HIGHER EDUCATIONAL INSTITUTIONS III-IV OF LEVEL OF ACCREDITATION
BY PREPARATION FOR THE PRACTICAL TRAINING
ON CHILDREN'S SURGERY
SUBSTANTIAL MODULES 5,6
ON the SUBJECT MATTER "CHILDREN'S SURGERY"
ON THE SPECIALITY: THE MEDICAL HAS PUT
THE MAINTENANCE OF METHODICAL WORKINGS OUT
For independent work of students
The thematic plan of a practical training
On semantic modules 5,6
1. The got intestinal impassability. 3
2. Bleedings from the alimentary system. A portal hypertensia. 19
3. A polytrauma at children. The occluded trauma of a gaste. A trauma of a thoracal lumen and esophagus damage. 38
4. Inflammatory diseases of an abdominal lumen. 61
5. Purulent diseases of lungs and a pleura. 83
6. Pyoinflammatory diseases of bones and joints. Pyoinflammatory diseases of soft tissues. 100
7. An urolithiasis. A syndrome of a hydropic scrotum. Traumatic damages мочевыделительной systems. 113
8. Good-quality and malignant neoplasms of soft tissues. Nefro neuroblastomas. Mediastinum tumours. 133
Внеудиторна independent work of students.
9. A deontology of children's age. 162
10. Features of an antibioticotherapia at children. 168
11. Different forms of an invagination of an intestine at children. 178
12. Complications of pyoinflammatory diseases at newborns. 187
13. A puncture of joints at children. 193
14. The Toksiko-septic shock at children. 198
15. Chemotherapeutic treatments of malignant neoplasms. 205
16. Laparocentesis at children. 213
17. Technics of a laparoscopy at children. 218
18. Possibilities of ultrasonic at children. 225
The got intestinal impassability
1. A theme urgency. Intestinal impassability is a syndrome which arises at various diseases of a gastrointestinal tract and shows disturbance of a peristalsis and эвакуаторной functions with morphological changes of the amazed part of an intestine.
Intestinal impassability is observed in 9 % of all patients with an acute pathology of an abdominal lumen. Among all kinds of the got intestinal impassability more often others at children meets dynamic паретическая impassability. More than 80 % of the got mechanical intestinal impassability are an acute invagination of an intestine. Disease can meet at any age. Boys are ill twice more often than girls.
Last years it is not observed tendencies to reduction of patients with this pathology.
To brake there are following kinds of an invagination:
• it is thin-is thin intestinal,
• thickly-thickly intestinal,
• the ileocecal form (podvzdoshno-obodochnaja, simple and complex; podvzdoshno-VALVING colonic and it is blind-obodochnaja).
2. Specific goals:
1. To familiarise with the most frequent forms of the got intestinal impassability at children.
2. To study an invagination, as the most frequent kind of the got intestinal impassability and its feature.
3. To acquire principles of diagnostics and treatment of adherent intestinal impassability.
4. To pay attention to modern methods of treatment паретической of intestinal impassability.
3. Basic knowledge, abilities, skills themes necessary for studying
Names of the previous discipline. The received skills.
1. Anatomy. Knowledge of anatomy of members of an abdominal lumen and its feature at children.
2. Physiology. Knowledge of physiology of a gastrointestinal tract at children.
3. Propaedeutics of children's illnesses. Inspection of the child with intestinal impassability. A case history writing.
5. A roentgenology. Interpreting of data of a X-ray inspection.
5. Surgical illnesses, operative surgery and topographical anatomy. Definition of priority methods of research and the indication to an operative measure.
4. Tasks for independent work by preparation for employment.
4.1. The list of the basic terms which the student should acquire by preparation for employment.
The term. Definition.
1. An invagination Infiltration of one department of an intestine into another.
2. Пневмоколография. A method of a X-ray inspection of an intestine when a contrast agent is air.
