Download ODESSA NATIONAL MEDICAL UNIVERSITY Department of Surgery

ODESSA NATIONAL MEDICAL UNIVERSITY
Department of Surgery № 1
Methodical development
practice the discipline of "Surgical Diseases of Pediatric Surgery and Oncology VI course for students of
medical faculty."
Module number 4. "Symptoms and Syndromes in surgery"
Information-rich module number 8. "Clinical signs of surgical disease"
Subject number 18 of acute diseases in the elderly.
Discussed and approved
Department meeting on methodological
"29" auguct 2014 р.
Protocol № 1.
Chair __________( P., I., B.)
/ signature /
Odessa – 2014
Post practice: "The course of acute illness in the elderly"
1. Relevance of the topic. This topic is relevant in terms of building clinical thinking among specialists of
different spetsіalnostey and directions
2. Goals Session:
2.1. Learning Objectives:
And for Bezpalko level - to acquaint students an idea about the etiology, pathogenesis, clinical
manifestations and basic data imaging studies of major diseases that cause bolevoy syndrome in
diseases of organs bryushnoy polosty.
II level for Bezpalko - the student must learn the peculiarities of painful syndromes in ostroy Pathology
bryushnoy polosty organs.
III level for Bezpalko - to give students the opportunity to explore the most common technique of
surgical intervention ostroy Pathology bryushnoy polosty; the following diagnostic and therapeutic
manipulation: setting nazohastralnoho probe, gastric lavage orohastralnыm probe performance
together with the doctor-fibrohastroduodenoskopiyi endoscopists, colonoscopy rektoskopiyi,
performance together with the doctor-radiologist X-ray examination of esophagus, stomach, small and
large intestines, rectum digital research, allow asystuvaty the most simple operations (eg kolostomiya,
Gastroenterostomia, anal sfinkterotomiya and the like).
IV level for Bezpalko - teach students to explore clinical, theoretical, experimental immediate and
remote results of different treatment options, including surgical diseases of bryushnoy polosty
depending on the specifics of pathogenesis, clinical choices flow and make scientifically sound
conclusions and recommendations regarding the indications and contraindications to the use of one or
another method.
2.2. Educational objectives related to:
- Formation of professionally significant substructures of personality;
- Relevant deontological aspects, environmental, legal, psychological, patriotic, professional liability and
more.
3. Interdisciplinary integration
Table 1. Interdisciplinary integration
Disciplines
1. Previous discipline.
2.
3. Anatomy
4. Next
5.
6. Propydevtyka internal disease
Know
Be able
Topohrafyya bryushnoy
polosty organs, pelvis
and their ynervatsyya.
Palpation
Percussion
Auscultation
3. Intra-subject integration.
Subject .
Acute abdomen.
Abdominal trauma.
External abdominal hernia.
Internal abdominal hernia.
Chemical burns and scar strictures of the
stomach.
Damage to the stomach and duodenum.
Peptic ulcer and dvenadtsetiperstnoy intestine
and its complications.
Stomach cancer.
Injuries to the liver.
Liver abscesses.
Not parasitic disease of the liver.
Cholelithiasis.
Obstructive jaundice.
Postholitsistetomichesky syndrome.
Liver tumors.
Acute pancreatitis.
Pancreatic zhelizy.
Injuries to the pancreas.
Damage to the spleen.
Splenic disease.
DAMAGE spleen.
Diseases of the spleen.
3. Content classes
Acute appendicitis in elderly patients, and especially in elderly patients, often runs smoother, often with
additional layers, so the correct decision on the nature of the disease in this group of patients is a
difficult diagnostic challenge.
With the increase in overall life expectancy numbers of elderly in recent years has increased. This can be
judged by percentage of patients with elderly, hospitalized on various diseases. So, Danovich and
Mushtakova presented data Institute of Emergency Care. Then, patients with acute appendicitis in the
age of 50 accounted for 2.6% (according to ND Kamensky).
In a study of patients with elderly should take into account their age psychology.
Older people, feeling lack of energy, feeling that the ability of many vital functions reduced, naturally,
are more cautious in their decisions. By this age, many of them have experienced a number of serious
illnesses, after which the residual effects often continue to harass them. If an elderly person shortly
before the attack of acute appendicitis, hernia, or were worried about the effects of gastritis, it is
especially inclined to explain the appearance of worsening pain in the lives of these diseases. Elderly
patients with acute appendicitis is often self-starting, use laxatives and cleansing enemas.
