Myocardial intestine. - Necrosis of the intestinal wall, associated with acute cessation of blood flow in the mesenteric vessels as a result of embolism or thrombosis. A characteristic feature of bowel infarction is intense abdominal pain in the absence of any objective data at the time of examination of the patient (mild stomach maloboleznenny). To clarify the diagnosis carried ultrasound and plain radiography SSB, duplex scanning and angiography of mesenteric vessels, laparoscopy. Conservative treatment neokklyuzionnyh forms of bowel infarction is only possible in the first hours of the disease, late stage and other forms require surgical treatment.
peritonitis. This pathology is one of the main problems of surgical gastroenterology in recent years. Most often, embolism, thrombosis, atherosclerosis and ischemic bowel neokklyuzionnaya vessels appear on a background of severe heart disease. In connection with the increase in the percentage of the elderly population and the rejuvenation of cardiovascular disease bowel infarction is becoming more common (063% compared to isolated cases at the end of the last century). The average age of patients with bowel infarction - 70 years, dominated by women (60%). Given the advanced age of patients, and a lot of background diseases, solve the problem of surgical treatment can be difficult.
Another problem is that the diagnosis of bowel infarction is difficult, and confirm it without angiography before surgery is almost impossible. Due to the erroneous diagnosis of prolonged preoperative preparation; During this time, irreversible changes in the bowel, leading to the death of the patient. The situation is compounded by the fact that the bowel infarction significantly rejuvenated in recent years (every tenth patient is younger than 30 years), and bowel resection in the late stages of the disease causes persistent disability. Despite the improvement of diagnostic and therapeutic measures in bowel infarction, mortality in various forms reaches 50-100%.
thrombosis of mesenteric arteries (less veins) in their proximal. Most often a blood clot localized in the mouth of the superior mesenteric artery. To thrombosis visceral branches of the aorta increased blood clotting can lead, polycythemia, heart failure, pancreatitis, trauma, tumors, hormonal contraceptives.
Embolic infarction option intestinal blockage develops in the mesenteric vascular embolism, migrated from proximal vascular bed. The reason for this is most often serve as atrial fibrillation, the formation of blood clots on the background of wall myocardial infarction, aortic aneurysm, expressed coagulation disorder. After obturation vessel embolus can be shifted in the distal vessel branches and causing intermittent migrating ischemia.
Neokklyuzionny kind of bowel infarction is not associated with occlusion of the visceral vessels, and with a decrease in blood flow through them. Due to limitations in visceral blood flow may be mesenteric thrombosis, decreased heart ejection fraction, expressed arrhythmia, spasm of the mesenteric vessels, hypovolemia in shock, sepsis, dehydration.
Factors of these three groups are often combined. The disease can occur with compensated and decompensated subcompensation blood flow. In addition, there are three successive stages intestinal infarction: ischemia, infarction and peritonitis. In the first stage of changes in the gut is still reversible, and the clinical manifestations are mainly associated with reflex reactions of the organism. The infarct stage, bowel necrosis, destructive changes continue even after restoration of blood flow. The protective properties of the intestinal wall is gradually weakened, the bacteria begin to penetrate through all its layers into the abdominal cavity. In peritonitis stage, the disintegration of the tissues of the intestinal wall, hemorrhagic propotevanie with the development of severe inflammation of the peritoneum.
diarrhea. Auscultation of the abdomen in the initial stage reveals increased peristalsis which fades within several hours.
The stages of a heart attack of peritonitis and the patient's condition progressively worsens. The skin is pale, dry. The pain gradually weakens, and in complete necrosis of the intestinal wall disappears completely, that is a poor prognostic sign. Tongue dry, with a touch. Bloating, but as is typical late appearance of symptoms of peritoneal irritation, stomach for a long time remains soft for bowel infarction. Pathognomonic symptom Kadyana-Mondor: palpation in the abdomen tightly-defined cylindrical flexible education malosmeschaemoe and painful - swollen portion of intestine and mesentery. Auscultation of abdominal areas bloat (voiced sound of pererazdutymi bowel loops) alternate with sections of the sound deadening (of necrotic hinges). Exudate in the abdominal cavity (ascites) may be formed after a few hours of onset.
