HERNIA
Hernia of the abdominal wall or external hernia (herniae abdominalis externae) is such surgical disease, which is characterized by outlet of the visceral organs from the place of their physiological placement through the natural channels or defects of the abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum and skin cover are not damaged.
Internal hernia (herniae abdominalis internae) is such disease, visceral organs hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and generally kept in the abdominal cavity.
Localizations of the abdominal wall hernias :1— Linea alba; 2—Umbilical; 3 —Spigelian li-nea; 4—Incisional hernia; 5—Direct inquinalis hernia;6—Femoral hernia;7—Indirect inquinalis hernia
Etiology and pathogenesis
Hernias are divided into two main groups: congenital (herniae conqenitae) and acquired (herniae acguisitae). The main reason of congenital hernias is malformation. Thus, inguinal hernia arose in case of noclosure of the process of peritoneum, which passes by inguinal channel during descending the testis. On such hernias testis is located in the hernia pouch. Acquired inguinal hernia has hernia pouch and testis located outside it. Many factors are of great importance in the beginning and developing of the acquired hernia. One of them contributes, other – causes disease. The first are hereditary, anatomical inferiority of the abdominal wall, sex (inguinal area weakness in males and largeness internal femoral ring in females), age (atrophic processes in older age, anatomical inferiority of the abdominal wall in babies), weight loss, injury, postoperative scar, physical activity, pregnancy, during which abdominal wall stretched (for example, midline increased in 12 times).
Such reasons, as increased abdominal pressure and weakness of the abdominal wall, cause hernia. That arise after hard physical activity, continued cough, constipation, nerves palsy, which innervated abdominal wall, injury of muscles or aponeurosis of the abdomen.
Inguinal hernia
Postoperative hernia
Pathomorphology
Each abdominal hernia consists of hernia gate, hernia sac and hernia contents. Hernia sac forms by outpouching of parietal peritoneum and can contain any organ from abdominal cavity, but mostly – small intestine and omentum. Sometimes it containes other organs: large intestine, urinary bladder, ovary, and appendix.
The main parts of the hernia pouch are neck, body and fundus. Through the hernia’s gate, peritoneum is outpouching. In the case of sliding hernia organ in the hernia pouch has mesoperitoneal disposition and not enclosed by peritoneum.
Classification
Hernia of the abdominal wall is divided:
1) Depends on anatomical localization: inguinal (indirect and direct), midline hernia, omphalocele, femoral hernia, lumbar hernia, sciatic hernia, (enterischiocele), lateral hernia, ischiorectal [perineal] hernia (perineocele).
2) depends on etiology: congenital (herniae conqenitae) and acquired (herniae acguisitae).
3) Depends on clinical presentations: complete and incomplete, reducible and nonreducible, traumatic and postoperative, complicated and noncomplicated.
Clinical management
The typical symptom of hernia is swelling, which arises on vertical position of the patient or during rise of intraperitoneal pressure. These can disappear in a state of dormancy, on vertical position of the patient or after applying small pressure. Such factors make it possible to confirm hernia.
In the case of hernia primary formation skin over the swelling almost not changed. Hernia is determined by finger examination of the inguinal channel. We can feel positive symptom of the “cough push”, which is caused by cough or by the rise of intraperitoneal pressure. In the case of late stage of hernia developing evagination appear on changing body position from horizontal to verticalor after rising of the intraperitoneal pressure. If hernia sac contained small intestine than every next tension of the abdominal muscle inflated hernia sac by intestinal loop.
Symptom of the “cough push”
Diagnostics of the noncomplicated external abdominal hernias is easy. Anamnesis of patients and clinical data are enough. However, we should remember about nonreducible hernias. Such hernia’s shape and dimension often does not change. Patients complicated for continuous pain in the hernia region, which irradiated to other abdominal organs. The main danger of the nonreducible hernias is jamming.
Clinical variants and complications
Inguinal hernias is developed in two ways: through the internal (middle) inguinal cavity and external (lateral). In the first case formed direct in other – indirect inguinal hernia.
Indirect hernias could be congenital and acquired. Direct hernias are only acquired and occur in older patients.
There are two main signs, which differentiate direct and indirect hernias. Direct hernia is always located medially from a. epigastrica inf. Indirect hernia is always located laterally from a. epigastrica inf. The other sign is: direct hernia located medially from deferent duct, indirect hernia located inside it
Femoral hernias are such pathological formation, which is encountered 10-20 times more often in males then females. This is explained by anatomical peculiarity of the females’ pelvis, wider interval between femoral vein and lacunar [Gimbernat’s] ligament and inguinal [Poupart’s] ligament weakness.
There are distinguished femoral hernias, vasculo-lacunar, rural pectineal [Cloquet’s] hernia, Hesselbach’s hernia.
In addition, there are some kinds of femoral hernias, which can be identified only during the operation:
1) Medial vascular-lacunar femoral hernia, most common;
2) Hernia, which passed through the middle part of vascular lacuna or through the vascular sheath;
3) Lateral vascular-lacunar hernia, which pass outside of the femoral vessels.
Besides, there is middle or prevascular hernia.
Medial vascular -lacunar femoral hernia has three stages of developing:
1) Beginning femoral hernia – swelling does not pass outside internal femoral ring;
2) Incomplete (interstitial) hernia – swelling does not pass outside of superficial fascia;
3) Complete femoral hernia – swelling passed through all anatomical part of the femoral channel and outgoing to the subcutaneous cellular tissue on the anterior femoral surface below inguinal [Poupart’s] ligament.
In spite of small size of the hernia sac, femoral hernia could contain omentum, small intestine and urinary bladder. It is more difficult to diagnose femoral hernia in overweight patients because of inexpressive clinical signs.
We should differentiate femoral hernias with inguinal hernias, increased or varicose changed lymphatic nodes. In those cases, we should determine external inguinal ring and inguinal ligament.
Midline [epigastric] hernia usually has males in giving age.
There are distinguished supraumbilical, umbilical and paraumbilical hernias.
Very often, such kind of the hernia has no clinical signs and can be determined on the medical examinations. The usual clinical signs are: swelling on linea alba and intermittent pain.
Umbilical hernias occur in 2 % from all kinds of hernia. The most frequent hernias in females (the ratio is 5:1), which is explained by anatomical peculiarity of the females’ umbilicus after pregnancy. Such hernia often has two- and three-chambers hernia sacs, which could contain omentum, small intestine, and sometime stomach. Clinical signs depend on those contents. However, it always characterized by pain and swelling. In some patients swelling is very large.
Diagnosis of the umbilical hernia in typical case is not very difficult. Sometimes it is arduous to differentiate incarcerated umbilical hernia and umbilical metastasis of tumor. We should remember about umbilical evagination (without organs) in the patients with liver cirrhosis because of presence ascitic fluid in the abdominal cavity.
Lumbar hernias are abdominal wall or retroperitoneal outpouchings. It does not occur very often. The area of the hernia orifice includes the superior costolumbar triangle and the inferior iliolumbar triangle. Besides that, it could be in aponeurosis slit.
Lumbar hernias could be congenital and acquired. Congenital lumbar hernias are frequently the result of aponeurosis slit or enlargement of the Pti triangle or Hrunfeld interval. Acquired lumbar hernias are usually result of injury those anatomical structure or after pyoinflammatory diseases.
The most frequent clinical sign is pain. The other signs depend on hernia content. The hernia contents may include any intra- and retroperitoneal structures, e.g., the kidney, small bowel, and omentum.
Diagnosis is made by clinical examination: in the horizontal patient position on healthy side, swelling disappeared, and on the vertical patient position appeared again.
Obturator hernia is the result of wide obturator channel. In those cases hernia sac formes inside pelvic cavity, and than passes through the obturator channel, and arises on internal femoral surface.
Diagnosis of the obturator hernias is not easy, especially in the patients without swelling on the hip. In such cases, patients have complaints for pain along obturator nerve with irradiation to knee joint or hip joint. Pain increases during leg rotation or abduction. Sometime pain irradiates to the foot.
Sciatic hernias is divided into two main types: hernia of the major sciatic foramen, which passes above and under piriform muscle and hernias of the small sciatic foramen, which passes under sciatic muscle. Patients complained for pain in the sciatic region, which increased during walking. Sometime pain irradiated along sciatic nerve.
Ischiorectal [perineal] hernia is formed in the urogenital diaphragm or in the perineum muscle. Anterior and posterior hernias are distinguished depending on whether the hernia is anterior or posterior to the transverse perineal muscle and sacrospinal ligament. Hernia ring formed by rectouterine [
Diagnosis of the anterior ischiorectal hernias, which passed to perineum, usually is not difficult. Diagnostic pitfall should be on the patients with posterior hernias, which is located under large sciatic muscle and looks like sciatic hernia. In such cases, we performed vaginal and rectal examination or X-Ray examination of the urinary bladder and intestine as required.
There are three types of the lateral abdominal hernias:
1) Acquired hernia of the rectus sheath;
2) Acquired hernias of the Spigelian line;
3) Congenital hernias because of congenital hypoplasia of the abdominal wall.
Clinical signs of lateral abdominal hernias are the same as for other types of hernias, so diagnosis is not very difficult.
The most common complications for all those hernias are incarceration.
Diagnosis program
1. Anamnesis and physical examination.
2. Digital investigation of the hernia channel.
3. Sonography of the hernia pouch.
4. Common blood analysis.
5. Common urine analysis.
Tactics and choice of treatment method
Inguinal hernia usually should be surgically repaired. 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
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 латеральним moving of spermatic duct.
The plastic narrowing of internal inguinal ring of to
LAPAROSCOPIC HERNIOPLASTY
a b
c d
e
Laparoscopic hernioplasty:
a — view from inside; b — cutting of the peritoneum; c — remuving the hernia; d — fixation by mesh material; e — suturing
Pic. Laparoscopic hernioplasty
HERNIOPLASY BY LICHTENSTEIN
Fixation the mesh material
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View of the knotless suture
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Fixation to the muscle
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Formation of the internal inguinal ring
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Knotless suture of the aponeurosis of the oblique external muscle
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Hernioplasty by PROLENE HERNIA SYSTEM
FEMORAL HERNIA
The are some methods of surgical treatment of the femoral hernia, when the plastic are performed intraperitoneal from the side of thigh through the inguinal channel.
The Bassini method is attributed to “femoral”. It is performed from a cut, that passes under inguinal fold. After removal of hernia sack a hernia gate is liquidated by suturing of inguinal to the pectineal ligament.
The Rudgi-Parlavecho Method. A cut passes parallel to the inguinal fold and higher it (the same as at inguinal hernia). A hernia sack is removed. After that the edges of the transversal and internal oblique muscles and inguinal ligament sutured to the periosteum of pubic bone.
UMBILICAL HERNIA
For operative treatment of umbilical hernia a few methods are used. The Lexer operation is most widespread. It performed by imposition of sutures on an umbilical ring.
After the Meyo method defect of anterior abdominal wall in the umbilical ring is sutured by U-shaped stitches in transversal direction.
Meyo method
Sapezhko proposed to form duplication of the abdominal white line by stitches in longitudinal direction.
Sapezhko method
At surgical treatment of hernia of abdominal white line, abdominal lateral hernia, lumbar and obturator hernia, sciatic and ischiorectal hernias after deleting of hernia sack it is needed to try to close a hernia orifice by suturing of fissures in aponeurosis and muscles.
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.
Differential diagnostics and clinical variants
Acute appendicitis is an inflammation of vermiform appendix caused by festering microflora.
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).
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.
Four phases are distinguished in clinical passing 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.
The Voskresenkyy 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.
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.
Clinical passing of acute appendicitis at the atipical placing (not in a right iliac area) will differ from a classic vermiform appendix (Pic. 3.3.1).
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 atipical clinic arises, as a rule, at the retroperitoneal location. The patients complain at pain in lumbus or above the wing of right ilium. 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.
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 atipical 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.
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.
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, vomitings 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 atipical 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 anaemia, 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.
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 (Pic. 3.3.2).
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 conducted (Pic. 3.3.3). 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. 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.
Intestinal obstruction is a complete or partial violation of passing of maintenance by the intestinal truct.
The principal reasons of intestinal obstruction can be:
1) commissures of abdominal cavity after traumas, wounds, previous operations and inflammatory diseases of organs of abdominal cavity and pelvis;
2) long mesentery of small intestine or colon, that predetermines considerable mobility of their loops;
3) tumours of abdominal cavity and retroperitoneal space.
Such principal reasons can cause violation of passing of intestinal maintenance, disorder of suction from the intestine and loss of plenty of electrolytes both from vomiting and in the intestine cavity as a result of disorders of bloodflow in its wall.
The morphological signs of dynamic intestinal obstruction are: small thickening of wall (at considerable paresis is thinning), friability of tissue (the bowel breaks easily) and presence of liquid maintenance and gases in cavity of bowel. At mechanical obstruction it is always possible to expose the obstacle: strang, commissures, tumours, jammings of hernia, cicatricial strictures, wrong entered drainages, tampons and others like that. In place of compression strangulation is exposed. The bowel loop higher strangulation is extended, and distally — collapsed. In case of released invagination on small distance two strangulation furrows are observed, and distally from the second ring cylinder expansion of bowel lumen is observed.
Beginning of clinical signs of intestinal obstruction is sudden — in 1–2 hours after taking the meal. The pain in the abdomen has the intermittent character and is met in all forms of mechanical intestinal obstruction. However, some types of strangulated intestinal obstruction (node formation, volvulus of thin and colons) can be accompanied by permanent pain. It is needed to mark that at spike intestinal obstruction, invagination and obturation cramp-like pain can be considered as pathognomic sign of disease. For paralytic intestinal obstruction more frequent is inherent permanent pain which is accompanied by the progressive swelling of abdomen. At spastic obstruction of intestine the pain is mainly acute, the abdomen is not blown away, sometimes pulled in.
Nausea and vomiting are met in 75–80 % patients with the heaviest forms of high level of intestinal obstruction (node formation, volvulus of small intestine, spike obstruction). At obturation obstruction and invagination they are observed not so often.
There is a characteristic thirst which can be considered as an early symptom. Besides, the higher intestinal obstruction, the greater the thirst.
Swelling of abdomen, the delay of emptying and gases are observed in 85–90% patients, mainly, with the high forms of obstruction (volvulus of small intestine, spike intestinal obstruction).
Together with that, for invagination emptying by liquid excrement with the admixtures of mucus and blood are more characteristic.
In patients during palpation the soft abdomen is observed, sometimes — with easy resistance of front abdominal wall, and at percussion — high tympanitis. At auscultation at the beginning of disease increased peristaltic noises are present, then gradual fading of peristalsis is positive (the Mondor’s symptom, “noise of beginning, quietness of end”).
There are other symptoms pathognomic for intestinal obstruction.
The Vala’s symptom is the limited elastic sausage-shaped formation.
The Sklarov’s symptom is the noise of intestinal splash.
The Kywul’s symptom is the clang above the exaggerated bowel.
The Schlange’s symptom is the peristalsis of bowel, that arises after palpation of abdomen.
The Spasokukotsky’s symptom is ”noise of falling drop”.
The Hochenegg’s symptom — incompletely closed anus in combination with balloon expansion of ampoule of rectum.
At survey roentgenoscopy or -graphy of the abdominal cavity in the loops of bowels liquids and gas are observed — the Klojber’s bowl (Pic. 3.3.4).
Strangulated obstruction. The ischemic component is the characteristic feature of this form of intestinal obstruction, that is investigation of squeezing of mesentery vessels, which determines the dynamics of pathomorphologic changes and clinical signs of disease, and the basic place among them belongs to the pain syndrome. Consequently, sudden appearance of disease, acuteness of pain syndrome and ischemic disorders in the wall of bowel cause necrosis changes of area of bowel pulling in a process. It is accompanied by the making progress worsening of the patient condition and origin of endotoxicosis.
Obturation intestinal obstruction, unlike strangulated, pass not so quickly. In its clinical picture on the first place there are the symptoms of violation of passage on the intestine (protracted intermittent pain, flatulence), instead of symptoms of bowel destruction and peritonitis.
For high, especially strangulated, intestinal obstruction progressive growth of clinical signs of disease and violation of secretory function of intestine is inherent. Thus the volume of circulatory blood diminishes, the level of haematocritis rises and leukocytosis grows. There are also deep violations of homeostasis (hypoproteinemia, hypokalemia, hyponatremia, hypoxia and others like that). In patients with low intestinal obstruction above-named signs are less expressed, and their growth is related to more protracted passing of disease. Invagination of bowel which can be characterized by the triad of characteristic signs is the special type of intestinal obstruction with the signs of both obturation and strangulation: 1) periodicity of appearance of the intermittent attacks of pain in the abdomen; 2) presence of elastic, insignificantly painful, mobile formation in an abdominal cavity; 3) appearance of blood in the excrement or its tracks (at rectal examination).
The special forms of obturation intestinal obstruction is the obstruction caused by gall-stones. The last are got in the small intestine as a result of bedsore in the walls of gall-bladder and bowel, that adjoins to it. It is needed to mention that intestinal obstruction can be caused by concrement with considerably more small diameter than bowel lumen. The mechanism of such phenomenon is related to irritating action of bilious acids on the bowel wall. The last answers this action by a spasm with the dense wedging of stone in the bowel lumen.
Development of intestinal obstruction caused by gall-stones the attack of colic and clinic of acute cholecystitis precede always. Characteristically, that in the process of development of disease the pain caused by acute cholecystitis calms down, whereupon the new pain characteristic of other pathology — intestinal obstruction appears.
Dynamic intestinal obstruction is divided into paralytic and spastic. Paralytic obstruction often arises after different abdominal operations, inflammatory diseases of organs of abdominal cavity, traumas and poisonings. The reason of spastic intestinal obstruction can be the lead poisonings, low-quality meal, neuroses, hysterias, helminthiasis and others like that. Clinic of dynamic intestinal obstruction is always variable in signs and depends on a reason, that caused it. Disease is characterized by pain in the abdomen, delay of gases and emptying. During palpation the abdomen is blown away, painful, however soft. To diagnose this form of intestinal obstruction is not difficult, especially, if its etiology is known.
Hemostatic intestinal obstruction develops after embolism or thromboses of mesenteric arteries and thromboses of veins, there can be mixed forms. Embolism of mesenteric arteries arises in patients with heart diseases (mitral and aortic failings, heart attack of myocardium, warty endocarditis) and declared by damaging, mainly, upper mesentery arteries. Beginning of disease, certainly, is acute, with nausea, sometimes — vomiting. At first there is a picture of acute abdominal ischemic syndrome, that is often accompanied by shock (frequent pulse, decline of arterial and pulse pressure, death-damp, cyanosys of mucus membranes and acrocyanosis). Patients become excitative, uneasy, occupy the forced knee-elbow position or lie on the side with bound legs.
During the examination the abdomen keeps symmetry, abdominal wall is soft, the increased peristalsis is heard from the first minutes during 1–2 hours (hypoxic stimulation of peristalsis), which later goes out gradually (“grave quiet”). According to the phenomena of intoxication peritonitis grow quickly. At the beginning of disease the delay of gases and emptying is observed, later there is diarrhea with the admixtures of blood in an excrement. When the last is heavy to set macroscopically, it is needed to explore scourage of intestine.
Intestinal obstruction must be differentiated with the acute diseases of organs of abdominal cavity.
The perforation of gastroduodenal ulcer, as well as intestinal obstruction, passes acutely with inherent to it by sudden intensive pain and tension of muscles of abdomen. However, in patients with this pathology, unlike intestinal obstruction, the abdomen is not exaggerated, and pulled in with “wooden belly” tension of muscles of front abdominal wall. There is also characteristic ulcerous anamnesis. Roentgenologic and by percussion pneumoperitoneum is observed. Certain difficulties in conducting of differential diagnostics of intestinal obstruction can arise at atipical passing and in case of the covered perforations.
