Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
HEALTH CARE MINISTRY OF KAZAKHSTAN REPUBLIC Karaganda State Medical University R.D. Konakbaeva, Ye.M. Laryushina CONSTIPATION (Clinical aspects, diagnostics and treatment) Karaganda 2011 1 УДК 616.34–008.15-07-08 ББК 54.133 К 64 REVIEWEPS: Iskakov B.S. d.м.s., the professor, Umbetalina N.S. d.м.s., the professor, the head of the transfusiology, pathological anatomy, pharmacy with the course of increasing of pedagogic qualification DNIQ of KSMU department. Kosherova B.N. d.м.s., the professor, the head of the department of infectious diseases К 64 Konakbaeva R.D., Laryushina Ye.M. Constipation (Clinical aspects, diagnostics and treatment).-Караганда.-2011.- 32p. ББК 54.133 К 64 The presented educational-methodical manual is devoted to one of the most actual sections of internal medicine - to diseases of intestines. The majority of diseases of organs of the digestion is revealed by the general syndromes basis of which is in the functional disturbances contributing to involving into the pathological process motoric-evacuational function of organs of digestion, the significant place in its clinical picture is paid to a syndrome of constipation. The educational-methodical manual is for the students, interns and doctors. It is confirmed and recommended to the edition by typographical way by МС of KSMU the protocol № 3 10.11.2010 y. It is confirmed and recommended to the edition by typographical way by AC of KSMU the protocol № 4 25.11.2010 y. © R.D.Konakbaeva, Ye.M.Larjushina 2011 2 CONTENTS Introduction 4 1. Definition 5 2. Epidemiology 6 3. Etiology 6 4. Pathogenesis 9 5. Clinic and diagnostic 14 6. Treatment 18 Conclusion 25 Tests 26 Bibliography 31 3 INTRADUCTION Despite of the significant achievements in the field of diagnostics and treatment of constipation the effective solution of this problem is complicated, first of all, because of bashfulness of patients to tell in details about the peculiarities of their defecation, and also because of restraint of doctors which feel the certain difficulties in making the solution of problems connected with constipattion. As a result the patient often remains without the appropriate help that represents threat not only to his health, but also disables the patient in social plan. Simultaneously the problem becomes complicated with the increased number of complaints with imaginary constipation. This condition is connected with feeling of difficulty of the act of defecation and the disturbance of a regularity of ejection, but not connected with constipation itself. By formalistic approach such patients take in various medications for a long period of time, are followed-up at specialists without the certain results. Therefore the purpose of this article is the interpretation of basic questions connected with an origin, diagnostics and treatment of constipation. Constipation is a payment for a way of life. The constipation can be a symptom of many diseases, including oncological ones. Therefore the chronic constipation is a serious reason to get consultation of a gastroenterologist. It is with a doctor that one should discuss the taking in of laxative drugs and the administration of enema in constipation. Since uncontrolled taking in of laxative drugs (about 200 preparations are registered in the Russian market) and administration of enema can only aggravate chronic constipation, having formed a syndrome of ’’lazy large intestine”. 4 1. DEFINITION Constipation (from Latin: constipatio) is a syndrome characterising disturbance of process of ejection (defecation): increase in intervals between acts of defecation in comparison with individual physiological norm or regular insufficient ejection. Normally, it is considered to be 3 times a day up to 3 times a week. However the norm in every person is individual, and if stool begins to occur in the patient 3 times a week and earlier it was a daily norm, only then it is necessary to state the changing of function of intestines and development of tendence to constipation. To the constipation one may also refer daily, but a firm stool in a small amount that can be accompanied with pains, additional expulsive efforts, finger stimulation and as a result feeling of incomplete ejection. It is necessary to consider constipation the difficulty of an act of defecation (with the preservation of normal periodicity of stool). A clinical picture can be complicated with difficult defecation, feeling of incomplete ejection and discomfort in the abdomen. As concerning chronic constipation one may speak about it in case if ejection of intestines occurs in 48 hours and more. The chronic one is considered constipation at presence of two and more signs within 3 months. Presence or absence of constipation is defined by the following characteristics: frequency of stool, duration of expulsive efforts at an act of defecation, quality, consistency and the form of stool, feeling of full or incomplete ejection of content of intestines, presence or absence of anal or perianal pains (tenderness at an act of defecation), abdominal pains, use of the finger help during an act of defecation. The term "constipation" often used by patients and doctors, is interpreted by them differently. In the majority of adults (70 %), following the European style of diet, stool happens once a day. Frequency of acts of defecation is proved to be less often in women. In men consistency of feces is softer, than in women. For the description of the form and consistency of feces, it is purposefult to use the Bristol’s scale. In healthy people the weight of feces a day on the average makes 110 g, but fluctuations may be from 40 up to 260g. The consistency of feces is determined by the quantity of water in it; in firm feces the quantity of it does not exceed 40 %, in normal - 70 % and in liquid 95 %. Objective criterion of constipation is considered the weight of feces less than 35g a day. In men and in young people the weight of feces is more, than in women and in elderly people. The quantity of feces is variable and depends on many reasons: peculiarities of diet, social conditions, change of a usual daily regime, climate, volume of liquid use, hormonal cycle (menses). All the specified characteristics of an act of defecation depend on time of transit of intestinal content through the gastrointestinal tract. Studying the time of transit with the use of contrast markers or radioactive isotopes it was established, that in healthy people it takes about 60 hours: in women - 72 h, in men - 55 h. 5 2. EPIDEMIOLOGY The wide spreadness of this disturbance has given the grounds to refer constipation to illnesses of civilization. In different countries from 2 up to 27 % of adult population and also 60-70-% of patients being for long time in a hospital on a confinement to bed suffer from chronic constipation. In Great Britain up to 50 % of adult population suffers from chronic constipation, that’s why this problem was erected in a rank of the national one for this country; in Germany-30 %, in France and the USA-20 %, in Russia - about 30-35 %. City dwellers suffer more often and among them women (in 2 times) prevail. By available estimations, 10-25 % of children suffer from chronic constipation, among of 60 years-old persons and older the frequency of constipation increases up to 60 %. Unfortunately, women because of biological features of an organism suffer from constipation in 3 times more often than men. In gastroenterological patients frequency of constipation comes nearer to 60-65 %, thus «the latent spreadness» is not taking into account because of false bashfulness or underestimation of the importance of chronic constipation. In any case it is not a harmless symptom, and it is the universal pathogenic factor reducing quality of a life on 20 % and more. 3. ETIOLOGY If not taken into account cases of development of constipation, connected with peculiarities of way of life, then according to data by E.K.Hammad, G.A.Grigorevoj (2000) among the reasons of chronic constipation in age group till 20 anatomic peculiarities of large intestine dominate; in age of 20-40 - a pathology of anorectal zone dominate; after 40 - psychogenic, neurogenic and endocrine reasons of constipation and the reasons connected with a pathology of anorectal zone are often met equally. Depending on the reasons constipations are divided into three big groups: primary, secondary and idiopathic. The reasons of primary constipation are anomalies, malformations of large intestine development and its innervation. The reasons of secondary constipation first of all are illnesses and injuries of colon and rectum, also numerous illnesses of other organs and systems, and metabolic disturbances developing along with them. Constipation may develop due to unfavourable action of medicines (drugs). Idiopathic constipation is caused by disturbances of motor function of rectum and colon, the reason of the last is unknown (innert intestines, idiopathic megacolon and etc.). But the most severe pathology contributing to the constipation is cancerous and precancerous diseases of intestines. Indeed, the cancer of intestines occurs rather seldom - in 3-5 % from all people (more often in age of above 40, but there are also tragical exceptions). At early revealing the cancer of intestines is quite curable, and it may be prevented!!! The truth is that if a person reveals the malignant tumour of intestines, then, according to statistics it may affect up to 10-15 % of his blood (genetically close) relatives. 6 Constipation may be situational, incidental and chronic. For example, situational or incidental constipation occurs in various situations. For example, at pregnancy, using some products or medicines, such constipations cannot be reffered to the disease, this phenomenon is temporary and passing. Constipation can be organic or functional by nature. According to the Roman criteria II (1999), the diagnosis of functional constipation can be made only in those cases when 2 or more of the following symptoms are present for the period of 12 weeks, unessentially consecutive, during 12 months: - frequency of an act of defecation less than 3 a week; - expulsive efforts at an act of defecation, taking 25 % of its time; - fragmented and (or) firm stool not less than at 1 from 4 of acts of defecatoin; - feeling of incomplete evacuation of intestinal content not less often than at 1 from 4 of acts of defecatoin; - feeling of an obstacle at moovement of feces not less often than at 1 from 4 of acts of defecatoin; - necessity of finger manipulations giving the relief to an act of defecation more than at 1 from 4 of acts of defecatoin. The reason of constipation is more often the way of life. It is as a person eats how much active he is, etc. In particular, constipations are caused by the refined high-calorific food. But it is quite possible that the reason of constipation may be the tumour of colon. In any case each person has different reasons. One shouldn’t say that this phenomenon occurs only because of one type of reasons. But all the same, the main causes must be pointed out. 1. "floating" schedule of work (day time - night changes). 