excision of tissue necrosis. Tissue necrosis: types and treatment. Bone necrosis

The term necrosis means the complete death of the cell, with complete damage to the cellular structure. Can cause membrane defects that cause uncontrolled leakage of cell contents into its environment.

Often, infection is the reason for the accumulation of acid metabolism products, which leads to the irreversible destruction of protein structures in the cytoplasm. The final result and reaction of the body is inflammation.

Also, under the influence of necrosis, the cell nucleus is destroyed, and the chromatin contained in it is broken into separate parts. At the same time, the cell membrane begins to shrink. Ultimately, karyolysis occurs - the complete death of the nucleus.

Thus, necrosis describes the breakdown and death of cells seen under a microscope. However, the term itself is most often used to refer to dead tissue, the destruction of which can be seen with the naked eye.

Necrosis consists of several layers. The top layer is firm and has the texture of leather. This is followed by a granular layer, the granules of which do not exceed 0.6 mm. The bottom layer reaches the healthy area while maintaining necrosis.

Dead cells are used as dead tissue, thus providing a good breeding ground for bacteria - due to this feature, the spread of various microbes and pathogens almost always occurs.

Causes of the disease

The main cause is inflammation, which can be triggered by various environmental influences or lack of nutrients and oxygen.

Additional factors include:

• radioactive radiation.
• Colds.
• Toxins.
• Infection with viruses, bacteria, fungi.
• Mechanical impact
• Lack of oxygen.

Depending on which area is affected, a scar will form in that area. In severe stages of necrosis, the dead area dries up completely and dies.

Also, circulatory disorders can be the root cause for the development of tissue necrosis. These factors can trigger the death of individual cells, which can eventually trigger an inflammatory response in the surrounding tissues.

Secondary gangrene can also be caused by bacteria. This is especially true for poorly perfused limbs, the complications of which can also accompany occlusive diseases of the vessels and arteries.

Symptoms

Often, infected areas become red, swollen, and feel warm. Inflammation usually remains around the dying part and thus the patient may feel tense. With the death of bone and joint cells, movement restrictions almost always appear. In many cases, sensitivity in infected areas is reduced.

According to the method of exposure, cell death can be superficial and affect the skin, in more severe cases, damage to internal organs occurs. The outcomes of necrosis are manifested as black and yellow discoloration of tissues.

In case of internal deadness, pains and other associated symptoms occur:

• Heat.
• Chills.
• Dizziness.
• Nausea.

Also, when organs are affected, specific symptoms are revealed that indicate a disease of the corresponding organ. There are also pain symptoms in the infected area.

Less perfused tissue is rapidly damaged, gradually acquiring a bluish tint, which eventually leads to its complete death.

Types of necrosis

Doctors distinguish different forms of necrosis. For example, a severe circulatory disorder, such as peripheral arterial occlusive disease in the leg, can cause gangrene of the toes.

Necrosis refers to various processes that often lead to the destruction and death of cells. Due to this feature, there are different types of disease:

• coagulation type. First of all, it is distinguished by the dark contour of the infected tissue. Within a few days after the onset of necrotic changes, residual stability occurs.
• Colliquation type. Occurs in tissues low in collagen and high in fat, especially in the brain and pancreas.
• fat type. Differs in the destruction of adipose tissue and fat cells. In this type, the collagen structure is corroded in the infected area. It occurs in connective tissue or smooth muscle - especially in autoimmune diseases.
• hemorrhagic type. Causes severe bleeding in the affected area.
• Gangrene. It is a special form of coagulation type. Usually occurs after prolonged or absolute ischemia and is characterized by shrinkage of the tissue, as well as the appearance of a black tint.

Types of infection differ in the main mechanism of tissue necrosis, which is always localized, so it covers only a part of the cells.

Necrosis is an irreversible process of necrosis of the affected tissues of a living organism as a result of external or internal factors. Such a pathological condition is extremely dangerous for a person, fraught with the most serious consequences and requires treatment under the supervision of highly qualified specialists.

Causes of necrosis

Most often lead to the development of necrosis:

• injury, injury, exposure to low or high temperature, radiation;
• exposure to the body of allergens from the external environment or autoimmune antibodies;
• impaired blood flow to tissues or organs;
• pathogenic microorganisms;
• exposure to toxins and certain chemicals;
• non-healing ulcers and bedsores due to impaired innervation and microcirculation.

Classification

There are several classifications of necrotic processes. According to the mechanism of occurrence, the following forms of tissue necrosis are distinguished:

1. Direct (toxic, traumatic).
2. Indirect (ischemic, allergic, trophoneurotic).

1. Colliquation necrosis (necrotic tissue changes are accompanied by edema).
2. Coagulative necrosis (complete dehydration of dead tissue). This group includes the following types of necrosis:
   • caseous necrosis;
   • Zenker's necrosis;
   • fibrinoid necrosis of connective tissue;
   • fat necrosis.
3. Gangrene.
4. Sequester.
5. Heart attack.

Symptoms of the disease

The main symptom of the pathology is the lack of sensitivity in the affected area. With superficial necrosis, the color of the skin changes - at first the skin turns pale, then a bluish tint appears, which can change to green or black.

If the lower extremities are affected, the patient may complain of lameness, convulsions, and trophic ulcers. Necrotic changes in the internal organs lead to a deterioration in the general condition of the patient, the functioning of individual body systems (CNS, digestive, respiratory, etc.)

With colliquation necrosis in the affected area, the process of autolysis is observed - decomposition of tissues under the action of substances secreted by dead cells. As a result of this process, capsules or cysts filled with pus are formed. The most characteristic picture of wet necrosis for tissues rich in fluid. An example of colliquative necrosis is an ischemic stroke of the brain. Diseases accompanied by immunodeficiency (oncological diseases, diabetes mellitus) are considered predisposing factors for the development of the disease.

Coagulative necrosis, as a rule, occurs in tissues that are poor in fluid, but contain a significant amount of protein (liver, adrenal glands, etc.). The affected tissues gradually dry out, decreasing in volume.

• With tuberculosis, syphilis, and some other infectious diseases, necrotic processes are characteristic of internal organs, the affected parts begin to crumble (caseous necrosis).
• With Zenker's necrosis, the skeletal muscles of the abdomen or thighs are affected, the pathological process is usually triggered by pathogens of typhoid or typhus.
• With fat necrosis, irreversible changes in fatty tissue occur as a result of injury or exposure to enzymes of damaged glands (for example, in acute pancreatitis).

Gangrene can affect both individual parts of the body (upper and lower limbs) and internal organs. The main condition is the obligatory connection, direct or indirect, with the external environment. Therefore, gangrenous necrosis affects only those organs that, through the anatomical channels, have access to air. The black color of dead tissues is due to the formation of a chemical compound of iron, hemoglobin and hydrogen sulfide of the environment.

There are several types of gangrene:

• Dry gangrene - mummification of affected tissues, most often develops in the limbs due to frostbite, burns, trophic disorders in diabetes mellitus or atherosclerosis.
• Wet gangrene usually affects the internal organs when infected tissues are infected, has signs of colliquat necrosis.
• Gas gangrene occurs when necrotic tissue is damaged by anaerobic microorganisms. The process is accompanied by the release of gas bubbles, which is felt on palpation of the affected area (symptom of crepitus).

Sequestration most often develops in osteomyelitis, is a fragment of dead tissue, freely located among living tissues.

A heart attack occurs due to a violation of blood circulation in a tissue or organ. The most common forms of the disease are myocardial and cerebral infarction. It differs from other types of necrosis in that necrotic tissues in this pathology are gradually replaced by connective tissue, forming a scar.

