced secretion is not a separate disease and is treated in the same way as gastritis itself. With adequate replacement therapy with enzyme preparations and hydrochloric acid, diarrhea goes away extremely quickly.

Treatment of colitic diarrhea with traditional methods

Dysentery

Patients with dysentery can be treated both in an infectious diseases hospital and at home. Among antibiotics, tetracycline (0.2–0.3 g 4 times a day) or chloramphenicol (0.5 g 4 times a day for 6 days) has recently been used. However, sensitivity to them has decreased significantly. Nitrofuran preparations (furazolidone, furadonin, etc.) are also used, 0.1 g 4 times a day for 5–7 days. A complex of vitamins is shown. In severe forms, inpatient treatment using detoxification therapy is indicated.

Chronic colitis

Diet therapy takes a dominant place in treatment. Meals should be fractional 6-7 times a day. In case of severe exacerbation, fasting is recommended for the first 1–2 days. Then the patients are shown slimy soups, weak meat broths, pureed porridges in water, boiled meat in the form of steamed cutlets and meatballs, soft-boiled eggs, boiled river fish, jelly, sweet tea. Antibacterial therapy is prescribed in courses of 4–5 days, for mild and moderate severity - sulfonamides, if they have no effect - broad-spectrum antibiotics: tetracycline, biomycin in the usual therapeutic dosage. In severe cases, a combination of antibiotics with sulfonamides. For severe pain, you can take antispasmodics (papaverine, no-shpu, platifillin), B vitamins, ascorbic acid, preferably by injection. If the rectum is predominantly affected, therapeutic enemas are prescribed: oil enemas (sea buckthorn oil, rose hips, fish oil with the addition of 5-10 drops of vitamin A), as well as anti-inflammatory ones with hydrocortisone.

Nonspecific ulcerative colitis

Treatment of exacerbation is carried out only in a hospital setting. The patient must remain in bed. An important role is played by the diet, which includes fruits and vegetables in the form of puree, pureed mucous soups, cereal porridges in water, boiled meat (minced meat, steamed cutlets, meatballs), boiled fish. Avoid whole milk and its products. Drug treatment begins with the group of drugs sulfasalazine and salazopyridazine. In severe cases, prednisolone is prescribed, the doses are selected individually by the doctor with gradual withdrawal after a month, the duration of the course of treatment is 3–4 months.

In milder cases, you can limit yourself to drip enemas with hydrocortisone (125 mg per 200–250 ml of warm water 1–2 times a day) or microenemas with prednisolone (30–60 mg per 50 ml of warm water). You can also use suppositories with prednisolone. Astringents are indicated - bismuth with tanalbin 0.5 g 3 times a day, white clay (1-2 tsp 3 times a day). B vitamins, solutions of glucose, salts, protein preparations are administered, if necessary, by injection and dropper. If medications are ineffective, intestinal obstruction occurs, the intestinal wall is perforated, or degenerates into cancer, surgical intervention is necessary.

Crohn's disease

Treatment of Crohn's disease is similar to the treatment of ulcerative colitis. If complications develop, surgical intervention is indicated.

Treatment of gastroenterocolitic diarrhea using traditional methods

Food poisoning

To remove infected foods and their toxins in the first hours of the disease, gastric lavage is necessary. However, in case of nausea and vomiting, this procedure can be performed at a later date.

Washing is carried out with a 2% solution of sodium bicarbonate (baking soda) or a 0.1% solution of potassium permanganate until clean wash water is discharged. For the purpose of detoxification and restoration of water-salt balance, salt solutions are used: trisol, quartasol, rehydron and others.

The patient is given plenty of fluids to drink in small doses. Nutritional therapy is important. Avoid foods that can irritate the gastrointestinal tract from the diet.

Chemically and mechanically gentle food (well-cooked, pureed, non-spicy) is recommended. In order to correct and compensate for digestive insufficiency, it is necessary to use preparations of enzymes and enzyme complexes - pepsin, pancreatin, festal and others for 1-2 weeks.

To restore normal intestinal microflora, the use of colibacterin, lactobacterin, bificol, bifidum-bacterin is indicated.

Dysbacteriosis

Treatment of dysbiosis is based on the suppression of foreign flora with subsequent restoration of normal intestinal microflora. In case of dysbacteriosis resulting from irrational antibiotic therapy, the antibiotic that caused it should be discontinued. For digestive disorders, enzymes and enzyme preparations should be used. However, the dominant role should be played by the treatment of the underlying disease. Among the general strengthening agents, vitamins are indicated, especially group B. In order to normalize the microbial composition of the intestinal flora, various bacterial preparations are used - special bacteriophages, bacterial preparations such as lactobacterin, colibacterin, bifidumbacterin, bificol. In the presence of candidiasis, nystatin and levorin are prescribed in an age-appropriate dosage.

The so-called nutritional, or food, diarrhea is also of a mixed nature. They occur due to poor nutrition, gross errors in diet, and eating disorders.

Diarrhea can appear after massive overeating, haste and poor chewing of food, abuse of coarse, bulky fatty foods, copious cold drinks after meals, and even as a result of physical overexertion after a massive food load.

Treatment of diarrhea in endocrine diseases using traditional methods

Thyrotoxicosis

Treatment of diarrhea due to thyrotoxicosis depends on the treatment of the underlying disease. It is necessary to refrain from spicy foods and stimulating drinks, and smoking.

For diffuse toxic goiter, drug therapy with Mercazolil is carried out, the course of treatment is 1.5–2 years.

For large goiters, as well as drug intolerance or lack of effect, a surgical method is used. If there are contraindications to surgery, radioactive iodine is used.

Chronic adrenal insufficiency

Treatment of the disease should be aimed, on the one hand, at eliminating the pathological process that caused damage to the adrenal glands, and on the other, at replacing hormonal deficiency. Replacement therapy is carried out with synthetic analogues of glucocorticoids, mineralocorticoids and androgens. For patients, it is vital and cannot be canceled under any circumstances.

Treatment of neurogenic diarrhea using traditional methods

If there is pronounced neuroticism of the personality in combination with diarrhea that periodically occurs for no apparent reason, treatment with a psychotherapist can be recommended. In addition, in this case, acupressure or self-massage of the following points is indicated. The chi-hai point (VC 6) of the anteromedian meridian is located one and a half times the diameter of the thumb down from the navel along the midline of the abdomen. The Zhongwan point (VC12) of the anteromedian meridian is located 4 thumb diameters above the navel - between it and the xiphoid process in the midline of the abdomen. The Tianshu point of the stomach meridian (E25) is located at the level of the navel, 2 thumb diameters away from it. The yin-ling-quan point of the spleen meridian (RP9) is located under the lower edge of the tibial condyle, 2 thumb diameters below the patella. The Qu Chi point of the large intestine channel (GI11) is located between the end of the elbow fold and the most prominent bony protrusion of the elbow joint with the arm bent and closely brought to the chest. The Tzu-san-li point of the stomach channel (E36) is located at a distance equal to the width of three diameters of the thumb, below the kneecap and one finger outward from the sharp protruding bone frame of the lower leg (tibia crest). All points must be treated in a sedating (inhibiting) way. It is used when you need to calm the nervous system, ease pain, and relax spasmodic muscle groups. Within 1–2 s, find the desired point and then begin a clockwise rotational movement. With each turn, the pressure on the point increases for 5–6 seconds. Having reached the desired level, the pressure is no longer changed for 1–2 s, and then a gradual weakening occurs, accompanied by counterclockwise movements, also for 5–6 s. Returning to the original pressure force, the cycle is repeated again. The movements are reminiscent of screwing in and unscrewing a screw. You should not lift your finger from the point; the duration of the effect depends on the specific purpose. You need to do 4 cycles of “screwing in and out” per minute.