2. nervous overstrain. 3. long sleep and as a consequence lack of time for morning defecation. 4. decrease in vegetative fibres in food. (Vegetative fibres increase volume of stool masses and stimulate peristalsis). 5. the use in a plenty of the refined (cleared) products (such food does not contain slags). 6. the use of fatty and protein food of animal origin. 7. fast food. 8. insufficient volume of liquid in diet. 9. abusing strong tea and coffee. 10. "sedentary" work, inactive way of life. 11. various drugs. These are only a part of the reasons of constipation. But these are the reasons which a person is able to regulate (to eat correctly, to be physically active, etc.). Tthe reason of development of temporary constipation is changing of conditions of a life and character of food, presence of unusual and not comfortable conditions for defecation (so-called «constipation of travellers»). The emotional stress is alco capable to provoke temporary disturbance in an act of defecation. Besides, temporary constipations are quite often observed in pregnant women in connection with natural physiological changes. In conditions of a hospital the 7 reason of disturbance of an adequate ejection of the large intestine may be confinement to bed for a long period, use of various medications, administration of barium sulfate in radiological contrast examinations. In some situations, when expulsive efforts are especially harmful for the patient (in acute period of myocardial infarction, the early period after operative interventions on organs of the abdominal cavity), the prevention and treatment of constipation becomes especially important. The temporary stool retention not in all cases should be considered as a sign of any pathological condition. But there are many other reasons. Constipation, as a signal or consequence of some diseases needs serious treatment. Occurrence of constipation in the patient of an average or advanced age must be of oncological alarm. Traditionally most frequent reason of disturbance of intestinal transit is considered irrational food (irregular diet, intake of small amounts of liquid and food fibers). However the comparative analysis of character of food of persons with constipation and those with normal stool testify to the absence of differences in the use of ballasting substances. At the same time patients with constipation revealed the weight of feces less, and time of intestinal transit is much more, than in people with normal stool irrespective of whether they used food with cellulose or not [6]. Quite often constipation occurs due to habitual suppression of desire to defecate, caused by way of a life (morning hurry, peculiarities of work regime, absence of conditions in a toilet). Food plays an important role in regulation of motor function of intestines. The long use of mechanically plain food, high-caloric, little volume of food, lack in a diet of the products containing rough cellulose, or food fibers contribute to the occurrence of constipation. There are products which possess consolidation action, for example: strong coffee and tea, cocoa, cottage cheese, rice, pomegranates, pears, quince, astringents, chocolate, starchy foods. Painfullness during defecation (in thrombosis of external hemorrhoidal nodules, anal fissure) acts as the additional factor contributing to stool retention. Overdosage of many drugs or their unfavorable effects may also cause constipation. Narcotic anaelgetics, anticholinergic substances, some hypotensive remedies inhibit peristaltic activity of intestines, influencing its nervous regulation. Aluminium containing antacids, ferum remedies also cause constipation. The diseases of systems, accompanied with injuries of vessels and nerves of intestines (diabetes mellitus, sclerodermatitis, and myopathy) form a picture of chronic intestinal obstruction - a syndrome of intestines pseudo-obstruction. Constipation is a rather characteristic symptom of such endocrine diseases, as hypothyroidism, hyperparathyroidism. Deficiency of thyroid hormones and hypercalcemia are accompanied with hypotonia of intestines. Terms of constipation occurrence in patients with diabetes depend on severity of course of the disease. The special group consists of patients with constipation which persists despite of following of all recommendations: increase of vegetative cellulose in food content; increase of liquid, leading an active way of life. In such situation we speak about presence of refracter (resistent) constipation that is the indication for the administration of laxatives remedies. 8 Constipations connected with disturbance of the anorectal transit are caused by either primary disturbance of motility of rectum and muscles of pelvic floor or their structural changes. Quite often the reason of constipation may be pathological and viscerovisceral reflexes, occuring in ulcer disease, gastroduodenitis, cholecystitis and also adhesive processes, in diseases of organs of small pelvis, etc. Constipation is also caused by organic diseases of spinal cord and brain, cranial and spinal nerves and nodules, horse tail where there is an injury of nervous regulation of intestines. Quite often constipations develop in neurosis and mental diseases, especially in depressions, schizophrenia, and nervous anorexia. Constipation may be one of the manifestations of myxedema and diabetes complicated with neuropathy. Stool retentions are often observed in pregnancy in connection with increased production of progesterone, and in late terms - in connection with pressure of sigmoid colon and enlarged uterus. Patients with cardiac insufficiency, lungs emphysema, portal hypertensia with ascitis, and also obese ones may have constipation due to weakening of muscular tone of diaphragm and frontal abdominal wall, providing increase of intraabdominal pressure during an act of defecation. The atrophy of muscles of rectum may develop in sclerodermatitis. The reason of senile constipation also can be hypotonia of the muscles participating in the act of defecation. It was revealed that people of elderly and senile age with constipation have slower moovement of intestine content than young people do. The difficulty of promotion of intestinal content due to tumour, usually of the large intestine, stenosis of intestines, formation of impacted feces, and compression of intestinal loops by tumoural formations of other organs of the abdominal cavity often causes chronic reccurent diarrhea or contributes to the alteration of diarrhea and constipation. However in these diseases persistent constipation can be observed sometimes before the other symptoms. Not always it is possible to find out the reason of constipations and their connection with changes of the large intestine. These cases are defined as idiopathic ones. Studying the duration of transit of radiocontrast marker along the large intestine of similar patients it was established that in some of them markers are placed along the whole large intestine, in other ones they accumulate either in sigmoid colon or in rectum.Thus, constipations are caused by the different reasons both of functional and organic character. 4. PATHOGENESIS Mechanisms and the reasons of development of constipation. There are two basic mechanisms of development of chronic constipation - dyskinesia of the large intestine and disturbance of an act of defecation (disshezia). In the first case constipation develops because of disturbance of coordination of intestinal contractions and/or disturbance of tone of an intestinal wall in disturbances of nervous regulation of large intestine, dyshormonal disturbances. 9 The second mechanism – decrease in sensitivity of the nervous endings of large intestine and muscles of the pelvic floor in frequent psychogenic suppression of an act of defecation or hypertone (the increased tone) of anal sphincter, and in this connection for the excitation of an act of defecation the greater accumulation of fecal masses in rectum is needed. These two kinds of constipation differ by clinical pictures and by the results of instrumental methods of examination (measuring the time of moovement of content along the large intestine and defectography etc.). From the pathogenetic positions constipation can be divided into three main types: alimentary, mechanical and dyskinetic (tab. 1). Table 1. Pathogenesis of constipation (Parfenov A.I., 1997) Type of constipation Alimentary (decrease of excrements volume) Pathognetic mechanisms Increased extra-intestinal loss of water (polyuria etc.) Decreased use of wate. Decreased use of fibers Decreased use of food. Decrease of alimentary fibers in diet Mechanical (disturbane of moovement in the intestine) Small intestinal obstruction: At suppression of the intestine externally (adhesions, tumour of the other organs); Intraparietal (diverticulitis); Intralumenal (cancer, polyp, invagination etc.) Large intestinal obstruction: At suppression of the intestine externally (adhesions, tumour of the other organs); Intrawall (diverticulitis, hematoma etc.); Intralumenal (cancer, other tumours) Anal obstruction: At suppression externally (fibrosis, paraprocitis etc.); Intralumenal (tumour, impacted feces etc.) At anorectal malformations (atresia, stenosis) Anomalies of development (drolichocolon, megacolon) Anomalies of development of intramural nervous system of the large intestine – Girshprung’s disease) Diseases of periferal nervous Pseudoobstruction of the intestine Sclerodermatitis Hypothyroidism and other endocrinopathies Diseases of inner organs Mental diseases Metabolic disturbances Drugs’ action (opiates etc.) Syndrome of irritated intestine Disturbance of defecative reflex. Dischezia Mechanism is unknown Hypo- and dyskinetic (reduced speed of transit along the intestine) Idiopathic To alimentary ones we refer constipations that caused by dehydration, i.e. decrease of water in an organism, caused either by decrease of its use or increased in evacuation by kidneys or with sweat. Due to dehydration, content of water in feces decreases, its volume decreases and constipation occurs. Decrease of feces volume is contributed by the decrease of volume of used food and content of alimentary fibers in it. 10 