Sharp occlusion of mezenterialny vessels
Sharp occlusion of mezenterialny vessels – the sharp violation of blood circulation in bryzheechny vessels leading to intestines ischemia. The disease is shown by sharp, intolerable belly-ache, vomiting and a diarrhea with blood impurity, a state of shock. The diagnosis of sharp occlusion of mezenterialny vessels is defined on the basis of a clinical picture, data of a selective angiography, X-ray analysis of an abdominal cavity, a laparoscopy. Sharp occlusion of mezenterialny vessels demands the emergency surgery (embol-or trombendarterioektomiya, resections of the struck departments of intestines), prevention of peritonitis and repeated occlusions.
Sharp occlusion of mezenterialny vessels
Sharp occlusion of mezenterialny vessels - the urgent pathology in gastroenterology arising owing to thrombosis or an embolism of vessels of a bryzheyka. Sharp occlusion of mezenterialny vessels is shown by sharp violation of blood circulation in vascular sites proksimalny and distalny places of obstruction, is followed expressed angiospazmy and an additional tromboobrazovaniye therefore there is a sharp violation of food and ischemic defeat of a wall of intestines. Further irreversible destructive changes begin to develop, the anemichesky and hemorrhagic heart attack (necrosis) of intestines is formed. Sharp occlusion of mezenterialny vessels is characterized by extremely heavy current and a vyyosoky lethality.
Localization and protyazhenyonost of ischemic damage of intestines at sharp occlusion of mezenterialny vessels depends on a look and the level of obstruction, existence of collateral ways of compensation of a blood-groove. In 90% of cases occlusion of the main trunk or one of branches of the top bryzheechny artery more providing blood supply of a digestive tract is observed. The lower bryzheechny arteyoriya has good collateral communications therefore at its occlusion seldom there are serious violations of mezenterialny blood circulation. Occlusion of bryzheechny veins meets less often; also mixed damage of bryzheechny arteries and veins at which sharp occlusion of one of vessels is preceded by chronic obstruction of another is possible.
Sharp occlusion of mezenterialny vessels occurs mainly at males aged 50-60 years are more senior.
Reasons of sharp occlusion of mezenterialny vessels
Sharp occlusion of mezenterialny vessels develops as a complication of various cardiovascular diseases (atherosclerosis, heart diseases, system allergic vaskulit, rheumatism, hypertension, aneurism of a belly aorta, arrhythmia), the previous heart and aorta operations, malignant tumors, injuries.
Thrombosis and embolism are an immediate cause of sharp occlusion of mezenterialny vessels. At thrombosis the gleam of vessels of a bryzheyka is blocked by the blood clot formed owing to change of vascular walls against the background of the increased coagulability of blood and the slowed-down blood-groove (a pathogenetic triad of Vikhrov). At an embolism obstruction of bryzheechny vessels by a particle the tumor fabric, a foreign matter or a vial of air migrating from primary source of defeat with blood current is observed.
Sharp occlusion of mezenterialny vessels can proceed with compensation, subcompensation and a decompensation of a mezenterialny blood-groove. At compensation of a mezenterialny blood-groove (it is spontaneous or as a result of conservative therapy) all functions of intestines are restored completely. Subcompensation of a mezenterialny blood-groove in view of nedostayotochny blood supply can lead to a number of diseases of intestines: to a belly toad, ulcer enteritis and to colitis, etc. The decompensation of a mezenterialny krovoobrayoshcheniye causes widespread purulent peritonitis and development of heavy abdominal sepsis.
Symptoms of sharp occlusion of mezenterialny vessels
The disease harbingers similar to a preinfarction angina can precede the developed clinical picture of sharp occlusion of mezenterialny vessels, – a so-called "belly toad".
In most cases sharp occlusion of mezenterialny vessels has the sudden beginning and at an ischemia stage (the first 6-12 hours) is characterized by intolerable, skhvatkoobrazny belly-aches. The patient feels concern, cannot find any peace, accepts the compelled pose with the legs given to a stomach. There are nausea and vomiting with impurity of bile and blood, later vomiting with a kalovy smell, a numerous liquid chair with blood impurity ("an ischemic opoyorozhneniye of intestines").
