POSTRESECTION AND POSTVAGOTOMY SYNDROMES. CLASSIFICATION. CLINICS

POSTRESECTION AND POSTVAGOTOMY SYNDROMES. CLASSIFICATION. CLINICS. DIAGNOSTICS. CONSERVATIVE AND SURGICAL TREATMENT. PROPHYLAXIS.

 

DUMPING SYNDROME

 

Etiology and pathogenesis

 

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.

 

Clinical management

 

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 5 kg. A working capacity is well-kept. Medicinal and dietary treatment gives a good effect.

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 10 kg. Patients, as a rule, are disabled. Conservative treatment is uneffective.

 

Pic. 1. Dumping syndrome (quick evacuation of the contrast)

 

 

Tactic and choice of treatment method

 

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.

 

HYPOGLYCEMIC SYNDROME

 

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.

 

STAGES OF THE HYPOGLYCEVIC SYNDROME

 

 

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).

 

POSTGASTRECTOMY (AGASTRIC) ASTHENIA

 

Etiology and pathogenesis

 

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.

 

Clinical management

 

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.

 

Tactic and choice of treatment method

 

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.

 

SYNDROME OF AFFERENT LOOP

 

Etiology and pathogenesis

 

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).

 

Clinical management

 

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 1 liter of bile with vomiting masses. During the objective examination observed subicteritiousness of the sclera, sign of dehydration of organism (decline of turgor of skin, dry tongue, oliguria, concentrated urine). Emptying is irregular, grey color, with considerable content of undigested fat and muscular fibres. Anaemia can develop at heavy passing of disease.

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).

 

DEGREES OF AFFERENT LOOP SYNDROME

 

 

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.

 

 

Tactic and choice of treatment method

 

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.

 

 

Рис. 2. Resection by Roux

 

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.  video

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.

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.

 

REFLUX-ESOPHAGITIS

 

Etiology and pathogenesis

 

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.

 

Clinical management

 

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.

 

Tactic and choice of treatment method

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

 

Etiology and pathogenesis

 

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.

Clinical management

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 can not 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.

Tactic and choice of treatment method

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.

 

PEPTIC ULCER OF THE ANASTOMOSIS

 

Etiology and pathogenesis

 

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.

 

Clinical management

 

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.

 

Tactic and choice of treatment method

 

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.

 

GASTRIC-COLON FISTULA

 

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.

 

Clinical management

 

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.

 

Tactic and choice of treatment method

 

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.

 

THE SCAR DEFORMATION AND NARROWING OF ANASTOMOSIS AFTER THE STOMACH RESECTION

 

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.

 

Clinical management

 

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.

 

Tactic and choice of treatment method

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.

 

CONSEQUENCES AND COMPLICATIONS OF GASTRECTOMY

 

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.

 

Tactic and choice of treatment method

 

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.

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 20 cm and more) pneumatizated bowel is exposed. During the perforation of bowel signs of pneumoperitoneum are present (air under the right cupula of diaphragm). Contrasting irrigoscopy examination in such patients enables to establish the presence of “water-pipe” symptom. Thrusting out of tailings of well-kept mucus membrane on the background of plural ulcers and cicatricial changes of bowel walls at pseudopolyposis creates roentgenologic reality of “shot target through”symptom (Pic. 3.3.9). Often in case of transformation of ulcerous colitis in the cancer on roentgenograms, stenosis cavity of bowel or defect of filling is observed (Pic. 3.3.10).

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 5 g per days, and salazopiridazine and salazodimetoxine — about 2 g during that time. The course of treatment must proceed 1–2 months. For local steroid therapy prednisolone is used as powder in a dose 60–80 mg or hydrocortisone — to 125 mg. It is dissolved in 100 ml physiologic saline and entered rectal dropwise one time per days during 3–4 weeks.

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 North America colorectal cancer (CRC) is one of most widespread malignant neoplasm. Morbidity in these regions exceeds 20,0 on a 100000 of population. In Japan, South America, Africa and countries of Asia this tumour is met rarer (6,0:100000). There is an annual increase of frequency of cancer of colon approximately by 3 % in the developed countries. Morbidity of population of Ukraine by malignant neoplasm in 1995 was 16,3:100000.

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 5-6 cm from the edge of tumour. In patients who are hospitalized in an urgent order with the signs of intestinal obstruction, perforations and peritonitis, after intensive preoprative preparation the Hartmann operation is executed (at tumours of left half of colon). It is the resection of the damaged area of intestine and exteriorization of proximal segment on a front abdominal wall as colostomy. A distal end is sutured and is remained in the abdominal cavity. Through half-year there is a possibility of reconstructive operation. To the patients with the damage of right half of colon operation in a radical volume can be executed (right hemicolectomy).

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 basis of disease of pancreas is degenerative-inflammatory processes which are considered to be acute pancreatitis, the so called autolysis tissue by its own enzymes. In the structure of acute pathology of organs of abdominal cavity this disease takes the third place after acute appendicitis and cholecystitis. Women suffer from acute pancreatitis 3–3,5 times more frequently than men.

Acute pancreatitis is a polyetiology disease. Its secondary forms, which arise on the background of pathologies of bile-excreting system and duodenum are closely associated with anatomic and functionally with pancreas, and are met in clinical practice.

Among the “starting” factors of origin of cholelithiasis disease (biliary pancreatitis) abuse by an alcohol and food overloads (fat and irritating products), traumas of pancreas, operating-room in particular, and also separate infectious diseases (parotitis, mononucleosis) are most frequent, especially infection of bilious ways. However, in 10–20 % of patients the reason of acute pancreatitis remains unknown (cryptogenic form).

In the basis of such damages of pancreas and enzymic toxemia lies mainly activating of pancreatic, and then the tissue enzymes (tripsin, lipase, amylase). Often the combination of the broken outflow of pancreatic secret and promoted secretion takes place, which provokes intraductal hypertension.

Among explanations of primary mechanisms of activating of pancreatic enzymes the most value belongs to: a) theory of “general duct” with reflux of bile in the ducts of pancreas; b) blockade of outflow of pancreatic juice with development of intraductal hypertension and penetration of secret in interstitial tissue; in) violation of blood flow of pancreas (vasculitis, thrombophlebitis and embolisms, cardiac insufficiency and others like that); g) toxic and allergic damages of gland. The role of alcohol in such situations can be dual: stimulation of secretion of pancreas and direct damaging action on its tissue.

The process of acute inflammation of pancreas consistently passes the stages of edema, pancreatonecrosis and festering pancreatitis. In the stage of edema there is pancreas of hyperemic, increased in volume, with the shallow hearths of necrosis or, as it is in swingeing majority of cases, without them.

Pancreatonecrosis can pass with fatty or hemorrhagic character. In the first case, as a rule, pancreas is increased, dense, cut whity-yellow hearths are selected to necrosis. Increase of crimson-black pancreas with darkly-brown infiltrate on a cut is characteristic for hemorrhagic pancreatonecrosis.

Dystrophy of parenchyma is exposed microscopically, up to necrosis, hemorrhages, thromboses of vessels and signs of inflammatory infiltration.

