REFLUX (Latin refluxus back-flow, a reversed current) — passive movement of liquid contents of hollow bodies or vessels in the opposite (anti-physiological) direction owing to the change in them of a pressure gradient or dysfunction of the valve device or sphincters interfering retrograde current.
Unlike regurgitations (see) — retrograde pushing out of contents from hollow body as a result of active reduction of his muscles, R. represents passive movement (flowing) in the reported cavities at change of hydrostatic pressure in them as a result of obstruction of ways of normal outflow or owing to changes of the direction of gravity at a postural change of a body. Growth of intracavitary pressure due to obstruction of outflow tracts causes R. of hl. obr. in the reported cavities deprived of valves or sphincters as, e.g., between a renal pelvis and tubular system of a kidney. The ruble connected with a postural change of a body usually is observed at disturbance of locking function of valves or sphincters; more rare it is caused by existence patol. soustiya between cavities — inborn or acquired (fistulas) as a result of diseases or surgeries.
R.'s identification quite often helps recognition of the basic patol. process or state. E.g., piyelotubulyarny R.'s detection almost always indicates obstruction of uric ways. Besides, R.'s identification is necessary for development of therapeutic tactics taking into account importance of elimination of R. as the phenomenon playing an independent pathogenic role.
As the reported cavities with the contents moving to them in an organism are generally vessels, went. - kish. a path (with the channels of digestive glands falling into it) and hollow formations of uric system, that the greatest a wedge, matter R. in angiology, gastroenterology and urology.
The ruble in bodies went. - kish. a path and in uric ways not only breaks normal advance of the Wednesdays which are contained in them, but also also bacterial is followed by receipt unusual on physical, chemical. to structure of contents of distal departments that promotes development of dystrophic, inflammatory and destructive changes.
R. blood most often observe a reflux in venous system in varicose expanded veins of the lower extremities where it arises in connection with insufficiency of valves of veins. At a considerable and widespread varicosity because of R. are broken as local blood supply of fabrics (delay of a blood-groove, build-up of pressure on the weakened walls of veins and a wall of a venous part of capillaries that conducts to a delay of liquid in fabrics up to visible hypostasis), and the general hemodynamics (see) that is characterized by decrease in venous return of blood to heart, reduction of minute volume of heart up to development of orthostatic circulatory disturbances (see. Orthostatic changes of blood circulation ). For R.'s identification in veins of the lower extremities use Troyanov's reception - Trendelenbur-hectare and other diagnostic receptions and methods (see. Varicosity ).
The reflux in bodies of digestive tract
In a wedge, displays of diseases and malformations of bodies went. - kish. a path gastroezofagalny and duodeno-gastralny R., flowing of pancreatic juice in bilious ways and a gall bladder (pankreatobili-arny R.) and flowing of bile to a pancreatic channel have the greatest practical value (biliary and pancreatic, or holedokhopankreaticheskiya, R.).
Gastroezofagalny reflux, i.e. flowing of gastric contents in a gullet testifies to cadioesophagal relaxation, edges is most often observed at hernias of an esophageal opening diaphragms (see) — the anatomic defect of a muscular ring coming in some cases after a resection of a stomach and also at peptic ulcer (see), especially in a phase of an aggravation, and at hron. cholecystitis (see). The irritation of a mucous membrane of a gullet acid contents of a stomach (or alkaline if gastroezofagalny R. is combined with duodenogastralny) causes its inflammation — a reflux esophagitis (see. Esophagitis ) also can lead to formation of a round ulcer of a gullet.
The main subjective manifestation of gastroezofagalny R. — the heartburn (sometimes with a thermalgia) arising in horizontal position of the patient and decreasing at a postural change of a body on vertical. This R.'s recognition is possible by means of a X-ray contrast research of a stomach (flowing of a contrast agent from a stomach in a gullet at transfer of the patient from a standing position in a prone position), and also at an ezofagogastroskopiya. Auxiliary diagnostic methods — an ezofagotonokimografiya (see. Ezofagotonografiya ) and an esophageal rn-metriya (see. Gullet ).
