INFECTIOUS DISEASES : THE BACTERIAL DYSENTERY (DYSENTERIA BACTERIALIS) - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
Etiology. Agents dysentery - a large group of gram still sticks. Practically, it is important to distinguish between the following types:
1) scribe Grigoreva-Shiga - the most pathogenic and toxicoproteomic exciter;
2) group the Flexner - gissa, including several serological types;
3) wand Kruse-sonnei (common in Central Europe, and in recent years in Russia and CIS countries);
4) wand Fitting-Smita;
5) stick Newcastle (planted relatively rare).
Epidemiology has many features in common with the epidemiology of typhoid fever. Reservoirs of virus - diseased; convalescents and subactive media (chronic form)recognized rektoromanoskopii and bacteriologically - play a critical role in the rapid infection of environment and contacting people; explicit dysenteric patient, due to frequent tenesmus, infects the environment more intensively than bruchnotifosny, and also from the first hours of the disease. A significant number allocated from the body dysenteric bacilli remain in the environment: flies carry the infection not only on mechanical legs, but in your gut, releasing microbes from faeces and belching on food, utensils and on the lips of sleepers. Reproduction dysenteric bacilli (especially Kruse-sonnei) on the number of foods is very intense; water factor, on the contrary, plays only a negligible role. Dysentery infected with the least clean people; in terms of age - children and the elderly (disease of dirty hands!), domestic for - persons living in unsanitary conditions. Food also plays an important role (nutritional errors, violations of the requirements of hygiene). The frequency dysenteric waves ceteris paribus strictly coincides with the hot season (peak wavelength July - August), which stands in connection with the best persistence of pathogens in the environment (heat), the presence of vector - flies, greater contamination of the hands and lower body resistance (loss of appetite, thirst, heat, change in blood flow). And epidemiological majapidamisi period is of importance, because in winter the disease is not stopped. A significant portion of these diseases is associated with exacerbation of dysentery, moved in the summer, but not completely cured. Of great importance precapitalistic (spring) season, during which the usually observed increase in recurrence and created more favorable conditions for the spread of infection.
The pathogenesis. Complex in its structure dysenteric toxin has two practically important components: soluble exotoxin, which affects the nervous system, and endotoxin - entero - or, rather, calotropis poison that affects the colon. Under natural infection dysenteric infection must penetrate through the mouth and a long way to go for the gut to have a pathogenic effect on the bottom segment of the intestine ( infections per rectum unsuccessful); experimental introduction dysenteric culture or toxin intravenously leads to typical lesion of the colon. For the manifestation of pathogenic action is necessary to:
1) lack of digestive enzymes and intense digestive processes,
2) more or less traumatisierung, at least thick feces, intestinal epithelium (beginning with pathological folds of mucous).
The local process is differencesee inflammation of the mucous membrane of the colon with the formation of hemorrhages, fibrinous deposits, necrosis and ulceration. He is accompanied by local and General intoxication. Pathological disorders of the body go in two directions: local changes under the influence virulence of a microbe and endotoxin levels and the overall effect dysenteric exotoxin on the nervous system, metabolism and replacerules. Local effects: redness wrinkles, the appearance of them gentle fibrinous film, seal plaque, blood mickleton spaces, sprawling RAID on these spaces, sharp thickening plaque, necrotization it with the formation of ulcerations. The lower plot, the more he was struck. The muscles of the intestine followed by increased peristalsis goes into a state of spasm, stopping the movement of intestinal contents (spastic constipation); chair loses fecal character, and defecation patient consist of pathological products of mucus mixed with blood. Minor irritation of the rectum flowing mucus causes spasm of the intestinal muscles, tenesmus, ending eruption scant amount of blood and mucus masses. Intoxication with dysentery is manifested by termination of the reaction temperature with the temperature drop to subnormal numbers, a sharp weight loss of the patient and recurrent flow of blood into the abdominal cavity. Hypothermia is closely associated with reduction of oxidative processes, which in turn even more are inhibited by low temperature. With a sharp decrease in heat production, which may be associated with lesions of the nervous system, but mainly to a sharp decrease in oxidative processes (grip), the heat transfer depends on the temperature of the external environment (poikilothermic). Weight loss occurs due to the rapid disappearance of fat reserves. Disorder of blood circulation is reduced to a lower tone, paresis and even paralysis n.splanchnici. In the acute period of the heart muscle, and peripheral vessels are not affected: blood pressure is kept at a level close to normal. Upon the occurrence of collapse sharply falling pulse pressure due to reflux of blood into the abdominal cavity. Peripheral vessels while spazmaticly compressed (pallor dysenteric patients), heart become empty due to the reduction of inflow to him the blood (intravascular hemorrhage). Recurrent collapses lead to anemia of the brain, to a kind of shallow, slow breathing, punctuated by deep breaths. Respiratory paralysis occurs when another distinct heart beat. The intoxication of the heart muscle is manifested in the later (14 - 16) days of the enlargement of the heart and the fall of blood pressure.