3. A tonometer. The device for measurement of arterial pressure.
5. An intestine intubation. Carrying out of a special probe in a gastrointestinal tract.
4.2. Theoretical questions to employment:
1. Kinds of the got intestinal impassability.
2. Definition of a paresis of an intestine.
3. Radiological stages of a paresis of an intestine.
4. Modern methods of treatment of a paresis of an intestine.
5. Clinical symptoms of acute intestinal impassability.
6. Classification of acute adherent impassability.
7. Kinds of operative measures at adherent impassability.
8. To make definition of an invagination of an intestine.
9. Frame инвагината.
10. The causes of an invagination of an intestine.
11. Theories and an invagination pathogeny.
12. Classification инвагинациии an intestine.
13. The basic clinical symptoms of an invagination of an intestine.
14. Flow of an invagination of an intestine.
15. Methods of diagnostics of an invagination of an intestine.
16. Differential diagnostics.
17. Procedure пневмоколографии.
18. Contraindications for conservative disinvagination.
19. Procedure of conservative disinvagination.
20. Indications to an operative measure.
21. Procedure of operative disinvagination.
22. Surgical tactics of operative treatment of disinvagination.
23. Results of treatment.
4.3. Practical works (problem) which are carried out on employment.
1. To collect complaints, the anamnesis of life and disease at the sick child with the got intestinal impassability (ПКН).
2. To show survey, a palpation and a percussion of members of an abdominal lumen and to compound the plan of inspection of the patient with ПКН.
3. To carry out differential diagnostics ПКН with development disadvantages.
4. To interpret data of survey roentgenograms of members of an abdominal lumen and auxiliary methods of diagnostics.
5. To estimate gravity of a state of the patient with ПКН and to define rendering assistance philosophy.
6. To define the general principles of medical tactics of patients with ПКН.
7. To acquire indications to operative treatment ПКН.
8. To show technics of execution пневмоколографии, at an invagination at children.
9. To define the basic methods of an operative measure at ПКН at children.
10. To define the basic methods of treatment got паретической and dynamic impassability.
11. To be able to supply назогастральный a probe at an intestine paresis.
12. To master various kinds of clysters at ПКН.
The theme maintenance.
Intestinal impassability - a morbid condition bound to occurrence of an interrupting in progression of intestinal contents (at mechanical impassability) or as a result of peristalsis disturbance (at functional impassability. Mechanical impassability shares on congenital and got, on the occurrence mechanism on обтурационную, странгуляционную and admixed (invagination), and also a torsion. On occurrence level on high (level of an initial third of jejunum) and low. High impassability educes more roughly, quickly result ins to vodno-ELECTROLYTIC and hemodynamic disturbances. Low impassability proceeds more slowly, a leading syndrome is intoxication development.
The got intestinal impassability can meet at any age. Most typical for children an intestine invagination, adherent intestinal impassability, dynamic impassability.
On a state of passableness of intestinal contents: full and particulate.
On clinical flow: acute and chronic.
On a causative factor: mechanical and dynamic.
To mechanical acute intestinal impassability (ОКН) carry:
- Странгуляционную ОКН (blood supply disturbance, веностаз): infringement, a torsion;
- Обтурационная ОКН (a tumour, a foreign body, a ball of worms, a coprostasia, a prelum outside);
- Paralytic (a peritonitis, damages of a spinal cord, a venenating, etc.);
On impassability level distinguish high ОКН (enteric) and low ОКН (it is thin colic).
At acute обтурационной intestinal impassability, beginning from an interrupting place proximally the intestine swells, overflowed with intestinal contents and gases. The side swells, then истончается, in it there are hemorrhages, fibrinferments of small pots (veins) that result ins to a necrosis.
For странгуляцийнои ОКН characteristicly fast disturbance of a circulation, a lymph drainage and alterative-destructive processes. The most expressed changes are in compression places (странгуляцийних lines). Macroscopicly amazed loop at first bluish-red, and in 20-24 hours becomes black with available hemorrhages and тромбовированными veins. странгуляцийной change lines pass in a place in five stages:
- Compression of all layers with an anaemia;
- A compression failure, a necrosis mucous, a thinning подслизистого a layer and deformation of muscular fibers;
- Destruction of muscular fibers;
- A prepunched state of a serous cover;
- Punching of a serous cover.
The hyperinflate resulting intestine истончается, in it comes a capillary stasis, hemorrhages which are more narrow in 20-24 hours propagate from a compression place on 40-60 the Destructive changes of an abducent loop of an intestine below a lesion place see propagate till 8-10 the Hyperinflate intestine see becomes атоничной, easily permeable for microorganisms and their toxines. In an abdominal lumen occurs transparent трансудат in which it is gradual through an intestinal side inpour formulated elements and bacteria - трансудат becomes cloudy, dark-brown with a putrefactive odour. There is a peritonitis.