Treatment of diarrhea with unconventional methods

It is good to treat colitis during the cucumber season if you consume 100 g of cucumber pulp puree daily as your first breakfast.

Red currants perfectly soften spastic colitis. You can eat 100–150 g of it daily during the season, or you can prepare purees, jellies, decoctions, compotes and take it throughout the year.

Colitis can be treated with coltsfoot if 1/3 tsp. powder from its leaves 3 times a day, 20–30 minutes before meals, washed down with hot milk or honey water.

Dandelion infusion, which is made at the rate of 1 tbsp, helps well with colitis. l. dandelion roots or grass per 0.5 liters of boiling water. Infuse for 8–10 hours in a 0.5-liter thermos, then take 3 times a day before meals 30 minutes before meals.

It is very good for the treatment of acute and chronic diseases of the small and large intestines to use infusion, extract, and syrup of blueberries. An effective way is also to take a decoction of rose hips and fresh apples. Pectin substances contained in rose hips and apples perfectly relieve inflammation in the intestines. To treat, wash the apples well, grate them, and eat them 5–7 minutes after cooking, 4–6 times a day. Apples should be chosen that are not very hard, sour, you can add a little honey or sugar. Already on the 3rd day, signs of improvement appear, and you can switch to a vegetable diet, but continue to eat apples. The pectin substances in apples are an excellent treatment for colitis and enterocolitis in the elderly and children. However, you need to know that apples have a healing effect only until January 1st. After the New Year, it is preferable to use rose hips for treatment.

Proven folk remedy for the treatment of colitis: 1 tsp. Brew centaury, sage, chamomile in 1 cup of boiling water. Drink 1 tbsp. l. every 2 hours after meals, approximately 7–8 times a day. After 1–3 months, reduce the dose and lengthen the time intervals between doses.

Anise tea relieves pain and removes gases from the intestines during colitis. 1 tsp. Pour 1 cup of boiling water over dry or fresh green anise. It is better to cook in a teapot, cover with a linen towel, leave for 5-7 minutes. Drink little and often throughout the day. If the pain does not go away after several doses, then you need to add a pinch of dry or fresh dill to brewing fresh anise tea.

A recipe for a tincture for the treatment of colitis was proposed by the zemstvo doctor S. M. Arensky, the author of a whole collection of medicinal remedies from herbs, vegetables and fruits. Its effectiveness has been tested by several generations. It is always useful to have such a tincture in your home pharmacy.

Tincture of sunflower caps. They are collected from May to mid-June, until the heads are colored. For the course of treatment, a tincture is prepared in the following proportions: 9 tbsp. l. 96% alcohol and 50 g of finely chopped sunflower caps. Carefully place the sunflower caps into a bottle. Pour alcohol and leave for 5-6 days. Then strain through several layers of gauze. Adults drink 20–25 drops per 0.25 glass of warm boiled water, children under 14 years old - from 5 to 15 drops per the same amount of water. For severe, unbearable pain, drink 5-6 times a day, in other cases - 3 times a day 20 minutes before meals.

M.A. Nosal, compiler of a collection of folk medicines from cultivated and wild herbs, recommended making enemas from an aqueous infusion of orchis. Brew 1 tsp for children, 1 tbsp for adults. l. in a glass of boiling water. Leave until cool, strain.

An ancient and very effective method of treating diarrhea using powder from a dry film covering the stomach of a chicken. The film must first be washed well, dried, and crushed. Store in a jar. It is useful to always have this medicinal powder in the house. For one use, it is enough to pour the powder into 1 tsp on the tip of a knife. water. Take several times a day.

Green walnut shells can be used to treat diarrhea. It must be finely chopped and dried. Brew 1 tbsp. l. raw materials 1 cup of boiling water. It is better to do this in a thermos. Drink 1 tbsp. l. several times a day.

Strawberries, strawberries, sour plums, cherries (preferably dry), pears (preferably a decoction of dry ones, especially wild ones), blackberries, blueberries, and fresh green (unripe) apples are successfully used for diarrhea. They are brewed with boiling water and consumed in small portions throughout the day.

A decoction of young twigs and stalks of cherries helps well. It is worth drying up an easily accessible medicine for the winter. 1 tbsp. l. pour 1 cup of boiling water over the raw materials, it is better to use a thermos for 3-4 hours. Strain, drink a few sips every 30 minutes.

Eucalyptus leaf is brewed at the rate of 1 tbsp. l. for 1 liter of boiling water. Leave until cool, drink 0.25 cups 6-8 times a day. It is advisable to eat rice porridge on this day.

A decoction of yarrow helps a lot. It is prepared at the rate of 1 tbsp. l. for 1.5 cups of boiling water. The broth is left to cool until it cools, and a few sips are drunk 7-9 times a day.

For centuries, diarrhea has been successfully treated with rose stamens. 1 dec. l. (or 7 g) pour 1 glass of boiling water, preferably in a thermos. Drink a few sips 7-8 times a day.

A strong infusion of St. John's wort is prepared at the rate of 2 tbsp. l. for 1 cup boiling water. Leave for 20–30 minutes, strain, drink little by little throughout the day until the diarrhea stops. Recovery occurs faster if you add garlic water to this infusion: crush 1 clove of garlic or squeeze the juice into 0.5 glasses of water. Mix the infusions and drink throughout the day. At this time, eat porridge cooked only in water, or drink strong tea with crackers.

Barberry leaves and berries are good for treating diarrhea. The infusion is prepared based on the calculation of 1 tbsp. l. leaves or berries for 1.5 cups of boiling water. It is better to brew in a thermos and leave for 3 hours. Drink several sips several times.

An ancient folk and effective method is birch ash. 1 tbsp. l. pour 0.5 cups of boiling water over the ash. Let cool. Absorb this paste gradually over 3-4 hours.

For bloody diarrhea, it is good to use an infusion of plantain seeds. Brew 1 tbsp in the evening. l. raw materials 1 cup boiling water. Leave overnight in a thermos, strain, start drinking 1/3 cup every 30 minutes in the morning, with 1/3 cup of hot water (if it’s hard to tolerate hot water, you can drink it warm, but try to make it as hot as possible).

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Shigellosis

What is Shigellosis -

Shigellosis- acute anthroponotic infectious disease with a fecal-oral transmission mechanism. Characterized by general intoxication and predominant damage to the mucous membrane of the distal colon, cramping abdominal pain, frequent loose stools mixed with mucus and blood, and tenesmus.

Brief historical information
Clinical descriptions of the disease were first given in the works of the Syrian physician Aretaeus of Cappadocia (1st century BC) under the name “bloody, or strained, diarrhea” and in ancient Russian manuscripts (“bloody womb”, “washed”).

