Surgery=Хірургія / Березницький Я.С. та ін.— 2-ге вид. by Nova Knyha

SURGERY Edited by

Bereznyts'kyy Ya. S. Zakharash M. P. Mishalov V. G.

2nd edition

Vinnytsia Nova Knyha 2018

УДК 617(075.8) Х50 Recommended by the Ministry of Health of Ukraine as a textbook for students of higher medical educational institutions of Ministry of Health of Ukraine (Report # 2 of 02.06.2016 of the Commission for preparing training and educational materials for persons who study in higher medical educational institutions and institutions of postgraduate education)

Authors: Kateryna M. Amosova, Yakov S. Bereznyts'kyy, Anatoliy O. Burka, Vadym G. Getman, Georgiy Y. Khapat’ko, Vasyl V. Khrapash, Olena M. Kligunenko, Volodymyr M. Klimenko, Igor V. Korpusyenko, Oleksandr B. Kutovyi, Anatoliy V. Makarov, Volodymyr G. Mishalov, Robert M. Molchanov, Oleksandr S. Nikonenko, Sergiy D. Shapoval, Viktor O. Shidlovskyy, Olena Y. Sorokina, Volodymyr P. Sulyma, Mykhailo P. Zakharash Reviewers: Petro D. Fomin – M.D., D.Med.Sc., Academician of the National Academy of Medical Sciences of Ukraine, Professor and Chairman of the Department of Surgery № 3 of Bogomolets National Medical University. Volodymyr V. Grubnik – M.D., D.Med.Sc., Professor and Chairman of the Department of Surgery № 1 of Odessa National Medical University Edited by Yakov S. Bereznyts'kyy, Mykhailo P. Zakharash, Volodymyr G. Mishalov

Х50

Хірургія = Surgery : textbook for students of higher medical educational institutions / K. M. Amosova, Y. S. Bereznyts'kyy, A. O. Burka [et al.] ; edited by: Bereznyts'kyy Ya. S., Zakharash M. P., Mishalov V. G. – 2nd ed. – Vinnytsia : Nova Knyha, 2018. – 712 р. : il ISBN 978-966-382-714-8 The textbook meets the program for preparing general practitioners in clinical surgery approved by the Ministry of Health of Ukraine. The material in the book is distributed depending on the nature of the disease and the priorities of medical care. Each theme is structured according to the principal clinical syndrome, with a precise division into chapters and due to professionally-oriented tasks of the approved branch standards. Each chapter is algorithmized that, in the judgement of the authors, should contribute to better assimilation of the material using the credit-module system. The textbook is intended for 4–6-year English-speaking students of higher medical educational institutions of III–IVth levels of accreditation, interns. УДК 617(075.8) ББК54.5я73

ISBN 978-966-382-714-8

Authors Kateryna M. Amosova, M.D., D.Med.Sc. Bogomolets National Medical University of Health Ministry of Ukraine Yakov S. Bereznyts'kyy, M.D., D.Med.Sc., Editor SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Anatoliy O. Burka, M.D., D.Med.Sc. Bogomolets National Medical University of Health Ministry of Ukraine Vadym G. Getman, M.D., D.Med.Sc. Shupyk National Medical Academy of Postgraduate Education Georgiy Y. Khapat’ko, M.D., Ph.D. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Vasyl V. Khrapash, M.D., D.Med.Sc. Bogomolets National Medical University of Health Ministry of Ukraine Olena M. Kligunenko, M.D., D.Med.Sc. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Volodymyr M. Klimenko, M.D., D.Med.Sc. Zaporozhye State Medical University Igor V. Korpusyenko, M.D., Ph.D. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Oleksandr B. Kutovyi, M.D., D.Med.Sc. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Anatoliy V. Makarov, M.D., D.Med.Sc. Shupyk National Medical Academy of Postgraduate Education Volodymyr G. Mishalov, M.D., D.Med.Sc., Editor Bogomolets National Medical University of Health Ministry of Ukraine Robert M. Molchanov, M.D., D.Med.Sc. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Oleksandr S. Nikonenko, M.D., D.Med.Sc. Zaporozhye State Medical University Sergiy D. Shapoval. M.D., D.Med.Sc. SI “Zaporizhia Medical Academy of Post-Graduate Education Ministry of Health of Ukraine” Viktor O. Shidlovskyy, M.D., D.Med.Sc. I. Horbachevsky Ternopil State Medical University Olena V. Sorokina, M.D., D.Med.Sc. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Volodymyr P. Sulyma, M.D., Ph.D. SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine” Mykhailo P. Zakharash, M.D., D.Med. Sc., Editor Bogomolets National Medical University of Health Ministry of Ukraine

DEDICATED

100

175

Anniversary of Bogomolets

Anniversary of Dnipropetrovsk State Medical Academy

Surgery. English edition

National Medical University

Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CHAPTER 1. General principles of recognition and formation of clinical diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Principles of diagnostic thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Nosological principle of diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Syndromic principle of diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Principles of preliminary diagnosis FORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Algorithm of preliminary diagnosis formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 SUBSTANTIATION OF DIAGNOSTIC PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Principles of differential diagnosis performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Differential diagnosis in an examined supervised patient with “acute cholecystitis” disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 General principles and stages of clinical diagnosis formation . . . . . . . . . . . . . 24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Test questions to Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 CHAPTER 2. Surgical diseases of abdominal wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Abdominal hernias (Herniation syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 General issues of development, diagnostics and treatment of hernias of anterior abdominal wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Inguinal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Femoral hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Umbilical and white line (midline) hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ventral hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Complications of hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Test questions to Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 CHAPTER 3. Urgent surgical diseases of abdominal organs . . . . . . . . . . . . . . . . 49 3.1. ACUTE INFLAMMATORY DISEASES OF ABDOMINAL ORGANS (acute inflammatory abdominal syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 General issues of development and manifestation of acute inflammatory abdominal syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Acute appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Acute cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Acute pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 3.2. Diseases of abdominal organs complicated by bleeding (syndrome of gastrointestinal bleeding) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 General issues of diagnostics and treatment of bleeding into the lumen of gastrointestinal tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Gastroesophageal reflux disease complicated by bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Bleeding from esophageal varices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Mallory – Weiss syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Peptic ulcer complicated by bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Contents

