Symptoms and treatment of intestinal obstruction. Specific symptoms of windows Diagnosis of the form of intestinal obstruction
Malfunctions in the digestive tract can lead to dangerous conditions. About 3% of such cases in abdominal surgery are intestinal obstruction. Pathology in children and adults develops quickly and has many causes. Already in the first 6 hours from the onset of signs of the disease, the risk of death of the patient is 3-6%.
Classification of intestinal obstruction
The pathology is associated with impaired movement of contents or chyme through the digestive tract. Other names for the disease: ileus, obstruction. The ICD-10 code is K56. Based on its origin, the pathology is divided into 2 types:
- Primary– associated with abnormalities in the structure of the intestinal tube that occur in the womb. It is detected in children in the first years of life. In 33% of newborns, pathology occurs due to intestinal clogging with meconium, the original feces.
- Secondary– acquired disease, develops under the influence of external factors.
According to the level of location of the area of obstruction, the pathology has 2 types:
- Short– affects the large intestine, occurs in 40% of patients.
- High– small intestinal obstruction, accounts for 60% of cases.
According to the mechanisms of development, ileus is divided into the following subtypes:
- Strangulational– blood circulation in the gastrointestinal tract is disrupted.
- Obstructive– Occurs when there is a blockage in the intestines.
- Mixed– this includes intussusception (one section of the intestinal tube is embedded in another) and adhesive obstruction: develops with rough cicatricial adhesions of tissue.
- Spastic– hypertonicity of intestinal muscles.
- Paralytic– the force of movement of the intestinal walls is reduced or absent.
Based on their effect on the functioning of the digestive tract, there are 2 forms of pathology:
- Full– the disease manifests itself acutely, the movement of chyme is impossible.
- Partial– the intestinal lumen is partially narrowed, the symptoms of the pathology are erased.
According to the nature of the course, intestinal obstruction has 2 forms:
- Acute– symptoms arise suddenly, the pain is severe, the condition quickly worsens. This form of pathology is dangerous for the death of the patient.
- Chronic– the disease develops slowly, relapses occur occasionally, constipation and diarrhea alternate. When the intestines are blocked, the pathology moves to the acute stage.
Causes
The development of pathology is based on the following mechanisms:
- Dynamic– failure of intestinal muscle contraction processes. Fecal plugs appear that block the lumen.
- Mechanical– obstruction is associated with the appearance of an obstacle to the movement of feces. Obstacles are created by intestinal volvulus, knots, and bends.
- Vascular– develops when blood flow to an area of the intestine stops and tissues die: a heart attack occurs.
Mechanical
Obstruction develops due to obstacles in the path of chyme (intestinal contents), which appear against the background of such pathologies and conditions:
- fecal and gallstones;
- tumors of the pelvic and abdominal organs – compress the intestinal lumen;
- foreign body;
- bowel cancer;
- strangulated hernia;
- volvulus;
- cicatricial bands, adhesions;
- bending or torsion of intestinal loops, their fusion;
- rise in intra-abdominal pressure;
- overeating after a long fast;
- obturation – blockage of the intestinal lumen.
Dynamic
Pathology develops due to intestinal motility disorders, which occur in 2 directions: spasm or paralysis. Muscle tone increases under the influence of such factors:
- foreign body;
- worms;
- colic in the kidneys, gall bladder;
- acute pancreatitis;
- pleurisy;
- salmonellosis;
- abdominal injuries;
- damage to the nervous system;
- traumatic brain injury;
- circulatory disorders in the vessels of the mesentery.
Dynamic intestinal obstruction with paresis or muscle paralysis develops against the background of the following factors:
- peritonitis (inflammation of the peritoneum);
- operations on the abdominal area;
- poisoning with morphine, salts of heavy metals.
Symptoms
Signs of intestinal obstruction in adults and children in acute form vary depending on the stage of the pathology:
- The early period is the first 12 hours from the onset of ileus. Abdominal bloating, a feeling of heaviness, sharp pain, and nausea appear.
- Intermediate – next 12 hours. The signs of pathology are intensifying, the pain is constant, vomiting is frequent, there are bowel sounds.
- Late – terminal stage, which occurs on the 2nd day. Breathing quickens, temperature rises, and intestinal pain intensifies. Urine is not excreted, there is often no stool - the intestines are completely clogged. General intoxication develops and repeated vomiting occurs.
The main symptoms of intestinal obstruction are stool disturbances, bloating, severe pain, but with a chronic course other signs of pathology appear:
- yellow coating on the tongue;
- dyspnea;
- lethargy, fatigue;
- decreased blood pressure;
- tachycardia.
Intestinal obstruction in infants is a dangerous condition when there are the following symptoms of pathology:
- vomiting with bile;
- weight loss;
- fever;
- bloating in the upper part of the abdomen;
- gray skin.
Pain
This sign of pathology appears against the background of damage to nerve receptors. At the early stage, the pain is acute, occurs in attacks within 10-15 minutes, and then becomes constant and aching.
If this symptom disappears after 2-3 days during an acute course of the disease, call an ambulance - intestinal activity has stopped completely
Retention of stool
An early symptom of the disease, which indicates low obstruction. If the problem is in the small intestine, stool is frequent in the first day, constipation and diarrhea alternate. When complete inferior ileus develops, feces stop coming out. With partial constipation, constipation is constant, diarrhea rarely occurs. In children under one year of age, one section of the intestinal tube is often embedded in another, so blood is visible in the stool. In adults, its appearance requires calling an ambulance.
Vomit
This symptom occurs in 70-80% of patients. At an early stage of the disease, gastric masses come out. Afterwards, vomiting is frequent, has a yellow or brown tint, and a putrid smell. Often this is a sign of small intestinal obstruction and an attempt to remove feces. If the colon is affected, the patient experiences nausea, vomiting occurs rarely. In the later stages it becomes more frequent due to intoxication.
Gases
The symptom is caused by stagnation of feces, paresis of nerve endings and dilation of intestinal loops. Gases accumulate in the abdomen in 80% of patients; in the spastic form of ileus they rarely appear. With vascular - swelling over the entire surface of the intestine, with mechanical - in the area of the afferent loop. Children under one year old do not pass gas and experience severe abdominal pain. The baby often spits up, cries, refuses to eat, and sleeps poorly.
Valya's symptom
When diagnosing intestinal obstructions, 3 clinical signs of pathology are assessed:
- in the area of blockage, the abdomen is swollen, there is its asymmetry;
- contractions of the abdominal wall are clearly visible;
- the intestinal loop in the area of swelling is easy to feel.
Complications
When fecal debris is not removed from the intestines for a long time, it decomposes and poisons the body. The microflora balance is disrupted and pathogenic bacteria appear. They release toxins that are absorbed into the blood. Systemic intoxication develops, metabolic processes fail, and coma rarely occurs.
More than 30% of patients with ileus die without surgery
Death occurs due to the following conditions:
- sepsis – blood poisoning;
- peritonitis;
- dehydration.