Acute pancreatitis almost always passes with the phenomena of dynamic intestinal obstruction and symptoms of intoxication and repeated vomiting, with rapid growth. During the examination in such patients, unlike intestinal obstruction, rigidity of abdominal wall and painfulness is observed in the projections of pancreas and positive Korte’s symptom and Mayo-Robson’s. The examination of diastase of urine and amylase of blood have important value in establishment of diagnosis.
Acute cholecystitis. Unlike intestinal obstruction, patients with this pathology complain for pain in right hypochondrium, that irradiate in the right shoulder-blade, shoulder and right subclavian area. Difficulties can arise, when the symptoms of dynamic intestinal obstruction appear on the basis of peritonitis.
The clinic of kidney colic in the signs and character of passing are similar to intestinal obstruction, however, attacks of pain in the lumbar area with characteristic irradiation in genital parts, the thigh and dysuric disorders help to set the correct diagnosis. Certain difficulties in conducting of differential diagnostics also can arise in difficult patients, at frequent vomiting which sometimes can be observed in patients with kidney colic.
During the first 1,5–2 hours after hospitalization of patient complex conservative therapy which has the differential-diagnostic value and can be preoperative preparation is conducted.
It is directed on warning of the complications related to pain shock, correction of homeostasis and, simultaneously, is the attempt of liquidation of intestinal obstruction by unoperative methods.
1. The measures directed for the fight against abdominal pain shock include conducting of neuroleptanalgesia, procaine paranephric block and introduction of spasmolytics. Patients with the expressed pain syndrome and spastic intestinal obstruction positive effect can be attained by epidural anaesthesia also.
2. Liquidation of hypovolemia with correction of electrolyte, carbohydrate and albuminous exchanges is achieved by introduction of salt blood substitutes, 5–10 % solution of glucose, gelatinol, albumen and plasma of blood. There are a few methods suitable for use in the urgent surgery of calculation of amount of liquid necessary for liquidation of hypovolemia. Most simple and accessible is a calculation by the values of hematocrit. If to consider 40 % for the high bound of hematocrit norm, on each 5 % above this size it is needed to pour 1000 ml of liquids.
3. Correction of hemodynamic indexes, microcirculation and disintoxication therapy is achieved by intravenous infusion of Reopolyhlukine and Neohemodes.
4. Decompression of intestine truct is achieved by conducting of nasogastric drainage and washing of stomach, and also conducting of siphon enema. It is needed to underline that technically the correct conducting of siphon enema has the important value for the attempt of liquidation of intestinal obstruction by conservative facilities, therefore this manipulation must be conducted in presence of a doctor. For such enema the special device is used with the rectal tip, by a PVC pipe by a diameter of 1,5–2,0 cm and watering-can of very thin material. A liquid into the colon is brought to appearance of the pain feeling, then drop the watering-can below the level of patient who lies. The passage of gases and excrement is looked after. As a rule, this manipulation is to repeat repeatedly with the use of plenty of warm water (to 15–20 and more litres).
Liquidating of the intestinal obstruction by such conservative facilities is succeeded in 50–60 % patients with mechanical intestinal
obstruction.
Patients with dynamic paralytic intestinal obstruction are expedient to stimulation of peristalsis of intestine to be conducted, besides, necessarily after infusion therapy and correction of hypovolemia. A lot of kinds of stimulation of intestine peristalsis are offered. Most common of them are:
1) hypodermic introduction of 1,0 ml of 0,05 % solution of proserin; 2) through 10 min — 60 ml intravenously stream of 10 % solution of chlorous sodium; 3) hypertensive enema.
Surgical treatment of intestinal obstruction must include such important moments:
1. According to middle laparotomy executed the novocaine blockade of mesentery of small and large intestine and operative exploration of abdominal cavity organs during which the reason of intestinal obstruction and expose viability of intestine is set.
The revision at small intestine obstruction begins from the Treitz’ ligament to iliocecal corner. At large intestine obstruction the hepatic, splenic and rectosigmoid parts are observed intently. Absence of pathological processes after revisioeeds the examination of places of cavity and jamming of internal hernia: internal inguinal and femoral rings, obturator openings, pockets of the Treitz’ ligament, Winslow’s opening, diaphragm and periesophageal opening.
2. Liquidation of reasons of obstruction (scission of connection, that squeezes a bowel, violence of volvulus and node formation of loops, desinvagination, deleting of obturative tumours and others like that).
It is needed to mark that the unique method of liquidation of acute intestinal obstruction does not exist. At the lack of viability of bowel the resection of nonviable area is executed with 30–40 cm of afferent and 15–20 cm of efferent part with imposition of “side-to-side” anastomosis (Pic. 3.3.5) or “end-to-end” (Pic. 3.3.6).
3. Intubation. Decompression of intestine foresees conducting in the small intestine of elastic probe by thickness of 8–9 mm and length of 3–3,5 м with the plural openings by a diameter 2–2,5 mm along all probe, except for part, that will be in the oesophagus, pharynx and outwardly. A few methods of conducting of probe are offered in a bowel (nasogastric, through gastrostomy, ceco- or appendicostoma). Taking it into account, such procedure needs to be executed individually and according to indications.
Each of them has the advantages and failings. In connection with the threat of origin of pneumonia, entering an intubation probe to the patients of old ages is better by means of gastrostomy. Most surgeons avoid the method of introduction of probe through ceco- or appendicostoma because of technical difficulties of passing in a small intestine through a Bauhin’s valve. Today the most wide clinical application has intubation of intestine extracted by the nasogastric method with the use of other thick probe as explorer of the first (by L.J. Kovalchuk, 1981). Such method not only simplifies procedure of intubation but also facilitates penetration through the piloric sphincter and duodenojejunal bend, and also warns passing of intestinal maintenance in a mouth cavity and trachea. Thus probe is tried to be conducted in the small intestine as possible farther and deleted the next day after appearance of peristalsis and passage of gases, however not later than on 7th days, because more protracted sign of probe carries the real threat of formation of bedsores in the wall of bowel.
4. Sanation and draining of abdominal cavity is executed by the generally accepted methods of washing of antiseptic. Draining of the abdominal cavity it is needed from four places: in both iliac areas and both hypochondrium, better by the coupled synthetic drainpipes.
Crohn’s disease is an unspecific inflammatory process of submucosal membrane of gastrointestinal truct with propensity to the segmental lesions and recurrent passing. The local signs of disease exist in different areas of digestive truct organs, however, most frequent and most intensive they are in the distal segment of small intestine, therefore it was named terminal ileitis.
The reason of origin of the Crohn’s disease for today is not finally found out. An infection and allergy are infringement factors. Together with that, granuloma, which is exposed at histological examination with present in its lymphocytic and protoplasmatic infiltrations, grounds to consider that the defined value in the origin of the Crohn’s disease have immune factors. Thus inflammation begins in the submucosal membrane, and afterwards engulfs all bowel walls. The mucus membrane acquires the crimson colouring, there are deep cracks and ulcers. Combination of the damaged areas of mucus membrane with healthy creates a picture similar to the roadway. In future granuloma appears, an inflammatory process goes out outside the wall of bowel and gets to the contiguous organs (large and small intestines, urinary bladder, abdominal wall). In the eventual result there are infiltrate, abscesses and fistula. Finally, it is needed to mark that the people of young ages mainly are ill by terminal ileitis.
The morphological changes are concentrated, mainly, in the terminal part of iliac bowel, anal segment of rectum and appendix. Internal surface is hilly, thickened, swelling, deep ulcers are intermittent with the unchanged areas of mucus. The serous tunic is covered by plural, similar on tuberculosis, knots. Mesentery is sclerosed, regional lymphatic knots are hyperplastic, of whiter-rose color. By the most characteristic microscopic sign of Crohn’s disease is presence of unspecific sarcoid granuloma. Hyperplasia of lymphoid elements of submucosal membrane and formation of fissured ulcers is observed also.
The Crohn’s disease begins from the insignificant signs as a general weakness, increase of temperature of body, intermittent pain, that arises after the reception of meal, diarrhea without some visible features or with the admixture of blood. As this process strikes the terminal segment of small intestine, pain is concentrated in the right iliac area. Together with that, at localization of pathological focus in a colon with an anal segment pain is concentrated by its passing to the anal opening. A granuloma process takes place in the area of oesophagus, abdomen or duodenum, pain can arise up in the area of lesions. With progress of disease on endoscopy examination (proctosigmoidoscopy, fiberoptic colonoscopy, fiberoptic gastroscopy) hyperemia and deep cracks of mucus membrane, ulcers, symptom of “roadway” and stenosis are observed. At roentgenoscopy survey of organs of abdominal cavity in patients with the perforation it is possible to expose pneumoperitoneum, and at contrasting sciagraphy — stenosis of initial part of stomach, presence of ulcers or granuloma in the oesophagus. The examination of the passage on the small intestine enables to eliminate or confirm stenosis (Pic. 3.3.7). Irrigoscopy determines the defect of filling.
At acute passing of terminal ileitis, the pain appears acute in the right iliac area, sometimes intermittent, accompanied by nausea, vomitings, emptying by a liquid excrement with the admixture of blood or delay of emptying. During the examination of patient the abdomen can be exaggerated, tension of muscles and positive symptoms of irritation of peritoneum, high temperature is observed. In the general analysis of blood leukocytosis is present with the change of leukocyte formula to the left. In such difficult situation often only laparotomy helps to specify the diagnosis. The swollen segment of iliac bowel is thus observed with increased mesentery lymphatic knots. The changed area of bowel can perforate in the free abdominal cavity or penetrate in the contiguous loops of large or small intestine. It causes forming of inflammatory infiltrate, and in future —abscess formation. The unoperated abscesses are always inclined to the independent opening in surrounding organs with subsequent formation of fistula ducts.
The disease with the lesions of other parts of small and large intestine passes acutely (granulomatous enteritis, colitis). By palpation in these patients painful infiltrate is exposed, which by the character remind the clinic of invagination. Only the meticulous examination and present data analysis enable to set correct diagnosis. At granulomatous proctitis the plural cracks of mucus membrane without the signs of spasm of sphincter appear often, on the basis of which afterwards there are ulcers, that badly granulate. The same changes can develop on skin round the anal opening.
The chronic forms of disease often pass with insignificant symptoms. From the beginning of disease to establishment of diagnosis sometimes 1–2 years and more pass. Such patients periodically complain for pain, diarrhea, weight loss, increase of body temperature, nausea, vomitings and bleeding from a rectum.
Objectively in the abdominal cavity painful infiltrate is determined, and at laboratory examination — anaemia and hypoproteinemia.
Complications of the Crohn’s disease can be divided into local and general. Among local, formations of fistula which arise on the front abdominal wall between the damaged bowel and surrounding organs are most characteristic (ileoileal fistula, entero-entero, enterovesical fistula). Sometimes fistulas are opened in the area of scars after the operations on the lateral wall of abdomen or in the area of anus. Next to that, stenosis inflammatory infiltrate of bowel can be transformed in acute or chronic intestinal obstruction. Some patients have the obvious threat of perforation of the changed wall of bowel or intestinal bleeding. The protracted passing of disease can be also complicated by malignization. The aphthous ulcers of tongue, node erythema, arthritises and chronic lesionss of liver are general complications.
The Crohn’s disease must be differentiated with the unspecific ulcerous colitis and cancer of colon.
An unspecific ulcerous colitis mainly initially strikes the mucus membrane of all colon. The disease is accompanied by the excreta with the excrement of plenty of blood and mucus. For Crohn’s disease languid passing of disease is characteristic. Acute passing of disease is met considerably rarer, than chronic. The modern methods of endoscopic examination with the biopsy of mucus membrane, which helps to specify diagnosis, are helpful in differential diagnostics.
The cancer of colon is mostly accompanied by formation of deep ulcers and infiltrate. However, for the cancer process slowly progressive passing without the periods of remission is more inherent, thus the disease more frequently ends with the phenomena of intestinal obstruction. At roentgenologic examination on the background the relatively unchanged colon the lonely defect of filling is observed, and during colonoscopy — thrusting out in the lumen of bowel with an erosive surface or signs of disintegration. Histological examination of biopsy material enables to expose cancer cells.
Conservative treatment. The diet of patient, generally, must be ordinary, except for products with bad intestinal uptake. The medicine of the first row is 5-АSК (aminosalicylic acid, sulfasalazone and glucocorticoid). The medicines of the second row are: 6- mercaptopurine, azatiopurine and metronidazole. At diarrhea diphenoxilate is used — 5 ml peroral three times per days, loperamide— 2 mg peroral 3–4 times per days, smecta —1 pack 3 times per days. At the expressed anaemia, to the considerable loss of weight, system complications, relapse of disease after operation prednisolone is applied — for 40–60 mg peroral every day during 1–2 weeks. After that its day’s dose is diminished to 10–20 mg during 4–6 weeks and, in the end, stopped. For patients which are irresponsive to steroid, asatioprine is appointed (2 мг/кг) peroral. Metronidazole in a dose of 400 mg twice a days is used in the case of granulomatous disease of perineum.
The presence of external and internal fistula, stenosis of bowel, perforation and recurrent bleeding is an indication to operative treatment. The method of choice of operation is the segmental resection of the pathologically changed bowel in the distance of 30–35 cm of proximal and distal from the damaged area. The regional limph nodes is also deleted. In case of the perforation of bowel with poured peritonitis, it is recommend not to perform primary anastomosis because of possible insolvency of stitches after the resection. In this connection, afferent and efferent loops exteriorizes on the wall of abdomen as two-channel stoma (Pic. 3.3.8). The passage by an intestine (liquidation of stoma) is restored in 2–4 months after liquidation of the peritonitis signs.
An unspecific ulcerous colitis is a diffuse inflammatory process that is accompanied by the ulcerous-necrosis changes in the mucus membrane of colon and rectums.
Etiology of unspecific ulcerous colitis to this time is not finally found out. This disease is suffered by people in the age from 20 to 40 years. An infectious factor in development of disease for today is not confirmed. However, as the exception of meal of food allergens (milk, eggs) results in the improvement of passing of disease, it is possible to consider that allergy assists to development of inflammatory process. Important significance in genesis of this pathology is also attached to immunological violations. In the blood of patient sensibilizing on the antigen of mucus membrane of colon specifically lymphocytes and immune complexes are found. The antigen-antibody reaction can cause colitis. In most patients with the chronic recurrent unspecific ulcerous colitis a stress situation causes the process of acutening. In future, obviously, there are violations of microcirculation and cellular structures, and also the transport system of cells membranes suffers, that carries potassium and sodium ions. Taking it into account, the timely exposure of disease in which the process is localized and has a reverse tendency, can result in the positive therapeutic effect.
In patients with an unspecific ulcerous colitis the relatively isolated damages of rectum and sigmoid colon, sigmoid colon and transverse colon, so total colitis are met. The necrosis component prevails as the acute form. The wall of bowel in such cases is swollen, hyperemic, with plural erosions and ulcers of irregular form. Its infiltration by lymphocytes, plasmocytes and eosinophils with characteristic formation of granulation, crypt and abscesses are microscopically observed. In patients with a chronic process prevail, mainly, reparative-sclerotic processes. A bowel is deformed, dense, segmentally narrowed. As a result of the disfigured regeneration plural granulomatous and adenomatous pseudopolypuses appear.
Pain in the abdomen and diarrhea is one of basic signs of unspecific ulcerous colitis with emptying from 3 to 20 and more times per days. Thus during defecation the mixture of liquid excrement, mucus and blood are observed. As far as progress of disease the pain has the intermittent character and is localized by the passing of colon. By palpation it is spastic and painful. Frequent diarrhea is brought to dehydration, loss of electrolytes, albumen and anaemia. Patients are weak, there are the strongly expressed signs of intoxication, the temperature of body rises to 40 oС and the psyche is repressed. Characteristic also are tachycardia, decline of arterial pressure, avitaminosises and edemata. Hypochromic anaemia is exposed in the general analysis of blood, leukocytosis, change of leukocyte formula to the left and increased ESR. In plasma of blood the decline of maintenance of potassium and sodium ions and level of general protein, especially albumen are marked. In future there are the progressive degenerative changes of parenchymatous organs.
At endoscopic examination (proctoscopy, fiberoptic colonoscopy) hyperemia of mucus membrane, swollen, contact bleeding, plural erosions, ulcers, festering and necrosis stratifications, are observed. At heavy passing of disease fiberoptic colonoscopy or irrigoscopy always has the danger of perforation or acute bowel dilatation, therefore more rationally it is to conduct it in the period of calming down of inflammatory process. During roentgenoscopy survey of organs of abdominal cavity in case of disease, complicated of acute toxic dilatation, the extended (from 10 to
Acute, especially fulminant form of the unspecific ulcerous colitis passes the heaviest, so the prognosis is always doubtful. Taking it into account, death can come in the first days of disease. Thus an inflammatory process will strike all colon. During 1–2 days the heavy clinical picture is observed with frequent diarrhea with mucus, blood and pus, vomiting, dehydration and loss of weight of body. Next to that, deep intoxication, darkened consciousness, and the temperature of body rises to 39–40 оС is present. The expressed anaemia, tachycardia and hypovolemia are observed. The loss of albumens causes the decline of oncotic pressure and causes dehydration. The disbalance of electrolytes grows with progress of disease, microcirculation gets worse and day’s diuresis goes down. In most cases this form of disease requires urgentoperative treatment (absolute indications).
A chronic recurrent unspecific ulcerous colitis is characterized by the periods of acuteening and remission. Thus in patients with the total lesions of colon in the period of acuteening the heavy degree of disease is observed, and in the period of remission— middle or even easy degree of disease, thus, such “calming down” can last 6 months and more.
A chronic continuous unspecific ulcerous colitis at the total lesions of intestine in most patients passes as middle heavy degree, and in the period of worsening the disease takes heavy shape. The easy form is met, mainly, at presence of inflammatory process in the rectum and sigmoid colon, considerably rarer it is at the lesions of left half of colon and quite rarely — at the total lesions in the period of calming down of the process. Conventionally, the unspecific ulcerous colitis begins from the rectum and engulfs all parts of colon. Thus emptying are 2–3 times per days with the admixtures of mucus, sometimes blood. Thus, diarrhea can be intermittent with constipation. The temperature of body remains within the limits of norm. From the side of global and biochemical analysis of blood noticeable changes do not arise. Weight of body does not diminish. At endoscopic examination hyperemia of mucus membrane, contact bleeding, expressed vascular picture, erosions, point hemorrhages and superficial ulcers are observed. It is needed also to mark that in this situation the presence of erosions must be equated with an ulcerous process.
The middle heavy form of disease of the unspecific ulcerous colitis can be met in patients with the ulcerous colitis and proctosigmoiditis in the period of process acutening. Thus there are the subjective feelings with considerable expression of tenesmus and heartburns.
The chronic forms of unspecific ulcerous colitis both at total and at the left-side lesions of colon, pass at the level of middle heavy degree. Frequency of emptying reaches to 5–10 times with mucus, blood and pain. Low grade fever, general weakness, nausea and loss of appetite appear, and weight of body diminishes on 5–8 kg. Moderate anaemia is exposed in the general analysis of blood, leukocytosis, increased ESR. Among the biochemical indexes of blood hypoproteinemia and hypokalemia are marked. At endoscopic examination of colon there is a considerable hyperemia and edema of mucus membrane, plural erosions, contact bleeding and superficial ulcers.
The heavy form of unspecific ulcerous colitis is at the total lesions, especially with acute, and also chronic recurrent passing of disease. The temperature of body in such patient rises to 39–40 оС, there is diarrhea (more than 10 times per days) with mucus, blood and pus, vomitings, heavy intoxication grows, weight loss on 25–30 kg, acutely expressed anaemia, leukocytosis with the change of leukocyte formula to the left, considerable changes of albuminous and electrolyte exchanges. At endoscopic examination of colon the blood is exposed in its cavity, slid, pus, fibrin incrustation, often pseudopolypuses and almost complete absence of mucus membrane. Roentgenologically some signs of complications of unspecific ulcerous colitis are confirmed.
The complications are divided into local and general. Local complications are: profuse intestinal bleeding, perforation, acute toxic dilatation, stenosis and malignization. To general the following are included: damage of liver (hepatitis, cirrhosis), stomatitis, ulcer of lower extremities, lesions of joints, eyes and skin.