Symptoms. Fever, abdominal pain, imperative urge on the bottom, originally diarrhea feces, quite often the chair in the form of meat slops, then tenesmus, stool mixed with mucus, the disappearance of feces, blood and mucus scanty stool with painful tenesmus. Spasm in the S-shaped ulcers, painful when palpated.
For acute dysentery, it is very diverse: from the lung, or, as it is erroneously called, vulgar colitis to severe toxic disease in which death may occur before clinical signs appear specific lesions of the distal segment of the colon.
Currently dominated by mild forms, but often apparent ease of flow can be deceiving and after a seemingly quick recovery may receive a relapse. Therefore, every patient with acute colitis requires close attention and a comprehensive study to address the question about the etiology of this disease and its clinical form. The last question is decided depending on the severity of local and systemic manifestations of the disease and the ability of the body to return to defensive reactions. Depending on whether there is any indication of the total accountexecutive, Rosenberg pointed out the two main forms of dysentery: toxic and infectious.
Views of the pathogen has a known effect on the severity of the clinical course, although the latter depends largely on the properties of the microorganism. Coli Shiga often gives severe phenomena accountexecutive. A group of GISS-Flexner, which includes several different serotypes antigenic structure, gives varied in relation to the severity of the clinical picture. Dysentery caused by this group, relatively often becomes chronic. Wand Kruse-sonnei is the causative agent of predominantly mild forms of heavy firms are more common in children. When food poisoning dysentery gives shape similar to intoxication. Wand Fitting-Smica is not severe, but with a somewhat lengthy recovery; in some cases, possible toxic forms.
Infectious form begins by raising the temperature to 38 - 39º, loss of appetite, cramping pains in the stomach and often vomiting. Chair, due to abundant serous of exudate, takes the form of meat slops, and then becomes a typical dysentery. The severity and dynamics of the intestinal lesions affect the nature of the chair, watching which obliged the doctor. In acute lesions ulcers with fibrinous-ulcerative process and in the presence of spasm chair is very frequent, with abdominal pain, tenesmus, scanty, bloody-mucous, odorless. As exclusion films stool character changes: he becomes fetid, krasnoselskogo color. In the period of purification and healing of the ulcer liquid stool, purulent and, finally, with the relaxation of spasm and restore the patency appear first portions of feces.
Systematic examination of faeces for laboratory table (breeding saline solution, examination in a Petri dish on a black background), and even more pathological microscopy of particles greatly facilitates the observation of the dynamics of the inflammatory process. Yacanna above the sequence of the individual phases is one of the important indicators correctly flowing reaction (cycles by C. A. Pospelova). Expressed cell response (mucus plenty of fresh leukocytes) gives a favorable Outlook for the rapid healing of ulcers; long-term predominance of red blood cells and degenerated leukocytes indicates weakened local reaction and delayed healing of ulcers.
The phenomenon of intoxication due to the action of endotoxin and absorption of inflammatory products occur in varying degrees in any form of acute dysentery (state of weakness, nausea, sometimes vomiting, digestive disorders, degenerative changes in the heart muscle and parenchymatous organs). The phenomenon of these differ from signs of accountexecutive. The language is heavily lined and dry. He has no appetite. The decrease in acidity of gastric juice, reaching full ahilii, a sharp decrease of the enzymes of duodenal contents, in particular, lipases, lead to a decrease in digestive abilities and are one reason for the rapid emaciation. When the extent of ulceration in the colon may be received from the intestine secondary infection (remittent fever, enlargement of the spleen), addictive disease, and poor prognosis. Various symptoms are: improvement of health, reduction of temperature, the disappearance of tenesmus, reducing the frequency of urges, the more abundant fecal quickly formed stool. These signs of improvement should not be regarded as indicators of recovery. Often there may come a sharpening process with increasing temperature, return tenesmus and mucous bloody stool. Such deterioration, in contrast to the phenomena of secondary infection amenable to specific therapy. The most reliable indicator of recovery is the restoration of normal rektoromanoskopiya picture. The duration of the disease is different: on average 10 to 14 days, but may take up to a month or longer.
