Ministry of health of Ukraine

Esophageal atresia. Congenital diaphragm hernia

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Esophageal atresia. Congenital diaphragm hernia.

1. Background.

Esophageal atresia is not only one of the most frequent, but also one of the most difficult to treat newborns malformation. Population frequency of defects: 1 case per 5000 newborns. Most of this pathology is diagnosed in preterm infants. In 20 - 50% of cases this malformation combined with other disabilities. Thus, knowledge of basic clinical signs and diagnostic features help determine the correct treatment strategy and contribute to reducing complications.

2. Specific objectives:

1. To analyze the frequency and structure of esophageal atresia, congenital diaphragm hernia in children.
2. Classify esophageal atresia, congenital diaphragm hernia.
3. Master the embriopatohenez esophageal atresia, congenital diaphragm hernia.
4. Recognize the main symptoms of esophageal atresia, congenital diaphragm hernia in children.
5. Develop the skills of physical examination of the patient: inspection, palpation and other clinical examination of patients with esophageal atresia, congenital diaphragm hernia.
6. Familiarize with methods of diagnosis esophageal atresia, congenital diaphragm hernia.
7. Substantiate diagnostic methods esophageal atresia, congenital diaphragm hernia.
8. Interpret the results of laboratory tests, perform differential diagnosis, formulate a clinical diagnosis, prescribe treatment for patients with esophageal atresia, congenital diaphragm hernia.
9. Identify indications for conservative and surgical treatment of this pathology.
10. Offer medical tactic in the presence of malformations of esophagus and diaphragm.
11. Formulate a complete clinical diagnosis, according to the classification of these diseases.
12. Establish psychological contact with patients and parents to improve preparedness for treatment (including surgery) and awareness of the negative consequences of the disease in the event of failure of medical advice.

4.2 Theoretical question for the class:

1. Define the concept defects diaphragm, esophagus
2. Classification of esophageal atresia.
3. Classification of diaphragm hernia.
4. The main clinical symptoms of defects diaphragm.
5. The main clinical symptoms of esophageal defects.
6. Methods of diagnosis of esophageal atresia.
7. Differential diagnosis of esophageal atresia
8. Differential diagnosis of diaphragm hernia
9. Indications for surgical treatment of esophageal atresia.
10. Timing and indications for surgical treatment of diaphragm hernia.
11. Major surgery with atresia of the esophagus.
12. Major surgery with diaphragm hernia.

4.3 Practical work used in class

(Knowledge assimilation III)
1. Installing psychological contact with patients, parents. Compilation of complaints, history of life and disease.
2. The Plan examination of the patient with esophageal atresia, diaphragm hernias.
3. Examination of the patient with esophageal atresia, diaphragm hernias: inspection, palpation, percussion, auscultation.
4. Choosing probe for sensing the stomach samples of Elephanta, the interpretation of research data.
5. Interpretation of the data X-ray, CT research and study of the diagnosis.
6. Definition of indications and contraindications to conservative or surgical treatment.
7. Demonstration video scenes surgeries with atresia of esophagus and diaphragm hernia.
8. Mounting system for drainage of the pleural cavity.
9. The Plan postoperative management of patients with esophageal atresia, diaphragm hernias.
10. Prediction of long-term results with atresia of esophagus, diaphragm hernia.
Contents subject.
Esophageal atresia. The esophagus and trachea are laid in the early parts of the primary intestinal tube (Figure 1).
In the middle of the bottom groove of the pharynx appears that quickly turns into a tubular outgrowth - the trachea (Fig. 1-b), which runs parallel to the intestinal tube. Caudal end of the trachea begins to increase and forks (Figure 1-c), forming bookmarks lungs. Distal esophageal tube from the pharynx narrows significantly, forming the esophagus. For non-direction and rate of growth of the trachea and esophagus may develop esophageal atresia with fistula traheostravohidnoyu. Probable cause of atresia and stenosis believe disruption of vacuolization in the solid phase (from the 20th to the 40th day). How the pathology of chromosomal abnormalities is now increasingly attracting the attention of researchers

Atresia of the esophagus and diaphragm hernia with autosomal recessive inheritance where both parents are carriers of recessive gene (heterozygotes): the possibility of having a healthy child - 25% of the patient - 25% heterozygotes - 50%. Marriage patient with a healthy give 100% in the offspring of heterozygotes. Marriage provides the patient with heterozygote offspring in 50% of patients and 50% - heterozygotes (carriers).

