RCRZ (Republican Center for Health Development MD RK)
Version: Clinical protocols MOR RK - 2014

Pelvic peritoneal spikes in women (N73.6)

obstetrics and gynecology

general information

Short description

Approved on the expert commission

On health development

Ministry of Health of the Republic of Kazakhstan

Spikes - These are subtle trenches, films and fits arising between neighboring bodies. The appearance of the adhesive process is the irritation of the peritoneum - a peculiar shell covering the internal organs from the abdominal cavity. Factors leading to the formation of adhesions in a small pelvis: preceding operations on abdominal organs and small pelvis (laparotomy, laparoscopy), inflammatory diseases of the uterus, outer genital endometriosis [2, 3,4,5,6].

I. Introductory part

Protocol name: Pelvic peritoneal spikes

Protocol code

Code (s) μb-10:

Abbreviations used in the protocol:

Ultrasound ultrasound examination

MRI - magnetic resonance tomography

OMT - small pelvis organs

OAK - Common Blood Analysis

Asat - Aspartate Transaminase

Alat - Alaninotransferase

ECG - electrocardiogram

RW - Wasserman Reaction

HIV - human immunodeficiency virus

UD - level of evidence

Protocol development date: year 2014.

Category of patients - Patients who have a history of several operations on the abdominal and pelvic cavity organs, expressed pelvic peritoneal spikes with the involvement of the intestine, the gland and the organs of the small pelvis.

Users Protocol - Doctors obstetrician - gynecologists of hospitals.

I: The evidence obtained from at least one properly randomized controlled study.

II-1: Evidence of well-developed controlled studies without randomization.

II-2: evidence of well-developed cohorts (alleged or

Retrospective) or study by case-control method, preferably more than one center or research group.

II-3: Evidence derived from comparisons between times or places with or without interference.

III: Expert opinions based on clinical experience. Descriptive studies or expert reports.

A. There are reliable evidence to recommend a clinical prophylactic effect.

B. There are fair evidence to recommend a clinical prophylactic effect.

C. Existing evidence is in contradiction and do not allow

D. There are fair evidence to recommend against a clinical solution.

E. There are reliable evidence to recommend against a clinical solution.

I. There are insufficient evidence (in quantity or quality) to make a recommendation; However, other factors can affect decision making.

Classification

Clinical classification

Classification of the stage of the adhesive process in the laparoscopic picture:

I Stage - Single Slim Spikes;

Stage II - dense spikes, which occupy less than half the surface of the ovary;

III stage - numerous dense spikes, which occupy over half of the ovary surface;

IV Stage - Dense Plate Spikes, which occupy the entire surface of the ovary.

The severity of the adhesive process in a small pelvis correlates with the degree of adhesive process in the abdominal cavity.

Diagnostics

II. Methods, approaches and diagnostic and treatment procedures

List of basic and additional diagnostic events

Main diagnostic measures:

Blood group and rhesus - factor

General analysis urine

Common blood test (hemoglobin, hematocrit, platelets)

Biochemical blood test (total protein, albumin, creatinine, alote, asat, urea, bilirubin (general, straight)

Coagulogram

HIV Blood, Hepatitis, RW

Fluorography chest

Grinding

Smear on oncocytology

Consultation therapeuts

Ultrasound of a small pelvis and abdominal cavity

Additional diagnostic measures:

MRI small pelvis

Consultation Surgeon.

Diagnostic criteria:

1) complaints and history - Symptoms of small pelvis, most often manifested in the form of pelvic pain. Depending on the affected organ, the pelvic pain can be given to the area of \u200b\u200bthe rectum, the sacrum, the vagina. In the spikes of the intestine there are pain in the abdomen, most often near the place of operational incision. The character of painful or pulling.

Small pelvic spikes, symptoms can enhance with exercise, movements or change poses. Indicate the intestinal spikes, the treatment of which cannot be postponed, can frequent diarrhea or constipation, vomiting, bloating, postoperative spikes or after inflammation with time "grow" to neighboring organs. After previous laparotomic operations, spikes first can manifest themselves barely noticeable pelvic pains. Spikes whose treatment is not carried out, grow and cause painful feelings In all small pelvis.

When developing spikes in the pipes does not come pregnancy.

2) physical examination

Inspection on the mirrors - the shift of the cervix on the sides;

Palpation of the abdomen - there is pain with deep palpation of the front abdominal wall, the scars on the front wall of the belly, not shifted during palpation, swept with the subjectable tissues;

Bimanual gynecological research is a sharp pain, the uterus displacement to the side, the intestinal involvement in safety process, Education of conglomerates in the cavity of a small pelvis.

3) Laboratory Studies

The smear on the flora of the vagina is the 4th degree of purity of the vagina: the reaction is alkaline, the deterlee sticks are not at all, a large number of coccoints, there may be other types of microorganisms - enterobacteria, bacteroids, leukocytes in a huge amount.

4) instrumental research

OMT and abdominal ultrasound, MRT OMT - anechogenic white trash is noted.

5) testimony for consultation of specialists- Surgeon - a pronounced adhesion process of the abdominal cavity and a small pelvis, the coarse scars of the anterior abdominal wall paved with the subjectable fabrics.

Differential diagnosis

Differential diagnosis

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Treats of treatment - Elimination of adhesions, restoration of fertility

Tactics of treatment - Operational treatment with laparoscopic access, separation of adhesions.

Medicia treatment

Main preparations:

Cephalosporins 3 generations

Ketoprofen.

Tramadol.

Acetylsalicylic acid

Snaropean calcium

Physiological sodium chloride solution 0.9%

H2 receptor antagonists or proton pump inhibitors

Lidocaine

Ropivacaina hydrochloride

Metoclopromide

Gelatin

Phenylephrin

Norepinephrin

Propofol.

Atrakuria Beales

Fentanyl

Atropine Sulfat.

Sevofluran

Diphenhydramine

Additional drugs:

Gentamicin

Cefasoline

Metronidazole.

Meropein 1G.

Other types of treatment: Physical examination, mud.

Surgical intervention:

The treatment of adhesive disease is entirely dependent on the severity of the disease. With acute and intermittent form of the disease, surgical treatment - laparoscopy, is the only method of treatment due to high efficiency and rapid effect.

