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},
"code": "E44",
"name": "Белково-энергетическая недостаточность умеренной и слабой степени",
"icd_name": "Белково-энергетическая недостаточность умеренной и слабой степени",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
3
],
"periodicity": 1,
"slug": "e44_belkovo-energeticheskaya_nedostatochnost_umerennoy_i_slaboy_stepeni",
"lead": "Нарушение здоровья, относящееся к группе недостаточность питания",
"description": "Белково-энергетической недостаточностью называется патологическое состояние, которое развивается при недостаточном поступлении белка в организм вследствие неправильного (недостаточного) питания или усиленного распада в организме (в случае некоторых заболеваний) \r\n\r\n ",
"etiology": "<p>Основные причины развития белково-энергетической недостаточности: </p>\r\n<ol>\r\n<li>Недостаточное поступление нутриентов. </li>\r\n<li>Недостаточное питание может быть следствием социально-экономических, религиозных факторов. Может быть вызвано ятрогенными причинами: госпитализация (необходимость соблюдения больничных диет), голодание в связи с обследованиями, диеты при различных заболеваниях, нерациональное искусственное питание. </li>\r\n<li>Причиной недостаточности питания могут стать психические заболевания, при которых извращается пищевое поведение: неврогенная анорексия, психозы. </li>\r\n<li>При гастроинтестинальной обструкции, дисфагии появляются механические препятствия для перорального приема пищи. </li>\r\n<li>Нарушения переваривания и/или всасывания нутриентов (синдромы мальдигестии и мальабсорбции). </li>\r\n<li>Нарушение переваривания и/или всасывания нутриентов отмечается при поступлении в организм их антагонистов при алкоголизме, отравлении лекарствами. </li>\r\n<li>Дефекты транспорта питательных веществ.</li>\r\n<li>Недостаточность питания может развиваться при ускорении катаболических процессов у пациентов с онкологическими заболеваниями, инфекциями, гипертиреозом, сахарным диабетом. </li>\r\n<li>При нефротическом синдроме, ХОБЛ, кишечных свищах, экссудативной энтеропатии, плазморее при ожоговой болезни, десквамативных дерматитах наблюдаются повышенные потери нутриентов. </li>\r\n<li>Недостаточность питания может развиваться в периоды, когда потребность в нутриентах максимальная, а именно: во время беременности, лактации, в детском и подростковом возрасте, в период реконвалесценции после травм и острых инфекционных заболеваний, после операций. </li>\r\n</ol>",
"pathogenesis": "<p>Начальная метаболическая реакция – уменьшение интенсивности обмена веществ. Для обеспечения энергией организм сначала использует жировую ткань. Однако позже, когда эти ткани истощаются, тело может использовать белки для получения энергии, в результате чего развивается отрицательный азотистый баланс. Затем внутренние органы и мышцы также начинают разрушаться, и их масса уменьшается. Наибольшая потеря массы у печени и кишечника, промежуточное положение занимают сердце и почки, и меньше всего теряет в весе нервная система. </p>\r\n<p>Прогрессирующая белково-энергетическая недостаточность приводит к нарушению функции органов. Уменьшение синтеза белков сыворотки крови в печени приводит к резкому снижению уровня циркулирующих белков. </p>\r\n<p>Снижаются сердечный выброс и сократительная способность миокарда. При тяжелой белково-энергетической недостаточности развиваются миофибриллярная атрофия и интерстициальный отек сердца. </p>\r\n<p>Слабость и атрофия дыхательных мышц приводит к нарушению респираторной функции. Характерны снижение жизненной емкости легких, частоты и минутного объема дыхания, нарушения мукоцилиарного клиренса. </p>\r\n<p>Поражение ЖКТ проявляется атрофией слизистой оболочки и потерей ворсинок тонкой кишки, приводящих к синдрому мальабсорбции. Развиваются панкреатическая и тонкокишечная дисахаридазная недостаточность. </p>",
"diagnostics": "<p>Диагностика белково-энергетической недостаточности осуществляется на основании данных анамнеза, истории болезни пациента и результатов объективного обследования. Для окончательного подтверждения диагноза, а также определения вида и причин белково-энергетической недостаточности проводят лабораторные исследования (измерение уровня альбумина в плазме, количества лимфоцитов, а также реакция на кожные антигены). </p>",
