Vyresnių pacientų vidurių užkietėjimo gydymo galimybių apžvalga

Vyresnių pacientų vidurių užkietėjimo gydymo galimybių apžvalga

Vyresnių pacientų vidurių užkietėjimo gydymo galimybių apžvalga

Įvadas

Lėtinis vidurių užkietėjimas vargina 16 proc. suaugusiųjų (1), tačiau senyvo amžiaus pacientų grupėje ši būklė yra kur kas dažnesnė. Apie trečdalį vyresnių nei 60 metų asmenų protarpiais vargina vidurių užkietėjimas (1), o tarp slaugos namų gyventojų šis sveikatos sutrikimas pasireiškia net 50 proc. pacientų (2). Jungtinėse Amerikos Valstijose (JAV) vidurių užkietėjimas yra viena dažniausių vizito pas šeimos gydytoją priežasčių (3).

 Apibrėžimas

Vidurių užkietėjimas diagnozuojamas remiantis paciento skundais. Ligoniai skundžiasi arba pasunkėjusiu tuštinimusi, arba ne visiško išsituštinimo pojūčiu. Kartais vienu metu vargina abu simptomai. Dažniausiai sergantys vidurių užkietėjimu pacientai skundžiasi kietomis išmatomis, pilvo pūtimu, skausmu. Lėtiniu vidurių užkietėjimu vadinama būklė, kai vidurių užkietėjimui būdingi simptomai vargina bent 3 mėnesius per pastaruosius 12 mėnesių.

Pirminis vidurių užkietėjimas

Pirminis (funkcinis) vidurių užkietėjimas skirstomas į 3 tipus:

  • vidurių užkietėjimas esant normaliam turinio slinkimui;
  • vidurių užkietėjimas dėl sulėtėjusio turinio slinkimo;
  • tuštinimosi sutrikimas.

Gana dažnai vidurių užkietėjimą gali nulemti daugiau nei vienas mechanizmas – toks pirminis vidurių užkietėjimas vadinamas mišriu (4). Dažniausiai ligonius vargina vidurių užkietėjimas esant normaliam turinio slinkimui. Tuomet pacientai skundžiasi kietomis išmatos, jiems sunku išsituštinti, tačiau tuštinimosi dažnis nepakinta (4). Vidurių užkietėjimas dėl sulėtėjusio turinio slinkimo pasireiškia sutrikus žarnų lygiųjų raumenų inervacijai arba sergant žarnų lygiuosius raumenis tiesiogiai pažeidžiančia liga. Šiuo atveju ligonius vargina pilvo pūtimas ir diskomfortas, retas tuštinimasis (5). Tuštinimosi sutrikimai vargina įvairaus amžiaus pacientus, tačiau dažniausiai jie diagnozuojami senyvo amžiaus pacientams (6). Šiam tipui priskiriamas tiesiosios žarnos lygiųjų raumenų ir tarpvietės raumenų tonuso pokyčių sukeltas vidurių užkietėjimas: tuštinimosi procese dalyvaujantys raumenys nesugeba susitraukti arba atsipalaiduoti. Senyvo amžiaus pacientams nustatomas tiesiosios žarnos receptorių sutrikimas – jie tinkamai nereaguoja į žarnos sienelės tempimą. Dėl to net ir pakankamai dideliam žarnų turinio kiekiui susikaupus tiesiojoje žarnoje nekyla noras tuštintis.

 Antrinis vidurių užkietėjimas

Antrinį vidurių užkietėjimą sukelia įvairūs medikamentai, lėtinės ligos ir psichosocialiniai veiksniai. Visuomet reikia įvertinti galimas antrinio vidurių užkietėjimo priežastis, nes pacientams pritaikomas savitas ištyrimo ir gydymo algoritmas.

 Gydymas

Gydymo tikslus svarbu aptarti su pacientu ir jį slaugančiais asmenimis. Pirminis gydymo tikslas – pacientą varginančių simptomų palengvinimas. Antrinis gydymo tikslas – tuštinimosi minkštomis ir suformuotomis išmatomis bent 3 kartus per savaitę užtikrinimas (4). Jei tiesiojoje žarnoje yra susiformavusių kietų išmatų darinių, juos pirmiausia reikėtų pašalinti pirštu arba klizma.

