PYLOROSTENOSIS (pylorostenosis; pyloros gatekeeper + stenosis narrowing) narrowing of the gatekeeper.
P. can be acquired and inborn. Most often the acquired P. which is a consequence of diseases of a stomach meets. The inborn P. carried to malformations is observed rather seldom, generally at children.
As the reasons of the acquired P. serve the cicatricial changes resulting peptic ulcer (see) or a burn strong to-tami and alkalis, the benign and malignant tumors which are localized in the field of the gatekeeper. Can also lead to P. the inflammatory and tumoral processes which are located out of the peloric channel. P.'s development at tuberculosis and syphilis is possible stomach (see). The rare reason of P. at adults — an inborn hypertrophy of a muscular coat of the gatekeeper.
Narrowing, rigidity and the perverted sokratitelny activity of the gatekeeper create an obstacle for transition of contents of a stomach to a duodenum. In a phase of compensation the hypertrophy of a wall of a stomach develops, the peristaltics amplifies, the tone of a muscular wall raises thanks to what gastric contents, though in a slowed-up way, overcome the narrowed site. In a phase of a decompensation muscles of a stomach become thinner, its tone decreases, the peristaltics weakens, the stomach in the form of the stretched bag falls, aggravating evakuatorny frustration due to dislocation of output department. The stagnating contents of a stomach are exposed to fermentation and rotting. The frequent vomiting characteristic of this phase P. has an adverse effect on the general condition of an organism since with an emetic masses a large amount of liquid and electrolytes is lost. Extreme degrees of P. cause the starvation which is combined with intoxication and deep disturbances of all types of exchange.
change of the peloric ring taking the rounded or slit-like shape is characteristic Of partial P., the inborn P. which is combined with deformation of the gatekeeper (Landerer's pylorostenosis — Maier). Microscopic changes at this type of P. or completely are absent, or the hypertrophy of separate muscle fibers of a peloric ring is found. At a pylorostenosis of Girshsprunga the peloric channel gets a form of a tube with sharply reinforced wall reaching density of a cartilage. The hypertrophy of a mucous membrane of peloric department up to formation of polyps is microscopically observed, however the most typical sign is the sharp hypertrophy of muscle fibers of preferential circular layer which is combined with a hypertrophy of elastic fibers and a degeneration of kernels of ganglionic cells of neuroplexes of a wall of a stomach. Changes of muscles connect with a hypertrophy of «a peloric thickening the» of an embryo arising at early stages of an embryogenesis.
The acquired P. is divided on functional and organic. At functional P. there is a thickening of a wall of peloric department of a stomach without narrowing of its gleam and expansion of other departments of a stomach. Organic P. can be partial (compensated and subcompensated) or full (dekompensirovanny). At partial P. the peloric ring has diameter not less than 0,5 cm. Narrowing of a peloric ring to several millimeters is referred to the full Item. At the acquired P. the mucous membrane of peloric department of a stomach is usually thickened, folds its rough. The mucosal atrophy develops only in late stages of a disease. Muscular layers of a wall of a stomach are in most cases condensed and thickened. At long existence of P. muscle fibers of a peloric ring become thinner. The hyperplasia of peloric glands of a mucous membrane is microscopically observed, their gleam is muciferous. Also the hyperplasia of obkladochny and covering cells of the main glands is noted (fig. 1, a) that demonstrates their increased secretory activity. Hypostasis of a mucous membrane, proliferation of mast cells in it, a hypertrophy of its muscle fibers with thinning and their crimpiness in late phases of process is observed. In a submucosal layer — increase in number of vessels (fig. 1,6). In muscular layers the focal or diffusion hypertrophy of muscle fibers with increase in the sizes of their kernels and vacuolation of cytoplasm (fig. 1, c) in combination with a hyperplasia of elastic fibers around them is noted. The number of ganglionic cells in neuroplexes of a stomach is reduced, in their kernels dystrophy is observed.
