Nyob rau hauv tsab xov xwm, peb yuav xav txog qhov ua rau lub plab ascites.
Nws yog ib qho mob thib ob uas yog tus cwj pwm los ntawm kev sib sau ntawm cov khoom siv los yog exudate hauv cov kab noj hniav dawb ntawm lub peritoneum. Ascites tau tshwm sim nyob rau hauv daim ntawv ntawm ib qho kev nce nyob rau hauv lub plab mog, ib tug kev xav ntawm fullness, ua tsis taus pa thiab mob nyob rau hauv lub peritoneum. Kev kuaj mob ntawm pathology suav nrog CT, ultrasound, kuaj mob laparoscopy, ultrasound nrog kev tshuaj xyuas cov kua ascitic. Txhawm rau pib kho cov kab mob pathogenetic ntawm ascites, nyob rau hauv txhua rooj plaub, nws yog ib qho tsim nyog los txiav txim siab qhov ua rau ua rau cov kua dej ntau ntxiv. Nyob rau hauv cov ntaub ntawv ntawm ascites, cov tsos mob ntsuas yog teem caij diuretics rau tus neeg mob, nrog rau cov puncture tshem tawm cov kua los ntawm lub peritoneal kab noj hniav.
Ascites
o ntawm lub plab, tseem hu ua mob plab los yog ascites, tuaj yeem nrog rau cov npe ntawm cov kab mob ntau tshaj plaws hauv thaj chaw gynecology, lymphology, gastroenterology, rheumatology, cardiology, oncology, endocrinology, urology. Kev tsim cov kua dej peritoneal hauv cov kab mob noNws tshwm sim los ntawm kev nce siab hauv lub peritoneum, thawb lub diaphragmatic dome rau hauv lub hauv siab kab noj hniav. Nyob rau tib lub sijhawm, kev ua pa pulmonary excursion yog qhov txwv tsis pub, cov ntshav ncig, kev ua haujlwm ntawm lub plawv thiab cov kab mob peritoneal cuam tshuam. Loj plab edema kuj tseem tuaj yeem nrog cov electrolyte tsis xws luag thiab poob protein ntau. Nrog ascites, yog li, lub plawv thiab ua pa tsis ua haujlwm, cov kab mob metabolic loj tuaj yeem tsim, vim tias qhov kev tshwm sim ntawm tus kab mob loj zuj zus.
Ua rau plab ascites
Lub serous cover ntawm lub peritoneal kab noj hniav yog ib txwm - qhov no yog tsim ib tug me me ntawm cov kua los ntawm lub peritoneum, uas yuav tsum tau rau lub dawb txav ntawm txoj hnyuv loops thiab kev tiv thaiv ntawm ua tau gluing ntawm nruab nrog cev. Qhov no exudate yog reabsorbed los ntawm tib lub peritoneum. Vim muaj ntau yam kab mob, qhov teeb meem, resorptive thiab secretory functions ntawm peritoneum raug cuam tshuam, uas ua rau ascites.
Ntau zaus muaj o ntawm plab hauv cov txiv neej uas muaj cirrhosis.
Nyob hauv ascitic syndrome, lub plab feem ntau yog loj sib npaug, daim tawv nqaij yog ncab. Hauv ntau tus neeg mob, cov qauv xiav tuaj yeem pom ntawm phab ntsa plab uas zoo li lub taub hau ntawm jellyfish. Lawv qhov tshwm sim provokes portal hypertension thiab, vim li ntawd, nthuav cov hlab ntsha venous. Raws li intra-abdominal siab nce, cov hlab ntsha protrudes sab nraud. Nyob rau tib lub sij hawm, nyob rau hauv cov neeg mob uas raug kev txom nyem los ntawm ascites, ib tug hernia ntawm lub umbilical nplhaib yog pom. o ntawm lub plab nrog cirrhosis ntawm daim siab tshwm sim nyob rau hauv lub xeem theem ntawm pathology.
UNeonatal ascites feem ntau pom nyob rau hauv cov kab mob hemolytic ntawm fetus. Thaum muaj hnub nyoog ntxov - nrog exudative enteropathy, malnutrition, congenital nephrotic syndrome. Ascites tuaj yeem txhim kho nrog ntau yam mob plab:
- diffuse peritonitis ntawm tuberculous, parasitic, fungal, non-specific etiology;
- pseudomyxoma;
- abdominal mesothelioma;
- peritoneal carcinosis vim mob qog noj ntshav ntawm lub plab thiab txoj hnyuv, zes qe menyuam, endometrium lossis mis.
