Острый живот

Острый живот - ни                    | Щеткина в начале  |                        |                                  | |                                 |                                 |                             |                                 |                                  | заболеваний нет.    |                        |                                  | |                                 |                                 |                             |                                 |                                  | При аускультации  |                        |                                  | |                                 |                                 |                             |                                 |                                  | живота кишечные   |                        |                                  | |                                 |                                 |                             |                                 |                                  | шумы                     |                        |                                  | |                                 |                                 |                             |                                 |                                  | неравномерны,       |                        |                                  | |                                 |                                 |                             |                                 |                                  | усилены.                |                        |                                  | |                                 |                                 |                             |                                 |                                  | Выслушивается     |                        |                                  | |                                 |                                 |                             |                                 |                                  | «шум плеска». При |                        |                                  | |                                 |                                 |                             |                                 |                                  | ректальном            |                        |                                  | |                                 |                                 |                             |                                 |                                  | исследовании —    |                        |                                  | |                                 |                                 |                             |                                 |                                  | зияние сфинктера  |                        |                                  | |                                 |                                 |                             |                                 |                                  | прямой кишки         |                        |                                  | |-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Тромбоз и эмболия   | Сердечно-                | Внезапная,           | Многократная, не      | Тяжелое, больной      | Живот мягкий,        | В крови —       | Скопление газа в       | | брыжеечных             | сосудистые              | постоянная,         | приносит                  | беспокоен.                 | вздут, умеренно     | увеличение     | кишечнике                 | | сосудов                    | заболевания.            | очень                   | облегчения               | Бледность,                | болезненный во      | содержания     |                                  | |                                 | Нарушения ритма     | интенсивная по    |                                 | холодный пот,           | всех отделах.        | гемоглобина,   |                                  | |                                 | сердца                     | всему животу       |                                 | акроцианоз. Пульс     | Кишечные шумы    | выраженный    |                                  | |                                 |                                 |                             |                                 | учащен, аритмичен.   | ослаблены, потом  | лейкоцитоз,     |                                  | |                                 |                                 |                             |                                 | АД снижено.              | — отсутствуют.     | сдвиг              |                                  | |                                 |                                 |                             |                                 | Температура тела не | Перитонеальные     | лейкоцитарной |                                  | |                                 |                                 |                             |                                 | повышена. В начале  | симптомы              | формулы         |                                  | |                                 |                                 |                             |                                 | заболевания стул с    | выражены              | влево, СОЭ     |                                  | |                                 |                                 |                             |                                 | примесью крови,       | нечетко. При          | увеличена       |                                  | |                                 |                                 |                             |                                 | потом — задержка     | ректальном            |                        |                                  | |                                 |                                 |                             |                                 | стула и газов             | исследовании —    |                        |                                  | |                                 |                                 |                             |                                 |                                  | примесь крови в     |                        |                                  | |                                 |                                 |                             |                                 |                                  | кале                       |                        |                                  | |-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Нарушенная             | Нарушения               | Внезапная,           | Редко                       | Тяжелое,                   | Живот мягкий,        | Снижение        | Рентгенологическая   | | внематочная             | менструального        | интенсивная, над |                                 | выраженная               | болезненный над    | гематокрита,   | картина без               | | беременность           | цикла, кровянистые  | лонным                |                                 | слабость,                  | лонным                  | уровня            | особенностей            | |                                 | выделения из           | сочленением или  |                                 | обморочное               | сочленением или в | гемоглобина,   |                                  | |                                 | влагалища                | разлитая,             |                                 | состояние. Кожа и     | подвздошных         | количества      |                                  | |                                 |                                 | отдающая в         |                                 | слизистые оболочки   | областях,               | эритроцитов    |                                  | |                                 |                                 | поясничную         |                                 | бледные. Частый,      | перкуторно —        |                        |                                  | |                                 |                                 | область, прямую  |                                 | слабый пульс,           | притупление звука  |                       |                                  | |                                 |                                 | кишку                   |                                 | низкое АД,                 | в отлогих местах.   |                        |                                  | |                                 |                                 |                             |                                 | температура тела      | Симптом                |                        |                                  | |                                 |                                 |                             |                                 | нормальная               | Блюмберга —        |                        |                                  | |                                 |                                 |                             |                                 |                                  | Щеткина слабо       |                        |                                  | |                                 |                                 |                             |                                 |                                  | выражен.               |                        |                                  | |                                 |                                 |                             |                                 |                                  | Кровянистые          |                        |                                  | |                                 |                                 |                             |                                 |                                  | выделения из         |                        |                                  | |                                 |                                 |                             |                                 |                                  | увеличенной          |                        |                                  | |                                 |                                 |                             |                                 |                                  | мягкой матки,         |                        |                                  | |                                 |                                 |                             |                                 |                                  | нависание заднего |                        |                                  | |                                 |                                 |                             |                                 |                                  | свода влагалища   |                        |                                  | |-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Разрыв яичника,       | Ранее                       | Внезапная,           | Не характерна          | Удовлетворительное, | Живот мягкий,        | Как правило,   | То же                        | | перекрут кисты         | диагностированная   | интенсивная в      |                                 | умеренная                 | болезненный в       | без                  |                                  | | яичника                    | киста яичника           | нижних отделах   |                                 | тахикардия,               | нижних отделах,    | отклонений от  |                                  | |                                 |                                 | живота,                |                                 | температура тела      | там же                   | нормы             |                                  | |                                 |                                 | иррадиирует в      |                                 | нормальная               | определяется         |                        |                                  | |                                 |                                 | поясничную         |                                 |                                  | мышечное              |                        |                                  | |                                 |                                 | область и             |                                 |                                  | напряжение.           |                        |                                  | |                                 |                                 | внутреннюю         |                                 |                                  | Может быть           |                        |                                  | |                                 |                                 | поверхность         |                                 |                                  | положительным      |                        |                                  | |                                 |                                 | бедра                   |                                 |                                  | симптом                 |                        |                                  | |                                 |                                 |                             |                                 |                                  | Блюмберга —        |                        |                                  | |                                 |                                 |                             |                                 |                                  | Щеткина. Резкая    |                        |                                  | |                                 |                                 |                             |                                 |                                  | болезненность при |                        |                                  | |                                 |                                 |                             |                                 |                                  | смещении шейки    |                        |                                  | |                                 |                                 |                             |                                 |                                  | матки и при            |                        |                                  | |                                 |                                 |                             |                                 |                                  | пальпации заднего |                        |                                  | |                                 |                                 |                             |                                 |                                  | свода влагалища.  |                        |                                  | |                                 |                                 |                             |                                 |                                  | Резко болезненное |                        |                                  | |                                 |                                 |                             |                                 |                                  | округлое                |                        |                                  | |                                 |                                 |                             |                                 |                                  | эластичное            |                        |                                  | |                                 |                                 |                             |                                 |                                  | образование           |                        |                                  | |                                 |                                 |                             |                                 |                                  | справа или слева   |                        |                                  | |                                 |                                 |                             |                                 |                                  | от матки                 |                        |                                  | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Лечебная тактика. Больного с подозрением на «острый живот» следует немедленно госпитализировать в профильное учреждение. Транспортировка больных, находящихся в тяжелом состоянии, должна быть быстрой, безопасной, щадящей. Необходимо предусмотреть возможность проведения лечебных мероприятий, направленных на стабилизацию гемодинамических нарушений, на догоспитальном этапе. Характер лечебных мероприятий при О. ж. зависит прежде всего от основного заболевания, что диктует необходимость уточнения диагноза, проведения специальных дополнительных исследований. До постановки окончательного диагноза, решения вопроса о необходимости экстренной операции и, соответственно — определения всей лечебной тактики, запрещен прием жидкости и пищи, следует воздержаться от применения анальгезирующих, снотворных средств, нейролептиков, транквилизаторов, слабительных средств, клизм. При некоторых воспалительных процессах, не угрожающих развитием перитонита, проводят комплексное консервативное лечение, однако в большинстве случаев О. ж. (перитонит, перфорация полых органов, механическая непроходимость кишечника и др.) необходимо экстренное оперативное вмешательство. Оно проводится немедленно после госпитализации или ему предшествует интенсивная инфузионная предоперационная подготовка в течение 2—3 ч с целью коррекции возникших гемодинамических, водно-электролитных и других нарушений. Больным, находящимся в очень тяжелом состоянии с продолжающимся внутренним кровотечением, оперативное вмешательство проводят сразу же после поступления в стационар, параллельно выполняя реанимационные мероприятия. В сложных случаях характер и объем лечебных мероприятий определяется консилиумом специалистов (хирург, реаниматолог, терапевт и др.). Прогноз зависит от характера и тяжести основного заболевания, а также от срока, прошедшего с момента начала заболевания до поступления больного в стационар, его возраста и сопутствующих заболеваний. Прогноз неблагоприятный при запущенных распространенных формах перитонита, непроходимости кишечника с его обширным некрозом, тромбозе брыжеечных сосудов, особенно в пожилом и старческом возрасте. Чем быстрее при синдроме О. ж. больной госпитализирован, чем раньше поставлен точный диагноз и проведено адекватное (в т.ч. оперативное) лечение, тем ниже летальность и лучше ближайшие и отдаленные результаты. Библиогр.: Мандор Г. Неотложная диагностика, пер. с франц., т. 1, М. — Л., 1939; Руководство по неотложной хирургии органов брюшной полости, под ред. В.С. Савельева, М., 1986.