ÓÄÊ 616.33-002.44/.446:617-089-022]-084 À.À. ÌÀÐ×ÅÍÊÎ, À.Ã. ÑÎÍÈÑ, È.Í. ÞÐ×ÅÍÊÎ Ñàìàðñêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò ÏÐÎÔÈËÀÊÒÈÊÀ ÑÈÍÄÐÎÌÀ ÎÑÒÐÎÃÎ ÏÎÂÐÅÆÄÅÍÈß ÆÅËÓÄÊÀ Ó ÏÀÖÈÅÍÒΠÃÍÎÉÍÎ-ÕÈÐÓÐÃÈ×ÅÑÊÎÃÎ ÑÒÀÖÈÎÍÀÐÀ  ñòàòüå ïðèâåäåí àíàëèç ëèòåðàòóðíûõ äàííûõ ïî ôàêòîðàì ðèñêà ðàçâèòèÿ îñòðûõ ýðîçèâíî-ÿçâåííûõ ïîâðåæäåíèé âåðõíèõ îòäåëîâ æåëóäî÷íî-êèøå÷íîãî òðàêòà ó áîëüíûõ ãíîéíî-õèðóðãè÷åñêîãî ñòàöèîíàðà. Ïðåäñòàâëåíû ðåçóëüòàòû ñîáñòâåííûõ èññëåäîâàíèé äàííîé ïðîáëåìû. Êëþ÷åâûå ñëîâà: ñòðåññîâûå ÿçâû, ñèíäðîì îñòðîãî ïîâðåæäåíèÿ æåëóäêà, æåëóäî÷íîå êðîâîòå÷åíèå, õèðóðãè÷åñêàÿ èíôåêöèÿ Ìàð÷åíêî Àíòîí Àëåêñàíäðîâè÷ - âðà÷-õèðóðã õèðóðãè÷åñêîãî îòäåëåíèÿ ¹2 êëèíèêè ïðîïåäåâòè÷åñêîé õèðóðãèè Êëèíèê ÑàìÃÌÓ, àññèñòåíò êàôåäðû îáùåé õèðóðãèè, âðà÷ýíäîñêîïèñò ýíäîñêîïè÷åñêîãî îòäåëåíèÿ Êëèíèê ÑàìÃÌÓ. E-mail: a.a.marchenko1985@yandex.ru Ñîíèñ Àëåêñàíäð Ãðèãîðüåâè÷ - ä.ì.í., äîöåíò, çàâåäóþùèé êàôåäðîé îáùåé õèðóðãèè. E-mail: sonis_ag@mail.ru Þð÷åíêî Èðèíà Íèêîëàåâíà - ê.ì.í., çàâåäóþùàÿ ýíäîñêîïè÷åñêèì îòäåëåíèåì Êëèíèê ÑàìÃÌÓ, äîöåíò êàôåäðû ôàêóëüòåòñêîé òåðàïèè. E-mail: in-samendo@mail.ru A.A. MARCHENKO, A.G. SONIS, I.N. YURCHENKO Samara State Medical University PREVENTION OF SYNDROME OF ACUTE LESION OF THE STOMACH IN PATIENTS OF PURULENT SURGICAL DEPARTMENT The article presents the analysis of published data on the risk factors for development of acute erosive-ulcerative lesions of the upper gastrointestinal tract in patients of purulent surgical department. The results of the own research of this problem are presented. Keywords: stress ulcers, syndrome of acute lesion of the stomach, gastric