Outcome of the disease

In a favorable case for the patient, the necrotic tissue is replaced with bone or connective tissue, and a capsule is formed that limits the affected area. Extremely dangerous necrosis of vital organs (kidneys, pancreas, myocardium, brain), they often lead to death. The prognosis is also unfavorable for purulent fusion of the focus of necrosis, leading to sepsis.

Diagnostics

If there is a suspicion of necrosis of internal organs, the following types of instrumental examination are prescribed:

• CT scan;
• Magnetic resonance imaging;
• radiography;
• radioisotope scanning.

Using these methods, you can determine the exact location and size of the affected area, identify characteristic changes in the structure of tissues to establish an accurate diagnosis, form and stage of the disease.

Superficial necrosis, such as gangrene of the lower extremities, is not difficult to diagnose. The development of this form of the disease can be assumed on the basis of the patient's complaints, cyanotic or black color of the affected area of ​​the body, lack of sensitivity.

Treatment of necrosis

With necrotic changes in tissues, hospitalization in a hospital for further treatment is mandatory. For a successful outcome of the disease, it is necessary to correctly establish its cause and take timely measures to eliminate it.

In most cases, drug therapy is prescribed, aimed at restoring blood flow to the affected tissues or organ, if necessary, antibiotics are administered, and detoxification therapy is performed. Sometimes it is possible to help the patient only by surgery, by amputating part of the limbs or excising dead tissues.

In the case of skin necrosis, traditional medicine can be used quite successfully. In this case, baths from a decoction of chestnut fruits, ointment from lard, slaked lime and oak bark ash are effective.

The cause of tissue necrosis is a malnutrition of a certain tissue area due to trauma or its putrefactive inflammation, and more often the combined effect of both. This happens due to the impact on the cells of mechanical force (ruptures, compression), as well as due to developing infection and high or low temperatures.

Any tissues and organs can become necrotic. The speed and extent of the spread of necrosis is influenced by the ongoing mechanical impact, the addition of infection, as well as the features of the anatomical and physiological structure of the damaged organ.

To begin the manifestation of the development of necrosis, severe pain is characteristic, the skin becomes pale and cold and takes on a marble appearance. There is numbness and sensitivity is lost, the function is disturbed, although its manifestations are possible for some time after ascertaining necrosis. The necrosis begins from the lower sections and gradually spreads to the level of malnutrition, and then a line called "demarcation" is determined on the border of dead and living tissues. The presence of demarcation indicates the possibility of performing an operation - removing the necrotic part along this line or above it. This long-established rule of tactics among surgeons is the only correct one that meets today's ideas.

Therapeutic measures are aimed at maintaining the general condition using active infusion therapy (blood, blood substitutes, antibiotics, vitamins, etc.).

Local treatment consists in removing necrosis within healthy tissues, and the amount of surgical intervention depends on the type of gangrene, which is dry and wet. Dry proceeds favorably, and surgical intervention is indicated when a demarcation line is formed. With wet gangrene, when general manifestations are pronounced, accompanied by severe intoxication, an immediate amputation of the limb is carried out within healthy tissues, that is, above the level of the necrosis border.

It is known that more differentiated tissues are affected much earlier. Therefore, with necrosis of the muscles and skin, the tendons and bones are in a relatively unaffected state. During surgical intervention, it is necessary to take into account this phenomenon and not to remove necrotic areas to the full depth, but to excise only the affected ones (do not excise the bone tissue regardless of the state of viability) with replacement with a full-fledged skin-subcutaneous pedicled flap. Purulent complications should be eliminated by regional infusion of antibiotics.

When unaffected bones and tendons are identified, they are closed with plastic material according to one of the existing methods. In such cases, it is possible to save the segment of the limb and prevent the disability of the victim. There were 11 such patients.

All of them were operated on according to the technique adopted by us, which consisted in catheterization of the main vessel, removal of necrotic soft tissues with replacement of the soft tissue defect with a pedicle flap.

5 of them had damage to the lower leg, two to the foot, one to the forearm, and three to necrosis of the hand.

All patients had a very severe injury with damage to soft tissues and bones, in 2 patients with a closed fracture of the tibia, as a result of improper treatment (a circular plaster bandage was applied), necrosis of the tibia occurred, which required necrectomy of the segment.

One patient admitted 3 days after the injury of the forearm had signs of segment necrosis at the level of the fracture. Another patient has necrosis of the calcaneus and talus, which were removed during the treatment.

Three patients had an open fracture of the lower third of the leg bones with an acute purulent complication and necrosis of the tibia within 10-15 cm.

One patient, whose hand was under pressure, developed soft tissue necrosis of the hand and other injuries. All patients required a non-standard approach to rehabilitation treatment.

Since the degree of damage and affection of the patients under consideration is very diverse, and systematization is difficult, as an illustration, we will give several different types of lesions.

An example would be patient B., aged 26.

While working on the press, the right hand fell under it. The patient was taken to the surgical department of the regional hospital.

It was necessary to take into account the mechanism of formation of a wound around the hand, caused by compression by the press and arising along the edge of its impact. It could be assumed that the soft tissues were so affected that it was impossible to count on their recovery after exposure to a two-ton press. The resulting wound at the level of the wrist joint from the back surface and along the upper groove on the palmar side was sutured tightly, a plaster splint was applied.

Within a few days, the phenomena of necrosis of the damaged area of ​​the hand and signs of severe intoxication were clearly indicated.

She was admitted to the regional hospital from the Central District Hospital, where the amputation of the hand and the formation of a stump were proposed, in a serious condition. The right hand on the rear from the level of the wrist joint, on the palmar surface from the upper palmar groove - necrotic. In the indicated area, the skin is black, hard in places, all types of sensitivity are absent, there is profuse purulent discharge from under the scab and from the wound. When the scab is cut, there is no bleeding, but copious fetid pus is released. The function of the brush is completely broken. Radiography - no bone changes, sowing detritus on the flora and sensitivity to antibiotics.

Diagnosis: severe injury with crushing and necrosis of part of the hand and 2nd, 3rd, 4th, 5th fingers of the right hand.

Operated. The brachial artery was catheterized through a.Collateralis ulnaris superior and infusion of penicillin 20 million units was started. in the infusate.

A day later, rather loosely, in the form of a “glove”, necrotic soft tissues of the hand and fingers were removed. Excised necrotic, already darkened ends of the distal phalanges (Fig. 1).

The tendons of the deep flexors and extensors are sutured over the butt of the treated phalanges.

After excision of necrotic tissues and dressing of the wound of the hand, a skin-subcutaneous-fascial flap was cut out in the area of ​​the chest and abdomen according to the size of the defect of the hand and fingers, which were placed in this flap (Fig. 2).

Four weeks after the operation, the pedicle of the transplanted flap was cut off. Hand after cutting off the feeding leg. After wound healing, the patient was discharged home.

The infusion of antibiotics into the artery continued for 40 days with breaks between surgical interventions for two weeks. Two months after the healing of the wounds, the second finger was formed, and after the healing of the wounds, the patient was discharged and started to work (Fig. 4, 5).

Thus, our tactics with the use of plastic techniques under the guise of a long-term regional administration of antibiotics made it possible to preserve the function of the hand to a certain extent and, most importantly, prevent the disability of a still young woman.

In all patients, the engraftment of the flap occurred, in some with phenomena of marginal necrosis, followed by wound healing on its own, or with the addition of a split skin flap.

A complex subgroup of patients with tissue necrosis were patients with necrosis of more deeply located bone tissue.

The previous experience gained in the treatment of patients with soft tissue necrosis made it possible to reconsider the attitude towards the separation of the necrotic part of the limb, that is, not to carry out its amputation.

