Gostry pancreatitis. lykuvannya

Gostry nabryakliy pancreatitis - maximal conservative therapy in advanced intensive therapy, absolute hunger (exclusion of pancreatic stimulation), parenteral feeding, Shlunkovy probe for the removal of shlunkovy vіstі і H2 blockers (Ranitidin, Zantic), in order to shlunkovy sіk without stimulating the secretion of the slurry.

Reserve birth (close to 4 liters per day for the maintenance of blood supply to unaffected tissue in the presence of arterial, central venous vise, temperature).

Storage of electrolytes (K, Ca, Na, Cl) as per consumption Analgesia: for moderate pain Pethidin (Dolantin), for severe pain: Procain 2 gr. / Day and additional Pethidin (Dolantin) 50 mg intravenously, 50-100 mg intravenously, or intravenous skin for 3-4 years (this is not possible, since the stench can lead to a stench in the ducts of spasm).

Prevention of infection for additional help in case of an increased temperature, in some clinics, antibiotic-prophylaxis is carried out in quality come regularly Hemodialysis or plasmapheresis: for the visualization of toxic mediators in the development of the lack of decile organs. Insulin indications for hyperglycemia> 250 mg / dl. When going to normal food - giving pancreatic enzymes. Additional medications: Calcitonin, Somatostatin, carbonanhydrazi blockers, glucagon for lowering hormonal secretion, Aprotinin, Trasylol, all medications reduce the world’s severity and lethality.

In case of bilious pancreatitis in case of gum disease: ERPHG and endoscopic papillotomy (ERT) with visible stones.

With pancreatic pseudocysts: 50% of the disease is self-sustaining for 6 months. If the value is> 10 cm, self-knowledge is unrealistic, the need for repeated punctures before ultrasound control is not operative (cystojejunostomy). Indicated before surgery: persistent hands> 5-8 cm for 6 types (at a value of 50% of the size of the drop, the rate is accelerated). An operation is carried out to apply a pancreatic fistula named in the state of the art - marsupialization (for example, for an additional item under CT control, or ultrasonic scanning, or the placement of the brush wall to the black wall). More beautiful is the internal drainage behind the help of fistula to the small intestine - cystojejunostomy. Bites in case of gastrointestinal pancreatitis, the need to develop from secondary cysts: cystic fibrosis, echinococcus, polycystosis of the pancreatic disease (congestion), mucinous cystoadenoma (potentially malignant).

In case of an abscess of a pseudocyst infection or a superinfection of a pseudocyst - a puncture under the control of ultrasound and the appointment of a doctor for direct antibiotic therapy.

Prompt treatment of gosstry pancreatitis

Indicated for operative treatment - gostry necrotic pancreatitis with enlargement on suspicion organ ("gumy live", peritonitis), abscess formation of necrosis, great necrosis, sepsis, ascites in cases of protruding secretions in the middle pogirshuєtsya, as well as when suspicious of an evil process.

Rapid access: upper transverse, rosten Bursa omentalis and necroectomy, repeated prominence (promising up to 12 liters per day) of the pancreatic bed through the drainage, relaparotomies behind the additional lock at the vyglyadі bliskavitsya (during the hour).

If necessary, a partial resection of the underwire in case of widened necrosis (temporal lethality).

Likuvannya gosstry pancreatitis in the phase of renewal Parenteral feeding with a stretch of 1 st period; drink tea, crackers. When there is a scarg: mucus eating, rapid infusion therapy. Harchuvannya from the 8-9th day: mashed potatoes, milk, lokshina, low-fat kefir, infusion therapy. Kharchuvannya from the 10-14th day: dodatkovo meat. 4-8 types of unicati It is important to overtravel with fat, grease, cabbage, gostrich spices. Alcohol intake in case of obrican pancreatitis is a minimum of 6 months, in case of necrosis for all life.

Oral dacha of enzymes: for a quick reduction of food in the state standard phase I with the ear of enteral food. Pislya 8 tizhniv enzyme preparations only shown in the breakdown of the processes of wetness (decrease in chymotrypsin in style, steatorrhea, pathological pancreatitis test).

Prognosis for gostromy pancreatitis

Nabrekla form: more often than not (lethality is maximum 5%), for necrosectomy with programmed lavage Bursa omentalis (lethality is 10%), the lethality is close to 10-15%. With hemorrhagic-necrotic forms ( stage III) Mortality 25-50%.

Decreased gastrointestinal pancreatitis

• necrosis of the adipose gland (gostry necrotic pancreatitis) with a bad prognosis, uterine necrosis of the adipose tissue
• pseudo-bones are established in the area of ​​cicatrices (infectious, traumatic, as well as the inheritance of a grievous one (reach up to 10 cm)
• bleeding, suppression of the splenic veins, choledochus, arrosis of A. gastroduodenalis, replacement of the slurry, 12-palate intestine, small intestine, improvement of fistulas with suspicious organs, perforation, hemorrhage, inflammation, blockade of the disease
• shlunkovo-intestinal bleeding with arrosion of sudin, thrombosis of the splenic veins
• shock with nirkovy deficiency, state respiratory insufficiency, coagulopathy of recovery, small intestinal impairment, gosdra lack decilkoh organs
• approval of abscesses, sequestration, sepsis
• transition to chronic pancreatitis

Prevention of pancreatitis: recovery from alcohol, treatment of the main ailment

Gostry pancreatitis is a disease of the dermal zone, as a result of the autolysis of tissues of the dermal zone of polypolytic and active proteolytic enzymes.

Ethiology and pathogenesis. Pathogenesis of malignant pancreatitis. Main ethological factor- autolysis of parenchyma of the papillary papilla; State development of internal duct hypertension in the form of an increase in the penetration and penetration of the thermal ducts. Create mind for activization of enzymes, going out of the boreal ducts, for infiltrating parenchyma and autolysis of the tissue of the flesh.

Often the cause of severe pancreatitis is overwhelming alcohol and fatty consumption.

The most common cause of intraductal hypertension is the development of bilious and alcoholic pancreatitis. Diseases of pancreatitis account for 90% of all pancreatitis. The skin of them has a great specialty in the key interruption and the result of ailments. Before bіlsh rіdkіsnih reasons rozvitku GOSTR pancreatitis vіdnosyatsya vіdkritі i zakritі abdominal trauma, іntraoperatsіynі poshkodzhennya tkanini zalozi, aterosklerotіche-ska oklyuzіya vіstseralnih gіlok abdomіnalnogo vіddіlu aorta, portal gіpertenzіya, deyakі lіkarskі drugs (kortikosteroїdi, estrogennі contraceptives i antibіotiki tetratsiklіnovogo row).

Necrosis of pancreatic cells and clitkovini, which will drain the lobules of the slurry, on the very cob of the process will be taken from the infusion of slime. Lipase penetrates into the middle of the blood cell, hydrolyzing the inner cells of triglyceride from the fatty acids. In young cells, internal cell acidosis develops from pH down to 3.5-4.5. In the acidosis drainage, inactive trypsinogen is transformed into active trypsin, which activates phospholipase A, vivid and activates lysosomal enzymes (elastase, collagenase, chymotrypsin, etc.). Zmist of phospholipase A and lizolecytin in the tissue of the underworld with severe pancreatitis is signi fi cantly improved. Tse to inform about її roles in the autolysis of tissue. With the introduction of polypolytic, active proteolytic enzymes, there are microscopic or macroscopic changes in the presence of fatty necrosis of parenchymal fodder deposits. At the same time, elastasis gives rise to the lysis of venule walls and interlobular septal tissue partitions. As a result, there are great hemorrhages, transformation of fatty pancreatic necrosis into hemorrhagic. Leukocytes are recruited to the primary necrosis. The purchase of leukocytes near the end of necrosis means the development of a burned out reaction, which is superfluous. For the prevention of necrosis and elimination of necrotic tissue, macrophages, leukocytes, lymphocytes, endothelial cells see pro-fired and anti-festering interleukin, active acid radicals. There are few mid-term necrosis as a result of the cycle of reaction to interchange, to lysis with the onset of elimination of products in the fall. The processes are wicked into the organism, I will match the reaction to the ignition.

With great necrosis of macrophages, neutrophilic leukocytes, lymphocytes, overwhelming stimulation, the production of interleukin and acidic radicals of growth, go to the control of the immune system. Change in the production of anti-ignition interleukins. The stench will not just shimmer the fabric, but the organics. Tissue necrosis does not affect interleukin, but active acid radicals, nitrogen oxide (NO) and most aggressive peroxynitrite (ONOO). Interleukin is deprived of preparing soil for the whole: to reduce the tone of venous capillaries, to increase penetration, to thrombosis of capillaries.

The changes in the microcirculatory channel are affected by nitrogen oxide. The ignition reaction is progressing, the zone of necrosis is expanding. Misce's reaction to the heat is transformed into a systemic one, the syndrome of a systemic reaction to the heat develops.

Classification. Behind the nature of the changes in the greenhouse you see:

Nabryaklium, abo interstitial, pancreatitis;

Fatty pancreatic necrosis,

Hemorrhagic pancreatic necrosis.

Nabryakla abortive form of pancreatitis develops on aphids of an insignificant, microscopic microscopic disorder of the disease. The filling phase can, over a period of 1–2 days, re-form into the necrosis phase. With progressive pancreatitis, fatty pancreatic necrosis develops, which, in the world, the development of hemorrhages is transformed into hemorrhagic cells due to the establishment of an extensive accumulation in the uterine cellulitis and the appearance of hemorrhagic vomiting in the midsection. In a number of patients, there is a decrease in the form of pancreatitis: hemorrhagic pancreatitis with adipose necrosis and adipose pancreatic necrosis with hemorrhages.

Falsely, as a result of the broadening process, the process of development is degenerative, subotal and total pancreatic necrosis.

For a critical overload, there is an abortion and progressive overload of ailments.

Behind the phases of the passage of important forms of gastrointestinal pancreatitis, there is a period of hemodynamic damage - pancreatogenic shock, functional impairment (dysfunction) internal organs and the period of the longest acceleration, which occurs in 10-15 days.

Klinichna picture and diagnostics. In the cob period (1-3rd dobi), both in case of obstruction (abortive) pancreatitis, and in case of progressive pancreatitis ailment, it will jump on acute, persistent pain in epigastric dysplasia, dyspnea.

In the early term, there is a sprinkle of obscurity of active data even more small, especially in case of embryo: blistering curvatures, light sclera (with bilious pancreatitis), mild cyanosis. The pulse can be normal or accelerate, the temperature is normal. Pislya information in the field of necrosis won’t move, as in any nasty process.

Lives meek, everyone seems to take part in the act of behavior, and sometimes it means something to the belly. Symptom Schotkіna-Blumberg negative. Approximately 1-2% of severely ill patients on the left side of the abdomen develop cyanosis, some of which are covered with cyanosis (Gray Turner's symptom) and as a result of the removal of blood in the area of ​​the lateral hematoma Also, the beaches can be spared in the area of ​​the navel (symptom Purchased). Percussion causes a viscous tympanitis over the entire surface of the abdomen - intestinal paresis of the vein as well as teasing or phlegmon of the urinary cellulitis or abdominal peritonitis. When buying a significant number of exudates in the black empty, it means dulling the percussion sound in the shallow parts of the abdomen, it is easier to appear in the position of a sick person on the boat.

With palpation of the abdomen, there is a soreness in the epigastric disease. Tension of the abdominal muscles in the cob period does not develop pancreatitis. If there is only some resistance and soreness in the epigastric zone in the zone of growth of the lumpy root (Kerte's symptom). Palpation in the livo costal-spinal groove (projection of the tail of the lump) is often sore (Mayo-Robson's symptom).

In most ailments, there is a mental breakdown: anxiety, confusion of evidence, steps of the breakdown of which are completely determined by the points of the Glasgow scale.

Functional breakdown of the liver is more likely to show up as well as the breakdown of the liver. With a stiff obturation of the backbone duct, the mechanic zhovtyanitsa with the help of the rivnya bilirubin, transaminases, and the improvement of the stove. For gastrointestinal pancreatitis, the development of amylase and lipase in syrovatz blood is characteristic. Significantly increase in the concentration of amylazi (diastasis) in the section, in the exudate of the black and pleural empty. With total pancreatic necrosis, the level of amilazi decreases. More specific advice for early diagnostics pancreatitis is the presence of trypsin in the bloodstream, achimotin, elastase, carboxypeptidase and especially phospholipase A, which has a key role in the development of pancreatic necrosis. However, the versatility of streaming values ​​is wider in terms of methods.

Ultrasound dosage. I will help you in the diagnosis of ultrasonic diagnostics, allowing you to establish the causal factors (cholecystosis and choledocholithiasis), to identify the growth and increase in the size of the intestinal tract, the purchase of gas in the intestines. Signs of an increase in the size of a creeper, a reduction in the efficiency of a fabric, a reduction in the degree of display of a signal. In case of necrosis of the slurry bark, there is a sharp increase in the number of decreased efficiency or more of the signal.