If the disease progresses, symptoms of intoxication and dehydration increase, the patient becomes indifferent, apathetic. Even if you start assisting the patient at this stage, the condition can deteriorate progressively, coma, convulsions. At this stage of the disease mortality reaches almost 100%.
Ultrasonography of the abdomen when the disease is detected thickened bowel wall, the presence of free fluid in the abdominal cavity. Duplex color ultrasound scan is the only reliable method of ultrasound diagnosis of mesenteric vascular thrombosis.
Panoramic radiography of the abdominal organs informative in the later stages, when they become visible bowl Kloybera, intestinal arch. Conducting a contrast X-ray examination it is not recommended because it does not provide any of the data for statement of the diagnosis, but considerably delays the phase of diagnosis. Multisrezovaya spiral computed tomography of the abdominal cavity allows for a more precise study of the bowel loops (makes it possible to detect gas in the mesentery and intestinal wall), and magnetic resonance angiography of mesenteric vessels - to assess the condition of the vascular bed, to detect blood clots and emboli.
The most accurate method of research is angiography of mesenteric vessels. This study is preferably carried out in two projections - direct and lateral. This technique allows us to calculate the exact localization of the pathological process, identify the affected branches of visceral vessels, determine the tactics and volume of surgical intervention. It helps in diagnosing and determining treatment strategy and consulting physician-endoscopist. Diagnostic laparoscopy allows you to visually assess the condition of the intestinal loops, identify some pathognomonic for myocardial bowel symptoms. These include changes in the intestinal wall color, the absence of pulsations boundary vessels, changes in vascular pattern (instead of a longitudinal cross). The determination of the data allows you to set the indication for urgent surgery even if it is impossible angiography. Contraindications for laparoscopy are expressed flatulence, the presence of extensive laparotomy history, is extremely serious condition of the patient.
Specific laboratory signs of intestinal infarction, especially in the early stages of the disease does not exist. The general analysis of blood as the disease increases leukocytosis, left shift leykoformuly. Fecal occult blood also becomes positive for intestinal necrosis stage. Some authors point to the rise in blood lactate as a specific sign of bowel infarction.
infusion therapy. Infusion of crystalloid and colloid solutions designed to compensate for the missing blood volume, restore perfusion of the ischemic areas of the intestine. Since kardiotropnyh therapy should eliminate the use of vasopressors, since they cause a spasm of the mesenteric vessels and aggravate ischemia. When neokklyuzionnoy ischemia shows the introduction of antispasmodics to improve visceral blood flow.
Conservative therapy is justified only in the absence of the patient's symptoms of peritonitis. Maximum efficiency is achieved when treatment started in the first two to three hours from the onset of symptoms. The longer the last stage of medical treatment, the less chance of a favorable outcome, so the stage of non-surgical therapy should be as concise as possible. Urgent surgery is performed In the absence of a rapid effect. The same applies to the preoperative preparation - than it is shorter, the better the chances of recovery.
Myocardial bowel radical surgery is only considered in the bloodstream (when indicated - in conjunction with bowel resection). Isolated resection of necrotic intestinal loop without removing thrombus from a vessel does not eliminate the main pathogenetic mechanism of occurrence of bowel infarction, which means - does not improve the patient's condition. If the surgery is made in time for more than 24 hours from the onset of the disease, laparotomy in 95% of cases, merely states irreversible changes in most parts of the intestine. Radical resection of the affected colon in such a situation does not prevent the death of the patient.
If you had made extensive resection of the bowel, in the postoperative period, the patient may need consultation of the gastroenterologist to determine the tactics of enteral and parenteral nutrition. Sometimes these patients require lifelong partial or total parenteral nutrition with intravenous carbohydrates, protein and fat fractions.
Prediction and prevention of myocardialintestine.
The prognosis of adverse myocardial intestine, as this disease is rarely diagnosed in a timely manner, and in the later stages surgical treatment is often ineffective. Preventing bowel infarction is a timely treatment of diseases leading to it (aortic and mitral heart disease, arrhythmia, atherosclerosis, thrombophilia).