Acute dysentery passes with bloody diarrheas, increased temperature of body, pain in the abdomen. Bacteriological examination of excrement enables to expose dysenteric bacillus and specify diagnosis.
Crohn’s disease (granulomatous colitis) is this local process, that begins from the submucosal layer of bowel and distributes outside of walls with subsequent formation of infiltrate, abscesses and fistula. Exposure of granulomas, and during microscopic examination — accumulation of lymphocytes, neutrophils, protoplasmatic cells and the Pyrohov-Lunghans’ cells are confirmed diagnosis.
The cancer of colon, in particular its enterocolitis and toxicoanemic forms, also often can simulate an unspecific ulcerous colitis. Irrigoscopy, fiberoptic colonoscopy with biopsy and subsequent histological examination almost always help to diagnose cancer process.
Treatment of unspecific ulcerous colitis, certainly, begins with application of conservative facilities. Thus patients with easy and middle heavy forms must be under protracted conservative treatment.
The leading role is taken to the parenteral feed of patients with heavy common exhaustion (hydrolyzate of casein, aminopeptid, amynosol, vamin, alvesin, moriamin, intralipid, lipofundin, glucose and others like that). Electrolytes (chloride of sodium, sulfate of magnesium, chloride of potassium, panangin) and vitamins are entered (В6, В12, С, К, РР and others). Intensity and methods of conservative therapy always must depend on the phase of disease:
а) moderately expressed passing of disease or proctitis — corticosteroid enema and sulfasalazone peroral;
б) at heavy passing is parenteral introduction of liquids, nutritives, blood transfusion, system use of corticosteroids, surgical treatment;
в) at chronic passing is corticosteroids peroral, asatioprine, surgical treatment;
г) at remission is preparations of 5-aminosalicylic acid peroral, examination for the exception of cancer of colon.
The heavy form of passing of disease is absent of effect from the conducted conservative treatment during two weeks and progress of process testifies to the necessity of surgical treatment.
The conservative treatment must include antibacterial agent, antidiarrheal preparations, steroid hormone.
A diet is considered an important factor in treatment of such patient (diet № 4). Thus it is recommended to take a meal to 6 times per days by small portions, withdrawing milk, fruit, vegetables, wheat and rye bread from it. It is possible to appoint unfat meat and fish. Parenteral introduction of vitamins B, С, A, folic acid are helpful.
The basic antiinflammatory facilities are: sulfasalazopreparations (sulfasalazone, salazopirine), salicylazosulfanilamide (salazosulfa¬pyridine, salazodimetoxine) and corticosteroids. Practice showed that sulfasalazone was one of the best antirecurrent facilities.
In patients with easy and middle heavy forms (distal or left-side lesions of colon) sulfasalazone is applied in a dose about
At erosive proctitis and proctosigmoiditis 5 % (100,0 ml) solution of kolargole or extract of camomile in microclyster is applied.
At the heavy forms of ulcerous colitis with fulminant passing and frequent vomiting the treatment is needed to begin with intravenous introduction of 350–380 mg hydrocortisone per day. Thus procedures must proceed to appearance of positive clinical effect and realization of possibility of transition on enteral treatment. Such period lasts on the average of 6–7 days. In future it is recommended to adopt prednisolone peroral.
Sulfasalazopreparations is used in the same dose, as at the middle heavy form of flow of disease. As in patients at this form of disease water-electrolyte and albuminous exchanges are considerably violated, there are the expressed intoxication and anaemia, it is expedient to conduct adequate therapy (intravenously – NaCl solution, glucose, chlorous potassium, albumen, hemodes, protein, whole blood), and also hemodialysis and oxygenotherapy is used.
An absolute indication for surgical treatment is the presence of such complications of unspecific ulcerous colitis as: perforation of wall of bowel, acute toxic dilatation, stenosis, profuse bleeding and malignization. By the choice of method of operation at such pathology it is needed to count colproctectomy with exteriorization of ileostomy.
However, during the perforation of colon or toxic dilatation the operative treatment can be limited to colectomy because proctectomy will be conducted as the next stage.
For patients with total ulcerous colitis with chronic heavy passing and without the tendency to the visible improvement expedient radical operative treatment — colproctectomy with exteriorization of ileostomy. At such tactic postoperative lethality is diminished in 5-6 times, comparative with palliative operations which were conducted earlier.
In Western Europe and
Approximately 85 % of patients for CRC are of over 50 years old, with age frequency of cancer is increased.
The nutrition by fat and albuminous food promotes the elimination to the intestine of bile. Under the act of bacterial flora there is transformation of primary bilious acids to the secondary, which has the carcinogenic and mutagenic activity. A meal with vitamins A, C and that which contains plenty of vegetable cellulose has a braking carcinogenic influence.
The factors of risk which predetermine the origin of cancer of bowel are:
1) diffuse (family) poliposis, which is considered obligate precancer;
2) plural and single adenomatous polypuses;
3) chronic unspecific ulcerous colitis (anamnesis more than 10 years);
4) Crohn’s disease (granulomatous colitis).
Localization. A tumour is mostly lacalized in sigmoid (35–40 % cases) and blind (20–25 % cases) bowels.
Macroscopic forms. Exophytic tumours grow in the lumen of bowel as a polypus or knot and at disintegration have the appearance of ulcer with a dense bottom that is swelling by edges which come forward above the surface of the damaged mucus (saucer-shaped cancer). The endophytic (infiltrate) cancer grows in walls of bowel. The tumour spreads on the perimeter of bowel and engulfs it circular, causing narrowing of its lumen. In the right half of colon exophytic tumours grow, as a rule, in left — endophytic tumours.
Histological structure. Cancer of colon in 95 % cases has the structure of adenocarcinoma. Metastasis takes place by lymphatic and hematogenic ways in regional retroperitoneal lymphatic knots, liver, lungs.
The symptoms of cancer of colon are so numerous and various, that many authors group them in such clinical forms: toxico-anemic, dyspeptic, enterocolitic, obturation, pseudoinflammatory and tumular.
A toxico-anemic form shows up by indisposition, weakness, rapid fatigability, increase of temperature, progressive anaemia. Characteristic for the cancer of right half of colon.
The enterocolitic form is characterized by symptom of complex intestinal disorders: diarrhea, constipation, swelling, grumbling, pain.
The dyspeptic form is characterized by functional disorders of gastrointestinal truct.
An obturation form shows up by intestinal obstruction.
A pseudoinflammatory form is characterized by the symptoms of inflammatory process in the abdominal cavity.
A tumour form passes asymptomatic. A tumour is exposed by chance by a patient or doctor.
Obturation and enterocolitic forms more characteristic for the cancer of left half, other ones — of the right. For the cancer of right half of colon tendency to gradual progress is characteristic, and the tumours of left half often show up suddenly by intestinal obstruction.
Intestinal obstruction, germination ieighbouring organs and tissue, perforation, bleeding are considered as the most frequent complications of colon cancer.
Depending on the clinical signs of colon cancer, a differential diagnosis is to be conducted with appendiceal infiltrate, by different chronic specific and unspecific diseases of colon, and also other organs of abdominal cavity and retroperitoneal space (gall-bladder, pancreas, kidneys, genital organs and others like that), with the tumours of other organs of abdominal cavity and retroperitoneal space.
Radical treatment. Operative treatment is the unique method of radical treatment of colon cancer. The choice of method of operation depends on localization of tumour (Pic. 3.3.11). At cancer of right half of colon right hemicolectomy, (deleting of all right half of colon, including right third of transversal colon and distal segment of iliac bowel by length 20–25 cm) is conducted. In patients with tumours of left half of colon left hemicolectomy (segment from middle or from left third of transversal colon to overhead part of sigmoid is resected) is executed. At cancer of transversal colon, middle and distal parts of sigmoid bowels the resection of the damaged area is conducted, stepping back 5-
During treatment with palliative purpose (at presence of solitary metastases) operations in a radical volume with removing of metastatic knot (in a liver) or subsequent chemotherapy (by 5- fluorouracil) can be used.
In recent years for the improvement of remote results treatment is applied by the adjuvant chemotherapy and intensive preoperative gamut-therapy.
The remote results of treatment of patients on the initial stages of CRC are fully satisfactory. At I stages the five-year survival is 85-100 %, at II — 65–70 %, at III — 25–30 %. On the whole at the I–III stages the five-year survival is 45 %.
Persons who refused from operative treatment perish in a short time. The combined treatment improves remote results approximately on 15–20%.
The gastric ulcer is the chronic disease with polycyclic passing. The main typical of peptic ulcer is the presence of ulcerous defect in a mucous tunic. One of basic places belongs among the gastroenterology diseases to this pathology. Such phenomenon explained by not only considerable distribution of disease but also those dangerous complications which always accompany gastric ulcers.
Frequency of morbidity on the peptic ulcer among the adult population is about 4 %. More frequent age in patients with gastric ulcers is 50–60 years.
To development mechanism of disease is still not enough studied. From a plenty of different theories in relation to genesis of peptic ulcer no one able to explain the disease. So, each of such factors as neurogenic, mechanical, inflammatory, vascular is present in the mechanism of development of peptic ulcer. Consider for today, that disturbance between the factors of aggression and defense of mucous tunic arose peptic ulcer. To the first factors belong: hydrochloric acid, pepsin, reverse diffusion of ions of hydrogen, products of lipid hyperoxidizing. To the second: mucus and alkaline components of gastric juice, property of epithelium of mucous tunic to permanent renewal, local blood flow of mucous tunic and submucous membrane.
In the terminal stage of mechanism of origin of gastric ulcers important role has the peptic factor and disturbance of trophism of gastric wall as a result of local ischemia. It confirmed by decreasing of blood flow in the wall of stomach at patients with ulcers on 30–35 % compared to the norm. It is proved, that a local and functional ischemia more frequent arises up on small curvature of stomach in the areas of ectopy of the antral mucous tunic in acid-forming. Exactly there ulcers appear.
Important part in ulcerogenesis is acted by duodenogastric reflux and gastritis. Also, gastrostasis can provoke hypergastrinaemia and hypersecretion and formed gastric ulcers.
Numeral scientific developments of the last years testify to the important infectious factor in the mechanism of origin of peptic ulcer conditioned, mainly, by helicobacter pylori.
Such stages of disease are distinguished: erosion, acute and chronic ulcers.
Erosions, mainly, are plural. Their bottom as a result of formation of muriatic haematine is black, edges — infiltrated by leucocytes. A defect usually does not penetrate outside muscular tissue of the mucous tunic. If necrosis gets to more deep layers of wall of stomach, a acute ulcer develops. It has a funnel-shaped form. Bottom is also black, edges is swelled. Chronic ulcers are mainly single, sometimes arrive to the serous layer. A bottom is smooth, sometimes hilly, edges is like elevation, dense.
For today the most known classification of gastric ulcers by Johnson (1965). There are three types of gastric ulcers are distinguished: I – ulcers of small curvature (for
The complaints of patients with the gastric ulcer always give valuable information about the disease. The detailed analysis of their anamnesis allows to pay attention to the possible reasons of origin of ulcer, time of the first complaints, to the changes of symptoms.
Pain. A pain symptom in the peptic ulcer disease is very important. There are typical passing for this disease: hunger – pain – food intake – facilitation – again hunger – pain – food intake – facilitation (so during all days). Night pain for the gastric ulcer is not typical. The such patients rarely wake up in order to take a food. For diagnostics of ulcer localization it is important to know the time of appearance of pain. Between acceptance of food and appearance of pain it is the shorter, than the higher placed gastric ulcer. Thus, at patients with a cardial ulcer pain arises at once after the food intake, with the ulcers of small curvature — in 50–60 minutes, at pyloric localization — approximately in two hours. However this feature it is enough relative and some patients in general do not mark dependence between food intake and pain. In other patients the pain attack is accompanied by the salivation.
A epigastric regioear the xiphoid process is typical localization of pain. The irradiation of pain is not usual for gastric ulcers. Irradiation occur in patients with penetration and depended from organ, in which an ulcer penetrates.
At the examination of ulcerous patient it is expedient to determine the special pain points: Boas (pain at pressure on the left of the Х–ХII pectoral vertebrae), Mendel (pain at percussion on the left to epigastric region).
Vomiting, the sign of disturbance of motility function of stomach, is the second typical symptom of gastric ulcer. More frequent gastrostasis arises as a result of failure of stomach muscular, it atony which can be effect of organ ischemia. Vomiting could arises both on empty stomach and after food intake.
Heartburn is one of early symptoms of gastric ulcer, however at the prolonged passing of disease it can be hidden or quite disappear. Often it precedes of pain arising (initial heartburn) or accompanies a pain symptom. Mostly heartburn arises after the food intake, but can appear independently. it is observed not only at hypersecretion of the hydrochloric acid, but at normal secretion, even reduced acidity of gastric juice.
The belching at gastric ulcers is examined rarely, more frequent in patients with cardial and subcardial ulcers. It is necessary to bind to disturbance of function of cardial valve.
The general condition of patients with the uncomplicated gastric ulcer usually satisfactory, and in a period between the attacks — even good. However for most patients lost of the body weight and pallor are typical. In a epigastric region hyperpigmental spots are examined after the prolonged application of hot-water bottle. At palpation of stomach in this area sometimes appears local painful. It is needed also to check up “noise of splash”, the presence of which can be the sign of possible gastrostasis.
At the examination of mouth cavity a tongue has whiter-yellow incrustation. In patients with penetration ulcers and disturbances evacuations from a stomach examined dryness of tongue.
Stomach, as a rule, regular rounded shape, however during the pain attack is pulled in. There is antiperistalsis arises during the pylorostenosis.
The increased secretion of hydrochloric acid in patients with gastric ulcers observed rarely and, mainly, at prepyloric ulcer localizations. Mostly secretion is normal, and in some patients is even reduced.
X-Ray examination. The direct signs of ulcer at X-Ray examinations are: symptom of “Haudek’s niche” (Pic. 3.2.1), ulcerous billow and convergence of folds of mucous tunic. Indirect signs: symptom of “forefinger” (circular spasm of muscles), segmental hyperperistalsis, pylorospasm, delay of evacuation from a stomach, duodenogastric reflux, disturbance of function of cardial part (gastroesophageal reflux).
Gastroscopy can give important information about localization, sizes, kind of ulcer, dynamics of its cicatrization, and also allow to perform biopsy with subsequent histological examination.
The gastric ulcer passing can be acute and chronic. Acute ulcers arise as answer for the stress situations, related to the nervous overstrain, trauma, loss of blood, some infectious and somatic diseases. By a diameter ulcers has from a few millimeters to centimeter, a round or oval form with even edges. Thus in most cases clinically observed clear ulcerous clinical signs. If complications is absent (bleeding, perforation) such ulcers treated and mostly heal over.
G.J. Burchynskyy (1965) such variants of clinical flow distinguished:
1. Chronic ulcer which does not heal over long time.
2. Chronic ulcer which after the conservative therapy heals over relatively easily, however inclined to the relapses after the periods of remission of a different duration.
3. Ulcers, which localization are had migrant character. Observed in people with acute ulcerous process of stomach.
4. Special form of gastric ulcer passing after the already carried disease. Passed with the expressed pain syndrome. Characterized by the presence in place of ulcerous defect of scars or deformations and absence of symptom of “niche”.
There are such complications can develop in patients with gastric ulcer: penetration, stenosis, perforation, bleeding and malignization.
Chronic gastritis, as well as at an gastric ulcer, characterized by the pain syndrome, that arises after the food intake. In such patients it is possible to observe nausea and vomiting by gastric content, heartburn and belch. However, unlike an gastric ulcer, for gastritis typical symptom of “quick satiation by a food”. Unsteady emptying, diarrhea also more inherent to gastritises. At gastric ulcer more frequent the delays are observed, constipation for 4–5 days.
The cancer of stomach, it is comparative with an gastric ulcer, has considerably more short anamnesis. The most typical clinical signs of this pathology are: absence of appetite, weight loss, rapid fatigability, depression, unsociability, apathy. In such patients X-Ray examination expose the “defect of filling”, related to exophytic tumor and deformation of walls of organ. A final diagnosis is set after the results of multiposition biopsy of shady areas of mucous tunic of stomach.
Differential diagnostics also needs to be conducted with the so called precancerous states: gastritis with the achlorhydria; chronic, continuously recurrence ulcers, poliposis and Addison-Biermer anemia.
Conservative treatment of gastric ulcer always must be complex, individually differentiated, according to the etiology, pathogeny, localization of ulcer and character of clinical signs (disturbance of functions of gastroduodenal organs, complication, accompanying diseases).
Conservative therapy must include: a) anticholinergic drugs (atropine, methacin, platyphyllin) and myolitics (papaverine, halidor, nospanum); antiacid drugs — in accordance with the results of pH-metry; b) Н2- blocker histamine receptor (ranitidine) — 150 mg in the evening, famotidine — 40 mg at night, roxatidine — 150 mg in the evening, c) reparative drugs (dalargin, solcoseryl, actovegin) — for 2 ml 1–2 times per days; д) antimicrobial drugs (de-nol, metronidazole, semisynthetic antibiotic); е) vitamins of group B and symptomatic medicine.
Treatment of patient with a gastric ulcer must continues not less than 6–8 weeks.
Surgical treatment must performed in cases:
a) at the relapse of ulcer after the course of conservative therapy;
b) in the cases when the relapses arise during supporting antiulcer therapy;
c) when an ulcer does not heal over during 1,5–2 months of intensive treatment, especially in families with “ulcerous anamnesis”.
d) at the relapse of ulcer in patients with complications (perforation or bleeding);
e) at suspicion on malignization ulcers, in case of negative cytological analysis.
The choice of method of surgical treatment of gastric ulcer depended from localization and sizes of ulcer, presence of gastro- and duodenostasis, accompanying gastritis, complications of peptic ulcer (penetration, stenosis, perforation, bleeding, malignization), age of patient, general condition and accompanying diseases. In patients with cardial localization of ulcer the operation of choice is the proximal resection of stomach, which, from one side, allows to remove an ulcer, and from other — to save considerable part of organ, providing it functional ability (Pic. 3.2.2). In case with large cardial ulcers, when the vagus nerves pulled in the inflammatory infiltrate and it is impossible to save integrity even one of them, operatioeeds to be complemented by pyloroplasty. It will give possibility to warn pylorospasm and gastrostasis, which in an early postoperative period can be the reason of anastomosis insufficiency and other complications.
At the choice of method of surgical treatment of gastric ulcers with subcardial localization on small curvature without duodenostasis it is better to apply the methods of stomach resection with saving of passage through a duodenum.
For this purpose we are developed the method of segmental resection of stomach with addition selective proximal vagotomy. The redistribution of gastric blood flow between the functional parts of stomach as reply to medicinal vagotomy (intravenous introduction 1,0 ml 0,1 % solution of atropine of sulfate) is studied. Hyperemia of acid-forming part of stomach comes after introduction of preparation. The functional scopes of stomach parts are determined. The border between acid-forming and antral parts are the most frequent localization of gastric ulcers.
During this operation middle laparotomy is performed, intravenously entered 1,0 ml 0,1 % solution of atropine, then the scopes of functional stomach parts are identified and by stitches-holders is marked a intermedial segment. Selective proximal vagotomy is performed. After mobilization of large curvature of stomach within the limits of intermedial segment it resection is performed. After that gastro-gastro anastomosis “end-to-end” is formed (Pic. 3.2.3).
The analysis of supervisions of the patients operated by such method in postoperative period has good results. It allows to recommend this operation for clinical practice, in case of gastric ulcers of subcardial localizations, without duodenostasis, penetration, malignization or nerves Latarjet damaging.
The operation of choice in patients with subcardial ulcers and duodenostasis is gastric resection by Billroth II.
