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ODESSA NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF SURGERY № 1
METHODOLOGICAL RECOMMENDATION
of the practical lesson from the discipline
"Surgical diseases with child's surgery and oncology" for teachers
Module № 4. "Symptoms and syndromes in surgery"
Semantic module № 8. "Clinical displays of surgical diseases".
Theme № 19. "Surgical treatment of infectious diseases. Reasons of origin, diagnostics and differential diagnostics, medical tactic"
It is discussed and ratified on to the methodical conference of the Department
"29" auguct 2014 р.
Protocol № 1.
Head of the Department
Professor __________Grubnik V.V..
ODESSA 2014
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1. Theme of practical work: “Surgical treatment of infectious diseases.
Reasons of origin, diagnostics and differential diagnostics, medical tactic”.
2. Actuality of theme.
Surgical complications of infectious diseases in surgical practice occupy one
of main places. History of surgery is indissolubly related to the fight against an infection. Wide application of antibiotics as a result of their mutagenic action caused
the change of specific composition and properties of pyogenic microbial flora that
reduced efficiency of antibiotic therapy. The special value is acquired by the questions of surgical treatment of complications of infectious diseases, where must be
rationally combined conservative methods with timely operative interference, determination of indications for hospitalization such of patients.
The existent methods of treatment of infectious diseases stipulate oppression
and destroying an infection not always. The most essential moment is surgical
complications of infectious diseases which have one of main places for treatment
of complications of infectious diseases.
3. Whole of the work:
3.1. General aims: A student must learn:
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2
3
4
5
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To find out the anamnesis and clinical objective signs of
surgical complications at infectious diseases
To basic principles of diagnostics, differential diagnostics
To appoint the plan of examination with the use of laboratory, roentgenologic examinations
To give an urgent conservative help patients with surgical
complications at infectious diseases
To determine indications to operative interference and in
theory to know the method of their conducting
ІІ level
ІІ level
ІІІ level
ІІІ level
ІІ level
3.2. Educate aims:
1. Forming professionally of meaningful personality of doctor. To underline
achieving national surgical school of surgeons in development of modern methods
of treatment of surgical complications at infectious diseases.
3.3. Concrete aims:
to know:
Etiology, pathogenesis.
Clinical picture of surgical complications at infectious diseases;
Differential diagnostic criteria of surgical complications are at
infectious diseases;
Methods of instrumental and laboratory investigations of patients are
with surgical complications at infectious diseases;
Conservative and operative treatment of patients with surgical
complications at infectious diseases;
3.4. On the basis of theoretical knowledges from a theme.
Able (to lay hands on methods):
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To collect anamnesis of disease.
To conduct differential diagnostics between the festering diseases of
different genesis and by other infectious diseases;
To define the diagnosis of disease.
To appoint conservative or operative tactic of treatment of disease.
№
4. Interdisciplinary integration
Disciplines
To know
Able
1. Previous disciplines
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Anatomy, topographical Structure of skin, lungs, livanatomy
er, spleen, stomach, intestine. Ways of possible flow
of festering exudate for to
the anatomic channels of
conducting of cut
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Pharmacology
To set the source
of inflammation.
Conduct differential diagnostics between the festering
diseases of different genesis and by
other
infectious
diseases.
Mechanism of action of antibacterial preparations
5. Contents of the theme: Etiology and pathogenesis of infectious diseases which can have surgical complications. Classification. Diagnostics. Differential diagnostics.
Etiology and pathogenesis.
Surgical complications of infectious diseases in surgical practice occupy one
of important places. More frequent these complications arise up at patients with
specific infections: tuberculosis, HIV-infection, typhoid, cholera, Kron’s disease,
meningococcous infection, helminthiasis - (ascariasis, echinococcosis, lambliasis,
nematodes), malaria, anthrax, diseases of blood, syphilis, poisoning.
However to the specific infection very often joins and other infection: staphylococcus, streptococci, pneumococcus, gonococci, intestinal and pyocyanic stick
and other, quite often in symbiosis with anaerobic microorganisms. Bacteria which
got in a wound begin to show the vital functions and propagate oneself in it on the
average in 6 - 12 hours. To introduction of infection and development of diseases
which assist their development are:
а) presence in the area of trauma of nourishing for them environment (hemorrhage, necrotic tissues);
b) simultaneous coexistence of a few types of microbes (poly-infection);
c) penetration of microbes of the promoted virulence, for example, of contamination of site of damage festering separated other patient;
d) weakness of immunological reactions;
e) disorders of local and general circulation of patient’s blood.
On appearance of bacteria an organism answers a local and general reaction.
The local reaction of tissues is expressed foremost, by the change of circulation of
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blood of neural-reflector nature. Arterial hyperemia develops, and then venous stasis with formation of edema, pain, local increase of temperature and other, appears
plenty of neutrophil leucocytes accumulate in an inflammatory hearth.
The general reaction of organism on introduction of specific and pyogenic
microbes arises up simultaneously with local. The degree of it depends on the
amount of bacterial toxins and products of disintegration of tissues, and also resistibility of organism. Especially virulent microbes which select toxins cause the
strong general reaction of organism usually. The displays of it are: fever, darkening, and sometimes fainting fit, head pain, general indisposition, tachycardia, the
changes of blood indexes, disorder of liver function, arterial pressure, stagnation in
the small circle of circulation of blood, are acutely expressed. Patients need careful
examination for the exposure of primary festering hearth and entrance gate.
Distinguish hyperergic, normergic and hypoergic reactions.
Hyperergic - a process with a stormy flow and in spite of timely, rational
treatment often ends with a lethal result.
Normergic - a process develops less stormily, fewer tissues are involved in
an inflammatory process, and changes from the side of blood do not take the expressed character. This process easier responds to treatment.
