Children's surgery. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets
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Children's surgery. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Table of contents

1. Features of the treatment of children with surgical diseases

Successful treatment of children with acute surgical diseases primarily depends on timely diagnosis and early implementation of the necessary set of therapeutic measures.

Complexity diagnostics many surgical diseases and malformations are mainly associated with the mental immaturity of the child and the functional characteristics of its systems and organs.

General symptoms do not always arouse the alertness of the attendants, since they are too often observed in various physiological conditions and functional disorders.

In infants, for the recognition of acute surgical pathology, the correct evaluation changes in the child's behavior.

Periodic restlessness, sudden "unreasonable" cry, refusal to eat - everything should be taken into account by the surgeon when examining the patient.

General symptoms diseases (deterioration, high body temperature, vomiting, etc.) in some cases play a lesser role in establishing a diagnosis than "insignificant" objective data.

X-ray examination of the digestive tract in newborns is carried out in a vertical position by a non-contrast method.

For certain indications, contrasting is carried out with iodized oil or a 20% solution of sergosin. Examination using barium sulphate can cause severe complications.

In older children, more complex methods of X-ray examination (retropneumoperitoneum, pneumomediastinography, angiography) should be used.

However, the interpretation of the data should be made taking into account age-related anatomical features (physiological enlargement of the thymus gland, various periods of the appearance of ossification nuclei).

Special and instrumental research methods (esophagoscopy, bronchoscopy, splenoportography) are widely used in emergency surgery.

The choice of the method of surgical treatment, as well as medical tactics, is impossible without taking into account the peculiarities and originality of the further development of the growing body of the child.

In acute surgical diseases, the need for surgical treatment is usually dictated by absolute indications. However, in debilitated and preterm infants with severe malformations or comorbidities, surgery may sometimes be abandoned in favor of less risky conservative treatments.

To absolute contraindications, which are encountered extremely rarely and only in newborns, refers only to the obvious non-viability of the child, for whom surgical intervention will obviously not benefit. It should be noted that thanks to the rapid development of pediatric surgery and the improvement of surgical treatment methods, the scope of absolute contraindications to interventions is steadily narrowing.

2. Preoperative preparation

In emergency surgery in the preoperative period, tasks of non-specific preoperative preparation: solving the problem of "full stomach", improving the function of vital organs and systems, conducting premedication.

Premedication technique depends on the subsequent choice of anesthesia and therefore will be discussed in the appropriate section.

The problem of "full stomach" is of no small importance for the prevention of regurgitation and aspiration of gastric contents.

Regardless of the time elapsed since the last meal, the emergency patient should be considered a potential aspiration hazard at the time of anesthesia.

First of all, this applies to patients with peritonitis, various types of intestinal obstruction and other diseases of the "acute abdomen".

Before the start of anesthesia, each child is inserted into the stomach with a probe to suck out gastric contents. Then the probe is removed so that it is not a conductor for subsequent regurgitation.

Aspiration can be prevented to some extent by using nitrous oxide with oxygen for induction of anesthesia (2: 1 or 1:

1) in combination with fluorotane or cyclopropane, ketalar. With such anesthesia, the cough reflex is suppressed relatively late, which reduces the risk of gastric contents entering the respiratory tract.

At the same time, the child must be given the Trendelenburg position.

During tracheal intubation, it is advisable to press the thyroid cartilage towards the spine. With the help of this technique, the exit from the esophagus is reliably blocked, which prevents food masses from entering the trachea.

If, despite the measures taken, aspiration still occurs, then it is necessary to immediately intubate the trachea with thorough washing of the tracheobronchial tree with saline sodium chloride solution with antibiotics; if it is ineffective, bronchoscopy is indicated.

Measures to improve the function of vital organs and systems depend on the nature of the pathological syndrome that dominates the clinical picture of an acute surgical disease.

Most often, preoperative therapy requires intoxication, traumatic shock, and respiratory failure. Special preparation is necessary for newborns and premature babies, in whom physiological borderline conditions during surgery can turn into a pathological process. It should be emphasized that the task of training does not include the complete normalization of the function of the main organs and systems. It is only necessary to "push" the process of recovery, that is, to transfer the pathological state from decompensation to compensation.

3. Manifestation of intoxication

Intoxication - a condition with a characteristic combination of clinical and laboratory signs of pathology of the nervous system, microcirculation system and water and electrolyte metabolism against the background of an infectious and inflammatory process.

In emergency surgery feature of intoxication is that it occurs against the background of infections caused by staphylococcal or gram-negative bacterial flora. Unlike viral and viral-bacterial infections, neurological symptoms do not prevail in these cases.

Most often, hyperthermia and inhibition serve as a background against which a local process unfolds with a generalized reaction of the microcirculation system. Changes in peripheral blood flow are manifested in rheological disorders, intracapillary disorders with intravascular coagulation and activation of the kinin system.

Frequent involvement in the pathological process of the organs of the gastrointestinal tract leads to isotonic or salt-deficient dehydration.

In combination with the pathology of the transmembrane transfer of sodium and potassium, typical of any intoxication, dehydration causes the symptoms of disorders of water and electrolyte metabolism.

Loss with vomiting or fluid sequestration in paretically distended bowel loops or in peritoneal exudate leads to salt deficiency or isotonic dehydration; hyperthermia or hyperventilation of any origin - to water deficiency.

Hyperproteinemia does not occur with dehydration in children with purulent-inflammatory diseases of the chest and abdominal cavities and with malformations of the gastrointestinal tract, accompanied by hypotrophy of II-III degrees. The level of total serum protein in this pathology may be normal.

Confirmation of hemoconcentration in such situations is a high hematocrit. And, conversely, if isotonic or salt-deficient dehydration develops against the background of anemia, an increase in the number of erythrocytes and hematocrit is not expressed, only hyperproteinemia has diagnostic value.

As long as the body is able to maintain stable hemodynamics, we can talk about the stage of dehydration compensation, decompensation occurs with the appearance of circulatory disorders.

With isotonic and hypotonic (salt-deficient) dehydration, signs of decompensation are arterial hypotension, acrocyanosis, hypothermia and oliguria. Decompensation occurs only with dehydration, corresponding to a loss of 10% of body weight.

If before the operation the phenomena of intoxication and water-electrolyte imbalance are not reduced, then during the intervention, sensitivity to blood loss increases, peripheral blood flow insufficiency worsens, and the prognosis worsens. Hyperthermia caused by the inflammatory process, water-deficient dehydration, intoxication, increases sensitivity to hypoxia and narcotic drugs.

4. Preoperative preparation for acute surgical diseases accompanied by intoxication

In this regard, tasks of preoperative preparation when intoxicated, they are reduced to normalizing the patient's body temperature, improving peripheral blood flow and reducing the degree of dehydration. These tasks are solved by infusion therapy.

The sequence of goals for infusion therapy in this situation should be as follows:

1) providing a volume of liquid corresponding to the degree of water deficiency;

2) reduction of energy deficit with normalization of electrolyte transport through the cell membrane and prevention of intracellular edema with the help of concentrated glucose solutions with insulin;

3) improvement of blood rheology and detoxification using low molecular weight plasma substitutes;

4) normalization of the acid-base state of the blood. The volume of fluid that the patient needs to eliminate the deficit of water and electrolytes in the preoperative period is calculated taking into account the degree of dehydration and the age of the child. With isotonic or salt-deficient dehydration, the most common in surgical diseases, the calculation is based on the hematocrit value.

In cases where it is not technically possible to determine the hematocrit or there are no laboratory signs of hemoconcentration, the liquid for the preoperative period is prescribed in the amount of 2-3% of body weight (20-30 ml / kg).

The composition of the injected solutions depends on the state of hemodynamics and the stage of dehydration. In case of circulatory decompensation, the infusion is started with the transfusion of volemic drugs: plasma (10 ml/kg), 10% albumin solution (10 ml/kg) or rheopolyglucin (20 ml/kg). The remaining volume is administered in the form of a 10% glucose solution with insulin (1 unit - 5 g). With normal indicators of central hemodynamics and the predominance of intoxication over dehydration, volemic preparations are replaced with low molecular weight blood substitutes of the hemodez group (10 ml/kg). Infusion in these cases begins with concentrated glucose solutions.

Therapy should only be initiated when standard blood bicarbonate falls below 15 mmol/L. In clinical practice, 1,3-5% sodium bicarbonate solutions are used to treat metabolic acidosis.

In children older than 2 months, it is advisable to use hypertonic solutions of sodium bicarbonate.

If laboratory control is not carried out, then alkalizing solutions should be used very carefully. Absolute indication to their use are: insufficiency of peripheral circulation with pallor, "marbling" of the skin; symptom of "white spot" with arterial hypotension; oligoanuria, resulting from spasm of the leading arterioles of the kidneys.

Sodium bicarbonate in these cases is prescribed at a dose of 0,12-0,25 g of dry matter or 5-7 ml of a 5% solution per 1 kg of the child's body weight.

5. Therapy of traumatic shock

In children, the classic picture of traumatic shock is rarely observed. The younger the child, the less pronounced are the differences between the erectile and torpid phases of shock. With the same probability, against the background of clinical signs of circulatory insufficiency, psychomotor agitation or lethargy can be found.

There are four degrees of severity of traumatic shock.

Light Shock (I). Most often observed with injuries of the musculoskeletal system (damage to more than two bones, excluding pelvic bone fractures), blunt abdominal trauma without damage to internal organs.

Within 3 hours from the moment of injury, the patient steadfastly maintains a shock clinic in the stage of centralization of blood circulation.

This stage is characterized by psychomotor agitation or depression, systolic blood pressure within the age norm or increased by 20 units, a decrease in pulse pressure, a tense pulse, tachycardia up to 150 beats / min, sometimes bradycardia.

Moderate shock (II) usually accompanies damage to the pelvic bones, extensive damage to soft tissues with significant crushing of tissues, traumatic amputations of one of the limbs, isolated injuries of the abdominal organs, trauma to the chest with fractures of the ribs.

During the first hour from the moment of injury, there is a rapid transition from the stage of centralization of blood circulation to the transitional stage.

In the transitional stage, the child's behavior is inhibited. Systolic blood pressure is reduced, but not more than 60% of the age norm. Pulse of weak filling, its frequency is more than 150 beats / min of the age norm.

Heavy Shock (III) typical for combined and multiple injuries of the chest and pelvis, for traumatic amputation of several limbs, for bleeding from large vascular trunks. During the first hour from the moment of injury, the stage of decentralization of blood circulation develops.

This stage is manifested in the fall of systolic blood pressure below 60% of the age norm. Diastolic blood pressure is not determined. The pulse is thready, tachycardia with a pulse rate of more than 150 beats / min. The skin is pale cyanotic.

Terminal shock (IV) with the clinic of the agonal state. The severity of the course of shock dictates the intensity of therapeutic measures and determines the prognosis.

Emergency operations for shock of any severity are indicated for abdominal trauma with damage to internal organs and bleeding; with traumatic brain injury with external bleeding or symptoms of cerebral compression; with a spinal injury with symptoms of spinal cord injury; with detachments and injuries of the limbs with a violation of the integrity of large vessels and nerve trunks; with thoracic injury with suspected injury to the heart; intrapleural bleeding; massive crushing of the lung tissue; open valvular or tension pneumothorax.

6. Therapy of traumatic shock depending on the stage of hemodynamic disturbance

Stage of centralization of blood circulation:

1) stop external bleeding;

2) alcoholone-vocaine (trimecaine) blockade of the fracture area or nerve trunks throughout;

3) immobilization of injured limbs;

4) narcotic analgesics can be introduced (omnopon, promedol 1% solution - 0,1 ml / year of life);

5) analgesia by inhalation of methoxyflurane. Possible neuroleptanalgesia with a decrease in the dose of fentanyl to 0,05 ml / kg of a 0,25% solution;

6) intravenous fluid administration begins with any medium-molecular or protein blood substitute (polyglucin, polyvinol, plasma, albumin, etc.);

7) at the first intravenous puncture, blood sampling is necessary to determine the group and Rh factor of the patient, tests for individual compatibility. The total blood volume of medium molecular weight and protein blood substitutes under conditions of stopped internal or external bleeding should be at least 15-20 ml/kg;

8) it is desirable to control blood substitution according to the dynamics of CVP (gradual decrease to normal values, i.e. 8 cm H2O (0,78 kPa) and average hourly diuresis (up to 1 year - 20-25 ml, 3-5 years - 30 -40 ml, 6-14 years old - 50-60 ml);

9) with persistent high CVP and the appearance of signs of stagnation in the small circle, the introduction of ganglioblocking drugs is indicated;

10) the question of the operation is decided depending on the indications.

Transitional stage of hemodynamic disturbance:

1) immobilization of the damaged organ and anesthesia;

2) infusion therapy begins with any medium-molecular or protein plasma substitute. If bleeding is stopped, the total volume of transfused drugs is at least 25-30 ml / kg;

3) clinical and laboratory signs of the adequacy of blood replacement are the same;

4) shows the introduction of gangliolytics followed by blood transfusion in case of repeated hypotension;

5) after normalization of central hemodynamics, it is advisable for the patient to transfuse mannitol;

6) the appointment of a complex of vitamins of group B is mandatory;

7) a single administration of hydrocortisone 5-10 mg/kg is indicated, especially with a tendency to arterial hypotension;

8) antibiotic therapy should be started;

9) tactics in relation to surgical intervention.

Stage of decentralization of blood circulation:

1) the beginning of treatment with an immediate blood transfusion: initially O (1) Rh (-) with a subsequent transition to the introduction of blood corresponding to the group and Rh factor of the patient. The transfusion rate should be 30-40 ml/min.

2) the introduction of hormones of the adrenal cortex.

7. Malformations of the lungs. Lobar emphysema. Clinic. Differential Diagnosis

congenital lobar emphysema is rare. It occurs as a result of rupture of the alveolar septa with stenosis of the adductor bronchi of various origins or is a consequence of a defect in the development of the lung parenchyma.

clinical picture

Lobar emphysema is manifested by shortness of breath, often with prolonged exhalation, bouts of cyanosis, shortness of breath, cough. The severity of symptoms depends on the degree of bronchial obstruction. According to the clinical course, lobar emphysema should be divided into acute and chronic.

The acute course of lobar emphysema is usually observed in children during the first months of life (often soon after birth). The disease is manifested by a progressive increase in signs of respiratory failure.

The general condition of the child is severe, the skin is pale, with a cyanotic tint; punctate subcutaneous hemorrhages are visible, cyanotic lips. Sharp shortness of breath is determined, auxiliary muscles are involved in inhalation. The chest is barrel-shaped.

Percussion over the lung field on the side of the lesion reveals high tympanitis, with auscultation there are no respiratory sounds. The boundaries of the heart are shifted to the healthy side. Heart sounds are muffled.

Plain chest x-ray shows that the affected part of the lung is sharply swollen, against its elevated air background there are shadows of medium- and large-caliber vascular ramifications.

Neighboring areas of the lung are collapsed.

The swollen lobe partially penetrates the opposite side of the chest, displacing the mediastinum and forming a mediastinal hernia.

On bronchography and bronchoscopy, narrowing of the lobar bronchus, displacement and convergence of the bronchi of healthy parts of the lung are determined.

In the chronic course of lobar emphysema, the phenomena of respiratory failure increase slowly, the body adapts to the changes that have occurred and compensates for them. The disease is usually detected during preventive examinations or x-ray examinations.

Differential diagnosis

Lobar emphysema should be differentiated from pulmonary cyst and diaphragmatic hernia.

With a pulmonary cyst, the clinical manifestations of the disease can be acute or chronic, with signs of respiratory failure.

Pulmonary cysts on radiographs look like well-defined air cavities of a rounded shape, without a mesh pattern characteristic of lobar emphysema.

Finally, the nature of the pathological process in such cases is revealed during surgery and after a histological examination of the drug.

Diaphragmatic hernia in the presence of an asphyxic component in newborns is similar to the acute form of lobar emphysema. In doubtful cases, the final diagnosis is made after x-ray examination with a contrast agent. Contrasting intestinal loops located in the pleural cavity makes the diagnosis of diaphragmatic hernia undoubted.

