Ministry of health of Ukraine

Differential diagnosis of hydronephrosis

1. Background.

Number of children with abnormalities of the kidneys is increasing every year. Among obstructive uropatiy in childhood disorders patency pelvis-ureteral segment is one of the first places. Chastist hydronephrosis and complications, which causes this pathology, diagnosis necessitates hydronephrosis.

2. The specific objectives.

1. Analyze the list of diseases that need to differential diagnosis of hydronephrosis.
2. To analyze the clinical course of kidney abnormalities, manifested abdominal extension of the kidney.
3. Suggested methods of diagnosis kidney defects in the differential diagnosis of hydronephrosis.
4. Interpret laboratory results, and radiographic examination sonolohichnoho patients with hydronephrosis.
5. Clinical management of patients with hydronephrosis.
4.2 Theoretical question for the class:
1. Perelikuyte congenital malformations that have extended cavity system of the kidney.
2. Etiopathogenesis, clinical manifestations of polycystic kidney disease.
3. Etiopathogenesis, clinical manifestations and hydronephrosis megaloureter.
4. Clinical and laboratory diagnosis of hydronephrosis.
5. What sonolohichna pattern typical for hydronephrosis?
6. Opportunities ultrasound of the kidneys, the differences in the diagnosis of renal disease and ureter.
7. Identify methods of X-ray examination, which will confirm the diagnosis of hydronephrosis.
8. Features of X-ray examination of children first years of life.
9. Complications of hydronephrosis and diagnostics.
10. Perelikuyte diagnostic methods that help to establish the final diagnosis of hydronephrosis.
Content themes
Hydronephrosis - is expanding cavity of the kidney due to obstruction in the pelvis-ureteral segment. Obstruction can result from various causes: embryonic adhesions, stenosis in prymyskovomu segment, high discharge valve or ureter aberrant vessel dynamic obstruction (Figure 1).
Causes of hydronephrosis
Causes of obstruction can be divided into internal and external, organic and functional. For clinicians the importance of separating the organic and functional.
A. During the stage of embryogenesis solid vacuolization and recanalization of the ureter may lead to obstruction pelvis-ureteral segment, which manifests structure, narrowing, valve ureter. For organic causes of obstruction include high discharge ureter or retrokavalne location. With external causes in this group include compression of the pelvis in ureteral segment embryonic adhesions and fibrous strands, aberrant vessels, cicatrices after periuretrytu.
B. Functional causes obstruction pelvis-ureteral segment associated with segmental dysplastic process. Congenital absence of smooth muscle or change its collagen fibers, the absence of prolonged muscular layer of the ureter leads to impaired patency and delays evacuation of urine from the renal pelvis into the ureter.
Anatomical defects of violations, the outflow of urine from stasis, which may lead to the development of conditions for bacterial infection. A significant violation of the outflow of urine, increased pressure in the bowl further reduces the renal parenchyma, nephrogenic hypertension and renal failure. This determines the need for early detection and early elimination of defects with the restoration of anatomic relationships necessary for normal function of the genitourinary system.
In recent years, due to the extensive use sonolohichnoho pregnancies, much earlier began to show expansion cavity of the kidney. Malformations that have similar sonolohichnu picture and determined perinatally. Often - is hydronephrosis, megaloureter, polycystic kidney disease, congenital changes cups kidney abnormalities location. In older children mentioned changes may occur in urolithiasis, Nephroptosis.
Polycystic kidney - is a bilateral kidney lesions associated with impaired kidney structure in the early stages of fetal development. In the genesis of renal cystic formations kidney heredity plays a central role. Polycystic kidney in children often spadkuyetsya in an autosomal retsysyvnomu type. Very often the malformation is incompatible with life, combined with malformations of the brain (hydrocephalus, hidromiyeliya), malformations of the heart. In polycystic kidney disease in newborns may be affected cystic disease of the liver and pancreas. Renal cystic disease in infants shows diffuse enlargement gathering tubules, nephron structure as cystic change. Unchanged areas renal parenchyma may only be stored in a capsule. Clinically: palpable enlarged kidneys child behind in physical development; periodically z'yavlyayetsya vomiting, oliguria, increased numbers urea nitrogen end, high blood pressure. In 80-95% of the forecast is not favorable and within 2 to 4 months ends in death of the child.
Manifested in the formation of voluminous retroperitoneal space revealed by ultrasound. Clinically asymptomatic.
Solitary cyst localized in one of the poles of the kidneys. When large amounts can manifest itself Billy even renal colic, hematuria possible. In 66% of cases large cyst can compress and shift the pelvis, large and small cups, violates urodynamics. When squeezing vascular cyst may develop hypertension vasorenal.