Diagnostics
To diagnose and separate intestinal obstruction from acute appendicitis, pancreatitis, cholecystitis, perforated ulcers, renal colic and ectopic pregnancy, the gastroenterologist, after examining the patient’s complaints, conducts an examination using the following methods:
- Auscultation– intestinal activity is increased, there is a splashing noise (Sklyarov’s symptom) at an early stage of the pathology. Later, peristalsis weakens.
- Percussion– the doctor taps the abdominal wall and, if there is obstruction, detects tympanitis and a dull sound.
- Palpation– in the early stages, Val’s symptom is observed, in the later stages – the anterior abdominal wall is tense.
- X-ray– intestinal arches swollen with gas are visible in the abdominal cavity. Other signs of pathology in the image: Kloiber cups (dome above the liquid), transverse striations. The stage of the disease is determined by injecting a contrast agent into the intestinal lumen.
- Colonoscopy– examination of the colon using a probe that is inserted rectally. The method identifies the causes of obstruction in this area. In case of acute pathology, treatment is carried out during the procedure.
- Abdominal ultrasound– identifies tumors, foci of inflammation, conducts differential diagnosis of ileus with appendicitis, colic.
Treatment without surgery
In the chronic course of the pathology, the patient is hospitalized and treated in a hospital.
Before the ambulance arrives, do not take laxatives or do enemas.
Treatment goals:
- eliminate intoxication;
- cleanse the intestines;
- reduce pressure in the digestive tract;
- stimulate intestinal peristalsis.
Decompression
Inspection of intestinal contents is performed using a Miller Abbott probe, which is inserted through the nose. It remains for 3-4 days; in case of adhesions, the period is extended. Chyme is suctioned every 2-3 hours. The procedure is performed under general anesthesia in children and adults under 50 years of age. It is effective for ileus of the upper gastrointestinal tract.
Colonoscopy
A stent is inserted into the narrowed section of the intestinal tube, which widens it. After the procedure he is taken out. The doctor gains access through the anus, and the work is carried out using endoscopic equipment. Cleansing is quick and effective for partial obstruction. For children under 12 years of age, the procedure is performed under anesthesia.
Enema
Adults are injected with 10-12 liters of warm water through a glass tube several times before clear liquid comes out. A siphon enema is done to cleanse the lower intestinal sections. Afterwards, the tube is left in the anus for 20 minutes to remove gases. The enema relieves the gastrointestinal tract and is effective in case of obstruction due to a foreign body. The procedure is not performed for rectal tumors, perforation, or bleeding.
Medicines for intestinal obstruction
In the scheme of conservative treatment of ileus in adults and children, the following drugs are used:
- Antispasmodics (Papaverine, No-Shpa)– relax intestinal muscles, improve peristalsis, relieve pain.
- Anticoagulants (Heparin)– thin the blood, prescribed at the early stage of obstruction due to vascular thrombosis.
- Thrombolytics (Streptokinase)– dissolve blood clots, used by injection.
- Cholinomimetics (Prozerin)– indicated for muscle paresis, stimulates intestinal motility.
- Anesthetics (Novocaine)– instantly relieve pain, injected into the perinephric tissue.
Refortan
The product binds water in the body, reduces blood viscosity, improves blood circulation and reduces platelet aggregation. Refortan has a plasma-substituting effect and is available as a solution for infusion. The effect comes quickly and lasts 5-6 hours. The drug rarely causes vomiting, swelling of the legs, or lower back pain. Contraindications:
- hypertension;
- decompensated heart failure;
- pulmonary edema;
- age under 10 years.
Papaverine
The drug relaxes smooth muscle tone, reduces pain and facilitates the movement of chyme through the intestines. Papaverine is produced in the form of tablets, suppositories and solution for injection. The effect occurs within 10-15 minutes, depending on the dose of the product, and lasts from 2 to 24 hours. Rarely, the medicine lowers blood pressure, causes drowsiness, nausea, and constipation. Contraindications:
- liver failure;
- glaucoma;
- age younger than 6 months and older than 65 years;
- traumatic brain injury in the last six months.
Heparin
The drug reduces platelet aggregation and slows down blood clotting. After injection intramuscularly, the effect occurs within 30 minutes and lasts 6 hours. The drug works intravenously for 4 hours. Heparin is available as an injection solution. During treatment, the risk of bleeding increases and there is a possibility of an allergic reaction. Contraindications:
- hypertension;
- stomach ulcer.
Streptokinase
The drug dissolves blood clots by stimulating the conversion of blood clots into plasmin. Available in the form of a solution for infusion. The effect occurs within 45 minutes and lasts up to a day. The drug has a large number of contraindications; it is used with caution in elderly people over 75 years of age and with anticoagulants. Adverse reactions:
- bleeding;
- local allergy symptoms – rash, itching, swelling;
- anaphylactic shock;
- hematoma at the injection site.
Folk remedies
For functional chronic obstruction, treatment is carried out at home and alternative medicine recipes are used.
Discuss your treatment plan with your doctor: it may be harmful.
The following herbs improve intestinal motility, relieve inflammation and soften stool:
- buckthorn bark;
- fennel;
- chamomile;
- toadflax;
- St. John's wort.
When treating with this remedy, drink 1.5-2 liters of water per day - this will prevent stomach pain. Basic recipe: grind 100 g of flaxseed in a coffee grinder, pour in 30 g of cold-pressed olive oil. Leave for a week, stir or shake the container once a day. Take 1 tbsp. l. half an hour before meals 3 times a day for 10 days.
Beet
Peel the root vegetable, cover with cold water and cook over low heat, covered, for 1.5-2 hours until soft. Grate coarsely, add 1 tsp. vegetable oil and honey for every 100 g of dish. Morning and evening, eat 1 tbsp. l. this mixture. Continue treatment until symptoms of obstruction resolve. Prepare a new portion every 2-3 days.
Buckthorn bark
Pour 1 tbsp. l. raw materials half a liter of boiling water. Heat over medium heat, covered, for 30 minutes, leave for an hour. Strain the broth, drink 1 tsp. between meals 5-6 times/day. The product has a strong laxative effect, so if you experience discomfort in the stomach, reduce the frequency of its use to 3-4 times a day. The course of treatment is 10 days. Buckthorn bark is not recommended for children.
Surgery
The operation is performed when therapy does not produce results, the pathology occurs in an acute form, or ileus is associated with volvulus of the small intestine, gallstones, or nodes. Surgery takes place under general anesthesia. In the case of a mechanical form of pathology, the following actions are performed during surgery:
- viscerolysis - dissection of adhesions;
- disinvagination;
- unwinding the knot;
- removal of the area of necrosis.
Enterotomy
During the operation, the anterior abdominal wall is cut with an electric knife or scalpel and the small intestine is opened. The surgeon removes its loop, removes the foreign body and applies sutures. There is no narrowing of the intestinal lumen, its length does not change, and peristalsis is not disturbed. The patient remains in the hospital for 3-10 days. For adults and children, the operation is low-traumatic; the following complications rarely occur:
- inflammation of the abdominal cavity;
- seam divergence.