At the choice of method of surgical treatment of ulcers which are localized in upper and middle third of stomach, it is necessary to consider such factors, as absence of penetration in a small omentum and absence of the duodenostasis. In such patients is performed segmental resection of stomach with ulcer removing with selective proximal vagotomy. In case of penetration ulcer in a small omentum with involvement in infiltrate Latarjet nerves, such operation is impossible because of future spasm of pylorus and gastrostasis. If duodenostasis is absence than better to apply pylorus-saving resection by Maki-Shalimov. In patients with duodenostasis better to apply gastric resection by Billroth II.
At the border of gastric resectioear pyloric sphincter can be spasm and gastrostasis in a postoperative period . Avoiding such complication is possible, if this border of gastric resection passes no more than
Patients with antral ulcers without the duodenostasis performed the gastric resection by Billroth I (Pic. 3.2.6), and on presence of duodenostasis – Billroth II.
Prepiloric ulcers is similar to the ulcers of duodenum. Such localization of gastric ulcers without malignization allow to perform selective proximal vagotomy. However, at large prepyloric ulcers with penetration without duodenostasis is better to perform the gastric resection by Billroth I and on presence of duodenostasis – by Billroth II.
By contra-indication to operations with saving of food passing through the duodenum are also decompensated pylorostenosis , functional gastrostasis and duodenostasis. In such patients it is better to perform gastric resection by Billroth II.
The duodenal ulcer is the chronic recurrent disease which characterized by ulcerous defect on a mucous tunic of duodenum. Pathology often makes progress with complications development.
There are some etiologic factors of the duodenal ulcer: Helicobacter pylori, emotion tension and neuropsychic stress overstrain, heredity and genetic inclination, presence of chronic gastroduodenitis, disturbance of diet and harmful habits (alcohol, smoking). In pathogenesis of peptic ulcer a leading role is played disturbance of equilibrium between aggressive and projective properties of secret of stomach and it mucous tunic. The aggressive factors are vagus hyperfunctioning and hypergastrinemia; hyperproduction of hydrochloric acid and pepsin, and also reverse diffusion of the ions Н+, action of bilious acids and isoleucine, toxins and enzymes of helicobacter pylori (HP). There are factors which are contribute to ulcerogenic action: disturbance of motility of stomach and duodenum, ischemia of duodenum, and metaplasia of the epithelium.
Morphogenesis of duodenal ulcer fundamentally does not differ from ulcer in a stomach. Chronic ulcers are mainly single, is localized on the front or back wall of bulb (bulbar ulcer) and only in 7–8 % cases – below it (postbulbar ulcer). The plural ulcers of duodenum are met in 25 % cases.
Pain in the epigastric region is the most expressed symptom of duodenal ulcer, often with displacement to the right in the projection area of bulb of duodenum and gall-bladder. Also for this pathology is typical the pain, that arises in 1,5–2 hours after food intake, “hungry” and nightly pain. As a rule, it is acute, sometimes unendurable, and is halted only after the use of food or water. Such patients complains for the seasonal exacerbation, more frequent in spring and in autumn. However exacerbation can be also in winter or in summer. In the acute period of disease heartburn often increases. However heartburn is the frequent symptom of cardial insufficiency and gastroesophageal reflux. For an duodenal ulcer the acute burning feeling of acid in a esophagus, pharynx and even in the cavity of mouth is especially typical. Often are belch by air or sour content, excessive salivation. Vomiting is not a typical symptom for duodenal ulcer. More typical sign is nausea. Sometimes for facilitation patients wilfully cause vomiting. These symptoms, arises in the late periods of passing of duodenal ulcer.
Intensity of pain and dyspepsia syndromes depends both on the depth of penetration and from distribution of ulcerous and periulcerous processes. Superficial ulceration within the mucous tunic, as a rule, does not cause the pain because it does not have sensible receptors. However, more deep layers of wall (muscular and especially serous) have plural sensible vegetative receptors. Therefore, on deepening and distribution of process arises visceral pain. At evident periulcerous processes and penetration of ulcers to neighboring organs and tissues, usually, a parietal peritoneum, that has spinal innervation, is pulled in. Pain becomes viscero-somatic, more intensive. A such pain syndrome (with an irradiation in the back) is typical for low postbulbar ulcers and bulbous ulcers of back wall, which penetrates in a pancreas and hepato-duodenal ligament. Usually such patients has good appetite. Some of them limit themselves in acceptance of ordinary food, go into to the dietary feed by small portions, and some — even hold back from a food, being afraid to provoke pain, and as a result of it weight is lost. Some of patients feeds more intensive and often.
The psychical status of patients often are changed as a asthenoneurotic syndrome: irritates, decline of working capacity, indisposition, hypochondria, abusiveness.
An inspection, as a rule, gives insignificant information. In many cases on the abdominal skin it is possible to notice hyperpigmentation after application of hot-water bottle. During the pain attack patients often occupy the forced position. At superficial palpation on the abdominal wall determined hyperesthesia in ulcer projection. In the epigastric region, during deep palpation, it is possible to define pain and muscular tension, mostly moderate intensity. There is important symptom of local percussion painful (Mendel’s symptom): percussion by fingers in the symmetric epigastric areas provoke pain in the ulcer, which is increased after the deep breath. The roentgenologic and endoscopic are main diagnostic methods. The symptom of ulcerous “niche” is a classic roentgenologic sign. It is depot of contrast agent, which is corresponded to ulcerous defect, with clear contours and light bank to which converged fold mucus. Cicatricial deformation of bulb of duodenum as a shamrock, butterfly, narrowing, tube, diverticulum and other forms is the important sign of chronic ulcerous process. A roentgenologic method is especially important for determination of configuration and sizes of stomach and duodenum, and also for estimation of motility functions. X-Ray examination is the main method at the peptic ulcer complicated by stenosis, with disturbance of evacuation, duodenostasis, duodenal-gastric reflux, gastroesophageal reflux, diverticulum. But by X-Ray examination is difficult to diagnose small superficial ulcers, acute ulcers, erosions, gastritises and duodenitises. The most informing method in such cases it endoscopy.
During endoscopy examination it is possible to define localization, form, sizes and depth of ulcer. During bleeding grumes, trickle or pulsating of blood are observed. By irrigation by styptic solutions, by cryocoagulation, by laser coagulation endoscopy allows to secure hemostasis. Endoscopy allows to perform the biopsy of ulcer tissues for determination of possible malignization.
In patients with low postbulbar ulcers the clinical signs are more expressed. It characterized by late (in 2–3 hours after food intake) and intensive “hungry” and nightly pain, that often irradiate to the back and to the right hypochondrium. The postbulbar ulcers are inclined to more frequent exacerbation, and also to more frequent complications, such, as penetration, stenosis and bleeding.
The are more frequent ulcerous bleeding (the bulbous happen in 20–25 % cases, postbulbar — in 50–75 %), perforations (10–15 % cases). Penetration, stenosis and malignization in patients with duodenal ulcers are observed rarely.
Penetration is frequent complication of “low” and postbulbar ulcers of duodenum, which are placed on posterior, posterior superior and posterior inferior walls. Penetrates, usually, deep chronic ulcers, by passing through all layers of duodenum ieighboring organs and tissues (head of pancreas, hepato-duodenal ligament, small and large omentum, gall-bladder, liver). Such penetration is accompanied by development of inflammatory process in the neighboring organs and surrounding tissues and forming of cicatrical adhesions. A pain syndrome becomes more intensive, permanent and often pain irradiated in the back. Sometimes in the area of penetration it is possible to palpate painfully infiltrate.
The duodenal ulcer must be differentiated from acute and chroniccholecystitis, pancreatitis, gastroduodenitis. Endoscopy is help to diagnose duodenal ulcer.
Conservative treatment. In most patients after conservative treatment an ulcer heals over in 4–6 weeks. Warning of relapses can be carried out by only supporting therapy during many years.
The best therapy of duodenal ulcer is associated with a helicobacter infection, there is the use of antagonists of Н2- receptors of histamine (renitidine— 300 mg in the evening or 150 mg twice for days; famotidine— 40 mg in the evening or 20 mg twice for days; nisatidine — 300 mg in the evening or 150 mg twice for days; roxatidine — 150 mg in the evening) in combination with sucralfate (venter) — for
In treatment of duodenal ulcer used chinolitics and miolitics (atropine, methacin, platyphyllin), and also mesoprostol (200 mg 4 times per days) and omeprasole (20 or 40 mg on days).
Such treatment of patients with the duodenal ulcer must be 4–6 weeks. If complications absents there is no necessity in the special diet.
Because of appearance of new pharmaceutical preparations and modern therapeutic treatment, indication to the operative methods narrowed. But the number of acute complications of duodenal ulcer does not go down, especially bleeding and perforations which require the urgent surgery.
Indications to the elective operation:
1. Passing of duodenal ulcer with the frequent relapses which could not treated conservatively.
2. Repeated ulcerous bleeding.
3. Stenosis of outcome part of stomach.
4. Chronic penetration ulcers with the pain syndrome.
5. Suspicion for malignization ulcers.
Methods of surgical treatment.
At patients with the duodenal ulcer three types of operations are distinguished:
— organ-saving operations;
— organ-sparing operations;
— resection.
From them the better are: organ-saving operations with vagotomy, excision of ulcer and drainage operation.
Types of vagotomy: trunk (TrV) (Pic.. 3.2.7), selective (SV) (Pic. 3.2.8), selective proximal (SPV) (Pic. 3.2.9). Selective proximal vagotomy is optimal in the elective surgery of duodenal ulcer. However in urgent surgery a trunk, selective or selective proximal is often used in combination with drainage operations.
Drainage of the stomach operations are: Heineke-Mikulicz pyloroplasty, Finney pyloroplasty, submucous pyloroplasty by Diver-Barden-Shalimov, gastroduodenostomy by Jaboulay, gastroenteroanastomosis.
It is necessary to mark that “clean isolated” SPV, performed in patients with duodenal ulcer, often (in 15–20 % cases) results in the relapses. The considerably less number of relapses (8–10 %) is observed after SPV in combinations with drainage operations. Especially dangerous is the relapses of the ulcers placed in the projection of large duodenal papilla, after gastroduodenostomy by Jaboulay.
The least number of relapses of duodenal ulcer is observed after organ-saving operations, that combine SPV and ulcer excision.
If ulcer localized on the anterior surface of duodenal bulb it can be performed by the method Jade (Pic. 3.2.13) with subsequent to the pyloroplasty by Heineke-Mikulich.
At patients with decompensate stenosis and expressed dilatation and by the atony of stomach it is needed to apply the classic resection of stomach depending on possible damping-syndrome by Billroth -I or Billroth -II.
The choice of subtotal resection of stomach needs to be done at suspicion for malignization or at histological confirmed malignization ulcers. In a duodenum this process happens very rarely.
Ulcerous stenosis is complication of Peptic ulcer or duodenum, which characterized by narrowing.
Stenosis of outgoing part of stomach and duodenum of ulcerous origin arises as a result of scarring and common morphological changes around an ulcer. Narrowing, disturbance of the coordinated motility of goalkeeper come as a result of it and creates the obstacle to the even moving of stomach content to the duodenum.
Such pathology in the compensation stage arises hypertrophy of the stomach walls. The pyloric ring has a 0,5–0,7 cm in diameter. The mucous tunic of pyloric part of stomach is thickened, with rough folds. Muscular fibers are hypertrophied and solid. Histological hyperplasia of pyloric glands is observed.
During decompensation the muscular layer of stomach higher stenosis becomes thinner, tone of him goes down, and a pyloric ring narrows to a few millimetres. Microscopically present atrophy of mucous tunic and muscular fibers, vessels sclerosis. A stomach collects the form of the stretched sack which goes down to the level of small pelvis.
The first signs of stenosis can be exposed already in eight-ten years from the beginning of the peptic ulcer disease., Mainly, this is narrowing and rigidity and disturbance of retractive activity of goalkeeper, which create a barrier for transition of stomach content to the duodenum.
In the stage of the compensated stenosis hypertrophy of wall of stomach develops and tone of muscular shell rises. Hereupon gastric content, slowly, but passes through the narrowed area of stomach output. In this stage patients, usually, complained about feeling of plenitude in a epigastric area after food intake, periodic vomitings by sour gastric content. On empty a stomach by a stomach pump 200–300 ml gastric content is removed.
In the subcompensated stage muscular layer of stomach becomes thinner. Tone of him goes down, a peristalsis relaxes, and it looks like the stretched sack. Evacuation disorders is increased. Fermentation and rotting developed in stagnant gastric content. On this stage of disease development patients, usually, complain for the permanent feeling of weight in epigastric region and regurgitation with an unpleasant “rotten” smell of sulphuretted hydrogen.
Vomiting becomes systematic (once or twice on a day) up to half of liter per day. On empty a stomach it possible to aspirate from it more 500 ml of content with the food used the day before.
In the decompensation stage of the clinical sighn make progress quickly. There are heavy disturbances of the general condition of patient, considerable loss of weight (to 30–40 %), acutely expressed dehydration of organism, hypoproteinemia, hypokalemia, azotemia and alkalosis. In case of the protracted neglected disease, as a result of progress of disturbances of metabolism, there can be a convulsive syndrome (gastric tetany). Vomiting in this stage not always can be considered by a typical sign, in fact patients often renounce to adopt a food, and a stomach acquires considerable sizes, overdistension form, it tone is violated and atrophy of wall comes. In such patients in a epigastric area it is possible to define the contours of the stretched stomach, with a slow peristalsis,. In the distance it is possible to hearken the splash. By a probe from a stomach to 1.5-
A diagnosis is set according to a typical syndrome, results of sounding of stomach, rontgenoscopy, at which by contrasting of a barium expose stenosis of initial part of stomach or duodenum, determines it origin and estimate a degree.
Roentgenologically in the compensation stage stomach iormal sizes, it peristalsis deep, increased, evacuation of content proceeds no more than 6 hours. In the stage of subcompensation a stomach is megascopic, a peristalsis is loosened, evacuation stays too long to 24 hours. During decompensation a stomach is considerably extended as a sack, deformed, the waves of antiperistalsis can take place, a contrast stays too long more than 24–48 hours. The method of the double contrasting by a barium and air considerably facilitates diagnostics.
Determination of stomach motility has not only diagnostic but also prognostic value for the choice of method of operation.
In the stage of compensation motility of stomach is well-kept, often even increased. With the increasing the degree of stenosis the motility disturbance increased, up to gastroplegia.
In the biochemical blood test is marked the decline of content of albumen to 54–48 g/l; potassium — to 2,9–2,5 mmol/l; chlorides — to 85–87 mmol/l. The changes of such indexes are most expressed at patients with gastrogenous tetany.
The study of secretory function of stomach allows to define the degree of compensation of stenosis and importent at the choice of adequate method of operation.
Gastroscopy with a biopsy is the enough informing method of examination of such patients. By this method is possible to determine a reason and degree of stenosis, and also state of mucous tunic of stomach.
Stenosis of the output part of stomach and duodenum of ulcerous origin it is needed to differentiate with functional gastrostasis and narrowing of tumour and chemical genesis.
Functional gastrostasis more frequent meets at women. Basic, that distinguishes it from other pathologies, there is absence of some organic changes in the area of pyloric part of stomach or in a duodenum, that can be exposed during fibergastroscopy.
Differential diagnostics of stenosis of tumour genesis, as a rule, also does not cause the special difficulties. A diagnosis is finally confirmed by histological examinations of the biopsy material taken during endoscopy.
Postburn stenosis of piloroantral area of stomach observed, from data of statistics, more than in 25 % cases of patients with the burn of esophagus. In anamnesis in each of such patients takes place by mistake or the intentionally taken an a swig at acid, alkali or other chemical matter. Some diagnostic difficulties can arise up at the isolated postburn stenosis of pyloric part of stomach. The however attentively collected anamnesis and professionally conducted endoscopic examination enable to set a correct diagnosis.
Treatment of ulcerous stenosis of piloroantral part of stomach and duodenum must be exceptionally operative. A method depend on many factors: degree of stenosis, these secretory and motility functions of stomach, age of patient, presence of accompanying diseases and others like that. In the compensated and subcompensated stages of stenosis and at enough well-kept functions of stomach it is possible to perform of organ-saving operations (vagotomy with drainage stomach operations, economy resection of stomach). At growth of the signs of stenosis and disturbance of basic functions of stomach, the volume of operation must be increased up resection by the Bilroth’s second method.
At the patients and older age persons with heavy accompanying pathology is performed minimum surgery —gastroenteroanastomosis.
Preoperative preparation must be strictly individual.
At patients with insignificant disturbances of gastric motor activity (stage of compensation, subcompensations) and with good level of metabolism indexes it is better to shorten preoperative preparation in time. Such patients, usually, operated on 3–4 day. Preparation before operation at patients with decompensated pilorostenosis must be directed for the correction of metabolism disturbances. Such patients must receive transfusion of liquid up to 2,5–3 l per day with content of the ions К+, Na+, Са++, amino acid and glucose; plasma, albumen. Twice on days performed decompression and washing of stomach and anti-ulcerous therapy. Effective preoperative preparation in such patients requires 5–7 days, sometimes more.
The typical perforation of gastric or duodenum ulcer is strengthening of necrosis process in the area of ulcerous crater with subsequent disturbance of integrity of wall, that result to the permanent effluence of gastroduodenal content and air in a free abdominal cavity.
In 50,7 % cases perforates the ulcers of duodenum, in 42,8 % are ulcers of pyloric part of stomach, in 4,8 % are ulcers of small curvature of body of stomach and in 0,7 % are cardial ulcers.
Ulcers, which lie on the front wall of stomach and duodenum more frequent give the perforation with general peritonitis, while ulcers on a back wall — perforation with adhesive inflammation.
The reasons of ulcers perforation are: exacerbation of peptic ulcer, harmful habits, stresses, professional, athletic overexertion, faults in the feed and abuses by strong waters.
In pathogeny of acute perforation important: progressive necrosis processes in the area of ulcerous crater with activating of virulent infection; hyperergic type of local vaculo-stromal reaction with the thrombosis of veins of stomach and duodenum; local manifestation of autoimmune conflict with accumulation of sour mucopolysaccharides on periphery of ulcer and high coefficient of plasmatization of mucous tunic (К.I. Mishkin, А.А. Frankfurt, 1971).
The clinical picture of perforation is very typical and depends on distribution of inflammatory process and infection of abdominal cavity. In clinical passing of the perforations distinguish three phases: shock, “imaginary prosperity” and peritonitis (Mondor, 1939).
For the phase of shock (to 6 hours last) typical very acute pain in epigastric region (Delafua compares it to pain from the stab with a dagger) with an irradiation in a right shoulder and collar-bone, a face is pale, with expression of strong fear, lines become (facies abdominalis) acute, a death-damp irrigates skin covers. A pulse is at first slow (vagus pulse), later becomes frequent and less filling. Sometime observed the reflex vomiting and delay of gases. Arterial pressure is reduced. On examination stomach is pulls in, does not take part in the act of breathing. At palpation is “wooden belly stomach”, especially in an upper part, where, usually, there is most pain. Positive Blumberg’s sign. At percussion is disappearance of hepatic dullness (the Spizharnyy symptom). At rectal examination expose painful in the area of rectouterine or rectovesical pouch (the Kulenkampff’s symptom).
The phase of shock changes by the phase of “imaginary prosperity”, when the reflex signs go down: the general condition of patient gets better, a pulse becomes normal, arterial pressure rises, a stomach-ache diminishes partly. However observed tension of muscles of front abdominal wall, positive Blumberg’s sign.
The phase of “imaginary prosperity” in 6–12 hours from the moment of perforation changes by the phase of peritonitis: a pulse is frequent, a stomach is swollen through growing flatulence, intestinal noises are not listened, a face acquires the specific kind — facies Hippocratica —the eyes fall back, lips turn blue, a nose becomes sharp, a tongue becomes dry and furred, breathing superficial and frequent, a temperature rises.
Covered perforation (А.М. Shnicler, 1912). At this pathology the perforative hole after a perforation is closed by a fibrin, by a omentum, by the fate of liver, sometimes — piece of food. After that some amount of stomach content and air gets in an abdominal cavity. After the protection a stomach-ache diminishes, but proof tension of muscles of front abdominal wall, especially overhead quadrant of stomach is kept. At percussion hepatic dullness is doubtful. During x-Ray examination it is not always possible to mark gas in right hypochondrium (Pic. 3.2.14).