Late arrival of patients with acute appendicitis for several reasons. Another reason is that acute
appendicitis in the elderly and old age, most patients initially occurs without the express pain. It is noted
Besfamilnov and Pyastolov, who believe that acute appendicitis in patients with middle and old age
"does not give striking symptoms."
In old age, acute appendicitis often starts gradually, with general malaise, impaired physiological
functions. Appear bloating, mild nausea, delayed gas and stool. Such phenomena are often ill explain old
age.
Expressed mild abdominal pain in patients with middle and old age, and doctors often explain
phenomena coprostasia and flatulence in the intestine. Cleansing enemas at the same time can give a
positive result. After a bowel movement stomach such a patient becomes less swollen, the pain
subsides, the general condition improves.
Shmerelson said unsharp abdominal distension and reflex delay gases in elderly patients are often
treated as a manifestation of coprostasia and partial bowel obstruction. According to the author, half of
the misdiagnosis of acute appendicitis in elderly and senile patients is associated with a suspected
intestinal obstruction. Zarubin reported that 21% of elderly patients with acute appendicitis was
installed wrong diagnosis at the direction of their hospitalization.
Peculiarities of a peptic ulcer in the elderly will be rewarded:
Hyperproduction HCl pepsinaRost number of elderly patients with peptic ulcer disease and its
complications, increase in the structure of ulcer disease of large and giant size, long-term scarring
represent a serious problem in choosing a method of treating a disease.
Features of functional and morphological changes in ulcer disease, such as a reduction in secretory
activity of the stomach, the prevalence of atrophic gastritis forms expressed microcirculatory disorders
in the elderly require further study and systematization to create diagnostic and treatment algorithm for
predicting the course of the disease.
According to acid-peptic theory in the basis of ulcer formation is primarily an imbalance between the
state of protective factors that determine the resistance of the gastroduodenal mucosa, and factors of
aggression.
In old age increases the aggressive role of gastroduodenal motility disorders. One manifestation of these
factors, aggression is duodenogastric reflux (DGR). Distinguish two forms of the GDR: saline, which is an
additional factor in the neutralization of hydrochloric acid, and pathological performing pepsinogen
activation even in the absence of hydrochloric acid. In old age, pathological DGR occurs in 45% of
patients. In contact with bile acids in the lumen of the stomach in conditions of delayed feedback
evacuation, especially in the hungry or mezhpischevaritelny periods, realized the phenomenon back
diffusion of hydrogen ions, which plays an important role in ulcer formation. Probably, this may explain
the increase in the number of combined ulcers of the stomach and duodenum in the elderly.
Indicators of secretory activity of the stomach according to the pH-metry differ among young and
elderly.
If a peptic ulcer in the elderly active gastritis is observed in more than half the cases, however, duodenal
ulcer no atrophy and intestinal metaplasia and Hp infection was found more than half of patients.
Gastric ulcer is dominated by the phenomenon of atrophy and intestinal metaplasia in the antral and Hp
infection was detected in 13.5% of cases. The presence of atrophy in the fundal part of the stomach (3740% of our patients) said the insolvency protection factors, is a poor prognostic sign and occurs in 7580% of patients with giant and trudnorubtsuyuschimisya ulcers.
Thus, in elderly and younger duodenal ulcer is characterized by similar morphological changes,
indicating that maintaining the functional activity of the stomach. In gastric ulcer in the elderly
decreased the functional and morphological parameters, which can lead to malignancy.
After analyzing the results, you can select the criteria for prognosis of peptic ulcer in old age.
In the presence of ulcer history and a combination of the two forms of comorbidity with one of the
factors of aggression, there is a risk of complicated peptic ulcer disease. The most frequent
complications in this case are perforation ulcer or bleeding.
If patients during ulcer associated with factors of inadequate protection of the mucosa and combined
with two or more concomitant diseases, then we see ulceration of large and giant sizes. Another feature
in this group of elderly patients is a long scarring of these plagues and resistant to conservative
treatment.
Features of acute cholecystitis in patients with advanced age:
Their characteristic is the high incidence of destructive forms of cholecystitis and complications of
peritonitis. It must be borne in mind that such changes in the gallbladder may develop in the very first
day, due to perforation of bladder. Atypical course of discrepancy manifested clinical disease
pathomorphological changes in, available in the gallbladder. The clinical picture in the foreground
intoxication symptoms, whereas pain and signs of peritonitis can be expressed clearly.
COMPLICATIONS:
Hydrops of gallbladder - is it an aseptic inflammation that occurs because the block of cystic duct
concretions or mucus. In this case, the bile is absorbed from the bladder, but in its lumen accumulates
transparent exudate (white bile). During palpation of the patients noted an increase in gall bladder and
painless. In the cavity of the gall bladder - purulent bile.