With the prolonged distribution of adhesions, therapeutic and diagnostic laparoscopy is shown. As a rule, a surgeon - a gynecologist diagnoses adhesive disease already on the operating table and at the same time conducts operation - dishes and removes spikes.

Perhaps 3 variants of laparoscopy:

Spikes dissect by laser - laser therapy;

Spikes dissect with water under pressure - aquadissection;

Spikes dissect with electrose-electrosurgery.

Alternative laparoscopy methods are used to enter the abdominal cavity in patients with waste and adhesive process:

Methodology using high pressure pneumoperitoneum. After introducing the needle of the versol and creating pneumoperitoneum at 20 - 30 mm Hg. In the deepest section of the navel through a vertical inoperative incision, a short trocar is administered. High pressure The pneumoperitoneum used at the initial introduction of the Troacar is reduced immediately after confirmation of the atraumaticness of penetration into the abdominal cavity. High intra-abdominal pressure significantly increases the distance between the front abdominal wall and large retroperitoneal vessels [UDI II-1 A].

Atypical Troacar Introduction and Double Laparoscopy:the first puncture of the anterior abdominal wall is made in atypical points, i.e. In distance from the navel, using the area of \u200b\u200bthe left hypochondrium - the needle of the versol is introduced in the left upper quadrant on the front axilar line laterally the straight abdominal muscle into two fingers below the rib arc. This choice also helps to avoid the injury of A.Epigastrica Superior, passing through the outer edge of the straight muscle of the abdomen and an anastamosing on the navel level with the lower contractual artery. Then under the control of the telescope introduced into this trocar, choose a space-free place in the aircraft region for a 10 millimeter trocar. It is possible to introduce the needle of the versa in the ninth intercostal in the anterior axillary line, the parietal peritonean in this place is separated from the skin only with a layer of intercostal muscles and fascia, and there is practically no subcutaneous fiber. There is a risk of injury of the diaphragm and the formation of pneumothorax. The contraindications are splenomegaly, inflating the stomach, the tumor of the abdominal cavity. The technique requires an additional puncture and the presence of a 5 mm laparoscope.

Conducting similar manipulations in the right intercoreria is excluded due to the high risk of liver injury [UD A].

Open laparoscopy. Allows avoiding damage associated with the "blind" entry into the abdominal cavity. The procedure lies in the dissection of a small section at the level of the navel of the abdominal wall, overlapping on the aponeurosis and (or) brush the brush and one suture from the edges. After that, trochar is introduced into the abdominal cavity with a blunt way without a style. This method is minilapotomy. This method It is relatively safe, but requires a large length of the cut, which causes the potential risk of the formation of hernia and thorough sealing of the wound. This technique increases the duration of the operation [UD II-2 C]. Fencing trocacares Can be used to decrease input wounds. There is no evidence that they lead to minimal internal damage to vessels during laparoscopic access [UD II-B].

Direct introduction of trocara

The technique is based on the assumption that the complications of the laparoscopic entry into the abdominal cavity are caused to a greater degree in the introduction of the needle of the versol and insufflation of carbon dioxide. A hand surgeon lifts the front abdominal wall, while creating a negative pressure in the abdominal cavity. The first trocacar is carried out through all layers of the anterior abdominal wall in the middle line submbled, then laparoscope is introduced and the surrounding tissues inspect. Advantages: direct access short on 4, 3 min [UD II-2 V].

The traditional entry into the abdominal cavity using the palmer dough is used. This test is designed to determine whether the location of the needle from the battles or intestinal loops as a result of previously transferred operations is free. After the introduction of the needle of the Vereasha Abdominal cavity is filled carbon dioxide. A half-filled with a needle with a needle, an abdominal puncture is carried out next to the needle in the estimated direction of the first Troacar movement, due to increased pressure There is an aspiration of the contents of the abdominal cavity in the syringe. Pure gas shows that the place is free, the absence of aspirate or blood points to the spikes, the turbid liquid indicates the puncture of the intestinal loop. Repeat repeatedly in various places of the front abdominal wall until pure gas is obtained [UD I-A].

Preventive actions:

Regular observation in the gynecologist, timely treatment of urogenital infections, natural family planning: protection against unwanted pregnancy, abortion failure, childbirth through natural labor pathways, regular sex life, careful intervention, use of the anti-barrier (gel), early activation after surgery, physilation .

Further maintenance - On the outpatient stage, physical peace, mud, physical peace for 3-6 months, dynamic observation of a gynecologist's doctor.

Hospitalization

Indications for hospitalization indicating the type of hospitalization

Indications for hospitalization - chronic pain symptom, infertility, chronic pelvic pain, intestinal disorders due to adhesions, hospitalization type - planned .

Information

Sources and literature

1. Protocols of the Expert Commission on Health Development Mort RK, 2014
   1. 1) Philippe Laberge, George Vilos, Jeffrey Demptster, Artin Ternamian. Full Guideline. LaparoScopic Entry: A Review of Techniques, Technologies, And Complications No. 193, May 2007. 2) Adamyan L.V., Mynbaev O.A., Arslanyan K.N., Strugatsky V.M., Kocharyan L.T., Danilov A.Yu. Characteristics of peritoneal adhesions with repeated operations in gynecology // Endoscopy and alternative approaches in surgical treatment female diseases (gynecology, obstetrics, urology, oncogynecology). Ed. V.I. Kulakova, L.V. Adamyan. M., 2001. - S.533-537. 3) Kumakiri J, Kikuchi I, Kitade M, Kuroda K, Matsuoka S, Tokita S, Takeda S. Incidence of Complications During Gynecologic Laparoscopic Surgery in Patients After Previous Laparotomy.//j Minim Invasive Gynecol. 2010 jul-aug; 17 (4): 480-6. 4) Krasnova I.A., Mishukova L.B., Golovkin N.V., Shtyos S.V., Bresenko N.V. The significance of the ultrasound method of research to diagnose the adhesive process to laparoscopic operations // Laparoscopy and hysteroscopy in gynecology and obstetrics. Ed. V.I Kulakova, L.V. Adamyan. M.: Panter, 2002. - S.509-510. 5) Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, Botchorishvili R, Pouly J, Mage G, Canis M. Complications After Surgery for Deeply Infiltrating Pelvic Endometriosis. // BJOG. 2011 Feb; 118 (3): 292-8. DOI: 10.1111 / J.1471-0528.2010.02774.x. 6) Merviel P, Lourdel E, Brzakowski M, Garriot B, Mamy L, Gagneur O, Nasreddine A. Should A Laparoscopy BE Necessary in Case of Infertility with Normal Tubes at Hysterosalpingography?.. // Gynecol Obstet Fertil. 2011 SEP; 39 (9): 504-8.
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The inspiration is a special pathological condition of the body, with the development of which the serous membranes of internal organs occurs. This problem is accompanied by the formation of battles that are formed from the connective tissue. The adhesive disease of the abdominal cavity is assigned the code on the ICD-10 K66. This is a serious pathology that is relevant problem Abdominal surgery.

