Page 22 of 73 DIVERTICULUMS AND DUPLIKATURA
These educations consist from patholologically the changed fabrics and are closely connected with this or that part of a digestive tract. In many of them the malrelated mucous membrane of a stomach, a duodenal, ileal and large intestine, and also a pancreatic channel is found. The wrong forming of bodies and channels, and also lack of an obliteration of the last is the cornerstone of these congenital anomalies. Diverticulums of any localization (except located at antimesenteric edge of a gut) come from dorsal part of an intestinal tube.
The inborn and acquired single and multiple diverticulums, except for Mekkel's diverticulum, are extremely rare at children. A diverticulum z, i.e. multiple eminating pockets of hollow bodies, and a diverticulitis occur mainly at adults.
Mekkel's diverticulum occurs at 2 — 3% of people. Its most frequent complication — bleeding from a digestive tract; other complications happen seldom.
At an embryo the gut connects to a vitellicle a vitelloduct. If this channel does not atrezirutsya, then it remains in the form of a diverticulum of an ileal gut (Mekkel's diverticulum). The part of the canal is transformed to the fibrous tyazh going from a diverticulum to a peritoneal surface of a navel; on the course of a tyazh the set of cystous educations is had. If all embryonal channel remains open, then kishechnokozhny fistula is formed. In that case when the intestinal end of this channel is closed, from the fistular course only slime is emitted. The vitelline artery can also turn into a fibrous tyazh which in certain conditions becomes the reason of impassability of intestines.
Pathogeny. The diverticulum of an ileal gut usually is located on 50 — 75 cm proksimalny ileocecal connection on the protivobryzheechpy party of a gut. A mucous membrane in a diverticulum same as in an adjacent ileal gut, but at least in 35% of cases find malrelated gastric or pancreatic tissue in a top of a diverticulum. The malrelated tissue can cosecrete hydrochloric acid or pepsin, causing ulceration in the basis of a diverticulum or in an ileal gut. The erosion of a slpzisty cover conducts sometimes to massive bleeding. Much less often in a diverticulum inflammatory process develops; the diverticulitis arises, as a rule, for no apparent reason, and only in rare instances it is possible to find a foreign body. Perforation and fecal peritonitis can turn out to be consequence of a diverticulitis. Cases when the diverticulum was involved in a cavity of a gut are described and became the reason of ileal and ileal invagination. The slanting inguinal hernia containing Mekkel's diverticulum is called Littre's hernia. Diverticulum torsion is possible; tyazh, going from it, can become the reason of torsion of loops of a small bowel from the outcome in gangrene.
Clinical manifestation. The symptoms caused by a diverticulum of an ileal gut can appear at any age, but especially often they arise in the first two years of life.
Children have the most frequent sign — a painless proctorrhagia, and it can be periodic as aggravations of a peptic ulcer. Bleeding begins sharply, but only in rare instances it happens profuse. Release of blood often is not connected with defecation; usually blood of dark red color, and at plentiful blood loss — bright red. The chronic zhelezodefitsitpy anemia which is not giving in to treatment by iron preparations can turn out to be consequence of recurrent bleedings. Existence at the small child of anemia and repeated positive takes of test on the occult blood force to think of Mekkel's diverticulum.
The abdominal pains caused by a diverticulitis begin with the bad attack which is clinically reminding an acute appendicitis, however the dull repeating aches are possible. Irradiation of such uncertain pains in a navel allows to suspect Mekkel's diverticulum. Perforation of an ulcer of a diverticulum in an abdominal cavity causes intra belly hemorrhage and peritonitis. Mekkel's diverticulum can become the reason of invagination of a small bowel. Pathological process in a diverticulum can be shown by the symptoms similar to symptoms of the restrained hernia, torsion of guts, appendicitis or impassability of intestines. If at the child who already left the neonatal period impassability of intestines (in the absence of instructions on earlier performed operation or invagination signs), then the most probable cause of a disease — Mekkel's diverticulum or fibrous tyazh develops.
Diagnosis. At babies the diverticulum of an ileal gut with a malrelated tissue of a stomach often gives bright symptomatology; in such cases it is necessary to make the correct diagnosis quickly. By means of X-ray contrast research the diverticulum does not manage to be found. It is possible to make the exact diagnosis before operation by means of the method based that radioactive technetium is excreted by a mucous membrane of a stomach; the negative take of such research is also informative as it highly correlates with lack of a diverticulum. Before operation the diverticulitis is taken sometimes for an acute appendicitis, but operation pases, as a rule, make the true diagnosis and carry out the corresponding treatment. The open vitelloduct and its communication with a loop of a gut can be revealed by means of the rentgepokontrastny substance entered into fistula.