During surgery, part of the organ is removed. The technique is applied to the duodenum, jejunum, and sigmoid colon for vascular thrombosis, strangulated hernia, and tumor. The integrity of the tube is restored by stitching together healthy tissue. Resection is effective for any obstruction, but has many disadvantages:
- Damage to blood vessels– occurs during laparotomy intervention.
- Suture infection or inflammation– with an open surgical technique.
- Secondary obstruction– due to the formation of connective tissue in the resection area.
- Long recovery period– 1-2 years.
Diet for intestinal obstruction
1-2 weeks after surgery and in case of chronic pathology, change your diet taking into account the following principles:
- Avoid alcohol, coffee and carbonated drinks.
- Introduce boiled and steamed vegetables, fruits, lean fish, and chicken into your diet. Use cottage cheese 0-9%, compotes and jelly. For cereals, give preference to oatmeal, round rice, and buckwheat. Cook porridge in water.
- Eat pureed food in the first month after surgery and during exacerbation of obstruction.
- Eat 6-7 times/day in portions of 100-200 g.
- Reduce the amount of salt to 5 g/day.
- Every day, eat boiled or baked pumpkin, beets, mix them with honey or vegetable oil.
If intestinal obstruction occurs, remove the following foods from your diet:
- apples, cabbage, mushrooms;
- confectionery;
- hot, spicy, salty dishes;
- fresh bakery;
- cream, sour cream;
- milk;
- millet, pearl barley;
- fat meat.
Prevention
To prevent intestinal obstructions, follow these recommendations:
- consult a doctor for abdominal injuries;
- treat gastrointestinal diseases in a timely manner;
- eat right;
- avoid excessive physical activity;
- Observe safety precautions when working with chemicals and heavy metals;
- wash fruits and vegetables well;
- undergo a full course of treatment for helminthic infestations;
- after surgery on the abdominal area, follow the recommendations for proper rehabilitation to prevent adhesions.
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1. Wahl's syndrome(adductor loop syndrome): abdomen in “waves”, expansion of the afferent loop, percussion above it - tympanitis, increased peristalsis of the afferent loop.
2. Mathieu-Sklyarov's symptom -“splashing” noise (caused by sequestration of fluid in the intestines).
3. Spasokukotsky’s symptom- “falling drop” symptom.
4. Grekov’s symptom (Obukhov hospital)- gaping anus, dilated and empty rectum (caused by the development of colonic obstruction at the level of the left half of the colon).
5. Gold's sign- bimanual rectal examination reveals an enlarged (sausage-shaped) afferent intestinal loop.
6. Symptom Dansa - retraction of the right iliac region with ileocecal intussusception (absence of the cecum in “its place”).
7. Tsege-Manteuffel sign- when performing a siphon enema, only up to 500 ml of liquid enters (obstruction at the level of the sigmoid colon).
8. Bayer's sign- “oblique” belly.
9. Anschutz's sign- swelling of the cecum with colonic obstruction.
10. Bouveret's sign- collapsed cecum with small intestinal obstruction.
11. Gangolf's symptom- dullness in sloping areas of the abdomen (effusion).
12. Kivulya symptom- metallic percussion sound above the abdomen.
13. Rousche's sign- palpation of a smooth, painful formation during intussusception.
14. Alapi symptom- with intussusception, there is no muscular protection of the abdominal wall.
15. Ombredan's symptom- with intussusception, hemorrhagic or “raspberry jelly” type discharge from the rectum.
16. Babuk's sign- with intussusception, the appearance of blood in the rinsing waters after palpation of the abdomen (zone of intussusception) during a primary or repeated enema.
The importance of the diagnostic and treatment complex for intestinal obstruction.
1. distinguishes mechanical CI from functional,
2. allows functional CI,
3. eliminates the need for surgery in 46-52% of patients,
4. prevents the development of additional adhesions,
5. shortens the treatment time for patients with CI,
6. reduces the number of complications and mortality,
7. provides the physician with a powerful method of treating CI.
RULES FOR EXECUTION OF LDP.
in the absence of obvious mechanical CI:
1. subcutaneous injection of 1 ml of 0.1% atropine sulfate solution
2. bilateral novocaine perinephric blockade with a 0.25% novocaine solution
3. pause 30-40 minutes + treatment of associated disorders,
4. aspiration of gastric contents,
5. siphon enema with assessment of its effect by the surgeon,
6. determination of indications for surgery.
ASSESSMENT OF THE RESULT OF LDP
1. according to subjective data,
2. according to the effect of a siphon enema, according to objective data:
Ø dyspeptic syndrome disappeared,
Ø no bloating or asymmetry of the abdomen,
Ø no “splash noise”,
Ø ordered peristaltic sounds are heard,
Ø “Kloiber cups” are allowed; after taking a suspension of barium, its passage through the intestines is determined.
REASONS FOR FALSE ASSESSMENT OF LDP
1. analgesic effect of novocaine,
2. assessment of the result only based on subjective data,
3. objective symptoms and their dynamics are not taken into account,
4. The effect of siphon enema is incorrectly assessed.
67. Modern principles of treatment of patients with intestinal obstruction, outcomes, prevention.
TREATMENT OF INTESTINAL OBSTRUCTION Urgent surgery for intestinal obstruction is indicated:
1. If there are signs of peritonitis.
2. If there are obvious signs or suspicion of strangulation or mixed intestinal obstruction.
In other cases:
1. A diagnostic and treatment appointment is carried out; if the reception is negative, an urgent operation is performed, if it is positive, conservative treatment is carried out.
2. 250 ml of liquid barium sulfate is given orally.
3. Infusion therapy is carried out.
4. The passage of barium is assessed - when it passes (after 6 hours into the colon, after 24 hours into the rectum), the diagnosis of intestinal obstruction is removed, and the patient is subjected to a detailed examination.
The decision on surgery for acute intestinal obstruction should be made within 2-4 hours after admission. When indications for surgical treatment are given, patients should undergo brief preoperative preparation.
Surgery for intestinal obstruction involves performing a number of successive steps:
1. Performed under endotracheal anesthesia with myoplegia; In most cases, the surgical approach is a midline laparotomy.
2. Search and elimination of ileus is carried out: dissection of adhesions, mooring, enterolysis; disinvagination; unwinding of the torsion; bowel resection, etc.
3. After novocaine blockade of reflexogenic zones, decompression (intubation) of the small intestine is performed:
a) nasogastrointestinal
b) according to Yu.M. Dederer (via gastrostomy tube);
c) according to I.D. Zhitnyuk (retrograde through ileostomy);
d) according to Shede (retrograde through a cecostomy, appendicocecostomy).
Intubation of the small intestine for intestinal obstruction is necessary for:
Decompression of the intestinal wall in order to restore microcirculation and intramural blood flow in it.
To remove highly toxic and intensely infected intestinal chyme from its lumen (the intestine in case of intestinal obstruction is the main source of intoxication).
For carrying out intestinal treatment in the postoperative period (intestinal dialysis, enterosorption, oxygenation, motility stimulation, restoration of the barrier and immune function of the mucosa, early enteral feeding, etc.).
To create a frame (splinting) of the intestine in a physiological position (without angulation along the “large radii” of intestinal loops). Intestinal intubation lasts from 3 to 8 days (on average 4-5 days).