The medical literature of the 17th - 19th centuries emphasizes the tendency of the disease to spread widely in the form of epidemics and pandemics. The properties of the main pathogens of dysentery were described at the end of the 19th century (Raevsky A.S., 1875; Chantemess D., Vidal F., 1888; Kubasov P.I., 1889; Grigoriev A.V., 1891; Shiga K., 1898), later, some other types of pathogens were discovered and described.

What provokes / Causes of Shigellosis:

Pathogens- gram-negative non-motile bacteria of the genus Shigella of the Enterobacteriaceae family. According to the modern classification, Shigella is divided into 4 groups (A, B, C, D) and, accordingly, into 4 species - S. dysenteriae, S.flexneri, S. boydii, S. sonnei. Each species, except Shigella Sonne, includes several serovars. Among S. dysenteriae, there are 12 independent serovars (1 - 12), including Grigoriev-Shigi (S. dysenteriae 1), Stutzer-Schmitz (S. dysenteriae 2) and Large-Sachs (S. dysenteriae 3-7). S.flexneri includes 8 serovars (1-6, X and Y), including Newcastle (S.flexneri 6). S. boydii comprises 18 serovars (1 – 18). S. sonnei is not differentiated serologically. There are about 50 Shigella serovars in total. The etiological role of different Shigella is not the same. The most important in almost all countries are Shigella Sonne and Shigella Flexner - the causative agents of the so-called major nosological forms. The etiological significance of individual Shigella serovars is also different. Among S. flexneri, subserovars 2a, lb and serovar 6 dominate, among S. boydii - serovars 4 and 2, among S. dysenteriae - serovars 2 and 3. Among S. sonnei, the biochemical variants He, Ilg and 1a predominate.

The causative agents of bacterial dysentery are distinguished by enzymatic activity, pathogenicity and virulence. All Shigella grow well on differential diagnostic media; temperature optimum is 37 °C, Sonne bacteria can multiply at 10-15 °C.

Shigella is not very stable outside the human body. The virulence of bacteria is quite variable. The virulence of Shigella Flexner, especially subserovar 2a, is quite high. Shigella Sonne is the least virulent. They are distinguished by high enzymatic activity and unpretentiousness to the composition of nutrient media. They multiply intensively in milk and dairy products. At the same time, their preservation time exceeds the sales period of the products. The pronounced deficiency of virulence in Shigella Sonne is fully compensated by their high biochemical activity and reproduction rate in the infected substrate. To accumulate a dose of S. sonnei that infects adults in milk at room temperature, it takes from 8 to 24 hours. In the hot season, these periods are minimal: to accumulate a dose of bacteria sufficient to infect children, it takes only 1-3 hours. In the process The proliferation of Shigella Sonne in contaminated products accumulates heat-stable endotoxin, which can cause severe damage if the results of bacteriological examination of contaminated food products are negative. S. sonnei is also distinguished by high antagonistic activity towards saprophytic and lactic acid microflora.

An important feature of Shigella Sonne is its resistance to antibacterial drugs. Outside the body, the resistance of different species of Shigella varies. Shigella Sonne and Flexner can persist in water for a long time. When heated, Shigella quickly dies: at 60 °C - within 10 minutes, when boiled - instantly. The least resistant are S.flexneri. In recent years, thermoresistant (able to survive at 59 °C) strains of Shigella Sonne and Flexner have often been isolated. Disinfectants in normal concentrations have a detrimental effect on Shigella.

Epidemiology
Reservoir and source of infection- human (sick with acute or chronic form of dysentery, carrier, convalescent or transient carrier). The greatest danger is posed by patients with mild and erased forms of dysentery, especially persons of certain professions (working in the food industry and persons equivalent to them). Shigella begins to be excreted from the human body at the first symptoms of the disease; The duration of discharge is 7-10 days plus the convalescence period (on average 2-3 weeks). Sometimes the release of bacteria lasts up to several weeks or months. The tendency to chronicity of the infectious process is most characteristic of Flexner's dysentery, and the least characteristic of Sonne's dysentery.

Mechanism of transmission of infection- fecal-oral, transmission routes - water, food and contact-household. In Grigoriev-Shiga dysentery, the main route of transmission is through household contact, which ensures the transmission of highly virulent pathogens. In Flexner's dysentery, the main route of transmission is water, with Sonne dysentery - food. Sonne bacteria have biological advantages over other types of Shigella. While inferior to them in virulence, they are more stable in the external environment, and under favorable conditions they can even multiply in milk and dairy products, which increases their danger. The predominant action of certain factors and transmission routes determines the etiological structure of the disease of dysentery. In turn, the presence or prevalence of different transmission routes depends on the social environment and living conditions of the population. The range of Flexner's dysentery mainly corresponds to areas where the population still consumes epidemiologically unsafe water.

Natural sensitivity of people high. Post-infectious immunity is unstable, species-specific and type-specific, recurrent diseases are possible, especially with Sonne dysentery. The population's immunity does not serve as a factor regulating the development of the epidemic process. At the same time, it has been shown that after Flexner's dysentery, post-infectious immunity is formed, which can protect against recurrent disease for several years.

Basic epidemiological signs. Bacterial dysentery (shigellosis) is a widespread disease. Making up the bulk of so-called acute intestinal infections (or diarrheal diseases, according to WHO terminology), shigellosis represents a serious public health problem, especially in developing countries. The widespread prevalence of intestinal infections in developing countries is due to the miserable level of people living in unsanitary living conditions, customs and prejudices that contradict basic sanitary standards, poor-quality water supply, poor nutrition against the backdrop of an extremely low level of general and sanitary culture and medical care for the population. The spread of intestinal infections is also facilitated by various types of conflict situations, migration processes and natural disasters.

The development of the epidemic process of dysentery is determined by the activity of the mechanism of transmission of infectious agents, the intensity of which directly depends on social(level of sanitary and communal improvement of settlements and sanitary culture of the population) and natural and climatic conditions. Within the framework of a single fecal-oral transmission mechanism, the activity of individual routes (water, household and food) for different types of shigellosis is different. According to developed by V.I. Pokrovsky and Yu.P. Solodovnikov (1980) theories of etiological selectivity of the main (main) transmission routes of shigellosis, the spread of Grigoriev-Shiga dysentery is carried out mainly through household contact, Flexner's dysentery - by water, Sonne's dysentery - by food. From the position of the correspondence theory, the main ones are transmission routes that ensure not only widespread distribution, but also the preservation of the corresponding pathogen in nature as a species. Cessation of the activity of the main transmission route ensures the attenuation of the epidemic process, which is unable to be constantly supported only by the activity of additional routes.