Empyema of the gallbladder is not timely liquidated dropsy, which, when re-infection was transformed
into a new form. Gallbladder in such patients is palpated in the form of dense, moderately painful
education. Symptoms of peritoneal irritation are absent.
Periodically observe a high body temperature, chills. In the blood, high leukocytosis with a shift of blood
to the left of the formula.
Biliary pancreatitis. Its main manifestation is the deteriorating condition of the patient, the appearance
of encircling pain, repeated vomiting, signs of cardiovascular disease, high amylasuria, the presence of
infiltration in the epigastric region and the positive symptoms of the Resurrection and the MayoRobson.
Jaundice often occurs in violation of passage of bile into the duodenum due to choledochal obstruction
concretions, putty, or in connection with swelling of pancreatic head. Thus there is scleral jaundice,
bilirubinemia, dark urine and light stools unpainted.
Cholangitis. Patients with this disease, against jaundice, body temperature rises to 38-39 ° C, there is
fever with heavy sweats, high leukocytosis and reduced rates of liver function tests.
Hepatitis is manifested jaundice, increase in the phenomena of general weakness, increase in blood
indicators alaninamino and asparaginaminotransferaz and alkaline phosphatase. Liver in this pathology
during palpation is painful, with sharp edges.
Infiltration - a complication that can develop in 3 - 4 days after the onset of acute cholecystitis. Its
characteristic is a dull pain, the presence of right upper quadrant of dense tumor-like formation with
indistinct contours, increased body temperature up to 37,5-38 ° C and negative symptoms of irritation of
the peritoneum.
Abscess. Patients complain of fever, pain in the upper right quadrant, where palpate a painful tumor
formation, for fever, general weakness, anorexia, jaundice, and sometimes vomiting. Radiographically in
the right upper quadrant is determined by the horizontal level of liquid and gas above it. In the blood,
high leukocytosis with a shift to the left of leukocyte formula.
Hepato-renal failure may develop in very severe cholecystitis. The general condition of the patient with
the heavy, pronounced intoxication, agitation, hallucinations, delirium, oliguria and anuria.
Peritonitis is the most frequent complication of perforation of the gallbladder into the free abdominal
cavity and shows a sharp pain in the abdomen and repeated vomiting. The patient is covered with cold
sweat, pale skin, blood pressure decreases, pulse frequent and weak filling. During an objective
examination of tension of anterior abdominal wall, positive symptom Shchetkina-Blumberg on the right
side of the abdomen or in all departments.
Acute pancreatitis in older people:
Acute pancreatitis is one of the most difficult and dangerous abdominal diseases and the mortality rate
for acute pancreatitis, according to the World Congress of Gastroenterology, reaches 15-20%. Among
patients with acute pancreatitis, older people account for 30-66%. The highest frequency of disease is
noted between 61 th and 70 th year of life. Among the patients are women. All this suggests that with
age there are a number of factors contributing to the development of this pathology.
The most common cause of acute pancreatitis in older people - biliary tract diseases. According to
statistics, in 60-80% of patients with acute pancreatitis was noted prior or concomitant disease biliary
tract. ^
Great importance in the occurrence of this disease in old age has nutritional factor. Often the disease
develops after a large consumption of protein and especially fatty foods, alcohol. Promotes it as an
ample meal at night.
These causes play a major role in causing disease in middle-aged people, but in the process of human
aging their value increases substantially. This is due primarily to morphological and functional changes in
the pancreas during aging. Established that age degradation ducts, blood and lymph vessels of the
pancreas begins to be detected after 30-40 years. In this regard, special attention should develop
periprotochnogo fibrosis, hyperplasia of the epithelium up to the formation soskoobraznyh outgrowths
of inward flow, obliteration of the ducts, reducing the total weight of glandular parenchyma, the
development of adipose tissue. By 75-90 years of cloves completely replaced by fatty tissue, and the
total amount of functioning tissue is sometimes reduced to 30-40%. There is a certain sequence of
morphological changes in the prostate: first, develop vascular changes, and then expand the connective
tissue and fatty tissue, followed by a gland atrophy.
In turn, age-related changes in the structure of the secretory apparatus of cancer is one of the main
reasons for the weakening of its exocrine function with aging.
The most frequent symptom of the disease in older people - an attack of sudden pain in the epigastric
region while taking copious amounts of food, especially oily or canned. Pain are contractive in nature,
are often zoster. In this case, they can be so intense that some patients there is a shock. The second
most common symptom of illness in older people - a frequent anacatharsis small portions (spoonful), as
a rule, does not facilitate the patient's condition. Vomiting in 80-'90% of the cases accompanied by pain.