Computer tomography is a more accurate method for diagnosing gastrointestinal pancreatitis in the context of ultrasound. For carrying out її nemaє transfer. The reliability of diagnostics is improved in case of intravenous or oral administration with contrast material. Computer tomography with the strength of the allowance allows for more clear development of the diffuse, but for the local growth of the growth of the zoster, the midst of necrosis, the purchase of birth, the changes in the parapancreatic dystrophy of the interstitial cells, "

Magnetic resonance tomography is a more thorough diagnostic method. Vona gives information similar to that obtained with computer tomography.

Radiological advances in allowing pathological changes in the black empty in large ailments: isolated dilatation of the transverse colon intestine, segments in the poor two-fingered intestines, Snuggled up to the lumpy galls, some X-ray contrast calculi in the galls, in the prototypes of the lumpy galls, for example, the calcification in the parenchyma.

Esophagogastroduodenoscopy is observed in case of shlunkov-intestinal bleeding from gostrich eroziy and virazok, such as accelerated severe (most often destructive) pancreatitis. Retrograde pancreato-cholangiography in case of gastric pancreatitis is contraindicated, as during the whole procedure, a grip in the head prototypes of the fledgling zone is moving.

Laparoscopy is indicated in case of an unclear diagnosis, if a laparoscopic installation of drains is required for the treatment of gastrointestinal pancreatitis. Laparoscopy allows you to poke the midsection of steatonecrosis (stearic beaches), the firing snake of the queue, the chewing gum, penetrate into the empty area of ​​the lesser omentum and glance at the bottom of the small omentum, install drainage and drainage for the small scale.

Likuvannya. Perchochergovim zavdannyam є zyattya pain and spasm sphinkter Oddi. Using this method, I recognize non-narcotic analgesics, antispasmodics, and holinolitics. If the diagnosis is firm, it is permissible to introduce narcotic analgesics. Zastosuvannya drugs in the morphine row, wiklikayut spasm of the sphinkter Oddi, is unacceptable. For sickness, inject also internally dropwise glucose-novocaine sum (10 ml of 1% novokain and 400 ml of 5% glucose). Most of all I am sick with epidural anesthesia.

For the hormonal stimulation of the exocrine function of the body, it is necessary to increase the rate of release through the mouth. Also shown is post-aspiration in place of the slunk through a nasogastric tube. An important role in the treatment of pancreatitis is to lead the secretory function of the slurry to the additional blockers of H2-histamine receptors, antacids, anticholinergic drugs (gastrocepin, atropin).

More effective means of stifling the exocrine function of the pancreas є cytostatics (5-fluorouracil, cyclophosphamide), synthetic neuropeptides (dalargin), synthetic analogs of somatostatin (sandostatin, styramin).

For the fight against enzymatic toxemia in the first phase of gastric pancreatitis, vicoristovyt ingibitori proteases (trasilol, contrikal, gordox et al.). The preparation helps to reduce the toxicity and proteolytic enzymes. In the last few years, the effectiveness and efficiency of the funds are set for the sake of sums.

For the correction of BCC, it is necessary to inject internally the differences of coloidal and crystalline differences under the control of the level of the central venous vise and weathering duresis. The number of great and crystal breakdowns is guilty about 1: 1.

Parenteral feeding is an obovascous component of the liquefaction, so it can be harvested through the mouth for 3-5 days. Energy consumption by the organism of the sick person (30 calories per day per 1 kg. Masi tila with increased amounts of up to 60 calories per 1 kg. Masi tila per day) without the introduction of concentrated solutions of glucose with insulin, hydrochloric acid

For detoxification, it is often necessary to stop forcing duresis. For normalization of circulating blood for additional infusion therapy, inject sechoginny drugs (lasix, furosemid). At the same time, toxins are emitted from the cross section, toxins are emitted, products of a drop of blood, ferments.

Peritoneal lavage stasis is not only for diagnosis, but for the treatment of pancreatic necrosis (most often hemorrhagic). With a lot of emptying, they see exudate, rich in proteolytic and lipolytic enzymes, cytokines, kinin and other toxic fluids, products of melted necrotic tissue. Peritoneal lavage in order to reduce the moisture of toxic products and reduce the amount of toxins on the parenchymal organisms.

To carry out peritoneal lavage under the control of the laparoscope, install drains in the upper side of the black empty, in the empty small pelvis and in the right lateral canal. For the upper drainage, introduce the rods into the empty hole, through the lower - the groove, see the name. At the same time, it is necessary to follow the balance to be introduced and introduced, to control the CVP, and to transfer the potential for acceleration.

For the improvement of microcirculation, including in the middle zone, inject rheopolyglyukin, small doses of heparin, stagnate kerovan hemodilution.

Antibacterial therapy for pancreatic necrosis should be carried out for the prevention of infection in the presence of necrosis, as well as for the development of infections. Perevagu provide antibiotics wide range diy (cephalosporin 3-4 generation, carbopenemi, aminoglycosidi), important development of gram-positive and gram-negative microflori. An obligatory component of antibacterial therapy is the introduction of metronidazole (prapori), which is a vibrating infusion on the non-clostridial microbial flora.

Indicated before operative detection є: 1) inability to diagnose; 2) treatment of secondary infection (late development of gastric pancreatitis with destructive cholecystitis, infection of necrotic tissue of clotting, gnarial infections in the uterine cells, enlargement of peritoneal peritoneum, abscess in early childhood 3) the progressive death of the sick person, uninvolved at an adequate intensity of treatment (including with the failure of the laparoscopic lavage of the empty waste), massive arrosive bleeding.

meteyu surgical treatmentє visualization of necrotic tissue doughs until the development of suppuration, optimal drainage of black emptying for treatment of peritonitis, or of a visible birthplace, in order to reveal a large number of enzymes in salmon.

In case of a large number of focal pancreatic necrosis in the presence of peritonitis, it can be inflated to a gradual non-correctness, i.e., Programmed revision and industrialization of severe emptying. With this method, do not close the wound tightly, but wipe it in a bandage for the peritoneal exudate. As a result, I will come to the sick and given instrumental methods to open the wound (ultrasound or CT) in 1-2 days, carry out a revision with the visible signs of necrosis and repeated treatments of the black emptying.

In case of focal pancreatic necrosis in the area of ​​the tail of the flesh root and failure of complex intensive treatment, distal resection of the root can be performed. In children with total pancreatic necrosis, total or subtotal pancreatectomy was previously violated. However, the whole operation is to endure a traumatic one, to lead to a high lethality, which, by the way, was taken into account.

In the last few years, in clinical practice, in the implementation of minimally invasive methods of "closed" treatment of pancreatic necrosis and its acceleration. Emerging operative patients who have been diagnosed earlier with additional wide laparotomy (cholecystostomy, drainage of the omentum bursa, black emptying, the drainage of abscesses and ultrasound diseases) computer tomography... Through the installation of drainage in this way, it is possible to aspirate the empty empty and cyst, remove the empty and inject antibacterial drugs. The given technique is less traumatic, easier to be tolerated by ailments, it is easier to tolerate a smaller number of faster and more low lethality.

Hirurgical treatment of gastrointestinal pancreatitis is required in situations where there is evidence of necrosis in the tissue of the flesh. It is not often the death of fabrics that is supervised over the years.

Independently of the need for surgical involvement in nutrition, such as a disease for pancreatitis, if the word is surgery. It is only possible to quickly find out the accelerated and vibrate the correct tactics for the patient.

Hirurgic involvement in case of gastric pancreatitis carried out in two options:

• laparotomy, if you have access to the licks, the license will be removed through the razrizi on the cherevniy stintsi and in the dialects of nirok;
• minimally invasive methods (laparoscopy, punctual-draining in hand), which can be seen through punctures in the patient's cherevniy station.

The laparotomy should be performed if there is a diagnosis of advanced pancreatic necrosis: abscesses, infection of the bone and pseudo-fluid, enlargement of the diagnosis of pancreatic necrosis, phlegmon of the uterine cells.

Arrives to great deals and when there is a read negative dynamism on the way of little invasive conservative methods, Bleeding.

Laparoscopy and puncture with additional drainage to be used for visualization in case of aseptic forms of aseptic disease and in the place of inferred antecedents. Also minimally invasive methods can be used as a preparatory stage before laparotomy.

The main call when preparing a patient is before the surgical engagement є hunger. Wono w - persha additional help with pancreatitis.

The viscosity of the patient in the slunker and intestines of the patient significantly reduces the risk of reducing the amount of time it takes to carry out anesthesia in the intestines, as well as the aspirating mass during anesthesia.

On the day of the operation:

• ailments are not accepted niyakoi їzhі;
• to the patient to cheat the cleanliness;
• patients to carry out premedication.

Premedication of the treatment of the injected drugs, which lays down the patient's input into anesthesia, reduces the fear of the operation, reduces the secretion of the disease, and prevents allergic reactions.

For a variety of vikoristovuyt sodin, tranquilizator, antihistamines, holinolitics, neuroleptics, analgesics.

Surgical treatment of gastrointestinal pancreatitis, as a rule, should be carried out with endatracheal anesthesia in the second place. The patient before the hour of the operation will be at the SHVL.

Naybіlshіnі operativenі engravnіya with gostromy pancreatitis

1. distal resection pidshlunkovoy zalozi. It is the appearance of the tail and the tila of the fledgling burrow of the growing volume. It is carried out in vipadkas, if the reduction of the flesh zone is surrounded and the whole organ is not buried.
2. resection glades at the visible tail, til and a large part of the head of the fawn. You can save yourself from lying down to the twelve-fingered intestine of the dilyanka. The operation is permissible for deprivation in case of total damage. Oscillated organ is unpaired, I will increase its function for such an operation, it will only be possible to transplant the debris.
3. Necrsequestrectomy carried out under the control of ultrasound and fluoroscopy. Revealed new insights into the bottom hole are punctured and behind the addition of drainage tubes they see them. Allow in empty to introduce drains of a large caliber and carry out cleaning and vacuum extraction. At the final stage of the process of large-scale drainage, it will be replaced by non-motorized ones, which will prevent the actions of starting the emptying and operating injuries while saving the flow from the country.

Management of operative treatment for gastrointestinal pancreatitis

Naybіlsh not safe acceleration of the period of operation є:

• polyorganna lack;
• pancreatogenic shock;
• septic shock.

For a larger period of time, the patients, who had an operation on the underwire Heritage can be as follows:

• pseudo-filaments;
• pancreatic fistula;
• high diabetes and exocrine deficiency;
• dyspeptic symptoms.

Harchuvannya and the mode of the patient for the operation on the slurry zone

Have the first 2 add to the operation of the hunger patient. Then we gradually introduce tea into the race, wipe vegetarian soups, roasted cereals, steamed white omelette, rusks, sir - that's all, you can go through the operation on the bottom hall with a stretch of the first meal.

Nadal ailments get caught up in the sickness of the organs of child poisoning. Physical activity the patient's visa begins with a comprehensive operation.

SMOLENSKA State Medical Academy

LIKUVALNY FACULTY

CHAIR OF HOSPITAL SURGERY

Discussed on the methodical narada

(Minutes No. 3)

METHODOLOGICAL DISTRIBUTION

BEFORE PRACTICAL EMPLOYMENT

Topic: "Hostry pancreatitis"

methodical distribution

sklav: A.A. Beskosny

METHODOLOGICAL DISTRIBUTION

(for students)

Topic: "Hostry pancreatitis"

Triviality of employment - 5 years

I. Employment plan

II... motivation

gostry pancreatitis- fiery-necrotic lesion of podshlunkovoy zalozi, pumatized by enzymatic autolysis, vicious for different reasons.

Ailments for pancreatitis gostry store 5-10% of the number of patients in the surgical profile. In 15-20% of cases, the development of severe pancreatitis is destructive. In case of pancreatic necrosis in 40-70% of ailments, there is evidence of necrotic destruction. Infectious diseases accelerated store 80% of the causes of death of ailments with destructive pancreatitis.

