Postoperative ostroyazvenny gastrointestinal tract diseases

Description:

Postoperative ostroyazvenny damages of a digestive tract cankers of a sliisty cover of a GIT, voznikyushchy during the postoperative period. In relation to operation time these complications can be early and late.

Symptoms of Postoperative ostroyazvenny gastrointestinal tract diseases:

Diagnosis of ostroyazvenny bleeding is based not only on abdominal manifestations of this complication (pain in epigastriums, usually stupid, a hematemesis, a melena) and symptoms of internal bleeding, the bystry or slowed-down blood loss (unexpected acute anemia). One of the main features of the bleeding acute erosion of ulcers is what they not always demonstrate external symptoms of bleeding and against the background of a postoperative disease proceed quite often with very scanty symptomatology.

The blood circulation collapse which is usually connected with a protragirovanny axis or a myocardial infarction appears quite often first and only clinical sign of a complication. Especially as the ECG - a research reveals symptoms of diffusion ischemia of a myocardium at this time. Vomiting can be recorded by "a coffee thick" not at all patients, and the melena comes to light days later after the beginning of bleeding. Therefore it is necessary to pay attention and to character separated on a constant gastric tube which is quite often established routinely when maintaining certain categories of patients.



The final diagnosis manages to be made during an urgent fibrogastrodoudenoskopiya which not only will reveal existence of an erosive canker of a mucous membrane, its localization, will allow to define gastric рН, but also can become the first stage in haemo static therapy. The advantage of the emergency endoscopic research is the possibility of an aim biopsy of the site of an ulceration and medical impact on it and surrounding fabrics.

Early acute ulcers, especially small, multiple are localized in a zone of the maximum kislotoproduktion against the background of a "juicy" hyperemia, extensive erosive change of a mucous membrane of a stomach. Sometimes single chronic stomach ulcer against the background of erosive and ulcer gastritis appears a source of "early" bleeding. Late acute ulcers are more often than an odinochna, large. Their education happens as a creeping necrosis of a mucous membrane of a stomach which looks pale and exhausted.

Reasons of Postoperative ostroyazvenny gastrointestinal tract diseases:

Early erosive cankers of a mucous membrane of a stomach and duodenum arise because against the background of the complicated postoperative period show the action the majority of the factors defining their development: an operational injury, a long noncompensated hypovolemia and hemorrhagic shock, dysfunctions of bodies of life support (lungs, a liver, kidneys), heavy intestinal paresis with the advent of a duodenogastralny reflux of bile acids, postoperative pancreatitis, septic complications (Khokhlov V. P., etc., 1987; Scriabin O. N., 1994).

On R. Heinkien (1970), actions of the factors supporting a condition of a stress ischemia of a mucous membrane not only stomach, but also bodies of a stomach results that leads to disturbance of organ energy balance, reduction of products of slime, decrease in regenerator opportunities of a gastric and duodenal epithelium.
From here the role of inadequate anesthesiology providing and weight of surgical interventions in genesis of early ulcers is clear (Chepky L. P., etc., 1985, 1987).

Acute ulcerations can become a serious problem at the patients who transferred cardiac interventions with artificial circulation (Kryshen of Item F., Weaver, YU.I., 1980; Savichevsky M. S., Badayev F.I., 1983; Maystrenko N. A., etc., 1989). A number of researchers believes that against the background of stressorny influences the vasospasm of a celiac zone becomes so expressed that outflow of blood from a mucous membrane of a stomach and a duodenum is broken. It leads to stagnation of blood, increase in capillary pressure, intraorganic loss of plasma and local haemo concentration with the subsequent microthrombosis. Such condition of intraparietal vessels promotes disclosure of preterminal arteriovenous shunts that aggravates ischemia of a mucous membrane.

Treatment of Postoperative ostroyazvenny gastrointestinal tract diseases:

Treatment of ostroyazvenny bleeding is impossible without complex therapy of the damage of a mucous membrane.

During conservative treatment of the bleeding acute erosion and ulcers it is necessary to solve a number of problems:

    - to provide a steady hemostasis;
    to reduce the phenomena of ischemia of a mucous membrane of a stomach and a duodenum;
    - to suppress excess gastric secretion;
    - to increase protective properties of the mucous membrane injured by erosive and ulcer process;

    - to activate its reparative opportunities.



