Diagnostic and Diagnostic and emergency assistance to the emergency assistance to the

syndrome of "acute abdomen"syndrome of "acute abdomen"

Prepared by:Prepared by:C.M.S., assistant professor C.M.S., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KSMUemergency KSMUA.R. AlpyssovaA.R. Alpyssova

The purpose of the lectureThe purpose of the lecture

After completing the lecture, students After completing the lecture, students

should focus on issues of diagnosis and should focus on issues of diagnosis and

emergency treatment with the syndrome of emergency treatment with the syndrome of

"acute abdomen" in the amount of the first "acute abdomen" in the amount of the first

medical care (doctor's line crews), and medical care (doctor's line crews), and

depending on the patient - in the amount depending on the patient - in the amount

of specialized care (reanimation of specialized care (reanimation

teams, intensive care team) .teams, intensive care team) .

The plan of the lectureThe plan of the lecture

Acute abdominal pain: causes, classification, clinical Acute abdominal pain: causes, classification, clinical picture, differential diagnosis, advices for callerpicture, differential diagnosis, advices for caller

Action on the call, prehospital treatmentAction on the call, prehospital treatment acute appendicitisacute appendicitis acute cholecystitisacute cholecystitis acute pancreatitisacute pancreatitis Perforated gastric ulcerPerforated gastric ulcer and duodenumand duodenum Acute intestinal obstructionAcute intestinal obstruction strangulated herniastrangulated hernia "Acute abdomen" in gynecology"Acute abdomen" in gynecology Acute mesenteric circulatory disordersAcute mesenteric circulatory disorders

The concept of "acute abdomen". Pathogenesis The concept of "acute abdomen". Pathogenesis and clinical picture. Tactics emergency doctor in and clinical picture. Tactics emergency doctor in detecting acute surgical abdominal pathology.detecting acute surgical abdominal pathology.

Under severe pain Under severe pain understands pain in the abdomen that understands pain in the abdomen that has developed over a period of several minutes up to 7 days.has developed over a period of several minutes up to 7 days.

Causes of acute abdominal pain due to internal organCauses of acute abdominal pain due to internal organ Inflammation of the parietal peritoneum Inflammation of the parietal peritoneum  in acute in acute

inflammatory and / or destructive diseases of internal inflammatory and / or destructive diseases of internal organs (acute appendicitis, acute cholecystitis, acute organs (acute appendicitis, acute cholecystitis, acute pancreatitis, pancreatic, Perforated ulcer, perforation of pancreatitis, pancreatic, Perforated ulcer, perforation of the colon and cecum of the appendix, a the colon and cecum of the appendix, a bacterial inflammation of the pelvis, abdominal abscesses, bacterial inflammation of the pelvis, abdominal abscesses, diverticulitis, Crohn's disease , ulcerative colitis).diverticulitis, Crohn's disease , ulcerative colitis).

Obstruction of any of the hollow organs Obstruction of any of the hollow organs of the of the abdomen (ileus, coprostasia, biliary colic, abdomen (ileus, coprostasia, biliary colic, obstructive pancreatitis, renal colic)obstructive pancreatitis, renal colic)

Violation of perfusion of internal organsViolation of perfusion of internal organs due to embolism,  due to embolism, thrombosis, rupture, stenosis or compression of the thrombosis, rupture, stenosis or compression of the arteries and abdominal aorta (acute ischemic colitis, exacerbation arteries and abdominal aorta (acute ischemic colitis, exacerbation of chronic intestinal ischemia, acute mesenteric thrombosis, or of chronic intestinal ischemia, acute mesenteric thrombosis, or rupture of a bundle of an aortic aneurysm, cyst torsion, testicular rupture of a bundle of an aortic aneurysm, cyst torsion, testicular torsion, hernia incarceration, venous infarcted bowel).torsion, hernia incarceration, venous infarcted bowel).

Stretching the capsule internal organs Stretching the capsule internal organs  in acute in acute inflammation or swelling of the parenchymatous inflammation or swelling of the parenchymatous organs (acute alcoholic hepatitis, acute thrombosis of the spleen, organs (acute alcoholic hepatitis, acute thrombosis of the spleen, acute thrombosis of the portal or hepatic veins -the syndrome acute thrombosis of the portal or hepatic veins -the syndrome of Budd-Chiari syndrome, congestive heart failure (stagnation in of Budd-Chiari syndrome, congestive heart failure (stagnation in the liver), nephrolithiasis.the liver), nephrolithiasis.

Irritation of the peritoneumIrritation of the peritoneum in violation of the metabolism and  in violation of the metabolism and endogenous intoxication (diabetic endogenous intoxication (diabetic ketoacidosis, alcoholic ketoacidosis, uremia, adrenal ketoacidosis, alcoholic ketoacidosis, uremia, adrenal insufficiency, porphyria).insufficiency, porphyria).

Immunological disorders Immunological disorders (anaphylaxis, angioedema, vasculitis).(anaphylaxis, angioedema, vasculitis). Infectious causes Infectious causes (gastroenteritis, hepatitis, infectious (gastroenteritis, hepatitis, infectious

mononucleosis, cold sores, sepsis, etc.).mononucleosis, cold sores, sepsis, etc.).

Acute or chronic exogenous intoxication Acute or chronic exogenous intoxication (chronic (chronic poisoning by mercury and lead, methyl poisoning by mercury and lead, methyl alcohol poisoning, bites of poisonous spiders, or an alcohol poisoning, bites of poisonous spiders, or an overdose of drugs cumulation).overdose of drugs cumulation).

Abdominal trauma.Abdominal trauma. Causes reactive acute abdominal painCauses reactive acute abdominal pain Diseases of organs outside the abdomen (myocardial Diseases of organs outside the abdomen (myocardial

infarction, pneumonia, pleurisy, infarction, pneumonia, pleurisy, pericarditis, pyelonephritis and paranefrit).pericarditis, pyelonephritis and paranefrit).

Diseases of the pelvisDiseases of the pelvis Diseases of the musculoskeletal and nervous systems, Diseases of the musculoskeletal and nervous systems,

leading to the defeat of the sensory nerves (spondylosis leading to the defeat of the sensory nerves (spondylosis deformans, causalgia, syringomyelia, tabes, deformans, causalgia, syringomyelia, tabes, psychogenic).psychogenic).

CLASSIFICATIONCLASSIFICATION

Acute abdominal pain Acute abdominal pain originallyoriginally distinguished as: distinguished as: Surgery that requires hospitalization in the surgical Surgery that requires hospitalization in the surgical

department of a hospital.department of a hospital. Gynecology - to a gynecological ward hospital.Gynecology - to a gynecological ward hospital. Urologic - urology department at the hospital.Urologic - urology department at the hospital. Non-surgical - a multi-disciplinary hospital.Non-surgical - a multi-disciplinary hospital. With infectious diseases - infectious hospital.With infectious diseases - infectious hospital.

CLINIC PICTURECLINIC PICTURE Acute abdominal pain may have a Acute abdominal pain may have a

different localization, characterization, and irradiation.different localization, characterization, and irradiation.Localization of acute abdominal pain in acute surgical Localization of acute abdominal pain in acute surgical

diseasesdiseases The upper right quadrant of the abdomenThe upper right quadrant of the abdomen: :

acute cholecystitis, biliary colic, hepatitis, pancreatitis, liver, acute cholecystitis, biliary colic, hepatitis, pancreatitis, liver, and subdiaphragmatic abscess, myocardial infarction, and subdiaphragmatic abscess, myocardial infarction, pneumonia, pleurisy, pericarditis, intestinal obstructionpneumonia, pleurisy, pericarditis, intestinal obstruction

The lower right quadrant of the abdomen: The lower right quadrant of the abdomen: appendicitis, appendicitis, intestinal obstruction, diverticulitis, Perforated ulcer, hernia intestinal obstruction, diverticulitis, Perforated ulcer, hernia incarceration, renal colic, ectopic pregnancy, ovarian disease, incarceration, renal colic, ectopic pregnancy, ovarian disease, endometriosis, testicular torsionendometriosis, testicular torsion

The upper left quadrant of the abdomen: The upper left quadrant of the abdomen: pancreatitis, splenic pancreatitis, splenic rupture, infarction of spleen, gastritis, myocardial infarction, rupture, infarction of spleen, gastritis, myocardial infarction, pneumonia, pleurisy, intestinal obstruction.pneumonia, pleurisy, intestinal obstruction.

The lower left quadrant of the abdomen: The lower left quadrant of the abdomen: the gap of an aortic the gap of an aortic aneurysm, aortic dissection, bowel aneurysm, aortic dissection, bowel obstruction, diverticulitis, retroperitoneal abscess, renal colic, obstruction, diverticulitis, retroperitoneal abscess, renal colic, ectopic pregnancy, ovarian disease, endometriosis, testicular ectopic pregnancy, ovarian disease, endometriosis, testicular torsion.torsion.

In acute surgical diseases often develops acute In acute surgical diseases often develops acute pain in the abdomen perforation of a hollow organ and pain in the abdomen perforation of a hollow organ and the subsequent development of the subsequent development of peritonitis (Perforated ulcer, peritonitis (Perforated ulcer, acute cholecystitis or appendicitis destructive, intestinal acute cholecystitis or appendicitis destructive, intestinal perforation at the restrained hernia or intestinal perforation at the restrained hernia or intestinal obstruction, pancreatic). At the moment of destruction of obstruction, pancreatic). At the moment of destruction of the body of a patient suddenly there is a strong pain in the body of a patient suddenly there is a strong pain in my stomach. Within minutes it grows to the my stomach. Within minutes it grows to the maximum. This pain is a reflection of an acute irritation maximum. This pain is a reflection of an acute irritation of the peritoneum contents of a hollow organ and leads of the peritoneum contents of a hollow organ and leads to symptoms of acute abdomen. It is defined to symptoms of acute abdomen. It is defined as continuous and sudden pain, increasing as continuous and sudden pain, increasing dramatically at the slightest exertion, motion, shake the dramatically at the slightest exertion, motion, shake the stomach and even beds. Pain is the strongest at the stomach and even beds. Pain is the strongest at the perforation ulcer on the background of peptic ulcer perforation ulcer on the background of peptic ulcer disease and pancreatitis, the patient may disease and pancreatitis, the patient may develop hypotension and collapse due to a painful develop hypotension and collapse due to a painful shock.shock.

