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SEMIOLOGIA APARATULUI DIGESTIV

medicina












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 SEMIOLOGIA APARATULUI DIGESTIV

                                                          VĂRSĂTURA



= expulzarea fortata, sub presiue, a continutului gastric prin cavitatea bucala

   sau/si prin narine

- poate fi -precedata de greata

               - īnsotita de : - hipersalivatie

                                      - paloare

                                      - transpiratii

                                      - tahicardie

CLASIFICAREA = īn functie de 3 criterii :

A. ĪN FUNCŢIE DE ASPECT : - alimentare

                                                      - bilioase

                                                      - fecaloide

                                                      - cu continut de sānge - striuri sanghinolente

                                                                                            - hematemeza

B. ĪN FUNCŢIE DE MECANISMUL DE PRODUCERE :

                      - prin mecanism obstructiv

                      - de cauza reflexa (īn infectii sau īn boli metabolice)

                      - centrale (īn sindr. HIC)

C. ĪN FUNCŢIE DE ETIOLOGIE :

1) VĂRSĂTURI DE CAUZĂ ALIMENTARĂ :         

             - depasirea tolerantei digestive (cantitativ sau calitativ)

             - tehnica de alimentatie gresita

             - aerofagie

2) VĂRSĂTURI DE CAUZĂ INFECŢIOASĂ :

          a) ĪN INFECŢII DIGESTIV 11211e420l E : = stomatite

                                                                 = esofagite

                                                                 = gastrite (cu HP)

                                                                 = ulcer gastric si duodenal (cu HP)

                                                                 = gastroenterocolite

                                                                 = angiocolite, colecistite

                                                                 = hepatita ac.

                                                                 = pancreatita ac.

                                                                 = apendicita ac.

                                                                 = peritonita

          b) ĪN INFECŢII EXTRADIGESTIVE :

* Din sfera ORL : - rinofaringita

                                - amigdalita

                                - adenoidita

                                - otita

                                - sinuzita

* Urinara : - pielonefrita

                    - glomerulonefrita

* SNC : - meningita

              - encefalita

3) VĂRSĂTURI DE CAUZĂ MECANICĂ :

-         atrezia, stenoza, malrotatia, duplicatia intestinala

-         imperforatia anala

-         stenoza hipertrofica de pilor

-         ocluzia intestinala

-         b. Hirschprung

-         hernii (diafragmatica, hiatala, inghinala strangulata)

-         ascaridiaza, teniaza

-         sindr. aderential

-         corpi straini īn tubul digestiv

4) VĂRSĂTURI ĪN BOLI DIGESTIVE NEINFECŢIOASE :

-         esofagita chimica

-         gastrita medicamentoasa

-         enterocolita necrozanta

-         intoleranta la proteinele LV

-         enteropatia gluten-sensibila

-         b. inflamatorii cronice intestinale (b. Crohn, colita ulceroasa)

-         b. vasculare (infarctul intestino-mezenteric)

5) VĂRSĂTURI DE CAUZĂ METABOLICĂ :

- hipoglicemie

- hipercalcemie

- uremie

             - īn boli genetice de metabolism : - galactozemia                                                                                          

                                                                      - fenilcetonuria

                                                                      - intoleranta genetica la fructoza

                                                         - acidemii metabolice genetice

                                                         - deficitul de 21-hidroxilaza, tip II

                                                           decompensata

6) VĂRSĂTURI DE CAUZĂ ENDOCRINĂ :

                 - hiperparatiroidism

7) VĂRSĂTURI DE CAUZĂ CEREBRALĂ :

-         hidrocefalie

-         edem cerebral

-         hemoragie intracraniana

-         abces cerebral

-         tumori crebrale

-         enefalopatia hipertensiva

-         migrena

8) VĂRSĂTURI DE CAUZĂ RENALĂ (īn afara cauzelor infectioase si a uremiei) :

-         litiaza urinara

-         hidronefroza

-         tumori renale

9) VĂRSĂTURI DE CAUZĂ TOXICĂ :

           - intoxicatii : = salicilati

                                 = digitala

                                 = teofilina

                                 = vitamina D

10) ALTE CAUZE DE VĂRSĂTURI :

          - varsaturi ciclice acetonemice

          - insolatia

          - kinetoza ("raul" de masina sau avion)