When characterizing the epidemic process of shigellosis, it should be emphasized that these infections include a large group of epidemiologically independent diseases, including the so-called large(shigellosis of Sonne, Flexner, Newcastle, Grigoriev-Shigi) and small (shigellosis of Boyd, Stutzer-Schmitz, Large-Sachs, etc.) nosological forms. Large nosological forms constantly remain widespread; the epidemiological significance of small forms is small. At the same time, it should be mentioned that over the last century the significance of individual shigellosis in human pathology has changed. Thus, at the beginning of the 20th century, during the years of the civil war and intervention, famine and poor sanitary conditions, high morbidity, severe forms and mortality were associated with the spread of Grigoriev-Shiga dysentery. In the 40-50s, up to 90% of diseases were caused by Flexner's Shigella, while the second half of the century was marked by the predominant spread of Sonne's dysentery. This pattern was determined by the biological properties of the pathogen and socio-economic changes in human society at different stages of its development. Thus, changes in the social environment and living conditions of the population turned out to be the main regulator of the etiology of dysentery. In recent years, Grigoriev-Shiga dysentery has again attracted attention. Three large foci of this infection have formed in the world (Central America, Southeast Asia and Central Africa) and cases of its import to other countries have become more frequent. However, for it to take root, certain conditions exist on the territory of the Central Asian states. World experience indicates the possibility of spreading shigellosis through secondary routes. Thus, large water outbreaks of Grigoriev-Shiga dysentery are known, which arose in many developing countries during the late 60-80s against the backdrop of its global spread. However, this does not change the essence of the epidemiological patterns of individual shigellosis. As the situation normalized, Grigoriev-Shiga dysentery again became predominantly spread through everyday life.

The dependence of the incidence on sanitary and communal amenities has made Sonne dysentery more common among the urban population, especially in preschool institutions and groups united by a single source of food. Nevertheless, Sonne shigellosis still remains predominantly a childhood infection: the share of children in the morbidity structure is more than 50%. This is explained by the fact that children consume milk and dairy products more than adults. Children under 3 years of age are more likely to get sick. There is an opinion that the high incidence of illness in children, which is detected much more fully, is a direct consequence of the widespread spread of undetected infection among the adult population. Children, who are more susceptible to infection compared to adults, require a much smaller dose of the pathogen to develop the disease. Unidentified patients and bacteria carriers form a massive and fairly constant reservoir of the infectious agent among the population, which determines the spread of shigellosis both in the form of sporadic cases and in the form of epidemic morbidity. Most outbreaks of Sonne's dysentery associated with infection of milk and dairy products (sour cream, cottage cheese, kefir, etc.) arise as a result of their contamination by undetected patients at various stages of collection, transportation, processing and sale of these products.

City dwellers get sick 2-3 times more often than rural residents. Dysentery is characterized by a summer-autumn seasonality of the disease. The natural (temperature) factor mediates its impact through the social one, contributing to the creation of the most favorable (thermostatic) conditions for the accumulation of Shigella Sonne in contaminated dairy products in the warm season. Similarly, heat provides an increase in the intensity of the epidemic process in Flexner's dysentery, mediating its effect through the main transmission route of this nosological form - water. During the hot season, water consumption sharply increases, which, against the backdrop of poor-quality water supply to the population, leads to the activation of the water factor, mainly realized in the form of chronic epidemics. There is evidence that a decrease in the incidence of Sonne dysentery occurs against the background of a sharp decline in the production and consumption of milk and dairy products. The intensification of the epidemic process in Flexner's dysentery is obviously associated with the socio-economic living conditions of the population that have changed in recent years. The spread of Flexner's shigellosis occurs predominantly through the secondary food route through a wide variety of food products (a chronic decentralized food transmission route operates, implemented without the preliminary accumulation of pathogens characterized by high virulence and an extremely low infectious dose). High levels of morbidity and mortality are mainly recorded among adults from the socially disadvantaged and disadvantaged population.

It is necessary to point out that in recent years, with Sonne's dysentery, as with other intestinal anthroponoses, an increase in the proportion of adults has been noted. This is due to the fact that in the new socio-economic conditions of life, a significant part of the population is forced to purchase the cheapest products, especially dairy products, of far from guaranteed quality - flask milk, loose cottage cheese and sour cream, which are still sold in the city in conditions of unauthorized street trading. In addition, the epidemic process is strongly influenced by unfavorable social factors in recent years, including the emergence of large contingents of antisocial groups of the population (persons without a fixed place of residence, vagabonds, etc.). As a result, the proportion of older age groups of the population, including pensioners, has significantly increased among patients, and against this background the proportion of the child population has noticeably decreased. This clearly proves that among the adult population of this contingent, a kind of independent epidemic process is developing, which actually does not affect children, as a result of the most pronounced adverse social impact on the spread of dysentery precisely among this contingent of adults.

Pathogenesis (what happens?) during Shigellosis:

There are two phases in the pathogenesis of shigellosis infection: small intestine and colon. Their severity is manifested by the clinical features of the variants of the course of the disease. When infected, Shigella overcomes nonspecific oral defenses and the gastric acid barrier, then attaches to enterocytes in the small intestine, secreting enterotoxins and cytotoxins. When Shigella dies, endotoxin (lipopolysaccharide complex) is released, the absorption of which causes the development of intoxication syndrome.

In the colon, the interaction of Shigella with the mucous membrane goes through several stages. Specific proteins of the outer membrane of Shigella interact with receptors of the plasma membrane of colonocytes, which causes adhesion and then invasion of pathogens into epithelial cells and the submucosal layer. Shigella actively multiplies in intestinal cells; The hemolysin released by them ensures the development of the inflammatory process. Inflammation is maintained by a cytotoxic enterotoxin secreted by Shigella. When pathogens die, a lipopolysaccharide complex is released, which catalyzes general toxic reactions. The most severe form of dysentery is caused by Shigella Grigoriev-Shiga, which can secrete a heat-labile protein exotoxin (Shiga toxin) during life. Homogeneous preparations of Shiga toxin exhibit simultaneously cytotoxic activity, enterotoxicity and neurotoxicity, which determines the low infectious (infecting) dose of this pathogen and the severity of the clinical course of the disease. There are now reports that other Shigella species may produce Shiga-like toxins. As a result of the action of Shigella and the response of the macroorganism, disturbances in the functional activity of the intestine and microcirculatory processes, serous edema and destruction of the colon mucosa develop. Under the influence of Shigella toxins, acute catarrhal or fibrinous-necrotic inflammation develops in the colon with the possible formation of erosions and ulcers. Dysentery constantly occurs with symptoms of dysbiosis (dysbacteriosis), preceding or accompanying the development of the disease. Ultimately, all this determines the development of exudative diarrhea with hypermotor dyskinesia of the colon.

Shigellosis symptoms:

In accordance with the characteristics of clinical manifestations and the duration of the disease, the following forms and variants of dysentery are currently distinguished.

Acute dysentery of varying severity with options:
- typical colitis;
- atypical (gastroenterocolitic and gastroenteric).
- Chronic dysentery of varying severity with options:
- recurrent;
- continuous.
- Shigella bacterial excretion:
- subclinical;
- convalescent.

The variety of forms and variants of dysentery is associated with many reasons: the initial state of the macroorganism, the timing of onset and the nature of treatment, etc. The type of pathogen that caused the disease is also of certain importance. Thus, dysentery caused by Shigella Sonne is distinguished by a tendency to develop milder and even erased atypical forms without destructive changes in the intestinal mucosa, a short-term course and clinical manifestations in the form of gastroenteric and gastroenterocolitic variants. For dysentery caused by Shigella Flexner, a typical colitis variant is more typical with intense damage to the mucous membrane of the colon, pronounced clinical manifestations, and an increase in the frequency of severe forms and complications in recent years. Grigoriev-Shiga dysentery is usually very severe and is prone to the development of severe dehydration, sepsis, and infectious-toxic shock.

