Abdominal pain, evaluation of pain characteristics in the differential diagnostic of abdominal diseases
Abdominal pain (or stomach ache) is a common symptom associated with transient disorders or serious disease. Diagnosing the cause of abdominal pain can be difficult, because many diseases can cause this symptom. Most frequently the cause is benign and/or self-limiting, but more serious causes may require urgent intervention.
DIFFERENTIAL DIAGNOSIS
· Gastrointestinal
· GI tract
· Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis,Crohn’s disease, ulcerative colitis, microscopic colitis
· Obstruction: hernia, intussusception, volvulus, post-surgical adhesions,tumours, superior mesenteric artery syndrome, severe constipation,hemorrhoids
· Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), Postural orthostatic tachycardia syndrome
· digestive: peptic ulcer, lactose intolerance, coeliac disease, food allergies
· Glands
· Bile system
· Inflammatory: cholecystitis, cholangitis
· Obstruction: cholelithiasis, tumours
· Liver
· Inflammatory: hepatitis, liver abscess
· Pancreatic
· Inflammatory: pancreatitis
· Renal and urological
· Inflammation: pyelonephritis, bladder infection
· Obstruction: kidney stones, urolithiasis, Urinary retention, tumours
· Vascular: left renal vein entrapment
· Gynaecological or obstetric
· Inflammatory: pelvic inflammatory disease
· Mechanical: ovarian torsion
· Endocrinological: menstruation, Mittelschmerz
· Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer
· Pregnancy: ruptured ectopic pregnancy, threatened abortion
· Abdominal wall
· muscle strain or trauma
· muscular infection
· neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis
· Referred pain
· from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
· from the spine: radiculitis
· from the genitals: testicular torsion
· Metabolic disturbance
· uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal
· Blood vessels
· aortic dissection, abdominal aortic aneurysm
· Immune system
· sarcoidosis
· vasculitis
· familial Mediterranean fever
· Idiopathic
· irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)
Acute abdominal pain
Acute abdomen can be defined as severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock. One of the most common conditions associated with acute abdominal pain is acute appendicitis.
Selected causes of acute abdomen
· Traumatic : blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney
· Inflammatory :
· Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess
· Perforation of a peptic ulcer, a diverticulum, or the caecum
· Complications of inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
· Mechanical :
· Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignantneoplasms
· Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia
· Vascular : occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery
By location
Location
· Upper middle abdominal pain
· Stomach (gastritis, stomach ulcer, stomach cancer)
· Pancreas pain (pancreatitis or pancreatic cancer, can radiate to the left side of the waist, back, and even shoulder)
· Duodenal ulcer, diverticulitis
· Appendicitis (starts here, after several times moves to lower right abdomen)
· Upper right abdominal pain
· Liver (caused by hepatomegaly due to fatty liver, hepatitis, or caused by liver cancer, abscess)
· Gallbladder and biliary tract (gallstones, inflammation, roundworms)
· Colon pain (below the area of liver – bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer)
· Upper left abdominal pain
· Spleen pain (splenomegaly)
· Pancreas
· Colon pain (below the area of spleen – bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer)
· Middle abdominal pain (pain in the area around belly button)
· Appendicitis (starts here)
· Small intestine pain (inflammation, intestinal spasm, functional disorders)
· Lower abdominal pain
· Lower right abdominal pain
Cecum (intussusception, bowel obstruction)
· Appendix point (Appendicitis location)
· Lower left abdominal pain
· Sigmoid colon (polyp), sigmoid volvulus, obstruction or gas accumulation)
· Pelvic pain
· bladder (cystitis, may secondary to diverticulum and bladder stone, bladder cancer)
· pain in women (uterus, ovaries, fallopian tubes)
· Right lumbago and back pain
· liver pain (hepatomegaly)
· right kidney pain (its location below the area of liver pain)
· Left lumbago and back pain
· less in spleen pain
· left kidney pain
· Low back pain
· kidney pain (kidney stone, kidney cancer, hydronephrosis)
· Ureteral stone pain
Diagnostic approach
When a physician assesses a patient to determine the etiology and subsequent treatment for abdominal pain the patient’s history of the presenting complaint and physical examination should derive a diagnosis in over 90% of cases.
It is important also for a physician to remember that abdominal pain can be caused by problems outside the abdomen, especially heart attacks and pneumonias which can occasionally present as abdominal pain.
Investigations that would aid diagnosis include
· Blood tests including full blood count, electrolytes, urea, creatinine, liver function tests, pregnancy test, amylase and lipase.
· Urinalysis
· Imaging including erect chest X-ray and plain films of the abdomen
· An electrocardiograph to rule out a heart attack which can occasionally present as abdominal pain
If diagnosis remains unclear after history, examination and basic investigations as above then more advanced investigations may reveal a diagnosis. These as such would include
· Computed Tomography of the abdomen/pelvis
· Abdominal or pelvic ultrasound
· Endoscopy and colonoscopy (not used for diagnosing acute pain)
Acute appendicitis
Acute appendicitis is an inflammation of vermiform appendix caused by festering microflora.
Etiology and pathogenesis
Most frequent causes of acute appendicitis are festering microbes: intestinal stick, streptococcus, staphylococcus. Moreover, microflora can be in cavity of appendix or get there by hematogenic way, and for women – by lymphogenic one.
Factors which promote the origin of appendicitis, are the following: a) change of reactivity of organism; b) constipation and atony of intestine; c) twisting or bends of appendix; d) excrement stone in its cavity; e) thrombosis of vessels of appendix and gangrene of wall as a substance of inflammatory process (special cases).
Pathomorphology
Simple (superficial) and destructive (phlegmonous, gangrenous primary and gangrenous secondary) appendicitises which are morphological expressions of phases of acute inflammation that is completed by necrosis can be distinguished.
In simple appendicitis the changes are observed, mainly, in the distant part of appendix. There are stasis in capillaries and venule, edema and hemorrhages. Focus of festering inflammation of mucus membrane with the defect of the epithelium covering is formed in 1–2 hours (primary affect of Ashoff). This characterizes acute superficial appendicitis. The phlegmon of appendix develops to the end of the day. The organ increases, it serous tunic becomes dimmed, sanguineous, stratifications of fibrin appear on its surface, and there is pus in cavity.
In gangrenous appendicitis the appendix is thickened, the its serous tunic is covered by dimmed fibrinogenous tape, differentiating of the layer structure through destruction is not succeeded.
Classification
(by V.I. Kolesnikov)
1. Appendiceal colic.
2. Simple superficial appendicitis.
3. Destructive appendicitis:
а) phlegmonous;
б) gangrenous;
в) perforated.
4. Complicated appendicitis:
а) appendicular infiltrate;
б) appendicular abscess;
в) diffuse purulent peritonitis.
5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).
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Symptoms and clinical course
Four phases are distinguished in clinical course of acute appendicitis: 1) epigastric; 2) local symptoms; 3) calming down; 4) complications.
The disease begins with a sudden pain in the abdomen. It is localized in a right iliac area, has moderate intensity, permanent character and not irradiate. With 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute appendicitis. In 2–4 hours it moves to the place of appendix existance (the Kocher’s symptom). At coughing patients mark strengthening of pain in a right iliac area – it is a positive cough symptom.