The disease begins suddenly, after the surplus reception of rich spicy food and use of alcohol. Pain, vomiting and phenomena of dynamic intestinal obstruction are considered the most characteristic signs of acute pancreatitis.

A stomach-ache is permanent and so strong, that can result in shock, localized in an epigastric area and left hypochondrium. Some patients feel pain in right hypochondrium with irradiation in the back, loin or breastbone.

In a short period of time after appearance of pain there is a repeated strong vomiting, that does not facilitate the state of patient.

In general vomiting is considered a frequent and characteristic symptom. It is repeated or continuous and never brings facilitation. Vomit masses contain bile, as admixture, and at the difficult form of acute pancreatitis remind “coffee-grounds”.

Nausea, hiccup, belch and dryness in a mouth are attributed as less characteristic symptoms of this pathology.

During the examination the skin is pale, often subicterus. Some patients have cyanosys with a “marble picture” as a result of violation of microcirculation. Later the component of respiratory insufficiency can join it. At progressive general condition the patient quickly gets worse to passing of acute pancreatitis, intoxication grows. The skin takes shelter with sticky sweat.

The temperature of body of patients at the beginning of disease can be normal. It rises at resorption of products of autolysis tissue and development of inflammatory process in bilious ways.

The pulse in most cases is at first slow, then becomes frequent, notedly passing ahead the increase of temperature of body.

 Arterial pressure goes down.

The tongue in the first hour of disease is moist, assessed by white and grey raid. At vomiting by bile the raid has yellow or greenish tint.

The abdominal is blown away, peristaltic noises are loosened. The signs of paresis of stomach and intestine demonstrate early. They need to be included in the pathological process of mesentery root of bowel. At palpation painfulness in an epigastric area and in right, and sometimes and in left, hypochondrium is marked. However, in spite of great pain in stomach, it remains soft for a long time. A little later there is moderate tension or resistance of muscles of front abdominal wall.

Poor local symptoms during heavy intoxication are characteristic for the early period of acute pancreatitis. Later there are symptoms of irritation of peritoneum, and at percussion dulling is marked in lateral parts of abdominal as a result of accumulation of liquid, and also the sign of aseptic phlegmon of retroperitoneal cellulose as slurred or edema of lumbar area is seen. For diagnostics of acute pancreatitis there is the row of characteristic symptoms which have different clinical value.

The Mondor’s symptom is violet spots on face and trunk.

The Lagermph’s symptom is acute cyanosys of person.

The Halsted’s Symptom is cyanosys of abdominal skin.

The Gray’s symptom is cyanosys of lateral walls of abdomen.

The Kullen’s symptom is the yellow colouring of skin near a belly-button.

The Korte’s symptom is painful resistance as a lumbar bar in a epigastric area on 6–7 cm higher belly-button.

The Voskresynskyy’s symptom is absence of pulsation of abdominal aorta in an epigastric area.

The Mayo-Robson’s symptom is feeling of pain at pressure by fingers in the left costal-vertebral corner.

The Rozdolskyy’s symptom — painfulness at percussion above pancreas.

The Blumberg’s symptom — in patients with acute pancreatitis more frequently is low-grade. Such feature of this sign of irritation of peritoneum needs to be explained by character of localization of pathological process, mainly in retroperitoneal spacious.

In clinical passing of pancreatonecrosis it is possible to select three periods (V.S. Saveljev, 1978).

The I period (hemodynamic violations and pancreatogenic shock) lasts during 2–3 days. Violation of central hemodynamics, diminishment of volume of circulatory blood and disorders of microcirculation, which at first arise as a result of angiospasm, are considered the most characteristic signs, and later as a result of joining of the intravascular rolling up and laying of elements of blood.

The II period (insufficiency of parenchymatous organs) lasts from 3rd to the 7th day of disease. Violation of functions of basic organs and systems, sign of cardio-vascular, hepatic and kidney insufficiency and growth of violations of breathing are thus observed. In this period there is possible damaging of the central nervous system, which is erected mainly to disorders of psyche, appearances of delirium and commas which in the eventual result are the main reasons of patients’ death.

The III period (postnecrosis dystrophic and festering complications) comes in 1–2 weeks after the beginning of disease. During it, on the background of progress of necrosis processes in pancreas, the regenerative changes develop, there are parapancreatic infiltrate and cysts, cystic fibrosis of pancreas. Aseptic retroperitoneal phlegmon which strengthens intoxication can also develop. There is festering pancreatitis at joining of infection. During this period such complications, as erosive bleeding, internal or external fistula, retroperitoneal phlegmon, can develop in patients.

From laboratory information leucocytosis which at the necrosis and hemorrhagic forms of pancreatitis sometimes arrives at 25-30 х 109, lymphopenia, change of leukocytic formula to the left and the increased ESR are characteristic. Growth of activity of amylase of blood and urine is very often marked, and is the important sign of pancreatitis. For estimation of the state of other organs maintenance of general albumen and its factions, glucose of blood, bilirubin, urea, electrolytes, acid-base equilibrium (ABE), and also the state of blood coagulation are determined. It is necessary to mark that the exposure of hypocalcemia is considered a bad predictive sign of heavy passing of acute pancreatitis.

Ultrasonic examination (Pic. 3.5.1) of gall-bladder and pancreas often specifies the increase of their sizes, bulge of walls and presence or absence of concrement of gall-bladder and general bilious duct.

Computer tomography enables to describe in details the changes in pancreas and surrounding organs.

At sciagraphy survey of organs of abdominal cavity gives a possibility to expose the unfolded “horseshoe” of duodenum, pneumatization, expansion of transverse colon (the Gobia’s symptom). On the 1st stage of diagnostics in the plan of differential diagnosis of acute destructive pancreatitis with other diseases of abdominal cavity, diagnostics of distribution of destructive damaging of different parts of pancreas and estimation of distribution of parapancreatitis is possible only by the method of computer tomography which depending on clinico-laboratory signs and weight of passing is needed to apply in a different period, and sometimes a few times in dynamics with interval of 4–5 days.

Laparoscopy and laparocentesis are often used for a doubtful diagnosis or necessity of taking away the exudation of abdominal cavity for biochemical or bacteriological examination.

Retrograde endoscopic cholangiopancreatography is used in case of mechanical icterus and suspicion of choledocholithiasis. The last methods are invasive and can if it is necessary transform from diagnostic to manipulation treatments: laparoscopic draining of abdominal cavity at pancreatogenic peritonitis and endoscopic papillotomy at choledocholithiasis and biliary pancreatitis.

Clinical passing of disease can be abortive, slowly or quickly progressive. At abortive passing the process is limited to acute edema of pancreas with convalescence in 7–10 days.

Rapid progress is characteristic for pancreatonecrosis. In patients expressed toxemia, impregnation by exudation of retroperitoneal cellulose and development of fermentative hemorrhagic peritonitis can be seen. Strengthening of stomachache, continuous vomiting, proof paresis of intestine, positive symptoms of irritation of peritoneum and growth of hemodynamic violations are the clinical signs of necrosis of pancreas.