4. In some cases (resection of the intestine in conditions of peritonitis, resection of the colon, extremely serious condition of the patient), the imposition of an intestinal stoma (end, loop or Meidl) is indicated.
5. Sanitation and drainage of the abdominal cavity according to the principle of treating peritonitis. This is due to the fact that in the presence of effusion in the abdominal cavity with ileus, anaerobic microorganisms are inoculated from it in 100% of cases.
6. Completion of the operation (suturing of the abdominal cavity).
Surgery for intestinal obstruction should not be traumatic or rough. In some cases, one should not engage in long-term and highly traumatic enterolysis, but resort to the application of bypass anastomoses. In this case, the surgeon must use those techniques that he is fluent in.
POSTOPERATIVE TREATMENT
The general principles of this treatment must be formulated clearly and specifically - it must be: intensive; flexible (if there is no effect, a quick change of appointments should be carried out); complex (all possible treatment methods must be used).
Postoperative treatment is carried out in the intensive care unit and then in the surgical department. The patient in bed is in a semi-sitting position (Fovler), the “three catheters” rule is observed. The complex of postoperative treatment includes:
1. Pain relief (non-narcotic analgesics, antispasmodics, prolonged epidural anesthesia are used).
2. Carrying out infusion therapy (with transfusion of crystalloids, colloid solutions, proteins, according to indications - blood, amino acids, fat emulsions, acid-base correctors, potassium-polarizing mixture).
3. Carrying out detoxification therapy (carrying out “forced diuresis”, performing hemosorption, plasmapheresis, ultrafiltration, indirect electrochemical oxidation of blood, intestinal dialysis of enterosorption, increasing the activity of the “reserve deposition system”, etc.) -
4. Conducting antibacterial therapy (based on the principle of treating peritonitis and abdominal sepsis):
a) with the prescription of drugs: “broad spectrum” with effects on aerobes and anaerobes;
b) administration of antibiotics into a vein, aorta, abdominal cavity, endolymphatic or lymphotropic, into the lumen of the gastrointestinal tract;
c) prescription of maximum pharmacological doses;
d) if there is no effect, quickly change assignments.
5. Treatment of enteral insufficiency syndrome. Its complex includes: intestinal decompression; carrying out intestinal dialysis (saline solutions, sodium hypochlorite, antiseptics, oxygenated solutions); carrying out enterosorption (using dextrans, after the appearance of peristalsis - carbon sorbents); administration of drugs that restore the functional activity of the gastrointestinal mucosa (antioxidants, vitamins A and E); early enteral nutrition.
6. Relieving the activity of the systemic inflammatory response of the body (systemic inflammatory response syndrome).
7. Carrying out immunocorrective therapy. In this case, the patient is administered hyperimmune plasma, immunoglobulin, immunomodulators (tactivin, splenin, imunofan, polyoxidonium, roncoleukin, etc.), ultraviolet and intravascular laser irradiation of blood, and acupuncture neuroimmunostimulation are performed.
8. A set of measures is being taken to prevent complications (primarily thromboembolic, from the respiratory, cardiovascular, urinary systems, from the wound).
9. Corrective treatment of concomitant diseases is carried out.
Complications of gastroduodenal ulcers.
68. Etiology, pathogenesis, gastroduodenal ulcers. Mechanisms of pathogenesis of gastroduodenal ulcers.
ULCER DISEASE is a disease that is based on the formation and long-term course of an ulcerative defect on the mucous membrane with damage to various layers of the wall of the stomach and duodenum.
Etiology. Causes:
Social factors (tobacco smoking, unhealthy diet, alcohol abuse, poor conditions and irrational lifestyle, etc.);
Genetic factors (close relatives have a 10-fold higher risk of developing peptic ulcers);
Psychosomatic factors (personality types who experience constant internal tension and a tendency to depression are more likely to get sick);
Etiological role of Helicobacter pylori - a gram-negative microbe, located intracellularly, destroys the mucous membrane (however, there is a group of patients with chronic ulcers in whom this microbe is absent in the mucous membrane);
Physiological factors - increased gastric secretion, hyperacidity, decreased protective properties and inflammation of the mucous membrane, local microcirculation disorders.
Modern concept of etiopathogenesis of ulcers - “Scales of the Neck”:
Thus, a decrease in protective factors plays a major role in ulcerogenesis.
Clinic, diagnosis of complications of gastroduodenal ulcers, indications for surgical treatment: perforated and penetrating gastroduodenal ulcers;
PERFORMANCE (OR PERFORATION):
This is the most severe, rapidly developing and absolutely fatal complication of peptic ulcer disease.
The patient can only be saved through emergency surgery.
The shorter the period from the moment of perforation to surgery, the greater the patient’s chances of survival.
| Pathogenesis of perforated ulcer 1. entry of stomach contents into the free abdominal cavity; 2. chemically aggressive gastric contents irritate the huge receptor field of the peritoneum; 3. peritonitis occurs and steadily progresses; 4. initially aseptic, then peritonitis inevitably becomes microbial (purulent); 5. as a result, intoxication increases, which is enhanced by severe paralytic intestinal obstruction; 6. intoxication disrupts all types of metabolism and inhibits the cellular functions of various organs; 7. this leads to increasing multiple organ failure; 8. it becomes the direct cause of death. | Periods or stages of a perforated ulcer (peritonitis) Stage I of pain shock or irritation (4-6 hours) - neuro-reflex changes, clinically manifested by severe abdominal pain; Stage II of exudation (6-12 hours) is based on inflammation, clinically manifested by “imaginary well-being” (some reduction in pain is associated with partial death of nerve endings, covering of the peritoneum with fibrin films, exudate in the abdomen reduces friction of the peritoneal layers); Stage III of intoxication - (12 hours - 3 days) - intoxication will increase, clinically manifested by severe diffuse purulent peritonitis; Stage IV (more than 3 days from the moment of perforation) is the terminal period, clinically manifested by multiple organ failure. |
Clinic
The classic pattern of perforation is observed in 90-95% of cases:
Sudden, severe “dagger” pain in the epigastric region,
The pain quickly spreads throughout the abdomen,
The condition is deteriorating sharply,
The pain is severe and the patient sometimes goes into a state of shock,
Patients complain of thirst and dry mouth,
The patient grabs his stomach with his hands, lies down and freezes in a forced position,
The slightest movement causes increased abdominal pain,
ANAMNESIS
Perforation usually occurs against the background of a long course of peptic ulcer disease,
Perforation is often preceded by a short-term exacerbation of peptic ulcer disease,
In some patients, ulcer perforation occurs without a history of ulcers (approximately 12%),
this happens with “silent” ulcers.