The basic pathomorphologic changes at ОКН
- Disturbance of a passage of intestinal contents → a stasis → intestine dilating → distress of motor function → веностаз → a paresis.
- Disturbance of gastrointestinal secretion towards its augmentation. In norm (at the adult) within days in an organism 6-8 l of digestive juices enter: spits - 1500 ml; a gastric juice - 1500 ml; biles - 800-1000 ml; pancreatic contents - 1000-1200; intestinal contained - 4000-5000 ml. Only 6000-8000 ml, which in standard conditions completely реабсорбируются.
- Disturbance of an adsorption from an intestine (Samarin's theory);
- Losses of a considerable quantity of water and electrolytes as outside (vomiting), and in an intestine lumen "a sequestration in the third space" and a filtration in an abdominal lumen. A hypovolemia, a hypopotassemia, a hypoproteinemia, deficiency of a serotonin. It is necessary to notice, that diurnal loss of protein in grammes compounds: at обтурационной obstructions - 50-100 g, at a torsion of a thin intestine - 100-170 g, at adherent impassability - 100-150 g, at a nodulation - 300 g;
- Depression ОЦК, is bound to fluid loss → haemoconcentration (hematocrit growth) → a hypovolemic shock, with development of syndrome ДВС → occurrence of a shock lung, hepatic and renal dysfunction, a hypoxia;
- An intoxication of an organism as a result of an adsorption of toxines, microbes and decomposition products of proteins from an intestine and an abdominal lumen.
In a clinical pattern mechanical ОКН excrete three seasons or stages:
- Initial or "илеусного cry" - from 2 till 12 o'clock. Educes owing to passage disturbance on an intestine, it is characterised гиперперестальтикой, a distention of an intestine above an obturation place, a colicy pain, vomiting. The necrosis comes quickly.
- A stage of hemodynamic distresses - from 12 till 24 o'clock. The pain becomes a constant, the gaste is blown up, azygomorphous, there is a full delay отхождения fecal masses and gases. An intestine peristalsis flabby, there are the hemodynamic changes bound to a hypovolemia and centralisation of a circulation. Thirst, dryness of tongue, depression of a turgor of a skin, depression of a tonus of eyeballs, BP depression, a tachycardia, hematocrit rising, fall of cervical veins, diuresis reduction is observed.
- A stage of a peritonitis and multiorgan dysfunction. A state of the patient the extremely serious, a Hippocratic face, dry tongue, vomiting by fecal contents, a gaste it is blown up, the peristalsis is not auscultated, the body heat, frequent sphygmus, a BP to 60-70 mm Hg Educes a hypovolemic shock, a hypopotassemia, a blood acidosis. The hypomyotonia, depression of jerks, the general delicacy, apathy, BP depression, disturbance of a warm rhythm, a systolic apex murmur, an intestine paresis testifies to a hypopotassemia. In serious cases - a breath paralysis, an asystolia.
Basic clinical signs ОКН:
- A paroxysmal pain. At странгуляционной ОКН - a constant pain which strengthens on всоте a peristaltic wave. At обтурационной ОКН - a pain only at peristalsis height, in the started cases - a constant pain.
- Vomiting. At high ОКН does not bring simplification. At low ОКН - in the disease beginning is absent. In vomitive masses stomachal contents, then bile, in the started cases - dark fluid with a feces odour.
- A delay of a chair and gases.
- The general state - in most cases serious.
- Position in bed on a back or (edgewise seldom). The patient restless during a pain attack, his face expresses sufferings.
- The body temperature in the beginning normal, then drops. In the presence of a peritonitis the temperature increases to 38-400С.
- Sphygmus at first without changes, then becomes frequent, weak filling and a strain.
- The BP drops (result of a hypovolemia and a hypopotassemia).
- Tongue initially wet, is covered by grey scurf, then dry with dirty scurf.
- The gaste is blown up, at a nodulation - azygomorphous.
- The peristalsis at first enhanced and sonorous, then weakens and remits (a symptom "death silence).
