Surgical diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets
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Surgical diseases. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Table of contents

Brief anatomical and physiological characteristics, research methods, classification of diseases of the esophagus
Functional diseases, esophageal diverticula, foreign bodies
Burns of the digestive tract
Esophageal carcinoma
Stomach ulcer and duodenal ulcer
Pyloric stenosis
Perforated ulcer of the stomach and duodenum
Acute gastroduodenal bleeding
Stomach cancer
Brief anatomical and physiological characteristics of the large intestine
Methods for examining the large intestine
Colonoscopy, polyps, lipomas, diverticula
Nonspecific ulcerative colitis
Sigmoidoscopy, irrigoscopy, biopsy, treatment
colon cancer
Diagnosis of colon cancer
Colon cancer treatment
Hemorrhoids
Fissures in the anus
Acute paraproctitis
Ulcers with paraproctitis, diagnosis, treatment
Fistulas of the rectum
Rectal cancer
Epithelial-coccygeal passages
Intestinal obstruction
Paralytic ileus, mechanical ileus, clinic
Diagnosis of intestinal obstruction
Separate forms and types of mechanical intestinal obstruction (obstructive, strangulation and intestinal volvulus)
Small intestine volvulus
bowel nodulation
Anatomical and physiological characteristics of the biliary zone
Pancreas
Methods for examining the liver
Liver biopsy and methods of examination of the gallbladder and bile ducts
Acute cholecystitis
Specific symptoms of acute cholecystitis, uncomplicated cholecystitis
Complicated cholecystitis
Differential diagnosis and treatment of acute cholecystitis
Liver abscesses
Liver tumors
portal hypertension syndrome
Acute pancreatitis
Acute pancreatic edema, hemorrhagic pancreatitis, pancreatic necrosis
Differential diagnosis and treatment of pancreatitis
Chronic pancreatitis
Cysts and pancreatic cancer
Endemic goiter
Diffuse toxic goiter
Classification of the severity of thyrotoxicosis
Nodular toxic goiter
Treatment with antithyroid drugs, surgical treatment
Hypothyroidism, myxedema, thyroid cancer classification
Treatment of thyroid cancer, Hashimoto's goiter
Anatomy and physiology of the breast, manifestations of breast cancer
TNM classification of breast cancer
Classification of metastases, clinical forms of breast cancer

1. Brief anatomical and physiological characteristics, research methods, classification of diseases of the esophagus

Brief anatomical and physiological characteristics. There are three sections of the esophagus - cervical, thoracic and abdominal. Its total length is on average 25 cm. The esophagus is fixed only in the cervical region and in the region of the diaphragm, the rest of its departments are quite mobile both in vertical and lateral directions. It has three narrowings: in the initial section, at the level of the bifurcation of the trachea and at the transition through the diaphragm. The blood supply of the cervical esophagus is carried out by branches of the lower thyroid arteries, in the middle third - from the bronchial and unpaired ones, coming directly from the aorta, small esophageal arteries and below - from the esophageal branches of the left gastric artery and diaphragmatic arteries. In the region of the esophagus, there are venous anastomoses between the portal vein of the liver and the superior vena cava. The physiological function of the esophagus consists mainly of voluntary and involuntary acts.

Research methods. In addition to the generally accepted clinical methods, special research methods are used in the pathology of the esophagus: fluoroscopy, radiography, X-ray cinematography, esophagoscopy, pneumomediastenography.

To obtain comprehensive data regarding the esophagus, it is advisable to conduct an X-ray examination in the following order:

1) survey roentgenoscopy of the neck, chest and abdominal organs;

2) a study with 1-2 sips of a liquid barium suspension of the cardia area and the relief of the gastric mucosa;

3) examination of the pharynx and esophagus with a liquid barium suspension;

4) study of "pneumorelief" - double contrasting of the esophagus;

5) study of the contours of the peristalsis of the walls of the esophagus with a thick barium suspension;

6) study of the relief of the mucous membrane of the esophagus.

With esophagoscopy, you can examine the entire mucosa of the esophagus, as well as the cardiac and subcardial sections of the stomach, determine the source of bleeding, the presence of diverticula, tumors, take a tumor site for a biopsy, using a camera attachment, you can get black and white and color photographs.

Classification of diseases of the esophagus.

1. Malformations. These include atresia, congenital narrowing, congenital idiopathic enlargement, cardiac insufficiency (or chalazia), duplication of the esophagus, undescended stomach.

2. Foreign bodies of the esophagus.

3. Functional diseases of the esophagus (esophageal achalasia, cardiospasm, esophageal dyskinesia - esophagospasm).

4. Diverticula of the esophagus.

5. Burns of the esophagus.

6. Benign tumors and cysts of the esophagus.

7. Cancer of the esophagus.

2. Functional diseases, esophageal diverticula, foreign bodies

Functional diseases of the esophagus according to the pathophysiological substrate include a variety of lesions of the esophagus and its sphincter mechanisms and are manifested by a peculiar clinical and radiological picture. A common clinical symptom of these diseases of the esophagus is dysphagia.

With cardiospasm at the time of swallowing and relaxation of the esophageal tube, an important function of opening the cardia falls out.

Cardiospasm is divided into three stages: the first is an intermittent spasm of the cardia, the second is hypertonic and the third is atonic. With a long-term course, cardiospasm is not inclined to turn into cicatricial stenosis of the cardia, if the disease is not complicated by chemical or thermal damage (alcohol, spicy, salty, sour dishes, hot food, etc.), as well as significant tears of the esophagus wall during cardiodilation.

This category of patients is treated with a metal Stark-type cardiodilator or a pneumatic dilator. Treatment of cardiospasm with a cardiodilator gives satisfactory long-term results, but requires repeated reinforcing sessions.

A number of methods for the surgical treatment of cardiospasm have been proposed: cardiogastroplasty, cardiomentoplasty, etc. The most widespread operation was BV Petrovsky's operation - cardia plastic surgery with a diaphragm flap on a leg.

Diverticula of the esophagus

Limited expansion of the lumen of the esophagus in the form of a saccular protrusion of its wall.

The classification of diverticula is based on their localization and mechanism of occurrence.

In the early stage of diverticulum formation, characteristic symptoms are not observed. Then, as the diverticulum increases (stage), a characteristic clinical picture appears: due to the rapid filling of the diverticulum with food, the esophagus is compressed and dysphagia sets in. To swallow food, patients put pressure on the neck, tilt their heads in different directions, make vomiting movements, etc. When the bag is emptied, there is a noticeable improvement, the patient can swallow food again. However, part of the food remains in the diverticulum, stagnates and decomposes, a fetid odor appears from the mouth, and dyspeptic phenomena are observed.

The diagnosis of diverticulum is made on the basis of the clinical picture and mainly x-ray examination. Additional data are provided by esophagoscopy. The radical method of treating diverticula is surgical. Operations are subject to diverticula II and III stages and especially complicated ones.

Foreign bodies

Most often, foreign bodies enter the esophagus by accident, with a hasty meal. The vast majority of these are various bones, dentures and other items.

The clinical picture of the disease depends on the size, shape and nature of the foreign body, on the level of its location and duration of stay in the esophagus, the degree of damage to the esophagus.

3. Burns of the digestive tract

Burns of the digestive tract with acids and alkalis are a severe pathology, as evidenced by high mortality (10-20%). As a result of ingestion of caustic substances, not only the esophagus and stomach are affected, but also the function and structure of the liver, kidneys, adrenal glands and other organs are disrupted due to neurotrophic disorders and intoxication due to resorption of poison, absorption of tissue decay products, and purulent infection.

In the clinical course of burns, three periods are distinguished: acute, low-symptomatic (recovery) and the period of outcomes.

The acute period, as a rule, within 10 days is manifested by a pronounced pain syndrome, dysphagia, toxemia, fever, disorders of the functions of internal organs.

The low-symptomatic (recovery) period occurs after the elimination of acute pain syndrome and the reduction of dysphagic disorders by the end of the 2-3rd week from the moment of the burn. But this is a period of imaginary recovery.

The period of outcomes is characterized by the development of persistent consequences of burns and poisoning in the form of cicatricial narrowing of the esophagus, postnecrotic cirrhosis of the liver, chronic esophagitis, mediastinitis, chronic pneumonia, exacerbation of the tuberculosis process, and persistent functional disorders of internal organs.

Household burns of the pharynx and esophagus with various chemicals are quite common. Poisoning by acids and alkalis occurs in both children and adults. Patients need urgent medical care and appropriate treatment.

To do this, in the first hours after poisoning, the stomach is abundantly washed with warm water (5-8 l). In case of acid poisoning (acetic, hydrochloric, sulfuric, etc.), a 2% solution of ordinary baking soda, burnt magnesia can be used to neutralize. In case of poisoning with alkalis (caustic soda, caustic soda) - a solution of table vinegar, diluted by half with water, 1% solution of citric acid.

Within a few days (3-4), narcotic drugs should be prescribed. In violation of cardiac activity, caffeine, cordiamine are administered.

It is not recommended to induce a gag reflex, and if it appears, it must be suppressed. An ice pack is placed on the stomach area.

Therapeutic measures are carried out taking into account the severity of poisoning and the general condition of the patient.

To combat dehydration of the body and to maintain protein balance, a 5% glucose solution in an isotonic NaCl solution (2-3 l), polyglucin, blood, plasma, and blood substitutes are administered intravenously. The patient is prescribed a complete diet rich in vitamins. Recommend butter, fish oil, milk, cream, raw eggs, olive oil.

In order to prevent the development of a secondary infection in the oral cavity, pharynx and esophagus, large doses of antibiotics are prescribed. Care is needed for the oral cavity and pharynx, for which, in case of acid poisoning, alkaline rinses are prescribed, in case of alkali poisoning, a 2% solution of boric acid is prescribed.

After the general phenomena of intoxication pass, and the acute inflammatory process subsides, further treatment is continued. In milder cases of burns, bougienage of the esophagus or drainage of its lumen with tubes should be started on the 4-6th day, in severe cases - on the 8-10th day.

4. Cancer of the esophagus

The esophagus is one of the organs that are very often affected by cancer, so the problem of esophageal cancer is in the focus of attention of Russian surgeons.

One of the earliest and main symptoms of esophageal cancer is dysphagia (difficulty swallowing). It is associated with the direction of tumor growth: with exophytic tumor growth, dysphagia appears relatively faster than with endophytic growth. When collecting an anamnesis, attention is drawn to the fact that the emerging swallowing disorder is slowly but steadily progressing.

At the onset of the disease, the general condition of most patients remains satisfactory, although some show weight loss by the time dysphagia appears.

Other primary local symptoms of esophageal cancer include pain and discomfort behind the sternum when food is swallowed. This is due to trauma to the inflamed wall of the esophagus near the tumor and spasm. Early local signs also include a feeling of fullness behind the sternum when swallowing hot food.

With germination and compression of the recurrent nerve by the tumor, hoarseness appears, indicating an advanced stage of cancer and its localization in the upper esophagus. A common symptom of esophageal cancer of various localizations is emaciation and progressive weight loss.

In the late stages of tumor development, especially in the presence of metastases, severe anemia, leukopenia, a shift of the leukocyte count to the left, and toxic granularity of neutrophils are noted in the blood.

In the early diagnosis of esophageal cancer, X-ray examination plays a decisive role. The presence of spasm in a certain area of the esophagus makes one suspect the presence of a pathological process and obliges to repeat x-ray studies.

According to the X-ray examination, one can judge the extent of the lesion and the localization of the tumor in relation to the walls of the esophagus. In unclear cases, a thorough esophagoscopic examination is indicated.

The generally accepted method of surgical treatment of esophageal cancer is the resection of the esophagus, which is widely used in surgery.

Contraindications to radical surgical treatment of esophageal cancer:

1) distant metastases in the cervical and supraclavicular lymph nodes;

2) involvement in the cancer process of the bronchus, recurrent and phrenic nerves, the trunk of the sympathetic nerve;

3) decompensation of cardiovascular activity due to organic heart disease and hypertension.

To access the cardial part of the stomach and the lower part of the esophagus, the following methods are currently used: pleural, transpleural-peritoneal, peritoneal, transperitoneal-pleural. If the tumor has spread to the fundus of the stomach, a loop of the small intestine is used for the bypass.

5. Peptic ulcer of the stomach and duodenum

Peptic ulcer of the stomach and duodenum is one of the main problems of gastroenterology.

When examining these patients, the following are necessary: a carefully collected history, examination of the phases of gastric secretion, ph-metry, determination of gastric motility, fluoroscopy, fibrogastroscopy, fibroduodenoscopy.

According to localization, ulcers of the duodenum, pyloroanthral part of the stomach, ulcers of the lesser curvature of the stomach, cardial part of the stomach, other localizations (greater curvature of the stomach, esophagus, small intestine), peptic ulcer of the anastomosis and small intestine are observed.

According to the nature of gastric secretion, there are ulcers with reduced secretion in both phases (neuroreflex and neurohumoral, or antral), with normal secretion in both phases, with normal secretion in the first phase and increased in the second, with increased secretion in the first phase and normal during the second, with increased secretion in both of its phases.

In the course of the disease, ulcers are uncomplicated and complicated. The latter are accompanied by increased proliferative-sclerotic processes on the part of the connective tissue (callous ulcers), penetration, perforation, bleeding, malignancy, pyloric stenosis and deformities of the stomach with impaired evacuation.

Treatment complicated peptic ulcer of the stomach and duodenum operational. There are absolute and relative indications for surgical treatment of this disease.

Absolute indications include perforation (perforation) of the ulcer, unstoppable bleeding, organic pyloric stenosis with impaired evacuation from the stomach, suspicion of the transformation of a stomach ulcer into cancer.

Relative indications - callous ulcers with penetration that do not tend to heal, re-bleeding ulcers, peptic ulcer disease, accompanied by a sharp limitation or disability, lack of effect of therapeutic treatment for 3-5 years, pyloric ulcers, ulcers of greater curvature and posterior wall, cardiac th part of the stomach, as the most frequently malignant.

Currently, in the surgical treatment of gastric and duodenal ulcers, three methods of operations are used - gastroenterostomy, gastric resection and vagotomy.

Gastroenterostomy (imposition of the gastrointestinal anastomosis). The essence of this operation is to create a message between the stomach and the jejunum for the passage of food from the stomach into the small intestine, bypassing the pylorus and duodenum.

Of the existing methods of gastroenterostomy, anterior anterior and posterior retrocolic gastroenterostomy is currently used.

In the first operation, the small intestine is brought to the stomach in front of the transverse colon and sutured to the anterior wall of the stomach.

To avoid a "vicious circle" between the afferent and efferent loops of the small intestine, an inter-intestinal anastomosis according to Brown is applied. In the second operation, the small intestine is sutured behind the transverse colon to the posterior wall of the stomach.

6. Pyloric stenosis

Pyloric stenosis should be understood as a pathological change in the pyloric part of the stomach, which causes a narrowing of its lumen and disrupts the normal emptying of the stomach from its contents.

The greatest clinical significance is cicatricial pyloric stenosis or narrowing of the initial part of the duodenum, in which the evacuation of contents from the stomach is disturbed. Persistent narrowing of the pylorus usually develops after many years of peptic ulcer.

During ulcerative stenosis, three stages are distinguished: compensated (or relative), subcompensated and decompensated.

In the compensated stage, pyloric stenosis is not manifested by any pronounced clinical signs. The general condition of such patients usually suffers little. They note a feeling of heaviness and fullness in the epigastric region, mainly after a heavy meal. Some patients have sour eructations, and sometimes vomiting. Examination of gastric contents reveals hypersecretion. At this stage, the diagnosis of pyloric stenosis is difficult. X-ray examination of the stomach appears to be hypertonic, the evacuation of the contrast mass proceeds in a timely manner.

In the stage of subcompensation, the feeling of heaviness and fullness in the stomach increases. Paroxysmal pains associated with increased peristalsis of the stomach become more severe. There are unpleasant eructations with the smell of "rotten eggs" due to prolonged retention of food in the stomach. At times there is profuse vomiting, which brings relief, so patients try to cause it themselves. An objective examination of the majority of patients revealed on an empty stomach "splashing noise" in the stomach and visible peristalsis. This stage is characterized by general weakness, fatigue, emaciation, reduced digestibility of food, vomiting, impaired water-salt metabolism. Radiologically, there is a pronounced slowdown in the evacuation of the contrast mass, after 6-12 hours its remains are still in the stomach, but after 24 hours they are usually not detected.

With decompensated pyloric stenosis, the hypertrophied muscles of the stomach are no longer able to completely empty it, especially with a heavy meal. It stagnates for a longer period and undergoes fermentation. The stomach is stretched, the phenomena of the so-called gastroectasia occur. Gradually, clinical symptoms also increase: a feeling of heaviness and fullness in the epigastric region becomes longer, and then almost constant, appetite decreases, sour eructations appear, in some cases having a fetid odor. Sometimes excruciating thirst develops due to a sharply reduced flow of fluid into the intestines. A full stomach begins to empty itself by vomiting, while the vomit contains the remnants of food eaten the day before or several days before, and in advanced cases even a week or longer.