Inspection and objective examination data:
ü patients lie down and try not to make any movements,
ü the face is sallow-gray, the features are pointed, the gaze is suffering, covered with cold sweat, the lips and tongue are rather dry,
ü blood pressure is slightly reduced and the pulse is slow,
ü the main symptom is tension in the muscles of the anterior abdominal wall, the stomach is “board-shaped”, does not participate in breathing (in thin people, segments of straight lines of the abdomen appear and transverse folds of skin are noted at the level of the navel - Dzbanovsky’s symptom),
ü palpation of the abdomen accompanied by sharp pain, increased pain in the abdomen, more in the epigastric region, right hypochondrium, then the pain becomes diffuse,
ü strongly positive Shchetkin-Blumberg symptom - first in the epigastric region, and then throughout the abdomen.
Related information.
5. Symtom Vit Stetten- bloating of the left lower quadrant of the abdomen due to perforation of the duodenum.
SYMPTOMS: DETECTED BY PERCUSSION OF THE PATIENT’S ABDOMEN:
1. Spizharny-Clark sign- high tympanitis on percussion between the xiphoid process and the navel. Disappearance of liver dullness.
SYMPTOMS DETECTED BY AUSCULTATION IN THE PATIENT'S ABDOMEN:
1. Symptom, Brown- crepitation, heard when pressing with a phonendoscope on the right side wall of the abdomen.
2. Brenner's sign- metallic friction noise, heard above the XII rib on the left when the patient is sitting. Associated with the release of air bubbles into the subdiaphragmatic space through the perforation.
3. Brunner's sign- diaphragm friction noise heard under the costal margin (left and right) due to the presence of gastric contents between the diaphragm and the stomach.
4. Gustin's triad- clear auscultation of heart sounds through the abdominal cavity to the level of the navel, friction noise in the hypochondrium and epigastrium, and a metallic or silvery noise appears during inspiration and is associated with the release of free gas into the abdominal cavity through the perforation.
The Gustin triad includes the previously described symptoms of Lotey-Sen-Bailey-Federecchi-Claybrook-Gustin, Brenner, Brunner.
INTESTINAL OBSTRUCTION
SYMPTOMS REVEALED IN COMPLAINTS OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Cruvelier's symptom - blood in the stool, cramping abdominal pain and tenesmus. Characteristic of intussusception.
2. Tiliax's sign- pain, vomiting, gas retention. Characteristic of intussusception.
3. Carnot's sign- pain in< эпигастрии, возникающая при резком разгибании туловища. Характерно для спаечной болезни.
4. Koenig's sign- reduction of pain after rumbling above and to the left of the navel. Characteristic of chronic duodenostasis.
SYMPTOMS REVEALED DURING A GENERAL INSPECTION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Valya's symptom- a distended intestinal loop contouring through the anterior abdominal wall.
2. Schlange-Grekov sign- intestinal peristalsis visible through the abdominal wall.
3. Bayer's sign- asymmetrical bloating.
4. Bouveray-Anschutz symptom - protrusion in the ileocecal region with obstruction of the large intestine.
5. Borchardt's triad- bloating in the epigastric region and left hypochondrium, inability to probe the stomach and vomiting that does not bring relief. Observed during gastric volvulus.
6. Delbe Triad- rapidly increasing effusion in the abdominal cavity, bloating, vomiting. Observed during volvulus of the small intestine.
7. Karevsky's sign- sluggish intermittent intestinal obstruction. It is observed with intestinal obstruction caused by gallstones.
SYMPTOMS REVEALED WHEN PALPATIZING THE ABDOMINAL OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Leotta's sign- the appearance of pain when pulling and moving towards the skin fold of the abdomen. It is noted in adhesive disease.
2. Kocher's sign- pressure on the anterior abdominal wall and its rapid cessation do not cause pain.
3. Schiemann-Dans symptom - upon palpation in the area of the cecum, a kind of emptiness is determined. Observed during cecal volvulus.
4. Schwartz's sign - a painful elastic tumor is palpated in the epigastrium with simultaneous bloating. Observed with acute dilatation of the stomach.
5. Tsulukidze’s symptom- upon palpation of the intussusception of the colon, a depression with folded edges is detected, around which small tumor-like formations are palpated - fatty pendants.
SYMPTOMS DETECTED BY PERCUSSION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Kivulya symptom- with percussion of the abdomen and simultaneous auscultation, a sound with a metallic tint is heard.
2. Wortmann's sign- a sound with a metallic tint is heard only over the swollen large intestine, and over the small intestine - ordinary tympanitis.
3. Mathieu's sign- splashing sound heard in the epigastrium with rapid percussion above the navel.
SYMPTOMS DETECTED BY AUSCULTATION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Sklyarov’s symptom- splashing noise in the abdominal cavity.
2. Spasokukotsky's symptom- - the noise of a “falling drop”.
3. Gepher's symptom- Breath sounds and heart sounds are best heard above the site of narrowing. Observed in later stages.
SYMPTOMS DETECTED DURING A FINGER RECTAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Grekov's symptom-Hohenega- an empty ampulla-shaped rectum, the anterior wall of which is protruded by intestinal loops. The anus is gaping. The synonym is “symptom of the Obukhov hospital.”
2. Trevs's symptom - in When fluid is introduced into the rectum, a rumbling sound is heard at the site of obstruction.
3. Tsege von Manteuffel's sign- in case of obstruction of the sigmoid colon, only 200 ml of water can be introduced into the rectum. The patient cannot retain large doses of water.
SYMPTOMS USED TO DIFFERENTIALLY
DIAGNOSIS OF INTESTINAL OBSTRUCTION: 1
1. Kadyan's symptom- for differential diagnosis of pneumoperitoneum and intestinal paresis. With pneumoperitoneum, hepatic dullness disappears, the percussion sound is uniform everywhere, and with intestinal paresis, hepatic dullness does not completely disappear, the tympanic sound retains its shades.
2. Babuk's sign- differential diagnosis between a tumor and intussusception. The absence of blood in the washing water after an enema and kneading of a pathological formation indicates the presence of a tumor.
1. Vikker M. M. Diagnosis and medical tactics for acute abdominal diseases (“acute abdomen”). North Caucasus regional publishing house. Pyatigorsk, 1936, 158 pp.
2. Lazovsky I. R. Directory of clinical symptoms and syndromes. M. Medicine. 1981, pp. 5-102.
3. Lezhar F. Emergency surgery. Ed. N. N. Burdenko, vol. 1-2. 1936.
b4. Matyashin I. M. Symptoms and syndromes in surgery. Kyiv.
|Olshanetsky A. A. Health, 1982, 184 p.
V Gluzman A. M.
5. Mondor G. Urgent diagnosis. Belly, vol. 1-2, M-L. Medgiz, 1939.
Kocher-Volkovich symptom – movement of pain from the epigastric region to the right lower quadrant of the abdomen.
The Kocher-Wolkovich symptom is characteristic of acute appendicitis
2. Symptom "splashing noise".
A gurgling sound in the stomach, heard in the supine position with short, quick blows of the fingers on the epigastric region; indicates the presence of gas and liquid in the stomach, for example, with hypersecretion of the stomach or with delayed evacuation of its contents. with pyloric stenosis)
Ticket number 2.
1. Determination of the size of the hernial orifice.
Determining the size of the hernial orifice is possible only with reducible hernias (with irreducible strangulated hernias, it is impossible to determine the hernial orifice).
