Sharp stomach – a complex of the clinical, laboratory and tool signs demonstrating accident in an abdominal cavity and need of rendering the emergency surgical aid to the patient. It is shown by the main triad of symptoms: abdominal pain syndrome, tension of a forward belly wall, violation of evakuatorny function of intestines (vermicular movement). Correctly collected anamnesis, survey, a X-ray analysis of bodies of an abdominal and chest cavity, ultrasonography, a laparoscopy are of diagnostic value. This syndrome usually demands urgentny surgical intervention for rescue of life of the patient.
The sharp stomach represents the collective concept including any catastrophic situation in an abdominal cavity (sharp diseases of inflammatory character, violation of blood circulation, a trauma and damage of bodies, intestinal impassability of any etiology) which demands bystry diagnostics, statement of the correct diagnosis and performing urgentny surgery. The understanding of an essence of a syndrome of a sharp stomach is the most urgent for emergency doctors and accident wards of hospitals since they have to establish the correct diagnosis in the shortest possible time and hospitalize the patient in profile surgical office.
Need of drawing up an algorithm of diagnostic search at a syndrome of a sharp stomach arose at the beginning of the twentieth century. This need was dictated by the fact that a significant amount of death in a hospital was caused by postponement of operation at patients with sharp surgical pathology of an abdominal cavity because of difficulties of diagnostics and the differential diagnosis. Statistically, the lethality among the patients with the diagnosis a sharp stomach hospitalized and operated in the first six hours from the beginning of a disease is 5-8 times lower, than among patients with the same pathology to whom surgical help was given in later terms. It should be noted that hyper diagnostics of a sharp stomach (a pseudoabdominal syndrome against the background of somatic pathology) is also a big problem as unreasonable surgery can worsen a condition of such patients considerably.
Reasons of a sharp stomach
Can lead the surgical and not surgical reasons to developing of the sharp pathology of bodies of a stomach demanding the emergency surgery. In gynecology, traumatology, abdominal surgery the sharp stomach is often tied with intra belly bleeding which can accompany extra-uterine pregnancy, an ovary apopleksiya, a stomach injury, perforation of hollow bodies. In this case blood comes to an abdominal cavity, causing irritation of a peritoneum and symptoms of sharp blood loss.
Other mechanism of development of a sharp stomach is observed at violation of blood circulation in abdominal organs and a small pelvis: sharp occlusion of mezenterialny vessels, the restrained hernia, intestinal impassability, overwind ovary cyst legs, a necrosis of miomatozny knot, overwind a small egg, etc. In similar situations peritonealny symptoms are caused by ischemia, quickly accruing nekrobiotichesky changes in this or that body and the beginning peritonitis. At such diseases as an acute appendicitis, cholecystitis, sharp pancreatitis, salpingooforit, the characteristic clinical picture is defined sharp, sometimes by purulent inflammatory process.
The surgical reasons of a sharp stomach are excluded first of all. However there is a number of diseases at which the expressed abdominal pain syndrome is not connected with pathology in an abdominal cavity. Such states feign clinic of a sharp stomach, but do not demand the emergency surgical intervention. Some infectious diseases (sharp intestinal infection, , hepatitis), dismetabolichesky frustration (ketoacidosis belong to not surgical reasons of an acute pain in a stomach at diabetes, hemochromatosis, the increased level of triglycerides in blood, etc.). Intensive pain can irradiate to the area of a stomach at a myocardial infarction, pleurisy and a pleuropneumonia.
Symptoms of a sharp stomach
The triad of the main symptoms enters a clinical picture of a sharp stomach: abdominal pain, tension of muscles of a forward wall of an abdominal cavity, frustration of a vermicular movement of intestines. These signs can be combined among themselves and with less significant symptoms in various combinations.
Pains are the first and brightest symptom of a sharp stomach. They can have various localization, prevalence and intensity. The most expressed and poured pains are noted at extensive injuries of an abdominal cavity, a pankreonekroza. On the contrary, the elderly and weakened patients, children, against the background of intoxication can have not intensive pain, wandering. More often pain happens sharp, dagger though also cases meet the gradual beginning of a pain syndrome. Most of patients indicate migration of pain from an initial source, distribution on other regions or all stomach. On character she can remind blow of a knife, to be skhvatkoobrazny, exhausting, burning down etc.
At some pathological states (intestinal impassability, destructive appendicitis) alternation of episodes of an acute pain and imaginary wellbeing is possible. Often pain syndrome can be followed by a resistant hiccups, vomiting. The inflammatory exudate and blood accumulating in an abdominal cavity irritate nervous receptors and cause positive symptoms of "vanki-vstanka" (the expressed strengthening of morbidity upon transition from a sitting position in horizontal in this connection the patient sits down at once again), a frenikus-symptom (considerable morbidity when pressing between legs - a clavicular and mastoidal muscle). Tension of a muscular corset of an abdominal cavity is also connected with irritation of leaves of a peritoneum exudate, contents of a digestive tract and blood. As it was already told above, at the elderly, weakened patients and children this symptom can be also not expressed.
Character changes a calla, locks and eases of a chair, a delay of an otkhozhdeniye of gases can serve as manifestation of violation of work of intestines. So, in initial phases of an acute appendicitis, an invagination of intestines the liquid chair can be noted. At an invagination, a probodny ulcer, mezenterialny thrombosis in a chair blood will be defined. Absence a calla and gases speaks well for intestinal impassability.