A clinical picture
Allocate three phases of development of the acquired P.: compensations, subcompensations and decompensations. In a phase of compensation of P. complaints to feeling of completeness in epigastriums after food, periodic vomiting are noted. In a phase of subcompensation the constant feeling of weight in epigastriums, an eructation «rotten», the plentiful vomiting seen approximately a peristaltics is observed. On an empty stomach from a stomach a large number of contents with impurity on the eve of the eaten food with signs of putrefactive fermentation is pumped out. Heavy disturbances of the general state, a big lose of weight are characteristic of a phase of a decompensation, dehydration of an organism (see), hypoproteinemia, hypopotassemia (see), azotemia (see), alkalosis (see). In far come cases owing to progressing of disturbances of water and electrolytic balance, sharply expressed hypochloraemia (see) and hypocalcemias (see. Tetany ) the convulsive syndrome (a so-called gastric tetany) develops. Vomiting at the same time can be absent. Contours of the crowded stomach are visible, capotement constantly is defined. During the sounding a large number of the decaying food masses is removed.
the Diagnosis is established on the basis of a characteristic symptom complex, results of sounding of a stomach, gastroscopy, rentgenol, data and studying of motor function of a stomach. Plays an important role in P.'s diagnosis gastroscopy (see) by which it is possible to define a cause of illness (an ulcer, a tumor, a hem), and also precisely to establish diameter of the narrowed gatekeeper.
The task rentgenol, researches comes down to P.'s detection, specification of its origin and assessment of extent of compensation of a stenosis. For more dense filling of peloric department with contrast weight it is necessary to resort to a polyposition research, in particular to a lateroskopiya (see. Polyposition research ). Facilitates diagnosis and a double contrast study of a stomach — barium and air. For differentiation of organic narrowing of the gatekeeper and pylorospasm (see) use pharmakol. tests.
The narrowing caused by a malignant tumor has rigid character, contours its fillings, uneven with defects. At P. of other etiology contours of narrowing smooth, variability of the narrowed site in serial pictures is observed.
In a phase of compensation of P. the stomach of the normal sizes or is a little increased, evacuation is not detained or lasts 8 — 12 hours, a peristaltics its deep, strengthened. In a phase of subcompensation the stomach is increased in sizes, on an empty stomach contains liquid, the peristaltics is weakened, emptying is late to the 24th hour. The decompensation is shown by a gastrectasia which contains a lot of liquid, slime, the remains of food, gipotonichen, owing to what contrast weight falls by a greater cul-de-sac, forming a figure of a bowl with the horizontal level (fig. 2). The peristaltics is weakened, waves of an antiperistalsis are sometimes visible. At repeated researches in 24 hours and more in a stomach the delay of a contrast agent is noted.
Treatment — operational. Preoperative preparation is important, to-ruyu in hard cases carry out in chamber of an intensive care or the intensive care unit. It shall be directed to recovery of a tone of a stomach (regular gastric lavages), and also normalization of water and electrolytic balance, acid-base balance, protein metabolism (intravenous administration of potassium chloride, sodium chloride, calcium chloride, 10% of solution of glucose, protein hydrolyzates, blood, etc.).
At a malignant tumor of output department of a stomach make a subtotal resection of a stomach (see. Stomach, operations ). At the benign tumor complicated by a pyloric stenosis the economical resection of a stomach is shown. At a serious general condition of the patient, a nonresectable tumor are limited to imposing of a gastroenteroanastomosis (see. Gastroenterostomy ). At the peptic ulcer complicated by P. make a resection of a stomach, and also vagisection (see) in combination with an economical resection of a stomach, pyloroplasty (see), gastroduodenostomy (see) or gastroenteroanastomosis.
The forecast and Prevention
the Forecast at not tumoral process favorable.
Prevention of the acquired P. comes down to timely treatment of a basic disease.
The pylorostenosis at children
Inborn P. — a malformation went. - kish. a path, revealed at 5 — 40 children on 10 Ltd companies which were born. At boys it is observed by 5 — 10 times more often than at girls.
An etiology and a pathogeny
Narrowing of the peloric channel is caused by overdevelopment and disturbance of structural relationship of muscular layers and connecting tissue of the gatekeeper. These changes on a structure are very close to structure of an excess laying of peloric department of a stomach that gives the grounds to consider inborn P. result of a delay of its involution under the influence of disturbing factors (possibly, hormonal disturbances). After the birth of the child there is congestive gastritis, the pylorospasm and hypostasis of tissues of the gatekeeper joins that aggravates narrowing of the peloric channel and causes displays of a disease which expressiveness and weight can be various.