In In obstruction of a hollow obstruction of a hollow organ organ develops severe paroxysmal pain or cramping -develops severe paroxysmal pain or cramping -colic. Attacks of colic can be mixed with light gaps of colic. Attacks of colic can be mixed with light gaps of different duration, accompanied by a feeling of fear and different duration, accompanied by a feeling of fear and excitement patient. Pain with colic before the onset of excitement patient. Pain with colic before the onset of degradation and peritonitis is independent of the patient.degradation and peritonitis is independent of the patient.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Differential diagnosis of acute surgical diseases is Differential diagnosis of acute surgical diseases is

beyond the scope of the EMC (emergency medical care). beyond the scope of the EMC (emergency medical care). To determine the indications and the direction of To determine the indications and the direction of hospitalization of patients with non-surgical causes hospitalization of patients with non-surgical causes of acute abdominal pain in the prehospital important to of acute abdominal pain in the prehospital important to avoid the most common acute surgical diseases.avoid the most common acute surgical diseases.

ADVICES FOR CALLERADVICES FOR CALLER Let the patient take a comfortable position for him or have Let the patient take a comfortable position for him or have

him lie on his back with legs elevated.him lie on his back with legs elevated. Do not let the patient eat or drink.Do not let the patient eat or drink. If you suspect a fever, measure body temperature.If you suspect a fever, measure body temperature. Find the medication that the patient takes, and Find the medication that the patient takes, and

show their doctor or nurse UMC (Urgent medical care).show their doctor or nurse UMC (Urgent medical care). Do not leave patient unattended.Do not leave patient unattended.

ACTIONS ON CHALLENGE ACTIONS ON CHALLENGE DiagnosisDiagnosis

OBLIGATORY QUESTIONSOBLIGATORY QUESTIONS At what point do you feel abdominal pain? Pain moved?At what point do you feel abdominal pain? Pain moved? How long does the pain?How long does the pain? What kind of pain (constant, paroxysmal, aching, What kind of pain (constant, paroxysmal, aching,

sudden, unbearable)?sudden, unbearable)? What is best for you: lie quietly or move?What is best for you: lie quietly or move? Since the beginning of what you associate pain (the Since the beginning of what you associate pain (the

error in the diet, past infectious diseases, etc.)?error in the diet, past infectious diseases, etc.)? Did you vomit (how many times and how)? Has Did you vomit (how many times and how)? Has

the nature of the chair? Increased if the temperature?the nature of the chair? Increased if the temperature? Did you have such attacks earlier (with cholelithiasis, Did you have such attacks earlier (with cholelithiasis,

chronic pancreatitis, and kidney stones pain chronic pancreatitis, and kidney stones pain attacks recur)?attacks recur)?

What operations you have had in the past (post-What operations you have had in the past (post-surgical scars, adhesive disease, hernia increases the risk surgical scars, adhesive disease, hernia increases the risk of strangulation intestinal obstruction)?of strangulation intestinal obstruction)?

What diseases you are suffering (for cardiovascular What diseases you are suffering (for cardiovascular disease, hypertension, atrial fibrillation may be ischemia of disease, hypertension, atrial fibrillation may be ischemia of the intestine, aortic dissection, aortic aneurysm rupture, the intestine, aortic dissection, aortic aneurysm rupture, thrombosis, with gallstone thrombosis, with gallstone disease - obstructive pancreatitis)?disease - obstructive pancreatitis)?

How much alcohol do you drink a day (with alcohol abuse How much alcohol do you drink a day (with alcohol abuse and possibly exacerbation of chronic pancreatitis, and possibly exacerbation of chronic pancreatitis, hepatitis, cirrhosis of the liver)?hepatitis, cirrhosis of the liver)?

In women of reproductive age should be In women of reproductive age should be collected gynecological history: when was the last menstrual collected gynecological history: when was the last menstrual period (to be confirmed presence or possibility period (to be confirmed presence or possibility of pregnancy)?of pregnancy)?

Painful menstruation is (a common symptom of Painful menstruation is (a common symptom of endometriosis)?endometriosis)?

There was a sharp pain in the middle of the menstrual cycle There was a sharp pain in the middle of the menstrual cycle (ovulation suggests)?(ovulation suggests)?

Acute abdominal pain Acute abdominal pain - a subjective feeling that the - a subjective feeling that the doctor must be properly interpreted.doctor must be properly interpreted.

1. Start: sudden slow gradual delayed1. Start: sudden slow gradual delayed 2. Intensity: strong, moderate2. Intensity: strong, moderate 3. Dynamics: subsided, the growth, the changing nature3. Dynamics: subsided, the growth, the changing nature 4. Character: constant cramping (colic)4. Character: constant cramping (colic) 5. Depth: deep, surface5. Depth: deep, surface 6. Dependence from movements of physiological 6. Dependence from movements of physiological

functions, from food intakefunctions, from food intake 7. Location: in a particular area of  the abdomen, diffuse, out 7. Location: in a particular area of  the abdomen, diffuse, out

of the stomachof the stomach 8. Stability: Stable, migration8. Stability: Stable, migration 9. Irradiation: the segmental type, reflected the pain in the 9. Irradiation: the segmental type, reflected the pain in the

affected organs previouslyaffected organs previously Pharmacological  anamnesis: glyukortikosteroidy, unstereoid Pharmacological  anamnesis: glyukortikosteroidy, unstereoid

anti inflammatory means, alcohol, thiazide diuretics, anti inflammatory means, alcohol, thiazide diuretics, pentamidine, azathioprine, sulfonamides, barbituratespentamidine, azathioprine, sulfonamides, barbiturates

INSPECTION AND PHYSICAL EXAMINATIONINSPECTION AND PHYSICAL EXAMINATION Assessment of general condition and vital Assessment of general condition and vital

signs: consciousness (anxiety or a tendency to signs: consciousness (anxiety or a tendency to fainting), breathing (tachypnea, gentlebreath).fainting), breathing (tachypnea, gentlebreath).

Determination of posture that the patient takes to Determination of posture that the patient takes to relieve pain:relieve pain:

- Position of the embryo (with pancreatitis);- Position of the embryo (with pancreatitis);- Right leg bent at the hip and knee joints (with lumbar - Right leg bent at the hip and knee joints (with lumbar appendicitis and intestinal colic);appendicitis and intestinal colic);- The patient is trying to lie perfectly still (with diffuse - The patient is trying to lie perfectly still (with diffuse peritonitis).peritonitis).

A visual assessment of skin color (pale, moist, yellow), A visual assessment of skin color (pale, moist, yellow), visible mucous membranes (dry tongue, the visible mucous membranes (dry tongue, the presence of plaque), participation in the act of presence of plaque), participation in the act of breathing the abdomen.breathing the abdomen.

Study of heart rate, heart rate measurement, the Study of heart rate, heart rate measurement, the measurement of blood pressure (tachycardia, measurement of blood pressure (tachycardia, hypotension in  hypovolemia ).hypotension in  hypovolemia ).

Inspection of the abdomen:Inspection of the abdomen:

- Post-surgical scars and hernias (increased risk - Post-surgical scars and hernias (increased risk of bowel obstruction);of bowel obstruction);- A flat stomach (perforation);- A flat stomach (perforation);- Flatulence (intestinal obstruction);- Flatulence (intestinal obstruction);- Local protrusion of the abdomen - Local protrusion of the abdomen (neoplasm), volvulus of the intestine;(neoplasm), volvulus of the intestine;- Varicose veins, the anterior abdominal - Varicose veins, the anterior abdominal wall (alcoholism);wall (alcoholism);- Ascites (cirrhosis of the liver, etc.).- Ascites (cirrhosis of the liver, etc.).

Auscultation of the abdomen and bowel sounds assessment:Auscultation of the abdomen and bowel sounds assessment: --weak or absent (in case of peritonitis and paralytic ileus);weak or absent (in case of peritonitis and paralytic ileus);

- Normal (for a local irritation of the peritoneum on the - Normal (for a local irritation of the peritoneum on the background of acute appendicitis, diverticulitis, etc.);background of acute appendicitis, diverticulitis, etc.);- Reinforced, clear (at the onset of mechanical intestinal - Reinforced, clear (at the onset of mechanical intestinal obstruction, and then disappear);obstruction, and then disappear);- Splashing (mechanical obstruction);- Splashing (mechanical obstruction);- Vascular noise (with stenosis or aneurysm of the - Vascular noise (with stenosis or aneurysm of the abdominal aorta and its branches).abdominal aorta and its branches).Percussion BellyPercussion Belly- Increased pain in - Increased pain in low abdomen shake (with diffuse peritonitis);low abdomen shake (with diffuse peritonitis);- Dull percussion sound (with tumors and ascites);- Dull percussion sound (with tumors and ascites);- Tympanic percussion sound (if there is gas in the - Tympanic percussion sound (if there is gas in the abdomen, flatulence in the intestines);abdomen, flatulence in the intestines);- Increase the size of percussion of the liver (with - Increase the size of percussion of the liver (with alcohol disease and heart failure);alcohol disease and heart failure);- Reducing the size of the liver (with ascites).- Reducing the size of the liver (with ascites).

Palpation of the abdomenPalpation of the abdomen - Presence of muscle tension in the abdominal wall:- Presence of muscle tension in the abdominal wall:

- Local (with local peritonitis);- Local (with local peritonitis);- Wooden belly (with diffuse peritonitis).- Wooden belly (with diffuse peritonitis).- Identification of areas most pain during deep palpation.- Identification of areas most pain during deep palpation.- Identify the volume of education in the abdominal - Identify the volume of education in the abdominal cavity.cavity.

Estimating the size of the spleen and kidney.Estimating the size of the spleen and kidney. Detection of specific symptoms of acute Detection of specific symptoms of acute

surgical diseases:surgical diseases: Visual inspection and palpation of external Visual inspection and palpation of external

genitalia (swelling and tenderness of the testicles).genitalia (swelling and tenderness of the testicles). Digital rectal examination.Digital rectal examination. Morbidity and overhang the front wall of the rectum.Morbidity and overhang the front wall of the rectum. The presence of feces, stool color.The presence of feces, stool color.

Detection of bleeding (in the tumor, ischemia of the Detection of bleeding (in the tumor, ischemia of the intestine).intestine).

The presence of associated symptoms:The presence of associated symptoms: -General: fever, weight loss, jaundice.-General: fever, weight loss, jaundice.

