Diarrhea and constipation

Diarréia e constipação são sintomas que refletem alteração do hábito intestinal. Para o diagnóstico da causa desses sintomas são fundamentais a anamnese detalhada e o exame físico completo. Informações quanto ao início do sintoma, duração, evolução, comprometimento do estado geral e a presença de outros sintomas, são indispensáveis. Exames complementares somente devem ser realizados após a completa observação clínica.Diarrhea and constipation are symptoms that need a careful history and physical examination, which will help to localize the disease process and establish its nature. The questions to ask at first visit are about the onset and characterization of the symptom, duration and the evidences of systemic disease. Only then ancillary exams should be ordered

Tempo de alcoolismo no desenvolvimento de doenças orgânicas em mulheres tratadas no Hospital das Clínicas de Ribeirão Preto, SP, Brasil

To determine the period of frequent alcoholic drink intake (mean intake of 100 ml of ethanol per day on at least three days a week) up to the onset of signs and symptoms of organic diseases caused by the habit, 95 women treated at the University Hospital of the Faculty of Medicine of Ribeirão Preto for organic diseases associated with alcoholism between 1978 and 1982, we studied. Clinical and laboratory diagnosis of cirrhosis of the liver was made in 32 patients, of chronic pancreatitis in 13, and of other diseases (pellagra, malnutrition, peripheral neuritis, and alcoholic hepatitis) in 50. Patients showing only psychiatric symptoms were excluded from the study. Patient history was obtained after a few days of treatment. On average, the age when signs and symptoms of the diseases that motivated them to seek hospital treatment began to appear was 35.30 ± 7.72 years for chronic pancreatitis patients, 36.53 ± 8.39 for patients with cirrhosis of the liver, and 33.90 ± 11.27 for the patients with other diseases. Time of alcohol intake was 15.92 ± 7.15 years for chronic pancreatitis patients, 14.62 ± 8.70 years for patients with cirrhosis of the liver, and 13.24 ± 9.58 years for patients with other diseases. A family history ol afcoholism was present in 64.2% of cases and generally involved the husband. None of the patients reported other women with problems of alcoholism in the family. The period of alcoholism before the onset of cirrhosis of the liver among the women studied (14.62 years) was shorter than that encountered for men from the same population (21.10 years), studied in previous investigations.Com o objetivo de conhecer o tempo de ingestão freqüente de bebidas alcoólicas (ingestão média de mais de 100 ml de etanol por dia, pelo menos três dias por semana), até o aparecimento de sinais e sintomas de doenças orgânicas conseqüentes ao hábito, estudamos 95 mulheres tratadas entre 1978 e 1982 no Hospital das Clínicas de Ribeirão Preto, portadoras de doenças orgânicas associadas ao alcoolismo. Foi feito diagnóstico clínico e laboratorial de cirosse hepática em 32 pacientes, de pancreatite crônica em 13 e de outras doenças (pelagra, desnutrição, neurite periférica e hepatite alcoólica) em 50. Pacientes com apenas sintomas psiquiátricos não foram estudadas. A obtenção das informações ocorreu após alguns dias de tratamento. Em média a idade em que começaram a ter sinais e sintomas das doenças que motivaram a procura de hospital para tratamento foi de 35,30 ± 7,72 anos na pancreatite crônica, 36,53 ± 8,39 anos na cirrose hepática e de 33,90 ± 11,27 anos nas outras doenças. O tempo de ingestão da bebida foi de 15,92 ± 7,15 anos na pancreatite crônica, 14,62 ± 8,70 anos na cirrose hepática e 13,24 ± 9,58 anos nas outras doenças. Antecedentes familiares de alcoolismo estiveram presentes em 64,2% dos casos, geralmente marido ou companheiro. Nenhuma delas tinha outras mulheres na família com problemas de alcoolismo. A média do tempo de alcoolismo para o aparecimento de cirrose hepática nas mulheres (14,62 anos) foi menor do que a encontrada para homens da mesma população (21,10 anos), estudados em trabalhos anteriores