 Nemedikamentinis gydymas

Elgesio intervencijos

Viena svarbesnių elgesio intervencijų – skrandžio ir tiesiosios žarnos reflekso skatinimas. Pacientai mokomi tuštintis po kiekvieno valgio (4). Tuštinantis rekomenduojama pėdas pastatyti ne ant grindų, o ant paaukštinimo, pavyzdžiui, neaukštos kėdutės, taip ištiesinama anorektalinė jungtis, sudaromos palankesnės anatominės sąlygos tuštintis. Slaugos namų gyventojams turi būti sudaromos tinkamos sąlygos tuštintis – svarbu užtikrinti privatumą, tuštinimuisi skirti pakankamai laiko. Reikėtų vengti tuštinimosi į sauskelnes (7).

Senyviems pacientams ir slaugos namų gyventojams mankštos programos nepalengvina vidurių užkietėjimo simptomų (8–10). Vis dėlto vieno nedidelio klinikinio tyrimo rezultatai atskleidė, kad kartu taikant mankštos ir mitybos intervencijas (suvartoti daugiau skysčių bei maistinių skaidulų) galima palengvinti vidurių užkietėjimą (11).

Vien tik skysčių vartojimo įtaka vidurių užkietėjimui nebuvo tirta atsitiktinės imties, kontroliuojamaisiais tyrimais. Atlikus klinikinį tyrimą, kuriame dalyvavo nuo vidurių užkietėjimo kenčiantys vidutinio amžiaus suaugusieji, nustatyta, kad padidinus per dieną suvartojamo vandens kiekį iki 1,5–2 litrų ir maitinantis gausiu skaidulų maistu pavyksta palengvinti vidurių užkietėjimo simptomus (12).

Rekomenduojama per dieną suvartoti 20–35 g maistinių skaidulų. Maistinių skaidulų suvartojimas didinamas palaipsniui. Taip siekiama išvengti galimų nepageidaujamų reiškinių – pilvo pūtimo, spazmų, diskomforto.

 Grįžtamojo ryšio terapija

Grįžtamojo ryšio terapija gali pagerinti tuštinimosi procese dalyvaujančių raumenų funkciją. Toks gydymas gali efektyviai palengvinti vidurių užkietėjimo simptomus, kuriuos lemia dubens sutrikimai. Į tiesiąją žarną įstumiamas balionėlis, naudojami raumenų veiklos jutikliai. Pacientas stengiasi išsituštinti, jo pastangos matomos ekrane. Taip pacientui suteikiamas grįžtamasis ryšys. Ši gydymo metodika taikoma asmenims, kurių fizinė bei psichinė būklė leidžia dalyvauti užsiėmimuose (14, 15).

 Medikamentinis gydymas

Daugumai lėtiniu vidurių užkietėjimu sergančių senyvo amžiaus pacientų anksčiau ar vėliau tenka skirti vidurius laisvinančius vaistus. Šių medikamentų sisteminės apžvalgos rezultatai atskleidė, kad vidurius laisvinančių preparatų efektyvumas gydant senyvo amžiaus pacientus yra nevienodas, todėl gydymą reikia individualizuoti (16). 1 lentelėje pateikiamas vidurių užkietėjimui gydyti skirtų medikamentų sąrašas. Jei elgsenos korekcija ir vidurius laisvinantys preparatai neefektyvūs, atliekamas detalesnis specializuotas ištyrimas (turinio slinkimo žarnynu vertinimas, tiesiosios žarnos manometrija).

Senyvo amžiaus pacientų lėtinio vidurių užkietėjimo gydymo algoritmas pateikiamas 1 pav.