There are various anatomical variants of this defect. In "Atlas of esophageal atresia» D.Kluth (1976) described 97 species and "subspecies" atresia of the esophagus. Frequent following oesophageal pathology (Figure 2).

But, basically, are two classic types of esophageal atresia:

1. Oral segment ends blindly, and stomach - is connected to the respiratory tract;
2. Oral and distal segments ending ends blindly and not connected to the airway.
Atresia top drive segment to form the lower traheostravohidnoyi fistula is the most common defect esophagus - it is diagnosed in 85 - 95% of patients. Regardless of the type of esophageal atresia oral segment is always more advanced than the lower, gastric. The wall of the upper end thickened, hypertrophied.
When esophageal atresia observed characteristic clinical picture. Within 2-3 hours after birth top Oral blind bag esophagus and nasopharynx filled with mucus, resulting in newborn appear frothy discharge from the mouth and nose. This is an early symptom. Nespravzh ¬ tion hypersalivation due to the fact that in the viscous mucus exhaled breath and thrown into the nasopharynx. After vidsmoktu ¬ ing mucus again he quickly accumulates and part of his aspiruyetsya. There are attacks of asphyxia, so by the end of the 1st to ¬ would appear after birth dyspnea, cyanosis nasolabial triangle bugged many moist rales riznokali ¬ Bern. During feeding bouts of cyanosis intensified. These symptoms indicate a violation of patency of the esophagus. There respiratory failure due to pneumonia and atelectasis develops idiopatychpyy respiratory distress syndrome (RDS).
If the top section of esophagus connects to the trachea, the clinical picture of respiratory failure prevail because the contents of the upper segment of the esophagus passes through a fistula to the trachea. Having lower traheostravohidnoho links diagnosed during the inspection and percussion of the abdomen. In the absence of communication stomach hollow, percussion determined dull sound. If fistula stomach and intestine filled with air. As a result antyperystaltyky acidic stomach contents thrown into the trachea and bronchi, is the death of ciliated epithelium and violation of the drainage function of bronchi.
Peristalsis in Esophageal atresia and traheostravohidnyh fistulas impaired. In addition, amniotic fluid stretched upper segment of the esophagus compressing the trachea, which can lead to tracheomalacia. Low prenatal intrabronhialnyy pressure time ¬ shuye process branching bronchi and alveoli.
Diagnosis of classical defects not difficult, especially if there is no associated malformations. There are several methods of diagnosis: sensing strategy ¬ vohodu using thin rubber catheter (№ 8-10). This procedure should be performed in the delivery room. If it is not informative, air is blown through a catheter (10-20 ml.) (Elephanta test), which is released through the nose or mouth. The child should be transferred to the surgical hospital. The most informative is contrasting esophagus. Is put ¬ ing contrast catheter under radiological control in the upper segment of the esophagus informative (Figure 3).

Communication between gastric segments ¬ volume and respiratory system causes the appearance of air in the stomach and intestines, which exhibit during X-ray of abdomen in ¬ rozhnyny. During contrast study due to falling material in the airways develops severe air ¬ Niya, so mostly prefer research without injections ¬ tion of contrast material.

