Mirizzi syndrome: gulu, matenda, mankhwala

dzina "Mirizzi syndrome" kugwirizana ndi dzina la dokotala ku Argentina Mirizzi, amene ndi woyambitsa wa ntchito zambiri zokhudzana ndi Maphunziro Akakhalidwe Kazolengedwa wa excretion biliary, komanso kumapeto matenda m'munda wa cholegraphy intraoperative.

Mu 1948, ntchito dokotala sayansi anafotokoza semiotics radiological kwa chiwindi matenda, zizindikiro za amene anaonekera yowala ya ndulu stasis ndi contracture wa ya ndulu ritsa. Komanso, chithunzi calculouse syndrome inali kuperekedwa, amene afotokozedwa mu maonekedwe a fistula pakati pa ndulu ndi hepaticocholedochus.

Pali kutsutsana

Osati aliyense ndi bwino matenda matenda Mirizzi. Kodi izo, ife kufotokoza pansipa. Koma poyamba Dziwani kuti mpaka mu mankhwala lingaliro kwambiri si bwino kumatanthauza. Mwachitsanzo, madokotala ambiri amakhulupiriranso kuti maziko a matenda ndi kuchepetsa wa lumen mu ducts chiwindi. Kwambiri kukodzedwa chiphunzitso syndrome kumafuna chizindikiritso cha matenda chiwindi ndi stenosis m'dera ritsa kapena thumba Hartmann kakyulasi, amene anatsagana ndi kutukusira kwa chikhodzodzo ndulu ndi kumaonekera mu cholangitis munda kapena matenda a chikasu ndiyo.

Mirizzi syndrome, amene gulu ali m'nkhani ino ndi maganizo a asayansi ambiri, amakhala osati kuchepetsa wa lumen wa. The ndondomeko pathological kumafuna bwino wamba ndi wamba ya ndulu ritsa.

Mwamtheradi mosiyana kuchiza matenda a asayansi amene amakhulupirira kuti maziko a matenda ndi puzyrnoholedohealny fistula. Pali adani pa kutanthauzira kwa ndondomeko pathological. M'nkhani zina sayansi anatchula ubale malo pakati pa ndulu ndi wamba kwa chiwindi ritsa, ndi mapepala ena kufufuza zitsanzo za kupezeka fistula pakati pa ndulu ndi wamba ya ndulu ritsa.

Mwachitsanzo, mu gulu la MV Corlette, H. Bismuth (1975) ankaimira bilio-biliary fistula mitundu iwiri malingana ndi kutanthauzira za Mphambano (pamwamba kapena m'munsimu pawiri yaikulu ya ritsa enaake ndi ndulu).

Akatswiri ena amanena chiwonetsero cha matenda kwa kuchepetsa wa lumen ndi mapangidwe hepaticocholedochus holetsistoholedohealnogo fistula.

Zosiyanasiyana kutanthauzira kwenikweni syndrome complicates amaonera alili ake komanso wolemera kupeza njira yabwino kuchitira izo.

M'zaka zaposachedwapa, Kawiri kawiri mutha kupeza kutanthauzira watsopano wa kudwala ichi matenda Mirizzi? Mitundu kwake amaoneka mitundu iwiri ya matenda:

• pachimake mawonekedwe, imene mwapang'ono lumen hepaticocholedochus;
• mawonekedwe aakulu, amene amakwiya maonekedwe a fistula pakati hepaticocholedochus ndi ndulu lumen.

Malongosoledwe chakale

Malongosoledwe tingachipeze powerenga za ndondomeko matenda monga Mirizzi syndrome, chithunzi chimene anapereka mu pepala ili tichipeza kamba zinayi zikuluzikulu:

• malo pafupi kufanana ritsa ya ndulu ndi chiwindi wa ritsa chachikulu;
• Kupezeka kwa miyala ndulu kapena ritsa mu khosi lake;
• obstructive ndondomeko chiwindi otaya, amene amayambitsidwa ndi kuliika concrement ritsa ndi ndulu kutupa pozungulira ilo;
• pamaso pa matenda a chikasu ndiyo kapena wopanda cholangitis iye.

mfundo za gulu

Kodi mitundu ya matenda lagawidwa matenda Mirizzi? Gawo amatenda kuwonongedwa mlingo wa chachikulu ritsa khoma chiwindi puzyrnoholedohealnym fistula (Csendes):

• Lembani I - kufinya wamba ritsa miyala khosi chiwindi ndulu kapena ritsa.
• Mtundu II - pamaso pa vesico-holedohealnogo fistula agwilitse zosakwana 1/3 wa circumference onse a ritsa chiwindi;
• Mtundu III - pamaso pa vesico-holedohealnogo fistula, amene ali 2/3 wa circumference wa ritsa chiwindi;
• Mtundu IV - pamaso pa vesico-holedohealnogo fistula zimafunika zonse circumference kwa chiwindi ritsa, mmene khoma ritsa pansi pa kumaliza chiwonongeko.