Ascites yog ib qho kab mob uas tuaj yeem dhau los ua tus cim ntawm polyserositis (uas yog, ib txhij pleurisy, pericarditis thiab dropsy ntawm peritoneum), uas tau pom nyob rau hauv lub cev lupus erythematosus, rheumatism, uremia, rheumatoid mob caj dab, Meigs syndrome (xws li. Nrog rau kev suav nrog hydrothorax, ascites thiab zes qe menyuam fibromas).
Ascites feem ntau tshwm sim los ntawm pathologies uas tshwm sim nrog portal hypertension - siab siab ntawm lub portal hepatic system (portal leeg nrog ducts). Abdominal edema thiab portal hypertension tuaj yeem tshwm sim vim mob siab rau daim siab, cawv kab mob siab, kab mob siab; thrombosis ntawm daim siab veins tshwm sim los ntawm daim siab mob cancer, ntshav kab mob, hypernephroma, thrombophlebitis thoob plaws, thiab lwm yam.; thrombosis (stenosis) ntawm inferior vena cava los yog portal leeg; congestion ntawm cov leeg nyob rau hauv txoj cai ventricular tsis ua hauj lwm.
Protein deficiency
Ascites tuaj yeem txhim kho vim tsis muaj protein ntau, kab mob raum (mob glomerulonephritis, nephrotic syndrome), myxedema, plawv tsis ua haujlwm, lymphostasis vim compressionlymphatic duct ntawm lub sternum, obstruction ntawm lymph outflow los ntawm peritoneal kab noj hniav, lymphangiectasias, kab mob plab (Crohn's kab mob, pancreatitis, mob raws plab).
Yog vim li cas rau qhov nce hauv plab yuav tsum tau txiav txim los ntawm tus kws kho mob. Lub pathogenesis ntawm ascites yog li raws li ib tug complex complex ntawm hemodynamic, inflammatory, dej-electrolyte, hydrostatic thiab metabolic tsis xws luag, vim hais tias ntawm cov interstitial kua yog los thiab accumulates nyob rau hauv lub peritoneal kab noj hniav.
Cov tsos mob ascites
Lub plab o, nyob ntawm qhov ua rau, tuaj yeem maj mam, thaum nws nce ntau ntau lub hlis, lossis tam sim ntawd. Tus neeg mob feem ntau pom qhov hnyav nce, hloov pauv ntawm cov khaub ncaws loj, lossis nyuaj rau kev ceev txoj siv.
Cov tsos mob ntawm ascites yog qhov txawv ntawm qhov kev xav ntawm plab plab, mob plab, hnyav, flatulence, belching thiab heartburn, xeev siab. Lub plab, raws li qhov ntim ntawm cov kua dej nce, nce hauv qhov loj, lub plab protrudes. Nyob rau hauv ib txoj hauj lwm sawv - lub plab yog sagging, nyob rau hauv lub prone txoj hauj lwm - flattened, swells nyob rau hauv lub lateral seem (lub thiaj li hu ua "qav plab"). Yog hais tias lub peritoneal effusion yog loj, muaj o nyob rau hauv ob txhais ceg, ua tsis taus pa luv, tsis yooj yim rau txav, tshwj xeeb tshaj yog khoov thiab tig lub cev. Kev nce siab hauv lub peritoneum nrog ascites tuaj yeem ua rau femoral lossis umbilical hernia, hemorrhoids, varicocele thiab qhov quav prolapse.
tuberculosis peritonitis
Thaumtuberculous peritonitis, ascites yog tshwm sim los ntawm kev kis kab mob thib ob ntawm cov kab mob peritoneal vim txoj hnyuv lossis qhov chaw mos tuberculosis. Tuberculous ascites kuj yog ua npaws, poob phaus, cov tsos mob ntawm kev qaug dab peg. Ntxiv nrog rau cov kua dej ascitic, cov qog nqaij hlav raws li txoj hnyuv mesentery raug kuaj pom hauv cov kab noj hniav peritoneal. Cov exudate, uas tau los ntawm tuberculous ascites, muaj qhov ceev ntawm ntau tshaj 1016, thiab cov ntsiab lus ntawm cov protein yog los ntawm 40 mus rau 60 g / l, cov sediment, nrog rau endothelial hlwb, erythrocytes thiab lymphocytes, muaj tuberculous mycobacteria, ib tug zoo Riv alt kuaj..
