Syndrom dráždivého tračníku
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67
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Synonyma
- SDT
- Střevní neuróza
- Irritable bowel syndrom
- IBS
- Colon irritabile, irritable colon
- Spastický tračník
- Colon spasticum, spastic colon
- Mukózní kolitida
- Colitis mucosa, mucus colitis
- Funkční poruchy gastrointestinálního traktu
- Funkční dyspepsie dolního typu
Epidemiologie
- Zhruba pětina dnešní populace (15-20%)
- 14 % – 24 % žen
- 5 % – 19 % mužů [2]
- Příčinou až 40% všech vyšetření v gastroenterologických ordinacích [1]
- Nejčastěji mezi 20. a 50. rokem
- Ve věku vyšším se obvykle se jedná o jinou nemoc
- Výjimkou kdy pacient problémy dlouho přehlížel
- Dánsko nebo Nizozemí
- Pouze 7-9%
Klinický obraz
- Skupina chronických či rekurentních gastrointestinálních symptomů
- T.č. nelze obecně vysvětlit, resp. zjistit typické strukturální či biochemické změny
- Hlavní symptomy
- Bolesti v oblasti břicha
- Poruchy činnosti střeva (defekace) [1]
- Problémy s vyprazdňováním stolice
- Nucení na stolici (hlavně ráno)
- Průjmy a zácpy se mohou střídat
- Detailní popis obtíží
Kritéria pro Dg.
- Minim. 12 týdnů
- Během posledních 12 měsíců
- Alespoň 2 z 3 příznaků:
- 1) Po defekaci dochází k úlevě
- 2) Nástup onemocnění souvisel se změnami frekvence nucení na stolici
- 3) Nástup onemocnění souvisel se změnou struktury (vzhledu) stolice [1]
Podpůrné příznaky pro diagnózu:
- Abnormální frekvence stolice
- Méně než 3 stolice / týden
- Více než 3 stolice / den
- Abnormální forma stolice
- Tuhá hrudkovitá nebo řídká, kašovitá
- Abnormální průchod stolice konečníkem
- Nepřirozené napětí
- Nutkavý pocit
- Pocit že „nevyšlo vše“
- Pocit plného břicha
- Vyměšování hlenu
- nadýmání břicha nebo otékání
- Pocit abdominální distenze [1]
Další časté možné příznaky
- Fibromyalgie
- Migrenosní cephalea
- Dráždivý měchýř
- Dyspareunie
- Poruchy spánku
- Deprese
- Prostatitis syndromes and IBS are frequently associated in patients with PS- or IBS-related symptoms. These patients have an increased prevalence of chronic bacterial and non-inflammatory prostatitis. [8]
Alarmující příznaky
- Svědčí proti funkční etiologii obtíží
- U horní dyspepsie:
- Známky anemie nebo krvácení
- Dysfagie
- Perzistentní zvracení
- Hubnutí
- Palpační nález na břiše
- Lymfadenopatie
- Věk nad 45 let je nezávislým rizikovým faktorem pro nádorové onemocnění (karcinom žaludku)
- U syndromu dráždivého tračníku
- Nástup obtíží ve věku nad 50 let
- Jejich setrvalá progrese
- Teplota
- Váhový úbytek
- Příměs krve či hnisu na stolici
- Steatorea
- dehydratace
- Buzení obtížemi ze spánku
Klasifikace - Subtypy dráždivého tračníku
Dráždivý tračník se zácpou (constipation) (IBS-C)
- Tvrdá nebo kouskovitá (bobkovitá) stolice > 25 %
- řídká (kašovitá) nebo vodnatá stolice < 25 %
Dráždivý tračník s průjmem (diarrhea) (IBS-D)
- řídká (kašovitá) nebo vodnatá stolice > 25 %
- Tvrdá nebo kouskovitá (bobkovitá) stolice < 25 %
Smíšený (mixed) dráždivý tračník (IBS-M)
- Tvrdá nebo bobkovitá stolice ve > 25 %
- řídká (kašovitá) nebo vodnatá stolice ve > 25 %
Nezařaditelný dráždivý tračník
- Nedostatečné abnormality v konzistenci stolice
- Nejsou klasifkovatelné jako typ IBS-C, -D, -M
Etiologie
- Odedávna považován za psychosomatické onemocnění s heterogenními projevy
- Dosud nejasná
- Multifaktoriální onemocnění
- Zánětlivé
- Genetické
- Alergické
- Dietetické
- Psychologické faktory
Neprokázané teorie
- Abnormální motilita střeva
- Nejsou příčinou, ale už následkem onemocnění
Zvažované teorie
1) Pociťují bolest během průchodu potravy střevem. Hladká svalovina střev má u pacientů tendenci reagovat přemrštěně na nejrůznější stimuly
- Zvýšená senzitivita receptorů ve střevě
- Poruchy v přenosu na nervových drahách
- Změny ve zpracování podnětů ze střeva v CNS
- Porucha imunitního systému
- Receptory ve střevech vyhodnocují prakticky veškerou potravu jako alergeny [4]
- Já bych předpokládala mírně narušenou funkci sliznice s poruchou trávení / resorpce / vylučováním trávicích enzymů ev. zvýšený prosak sliznice a alergické reakce na kde co. Ale co myslí autor výrazem "receptory ve střevech" ???