The reasons of mechanical constipation are stenosis, tumours and other obstacles of the organic nature, and hypo-and dyskinetic functional disturbances of a motility of intestines. Disturbance of ejection of the large intestine at functional constipation is connected with the changing of peristaltic activity of a wall of intestines. Constipations are characterized as spastic when the tone of any site of intestine is increased and fecal masses cannot pass through this place. Feces get a kind of "sheep’s one". Hypotonic or atonic functional constipations are connected with loss of a tone of a site of the large intestine. In this case the retention of stool can reach 5-7 days; feces can be of great volume, leaky by a consistency. Pathogenesis of constipation is connected with disturbance of regulation of motor function of intestines. At constipation these disturbances usually associate with increase of unproductive motor activity of intestines, especially of sigmoid colon. If it regularly inhibits moovement of fecal masses constipation occurs. If inhibition influence of sigmoid colon stops, there is diarrhea. Occurrence of constpation speaks about disturbance of regulation of motor function of intestines. Normally, a person’s rectum is empty. Feces accumulate in sigmoid intestine and only its moving to an ampula of the rectum causes reflexly a desire to defecate. In healthy people the desire occurs regularly in the morning under orthostatic influence, after getting up from bed or soon after a breakfast under influence of gastrocecal reflex. An act of defecation is controlled by the central nervous system, and the healthy person can suppress a desire. The habit to suppress a desire to defecate can lead to chronic overdistention of the rectum, to suppression of efferent signals and to the development of so-called habitual constipation. Disturbance of an afferent phase of defecative reflex leads to the development of atony of the rectum and to the increase of its volume. This condition has received the name "megarectum", or "inert" rectum. In patients, suffering from constipation, not only inert rectum is revealed, but also inert sigmoid intestine. Thus, pathophysiology of constipation finally is connected with the decrease of volume of the fecal masses reaching an ampula of the rectum, or with disturbance of an act of defecation, complicating evacuation of feces. The volume of the fecal masses reaching the ampula of the rectum decreases at mechanical obstruction, disturbance of motility or decrease of volume of intestinal content in starvation. In the basis of constipation development 3 basic pathogenetic mechanisms occuring separately or in combination may be pointed out: 1) increased absorbtion of water in the large intestine; 2) inhibited transit of fecal masses along the large intestine; 3) inability of a patient to defecate. Comparison of pathogenetic mechanisms with "functional units" of the large intestine in some cases allows localizing the affected area of the large intestine. So, formation of dense fragmented feces is characteristic for disturbance of propulsive peristalsis of colon where the most intensive absorbtion of water occurs. If a patient has no desire to defecate it points to the disturbance in sensitivity of receptor apparatus of anorectal area which performs the function of accumulation 11 and evacuation of fecal masses. The basic mechanism of chymus moovement is highly amplitude contractions of smooth muscles of a wall of intestines. Decrease in amplitude of these contractions leads to the increase of time of transit of content along the intestines and causes development of functional constipation. At the retention of content in the lumen of intestines absorbtion of liquid increases, that contributes to condensation of fecal masses, that else in a greater degree prevents intestinal content from moovement and leads to the development of coprostasis. Regulation of peristaltic contractions in large intestine is performed by sympathetic and parasympathetic components of vegetative nervous system that in turn depend on the central sections of nervous system. The any component of an act of defecation is carried out with the participation of the cortex of big cerebral hemispheres. In patients with constipation average time of transit takes from 67h up to 120h. Normally, consequent moovement of content alont the large intestine is provided by various types of its contraction. According to research of myoelectrical activity the motility of large intestine is presented to activity as by segmentary contractions (single or organized group phase contractions), so by propulsive ones - special propulsive contractions. [3,4]. For large intestine are usual circadian and day time rhythms of motor function. During a sleep its motor activity is inhibited [5]. Within day segmentary and propulsive activity of large intestine considerably increases, especially at morning awakening and after taking meals. Excitation of motor activity occurs during 1-3 minutes after taking meals and lasts up to 3 h. [6]. The motility of large intestine depends on structure of the eaten food. Fats and carbohydrates stimulate, and amino acids and fibers suppress motor activity of large intestine. In proxymal departments alimentary chymus mixs up, accumulates and closely contacts with intestinal bacteria. Lactose bacteria (bifid - and lactobacteria, Enterococcus faecalis) ferment cellulose and hemicellulose, containing in a peel of vegetables and fruit and coat of grain, up to end-products of disintegration - shortchain fat acids (lactic, propione acid, etc.) and gases (metane, hydrogen, carbon dyoxide) which stimulate peristalsis of intestines. Besides, indigestible cellulose retains water in the lumen of intestine, increasing volume of intestinal content. Laxative action of food fibers is complex and is connected with increase in volume of intestinal content due to retention of molecules of water, increase in bacterial weight and irritation of receptors of large intestine. Protheolitical bacteria, in particular, representatives of sorts of Bacteroides, Proteus, Clostridium, and also Escherichia coll separate fibers up to ammonium, phenols, mercaptopurines and purines. Normally, at microbiocenosis protheo- and diabetic bacteria work together, separating fibers and carbohydrates up to endproducts of disintegration. Changes of structure of intestinal microflora can lead to disturbance of a metabolism (disbalance of vitamins, electrolits) and transit along a large intestine. Distal parts of a large intestine moove faecal masses to a rectum. In these parts electrolits and water (about 2 l/d) are finally absorbed. The defecation begins at sufficient filling of sigmoid colon. Results of 24-hour manometry of a large intestine showed, that defecation is preceded by increase in frequency of highky amplitude and peristaltic contractions. 12 The reflex of defecation occurs at acute distension of rectum. If supraspinal the centers contribute to this process, then during contraction of sigmoid colon and rectum pressure in the ampule of rectum increases, smooths out rectosigmoid corner. As a result of relaxation of internal and external anal sphincters excrement masses are evacuated. The nervous centers of lumbar and sacral parts of a spinal column participate in regulation of this function. The desire to defecate can be strengthened due to increase in intraabdominal pressure by means of Valsalva’s method (expulsive l efforts) or to suppress it by contraction of pelvic muscles of diaphragm and external anal sphincter. Frequent suppression of desires to defecate can lead to a chronic distension of rectum, decrease in tone and chronic constipation. The important reason contributing to the loss of motor-evacuational features of intestines is the disturbance of sensitivity of bioreceptors of an intestinal wall. At constipation disturbance of transferment of a nervous signal can be caused be neuropathy of sacral part of spinal column after injury of afferent and efferent parasympathetic nervous fibers in the lower hypogastral plexus. At loss of afferent phase of defecative reflex of various genesis rectum increases in volume and atony of its walls develops. In consequence of it, the desire to defecate occurs only after the big accumulation of excrements in it (megarectum, or inert rectum). In patients with chronic constipation at manometry of large intestine amount and duration higly amplitude peristaltic contractions are considerably reduced, and also «gastrocolitic» reply to taken food is suppressed or is absent in all segments of large intestine. Thus, at constipation transit chymus mainly along large intestine or in anorectal zone can be disturbed or there is a combination of these disturbances. It is supposed the role of disbalance in the system gastrointestinal hormones stimulating (gastrin, cholecystolinin, substance Р, enkefalines, and motilin) or inhibiting a motility of intestines, in particular, glucagone, vasoactive intestinal polipeptide (VIP), glucagone, serotonine, changes of sensitivity of receptor apparatus of large intestine to various stimul. Significant attention is paid to the disturbance of function of neuro-receptor apparatus of an intestinal wall responsible for its motor activity. In practice of a doctor there are more often constipations caused by secondary motor disturbances of intestines. Motility of intestines, in particular the tone, propulsive movements and their coordination, can be injured in the most various combinations at diseases of abdominal cavity diseases, brain and spinal cord, endocrine system. So-called dyskinetic constipations are one of the most often meeting forms of this symptom. The term «dyskinetic constipation» reflects a true condition of intestines more precisely, than the terms accepted in the past "spastic" and «atonic» constipation. As radiological researches show, rarely it is possible to observe total atony of intestines or prevalence of spastic contractions of its parts. In the majority of patients the combination of spastically reduced and relaxed sites of intestines was revealed, as a result barium moves unequally. Disturbance of motor activity in anorectal zone testifies to constipations with incomplete ejection of rectum even after strong expulsive efforts, with pains in the lower part of the abdomen, in anal and perianal areas and fecal incontinence. In 13 spite of the fact that constipation and fecal incontinence, apparently, exclude each other, quite often mechanisms causing them appear identical. So, repeated and long expulsive efforts at constipation injure mucous membrane of rectum, sacral nerves and muscles of pelvic floor. Finally these circumstances cause disturbance of function of anal sphincters and fecal incontinence. Besides, with the formation of fecal plugs at constipation liquefaction of fecal masses take place in the upper parts of intestines, which flow dense fecal masses round and abundantly evacuate from the anus – so called paradoxical diarrhea. Thus, pathophysiology of constipation finally connects with the decrease in volume of fecal masses, reaching an ampule of rectum or with the disturbance of defecation, complicating ejection of excrements. The volume of fecal masses reaching an ampule of rectum can be reduced as a result of mechanical obstruction, disturbance of a motility or the general decrease in volume of intestinal content (for example, at starvation). 