Taste perception in stroke patients

OBJETIVO: avaliar a percepção dos sabores amargo, azedo, doce e neutro. MÉTODO: foram estudados 36 pacientes com Acidente Vascular Encefálico (AVE) (5 hemorrágicos e 31 isquêmicos) e 30 sujeitos controles. Foi realizada avaliação fonoaudiológica estrutural e funcional incluindo postura, vedamento labial, presença de resíduos, tosse, engasgo, e ausculta cervical. Cada sujeito deglutiu em sequência aleatória 5 mL de líquido com os 4 sabores [chá de boldo (amargo), suco de limão diluído (azedo), sacarose diluída (doce) e água (neutro)] na temperatura ambiente. Entre as deglutições os participantes eram questionados sobre a dificuldade em deglutir e qual o sabor do líquido daquela deglutição. RESULTADOS: entre os pacientes houve maior freqüência de erros na identificação dos sabores amargo (controles: 16,7%, AVE: 47,3%, p=0,01) e azedo (controles: 6,7%, AVE: 27,8%, p=0,05), sem diferenças para o sabores neutro (controles: 10,0%, AVE: 16,7%, p=0,50) e doce (controles: 13,3%, AVE: 16,7%, p=0,80). Os pacientes com AVE tiveram maior dificuldade para deglutir os líquidos do que os controles (p<0,04). CONCLUSÃO: houve maior dificuldade na percepção dos sabores amargo e azedo no grupo com AVE do que nos controles.PURPOSE: to assess the perception of bitter, sour, sweet and neutral flavors in stroke patients. METHOD: we studied 36 patients with stroke (5 hemorrhagic and 31 ischemic) and had a 30 subjects' control group. W performed a structural and functional oral and pharyngeal evaluation including posture, lip sealing, presence of residues, cough, choking, and cervical auscultation. Five ml of fluids with the 4 flavors ["boldus" tea (bitter), diluted lemon juice (sour), diluted sucrose (sweet), and water (neutral)] were offered in random sequence under room temperature. Participants were questioned, between swallows, on the difficulty in swallowing and which flavor they had just swallowed. RESULTS: patients with stroke had greater difficulty in swallowing the fluids than control group (p<0.04). Patients made more mistakes in identifying bitter (control: 16.7%, stroke: 47.3%, p=0.01) and sour (control: 6.7%, stroke: 27.8%, p=0.05) flavors, without differences in the identification of neutral (control: 10.0%, stroke: 167%, p=0.50) and sweet (control: 13.3%, stroke: 16.7%, p=0,80). CONCLUSION: the group with stroke had more difficulty in perceiving bitter and sour flavors than the control group subjects