Etiology and pathogenesis of the disease

The adhesion process flowing in the abdominal cavity may be congenital or acquired. In the first case, the defect is developing as a result of pathologies of intrauterine development. The acquired disease is a consequence of natural protective mechanisms of the body.

Most often, the sleeping process develops against the background of inflammatory diseases of the peritriate cavity. A mechanical injuries that are accompanied by a long recovery process are capable of such pathology. Also spikes can be formed due to surgical interventions made in the abdomen (cesarean section, operations on organs).

Other reasons for the development of the disease include:

• inflammation of peritoness leaflets caused by bacterial microflora;
• gynecological diseases - endometriosis, salpingoophoritis, endometritis;
• a tendency to the formation of adhesions, transmitted by inheritance;
• bloodsieved in the abdominal cavity;
• tuberculous peritonitis of chronic flow;
• damage to tissues by chemicals.

Clinical manifestations of adhesive disease develop against the background of inflammation in the abdominal cavity. The affected tissues react with a special protein of blood - fibrinogen. As a result, fibrin is formed. He is able to enter into various toxins. After a while, the fibrin covers the puretes, gluing them. Observe the separation of inflammation zone from healthy tissues.

If there are insignificant spike injuries, they are able to dissolve. With the development of deeper damage between fibrin fibers, collagen threads, anastomosis of nerve endings and vessels are formed. An independent absorption of such formations is impossible.

Clinical picture

The list of symptoms of the adhesive process in the abdominal cavity depends on the localization and severity of the pathological process. The disease can flow without any clinical signs Or manifest itself sharply with the need to hospitalize the patient to the department of surgery.

Urgent states in the presence of adhesions are most often caused by the obstruction of the intestine. In such a situation, the development of the following symptoms is observed:

• pronounced pain syndrome without clear localization;
• disorder of the digestion process, which is manifested by nausea, vomiting;
• increasing body temperature;
• violation of the intestinal work with the advent of diarrhea or constipation;
• reduction of blood pressure indicators;
• weakness and decay of forces.

For adhesive disease, it is characterized by periodic disappearance and the emergence of its main symptoms. With this nature of the development of pathology, the patient complains of abdominal pain, on the intestinal work disorder. With poorly pronounced symptoms, they talk about chronic adhesions.

Diagnosis of adhesive disease of the abdominal cavity

It is possible to suspect the presence of adhesive disease on the basis of developing symptoms and the corresponding anamnesis. The patient usually identifies the facts of surgical interventions on the ORP, the presence of infectious or inflammatory diseases. To clarify the reasons for the appearance of patient complaints, doctors carry out comprehensive diagnosis using the following instrumental techniques:

• review radiography of the abdominal cavity;
• gastroscopy;
• ultrasonic diagnosis of abdominal organs;
• colonoscopy;
• laparoscopy;
• radioisotope examination using iodine radioactive isotopes.

Barium is used to assess the intestinal passability, which is determined using X-ray radiation. An irrigoscopy is used to check the status of the colon. It is performed with an additional introduction of a contrast agent.

Methods of therapy

The treatment of adhesions in the abdomen area is carried out by a conservative or surgical method. The first method of therapy is used to prevent the formation of adhesions and their negative consequences, to relieve developing symptoms. Operation is carried out mainly in development. urgent states, with frequent relapses or exacerbations of the disease.

While doing conservative treatment Clearing acute pain syndrome is performed. When the unpleasant sensations are caused by the accumulation of gases in the intestine and constipation, the cleansing enema is carried out. The pain syndrome should also be treated by producing warm compress on the stomach, the reception of spasmolitics. In the presence of vomiting, antiemetic drugs are prescribed. If the patient has signs of dehydration of the body, infusion therapy is carried out. To prevent the development of constipation, doctors recommend adhering to the following recommendations:

• compliance with a special diet aimed at enhancing intestinal peristals;
• the use of light laxatives;
• conducting some physioproches - paraffin applications, mud, ionophoresis and other;
• the use of folk remedies for improving the intestinal functions;
• the elimination of intense physical exertion.

Surgical intervention in the presence of this pathology is quite complex. It implies serious preparation that prevents development postoperative complications. Before interfering, patients intravenously poured solutions to prevent dehydration, normalize blood composition, for detoxification. After surgery, patients entered proteolytic enzymes, anti-inflammatory and antihistamines, measures are taken to stimulate peristalsis.

Possible complications and consequences

For chronic flow Diseases in patients develop somatogenic neuroses, which cause irritability, poor mood and well-being. Gradually become more pronounced disorders of the motor-evacuation function of the digestive tract, which leads to the need of patients more and more limit themselves in nutrition. Other hazardous consequences of adhesive disease are found in patients:

• significant loss of body weight;
• violations in the work of the nervous system;
• development of endocrine disorders;
• violation of the functions of the cardiovascular system.

In women, adhesive disease can cause infertility and development of various problems of a gynecological nature. Also, this pathology is dangerous in that even in cases of successfully completed treatment, there is a high probability of recurrence.

Preventive measures and forecast

Prevention of adhesive disease lies in timely treatment inflammatory processes localized in the abdominal cavity and in a small pelvis. If there are concomitant diseases, it is important to correctly choose treatment and carefully approach the needs of the operational intervention. Other recommendations should be observed for preventing the formation of adhesions in the abdomen:

• adhere to healthy image life;
• abandon any bad habits;
• if you have health problems in a timely manner to see the doctor and fulfill all its recommendations;
• do not neglect physical activity;
• to carefully follow the work of the intestine and prevent the development of constipation.