8. Treatment of lobar emphysema

Treatment of congenital lobar emphysema in all cases surgical. In the acute course of the disease with a clinical picture of severe respiratory failure, the operation should be undertaken according to emergency indications. In cases of a chronic course, intervention is carried out in a planned manner.

Preoperative. The scope and duration of preparing the patient for surgery depend on the nature of the clinical manifestations.

In acute cases, preoperative preparation is limited to a few (2-3) hours. The patient is prescribed oxygen, cardiac agents, warmed up and transferred to the operating room.

Operative therapy. The nature of the surgical intervention is determined by the localization of the lesion and comes down to lobectomy.

The lung lobes are removed from the anterolateral thoracotomy in the fourth or fifth intercostal space with the patient in a semi-lateral position.

Technically, lobectomy is carried out according to the rules set out in special guidelines for operative surgery, with the obligatory separate processing of the elements of the lung root.

After removal of the affected lung section, high drainage is established in the pleural cavity, which is introduced through a separate incision - a puncture in the seventh-eighth intercostal space along the midaxillary line. The operation is completed by layer-by-layer suturing of the thoracotomy wound. The skin is sutured with nylon threads.

Postoperative treatment. A high drainage is left in the pleural cavity for active aspiration of exudate during the first 24-48 hours. For pain relief in the immediate postoperative period, prolonged epidural anesthesia is performed. It is advisable to prescribe parenteral fluid administration (12% glucose solution with insulin, protein preparations) in accordance with the child’s weight and age for the first 24-10 hours after surgery.

In the absence of vomiting, the next day after the intervention, the child begins to feed through the mouth. Blood transfusions are done taking into account the indicators of red blood tests, as well as taking into account the amount of exudate aspirated from the pleural cavity.

To prevent pulmonary complications (blockage of the bronchial tree, atelectasis), from the first hours after the operation, the patient is prescribed respiratory and cough exercises, alkaline aerosols.

With the ineffectiveness of these measures, direct laryngoscopy is performed with secretion suction and the introduction of antibiotics into the respiratory tract. From the 3rd to 4th day, older children begin to walk.

The presence of atelectasis is an indication for the appointment of more intense breathing exercises, which usually leads to the complete elimination of this complication, and in case of ineffectiveness, tracheobronchoscopy is resorted to.

In the postoperative period, patients receive broad-spectrum antibiotics for 6-7 days, vitamins, oxygen therapy, physiotherapy and massage. The sutures are removed on the 7-8th day.

9. Complicated congenital lung cysts. Clinic. Differential Diagnosis

Lung cysts is a relatively rare disease. Cysts are single and multiple. Multiple lung cysts include their polycystic lesion.

Cysts are more common in the right lung than in the left. The sizes of cysts vary widely. They can be single or multi-chamber, very small, sometimes reaching gigantic sizes, occupying almost the entire lobe or lung. If the cysts do not communicate with the tracheobronchial tree (closed), then they usually contain a sterile mucous liquid, colorless, yellowish or brown. Cysts communicating with the bronchi are filled with air and infected fluid.

clinical picture. Suppurated cysts of the lungs. With suppuration of single lung cysts, the disease develops acutely, with a sharp deterioration in the general condition of the child, an increase in body temperature to high numbers, chills, and sweating.

On examination, the patient noted pallor of the skin, cyanosis in the area of the nasolabial triangle. Breathing is fast, pulse is tense.

On the side of the localization of the cyst, areas of dullness of percussion sound and tympanitis are revealed, respectively, of inflammatory infiltration, accumulation of exudate and air.

During auscultation in these places, breathing is weakened, after coughing, moist coarse rales appear. Changes in the blood indicate an acute inflammatory process: high leukocytosis with a shift to the left, increased ESR.

X-ray examination reveals a cavity filled with fluid, around which there is an inflammatory infiltrate. With partial emptying of purulent contents, a horizontal level appears in the cyst cavity.

Differential diagnosis. It is necessary to differentiate infected cysts with lung abscess and pyopneumothorax.

The final diagnosis of a lung cyst can be made in cases where the anamnesis indicates the presence of an air cavity in the lung, which was previously found during an X-ray examination, or there is repeated suppuration in the lung with the same localization of the focus.

Pyopneumothorax develops against the background of severe asbestos pneumonia and is its complication. Radiologically, the cavity is located along the outer edge of the lung field.

With a purulent-inflammatory lesion of a polycystic lung, if infection occurs at an early age, the disease becomes protracted with frequent exacerbations. The general condition of the child is progressively deteriorating, the phenomena of intoxication are increasing, the patient is exhausted, the body temperature rises.

When examining a child, a rigid chest wall is revealed on the side of the lesion, which is not involved in the act of breathing. The borders of the heart are not changed. Percussion above the pulmonary field - a motley picture: areas of pulmonary sound alternate with tympanitis and dullness.

10. Treatment of congenital cysts

All congenital pulmonary cysts are subject to surgical treatment, however, the timing of the operation is determined by the course of the disease, the condition of the child.

Preoperative depends on the nature of the complication. An infected cyst or cysts of the lung require intensive complex therapy, which is a kind of preoperative preparation. Therapeutic measures in these patients are aimed at removing intoxication, restorative therapy.

Sanitation the purulent cavity is produced by puncturing it, with the suction of pus, washing with antiseptic solutions and the introduction of antibiotics. The cyst is punctured again after 2-3 days (depending on the accumulation of exudate). At the same time, the patient is prescribed therapeutic exercises with a drainage position.

With insufficient drainage function of the afferent bronchus, it is advisable to include repeated tracheobronchoscopy in the complex of therapeutic measures.

As a result of the rehabilitation of the purulent focus, the patient's symptoms of intoxication are reduced, which is also facilitated by vigorous general strengthening therapy - transfusion of blood, plasma, intravenous fluids, parenteral administration of vitamins and massive antibiotic therapy.

Operative therapy. The extent of the operation depends on the nature of the pathological process.

With single cysts, surgery can be reduced to thoracotomy and cyst exfoliation.

Operation technique. Thoracotomy is performed according to the general rules with an anterolateral incision. The lung is isolated from the adhesions. The pleura is carefully dissected over the cyst, after which the lung is gradually peeled off from the wall of the cyst. The fibrous cords that connect the cyst to the surrounding lung tissue are cut and ligated.

There are especially many strands on the basal pole of the cyst. Here, the passage of fairly large vessels and one or more bronchial branches that communicate with the cyst is possible.

They are ligated with silk. Bleeding areas of the lung edge are sheathed with catgut. If it is impossible to enucleate the cyst, a lobectomy is performed according to the general rules. After removal of the cyst in the pleural cavity, drainage is left for 24-48 hours.

The extent of surgery for polycystic lung depends on the extent of the lesion. With lobar localization, the operation is reduced to a lobectomy. In the case of cystic degeneration of the entire lung, a pneumonectomy is performed.

Postoperative treatment. In general, the treatment of patients who have undergone surgery for lung cysts does not differ from that for lobar emphysema. After removal of previously infected cysts, special attention should be paid to antibacterial therapy. Careful care of the postoperative wound is also necessary - daily dressings, treatment of sutures, ultraviolet irradiation.

11. Obstruction of the esophagus. Clinic

Congenital obstruction of the esophagus due to atresia. This complex malformation is formed in the early stages of intrauterine life of the fetus.

With atresia, in most cases, the upper end of the esophagus ends blindly, and the lower part communicates with the trachea, forming a tracheoesophageal fistula (90-95%). Amniotic fluid and the fluid that the baby swallows after birth cannot enter the stomach and accumulates along with mucus in the upper blind sac of the esophagus, then regurgitated and aspirated. The child quickly develops aspiration pneumonia, which is aggravated by the throwing of the contents of the stomach into the trachea through the esophageal-tracheal fistula of the lower segment. A few days after birth, death occurs from aspiration pneumonia.

clinical picture. The first earliest and most consistent sign that suggests esophageal atresia in a newborn is a large amount of frothy discharge from the mouth and nose. Suspicion of esophageal atresia should be increased if, after the usual suction of mucus, the latter continues to accumulate rapidly in large quantities.

Mucus at times has a yellow color, which depends on the throwing of bile into the trachea through the fistula of the distal segment of the esophagus. In all children with obstruction of the esophagus, by the end of the 1st day after birth, quite distinct respiratory disorders (arrhythmia, shortness of breath) and cyanosis can be detected.

Auscultation in the lungs is determined by an abundant amount of moist rales of various sizes. When the upper esophagus communicates with the trachea, aspiration pneumonia is diagnosed immediately after birth. Abdominal distension indicates an existing fistula between the distal esophagus and the airways.

With atresia, a freely pushed catheter is delayed at the level of the top of the bag of the proximal segment of the esophagus (10-12 cm from the edge of the gums). If the esophagus is not changed, then the catheter easily passes for a greater distance.

It must be remembered that in some cases the catheter can develop, and then a false impression is created about the patency of the esophagus. To clarify the diagnosis, the catheter is carried to a depth of more than 24 cm, and then its end (if there is atresia) is inevitably found in the child's mouth.

At the first feeding obstruction of a gullet comes to light quite definitely. All drunk liquid (1-2 sips) immediately pours back. Feeding is accompanied by a sharp violation of breathing: the newborn turns blue, breathing becomes superficial, arrhythmic, it stops. A coughing fit can last from 2 to 10 minutes, and difficulty and arrhythmia of breathing can last even longer.

Gradually increasing cyanosis. When listening to the lungs, an abundant amount of various wet rales is revealed, more on the right. The general condition of the child progressively worsens.

12. Obstruction of the esophagus. Diagnostics

With exhaustive completeness and reliability, the diagnosis is made on the basis of an X-ray examination of the esophagus using a contrast agent, which is carried out only in a surgical hospital. The data obtained are a necessary part of the preoperative examination and serve as a guideline for choosing the method of surgical intervention. X-ray examination of children with suspected esophageal atresia begins with a plain chest radiograph.

Then, a rubber catheter is passed into the upper segment of the esophagus and the mucus is sucked off, after which 1 ml of iodo-lipol is injected through the same catheter into the esophagus with a syringe. The introduction of a large amount of iodized oil can lead to an undesirable complication - overflow of the blind upper segment of the esophagus and aspiration with filling of the bronchial tree with a contrast agent.

Pictures are taken in the vertical position of the child in two projections. The contrast agent after X-ray examination is carefully sucked off.

The use of barium sulfate as a contrast agent for examination of the esophagus in newborns with any form of atresia is contraindicated, since its entry into the lungs, which is possible during this study, causes atelectatic pneumonia.

In the general serious condition of the child (late admission, prematurity III-IV degree), you can not undertake examinations with a contrast agent, but limit yourself to the introduction of a thin rubber catheter into the esophagus (under the control of an X-ray screen), which will allow you to fairly accurately determine the presence and level of atresia. It should be remembered that with the rough introduction of a low-elastic thick catheter, the pliable film of the blind oral segment of the esophagus can be displaced, and then a false impression is created about the low location of the obstruction.

A characteristic radiological symptom of esophageal atresia when examined with a contrast agent is a moderately dilated and blindly ending upper segment of the esophagus. The level of atresia is more accurately determined on lateral radiographs.

The presence of air in the gastrointestinal tract indicates an anastomosis between the lower esophagus and the respiratory tract.

The visible upper cecum and the absence of gas in the gastrointestinal tract suggest atresia without a fistula between the distal esophagus and the trachea. However, this radiographic finding does not always completely rule out a fistula between the distal esophagus and the airways.

The narrow lumen of the fistula is clogged with a mucous plug, which serves as an obstacle to the passage of air into the stomach.

The presence of a fistula between the upper segment of the esophagus and the trachea can be detected radiologically by throwing a contrast agent through the fistula into the respiratory tract. This examination does not always help to detect a fistula.

13. Treatment of obstruction of the esophagus

The success of surgical intervention depends on the early diagnosis of the defect, and hence the timely start of preoperative preparation, the rational choice of the method of operation and the correct postoperative treatment.

Preoperative. Preparation for surgery begins from the moment the diagnosis is made in the maternity hospital. The child is continuously given humidified oxygen, antibiotics and vitamin K are administered.

The mucus secreted in large quantities is carefully aspirated through a soft rubber catheter inserted into the nasopharynx at least every 10-15 minutes. Feeding by mouth is absolutely contraindicated.

Children admitted within the first 12 hours after birth do not require long preoperative preparation (1,5-2 hours are enough). At this time, the newborn is placed in a heated incubator, constantly given humidified oxygen, every 10-15 minutes mucus is sucked out of the mouth and nasopharynx. Antibiotics, heart medications, and vitamin K are administered.

Children admitted later after birth with symptoms of aspiration pneumonia are prepared for surgery 6-24 hours after birth.

The child is placed in an elevated position in a heated incubator with a constant supply of humidified oxygen. Every 10-15 minutes, mucus is suctioned from the mouth and nasopharynx (the child needs an individual nursing post).

Antibiotics, cardiac agents are administered, an aerosol with alkaline solutions and antibiotics is prescribed. Late admission shows parenteral nutrition.

Preoperative preparation is stopped with a noticeable improvement in the general condition of the child and a decrease in the clinical manifestations of pneumonia.

If during the first 6 hours the preoperative preparation does not have a noticeable success, the presence of a fistulous tract between the upper segment and the trachea, in which mucus inevitably enters the respiratory tract, should be suspected.

Surgery for esophageal atresia is performed under endotracheal anesthesia. The operation of choice should be considered the creation of a direct anastomosis. However, the latter is possible only in cases where the diastasis between the segments of the esophagus does not exceed 1,5 cm.

On the basis of clinical and radiological data, it is almost impossible to establish the true distance between the segments.

If during thoracotomy a significant diastasis (more than 1,5 cm) between the segments or a thin lower segment (up to 0,5 cm) is detected, then the first part of the two-stage operation is performed - the esophageal-tracheal fistula of the lower segment is eliminated and the upper end of the esophagus is brought to the neck.

These measures prevent the development of aspiration pneumonia, thereby saving the life of the patient. Created lower esophagostomy serves to feed the child until the second stage of the operation - the formation of an artificial esophagus from the colon.

14. Operations for creating an anastomosis of the esophagus

Extrapleural access technique. Position of the child on the left side. The right arm is fixed in a raised and forward position. A rolled-up diaper is placed under the chest. The incision is made from the nipple line to the angle of the scapula along the 5th rib.

Bleeding vessels are carefully ligated. The muscles are carefully dissected in the fourth intercostal space. The pleura is slowly exfoliated (first with a finger, then with a wet small tipper) along the incision up and down by 3-4 ribs. With a special screw wound dilator of small sizes, the hooks of which are wrapped with wet gauze, the edges of the wound of the chest cavity are parted, after which the lung covered with pleura is retracted anteriorly with a Buyalsky spatula (also wrapped in gauze). The mediastinal pleura is exfoliated above the esophagus up to the dome and down to the diaphragm.

Technique for mobilizing esophageal segments. Find the lower segment of the esophagus. The reference point is the typical location of the vagus nerve. The latter is removed inside, the esophagus is relatively easily isolated from the surrounding tissues and taken on a holder (rubber strip).

The lower segment of the esophagus is mobilized over a short distance (2-2,5 cm), since its significant exposure can lead to impaired blood supply. Directly at the point of communication with the trachea, the esophagus is tied up with thin ligatures and crossed between them.

A suture is applied to the top of the blind sac, for which it is pulled up, exfoliating the mediastinal pleura, and carefully isolated upward with a wet tupfer. The oral segment has a good blood supply, which allows it to be mobilized as high as possible.

The mobilized segments of the esophagus are pulled towards each other by the threads. If their ends freely go behind each other (which is possible with diastasis up to 1,5 cm, in premature babies - 1 cm), then they begin to create an anastomosis.

Anastomosis technique. Creation of the anastomosis is the most difficult part of the operation. Difficulties arise not only due to diastasis between segments of the esophagus, but also depend on the width of the lumen of the distal segment.

The narrower its lumen, the more difficult it is to suture, the greater the likelihood of their eruption and the occurrence of narrowing of the anastomosis site in the postoperative period.

Anastomosis by connecting segments of the esophagus in an end-to-end fashion. The first row of separate silk sutures is applied through all layers of the lower end of the esophagus and the mucosa of the upper segment.