7. Perforated ulcer of the stomach and duodenum

In the clinical course of a perforated ulcer of the stomach and duodenum into the free abdominal cavity, I. I. Neimark conventionally distinguishes three periods - shock, imaginary well-being, peritonitis.

In none of all acute diseases of the abdominal organs is there such a strong, sudden onset of pain as in a perforated ulcer of the stomach and duodenum. The pain in the abdomen is unbearable, "dagger", it causes severe abdominal shock. The patient's face often expresses fright, is covered with cold sweat, pallor of the skin and visible mucous membranes is noted.

The position of the patient is always forced, most often with the hips adducted to the navicular retracted tense "board-like" abdomen.

The abdomen does not participate or participates little in the act of breathing. The type of breathing becomes chest, superficial, rapid. Along with pain, irritation of the peritoneum also appears. Shchetkin-Blumberg's symptom is sharply positive. The pain quickly spreads throughout the abdomen, although many patients indicate that the pain began suddenly in the upper abdomen. In the vast majority of patients, pneumoperitoneum phenomena are observed, determined by percussion (disappearance of hepatic dullness - a positive Spizharny symptom) or radiographically.

When making a diagnosis of a perforated ulcer of the stomach and duodenum, an ulcerative history is of great importance, but in some patients it may be absent and perforation occurs in a state of apparent complete health ("silent" ulcers).

A perforated ulcer of the stomach and duodenum must be differentiated from acute appendicitis, acute cholecystitis, acute pancreatitis, intestinal obstruction and other diseases of extraperitoneal localization that simulate an "acute abdomen" (pleuropneumonia, myocardial infarction, hepatic and renal colic, etc.).

Patients with perforated gastric and duodenal ulcers should be urgently operated upon diagnosis. Indications for resection of the stomach:

1) the time from perforation to the time of admission to the hospital should not exceed 6-8 hours;

2) the presence of an ulcer history before perforation;

3) a satisfactory general condition and the absence of severe concomitant diseases;

4) the age of the patient is from 25 to 59 years;

5) the absence of purulent exudate and a large amount of gastroduodenal contents in the abdominal cavity.

Contraindications for resection of the stomach:

1) the phenomenon of advanced widespread peritonitis due to late admission;

2) advanced age with concomitant effects of cardiovascular insufficiency, pneumosclerosis and emphysema.

8. Acute gastroduodenal bleeding

Gastroduodenal (gastrointestinal-duodenal or gastrointestinal) bleeding may occur suddenly in the midst of full health or be accompanied by previous illnesses. These are formidable, often fatal complications of a number of diseases.

The clinical picture of acute gastroduodenal bleeding mainly depends on their etiology and the degree of blood loss.

The first signs of gastroduodenal bleeding: general weakness, dizziness, pallor of the skin and mucous membranes, tachycardia, palpitations and a decrease in blood pressure.

In some cases, a collapse may develop with a hundred-strong loss of consciousness: the face becomes pale, the skin becomes waxy and covered with cold sweat, the pupils dilate, the lips are cyanotic, the pulse is thready, frequent, sometimes not counted.

One of the main signs of gastroduodenal bleeding is bloody vomiting (hematemesis) such as coffee grounds, which accompanies gastric and esophageal bleeding and, extremely rarely, duodenal bleeding. Such vomiting most often occurs after a few hours (sometimes after 1-2 days) from the onset of bleeding when the stomach is full of blood. In some cases, it may be absent, and blood is excreted from the gastrointestinal tract in the form of tarry stools. Most often this happens with bleeding from the duodenum or with mild bleeding from the stomach, if it has time to empty itself from the bloody contents through the gaping pylorus. Bloody vomiting like coffee grounds is explained by the formation of hematin hydrochloride in the stomach, and tarry stools (melena) - by the formation of iron sulfate from hemoglobin in the intestine (under the influence of enzymes).

The results of a blood test (the content of the number of red blood cells and hemoglobin) in the first 24-48 hours from the onset of acute gastroduodenal bleeding do not reflect the true amount of bleeding and cannot be a criterion for the severity of the condition. In this case, it is necessary to take into account the indicators of hematocrit and the volume of circulating blood (VCC). Determination of BCC and its components is a reliable method for determining the amount of blood loss in gastroduodenal bleeding. Important objective data for the diagnosis of acute gastroduodenal bleeding gives an urgent x-ray examination of the stomach and duodenum, it does not aggravate the condition of patients, is diagnostically effective and in the vast majority of patients gives a clear idea of the source of bleeding. Fibrogastroscopy and fibroduodenoscopy are increasingly used in the differential diagnosis of gastroduodenal bleeding. A special role is played by fibrogastroscopy in the recognition of acute superficial lesions of the gastric mucosa, in which X-ray examination is not very effective.

9. Stomach cancer

Of the entire gastrointestinal tract, cancer most often affects the stomach. According to statistics, it occurs in approximately 40% of all cancer sites. At present, the possibilities of X-ray examination in the diagnosis of gastric cancer have significantly expanded, which is associated with the use of both new methods and new techniques (parietography, double contrasting, polypositional examination, X-ray cinematography, etc.).

precancerous diseases. It is necessary to pay special attention to the so-called precancerous diseases, which include chronic gastritis, gastric ulcers and polyposis of the gastric mucosa. Using active clinical examination and therapeutic measures, you can achieve real success in the prevention of stomach cancer.

The international clinical classification of gastric cancer according to TNM is the same as for colon cancer.

V. V. Serov considers the following morphological forms:

1) crayfish with predominantly exophytic expansive growth:

a) plaque-like cancer;

b) polyposis or mushroom-shaped cancer (including those developed from a stomach polyp);

c) ulcerated cancer (malignant ulcers); primary ulcerative form of gastric cancer (saucer-shaped or bowl-shaped);

2) cancers with predominantly endophytic infiltrating growth:

a) infiltrative-ulcerative cancer;

b) diffuse cancer;

3) crayfish with endoexophytic mixed growth patterns (transitional forms). The syndrome of small signs of A.P. Savitsky includes:

1) loss of interest in the environment, in work, apathy, mental depression, alienation;

2) the appearance in patients during the last few weeks or months of general weakness, fatigue, decreased ability to work;

3) progressive weight loss;

4) loss of appetite, aversion to food or some of its types (meat, fish);

5) the phenomena of the so-called gastric discomfort - the loss of the physiological feeling of satisfaction from the food taken, the feeling of fullness and fullness of the stomach, heaviness in the epigastric region, belching;

6) persistent or growing anemia. The clinical picture of gastric cancer also depends on

its localization. So, with cancer of the pylorus, the clinical picture of narrowing of the pylorus is typical, vomiting appears. After taking breakfast, the patient has a feeling of heaviness in the epigastric region, which intensifies after dinner, since not all food is evacuated from the stomach.

10. Brief anatomical and physiological characteristics of the large intestine

Colon consists of the ascending colon, which includes its initial section and the caecum, the transverse, descending and sigmoid colon. The latter passes into the rectum. Normally, the colon has a grayish tint (the small intestine is pinkish) and a special arrangement of muscle layers - the presence of longitudinal muscle bands, protrusions and omental appendages. The diameter of the colon is 4-5 cm.

Ascending colon (colon ascendens) is located in the right lateral region of the abdomen, somewhat closer to the midline than the descending one, and the right (hepatic) curvature lies in the right hypochondrium. From above and in front, the ascending colon is covered by the right lobe of the liver, and inside the right curvature is in contact with the bottom of the gallbladder.

Transverse colon (colon transversum) begins in the region of the right hypochondrium at the level of the 10th costal cartilage from the hepatic flexure, goes somewhat in an oblique direction from right to left and upwards to the region of the left hypochondrium. Here, at the level of the 9th costal cartilage or the 8th intercostal space, it ends at the left bend of the colon, passing into the descending colon.

Descending colon (colon descen-dens) starts at the top of the left (splenic) flexure, descends along the back wall of the abdomen, being located with its posterior, devoid of peritoneal cover surface in front of the lateral section of the left kidney and square muscle of the lower back, to the level of the crest of the left iliac bone and passes into the next section - sigmoid colon.

Sigmoid colon (colon sigmoi-deum) is the mesenteric part of the colon, following the descending. It is located in the left iliac fossa, starting from above and laterally at the level of the posterior edge of the crista ilei. Having formed two loops, it goes to the right (medially) and down, bending over the boundary line, and enters the cavity of the small pelvis, where it passes into the rectum at the level of the III sacral vertebra.

The rectum consists of departments: rectosigmoid, ampullar and anal.

The blood supply to the colon and rectum is carried out by branches of the superior and inferior mesenteric arteries. The veins accompany the arteries in the form of unpaired trunks and belong to the portal vein system, and the innervation of the colon is carried out by the branches of the superior and inferior mesenteric plexuses.

Lymph nodes related to the colon are located along the arteries, they are divided into nodes of the caecum and appendix and nodes of the colon.

There are the following diseases of the colon:

1) benign tumors (polyps, lipomas, fibroids, fibroids, angiomas);

2) diverticula;

3) nonspecific ulcerative colitis;

4) Hirschsprung's disease;

5) cancer.

11. Methods of examination of the large intestine

Diseases of the colon belong to the section of proctology, and diseases of the rectum also belong to it. Therefore, it is advisable to consider methods for studying patients with diseases of the colon and rectum together.

For a successful examination of the colon and rectum, it is necessary to prepare the intestine the day before. Examination for urgent indications can be carried out without special preparation, which consists only of a cleansing enema. First, an enema is given the night before, and then at 7-8 in the morning on the day of the examination. In preparation for an X-ray examination of the colon the night before, the patient is not allowed to eat. At 5 o'clock in the morning he is given a cleansing enema.

Special methods for examining the rectum include external examination, digital examination, examination with rectal mirrors, sigmoidoscopy, X-ray examination, parietography, colonoscopy, anal sphincter function examination, scatological analysis.

External inspection. A detailed examination of the perineal-anal region is necessary in all cases when the patient makes relevant complaints. Examination is best done in the knee-elbow position of the patient, paying attention to the condition of the skin, the presence or absence of swelling, redness, maceration or damage to the skin and the circumference of the anus, the presence of external hemorrhoids, prolapse of the mucous membrane or all layers of the rectum, tumors, pararectal fistulas.

Finger research. This is the simplest, most accessible and safe method that should be applied to every patient who complains of pain, abnormal discharge from the rectum or dysfunction of this organ.

Inspection with rectal mirrors. The patient is examined in the knee-elbow position or lying on his back with his legs raised or on his side with the hips brought to the stomach. You can visually examine the anal and lower parts of the rectum, see anal fissures, internal hemorrhoids, polyps, tumors, ulcers, wounds, foreign bodies, rectovaginal fistulas, changes in the mucous membrane and other pathological processes at a depth of 8-10 cm.

Sigmoidoscopy. Sigmoidoscopy is performed for pain in the rectum, bleeding from the anus, suspected malignant or benign neoplasm, constipation and diarrhea (especially with blood and mucus), strictures, ulcers, rectovaginal, vesico-rectal fistulas and other indications, as well as in the absence of any complaints, i.e. with a preventive purpose to detect asymptomatic diseases, especially among workers in food and children's institutions. Sigmoidoscopy, if necessary, is used for the purpose of biopsy and taking material from the intestinal mucosa for sowing, smear, microscopic examination.

12. Colonoscopy, polyps, lipomas, diverticula

Colonoscopy. It makes it possible to identify pathological changes in the colon, is an additional and final diagnostic method, since with the help of an operating colonoscope, it is possible to take material for histological examination from any part of the colon.

Benign tumors

Polyps. It affects all parts of the colon, most often at a young age. With an increase in the number of polyps, the possibility of their malignancy increases.

The clinic of polyps and polyposis depends on their number, localization, distribution and structural features. With single polyps, the disease can be asymptomatic, with adenomatous polyps, loose stools appear mixed with blood and mucus. With polyposis, pain in the lumbar region and constipation are often observed, and when it is localized in the sigmoid colon, a feeling of incomplete emptying of the intestine. Such patients lose weight, become pale, anemic. With sigmoidoscopy, sigma polyps of various shapes, sizes and colors are visible. X-ray examination gives a typical cellular image, i.e. multiple filling defects.

Lipomas. They are characterized by duration and asymptomatic course. In some cases they have a broad base, usually covered by a normal mucosa. Lipomas can be palpated through the anterior abdominal wall. They have a smooth surface, move freely, and are often the cause of acute or chronic intussusception. X-ray examination will give valuable data, but sometimes the diagnosis can be established only during the operation.

Fibromyomas and angiomas. Rarely seen in the colon. Angiomas can produce persistent or intermittent, sometimes profuse bleeding during defecation, which can lead to significant anemia. If angiomas are localized in the sigmoid colon, then with sigmoidoscopy and fibrocolonoscopy, on a pale background of the mucosa, grape-shaped vascular formations protruding from the submucosal layer are visible.

The diagnosis of the above benign tumors of the colon is most often established on the operating table.

Diverticula. Colon diverticula are acquired limited saccular dilatations and occur mainly in individuals over 40 years of age. More often they are localized in the sigmoid colon, less often in other parts of the colon. Often, inflammation occurs in the diverticulum - diverticulitis.

Diverticulitis can give complications: intestinal obstruction, suppuration, fistulas, bleeding. For diverticulitis, spasmodic pain is typical, often constipation and, less commonly, diarrhea. Often there is an increase in temperature, weakness, leukocytosis in the blood, an admixture of pus, mucus and blood in the feces.

13. Nonspecific ulcerative colitis

Nonspecific ulcerative colitis is a disease of unknown etiology, characterized by the development of an inflammatory process, hemorrhage, ulcers, bleeding, secretion of mucus and pus from the colon and rectum.

There are a number of theories trying to explain the etiology and pathogenesis of nonspecific ulcerative colitis: infectious, enzymatic, endocrine, neurogenic, psychogenic stress theory, alimentary, the theory of large collagenosis, the theory of allergy, or autoimmune aggression.

Along the course, acute (severe, fulminant) and chronic (continuous, recurrent) forms of ulcerative colitis are distinguished.

According to symptoms, they are distinguished four stages of non-specific ulcerative colitis:

1) rectal bleeding (scarlet blood), normal stool, no mucus (stage "hemorrhoids" and "anal fissures");

2) after two weeks, the appearance of blood in the stool increases, mucus in large quantities, frequent stools (the stage of the "infectious hospital", or dysentery);

3) in the second month, the phenomena of intoxication increase, pain in the abdomen, hectic body temperature are noted;

4) in the third month of the disease, the stool becomes more frequent (10-80 times a day), the stool is fetid, in the form of a bloody irritating liquid, continuous tenesmus, the patient is untidy, depressed, there is depletion of the subcutaneous tissue, pallor of the skin and mucous membranes with an icteric tinge, hectic

body temperature, tachycardia, bloating, dry tongue, oliguria, leukocytosis, peitrophilic shift of the leukocyte count to the left, hypoproteinemia, hypokalemia, hyponatremia, hypoalbuminuria.

Extraintestinal manifestations - arthritis, conjunctivitis, neurodermatitis, dermatitis, pyoderma gangrenosum of the anus.

Complications of nonspecific ulcerative colitis:

1) specific - damage to the skin, joints, eyes;

2) associative - violations of the hematological picture, water and electrolyte balance, absorption from the small intestine, changes in the hemocoagulation system;

3) surgical:

a) perforation of the colon;

b) massive intestinal bleeding (usually recto-sigmoid angle);

c) acute toxic dilatation of the colon (toxic megacolon);

4) lesions of the anorectal region - strictures, fistulas, anal fissures.

Complications of chronic nonspecific ulcerative colitis: colonic strictures, cancerous transformation, bleeding.

To make a diagnosis of nonspecific ulcerative colitis, special research methods are used - sigmoidoscopy, irrigoscopy, colonoscopy, aspiration biopsy.

14. Sigmoidoscopy, irrigoscopy, biopsy, treatment

Sigmoidoscopy at the height of the disease reveals the symptom of "weeping mucosa", contact bleeding, with a large release of blood, pus, with excessive growth of granulations (pseudopolyps), in the late stage - smoothness of the mucosa, deformation of the intestine. Colonoscopy gives the same picture.

Irrigoscopy provides data two months after the onset of the disease. Colon without haustra, shortened, caecum pulled up to the hepatic angle, there is no mucosal relief, pseudopolyps (at a late stage).

Aspiration biopsy establishes inflammation in the intestinal mucosa.

Nonspecific ulcerative colitis must be distinguished from Crohn's disease, tuberculosis, and cancer.

For treatment ulcerative colitis requires a diet (liquid food 6 times a day, in very serious patients - hunger). Food should be well thermally and mechanically processed and rich in proteins and vitamins. Carbohydrates, milk and canned foods should be excluded, the amount of fat is limited.