Clinical manifestations of hydronephrosis and megaloureter sometimes absent. Hydronephrosis and megaloureter children in the first years of life may show different clinical picture, depending on the child's age and degree of urodinamiky.

The existence of this disease most often learn at sonolohichnomu surveyed pregnant. The second group of children examined in z'yavzku with high fever, vomiting, diarrhea, anorexia and leykotsiturii. Sonolohichne test helps in determining the further management of the patient. In older children hydronephrosis can occur asymptomatic or accompanied by pain, leykotsiturii.
Anomalies structure cups and pelvis also give a modified picture of the kidneys in sonolohichnomu survey.
Diverticula calices arising from degeneration favorites ureter III - IV order. Formed pocket that vystlanyy transitional epithelium and combined with calyx-pelvic area in the vault cup. One-third of patients manifested stone formation, constant inflammation.
Hidrokalikos and mehakalikos (expansion cup due to compression of blood vessels scarring or achalasia neck calices) are rare. Advanced calyx of one or both kidneys without signs of obstruction, its number increased to 25 (8-10), can occur as complications of urolithiasis, infection.
Obstruction in prymyskovomu segment in the progression of renal colic may occur, surround the formation of the retroperitoneal space, leukocyturia, hematuria, dyspeptic disorders.
Sonolohichna picture:
for polycystic characteristic bilateral lesions larger formation;
 multykistozna kidney: vizyalizuyetsya ehonehatyvni numerous plots of various sizes, not linked, or represented by a large brain cyst layer, parenhyma absent.
 hydronephrosis - numerous hyperechoic structures are interconnected, most of them (bowl) is located in the medullary layer, parenchyma is defined differently.

 megaloureter - numerous interconnected hyperechoic formation, as well as advanced ureter.

Ekstretorna urography:
 with polycystic - defined large kidneys, renal parenhyma kontrastuyetsya a long delay or not kontrastuyetsya;
 when multykistozniy kidney - no kidney function of the affected party;
 with hydronephrosis - contrast agent on the affected side accumulates slowly or not kontraktuyetsya, pelvis and calyx expanded differently depending on the degree of hydronephrosis. At a delay emptying kidney contrast agent may conduct a test load (Continuous IV administration laziksu 0.1 mg \ kg).
According stsyntihrafiyi kidney function partly preserved, delayed emptying more than 20-30 minutes.

Materials for self-

Situational tasks
Task 1. On the advice of a urologist approached parents of a newborn child, which in the perinatal period revealed piyeloektaziyu right. Ureter not appear.
1. What method of diagnosis will help in determining future tactics in treatment?
2. What additional diagnostic methods should be conducted?
3. What diseases need to distinguish?
Replies
1. Sonolohichne survey.
2. Laboratory examination ekstretorna urography.
3. Megaloureter, bubble-ureteric reflex cyst right kidney.

Task 2. In urology department for treatment of a boy is 3 months, who had come in connection with a high fever, vomiting, dyspeptic disorders. In the analysis of blood - leukocytosis, neutrophilic left shift, accelerated ESR in urine - leukocyturia, proteinuria. When sonolohichnomu examination - both kidneys are enlarged, the right cup to 10 ml in diameter, pelvis - 27h18 mm, left - expansion pelvis - 18h12 mm.