Together with it, nausea and vomiting that have reflex character can disturb a patient. Often there is a delay of gases. The temperature of body of most patients rises, but high temperature can occur rarely and, mainly, it is a low grade fever. The general condition of patients gets worse only in case of growth of destructive changes in appendix.
During the examinationIt is possible to mark, that the right half of stomach falls behind in the act of breathing, and a patient wants to lie down on a right side with bound leg.
Painfulness is the basic and decisive signs of acute appendicitis during the examination by palpation in a right iliac area, tension of muscle of abdominal wall, positive symptoms of peritoneum irritation. About 100 pain symptoms characteristic of acute appendicitis are known, however only some of them have the real practical value.
The Blumberg’s symptom. After gradual pressing by fingers on a front abdominal wall from the place of pain quickly, but not acutely, the hand is taken away. Strengthening of pain is considered as a positive symptom in that place. Obligatory here is tension of muscles of front abdominal wall. Slide.
The Voskresensky’s symptom. By a left hand the shirt of patient is drawn downward and fixed on pubis. By the taps of 2-4 fingers of right hand epigastric area is pressed and during exhalation of patient quickly and evenly the ha nd slides in the direction of right iliac area, without taking the hand away. Thus there is an acute strengthening of pain.
The Bartomier’s symptom is the increase of pain intensity during the palpation in right iliac area of patient in position on the left side. At such pose an omentum and loops of thin intestine is displaced to the left, and an appendix becomes accessible for palpation.
The Sitkovsky’s symptom. A patient, that lies on left, feels the pain which arises or increases in a right iliac area. The mechanism of intensification of pain is explained by displacement of blind gut to the left, by drawing of mesentery of the inflamed appendix.
The Rovsing’s symptom. By a left hand a sigmoid bowel is pressed to the back wall of stomach. By a right hand by ballotting palpation a descending bowel is pressed. Appearance of pain in a right iliac area is considered as a sign characteristic of appendicitis.
The Obrazcov’s symptom. With the position of patient on the back by index and middle fingers the right iliac area of most painful place is pressed and the patient is asked to heave up the straightened right leg. At appendicitis pain increases acutely.
The Rozdolskyy’s symptom. At percussion there is painfulness in a right iliac area.
The general analysis of blood does not carry specific information, which would specify the presence of acute appendicitis. However, much leukocytosis and change of formula to the left in most cases can point to the present inflammatory process.
Variants of clinical course and complication
Acute appendicitis in children. With children of infancy acute appendicitis can be seen infrequently, but, quite often carries atipical character. All this is conditioned, mainly, by the features of anatomy of appendix, insufficient of plastic properties of the peritoneum, short omentum and high reactivity of child’s organism. The inflammatory process in the appendix of children quickly makes progress and during the first half of days from the beginning of disease there can appear its destruction, even perforation. The child, more frequent than an adult, suffers vomiting. Its general condition gets worse quickly, and already the positive symptoms of irritation of peritoneum can show up during the first hours of a disease. The temperature reaction is also expressed considerably acuter. In the blood test there is high leukocytosis. It is necessary to remember, that during the examination of calmless children it is expedient to use a chloral hydrate enema.
Acute appendicitis of the people of declining and old ages can be met not so often, as of the persons of middle ages and youth. This contingent of patients is hospitalized to hospital rather late: in 2–3 days from the beginning of a disease. Because of the promoted threshold of pain sensitiveness, the intensity of pain in such patients is small, therefore they almost do not fix attention on the epigastric phase of appendicitis. More frequent are nausea and vomiting, and the temperature reaction is expressed poorly. Tension of muscles of abdominal wall is absent or insignificant through old-age relaxation of muscles. But the symptoms of irritation of peritoneum keep the diagnostic value with this group of patients. Thus, the sclerosis of vessels of appendix results in its rapid numbness, initially-gangrenous appendicitis develops. Because of such reasons the destructive forms of appendicitis prevail, often there is appendiceal infiltrate.
With pregnant women both the bend of appendix and violation of its blood flow are causes of the origin of appendicitis. Increased in sizes uterus causes such changes. It, especially in the second half of pregnancy, displaces a blind gut together with an appendix upwards, and an overdistension abdominal wall does not create adequate tension. It is needed also to remember, that pregnant women periodically can have a moderate pain in the abdomen and changes in the blood test. Together with that, psoas-symptom and the Bartomier’s symptom have a diagnostic value at pregnant women.
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Clinical course of acute appendicitis at the atipical location (not in a right iliac area) will differ from a classic vermiform appendix .
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Appendicitis at retrocecal and retroperitoneal location of appendiceal appendix can be with 8–20 % patients. Thus an appendix can be placed both in a free abdominal cavity and retroperitoneal. An atypical clinic arises, as a rule, at the retroperitoneal location. The patients complain at pain in lumbus or above the wing of right ileum. There they mark painfulness during palpation. Sometimes the pain irradiates to the pelvis and in the right thigh. The positive symptom of Rozanov — painfulness during palpation in the right Pti triangle is characteristic. In transition of inflammatory process on an ureter and kidney in the urines analysis red corpuscles can be found.
Appendicitis at the pelvic location of appendix can be met in 11–30 % cases. In such patients the pain is localized above the right Poupart’s ligament and above pubis. At the very low placing of appendix at the beginning of disease the reaction of muscles of front abdominal wall on an inflammatory process can be absent. With transition of inflammation on an urinary bladder or rectum either the dysuric signs or diarrhea developes, mucus appears in an excrement. Distribution of process on internal genital organs provokes signs characteristic of their inflammation.
Appendicitis at the medial placing of appendix. The appendix in patients with such pathology is located between the loops of intestine, that is the large field of suction and irritation of peritoneum. At these anatomic features mesentery is pulled in the inflammatory process, acute dynamic of the intestinal obstruction develops in such patients. The pain in the abdomen is intensive, widespread, the expressed tension of muscles of abdominal wall develops, that together with symptoms of the irritation of peritoneum specify the substantial threat of peritonitis development.
For the subhepatic location of appendix the pain is characteristic in right hypochondrium. During palpation painfulness and tension of musclescan be marked.
Left-side appendicitis appears infrequently and, as a rule, in case of the reverse placing of all organs, however it can occur at a mobile blind gut. In this situation all signs which characterize acute appendicitis will be exposed not on the right, as usually, but on the left.
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Among complications of acute appendicitis most value have appendiceal infiltrates and abscesses.
Appendiceal infiltrate is the conglomerate of organs and tissue not densely accrete round the inflamed vermiform appendix. It develops, certainly, on 3–5th day from the beginning of disease. Acute pain in the stomach calms down thus, the general condition of a patient gets better. Dense, not mobile, painful, with unclear contours, formation is palpated in the right iliac area. There are different sizes of infiltrate, sometimes it occupies all right iliac area. The stomach round infiltrate during palpation is soft and unpainful.
At reverse development of infiltrate (when resorption comes) the general condition of a patient gets better, sleep and appetite recommence, activity grows, the temperature of body and indexes of blood is normalized. Pain in the right iliac area calms down, infiltrate diminishes in size. In this phase of infiltrate physiotherapeutic procedure is appointed, warmth on the iliac area.