- Gastrointestinal: aversion to food, nausea, vomiting, - Gastrointestinal: aversion to food, nausea, vomiting, diarrhea, constipation, traces of blood or mucus in the diarrhea, constipation, traces of blood or mucus in the stool, pain during bowel movements.stool, pain during bowel movements.- Vomiting eaten food (with pyloric stenosis);- Vomiting eaten food (with pyloric stenosis);- Vomiting bile (high intestinal obstruction at the level of - Vomiting bile (high intestinal obstruction at the level of the proximal small intestine);the proximal small intestine);- Copremesis (low intestinal obstruction at - Copremesis (low intestinal obstruction at the ileum or colon).the ileum or colon).- Urology: dysuria, hematuria, frequent urination.- Urology: dysuria, hematuria, frequent urination.- Gynecological: vaginal discharge, the possibility of - Gynecological: vaginal discharge, the possibility of pregnancy.pregnancy.

For suspected myocardial infarction: the ECG.For suspected myocardial infarction: the ECG.

Indications for hospitalizationIndications for hospitalization Patients with acute abdominal pain to be an urgent Patients with acute abdominal pain to be an urgent

admission to the surgical, therapeutic or infection clinic, admission to the surgical, therapeutic or infection clinic, depending on the presumptive diagnosis.depending on the presumptive diagnosis.

Transportation lying on a stretcher.Transportation lying on a stretcher.

Common errorsCommon errors

Appointment of drugs and other analgesics to patients Appointment of drugs and other analgesics to patients with any acute abdominal pain in with any acute abdominal pain in the prehospital contraindicated.the prehospital contraindicated.

TREATMENT ON PREHOSPITAL STAGETREATMENT ON PREHOSPITAL STAGEThe main objectives of the UMC (Urgent medical care)The main objectives of the UMC (Urgent medical care)  in  in

assisting the patient with acute abdominal pain.assisting the patient with acute abdominal pain. Identifying patients with acute surgical Identifying patients with acute surgical

diseases and their emergencydiseases and their emergency hospitalizationhospitalization Identification of patients with non-surgical causes of acute Identification of patients with non-surgical causes of acute

abdominal pain and determination of the indications abdominal pain and determination of the indications for their emergency hospitalization.for their emergency hospitalization.

Ensure venous access, monitoring and maintenance of vital Ensure venous access, monitoring and maintenance of vital functions (in accordance with general principles of intensive care) functions (in accordance with general principles of intensive care) in patients with acutein patients with acute abdominal pain of any etiology.abdominal pain of any etiology.

When signs of hypovolemia, hypotension: intravenous sodium When signs of hypovolemia, hypotension: intravenous sodium chloride 0.9% - 400 ml.chloride 0.9% - 400 ml.

With clearly defined because of colicky pain is With clearly defined because of colicky pain is acceptable introduction miotropnymantispasmodics: Drotaverinum iacceptable introduction miotropnymantispasmodics: Drotaverinum intravenous slow, 40-80 mg (2% solution - 2.0 ml).ntravenous slow, 40-80 mg (2% solution - 2.0 ml).

Permissible to use nitroglycerin under the tongue tablets (0.25 Permissible to use nitroglycerin under the tongue tablets (0.25 mg or 0.5 tablets) ormg or 0.5 tablets) or spray (400 micrograms or 1 dose).spray (400 micrograms or 1 dose).

Vomiting, nausea: metoclopramide 10 mg (5% solution - 2 Vomiting, nausea: metoclopramide 10 mg (5% solution - 2 ml) intravenous (onset of action within 1-3 minutes) or ml) intravenous (onset of action within 1-3 minutes) or intramuscularly (onset of action 10-15 min.)intramuscularly (onset of action 10-15 min.)

ACUTE APPENDICITISACUTE APPENDICITIS

Acute appendicitisAcute appendicitis - inflammation of the appendix cecum. - inflammation of the appendix cecum.

CLASSIFICATIONCLASSIFICATION

Depending on the variant of the disease is Depending on the variant of the disease is isolated appendicitis:isolated appendicitis:

simplesimple destructive,destructive, complicated.complicated.

CLINICAL PICTURECLINICAL PICTURE Attack of appendicitis usually develops suddenly, there Attack of appendicitis usually develops suddenly, there

is acute pain, initially localizes in the epigastric is acute pain, initially localizes in the epigastric region or around the navel. After a while the pain is region or around the navel. After a while the pain is localized in the right iliac region and is growing. Against localized in the right iliac region and is growing. Against the background of the pain may develop indigestion, the background of the pain may develop indigestion, nausea, diarrhea is a single, low-grade fever, false urge nausea, diarrhea is a single, low-grade fever, false urge to urinate in men. When a destructive acute to urinate in men. When a destructive acute appendicitis develops the classic symptom of acute appendicitis develops the classic symptom of acute abdomen, whose appearance indicates the development abdomen, whose appearance indicates the development of acute, sharply worsens the prognosis of the of acute, sharply worsens the prognosis of the disease. For the elderly is characterized disease. For the elderly is characterized by blurred over, low-intensity pain.by blurred over, low-intensity pain.

Identifying symptoms of acute appendicitis.Identifying symptoms of acute appendicitis. Kocher-Volkovych - offset the pain of Kocher-Volkovych - offset the pain of

the epigastrium or upper abdomen in the right iliac region.the epigastrium or upper abdomen in the right iliac region. Bartome-Michelson - increased pain with palpation of the Bartome-Michelson - increased pain with palpation of the

right iliac region with the patient on her left side.right iliac region with the patient on her left side. Obraztsova - increased pain during palpation in the right iliac Obraztsova - increased pain during palpation in the right iliac

region when picked up straight at the knee right leg.region when picked up straight at the knee right leg. Rovzinga - the emergence or worsening pain in the right iliac Rovzinga - the emergence or worsening pain in the right iliac

region in jerky pressing on the left iliac region.region in jerky pressing on the left iliac region. Sitkovskiy - the emergence or worsening pain in his right Sitkovskiy - the emergence or worsening pain in his right

side when turning the patient on his left side.side when turning the patient on his left side. SHCHetkina-Bljumberga (peritonitis) - increased pain at the SHCHetkina-Bljumberga (peritonitis) - increased pain at the

time of abrupt withdrawal produces pressure arm.time of abrupt withdrawal produces pressure arm. Rectal finger examination: tenderness and the overhang of Rectal finger examination: tenderness and the overhang of

the front wall of therectum.the front wall of therectum.

Possible complications.Possible complications. Perforation of the  Perforation of the appendix, appendiceal abscess formation, peritonitis, appendix, appendiceal abscess formation, peritonitis, formation of appendicular infiltrate with late appeal for formation of appendicular infiltrate with late appeal for medical help.medical help.

Differential diagnosis. Differential diagnosis. Carried out with all the acute Carried out with all the acute diseases of abdominal organs, in women - a disease of diseases of abdominal organs, in women - a disease of the uterus and appendages.the uterus and appendages.

TreatmentTreatment Indications for hospitalization.Indications for hospitalization. For suspected acute  For suspected acute

appendicitis, the patient should appendicitis, the patient should be immediately hospitalized in the surgical department be immediately hospitalized in the surgical department of a hospital. Transportation lying on a stretcher.of a hospital. Transportation lying on a stretcher.

ACUTE CHOLECYSTITISACUTE CHOLECYSTITIS

Acute cholecystitisAcute cholecystitis - an acute inflammation of the  - an acute inflammation of the gallbladder.gallbladder.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS

The main causes of acute cholecystitis:The main causes of acute cholecystitis: cholelithiasis;cholelithiasis; Violation of the vascularization of the gallbladder, bile Violation of the vascularization of the gallbladder, bile

ducts and duodenum;ducts and duodenum; lymphatic, hematogenous, or contact infection of the lymphatic, hematogenous, or contact infection of the

gallbladder.gallbladder.

CLASSIFICATIONCLASSIFICATION Acute cholecystitis is divided into:Acute cholecystitis is divided into: catarrh;catarrh; abscess;abscess; gangrenous.gangrenous. On prehospital stage the differential diagnosis of these forms is not On prehospital stage the differential diagnosis of these forms is not

always possible, so appropriatealways possible, so appropriate distinguishdistinguish two groups of patients: two groups of patients: patients with acute cholecystitis complicated;patients with acute cholecystitis complicated; patients with acute uncomplicated cholecystitis.patients with acute uncomplicated cholecystitis. Among the complicated forms of acute cholecystitis release:Among the complicated forms of acute cholecystitis release: jaundice;jaundice; suppurative cholangitis;suppurative cholangitis; peritonitis;peritonitis; aboutcystic infiltration and abscess;aboutcystic infiltration and abscess; empyema of the gall bladder;empyema of the gall bladder; perforation;perforation; combination with acute pancreatitis;combination with acute pancreatitis; biliary fistula.biliary fistula.

CLINIC PICTURE CLINIC PICTURE The most specific symptom of acute cholecystitis - an The most specific symptom of acute cholecystitis - an

intense constant pain in the right upper quadrant, often with intense constant pain in the right upper quadrant, often with the irradiation in the right shoulder blade, rightthe irradiation in the right shoulder blade, right supraclavicular supraclavicular area. The pain is often accompanied by restless patient behavior,area. The pain is often accompanied by restless patient behavior, trying to find a posture to relieve the suffering. With trying to find a posture to relieve the suffering. With simultaneous lesion of the simultaneous lesion of the pancreas gets shingles pain character. Often in acute pancreas gets shingles pain character. Often in acute cholecystitis developscholecystitis develops nausea and repeated vomiting, increased nausea and repeated vomiting, increased body temperature.body temperature.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Carried out with the perforation of duodenal ulcer, Carried out with the perforation of duodenal ulcer,

appendicitis, pancreatitis, myocardial infarction, renal pathology.appendicitis, pancreatitis, myocardial infarction, renal pathology. TreatmentTreatment Indications for hospitalization. Indications for hospitalization. Patient with acute Patient with acute

cholecystitis should be hospitalized in the surgical hospital.cholecystitis should be hospitalized in the surgical hospital. TransportationTransportation lying on a stretcher. lying on a stretcher. Common errors.Common errors. The introduction of narcotic analgesics. The introduction of narcotic analgesics.

ACUTE PANCREATITISACUTE PANCREATITIS

Acute pancreatitisAcute pancreatitis - acute inflammation of the pancreas. - acute inflammation of the pancreas.