bleeding, surgical infection Anton Marchenko - surgeon of the Surgical Department ¹2 of propaedeutic surgery clinic of SSMU, assistant at the Department of General surgery, endoscopist of the Endoscopic Department of SSMU Clinics, E-mail: a.a.marchenko1985@yandex.ru Alexandr Sonis - doctor of Medical Sciences, Professor, Head of the Department of General surgery, E-mail: sonis_ag@mail.ru Irina Yurchenko - candidate of Medical Sciences, Head of the Endoscopy Department of SSMU Clinics, associate professor at the Department of faculty therapy, E-mail: in-samendo@mail.ru Ñèíäðîì îñòðîãî ïîâðåæäåíèÿ æåëóäêà (ÑÎÆÏ) – ýòî ïîâðåæäåíèå ñëèçèñòîé îáîëî÷êè æåëóäêà è äâåíàäöàòèïåðñòíîé êèøêè (ÄÏÊ), âîçíèêàþùåå ïðè íàðóøåíèè ôàêòîðîâ çàùèòû ó áîëüíûõ, íàõîäÿùèõñÿ â êðèòè÷åñêèõ ñîñòîÿíèÿõ [2]. Äëÿ ïàöèåíòîâ, íå íàõîäÿùèõñÿ â êðèòè÷åñêèõ ñîñòîÿíèÿõ, ïðèíÿò òåðìèí «ñòðåññîâûå ÿçâû».  ïîñëåäíåå âðåìÿ îòìå÷àåòñÿ ïîñòåïåííîå ñëèÿíèå óêàçàííûõ òåðìèíîâ. Äëÿ äàííîé ïàòîëîãèè òèïè÷íî áûñòðîå, â òå÷åíèå íåñêîëüêèõ äíåé è äàæå ÷àñîâ, èõ âîçíèêíîâåíèå è ñòîëü æå áûñòðîå çàæèâëåíèå ïîñëå óñòðàíåíèÿ ýòèîëîãè÷åñêèõ ôàêòîðîâ, à òàêæå íåòèïè÷íàÿ êëèíè÷åñêàÿ êàðòèíà (ñòåðòîñòü áîëåâîãî ñèíäðîìà, îòñóòñòâèå ñåçîíí îñòè è ò.ä.). Íàèáîëåå îïàñíûì è ÷àñòûì îñëîæíåíèåì ÑÎÆÏ ÿâëÿþòñÿ æåëóäî÷íî-êèøå÷íûå êðîâîòå÷åíèÿ, ëåòàëüíîñòü ïðè êîòîðûõ äîñòèãàåò 5% [3, 4, 5, 8, 9,10]. Öåëü èññëåäîâàíèÿ: óñòàíîâèòü íàèáîëåå ÷àñòûå ïðè÷èíû ðàçâèòèÿ æåëóäî÷íî-êèøå÷íûõ êðîâîòå÷åíèé ó ïàöèåíòîâ îòäåëåíèÿ ãíîéíîé õèðóðãèè è âíåäðèòü â ïðàêòèêó ìåðû ïðîôèëàêòèêè ÑÎÆÏ. Ìàòåðèàëû è ìåòîäû Çà 2010–2012 ãîäû âûïîëíåí ðåòðîñïåêòèâíûé àíàëèç èñòîðèé áîëåçíè