III.Purpose of Vivchennia

the student is guilty vmіti:

- Estimate the scars of the ailing, accentuating respect for the signs characteristic of the severe pancreatitis (strong, post_in_ boli to be localized in the epigastria, it is not easy to have an operational character; bagatorazova blues, do not bring lodging; swelling of the abdomen);

- in the anamnesis of illness, especially respect for the animals for the appearance of skarg, for the reception of hospitality, grease, fatty food, alcohol, and also postponed sickness shlunkovo-intestinal tract(Gastritis, febrile ailment and 12-palate intestine, cholecystitis, pancreatitis);

- in the anamnesis of the life of the disease: the malignant alcohol, passing over the fatty and hostile life, ailments of the organs of poisoning among the relatives;

- when looking at the animals, I respect the camp of shkirny crooks and slimy (extravazati, zmіna koloru, local swelling), symptoms typical for destructive forms of pancreatitis: belly, petechia on the side of the house and the borax of the shkiri across), Kallen (zhivtushn_st and nagging of the shkiri near the navel);

- in case of physical pre-existing symptoms of gastrointestinal pancreatitis: in addition to the condition in the epigastrium in connection with intestinal paresis, the rigidity of the intestinal palsy, the pain in the hypogastric region and in the case of a specific condition Kerte, Mayo-Robson, V.M. Voskresensky;

- assessment of the heart-vascular system (heart tone, pulse, arterial vise, CVP, EKG, microcirculations, legenevia accelerated (pneumonia, pleurisy, RDS, "shock" lung), liver diseases (heart disease, colitis) kolіr sechі);

- correctly interpret the data of laboratory blood monitoring, emphasizing the respect for leukocytosis and leukocyte formulas, electrolyte balance, acid-base balance, rivin bilirubin, sechovine, zucru, amilazi, creatinine, enzyme indicators of coagulation (adjustment of the throat and reduction of fibrinolytic activity, additional reduction and changes in the section (proteinuria, microhematuria);

- assess the data of instrumental diagnostics:

a) fluoroscopy and radiography of a black empty breast cancer.

b) endoscopic methods (laparoscopy and gastroduodenoscopy;

c) X-ray computer tomography of a black empty;

d) ultrasonoscopy of the periampal zone and organs.

- to carry out differential diagnostics: from a perforated viral slunk, gastrointestinal impairment, cholecystitis, malignant toxicosis, thrombosis of mesenteric vessels, myocardial infarction;

- viconuvati novokainov blockade (perinephric, round ring of the liver).

the student is guilty nobility ;

— anatomical views, topography and secretory function

- etiology, pathogenesis and clinical and morphological forms of gastric pancreatitis;

- period key overrun, Decreased gastrointestinal pancreatitis; - laboratory and instrumental methods of diagnostics; - methods of conservative treatment,

- evidence and surgery of the operative involvement in the presence of the nature of the accelerated pancreatitis (peritonitis, necrosis and abscesses of the hypochondriacitis, nasal omentobursitis, cranial parapancreatic phlegmon, destructive arthritic hollowness)

IV-A. basic knowledge

1. Surgical anatomy of the biopancreatoduodenal zone.

lectures on topographic anatomy.

1. Clinical and biochemical indicators of the function of the slurry zone and the liver.

Lectures from clinical biochemistry.

1. Morphological forms of severe non-acceleration and accelerated pancreatitis.

lectures on pathological anatomy.

1. Poisoning of the slurry, stoves and ducts.

Lectures for internal ailments and surgery.

IV-B. Literature on a new topic

Main:

1. Hirurgic ailments / Ed. M.I. Kuzina (MMA). Pidruchnik

MZ.-Publishing house "Medicine", 2000 ..

2. Hirurgic ailments / Pidruchnik of the Ministry of Health. - View "Medicine", 2002 ..

3. Hirurgiya / Pid. Ed. Yu.M. Lopukhina, V.S. Savel'va (Russian State Medical University). Pidruchnik UMO MOZ. - View "GEOTARMED", 1997.

4. Hirurgic ailments / Pid. Ed. Yu.L. Shevchenko. Pidruchnik of the Ministry of Health. - in 2 volumes. - Publishing house "Medicine", 2001.

5.Kerіvnitstvo before practical to take according to the local surgery / Edited by V.K.Gostishchev (MMA) -Izd-in "Medicine", 1987.

7. Lectures for the course of hospital surgery.

Dodatkova

1. Surgical pancreatology. Kerіvnіstvo for lіkarіv / Ed. V.D. Fedorova, I.M. Burieva, R.Z. Ikramova, M. "Medicine", 1999.

1. Pancreatic necrosis (clinical diagnosis, diagnosis, treatment) / Ed. Yu.A. Nemsterenko, S.G. Shapovolyantsa, V.V. Lapteva, Moscow - 1994.
2. Hospital surgery: workshop / A.M. Ignashov, N.V. Putov. - SPb.:

Peter, 2003.

5. Hirurgiya pidshlunkovoy zalozi / Ed. M.V. Danilova, V.D. Fedorova. M. Medicine, 1995.

5. Methodical development of the department on topics: "Gostriy pancreatitis".

Food for self-preparation:

a) by basic knowledge:

1. Anatomy of the liver, gut ducts and subshlunks.

2.Topographic anatomy of the pancreatic cavity and organs of the biliopancreatoduodenal zone.

3. Physiology of pidshlunkovoy zalozi.

b) behind a new topic:

1. Causes of alimentary gastrointestinal pancreatitis and traumas
2. Causes and pathogenesis of bilious pancreatitis.
3. Causes of pancreatitis
4. Methods for the maintenance of the slurry lining and the gut ducts.
5. Indicators of synthetic, detoxification and visual functions of the liver.
6. Symptomatology and clinic of gastrointestinal pancreatitis.
7. Clinical and paraclinical signs of severe interruption of severe pancreatitis.
8. Symptomatology of accelerated destructive pancreatitis.
9. Symptomatology of organ failure, gastrointestinal accelerated pancreatitis.

10. Differential diagnosis of gastrointestinal pancreatitis, hosprim appendicitis, Cholecystitis, mesenterothrombosis, intestinal impairment, myocardial infarction.

11. Differential pidhid before the appearance of severe pancreatitis in the presence of the degree of severity and acceleration.

12. Lіkuvannya not accelerated gastrointestinal pancreatitis.

13. Lіkuvannya іnfіkovany pancreatonecrosis and thіѕ acceleration.

14. prognostic criteria for overcoming the state of pancreatitis.

15. Shown to surgical treatment of pancreatic necrosis.

V.1. Food history

The first messages about the state of the art of pathology of pidshlunkovoy zolozi are reported until the middle of the 17th century. In 1641 r Tulpius (Holland), having described the manifestations of an abscess by him for an hour, the corpse of a woman died, the yaka died from a hospitable grievous emptying. Diagnosis of gastrointestinal pancreatitis is unavoidable. All ailments were spared and caught up in the mask of those who were ill. The exact diagnosis was established only by the pathologist on the sectional table. The cases of pancreatitis only appeared on the cob of the 19th century and accelerated pancreatitis was observed. U 1804r. The portal has inoculated his caution about abscesses and necrosis of the lump. Rekur demonstrated the drug with multiple abscesses. I only in 1865r. Rokitansky for the first time describing the hemorrhagic form of pancreatitis.

Gostry pancreatitis, as an independent disease becoming a vid_lyaty E. Klebs since 1870r.

The first clinical and morphological characterization of gastrointestinal pancreatitis was given by the pathologist from Boston Reginald Fitz in 1889. Super-streams have been going on for a long time, like a slid lіkuvati gostry pancreatitis. Bagato authors were respected, that the most beautiful method of treatment is conservative, without surgical involvement, at that time they were respected, as they were guilty of draining new fabrics and chewing gates. Fitz made a mistake to see a problem with pancreatic necrosis: "Vision of pancreatic necrosis looks like an area of ​​tissue damage."

The majestic additions to the vyvchennya of physiology of the first-class secretary activity of the pedigree zone belong to I.P. Pavlov and the first school (1898).

Two absolutely promising to go to the diagnosis of gastrointestinal pancreatitis occurred, while E.L. Opie (1901), having hung up the hypothesized theory: obturation of the ampulla of the great duodenal papilla with the underlying hypertension of the ducts of the subalpine cavity (the theory of the posterior canal).

First successful operation at the state pancreatitis of the viconav in 1890r. W.S. Halsted (Boston). I performed an operation in Europe at the Werner Korte (Berlin) in 1895. So, as N. Senn and W. Halsted, I was guilty of a surgical treatment for a hospitable pancreatitis about the need, as there might be a problem earlier. Pidhid in the liking of a state of pancreatitis is very subtle, both by the henchmen of the operative treatment and by the opponents.

In 1908, Julius Wohlgemuth (Berlin) described the method of increasing the concentration of amylase (dyastasis) in the blood. The method of shvidko knowledge of storing in medical practice. Prior to the diagnosis of the prescribed method, the diagnosis of pancreatitis gostry is primed only on the intraoperative doctor, or on the data taken during the autopsy.

Until the 20s of the 20th century, the robots of Lord Moynihan were working on the surgical tactics of treating severe pancreatitis. Operations caused ailments only with an important interruption of ailments. In the period from 30 to 60-ies in the treatment of severe pancreatitis, the thought about the effectiveness of conservative treatment was overtaken. Nezvazhayuyu on the price of 50% of ailments with accelerated forms of gastrointestinal pancreatitis prodovzhuvali ginuti.

From the earliest 1960s rock group of surgeons to choli with L.F. Hollender on the key and intraperitoneal materials started to develop pancreatic necrosis and its connection with these accelerated ones, as a result of the development of pancreatic necrosis. The author came to the point of thinking that only early seeing necrotic fabrics could zupiniti the process and pass the importance of slowing down. Until the 80s, radical operations were widely carried out for pancreatic necrosis - from resection of the pancreas to pancreatectomy, including pancreatic duodenectomy and pancreaticastrectomy. The mortality rate during such operations reached 50-80%.

In 1980, X-ray computed tomography and in 1984, the C-reactive cell in clinical practice allowed identification of preoperative stage of pancreatic necrosis. On the basis of new technologies, Hans Beger and Spivautory (Ulm, 1985) violated a new surgical approach in the treatment of pancreatic necrosis. On the basis of it is laid dbayliv nekrektomіya, as an alternative to resection pіdshlunkovoi zalozi.

V.2.Ethiology

cause the development of gossty pancreatitis: zhovchnokam'yana ailment, choledocholithiasis, stenosis Vaterova papilla), alcoholic treatment and fatty tissue, abdominal trauma due to small amounts of fatty tissue, operative involvement on fatty areas and adjacent organs, hospitals, blood circulation in the room intestines (virazkov ailment, parapapillary diverticulum, duodenostasis).

gostry pancreatitis in the case of damage to pancreatic juice in the intestine, development of ductal hypertension, reduction of acetic cells, leading to enzymatic necrosis and autolysis of pancreatic infections in general

1) Slurry duct z'єnuitsya і from the zalny zhovchny duct on the івні Vaterova papilla in 80% of vipads; pereskoda in viglyadі pinched stone, stenosis of the great duodenal papilla, spasm of the sphincter Oddі in case of calculous cholecystitis or choledocholithiasis, it can lead to destruction of the pancreatic juice flow and / or reflux in virzungov duct.

2) Alimentary factor (alcohol) stimulates slurry and pancreatic secretion, wickle swelling of the mucous membrane of the duodenal intestine and damage to the passage of pancreatic juice, leading to the development of severe pancreatitis.

V. 3. Pathogenesis

The main functions of acetyl cells are: 1) synthesis of alternatives to herbal enzymes and vitogens (trypsinogen, chymotrypsinogen, proelastasis, procarboxyl peptidase A and B, phospholipase A2); 2) saving them in inactive viewers; 3) the passage of enzymes in the storehouse for the juice of the slurry into the lumen of the two-fingered intestine.

The gene is synthesized in the EPR and stored in secretory granules. For the stimulation of acinous cells, instead of granules, it is necessary to follow the cat's exocytosis in the small space and distal - in the ducts of the intestinal cavity, which, at the same time, enter the two-fingered intestine. In the enlightenment of the twelve-fingered intestine, the conversion of trypsinogen into trypsin along with Enterokinase is observed.

Trypsin is a key enzyme, when all of the proenzymes are quickly activated when not active and the power of the enzyme is trypsinogen. Trypsinogen is stored in the storehouse of the juice of the slurry zone in two isoforms - trpsinogen -1 and trpsinogen -2. In a healthy sub-act, the setting of trypsinogen -1 to trypsinogen-2 becomes 4: 1. In the course of conversion, trypsinogen is absorbed by the pineal peptide - the active trypsin peptide.

In normі, the main mechanism is the proteolysis of polyagus in the synthesis and interchangeable internally inactive forms of enzymes and inhibition of proteases a -1- antitrypsin and a2-macroglobulin, which are located in the intravascular systemic space.

persha phase

Pathogenesis of gastrointestinal pancreatitis in the general community of rozkrito. The first phase of the field is in the launch of the mechanisms of the ear, as it is often localized behind the boundaries of the bottom hole. Tse can be tied with zhovchnokam'yanu ailment or alcohol. The link of the cich stanіv is firmly established, the protest in practice, the mechanics of explaining the cue of the dosage unavoidable. In the course of the experimental gastric pancreatitis (ligation of the posterior zhazhnoy duct) in the first year, after the data of the histological preliminaries, the boules appeared in the head of the necrosis of the flesh-throat. V CLINIC PRACTICE a correlative connection was established between the hour of obstruction (calculi) of the backbone duct and the state of pancreatitis.

