Increasing the depth of knowledge of the pathophysiology of peritonitis did not lead to a change in priority of surgery, known since Kirschner, such as the removal of the causes of peritonitis, brushing the abdomen and effective drainage of the [8.18]. In recent years the doctrine of treatment WP surely includes such methods as "laparostomy", "Decompression of the gastrointestinal tract", "peritoneal-enteral lavage [1], therapy of abdominal sepsis" [4.19], "detoxification" [14 ], which are aimed at removing the most significant pathophysiological links of the ER. Development of new surgical treatments are not always easy solutions specific diagnostic and tactical problems at the bedside, during which should guide the selection of one of the following methods of treatment WP:
Closed-way - rarely used, at a low level of bacterial contamination of the abdominal cavity and in terms of developing the disease, not to exceed 6 hours.
Laparoscopic (laparoscopic assisted) method - is used since the late 90s. Indications for this method are similar to the testimony at the closed method, but need to be clarified.
Semi-closed method - a traditional, most commonly used method of surgical treatment, which consists in laparotomy, removal of the source of peritonitis, sanitation and drainage of the abdominal cavity.
Semi-open way - Improved sanitation landmark relaparotomy. The method is applied at a high bacterial contamination of the abdominal cavity, the impossibility in a single operation to eliminate completely the source of peritonitis or factors of progression in the presence of multiple organ dysfunction syndrome.
Clear the way - laparostomy is used in large neudalimyh destructive changes in the abdominal cavity, intestinal brand viagra fistulas, and infected pancreatic necrosis.
We have analyzed results of treatment of 575 patients with various forms of RP. For a more adequate assessment of the outcome of treatment patients were divided into four main groups according to the choice of surgical approach.
1. Peritonitis, treatment of which was half-closed manner. It took a single operation, during which eliminated the cause of Poland, made an effective drainage and sanitation of the abdominal cavity. As an objective macrofactors determining the severity of the patient can distinguish the initial intoxication and operating a trauma.
2. The next group consisted of patients whose treatment was half-open manner. This tactical option chosen on the basis of the above criteria. Improved sanitation landmark relaparotomy performed 24-36 hours after the previous operation. Efficacy of treatment in this group depended on the initial severity of the patient, surgical trauma, the effectiveness of the stages of organo-resuscitation in the abdominal cavity, the methods of detoxification.
3. Group consisted of patients whose starting point for the development of peritonitis is an elective surgery on unmodified tissue of the abdominal cavity or emergency intervention on the pathology, not complicated by peritonitis. In these cases, we apply the term "appearance of RP. The time of surgery for RP of this group can and must be well justified. Tactics of treatment may be different depending on the pre-and intraoperative data.
4. Group of patients who had peritonitis (any distribution) took place at the first operation, but complications led to its progression. A distinctive feature of this group is the ability to influence the initial state of the inflamed peritoneum in the formation of complications.
This division of patients into groups aims to not only reflect the most common tactical schemes, but also to define a springboard for further research. For example, interest is the dynamics of clinical and laboratory parameters in the event or the progression of RP prior to installation of this diagnosis, identify the most weight (or pathognomonic) of symptoms in these patients.
Considering the whole set of patients studied, it should be noted that it did not include patients with pancreatic necrosis, oncopathology, bowel infarction, since the pathophysiology of RP in these cases is quite different. Main nosology: acute appendicitis, trauma, abdominal and retroperitoneal space, perforated ulcer of the stomach or duodenum, strangulated hernia of the anterior abdominal wall, acute intestinal obstruction (adhesive, gut volvulus, and other forms), gynecological pathology (inflammation of the appendages, abstsedirovanie, metroendometrit).
obese patients
wrong interpretation
sympathetic activation
effectiveness
tactics
الأربعاء، 26 يناير 2011
الأحد، 9 يناير 2011
Encountered bouts
Gallstone disease (GSD) is one of the common diseases. In surgical hospitals among patients with chronic abdominal gallstone patients occupy the first place. In the postwar period in the economically developed countries in Europe and North America, the number of patients with gallstone disease has increased significantly. This is evidenced by the number of surgeons performed the operations - for example, only in the U.S. annually more than 500 000 cholecystectomies. In our country also has a high incidence of gallstone disease, and in each subsequent decade, the number of patients doubled. The disease is rightly considered a "disease of the century" and "the disease of prosperity," referring to a direct link its development with the nature of power.