Hypoergic - an inflammatory process is limited only a small area, less than
was swollen. These processes easily respond to treatment, and in some and without
treatment, but if good protective forces of organism, and differently an infection
adopts the protracted character.
Classification. Diagnostics. Treatment
At the account of features of clinical flow and character of changes from the
all forms of inflammation at surgical infection acute and chronic forms select.
1. Acute surgical infection:
а) festering;
b) putrid;
c) anaerobic;
d) specific (stupor, anthrax, tuberculosis, HIV-infection, typhoid, cholera, Kron’s
disease, meningococcous infection, helminthiasis - (ascariasis, echinococcosis,
lambliasis, nematodes), malaria, anthrax, diseases of blood, syphilis, poisoning.
2. Chronic surgical infection:
а) unspecific (pyogenic);
b) specific (tuberculosis, syphilis, actinomicosis and other).
At each of the transferred forms there can be forms with predominance of
local displays (local surgical infection) or with predominance of the general phenomena with a septic flow (general surgical infection).
Tuberculosis.
A term «Tuberculosis» was entered by Laenneck, originates from the Latin
word, in the translation of which means a «hump».
In 1882 years the German researcher Robert Koch due to the scientific labours gave exhaustive proofs of infectious nature of tuberculosis. He selected and
described the exciter of disease. It is accepted to name a Kohch’s bacterium (KB)
or mycobacterium of tuberculosis the exciter of tuberculosis (MBT). It is the repre-
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sentative of large group of mycobacteruim, family lower vegetable organisms, - to
the effulgent mushrooms.
Distinguish a few types of mycobacteruim of tuberculosis, able to cause a
disease for a man: human, bovine, bird, mouse and African kinds.
At the human 92-95% cases of disease a human kind causes, in 3-5% cases bovine kind. Two other - bird and mouse-coloured for a man almost safe. In 1969
year in the countries of Central Africa was first selected from a man subspecies of
mycobacteruim of tuberculosis, adopted African.
In our country for today there are 3 methods of exposure of tuberculosis: tuberculin diagnostics, fluorographic method and bacteriological investigations of
sputum.
Tuberculin diagnostics is used for children and teenagers to 15 years old.
For these aims unique intra-skin tuberculine probe of Mantu is utilized. The result
of test is estimated in 72 hours, the size of infiltrate is determined by a transparent
line. A reaction can be negative, doubtful, positive, poorly positive, middle intensity and brightly is expressed. Negative tests are observed for the healthy, people not
infected on tuberculosis.
By the basic method of prophylactic reviews of population from 15 years old
and more senior there is fluorographic examination.
Chemotherapy - treatment of patients by anti-tuberculosis preparations. It
takes a leading seat in treatment of patients with tuberculosis.
Classification
Tuberculosis of breathing organs:
• Focal tuberculosis of lungs
• Tuberculosis inwardly breast of lymph nodes
• Tuberculoma of lungs
• Tubercular intoxication
• Infiltrative tuberculosis of lungs
• Cavernous tuberculosis of lungs
• Fibrosis-cavernous tuberculosis of lungs
• Cyrrotic tuberculosis of lungs
• Tuberculosis of overhead respiratory tracts, a bit, bronchial tubes.
Tuberculosis of breathing organs, combined with the dust professional diseases of lungs.
Tuberculosis of lymph nodes:
• Tuberculosis of peripheral lymph nodes
• Tuberculosis of mesenterial lymph nodes
Bone-joint tuberculosis:
• humeral joint
• elbow joint
• hip joint
• knee-joint
- Tuberculosis of brain
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- Tuberculosis of eye
- Tuberculosis of larynx
- Tuberculosis of urethra and privy parts
- Tuberculosis of adrenal glands
- Tuberculosis of intestine
- Tuberculosis of skin
Clinic
• Primary tuberculosis.
Primary tuberculosis develops after the contact of mycoorganisms with mycobacterias of tuberculosis. Mainly it is pulmonary tuverculosis.
• Secondary tuberculosis.
Secondary tuberculosis - tuberculosis of persons which carried primary tuberculosis in the past can arise up both an endogenous way and as a result of the
repeated (exogenous) infecting of organism.
Clinical signs of tuberculosis.
From all of organs and systems lungs are most often damaged by tuberculosis, and the injury of other organs quite often develops as complication of pulmonary process. An early exposure of tuberculosis is one of important tasks of doctor.
For children external lymph nodes (neck, submaxillary, arm-pits, inguinal), and also lymph nodes of pectoral and abdominal cavities, are often struck tuberculosis.
At development of tubercular process in easy one of signs of disease there can be
an increase of temperature. A high temperature can stick to 2-3 weeks, and then go
down to 37,2-37,4°C. From the fever of lungs at tuberculosis decline of temperature does not conduce declension to convalescence, and from patients all or part
early the noted symptoms continue to be determined. Deep disorders of exchange
processes which are in organism - disorders of digestion, disintegration of albumens to the finished goods of their time-table and death of tissue, are reason of
thinning and loosening an organism at pulmonary tuberculosis.
Laboratory diagnostics.
Laboratory diagnostics of tuberculosis includes, bacteriological and bacterioscopic methods of investigations, conducting of biological and allergic reaction.
serologic reactions are offered also, but practical application was not found.
Typhoid. Paratyphoid A and B
Acute infectious diseases which are caused the bacteria of salmonella, which
striking lymph formations of thin bowel, get in blood, and, carried on an organism,
the phenomena of intoxication, multiplying a liver and spleen, appearance of the
roseolous pouring out and oppressing the central nervous system, cause.
Reasons of origin
Use of the infected water, meal. Passed through dirty hands or objects, infected excretions of patient or transmitter.