5. CLINIC AND DIAGNOSTIC Clinical features of constipation substantially depend on their reason, duration, severity and features of injury of intestines. Not only intestines suffer from constipation, people do not die because of it, but suffer much. Constipation interfere duly ejection of intestines, poison one of the main charms of a life – to eat well and tasty. If only in the abdomen was not the order, but constipation because of accumulation of intestinal toxins affects the inner sanctum - the brain. Here only some consequences of constipation: a fog in a head, impossibility to concentrate, gloomy mood. At constipation suffers both brainwork and vital optimism, and high spirituality. Therefore the banal constipation often poisons quality of a life more, than diseases much more serious and dangerous to a life. Clinically the course of constipation can be divided into 3 stages: The compensated stage: frequency of stool occurs in 2-3 days, feeling of incomplete ejection of intestines. In half of patients meteorism is revealed. Pains in the abdomen are available in half of cases, which disappear or strengthen after defecation. The subcompensated stage: stool retention takes place from 3 till 5 days. There is no stool of its own and it can be received only with the help of laxatives or with the use of cleansing enema. Quite often there are pains in the abdomen, meteorism, painful defecation, extraintestinal manifestations of constipation appear. Decompensated stage: stool retention takes place till 10 days and more. There is no stool of its own. Stool can be received only after use of hypertonic or siphon enema. At palpation of the abdomen it is possible to find out fecal bolus. Encopresis develops, marked signs of fecal intoxication are revealed. Symptoms: 1. Ejection of intestines less often, than 3 times a week. 2. Small amount of feces. 3. Defecation needs expulsive efforts. 14 4. A dry and firm consistency of feces. 5. Feeling after ejection, that the intestine is evacuated not up to the end. If one of these signs is observed we may say about chronic constipation. There are still symptoms from the category "unessential", i.e. these symptoms do not occur in everybody, suffering from chronic constipation. One of such symptoms – bloating of abdomen or meteorism, it occurs when fecal masses move slowly along large intestine and increases gas formation (because of bacteria activity in intestines). This symptom passes after defecation. Symptoms which need the immediate manipulation of the doctor: 1. Cramp-like pains in an abdomen. 2. Body temperature elevation. 3. Blood from rectum during defecation or change of fecal color (black, tar-like). 4. Nausea, vomiting. 5. A pain in the field of anal orifice during defecation. 6. Change of fecal structure (ribbon stool). For the establishment of diagnosis it is enough to register not less than 2 named signs within last 3 months. The stool retention is quite often accompanied by unpleasant subjective sensations, such as slackness, headache, insomnia (sleeplessness), bad mood, reduction of appetite, nausea, unpleasant taste in a mouth; discomfort, feeling of weight or overflow in abdominal cavity, bloating, pains in abdomen of spastic character. For a significant part of the patients, suffering from chronic constipation, characteristic features of psychological shape are «leaving into illness», suspiciousness. Examination of the patient with a syndrome of disturbance of ejection of intestines must include thorough asking and examination of the patient, estimation of a way of life, getting «drugs" anamnesis, digital examination «per rectum», examination of general and biochemical analysis of blood, coprogram. Obtained data determine algorithm of the further examination. Severe forms of constipation and coprostasis may cause the following complications: - loss of appetite, nausea, vomiting - abdominal pains - fecal incontinence, "paradoxical" diarrhea - retention of urine (ischuria) and enuresis - rectal bleeding - mechanical intestinal obstruction - peritonitis In the majority of patients constipation develops gradually. The most important anamnesis data are duration of constipation, presence or absence of a painful syndrome and loss of weight. In process of deterioration of a motility ejection of intestines of its own occurs less often and is carried out mainly after taking of laxatives or enema. The patient may connect irregular ejection of intestines with absence of desire to дефекации or with difficulty of excrements evacuation. Absence of desires or their rare occurrence is the consequence of their regular suppression. Some patients do not feel full ejection of intestines after stool. 15 It is caused either by retention of a part of fecal masses in the rectum that reveals by digital examination, or by rectoscopy after defecation. More often the feeling of incomplete ejection is caused by an insufficient relaxation of muscles of the rectum and pelvis after finishing the defecation. Intensive, spasmodic pains before defecation and during it especially in patients with recently appeared constipation are characteristic for stenosis processes in intestines. However they can be observed in patients with spastic large intestine at a syndrome of irritating intestines. Pains in the rectum and anal orifice during defecation testify to injury of distal parts of large intestine. Thus filling of the rectum with fecal masses can be accompanied by pain. Often patients, suffering from constipation, complain of bleeding from the rectum at defecation. Thus the most frequent reasons of rectal bleedings are a hemorrhoids, sphincterites or anal fissure. However even in case of revealing of these diseases it is necessary to exclude other sources of bleeding by carrying out colonoscopy or irrigoscopy. The long anamnesis of an obstructive syndrome, especially with diagnostic laparatomy or laparoscopy in the past, should force the doctor to suspect intestinal pseudo-obstruction. Anamnesis data about diseases of anal canal, such as chronic anal fissures, long using of enemas at constipation and abdominal pains allow assuming an opportunity of a syndrome of the irritating intestines. The sudden beginning of constipation in more advanced age group always should suspect at the doctor an idea of cancer of large intestine. During abdominal examination it is possible to palpate a tumour of large intestine. Examination of rectum allows revealing injuries of perianal and anal zones. The empty ampule of rectum may serve as a symptom of Girshprung’s disease with injury of a short segment. Presence of blood in excrements or at examination of rectum points to the injury of mucous membrane of intestines, character of which should be found out during the further examination. The closest and authentic connection is traced between the development of clinical manifestations and complications of diverticular disease and chronic constipation which serve as one of the factors of pathogenesis of diverticulitis development. In patients, suffering from long constipation, diverticular disease acts as combined disease which frequency after 60 years reaches 50-70%, therefore knowledge of features of clinics, course, and diagnostics of this disease is extremely important from the practical point of view. The following clinical forms of diverticular disease are distinguished: asymptomatic diverticulosis, not complicated diverticulitis, complicated diverticulitis and it is frequently recurrent diverticulitis of large intestine. To the complications of diverticulitis one may refer such severe conditions, as an abscess, perforation of a wall of intestine, formation of fistulas, fecal peritonitis, bleeding and intestinal obstruction. Diverticulosis of large intestine in 75 % of cases has asymptomatic course, only 15 % of patients mark pains in the lower part of abdomen, meteorism, diarrheas, constipations, blood admixture and mucus in stool. In diverticulitis 95 % of patients have pains alonh the large intestine, in 50 % of patients may be the elevation of body temperature; 30 % of patients have 16 disturbance of stool (constipations or diarrheas), about 20 % of patients complain of nausea and vomiting. Methods of choice of diagnostics of diverticular disease are irrigoscopy and computer tomography of large intestine. If the patient has clinical signs of diverticulitis it is possible to carry out irrigoscopy only after relieving of symptoms of an inflammation while the computer tomography has no contraindications to be carried out. Colonoscopy serves as less sensitive method of diagnostics of diverticular disease. Diverticulitis serves as contraindication for carrying out colonoscopy because during examination the risk of perforation of the inflamed wall of diverticula of large intestine increases. The basic measure of prophylaxis of diverticulitis development and its complications is the treatment of accompanying constipation. Examination of patients with constipation includes two stages. At the first stage diagnostic search is aimed to exclude organic pathology. The patients are carried out with: general clinical examinations; digital examination of rectum; rectoromanoscopy; irrigoscopy, if necessary - colonoscopy; examination by the gynecologist (for women) the urologist (for men). Especially thorough examination is needed by patients with constipation and symptoms of "anxiety": unmotivated loss of body weight, night semiology (pains), constant and intensive pains in the abdomen, the beginning of the "disease" in advanced age, cancer of large intestines in relatives, fever, blood in stool, leucocytosis, anemia, increased ESR (erythrocytes sedimentation rate), change of the biochemical status, hepato-hypersplenism. After organic pathology has been excluded, at the second stage of examination the level of stasis of intestinal content is defined exactly, the type of motor disturbances is determined ( hyper- or