Lub plab o nrog mob qog noj ntshav yog qhov tshwm sim heev. Yog hais tias ascites nrog peritoneal carcinosis, nws yog qhov txawv los ntawm ntau cov qog nqaij hlav loj uas yog palpable los ntawm phab ntsa ntawm lub peritoneum. Cov kev tsis txaus siab tseem ceeb hauv daim ntawv no ntawm ascites yog kuaj los ntawm qhov chaw ntawm cov qog thawj. Peritoneal effusion nyob rau hauv yuav luag tag nrho cov muaj ib tug hemorrhagic cim, tej zaum kuj muaj atypical hlwb nyob rau hauv sediment.
Nyob rau hauv cov neeg mob uas muaj Meigs syndrome, zes qe menyuam fibroma (qee zaum, malignant zes qe menyuam hlav), hydrothorax thiab ascites raug txiav txim. Tus cwj pwm los ntawm kev ua tsis taus pa hnyav thiab mob plab. Txoj cai ventricular tsis ua hauj lwm ntawm lub plawv, pib nrog ascites, yog qhia los ntawm edema ntawm ob txhais taw thiab ob txhais ceg, acrocyanosis, mob nyob rau hauv txoj cai hypochondrium, hepatomegaly, hydrothorax. Ascites nyob rau hauv lub raum tsis ua hauj lwm yog txuam nrog diffuse edema ntawm cov ntaub so ntswg subcutaneous thiab daim tawv nqaij - anasarca.
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Ascites tshwm sim ntawm keeb kwm ntawm portal vein thrombosis muaj tus cwj pwm tsis tu ncua,thiab kuj yog nrog los ntawm qhov mob pom tseeb, mob hepatomegaly, splenomegaly. Vim yog qhov tshwm sim ntawm cov khoom lag luam, cov ntshav los ntawm hemorrhoids lossis varicose esophageal veins feem ntau tshwm. Thrombocytopenia, leukopenia, anemia yog txiav txim siab nyob rau hauv cov ntshav peripheral.
Ascites yog ib yam mob uas nrog portal intrahepatic hypertension, tus cwj pwm los ntawm nruab nrab hepatomegaly, muscular dystrophy. Ntawm daim tawv nqaij ntawm lub plab, kev nthuav dav ntawm cov hlab ntsha hauv daim ntawv ntawm "lub taub hau jellyfish" yog pom meej. Persisent ascites nyob rau hauv postrenal portal hypertension yog nrog jaundice, ntuav, xeev siab, thiab hnyav hepatomegaly.
Tseem muaj mob plab plab nrog lub plawv tsis ua hauj lwm. Hauv cov neeg mob sedentary uas muaj kab mob plawv, muaj cov kua dej ntau hauv lub plab, sacrum, sab, thiab lub plab pelvic. Puffiness, txawm tias suav hais tias yog qhov cim tshwj xeeb tshaj plaws ntawm lub plawv tsis ua haujlwm, tsis yog tib qho xwb. Cov neeg mob muaj qhov ua tsis taus pa thiab tachycardia, uas qhia txog kev tsis saib xyuas ntawm pathology.
Nrog tsis muaj protein ntau, ascites feem ntau me me; pleural effusion, peripheral edema tau sau tseg. Hauv cov kab mob rheumatic, polyserositis yog qhia los ntawm cov tsos mob ntawm daim tawv nqaij, muaj cov kua dej hauv cov kab noj hniav ntawm lub pleura thiab pericardium, ascites, arthralgia thiab glomerulopathy. Nrog kev ua txhaum ntawm cov qog ntshav tawm (chylous ascites), qhov loj ntawm lub plab yuav nce sai. Cov kua dej ascitic ntawm cov xim muaj kua mis, pasty sib xws, hauv nws hauv chav kuajTxoj kev tshawb no txiav txim siab lipoids thiab rog. Qhov ntim ntawm cov kua dej nyob rau hauv peritoneal kab noj hniav nrog ascites tuaj yeem ncav cuag li 5-10 lossis 20 litres.
o ntawm plab hauv cov neeg laus muaj ntau dua li cov hluas.