ïàöèåíòîâ, íàõîäèâøèõñÿ íà ëå÷åíèè â îòäåëåíèè ïðîïåäåâòè÷åñêîé õèðóðãèè Êëèíèê Ñàìàðñêîãî ãîñóäàðñòâåííîãî ìåäèöèíñêîãî óíèâåðñèòåòà ïî ïðîôèëþ «õèðóðãè÷åñêàÿ èíôåêöèÿ», êîòîðûì â ýêñòðåííîì ïîðÿäêå áûëà âûïîëíåíà ýçîôàãîãàñòðîäóîäåíîñêîïèÿ (ÝÃÄÑ) è äèà- Àñïèðàíòñêèé âåñòíèê Ïîâîëæüÿ ¹ 5-6, 2015. ×àñòü I 137 ãíîñòèðîâàí ÑÎÆÏ. Ó ïàöèåíòîâ áûëè âûÿâëåíû ôàêòîðû ðèñêà ðàçâèòèÿ äàííîé ïàòîëîãèè. Çà 2013-2014 ãîäû îáñëåäîâàíû 64 ïàöèåíòà, ó êîòîðûõ âûÿâëåíû âûøå îáîçíà÷åííûå ôàêòîðû ðèñêà. Äàííîé êàòåãîðèè áîëüíûõ, â êà÷åñòâå äîïîëíèòåëüíîãî ìåòîäà èññëåäîâàíèÿ, áûëà âûïîëíåíà ÝÃÄÑ, à òàêæå â õîäå ëå÷åíèÿ áûë ïðèìåíåí ñòàíäàðòíûé ïðîòîêîë ïðîôèëàêòèêè ðàçâèòèÿ ÑÎÆÏ ñ äîïîëíåíèÿìè. Ðåçóëüòàòû è îáñóæäåíèå Âî âðåìÿ èçó÷åíèÿ èñòîðèé áîëåçíè ìû îáðàòèëè âíèìàíèå íà òîò ôàêò, ÷òî çà 2010-2012 ãã. ïðîèçîøåë ðîñò êîëè÷åñòâà ñëó÷àåâ âîçíèêíîâåíèÿ æåëóäî÷íîêèøå÷íûõ êðîâîòå÷åíèé (ÆÊÊ) ó ïàöèåíòîâ ñ ãíîéíî-õèðóðãè÷åñêîé ïàòîëîãèåé, â òî âðåìÿ êàê îáùåå êîëè÷åñòâî ïðîëå÷åííûõ â îòäåëåíèè ïàöèåíòîâ îñòàâàëîñü ïðèìåðíî îäèíàêîâûì èç ãîäà â ãîä è ñîñòàâèëî 742±12 ÷åëîâåêà. Òàê, îñíîâûâàÿñü íà äàííûõ ñîáñòâåííûõ èññëåäîâàíèé, çà ïåðèîä ñ 2007 ïî 2009 ãã. êîëè÷åñòâî ýïèçîäîâ ðàçâèòèÿ ÆÊÊ íå ïðåâûøàëî 5 â ãîä.  àáñîëþòíîì áîëüøèíñòâå ñëó÷àåâ, êðîâîòå÷åíèå âîçíèêàëî íà ôîíå ñåïñèñà.  ñâîþ î÷åðåäü, ñ 2010 ïî 2012 ãã. îòìå÷àëñÿ ðîñò êîëè÷åñòâà êðîâîòå÷åíèé äî 8±2 ñëó÷àåâ â ãîä. Îáùåå êîëè÷åñòâî ïàöèåíòîâ çà ýòîò ïåðèîä, ó êîòîðûõ ïî äàííûì ÔÃÄÑ áûëè âåðèôèöèðîâàíû ïîðàæåíèÿ âåðõíèõ îòäåëîâ æåëóäî÷íî-êèøå÷íîãî òðàêòà, ïîòåíöèàëüíî îïàñíûõ â ïëàíå ðàçâèòèÿ æåëóäî÷íî-êèøå÷íîãî êðîâîòå÷åíèÿ, ñîñòàâèëî 33 ÷åëîâåêà.  