          - sarcina

          - psihogene

                                                  REGURGITAREA

= eliminarea orala, postalimentara, fara efort, a unei cantitati, de obicei mici,     

   de alimente ingerate, concomitent sau nu cu fenomenul de eructatie

= simptom nespecific

= se impune dgs. diferential  cu varsatura

= poate fi : = fara semnificatie patologica (cant. mica, curba ponderala neinfluentata)

                   = cu semnificatie patologica (cant. mare, curba ponderala influentata)

CAUZE : - regurgitatii fiziologice (la nou nascut si sugar)

    - greseli de tehnica alimentara

    - RGE

    - b. ale esofagului  : a) Congenitale = atrezia, stenoza esofagiana

                                                                = duplicatia esofagiana

                                                                             = esofag scurt

                                                                             = hernie hiatala

                                                    b) Dobāndite = esofagite

                                                                           = stricturi (postcaustice, sclerodermie)

                                                                           = corpi straini esofagieni

                - b. ale cardiei = cardiospasm

                - b. ale diafragmului = eventratie diafragmatica

                - b. care determina cresterea presiunii intraabdominale

                - ruminatia

   - alte cauze = dispneea

                                                     RUMINAŢIA

= manifestare de tip nevrotic, cu debut la v. de 2-3 luni

= consta īn autoprovocarea de regurgitari repetate, cu o cantitate variabila de

   alimente din continutul gastric, care sunt apoi redeglutitionate sau eliminate

   īn exterior

- uneori determina scadere ponderala importanta

CAUZE : - sugarul neglijat (are semnificatie de autogratificatie)

                 - psihoze

    - acidemia propionica

             TULBURĂRI ALE COMPORTAMENTULUI ALIMENTAR

1.     INAPETENŢA - ANOREXIA

2.     POLIFAGIA (HIPERFAGIA) - BULIMIA

3.     POLIDIPSIA

4.     PICA

1. INAPETENŢA - ANOREXIA

         = lipsa apetitului

         = forma cea mai severa = anorexia

      a) Inapetenta falsa : = apetitul copilului nu satisface exigentele apartinatorilor

                                         = curba ponderala nu este influentata

      b) Inapetenta reala : = determina stationare sau scadere īn greutate ± īnaltime

               CAUZE : * Organice = infectii ac.

                                                    = b. cronice

                                * Exlcuderea pt. un timp a alimentatiei orale :

                                          = alimentatie parenterala totala

                                          = gastrostomie

                                * Inapetenta psihogena

               Cauze posibile ĪN FUNCŢIE DE VĀRSTĂ :

·        La sugar : = secundara alimentatiei excesive cu lapte

·        La prescolar si scolar : = inapetenta cu caracter selectiv

·        La pubertate si adoescenta : = anorexia nervoasa (forma cea mai severa)

2. POLIFAGIA - BULIMIA

POLIFAGIA (HIPERFAGIA) = aport alimentar excesiv, datorat cresterii exagerate

                                                        a apetitului



             CAUZE : * Neurologice : = leziuni hipotalamice

                              * Psihice : = anxietate

                                                = depresie

                              * Endocrine : = hipertiroidism

                                                      = feocromocitom

                            * Metabolice : = DZ

                            * Sindroame : = s. Prader-Willi

                                                    = s. Kleine-Levin

                            * Alte cauze : = unele glicogenoze

                                                    = nanismul psiho-social 

BULIMIA = forma de hiperfagie, de care se diferentiaza prin :

-         intensitatea maxima

-         caracterul episodic

-         asocierea varsaturilor autoprovocate

-         abuz de laxative si diuretice

-         caracterul secret al consumului exagerat de alimente, cu pastrarea unui

comportament alimentar normal  īn prezenta altor persoane

   CAUZA = psihogena

3. POLIDIPSIA

 = consum excesiv de lichide (apa), din cauza unei senzatii exagerate de sete

a)      POLIDIPSIE PRIMARĂ = dipsomania (neuroza setei)

b)      POLIDIPSIE SECUNDARĂ POLIURIEI :

                 = diabet insipid

                 = DZ

                 = insuficienta renala cronica

                 = tubulopatii

4. PICA

 = consumul unor substante si materiale care nu constituie alimente

 - apare la copilul mic si la anteprescolar

 - sa datoreste unor carente afective si probleme emotionale

 - se asociaza frecvent cu prelungirea utilizarii suzetei si a biberonului 

  

