Complications: * empyema of cyst; * ‘bleeding into the cavity of cyst; = cyst rupture 12 Examples of setting a clinical diagnosis: A) Postnecrotic cyst of the body of pancreas. 8) Postnecrotic cyst ofthe body of pancreas, complicated by bleedingiinto the cavity of cyst. ) Posttraumatic cyst of the body of pancreas. ‘5 Treatment of pancreatic cyst: A) Surgery is performed in 5-6 months after cyst emergence. 8) While choosing the method and extent of surgery one should take into account localiza- tion, size and contents of cys: 4) operation of choice internal drainage of the cyst into the cavity of the loop of jeju- ‘num excluded from digestion; b) external drainage of cyst: » Inthe presence of infected content in cyst; » in case of immature and thin-walled cyst. % Disability examination and rehabilitation of operated patients: A) Temporary disability after the surgery lasts 2.5-3 months, 8) Patients who underwent direct surgery of pancreas require rehabilitation treatment with pancreatic enzymes for digestive function correction ) Permanent disability is probable. § 4.4. CHRONIC OBSTRUCTION OF GASTROINTESTINAL TRACT (SYNDROME OF CHRONIC OBSTRUCTION OF GASTROINTESTINAL TRACT) ‘Syndrome of chronic obstruction of gastrointestinal tract is conditioned by clinical manifes ‘ations of partial disorder of movement of food masses and secretions through gastrointestinal tact Clinical manifestations of chronic obstruction of gastrointestinal tract require thor- ‘sugh analysis of all symptoms of the disease, course of the disease and evaluation of ‘bjective signs. it provides an opportunity to plan and carry out purposeful, first ofall sventgenological, examination for setting clinical diagnosis and treatment approach de- ‘ermination ‘The most common causes of chronic intestinal obstruction are peptic ulcer complicated by stenosis; chronic arterio-mesenteric duodenal compression syndrome; adhesive disease ‘of abdominal cavity organs with partial intestinal obstruction. £4 Chronicobstructionofgastrointestinaltract(syndomeofchronicobstructionafgastrointestinaltract) 219GENERAL ISSUES OF DEVELOPMENT, DIAGNOSTICS AND TREATMENT OF CHRONIC OBSTRUCTION OF GASTROINTESTINAL TRACT 1. Definition, Partial obstruction of gastrointestinal tract with chronic course. 2. Essentials of the problem: ‘A) May occur in different diseases and at different levels of gastrointestinal tract. 8) Slow development of the disease leads to evident metabolic disorders due to malnutri- tion, 53. Causes of development of chronic obstruction of gastrointestinal tract: |A) Formation of stenosis in the pyloric part of stomach or in duodenal cap caused by ulce- rou process or tumor. 8) Compression of duodenum between aorta and vessels of mesenterium. C) Adhesive processes and strictures in small and large intestines due to past surgeries and inflammatory processes. 4, Clinical signs of chronic obstruction of gastrointestinal tract (depend on the level of obstruction and degree of narrowing of the lumen of digestive tube): A) Complaints + in obstruction atthe level of pyloric part of stomach: » feeling of heaviness after eating; » heartburn; » probably vomiting with consumed food. + in obstruction atthe level of distal part of duodenum: » feeling of heaviness after eating, » bitter taste in the mouth; » bile vomiting. + in obstruction atthe level of different parts of small and large intestines: nausea and probable vomiting with intestinal contents. 8) Medical history: + evaluation of recent diseases and their courses. ©) Objective signs of disease: a) physical examination: > expanded abdomen; » possible asymmetry of abdomen due to expanded stomach and overfull loops of small and large intestines ) palpation: + abdomen is soft; moderately painful in some regions; » possible palpation of tumor lke mass in ballottement of abdominal wall: + splashing sound in the stomach and small or large intestine. 4) percussion: possible high-pitched tympanic sounds above the areas of abdominal asymmetry; ) auscultation + without specific changes, 220 Chapter 4, Chronic surgical diseases of gastrointestinal tract organs5 Diagnostics of chronic obstruction of gastrointestinal tract: A) Clinical signs a) complaints; b) medical history, ) objective signs of disease. 