Most clinicians to early diagnosis of defects recommend to everyone without exception newborns in the first hours after birth conduct sensing esophageal catheter. Such tactics, as evidenced by long experience, is justified. However, existing diagnostic methods allow only to determine the level of obstruction of the upper segment of the esophagus. Surgeon to select the appropriate treatment strategy is necessary to have information on the amount of diastase between the upper and lower ends of the esophagus, level location bronhostravohidnoho connections.
There is a way to prompt diagnosis of anatomical disorders in esophageal atresia: retrograde рентгеноезофагобронхологічне study, to determine the length of the defect of the esophagus and precise anatomic localization bronhostravohidnoho connections. Methodology is verhnoseredynniy laparotomy. Through the hole made in the wall of the stomach during gastrostomy by Kader, conduct retrograde catheterization of the distal segment of the esophagus radiopaque probe.
Preoperative preparation of children who were hospitalized in the first 12 hours:
1) a complete cessation of feeding by mouth;
2) high head end and change position every 30-45 minutes;
3) humidified oxygen;
4) warming;
5) infusion therapy based daily physiological needs in the fluid by 10% glucose solution, fresh frozen plasma electrolytes;
6) antibiotic therapy;
7) symptomatic therapy;
8) thorough suctioning of mucus every 10 - 15 minutes of upper ¬ th segment esophagus, upper airway and trachea;
9) endotracheal intubation with mechanical ventilation, spontaneous breathing under increased pressure from Gregory.
Duration of preoperative preparation depends on the general condition of the child ¬ tion, hospitalization time and nature of pathological changes in the lungs. Determine the severity of disorders of homeostasis, hemodynamics, respiratory failure and the degree of dehydration. ¬ but depends on the condition and degree of operational risk are three groups of newborns Ashkraftom and Holder:
A - newborns weighing more than 2500h without accompanying defects and pneumonia;
B - infants weighing 1800 - 2500h without pneumonia and weighing more than 2500h with pneumonia or atelectasis (16%);
C - newborns weighing less than 1800 for lack ¬ ARRANGEMENTS pneumonia and weighing 1800 - 2500h with pneumonia, RDS, associated malformations, sepsis (34%).
Children who were hospitalized in the first 12 hours after birth, do not require prolonged preoperative preparation. Hospitalization ¬ cialized later with symptoms of aspiration pneumonia prepared for operation from 12 hours to 3 days. In addition to the above, they pro ¬ drive:
1) inhalation of alkaline solutions and antibiotics;
2) parenteral nutrition by the existing scheme
Type of surgical treatment depends on many factors. First of all forms of atresia. When atresia with fistula, most authors recently impose direct anastomosis of the esophagus. With a large diastase more than 1.5 cm proposed different methods for applying the anastomosis, including deferred. Access: transpleural (postoperative complications - mediastinitis, pneumonia, pleural empirical ¬ EMA) and extrapleural in the fourth intercostal spaces. Retroplevralnyy access is safest. First mobilize the lower segment of the esophagus. Then eliminate traheostravohidnu fistulas. Directly near where communication with the trachea to the esophagus impose silk ligatures, it cut the, trachea ushyvayut. Then mobilize the upper segment of the esophagus. It is recommended to apply single-row suture threads that dissolve on atraumatic needle inside the nodes along the entire perimeter oblique anastomosis. One of surgical techniques aimed at reducing diastase between segments: ezofahomiotomiya around the upper segment, mobilization of the upper segment of the esophagus with vykroyuvannyam with its apex triangular flap, dissection distal segment longitudinally on its lateral surface, the comparison ends of segments with an oblique line location invertuyuchyh seams.
Hovard (1965) offers buzhuvaty oral segment of the esophagus in order to extend it to 2 - 2.5 cm for 3-6 weeks followed by imposition of direct anastomosis and disconnection traheostravohidnoyi fistula. Recently, during a separate gastrostomy catheter drains the lower segment of the esophagus.
T.K.Nemilova and spiv.avtory (2003) offered at the lower esophageal atresia tracheo-esophageal fistula (TSN), create a primary or delayed anastomosis. Primary, with the possible construction ends esophagus without tension and with significant deferred diastase ends. Then, after the elimination of TSN clearance lower segment ushyvayut obvyvnym seam tightly and fix it to the intercostal muscles as possible. The upper segment is not shown, superimposed Gastrostomy. Required adjustment passive outflow of saliva through nazofarenhealnyy probe its active aspiration of the upper segment of the esophagus. By 2-2.5 months of segments grow. There is an opportunity to impose direct anastomosis without tension. Gastrostomy closed within 1.5-2 months after imposition of deferred anastomosis.
In isolated form atresia (without traheostravohidnoyi fistulas) are multi-stage operation. The first stage is carried out double ezofahotomiyu, and the lower segment of the esophagus deduce the peritoneal cavity of laparotomy access without thoracotomy or ezofaho and gastrostomy. While cervical esophagus segment ezofahostomiyi oral derive the neck, distal to the anterior abdominal wall. The second stage of the operation - plastic esophageal intestinal transplant with antireflux protection by the method of Stepanov-Razumovsky, at an age of 6 months - 1 year. Operation of choice now becomes rear Mediastinal koloezofahoplastyka. Early and remote postoperative course of the performance of different retrosternal koloezofahoplastyky severe complications as graft necrosis - 0.6% and mortality - 0.3% (A.Yu.Rozumovskyy and others., 2003).
Postoperatively continue intensive tera ¬ piyu, conduct sanitation tracheobronchial tree at Hearth ¬ weighted intubation. Fed baby through a plastic tube. The probe is removed by 8-9th day. Capacity anastomosis re ¬ viryayut using radiological control vodoroz ¬ force of contrast material. In the absence of complications th ¬ pensation through the mouth begin with 10-20 ml, increasing the dose of 10 - 15 ml daily, bringing to normal according to age and body weight. If there Gastrostomy then starts feeding ¬ tion on the 2nd day after surgery.
Possible postoperative complications: pneumonia, failure to ¬ mozhnist anastomosis, mediastinitis, pleuritis, pneumoempyema, atelectasis, recurrent fistula traheostravohidnoyi (recanalization). Narrowing of the anastomosis occurs in 30-40% of cases unasli ¬ docking formation of adhesions and scarring and requires bouginage (buzhi № 20-26).
Must have a control fibroezofahohastroskopiyi of assessing the degree of patency of the anastomosis area, especially if dysfahiy. In addition, assess the severity of esophagitis resulting from possible gastroesophageal reflux as a result of congenital dysfunction of the esophagus. Assign conservative treatment (Reglan, cisapride), and in case of failure - surgery for Nissen to form complete'' clutch "or" half-coupling "with Tal.
The children set constant clinical supervision, prescribe feeding homogenized mixtures.