Obdobně jako jsou poruchy erektilní dysfunkce ?
Je nějaká práce, která by se tím zabývala ?
Nahrával by tomu
Věk výskytu prvních obtíží
Porucha resorpce plynů a bolestivé rozpínání střeva a bolestivé pohyby
Vyšší propustnost střevní sliznice jako ev. důsledek
- Recently, our group detected chlamydial antigens in enteroendocrine cells (EEC) of jejunum biopsies from patients with IBS [7]
- Endogenous or deriving from commensal bacteria may play an important role [10]
- Barrier dysfunction and in the generation of IBS symptoms [10]
- Activation of PAR1 and 2 on enteric neurons provokes the release of neuropeptides which in turn activate their receptors present on endothelium and mast cells. Such PAR-induced micro-infammation might participate in the generation of IBS symptoms
- PAR2-induced permeability and rectal hypersensitivity could be inhibited by a tight junction blocker. [10]
Vyvolávající faktory
- Genetické faktory
- TLR9, a gene responsible for bacterial recognition
- IL6, involved in infammatory response
- Cadherin-1 (CDH1), involved in epithelial integrity [10]
- COMT
- Nevhodná dieta
- Infekce GIT - častý spouštěč
- Campylobacter
- Shigella
- Salmonella
- Escherichia coli
- Narušená motilita střeva
- Psychické poruchy [1]
- Stresu
- V mládí drogy
- Deprese
- kouření
- ženské pohlaví
- úzkostlivost
Vyšetření
Kolonoskopie
- Vyloučení jiné příčiny
Objektivní somatické nálezy
- Bolestivé kontrakce střeva
- Sdruženy s vysokou tlakovou amplitudou
- Procházejí ileocekální oblastí
- Motilita může být u pacientů s IBS také zpomalena (hypokineze)
- Zvýšený počet žírných buněk ve střevní sliznici
- Mohou uvolňovat prozánětlivé mediátory, které působí na neurotransmitery ve střevě
- Znovuvyvolávají symptomy asociované s původní infekcí
- Zvýšený transit time ve vzestupném a příčném tračníku
- Zvyšuje břišní bolest
- Hladina leptinu
- Výrazně nižší ve skupině účastníku s IBS, než v kontrolní skupině
- Serotoninové transportéry pro zpětné vychytávání
- Serotonin binds to 5-HT4 and 5-HT3 receptors
- Its signaling activity is terminated by binding to the specifc serotonin reuptake transporter
- Activity of this transporter is reduced in several GI disorders (including IBS)
- Dysregulated intestinal motility caused by persistent serotonin release at its respective receptors. [8]
- Biopsy studies revealed persistent low-grade inflammation and altered immunological function
- Which may lead to abnormal pain perception and motor activity within the gastrointestinal tract. [9]
- The mediators released by mast cells increase intestinal permeability, facilitating translocation of intraluminal bacteria and bacterial products [9]
- Once the beads enter the intestinal wall, they were transported to the lymph nodes via the lymphatic system or phagocytosed by the resident macrophages. [9]
- Stimulated macrophages secrete proinfammatory cytokines and chemokines leading to the upregulation of adhesion molecules (ICAM1) in the endothelium and the progressive infux of leucocytes.
- Leucocytes and activated resident macrophages will synthesise enzymes such as iNOS and COX-2 which contribute to the impaired gastrointestinal motility, the main characteristic of POI (post-operative illeus).