The presence of vomiting bile fluid suggests patency of the common bile duct. In severe forms of acute
pancreatitis observed hematemesis.
Often, elderly patients with acute pancreatitis observed paresis of the intestine. Despite the expressed
pain, stomach soft on palpation in the epigastric region revealed only a slight muscle strain. This
discrepancy is a characteristic feature of pancreatitis in older people. Language is usually dry, furred.
Floor restless. The facial skin becomes pale-cyanotic hue, sometimes marked yellowness of sclera and
skin. Many patients are identified areas of skin hyperalgesia in segments D. Breathing speeded (28-30
min), pulse frequent (100-140 per minute), filling the small and the voltage was lowered blood pressure
more frequently.
However, older people are more likely than young, acute pancreatitis are mild and slowly progressive
severe symptoms: there are light pain in the epigastric area without irradiation in the back and waist, no
vomiting, stomach slightly distended. Often there are pains in the heart, mimicking the picture of
coronary insufficiency, sometimes painful attacks resemble renal or hepatic colic. In some cases, the
pain is continuous, resembling those for acute cholecystitis, and sometimes paroxysmal, as in the bile or
kidney stones.
For older people is characterized by more frequent passage of acute necrotizing pancreatitis in serous
and purulent. The main criteria for such a transition - increased abdominal pain, the signs of rebound
tenderness, fever up to 38-39 ° C, effusion in the abdominal and chest cavity (exudate in this case
contains pancreatic enzymes), increase the level of diastase in the urine, leukocytosis and an increase in
neutrophil leftward shift, worsening of general condition during the increase of intoxication and, finally,
the development of shock, are often the immediate cause of death. Along with these elderly patients as
the temperature reaction and changes in the blood may be expressed weakly. Quite often, the elderly
and old patients with relatively favorable course of acute pancreatitis complicated by a sudden acute
cardiovascular and renal insufficiency, renal coma, ileus.
Important diagnostic value in the diagnosis of acute pancreatitis belongs to laboratory tests. One of the
most persistent symptoms (at 75-90% of patients) - increase in urine and blood after 2-4 hours from
start to attack the level of amylase 256-5000 units. and more (by Wohlgemuth). Determination of
amylase expedient to carry out an attack at a height several times a day. However, older people with
acute pancreatitis, amylase figures may be low, as in the case of pancreatic necrosis on the background
of deterioration of the patient's amylase in blood and urine may even be within normal limits. This is
explained by the fact that the existing age decrease in the number of functional pancreatic parenchyma
join destructive changes caused by the pathological process. The result is an almost complete
destruction of the acinar cells of glands that produce pancreatic enzymes. Thus, the absence
hyperfermentemia and giperfermenturii not yet exclude the presence of acute pancreatitis in patients
with advanced age.
At a blood analysis revealed mild leukocytosis with a neutrophilic shift to the left, eosinopenia,
lymphopenia, monotsitopeniya, increased sedimentation rate, hypoproteinemia, increased fraction of
gamma globulin. Often in older patients the hyperglycemia and glucosuria, which is due to lack of
endocrine pancreatic function.
Acute pancreatitis should be primarily differentiated from diseases such as myocardial infarction, acute
cholecystitis, hepatic colic, perforated ulcer, acute peritonitis, intestinal obstruction, acute appendicitis.
It should be emphasized that acute pancreatitis in older people due to its frequent atypical promptly
diagnosed in approximately 25% of cases. Therefore, for any pains in the abdomen in the elderly and old
people should think about acute pancreatitis.
Therapeutic measures in acute pancreatitis should be conducted in a hospital and as early as possible.
Necessary to create a physiological rest to cancer: strict bed rest, starvation for 3-5 days, the ice pack on
his stomach. In the days of fasting patient intravenously injected with saline with 5% glucose - no more
than 1500-2000 ml per day to deal with intoxication and dehydration. Shall adjust the electrolyte
metabolism, as it often breaks down. With frequent vomiting and severe bloating of the stomach
advisable to pump out the contents of a thin probe inserted through the nose.
For relief of pain and oppression of exocrine pancreatic function is administered 2-3 times in 0.75 ml of
0.1% solution of atropine subcutaneously, appropriate use of no-shpy, papaverine, galidora and other
antispasmodics in combination with promedolom, dimedrolom. Prescribe morphine is not
recommended because it may cause spasm of sphincter of Oddi and increase pain. A good therapeutic
effect have sided pararenal novocaine (50-80 ml 0,25-0,5% solution) blockade and intravenous
novocaine (5-10 ml 0.5% solution) in saline.