Toxic form from the first days differs from the previous one. Temperature reaction, vomiting and enlargement of the spleen usually absent; but this form is peculiar pallor of the skin, retraction of the eyes, weakness, prostration, sarcosomataceae a state of complete indifference, complaints of feeling cold ("as if covered with ice"). Dynamics of intestinal phenomena is the same as described above. The severity of intoxication often, but not always coincides with the severity of intestinal phenomena. With a very strong production of exotoxin a fatal intoxication of the nervous system ahead of the intestinal damage by endotoxin produced only after the collapse of the microbial bodies (anergicakimi toxic form), and patients die on the 3 - 4th day of illness with a relatively insignificant changes in the intestine. Hypothermia, reaching subnormal numbers, and sarcosomataceae condition are bad prognostic signs. Pulse weak filling, type pulsus durus. Blood pressure measurement gives the possibility to navigate in the state of circulation; at sufficiently high pulse pressure (20 to 25 mm and above), the prognosis is good, with a decrease of more than 15 mm is bad. The heart is usually not extended, the colours muted. In severe intoxication on the skin appear blue-purple hemorrhage, various sizes and shapes, giving a very poor prognosis. Death occurs with symptoms of acute reflux of blood into the abdominal cavity. The duration of the disease is 3 to 4 weeks. The severity depends on the degree of intoxication, on the ability of the body to produce antitoxin and from time to inject. Immunoreactive form occurs in individuals with some, but not complete, local and General immunity or able to quickly mobilize protective apparatus body. The clinical course she can begin sharply enough, but reverse the development of local pathological process will begin earlier education dipteridaceae plaque. In accordance with this disease will abortifacient course, with rapid drop in temperature, the disappearance of pathological substances in the stools, formation of feces, the restoration of normal rektoromanoskopiya picture. Another, subacute variant form gives little symptoms with the onset of the disease (erased); dysenteric nature it is set bacteriologically, rektoromanoskopii and by epidemiological associations. Such easy flowing dysenteric colitis require a great deal of attention both in terms of their recognition and conclusions about the recovery. To immunoreactive forms they may be assigned only when a quick stop bucillamine, restore normal coprogram and rektoromanoskopiya picture. Often very similar subacute forms are proactive in nature; despite the deceptive ease of a clinical course and seemingly quick recovery when they are experiencing a long baculoviridae, the presence of microscopically detectable pathological products (mucus, pus) n preservation of pathological conditions of the mucous membrane of the colon. Such forms are often exacerbation of chronic dysentery, the true nature of which remains unrecognized because of carelessly collected history.
Toxicoinfection form associated with infection bazillionaires food, mostly liquid (milk) and semisolid (jellies, headcheese), which breed freely pathogens (often sticks Kruse-sonnei). Incubation shortened to 6 - 24 hours. Diseases take a group or a mass character. The clinical course is very similar to salmonellezny diseases. Onset corresponds to the picture of acute gastroenteritis with a sharp rise in temperature, abdominal pain, diarrhea liquid feces, repeated vomiting and fall of cardiac activity. On the second day the character of the stool changes: there was a fibrinous film, mucus and a little blood. If in rare cases death occurs within 1 to 2 days, and recovery is rapid. In the acute period with bowel movements releases massive amounts of pathogens (up to 95 - 100% of positive cultures), but very quickly (after 3 to 5 days) baculoviridae stops.
Chronic forms should be the subject of special attention. They develop from acute forms. Causes of transition dysentery chronic studied is not yet complete. They are divided into two groups:
(I) medical diagnostic characteristic late visit to the doctor, diagnostic errors, incorrect or incomplete treatment (lack of proper contralaterally);
2) but the state of host - deep imbalances in the body on the grounds of intoxication in the acute period, the presence of concomitant diseases (tuberculosis, malaria, helminthic and protocollie invasion) and pathological conditions (malnutrition, avitaminosis). Causes of the first group lead to incomplete recovery, which are relapses; the causes of the second group, as reducing the reactive ability of the body, contributes to the development of a long course with exacerbations.