There is a formation of parapancreatic infiltrate at slow progress.

Among early complications of acute pancreatitis shock, peritonitis and acute cardiac, pulmonary, hepatic and kidney insufficiency can be distinguished.

Before later complications it is needed to deliver the abscesses of pancreas, subdiaphragmatic, interintestinal abscesses, pyogenic abscess omentum bag, phlegmons of retroperitoneal space and erosive bleeding.

In future formations of pseudocysts, fistula of pancreas, intestinal fistula and development of saccharine diabetes are possible.

Acute pancreatitis needs to be differentiated with the row of acute diseases of organs of abdominal cavity.

Acute mechanical intestinal obstruction. In patients with this pathology pain is of the alternated character and is accompanied by nausea, vomiting, delay of gases and emptying. It is possible to see the Klojber bowls on the sciagram survey of organs of abdominal cavity.

Acute cholecystitis runs with characteristic localization of pain and muscular defense, with presence of increased, painful gall-bladder or infiltrate in right hypochondrium. Often acute (especially lately) pancreatitis develops on the background of gallstone disease (biliary pancreatitis).

Thrombosis or embolism of mesenteric vessels. Both for pancreatitis and for the thrombosis of mesenteric vessels great pain at soft abdomen (absence of defense muscles of front abdominal wall), that precedes to development of peritonitis, is inherent. Yet from the beginning the disease gains heavy character of passing. In anamnesis in such patients a heart disease or heart attack of myocardium rheumatic is met. As a result of gangrene of intestine, the symptoms of peritonitis appear very quickly and intoxication grows. The fragments of mucus shell are found in flushing waters of intestine at the detailed examination, which have the appearance of ”meat flushing”.

A perforated gastric and duodenum ulcer is distinguished by the presence of dagger pain, defense of abdominal wall, ulcerous anamnesis.

The conservative method is considered the basic one for treatment of acute pancreatitis, but in connection with that unsuccessful conservative treatment of patients with acute pancreatitis can often put a question about the necessity of operation, therefore patients must be in permanent surgical establishment. Thus acute pancreatitis with heavy passing is necessary to be treated under the conditions of separation of intensive therapy.

Before conservative treatment hunger, bed rest, fight against pain and enzymic toxemia, conducting of acid-base state, prophylaxis of festering infection and acute ulcers of digestive duct are to be entered .

Patient’s stomach is washed by cold soda solution and a cold on an epigastric area and left hypochondrium is used. Medicinal therapy is prescribed also: spasmolytics (papaverine, platyphyllin, no-shparum, baralgine, atropine); inhibitor of protease (contrical, trasilol, gordox, antagosan); cytostatic agent (5-fluorouracil, ftorafur). Positive action of inhibitor of protease is marked only in the first days of disease which are subject to conditioned application of large doses. Antibiotics of wide spectrum of action: a) tienam, which most effective in the prophylaxis of festering pancreatitis, as is selected by pancreatic juice; b) cephalosporins (kefzol, cefazoline); c) cefamizine (mefoxine).

Disintoxication therapy is conducted also (5 % but 10 % solutions of glucose, hemodes, reopolyhlukine, polyhlukine, plasma of blood, only from 3 to 5 liters on days, in accordance with a necessity).

For the improvement of rheological properties of blood heparine is prescribed (5 000 ODES every 4 hours).

If patients have the expressed pain syndrome and phenomena of general intoxication during all pain period plus 48 hours (by Bakulev), hunger is used. Such mode lasts on the average of 2–4 days. The parenteral feed of albuminous hydrolyzate is thus conducted, by the mixtures of amino acid and fatty emulsion. Alkaline water of to 1–2 l. and albuminous-carbohydrate diet are also appointed. Infusion therapy is complemented by plasma, by albumen, hemodes, reopolyhlukine. The improvements of microcirculation in pancreas are achieved due to introduction of reopolyhlukine, komplamine, trental and heparin 5000 ODES 6 times per days under the control the indexes of the coagulation system of blood. Anticholinergic drug (sulfate of atropine, methacin, platyphyllin), Н2-histamin blocker (cimetidine, ranisan, ranitidine, famotidine, omeprazol) are also applied. For the removal of pain: 1) sulfate of the atropine 0,1 % — 1 ml + promedol 2 % — 1 ml + papaverine 2 % — 2 ml + analgin 50 % — 2 ml; 2) isotonic solution of chloride of sodium — 500 ml + baralgine — 5 ml + diphenhydramine hydrochloride 1 % — 1 ml + papaverine 2 % — 2 ml + magnesium the sulfate 25 % — 5 ml + ascorbic acid — 5 ml + lipoic acid 0,5 % — 2 ml + novocaine 0,5 % — 10 ml. are used. From the first days by a nasogastral probe the permanent aspiration of gastric maintenance is conducted also. The Motility function of gastro-intestinal highway gets better at application of cerucal or primperane. With the same purpose forced diuresis (maninil, furosemide, aminophylline) is used on the background of intravenous introduction of plenty of liquid.

At uneffective conservative treatment of patients with acute pancreatitis of middle weight and heavy form it is expedient to apply surgical treatment.

Surgical treatment is carried out for patients with biliary pancreatitis (for a day long from the beginning of disease) in combination with the destructive forms of cholecystitis, at complications of acute pancreatitis by peritonitis, abscess of omentum bag or phlegmon of retroperitoneal cellulose.

Overhead-middle laparotomy, which allows to estimate the state of pancreas, bilious ways and other organs of abdominal cavity, is the best access in this situation. In case of destructive pancreatitis the possible use of lumbar laparotomy from left to right hypochondrium through a mesogastric area is useful.

Cholecystectomy is executed at calculous cholecystitis, phlegmonous inflammation of walls of gall-bladder and biliary pancreatitis. If there are more than 0,9 cm at expansion of choledochus, presence of concrement, ointment-like bile in it, increase of concentration of bilirubin in the whey of blood over 21 mmol/L, choledochuslithotomy is complemented by external draining of choledochus. Information of lithiasis of general bilious duct is absent, cholecystectomy in patients with acute pancreatitis is complemented by external draining of choledochus, better by Pikovskyy method (through stump of cystic duct).

Transduodenal sphincteroplasty is shown at fixed concrement of large duodenal papilla (Pic. 3.5.2), if they are diagnosed intraoperative, and also in the cases of papillotomy with extraction of concrement when there is no possibility to execute endoscopic operation .

Omentopancreatopexy. After laparotomy and cutting of gastro-colon and gastro-pancreatic ligament mobile part of large omentum through opening in gastro-colon ligament is conducted and fixed by separate stitches to the peritoneum along the overhead and lower edges of pancreas. Such operatioeeds to be considered rational at the expressed edema of pancreas and presence of necrosis in it.

Abdominisation of pancreas. A cellulose round pancreas (along the lower and overhead edges of body and tail) is infiltrated by solution of novocaine, after it parietal peritoneum is cut. Under the body and tail glands free end of omentum is conducted and is bundled by a gland. This operation is able to warn the hit of enzymes and products of disintegration in retroperitoneal space.