An important factor in the treatment of acute pancreatitis - the use of drugs that suppress the activity of
pancreatic enzymes (trasilol, tsalol, contrycal). In the first 3-4 days is administered in 25 000-50 000
units. preparation per day intravenously in 200 ml of saline, then reduce the dose to 10 000-20 000
units. a day every day during the week.
When a shock is administered intravenously 1,5-2 liters of 5% glucose solution, sc - caffeine, ephedrine,
camphor, kordiamin daily transfusions of 200-250 ml of blood or plasma. From the first days of illness
prescribe calcium gluconate or calcium chloride intravenously. In severe edematous phase of acute
pancreatitis advisable to use steroid hormones. To fight infection prescribe antibiotics. In order to
prevent blood clots in the first days of disease is treated with anticoagulation therapy.
Patients with elderly surgical intervention in acute pancreatitis is carried out only for health reasons in
connection with the development of complications (abscess, hemorrhage, perforation, pseudocyst). This
is due to the fact that the patients of this age change existing cardiovascular and respiratory systems,
metabolic disorders and so severely limit the adaptive capacity of the body, causing them from
developing serious complications in the postoperative period (cardiovascular failure, pneumonia,
thromboembolism, etc.).
Acute pancreatitis is significantly heavier than occurs in older people, often ends with mortality (70% of
all deaths from acute pancreatitis over 50 years). The most frequent causes of death should be indicated
on the development of cardiac, hepatic and renal failure, intestinal obstruction. Significant percentage,
are focal pneumonia, thromboembolic complications, diabetic coma.
In the prevention of acute pancreatitis the main significance timely treatment of diseases of liver and
biliary tract, diet and good eating habits. Caloric content of the diet in the interictal period in the elderly
should not exceed 2200 kcal, in the elderly - 2000 kcal.
Recommended a four-time meal at the same clock, in the form of heat. Products included in its
composition, should be good grind. Excluded from the diet cakes, cream products, roasted meat,
smoked sausage, canned soup and fatty soups strong meat or fish broth, pickled and salted vegetables,
spicy marinades and seasonings, boiled eggs, any alcoholic beverages.
Recommended yogurt, kefir and other milk products. Diet patients should contain foods rich in protein
(1.2 -1.5 g protein per 1 kg of weight per day), with preference given to products such as cottage cheese,
lean beef, egg white, various cereals (buckwheat, oats, etc .). Allowed to eat as lean boiled meat, roast
meat pudding, meatballs, minced meat, lean, fresh-water fish species. In the diet should be restricted to
carbohydrates (300 g / day) and fat (30 g / day), when the atom is better to use vegetable oils
(sunflower and corn oil).
In the menu on a daily basis should be at least 600 grams of vegetables, potatoes and counting. Part of it
is desirable to eat vegetables in raw form. Normal digestion contribute to fruit and berries (apples, black
currant, rose, plum).
Useful once a week to conduct a so-called discharge day by giving the patient 1 liter of yogurt and 400 g
apples or 1 liter of fruit juice and 400 grams of cheese per day. With good endurance can practice
drinking option of unloading: 10-15 glasses of boiled water and a cup of raisins or dried compote. The
strictness of dieting due to the fact that the vast majority of cases the disease is associated with the
retreat from it.
The elderly and senile patients is recommended to systematically use the light cholagogue - rosehip
extracts, corn stigmas, choleretic tea. Drink infusions must be for 30 minutes before eating half a cup 3
times a day in the form of heat. It is also advisable to hold weekly blind sensing - fasting patient drinks a
glass of warm solution of sorbitol or xylitol (20 g) of Carlsbad salts or Barbara (1-3 teaspoons per cup of
water), then it is necessary for 1 ½ hours to lie down on the right side, placing under him a warm heating
pad.
It is advisable for prophylactic purposes periodically conduct courses of sanatorium treatment on
drinking resorts (Truskavets Essentuki, Borjomi, Zheleznovodsk, Carlsbad).