Diaphragm hernia.

Diaphragm hernia called moving abdominal organs into the chest cavity through natural or abnormal opening in the diaphragm or by protrusion thinned diaphragm (all or only part of it). In children arise mainly congenital diaphragm hernia.
Development of the diaphragm is completed at the end of the 2nd month of fetal development (Fig.5.)

The diaphragm is placed in the main department at III-V cervical segment. At 4 weeks of growing its ventral division as folds that partially separates the pericardial cavity from pleural sacs and abdominal cavity, is primitive connective plate or diaphragm. Dorsal department pleural cavity is still connected to the abdominal cavity. At the end of the 6th week on the side and rear walls of the trunk appear folds (pillars Uskova) that gradually grow towards the transverse septum, fused with it and form a diaphragm. At the end of the 3rd month of the diaphragm gradually descends and takes its anatomical position.

In the case of underdevelopment pillars Uskova formed defects often placed in the dorsal, at least - in its central part. Depending on the degree of underdevelopment Uskova pillars formed the central part of the diaphragm defects of varying sizes, sometimes it does not.
There diaphragm hernia true and false.

Their formation depends on the time of termination of the diaphragm. If it happened early on abdominal organs stay for directly by the lungs that helps hypoplastic lung tissue. Late hypoplasia bodies abdominal bulge through defects in the diaphragm and peritoneum and form a hernial sac.