1. Perelikuyte disease which is necessary to conduct a differential diagnosis.
2. What methods of diagnosis and timing of further investigation?
3. Explain your diagnosis.
Replies
1. Polycystic kidney disease, a bilateral megaloureter, acute pyelonephritis.
2. Excretory urography, laboratory examination, Doppler.
3. A bilateral hydronephrosis.

Problem 3. Boy 5 months neodnarozovo fed to the physical separation of high fever, vomiting, diarrhea. In Urinalysis observed proteinuria, leukocyturia in blood tests - leukocytosis, accelerated ESR. When renal ultrasonography revealed piyeloektaziyu right.

1. What diseases can be suspected?
2. Perelikuyte diagnostic methods for diagnosis.
3. Your diagnosis.
Replies
1. Hydronephrosis, megaloureter, bladder-ureteral reflux.
2. Excretory urography, laboratory examination, cystography.
3. By increasing the cavity size of the right kidney - hydronephrosis.

Problem 4. Girl in '10 came to the hospital with clinical renal colic: pain in the right lumbar region with iradiatsiyeyu the right inguinal area, vomiting, anxiety. In Urinalysis - leukocyturia, erytrotsyturiya, in blood tests - white blood cells. When sonolohichnomu examination expansion pelvis and calices of the right kidney.

1. Perelikuyte disease that can manifest this clinical picture.
2. Assign the required survey methods and timing of their implementation.
3. Explain your diagnosis.
Replies
1. Hydronephrosis, urolithiasis, pyonephrosis.
2. Purchasing attack of pain, and then excretory urography, laboratory examination.
3. Urolithiasis.

Problem 5. In consultation with the urologist asked parents of children 3 months of complaints sonolohichni changes both kidneys. When sonolohichnomu examination revealed an increase of both kidneys, renal parenchyma compacted determined many anehohennyh formations. In history - in polycystic mother, adult type.

1. What diagnoses should conduct a differential diagnosis.
2. What methods of diagnosis will help in diagnosis?
3. What is your diagnosis?
Replies
1. Hydronephrosis, megaloureter, polycystic kidneys.
2. Excretory urography, laboratory examination, renografiya.
3. Polycystic kidney disease.

Problem 6. In urology department for examination came a girl of 3 months, born to teenage mothers. Pregnancy against pyelonephritis. When sonolohichnomu examination determined the left kidney large kidney vizializuyetsya large cyst cerebral layer, parenchyma absent.

1. What diagnosis can be suspected?
2. What diseases to the differential diagnosis?
3. What methods of diagnosis confirm the diagnosis?
Replies
1. Multykistozna left kidney.
2. Polycystic kidney disease, hydronephrosis, ureterohydronephrosis.
3. Excretory urography, laboratory examination, renografiya.

Tests.
1. Child '10 Received urology department with the diagnosis left kidney hydronephrosis fourth degree. An excretory urograms. What are the radiological signs of hydronephrosis detected in the patient?

A. Belated contrast, expansion bowl and cups left kidney on delayed radiographs.
B. Increased shadow left kidney.
C. The presence of rounded contrasting spots (extended cup).
D. Spasm necks cups.
E. Delay contrast and reduce the intensity of the shadow of the left kidney.

2. In urology department received a boy of 7 years with clinical renal colic. Which of perelikovanyh defects kidneys and ureters harakteren this syndrome?

A. Intermittent hydronephrosis.
V. bladder-ureteral reflux.
S. Hypoplasia kidney.
D. Doubling the upper urinary tract.
E. Polycystic kidney.

3. In urology department for examination is the girl with the extension calices and pelvis of the right kidney. Object of perelikovanyh diagnostic methods should begin examination of the patient?