                                TULBURĂRI DE DEGLUTIŢIE

DISFAGIA = dificultatea de a deglutitiona

ODINOFAGIA = deglutitia dureroasa

PSEUDO-DISFAGIA = refuzul de a īnghiti

                                      = apare la : - copilul neglijat afectiv

                                                          - copilul retardat psihic

 a) DISFAGIA PRIN PERTURBAREA FAZEI OROFARINGIENE A DEGLUTIŢIEI

      1. CAUZE ANATOMICE : - cheilognatopalatoschisis

                                                     - micrognatism, microretrognatism (s. Pierre-Robin)

                                                     - microstomie

                                                     - macroglosie

                                                     - modificari anatomice ale reg. orofaringiene :

                                                            * hipertrofie amigdaliana

                                                            * duplicatia si diverticulul faringian

                                                            * abces retrofaringian

                                                            * tumori faringiene

                                                            * tiroida ectopica

                                                      - alte cauze : - atrezia choanala

                                                                            - posttraheostomie

                                                                            - artrita temporo-mandibulara  

2. CAUZE NEUROLOGICE :

         -  b. ale SNC : = meningoencefalite

                     = malformatii cerebrale

                     = hemoragie cerebrala

                     = tumori

                     = traumatisme

        -  poliradiculonevrita

        -  incoordonare cricofaringiana

3. CAUZE MUSCULARE :

        - miastenia gravis

        - distrofia musculara progresiva Duchenne

        - dermatomiozita

4. CAUZE METABOLICE :

        - b. Pompe

        - leucodistrofia adrenala

        - s. Zellweger

b) DISFAGIA PRIN PERTURBAREA FAZEI ESOFAGIENE A DEGLUTIŢIEI

1. CAUZE ANATOMICE : - stenoze esofagiene (congenitale sau dobāndite)             

                                               - duplicatia sau diverticulul esofagian

                                               - esofagita caustica

                                               - tumori esofagiene

                                               - compresiuni asupra esofagului

2. CAUZE INFECŢIOASE : esofagite

3. CAUZE NEUROLOGICE : achalazia (megaesofagul congenital)

4. ALTE CAUZE : - RGE (chalazia)

                                 - corpi straini esofagieni

                                 - cauze metabolice si musculare (identice cu cele care produc

                                   perturbarea fazei orofaringiene a deglutitiei)

SINDROMUL ESOFAGIAN = durere retrosternala

                                                                     +

                                                      disfagie, odinofagie

                                                                     +

                                                      regurgitatii

 

             TULBURĂRI DE DEFECAŢIE

I. CONSTIPAŢIA

II. ENCOPREZIS

III. INCONTINENŢA FECALĂ

                                                    I. CONSTIPAŢIA

= eliminarea dificila, la intervale mari, a unor scaune de consistenta crescuta

CLASIFICARE = īn functie de : a) Evolutie

                                                        b) Tablou clinic

                                                        c) Etiologie

                                                        d) Vārsta bolnavilor

a) ĪN FUNCŢIE DE EVOLUŢIE

           A) ACUTĂ  : - dupa interventii chirurgicale

                                   - īn boli febrile

                   La tuseul rectal = rectul este gol

          B) CRONICĂ = mai frecventa

                   La tuseul rectal = rectul este plin cu materii fecale

b) ĪN FUNCŢIE DE TABLOUL CLINIC 

A)    IZOLATĂ : - constipatia habituala

B)    ASOCIATĂ CU ALTE SIMPTOME : - īn hipotiroidism

                                                                        - īn megacolonul congenital etc.

c) ĪN FUCŢIE DE ETIOLOGIE

A)    DE CAUZĂ EXOGENĂ

B)    DE CAUZĂ ENDOGENĂ

C)    IDIOPATICĂ

A) CONSTIPAŢIA DE CAUZĂ EXOGENĂ :

          1) Cauze alimentare :  - aport excesiv de LV

                                                 - bol fecal cantitativ redus : = subnutritie

                                                                                                 = varsaturi

                                                                                                 = deficit de fibre  alimentare

         2) Cauze medicamentoase : - hidroxid de Al

                                                         - antidepresive

                                                         - antihistaminice

                                                         - anticolinergice

                                                         - opiacee

B) CONSTIPAŢIA DE CAUZĂ ENDOGENĂ :