Hemorrhagic gastritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Stomach cancer complicated by bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Cancer of bowels complicated by bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Hemorrhoids complicated by bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 3.3. ACUTE INTESTINAL OBSTRUCTION (syndrome of acute intestinal obstruction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 General issues of diagnostics and treatment of acute intestinal obstruction . . . . . . . . . . . . 110 Dynamic intestinal obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Mechanical obstruction of small and large intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Obturative obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Strangulation obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Мixed intestinal obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Thrombosis of mesenteric vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 3.4. PERITONITIS (Peritoneal syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 General issues of diagnostics and treatment of peritoneal syndrome . . . . . . . . . . . . . . . . . . . 125 Peritonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Perforation of peptic ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Perforation of small and large intestines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 3.5. ACUTE PROCTOLOGIC DISEASES (syndrome of acute pain in rectum, anal canal and perianal area) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 General issues of development and diagnostics of pain syndrome in anorectal area . . . . 143 Thrombosed hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Acute anal fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Acute periproctitis/acute anal abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Suppurative pilonidal sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Test questions to Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 CHAPTER 4. Chronic surgical diseases of gastrointestinal tract organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 4.1. Chronic obstructive disorders of esophagus (syndrome of dysphagia) . . . 162 General issues of dysphagia development and its diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . 162 Esophageal achalasia (achalasia cardiae) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Esophageal stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Tumors of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Benign tumors of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Malignant tumors of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Diverticulum of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 4.2. CHRONIC DISEASES OF ESOPHAGUS CAUSED BY REFLUX OF GASTRIC CONTENTS (REFLUX AND HEARTBURN SYNDROME) . . . . . . . . . . . . . . . . . . . . . . . 177 General issuess of development and diagnostics of heartburn and regurgitation of gastric contents into the esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Gastroesophageal reflux disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Hiatal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 4.3. CHRONIC DISEASES OF STOMACH AND PANCREATOBILIARY SYSTEM (pain syndrome in the upper part of abdominal cavity) . . . . . . . . . . . . . . . . . . . . . . . . 188 Peptic ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Contents

Peptic (postoperative) ulcer of anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recurrent duodenal ulcer after isolated selective proximal vagotomy . . . . . . . . . . . . . . . . Cholelithiasis (gallstone disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of cholelithiasis . . . . . . . . . . . . Chronic calculous cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Сholedocholithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic obstructive pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pancreatic cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. CHRONIC OBSTRUCTION OF GASTROINTESTINAL TRACT (syndrome of chronic obstruction of gastrointestinal tract) . . . . . . . . . . . . . General issues of development, diagnostics and treatment of chronic obstruction of gastrointestinal tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peptic ulcer complicated by stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arteriomesenteric compression of duodenum (chronic duodenal arteriomesenteric obstruction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adhesive disease of abdominal cavity organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. DISEASES OF HEPATOPANCREATOBILIARY ZONE COMPLICATED BY OBSTRUCTIVE JAUNDICE (syndrome of obstructive jaundice) . . . . . . . . . . . . . . . . . . . General issues of jaundice diagnosing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of obstructive jaundice diagnostics and treatment . . . . . . . . . . . . . . . . . . . . . . Choledocolithiasis complicated by obstructive jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumor of extrahepatic bile ducts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumor of major duodenal papilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tumor of the head of pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. CHRONIC INFLAMMATORY DISEASES Of small and large intestinES (Diarrheal-inflammatory syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of diseases with diarrheal-inflammatory syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ulcerative colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crohn’s disease (terminal ileitis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7. PROLAPSE OF RECTUM (rectal prolapse syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . General ussues of development, diagnostics and treatment of rectal prolapse syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rectal prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8. Chronic proctologic diseases (Chronic pain syndrome in the area of anal canal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of diseases, characterized by chronic pain syndrome in the area of anal canal . . . . . . . . . . . . . . . . . . . . . Anal fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rectal fistulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pilonidal sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Control questions to Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contents

196 200 203 205 206 208 212 216 219 220 221 224 226 228 228 231 233 236 238 240 241 243 243 248 255 259 260 261 264 268 268 269 271 274 276 277

CHAPTER 5. Surgical diseases of thorax and organs of thoracic cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Topographic anatomy of thorax and mediastinum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. PNEUMOTHORAX (syndrome of collapsed lung) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of collapsed lung . . . . . . . . . . . Spontaneous pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Traumatic pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. FLUID IN PLEURAL CAVITY (PLEURAL FLUID) (syndrome of fluid in pleural cavity) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of fluid accumulations in pleural cavity (hydrothorax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pleurisy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hemothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chylothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pleural empyema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3. PULMONARY HEMORRHAGE (pulmonary hemorrhage syndrome) . . . . . . . . . . . General issues of development, diagnostics and treatment of pulmonary hemorrhage . Pulmonary embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiple bronchiectasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Benign tumors of bronchi and lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4. INFLAMMATORY DISEASES OF THORACIC ORGANS (inflammatory syndrome in thoracic surgery) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of inflammatory syndrome in thoracic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pulmonary abscess and gangrene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mediastinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5. OBSTRUCTION OF TRACHEA AND BRONCHI (syndrome of asphyxia) . . . . . . . . . . . Foreign bodies of trachea and bronchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER 6. Trauma of abdominal and thoracic organs . . . . . . . . . . . . . . . . . . . TRAUMA OF ABDOMEN, CHEST AND RETROPERITONEAL SPACE . . . . . . . . . . . . . . . . . . . . . . . General issues of diagnostics and treatment of traumatic influence on patient’s organism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. ABDOMINAL TRAUMA (syndrome of traumatic abdominal injury) . . . . . . . . . . General issues of development, diagnostics and treatment of abdominal traumas . . . . . Closed (blunt) abdominal trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Open abdominal trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma of rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2. TRAUMA OF THORAX AND THORACIC ORGANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of traumas of thorax . . . . . . . Closed trauma of thorax and thoracic organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Open trauma of thorax and thoracic organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3. MULTIPLE TRAUMA (POLYTRAUMA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of multiple trauma (polytrauma) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contents

285 286 296 296 299 303 306 307 308 311 315 318 324 324 326 330 334 338 341 341 343 348 352 352 355 355 359 360 360 362 362 366 370 372 375 375 381 388 393 393

6.4. ESOPHAGEAL TRAUMA (syndrome of traumatic injury of esophagus) . . . . . General issues of development, diagnostics and treatment of esophageal traumas . . . . Mechanical trauma of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chemical burn of esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398 399 401 405 409 409

CHAPTER 7. Surgical diseases of arterial vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1. Acute disturbance of arterial circulation (syndrome of acute ischemia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of diagnostics and treatment of acute occlusion of arterial vessels . . . . . . Acute arterial occlusion of lower extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pulmonary embolism (PE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2. Ischemic diseases of lower extremities (syndrome of chronic ischemia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of diagnostics and treatment of obliterating arterial lesions . . . . . . . . . . . . Obliterating atherosclerosis of vessels of lower extremities . . . . . . . . . . . . . . . . . . . . . . . . . . Obliterating endarteritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Raynaud’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peripheral angiopathy in diabetes mellitus (diabetic angiopathy) . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