A. Excretory urograms.
B. Retrograde ureteropiyelohrafiya.
S. Angiography.
D. Renography.
E. Cystoscopy.

4. In the emergency department of children's surgical hospital received child 12 years with abdominal pains that are characteristic of renal and urinary tract infections. Perelikuyte diagnostic methods that can help establish the diagnosis.

A. Palpation of the lumbar region, kidney ultrasound, laboratory tests.
B. Excretory urography.
C. Laboratory examination.
D. Definition Pasternatsky.
E. Percussion lumbar, plain film.

5. The girl 11 years after physical exertion appeared paroxysmal pain in the right lumbar region. In the history of an attack of pain for the first time. After the attack in urine - microhematuria. Perelikuyte disease that can produce a similar clinical picture.

A. Intermittent hydronephrosis.
V. megaloureter right.
S. Urolithiasis.
D. Chronic pyelonephritis.
E. Polycystic kidney.

6. The girl, who is in the urology department in connection with piyeloektaziyeyu right kidney, conducted the survey and found intermittent hydronephrosis. What methods of examination conducted child?

A. Excretory urography in standing and lying down.
V. Ureterotsystohrafiya.
S. cystography.
D. Renography.
E. Cystoscopy.

7. In the department examined child 5 months in connection with changes in the structure sonolohichnymy left kidney. When sonolohichnomu examination revealed the size and age structure of the right kidney, and a large number ehonehatyvnyh entities that are not connected to each other, the absence of parenchyma in the left kidney. What diagnosis can be suspected?

A. Multykistozna left kidney.
V. Polycystic kidney.
S. hydronephrosis.
D. Megaloureter.
E. sponge kidney.

8. In genetics applied mother of a newborn child with a diagnosis: microcephaly, polycystic kidney disease. What is the most common factor in this disease?

A. Continuity.
V. Endocrine diseases parents.
C. Chronic pyelonephritis mother.
D. Acute respiratory disease during pregnancy.
E. Working mothers in the chemical industry.

9. Surveyed child of 3 months, born from full-term pregnancy and mother, a history in which polycystic kidney disease. Identified changes give the opportunity to exhibit diagnosed polycystic kidney. What sonolohichni changes characteristic of this disease?

A. Increased two kidneys, a large number ehohnehatyvnyh formations, not interconnected, sealing parenchyma.
B. Extended abdominal renal system.
C. Advanced calyx, pelvis and upper third of the ureter.
D. A large cyst cerebral layer, parenchyma absent.
E. Extended pelvis and ureter throughout.

10. Girl 5 years old came to the hospital with complaints of pain in the left lumbar region. Ill during the year. When X-ray examination revealed a significant increase calices and pelvis, ureter not kontrastuyetsya. What is the most likely factor in this expansion pelvis.

A. Stricture of the ureter.
V. bladder-ureteral reflux.
S. Multykistozna kidney.
D. Megaloureter.
E. pyonephrosis.
FIRST AID liver failure

1. Background:

Liver failure in children due to violation of metabolic processes in the liver, accompanied by general intoxication and lead to neurological and psychiatric disorders.

2. Specific objectives:

1. Analyze the list of diseases or conditions that cause liver failure in children.
2. Explain the major clinical manifestations of liver failure in children.
3. Differentiate hepatic failure in children depending on the cause of.
4. Interpret helper methods: ultrasound, x-ray, laboratory and biochemical analyzes, hemodynamic parameters.
5. Demonstrate the technique of palpation the liver.
6. Identify peculiarities of liver failure in children.
7. Justify and formulate preliminary clinical diagnosis.
8. Submit algorithm Action physician in hepatic failure in children.
9. To interpret the general principles of treatment of liver failure in children.