Sequestrectomy is deleting of necrosis part of gland within the limits of nonviable tissue. Operation is executed in a dull way.

Necrectomy (deleting of necrosis part of gland within the limits of healthy tissue) is executed by an acute way: tissue of gland is cut on verge of necrosis and bleeding vessels are carefully bandaged.

The resection of pancreas is deleting the part of organ with its transversal cutting within the limits of the unchanged (ad осulus) tissue of gland. The resections of tail and body of pancreas are distinguished (Pic. 3.5.3).

Pancreatectomy is a complete deleting of pancreas. Operative treatment is applied infrequently. After the resection of pancreas adequate draining of its bed is very responsible.

The prognosis of disease depends on character of morphological changes of parapancreatic to the cellulose in pancreas. The more difficult destructive changes, the worst the prognosis.

Chronic pancreatitis is a progressive inflammation of pancreas with the periodic acutening and remission, related to the process of autolysis, that shows up by pain, by violation of exocrine and endocrine functions of gland with the eventual result of fibrosis of organ and high risk of malignization.

A gallstone disease is considered the most frequent reason of chronic pancreatitis. Pathogenesis of cholangiogenic pancreatitis acted in pancreatic ducts (theory of general duct) is in part of difficulty of outflow of pancreatic secret and reflux of infected bile or maintenance of duodenum. Dyskinesia, spasms and stenosis of the Fater’s papilla of duodenum are instrumental in reflux. Bile or duodenal maintenance, that gets Wirsung’s duct, activates the enzymes of pancreas and is instrumental in the origin of its inflammation. Development of pancreatitis potentiates infection. The last can penetrate pancreas not only due to reflux but also in a hematogenic or lymphogenic way.

Thus, chronic pancreatitis develops as a result of functional violations of pancreas, which with the flow of time pass to organic. The reasons of such violations are the attack of acute pancreatitis suffered the in past, alcoholism, traumas of gland, pathology of its vessels, gastroduodenal ulcers, gastritis or duodenostasis.

The morphological changes in pancreas at chronic pancreatitis are mainly taken to development of passionately-degenerative processes and atrophy of parenchyma. Connecting tissue in such cases develops both in the particles of gland and between them. In one case the process has diffuse character, in the other it is limited. Thus pancreas becomes dense as a result of excrescence of connecting tissue. It can be multiplied, taking shape of chronic hypertrophy pancreatitis. Atrophy of gland comes in other cases, besides, not evenly in different parts.

The inflammatory edema of parenchyma is exposed in case of acutening of process. Hemorrhages, fatty necrosis and pseudocysts are exposed on the surface of cut.

As passing of disease has cyclic character with the periodic changes of remission and acuteening, the clinic of chronic pancreatitis depends on the phase of development of inflammatory process. Violation of excretory and incretory functions of pancreas influences polymorphic of symptoms which remission is especially determining in the phase.

Pain, dyspepsia phenomena and progressive loss of weight of body are the basic signs of chronic pancreatitis. Besides, pain, is permanent, changes only its intensity, mainly in epigastric region, sometimes on the left, burning, squeezing or prickly, comes forward the unique symptom of disease, complaints about it precede other symptoms. In some patients the pain feelings increase in lying position. Therefore patients occupy forced sitting position. Intensity of pain can change throughout a day. Patients explain it by acceptance of rich, fried food, boiled eggs, coffee. The last is the principal reason of acutening of process with acute pain syndrome.

It is needed to mark, that occasionally passing of chronic pancreatitis can take hidden, smooth shapes, with the moderately expressed pain syndrome or pain, that has atipical character, for example, stenocardia. In such patients the symptoms related to violations of exogenous function of pancreas come forward. They complain about absence of appetite, nausea, belch, sometimes vomiting and diarrhea with putrid smell. Thirst, general weakness and progressive loss of weight is observed also.

At palpation of abdomen pain does not arise, or it is quite insignificant. It is sometimes succeeded to palpate horizontally placed pancreas as dense, moderately painful tension bar. The transmission of pulsation of aorta at palpation in a epigastric area count characteristic for pathology.

During intervals between the attacks the feeling of patients remains satisfactory.

Development of saccharine diabetes is the basic sign of endocrine insufficiency, hypoglycemia is rarer. The feature of this form of saccharine diabetes consists in the fact that it shows up in a few years after the beginning of disease, runs easier and often carries latent character. There can be hypoglycemia at the insufficient products of glucagon.

The syndrome of biliary hypertension with development of mechanical icterus and cholangitis determining it can develop in some patients. The reasons for such cholestasis more frequently are tubular stenosis of choledochus, choledocholithiasis or stenotic papillitis. There is duodenal obstruction in some cases.

Important information about it can be given by the laboratory and instrumental methods of examination.

Examination of excretory function of pancreas is based on establishment of level of amylase in the whey of blood and urine. In acutening period of chronic pancreatitis this level of amylase rises, the numbers of tripsin and lipase grow.

Coprologic examination. Macroscopic picture of excrement gets greyish color, in large masses — with unpleasant smell. Steatorrhea (increase of amount of neutral fat) and creatorrhea are characteristic for it (a plenty of muscular fibres).

Examination of incretory function of pancreas includes: 1) determination of sugar in blood and urine (characteristic is hyperglycemia and glycosuria); 2) radioimmunoassay of hormones (insulin, С-peptide and glucagon).

Sciagraphy survey of organs of abdominal cavity in two projections enables to expose existent concrement in ducts and calcificat in parenchyma of pancreas.

Relaxation duodenography. Thus the development of “horseshoe” of duodenum and change of relief of its mucus can be seen (Pic. 3.5.4).

Cholecystocholangiography with the purpose of diagnostics of gallstone disease and second damaging of bilious ways is conducted.

Ultrasonic examination (sonography) is one of the basic methods of diagnostics. With the help of symptoms of chronic pancreatitis it is possible to expose inequality of contours of gland, increase of closeness of its parenchyma, increase or diminishment of sizes of organ, expansion of pancreatic duct and wirsungolithiasis or presence of concrement of parenchyma. Thus it is necessary to inspect gall-bladder, liver and bile-excreting ways for diagnostics of gallstone disease and choledocholithiasis (Pic. 3.5.5).

Scintigraphy of pancreas. On early stages strengthening of scintigraphic picture is observed, on later ones — defects of accumulation to radionuclide (symptom of “sieve” or “bee honeycomb”).

Computer tomography allows to expose the increase or diminishment of sizes of gland, presence of calcificats, concrement, inequality of contours of organ, focuses or diffuse changes of its structure (Pic. 3.5.6, Pic. 3.5.7).

Endoscopic retrograde cholangiopancreatography (ERCPG). Expansion of pancreatic duct its deformation, wirsungolithiasis is marked, (Pic. 3.5.8).

It is expedient to apply laparoscopy in the phase of acutening of chronic pancreatitis at development of fatty and hemorrhagic pancreatonecrosis (“steariame-plates”, exudation).