Incubation period in the acute form of dysentery it ranges from 1 to 7 days, with an average of 2-3 days. Colitic variant Acute dysentery most often occurs in a moderate form. Characterized by an acute onset with an increase in body temperature to 38-39 ° C, accompanied by chills, headache, a feeling of weakness, apathy and lasting for the first few days of the illness. Appetite quickly decreases, leading to complete anorexia. Nausea and sometimes repeated vomiting often occur. The patient is bothered by cutting, cramping pain in the abdomen. At first they are diffuse in nature, later they are localized in the lower abdomen, mainly in the left iliac region. Almost simultaneously, frequent loose stools appear, initially fecal in nature, without pathological impurities. The fecal character of the stool is quickly lost with subsequent bowel movements, the stool becomes scanty, with a large amount of mucus; later, streaks of blood and sometimes admixtures of pus often appear in the stool. Such stools are referred to as "rectal spit". The frequency of bowel movements increases to 10 times a day or more. The act of defecation is accompanied by tenesmus - excruciating nagging pain in the rectal area. False calls are common. The frequency of stool depends on the severity of the disease, but with the typical colitic variant of dysentery, the total amount of feces excreted is small, which does not lead to serious water and electrolyte disorders.

When examining the patient, a dry and coated tongue is noted. Palpation of the abdomen reveals pain and spasm of the colon, especially in its distal section. (“left colitis”). However, in some cases, the greatest intensity of pain is noted in the area of ​​the cecum (“right colitis”). Changes in the cardiovascular system are manifested by tachycardia and a tendency to arterial hypotension. During colonoscopy or sigmoidoscopy, which has recently been rarely used for the typical colitic variant of acute dysentery, a catarrhal process or destructive changes in the mucous membrane in the form of erosions and ulcers are detected in the distal parts of the colon. Severe clinical manifestations of the disease usually subside by the end of the first - beginning of the 2nd week of illness, but complete recovery, including repair of the intestinal mucosa, requires 3-4 weeks.
The mild course of the colitic variant of acute dysentery is characterized by short-term low-grade fever (or body temperature does not rise at all), moderate abdominal pain, the frequency of bowel movements only several times a day, catarrhal, and less often catarrhal-hemorrhagic changes in the mucous membrane of the colon.

In severe cases of the disease, hyperthermia with pronounced signs of intoxication (fainting, delirium), dry skin and mucous membranes, stool in the form of “rectal spitting” or “meat slop” up to tens of times a day, sharp abdominal pain and painful tenesmus, pronounced changes are observed. hemodynamics (persistent tachycardia and arterial hypotension, muffled heart sounds). Possible intestinal paresis, collapse, infectious-toxic shock.

Gastroenterocolitic variant Acute dysentery is characterized by a short (6-8 hours) incubation period, an acute and violent onset of the disease with an increase in body temperature, early onset of nausea and vomiting, and widespread cramping abdominal pain. Almost simultaneously, multiple, fairly copious loose stools without pathological impurities occur. Tachycardia and arterial hypotension are noted.

This initial period of gastroenteric manifestations and symptoms of general intoxication is short and very similar to the clinical picture of food toxic infection. However, later, often already on the 2-3rd day of illness, the disease takes on the character of enterocolitis: the amount of excreted feces becomes scarce, mucus appears in them, sometimes streaked with blood. Abdominal pain is predominantly localized in the left iliac region, as with the colitic variant of dysentery. During the examination, spasm and soreness of the colon are determined.

The more pronounced the gastroenteric syndrome, the more demonstrative the signs of dehydration, which can reach II-III degrees. The degree of dehydration must be taken into account when assessing the severity of the disease.

Gastroenteric variant begins sharply. The rapidly developing clinical symptoms are very similar to those of salmonellosis and food toxic infection, which makes clinical differential diagnosis extremely difficult. Repeated vomiting and frequent loose stools can lead to dehydration. In the future, symptoms of damage to the colon do not develop (a hallmark of this variant of dysentery). The course of the disease is rapid, but short-lived.

Erased course of dysentery currently found quite often; this condition is difficult to diagnose clinically. Patients complain of a feeling of discomfort or pain in the abdomen of various types, which can be localized in the lower abdomen (usually on the left). Manifestations of diarrhea are minor: stool 1-2 times a day, mushy, often without pathological impurities. Soreness and spasm of the sigmoid colon in most cases are clearly determined by palpation. Body temperature remains normal or rises only to subfebrile levels. Confirmation of the diagnosis is possible with repeated bacteriological examination, as well as with colonoscopy, which in most cases reveals catarrhal changes in the mucous membrane of the sigmoid and rectum.

The duration of acute dysentery is subject to significant fluctuations: from several days to 1 month. In a small percentage of cases (1-5%), a protracted course of the disease is observed. At the same time, intestinal dysfunction in the form of alternating diarrhea and constipation, diffuse abdominal pain or localized in the lower abdomen persists for 1-3 months. Patients' appetite worsens, general weakness develops, and weight loss is observed.

Chronic form of dysentery- a disease with a duration of more than 3 months. Currently, it is rarely observed. Clinically, it can occur in the form of recurrent and continuous variants.

- Recurrent variant Chronic dysentery during periods of relapse in its clinical picture is basically similar to the manifestations of the acute form of the disease: periodically there is severe intestinal dysfunction with abdominal pain, spasm and tenderness of the sigmoid colon on palpation, subfebrile body temperature. Changes in the mucous membrane of the sigmoid and rectum are basically similar to those in the acute form, however, alternation of affected areas of the mucous membrane with slightly changed or atrophied ones is possible; the vascular pattern is enhanced. The timing of onset, the duration of relapses and the “bright intervals” between them, characterized by completely satisfactory health of patients, are subject to significant fluctuations.

-Continuous option Chronic dysentery is much less common. It is characterized by the development of profound changes in the gastrointestinal tract. Symptoms of intoxication are weak or absent, patients are bothered by abdominal pain, daily diarrhea from one to several times a day. The stool is mushy, often with a greenish color. No remissions are observed. Signs of the disease are constantly progressing; patients lose weight, become irritable, and develop dysbacteriosis and hypovitaminosis.

The pathogenesis of protracted and chronic dysentery has not yet been sufficiently studied. The role of autoimmune processes in the development of these conditions is currently being discussed. They are facilitated by a variety of factors: previous and concomitant diseases (primarily gastrointestinal diseases), disorders of the immunological response during the acute period of the disease, dysbacteriosis, dietary disorders, alcohol consumption, inadequate treatment, etc.

Shigella bacterial excretion may be subclinical and convalescent. Short term subclinical bacterial carriage observed in individuals in the absence of clinical signs of the disease at the time of examination and 3 months before it. However, in some cases, antibodies to Shigella antigens can be detected in the RNGA, as well as pathological changes in the colon mucosa during endoscopic examination.

After clinical recovery, the formation of longer convalescent bacterial carriage is possible.

Complications

Complications are currently rare, but in severe cases of Grigoriev-Shiga and Flexner dysentery, infectious-toxic shock, severe dysbiosis, intestinal perforation, serous and perforated purulent peritonitis, paresis and intussusception, fissures and erosions of the anus, hemorrhoids, prolapse can develop rectal mucosa. In some cases, after the disease, intestinal dysfunction develops (post-dysenteric colitis).