Treatment of patients with gastroezofagalny R. is directed to elimination of a basic disease, also to stimulation of tonic function of a cardial press, normalization of motor function of a stomach and rn its contents.
Duodenogastralny reflux it is connected with functional or organic insufficiency of the gatekeeper. It is observed at a peptic ulcer of a duodenum, a duodenostaza (see. Duodenum ), duodenitis (see), cholecystitis, pancreatitis (see), later resections of a stomach (see). Alkaline condition and bilious to - you intestinal contents change pH of a gastric juice, dissolve gastric slime and cause injury of a mucous membrane with formation of erosion or stomach ulcers. Alkalization of contents of a stomach creates premises for reorganization of glands of a mucous membrane on intestinal type that can be the cause hron. gastritis (see), a polypose of a stomach (see).
Duodenogastralny R.'s diagnosis is carried out by means of radiological and endoscopic methods of a research.
Treatment is always defined by a basic disease.
Pankreatobiliarny reflux arises, as a rule, as a result of organic changes of a duodenum and the channels falling into it in the conditions of hypertensia of a duodenum and a staz of its contents. Considerable peptic activity of pancreatic juice causes at the same time development of heavy cholangitis (see), acute enzymatic cholecystitis.
The diagnosis is established by means of a retrograde duodenopankreatokho-langiografiya.
Treatment is generally operational; conservative antiinflammatory treatment is effective only at R. caused by acute inflammatory hypostasis of walls of channels and a duodenum.
Biliary and pancreatic, or holedokho-pancreatic, the reflux is possible only at a certain anatomic relationship: merge of the general bilious channel and pancreat duct to the general canal with formation of an ampoule before falling into a duodenum. Other important point is existence of an obstacle to outflow of bile at the level of a faterov of a nipple (a big nipple of a duodenum, T.). In usual fiziol. conditions pressure in a pancreatic channel is higher, than in the general bilious channel, and the throwing of bile does not happen. The river can arise at a choledocholithiasis, a functional spasm of a sphincter of Oddi (a sphincter of the general bilious channel, T.), its stenosis or inflammatory hypostasis. Its emergence can be promoted by also duodenal hypertensia on condition of insufficiency of a sphincter of Oddi (hypotonic dyskinesia).
Causing staz and leads hypertensia, biliary and pancreatic R. to damage of a wall of channels and hit of pancreatic juice in interstitial fabric that can be the cause of acute pancreatitis. Huo-ledokhopankreatichesky R. is possible also at the operating room Cholanum-giografii as a result of disturbance of the technology of administration of contrast mediums that it can lead to development of pancreatitis in the postoperative period. Therefore at the operating room holangiografiya (see) it is necessary to apply weak solutions of contrast agents and to exercise control of pressure, under the Crimea they are entered. R.'s diagnosis is carried out by means of an intravenous holangiografiya and a retrograde pankreatokholangiografiya (see. Pankreatokholangiografiya retrograde ).
A reflux in uric ways
the First descriptions of R. of urine at the Urals. diseases appeared in the middle of 19 century, and methods of its identification began to be developed and be applied in a wedge, practice from the second half of 20 century. Allocate the following types of uric R.: from a renal pelvis in a parenchyma of a kidney and its vessels — lokhanochno-renal R.; from an ureter in large veins and limf, vessels — ureteric and venous, ureteric and lymphatic R.; from a bladder in ureters and a renal pelvis — vesical ureteric lokhanochny R.; from an urethra in veins of a basin — uretrovenozny R.; from an urethra in a deferent duct — uretroeyakulyatorny Ruble.