         1) Defecte structurale la nivelul tractului gastrointestinal :

                 = stomac : - stenoza fipertrofica de pilor

                 = intestin subtire si colon : - stenoze, atrezii

                                                              - invaginatie

                                                              - volvulus

                                                              - tumori

                = rect : - stenoze

                             - duplicatii

                             - diverticuli

                             - prolaps

                             - abces

                = anus : - imperforatie

                              - stenoza

                              - fisuri

                              - abces perianal

                = la orice nivel : - compresiuni extrinseci

2) Anomalii ale celulelor ganglionilor intramurali : - b. Hirschprung

                                                                                        - b. Von Recklinghausen

3) Boli musculare : - absenta musculaturii abdominale

                                 - sindr. Prune - Belly

                                 - amiotonia congenitala

4) Boli ale maduvei lombosacrate : - spina bifida

                                                            - meningomielocel

                                                            - diastematomielie

                                                            - tumori ale cozii de cal

                                                            - paraplegie

5) Boli metabolice : - acidozele tubulare renale

                                  - intoxicatia cu vitamina D

                                  - hipercalcemia

                                  - hipopotasemia

6) Boli endocrine : - diabet insipid

                                - hipotiroidism

                                - hipoparatiroidism

7) Boli neurologice si psihice : - leziuni cerebrale (encefalite, hemoragie, traumatism,

                                                                                     tumori)

                                                    - retard mental

                                                    - psihoze

C) CONSTIPAŢIA IDIOPATICĂ (HABITUALĂ, CONSTITUŢIONALĂ)

d) ĪN FUNCŢIE DE VĀRSTĂ

A)    ĪN PERIOADA PERINATALĂ : - fibroza chistica → ileus meconial

                                                                     - atrezii, stenoze intestinale

                                                                     - imperforatia anala

                                                                     - megacolonul congenital

 B) LA NOU NĂSUT sI SUGAR :

          1) Cauze digestive : - megacolonul congenital

                                            - stenoza hipertrofica de pilor

                                            - fisuri anale

          2) Cauze alimentare : - exces de LV

                                                - introducerea precoce a alimentelor solide

          3) Cauze metabolice : - acidoze tubulare renale

                                                - intoxicatia cu vitamina D

          4) Cauze endocrine  : - hipotiroidismul congenital

C) LA PREsCOLAR sI sCOLAR : - suprimarea voluntara a defecatiei

                                                                (īn timpul orelor solare sau al jocului)




                                                          II. ENCOPREZIS

= emisia necontrolata a materiilor fecale dupa vārsta de 2 ani

= o forma a incontinentei fecale , dar : - cantitatea de materii fecale este mica

                                                                    (pateaza lenjeria)

                                                                  - nu exista forme īnsotite de diaree   

CAUZE : - prin "prea plin"= secundar constipatiei cronice

                 - fistule ano-rectale

                 - boli ale maduvei lombosarate

                 - abuzul sexual

                                                    III. INCONTINENŢA FECALĂ

= pierderea necontrolata, quasipermanenta, de materii fecale

CAUZE : 1) Boli anorectale : - malformatii cong.

                                                  - prolaps rectal

                                                  - postinterventie chirurgicala

                 2) Boli neurologice : - agenezie sacrata

                                                    - teratom sacrococcigian

                                                    - boli ale maduvei lombosacrate

                                                    - leziuni cerebrale

                 3) Boli īnsotite de diaree : - enterocolite

                                                              - b. Crohn, colita ulceroasa

                                                              - sindr. intestinului scurt

                                                              - abuzul de laxative

                 4) Encoprezis prin "prea plin"

 

 

 

 

 

 

 

                                              DIAREEA

= eliminarea frecventa de scaune neformate care contin resturi alimentare

   nedigerate sau partial digerate ± produse patologice (mucus, puroi, sānge)

CLASIFICARE :

   1) Īn functie de mecanismul patogenetic : = secretorie

                                                                          = osmotica

                                                                          = motorie

   2) Īn functie de evolutie :  = acuta  (evolutia < 3 sapt.) : - enteraa

                                                                                                - parenterala

                                               = trenanta (evolutia = 3 sapt. - 3 luni)

                                               = cronica (evolutia > 3 luni)