The puncture biopsy of pancreas under sonography control can have an important value for differential diagnostics of pancreatitis and cancer.

Percutaneous transhepatic cholangioduodenography and -stomy. This method is used both for differential diagnostics of pseudo tumor-like form of chronic pancreatitis and cancer of pancreas and with the purpose of preoperative preparation at presence of icterus. During it there is a possibility to expose expansion of intra- and out-of-hepatic ducts, localization and slowness of their stricture.

Chronic recurrent pancreatitis. The changes of periods of acuteening and remission are characteristic for it. The first period shows up by the attacks of pain of different frequency and duration, and during remission patients feel satisfactory.

Chronic pain pancreatitis. Intensive pain in the overhead half of abdomen with an irradiation in loin and region of heart is inherent for this form. Also belting pain often appears.

Chronic painless (latent) pancreatitis. In patients with this form of pathology for a long time the pain is either absent in general or arises after the reception of spicy food rich and can be insignificantly expressed. Violation of excretory or incretory function of pancreas come forward on the first plan.

Chronic pseudo tumor-like pancreatitis. Dull pain in the projection of head of pancreas, dyspepsia disorders and syndrome of biliary hypertension are clinical its signs.

Chronic cholangiogenic pancreatitis. Both clinic of chronic cholecystitis and cholelithiasis and clinic of pancreatitis are characteristic for this form.

Chronic indurative pancreatitis. In patients with this diseases symptoms of excretory and incretory insufficiency of pancreas are present. The low indexes of amylase in blood and urine are characteristic. At the expressed sclerosis of head of pancreas the with including process of general bilious duct, development of mechanical icterus is possible.

Among complications of chronic pancreatitis, fatty dystrophy and cirrhosis of liver, stricture of terminal part of general bilious duct, ulcers of duodenum, thrombosis of splenic vein, saccharine diabetes, pseudocysts of pancreas, exudation pleurisy and pericarditis and heart attack of myocardium are observed.

Disease of gall-bladder and bilious ways (gallstone disease, dyskinesia of bilious ways). For these diseases pain in right hypochondrium is inherent, that irradiates in right shoulder-blade and shoulder. At chronic pancreatitis pain is localized in epigastric area, left hypochondrium, often is of belting character. One of the basic additional methods of inspection for confirmation of diseases of gall-bladder and ducts is sonography.

Ulcerous disease of stomach and duodenum. Pain at ulcerous disease is seasonal (relapses more frequent in spring and autumn), unites with heartburn and has tendency to diminishment after vomiting. In patients with chronic pancreatitis pain arises after faults in a diet, often is of belting character. Frequent vomiting is determining, that does not bring facilitation to the patient. Also violations of excretory and incretory functions of pancreas can take place.

Abdominal ischemic syndrome. Patients with this pathology complain about pain, that arises at once after the reception of meal, somewhat diminishes after application of spasmolytics. For the disease considerable weight loss and waiver of meal in connection with dread of pain attack can be characteristic. The basic method of examination, with a necessity for differential diagnostics, celiacography is useful, which enables to expose oclusion of abdominal trunk or its compression. During conducting of differential diagnostics with two last nosologies it is necessary to state a possibility of origin of secondary pancreatitis.

Cancer of pancreas. Mechanical icterus and presence of Courvoisier’s symptom are considered the clearest and most important displays of cancer of head of pancreas, and carcinoma of body and tail is a proof pain syndrome. For the cancer the damage of pancreas, rapid progress of symptomatology are characteristic, and for chronic pancreatitis the protracted passing with proper clinical symptomatology and changes which can be exposed by the laboratory, roentgenologic and instrumental methods of examination are characteristic. The most informative among methods of diagnostics of cancer of pancreas are sonography (echo-producing formations in parenchyma of pancreas), computer tomography (tumor knots) and puncture biopsy of gland with the histological examination (reliable diagnostics of cancer).

Heart attack of myocardium. In anamnesis of patients with the heart attack of myocardium it is possible to expose pain behind breastbone, that arises at the physical activity and emotional stress, it is irradiated in left shoulder-blade and left shoulder, unrelated with the reception of meal and disappears as a result of action of coronarolytics. The typical changes of ECG confirm the diagnosis of heart attack of myocardium. In addition, no violations of external and incretions of pancreas are characteristic. The roentgenologic and instrumental methods of examination can help in differential diagnostics.

Treatment is conducted in the phase of acutening of chronic pancreatitis, as well as at its acute form. In the first days the bed rest and medical starvation is prescribed without limitation of alkaline drink (mineral water). The fight against pain syndrome includes application of anaesthetic preparations and spasmolytics (promedol, analgin, baralgine, papaverine, no-shparum, platyphyllin). Preparation action is directed on the decline of pancreatic secretion (atropine, methacin, sandostatine, dalargine, stilamine, somatostatine) or on oppression of gastric secretion: Н2-blockers (hystodil, cimetidine, hastrocepin, ranisan, tagamet and others like that), antiacides (almagel, gastropan). Appoint, next to it, and antihistaminic preparations (diphenhydramine hydrochloride, suprastine, fenkarol, tavegil). Antienzymic therapy is also important: a) inhibitor of protease (contrical, trasilol, hordox, antagosan), the dose of which must depend on the level of hyperenzymeemia; b) cytostatic agent (ftorafur, 5-fluorouracil); c) chemical inhibitor of tripsin (aminocapronic acid, pentoxil). For the improvement of microcirculation at this pathology heparin, reopolyhlucine and reohluman are applied. The ponderable value is achieved by disintoxication therapy (hemodes, hluconeodes, enterodes). With the purpose of parenteral feed 5–10–40 % glucose with insulin, plasma, albumen, alvesyn, polyamin and lipofundine are used. Normalization of agile function of organs of digestion is achieved by settings of cerucal and reglan. In complex treatment it is necessary to include vitamins (С, В1, В6, В12) and anabolic hormones (retabolil, nerobol).

At calming down of the inflammatory phenomena a diet № 5 is prescribed in pancreas and conduct correction of excretory insufficiency of pancreas (festal, pansinorm, panccreosymin, digestal and others like that). With the purpose of stimulation of function of pancreas it is possible to apply secretin.

Correction of endocrine insufficiency of pancreas. At development of the secondary saccharine diabetes of easy degree a diet is recommended with limitation of carbohydrates, bukarban, maninil and other peroral preparations, at middle and heavy degrees — insulinotherapy.

Physical therapy procedures. Except medical treatment it is possible to apply inductothermy, microwave therapy (high frequency) and electro-stimulation of duodenum. For spa treatment visiting of Morshyn, Husjatyn, Shidnytsja is recommend.