Treatment. Method of the choice is removal of a diverticulum. In the presence of a round ulcer in an adjacent site of an ileal gut the struck part of a gut is resected together with a diverticulum.
At X-ray inspection or on autopsy sometimes accidentally find diverticulums of a duodenal, lean, ileal or large intestine. Occasionally they become a cause of illness, putting the mechanical pressure upon body; besides, the inflammation, an ulceration or perforation of such diverticulums are possible.
Dorsal duplikatura of a digestive tract
Duplikatura arise for the following reasons: a) disturbance of normal regression of embryonal diverticulums; b) persistirovaniye of tranzitorny diverticulums of intestines; c) formation of a median intra intestinal partition; d) disturbance of a rekanalization of epithelial "traffic jams"; e) traction between a neurotubule ectoderm (or a mesoderm) and an endoderm of an intestinal tube. Frequent existence of a tyazh who goes from the doubled intestines through a diaphragm and a postmediastinum to chest or cervical department of a backbone is explained by the last mechanism. This anomaly in many cases is accompanied by backbone pathology, for example, ateliosis of vertebrae or spina bifida anterior.
Pathogeny. Duplikatura looks as tubular or sacculate education which has mucous and smooth muscle covers, as well as other departments of a digestive tract. These educations are localized on mesenteric side of intestines, their form and size considerably vary. Duplikatura have the general with adjacent sites of a gut blood supply that complicates their selective removal. Sacculate duplikatura are not reported with the main gut, are not covered by a mucous membrane of gastric type and, therefore, are not subject to peptic erosion. Duplikatura is such large that intestines are as if wound around her; the neprokhodpmost results. In rare instances the duplikatura becomes the intestines invagination reason.
Tubular duplikatura are covered by a mucous membrane of gastric type and connect to an adjacent gut one or several openings. The acid secret following from them can cause a round ulcer and thereof bleeding or perforation in the unprotected small bowel.
Clinical manifestations. Symptoms of a duplikatura appear in the earliest childhood and include: a) compression impassability of an adjacent gut; b) intestinal bleeding from a round ulcer; c) pains owing to stretching a secret of the "closed" duplikatura; d) gut gangrene at a full prelum of blood vessels; e) detection of a mobile tumor in an abdominal cavity at routine inspection. Duplikatura most often proceed from an ileal gut, an ileocecal zone and a gullet, but can arise in any site of a digestive tract. In a thorax of a duplikatura proceed from a gullet or a stomach, but, as a rule, have the closed cavity. They cause the dysphagy and pulmonary symptoms caused by a prelum of a gullet or respiratory tracts; they are revealed by means of a X-ray analysis. This pathology is quite often accompanied by anomalies of the vertebrae located usually higher than the level of a duplikatura. Some intrathoracic duplikatura proceed from duodenal or a jejunum.
Cystous duplikatura of a rectum
These educations are located between an anus and a sacrum or a tailbone. One authors consider them as derivatives of caudal part of primary gut, others — duplikatura or teratomas of a rectum. The symptomatology is defined by existence of tumorous education which at the big sizes can cause impassability of a rectum.
Full bifurcation thick and rectum
This rare anomaly consists that the part of a digestive tract (usually that that place where it is formed mekkelev a diverticulum, to an anus) is doubled by a longitudinal partition. At the same time doubling of a vagina (or a penis), a bladder, sacral and lumbar vertebrae is possible.
Internal hernias of a stomach
The wrong turn and fixing of an intestinal tube to a back wall of an abdominal cavity when loops of a small bowel are kept by an abnormal fold of a peritoneum, lead to forming of internal hernia. Inborn defects of a mesentery, in particular in the field of distal department of an ileal gut are other reason of a gryzheobrazovaniye. This disease can be complicated by passing acute impassability of intestines, and also gangrene if blood circulation is broken. It is necessary to eliminate hernia and to recover normal anatomic ratios carefully on the basis of knowledge of embryonal anatomy as an operative measure can lead to disturbance of blood circulation of intestines.
Outside hernias of a stomach see in appropriate sections.