Classification (SY Doletskyy, 1970) congenital diaphragm hernia depending on the location of hernial gate and sizes:
I. Hernia own diaphragm (43%).
1. Thinned bulging of the diaphragm (true hernia):
a) protrusion limited part of the dome diaphragm;
b) protrusion of a large part of the dome of the diaphragm;
c) complete protrusion of one dome of the diaphragm (relaxation).
2. Defects in the diaphragm (hernia false):
a) back slit defect (hernia Bohdaleka);
b) lack of a dome diaphragm (aplasia).
3. Transitional forms.
II. Hiatal hernia (hernia true) - 10%:
a) esophageal;
b) paraezofahealni.
III. Hernias anterior diaphragm - 10%:
a) front hernia (hernia true) - parasternal (Larreya crack, hole Morgagni);
b) frenoperykardialni hernia (false);
c) retrograde frenoperykardialni hernia (false).
Congenital diaphragm hernia occurs in one excrete ¬ begotten approximately 3,000 births (excluding stillborns with congenital diaphragm).
For all types of diaphragm hernia in either less op ¬ Ghana abdomen moved into the chest, resulting cho ¬ nd there is compression of the lungs and heart shift. Mostly it stomach, omentum, small and large intestine, part of the liver, sele ¬ zinka, less kidney.
Depending on the size of hernial gate, their localization char ¬ ture and magnitude of movement of the abdomen can be impaired respiratory, digestive and cardiovascular activity. For each type of hernia is characterized by certain symptoms. The clinical picture in some forms of diaphragm hernia occurs race ¬ c. Most are left-handed diaphragm hernia. Pain ¬ six patients (especially infants) to one hundred hospitalized ¬ tsionaru due to complications that arise when false hernias own diaphragm, at least in its relaxation. Weather in pa ¬ with congenital diaphragm hernia in premature neonatal ¬ tive and children with functional immaturity body adverse ¬ tive.
Most of diaphragm hernia manifested symptoms of asphyxia and increasing cardiovascular insuffi ¬ ARRANGEMENTS, which arise from compression of the lungs and mediastinum shift displaced into the chest cavity loops ¬ ing shock, stomach and other internal organs. This condition name ¬ tion SJ Doletskym "asfiktychnym strangulation."
The first and most characteristic feature is to progressively ¬ rostayucha respiratory distress, cyanosis, which, unlike the heart, is intermittent in nature, occurs in the form of attacks associated with eating or crying. Can be watched ¬ tysya bouts of coughing and shortness of breath. Child frail, weak cry. Possible cardiac disorders due to displacement ¬ this August. Also characteristic disorders of the digestive system. If the entire stomach and a large number of loops of intestines move into the pleural cavity and stretched liquids and gases, in addition to dyspnea, cyanosis and heart rate acceleration occur as cough, vomiting, and difficulty swallowing. The abdomen is sunken, boat ¬ nopodibnyy the lack there of abdominal in ¬ rozhnyny.
These objective studies help in establishing the diagnosis. During the test, the patient percussion determine displacement of the heart in the direction opposite the hole in the diaphragm, tympanitis sometimes blunting percussion sound during auscultation - the absence or weakening of breath. On the opposite side of the vo ¬ but also weakened. While attentive repeat of hearings can determine peristaltic intestinal noises.
Diagnosis of congenital diaphragm hernia rather composition ¬ on through a variety of clinical pictures. Crucial radiological examination using contrast material.

X-ray study carried out in a vertical in ¬ applies. This exhibit displacement of the heart in the opposite direction, the presence of gas-filled intestinal loops in abdominal in ¬ rozhnyni intestinal loop is not defined. In contrast studies yodolipolom, which is injected through a tube in the stomach within 2 hours contrast agent fills the small intestine and expression ¬ lyayetsya in the chest cavity.