412 413 413 415 417 422 422 426 431 435 437 441 441

CHAPTER 8. Surgical diseases of veins of lower extremities . . . . . . . . . . . . . . 444 SURGICAL DISEASES OF VEINS OF LOWER EXTREMITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 Topographic anatomy of veins of lower extremities, their physiology and methods of investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 8.1. Chronic venous insufficiency (syndrome of chronic venous insufficiency) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 General issues of diagnostics and treatment of chronic venous insufficiency . . . . . . . . . . . . 451 Varicose vein disease of lower extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453 Post-thrombophlebitic disease (PTD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 8.2. Acute venous obstruction (syndrome of acute venous thrombosis) . . . . 461 General issues of diagnostics and treatment of acute venous obstruction . . . . . . . . . . . . . . 461 Thrombophlebitis of superficial veins of lower extremities . . . . . . . . . . . . . . . . . . . . . . . . . . 465 Thrombosis of deep veins of lower extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469 Test questions to Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470 CHAPTER 9. Surgical diseases of endocrine organs . . . . . . . . . . . . . . . . . . . . . . . . . 472 SURGICAL DISEASES OF ENDOCRINE ORGANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473 9.1. Surgical diseases of thyroid gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473 9.2. Goiter without thyroid function abnormality (Syndrome of thyroid gland hypertrophy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 General issues of development, diagnostics and treatment of surgical diseases of the thyroid gland without disturbance of its function (euthyroid goiter) . . . . . . . . . . . . . 478 Diffuse endemic goiter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480 Nodular endemic goiter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482 Autoimmune thyroiditis – Hashimoto’s goiter (euthyroid form) . . . . . . . . . . . . . . . . . . . . . . 483

Contents

9.3. Thyrotoxicosis (syndrome of thyrotoxicosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of surgical thyroid diseases with signs of thyrotoxicosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffuse toxic goiter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional anatomy of thyroid gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4. Inflammatory diseases of thyroid gland (Thyroid gland inflammation syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of inflammatory diseases of thyroid gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute suppurative thyroiditis and strumitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subacute thyroiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5. Surgical diseases of parathyroid glands (hypercalcemia syndrome) . . . Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6. Surgical diseases of adrenal glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Itsenko – Cushing’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary (hyper)aldosteronism (Conn’s syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

485

CHAPTER 10. breast Anomalies and diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BREAST ANOMALIES AND DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1. CONGENITAL BREAST ANOMALIEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amastia (breast aplasia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polymastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polythelia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Athelia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2. HORMONE-DEPENDENT BREAST DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibrocystic mastopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thyroid form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ovarian form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suprarenal form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffuse mastopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nodal mastopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cystic mastopathy (Reclus’s disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mastodynia (mastalgia, Cooper’s disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibroadenoma of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Breast cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

511 512 516 516 517 517 518 518 518 519 520 520 521 521 522 522 523 523 525 525

CHAPTER 11. surgical Purulent infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of purulent surgical infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1. WOUND INFECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causes and mechanism of development of wound infection . . . . . . . . . . . . . . . . . . . . . . . . Microbiological diagnostics of wound infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immune response of organism to wound infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

527

Contents

485 488 490 492 492 493 495 496 497 500 503 504 506 510 510

528 531 531 534 536

Clinical diagnostics of wound infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Principles of prevention and treatment of wound infection . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2. GENERALIZED INFLAMMATORY REACTIONS (sepsis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics and treatment of generalized inflammatory reactions (sepsis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

538 539 543

CHAPTER 12. Fundamentals of transplantology . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of transplantology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social and legal aspects of transplantology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental and ethical (bioethical) and legal issues of transplantology . . . . . . . . . . . . . . . . . . . . Fundamentals of transplant immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Particular issues of of vital organ transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kidney transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Liver transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heart transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pancreas transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

558 559 560 560 561 563 563 564 565 566 567 567

CHAPTER 13. Shocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General issues of development, diagnostics andÂ treatment of shocks . . . . . . . . . . . . . . . . . . Hemorrhagic shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burn shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anaphylactic shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Test questions to Chapter 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

569 570 579 585 595 601 602

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential diagnosis TABLES OF SURGICAL DISEASES . . . . . . . . . . . . . . . . . . . . . . . . Multiple-choice clinical tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Answers to clinical tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cluster type Clinical tasks on surgery to prepare for problem-oriented state tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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CHAPTER

3 URGENT SURGICAL

ABDOMINAL

DISEASES

Surgery. English edition

ORGANS

Chapter 3. Urgent surgical diseases of abdominal organs

3.1. Acute inflammatory diseases of abdominal organs (acute inflammatory abdominal syndrome) Acute inflammatory abdominal syndrome is caused by obstruction of the organ cavity or duct with progressive development of inflammation in it and destruction that causes pain, increasing symptoms of intoxication and inflammatory changes in blood count. If acute inflammatory abdominal syndrome is suspected, an urgent surgical consultation is indicated and confirmed – urgent hospitalization to the surgical department. The most common causes of acute inflammatory abdominal syndrome are acute appendicitis, acute cholecystitis and acute pancreatitis.

General issues of development and manifestation of acute inflammatory abdominal syndrome 1. Definition. Acute inflammatory diseases of the stomach, combined in term “Acute abdomen” are characterized by development of the inflammatory process, which may have aseptic or microbial background. 2. Essentials of the problem: A) Acute inflammatory diseases of the stomach – the main pathological processes requiring emergency surgical hospitalization. B) Acute inflammatory diseases of the stomach – the most common cause of surgeries performed by urgent indications. 3. Causes of acute inflammatory abdominal syndrome: A) Acute appendicitis. B) Acute cholecystitis. C) Acute pancreatitis. 4. Mechanisms of acute inflammatory abdominal syndrome development: A) Obstruction of organ cavity or its duct system. B) Circulatory disorders in the affected organ. C) Development of aseptic or microbial inflammation. D) Spreading of microbial agents beyond the affected organ. E) Destruction of the organ. F) Development of extraorgan localized complications. G) Development of extraorgan systemic complications. H) Development of multiple organ failure. 5. Clinical features of acute inflammatory abdominal syndrome: A) Complaints: a) pain; b) inflammatory syndrome; c) dyspeptic syndrome; d) intoxication syndrome. 50