Consequences of passing of the covered perforation: the repeated perforation with development of classic clinical signs can come; at separation of process from a free abdominal cavity a subdiaphragmatic or subhepatic abscess is formed; complete closing of defect by surrounding tissue with gradual convalescence of patient.
The atypical perforation is the perforation, at which gastric or intestinal content gets not to the abdominal cavity, but in retroperitoneal space (ulcers of back wall of duodenum), large or small omentum (ulcers of small curvature of stomach), hepato-duodenal ligament.
In such patients during a perforation pain is not acutely expressed. During palpation observed insignificant rigidity of muscles of front abdominal wall. On occasion, especially on the late stages of disease, there can be hypodermic emphysema and crepitation.
The diagnosed perforated gastric and duodenum ulcer is an absolute indications to operation. Preoperative preparation must include: in I phase are antishock action; in the II and III phases — reanimation preparations, introductions of antibiotics for 2–3 hours before operation, liquidation of hypovolemia by salt blood substitutes (solution of chlorous sodium), solutions of dextran (polyhlukine, reopolihlukine, hemodes). Amount of liquid necessary for correction of hypovolemia, calculate after hematokrit by central vein pressure. Taking for the norm of hematokrit 40 %, on each 5 % higher norms need to be poured 1000,0 ml liquids.
Conservative treatment (method of Tejlor, 1946) can be justified at the refusal of patient from operation or in default of conditions for its implementation.
It must include:
— permanent nasogastral aspiration of gastric content;
— introduction of preparations which brake a gastric secretion (atropine, Н2- blockers and others like that);
— introduction of antibiotics;
— correction of metabolism;
— laparocentesis with drainage and closed lavage of the abdominal cavity.
In the decision of question about the choice of method of operative treatment of perforated gastroduodenal ulcers the important value has the following factors: localization of ulcer, clinico-morphological description of ulcer (perforation of acute or chronic ulcer), connected with the perforation such complications of ulcer, as bleeding, cicatricial-ulcerous stenosis, penetration, degree of risk of operation and feature of clinical situation.
Operative treatments at a perforated ulcer divide into palliative and radical.
Palliative operations are: closure of the perforative hole of ulcer, tamponade of the perforative hole by a omentum on a leg by В.А. Oppel – P.N.Polikarpov – М.А.Pidhorbunskyy (1896, 1927, 1948) (Pic. 3.2.15). Indications and terms for their implementation are:
— perforation of acute duodenal ulcer in youth and young age without anamnesis;
— perforation of acute ulcer in the II–III phases of passing;
— perforation of callous gastric ulcer in the II–III phases of passing;
— expressed and high degrees of risk of operation.
The radical operations at perforated ulcers are: resection of stomach and excision of the perforative hole of ulcer in combination with pyloroplasty and StV, SV or SPV.
Indications and terms for implementation of resection of stomach are:
— perforation of callous gastric ulcer in I phase of clinical passing;
— repeated perforation of ulcer;
— perforation of ulcer in I phase of clinical passing in combination with stenosis and bleeding of ulcer;
— perforation of duodenal ulcer in I phase of passing in combination with a gastric ulcer;
— unexpressed and moderate degree of risk of operation;
— sufficient qualification of surgeon and material resources of operating-anaesthetic brigade.
Indications for implementation of operation of excision of the perforative hole of ulcer with pyloroplasty, StV, SV and SPV are: perforation of ulcer of front wall of duodenum or pyloric part of stomach in the I–II phases of passing;
— perforation of ulcer of front wall of duodenum in the I–II phases of passing in combination with the bleeding ulcer of back wall;
— perforation of duodenal ulcer in the I–II phases of passing in combination with the compensated stenosis of outgoing part of stomach;
— increased gastric secretion;
— insignificant and moderate degree of risk of operation;
— sufficient qualification and technical preparedness of surgeon.
Bleeding gastroduodenal ulcers are outpouring of blood in the gastrointestinal tract cavity as a result of strengthening and distribution of necrosis process in the ulcer area to vessels with the subsequent melting of their walls.
Complication of peptic or duodenal ulcer by bleeding is critical situation which threatens to life of patient and requires from the surgeon of immediate and decisive actions for clarification of reasons of bleeding and choice of tactic of treatment. The ulcerous bleeding has 60 % of the acute bleeding from the upper parts of gastrointestinal tract.
The origin of the gastrointestinal bleeding at patients with a gastric or duodenal ulcer almost is always related to exacerbation of ulcerous process. The reason of bleeding is a erosive vessel, that is on the bottom of ulcer. The expressed inflammatory and sclerotic processes round the damaged vessel embarrassed its contraction, that diminishes chances on the spontaneous stop of bleeding.
Gastric ulcers, compare with the ulcers of duodenum, complicated by bleeding more frequent. Bleeding at gastric ulcers are more expressed, profuse, with heavy passing.
At the duodenal ulcer bleeding more frequent complicate the ulcers of back wall, which penetrates in the head of pancreas.
At the men ulcer is complicated by bleeding twice more frequent, than at women. It costs to mark that 80 % patients which carried bleeding from an ulcer and treated oneself by conservative preparations, are under the permanent threat of the recurrent bleeding.
Strengthening of necrosis process are leading factors in the origin of the ulcerous bleeding in the area of ulcerous crater with distribution of this process to a vessel and subsequent melting of vascular wall; activation of fibrinolysis in tissues of stomach and duodenum; ischemia of tissues of wall of stomach.
At patients with an peptic ulcer disease, bleeding pops up, mainly at night. Vomiting can be the first sign of it, mostly, at gastric localization of ulcers. Vomiting masses, as a rule, looks like “coffee-grounds”. Sometimes they are as a fresh red blood or its grume.
The black tar-like emptying are the permanent symptom of the ulcerous bleeding, with an unpleasant smell (“melena”), that can take place to a few times per days.
Bloody vomiting and emptying as “melena” is accompanied by worsening of the general condition of patient. A acute weakness, dizziness, noise in a head and darkening in eyes, sometimes — loss of consciousness. A collapse with the signs of hemorrhagic shock can also develop. Exactly with a such clinical picture the such patients get to the hospital. It is needed to remember, that for diagnostics anamnesis is very important. Find out often, that at a patient an peptic ulcer was already diagnosed once. It appears sometimes, that bleeding is repeated or surgery concerning a perforated ulcer took place in the past. At some patients a gastric or duodenum ulcer is was not diagnosed before, the however attentively collected anamnesis exposed, that at a patient had a stomach-ache. Thus it communication with acceptance of food and seasonality is typical (more frequent appears in spring and in autumn). Patients tell, that pain in overhead part of abdomen which disturbed a few days prior to bleeding suddenly disappeared after first its displays (the Bergmann’s symptom).
At patients with the ulcerous bleeding there are the typical changes of hemodynamic indexes: a pulse is frequent, weak filling and tension, arterial pressure is mostly reduced. These indexes need to be observed in a dynamics, as they can change during the short interval of time.
There is the pallor of skin and visible mucous tunics at a examination. A stomach sometimes is moderately exaggerated, but more frequent is pulled in, soft at palpation. In overhead part it is possible to notice hyperpigmental spots — tracks from the protracted application of hot-water bottle. Painful at deep palpation in the area of right hypochondrium (duodenal ulcer) or in a epigastric area (gastric ulcer) it is possible to observe at penetrated ulcers. Important symptom of Mendel also — painful at percussion in the projection of piloroduodenal area.
At the examination of patients with the gastrointestinal bleeding finger examination of rectum is obligatory. It needs to be performed at the first examination, because information about the presence of black excrement (“melena”) more frequent get according to a patient anamnesis, that can result in erroneous conclusions. Finger examination of rectum allows to expose tracks of black excrement or blood. In addition, it is sometimes possible to expose the tumour of rectum or haemorrhoidal knots which also are the source of bleeding.
The deciding value in establishment of diagnosis has the endoscopic examination. Fiber-gastroduodenoscopy enables not only to deny or confirm the presence of bleeding but also, that it is especially important, to set its reason and source. Often embarrassed the examination of stomach and duodenum present in it blood and content. In such cases it is necessary to remove blood or content, by gastric lavage, and to repeat endoscopic examination. During the examination often exposed the bleeding with fresh blood from the bottom of ulcer or ulcerous defect with one or a few erosive and thrombosed vessels (stopped bleeding). The bottom of ulcer can be covered by the package of blood.
Important information about such pathology is given by haematological indexes also. Diminishment of number of red corpuscles and haemoglobin of blood, decline of haematocritis is observed in such patients. However always needed to remember, that at first time after bleeding haematological indexes can change insignificantly. Conducting of global analysis of blood in a dynamics in every a few hours is more informing.
It is necessary always to remember that complication of peptic ulcer by bleeding happens considerably more frequent, than is diagnosed. Usually, to 50–55 % moderate bleeding (microbleeding) have the hidden passing. The massive bleeding meet considerably rarer, however almost always run across with the brightly expressed clinical signs which often carries dramatic character. In fact profuse bleeding with the loss 50–60 % to the volume of circulatory blood could stop the heart and cause the death of patient.
The clinical signs and passing of disease depend on the degree of lost of blood (О.О. Shalimov and V.F.Saenko, 1987).
For lost of blood I degree typical there is a frequent pulse to 90–100, decline of arterial pressure of to 90/60 mm Hg. The excitability of patient changes by lethargy, however clear consciousness is, breathing some frequent. After the stop of bleeding and in absent of hemorrhage compensation the expressed disturbances of circulation of blood does not observe.
At patients with the II degree of hemorrhage the general conditioeeds to be estimated as average. Expressed pallor of skin, sticky sweat, lethargy. Pulse — 120–130 per min., weak filling and tension, arterial pressure — 90–80/50 mm Hg. At first hours the spasm of vessels (centralization of circulation of blood) comes after bleeding, that predetermines normal or increased, arterial pressure. However, as a result of the protracted bleeding compensate mechanisms of arterial pressure are exhausted and can acutely go down at any point. Without the proper compensation of hemorrhage the such patients can survive, however almost always there are considerable disturbances of blood circulation with disturbance of functions of liver and kidneys.
The III degree of hemorrhage characterizes heavy clinical passing. There is a pulse in such patients — 130–140 per min., and arterial pressure — from 60 to
But, not always weight of bleeding which is conditioned by the degree of hemorrhage correspond the general condition of patient. On occasion the considerable loss of blood during the set time is accompanied by the relatively satisfactory condition of patient. And vice versa, moderate hemorrhage can bring to the considerable worsening of general condition. It can depend both on compensate possibilities of organism and from the presence of accompanying pathology.
It is needed to remember, that the ulcerous bleeding can accompanying with the perforation of ulcer. During perforation ulcers are often accompanied by bleeding. Correct diagnostics of these two complications has the important value in tactical approach and in the choice of method of surgical treatment. In fact simple suturing of perforated and bleeding ulcer can complicated in postoperative period by the profuse bleeding and cause the necessity of the repeated operation.
At wide introduction of gastroduodenoscopy of question of differential diagnostics of bleeding lost the actuality. However much a problem arises up at impossibility to execute this examination through the heavy general condition of patient or taking into account other reasons. Differential diagnostics is conducted with bleeding of unulcerous origin, which arise up in different parts of digestive tract.
For bleeding from the varicose extended veins of esophagus during portal hypertension at patients with the cirrhosis of liver the acute beginning without pain is characteristic, like during exacerbation of ulcerous disease. These bleeding differ by the special massiveness and considerable hemorrhage. Vomiting by fresh blood, expressed tachycardia, falling of arterial pressure are observed. In such patients it is possible to find the signs of cirrhosis of liver and portal hypertension (“head of jelly-fish”, hypersplenism, ascites, often is icterus).
Sliding hernia of the esophagus opening of diaphragm can be accompanied by formation of ulcers in the place of clench of the stomach by the legs of diaphragm and bleeding from them. However for this pathology are more typical microbleeding, that is hidden. In such patients often the present protracted anaemia which can achieve the critical values. Sometimes in them observe more expressed bleeding with “classic” vomiting “coffee-grounds” and melena. During the roentgenologic examination with barium is possible to expose the signs of sliding hernia of the esophagus opening: the obtuse cardial angle, absence or diminishment of gas bubble of stomach or “ringing symptom”.
The cancer tumour of stomach in the destruction stage can be also complicated by bleeding. However, such bleeding are massive, and chronic character is carried mostly with gradual growth of anaemia. For this pathology there are the inherent worsenings of the general condition of patient, loss of weight of body, decline of appetite and waiver of meat food. At the roentgenologic examination the “defect of filling” is exposed in a stomach.
The gastric bleeding can be related to the diseases of the cardio-vascular system (atherosclerosis, hypertensive disease), however such happens mainly in the older years people. Clearly, that in such patients during the endoscopic examination the source of bleeding exposing is not succeeded.
Among other diseases, with which it is necessary to differentiate the ulcerous bleeding, it is needed to remember the Mallory-Weiss syndrome, benign tumours of stomach and duodenum (more frequent leiomyoma), hemorrhagic gastritis, acute (stress) erosive defeats of stomach, arteriovenous fistula of mucous tunic.
Often differential diagnostics performed according to the level of localization of source of bleeding in different parts of gastrointestinal tract. For the upper parts of digestive tract (esophagus and stomach) typical there is vomiting by grume or “coffee-grounds” content and emptying by “melena”. The farther aboral placed source of bleeding, the bloody emptying changes the more so. During the bleeding from a thin bowel excrement looks as “melena”. In case of such pathology of colon (polypuses, tumours, unspecific ulcerous colitis) emptying have the appearance of fresh red blood, mostly as packages.
The conservative therapy indicated to patients with the stopped bleeding of I degree and bleeding of the II–III degrees at patients which have heavy accompanying pathology, because of operative risk.
Conservative therapy must include:
— prescription of hemostatic preparations (intravenously the aminocapronic acid 5 % — 200–400 ml, chlorous calcium 10 % — 10,0 ml, vicasol 1 % — 3,0 ml);
— addition to the volume of circulatory blood (gelatin, poliglukine, salt blood substitutes);
— preparations of blood (fibrinogen — 2–3 г, cryoprecipitate);
— blood substitutes therapy (red corpuscles mass, washed red corpuscles, plasma of blood);
— antiulcerous preparations — blocker of Н2- receptor (ranitidine, roxatidine, nasatidine— for 150 mg 1–2 times per days);
— antacid and adsorbents (almagel, phosphalugel, maalox— for 1–2 dessert-spoons through 1 hour after food intake).
It is expedient to apply washing of stomach by water with ice and the use 5 % solution of aminocapronic acid inward for to a 1 soupspoon in every 20–30 minutes.
The endoscopic methods of stop of bleeding are used also. Among them most effective is a laser and electro-coagulation.
Absolute indications to surgical treatment are: 1) lasting bleeding I degree; 2) recurrent bleeding after hemorrhage I degree; 3) bleeding of the II–III degrees; 4) stopped bleeding with hemorrhage of the II–III degrees at the endoscopically exposed ulcerous defect with a presence on the ulcer bottom thrombosed vessels or erosive vessels covered by the package of blood.
The choice of method of surgical treatment always needs to be decided individually. On today the best tactic which gives advantage to organ-saving and organоsparing methods of operations. The removing ulcer as sources of bleeding must be an obligatory condition. The methods of sewing of bleeding vessels or edging of ulcer and bandaging of vessels which feed a stomach and duodenum did not justify itself through the real threat of relapse of bleeding already in an early postoperative period (9–12 days).
Palliative operations (cutting of ulcer, forming of roundabout anastomosis) can be justified only taking into account the general condition of patient and on a necessity as possible quick and least traumatically to make off operation.
At the bleeding ulcers of duodenum it is better to apply excision of ulcer or it exteritirization after methods, developed by V.Zajtsev and Velihotskyy. Operation complemented by one of types of vagotomy, it is better by a selective proximal with piliroplastic. The resection of stomach on the second or first method of Bilroth can be realized only in the stable general condition of patient. During the resection of stomach in case of low bleeding duodenal ulcers it is better to execute mobilization of duodenum and suturing of its stump on transcholedochus drainage which formed as transcholedochus duodenotomy (Laqey, 1942). This method warns the possible intraoperative damages of choledoch, that are the possible at low duodenal ulcers. Transcholedochus duodenotomy by performing the decompression of stump of duodenum, warns insufficiency of its stitches, that can arise up in an early postoperative period.
In case of bleeding gastric ulcers, the resection methods of operations are also usable. Only on occasion, when patients has the grave general condition, it is possible to assume the wedge cutting of ulcer.
The origin of acute linear breaks of mucous tunic of esophagus and cardial part of stomach, which are accompanied by bleeding of a different degree of weight to the gastrointestinal tract lumen, is named the Mallory-Weiss Syndrome. First described by К. Mallory and С. Weiss in 1929. As the reason of the gastroduodenal bleeding observed in 10 % cases. Men are ill mainly in age 30–50 years.
The predetermining factors of origin of syndrome are: protracted whooping, attacks of cough, physical overstrain after the surplus food intake, alcohol with vomiting, chronic diseases of stomach, with the acute increase of intaragastric pressure as a result of discoordinated function of cardial and pyloric sphincter, especially at older patients with atrophy gastritis. The increase of intaragastric pressure causes change of blood flow in the wall of the stretched stomach. Spontaneous break of mucous tunic of cardial part of stomach, is accompanied by bleeding in the gastrointestinal tract lumen. The break takes not only mucous tunic but also muscular layer, that weight of bleeding is predetermined. Most often the breaks are localized on small curvature, on the back wall of stomach and esophagus.
The main symptom of syndrome is “bloody” vomiting which the dyspeptic signs preceded: nausea and “unbloody” vomiting. Sometimes patients complain for pain in a epigastric area, in the lower part of thorax, which is related to sudden cardial and lower part of esophagus distension.
Weight of bleeding depends on length and depth of breaks and caliber of the damaged vessels. In one case at first the some dark blood is excreted and only at the repeated vomiting is a lot of bright red blood. In other case at once there is vomiting by a bright red blood. Sometimes bleeding looked as the tar-like emptying. The degree of hemorrhage and its weight is determined after the generally accepted chart.
Taking into account that a syndrome arises up after acceptance of a plenty of alcohol and food, the clinical forms of passing are distinguished: simple, delirious, with the signs of acute hepatic insufficiency, without the signs of acute hepatic insufficiency, that matters very much for the choice of medical tactic.
Urgent esophagogastroscopy is the basic method of diagnostics of syndrome. During it in the cardial part of stomach or esophagus single or plural fissures are diagnosed by length 0,5–4,0 cm, by width 0,5–0,8 cm which pass longitudinally, bleeding. The edges of mucus round a fissures swelled, elevated, covered by a fibrin. Often the muscular layer of stomach or esophagus is the bottom of fissure.
Conservative treatment of the Mallory-Weiss syndrome is indicated at the small rupture of mucus stomach, to the stop of bleeding, absence of bleeding. Treatment of patients is begun with active conservative therapy, which includes blood transfusion, infusion of hemostatic, application of antacid, Meulengracht’s diet. At the rupture of the I–II degrees indicated endoscopy by a monopolar electrocoagulation of the fissure and covering of aerosol film-forming preparation Lifusol. The conservative method of stop of bleeding in such patients is especially perspective, because most of them has the delirious state or acute hepatic insufficiency.
Operative treatment is indicated at the deep large ruptures of mucus and muscular layers, cardial part of stomach, which are complicated by bleeding. In such cases conduct gastrotomy and suturing of raptures by interrupted suture or 8-shaped stitch, applying nonabsorbable filaments. Sewings of ruptures of mucus stomach often supplement with vagotomy with pyloroplasty. At deep, especially plural ruptures which are accompanied by the edema of tissues, sewing of ruptures is supplement with bandaging of left gastric artery.