Clinical evaluation of swallowing in Chagas disease

OBJETIVO: Avaliar clinicamente a deglutição orofaríngea de pacientes portadores da doença de Chagas com disfagia e comparar os achados da anamnese entre os doentes chagásicos de acordo com o grau do megaesôfago. MÉTODOS: Utilizando protocolo de avaliação, estudamos a deglutição de 21 pacientes com doença de Chagas e comprometimento do esôfago diagnosticado por sorologia e exame radiológico do esôfago, e de 18 sujeitos sadios assintomáticos pareados por idade e gênero. Nos dois grupos foi realizada anamnese contendo questões relacionadas à queixa de disfagia. Após este procedimento, foi realizada avaliação clínica da deglutição, sem introdução de dieta via oral e com dieta via oral nas consistências líquida e pastosa, abrangendo aspectos estruturais e funcionais. Os resultados foram analisados estatisticamente. Este é um estudo experimental e transversal. RESULTADOS: Maior proporção de pacientes chagásicos apresentou deglutições múltiplas e elevação laríngea reduzida na deglutição das consistências líquida e pastosa, em relação aos sujeitos sadios. Os pacientes com aumento do diâmetro do esôfago referiram mais frequentemente queixa de perda de peso quando comparados aos pacientes sem aumento do diâmetro do esôfago. CONCLUSÃO: Os pacientes chagásicos podem apresentar alterações na deglutição orofaringeana e pacientes com maior comprometimento do esôfago apresentam maior perda de peso do que os pacientes com menor comprometimento.PURPOSE: To clinically evaluate oropharyngeal swallowing in dysphagic patients with Chagas disease, and to compare anamnesis data among chagasic subjects according to the degree of megaesophagus. METHODS: An evaluation protocol was used to assess the swallowing of 21 patients with Chagas disease and involvement of the esophagus, diagnosed through serology and radiologic evaluation of the esophagus, and 18 asymptomatic healthy subjects paired by age and gender. Both groups answered an anamnesis that addressed questions related to dysphagia complaint. After this procedure, it was carried out a clinical evaluation of swallowing, involving both structural and functional aspects, with and without the introduction of oral feeding with liquid and pasty consistencies. The results were statistically analyzed. This is an experimental and transversal study. RESULTS: A larger number of chagasic patients presented multiple swallows and reduced laryngeal elevation during deglutition of food with pasty and liquid consistencies, when compared to healthy subjects. Patients with increased esophageal diameter reported weight loss more frequently, when compared to patients with normal esophageal diameter. CONCLUSION: Chagasic patients might present oropharyngeal swallowing alterations, and patients with more significant esophageal involvement present more weight loss than patients with less esophageal involvement

Dysphagia in patients with Chagas' disease and Zenker's diverticulum

Descrevemos dois pacientes, um do sexo feminino e outro do sexo masculino, ambos com 64 anos, que apresentavam a associação entre divertículo de Zenker e esofagopatia provocada por doença de Chagas. Um dos pacientes iniciou com disfagia esofágica há cinco anos, que depois se associou a disfagia orofaríngea há nove meses. O outro paciente tinha disfagia orofaríngea há oito meses. Ambos tinham antecedentes de doença de Chagas. Os dois pacientes tinham alterações do exame clínico da deglutição, ou seja, dificuldade de ingestão de líquidos e pastosos. A ingestão era lenta e havia resíduos em cavidade oral, sem tosse após a deglutição. O diagnóstico foi feito por exame sorológico e estudo radiológico de faringe e esôfago, complementados por exame endoscópico. Os resultados dos exames radiológicos de faringe e esôfago mostraram, em um paciente, o divertículo faringo-esofágico (Zenker), trânsito lento (duração superior a dez segundos) do meio de contraste pelo esôfago e, no outro, o divertículo de Zenker e trânsito pelo esôfago com duração normal (duração inferior a dez segundos) com presença de contrações terciárias. O tratamento foi realizado com diverticulectomia, miotomia do cricofaringeo e miotomia da transição gastroesofágica em um paciente e miotomia do cricofaríngeo no outro. Concluímos que é possível haver a associação de duas causas de disfagia no mesmo paciente, a orofaríngea, consequente a divertículo de Zenker, e a esofágica, consequente à doença de Chagas. O pleno conhecimento da relação causa-efeito destas duas condições necessita novos estudos.It is described the cases of two patients, one female and one male, both 64 years old, who had Zenker's diverticulum associated to chagasic esophagopathy. One of them had esophageal dysphagia for five years, later associated with oropharyngeal dysphagia (for nine months). The other patient had oropharyngeal dysphagia for eight months. Both had lived in endemic areas for Chagas' disease, and had positive serologic tests for the disease. In the clinical evaluation, both patients had slow ingestion of liquids and paste bolus, and residues in oral cavity, without coughing after deglutition. Diagnosis was made by serologic test and radiologic examination of pharynx and esophagus, as well as a careful endoscopic examination. Radiologic results showed, in one of the subjects, pharyngo-esophageal diverticulum (Zenker), and slow barium bolus transit (more than ten seconds to cross the esophageal body), and, in the other patient, Zenker's diverticulum and normal esophageal transit duration (less than ten seconds), with presence of tertiary contractions. Treatment consisted of diverticulectomy, cricopharyngeal myotomy, and cardiomyotomy of the lower esophageal sphincter for one patient, and cricopharyngeal myotomy for the other one. It is concluded that it is possible to have association of two causes of dysphagia in the same patient: the oropharyngeal, due to Zenker's diverticulum, and the esophageal, due to Chagas' disease. The knowledge of cause-effect relationship between these conditions needs further investigations