Many diseases which are shown clinic of a sharp stomach are followed by the anemia phenomena: pallor of integuments, cold then, chill. The started episodes of a sharp stomach are accompanied by the shock phenomena – indifference, block, pointedness of features, earthy-gray skin color.
Diagnostics of a sharp stomach
In diagnosis of a sharp stomach huge value has correctly collected anamnesis in combination with competently performed fizikalny inspection. It is important to find out whether pain sharply developed (perforation of hollow body) or the pain syndrome gradually amplified (peritonitis); whether pain in one place is localized or migrates; whether developing of pain is connected with meal. Vomiting indicates violation of a passage of food on intestines of mechanical or reflex character (intestinal impassability, colic). Surely it is necessary to find out whether change of character and frequency of a chair was noted recently, whether was pathological impurity in Calais (blood, slime in the form of "crimson jelly", etc.).
During inspection pay close attention to a condition of cardiovascular system (ChSS, the level of arterial pressure) for timely diagnosing of bleeding, shock. At survey of a stomach its form (sunk down or boatshaped, intense - is estimated at perforation of a stomach, intestines; reinflated and asymmetric – points out impassability of intestines), cicatricial changes and hernial defects come to light. The palpation allows to find criteria of irritation of a peritoneum, volume educations in a stomach, to localize a pain source. At percussion it is possible to define expansion of borders of a liver, availability of free gas or an exudate in a stomach cavity. When listening a stomach intestinal noise or considerably amplify (in initial phases of impassability of intestines) or are not listened at all (in an impassability heat phase).
All patients with suspicion on a sharp stomach should conduct a rectal research. It is necessary to focus attention to a sharpening of morbidity when pressing by a finger on rectum ampoule walls (it speaks about existence of an exudate in a small basin). At identification at the patient even of small hernial protrusions it is recommended to conduct a manual research through hernia gate. When using this reception there is a direct irritation of a parietal leaf of a peritoneum therefore morbidity and tension of a belly wall will be more expressed. At children it is useful to make a palpation of bodies of a stomach in a condition of a dream or a sedation when it is possible to exclude the involuntary tension of a belly wall.
Laboratory analyses at a sharp stomach are not informative, reveal pyoinflammatory changes, anemia. Odnin from the simplest and available methods of verification of accident in a stomach - a survey X-ray analysis of OBP. To patients in critical condition pictures are made in horizontal position (in a side projection), in other cases the X-ray analysis in vertical position is executed. In pictures free gas in stomach cavities, blackout in sloping places (exudate), arches and levels in intestines loops, gas in zabryushinny cellulose is visualized. Advanced diagnostic search includes X-ray contrast researches: gas, contrast substance is entered into a stomach or intestines. If air or contrast get into a free abdominal cavity, it demonstrates perforation of hollow body. If when contrasting a stomach its shift kpered is noted, it is possible to think of a pankreonekroza. The specialized radiological research (tseliakografiya, mezenterikografiya) can sometimes be required.
Ultrasonography of OBP will allow to reveal exudate in an abdominal cavity, gas in system of a vorotny vein, a tumoral conglomerate, and other pathological states which could serve as the reason of sharp surgical pathology. Ultrasonography is the leading method of diagnosis of sharp urological and gynecologic pathology. In difficult situations the diagnostic laparoscopy will help to establish the correct diagnosis.
If at the patient the sharp stomach is supposed, it is necessary to approach an exception of the states imitating accident in a stomach carefully. The operation performed to the patient with heavy somatic pathology often leads to deterioration in its state and death. For this reason at receipt to the accident ward it is required to exclude not surgical factors of a sharp stomach: heart attack (ischemia) of a myocardium, pneumonia, pleurisy, pheumothorax, urolithic and cholelithiasis (colic), intestinal infections.
Treatment of a sharp stomach
All patients with clinic of a sharp stomach demand hospitalization in profile surgical office. If the pseudoabdominal syndrome is revealed, and sharp surgical pathology is excluded, the patient is transferred to office of gastroenterology or therapy. Preoperative preparation has to be most reduced if a condition of the patient very heavy – preparation and antishock therapy are carried out in intensive care unit within several hours. Before statement of the exact diagnosis it is impossible to eat food and liquids, to apply anesthetics and hypnotic drugs, to do enemas.
Application of analgetics (especially narcotic) has the investigation easing of pain and relaxation of a muscular corset that in turn conducts to errors of diagnostics and unreasonable postponement of operation. After establishment of the correct diagnosis patients with pains of spastic character are allowed to inject spazmolitichesky drugs.
The majority of the states leading to development of a sharp stomach demand urgent surgical intervention. Operation is recommended to be performed within six hours from emergence of symptoms of a disease – in this situation the frequency of complications considerably decreases, the forecast improves. If the patient came to a hospital in an agonalny state, preparation is not carried out, operation begins immediately, along with holding resuscitation actions.
Forecast of a sharp stomach
The forecast for health and life at a sharp stomach considerably depends on the reason of this state, age of the patient, existence of the accompanying pathology, term from the beginning of a disease before hospitalization and surgery. Considerably the forecast worsens at it is long the current peritonitis, an intestines necrosis, thrombosis of mezenterialny veins. These states at the weakened and elderly patients, children of early age are especially dangerous. The lethality considerably decreases at early diagnosis and timely performing surgery. Specific prevention of a sharp stomach does not exist.