The clinical picture
the Disease is shown on 2 — 4th week of life by the vomiting passing within several days into vomiting with the fountain fresh and stvorozhenny milk without impurity of bile. Frequency of vomiting fluctuates from 2 — 3 to 10 — 16 times a day, and the general state a long time remains satisfactory. With development of expansion and an atony of a stomach vomiting arises less often, the number of emetic masses exceeds the volume of the eaten milk, they contain slime, because of availability of blood in them they have an appearance of a coffee thick, off-flavor appears. Restriction of intake of milk in intestines leads to weight reduction of a body, emaciation, dehydration, an oliguria, a false lock. During the stroking of an anticardium, especially after feeding, the segmenting peristaltics of a stomach often comes to light. It is quite often possible to palpate under a liver edge a dense slivoobrazny tumor — the reinforced gatekeeper.
At early stages of P. at children with easy forms of inborn P. minor deficit of volume of the circulating blood is observed. At a long disease, increase of weight of the general state a wedge, and a lab. signs dehydration of an organism (see), hypopotassemias (see), hypochloraemia (see) become more expressed that can lead to development of noncompensated gipokhloremichesky alkalosis (see), gipokhloremichesky coma (see).
Diagnosis the wedge, symptomatology is based on characteristic. Among methods of objective diagnosis the research and gastroscopy have major importance rentgenol. At rentgenol, a research to children enter barium into 10% solution of glucose or with the decanted milk. For elimination of the accompanying pylorospasm appointment within 2 — 3 days prior to a research of aminazine or Pipolphenum is recommended. The research consists in a periodic X-ray analysis in vertical or semi-inclined position of the child. The main sign of P. — narrowing and lengthening of the peloric channel which has an appearance of a threadlike shadow 1,5 — 3 mm wide and 8 — 20 mm long (fig. 3, a). If the peloric channel is not filled with contrast weight, on the rounded-off contour of antral department it is possible to see sharp-pointed protrusion — a symptom of «beak» (fig. 3, b). The stomach is expanded, evacuation from it is slowed sharply down or completely is absent.
Inborn P. is shown by lengthening of the peloric channel with its permanent narrowing, a cut smoothly passes into a contour of a neizkhmenenny wall of a stomach. In a series of aim pictures change of caliber of the gatekeeper can be noticeable a nek-swarm. The hypertrophied gatekeeper, pressing in a bulb of a duodenum, gribovidno deforms it. Folds of a mucous membrane in the peloric channel look normal.
Differential diagnosis inborn P. carry out with diseases 1 — the 2nd month of life, the followed vomiting and emaciation of the child. Functional vomiting at children with inflammatory processes does not differ in constancy and is not the leading symptom of a disease. Difficulties at differentiation with pylorospasm (see) are resolved on the basis of distinctions in a wedge, and rentgenol, to a picture, is more rare on the basis of results of trial conservative treatment. Differentiation with adrenogenital syndrome (see), anomalies of distal department gullet (see), an atresia and a stenosis of prepyloric department of a stomach (see) and duodenum (see) it is carried out on the basis of data of radiological and endoscopic methods of a research.
The item as a result of scarring of an ulcer of peloric department of a stomach and a duodenum at children's age meets seldom and is shown by a picture of the increasing impassability of escaping of a stomach which is combined with the expressed pain syndrome.
Treatment operational. It will be out after 2 — 3 days of the preparation directed to elimination of dehydration, a hypopotassemia and hypochloraemia by intravenous transfusions of glyukozosolevy solutions, blood and blood substitutes. Operation of the choice is the longitudinal extramucosal pyloromyotomy according to Freda — to Ramshtedt (see. Pyloroplasty ). The lethality at inborn P. does not exceed 1%. In the remote period children develop well.
The clinic also to lay down. tactics at a cicatricial pyloric stenosis significantly does not differ from those at adult patients.
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V. A. Ageychev; V. V. Kitayev (rents), Yu. P. Kukuruz (it is put. hir.), M. A. Sapozhnikova (stalemate. An.).