Mecanismos intracelulares dos mediadores inibitórios não adrenérgicos e não colinérgicos no trato gastrointestinal

A inibição da musculatura lisa do tubo digestivo ocorre em vários reflexos fisiológicos, e depende de um ou mais mediador(s) não adrenérgico e não colinérgico (NANC) liberado(s) pelo sistema nervoso entérico. O objetivo deste trabalho foi o de fazer uma revisão na literatura sobre os mediadores inibitórios NANC no trato gastrointestinal e os mecanismos intracelulares envolvidos. Os principais mediadores e/ou candidatos a mediador inibitório NANC no trato gastrintestinal são óxido nítrico (NO), trifosfato de adenosina (ATP), peptídeo intestinal vasoativo (VIP), peptídeo ativador de adenilato ciclase pituitária (PACAP), monóxido de carbono (CO) e mais recentemente, substâncias que ativam os receptores ativados por proteases (PARs)

The relationship between the oral and pharyngeal phases of swallowing

OBJECTIVE: This study was designed to investigate a possible relationship between the duration of the oral and pharyngeal phases of swallowing. INTRODUCTION: The oral and pharyngeal phases of swallowing are independent from each other but may be related. METHODS: We used videofluoroscopy to evaluate 30 healthy volunteers between 29 and 77 years of age who swallowed 5- and 10-ml liquid and paste boluses in duplicate. The duration of the oral phase, pharyngeal transit, and pharyngeal clearance were measured. RESULTS: There were no differences in oral or pharyngeal transit times between the liquid and paste boluses or between the volumes of 5 and 10 ml (p>0.40). The pharyngeal clearance time for the paste bolus (0.48 ± 0.27 s) was longer than for the liquid bolus (0.38 ± 0.11 s, p = 0.03) with no difference between the volumes of 5 and 10 ml. There was no significant correlation between the oral transit time and the duration of pharyngeal transit for the liquid (5 ml, Spearman's coefficient p: -0.14; 10 ml, p: 0.18) or the paste (5 ml, p: 0.08; 10 ml, p: 0.10). The correlation between the oral transit time and the pharyngeal clearance time was not significant for the liquid bolus (5 ml, p: 0.31; 10 ml, p: 0.18), but it was significant for both the 5 ml (p: 0.71) and 10 ml (p: 0.64) paste boluses. DISCUSSION: The relationship between the oral and pharyngeal phases of swallowing can be affected by bolus consistency. CONCLUSION: There is a correlation between the duration of oral transit and the duration of pharyngeal clearance during the swallowing of paste boluses

Influence of Body Height on Oral and Pharyngeal Transit Time of a Liquid Bolus in Healthy Volunteers

Swallowing duration may be influenced by several factors. The effect of body height on oral-pharyngeal bolus transit has not been clearly elucidated. The hypothesis of this investigation was that height has influence on oral-pharyngeal transit time of a liquid bolus. Videofluoroscopic assessment of swallowing was performed on 40 healthy volunteers: 20 "tall" (171 cm to 207 cm) and 20 "short" (152 cm to 170 cm) subjects, 10 men and 10 women in each group. Each subject performed three swallows of 10 mL of liquid barium bolus. The following parameters were measured: oral transit time (OTT): time from the beginning of tongue tip movement at incisors to arrival of the bolus tail at the fauces; pharyngeal transit time (PTT): time between the arrival of the bolus tail at fauces and complete passage of the bolus tail through the upper esophageal sphincter (UES); pharyngeal clearance (PC): time between the arrival of the bolus head at fauces to complete passage of the bolus tail through the UES; UES opening (UESO): time between the arrival of the bolus head at the UES to complete passage of the bolus tail through the UES; duration of hyoid movement (HM): time interval between the onset and the end of hyoid movement; oral-pharyngeal transit time (OPTT): time from the beginning of tongue tip movement at incisors until complete passage of the bolus tail through the UES. The statistical analysis was done by a linear model with mixed effects. Correlation between height and swallowing events duration was assessed by Spearman's correlation coefficient (r). In women OTT, PC, HM and OPTT were longer in tall than in short subjects, what was not seen in men. In women there was a positive correlation between OTT, PTT and OPTT and height. Men (mean height: 177 cm) had longer PTT and PC than women (mean height: 166 cm). In women, oral and pharyngeal transit time of a 10 mL liquid bolus were influenced by height and was longer in taller subjects