In the past three decades, significant progress in addressing the diagnosis and treatment of brand viagra gallstone disease, largely due to progress in the development of medical technology and basic sciences. Thanks to these advances in medical practice appeared effective diagnostic methods: ultrasonography (U.S.), computed tomography, magnetic nuclear imaging, direct methods of contrasting the biliary tract. Along with this have not lost their value, such methods as oral cholecystography and intravenous holegrafiya. The traditional treatment with open cholecystectomy, laparoscopic techniques were added and malotravmaticheskie of minimal access surgery. Moreover, the disposal of physicians came non-operational methods of treatment: drug dissolution and extracorporeal lithotripsy. Wide range of diagnostic and treatment methods led to a revision of strategy and tactics in GSD. Naturally, it was necessary to optimize the selection of diagnostic tests and therapies for each individual patsmenta.
The need to free the patient from the GSD is dictated not only encountered bouts of biliary colic, but also the risk of severe complications (acute cholecystitis, obstructive jaundice, destructive pancreatitis, etc.) that may require urgent surgical intervention, and with prolonged duration of the underlying disease cancer of the gall bladder. Therefore, treatment must be subject to both patients with symptomatic gallstone disease, and with its latent form, in which there is always the danger of sudden severe complications of the pathological process. Recommendation of a specific patient treatment should be based on an assessment of his physical condition, the nature of the disease, concomitant changes in the bile ducts (stones, stricture). Necessary information can be obtained through a series of instrumental and laboratory tests.
Diagnosis
Ultrasound examination
The main method of diagnosis of cholelithiasis. Its non-invasive, security and ease of implementation make it possible to survey a large contingent of the population and to resort to re-study in the next 23 days in case of failure or Noninformation primary research. Ultrasound can determine: the presence of gallstones, their number and size, the total volume and, more importantly, the qualitative composition of concretions, location, size and shape of the gallbladder, the thickness of its walls and the presence in it of the restrictions, the degree of inflammatory and infiltrative changes; diameter gepatikoholedoha and presence of stones in it. Variant of the functional ultrasonography using a choleretic breakfast allows us to estimate the contractility and evacuation functions of the gallbladder.
Oral cholecystography
The method of X-ray study of the gallbladder, based on oral iodine-containing drugs. Its use is appropriate in cases where it is necessary to have accurate data on the functional status of the gallbladder, radiolucency concretions and their degree of calcification. This information is extremely important for the selection of patients for litoliticheskuyu therapy and extracorporeal lithotripsy (EKLT). One of the drawbacks of this method is the impossibility of contrasting the bile duct, the state where you need to know in all cases without viagra cost per pill exception, when the patient require treatment.
Intravenous holegrafiya
Based on the intravenous injection of contrast solution method makes it possible to get a clear picture not only of the gallbladder, and bile duct. This fact is extremely important for identifying stones in the bile duct, determine the extent of dilation or constriction. Detection cholangiogram even a moderate expansion of the bile duct is an indirect indication of violations of outflow to the intestine, and in this case, more research is needed to identify the causes of biliary hypertension. Intravenous holegrafii absolutely shown in cases where on the basis of anamnestic and clinical signs is suspected in the concomitant loss of bile ducts of the presence of stones and strictures. To remove this suspicion, you can resort to the use of endoscopic retrograde cholangiopancreatography (ERCP). But compared with the diagnostic method of intravenous holegrafiya is gentle and less dangerous method, which is not peculiar to life-threatening complications.
You should inform
need advice
General stage
In the past three decades, significant progress in addressing the diagnosis and treatment of brand viagra gallstone disease, largely due to progress in the development of medical technology and basic sciences. Thanks to these advances in medical practice appeared effective diagnostic methods: ultrasonography (U.S.), computed tomography, magnetic nuclear imaging, direct methods of contrasting the biliary tract. Along with this have not lost their value, such methods as oral cholecystography and intravenous holegrafiya. The traditional treatment with open cholecystectomy, laparoscopic techniques were added and malotravmaticheskie of minimal access surgery. Moreover, the disposal of physicians came non-operational methods of treatment: drug dissolution and extracorporeal lithotripsy. Wide range of diagnostic and treatment methods led to a revision of strategy and tactics in GSD. Naturally, it was necessary to optimize the selection of diagnostic tests and therapies for each individual patsmenta.