                                               = recidivanta 

CAUZE DE DIAREE ACUTĂ = a se vedea la diagnosticul diferential al enterocolitei acute

CAUZE DE DIAREE CRONICĂ = a se vedea la diagnosticul diferential al sindr. de

malabsorbtie

                                             DUREREA ABDOMINALĂ

= simptom frecvent la copil,  cu caracter nespecific, cauze posibile multiple,

   intensitatea influentata de reactia subiectiva la durere

ANAMNEZA : - momentul si modalitatea de debut

                           - evolutia (acuta, cronica, recidivanta)

                           - localizarea si iradierea

                           - caracterul si intensitatea

                           - ritmicitatea īn raport cu alimentatia

                           - conditii de ameliorare a durerii

                           - corelarea cu o posibila cauza (alimente, medicamente, toxice,

                             traumatisme, ciclul menstrual

                           - simptome asociate

EX. OBIECTIV : - localizarea si iradierea  durerii

                                                           ±

                               - aparare musculara

                               - organomegalie

                               - ascita

                               - glob vezical

                               - hernii

                               - suferinta altor aparate si sisteme

                           Include = tuseul rectal

                                         = termometrizarea axilara si rectala

                                                                  

                                           diferenta > 1°C = indica un proces inflamator īn micul

                                                                         bazin (apendicita, pelviperitonita)

EXPLORĂRI DIAGNOSTICE = indvidualizate de la caz la caz

I. DUREREA ABDOMINALĂ ACUTĂ

A) CAUZE ORGANICE :

      a) BOLI ALE ORGANELOR INTRAABDOMINALE :

              1) Boli ale tubului digestiv :

                      - b. chirurgicale : = malf. obstructive

                                                    = ileus meconial

                                                    = volvulus

                                                    = invaginatie

                                                    = diverticulita Meckel

                                                    = apendicita acuta

                                                    = peritonita

                       - gastroenterocolita acuta

                       - intoleranta la proteinele LV

                       - ulcerul peptic

 

             2) Boli ale cailor biliare : - angiocolita

             3) Boli pancreatice : - pancreatita acuta

             4) Boli splenice : - ruptura traumatica a splinei

             5) Limfadenita mezenterica

             6) Boli urogenitale : - infectia urinara

                                                - hidronefroza

                                                - litiaza urinara

                                                - torsiunea testiculaa

                                                - torsiunea ovariana

                                                - chist ovarian

                                                - inflamatii genitale

b) BOLI ALE PERETELUI ABDOMINAL : - hernii īncarcerate

c) BOLI EXTRAABDOMINALE DE VECINĂTATE :        

              - pneumonii, pleurezii bazale

              - osteite de coaste sau vertebre dorsale

B) CAUZE ALIMENTARE :

         - depasirea tolerantei digestive

C) FUNCŢIONALE :

        - colici infantile

        - psihogene  

II. DUREREA ABDOMINALĂ RECIDIVANTĂ SAU CRONICĂ

A) CAUZE ORGANICE :

     a) BOLI ALE ORGANELOR INTRAABDOMINALE :

           1) Boli ale tubului digestiv : - gastrita cronica

                                                           - ulcerul peptic

                                                           - enterocolita trenanta

                                                           - b. inflamatorii intestinale cronice

                                                           - parazitoze digestive

                                                           - alergia digestiva

                                                           - constipatia cronica

                                                           - RGE

                                                           - deficitul partial de lactaza 

                                                           - tumori

          

           2) Boli hepato - biliare : - hepatita cronica

                                                     - congestia hepatica (insuficienta cardiaca cr.)

                                                     - tumori hepatice

                                                     - angiocolita cronica

                                                     - litiaza biliara

           3) Boli pancreatice : - pancreatita cronica

           4) Boli splenice (cu splenomegalie impotanta) : - b. Gaucher

                                                                                           - limfom

           5) Boli urogenitale : - pielonefrita cronica

                                              - hidronefroza

                                              - litiaza urinara

                                              - tumori renale

                                              - b. inflamatorii genitale cronice

                                              - tumori genitale

         6) Tumori abdominale

 

b) BOLI ALE PERETELUI ABDOMINAL : - hernii

c) BOLI EXTRAABDOMINALE :

         1) Boli de vecinatate : - respiratorii (pleurezii, pneumonii)

