Intestines heart attack
Intestines heart attack – the necrosis of an intestinal wall connected with the sharp termination of a blood-groove on mezenterialny vessels owing to their embolism or thrombosis. A characteristic symptom of a heart attack of intestines is intensive belly-ache at total absence of any objective data during inspection of the patient (a stomach soft, low-painful). For specification of the diagnosis ultrasonography and a survey X-ray analysis of OBP, duplex scanning and an angiography of mezenterialny vessels, a laparoscopy is carried out. Conservative treatment of neokklyuzionny forms of a heart attack of intestines is possible only during the first hours diseases, late stages and other forms demand surgical treatment.
Intestines heart attack
Intestines heart attack – sharp violation of mezenterialny blood circulation with the subsequent necrosis of a gut and development of peritonitis. This pathology is one of the main problems of surgical gastroenterology of the last years. Most often the embolism, thrombosis, atherosclerosis and neokklyuzionny ischemia of vessels of intestines arise against the background of heavy pathology of heart. Due to the increase in percent of the elderly population and rejuvenation of cardiovascular pathology the heart attack of intestines meets even more often (0,63% compared with isolated cases at the end of the last century). Average age of patients with an intestines heart attack – 70 years, women (more than 60%) prevail. Considering solid age of patients and mass of background diseases, to resolve an issue of surgical tactics of treatment happens rather difficult.
One more problem is that it is rather difficult to make the diagnosis of a heart attack of intestines, and it is almost impossible to confirm it without carrying out an angiography before operation. Owing to wrong diagnostics preoperative preparation drags on; during this time there are irreversible changes in a gut leading to the death of the patient. The situation is aggravated with the fact that in recent years the intestines heart attack considerably rejuvenated (every tenth patient younger 30 years), and the radical resection of intestines brings in a late stage of a disease a resistant invalidization. Despite improvement of diagnostic and medical actions at an intestines heart attack, mortality at its various forms reaches 50-100%.
Intestines heart attack reasons
All causal factors leading to an intestines heart attack can be divided into three groups: trombotichesky, embolichesky and neokklyuzionny. The Trombotichesky option of a heart attack of intestines is characterized by thrombosis of mezenterialny arteries (more rare than veins) in their proximal departments. Most often blood clot is localized in the mouth of the top bryzheechny artery. The increased coagulability of blood, a politsitemiya, heart failure, pancreatitis, injuries, tumors, reception of hormonal contraceptives can lead to thrombosis of visceral branches of an aorta.
The Embolichesky option of a heart attack of intestines develops at obstruction of bryzheechny vessels of a tromboembolama, migrating from proximal departments of the vascular course. As the reason of it most often serve vibrating arrhythmia, formation of pristenochny blood clots against the background of a myocardial infarction, aorta aneurisms, the expressed coagulation violations. After a vessel obturation it can be displaced in disteel departments and branches of a vessel, causing the faltering, migrating ischemia.
The Neokklyuzionny type of a heart attack of intestines is connected not with an obturation of visceral vessels, and with decrease in inflow of blood on them. Mezenterialny thrombosis, decrease in fraction of warm emission, the expressed arrhythmia, an angiospasm of a bryzheyka, a gipovolemiya at shock, sepsis, dehydration can be the reasons of restriction of a visceral blood-groove.
Factors from the listed three groups quite often are combined. The disease can proceed with compensation, subcompensation and a decompensation of a blood-groove. Besides, allocate three consecutive stages of a heart attack of intestines: ischemia, heart attack and peritonitis. In the first stage of change in intestines are still reversible, and clinical manifestations are generally connected with reflex reactions of an organism. In an infarktny stage there is an intestines necrosis, destructive changes continue even after restoration of a blood-groove. Protective properties of an intestinal wall gradually weaken, bacteria begin to get through all its layers into an abdominal cavity. In a stage of peritonitis there is a disintegration of fabrics of an intestinal wall, a hemorrhagic propotevaniye to development of the hardest inflammation of a peritoneum.
Intestines heart attack symptoms
The first stage of a heart attack of intestines – ischemic – usually lasts no more than six hours. During this period of the patient severe pains in a stomach, in the beginning skhvatkoobrazny, then constants disturb. Localization of pain depends on what department of intestines is struck: at ischemia of a small intestine pain in the okolopupochny area ascending and a blind gut – in the right half of a stomach, cross and descending – in the left half disturbs. Pain is very strong, however does not correspond to the objective data obtained at survey of the patient. At a palpation a stomach soft, low-painful. Sharp emergence of a pain syndrome is characteristic of a heart attack of intestines, however also gradual, sometimes the two-stage beginning of a disease is possible. Except belly-aches, the patient can complain of nausea, vomiting, diarrhea. Auskultation of a stomach in an initial stage reveals the raised vermicular movement which gradually weakens within several hours.
In stages of a heart attack and peritonitis the condition of the patient progressively worsens. Integuments are pale, dry. Pain gradually weakens, and at a full necrosis of a wall of intestines completely disappears that is a bad predictive sign. Language dry, with a raid. The stomach which is blown up, but as late emergence of symptoms of irritation of a peritoneum is characteristic of a heart attack of intestines, a stomach long time remains soft. Patognomonichen Kadyana-Mondor's symptom: at a palpation in an abdominal cavity cylindrical dense and elastic education, low-movable and painful - the swelled site of a gut and bryzheyka is defined. At an auskultation of an abdominal cavity sites of a timpanit (a ringing sound over the reinflated intestines loops) alternate with sites of obtusion of a sound (over nekrotizirovanny loops). The exudate in an abdominal cavity (ascites) can be formed in several hours from the beginning of a disease.
