Professor O.N.Minushkin MTS Administrative offices of the President of the Russian Federation, Moscow the pain Problem in a stomach exists because pains can accompany chrezvychajno the big number of diseases. The reason of pains in a belly cavity is odna from three extensive nozologicheskih groups:

As in this extensive group of diseases enter such which demand hirurgicheskogo treatment, the pain symptom will be always considered, how urgentnyj, po to an extreme measure until the pathology which as a whole across Moscow last years has tendentsiju to growth (B.S.Briskin, etc. 2002) will be rejected or confirmed sharp hirurgicheskaja .

Bodies of a belly cavity usually are not sensitive to many stimulus which pri action on a skin provoke a strong pain. Cuts, ruptures or others povrezhdenija internal bodies of a belly cavity do not call painful sensations. Osnovnymi influences to which vistseralnye painful fibres are sensitive, javljajutsja a stretching or infringement of a wall of intestines. It can be: a tension brjushiny (for example, at a tumour), a stretching of hollow body (for example, at bilious kolike) or strong muscular reductions (for example, at intestinal impassability). Nervnye the terminations of the fibres which are responsible for a pain in hollow bodies (intestines, bilious puzyr, a bladder), are localised in muscular layers. In parenhimatoznyh organah (a liver, kidneys, a spleen) the nervous terminations are in their capsule and otvechajut on its stretching at increase in volume of body. Bryzhejka, parietalnaja plevra and peritonealnaja vystilka a back wall of a belly cavity are sensitive to boli whereas vistseralnaja the pleura and the big epiploon is not present. For pain occurrence skorost pressure increase should be enough big. Gradual narastanie pressure, for example, such as at tumoral obstruction zhelchevyvodjashchih ways, can long proceed without serious consequences.

the Inflammation and an ischemia also are capable to call vistseralnuju a pain, thus vospalenie can raise sensitivity of the nervous terminations and reduce a threshold chuvstvitelnosti to a pain from other stimulus (including in development odnogo diseases in its different phases). And progressirovanija pains at an inflammation participate In mechanisms of occurrence many biological active veshchestva (bradikinin, serotonin, gistamin, prostaglandiny, etc.) .

Listed shortly patofiziologicheskie formation mechanisms abdominalnoj be ill are the initial difficulty quite often leading late, in luchshem a case to delayed diagnostics. That is why the repeated reference to this probleme always is important and useful.

it is necessary to confirm expediency of the term a sharp stomach, kotorym designate the statuses arising within several hours or days and harakterizujushchiesja limited or diffuznymi by the phenomena of irritation brjushiny. In pervye hours, and sometimes days of supervision over such patients allocate group nuzhdajushchihsja in operative treatment. Patients who in surgical treatment not nuzhdajutsja, should be passed therapists, cardiologists, lung specialists, gastroenterologam, etc. That is why to consider the term a sharp stomach purely hirurgicheskim as concept hardly it is expedient, as the most part bolnyh as a result appears requiring not surgical treatment.

As the basic symptom simptomokompleksa the sharp stomach is a pain and osnovnym diagnostic reception for finding-out of its reason is the method differentsialnoj diagnostics.

the First group make intrabelly ochagovye purulent inflammatory protsessy and their complications.

the Sharp appendicitis . Irrespective of initial localisation of a pain, in dalnejshem at overwhelming majority of patients of a pain and irritation symptoms brjushiny lokalizujutsja in the right bottom department of a stomach, it is fixed accruing lejkotsitoz and uvelichenie SOE. In the absence of the tendency to normalisation of the named indicators and pri semiology increase it is shown laparotomija. It is necessary to mean and levostoronnjuju process localisation at a full return arrangement of bodies.

the Suppuration kist and divertikulov cherveobraznogo a shoot: clinical priznakov, distinguishing this pathology from a sharp appendicitis, no, but they can pojavitsja at carrying out urgentnogo ultrasonic research.

the Cholecystitis, empiema and a dropsy of a bilious bubble . Pain localisation in right verhnem department of a stomach with irritation symptoms brjushiny or without those. Lejkotsitoz with formula shift to the left and increase SOE. At an aggravation hronicheskogo a cholecystitis at elderly, at corking puzyrnogo a channel without priznakov inflammations the specified signs can be absent. The same semiology mozhet to show and a sharp appendicitis (at considerable length and raspolozhenii an appendicitis).

the Most reliable diagnostic reception in the given situation is ultrazvukovoe research as radiological research at sharp i an aggravation of chronic process appears inefficient.