The need to free the patient from the GSD is dictated not only encountered bouts of biliary colic, but also the risk of severe complications (acute cholecystitis, obstructive jaundice, destructive pancreatitis, etc.) that may require urgent surgical intervention, and with prolonged duration of the underlying disease cancer of the gall bladder. Therefore, treatment must be subject to both patients with symptomatic gallstone disease, and with its latent form, in which there is always the danger of sudden severe complications of the pathological process. Recommendation of a specific patient treatment should be based on an assessment of his physical condition, the nature of the disease, concomitant changes in the bile ducts (stones, stricture). Necessary information can be obtained through a series of instrumental and laboratory tests.
Diagnosis
Ultrasound examination
The main method of diagnosis of cholelithiasis. Its non-invasive, security and ease of implementation make it possible to survey a large contingent of the population and to resort to re-study in the next 23 days in case of failure or Noninformation primary research. Ultrasound can determine: the presence of gallstones, their number and size, the total volume and, more importantly, the qualitative composition of concretions, location, size and shape of the gallbladder, the thickness of its walls and the presence in it of the restrictions, the degree of inflammatory and infiltrative changes; diameter gepatikoholedoha and presence of stones in it. Variant of the functional ultrasonography using a choleretic breakfast allows us to estimate the contractility and evacuation functions of the gallbladder.
Oral cholecystography
The method of X-ray study of the gallbladder, based on oral iodine-containing drugs. Its use is appropriate in cases where it is necessary to have accurate data on the functional status of the gallbladder, radiolucency concretions and their degree of calcification. This information is extremely important for the selection of patients for litoliticheskuyu therapy and extracorporeal lithotripsy (EKLT). One of the drawbacks of this method is the impossibility of contrasting the bile duct, the state where you need to know in all cases without viagra cost per pill exception, when the patient require treatment.
Intravenous holegrafiya
Based on the intravenous injection of contrast solution method makes it possible to get a clear picture not only of the gallbladder, and bile duct. This fact is extremely important for identifying stones in the bile duct, determine the extent of dilation or constriction. Detection cholangiogram even a moderate expansion of the bile duct is an indirect indication of violations of outflow to the intestine, and in this case, more research is needed to identify the causes of biliary hypertension. Intravenous holegrafii absolutely shown in cases where on the basis of anamnestic and clinical signs is suspected in the concomitant loss of bile ducts of the presence of stones and strictures. To remove this suspicion, you can resort to the use of endoscopic retrograde cholangiopancreatography (ERCP). But compared with the diagnostic method of intravenous holegrafiya is gentle and less dangerous method, which is not peculiar to life-threatening complications.
You should inform
need advice
General stage
الأحد، 2 يناير 2011
Neutropenia
Neutropenia (granulocytopenia, agranulocytosis) - reduction of blood neutrophils, often increases susceptibility to bacterial and fungal infections.
On the number of neutrophils in the blood (the total number of leukocytes, multiplied by the percentage of neutrophils) and, accordingly, the risk of infection distinguish light (1000 - 2000 of neutrophils in 1 mm), medium (500 - 1000/mkl) and severe neutropenia (less than 500/mkl) . Severe acute neutropenia caused by a violation of Education of neutrophils, often poses a risk to life.
Reasons. Neutropenia is due to a breach of education neutrophils, regional state of neutrophils (congestion at the walls of blood vessels) with redistribution of blood, their rapid recovery and reduce the lifetime. The condition may be acute (developing over several days) or chronic (lasts months or years). Sometimes this is an isolated anomaly, but in other cases - a manifestation of hematologic (blood-related) diseases.
The most common cause of neutropenia - neutrophil brand name viagra depression education drugs (such as cytotoxic antitumor agents, anticonvulsants, sulfonamides, etc.). Neutropenia refers to an inevitable side effect of some antitumor drugs (eg alkylating agents, antimetabolites). Other drugs cause neutropenia as an idiosyncratic reaction (does not depend on the dosage or duration of the medication).
The decrease of neutrophil production is also observed in some rare hereditary and congenital anomalies (eg, hereditary agranulocytosis in children during the first months of life, with family neutropenia, cyclic neutropenia, in some diseases in which the violation production of neutrophils combined with a severe immunodeficiency). Sometimes the formation of neutrophils disrupted due to a bone marrow transplant or destruction (eg, cancer and granulomatous disease) as well as the usual manifestation of severe deficiency of vitamin B12 and folic acid.