Age-related physiological changes in the gastrointestinal tract:
Malabsorption syndrome
Diverticulosis, constipation
Scatacratia
Pancreatic insufficiency
GSD
Esophagus: reduction of force reductions, delayed relaxation of sphincters
Stomach: atrophy, slowing down motor activity, reduction of gastric secretion
Small intestine: decrease absorption of D-xylose large amounts of fats, vitamin D, folate, calcium, zinc
Colon: atrophy of muscle plates, increasing collagen and elastin, increase transit time of food
Anorectal zone: reducing the tone of the anal sphincter due to a decrease in muscle mass and a violation
of the innervation of the perineum
Pancreas: atrophy, increasing the diameter ducts at 10-15% - amyloid deposition in the pancreas
Gall bladder: lower responses to cholecystokinin, an increase of bile lithogenicity (elevated levels of
cholesterol in bile, the increase in the size of the micelles
Diseases characteristic of old age
Dysphagia, reflux esophagitis, esophageal diverticulitis
Atrophic gastritis, erosive and ulcerative lesions
Malabsorption syndrome
Diverticulosis, constipation
Scatacratia
Pancreatic insufficiency
GSD
The characteristic pathology - vascular disorders
Ulcers and erosions of the stomach and duodenum
Bleeding
Ischemic pancreatitis
Abdominal coronary heart disease
Mesenteric thrombosis
Abdominal coronary heart disease
Pool celiac trunk and superior mesenteric artery:
Feeling of heaviness and fullness, paroxysmal abdominal pain (epigastric and mesogaster)
After 20-40 minutes after eating
Duration of pain: 30 minutes - 2-2,5 h
Are themselves
Pool of upper and lower mesenteric artery:
Violations of the motor and secretory functions of intestinal
Bloating, belching, unstable chair (alternating diarrhea and constipation)
Progressive weight loss
Erosion and ulceration of CO bowel
Fecal blood
Diagnosis
Paucity of objective symptoms, discrepancy of pain syndrome
Palpation of the abdomen - moderate pain in the epigastric and around the navel
Systolic murmur over the abdominal aorta, in mesogaster (not always)
Instrumental methods (radiological, endoscopic) - no change, ulceration
Laboratory techniques - lipid metabolism
Investigation of fecal neutral fat, undigested muscle fibers and mucus
Verification of diagnosis
UZDG vessels of the abdominal cavity
Angiography of the abdominal aorta and its branches - the gold standard
Treatment of abdominal ischemia
Split meals
Calcium channel blockers (nifedipine) to 10 mg orally before each meal
Antispasmodics (no-spa, Duspatalin, spazmomen, ditsetel)
Pentoxifylline / in and inside
Disaggregants (aspirin, cardiomagnil)
Reopoliglyukin 400 ml / d / a
Derivatives of nicotinic acid (150 mg komplamin 3 r / d Teonikol 150 mg 3 p / q)
Surgical reconstruction of blood flow
Thrombosis and embolism of mesenteric arteries
The sudden appearance of intense cramping abdominal pain with a maximum mesogaster and right
abdomen
On palpation - bloating, mild pain, muscle tension in the abdominal wall is not
In the following - vomiting, loose stools mixed with blood and mucus
Shock
Signs of intestinal obstruction (abdominal X-ray - increased pneumatization by the end of a-days
horizontal levels)
Gangrenous bowel, peritonitis
Acute impairment of mesenteric blood flow
Mortality - 85-95%
For the diagnosis of ischemia does not exist any characteristic clinical and laboratory studies of specific
standard
Late diagnosis - the main cause of death in patients with ischemic bowel
Suspected intestinal ischemia is necessary in all older patients with acute abdominal pain!
Clinical features of peptic ulcer disease in elderly
Frequent failure of the stomach: a stomach ulcer - 73%, duodenal ulcer - 27%
HP infection - poor (atrophy)
Large size of the ulcer (2-3 cm)
Manifestation of the disease and exacerbations in the form of bleeding (52%)
Susceptibility to frequent and prolonged exacerbation (76%)
Atypical pain or lack of it (78%), weight loss, weakness
Lack of seasonality of exacerbations (82%)
On the basis of complaints data and instrumental examination is necessary first to eliminate the disease
extraperitoneal organs, mimicking acute abdomen: myocardial infarction, basal pleuropneumonia,
spontaneous pneumothorax, renal colic, kapillyarotoksikoz Schonlein-Henoch. Then choose the optimal
program of studies for the differential diagnosis of acute abdominal diseases. With modern,
instrumental diagnostics (ultrasound, radiological and endoscopic techniques, laboratory studies) to
establish a disease caused by a clinical picture of acute abdomen, presents no great difficulties.
4. Plan and organizational structure of the lesson
The main stages of
training, their
functions and
contents.
№
1
Preparatory stage
A basic phase
Learning
Objectives in
the levels of
learning.