The differential diagnosis of congenital diaphragm hernia must be made with other diseases that accompany ¬ vodzhuyutsya respiratory insufficiency: edematous hemorrhagic son ¬ Drom, lobarnoyu emphysema or lung cysts, spontaneous pneumothorax.
The most severe complication of congenital diaphragm hernia is strangulation. There phenomenon ileus, in ¬ rushuyetsya activities of the chest. Absence of this Request for Proposal ¬ cha belly complicates diagnosis. Always be aware of diaphragm hernia and internal strangulation. Weather in the case of diaphragm hernia strangulation unfavorable. Therefore, the indications for surgical intervention, regardless of the child's age determined after diagnosis.
Congenital hernia of the diaphragm asfiktychnym dunk ¬ tion is an absolute indication for surgery.
Treatment of newborns with congenital diaphragm hernia - one of the most difficult problems in surgery due to the complex pathophysiology of respiratory (breathing) disorders, high ¬ koyi mortality, serious complications in the postoperative peri ¬ units, care for further rehabilitation of children with this disease.
Successful treatment depends on adequate anesthesia: a plan of ventilation mode normoventylyatsiyi with hypercapnia, extracorporeal membrane oxygenation, with no necessity ¬ inhalation of nitric oxide to blood pressure reduction in the le ¬ geneva artery. Recently in infants with thoracic operations ostsyllotorna used high-frequency ventilation (HFOV).
When diaphragm hernia spend focused on tracking child ¬ and ¬ operative treatment is aimed at determining the size of the defect diaphragm disease of the chest and abdominal cavity ¬ nyny and plastic diaphragm. Use laparotomy or torakotomnyy accessibil ¬ pi.
In the case of jamming of the digestive system (when it nespravzh ¬ diaphragm hernia) shown urgent surgical interventions ¬ supply. Children who surgery about the real diaphragm hernia was not carried out behind in physical development, they develop serious complications. Only normal operation provides further physical development of the child. The operation was postponed to stabilize in ¬ indicators of hemodynamics, gas exchange and adequate urine output, ne ¬ redoperatsiynu preparation conducted within 12-32 hours. Volume surgery defined the essence of malformations.
Children with this diaphragm hernia spend diafrahmoplastyku as tryplikatury, children with schilynopodib ¬ him defect diaphragm - quilting diaphragm muscle to roll, and if he is absent - to the ribs.

If there is aplasia dia ¬ Phragmen must carry through plastic mesh allograft.

Given the importance of intra-abdominal pressure in the development of hypoxia, pulmonary hypertension, cardiac activity of the abdominal wall can not zashyvatysya, formed a ventral hernia. Yu.P.Kukurudza, Ye.Ye.Loyko and others. (2007) covering the intestines silicon film fixed to the peritoneum, the anterior abdominal wall. Relaxation of the abdominal muscles held vertical traction at the seams, which gradually reduced the size of the defect and allowed to remove tape and sew up the wound for 6-8 hours. Gradually increase the size of the abdominal cavity, eliminating pressure on the diaphragm, improves hemodynamics.
Indicators of overall mortality, according to the national av ¬ tors (VF Shish, A. Losev, VN Grapes, OG Momotov, 1999), ranged from 14 to 30%. Causes of death can bu ¬ you multiple defects (severe heart defects, kidney, central nervous system), bilateral lung hypoplasia, profound prematurity and functional immaturity ¬ tional body, the development of sepsis due to de ¬ structive pneumonia in hipoplazovaniy lungs or generalization of intrauterine infection, decompensated heart vascular insufficiency.
Zahn et al (2007, Germany) indicate that according to the literature relapses after treatment diaphragm hernias ranged from 20 to 80% and depend on the technology operations. Among the 4 different methods (primary suturing, simple reward, a large reward and conical), the most rational way to apply bevel patches.

Materials for selfcontrol.

Situational tasks:
Task 1. In the newborn child after birth gradually began to grow signs of respiratory failure. Gradually intensified displacement of the heart to the right, the left half of the chest bulges, lags in breathing, percussion - it normal lung sounds, left - tympanitis, and during auscultation listen "gurgling" noises. Plain radiographs of the chest - the mediastinum shifted to the right, left to level 3 ribs defined air cavity sizes.
1. What is pathology in neonatal ¬ Jen child you are dealing with?
2. What diseases should conduct dyf.diahnostyku?
3. Surgical tactics of another doctor.