Diagnosis of Shigellosis:

Acute dysentery is differentiated from food toxic infections, salmonellosis, escherichiosis, rotavirus gastroenteritis, amoebiasis, cholera, ulcerative colitis, intestinal tumors, intestinal helminthiasis, thrombosis of mesenteric vessels, intestinal obstruction and other conditions. In the colic variant of the disease, take into account the acute onset, fever and other signs of intoxication, cramping abdominal pain with a predominant localization in the left iliac region, scanty stool with mucus and streaks of blood, false urges, tenesmus, compaction and tenderness of the sigmoid colon on palpation. With a mild course of this variant, intoxication is mild, loose stool of a fecal nature does not contain blood impurities. The gastroenteric variant is clinically indistinguishable from that of salmonellosis; with the gastroenterocolitic variant, the phenomena of colitis become more clearly expressed in the dynamics of the disease. The erased course of acute dysentery is most difficult to diagnose clinically.

Differential diagnosis of chronic dysentery is carried out primarily with colitis and enterocolitis, oncological processes in the colon. When making a diagnosis, anamnesis data are assessed indicating acute dysentery over the past 2 years, constant or occasional mushy stools with pathological impurities and abdominal pain, often spasm and tenderness of the sigmoid colon on palpation, weight loss, manifestations of dysbiosis and hypovitaminosis.

Laboratory diagnostics

The diagnosis is most reliably confirmed by the bacteriological method - the isolation of Shigella from feces and vomit, and in case of Grigoriev-Shiga dysentery - from the blood. However, the frequency of Shigella inoculation in various medical institutions remains low (20-50%). The use of serological laboratory diagnostic methods (SLDT) is often limited by the slow increase in titers of specific antibodies, which gives the doctor only a retrospective result. In recent years, rapid diagnostic methods that detect Shigella antigens in feces (RCA, RLA, RNGA with antibody diagnosticum, ELISA), as well as RSC and hemagglutination aggregate reaction have been widely introduced into practice. To adjust therapeutic measures, it is very useful to determine the form and degree of dysbiosis by the ratio of microorganisms of the natural intestinal flora. Endoscopic examinations have a certain significance for diagnosing dysentery, but their use is advisable only in difficult cases of differential diagnosis.

Treatment of Shigellosis:

If there are satisfactory sanitary and living conditions, patients with dysentery can in most cases be treated at home. Persons with severe dysentery, as well as elderly people, children under 1 year of age, and patients with severe concomitant diseases are subject to hospitalization; Hospitalization is also carried out for epidemic indications.

A diet is required (table No. 4), taking into account individual food tolerance. In moderate and severe cases, semi-bed rest or bed rest is prescribed. In case of acute dysentery of moderate and severe course, the basis of etiotropic therapy is the prescription of antibacterial drugs in medium therapeutic doses for a course of 5-7 days - fluoroquinolones, tetracyclines, ampicillin, cephalosporins, as well as combined sulfonamides (cotrimoxazole). Without denying their possible positive clinical effect, antibiotics should be used with caution due to the development of dysbiosis. In this regard, the indications for prescribing eubiotics (bifidumbacterin, bificol, colibacterin, lactobacterin, etc.) have been expanded, 5-10 doses per day for 3-4 weeks. In addition, one should take into account the increasing resistance of dysentery pathogens to etiotropic drugs, especially with respect to chloramphenicol, doxycycline and cotrimoxazole. Drugs of the nitrofuran series (for example, furazolidone 0.1 g) and nalidixic acid (nevigramon 0.5 g) 4 times a day for 3-5 days are currently still prescribed, but their effectiveness is reduced.

The use of antibacterial drugs is not indicated for the gastroenteric variant of the disease due to a delay in clinical recovery and rehabilitation, the development of dysbacteriosis, and a decrease in the activity of immune reactions. In cases of dysentery bacteria carriage, the feasibility of etiotropic therapy is questionable.

According to indications, detoxification and symptomatic therapy is carried out, immunomodulators are prescribed (for chronic forms of the disease under the control of an immunogram), enzyme complex preparations (Panzinorm, Mezim-Forte, Festal, etc.), enterosorbents (Smecta, Enterosorb, Enterokat-M, etc. ), antispasmodics, astringents.

During the period of convalescence in patients with severe inflammatory changes and delayed repair of the mucous membrane of the distal colon, therapeutic microenemas with infusions of eucalyptus, chamomile, rosehip and sea buckthorn oils, vinylin, etc. have a positive effect.

In cases of chronic dysentery, treatment can be complex and requires an individual approach to each patient, taking into account his immune status. In this regard, treatment of patients in a hospital is much more effective than outpatient treatment. In case of relapses and exacerbations of the process, the same means are used as in the treatment of patients with acute dysentery. However, the use of antibiotics and nitrofurans is less effective than in the acute form. To maximize sparing of the gastrointestinal tract, diet therapy is prescribed. Physiotherapeutic procedures, therapeutic enemas, and eubiotics are recommended.

Prevention of Shigellosis:

Epidemiological surveillance includes control over the sanitary condition of food facilities and preschool facilities, compliance with the proper technological regime during the preparation and storage of food products, sanitary and communal improvement of populated areas, the condition and operation of water supply and sewerage facilities and networks, as well as the dynamics of morbidity in the serviced territories, biological properties of circulating pathogens, their species and type structure.

Preventive actions

In the prevention of dysentery, a decisive role belongs to hygienic And sanitary and communal measures. It is necessary to observe the sanitary regime at food enterprises and markets, in public catering establishments, grocery stores, child care institutions and water supply facilities. Of great importance are the cleanup of populated areas and the protection of water bodies from pollution by sewage, especially wastewater from medical institutions. Compliance with personal hygiene rules plays a significant role. Health education is of great importance in the prevention of shigellosis. Hygiene skills should be instilled in children in the family, child care institutions and school. It is important to ensure effective sanitary and educational work among the population to prevent drinking water of questionable quality without heat treatment and swimming in polluted water bodies. Hygienic training is of particular importance among persons of certain professions (workers of food enterprises, public catering facilities and food trade, water supply, preschool institutions, etc.); When applying for such jobs, it is desirable to pass sanitary minimums.
Persons entering work at food and similar enterprises and institutions are subjected to a one-time bacteriological examination. When pathogens of dysentery and acute intestinal diseases are isolated, people are not allowed to work and are referred for treatment. Children newly admitted to nursery groups of preschool institutions during the seasonal rise in the incidence of dysentery are admitted after a single examination for intestinal infections. Children returning to a child care facility after any illness or long-term (5 days or more) absence are accepted with a certificate indicating the diagnosis or cause of the illness.

Activities in the epidemic outbreak

Patients are subject to hospitalization for clinical and epidemiological indications. If the patient is left at home, he is prescribed treatment, educational work is carried out about the procedure for caring for him, and routine disinfection is carried out in the apartment.