Chronic recurrent form develops from acute forms, mainly proceeding with an average weight. Relapses usually occur after 3 to 6 months after the supposed recovery; consistent frequency and the total number of relapses varies. The duration of the disease often limited to 1 ½ - 2 years, but in some cases delayed for a longer time. Especially often relapses appear in preepidemic season (April - June). Clinical manifestations of recurrence differs from the acute form by the absence of intoxication and a benign course. Often all clinical phenomena are limited to short-term diarrhea with persistent craving for the bottom and moderate pain in the left abdomen. The chair does not lose fecal character, but the amount of vomit feces is relatively small, and in them is found the admixture of pathological products. In some cases, relapses are usually severe (keep in mind the possibility of reinfection). In miracidium periods of feeling sick quite satisfactory, but it is possible dyspeptic symptoms (loss of appetite, heaviness in the epigastric region, belching and constipation. A prolonged form develops directly from sharp. Started a improvement does not go into recovery, diarrhea takes stubborn character (5 to 6 times a day), liquid stools, fecal, with a small admixture of mucus and pus. Growing exhaustion, possible marasmic swelling. In some cases, a prolonged form is a series of consecutive local exacerbations with wavy temperature reaction. Relapse as a consequence of superinfection (planted another representative of the dysentery group or a different serotype than in the acute period).
Complications are few, often in severe forms. Children often have a place of rectal prolapse, maceration of the skin (if not attentive care), pneumonia; in adults is arthritis. Perforations, pericolic and intestinal bleeding are very rare; more often - stricture formation. In addition to complications, possible pathological layers: malnutrition and avitaminosis as the effects of dysentery in infants - dyspepsia; additional infection - Salmonella and nonspecific intestinal microflora.
Recognition in patients with severe clinical course is not difficult (see Symptoms). When less severe and milder forms of the symptoms are the same, but in a milder form; pain predominantly in the left half of the abdomen; the urgency and tenesmus less frequent; the chair retains fecal character, but the number of bowel movements slightly. There is an admixture of pathological substances (mucus, pus, sometimes blood); the seal of the sigmoid colon. In the acute form usually there are General effects: fever, loss of appetite, nausea and varying degrees of endotoxicosis. The harder recognition chronic dysentery and differentsirovki relapse from the same disease again. When relapse is dominated by local phenomena; intoxication is rare. Great importance is well assembled a history of previous acute dysentery, the former recurrence intervals between them. No relapse in the past year diagnoses of chronic dysentery questioned. Preferably the mapping of pathogens prior to diseases and this disease. If the exacerbation is very important repeat bacteriological examination and comparison of pathogens (exacerbation or superinfection). The so-called colitis and enterocolitis, if they come in contact with dysentery, covers a group of persons, proceed with increased temperature or periodically repeated at one and the same person, of course, suspicious of dysentery. A careful macro - and microscopic examination of stool; mucus with the inclusion of significant quantities of LEU-koltov, and the more red blood cells should be considered as one of the symptoms of dysentery. Microscopic examination requires careful selection of the particles of mucus (glass Cup on a dark background), view multiple medications and follow-up examinations (at the end of the study to disinfect drugs and defecation in the bleach solution). In the presence and rectoromanoscope it is used for diagnostic purposes in case of poorly expressed and doubtful cases (strong inflammation and spasm his introduction painful). The use of rectoromanoscope important for differential diagnosis (tumor, polyps), to monitor the dynamics of the process and to monitor recovery. Bacteriological examination should be carried out before and again. Crops can best be achieved. directly at the bedside or send to the laboratory freshly isolated material. The reaction capriglione the Baptist (the filtrate stool agglutinated dysenteric diagnosticum) gives a positive result is mainly expressed in the forms. Care must be taken during the handling of faeces. Serological agglutination convincing when titers of 1:200 with culture Shiga and 1 : 400 with the culture of the Flexner. Great diagnostic importance increase in titer with repeated testing (non-wealth - not before the appearance of the 5 - 7th day of illness). The admixture of blood to the stool without the presence of mucus and purulent Taurus does not indicate dysentery (hemorrhoids, menstruation, polyps). Disintegratable chair can be: in case of poisoning by heavy metelli, especially sublimate (change on the gums, oral mucosa, loosening of teeth); uremia (pathological urine, oliguria or anuria, hypertension, vomiting, loss of consciousness, convulsions); malignant neoplasms of the colon (palpation, macroscope chair, General status, anemia, sigmoidoscopy); amebiasis (cm ); tuberculosis of intestines (fecal stool character, no tenesmus, specific changes in the lungs or lymph system).
Practically it is important to avoid contamination from the patient, taking into account the possibility of baillonella. Recognition erased cases and notication of chronics (baillonella) are particularly important. In terms of current disinfection and when a serious health promotion among these categories of sources of infection and their environment - the risk of infection is greatly reduced.