Indication to operation and its volume depend on the form of pancreatitis. Acutening of chronic cholangiogenic pancreatitis at presence of gallstone disease must be examined as indication to operation in first 24 hours since disease’s beginning. Operative treatment is done in case of:

1) calcinosis pancreas with the expressed pain syndrome;

2) violation of patency of duct of pancreas;

3) presence of cyst or fistula of resistance to conservative therapy during 2–4 months;

4) mechanical icterus on soil of tubular stenosis of distal part of general bilious duct;

5) compression and thrombosis of portal vein;

6) gallstone disease complicated by chronic pancreatitis;

7) ulcerous disease of stomach and duodenum complicated by secondary pancreatitis;

8) duodenostasis, complicated by chronic pancreatitis;

9) impossibility of exception to operation tumors or violations of arterial circulation of blood of pancreas.

Cholecystectomy at presence of calculous cholecystitis and secondary pancreatitis, acute destructive cholecystitis or hydropsy of gall-bladder.

Choledochuslithotomy is executed for patients with cholangiolithiasis: a) with the deaf stitch of general bilious duct (use rarely); b) with its external draining for taking of infected bile (cholangitis), decline of biliary hypertension (at the edema of head of pancreas); c) with internal draining (at tubular stenosis of distal part of general bilious duct, acute expansion of choledochus with the complete loss of elasticity of its wall (execute one of variants of choledochoduodenostomy).

Papillosphincterotomy: a) execute transduodenal with papillosphincteroplasty; b) endoscopic is recommended at the isolated or connected with choledocholithiasis stenosis of large duodenal papilla, fixed concrement of large papilla of duodenum.

Wirsungoplasty is scission of plastic arts of narrow part or distal part of main pancreatic duct (apply at patients with stricture of proximal part of duct by a slowness no more than 2 cm). Lately at the isolated stenosis of bee-entrance of main pancreatic duct endoscopic wirsungotomy is executed.

Pancreatojejunostomy: a) longitudinal (it is executed at considerable expansion of pancreatic duct); ) caudal (by Duval) with the resection of distal part of pancreas (Pic. 3.5.9).

Resection of pancreas: a) distal or caudal; b) distal subtotal; c) pancreatoduodenal (PDR); e) total duodenopancreatectomy heads or bodies of gland (execute in case of fibrous-degenerative pancreatitis).

Oklusion of ducts of pancreas by polymeric connections (cianocrylat, prolamine, neopren and others like that) results in atrophy of exocrine parenchyma, but keeps to the islet of tissue.

Operations on the nervous system are used in case of the pain forms of chronic indurative pancreatitis, resistant to conservative therapy, in default of rough morphological changes of parenchyma, stroma of gland and deformation of main pancreatic duct: a) left-side splanchnicectomy; b) bilateral pectoral splanchnicectomy and sympathectomy; c) postganglionic neurotomy of pancreas.

Cyst of pancreas is a cavity, filled by liquid (pancreatic juice, exudation, pus), intimately soldered with head, body or tail of organ, is limited by capsule, which has epithelium on internal surface.

Pseudocyst (unreal cyst) is a cavity in pancreas which appears as a result of its destruction, limited by capsule, that does not have epithelium on internal surface.

The reasons of pseudocysts are destructive pancreatitis, traumas of pancreas, oklusion of Wirsung’s duct by parasite, concrement, tumors, innate anomalies of development.

To the real cysts belong: innate (dysontogenetic) cysts which are anomalic in development; acquired retention cysts which develop as a result of difficult outflow of pancreatic juice, cystadenoma and cystadenocarcinoma (by mechanism the origins belong more frequently to proliferative, sometimes — degenerative cysts).

The mechanism of development of pseudocysts consists in the focus necrosis of gland, difficult normal outflow of its secret, there is a destruction of walls of pancreatic ducts with overrun of pancreatic juice gland that causes reactive inflammation of peritoneum of surrounding organs which form the walls of pseudocyst.

Morphologically the cysts of pancreas are divided into: pseudocysts retention to the duct are innate, single and multiple.

Pseudocysts are fresh and old. The internal surface of fresh pseudocyst is rough, granulating, grey-red. The table of contents is alkaline, grey or with a brown tint. In an old pseudocyst the wall is smooth and shiny, pale-grey. The table of contents is lighter. Epithelium pseudocysts is absent. More frequently they are met in body and tail of gland and are not connected with ducts.

Retention cysts connected with an obturated duct. The cavity has smooth, grey-white surface, maintenance is transparent, watery or mucous-like. Innate cysts are mainly multiple and shallow. A simple retention cyst differ from those that are always connected with the anomalies of development of ducts and are unite with polycystosis buds and liver.

Rarely there are echinococcus cysts, which have a clear chitinous shell, liquid in cavity and daughter’s blisters. They are localized in the area of head of pancreas.

According to clinical passing pseudocysts are divided into acute, subacute and chronic.

According to weight of passing — into simple (uncomplicated) and complicated.

In patients with the cystic damaging of pancreas there can be pain of different character and intensity (dull, permanent, cramp-like and belting). It is localized more frequently in right hypochondrium, epigastric area (cyst of head and body of gland), left hypochondrium (cyst of tail of pancreas). Pain is irradiated in the back, left shoulder-blade, shoulder and spine.

Dyspepsia violations are characteristic. Nausea, vomiting and belch are observed.

The syndrome of functional insufficiency of pancreas shows up by disorders of exocrine and endocrine insufficiency and depends on the degree of damage of organ. The unsteady emptying, replacement of diarrhea of constipation, steatorrhea and creatorrhea, development of the second diabetes are marked.

Compression syndrome. Arises as a result of compression of neighbouring organs. Clinically the compression of organs of gastro-intestinal highway shows up by complete or partial obstruction of general bilious duct (mechanical icterus), vein (portal hypertension) gate, splenic vein (splenomegaly).

During the examination patients with large cysts are marked by asymmetry of abdomen in epigastric and mesogastric areas. At palpation of abdomen tumular formation of elastic consistency with an even, immobile surface is found.

Sonography examination shows echo-free formation with a clear capsule, determines localization and sizes of cyst (Pic. 3.5.10).

Contrasting roentgenologic examination of stomach and duodenum with the sulfate of barium at the cyst of head of pancreas exposes moving of pyloric part of stomach upwards and breeding of ,,horseshoe” duodenum (at relaxation duodenography in the conditions of low artificial blood pressure). If a cyst is localized in the area of body of gland, displacement of stomach is marked forward and upwards or downward, rapprochement of its walls, moving of duodenal transition and loops of thin bowel downward and to the right; at lateral projection the distance between stomach and spine is increased. The cyst localized in the area of tail of gland, displaces the stomach forward and upwards, to the left or to the right (Pic. 3.5.11).

Cholecystocholangiography exposes calculous cholecystitis and cholelithiasis.

Retrograde pancreatocholangiography exposes the changed and deformed, infrequently extended pancreatic duct, occasionally there can be filling of cavity of cyst by the contrasting matter.

Computer tomography shows accumulation of liquid limited by the capsule of different closeness and thickness (Pic. 3.5.12).

Laboratory examinations exposes hyperamylasemia, steatorrhea and creatorrhea, sometimes — hyperglycemia and glycosuria.

Clinical passing of cysts of pancreas depends on their kind, localization, size, stage of forming and complications.

Four stages of forming of pseudocyst are distinguished (Р.G. Karaguljan, 1972).