 Klizmos ir žvakutės

Klizmos ir žvakutės tinkamiausios netoleruojantiems geriamųjų medikamentų pacientams arba tuomet, kai tiesiojoje žarnoje susiformuoja labai kietos išmatos. Senyvo amžiaus pacientų nederėtų gydyti fosfatų turinčiomis klizmomis, nes toks gydymas gali sukelti net ir gyvybei grėsmingus elektrolitų balanso sutrikimus (25). Tinkamesnė alternatyva – mineralinių aliejų pagrindu pagamintos klizmos, kurioms būdingi lengvi nepageidaujami poveikiai, pavyzdžiui, vietinis tarpvietės sudirginimas. Reikėtų vengti muilo ir vandens mišinio pagrindu pagamintų klizmų, nes toks gydymas gali pažeisti žarnos gleivinę. Saugesnis pasirinkimas yra paprasčiausios vandens klizmos. Kita saugi gydymo alternatyva – glicerino pagrindu pagamintos žvakutės, kurios veiksmingai palengvina tuštinimąsi (26).

 Išmatų tūrį didinantys preparatai

Išmatų tūrį didinančios medžiagos gali būti tirpios (psyllium) arba netirpios (metilceliuliozė ir kt.). Šios priemonės sugeria didelį kiekį vandens, skatina vandens dalelių judėjimą į žarnos spindį. Taip efektyviai suminkštinamos išmatos, palengvinamas tuštinimasis. Šiais medikamentais gydomi pacientai tuštinasi dažniau (16–18). Išmatų tūrį didinantys preparatai gali sukelti pilvo pūtimą, dujų kaupimąsi žarnyne, tempimo pojūtis. Šių vaistų nederėtų skirti, jei tiesiojoje žarnoje yra susiformavusių kietų išmatų darinių.

 Osmosiniai vidurius laisvinantys vaistai

Osmosiniai vidurius laisvinantys vaistai į kraujotaką nepatenka. Veikdami žarnyno gleivinę, šie preparatai skatina vandens dalelių judėjimą į žarnos spindį. Osmosiniams preparatams priskiriami hiperosmosiniai cukraus alkoholiai, pavyzdžiui, laktuliozė ir sorbitolis. Šie vaistai padidina tuštinimosi dažnį ir mažina vidurių užkietėjimo sukeliamą tempimo pojūtį. Pavartojus sorbitolio ar laktuliozės, veikliosios medžiagos patenka į žarnyną, kur žarnyno mikroorganizmai jas skaido, susidarę aktyvūs junginiai veikia žarnyno gleivinę ir skatina vandens judėjimą į žarnos spindį. Šių medikamentų efektyvumas ir saugumas gydant senyvo amžiaus pacientus įrodytas atsitiktinės imties klinikiniais tyrimais (19, 28). Jei laktulioze gydomas asmuo netoleruoja veikliosios medžiagos, gali pasireikšti viduriavimas. Osmosiniams vidurius laisvinantiems vaistams priskiriamas ir polietileno glikolis (PEG). Metaanalizės, kurioje palygintas PEG ir laktuliozės efektyvumas ir saugumas, rezultatai atskleidė, kad vyresnių nei 75 metai pacientų grupėje PEG efektyviau gydo vidurių užkietėjimą, sukelia mažiau nepageidaujamų reiškinių nei laktuliozė (29). Remiantis nedidelės atsitiktinės imties, klinikinio tyrimo rezultatais, prieita prie išvados, kad PEG efektyviau nei tirpios medžiagos gydo vidurių užkietėjimą, o jo veikimo pradžia yra greitesnė (30).

Magnio hidroksido ir magnio citrato efektyvumas ir saugumas gydant senyvo amžiaus pacientų vidurių užkietėjimą nėra įrodytas atsitiktinės imties, kontroliuojamųjų klinikinių tyrimų rezultatais. Ilgą laiką vartojant magnio turinčių preparatų, gali pasireikšti pavojingi nepageidaujami reiškiniai, pavyzdžiui, žarnų nepraeinamumas. Šių medikamentų reikėtų vengti gydant inkstų funkcijos nepakankamumu sergančius pacientus. Kadangi magnio preparatų poveikis nėra gerai ištirtas, ilgalaikis gydymas jais nerekomenduojamas.