Current disinfection of faeces produced twice the amount of 20% solution of bleach (it is convenient to pour the solution in the vessel prior to its submission to the patient). Drain defecation in a special tank, painted with enamel paint, with cover and stand them in a bleach solution for 2 hours. Walking patients are cautioned not to use a regular toilet seat - they fit tank with seat and cover. After a two-hour disinfection and feces poured into the bowls. In hospitals when there is sewage must be equipped with Central chlorination - wastewater. Personnel should wash hands frequently and to wipe them with a 0.5 % solution of bleach or 0.2% bleach solution. This same solution to disinfect the floor, furniture, painted with oil paint walls. Wipe up patients should be soaked in a chlorine solution with a cotton swab and anus greased with vaseline. Before discharge to produce two-time study in germ-carriers: the first study is made after clinical recovery (decorated chair without pathological impurities), the second after 2 to 3 days. It is important to check the anatomical recovery (scatological, rektoromanoskopii) in order to prevent recurrence. Food handlers and food establishments, water, childcare examined bacteriologically weekly for 1 ½ months after discharge and before this date are not allowed to work (about their statement to notify the sanitary-epidemiological organization). If you cannot bacteriological studies to patients discharged 8 days after full clinical recovery in case of a negative coprogram. For children who recover from acute and chronic dysentery and colitis, it is advisable to allocate a special day nurseries and kindergartens patronage type. Desirable subsequent patronage and over ill adults (medical surveillance, health education, improvement of living conditions).
Combating flies is destruction in breeding sites, protection from flies premises sick, toilets, washer, boats, kitchens, cupboards / rooms, food (saatciane) and the destruction of winged flies (the most effective drugs DDT). Sanitary propaganda among the population should be widely deployed in accordance with the preventive activities in every season: majapidamises (identifying patients with chronic dysentery), precipitations (identifying lung disease, recurrent, active immunization, hygiene regime in everyday life, fighting flies) and epidemic (food and drinking regime, early medical care, pageprotection, current disinfection, fighting flies). Active immunization is parenteral immunization with pentadaktylos (typhoid, paratyphoid a and b, Shiga dysentery and Flexner) or dysenteric dunavarsany according to the guidelines of the local health authorities (the time of vaccination - April - may). Less valid enteral immunization tablets according to the method of Besredka - fasting 3 days in a row, one tablet for 2 hours before eating.
Pageprotection used primarily among persons who come into contact with patients (15 - 20 ml of the bacteriophage with 5% soda solution no earlier than 4 hours after a meal and 4 hours before eating); epidemiological evidence -- pageprotection threatened groups every 5 to 7 days.
a) Chemotherapy: alfasol, disulfid, sulgin, sulfathiazole have a bacteriostatic effect and give rapid clinical effect. To obtain not only clinical, but also anatomical recovery needs: early application of sufficient dosage and duration of use (4 to 6 days). Approximate dosage of sulfonamides by day: heavy and expressed forms: day 1 - 6 g, day 2 - 6 g day 3 - 5 g, 4-day - 4 G. I. day - 3 g, 6-day - 2 g; mild forms: day 1 - 4 g, day 2 - : g, 3-day, 2 g, 4-th day - 1, drink plenty of water; contraindicated with the use of saline laxatives. Dosage for children is 0.2 to 1 kg of weight. If it is impossible the introduction of per os recommended the introduction of hot enema 38 - 40º (a small amount in the soda solution is found through a thin catheter may above) or in the candlelight. In order to avoid relapse not to use small dosages, giving the deceptive effect. Recently proposed treatment colloidal disperse the preparation of the silver salt of sulfathiazole (Bilibin). The drug is administered in the form of therapeutic enemas; 100 ml of 1 - 2% solution is injected after enemas through the catheter 3 days in a row. The results are controlled by rectoromanoscope; in the presence of pathological changes in the course of treatment is repeated.
b) phage therapy makes a great effect in the early period and the infectious forms. The phage is given by 15 to 20 ml with 5 % soda solution on an empty stomach 2 times after 4 to 5 hours. Convenient single use 30 to 50 ml With insufficient effectiveness must be repeated reception of bacteriophage in 24 hours; in severe effect in order to avoid relapse - re-giving it 48 hours. Children can enter the bacteriophage enema. In toxic forms necessarily at the same time to enter the antitoxic serum. Simultaneously with the bacteriophage not to use laxatives (only after 2 to 3 days after treatment with phage).