CONTENTS TOPICS

"Hepatic NEDOSTATANIST IN CHILDREN"
Liver - unpaired organ of the gastrointestinal tract, which is located in the right subdiaphragmatic area. The liver has an important function in the digestive process (synthesis and secretion of bile, which promotes the consumption of fat) in the cells of the exchange of proteins, fats and carbohydrates are synthesized proteins, various enzymes. The special mechanism (microsomal oxidation) in the liver detoxification processes of various poisons both exogenous and endogenous origin. Liver - one of the blood, it also serves as a depot, is involved in the regulation of acid-base balance of the body.
On the metabolic needs of the liver normally takes up to 25% of the oxygen necessary for the functioning of the body, with severe intoxication, these expenses increased to 40%.
Hepatic blood supply by 20% at the expense of the hepatic artery, and 80% - of portal vein. With this authority comes to blood that contains significantly reduced amount of oxygen. So, different hypoxic conditions arising in the body, leading to disruption of oxygenation, primarily liver tissue. In countering this body has a powerful mechanism for regeneration. Yes, the death of over 70% tissue accompanied by hepatic failure, but after a while, in these cases, the volume of the liver can recover.

Etiology and pathogenesis of liver failure

Liver failure is often caused by viral hepatitis (virus A and B), acute poisoning (mushrooms, dichloroethane, phosphorus, carbon tetrachloride, arsenic) as a result of severe toxemia of pregnancy, burn disease, the use of inhaled anesthetics, antibiotics or sulfanilamide the means of hepatotoxic action with massive bacterial invasion, cirrhosis, primary and metastatic tumors of the liver.
Severe liver failure manifested by a comma. Hepatic coma is endogenous (hepatocellular, "rozpadna"), exogenous (porto-caval, "shunt") and mixed.
Toxic liver lesions with destruction of more than 70% of hepatocytes leads to the development of endogenous coma.
When cirrhosis high pressure in the portal vein blood flow prevents it goes into the system vena cava. Because the liver is not able to effectively purify the blood - there is exogenous coma. In clinical practice, most watched mixed forms of liver failure.
Central nervous system in hepatic coma due to several reasons. This primarily ammonia encephalopathy (synthesis of uric acid from ammonia disrupted, and its level in the blood increases several times). Precipitating factors may be foods rich in proteins, gastrointestinal bleeding, the means hypnotic drugs and drug series, alcohol, surgery, infection, metabolic alkalosis. In CNS tissues accumulate so-called "false" neurotransmitters (oktopamin), amino acids (methionine, phenylalanine, tyrosine, tryptophan) and their toxic metabolites. Against hypoproteinemia arise interstitial edema, which leads to respiratory and tissue hypoxia. Violation of the synthesis of various enzymes, impairment of carbohydrate and fat metabolism, metabolic alkalosis with hypokalemia complicating central nervous system.
Clinical manifestations LIVER FAILURE
Liver failure can be run as:
1. Excretory form (violation of the secretion of bile, a characteristic feature - jaundice).
2. Vascular form (predominant clinical portal hypertension).
3. Hepatocellular forms (disruption of hepatocytes with various disorders of the liver).
Over the course of acute and chronic liver failure, the degree of compensation - offset subcompensated and asthma.
CNS occurs phasically: prekomy, threatening coma and coma own.
In patients with liver failure characterized by the following clinical manifestations:
• the inspection of skin - jaundice, spider veins, "palmarna" hand, the expansion of small surface vessels of the face,
• often - fever,
• liver breath with sweat and urine (due to the formation of methionine metylmerkaptanu)
• digestive disorders (nausea, hiccups, lack of appetite, red, smooth tongue, abdominal pain, flatulence, defecation disorders)
• respiratory failure (interstitial pulmonary edema with the development of restrictive, obstructive and diffusion of respiratory disorders - hypoxic hypoxia)
• disorders of the cardiovascular system (hypotension, tachycardia, extrasystoles)
• hemorrhagic syndrome, anemia (due to disturbance of synthesis in the liver clotting factors and bleeding from erosions and ulcers of the stomach and esophagus);