I stage (1–1,5 months last) — in the center of inflammatory process the cavity of disintegration, which takes surrounding tissue, appears in an omentum bag.

The II stage (2–3 months) is characterized by the beginning of forming of capsule of pseudocyst. Cyst is magnificent, unformed, acute inflammatory phenomena calms down.

The III stage (3–12 months) is completion of forming of capsule of pseudocyst. Last accretes with surrounding organs.

The IV stage (begins an in year from the origin of cyst) is a separated cyst. The cyst is mobile, easily selected from connections with surrounding organs.

Retention cysts arise at closing of lumen of pancreatic duct (concrement, sclerosis). The internal surface of cyst is covered with epithelium. Pain syndrome, violation of exocrine function of gland are characteristic.

Traumatic cysts belong to the pseudocysts with similar passing and clinic, as well as inflammatory pseudocysts.

Parasite cysts (to echinococcus, cysticercotic) are met as casuistry. In such patients Kaconi test and serological Weinberg’s reaction are positive.

The variants of clinical passing of the real and unreal cysts depend on their complications.

Perforation in free abdominal cavity. Clinic of the poured peritonitis is characteristic. Tormina, positive symptoms of irritation of peritoneum, possible shock state as a result of irritation of peritoneum by pancreatic juice arise.

Perforation in stomach, duodenum, small, rarer in large intestine is accompanied by diminishment of cyst in sizes or complete disappearance, sometimes diarrhea appears.

Suppuration of maintenance of cyst is accompanied by pain which becomes more intensive, temperature rises, leucocytosis grows.

The erosive bleeding appears suddenly and is accompanied by the symptoms of internal bleeding (expressed general weakness, dizziness). The pallor of skin and mucus shells, sticky death-damp, tachycardia and anemia are observed.

Mechanical icterus arises as a result of compression of cyst on the terminal part of choledochus. The icterus of skin and mucus shells, acholic excrement, dark urine, hyperbilirubinemia, increase of the AlT and AsT level are exposed.

Portal hypertension develops as a result of compression of portal vein. Ascites, varicose expansion of veins of esophagus and stomach, moderate icterus are diagnosed.

Reactive exudation pleurisy more frequently arises in left pleura cavity, where roentgenologic exudation is diagnosed with high maintenance of amylase.

At malignization the walls of cyst specific symptoms are absent, a diagnosis is set during operation (surgical biopsy of cyst wall).

The cysts of pancreas are differentiated with the tumors of abdominal cavity and of retroperitoneal space.

Cancer of pancreas. For the cancer tumor of pancreas syndrome of “small signs” (discomfort in epigastric area, loss of appetite, general weakness), permanent dull pain, unrelated with the reception and composition of meal, icterus (cancer of head of gland), Courvoisier’s symptom (increased, unpainfully gall-bladder) are characteristic. Inconstant pain at cysts of pancreas is more frequently related to faults in a diet; in anamnesis destructive pancreatitis, traumas of gland are carried. Sonography examination, retrograde pancreatocholangiography and computer tomography help in establishment of diagnosis.

Tumors of retroperitoneal space are passed asymptomatic, clinic shows up by a considerable compression oeighbouring organs. Nausea, vomit, chronic intestinal obstruction, dysuric disorders arise. Clinic of cysts of pancreas, on the opposite, are expressed on early stages. Pain, dyspepsia syndromes, syndrome of exocrine and endocrine insufficiency of pancreas are characteristic. Pain is related to the reception of meal and alcohol.

Aneurism of abdominal aorta. Dull, indefinite pain in abdomen which is unrelated with the reception of meal, pulsation and pulsating formation in abdomen are characteristic, auscultatory is systolic murmur. Aortography allows to confirm a diagnosis.

The cyst of mesentery of thin bowel has painless passing, at palpation it is mobile, easily changes position in abdomen. The cysts of pancreas are practically immobile, pain, anamnesis and laboratory information are characteristic.

The cyst of liver has protracted asymptomatic passing. Pain appears at infection of cyst. For this pathology symptoms which take place at the cysts of pancreas are not typical (pain related to the reception of rich food, alcohol, hyperamylasemia). Topic diagnostics is carried out at ultrasonic examination, scintigraphy, computer tomography.

Conservative treatment. Treatment of acute or chronic pancreatitis is conducted in accordance with principles. At the unfavorable dynamics of passing the diseases hunger with the permanent sucking of gastric maintenance, parenteral feed and intravenous introduction of liquids are appointed. Puncture of cysts is used through abdominal wall under sonography control with aspiration of maintenance.

Surgical treatment is the method of choice of treatment of cysts of pancreas. The choice of treatment method depends on the stage of forming of pancreas cysts.

On the I stage operation is not used, conservative treatment of pancreatitis is conducted. On the II stage it is used at suppuration of pseudocyst (external draining of cyst). On the III — internal draining of cyst is used. More frequently cystojejunostomy on the eliminated loop of thin bowel by Roux (Pic. 3.5.13), cystojejunostomy with entero-entero anastomosis by Brawn and closing of afferent loop by Shalimov. Cystogastrostomy (Pic. 3.5.14) are executed and cystoduodenostomy is now not applied because of possible complications (infection of cyst, erosive bleeding). Marsupialization (opening and sewing down of cyst to the parietal peritoneum and skin) is used infrequently (at suppuration of cyst is seriously patientsing with the septic state). On the IV stage external and internal draining of cyst and radical operations are applied: a) enucleation of cysts (executed very rarely); b) distal resection of pancreas with a cyst.

The cancer of pancreas is a malignant tumor of epithelium tissue. Its specific gravity among all malignant tumors makes 10 %. Greater part of patients with cancer of pancreas (to 80 %) is made by the persons of capable working age.

The origin of cancer of pancreas is related to character of nutrition: with the promoted maintenance of albumens and fats in meal.

Shortage of vitamins, especially B and С, harmful habits (abuse of alcohol, smoking), presence of carcinogenic matters in food (nitrite, nitrates and others like that), tonsillectomy suffered in the past also belong to etiologic factors. The cancer tumor of pancreas can arise on the background of protracted period of chronic pancreatitis.

A cancer tumor is localized in the head. Rarer — in the area of body or tail, rarer there is a diffuse damage of pancreas.

A tumor has the appearance of a dense knot or conglomerate of knots of different sizes. It resembles epithelium of pancreatic ducts or epithelium of acinous tissue, sometimes — the Langerhans’ islet.

Adenocarcinoma (50–55 %) is exposed microscopically, carcinoid (32–35 %), epidermoid cancer or skir is seldom met.

The cancer of pancreas gives metastases quickly enough which spread in lymphogenic way in parapancreatic lymphatic knots, and afterwards — in the gate of liver. The hematogenic metastases are often exposed in lungs, bones, buds and brain. Possible also remote metastases to the type of Virhov’s, Shnitsler’s, Krukenberg’s.

The clinical signs and passing of cancer of pancreas are various. They depend both on localization of tumor in pancreas and the mutual relations of pathological process with surrounding organs or tissue.