Check
students'
knowledge
and their level
of training
formation of
professional
abilities, skills,
mastering the
skills .. of Ku
HH,
determining
the treatment
regimen,
laboratory
research
Learning tools
and controls.
Materials on
methodology
of providing
visual training,
knowledge
control
learners.
Seminar
Test items
2
Timing (in
minutes or%)
of the total
training time.
10%
Working with
patients and
the
department of
general
gastrosurgery
60%
control and
stages of
professional
skills,
summarizing
lessons,
provide
homework
Daily poll
Studenov,
verification of
practical skills
3
Concluding phase
Conducting
classes in a
room of
practical skills
30%
6. Materials on methodological support classes.
6.1.Materialy control for the preparatory phase of training: the job of test questions "yshodnыy level of
knowledge".
6.2.Materialy methodological support basic stage of training: Medodycheskye of developing a
department on topics of diseases and organs bryushnoy polosty of practical skills.
6.3.Materialy control the final stage of training: issues and speech material yshodnoho Level Meter is
known, the task of Step 2.
6.1. Control materials for the preparatory phase of training - a collection of questions
1.Ponyatye hostyыy belly?
2. Characteristics of pain in the faces of elderly living in the Age?
4. Briefly tell the anatomy, histology and physiology of the liver and the pancreas?
5.Korotko describe the anatomy, histology and physiology of the stomach and duodenum
6. Briefly describe the anatomy, histology and physiology of the small and large intestines
7. Briefly describe the anatomy, histology and physiology of a thin rectal and pelvic floor.
10. Briefly tell pathogenesis of peptic ulcer of stomach and duodenum.
11. Briefly describe different options pathogenesis of intestinal obstruction, acute abdominal disease
(ruptured yazva, acute cholecystitis, pancreatitis, appendicitis)
6.2. Materials methodological support basic stage of training
6.2.1. See paragraph 3.
6.2.3. Plans interventions (tables, atlases, electronic images).
6.3. Materials control of the final phase of occupation
6.3.1. Case studies
2. Patient P., 68 years admitted to hospital to hospital with complaints of mild epigastric pain, weakness,
weight 10 kg last month, jaundice, dark urine, stool discoloration. Bilirubinemiyi level is 86 g / liter.
Alkaline phosphatase 350 g / liter. Sterkobilinu in the stool is not radiological research znaydeno.Yakyy
method should be used for diagnosis?.
A. Pereralnu holetsystohrafiyu.
V. holetsystohrafiyu jet.
S. holetsystohrafiyu infusion.
* D. Retrograde holanhiopankriatohrafiyu.
E. None of the above.
6. 76r patient with gall-stone Jana disease complicated by cholecystitis, obstructive jaundice done
cholecystectomy, bile duct stones, with litotomiyu cathment. What research should be required to make
sure before deleting drainage of bile duct stones?
A. Plain radiography of the abdomen.
V. Transcutaneous - cherezpechinkovu cholangiography.
S. retrograde cholangiopancreatography.
* D. Fistulography.
ED ultrasound.
8. Patient Z., 1962 hospitalized for surgical department with pain in epigastric attack, vomiting, fever up
to 380 C, the pain extends to the waist. Ill bilious-stone Jana disease (during the ultrasound found
small stones in the gallbladder). Exhibited diagnosis - acute calculous cholecystitis. Which of the
following complications may arise from this disease?
A. Jaundice.
* B. Kyshkovnyka spastic obstruction.
S. pancreatitis.
D. cholangitis.
E. gallbladder empyema.
17. Patient P., 1991 taken to hospital with a diagnosis of acute cholecystitis, peritonitis limited. In the
past, the patient underwent double heart attack, suffers from hypertension, severe diabetes. Which
surgical intervention should be limited in this case?
A. cholecystectomy.
* B. Cholecystostomy, drainage of the abdominal cavity.
S. cholecystectomy with choledochotomy.
D. drainage of the abdominal cavity.
E. Холецистоентероанастомозом
22.Cholovik, 82 years, 10 months ago underwent cholecystectomy for acute calculous cholecystitis. For
the last 2 months harassing periodic pain in right hypochondrium, ikterychnist sclera and mucous
membranes, urine rich brown. Suspected residual calculus of bile duct stones. What is the optimal
amount of medical diagnostic manipulations?
A. laparotomy holedoholitotomiya.
V. laparotomy holedoholitotomiya, internal drainage of bile duct stones.
S. laparotomy holedoholitotomiya, naruzhe cathment.
* D. Papillosfinkterotomiya, RHPH, endoscopic removal of calculus.