- Increase in mast cell numbers in close proximity of nerve fbres in intestinal biopsies of IBS patients demonstrating interactions between mast cells and nerves may be relevant for symptom generation [10]
- Mast cells release neurally active mediators (histamine, proteases, prostaglandins) which sensitise afferent neurons inducing increased visceral pain perception [10]
- Antibodies against nonspecifc bacterial products, fagellin, are increased in IBS patients together with the increase in IgG+ B cells in PI-IBS patients [10]
- Infammation in PI-IBS involves chronic loss of epithelial barrier integrity
- Followed by mast cell activation
- Chronic low-grade infammation
- Release of proinfammatory mast cell mediators sensitise nociceptive neurons
- Resulting in increased visceral pain sensitivity.[10]
Diferenciální diagnóza chronických průjmů
(chronické průjmy = recidivující průjmy nad 3 týdny)- Crohnova choroba
- Tumory
- X funkce žlučníku
- Gynekologické obtíže u žen
- Celiakie
- Protktokolitis
- X pankreas
- Hepatobiliární příčiny
- Stavy po operacích
- Urémie
- Diabetes
- Zollinger-Ehlersův syndrom
- Vipom
- Karcinoid
- Sklerodermie
- Amyloidóza
- Inkontinence stolice
- St. p. vagotomii, gastrektomii, resekci pankreatu, cholecystektomii, resekci střev
- Syndrom slepé kličky
- Rozčilení, nervozita
- Hypertyreóza
- Enteropatie
- Otravy
- Hypokortikalismus
- Intolerance potravin
- Giardia lamblia
- Entamoeba histolytica
- Clostridium difficile
- Campylobacter
- Yersinia
- HIV
- Ulcerózní kolitda
- kolagenní kolitida
- Whippleova choroba
- divertikulitida
- Lymfocytární kolitida
- Vnitřní píštěle
- Antibiotika
- Cytostatika
- Některí antihypertenziva vč. diuretik
- Antiarytmika
- Antacida s Mg solemi
- Kyseliny dihydroxyžlučové
- Kolchicin
- Glykosidy
- Sorbit
- Fruktóza
- Alkohol
- Káva
- Kolorektální karcinom
- Lymfom
- X disacharidáz
- Pšeničný škrob
- vláknina
- Solární syndrom
- Neuropatické visceralgie
- Karcinofobie
- Hypochondrie
- Bludy, fobie, obsese
- Mentální anorexie, bulimie
- Neurodigestivní astenie
- Dráždivý konečník
Terapie
Psychoterapie
- Zmírní psychický stres
- Zlepší odolnost pacienta vůči němu
- Odpověď na terapii placebem dosahuje až 80%
- Kvalitní, empatický vztah lékaře a pacienta
- Důsledně vedený edukační pohovor
- Ujištění, že onemocnění je ve své podstatě benigní
- "jsem ve stresu = mám průjem"
- Za nemocí stojí např.
- Podvědomý pocit vlastní nedokonalosti
- Traumatické následky ponižování v dětství
- Brain can downregulate this infammatory response through a parasympathetic anti-infammatory pathway (Tracey et al)
- Activation of afferent vagus nerve fbres by infammatory endotoxins or cytokines stimulated a parasympathetic anti-infammatory pathway.
- Acetylcholine, the principle vagal neurotransmitter, signifcantly attenuated the release of proinfammatory cytokines
- Direct electrical stimulation of the peripheral vagus nerve during lethal endotoxaemia prevented the development of shock.