"treatment": "<p>При БЭН 1 - II степени проводят традиционную диетотерапию с поэтапным изменением рациона с выделением: </p>\r\n<p>этапа адаптационного, осторожного, толерантного питания; </p>\r\n<p>этапа репарационного (промежуточного) питания; </p>\r\n<p>этапа оптимального или усиленного питания. </p>\r\n<p> В период определения толерантности к пище осуществляют адаптацию к её необходимому объёму и проводят коррекцию водно-минерального и белкового обмена. В репарационный период осуществляют коррекцию белкового, жирового и углеводного обмена, а в период усиленного питания повышают энергетическую нагрузку. При БЭН в начальные периоды лечения уменьшают объём и увеличивают частоту кормления. . При I степени БЭН адаптационный период обычно длится 2–3 дня. В первый день назначают 2/3 необходимого суточного объёма пищи. В период выяснения толерантности к пище её объём постепенно увеличивают. По достижении необходимого суточного объёма пищи назначают усиленное питание. </p>\r\n<p>При II степени БЭН в первый день назначают 1/2- 2/3 необходимого суточного объёма пищи. Недостающий объём пищи восполняют за счёт приёма внутрь регидратационных растворов. Адаптационный период заканчивается при достижении необходимого суточного объёма пищи. </p>\r\n<p>При нормальной переносимости, начинается период репарации, когда объем питания постепенно (в течение 5–7 дней) увеличивается, при этом расчет нутриентов проводят на долженствующую массу тела. Вначале повышают углеводную и белковую составляющие рациона, затем - жировую. </p>\r\n<full></full>\r\n<p>Основные лекарственные средства: </p>\r\n<p>Ферментные препараты – лекарственные средства, способствующие улучшению процесса пищеварения и включающие в свой состав пищеварительные ферменты (энзимы). </p>\r\n<p>Витамины жирорастворимые, водорастворимые – для коррекции дефицитных состояний </p>\r\n<p>Антибиотики – применяются различные группы антибиотиков, для предупреждения и лечения инфекций. </p>\r\n<p>Пробиотики – живые микроорганизмы, которые являются нормофлорой кишечного тракта человека. При БЭН у детей отмечаются дисбиотические процессы. Назначаются препараты пробиотики - содержащие лакто и бифидобактерии. </p>\r\n<p>Препараты железа – применяют при БЭН для коррекции железодефицитного состояния. </p>\r\n<p>Препараты, восполняющие дефицит гормонов щитовидной железы, рекомендуются при гипотиреоидных состояниях различной этиологии. </p>\r\n<p>Глюкокортикоиды оказывают выраженное противовоспалительное, противоаллергическое, противошоковое, антитоксическое действие. </p>\r\n<p>Иммунологические препараты, применяемые для заместительной и иммуномодулирующей терапии. Снижают риск развития инфекций при первичном и вторичном иммунодефиците. </p>\r\n<p>Плазмозамещающие препараты предназначены для коррекции выраженных нарушений белкового метаболизма (гипопротеинемии), восстановления коллоидно-онкотического давления, нарушенной гемодинамики. </p>\r\n<p>Растворы аминокислот – растворы специальные, питательные для парентерального питания. Растворы для инфузий, состоящие из электролитов и аминокислот, которые являются метаболическими аналогами или физиологическими веществами для образования белков. Сбалансированные по содержанию незаменимых и заменимых аминокислот. </p>\r\n<p>Жировые эмульсии – обеспечение организма незаменимыми жирными кислотами в составе парентерального питания. </p>\r\n<p>Раствор глюкозы – глюкоза участвует в различных процессах обмена веществ в организме, 5%, 10%, 20%. </p>",
"prevention": "<p>Во всем мире самая важная стратегия профилактики белково-энергетической недостаточности состоит в том, чтобы снизить уровень бедности, улучшить знания о правильности питания и уровень оказания медицинской помощи. </p>\r\n<p>Кормление грудью ребенка в течение по крайней мере шести месяцев с момента рождения считается лучшим способом предотвращения недоедания в раннем детстве. </p>\r\n<p>У взрослых профилактика недоедания заключается в соблюдении качественного рациона, получении максимума витаминов и минералов с пищей. </p>",