Divertikulit . Mainly in sigmovidnoj to a gut; morbidity and simptomy irritations brjushiny, mainly in the left bottom department of a stomach. More often bolejut the older persons, suffering a pathology of a thick gut, it is frequent to an aggravation predshestvujut proof locks (seldom indulgence). Quite often there are phenomena chastichnoj intestinal impassability and blood in kale. Kolonoskopija and irrigoskopija in etoj situations are counter-indicative. The anamnesis, clinical supervision and dynamic ultrazvukovoe research are the most adequate diagnostic priemami.

Sharp adneksit . Irritation symptoms brjushiny are insignificant. On klinikolaboratornym to data it can be similar to any sharp ochagovoj a pathology. Diagnostichesky reception the most adequate ultrasonic research, at neeffektivnosti a laparoscopy.

In the presented group of illnesses (especially at an early stage) it is necessary to note preobladanie local symptoms over the general frustration. In the complicated stage bolezni at stabilisation of local displays frustration and an intoxication first of all start to accrue and leave forward obshchie.

This group of illnesses accurately shares on two subgroups: the first makes sharp peritonit in which diagnostics the basic role is played by the previous anamnesis (for iskljucheniem a debut of a stomach ulcer at young); the second chronic forms peritonita which diagnostics is extremely difficult. Position is facilitated, if osnovnoe disease is known also its continuation or complication is protsess in a belly cavity.

Intestinal impassability (sharp, chronic) . On the development mechanism: mechanical (adhesive, owing to infringement of a hernia, a tumour, invaginatsii more often at children). At adults quite often reason invaginatsii are polipy guts, ulcer hems, gleam corking by alien bodies (bilious kamni, bezoary, etc.) . At obturatsii a pain shvatkoobraznaja, at stranguljatsii narjadu with fights the pain is constant (more often the shock phenomena); paralytic (owing to frustration innervatsii and blood supplies of an intestinal wall), intoksikatsionnaja, owing to a thrombosis and embolii mezenterialnyh vessels, infarkta bryzhejki, after heavy operations, at a peritonitis, at heavy infections, nervnoreflektorno; medicinal at treatment ganglioblokatorami, b-adrenoblokatorami in the big doses, etc.

In diagnostics of this group of patients the great value has the careful analysis anamnesticheskih data (including medicinal) and the general status of the patient, in chastnosti, vascular defeats at the elderly and old people suffering zabolevanijami of heart and vessels, leading to a thrombosis and embolii mezenterialnyh ven. Thus the important diagnostic sign are krovjanistye liquid isprazhnenija. This group of patients is the most relief and clear in prakticheskom the relation. Special attention deserves chronic (or partial) kishechnaja impassability which is often an early symptom tumoral neprohodimosti and demands very careful inspection of the patient with obligatory ispolzovaniem kolonoskopii. The group with lekarstvennoj paralytic impassability is not less significant also, and in this respect medicinal anamnez is the leader that allows to avoid unnecessary surgical vmeshatelstva.

sharp and chronic kalkuleznyj a cholecystitis;

holedoholitiaz;

sharp or an aggravation of a chronic pancreatitis;

a progressing stenosis of terminal department of the general bilious channel;

a cancer of a bilious bubble, the general bilious channel and pozheludochnoj glands;

illnesses of a liver: sharp and an aggravation of a chronic hepatitis, a cirrhosis, pervichnyj sklerozirujushchy holangit, a metastatic liver.

the Basic analyzed sign a jaundice. From laboratory tests the greatest znachenie for suspicion about its mechanical character has definition alkaline fosfatazy. The further program of research specifying character and patogenez zheltuhi, should be under construction as follows:

Ultrasonic research (revealing biliarnuju a hypertensia protokovuju and intrahepatic; quite often thus level prepjatstvija is defined also. It can be not only the research program, but also zakonchena) is opened.

Endoskopija the top departments zheludochnokishechnogo a path (there can be polucheny relative signs of defeat of a pancreas, defeat faterova a dummy, tumours of a stomach and a duodenal gut, parafateralnyj divertikul with the phenomena divertikulita).

retrogradnaja pankreatoholangiografija (defeat pancreatic, obshchih bilious and hepatic channels, stones in them, obturirujushchaja a pathology).

the Laparoscopy (has advantage in cases when the previous methods ne have allowed to specify the diagnosis, and the clinical picture of disease testifies o increase of sharp process operation becomes inevitable. With the help laparoskopii quite often it is possible not only to establish level obturatsii, but also provesti unloading biliarnoj systems (drenirovat a bilious bubble, considering eto as the first stage of operation, drenirovat small salnikovuju a bag, etc.) .