The second row of sutures is passed through the muscle layer of both segments of the esophagus.

To connect the ends of the esophagus, you can use special seams such as wrapping. Four pairs of such threads, superimposed symmetrically on both segments of the esophagus, first serve as holders, for which the ends of the esophagus are pulled up.

After the convergence of their edges, the corresponding threads are tied. When tying the sutures, the edges of the esophagus are screwed inward. The anastomosis is reinforced with a second row of separate silk sutures.

15. Postoperative treatment of obstruction of the esophagus

Postoperative treatment. The success of the operation largely depends on the correct conduct of the postoperative period. The child is placed in a heated incubator, giving the body an elevated position, and is constantly given humidified oxygen. The administration of antibiotics, vitamins K, C, B is continued, and UHF currents are prescribed to the chest. A control radiograph of the chest cavity is taken 24 hours after surgery.

In the first hours after surgery, the child may progressively develop respiratory failure, which requires urgent intubation and assisted breathing.

After a few hours, the child's condition usually improves, and the tube can be removed from the trachea. Re-intubation after anastomosis should be done with great care.

A positive effect is given by oxygen barotherapy. In the postoperative period after the simultaneous restoration of the continuity of the esophagus, children receive 1-2 days of parenteral nutrition. The correct calculation of the amount of fluid required for parenteral administration to a child is very important.

The patency of the esophagus and the state of the anastomosis is controlled after 9-10 days by X-ray examination with iodolipol. The absence of signs of anastomotic failure allows you to start feeding through the mouth from a horn or a spoon. At the first feeding, the child is given 10-20 ml of 5% glucose, and then - breast milk in half the dose of the amount that the newborn received when feeding through a tube. On the 10-14th day, the child is applied to the chest for 5 minutes first and a control weighing is carried out. Feeding the child from the horn.

Gradually increase the time of attachment to the breast and at the beginning of the 4th week they switch to 7 meals a day.

Postoperative management of a child who underwent the first part of a two-stage esophageal plasty has some differences due to the possibility of feeding through the esophagostomy opening. The small size of the stomach of a newborn, a violation of its motor function due to trauma during the creation of a fistula, requires fractional feeding with a gradual increase in the amount of fluid administered. From the 7th day after the operation, the volume of the stomach increases so much that up to 40-50 ml of liquid can be slowly injected through the esophagostomy hole. From the 10th day they switch to 7 meals a day with normal dosages.

In the first days after the intervention, careful care of fistulas on the neck and anterior abdominal wall is necessary. The latter especially needs frequent dressing changes, skin treatment with antiseptic pastes, and exposure to ultraviolet rays. A thin rubber drainage inserted into the stomach is not removed for 10-12 days until the lower esophageal fistula is completely formed. Then the probe is inserted only at the time of feeding.

The sutures are removed on the 10-12th day after the operation. Children are discharged from the hospital after a persistent weight gain is established.

16. Esophageal-tracheal fistulas. Clinic. Differential Diagnosis

There are three main variants of the defect, among which there is a predominantly short and wide fistulous tract. The anastomosis, as a rule, is located high, at the level of the first thoracic vertebrae.

The presence of a fistulous tract between the esophagus and trachea leads to the rapid development of pneumonia due to the aspiration of fluid.

clinical picture. Clinical symptoms of the esophageal-tracheal fistula appear in most cases after the first feeding of the child, but their intensity depends on the variant of the malformation.

A narrow and long fistulous tract, as a rule, is not detected in the neonatal period.

These babies occasionally have severe coughing spells while feeding. Parents do not attach importance to them, since feeding in a certain position of the child saves him from seizures. The child often suffers from pneumonia.

In cases of a wide and short fistula, feeding a newborn is almost always accompanied by a fit of coughing, cyanosis, and frothy discharge from the mouth. These children quickly develop aspiration pneumonia.

A large fistula, in which both organs at some distance are represented as if by one common tube, appears at the first feeding.

Each sip of the liquid triggers a coughing fit. Respiratory failure is prolonged, accompanied by severe cyanosis.

The general condition progressively worsens due to severe pneumonia and extensive atelectasis of the lungs.

X-ray examination is of some importance for the diagnosis of esophageal-tracheal fistula. Survey pictures reveal the nature of pathological changes in the lungs.

In older children, the fistulous tract can be detected radiologically when examining the esophagus with a liquid contrast agent.

The contrast medium is given from a spoon or injected through a catheter placed in the initial part of the esophagus. It is generally accepted that partial or complete filling of the bronchial tree with a contrast agent indicates the presence of an anastomosis.

Clinical and radiological data on the presence of an esophageal-tracheal fistula can be confirmed by esophagoscopy. With the introduction of an esophagoscope and examination of the esophagus, the fistulous tract becomes noticeable by small air bubbles emerging from it in time with breathing. A narrow fistula is usually not visible during esophagoscopy, it is masked by mucosal folds.

A clearly fistulous course is determined only with tracheobronchoscopy, which is performed under anesthesia for all children with suspected esophageal-tracheal fistula.

Differential diagnosis

Differential diagnosis is difficult in children of the neonatal period, when it is necessary to exclude an esophageal-tracheal fistula if the child has a birth injury, accompanied by a violation of the act of swallowing or paresis of the soft palate.

For differential diagnosis, the child begins to feed only through a probe inserted into the stomach.

17. Treatment of esophageal-tracheal fistulas

Elimination of congenital esophageal-tracheal fistula only possible through surgery. Surgical intervention is carried out after the diagnosis is established.

Preoperative. The child is completely excluded from oral feeding - all the required amount of liquid is introduced into the stomach through a tube, which is removed after each feeding. From the first day, active anti-pneumonic treatment begins: antibiotics, oxygen therapy, UHF currents on the chest, alkaline aerosol.

The operation for congenital esophageal-tracheal fistula is performed under endotracheal anesthesia and with blood transfusion. The position of the child is on the left side.

Operation technique. The most convenient access for infants is extrapleural. Along the fourth intercostal space on the right.

The lung covered with pleura is retracted forward and inward, the mediastinal pleura is exfoliated above the esophagus. The esophagus is mobilized for 1,5-2 cm up and down from the place of its communication with the trachea.

In the presence of a long fistulous passage, the latter is isolated, tied with two silk ligatures, crossed between them, and the stumps are treated with an iodine solution.

With a wide and short fistula, the esophagus is carefully cut off with scissors from the trachea, and the holes formed are closed with a double-row continuous suture with atraumatic needles. To prevent postoperative narrowing of the esophagus, the latter is sutured in the transverse direction (over the catheter inserted before the operation).

The most difficult to eliminate is a large esophageal-tracheal fistula, in which both organs have common walls for some length (0,7-1 cm).

In such cases, the esophagus is transected above and below the junction with the trachea. The holes formed on the trachea are sutured with two rows of sutures, then the continuity of the esophagus is restored by creating an end-to-end anastomosis.

Postoperative treatment. In the postoperative period, the child continues to receive active antipneumonic therapy, since surgery usually causes an exacerbation of the process in the lungs.

An elevated position is created for the patient, an aerosol is prescribed, humidified oxygen is constantly given, antibiotics, cardiac agents are administered.

On the first day, the child needs parenteral nutrition, then feeding is carried out in fractional doses every 3 hours through a thin tube left during the operation. The amount of fluid is calculated depending on the age and body weight of the child. Within 2-3 days, 1/3 of the volume of liquid is injected through a probe, the rest is intravenous drip. The probe is removed on the 5th-6th day (when creating an end-to-end anastomosis, feeding through the probe is continued for 9-10 days). By the 6-8th day, the child should receive the usual age norm of breast milk. Older children are prescribed liquid food from the 7-8th day after the operation.

18. Damage to the esophagus. Chemical burns. Clinic

In children, damage to the esophagus is relatively rare, occurring mainly due to chemical burns or perforation of the organ wall.

The severity of the esophageal burn and the degree of its pathological and anatomical changes depend on the amount and nature of the chemical swallowed by the child.

When exposed to acids, the depth of damage to the esophageal wall is less than when exposed to alkalis. This is due to the fact that acids, neutralizing the alkalis of tissues, coagulate the protein of the cells and at the same time take away water from them.

As a result, a dry scab is formed, which prevents the penetration of acids into the depths. The impact of alkalis on tissues is accompanied by colliquat necrosis. The absence of a scab leads to a deep penetration of the caustic substance into the tissues and damage them.

There are three degrees of burns of the esophagus: light, medium and heavy.

Mild degree characterized by damage to the mucous membrane of the type of desquamative esophagitis. At the same time, hyperemia, edema and areas of superficial necrosis are noted. The inflammatory process subsides and epithelialization occurs within 7-10 days. The resulting superficial scars are elastic, do not narrow the lumen of the esophagus and do not affect its function.

With an average degree deeper lesions. Necrosis extends to all layers of the organ. After 3-6 weeks (as necrotic tissues are rejected), the wound surface is covered with granulations and then scarred. The depth and prevalence of cicatricial changes depend on the severity of damage to the esophageal wall.

A severe degree is characterized by deep and extensive damage to the esophagus with necrosis of all layers of its wall. The burn is accompanied by mediastinitis.

clinical picture

The clinical picture of a burn of the esophagus depends on the nature of the substance that caused the burn and the degree of damage to the esophagus. From the first hours after the burn, the condition of the children was severe.

As a result of rapidly growing inflammation, profuse salivation is noted, often repeated and painful vomiting. From the moment of contact with a caustic substance, there is a burning pain in the mouth, in the pharynx, behind the sternum and in the epigastric region.

Three periods are distinguished in the clinical course of the disease. The first period is characterized by acute inflammation of the mucous membrane of the mouth, pharynx and esophagus.

This condition often lasts up to 10 days, and then improves, pain disappears, swelling decreases, temperature normalizes, esophageal patency is restored - children begin to eat any food. The acute stage gradually passes into the asymptomatic period. The apparent well-being sometimes lasts up to 4 weeks.

3-6 weeks after the burn, a period of scarring begins. Gradually, the phenomena of obstruction of the esophagus increase. In children, vomiting occurs, retrosternal pains join.

X-ray examination with a contrast agent during the scarring period reveals the nature, degree and extent of the pathological process.

19. Treatment of damage to the esophagus

A child who has received a chemical burn of the esophagus requires emergency hospitalization. In the acute stage of the disease, measures are taken to remove from the state of shock and vigorous detoxification therapy aimed at preventing or reducing the local and general effects of the poison. For this purpose, painkillers and cardiac drugs are administered to the victim, the stomach is washed through the tube. Depending on the nature of the caustic substance, washing is done either with a 0,1% solution of hydrochloric acid (with an alkali burn), or with a 2-3% solution of bicarbonate of soda (with an acid burn) in a volume of 2-3 liters. As a rule, there are no complications from the introduction of a gastric tube.

The complex of anti-shock measures, in addition to the introduction of cardiac agents and oinopon, includes intravenous infusions of plasma, glucose solution, vagosympathetic cervical novocaine blockade.

The possibility of layering secondary infection dictates the early use of antibiotic therapy.

Gastric lavage is used not only in emergency care, but also 12-24 hours after the burn. This removes the remaining chemicals in the stomach.

An important therapeutic factor is the use of hormones, vitamin therapy and the appointment of a balanced diet. In severe cases, when children refuse to drink and water, protein preparations and liquid are administered intravenously for 2-4 days to relieve intoxication and for the purpose of parenteral nutrition. To improve the general condition, the patient is prescribed oral feeding with high-calorie, chilled food, first liquid (broth, milk), and then well-mashed (vegetable soups, cottage cheese, cereals).

From the first days after the injury, children should receive one dessert spoon of vegetable or vaseline oil through their mouths, it has a softening effect and improves the passage of the lump through the esophagus.

Until recent years, bougienage has been considered the main method of treating burns of the esophagus. Distinguish between early, or preventive, bougienage and later, therapeutic - with cicatricial stenosis of the esophagus. The tactics of treatment is determined by the degree of burns of the oral cavity, pharynx and esophagus. To identify and assess the nature of the lesion and its prevalence, diagnostic esophagoscopy is performed.

Early bougienage prevents the formation of cicatricial stenosis of the esophagus. Bougienage is started from the 5-8th day after the burn.

Only special soft bougie are used. By this time, acute inflammatory changes in the wall of the esophagus subside, granulations appear, the general condition of the child improves, and the temperature returns to normal.

Bougienage is carried out without anesthesia three times a week for 1,5-2 months. During this period, the child is in the hospital.

Then he is discharged for outpatient treatment, having prescribed bougienage once a week for 2-3 months, and in the next six months - 1-2 times a month.

20. Perforation of the esophagus. Clinic

Esophageal perforation in children, it occurs mainly during bougienage for cicatricial stenosis, damage by a sharp foreign body, or during instrumental examination.

clinical picture

With the slow formation of perforation, observed in connection with a decubitus of the esophageal wall by a foreign body (coin, bone), the surrounding tissues are gradually involved in the process, which react with inflammatory demarcation.

One of the first symptoms of acute purulent mediastinitis is chest pain. It is difficult to find out localization, and only in older children can it be clarified that it is retrosternal and intensifies when swallowing.

The child becomes inactive, any change in position in bed causes anxiety due to increasing pain. The general condition of the patient is rapidly deteriorating. Shortness of breath appears. The disease is often accompanied by a persistent cough. The body temperature rises to 39-40 ° C.

Physical examination reveals moist rales, in some cases shortening of percussion sound in the interscapular space.

When examining blood, there is a sharp increase in the number of leukocytes, neutrophils with a shift to the left.

The X-ray method of research, as a rule, confirms the presumptive diagnosis. Widening of the mediastinal shadow, the presence of emphysema, and examination with a contrast medium usually allow you to determine the level of damage to the esophagus.

Mediastinitis that occurs in children with perforation of the esophagus by sharp foreign bodies is diagnosed with less difficulty.

The very fact of the presence of a sharp body in the esophagus allows us to think about damage to the wall of the organ. If the instrumental removal of the foreign body turned out to be impossible and the patient experienced a sharp deterioration in his general condition, chest pain appeared, body temperature increased, there is no need to doubt the diagnosis.

Recognition of mediastinitis is helped by X-ray data (stationary position of a foreign body, expansion of the shadow of the mediastinum, and sometimes the presence of gas in it). In such cases, immediate surgical removal of the foreign body is indicated.

Perforation of the esophagus with instruments usually occurs during bougienage for cicatricial narrowing or during esophagoscopy. Diagnosis is usually not difficult due to the appearance of sharp pain at the time of damage to the esophageal wall.

Perforation is accompanied by phenomena of shock: the child turns pale, the filling of the pulse becomes weak, and blood pressure noticeably decreases. After removing the bougie and conducting special therapy (painkillers, intravenous infusion of calcium chloride, blood, anti-shock fluid), the patient's condition improves somewhat, but chest pain continues to bother the child.

The general symptoms of mediastinitis develop rapidly: the temperature rises, pneumonia appears, shortness of breath, the blood picture changes, and the state of health deteriorates sharply.

21. Treatment of esophageal perforation

Operative therapy start with the creation of a gastrostomy. Further surgical tactics depend on the nature of the damage to the esophagus and the extent of mediastinitis.

The presence of an acute foreign body in the esophagus, which led to perforation and the development of mediastinitis, is an indication for urgent mediastinotomy. The operation in such cases has a dual purpose - removal of the foreign body and drainage of the mediastinum. Delay in surgical intervention worsens the course of the postoperative period.

With the slow formation of a perforation (pressure sore) associated with a long stay of a foreign body in the esophagus, drainage of the mediastinum is indicated. The nature of the operative access depends on the level of inflammation: the upper sections are drained by cervical mediastinotomy according to Razumovsky, the middle and posterior lower sections are drained by extrapleural access according to Nasilov. Regardless of the methods of drainage during intervention, it is necessary to spare the adhesions formed in the mediastinum, which to a certain extent prevent the spread of the purulent process.

In cases where the complication is diagnosed relatively late and the child has a formed delimited abscess, mediastinal drainage surgery is also necessary and often effective.