Development of disease
At a hit through a mouth in the organism of man, exciters of typhoid and
paratyphoid A and B get to the road clearance of thin bowel, where inculcated in
its lymphoid elements, propagate oneself, break through a lymph protective barrier
and get in blood. Carried with the current of blood on an organism, settle in differ-
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ent organs and cause dystrophic processes for them, and their toxins strike the central nervous system. At the hit of exciters of disease in the vessels of skin roseolous
rash appears. Part of exciters from a liver, through a gall-bladder with a bile again
gets in the road clearance of thin bowel, where again inculcate in lymphoid elements, causes very rapid death of their mews, destruction and formation of ulcers
in the wall of bowel due to an allergic reaction. As a result of formation of ulcers
perforation and development of peritonitis in a wall is possible, and at destruction
of vessels in the area of formation of ulcers bleeding is possible.
Symptoms
The period of disease (incubation) is hidden to appearance of the first symptoms can last from 7 to 25 days at typhoid and something less than at to the paratyphoid. More frequent than all it lasts 9-14 days.
At a typical form a disease flows cyclic. The initial period of disease is characterized mushroom or slow growth of syndrome of intoxication (a weakness, fatigueability, chill, head pain, violation of sleep, stepped increase of temperature, is
to 40°С.), appearance of flatulence, which is expressed more frequent by delaying
of defecation, than diarrhea. A patient is putting on the brakes, pale. Slowly and
monosyllabically answers a question. There is disparity between a pulse and high
temperature, his frequency less than, than must be. A liver and spleen is multiplied.
To the end of the first - beginning of the second week comes period of height of
disease, when all of symptoms achieve the maximal development. On 8-10 day of
disease on the skin of stomach and thorax poor roseolous rash appears. A stomach
is exaggerated, painfulness in right department. It is the most dangerous period of
disease, when complications are possible. The period of convalescence comes farther, when the broken functions of organism recommence and there is a release
from an infection.
Diagnostics
Diagnosis of typhoid and paratyphoid A and B belongs on the basis of clinical symptoms, dynamics of development of disease and laboratory information (the
bacteriological occupied an excrement, urine, blood and bile on the special environments, and also exposure in blood of specific antibodies against typhoid and
paratyphoid).
Treatment
Patients are hospitalizing in an infectious hospital in connection with weight
of the state, danger for surrounding and necessity of conducting of timely treatment. Obligatory observance of the special mode and diet. For treatment apply antibiotics and antibacterial facilities (levomicetin, tarevit, dordum and other). At development of complications the special facilities are used, up to an operation.
Prophylaxis
The early exposure of patients and their hospitalization has a large value that
allows decreasing probability of forming of bacterium careering and reducing the
risk of infection of surrounding. To all of persons, who were in touch with a patient
with typhoid, take occupied excrement and during 21 day daily conduct measuring
of temperature and review. It is necessary observance of the personal hygiene. A
vaccine which protects from a disease on 5 years is used.
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Cholera
Cholera - acute antropozoonotic fecal-oral infection which is caused by
cholera germ, that flows with the symptoms of watery diarrhea, vomit with possible development of dehydration shock.
It behaves to the especially dangerous infections.
Etiology. An exciter of cholera is a cholera germ.
Epidemiology.
A mechanism of infection of cholera is fecal-oral. Ways of transmission water, alimentary, contact domestic.
As well as for all of intestinal infections, for cholera there is peculiar summer-autumn seasonality.
Pathogenesis.
Overcoming a gastric barrier, cholera germ quickly contaminates mucus
shell of thin bowel. This infection does not behave to the number of invasion - vibrios are localized on the surface of mucus shell and in its education. A basic value
in pathogenesis of cholera is played by plenties of exotoxin which is selected vibrios at their vital functions.
Clinic.
A latent period hesitates from a few hours to 5 days, in middle making 2
days. The typical and atypical forms of cholera distinguish. At a typical cholera select easy, middle weight and heavy flow.
An atypical form can flow as the «dry» and quick as lightning cholera effaced.
Chair of watery character, in typical cases has the appearance of rice-water. Distinguish 4 degrees of dehydration.
Dehydratation of the Ist degree is a loss of liquid an amount a 1-3% mass of
body. The state of patients in this period suffers little. A basic complaint is thirst.
Dehydratation of the IInd degree - the loss of a 4-6% mass of body is characterized the moderate diminishing of volume of circulatory plasma. It is accompanied strengthening of thirst, weakness, dryness of mucus shells, tachycardia, propensity to the decline of systolic of arterial pressure and diuresis.
Dehydratation of the IIIrd degree the loss of a 7-9% mass of body is characterized. Thus the volume of circulatory plasma and intercellular liquid diminishes
substantially, kidney circulation of blood is violated, and metabolic disorders appear: with the accumulation of suckling acid. There are cramps of gastrochemius
muscles, feet and brushes, turgor of skin is reduced, tachycardia, hoarsing of voice,
cyanosis. Through acute dehydration the lines of face are tapered, eyes retraction,
the «symptom of dark glasses» is marked, «Fades cholerica», wrinkling of skin of
hands determines the symptom of «hand of laundress».
Low blood pressure, hypocaliemia, oliguria, characteristic for the dehydration of IIIrd degree, can be stopped by adequate therapy. At its absence the IVth degree of dehydration (a loss by organism more than 10% mass) results in development of dehydratation shock deep. The temperature of body goes down below than
norm (choleric algid), the shortness of breath increases, aphonia, heavy hypotension, anuria, muscular fibrillation, appear. Decompensated metabolic and signs of
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heavy tissue hypoxia develops. Only the first aid on the pre-hospital stage and hospital therapy can rescue a patient.
In those cases, when dehydratation shock develops during a few hours (one
days), the form of disease is named quickly as lightning. A dry cholera flows without diarhea and vomit, but with the signs of mushroom growth of dehydratation
shock - acute falling of arterial pressure, development of tachypnoe, shortness of
breath, aphonia, anuria, cramps.