The fact of activation of trypsinogen by lysosomal hydrolases ( cathepsin B). Danish Mechanism is the main one, from the point of view of the reasons for the internal development of gastrointestinal pancreatitis. As a result of the interaction of herbal and lysosomal enzymes, there will be a ruinous clitin of the seedlings. Once the enzyme is boiled into the small space of the bottom of the mucous membrane, beyond the uterine space, into the empty space and the systemic blood flow to destroy the tissue as a result of lipolysis, proteolysis and local self-digestion of tissue from the bottom.

friend phase

Only if it is infused with enzymes on the podshlunkovy zloza it is hard to explain the pathogenesis of pancreatic necrosis. The most important mechanism for the pathogenesis of gastrointestinal pancreatitis is in the implementation of young mediators. In fact, the pathogenesis of pancreatic necrosis is identical to such conditions, which contradict the systemic ignition syndrome - sepsis, polytrauma, reperfusion of ischemic tissues and symptoms. With a wide range of ferments, the ferment of the slurry plant does not become involved in the pathogenesis of the corresponding stanis. A cascade of pro-fired cytokines follows immediately after the pro-fired cytokines.

Surrounding zapalennya in pidshlunkov_y zalozі - a chain cob physiological zhisny type, which is controlled by the forces of the whole body. The loss of control over local firing is to lead to uncontrolled activation of cells firing and transmitting mediators, as it is clinically identifiable, like systemic firing syndrome. Organ dysfunction is often an accelerated syndrome of systemic ignition. Її types є legeneva lack, shock, nirkova, pechinkova and polyorganic lack.

In such a rank, the pathogenesis of pancreatic necrosis develops from local necrosis and inflammation of the pancreatic cavity to the syndrome of systemic ignition.

On the thought of H. Beger і spіvavt., Іnfіkuvannya devіtalіzіvannya fіsnіnі pіdshlunkovoi zolozi insisted in case of penetration of intestinal space in the already very necrotic in the head and emptying of aseptic so-called abscesses. bacterial translocation. The first path of contamination - along the bloodstream, lymphatic vessels and for additional reflux in the pancreatic ducts. Bagato authors do not include the discovery of saprophytic microflora in the tissue of the creeping zone, which becomes virulent for singing minds.

V... 4. Terminology and classification

The definition of the terms of the state of the art pancreatitis and the second

Celebrating the peculiarities of the evolution of pancreatic necrosis, the basis of the modern classification of the state of pancreatitis is made by the officials themselves, who appear in the real regime at the time of the beginning of a fatal result or accelerated development:

The widening of the necrotic process in the lateral cavity, in the lower parts of the abdominal cell and in the black emptying;

Factor for the information of necrotic tissues in the development of localization;

The step of the gravity of the sick person is behind the integral systems-scales.

According to tsikh tributes in the evolution of pancreatic necrosis see the pre-infectious and infectious phase of the pathological process, and the day to assess the position of the sick person, as in the fallowness due to the widening of necrotic lesions in the dewclaws, in the wartholes and in the black debris and in terms of the incapacitation and the "flaws" of intensive laboratory therapy In a distinctive way to the choice of differentiated tactics of surgical treatment in the classification of destructive forms of gastrointestinal pancreatitis, along with the characteristics of the breadth of the process (dynamic, large-scale, subtotal)

1) sterile pancreatic necrosis;

2) the diagnosis of pancreatic necrosis. The main provisions of the classifications will increase to be based on the international classification adopted in 1991 in Atlanta, in 1997 in Europe and in 2000. in Russia.

In the first, pre-infectious phase of seizure, they see the onset of the internal diabetic acceleration:

1) enzymatic ascites-peritonitis, the development of which is the beginning of autoferment "aggression", which is opposed in abacterial minds, as a rule, in the early term of becoming ill;

2) parapancreatic infiltration, the morphological basis of such a warehouse, necrotic ("abacterial") phlegmon of new types of children

3) pseudo-copy of a risky step maturity, as it forms through the month and more from the ear of the disease.

For the infectious phase of the pathological process, the most characteristic features are:

1) septic necrotic phlegmon of small forms of the uterine space;

2) pancreatogenous abscess (retroperitoneal or intracranial), which is a wider world of evolu- tion of inter-mediated (other- or great-burning) forms of damage to the mid-lump of cells;

3) nasal peritonitis (in case of “depressurization” of the urethral space).

In the middle of extra-abdominal acceleration you can see:

1) pancreatogenic enzymatic shock;

2) septic (or infectious-toxic) shock;

3) polyorgan dysfunction / deficiency due to the degree of severity of the sick person according to the integral systems-scales - APACHE II, MODS, SOFA;

4) important pancreatogenic sepsis.

for the broadening: local, subtotal, total.

For interruption: abortive and progressive.

periodi become ill

(1) hemodynamic loss (1-3 dB).

(2) Functional deficiencies of parenchymal organs (5-7 dB).

(3) post-necrotic acceleration (3-4 days).

Phases of morphological changes: swelling, necrosis and slowing down.

Decreased: toxic, (pancreatic shock, delirious syndrome) pancreatic-nirkov and cardiac insufficiency) and postnecrotic (abscess of fenestration, phlegmon of uterine blood cells, arthrosis, peritoneal disease

V... 5. Klinichna picture

Pain syndrome

1) For gastrointestinal pancreatitis, it is characteristic of persistent severe pain and pain in epigastric disease, which is superfluous and boring.

2) Lives with palpation painful, stress and in addition to swelling in epigastric disease.

3) Positive symptom Schotkіna-Blumberg, Voskresenskogo(Detection of pulsation of the cranial aorta, do not cheat with a symptom shirts), Mayo-Robson, Rozdolsky . The variability of symptoms is found in the form of a disease, the stage of intoxication and acceleration.

4) With an adequate response to pain, the reaction is up to 3-5 dB, the pulse, temperature and arterial pressure normalize.

5) Nibilsh turns pain syndrome with pancreatic necrosis (severe pain, in epigastric disease). With a progressive interruption of pancreatic necrosis by 7-10 dB. pain in the abdomen changes through the bend of the sensitive nerves to the end of the lungs.

Shkіra and mucous membranes often blіdі, inodі cyanotic or zhovtyanichny. Cyanosis appears on the face and tulub (syndrome Mondor), faces and cues (symptom Lagerlef), ekkhimozi - on the screen of biches of the abdomen (symptom, Gray Turner), near the navel (symptom Cullen). symptoms Grunwald(Petechia near the navel) Devisa(Petekhii on s_dnitsyah) are characteristic of pancreatic necrosis.

The temperature of thyl is normal in case of swelling pancreatitis;

Pancreatic necrosis is characterized by important camp, Bloating, temperature change, cyanosis of shkirnykh curvatures, tachycardia, hypotension, oliguria, symptoms of peritonitis. Frequently, the zagalny signs of intoxication prevail over the muscular manifestations of the disease.

with parapancreatic phlegmon i abscess undershoot zaloz'yayutsya depletion of the camp, an increase in temperature, chills, igniting infiltration in the upper upper part of the black light, leukocytosis due to the ruptured leukocyte formula alone.

Voschke firing and necrosis of the slurry cavity can be vicious bleeding in the urea space, zdatno leads to hypovolemia (hypotension, tachycardia) and the purchase of blood in soft fabrics;

1) The embryo with the blood of the soft tissues of the uterine space expands on the bottom of the abdomen, leading to the appearance of ecchymosis - Gray Turner's symptom.

2) Increase the blood on the fatty cells of the sickle-shaped ligament of the liver to produce the appearance of ecchymosis in the umbilical region - Cullen's symptom. |

V. 6. Diagnostics

\

Anamnesis. If there is a strong connection between the development of an attack of pancreatitis and a great amount of fatty and meaty food in combination with alcohol 1-4 years before the first symptoms appear (bile in the epigastric period). The intensity of the trochie pain changes, as the ailments sit down, having healed forward.

Laboratory methods for follow-up:

1. 1. ? -Amylase of blood sugar. Do people with pancreatitis suffer from syrovatkov activity? -Amilases are improved in 95% of cases. At least in 5% of the results and until late Hibopositive, in 75% of patients with characteristic pain in the belly and the increased activity of the sirovatkov? -amilazi viyavlyayut gostry pancreatitis. At the pidshlunkovy zalozi, shkodzheno chronic flames, Synthetic driving processes; to that with aggravated chronic pancreatitis zmist? -amilazi may not move. In case of pancreatic necrosis, the destruction of the pancreatic cavity is also supervised to decrease the activity? -Amilazi. Circulating in the blood? -Amylase secret not only pidshlunkova zalosa, but th salivating... To this, the activity of the enzyme in the blood is increased in case of mumps.
2. 2. Clearance amylase / clerance creatine. The value of amylase is more informative in the case of porous levels of amylase and endogenous creatine. The feature "clearence amylazi / clearence creatine" is 5 to indicate the manifestation of pancreatitis.
3. 3. C-reactive block- the building of the hotel is heated. With a level of CRP in the blood of 120 mg / l, 95% of the ailments show necrosis of the lump. CRP is seen as a discriminatory indicator of virtualized and deviated tissue of the pancreatic disease.

Change and Inshi Methods of Advancement

1.Oglyadova radiography organs of the worms empty for the diagnosis of pancreatitis is not very informative. In some cases, the onset of a change can be seen on the x-ray picture.

- Calcifications in the area of ​​the lesser omentum and undergrowth, often show up in ailments for chronic pancreatitis, and are malignant with alcohol.

- The purchase of gas in the area of ​​the small omentum is a sign of an awareness of the abscess in the middle or close to the bottom.

- Razmiti tіnі club-transverse m'yazіv (m. psoas) with urethral necrosis of pidshlunkovoy zalozi.

- Substitution of organs in the black emptying in case of exudation and filling of the small omentum and organs that have been roasted in the immediate vicinity of the bottom hole.

- spasm of the dilenca of the transverse colon intestine; vyavlyayut gas in the intestinal lumen ( Gobier symptom).

- With chronic pancreatitis arises as a symptom inverted tricycle.

2. Radiopaque monitoring with a bar of suspension vikoristovoyt for diagnostics of pathology of the upper forms of the slunk-intestinal tract:

You can increase the radiality of the two-fingered intestines as much as you can.

With relaxation duodenography, it is possible to viyaviti pillow symptom- Smoothing or obliteration of the folds of the mucous membrane of the medial wall of the duodenal intestine as a result of the accumulation of the mucous membrane and the similar ignition reaction of the duodenal intestine.

3. Ultrasound pre-detection of slurry formation- a valuable method for diagnosing pancreatitis. When carrying out ultrasound, it is necessary, first for everything, to pay respect to the anatomy of the pied-shunny zalozi and її sudinni orintiri:

Nabryak pidshlunkovaya zalozi, її dragging in the anterior-posterior straight, practical visibility of tissues between pidshlunkovaya zalozi and splenic veins - signs of a hostile pancreatitis.

With ultrasound, it is also possible to reveal the pathology of the flesh-like cavity ( by the way, change of duct diameter). In chronic pancreatitis, calcification is often caused by the formation of pseudo-filaments, in order to avenge the ridin. In case of chronic pancreatitis in the cage empty it is possible to buy up ascitic ridin, it is good to appear with ultrasound. rіznі ailing underslung coarseness can be victorious against the changes in echogenicity and fabrics:

In most cases, in case of sickness, the degree of degradation decreases as much as it gets too hot. Pukhlini may even be zazhdi hypoechogenic.

Adoption of ekhogenosti - the inheritance of the purchase of gas abo calcifikash zalozi.

Ridin structure, roztasovana in the tissue of the lump, maybe a cyst, an abscess or a lymphoma.

With ultrasound, it is possible to reveal the pathology of the chewing mikhur (For example, cholecystitis, choledocholithiasis or widening of the posterior zhazhnoy duct). Ultrasonic inspection of a carriage of empty vehicles. So, with a great purchased gas in the intestines (For example, in case of intestinal imperfections), visualization of internal organisms is important or unpleasant. By the way of ultrasonography є - efficiency, non-invasiveness, dullness (when used) and the possibility of bagatorazovy vikorstannya. Especially the value of ultrasound imaging in diagnostics of bilious pancreatitis and verification of diagnosed pancreatic necrosis for additional thin-brain aspirating tissue of the flesh and filling of aspirate. Informativeness of up to 50% to 85%. Difficult diagnostics of viclican intestinal paresis and adiposity.

4. Contrast dynamic X-ray computer tomography(CD RKT) to be carried out for patients with severe interruptions of severe pancreatitis. As a guide for conducting CD RCT to serve as a discriminatory indicator of the C-reactive test scale and the integral scale of assessment, I will be able to indicate an important change and / or predict an organ deficiency in the form of gastrointestinal pancreatitis.

Pancreatic necrosis is characterized by destruction of the duct system. Moreover, with the manifestation of non-contrasting dylyanoks of the ditches, interstitial origin, for the data of the PKT CD, it is interpreted as necrosis of the ditches and depletion of the duct system.