It is known from practical surgery and scientific research (M. V. Volkov, V. A. Bizer, 1969; S. S. Tkachenko, 1970; M. V. Volkov, 1974; T. P. Vinogradova, G. I. Lavrishcheva, 1974; I. V. Shumada et al. 1985) that transplanted preserved bone allografts, which initially perform a fixing role, then turn into normal bone, and subsequently perform a stabilizing and functional support role.

The process of restoring the bone to a normal functional state, depending on the properties of the graft, is not the same. In particular, T. P. Vinogradova, G. I. Lavrishcheva (1974) in their fundamental work clearly differentiated the activity of regeneration depending on the characteristics of the graft. The most active in regeneration and effective in the treatment of patients with bone defects is an autograft, in second place is a frozen allograft, and then lyophilized.

These ideas forced us to think about the advisability of using an autograft as a plastic material, and its source should be a non-rejected necrotic fragment in severe open fractures of the long bones of the extremities. This method was used in the treatment of 11 patients with severe injuries of the extremities with purulent complications and necrosis of soft tissues and bones.

An application for an invention has been submitted and a patent has been received for "METHOD FOR THE TREATMENT OF OPEN INFECTED FRACTURES WITH NECROSIS OF SOFT TISSUES AND BONES" No. 2002455, 1995.

inventions. Upon admission, the patient is examined. Conduct clinical, laboratory, bacteriological, functional, radiological and other types of research.

The main artery is catheterized and antibiotics are administered as part of the infusate. After the elimination of inflammation, necrotic soft tissue formations are excised. They provide fixation with the help of author's fixators (extrafocal-compression-distraction or rod devices) or immobilization with a plaster cast.

Bone fragments are processed to create contact - with a transverse fracture in the end part, and with oblique fractures - according to its shape, but ensuring maximum contact of the bone fragments with fixation with the named fixators.

The existing soft tissue defect is replaced with a pedicled flap, for the lower limb, from the opposite leg, and for the upper limb, from the abdominal region.

After the engraftment of the flap, after 30 days from the moment of replacement of the defect, the feeding leg of the flap is cut off. Plaster immobilization or fixation with a compression-distraction apparatus is carried out until complete consolidation.

An illustration of the application of the method can serve as a patient K. 35 years old.

Entered three weeks after an open comminuted fracture of both bones of the right leg in the middle third, with displacement of fragments.

He was treated at the regional hospital. Osteomyelitis of the right leg developed with tissue necrosis and a defect of 6x8 cm with necrosis of the ends of tibial fragments and pin osteomyelitis of the calcaneus as a result of skeletal traction. Phenomena of the general inflammatory reaction.

X-ray showed a spiral comminuted fracture of both bones of the lower leg with displacement of fragments.

Operated. The femoral artery was catheterized through the returning iliac artery. Introduced 10 million units. penicillin. Soft tissue necrectomy. The pointed non-viable ends of the proximal and distal fragments about 1 cm were excised to create supportive congruence. There is no bleeding on the sawdust of the bone on both sides, the bone is white. Fragments taken for research. The ends of the fragments of the tibia are devoid of periosteum about 5 cm above and below, the fragments are pale grayish in color.

The bone fragments were compared end to end and fixed using the Ilizarov apparatus.

Infusion of antibiotics for a week, followed by plasty of the soft tissue defect with covering of exposed fragments of the tibia with a skin-subcutaneous-fascio-muscular flap cut from the opposite leg.

The transplanted flap took root, the pedicle was cut off after 32 days. The Ilizarov apparatus was removed after 2 months. A circular plaster bandage was applied.

X-ray four months after the start of treatment showed that the fragments had grown together. Permissible load on the leg.

Morphological examination of bone tissue taken during excision of fragments.

Morphological picture of the state of viability of bone tissue.

We studied 16 preparations taken from patients with an open complicated fracture of long bones with necrosis of soft tissues and adjacent bone.

Fragments of the proximal and distal fragments of a broken bone were taken. Fixed in 12% neutral formalin solution. After decalcification in a 5% solution of nitric acid and celloidin, sections were made, which were stained with hematoxylin and according to Van Gieson.

Bone tissue is devoid of osteocytes, homogeneous in places, gluing lines are not contoured. Tinctorial properties are sharply violated. Zones of basophilia alternate with areas of oxyphilic coloration. In some places, foci of complete necrosis of bone tissue (melting bone) are visible. The process of osteogenesis is not expressed. Between the areas of necrotic bone in some preparations, the formation of scar tissue is visible, in which lymphoid infiltrates with the presence of plasmocytes are traced.

In connection with the non-standard tactical and surgical decisions, we will dwell in more detail on the discussion of patients in this group.

Two patients were admitted with pronounced necrosis of the lower leg, and necrosis of the forearm - one. There were no doubts about the actions, the plans were to save the knee joint in case of damage to the lower leg and the elbow joint in case of damage to the forearm, which was quite successfully succeeded.

In all patients operated on by the proposed method, bone fragments were consolidated and the function of the leg or arm was restored, depending on the initial damage to the limb. Most importantly, the necrotic bone was not excised. She played the role of an autograft. Thus, the terms of treatment of patients were reduced several times in comparison with traditional methods of treatment, even with the currently recognized most progressive method of bilocal osteosynthesis, with all the possibilities of which it takes at least two years to correct the length of a limb segment with a bone defect of 10 cm.

If you wish to become more familiar with traumatological and orthopedic problems and the possibility of solving them, you can order books reflecting our experience.

Skin necrosis is an irreversible process of death of living cells. It develops after primary damage as a result of which blood circulation is disturbed. The disease is very dangerous and needs to be monitored by doctors. It is worth noting that the disease can be of different types.

Reasons for the development of necrosis

The condition can start after tissue damage in the following ways:

tissue necrosis

• traumatic;
• toxic;
• trophoneurotic;
• infectious-allergic diseases, as a result of which fibroid necrosis may occur;
• vascular.

Traumatic

A typical case of traumatic necrosis due to frostbite, less often can be caused by: burns, injury, electric shock or radioactive radiation. It is expressed in a change in skin color to pale yellow, the tissues are dense to the touch, later vascular thrombosis is formed. In case of damage to large areas of the epidermis, a person may have a fever, decrease appetite, and regular vomiting will appear.

Toxic

It is formed due to the influence of toxins on the epidermis. It is more often formed with syphilis, diphtheria, leprosy. Toxic, epidermal necrolysis may appear as a result of exposure to the skin of medicines, alkalis, acids.

Trophoneurotic

It is provoked by a malfunction of the central nervous system. This type includes bedsores, which manifest themselves as a change in the color of the epidermis, numbness, redness and the appearance of a bubble with liquid, then the process fester.

Allergic

This species can threaten people with allergic reactions. Polypeptide protein injections become irritants.

Vascular

It occurs due to a violation of blood circulation in the arteries, due to blockage of blood vessels. Almost all internal organs can be exposed to this type.

Tissue death can begin after bedsores and non-healing ulcers. Violation of blood microcirculation in tissues can cause a heart attack, diabetes mellitus, injuries of the spinal cord and large vessels

Symptoms

Tissue necrosis begins to manifest itself with numbness of the affected area, its color becomes pale and shiny, which highlights the process that has begun against the background of a healthy epidermis. The process that has begun is easiest to stop and restore blood circulation, if this is not done, then the damaged areas turn blue and then turn black.

Other clinical manifestations include:

• convulsions;
• temperature;
• loss of appetite;
• general weakness;
• lameness
• trophic ulcers.

