Now 80 years

Materials and Methods: The two case histories of patients (86 years and 80 years) with occlusion of the small intestine gallstone. Attention of researchers is accented on the clinical features and symptoms of abdominal sepsis and criteria for the scale of APACHE II.

Results: In the course of examination and treatment of two patients (MKSB № 4726-2001., MKSB № 2703-2002). With obstructive ileus caused by gallstone migration into the small intestine, it was found that the progression of the disease at its earliest stages was a mask of acute cholecystitis and pancreatitis (anamnesis morbi 7 days and 4 nights). Conservative treatment is conducted within, respectively, 40 and 15 hours did not lead to relief of pain, after which it was noted the progression of symptoms that characterize abdominal sepsis [BR Gel'fand, 2000] and intestinal obstruction. Set of criteria of systemic inflammatory reaction occurred, both before surgery and in the first three days after her. Preoperative APACHE II score was 18 and 16. Pain syndrome was intermittent in nature. The operation of the first patient started with a slash in the right upper quadrant, as obtained clinical and diagnostic data left no doubt in the diagnosis of "destructive cholecystitis. The diagnosis of small bowel obstruction gallstone was installed in both cases intraoperatively. Cholecysto-duodenal fistula (CDU) has a diameter of 4 cm, which ensured the migration of gallstone size 4.0? 3.5? 3.5 cm through tissue infiltrated duodenum into the small intestine. Obstruction of the small intestine occurred respectively in 40 cm and 150 cm from fl.duodenojejunalis. After moving the gallstone proximal obstruction in both cases made enterotomy and removal of gall stones. Cholecystectomy (destruction of the wall) and seam duodenum performed in the first patient. Infiltrated tissue in the area holetsistoduodenalnogo anastomosis dramatically hinders probe for intestinal decompression, which is made only in the second patient in tension resulting in the small intestine up to 6 cm and bacterial contamination of the corresponding purulent exudate of the abdominal cavity. Postoperative period in the first patient was complicated by duodenal fistula, development of which led to the progression of widespread peritonitis (APACHE II 21) it took remedial relaparotomy on the third day after the first operation. After the effective drainage of the abdominal cavity and restore peristalsis duodenal fistula itself was closed for 9 days (duodenal discharge up to 200 ml / day). As a method of detoxification were held on 3-4 sessions of HBO. Antibacterial therapy - klaforan, metronidazole, ampicillin. Patient spent in hospital 31 and 15 bed-days and were discharged with complete recovery.

Conclusions: The diagnosis of small bowel obstruction gallstone, usually installed intraoperative and differentiated with acute cholecystitis and pancreatitis. Intermittent nature of pain, nekupiruemy medication, is a characteristic but poorly recognizable symptom, which in the presence of clinical and sonographic brand viagra signs of cholecystitis may indicate a developing intestinal obstruction. Resistance criteria of abdominal sepsis and the lack of effect of conservative therapy are a reason to accelerate decision-making about the operation. Cholecystectomy is not feasible and should be enforced only when the nature of destruction of the gallbladder wall. The presence of the CDU should be regarded as a relative contraindication to perform intestinal decompression, which is shown only when absolutely purulent peritonitis and small bowel resection about its necrosis. Late diagnosis affects the prognosis of the disease, health and economic outcomes.

sensitivity to sodium
sympathetic activation
multivitamin
tactics
quantitative and qualitative