Pain is a permanent symptom on which 60–90 % patients specify. It is conditioned by involvement in the process of nervous elements of pancreas and retroperitoneum space. The pain feelings at cancer of pancreas are unrelated with acceptance of meal, can be periodic with irradiation in the back. The insignificant loss of weight makes progress and for a short time becomes considerable enough. Such is clinic of cancer of body and tail of pancreas.

Icterus is characteristic of the cancer of head of pancreas, that arises as a result of obturation of general bilious duct and develops slowly but with steady growth. At palpation of abdomen Courvoisier’s symptom is observed. Protracted, to 3–4 weeks, icterus results in piling up of products of disintegration of bile in blood and tissue, causing heavy intoxication of organism, violation of liver unction, buds and coagulation system of blood. Obturation of duct of pancreas causes dyspepsia disorders: belch, nausea, vomiting, diarrhea (“fat” emptying). Distributions of tumor on duodenum and narrowing of its lumen show up by the signs of stenosis of exit from the stomach of a different degree (feeling of plenitude in a epigastric area, periodic pain, belch and vomiting).

Bilirubinemia grows gradually, mainly due to direct bilirubin. The increase of activity of alkaline phosphatase and level of cholesterol are observed in blood. As at mechanical icterus a bile does not get the intestine, stercobilin in excrement is absent (acholic excrement). There is also no urobilinу in urine, although bilious pigments are present there (bilirubin). It is possible to expose steatorrhea and kreatorrhea in excrement as a result of obturation of pancreatic duct and exception of enzymes of pancreas from digestion.

With the help of radioimmunoassay it is sometimes succeeded to mark the increase of level of tumor markers in the whey of blood: cancer-embryo to the antigen, ferritin.

Sciagraphy of gastro-intestinal highway can expose the cancer heads of pancreas, the unfolded “horseshoe” of duodenum, and in case of localization of tumor in the body of gland — displacement of back wall of stomach forward. At duodenoscopy rigidity of mucus shell of descending part of duodenum, narrowing of its lumen are determined, and sometimes there is germination of bowel by tumor.

Scanning is an informing method of examination with the use of 75 Se-methionine. Such examinations can expose the hearths of reduced accumulation of isotope or its absence in tissue of gland at the damage by tumor.

During laparoscopy the cancer of pancreas is visualized infrequently, however, dissemination of peritoneum and its metastatic hearths in liver are diagnosed without difficulties.

By ultrasonic (sonography) examination it is succeeded to expose the places of promoted closeness of tissue of gland, sign of mechanical icterus at localization of tumor in the head.

Most informing among all is computer tomography (Pic. 3.5.15). It is possible to define both the tumor of gland and its size and metastatic knots. The changes of main duct of pancreas as segmental stenosis or breaking are fixed on retrograde endoscopic pancreatography.

Clinical passing of cancer of pancreas in 70 % patients is marked by the background diseases and complications. This circumstance allows to select a few clinical forms of the cancer of pancreas before appearance of icterus: pancreatitic, diabetogenic, cholangitic and gastritis-like. The names specify the feature of clinical signs of different forms of disease.

Mechanical icterus is the heaviest complication of cancer of pancreas. With the increase of duration and growth of its intensity development of such dangerous complications, as hepatic or hepatic-kidney insufficiency, cholemic bleeding is possible.

Anamnesis has an important value for differential diagnostics. The presence of attacks of pain or intermittent icterus testifies its calculous origin. A pain syndrome at the cancer of pancreas does not have such acuteness and intensity, as at gallstone disease. Icterus in cancer patients, unlike cholelithiasis, develops gradually, incessantly grows and is of proof character.

Often substantial difficulties arise during conducting the differential diagnostics of obturative and infectious icterus. It is necessary to remember, that at viral hepatitis the level of transaminase and aldolase in the whey of blood rises by 2–3 times. At obturation icterus their level does not change substantially, and the increase of activity of alkaline phosphatase and instead of that the level of cholesterol is marked.

However, most operation difficulties are met during conducting the differential diagnosis of the cancer of pancreas and chronic indurative pancreatitis. In fact both processes during examination and palpation produce similar pictures. In such cases puncture of the densest area of pancreas is executed and cytologic examination is quickly conducted.

Treatment of cancer of pancreas is mainly surgical. The choice of method and volume of operation depends on localization of tumor, stage of process, age of patient and his general condition.

Taking it into account, as practice shows, radical operations in the moment of establishment of final diagnosis are successfully executed only in 15–20 % of patients. Pancreatoduodenal resection is the method of choice of operation in patients with the damage of head of pancreas. Operation foresees deleting one block of head of pancreas, distal part of stomach, duodenum and distal part of general bilious duct. Four anastomosis are thus imposed: gastroenteroanastomosis, cholecysto¬enteroanastomosis or choledochoenteroanastomosis, pancreatoentero¬anastomosis and enteroenteroanastomosis. Sometimes this operation is executed in two stages. On the first one biliary-enteric anastomosis is formed for taking bile and improvement of function of liver, and the second stage is carried out in 3–4 weeks. However, more frequently symptomatic operations are to be executed: cholecysto¬enteroanastomosis or choledochoduodenoanastomosis. They are able to liquidate icterus and prolong the life of patients for 5–9 months. In case of damage of body and tail of pancreas the distal subtotal resection of gland with spleen is radical.

 

 

POSTVAGOTOMY SYNDROMS

 

RELAPSE OF ULCER

 

Etiology and pathogenesis

 

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).

 

Clinical management

 

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.

 

Pic 3. Postvagotomy dilatation of the stomach.

 

Tactic and choice of treatment method

 

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.

 

Postvagotomy diarrhea

 

Etiology and pathogenesis

 

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.

 

 

Clinical management

 

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.

 

Tactic and choice of treatment method

 

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 4 g 3 times per a day with the subsequent decline of dose to 4 g per days).

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.

 

 

Differential diagnostics and clinical variants

 

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 3 cm and thickness up to 2 cm. Deep cracks, which the massive bleeding are from, appear between folds. Diagnostics of bleeding is confirmed by endoscopy. Treatment is conservative, including the hemostatic therapy. If conservative treatment are uneffective, indicated resection of stomach. During operation round a stomach the megascopic lymphatic knots with soft consistency are observed.

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 5 kg. A working capacity is well-kept. Medicinal and dietary treatment gives a good effect.

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 10 kg. Patients, as a rule, are disabled. Conservative treatment is uneffective.

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 1 liter of bile with vomiting masses. During the objective examination observed subicteritiousness of the sclera, sign of dehydration of organism (decline of turgor of skin, dry tongue, oliguria, concentrated urine). Emptying is irregular, grey color, with considerable content of undigested fat and muscular fibres. Anaemia can develop at heavy passing of disease.

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 can not 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 4 g 3 times per a day with the subsequent decline of dose to 4 g per days).

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 2 cm in a diameter, appearance of the heightened edges.

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 5 mm and conduct an aiming biopsy with histological examination of the taken material.

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 ieighbouring 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 %.

        

 

 

 

 

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