Competency of existence and allocation of this group of the patients who have entered kliniku with the diagnosis a sharp stomach, does not call doubts because the symptom zheltuhi at patients of this group appears later.

the Second group diseases illnesses of bodies out of limits belly polosti, but forming simptomokompleks, similar to a sharp stomach so-called psevdoabdominalnyj make a syndrome (PASS).

So, diseases of bodies of the thorax forming the PASS, are connected with a generality innervatsii a thorax and a forward belly wall (spinal nerves for parietalnoj brjushiny the top 2/3 belly cavities (ДXL1) in nachalnoj the part pass in a thorax, and sharp disease of heart, legkih and pleurae during the first hours, at absence fizikalnyh and auskultativnyh dannyh, can be interpreted as sharp disease of bodies of a belly cavity. Opredelennuju a role in formation the PASS the reflected pains (play zones giperalgezii G.A. Zaharina, 1885; Geda, 1888) ; Irritation diafragmalnyh, simpaticheskih and the wandering nerves participating in formation solar spletenija; at a pneumonia, as a result of toxic influence on nervous sistemu and #65387; an intestinal tube and # 65403; there can come a paralysis zheludochnokishechnogo a path razlichnoj intensity; sharply developed stagnant warm insufficiency po to the big circle of blood circulation in general and a sharp stretching glissonovoj capsules v particulars. At illnesses of kidneys the PASS develops owing to a generality innervatsii and reflektornyh communications between pochechnomochetochnikovymi nervous textures and zheludochnokishechnymi.

As the basic symptom the PASS is a pain also the core priemom for finding-out of its reasons the method of differential diagnostics is diagnostic. Programma researches it is formed depending on the symptoms entering in konkretnyj a syndrome. As wasps novnogo a symptom the PASS, except a pain, can byt:

So, a sharp pain in a stomach and a fever can be at a sharp pneumonia, bazalnom a pleurisy, sharp perikardite, rheumatic kardite, tireotoksicheskom krize, periodic illness, nenagnaivajushchemsja pannikulite (illness VeberaKrischena kozhnovistseralnom, vistseralnom, abdominalnom variants), sharp mezadenite, a pyelonephritis surrounding lishae, gemorragicheskom vaskulite and vospalitelnyh diseases of bodies of a belly cavity; Sharp pain in a stomach and padenie arterial pressure are observed at a sharp heart attack of a myocardium, sharp pankreatite, to a stratifying hematoma of belly department of an aorta, sharp nadpochechnikovoj insufficiency, at rupture of trumpet pregnancy, punching jazvy a stomach, sharp infringement mezenterialnogo blood circulations etc. Everyone simptomokompleks allows to limit a circle nozologicheskih forms and to make diagnostiku probable and as into everyone simptomokompleks enter sharp zabolevanija bodies of a belly cavity also the research program should stroitsja so that either to confirm them, or to reject. Thus in all sluchajah after carrying out of the standard research application tool metodov should be begun with ultrasonic which needs to be spent the following obrazom:

as the Second, most logical reception of research (if the diagnosis remained it is not clear) sleduet to consider an urgent laparoscopy. The method allows to spend differentsialnuju diagnostics of a sharp appendicitis, a sharp cholecystitis, probodnoj gastroduodenalnoj ulcers, a sharp pancreatitis, a heart attack of intestines, sharp zabolevany bodies of a small basin. Thus, if there are indications, simultaneously mozhet to be spent drenirovanie a belly cavity, salnikovoj bags, holetsistektomija. These two tool researches, as a rule, dostatochno to confirm or reject a sharp stomach, to affirm in diagnostike the PASS, substantially to define its reason and to choose naibolee a rational way of further diagnostics (an electrocardiogram, EhoKG; rentgenologicheskoe research, KT; special laboratory, serologicheskie, morfologicheskie researches in the conditions of specialised hospitals).

the Third group the diseases forming pains in a stomach, make: sistemnye diseases; the general diseases proceeding with the expressed intoxication; hronicheskie and sharp intoxications; some forms of functional frustration, protekajushchih with pains (a syndrome of angry intestines a variant proceeding with and #65387; a swelling and # 65403;) .