E. Oral cholangiography, remote lithotripsy.
28.Hvoryy S., 1968, operated with acute cholecystitis and abscess. During the operation to allocate from
the bed of gallbladder, was found duct diameter of 5 mm, which stand out from the bile. Realized
insertion and ligation, as surgeons decided - hepatocytic Strait. In the postoperative period on the third
day - narastannya bilirubinemiyi, intoxication. What complications should be excluded in the first place?
A. cholangitis.
V. postoperative pancreatitis.
S. Pidpechinkovyy abscess.
* D. Damage to the right hepatic duct.
E. residual choledocholithiasis.
1. In the intensive care unit and surgical intensive care hospital day 5 th patient treated in 1968 with
acute destructive pancreatitis. Patient's condition is extremely serious. Despite the complex intensive
therapy, the patient's condition is deteriorating, there were signs of peritonitis. Exhibited indications for
urgent surgical treatment of involuntary (on the life conditions). What expedient surgical intervention in
this patient?
* A-mikroholetsystostomiya and Laparoscopic drainage of the abdominal cavity;
B-laparotomy, drainage of the abdominal cavity;
C-laparotomy, drainage of abdominal and omental;
Dr. laparotomy mikroholetsystostomiya, drainage of abdominal
There-draining omental through lyumbotomnyy access.
2. Patient S., 1972 delivered to the induction center in serious condition with complaints of caps belly,
belly pain without clear localization for three days. Overall condition is difficult, skin and visible mucous
membranes pale. Tongue dry. Pulse 98, blood pressure 100/60 mm Hg. Art. Abdomen swollen, painful in
all areas defined fuzzy peritoneal irritation. When akuskultatsiyi - peristaltic noises not vysluhovuyutsya.
Rer rectum - rectal ampoule blank, the glove - traces of blood (herbaceous, mucous discharge. The most
likely preliminary diagnosis?
A-perforation of cavernous body.
V. Acute pancreatitis;
* C-mesenteric vascular thrombosis;
D-Acute intestinal obstruction;
There-ulcer disease.
3. Patient M., 60 years old suffers from chronic pancreatitis. Which causes more diseases could help?
A-Not following the diet;
B-cholelithiasis;
* C-Alcohol abuse;
D-immune disorders;
There-hyperlipidemia.
20. Patient B 72r came to the clinic with the diagnosis - acute appendicitis. From history: sick about 2
days when the pain appeared pidvzdoshniy right area to 38oS fever, nausea. Medical care is sought.
When the pain intensified addressed the surgical hospital. On palpation - symptom Schotkina Blyumberha in the lower abdomen. What is the most common complication of acute appendicitis?
* A. local peritonitis;
V. abscess;
S. infiltration
D. pileflebit;
E. widespread peritonitis.
10. Patients 65 years turned to the clinic for scheduled surgical treatment, about zhovchonokam
wooden disease with chronic calculous cholecystitis. Patients held cholecystectomy. In the
postoperative period in patients on drainage that was installed in over liver space vydilylos about 50.0
ml of bile. Your tactics:
A. Immediate laparotomy.
* B. Active surveillance for patients treated conservatively +.
S. celiocentesis.
D. Laparoscopy.
E. endoscopic sphincterotomy.
11. The patient in 1975 turned to the hospital with complaints of sharp pain in the left abdominal
weakness. When examining the set of indications for emergency surgery. During surgery in connection
communication about peritonitis, the patient had found a tumor perforation of the lower 1 / 3 sigma.
The volume of transactions?
* A. Hartmann operation.
V. closure of perforation of the tumor. Peritoneal drainage
cavity.
S. left-hemicolectomy. Tsekostomiya.
D. Resection sigma overlapping pervichnoho anostomozu.
E. Transferzostomiya dvustvilna.
7. Literature for the teacher.
1.Spravochnyk on neotlozhnoy therapy and surgery. Ed. J. Xoron'ko, SV Savchenko Rostov n / D Edition
of "Phoenix", 1999.-608p.
2.Neotlozhnaya abdomynalnaya surgery. Reference manual for doctors. Pod. yet. AA Hrynberha.:
Moscow "Tryada - X, 2000 .- 496 p..
8. Literature for Students:
- Basic training;
1. Hyrurhycheskye disease: Textbook. Ed. Kuzina MI Moscow: Medicine, 1995 - 640 sec.
2. Hospital Surgery: Textbook. Ed. Kovalchuk LY Ternopil: Ukrmedkniga, 1999. - 580
10. Theme of the next session.
Providing the following training topics.
Methodological development was ___________________________ / stalwart. /
/ Signature /