Parenteral nutrition provides mechanical and functional rest of the digestive tract. It compensates for the lack of enteroplastic material, reduces the exhaustion of patients, increases the overall resistance of the body, reduces toxemia, bacteremia, anemia, beriberi, improves water-electrolyte and protein metabolism. The effect of parenteral nutrition depends on the biological activity of the administered drugs, the balance of amino acids. Electrolytes are administered intravenously: salts of sodium, potassium, calcium, magnesium, chlorine, phosphorus, iron; subcutaneously - a triple daily dose of vitamins of groups A, B, C.

Hormone therapy eliminates adrenal insufficiency, suppresses hyperallergic inflammation, and reduces toxemia.

In severe forms, hydrocortisone is administered parenterally, 50-100 ml every 6-12 hours for 10 days. Then they switch to oral prednisolone (20-30 mg per day for 2-3 months, the last week - 5 mg per day).

They also carry out treatment aimed at eliminating dysbacteriosis.

Local treatment - enemas with manganese, rosehip oil, sea buckthorn and chamomile.

With multiple perforation of the intestine, toxic megacolon, profuse bleeding, emergency surgery is indicated.

Indications for planned surgical treatment: acute form of the disease, which is not amenable to conservative therapy within a month; chronic continuous form that lasts 3 years and is accompanied by bleeding; stricture in one of the sections of the colon, cancer that developed against the background of nonspecific ulcerative colitis.

Surgical treatment is divided into two stages:

1) subtotal colonectomy with removal of the ileostomy according to Brook;

2) ileosigmoanastomosis with sanitized sigma and rectum 3-6 months after the first stage.

15. Colon cancer

colon cancer ranks fourth in the number of cases after cancer of the stomach, esophagus and rectum. The small intestine is affected less frequently than the colon and rectum.

Colon cancer is a relatively benign form of cancer. With timely diagnosis and adequate therapy, treatment outcomes can be significantly better than with gastric cancer. Cancer affects all its departments, almost equally the right and left sides, and relatively less often - the transverse colon.

International classification. This classification applies to all organs of the gastrointestinal tract.

T - primary tumor.

TX - insufficient data to evaluate the primary tumor.

That - the primary tumor is not determined.

T in situ - preinvasive carcinoma.

T1 - the tumor infiltrates the intestinal wall to the submucosal layer.

T2 - the tumor infiltrates the muscular layer of the intestinal wall.

TK - the tumor infiltrates the subserosis or tissue of the retonized areas of the intestine.

T4 - the tumor sprouts the visceral peritoneum or directly spreads to neighboring organs.

N - metastases in regional lymph nodes. NX - insufficient data to assess the status of regional lymph nodes.

NO - no signs of metastatic involvement of regional lymph nodes.

N1, 2, 3 - there are metastases in the lymph nodes.

M - metastases to distant organs.

MX - insufficient data to determine distant metastases.

MO - no signs of metastatic lesions of regional lymph nodes.

Ml - there are distant metastases.

domestic classification.

Stage I - a tumor of small size, limited, localized in the mucous thickness and submucosal layer of the colon, without regional metastases.

Stage II - the tumor does not extend beyond the intestine, is relatively large, but does not occupy more than a semicircle of the wall, without regional metastases, or has the same or smaller size, single metastases are observed in nearby lymph nodes.

Stage III - the tumor process occupies more than the semicircle of the intestine, germinates its entire wall or adjacent peritoneum, there are metastases; tumor of any size with multiple metastases to regional lymph nodes.

Stage IV - an extensive tumor that grows into neighboring nearby organs and has multiple metastases, or a tumor of any size with distant metastases.

16. Diagnosis of colon cancer

Diagnostics. When diagnosing colon cancer, it is necessary to take into account the data of anamnesis, external examination, palpation, sigmoidoscopy, colonoscopy, X-ray and laboratory studies of feces for obvious and latent blood. When collecting an anamnesis, it is necessary to find out whether the patient noted the phenomena of intestinal obstruction, if so, how they developed, whether there were short-term paroxysmal pains in the abdomen, whether rumbling, swelling, etc. were observed. discharge from the rectum.

Most patients with colon cancer have an outwardly healthy appearance, with the exception of those in whom the disease proceeds against the background of anemia, which is especially characteristic of cancer of the right half of the colon. Relatively quickly to emaciation lead to manifestations of intestinal obstruction.

When the tumor is localized in the left half of the colon, local swelling and visible peristalsis appear, which are accompanied by rumbling, sometimes heard even at a distance. In some cases, this can cause splashing noise, which indicates the presence of a large amount of stagnant liquid content in the caecum and partly in the ascending colon.

Great importance in the diagnosis of colon cancer is attached to palpation examination, the success of which depends not only on the degree of bowel emptying and relaxation of the muscles of the anterior abdominal wall, but also on the anatomical localization of tumors. It is easier to palpate the tumor of the fixed part of the colon - the ascending and descending intestines, devoid of the posterior peritoneum.

With stenosing cancer of the distal colon, the "symptom of the Obukhov hospital" (an empty dilated rectal ampulla) is often positive. Differentiation of tumors of intestinal localization with tumors emanating from the genitals is helped by a combined vaginal and rectal examination. With a digital examination through the rectum, metastases can be determined in the Douglas space and in the pelvic tissue. The abdominal cavity should be palpated after thorough bowel cleansing.

Various methods of x-ray examination of the colon in the vast majority of clinically unclear cases of tumors of the colon give a clear answer, which puts x-ray examination in first place among other methods. This study makes it possible not only to diagnose colon cancer, but also to distinguish it from other diseases that are considered precancer. Colon cancer may be preceded by multiple villous tumors associated with adenomatous polyps.

X-ray examination should be carried out not only in cases of suspected colon cancer, but also in patients with prolonged intestinal disorders of unknown etiology and with severe symptoms of intoxication, anemia, and emaciation of unexplained origin.

17. Treatment of colon cancer

Treatment. Colon cancer is treated exclusively with surgery. It consists in a wide resection of the affected area of the intestine and the corresponding section of the mesentery with regional lymph nodes.

If colon cancer is not complicated by acute intestinal obstruction, where the surgeon is forced to perform an operation for urgent indications, then patients undergo thorough preoperative preparation, taking into account their individual characteristics.

In preoperative preparation, diet is of great importance. Food should be high-calorie, rich in vitamins, with a small amount of fiber (chopped boiled meat, milk soup, butter, eggs, fruit juice, cream, rice, pure chocolate, crackers, dry biscuits). All indigestible and coarse foods are excluded from food - potatoes, cabbage, mushrooms, fruits, etc.

To eliminate dehydration and hypoproteinemia, blood, plasma, polyglucin, saline are transfused intravenously.

B. L. Bronshtein recommends systematically taking a laxative in the form of a 8% solution of magnesium sulfate for 10 tbsp within 15-12 days before the operation. l. per day (about 6 doses). This laxative is not so debilitating. A single large dose of a laxative is contraindicated and dangerous. On the eve of the operation, cleansing enemas are done in the morning and evening. In order to reduce fermentation in the intestines, benzonaphthol and salol are prescribed before and after the operation, antibiotics are prescribed two days before the operation.

Proper management of patients in the postoperative period largely determines the outcome of surgery.

Immediately after the operation, a drip transfusion of blood (220 ml) is established, then a 5% glucose solution in an isotonic NaCl solution with the addition of vitamins. The first 2-3 days are prescribed narcotic drugs, atropine, cardiac. It is necessary to strictly observe oral hygiene to prevent parotitis. It is allowed to move in bed from the second day, all measures are taken to prevent postoperative pneumonia.

Intestinal function deserves special attention. For the unhindered discharge of gases and the prevention of increased pressure inside the colon, candles from glycerin and belladonna are used, a gas outlet tube is inserted into the rectum. Some surgeons perform digital sphincter stretching towards the end of the operation.

If the patient has a metastatic stage of the disease, then, in addition to surgical treatment, chemotherapy is used (usually in adjuvant mode). They use the well-known methyluracil, methotrexate, as well as modern xeloda, doxyrubicin (anthrocyclines), paclitaxel (taxanes), etc. The drugs are administered both intravenously and intraperitoneally into the abdominal cavity through drains specially left in operation time. In liver metastases, drugs are injected into the round ligament of the liver.

18. Hemorrhoids

Hemorrhoids (varices haemorrhoidales) - varicose veins of the hemorrhoidal plexuses, accompanied by such clinical symptoms as bleeding, pain, inflammation, prolapse of hemorrhoids. However, not all of these symptoms appear at the same time.

There are internal and external hemorrhoids. The first develops from the internal venous plexus, the second - from the outside. However, there are cases when two plexuses are involved in the formation of hemorrhoids.

The development of hemorrhoids begins imperceptibly. In the anus, a feeling of tickling or itching gradually arises, in some cases - a feeling of heaviness and a feeling of the presence of a foreign body. When the expansion of the veins reaches a significant value, the intestinal lumen narrows and during the act of defecation, severe pain appears, which makes patients refrain from defecation as long as possible. All this leads to the destruction of the walls of the veins and causes bleeding, and then prolapse of hemorrhoids. The disease enters the phase of its full development.

V. R. Braitsev distinguishes four degrees of prolapse:

1) nodes fall out only during the act of defecation and go back themselves;

2) nodes fall out at sharp voltages, but do not reset on their own;

3) nodes fall out when walking and remain in this position until they are set to the patient;

4) nodes fall out constantly and after reduction they fall out again.

The prolapsed hemorrhoids close the opening of the anus and prevent normal bowel movements, resulting in headache, belching, vomiting, aversion to food, sometimes bloating, frequent urge to urinate or its delay, fever, and pulse quickens.

Bleeding is one of the typical and frequent manifestations of hemorrhoids. Mostly give bleeding internal hemorrhoids. It most often occurs during the act of defecation, when the anal ring relaxes, and the pressure in the hemorrhoidal veins increases (it proceeds painlessly). The amount of blood lost during hemorrhoidal bleeding can vary widely - from barely noticeable traces in the form of colored stripes on feces or poor staining of toilet paper to the expiration of a jet. Repeated heavy bleeding can lead the patient to anemia and severe exhaustion.

However, bleeding from the rectum can be caused not only by hemorrhoids, but also by polyps, cancer of the rectum and overlying colon, chronic ulcerative proctitis, anal fissures, etc. Bleeding from the rectum is a distress signal, so the patient should be comprehensively examined . Already in the conditions of the clinic, it is necessary to examine the intestine with the help of a rectal mirror.

19. Fissures in the anus

Fissure of the anus (fissura ani) - a slit-like rupture of the mucous membrane of the anal canal, located, as a rule, on its back wall.

The onset of the disease can be imperceptible, gradual or acute, sudden. The patient is concerned about the burning sensation, pressure, expansion, the presence of a foreign body in the rectum with irradiation of pain in the perineum, bladder, sacrum, buttocks, inner thighs. The pain comes on shortly after a bowel movement and lasts for many hours.

The fissure of the anal canal in 90% of cases is localized on the back wall of the white line, in isolated cases (10%) - on the anterior wall of the anus (more often in women). There are no cracks on the side wall of the anal canal. In 3% of cases, there are two cracks on the back and front walls of the anal canal.

The length of the anal fissure is 0,5-2 cm, the depth is 0,3-0,5 cm.

Cause constipation cracks, hemorrhoids. In this case, the mucosa of the anal canal ruptures, as a result of which the nerves that are affected by toxins are exposed. With prolonged action of toxins, neuritis and spasm of the sphincter of the rectum occur, and this does not allow the fissure to heal.

With cracks, sharp pains occur both during defecation and after stool. Sometimes isolated drops of blood are released. Some patients are afraid of stools, restrict food intake, which further leads to constipation. An acute fissure (up to 3 months) later becomes chronic. With a chronic fissure, the pain in the anus is somewhat less than with an acute one.

Chronic fissure in 33% of cases has a distal tubercle and in 3% - a proximal tubercle in the form of a polyp.

Treatment: warm sitz baths, microclysters with chamomile, hemorrhoidal suppositories with anesthesin. Stretching of the sphincter of the rectum according to Recomier is used, the injection method is used with a mixture of Schnee (5% sovkain - 0,1 ml, phenolphthalein - 0,2 g, medical alcohol with a strength of 70% - 1 ml, peach oil - 8,7 g). After anesthesia with a 0,5% solution of novocaine, 1,5 cm from the anal ring, 0,5-2,0 ml of Schnee fluid is injected under the bottom of the crack, where fiber degeneration occurs, and the pain disappears within a month. In addition, alcohol-novocaine blockade is used. A 0,5% solution of novocaine (50 ml) is introduced under the crack and medical alcohol with a strength of 90% (1 ml) is injected along the entire length. The procedure is repeated every 7-10 days. Widely used microclysters with a 0,5% solution of novocaine (50 ml).

Surgical treatment is indicated in cases where there is no effect within three months of conservative therapy, when a chronic fissure takes the form of an ulcer, when there are border tubercles and itching.

The operation for the crack is carried out according to Gabriel not in the form of a triangle, but in the form of a "racquet" size 3 х 3 cm. Sphincterotomy is not performed; in some cases, a chronic fissure is excised with an incision of the outer portion of the sphincter so that no scar tissue remains.

The wound heals in 3-4 weeks. The patient is discharged on the 8-9th day.

20. Acute paraproctitis

Acute paraproctitis call all acute purulent lesions of the rectal wall and surrounding tissue. The same concept includes pararectal ulcers, anal and perianal abscesses located under the skin and mucous membranes of the anus.

The cause of acute paraproctitis is trauma (repeated superficial abrasions, cracks or ruptures) that occurs when solid feces pass through a tonically closed anal canal. Overstretching of the perineal part of the rectum with constipation, loosening of the mucosa, as well as prolonged diarrhea can cause it to tear and excoriate.

The occurrence of paraproctitis is facilitated by diseases such as hemorrhoids, anal fissures, rectal strictures, proctitis of various etiologies (catarrhal, ulcerative, dysentery, typhoid, gonorrheal, tuberculosis).

The causative agents of paraproctitis are Proteus, Streptococcus aureus, Staphylococcus aureus, anaerobic bacillus, anaerobic gram-positive bacillus. The infection can be very different (both pyogenic and anaerobic).

The classification of acute paraproctitis is based on the anatomical location of the purulent accumulation. Distinguish:

1) subcutaneous paraproctitis, or perianal abscess;

2) ischiorectal (ischiorectal);

3) pelvic-rectal (pelviorectal);

4) retrorectal (retrorectal);

5) submucosal abscess of the rectum. Subcutaneous abscesses are more common than other forms of acute paraproctitis. Pus accumulates in the subcutaneous tissue on either side of the anus (perianal abscess).

Subcutaneous paraproctitis manifests itself acutely, body temperature rises to 38-39 ° C, chills are sometimes observed, the patient complains of pain in the anus, aggravated by defecation.

Clinically, the disease is manifested by a feeling of heaviness and dull pain in the depths of the buttock or perineum, body temperature rises to 38-40 ° C (often with chills), patients note increasing weakness, loss of appetite, and insomnia. At the time of defecation, pain in the depths of the perineum intensifies, sometimes there is urinary retention. Locally, slight swelling of the corresponding buttock is noted. When pressed, deep pains are felt. After 3-6 days from the time of the first pain on the side of the anus, that is, on the right or left buttock, there is an extensive swelling of the tissues, painful when pressed. The skin, as a rule, is of normal color, but in some patients it is slightly hyperemic. Palpation reveals deep doughiness, loose tissue infiltration. Fluctuation is not detected, it can only be after the breakthrough of the abscess under the skin, then skin hyperemia also occurs. A digital examination of the rectum on the side of the lesion reveals a painful compaction of the rectal wall, sometimes with abscesses filling the entire ischiorectal fossa, a protrusion of this wall in the intestinal lumen is observed. Ischiorectal ulcers, left to their own course, most often break out through the skin of the gluteal region, less often they open into the lumen or through the muscle that lifts the anus, penetrate into the pelvic-rectal space.

21. Ulcers with paraproctitis, diagnosis, treatment

With ischiorectal ulcers much more often than with subcutaneous ulcers, a horseshoe-shaped or bilateral form of paraproctitis is formed.

Ulcers in pelvic-rectal paraproctitis are localized in the fascial space of the same name, located between the levator ani muscle and the peritoneum of the pelvic floor. This is the most severe and difficult to recognize form of paraproctitis, which is relatively rare (7,5%).

Ulcers can occur in the lymphogenous way on the basis of minor damage (microtrauma) of the mucous membrane of the final section of the rectum. In rare cases, they develop secondary to purulent prostatitis and vesiculitis in men or infection of the appendages and broad ligaments of the uterus in women.

Clinical signs of the disease: pain and a feeling of heaviness in the pelvis, constant pressure on the bottom; pains sometimes radiate to the area of the bladder, and in women - to the area of the uterus; increased urination, sometimes pain at the end of it; during defecation, the pain is not sharp, sometimes absent.