Damage to the esophagus and the rapid spread of the purulent process in the mediastinum usually lead to the breakthrough of the abscess into the pleural cavity. In such cases, urgent thoracotomy with pleural drainage is indicated.

Postoperative treatment in children with esophageal perforation and mediastinitis requires perseverance and great attention in identifying the entire range of therapeutic measures.

After the operation, the child is placed in an elevated position, constantly humidified oxygen is prescribed. Painkillers are administered after 4-6 hours. Drip intravenous infusion continues for 2-3 days. Transfusion of blood and protein preparations (plasma, albumin) is performed daily in the first week, then after 1-2 days. The child is prescribed broad-spectrum antibiotics (according to sensitivity), replacing them after 6-7 days. Tampons are tightened after 2-3 days, then removed. Drainage in the mediastinum is left until the purulent discharge stops. An esophageal fistula usually closes on its own. The child is undergoing physiotherapy (for example, UHF). If there is a communication of the mediastinal abscess with the pleural cavity and the latter has been drained, then a minimum negative pressure of 5-7 cm of water should be created in the active aspiration system. Art. The tube from the pleural cavity is removed after the elimination of the esophageal fistula and pleurisy.

After elimination of mediastinitis and healing of the wound of the esophagus, feeding through the mouth is started (if there is no stenosis). Plastic surgery on the esophagus (intestinal transplantation, resection) is possible after at least 2 years after complete recovery from mediastinitis.

22. Bleeding from dilated veins of the esophagus in portal hypertension

The most severe and common complication of portal hypertension syndrome is bleeding from esophageal varices..

The cause of bleeding is mainly an increase in pressure in the portal system, peptic factor, as well as disorders in the blood coagulation system. Bleeding from dilated veins of the esophagus may be the first clinical manifestation of portal hypertension.

clinical picture. The first indirect signs of incipient bleeding are the child's complaints of weakness, malaise, nausea, and lack of appetite.

The body temperature rises. Sudden profuse hematemesis explains the sharp deterioration in the general condition of the child.

Vomiting is repeated after a short period of time. The child turns pale, complains of headache, dizziness, becomes lethargic, drowsy. A tarry, fetid stool appears.

Arterial pressure drops to 80/40-60/30 mm Hg. Art. A blood test reveals an increasing anemia. The volume of circulating blood decreases sharply. After 6-12 hours, the severity of the condition is aggravated by intoxication as a result of the absorption of blood decay products from the gastrointestinal tract.

Differential diagnosis. If the child is admitted to the surgical clinic again due to bleeding in the syndrome of portal hypertension or he underwent surgery for this disease, then the diagnosis should not be in doubt.

It is more difficult to make a differential diagnosis if bleeding was the first manifestation of portal hypertension, since similar clinical symptoms occur in children with a bleeding stomach ulcer, hiatal hernia, and after severe nosebleeds.

Children who bleed from chronic gastric ulcers usually have a characteristic and long-term "ulcerative" history. Profuse bleeding is extremely rare.

Acute ulcers in children receiving long-term hormonal therapy are also rarely complicated by bleeding.

In children with a hernia of the esophageal opening of the diaphragm, intermittent hematemesis is not abundant, the presence of a "black" stool is not always observed.

The general condition of the child worsens slowly over many months.

Children usually come to the clinic for mild anemia of unknown etiology. Clinical and radiological examination establish the presence of a hernia of the esophageal opening of the diaphragm.

The cause of bloody vomiting that occurs after nosebleeds is clarified with a detailed history taking and examination of the patient.

23. Treatment of bleeding from dilated veins of the esophagus

Conservative therapy in some cases leads to a stop of bleeding. After the diagnosis is established, the child is given a transfusion of blood products.

Sometimes 200-250 ml is required, and in case of severe unstoppable bleeding, 1,5-2 liters of blood products are transfused on the first day.

It is necessary to resort to direct transfusions more often, combining them with transfusion of conservative blood. With a hemostatic purpose, concentrated plasma, vikasol, pituitrin are administered; inside designate amino-caproic acid, adroxon, thrombin, hemostatic sponge.

The child is completely excluded from feeding by mouth, prescribing parenteral administration of an appropriate amount of liquid and vitamins (C and group B).

The infusion is carried out slowly, since a sharp overload of the vascular bed can lead to re-bleeding. An ice pack should be placed on the epigastric region.

All children are prescribed broad-spectrum antibiotics, detoxification therapy. Humidified oxygen is constantly given through nasal catheters to combat hypoxia. In case of severe intractable bleeding, hormonal therapy is included (prednisone 1-5 mg per 1 kg of body weight of the child per day).

Patients with an intrarenal form of portal hypertension for the prevention of liver failure are prescribed a 1% solution of glutamic acid. With successful conservative treatment after 4-6 hours, the general condition improves somewhat.

Blood transfusions are carried out 2-3 times a week, the administration of vitamins is continued. The course of antibiotics is completed on the 10-12th day. Hormonal drugs are canceled, gradually reducing their dosage.

Along with the specified conservative therapy, resort to an attempt to mechanically stop bleeding. This is achieved by introducing into the esophagus an obturating Blackmore probe, the inflated cuff of which presses the varicose veins of the esophagus.

The choice of the method of surgical treatment at the height of bleeding primarily depends on the general condition of the patient and on whether the child was operated on for portal hypertension earlier or bleeding occurred as one of the first manifestations of portal hypertension.

In children previously operated on for portal hypertension (splenectomy, creation of organ anastomoses), the operation is reduced to direct ligation of varicose veins of the esophagus or the cardia of the stomach. In patients who have not previously been operated on for portal hypertension syndrome, the operation should be aimed at reducing pressure in v. portae by reducing blood flow to esophageal varices.

In order to reduce blood flow to varicose veins of the esophagus, a modified Tanner operation is used - suturing the precordial veins without opening the lumen of the stomach.

24. Hernia of the diaphragm itself. Complicated false hernia of the diaphragm proper. Clinic

Congenital defects of the diaphragm, through which the organs of the abdominal cavity move into the chest, usually are of three types: a slit-like defect in the region of the lumbocostal region (Bogdalek's fissure), a significant defect in the dome of the diaphragm and aplasia - the absence of one of the domes of the diaphragm.

clinical picture. In the presence of a slit-like defect in the region of the lumbocostal region (Bogdalek's fissure), an acute course of a false hernia of the diaphragm proper occurs, usually in the first hours or days after the birth of a child.

In most cases, a hernia is manifested by symptoms of increasing asphyxia and cardiovascular insufficiency, which develop as a result of flatulence of the intestinal loops and stomach moved into the chest cavity.

In the first hours of life, intestinal loops and the stomach are filled with gas, their volume increases sharply and the compression of the organs of the chest cavity increases.

With a narrow slit-like defect, the hollow organs are unable to move back into the abdominal cavity on their own.

On the side of the hernia (usually on the left), breathing is sharply weakened or not audible.

In older children, faint noises of intestinal peristalsis are detected. On the opposite side, breathing is weakened to a lesser extent.

Heart sounds are heard clearly, as a rule, dextrocardia is detected.

At the birth of a child, heart sounds are heard in the usual place, but relatively quickly (1-2 hours) shift to the right beyond the midline or even the nipple line.

The main symptoms of a diaphragmatic hernia are a displacement of the boundaries of the heart (usually to the right) and the appearance in the lung field of cellular cavities of uneven size, corresponding to the filling of displaced intestinal loops with gas.

When examining a child in the first hours after birth, the cavities are relatively small, their number gradually increases, and they become larger.

A contrast study, which is carried out with iodo-lipol, is indicated only if the diagnosis is in doubt. For these purposes, a newborn is injected through a tube into the stomach with 5-7 ml of iodized oil (iodolipol), which, spreading, well contours the wall of the stomach.

A re-examination after 2-3 hours can show the passage of the contrast agent through the small intestine and reveal its displacement into the chest cavity.

Infringement of false diaphragmatic hernias. Due to the presence of "hard" hernial orifices in false diaphragmatic hernias, infringement of the displaced abdominal organs is possible more often than in other hernias of the abdominal obstruction. Infringement of hollow organs is characterized by a sudden onset.

The phenomena of acute obstruction of the gastrointestinal tract in combination with respiratory failure come to the fore.

An early sign that allows you to suspect infringement are bouts of cramping pain. Infants suddenly begin to worry, toss about in bed, grab their stomachs with their hands.

25. Diagnosis and treatment of diaphragmatic hernias

X-ray examination. X-ray examination reveals symptoms typical of a diaphragmatic hernia: mediastinal displacement; the presence of cellular cavities due to intestinal loops moved into the chest cavity.

Characteristic of obstruction caused by infringement is the presence of several large or multiple horizontal levels.

Differential diagnosis. The differential diagnosis of a false diaphragmatic hernia in a newborn should be carried out with some congenital heart defects and birth trauma of the brain, in which cyanosis and general weakness of the child give reason to suspect "asphyxial infringement".

Attacks of cyanosis are also observed in a newborn with acute lobar emphysema or lung cyst. Clinical symptoms in such cases are of little help in the differential diagnosis.

X-ray examination in these diseases, as well as in diaphragmatic hernia, shows a sharp shift in the boundaries of the heart, but in acute emphysema there is no characteristic cellular structure of the pulmonary field on the side of the lesion, corresponding to gas bubbles of intestinal loops.

A lung cyst appears as separate large cavities, but unlike a hernia, there is a visible closed diaphragm contour, a normal gastric bladder and the usual number of intestinal loops in the abdominal cavity. A contrast study of the digestive tract helps to make a definitive diagnosis.

Differentiation of infringements of false diaphragmatic hernias has to be carried out with pleurisy, which, with staphylococcal pneumonia, begins acutely, has a variable x-ray picture, and in older children it is multi-chamber.

Treatment. Congenital false diaphragmatic hernia of the diaphragm itself with an acute course in newborns ("asphyxic strangulation") and the phenomenon of strangulation in infants and older children are an absolute indication for immediate surgery.

Preoperative preparation for emergency operations is short-term.

The newborn is placed in an oxygen tent (couveuse), warmed. In some cases, if there is severe hypoxia and the effects of asphyxia increase, the child is immediately intubated and begin to conduct controlled breathing.

In newborns and children of the first months of life, in some cases there are difficulties in suturing the wall of the abdominal cavity, the dimensions of which are insufficient, and it does not contain the reduced organs.

In such children, a two-stage closure of the abdominal cavity should be resorted to, which reduces the tension of the diaphragm sutures and reduces intraperitoneal pressure.

26. Complicated true hernia of the diaphragm proper

The nature of the course of the disease depends mainly on the degree of displacement of the abdominal organs into the chest. In some cases, the hernial gates are small in size, and the hernial sac is stretched to a significant extent and filled with organs moved into the pleural cavity.

Compression of the lungs, displacement of the heart and mediastinal vessels with a significant violation of their function. The patency of the gastrointestinal tract may be impaired.

clinical picture. The acute course of a true congenital hernia of the diaphragm itself occurs in the presence of a total displacement of the abdominal organs into the chest, which is usually observed in newborns and children in the first months of life.

In older children, infringement of the displaced abdominal organs may occur in the presence of a relatively small defect in the diaphragm proper and a significant hernial sac. The clinical manifestations of these complications have some differences.

The acute course of true hernias and relaxation of the diaphragm usually manifests itself in the first days after birth as a symptom of "asphyxial infringement".

The general condition of the child progressively worsens, cyanosis increases, breathing becomes superficial, slow. The abdomen is retracted, while breathing, the epigastric region sinks. There is vomiting.

However, the listed symptoms are less pronounced than with false hernias, and are not so constant.

Infringement of true hernias of the diaphragm itself is extremely rare. This is mainly due to the absence of clearly defined ("hard") hernial orifices or their significant diameter.

With a limited diaphragm defect, infringement manifests itself with a sudden onset. The clinical picture is characterized by sharp pains in the chest and abdomen, respiratory failure and intestinal obstruction.

X-ray examination. X-ray examination allows you to clarify the diagnosis. The pictures show the movement of intestinal loops into the pleural cavity and a sharp shift of the mediastinum in the opposite direction.

A characteristic radiological sign of significant true hernias of the diaphragm itself, as well as its relaxation, is the high standing and paradoxical movement of the abdominal obstruction. With multi-axis transillumination, the diaphragm is visible in the form of a thin regular arcuate line, below which gas bubbles of the stomach and intestinal loops are located.

Differential diagnosis. Differential diagnosis should be carried out, as in the acute course of a false hernia, with some congenital heart defects, birth trauma of the brain and lobar emphysema of the lung.

27. Treatment of complicated true hernias of the diaphragm proper

In case of an acute course or infringement of a true hernia of the diaphragm itself, an urgent operation is indicated. Preoperative preparation is minimal.

The young child is warmed after transport, the necessary drugs for anesthesia are administered, and an intravenous fluid infusion machine is applied.

The operation is performed under endotracheal anesthesia. The position of the child with transthoracic access is on the side opposite to the hernia, with laparotomy - on the back.

With the parietal location of the hernial sac, so-called sliding hernias are usually observed. In such cases, it is more convenient to dissect the thinned zone in an arcuate manner over the displaced organs and move the latter in a blunt way (together with part of the hernial sac) downwards.

Postoperative treatment. In the postoperative period, newborns are placed in a heating incubator and an elevated position is created (after the child has recovered from the state of anesthesia), and humidified oxygen is prescribed.

On the first day, every 2 hours, the accumulating contents are sucked out of the stomach with a thin probe. Parenteral nutrition is carried out for 24-48 hours. After 2-3 days, for the purpose of stimulation, blood transfusions are performed in the amount of 20-25 ml. Feeding by mouth usually begins on the 2nd day after surgery: every 2 hours, 10 ml of glucose solution, alternating with breast milk. The fluid deficiency is replenished by intravenous administration of a glucose solution, and after the removal of the drip infusion apparatus, by single-stage transfusions.

If there is no vomiting, then from the 3rd day the amount of fluid is increased, gradually bringing it to the age norm. On the 7-8th day, the child is applied to the chest.

Older children are also transferred to parenteral nutrition on the first day, then a liquid postoperative table with a sufficient amount of proteins and vitamins is prescribed. The usual diet starts from the 6-7th day.

All children after surgery are prescribed broad-spectrum antibiotics to prevent pneumonia and heart medications. Physiotherapy (UHF currents, then KI iontophoresis) is prescribed from the day following the operation. Therapeutic breathing exercises begin from the first days, gradually moving to more active exercises.

After the operation, the first x-ray examination is carried out on the operating table, while determining the level of standing of the diaphragm and the degree of expansion of the lung. Re-examination in a satisfactory condition is done in 3-5 days.

If prior to this, an effusion in the pleural cavity is clinically detected and the child's condition remains severe, an X-ray examination is performed on the 2nd day after the operation. In some cases, this helps to identify indications for puncture (presence of profuse effusion).

28. Hernias of the esophageal opening and the anterior part of the diaphragm

hiatal hernia It is customary to call the movement of the abdominal organs into the posterior mediastinum or pleural cavities through the dilated esophageal opening.

clinical picture. In children with a hernia of the esophageal opening of the diaphragm, as a rule, already in infancy, regurgitation is noted, then vomiting, which are permanent. As a result, aspiration pneumonia recurs.

A lag in physical development is characteristic, they are noted; pallor, decreased hemoglobin. Relatively often, patients develop hemorrhagic syndrome.

Infringement of a hernia of the esophagus occurs acutely. There are severe cramping pains in the epigastric region. The child becomes restless, there is vomiting "fountain".

X-ray examination. A child with a suspected strangulated hiatal hernia is photographed in anteroposterior and lateral projections, which show a gas bubble of the displaced stomach with a large horizontal level of fluid on one or both sides of the midline.

In some cases, the gas bubble is not determined, since the displaced and strangulated stomach is filled with liquid. For better orientation in the pathology, it is necessary to supplement the examination with images with a contrast agent administered through the mouth.

With hernias with a raised esophagus, the contrast agent enters the stomach above the site of infringement.

In paraesophageal hernias, the contrast agent stops in the esophagus above the diaphragm.

Treatment. For a strangulated hiatal hernia in children, radical surgery is performed using a transthoracic approach.