The hemostasis is reached:

    - by physical methods in the form of a gastric lavage ice isotonic solution of sodium of chloride with addition of 50 ml of 5% of solution an epsilon aminocapronic acid on each 400 ml of washing solution;
    - administration of etamsylate (Dicynonum) on 250-500 mg 3 times in the first days of treatment and Adroxonum (Hemostatum) of 2-3 ml a day intravenously, intramusculary or inside;
    - transfusion of vikasolny donor plasma (on 2 ml of Vikasolum on each 250 ml) or cryoprecipitate at long jaundice and a gepatoprivny syndrome;
    suppression of local proteolysis peroral use of the ofitsinalny solution divorced by 4-5 times an epsilon aminocapronic acid on 15 ml (tablespoon) each hour during wakefulness of the patient;
    - the medicamentous program needs to be added with endoscopic influence with aim irrigation of the bleeding sites haemo static drugs (Haemophobinum, kaprofery, etoksilkleroly), diathermocoagulation or laser coagulation of the bleeding acute ulcers with drawing film-forming compositions like лифузоля (Yukhtimovskaya L. P., 1995; Kurygin A. A., Scriabin O. N., 1996, etc.).



Against the background of achievement (at least temporary) a hemostasis it is desirable to try to obtain reduction of ischemia of a mucous membrane of a digestive tract by means of infusion-transfusion therapy which problem includes stabilization of a hemodynamics and kislorodtransportny function of blood. Preference is given желатинолю, to a gelofuzin, drugs on the basis of plasma protein with inclusion in the program of transfusion of fresh eritrotsitsoderzhashchy environments.

It is at the same time necessary to aim at stimulation of contractility of a myocardium at decrease in cordial emission, up to use of kardiotropny support. In any case, use of "renal" doses of dopamine has to be rather a rule in such situation. The antihypoxemic effect of infusion-transfusion therapy can be fixed by use of antigipoksant (a mafusol, an amtizol, hydroxybutyrate of lithium, piracetam), holding 3-5 sessions of GBO in single medical pressures chamber. The possibility of local improvement of the oxygen budget of a mucous membrane of a stomach due to endoscopic leading of an oxygenic perftoran is shown (Tsygankov V. K., 1998).



Suppression of gastric secretion. Action of anti-secretory means which usually use after operation preventively at patients with the accompanying peptic ulcer (гастоцепин intramusculary 10-25 mg 2-3 times a day, methacil on 4 mg twice a day) in this clinical situation is already not enough.

Their action should be supplemented or replaced with purpose of blockers of H2 receptors of a histamine: Cimetidinum (gistodit, Gedeon Richter; primamt, LEK) intravenously 200 mg or ranitidine (гистак, Ranbaxy; зантак, Glaxo, ранитин, Torrent) on 50-100 mg in 6 h, or famotidine (a kvamatel, Gedeon Richter) on 20 mg 2 times a day.

Emergence at the disposal of clinical physicians of parenteral forms of the inhibitors of "the protonew pump" of an omeprazol (лосек, Astra) operating is long, about one days, after single introduction in the form of drop introduction of one dose of drug, allows to achieve the maximum braking of action of factors of aggression. Let's emphasize the important guarding point of such therapy: frequency of postoperative pneumonia against the background of systematic use of H2 blockers clearly increases.

The treatment patogenetichnost confirms the fact of prevention of emergence of new ulcers and erosion against the background of action of blockers of histamine receptors, despite preservation of risk factors of development of such defeats. On the other hand, it is established that at рН mucous more than 6,0 blood clots in vessels are formed quicker, and dissolution by their pepsin happens much more slowly, providing a certain stability of a spontaneous hemostasis that justifies expansion of therapy towards inclusion in the program of treatment of antacids.

If the gastrointestinal passage is not broken, anti-secretory means it is necessary to combine santatsidam (Almagelum, gastaly, gelyusily, maaloksy, fosfalyugely) in the maximum dose. Antacids in addition to counteraction to hydrochloric acid have sorption activity in relation to pepsin and bile acids.
In the most hard cases of an erosive canker it is necessary to use on 1 medical dose of an antacid each 2 h, but not longer than 48 h because of danger of a gipermagniyemiya, a hypophosphatemia, a hypercalcuria as a result of excess action of high doses magnesium-aluminosilicates (Almagelum, a gastal, etc.).
Therefore if there is a need to use antacids, it is desirable to apply only those from them which do not contain magnesium.