Considering this group of diseases, it is necessary to mean:

Prekomatoznye statuses at the patients, suffering a diabetes (giperglikemija, atsetourija, gipoglikemija).

the Tireotoksichesky crisis . Rise in temperature of a body to febrilnyh figures, giperemija and tsianoz integuments, especially cheeks, a neck and finitenesses, a tachycardia do 150160 blows in minute, increase pulsovogo pressure, breath increase, pojavlenie or increase of mental frustration. Very often there are pains in zhivote, accompanied by vomiting, a diarrhoeia, as serves as diagnostics reason ostrogo a stomach. Quite often tireotoksichesky the crisis is accompanied by a jaundice that is priznakom accruing hepatic insufficiency. Skriningtestom tireotoksicheskogo a crisis definition can serve in plasma of blood of concentration svjazannogo with iodine fiber (SBJ) which, being raised at tireotoksikoze, rezko increases during a crisis. The second test is therapy ex juvantibus: vnutrivennoe introduction blokatorov synthesis tireoidnyh hormones tiamazol in a dose 100 mg and b-blokatorov in a dose of 210 mg (effect about 34 hours).

the intestinal form , is formed owing to atonii smooth muskulatury intestines;

zhelchnopuzyrnaja in connection with atoniej a bilious bubble, thus formiruetsja a clinical picture gepatopankreaticheskogo a syndrome.

In diagnostics revealing giperholesterinemii, decrease in level SBJ nizhe 3,5 mg of % helps; from clinical data low arterial pressure, a bradycardia, gipotermija, urezhenie breath, oligurijaanurija.

Chronic nadpochechnikovaja insufficiency (crisis): pigmentation of a skin and mucous turns on itself vnimanie; as a rule, always are available provoking momenty.

the Intoxication lead . The stomach can be strained, but nevertheless is accessible palpatsii; irritation signs brjushiny are absent. In diagnostics it is necessary uchityvat anamnesis data, to search for a lead border, bazofilnuju punktatsiju eritrotsitov, to pay attention to allocation with kalom koproporfirina, raised vydelenie with kalom and lead urine. The grave condition of the patient is important at otsutstvii instrumentalno extracted signs of a pathology (including ultrasonic, etc.). .

porfirija (sharp intermittirujushchaja). Gripes in a stomach, parez muscles, tahikardija, a fever, an arterial hypertension with the big amplitude; urine krasnovataja with the subsequent dimness this important phenomenon almost always and #65387; it is extracted and # 65403; sluchajno. Young men suffer (more often women), disease is shown soon posle approaches of a sexual maturity (2030). In diagnostics it is important to remember, that vsegda it is defined urobilinogen, uroporfirin, porfobilinogen.

Secondary porfirija (at the heart of a classical picture lays parez capillaries brjushnoj cavities). It is defined only korpoporfirin.

the Poisoning taliem . Strong pains in a stomach, retsidivirujushchaja vomiting, a diarrhoeia tipa rice broth with a blood impurity, dehydration, a blood condensation, oligurija, anurija. In diagnostics it is necessary to consider especially anamnesis data, use myshinogo poison. As a whole diagnostics is extremely difficult, and time is limited, therefore at podozrenii it is necessary to enter unitiol, inside a water suspension zhzhenoj magnesias and aktivirovannogo coal, to combat dehydration and a collapse.

Tetanija (develops at decrease in level of calcium, it is known two klinicheskih a variant: the first with difficulty of breath as an asthma and the second with boljami in a stomach, connected with parezom intestines (expressed in different degree). In diagnostike symptom Hvosteka, lengthening of interval QТ on an electrocardiogram, level decrease kaltsija. Clinical displays are stopped in/vennym solution introduction kaltsija.

Essentsialnaja giperlipidemija .

Easily reproduces a clinical pictur e of a sharp stomach of any variant (pravopodrebernyj, levopodrebernyj; gepatosplenomegalija). Diagnostics is simple whey has molochnyj a kind with the high maintenance of fats.

As a whole their diagnostics is not difficult, the basic and necessary condition is napominanie, that they should be entered into a circle nozologicheskih the forms similar on simptomatike.