Hemorrhagic erosive gastritis is diffuse bleeding from mucous tunic stomach as a result of single or plural superficial defects (erosions) of mucous tunic. The gastrointestinal bleeding during erosive gastritis meet in a clinic in 13–17 % cases of acute hemorrhage in a gastrointestinal tract and take first place among bleeding of unulcerous etiology. The disease is met both at men and at women, but more frequent observe in declining years.
The spasm of large vessels in the deep layers of gastric wall, which results in disturbance of local microcirculation, hypoxia and increases of permeability of vascular wall, matters in etiology and pathogenesis of hemorrhage erosive gastritis. The local reaction causes strengthening of reverse diffusion of hydrogen ions, liberation of pepsin, histamine. Such process often is consequence of local damaging factor — action of medicinal or toxic factors for the vessels of mucus. Damaging factor could be the matters which violate a blood flow in mucus stomach (aspirin, reserpine, hormones of adrenal glands cortex). The large value in formation of erosions is had by the anatomic features of blood flow of stomach in a cardial part on small curvature. In connection with absence of submucosal vascular plexus, eventual vessels on small curvature are disposed in relation to mucus tangentially. It results in shelling of epithelium, origin of erosions. Veins damaged at first, that predetermines a hemorrhage and then bleeding. In the origin of acute hemorrhage gastritis matter also acute damage of mucus stomach by mechanical, chemical (burns) and other factors, accompanying diseases (uremia and others like that).
For hemorrhage erosive gastritis there are typical two clinical syndromes: ulcerous and hemorrhagic. The ulcerous syndrome is the most frequent sign of hemorrhage gastritis. “Typical ulcerous pain” is observed in such patients. A hemorrhagic syndrome shows up by the repeated gastric bleeding and moderately increasing anaemia. Bleeding are capillary and are not such catastrophic, as at gastric ulcers.
The clinical picture of hemorrhage gastritis is characterized by dull pain in a epigastric area, which appears at faults in a food, reception of alcohol. Patients disturbs vomiting like “coffee-grounds”, “melena”, which arise up among a complete health, symptoms of hemorrhage (dizziness, general weakness, acceleration of pulse, decline of arterial pressure). The decline of amount of red corpuscles is observed in the blood test, haemoglobin, haemathokritis, leukocytosis. During the roentgenologic examination observed the thickened winding folds of mucus stomach with the small depots of barium. At endoscopic diagnostics of bleeding the presence of single or plural erosions on mucus up to 5–7 mm in diameter are noticed, symptom of “morning dew” (“weeps” all mucus stomach).
Treatment of hemorrhage erosive gastritis, mainly, is conservative. Washing of stomach an effective by cold water or by 5 % solution of aminocapronic acid with subsequent irrigation of mucous tunic by film-forming preparations through endoscope and introduction of hemostatic. It is important the neutralization of hydrochloric acid in a stomach (antacid, additional introduction of atropine of sulfate, aspiration of gastric content), setting of preparations which stimulate reparative processes in a mucous tunic (methyluracyl, sayotek, sea-buckthorn oil), antihelicobacter preparation (de-nol). If under the endoscopy control effect from conservative treatment is absent and it is the obvious threat of life of the patients, operative treatment is indicated.
Surgical treatment must be minimum. Sewing and edging of bleeding areas, selective vagotomy with pyloroplasty in most cases is effective. Only at bleeding from arising acute erosions after submucosal telangiectasia, indicated resection of stomach. It is needed to remember, that the additional focus of bleeding can be in fundal and cardial part of stomach. Without their edging and local hemostasis operation caot be radical. At the considerable damage of stomach by an erosive process, for a patient indicated resection of stomach or gastrectomy.
The hereditary hemorrhagic teleangiectasia, Rendu-Osler-Weber Disease — hemorrhage angiopathy, which is characterized by focus microvascular expansion by the type of teleangiectasia and angiomas with the break of which possible bleeding. Meets rarely, inherited after a autosomal-dominant type, sometimes arises up sporadically.
Teleangiectasia and angiomas develops as a result of thinning and expansion of shallow vessels. At the same time local hemostasis is violated as a result of hypoplasia of subendothelium and collagen deficiency. Bleeding is related to small resistance and easy vulnerability of vascular wall, by weak stimulation in these areas of aggregation of thrombocyte and blood coagulation. Teleangiectasia is disposed on the mucous tunics of mouth cavity, rarer is mucus of the trachea, bronchial tubes, gastrointestinal tract, urinary bladder and liver.
The disease is characterized by the frequent nose-bleeds which appear in early child’s age, teleangiectasias and angiomas with certain localization. The gastrointestinal bleeding can be profuse and result in lethal termination, chronic, with the expressed anaemia. At differential diagnostics of bleeding it is necessary to observe the skin and mucous tunics. Teleangiectasias and angiomas is characterized by expansion of granulomatous vessels and is disposed, mainly, on a head, skin, mucus of the mouth, nose, on hands, finger-tips, genital organs.
Treatment of the Rendu-Osler-Weber disease is conservative, symptomatic, including hemostatic therapy. There is the indicated blood transfusion at considerable hemorrhage. Often during recrudescent and profuse gastrointestinal bleeding the resection of stomach is indicated. It is represents a problem for a surgeon, because teleangiectasias after the decline of arterial pressure, become pale and unnoticeable. A prognosis is often unfavorable, because not always it is possible to expose teleangiectasias in other organs.
Menetrie syndrome is pseudotumor gastritis. The disease rarely. Etiology and pathogenesis is unknown. During disease observed the increasing of folds of mucus stomach by the height up to
Hemobilia is bleeding from bilious ways and liver to the intestine. Meets in 0,01 % all gastric bleeding of unulcerous genesis.
The most frequent reason of hemobilia is the traumas of liver. Among other reasons are inflammatory processes of liver, external bilious ways (abscesses, cholangitis), vascular anomalies as aneurism of hepatic artery and vein gate.
The typical signs of hemobilia: attack-like pain in right hypochondrium, moderate icterus, anaemia, presence of grume in vomiting masses and in the excrement which looks like a pencil or worm (imprints of bilious ducts). Bleeding have cyclic passing (repeat oneself in 6–8 days). A diagnosis is based on the clinical signs, information of endoscopy, at which founded the blood flow to the duodenum from a general bilious duct or bloody clot in the papilla Fateri. The most diagnostic value has selective angiography of the hepatic artery and cholangiography, which allow to expose the flowline of contrasting matter in tissues of liver.
Bleeding from biliary tracts during the damage of large vessels can be severe. So, operation is the unique treatment method in such cases. In patients with hemobilia performed opening, draining and tamponade of the haematomas with obligatory draining of general bilious channel for decompression of biliary tracts. The most radical method some surgeons count opening of haematoma with bandaging of bleeding vessel and bilious channel or resection of liver. Bandaging of hepatic artery after angiographic study of the intraorgan arterial vessels is sometimes recommended only. Better to bandage that branch of hepatic artery from which observed bleeding.
The particle of the rare extragastric diseases complicated by the acute gastrointestinal bleeding is 2 %. Among them the diseases of blood are met, blood vessels, system diseases (leukosis, haemophilia, autoimmune thrombocytopenia, hemorrhagic vasculitis, the Werlhof’s disease and others like that).
Leukosis are tumours which developed from hemopoietic cells. Etiology and pathogenesis to this time is not exposed. Patients with a leucosis with the gastrointestinal bleeding is 1 % of all patients with the unulcerous bleeding.
During leucosis in the process of extramedullar hematosis the cells of vascular wall and vessel are pulled in and from the circulatory changed into hemopoietic, that results in disturbance of permeability of vessel wall. In development of hemorrhage diathesis large part is acted the changes of thrombocytopesis, declines of growth of tissue’s basophiles, which produce heparin, that shows up by wide hemorrhages in a gastrointestinal tract. Bleeding can be both insignificant and threatening to life of patient. In establishment of diagnosis sometimes there is enough simple examination of blood (hyperleukocytosis), to suspect leucosis bleeding. During endoscopy in such patients observe the presence of flat, superficial defects of mucus stomach. A final diagnosis is based on the results of biopsy and haematological examination of bone marrow.
Treatment includes complex application of hemostatic, preparations of blood and cytostatic agents, that results in the stop of bleeding and even to bring a patient into remission.
Haemophilia is the innate form of bleedingwhich coused by the deficit of one of three antihemophilic factors (VIII, IX, XI). The gastrointestinal bleeding is observed in 6–24 % patients with haemophilia. Absence or insufficient content in the blood of antihemophilic globulin lies in basis of disease. At diminishment of it level below 30 % there is bleeding. Haemophilia is inherited, men are ill more frequent.
Pointing in anamnesis on bleeding from babyhood allow to suspect haemophilia. Roentgenologic information and results of fibergastroscopy does not expose the substantial changes in a gastrointestinal tract. Main in diagnostics of haemophilia — examination of the system of blood coagulation. Time of blood coagulation continued to 10–30 minutes, sometimes a blood does not coagulate by hours.
Treatment is directed on compensation of insufficient components of the of blood coagulation system. In patients with haemophilia A, for which typical deficit of antihemophilic globulin, fresh blood transfusion is indicated, because in a banked blood a antihemophilic globulin collapses during a few hours. At haemophilia B and С are used dry and native plasma, cryoprecipitate, banked blood, because factors IX, XI, which predetermine the form of haemophilia, is kept in them long. ordinary hemostyptic preparation (vicasol, the С vitamin, chloride of calcium and others like that) does not give the effect. So, if form of haemophilia does not established, the treatment is necessary to begin from fresh blood transfusion, antihemophilic plasma and antihemophilic globulin transfusion.
Autoimmune thrombocytopenia, or idiopathic thrombocytopenic purpura, is accompanied by the gastrointestinal bleeding and is arisen up in 0,5–2 % patients. Often bloody vomiting and black excrement conditioned by swallowing of blood from a nose and gums.
The disease shows up by plural hypodermic hemorrhages and hemorrhages into submucous membrane. At girls and women the uterine bleeding is often observed. Thrombocytopenia on very low numbers and it is the most pathognomonic sign of disease. Typical acute increase of duration of bleeding, especially in the period of acute hemorrhage.
Fresh blood and thrombocyte mass transfusion is the most effective treatment in the case of the gastrointestinal bleeding during autoimmune thrombocytopenia. Other hemostatic preparations are indicated also. During operative treatment performed splenectomy. The absolute indications to it are frequent and protracted bleeding, threat of hemorrhage in a brain.
The Schonlein-Henoch disease is hemorrhagic vasculitis, which caused by plural microfocus microthrombovasculitis. The gastrointestinal bleeding at the Schonlein-Henoch disease is observed in 0,5–1 % cases and accompanied with great pain in a epigastric area like “abdominal colic”. For this disease typical presence of purpura which has the symmetric location on the external surface of feet, legs, shoulders, buttocks, also joint syndrome with pain and edema in large joints, kidney syndrome by the type of acute or chronic glomerulonephritis. Women have the possible uterine bleeding. The intestinal bleeding can be accompanied by the edema of wall of intestine, that results in invagination or perforation of wall of bowel.
The basic and pathogenetic treatment method of patients is early application of heparin with blood transfusion, introduction of heparinized blood under the control of blood coagulation, which after adequate therapy must be increased in two times, comparative with a norm. For a patient in the initial form of disease indicated introduction of antibiotics of wide spectrum of action, hormones of adrenal glands cortex.
The diseases of the operated stomach (postgastrectomy and postvagotomy syndromes) are the diseases which arise up after surgical treatment of peptic or duodenum ulcer or other pathology of these organs.
Dumping syndrome is frequent complication of operations which are related to deleting or disturbance of function of goalkeeper (resection of stomach, vagotomy with antrectomy, vagotomy with drainage operations). It takes place in 10–30 % patients.
The rapid receipt (dumping) is considered the starting mechanism of dumping syndrome. During this concentrated, mainly carbohydrate, food passed from a stomach in an empty bowel.
In the phase changes of motility of thin bowel during dumping syndrome important part is acted by the hormones of thin bowel. In endocrine cells of APUD-системи on during dumping-syndrome observed degranulation and presence of hormones of mothiline, neurotensin and enteroglucagon.
The inadequate mechanical, chemical and osmotic irritation of mucous tunic of thin bowel by chymus results for the acute increase of blood flow in a bowel. The last is accompanied by the considerable redistribution of blood, especially in heavy case of dumping syndrome : blood supply of head, lower extremities is diminishes, a blood flow in a liver is multiplied.
The numeral examinations resulted in creation of osmotic theory ¬–the principal reason of dumping syndrome is the decline of volume of circulatory plasma as a result of coming a plenty of liquid into the lumen of thin bowel from an of circulatory system and intercellular space.
For the clinical finding of dumping syndrome typical there is the origin of attacks of general weakness during acceptance of food or during the first 15–20 minutes after it. The attack begins from feeling of plenitude in a epigastric area and is accompanied by the unpleasant feeling of heat, that “spills” in the overhead half of trunk or on all body. Thus is acutely multiplied sweating. Then there is a fatigue, appear somnolence, dizziness, noise in ears, shaking of extremities and worsening of sight. These signs sometimes achieve such intensity, that patients forced to lie down. Loss of consciousness could be in the first months after operation. The attacks are accompanied by tachycardia, sometimes by the shortness of breath, headache, paresthesia of upper and lower extremities, polyuria and vasomotor rhinitis. At the end of attack or after it patients ofteotice grumbling in a stomach and diarrhea.
A milk or carbohydrate food is the most frequent provoking factor of dumping syndrome. In a period between the attacks patients complain about rapid fatigueability, weakening of memory, decline of working capacity, change of mood, irritates, apathy. During roentgenologic examination after 5–15 minutes observed the increased evacuation of barium mixture through anastomosis by a wide continuous stream, expansion of efferent loop and rapid advancement of contrasting matter in the distal parts of thin bowel (Pic. 3.2.16).
By the expression of symptoms dumping syndrome is divided into three degrees of weight:
I degree is easy. Patients have the periodic attacks of weakness with dizziness, nausea, that appear after the use of carbohydrates and milk food and last no more than 15–20 min. During the attack a pulse becomes more frequent on 10–15 per min., arterial pressure rises or sometimes goes down on 1.3-2 KPa (10–15 mm Hg), the volume of circulatory blood diminishes on 200–300 ml. The deficit of mass of body of patient does not exceed
II degree — middle weight. Attacks of weakness with dizziness, pain in the region of heart, hyperhidrosis, diarrhea. Such signs last, usually, 20–40 min., arise up after the use of ordinary portions of some food. During such state a pulse becomes more frequent on 20–30 per min., arterial pressure is rises (sometimes goes down) on 2–2,7 KPa (15–20 mm Hg), the volume of circulatory blood diminishes on 300–500 ml. The deficit of mass of body of patient achieves 5–10 kg. A working capacity is reduced. Conservative treatment sometimes has a positive effect, but brief.
The III degree is hard. Patients are disturbed by the permanent, acutely expressed attacks with the collaptoid state, by a fainting fit, by diarrhea, which do not depend on character and amount of the accepted food and last about 1 hour. During the attack is multiplied frequency of pulse on 20–30 per 1 min; arterial pressure goes down on 2,7–4 KPa (20–30 mm Hg), the volume of circulatory blood diminishes more than on 500 ml. The deficit of mass of body exceeds
The problem of treatment of patients with dumping syndrome is not easy. Before the surgical treatment, as a rule, must precede conservative. Patients with the disease of easy and middle degrees respond to conservative treatment, mainly with an enough quite good effect. At the heavy degree of disease such treatment more frequent serves as only preparation to operative treatment. If a patient does not give a consent for operation or at presence of contra-indications to operative treatment (disease of heart, livers, kidneys), conservative therapy is also applied. Such treatment must include dietotherapy, blood and plasma transfusion, correction of metabolism, hormonal preparations, symptomatic therapy, electro-stimulation of motility function of digestive tract.
The dietotherapy: using of high-calorie, various food rich in squirrel, by vitamins, by mineral salts, with normal content of fats and exception from the ration of carbohydrates which are easily assimilation (limitation of sugar, sweet drinks, honey, jam, pastry wares, kissel and fruit compotes). All it is needed to use by small portions (5–6 times per days). If the signs of dumping syndrome appear after a food, such patients it is needed to lie down and be in horizontal positioot less than 1 hour. At the heavy degree of dumping syndrome patients need to eat slowly, desirably lying on left. Such position creates the best terms for evacuation of food from a stomach. Thus recommend also to repudiate from too hot and cold foods.
Medicinal treatment must include sedative, replaceable, antiserotonin, hormonal and vitamin therapy. The indications to operative treatment of patients with dumping syndrome are: heavy passing of disease, combination of dumping syndrome of middle degree with other postgastrectomy syndromes (with the syndrome of efferent loop, hypoglycemic syndrome and progressive exhaustion) and uneffective of conservative treatment of the dumping syndrome of middle degree. Most methods of operative treatment of dumping syndrome are directed on renewal of natural way of passing of food on a stomach and intestine, improvement of reservoir function of stomach and providing of proportioning receipt of food in a thin bowel.
Depending on reasons and mechanisms of development of dumping syndrome there are different methods of the repeated reconstructive operations. All of them can be divided into four basic groups: I. Operations which slow evacuation from stump of stomach. II. Redoudenization. III. Redoudenization with deceleration of evacuation from stump of stomach. IV. Operations on a thin bowel and its nerves.
Basic stages of reconstructive operations: 1) disconnection of adhesions in an abdominal cavity, releasing of gastrointestinal and interintestinal anastomosis and stump of duodenum; 2) cutting or resection of efferent and afferent loops; 3) renewal of continuity of upper part of digestive tract.
For correction of the accompany postgastrectomy pathology it is better to apply combined anti- (iso-) peristaltic gastrojejunoplasty. Thus transplant by length 20–22 cm, located between a stomach and duodenum, must consist of two parts: antiperistaltic (7–8 cm), connected with a stomach, and isoperistaltic, connected with a duodenum. An antiperistaltic segment brakes dumping of stomach stump, and isoperistaltic — hinders the reflux of duodenum content.
The attacks of weakness at a hypoglycemic syndrome arise up as a result of decline of content of sugar in a blood. It is accompanied by a acute muscular weakness, by headache, by falling of arterial pressure, by feeling of hunger and even by the loss of consciousness. It is needed to remember, that at this pathology, unlike dumping-syndrome, acceptance of food especially sweet facilitates the state of patient. However in some patients both syndromes unite and the attacks of weakness can arise up as directly after food intake, so in a few hours after it. In patients with such pathology the best results are got after antiperistaltic gastrojejunoplasty (Fink, 1976).
The postgastrectomy (agastric) asthenia arises up as a result of disturbance of digestive function of stomach, pancreas, liver and thin bowel.
In patients with such pathology stump of stomach almost fully loses ability to digest a food. It is related to the small capacity of stump and rapid evacuation of food from it, and also with the acute decline of production of hydrochloric acid and pepsin. In the mucous tunics of stump of stomach, duodenum and thin bowels as a result of fall of trophic role of gastrin and other hormones of digestive tract there are the progressive atrophy changes. Absence in gastric juice of free hydrochloric acid is the reason of acute diminishment of digestive ability of gastric juice and decline of it bactericidal. Such situation is assist in advancement to ascending direction of virulent flora, to development duodenitis, hepatitis, cholecystitis, dysbacteriosis, hypovitaminosis and decline of antitoxic function of liver. All it results in acute disturbance of evacuation from a stomach.
The clinical signs of postgastrectomy asthenia arise up after a some latent period which can last from a few months to some years. During this period patients often complain for a general weakness and bad appetite. The basic symptoms of postgastrectomy asthenia are: general weakness, edemata, acute weight loss, diarrhea, skin and endocrine abnormalities. The postgastrectomy asthenia more frequent meets at men at 40–50 years. In most cases diarrhea is the first symptom of disease, that can arise up in 2 months after operation. Diarrhea, usually, has permanent character and sometimes becomes profuse.
Weight loss appears too early, the deficit of mass of body achieves 20–30 kg. A patient quickly loses forces.