 Stimuliuojamuoju poveikiu pasižymintys preparatai

Šiai medikamentų grupei priskiriami senos turintys vaistai ir bisakodilis. Bisakodilio efektyvumas gydant lėtinį vidurių užkietėjimą įrodytas atlikus atsitiktinės imties, kontroliuojamąjį tyrimą. Vidutinis šio tyrimo dalyvių amžius buvo 55 metai (21). Kadangi stimuliuojamuoju poveikiu pasižyminčios medžiagos gali sukelti daug nepageidaujamų poveikių, senyvo amžiaus pacientams juos reikėtų pasirinkti tik tuomet, jei skaidulos ir osmosiniai vidurius laisvinantys vaistai yra neefektyvūs.

 Kiti preparatai

Ilgalaikiam lėtiniam suaugusiųjų viduriavimui gydyti galima rinktis lubiprostoną. Lubiprostonas – tai chloro kanalus aktyvinantis preparatas, kuris skatina vandens dalelių judėjimą į žarnos spindį (16). Šis medikamentas efektyviai gydo vidurių užkietėjimą, tačiau gana dažnai sukelia tam tikrus lengvus nepageidaujamus poveikius (16). Pastebėta, kad net 18 proc. lubiprostonu gydomų pacientų vargina pykinimas (22). Nustatyta, kad šio medikamento efektyvumas prilygsta senos preparatams (31). Platesnį vaisto panaudojimą riboja gana didelė kaina, todėl jį derėtų pasirinkti tuomet, kai kitos pakankamai saugios ir efektyvios, tačiau pigesnės gydymo alternatyvos nepadeda.

Linaklotidu galima gydyti lėtinį vidurių užkietėjimą. Pastebėta, kad gydant šiuo vaistu padažnėja tuštinimosi dažnis, sumažėja pilvo skausmas. Dažniausiai pasireiškiantis nepageidaujamas poveikis yra viduriavimas, kuris diagnozuojamas 4 proc. linaklotidu gydomų pacientų (24).

Sisteminė atsitiktinės imties kontroliuojamųjų klinikinių tyrimų analizė atskleidė, kad probiotikai nepagerina vidurių užkietėjimu sergančių pacientų būklės (32).

Periferijoje veikiantys opiatų receptorių miu antagonistai naudojami opiatų sukeltam vidurių užkietėjimui gydyti. Šiems preparatams priskiriamas metilnaltreksonas, alvimopanas ir naloksegolis veikia periferijoje, neslopina opiatų sukeliamo skausmą malšinančio poveikio. Naloksonas gali palengvinti vidurių užkietėjimo simptomus, tačiau jis slopina ir skausmą malšinantį opiatų poveikį. Iki 40 proc. opiatais gydomų pacientų vargina vidurių užkietėjimas, tačiau vidurius laisvinantys preparatais padeda tik 46 proc. atvejų (33). Metilnaltreksonas, alvimopanas ir naloksonas efektyviau nei placebas slopina opiatų sukelto vidurių užkietėjimo simptomus (23). Švirkščiamas po oda metilnaltreksonas efektyviai gydo opiatų sukeltą vidurių užkietėjimą net ir tuomet, kai gydant įprastais vidurius laisvinančiaisiais vaistais nepavyksta pasiekti gero gydomojo poveikio (34). Šio vaisto nederėtų vartoti, jei pacientui diagnozuota žarnų obstrukcija. Metilnaltreksonu atsargiai reikėtų gydyti onkologinėmis žarnyno ligomis sergančius pacientus. Alvimopanas padidina miokardo infarkto riziką, todėl JAV šio vaisto skyrimas ribojamas. Naloksegolis vartojamas per burną. Juo gydomi opiatų sukeltu vidurių užkietėjimu sergantys pacientai, kurie opiatus vartoja ne onkologiniam skausmui malšinti. Periferijoje veikiantys opiatų receptorių miu antagonistai yra brangūs. Jais gydyti reikėtų tik tuomet, kai kitos gydymo alternatyvos nėra efektyvios.
Daugiau skaitykite leidinyje „Internistas“ Nr.10, 2017 m.

Parengta pagal Mounsey A, Raleigh M, Wilson A. Management of Constipation in Older Adults. Am Fam Physician. 2015 Sep 15;92(6):500-4.

Gyd. Justas Simonavičius

Vilniaus universiteto ligoninės Santaros klinikos

 


386 mintys apie “Vyresnių pacientų vidurių užkietėjimo gydymo galimybių apžvalga

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