Diagnostics.
At laboratory diagnostics possibly of bacterioscopic investigations of excrement and vomit the masses of, which has a reference value. Among the express
methods of diagnostics: RIF, IFA and other.
Treatment.
All of patients with a cholera or with suspicion on it subject obligatory hospitalization. An immediate medical measure is water and electrolytes deficit filling
by solutions for oral regidratation. At presence of vomit, and also by the patient of
the heavy flow of disease intravenously polyionic solutions entered.
Basic principle of patients with cholera treatment - immediate at the first
contact with the patient rehydratation at home, in an ambulance and permanent establishment doing. At easy and middle weight of flow it follows to conduct peroral
rehydratation.
The committee of experts of WHO recommends the following composition
for peroral rehydratation: sodium chloride - 3,5 g, sodium of hydrocarbonate - 2,5
g, potassium chloride - 1,5 g, glucose - 20 g, water is boiled – 1 l.
For a specific prophylaxis utilize cholerogen-anatoxin.
Differential diagnostics
Cholera is differentiated from salmonollosis, food toxic infectious, schigellosis, salts of heavy metals and mushrooms, to rotaviral gastroenteritis, ecsherichiosis.
Laboratory diagnostics
At heavy flow of cholera a previous diagnosis is formed on the basis of information of clinical picture and epidemiology anamnesis. However possible establishment of final diagnosis is upon only receipt result of bacteriological investigations which requires 36-48 h.
Complications at cholera can be conditioned joining of the secondary infection with development of pneumonias, abscesses and phlegmon. The protracted intravenous manipulations can cause pyrogenic reactions, phlebitises and thrombophlebitis. Acute disorders of cerebral circulation of blood, myocardium infarction,
thrombosis of medenterial vessels, are also possible.
Anthrax
An anthrax (synonyms: malignant carbuncle; anthrax - engl.; Milzbrand germ.; Charbon, anthrax carbon - fr.) is the acute infectious disease, from the group
of infections of external covers. Entered in the group of especially dangerous infections. The name of microbe takes the name from greek "anthracis" is coal which is
explained formation at infection on the skin alike in color ulcers.
Description of exciter
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Exciter - Bacillus of anthrax, aerobe, optional anaerobe, is a Gram-positive
immobile large enough stick long 6-10 mcm and breadthways 1-2 mcm; painted
after Gram. In receptive for an organism vegetative form at access of free oxygen
of air and temperature 15-42°С forms a capsule which indications by itself polypeptide, has antiphagocytic activity, opsonization and phagocytosis of bacilli hinders and simultaneously contributed to fixing of them on the mews of owner. The
presence of capsule distinguishes the virulent cultures of anthrax from a vaccine.
The aggressiveness of microbe in an organism generally conditioned by capsule substance which indications by itself the polymer of D-glutamine acid. Exactly capsule phagocytosis inhibit, preventing death of bacillus, protects it from the
bactericidal action of lymph and blood.
Bacillus is sensible to most ordinary antibiotics of penicillin, tetracycline
groups, levomycitin, streptomycin, neomycin.
The exciter of anthrax was opened and selected in a clean culture in 1876 by
Koch. He reared a bacterium on an artificial nourishing environment; discovered
spore formation in it and reproduced of anthrax infection in experiment on mice.
Only in 5 years L. Paster got everything and aprobing living anthrax vaccine on animals.
Epidemiology
Anthrax is a unique infectious disease of animals and man. Arising up once
in any locality, it can be rooted in, keeping the threat of the repeated flashes on
many years.
Ways of infection
Entrance gate at a skin (to noncommunicative) form is any area of skin or
mucus covers. Thus exciters form capsules and select exotoxin which causes a
dense edema and necrosis. Upon termination of 2-14 days anthrax carbuncle develops in the place of introduction.
For alimentary infection the mechanical damages of mucus shell to the intestine are needed. At the use of the infected (and not enough treated) meat spores get
to the under-mucosal shell and regionar lymph nodes. The intestinal form of anthrax at which exciters also get to blood and disease generalized and passes to the
septic form develops. Primary anthrax injury does not develop an intestine.
Anthrax well responds to treatment, if a diagnosis is set on the early stages
of disease.
Diagnosis and differential diagnosis. Authentication of exciter.
Laboratory confirmation of diagnosis is a selection of culture of anthrax
stick and its authentication. For investigations take maintenance of pustule, vesicula, tissue exudate from under scab. At suspicion on a pulmonary form take blood,
sputum, emptying. At skin forms of hemoculture selected rarely. For investigations
of material (hides, wool) apply the reaction of thermo-precipitation (Ascoly’s reaction). For the exposure of exciter immune-fluorescenting method is utilize.
Differentiating is necessary from a furuncle, carbuncle, erysipelas, in particular from a bullous form. The pulmonary (inhalation) form of anthrax is differentiated from a pulmonary form of plague, to the tylaremia, melioidosis, Legionnaires'
Disease and heavy pneumonias of other etiology.
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Adults are ill more frequent, than to put and men, than women.
Anthracic sepsis
After lymphatogenous (lymphohematogenous) distribution of B. anthracis
from the areas of primary injuries (skin, intestinal highway and lungs) a sepsis develops. Clinical lines are a high temperature, toxemia and shock with next death
through of short duration time.
At differential diagnostics it is necessary to mean sepsis, caused other bacteria. A final diagnosis belongs after the selection of B. anthracis from the areas of
primary injuries and from the culture of blood.
Prognosis
Before introduction to practice of antibiotics a death rate at a skin form
achieved 20%, at the modern early begun treatment it does not exceed 1% antibiotics. At pulmonary, intestinal and septic forms a prognosis is unfavorable.