hypokinetic), the accompanying pathology of gastrointestinal tract, endocrine and nervous systems are revealed. Measurement of time of transit can be carried out by a radiological method with barium passage or radioisotope markers along the large intestine. Thus not only a level of stasis in intestines can be revealed, but also the type of motor disturbances in this or that segment of intestines. It is necessary to include into the protocol of research: ultrasound examination of organs of abdominal cavity, laboratory tests for exclusion of hypothyroidism, diabetes, dehydration, hypokaliemia and hypercalcemia; examination of stool microflora; psychoneurological examination. At stasis of content in the rectum the special examinations may be carried out in the specialized medical centers (anometry defecography, electromyography of muscles of pelvic floor, etc.). In the basis of diagnostic concept must be said that constipation is not an illness, but a symptom. The sequence of diagnostic process at constipation is shown on the scheme 3 in the form of algorithm. At absence of data for organic diseases of intestines and exclusion of other reasons constipation is more often connected with a syndrome of irritating intestines. The diagnosis is based on the objective anamnesis and laboratory examinations. For more detailed definition of a degree of disturbance of motor 17 function time of large intestine transit is examinated, and if it is possible physiological examination of anorectal area is carried out: sphincteromanometry is appleid and biopsy of a wall of rectum by Svenson in order to exclude aganglionosis. To determine the time of transit along intestines various markers are used. Tests for determining time of transit are of diagnostical value not only for objectivisation of constipation, but also for strict selection of patients for surgical treatment of constipation. Disturbances of nervous-muscular coordination of an act of defecation, occuring as a result of disturbance of fecal evacuation, are revealed with the help of anal manometry. In normal people rectum filled with excrements or with air stimulates relaxation of internal sphincter and contraction of external sphincter. At Girshprung’s does not relax disease or at aganglionosis of segments of large intestine internal sphincter at filling rectum with excrements. Therefore the use of manometry allows establishing the diagnosis of this disease both in children and in adults. 6. TREATMENT If constipations have occured recently- it is not necessary to worry. This phenomenon is probably episodic. In urgent case it is useful to take in laxatives and then to overview the way of life. It is necessary to increase use of food fibers bran, vegetables, and fruit. Each person should accustom himself to certain time of defecation (it is better in the morning, after sleep). Do any kind of gymnastics. Better the special exercises, improving peristalsis. Do not get used to laxative preparations. The case may be once, twice, but if more it is out of norm. Constant use of laxative preparations may cause injury of mucous membrane of large intestine. Drink more liquid - not less than 2 litres a day. Main principle of treatment of constipation should be carrying out etiotropic therapy, elimination of the reason contributing to the disturbance of ejection of intestines. As it has been told above, it is rather frequent the only reason of disturbance of normal peristaltic activity of intestines in inhabitants of the developed countries is the lack of food fibers in food, and also decrease of motor activity. In this connection a first step in treatment of constipation should be the actions directed on following of a healthy way of life. Main principles of not medicamentous correction of function of intestines include: 1) the use of food with the high content of food fibers. Indigestible food fibers contribute to water retention, increase fecal volume and make its consistency soft, that contributes to the restoration of peristalsis. The use of crude vegetables, fruit, melon-growing cultures, sea kale, stoneberries, bananas, sour-milk products, friable porridges, bread from a flour of a rough grinding, vegetable oil is recommended. It is expedient to reduce the use of the products possessing action (cottage cheese, tea, coffee, cocoa, rice, chocolate, farinaceous foods). 2) regular meals (to eat breakfast is especially important); 3) the sufficient use of liquid (it is desirable - up to 2 l a day); 18 4) to follow the rule of regular ejection of intestines. Activity of large intestine increases after awakening and after meals so desires are observed mainly after breakfast. Do not ignore desires to defecate as decrease in threshold of excitability of receptors of rectum can be observed; 5) daily physical activity. It contributes to the increase of peristaltic activity of intestines. At absence or insufficient efficiency of etiotropic therapy and not medicamentous ways of stool restoration symptomatic therapy may be used. With this purpose the preparations artificially increasing peristaltic activity of intestines – laxatives are used. The first stage of treatment includes the most important actions on training the patient with constipation. Conversation with the patient concerning what is a normal stool and the physiologic act of defecation, an explanation of connection of function of intestines with character of food, a way of life. It is necessary to explain, that the an act of defecation occures, as a rule, at one and the same time, and training of "a gastroenteric reflex" is possible. For this purpose it is necessary to recommend the patient visiting the toilet at one and the same time, it is better in the morning as " the gastroenteric reflex " occures in 15-30 minutes after breakfast more often. A glass of cold juice or water taking into an empty stomach before breakfast may contribute to the defecation. It is necessary the use in food the products rich in food fibers. Food fibers increase volume, weight and speed of fecal transit, thus pressure in the lumen of intestines and contact of intestinal content with mucous membrane decreases. To the products rich in food fibers refer: bran, a seed of flax, beans, peas, a flour of rough grinding, soya, corn flakes, dogrose, wood nuts, and raspberry. On the contrary, the products making the is of diet of a odern person, such as butter, meat, fish, eggs, milk, tea, coffee, do not contain at all food fibers. It is necessary to remind the importance of taking enough liquid - not less than 1-1,5 l a day. Treatment of constipation represents a difficult problem. It is complicated with accustoming to the regular use of laxatives, often observed in these patients. Especially often the doctors meet with this problem in patients of senile age. It is necessary to convince the patient to refuse of bad habit to do regularly enemas and to learn to regulate stool by means of food, correct chewing, and also to recommend more mobile way of life. It is necessary to remember also, that the uncontrolled regular use of laxatives can break absorbtion of various medicines, as a result of fast transit and chemical linkage of some of them (for example, tetracycline or digoxin packed into a cellulose matrix, etc.). At last, use of laxatives is contraindicated because of abdomen, inflammatory diseases of intestines. Diet. For improvement of intestinal transit and reduction of intraintestinal pressure bran is used. Food fibers containing in bran absorb water and as they do not undergo digestion increase fecal volume stool and make by it less firm. At present, along with bran pleasant mixes containing food fibers of grain cereals are used. They are for example, divizit and mukofalk. Divizit is prepared of grains of oats, wheat and soya. In 100 g of the preparation 25 g of food fibers are contained. The preparation is administrated for 50 g/a day. It is established that in patients with constipation divizit stimulates 19 motility of intestines, stool becomes softer and necessity for use of laxatives either disappears, or decreases. Divizit reduces also the content of cholesterol in blood serum in patients with hypercholesteronemia. Mukofalk - a preparation containing seeds of plantain. Due to high hydrofilling mukofalk eliminates constipation, bloating of abdomen and pain. It stimulates motility of the left parts of colon and is administrated at chronic constipation of functional origin. (Mihajlova T.L., 1997). Medicamentous treatment. It is known, that the main regulator of intestinal functions at action of various neuromediators is intestinal nervous system. Enkephalines are produced by intestinal system and influence the specific receptors of enkephalinergic type. The new direction of searching for the preparations regulating motility of gastro-intestinal tract is in the field of investigation of neuropeptides – endorphins and enkefalines. These substances carry out a role of intercellular neuroregulators in an organism. Enkephalines are of natural origin - opiate substances - play the important role in regulation of motor function of stomach and intestines. The modulating effect on motility of intestines makes synthetic enkephalinergic agonist (trimebutin). Debridat interacts with each of three receptors of enkephalines: possess sttimulating and inhibiting effects on motility of intestines. As well as natural enkephalines, trimebutin is capable to stimulate or suppress peristaltic activity of intestines. Debridat (trimebutin) is administered 0,1-0,2 g 3 times a day, before meals, duration of treatment 2-4 weeks. Medicamentous therapy is administered taking into account peculiarities of disturbance of motility. At hypomotoric function prokinetics (mozaks) are administered. At markable dyskinesia of spastic type the certain effect can act as blocators of m-cholinorecptors (atropine, aprophen, levzin, buskopane, metacine, gastrocepine, pirencepine) and myotropic spasmolitic preparations (nospa, papaverin, gnalidor). These preparations reduce spastic contractions of large intestine and pain, but do not influence propulsive function, moreover, even reduce it and, hence, do not influence constipation. Therefore at markable hypokinetic constipation (inert large intestine, idiopatic constipation) it is purposeful to administer prokinetics – preparations increasing tone and motility of gastrointestinal tract. They are, besides listed above, inhibitors cholinesterase ubretid, prozerin and kalymin. Ubretid (distigimin bromide) is administered - 0,5 mg a day, in the morning. Then if necessary and at good tolerance a doze is increased in 2 times. Proserin is administered 10-15 mg 2-3 times a day. Kalymin (pyridostigmini bromidum) - 0,06 g (1 dragee) from 1 up to 3 times a day. In complex therapy of constipation an important role have the preparations possessing choleretic effect, especially containing bilious acids (allocholum, liobilum), also including preparations containing chenodeoxycholic and ursodeoxycholic acids (chenochol, chenofalk, ursofalk). The last, as is known, have the expressed stimulating effect on motility of large intestine due to irritation 20 of its mucous membrane. This circumstance is one of the unfavourable effects observed in patients who are administered with cheno -and ursofalk with the purpose of dissolution of gallstones in bile duct. Laxative medical preparations need to be administered as a rule, only at the first stage of treatment of constipation with the purpose of more effective restoration of lost defecative reflex. By the mechanism of action laxatives are divided into four groups. 