ETIOLOGY PATHOGENESISETIOLOGY PATHOGENESIS

Causes of acute pancreatitis:Causes of acute pancreatitis: alcohol and spicy or fatty foods;alcohol and spicy or fatty foods; cholelithiasis;cholelithiasis; trauma of the pancreas;trauma of the pancreas; nontraumatic strictures of the pancreatic ducts;nontraumatic strictures of the pancreatic ducts; duodenal ulcer disease (ulcers, duodenostasis).duodenal ulcer disease (ulcers, duodenostasis).

CLASSIFICATIONCLASSIFICATION Acute pancreatitis Acute pancreatitis is expedient to classify the clinical course at:is expedient to classify the clinical course at: easyeasy average;average; HeavyHeavyAcute destructive pancreatitis (ie pancreatic necrosis) is the Acute destructive pancreatitis (ie pancreatic necrosis) is the

phase over:phase over: Enzymatic phase (first 5 days of illness) is characterized by the Enzymatic phase (first 5 days of illness) is characterized by the

formation offormation of pancreatic and development of endotoxemia.pancreatic and development of endotoxemia. In the reactive phase (the In the reactive phase (the 22nd week of nd week of

illness) is formed by reaction of the body in the form illness) is formed by reaction of the body in the form of pancreatic peripancreatic infiltration.of pancreatic peripancreatic infiltration.

In the phase of sequestration (3rd week or In the phase of sequestration (3rd week or more) is shaping seizures and rejection of necrotic tissue:more) is shaping seizures and rejection of necrotic tissue:

- Aseptic sequestration (without infection) - the formation - Aseptic sequestration (without infection) - the formation of cysts of the pancreas;of cysts of the pancreas;- Septic sequestration (with infection) - the development - Septic sequestration (with infection) - the development of septic complications.of septic complications.

CLINIC PICTURECLINIC PICTURE Suddenly there is a strong constant pain in the Suddenly there is a strong constant pain in the

epigastrium and upper abdomen that radiates to the epigastrium and upper abdomen that radiates to the back or a surrounding nature. A patient with acute back or a surrounding nature. A patient with acute pancreatitis often takes a forced situation (position of the pancreatitis often takes a forced situation (position of the embryo), which reduces pain. Often embryo), which reduces pain. Often develops uncontrollable vomiting, tachycardia, develops uncontrollable vomiting, tachycardia, hypotension, intestinal paresis, acute respiratory distress hypotension, intestinal paresis, acute respiratory distress syndrome of adults. Hemodynamic disturbances in acute syndrome of adults. Hemodynamic disturbances in acute pancreatitis can be extremely severe, until the pancreatitis can be extremely severe, until the development of shock. The severity of common development of shock. The severity of common symptoms of acute pancreatitis is closely related to the symptoms of acute pancreatitis is closely related to the severity of the disease, which largely determines severity of the disease, which largely determines the prognosis.the prognosis.

Symptoms of acute pancreatitis:Symptoms of acute pancreatitis: - Kert - local swelling along the transverse colon and muscle tension - Kert - local swelling along the transverse colon and muscle tension

anterioranterior abdominal wall.abdominal wall.- Mayo-Robson-localization of pain in the left costovertebral angle;- Mayo-Robson-localization of pain in the left costovertebral angle;- Resurrection - the lack of pulsations of the abdominal aorta;- Resurrection - the lack of pulsations of the abdominal aorta;- SHCHetkina-Blyum6erga (peritonitis) - increased pain at the time - SHCHetkina-Blyum6erga (peritonitis) - increased pain at the time of abruptof abrupt withdrawal produces pressure arm.withdrawal produces pressure arm.The presence of associated symptoms: vomiting, hypotension, The presence of associated symptoms: vomiting, hypotension, flatulence, anuria.flatulence, anuria.

Predictors of severity of acute pancreatitis:Predictors of severity of acute pancreatitis: age over 55 years;age over 55 years; peritoneal syndrome;peritoneal syndrome; oliguria;oliguria; reduction in systolic blood pressure below 100 mm Hg;reduction in systolic blood pressure below 100 mm Hg; leukocytosis more leukocytosis more 14х109/л; 14х109/л; уу

increase in hemoglobin of more than increase in hemoglobin of more than 160 г/л;160 г/л; hyperglycemia of more than hyperglycemia of more than 11 мкмоль/л; 11 мкмоль/л; urea level of more than urea level of more than 12 ммоль/л.12 ммоль/л.

POSSIBLE COMPLICATIONSPOSSIBLE COMPLICATIONS

Complications of acute pancreatitis include:Complications of acute pancreatitis include: endotoxic shock;endotoxic shock; peritonitis (including enzymatic);peritonitis (including enzymatic); acute renal failure;acute renal failure; acute respiratory failure.acute respiratory failure.

Differential diagnosis.Differential diagnosis. Carried out with the perforation of duodenal ulcer, acute Carried out with the perforation of duodenal ulcer, acute

cholecystitis, intestinal obstruction, toxic hepatitis in cholecystitis, intestinal obstruction, toxic hepatitis in patients who abuse alcohol.patients who abuse alcohol.

Patients with acute pancreatitis Patients with acute pancreatitis require require hospitalizationhospitalization in the emergency  in the emergency department (emergency room), a specialized hospital.department (emergency room), a specialized hospital.

TREATMENT PREHOSPITALTREATMENT PREHOSPITAL Ensure venous access, monitoring and maintenance of Ensure venous access, monitoring and maintenance of

vital functions (in accordance with general principles vital functions (in accordance with general principles of resuscitation).of resuscitation).

Infusion therapy (800 ml or more) intravenously Infusion therapy (800 ml or more) intravenously drip: sodium chloride 0.9% - 400 ml glucose 5%- 400 ml.drip: sodium chloride 0.9% - 400 ml glucose 5%- 400 ml.

Pain relief (after the start of infusion therapy because of Pain relief (after the start of infusion therapy because of possible blood pressure lowering)possible blood pressure lowering)

When the average intensity of When the average intensity of pain used antispasmodics: drotaverinum intravenously pain used antispasmodics: drotaverinum intravenously slow, 40-80 mg (2% solution - 2-4 ml). Let slow, 40-80 mg (2% solution - 2-4 ml). Let us welcome nitroglycerin sublingual tablets (0.25 us welcome nitroglycerin sublingual tablets (0.25 mg or half tablets) or spray (400 micrograms or 1 dose).mg or half tablets) or spray (400 micrograms or 1 dose).

When expressed pain syndrome are used non-narcotic When expressed pain syndrome are used non-narcotic analgesics: ketorolac 30 mg (1 ml) intravenously, the analgesics: ketorolac 30 mg (1 ml) intravenously, the dose must be entered no less than 15 s (intravenously dose must be entered no less than 15 s (intravenously muscularly administration analgesic effect develops muscularly administration analgesic effect develops within 30 minutes).within 30 minutes).

PERFORATED GASTRIC ULCERPERFORATED GASTRIC ULCER  AND DUODENUM   AND DUODENUM

Perforated (perforated), gastric ulcer or duodenal ulcer - Perforated (perforated), gastric ulcer or duodenal ulcer - the formation of holes in the wall of the the formation of holes in the wall of the stomach or duodenum in a pre-existing ulcer and gastro-stomach or duodenum in a pre-existing ulcer and gastro-intestinal flow of contents into the abdominal cavity.intestinal flow of contents into the abdominal cavity.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS

Perforated peptic ulcer disease is preceded Perforated peptic ulcer disease is preceded by worsening or development of acute ulcers.by worsening or development of acute ulcers.

Perforations help:Perforations help: alcohol intake;alcohol intake; fullness of food;fullness of food; excessive physical stress.excessive physical stress.

CLASSIFICATIONCLASSIFICATION Perforated ulcers are classified:Perforated ulcers are classified: - the etiology:- the etiology: chronic ulcer perforation;chronic ulcer perforation; acute ulcer perforation (including medication, stress, acute ulcer perforation (including medication, stress,  uremic);uremic); - - on localization:on localization: in the stomach;in the stomach; in the duodenum;in the duodenum; - On the clinical course:- On the clinical course: perforation into the free peritoneal perforation into the free peritoneal

cavity (including cover);cavity (including cover); Atypical burst;Atypical burst; in combination with gastrointestinal bleeding;in combination with gastrointestinal bleeding; in combination with stenosis of the outlet of the stomach.in combination with stenosis of the outlet of the stomach.

CLINIC PICTURECLINIC PICTURE For probodnoy ulcer is typical:For probodnoy ulcer is typical::: A sudden sharp dagger and constant epigastric A sudden sharp dagger and constant epigastric

pain. field or right upper quadrant,pain. field or right upper quadrant, quickly spreading throughout quickly spreading throughout the abdomen, usually on the right flank of the abdomen.the abdomen, usually on the right flank of the abdomen.

Tension the anterior abdominal wall, wooden Tension the anterior abdominal wall, wooden belly. Patients taking a forced situation on the back or right belly. Patients taking a forced situation on the back or right side from here to the stomach down.side from here to the stomach down.

A history of peptic ulcer disease.A history of peptic ulcer disease. In the course of the disease is isolated:In the course of the disease is isolated: period of shock (up to 6 hours of onset);period of shock (up to 6 hours of onset); period of an imaginary being (6-12 hours after perforation);period of an imaginary being (6-12 hours after perforation); period of progressive peritonitis (12-14 hours after perforation).period of progressive peritonitis (12-14 hours after perforation). Possible complications.Possible complications. The most common complication, peritonitis.The most common complication, peritonitis.

     With veiled perforation may form an abscess of the      With veiled perforation may form an abscess of the abdominal cavity.abdominal cavity.

Differential diagnosis.Differential diagnosis. Carried out with all the acute  Carried out with all the acute diseases of abdominal organs,diseases of abdominal organs, as well as with as well as with myocardial infarction, distal right-sided pneumonia.myocardial infarction, distal right-sided pneumonia.

TreatmentTreatment Indications for hospitalization. Indications for hospitalization. Patients Patients

with perforated ulcer in need of emergency with perforated ulcer in need of emergency hospitalization in the surgical department of a hospital.hospitalization in the surgical department of a hospital.

The patient was transported on a stretcher, to ensure The patient was transported on a stretcher, to ensure maximum tranquility.maximum tranquility.