8) Instrumental diagnostic methods: a) hourly roentgen examination of barium passage through gastrointestinal tract (exam- ination is being performed during 6-24 hours after swallowing of barium); ) gastroscopy, in disorder of gastric emptying 6 Treatment of chronic obstruction of gastrointestinal tract: 4) In case of organic cause ofthe passage disorder, surgical operation is indicated. 8) Extent of operation depends on the nature of pathological process leading to passage disorder through gastrointestinal tract. Peptic ulcer complicated by stenosis 1 Definition. Cicatrical or periulcerous inflammatory deformation of the pyloric part of stom- -2ch or of the initial part of duodenum (duodenal cap) due to recurrent course of peptic ulcer ‘mith impairment of motor-evacuatory function of stomach 2 Essentials of the problem: A) Stenosis develops in 5-10 % of patients with peptic ulcer. 8) More common in protracted course of peptic ulcer. C) More common in men, 5 Causes of development of pyloraduodenal stenosis: AA) Organic narrowing of the pylorus or inital part of duodenum due to cicatricial defor- ity. 8) Functional formation of stenosis in the pylorus or intial part of duodenum due to periut- ‘cerous inflammatory infiltration in active ulcer, effective pharmacotherapy of which leads to restoration of patency. 4 Classification of pyloroduodenal stenosis (according to roentgenologic findings): = compensated stenosis; = subcompensated stenosis; = decompensated stenosis. 5 Clinical signs of pyloroduodenal stenosis (depend on the level of compensation of mo- tor-evacuatory function of stomach): A) Complaints: a) compensated stenosis: » nausea: + feeling of heaviness inthe epigastrium: > enuctation; > heartburn, b) subcompensated stenosis: » hiccup, nausea, eructation with acid gastric contents; > vomiting with stagnant gastric contents, predominantly in the evening; ‘£4 Chronicobstructionofgastrointestinaltract(syndromeofchronicobstructionafgastrointestinaltrat) 221» general weakness; thirst. ©) decompensated stenosis: + eructation with rotten gastric contents; » vomiting with stagnant gastric material, food consumed the day before; permanent thirst; » increasing weakness; + inneglected cases ~ spasms. 8) Medical history |cerative anamnesis’ for many years * possible presence of ulcer perforation in case history. ©) Objective signs of disease: a) compensated stenosis: + general condition without changes. b) subcompensated and decompensated stenosis: » during physical examination: * poor skin turgor; + pallor of the skin; + weightloss. + inballottement ofthe abdominal wall + splashing sound in stomach 6. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis is based on patient's complaints, medical history and objective signs confirmed by physical examination methods. To confirm or specify the diagnosis, roentgenologic examination of barium passage through gastrointestinal tract is performed 7. Diagnostics of stenosis — hourly roentgen examination of barium passage from the stomach: a) compensated stenosis ~ increased tone and peristalsis of abdominal wall; barium passes into the duodenum by portions; gastric emptying delay ~ from 3 to 12 hours; alternatively, Up to 30% of barium remain in the stomach in 3 hours; b) subcompensated stenosis ~ delay in barium evacuation from the stomach into the du- ‘odenum - from 12 to 24 hours; alternatively, from 30 to 80% of barium remain in the stomach in 3 hours; ©) decompensated stenosis ~ delay in barium evacuation from the stomach into the du- odenum exceeds 24 hours; the stomach is expanded, the wall of stomach is atonic, its peristalsis is reduced or absent; alternatively, over 80.% of barium remain in the stomach in3 hours (Fig. 44.1), 8. Clinical and statistical classification of duodenal ulcer complicated by steno: K26 Duodenal ulcer Clinical diagnosis model: (I,} ulcer of {L,) {K,} complicated by (0,) Endoscopic manifestations: Active ~ Cicatrizing = Gieatrized 222. chapter. Chronic surgical diseases of gastrointestinal tract organs_ a & Fig. 4.4.1. Roentaenogremm (A) and schematic representation (8) of stomach in decompensated stenosis (the stomach is big, greater curvature is located under the lac bone ridge) ‘Localization: 1, - duodenal cap 1, ~ etrobulbar duodenum Helicobacter pylori invasion: K, ~ associated with Hp , = not associated with Hip Complications: ©, ~ acute bleeding {,) ©, ~{T, degree} hemorrhage ©, - perforation (F, stage ©, - perforation and bleeding ©, - penetration {into L,} (L) ~ pancreas (C) = hepatoduodenal ligament (C) gallbladder (A) = Iver (C) = large intestine 0, {1 stenosis Clinical roentgenologic signs of stenosis degree: |, ~ compensated stenosis (satisfactory condition, rare vomiting, normal body weight if roent- genologicexamination barium passesinto the duodenum by portions gastric emptying delay ~ from 3 to 12 hours; alternatively, up to 30% of barium remain in the stomach in’ hours) |, = subcompensated stenosis (feeling of heaviness in the epigastrium, vomiting in 1-2 hours after eating, weight loss; roentgenologic examination — delay in barium evacua- 4.4 Chronicobstructionofgastrointstinaltract(syndromeofchronicobstructionofgastrointestinaltract) 223tion rom the stomach into the duodenum — from 12 to 24 hours; alternatively, from 30% {80% of barium remain inthe stomach in 3 hours). 1, ~ decompensated stenosis (drastic dehydration, vomiting with stagnant gastric com tents, exhaustion; roentgenologic examination - delay in barium evacuation from the stomach into the duodenum exceeds 24 hours; in 3 hours over 80 % of barium remaim in the stomach, which is expanded, its wal is atoni, peristalsis of the wall is reduced or absent) 9. Treatment of pyloroduodenal stenosis: A) Stage of compensated stenosis - relative indications for surgery. 8) Stage of sub- and decompensated stenosis ~ absolute indications for surgical treatment. C) Operation is aimed at restoration of passage from the stomach into the bowel and stable suppression of aggressive peptic factors in the stomach. 1) Surgery of choice - conservative operations with the use of vagotomy and surgery with drainage of stomach or duodenoplasty.. Arteriomesenteric compression of duodenum (chronic duodenal arteriomesenteric obstruction) 1. Definition, Obstruction of the duodenum due to compression between the aorta and sup= rior mesenteric artery at the level of distal part ofits inferior-horizontal part. 2, Essentials of the problem: more common in young women or girls with lowered body weight. 3. Causes of chronic duodenal arteriomesenteric obstruction: A) Descent of the abdominal viscera (visceroptosis) 8) insufficiently developed retroperitoneal fat 14, Prothogenesis of chronic duodenal arteriomesenteric obstruction ~ compression of inf= rior-horizontal part of duodenum between the aorta and superior mesenteric artery (Fig. 4.4.2). 5, Clinical signs of chronic duodenal arteriomesenteric obstruction (depend on the com- pensation of motor-evacuatory function of stomach and duodenum): A) Complaints: feeling of heaviness in the epigastrium after eating; nausea; eructation; heartburn; bile vomiting; significant reduction or absence of complaints in prone position of patients. 8) Medical history: + gradual development af the disease; + predominantly in teenage years ) Objective signs of disease: * during physical examination - weight loss; + during palpation - splashing sound in the stomach. 6, Forming a preliminary diagnosis based on clinical data 224 chapter 4. Chronic surgical diseases of gastrointestinal tract organsFig. 4.4.2. Areriomesenteric compression of duodenum: ‘A schematic representation of inferior horizontal branch of duodenum between the aorta and superior esenterc vessels: | ~ aorta; 2~ superior mesenieric artery and vein, 3 ~ inferiorsiorizontal branch of du 3B radiographic image of chronic duodenal arteriomesenteric obstruction: lation of duadenur up to Se place of obstruction (1) and absence of contrast agent in the distal part af bowel Preliminary diagnosis is formed on the basis of patient's complaints, medical history and its ‘ebjectve signs confirmed by physical methods of examination. Special roentgen examination is performed in order to confirm or clarify the diagnosis > Diagnostics of chronic duodenal arteriomesenteric obstruction: * roentgenologic monitoring of barium passage from the stomach and through the duo- inconstant sign retention of faeces and flatus: 226 Chapter 4. Chronic surgical diseases of gastrointestinal tract organs» frequent and important symptoms in partial obstruction of intestines; > passage of faeces and gases can be achieved in case of conservative measures per- formance. 