Convalescents after dysentery are discharged no earlier than 3 days after normalization of stool and body temperature with a negative result of a control single bacteriological study conducted no earlier than 2 days after the end of treatment. Employees of food enterprises and persons equivalent to them are discharged after a 2-fold negative control bacteriological test and are allowed to work with a doctor’s certificate. Young children attending and not attending child care institutions are discharged in compliance with the same requirements as for food workers, and are admitted to groups immediately after recovery. After discharge, convalescents must be under the supervision of a doctor in the infectious diseases office of the clinic. For persons suffering from chronic dysentery and secreting the pathogen, as well as bacteria carriers, dispensary observation is established for 3 months with monthly examination and bacteriological examination. Employees of food enterprises and persons equivalent to them who have suffered acute dysentery are subject to dispensary observation for 1 month, and those who have suffered chronic dysentery - for 3 months with a monthly bacteriological examination. After this period, with complete clinical recovery, these persons may be allowed to work in their specialty. Children who have had dysentery and attend preschool institutions, boarding schools, and children's health institutions are also subject to observation for 1 month with a double bacteriological examination and a clinical examination at the end of this period.

Persons who have been in contact with a patient with dysentery or a carrier are placed under medical observation for 7 days. Employees of food enterprises and persons equivalent to them are subjected to a one-time bacteriological examination. If the test result is positive, they are removed from work. Children attending preschool institutions and living in a family where there is a patient with dysentery are allowed into the child care institution, but they are placed under medical supervision and undergo a one-time bacteriological examination.

Which doctors should you contact if you have Shigellosis:

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Quite a lot of people have heard about such a problem as dysentery. What is shigellosis, the features of this disease, the causes of its occurrence and ways to get rid of it - I would like to talk about all this in detail now.

Terminology

Initially, you need to understand the basic terms that are used in the presented article. So what is shigellosis? In more common language, this is dysentery, i.e. bacterial intestinal infection. It is caused by bacteria that belong to the Shigella family (this is where the name of the disease itself came from).

Doctors also say that this problem most often occurs in the hot season, i.e. mostly in summer rather than winter. People suffer from it equally, regardless of gender. However, children aged 2 to 4 years are most often affected.

About the pathogen

The causative agent of shigellosis is bacteria of the Shigella family. Shigella Sonne is especially tenacious. They can maintain their functionality for a very long time and even several months (in especially hot times). The most favorable conditions for the proliferation of these microorganisms are food products (minced meat, boiled meat and boiled fish, milk and dairy products, as well as jelly and compotes). The mechanism of transmission of bacteria is fecal-oral. It is transmitted through household contact, water and food. It is important to note that you can become infected even if less than 100 Shigella cells enter the human body.

Doctors also say that the susceptibility of different people to this disease is different, for example, depending on their blood type. Persons with blood groups: A (II), Hp (2), Rh (-) are considered the most sensitive.

Pathogenicity factors

• Invasins. These are special proteins that help harmful microorganisms penetrate the intestinal mucosa. Most often, the lower part of this organ is affected.
• Endotoxin. It is thanks to these microelements that a person experiences symptoms of body intoxication.
• Exotoxin. This is what the bacteria releases into the patient’s blood. This is what causes the problem of diarrhea.

Symptoms

If we talk about a problem like shigellosis, the symptoms are what you definitely need to talk about. Initially, it should be noted that the onset of the disease is mainly acute. What does a person feel with this disease?

1. First of all, diarrhea occurs, the so-called “bloody diarrhea”.
2. Abdominal cramps. Initially, the pain is dull, but later it becomes sharp and has a cramping character. Localization: lower abdomen, mainly on the left. The pain may intensify before defecation, and false urges often occur.
3. Fever.
4. increased body temperature, pain in joints and muscles, weakness.

All these indicators appear already approximately the next day after infection. Thus, the incubation period of the disease is approximately 1-7 days (in some cases it can be shortened to 5-10 hours).

Acute dysentery

This disease can have both acute and chronic forms. What is acute shigellosis? It is worth noting that this particular type of disease manifests itself very actively. The symptoms are clear. Doctors note that in this case, it is the large intestine that is primarily affected. Symptoms for this type of disease:

• Fever. The temperature rises. If we are talking about children, then the indicators can reach 40°C.
• Diarrhea. At first, the bowel movements are short-lived and have a watery consistency. However, as the disease progresses, the number of trips to the toilet increases, sometimes reaching 30 times per day. Mucus, blood and even pus can be found in waste. It should be noted that it is the admixture of blood in the stool that “speaks” that a person has dysentery, and not another intestinal disorder.
• They are cramping in nature. Gradually increasing.
• Tenesmus. Those. The patient may experience a false urge to defecate. There is also pain in the anus after going to the toilet.
• Less often, but still sometimes, nausea and vomiting occur.

If you start treatment on time, the problem can be dealt with in a week. Otherwise, there is a risk of complications. Moreover, death is also possible.

Chronic dysentery

Chronic shigellosis can be diagnosed if the disease continues for more than three months. The course of the disease here can be completely different.

So, the problem can occur on an ongoing basis, and relapses can occur. This type of disease is also characterized by periods of exacerbations. Symptoms manifest themselves to a much lesser extent than in the acute form. The signs of the disease are more smoothed out and not so pronounced. Most often, there is no blood in the stool, and body temperature does not exceed 37.5°C.

A few words about children

Shigellosis in children most often occurs in preschool age. A huge problem is the fact that the baby often puts dirty hands and toys into his mouth, which is how he gets infected. Doctors' statistics say that approximately 70% of all patients are children.

It should be noted that shigellosis in children occurs somewhat differently than in adults. What will be typical for the youngest patients:

• The stool is profuse, foul-smelling, green in color. You can find mucus in it, as well as lumps of undigested food. Blood streaks rarely appear.
• Children's tummy does not retract, but inflates.
• Primary toxicosis manifests itself weakly, but secondary toxicosis manifests itself strongly. Metabolic processes and water-salt balance are disrupted.
• Otitis media or pneumonia often develop - secondary bacterial infections.
• The disease has a wave-like character. Also, young children have a tendency to become chronic.

Diagnostics

What else do you need to know about a disease like shigellosis? Diagnostics (primary) can be carried out even at home. As mentioned above, the main indicator of the presence of this disease is the presence of blood in the stool. If this symptom appears, you should immediately seek medical help. What will the specialist do?

1. Bacteriological method. It consists of stool culture, which will make it possible to identify pathogenic microorganisms.
2. Serological method. In this case, antibodies to Shigella are looked for in the blood. But it should be noted that this method is practically not used. After all, all the information can be obtained thanks to the easier and more reliable bacteriological method.
3. PCR. This method is also used extremely rarely, as it is very expensive. The essence: detection of Shigella genes in feces.

Treatment

• The drug "Regidron". It helps regulate the water-salt balance, which is definitely disturbed if the patient has diarrhea.
• Sorbents. These are drugs such as Smecta, Enterosgel. Their main goal is to minimize the toxic effects on the body, as well as combat diarrhea.
• Antibiotics. If the disease is mild, their use is not required. However, in most cases, if there is blood in the stool, doctors most often prescribe a drug such as Ciprofloxacin. You can also use products such as Tetracycline and Ampicillin. The duration of treatment may vary, but the average is 5 days.

Attention! Taking antidiarrheal drugs such as Loperamide and Immodium is strictly prohibited. They slow down the release of the pathogen from the intestinal lumen. And this significantly lengthens the healing process and removal of harmful bacteria from the body.

Nutrition, diet

From this article it is clear that shigellosis is dysentery, i.e. problem related to the functioning of the gastrointestinal tract. That is why, along with treatment, the patient is prescribed a certain diet. If the patient continues to have diarrhea, he is shown table No. 4. Its essence: reduced fat and carbohydrate content with a normal amount of protein consumed. In this case, it is important to exclude foods that cause increased gas formation and flatulence.