While doing operational treatment On the abdominal organs, patients recommended various physiothereders to accelerate the healing process, prevent inflammation and formation of scar tissue. Patients who have increased the risk of degraded development, prescribe immunoassophia, fibrinolytic drugs to prevent fibrin formation.

Despite the treatment and implemented prevention, the forecast for this disease is not always favorable. Operation to remove adhesions is able to facilitate the patient's condition, but does not always completely eliminate pathology. On the contrary, surgical intervention can increase the likelihood of recurrence.

Fast disease is called a pathological condition due to the occurrence of dense connective tissue structures (heavy) between the peritoneum and internal organs.

All sorts of inflammation and traumatic damage to the peritoneum can be an impetus for the development of adhesive disease, as well as surgical operations on the abdominal organs.

The formation of adhesions is protective reaction The body trying to protect the healthy organs from damaged structures by forming a white adhesive tank with a high fibrin content.

The main purpose of this sticky of the connective tissue film is to glue the adjacent surfaces, which helps limit the lesion zone. As the inflammatory process is raised, more dense structures that connect the peritone with the internal organs can form in the places of formed.

Treating and significantly limiting the mobility of internal organs and blood vessels peritoneum, spikes over time are increasingly compacted and shortening, creating conditions for occurrence dangerous diseases, ending, for example, female infertility or complete intestinal obstruction.

The inflammatory process in the abdominal cavity does not always lead to adhesions. If a whole range of preventive measures aimed at preventing adhesive disease can be in a timely manner, it is possible to avoid this severe pathology.

Forms

Depending on the etiology of the occurrence, adhesive disease can be:

• Congenital. Rare cases of such pathologies are usually represented by the sacrifices between the loop of the colon (Jackson membranes) or flat interchequctal battles (the so-called damasters of Lane).
• Acquired, developing as a result of surgical operations, inflammatory diseases of the peritoness (peritonitis, viscerite, periprocesses of internal organs) or its traumatic damage accompanied by hemorrhages in the visceral leaf area.

Features clinical flow Allocate three main forms of adhesive disease:

• acute, accompanied by pronounced symptomatic intestinal obstruction;
• an intermittent, distinguished calm clinical flow;
• chronic, characterized by alternating periods of the complete absence of clinical manifestations and exacerbations of the ailment.

Code of the ICD-10

In the last version international Classification Diseases (ICD-10) The spikes of the abdominal cavity are attributed to the XI class covering the diseases of the digestive system.

In the "Other defeat of the peritoneum" (under the code K66. 0) Spikes are combined:

• stomach;
• diaphragms;
• mesenters;
• abdominal;
• intestines;
• self;
• pelvic (in men).

Peritoneal spikes in women localized in the field of small pelvis are attributed to the XIV class, including diseases of the urogenital system, under the code N73.6. For postoperative peritoneal pelvic spikes in women, the code N99.4 is fixed.

According to this classification, adhesive disease is referred to immediately to two classes. The basis for the extraction of adhesive diseases of a small pelvis into a separate category is inflammatory lesions of female genital organs.

Causes of the disease

There is a huge number of reasons that can provoke the development of the adhesive process.

The only moment uniting all these reasons is the final result - damage to the tissues and organs of the abdominal cavity (the type of damage in this case does not have the value).

Damaging factors for convenience are made to divide into three groups.

Mechanical damage to the abdominal cavity, accompanied by the occurrence of internal bleeding, the formation of the hematoma, metabolic disorders and the outflow of lymph in the structures of the affected tissues, may occur as a result:

• surgical interventions;
• strong blows;
• all sorts of drops (on solid objects or from height);
• bullet wounds;
• koloto-cut wounds.

A group of inflammatory diseases capable of leading to the emergence of adhesive disease is presented:

• appendicitis (inflammation of the appendix);
• colitis (inflammation of the colon);
• enteritis (inflammation of the small intestine);
• ooforitis and salpingitis (ointment of uterine pipes and appendages);
• cholecystitis (inflammation of the gallbladder).

Chemical injuries of the abdominal organs can be obtained as a result:

• - the most dangerous complication peptic diseaseending in the abdominal cavity of the contents of the stomach and concentrated gastric juice;
• severe pancreatitis, leading to spreading specific enzymes throughout the abdominal cavity;
• alkaline or acid burns obtained due to the intentional or random use of acids and alkalis;
• gap bubble with inevitable oral influence.

A fairly common cause of adhesion disease in the field of small pelvis and intestines and intestines is the presence of a chronic inflammatory process in genital female organs.

The cunning of this illness is that due to the gloveness of clinical manifestations, it may proceed for many years, leading to irreversible changes, the most difficult of which is infertility.

In rare cases, the adhesion process can be a consequence of intrauterine defects of development and congenital anomalies.

Symptoms of adhesive diseases of the abdominal cavity

Features of the clinical course of adhesive disease are directly related to the form of the pathological process.

Acute form always starts suddenly. The patient has severe abdominal pain. Against the background of gradually reinforcing intestinal peristals, vomiting develops and an increase in body temperature occurs. A common blood test taken at this point will indicate the presence of leukocytosis and an increased erythrocyte sedimentation rate.

As increasing the obstruction of the intestine of the patient suffers from:

• Constant thirst.
• Frequent attacks of vomiting (the composition of the vomit first is presented by the content fine intestine, then - gastric juice and bile). Vomiting, not bringing relief, leaves a feeling of gravity in the stomach.
• Discomfort caused by a bowl of the intestines.

In addition to the above manifestations, it should be noted:

• skin sinusiness, tight lips, ears, fingers on hands and legs, nose tip;
• braking of conditional reflexes;
• a significant reduction in the volume of urine produced by the kidneys during the day (daily diurea).

When the belly palpation, the patient experiences acute pain, to establish the localization of which it is difficult.

The intermittent form of adhesive disease is characterized by the frequency of emerging pain. For this form of illness, a whole complex of dyspeptic disorders is characterized (the occurrence of heartburn, bumps, oxygen, increased gas formation, sensation of the stomach) and a significant change in intestinal peristaltics. In some patients, it, intensifying, leads to the emergence of diarrhea, the others weakens so much that it provokes the appearance of constipation.