C) Serotherapy. In toxic forms of early use of antitoxic serum (not less than 40 000 AE again 3 days in a row) has great action. The best effect of antitoxic sera with high titers (concentrated). Introduction intramuscular.
g) Antibiotics are little tested in the treatment of dysentery, but there were reasons for their use; gramicidin - 1 ml of 4% solution of 100 ml of fashion enema 38 - 40º; penicillin 1 000 000 - 150 000 units per day for chronic dysentery to eliminate additional infection; volatile - 5 - 10 % water extract of garlic pulp by I 00 ml hot enema (after prdvaritelno purification) in acute and chronic form; it is recommended to combining with phage therapy (C. I. Ratner).
2. Increase the reactivity of the organism plays a particularly important role in the treatment of persistent and chronic forms of dysentery. First of all it is necessary to eliminate all pathological layers, reducing the strength of the body of the patient: worm and protocollie invasion, comorbidities, state of Hypo - or avitaminosis. Reactivity increases nutrition patients, repeated fractional blood transfusions (50 - 100 ml), intramuscular blood plasma (50 ml).
Autohemotherapy - 10 - 15 ml of Local reaction from the mucosa of the colon can be enhanced by the application of medicinal enemas and washes and appointment of rough food - buckwheat on N. K. Rosenberg.
3. Drug therapy should not be ignored in the selection of a specific therapy. Laxatives in the presence of specific means has lost its meaning. In the absence of sulfa drugs or bacteriophage should in the early days of the disease to assign a 1 to 1.5% solution of sodium sulfate or magnesium in the amount of 800 to 1 000 ml; drink throughout the day in small portions. In the later days of illness weak solutions are saline laxatives promote removal of pathological products (washing up). Sulfate salts cannot be used in conjunction with sulfa drugs; not to assign earlier than 2 - 3 days after the end of sulfa therapy. Antispastic drugs (candles with Extr. Belladonnae, the solution of atropine sulfate 1 : 1 000 under the skin, heating pad on the abdomen) are assigned when the presence of pain, tenesmus and spasm of the colon. Local treatment with enemas (solutions of silver nitrate, potassium permanganate, hydrogen peroxide, infusion of chamomile, starch) makes sense after discharge films. Enemas should be hot (about 40 ° ) and small volume (150 ml). Do not use laxative. Apply after cleansing enema of the physiological solution. In protracted cases, the washing of the intestine of a short, proctoscope and long soft tip. Warm the body during hypothermia with multiple heaters, hot water and electric air baths: heating pad on my stomach. Subcutaneous saline infusion in severe intoxication, especially when the loss of skin turgor. Intravenous infusion of calcium chloride solution or a subcutaneous injection of blood plasma with a large amount of blood in the stool. Caffeine, strophanthin, pituitrin, strychnine and adrenaline in the flow of blood into the abdominal cavity. Astringent and disinfectant per os in introducing liquid feces chair and members consistent enteritis (nitrate bismuth, kseroforma, dermatol, benzenethiol, tanalin). When there are painful contractions medicine N. K. Rosenberg. Such a large number of funds forces to prevent them from piling up numerous appointments to one patient. Each assignment must be justified.
4. Dietetics. Contraindicated giving fat and whole milk. Diet sets of dishes, absorbed in the upper intestine and not giving a gross residue. It should be rich in vitamins, carbohydrates and easily digestible proteins. As the dynamics of disease diet changes. Lowering the acidity of gastric juice to assign natural gastric juice or diluted hydrochloric acid with pepsin and Pancreatin (1,0) Apple therapy: clean and cut the core out of the apples, passed through a meat grinder, give the patient small amounts in the total amount of 0.5 - 1 kg per day from the first days of the disease; at the same time congee, tea, blueberry tea, coffee, diluted in half with water hot red table wine (adults) and protein milk (children); 3 - 4th day thick almond milk, mashed rice porridge or sago with wine or vitamin syrups, blueberry pudding, jelly, yogurt and 2 - 3 biscuit; 50 g fresh pressed cottage cheese. In further fat-free chicken or veal broth, boiled beef and fish, passed through a meat grinder, a stale loaf, boiled eggs, potato shore. On the second week - cauliflower,porridge from Smolensk cereals. At the end of the second week - a little bit ( up to 15 g) butter. The specified sample diet is prescribed depending on the case, compressed terms in mild cases and stretched in heavy. With the protracted diarrhea in the recovery period used cottage buckwheat by Rosenberg (1 tea saucer) with the subsequent appointment of a saline laxative. When acidic stool should be abolished hydrochloric acid and assign alkali (Borjomi); frothy stool to limit carbohydrates, the rotten - to reduce proteins.