Zimayambitsa chitukuko syndrome

The chikuchititsa mavuto a matenda monga matenda Mirizzi ndi:

• psinjika lumen ya ndulu ritsa kunja chikwiyire calculous pachimake cholecystitis;
• kukhalapo ya ndulu ritsa stricture linali kunja m'dera la chiwindi;
• hepaticocholedochus mapangidwe perforations pamaso pa stricture;
• chitukuko cha vesicovaginal fistula holedohealnogo kufanana Kupha stricture.

Malinga ndi kapangidwe ka ducts biliary, kukula ndi kulemera kwa miyala komanso njira ndondomeko chithandizo akhoza zizikhala aliyense wa masitepe pamwamba, koma kusinthika kwa psinjika pang'ono ya ndulu ritsa mu vesico-holedohealny fistula zingaoneke kokha pa matenda gallstone.

Psinjika likunyonyotsoka mu ya ndulu ritsa stricture ngati opaleshoni anachedwa ndi matenda amakhala mawonekedwe aakulu, imene nthawi ya chikhululukiro m'malo peaking. Pamene nthawi khoma ndulu ndi hepaticocholedochus kuyamba kukhudzana kuti zinayambitsa mwala waukulu mu thumba la Hartmann. Mu mavuto sikelo yake chatsika trophism ukapezeka decubitus ndulu khoma ritsa. Ndiye puzyrnoholedohealny fistula aumbike.

Kudzera nkhani zimenezi pathological ku ndulu mu lumen hepaticocholedochus kugwa concretions. Fistula kuchuluka awiri ndi kuchepetsa minofu psinjika ake nthambi. Chifukwa, ndi kuchepetsa a mbali proximal wa hepaticocholedochus Chathu, ndi ndulu yafupika kukula, izo Mwamsanga khosi, Hartmann m'thumba, ndipo mbali yaikulu ya thupi. Chifukwa, ndi ndulu akhala ngati maphunziro divertikulopodobnoe, yomwe ndi uthenga ndi lumen wa extrahepatic ya ndulu ritsa ntchito anastomosis lonse. Monga ulamuliro, palibe otaya kuwira.

symptomatology

Kodi syndrome Mirizzi? Zizindikiro khalidwe la cholecystitis kumachitika mu mawonekedwe pachimake kapena aakulu ndi chitukuko cha matenda a chikasu ndiyo makina. The ambirimbiri odwala zolemba zachipatala zina alipo gallstone matenda nafe pafupipafupi, cyclical makina matenda a chikasu ndiyo. About deta sayansi, yowala ndipo ambiri zizindikiro zambiri kuwonetseredwa monga ululu pamimba chapamwamba bwino. Zowawa ndi matenda a chikasu ndiyo nkhawa mu 60-100% ya milandu.

Matenda a chikasu ndiyo limapezeka mu kukhalapo kwa vesico-holedohealnogo fistula.
Pamene cholangitis taonera malungo. Nthawi zina kudodometsa ululu hypochondrium ndi, kuledzera, chitukuko kapamba (zochita ngati anakuta pa matenda wamba). M'magazi kumawonjezera mlingo wa bilirubin, alt, Ast, ndi zamchere phosphatase.

Amene ali wamba?

Mirizzi syndrome amapezeka 0.1% odwala ndi pamaso pa matenda gallstone. Ngati alowererepo opaleshoni zimawonedwa mu 0.7-2.5% odwala. Odwala, amuna ndi akazi mwamtheradi mafuko ndi mitundu yonse. Mu ukalamba, matenda amapezeka kwambiri kawirikawiri.

njira matenda

ndi zovuta za mankhwala a matenda monga matenda Mirizzi chiyani? Matendawa ndi njira opaleshoni si bwino kumatanthauza.