If the disease progresses, the phenomena of intoxication and dehydration accrue, the patient becomes indifferent, apathetic. Even if to begin assistance to the patient at this stage, the state can progressively worsen, there comes the coma, spasms begin. At this stage of a disease mortality reaches nearly 100%.
Diagnosis of a heart attack of intestines
Low knowledge of doctors of a pre-hospital stage of an intestines heart attack considerably complicates timely diagnosis of this disease. Also late detection of this pathology is promoted by insufficient equipment of hospitals the diagnostic equipment (the angiograph, the computer tomograph). However it is possible to suspect a heart attack of intestines and with the help of research methods to others. On ultrasonography of abdominal organs at this disease the reinforced wall of intestines, availability of free liquid in an abdominal cavity comes to light. Duplex color ultrasonic scanning is the only thing reliable BONDS methods of diagnosis of thrombosis of mezenterialny vessels.
The survey X-ray analysis of abdominal organs is informative at later stages when Kloyber's bowls, intestinal arches become visible. Carrying out a contrast radiological research is not recommended as it does not provide any data, valuable to diagnosis, but considerably tightens diagnostics stage. The multislice spiral computer tomography of abdominal organs allows to conduct more exact research of loops of intestines (gives the chance to find gas in a bryzheyka and a wall of a gut), and MRT of mezenterialny vessels – to estimate a condition of the vascular course, to find blood clots and embola.
The most exact method of a research is the angiography of mezenterialny vessels. This research is recommended to conduct in two projections – direct and side. Such technique allows to calculate exact localization of pathological process, to reveal the struck branches of visceral vessels, to define tactics and volume of surgery. Also consultation of the endoscopist helps with diagnostics and definition of medical tactics. The diagnostic laparoscopy gives the chance to visually estimate a condition of loops of intestines, to reveal some signs, patognomonichny for an intestines heart attack. Refer change of color of an intestinal wall, lack of a pulsation of regional vessels, change of the vascular drawing to them (longitudinal instead of cross). Identification of these signs allows to expose indications to urgentny operation even at impossibility of carrying out an angiography. Contraindications to a laparoscopy are: the expressed intestines swelling, existence of extensive laparotomies in the anamnesis, critical condition of the patient.
Specific laboratory symptoms of a heart attack of intestines, especially in initial stages of a disease, do not exist. In the general blood test in process of development of a disease the shift of a leykoformula accrues , to the left. The analysis a calla on the hidden blood also becomes positive at an intestines necrosis stage. Some authors point to increase in level of a lactate in blood as on a specific symptom of a heart attack of intestines.
Treatment of a heart attack of intestines
The purpose of treatment of a heart attack of intestines – elimination of all pathogenetic links of this disease. One of the fundamental principles of therapy of thrombosis of mezenterialny vessels – the early beginning of a fibrinoliz. However the beginning of pathogenetic treatment at a pre-hospital stage is possible only theoretically because this diagnosis practically is never made before hospitalization of the patient. Right after hospitalization begin correction of pathology which led to development of a heart attack of intestines, along with infusional therapy. Infusion of kristalloidny and colloidal solutions is intended to compensate the missing volume of the circulating blood, to restore perfusion of ischemic sites of a gut. Beginning kardiotropny therapy, it is necessary to refuse use of vazopressor as they cause an angiospasm of a bryzheyka and aggravate ischemia. At neokklyuzionny ischemia introduction of spazmolitik for improvement of a visceral blood-groove is shown.
Conservative therapy is justified only at absence at the patient of symptoms of peritonitis. The greatest efficiency is reached at the therapy begun in the first two-three hours from emergence of symptomatology. The longer the stage of conservative treatment will last, the it is less than chances of a favorable outcome therefore the stage of not surgical therapy has to be the shortest. In the absence of bystry effect urgentny operation is performed. The same concerns also preoperative preparation – the it is shorter, the chances of recovery are higher.
At an intestines heart attack only surgeries on the vascular course are considered as radical (in the presence of indications - in combination with an intestines resection). The isolated resection of a nekrotizirovanny intestinal loop without removal of blood clot from a vessel does not eliminate the main pathogenetic mechanism of developing of a heart attack of intestines, so – does not lead to improvement of a condition of the patient. If surgery is made in terms more than 24 watch from the beginning of a disease, the laparotomy in 95% of cases only states irreversible changes in the most part of intestines. The radical resection of the struck gut in such situation does not prevent the death of the patient.
If the extensive resection of intestines was made, in the postoperative period consultation of the gastroenterologist for definition of tactics of enteralny and parenteral food can be required by the patient. Sometimes such patients demand lifelong partial or full parenteral food by means of intravenous administration of carbohydrates, proteinaceous and fatty fractions.
Forecast and prevention of a heart attack of intestines
The forecast at an intestines heart attack adverse as this disease is seldom in due time diagnosed, and at late stages expeditious treatment often happens inefficient. Prevention of a heart attack of intestines consists in timely treatment of the diseases bringing to it (aortal and mitralny heart diseases, arrhythmias, atherosclerosis, trombofiliya).