After the hernia has been reduced, the size of the hernial orifice in two dimensions or its diameter (in cm), as well as the condition of its edges, are determined using the tips of one or several fingers.
The hernial orifices are most accessible to research for umbilical, epigastric and median postoperative hernias; for hernias of other localizations they are less accessible.
Determination of the hernial orifice in umbilical hernias is made by palpation of the bottom of the umbilical fossa.
For inguinal hernias, examination of the hernial orifice (external inguinal ring) in men is carried out with the patient lying down, using the index or 3rd finger through the lower pole of the scrotum.
2.Technique and interpretation of pre- and intraoperative cholegram data.
Interpretation of endoscopic retrograde cholangiopancreatography (ERCP) data: dimensions of the intrahepatic bile ducts, hepaticocholedochus, presence of stones in the gallbladder, common bile duct, narrowing of the distal common bile duct, contrasting of the Wirsung duct, etc.
Technique of intraoperative cholangiography:
b) a water-soluble contrast agent (bilignost, biligrafin, etc.) is introduced by puncture or through the cystic duct; after the administration of the contrast agent, an image is taken on the operating table.
The morphological state of the bile ducts is assessed - shape, size, presence of stones (cellularity, marbling of the shadow or its absence (“silent bubble”), presence of filling defects); length, tortuosity of the cystic duct, width of the common bile duct; entry of contrast into the duodenum.
Ticket number 3.
1. Palpation of the gallbladder (Courvoisier’s symptom).
Palpation of the gallbladder is carried out in the area of its projection (the point of intersection of the outer edge of the rectus abdominis muscle and the costal arch or slightly lower if there is an enlargement of the liver), in the same position of the patient and according to the same rules as when palpating the liver.
An enlarged gallbladder can be palpated in the form of a pear-shaped or ovoid formation, the nature of the surface of which and consistency depend on the condition of the bladder wall and its contents.
If the common bile duct is blocked by a stone, the gallbladder relatively rarely reaches large sizes, since the resulting long-term, sluggish inflammatory process limits the extensibility of its walls. They become lumpy and painful. Similar phenomena are observed with a tumor of the gallbladder or the presence of stones in it.
You can palpate a bladder in the form of a smooth elastic pear-shaped body in case of obstruction of the exit from the bladder (for example, with a stone or with empyema, with hydrocele of the gallbladder, compression of the common bile duct, for example, with cancer of the head of the pancreas - Courvoisier-Guerrier symptom).
Courvoisier's sign: palpation of an enlarged, distended, painless gallbladder in combination with obstructive jaundice caused by a tumor.
SYMPTOMS1. Kivul's symptom - upon percussion, a tympanic sound with a metallic tint can be heard over a distended intestinal loop.
Kivulya's symptom is characteristic of acute intestinal obstruction.
2. Wilms symptom of a falling drop (M. Wilms) is the sound of a falling drop of liquid, determined by auscultation against the background of peristalsis noises with intestinal obstruction.
3. “splashing noise” described by I.P. Sklyarov (1923). This symptom is detected with a slight lateral concussion of the abdominal wall and can be localized or detected throughout the abdomen. The appearance of this phenomenon indicates the presence of an overstretched paretic loop filled with liquid and gas. Mathieu described the appearance of a splashing noise during rapid percussion of the supra-umbilical region. Some authors consider the appearance of a splashing noise to be a sign of neglected ileus and, if it is detected, consider emergency surgery indicated.
4. Rovsing's symptom: sign of acute appendicitis; with palpation in the left iliac region and simultaneous pressure on the descending colon, gas pressure is transferred to the ileocecal region, which is accompanied by pain.
The cause of Rovsing's symptom: redistribution of intra-abdominal pressure and irritation of the interoreceptors of the inflamed appendix occurs
5. Sitkovsky’s symptom: sign of appendicitis; When the patient is positioned on the left side, pain appears in the ileocecal region.
Cause of Sitkovsky's symptom: irritation of interoreceptors as a result of stretching of the mesentery of the inflamed appendix
6. Barthomier-Michelson's sign: sign of acute appendicitis; pain on palpation of the cecum, increasing when lying on the left side.
The cause of the Filatov, Bartemier - Michelson symptom: tension of the mesentery of the appendix
7. Description of Razdolsky’s symptom - pain on percussion in the right iliac region.
Cause of Razdolsky's symptom: irritation of the receptors of the inflamed appendix
8. Cullen's symptom - limited cyanosis of the skin around the navel; observed in acute pancreatitis, as well as in the accumulation of blood in the abdominal cavity (more often with ectopic pregnancy).
9. Gray Turner's symptom - the appearance of subcutaneous bruises on the sides. This symptom appears 6-24 months after retroperitoneal hemorrhage in acute pancreatitis.
10. Dalrymple's sign is a widening of the palpebral fissure, which is manifested by the appearance of a white strip of sclera between the upper eyelid and the iris of the eye, caused by increased tone of the muscle that lifts the eyelid.
Dalrymple's sign is characteristic of diffuse toxic goiter.
11. Mayo-Robson symptom (pain at the point of the pancreas) Pain is detected in the area of the left costovertebral angle (with inflammation of the pancreas).
12. Voskresensky’s symptom: a sign of acute appendicitis; when quickly running the palm along the anterior abdominal wall (over the shirt) from the right costal edge downwards, the patient experiences pain.
13. Shchetkin-Blumberg sign: after gentle pressure on the anterior abdominal wall, the fingers are sharply torn off. With inflammation of the peritoneum, pain occurs, which is greater when the examining hand is lifted from the abdominal wall than when pressing on it.
14. Kehr’s symptom (1): a sign of cholecystitis; pain when inhaling during palpation of the right hypochondrium.
15. Kalka's symptom - pain on percussion in the projection of the gallbladder
16. Murphy's symptom: sign o. cholecystitis; the patient is in a supine position; the left hand is positioned so that the thumb fits below the costal arch, approximately at the location of the gallbladder. The remaining fingers of the hand are along the edge of the costal arch. If you ask the patient to take a deep breath, he will be interrupted before reaching the top, due to acute pain in the abdomen under the thumb.
17. Ortner's symptom: sign o. cholecystitis; the patient is in a supine position. When you tap the edge of your palm on the edge of the costal arch on the right, pain is detected.
18. Symptom of Mussi-Georgievsky (phrenicus symptom): sign of o. cholecystitis; pain when pressing with a finger above the collarbone between the front legs of m. SCM.
19. Lagophthalmos (from the Greek lagoos - hare, ophthalmos - eye), hare eye - incomplete closure of the eyelids due to muscle weakness (usually a sign of damage to the facial nerve), in which an attempt to cover the eye is accompanied by a physiological upward rotation of the eyeball, the space of the palpebral fissure is occupied only the protein membrane (Bell's symptom). Lagophthalmos creates conditions for drying out of the cornea and conjunctiva and the development of inflammatory and dystrophic processes in them.
The cause of damage to the facial nerve, leading to the development of lagophthalmos, is usually neuropathy, neuritis, as well as traumatic damage to this nerve, in particular during surgery for neuroma VIII
cranial nerve. The inability to close the eyelids is sometimes observed in seriously ill people, especially young children.