5. X-ray computer tomography without contrast

In case of concomitant pathology of nirok, increased sensitization on contrasting speech, CD PKT is contraindicated. Cich vixens have a non-contrast PKT, which is interpreted in a way according to the Balthazar-Ranson integral scale. So, step A is characterized by an overall necrosis and 0 points for the Ranson scale; step B ( locally abo diffuse zbіlshennya podshlunkovoy zolozi in the additional with hypodensic included in the tissue and with unclear contours, enlarged pancreatic duct) - necrosis of the slurry zone borrows an area of ​​no more than 30% and results in 2 points; step C ( change of fabric and closure of analogous stage B, before which one can enter the ignition, in the parapapcreatic cell) - 30% -50% of the area of ​​necrosis of the ground and the appearance of 3 points; grade D more than 50% necrosis of the slurry zone ( characteristic change of steps Z + one by one re-insight into the pose) - іdpovіdaє 4 balam; E- ( depending on the changes of step D + two, or more, the posture of the bottom hole, or the abscess is gas) - return 6 points.

6. selective celiacography. In case of nabric pancreatitis, there is an increase in the strength of the calf, in case of pancreatic necrosis, there is an increase in education. celiac stovbur, Pogirshennya bloodstatic zolozi with dilyanki vimikannya the ship channel.

7. radioisotope not available in case of pancreatic necrosis: the visibility of the isotope fixation in the pancreatic cavity, a decrease in the visual function of the liver.

8. Laparoscopy. Vyavlyayutsya in the head of fatty necrosis, hemorrhage and swelling of the shlunkovy-rim connection, the nature of the eksudatu (serous abo haemorrhagic), estimate the stanchion of the zhovny mikhur.

9. Viznennya p and O 2 and X-ray of the chest. Respiratory distress syndrome rarely develops in ailments with important pancreatitis; pleural emptying accumulate vipit. Most of the vipit, at the great ones to take revenge? -Amylase, appear in pleural empty spaces. In connection with cymosis in ailments with an important form of gastrointestinal pancreatitis, it is necessary to initiate a О 2, and to determine the radiography of the organs of the breast for early diagnosis of pleurisy and pneumonia.

V. 7.forecast

Renson

a. Signs that appear before I enter

(1) Вік older than 55 years.

(2) The number of leukocytes in the peripheral blood is greater than 16x10 9 / l.

(3) The blood glucose concentration is 11 mmol / l.

(4) LDH activity in blood is 350 MO / L.

b. Signs that appear in 48 years since the hope

(1) Fall Ht by 10%.

(2) Increase in blood versus AMK up to 1.8 mmol / l.

(3) The concentration of calcium in the blood is lower than 2 mmol / l.

(4) p a O 2 lower than 60 mm Hg.

(5) Deficiency is more than 4 meq / l.

(6) Spend ridin in third space .

Integral scale for assessing the severity of severe pancreatitisAPACHE— II

Glasgow Komi Scale (GCS)

APACHE-II indicator: sum of balivA + B + C

B. Vіkovy indicator

C. Indicator of chronic illnesses

Even in the anamnesis of the sick person, there is a history of serious damage to the functions of the internal organs, or to the damage to immunity, and he will be judged by the offensive rank:
a) patient, who did not get promptly involved
viconano for an extraordinary operation - 5 points;
b) a patient for a planned operation - 2 bali.
It is necessary to prove the presence of a breakdown in the functions of internal organs, or immunodeficiency, to the appropriate level in the clinic, as soon as possible before the onset of the criteria:
pechinka: morphological reports of liver cirrhosis, verified pechinkov hypertension, episodes of hemorrhage from the upper cases of the intestinal tract, tying to portal hypertension, in the middle of the disease of the liver,
Sertsevo-sudinna system: angina pectoris of the IV functional class is well known in the New York classifications.
Dichny system: chronic restrictive, obstructive abo Suddenly ill lungs, scho produce to a significant physical navantazhennya(For example, the unwillingness of pidnimatisya at gatherings or service staff); chronic hypoxia, hypercapnia, secondary polycythemia, importance of the Legeny hypertension (> 40 mm Hg), obesity piece ventilation lungs.
nirki: repeated procedure of hemodialysis for a trivial hour.

immunodeficiency: a person who is ill undergo therapy to reduce the efficiency of the body to infections, to diagnose diseases (immunosuppressive drugs, chemotherapy, optimization, trivial therapy with steroids, or high doses), for example, in the patient's body, the importance of taking care of

Disruption of the function of nirok, tied with hypovolemia, assimilate intensive infusion therapy. The development of a state of the art tubular necrosis in the form of peritoneal dialysis or hemodialysis.
Necessary monitoring control of sour blood, with a decrease in its mensh

residual forecast

Yaksho at the ailing mensch 3 (Ranson) / 8 (APACHE II) from significant signs, lethality become 0.9%; If it signifies more than 7/25, the lethality becomes practically 100%.

(1) Disgusting prognostic signs in 48 years from the moment of needfulness will lead to the accumulation of toxic shock and important muscle destruction of the flesh.

(2) Home efects (For example, shock and hypoxia) to wick the product down to the bottom of the slurry, so that it goes into the bloodstream.

V... 8. Conservative treatment for gastric pancreatitis

is aimed at combating hypovolemic shock, intoxication with products of the dehydration of the debris; heart-vasodenal, hemodynamic, water-salt and obscenities, peritonitis and postnecrotic accelerated.

Likuvannya nabryak forma pancreatitis to carry out in a surgical manner only by conservative methods.

(1) Likuvalnaya hunger for a stretch of 2 dB, the introduction of glucose solutions, Ringer-Locke in general, 1.5-2 l, lytic sum (promedol, atropin, diphenhydramine, novokain), ingibitoriv proteases (counterkal, trasilol, gordox), 5-FU and forcing duresis.

(2) For the knowledge of the sphinkter's spasm Oddі The following drugs are indicated for sudin: papaverine hydrochloride, atropine sulfate, platifilin, no-spa and eufilin in therapeutic doses.

(3) Antihistamines (pipolphene, suprastin, diphenhydramine) to reduce the permeability of the brain, volodynuyu and sedative effects.

(4) Paranephral novocaine blockade and blockade of the celiac nerves with the help of suppression of the ignition process and pain reaction, reduction of the external secretion of the fatigue, normalization of the sphincter's tone Oddi, polishhennya in the juice and pancreatic juice. The process of management can be substituted for the internal introduction of 0.5% to the price of the new company.

(5) Pererakhovanі vische conservative go in polіpshuyut the camp of the ailments with the bulging form of pancreatitis. As a rule, for 3-5 people get sick in the back seat.

lykuvannya pancreatic necrosis spend in the emergency room.

(1) For a quick update of the BCC and normalization of water-electrolyte exchange i / v introducing roschini glucose, Ringer-Locke, sodium bicarbonate, rheopolyk-Lyukin, hemodez, politically sum, ingibitorium of proteases, cytostatics, hearts, and also plasma, albumin, protein with one-hour stimulation of duresis. Reopolyglyukin reduces the viscosity of blood and changes in the aggregation of forms of blood elements, which leads to the development of microcirculation and changes in the formation of the lump. Hemodesis zyazu toxins і quickly vivodit їх from the cross.

(2) Cytostatics (5-FU, cyclophosphamide) may be anti-fatigue, desensitizing, and smut! - galvanize the synthesis of proteolytic enzymes.

(3) Ingibitori proteases (counterkal, trasilol, gordox) induce the activity of trypsin, calcarein, plasmin, and inactive complexes with them. їх introduce i / v skin 3-4 years and shock doses (80-160-320 yew. UNITS - dobova dose counter).

(4) For the forcing of dyuresis, take 15% manitol (1-2 g / kg mass) or 40 mg lasix.

(5) Antibiotics of a wide spectrum of diy (kefzol, cefamezin and in.) And thienam (group of carbapenems) accelerate the development of antibiotics.

(6) For the reduction of the primary secretion of the slurry zone, the cold is shown on the epigastric day, the aspiration of the slurry cavity, the internal slurry hypothermia.

(7) Methods of extracorporeal detoxification (plasmapheresis, lymphosorption ) Directly on the activity of the organisms of the enzymes in the diet, calories, toxins, and products in the blood pressure.

(8) Close-focus exchange therapy can be used for anti-firing therapy. Conduct 3-5 sessions.

(9) In case of progressing signs of peritonitis, surgical drainage of the small omentum emptying and black emptying is shown (you can visit it for additional laparoscopy, as well as laparotomy).

V... 9. Surgery for pancreatic necrosis

Shown before early operation(1-5 will get sick): symptoms of diffuse peritonitis, discomfort in the condition of surgical treatment of the organs of an empty stomach, additional pancreatitis with destructive cholecystitis, ineffectiveness of conservative therapy.

Meta operatsії: usunennya reasons scho viklikala peritonіt, vidalennya ekssuda of cherevnoї porozhnini, zmіnenogo zhovchnogo mіhura, konkrementіv іz zagalnogo zhovchnogo duct usunennya pereshkod for vіdtoku pankreatіcheskogo.sekreta i zhovchі, dekompresіya zhovchnih shlyahіv, vіdmezhuvannya seed-necrotic pattern during the packing sumtsі, drenuvannya і flowing dialogue of the omentum bags of the black empty, resection of the necrotic part of the dead skin.

at gross cholecystitis, accelerated gostim pancreatitis, To perform surgery on female paths (cholecystostomy, cholecystectomy, choledocholitotomy, endoscopic papilotomy) in addition to parapancreatic novocaine blockade, necrectomy, drainage of bursa

Abdominalization It is possible to detect in case of semi-fatty and hemorrhagic pancreatic necrosis by means of an increase in the enlargement of enzymes and products in the drop on the extra-urethral cell line and in the presence of a necrotic process in the mid-lucid cavity and omentum.

In a number of vipadkiv resection of the necrotic part of the slurry lowering lethality, intoxication with enzymes of the slurry zone, reducing hemodynamics and accelerating the development of post-necrotic acceleration. It is more beautiful than viconuvati for 5-7 if you get sick, since necrosis clearly begins, it becomes obvious that conservative therapy is ineffective. Resection, part of the organ stagnates through trauma and low efficiency. Vyadyayut deprived of tissue with signs of obvious necrosis.

At the phase of the nighth acceleration(2-3 cases of sickness) it is necessary to carry out rostin abscesses of the papillary cavity, seeing the glandular exudate from the omentum bursa and black emptying, rostin of the urethral phlegmon, sequestrectomy and drainage.

1. Vi.Scheme of a sick person.

With the occurrence of scarg, I especially respect the beasts of pain in the epigastric pain, pain, pain, do not bring relief from the attacks of blues.

Taking an anamnesis of sickness, especially respect for the animals for an hour, the first signs of sickness, implantation of alcohol, fatty, greased їzhі, abdominal injuries.

A known anamnesis of the disease has been transferred (gum disease, postcholecystectomy syndrome, early postponed surgery on the organs of a black-eyed woman), taking a family history.

In case of physical obstinacy of animals, respect for the camp of small curves, peripheral lymph nodes, the manifestation of signs of zhovtyanitsi, peritonitis, intoxications.

When a sign of gastrointestinal pancreatitis is detected, one should go into additional laboratory and instrumental methods of diagnostics (amilase of a section / syrovatka, instead of glucose in syrovatki, calcium, OAK, OAM, B \ X, ultrasound scan).

Vii.situation

1. Khvoriy, 60 years, having entered the surgical department with scargs for intensive pain in the epigastric period with the irradiation in the ridge, you can also spend money on post-boring tediousness, and to sweat the blues.

She has a history of illness because of a great number of alcoholic beverages.

Objectively: the camp is important, shkіrnі show off the faces of the blіdі with cyanosis, scleri kіlka zhovtyanichnym. AT 90/50 mm Hg Pulse 120 beats per gilin. On the anterior surface of the abdomen of the skin of the child with cyanosis dylyans, in the navel area, dylyanka ekkhimoziv appear. Lives along with swellings, strains, painful at the upper viddils, peristalsis does not become audible. Palpation, pulsation of the cranial aortic viddilu does not appear. When an oglyadov_ roentgenography of a black emptying was revealed, the loops of the rim intestine were blown out. The ultrasonography revealed the growth of the greenhouse forest with unclear cordons and irregular dialects of hypoechogenic production, as well as a verge in the black empty ones. There is no pathology on the side of the stove and the cheeks. Paraclinic preliminaries: blood leukocytes - 16 × 10 9 / l, blood section - 11.2 mmol / l, calcium serum - 1.5 mmol / l, lactate dehydrogenase (LDH) - 1800 units / l, hematocrit - 29%, amylase activity Sich on Wolhelmuth put 2048 od.

Nutrition: 1. Name the main clinical and paraclinical symptoms of illness. About yake zhvoryuvannya id mova? 2. Do you need to spend time with someone who is sick?