1. Osmotic or salt laxatives. They contain badly absorbed carbohydrates (normaze) or the high-molecular polymers, capable to retain molecules of water (forlax). Remaining in small intestine, they increase osmotic pressure of chymus and contribute to secretion of water into the lumen of intestines. As a result the large intestine is filled with a great amount of liquid fecal masses which stimulate peristalsis and easily move along intestines. Purgating effect usually occurs in 6-8 h. Unlike the majority of laxatives these preparations do not influence irritatingly the mucous membrane of large intestine and do not cause accustoming. Therefore they may be administered for a long time. Normaze is administered - 1 dessert spoon at night. Forlax is administered at night till 10-20 g (1-2 bags), preliminary having dissolved in water. 2. Preparations inhibiting water absorption from intestines and stimulating secretion. This effect is reached by irritation of chemoreceptors of mucous membrane mainly of large intestine. They arev the preparations of a phytogenesis containing antraglycosides (preparations of Folium Sennae, Radix Rhei, Fructus Rhamni catharticae and Cortex Frangulae, Oleum Ricini), synthetic compounds (bisakodil, dulkolaks, guttalaks, laxigal etc.) and salt laxatives (sodium sulfate, magnesium sulfate, Sal carolinum factitium, etc.). Some of them are absorbed, metabolized by liver and return to intestines with bile. The increase of peristalsis and liquids in lumen of intestines reduces fecal moovement along the large intestine up to 6-8 h. At continuous use of laxatives containing Sennae extract, in mucous membrane of large intestine accumulates the pigment staining it in black color, the degeneration of the nervous endings in large intestine develops. As a result develops inert large intestine. Also can develop watery-electrolytes disturbances connected with disturbance of sodium and water absorbtion in large intestine. 3. Preparations causing increase of volume fecal masses. They are methylcellulose, psillium (fiberlak), calcium polycarbofil, bran, the linen seed, not absorbed diglucosides (lactulose, sorbitol) Laminaria saccharina, methylcellulose, psillium (fiberlak). Volumetric agents are the unique laxatives of long-term use. They work slow, soft and safe for a regular support of normal stool. Causing irritation of mechanic receptors due to increase in volume of fecal masses, they stimulate motor-evacuative function of large intestine. To take these food additives is better in the morning and at night with enough amount of liquid, adding 2-3 glasses a day of a liquid in addition. Preparations softening stool and facilitating its moving along intestines by greasing effect. They are Oleum vaselini, Oleum Amygdalarum and Oleum Olive, norgalax, enimax. The majority of them possess as waterproof so hydrofilling 21 properties so that they increase the ability of small intestine to retain water, and keep it in fecal masses increasing their volume. The increase of fecal volume stimulates peristalsis, and softer consistency facilitates itsmoovement along intestines. Mineral oils and other preparations of this group are purposeful to administer to those patients being on a long confinement to bed, and those who underwent surgical interventions on anorectal area. Norgalaks is produced in the form of gel on 10 g in a tube with a tip, contains sodium dokusate, carboximethylcellulose and glycerin, is administered in the form of microenema in case of incidental constipation or for prepareness of patients to endoscopic investigations of large intestine. Purgative action occurs in 5-20 minutes after introduction of the preparation into rectum. Enimaks represents a hypertonic solution of sodium phosphate, is issued on 120 ml in disposable plastic enema. It is administered mainly to prepareness of patients for surgical operations, endoscopic and to radiological investigations of large intestine. The majority of preparations used nowadays act a level of large intestine (the plants containing antraglycozides, bisakodil, dulkolax, guttalax, laxigal and other synthetic preparations). Their action occurs in 5-12 h after taking. Stool is more often porridge-like or liquid. At a level of small intestine вазелиновое and vegetable oils act. Their effect occurs in 4-5 h after taking. Stool is often close to normal. At introduction of laxative preparations directly into rectum in the form of suppositories the purgative effect occurs in 10-20 minutes (suppositories dulkolaks, etc.). All the parts of intestines are influenced by all salt laxatives possessing, as is known, most rough (drastic) effect in the form of abundant liquid stool, occuring in 4-6 h after taking in of the preparation. They are usually administered at acute constipations and at food intoxications when it is necessary to empty intestines quickly from toxic substances. If laxatives are used incidentally at absence of contraindications their administration is safe. Volumetric agents can reduce absorbtion of some substances and medicines, but it usually has no clinical value. The general contraindications for administration of laxatives are inflammatory processes in abdominal cavity, intestinal obstruction and acute feverish diseases, and also pregnancy in avoidance of complications. During the period of lactation it is impossible to administer antraglykozides and synthetic laxatives (dulkolaks, bisakodil) as they are absorbed and enter the milk. The chronic use of stimulating laxatives causes irritation of intestines. Besides, long uncontrolled taking of laxative preparations leads to fast enough accustoming. Therefore patients have to to increase gradually a doze; leading up it is frequently up to ultrahigh. Meanwhile at the long use of synthetic preparations and preparations of antraglykozides greater dozes are capable to affect liver and kidneys, nervous plexus in a wall of large intestine. As a result its motility is even more injured. The inert large intestine develops. At the long use of сены melanois of large intestine develops: its mucous membrane gets dark color due to deposit of a pigment on the wall. 22 The least unfvourable effects at the long use cause modern osmotic laxative preparations as forlax and normaze. Forlax and normaze. These laxatives are not split, absorbed in the gastrointestinal tract and do not undergo metabolism. Regular long use of laxative preparations is inadmissible. Therefore for successful treatment of constipation it is necessary to establish first the reason of their occurrence, i.e. the exact diagnosis, and only after that to develop a technique of treatment. At constipation with a spastic dyskinesia for prevention of strengthening of spasms under the influence of food fibers the treatment begins with slagless diet with an fat admixture, gradually adding to it boiled vegetables, and then crude ones. As stimulators of an intestinal motility it is possible to use wheaten bran: begin with 3 tea spoons a day and gradually increase a doze up to 3~6 table spoons. Patients with constipation are administered mineral waters «Esentucki », «Batalinscaya », «Slovenic», «Djemruc ». More mineralized water, in particular, « Esentucki №17 », is administered at constipation with hypomotor dyskinesia on 150-200 ml in a cold kind 2-3 times a day; less mineralized - in the same dozes in a warm kind, for example, « Esentuki №4 » - at hypermotor dyskinesia. Patients with constipation are recommended to increase physical activity (walking, swimming, physical exercises, including ones for strengthening muscles of pelvic floor and abdominal tension). In the morning the patient should provide time (1530 mines) for defecation after plentiful breakfast. The glass of water of a room temperature or juice also can be sufficient for excitation gastrointestinal reflex. At absence of defecation the first days laxative suppositories may be used. The diet and physical exercises can be strengthened by physiotherapeutic procedures. For electrostimulating therapy threshold and exponencial electroimpulses are used. This method in a combination with a diet gives a positive effect on many patients with hypokinetic constipation. Medicamentous therapy is administered taking into account character of motor disturbances of large intestine. At hypomotor dyskinesia of large intestine prokinetics are used, at spastic dyskinesia – spasmolitics of myotrope action. For the last years significant progress has been reached in specification of the mechanisms cntrolling motor function of digestive tract, and creation of new medical preparations for correction of motor disturbance. The motility of gastrointestinal tract is regulated by activity of the central and vegetative nervous systems. In intestines the leading part belongs to the vegetative innervation, presented by intramural (autonomous) and inserted neurons, united into submucosal and muscular plexus. To intramural mediators refer: acetylcholin for cholinergic neurons; serotonin - for serotonine neurons; ATP - for purinergic neurons (purinergic system inhibits the tone of smooth muscular fibers). To intramural mediators refer also neuropeptides: VIP which can activate and inhibit function of neurons muscles; somatostatin, inhibiting and stimulating intramural neurons; the substance Р exciting intramural neurons; enkephalines, modulating activity of intramural neurons. Strengthening of motility is observed at stimulation of cholinoreceptors (through acetylcholine), of some opiate (ОР 1 and ОР 3) and serotonin receptors, weakening at stimulation of adrenoreceptors, dophamine, purine and other opiate (ОР 2) receptors. To prokinetics refer the following groups 23 of preparations: agonists 5-hydroxytriptamin (5НТ 4)-receptors (cysapride, tegaserode, prukalopride, mossapride); agonists 