When examining the perineum, anus and buttocks, no signs of the disease are noted. With superficial palpation of the buttocks, there is no pain, however, strong pressure with a finger or pushes on the buttock of the affected side causes a feeling of pain in the depths of the pelvis.

A digital rectal examination reveals a sharp painful induration of one of the side walls of the rectum, located above the levator ani muscle, i.e., 5-9 cm above the anus. Sometimes, with the localization of the abscess on the right, there are signs of acute appendicitis. There were cases when the abscess broke into the bladder, vagina and even into the abdominal cavity.

An important diagnostic sign of a retrorectal abscess is a sharp pain with finger pressure on the skin of the posterior perineum between the tip of the coccyx and the anus.

Clinically, in patients there is an increase in temperature (37-38 ° C), a deterioration in the general condition. Complaints come down to a feeling of dull, sometimes throbbing pain in the lower rectum, heaviness in it. The pain is always aggravated by defecation. Outside, there are no signs of the disease. The diagnosis is made on the basis of a digital examination of the rectum, in the lumen of which a round elastic painful tumor is determined on one of the walls.

With primary acute paraproctitis of superficial localization, it is necessary to carry out a radical operation - to excise the outer wall of the abscess along with the affected crypts according to Gabriel.

With deep (ischiorectal, pelviorectal, retrorectal) acute paraproctitis, in order to eliminate the internal opening, it is recommended to open abscesses with necrectomy and passing a silk ligature through the internal opening.

If during the operation for acute para-proctitis of deep localization, with the introduction of methylene blue into the abscess cavity, the internal opening is not detected and there is no visible purulent passage to the crypt line, then it can be limited to a wide arcuate opening of the abscess and drainage of the cavity.

22. Fistulas of the rectum

Under rectal fistulas it is necessary to understand the fistulous passages located near the anus. Rectal fistulas are also considered as a pathological course or abnormal communication between the rectum and adjacent tissues, pelvic organs, or the skin of the perineal-buttock region.

Fistulas of the rectum are characterized by frequent recurrence. A significant proportion of relapses after operations for rectal fistulas depends on the presence of an undetected internal opening.

The formation of fistulous passages develops in the following stages:

1) the gate of infection on the mucous membrane of the anal canal;

2) primary purulent course;

3) pararectal abscess;

4) rectal fistula.

Fistulas of the rectum are the result of acute paraproctitis, in which there is always a more or less pronounced internal opening of the abscess in one of the Morganian crypts.

According to the anatomical location, fistulas are divided into subcutaneous-submucosal, ischiorectal, pelviorectal, retrorectal and rectovaginal.

In relation to the sphincter - intrasphincteric, transsphincteric and extrasphincteric.

According to the location of the fistulous openings - complete (external and internal), incomplete (external and internal) with a temporarily recurrent internal opening.

According to the clinical picture - simple, complex (branched, with extensions, streaks, infiltrates), horseshoe-shaped and recurrent.

Diagnosis of fistulas of the rectum begins with an external examination, in which the location of the external opening of the fistula, the number of external openings, and the nature of the discharge are determined. The closer the external opening of the fistula to the anus, the easier the fistula.

On palpation, a cord-like cord can be determined, corresponding to the course of the fistula. A digital examination of the rectum finds the internal opening of the fistula, which can be located in one of the crypts - anterior, posterior or lateral.

The study of the fistulous tract with a bellied probe is mandatory, it helps to determine the location of the fistula in relation to the sphincter. If the thickness of the tissues above the probe does not exceed 1 cm, then we can assume an intra-or transsphincteric direction of the calico passage.

In cases where the fistulous tract is convoluted and the probe does not pass into the lumen of the rectum, a 1% solution of methylene blue is injected into the fistulous tract to determine the location of the internal opening of the fistula.

Fistulography is used for complex fistulas to clarify the directions of additional moves, the presence of streaks, pockets.

Many surgical interventions have been proposed for the treatment of rectal fistulas.

23. Cancer of the rectum

Of all the neoplasms of the rectum, cancer is the most common. People of any gender and age suffer from rectal cancer, but most often from 40 to 60 years.

Depending on its localization, anal cancer, cancer of the rectal ampulla and its proximal part are distinguished.

The clinical course of rectal cancer is diverse, it depends on the localization of the tumor, the stage of its development, the degree of malignancy, the presence or absence of ulceration.

International clinical and domestic classifications are similar to colon cancer classifications.

In the initial period of the disease, regardless of the localization of cancer in the rectum, symptoms may be absent.

The first, most characteristic signs of rectal cancer include discomfort in the anus and sacrum, tenesmus, constipation, alternating with diarrhea, dull pain during bowel movements, the release of blood and mucus (sometimes blood and pus).

If there is ulceration of cancer of the anus, then blood is released. With deep infiltration of the sphincter, with the germination of sensory nerves, sometimes severe pain occurs. As a sign of developing stenosis, the ribbon-like shape of feces attracts attention. With an ulcerative form of cancer, a pronounced anemization of patients occurs, a pale icteric color of the skin. There are constant severe pains in the pelvic area and the sacrum, and sometimes dysuric phenomena when the tumor grows into the tissue of the pelvis or neighboring organs - the prostate gland, urethra, etc. In some cases, highly located rectal cancer can give a picture of acute intestinal obstruction .

The diagnosis of rectal cancer is made on the basis of digital examination, sigmoidoscopy and X-ray examination.

In digital examination, in cases where rectal cancer is available, the formation of a dense consistency, especially at the base and edges, ulceration with roller-like thickened and compacted edges is found. With highly located stenosing crayfish, a sharp expansion of the empty ampoule is noted. In some cases, infiltration of the rectal wall without clear boundaries, traces of blood or bloody-purulent discharge on the finger are determined.

During sigmoidoscopy, you can take a piece of the tumor from the area of altered tissue with a conchotome for biopsy.

X-ray examination of the rectum with suspected cancer is performed using a small amount of contrast mass. In this case, the following signs are revealed: rigidity of the rectal wall and narrowing of its lumen, absence of mucosal folds, filling defects with uneven and indistinct contours, expansion of the intestine above the site of narrowing, absence of peristaltic movements in the affected area.

Differential diagnosis of rectal cancer should be carried out with the following diseases: hemorrhoids, tuberculous ulcer of the perianal skin and anal canal, syphilis and rectal polyps, benign tumors delimited by infiltrative paraproctitis.

24. Epithelial-coccygeal passages

Epithelial-coccygeal passages is a congenital disease characterized by the presence in the subcutaneous tissue of a passage lined with epithelium.

There are mainly uncomplicated and complicated coccygeal passages.

With uncomplicated epithelial-coccygeal passages, patients complain of dull persistent pain in the sacrococcygeal region, especially when walking and physical exertion, itching and maceration of the skin in the intergluteal region. Visually, strictly in the intergluteal fold at the level of the fifth sacral vertebrae, there is one or more holes, from which a bunch of long, thin, atrophic hair protrudes. If there are many holes, then they all communicate with each other. Away from the hole in the sacrococcygeal region, sometimes you can feel a soft tumor-like formation without inflammation. A meager amount of serous or serous-purulent fluid is released from the hole.

With complicated epithelial-coccygeal passages, an abscess of the sacrococcygeal region is observed on the basis of the epithelial-coccygeal passage, which occurs after an injury. There is malaise, general weakness, fever. Locally there is a painful swelling and infiltration in the intergluteal region, the skin over it acquires a bluish-violet or red tint. In the later stages, shaking appears. At the edge of the abscess, strictly along the intergluteal fold, there is always the primary opening of the epithelial-coccygeal passage.

There may also be an epithelial-coccygeal passage with secondary purulent fistulas and streaks.

After an independent or surgical opening of the abscess, a temporary improvement occurs, followed by an exacerbation with the formation of a new abscess, then additional fistulous openings with streaks appear. With a long-term course of the disease, multiple fistulous passages are observed against the background of scars and indurations of the skin of the sacrococcygeal region with an obligatory primary opening in the intergluteal fold at the level of the sacrococcygeal joint. This is the main differential symptom that distinguishes this disease from chronic paraproctitis and other suppurative diseases of the sacrococcygeal and perineal regions.

It is difficult to differentiate the epithelial-coccygeal passage from the rectal fistula only if the primary opening of the epithelial-coccygeal passage is located atypically. To clarify the diagnosis, methylene blue is injected into the primary opening of the passage, which always pours out through the secondary fistulous passages.

Treatment of epithelial-coccygeal passages is a rather difficult task. There are a large number of different methods of treatment. Conservative methods of treatment are abandoned by all. Now they use radical methods of surgical treatment of epithelial-coccygeal passages. All surgeons spend the first moment of the operation in the same way. It consists in excision of the epithelial-coccygeal tract along with its streaks and fistulas within healthy tissue under the control of methylene blue. The second part of the operation is performed differently.

25. Intestinal obstruction

Intestinal obstruction (ileus) is characterized by the cessation of the movement of intestinal contents in the direction from the stomach to the rectum and is one of the most formidable syndromes encountered in abdominal surgery.

Intestinal obstruction is a complex of symptoms (syndrome) characterized by pain, vomiting, stool retention, gas, bloating and combining numerous diseases of the abdominal organs with different etiology and course. Correct and timely diagnosis of intestinal obstruction plays a decisive role in the outcome of the treatment of this serious disease.

I. According to the mechanism of occurrence:

1) dynamic (functional) obstruction:

a) spastic;

b) paralytic;

2) mechanical obstruction:

a) obstructive (obstruction by a tumor, blockage by a foreign body, fecal or gallstone, ascaris tangle, coprostasis);

b) strangulation (torsion, knotting, internal infringement);

c) mixed forms of obstructive and strangulation obstruction (adhesions, intussusception);

3) vascular obstruction (intestinal infarction):

a) thrombosis of the mesenteric veins;

b) thrombosis and embolism of the mesenteric arteries.

II. By clinical course:

1) acute;

2) subacute;

3) chronic.

III. By degree:

1) complete;

2) partial.

IV. By stages: the first - neuroreflex; the second is the stage of compensation and organic changes; the third is terminal.

Dynamic intestinal obstruction Dynamic intestinal obstruction occurs as a result of a violation of the muscle tone of the intestine on the basis of functional or organic lesions of its innervation mechanisms. Spastic intestinal obstruction (spastic ileus). It occurs with intestinal spasm and can be caused by various factors: helminthic invasions, fecal stones and other foreign bodies that irritate the intestines from the side of its lumen; bruises of the abdomen, hemorrhages in the abdominal cavity, hematomas and suppurative processes of retroperitoneal tissue (mechanical irritants of the intestines); renal and hepatic colic, basal pneumonia, hemo- and pneumothorax, which reflexively irritate the intestines; functional and organic lesions of the nervous system; spasm of intestinal vessels, dysentery.

26. Paralytic ileus, mechanical ileus, clinic

Paralytic ileus (paralytic ileus). Occurs with paresis or paralysis of the intestine. The most common causes of this type of obstruction are peritonitis, surgical trauma (during surgical interventions on the abdominal organs), blood, urine or bile that has poured into the abdominal cavity.

Mechanical intestinal obstruction. With mechanical obstruction, there is a violation of the patency of the intestine as a result of any mechanical obstruction. The symptomatology of mechanical intestinal obstruction consists of pain and dyspeptic syndromes, hemodynamic disturbances and disorders of water-salt, protein, carbohydrate metabolism, complicating factors associated with the development of peritonitis.

The diagnosis is clarified with a thorough history taking, an objective clinical examination, X-ray examination of the abdominal and thoracic cavities, laboratory blood and urine tests.

Depending on the degree of violation of the blood supply to the intestine, mechanical obstruction is divided into obstructive and strangulation.

The clinical picture of mechanical intestinal obstruction is extremely diverse and depends on the duration of the disease, the level and type of obstruction, the individual characteristics of the patient (age, gender, general condition at the time of the disease).

The higher the level of obstruction, the more severe the disease.

Diagnosis and treatment. Of great importance in the diagnosis of intestinal obstruction is the anamnesis, since obstruction is not an accidental disease of a healthy person, in most cases it is a complication or a secondary symptom complex of another disease. When collecting an anamnesis, it is necessary to establish whether the patient had abdominal injuries, operations on the abdominal organs, whether the patient suffers from peptic ulcer, cholecystitis, appendicitis, and women from inflammatory diseases of the genitals. All these data can lead to the idea that the patient has adhesive intestinal obstruction. Next, you need to pay attention to the activity of the intestines (the presence of constipation, followed by diarrhea). It is important to find out when and what the patient ate before the onset of the disease, whether there were gross violations in the mode and quality of nutrition or a sudden increase in intra-abdominal pressure when lifting weights and other physical stresses.

The onset of the disease is acute or gradual. The acute onset indicates severe obturation or strangulation obstruction or an acute form of intussusception. Patients indicate the exact time of onset of the disease. With an exacerbation of chronic intestinal obstruction, the disease often begins not so violently.

One of the constant symptoms of intestinal obstruction is cramping pain. After fading away, she reappears. The periodicity and cramping nature of the pain are caused by increased peristalsis of the intestinal loops.

27. Diagnosis of intestinal obstruction

When examining the abdomen, it is necessary to pay attention to its configuration, general or local flatulence and asymmetry of the anterior abdominal wall.

In the initial period of intestinal obstruction, the loop of the intestine closest to the site of obstruction is stretched first. It can even protrude somewhat (limited flatulence) - Val's symptom. Percussion in this place of the abdomen is heard high tympanitis. In some cases, with multiple constriction of intestinal loops, for example, by adhesions, sharply protruding stretched loops are noticeable, giving asymmetry of the abdomen.

An important sign of intestinal obstruction is peristalsis of the intestine, which is noticeable to the eye, which occurs independently or after mild irritation of the abdominal wall, such as palpation. Most often, the beginning of peristalsis coincides with an increase in pain, and the end - with their decrease. Visible peristalsis also serves as a reliable symptom of intestinal obstruction. Peristalsis is especially pronounced in chronic obstructive obstruction caused by intestinal tumors, with hypertrophy of the intestinal wall above the obstacle.

In acute intestinal obstruction, especially with strangulation, abdominal pain is noted during palpation. Sometimes it is possible to palpate the focus of obstruction - a tumor, induration at the site of invagination, a foreign body that caused obstruction.

Splashing noise, first described by I.P. Sklyarov in 1922, is of great diagnostic value in this disease.

Bowel sounds of various heights are auscultated, which are very diverse in nature (voiced, crackling, sometimes resembling the bursting of bubbles). The presence of bowel sounds indicates preserved peristalsis. For intestinal obstruction, the coincidence of intestinal noises with peristalsis and bouts of pain is characteristic.

With the development of peritonitis in the abdominal cavity, silence sets in, only occasionally can you hear the noise of a falling drop (Spasokukotsky's symptom) or rare peristaltic noises in high tones.

A digital examination of the per rectum can reveal a balloon-like swelling of an empty ampoule of the rectum, a "gaping anus" (a symptom of the Obukhov hospital).

In most cases, the temperature at the onset of the disease is normal, and with the development of peritoneal symptoms, it reaches 37,5-38,5 ° C.

X-ray diagnostics is a valuable tool in the recognition of intestinal obstruction. Panoramic fluoroscopy and radiography of the abdominal cavity without the use of contrast agents are widely used in our country. This method does not require preliminary preparation of the patient, is available to every doctor, is simple and safe.

X-ray signs of intestinal obstruction: the accumulation of gas in the gastrointestinal tract and the appearance of horizontal levels of liquid with gas bubbles above them in the form of overturned bowls, called Cloiber bowls.

28. Separate forms and types of mechanical intestinal obstruction (obstructive, strangulation and intestinal volvulus)

Obstructive obstruction. With obstructive intestinal obstruction, there is no compression of the intestinal mesentery with its neurovascular apparatus, and therefore the blood supply to the intestine at the site of obstruction at the onset of the disease is almost not disturbed. At a later date, venous stasis occurs in the leading section of the intestine, and due to the overstretching of this section of the intestine, capillary permeability is disturbed, which leads to cyanosis and edema of the intestinal wall.

Causes of obstructive ileus can be:

1) tumors that cause blockage of the intestinal lumen, ascaris tangles, fecal and gallstones;

2) tumors of other abdominal organs, inflammatory infiltrates that compress the intestine from the outside;

3) adhesions and strands that cause bending of intestinal loops;

4) cicatricial stenosis as a result of ulcerative processes in the intestine (tuberculous or other).

Treatment obstructive mechanical obstruction in colon cancer only operational. With the development of acute intestinal obstruction with no symptoms of perforation of the tumor, it is first necessary to impose a fecal fistula, a radical operation should be performed after the elimination of intestinal obstruction.

When eliminating intestinal obstruction caused by narrowing of the intestine, the nature of the surgical intervention depends not only on the degree of narrowing of the intestine and the cause of the narrowing, but also on the number of strictures, their localization and the length of the narrowing.

