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Endocrinology

Nutritional dystrophy

Nutritional dystrophy (alimentary exhaustion, hungry hypostasis, protein-free hypostasis, edema disease, hungry illness) — the disease which is developing owing to the long and expressed malnutrition, starvation and characterized by the progressing emaciation which is often followed by widespread hypostases.

Epidemiology
Now in a number of developing countries defectively in the quantitative and qualitative relation more than 500 million people eat. According to the UN, every third of total number of the dead dies of the hunger or the reasons connected with malnutrition.

Etiology and pathogeny
The major etiological factor of a nutritional dystrophy — the low caloric content of food. It is conditionally possible to accept that decrease in energy value of food by 40 — 50% against initial normal caloric content leads to a course of a disease. Sharp reduction of protein content (to 20 — 10 g/days) and relative dominance of carbohydrates is characteristic. At the same time in food the content of ascorbic acid, B1, B2, B3, A vitamins, etc., as a rule, decreases.

At long starvation the increased consumption of table salt is often observed ("soleedstvo") and waters that in turn aggravates disbolism in fabrics and promotes development of hypostases.

In the conditions of hot climate the insufficient caloric content of food at a considerable exercise stress also leads to emergence of group cases of a nutritional dystrophy; accession of intestinal infections forces this process. Exceptional cases of neurogenic anorexia at which emaciation reaches a cachexia stage meet.

Classification

It agrees the classification accepted in our country distinguish two forms: 1) the dry, or cachectic form less favorable according to the forecast, and 2) an edematous form in which allocate edematous and ascitic (ascitic) option with the most adverse forecast. On weight allocate 3 stages of an illness, carry cases when strongly thin people still keep some working capacity To the I stage; they complain of weakness, a chill, the speeded-up urination, strengthening of appetite and I am eager; at them the moderate hypoproteinemia due to decrease in maintenance of seralbumin usually is defined. Sharp emaciation, working capacity loss, but the opportunity still remaining to move, service itself are characteristic of the II stage of a nutritional dystrophy. Often these patients have peripheral hypostases, further decrease in level of a seralbumin is observed, are frequent a hypoglycemia. At the III stage of weight of the patient it is sharply exhausted, often is not able to sit down independently in beds, lies, usually not movably and it is indifferent on one side with the legs bent in knees. Emergence of a hungry coma (even if it developed at the patient continuing to work) has to indicate existence of the III stage of a disease.

Approximate formulation of the diagnosis:
1. Nutritional dystrophy, cachectic form, II stage; B2 hypovitaminosis, angular stomatitis, focal pneumonia of the lower share of the right lung.
2. A nutritional dystrophy, an edematous form, the III stage, a cachexia, myocardium dystrophy (symptomatic), a circulatory unefficiency mainly on right ventricular type II of a stage, a hypovitaminosis With, an ulitis, an exacerbation of chronic dysentery.

Preliminary diagnosis
The disease develops usually gradually and the first symptoms appear in 3 — 4 weeks — 2 — 3 months from the beginning of malnutrition.

Verification of the diagnosis
Diagnosis of a nutritional dystrophy usually does not cause difficulties and is based on existence of the corresponding symptomatology, anamnestic instructions on starvation, an exception of the disease causing exhaustion. Differentiate first of all from a carcinoma of the stomach and intestines, tuberculosis and endocrine diseases (a diabetes mellitus, a thyrotoxicosis, a pituitary cachexia). It should be noted that sharp increase of appetite (bulimia), thirst, special "hungry psychology" considerably distinguish patients with a nutritional dystrophy from persons with the cachexia which developed owing to the listed above diseases. At cancer and tuberculosis there is no such heavy muscular atrophy as at a nutritional dystrophy. The symptomatology inherent in endocrine diseases significantly distinguishes each of these diseases from a nutritional dystrophy.

Treatment of a nutritional dystrophy

At treatment of a nutritional dystrophy good sanitary and hygienic conditions, the due mode and leaving are important. Patients should be placed in spacious, light and warm chambers. Maintenance of temperature in chambers within 21 — 23 °C is important because patients differ in a chill. Patients with pneumonia, a diarrheal syndrome need to be isolated from the others in view of their sensitivity to an infection. The bed rest (not less than 5 — 7 days) is appointed the patient with a nutritional dystrophy of II and III stages. The patient with a nutritional dystrophy of the II stage in the first days only the insignificant exercise stress is allowed (to sit down in beds, to rise slowly in the presence of medical personnel etc.) in view of danger of development of a hungry faint and even a coma. Provide to patients not only physical, but also mental rest; observation over them is made taking into account change of their mental state.

Patients receive the fractional, mechanically sparing food not less than 6 — 7 times a day. Daily caloric content in the first 7 — 10 days of 2500 — 3500 kcal. In a daily diet not less than 100 — 120 g of protein, 70 — 80 g of fats, to 500 g of carbohydrates. Further the caloric content of food increases (3500 — 4000 — 4500 kcal). There are offers to carry out suralimentation cycles with increase of protein content to 130 — 150 g.

Limit to the patient with an otechny form of a nutritional dystrophy consumption of table salt to 5 g/days and water to 1 — 1,5 l. The food has to be well vitaminized; patients receive during a day of not less than 100 mg of ascorbic acid, up to 10 000 ME of vitamin A, not less than 10 mg of B1 vitamin, 50 — 100 mg of niacin. For improvement of digestion appoint Acidum hydrochloricum, pepsin, Pancreatinum (and similar fermental drugs).

Now apply an enteroalimentation and artificial drugs to an enteroalimentation — enpita. In hard cases (the III stage) use methods of parenteral food (various proteinaceous hydrolyzates, amino-acid drugs; fatty emulsions etc.).

With 2 — the 3rd week for the purpose of rehabilitation by the patient taking into account specific features appoint physical methods of treatment and physiotherapy exercises.

Treatment of a hungry coma. This heavy and predictively extremely dangerous state demands an emergency intensive care. Immediately it is necessary to enter 50 ml of 40% of solution of glucose into a vein and then to repeat these introductions in each 2 — 3 h. This action is most effective. It is possible to believe" that positive takes are yielded by drop intravenous administration of isotonic solution of glucose or a reopoliglyukin with 1 — 2 ml of 0,2% of solution of noradrenaline and 125 mg of a hydrocortisone. Appoint also parenterally drugs of caffeine, strychnine, Cordiaminum. At spasms use calcium drugs (10 ml of 10% of solution of calcium chloride in a vein or 10 ml of 10% of solution of a gluconate of calcium in a muscle).

 
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