Conservative treatment is the blood, plasma and albumen transfusions. These preparations are prescribed 2–3 times per a week. Correction of disturbances of electrolyte exchange is conducted at the same time (transfusion of solutions to potassium, calcium and others like that). For the improvement of processes of albumen synthesis anabolic hormones are prescribed.
Operative treatment foresees the inclusion in the digestion process of duodenum, increase of capacity of stump of stomach and deceleration of evacuation of its content.
The afferent loop consists of part of duodenum, that stopped behind after a resection, area of empty bowel between a duodenojejunal fold and stump of stomach. The syndrome of afferent loop can arise up after the resection of stomach after the Bilrhoth-II method. Violation of evacuation from a afferent loop and vomiting by a bile are its basic signs.
Acute and chronic obstruction of afferent loop are distinguished. The reason of acute obstruction is mechanical factors: postoperative commissure, volvulus, internal hernia, invagination, jamming behind mesentery of loop of bowel and stenosis of anastomosis.
Frequency of origin of sharp obstruction of afferent loop hesitates within the limits of 0,5–2 %. The disease can arise up in any time after operation: in a few days or a few years.
Chronic obstruction of afferent loop (actually syndrome of afferent loop), as well as acute, can arise up in any time after operation, however more often it develop after the resection of stomach with gastroenteroanastomosis on a long loop, especially when operation is performed without entero-enteroanastomosis by Brown.
The etiologic factors of syndrome of afferent loop are divided into two groups: 1) mechanical (postoperative commissure, invagination, disturbance of evacuation on a afferent loop, wrong location of afferent loop, very long afferent loop, fall of mucous tunic of afferent loop into a stomach); 2) functional (hypertensive dyskinesia of bilious ways and duodenum, damage and irritation of trunks of vagus nerves, hypotensive and spastic states of upper part of digestive tract, heightened secretion of bile and juice of pancreas under act of secretin and cholecystokinin).
For the clinical picture of acute obstruction typical is permanent, with a tendency to strengthening, pain in a epigastric area or in right hypochondrium, nausea and vomiting. At complete obstruction a bile in vomiting masses is absent. The general condition of patient progressively gets worse, the temperature of body rises, leukocytosis grows, tachycardia grows. At the objective examination painful and tension of muscles of abdominal wall is observed. In a epigastric area it is often possible to palpate tumular lump. Possible cases, when the increase of pressure in a bowel is passed on bilious ways and channels of pancreas. There can be pain and icterus in such patients. There are necrosis and perforation of duodenum with development of peritonitis during further progress of process. Acute obstruction of afferent loop in an early postoperative period can be the reason of insufficiency of stump of duodenum also.
During the roentgenologic examination of organs of abdominal cavity it is visible round form area of darkening and extended, filled by gas, bowels loop.
Patients, usually, complain for feeling of weight in a epigastric area and arching in right hypochondrium, that arises in 10–15 min. after acceptance of food and gradually grows. Together with that, appear nausea, bitter taste in a mouth, heartburn. Then there is increasing pain in a right to epigastric area. During this pain arises intensive, sometimes repeated vomiting by a bile, after which the all symptoms disappear. It could be after certain kind of food (milk, fats) or its big amount. Very rarely vomiting by bile unconnected with the feed. In heavy case patients lose up to
Distinguished easy, middle and heavy degrees of afferent loop syndrome. In patients with the easy degree of disease vomiting is 1–2 times per a month, and insignificant regurgitation arise up through 20 min – 2 hour after a food, more frequent after the use of milk or sweet food. At middle degree of afferent loop syndrome such attacks repeat 2–3 times per week, patients are disturbed by the considerably expressed pain syndrome, and with vomiting up to 200–300 ml of bile is lost. For a heavy degree the daily attacks of pain are typical, that is accompanied by vomiting by a bile (up to 500 ml and more).
A roentgenologic examination of the patients with the afferent loop syndrome is unspecific. Neither the passing of contrasting matter nor absence of filling of afferent loop can be considered as pathognomic signs of syndrome of afferent loop.
Treatment of acute obstruction of afferent loop is mainly operative. Essence of it is the removal of barriers of evacuation of content from an afferent loop. Adhesions are dissected, volvulus is straightened, invagination or internal hernia is liquidated. For the improvement of evacuation between afferent and efferent loops performes the entero-enteroanastomosis type “end-to-end” or after the Roux method.
Conservative treatment of syndrome of afferent loop is ineffective and, mainly, is mean the removal of hypoproteinemia and anaemia, spasmolytic preparations and vitamin are appointed. With this purpose a blood, plasma and glucose is poured with insulin, a novocaine lumbar blockade and blockade of neck-pectoral knot, washing of stomach is also done.
All operative methods of treatment of afferent loop syndrome can be divided into three groups:
I. Operations, that will liquidate the bends of afferent loop or shorten it.
II. Drainage operations.
III. Reconstructive operations.
The operations of the first group, directed on the removal of bends and invagination of afferent loop, caot be considered as radical. They need to be performed only at the grave general condition of patient.
The widest application in clinical practice at the syndrome of afferent loop has the operation offered by Roux (Pic. 3.2.17).
For the prophylaxis of afferent loop syndrome it is necessary to watch after correct imposition of anastomosis during the resection of stomach: to use for the gastroenteroanastomosis short loop of thin bowel (6–8 cm from the Treits ligament) for imposition, to sew afferent loop to small curvature for creation of spur, to fix reliably stump of stomach in peritoneum of transverse colon.
The origin of reflux after the distal resection of stomach is conditioned by some factors:
I. Traumatic factors: 1) traction of stomach during operation as reason of sprain of ligament of proximal part of stomach and mobilization of large curvature of stomach; 2) cutting of vessels of stomach and oblique muscles of it wall, in particular on small curvature; 3) vagotomy, that is accompanied by cutting of phrenico-esophageal and gastrophrenic ligaments; 4) imposition of gastrointestinal anastomosis, especially direct gastroduodenoanastomosis by Billroth-I, that results in smoothing of the Hisa corner; 5) frequent aspiration of gastric content in a postoperative period, that causes superficial esophagitis.
II. Trophic factors: 1) damage of vessels which are the reason of ischemia in the area of esophago-gastric connection, and thrombophlebitis of cardial part of stomach; 2) disturbance of influencing of neurohumoral factors which take part in innervations of esophagus; 3) disturbance of trophism of diaphragm as a result of hypoproteinemia and weight loss; 4) ulcerous diathesis and megascopic volume of gastric secretion (especially nightly); 5) regurgitation of alkaline content of duodenum in stump of stomach which reduces tone of it muscular shell.
III. Mechanical factors: 1) gastric stasis; 2) diminishment of volume of gastric reservoir, that is accompanied by the increase of intragastric pressure.
The clinical picture of gastroesophageal reflux is conditioned by the mechanical and chemical irritations of esophagus by content of stomach or thin bowel. As a result, there is esophagitis, which can be catarrhal, erosive or ulcerous-necrotic. The symptoms of reflux are very various and can simulate different diseases of both pectoral and abdominal cavity organs.
The basic complaint of patients with this pathology is a smart behind a breastbone, especially in the area of the its lower part. It, usually, spreads upwards and can be accompanied by considerable salivation. Strengthening of pain at inclinations of trunk gave to the French authors an occasion to name this sign the “symptom of laces”. Unendurable heartburn is the second complaint, that arises up approximately in 1–2 hours after the food intake. Patients forced often to drink, somehow to decrease the unpleasant feelings, however this, certainly, does not bring them facilitation. Some of them, in addition, complain for bitter taste in a mouth.
Pain behind a breastbone often can remind the attack of stenocardia with typical irradiation. Sometimes such reflux is able to provoke real stenocardia.
Hypochromic anaemia is the frequent symptom of gastroesophageal reflux too.
The diagnosis of gastroesophageal reflux, mainly, is based on clinical information, results of roentgenologic examination, esophagoscopy.
The edema, hyperemia of mucous tunic of esophagus, easy bleeding and vulnerability it during examination, surplus of mucus and erosions covered by fibrin tape is considered the endoscopic signs of esophagitis. In doubtful case at the insignificantly expressed macroscopic changes the biopsy of mucous tunic helps to set a diagnosis.
Treatment of patients with gastroesophageal reflux is mainly conservative. Very important is diet, which avoid spicy, rough and hot food. Eating is needed often, by small portions. It is impossible also to lie down after the food intake, because the gastric content can flow in a esophagus. A supper must be not later than for 3–4 hours before sleep. Between the reception of food does not recommend to use a liquid. Next to that, it is necessary to remove factors which promote intraperitoneal pressure (carrying to the bracer, belt, constipation, flatulence). Sleeping is needed in position with a lift head and trunk. From medicinal preparations it is useful to recommend enveloping preparation.
Operative treatment of gastroesophageal reflux, that arose up after the distal resection of stomach, it is needed to recommend to the patients with the protracted passing and uneffective of conservative treatment. During operation, mainly, performed renewal of the broken Hisa angle. In addition, performed esophagoplasty, fundoplication by Nessen’s and esophagofrenofundoplication.
The prophylaxis of this complication consists in the study of the state of cardial part of stomach before and during every resection and fixing of bottom of stomach to the diaphragm and abdominal part of esophagus during leveling the Hisa angle.
Alkaline reflux-gastritis meets in 5–35 % operated patients after the resection of stomach, antrectomy, gastroenterostomy, vagotomy with pyloroplasty, and also cholecystectomy and papillosphincteroplasty.
The reason of this complication is influence of duodenum content for the mucous tunic of stomach (bilious acids, enzymes of pancreas and isolecithin). Last, forming from bile lecithin under act of phospholipase A, able to destroy the cells of superficial epithelium of mucous tunic of stomach by removing of lipid from their membranes. As a result the erosions and ulcers are formed in the patient organism. Bilious acids also has the expressed detergent’s properties. As isolecithin and bilious acids, the very important bacterial flora which directly and through toxins can cause the damage of mucous tunic of stomach stump. Also, alkaline environment and disturbance of evacuation from the operated stomach influence favourably on microflora growth.
For the clinical picture of alkaline reflux-gastritis the permanent poured out pain in a epigastric area, belch and vomiting by a bile are typical. At some patients heartburn and pain is observed behind a breastbone also. In majority patients so proof loss of weight takes place, that even the protracted complex therapy and valuable feed does not provide addition to the deficit of mass of body. There are typical signs also – anaemia, hypo- or achlorhydria.
Reliable diagnostics of alkaline reflux-gastritis became possible after wide introduction in clinical practice of endoscopic examination. In such patients during gastroscopy hyperemia of mucous tunic of stomach is observed. It is often possible to observe reflux in the stomach of duodenum content. During histological examination of biopsy material a chronic inflammatory process, intestinal metaplasia, diminishment of mass of coating cells and area of hemorrhages are found. All it testifies the deep degenerative changes in the mucous tunic of stomach. The some authors underlines that the inflammatory changes, at least in the area of anastomosis, are observed in most persons which carried the resection of stomach. So, endoscopic examination caot be considered deciding in diagnostics. Even the diffuse inflammatory changes can take place in absent of clinical symptoms and, opposite, in case with expressed clinical symptoms the minimum changes of mucous tunic of stomach are sometimes observed.
Conservative treatment of reflux-gastritis (sparing diet, antacides, enveloping preparations), usually, is ineffective. Existent methods of surgical treatment, mainly, directed on the removal of reflux of duodenum content to the stomach. Most popular is operation by the Roux method. The some surgeons considers that distance from gastroenteroanastomosis to interintestinal anastomosis must be 45–50 cm.
Main reason of origin of peptic ulcer of anastomosis is leaving of the hyperacid state of stomach mucous, even after the performed operation. Such phenomenon can be consequence of many reasons: primary economy resection, wrong executed resection (when the mucous tunic of pyloric part is abandoned in stump of duodenum or stomach), heightened tone of vagus nerves and the Zollinger-Ellison syndrome.
Peptic ulcers, usually, arise up after operation during the first year. Typical signs are pain, vomiting, weight loss, bleeding, penetration and perforation.
Pain is the basic symptom of peptic ulcer. Often it has the same character and localization, as well as at peptic ulcer. However often observe it moving to the left or in the umbilical area. At first patients bind such feelings to the use of food, but then specify nightly and hungry pain. It at first is halted after a food, but in course of time is become permanent, unendurable, independent from food intake. It can increase during the flounces, the walk, can irradiate in the back, thorax or shoulder.
During the objective examination of patients is often possible to expose on a stomach hyperpigmentation from a hot-water bottle. During palpation to the left from epigastric area near a umbilicus the painful and moderate muscles tension of abdominal wall is observed. Sometimes is possible to palpate inflammatory infiltrate of different sizes. During the examination of patients with a peptic ulcer the important role has determination of gastric secretion against a background of histamine and insulin stimulation. There is a necessity also examination of basal secretion. These preoperative examinations in most patients enable to set the reason of hypersecretion which can be: 1) heightened tone of vagus nerves (positive Hollander test); 2) economy resection of stomach, often in combination with the heightened tone of vagus nerve (considerable increase of gastric secretion after histamine or pentagastrin stimulation in combination with the positive Hollander test); 3) abandoned part of mucous tunic of antral part of stomach (high basal secretion and small increase of secretion in reply to histamine and insulin stimulator); 4) the Zollinger-Ellison syndrome.
Roentgenologic diagnostics of peptic ulcer, usually, is difficult, especially at shallow, flat ulcers, bad mobility and insufficient function of anastomosis. A niche is the direct sign of a similar pathology, indirect are the expressed inflammatory changes of mucous tunic of stump of stomach and bowel, painful point in the projection of stump of stomach and anastomosis and bad function of anastomosis. The deciding value in diagnostics has endoscopic examination.
Conservative treatment of peptic ulcers, as a rule, is ineffective. So, operation must be the basic type of treatment. The choice of method of operative treatment depends on character of previous operation and from abdominal cavity pathology found during the revision. For today the most important parts of the repeated operations is vagotomy. There is obligatory also during the resection of stomach on the exception the revision of duodenum stump for liquidation of possibly abandoned mucous tunic of antral area.
Operative treatment at a peptic ulcer must consist of certain stages. Laparotomy and disconnection of adhesions through a considerable spike process (increasing of stomach, loops of intestine and liver to the postoperative scar) almost always causes large difficulties.
After the selection of anastomosis with afferent and efferent loops the last cut by the “UKL-60 appliance”, within the limits of healthy tissues with renewal of intestine continuity by “end-to-end” type anastomosis.
At patients with a peptic ulcer, that developed after gastroenterostomy, cut a duodenum and sutured its stump by one of the described methods. During it there can be the difficulties related to the presence in it active ulcer. When peptic ulcers do not cause rough deformation of stomach, apply degastroenterostomy, vagotomy and drainage operations.
In the case of the considerably expressed spike process it is possible to execute trunk subdiaphragmatic vagotomy, and in case of the insignificantly changed topography of this area — selective gastric vagotomy.
It is important to note, that stomach resected together with anastomosis, peptic ulcer and eliminated area of empty bowel by one block.
This pathology arises up as a result of perforated of peptic ulcer in a transverse colon with formation of connection between a stomach, small or large intestine.
Diagnostics of gastro-colon fistula at patients with expressed clinical signs of disease does not difficult. However, symptoms are often formed and is indicated up slowly, so such patients with different diagnoses long time treat oneself in the therapeutic or infectious parts.
The typical signs of this pathology is considered diminishment or disappearance of pain, that was before, and proof, profuse, that does not respond to treatment, diarrhea. Patients has emptying up to 10–15 times per days and even more frequent. An excrement contains a plenty of undigested muscular fibres and fat acids (steatorrhea). In case of wide fistula an undigested food can be with an excrement.
Excrement smell from a mouth, usually, notice surrounding. The patients does not feel it. However appearance of excrement belch is indicate the hit into the stomach of excrement masses and gases, and could confirm this pathology.
The such patients very quickly lose weight (mass of body goes down on 50–60 %), their skin becomes pale with a grey tint. The protein-free edemata, ascites, hydrothorax, anasarca, signs of avitaminosis appear ion-treated case.
Through the severe losses of liquid and nonassimilable food there can be the increased appetite and unendurable thirst in such patients. However, they adopt a plenty of liquid and food but the state of them continues to get worse.
Headache, apathy and depression is observed, and at the objective examination is exhaustion (ochre colour of skin, dryness and decline of it turgor, edemata or slurred of swelling extremities, atrophy of muscles). A stomach often moderately pigmented from hot-water bottles, subinflated, with the visible peristalsis of intestine. During the changes of patient position it is possible to hear grumbling, splash and transfusion of liquid. The examination of blood can expose hypochromic anaemia.
Roentgenologic examination is a basic diagnostic method. There are three varieties of such examinations of gastro-colon fistula. During the examination with introduction of barium mixture through a mouth the hit of contrasting matter directly from a stomach into a colon is the typical roentgenologic symptom of such pathology. Irrigoscopy is more perfect and effective method. With suspicion on gastro-colon fistula it is better to perform irrigoscopy. Passing of contrasting matter to the stomach at this manipulation testifies the presence of fistula. The third method is insufflation of air in a rectum. With it help on the screen it is possible to observe the location and passing of fistula, and also, as a result, hit of air in a stomach, increase of it gas bubble. Thus there can be the belch with an excrement smell.
The important role played the tests with dyes: at peroral introduction of methylene-blue after the some time it found in excrement masses or, opposite, after an enema with methylene-blue dye appears in a stomach.
Treatment of gastro-colon fistula is exceptionally operative. It needs to be conducted after intensive preoperative preparation with correction of metabolism. All operations which can be applied at treatment of patients with gastro-colon fistula divide into palliative and radical (single-stage operation and multi-stage operation).
During the palliative operations the place of fistula of stomach, transverse colon and jejunum is disconnected and then sutured the created defects. Other variant is disconnection of stomach and transverse colon and leaving the gastroenteroanastomosis. It is necessary to remember, that during such operations the only fistula always removed and does not performed the resection of stomach. Clearly, that such situation also does not eliminate possibility of relapse of peptic ulcer and development of its complications. Taking into account it, palliative operations can be recommended in those case only, when the general condition of patient does not allow to perform radical operation.
Single-stage operation radical operations. The most widespread is degastroenterostomy with the resection of stomach. However, it is needed to remember that operation of disconnection of fistula, suturing of opening in the jejunum and transverse colon on the lines of fistula and resection of stomach applies only in case of absent of infiltrate and deformation and in the conditions of possibility to close a defect in bowels without narrowing of their lumen. This operation is the simplest, is enough easily carried by patients and it is enough radical.
Such complications appear through considerable time after operation (from 1 month to one year). Disturbances of function of gastrointestinal anastomosis can be caused by the reasons, related both to the technical mistakes during operation and with pathological processes which arose up in the area of anastomosis.
The clinical picture of disturbance of anastomosis function, mainly, depends from the degree of its closing. At complete it obstruction in patients arise up intensive vomiting, pain in a epigastric area, the symptoms of dehydration and other similar signs appear. In other words, the clinic of stenosis of the stomach output develops. Clearly, that during incomplete narrowing the clinical signs will be expressed less, and growth of them — more slow. Sometimes disturbance of evacuation can unite with the syndrome of afferent loop with a inherent clinical picture. At the roentgenologic examination of such patients expansion of stomach stump is exposed with the horizontal level of liquid and small gas bubble. Evacuation from it is absent or acutely slow.
Treatment of scar deformations and narrowing of anastomosis must be operative and directed for the disconnection of accretions and straightening of the deformed areas. In case of presence in patients large inflammatory infiltrate it does not need to perform disconnection. In such cases it is the best to apply roundabout anastomosis. If a resection by Finsterer was done in such patient, better to perform anterior gastroenteroanastomosis, and after a resection by Billroth-I — posterior. As a result of conducting of such operations the state of patient, as a rule, gets better, and often recovered the function of primary anastomosis.
Removing of all stomach and exception of duodenum from the process of digestion of food cause plural functional disturbances in an organism. Some of them meet already after the resection of stomach (dumping-syndrome, hypoglycemic syndrome), other more inherent for gastrectomy (anaemia, reflux- esophagitis and others like that).