Chapter 3. Urgent surgical diseases of abdominal organs

B) Medical history provides the opportunity to analyze the sequence of the disease development. C) Objective data: a) examination: ÌÌ general examination of patient; ÌÌ examination of abdomen. b) palpation: ÌÌ superficial palpation reveals tenderness and abdominal tension; ÌÌ deep palpation and presence of pathognomonic symptoms enable doctor to specify the nature of pathological process. c) percussion: ÌÌ the nature of percussion sound indicates the presence of free fluid in the abdominal cavity; ÌÌ clarifies the nature of percussion sound above the abdominal cavity organs. d) auscultation: ÌÌ nature of respiratory sounds over the lungs; ÌÌ nature of bowel sounds. 6. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis is formed on the basis of patient’s complaints, medical history and objective signs confirmed by physical methods of examination. To confirm or clarify the diagnosis, the diagnostic program should be formed, which includes research methods that affect the specification of the diagnosis. When choosing the method of examination, one should always start with less invasive procedures and progress to more invasive ones. 7. Diagnostic program in patients with suspected acute inflammatory abdominal syndrome: A) Clinical signs: a) complaints; b) medical history; c) physical objective data. B) Laboratory tests: a) complete blood count (CBC) – presence of inflammatory changes in the blood manifests itself in form of leukocytosis and leukocyte left shift. More pronounced changes are observed in destructive forms of the disease; b) urinalysis – at the initial stages of the inflammatory process there are no changes in urinalysis, in destructive forms – protein and casts may be present in urine, and in case of retrocecal location of the appendix – fresh erythrocytes that need to be considered in differential diagnosis. C) Additional methods of investigations: a) plain abdominal radiography (to exclude or confirm the intestinal obstruction); b) ultrasonography (to assess the state of the gallbladder, pelvic organs in women, the presence of fluid in the abdominal cavity, and the state of the kidneys); c) laparoscopy (when confirming the diagnosis of acute appendicitis or acute cholecystitis it can be used for endoscopic removal of the appendix or gallbladder, and in acute pancreatitis complicated by enzymatic peritonitis – drainage of the abdominal cavity). 3.1. Acute inflammatory diseases of abdominal organs

8. Differential diagnosis: A) Differentiation of the disease is carried out by choosing pathological states with similar clinical symptoms. B) When carrying out differential diagnosis one should consider the pathological stage of the process, as it often affects the clinical manifestations. 9. General principles of Therapeutic approach to acute inflammatory abdominal syndrome: A) Therapeutic approach is grounded by clinical diagnosis. B) The nature and type of surgical interventions are selected depending on the detected pathology, complications and availability of concomitant diseases in the patient.

Acute appendicitis 1. Definition. Acute nonspecific inflammation of the appendix. 2. Essentials of the problem: A) A large proportion of acute appendicitis in emergency surgery (60 %). B) The difficulty in diagnosis (delayed diagnosis – up to 50 % of general practitioners and up to 15–18 % of surgeons). C) Probability of technical difficulties when performing the operation. D) Complications of acute appendicitis; probability of early and late postoperative complications. E) Postoperative mortality (0.1–0.2 %). 3. Anatomy of cecum and vermiform appendix: A) Variants of cecum and vermiform appendix location in the abdomen (Fig. 3.1.1): a) Variants of cecum location: ÌÌ pelvic location of cecum and appendix (1); ÌÌ (typical) location of cecum and appendix (2) in the right iliac region; ÌÌ subhepatic location of cecum and appendix (3); ÌÌ left-sided location of cecum and appendix (4). b) variants of vermiform appendix location: ÌÌ pelvic; ÌÌ medial; ÌÌ retrocecal; 3 ÌÌ retroperitoneal. 4 c) location of vermiform appendix near the cecum (Fig. 3.1.2): 2 ÌÌ near the head of cecum; ÌÌ at the site of junction of three longitudinal 1 muscle strips (tenia). B) S tructural features of appendix walls (Fig. 3.1.3): a long narrow lumen; presence of colonic contents in the appendix cavity; deep mucosal crypts and thick muscle layer; presence of submucosal lymphoid aggregates. Fig. 3.1.1. Variants of location of C) Variants of blood supply of cecum and vermiform cecum and vermiform appendix appendix (Fig. 3.1.4). in the abdominal cavity 52

Chapter 3. Urgent surgical diseases of abdominal organs

B 4

5 1 3

3 4 5

fig. 3.1.2. Location of vermiform appendix near the cecum: A – typical location of organs in the right iliac region (1 – vermiform appendix; 2 – cecum; 3 – terminal portion of small intestine; 4 – mesentery of vermiform appendix; 5 – artery of vermiform appendix). B – location of vermiform appendix near the head of cecum (1 – vermiform appendix; 2 – head of cecum; 3 – taenia mesocolica; 4 – taenia omentalis; 5 – taenia libera)

2 3 7 4 5

fig. 3.1.3. Structure of the appendix wall: 1 – mesentery of vermiform appendix; 2 – serous membrane; 3 – longitudinal muscular layer; 4 – circular muscle layer; 5 – submucous layer; 6 – submucosal lymphoid aggregates; 7 – mucosa (crypts) of appendix

3.1. Acute inflammatory diseases of abdominal organs

4. Pathogenesis of acute appendicitis (Scheme 3.1): Obstruction of the appendix cavity (coprolites, muscle spasm, worms) Formation of a closed cavity distal to the obstruction Filling the closed cavity with mucus, transudate Increase of pressure in the closed cavity Appropriate conditions for infection in the formed closed cavity Dysfunction of the neuro-reflex mechanism of appendix due to compression of nerve endings Spasm of muscular layer and blood vessels of the appendix wall Appendix wall ischemia with trophic changes in the mucosa Penetration of infection from the closed cavity into the mucosa (Aschoff’s primary affect) Development of inflammation Swelling of the wall

Purulent destruction of appendix

Necrosis of appendix wall

Penetration of infection into the abdominal cavity Development of complications

5. Pathological forms of acute appendicitis: there are three forms of morphological changes in acute appendicitis: acute simple appendicitis; acute phlegmonous appendicitis; acute gangrenous appendicitis. A) Simple form of acute appendicitis (on examination): appendix is slightly tense; its serous membrane is hyperemic and edematous; there is odorless serous fluid in the appendix cavity; microscopically – mucosal edema, single erosions. 54

Chapter 3. Urgent surgical diseases of abdominal organs

2 3

1 5 4 6

2 5 4

2 4

1 5

Fig. 3.1.4. Visual variants of blood supply of cecum and vermiform appendix: 1 – a. ileocolica; 2 – ramus a. ileocolica; 3 – a. caecalis anterior; 4 – a. caecalis posterior; 5 – a. appendicu laris; 6 – ramus ilealis

B) Phlegmonous form of acute appendicitis (on examination): appendix is thickened, tense, hyperemic, covered with fibrin; there is pus in the appendix cavity; there is turbid serous or purulent exudate in the abdominal cavity, peritoneum is lackluster in some areas; microscopically – leukocyte infiltration of the appendix tissue; purulent destruction of its walls in some areas. C) Gangrenous form of acute appendicitis (on examination): necrosis of sections of the appendix wall, possible perforation of its walls; there is necrotic detritus in the lumen of the appendix; there are purulent necrotic contents in the abdominal cavity; microscopically – thrombosis of the appendix vessels, necrotic changes in its wall. 6. Clinical signs of acute appendicitis: A) Complaints: a) pain in the right iliac region: ÌÌ constant; ÌÌ moderate; ÌÌ without irradiation. b) nausea; c) one-time vomiting; d) delayed defecation. B) Medical history: a) acute onset; b) pain occurs in the healthy state of patient; c) pain occurs without initiating agents; d) epigastric pain or wandering pain throughout the abdomen, which shifts to the right iliac region in 2–3 hours (Volkovich – Kocher sign). C) Objective signs of disease: a) general clinical signs: ÌÌ general weakness; 3.1. Acute inflammatory diseases of abdominal organs