                                               - osoase (osteomielita coloanei si bazinului)

         2) Metabolice : - spasmofilie

                                   - porfiria

                                   - DZ cu cetoza

                                   - saturnismul

        3) Neurologice : - epilepsie abdominala

        4) Hematologice : - anemii hemolitice cronice

        5) Alte boli : - lupusul  eritematos sistemic

B) CAUZE ALIMENTARE

 

C) PSIHOGENĂ (90%)

                                   ABDOMENUL MĂRIT DE VOLUM

I. CAUZE INTESTINALE :

     1) MALFORMAŢII DIGESTIVE OBSTRUCTIVE :

                - stenoza, atrezia, duplicatia intestinala

                - malrotatia intestinala → volvulus

                - megacolonul congenital

                - imperforatia anala

     2) ALTE BOLI OBSTRUCTIVE :

                - hernii īncarcerate   

                - invaginatia intestinala

                - ocluzie intestinala prin sindrom aderential

                - corpi straini intralumenali

                - fito - sau  tricobezoar

     3) SINDR. DE MALABSORBŢIE

 

    4) CONSTIPAŢIA CRONICĂ 

    5) AEROFAGIA; FISTULE TRAHEO-ESOFAGIENE

 

   6) PROCESE ĪNLOCUITOARE DE SPAŢIU  :

               - tumori

               - chiste

               - abcesul apendicular 

II. CAUZE ABDOMINALE EXTRAINTESTINALE

    a) PROCESE ĪNLOCUITOARE DE SPAŢIU :

                   - chiste : = coledocian

                                   = hepatic

                                   = pancreatic

                                   = ovarian

                                   = mezenteric

                                   = omental

                  - abcese

                   - tumori : = hepatice (hepatoblastom, hepatocarcinom)

                                    = renale (nefroblastom)

                                    = ovariene

                                    = neuroblastom  

b) ORGANOMEGALIE :

             - hepatosplenomegalie : = b. Gaucher

                                                      = ciroza hepatica

                                                      = anemii hemolitice cronice

            - nefromegalie : = b. von Gierke

c) DILATAREA UNOR ORGANE CAVITARE :

           - hidronefroza

           - glob vezical

           - hidrometrocolpos

           - hidrops vezicular

d)DEFECTE ALE PERETELUI ABDOMINAL

III. ASCITA

 

 

                                     SINDROAME DISPEPTICE

= reflecta prezenta unor tulburari digestive



A) SINDR. DISPEPTICE ORGANICE :

      1) SINDR. DISPEPTIC ESOFAGIAN = disfagie

                                                                        = odinofagie

                                                                        = regurgitatii 

                                                                        = dureri retrosternale

      2) SINDR. DISPEPTIC ULCEROS (HIPERSTEN)

                       = durere postprandiala  - precoce sau tardiva

                                                                 - cu o anumita ritmicitate si periodicitate

                       = varsaturi

      3)SINDR. DISPEPTIC BILIAR = gust amar matinal

                                                             = greturi

                                                             = varsaturi bilioase

                                                             = durere īn hipocondrul drept

                                                             = balonari postprandiale

                                                             = eructatii

                                                             = intolerante alimentare (grasimi, oua)

                                                             = cefalee (migrena biliara)

B) SINDR. DISPEPTICE FUNCŢIONALE

        1) SINDR. DISPEPTIC DE TIP ULCEROS (ULCER-LIKE)

               - este prezenta hipersecretia gastrica acida

               - diagnosticul diferential cu ulcerul = prin endoscopie digestiva sup.

      2) SINDR. DISPEPTIC DE TIP DISMOTILITATE (SINDR. DE STAZĂ

          GASTRO-DUODENALĂ) (SINDR. DISPEPTIC HIPOSTEN)

                        = epigastralgii postprandiale

                        = satietate precoce

                        = greturi

                        = varsaturi

                        = inapetenta

     3) SINDR. DISPEPTIC DE TIP REFLUX = regurgitatii

                                                                              = arsuri retrosternale

     4) SINDR. DISPEPTIC GAZOS (cauzat de aerofagie) = balonari

                                                                                                  = eructatii

     5) SINDR. DISPEPTIC NESPECIFIC (NESISTEMATIZAT) 