5НТ-receptors (sumatriptane); antagonists of dophamine D 2-receptors (methochlopromide, domperidone). From the listed groups only agonists of 5НТ 4-receptors cause effective propulsive action on large intestine. If regularly following of all listed measures does not help to reach occurrence of a regular stool then we speak of refracter constipation, and in such situation the patient accepts long course of treatment by laxative medical products, i.e. transition to the second stage of treatment. Laxatives are the medicines accelerating evacuation of fecal masses from intestines. "Ideal" laxative should promote occurrence of the shaped stool, should not cause unfavourable effects, a diarrhea, to be well toleranted, to not possess doze depending action and to have predicted time of effect after taking of a standard doze. Often patients select for themselves a laxative preparation by methods of tests or according to friends or acquitances. There is a plenty of laxative medicines and their various division into groups by the mechanism of action laxative preparations are conditionally divided into four groups: 1) causing chemical irritation of receptors of mucous membrane of intestines: антрахиноны (derivatives Sennae, Frangulae, rhubard, aloe), diphenolls (bisacodil, sodium picosulfate), castor oil; 2) possessing osmotic properties: salt (sodium or magnesium sulfate, Carlsbad’s saltsalt), DISAGHARAIDES (lactulose), multinuclear spirits (mannitol, sorbitol), macrogol; 3) increasing volume of content of intestines - ballast substances (an agaragar, methylcellulose, bran, seed of flax); 4) promoting softening of stool (liquid paraffin, Oleum vaselini, macrogol). The acting substance of vegetative extracts are di-or trihydroxilantrachinones in the form of antrachinone glicozides. From the extracts of aloe, Sennae, Frangulae and rhubard in the large intestine active derivatives of antrachinones which stimulate peristalsis of large intestine, inhibit the absorbtion of water and electrolits. Action of preparations of this group depends on time of evacuation of stomach, passage along large intestine and occures later in 6 hours after taking them before meals. By the laxative effect the preparations are settled down in following sequence: leaves of Sennae fruits > Cortex Frangulae> Radix Rhei. Usage for a long period of time may cause melanosis of mucous membrane of intestines. Often there is an accustoming to the given preparations, therefore at the long use the increase in their doze is required. So, in 5 years of acception of the same laxative medicine each 2-nd patient replies, and in 10 years - every 10-th. Derivative of diphenylmethane - bisakodil - by frequency of administration takes the 1st place among preparations of this group. It is issued in two medical forms: in a form of a dragee and supposititory. Unlike the preparations containingantrachynions, bisakodil is active at intake already in the stomach. Therefore its taking, especially at increase in a doze, is often accompanied by spastic pains in the upper part of the abdomen. 24 CONCLUSION Syndrome of chronic constipation is an actual problem of gastroenterology in connection with negative influence on quality of a life of patients. At the same time, in daily clinical practice the constipation remains to one of least effectively diagnosed and corrigated syndromes. Wide diapason of reasons causing a constipation, later the reference of patients behind medical aid, because of bashfulness in details to tell about features defecation increases probability of occurrence of the patient with constipation in practice of doctors - therapists, doctors general practice and other specialities. In the educational-methodical grant questions etiology, epidemiology, pathogenesis are submitted, clinics, diagnostics and treatment of a constipation, and also are analyzed results of numerous researches. The wide circulation of a syndrome of a chronic constipation and influence on quality of a life of patients dictates necessity of early diagnostics and therapy. 25 TESTS 1. In pathophisiology of asyndrome maldigesty and malabsorbtion everything matters, except for: A) Reduction in production of pancreatic enzymes B) Fast transit of intestinal contents C) Reduction in concentration of enzymes as a result of cultivation D) Deficiency of bilious acids in thin intestines E) Infringement absorbtion products of hydrolysis of carbohydrates, fats, proteins 2. At the woman of 45 years alternation of constipations and diarrheas, a swelling of a stomach, sensation of inflow, pains in a stomach at the certificate defication, absence menstruation. Stool with an impurity of slime. It is closed, depressive. A stomach soft, sensitive on a course of thick intestines. Full clinico-laboratory research has not revealed pathological changes. The presumable diagnosis: A) A chronic pancreatitis B) Nonspecific ulcer colitis C) Crone 's disease the D) amebiasis E) A syndrome of the irritated intestines 3. The syndrome of the irritated intestines is characterized by frustration motor and secretion functions of intestines at absence of an organic pathology. The given definition: A) True B) Not true C) True, only frustration of motor function D) True, only frustration secretion functions E) Not true, the organic pathology should be 4. That is incorrect concerning a syndrome of the irritated intestines: A) Disease is known as well as spastic colitis, membranous colitis B) Propensity to constipations or diarrheas or their alternation C) Frequently there is a feeling of alarm, excitation D) More often at women than 40 years are more senior E) There can be an allocation of slime with stool 5. What from statements concerning a syndrome of the irritated intestines incorrectly: A) The direct gut is usually filled feaces with weights B) rectoromanoscopy it is necessary for exception of organic disease distal a department of a small gut C) Characteristic radiological attributes are not present D) constipations with allocation of slime E) constipations with allocation of blood 6. What from the subsequent positions truly for a syndrome of the irritated thick gut: A) The most preferable definition - deficiency of lactose B) Presence of nervous - muscular or hormonal defect is probable C) Presence of the defect developed on the immune mechanism is probable D) The syndrome can be a precancer condition E) A usual clinical attribute - non holding of stool 7. The young woman has acted with complaints to a swelling of a stomach, his feeling , pains in a stomach, an often liquid aqueous chair. rectoromanoscopy a mucous membrane of a gut without features. The prospective diagnosis: A) Nonspecific ulcer colitis B) A syndrome of the irritated gut C) lambliosis D) A chronic pancreatitis E) disease the Crone 26 8. For a hypermotor dyskinesia of a thick gut are characteristic: A) The diarrheas, varying constipations (a unstable chair, "sheep" Stool) B) Blood and slime in stool C) Phobias, depressions D) sphyncteritis E) Persistent headaches 9. Everything concern to symptoms excluding a syndrome of the irritated gut, except for: A) Loss of weight of a body B) The beginning of disease in advanced age C) Imperative desires on the certificate defication D) Constant intensive pains in a stomach, as a unique and conducting symptom E) A fever 10. Contra-indication for assignment mesalasine at patients with a syndrome of the irritated gut is his ability to cause: A) diarrhea B) A constipation C) meteorism D) maldigestion E) malabsorbtion 11. On the mechanism of action laxative share on all listed, except for: A) Causing chemical irritation receptor's the device of a thick gut B) Possessing osmotic properties C) Increasing volume of contents of intestines D) Promoting a softening feaces weights E) Walls of intestines causing mechanical irritation 12. At the patient 21 years, disturb constipations, a swelling of a stomach, periodically changed diarrheas. Persistent constipations marks since the childhood. Periodically comes to light Stool as "fuse". At radiological research narrowing in rectosigmoid a department of a thick gut sharply contrasting with suprastenotic expansion of colon guts is revealed. The most probable preliminary diagnosis is: A) Nonspecific ulcer colitis B) A syndrome of the irritated gut C) Yersiniose enteritis D) Girshprung'sdisease E) дисахаридазная insufficiency 13. The difficulty of the certificate defication refers to: A) meteorism B) A constipation C) disshezia D) flatulention E) apstipation 14. What statement concerning a syndrome of the irritated intestines incorrectly: A) The basic symptom - alternation of diarrheas and constipations B) The diagnosis proves to be true characteristic changes at irrigoscopy C) Symptoms are connected to infringement motor and secretion functions of intestines D) In stool there can be an impurity of slime E) Pains in a stomach changeable and varying localization 15. The patient of 46 years disturb alternation of a liquid chair and constipations, occurrence of blood in stool, change of the form feaces (lentiforms), pains in a bottom of a stomach. Objectively: the common condition satisfactory, the stomach is moderately inflated, in the rest palpation a stomach without features. Periodically there is a sensation incomplete palpation intestines after the certificate defication. Pick up the most probable reason of disease: A) Nonspecific ulcer colitis 27 B) cologenic colitis C) pseudomembranose colitis D) A syndrome of the irritated gut E) An infection campilobacter 16. What from below listed symptoms is not characteristic for a syndrome of the irritated intestines: A) The most often symptom - pains in illiac or hypogastial areas B) Pains in a stomach always intensive C) Pains in a stomach of varying localization D) There are constipations, changed diarrheas E) Frequently there is a rumbling and transfusion in a stomach 17. For the patient of 46 years it is diagnosed SII with prevalence of constipations, with pains in a stomach, occurrence of blood in stool, change of the form feaces . A condition satisfactory, the stomach is moderately inflated, in the rest palpation a stomach without features. Treatment includes everything, except for: A) A diet with addition of food fibres B) dicetile C) forlacs D) smecta E) dicicloverinum 18. The man of 42 years has addressed with complaints on pains in a stomach, amplifying after reception of food; constipations till 2-3 days, feeling of a swelling of a stomach, and also character of a chair on type « sheep feaces ». Carrying out of colonoscopy was painful; on a mucous membrane of a thick gut a plenty of slime was defined. What from the listed diagnoses IS MOST PROBABLE? A) Crone's