In two months after resorption of infiltrate appendectomy is conducted.
At abscessing of infiltrate the condition of a patient gets worse, the symptoms of acute appendicitis become more expressed, the temperature of body, which in most cases gains hectic character, rises, the fever appears. Next to that, pain in the right iliac area increases. Painful formation is felt there. In the blood test high leukocytosis is present with the acutely expressed change of leukocyte formula to the left.
Local abscesses of abdominal cavity, mainly, develops as a result of the atypical placing of appendix or suppuration. More frequent from other there are pelvic abscesses. Thus a patient is disturbed by pain beneath the abcupula, there are dysuric disorders, diarrhea and tenesmus. The temperature of body rises to 38,0–39,0oС, and rectal — to considerably higher numbers. In the blood test leukocytosis, change of formula of blood is fixed to the left.
During the rectal examination the weakened sphincter of anus is found. The front wall of rectum at first is only painful, and then its overhanging is observed as dense painful infiltrate. Slide.
A subdiaphragmatic abscess develops at the high placing of appendix. The pain in the lower parts of thorax and in a upper quarter of abcupula ofn to the right, that increases at deep inhalationis except for the signs of intoxication, is characteristic of it. A patient, generally, occupies semisitting position. Swelling in an epigastric area is observed in heavy cases, smoothing and painful intercostal intervals. The abcupula ofn during palpation is soft, although tension in the area of right hypochondrium is possible. Painfulness at pressure on bottom (9–11) ribs is the early and permanent symptom of subdiaphragmatic abscess (the Krukov’s symptom).
Roentgenologically the right half of diaphragm can fall behind from left one while breathing, and there is a present reactive exudate in the right pleura cavity. A gas bubble is considered the roentgenologic sign of subdiaphragmatic abscess with the horizontal level of liquid, which is placed under the diaphragm.
Interloop abscesses are not frequent complications of acute appendicitis. As well as all abscesses of abdominal cavity, they pass the period of infiltrate and abscess formation with the recreation of the proper clinic.
The poured festering peritonitis develops as a result of the timely unoperated appendicitis. Diagnostics of this pathology does not cause difficulties.
Pylephlebitis is a complication of both appendicitis and after-operative period of appendectomy.
The reason of this pathology is acute retrocecal appendicitis. At it development the thrombophlebitis process from the veins of appendix, passes to the veins of bowels mesentery, and then on to the portal vein. Patients complain at the expressed general weakness, pain in right hypochondrium, high hectic temperature of body, fever and strong sweating. Patients are adynamic, with expressed subicteritiousness of the scleras. During palpation painfulness is observed in the right half of abcupula ofn and the symptoms of irritation of peritoneum are not acutely expressed.
In case with rapid passing of disease the icterus appears, the liver is increased, kidney-hepatic insufficiency makes progress, and patients die in 7-10 days from the beginning of disease. At gradual subacute development of pathology the liver and spleen is increased in size, and after the septic state of organism ascites arises.
Diagnostic program
1. Anamnesis information.
2. Information of objective examination.
3. General analysis of blood and urine.
4. Vaginal examination for women.
5. Rectal examination for men.
Differential diagnostics
Acute appendicitis is differentiated with the diseases which are accompanied by pain in the abcupula ofn.
Food toxicoinfection. Complaints for pain in the epigastric area of the intermittent character, nausea, vomiting and liquid emptying are the first signs of disease. The state of patients progressively gets worse from the beginning. Next to that, it is succeeded to expose that a patient used meal of poor quality. However, here patients do not have phase passing, which is characteristic of acute appendicitis, and clear localization of pain. Defining the symptoms of irritation of peritoneum is not succeeded, the peristalsis of intestine is, as a rule, increased.
Acute pancreatitis. In anamnesis in patients with this pathology there is a gallstone disease, violation of diet and use of alcohol. Their condition from the beginning of a disease is heavy. Pain is considerably more intensive, than during appendicitis, and is concentrated in the upper half of abcupula ofn. Vomiting is frequent and does not bring to the recovery of patients.
Perforative peptic and duodenum ulcer. Diagnostic difficulties during this pathology arise up only on occasion. They can be in patients with the covered perforation, when portion of gastric juice flows out in an abdominal cavity and stays too long in the right iliac area, or in case of atypical perforations. Taking it into account, it is needed to remember, that the pain in the perforative ulcer is considerably more intensive in epigastric, instead of in the right iliac area. On the survey roentgenogram of organs of abdominal cavity under the right cupula of diaphragms free gases can be found.
The apoplexy of ovaryа more frequent is with young women and, as a rule, on 10-14 day after menstruation. Pain appears suddenly and irradiate in the thigh and perineum. At the beginning of disease there can be a collapse. However, the general condition of patients suffers insignificantly. Wheot enough blood was passed in the abdominal cavity, all signs of pathology of abdominal cavity organs calm down after some time. Signs, which are characteristic of acute anemia, appear at considerable hemorrhage. Abdomen more frequent is soft and painful down, (positive Kulenkampff’s symptom: acute pain during palpation of stomach and absent tension of muscles of the front abdominal wall).
During paracentesis of back fornix the blood which does not convolve is got.
Extra-uterine pregnancy. A necessity to differentiate acute appendicitis with the interrupted extra-uterine pregnancy arises, when during the examination the patient complains at the pain only down in the stomack, more to the right. Taking it into account, it is needed to remember, that at extra-uterine pregnancy a few days before there can be intermittent pain in the lower part of the abdomen, sometimes excretions of “coffee” colour appear from vagina. In anamnesis often there are the present gynaecological diseases, abortions and pathological passing of pregnancy. For the clinical picture of such patient inherent sudden appearance of intensive pain in lower part of the abdomen. Often there is a brief loss of consciousness. During palpation considerable painfulness is localized lower, than at appendicitis, the abdomen is soft, the positive Kulenkampff’s symptom is determined. Violations of menstrual cycle testify for pregnancy, characteristic changes are in milk glands, vagina and uterus. During the vaginal examination it is sometimes possible to palpate increased tube of uterus. The temperature of body more frequently is normal. If hemorrhage is small, the changes in the blood test are not present. The convincing proof of the broken extra-uterine pregnancy is the dark colour of blood, taken at punction of back fornix of vagina.
Acute cholecystitis. The high placing of vermiform appendix in the right half of abdomen during its inflammation can cause the clinic somewhat similar to acute cholecystitis. But unlike appendicitis, in patients with cholecystitis the pain is more intensive, has cramp-like character, is localized in right hypochondrium and irradiate in the right shoulder and shoulder-blade. Also the epigastric phase is absent. The attack of pain can arise after the reception of spicy food and, is accompanied by nausea and frequent vomiting by bile. In anamnesis patients often have information about a gallstone disease. During examination intensive painfulness is observed in right hypochondrium, increased gall-bladder and positive symptoms Murphy’s and Ortner’s.
Right-side kidney colic. For this disease tormina at the level of kidney and in lumbus is inherent, hematuria and dysuric signs which can take place at the irritation of ureter by the inflamed appendix. Intensity of pain in kidney colic is one of the basic differences from acute appendicitis. Pain at first appears in lumbus and irradiate downward after passing of ureter in genital organs and front surface of the thigh. In diagnostics urogram survey is important, and if necessary — chromocystoscopy. Absence of function of right kidney to some extent allows to eliminate the diagnosis of acute appendicitis.
Tactics and choice of treatment method
As experience of surgeons of the whole world testifies, in acute appendicitis timely operation is the unique effective method of treatment.
Access for appendectomy must provide implementation of operation. McBurney’s incision is typical.
When during operation the appendix without the special difficulties can be shown out in a wound, antegrade appendectomy is executed. On clamps its mesentery is cut off and ligated. Near the basis the appendix is ligated and cut. Stump is processed by solution of antiseptic and peritonized by a purse-string suture .
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If only the basis of appendix is taken in a wound, and an apex is fixed in an abdominal cavity, more rationally retrograde appendectomy is performed. Thus the appendix near basis is cut between two ligatures. Stump is processed by antiseptic and peritonized. According to it the appendix is removed in the direction from basis to the apex.
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According to indication operation is concluded by draining of abdominal cavity (destructive appendicitis, exudate in an abdominal cavity, capillary hemorrhage from the bed). In recent years the laparoscopy methods of appendectomy are successfully performed.
In patients with appendiceal infiltrate it is necessary to perform conservative-temporizing tactic. Taking it into account, bed rest is appointed, protective diet, cold on the area of infiltrate, antibiotic therapy. According to resorption of infiltrate, in two months, planned appendectomy is executed.
Treatment of appendiceal abscess must be only operative. Opening and drainage of abscess, from retroperitoneal access, is performed. To delete here the appendix is not necessary, and because of denger of bleeding, peritonitis and intestinal fistula — even dangerously.
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Acute pancreatitis
The basis of disease of pancreas is degenerative-inflammatory processes which are considered to be acute pancreatitis, the so called autolysis tissue by its own enzymes. In the structure of acute pathology of organs of abdominal cavity this disease takes the third place after acute appendicitis and cholecystitis. Women suffer from acute pancreatitis 3–3,5 times more frequently than men.
Anatomy(Fig.1;Fig.2; Fig.3.)
Fig.1.Anatomic and topographic features of the pancreas:
1 — ventriculus; 2 — a. et v. gastrica sinistra; 3— lien; 4— lig. phrenicolienale; 5 — lig. gastrolienal; 6 — corpus pancreatis; 7— cauda pancreatis; 8— proection of attaching of the mesocolon transversum; 9 — flexura duodenojejunalis; 10 — caput pancreatis; 11 — duodenum; 12 — foramen epiploicum; 13 — lig. hepatoduodenale; 14 — hepar; 15 — lig. hepatogastricum; 16 — vesica fellea
Fig.2.Topography of the pancreas:
1 — v. cava inferior; 2 — aorta abdominalis; 3 — truncus coeliacus; 4-аrt., gastrica sinistra; 5-аrt. lienalis; 6— v. lienalis; 7— v. mesenterica inferior; 8-аrt. mesenterica superior; 9 — v. mesenterica superior; 10— caput pancreatis; 11 — duodenum; 12— art. gastroduodenalis; 13 — art. hepatica communis; 14 — art. hepatica propria; 15 — ductus choledochus; 16 — art. gastrica dextra; 17 — v. portae; 18 — ductus cysticus; 19 — ductus hepaticus communis
Fig.3. Lymphatic drainage of the pancreas
Etiology and pathogenesis
Acute pancreatitis is a polyetiology disease. Its secondary forms, which arise on the background of pathologies of bile-excreting system and duodenum are closely associated with anatomic and functionally with pancreas, and are met in clinical practice.
Among the “starting” factors of origin of cholelithiasis disease (biliary pancreatitis) abuse by an alcohol and food overloads (fat and irritating products), traumas of pancreas, operating-room in particular, and also separate infectious diseases (parotitis, mononucleosis) are most frequent, especially infection of bilious ways. However, in 10–20 % of patients the reason of acute pancreatitis remains unknown (cryptogenic form).
In the basis of such damages of pancreas and enzymic toxemia lies mainly activating of pancreatic, and then the tissue enzymes (tripsin, lipase, amylase). Often the combination of the broken outflow of pancreatic secret and promoted secretion takes place, which provokes intraductal hypertension.
Among explanations of primary mechanisms of activating of pancreatic enzymes the most value belongs to: a) theory of “general duct” with reflux of bile in the ducts of pancreas; b) blockade of outflow of pancreatic juice with development of intraductal hypertension and penetration of secret in interstitial tissue; in) violation of blood flow of pancreas (vasculitis, thrombophlebitis and embolisms, cardiac insufficiency and others like that); g) toxic and allergic damages of gland. The role of alcohol in such situations can be dual: stimulation of secretion of pancreas and direct damaging action on its tissue.
Pathomorphology
The process of acute inflammation of pancreas consistently passes the stages of edema, pancreatonecrosis and festering pancreatitis. In the stage of edema there is pancreas of hyperemic, increased in volume, with the shallow hearths of necrosis or, as it is in swingeing majority of cases, without them.
Pancreatonecrosis can pass with fatty or hemorrhagic character. In the first case, as a rule, pancreas is increased, dense, cut whity-yellow hearths are selected to necrosis. Increase of crimson-black pancreas with darkly-brown infiltrate on a cut is characteristic for hemorrhagic pancreatonecrosis.
Dystrophy of parenchyma is exposed microscopically, up to necrosis, hemorrhages, thromboses of vessels and signs of inflammatory infiltration.
Classification
(V All-russian convention of surgeons, 1978)
I. Clinico-anatomy forms:
1. Arching form.
2. Fatty pancreatonecrosis.
3. Hemorrhagic pancreatonecrosis.
II. Prevalence of necrosis:
1. Local (focus) damage of gland.
2. Subtotal damage of gland.
3. Total damage of gland.
III. Ran across: abortive, progressive.
IV. Periods of disease:
1. Period of hemodynamic violations and pancreatogenic shock.
2. Period of functional insufficiency of parenchymatous organs.
3. Period of degenerative and festering complications.
Symptoms and clinical passing
The disease begins suddenly, after the surplus reception of rich spicy food and use of alcohol. Pain, vomiting and phenomena of dynamic intestinal obstruction are considered the most characteristic signs of acute pancreatitis.
A stomach-ache is permanent and so strong, that can result in shock, localized in an epigastric area and left hypochondrium. Some patients feel pain in right hypochondrium with irradiation in the back, loin or breastbone. (Fig.4)
Fig.4.Scheme of pain irradiation at acute pancreatitis
In a short period of time after appearance of pain there is a repeated strong vomiting, that does not facilitate the state of patient.
In general vomiting is considered a frequent and characteristic symptom. It is repeated or continuous and never brings facilitation. Vomit masses contain bile, as admixture, and at the difficult form of acute pancreatitis remind “coffee-grounds”.
Nausea, hiccup, belch and dryness in a mouth are attributed as less characteristic symptoms of this pathology.
During the examination the skin is pale, often subicterus. Some patients have cyanosys with a “marble picture” as a result of violation of microcirculation. Later the component of respiratory insufficiency can join it. At progressive general condition the patient quickly gets worse to passing of acute pancreatitis, intoxication grows. The skin takes shelter with sticky sweat.