ñòðóêòóðå äèàãíîçîâ, âûÿâëåííûõ ïðè ýíäîñêîïè÷åñêîì îáñëåäîâàíèè, âåäóùèìè áûëè ÿçâåííûå ïîðàæåíèÿ – 16 ñëó÷àåâ, íà âòîðîì ìåñòå ýðîçèâíûå ïîðàæåíèÿ ÆÊÒ – 9 ñëó÷àåâ, è â 8 ñëó÷àÿõ âûÿâëåíà äðóãàÿ ïàòîëîãèÿ (ãåìîððàãè÷åñêèé ãàñòðèò, ðàñïàäàþùàÿñÿ îïóõîëü æåëóäêà è ò.ä.). Ïî ïðè÷èíàì ãîñïèòàëèçàöèè â ñòàöèîíàð ïàöèåíòû áûëè ðàñïðåäåëåíû ñëåäóþùèì îáðàçîì: 12 ÷åëîâåê áûëè ãîñïèòàëèçèðîâàíû ñ äèàãíîçîì îáëèòåðèðóþùèé àòåðîñêëåðîç í/ê III – IVá ñò., êîãäà âûïîëíåíèå ðåêîíñòðóêòèâíîé îïåðàöèè áûëî íåâîçìîæíî è èìåëîñü îñëîæíåíèå â âèäå ðàíåâîé èíôåêöèè, 7 ÷åëîâåê ñ äèàãíîçîì ñåïñèñ, 5 ÷åëîâåê ñî ñâèùåâîé ôîðìîé îñòåîìèåëèòà, 3 ÷åëîâåêà ñ ñàõàðíûì äèàáåòîì (íåéðîïàòè÷åñêàÿ ôîðìà ñèíäðîìà äèàáåòè÷åñêîé ñòîïû) è 4 ÷åëîâåêà ñ èíûìè çàáîëåâàíèÿìè (ãíîéíûå çàáîëåâàíèÿ ìÿãêèõ òêàíåé). Ñðåäíèé âîçðàñò áîëüíûõ ñîñòàâëÿë 65±5 ëåò. Áîëüøîå êîëè÷åñòâî ïàöèåíòîâ ñ àòåðîñêëåðîçîì ìîæíî îáúÿñíèòü ñëåäóþùèì îáðàçîì: ïîñëå èçó÷åíèÿ ëèòåðàòóðíûõ äàííûõ áûëî âûÿñíåíî, ÷òî â âîçðàñ- 138 òå 65±5 ëåò â 92% ñëó÷àåâ íàáëþäàåòñÿ ìóëüòèôîêàëüíûé àòåðîñêëåðîç, ñ ñî÷åòàíèåì 2-õ è áîëåå ôîðì, à ó 62,7% ïàöèåíòîâ àáäîìèíàëüíàÿ èøåìèÿ ïðîòåêàåò áåññèìïòîìíî [7]. Òàêèì îáðàçîì, êðàéíå âûñîêà âåðîÿòíîñòü ñî÷åòàíèÿ îáëèòåðèðóþùåãî àòåðîñêëåðîçà íèæíèõ êîíå÷íîñòåé ñ ñèíäðîìîì àáäîìèíàëüíîé èøåìèè, è êàê ñëåäñòâèå – íàëè÷èå ó ïàöèåíòîâ ýðîçèâíî-ÿçâåííûõ äåôåêòîâ â ÆÊÒ. Åùå îäíèì ôàêòîðîì, âëèÿþùèì íà ÷àñòîòó âîçíèêíîâåíèÿ ýðîçèâíîÿçâåííûõ ïîðàæåíèé ó ïàöèåíòîâ ñ õèðóðãè÷åñêîé ãíîéíî-ñåïòè÷åñêîé ïàòîëîãèåé, ÿâëÿåòñÿ áåñêîíòðîëüíîå óïîòðåáëåíèå îáåçáîëèâàþùèõ ïðåïàðàòîâ, îòíîñÿùèõñÿ ê ãðóïïå íåñòåðîèäíûõ ïðîòèâîâîñïàëèòåëüíûõ ñðåäñòâ (ÍÏÂÑ). Äëèòåëüíûé ïðèåì ÍÏÂÑ áûë îòìå÷åí â 65% ñëó÷àåâ ðàçâèòèÿ îñëîæíåíèé ñî ñòîðîíû âåðõíèõ îòäåëîâ ÆÊÒ è â 60% ñëó÷àåâ ðàçâèòèÿ æåëóäî÷íî-êèøå÷íûõ êðîâîòå÷åíèé. Ïî äàííûì çàðóáåæíûõ ýêñïåðòîâ, èñïîëüçîâàíèå â ìåäèöèíñêèõ öåëÿõ îïèîèäñîäåðæàùèõ àíàëüãåòè÷åñêèõ ñðåäñòâ â ìèðå (â ïåðåñ÷¸òå íà ìîðôèí â êèëîãðàììàõ íà îäèí ìèëëèîí íàñåëåíèÿ) ïðåäñòàâëåíî ñëåäóþùèì îáðàçîì: Êàíàäà – 57,9 êã, Çàïàäíàÿ Åâðîïà è ÑØÀ – îêîëî 32 êã, Ðîññèÿ – 0,5 êã [6]. Âñ¸ ýòî âëå÷¸ò çà ñîáîé ðåçêîå óâåëè÷åíèå ó ïàöèåíòîâ êîëè÷åñòâà ýïèçîäîâ ðàçâèòèÿ àññîöèèðîâàííûõ ñ ïðèåìîì äàííûõ ïðåïàðàòîâ ýðîçèâíî-ÿçâåííûõ ïîðàæåíèé ÆÊÒ.  ñëó÷àÿõ, êîãäà ýðîçèâíî-ÿçâåííûå ïîðàæåíèÿ ðàçâèâàëèñü íå íà ôîíå ñåïñèñà è îáëèòåðèðóþùåãî àòåðîñêëåðîçà, âåäóùèì ôàêòîðîì ñòàíîâèëîñü íàëè÷èå ÿçâåííîé áîëåçíè âåðõíèõ îòäåëîâ ÆÊÒ â àíàìíåçå. Ñ 2013 ãîäà â íàøåé êëèíèêå íà÷àëè ïðèìåíÿòü ðÿä ïðîôèëàêòè÷åñêèõ ìåðîïðèÿòèé äëÿ ïàöèåíòîâ, ïðè îñìîòðå è îáñëåäîâàíèè êîòîðûõ âûÿâëåíû ôàêòîðû, ïîâûøàþùèå ðèñê ðàçâèòèÿ ÑÎÆÏ. Êîìïëåêñ âêëþ÷àåò â ñåáÿ îáÿçàòåëüíûé ïðèåì ïðåïàðàòîâ èç ãðóïïû áëîêàòîðîâ ïðîòîííîé ïîìïû (ñîîòâåòñòâóåò êëèíè÷åñêîìó ïðîòîêîëó ïðîôèëàêòèêè ñèíäðîìà îñòðîãî ïîâðåæäåíèÿ æåëóäêà ó áîëüíûõ â êðèòè÷åñêîì ñîñòîÿíèè, Ñàìàðà, 2014) [1], óìåíüøåíèå êîëè÷åñòâà ïðèìåíåíèÿ ÍÏÂÑ çà ñ÷åò íàçíà÷åíèÿ â ïîñëåîïåðàöèîííîì ïåðèîäå àíàëüãåòèêîâ èíûõ ãðóïï, ïî âîçìîæíîñòè ñêîðåéøóþ àêòèâèçàöèþ ïàöèåíòîâ. Âñåãî â 2014 ãîäó â õîäå èññëåäîâàíèÿ áûëî âûÿâëåíî 64 ïàöèåíòà, ïîïàäàþùèõ â ãðóïïó ðèñêà ïî ðàçâèòèþ ÑÎÆÏ, 52-ì èç íèõ âûïîëíåíî ýíäîñêîïè÷åñêîå èññëåäîâàíèå, ÷òî ñîñòàâèëî 81%. Îñòàëü- Íàó÷íî-èíôîðìàöèîííûé ìåæâóçîâñêèé æóðíàë íûì 12-òè ïàöèåíòàì (19%) èññëåäîâàíèå íå âûïîëíÿëîñü â ñâÿçè ñ èõ îòêàçîì, ëèáî òÿæåñòüþ ñîñòîÿíèÿ.  