Complications of anthrax can be anthrax sepsis, festering meningitis, festering-toxic injury of kidneys and liver, intestine.
Prophylaxis
A prophylaxis consists in decline and liquidation of morbidity among home
animals.
It follows to conduct a prophylaxis in the earliest terms after the possible infecting (to days). In these situations apply antibiotics – peroral fenoximethylpenicillin for 1.0 g - 2 times per days during five days or tetracycline for 0,5 g - 2
times per days during five days. The use of ampicillin is assumed for 1.0 g - 3
times per days, oxacillin - for 0.2 g - 1 time per days, rifampicin for 0.3 g - 2 times
per days.
For creation of active artificial immunity to the exciter of anthrax utilize
vaccines. The founder of development of living anthrax vaccine is by L. Paster. In
two years in Russia the similar vaccine of two variants was got by L.S. Tsenkovskiy.
Ascariasis
Ascariasis - helminthiasis which is known from times of deep antiquity in
the population of countries with a temperate, warm and hot climate on condition of
sufficient humidity during throughout the year. Ascariasis is most frequent from
helmintosis, widespread on all of earth. In countries with a dry climate meets rarely, absent after the Arctic Circle.
Etiology.
The exciter of ascariasis is round helmint - ascarid of human (Ascaris of
lumbricoides). Adult individual is a fusiform.
Epidemiology.
People, in the intestine of whom females and males of ascarids parasitize, is
the unique source of invasion. A female ripened able to set aside to 245000 eggs
on days, thus put aside can be both impregnated and unfertilized eggs.
Pathogenesis.
From mature eggs, which are swallowed by people, larvae go out in a thin
bowel, inculcated in the wall of bowel and get to the circulatory system of capillaries, then hematogenic migrate in a liver and lungs. Except for to the intestine, liver
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and lungs larvae of ascarids found in a brain, eye and other organs. They intensively feed on the whey of blood and red corpuscles. In lungs a larva actively goes out
in alveoli and bronchioles, moves up for shallow and large bronchial tubes by a
blinking epithelium to stomatopharynx, where smallow of sputum with larvae.
Getting in an intestine, a larva during 70-75 days achieves puberty. Life-span
grown man ascarid achieves a year, whereupon there is its death together with excrement it is deleted outside.
Symptoms and flow.
The clinical displays of ascariasis depend on localization of vermin and intensity of invasion. In clinical flow of ascariasis select two phases - early (migratory) and late (intestinal). The first phase coincides with the period of migration of
larvae, while the second is conditioned parasitizing of helminthes in an intestine
and possible complications.
Complications.
Frequent complication of ascariasis is impassability of the intestine, which is
conditioned closing of road clearance of intestine by a ball from ascarids or as a
result of disorder of the neuro-muscular adjusting of tone of bowel. Heavy complication of ascariasis is penetration of helminths in bilious channels and gall-bladder.
In cases of origin of cholangiohepatitis and mechanical corking by ascarids of general bilious channel icterus occures. A temperature at development of complications can be septic character with stunning chills. As a result of joining of bacterial
infection quite often there are festering cholangitis and plural abscesses of liver,
which in same queue can be complicated by peritonitis, festering pleurisy, sepsis,
abscesses in abdominal region. Penetration of ascarids in the channels of pancreas
causes acute. The hit of them in appendix becomes reason of appendicitis or appendicular colic without inflammatory displays.
Diagnosis and differential diagnosis.
The roentgenologic picture of infiltrates can simulate tuberculosis, pneumonia, tumour of lungs. A basic difference of infiltrates at ascariasis is their decampment without any remaining phenomena. Similar infiltrates can appear and at other
helminthosises - ankylostomidiasises and strongyloidiasises.
Reliable establishment of ascariasis in the first phase is based on the exposure of larvae of ascarids in sputum and raising of immunological reactions which
find out in blood of patients specific antibodies. In the intestinal stage of disease a
basic method there is investigations of excrement on the eggs of ascarids.
Echinococcosis of liver
Select two forms of echinococcosis: cystic (granulosus) and alveolar.
Hydatic form of echinococcosis is a disease, conditioned the cystic or larval
stage of development of echinococcouse tapeworm Echinococcus granulosus.
Basic owner of intestinal worm - a dog, intermediate - a people, sheep, cattle. At a
hit in the people’s organism by water, vegetables eggs of intestinal worms they are
inculcated in the wall of stomach or thin bowel and farther on of the circulatory
system and lymph ways achieve a liver or lungs (most frequent places of injury).
At the beginning of development of parasite in the organism of people it is filled a
liquid; a colourless bubble has the appearance by a diameter about 1mm which in
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course of time is multiplied in sizes. Wall of hydatide consists of internal (herminative and external (chitinous or cuticles) shells. Outwardly to such echinococcosis
cyst a dense fibrotic shell precedes which is the result of reaction of tissue of liver
in reply to the presence of parasite. This shell is very dense and practically inseparable from healthy parenchyma of liver, but can be separated from chitinous shells.
More than in 80% patients the right particle of liver is staggered, in 1/2 plural cysts
find out patients.
Clinic and diagnostics: long time (sometimes during many years), beginning
from the moment of infection, there are no clinical signs of disease, and a people
feels practically healthy. Most frequent complications of echinococcosis granulosis: icterus, rupture of hydatic cysts, suppurations of hydatic cyst. The most serious
complication - perforation of cyst in a free abdominal cavity. There are symptoms
of anaphylactic shock and widespread peritonitis. In the global analysis of blood
often find out eosinophilia (to 20% and higher). For diagnostics a skin reaction of
Kazoni with the sterile liquid of ecinococcosis bubble is apply. The mechanism of
this test is analogical to tuberculin reaction at tuberculosis. The test of Kazoni is
positive in 50% patients. Approximately in 1 year after death of parasite a reaction
becomes negative. Most reliable and simple are ultrasonic echolocation and computer tomography. Among invasion methods of investigations of wide distribution
purchased laparoscopy and angiography.