Before necrosis, the affected cells go through several stages:

1. Paranecrosis is a reversible change, a state in which the cell is in agony.
2. Necrobiosis is a period of cell disease that cannot be changed.
3. Apoptosis is the process of death.
4. Autolysis - decomposition.

Regardless of where the pathology is formed, the patient's internal organs are disrupted: kidneys, liver, lungs. This is due to a decrease in the immune system, metabolic disorders, which lead to hypovitaminosis and exhaustion.

Types of necrosis

Colliquation necrosis

This type is called wet, the affected tissues are flabby with the presence of pathogenic microorganisms in them. In terms of symptoms, it is similar to wet gangrene, the difference of the latter is that tissue liquefaction occurs a second time due to the addition of pyogenic bacteria. Colliquation necrosis develops very quickly, a person has collateral hyperthermia.

coagulative necrosis

This type is called dry and mainly spreads to protein-filled organs: kidneys, adrenal glands, spleen, myocardium.

The state is also divided into the following types:

Gangrene

The foci are black and dark green in color. Depending on the type of infection, it is dry, wet and gas. It is more often observed on the limbs, before its appearance they become inactive, the skin becomes numb and dries, hair falls out. Basically, preliminary diagnoses are atherosclerosis, endarteritis and others. Then the site begins to hurt as long as there are living cells on it, after which the sensitivity completely disappears.

Joint necrosis

In addition to the skin, pathology can affect the articular tissues, mainly the head, which occurs due to a lack of nutrients supplied to it. Causes can be physical trauma, arterial thrombosis, bad habits, and certain medications. The main symptom is the appearance of a sharp pain, the last stage leads a person to disability. A common example of joint necrosis is aseptic necrosis of the femoral head.

heart attack

Ischemic necrosis is the most common form, it becomes a consequence of ischemia. It is formed in the heart muscle, lungs, kidneys, spleen, brain, intestines, etc. Distribution options: the entire organ, part of the organ, can only be seen with a microscope (microinfarction).

Sequester

A sequester is an affected area with pus, located among healthy skin, more often a bone fragment is damaged in osteomyelitis, but may be lung tissue, muscles or tendons.

Hemorrhagic pancreatic necrosis

This is a severe pathology of the pancreas. It develops in the acute stage of pancreatitis or in chronic inflammation of the organ. It is manifested by severe pain in the region of the left rib, can be given to the lower back, chest, shoulder. There is nausea, tachycardia, temperature, red-blue spots form on the sides. With symptoms of pancreatic necrosis, the patient is brought by ambulance to a medical facility.

Diagnosis and treatment of skin necrosis

Superficial necrosis is diagnosed based on the patient's complaints, blood and fluid tests from the affected area.

To recognize the pathology of internal organs appoint:

• x-ray;
• radioisotope scanning;
• computed and magnetic resonance imaging.

When choosing a treatment, doctors take into account the type, form of the disease, stage, as well as the presence of other diseases. Treatment of the skin is carried out under the supervision of an infectious disease specialist, resuscitator and surgeon.

Apply intravenous therapy with penicillin, clindomycin, gentamicin. Appropriate antibiotics are selected according to microbiological data. Conduct infusion therapy and stabilize hemodynamics. The affected parts of the skin are removed surgically.

Treatment of aseptic necrosis of the femoral head

With the destruction of the bone mass, medical and surgical treatment is carried out. Aseptic necrosis of the head of the hip joint requires bed rest and walking with a cane so as not to burden the affected area.

In the treatment used:

1. Vascular drugs (Curantil, Trental, Dipyridamole, etc.)
2. Calcium metabolism regulators (Ksidifon, Fosamax)
3. Calcium with vitamin D and mineral preparations (Vitrum, Osteogenon, Aalfacalcidol)
4. Chondoprotectors (Artra, Don, Elbona)
5. Non-steroidal anti-inflammatory drugs (Ibuprofen, Diclofenac, Naklofen)
6. Muscle relaxants (Mydocalm, Sidralud)
7. B vitamins

All medical devices are selected exclusively by a doctor, self-treatment is unacceptable. If the drugs are not effective, and aseptic necrosis of the femoral head progresses, surgery is performed.

Treatment of hemorrhagic pancreatic necrosis

Treatment takes place in the hospital, mainly in the intensive care unit.

For pain relief, they use: No-shpa, Ketons, Platifillin, Hydrotartate. The removal of pain is also facilitated by the introduction of injections of Novocain, as well as Pomedol with Atropine Sulfate and Diphenhydramine.
Antibiotics are prescribed: Cefalexin, Kanamycin.

Based on the condition of the patient, doctors decide on the operation. Without infection, the patient is given laparoscopic or percutaneous drainage of the peritoneal area. With a large amount of inflammatory fluid, you need to cleanse the blood. In the presence of an infection, part or all of the pancreas is removed.

Complications and preventive measures

The outcomes of necrosis are positive, in the case of enzymatic fusion of lesions and germination of connective tissue, scarring. Complications are purulent fusion, bleeding, sepsis.

If the treatment of necrosis of the head of the hip joint is later, the consequences threaten with disability. For the purpose of prevention, timely treatment of acute chronic diseases, reduction of trauma, strengthening of the vascular and immune systems are carried out.

Lethal outcome is typical for ischemic strokes, myocardial infarctions and other lesions of internal organs.

A normal healthy organism, faced with an attack of pathogenic microbes, launches all kinds of immune reactions designed to cope with pathological particles and protect the body from their aggressive effects. However, in certain cases, this process occurs with violations. In these cases, microbes can cause serious destructive reactions and even death of tissue cells. This process is called necrosis, it can develop as a result of the influence of external or internal factors. This condition is more than dangerous for the body and requires extremely careful treatment under the supervision of qualified professionals.

How does tissue necrosis manifest itself? Symptoms

The main symptom that should alert the patient is a feeling of numbness, as well as the absence of any sensitivity. The skin in the affected area is painted in pale tones, the appearance of deathly pallor and the appearance of waxy skin are recorded. If at this stage no measures are taken to treat pathological processes, in other words, to restore full blood circulation, then the skin will become cyanotic. It will begin to turn black or green rather quickly.

In the event that necrosis, in other words gangrene, threatens the lower extremities, patients complain of a quickly emerging feeling of fatigue while walking. At the same time, the patient's legs are constantly cold, even if the weather is hot outside. Over time, these symptoms are joined by convulsions that develop while walking. They can cause intermittent claudication - at first, a spasm affects one limb, and then it passes to the second. As pathological processes develop, trophic ulcerative lesions appear on the skin, which quickly necrotic. It is after this that gangrene develops directly.

The general deterioration of the patient's body is due to violations of the functional activity of the nervous system, as well as blood circulation. Pathological processes, regardless of the localization of necrosis, adversely affect the functioning of the respiratory system, as well as the kidneys and liver. The patient's immunity is significantly reduced, since the processes of tissue death cause concomitant blood ailments and anemia. There is a disorder of metabolic processes, which leads to exhaustion and hypovitaminosis. Against the background of all this, the patient develops constant overwork.

There are several variants of necrosis, which differ in their manifestations. We have already mentioned gangrene, which is accompanied by the death of the epidermis, as well as the mucous surfaces and muscle tissues.

A heart attack appears as a result of a sudden cessation of blood circulation in the area of ​​\u200b\u200bthe tissue or organ. So ischemic necrosis is the death of a part of some internal organ, for example, a heart attack of the brain, heart, or intestines and other organs.

If the infarction was small, autolytic melting or tissue resorption and repair occurs. However, an unfavorable course of a heart attack is also possible, in which the vital activity of the tissue is disrupted, or complications and even death occur.