Kev kuaj mob nta
Ua ntej tshaj plaws, nws yuav tsum tsis suav nrog lwm yam ua rau muaj qhov loj ntawm lub plab - lub zes qe menyuam, rog rog, qog nqaij hlav hauv plab, cev xeeb tub, thiab lwm yam. Txhawm rau kuaj xyuas cov kab mob pathology thiab nws qhov chaw, palpation thiab percussion ntawm lub plab, MSCT ntawm peritoneum, ultrasound ntawm lymphatic thiab venous hlab ntsha, ultrasound ntawm peritoneal kab noj hniav, daim siab scintigraphy, kuaj cov kua ascitic, kuaj laparoscopy yog ua.
Yuav ua li cas thiaj txiav txim siab lub plab o, nws nthuav rau ntau.
Nrog ascites, percussion ntawm lub plab yog tus cwj pwm los ntawm dullness ntawm lub suab, nrog rau kev hloov ntawm ciam teb ntawm dullness thaum lub sij hawm hloov hauv lub cev txoj hauj lwm. Yog tias koj muab koj xib teg rau ntawm lub plab mog, koj tuaj yeem hnov qhov tshee (ib qho cim ntawm kev hloov pauv) thaum koj coj koj cov ntiv tes rau ntawm qhov chaw ntawm lub plab mog. Cov duab hluav taws xob ncaj qha ntawm cov kab noj hniav tuaj yeem txheeb xyuas cov ascites yog tias cov kua dej dawb ntau tshaj li ib nrab litre.
Nrog ascites los ntawm kev sim kuaj, tsom xam ntawm coagulogram, qib ntawm IgG, IgM, IgA, biochemical daim siab kuaj, qib ntawm cov zis tsom xam. Hauv cov neeg mob uas muaj ntshav siab portal, EGDS tau muab tshuaj los kuaj xyuas cov leeg varicose leeg ntawm lub plab lossis txoj hlab pas. Cov kua dej hauv cov kab noj hniav pleural, lub xeev siab ntawm diaphragmatic fundus, thiab kev txwv ntawm kev ua pa ntawm lub ntsws tuaj yeem txiav txim siab ntawm fluoroscopy ntawm sternum.
BNyob rau hauv tus txheej txheem ntawm ultrasound ntawm lub cev ntawm lub peritoneal kab noj hniav nrog ascites, tus mob thiab qhov luaj li cas ntawm cov ntaub so ntswg ntawm tus po thiab daim siab raug txiav txim, cov txheej txheem ntawm cov qog thiab o ntawm lub peritoneum yog tsis xam. Ua tsaug rau hepatoscintigraphy, kev nqus-excretory ua haujlwm ntawm lub siab, nws cov qauv thiab qhov loj me, thiab qhov hnyav ntawm cov kab mob cirrhotic tau txiav txim siab. Dopplerography ua rau nws muaj peev xwm los ntsuas cov ntshav vascular ntawm lub portal system. Txhawm rau ntsuas lub xeev ntawm lub txaj splenoportal, xaiv angiography yog ua - splenoportography (portography).
Txhua tus neeg mob ascites, kuaj pom thawj zaug, raug kuaj xyuas laparocentesis ntawm kev kuaj thiab tshuaj xyuas qhov xwm txheej ntawm cov kua dej: tsim kom muaj cov cellular muaj pes tsawg leeg, qhov ntom ntom, cov ntsiab lus protein, nrog rau kab lis kev cai bacteriological. Yog hais tias cov ntaub ntawv ntawm ascites nyuaj rau kev sib txawv, kev tshawb nrhiav laparotomy lossis laparoscopy nrog tsom rau kev kuaj mob plab yog qhia.
kev kho mob ascites
Nyob rau hauv txoj kev kho mob pathogenetic ntawm ascites, nws yog ib qho tsim nyog los tshem tawm qhov chaw ntawm nws txoj kev loj hlob, uas yog, thawj kab mob. Txhawm rau txo cov tsos mob ntawm ascites, txwv tsis pub haus dej, noj zaub mov tsis muaj ntsev, diuretics (Furosemide, Spironolactone nyob rau hauv lub npog ntawm cov tshuaj nrog cov poov tshuaj) raug kho, qhov tsis xws luag hauv dej-electrolyte metabolism raug kho thiab portal hypertension yog txo los ntawm cov receptor antagonists. ACE inhibitors thiab angiotensin II. Nyob rau tib lub sijhawm, hepatoprotectors tau siv, nrog rau kev tswj hwm kev txhaj tshuaj ntawm cov protein npaj (albumin tov, cov ntshav plasma).