Treatment.
There is not one medicinal preparation which gives the therapeutic operating
on the cystic forms of echinococcosis. Optimum method of treatment is hydatidectomy. At large cysts, located in more thick tissues of liver, such method threatens
the damage of large vessels and bilious channels. More frequent is deleting of cyst
from its herminative and chitinous shells after previous puncture of cavity of cyst,
with sucking of its maintenance. This reception allows avoiding the cysts of its
break and dissemination parasite during a selection. After the cyst deleting a fibrotic shell from within 2% solution of formalin is processed and takes in separate
stitches from within (capitonage). At impossibility to take in a cavity succeeded to
tamponade its stuffing-box. At suppuration of maintenance of cyst after completion
of the basic stage of operation cavity which remained is drainage.
Treatment of pulmonary echinococcosis
Treatment of pulmonary echinococcosis is only surgical. By an optimum operation, to implementation of which it follows to aim in all cases, there is "ideal
hydatidectomy" is a delete, enucleation from the fibrotic capsule the parasite in a
chitinous shell, not in contempt of to its integrity (without the section of bubble).
Can be executed:
• hydatidectomy after the previous sucking of maintenance of hydatid cyst.
At this method after fencing off serviettes punctured a cyst by thick needle, aspirate from it maintenance and dissect a fibrotic capsule.
• resection lungs make at echinococcosis, mainly at the large second inflammatory processes or combination of echinococcosis with other diseases which
need resection lungs.
Crohn’s disease
14
Crohn’s disease is a chronic relapsing disease the specific feature of which is
segmental transmural granulomatous inflammation of any department of digestive
channel from the cavity of mouth to anus. Small and large intestines (ileocolitis 40-55%) and anorectal area are most often struck simultaneously (30-40%). Something rarer disease is limited only a small (25-30%), large (20-25%) or straight (1126%) intestines, overhead departments are struck in 3-5% cases: gullet, stomach
and duodenum.
Prevalence in the world makes 50-70 cases on 100 thousands of population
and grew for the last decades in once or twice. Most morbidity registers in Scandinavian countries. In the first time a disease, as a rule, arises up in age 15-35. Women and men are ill identically often.
Etiology
For today is not known.
Clinical picture
Characterized by polymorphism of clinical, gradual beginning of disease,
likeness of clinic with other inflammatory diseases of the intestine. By the characteristic symptoms of disease, there is permanent or nightly diarrhea, abdominal
pain, loss of weight, increase of temperature and rectal bleeding. Rarely a disease
begins acutely; it usually has fulminant flow and even makes a debut by toxic
megacolon.
Basic factor which influences on a clinic and flow of disease is localization
of injury. More frequent than all caecum and large intestines are pulled in an inflammatory process that can be complicated intestinal an obstruction, inflammatory infiltrates and abscesses.
The protracted flow of Crohn’s disease also can be complicated by adenocarcinoma of gastrointestinal tract and rarely – by lymphoma.
Clinical classification
After localization of process:
• terminal ileitis
• ileocolitis
• overwhelming injury of colon
• injury of overhead departments of gastrointestinal tract (gullet, stomach, duodenum).
After a form:
• inflammatory
• fibrostenotic
• with formation of fistulas.
After the stages of disease:
• active
• remission
After the degree of weight:
- Heavy:
- Middle weight:
- Easy
The degree of activity of Crohn’s disease is determined after the index of Беста
15
Diagnostics
Physucal methods of examination:
• questioning - chronic diarrhea (sometimes nightly), abdominal pain, loss of mass
of body, fever, presence of blood in incandescence;
• examination - the compression of bowel (more frequent than all in the right lower
quadrant of stomach), perianal cracks, fistulas and abscesses are palpated.
Extraintestinal symptoms:
• inflammatory diseases of eyes (iridocyclitis, episcleritis and other);
• arthritises (large joints are struck);
• injuries of skin and mucus (nodosal erythema and other);
• injury of kidneys (appearance of oxalates, obstructive hydronefrosis);
• injury of liver (fatty hepatosis, hepatitis);
• inflammatory displays (В12-deficite anemia, amyloidosis, hypoalbuminemia, deficit of electrolytes).
Complication:
• intestinal impassability;
• origin of fistulas, abscesses, cracks, strictures of bowel;
• toxic dilatation of bowels (very rarely);
• cancer of bowel (rarer than at an ulcerous colitis).
Instrumental and other methods of diagnostics
• endoscopic examination with morphological investigations of bioptates
(conducted in all cases of diagnosis verification - characteristically hearth, asymmetric, transmural granulomatous inflammatory injury of any part of intestinal tube
for as a «roadway»);
• morphological investigations of bioptates - finds out specific granulomatous inflammation.
• roentgenologic investigations - irigoscopy and arcade of barium on a small
intestine (conducted for determination of prevalence of process and presence of
complications - fistulas, intestinal impassability and other);
Treatment
At presence of indications - surgical treatment:
• Complication of Crohn’s disease (intestinal bleeding, intestinal obstruction
with the signs of impassability, abscesses, fistulas), dysplasia of II-III degree, malignization, lag in growth and development for children; refractivity of Crohn’s
disease to medicinal therapy. Approximately 70% the patients with Crohn’s disease are operated even one time during life.
Criteria of efficiency of treatment
Liquidation (diminishing) of symptoms of disease and achieving clinical, laboratory and endoscopic remission.
Complete convalescence does not come, although at adequate treatment patients can conduct valuable life.
Lymphogranulomatosis
Lymphogranulomatosis is the tumoral disease of the lymph system.
16
Lymphogranulomatosis meets in 3 times more frequent in families, where
such patients were already registered, in comparing to families, wherever they
were.