System vaskulity (abdominalnyj a variant nodular arteriita, kapilljarotoksikoz). At their diagnostics it is necessary to remember, that gemorragicheskie vysypanija can be and on a skin; a high arterial hypertensia, artralgii, krovjanistaja vomiting, a blood impurity in kale and absence of organic changes otmechajutsja at program inspection.

Illness veberakrischena (nenagnaivajushchijsja pannikulit). The basic substratum bolezni is a fatty fabric in which from time to time are formed asepticheskie infiltraty with their subsequent dynamics and formation and #65387; the involved hem and # 65403; on a skin eto a visible part of illness. Distinguish a skin variant; kozhnovistseralnyj; vistseralnyj (chest and abdominalnyj). The way to the diagnosis is difficult, quite often it lays cherez repeated laparoscopies. In diagnostics it is necessary biopsija an epiploon, fatty tkani, suspicious on singularity.

Suhotka a spinal cord . Its knowledge gets recently opredelennyj sense, t.k the syphilis steadily grows. If the analysis of pains in a stomach vyzyvaet suspicion on presence back suhotki, it is necessary to search and other symptoms etogo for sufferings: eye symptoms (anizokorija, ptoz, a reflex immovability); narushenie reflexes (knee are lowered, are absent); the phenomena ataksii; an atrophy zritelnogo a nerve.

the Diagnosis tabesa is absolutely authentic at presence 4х symptoms and rather verojaten at presence 3х. From laboratory acknowledgement reaction Vassermana and research of a spinal liquid is necessary.

Periodic illness (abdominalnyj a variant). The suspicion should voznikat always if there is a speech about the people of the Mediterranean. At illness height in krovi it is possible to reveal limfotsitoz, adhesive process in a belly cavity at otsutstvii the visible reasons; at kolonoskopii a pale hypostasis of a mucous membrane tolstoj guts.

Functional frustration which were issued recently in sindrom angry intestines. Unlike others diskineticheskih frustration on with pains it always proceeds and is its difference. Most often in hirurgichesky a hospital patients with a variant characterised by pains and vzdutiem of a stomach get, and its swelling can be pristupoobraznym. Diagnostics osushchestvljaetsja by process of elimination an organic pathology and absence laboratornyh changes. In treatment of functional frustration are used spazmolitiki since the pain is substantially formed at the expense of a spasm. From preparatov which have attracted attention recently, follows otmetit Djuspatalin (mebeverin) , which in therapeutic doses okazyvaet direct blocking effect on natrievye channels. It reduces inflow natrija and prevents sequence of the events leading to a muscular spasm (restriction of receipt of calcium in a cage), that practically excludes development nezhelatelnyh the effects peculiar antiholinergicheskim to preparations, working cherez muskarinovye receptors. We have experience of treatment Djuspatalinom sick s a syndrome of angry intestines and functional frustration bilious puzyrja and bilious ways, including the comparative. The effect of treatment, on ours dannym, has made 90 % and is confirmed by studying of a motility of intestines and bilious puzyrja, that is very important in the absence of undesirable effects.

We realise that listed nozologicheskie forms not javljajutsja the full list of the illnesses giving a clinical picture of pains in a stomach (sharp zhivot), but nevertheless make the most part of meeting illnesses, and we hope, chto the resulted clinical, pathogenetic and diagnostic information okazhetsja useful to practical doctors (the therapist, gastroenterolog, the surgeon).

the Literature:

1. Smagin V. G, Minushkin O. N. A sharp stomach. Rubbed. Archive №11,1983,8691.

2. Minushkin O. N, Sokolov L.K., Savrasov V. M, etc. Value ultrasonic i radiological methods in diagnostics of sharp surgical diseases organov a belly cavity. Surgery №2, 1989, 2832.

3. Briskin B.S., Vertkin A.L., Vovk E.I., etc. the Pre-hospital help at hirurgicheskih diseases of bodies of a belly cavity: sharp abdominalnaja a pain. The attending physician, №6, 2002, 7277.

4. Henderson D.M.Patofiziologija of digestion bodies. SanktPeterburg, 19976 (transfer with English)

5. Minushkin O. N, Of Elizabeth A, Ardatsky M.D.Lechenie functional rasstrojstv intestines and zhelchevyvodjashchej the systems, proceeding with abdominalnymi boljami and meteorizmom. Clinical pharmacology and therapy, 2002, 11, 2426.

Opublikovano from the permission administrations  Russian Medical Zhurnala.