If coprostasis is suspected, conservative treatment is carried out: siphon enemas, manual removal of feces when it is retained in the rectum. If conservative treatment fails, surgery is indicated.

Strangulation intestinal obstruction.

With strangulation obstruction, the mesentery of the intestine with the vessels and nerves passing through it is infringed or compressed, which leads to a sharp violation of the blood supply. The nature of the circulatory disorder depends on the degree of infringement or compression of the mesenteric vessels and on the state of the blood vessels before the onset of the disease. Strangulation ileus includes volvulus, nodulation, strangulation of intestinal loops by adhesions and strands in internal hernial rings and congenital mesenteric defects.

Volvulus.

inversion (volvulus) is called the rotation of the intestine over a greater or lesser extent around an axis (270 °, 360 °) perpendicular to the intestine and the line of the mesentery root. Following the intestinal loops, the mesentery is twisted.

The anatomical prerequisites for the occurrence of volvulus are the presence of a sufficiently long mesentery, the ratio of the width of the base of the mesentery and its length (the narrower the base, the closer the adductor and efferent loops (legs) of the corresponding intestine section are). Thus, there is a starting position for inversion.

29. Volvulus of the small intestine

One of the most common types of strangulation intestinal obstruction is volvulus of the small intestine.

The earliest symptom of small bowel volvulus is an acute, indescribable pain, which is more often localized in the epigastric or umbilical region and less often in the right half or lower abdomen. In addition, a characteristic and early sign is vomiting of food eaten the day before. Initially, it has a reflex character, but as a result of irritation of the restrained mesenteric nerve trunks, it later becomes frequent, abundant and acquires a bilious character. The higher the level of volvulus, the earlier vomiting occurs and is more frequent and more abundant.

Early and permanent signs also include stool and gas retention. In some patients, immediately after the onset of volvulus, a false urge to stool and urination appears, sometimes in the first hours of the disease an act of defecation occurs due to the contents of the lower intestine, but there is no relief from this.

At the onset of the disease, the abdominal wall is not tense and is painless on superficial palpation. With deep palpation, pain is noted and sometimes a test conglomerate of intestinal loops is palpated. Percussion in sloping places of the abdominal cavity is determined by free effusion. Of the acoustic phenomena, splash noise is the most characteristic and earliest.

X-ray examination of the abdominal cavity helps to establish the diagnosis of small bowel obstruction and to some extent its level.

The above symptoms are observed not only with volvulus of the small intestine, but also with other types of strangulation obstruction of the small intestine.

In the presence of symptoms of volvulus of the small intestine, it is necessary to immediately perform an operation, without waiting for the appearance of the entire classical picture of the disease.

The volume and nature of the operation for volvulus of the small intestine depend on the anatomical changes and the functional state of the affected intestinal loops. With a viable intestine, in the event of the appearance of peristalsis and pulsations of the vascular arcades, they are limited to untwisting, sometimes adhesions are additionally dissected, which contribute to volvulus.

With obvious signs of necrosis (black color and dullness of the serous cover of the intestine, the presence of ichorous-hemorrhagic peritonitis), the intestine is resected together with the affected part of the mesentery 30-40 cm above and below the affected area.

If there is doubt about the viability of the intestine, they resort to warming the intestinal loops with napkins moistened with warm saline saline.

Volvulus of the sigmoid colon is the most common form of strangulation ileus and slightly outnumbers volvulus of the small intestine. The causes of volvulus of the sigmoid colon are the same as for volvulus of other parts of the intestine.

Volvulus of the sigmoid colon develops either rapidly, accompanied by shock (acute form), or gradually, with preceding constipation, intestinal atony, and even partial obstruction (subacute form).

30. Bowel nodulation

This is one of the rarest and most severe types of strangulation intestinal obstruction, since in this form there is a compression of the mesentery of both intestinal loops involved in the nodulation, and one of them always refers to the small intestine.

There are four main types of knotting:

1) between the sigmoid and small intestines;

2) between two different loops of the small intestines;

3) between the small intestine and the ileocecal angle;

4) between the sigmoid colon and the ileocecal angle.

Nodulation most often occurs at night and is manifested by a severe constant pain syndrome. Patients at the same time are extremely restless, rush about in bed, often change their position of the body, many of them take a bent or knee-elbow position.

Pain is more often localized in the umbilical or epigastric region, is permanent in nature with periodic amplifications. Most of the gases do not go away, there is also no stool, although it may be in the first hours. The face and skin quickly acquire an earthy-gray hue, covered with sticky cold sweat, acrocyanosis appears, the tongue becomes dry. The tension of the abdominal muscles, quite strong at the beginning of the disease, soon almost disappears. Due to the rapidly developing intestinal paresis, peristalsis is not audible and intestinal loops are not contoured through the anterior wall. Abundant effusion accumulates in the abdominal cavity, in the future, as the necrosis of the intestinal loops, a picture of peritonitis develops.

X-ray in the restrained loops of the intestine, the presence of gas and horizontal levels of liquid is observed.

The only method of treatment of nodulation is early surgery. Even with undetectable blood pressure and a non-palpable pulse, it can save the patient's life. Under invagination understand the introduction of one intestine into another. Most often, it develops along the intestinal motility, but sometimes in a retrograde (ascending) way. In practice, the small intestine can intrude into the small, small into the large, and thick into the large. Ileocecal intussusception is the most common. Together with the loop of invagination, the mesentery of the intestine is also exposed. As a result of circulatory disorders that have arisen in this area, as well as inflammatory edema, a tumor-like formation is formed, consisting of three cylindrical layers of the intestinal wall (simple invagination). Distinguish between the head of the invaginate (the upper border of the invading intestine) and its neck (the place where the outer layer passes into the middle one). Along with the general symptoms characteristic of acute intestinal obstruction (acute onset of cramping abdominal pain, vomiting, bloating, absence of stools and gases, visible peristalsis), intussusception also has its own specific signs - a palpable intussusceptum tumor and bloody-mucous stools.

31. Anatomical and physiological characteristics of the biliary zone

Liver (hepar) is located in the upper abdominal cavity, asymmetrically to the midline of the body, most of it occupies the right hypochondrium and epigastric region, and the smaller one is placed in the left hypochondrium.

The liver has a wedge-shaped shape, its upper, lower and posterior surfaces are distinguished. In the abdominal cavity, the liver is located mesoperitoneally. The upper surface of the liver is completely covered by the peritoneum, on the lower surface the peritoneal cover is absent only in the area of the furrows, the posterior surface is devoid of the peritoneal cover at a considerable distance.

The peritoneum covering the liver passes to neighboring organs and forms ligaments at the transition points, all of them, except for the hepatic-renal one, are double sheets of the peritoneum. These include the coronary, falciform, left triangular, right triangular, hepato-renal, hepato-gastric, hepato-duodenal ligaments.

Blood enters the liver through the hepatic artery and portal vein.

Common hepatic artery (a. hepatica communis) usually departs from the celiac artery and is located in the retroperitoneal space along the upper edge of the pancreas, then it is divided into proper hepatic and gastroduodenal arteries. In a number of people (30% of cases), accessory hepatic arteries participate in the arterial blood supply to the liver. Arterial blood rich in ki

oxygen, makes up one third of the volume of all blood entering the liver.

Portal vein (v. portae) collects blood from almost the entire intestine, stomach, pancreas and spleen. The volume of blood entering the liver through the portal vein reaches 2/3 of the circulating blood in this organ. It is rich in chemical products that form the basis of synthesis during digestion.

The portal vein is formed behind the pancreas, at the border of the transition of the head into the body of the gland, corresponding to the XNUMXst lumbar vertebra, and its roots are most often the superior mesenteric and splenic veins.

Gallbladder (vesica fellae) is located in the fossa vesicae fellae of the liver, has a spindle-shaped or pear-shaped shape, contains 40-60 ml of bile, its length is 5-13 cm, the width at the base is 3-4 cm. The ratio of the gallbladder to the peritoneum is not constant. The neck of the bladder is located at the gate of the liver and continues into the cystic duct. The blood supply to the gallbladder is carried out from the cystic artery (a. cystica), which most often departs from the right branch of the hepatic artery.

The bile ducts - external bile ducts - are a system of ducts that carry bile from the liver to the intestines. Their beginning consists of two trunks from the bile ducts (duct, hepaticus) of both hepatic lobes merging at an obtuse angle at the gates of the liver and the common hepatic duct (duct, hepaticus communis) created from them. The latter goes further down and to the right until it meets the gallbladder duct (duct, cysticus).

32. Pancreas

Pancreas (pancreas) is an oblong, prismatic organ in shape, located retroperitoneally and lying almost across the posterior wall of the abdominal cavity.

The pancreas plays an important role in the processes of digestion and metabolism. Its external secretory activity consists in the secretion of pancreatic juice into the duodenum.

Pancreatic juice has an alkaline reaction (pH 8,4) due to the presence of sodium bicarbonate and is a colorless liquid. During the day, the pancreas secretes 1500-2000 ml of pancreatic juice, and the liver - 500-1200 ml of bile.

The composition of pancreatic juice includes enzymes that are of great importance in the processes of digestion - trypsin, lipase, amylase, maltase, lactase, invertase, nuclease, as well as a small amount of trepsin and renin.

The main pancreatic duct (ductus Wirsungi) runs through the entire length of the pancreas from tail to head, closer to its posterior surface. It is formed from the fusion of small ducts of the lobules of the gland. In the head of the pancreas, this duct connects with the accessory duct (duct, accesso-rius, s. Santorini), and then, making a slight downward bend, penetrates the posterior wall of the descending part of the duodenum with the common bile duct, opens into papilla Fateri, which is located at 2-10 cm from the pylorus.

The relationship between duct. Wirsungi and duct. San-torini can be very different. The intimate relationship of the duct, choledochus with the head of the pancreas, the various relationships of the common bile duct with the main pancreatic duct and, finally, their connection with the duodenum are of great importance for understanding the mechanism of development of pathological processes in the pancreas, biliary tract and duodenum.

In some cases, the inflammatory process can move from the biliary tract to the pancreatic parenchyma, in others - from the pancreas to the bile ducts.

The sphincter of Oddi has powerful circular muscles around the common bile duct and longitudinal muscle fibers in its corner and in the pancreatic duct. Around the ampulla of Vater's papilla there is also a musculature consisting of circular and longitudinal muscle fibers.

A normally functioning sphincter tightly closes the entrance to both ducts, thereby preventing the penetration of contents from the intestine. Dysfunction of the sphincter can contribute to the development of pancreatitis.

Bile secretion is a specific function of the liver. Normally, a person secretes from 500 to 1200 ml of bile per day, but up to 4000 ml was obtained with a duodenal probe. Bile is involved in intestinal digestion: it helps to neutralize the acids of the food gruel coming from the stomach into the duodenum, splitting (hydrolysis) and absorption of fats and fat-soluble vitamins, and has an exciting effect on the peristalsis of the large intestine.

33. Liver research methods

All methods for examining the liver can be divided into three groups: laboratory, radiological and special.

Laboratory research methods. These include research:

1) pigment metabolism (bilirubin in blood, urine, stercobilin in feces, urobilin and bile acids in urine);

2) protein metabolism (determination of prothrombin);

3) serum enzymes - transaminases, alkaline phosphatase, lactate dehydrogenase;

4) excretory function of the liver (bromsulfalein test);

5) carbohydrate metabolism (test with galactose);

6) fat metabolism.

Laboratory biochemical methods for studying the functional state of the liver during a clinical examination of patients with hepatic pathology help to clarify the diagnosis, determine the severity of the condition, the activity of the pathological process, and make it possible to more accurately assess the effectiveness of treatment and make a prognosis.

X-ray research methods. Pneumoperitoneography - the introduction of gas into the abdominal cavity, followed by x-ray examination of the right subdiaphragmatic space.

Transumbilical portohepatography - the introduction of contrast agents into the portal system through the awakened umbilical vein, which lies extraperitoneally. This access is also used to measure intraportal pressure. Intraportal pressure with unchanged portal circulation averages 120-180 mm of water. Art., increasing it over 200 mm of water. Art. indicates portal hypertension.

After measuring intraportal pressure, transumbilical portohepatography is started.

Transumbilical manometry and portohepatography give a complete picture of the true numbers of intraportal pressure and more complete information about the vascular structure of the liver itself, about the trunk of the portal vein, the nature of intra- and extra-hepatic anastomoses and collaterals.

In particularly difficult cases, it is recommended to use a comprehensive angiographic study - transumbilical portohepatography and manometry in combination with splenoportography and splenomanometry.

ciliacography - selective angiography of the branches of the abdominal aorta. Recently, it has been increasingly used due to its diagnostic capabilities, and its most common method is puncture through the femoral artery according to Seldinger under local anesthesia with a 0,25% solution of novocaine. Ciliacography provides important data on the state of the arterial blood supply to the liver and spleen.

Direct portography - the introduction of a radiopaque substance into the mesenteric vessels - allows you to clarify the nature and degree of the disorder of the portal circulation (the state of the extra- and intra-hepatic portal bed), identify collaterals that are not contrasted with splenoportography, helps determine the amount of surgical intervention.

34. Liver biopsy and methods of examination of the gallbladder and bile ducts

Needle biopsy of the liver:

1) percutaneous, or blind, biopsy;

2) biopsy under the control of a laparoscope (targeted biopsy);

3) surgical, or open, biopsy.

Methods for the study of the gallbladder and bile ducts. Special methods for examining the gallbladder and bile ducts include chromatic duodenal sounding (Febres colorful test) and oral, intravenous or infusion cholegraphy.

During duodenal sounding using the colorful Febres test, the patient is given 14 g of methylene blue orally 0,15 hours before sounding and during this time it is forbidden to eat and drink. D. Febres (1942) found that methylene blue administered orally is excreted partly by the kidneys, partly by the liver. When excreted from the liver, it becomes colorless, but in the gallbladder it again turns into a chromogen and stains the gallbladder bile in a bluish-greenish color, portions "A" and "C" have the usual yellow color.

An important role is played by laboratory and microscopic examination of the obtained portions of bile ("A", "B", "C").

X-ray examination of the biliary tract in chronic cholecystitis makes it possible to establish calculous and non-calculous forms, to identify patients with a non-functioning (disabled) gallbladder.

Cholecystography is based on physiological mechanisms: the ability of the liver to extract some contrast agents from the blood and excrete with bile, and the gallbladder to concentrate them in its contents. Currently, for cholecystography, the oral route of administration of the contrast agent bilitrast is mainly used.

Cholegraphy - X-ray method of research, in which an image is obtained on the radiograph not only of the gallbladder, but also of the bile ducts.

Like cholecystography, cholegraphy is based on the ability of the liver to excrete organic iodine compounds from the blood with bile. For cholegraphy, contrast agents are used, with high hepatotropy, containing a lot of iodine (bilignost, adipiodone, cholegrafin, endographin, bilivpetan, etc.).

Intravenous holography. X-rays are taken within an hour every 15 minutes after the administration of the entire dose of the drug, then after 1,5-2 hours. The maximum intensity of the shadow of the bladder is observed 15-30 hours after the introduction of bilignost. After the patient has taken two egg yolks, the contractility of the gallbladder is studied.

Obese patients should use 20 ml of a 50% solution of biligrafin. Bilignost is administered to children at a dose of 0,1-0,3 g per 1 kg of body weight.

Cholangiography - X-ray method for examining the biliary tract after the introduction of a contrast agent directly into the gallbladder or into one of the bile ducts on the operating table (direct surgical cholangiography).

35. Acute cholecystitis

Acute cholecystitis - inflammation of the gallbladder. The following classification of acute cholecystitis is most acceptable.

I. Uncomplicated cholecystitis.

1) Catarrhal (simple) cholecystitis (calculous or acalculous), primary or exacerbation of chronic recurrent.

2) Destructive (calculous or acalculous), primary or exacerbation of chronic recurrent:

a) phlegmonous, phlegmonous-ulcerative;

b) gangrenous.

II. Complicated cholecystitis:

1) Occlusive (obstructive) cholecystitis (infected dropsy, phlegmon, empyema, gangrene of the gallbladder).

2) Perforated with symptoms of local or diffuse peritonitis.

3) Acute, complicated by lesions of the bile ducts:

a) choledocholithiasis, cholangitis;

b) stricture of the common bile duct, papillitis, stenosis of the papilla of Vater.

4) Acute cholecystopancreatitis.

5) Acute cholecystitis complicated by perforated bile peritonitis.

The main symptom in acute cholecystitis is pain, which occurs, as a rule, suddenly in full health, often after eating, at night during sleep. The pain is localized in the right hypochondrium, but can also spread to the epigastric region with irradiation to the right shoulder, scapula, supraclavicular region. In some cases, before its appearance, patients for several days, even weeks, feel heaviness in the epigastric region, bitterness in the mouth, and nausea. Severe pain is associated with the reaction of the gallbladder wall to an increase in its contents as a result of a violation of the outflow during inflammatory edema, an inflection of the cystic duct, or when the latter is blocked by a stone.