- A symptom Bringing down - at gaste survey lineaments of a swollen loop are visible, or the swollen loop of an intestine is palpated балоноподобная.
- Sklyarov's symptom - "capotement" at a lung сотрясании an abdominal wall.
- Symptom Кивуля - at a percussion with simultaneous auscultation of a gaste becomes perceptible a high thympanitis with metal shade over overflowed with gases and a swollen loop of an intestine.
- Symptom Спасокукотського - at auscultation is audible "hum of a dropping drop".
- A symptom Hose pipes - peristalsis intensifying at a lung сотрясании or palpations of a forward abdominal wall.
- The symptom of "death silence" - is not auscultated a peristalsis.
- Symptom Лотейсена - at auscultation is not auscultated a peristalsis and respiratory hums and warm tints (a peritonitis sign) are auscultated.
- Symptom Мондоро - a rigidity of a forward abdominal wall which reminds a consistence of a swollen ball (a peritonitis sign).
- Symptom Дансе - asymmetry of the right ileal range at a caecum torsion.
- Bayer's symptom - asymmetry of a gaste ("a slanting gaste") всдедствие шинообразного раздутия a sigmoid intestine.
- Symptom Tsege-Mantejfelja - is possible to introduce into a rectum (adult) only 300-500 ml of water. The larger volume pours out by a clyster handpiece (a sign low colic ОКН).
- Symptom Грекова - an atony and зияние a fundament.
- Симтом doctors of Obuhovsky hospital - балоноподобное раздутие the empty ampula of a rectum.
- Symptoms ShChetkina-Bljumberga, Voskresensky, кашлевой a symptom (a peritonitis sign).
- The review per rectum: a fecal blockage, a tumour, инвагинат, blood on a glove.
For diagnostics complaints, the illness and life anamnesis, physical methods of inspection, blood bulk analysis (a hyperglobulia, a leukocytosis, formula alteration to the left, high haemoglobin, a hematocrit and an ESR), urine bulk analysis (an oliguria → анурия, protein presence, a leukocyturia, a cylindruria), a blood biochemical analysis (a disproteinemia, crude protein depression, reduction of maintenance Cl, To, Na, rising of a creatinine, urea, nitrogen), survey roentgenography of members of an abdominal lumen (bowl Клойберга and an automobile tyre symptom) matter.
Странгуляционная ОКН. To it carry: turn, a nodulation and infringement. The mesentery torsion on an axis can be on 180-3600 and more.
Torsion of a thin intestine - the beginning subitaneous from a strong "tearing apart" pain in epigastriums or mesogasters. The pain paroxysmal and intolerable with иррадиацией in a back, a loin, a thorax, constantly strengthens at breath and locomotions. Almost simultaneously there is a vomiting which does not bring simplification. Pallor of integuments and mucous becomes perceptible, the person expresses pavor, tongue is imposed by grey scurf, dry. A gaste at first a usual configuration, soft and малоболезненный, except for a field in region strangulations. Later the gaste is blown up, positive symptoms Bringing down, Sklyarov, Кивуля, Спасокукотського, Obuhovsky hospital. Quickly there is a tachycardia, a hypotension, there are bowls Клойберга in мезогастральний ranges on the survey roentgenogram of members of an abdominal lumen in vertical position.
Caecum torsion - the beginning acute, with a strong pain in the right half of gaste or in the field of a belly-button, a gaste azygomorphous, positive symptoms Bringing down, Дансе, Кивуля, occur bowls Клойберга on the survey roentgenogram of members of an abdominal lumen in vertical position.
The torsion of a sigmoid intestine arises in advanced age is more often, there is a paroxysmal pain in the left ileal range with иррадиацией in a loin. The nausea and vomiting in serotinal stages, quickly occurs a delay отхождения a chair and gases, Bayer's positive symptoms, Кивуля, Sklyarov, Spasokukotsky, Tsege-Mantejfelja, Грекова, Obuhovsky hospital, there are bowls Клойберга on the survey roentgenogram of members of an abdominal lumen in vertical position.
Nodulation - a torsion of two or more segments of an intestine with formation of a steady conglomerate. A clinical pattern same, as well as at a torsion, however the general state of the patient more serious.