• often joins complications: kidney failure; hepatorenalnyy syndrome is prognostically unfavorable for the patient.
With an increase in liver failure progressing symptoms of intoxication of the central nervous system: fatigue, headache, lethargy, apathy, change the sleep period and vivacity. Gradually growing disorientation, possible periods of psychomotor agitation, epileptic seizures. In patients exhibit increased tendon reflexes limbs klonus stop, positive symptom Babinsky. One of the most frequent symptoms - flapping - symptom (tremor of the limbs and face, especially pronounced in outstretched hands and wrists in the lowered position, pronation). In the state of deep coma pupils are dilated, eyeballs fixed tendon reflexes are called; progressive rapid (within hours) reduced size of the liver. In chronic disease, especially in the presence of pronounced regenerative fibrotic processes may remain enlarged liver.
Intensive therapy of liver failure
The basis of intensive care treatment principle laid causative pathology that led to liver failure, and prevention and treatment of major syndromes of liver failure during the period (10-14 days) required for spontaneous regeneration of hepatocytes.
1. Assign patient strict bedrest in boxed wards and meet medical staff complete asepsis and antisepsis.
2. In order to prevent encephalopathy removed from the diet of animal protein and fat.
3. Eliminate hepatotoxic factors (hypoxia, hypovolemia, hemorrhage, intoxication): to eliminate hypoxia used oxygen therapy (feed 3-4 liters / min oxygen via intranasal catheter HBO sessions, prolonged continuous administration of oxygen through the catheter into the small intestine - 0.2 - 0, 3 ml / kg body weight per minute, oxygenated blood in the umbilical vein rekanalizovanu);
to increase hepatic blood flow is reduced CBV, improves blood rheology, eliminate intestinal paresis. For this purpose, use crystalloids infusion, salt-free and hemodynamic the means, Mr. aminophylline (2.4% of 20-30 ml / day), sympatholytic means. Putting 10% district albumin (200-300 ml), Mr. mannitol (1 g / kg) dextran increases plasma oncotic pressure, which reduces interstitial edema liver tissue;
for the prevention of stress ulcers and gastrointestinal bleeding used H2 blockers (cimetidine 150 mg), and bleeding from esophageal varices insert probe Blackmore;
the presence of blood in the intestines to reduce intoxication necessarily should clean;
if necessary, blood transfusions should only be used svizhostabilizovanu blood preservative which should be a solution of heparin.
For the prevention and treatment of intoxication used the following methods:
purgation (frequent enemas, saline laxatives, antibiotics that are not hepatotoxic action of kanamycin to 6 g / day, ampicillin - 1g 4 hrs.)
blood purification - (using plasmapheresis sessions, hemosorption or hemodialysis, or connecting ksenoselezinky ksenopechinky etc.);
injected substance capable of binding ammonia in the blood (glutamic acid - 40-50 ml of 1% district, with glucose, three times a day, Mr. and-arginine - 2 grams intravenous infusion every 8 hours).
4. To improve energy processes in hepatocytes injected concentrated (10-20%) districts glucose (5 g / kg per day). Such therapy also reduces the breakdown of the body's own proteins and slag formation.
5. The aim of stabilizing cell membranes of hepatocytes prescribe corticosteroids (10-15 mg / kg hydrocortisone overnight).
6. To stimulate lipotransportnyh mechanisms and stabilize energy metabolism used choline chloride (10% ml10 district, along with 200 ml glucose district, after previous atropinizatsiyi twice a day).
7. Importance of providing vitamin (C, B1, B2, B6, C, E, B12, folic and nicotinic acid in doses 2-3 times higher of daily needs) Cardiac glycosides.

Materials for self-

Situatsiyne tasks:
Task 1. Boy, 11, is being treated in the department planned surgery RCCH about the syndrome of portal hypertension. Ill for seven years. Took a course of conservative treatment. During the last admission to the hospital appeared complaints about the lack of consciousness, often noisy breathing, bleeding from esophageal varices, ascites, anemia, high levels of transaminases.
1. What form of liver failure characterized these clinical manifestations?
2. What methods of diagnosis should be conducted?
Answers:
1. For vascular form.
2. Biochemical blood FEHDS, ultrasound Doppler vascular liver and spleen.