The temperature of body of patients at the beginning of disease can be normal. It rises at resorption of products of autolysis tissue and development of inflammatory process in bilious ways.
The pulse in most cases is at first slow, then becomes frequent, notedly passing ahead the increase of temperature of body.
Arterial pressure goes down.
The tongue in the first hour of disease is moist, assessed by white and grey raid. At vomiting by bile the raid has yellow or greenish tint.
The abdominal is blown away, peristaltic noises are loosened. The signs of paresis of stomach and intestine demonstrate early. They need to be included in the pathological process of mesentery root of bowel. At palpation painfulness in an epigastric area and in right, and sometimes and in left, hypochondrium is marked. However, in spite of great pain in stomach, it remains soft for a long time. A little later there is moderate tension or resistance of muscles of front abdominal wall.
Poor local symptoms during heavy intoxication are characteristic for the early period of acute pancreatitis. Later there are symptoms of irritation of peritoneum, and at percussion dulling is marked in lateral parts of abdominal as a result of accumulation of liquid, and also the sign of aseptic phlegmon of retroperitoneal cellulose as slurred or edema of lumbar area is seen. For diagnostics of acute pancreatitis there is the row of characteristic symptoms which have different clinical value.
The Mondor’s symptom is violet spots on face and trunk.
The Lagermph’s symptom is acute cyanosys of person.
The Halsted’s Symptom is cyanosys of abdominal skin.
The Gray’s symptom is cyanosys of lateral walls of abdomen.
The Kullen’s symptom is the yellow colouring of skiear a belly-button.
The Korte’s symptom is painful resistance as a lumbar bar in a epigastric area on 6–7 cm higher belly-button.
The Voskresynskyy’s symptom is absence of pulsation of abdominal aorta in an epigastric area.
The Mayo-Robson’s symptom is feeling of pain at pressure by fingers in the left costal-vertebral corner.
The Rozdolskyy’s symptom — painfulness at percussion above pancreas.
The Blumberg’s symptom — in patients with acute pancreatitis more frequently is low-grade. Such feature of this sign of irritation of peritoneum needs to be explained by character of localization of pathological process, mainly in retroperitoneal spacious.
In clinical passing of pancreatonecrosis it is possible to select three periods (V.S. Saveljev, 1978).
The I period (hemodynamic violations and pancreatogenic shock) lasts during 2–3 days. Violation of central hemodynamics, diminishment of volume of circulatory blood and disorders of microcirculation, which at first arise as a result of angiospasm, are considered the most characteristic signs, and later as a result of joining of the intravascular rolling up and laying of elements of blood.
The II period (insufficiency of parenchymatous organs) lasts from 3rd to the 7th day of disease. Violation of functions of basic organs and systems, sign of cardio-vascular, hepatic and kidney insufficiency and growth of violations of breathing are thus observed. In this period there is possible damaging of the central nervous system, which is erected mainly to disorders of psyche, appearances of delirium and commas which in the eventual result are the main reasons of patients’ death.
The III period (postnecrosis dystrophic and festering complications) comes in 1–2 weeks after the beginning of disease. During it, on the background of progress of necrosis processes in pancreas, the regenerative changes develop, there are parapancreatic infiltrate and cysts, cystic fibrosis of pancreas. Aseptic retroperitoneal phlegmon which strengthens intoxication can also develop. There is festering pancreatitis at joining of infection. During this period such complications, as erosive bleeding, internal or external fistula, retroperitoneal phlegmon, can develop in patients. (Fig.5)
Fig.5. Scheme of pyo-inflammatory diffusion at acute pancreatitis
1- subhepatic space(6%)
2- right lateral flanc(23%)
3- subphrenic space(36 %)
4- left lateral flanc(40%)
5- retroperitoneal space(67%)
From laboratory information leucocytosis which at the necrosis and hemorrhagic forms of pancreatitis sometimes arrives at 25-30 х 10G/l, lymphopenia, change of leukocytic formula to the left and the increased ESR are characteristic. Growth of activity of amylase of blood and urine is very often marked, and is the important sign of pancreatitis. For estimation of the state of other organs maintenance of general albumen and its factions, glucose of blood, bilirubin, urea, electrolytes, acid-base equilibrium (ABE), and also the state of blood coagulation are determined. It is necessary to mark that the exposure of hypocalcemia is considered a bad predictive sign of heavy passing of acute pancreatitis.
Ultrasonic examination of gall-bladder and pancreas often specifies the increase of their sizes, bulge of walls and presence or absence of concrement of gall-bladder and general bilious duct.
Computer tomography enables to describe in details the changes in pancreas and surrounding organs.
At sciagraphy survey of organs of abdominal cavity gives a possibility to expose the unfolded “horseshoe” of duodenum, pneumatization, expansion of transverse colon (the Gobia’s symptom). On the 1st stage of diagnostics in the plan of differential diagnosis of acute destructive pancreatitis with other diseases of abdominal cavity, diagnostics of distribution of destructive damaging of different parts of pancreas and estimation of distribution of parapancreatitis is possible only by the method of computer tomography which depending on clinico-laboratory signs and weight of passing is needed to apply in a different period, and sometimes a few times in dynamics with interval of 4–5 days.
Laparoscopy and laparocentesis are often used for a doubtful diagnosis or necessity of taking away the exudation of abdominal cavity for biochemical or bacteriological examination.
Retrograde endoscopic cholangiopancreatography is used in case of mechanical icterus and suspicion of choledocholithiasis. The last methods are invasive and can if it is necessary transform from diagnostic to manipulation treatments: laparoscopic draining of abdominal cavity at pancreatogenic peritonitis and endoscopic papillotomy at choledocholithiasis and biliary pancreatitis.
Variants of clinical passing and complications
Clinical passing of disease can be abortive, slowly or quickly progressive. At abortive passing the process is limited to acute edema of pancreas with convalescence in 7–10 days.
Rapid progress is characteristic for pancreatonecrosis. In patients expressed toxemia, impregnation by exudation of retroperitoneal cellulose and development of fermentative hemorrhagic peritonitis can be seen. Strengthening of stomachache, continuous vomiting, proof paresis of intestine, positive symptoms of irritation of peritoneum and growth of hemodynamic violations are the clinical signs of necrosis of pancreas.
There is a formation of parapancreatic infiltrate at slow progress.
Among early complications of acute pancreatitis shock, peritonitis and acute cardiac, pulmonary, hepatic and kidney insufficiency can be distinguished.
Before later complications it is needed to deliver the abscesses of pancreas, subdiaphragmatic, interintestinal abscesses, pyogenic abscess omentum bag, phlegmons of retroperitoneal space and erosive bleeding.
In future formations of pseudocysts, fistula of pancreas, intestinal fistula and development of saccharine diabetes are possible.
Diagnosis program
1. Anamnesis and physical methods of inspection.
2. General analysis of blood and urine.
3. Biochemical blood test (amylase, bilirubin, sugar).
4. Analysis of urine on diastase.
5. Sonography.
6. Computer tomography.
7. Cholecystocholangiography.
8. Endoscopic retrograde cholangiopancreatography.
9. Laparoscopy.
10. Laparocentesis.
Differential diagnostics
Acute pancreatitis needs to be differentiated with the row of acute diseases of organs of abdominal cavity.