"clinical_picture": "<p>Белково-энергетическая недостаточность слабой степени диагностируется не всегда, так как общее состояние ребёнка страдает мало.</p>\r\n<p>Симптомы: умеренное двигательное беспокойство, урежение дефекаций, лёгкая бледность кожных покровов, истончение подкожно-жировой клетчатки в области туловища и-(или) на животе. </p>\r\n<p>Масса тела снижается на 10–20% от долженствующей. Психомоторное развитие соответствует возрасту, иммунологическая реактивность и толерантность к пище не изменены. Симптомы рахита, дефицитной анемии.</p>\r\n<p>Белково-энергетическая недостаточность умеренной степени характеризуется выраженными изменениями со стороны всех органов и систем. Наблюдается снижение аппетита, периодическая рвота, нарушение сна. Отмечается отставание в психомоторном развитии: ребенок плохо держит голову, не сидит, не встаёт на ноги, не ходит. Нарушения терморегуляции проявляются существенными колебаниями температуры тела в течение дня. Резкое истончение подкожно-жировой клетчатки на животе, туловище и конечностях. </p>\r\n<p>Отставание в массе на 20–30%, в длине тела на 2–4 см. Кожные покровы бледные, бледно-серые, отмечается сухость и шелушение кожи (признаки полигиповитаминоза). Снижается эластичность, тургор тканей и тонус мышц. Волосы тусклые, ломкие. Снижается толерантность к пище. Изменяется характер дефекаций – стул неустойчивый, чередование запоров и поносов. В кале могут обнаруживаться крахмал, нейтральный жир, слизь, мышечные волокна, нарушение флоры кишечника. Моча имеет запах аммиака. Сопутствующая соматическая патология (пневмония, отит, пиелонефрит), дефицитные состояния. </p>",
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"code": "E46",
"name": "Белково-энергетическая недостаточность неуточненная",
"icd_name": "Белково-энергетическая недостаточность неуточненная",
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3,
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"slug": "e46_belkovo-energeticheskaya_nedostatochnost_neutochnennaya",
"lead": "Состояние питания, при котором дисбаланс энергии, белков и других питательных веществ ведет к измеримым нежелательным эффектам на ткани, функции и клинические исходы.",
"description": "При недостаточном поступлении белков и энергии уменьшаются безжировая масса тела и количество жировой ткани, причем одно из этих изменений может быть более выраженным.",
"etiology": "<p>Белково-энергетическая недостаточность может быть первичной или вторичной. Первичная белково-энергетическая недостаточность обусловлена неадекватным поступлением питательных веществ, а вторичная белково-энергетическая недостаточность является следствием различных расстройств или приема лекарственных препаратов, которые препятствуют использованию питательных веществ.</p>",
"pathogenesis": "",
"diagnostics": "",
"treatment": "<p>При легкой и умеренной белково-энергетической недостаточности следует устранить возможные причины этого состояния. Суточный приход белков и энергии увеличивают (в соответствии с идеальным весом) для ликвидации их дефицита. Всем больным назначают поливитамины. Проводят также лечение и профилактику дефицита минеральных веществ (в том числе микроэлементов) для предупреждения угрожающих жизни гипокалиемии, гипомагниемии, гипофосфатемии и т. д. Если больной способен принимать пищу и глотать, достаточно самостоятельного питания. При снижении аппетита или в отсутствие зубов дополнительно назначают жидкие питательные смеси для самостоятельного или зондового питания.</p>\r\n<full></full>\r\n<p>При тяжелой белково-энергетической недостаточности требуется более срочное вмешательство. Лечение таких больных затруднено по нескольким причинам:</p>\r\n<ul>\r\n<li>Заболевания, вызвавшие белково-энергетическую недостаточность, протекают тяжело, их труднее лечить. Иногда азотистый баланс можно восстановить только после излечения инфекции и устранения лихорадки.</li>\r\n<li>Белково-энергетическая недостаточность сама по себе может препятствовать излечению вызвавшего ее тяжелого заболевания. В таких случаях необходимо как можно раньше начать зондовое или парентеральное питание.</li>\r\n<li>Поступление пищи через ЖКТ способствует поносу из-за атрофии слизистой и дефицита ферментов кишечника и поджелудочной железы. При этом может быть показано полное парентеральное питание.</li>\r\n<li>Следует устранить сопутствующий дефицит других компонентов пищи (витаминов, незаменимых минеральных веществ, микроэлементов).</li>\r\n</ul>\r\n<p>У взрослых восстановление питательного статуса наступает медленно и не всегда полностью; у детей выздоровление происходит в течение 3-4 мес. Во всех случаях необходимы образовательные и реабилитационные программы, а также меры психологической и социальной поддержки.</p>",
"prevention": "",