Clinical and scintigraphic swallowing evaluation of post-stroke patients

TEMA: a deglutição em pacientes pós Acidente Vascular Encefálico (AVE). OBJETIVO: estudar a deglutição de pacientes pós-AVE através de avaliação clínica fonoaudiológica e do método cintilográfico. MÉTODO: estudou-se 26 pacientes, sendo o primeiro AVE ocorrido há no máximo dois meses; o grupo controle continha 15 voluntários saudáveis; ambos grupos foram submetidos a avaliação clínica e cintilográfica da deglutição, ingerindo 5ml de líquido e 5ml de pastoso. A avaliação clínica constou de anamnese, avaliação estrutural (sem alimento) e funcional (com alimento). RESULTADOS: durante avaliação fonoaudiológica, o grupo controle apresentou elevação laríngea ineficiente e sinais clínicos de aspiração em um indivíduo. Quanto aos pacientes, 27% apresentaram, na fase oral, um preparo ineficiente do líquido e 42% do pastoso. Na fase faríngea, 12% apresentaram tosse e engasgo. Na avaliação cintilográfica, três pacientes foram excluídos da análise, pois dois deles não deglutiram durante o tempo de aquisição do exame e um engoliu antes da instrução da pesquisadora. Os pacientes apresentaram maior quantidade de resíduo oral e menor duração de trânsito faríngeo na deglutição de pastoso, comparado ao grupo controle. CONCLUSÃO: a complementaridade da avaliação clínica e instrumental no estudo da deglutição de pacientes com AVE é necessária e importante para o desempenho do trabalho fonoaudiológico e para o paciente que será reabilitado. O método cintilográfico deve ser mais utilizado como instrumento de pesquisa para quantificar o tempo de trânsito, o resíduo e o tempo de depuração em cada fase da deglutição, estabelecendo-se parâmetros para outros estudos.BACKGROUND: deglutition of post-stroke patients. AIM: to study the swallowing of post-stroke patients through clinical and scintigraphic evaluations. METHOD: participants were 26 patients, who had suffered their first stroke within the last two months. The control group was composed by 15 healthy volunteers. Both groups were submitted to a clinical and scintigraphic evaluation of swallowing; using 5ml of liquid (water) and 5ml of paste bolus. Clinical evaluation was composed by an interview, an assessment of the oral structures (without food) and by a functional assessment (with food). RESULTS: during the clinical evaluation, one individual of the control group presented inefficient larynx elevation and clinical signs of aspiration. As for the group of post-stroke patients, 27% presented inefficient prepare of the liquid bolus and 42% presented inefficient prepare of the paste bolus, in the oral phase. Considering the pharyngeal phase, 12% presented cough and choked. In the scintigraphy evaluation, three post-stroke patients were excluded from this analysis for the following reasons: two did not swallow during the exam acquisition time and one swallowed before the instruction given by the researcher. The group of post-stroke patients presented more oral residues and shorter pharyngeal transit with the paste bolus when compared to the control group. CONCLUSION:clinical and objective swallowing evaluations of post-stroke patients are necessary and important to determine therapy intervention and possible outcomes. Patients who have suffered stroke have more residues and shorter pharyngeal transit than healthy individuals. The scintigraphic method should be used more often as a research instrument to quantify the residue, transit time and clearance in each of the swallowing phases