The movement of the abdominal organs through the Lorrey fissure, or Morgagni's hole, into the retrosternal space is commonly called hernia of the anterior diaphragm. There are parasternal and frenic-pericardial hernias.

clinical picture. The clinical picture of phrenic-pericardial diaphragmatic hernias manifests itself acutely from the first hours or days of a child’s life: constant cyanosis, shortness of breath, vomiting, anxiety.

In some cases, the displacement of the abdominal organs into the heart sac through a defect in the tendon part of the diaphragm and pericardium disrupts the function of the heart so much that a sharp arrhythmia occurs or it stops.

X-ray examination. X-rays can make a correct diagnosis. When examined in two projections, there is a layering of the contours of the intestine on the shadow of the heart.

Treatment. Surgery for phrenic-pericardial hernia of the diaphragm is performed after the diagnosis is made.

29. Hernia of the umbilical cord. Clinic.

Hernia of the umbilical cord has a typical appearance. At the first examination after birth, a child is found in the center of the abdomen with a tumor-like protrusion that is not covered by skin, emanating from the base of the umbilical cord. The protrusion has all the elements of a hernia: a hernial sac, consisting of stretched amniotic membranes, a hernial ring formed by the edge of a skin defect and aponeurosis, as well as the contents of the hernia - the abdominal organs.

Uncomplicated hernia of the umbilical cord covered with moist smooth, grayish, stretched amniotic membranes. In the first hours after birth, the membranes are so transparent that you can see the contents of the hernia: the liver, intestinal loops, stomach and other organs.

In some cases, the skin spreads on the base of the hernia in the form of a ring up to 1,5-2 cm high. The shape of the hernial protrusion is more often hemispherical, spherical and mushroom-shaped. Small hernias of the umbilical cord sometimes resemble an enlarged umbilical cord.

The contents of small hernias is the intestines. The general condition of such newborns does not suffer. Medium-sized hernias are filled with a significant number of intestinal loops and may contain part of the liver.

Complications of hernias of the umbilical cord have a peculiar clinical picture, are congenital or acquired.

The most severe complication is rupture of the hernial sac membranes. A child is born with intestinal loops falling out of the abdominal cavity.

Ectopia of the heart occurs in children with large hernias of the umbilical cord. Diagnosis of the defect is simple, since upon examination, a pulsating protrusion is clearly defined in the upper part of the hernia under the amniotic membranes - displaced heart.

Incomplete reverse development (non-closure) of the vitelline duct is detected during the first careful examination of the hernial protrusion: at the base of the umbilical residue, intestinal fistula with bright red edges of everted mucous membrane.

Bladder exstrophy often combined with a hernia of the umbilical cord. In the presence of these defects, the abdominal wall is absent almost throughout.

congenital intestinal obstruction - the most "insidious", from the diagnostic point of view, the combined malformation.

More often there is a high obstruction due to duodenal atresia or a violation of the normal rotation of the middle intestine.

Severe congenital heart defects sharply worsen the general condition of the newborn and are detected by the corresponding set of clinical signs.

Purulent fusion of the superficial membranes of the hernial sac inevitably occurs in cases where the child was not operated on the first day after birth. In such children, the hernial protrusion is a dirty gray purulent wound with mucous discharge and areas of necrosis in the form of dark clots.

30. Treatment of a hernia of the umbilical cord

The main treatment for umbilical cord hernia is immediate surgery. Surgical treatment. Basic the purpose of the operation - reduction of organs into the abdominal cavity, excision of the membranes of the hernial sac and closure of the defect of the anterior abdominal wall.

Preoperative preparation should start from the moment the baby is born. Immediately after the usual toilet of a newborn, wipes moistened with a warm solution of antibiotics are applied to the hernial protrusion.

In cases of congenital rupture of the membranes with eventration of the internal organs, the latter are closed with a multilayer gauze compress, abundantly moistened with a warm 0,25% solution of novocaine with antibiotics.

The duration of preparation should not exceed 1-2 hours. During this time, the necessary studies are carried out, the patient is warmed up, antibiotics and cardiac agents are re-introduced.

Surgical treatment of uncomplicated hernias of the umbilical cord has its own characteristics, which depend on the size of the hernial protrusion and its shape.

In newborns with hernias of the umbilical cord, the abdominal cavity is developed normally, and the reduction of the viscera from the hernial protrusion during surgery cannot cause complications, just like suturing a relatively small defect in the anterior abdominal wall. These children undergo a one-stage radical operation.

Newborns with medium-sized hernias are mostly subject to one-stage radical surgery. However, in some of them (especially in premature II degree), the reduction of internal organs and especially the suturing of the aponeurosis defect is accompanied by an excessive increase in intra-abdominal pressure due to the relatively small size of the abdominal cavity and the presence of a part of the liver in the hernial sac.

If, in the process of immersion of organs, the pressure in the inferior vena cava progressively increases (to measure the pressure before surgery, the child undergoes a venesection of the great saphenous vein of the thigh with the introduction of a catheter by 5-6 cm), and in the superior vena cava (Seldinger catheterization) drops to zero or also increases to the level of pressure in the inferior vena cava, then the depth of immersion of the intestines and liver into the abdominal cavity should be minimized.

The surgeon needs to change the operation plan, ending it with the first stage of the two-stage technique.

Surgical treatment of newborns with large hernias of the umbilical cord presents significant difficulties and the prognosis remains extremely difficult until recently. This is due to the fact that the abdominal cavity in such children is very small, and the contents of the hernia (part of the liver, intestinal loops, sometimes the spleen) cannot be reduced into it during a radical operation.

Premature newborns weighing up to 1,5 kg (III degree), with medium and large hernias, are subject to conservative treatment methods. Only in case of complications with rupture of the membranes and eventration of the internal organs should an attempt be made to surgically correct the defect.

31. Postoperative treatment of children with hernias of the umbilical cord

Character postoperative treatment depends on the general condition of the child, his age and the method of surgical intervention.

In the first 2-3 days after the operation, all children are given prolonged epidural anesthesia, an elevated position is created.

Humidified oxygen is constantly supplied to the flask. Prescribe broad-spectrum antibiotics (5-7 days), cardiac drugs (according to indications) and physiotherapy. Produce 1-2 times a week transfusion of blood or plasma.

Children with small and medium hernias begin to feed through the mouth 6 hours after the operation (in more severe cases - after 10-12 hours), in doses of 10 ml every 2 hours, adding 5 ml with each feeding. Fluid deficiency is replenished by intravenous drip. By the end of the 2nd day, the child should receive a normal (by body weight and age) amount of breast milk; applied to the chest on the 3-4th day. Skin sutures are removed on the 8-10th day.

Children with large hernias after stage I of a two-stage operation are given parenteral nutrition for 48 hours. From the beginning of day 3, they begin to give 5-7 ml of a 5% glucose solution through the mouth, then expressed breast milk every 2 hours, 10 ml.

The total daily amount of fluid administered per os and intravenously should not exceed the age dosage, taking into account the child's body weight. Gradually increasing the amount of breast milk, by the 8th day the child is transferred to normal feeding (expressed milk). Apply to the mother's breast on the 12-14th day.

Children are given daily control dressings and careful wound care. The sutures are removed on the 9-12th day, depending on the degree of tension of the edges of the surgical wound.

In cases of surgical interventions on the intestine, the child is prescribed a diet indicated after resection of the intestine in a newborn.

The most significant problem in the management of the postoperative period during stage I of a two-stage intervention or radical correction is the child's adaptation to high intra-abdominal pressure. This adaptation is facilitated by a set of measures, which includes oxygen barotherapy, prolonged epidural blockade and a late start of feeding the child. In premature infants after the first stage of correction of large hernias, if signs of circulatory disorders in the lower extremities appear on the operating table, it is advisable to use prolonged nasotracheal intubation for 2 days. It reduces dead space and reduces ventilation disturbances due to the high standing of the diaphragm and the restriction of its mobility. Oxygen therapy should be carried out in the same cases with repeated sessions every 12-24 hours for 12 days.

From the day of admission, broad-spectrum antibiotics begin to be administered. A change of antibiotics is necessary after 6-7 days, depending on the results of sowing of purulent discharge and the sensitivity of microbes.

32. Strangulated inguinal hernia. Clinic. Differential Diagnosis

Infringement of inguinal hernia occurs in children of various age groups. The internal organs of the abdominal cavity with a slight tension can go into the hernial sac. The resulting spasm of the muscles creates an obstacle to their return to the abdominal cavity.

clinical picture. The most constant sign of strangulated hernia in infants is anxiety, which occurs in the midst of complete well-being and is constant, periodically intensifying.

Sometimes the swelling appears for the first time and may go unnoticed for some time due to the small size and pronounced subcutaneous fat layer in the inguinal regions in newborns.

In older children, the clinical manifestations of infringement are more distinct. The child complains of sudden sharp pains in the inguinal region and a painful swelling that appears (if the hernia was incarcerated at the first appearance). In those cases when the child knows about the presence of a hernia, he indicates its increase and the impossibility of reduction.

Soon after the infringement, many children (40-50%) have a single vomiting. The chair and gases in the beginning depart independently. When the intestinal loop is infringed, the phenomena of intestinal obstruction develop (70% of observations).

When a child is admitted late from the onset of the disease (2-3 days), the following are detected: severe general condition, fever, severe intoxication, clear signs of intestinal obstruction or peritonitis.

Locally, hyperemia and swelling of the skin appear, associated with necrosis of the strangulated organ and the development of phlegmon of the hernial protrusion. Vomiting becomes frequent, with an admixture of bile and fecal odor. There may be urinary retention.

Differential diagnosis. Differential diagnosis in young children, first of all, has to be carried out with acutely developed hydrocele of the spermatic cord. In such cases, accurate anamnestic data is important - with dropsy, swelling occurs gradually and increases over several hours.

The basis for differential diagnosis is palpation data: a tumor with dropsy is moderately painful, oval in shape, with a clear upper pole, from which a dense cord characteristic of a hernial protrusion does not extend into the inguinal canal.

Quite often, an acutely developing cyst of the spermatic cord can be extremely difficult to distinguish from a strangulated hernia. In such cases, the diagnosis is made during surgery.

In contrast to a strangulated hernia, the child has no symptoms of intestinal obstruction, and a thin cord is determined, coming from the swelling into the inguinal canal. In doubtful cases, an operation should be prescribed.

Torsion of the spermatic cord ("torsion of the testicle") is also manifested by the sudden anxiety of the child.

33. Treatment of strangulated inguinal hernias

Availability strangulated inguinal hernia is an indication for urgent surgery.

In newborns and children of the first months of life, emergency surgery is absolutely indicated:

1) in cases where the anamnesis is unknown or more than 12 hours have passed since the infringement;

2) in the presence of inflammatory changes in the area of hernial protrusion;

3) in girls, since they usually have appendages with hernial contents, which are not only infringed, but rotated, which leads to their rapid necrosis.

Conservative treatment. All children who do not have absolute indications for surgery are given a set of conservative measures upon admission to the surgical hospital, creating conditions for spontaneous reduction of the hernial protrusion.

The patient is given a single age dose of pantopon, then a warm bath (37-38 ° C) is taken for 10-15 minutes or a heating pad is placed on the area of the hernia.

Gradually, the child calms down, falls asleep, and the hernia is spontaneously reduced.

Preoperative. Children who have absolute indications for surgery do not receive special preoperative preparation.

Surgical treatment consists in the elimination of infringement and radical plastic surgery of the inguinal canal. Surgical intervention is performed under general anesthesia.

Postoperative treatment. The child is prescribed antibiotics for 2-3 days. To prevent swelling, the scrotum is pulled anteriorly with a bandage and physiotherapy (sollux) is used. The child’s activity is not limited; he is allowed to turn over in bed and sit up independently on the 2-3rd day after surgery. The patient is prescribed a normal (age-appropriate) diet.

Children of the first months of life are applied to the mother's breast 5-6 hours after the operation. To prevent complications from the wound in infants, the sticker should be changed when contaminated. The sutures are removed on the 5-6th day after the operation, the next day the child is discharged.

In the postoperative period, an infiltrate is sometimes observed in the suture area. The appointment of UHF currents and the extension of the course of antibiotics stop the complication.

If you suspect the occurrence of suppuration, you should (except for antibacterial and restorative measures) dilute the gluing edges of the wound with a bellied probe and put a thin rubber graduate on the first day. This is usually enough to eliminate the complication. In some cases, the removal of sutures and dilution of the edges of the entire wound is required.

School-age children after being discharged home are exempted from classes for 7-10 days and from physical activity for 2 months. In the future, dispensary observation of the surgeon for the child is necessary.

34. Prepyloric obstruction of the stomach. Clinic

Malformations of the stomach, localized in its prepyloric section, are an extremely rare pathology. Violation of the patency of the stomach usually cause atresia and stenosis.

According to the classification, there are three main variants of gastric anomalies: membranous, cord-like and segmental aplasia of the mucosa. With all types of atresia and stenosis of the stomach, the obstruction is localized only in the mucous and submucosal layers, the muscular and serous membranes retain their continuity.

The membrane can close the lumen of the stomach completely (atresia) or partially (stenosis), having holes of various sizes on the side or in the center of the septum: from a pinpoint to a large one, occupying more than half of the membrane. The thickness of the latter ranges from a thin sheet to a thick folded "hypertrophied" wall protruding into the pyloric canal of the stomach.

Histological examination of the membranes reveals an altered gastric mucosa with a submucosal layer and muscle tissue in the form of single fibers. The thick septum has the structure of the wall of the stomach.

clinical picture. Prepyloric gastric atresia and decompensated stenosis usually appear from the first hours or days of life. The main symptom is profuse vomiting of gastric contents without bile. Due to overdistension of the stomach and irritation of its walls from frequent vomiting, a “hemorrhagic symptom” is often associated (vomit the color of coffee grounds or streaked with blood and a tarry coloration of the stool.

Frequent, vomiting usually leads to exsicosis with a large drop in body weight (0,25-0,3 kg per day). On examination, swelling of the epigastric region is revealed, which disappears after vomiting or suction of gastric contents. On palpation, waves of peristalsis and the contours of a distended stomach are visible, often descending below the navel.

X-ray examination. X-ray examination is one of the main diagnostic methods. Plain x-ray of the abdominal cavity in a vertical position shows a large gas bubble and a liquid level corresponding to a distended stomach; there is no gas in the intestinal loops.

Prepyloric stenosis may appear days or weeks after the baby is born. The time of onset of symptoms depends on the size of the hole in the membrane. The disease begins with regurgitation without an admixture of bile, turning into vomiting. Soon, vomiting takes on the character of vomiting "fountain". Decreased body weight. The chair becomes more scarce. On examination, swelling of the epigastric region and visible peristalsis of the distended stomach are revealed.

Plain radiographs of the abdominal cavity with the child in an upright position show a large level of fluid in the stomach and a small amount of gas in the bowel loops. In such cases, a contrast study with iodolipol is undertaken.

35. Differential diagnosis and treatment of prepyloric obstruction of the stomach

Differential diagnosis have to be carried out with diseases that occur in the first days and weeks of life and are accompanied by regurgitation and vomiting that does not contain bile.

Pyloric stenosis. It is most difficult to differentiate this anomaly from prepyloric gastric stenosis if the symptoms of the latter arose from the 2-3rd week of the child’s life. In all cases, it is necessary to perform an X-ray examination with a contrast agent. Often this examination does not definitively establish the cause of gastric obstruction. In such cases, the diagnosis is made based on laparotomy data.

Pylorospasm. Due to the fact that with this pathology, symptoms arise from the first days of a child’s life, it is necessary to differentiate pyloric spasm with atresia or decompensated gastric stenosis. Persistent, numerous vomiting, causing a disturbance in the general condition of the child and leading to a sharp drop in body weight, is not characteristic of pylorospasm. In addition, the effectiveness of antispasmodic drugs indicates the functional nature of the disease.

Congenital obstruction of the duodenum when the obstruction is located above the Vater nipple has a similar clinical and radiological picture. Usually the final diagnosis is made during surgery. In other types of congenital intestinal obstruction, vomit contains bile, which makes it possible to exclude an anomaly in the development of the stomach.