Acute mechanical intestinal obstruction. In patients with this pathology pain is of the alternated character and is accompanied by nausea, vomiting, delay of gases and emptying. It is possible to see the Klojber bowls on the sciagram survey of organs of abdominal cavity.
Acute cholecystitis runs with characteristic localization of pain and muscular defense, with presence of increased, painful gall-bladder or infiltrate in right hypochondrium. Often acute (especially lately) pancreatitis develops on the background of gallstone disease (biliary pancreatitis).
Thrombosis or embolism of mesenteric vessels. Both for pancreatitis and for the thrombosis of mesenteric vessels great pain at soft abdomen (absence of defense muscles of front abdominal wall), that precedes to development of peritonitis, is inherent. Yet from the beginning the disease gains heavy character of passing. In anamnesis in such patients a heart disease or heart attack of myocardium rheumatic is met. As a result of gangrene of intestine, the symptoms of peritonitis appear very quickly and intoxication grows. The fragments of mucus shell are found in flushing waters of intestine at the detailed examination, which have the appearance of ”meat flushing”.
A perforated gastric and duodenum ulcer is distinguished by the presence of dagger pain, defense of abdominal wall, ulcerous anamnesis.
Tactics and choice of treatment method
The conservative method is considered the basic one for treatment of acute pancreatitis, but in connection with that unsuccessful conservative treatment of patients with acute pancreatitis can often put a question about the necessity of operation, therefore patients must be in permanent surgical establishment. Thus acute pancreatitis with heavy passing is necessary to be treated under the conditions of separation of intensive therapy.
Before conservative treatment hunger, bed rest, fight against pain and enzymic toxemia, conducting of acid-base state, prophylaxis of festering infection and acute ulcers of digestive duct are to be entered .
Patient’s stomach is washed by cold soda solution and a cold on an epigastric area and left hypochondrium is used. Medicinal therapy is prescribed also: spasmolytics (papaverine, platyphyllin, no-shparum, baralgine, atropine); inhibitor of protease (contrical, trasilol, gordox, antagosan); cytostatic agent (5-fluorouracil, ftorafur). Positive action of inhibitor of protease is marked only in the first days of disease which are subject to conditioned application of large doses. Antibiotics of wide spectrum of action: a) tienam, which most effective in the prophylaxis of festering pancreatitis, as is selected by pancreatic juice; b) cephalosporins (kefzol, cefazoline); c) cefamizine (mefoxine).
Disintoxication therapy is conducted also (5 % but 10 % solutions of glucose, hemodes, reopolyhlukine, polyhlukine, plasma of blood, only from 3 to 5 liters on days, in accordance with a necessity).
For the improvement of rheological properties of blood heparine is prescribed (5 000 ODES every 4 hours).
If patients have the expressed pain syndrome and phenomena of general intoxication during all pain period plus 48 hours (by Bakulev), hunger is used. Such mode lasts on the average of 2–4 days. The parenteral feed of albuminous hydrolyzate is thus conducted, by the mixtures of amino acid and fatty emulsion. Alkaline water of to 1–2 l. and albuminous-carbohydrate diet are also appointed. Infusion therapy is complemented by plasma, by albumen, hemodes, reopolyhlukine. The improvements of microcirculation in pancreas are achieved due to introduction of reopolyhlukine, komplamine, trental and heparin 5000 ODES 6 times per days under the control the indexes of the coagulation system of blood. Anticholinergic drug (sulfate of atropine, methacin, platyphyllin), Н2-histamin blocker (cimetidine, ranisan, ranitidine, famotidine, omeprazol) are also applied. For the removal of pain: 1) sulfate of the atropine 0,1 % — 1 ml + promedol 2 % — 1 ml + papaverine 2 % — 2 ml + analgin 50 % — 2 ml; 2) isotonic solution of chloride of sodium — 500 ml + baralgine — 5 ml + diphenhydramine hydrochloride 1 % — 1 ml + papaverine 2 % — 2 ml + magnesium the sulfate 25 % — 5 ml + ascorbic acid — 5 ml + lipoic acid 0,5 % — 2 ml + novocaine 0,5 % — 10 ml. are used. From the first days by a nasogastral probe the permanent aspiration of gastric maintenance is conducted also. The Motility function of gastro-intestinal highway gets better at application of cerucal or primperane. With the same purpose forced diuresis (maninil, furosemide, aminophylline) is used on the background of intravenous introduction of plenty of liquid.
At uneffective conservative treatment of patients with acute pancreatitis of middle weight and heavy form it is expedient to apply surgical treatment.
Surgical treatment is carried out for patients with biliary pancreatitis (for a day long from the beginning of disease) in combination with the destructive forms of cholecystitis, at complications of acute pancreatitis by peritonitis, abscess of omentum bag or phlegmon of retroperitoneal cellulose.
Overhead-middle laparotomy, which allows to estimate the state of pancreas, bilious ways and other organs of abdominal cavity, is the best access in this situation. In case of destructive pancreatitis the possible use of lumbar laparotomy from left to right hypochondrium through a mesogastric area is useful.
Cholecystectomy is executed at calculous cholecystitis, phlegmonous inflammation of walls of gall-bladder and biliary pancreatitis. If there are more than 0,9 cm at expansion of choledochus, presence of concrement, ointment-like bile in it, increase of concentration of bilirubin in the whey of blood over 21 mmol/L, choledochuslithotomy is complemented by external draining of choledochus. Information of lithiasis of general bilious duct is absent, cholecystectomy in patients with acute pancreatitis is complemented by external draining of choledochus, better by Pikovskyy method (through stump of cystic duct).
Transduodenal sphincteroplasty(Fig.6) is shown at fixed concrement of large duodenal papilla, if they are diagnosed intraoperative, and also in the cases of papillotomy with extraction of concrement when there is no possibility to execute endoscopic operation.
Fig.6.Transduodenal papillotomy with sphincteroplasty
Omentopancreatopexy. After laparotomy and cutting of gastro-colon and gastro-pancreatic ligament mobile part of large omentum through opening in gastro-colon ligament is conducted and fixed by separate stitches to the peritoneum along the overhead and lower edges of pancreas. Such operatioeeds to be considered rational at the expressed edema of pancreas and presence of necrosis in it.
Abdominisation of pancreas. A cellulose round pancreas (along the lower and overhead edges of body and tail) is infiltrated by solution of novocaine, after it parietal peritoneum is cut. Under the body and tail glands free end of omentum is conducted and is bundled by a gland. This operation is able to warn the hit of enzymes and products of disintegration in retroperitoneal space.
Sequestrectomy is deleting of necrosis part of gland within the limits of nonviable tissue. Operation is executed in a dull way.
Necrectomy (deleting of necrosis part of gland within the limits of healthy tissue) is executed by an acute way: tissue of gland is cut on verge of necrosis and bleeding vessels are carefully bandaged.
The resection of pancreas is deleting the part of organ with its transversal cutting within the limits of the unchanged (ad осulus) tissue of gland. The resections of tail and body of pancreas are distinguished.