Ntau tus xav paub tias Furosemide tau sau rau dab tsi.
Nws yog ib qho tshuaj diuretic uas muaj zog thiab nrawm nrawm (diuretic). Nws yuav tsum tau noj nyob rau hauv qhov tsawg kawg nkaus npaum li cas, uas yuav muab cov nyhuv xav tau. Furosemide yog tshuaj, feem ntau yog rau edema txuam nrog:
- mob plawv;
- congestion nyob rau hauv lub systemic thiab pulmonary ncig;
- kev kub ntxhov siab;
- mob raum (nephrotic syndrome);
- kab mob siab.
Tshuaj yuav tsum tau saib xyuas los ntawm kws kho mob vim muaj kev phiv tshwm sim thiab kev pheej hmoo ntawm kev noj ntau dhau ua rau lub cev qhuav dej, lub plawv tsis ua haujlwm, txaus ntshai ntshav siab thiab lwm yam kev phom sij.
Vim li cas "Furosemide" tau muab rau cov neeg mob tam sim no meej.
Nrog ascites, uas tiv taus kev kho mob tsis tu ncua, plab laparocentesis (paracentesis) yog siv, uas yog, puncture tshem tawm cov kua los ntawm cov kab noj hniav. Rau ib qho puncture, nws yog ntshaw kom khiav tawm tsis pub ntau tshaj plaub mus rau rau litres ntawm ascitic kua vim muaj peev xwm ntawm lub cev qhuav dej. Yog tias cov punctures feem ntau rov ua dua, cov xwm txheej raug tsim rau lub plab o, tsim cov adhesions, thiab qhov tshwm sim ntawm cov teeb meem los ntawm kev sib tham laparocentesis ntxiv. Tias yog vim li cas nrog kev tshem tawm cov kua dej nrog cov ascites loj heev, ib lub catheter peritoneal mus tas li raug teeb tsa.
Kev cuam tshuam uas muab cov xwm txheej ncaj qhaKev tshem tawm cov kua dej peritoneal yog ib nrab deperitonization thiab peritoneovenous shunt ntawm cov phab ntsa ntawm lub peritoneal kab noj hniav. Nrog ascites, kev cuam tshuam tsis ncaj yog kev ua haujlwm uas txo qis hauv qhov system portal. Cov no suav nrog kev tswj hwm nrog kev tswj hwm ntawm ntau hom porto-caval anastomoses (intrahepatic transjugular portosystemic shunting, porto-caval shunting, txo cov ntshav splenic), nrog rau lymphovenous anastomosis. Qee qhov xwm txheej, nrog refractory ascites, splenectomy tau ua.
Kho mob laparocentesis. Ntxiv rau qhov tseeb tias cov txheej txheem no yuav tsum tau siv sijhawm ntau rau tus neeg mob thiab tus kws kho mob, nws ua rau poob ntawm opsonins thiab protein, thaum lawv cov ntsiab lus tsis cuam tshuam los ntawm diuretics. Kev txo qis ntawm opsonins tuaj yeem ua rau muaj kev pheej hmoo ntawm thawj peritonitis
Qhov teeb meem ntawm kev nthuav qhia cov kev daws teeb meem colloidal rau tus neeg mob tom qab tshem tawm cov kua dej ascitic loj tseem tsis tau daws. Tus nqi ntawm ib qho albumin infusion yog li ntawm $ 120-1250. Kev hloov pauv hauv cov ntshav creatinine, electrolytes, thiab ntshav plasma renin hauv cov neeg mob uas tsis tau txais colloid infusion tsis tshwm sim los ntawm qhov tseem ceeb hauv kev kho mob thiab tsis ua rau muaj kev mob hnyav ntxiv lossis kev tuag.
