Задача 11
Больной Ч., 50 лет, жалуется на выпадение кишки из анального канала при акте дефекации и поднятии тяжестей, кишка самостоятельно не вправляется, требуется вправление рукой. Из анамнеза: болеет на протяжении года, впервые выпадение возникло год назад после поднятия чрезмерной тяжести, а затем стала выпадать и после акта дефекации. Вначале кишка вправлялась самостоятельно, а затем (три месяца назад) перестала вправляться, требовалось вправление рукой. В прошлом перенес несколько оперативных вмешательств на органах брюшной полости. Занимается тяжелым физическим трудом.
При обследовании: при осмотре больного в положении «на корточках» после натуживания выпадает до 10 см прямой кишки, слизистая кишки отечная, гиперемированная, имеются эрозии и мелкие язвы. При пальцевом ректальном исследовании после вправления – тонус сфинктера значительно ослаблен.
Задача 12
Больная С., 48 лет, жалуется на наличие алой крови в кале, на выпадение узловатых образований из прямой кишки при дефекации, при поднятии тяжести, которые самостоятельно не вправляются, требуется вправление рукой. Из анамнеза: болеет более двух лет, к врачу не обращалась, лечилась самостоятельно (ванночки, ректальне свечи).
При обследовании: при осмотре в области анального канала и перианальной области имеется мацерация кожи. В положении больной «на корточках» при натуживании из анального канала выпадают геморроидальные узлы, которые самостоятельно не вправляються, требуется вправление рукой. При пальцевом ректальном исследовании: на глубине 4 см пальпируются геморроидальные узлы (на 3-х, 7-ми и 11-ти часах), эластичные, умеренно болезненные, на перчатке – алая кровь.
Rectal prolapse syndrome
OBJECTIVE 1
Patient A. female , 58 y.o, complains of protrusion of bowel from the anus during defecation , prolapsed intestine after defecation is reduced by itself. Anamnesis : the first sign noticed a year ago after a hard stool. Underwent several surgical interventions on the pelvic organs , the work associated with weight lifting .
On examination : the examination of the patient in the " squatting " position after straining rectum falls up to 5 cm, moderately hyperemic mucosa , there are small erosion. Digital rectal examination after reduction - weakened sphincter tone .
TASK 2
Patient B. , 60 years old , complains of loss of bowel from the anus when defecation and weight lifting , bowel alone does not reduce a required reduction hand. From history : sick during the year , the first time a year ago loss arose after lifting too much weights, and then began to fall and after defecation . Initially reduce a gut yourself and then (three months ago) reduce a longer , required reduction hand. In the past, underwent several surgeries on abdominal organs . Engaged in heavy physical labor.
On examination : the examination of the patient in the " squatting " after straining falls to 10 cm of the rectum, colon mucosa edematous , hyperemic , are erosion and shallow ulcers. Digital rectal examination after reduction - sphincter tone considerably weakened .
OBJECTIVE 3
Patient T. , 37 years old . Complains of loss of bowel from the anal canal in an upright position , not reduce a self- gut . From history : suffered three births last birth was difficult, large fruit , Oslon rupture of the perineum. Shortly thereafter noticed that after defecation falls intestine , which reduce a first independently , and then demanded reposition hand. In the last month the gut beginning to fall and the vertical position of the patient .
On examination : when viewed in the " squatting " of the anal canal falls Bol 10 cm rectal mucosa edematous , hyperemic , covered with sores and fіbrinom is contact bleeds easily . After reduction by hand - again drops . Rectal sphincter " gaping ."
OBJECTIVE 4
Patient M. , aged 38, complains of itching in the perianal region , discomfort , periodically - select small amount of red blood in stool. From history : ill for several months , the disease is associated with weight lifting ( with a barbell workout ) .
On examination : Viewed - pathologists in the anal canal and perianal area not viyavleno . Digital rectal examination at a depth of 4 cm palpable education ( 3 , 7 or 11- hour) myagkoelasticheskoy consistency , painless. On the glove - traces of red blood .
OBJECTIVE 5
Patient D. , aged 42, complains of loss of "something" from the anus during bowel movements , which reduce a self after defecation, permanent allocation of red blood in the feces , blood on the toilet paper . From history : sick during the year , in the beginning there was a feeling of discomfort in the anal region , a slight discharge of blood . Then condition worsened during defecation was blood stand out more , become "something" to fall . Exacerbations occur after alcohol and spicy foods .