COMMON ERRORSCOMMON ERRORS Appointment of narcotic analgesics.Appointment of narcotic analgesics. Attempt gastric lavage.Attempt gastric lavage.

ACUTE INTESTINAL OBSTRUCTIONACUTE INTESTINAL OBSTRUCTIONAcute intestinal obstruction  (Acute intestinal obstruction  (AIOAIO) ) - violation of passage of - violation of passage of

intestinal contentsintestinal contents through the digestive tract.through the digestive tract.ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS

The etiology The etiology of AIO:of AIO: adhesions after previous abdominal surgery;adhesions after previous abdominal surgery; strangulation, volvulus bowel intussusception;strangulation, volvulus bowel intussusception; Closing the intestinal Closing the intestinal

lumen (tumor, feces or gallstones, foreign bodies, the lumen (tumor, feces or gallstones, foreign bodies, the accumulation of round worm);accumulation of round worm);

wrapping intestine (strictures, stenoses);wrapping intestine (strictures, stenoses); compression of the intestine from the outside (tumors of other compression of the intestine from the outside (tumors of other

organs);organs); infringement by a hernia;infringement by a hernia; endogenous intestinal dysmotility (neurogenic, endogenous intestinal dysmotility (neurogenic,

vascular or metabolic) nature of patients with vascular or metabolic) nature of patients with myocardial infarction, acute pancreatitis, renal colic, etc., as myocardial infarction, acute pancreatitis, renal colic, etc., as well as exogenous nature (drug or food poisoning, abdominal well as exogenous nature (drug or food poisoning, abdominal trauma).trauma).

PathogenesisPathogenesis of the disease is caused by: of the disease is caused by:

absorption from the intestine of toxic products, absorption from the intestine of toxic products,

including bacterial endotoxins bowel necrosis;including bacterial endotoxins bowel necrosis;

development of hypotension and shock, hypoglycemia, development of hypotension and shock, hypoglycemia,

hypo-and dysproteinemia;hypo-and dysproteinemia;

attendant loss of electrolytes due to vomiting.attendant loss of electrolytes due to vomiting.

Regardless of the reason (obturation of the lumen, poor Regardless of the reason (obturation of the lumen, poor

circulation in the mesentery and intestinal circulation in the mesentery and intestinal

wall, dysmotility) rapidly develop severe endogenous wall, dysmotility) rapidly develop severe endogenous

intoxication.intoxication.

CLASSIFICATIONCLASSIFICATION For the duration of the disease:For the duration of the disease: - Acute;- Acute;

- Chronic.- Chronic. On the mechanism of development:On the mechanism of development: - Mechanical (obstructive and strangulated);- Mechanical (obstructive and strangulated);

- Dynamic (spastic paralytic and);- Dynamic (spastic paralytic and);- Mixed (adhesive, invaginated).- Mixed (adhesive, invaginated).

On localization:On localization: - Enteric (high, low);- Enteric (high, low);

- Colonic.- Colonic. On the clinical course of conventionally divided into On the clinical course of conventionally divided into

three periods:three periods: - Striking clinical symptoms;- Striking clinical symptoms;

- An imaginary being;- An imaginary being;- The development of complications (peritonitis, shock).- The development of complications (peritonitis, shock).

CLINIC PISTURECLINIC PISTUREClinical manifestations is vary and depends on the type of bowel Clinical manifestations is vary and depends on the type of bowel

obstruction and the stage of pathological process.obstruction and the stage of pathological process.For any AIO are characterized by:For any AIO are characterized by: sudden onset of illness;sudden onset of illness; cramping abdominal pain, which cramping abdominal pain, which

soon becomes diffuse and becomes a permanent character;soon becomes diffuse and becomes a permanent character; bloating and gas and stool retention;bloating and gas and stool retention; lack of intestinal peristalsis;lack of intestinal peristalsis; repeated nausea and vomiting, and does not bring relief.repeated nausea and vomiting, and does not bring relief. Identifying symptoms of AIO:Identifying symptoms of AIO: Vaal - local loop bowel distension and high tympanitis over Vaal - local loop bowel distension and high tympanitis over

her because of twisting;her because of twisting; SklyarovSklyarov - - a slight concussion in the abdominal wall can be a slight concussion in the abdominal wall can be

heard splashing liquid in the crowded small intestine.heard splashing liquid in the crowded small intestine. FingerFinger rectal examination:rectal examination: - A symptom of Obukhov Hospital - Extended and empty vials of - A symptom of Obukhov Hospital - Extended and empty vials of

the rectum duringthe rectum during rectal examination indicates a low colonic rectal examination indicates a low colonic obstruction.obstruction.

Possible complications.Possible complications. Dehydration, toxemia,  Dehydration, toxemia, peritonitis.peritonitis.

Differential diagnosis. Differential diagnosis. Carried out with all the acute Carried out with all the acute diseases of the abdominaldiseases of the abdominal cavity.cavity.

TreatmentTreatment Patient with AIO urgently admitted to a hospital surgical Patient with AIO urgently admitted to a hospital surgical

department.department. Transporting a patient on a stretcher to provide Transporting a patient on a stretcher to provide

maximum peace, which reduces the intensity maximum peace, which reduces the intensity of abdominal pain.of abdominal pain.

COMMON ERRORSCOMMON ERRORS The appointment of any analgesics.The appointment of any analgesics. Gastric lavage.Gastric lavage.

STANGULATED HERNIASTANGULATED HERNIA

Strangulated herniaStrangulated hernia - a sudden compression of  - a sudden compression of

the contents of the hernia sac, consisting of internal the contents of the hernia sac, consisting of internal

organs (omentum, small intestine, urinary bladder), organs (omentum, small intestine, urinary bladder),

covered by peritoneum, the hernial ring, which leads to covered by peritoneum, the hernial ring, which leads to

disruption of blood flow and necrosis.disruption of blood flow and necrosis.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS

The most frequently violated inguinal hernias, The most frequently violated inguinal hernias,

less hip and umbilical hernia.less hip and umbilical hernia.

Causes of hernia incarceration:Causes of hernia incarceration:

a sharp increase in intra-abdominal pressure;a sharp increase in intra-abdominal pressure;

compression of the hernia contents.compression of the hernia contents.

CLINIC PICTURECLINIC PICTUREAcute hernia incarceration comes suddenly.Acute hernia incarceration comes suddenly.

Typical localTypical local  signs of hernia incarceration:  signs of hernia incarceration:           

sharp pain in the hernia, or throughout the abdomen;sharp pain in the hernia, or throughout the abdomen; irreducible hernia;irreducible hernia; tension and soreness hernial protrusion;tension and soreness hernial protrusion; miscommunication cough shock at the hernial outpouching.miscommunication cough shock at the hernial outpouching. Pain as expressed in the hernial protrusion.Pain as expressed in the hernial protrusion. A few hours after the infringement, when began necrosis of A few hours after the infringement, when began necrosis of

incarcerated organ, pain intensity may decrease, which creates a incarcerated organ, pain intensity may decrease, which creates a false picture of improvement. At this stage of the disease on the 1 st false picture of improvement. At this stage of the disease on the 1 st plan forefront symptoms of dysfunction of the organs inplan forefront symptoms of dysfunction of the organs in the the hernial sack.hernial sack.

In a later stage of diseases in the development In a later stage of diseases in the development of peritonitis abdominal pain renovated and develops the picture of peritonitis abdominal pain renovated and develops the picture of acute abdomen. In elderly patients, which them is naturally of acute abdomen. In elderly patients, which them is naturally impairment of fecal, pain in the hernial protrusion is impairment of fecal, pain in the hernial protrusion is increasing gradually, itincreasing gradually, it increases in size, becomes dense and tight.increases in size, becomes dense and tight.

Possible complications.Possible complications. Development of intestinal  Development of intestinal

obstruction and peritonitis.obstruction and peritonitis. Differential diagnosis. Differential diagnosis. Inguinal and Inguinal and

femoral hernia must be differentiated with femoral hernia must be differentiated with lymphadenitis and by thrombosis of the great saphenous lymphadenitis and by thrombosis of the great saphenous hip vein under rural arch, withhip vein under rural arch, with irreducible hernia.irreducible hernia.

ACTIONS ON CHALLENGEACTIONS ON CHALLENGEDIAGNOSISDIAGNOSIS

INSPECTION AND PHYSICAL EXAMINATION INSPECTION AND PHYSICAL EXAMINATION Assessment of general condition and vital Assessment of general condition and vital

signs: consciousness, breathing and circulation.signs: consciousness, breathing and circulation. Measurement of heart rate and heart rate, blood Measurement of heart rate and heart rate, blood

pressure measurement.pressure measurement. Visual observation of the presence of a hernia.Visual observation of the presence of a hernia. Palpation: stress and pain in the hernial protrusion.Palpation: stress and pain in the hernial protrusion. Identifying symptoms of strangulated hernia:Identifying symptoms of strangulated hernia: - Previously free managing a hernial protrusion stops to - Previously free managing a hernial protrusion stops to

manage;manage;- Negative symptom cough shock.- Negative symptom cough shock.

Assessment of symptoms of irritation of the peritoneum Assessment of symptoms of irritation of the peritoneum (the muscle tension and a positive symptom-(the muscle tension and a positive symptom-SHCHetkina Bljumberga - increased pain at the time SHCHetkina Bljumberga - increased pain at the time of abrupt withdrawal produces pressure arm).of abrupt withdrawal produces pressure arm).

INDICATION FOR HOSPITALIZATIONINDICATION FOR HOSPITALIZATION At the slightest suspicion of hernia At the slightest suspicion of hernia

strangulation shows immediate hospitalization of the patient strangulation shows immediate hospitalization of the patient in a hospital surgical department.in a hospital surgical department.

Transportation on a stretcher, to ensure Transportation on a stretcher, to ensure maximum peace and minimal pain.maximum peace and minimal pain.

Emergency hospital admissions are also Emergency hospital admissions are also subject patients to straighten their ownsubject patients to straighten their own denial of matter, when denial of matter, when there was a reduction - until the arrival of the brigade of there was a reduction - until the arrival of the brigade of the acute carethe acute care during inspection or during transport to during inspection or during transport to hospital.hospital.

COMMON ERRORSCOMMON ERRORS The appointment of any analgesic and antispasmodic drugs.The appointment of any analgesic and antispasmodic drugs. Attempts to reposition strangulated hernia (not allowed!).Attempts to reposition strangulated hernia (not allowed!). Application of heat to the area of hernia.Application of heat to the area of hernia.