For chronic form Favorable disease is characterized by the presence of weakly pronounced clinical manifestations: occasionally arising from the other pains and rather minor intestinal disorders.

As a rule, such a form acquires a safe process that struck the female genitals. His main danger is a negative impact on the formation of the menstrual cycle and the ability to the birth of children.

Diagnostic methods

To suspect the existence of the adhesive process, an experienced surgeon may still at the initial examination of the patient.

The basis for suspicion may be:

• whole complex of characteristic complaints;
• previously transferred inflammatory diseases of the abdominal organs;
• implemented surgical interventions;
• infectious pathologies.

To form an accurate diagnosis, a number of instrumental research is needed:

• Ultrasound of the abdominal organs. The main value of this diagnostic procedure consists in the possibility of identifying the adhesive process on its preclinical stage, which greatly facilitates the treatment of ailment and improves its forecast. In the case of detection of the adhesive process at a later stage of its development, ultrasound allows to determine the exact localization of connective tissues and their prevalence.
• Laparoscopy - procedures for the diagnostic examination of the condition of the abdominal cavity using the optical system of the laparoscope - the device introduced into the patient's body through small punctures in the front wall of the abdomen. An endovide camera mounted in a laparoscope transmits an image to a special monitor equipped with a multiple increase function, so the execution of laparoscopy is carried out under the control of vision. The main advantage of this diagnostic procedure is its low traumaticity and the possibility of diagnosing without waste. If necessary, diagnostic laparoscopy can easily transform into a medical procedure: finding spikes, the surgeon can perform an operation to eliminate them.
• MSCT (multispiral computed tomography) of the abdominal organs allowing to obtain two- and three-dimensional images of internal organs with which you can identify any neoplasms.
• The overview radiography of the abdominal cavity is a diagnostic technique that is of great importance in the formulation of an accurate diagnosis in adhesive disease. X-ray pictures obtained during the procedure can identify the presence of increased gas formation in the intestines, its bloating, as well as the presence of inflammatory exudate in the abdominal cavity. To determine the degree of intestinal obstruction, radiography is often performed using an X-ray-contrast substance - barium sulfate suspension.

Electrogastrography - electrophysiological studies of gastric peristaltic by registering the stomach biopotentials. To implement this procedure, the electrodes are either implanted into the wall of the stomach, or attach to the skin cover of the front wall of the abdomen.

How to treat adhesive disease?

The treatment of adhesive disease can be:

• Conservative. The main goal conservative therapy It is preventing the emergence of adhesions and their complications, as well as the elimination of their clinical manifestations.
• Surgical. Indications for surgery are: urgent acute states, frequent exacerbations and regular recurrence of adhesive disease.

The first priority of the conservative treatment of the adhesive process is to relieve pain syndrome. If a painfulness caused by the accumulation of gases in the intestine and the presence of constipation, to relieve the condition of the patient will help:

• cleansing enema;
• taking antispasmodics - drugs that contribute to the relaxation of smooth muscles;
• applying heat to the stomach.

To get rid of constipation, the patient is prescribed:

• A special diet consisting of products that contribute to the strengthening of intestinal peristaltics (there must be a large amount of plant fiber).
• Preparations that have a light laxative effect.
• A number of physiotherapy procedures. The ionophoresis (method of delivery of charged ions with electroplating currents of low voltage and low force), diathermy (heating the deep-resolidating organs and tissues, helps electric shock High frequency), mud and the cycle of paraffin applications.
• A complete refusal to severe physical exertion contributing to the spasmodics of smooth muscles and provoking the gain of pain syndrome.

To stop vomiting the patients prescribe antihores medicine, and intravenous administration Special preparations helps to cope with the effects of dehydration.

Operation

Operational interventions related to the treatment of adhesive process require a mandatory and very serious preoperative preparation of the patient.

To eliminate the symptoms of dehydration and normalize the acid-base condition of the blood, the patient intravenously - in addition to the blood plasma - solutions are poured:

• Ringer-Locke;
• sodium bicarbonate;
• sodium chloride.

The choice of operational intervention methods in each specific case is carried out individually: during operation, detected spikes can be removed, divided or spread.

Dissection of adhesions can be carried out with:

• electron-like (this area of \u200b\u200bmedicine is called electrosurgery);
• laser (during laser and therapy operation);
• water (this type of operation is called aquadissection).

The excision of the old scars remaining on the skin from the previous operation is not produced, since it is fraught with the development of complications associated with a durable soldering of intestinal loops.

In the detection of necrotic sections of the intestine, resection (removal) of the affected area is carried out with the subsequent restoration of intestinal passability or an artificial hole that restores the message between the cavity of the internal organ and the external environment.

In the presence of heavy, essentially deforming the intestines, impose bypass intercircuit anastomosis. If the Conglomerate of intestinal loops was too tight, perform resection of the problem area.

To prevent recurrence of adhesive disease, during surgery:

• cuts are made wide;
• take measures to prevent the dryness of the peritoness leaves;
• prevent the ingress of foreign bodies into an operating wound;
• bleeding timely and remove blood;
• dry antiseptic and antibiotic drugs for processing operating wounds;
• conduct conservative treatment by introducing barrier liquids - diplot, dextrana (with the same purpose, films are applied to the surface of the ovaries and uterine pipes);
• polymer suture is used.

During postoperative period In the abdominal cavity of the patient, proteolytic enzymes are introduced, the incentive peristaltics is stimulated, antihistamines and anti-inflammatory drugs are prescribed.

Diet

Patient food presumably suffering from adhesive disease must obey a number of rules:

• Acceptable food should be warm and rubbed, and the volume of portions - reduced to a minimum.
• It should be eaten at least five to six times a day.
• It is necessary to make a power schedule, which provides for the same clock of food intake: it will facilitate the body of the problem for its processing.

The main goal of such a diet is to prevent the intelligence sensations associated with the occurrence of constipation and driving the abdomen.