ÌÌ subfebrile fever (37.2–37.6 oC); ÌÌ tachycardia; ÌÌ the tongue is coated, moist; if development of destructive process in the appendix – dry. b) local clinical signs: ÌÌ examination of the abdominal wall: abdomen is symmetrical; abdominal wall in the right iliac region lags behind in the act of breathing. ÌÌ palpation of the abdominal wall: at superficial palpation – muscle tension and tenderness in the right iliac region (Fig. 3.1.5); at deep palpation – increased tenderness in the right iliac region. Pathognomonic signs of acute appendicitis: Rovsing’s sign – appearing or worsening of pain in the right iliac region as a result of jerky movements of the abdominal wall by the right hand of the surgeon in projection of descending part of the colon counterclockwise and simultaneous compression of the sigmoid colon with the left hand through the anterior abdominal wall; Razdolsky’s sign – pain in the right iliac region during percussion of the anterior abdominal wall; Sitkovsky’s sign – appearing or worsening of pain in the right iliac region by changing the position of patient – from supine position to the left lateral decubitus; Bartomier – Michelson’s sign – worsening of pain in the right iliac region of patient in the left lateral decubitus during deep palpation; Obraztsov’s sign (psoas sign) – worsening of pain in the right iliac region during palpation while the patient raises the right leg bent at the knee; Yaure – Rozanov’s sign – worsening of pain when pressure is applied in Petit’s triangle (the sign of retrocecal location of inflamed appendix). Symptoms of peritoneal irritation in the right iliac region: Shchetkin – Blumberg’s sign – worsening of pain when taking one’s hand sharply off the abdominal wall after pressing it in the right iliac region; Voskresensky’s sign (sign of "sliding" or sign 4 5 of “shirt”) – worsening of pain in the right iliA B 3 6 ac region when passing surgeon’s right palm 2 over the anterior abdominal wall from the 1 right subcostal area down on the patient’s shirt stretched with the left surgeon’s hand. 7. Acute appendicitis in elderly people: A) Clinical course of acute appendicitis in elderly Fig. 3.1.5. McBurney’s point – typical lopeople: calization of pain in acute appendicitis: less pronounced pain syndrome; 1 – vermiform appendix; 2 – cecum; 3 – iliac more pronounced dyspeptic disorders; bone; 4 – the most painful area (McBurney’s no fever response; point); 5 – m. rectus; 6 – umbilicus 56

Chapter 3. Urgent surgical diseases of abdominal organs

ore pronounced general symptoms (fatigue, malaise, decreased appetite); m less pronounced muscle tension and pain in the right iliac region; no or unexpressed symptoms of peritoneal irritation; less expressed leukocytosis with more severe changes in leucocyte count with shift to the left. B) Clinical course of acute appendicitis in elderly people due to: age-dependent hyporeactivity of organism; violations of regional blood circulation because of vascular sclerosis; low pain threshold; decrease in muscle tone; changes in psychoemotional reactions. C) Clinical course is influenced by: development of destructive and complicated forms of acute appendicitis; delay in seeking medical care; incorrect diagnosis and untimely surgical intervention; increasd number of postoperative complications; increase in the length of hospital stay; increased mortality rate. N.B.! Elderly patients with abdominal pain require particular attention! 8. Acute appendicitis in children: A) Clinical course of acute appendicitis in children: more severe abdominal pain that does not correspond to inflammatory and morpholo gical changes of the appendix; restless behavior of patient during examination; repeated vomiting; repeated watery stool; high temperature (38.5–39.5 °C); high white blood cell count; resisting examination because of child’s low consciously willing capacities. B) Clinical course of acute appendicitis in children is caused by: age-dependent hyperreactivity; small size of vermiform appendix and its wide mouth; weak plastic properties of the peritoneum, short greater omentum; increased psychological and emotional excitability. N.B.! Examination of a child should be performed during sleep (physiological or medication), for abdominal palpation one should pay attention to the positive signs: drawing up the right leg and pushing examiner’s hand away. 9. Acute appendicitis in pregnancy: A) Clinical course of acute appendicitis in pregnant women: In the first 2–3 months of pregnancy, acute appendicitis occurs without complications; muscle tension in the anterior abdominal wall is rarely observed; 3.1. Acute inflammatory diseases of abdominal organs

pathognomonic symptoms of acute appendicitis are rarely revealed; in the absence of leukocytosis there is leukocyte left shift; inconsistency between the absence of leukocytosis in the blood and changes in the urine (protein, leukocytes). B) Clinical course of acute appendicitis in pregnant women is caused by: changes in physical, physiological and homeostatic status caused by pregnancy; high location of cecum and appendix; presence of concomitant diseases (diabetes, nephropathy of pregnancy, etc.). N.B.! If acute appendicitis in pregnant women is suspected, mandatory examination by obstetrician-gynecologist and hospitalization to the pathologic pregnancy department for observation and planning a therapeutic approach are required. 10. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis is formed on the basis of patient’s complaints, medical history and objective signs confirmed by results of physical examination. To confirm the diagnosis, one should perform clinical blood count and urinalysis, and in cli nically complex cases – radiography, ultrasonography and diagnostic laparoscopy (in the first trimester of pregnancy). 11. Diagnostic program in patients with suspected acute appendicitis: A) Laboratory tests: a) complete blood count – presence of inflammatory changes in the blood manifested by leukocytosis and leukocyte left shift. More pronounced changes are observed in destructive forms of acute appendicitis; b) urinalysis – in a simple form of acute appendicitis there are no changes in urinalysis, however in destructive forms there may be protein, casts; at retrocecal location of the appendix – fresh red blood cells that ahould be considered in the differential diagnosis. B) Additional methods of investigation (applied in case of difficulties in diagnosis): a) abdominal radiography (to exclude or confirm the obstruction of the intestine, perforated ulcer); b) sonography (for assessment of the gallbladder, pelvic organs in women, kidney, presence of fluid in the abdomen). In patients with acute appendicitis, sonographic picture presents the thickened appendix and presence of fluid in the abdominal cavity (Fig. 3.1.6); c) diagnostic laparoscopy (when confirming the diagnosis of acute appendicitis it can be completed with endoscopic removal of appendix). 12. Differential diagnosis with: A) Urgent surgical diseases of the abdominal cavity: acute cholecystitis; duodenal ulcer complicated by perforation. B) Urgent gynecological diseases: ruptured cyst of the right ovary; ectopic pregnancy; acute adnexitis. 58