Pancreatectomy is a complete deleting of pancreas. Operative treatment is applied infrequently. After the resection of pancreas adequate draining of its bed is very responsible.
The prognosis of disease depends on character of morphological changes of parapancreatic to the cellulose in pancreas. The more difficult destructive changes, the worst the prognosis.
INCARCERATED HERNIA
Incarcerated hernia is sudden pressing of hernia contents in a hernia orifice. Incarceration is the most frequent and most dangerous complication of hernia diseases.
Pic. Types of incarcerations
Etiology and pathogenesis
Depending on mechanism, the elastic and fecal incarceration is distinguished. At the elastic incarceration, after increasing intraabdominal pressure, one or a few organs relocated from an abdominal cavity to the hernia sack, where it is compressed with following ischemia and necrosis in the area of hernia gate. At the fecal incarceration in the intestinal loop which is in a hernia sack, plenty of excrement passed quickly. Proximal part of loop is overfilled, and distal is compressed in a hernia gate. So, arose its strangulation, as well as at the elastic incarceration.
Most often the loop of bowel is incarcerated. Thus three parts are distinguished in it: proximal, distal loop, central part. The heaviest pathological changes during incarceration takes place in a strangulated furrow in the central part of the incarcerated bowel.
Pathomorphology
At incarcerated hernia an important role has all internal rings: inguinal, umbilical, “weak places” in a diaphragm, orifice of the omental bursa, numeral and “variant” folds of peritoneum.
In the place of compressing of the bowels and mesentery, as a rule, it is possible to find a strangulation furrow. If circulation of blood changes, the wall of bowel cyanotic, with hemorrhages and necrosis of a different size. The loop of bowel which is located proximally the places of strangulation are extended, and distal loop mainly without changes.
Pic. Mechanizm of the incarceration.
Pic. Scheme of the incarceration.
Pic. Retrograde incarceration.
Classification of the incarcerated hernia
The incarcerated hernia is divided into the complete and incomplete. The other types of incarceration is partial (the Richter’s hernia) and retrograde. The incarcerated hernia can be without the destructive changes of hernia contents and with the phlegmon of hernia sack.
Clinical management
The clinic of the incarcerated hernia depends on pulling in organ, character and duration of jamming. The clinical signs of the incarcerated hernia can be divided into three groups: 1) local changes; 2) common signs; 3) complication. From the most characteristic signs of local changes the most common is sharp pain, irreducible hernia, tension of hernia sack that and negative symptom of the “cough push”.
Pain sometimes is so intensive that causes pain shock. In the case of intestinal obstruction a pain is attack-like. In case of occurring of peritonitis pain changes the character and becomes permanent.
It is necessary to mean that tensions of hernia sack and incarceration of the hernia, as signs of jamming, lose it value, if hernia was irreducible.
From other side, the isolation of hernia sack from an abdominal region during jamming is the reason of the negative symptom of the “cough push”.
The common signs at the incarcerated hernia has phase character. Nausea and vomits during first hours of disease has reflex reason, and on 2nd and 3rd days has toxic reason, that is consequence of antiperistaltic and reflux of intestinal contents to the stomach.
The temperature of body at first time is normal, and than rises, but usually low grade fever.
The clinic of acute intestinal obstruction and peritonitis develops at the protracted jamming of intestine. The phlegmon of hernia sack can develop in the area of the hernia swelling.
Clinical variants and complications
There are different forms of incarceration of internal organs, and accordingly — different clinical variants.
Retrograde incarceration. In such cases a hernia sack contains no less than two loops of intestine. But these loops are damaged less, than loop which is in an abdominal cavity. At this variant of jamming peritonitis arose quicker. So, surgeon during operation must always remember about the necessity of careful revision of the incarcerated loops of bowel.
Parietal incarceration (the Richter’s hernia). Unlike retrograde, which has wide hernia gate, a similar pathology arises in case of narrow hernia gate. In a hernia sack in such patients located part of bowel wall, opposite it mesentery edge.
Thus, as a rule, patency of bowel is not broken. Such variant of jamming is dangerous, because there are no evident clinical signs or some of them are quite absent and intestinal patency almost is always present. Necrosis of bowel wall comes quickly and in 2-3 days the perforation with subsequent development of peritonitis begins after jamming.
The Littre’s hernia. Jamming of Meckel’s diverticulum can come at oblique inguinal hernia. Clinical signs of this pathology reminds the parietal incarceration. Sometimes is possible to palpate dense, short, thick tension bar in a hernia sack.
Incarceration at sliding hernia. It is observed at patients with inguinal hernia. At sliding hernia of colon, as a rule, there is the fecal incarceration. A bowel is the external wall of hernia sack in such cases. About it is necessary to remember during opening of hernia sack. Jammings of urinary bladder meet enough rarely, mainly at older-men at oblique sliding hernia of inguinal channel. It is necessary to ask before the operation, whether a patient had disorders of urination before jamming. Frequent urges, or, opposite, the reflex delay of urination is arose at the beginning of jamming already, and in urine expose macro- or microhematuria. If during operation at opening of hernia sack it medial wall has dense, doughy consistency, it is an urinary bladder.
At the incarcerated hernia the contents of hernia sack can be also omentum, appendages of colon, internal female genital organs. Sometimes combination of the incarcerated inguinal hernia with different pathological changes of testicle and deferent duct can take place.
Rough manual reduction of the incarcerated hernia can bring to pseudoreduction. Then the local signs of the incarcerated hernia disappear, and jamming of organs and its consequences is kept. There are five variants of the pseudoreduction: 1) at multicompartment hernia sacks there is the possible moving of strangulated organs from one chamber in other, that located more deep or in a preperitoneal adipose tissue; 2) separation and reduction of hernia sack together with it content in an abdominal cavity or in a preperitoneal adipose tissue; 3) abruption of the neck from other part of hernia sack and reduction it together with content in an abdominal cavity or in a preperitoneal adipose tissue; 4) abruption of the neck from a hernia sack and from a parietal peritoneum with reduction of the incarcerated organs in an abdominal cavity; 5) break of the incarcerated bowel at the rough reduction of hernia.
Untimely operative at the incarcerated hernia, usually, is complicated by the gangrene of bowel, peritonitis or phlegmon of hernia sack. Such complications considerably worsen clinical status of patient and require other surgical tactic.
Diagnosis program
1. Anamnesis examination.
2. Physical examination.
3. Blood analysis and urine analysis.
4. Digital investigation of the rectum.
5. Survey X-Ray of abdominal cavity organs.
Differential diagnostics
As experience shows, the incarcerated hernia we should differentiate with irreducible, which as a rule, is not tense, positive symptom of the “cough push”, painful on palpation. A patient complained for long duration of the disease. The incarcerated hernia needs to be differentiated with coprostasis. In such patients disorder of bowel loop patency, that is in a hernia sack, creates accumulation of excrement. Coprostasis mostly found at fecal hernia in older people, that suffer from intractable constipation. Clinically it develops gradually and slowly. The hernia swelling almost not painfully, some tense, a positive symptom of the “cough push”. Beginning of coprostasis is unconnected with physical tension. Application of cleansing siphon enema washed of excrement and liquidated coprostasis.