Mu mankhwala amakono, palibe malamulo ambiri amavomereza pochititsa njira yodziwira. Ngakhale patsogolo m'munda wa matenda kulingalira osiyanasiyana, ntchito matenda ndi kukhazikitsa movutikira. Izi zimathandiza pafupifupi 20% ya milandu. Only ndi ofufuza angapo amanena kuti ultrasound matenda pamaso ntchito umalandira chandamale yeniyeni 67,1% milandu, Kujambula - mu 94,4%, intraductal ultrasound - pa 97% ndi endoscopic retrograde cholangiopancreatography - 100%.

Zonsezi zikusonyeza kuti njira zamakono za matenda malangizo sikuti n'zotheka kudziwa syndrome Mirrizi mu nthawi yapitayi ntchito.

Nthawi zambiri, pamene ultrasound anapeza zizindikiro zotsatirazi:

• kutambasuka ritsa mu chiwindi komanso wabwino ake proximal kufanana kwa wamba ritsa unexpanded ndulu;
• kupeza ndulu makwinya boma.

CT Mirizzi syndrome zizindikiro lifanane ndi mbali wapezeka ndi ultrasound. Ngakhale CT sangathe kupereka zofunika zina zowonjezera njira akupanga ndi, udindo wake kudziwa pamaso pa khansara mu ducts proximal a ndulu ndi m'malo okwezeka, chimene chiri chofunika mu zosiyanasiyana Mirrizi syndrome ndi kukhalapo kwa khansara.

Maginito kumveka kulingalira, endoscopy ndi retrograde cholangiopancreatography (ERPHG) matenda njira ndi ofanana pankhani akudzizindikiritsa ndi stricture holetsistoholedohealnogo fistula. The zithunzi mu mode T1 ndi T2 akhoza kukhala molondola kwambiri kusiyanitsa kutupa khansa, si nthawi zonse ukoma CT ndi ultrasound. Komabe, chifukwa mtengo Kupenda ndi Kujambula njira yodziwira si ntchito malo onse thanzi.

Maginito kumveka cholangiopancreatography ndi watsopano, koma pang'ono kuphunzira mtundu wa matenda. Asayansi ambiri amaona ngati maganizo kwambiri zingamuthandize kuti uzipereke kudwala monga syndrome Mirrizi.

Asayansi ena akunena kuti m'mabuku awo ubwino laparoscopic ultrasonography pancreatoduodenal m'deralo. Pa opaleshoni kuti amaganiziridwa matenda a masentimita njira limachititsa kumanga zenizeni nthawi chifaniziro cha ducts ya ndulu mu ndege angapo chipatso cha kumathandiza kupeza ngodya zosiyanasiyana. Panopa Komabe, njira adakali kufikako ndi unexplored mpaka kumapeto.

Tikumbukenso kuti ngakhale kuli njira zosiyana matenda, kukhazikitsa pamaso pa masentimita akadali povuta, chimene chingalowe atchule dokotala asochere ndipo kuwononga kuti wamba ya ndulu ritsa, amene molakwika amaona ndulu kapena otaya lonse. Chosowa njira ambiri amavomereza matenda asanachite opareshoni akukankhira kukhala njira yabwino.

Malangizo chithandizo

Kodi kwathetsa matenda Mirizzi? Chithandizo kumafuna m'madera ziwiri: rentgenoendoskopichesky njira ndi alowererepo pa opaleshoni.

Rentgenoendoskopichesky mtundu wa mankhwala ingagwiritsidwe ntchito monga sitepe koyamba isanafike opaleshoni pokonzekera opaleshoni. Iye amachita monga njira palokha ya chithandizo cha odwala ndi kukhalapo kwa SM pa nkhani ya chiopsezo mankhwala ochititsa.

The kuipa Rev ofufuza ambiri monga:

• cheza kukhudzana odwala ndi ogwira ntchito zachipatala
• mtengo kwambiri endoscopy ndi X-ray Kupenda;
• kulephera kuthetsa kuchepetsa wa lumen wa gawo proximal a wamba ya ndulu ritsa.

Malinga ndi mabuku ambiri a sayansi zimasiyana kwambiri pakati pawo njira za phukusi kugwira ntchito. Pali zinthu zosiyanasiyana kwa ntchito opaleshoni pa SM.
Madokotala ena amakhulupirira kuti Mirrizi kuchizidwa syndrome laparoscopy ndi contraindicated mwamtheradi.

Ndi mawonekedwe ambiri a ntchito pamene yoyamba ndi cholecystectomy syndrome, amene wodzilemekeza ndi kukhetsa choledoch.

