Diarrea: cause e sintomi
Table of Contents
Che cos’è la diarrea?
La diarrea si definisce come una riduzione della consistenza delle feci associata o meno a un aumento del numero di evacuazioni giornaliere. La riduzione della consistenza è il risultato di un aumento del contenuto di acqua nelle feci; l’ aumento del numero delle evacuazioni può essere la conseguenza anche di alterata attività motoria.
Meccanismi fisiopatologici
Un ridotto assorbimento si può verificare o quando si produce un danno alla mucosa, come accade nelle infiammazioni (diarree infiammatorie), o in presenza di una accelerato transito intestinale (diarree motorie) o dopo resezione chirurgica.
Diarrea infiammatoria. L’infiammazione della mucosa intestinale è responsabile della diarrea con quattro meccanismi:
1. perdita di cellule epiteliali con un conseguente riduzione della superficie assorbente;
2. sostituzione delle cellule epiteliali perse con cellule immature che derivano da un aumento compensatorio dell’ attività proliferativa delle cripte, queste manifestano minori capacità assorbitive;
3. produzione e rilascio di citochine pro-infiammatorie e altri mediatori della flogosi che aumentano la secrezione intestinale;
4. perdita di sangue ed essudato muco-proteico specialmente quando l’infiammazione è più grave.
Clinicamente si caratterizza per un elevato numero di scariche di feci non formate, di volume complessivo inferiore a 500 ml /24
ore, frequente rilievo di tenesmo e, nei casi più gravi, comparsa di alcalosi metabolica dovuta all’ abbondante perdita fecale di NA+ e CL-. La colite ulcerosa e la malattia di Crohn sono le cause più frequenti di diarrea infiammatoria.
Diarrea motoria
I fluidi, per essere assorbiti, hanno bisogno di un adeguato tempo di contatto con l’epitelio intestinale e pertanto tutte le condizioni che determinano un aumento della velocità di transito causano diarrea. Accade quando si genera un danno al sistema nervoso enterico diabete, per iperstimolazione ormonale (ipertiroidismo) o quando aumenta il volume di fluidi intestinali (ipersecrezione). Ma anche una ridotta motilità può generare indirettamente diarrea, favorendo un aumentata colonizzazione batterica intestinale (sclerodermia e più raramente, diabete).
Resezioni intestinali
Le resezioni intestinali possono causare diarrea per riduzione della superficie mucosa deputata all’assorbimento. Generalmente queste forme sono transitorie perché col tempi intervengono fenomeni adattativi che sono capaci di compensare la ridotta superficie e consentire un’adeguata assorbimento. Un ampia resezione dell’ileo distale può generare diarrea per il mancato assorbimento degli acidi biliari coniugati che, nel colon, esercitano un’azione lassativa.
Diarrea osmotica
La diarrea osmotica si produce quando l’osmolarità endoluminale, superando di 100 mOsm /kg quella plasmatica, determina una secrezione netta di acqua, superiore al movimento opposto legato all’assorbimento di sodio. L’osmolarità endoluminale aumenta quando nel lume sono presenti soluti non assorbiti e non assorbibili. Le forme e più note sono quelle determinate da malassorbimento congenito o acquisito di carboidrati come succede nella cosidetta intolleranza al lattosio, causata da deficit di lattasi. È da ricordare anche la diarrea indotta da sorbitolo (chewing-gum,caramelle per diabetici,ecc…). Anche l’ aumentata quantità di presidio alimentare nel lume intestinale, che si rivela in caso di malassorbimento, agisce prevalentemente attraverso un meccanismo osmotico.
Diagnosi
La durata, il volume delle feci, il dolore e la presenza di sintomi e segni sistemici potranno fare orientare verso una diarrea infettiva, infiammatoria, funzionale o secondaria ad altre condizioni sistemiche. Comunque in qualsiasi caso di diarrea significativa è buona pratica clinica accertarsi che il paziente non sia disidratato (azotemia, creatininemia, elettroliti), non sia anemizzato (emocromo), non abbia segni sistemici di flogosi (PCR), non sia disprotidemico (protidogramma).
Durata
La diarrea acuta persistente (quando dura rispettivamente da meno di 2 settimane o tra 2 e 4) riconosce un’eziologia infettiva nella maggior parte ma può anche rappresentare l’inizio di una diarrea cronica. Recede spesso spontaneamente ma va seguita con molta attenzione soprattutto nei bambini, che possono disidratarsi facilmente, negli anziani perché può scompensare cormobilità, specialmente cardiovascolare e diabetica. In assenza di fattori di rischio potrebbe bastare una reidratazione. Coprocoltura e esame parassitologico delle feci, oltre a un’ anamnesi alimentare e farmacologica, possono aiutare nella diagnosi. La diarrea cronica (più di 4 settimane) interessa il 5% della popolazione occidentale rappresenta al 1,5% delle ospedalizzazioni degli adulti. Le malattie croniche infiammatorie, le sindromi da malassorbimento e il colon irritabile sono le cause più frequenti.
Volume
Il passaggio di un gran volume difesa associato a dolori periombelicali che non regrediscono con l’evacuazione orienta verso una malattia del tenue, mentre il passaggio frequente di piccoli volumi di feci, specialmente con sangue, associata a dolori addominali bassi che regrediscono con l’evacuazione, tenesmo e urgenza può indicare una malattia colon rettale distale. Volumi superiore a 1000 cc sono tipici della diarrea secretoria.
Eziologia organica o funzionale
Segni di allarme
Fattore orientativi per un origine organica sono: diarrea di breve durata presente anche di notte, non rispondente al digiuno; calo ponderale di più di 5 kg, aumento della PCR, a bassi livelli di emoglobina e albumina, peso fecale alto. Sangue, muco e pus nelle feci rappresentano ulteriori segni di allarme,così come alcuni sintomi sistemici quali la disidratazione, l’ipotensione, l’oliguria, l’anemia, gli edemi, la nausea il vomito, i crampi muscolari, la tachicardia la tachipnea e la febbre. Segni di possibile origine funzionale sono: diarrea che si alterna stipsi, assenza di masse addominali, presenza di dolori che passano con l’evacuazione, assenza di disidratazione, di disordini dell’equilibrio idro-salino e acido-base e altri segni sistemici.
Approccio al paziente
In caso di diarrea acquosa ad alto volume la valutazione delle condizioni generali del paziente e il suo stato di idratazione sono le prime preoccupazioni del medico come quella di assicurare al più presto un accesso venoso negli anziani e nei bambini. La diarrea acuta è spesso infettiva e autolimitantesi e si associa non di rado a febbre e vomito. In assenza di una malattia infettiva, bisogna valutare il ruolo di farmaci come antibiotici, antipertensivi, antiaritmici, antinfiammatori non steroidi, chemioterapici, broncodilatatori, antiacidi, lassativi e alcuni antidepressivi.
Tra gli alimenti bisognerebbe indagare sull’assunzione di uova, pollame, creme, carne e pesce poco cotti o del tutto crudi che sono i più comuni veicoli di infezione; i funghi possono essere fonti di sostanze tossiche. La presenza di sangue, se non è di origine emorroidaria, indica un danno della mucosa del retto/colon che più frequentemente si rileva nelle acuzie di una malattia infiammatoria cronica intestinale (MICI), in una colite ischemica o in una diverticolite. Diarree acquose croniche possono anche indicare la presenza di tumori secernenti ormoni come il VIPoma, il gastrinoma, il carcinoma midollare della tiroide o altri, ma anche un adenoma villoso del colon.
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