The presence of paralytic lagophthalmos or the inability to close the eyes for another reason requires measures aimed at preventing possible damage to the eye, especially to the cornea (artificial tears, antiseptic drops and ointments on the conjunctiva of the eyes). If necessary, which is especially likely in case of damage to the facial nerve, accompanied by dry eye (xerophthalmia), temporary stitching of the eyelids - blepharorrhaphy - may be advisable.
20. Val’s symptom: a sign of intestinal obstruction; local flatulence or protrusion of the proximal intestine. Wahl (1833-1890) - German surgeon.
21. Graefe's symptom, or eyelid delay, is one of the main signs of thyrotoxicosis. It is expressed in the inability of the upper eyelid to droop when lowering the eyes. To identify this symptom, you need to bring your finger, pencil or other object to a level above the patient’s eyes, and then lower it down, watching the movement of his eyes. This symptom appears when, as the eyeball moves downwards, a white stripe of sclera appears between the edge of the eyelid and the edge of the cornea, when one eyelid drops more slowly than the other, or when both eyelids drop slowly and tremble (see Definition of Graefe's symptom and bilateral ptosis). Eyelid retardation occurs due to chronic contraction of the Müller muscle in the upper eyelid.
22. Kerte’s symptom – the appearance of pain and resistance in the area where the body of the pancreas is located (in the epigastrium 6-7 centimeters above the navel).
Kerte's symptom is characteristic of acute pancreatitis.
23. Obraztsov’s symptom (psoas symptom): a sign of chronic appendicitis; increased pain during palpation in the ileocecal region with the right leg raised.
^ PRACTICAL SKILLS
Compatibility test for blood groups of the ABO system (on a plane)
The sample is performed on a plate with a wetted surface.
1. The tablet is marked, for which the full name is indicated. and recipient's blood group, full name. and the donor’s blood type and blood container number.
2. Carefully pipet the serum from the test tube with the recipient’s blood and apply 1 large drop (100 µl) to the plate.
3. From a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion specifically for this patient, take a small drop (10 μl) of donor red blood cells and apply next to the recipient's serum (serum to red blood cells ratio 10: 1).
4. The drops are mixed with a glass rod.
5. Observe the reaction for 5 minutes, constantly shaking the tablet. After this time, add 1-2 drops (50-100 µl) of sodium chloride solution, 0.9%.
the reaction in the drop can be positive or negative.
a) a positive result (+) is expressed in the agglutination of red blood cells; agglutinates are visible to the naked eye in the form of small or large red aggregates. The blood is incompatible and cannot be transfused! (see Figure 1).
Figure 1. Recipient and donor blood are incompatible
b) with a negative result (-), the drop remains homogeneously colored red, and no agglutinates are detected in it. The donor's blood is compatible with the recipient's blood (see Figure 2).
Figure 2. Donor's blood is compatible with recipient's blood
3.2. Tests for individual compatibility according to the Rhesus system
3.2.1. Compatibility test using 33% polyglucin solution
Procedure for conducting the study:
1. For the study, take a test tube (centrifuge or any other, with a capacity of at least 10 ml). The test tube is marked, for which the full name is indicated. and the blood group of the recipient, and the full name of the donor, the number of the container with blood.
2. From the test tube with the recipient’s blood being tested, carefully take the serum with a pipette and add 2 drops (100 µl) to the bottom of the tube.
3. From a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, take one drop (50 μl) of donor red blood cells, add it to the same test tube, add 1 drop (50 μl) of a 33% polyglucin solution.
4. The contents of the test tube are mixed by shaking and then slowly rotated along the axis, tilting almost to a horizontal position so that the contents spread along its walls. This procedure is performed within five minutes.
5. After five minutes, add 3-5 ml of saline to the test tube. solution. The contents of the test tubes are mixed by inverting the test tubes 2-3 times (without shaking!)
Interpretation of reaction results:
the result is taken into account by viewing the test tubes with the naked eye or through a magnifying glass.
If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of cleared or completely discolored liquid, it means that the donor’s blood is not compatible with the recipient’s blood. You can't overfill!
If the test tube contains a uniformly colored, slightly opalescent liquid without signs of red blood cell agglutination, this means that the donor’s blood is compatible with the recipient’s blood with respect to the Rhesus system antigens and other clinically significant systems (see Figure 3).
Figure 3. Results of compatibility testing using the Rhesus system (using a 33% polyglucin solution and a 10% gelatin solution)
3.2.2. Compatibility test using 10% gelatin solution
The gelatin solution must be carefully reviewed before use. If cloudiness or appearance of flakes occurs, as well as loss of gelling properties at t+4 0 C...+8 0 C, gelatin is unsuitable.
Procedure for conducting the study:
1. For research, take a test tube (capacity of at least 10 ml). The test tube is marked, for which the full name, blood group of the recipient and donor, and the number of the container with blood are indicated.
2. From a segment of a tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, take one drop (50 μl) of donor red blood cells, add it to a test tube, add 2 drops (100 μl) of a 10% gelatin solution heated in a water bath until liquefaction at a temperature of +46 0 C...+48 0 C. Carefully take serum from a test tube with the recipient’s blood with a pipette and add 2 drops (100 μl) to the bottom of the test tube.
3. The contents of the test tube are shaken to mix and placed in a water bath (t+46 0 C...+48 0 C) for 15 minutes or in a thermostat (t+46 0 C...+48 0 C) for 45 minutes.
4. After the end of incubation, the test tube is removed, 5-8 ml of saline is added. solution, the contents of the test tube are mixed by inverting once or twice and the result of the study is assessed.
Interpretation of reaction results.
the result is taken into account by viewing the test tubes with the naked eye or through a magnifying glass, and then viewing them by microscopy. To do this, a drop of the contents of the test tube is placed on a glass slide and viewed under low magnification.
If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of cleared or completely discolored liquid, this means that the donor’s blood is incompatible with the recipient’s blood and should not be transfused to him.
If the test tube contains a uniformly colored, slightly opalescent liquid without signs of red blood cell agglutination, this means that the donor’s blood is compatible with the recipient’s blood with respect to the Rhesus system antigens and other clinically significant systems (see Figure 3).
3.3. Compatibility test in gel test
When performing a gel test, compatibility tests are carried out immediately according to the ABO system (in a Neutral microtube) and a compatibility test according to the Rhesus system (in a Coombs microtube).
Procedure for conducting the study:
1. Before the study, check the diagnostic cards. Do not use cards if there are suspended bubbles in the gel, the microtube does not contain a supernatant, or there is a decrease in the volume of the gel or its cracking.
2. Microtubes are signed (last name of the recipient and number of the donor sample).
3. From a segment of a tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, 10 μl of donor red blood cells are taken with an automatic pipette and placed in a centrifuge tube.