Necrosis can also take the form of a sequester, when dead parts of the bone tissue are localized inside the sequester cavity and separated from healthy tissues due to the course of a purulent process, with a disease such as osteomyelitis.

Bedsores are also a type of necrosis. They appear in immobilized patients as a result of prolonged tissue compression or damage to the integrity of the epidermis. In this case, the formation of deep and purulent ulcerative lesions is observed.

What to do to defeat tissue necrosis? Treatment

Therapy of necrosis depends on their type. If the lesion is dry, then the tissues are treated with antiseptics, and dressings based on chlorhexidine or ethyl alcohol are applied to the place of death. The necrosis zone is dried with a five percent solution of potassium permanganate or ordinary brilliant green. Next, the affected non-viable tissues are excised, which is carried out two to three weeks after their clear designation. In this case, the incision is made in the area of ​​viable tissue.

With dry necrosis, the underlying ailment is treated, which helps to somewhat limit the volume of dead tissues. Operational optimization of blood circulation and drug treatment are also carried out, designed to improve blood supply. Antibacterial drugs are taken to prevent secondary infection.

If the necrosis is wet, it is accompanied by the development of infection and a rather severe general intoxication, respectively, the therapy should be radical and energetic. At an early stage of treatment, doctors try to transfer it to dry, but if such attempts do not work, the affected part of the limb is excised.

Local treatment in the treatment of wet necrosis involves washing the wound with a peroxide solution, doctors open the streaks, as well as pockets, and use different drainage techniques. In addition, the imposition of antiseptic dressings is practiced. All patients are subject to mandatory immobilization.
In parallel with local treatment, the patient is given antibiotics, detoxification solutions and vascular therapy.

At the slightest sign of necrosis, you should seek medical help.

Skin necrosis is a dangerous pathology in which part of the tissues in the body dies. Necrosis develops as a result of circulatory disorders, and also due to the fact that viruses and bacteria negatively affect the skin. Several types of necrosis can be defined: toxigenic, traumatic, ischemic, trophoneurotic. It all depends on the characteristics of the structure of tissues, organs. How to properly treat the disease? Is it dangerous?

The reasons

Pathology can develop subsequently, myocardial infarction, and also due to bedsores. The skin is affected due to physical, chemical trauma during allergies. No less dangerous is post-infectious necrosis, bedsores. They appear due to impaired blood circulation, metabolism, if the basic rules of hygiene are not observed by bedridden patients.

Necrosis can develop after an injection, when a large dose of the drug is administered, subsequently, arteriolospasm occurs first, and over time, tissue hypoxia. Is it possible to prevent skin necrosis? In this case, the drug + Novocain is administered. You can also apply cold to the injection site.

Symptoms

To find out in a timely manner about necrosis, computed tomography is performed. The doctor is reinsured, be sure to offer to do a biopsy to determine histological changes.

Attention! Patients with necrosis are examined by a surgeon, resuscitator, infectious disease specialist.

Be sure to carry out intravenous therapy intravenously using Gentamicin, Clindamycin, Penicillin. Additionally, antibacterial drugs are prescribed after microbiological examination, infusion therapy.

Bacterial gangrene develops slowly, so conservative treatments are used first, then the affected skin is removed with surgery. The sooner the disease is diagnosed, the better for the patient.

In addition, the following methods of treatment are necessarily used:

• Treatment of the affected tissue with a solution of potassium permanganate, brilliant green.
• Bandages are applied to the affected skin, which are pre-moistened in Chlorhexidine, Ethyl alcohol.

To cure dry necrosis, the cause is first eliminated, special medicines are used, an operation is performed, during which blood circulation is restored.

If the patient has wet necrosis, a slightly different treatment is prescribed:

• local procedures.
• Wounds are treated with Hydrogen Peroxide.
• Edema drains.
• Antiseptic dressings are used.
• Gypsum tires are used.

Medicines are used to prevent intoxication of the body. To get rid of pain, anti-inflammatory drugs are prescribed. With the help of the drug, the muscles relax, so blood flow can be restored. In this case, Diclofenac, Nimulid, Ketoprofen are prescribed.

To improve blood circulation, you need to take vasodilator drugs. Attention! Be extremely careful with these medicines if you have previously suffered a heart attack, stroke.

If necrosis affects the bone tissue, chondroprotectors are prescribed. With their help, cartilage tissue can be restored. Medicines must be taken at a late stage of the disease. The non-traditional method of treatment with leeches is excellent. Due to the fact that leeches release enzymes into the body, blood circulation improves.

With necrosis, massage is indispensable. The main thing is that it should not be rude, not lead to discomfort, pain, otherwise the state of health will worsen. The complex therapy includes ozocerite, laser, mud treatment. These methods do an excellent job with necrosis of the hip joint.

On a note! So that the muscles do not atrophy, you need to perform a special set of exercises, after consulting with your doctor.

So, necrosis is quite common. As a rule, it is very difficult to save a person, because everything ends with gangrene, sepsis and other unpleasant consequences. Take care of your health!

It is accompanied by a large detachment of skin-fat flaps, which leads to a deterioration in blood supply.

The skin of the anterior abdominal wall is supplied from four sources:

• arteries that go from below - the lower epigastric arteries, which are crossed during the incision;
• perforating arteries that pass through the muscles of the anterior abdominal wall and supply blood to the skin;
• branches of the intercostal arteries that supply the skin of the anterior abdominal wall from above and from the side.
• branches from the basin of the internal thoracic artery.

Of the three sources of blood supply, two - the lower epigastric arteries and the perforating arteries, we cross during the abdominoplasty operation.

The skin flap exfoliates widely, from the side - to the anterior axillary line, at the top - to the edge of the costal arch. Considering that most of the arteries that take the main part in the blood supply intersect, the risk of developing irreversible ischemia is quite high.

Rough work with tissues, excessive detachment of the skin-fat flap, when the surgeon tries to stretch the skin as much as possible, can lead to necrosis of the skin-fat flap.

Manifestation of necrosis

1. Darkening of the skin in the area of ​​poor blood supply - ischemia.

The degree of ischemia can vary from mild, when the skin is slightly red, to severe, when the skin is brown or maroon.

The greatest risk zone for development is the area of ​​the lower abdomen. In this area, the skin experiences the greatest tension and is the furthest area of ​​​​the skin from sources of blood supply.

2. Soreness, swelling.

When developed, there is pain in this area. The pain intensifies, swelling appears.

3. In some cases, when the zone of ischemia and necrosis is large enough, the temperature may rise, the general condition worsens.

Usually, the ischemia zone is small, about the size of a 5 ruble coin. It usually goes away on its own.

Causes of necrosis

1. Too wide aggressive detachment, with the intersection of a large number of vessels.

This is the most common reason. Therefore, the surgeon must understand to what extent he can exfoliate the skin without risking worsening the blood supply to the flap.

2. Excessive tension.

Strong tension on the edges of the wound leads to squeezing of the vessels and deterioration of the blood supply. Therefore, the tension of the skin-fat flap should be moderate, and the patient should walk with a slight stoop in the early postoperative period to minimize tension on the flap.

3. The presence of scars in the skin of the anterior abdominal wall.

For example, a scar after cholecystectomy in the right hypochondrium. During the operation, the skin, muscles are dissected in an open way, and one of the sources of blood supply is crossed.

When performing abdominoplasty, the presence of such a scar can also cause necrosis of the underlying skin.

4. The thickness of the subcutaneous fat.

If the subcutaneous fat is more than 5 cm, then the risk of necrosis increases. The thicker the subcutaneous fat, the higher the risk of skin necrosis.

Treatment of necrosis

Treatment of necrosis of the anterior abdominal wall should be comprehensive.