- Anti-infammatory effect of vagal nerve stimulation has been demonstrated in models of pancreatitis, ischaemia, colitis [9]
- Vagus nerve exerts an anti-infammatory action via activation of the alpha 7 subunit of the nicotinic receptor [9]
Úprava diety
- Omezení alkoholu
- Omezení kávy
- Někteří lidé jsou citliví na lepek, i když nemají přímo celiakii
- Jiným vadí mléko a mléčné výrobky
- Jiným někdy vadí cukr
- Dietary fat induces the release of cholecystokinin
- Activates the vagal nerve - an anti-infammatory effect in animal models of sepsis [9]
Přestat kouřit
Medikace
Při úzkosti
- Antidepresiva
- SSRI
- Fluoxetin - při zácpě
- TCA - cca 1/3 dávek z psychiatrické indikace
- U průjmů
- U horního dyspeptického funkčního syndromu
- Neuroleptika / antiepileptika
- Při průjmech
- Při úzkostech
- Rifaximin
- Pregabalin
- Gabapentin
- Clonidine
Při bolestech v břiše (a průjmech)
- Spasmolytika - na křeče v břiše
- Pinaverin
- Mebeverin
- Drotaverin
- Trimebutin
- Alverin
Při průjmech
- K zástavě motility - při průjmech
- Loperamid
- Lubiprostone
- Magistraliter směsi s kalciem
- Solubilní vláknina i u průjmové symptomatologie
5-hydroxytryptamine-3 antagonist
- Alosetrone
- Ondansetrone
Stabilizace žírných buněk
- Ketotifen
- On postoperative ileus in patients undergoing major abdominal surgery for gynaecological malignancy [9]
- Efekt i u dráždivého tračníku
- Mesalazine
- Anti-infammatory drug
- Reduction in mast cell numbers and mediators [10]
Při zácpách
- Projímadla
- Prokinetika - při nedokonalém vyprázdnění
- Metoclopramid
- Domperidon
- Cisaprid
- Itoprid
- Lubiprostone
- C-2 chloride channel activator
- More effective than placebo at relieving global IBS symptoms in patients with constipation-predominant IBS [11]
Zhojení prosakující bariéry střeva
- Glutamine supplementation
- Teraphy of a disruption of intestinal barrier integrity
- Important role in PI-IBS and improving its function
- A new therapeutic approach
- Výživa pro kolonocyty
- Fosfolipidy
- Snížení prosaku GIT
- Essenciale Forte aj.
- Jedno z nejaktuálnějších doporučeních
Antibiotika
- Nonabsorbable antibiotics
- A short term course of may improve global IBS symptoms
- Particularly in patients with diarrhea- predominant IBS [11]
Eradikační terapie H. pylori
- Součástí většiny západních doporučení
Potravinové doplňky / bylinky
- Psyllium
- Probiotika
- Ibišek - proskurník - Althea officinalis
- řepík lékařský
- Adstringentní prostředek
- Povzbuzuje žaludeční sekreci
- Enterální tobolky s olejem z máty peprné [3] - Enteric-coated Peppermint
- Steam distillation oil extracts from the peppermint plant (Mentha piperita, Lamiaceae)
- Oldest remedies for treatment of GI problems.
- Extracts are believed to improve IBS symptoms by exerting a spasmolytic efect on the smooth muscles in the digestive tract. [8]
- Turmeric (Curcuma longa, Zingiberaceae)
Cvičení
- Pranayama yoga
- Exercise regimen that increases sympathetic tone, which is decreased in IBS-D patients. [8]
- In a two-month study, a yoga intervention group practiced twice daily, while the conventional treatment group received 2-6 mg loperamide daily. Results indicated that yoga demonstrated improvement of IBS symptoms equivalent to conventional treatment. [8]
- Jízda na kole
Terapie, která neměla efekt
Kortikoidy
- In mice, early corticosteroid therapy has been shown to attenuate postinfectious neuromuscular dysfunction. [10]
- Small randomised controlled trial with 29 PI-IBS patients given 30 mg prednisolone/day for three weeks was negative. [10]
Literatura:
[1] Syndrom dráždivého tračníku: australský pohled. URL < www.zdrava-rodina.cz/med/med0901/med0932.html >.
[2] Syndrom dráždivého střeva. URL < www.celostnimedicina.cz/syndrom-drazdiveho-streva.htm >.
[3] Dráždivý tračník | Abeceda Zdraví .cz. URL
[4] Syndrom dráždivého střeva. URL < www.celostnimedicina.cz/syndrom-drazdiveho-streva.htm >.
[5] Syndrom dráždivého tračníku | Doktorka.cz. URL
[6] Podrobný popis
[7] Infection of human enteroendocrine ... [Neurogastroenterol Motil. 2011] - PubMed - NCBI. URL < www.ncbi.nlm.nih.gov/pubmed/21883697 >.
[8] High frequency of chronic bacterial and non-inflamm... [PLoS One. 2011] - PubMed - NCBI. URL < www.ncbi.nlm.nih.gov/pubmed/21494624 >.
[9] Neuroimmune mechanisms in functional bowel disord... [Neth J Med. 2011] - PubMed - NCBI. URL
[10] getpdf.php (application/pdf objekt). URL < www.njmonline.nl/getpdf.php?id=10000680 >.
[11] [Guidelines for the treatment of irri... [Korean J Gastroenterol. 2011] - PubMed - NCBI. URL < www.ncbi.nlm.nih.gov/pubmed/21350320 >.