Often there is irradiation of pain in the region of the heart, then an attack of cholecystitis can proceed as an attack of angina pectoris (Botkin's cholecystocoronary syndrome). The pain is aggravated by the slightest physical exertion - talking, breathing, coughing.

There is vomiting (sometimes multiple) of a reflex nature, which does not bring relief to the patient.

On palpation, a sharp pain and muscle tension in the right upper square of the abdomen is determined, especially a sharp pain in the area of the gallbladder.

Objective symptoms are not equally expressed in all forms of acute cholecystitis. Increased heart rate up to 100-120 beats per minute, intoxication phenomena (dry, furred tongue) are characteristic of destructive cholecystitis. With complicated cholecystitis, the temperature reaches 38 ° C and above.

Blood analysis reveals leukocytosis, neutrophilia, lymphopenia, increased erythrocyte sedimentation rate.

36. Specific symptoms of acute cholecystitis, uncomplicated cholecystitis

Specific symptoms of acute cholecystitis include:

1) Grekov-Ortner symptom - percussion pain that appears in the gallbladder area with light tapping with the edge of the palm along the right costal arch;

2) Murphy's symptom - increased pain that occurs at the time of palpation of the gallbladder with a deep breath of the patient. The doctor places the thumb of the left hand below the costal arch, at the location of the gallbladder, and the remaining fingers - along the edge of the costal arch. If the patient's deep breath is interrupted before reaching the height, due to acute pain in the right hypochondrium under the thumb, then Murphy's symptom is positive;

3) symptom of Courvoisier - an increase in the gallbladder is determined by palpation of the elongated part of its bottom, which protrudes quite clearly from under the edge of the liver;

4) Pekarsky's symptom - pain when pressing on the xiphoid process. It is observed in chronic cholecystitis, its exacerbation and is associated with irritation of the solar plexus during the development of an inflammatory process in the gallbladder;

5) Mussi-Georgievsky symptom (phrenicus symptom) - pain on palpation in the supraclavicular region at a point located between the legs of the sternocleidomastoid muscle on the right;

6) Boas' symptom - soreness on palpation of the paravertebral zone at the level of IX-XI chest

vertebrae and 3 cm to the right of the spine. The presence of pain in this place with cholecystitis is associated with zones of Zakharyin-Ged hyperesthesia.

uncomplicated cholecystitis.

Catarrhal (simple) cholecystitis can be calculous or acalculous, primary or as an exacerbation of chronic recurrent. Clinically, in most cases it proceeds calmly. The pain is usually dull, appears gradually in the upper abdomen; amplifying, localized in the right hypochondrium.

On palpation, there is pain in the gallbladder area, there are also positive symptoms of Grekov-Ortner, Murphy. There are no peritoneal symptoms, the number of leukocytes is within 8,0-10,0 G 109/l, the temperature is 37,6 °C, rarely up to 38 °C, there are no chills.

Attacks of pain last for several days, but after conservative treatment they disappear.

Acute destructive cholecystitis can be calculous or acalculous, primary or exacerbation of chronic recurrent.

Destruction can be phlegmonous, phlegmonous-ulcerative or gangrenous in nature.

With phlegmonous cholecystitis, the pain is constant, intense. Dry tongue, repeated vomiting. There may be a slight yellowness of the sclera, soft palate, which is due to infiltration of the hepatoduodenal ligament and inflammatory edema of the mucous membrane of the bile ducts.

37. Complicated cholecystitis

Occlusive (obstructive) cholecystitis develops when the cystic duct is blocked by a calculus and initially manifests itself as a typical picture of biliary colic, which is the most characteristic sign of cholelithiasis. A sharp pain occurs suddenly in the right hypochondrium with irradiation to the right shoulder, scapula, to the region of the heart and behind the sternum. Patients behave uneasily, vomiting appears at the height of the attack, sometimes multiple. The abdomen may be soft, while a sharply painful, enlarged and tense gallbladder is palpated.

An attack of biliary colic can last several hours or 1-2 days, and when the stone returns to the gallbladder, it suddenly ends. With prolonged blockage of the cystic duct and infection, destructive cholecystitis develops.

Perforated cholecystitis proceeds with the phenomena of local or diffuse peritonitis. The moment of perforation of the gallbladder may go unnoticed by the patient. If adjacent organs are soldered to the gallbladder - the greater omentum, the hepatoduodenal ligament, the transverse colon and its mesentery, that is, the process is limited, then complications such as subhepatic abscess, local limited peritonitis develop.

Acute cholecystitis, complicated by lesions of the bile ducts, can occur with clinical manifestations of choledocholithiasis, cholangitis, choledochal stricture, papillitis, stenosis of the Vater nipple. The main symptom of this form is obstructive jaundice, the most common cause of which is the calculi of the common bile duct, which obstruct its lumen.

When the common bile duct is blocked by a stone, the disease begins with acute pain, characteristic of acute calculous cholecystitis, with typical irradiation. Then, after a few hours or the next day, obstructive jaundice appears, which becomes persistent, accompanied by severe skin itching, dark urine and discolored (acholic) putty-like feces.

Due to the accession of the infection and its spread to the bile ducts, symptoms of acute cholangitis develop. Acute purulent cholangitis is characterized by severe intoxication - general weakness, lack of appetite, icteric coloration of the skin and mucous membranes. Constant dull pain in the right hypochondrium radiating to the right half of the back, heaviness in the right hypochondrium, with tapping on the right costal arch - a sharp pain. The body temperature rises in a remitting type, with profuse sweating and chills. Tongue dry, furred. The liver on palpation is enlarged, painful, soft consistency. Leukocytosis is noted with a shift of the leukocyte formula to the left. In a biochemical study of blood, an increase in the content of direct bilirubin and a decrease in the content of prothrombin in the blood plasma are observed. The disease can be complicated by life-threatening cholemic bleeding and liver failure.

38. Differential diagnosis and treatment of acute cholecystitis

Differential diagnosis. Acute cholecystitis must be differentiated from perforated gastric and duodenal ulcers, acute pancreatitis, acute appendicitis, acute coronary insufficiency, myocardial infarction, acute intestinal obstruction, pneumonia, pleurisy, thrombosis of mesenteric vessels, nephrolithiasis with localization of the calculus in the right kidney or right ureter, and also with liver diseases (hepatitis, cirrhosis) and biliary dyskinesia. Biliary dyskinesia must be differentiated from acute cholecystitis, which is of practical importance for the surgeon in the treatment of this disease. Dyskinesia of the biliary tract is a violation of their physiological functions, leading to stagnation of bile in them, and later to the disease. Dyskinesia in the biliary tract mainly consists of disorders of the gallbladder and the closing apparatus of the lower end of the common bile duct.

Dyskinesia includes:

1) atonic and hypotonic gallbladders;

2) hypertonic gall bladders;

3) hypertension and spasm of the sphincter of Oddi;

4) atony and insufficiency of the sphincter of Oddi. The use of cholangiography before surgery makes it possible to recognize the main varieties of these disorders in patients.

Duodenal sounding makes it possible to establish the diagnosis of an atonic gallbladder if there is an abnormally abundant outflow of intensely colored bile that occurs immediately or only after the second or third administration of magnesium sulfate.

With cholecystography in the position of the patient on the stomach, the cholecystogram shows a picture of a flabby elongated bladder, expanded and giving a more intense shadow at the bottom, where all the bile is collected.

Treatment. When the diagnosis of "acute cholecystitis" is established, the patient must be urgently hospitalized in a surgical hospital. All operations for acute cholecystitis are divided into emergency, urgent and delayed. Emergency operations are carried out according to vital indications in connection with a clear diagnosis of perforation, gangrene or phlegmon of the gallbladder, urgent operations - with the failure of vigorous conservative treatment during the first 24-48 hours from the onset of the disease.

Operations are performed in a period of 5 to 14 days and later with a subsiding attack of acute cholecystitis and an observed improvement in the patient's condition, i.e., in the phase of reducing the severity of the inflammatory process.

The main operation in the surgical treatment of acute cholecystitis is cholecystectomy, which, according to indications, is supplemented by external or internal drainage of the biliary tract. There is no reason to expand the indications for cholecystostomy.

Indications for choledochotomy - obstructive jaundice, cholangitis, impaired patency in the distal sections of the common bile duct, stones in the ducts.

39. Liver abscesses

Suppurative processes in the liver develop as a result of infection entering it by the hematogenous route from various organs: more often through the portal vein system, through which blood is drained to the liver from the abdominal organs, less often through the hepatic artery with a general purulent infection.

The appearance of abscesses in the liver is also possible when the infection passes from adjacent organs: as a result of a breakthrough of the gallbladder empyema into the liver, penetration of a stomach or duodenal ulcer into the liver, direct infection with a knife or gunshot wound to the liver.

In the vast majority of cases, so-called solitary abscesses occur, when there is only one cavity in the hepatic parenchyma, located subcapsularly. In some cases, there are also multiple non-communicating abscesses (small in size).

Early diagnosis of pyogenic liver abscesses is very difficult, since one of the main symptoms - liver enlargement - often appears very late. In the initial stage of the disease, the liver is almost painless on palpation, if the peritoneum and gallbladder are not involved in the process. It is necessary to take into account past sepsis, purulent lesions of the abdominal organs, etc.

In the initial stage of the disease, patients complain of dull pain in the right hypochondrium, epigastric region, aggravated by pressure. Pain radiates to the right shoulder, shoulder blade, back, diaphragm mobility is limited, breathing becomes difficult.

In patients with a strong increase in the liver, the gait changes. In bed, they usually lie motionless on their right side with legs bent and drawn to the stomach. The temperature in the evenings rises to 38-40 °C. K. G. Tagibekov notes that in severe, advanced cases, when the purulent cavity reaches a large size, an increase in temperature often follows tremendous chills, sometimes profuse sweats.

With large abscesses with a long course, the liver increases sharply, pain is noted during its palpation.

If a liver abscess is not diagnosed for a long time, the patient's strength quickly dries up - there is a subecternity, asymmetry of the abdomen and chest. Locally, there is some tension in the muscles of the anterior abdominal wall, pain in the right hypochondrium and chest on the right during palpation and tapping.

When analyzing blood, leukocytosis is noted (18,0-20,0 G 109/l) with a shift of the leukocyte count to the left. The pulse is usually weak filling and often reaches 120-130 beats per minute.

It helps to establish the diagnosis and x-ray examination, which is characterized by three main signs: an increase in the shadow of the liver, an increase in mobility and a rise in the diaphragm. Currently, the method of radioisotope hepatoscanning is successfully used, on the scan of the liver, abscesses appear as "silent fields".

With the localization of an abscess in the anterior parts of the liver, intra-abdominal intervention is performed.

40. Tumors of the liver

All tumors are divided into malignant and benign.

Malignant tumors

I. Primary:

1) cancer:

a) hepatoma - a tumor of the liver cells;

b) cholangioma - a tumor from the cells of the bile ducts;

c) cholangiohepatoma - a tumor containing cells of both types;

2) sarcoma:

a) angiosarcoma (sarcoma and endothelial cells);

b) alveolar sarcoma;

c) spindle cell sarcoma;

d) round cell sarcoma;

e) lymphosarcoma.

II. Metastatic:

1) cancer;

2) sarcoma.

Benign tumors

I. Epithelial:

1) benign hepatoma;

2) benign cholangioma (solid type and cystic);

3) benign cholangiohepatoma.

II. Mesenchial:

1) hemangioma;

2) hemangioendothelioma.

Primary tumors occur in the form of massive cancer of the nodular form and cancerous cirrhosis (diffuse cancerous infiltration). According to A. L. Myasnikov, cirrhosis of the liver in 75% of cases precedes the onset of primary liver cancer. BM Tareev attaches great importance to epidemic hepatitis in the origin of primary liver cancer. In addition, parasitic diseases (in particular, opisthorchiasis), chronic hepatitis, cholelithiasis, syphilis, and alcoholism contribute to the emergence of primary liver cancer.

The disease develops gradually, patients begin to lose weight quickly, there are pains in the right hypochondrium, nausea, vomiting, diarrhea, sometimes, on the contrary, constipation. Appetite decreases, temperature rises, jaundice appears. Pain in the right hypochondrium in most cases of a aching nature, less often - paroxysmal. The liver is enlarged (sometimes up to the pubis), of dense consistency, bumpy. Ascites occurs, the cause of which many see in tumor thrombosis of the portal vein or compression of its lymph nodes; in other cases, its occurrence is due to cirrhosis of the liver and carcinomatosis.

The diagnosis of primary liver cancer is made on the basis of the above symptoms, palpation of the tumor, x-ray data (chest x-ray to study the right dome of the diaphragm: its high standing, deformity).

41. Portal hypertension syndrome

It characterizes a complex of changes that occur when blood flow in the portal system is obstructed due to various diseases.

The main changes in portal hypertension syndrome:

1) the presence of high portal pressure with slow blood flow;

2) splenomegaly;

3) varicose veins of the esophagus, stomach and bleeding from them;

4) expansion of the veins of the anterior abdominal wall;

5) expansion of hemorrhoidal veins;

6) ascites.

Classification of portal hypertension

1. Suprahepatic blockade of portal circulation:

1) Peak cirrhosis of cardiac origin;

2) Chiari disease (thrombosis of the hepatic veins);

3) Budd-Chiari syndrome (thrombosis of the inferior vena cava at the level of the hepatic veins, stenosis or obliteration of it above the hepatic veins, compression by a tumor, scars).

2. Intrahepatic blockade of portal circulation:

1) cirrhosis of the liver of various forms - portal, postnecrotic, biliary, mixed;

2) liver tumors (vascular, parasitic, glandular);

3) liver fibrosis (portal, cicatricial, after trauma, local inflammatory processes).

3. Extrahepatic blockade of portal circulation:

1) phlebosclerosis, obliteration, thrombosis of the portal vein or its branches;

2) congenital stenosis or atresia of the portal vein or its branches; 3) compression of the portal vein or its branches by scars, tumors, infiltrates.

4. Mixed form of blockade of portal circulation:

1) cirrhosis of the liver in combination with thrombosis of the portal vein (primary cirrhosis of the liver, thrombosis of the portal vein as a complication);

2) portal vein thrombosis with liver cirrhosis. The first is compensated (initial), which is characterized by a moderate increase in portal pressure, compensated intrahepatic circulation, splenomegaly with or without hypersplenism.

The second is subcompensated, in which there are high portal pressure, splenomegaly, varicose veins of the esophagus and stomach with or without bleeding from them, and pronounced disturbances in the portohepatic circulation.

The third is decompensated, in which there are splenomegaly, varicose veins of the esophagus and stomach with or without bleeding from them, ascites, severe disorders in the port-hepatic and central circulation.

42. Acute pancreatitis

The term "acute pancreatitis" means not only inflammation of the pancreas, but also its acute disease, accompanied by necrosis of the parenchyma of the gland and adipose tissue, as well as extensive hemorrhages in the pancreas and retroperitoneal tissue.

In the etiology of acute pancreatitis, the following factors are of great importance: diseases of the biliary tract, stomach and duodenum, alcohol intake, circulatory disorders in the pancreas, overnutrition and metabolic disorders, allergies, abdominal trauma, chemical poisoning, infectious and toxic factors.

The disease begins suddenly after a rich fatty and protein food, accompanied by alcohol intake. Leading is the abdominal syndrome (pain, vomiting, dynamic intestinal obstruction).

Pain - one of the most constant symptoms of acute pancreatitis - is inherent in all forms of this disease. Excruciating pains occur in the epigastric region, in the navel region with irradiation to the lower back, shoulder blade, shoulders, and sometimes thighs. Girdle pain is the main subjective sign of this terrible disease.

Vomiting is the second most common symptom of abdominal syndrome. However, its absence cannot remove the diagnosis of acute pancreatitis. Most often, vomiting is continuous, bitter (with an admixture of bile), sometimes repeated and painful, so some patients suffer more from vomiting than from pain.

From the very beginning of the disease, the tongue is covered with a white coating, with the development of peritonitis it becomes dry.

The greatest number of symptoms of abdominal syndrome is detected during an objective examination of the abdomen.

On examination, the abdomen is swollen in the epigastric region, there is no peristalsis due to intestinal paresis. On palpation, there is a sharp pain in the epigastric region, no tension in the anterior abdominal wall is observed. Symptoms of Resurrection, Kerte, Mayo-Robson are positive.

Voskresensky's symptom - the absence of pulsation of the abdominal aorta above the navel as a result of compression of the aorta by the edematous pancreas.

Symptom Kerte - transverse soreness and resistance 6-7 cm above the navel, corresponding to the projection of the pancreas.

Mayo-Robson's symptom - pain in the left costovertebral angle.