It includes both medical therapy and surgical treatment.

At the first stage, drugs are prescribed that help improve blood rheology, to improve and restore blood circulation.

For this, the following drugs are used: actovegin, which improves oxygen absorption and improves tissue metabolism, trental, which improves blood rheology, aspirin, as an anticoagulant, the use of hirudotherapy gives a very good effect.

Leeches remove stagnant blood in the area of ​​ischemia, freeing blood vessels for further blood flow. In addition, they secrete the substance hirudin, which for a sufficiently long period of time does not allow blood to clot, thus improving blood circulation.

If the stage of drug treatment does not bring success, or success is limited, then one has to resort to surgical treatment, i.e. excision of dead skin.

The skin is excised, adaptive sutures are applied, which tighten the skin in the wound area, preventing it from dispersing, and then the wound is treated as purulent, with regular dressings with water-soluble ointments.

After cleansing the wound from necrotic areas of subcutaneous fat and the appearance of granulations, secondary sutures are applied.

The treatment of necrosis is quite complex, painstaking, lengthy, requiring both the patient and the doctor a lot of strength and energy.

The larger the area of ​​necrosis, the longer the treatment expects the patient.

Prevention of necrosis

1. Reasonable and neat detachment. This is a guarantee that the blood supply to the skin-fat flap will be good.

If white spots appear when the skin is stretched, this indicates that the tension is excessive and, as a result, there will be a violation of the blood supply.

Consequences for health and aesthetic result

It is important to note that such a complication affects not only the aesthetic result of the operation, there is a certain risk for the patient's health as well.

Extensive necrosis of the skin of the anterior abdominal wall is actually its defect.

If this defect is 5 mm, this is one thing, if the defect is 5 or 15 cm, then this is a completely different matter. It turns out a large non-healing wound, which, after cleansing, requires plasty with a free skin flap, or some other measures to close it. Large areas of necrosis worsen the general condition of the patient.

As for the aesthetic result of the operation, even a small necrosis always leads to the formation of a rough scar, which then has to be treated: excised, polished, etc.

If the scar is small, then it is easy to correct it.

A large scar will lead to cicatricial deformation of the skin and an ugly aesthetic appearance. In addition, a large, rough scar can limit mobility due to poor extensibility.

Trophic ulcer- this is a long-term non-healing defect of integumentary tissues on a pathological basis (with possible involvement of deeper tissues).

Reasons for the development of trophic ulcers:

1) Arterial inflow disorders:

• obliterating atherosclerosis.
• Obliterating endarteritis.
• Aortoarteritis.
• Thrombosis, embolism, vascular damage.
• Raynaud's disease (angiospasm).
• Arterio-venous shunts.

2) Violations of the venous outflow:

• Varicose veins of the lower extremities.
• Acute and chronic superficial and deep thrombophlebitis.
• Post-thrombophlebitic syndrome.
• congenital anomalies.

3) Lymph outflow disorders:

• Consequence of recurrent erysipelas.
• Elephantiasis.
• congenital anomalies.

4) Diseases of the nervous system:

• CNS - syringomyelia, poliomyelitis, tumors of the brain and spinal cord, stroke.
• PNS - paresis, paralysis, neuritis.

5) Specific infection:

• Tuberculosis.
• Leprosy (leprosy).
• Helicobacter infection.
• Syphilis.
• Actinomycosis.
• Anthrax, brucellosis, etc.

6) Decaying Tumors(for example, ulcerative form of cancer, etc.)

7) Traumatic lesions:

• Burns - thermal, chemical, radiation, electrical burns.
• Extensive wounds with large necrosis of integumentary tissues.

8) Systemic diseases:

• Scleroderma.
• Systemic lupus erythematosus.

9) Violations of metabolic processes:

• Disorders of hormonal metabolism: diabetes mellitus, Itsenko-Cushing's disease and syndrome.
• Hypo- and beriberi (for example: scurvy), hypo- and dysproteinemia, alimentary dystrophy.
• Severe anemia and other blood diseases.

Clinic

The ulcerative process is characterized by the simultaneous presence of processes of necrosis and tissue regeneration in the focus.

Skin ulcers are characterized by high polymorphism, are less complicated by secondary infection and are not exposed to the action of enzymes.

Mucosal ulcers are under the continuous influence of enzymes and various microflora, which creates conditions for their slow healing.

When examining the ulcer, pay attention to:

one). The shape of the ulcer: round, oval, stellate.

2). Localization: skin or mucous membranes, on which part of the body.

3). Dimensions (in centimeters).

four). Depth: superficial, deep, crater-like.

5). The edges of the ulcer: thinned, even, uneven, undermined, thickened, callused (calls).

6). The nature of the discharge: serous, purulent, hemorrhagic, etc.

7). The severity of necrotic processes.

eight). The presence of granulations and epithelialization.

The clinic of ulcers depends on the disease that led to the formation of the ulcer:

• With atherosclerosis ulcers are usually located on the lower leg and foot, they are small, rounded, pale granulations, the edges of the ulcer are dense, uneven. Clinically, this determines the weakening of the pulsation of the main vessels of the legs.
• With varicose veins ulcers are usually located in the lower third of the lower leg, in the region of the inner ankle, large, deep, slightly painful on palpation, the skin around them is sclerotic, pigmented. Clinically, varicose veins are found.
• With post-thrombophlebitic syndrome ulcers are also located in the lower third of the lower leg, in the region of the inner ankle, but they are usually larger in size (may cover the entire circumference of the lower leg). Ulcers are usually superficial with flat edges, around it there is pronounced edema and tissue sclerosis (indurated cellulitis).
• Radiation ulcers- deep (sometimes reaching the bones), rounded, with jagged edges, the skin around them is atrophic. The formation of radiation ulcers is usually preceded by certain skin changes: pigmentation, telangiectasia, ear prolapse, gradual skin atrophy and sclerosis of the subcutaneous fatty tissue.
• With ulceration of the tumor - the ulcer has dense, thickened, bumpy, uneven edges, the bottom is covered with necrotic tissues. Around the ulcer are often visible areas of tumor growth or dense, soldered to the surrounding tissues, infiltrate.

Differential Diagnosis

carried out with wounds, because they also have a defect in the integumentary tissues. However, wounds heal in no more than 2 months. If this does not happen, then regeneration slows down sharply and the process is commonly called a trophic ulcer.

In addition, long-standing ulcers with callused edges (calles ulcers) are prone to malignancy, so it is recommended to take a biopsy of several pieces of tissue and send it for histological examination.

trophic ulcers should be comprehensive and consist of general and local activities.

one). General treatment :

It is aimed at eliminating the causes that led to the emergence and development of trophic ulcers. If the root cause is not eliminated, then ulcers can form in the same place after 1-2 months. Since the causes are different, there is no single treatment regimen for trophic ulcers. However, always apply:

• Bed rest and immobilization the affected part of the body.
• Antibiotic therapy. Intra-arterial and endolymphatic administration is widely used.
• Detox Therapy- saline and detox solutions (hemodez) are used.
• Immunostimulating therapy(T-activin, thymalin, prodigiosan, levamisole).
• Vitamin therapy, good nutrition, normalization of metabolic processes(retabolil, methyluracil).
• Improvement of blood circulation in the area of ​​trophic ulcers (reopoliglyukin, detralex, etc.).
• And most importantly, the underlying disease is being treated, which led to the development of an ulcer.