TREATMENT ON PREHOSPITAL STAGETREATMENT ON PREHOSPITAL STAGE The main objective of the acute car The main objective of the acute car

 in strangulated hernia - emergency hospitalization in strangulated hernia - emergency hospitalization of the of the patient in a hospital surgical department. In addition, it is patient in a hospital surgical department. In addition, it is necessary to maintain the patient's vital functions in necessary to maintain the patient's vital functions in accordance with general principles ofaccordance with general principles of resuscitation.resuscitation.

““ACUTE ABDOMEN” IN GYNECOLOGYACUTE ABDOMEN” IN GYNECOLOGY

Acute abdomen in gynecologyAcute abdomen in gynecology - a syndrome that - a syndrome that develops as a result of acute pathology in the develops as a result of acute pathology in the

abdominal cavity, and manifests abdominal cavity, and manifests itself suddenly emerged pain in any part of the itself suddenly emerged pain in any part of the

abdomen, peritoneal signs and pronounced changes in abdomen, peritoneal signs and pronounced changes in the state of the patient.the state of the patient.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS Sharp pain in lower abdomen in women with Sharp pain in lower abdomen in women with

severe symptoms of peritoneal available for the following severe symptoms of peritoneal available for the following diseases.diseases.

Intra-abdominal haemorrhage:Intra-abdominal haemorrhage:

- Ectopic pregnancy, the risk factors which include the Ectopic pregnancy, the risk factors which include the previously deferred oophoritis, endomyometritis, abortion, previously deferred oophoritis, endomyometritis, abortion, surgery on the internal reproductive organs, disturbances of the surgery on the internal reproductive organs, disturbances of the hormonal function of the ovaries, genital infantilism, hormonal function of the ovaries, genital infantilism, endometriosis and an increased activity of the trophoblast.endometriosis and an increased activity of the trophoblast.

If an ectopic pregnancy the fertilized egg is If an ectopic pregnancy the fertilized egg is implanted and develops outside the uterus. Such pregnancies implanted and develops outside the uterus. Such pregnancies can develop or be violated (similar to tubal abortion and the can develop or be violated (similar to tubal abortion and the type of rupture of the uterine tube).type of rupture of the uterine tube).

— — When tubal abortion fertilized egg, not having the appropriate When tubal abortion fertilized egg, not having the appropriate conditions for development, is peeled from the walls of conditions for development, is peeled from the walls of the fallopian tube and expelled into the abdominal cavity. In the fallopian tube and expelled into the abdominal cavity. In connection with the rhythmic uterine tube blood into the connection with the rhythmic uterine tube blood into the abdominal cavity entered periodically.abdominal cavity entered periodically.

— — When you break the fallopian tube (at a delay When you break the fallopian tube (at a delay of menstruation at an average of 3-4 weeks) as a result of menstruation at an average of 3-4 weeks) as a result of violations of ectopic pregnancy, gestational sac villi of violations of ectopic pregnancy, gestational sac villi completely destroy the thin wall of the uterine tube and the completely destroy the thin wall of the uterine tube and the blood from damaged vessels enters the abdominal cavity.blood from damaged vessels enters the abdominal cavity.

- Apoplexy ovary Apoplexy ovary (ovarian rupture, (ovarian rupture, myocardial ovary, ovarian hematoma) - severe violation myocardial ovary, ovarian hematoma) - severe violation of the integrity of the ovary with bleeding into its stroma of the integrity of the ovary with bleeding into its stroma and subsequent bleeding into the abdominal cavity.and subsequent bleeding into the abdominal cavity.     Ovarian apoplexy usually occurs in women of      Ovarian apoplexy usually occurs in women of reproductive age, but may also develop in reproductive age, but may also develop in teenagers. Ovarian rupture often occurs during teenagers. Ovarian rupture often occurs during ovulation and in the process of vascularization of the ovulation and in the process of vascularization of the corpus luteum and flourishing as a result of long-corpus luteum and flourishing as a result of long-term congestion, the presence term congestion, the presence of varicose or sclerosal vascular sclerotic changes in the of varicose or sclerosal vascular sclerotic changes in the stroma and the dysfunction of autonomic and endocrine stroma and the dysfunction of autonomic and endocrine systems. The resulting hematoma causes sharp pain systems. The resulting hematoma causes sharp pain due to rise intra-ovarian pressure, and then leads to due to rise intra-ovarian pressure, and then leads to rupture of ovarian tissue.rupture of ovarian tissue.

Torsion leg cysts (cystoma) ovary Torsion leg cysts (cystoma) ovary - a complication - a complication of ovarian cysts or cystoma.of ovarian cysts or cystoma.

The disease onset is often associated with the following factors:The disease onset is often associated with the following factors: - Sudden change in body position.- Sudden change in body position.

- Increased intra-abdominal pressure due to straining, - Increased intra-abdominal pressure due to straining, prolonged coughing, heavy physical work.prolonged coughing, heavy physical work.- Violation of the blood supply to the cyst.- Violation of the blood supply to the cyst.

When torsion leg cysts (cystoma) arises circulatory When torsion leg cysts (cystoma) arises circulatory disorders and swelling of the cysts, hemorrhage and necrosis of disorders and swelling of the cysts, hemorrhage and necrosis of parenchyma.parenchyma.

Distinguish partial and full twisting leg cysts (cystoma)Distinguish partial and full twisting leg cysts (cystoma) - In case of partial (gradual) torsion pin changes its - In case of partial (gradual) torsion pin changes its

position to 90-180 °, resulting in arterial blood flow is preserved, position to 90-180 °, resulting in arterial blood flow is preserved, and the venous drainage is affected by the compression and the venous drainage is affected by the compression of blood vessels, that leading to the development of venous of blood vessels, that leading to the development of venous plethora and edema cyst wallplethora and edema cyst wall- At full (sudden) torsion pin changes its position by 360 ° - At full (sudden) torsion pin changes its position by 360 ° and arterial blood flow is terminated as a result of the and arterial blood flow is terminated as a result of the cyst (cystoma) ovary occur necrobiotic process, there cyst (cystoma) ovary occur necrobiotic process, there are symptoms of peritoneal infection and cysts (cystoma) are symptoms of peritoneal infection and cysts (cystoma) begins peritonitis.begins peritonitis.

Perforation of purulent formations of ovariesPerforation of purulent formations of ovaries By precipitating factor in the development of By precipitating factor in the development of

purulent formations appendages include:purulent formations appendages include:

- microbial invasion;- microbial invasion;-reduction or change the barrier properties of the uterus -reduction or change the barrier properties of the uterus and genital tract[physiological (menstruation, and genital tract[physiological (menstruation, childbirth) or iatrogenic (abortion, intrauterine devices, childbirth) or iatrogenic (abortion, intrauterine devices, surgery, hysteroscopy, in vitro fertilization) nature].surgery, hysteroscopy, in vitro fertilization) nature].            Ways of infection of the uterus:Ways of infection of the uterus:- Intrakanalikulyarny.- Intrakanalikulyarny.- Bottom-up.- Bottom-up.- Hematogenous.- Hematogenous.- Lymphogenous.- Lymphogenous.

PelviperitonitisPelviperitonitis

CLASSIFICATIONCLASSIFICATION

Ectopic pregnancies are classified according to location:Ectopic pregnancies are classified according to location: pipepipe ovarian;ovarian; cervical;cervical; in a rudimentary horn;in a rudimentary horn; Abdominal.Abdominal.

On the clinical course of ectopic pregnancy are On the clinical course of ectopic pregnancy are classified as follows:classified as follows:

ProgressingProgressing Impaired:Impaired:

- By type of tubal abortion;- By type of tubal abortion;- The type of rupture of the uterine tube.- The type of rupture of the uterine tube.

CLINICAL PICTURECLINICAL PICTURE Rupture the fallopian tubeRupture the fallopian tube occurs suddenly and leads to occurs suddenly and leads to

bleeding, usually massive(intraperitoneal). Patients bleeding, usually massive(intraperitoneal). Patients  concerned about spotting from the genital tract (in tubal abortion), concerned about spotting from the genital tract (in tubal abortion),

one-sided cramping or persistent pain in lower abdomen,one-sided cramping or persistent pain in lower abdomen, irradiated into the rectum, dizziness, weakness, nausea, irradiated into the rectum, dizziness, weakness, nausea, diarrhea, flatulence. In anamnesis delaying of menstruation for diarrhea, flatulence. In anamnesis delaying of menstruation for 4-8 weeks, the probable signs of pregnancy.4-8 weeks, the probable signs of pregnancy. Typical Typical positive immunological reactions to pregnancy, deterioration of positive immunological reactions to pregnancy, deterioration of general condition, pale skin and fainting condition in patient.general condition, pale skin and fainting condition in patient.

With continued bleeding developing hemorrhagic shock and With continued bleeding developing hemorrhagic shock and posthemorrhagic anemia. Severity of hemodynamic posthemorrhagic anemia. Severity of hemodynamic disorders directly related to the shortage of VCB (volume of disorders directly related to the shortage of VCB (volume of circulatory blood).circulatory blood).

For For ovarian apoplexy ovarian apoplexy is typical intra-abdominal bleeding is typical intra-abdominal bleeding (anemic form) and pain (pain form). Disease begins acutely, with (anemic form) and pain (pain form). Disease begins acutely, with a sudden pain in lower abdomen, mainly on the affected side.a sudden pain in lower abdomen, mainly on the affected side.

When When torsion leg cysts (cystoma) ovariantorsion leg cysts (cystoma) ovarian concerned  concerned the pains in lower abdomen on the affected side (slowly the pains in lower abdomen on the affected side (slowly incremental or severe), nausea, vomiting, incremental or severe), nausea, vomiting, flatulence, intestinal paresis. On examination, note flatulence, intestinal paresis. On examination, note the anterior abdominal wall stress and symptoms of the anterior abdominal wall stress and symptoms of irritation of the peritoneum.irritation of the peritoneum.

For For inflammatory diseases of female genital inflammatory diseases of female genital mutilation mutilation are often typical are often typical worn, oligosymptomatic clinical picture worn, oligosymptomatic clinical picture (including inflammation of the uterus).(including inflammation of the uterus).