During the preoperative period, the patient must completely refuse to use:

• Products containing a large amount of coarse vegetable fibers, overloading the intestines and the cause of increased gas formation. This category includes: corn, legume crops, any kind of cabbage.
• Smoked, pickled, salted and fried dishes.
• Mushrooms who are poorly digested by the human body.
• Baking baking I. white breadprovoking the "swelling" of the abdomen.
• Mayonnaise, fat broths and sauces activating fermentation processes and capable of reinforcing pain syndrome.
• Any sharp seasonings (adjika, pepper, mustard) capable of irritating the mucous membranes of organs gastrointestinal tract.
• Carbonated drinks, tea, coffee and milk. The best drinks during diet are green tea and drinking water.

At the table of a patient suffering from adhesive disease, should be:

• Puree from boiled vegetables.
• Lean broths.
• Low-fat fish, chicken and rabbit meat (exclusively in boiled form).
• Dishes from cottage cheese and cheese.
• Non-fat yogurt and kefir.
• Strongly strained liquid cereals (oatmeal or buckwheat), prepared on water with the addition of a small piece of butter.

Postoperative nutrition

Compliance with the diet after the elimination of adhesions is necessary so that the mucous membranes of the operated organs can fully recover.

• For twenty-four hours after the operation, the patient must refrain from eating any food. It is possible to drink water, but in small quantities.
• After a day, the diet of the operated patient includes lean broths and liquid rubbing cripples.
• In the following days, vegetable soups, purees, juices and ragners are introduced into the menu medicinal herbalSugar not containing.

As the patient's state normalizes (this happens during the week), the consistency of the dishes used becomes more dense, and the food is enriched with a whole complex of mineral and nutrients.

During this period, the operated patient is allowed to use:

• Scrambled eggs.
• Boiled chicken and fish.
• Puree soups cooked from carrots, beets and zucchini.
• Efficiency products (especially kefir), contributing rapid restoration organism.
• Apples (rubbed or baked).
• Compats, kisins and fruits.
• Fruit juices, which should be exclusively fresh and half diluted with clean drinking water.

The selection of a postoperative diet is individually carried out by the attending physician. The harder and launched was a transferred ailment - the more strict is the appointed diet.

The patient must in every way avoid the use of products capable of provoking the occurrence of constipation, bloating and irritation of the mucous membranes of digestive organs.

Folk remedies

Funds folk Medicine In case of adhesion, there may be an effective impact or as prevention of relapse (during the rehabilitation period), or in the earliest stages of illness as an additional fundamental treatment.

• Most often applies the decoction of the Hypericum. Taking a dining spoon of dry raw materials, poured it with a glass of steep boiling water and boiled in a water bath for a quarter of an hour. After the filping, they drink 100 ml three times a day.
• A similar action has a decoction made from a tablespoon of plantain seeds and 400 ml of water (The cooking technology is the same as in the prescription described above). The duration of the course of treatment - under the condition of three-time reception on one tablespoon - is at least four weeks.
• No less demanded infusion made from a hipsnik berry (30 g), lingonberries (15 g) and nettle leaves (30 g). Bay of phytosyrin liter boiling water, insist in a thermos overnight. Take 100 ml: before bedtime and only on an empty stomach.
• Mixing dry phytosyri (Dinner, Mother-and-stepmother and gold maternity, taken in equal shares), take a tablespoon herbal collection And, falling asleep it in the thermos, the glass of steep boiling water is poured. After two-hour instead, the infusion is taken by 100 ml at least five times a day. The minimum course of treatment is four weeks.

Prevention and forecast

In the presence of single adhesions, the forecast is favorable, which cannot be said about the disease leading to the emergence of multiple lesions.

It is possible to prevent the development of adhesive disease by complying with a number of uncomplicated rules prescribing:

• compliance with a healthy lifestyle;
• the need for rational and full nutrition;
• the obligation of optimal sports loads;
• invalidation of alternation of periods of long starvation with episodes of overeating;
• mandatory monitoring of the regularity of the chair;
• the need for measures aimed at ensuring full digestion;
• the obligation of regular inspections from the gastroenterologist.

The success of the prevention of adhesive disease largely depends on the level of qualification of attending specialists: from the adequacy of the treatment prescribed by them and the right choice of operational intervention techniques, which makes it possible to make an operation (with respect to first patients) the least traumatic, and the sleeping process is minimal.

To prevent the need for repeated surgical interventions, the specialists of the leading clinics resort to the method of preoperative identification of a constitutional hereditary predisposition to the formation of adhesions.

After performing the operation in the abdominal cavity of the patient, special antley preparations are introduced.

There is a suggestion that the economic benefit from the use of antisposhic drugs to the introduction of the method of preoperative detection of genetic predisposition to adopted diseases Russian Federation It may make more twenty million dollars only by reducing the cases of re-acute adhesive intestinal obstruction.

The video shows a complex of exercises recommended for adhesive disease during the remission:

The inspired disease is the direct effect of operational interventions in the human body, especially in the abdominal cavity. Any symptoms depend on the prevalence of the process and severity of complications. Many scientists say that almost all the abdominal surgery consists of sucks, but throughout life they are resolved.

How does adhesive disease develop?

Under appendicitis, which was not treated at one time, a limited cavity is formed when the permane is adjacent to the inflammation area. Such a process is called appendicular infiltrate. Such cases occur during operational interventions.

The peritonese can adhere to:

• Inflammation zone;
• Operated organ;
• Plusions.

During the so-called "gluing", the normal functioning and arrangement of organs is disturbed.

In the future, such spikes are shortened and compacted, which leads to even greater displacement. In this case, the normal bloodstream is disturbed and oxygen starvation begins to develop, which subsequently leads to painhers in the abdomen during adhesive disease.

With similar displacements, the movement of the exit of feces is disturbed, which leads to permanent constipation. In the future, intestinal obstruction can develop.

The ICD-10 (international classifier of disease) distinguishes two types of diseases, such as:

• Adhesive disease of a small pelvis;

Visceral

In essence, these are two identical diseases, as a small pelvis refers to the abdominal cavity. But this disease is made to relate to a separate category, because the cause of adhesions, precisely in this case, is the inflammatory disease of the female genital organs.

The reasons

The reasons for the development of the adhesive process are quite a lot, but they all lead to damage to the tissues and abdominal organs, no matter what kind they are.

Consider the very frequent reasons adhesive process. Such are:

1. Mechanical injuries of the abdominal cavity;
2. Chemical damage;
3. Inflammatory diseases.

The following indicators can be attributed to mechanical injuries of the abdominal cavity:

• Surgical operations;
• Bullet injuries;
• Wounded wounds;
• Falling from height;
• Strikes;
• Falling on a solid subject.