                                   HEMORAGIA DIGESTIVĂ

= prezenta sāngerarii la orice nivel al tubului digestiv

= se poate EXTERIORIZA : a) Pe cale bucala - sub forma de : = hematemeza

                                                                                                            = regurgitatie

                                                                                                               sanghinolenta

                                                  b) Pe cale anala - sub forma de : = melena

                                                                                                          = sānge proaspat

DIAGNOSTICUL include : 1) DG. POZITIV

                                                 2) DG. TOPIC

                                                 3)DG DE GRAVITATE

                                                 4)DG. ETIOLOGIC

1) DIAGNOSTICUL POZITIV :

    - hemoragie exteriorizata = dg este evident

                                                 - se impune diferentierea de o falsa hemoragie

                                                   (anumite alimente, coloranti alimentari

                                                                                      

                                                    coloratie rosie a scaunelor sau lichidului de

                                                    varsatura)

     - īn lipsa exteriorizarii hemoragiei digestive = dg bazat pe :

a)      Criterii de suspiciune : - tahicardie

                                              -hipotensiune arteriala

                                              - semne de anemie acuta (paloare, ameteli)

                               Accentuate la trecerea din clinostatism īn ortostatism

b)  Criterii de certitudine : = evidetierea prezentei sāngelui  īn :

                                                        - stomac - prin sondaj gastric

                                                           - rect - prin tuseu rectal

 

2) DIAGNOSTICUL TOPIC :

      - la cazurile cu hemoragie exteriorizata :

           HEMATEMEZA indica : - HDS (stomac, duoden)

                                                       - hemoragie la nivelul unei zone supraiacente

                                                         (cavitatea bucala, fose nazale) → sānge degluti-

                                                         tionat

           REGURGITAREA SANGHINOLENTĂ  apare īn : - hemoragie  esofagiana

           PREZENŢA SĀNGELUI PROASPĂT ĪN SCAUN indica :

                                       - HDI (colon, rect)

           MELENA : poate apare īn hemoragii digestive produse la orice nivel

                                (īndeosebi īn HDS)

      - la cazurile cu hemoragie neexteriorizata :

              Sondaj doudenal → prezenta sāngelui īn stomac = HDS

              Tuseu rectal → prezenta sāngelui proaspat = HDI

                                    → prezenta sāngelui digerat = melena

3) DIAGNOSTICUL DE GRAVITATE :

= se poate stabili īn baza unor : - criterii clinice

                                                      - examinari de urgenta

     a) CRITERIILE CLINICE : = cantitatea de sānge eliminat:

                                                               Nu este un criteriu fidel, deoarece :

                                                                      - este neutilizabil īn caz de hemoragie

                                                                        neexteriorizata

                                                                      - poate preta la erori prin supraestimare

                                                                        sau subestimare

                                                       = semne cardiovasculare : - tahicardia

                                                                                                    - hipotensine arteriala

                                                                                                    - tendinta la lipotimie

                                                       = sindr. de deshidratare acuta : - sete

                                                                                                            - oligurie

                              ↓TA cu 10mmHg

                               ↑ FC cu 20 batai/min

                               la ridicarea din clinostatism īn ortostatism → indica pierderea

                               a 20% din volumul sanghin īn cadrul hemoragiei digestive

b) CRITERII BIOUMORALE :

               - ↓Ht de la 40% → 30%  = indica pierderea a 20% din volumului sanghin

                  (Ht se va determina dupa reechilibrarea volemica, deoarece

                   hemoconcentratia din cadrul SDA determina o crestere aparenta

                   a valorii Ht)

               - cresterea ureii serice - prin : - SDA

                                                                  - metabolizarea de catre flora bacteriana

                                                                    a sāngelui  → cresterea amoniemiei 

                                                                    cresterea nivelului seric al ureei

               - hipoxia (anemica) = semn de gravitate īn hemoragia digestiva

4) DIAGNOSTICUL ETIOLOGIC :

= se bazeaza pe critriile oferite de : - anamneza

                                                            - ex. obiectiv

                                                            - examinari paraclinice

= modul de exteriorizare a hemoragiei = important criteriu orientativ

                                                                                 

             Bolile complicate cu hemoragie digestiva = au incidenta variabila

                                                                                       la diferite vārste 

                                                                                   = unele sunt caracteristice

                                                                                      unei anumite grupe de vārsta

A) CAUZELE HD EXTERIORIZATE ORAL (HEMATEMEZĂ)