Chapter 3. Urgent surgical diseases of abdominal organs

C) Urgent urologic diseases: right-sided renal colic. D) Therapeutic diseases: right lower lobe pneumonia; right-sided intercostal neuralgia. 13. Complications of acute appendicitis (due to delay in seeking medical care, incorrect diagnosis followed by untimely surgical intervention): A) Appendicular infiltrate – a conglomerate of inflamed intestinal loops and strands of omentum, soldered together and with the parietal peritoneum, which separates the inflamed appendix and accumulated exudate from the peritoneal cavity. B) Periappendiceal abscess – a localized volume of pus around the inflamed vermiform appendix. C) Peritonitis – inflammation of the peritoneum Fig. 3.1.6. Sonogram in acute appendicitis (the arrows indicate the thickened due to destruction of the appendix or bursting wall of appendix, in the lumen of appenof periappendiceal abscess into the abdominal dix – heterogeneous contents) cavity. D) Pylephlebitis – spreading of microbial infection through the venous system from the appendix to the portal system and liver resulting in formation of phlebitis and liver abscesses. 14. Therapeutic approach in patients with acute appendicitis: A) Once the diagnosis of acute appendicitis is set, an urgent operation should be performed. B) If the diagnosis of acute appendicitis is doubtful: dynamic monitoring of patients for 4–6 hours is conducted (during this period the patient is repeatedly examined by a surgeon, tests are performed, if necessary – instrumental examinations and consulting related professionals); in case of confirmation of the diagnosis of acute appendicitis by case monitoring, an urgent operation is indicated; if the diagnosis of acute appendicitis is neither confirmed nor excluded by case monitoring, Cope’s rule comes into effect – the patient is subject to the operation; if the diagnosis of acute appendicitis is excluded it is necessary to clarify the causes of pain syndrome. 15. Preparing for surgery: A) Shaving the surgical field. B) Emptying the bladder. C) Premedication. D) Gastric lavage (if operation under general anaesthesia is planned). 16. Anaesthesia during appendectomy (priority should be given to general anaesthesia): A) Intravenous anaesthesia – most often used. B) Endotracheal anaesthesia: in patients with excessive weight; in case of peritonitis; 3.1. Acute inflammatory diseases of abdominal organs

if destructive appendicitis suspected; in children; in patients with mental disorders; in pregnant women. C) Local anaesthesia – novocaine infiltration anaesthesia (if general anaesthesia is not possible). 17. Surgical treatment of acute appendicitis: A) Open appendectomy (approach in the right iliac region or inferomedian laparotomy). B) Laparoscopic appendectomy. 18. Clinical and statistical classification of acute appendicitis: K35 Acute appendicitis Clinical diagnosis model: A cute appendicitis {Mx form} complicated by {Ox} Morphological forms of acute appendicitis: M1 – simple M2 – phlegmonous M3 – gangrenous Complications: O1 – appendicular infiltrate O2 – periappendiceal abscess O3 – local peritonitis O4 – diffuse peritonitis O5 – pylephlebitis. 19. Examples of setting a clinical diagnosis: A) Acute appendicitis, simple form. B) Acute appendicitis, phlegmonous form. C) Acute appendicitis, gangrenous form complicated by periappendiceal abscess. D) Acute appendicitis, gangrenous form, complicated by local peritonitis. 20. Disability examination and rehabilitation of patients: A) I n uncomplicated postoperative period stitches are removed 6–7 days after the surgery. B) Outpatient treatment after the surgery – 3–4 weeks. C) If patient’s job involves heavy physical labour, Medical Oversight Subcommittee can restrict the ability to work for 6–8 weeks, and physical loads – up to 12 weeks.

Acute cholecystitis 1. Definition. Acute cholecystitis – an acute non-specific inflammation of the gallbladder. 2. Epidemiology: A) Male-female gallstones incidence ratio – 1 : 6. B) The most common age of onset – from 30 to 55 years, in patients older than 60 years the prevalence is 25–30 %. 3. Essentials of the problem: A) Among patients with acute surgical abdominal pathology, acute cholecystitis comprises about 20 %. B) Development of life-threatening complications requires urgent medical care. C) Technical difficulties of surgery in case of complicated disease. 60

Chapter 3. Urgent surgical diseases of abdominal organs

8 14

2 5

5 4

1 13

2 7

5 8 9

2 8

12 11 13

Fig. 3.1.7. Topographic-anatomical relationship of the biliary system: A – anatomy of the abdominal cavity in the right subhepatic space (1 – gallbladder; 2 – extrahepatic bile ducts; 3 – liver; 4 – cystic duct; 5 – cystic artery; 6 – hepatic artery; 7 – stomach; 8 – pancreas; 9 –colon; 10 – duodenum). B, C – schematic representation of the gallbladder and extrahepatic ducts (1 – gallbladder; 2 – fundus of the gallbladder; 3 – body of the gallbladder; 4 – neck of the gallbladder; 5 – cystic duct; 6 – right hepatic duct; 7 – left hepatic duct; 8 – common hepatic duct; 9 – common bile duct; 10 – pancreatic duct; 11 – ma jor duodenal papilla; 12 – ampulla of Vater; 13 – duodenum; 14 – hepatic artery; 15 – pancreas)

D) Emergence of a number of organic and functional disorders after the surgery. 4. Topographic anatomy of the gallbladder and extrahepatic bile ducts (Fig. 3.1.7): A) Gallbladder: a) gallbladder fundus; b) gallbladder body; c) gallbladder neck; d) cystic duct. B) Extrahepatic bile ducts: a) right and left hepatic ducts; b) common hepatic duct; c) common bile duct (supraduodenal and pancreatic parts). С) Blood supply of the gallbladder: Cystic artery has no collaterals and arises from the common or right hepatic artery. 3.1. Acute inflammatory diseases of abdominal organs

Fig. 3.1.8. Sonographic study of gallbladder: A – normal gallbladder. B – presence of concretions in the gallbladder. C – inflammation of the gallbladder wall (double contour, extracystic complications)

5. Examination of the gallbladder: A) Ultrasonography (Fig. 3.1.8) – the main method of diagnosis of gallbladder disease, which can help to assess the state of the galbladder, presence of stones in it, inflammatory changes and extracystic complications. In the absence of sonography, radiography can be used for examination of the gallbladder. B) Computed tomography – used for difficult diagnostic cases, when ultrasound study is uninformative. C) Endoscopic retrograde cholangiopancreatography (ERCP) – is used in the presence of jaundice, its episodes in past history, ultrasound signs of dilatation of extrahepatic bile ducts, laboratory signs of cholestasis. ERCP is performed using gastroduodenoscopy with a cannula inserting into the ampulla of Vater and contrasting duct systems of extrahepatic bile ducts, bile ducts of the liver and pancreatic duct. 6. Leading factors in the occurrence of acute cholecystitis: A) Microbial agents, which penetrate into the cavity of gallbladder through its wall. B) Inflammatory changes determined by virulence of infection, extent of infection and immune status reactivity. 7. Ways of penetration of infection into the gallbladder and factors contributing to microbial contamination: A) The main ways of infection penetration: hematogenous; lymphogenous; ascending infection from the duodenum. B) Secondary causes of microbial contamination of the gallbladder: violation of blood flow in the cystic artery; reflux of pancreatic juice; allergy. 8. Factors contributing to development of inflammation in the gallbladder: A) Presence of microbial flora. B) Violation of drainage function of the gallbladder: a) presence of concretions in the gallbladder (85–90 %); 62