Etalon vidpovidі: 1.Symptomy Halstead, Grunwald, Mondor, Voskresensky, Gobye. Mova idé about destructive pancreatitis - pancreatonecrosis. The illness was accelerated by enzymatic pancreatitis, shock. 2. To clarify the diagnosis and assessment of the life of important organs, it is necessary to establish biochemical, hemodynamic, parameters, the value of the acid-pool blood, partial pressure, parameters visual systems... Laparoscopy is used for diagnostics and treatment. Nayblyzhchy dobi to carry out an X-ray computer tomography of a black empty.

2. Khvora, 44 years old, is 11 dB with the diagnosis "gostry pancreatitis, important interruption." Skargi for beef in epigastric dilyantsi, chills. Mill of the middle stage of gravity. The skin is dry, the temperature is 39 0 C. In the epigastric period, the infiltrate 8x7x3 cm is palpable without clear, painful between. Symptoms of the teasing of the stem of the sum. An. blood: ep. 3.1x10 12 / l, leukocytes 16x10 9 / l, palichonuclear among them - 12, segmented - 56, lymphocytes -4, SHOE 20 mm / year. Ultrasonic examination of the pidshlunkovoy zalozi - looking around the ailing through the intestinal gases, scoping the zone around.

Pitannya: 1. About the yak form, is there any better pancreatitis? 2.How is it necessary to carry out ailments? 3. Viber tactics of treatment.

The standard of evidence: 1. Inflictions of pancreatic necrosis, acceleration of the abscess of the dermal cavity. 2. It is necessary to carry out an ailment X-ray-computer tomography of a black empty with the help of diagnostics confirmation. 3. Ailments are indicated for an operation - rostin and abscess drainage, antibacterial, disintoxication therapy.

3. Cholovik 35 years, hospitalizations with the diagnosis "gostry pancreatitis" after 2 add-ons. Skargi for bіl in epіgastralіy dіlyantsі, nudotu. The temperature of thila is 37.1 0 С. An. blood: ep. 4.1 x 10 12 / l, leukocytes 7.2 x 10 9 / l, maceous ones - 4, segmented ones - 70, lymphocytes -14, SHOE 12 mm / year. Ht 41%. Syrovatka glucose - 6.0 mmol / l, LDH - 465 MO / l, AST - 23 MO / l, sechovina 7.2 mmol / l. Ultrasonic inspection of parenchyma-napryak, heterogeneity of parenchyma. Size of the head - 32 mm, body - 28 mm, tail - 31 mm. Contour zolozi rozmiti. Pathology from the side of the bilious tract is not revealed. After 2 additions to the hospital, in the course of treatment, the camp of a sick person without dynamism: Ht - 40%, serovat section - 7.3 mmol / l, calcium serum - 1.8 mmol / l, p and O 2 - 64 mm Hg , delivery deficit 4 meq / l. The amount of slash for the remainder was added to 2100 ml, with infusion therapy - 3800 ml.

Nutrition: 1. Your prognosis on the basis of the Integrated Scale of Assessment of Renson's state of the art for pancreatitis. 2. Begin using personal tactics. 3.Tracking the introduction of antibacterial drugs to the sick?

Standard of opinion: 1. Friendly. For the Renson scale - 2 bali (LDH - 465 іcalcіy sirovatki - 1.8 mmol / l). 2. Slide to conduct the same way: calm; cold on an epigastric day for 1-2 dib; deprivation (type of oral feeding); znebolyuchі (baralgin), antispasmodic drugs (no-shpa); the drugs block the biological function of pidshlunkovaya zalozi (sandostatin); infusion therapy with the growth of the sickness, with the control of the weather-related diuresis. 3. Introduction antibacterial drugs do not get lost.

roћe ??? I (?? lymphatic, detoxification, antihypoxant activity and normalization of metabolic processes in the body.

Vikoristannya to nitrogen oxide. The incidence of endogenous nitrogen oxide (NO), which is produced by cells behind the additional NO synthase and the viconious function of a universal regulator-messenger, has become a great part of biology and medicine. In the experiment, the role of endogenous NO in oxygenation of tissue and its deficiency in severe wounds was established. One-hour retention of surgical treatment of malignant-necrotic lesions of macular tissue, manifestations of a complex of factors in physical infusion (ultrasound, ozone and NO? fibroblasts, growth of granulation tissue and regional epithelialization.

10. Anaerobic infection.

Anaerobi to become absolutely great normal microflori people. The stench is sluggish: in the mouth empty (in ash-trees, the flora is 99% stored in anaerobes), in the slunker (with hypo- that of anacid camps, the microbial landscape of the slunk comes close to the intestinal), in the small intestine (anaerobes in the midst) in tovst_y kishts_ (the main place of living of anaerobes). For etiology, anaerobes are subdivided into clostridial (argue), non-clostridial (do not argue), bacterioid, peptostreptococcus, fusobacterium.

One of the backward symptoms of anaerobic infection is the visibility of microflora in crops with standard methods of anaerostatics (without anaerostatics). Oscillations of microbiological identification of anaerobic microorganisms in a special setting for a trivial hour, more important swell methods of express diagnostics, Scho allow to confirm the diagnosis for a period of years:

Microscopic analysis of a native smear patterned after Gram;

Terminova biopsies of tissue tissue (characteristic of rotations of tissue tissue), destruction of the stroma of the dermis, tissue necrosis of the basal ball of epidermis, adipose tissue, fascia, fibroids, etc.

Gas chromatography (volatile fatty acids start, such as ostate, propionic, butyric, iso-butyric, valerian, isovalerian, nylon, phenol and other derivatives, which produce in the middle of the metabolism an abnormally healthy tissue

Based on the data of gas chromatography and mass spectrometry, it is possible to identify not only asporogenic anaerobes, but also clostridial microflora (abnormal gas gangrene), characteristic of which is the presence of 10? Hydroxy acids (10-hydroxystearin).

Independently of the localization of the fire, an anaerobic process can be found in a number of characteristic signs:

Unacceptable rotten smell of eksudatu.

The rotten nature of the battle.

Brudniy mezerny exudat.

Gas solution (gas bulbs from the wound, the growth of the pediatric cell, gas over the pus in the empty abscess).

The closeness of the wound to the world of natural life of anaerobes.

For anecdotal processes, which may occur in a surgical clinic, it is necessary to take into account a special form - an epifascial stimulation of the phlegmon of the anterior cranial wall, in order to develop and accelerate the operation of the

Anaerobic clostridial infection- gostre Infectious disease, Scho to viciously penetrate into the wound and reproduce in spore-producing anaerobes in the genus Clostridium ( Clostridium perfringens, Clostridium oedematiens, Clostridium septicum, Clostridium hystolyticum). Infections often develop in the first 3 days after being injured, later - after a few years or even a long time, to be prevented from being injured in the fire, in surgical cases - during amputation lower kintzivok from the drive of atherosclerotic gangrene and to help with apendectomy, etc. Immovability of an anaerobic infection is very susceptible to manifestations in wounds aliens, Fractures of the cysts and genitals of the great arteries, fragments in such wounds of rich, ischemic, necrotic tissue, glib, filthy aerated kishen.

Anaerobic clostridia see a number of the most powerful exotoxins (neuro-, necro-, enterotoxin, hemolizin) and enzymes (hyaluronidase, neuraminidase, fibrinolizin, collagenase and elastase tissue, the importance of intoxication to the body with the ears of the internal organs.

Ailments are in front of a bursting bill in the early, a swelling of tissue near her. On the shkiri there are midpoints of crimson-cyanotic barnacles, which broadens intermittently to the point of being from the wound in the proximal right, and puffy, reminiscent of the calamous hemorrhagic vmist. When palpation of tissue near the wound, crepitus begins.

Odnochasno of mіstsevimi Wink vіdznachayutsya glibokі zagalnі rozladi: slabkіst, depresіya (rіdshe - torn down i eyforіya) pіdvischennya temperature tіla to febrile digits rіzko superelevation tahіkardіya i pochastіshannya dihannya, blіdіst abo yellowness shkіri, progresuyucha anemіya i іntoksikatsіya at urazhennі pechіnki - zhovtushnіst sclera ...

When X-ray diffraction, gas appears in the tissues. Diagnostics of anaerobic infections is based mainly on clinical tributes. Likuvalnaya tactics will also be used for classy paintings getting sick.

In case of anaerobic infections, necrotic changes in tissues and practically from the daytime ignition and proliferation are treated.

Anaerobic non-clostridial infection(Rotten infection) to be vicious with anaerobes, but do not make a super-transmission: B. coli, B. putrificus, Proteus, bacteroids ( Bacteroides fragilis, Bacteroides melanogenicus), Fuzobakterіyamі ( Fusobacterium) І ін., Neridko in the combination of staphylococci and streptococci.

Behind the muscular tissue changes and the backward reaction of the organism, the rotten infection is close to the anaerobic clostridial infection. It is characteristic that the processes of necrosis perevazhannya over the processes of burning.

Clinically, the muscle process in soft tissues develops against the eyes of non-clostridial phlegmon, develops fat cells (cellulitis), fasciitis (fasciitis), mucositis (myositis).

Zagalny camp of the ailing patient suffers from severe toxemia, quickly leads to bacterial-toxic shock with often fatal results.

Rotten infection is often spared in case of important information, lacerated-clogged wounds, or in case of severe fractures with great rupture of soft tissues and obstructed wounds.

Hirurgicne involvement in case of anaerobic clostridial and non-clostridial infection of polyagus in a wide rosette and often hanging dead tissue, perspiration for all muscular tissues. Early use of the waste is clearly washed out with oxidative breakdowns (water peroxide, waste of potassium permanganate, ozonation, sodium hypochlorite); , they do not sew up early, they do not tampon, they will get in the fake air. For the operation of hyperbaric oxygenation.

Antibiotic therapy of anaerobic infections.

For empirical congestion in case of anaerobic infections, it is recommended clindamycin(Delacil C). I’ll look at the large number of such infections, the therapy should be carried out with a number of drugs, for example: clindamicin with aminoglycosides. Bagato strains anaerobiv driven rifampin, lincomicin(Linkotsin). On gram-positive and gram-negative anaerobic coca dobre benzylpenicillin... However, it’s unbearable. Yogo deputy є erithromicine, Ale vin is pogano din na Bacteroides fragilisі fusobacteria. Effectively anaerobic cocks and sticks є antibiotic fortum(Go along with aminoglycosides), cephobid(Cephalosporin).

Especially the middle of the preparations, which can be used for pouring into anaerobic microflora, borrowing metronidazole- metabolic sprout for strict anaerobes. On the gram-positive form of bacteria, metronidazole is significantly weaker, less on gram-negative, so it is not justified to be stuck in the cych vapors. Close a day before metronidazole viyavilsya іnshi imidazole – niridazole(More active than metronidazole), ornidazole, tinidazole.

Stagnate also 1% of the difference dioxidine(Up to 120 ml IV for older adults),
and also carbenicillin(12-16 g / day i.v. will grow up).

11. Practical carrying out of the bandage change.

Be-yaka the serpent of the bandage is guilty of being in sterile minds. It is necessary to be victorious about the so-called "non-touch technique" (non-contact technique). Until the wound, or the bandage, do not allow dots without a mitten. Likar, which rob the dressing, is guilty of surviving special calls for a hairy man from an infection: the necessary gloves for latex, a cover for the eyes, and also a mask for the mouth and nіs. The patient is required to be roztashuvati manually, and the area of ​​the wound is guilty of being good. Necessary good dzherelo illumination.

As the bandage is not known, it cannot be removed. The bandage should be aseptically rocked (peroxide, Ringer’s roschin), do not appear yet.

In case of inflicted wounds, the area of ​​the wound is cleaned directly in the middle; Necrosis in the early days can be seen with a mechanical walk behind a scalpel, a knife or a curette (perevagu next to a scalpel, seen with knives or a curette pulling behind itself the rhizik of tissue crushing and repeated traumatization).

To deliver effective for cleaning the wound by aseptic opening from the syringe with a light grip of the piston. In case of glibous wounds, the treatment is carried out behind the aid of the bulbous groove of the probe, or through a short catheter. Ridina slid pick up the servet in the tray for help.

Granulation tissue sensitively reacts to call inі factories, how to make your ears. We will improve the quality of the treatment of the granulation tissue after the injury to the wound at the vologue and the injury from the change of the dressings. Overwhelming granulation is inviting to see for the help of the cauterizing olivtsya (lyapis).

If the edge of the wound is shown to be smart before being fed and twisted in the middle, then it is shown that a surgical treatment of the edge of the wound has been carried out.

It is good to develop the experience of not being able to look at the face of the disease and cause injury when changing the dressings.

The surgeon is guilty of care, when the wound dressing is fitted optimally to the surface of the wound - the wound secret can only be picked up for good contact with the dressing and early. Inadvertently fixed bandages in Russia can fail to wipe out the wound and hope for it.