"clinical_picture": "<p>Легкая и умеренная белково-энергетическая недостаточность. У детей отсутствует прибавка веса и роста. У взрослых отмечается снижение веса, хотя при отеках или ожирении оно может быть не столь заметным. Уменьшаются толщина кожной складки над трехглавой мышцей плеча и мышечная масса в области плеча.</p>\r\n<p>В отсутствие болезней почек чувствительным показателем белковой недостаточности служит отношение суточной экскреции креатинина к росту (показатель измеряют еженедельно). Снижаются уровни альбумина, трансферрина и транстиретина (преальбумина) в крови. Уровень Т3 снижается, а реверсивного Т3 - повышается. Замедляется метаболизм. Возможны лимфопения и нарушение толерантности к глюкозе . Размеры сердца уменьшены .</p>\r\n<p>Тяжелая белково-энергетическая недостаточность. Тяжелая белково- энергетическая недостаточность сопровождается более выраженными изменениями клинических и лабораторных показателей. При физикальном исследовании обнаруживают западение межреберий, атрофию височных мышц и атрофию мышц конечностей. Подкожная клетчатка атрофирована или отсутствует. Характерны <a href=\"/symptom/apatiya/\" title=\"Перейти на страницу симптома Апатия\">апатия</a>, быстрая <a href=\"/symptom/utomlyaemost/\" title=\"Перейти на страницу симптома Утомляемость\">утомляемость</a>, чувство холода, депигментация кожи и депигментация волос, заострившиеся черты лица; кожа сухая, покрыта трещинами. В запущенных случаях образуются пролежни, кожа изъязвляется. АД снижено, также как и температура тела, пульс ослаблен. Нарушаются функции всех органов и систем.</p>",
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"etiology": "<p>Недостаточность витамина А может быть обусловлена нарушением абсорбции витамина в кишечнике при его хронических заболеваниях, целиакии, болезнях печени и поджелудочной железы, железодефицитной анемии, длительном употреблении минерального масла. При потреблении с пищей небольших количеств жира также снижается абсорбция витамина А.</p>\r\n<p>Причиной недостаточности витамина могут быть и чрезмерные потери его организмом. Так, экскреция витамина А увеличивается при раке, болезнях мочевыводящих путей и хронических инфекционных заболеваниях. Низкое потребление белка приводит к недостаточности белка-переносчика и способствует снижению уровня витамина в плазме.</p>",
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"diagnostics": "<p>При гиповитаминозе А понижено содержание в крови ретинола или каротина (ниже 200 мкг/л), нарушена темновая адаптация, развивается гемералопия. При биомикроскопии глаза на слизистой конъюнктивы могут выявляться белесые и желтоватые мелкие бляшки.</p>",
"treatment": "<p>азначают диету, богатую витамином А и провитаминами, а также препараты ретинола. Растворы ретинола применяют внутрь и в виде внутримышечных инъекций.</p>\r\n<p>Суточная лечебная доза 25 000-100 000 ME ретинола (при приеме внутрь дозу делят на 2-3 приема, больше одной инъекции в сутки обычно не делают), продолжительность курса лечения 2-4 нед. Ретинол содержится в поливитаминных препаратах.</p>",
"prevention": "<p>Профилактика гиповитаминоза А состоит в рациональном питании и назначении внутрь препаратов ретинола (5000-10 000 ME) в течение не менее 2-3 нед. До и после проведенного профилактического курса целесообразно определить содержание в сыворотке крови ретинола или каротина.</p>",
"clinical_picture": "<p>Наблюдаются сухость в полости рта и носа, <a href=\"/symptom/izmeneniya_struktury_kozhi/\" title=\"Перейти на страницу симптома Изменения структуры кожи\">сухость кожи</a>, ее <a href=\"/symptom/shelushenie_kozhi/\" title=\"Перейти на страницу симптома Шелушение кожи\">шелушение</a>, повышенное <a href=\"/symptom/vypadenie_volos/\" title=\"Перейти на страницу симптома Выпадение волос\">выпадение волос</a>. Ухудшается сумеречное зрение («куриная» <a href=\"/symptom/slepota/\" title=\"Перейти на страницу симптома Слепота \">слепота</a>). Одновременно возможны <a href=\"/symptom/svetoboyazn/\" title=\"Перейти на страницу симптома Светобоязнь\">светобоязнь</a> (<a href=\"/symptom/glaznaya_bol/\" title=\"Перейти на страницу симптома Глазная боль\">боль в глазах</a> при ярком освещении) и ксерофтальмия (сухость конъюнктивы с утратой присущего ей блеска, снижение секреции слезных желез, появление бляшек Искерского - Бито, разбросанных по склере). В наиболее тяжелых случаях воспалительные процессы в роговице могут осложняться ее некротическим размягчением (кератомаляция), что обычно заканчивается слепотой.</p>\r\n<p>Сочетание гемералопии с ксерофтальмией позволяет с высокой достоверностью думать о недостаточности витамина А.</p>",
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