Chapter 3. Urgent surgical diseases of abdominal organs

b) violation of cystic duct patency. C) Reflux of pancreatic juice into the common bile duct and gallbladder, resulting in develoment of enzymatic cholecystitis. D) Cystic artery thrombosis. 9. Mechanism of acute cholecystitis: A) Penetration of infection into the wall of the gallbladder causes mucosal edema, infiltration of it by neutrophils, lymphocytes and macrophages. B) Spreading of infection to the gallbladder wall leads to inflammatory destruction of its tissues with detritus and pus getting into the gallbladder cavity and extravasation of its infected contents into the abdominal cavity. C) Development of thromboangiitis with necrosis of the gallbladder wall and its perforation, massive getting of detritus and infection into the abdominal cavity, and development of complications. D) In cystic artery thrombosis there is development of primary necrosis of the gallbladder wall. 10. Clinical signs of acute cholecystitis depend on: A) form of inflammatory process in the gallbladder; B) nature and virulence of microbial flora; C) immunoreactivity of organism; D) presence of complications. 11. Pathomorphology of acute cholecystitis: A) Catarrhal form of acute cholecystitis – tense gallbladder, hyperemic serosa, edematic mucousa, foci of erosion, presence of odorless serous fluid in the abdominal cavity. B) Phlegmonous form of acute cholecystitis – tense hyperemic gallbladder covered with fibrin films, edematous bladder wall, foci of purulent destruction; presence of modified bile or pus in the gallbladder cavity, turbid exudate in the abdominal cvavity near the gallbladder or the gallbladder is located in the infiltrate. C) Gangrenous form of acute cholecystitis – necrosis of a part of the wall or entire gallbladder as a result of cystic artery thrombosis, probable perforation of the gallbladder wall, which causes getting of pyonecrotic or gall detritus into the abdominal cavity. 12. Clinical signs of acute cholecystitis: A) Complaints: a) pain localized in the right upper quadrant: ÌÌ constant; ÌÌ intensive; ÌÌ intensity increases with the progression of the disease; ÌÌ radiates to the right shoulder or scapula, lumbar region or right shoulder girdle, sometimes to the heart (cholecysto-cardiac syndrome) (Fig. 3.1.9); b) nausea; c) repeated bilious vomiting; d) chills. B) Medical history: a) acute onset; b) presence of initiating agents (fatty, fried and spicy foods); c) presence of similar pain attacks in past history. 3.1. Acute inflammatory diseases of abdominal organs

9 8 7

5 4 3 2 B

A Fig. 3.1.9. Localization of pain and its mechanism of irradiation in acute cholecystitis: A – localization of pain in acute cholecystitis (1 – right hypochondrium; 2 – right lumbar region, 3 – right shoulder girdle). B – mechanism of pain irradiation (1 – plexus hepaticus anterior et posterior; 2 – plexus gastroduodenalis; 3 – ganglia coeliaca; 4 – ganglia phrenica; 5 – ramus hepaticus trunci vagalis anterioris; 6 – truncus vagalis anterior; 7 – n. splanchnicus; 8 – medulla spinalis; 9 – ganglion spinale; 10 – truncus sympathicus)

C) Objective signs of disease: a) general clinical signs of acute cholecystitis: ÌÌ general weakness; ÌÌ increase in body temperature to 38–39 °C; ÌÌ tachycardia; ÌÌ probable icteric sclera and skin; b) local clinical signs of acute cholecystitis: ÌÌ dry and coated tongue; ÌÌ abdominal wall in the right upper quadrant lags behind in the act of breathing; ÌÌ during superficial palpation – muscle tension and tenderness in the right upper quadrant; ÌÌ during deep palpation – strengthening of local pain, palpation of the gallbladder fundus is possible; ÌÌ during percussion and auscultation – no changes. c) Pathognomonic pain symptoms of acute cholecystitis: ÌÌ Mussy – Georgievsky’s sign (phrenic nerve sign) – pain when pressing between edges of the right sternocleidomastoid muscle; ÌÌ Ortner – Grekov’s sign – pain at tapping the right costal arch; ÌÌ Parturier’s sign – the gallbladder is increased in size, tense and painful; ÌÌ Murphy’s sign – inability to take a deep breath due to increased pain during simultaneous palpation in projection of the gallbladder; 64

Chapter 3. Urgent surgical diseases of abdominal organs

ÌÌ Schetkin – Blumberg’s sign – increased pain upon removal of pressure on the ab-

dominal wall after pressing the right upper quadrant (rebound tenderness, sign of peritonitis). 13. Forming a preliminary diagnosis based on clinical data Preliminary diagnosis is formed on the basis of patient’s complaints, medical history and objective signs confirmed by physical methods of examination. Diagnosis is to be specified during ultrasound investigation and confirmed by laboratory tests. 14. Diagnostic program in patients with suspected acute cholecystitis is formed on the basis of the preliminary diagnosis: A) Clinical signs: a) complaints; b) medical history; c) objective data. B) Laboratory tests: a) complete blood count (leukocytosis with leukocyte left shift); b) biochemical blood analysis (bilirubin and its fractions, ALT, AST, serum electrolytes, blood clotting test); c) urinalysis (presence of protein, red blood cells, casts, bile pigments). C) Instrumental methods of examination: a) ultrasonography (evaluation of the state of the gallbladder, bile duct, pancreas and liver); b) p lain abdominal X-ray, if indicated (if needed to differentiate from obstruction of intestine, perforated ulcer); c) computed tomography (indicated in difficult diagnostic cases); d) endoscopic retrograde cholangiopancreatography (ERCP) – indicated for assessment of pathological changes of the extrahepatic bile ducts (Fig. 3.1.10); e) d iagnostic laparoscopy – may be used to confirm the diagnosis in difficult diagnostic cases; in the presence of technical possibilities it turns into treatment procedure, completing with a laparoscopic cholecystectomy. 15. Differential diagnosis with: A) Urgent surgical diseases of the abdominal cavity: acute appendicitis; ulcer of stomach and duodenum complicated by perforation; acute pancreatitis; acute intestinal obstruction. B) Urgent urologic diseases: right-sided renal colic. C) Therapeutic diseases: right lower lobe pneumonia; right-sided intercostal neuralgia; myocardial infarction. D) Chronic abdominal diseases: duodenal ulcer complicated by penetration; tumor of hepatic flexure of the colon. 3.1. Acute inflammatory diseases of abdominal organs

3 A

Fig. 3.1.10. X-ray image of bile duct system on ERCP: A – image of extrahepatic ducts in normal state (1 – common hepatic duct; 2 – common bile duct; 3 – gall bladder; 4 – pancreatic duct). B – concretions in the gallbladder and common bile duct (1 – a concretion in the common bile duct; 2 – concretions in the gallbladder)