Task 2. Girl, 1 month, send to the department planned surgery. According to the mother of the child is determined by the period of jaundice novonorodzhennosti, aholichny stools, dark-colored urine, spider veins on the skin, bloating, a biochemical analysis of blood high levels of transaminases, hyperbilirubinemia through direct fraction. Preliminary diagnosis of congenital malformation, atresia of the biliary tract.

1.Dlya forms of liver failure characterized these clinical manifestations?
2. Methods of diagnosis to help determine treatment strategy?
3. Principles of treatment of the above forms of hepatic insuffi
established?
Answers:
1. For excretory form.
2. Liver ultrasound, FYEHDS, liver biopsy.
3. Surgical treatment of biliary atresia.

Problem 3. Girl, 15, turned to dilnichoho pediatrician with complaints of jaundice, fever, nausea, lack of appetite, abdominal pain, flatulence. During the inspection determined liver smell from mouth, red smooth tongue, skin spider veins, "palmarni" palm expansion of small surface vessels of the face. From history we know that the girl had used mushrooms that samostino gathered in the forest. The same complaint appeared to parents who also ate mushrooms.

1. What preliminary diagnosis can be set?
2. What form of liver failure characterized these clinical manifestations?
3. What first aid is necessary to the child?
Answers:
1. Acute mushroom poisoning.
2. Hepatocellular form of liver failure.
3 gastric lavage, bowel cleansing, detoxification therapy.

Problem 4. Boy, 7 years old, is treated within the planned surgery on the syndrome of portal hypertension. In history was made operative intervention (spleno-renal anastomosis) 3 years ago. Recently (within 3 months) were complaints expansion of small surface vessels face periodic fever, liver smell from mouth, nausea, lack of appetite, abdominal pain, flatulence. During the biochemical blood analysis revealed high levels of transaminases.

1. What complication occurred in a child?
2. What are the principles of treatment of this complication?
Answers:
1. Hepatic failure, vascular type.
2. Assign patient strict bedrest in boxed wards.
In order to prevent encephalopathy removed from the diet of animal protein and fat.
Eliminate hepatotoxic factors (hypoxia, hypovolemia, hemorrhage, intoxication): to eliminate hypoxia used oxygen therapy.
For the prevention of stress ulcers and gastrointestinal bleeding used H2 blockers.
Colon Cleansing (frequent enemas, saline laxatives, antibiotics that are not hepatotoxic action of kanamycin to 6 g / day, ampicillin - 1g 4 hrs.).
Cleaning blood - (using plasmapheresis sessions, hemosorption or hemodialysis, or connecting ksenoselezinky ksenopechinky etc.).
To improve energy processes in hepatocytes injected concentrated (10-20%) districts glucose (5 g / kg per day). Such therapy also reduces the breakdown of the body's own proteins and slag formation.
The aim of stabilizing cell membranes of hepatocytes prescribe corticosteroids (10-15 mg / kg hydrocortisone overnight).
To stimulate lipotransportnyh mechanisms and stabilize energy metabolism used choline chloride (10% ml10 district, along with 200 ml glucose district, after previous atropinizatsiyi twice a day).
Importance of providing vitamin (C, B1, B2, B6, C, E, B12, folic and nicotinic acid in doses 2-3 times higher of daily needs) Cardiac glycosides.

Problem 5. The boy 13 years old, which is treated within the planned surgery on the syndrome of portal hypertension, vascular complications form liver failure appeared complaints of weakness, headache, lethargy, apathy, change the period of sleep and vivacity.

1. What complication of liver failure rozvylosya a child?
2. What methods of diagnosis will help in diagnosis?
Answers:
1. Encephalopathy.
2. Electroencephalogram.