Congenital diaphragmatic hernia of the esophagus in some cases it is manifested by vomiting from the first day of a child's life, but the vomit usually contains bile or blood. In addition, the diagnosis is aided by X-ray contrast examination, in which a diaphragmatic hernia is confirmed by the location of the stomach above the level of the thoracic obstruction.

Treatment. Preoperative preparation for atresias and decompensated stenoses usually does not exceed 24 hours and is aimed at restoring homeostasis and treating aspiration pneumonia. In case of stenosis, preparation for surgery, if necessary, can be extended to several days.

Postoperative treatment is aimed at correcting impaired water-salt metabolism, restoring the functioning of the gastrointestinal tract, preventing and treating aspiration pneumonia.

Within 2-3 days the child is on parenteral nutrition.

If the patient had a probe below the anastomosis site during the operation, then a day later they begin to introduce breast milk (5-10 ml every 3 hours), increasing the amount of the latter by 10 ml per feeding daily. The probe is removed after 4-5 days and oral feeding is started. The child receives antibiotic therapy, blood transfusions, administration of plasma, albumin. In the presence of pneumonia, aerosols are used up to 5-6 times a day, physiotherapy. The stitches are removed on the 10-12th day.

36. Pyloric stenosis. Clinic

To sharp forms pyloric stenosis refers to a kind of clinical manifestation of this malformation, in which the symptoms of the disease begin suddenly and proceed rapidly.

clinical picture. The time of onset of symptoms of the disease depends on the degree of narrowing of the pyloric canal and the compensatory capabilities of the body. The first signs of the disease appear between the ages of several days and 1 month. The main symptom of the acute form of pyloric stenosis is “fountain” vomiting, which begins suddenly in the middle of full health. Vomit does not contain bile; its amount exceeds the amount of milk sucked during the last feeding. Often, vomit has a stagnant, sour odor, which indicates retention of gastric contents. Prolonged debilitating vomiting leads to a deterioration in the child’s general condition and disruption of water-salt metabolism (hypochloremia, exicosis, and sometimes hypokalemia). The acute stage of the disease is characterized by the fact that the child develops complete obstruction of the gastric patency within a few days. Feeding becomes impossible; a few sips of milk cause vomiting. Children lose up to 1-2 kg of body weight in 0,4-0,5 days. The number of urinations decreases. There is stool retention or dyspeptic “hungry” stool appears. An indicator of the serious condition of a child with pyloric stenosis is the daily loss of body weight in relation to birth weight (as a percentage). This classification distinguishes three forms of the disease: mild (0-0,1%), moderate (0,2-0,3%) and severe (0,4% and above).

In children with an acute form of pyloric stenosis, weight loss reaches 6-8%. On examination, the child reacts poorly to the environment, the facial expression is suffering. The skin is pale, the mucous membranes are bright and dry. The fontanel sinks. Attention is drawn to the swelling of the epigastric region, decreasing or disappearing after vomiting. When stroking the abdominal wall or after several sips of food, waves of gastric peristalsis can be seen. Often the stomach takes the form of an hourglass. This symptom is a constant feature of congenital pyloric stenosis and is of great importance in establishing the diagnosis.

X-ray examination. First, a survey radiograph of the abdominal cavity is taken with the child in an upright position. This reveals a large gas bubble and a high level of fluid in the distended stomach. There is little or no gas in the intestinal loops. Then they begin the contrast study. In newborns in the first days of life, iodolipol (5 ml) is used as a contrast agent, observing its passage through the gastrointestinal tract. Lack of gastric emptying for more than 24 hours indicates an obstruction in the pyloric region.

37. Differential diagnosis and treatment of pyloric stenosis

Differential diagnosis acute form of pyloric stenosis should be carried out with pylorospasm, gastric obstruction, congenital high intestinal obstruction, habitual vomiting.

In children of the first days of life, differentiation with pylorospasm is of the greatest importance due to the different tactics used in their treatment. It should be borne in mind that with spasm, the disease begins gradually, with regurgitation, which is intermittent, without significantly affecting the general condition of the child and his body weight. In those cases when an X-ray examination is performed to differentiate these conditions, it should be borne in mind that with pylorospasm, gastric emptying begins 10 minutes after taking a contrast agent and ends after 3-6 hours.

Congenital obstruction of the stomach is clinically and radiographically extremely difficult to distinguish from the acute form of pyloric stenosis. Usually the final diagnosis is established during surgery.

Congenital anomalies of the duodenum, in which the obstruction is located below the nipple of Vater, is usually easy to distinguish from pyloric stenosis by bile-stained vomit and a characteristic x-ray picture.

Palpation determination of the thickened pylorus and the establishment of lengthening and narrowing of the pyloric canal during x-ray examination speak in favor of pyloric stenosis. Sometimes contrast the substance (with pyloric stenosis) remaining in the stomach may appear on the x-ray as two depots located on both sides of the spine, which is similar to the x-ray picture with high intestinal obstruction. In these cases, the diagnosis is aided by lateral radiography—the dilated duodenum is usually located posterior to the stomach.

Habitual vomiting and regurgitation are quite common in children in the first months of life, but this dysfunction of the stomach usually does not change the general condition of the child, does not cause a drop in body weight.

Treatment. Preoperative preparation. Preparation for surgery along with examination does not exceed 24 hours and is aimed at reducing disturbances in water-salt metabolism, as well as treating aspiration pneumonia. Immediately before the operation, gastric contents are suctioned.

Postoperative treatment. 3-4 hours after the operation, if no injury was noted to the mucous membrane of the stomach or duodenum, the child is given 7-10 ml of a 5% glucose solution through the nipple, after 1 hour - 10 ml of expressed breast milk, and then (if there is no vomiting) is prescribed 2 ml of milk every 10 hours. To prevent wound infection and complications, antibiotics are used (6-7 days). Vitamin therapy is prescribed. Sutures are removed on the 10-12th day after surgery.

38. High congenital intestinal obstruction

The clinical picture of high congenital obstruction appears, as a rule, from the first day of life, and sometimes in the first hours after birth. The most constant and early symptom is vomiting. With obstruction of the duodenum above p. Vateri vomiting occurs soon after birth, the amount of vomit is plentiful, there is no admixture of bile in their composition, which enters the intestine entirely. With obstruction of the duodenum below p. Vateri, and also in the presence of an obstruction in the initial section of the jejunum, the vomit is stained with bile. After the newborn is attached to the mother's breast, vomiting becomes repeated and profuse, exceeding the amount of milk taken by the child. The frequency of vomiting and the amount of vomit vary somewhat depending on the type of obstruction. With atresia, it is more frequent, continuous, striking in its abundance. In the vomit, there is sometimes an admixture of blood. With partially compensated stenoses, vomiting occurs on the 2nd-4th day of the child's life and usually not immediately after feeding, but after 20-40 minutes.

Children with high congenital obstruction usually have meconium. If the obstruction is located above p. Vateri, the amount and color of the meconium is almost normal, and its discharge is observed until the 3-4th day. With lower obstruction, the amount of meconium is small, the consistency is more viscous than in a healthy child, and the color is grayish.

The behavior of a child with congenital high intestinal obstruction is normal on the first day, but later lethargy may appear. At first, the newborn actively sucks, but as the general condition worsens, he refuses to breastfeed. Characteristic is the progressive loss of body weight (0,2-0,25 kg per day). Already from the 2nd day the dehydration phenomena are clearly expressed.

The abdomen is swollen in the upper sections (especially in the epigastric region) due to the distended stomach and duodenum. In the first days, you can see the waves of peristalsis. After profuse vomiting, swelling in the epigastric region decreases, sometimes completely disappears. There is some retraction of the lower abdomen.

X-ray examination. The examination of the newborn begins with a survey radiography of the abdominal cavity in the anteroposterior and lateral projections with the child in an upright position. With high obstruction, radiological symptoms are quite characteristic. On the anteroposterior images, two gas bubbles with horizontal levels of liquid are visible, which corresponds to a distended stomach and duodenum; on the lateral images, there are also two horizontal levels located at different heights. The size of gas bubbles varies. With a complete interruption of patency in the underlying sections of the intestine, gas is not detected. In rare cases, with partially compensated stenoses and congenital volvulus, single small bubbles of gas can be seen in the intestine.

39. Low congenital intestinal obstruction

One of the main symptoms of low intestinal obstruction is absence of meconium. After the insertion of a gas tube or an enema, the newborn produces only lumps of colorless mucus.

Vomiting appears relatively late, by the end of the 2nd - on the 3rd day of life, and is usually not associated with food intake. The amount of vomit varies (vomiting is often profuse, sometimes resembling regurgitation), but there is always bile staining. Soon the vomiting takes on a meconium character and acquires an unpleasant odor.

The behavior of the child in the first hours after birth does not give grounds to suspect a pathology, but motor restlessness appears very soon. The general condition deteriorates rapidly, intoxication phenomena increase, the child becomes lethargic, adynamic, the skin takes on a gray-earthy color, there may be an increased body temperature (37,5-38 ° C).

On examination, even on the first day, a uniform bloating is detected, which progresses rapidly. The size of the abdomen after vomiting does not decrease. Through the anterior abdominal wall, intestinal loops stretched by meconium and gas are contoured. Their peristalsis is often visible, which is not traced in the later periods, since intestinal paresis occurs. Percussion determined tympanitis in all parts of the abdomen. Auscultation revealed rare deaf noises of intestinal peristalsis. Palpation of the abdomen is painful, accompanied by anxiety and the cry of the child.

With meconium obstruction, sometimes (on the first day after birth) it is possible to palpate a sausage-shaped mobile tumor corresponding to the terminal ileum stretched by meconium.

Atresia of the ileum, as well as the colon, can be complicated by meconium peritonitis, which occurs due to perforation of the overstretched blind end of the intestine. The general condition of the child at the same time deteriorates sharply, vomiting becomes continuous, body temperature rises. The anterior abdominal wall becomes pasty, a network of dilated venous vessels is visible.

X-ray examination. X-ray examination begins with overview photographs of the abdominal cavity. Radiographs show distended loops of intestine with multiple uneven horizontal levels (obstruction of the distal ileum and colon) or several large gas bubbles with wide levels (obstruction of the jejunum or ileum, meconium ileus). If low intestinal obstruction is suspected, a study is performed with a water-soluble contrast agent injected into the rectum with a syringe through a catheter. With low obstruction, radiographs show a sharply narrowed colon filled with a contrast agent. Perforation of the dilated section of the intestine above the site of obstruction is usually detected radiographically by the presence of free gas in the abdominal cavity.

40. Treatment of congenital intestinal obstruction

Preoperative preparation carried out strictly individually. In newborns with high intestinal obstruction, the duration and quality of preoperative preparation depend on the severity of the condition, the time of admission to the hospital, and the presence of complications.

With low intestinal obstruction, preoperative preparation usually does not exceed 2-3 hours and consists of general measures (warming the child, the introduction of cardiac drugs, vitamins, antibiotics, gastric lavage) and in severe cases (with pronounced intoxication, hyperthermia) is aimed at an intensive fight with these conditions.

Postoperative treatment. The patient is placed in a heated incubator with a temperature of 29-30 °C and 100% humidity, and is constantly given humidified oxygen, cardiac medications and antibiotics for 7-8 days.

A feature of caring for newborns who have undergone surgery for obstruction is the mandatory constant suction of the contents from the stomach (every 3-4 hours) until the discharge of green fluid stops.

Extensive manipulations on the intestine lead to a profound violation of its motility within a few days. In cases where an anastomosis has been created, its patency is restored gradually, and the accumulation of a significant amount of intestinal contents above the anastomosis may be accompanied by suture divergence. In order to prevent intestinal paresis and more quickly restore its function, epidural anesthesia is used in all newborns operated on for congenital intestinal obstruction.

In the first 2-3 days, children are completely on parenteral nutrition. Feeding through the mouth after surgery for high obstruction begins on the 3-4th day, low - not earlier than the 4-5th day. First give expressed breast milk in fractional doses (5-7 ml) after 2 hours (alternating with 5% glucose solution).

In children, after the formation of a "unloading" Y-shaped anastomosis, the introduction of fluid through the drainage begins the next day after the operation (3-5 ml every 2 hours), and dosed feeding through the mouth is prescribed from the 3-4th day.

The management of children with meconium ileus after the operation of creating an enterostomy according to Mikulich has some features. The child is injected with a 5% solution of pancreatin (7-5 ml) twice a day for 4-5 days into the afferent and outlet ends of the excreted intestine, which helps soften the meconium and mechanically remove it. Parenteral nutrition is carried out for the first 3-4 days, and then fractional feeding through the mouth begins according to the above scheme. At the same time, it is recommended (V. Toshovsky and O. Vichitil) 6-fold injection into the stomach of 0,5 ml of a 5% solution of pancreatin (3 ml per day). Establishing a diet in the future, it is necessary to introduce a lot of proteins and vitamins (especially vitamin A) with food, sharply limiting fats.

41. Circular stenoses of the intestine

clinical picture. The clinical picture depends on the degree of narrowing and its location. The first signs of obstruction with significant narrowing of the lumen of the small intestine are observed in early infancy. The child experiences periodic attacks of anxiety, bloating, and vomiting. Stools are rare, but independent, gases pass away. The attacks are short-lived, occurring several times a day, sometimes much less frequently. The baby does not latch on well and gains little weight. Gradually, attacks of pain become more intense, stool retention appears, the general condition worsens, and the child is sent to a surgical hospital with a diagnosis of intestinal obstruction.

When examining a patient, attention is drawn to bloating and some asymmetry of the abdomen. Visible peristalsis is usually determined. Intestinal noises are heard, percussion - tympanitis. The abdomen is slightly painful, muscle tension is not detected. On digital examination of the rectum, the ampoule is empty, there may be a small amount of feces. There is no chair, gases do not depart. After an enema, a temporary improvement may occur, gases can pass.

X-ray examination helps in making a diagnosis. Plain radiographs show many horizontal levels in the upper abdomen and gas-distended loops of the small intestine. A study with a contrast agent is possible only in the "light" interval. Given through the mouth, a liquid suspension of barium sulphate in a serial study (every 2 hours) can be detected due to a long delay above the site of narrowing.

The presence of stenosis of the colon appears at an older age, usually after a year. Initially, parents note frequent stool retention, the presence of vomiting, loss of appetite, an increase in the abdomen, and a lag in physical development.

Less pronounced stenoses for a long time may be accompanied by very poor symptomatology: constipation, mild pain attacks, decreased appetite. With age, the compensatory possibilities of the hypertrophied wall above the located intestine weaken, and the clinical picture becomes more definite. Attacks of pain intensify, repeat more often, usually combined with a long delay in stool. Gradually the stomach increases, there is vomiting. Chronic intoxication, hypochromic anemia develops. On palpation of the abdomen, the large intestine is distended with feces.

X-ray examination. Diagnosis is aided by X-ray examination with a contrast mass, which shows prestenotic dilatation and normal distal parts of the colon. In some cases, it is possible to contour the narrowing site.

Treatment. During the period of relapse of obstruction, emergency surgery is indicated. Surgery is performed under endotracheal anesthesia and blood transfusion, and a midline laparotomy is performed.

42. Ledd's syndrome

clinical picture. The clinical picture of recurrent midgut volvulus is characterized by its variability. Most often, the first signs of obstruction are vomiting and regurgitation of bile in children in the first months of life. Characteristic painful attacks can be one-time, repeated daily, or occur at intervals of several months or even years.

In some cases, one of the relapses of volvulus is accompanied by a pronounced picture of acute intestinal obstruction. Suddenly there are paroxysmal severe pains in the abdomen, repeated vomiting, retention of stool and gases.

When examining a child during a painful attack, there are some swelling of the epigastric region and retraction of the lower abdomen. Palpation is slightly painful, no formations in the abdominal cavity are not determined. On digital rectal examination, the sphincter is well contracted, the rectal ampulla is empty.

X-ray examination. General photographs of the abdominal cavity (vertical position of the child) show two horizontal levels of fluid, corresponding to a distended stomach and duodenum. There is a relatively small amount of gas in the intestines. A contrast study clarifies the diagnosis. This per os suspension of barium sulfate accumulates at the bottom of the stomach and contours the distended duodenum. After a few hours, barium is distributed in small portions throughout the small intestine, the loops of which are presented in the form of a conglomerate. In cases of suspected volvulus, it is advisable to perform irrigography to determine the location of the cecum. If the latter is located high, then one can think of Ladd's syndrome or compression of the duodenum by an abnormally fixed cecum.