77% ñëó÷àåâ âûÿâëåíû ñîñòîÿíèÿ, ïîòåíöèàëüíî óãðîæàþùèå ïî ðàçâèòèþ æåëóäî÷íî-êèøå÷íîãî êðîâîòå÷åíèÿ, â âèäå òåõ èëè èíûõ äåôåêòîâ ñëèçèñòîé âåðõíèõ îòäåëîâ ÆÊÒ, êîòîðûå â 87% (35 ÷åëîâåê) ïðîòåêàëè àáñîëþòíî áåññèìïòîìíî.  ðåçóëüòàòå, ñ ìîìåíòà íà÷àëà ïðèìåíåíèÿ ìåð ïðîôèëàêòèêè â îòäåëåíèè ïðîïåäåâòè÷åñêîé õèðóðãèè íàáëþäàëñÿ ëèøü îäèí ýïèçîä ðàçâèòèÿ ýðîçèâíîÿçâåííîãî æåëóäî÷íî-êèøå÷íîãî êðîâîòå÷åíèÿ èç âåðõíèõ îòäåëîâ æåëóäî÷íîêèøå÷íîãî òðàêòà â ðàííåì ïîñëåîïåðàöèîííîì ïåðèîäå (ìåíåå 24 ÷àñîâ) ó ïàöèåíòà ñ ãåíåðàëèçîâàííûì àòåðîñêëåðîçîì, êîòîðûé áûë êóïèðîâàí êîíñåðâàòèâíûìè ìåòîäàìè. Âûâîäû Ñðåäè ïàöèåíòîâ ãíîéíî-õèðóðãè÷åñêîãî ñòàöèîíàðà ðèñê ðàçâèòèÿ ÑÎÆÏ ïðèñóòñòâóåò ó ïàöèåíòîâ ñ îáëèòåðèðóþùèì àòåðîñêëåðîçîì íèæíèõ êîíå÷íîñòåé, ñàõàðíûì äèàáåòîì, ñåïñèñîì, ëèö ïîæèëîãî è ñòàð÷åñêîãî âîçðàñòà, ëèö, ïðèíèìàþùèõ ÍÏÂÑ. Ðàçâèòèå ÑÎÆÏ ó òàêèõ ïàöèåíòîâ ÷àñòî ñîïðîâîæäàåòñÿ æåëóäî÷î-êèøå÷íûì êðîâîòå÷åíèåì. Èñïîëüçîâàíèå ó ïàöèåíòîâ ãðóïïû ðèñêà ïðåïàðàòîâ èç ãðóïïû èíãèáèòîðîâ ïðîòîííîé ïîìïû ïîçâîëÿåò äîñòîâåðíî ñíèçèòü ÷àñòîòó æåëóäî÷î-êèøå÷íûõ êðîâîòå÷åíèé. Ñïèñîê ëèòåðàòóðû 1. Êîðûìàñîâ Â.À., Ìà÷åõèí Ï.Â., Òðóõàíîâà È.Ã., Ñòàäëåð Â.Â. Êëèíè÷åñêèé ïðîòîêîë ïðîôèëàêòèêè ñèíäðîìà îñòðîãî ïîâðåæäåíèÿ æåëóäêà ó áîëüíûõ â êðèòè÷åñêîì ñîñòîÿíèè. - Ñàìàðà: ÑàìÃÌÓ, 2014. - l0 ñ. 2. Ãåëüôàíä Á. Ð. Ïðîôèëàêòèêà ñòðåññïîâðåæäåíèé âåðõíåãî îòäåëà æåëóäî÷íîêèøå÷íîãî òðàêòà ó áîëüíûõ â êðèòè÷åñêèõ ñîñòîÿíèÿõ / Á. Ð. Ãåëüôàíä [è äð.] // Õèðóðãèÿ. Consilium Medicum. 2003. Ïðèë. 2. Ñ. 16–20. 3. Ñòðåêàëîâñêèé Â. Ï. 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