Lokhanochno-pochechny reflux has the greatest practical value. Depending on the place of invasion of contents of a renal pelvis into tissue of a kidney it is subdivided into fornikalny R., at Krom contents of a renal pelvis get through the arch into a sine, venous or limf, vessels, in perivascular cracks, under a renal capsule, in its interstitial fabric, in retroperitoneal cellulose, and tubular R., at Krom contents get into tubules of a renal nipple. There is lokhanochno-renal R. at increase in intrapelvic pressure to 70 mm of mercury. above as a result of the smallest ruptures of the cup arches or owing to a gaping of mouths of collective renal tubules at sclerous changes of the arch and renal nipple.
Lokhanochno-renal R.'s reasons can be ureteral occlusion a concrement, an excess of an ureter at nephroptosis (see), hydronephrosis (cm). At the renal colic caused by these reasons, R. can be revealed approximately at 40% of patients. Contribute to lokhanochno-renal R.'s development tuberculosis of kidneys with defeat of renal nipples and cavitation, the active secondary pyelonephritis (see) expressed nephrosclerosis (see). Lokhanochno-pochechny R. easily arises at excretory urography (see) with a compression of ureters; thus it is more often observed piyelotubulyarny, then on the decreasing frequency, piyelosinusny, pyelolymphatic, pyelovenous and piyeloparenkhimatozny R. Sravnitelno easily arises R. and at retrograde piyelografiya (see) when quickly enter a large amount of contrast medium.
Lokhanochno-renal R.'s symptoms are acute nephralgias, a fever, fervescence, a neutrophylic leukocytosis, acceleration of ROE. Pyelolymphatic R. is observed in the presence of an anastomosis between a cavity of a pelvis and limf, vessels that is clinically shown chyluria (see).
The rupture of the arch and R. of the infected urine in a kidney and the fabrics surrounding it poses hazard to life of the patient since creates premises for emergence of an urosepsis (see. Sepsis ), apostematous nephrite (see), paranephritis (see). Lokhanochno-renal R. in genesis of intersticial nephrite, the ascending pyelonephritis is of great importance, pedunkulita (see), periureteritis (see), a peripelvikalny uric granuloma, retroperitoneal fibrosis (see. Ormond disease ) and fibrolipomatozny pseudocystic process — urinomas (see). Fornikalny R. with burrowing between a veniplex and a cavity of a cup can be one of the reasons so-called essential hamaturia (see). At newborns with obstruction of the lower uric ways the lokhanochnopochechny reflux has a direct bearing on emergence ascites (see). It is considered that R. matters for innidiation of tumors of kidneys.
Lokhanochno-renal R.'s diagnosis is based on a wedge, and rentgenol. yielded, results of a radio isotope research (see). The greatest value has rentgenol. a method with administration of contrast mediums. On the roentgenogram piyeloyeinusny R. looks as flowed a contrast agent into a parenchyma of a kidney to the periphery from the arch or in the form of accumulation of a contrast agent in the field of the arch (fig. 1). At penetration of a contrast agent into a for-nikalny veniplex and further in interlobar veins on the roentgenogram the arc-shaped shadows which are projected on a shadow of a kidney and proceeding towards a backbone (fig. 2) are visible.
At pyelolymphatic R. several minutes later after filling of a pelvis with a contrast agent on the roentgenogram there are shadows in the form of 3 — 5 narrow twisting strips with chetkoobrazny expansions going medially from a shadow of a kidney. On the course of these shadows larger shadows contrasted limf, nodes (fig. 3) meet.
Tubular R. on the roentgenogram has an appearance of a bunch, «whisk» or «a uvula of a flame», a coming from renal nipple of a top and stretching in brain, and sometimes and cortical substance (fig. 4).
Treatment and lokhanochno-renal R.'s prevention come down to timely elimination of obstruction of uric ways and recovery normal urodynamic, in careful performance of a retrograde ureteropiyelografiya, failure from a compression of ureters at excretory urography, careful treatment of inflammatory diseases of kidneys and uric ways.