Differential diagnosis. Differential diagnosis is carried out with diseases accompanied by vomiting and attacks of abdominal pain.

Worm infestation is a relatively common disease of older children, causing bouts of abdominal pain. Localized pain in the navel. During an attack, there is vomiting, nausea. The brevity of seizures, history data (the presence of worms in the child, etc.), laboratory tests (blood, feces) and examination of the child usually help to recognize the cause of the disease. However, in some children, attacks of pain during helminthic invasion are so strong and prolonged that the surgeon has a reasonable suspicion of mechanical obstruction.

Giardia cholecystitis is similar to recurrent obstruction, the presence of paroxysmal pain in the abdomen. However, their localization in the right hypochondrium, the presence of typical pain points, an enlarged liver, X-ray and laboratory data allow a correct diagnosis.

Treatment. Treatment of recurrent midgut volvulus can only be surgical.

43. Internal abdominal hernias

Malformations of the intestine and mesentery in some children cause incomplete narrowing of the lumen of the intestinal tube with a violation of its function, which creates the prerequisites for the periodic occurrence of attacks of acute obstruction. Similar conditions can also be associated with the presence of congenital cystic formations of the abdominal cavity and other causes. The first signs of the disease usually occur months or years after birth due to the weakening of the body's compensatory capabilities and changes in the nature of nutrition.

Recurrent bowel obstruction most often occurs in connection with the infringement of the intraperitoneal hernia and compression of the intestinal lumen by cystic formation.

Movement of intestinal loops into defects in the mesentery, omentum, or peritoneal pockets (without the exit of the viscera from the abdominal cavity) is commonly called internal hernias, which in children, as a rule, are congenital.

If the displaced intestinal loops are covered with sheets of peritoneum, which form a kind of hernial sac, then such internal hernias are called true. In cases of displacement of organs through the opening in the mesentery or other congenital defects, hernias occur that are not covered by the hernial sac, and they are called false. In children, paraduodenal hernias are predominantly found.

clinical picture. Internal abdominal hernias (both true and false) can be asymptomatic for an indefinite period of time and are first detected by intestinal obstruction in adults or older children. The possibility of acute intestinal obstruction occurring during the neonatal period cannot be ruled out. However, for internal abdominal hernias in children, the most typical symptomatology is recurrent obstruction.

X-ray examination. X-ray examination is of little help in recognizing internal abdominal hernias. In rare cases, it is possible to identify gas-filled loops of the small intestine on survey photographs, concentrated in the form of a regular round conglomerate (limited by the hernial sac).

To clarify the diagnosis, you can use a contrast study of the colon, which has an unusual position, bending around the hernial sac filled with strangulated loops of the small intestine.

Differential diagnosis. Differential diagnosis, as with other types of congenital recurrent obstruction, is carried out with diseases accompanied by abdominal pain, vomiting and intestinal discomfort.

Treatment. The operation is usually performed for urgent indications. Before the operation, the stomach is washed and intravenous drip infusion of fluid is started.

The duration of preoperative preparation is minimal - it is limited by the time necessary for drug preparation for anesthesia.

44. Compression of the intestinal lumen by cystic formations

Cysts of the abdominal cavity and retroperitoneal space, as well as cystic doubling of the gastrointestinal tract in some cases narrow the lumen of the intestinal tube and cause a symptom complex of recurrent obstruction.

clinical picture. In cases of compression of the intestinal lumen by a cyst, paroxysmal abdominal pain periodically occurs, the localization of which cannot be identified in young children. Older children complain of pain below the navel. The attacks are accompanied by vomiting and stool retention. When examining a child, asymmetry of the abdomen can be noted due to a protruding tumor-like formation and visible intestinal motility. Superficial careful palpation can sometimes identify a moderately mobile and painful cystic mass in the abdominal cavity. Its presence is confirmed by digital examination through the rectum. Detection of a small mesenteric cyst is almost impossible due to its easy displacement and difficulties associated with the patient’s anxiety.

X-ray examination. X-ray examination in such cases rarely helps to recognize the true cause of the disease.

Differential diagnosis. Complicated cysts must be differentiated from mechanical intestinal obstruction (chronic and acute) caused by other causes. A detailed analysis of anamnestic data (periodic attacks of pain, constipation, vomiting, abdominal enlargement) and clinical symptomatology (presence of a cystic mass in the abdominal cavity, atypical manifestations of supposed intussusception, helminthic obstruction), some radiological findings should be alarming in relation to a complicated mesenteric cyst.

Treatment. Children with complicated mesenteric cysts should be operated upon once the diagnosis is established. The choice of surgical intervention method is determined by the nature of the cyst and the patient’s condition.

postoperative treatment. All children are prescribed antibiotics intramuscularly, vitamins of groups B and C, heart medications (according to indications), oxygen for the first 2-3 days. In order to prevent pneumonia, the child is given an elevated position, physiotherapy, breathing exercises, and frequent turning in bed are carried out. In the presence of vomiting, the stomach is washed 1-2 times a day with a warm 1% soda solution. If the Ledd operation or the separation of adhesions was performed without violating the integrity of the intestine, then the child begins to drink by the end of the 1st day. For the prevention of pain and the fight against intestinal paresis, long-term epidural anesthesia (3-4 days) is indicated. In cases where a bowel resection was performed or a bypass anastomosis was formed, the child is on parenteral nutrition for 2 days. Compensation for the lack of proteins resulting from chronic malnutrition and losses during surgery is of great importance.

45. Acute intestinal intussusception

The introduction of a certain section of the intestine into the lumen below (or above) the located area is called intussusception. At the same time, at the injection site, the intestine has three cylinders: an external one and two internal ones - intussusception. The apex of the intussusception is usually called the head, which corresponds to the transition of the inner cylinder to the middle one. The increase in the length of the invaginated part of the intestine occurs only due to the screwing in of the outer cylinder; the “head” of the intussusception remains unchanged. The advancement of the intussusception is accompanied by “tightening” and pinching of the mesentery of the implanted part of the intestine between the internal and middle cylinders (the serous membrane facing each other). In rare cases, “double” intussusceptions are observed, in which the intussusceptum complex is introduced into the lower part of the intestine, forming 5 cylinders.

The direct cause of intussusception in children of the first year of life is considered to be a change in the dietary regimen characteristic of this age period. Various intestinal diseases (dyspepsia, colitis) are of some importance. In children older than 1 year, mechanical causes of intussusception are relatively common.

Intussusception can occur at any level of the intestinal tract. Isolated introduction of the large intestine into the large intestine and small intestine into the small intestine is relatively rare, mainly in children over the age of 1 year. Most often, the introduction occurs in the region of the ileocecal angle, which is associated with the anatomical features of this section of the intestine in infancy: greater mobility of the caecum and ileum, the frequent presence of a common mesentery, underdevelopment of the valvular apparatus of the Bauhinian valve, a discrepancy between the diameter of the ileum and its ampulla.

Not only the clinical picture, therapeutic measures, but to a certain extent the prognosis of the disease depend on the localization of the primary introduction (the level of formation of the vaginate head) and the nature of further progress. The most acceptable for practical purposes can be considered the classification of X. I. Feldman's intussusceptions:

1) small intestine intussusception (3,5%) - the introduction of the small intestine into the large intestine;

2) ileocolic invagination (41%) - the introduction of the ileum into the ileum and then into the colon through the Bauginian damper. With further advancement of the intussusceptum, the blind and further located sections of the colon are involved;

3) blind colonic invagination (52,7%) - the head of the invaginate is the bottom of the caecum. The appendix and the terminal ileum are passively retracted between the cylinders of the intussusceptum;

4) colonic invagination (2,8%) - the introduction of the colon into the colon;

5) rare forms of intussusception (isolated invasion of the appendix, retrograde intussusception, multiple).

46. Clinic of acute intestinal intussusception

Clinical picture of acute intussusception depends on the level of introduction of the intestine, the age of the child and the time elapsed since the onset of the disease.

Clinical picture of cecocolic and ileocolic intussusception. The disease begins acutely, in the midst of complete health. Suddenly the child begins to become extremely worried, scream, and convulsively kick his legs. The face becomes pale, sometimes covered in cold sweat. The attack of pain is usually short-lived (3-7 minutes), accompanied by vomiting and stops as suddenly as it began. The child immediately calms down, his behavior becomes normal; sucks the mother's breast and is interested in toys. After a few minutes (5-10, sometimes 15-20), the attack of pain repeats with the same intensity. Again, the child begins to kick his legs, scream, become extremely anxious, and rush about in bed or in the arms of his parents. Vomiting repeats. The occurrence of pain depends on pinching and tension of the mesentery, a sharp spasm of the intestine in the area of intussusception. Periodic increased peristalsis, followed by a weakening of intestinal motor function (response to sudden painful stimulation), explains the cramping nature of the pain. Their intensity depends on the compression force of the intussusceptum cylinders on the embedded mesentery and the degree of its tension.

As edema and circulatory disorders increase, pain sensations decrease due to the onset of neurological changes and limitation of invaginate advancement in the aboral direction.

Palpation of the abdomen is painless, the tension of the muscles of the anterior abdominal wall is not determined. One of the earliest and most persistent symptoms of intussusception is the presence of a tumor-like formation in the abdominal cavity, which is palpable along the colon.

Clinical picture of small bowel intussusception has some features depending on the severity of neurotrophic disorders in the intestine. The first signs of incipient implantation in infants will be intense restlessness and, as a rule, a high-pitched, loud cry. Older children complain of sharp pains. The child's face turns pale, vomiting appears, usually multiple. The duration of anxiety and cry is different (10-20 minutes). Then the patient calms down somewhat, but the typical "light" period does not occur, the child does not take the nipple, refuses the mother's breast, older children note the subsidence, but not the disappearance of pain.

Clinical picture of colonic intussusception. The penetration of the large intestine into the small intestine is manifested by less pronounced clinical signs than with other types of intussusception.

In an infant, the disease begins with a mild short-term anxiety. The general condition remains unchanged, pain attacks are relatively rare, there may be a single vomiting.

When examining a patient, it is always possible to feel the invaginate, which is localized in the left upper quadrant of the abdomen or the left iliac region. Finger examination through the rectum often allows you to determine the head of the intussusceptum.

47. Diagnosis of acute intestinal intussusception

Non-contrast survey radiography of the abdominal cavity does not provide significant assistance in establishing the diagnosis of intussusception and reveals only some indirect signs of obstruction (absence of gas in the large intestine, a homogeneous shadow due to intussusceptum, several loops of the small intestine swollen with gas with the presence of single horizontal levels of fluid). More valuable data for the diagnosis of intussusception is provided by a contrast study of the colon with the introduction of air. The indication for this research method is the doubt in the diagnosis or the need to clarify the type of invagination, but only in cases where the use of a conservative method of treatment is acceptable.

Differential diagnosis. Differential diagnosis must be made with diseases accompanied by attacks of abdominal pain, vomiting, bloody discharge from the rectum, and the presence of a tumor-like formation in the abdominal cavity.

In infants, intussusception is most often mistaken for dysentery. For dysentery, such an acute onset of the disease that occurs in the midst of complete health is uncharacteristic and is accompanied by severe bouts of abdominal pain, followed by "light" intervals, which is typical for intussusception.

Abdominal syndrome in Henoch-Schonlein disease often has manifestations similar to intussusception: sudden attacks of abdominal pain, vomiting, and bloody stools. The abdominal syndrome of Shenlein-Genoch disease is characterized by inconstancy and instability of symptoms, while with intussusception they persist and grow. A clinical feature of uncomplicated forms of abdominal purpura can be considered a discrepancy between the severity of the general condition of the patient and local signs of the disease.

In older children, intussusception often has to be differentiated from acute appendicitis. Symptoms of intussusception in older children are usually less pronounced than in typical cases in infants, however, consistent clinical examination reveals characteristic signs of the introduction of the intestines. In contrast to appendicitis with intussusception, abdominal pain is cramp-like in nature with "light" intervals. Signs of intestinal obstruction (stool retention, gases) are also not characteristic of appendicitis. With intussusception, the abdomen is always soft, while tension in the abdominal wall is the most constant symptom of acute appendicitis.

The most difficult differential diagnosis of intussusception with peptic ulcer of Meckel's diverticulum or intestinal hemangioma. In these diseases, intestinal bleeding is the first and main symptom. Unlike intussusception, bleeding is not preceded by pain attacks, the child remains calm. Older children do not complain about pain. Bleeding is usually so significant that symptoms of acute anemia soon come to light.

48. Treatment of acute intestinal intussusception

The basic principle of treatment of intussusception - early disinvagination is possible. Surgical tactics and methods of therapeutic measures depend on the localization and form of implementation, the timing of admission and the age of the child. There are two main methods of disinvagination - conservative and operative. Conservative treatment of invagination is relatively simpler and more atraumatic than the surgical method. It is based on the principle of mechanical action on the intussusceptum injected under pressure into the colon of liquid or air.

Recently, for the conservative treatment of intussusception, mainly dosed air injection into the colon is used.

Conservative treatment Intussusception of the intestines is indicated in infants with early admission to the hospital (up to 12 hours from the onset of the disease) and the established localization of the head of the intussusceptum in the colon.

Preoperative should be short-term and intensive, individual plan for each patient.

Postoperative treatment. The patient is placed in an intensive care unit, cardiac medications, broad-spectrum antibiotics, and oxygen therapy are prescribed. All children undergo prolonged epidural anesthesia for 4-5 days to prevent and treat intestinal paresis. Anti-adhesion physiotherapy is prescribed.

To detect relatively frequent hyperthermia, the child's body temperature is measured every 2 hours. An increase in temperature above 38 ° C is an indication for antipyretic measures.

Feeding of patients in whom the operation ended with disinvagination begins 6 hours after the intervention. Breastfed children are prescribed expressed human milk 15-20 ml every 2 hours. After a day, in the absence of vomiting and improvement in general condition, 10-15 ml of milk is added to each feeding, bringing to the 4-5th day to a normal amount corresponding to the mass body and age of the child.

These days, the missing amount of fluid is administered intravenously. If vomiting occurs after the first feeding, then the child is prescribed parenteral nutrition for a day, gastric lavage every 3-4 hours, and only after that fractional feeding begins again.

Older children 6-8 hours after the disinvagination operation are allowed to drink warm tea or glucose in the amount of 30-50 ml, prescribing parenteral nutrition at the same time. From the 2nd day, if there is no vomiting, a liquid diet is used, transferring to the postoperative table after 2-3 days, and the usual diet is allowed from the 6-7th day.

For children who underwent resection of the intestine, parenteral nutrition is carried out for three days, allowing them to drink a limited amount of liquid from the second day. Then a liquid postoperative table is prescribed and the diet is continued for up to two weeks. With an uncomplicated postoperative period, the child is discharged on the 12-14th day.

49. Adhesive intestinal obstruction

Adhesive process accompanies any inflammation or trauma of the abdominal cavity. Any laparotomy, even carried out under aseptic conditions, may be a predisposing moment to adhesion formation due to the inevitable damage to the serous membrane with tampons and surgical instruments. The process of adhesion formation is associated with the ability of the peritoneum to produce an adhesive exudate, which appears when the peritoneum is damaged or inflamed.

If there is no infection, then fibrin in the form of thin filaments settles on the damaged surface, and the cellular elements of the exudate undergo evolution and give rise to the formation of elastic and collagen fibers, which, intertwining with fibrin filaments, form a mesh. The surface of the mesh is covered with a thin layer of mesothelium, and thus the peritoneal cover is restored very quickly (in a few hours).

There is little fibrin in the exudate in the first hours, and its increase is noticeable by the 4-6th day. The death of the mesothelium during inflammation releases thrombase, under the influence of which fibrinogen is converted into fibrin. Other enzymatic processes lead to the formation of elastic and collagen fibers, which, settling on the damaged surface of the intestine, form a delicate mesh, which is subsequently covered with mesothelium. If for some reason these processes do not occur in a timely manner, then granulation tissue appears in the lesion.