disease B) A cancer of thick intestines C) SII with prevalence of constipations D) SII with prevalence of diarrheas E) A syndrome superfluous microbic contamination 19. To out intestinal to displays of a syndrome of the irritated gut most probably concerns: A) A constipation B) A pain in a stomach C) An often, liquid chair D) A constipation alternating to diarrheas E) A disturbing - depressive syndrome 20. At the patient with complaints to the constipations described by presence feaces of weights as balls with an impurity of slime of a pain in left iliac of the area, disappearing after the certificate defication, at rectoromanoscopy are revealed multilayered. The most probable diagnosis: A) diverticulesis B) diverticulitis C) A cancer of a thick gut D) pararectal an abscess E) adenomatous polyp 21. To the patient with diverticulesis initial medical action should be: A) Food rich tissue B) Food poor tissue C) lactulose D) Laxative means E) colomyotomy 22. Patient Н., 76 years has addressed with complaints to whining stupid pains in the bottom part of the stomach, disappearing after the certificate defication; constipations. Objectively: a stomach soft, painful on a course of thick intestines, 28 spasmed. Coprology: the microscopy without a pathology is a lot of slime, "sheep" Stool. Colonoscopy: catharal proctosigmoiditis. The diet with inclusion of bran, mineral waters is appointed. The MOST EXPEDIENT tactics: A) No-spa+ cerucal B) forlacs + motilium C) fortrans + motilium D) regulacs + cholestiramine E) An extract senum + maalocks 23. Patient Р., 86 years has acted with complaints to pains in a stomach, irradiated in lumbar area; a swelling of a stomach, propensity to constipations, "sheep" Stool with slime and blood on surfaces, weakness, losing of weight. In the anamnesis polyps of a thick department of intestines. At survey of the lowered feed, a leather pale. Language is impose. A stomach soft, painful in the bottom departments. In blood: leukocytes of-10 thousand, ESR-52 mm / h. Irrigoscopy: in area sigmoid during 20 sm circular the gleam, in the center of narrowing proof depot of barium is narrowed. What from the listed methods of inspection is MOST INFORMATIVE: A) FGDS B) Duodenography C) Roengenoscopy a stomach D) Colonoscopy with aim biopsy E) Fractional research of gastric juice 24. The patient of 56 years has addressed with complaints to constipations, occurrence of blood in stool, change of the form feaces (lentiforms), pains in the bottom of a stomach. Objectively: the common condition satisfactory, integuments and mucous pale, the stomach is moderately inflated, in the rest palpation a stomach without features. First of all it is necessary for patient to carry out research A) irrigoscopy B) coprogramm C) Manual research of a direct gut D) rectoromanoscopy E) fibrocolonoscopy 25. At the woman who one year ago have transferred cholecystectomy concerning cholelithiasis, pains in left hypohondrium, a nausea, constipations have appeared. Pains carry spastic character, arise after infringement of a diet. At inspection: a stomach soft, painful in the left half epigastrium. In blood: moderate leukocytosis, acceleration ESR, in coprogramm amylorrhea, crearorrhea, steatorrhea. What plan of medical actions is most expedient: A) spasmolitics, enzymes B) analgetics, spasmolitics C) inhibitors of prothease, starvation D) analgetics, inhibitors prothease E) desintoxication means, analgetics 26. The woman of 63 years complains on spastic pains in epigastrium and left hypohondrium, connected with errors in a diet, a nausea, propensity to constipations. 6 months ago has transferred cholecystectomy. Objectively: a stomach soft, painful in points of a projection of a pancreas. In the common analysis of blood: leukocytes - 9,8 thousand, ESR - 22 mm / ю, in coprogramm neutral fat, vegetative tissue. What from the listed diagnoses IS MOST PROBABLE: A) A chronic hepatites B) A cancer of a pancreas C) An aggravation chronic cholangitis D) The painful form of a chronic pancreatitis E) PCES, a chronic pancreatitis in a phase of an aggravation 29 27. The man of 43 years after stress complains of pains in a stomach, decreasing the ambassador passage a chair and gases; alternation of constipations and diarrheas; bad dream, irritability. Objectively: the stomach is inflated, morbidity on a course of a descending department of a thick gut is defined. At radiological research attributes of a dyskinesia of a thick gut are revealed; at colonoscopy propensity to spasms. What from the listed variants of a syndrome of the irritated intestines IS MOST PROBABLE: A) With prevalence of constipations B) With prevalence diarrhea C) With prevalence meteorism D) With prevalence of pains in a stomach E) With prevalence of pains in a stomach and метеоризмом 28. Patient E., 34 years has acted with complaints to whining pains in the bottom and lateral departments of the stomach, amplifying through 7-8 hours after meal; a unstable chair: the diarrheas alternating to constipations. Diarrheas arise after reception of milk, at constipations Stool fragmented. Objectively: morbidity, rumbling of thick intestines. On irrigoscopy narrowing of a gleam of a thick gut, presence plural gaustration, supporting an intestinal contour. What from the listed diagnoses is MOST PROBABLE: A) shygelesis B) disease the Crone C) Ischemic colitis D) pseudomembranose colitis E) Nonspecific ulcer colitis 29. The woman of 52 years who is taking place in the period menopause, within 2th years pains around umbiliccus a various degree of the intensity, disappearing the ambassador passage a chair disturb; periodically an indulgence of a chair; a swelling of a stomach. Objectively: morbidity of all thick gut. Coprological: a plenty of slime. At radiological research of thick intestines: attributes of a dyskinesia; at colonoscopy: propensity to spasms. What from the listed diagnoses is most probable: A) Ulcer colitis B) Chronic colitis C) lymhpocytic colitis D) pseudomembranose colitis E) A syndrome of the irritated intestines 30. Expressed sensitivity of all stomach, a pain at easy palpation at absence of an organic pathology of intestines is most probable for: A) Ulcer colitis B) Collagenic colitis C) Post infectious colitis List of answers: 1 2 3 4 5 - A E A D A 16 17 18 19 20 - B D C E A 6 7 8 9 10 - B B A C A 21 22 23 24 25 30 - A D D C A 11 12 13 14 15 - E D C B D 26 27 28 29 30 - C E E E E BIBLIOGRAPHY 1. Шульпекова Ю.О. Запор и методы его лечения / Ю.О. Шульпекова // Русский медицинский журнал.- 2007.- №15.- С. 25-32.3. 2. Attar A. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for the treatment of chronic constipation / A.Attar [et al.] // Gut.-2008.-Vol.44.-P.226–230. 3.Самсонов А.А. Синдром хронического запора / А.А. Самсонов // Русский медицинский журнал.- 2009.- №4.- C. 25-31. 4. Bernier J.J. Effect of low dose polyethylene glycol 4000 on fecal consistency and dilution water in normal subjects / J.J. Bernier, Y.Donazollo // Gastroenterol.Clin.Biol.-2007.-Vol.21.P.7–11. 5. Brandt L.J. Systematic rewiew on the management of chronic constipation in North America / L.J. Brandt [et al.] // Am. J. Gastroenterology.- 2005.- Vol. 100.-P.-5–21. 6. Higgins P.D. Epidemiology of constipation in North America: a systematic rewiew / P.D. Higgins, J.F.Johanson // Am. J. Gastroenterology.- 2006.- Vol. 99.-P.750–759. 7. Минушкин О.Н. Осмотические слабительные в лечении функциональных запоров / О.Н.Минушкин [и др.] // Русский медицинский журнал.- 2010.- №6.- С.12-17. 8. Щербаков П.Л. Метеоризм у детей / П.Л. Щербаков // Трудный пациент.-2006.-№9.С.19–21. 9. Кузьменко Л.Г. Расстройства пищеварения / Л.Г. Кузьменко //Фармацевтический вестник.- 2005.- №25.- С. 5-9. 10. Savino F. Lactobacillus reuteri (American type culture collection strain 55730) versus simethicone in the treatment of infantile colic: a prospective randomized study / Savino F. [et al.] // Pediatrics.2007.Vol.119.-P. 124–130. 11. Higgins P.D. Epidemiology of constipation in North America: a systematic review // P.D.Higgins, J.F. Johanson // Am. J. Gastroenterol. -2008. – Vol. 99.- P.750–759. 12. Bosshard W. The treatment of chronic constipation in elderly people: an update / W.Bosshard, R.Dreher, J.F.Schnegg Bula // Drugs Aging. -2004. Vol.21.-P.911–930. 13. Bassotti G. Italian Constipation Study Group. An extended assessment of bowel habits in a general population / G. Bassotti [et al.] // J. Gastroenterol. – 2009.–Vol.10.-P.713–716. 14. Тимофеева А.В. Дюфалак в лечении запора у пожилых пациентов, страдающих сердечно–сосудистыми заболеваниями/А.В.Тимофеева, Ю.Н.Моисеева, И.А.Либов // Русский медицинский журнал.- 2007.- № 6.- С. 17–21. 15. Koch A. Symptoms in chronic constipation. Dis. Colon Rectum / A.Koch [et al].-2006.Vol.40.-P.902–906. 16. Garrigues V., Galvez C., Ortiz V., Ponce M., Nos P., Ponce J. Prevalence of constipation: agreement among several criteria and evaluation of the diagnostic accuracy of qualifying symptoms and self–reported definition in a population–based survey in Spain. Am. J. Epidemiol. 2004; 159: 520–526. 17. Tramonte S.M. Is constipation associated with decreased physical activity in normally active subjects? / Tramonte S.M. [et al.] // Am. J. Gastroenterol. – 2005.-Vol.100.-P.124–129. 18. Барановский А.Ю., Кондрашина Э.А. Дисбактериоз кишечника. M.: Питер,2007.–240с. 19. Talley N.J.3rd. Constipation in an elderly community: a study of prevalence and potential risk factors / N.J.Talley [et al] // Am. J. Gastroenterol. – 2005.-Vol.91.-P.19–25. 20. Dukas L. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women / L.Dukas, W.C.Willett, E.L.Giovannucci // Am. J. Gastroenterol. – 2003.Vol. 98. P. 1790–1796. 21. Tramonte S.M. Is constipation associated with decreased physical activity in normally active subjects? / S.M.Tramonte [et al] // Am. J. Gastroenterol. – 2005.-Vol.100.P.124–129. 22. Chassagne P.Does treatment of constipation improve faecal incontinence in institutionalized elderly patients? / P.Chassagne [et al] // Age Ageing. – 2009. -Vol. 29. –P.159–164. 23. Gibson G.R. Dietary modulation of the human gut microflora using the prebiotics oligofwtose and inulin / G.R. Gibson // J. Nutr.-2008.- Vol. 129. –P.1438–1441. 24. Roberfroid M.B. Prebiotics and probiotics: are they functional foods / M.B. Roberfroid//Am.J.Clin.Nutr.-2007.-Vol.71.-P.1682–1687. 25. Пейлли Ф. Открытое полугодовое исследование безопасности применения Транзипега для лечения запора в рамках медицинского обслуживания / Ф.Пейлли, Н.Коломбей, Б.Аллоуми [и др.] // Русский медицинский журнал.- 2006.- № 11.- С.11–15. 31 Подписано в печать 13.12.2010 г. Объем 2 уч.печ.л. Формат 60х84 1/16. Тираж 100 экз. Отпечатано в типографии КГМУ г. Караганда, ул, Гоголя, 40 32