Chemical damage includes such indicators:

• Gap bubble with bile pouring;
• Severe pancreatitis with multiple consequences;
• Sprinkling the stomach with an exit to the abdominal cavity;
• Burns with alkali or acids with intentional or random application.

The following indicators include inflammatory diseases:

• Pipes and appendages;
• Tolstoy intestinal disease;
• Sickness of the small intestine;
• Diseases of the gallbladder;
• Appendix (appendicitis).

Very often in women, the development of adhesive disease is formed during chronic inflammatory processes In the female genital organs. With insignificant symptoms and long-term treatment, adhesive disease can lead to an irreversible process and infertility.

The accompanying launches of adhesive disease is diabetes, poor diet, foreign bodies In the wound

Classification

According to the international classification of diseases (ICD-10), the adhesives of the abdominal cavity are divided into the following types:

1. Abdominal spikes (K66.0);
2. Postoperative spikes in a small pelvis (N4);
3. Peritoneal inflammatory spikes in women in small pelvis (N6).

The abdominal spikes include the following species of adhesions:

• Spikes of the stomach;
• Spikes of the gland;
• Spikes mesentery of a thick or small intestine;
• Pelvic spikes in men;
• Spikes intestines;
• Spikes diaphragm;
• Abdominal spikes.

Types of pathologies

The outer surface of organs in the abdominal cavity and the abdominal cavity itself consists of translucent cell tissue, which formed with two plates:

These two plates gradually passes each other and form a closed space, which is called the abdominal cavity. All spaces that were formed between organs and their walls, do not have emptiness. All of them are filled with serous substance.

Spikes are divided into 2 types:

1. Viscero-parietal. Organs or guts grow to the wall of the abdominal cavity.
2. Viscero-viscerals. Intestinal loops or organs grow together.

What type of spike and which locations of their localization give to understand the obvious symptoms of the disease, and also provide the ability to recognize the effect on the functioning of other organs.

Symptoms

There are a number of symptoms for which the disease of the adhesions are determined. These indicators are:

• Long constipation. With normal and correct power mode, the absence of potassium masses is noticed. It happens more than two days. Such a symptom is the most dangerous, because it indicates the most dangerous complication of the adhesive process, such as intestinal obstruction.
• Disps syndrome. This symptom means a violation of the normal functioning of the stomach. In area digestive system There are inconvenience, discomfort, pain, the difficulty in digestion appears. With such symptoms, a tendency to constipate is often noticeable. The patient can feel pain in the abdomen, overflow, bloating, severity.
• Painfulness. Either pulling, or short-term seizures that can enhance with exercise or sharp turns and change the position of the body may appear.
• Violation of intestinal peristalsis. In case of failures, short constipation observed. In the normal state of the wall, the walls are reduced and progressive masses to the output.

Diagnostics

Treatment

Spikes intestines remove only surgically. No other methods for freeing the intestinal loops from connective tissue, no. The operating period also assigns a course of conservative therapy.

Surgical method

Recovery removal operation has two kinds.

Laparoscopy is the first (this is microoperation). On the front abdominal wall there are 3 not large cuts. Thin fiber optic tube with a video camera and a diode lamp and a manipulator for fixing internal organs are injected through them.

The operation does not carry strong injuries, so for 3 days the patient can write out.

The second is Laparotomy. On the abdominal wall there is a cut in 15 centimeters. This method is applied with a large number of intestinal adhesions.

Conservative treatment

1. Special diet.
2. Installing a nasogastric probe.
3. Spasmodics;
4. Hypertensive enemas;
5. Intravenous injection solutions.

Folk remedies

Spike pain. Apply 3 tablespoons of flax seeds, put in the bag and dip in boiling water for three minutes. After removal, squeeze, and the finished compress is applied to the patient area.

Common discomfort. Use 1 tablespoon of dry Hypericum and poured a glass of boiling water. Leave to strengthen about 15 minutes and filter. The finished decoction is divided into three parts and drink throughout the day.

Prevention

In order not to occur recurrence, the following actions must be performed:

• Follow correct nutrition;
• Do not lift gravity;
• Do wellness gymnastics.

- The disease caused by the formation of connective tissue heavys between internal organs and peritoneum. Pathology is most often associated with the previous operation. Symptoms depend on the localization of adhesions and their prevalence. For acute period, abdominal pains, diarrhea or constipation, vomiting, pressure drop, increase temperature, weakness. The diagnosis is to carefully collect anamnesis and complaints, as well as the radiography of the abdominal bodies, ultrasound, MRI, laparoscopy. Treatment is aimed at relieving symptoms, preventing the progression of pathology, with frequent exacerbations and relapses, the operation is shown.

General

Flash disease is a pathological condition due to the formation of connective tissue battles (adhesions) in the abdominal cavity. The human body is uniquely arranged, at a certain point in time, it includes protective mechanisms that can prevent the development of severe complications, but this is reflected in general condition. In order to fencing healthy organs from damaged structures around the pathological focus is formed connective tissue. It cannot fill the functions lost, but allows you to fill the emptiness and protect the surrounding fabrics from pathology. At first, this tissue is loose, then it is compacted and sometimes pinched. So the spikes are formed.

Spikes in the abdominal cavity are connective tissue tags that connect peritoneum and internal organs. The fights are drawling organs and limit their mobility, create conditions for violating their functions, so often cause serious diseases, for example, intestinal obstruction or female infertility.

The reasons

By provoking factors initiating the mechanism of adhesive disease, there may be diseases of internal organs in combination with operational injury (in 98% of cases). If the injury is joined by infection, blood, the drying of the peritoneum, the risk of adhesions is increasing.

Start the development of adhesive disease can bruise and abdomen injury. Dumb mechanical damage is often accompanied by internal bleeding, the formation of hematomas, impaired lymphottock and metabolism in the affected tissues. This leads to the frustration of blood flow in the peritoneum and the beginning of inflammation with all the ensuing consequences. Bashes may also cause congenital anomalies and malformations, chemicals, drugs and foreign bodies.