Task 2. The newborn from the first hours of life significantly pronounced signs of respiratory failure: shortness of breath, increasing horizontally. On examination: the left half of the chest bulges, heart shifted to the right, the dome of the diaphragm on the left is not detected. Auscultation of breath puerylne right, left, listens intestinal noises, shortness of breath. Sunken abdomen.

1. What is the most likely diagnosis?
2. What form of pathology?
3. Surgical tactics of another doctor.

Problem 3. In the newborn baby after the birth of his mouth and nose abundantly secreted saliva foamed, increasing dyspnea, cyanosis. Sunken abdomen, but swollen in the epigastric region. When probing the stomach - probe stopped.

1.Z what defect you are dealing with?
2. What more research should be conducted to clarify the diagnosis?
3. What form of the disease?

Problem 4. In the newborn child from the first minutes of life is determined saliva foaming from the mouth and nose, respiratory failure.

1. What disease is it?
2. What method of diagnosis should use neonatologist hospital to confirm defects?
3. What are the two main forms of the disease you know?

Problem 5. In the newborn child 2:00 suspected diagnosis of esophageal atresia with lower tracheobronchial fistula.

1. Tactics doctor in the hospital.
2. What should be done to prevent complications of the disease in the preoperative period?
3. Surgical tactics.
Problem 6. The child after birth appeared frothy discharge from the oropharynx, expressed phenomena of respiratory failure. Gastric probe could enter by 10 cm on plain film increased pneumatization intestine.
1. How to test Elephanta?
2. Which sign indicates a lower traheostravohidnuyu fistula?
3. What is your medical tactics?

Problem 7. In a 3-year child gradually began to grow signs of respiratory failure. Gradually intensified displacement of the heart to the right, the left half of the chest bulges, lags in breathing, percussion - it normal lung sounds, left - tympanitis. Plain radiographs of the chest - the mediastinum shifted to the right, left to level 3 ribs determined the formation of the liquid level.

1. What disease should consider first?
2. What research should be carried out to confirm the diagnosis?
3. Therapeutic tactics.

Task 8. In the delivery room in probing suspected gastric esophageal atresia. Plain radiograph of the abdomen - "dumb stomach," moderately severe respiratory failure.

1. On what basis in probing suspected gastric esophageal atresia?
2. What does "dumb belly" on plain film of the abdomen?
3. What is the x-ray can be done to clarify the diagnosis?

Problem 9. In 3 Sunday child gradually began to grow signs of respiratory failure. Was observed shift of the mediastinum to the right, the left half of the chest behind in breathing, lags in breathing, percussion - it normal lung sounds, left - tympanitis, and during auscultation listen "gurgling" noises, no signs of inflammation. Plain radiographs of the chest - the mediastinum shifted to the right, left to level 3 ribs defined air cavity sizes.

1. What kind of pathology should be thinking about in the first place?
2. What research should be conducted to confirm the diagnosis?
3. Therapeutic tactics.
Problem 10. In the neonatal intensive care unit hospitalized child the first day of life. The patient's severe and caused a pronounced respiratory failure. Suspected diagnosis wrong orifice hernia syndrome asfiktychnoho pinching.
1. What research will confirm this diagnosis?
2. First Aid in separate resuscitation.
3. Therapeutic tactics.

Tests:
1. Newborn hospitalized in surgical ward in a serious condition with respiratory failure. Left expansion intercostal spaces, auscultation of breath is not bugged, a sharp shift to the right cardiac impulse. Established syndrome intrathoracic tension left. Syndrome of tension in the chest cavity of a newborn can be caused by:

A. hernia Bohdaleka
V. hernia Morhan'yi
S. Congenital partial emphysema
D. Pneumoempyema
E. congenital lung cyst

2. In the Department of Surgery newborns hospitalized child syndrome asfiktychnoho pinching. The diagnosis: false left-sided diaphragm hernia. The basis of pathological disorders in false diaphragm hernia in newborn trait is the most significant:

A. Compression of mediastinal
V. pulmonary hypoplasia
C. Aspiration pneumonia
D. The shift of the mediastinum
E. Operation fetal cardio-pulmonary communications

3. In the newborn at birth diagnosed esophageal atresia with lower tracheo-bronchial fistulas. Contraindications to radical surgery for esophageal atresia:
A. Aspiration pneumonia
B. Deep prematurity
S. cranial trauma with signs of hemorrhage
D. The combination of anomalies and defects
E. Perinatal encephalopathy

4. In infants weighing 3200hr during the first feeding arose vomiting. What is the first event should be held in this case?