  1. LA NOU NĂSCUT :

       a) Cauze digestive : - sānge matern deglutitionat intrapartum

                                         - gastrita hemoragica

                                         - ulcer de stress

        b) Cauze generale : - b. hemoragica a noului nascut

  2. LA COPILUL DE ORICE ALTĂ VĀRSTĂ :

         a) Cauze digestive : - sānge deglutitionat (hemoragie bucala, epistaxis)

                                           - esofagita

                                           - varice esofagiene

                                           - gastrita hemoragica

                                           - ulcerul (de stress, peptic)

                                           - sindr. Mallory-Weiss

                                           - volvulus gastric

                                           - stenoza gastrica

                                           - tumora gastrica

                                           - corpi straini

                                           - hemobilie posttraumatica

                                           - intoxicatii (antiinflamatoare nesteroide, fier, teofilina)

        b) Cauze genrale : - sindr. de vasculita

 

B) CAUZELE HD EXTERIORIZATE RECTAL :

       MELENA = semn de HDS = are aceleasi cauze ca si hematemeza

       Cauze de SĀNGE PROASPĂT ĪN SCAUN :

1. LA NOU NĂSCUT : - enteocolita ulcero-necrotica   

                                        - intoleranta la proteinele LV

2. LA SUGAR sI COPILUL SUB 2 ANI : - intoleranta la proteinele LV

                                                                        - invaginatia intestinala

                                                                        - diverticulita Meckel

                                                                        - fisuri anale

                                                                        - hiperplazia limfoida nodulara

            Dg diferential cu "boala scutecelor rosii"

3. LA COPILUL DE ORICE VĀRSTĂ :

       a) Cauze digestive : - enterocolita ac (prin mecanism invaziv)

                                         - b. Crohn., colita ulceroasa

                                         - polipi intestinali

                                         - hemangiom, teleangiectazie

                                         - parazitoze digestive

                                         - proctita

                                         - hemoroizi

                                         - prolaps rectal

                                         - tumori

                                         - neurofibromatoza

      b) Cauze generale : - purpura Schonlein-Henoch

                                        - sindr. hemolitic-uremic

                                        - sindr. hemoragipare 

ANAMNEZA, EX. OBIECTIV AL BOLNAVULUI CU HD :

Se poate constata :

AHC : - ulcer īn familie

            - b. Wilson īn familie

APF : - omfalita neonatala  → HT portala prehepatica

APP : - traumatism abdominal

           - sindr. hemoragipar

IB : - momentul si modul de debut

       - este primul episod de HD sau aceasta este recidivanta

       - cantitatea si culoarea sāngelui eliminat

       - simptome asociate, care sugereaza cauza posibila sau comlicatiile HD

EX. OBIECTIV : -semne de anemie

                              - tulb. hemodinamice

                              - semne si simptome sugestive pt. o anumita etiologie

EXPLORĂRI DIAGNOSTICE 

A) TESTE BIOUMORALE : - hemoleucograma, uree, gaze sanghine - pt.

                                                     aprecierea gravitatii

                                                   - grupul sanghin, Rh, ionograma serica,

                                                     parametrii acido-bazici - pt. conducerea trat.

                                                   - teste de hemostaza

                                                   - teste functional-biochimice hepatice etc.

B) EXAMINĂRI ENDOSCOPICE sI IMAGISTICE :

      - endoscopia  -  digestiva superioara

                            - digestiva inferioara

             Se efectueaza = DE URGENŢĂ : - īn caz de hemoragie persistenta,

                                                                         neinfluentata de terapia initiala

                                                                       - īn  caz de varice esofagiene rupte                                        

                                                                         (pt. cauterizarea sau ligatura acestora)

                                      = ĪN A 2-A ETAPĂ DE EVALUARE A BOLNAVULUI

                                         (pt. stabilirea dg etiologic)

- ecografia abdominala

- ex. radiologic (importanta acesteia a scazut dupa introducerea  endoscopiei digestive)

- scintigrafia cu Technetiu (pt. evidentierea diverticulului Meckel)

- angiografia

Concomitent cu evaluarea bolnavului, se īncepe tratamentul :

      = echilibrarea hemodinamica

      = tratamentul anemiei posthemoragice

      = trat. bolii de baza

                                                           

                         

 

 

                                     













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