Vii.Scheme of a sick person.

When scarg is detected in a sick person, there is a given of an accelerated interruption of the wound process (signs of heat, temperature increase, and in.).

Anamnesis of ill health
on ethiological and pathogenetic moments of insight into wounds, background thoughts (stress, alcohol, medication, narcotic intoxication, rapists).

In the previous history of the disease, the patient has suffered an illness or, in fact, a citizen, which is infused into the reparative process and immune status, to establish the possibility of developing a pathological way of life and the minds of the patriotic patient.

Conduct a first round and an interpretative view of the bleeding (the nature of the tissue, the size of the wound, the number of ears, the localization, the manifestation of firing changes, the development of bleeding is not safe)

Assess the patient's home country, the steps of intoxication to the body, clarify the nature and health of the patient (the depth of the wound, placed in the wound canal until it is empty, the appearance of the shortages and the inner parts of the body)

Take away the material from the wound for microbiological preliminaries or interpret the results (the microbial landscape of the wound, the steps of microbial observance, the sensitivity of the microorganism to antibiotics).

Perevazuvati sick, if necessary, carry out necrectomy, wound care, drainage, physiotherapeutic treatment.

When re-perev'yaztsi assess the dynamism to interrupt the early process.

Consider antibacterial, immunocorrecting, disintoxicating treatment, physiotherapeutic methods of treatment.

VIII.Situations

1. Ailment 46 years old, having cut off an impenetrable knife, wounding breasts from undesirable ones. At the early term, turning for medical aid, Viconana was first of all surgical treatment of the wound, for the additional drainage and seam overlays, the prophylaxis was carried out with the help of antitoxic anti-toxic and pravtsev toxoid. When looking through
5 db with respect to hyperemia of small curvatures, tissue build-up, mousse temperature increase, painful infiltration in the area of ​​injury. For drainage є vidіlennya abominable character.

Introduce the early phase to the process, and start the tactics.

Etalon of opinion: In the classic butt, the phase of the burn is described in the sutured and drained wound during the surgical treatment of the non-penetrating knife wound of the breasts. Slіd znyati shvi, hold revіzіyu Rani obstezhiti її on gnіynі numb, vіdіbrati sterile syringes of Golko abo cotton swab materіal of Rani on mіkrobіologіchne doslіdzhennya (Direct mіkroskopіyu native materіalu, bakposev i viznachennya chutlivostі mіkroflori to antibіotikіv) vikonati sanatsіyu 3% rozchinom peroxide aqueous , install drainage and put on an antiseptic dressing with antibacterial ointment vodorozchinn_y (for example: s ointment "Levosin" or "Levomekol"). Meaning through the doba I will re-dressing.

2. The sickness of the 33rd rocky threw away the wounds of a torn-clogged Vipadka with a torn-clogged wound of a child from the ears of the shkiri, the pediatric fat cells and the mucus. At the surgical examination, the primary surgical treatment of the wound was carried out, with the overlays of the small seams; In addition to the development of the gn_y zapalennya at the stages of conquest of the wound shvi bully znat_. At the time of looking at the wound, the defect may be incorrectly sized, show up as granulations, in the region of the wound edges, it is susceptible to tissue necrosis.

Introduce the type of wound healing, the stage of the wound process, the provision of additional assistance for bandaging and the methodology of carrying out.

Etalon of opinion: The wound will start with a second interference, the stage of exudation (in the development of necrotic tissues) is completed, є signs of the stage of reparation (confirmation of granulation tissue). It is necessary to sanitize the wound with antiseptics, necrectomy, apply a bandage, which is antimicrobial, antibiotic, osmotic, antibiotic, wound-zagging, necrolytic (for example, ointment: hydrophilic antimicrobial wounds) Sterile minds have a bandage; cleanse the wound in a straight line in the middle, having stuck one of the antiseptic solutions; Necrosis to see a scalpel, press the wound from the syringe with a light grip of the piston, put on and fix the bandage.

3. For the appendicitis of the drive of a gangrenous apendicitis of ailments, becoming a presentation of scarg for a fire in the early. When you look around, you can see the bends of the tissue near the wound, on the skin - the middle of the crimson-cyanotic filling, which expands from the wound in the growing straights, more - to the lower abdominal wall, and also around the hemorrhages, reminiscent When palpation of tissue near the wound, crepitus begins. Ailment is kilka eiforic, it means febrile temperature, tachycardia.

What's your diagnosis? What rank can you clarify the diagnosis? Who can play the first ones

Etalon of vidpovidi: period of operation accelerated by the development of anaerobic infection in the operation early after the appendix. Diagnosis was established for the characteristic clinical signs, perhaps for refinements with a microscopic smear of a native smear, framed for Gram, term biopsy of tissues, gas chromatography and mass spectrometry. Slid znyati shvi; spread the edge of the wound; to secure wide access by way of additional space and general visualization of dead tissue; to carry out additional "stripe" growth in the zones of pathological changes of the crank stem behind the wound boundaries; when hanging necrosis is clearly prevented from wounds by oxidative breakdowns (water peroxide, calcium permanganate breakdown, ozonated breakdown, sodium hypochlorite); do not sew up and do not tamponuti; to prevent aeration of wounds. It is generally guilty of buty coriguvati antibacterial and disintoxication therapy, if possible, hyperbaric oxygenation is indicated.