Pathogenesis

The internal organs of the abdominal cavity are covered with thin leaflets of peritoneum. Normally, they have a smooth surface and secrete a small amount of fluid to ensure the free movement of the abdominal organs relative to each other. Various provoking factors lead to the tissue edema and the appearance of fibrin plaque on the peritoneum. Fibrin is a sticky substance that contributes to the connection of nearby tissues. If at this time not to carry out adequate therapy, then after an element of pathological processes at the place of gluing, spikes are formed.

The process of formation of battles takes place in several stages: the fibrin falls first, then in 2-3 days there are special cells (fibroblasts), which secrete collagen fibers. The pronounced substitution of inflamed tissues by connecting begins on the 7th day and ends at 21. During this period, the battle is turned into dense spikes, capillaries and nerves germinate.

Symptoms of adhesive disease

Clinical signs of adhesive disease depends on the localization of the adhesions and the prevalence of pathology. The disease can proceed asymptomatic or appear suddenly and sharply with the need for urgent hospitalization into the department of surgery.

Urgent states in adhesive disease are most often associated with intestinal obstruction. In such situations, patients impose complaints of intensive pain, nausea, vomiting, an increase in body temperature. The palpation of the belly causes sharp pain, and the patient cannot determine their exact localization. The disease has a strong influence on the intestinal peristals: it is possible to strengthen with the development of diarrhea or, on the contrary, weakening to complete disappearance, which leads to the appearance of constipation. Multiple vomiting sharply worsens the condition of patients and causes dehydration, it is combined with a fall in blood pressure, harsh weakness and fatigue.

Sometimes symptoms of adhesive disease have a periodic character, then appearing, then suddenly disappearing. In this case, the patient is disturbed by pain in the abdomen, constipation or diarrhea. If a clinical manifestations weakly expressed, occasionally arises it's a dull pain And minor intestinal disorders, then talk about the development of chronic adhesion disease. Most often, gynecologists face similar states, since the adhesion process may affect the internal genitals, having a negative impact on the menstrual function and the ability to childbear.

Diagnostics

The surgeon may suspect the adhesive disease during the initial inspection of the patient in the presence of characteristic complaints preceding inflammatory diseases of the abdominal bodies, operational procedures and infectious pathology. Diagnostic events It is implied by carrying out laparoscopy, ultrasound and MSCT of the abdominal organs, radiography, electric strooperography.

• Laparoscopic research - The most informative method for diagnosing adhesive disease. This is essentially microcumentation in the performance of small incisions, the introduction of special tools with the camera, which allows to conduct video physiization of internal organs. This is not only a diagnostic procedure: after the problem is detected, you can immediately implement surgery for the treatment of adhesive disease.
• Obvis Radiography Ob.plays a big role in the formulation of the diagnosis of adhesive disease. The method allows you to detect inflammatory exudate in the abdominal cavity, increased gas formation In the intestine and his bloating. Often the study is carried out using a contrast agent for determining the intestinal obstruction.
• Electrogastrightographyit implies the measurement of electrical signals from different departments of the digestive tract during its reduction.
• Ultrasound and CT abdominal organs- accurate methods allowing to determine the location of adhesions and their prevalence.

Treatment of adhesive disease

The treatment of adhesive disease is to carry out conservative and surgical procedures. Conservative therapeutic measures are aimed at preventing the formation of adhesions and their negative consequences, as well as the relief of symptoms. Operational intervention is carried out with acute urgent states, constant relapses of pathology and frequent exacerbations.

Conservative therapy

At the beginning of the conservative treatment of adhesive disease, the painful sensations will be bought first. This can be achieved by carrying out a cleansing enema (if the pain is associated with constipation and retention of gases), the imposition of heat on the stomach, the reception of spasmolitics. Solve the problem of constipation can be prescribed by a special diet enriched with products that enhance the peristaltics (any errors in nutrition can cause a sharp exacerbation of pathology). If it does not help, mild laxatives and physiotics are prescribed: diathermy, paraffin applications, ionophoresis, mud.

Patients recommend excluding physical exerciseTo prevent muscle spasms that cause increased pain. Antiwheat preparations are prescribed to eliminate vomiting, and intravenous solutions are used to remove the symptoms of dehydration.

Surgery

Surgical interventions in adhesive disease are quite complex, moreover, they imply serious preoperative training. Very often, the operations are made regarding urgent states: the preparation of such patients will be faithful, but always full. Patients are transfused by plasma, sodium chloride solution, ring meter, sodium bicarbonate to eliminate the symptoms of dehydration and normalization of the acid-base state of the blood. For the purpose of detoxification, saline solutions, refooliglucin with prednisone or hydrocortisone are introduced.

The old scars on the skin from the previous operation do not excine, as this can lead to complications, since the intestinal loops are soldered to the head. Spikes are removed, separated, spread out. The choice of method depends on the specific situation. If the intestinal necrosis areas are detected, the damaged area is led, and the permeability is restored or superimposed. In the spikes, deforming the intestines, form bypass anastomosis. Such manipulations are shown in the presence of a dense Conglomerate loops, but sometimes this area is respected.

During the operation, the basic measures to prevent the recurrence of the disease are observed: there are broad cuts, prevent the abridges of peritoness leaves, carry out a full stop of bleeding and blood removes in a timely manner, exclude in the wound of foreign items; Dry antiseptics and antibiotics are not made in the wound, polymer threads are used for stitching.

After the operation, an intraperitoneal administration of proteolytic enzymes is shown, the purpose of anti-inflammatory and antihistamine drugs, carrying out peristaltic stimulation. It should be noted that surgical manipulations of 15-20% of cases lead to the re-education of adhesions, so it is worth it to approach the therapy.

Prediction and prevention

The forecast for single spikes is favorable, but multiple lesions cause negative consequences. It is possible to prevent the development of adhesive disease, performing a number of simple actions: the correct lifestyle should be done, fully and rationally eat, play sports. It is impossible to allow periods of long starvation, alternating with attacks of overeating. It is important to monitor the regularity of the chair, as well as provide a full digestion, conducting the prevention of diseases of the gastrointestinal tract and passing regular inspections from the gastroenterologist. In many ways, the prevention of adhesive disease depends on the competence of doctors, compliance with the equipment and the rules of operation, the appointment of adequate therapy.