2). Local treatment

consists of 2 stages:

• Clearing the ulcer of necrotic tissue and suppressing infection. For this, staged necrectomy, dressings with antiseptics (chlorhexidine, miramistin, lavacept), proteolytic enzymes (trypsin), sorbents (polyphepan), as well as special dressing napkins with impregnation (Activtex, etc.) are used. The skin around the ulcer is treated with alcohol or iodine (to prevent infection). Physiotherapy (quartz, electrophoresis with trypsin, magnetotherapy), HBO, ozone therapy, vacuum therapy are successfully used. Some authors do not recommend the use of ointment dressings for the cleansing of trophic ulcers, however, good results have been obtained with the use of Iruxol ointment, which has an aetibacterial and necrolytic effect.
• Defect closure. With small ulcers, after its cleansing and the development of granulations, independent epithelialization occurs. In this phase, you can use wet-drying dressings with antiseptics, as well as ointments that stimulate epithelialization (actovegin, solcoseryl, methyluracil). For small ulcers (less than 1 cm), it can be “cauterized” with a solution of brilliant green or potassium permanganate - then the ulcer will heal under the scab. For venous ulcers, an occlusive zinc-gelatin dressing with Unna paste can be used, which is applied for 1-2 months.

Surgical treatment is used when attempts to close the defect in a conservative way are ineffective, and includes two points:

• Excision of pathologically altered granulations and scars.
• Plastic closure of a tissue defect with skin: excision of an ulcer with plasty with local tissues, plasty with a “pedunculated” skin flap (Filatov’s method) or free skin plasty is used.

A fistula is a pathological passage in tissues that connects an organ, a natural or pathological cavity with the external environment, or organs (cavities) with each other.

Classification

one). Origin:

• Congenital(malformations) - median and lateral fistulas of the neck, fistulas of the navel, etc.
• Acquired:

Caused by the inflammatory process (fistulas with osteomyelitis, paraproctitis, tuberculosis, etc.). When foreign bodies (ligatures) are infected, so-called ligature fistulas.

caused by trauma.

Caused by the decay of the tumor (for example, with ulcerative cancer).

Created in an operative way ( artificial fistulas) - stomas or interorgan anastomoses.

2). In relation to the external environment:

• External - communicate an organ, cavity or tissue with the external environment (for example, intestinal fistula).
• Internal - report 2 hollow organs, or an organ with a cavity (natural or pathological).

3). According to the lining of the fistulous passage, there are:

• Granulating The walls are covered with granulation tissue. They are usually pathological. Self-healing is hindered by the presence of “aggressive” discharge (pus, digestive juices, mucus, etc.).
• Epithelized (tubular) - walls are lined with epithelium. They are usually congenital. At the same time, regeneration is completed and there is no tissue defect. That is why it is impossible to spontaneously close it.
• labial- the epithelium of the mucous membrane of a hollow organ passes directly to the skin. They are usually artificial. Lip-shaped fistulas are complete (all contents are brought out) and incomplete (part of the contents passes through the organ, and the other part is taken out). A labial fistula can only be created or healed by surgery.

four). By the nature of the separated:

• Purulent (with purulent diseases - osteomyelitis, paraproctitis).
• Fecal (cecostoma, colostomy, transversostomy, sigmostoma, ileostomy, etc.).
• Urinary (epicystostomy, pyelostomy).
• Bile (cholecystostomy).
• Mucous membranes (tracheostomy).
• Salivary, cerebrospinal fluid, etc. - are very rare.

5). According to the organs and cavities that the acquired fistula connects:

• Tracheoesophageal.
• Biliary-pleural.
• Vesicouterine
• Vaginal-rectal, etc.

6). Artificial fistulas are divided into:

• Stoma, communicating the body with the external environment and serving to relieve the body when it is impossible to empty it normally.
• Interorgan anastomoses- imposed to restore disturbed anatomical relationships after resection of the organ.

7). Depending on the reasons that forced the imposition of an artificial fistula, there are:

• Permanent fistulas- imposed if the disease is incurable.
• Temporary fistulas- they are created granulating with the expectation that they will subsequently heal on their own.

eight). By difficulty:

simple and complex (4 degrees of complexity of the structure),

The clinical picture and discharge depends on the type of fistula.

one). outer hole usually does not exceed a few centimeters.

2). The discharge is different - pus, feces, urine, mucus, bile, etc.

3). The condition of the surrounding tissues depends on the type of discharge:

• With gastric and duodenal fistula - the skin around the hole is inflamed (dermatitis).
• With urinary fistula - there is a seal and swelling of the surrounding tissues.

four). Violation of the general condition: with purulent fistulas, there is an increase in temperature and symptoms of intoxication, which increases with difficulty in the outflow of pus. It is also possible secondary infection through the fistula.

5). Dysfunction of internal organs- for example, with a gastrostomy and ileostomy, a violation of the water-salt and protein balance develops (due to the loss of digestive juices). Pronounced violations of the function of the organs are caused by the leakage into their cavity of a secret that is not characteristic of this organ (for example: the leakage of food into the bronchus, or the entry of feces into the bladder).

6). Flow dynamics: granulating fistulas can heal on their own if the outflow of discharge through them stops. Surgery is necessary to close epithelialized and labial fistulas.

7). Additional methods for diagnosing fistulas:

• Probing the fistula - in some cases, it makes it possible to determine the direction of its course.
• Fistulography - a radiopaque substance (verografin, omnipack) is injected into the fistula and an x-ray is taken in 2 projections.
• After the injection of contrast, an ultrasound can be performed.
• If fistulas of internal organs are suspected, contrast radiography with a barium suspension is used, which is injected into the lumen of the desired organ.
• Examination of a discharged fistula for the presence of certain substances by which the affected organ can be identified (for example, the presence of uric acid is characteristic of a urinary fistula).
• With fistulas of hollow organs, a dye can be introduced into the fistula (brilliant green, methylene blue - mixed with hydrogen peroxide). In this case, the dye may appear in the contents of the organ.
• Sometimes you can apply endoscopic examination (EGD, colonoscopy, etc.).
• In a blood test with long-term purulent fistulas, inflammatory changes can be detected; in the analysis of urine - signs of amyloidosis (i.e. proteinuria, etc.).

However, despite this, sometimes the diagnosis of fistulas (especially internal) is made only during surgery.

If the fistula is combined with signs of inflammation, general treatment is carried out:

one). Antibiotic therapy.

2). Detoxification therapy - in the presence of intoxication.

3). Fortifying agents - vitamins, methyluracil, retabolil.

Local treatment depends on the type of fistula:

• With granulating fistulas it is necessary to achieve cleansing of the channel and prevent the expiration of the contents. To do this, the pathological focus is drained, creating a shorter and wider outflow path. The fistulous passage is washed daily with antiseptics, after which it heals. In rare cases, with flaccid granulations, it is necessary to excise them and the cicatricial-altered walls of the fistulous tract and suture them.
• With epithelized fistulas the only method of treatment is surgery: after staining the fistula with a mixture of methylene blue and hydrogen peroxide, the entire epithelial lining of the fistulous tract is removed and the wound is sutured.
• For labial fistulas the organ wall is mobilized and the hole in it is sutured. After that, the fistulous tract is removed and the wound is sutured. With cicatricial changes in the walls of the organ, it is necessary to perform its resection.

Care for artificial (labial) fistulas:

• With fecal fistulas - special colostomy bags are used, which are attached to the stomach like a belt. Sometimes (with incomplete fistulas) special obturators are used that close the external opening without preventing the chyme from moving through the intestine.
• With urinary or biliary fistulas (epicistostomy, cholecystostomy) - drainage of the fistula is used with the discharge of the discharge into the bottle.

The skin around the fistulas of hollow organs, in order to prevent its irritation, must be treated daily with Lassar paste, silicone pastes, a polymerizing film or an indifferent ointment.