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Gostry pancreatitis is a state of affliction of the flesh zone, which is based on degenerative-ignition processes, viclican by autolysis of tissues with iron-own enzymes. The term "pancreatitis" is clearer, collectible understanding. The firing changes in the hall are not decisive, but, as a rule, are secondary. It smells like some destructive changes occur, if there are more frequent destructive changes in the room, so that it can develop under the influence of the digestion of some of the active protein and polytetic enzymes. In the gallantry structures, the state of health of the organs of the black empties, it is 7-12% and the loan for the third month of the period of hospitable appendicitis and acute cholecystitis. .Distinguish: 1) gostry nabryak pidshlunkovoy zalozi, 2) hemorrhagic necrosis of the pancreatic zlozi, 3) ginny pancreatitis. We will explain such a subtlety in the known degree. In case of morphological prescription in one and the same patient, it is rarely possible to have more pathological forms It is more common to develop pancreatic pancreatic disease in practice (in 77-78% of patients). zustrіchayutsya vtorinnі FORMS etogozabolevanіya, SSMSC vinikayut on tlі zahvoryuvan іnshih organіv, of kotorimіpodzheludochnaya zalіza Got tіsnі funktsіonalnі that anatomіchnі svyazі.Vtorіchny pancreatitis nerіdko rozvivaєtsya at zagalnih іnfektsіyah i vospalіtelnihzabolevanіyah susіdnіh organіv Mozhna govorito about pankreatitі at cherevnomu i sipnomtіfe, іnfektsіynomu parotitі, gepatitі, divertikulі dvanadtsyatipaloї intestines, different forms of ejunita, ileitis, colitis. Penetration of infection into the pancreas is potentially hematogenous, lymphogenous, perishable "ductogenic" path and the result is a middleless spread. Syudazhe Mauger Buti vіdneseno viniknennya zahvoryuvannya vsledsgvіe retrogradnoypankreatoho-langіografіі at yakіy contrasting rechovina in protokіpodzheludochnoy zalozi insertion pid davlenіem.K rozvitku zahvoryuvannya privertayut: 1) vіdtoku sekretapodzheludochnoy zalozi torn down, yak Mauger Buti obumovleno stenosing papіllіtom, іdіopatichnoyu gіpertrofієyu m'yazіv sfіnktera great duodenal papilla , neurogenic or medi-stone-bearing papilomas (parasympatomy-METIC, morphine), injected into the duodenal papilla of ascarid. peripheral species the duct can be found as a result of chipping. The appearance of pancreatic juices collapses with stones, ducts, the formation of a viscous secret great together bіlka. Tsey poslednіypatogenetіcheskіy mehanіzm graє role in hronіchnomu alkogolіzmі, gіperkaltsієmії (hyperparathyroidism, peredozuvannya vіtamіnu D), distrofії at rezultatі goloduvannya, hronіchnoї nirkovoї nedostatnostі, rezektsії shlunka іgastrektomіі 2) metabolіchnі torn down: rozlad bloodstream prіsosudіstih zahvoryuvannyah, autoіmunnі Process, alergії, gormonalnі narushenіyavo hour vagіtnostі , Cushing's ailment, trivial steroid therapy, diuretic therapy for abdominal thiazide, hyperoproteinemia, and other factors leading to the development of hospitable pancreatitis є non -rogenic antihumoral stimulation of the secretion Approximately 2/3 of the ailments with pancreatitis are ill with cholelithiasis. However, the pathogenetic mechanism is not clear. You can play the role of communication between lymphatic collectors of the ruminant and the glandular gland. In the norm of activating enzymes in front of the proteases of the glandular gland, it proceeds, as a rule, in the enlightenment of the gut. When ostromautodіgestіvnom pankreatitі aktivatsіya Tsikh fermentіv yde Vzhe in samіy zheleze.Odnako not exactly vstanovleno, SSMSC enzyme zalozi at GOSTR pankreatіteneobhodіmi for samoperevarіvanіya її tkanі.Trіpsіn Je activator bіlshoї proenzіmov Chastain, hіmotripsinu, elastazi, collagenase i fosfolіpazi A. Stopping zvіlnyaє of fosfolіpіdіv i kletochnihmembran lysolecithin and lysokephalin, which are very strong cytotoxic action, active proteases are seen from the kininogen of tissue and blood polypeptides and kinase. Aktivnі lіpazi, rozscheplyuyuchi klіtinnі Giry naglіtserіn i zhirnі acid prizvodyat to rozvitku vazhkih distrofіchnih іzmenenіyv tkaninah, spriyayut utvorennyu dіlyanok Body nekrozіv (steatonekrozi) bezposeredno in samіy tkaninі zalozi in scho otochuє zalozu klіtkovinі, vbrizheykah tonkoї i tovstoї intestine, have great i small glands i in drugіhorganah.Vazhnuyu role in patogenezі zahvoryuvannya vіdіgraє kalіkreїn- kіnіnova system scho zabezpechuє vіdpovіdny reologіchnih krovі pitched tone sosudov.Trіpsіn i aktivnі kіnіni viklikayut rіzke pіdvischennya proniknostі kapіlyarіv, stasis, "mіkrotsirkulyatorny unit" s Povny pripinennyam perfuzії on kapіlyarah, іshemіyu, gіpoksіyu , acidosis, impaired hemocoagulation (trypsin activates Hageman factor - factor XII of blood larynx) with intravascular desemination and secondary coagulopathy of survival. Pathological anatomy: the gostry nabryak of the pidshlunkovaya zalozi is called catarrhal pancreatitis. Macroscopic zloza when there is a large increase in the community, swelling. The abscess can spread to the retroperitoneal cell and the brisket of the transverse colon. Serous-hemorrhagic vipit is often found in the black empty and in the omentum. With a histological examination, a swelling of the intermediate tissue, zones of small hemorrhages and moderately severe degenerative changes in the mucous tissue are found. In some cases, the whole hair appears to be embroiled with blood. In the midst of fatty necroses, in the middle of it, є in the great and small omentum and in the mouth, to revenge fatty tissue. Acute pancreatitis develops when bacterial flora is present. When microscopic research is carried out, it appears to be inflamed, which has the character of phlegmonous inflammation, or even without the size of abscesses. In the abdominal cavity, hemorrhagic and serous exudate. More rapt. However, they are provincials in the feeling of gravity in epigastric illness, mild dyspepsia. For its nature, the pain is even more intense, dull, persistent, and later cramping. The intensity of the pain is very high (seemingly "hammered in cola"), but the patient is sometimes uncomfortable. Localization of pain is a good idea to develop the disease in the pathological process of this part of the disease. Pain can be localized in the right and left under ribs, in the left rib-club cuff, it is not easy to have an operative character і Irradiate in the back, overplus, chest, but there may be a simulatory character of infarction. The blues are often repeated, uncorked, but do not bring ailments relief. It is not easy for a person to be in a semi-bent state. The temperature is normal, subnormal. Visoka temperature was feverish typical for the country, where ignition complications develop. It is not uncommon to be spared to rescue and damage, to increase the damage caused by damage or important toxic lesions. In destructive forms of pancreatitis, fermentation of the enzyme and the components of the kininovy ​​system come into the uterine cell and beyond the skin, to produce it until the development of hemorrhagic imbibition of the cell and even to the ecchymosis. With a localization of the destructive process, in the main, in the tail of the dehydration, there are similar changes in the localization of the lateral abdominal wall (Gray-Turner symptom), with localization in the head area in the navel (Cullen's symptom). Due to the large amount of adequate enzymes in the shelter, analogous worms can be localized near the distant dilenks of the tila, on the face. Lives when looking at blows. In the first year of the disease, there is an asymmetry of the abdomen for the swelling of only the epigastric and paraumbilical areas (cob paresis of the slunk and transverse colic). With the development of dynamic intestinal failure, the swelling grows and grows old. On the cob of palpation, there is a myaky, which causes pancreatitis from a large state of the abdominal cavity. At the same time, in some people with ailments, palpation may indicate a slight tension of the muscles in the epigastric region and pain along the pancreas (Kerte's symptom). Characteristic is the є symptom of pulsation of the abdominal aorta in the epigastric region (symptom of Voskresenskiy) and soreness in the rib-spinal cut (Mayo-Robson symptom). Symptoms of irritation of the abdomen become positive in destructive forms in connection with the development of anemic. Intestinal peristalsis is weakened in the early years of illness. In severe forms of peristaltic noises can be known at all. On the cob, you can get bradycardia, which is quickly replaced by tachycardia. For important forms of congestion, the characteristic parts of the thread-like pulse. forms pankreatіta.V parenhіmatoznih bodies rozvivayutsya distrofіchnі zmіni, porushuєtsya іhfunktsіonalnoe mill. In osnovі Tsikh Change log lie gіperenzіmemіya, mіkrotsirkulyatornі іntoksikatsіya torn down i. Especially rіzko porushuєtsya funktsіyapochek (y 10-- 20% Khvorov) znizhuєtsya dіurez right up anurії i rozvitku ostroypochechnoy nedostatnostі. at laboratory tests pathognomonic for gastrointestinal pancreatitis are the values ​​of an increase in the amount of enzymes in the pancreatic cavity in the blood and in the blood, glucosuria. The worm in the blood of trypsin and his ingibitor is observed early. The increase in the concentration of lipase in the blood is infused in the later term (on the 3-4th day, from the ear of the disease). Diagnostic value of ma pіdvischennya diastasis sechіvische 512 odinits according to Volgemut. The increased content of dastasis in the blood and in the presence of severe pancreatitis is not expected. In general, there is a lack of dystasis in the blood and it is quite unimportant, but it diminishes. Pathogenic and monic for destructive forms of acute pancreatitis of hypocalcemia. You will be able to get sick between the 4th and 10th days of illness, that is, during the period of the most advanced development of fatty necrosis. Snіzhenіekaltsіya krovі nizhche 4 mmol / l - trash predictive prіznak.Prі vazhkih destructive forms of pancreatitis scho protіkayut of yavlenіyamіvirazhennogo dinamіchnogo іleusu, yak usually sposterіgayut hypovolemia, zmenshennya ob'єmu tsirkulyuyuchoї krovі, plasma gіpokalієmіyu i-іzmenenіyakіslotno Luzhnogo will in bіk yak alkalosis , as well as acidosis. Redblood to cry out, but not to change. However, with a trivial transfer of severe forms of illness, anemia develops in conjunction with hemorrhages and toxic conditions of the functional brain. On the side of white blood, as a rule, there is a viral leukocytosis from the blood formula to the left. In important cases of development of toxic-infectious disease, it can lead to a state of disability, manifested by oliguria and anxiety, accumulated nitrogenous toxins in the blood. more late - abscesses of peritoneal clotting, phlegmon of peri-urethral cells, subphrenic, intercranial, oily tissue, Arro-Zone of bleeding in case of adrenal necrotic tissue deficiency, acute lesions. Zgoda mozhlive utvorennya pomilkovih kіst іsvіschey pіdshlunkovoї zalozi, kishkovih svischіv, rozvitok tsukrovogo dіabeta.Dіagnostіka: for setting dіagnozu GOSTR pancreatitis pіdstavoyu sluzhatdannie history (Priya velikoї kіlkostі їzhі that alcohol injury that іn.) Harakternі іntensіvnie.bolі in the upper abdomen vіddіlі, nerіdko attracting a girdling character, which is supervised by tachycardia and reduced arterial pressure. Characteristically, he lives up to the development of peritonitis to become myakim, however, he is swollen, during the day of peristalsis. Inodi є positive symptom of Mayo - Robson. Indirect signs of acute pancreatitis appear in case of radiological predictions. An enlarged roentgenogram shows the expansion of the slunk, the appearance in the germ. The loop ("pidkova") of the twelve-fingered intestine is expanded, in a state of paresis. Paretic also cob loop small intestine(Symptom "watchdog loop"), transverse rim gut ... In the case of pleural emptying, it is not uncommon to determine the type. In case of computed tomography and ultrasound scan, there is an increase in the size of the lump, the heterogeneity of the structure. Laparoscopic surgery daetvozmozhnost pobachiti in cherevnіy porozhninі characteristic gemoragіchny vipіt, pridoslіdzhennі yakogo znahodyat Visokiy vmіst fermentіv podzheludochnoyzhelezi, nayavnіst "stearic" plyam fatty necro-of іnodі uvelіchenniyrastyanuty zhovchny puzir.Ostry pancreatitis neobhіdno diferentsіyuvati in Perche Cherga of prorivnoї yazvoyzheludka i dvanadtsyatipaloї intestine. For a vigorous change, the characteristic young age of a sick person, an uncomfortably vague anamnesis, a rapid onset of pain, the appearance of blues, a "board-like" Hostry pakreatitis occurs predominantly in more recent years in people who suffer from cholelithiasis and impaired fat metabolism. Operіzuyuchy character bolіv, іhіrradіatsіya, re blyuvota, vіdsutnіst symptom "m'yazovoї Zahist" vzdutіezhіvota, leukocytosis, gіperenzіmemіya i dіastazurіya harakternі for ostrogopankreatіta.Dіfferentsіalny dіagnoz mіzh GOSTR pancreatitis i gostroї mehanіcheskoykіshechnoy neprohіdnіstyu conductive to pіdstavі otlіchіtelnihprіznakov the following: bolі at GOSTR pankreatitі wearing postіyny the nature and the weakening of the peristalsis, or more often in the daytime, is localized in the upper and middle parts of the abdomen. Navpaki, in case of gastrointestinal imperfections, pain is frequent in the whole abdomen; peristalsis of burhliv in cob period disease. A high amount of enzymes in the lactic acidosis in the blood and urine confirm the diagnosis of gastric pancreatitis. On the very ear, the disease is characterized by an important camp of ailments; in the anamnesis of transfers of rheumatic heart disease, myocardial infarction. More not typical. Even more quickly, due to intestinal gangrene, there are symptoms of peritonitis and growths of sycation. In any case, it is necessary to go into extra laparoscopy and urgent angiographic information (mesentericography). However, the localization of pain in the epigastric region, during the appendicitis, is short-lived, after 2-4 hours it will move to the right ileal region, joining the other abdominal symptoms and other symptoms of the onset of mild development. Pre-treatment of blood dysplasia and urgency allows for a residual differential diagnosis of two diseases. When the diagnosis is complete, laparoscopy is indicated. Acute cholecystitis and an attack of the female ring may cause a number of symptoms with acute pancreatitis (raptus ear, hospitable pain, irradiation pain, weakening of peristalsis, etc.) However, for the hospitable cholecystitis, localization of pain in the right papilla is more characteristic, a symptom of a malignant disease, a symptom of a malignant disease, a symptom of a malignant and ailing malignant fever in the right pancreatic disease. ailments (cholecystopancreatitis) .Treatment: complex therapy of gastrointestinal pancreatitis is guilty of including: the fight against more, enzymatic toxemia, adequate to the correction of hygroscopic problems in the acid-luzhny stan. For nobility or pain relief, it is necessary to use analgesics and antispasmodics (no-shpa, platifilin, papaverine). Horoshіyeffekt daє epidural block (kateterizatsіya epidural administration of prostranstvaspіnnogo mozk anestetikіv) .For Borotba of fermentnoї toksemієyu vikoristovuyut: 1) prignіchennya vneshnesekretornoyfunktsіі zalozi Shlyakhov aspіratsії shlunkovogo vmіstu i promivannya zheludkaholodnim soda rozchinom (hydrochloric acid shlunkovogo vmіstu yavlyaetsyastіmulyatorom pankreatichnoї sekretsії) administering atropіnu (y oberezhno patients with chronic alcoholism - a possible development of psychosis), hypothermia of the pancreas, the introduction of cytostatics for 4-5 days (5-fluorouracil, ftorafur and іn. 2) maintenance of normal evacuation of viral enzymes by the introduction of spasmolytic ticks; 3) eliminuvannya consumed in the bloodstream or the abdominal cavity of enzymes; drainage of the thoracic lymph duct with lymph absorption, stimulation of dyuresis; draining of black waste; 4) inactivating enzymes with ingibitors of proteases (counterkal, tsalol and in.). However, іngіbіtorіok show a positive action only in the first year of illness with the introduction of large (1-1.5 million OD) doses. In the phase of fatty necrosis, ingestion loses its message. For sv_dchennyi prescribe drugs kalii, sertsev_ glucoside. The number of introduced solutions is necessary for the renewal of the normal lining of the inner-vascular extracellular sector, which can be achieved as great (from 3 to 5 l / dobu). For polіpshennya reologіchnih vlastivostey krovі i profіlaktiki dіssemіnіrovannogovnutrіsosudіstogo zgortannya zastosovuєtsya reopolіlyukіn i heparin (ML 5000) kozhnі 4ch.S metoyu profіlaktiki i lіkuvannya mozhlivih vtorinnih glow іzmenenіynaznachayut antibіotiki broad spectrum deystvіya.Hіrurgіcheskoe lіkuvannya at GOSTR pankreatitі shown: 1) poєdnannі GOSTR destructive forms of pancreatitis acute cholecystitis; 2) with a short conservative treatment for 36-48 hours; 3) in case of pancreatogenic peritonitis in case of ill-feeling, laparoscopic renalization of the empty space; 4) with accelerated gastrointestinal pancreatitis: abscess bursa, phlegmon of urea cellulitis. In dіagnostitsі that lechenііdestruktіvnih forms GOSTR pancreatitis great significance of Got laparoscopic surgery at yakih mozhna utochniti dіagnoz, viyaviti gіpertenzіyu zhovchovivіdnih shlyahіv (napruzheny zhovchny mіhur) i zrobiti percutaneous holetsіschosto-Mia pіdkontrolem laparoscope Ale Basic - drenuvati cherevnu porozhninu for aspіratsііsoderzhіmogo (zmenshennya fermentnoї toksemії) the promotion of intracavity solutions of antibiotics and ingibitoriv proteases. In case of surgical treatment of acute pancreatitis, the following types of operations can be performed: 1) drainage of the bursal sac, 2) resection of the tail and the length of the bursa, 3) pancreatectomy. It is used in destructive forms of gastrointestinal pancreatitis, accelerated by peritonitis. The main method of operation is to stimulate the body from toxic words of active elements, which are found in peritoneal exudation; provision of conditions for adequate output of active pancreatic juice, exudate, and treatment of necrotic masses. When the glands are exposed, the glands infiltrate into the colorectal cells with a range of antibiotics from the antibiotic spectrum of the antibiotics and protease inhibitors. Sequestration and obviously non-negligible dilenks from the bottom hole is required to be seen. Leave it with a year until arrosive bleeding. When removing tissue from tissue, washing out of black empty tissue with antiseptics, performing a biological tamponade of an electronic bag with a large size. The most effective drainage of the omentum bag by way of carrying out the drainage through counterperture in the left transverse area. Two-lumen drainage tubes are used to allow the empty space to become empty afterwards. When there is evidence of suppression of gallbladder (stones, burning) and changes in other galls (choledocholithiasis, cholangitis, strictures), promptly, the patient is supplemented with cholecystostomy of abnormal cholecystinectomy. Power about dotsіlnіst operatsії nazhelchnom mіhurі i ducts not tіlki in razі virazhenih patologіcheskіhіzmenenіy (cholecystitis, holangіt, kamenі in ducts, strictures) ale i prіgіpertenzіі in zhovchovivіdnih Shlyakhov vnaslіdok їh stiskannya nabryakloyu golovkoypodzheludochnoy zalozi abo zbіlshenimi lіmfatichnimi vuzlami zalishaєtsya spornim.Rezektsіya distal pidshlunkovoy zolozi є more radialoperation. However, in case of important destructive forms of hostile punk therapy, it is technically foldable and disgusting to be tolerated by ailments, so it should be shown to it even more carefully. What is more important is the destruction of the fabric, the forecast is more important. To predict the outbreaks of the disease in the last years of the disease, the prognostic signs, disintegration during the retrospective analysis of the clinical breakdown of acute pancreatitis in a large group of ailments, were projected. They are known to include: sick people older than 55 years, leukocytosis (the number of leukocytes is more than 16 * 109 / l), hyperglycemia (the content of glucose is more than 2 g / l), the decrease in hematocrit is more lower than the decrease by 10%, l, the deficit is based on more than 4 meq / l, a decrease in the arterial vise below 60 mm Hg. Art. Mortality in a group of ailments, which may be less than three named signs, becomes 1%, with 3 or more signs 33%, with 7 or more signs 100%.