Reasons of lymphogranulomatosis
Reasons of lymphogranulomatosis finally are not found out. Some specialists consider that Epstain-Barr’s lymphogranulomatosis а associated with a virus.
Displays of lymphogranulomatosis
The displays of lymphogranulomatosis are very various. Beginning in lymph
nodes, a sickly process can spread practically on all of organs, accompanied the
expressed displays of intoxication (weakness, languor, somnolence, head pains).
The first display of lymphogranulomatosis is usually become by multiplying
lymph nodes, or in 60-75% cases a process begins in cervico-supraclavicular
lymph nodes, a bit more frequent business. Lymph nodes are megascopic mobile,
not soldered with a skin, on occasion sickly. In parts of patients a disease is begun
with multiplying the lymph nodes of mediastinum. In single cases disease is begun
with the isolated injury of coloaortal lymph nodes. A patient complains on pain in
the areas of small of the back of, which arise up, mainly, at night.
Most frequent localization of lymphogranulomatosis is pulmonary tissue. A
tumour in the lymph nodes of mediastinum can germinate in a heart, gullet, trachea.
Bones of people - so frequent, as well as pulmonary tissue, are localization
of disease at all variants of disease. Vertebrae more frequent than all are struck,
and then breastbone, bones of pelvis, rib, rarely - tubular bones.
Bringing in to the process of bones indications up pains, roentgenologic diagnostics is usually late. In single cases the injury of bone (breastbone) can become the first visible sign of lymphogranulomatosis.
The injury of liver through large compensate possibilities of this organ appears lately. Characteristic signs of specific injury of liver are not.
Gastrointestinal tract, as a rule, suffers the second time in connection with
squeezing or germination of tumour from the staggered lymph nodes. However on
occasion there is a lymphogranulomatosis injury of stomach and thin bowel. A
process touches a submucous layer usually, ulcers does not appear.
Diagnostics of lymphogranulomatosis
A morphological diagnosis can be considered reliable only at presence of in
the histological variant of mews by Berezovskiy-Shternberg. A disease not only
confirms and sets a histological analysis but also determines its morphological variant.
Treatment of lymphogranulomatosis
The modern methods of lymphogranulomatosis treatment are based on conception of curability of this disease. While lymphogranulomatosis remains the local injury of a few groups of lymph nodes (1-2 stages), it can bring through him
irradiations. The results of the protracted application of polichemotherapy "to the
border of bearableness of healthy tissues" allow assuming treatment at a widespread process.
17
Chemotherapy is given in the moment of raising of diagnosis. Also utilize
radial therapy. Many haematologists consider that it is necessary to combine
chemo- and radial therapy. Correct treatment in the first stage can result in complete convalescence.
Chemotherapy and irradiation of all groups of lymph nodes is very toxic. Patients difficultly carry treatment from frequent by-reactions which include nausea
and vomit, hypothyreosis, fruitlessness, second injuries of marrow, there is an
acute leucosis also.
6. Plan and organization structure of the lesson.
1
Preparatory stage
2
Basic stage
3
Final stage
To estimate
the ascending
level
of
knowledges
and abilities
of ascending
students
a
level
Forming of
professional
abilities
of
capture skills
and
knowledge,
curation
of
patients
Control
of
mastering of
material, level of abilities
and skills.
Questions for I-II level
control, tests
15%
Professional
algorithm,
scheme
of
treatment,
orienting
card, physical
methods
Educational tasks
of investigation,
interpretation of
laboratory and instrumental methods.
65%
Tasks
and Tasks of rector’s
tests of final control,
tests
level
of “KROK-II”
knowledges
20%
7. Materials of the methodical providing of lesson.
7.1. Control questions for primary level of knowledge:
1. Features of anatomic distribution of infection.
2. Main clinical signs of specific and suppurative diseases.
3. Determination, diagnostics, clinic, treatment of specific and suppurative diseases.
4. Development of specific and suppurative processes in lungs, liver, kidneys,
gastro-intestinal tract, brain, in the cellular spaces, skin.
5. Specific diseases of lungs, liver, kidneys, gastro-intestinal tract, brain, skin.
6. Specific diseases and immunological answers of organism.
7. Tactic of surgeon at the different stages of development of festering disease
of tissues.
8. Indications to operative interferences.
9. Methods of operative interferences are depending on localization of suppurative inflammation.
7.2. Orienting cart for individual work with literature
from the theme of the lesson
18
№
Basic tasks (to learn)
Pointing (to name)
1
Anatomy and physiology of lungs, liver,
spleen, stomach, intestine. Ways of possible flow of suppurative exudate for to the
anatomic channels structure of skin. it is a
structure of lungs, liver, spleen, stomach,
intestine of skin
Clinical and objective signs of surgical
complications at the infectious diseases of
lungs, liver, spleen, stomach, intestine of
skin
- function of lungs, liver, spleen, to the
stomach, intestine of skin.
2
3
A method of examination of patients with
surgical complications of the infectious
diseases of lungs, liver, spleen, stomach,
intestine of skin.
4
Features of treatment of patients with surgical complications of the infectious diseases of lungs, liver, spleen, stomach, intestine of skin
5
Methods of section and drainage of festering cavities of surgical complications at
the infectious diseases of lungs, liver,
spleen, stomach, intestine, skin.
- clinical picture of:
а) surgical complications at the infectious
diseases of lungs.
б) surgical complications at the infectious
diseases of liver, spleen, stomach and intestine; festering diseases of skin and hypodermic cellulose;
в) features of clinic of anaerobic infection.
г) features of clinic of specific infection.