Kodi adathandizapo ndi pamaso pa fistula biliobiliarnogo Mirizzi syndrome? ntchito Situational amafuna kulekana ndi kuchira hloledoha okhulupirika. Pamene njira ya kutseka wamba ya ndulu ritsa, omwe umagwiritsidwa ndi ambiri madokotala kuchotsa chilema cha mpanda wake kudzera mbali zotsala za chikhodzodzo ndulu. Komabe, madokotala ena amaona kuti kusiya minofu akhoza azitaya choledocholithiasis yotsalira.

Mu kukhalapo kwa fistula holetsistobiliarnogo akulimbikitsidwa kugwiritsa ntchito wamba ya ndulu ritsa stents mapulasitiki pa chikhalidwe zosakhalitsa. Kufunika kwa mtundu wa ntchito, asayansi ambiri amati pamaso pa kusintha yaitali zikuchitika m'dera la yotupa chikhalidwe hepatoduodenal Mitsemphayi, umene SM akhoza anazindikira kuwononga chitsanzo ya ndulu ritsa makoma. Pa ndithu awo mapindikidwe ya ndulu ritsa khoma m'gulu fistula lapansi.
Pa opaleshoni, pali mkulu mlingo wa chiopsezo matendawo.

zosokonezeka zotheka

Nthawi zambiri kumachitika pambuyo opaleshoni vuto ngati wamba ya ndulu ritsa stricture. Malinga ndi Russian kafukufuku GI Dryazhenkova (2009) odwala 46 amene opaleshoni, stricture zinachitika mu 6.5%.

Kodi zotsatira za ntchito pa otchedwa ngalande otayika, chimene chinapangidwa odwala anayi ndi koyamba mawonekedwe masentimita (stenotic view)? Akatswiri V. S. Savelev, VI Revyakin (2003) inati mphamvu zabwino matenda Komabe, fotokozani za kuchotsa ritsa dera dongosolo ngalande zifukwa zotsatirazi:

• chitukuko cha matenda a chikasu ndiyo;
• ngalande kutsekeka chikwiyire mapangidwe calculi yaing'ono;
• salt mafunsidwe pa makoma a ngalande;
• kudzikundikira detritus, ofanana mu kugwirizana kwa putty kuti amakwiya kuukira kobwereza wa cholangitis.

Mlingo wapamwamba mavuto a ntchito ndi odwala ndi digiri yapamwamba ya wamba ya ndulu chiwonongeko ritsa khoma. Ngati matenda ali mu gawo lachitatu kapena wachinayi, iwo anati amafa apamwamba pambuyo opaleshoni. Pamene matenda ili mu mlingo wachitatu kapena wachinayi, madokotala ambiri mtima ndi holedohoeyunoanastomoza.

Chithandizo pambuyo opaleshoni

Monga atazikocheza syndrome Mirizzi? Chithandizo pambuyo opaleshoni kumafuna magazi ndikupereka tsiku lotsatira pambuyo opaleshoni, sabata imodzi ndipo tsiku lina pamaso kumaliseche m'chipatala. Sutures amachotsedwa pa tsiku 10.

Pafupifupi kutalika m'chipatala ndi masiku 10-12. Kutalika okwana nthawi ayambe ndi miyezi iwiri.
Childs, odwala anasonyeza mpumulo mu chipatala chaching'ono mu dipatimenti konzanso.

Pomaliza

Chibwenzi Mirizzi syndrome, gulu, matenda ndi mankhwala amene akufotokozedwa mu nkhani iyi, mankhwala monga mmodzi wa mavuto a matenda gallstone. Komabe, mu munda wa matenda ndi opaleshoni akadali nkhani zosiyanasiyana osathetsedwa.

Ngakhale kuti pali osiyanasiyana osiyanasiyana alowererepo opaleshoni, mankhwala zotsatira si nthawi zonse kukumana kuyembekezera.
Pa opaleshoni, kuchuluka intra- ndi postoperative mlingo vuto.

Mavuto kuchititsa ntchito matenda, ngozi za kuwonongeka kwa ya ndulu ritsa, owerengeka kuyang'anila ndi sipekitiramu wachuma wa njira ya opaleshoni ndi chofunika kwambiri kuphunzira mozama za vutolo.

Mawu oyamba mfundo za makono matenda ndi chitukuko kupezerapo mulingo woyenera m'munda wa opaleshoni malingana siteji ya matenda chimathandiza wodwalayo konza mankhwala ndi vuto ili la cholelithiasis.