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ODESSA NATIONAL MEDICAL UNIVERSITY
Department of Surgery № 1
METHODOLOGICAL INSTRUCTIVE ELABORATION
practice the discipline of "Surgical Diseases of Pediatric Surgery and
Oncology for teachers."
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.
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
Post practice: "Within a ostrыh diseases in lyts pozhyloho Age - 2 hours.
1. Urgency of the theme: Dannaya topic yavlyaetsya aktualnoy in terms of generating clinical
professionals in thinking of different specialties and directions.
2. Goals Session:
2.1. Learning Objectives
- To acquaint students with the most frequently edly vstrechayuschymysya ostrыmy in diseases
of lyts pozhyloho Age. I level
- Student should know, having learned the fear of diseases in pathogenesis lyts pozhyloho Age.
Level II
- Give students the opportunity to develop the skills of palpation, and auscultation perkussyy
bryushnoy polosty, interpretation of laboratory and ynstrumentalnыh research. Level III
- Give students the ability to clinically analyzyrovat poluchennыe DATA Survey of bolnoho.
Fourth level
2.2. Educational objectives related to:
- Formation of professionally significant substructures of personality;
- Relevant aspects of professional activities and its responsibility.
3.Mizhdystsyplinarna integration.
Disciplines
1. Previous discipline.
2.
3. Anatomy
4. Next
5.
6. Propydevtyka internal disease
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.
Know
Be able
Topohrafyya bryushnoy
polosty organs, pelvis
and their ynervatsyya.
Palpation
Percussion
Auscultation
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 (37-40% of our patients) said the insolvency protection factors, is a poor
prognostic sign and occurs in 75-80% 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 Mayo-Robson.
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 must first be eliminated ¬ chit
disease extraperitoneal organs, mimicking acute abdomen: myocardial infarction, basal
pleuropneumonia, spontaneous pnevmoto ¬ raks, renal colic, kapillyarotoksikoz SchonleinHenoch. Then you take ¬ optimal program of studies for the differential diagnosis ¬ diagnostics
of acute abdominal diseases. With modern, instrumental diagnostics (ultrasound, radiological
and endoscopic techniques, laboratory studies) to establish disease ¬ tion that caused the clinical
picture of acute abdomen, presents no great difficulties.
5. Plan and organizational structure of the lesson.
№
The main stages
of training, their
functions
and
contents.
Learning
Learning
Objectives
tools and
in the levels controls.
of learning.
1
Preparatory stage
Check
Seminar
students'
knowledge
and
their
level
of
training
Materials on
methodology
of providing
visual
training,
knowledge
control
learners.
Timing (in
minutes
or%) of the
total
training
time.
10%
A basic phase
2
3
formation of Test items
professional
abilities,
skills,
mastering
the skills ..
of Ku HH,
determining
the
treatment
regimen,
laboratory
research
Concluding phase control and
stages
of
professional
skills,
summarizing
lessons,
Daily poll
Studenov,
verification
of practical
skills
Working
60%
with patients
and
the
department
of
general
gastrosurgery
Conducting
30%
classes in a
room
of
practical
skills
provide
homework
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: Voproы yshodnoho Level Meter and speech
material known, the task of Step 2.
6.4.sytuatsiyni task
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. radiograph 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 neotlozhnoy therapy in 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..
4. minimum ynvazyvnaya Surgery Pathology zhelchnыh ductular: Monograph / ME
NICHITAYLO, V. Hrubnyk, AL Kovalchuk, etc. - K.: Health, 2005 .- 424 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
9.Zavdannya with UDRS and NDRS on the subject.
10. The following are classes.
Methodological development was ___________________________/ P., I., B. /
/ Signature /