Unreal jamming of hernia. In clinical practice there are often such situation, when during the acute surgical diseases of organs of abdominal cavity free external abdominal hernia becomes irreducible, painfully and tense, and looks like incarcerated. This is the unreal jamming of hernia, which can be observed at the acute surgical diseases of organs of abdominal cavity, ascites. During examination of such patients it is necessary to remember, that at the unreal jamming abdominal pain, vomiting, worsening of the general condition and signs of the intestine obstruction come earlier, than changes in a hernia sack.
In addition, during the operation in patients with incarcerated hernia, it is needed to make sure, whether there is a strangulation furrow, or organ, that is in a hernia sack, fixed in a hernia gate. When these signs are absent, it is possible to consider that jamming is unreal.
The incarcerated femoral hernia must be differentiated with inguinal lymphadenitis, by varicose expansion of large hypodermic vein, varicose knot and their thrombophlebitis, tumor and abscess.
From such pathology without surgical procedure it is possible to differentiate only varicose expansion of veins (varicose knot), for which the positive Valsalv test — at horizontal position of patient with the leg heaved up a knot is empty.
The incarcerated inguinal hernia needs to be differentiated also with hydrocele and orchiepididymitis, cyst of deferent duct, cyst of round ligamentum of uterus, bartholinitis. Patients, who have with such diseases, a process usually does not spread higher external ring of inguinal channel. Also, absence of testicle in scrotum can be cryptorchiism sign.
The common clinical signs of the internal incarcerated hernia is abdominal pain and symptoms of the intestinal obstruction. A final diagnosis is set during the operation.
Tactics and choice of treatment method
The incarcerated hernia, regardless of time of its origin, localization and age of patient, must be operated on. However, if a patient is hospitalized already with the expressed symptoms of intestinal obstruction, than should be preoperative treatment. Such conservative therapy must be brief (1–1,5 hours), but always actively directed for correction of violations of metabolism and prophylaxis of possible pulmonary and cardiovascular complications. It is necessary also to conduct evacuation of the gastric contents and other preparatory procedures.
Patient with reduced hernia must be hospitalized and observed during 1–2 days. If a abdominal pain is contained or is growing, the signs of peritonitis and intoxication appear, than performed urgent laparotomy and necessary operation. If the symptoms of “acute” abdomen are not present, a patient examined and prepared for elective operation. On oblique inguinal hernias, we should strengthen anterior wall of the inguinal channel. On direct inguinal hernias, we should strengthen posterior wall of the inguinal channel. On recurrence hernias – we should strengthen anterior and posterior wall of the inguinal channel.
Bassini repair. After extraction of the hernia sac, we are taking spermatic duct on holders. Between the borders of transverse muscle, internal oblique muscle, transverse fascia and inguinal ligament interrupted sutures placed. Except that, couples sutures placed between border of abdominal rectus muscle sheath and pubic bone periosteum.
In such way, inguinal space closured and posterior wall strengthened. Spermatic duct placed on the new-formed posterior wall of the inguinal channel. Over the spermatic duct aponeurosis restored by interrupted sutures.
Girard in such kind of the operations propose to attach the edges of the internal oblique muscle and transversal muscle to the inguinal ligament over the spermatic duct. The aponeurosis of the external oblique muscle sutured by second layer of the suture. Excess of the aponeurosis is fixed to the muscle in the form of duplication.
Spasokukotskyy proposed to catch the edges of the internal oblique muscle and transversal muscle with aponeurosis of the external oblique muscles by single-layer interrupted suture.
Martynov proposed the fixation to the Poupart’s ligament only internal edge of the external oblique muscle aponeurosis without muscles. External edge of the aponeurosis sutured over internal in the form of duplication.
Kimbarovskyy, based on the principles of joining similar tissues, proposed special suture: Sutures placed on 1 cm from the edge of the external oblique abdominal muscle aponeurosis, grasped the part of the internal oblique and transversal muscle. After that, aponeurosis is sutured one more time from behind to the front and attached to the Poupart’s ligament.
Kukudganov proposed to restore back wall of inguinal interval. Sutures are placed between the Couper’s ligamentum, vagina of direct abdominal muscle and aponeurosis of the transversal muscle.
Postempskyy proposed the deaf closing of inguinal interval with the lateral moving of spermatic duct.
The plastic narrowing of internal inguinal ring of to 0,8 cm is the important moment of this modification. On occasion, when internal and external inguinal rings are in one plane, a spermatic duct is displaced inlateral direction by transversal incision of the oblique and transversal muscles. Then edge of the vagina of direct muscle and aponeurosis of the internal and transversal muscles is fixed to the Couper’s ligament.
Operation at the incarcerated hernia is executed under the general anesthesia. A hernia sack is selected from surrounding tissue, cut it in the area of bottom and remove hernia water, defining its character and sending to bacterial inoculation. Retaining the damaged organs, a strangulated ring is cut. It is necessary to remember, that at the incarcerated femoral hernia ring cut up and some medially, because a femoral vein passes from a lateral side.
If a bowel is contents of hernia sack, we must estimate its viability. Remembering about possibility of the retrograde jamming, special attention must be paid to the state of strangulation furrow. About viability of the bowels testify: 1) renewal of its normal color; 2) presence or renewal of peristalsis; 3) renewal of pulsation of vessels of mesentery and bowel. If there are the certain doubting, a bowel is dipped on a holder in an abdominal cavity and in 15–20 minutes it is examined repeatedly. If one of the resulted signs of viability is absent even, it is necessary to conduct the resection of bowel. The resection is executed, receded from the strangulation furrow on a proximal loop 30–40 cm and distal — 15–20 cm. Anastomosis between proximal and distal loops it is better to impose “end-to-end”. The plastic of hernia gate are conducted depending on indications after one of the surgical methods.
When the necrosis elements of omentum or fatty pendants of colon are contents of hernia sack, they must be removed within the limits of healthy tissue.
There can be necrosis of wall of colon or urinary bladder at sliding hernia. In such cases it is needed to be limited to the minimum surgical procedure: to dip a necrosis area by sutures inside the bowel or use it for forming of colostomy or epicystostomy. These are the best to conclude operation.
In similar situations at the incarcerated parietal hernia in most patients it is possible to be limited to peritonization of displaced area of wall of bowel. If after the peritonization there is the threat of narrowing of bowel or necrosis goes outside of the strangulation furrow, it is needed to conduct the resection of bowel.
Because of insufficient blood floow of Meckel’s diverticulum and, permanent threat of it necrosis, at patients with Littre’s hernia it resection must be performed.
At the phlegmon of hernia sack operation is begun with herniotomy. If the incarcerated organ is damaged by necrosis, and in a hernia sack present pus, than there is a necessity for surgeon to perform laparotomy. After that incarcerated organ resected within the limits of healthy tissue (in the generally accepted limits — 40 cm of proximal loop and 20 cm distal) and impose anastomosis. An abdominal cavity is sewn up. Incarcerated loops of bowel, together with it blind ends which lacated in an abdominal cavity, removed through a hernia sack, a peritoneum is sutured, the hernia sack is drained, the plastic of hernia gate are not performed. Skin is sewn up by widely spaced sutures.
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