Kev hla dhau. Kwv yees li tsib feem pua ntawm cov tshuaj diuretics ib txwm ua tsis tau zoo, thaum nce koob ua rau lub raum tsis ua haujlwm. Hauv cov xwm txheej zoo li no, shunting tau sau tseg. Qee zaum, sab-rau-sab portoqual shunting yog ua, tab sis nwscharacterized los ntawm kev tuag siab. Denver lossis peritoneovenous shunting, piv txwv li, raws li Le Vin, tuaj yeem txhim kho tus mob ntawm qee tus neeg mob. Feem ntau, ib tug neeg tseem yuav tsum tau noj cov tshuaj diuretics, tab sis lawv cov koob tshuaj tuaj yeem txo qis. Ntawm lwm yam, cov ntshav khiav ntawm lub raum txhim kho. Peb caug feem pua ntawm cov neeg mob tsim shunt thrombosis thiab yuav tsum tau hloov. Peritoneovenous shunting yog contraindicated nyob rau hauv lub plawv tsis ua hauj lwm, sepsis, los ntshav los ntawm varicose leeg, thiab keeb kwm ntawm malignant neoplasms. Cov neeg mob muaj sia nyob thiab cov teeb meem hauv cov neeg mob cirrhosis tom qab daim ntawv no ntawm kev phais bypass yog txiav txim siab los ntawm qib uas lub raum thiab lub siab ua haujlwm tsis zoo. Cov txiaj ntsig zoo tshaj plaws tau txais nyob rau hauv cov neeg mob uas tsis tu ncua ascites, tab sis tib lub sijhawm, lub siab ua haujlwm tsis zoo. Tam sim no, peritoneo-ovenous bypass phais yog tshwj tseg rau tsuas yog ob peb tus neeg mob uas tsis ua laparocentesis lossis diuretics, lossis cov uas tsis ua rau cov tshuaj diuretics rau cov neeg uas yuav tsum tau mus ntev heev kom pom tus kws kho mob rau ob lub lis piam kho laparocentesis
Kev hloov daim siab lub siab kuj tuaj yeem ua rau cov tawv nqaij ascites yog tias muaj lwm yam qhia rau nws.
YKev kuaj mob rau pathology
Lub xub ntiag ntawm lub plab o ua rau cov kab mob hauv lub cev hnyav zuj zus thiab ua rau qhov kev mob tshwm sim. Ascites nws tus kheej tuaj yeem tsim teeb meem xws li kab mob kab mob peritonitis, hepatorenal. Syndrome, hepatic encephalopathy thiab los ntshav.
Cov yam ntxwv tsis zoo rau cov neeg mob ascites yog cov hnub nyoog siab tshaj (tshaj 60 xyoo), lub raum tsis ua haujlwm, hypotension (tsawg dua 80 mm Hg), hepatocellular carcinoma, daim siab cirrhosis, ntshav qab zib mellitus, daim siab cell tsis ua haujlwm thiab lwm yam. Rau ascites, tus nqi ciaj sia ob xyoos yog li tsib caug feem pua.
Zoo tshwm sim thiab muaj teeb meem tshwm sim
Nws yuav tsum nco ntsoov tias vim yog ascites, txawm li cas los xij, cov kab mob loj zuj zus ntxiv, ua rau hydrothorax, ua pa tsis ua haujlwm, hernia, plab hnyuv thiab ntau lwm yam teeb meem. Txawm hais tias ascites tuaj yeem kho tau, koj yuav tsum tau ceev faj txog koj txoj kev noj qab haus huv, vim nws yeej muaj feem cuam tshuam. Tias yog vim li cas txawm tias tom qab tshem tawm ntawm ascites, nws yog ib qho tsim nyog yuav tsum ua raws li kev noj zaub mov tshwj xeeb.
Yog ib tug neeg xav tias yog vim li cas lub plab thiaj loj, nws yuav tsum tau ceev mus cuag kws kho mob.
Cov kua dej ntau hauv cov kab noj hniav tuaj yeem ua rau tsis xis nyob, tab sis ua ntej qhov no tshwm sim, lwm cov cim tshwm sim. Lawv yuav tsum tsis txhob tso tseg tsis muaj neeg saib xyuas, koj yuav tsum sab laj nrog kws kho mob.