Most patients, that carried gastrectomy, complain for a considerable physical weakness, heightened fatigueability, sometimes is complete weakness, loss of activity and acute decline of work capacity. Almost all of them notice bad sleep, worsening of memory and heightened irritates. The appearance of patients is typical. Their skin insignificantly hyperpigmentated, dry, its turgor reduced, noticeable atrophy of muscles. Can be the signs of chronic coronal insufficiency in such patients, and in older-year persons is typical picture of stenocardia. Except for it, can be hypotension, bradycardia and decline of voltage on EKG; during auscultation deafness of tones is observed. From the side of the hormonal system the decline of function of sexual glands is typical: in men — declines of potency, in women — disturbances of menstrual cycle, early climax. Can be the signs of hypovitaminosis A, B, С and decline of resistibility of organism to chill, infectious diseases and tuberculosis.
The decline of mass of body is observed in 75 % patients, that carried gastrectomy. It is conditioned by the decline of power value of food as a result of disturbance of digestion, bad appetite and wrong diet. As a result of progressive hypoproteinemia there can be the protein-free edemata.
Patients with such pathology must be under the permanent clinical supervision and 1–2 times per year during a month to have the course of stationary prophylactic treatment which includes psycho-, diet-, vitaminotherapy, correcting and replaceable therapy, and also prophylaxis of anaemia.
Psychotherapy is especially indicated in the psychodepressive and asthenic states. It is performed in combination with medicinal treatment. Hypnotic preparation, bromide, tranquilizers are applied.
A food must be correctly prepared, without the protracted cooking. Patients need to feed on 6–10 times per days by small portions.
Next to dietotherapy, it is constantly necessary to apply replaceable therapy (Pancreatine, Pansinorm, Festal, Intestopan). In case of absent of esophagitis hydrochloric acid is appointed. For the improvement of albuminous exchange anabolic hormones are applied.
In case of reflux-esophagitis there are indicated feeds by small portions with predominance of liquid, ground, jelly-like foods, astringent, coating, anticholinergic preparations. Between the receptions of food does not recommend to use a liquid. In case of dysphagy appoints a sparing diet.
For the prophylaxis of iron-deficiency anaemia, that arises up in the first 2–3 years after gastrectomy, important the indication of iron preparations.
For warnings and treatments of pernicious anaemia applied cyanocobalamin for 200 mcg through a day and folic acid. Packed red blood cells is indicated in heavy case.
The relapse of ulcer is enough frequent complication of vagotomy. It meets in 8–12 % patients. The reasons of such relapses of ulcer can be: 1) inadequate decline of products of hydrochloric acid (incomplete vagotomy, reinnervation); 2) disturbance of emptying of stomach (ulcerous pylorostenosis after selective proximal vagotomy or after pyloroplasty); 3) local factors (duodenogastric reflux with development of chronic atrophy gastritis, disturbance of circulation of blood and decline of resistibility of mucous tunic); 4) exogenous factors (alcohol, smoking, medicinal preparations); 5) endocrine factors (hypergastrinaemia: hyperplasia of antral G-cells, the Zollinger-Ellison syndrome; hyperparathyroidism).
Three variants of clinical passing of relapse of ulcer are distinguished after vagotomy: 1) symptomless, when an ulcer is found during endoscopic examination; 2) recurrent with protracted lucid space; 3) persisting ulcer with typical periodicity and seasonality of exacerbation.
It is needed to underline that the clinical signs of this pathology during the relapse are less expressed, than before operation, and absence of pain does not eliminate the presence of ulcer. Sometimes bleeding can be first its sign. Complex examination, that includes roentgenologic, endoscopic examination, study of gastric secretion and determination of content of gastrin in the blood, allows not only to expose an ulcer but also, in most cases, to set its reason. The interpretation the results of gastric secretion examination in such patients are heavy. Taking into account it, it is needed to study both a basal secretion and secretion in reply to introduction of insulin and pentagastrin, and also level of pepsin.
Approximately in 35 % patients, mainly with the first two variants of clinical passing of disease, the relapses of ulcers, are treated by ordinary methods of conservative therapy. Yet in 30–40 % cicatrization of ulcers comes after application of preparations which stop a gastric secretion (cimetidine, ranitidine—150 mg for night). At other 10–20 % patients, mainly with the third variant of clinical passing, is necessary operative treatment.
The question of choice of the repeated operation in patients with the relapse of ulcer after vagotomy still does not decided. Some surgeons execute revagotomy, trunk vagotomy with drainage operation, revagotomy with antrectomy or resection of stomach. However much majority from them in case of relapse ulcer after vagotomy performed antrectomy in combination with trunk vagotomy.
Frequency of postvagotomy diarrhea hesitates from 2 to 30 %. The basic sign of complication in patient is present the liquid watery emptying about three times per days. The reasons of diarrhea are: gastric stasis and achlorhydria, denervation of pancreas, small intestine and liver, and also disturbance of motility of digestive tract. Discoordination of evacuations from a stomach, stagnation and hypochlorhydria assist to development in it different microorganisms, and it also can be the reason of diarrhea.
The clinical signs of postvagotomy diarrhea are specific. Acute beginning are typical –patient often does not have time to reach to the rest room. Such suddenness repressing operates on patients. As a result they are forced whole days to be at home, expecting the duty attack. An excrement changes colorings as a result of breeding of pigment and becomes more light.
Treatment of diarrhea must be complex. Above all things it is needed to recommend a diet with the exception of milk and other provoking products. For the removal of bacterial factor antibiotics are applied. Favourable action in case of the signs of stagnation in a stomach are had weak solutions of organic acids (lemon, apple and others like that).
Among other most distribution was got by the А.А. Kuragin and S.D. Hroismann (1971) suggestion to treat postvagotomy diarrhea by benzohexamethonium (for 1 ml 2,5 % solution 2–3 times per a day). Reported also about successful application of cholesteramine (for
At heavy passing of postvagotomy diarrhea, that does not respond to conservative treatment, it is needed to recommend operative treatment — degastroenterostomy with pyloroplasty. However, the type of drainage operation, as practice shows, does not influence on frequency of diarrhea origin. In this connection, some surgeons with success applied the inversion of the segment of thin bowel, located distal from the area of maximal absorption.
The cancer of stomach is a malignant formation, that develops from epithelium tissue of mucus stomach. Among the tumours of organs of digestion this pathology takes first place and is the most frequent, by the reason of death from malignant formations in many countries of world. Frequency of it at the last 30 years considerably diminished in the countries of Western Europe and North America, but yet remains high in Japan, China, countries of East Europe and South America.
Etiology of cancer of stomach is unknown. It is known that, as other diseases of gastrointestinal tract, a cancer damages a stomach. According to statistical information, it meets approximately in 40 % of all localizations of cancer.
The factors of external environment has the substantial influencing on frequency of this pathology. Above all things, feed, smoke food, salting, freezing of products and their contamination of aflatoxin. Consider that a “food factor” can be: a) by a carcinogen; b) by the solvent of carcinogens; c) to grow into a carcinogen in the process of digestion; d) to be instrumental in action of carcinogens; e) not enough to neutralize carcinogens.
In the USA and countries of Western Europe frequency of cancer of stomach in 2 times more large in the lower socio-economic groups of population. Some professional groups also can it (miners, farmers, works of rubber, woodworking and asbestine industry). High correlation communication is set between frequency of cancer of stomach and use of alcohol and smoking. The value of genetic factors (heredity, blood type) is not led to.
The cancer of stomach arises up mainly in age 60 years and above, more frequent men are ill.
Precancer. The precancer diseases of stomach are: a) chronic metaplastic disregenerator gastritis conditioned by helicobacter pylori; b) villous polypuses of stomach and chronic ulcers; c) nutritional anemia due to vitamin B12 deficiency (pernicious); d) resected stomach concerning an ulcer.
The presence of precancer changes of mucous tunic of stomach has substantial influence for frequency of stomach cancer. In those countries, where morbidity on the cancer of stomach is higher, considerably more frequent chronic gastritises are diagnosed. Lately in etiology of chronic gastritises take the important value helicоbacter pylori. In Japan, where the cancer of stomach is in 40 % cases is the reason of death, chronic gastritis appears in 80 % cases of resected stomach, concerning a cancer.
Connection between polypuses, chronic gastric ulcers and possible it malignization comes into question in literature during many decades. Most authors consider that polypuses could be malignant differently. There are three histological types of polypuses: hyperplastic, villous and hamartoma. There are hyperplastic polypuses, but it not malignant.
Hamartoma is accumulation of cells of normal mucous tunic of stomach. They never becomes malignant.
Villous polypuses are potentially malignant in 40 % cases, but it happen in 10 times less, than hyperplastic. The possibility of malignization of chronic gastric ulcers is not proved. The American scientists support a hypothesis, that the cancer of stomach can be ulcerous often, but malignization of ulcers takes place rarely (no more than 3 %). From data of the Japanese scientists, on 50–70th there was higher correlation connection between chronic gastric ulcers and cancer of stomach. The frequent decline of this correlation is lately noticed (70 % on 50–70th and 10 % on 80th).
Frequency of cancer of stomach at patients with pernicious anaemia hesitates within the 5–10 %, that in 20 times higher, compare with control population. In patients with a resected stomach after peptic ulcers is multiplied the risk of origin of stomach cancer in 2–3 times (duration of latent period hesitates from 15 to 40 years). The reason of such dependence is not found out, but there is a version, that this is linked with a gastric epithelium metaplasia by an intestinal type.
From all malignant formations of the stomach in 95 % adenocarcinoma is observed. Epidermoid cancer, adeno-acanthoma and carcinoid tumours do not exceed 1 %. Frequency of leiomyosarcoma hesitates within the limits of 1–3 %. Lymphoma of gastrointestinal tract is localized in a stomach.
The prognosis of localization depends on the degree of invasion, histological variants of tumour.
The macroscopic forms of cancer of stomach in different times were described variously. More than 60 years ago the German pathologist Bermann described 5 macroscopic forms of cancer of stomach: 1) polypoid or mushroom-like; 2) saucer-shaped or with ulcerous and expressly salient edges; 3) with ulcerous and infiltration of walls of stomach; 4) diffuse -infiltrate; 5) unclassified.
American pathopsychologs is selected 4 forms. The tumours of stomach with ulcerous are the most frequent macroscopic form of cancer of stomach and arise up on soil of chronic ulcer. The signs suspicious on malignization are: the sizes of ulcer more than
The polypoid tumours of stomach observed only in 10 %. These tumours can achieve considerable sizes without an invasion and metastasis. Scirrhous carcinoma is the third macroscopic type. This category of tumours also does not exceed 10 %. The scirrhous carcinoma is the signs of infiltration by anaplastic cancer cells, diffusely developed connecting tissue which results in the bulge and rigidity of wall of stomach. So called “small cancers” belong to the fourth macroscopic type. It meet comparative rarely (no more than 5 %) and is characterized by superficial accumulation of cancer cells which substitute for normal mucus in such kind: a) superficial flat layer which does not rise above the level of mucus; b) salient (bursting) formation; c) erosions.
Mainly (more than 50 %) tumours arise up in a antral part or in distal (lower) third of stomach, rarer (to 15 %) — in a body and in cardia (to 25 %).
However, lately more often observed cardioesophageal cancers and diminishment of frequency of tumours of distal parts of stomach. In 2 % cases meet the multicentric focuses of growth, but from data of some authors, this percent could be multiplied in 10 times after carefully histological inspection of the resected stomaches. This assertion is based on the theory of the “tumour field” (D.I. Holovin, 1992). Especially this typically for patients which has pernicious anaemia or chronic metaplastic disregenerative gastritis.
Metastasis is carried out by lymphogenic, hematogenic and implantation ways mostly. Three (from data of some authors, four) pools of lymphogenic metastasis are selected: left gastric (knots on passing of small curvature of stomach in a gastro-subgastric ligament and pericardial); splenic (mainly, suprainfrapancreatic knots); hepatic (knots in a hepato-duodenal ligament, right gastric omentum that lower pyloric groups, right gastric and supraраpyloric groups, pancreatoduodenal group).
However, the such way of lymphogenic metastasis is conditional and incomplete, as at presence of block lymph flow passes retrograde metastasis, so called “jumping metastases” which predetermine the origin of remote lymphogenic metastases in left supraclavicular lymph nodes (Virhov metastasis) appear, in Lymph nodes of left axillar and inguinal areas, metastases in a umbilicus.
Direct distribution: small and large omentum, esophagus and duodenum; liver and diaphragm; pancreas, spleen, bile ducts.
Front wall of stomach: colon bowel and mesocolon; organs and tissues of retroperitoneal space.
Lymphogenic metastasis: regional lymph nodes, remote lymph nodes, left supraclavicular lymph node (Virhov), lymph node of axillar area (Irish); in a umbilicus (sisters Joseph).
Hematogenic metastasis: liver, lungs, bones, cerebrum.
Peritoneal metastasis: peritoneum, ovarium (the Krukenberg metastasis), Duglas space (the Shnicler metastasis).
All authors which are engaged in the study of problem of cancer of stomach underline absence or vagueness, no specificity of symptoms, especially on the early stages of disease. The displays of cancer of stomach are very various and depend on localization of tumour, character of its growth, morphological structure, distribution on contiguous organs and tissues. At localization of tumour in a cardial part patient complains firstly, as a rule, for appearance of dysphagy.
At careful, purposeful collection of anamnesis it is not succeeded to expose some other, most early symptoms, which precedes to dysphagy and forces a patient to appeal to the doctor. The unpleasant feeling behind a breastbone and feeling of unpassing of hard food on a esophagus appear at the beginning of disease. After some time (as a rule, it is enough quickly, during a few weeks, sometimes even days) a hard food does not pass (it is to wash down by water or other liquid). This period can be during 1–3 months. Patients address a doctor exactly in this period. Other symptoms appear to this time: regurgitation, pain behind a breastbone, loss of mass of body, sometimes even exhaustion, the grey colouring of person, a skin is dry, quickly grows general weakness. Sometimes patients address a doctor, when already with large effort a spoon-meat passes only or complete stenosis came.
At localization of tumour in the antral part of stomach the first complaints, as a rule, are up to appearance of feeling of weight in epigastric region after the reception of food (even in a two-bit), “feeling of saturation” (after the reception of glass of water), belch (at first it is simple by air, and then with a smell). Feeling of weight grows for a day, patients forced to cause vomiting. In the morning there can be vomiting by mucus with the admixtures of “coffee-grounds” (so called “cancer” water). Patients loses weight (mass of body is lost), a weakness, anaemia grows.
Tumours localized in the body of stomach show up either a pain syndrome or syndrome of so called “small signs” (А.I. Savitskyy, 1947), which is characterized by appearance of amotivational general weakness, decline of capacity, rapid fatigueability, depression (by the loss of interest to the environment), proof decline of appetite, gastric discomfort, making progress weight lost.
The carried chronic diseases of stomach, for which typical seasonality, can influence on the clinical sign of cancer of stomach. At appearance of “gastric” complaints out of season or in absent of effect from the got therapy concerning the exacerbation of “gastritis”, “ulcers” must guard a patient and doctor (symptom of “precipice” of gastric anamnesis).
In case of occurring of “gastric” symptoms first in persons in age 50 years and older it is foremost necessary to eliminate the cancer of stomach.
In parts of patients cancer of stomach shows up only the metastatic damage of other organs or complications. More than twenty so called “atypical” forms, which are characterized by “causeless” anaemia, ascites, icterus, fever, edemata, hormonal disturbances, changes of carbohydrate exchange, intestinal symptoms, are distinguished.
During the examination of patients with the cancer of stomach the pallor of skin covers (at anaemia) is observed, ieglected case is “frog” stomach (sign of ascites).
During palpation determined painful in a epigastric area, sometimes possible to palpate the tumour.
During auscultation of patients with pylorostenosis it is possible to define “noise of splash”.
Laboratory information: hypochromic anaemia, neutrophilic leukocytosis, megascopic ESR; during examination of gastric secretion: hypo- and anacidity and achlorhydria.
Gastroduodenoscopy enables to diagnose a tumour even smaller
Roentgenoscopy and roentgenography examination of stomach. Basic signs: defect of filling, local absence of peristalsis, “malignant” relief of mucous tunic (Pic. 3.2.18).
Ultrasonic examination: presence of metastases in a liver, pancreas.
Computer tomography allows to estimate the basic parameters of tumour, germination in neighbouring organs and presence of metastases.
It is expedient to apply laparoscopy, mainly, for the decision of question about operable of tumour (diagnostics of metastatic defeat of organs of abdominal cavity).
At an early cancer complaints depend on the previous gastric diseases. Therefore, on the basis of clinical information, suspecting a tumour is possible only on occasion, when in patients next to clear pain symptoms an appetite goes down, appear anaemia, general weakness. In practice an early cancer is recognized at purposeful screening, and also in the process of endoscopic or roentgenologic examination of gastric patients.
A differential diagnosis is conducted with an peptic ulcer, gastritis, polyposis, other gastric and ungastric diseases. For a cancer there is typical firmness of symptoms, instead of their seasonality (typical syndrome of “precipice” of gastric anamnesis) or tendency to their gradual progress.
The row of diseases, with which the cancer of stomach is to differentiate to the doctor, depends from character of complaints of patients.
Five basic clinical syndromes are selected:
1) pain;
2) gastric discomfort;
3) anaemic;
4) dysphagic;
5) disturbance of evacuation from a stomach.
At patients, at what cancer of stomach shows up a pain syndrome and syndrome of gastric discomfort, a differential diagnosis is conducted with the peptic ulcer, gastritis, cancer of body of pancreas.
It is oriented on features dynamics of development of pain syndrome, ingravescent of the general condition, change of character of complaints.
A question about character of anaemia, source and nature of bleeding decides at an anaemic syndrome. In the process of examination attention is paid to the state of bottom of stomach, where bleeding malignant formations can be.
At a dysphagic syndrome a differential diagnosis is conducted with the cicatrical narrowing, achalasia of esophagus. For malignant formations testify short anamnesis, gradual progress of symptoms, signs of gastric discomfort, general weakness, weight lost.
At disturbance of evacuation from a stomach during stenosis of pyloric part, absence of ulcerous anamnesis, declining years of patients, relatively quick (weeks, months) growth of stenosis testify for tumor.
The presence of cancer of stomach is a indications for surgical treatment. However, counting on success is possible only at presence of the limited tumours (within the limits of the 0–II stages). At the III stage of disease implementation of the widespread combined operations in a radical volume is possible, however most patients die during 1–2 years. A distal or proximal subtotal resection (Pic. 3.2.19) and total gastrectomy (Pic. 3.2.20) is performed with removing of large and small omentumes and regional areas of metastasis with obligatory histological examination of stomach on the lines of resections.
During the combined operations organs which are pulled in to the pathological process are removed.
In case of IV stage of disease and satisfactory state of patient palliative operations which improve quality of life of patient are performed.
In case of presence of complications (mainly stenosis) and grave common condition of patient perform symptomatic operative treatments.
Symptomatic is operations which will liquidate one of symptoms of cancer of stomach. In this group of operations include: 1) roundabout gastrojejunoanastomosis (Pic. 3.2.21) and jejunostoma (in case of the stenosis tumours of stomach output); 2) gastrostoma (Pic. 3.2.22) in case of the cancer of cardial part of stomach with disturbance of patency; 3) edging of bleedingх vessels in case of complication of cancer by bleeding; 4) tamponade by omentum during the perforation of tumour.
The value of radial therapy and chemotherapy, as independent methods of treatment of cancer of stomach, is limited. Radial therapy is indicated for patients with cardial cancer as preoperative course or as palliative treatment. Adjuvant mono- or polychemotherapy (mainly by 5-phtoruracil) is conducted in a postoperative period as combined therapy and in case of dissemination of the tumours.
Prognosis. The indexes of five-year survival of patients with the cancer of stomach hesitate within the limits of 5–30 %, but, from data of most authors, they do not exceed 10 %.
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.
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 —
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