16. Complications of acute cholecystitis: A) Paravesical infiltrate. B) Perivesical abscess. C) Gallbladder empyema. D) Gallbladder perforation. E) Peritonitis. F) Obstructive jaundice. G) Cholangitis. H) Hydrocholecystis. I) Acute pancreatitis. 17. Organizational principles of providing medical care for patients with acute cholecystitis: A) If there are clinical manifestations of acute cholecystitis the patient is hospitalized to the surgical department. B) If there are clinical and echographic signs of acute cholecystitis without involvement of the peritoneum into the pathological process, medication therapy is aimed at reduction of pain and inflammatory syndromes. C) If there are clinical and echographic signs of destructive cholecystitis without and with localized extracystic complications, the medication therapy is aimed at the reduction of pain and inflammatory syndromes for 24–48 hours. D) For reduction of inflammatory process, clinical and echographic signs of which are listed in B) and C) items, and in the presence of concretions elective surgery is indicated in 66

Chapter 3. Urgent surgical diseases of abdominal organs

10–12 days. With the progression of inflammation of the gallbladder to the peritoneum and ineffectiveness of conservative treatment there is a justified indication for urgent surgery within 24–48 hours after admission. E) If there are clinical and echographic signs of destructive cholecystitis with extracystic ge neralized complications, emergency surgery is indicated within 2–3 hours after setting the diagnosis and preoperative preparation. 18. Nature of surgical interventions in acute cholecystitis: A) Emergency surgery (2–3 hours from the time of admission) – if there are signs of destructive cholecystitis complicated by peritonitis. B) Urgent surgery (24–48 hours from the time of hospitalization) – in the absence of effectiveness of medication. C) Delayed surgery (48–72 hours from the time of admission) – if there are indications for emergency or urgent surgery, but the patient refuses surgery in the earlier period. D) Elective surgery – for relieving effects of acute cholecystitis and confirming the presence of gallbladder concretions. 19. Medical therapy of acute cholecystitis: A) Fasting for 2–3 days. B) Drinking alkaline fluids. C) Local hypothermia. D) Pain management (non-narcotic analgesics, antispasmodics). E) Anti-inflammatory therapy (broad spectrum antibiotics). F) Desintoxication infusion-transfusion therapy. 20. Surgical treatment of acute cholecystitis: A) Open cholecystectomy: supramedian laparotomy; inspection of the abdominal cavity and extrahepatic bile ducts; cholecystectomy from the neck or from the fundus with separate ligation of the cystic duct and cystic artery; drainage of the abdominal cavity; suturing of laparotomy wounds. B) Laparoscopic cholecystectomy: introduction of trocars into four standard points (above the navel, under the xiphoid process of the sternum, under the right costal arch on the mid-clavicular and the anterior axillary lines); visual inspection of the abdominal cavity; cholecystectomy from the neck (of the gallbladder) with a separate clipping of the cystic duct and artery; removing the gallbladder from the abdomen; drainage of the abdominal cavity; suturing wounds of the abdominal wall. 21. Clinical and statistical classification of acute cholecystitis: K80.0 Calculus of gallbladder with acute cholecystitis Clinical diagnosis model: A cute calculous cholecystitis {Mx form} complicated by {Ox} Morphological form: M1 – catarrhal 3.1. Acute inflammatory diseases of abdominal organs

M2 – phlegmonous M3 – gangrenous Complications: O1 – gallbladder empyema O2 – hydrocholecystis O3 – paravesical infiltrate O4 – perivesical abscess O5 – peritonitis O6 – vesico-intestinal fistula O7 – jaundice O8 – cholangitis O9 – acute pancreatitis.

22. Examples of setting a clinical diagnosis: A) Acute calculous cholecystitis, catarrhal form. B) Acute calculous cholecystitis, phlegmonous form complicated by paravesical abscess. C) Acute calculous cholecystitis, gangrenous form complicated by diffuse peritonitis. 23. Disability examination and rehabilitation of patients: A) In the uncomplicated postoperative period stitches are removed after laparotomy on the 9th or 10th day, and after laparoscopy – on the 5th or 6th day. B) O utpatient treatment: 4–5 weeks after laparotomy and 2–3 weeks after laparoscopy. C) If the patient’s job involves heavy physical labour, Medical Oversight Subcommittee restricts physical activity for 4–6 months. D) A diet with restriction of fatty, fried and spicy foods is recommended for 2–3 months after the surgery.

Acute pancreatitis 1. Definition. Acute pancreatitis – an acute degenerative inflammatory disease of the pancreas based on the autolysis of its own gland tissue activated by enzymes followed by microbial and aseptic inflammation. 2. Essentials of the problem: A) Among patients with acute surgical abdominal pathology patients with acute pancreatitis make 6–9 %. B) Mortality in destructive pancreatitis is 20–40 %. C) Mortality in destructive pancreatitis with complications reaches 80 %. 3. Anatomical and topographical location of pancreas (Fig. 3.1.11): A) Pancreas is retroperitoneal, located behind the stomach, at the level of the first and second lumbar vertebrae. B) Pancreas is in the horizontal position in the area between right and left kidney, from the descending part of duodenum to the spleen, its length is 20–27 cm, height – 4.6 cm, thickness – 2.4 cm. C) Pancreas consists of three parts: head; body; � tail. 68

Chapter 3. Urgent surgical diseases of abdominal organs

Підручник відповідає програмі, яка затверджена МОЗ України, з підготовки лікаря загальної практики з питань клінічної хірургії. Матеріал у підручнику розподілено залежно від характеру захворювання та пріоритетів надання медичної допомоги. Кожну тему викладено структуровано залежно від основного клінічного синдрому, з чітким розподілом основних розділів і відповідно до професійно-орієнтованих завдань затверджених галузевих стандартів. Кожний розділ теми подано в алгоритмізованому вигляді, що, на думку авторів, має сприяти кращому засвоєнню матеріалу при використанні кредитно-модульної системи навчання. Підручник розраховано на студентів 4–6 курсів вищих навчальних закладів медичного профілю III і IV рівнів акредитації, лікарів-інтернів.

Навчальне видання

Амосова Катерина Миколаївна Березницький Яків Соломонович Бурка Анатолій Олексійович та ін.

Хірургія Підручник (англійською мовою)

За редакцією: Я. С. Березницького, М. П. Захараша, В. Г. Мішалова Редактор О. В. Марчук Технічні редактори: І. В. Шпента, В. О. Кокряцька, Ж. С. Швець Коректор Ю. П. Тертун Комп’ютерна верстка: О. С. Парфенюк Підписано до друку 08.08.18. Формат 70×100/16. Папір офсетний. Гарнітура Arsenal. Друк офсетний. Ум. друк. арк. 57,68. Зам. № 996. ПП “Нова Книга” 21029, м. Вінниця, вул. М. Ващука, 20 Свідоцтво про внесення суб’єкта видавничої справи до Державного реєстру видавців, виготівників і розповсюджувачів видавничої продукції ДК № 2646 від 11.10.2006 р. Тел. (0432) 56-01-87. Факс 56-01-88 E-mail: info@novaknyha.com.ua www.novaknyha.com.ua