In the next 5-7 days, with a favorable course of the underlying disease, adhesions usually resolve spontaneously. However, the process of eliminating planar adhesions can be longer, and then some of them grow into thin blood capillaries. Gradually (by the 4-6th week) separate cord-like adhesions are formed, the fate of which is different. Most of the resulting adhesions due to the restored peristalsis are overstretched, thinned and atrophied.

In the postoperative period, in most children, the adhesive process proceeds within the physiological framework and does not cause complications. However, in some cases, multiple adhesions stick together intestinal loops, disrupting the passage of the contents and creating conditions for the occurrence of obstruction, which is in the nature of obturation.

Formed cord-like adhesions usually do not manifest themselves, but in some children months or years after surgery, they can cause strangulation intestinal obstruction.

Thus, acute adhesive intestinal obstruction should be divided into two main groups with certain differences in clinical manifestations: early adhesive obstruction - obstructive, developing in the first 3-4 weeks after surgery; late adhesive obstruction - strangulation - occurring months and years after surgery.

50. Early adhesive intestinal obstruction. Clinic

Children with severe intestinal paresis and peritonitis in the first days after surgery develop early adhesive-paretic form of obstruction. Due to the severe general condition of the patient and the pronounced symptoms of the underlying disease, the symptomatology of obstruction is initially not clearly expressed and develops gradually. The child complains of periodically increasing constant pain in the abdomen, not much different from what occurred in connection with intestinal paresis. Gradually, the pain becomes cramping, vomiting becomes more frequent and profuse. If a child has had a permanent tube inserted into the stomach, an increase in the amount of fluid sucked out can be noted.

Palpation of the abdomen is painful due to existing peritoneal phenomena. Stroking the abdominal wall increases peristalsis and causes repeated bouts of pain. There is no independent stool, after a siphon enema, you can get a small amount of feces, mucus and gases.

X-ray examination helps confirm the diagnosis of obstruction. Plain abdominal radiographs show multiple horizontal levels and gas bubbles in distended intestinal loops.

It is extremely rare that acute intestinal obstruction develops in the first 2-3 days after a relatively mild operation, performed on an urgent basis or in a "scheduled" manner.

Symptoms occur suddenly against the background of the usual postoperative state. The child begins to scream from severe pain in the abdomen. There is vomiting of gastric contents.

On examination the abdomen is not swollen, sometimes its asymmetry and visible peristalsis are determined. Palpation is somewhat painful. Periodic ringing intestinal noises are heard. There is no chair, gases do not depart.

Simple form of early adhesive obstruction, which develops during the period of subsidence of peritoneal phenomena and improvement in the general condition of the child (5-13 days after surgery), manifests itself most clearly. The child suddenly experiences paroxysmal abdominal pain, the intensity of which gradually increases. Vomiting appears, first with food masses, then with an admixture of bile.

Examination of the abdomen reveals asymmetry due to swollen intestinal loops. Periodically, you can trace the visible peristalsis, which is accompanied by bouts of pain. Auscultatory listening to voiced intestinal noise. Percussion over areas of swollen intestinal loops is determined by tympanitis. Palpation may be accompanied by increased peristalsis and repeated pain attacks.

Early delayed adhesive obstruction, which occurred on the 3-4th week of the postoperative period, usually complicates severe, long-term peritonitis. Clinical symptoms in such cases are more often characteristic of simple early adhesive obstruction - they develop gradually, periodically intensifying.

51. Treatment of early adhesive intestinal obstruction

Treatment of early adhesive obstruction requires an individual approach depending on the general condition of the child, the development of the underlying disease, associated complications and the time elapsed since the first operation.

Conservative treatment begin after the detection of the earliest signs of adhesive obstruction. In all cases, feeding through the mouth is canceled, a set of measures is prescribed that enhance intestinal motility, prevent intoxication and dehydration, and also raise the reactive forces of the body. The intensity and duration of conservative treatment depends on the general condition of the child, the presence and stage of intestinal paresis, as well as the timing of the onset of symptoms of early adhesive obstruction.

If in the postoperative period, antiparetic measures included prolonged epidural anesthesia, then usually by the time the child develops adhesive obstruction, intestinal motility is partially restored. In such cases, the introduction of trimecaine into the epidural space is continued at the usual time, and at the same time other therapeutic measures are carried out: the stomach is washed with a 2% soda solution, a siphon enema is administered, a hypertonic saline solution and prozerin are administered intravenously.

In children with adhesive obstruction and severe intestinal paresis, conservative measures continue for at least 10-12 hours. If during this period the pain attacks increase or remain the same intensity, then an operation is prescribed.

With the appearance of obstruction in the 3-4th week of the postoperative period, the strangulation nature of the ileus is possible. In this regard, short-term intensive conservative therapy is allowed. The patient is washed with a stomach, put a siphon enema.

Operative therapy. The volume and nature of surgical intervention are determined by the form of early adhesive obstruction. It should be remembered that the separation of multiple planar adhesions and one-stage “radical” elimination of obstruction are the most risky operations. In case of early adhesive obstruction, the most appropriate surgical intervention is the formation of a temporary enterostomy with the expectation of resorption of adhesions and spontaneous restoration of normal passage of intestinal contents.

Postoperative treatment. All children are given prolonged epidural anesthesia for 4-5 days, and in the presence of an adhesive-paretic form of obstruction, medications are additionally prescribed that enhance intestinal motility. Intensive treatment of the underlying disease is continued. Parenteral nutrition is carried out by drip infusion into the subclavian vein. From the 2nd day, anti-adhesion physiotherapy is prescribed.

In the presence of an enterostomy, the wound is toileted several times a day and the skin is treated with zinc paste.

52. Late adhesive intestinal obstruction

Late adhesive obstruction usually develops several months or years after the transferred laparotomy among the full health of the child.

clinical picture. The child suddenly develops severe cramping pain in the abdomen. Soon vomiting begins. Attacks of pain become sharp and frequent. Small children periodically scream, worry, and take a forced position. There is no stool, no gas.

The abdomen is asymmetrical due to the protruding swollen loop of the intestine. Peristalsis is clearly visible, which increases when the abdominal wall is stroked. Initially, the abdomen is painless on palpation. Percussion determined moving tympanitis.

A digital examination of the per rectum shows some relaxation of the sphincter of the anus and an empty ampoule of the rectum. Colorless mucus or a small amount of feces may pass behind the finger. The general condition of children with late adhesive obstruction rapidly worsens due to dehydration, intoxication and adjoining intestinal paresis.

X-ray examination

X-ray examination helps the diagnosis. Plain abdominal radiographs show horizontal levels and low levels of gas in the lower regions.

Treatment

Treatment of late adhesive obstruction, as a rule, should be prompt.

Preoperative. Gastric lavage, siphon enema, prozerin are prescribed, and a bilateral perirenal novocaine blockade is performed according to A.V. Vishnevsky.

If during the period of 2-3 hours of treatment the pain in the abdomen does not stop, the stool is not obtained and the gases are not removed, the child is operated on.

With late admission, the general condition of children is usually severe. In such cases, intensive treatment is begun, aimed at eliminating exicosis and intoxication.

According to the indications, cardiac agents, oxygen therapy are prescribed. Produce gastric lavage and siphon enema. Improving the general condition, reducing intoxication and dehydration allow you to proceed with the operation. Preoperative preparation is carried out no more than 2-3 hours.

Postoperative treatment. The child is given epidural anesthesia for 3-5 days (in the presence of II-III degree paresis, the entire complex of antiparetic therapy is carried out), hormones are prescribed in an age-appropriate dosage (2-3 days), antibiotics (5-7 days) and cardiac drugs (according to indications). ). In cases of severe paresis or intestinal resection, parenteral nutrition is indicated for 3-4 days.

All children from the 2nd day undergo physiotherapy (5 days of UHF currents, then iontophoresis with l

53. Spastic intestinal obstruction

Spastic obstruction intestine is relatively rare. Usually the cause of its occurrence is helminthic invasion.

clinical picture. The clinical picture of spastic intestinal obstruction is characterized by the occurrence of short-term attacks of severe abdominal pain without a specific localization.

Body temperature is normal or subfebrile. Sometimes there is a single vomiting. Gases usually move away, there is no stool, but it may be normal.

The abdomen is not swollen, symmetrical, sometimes sunken, on palpation - soft in all departments; in rare cases, it is possible to determine a spasmodic intestine.

X-ray examination. X-ray examination of the abdominal cavity has only differential diagnostic value.

Differential diagnosis. Differential diagnosis is made with mechanical obstruction and renal colic.

In cases of acute and severe intestinal spasms, it is sometimes difficult to exclude mechanical obstruction. Carefully collected anamnesis (indication of existing ascariasis) and objective examination data

Of certain importance is an x-ray examination of the abdominal cavity, which, with mechanical obstruction, helps to recognize the disease. Significant assistance in the diagnosis is provided by bilateral pararenal blockade or short-term epidural anesthesia.

The persistent disappearance of pain after the blockade makes it possible to exclude mechanical intestinal obstruction, in which pain attacks do not go away, but often intensify. In doubtful cases, surgery should be considered as a last resort.

Renal colic, in contrast to spastic obstruction, proceeds with excruciating attacks of pain, which are localized in the lumbar regions and are usually accompanied by typical irradiation.

In addition, dysuric disorders and pathological urinalysis are characteristic of renal colic, and shadows of calculi can be detected on plain x-rays.

Treatment. Treatment of spastic obstruction usually consists of conservative measures. The child is prescribed antispastic agents, a cleansing enema, and a heating pad is placed on the stomach.

In severe cases, a bilateral pararenal blockade according to A.V. Vishnevsky or prolonged (1-2 days) epidural anesthesia is performed several times. The cause of spastic obstruction (ascariasis, etc.) identified during the examination of the child is an indication for appropriate treatment (under the supervision of a surgeon).

54. Paralytic ileus

The greatest practical importance in emergency surgery in children is paralytic ileus, which is the most common and serious complication of the postoperative period.

In the presence of peritonitis (even after the elimination of the source of its origin), intestinal paresis in most cases acquires a leading role in a complex chain of developing systemic and local disorders.

The increased intra-intestinal pressure resulting from paresis exacerbates circulatory disorders in the intestinal wall.

Functional changes in intra-intestinal nerve endings are replaced by their organic damage.

Loss of fluid, proteins, electrolytes in the intestinal lumen, a violation of the absorption process in it, lead to hypovolemia, corresponding to violations of the central and peripheral hemodynamics.

The permeability of the intestinal wall increases, and there is a risk of secondary infection of the abdominal cavity. Dehydration, bacteremia close the resulting vicious circle, which is the more difficult to break, the more time has passed since the onset of paresis.

The failure of conservative treatment of postoperative intestinal paresis is mainly due to the following reasons:

1) insufficient assessment of systemic disorders that occur with paresis and their role in maintaining it;

2) the lack of sufficiently clear ideas about the nature of local pathophysiological disorders developing in the intestinal wall;

3) irrational treatment that ignores the stages of systemic and local disorders in the clinical course of postoperative paresis. The restriction of intestinal motor function that arose after surgery should probably be considered as a biologically justified, reflex protective reaction that develops in response to bacterial, mechanical or chemical irritation of the peritoneum and the nerve endings of the abdominal organs.

The chain of this reflex can be closed not only in the higher, but also in the spinal sections of the central nervous system. The latter, obviously, is due to the occurrence of intestinal paresis in pneumonia, trauma and inflammatory processes of the urinary tract.

In accordance with modern pathophysiological views, it is believed that, regardless of the causes that caused intestinal paresis, two interrelated circumstances contribute mainly to maintaining it: the degree of disturbances in the peripheral nervous apparatus and the severity of microcirculation disorders in the intestinal wall.

55. Clinic and diagnosis of paralytic ileus

I stage occurs immediately after surgery. At this stage of paresis, there are no organic changes in the intramural plexuses; microcirculatory changes in the intestinal wall are transient.

The general condition of patients, indicators of hemodynamics and external respiration, shifts in water and electrolyte balance are due to the trauma and duration of surgery and are not threatening in case of replenished blood loss.

The abdomen is moderately, evenly swollen; during auscultation, peristaltic noises, uneven in strength, are clearly heard throughout; vomiting is frequent or rare. It is possible that this stage of paralytic ileus is preceded by a spastic stage, but it cannot be detected clinically in a postoperative patient.

Stage II. With it, along with functional ones, there are also organic changes in the peripheral nervous systems, caused by more pronounced disturbances of microcirculation.

The general condition of the patients is severe. Children are restless, there is shortness of breath, tachycardia; blood pressure is kept at normal levels or increased.

The abdomen is significantly swollen, with auscultation it is occasionally possible to listen to sluggish single peristaltic noises; vomiting of duodenal contents is often repeated.

III stage. In this stage of paresis, morphological changes in the nervous apparatus of the intestinal wall and abdominal autonomic nerve plexuses predominate; microcirculatory changes are characterized by paretic expansion of precapillaries and pathological deposition of blood in the capacitive veins. The general condition of the patients is very serious.

Children are rarely excited, more often inhibited. Severe tachycardia and tachypnea, a decrease in systolic blood pressure to 90 mm Hg are noted. Art. and below, oliguria up to anuria.

The abdomen is sharply, evenly swollen, sometimes rises above the costal arches; during auscultation, it is not possible to listen to peristalsis throughout its entire length - "dumb stomach".

With percussion, dullness in sloping places is most often determined; the latter is more due to the accumulation of fluid in the lumen of the stretched loops ("heavy intestine"), rather than its presence in the free abdominal cavity. This stage of paresis is characterized by vomiting with an admixture of stagnant intestinal contents.

Differential diagnosis. Mechanical obstruction differs from paralytic acuteness of its first manifestations.

It is much more difficult to diagnose early postoperative adhesive obstruction 8 hours or more after its onset, when there is no or almost no symptom of visible peristalsis.

The presence of a soldered large intestine indicates mechanical obstruction, its normal or enlarged diameter makes it possible to suspect intestinal paresis.

56. Treatment of paralytic ileus

Treatment of paralytic ileus consists of the correction of systemic disorders of homeostasis and the fight against local manifestations of paresis.

Measures for the treatment of local manifestations of paresis can be divided into three groups:.

1. Activities aimed at passive evacuation of stagnant contents: constant probing of the stomach; operational methods of decompression of the intestine by probing it through the gastrostomy, through the enterostomy, through the cecostomy, retrograde insertion of the probe through the rectum.

2. Activities aimed at enhancing intestinal motility due to the direct activation of its neuromuscular apparatus:

1) strengthening the tone of parasympathetic innervation with the help of cholinesterase inhibitors (prozerin), M-cholinomimetics (aceclidin);

2) activation of the smooth muscles of the intestine (pituitrin);

3) strengthening of local reflexes: enemas, intestinal electrical stimulation;

4) impact on the intestinal osmoreceptors by intravenous administration of a hypertonic solution of sodium chloride, sorbitol, sormantol.

3. Measures aimed at improving regional blood flow, interrupting the flow of pathological impulses from the inflammatory focus and creating "functional rest" of the intestine:

1) repeated one-time perirenal blockades; prolonged pararenal blockade;

2) repeated introduction into the abdominal cavity of a 0,25% solution of novocaine;

3) intramuscular and intravenous administration of gangliolytics;

4) prolonged epidural blockade;

5) hyperbaric oxygenation.

In the treatment of late-stage paresis, continuous transnasal intubation of the stomach is indispensable as long as the stagnant nature of the contents persists.

Recovery impaired bowel function, regional vegetative blockades (perinephric, epidural) are of paramount importance. The antiparetic effect of epidural blockade is most pronounced with its prophylactic use.

When using prolonged epidural anesthesia in children operated on for peritonitis, the effects of intestinal paresis of stage II-III stop in the vast majority of cases no later than 2 - the beginning of 3 days.

Prolonged epidural blockade leads to the restoration of the motor-evacuation function of the intestine in the first days after surgery and thus largely prevents the increase in intoxication.

The maximum blockade of sympathetic innervation to the greatest extent contributes to the activation of parasympathetic activity, leading to an increase in intestinal motility.

Authors: Drozdov A.A., Drozdova M.V.

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