Manifestations. Neutropenia has no specific manifestations, except for those associated with the proceeding against it and the infection Viagra an epidemic usually depends on the severity, duration and causes of neutropenia. In acute neutropenia fever are not uncommon, the appearance of painful ulcers on the mucous membrane of mouth and anus, the development of bacterial pneumonia. If you do not start treatment in the future there develops bacteremia and septic shock. Chronic neutropenia is often far more benign, especially if it is a mild or moderate form, the number of monocytes in the blood normally, and the functions of other immune system components (eg immunoglobulins, complement and lymphocytes) are not changed.
Treatment by a doctor. Gargle every few hours with saline or hydrogen peroxide, pain relievers, lozenges (benzocaine, 15 mg every 3 - 4 h) or rinse the mouth of 1% chlorhexidine ease discomfort associated with ulceration.
Chronic neutropenia - a tactic should be expectant: patients should be warned that he should immediately seek medical attention when the temperature rises and other signs of infection.
Something interesting
Neutropenia (agranulocytosis) occurs (as a side effect), using very high doses of captopril (hood) of patients with connective tissue and impaired renal function after 3 - 6 months of treatment. Typically, the number of leukocytes recovered within three months after the abolition of drugs.
Excellent results
University of Minnesota
On the number of neutrophils in the blood (the total number of leukocytes, multiplied by the percentage of neutrophils) and, accordingly, the risk of infection distinguish light (1000 - 2000 of neutrophils in 1 mm), medium (500 - 1000/mkl) and severe neutropenia (less than 500/mkl) . Severe acute neutropenia caused by a violation of Education of neutrophils, often poses a risk to life.
Reasons. Neutropenia is due to a breach of education neutrophils, regional state of neutrophils (congestion at the walls of blood vessels) with redistribution of blood, their rapid recovery and reduce the lifetime. The condition may be acute (developing over several days) or chronic (lasts months or years). Sometimes this is an isolated anomaly, but in other cases - a manifestation of hematologic (blood-related) diseases.
The most common cause of neutropenia - neutrophil brand name viagra depression education drugs (such as cytotoxic antitumor agents, anticonvulsants, sulfonamides, etc.). Neutropenia refers to an inevitable side effect of some antitumor drugs (eg alkylating agents, antimetabolites). Other drugs cause neutropenia as an idiosyncratic reaction (does not depend on the dosage or duration of the medication).
The decrease of neutrophil production is also observed in some rare hereditary and congenital anomalies (eg, hereditary agranulocytosis in children during the first months of life, with family neutropenia, cyclic neutropenia, in some diseases in which the violation production of neutrophils combined with a severe immunodeficiency). Sometimes the formation of neutrophils disrupted due to a bone marrow transplant or destruction (eg, cancer and granulomatous disease) as well as the usual manifestation of severe deficiency of vitamin B12 and folic acid.
Manifestations. Neutropenia has no specific manifestations, except for those associated with the proceeding against it and the infection Viagra an epidemic usually depends on the severity, duration and causes of neutropenia. In acute neutropenia fever are not uncommon, the appearance of painful ulcers on the mucous membrane of mouth and anus, the development of bacterial pneumonia. If you do not start treatment in the future there develops bacteremia and septic shock. Chronic neutropenia is often far more benign, especially if it is a mild or moderate form, the number of monocytes in the blood normally, and the functions of other immune system components (eg immunoglobulins, complement and lymphocytes) are not changed.
Treatment by a doctor. Gargle every few hours with saline or hydrogen peroxide, pain relievers, lozenges (benzocaine, 15 mg every 3 - 4 h) or rinse the mouth of 1% chlorhexidine ease discomfort associated with ulceration.
Chronic neutropenia - a tactic should be expectant: patients should be warned that he should immediately seek medical attention when the temperature rises and other signs of infection.
Something interesting
Neutropenia (agranulocytosis) occurs (as a side effect), using very high doses of captopril (hood) of patients with connective tissue and impaired renal function after 3 - 6 months of treatment. Typically, the number of leukocytes recovered within three months after the abolition of drugs.
Excellent results
University of Minnesota
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