Necrosis is the death of tissues, organs or their parts in a living organism. Necrosis is a pathological process, it should be distinguished from the physiological renewal of body cells.

Gangrene is a special type of necrosis, which is characterized by certain signs:

• The tissues have a characteristic black color with a greenish tint, which is associated with the decomposition of hemoglobin upon contact with air.
• That is why only organs that are connected with the external environment (limbs, lungs, gallbladder, intestines, etc.) are affected. In this regard, there is no gangrene of the brain, liver, pancreas.
• The whole organ or a large part of it is affected. There is no gangrene of a limited part of the body (for example, the dorsum of the middle phalanx of the finger).

Etiology of necrosis

According to the etiology, all necoses can be divided into 2 groups:

one). Direct necrosis- occur at the site of exposure to an external factor (mechanical, thermal, chemical, etc.).

2). Indirect necrosis(circulatory) - arise in connection with malnutrition of cells in a living organism. For their occurrence, the influence of an external factor on a certain area of ​​​​the body is not necessary.

Causes of circulatory necrosis:

• Violation of arterial inflow (atherosclerosis, thrombosis, etc.).
• Violation of the venous outflow or lymphatic outflow (varicose veins, elephantiasis, etc.).
• Violation of microcirculation (diabetic microangiopathy, systemic vasculitis, bedsores).
• Violation of innervation (nerve damage, polyneuropathy, etc.).

All necrosis can be divided into dry and wet:

Dry necrosis It is formed with a chronic violation of the blood supply to a limited area of ​​\u200b\u200btissues. Usually these are patients with underdeveloped subcutaneous tissue. Necrosis develops according to the type of coagulation.

Wet necrosis are formed in acute violation of the blood supply to a large volume of tissues (thrombosis of the main vessel). Usually these are patients with well-developed subcutaneous tissue, suffering from concomitant diseases and decreased immunity. An important factor is the accession of infection. Necrosis develops according to the type of colliquation, it is deeper than coagulation.

The clinic of dry and wet necrosis is very different:

Dry necrosis can turn into wet and vice versa.

Treatment of dry necrosis (gangrene)

It is aimed at reducing the zone of necrotic tissues and maximizing the preservation of the organ.

one). General treatment:

• Etiotropic therapy- it is necessary to urgently act on the cause of necrosis: for example, in case of arterial thrombosis, it is necessary to urgently perform thrombectomy or other surgery, etc.
• Vascular Therapy- is aimed at improving blood circulation in the affected area and “removing” the necrosis zone to the periphery. The emphasis is on the intra-arterial administration of drugs (rheopolyglucin, trental, heparin, actovegin, etc.)
• Antibiotic therapy- to prevent the attachment of infection and the transition of necrosis to wet.

2). Local treatment:

• Infection prevention: the skin around the necrosis is treated with alcohol, boric acid, chlorhexidine, miramistin or other antiseptics.
• Drying fabrics: the necrosis zone is “cauterized” with a solution of brilliant green or potassium permanganate.
• After the formation of a line of demarcation lines (usually in 2-3 weeks), an economical necrectomy or amputation. The incision line should pass in the zone of healthy tissues, as close as possible to the demarcation line.

Treatment of wet necrosis (gangrene)

one). General treatment :

• Antibiotic therapy- prescribe 2 antibiotics and metrogil, which are administered intravenously, intramuscularly, and (mandatory) - intra-arterially (by puncture or catheterization of arteries).
• Intensive Vascular Therapy(reopoliglyukin, novocaine, actovegin, trental, heparin, nicotinic acid, detralex, etc.).
• Detox Therapy- hemodez, polyglucin, extracorporeal detoxification methods - hemosorption, ultraviolet and laser blood irradiation, electrochemical blood oxidation (intra-arterial administration of sodium hypochlorite). HBO is widely used.
• Correction of impaired functions of organs.

2). Local treatment:

In the early stages, in the absence of an immediate threat to life, attempt to convert wet necrosis to dry. To do this, at each dressing, the wound is washed with hydrogen peroxide, purulent streaks are opened and drained, necrectomy is performed and dressings are applied with antiseptics (chlorhexidine dioxidine, miramistin) and proteolytic enzymes (trypsin). You can use "cauterizing" antiseptics (potassium permanganate). Most surgeons do not recommend using ointments in this period.

With a successful effect (which happens quite rarely), dry necrosis is treated.

If the edema does not subside within 1-2 days against the background of local and general treatment, inflammation does not subside, the process spreads further, intoxication persists or progresses, this is an indication for an emergency life-saving operation.

The operation consists in the removal of necrotic tissues or organs within known healthy tissues. Amputations are performed, retreating some distance from the necrosis zone. More precisely, the level of amputation can be selected based on the data of functional tests and instrumental research methods: dopplerography, rheovasography, thermography, angioscintigraphy, polarography, etc.

bedsores

A bedsore is a soft tissue necrosis that develops when they are compressed as a result of circulatory disorders. In this case, soft tissues are compressed between the bony protrusions of the body and the bed ( exogenous bedsores). Bedsores are more common in debilitated patients (sepsis, cancer, chronic debilitating diseases) who lie in bed for a long time without movement. Sometimes bedsores occur even due to slight compression as a result of severe neurotrophic tissue changes ( endogenous bedsores).

The most common localization of bedsores: on the shoulder blades, sacrum, occiput, heels, greater trochanter, elbows. Sometimes bedsores are also formed in the internal organs (gall bladder, intestines, trachea) as a result of pressure on their wall (stones, drains, etc.). Sometimes bedsores are formed from tissue compression with a plaster cast, transport tire or tourniquet.

The following factors predispose to the development of bedsores:

• Disturbance of blood circulation in tissues due to compression of blood vessels.
• Violation of innervation (for example: with a spinal cord injury).
• Infection - often bedsores form with fecal fistulas, when there is constant irritation and infection of the skin.

one). The first signs of the development of a bedsore are symptoms of local circulatory disorders: pallor of the skin, and then - cyanosis.

2). Then there is swelling of the skin, detachment of the epidermis and the formation of small or large blisters filled with hemorrhagic contents.

3). Soon the blisters burst, leaving behind ulcerative surfaces of red or purple color.

four). At the site of ulcers, necrosis develops, which spreads to the entire depth of the tissues (sometimes reaching the bone), as well as in width. The size of necrosis sometimes reaches ten centimeters. Necrosis may be dry (in the absence of infection) or wet (in the presence of infection).

The period of development of bedsores can vary from 1 to several days.

one). General treatment is aimed at eliminating predisposing factors (treatment of sepsis, normalization of blood circulation and innervation in the focus, vitamin therapy, etc.).

2). Local treatment consists in staged necrectomy, which is performed both surgically and chemically (proteolytic enzymes). After removing all necrotic tissues and cleansing the wound surface, the wound is treated with ointments that accelerate regeneration and epithelization (sorcoseryl, actovegin).

Prevention

one). Proper patient care

• Periodically turn patients in bed.
• Place inflatable rubber circles under the bone protrusions.
• Eliminate wrinkles in bed linen.
• The skin in the places of the most frequent formation of bedsores 2 r / d is wiped with a solution of camphor or salicylic alcohol, cologne and sprinkled with talc.
• A thorough toilet of patients with dysfunction of the pelvic organs and external fistulas is necessary.

2). Drains should be removed on time.

3). In the treatment of fractures with a plaster bandage, constant monitoring of the patient is necessary - if pain occurs, the bandage should be removed.

four). If necessary, prolonged mechanical ventilation is carried out not through an endotracheal tube, but a tracheostomy is applied.