Pancreatocardiovascular syndrome includes a number of symptoms indicating the degree of involvement of the cardiovascular system in pancreatic disease. At the same time, general cyanosis is observed with pouring sweat, cooling of the whole body and especially the limbs, a thready pulse, a drop in blood pressure, i.e., with signs of severe collapse.

In a severe form of pancreatitis, the diaphragm is involved in the process, its excursion is difficult, the high standing of the dome is noted, breathing becomes superficial and rapid. An early leading sign of acute pancreatitis is shortness of breath.

43. Acute pancreatic edema, hemorrhagic pancreatitis, pancreatic necrosis

Acute swelling of the pancreas (acute interstitial pancreatitis)

This is the initial stage of acute pancreatitis. The disease usually begins with pronounced persistent pain in the epigastric region, which most often occurs suddenly, sometimes they are cramping. Most patients associate their appearance with a plentiful intake of fatty foods, while the pains are so strong that the patients scream and rush about in bed. Pain can be stopped by bilateral pararenal blockade or slow intravenous injection of 20-30 ml of a 0,5% solution of novocaine. Following the pain, as a rule, vomiting appears, the temperature rises.

During pain, the abdomen participates in the act of breathing, is somewhat swollen, palpation reveals soreness and stiffness of the muscles in the epigastric region, there are no symptoms of peritoneal irritation. The content of L-amylase in urine usually reaches 320-640 g/l, in some cases even higher figures. When examining blood, the number of leukocytes fluctuates within 8,0-12,0 х 109/l without any significant changes in the leukocyte formula.

Acute edema of the pancreas is often accompanied by inflammation of the gallbladder.

Hemorrhagic pancreatitis

At the onset of the disease, the clinical picture of hemorrhagic pancreatitis is similar to that of acute edema. The disease begins with severe pain with characteristic irradiation upwards, to the left, which are then joined by excruciating vomiting. As a rule, the general condition of such patients is severe. Visible mucous membranes and skin are pale, intoxication is pronounced, the pulse is quickened (100-130 beats per minute), weak filling and tension, the tongue is coated, dry, the stomach is swollen, there is a slight muscle tension in the epigastric region, symptoms of Voskresensky, Mayo-Robson , Kerte are positive. Dynamic intestinal obstruction is observed.

Pancreatic necrosis

The disease is acute, severe. It either passes from the stage of pancreatic edema, or begins on its own immediately with necrosis. Pancreatic necrosis is characterized by severe pain with severe intoxication, collapse and shock, peritoneal tension due to effusion, and the development of chemical peritonitis. Leukocytosis is pronounced with a shift of the leukocyte formula to the left, lymphopenia, elevated ESR. Many patients have protein, leukocytes, erythrocytes, squamous epithelium, and sometimes hyaline casts in the urine. L-amylase in the urine usually reaches high numbers, but with extensive necrosis of the pancreatic parenchyma, its content drops.

It is difficult to establish the diagnosis of hemorrhagic necrosis of the pancreas when the process captures the posterior surface of the pancreas. At the same time, the symptoms from the abdominal cavity are not very pronounced, since the process develops retroperitoneally. However, in these patients, the disease begins with a typical localization and recoil of pain, while there is a pronounced intoxication.

44. Differential diagnosis and treatment of pancreatitis

Acute pancreatitis must be differentiated from acute cholecystitis, perforated gastric ulcer, food intoxication, acute intestinal obstruction, mesenteric vascular thrombosis, ectopic pregnancy, acute appendicitis, and myocardial infarction.

In the treatment of acute pancreatitis, all measures should be directed to the main etiopathogenetic factors: perirenal blockade with 0,25% novocaine solution according to Vishnevsky as an effect on neuroreceptor factors; creation of physiological rest to the affected organ - hunger, aspiration of gastric contents (probe through the nose); inhibition of the secretory activity of the pancreas - atropine 0,1% subcutaneously, 1 ml every 4-6 hours; intravenous administration of blood, plasma, polyglucin-novocaine mixture (polyglucin 50 ml + 1% solution of novocaine 20 ml) up to 3-4 liters in order to eliminate circulatory disorders. Antienzymatic therapy - trasilol, tsalol, contrical (50-000 units, some recommend up to 75 units per injection), sandostatin, kvamatel; to eliminate pain - promedol (it is not recommended to use morphine, as it causes spasm of the sphincter of Oddi), diphenhydramine 000% - 300-000 times a day as an antihistamine; insulin - 2-2 units, 3% papaverine 4-12 times, nitroglycerin 2 g in tablets under the tongue; aminocaproic acid 2% in an isotonic sodium chloride solution intravenously, 3 ml; corticosteroid hormones - hydrocortisone or prednisolone (intravenously or intramuscularly - 0,0005-5 mg); antibacterial therapy, cardiac (100% strophanthin but 15-30 ml 0,05 times, 0,5% corglicon 1-2 ml 0,05 time).

When the condition improves on the 4-5th day, patients can be prescribed table No. 5a, i.e. food in liquid form with a limited calorie content, since carbohydrate-protein fat-free food reduces the secretion of the pancreas. The alkali that comes with food through the mouth also inhibits the separation of pancreatic juice.

On the 8-10th day, patients can be given table No. 5 and fractional meals should be recommended. Upon discharge from the hospital, it is forbidden to consume fatty and fried meat, spicy and sour dishes, seasonings for 1-2 months.

Surgery consists of the following steps:

1) median laparotomy (incision along the midline from the xiphoid process to the navel);

2) approach to the pancreas into the cavity of the omental sac, preferably through the gastrocolic ligament (the most direct and convenient way for draining the pancreas);

3) removal of exudate from the abdominal cavity with electric suction and gauze swabs;

4) dissection of the peritoneum covering the gland;

5) drainage of the cavity of the stuffing bag with tampons and a rubber tube.

45. Chronic pancreatitis

There are recurrent and primary chronic pancreatitis. A. V. Smirnov, O. B. Porembsky, D. I. Frid (1972) indicate that chronic pancreatitis, not associated with diseases of the biliary tract, is characterized by:

1) the rapid development of endocrine and metabolic disorders due to violations of external and internal secretion of the pancreas;

2) the occurrence of necrotic changes in the acute phase, followed by the formation of pancreatic pseudocysts;

3) relatively often observed formation of stones in the ducts and parenchyma of the pancreas.

An important factor in the pathogenesis of chronic pancreatitis is a violation of the outflow of pancreatic juice, stasis in the pancreatic duct system, various vascular disorders play a certain role. Some researchers attach great importance to metabolic factors in the genesis of chronic pancreatitis, others consider alcoholism one of the most important factors contributing to its occurrence.

Clinical manifestations of chronic pancreatitis:

1) pain syndrome;

2) violations of the exocrine function of the pancreas;

3) violations of the insular apparatus;

4) symptoms of complications of pancreatitis caused by biliary hypertension, the formation of cysts and fistulas of the pancreas, portal hypertension, etc.

One of the main and earliest symptoms of chronic pancreatitis is pain in the upper abdomen radiating to the lower back, left shoulder, left shoulder blade, left shoulder girdle. It can be constant, incessant, painful, can be aggravated after eating fatty, hot or cold foods, occur at night and often resemble the pain of a duodenal ulcer. The pain syndrome can also be expressed in the form of recurrent attacks of pancreatic colic. A painful attack is associated with difficulty in the outflow of pancreatic juice, which causes hypertension in the pancreatic ducts.

On palpation, the abdomen is usually soft, painful in the upper section and in the projection of the pancreas.

In addition to pain with typical localization, patients have a feeling of heaviness in the epigastric region after eating, belching, bloating, stool retention, constipation, in some patients - dyspeptic disorders, vomiting, loss of appetite.

In connection with the violation of the digestion and absorption of fats and proteins, insufficient absorption of nutrients and vitamins in the intestines and a disorder of pancreatic secretion, weight loss occurs, despite the fact that the appetite is preserved or even increased.

In chronic pancreatitis, a violation of the endocrine function of the pancreas is possible, manifested more often by the development of symptoms of diabetes mellitus and less often by hypoglycemia.

46. Cysts and pancreatic cancer

Cysts of the pancreas

Most surgeons adhere to the following classification:

1) false cysts:

a) inflammatory origin (after acute and chronic pancreatitis);

b) after trauma - blunt, penetrating wound, operating room;

c) in connection with a neoplasm;

d) parasitic (roundworm);

e) idiopathic;

2) true cysts:

a) congenital - simple cyst, polycystic disease, fibrocystic disease, dermoid cyst;

b) acquired - retention cysts (inflammatory origin, post-traumatic, secondary parasitic (ascariasis), parasitic (echinococcus, tapeworm);

c) tumor - benign (cystadenoma) vascular cyst, malignant - cystadeno-carcinoma, teratoma.

False cyst - a cyst located inside the pancreas or on it, lined with fibrous tissue. The inner surface of the cyst does not have an epithelial cover, and its contents are pancreatic juice.

Clinically, a false cyst of the pancreas is manifested by pain in the epigastric region or the left side of the abdomen. There is nausea, vomiting, loss of appetite. Some patients are asymptomatic.

X-ray examination of the gastrointestinal tract, tomography of the pancreas with retropneumoperitoneum, as well as scanning helps to establish the diagnosis.

In the surgical treatment of a false cyst, two operations are mainly used - excision and drainage of the cyst (external or internal).

Pancreas cancer

Pancreatic cancer can be primary, secondary - with the transition of the cancer process from the stomach, biliary tract and metastatic - with cancer of the esophagus, duodenum and colon.

The growth and spread of pancreatic cancer occurs in the following ways:

1) germination in the surrounding organs and tissues, when the cancer captures the duodenum, stomach, colon and left kidney;

2) along the lymphatic tracts, especially perineural and perivasal.

Pain of varying intensity (an early symptom of pancreatic cancer) is localized in the upper abdomen, spreading to the lower back. Along with pain, there is often a loss of appetite, there may be nausea, vomiting, feces become discolored, urine becomes the color of beer. Some patients develop itching. The patient loses weight. Pain and weight loss are followed by jaundice.

With the localization of cancer in the head of the pancreas, there may be a positive symptom of Courvoisier. In patients, ascites is determined, which is associated with portal hypertension or with the spread of a cancerous process in the peritoneum.

47. Endemic goiter

This is a disease of the whole body, which is accompanied by an increase in the thyroid gland. It occurs constantly within certain geographical boundaries and has its own patterns of development. It is now well known that endemic goiter is closely associated with iodine deficiency. As A.P. Vinogradov notes, endemic goiter occurs in "biogeochemical provinces", which are characterized by a low content of iodine in soil, water, food, and, as a result, in the human body. At the same time, normal metabolic processes in the human body are disturbed due to insufficient synthesis of iodinated thyroid hormones (thyroxine, triiodothyronine), which are the main iodine concentrators. Endemic goiter in women is more common than in men, and develops against the background of an enlarged thyroid gland. It is especially common during puberty, during menstruation and pregnancy. Its development is also affected by unfavorable sanitary and hygienic conditions.

One of the methods for determining the enlargement of the thyroid gland is to examine it during swallowing. When swallowing, it is possible to determine the external shape, size and consistency of the thyroid gland.

Symptoms of the clinical manifestation of endemic goiter mainly depend on its location and size. Relatively often there is a displacement of the trachea in the direction opposite to the location of the goiter, which can be established by X-ray examination. The most common disorder

breathing occurs with the retrosternal location of the goiter, which is characterized by an increase in shortness of breath when turning the head. When the goiter is located in the posterior mediastinum, dysphagia (difficulty swallowing) may occur due to pressure on the esophagus.

An in-depth and thorough examination of patients with endemic goiter reveals a number of common disorders of the nervous, cardiovascular and reproductive systems. Hypotension and, as a result, increased fatigue, weakness, palpitations, dizziness are noted.

Most often, endemic goiter develops slowly and gradually, however, under the influence of certain factors (nervous strain, change of residence, nature of work, injuries, childbirth, abortion, lactation), the progression of the disease can accelerate.

Endemic goiter can change from euthyroid to hyperthyroid form, give hemorrhages into the thyroid parenchyma (into cysts or nodes), go into a malignant form (most often into thyroid cancer).

Treatment. Conservative therapeutic treatment of endemic goiter is carried out mainly in the early stages of the disease with diffuse forms of goiter, especially in childhood and young age. This treatment can be considered as a preoperative preparation in the presence of nodular goiter in individuals who are indicated for surgical treatment.

The most reasonable and effective method of treating endemic goiter is with thyroid hormones (thyroxine, triiodothyronine) or the corresponding hormonal drug - thyroidin.

48. Diffuse toxic goiter

This form has many names, which are based either on the names of the authors who described it (Basedow's, Perry's, Grevs', Flayani's disease), or individual manifestations of the disease (thyrotoxicosis, hyperthyroidism, etc.).

Mental disorders occupy one of the leading places in the manifestation of toxic goiter. These patients are restless, fussy, anxious, timid and indecisive. Patients with thyrotoxicosis are characterized by increased excitability, irascibility, irritability, excessive mood lability, a tendency to a sad mood, resentment, increased fatigue, unmotivated mood swings, attacks of melancholy that appear without an external reason, and the absence of intellectual impairment.

According to a number of authors involved in the treatment of patients with toxic goiter, neuropsychiatric disorders are caused by the direct effect of excessively produced thyroid hormones on the nervous system as a whole.

Mental and physical performance of patients is significantly reduced. They are unable to focus their attention on any subject for a long time, they are easily exhausted, distracted. They seem to have an accelerated flow of thoughts. Patients instantly give answers, even if they are mistaken. Most patients suffer from insomnia, sleep is short, disturbing, not having a sufficiently refreshing effect on them.

Patients with thyrotoxicosis have ocular symptoms. One of the most common (but optional) is exophthalmos. In addition to bulging, a number of symptoms are characteristic, such as the expansion of the palpebral fissures (Delrim-Pl's symptom), rare blinking (Stelwag's symptom), the appearance of a white strip of sclera above the iris when the eyeball moves downward (Graefe's symptom), deviation outward of the eyeball when fixing vision at close range (Mobius sign), absence of wrinkling of the forehead when looking up (Geofroy sign).

In some patients, cardiovascular disorders come to the fore, while they complain of shortness of breath, palpitations, which increase even with slight physical exertion, excitement. There are intermittent aching, stabbing pains in the region of the heart without characteristic irradiation.

Patients feel the pulsation of blood vessels in the neck, head. Elderly patients experience angina pectoris with radiating to the left arm, shoulder blade, behind the sternum. Their heartbeat is constant at rest and during sleep. The pulse rate can reach up to 120-160 beats per minute.

If a patient with primary thyrotoxicosis develops atrial fibrillation during dynamic observation, then its cause is toxic goiter. However, after surgery for toxic goiter, even in the elderly, where the cause of atrial fibrillation was thyrotoxicosis, it is removed with medication before surgery.

In the absence of severe atherosclerosis of the coronary vessels, pain in the region of the heart in thyrotoxicosis is never complicated by thrombosis of the coronary vessels.

49. Classification of the severity of thyrotoxicosis

VG Baranov, VV Potin distinguish three degrees of severity of thyrotoxicosis.

I. Mild degree (SBI 9,4 ± 0,3 μg%) - mild symptoms, slight weight loss, moderate tachycardia (no more than 100 beats per minute), basal metabolic rate does not exceed + 30%;

II. Moderately severe (SBI 12,1 ± 0,4 μg%) - clearly expressed symptoms and weight loss, tachycardia (100-120 beats per minute), basal metabolism ranges from +30 to -60%.

III. Severe degree (SBI 16,3 ± 1,7 μg%) - pronounced symptoms, rapidly progressive weight loss with significant weight loss, tachycardia (over 120 beats per minute), basal metabolic rate exceeds +60%.

Regardless of the intensity of thyrotoxicosis, grade III includes its complicated forms - atrial fibrillation, heart failure, thyrotoxic liver damage, etc. Patients have muscle weakness, trembling of the whole body and its individual parts (eyelids, limbs, head, torso). Particularly characteristic is the frequent small involuntary trembling of the fingers of outstretched hands (with a relaxed hand), which is aggravated by excitement, fatigue and exacerbation of the thyrotoxic process.

There is a violation of thermoregulation, with a severe form of thyrotoxicosis, the temperature reaches 37,6-37,8 ° C. The nature of the temperature is thermoneurotic. Patients do not tolerate heat and thermal procedures, under the influence of which thyrotoxicosis can worsen. In addition, there is increased sweating, which, in severe form, can be so pronounced that it does not give patients rest day or night.

With thyrotoxicosis, all types of metabolism are increased, especially fat and water, fats burn intensively, the body loses a large amount of water. All this leads to drastic weight loss. Often weight loss is one of the first symptoms of thyrotoxicosis. If, in violation of metabolism, the breakdown of proteins is simultaneously increased, then emaciation and weakness are sharply expressed in patients.

The causes of toxic goiter in childhood and adolescence are the same as in adults, but mental trauma does not occupy such a significant place in them.