The differential diagnosis make with mechanical ОКН, dynamic ОКН, stratifying аневризмой a ventral aorta, the abdominal form of a myocardial infarction, a pleuropneumonia, a ruptured ulcer, an acute pancreatitis.
Treatment странгуляцийной ОКН. After short (1-1,5 hours) preoperative preparation (siphon a clyster, спазмолитики, anaesthetising, massive infusional therapy with its continuation during operation - saline solutions, plasma, an albumin, рефортан, стабизол, инфезол, Лактопротеин with сорбитолом, an oxygenotherapy) make operative treatment:
- A laparotomy with elimination of a torsion and liquidation штранги;
- If the intestine loop is nonviable - a resection, an anastomosis «the extremity in the extremity»;
- At a torsion сигмы - elimination of a torsion and сигмопексия (operation Gagen-Torna);
- At a necrosis of a sigmoid intestine - its resection with seizure of 10-20 sm приводной loops with deducing одноствольного противоестетственного passage (одноствольной ostomies) and a resection to 10 sm of an abducent loop with ушиванием it tightly (operation Гартмана);
- At infringement of a loop in hernial collars - dissection of the restraining ring;
- A decompression and mechanical excision of intestinal contents of a thin intestine through назогастральный a probe, or девульсия a sphincter of a rectum and contents excision through a rectum.
In the postoperative season: early stimulation of a peristalsis, antibacterial and infusional therapy.
Обтурационная ОКН can be caused:
- An obturation of a lumen of an intestine a foreign body, fecal or a gallstone, a ball of ascarides, a besoar;
- Narrowing of a lumen of an intestine at the expense of pathological processes in its side (a tumour, cicatrixes at illness of the Cron, an intestine tuberculosis);
- Compression of a lumen of an intestine from the outside: adnations, a tumour, an inflammatory infiltrate.
Disease begins with a strong paroxysmal pain, котораю in мижприступном the season disappears, and then accrues. Further the paroxysmal pain passes in a constant. Positive symptoms Bringing down, the Hose pipe, Sklyarov, Spasokukotsky, Лотейсена, рентгенологически - bowls Клойберга and an "autosplint" symptom. At tumours the clinical pattern educes gradually.
Treatment обтурационной ОКН. After carrying out 3-4 hour preoperative preparations (abstersive and some siphon clysters, spasmolytic therapy, infusionally-replaceable therapy, antibacterial therapy) ОКН can be liquidated. In this case perform planned operation after an establishment of cause ОКН. At impossibility to liquidate ОКН conservative measures - ургентная operation:
- In the presence of fecal masses, gallstones, foreign bodies, a ball of ascarides - ентеротомия and excision of cause ОКН;
- At adnations - their dissection;
- At a necrosis of a thin intestine - a resection некротизированного a field and 10-20 sm приводной loops and 5-15 sm deflecting. An anastomosis it is expedient to impose "the extremity in the extremity";
- At a tumour of a sigmoid intestine - operation Гартмана with an oncotomy.
The invagination - the admixed form of intestinal impassability having signs both странгуляцийной and обтурационной of impassability, also shows as introduction of one department of an intestine in a lumen of another, this kind of impassability compounds to 90 % of all kinds of impassability at children of early age. Characteristic age - 3-9 months. Distinguish an enteric, colic and ileocecal invagination.
2. Inflammatory diseases желудочно an intestinal tract.
3. Mechanical factors: diverticulum Меккеля, intestine tumours, developmental anomalies of an intestine.
At children after 1 year on the contrary.
If to consider background factors, and that that they are changeable at children about one year, there is clear an importance of the basic conservative approach to treatment. Owing to action of the listed factors there is a nonperishable enterospasm which under the influence of a peristalsis advances in a caudal direction. Инвагинат advances along an intestine. Its progression is accompanied by retraction in a mesentery of an intestine and its further infringement. The venous circulation is broken, there is a stasis, an edema, and then - an emigration and a bleeding, an edema of an intestinal side, inflammatory changes in it, fibrine deposit between choronomic and intrinsic cylinders, their coagglutination. Инвагинат migrates on an intestine course owing to what can drop out through a rectum. Circulatory disturbances result in to an intestine necrosis, first of all in region the greatest infringement. Thus, as wrote Мондор «. . Disease flies gallop and to us, to clinicians, it is not necessary to move on it the turtle gait... »