Vesicoureteral, or vesical ureteric lokhanochny, reflux meets more often at children, it is usually connected with anomalies of development or incomplete maturing of the vesical mouth ureters (see) and disturbance of passability of the lower uric ways. The river amplifies at the time of an urination when pressure in a bladder increases (see).
Symptoms vesical ureteric lokhanochnogo a reflux are pain in kidneys at the time of an urination, sometimes a duple urination, in the started cases polyuria (see), polydipsia (see), isosthenuria (see), testimonial of a renal failure and irreversible retentsionny changes in kidneys and uric ways.
Vesical ureteric lokhanochny R. reveal by means of roentgenoscopy or a kinematotsistogra-fiya on spontaneous flowing in ureters and a renal pelvis of solution of the contrast agent entered into a bladder. Active R. is revealed during the carrying out a miktsi-onny tsistografiya (see), kinemato-tsistografiya, and also a radio isotope renotsistografiya.
Vesicoureteral R. takes the leading place to the Urals. pathologies of children's age. It comes to light in 25 — 30% of cases at children with microbic and inflammatory process in uric ways. The short intramural department of ureters, more right angle of its falling into a bladder, immaturity of the switching muscular office of distal department of ureters, infravezikalny obstruction, cystitis, disturbances of an innervation of uric ways, doubling of an ureter contribute to R.'s emergence. At the high R. reaching a renal pelvis and tubules of kidneys (piyelotubulyarny R.), urine povrezhdayushche affects renal tubules and interstitial tissue of kidneys that the nefroteliya, to development of intersticial nephrite from the outcome in a sclerosis leads to dilatation and destruction of tubules, dystrophic changes. These processes are aggravated at an infection of uric ways. As a result of R. growth of kidneys and improvement of their functions are late; children of advanced age have a discrepancy between functionality of kidneys and requirements of an organism of the child that can be shown by disturbance of separate renal processes and a renal failure.
According to Heykel and Parkkulaynen's classification (R. of E. Heikel, To. V. Parkkulainen, 1966), accepted in pediatric practice, 5 degrees of vesicoureteral Ruble distinguish. At the I degree urine is thrown to an average third of an ureter, at II — to a renal pelvis, at the III—IV degree — a contrast agent fills pyelocaliceal system, at the IV degree the pyeloectasis and coarsening of the arches is noted, at the V degree — deformation of pyelocaliceal system, existence of hydronephrotic changes.
Vesicoureteral R. at children has characteristic no wedge, manifestations and it is found during the carrying out a miktsionny tsistografiya in its various modifications. R.'s presence can be suspected of nek-ry cases according to urography: filling of an ureter with a contrast agent throughout, irregularity of its gleam; piyelofornikalny R.'s definition, expansion of distal department of an ureter, a long delay of a contrast agent in upper uric ways, increase of dilatation of uric ways in process of filling of a bladder.
Conservative treatment of vesicoureteral R. includes recovery of function of a bladder by means of it electrostimulations (see), purpose of Melipraminum, Seduxenum, topical administration of Droperidolum, acetilsalicylic to - you, etc. The effect is reached approximately in 70% of cases. As the indication to operational treatment serves existence of infravezikalny obstruction, doubling of ureters, lateralization of mouths of ureters and inefficiency of conservative therapy at a reflux of the IV—V degree within one year. Conservative therapy is carried out in such cases as preoperative preparation. Operational treatment includes elimination of intra-vesical obstruction (a meatotomiya, bougieurage of an urethra, excision and coagulation of valves of an urethra etc.), lengthening of intramural department of ureters by Grégoire's technique, reimplantation of ureters on Political ANO-Lidbettera (see. Ureter, operations ). The positive effect at operational treatment takes place in 95 — 98%.
The forecast at the timely and correctly carried out treatment favorable.
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A. V. Kalinin; A.S. Belousov, L. G. Rakitskaya (gastr.), V. P. Lebedev, A. N. Sazonov (ped.), A. Ya. Pytel (Urals.).