Sharp pallor of skin poyokrov, cyanosis, a state of shock, increase in arterial pressure on 60-80 of units (Blinov's symptom), bradycardia is observed. Discrepancy between weight of a condition of the patient and data of his survey is characteristic of sharp occlusion of mezenterialny vessels: during the first hours the stomach remains soft, the belly wall participates in breath, insignificant morbidity without symptoms of irritation of a peritoneum is noted.
In a heart attack stage (in 6-12 hours from the beginning of sharp occlusion of mezenterialny vessels) pain decreases a little, but accrues local (in a zone of defeat of a gut) morbidity at a palpation, between a navel and a pubis can be probed a testovidny swelling (Mondor's symptom), the condition of the patient worsens. Evakuatorny function of intestines soyokhranyatsya, arterial pressure is normalized, pulse becomes frequent.
The stage of peritonitis begins in 18-36 hours from the moment of sharp occlusion of mezentralny vessels, is characterized by sharp deterioration in a state: strengthening of pains (especially at the movement), the expressed intoxication, symptoms of peritonitis, paralytic intestinal impassability.
Diagnostics of sharp occlusion of mezenterialny vessels
Recognition of sharp occlusion of mezenterialny vessels is guided by the analysis of a clinical picture of a disease: a sharp pain abdominal syndrome, damage of heart and vessels in the anamnesis. Important diagnostic value has a koagulogramma research, determination of quantity of platelets, blood cholesterol.
At a survey X-ray analysis of an abdominal cavity the intestines pnevmatization, presence of horizontal levels of liquid in an abdominal cavity is defined. A specific method of diagnostics of sharp occlusion of mezenterialny vessels is the selective mezenterikografiya which at an early stage of a disease can already reveal lack of a blood-groove in a trunk and branches of a bryzheechny artery. The magnetic and resonant angiography of mezenterialny vessels is if technically possible carried out.
The diagnostic laparoscopy allows to find izmeyoneniye of intestines and an abdominal cavity, existence of symptoms of an anemichesky and hemorrhagic heart attack of a gut. Sharp occlusion of mezenterialny vessels is differentiated from probodny stomach ulcer and a duodenal kishyoka, an acute appendicitis, intestinal impassability, sharp pancreatitis and sharp cholecystitis.
Treatment of sharp occlusion of mezenterialny vessels
At sharp occlusion of mezenterialny vessels the emergency surgical intervention as which purpose serves audit of intestines with assessment of its viability, audit of the main bryzheechny vessels, elimination of the reason of vascular impassability and restoration of a mezenterialny blood-groove, a resection of nekrotizirovanny departments of intestines, prevention of peritonitis is shown.
Revaskulyarization of intestines is carried out by an indirect embol-or a trombendarterioektomiya, in hard cases reconstructive roundabout shunting with use of vascular artificial limbs (prosthetics of the top bryzheechny artery) is carried out.
At an intestines necrosis the revaskulyarization is supplemented with a partial or extensive resection of affected areas of intestines and active nazointestinalny drainage for treatment of postoperative paresis of intestines. In 24-48 hours performance of a relaparotomiya for the purpose of control of a condition of an abdominal cavity or imposing of an otsroyochenny anastomoz is possible.
Before - and postoperative maintaining the patient with sharp occlusion of mezenterialny vessels includes purpose of antitrombotichesky medicines for prevention of a repeated embolism and a retromboz; actions of intensive therapy for the purpose of restoration of OTsK, elimination of intoxication, improvement of a blood-groove and fabric metabolism, stabilization of warm activity. Antibacterial therapy, drainage and sanitation of a bryushyony cavity for the prevention of gangrene and peritonitis is carried out.
Forecast and prevention of sharp occlusion of mezenterialny vessels
Restoration of a blood-groove in bryzheechny arteries within the first 4-6 hours ("the gold period") can prevent a heart attack of a kiyoshechnik and restore his functions. As a rule, surgery is the share of II and III stages of sharp occlusion of mezenterialny vessels therefore the lethality after operation reaches 80-90%. The forecast worsens existence of the main disease which led to sharp violation of mezenterialny blood circulation.
Prevention of sharp occlusion of mezenterialny vessels consists in timely elimination of a potential source of a thrombembolia, i.e. primary disease (atherosclerosis, vibrating arrhythmia, rheumatic heart disease, aneurisms, etc.).