1. Wheat crackers.
2. Soups on a light broth with the addition of cereals.
3. Boiled soft poultry and fish meat.
4. Fresh low-fat cottage cheese.
5. Porridge with water: oatmeal, rice, buckwheat.
6. Eggs: steamed or soft-boiled, no more than 2 pcs. in a day.
7. Boiled vegetables.

Taboo products:

1. Flour and bakery products.
2. Fatty broths and soups based on them.
3. Fatty meat, fish.
4. Milk and products derived from it.
5. Pasta.
6. Porridge: wheat, pearl barley, barley.
7. Legumes.
8. Fresh vegetables and fruits.
9. Cocoa, coffee, carbonated drinks.

If the stool has returned to normal, you can switch to diet No. 2. It is much softer than the previous one. In this case, you can include the following food products in your diet:

• Stale bread.
• Meat and fish.
• Dairy products.
• Ripe fruits, as well as ground berries.
• Sweets: marmalade, pastille, caramel.

Prevention

To avoid a problem like shigellosis, prevention is key. After all, by observing certain measures, it is easy to prevent the development of this disease.

1. You need to wash your hands as often as possible. It is especially important to do this after going to the toilet.
2. Young children should be taught the rules of personal hygiene from a very early age.
3. It is important to properly store and prepare various foods.
4. After contact with a sick person, you must wash your hands. The patient's linen must be disinfected.
5. Patients should not visit crowded places or groups (go to work, school, kindergarten). After all, they are carriers of infection. This can only be done after negative bacterial culture results.

Employees of public catering establishments should be especially attentive to all of the above precautions.

Complications

What is shigellosis - we figured it out. At the very end, it should be recalled that this disease, if not treated correctly, can develop various complications. What should we be afraid of in this case?

Secondary infection. Occurs as a result of In this case, diseases such as urinary tract infections or pneumonia often occur.

After recovery, stool disorders may persist for some time. All this can happen due to the fact that during shigellosis the intestinal mucosa is affected, which leads to serious lesions.

In young children, after suffering a severe illness, body weakness, exhaustion, and fatigue may remain for another couple of months. Also, a problem such as dysbiosis often arises.

MAIN COMPLAINTS

· Stool disorders (diarrhea, constipation, tenesmus)

Flatulence

· Stomach ache

· Intestinal bleeding

STOOL DISORDERS.

In case of intestinal diseases, stool disorders can manifest themselves in the form of changes in the frequency of bowel movements and/or disturbances in the physicochemical properties of stool. An increase in bowel movements or a single bowel movement with the release of copious liquid feces is called diarrhea (diarrhea), prolonged retention of feces in the intestines for more than 48 hours is called constipation.

The appearance of stool may vary. Thick stools are typical for constipation, while loose stools are typical for diarrhea. The stool may contain undigested pieces of food. With a high fat content, it becomes gray, shiny, and unctuous. Light foamy (due to gas content) stools without mucus and blood are a sign of fermentative dyspepsia , and liquid dark brown feces with a pungent putrid odor - putrefactive dyspepsia. Black, unformed, ointment-like feces (due to the presence of iron sulfide, methemoglobin and hematin) are observed in patients with esophageal, gastric or high intestinal bleeding. Such feces are called "melena".

Depending on the location of the lesion, a unique symptom complex is formed. Damage to the small intestine is characterized by a connection between diarrhea and food intake and the presence of undigested pieces of food in the stool. In some cases, patients with chronic enteritis note a violent urge to defecate soon (30-40 minutes) after eating. In this case, the bowel movements are abundant (polyfecal matter), have a liquid or mushy consistency, are light yellow in color, and contain pieces of undigested food. In such cases, the occurrence of diarrhea is associated with a gastrointestinal reflex, when filling the stomach with food causes a sharp increase in small intestinal motility. Damage to the large intestine is characterized by alternating constipation and diarrhea. Diarrhea that occurs in a number of patients immediately after eating is explained by the gastrocecal reflex. Feces contain an admixture of mucus. Patients feel insufficient bowel movements after defecation. When the distal part of the colon is predominantly affected, especially when the anus is involved in the pathological process, tenesmus appears - a frequent urge to defecate, with the release of small amounts of feces and gases. False urges to defecate are possible, while there is almost no feces, only a small amount of gas and mucus is released (the so-called “rectal spitting”).

FLATULENCE

Flatulence is a feeling of swelling, bloating, painful distension of the abdomen. It develops as a result of increased gas formation in the intestines, caused by the consumption of plant fiber and starch with food, which are easily subject to fermentation processes (peas, beans, cabbage, etc.). Flatulence is most pronounced in the afternoon at the height of intestinal digestion. Often accompanied by pain in the heart area, palpitations, and sometimes paroxysmal tachycardia (enteric cardiac reflex).

STOMACH ACHE

General characteristics of pain in intestinal diseases.

Abdominal pain in intestinal diseases is not a leading symptom

with the exception of acute surgical pathology, but are observed quite often.

Localization When the small intestine is affected, pain is often localized around the navel, and in chronic colitis - in the lateral abdomen and iliac region. Sharp pain in the left lower abdomen appear with intestinal obstruction, with inflammation of the sigmoid colon (sigmoiditis). Pain in the perineum, especially during defecation, in combination with the presence of blood in the stool, is characteristic of rectal disease (proctitis, cancer).

Character. The pain can be varied: dull, aching , sometimes cramping (spastic type), bursting.

Aching pain is typical for inflammatory bowel diseases. They are permanent in nature, worsen when straining from coughing or shaking, and do not decrease after defecation.

For intestinal motility disorders the pain is paroxysmal in nature, often localized around the navel, decreases or disappears after the passage of gas, defecation, the use of heat and antispasmodics.

Common signs of intestinal pain that allow us to distinguish them from stomach pain are:

· lack of strict connection with food intake; an exception is the inflammatory process in the transverse colon (transversitis), in which abdominal pain occurs immediately after eating; the pathogenesis of pain in this case is associated with reflex peristaltic contractions of the transverse colon when food enters the stomach;

· close connection of pain with the act of defecation; they can occur before, during and rarely after bowel movement;

Relief of pain after bowel movements or passing gas.

INTESTINAL BLEEDINGS

Intestinal bleeding most often occurs with ulcerative lesions of the digestive system. They can be observed with tumors, protozoal and helminth infestations, acute infectious diseases (typhoid fever, bacillary dysentery), with thrombosis of mesenteric vessels, ulcerative colitis, etc. Melena (black “tarry” feces) indicates bleeding from the esophagus, stomach or upper sections of the small intestines. The presence of scarlet blood indicates bleeding in their lower intestines.

ADDITIONAL COMPLAINTS

Nausea, belching of air, and a metallic taste in the mouth occur when intestinal motility is impaired.

GENERAL COMPLAINTS

Narrowing of interests, suspiciousness, cancerophobia, irritability, emotional weakness, malaise, decreased performance, memory impairment, headaches, dizziness are of false origin. Violation of higher vegetative regulatory processes, endogenous intoxication, and impaired absorption of microelements, vitamins, protein, fats and carbohydrates play a role in their occurrence.