On examination : there Slept external hemorrhoids in the " squatting " and straining - a few drops of hemorrhoids which independently reduce a . By digital rectal examination : at a depth of 4 cm palpable education ( 3 , 7 or 11- hour) myagkoelasticheskoy consistency , painless. On the glove - traces of red blood .
OBJECTIVE 6
Patient S. , 48 years old , complains of the presence of red blood in the stool, on the loss of nodular formations of the rectum during defecation, when lifting weights, that alone does not reduce a required reduction hand. From history : ill more than two years , the doctor did not address, treated independently ( bath , rectal suppositories ) .
On examination : when viewed in the anal canal and perianal skin maceration there . In the patient's " squatting " straining of the anal canal fall hemorrhoids that alone does not vpravlyayutsya required reduction hand. By digital rectal examination : at a depth of 4 cm palpable hemorrhoids ( for 3 , 7 or 11- hour ) , flexible , moderately painful , on the glove - crimson blood .
TASK 7
Patient R. , 52 years old, complains of urinary gas and liquid intestinal contents on a prolapsed hemorrhoid patient in an upright position , which after reduction - again fall . From history : ill more than 20 years , a prolapsed hemorrhoid began after childbirth large fruit (5 kg) , was repeatedly offered surgical treatment, the patient refused to MDM .
On examination : the patient in the position of " squatting " visible precipitated hemorrhoids , cyanotic , sometimes macerated , after reduction by hand - again fall . Digital rectal examination - anal sphincter tone sharply reduced.
TASK 8
Patient B. , 60 years old , complains of pain in the anal region and loss of bowel from the anal canal, which does not reduce a hand. From history : sick during the year , the first time a year ago loss arose after lifting too much weights, and then began to fall and after defecation . Initially reduce a gut yourself and then (three months ago) reduce a longer , required reduction hand. Four hours ago, after defecation patient could not straighten his arms intestine , there was pain .
On examination : the examination of the patient in the knee- elbow position is visible prolapsed rectum, up to 10 cm , edematous mucosa ulcer sharply , cyanotic , there are erosion and shallow ulcers. Intestine does not reduce a hand .
TASK 9
Patient G. , 50 years old , complains of severe pain in the anal region and lower abdomen, on the loss of bowel from the anal canal, which does not reduce a hand. From history : sick for 4 years , first loss arose after lifting too much weights, and then began to fall and after defecation . Initially reduce a gut yourself and then - ( three months ago ) reduce a longer , required reduction hand. 7 -NIL hours ago, after a hard stool and had the gut to straighten her patient could not, there was a pain in the anal area , and then the abdomen.
On examination : the examination of the patient in the knee- elbow position is visible from prolapsed rectum anal canal length up to 13 cm, dark bowel mucosa is purple , swollen dramatically , there are ulcers and black areas .
TASK 10
Patient S., 36 years old, complains of severe pain and foreign body sensation in the anal area . From history : ill more than two years , when there was loss of nodular formations of the rectum during defecation, when lifting weights, that alone does not reduce a , required reduction hand. To the doctor did not address, treated independently ( bath , rectal suppositories ) . Four hours after a difficult defecation straighten precipitated nodes hand could not, there was pain , which intensified .
On examination : when viewed in the anal canal are precipitated hemorrhoids , dark purple color , dense , painful , not reduce a hand.
TASK 11
Patient Ch , 50 years old , complains of loss of bowel from the anus when defecation and weight lifting , bowel alone does not reduce a required reduction hand. From history : sick during the year , the first time a year ago loss arose after lifting too much weights, and then began to fall and after defecation . Initially reduce a gut yourself and then (three months ago) reduce a longer , required reduction hand. In the past, underwent several surgeries on abdominal organs . Engaged in heavy physical labor.
On examination : the examination of the patient in the " squatting " after straining falls to 10 cm of the rectum, colon mucosa edematous , hyperemic , are erosion and shallow ulcers. Digital rectal examination after reduction - sphincter tone considerably weakened .
TASK 12
Patient S. , 48 years old , complains of the presence of red blood in the stool, on the loss of nodular formations of the rectum during defecation, when lifting weights, that alone does not reduce a required reduction hand. From history : ill more than two years , the doctor did not address, was treated independently ( bath , rectal suppositories ) .
On examination : when viewed in the anal canal and perianal skin maceration there . In the position of the patient " squatting " straining of the anal canal fall hemorrhoids that alone does not vpravlyayutsya required reduction hand. By digital rectal examination : at a depth of 4 cm palpable hemorrhoids ( for 3 , 7 or 11- hour ) , flexible , moderately painful , on the glove - crimson blood .