WhenWhen piosalpinks, pus in the ovaries and tubo- piosalpinks, pus in the ovaries and tubo-ovarian abscess ovarian abscess patients complain of persistent pain in patients complain of persistent pain in lower abdomen mainly by inflammation, chills, high lower abdomen mainly by inflammation, chills, high fever, weakness, tachycardia, nausea, fever, weakness, tachycardia, nausea, delayed stool, gas, pussy discharge from the genital delayed stool, gas, pussy discharge from the genital tract. Pain radiating to lower limbs, the lumbar tract. Pain radiating to lower limbs, the lumbar region. Abdomen soft, may be moderately swollen.region. Abdomen soft, may be moderately swollen.

Perforation of purulent formationsPerforation of purulent formations in the first  in the first hours shows mild symptoms of peritonitis, which hours shows mild symptoms of peritonitis, which are superimposed on the clinic severe inflammatory are superimposed on the clinic severe inflammatory process. Naturally intense, sometimes aching, process. Naturally intense, sometimes aching, fuzzy localization, chills, fever, tachycardia, painful fuzzy localization, chills, fever, tachycardia, painful urination, diarrhea, bloating, symptoms of local irritation urination, diarrhea, bloating, symptoms of local irritation of the peritoneum.of the peritoneum.

Possible complications of diseases associated Possible complications of diseases associated with syndrome of "acute abdomen":with syndrome of "acute abdomen":

Intra-abdominal bleeding.Intra-abdominal bleeding. Pelviperitonitis, peritonitis.Pelviperitonitis, peritonitis.

ACTION ON CHALLENGEACTION ON CHALLENGEDiagnosisDiagnosis Palpation of the abdomen:Palpation of the abdomen:- In peritonitis mark stress and pain of the abdominal wall, a - In peritonitis mark stress and pain of the abdominal wall, a

symptom-SHCHetkina Bljumberga.symptom-SHCHetkina Bljumberga.- When bleeding into the abdominal cavity - When bleeding into the abdominal cavity

(the ovary apoplexy, rupture of the uterine tube, splenic (the ovary apoplexy, rupture of the uterine tube, splenic rupture) reveal Kulenkampff symptom (pain and symptoms rupture) reveal Kulenkampff symptom (pain and symptoms of irritation of the peritoneum of the abdominal wall without of irritation of the peritoneum of the abdominal wall without tension).tension).

- When painful form of ovarian apoplexy register the pain When painful form of ovarian apoplexy register the pain in lower abdomen, symptoms of irritation of the in lower abdomen, symptoms of irritation of the peritoneum are mild.peritoneum are mild.

- When you break the fallopian When you break the fallopian tube stomach partially involved in the act of breathing, tube stomach partially involved in the act of breathing, painful on palpation and percussion, the symptoms painful on palpation and percussion, the symptoms of irritation of the peritoneum are positive.of irritation of the peritoneum are positive.

Percussion of bellyPercussion of belly with intraperitoneal hemorrhage, inflammatory exudate, with intraperitoneal hemorrhage, inflammatory exudate,

ascites noted blunting of sloping sites (iliac regions), ascites noted blunting of sloping sites (iliac regions), which is blended with a change in body position.which is blended with a change in body position.

If an ectopic pregnancy uterus size less than the time the If an ectopic pregnancy uterus size less than the time the alleged pregnancy, but also noted pain in the alleged pregnancy, but also noted pain in the displacement of the cervix and one-displacement of the cervix and one-sided adnekstumor(tumor formation in the sided adnekstumor(tumor formation in the uterus, detectable by pelvic examination).uterus, detectable by pelvic examination).

Instrumental study.Instrumental study. Measurement of blood pressure. Measurement of blood pressure. Indications Indications

for hospitalization.for hospitalization. Patients hospitalized on an  Patients hospitalized on an emergency basis in thegeneral hospital.emergency basis in thegeneral hospital.

COMMON ERRORSCOMMON ERRORS The introduction of pain drugsThe introduction of pain drugs Postponement of hospitalization.Postponement of hospitalization.

TREATMENTTREATMENTon prehospital stageon prehospital stage

With intraperitoneal bleeding shows the introduction With intraperitoneal bleeding shows the introduction of substituting solutions(solutions of dextran, drugs of of substituting solutions(solutions of dextran, drugs of hydroxyethyl starch) up to the hospital.hydroxyethyl starch) up to the hospital.

Assign an antibacterial drugs and a wide range of long-Assign an antibacterial drugs and a wide range of long-acting (1-2 g ceftriaxone acting (1-2 g ceftriaxone intravenously or intramuscularly in combination with intravenously or intramuscularly in combination with metronidazole 500 mg in metronidazole 500 mg in 100ml intravenously or amoxicillin at a dose of 2.4 100ml intravenously or amoxicillin at a dose of 2.4 g intravenously, in combination with metronidazole 500 g intravenously, in combination with metronidazole 500 mg in 100 ml intravenously).mg in 100 ml intravenously).

When torsion leg cysts (cystoma) ovary on pre-When torsion leg cysts (cystoma) ovary on pre-hospital treatment is not carried out.hospital treatment is not carried out.

ACUTE DISODERS OF MESENTERIC CIRCULATIONACUTE DISODERS OF MESENTERIC CIRCULATION Depending on the type of violation they are divided Depending on the type of violation they are divided

into occlusive and not occlusive.into occlusive and not occlusive.By occlusive disorders include:By occlusive disorders include: 1) mesenteric artery embolism;1) mesenteric artery embolism;

2) thrombosis of arteries;2) thrombosis of arteries;3) venous thrombosis;3) venous thrombosis;4) cover the mouths of the arteries from the aorta because 4) cover the mouths of the arteries from the aorta because of its atherosclerosis and thrombosis;of its atherosclerosis and thrombosis;5) occlusion of arteries as a result of separation of the 5) occlusion of arteries as a result of separation of the walls of the aorta;walls of the aorta;6) compression (germination), vascular tumors;6) compression (germination), vascular tumors;7) bandage of vessels.7) bandage of vessels.

Not occlusive mesenteric circulatory disorders are caused by:Not occlusive mesenteric circulatory disorders are caused by:     1) partial occlusion of arteries;     1) partial occlusion of arteries;     2) Angiospasm;     2) Angiospasm;     3) the fall in cardiac output      3) the fall in cardiac output and hemodynamic centralization.and hemodynamic centralization.

Embolism mesenteric arteries occurs normally in Embolism mesenteric arteries occurs normally in patients with atherosclerosis, myocardial patients with atherosclerosis, myocardial infarction, rheumatic heart infarction, rheumatic heart disease and hypertension, periarteritis nodosa, disease and hypertension, periarteritis nodosa, vasculitis, endarteritis, and cancer. More vasculitis, endarteritis, and cancer. More rarely occlusion of mesentericarteries is due rarely occlusion of mesentericarteries is due to thrombosis or embolism of a massive abdominal to thrombosis or embolism of a massive abdominal aorta and its dissecting aneurysm.aorta and its dissecting aneurysm.

Mesenteric vein thrombosis often occurs in patients with Mesenteric vein thrombosis often occurs in patients with intestinal infections, malignancies, liver cirrhosis, intestinal infections, malignancies, liver cirrhosis, splenomegaly, with splenomegaly, with cardiac decompensation after surgery.cardiac decompensation after surgery.

Acute occlusive mesenteric circulatory disorders are Acute occlusive mesenteric circulatory disorders are more often associated withmore often associated with vasospasm, such as in vasospasm, such as in atherosclerotic lesions of arteries in hypertension, atherosclerotic lesions of arteries in hypertension, allergic and infectious and allergic diseases, with an allergic and infectious and allergic diseases, with an overdose of drugs, possessingoverdose of drugs, possessing angiospastic properties angiospastic properties (digitalis, morphine, adrenergic drugs and oral (digitalis, morphine, adrenergic drugs and oral contraceptives).contraceptives).

Acute circulatory disorders of the abdominal organs can Acute circulatory disorders of the abdominal organs can occur in state, accompanied by cardiovascular collapse, occur in state, accompanied by cardiovascular collapse, reduced cardiac out put, hypotension, reduced cardiac out put, hypotension, hypovolemia and haemohypovolemia and haemo concentration.concentration.

The most frequently - it is a myocardial infarction, acute The most frequently - it is a myocardial infarction, acute renal failure, septic shock, severe infectious diseases, renal failure, septic shock, severe infectious diseases, acute liver failure.acute liver failure.

The clinical picture of acute occlusion of the various The clinical picture of acute occlusion of the various options mesenteric arteries is characterized options mesenteric arteries is characterized by similar symptoms. The disease begins suddenly with a sharpby similar symptoms. The disease begins suddenly with a sharp attack of abdominal pain. Initially, the pain is attack of abdominal pain. Initially, the pain is very intense, are cramping in nature.very intense, are cramping in nature. They can not arrest They can not arrest the drug administration. Some analgesic effect can be the drug administration. Some analgesic effect can be obtained with the introduction obtained with the introduction of antispasmodics and antispasmoanalgesics. With the of antispasmodics and antispasmoanalgesics. With the development of bowel infarction pain becomes development of bowel infarction pain becomes less severe, permanent. Pain relief is often regarded by patients less severe, permanent. Pain relief is often regarded by patients as an improvement. With the development ofas an improvement. With the development of peritonitis pain again intensified, particularly intense pain during mperitonitis pain again intensified, particularly intense pain during movement,ovement, coughing and palpation. During this period, the coughing and palpation. During this period, the pain decreased in the appointment of narcotic analgesics. Typical pain decreased in the appointment of narcotic analgesics. Typical signs of occlusion of mesenteric arteries are nausea signs of occlusion of mesenteric arteries are nausea and vomiting. In early disease there is a one-time reflexand vomiting. In early disease there is a one-time reflex vomiting of vomiting of gastric contents. In a subsequent vomiting becomes a constant, gastric contents. In a subsequent vomiting becomes a constant, vomitvomit frequently acquire color of coffee grounds due to admixture frequently acquire color of coffee grounds due to admixture of blood and foulof blood and foul putrid odor.putrid odor.