Symptoms are the same as in adults. However, here in the first place are the symptoms associated with insufficiency of the adrenal cortex - general weakness, fatigue, severe pigmentation of the skin, low diastolic (minimal) blood pressure, sometimes reaching 0.

The clinic of toxic goiter in the elderly is very diverse, but it is distinguished by a more pronounced manifestation of symptoms, the duration of the disease. With a long course of the disease, there are significant changes in the nervous, cardiovascular systems, in parenchymal organs.

50. Nodular toxic goiter

The disease is characterized by the formation in one of the lobes of the thyroid gland of a single node, reaching the size of III-IV degree, with a sharply increased functional activity and a decrease in the function of the rest of the thyroid gland. Women are more likely to get sick, older and middle-aged people are more prone to this disease.

Clinically, toxic adenoma is marked by a little noticeable onset, manifests itself gradually. Its initial symptoms: general weakness, fatigue, irritability, palpitations, weight loss. Then the disease progresses rapidly: efficiency decreases, headaches, sweating, increased heart rate, trembling fingers of outstretched hands appear, an increase in skin moisture is noted. Eye symptoms in toxic adenoma are mild or completely absent.

When examining the neck on its front surface in one of the lobes, a round or oval node is palpated, elastic, painless, with a smooth surface, not soldered to the surrounding tissues, participating in the act of swallowing.

The clinical course of toxic goiter largely depends on the predominant involvement in the pathological process of one or another system - neuropsychic, cardiovascular, etc. A certain role is played by the constitutional features of the organism, the age of patients, life and other factors of the external and internal environment of the body.

All methods of treatment of diffuse toxic goiter must be divided into two groups: therapeutic treatment with drugs and radioactive iodine and surgical. In some cases, therapeutic treatment is a method of preoperative preparation. There are deadlines for medical treatment, in case of ineffectiveness of which patients should be operated on.

Drug treatment. Treatment of diffuse toxic goiter, especially its severe and moderate forms, is a rather difficult task, since a number of vital organs and systems are involved in the pathological process.

In severe and moderate forms of the disease, treatment should begin in a hospital setting.

A patient with thyrotoxicosis must be provided with a deep 9-12-hour sleep, which is achieved by prescribing bromides, hypnotics.

For the treatment of primary thyrotoxicosis, bromides are used, since they have a calming effect on the nervous system by weakening the irritable cortical process. Treatment should begin with the appointment of bromides 1 tsp. 2 times a day (0,1 g per day), if necessary, gradually increasing the dose to 1,2 g per day - 2% sodium bromide (1 tsp 3 times a day).

In primary thyrotoxicosis, a number of specific drugs have been proposed to affect the central nervous system and its peripheral parts. However, in terms of the effectiveness of the action, the most widely used alkaloid from the rauwolfia plant is reserpine, which has parasympathomimetic properties.

51. Treatment with antithyroid drugs, surgical treatment

Various doses of iodine have been proposed for the treatment of primary diffuse toxic goiter. Quite effective for varying severity of primary thyrotoxicosis doses of 0,0005-0,001 g of iodine and 0,005-0,01 g of potassium iodide per day, usually prescribed in pills or mixture.

Thyrostatic (antithyroid) drugs - mercazolil and potassium perchlorate - are widely used in clinical practice.

Mercazolil is a very effective thyrostatic substance. It reduces the synthesis of thyroxine and triiodothyronine in the thyroid gland, as a result of which it has a specific therapeutic effect in case of its hyperfunction, causing a decrease in basal metabolism.

In mild and moderate forms of thyrotoxicosis, 0,005 g of Mercazolil is prescribed 2-3 times a day. When removing the symptoms of thyrotoxicosis, it is necessary for a long time to take a maintenance dose of the drug (up to several months) at 0,0025-0,005 g per day daily or 2-3 times a week until a stable therapeutic effect is obtained.

The use of Mercazolil in diffuse toxic goiter in combination with reserpine (0,25 mg 2-4 times a day) is very effective, while in some cases the dose of Mercazolil can be reduced to 0,005 g 2 times a day.

Potassium perchlorate is also an antithyroid (thyreostatic) agent. Its thyrostatic effect is associated with inhibition of the thyroid gland to accumulate iodine, which leads to inhibition of the formation of tetra- and triiodothyronine. According to its thyreostatic action, it is less effective than Mercazolil. It is prescribed for mild and moderate forms of toxic goiter in persons with a short duration of the disease.

Surgery. In cases where therapeutic treatment of diffuse toxic goiter does not work for 8-10 months, surgical treatment is indicated. The sooner the operation is performed, the faster and more fully the disturbed functions of the body will be restored and the faster compensation will come. Therefore, the operation for toxic goiter must be carried out before the onset of decompensation in various organs and systems. Acute forms of thyrotoxicosis with unsuccessful therapeutic treatment are operated on no later than 3 months from the start of treatment.

Currently, contraindications to surgical treatment of toxic goiter are sharply narrowed. The operation is contraindicated after a recent myocardial infarction, with acute cerebrovascular accident. In acute inflammatory diseases of various localizations, there are temporary contraindications. The advanced age of patients with toxic goiter is not a contraindication to surgical treatment, however, these patients need especially careful preoperative preparation, which should be carried out taking into account possible concomitant diseases.

Patients with nodular toxic goiter need the same thorough preoperative preparation as with diffuse toxic goiter, and its duration and intensity are determined individually.

52. Hypothyroidism, myxedema, classification of thyroid cancer

Hypothyroidism and myxedema

Hypothyroidism is a disease of the thyroid gland, due to the insufficiency of its function.

Distinguish between primary and secondary hypothyroidism.

Primary hypothyroidism may be caused by:

1) congenital aplasia or underdevelopment of the thyroid gland (leads to cretinism), which is more often observed in foci of endemic goiter (endemic cretinism);

2) complete or partial shutdown of the function of the thyroid gland (X-ray irradiation, thyroidectomy - complete removal of the thyroid gland, more often with its malignant neoplasms);

3) weakening of the hormonal activity of the thyroid gland as a result of the action of thyrostatic factors, both natural and synthetic;

4) weakening of the hormone-forming activity of the thyroid gland as a result of various inflammatory processes in it;

5) genetically determined disturbances in the biosynthesis of thyroid hormones.

Secondary hypothyroidism is associated with a loss of action of thyroid-stimulating hormone (TSH) from the pituitary gland, which stimulates thyroid function.

The clinical manifestations of hypothyroidism are directly opposite to thyrotoxicosis.

Patients with hypothyroidism, as a rule, are inhibited, slow in movements, are distinguished by slow-wittedness and weakening of memory and mental abilities. There is indifference to sexual life, men often have impotence. Patients suffer from constipation. There are compressive pains in the region of the heart.

Treatment of hypothyroidism is based mainly on the use of thyroid hormones (L-thyroxine, euthyrox), which compensate for thyroid insufficiency and normalize metabolic processes. It should be carried out only under the supervision and control of a physician. Treatment begins with small doses, gradually bringing to the desired effect.

Thyroid Cancer

Thyroid cancer most often occurs between the ages of 40 and 60.

International TNM classification (6th edition).

T - tumor.

T1 - one-sided single node.

T2 - unilateral multiple nodes.

T3 - bilateral, or isthmus, node.

T4 - the spread of the tumor outside the gland.

N - regional lymph nodes.

NO - no metastases.

N1a - nodes on the affected side.

N16 - bilateral, or contralateral, nodes.

M - distant metastases.

MO - no metastases.

M1 - metastases are present.

There are primary thyroid cancer, which manifests itself in a previously unchanged thyroid gland, and secondary thyroid cancer, which occurs on the basis of nodular goiter.

53. Treatment of thyroid cancer, Hashimoto's goiter

Treatment of thyroid cancer should be complex - surgery, radiation therapy, long-term use of L-thyroxine (at a thyreostatic dose of 2 μg / kg).

Treatment with radioactive iodine is used for medullary thyroid cancer or the metastatic stage of the disease. In this case, the main condition for starting therapy is the absence of thyroid tissue (thyroidectomy is performed).

Autoimmune thyroiditis (Hashimoto's goiter)

This disease is based on diffuse infiltration of thyroid parenchyma by lymphocytes.

The blood serum of patients suffering from autoimmune thyroiditis contains thyroid auto-antibodies, and the titer of these antibodies is very high.

Lymphoid tissue usually infiltrates both lobes of the thyroid gland, but the infiltration never extends to the tissues surrounding the thyroid gland. Lymphoid tissue destroys the parenchyma of the thyroid gland, and the place of the destroyed parenchyma is occupied by fibrous tissue.

Patients complain of thickening and soreness of the anterior surface of the neck in the thyroid gland, shortness of breath, symptoms of a feeling of food getting stuck in the esophagus when swallowing, weakness and general fatigue appear. On palpation, the thyroid gland is dense, but not to the same extent as with Ridel's goiter. The temperature is often elevated, leukocytosis is observed in the blood.

In the initial period of the disease, signs of hyperthyroidism are observed, which are soon replaced by symptoms of hypothyroidism. Radiologically, in most cases, there is a narrowing of the windpipe and esophagus.

In the treatment of autoimmune thyroiditis, pathogenetic therapy or a surgical method is used.

Pathogenetic treatment is aimed at the use of agents that can reduce the autoimmune stimulus, have an inhibitory effect on the process of autoimmunization, reduce or eliminate the infiltration of the thyroid gland by lymphocytes or plasma cells. This effect is exerted by some hormonal preparations and, first of all, thyroidin, the use of which contributes to the regression of the symptoms of autoimmune thyroiditis and the reduction of the thyroid gland to normal size. With this treatment, the general condition of patients improves, the level of antibodies in the blood decreases, and hypothyroidism decreases.

The drug is prescribed individually, and its initial dose is on average 0,1-1,15 g. Treatment continues for several months or years.

Recently, glucocorticoids (cortisone or prednisolone) and adrenocorticotropic hormone have been widely used to treat autoimmune thyroiditis.

Indications for surgical treatment:

1) symptoms of compression of the neck organs;

2) difficulties in differential diagnosis between autoimmune thyroiditis and thyroid tumors;

3) suspicion of a combination of autoimmune thyroiditis with adenoma or carcinoma of the thyroid gland.

54. Anatomy and physiology of the breast, manifestations of breast cancer

Anatomy and physiology

The mammary glands are glandular hormone-dependent organs that are part of the reproductive system of a woman, which develop and begin to function under the influence of a whole complex of hormones: releasing factors of the hypothalamus, gonadotropic hormones of the pituitary gland (follicle-stimulating and lute-inducing), chorionic gonadotropin, prolactin, thyrotropic hormone, corticosteroids, insulin and of course estrogens, progesterone and androgens.

The blood supply to the mammary glands is carried out due to the branches of the internal thoracic (about 60%) and axillary (about 30%) arteries, as well as due to the branches of the intercostal arteries. The veins of the mammary gland accompany the arteries and anastomose widely with the veins of the surrounding areas.

From the position of oncology, the structure of the lymphatic system of the mammary gland is of great importance. There are the following ways of outflow of lymph from the mammary gland:

1) axillary path;

2) subclavian path;

3) parasternal way;

4) retrosternal way;

5) intercostal path;

6) the cross path is carried out along the skin and subcutaneous lymphatic vessels passing the midline;

7) the path of Gerota, described in 1897. When tumor emboli blockade the main outflow tracts of lymph, the latter through the lymphatic vessels located in the epigastrium, perforating both layers of the sheath of the rectus abdominis muscle, enters the preperitoneal tissue, from there into the mediastinum, and through the coronary ligament - in the liver.

Forms of manifestation of breast cancer Hypothyroid form - cancer of the young (4,3%), occurs at the age of 15-32 years. Features: hypothyroidism, early obesity, menstruation up to 12 years, follicular ovarian cysts and tissue hyperplasia are common. The prognosis is unfavorable, the course is rapid, distant metastases develop rapidly.

The ovarian form occurs in 44% of women. Pathogenetic influences for this group are associated with ovarian function (childbirth, sexual life, fibroadenomatoses). The prognosis is unfavorable due to rapid lymphogenous dissemination, multicentric growth.

Hypertension-adrenal (39,8%) - patients aged 45-64 years, suffer from obesity, increased age-related levels of cholesterol, cortisol, and hypertension. Characterized by uterine fibroids, diabetes, signs of intensified aging. The prognosis is unfavorable due to the frequency of diffuse-infiltrative forms.

Senile, or pituitary (8,6%) - occurs in women in deep menopause. characteristic age-related changes. The prognosis is relatively favorable, the process is localized for a long time, metastasis develops later and proceeds slowly.

55. Classification of breast cancer according to the TNM system

T - primary tumor

Tx - insufficient data to evaluate the primary tumor.

That - the primary tumor is not determined.

Tis - preinvasive carcinoma: intraductal or lobular carcinoma (in situ), or Paget's disease of the nipple without the presence of a tumor node.

Paget's disease, in which the tumor node is palpated, is classified according to its size.

T1 - tumor up to 2 cm in greatest dimension.

- T1mic (microinvasion) - a tumor up to 0,1 cm in the largest dimension.

- T1a - tumor up to 0,5 cm in greatest dimension.

- Tib - tumor up to 1 cm in greatest dimension.

- Tic - tumor up to 2 cm in greatest dimension. T2 - tumor up to 5 cm in greatest dimension.

T3 - Tumor more than 5 cm in greatest dimension.

T4 Tumor of any size with direct extension to the chest wall or skin. The thorax includes the ribs, intercostal muscles, serratus anterior, but without the pectoral muscles.

- T4a - spread to the chest wall.

- T4b - swelling (including "lemon peel"), or ulceration of the skin of the breast, or satellites in the skin of the gland.

- T4c - signs listed in T4a and T4b.

- T4d - inflammatory form of cancer. N - regional lymph nodes

Nx - insufficient data to assess the state of regional lymph nodes.

N0 - no signs of damage to regional lymph nodes.

N1 - metastases in the displaced axillary lymph nodes on the side of the lesion.

N2 - metastases in the axillary lymph nodes fixed to each other, or clinically detectable metastases in the internal lymph nodes of the mammary gland on the side of the lesion in the absence of clinically detectable metastases in the axillary lymph nodes.

N3 - metastases in the subclavian lymph nodes with or without metastases in the axillary lymph nodes or clinically detectable metastases in the internal lymph nodes of the mammary gland on the side of the lesion in the presence of metastases in the axillary lymph nodes or metastases in the supraclavicular lymph nodes on the side of the lesion with metastases ( or without them) in the axillary or internal lymph nodes of the mammary gland.

- N3a - metastases in the subclavian lymph nodes.

- N3b - metastases in the internal lymph nodes of the mammary gland on the side of the lesion.

- N3c - metastases in the supraclavicular lymph nodes.

56. Classification of metastases, clinical forms of breast cancer

M - distant metastases

Mx - insufficient data to determine distant metastases. MO - no signs of distant metastases. M1 - there are distant metastases.

Clinical forms of breast cancer

I. Nodal.

II. Diffuse infiltrative:

1) edematous-infiltrative;

2) inflammatory (inflamatory):

a) mastitis-like;

b) erysipelatous Shell.

III. Cancer in the duct.

IV. Paget's cancer.

Nodal form. The most common among other forms of breast cancer (75-80%). In the early stages, the tumor usually does not cause unpleasant subjective sensations. The only complaint, as a rule, is the presence of a painless dense tumor-like formation or an area of induration in one or another part of the gland, more often in the upper outer quadrant.

During the examination, 4 categories of signs are evaluated:

1) skin condition;

2) condition of the nipple and areola;

3) features of the palpable seal;

4) state of regional lymph nodes. On examination, the symmetry of the location and shape of the mammary glands, the condition of the skin, areola and nipple are determined. Even with small (up to 2 cm) tumors, the symptom of "wrinkling" can be determined. With the central location of the tumor, even with small sizes, one can notice the retraction of the nipple and its deviation to the side.

On palpation, you can determine the "minimal" cancer - about 1 cm, it all depends on the location of the tumor. With its superficial or marginal location, at the smallest sizes, due to the shortening of the Kupffer ligaments, a symptom of "wrinkling", or retraction of the skin over the tumor, appears. The node on palpation is often painless, without clear contours, dense consistency, limited mobility along with the surrounding glandular tissue.

Swelling and infiltration of the skin - a symptom of "lemon peel", various deformities of the gland tissue, visible retraction of the skin over the tumor - a symptom of "umbilization", swelling of the areola and flattening of the nipple - a symptom of Krause, germination and ulceration of the skin, retraction and fixation of the nipple etc. There are signs of metastatic lesions of regional lymph nodes: the presence of single dense, enlarged, painless nodes or in the form of conglomerates.

In the metastatic stage, symptoms of tumor intoxication join: weakness, dizziness, loss of appetite, etc. Symptoms of damage to other organs appear: cough, shortness of breath, pain in the abdominal cavity and bones, which requires a clarifying diagnosis in order to establish the stage of the disease.

Author: Selezneva T.D.

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