8) Medical history: + development ofthe disease is clarified in the hourly aspect; * character of past operations and injuries; + character of changes in stool in recent months, ©) Objective signs a) physical examination. > signs of dehydration: dry tongue, decreased skin turgor; » asymmetrical and swollen abdomen (shape and asymmetry of the abdomen de- pends on severity of obstruction); » physical methods of examination » palpation of the anterior abdominal walt + assessment of character and localization of pain; + Sklyarovs sign ~ splashing sound in the small or latge intestine. » percussion of anterior abdominal wal! + tympanitis is over the whole abdominal wall » auscultation of abdomen + peristaltic sounds of high tone due to liquid and gas moving 5. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis is based on patient's complaints, medical history and objective signs confirmed by physical methods of examination. To confirm or clarify the diagnosis, the diagnostic program is formed that includes diag- ostic techniques which influence the diagnosis clarification. When choosing the technique ‘of examination, one should always start with less invasive procedures and progress to more invasive ones. & Diagnostics of adhesive disease with partial obstruction of intestines: A) Clinical signs: 4) patient's complaints; b) medical history; findings of physical examination of the patient. 8) Instrumental diagnostics: 4) plain abdominal radiography (to detect Kloibers cups); ) contrast exomination of small and large intestines: » roentgenologic passage through the small and large intestines (detection of cer- tain dilation of bowel loop above the area of obstruction and retention of contrast mass) + imrigoradiography for thorough intestine examination (allows to detect obstruction localization) urgent endoscopic examination of large intestine (colonoscopy, proctosigmoidosco: py). ©) Laboratory findings: 4) complete blood count (without characteristic changes); b) urinalysis (presence of protein, erythrocytes, casts); 44 Chronicobstructionofgastraintestinaltract(syndromeofchronicobstructionofgastrintestinatract) 227€ biochemical blood analysis (determination of albumen and electrolytes in blood se- rum) 1. Differential diagnosis of adhesive diseases with partial obstruct a) acute obturative and strangulated intestinal obstruction. b) acute pancreatitis. 8, Clinical and statistical classification of adhesive diseases of abdominal cavity organs: 66.0 Peritoneal adhesions Clinical diagnosis model: Adhesive disease of abdominal cavity organs {Q,} Clinical course: Q, - with partial obstruction of bowel Q,- painful form. 9, Treatment of adhesive partial obstruction of intestines: A Surgical treatment is performed only after roentgenological confirmation of passage ob struction through gastrointestinal tract; the extent of operation depends on spread of adhesive process; surgery of choice - visceroliss (dissection of adhesions), 8) Conservative treatment: spasmolytcs, dietary regimen, physiotherapy. 10. Disability examination and rehabilitation of operated patients: ‘) Adhesive disease of abdominal cavity organs with partial intestinal obstruction requires ‘observation in the period of pain syndrome occurrence. 8) Jobs not connected with physical exertion are recommended to patients with adhesive disease. C) Adhesive disease with partial intestinal obstruction is a contraindication for military ser vice and work connected with business trips. of intesti ™ 4.5. DISEASES OF HEPATOPANCREATOBILIARY ZONE COMPLICATED BY OBSTRUCTIVE JAUNDICE (SYNDROME OF OBSTRUCTIVE JAUNDICE) ‘syndrome of obstructive jaundice is a pathological state caused by violation of bile outfiow through biliary ducts due to complicated course ofa numberof diseases accompanied by ob- turation or compression of biliary ducts If there are clinical signs of obstructive jaundice, the patient is to be hospitalized for diag- nostic procedures specifying the cause of jaundice. Choledocholithiasis, tumors of major duodenal papilla, head of pancreas, extrahepatic biliary ducts and cholangitis are the most common causes of obstructive jaundice. GENERAL ISSUES OF JAUNDICE DIAGNOSING 1. Definition. Jaundice is a pathological process accompanied by icteric coloring of mucous membranes and skin due to inflow of products of bilirubin exchange and hepatic enzymes to vasculature. 2. Essentials of the problem: 228 Chapter 4. Chronic surgical diseases of gastrointestinal tract organs