Early there signs of bowel function. At the beginning Early there signs of bowel function. At the beginning of the disease in the superior mesenteric of the disease in the superior mesenteric artery lesions observed 1-2-artery lesions observed 1-2-fold diarrhea (ischemic bowel). In the absence of fold diarrhea (ischemic bowel). In the absence of intestinal contents may be only a sense of urge to intestinal contents may be only a sense of urge to defecate.defecate.     In the future when re-liquid stools in      In the future when re-liquid stools in it appears admixture of dark blood. The presence of it appears admixture of dark blood. The presence of blood in the rectum can be found in its study on digital. It blood in the rectum can be found in its study on digital. It should be remembered that in some cases, the should be remembered that in some cases, the disease can occur without diarrhea, and, moreover, be disease can occur without diarrhea, and, moreover, be accompanied by paresis of the intestine. Most often a accompanied by paresis of the intestine. Most often a delay of gases and feces has been observed in the delay of gases and feces has been observed in the stage of peritonitis. The condition of patients stage of peritonitis. The condition of patients quickly and progressively worsening disease from the quickly and progressively worsening disease from the outset.outset.

In the early hours of weight status is determined primarily by In the early hours of weight status is determined primarily by shock and hemodynamic instability, and then - increasing shock and hemodynamic instability, and then - increasing intoxication. Initially, the behavior of patients with restless, intoxication. Initially, the behavior of patients with restless, they feel a sense of fear. Then a few calm, even celebrate they feel a sense of fear. Then a few calm, even celebrate feeling better. With the development of peritonitis patients lie feeling better. With the development of peritonitis patients lie in bed, avoiding movements, because they increase the pain, in bed, avoiding movements, because they increase the pain, the skin is usually pale, often ashy-gray, his lips were the skin is usually pale, often ashy-gray, his lips were cyanotic. In the later stages of the disease on the background cyanotic. In the later stages of the disease on the background of peritonitis facial features are sharp, his eyes sunken, his of peritonitis facial features are sharp, his eyes sunken, his lips are dry, bluish. In most cases, the disease occurs with lips are dry, bluish. In most cases, the disease occurs with normal or even decreased body temperature. Only after normal or even decreased body temperature. Only after myocardial intestine and peritonitis may be marked increase myocardial intestine and peritonitis may be marked increase in body temperature. Pulse frequent - 100-120 beats per in body temperature. Pulse frequent - 100-120 beats per minute at the same time there is a decrease in blood minute at the same time there is a decrease in blood pressure. In hypertensive patients in the initial stage of the pressure. In hypertensive patients in the initial stage of the disease may be hypertension. Language and the inner disease may be hypertension. Language and the inner surface of the cheeks patient quickly becomes dry, the stage surface of the cheeks patient quickly becomes dry, the stage of peritonitis on them appear dirty gray plaque with brownish of peritonitis on them appear dirty gray plaque with brownish tinge. There is a painful feeling of thirst. In the initial stage of tinge. There is a painful feeling of thirst. In the initial stage of the disease is usually not swollen abdomen, palpation - soft, the disease is usually not swollen abdomen, palpation - soft, his wall is involved in breathing.his wall is involved in breathing.

Only against the background of peritonitis has been a gradual Only against the background of peritonitis has been a gradual bloating, even after repeated diarrhea. On palpation the abdomen bloating, even after repeated diarrhea. On palpation the abdomen is determined by diffuse pain, which is especially pronounced in is determined by diffuse pain, which is especially pronounced in the stage of peritonitis. On the development of peritonitis appears the stage of peritonitis. On the development of peritonitis appears also indicate muscle strain the abdominal wall and a positive also indicate muscle strain the abdominal wall and a positive symptom-SHCHetkina Bljumberga. Often with abdominal palpation symptom-SHCHetkina Bljumberga. Often with abdominal palpation in patients with thrombo embolism of mesenteric arteries is in patients with thrombo embolism of mesenteric arteries is determined by morbid tumor formation dough consistency, without determined by morbid tumor formation dough consistency, without clear boundaries, limited mobility, percussion sound stupid on clear boundaries, limited mobility, percussion sound stupid on him. Symptom has a name G. Mondor. The presence of Mondor’s him. Symptom has a name G. Mondor. The presence of Mondor’s symptoms associated with a sharp swelling of the affected bowel symptoms associated with a sharp swelling of the affected bowel and mesentery at the stage of a heart attack. A characteristic and mesentery at the stage of a heart attack. A characteristic feature of the disease is impaired intestinal motility, appears to feature of the disease is impaired intestinal motility, appears to decrease the intensity of the auscultatory noises in the decrease the intensity of the auscultatory noises in the abdomen. However, some patients in the initial stages of the abdomen. However, some patients in the initial stages of the disease are determined by acoustic phenomena of normal or even disease are determined by acoustic phenomena of normal or even enhanced intestinal motility. The complete absence of bowel enhanced intestinal motility. The complete absence of bowel sounds (a symptom of a "complete silence") appears only in the sounds (a symptom of a "complete silence") appears only in the terminal stage of peritonitis. Against the background of "complete terminal stage of peritonitis. Against the background of "complete silence" auscultated heart tones are distinct. In rare cases, silence" auscultated heart tones are distinct. In rare cases, mesenteric venous thrombosis can be detected swelling of the mesenteric venous thrombosis can be detected swelling of the hemorrhoidal veins (symptom Korochanskogo).hemorrhoidal veins (symptom Korochanskogo).

Diagnosis of acute disorders of mesenteric circulation is Diagnosis of acute disorders of mesenteric circulation is based primarily on thebased primarily on the clinical picture of clinical picture of disease and personal history. The disease and personal history. The disease usually affects the elderly and senile disease usually affects the elderly and senile patients suffering from various diseases of the patients suffering from various diseases of the cardiovascular system, chronic pneumonia, malignant cardiovascular system, chronic pneumonia, malignant neoplasms. It occurs sometimes in conjunction neoplasms. It occurs sometimes in conjunction with paralytic ileus and can simulate acute abdominal with paralytic ileus and can simulate acute abdominal disease (acutedisease (acute appendicitis, acute pancreatitis, IPOs).appendicitis, acute pancreatitis, IPOs).When the branches of mesenteric When the branches of mesenteric vessels thromboembolism may develop acuteulcers with vessels thromboembolism may develop acuteulcers with perforation of the intestinal wall and intestinal bleeding.perforation of the intestinal wall and intestinal bleeding.

A more accurate diagnosis of mesenteric blood flow is A more accurate diagnosis of mesenteric blood flow is possible only in a hospitalpossible only in a hospital using special methods of using special methods of examination.examination.

Thus, Thus, the emergency doctor tacticsthe emergency doctor tactics in  in acute mesenteric circulatory disordersacute mesenteric circulatory disorders should should be particularly urgent hospitalization. The reason for be particularly urgent hospitalization. The reason for leaving the patient at home may be leaving the patient at home may be the only extremely serious condition in end-the only extremely serious condition in end-stage disease, whenstage disease, when patient transportation is patient transportation is impossible. In these cases it is necessary to carry outimpossible. In these cases it is necessary to carry out resuscitation and intensive therapy aimed at resuscitation and intensive therapy aimed at restoring efficient hemodynamics, andrestoring efficient hemodynamics, and the the infusion detoxification.infusion detoxification.

TransportationTransportation of patients with  of patients with acute mesenteric circulatory disorders in theacute mesenteric circulatory disorders in the surgical surgical department should be carried out on a stretcher in the department should be carried out on a stretcher in the supine position. The patient should be referred directly supine position. The patient should be referred directly to surgical team and anesthesiologist on duty.to surgical team and anesthesiologist on duty.

Emergency CareEmergency Care on on prehospital stage performed in a prehospital stage performed in a

minimum volume that is dictated by the need for minimum volume that is dictated by the need for

urgent hospitalization.urgent hospitalization.

Its main objectives:Its main objectives:

1) to reduce the negative impact of the reflex zones of 1) to reduce the negative impact of the reflex zones of myocardial ischemia and the basic functions of life the myocardial ischemia and the basic functions of life the patient;patient;     2) to stabilize the disturbed functions of the      2) to stabilize the disturbed functions of the cardiovascular and respiratory systems;cardiovascular and respiratory systems;     3) to begin preparing the patient for diagnostic tests in      3) to begin preparing the patient for diagnostic tests in the hospital and for surgery.the hospital and for surgery.

These tasks are primarily conducting adequate pain These tasks are primarily conducting adequate pain relief. It is advisable to also use tools such relief. It is advisable to also use tools such as nitrong, sustak, nitrosorbid. It is possible, as nitrong, sustak, nitrosorbid. It is possible, and intravenous nitroglycerin - 0,125-and intravenous nitroglycerin - 0,125-0,25 mg overnight, while the remaining 1.2 mg - drip.0,25 mg overnight, while the remaining 1.2 mg - drip.

In the early stages of the disease designation of narcotic In the early stages of the disease designation of narcotic analgesics does not diminish the pain. Their analgesics does not diminish the pain. Their application is useful when developing a heart attack, and application is useful when developing a heart attack, and particularly of particularly of peritonitis. Assign morphine pantopon, promedol. Combiperitonitis. Assign morphine pantopon, promedol. Combine them effectively with antihistamines ne them effectively with antihistamines (diphenhydramine, pipolfen).(diphenhydramine, pipolfen).

In patients with acute mesenteric circulatory disorders, in In patients with acute mesenteric circulatory disorders, in spite of recurring vomiting, stomach is often filled spite of recurring vomiting, stomach is often filled with content. In order to avoid regurgitation and with content. In order to avoid regurgitation and asphyxia must empty it through the tube. This is asphyxia must empty it through the tube. This is particularly important event in severely ill with confusion.particularly important event in severely ill with confusion.

When instability indicators of central When instability indicators of central hemodynamics, in particular, hypotension,should be hemodynamics, in particular, hypotension,should be prescribed corticosteroids (hydrocortisone, prescribed corticosteroids (hydrocortisone, methylprednisolone,dexamethasone). Vasopressor theramethylprednisolone,dexamethasone). Vasopressor therapy, in contrast to cardio tonic should be py, in contrast to cardio tonic should be used very cautiously, only during used very cautiously, only during deep hypotension. If vasopressors (dopamine, deep hypotension. If vasopressors (dopamine, norepinephrine) are still used, it is advisable to maintain norepinephrine) are still used, it is advisable to maintain a systolic blood pressure level above 100 mm Hg. a systolic blood pressure level above 100 mm Hg. 

Under the provision of an ambulance preparation for Under the provision of an ambulance preparation for subsequent hospital care in a broader scope (such subsequent hospital care in a broader scope (such as infusion liquids) is unrealistic and can lead to loss of as infusion liquids) is unrealistic and can lead to loss of time.time.

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