A. X-ray study of the digestive tract
V. auscultation abdominal
C. Re-feeding a baby in an upright position
D. Plain radiography of the abdominal and thoracic cavities
E. Conducting the probe into the stomach

5. The boy was observed at birth increased salivation, frothy discharge from the mouth and nose, tremors cough. The diagnosis: esophageal atresia. What is the most common variant of this bug?

A. Esophagus forms two blind bags
B. The upper segment of the blind, the bottom is connected to the tracheal bifurcation
C. The upper segment of the blind, the bottom is connected to the trachea above the bifurcation
D. The upper and lower segments are connected to the trachea
E. The upper segment is connected to the trachea, the lower ends blindly

6. In the newborn was observed increased salivation, frothy discharge from the mouth and nose, tremors cough. Suspected diagnosis of esophageal atresia. To confirm the diagnosis of esophageal atresia at birth should be primarily to:

A. Sample Elephanta
B. Plain radiographs
S. radiocontrast study of the esophagus
D. Probing the esophagus
E. Ezafahoskopiya

7. Newborn transferred to the surgical department with a diagnosis: esophageal atresia. A clinical symptoms of esophageal atresia with lower tracheo - esophageal fistula owned all of the above except:

A. cyanosis
V. fervor abdomen
S. frothy discharge from the mouth
D. Krepituvalnyh wheezing during auscultation of the lungs
E. Increased salivation
8. The child in the delivery room diagnosed esophageal atresia. The child is put in office in surgery new birth. Before sending a child with esophageal atresia must do everything except:
A. The introduction of antibiotics
B. Approve vikasol
C. Arrange child in shipping ditch
D. Get emptying
E. Introduce catheter for aspiration of saliva
9. Newborn diagnosed congenital diaphragm hernia. Condition of the child due to severe respiratory failure. When asfiktychnomu jamming diaphragm hernia is all of the symptoms, except:
A. cyanosis
V. Excitement
C. The shift of the mediastinum
D. Bloating
E. Tachycardia
10. In surgery newborns hospitalized child the first day of life. The patient's severe and caused a pronounced respiratory failure. The diagnosis: syndrome asfiktychnoho pinching. Among the defects and diseases of the chest cavity most common cause asfiktychnoho syndrome requiring surgical correction are:
A. Lobarna emphysema
V. Destructive pneumonia
C. False diaphragm hernia
D. Congenital atelectasis
E. Tumor

List of theoretical issues.

1. Embryogenesis esophagus.
2. Determination of esophageal atresia.
3. Classification of esophageal atresia.
4. The frequency of esophageal atresia.
5. The main clinical symptoms of esophageal atresia.
6. Methods of diagnosis of esophageal atresia.
7. Methods of test Elephanta.
8. Method of sensing the stomach.
9. What contrasting substance used in the diagnosis?
10. Radiographic signs of atresia of the esophagus.
11. Terms of surgical interventions in esophageal atresia
12. Indications for surgery
13. Surgical management of esophageal atresia
14. Types of surgery.
15. Rehabilitation of children with esophageal atresia
16. Postoperative complications.
17. . Embryogenesis diaphragm.
18. Classification of congenital diaphragm hernia.
19. Methods of diagnosis of diaphragm hernia.
20. Indications for contrast study stomach.
21. Indications iryhorafiyi.
22. Indications for immediate surgical intervention.
23. Options transactions in diaphragm hernia.
24. Postoperative complications of diaphragm hernia

Practical tasks.

1. Analysis of X-ray images of the esophagus and diaphragm pathology.
2. Methods of diagnosis of esophageal atresia and the samples Elephanta.