4. Add 1 ml of dilution solution.
5. Open the required number of microtubes (one Coombs and Neutral microtube each).
6. Using an automatic pipette, add 50 μl of diluted donor red blood cells into Coombs and Neutral microtubes.
7. Add 25 μl of recipient serum to both microtubes.
8. Incubate at t+37 0 C for 15 minutes.
9. After incubation, the card is centrifuged in a centrifuge for gel cards (time and speed are set automatically).
Interpretation of the results:
if a sediment of red blood cells is located at the bottom of the microtube, then the sample is considered compatible (see Figure 4 No. 1). If agglutinates linger on the surface of the gel or in its thickness, then the sample is incompatible (see Figure 4 No. 2-6).
№1 №2 №3 №4 №5 №6
Figure 4. Results of testing samples for individual compatibility according to the Rhesus system using the gel method
3.4. Biological sample
To conduct a biological test, blood and its components prepared for transfusion are used.
Biological sample carried out regardless of the volume of the blood transfusion medium and the speed of its administration. If it is necessary to transfuse several doses of blood and its components, a biological test is carried out before the start of the transfusion of each new dose.
Technique:
transfuse 10 ml of blood transfusion medium once at a rate of 2-3 ml (40-60 drops) per minute, then stop the transfusion and observe the recipient for 3 minutes, monitoring his pulse, respiratory rate, blood pressure, general condition, skin color, measure body temperature. This procedure is repeated twice more. The appearance during this period of even one of the clinical symptoms such as chills, lower back pain, a feeling of heat and tightness in the chest, headache, nausea or vomiting requires immediate cessation of the transfusion and refusal to transfuse this transfusion medium. The blood sample is sent to a specialized blood service laboratory for individual selection of red blood cells.
The urgency of transfusion of blood components does not exempt from performing a biological test. During this procedure, it is possible to continue transfusion of saline solutions.
When transfusing blood and its components under anesthesia, the reaction or incipient complications are judged by an unmotivated increase in bleeding in the surgical wound, a decrease in blood pressure and an increase in heart rate, a change in the color of urine during bladder catheterization, as well as by the results of a test to detect early hemolysis. In such cases, the transfusion of this blood transfusion medium is stopped, the surgeon and the anesthesiologist-resuscitator, together with the transfusiologist, are obliged to find out the cause of the hemodynamic disturbances. If nothing other than transfusion could cause them, then this blood transfusion medium is not transfused; the issue of further transfusion therapy is decided by them depending on clinical and laboratory data.
A biological test, as well as a test for individual compatibility, is also required in cases where red blood cell mass or suspension, individually selected in the laboratory or phenotyped, is transfused.
After the end of the transfusion, the donor container with a small amount of the remaining blood transfusion medium used for individual compatibility tests must be preserved for 48 hours at a temperature of +2 0 C...+8 0 C.
After the transfusion, the recipient remains in bed for two hours and is observed by the attending physician or the doctor on duty. His body temperature and blood pressure are measured hourly, recording these indicators in the patient’s medical record. The presence and hourly volume of urine output and the color of urine are monitored. The appearance of red coloration of urine while maintaining transparency indicates acute hemolysis. The next day after the transfusion, a clinical blood and urine test must be performed.
When performing an outpatient blood transfusion, the recipient after the end of the transfusion must be under the supervision of a physician for at least three hours. Only in the absence of any reactions, the presence of stable blood pressure and pulse, and normal urination can the patient be released from the hospital.
Determining indications for blood transfusion
Blood transfusion is a serious intervention for the patient, and the indications for it must be justified. If it is possible to provide effective treatment to a patient without blood transfusion or there is no confidence that it will benefit the patient, it is better to refuse blood transfusion. Indications for blood transfusion are determined by the purpose it pursues: replacement of the missing volume of blood or its individual components; increased activity of the blood coagulation system during bleeding. Absolute indications for blood transfusion are acute blood loss, shock, bleeding, severe anemia, severe traumatic operations, including those with artificial circulation. Indications for transfusion of blood and its components are anemia of various origins, blood diseases, purulent-inflammatory diseases, severe intoxications.
Determination of contraindications to blood transfusion
Contraindications to blood transfusion include:
1) decompensation of cardiac activity due to heart defects, myocarditis, myocardiosclerosis; 2) septic endocarditis;
3) stage 3 hypertension; 4) cerebrovascular accident; 5) thromboembolic disease, 6) pulmonary edema; 7) acute glomerulonephritis; 8) severe liver failure; 9) general amyloidosis; 10) allergic condition; 11) bronchial asthma.
Determination of indications
^ Preparing the patient To blood transfusion. The patient has
admitted to the surgical hospital, the blood type and Rh factor are determined.
Studies are being carried out on cardiovascular, respiratory, urinary
systems in order to identify contraindications to blood transfusion. 1-2 days before
transfusions perform a general blood test before transfusion of blood to the patient
must empty the bladder and bowels. Blood transfusion is best done
in the morning on an empty stomach or after a light breakfast.
Choice of transfusion environment, method of transfusion. Transfusion of whole
blood for the treatment of anemia, leukopenia, thrombocytopenia, coagulation disorders
system, when there is a deficiency of individual blood components, is not justified, since
how others are used to replenish individual factors, the need for
which the patient does not need to administer. The therapeutic effect of whole blood in such cases
lower, and blood consumption is significantly greater than with the introduction of concentrated
blood components, for example, red or leukocyte mass, plasma,
albumin, etc. Thus, with hemophilia, the patient only needs to be administered factor VIII.
To cover the body's needs for it with whole blood, it is necessary
administer several liters of blood, whereas this need can only be met
several milliliters of antihemophilic globulin. With plaster and
afibrinogenemia, it is necessary to transfuse up to 10 liters of whole blood to replenish
fibrinogen deficiency. Using the blood product fibrinogen, it is enough to inject
its 10-12 g. Whole blood transfusion can cause sensitization of the patient,
formation of antibodies to blood cells (leukocytes, platelets) or plasma proteins,
which is fraught with the risk of severe complications during repeated blood transfusions or
pregnancy. Whole blood is transfused in case of acute blood loss with sudden
decrease in blood volume, during exchange transfusions, during artificial circulation in
time of open heart surgery.
When choosing a transfusion medium, you should use the component in which
the patient also needs blood substitutes.
The main method of blood transfusion is intravenous drip using
puncture of the saphenous veins. With massive and long-term complex transfusion
therapy, blood along with other media is injected into the subclavian or external
jugular vein. In extreme situations, blood is administered intra-arterially.
Grade validity canned blood and its components for
transfusion. Before transfusion, determine the suitability of blood for
transfusions: take into account the integrity of the packaging, expiration date, violation of the regime
blood storage (possible freezing, overheating). Most appropriate
transfuse blood with a shelf life of no more than 5-7 days, since with prolongation
during storage, biochemical and morphological changes occur in the blood,
which reduce its positive properties. On macroscopic assessment, blood
must have three layers. At the bottom there is a red layer of red blood cells, it is covered
a thin gray layer of leukocytes and slightly transparent on top
yellowish plasma. Signs of unsuitable blood are: red or
pink coloration of plasma (hemolysis), appearance of flakes in plasma, turbidity,
the presence of a film on the surface of the plasma (signs of blood infection), the presence
clots (blood clotting). For urgent transfusion of unsettled blood
