HAIGUSJUHT 23 AASTANE MEES ALAKÕHUVALUGA. Jevgeni Kulikov 3. aasta resident
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1 HAIGUSJUHT 23 AASTANE MEES ALAKÕHUVALUGA Jevgeni Kulikov 3. aasta resident
2 Anamnees öösel kõhuvalu, korduvalt oksendanud, oksemassid tavapärased, kõht käib läbi. Kõhuvalu kirjeldab rohkem kui "vaev" alakõhus, mis surub põiele. Kaasuvaid haigusi pole teada Varasemad uuringud: Thorax rtg 2013, liigeste rtg.
3 Objektiivne leid Obj. heas üldseisundis, kõhukatted pinges, suurim valu vasakul alakõhus. Blumberg alakõhus positiivne, enim vasakul. Rovsing-, Psoas -. Epigastriumi piirkond valutu. Peristaltika tavapärane, tasane. Kehatemp. 36.3, WBC 12,3, neut 10,1 (83%), CRP <5 mg/l, ALAT/ASAT/GT/Bil/Amyl normis, uriin puhas Alvarado skoor 7/10 (58-88% chance of positive appedncitis)
4 Tellitud UH Appenditsiit? Divertikuliit?
5 Alakõhus piiratud nähtavus, sooled on promineeruva laiusega ja elavnenud peristaltikaga, veenvat appendiksit nende foonil visualiseerida ei õnnestu. Alakõhus soolte vahel on kohati vähest vaba vedelikku.
6 Maks on laterolateraases suunas suurenenud, ulatub vasaku neeru ülapooluseni, põrna visualiseerida ei õnnestu. Parema neeru ülapooluse ja maksa vahel lisastruktuurid - lümfisõlmed? migreerunud lisapõrnad? Soovitan täiendavana KT uuringut.
7
8
9 KT
10 APP
11 APP
12 APP
13 KT leid Kõhuõõne organite asendianomaalia (situs ambigous polüspleeniaga) Maks ja sapipõis keskjoonel Polysplenia (> 10) paremal Magu ja peensool paremal Pankrease pea vasakul IVC vasakul Kogu jämesool vasakul, laienenud Põletikuline appendiks vasakul alakõhus Vähene vaba vedelik
14 Operatsioon Laparoskoopiline apendektoomia. Troakaarid sisestatud paremalt poolt. Esineb soolte malrotatsioon - magu ja peensool on paremal pool kõhus ja suurem osa jämesoolest on vasakul pool kõhus. Apendiks on vasakul pool kõhus peen- ja jämesoole ülemineku kohal, flegmonoosses põletikus. Ei esine normaalset vaba rasvikut. Kõhus on purulentne peritoniit. Postop Postoperatiivne kulg soodne, alates põletikunäitajate osas selge positiivne dünaamika ja patsient lubatud kodusele ravile heas üldseisundis.
15 SITUS ANOMAALIAD
16 Situs solitus Situs ambigous (Heterotaxy) Situs inversus Polysplenia Asplenia Situs inversus totalis (Dextrocardiaga) Situs inversus incompletus (Levocardiaga) Ladina keelest: "situs" - positsioon, lokalisatsioon "solitus" - tavaline "inversus" - tagurpidi, ümberpööratud "ambigous" - ebamäärane, ebakindel, varieeruv
17 Ann S. Fulcher Abdominal manifestations of situs anomalies in adults Radiographics 2002; Situs solitus Situs solitus normaalne organite positsioon parem kops 3 sagaraga, vasak 2 sagaraga südame apex, põrn, magu, aorta vasakul maks, VC paremal Kaasasündinud südamerikked 0,6-0,8%
18 Ann S. Fulcher Abdominal manifestations of situs anomalies in adults Radiographics 2002; Situs inversus Normist peegelpilt Dextrocardiaga (totalis) ~0,01% Levocaridaga (incompletus) ~ % (200 korda haruldasem) Kaasasündinud südamerikked: 3-5% dextrocardiaga, ~100% levocardiaga Seos Kartageneri sündroomiga
19 Kartagener syndrome primaarne tsiliaarne düskineesia Triaad: 1) Situs inversus 2) Sinonasaalne polüpoos/kroonilin e sinusiit 3) Bronhektaasiad ~20% situs inversus patsientidest
20 32 a. mees Situs inversus levocardiaga 1: PERH 05/17 PERH 11/17
21 Situs ambigous Heterotaxy abnormaalne organite positsioon, solituse ja inversuse vahepealne variant, organite duplikatsioon. Esinemissagedus ~1: Ei ole spetsiifilist leidu, asendi anomaaliate erinevad variatsioonid polysplenia asplenia
22 Polysplenia/left isomerism/bilateral leftsidedness Mitu põrna, keskjoone maks, mõlemas kopsus 2 sagarat, alumise õõnesveeni katkenemine. F>M Vähem südamerikkeid (50-90%) ja immunodefitsiiti, parem prognoos Rohkem anatoomilisi/kliinilisi variatsioone Interrupted IVC with Az/HemiAz continuation
23 Asplenia/Right isomerism/bilateral rightsidedness/ivemark syndrome Asplenia (rudimentaarne põrn), keskjoone maks, ipsilateraalne aort ja IVC, mõlemas kopsus 3 sagarat. M>F 99% 100% kaasasündinud südameriked, tsüanoos, immunodefitsiit Kõrge suremus, 1. eluaasta jooksul 80-95% Haruldane täiskasvanutel. Kimberly E Applegate Situs revisited: imaging of the heterotaxy Radiographics 1999
24 Eparterial bronchi (Asplenia) Hyparterial bronchi (Polysplenia) Kimberly E Applegate Situs revisited: imaging of the heterotaxy Radiographics 1999
25 Truncated pancreas pankrease dorsaalne agenees A.Arora "God Loves Variety Even if We Don't" ECR 2013
26 From the Department of Radiology, Section of Pediatric radiology, Cleveland Clinic Childrens Hospital, Ohio. Radiographics 1999
27 From the Department of Radiology, Medical College of Virginia of Virginia Commonwealth University, 401 N 12th St, Rm 3-407B, Richmond Radiographics 2002
28 Situs ambigous Kokkuvõte: Polysplenia > Asplenia Inversuse ja solituse vahepealne variant, varieeruv anatoomia, võib simuleerida teisi haigusi Meie patsiendil: Heterotaaksia sündroom parempoolse polüspleeniaga ja maoga, levokardiaga, vasakpoolse ipsilateraalse alumise õõnesveeniga. UH IVC asend! Edasised uuringud: Ehho, rindkere KT, südame KT/MRT?
29 Kasutatud kirjandus: Ann S. Fulcher, Mary Ann Turnen Abdominal manifestations of situs anomalies in adults Radiographics 2002; 22: Kimberly E Applegate, Marilyn J. Goske, Gregory Pierce, Daniel Murphy Situs revisited: imaging of the heterotaxy Radiographics 1999; 19: A.Arora "God Loves Variety Even if We Don't" ECR viewsection&pi=114841&ti=370421&searchkey=
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