д) features of clinic of specific infection at
the injury of skin and hypodermic cellulose
Laboratory investigations;
- immunological investigations;
- bacteriological investigations;
- puncture of infiltrate;
- US Investigations;
- R- roentgenologic investigations;
- CТ
Antibacterial therapy;
- Features of treatment of patients with surgical complications of the infectious diseases of lungs, liver, spleen, stomach, intestine
of skin and hypodermic cellulose of person,
neck, extremities, brush and fingers
- Features of section of patients with festering complications at infectious diseases,
lungs, stomach, liver, spleen, intestine, skin
and hypodermic cellulose, person, neck, extremities, brush and fingers
7.3. Situation tasks.
1. Patient С., 38 years old, appealed to the surgeon with complaints about
deformation of neck, little sickly nodes of the rounded and wrong form. Skin above
them is ordinary color. Fever is to 390С. Most reliable diagnosis? Most correct tactic?
А. Neck’s lymphadenitis.
B. Lymphogranulomatosis.
С. Tuberculosis of the necks.
D. Lipomatosis of the necks with suppuration.
Е. Metastatic process.
Standard of answer: Lymphogranulomatosis.
2. In a patient 40 years old, a few sickly separated infiltrates of wrong form
with the hearth of one softening influence of them. On the edges of this softening
19
influence a few narrow foramina, where pus is selected from. The edges are raised.
A fever is perceptible. Near 14 days, patient returned from Sverdlovsk, (Russia)
where took part in hunt on a wolf.
Most reliable diagnosis:
А. Anthracic carbuncle.
B. Tuberculosis of skin.
C. Lipoma with suppuration.
D. Metastatic process.
E. Skin displays of hydrophobia.
Standard of answer: Anthracic carbuncle.
3. At patient A., 31 years old, after sleep, painless hemorrhages in a skin appeared, mucus shells и bleeding from to the nose, weakness, dizziness. The sick
already a few months have shallow and large hemorrhages in a skin, mucus shells.
Most reliable diagnosis.
А. Multiple myeloma.
|B. Erysipelas.
С. Werlhof’s disease.
D. Erysipeloid.
Е. Thrombosis of vena cava superior.
Standard of answer: Werlhof’s disease.
4. The displays of lymphogranulomatosis are very various. Beginning in
lymph nodes, processes can extend practically on all organs, provide by the different displays of intoxication (weakness, sickliness, somnolence, head pain). The
first display of lymphogranulomatosis is multiplying lymph nodes. Where more
frequently process has begun?
A In the lymph nodes of mediastinum.
B. In cervico-supraclavicular lymph nodes.
С. In axillary lymph nodes.
D. In lymph nodes to the intestine.
Е. In lymph nodes of skin.
Standard of answer: In cervico-supraclavicular lymph nodes.
1.
2.
3.
4.
5.
6.
8. Literature for teachers:
Mich`ele Mock and Agn`es Fouet. ANTHRAX // Annu. Rev. Microbiol. 2001. – Vol. 55. – P. 647–671
Бакулов И.А., Гаврилов В.А., Селиверстов В.В. Сибирская язва
(антракс). Новые страницы в изучении старой болезни. – Владимир :
«Посад», 2001.
Хірургічні хвороби (під ред.проф. В.В.Грубника). - Одеса, 2003. – 418
с.
Клінічна хірургія /За ред. Ковальчук Л.Я., Саенко В.Ф. – Тернопіль :
Укрмедкнига, 2002.
Хірургічні хвороби / За ред. П.Г. Кондратенка. - Харків, 2006.
Ефименко Н.А., Гучев И.А., Сидоренко С.В. Инфекции в хирургии.
Фармакотерапия и профилактика. - Смоленск, 2004.
20
7. Distribution, organization, and ecology of bacteria in chronic wounds / Kirketerp-Moller K., Jensen P.O., Fazli M. [et al.] // J. Clin. Microbiol. – 2008.
– Vol. 46, № 8. – P. 2717–2722.
8. Lewis K. Multidrug tolerance of biofilms and persister cells // Curr. Top.
Microbiol. Immunol. – 2008. – Vol. 322. – P. 107–131.
9. Palmer R. J.Jr, Stoodley P. Biofilms 2007: Broadened Horizons and New
Emphases / J. Bacteriol. – 2007. – Vol. 189, № 22. – P. 7948–7960.
10.Бухарин О.В., Гинцбург А.Л., Романова Ю.М., Эль-Регистан Г.И.
Механизмы выживания бактерий. М.: Медицина, 2005.
1.
2.
3.
4.
5.
6.
7.
9. Literature for students:
Клінічна хірургія /За ред. Ковальчук Л.Я., Саенко В.Ф. – Тернопіль :
Укрмедкнига, 2002.
Хірургічні хвороби / За ред. П.Г. Кондратенка. - Харків, 2006.
Ефименко Н.А., Гучев И.А., Сидоренко С.В. Инфекции в хирургии.
Фармакотерапия и профилактика. - Смоленск, 2004.
Distribution, organization, and ecology of bacteria in chronic wounds / Kirketerp-Moller K., Jensen P.O., Fazli M. [et al.] // J. Clin. Microbiol. – 2008.
– Vol. 46, № 8. – P. 2717–2722.
Lewis K. Multidrug tolerance of biofilms and persister cells // Curr. Top.
Microbiol. Immunol. – 2008. – Vol. 322. – P. 107–131.
Palmer R. J.Jr, Stoodley P. Biofilms 2007: Broadened Horizons and New
Emphases / J. Bacteriol. – 2007. – Vol. 189, № 22. – P. 7948–7960.
Бухарин О.В., Гинцбург А.Л., Романова Ю.М., Эль-Регистан Г.И.
Механизмы выживания бактерий. М.: Медицина, 2005.
10. Task from educational-experimental work of students and research work
of students from this theme:
Complication after operations for patients with diabetes mellitus with echinococcous of liver.
The methodological
instructive elaboration is made
by associated professor
Martynuyk V.A.