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Clinic, diagnosis and treatment.

To differentiate each of the purulent forms of the process is practically impossible and inexpedient, since their treatment is fundamentally the same. This is due to the variety of damaging agents and factors, the initial characteristics of the body, with a change in the biological properties of pathogens and the emergence of new methods of exposure (antibiotics, chemotherapeutic drugs, etc.). However, the basis is always the irreversible nature of the inflammatory process. Irreversibility is due to:

- morphological changes;

- the depth and severity of the process;

- functional disorders in which the only and rational method of treatment is surgical.

Conservative treatment of irreversible changes in the uterine appendages is unpromising. If this is carried out, it creates the prerequisites for new relapses, aggravation of impaired metabolic processes, the development of severe renal dysfunction, which increases the risk of an upcoming operation (inability to perform the necessary intervention, a real possibility of trauma to adjacent organs, etc.).

Purulent tubo-ovarian formations represent a difficult process in the diagnostic and clinical plan. Nevertheless, during the course of the disease, one can distinguish:

- intoxication syndrome;

- pain syndrome;

- infectious syndrome;

- early renal syndrome;

- syndrome of hemodynamic disorders;

- inflammation syndrome of adjacent organs;

- a syndrome of metabolic disorders.

Intoxication syndrome

Intoxication syndrome (IP) is that the lysosomal hydrocatalases formed in leukocytes enter the bloodstream, cause catabolic processes and the release of polypeptides. Products of the kinin-kininogen system (primarily bradykinin) are involved in the pathological process, adversely affecting the enzymatic systems of tissues, increasing the permeability of the walls of the capillaries, which leads to the passage of electrolytes, blood cells, proteins, and other disorders beyond the vascular system. The volume of circulating fluid is reduced. Microbial intoxication develops (initially due to aerobes), to which the action of toxins of non-spore-forming and / or spore anaerobes, which are distinguished by extreme toxicity, joins.

IS is accompanied by exogenous intoxication - the action of microbial toxins and endogenous intoxication (EI), a membrane-destructive process and the accumulation of substances of low and medium molecular weight (VNSMM). There are 5 stages of EI:

1st, initial, stage - compensatory phase; there is an increase in the sorption capacity of erythrocytes without increasing the concentration of VNSMM in blood plasma; occurs in patients with acute salpingo-oophoritis or exacerbation of the chronic process;

2nd stage - the phase of accumulation of products from the focus of aggression; there is an increase in the concentration of VNSMM both in blood plasma and in red blood cells; observed in patients with tubo-ovarian abscesses;

3rd stage - phase of reversible decompensation of detoxification organs (liver, kidneys, lungs, skin), or phase of full saturation; the concentration of VNSSM in erythrocytes remains unchanged, and in the blood plasma it continues to increase, reaching significant values; observed in patients with tubo-ovarian abscesses;

4th stage - phase of irreversible decompensation of detoxification organs (homeostasis insolvency phase); the concentration of VNSMM in erythrocytes decreases, changes in the structure of membranes are possible and the content of VNSMM in blood plasma rises;

5th, terminal, stage - the phase of complete disintegration of systems and organs; membrane damage occurs, the concentration of VHSSM in erythrocytes and plasma, and intracellular accumulation of metabolic products decrease.

Determination of VNSMM content both in blood plasma and in red blood cells allows you to determine the degree and phase of intoxication and choose a method of detoxification therapy. At the 1st stage of EI, membrane stabilizing therapy (antioxidants, polyene, ascorbic acid, etc.) is used. At the 2nd stage of EI, membrane-stabilizing therapy is combined with detoxification by hepatoprotectors (essentiale, karsil, glutamic acid) and drugs that improve kidney function (uroseptics, aminophylline, trental). At the 3rd and 4th stages of EI, the above therapy is combined with powerful detoxification therapy (hemosorption, ultrafiltration, lymphosorption, blood oxygenation, HBO).

In the development of IP, the effect of products that are not sufficiently rendered harmless by the liver in connection with the violation of urea-forming and detoxification functions in patients is essential.

Evaluation of the activity of the enzymatic systems of the liver responsible for the metabolism of drug compounds is of interest to obstetrician-gynecologists. Among the enzyme systems of microsomes, the oxyreductase system and especially the monooxygenase system containing cytochrome P450 should be distinguished. These systems carry out the oxidative metabolism of xenobiotics, steroid hormones, prostaglandins, fatty acids, toxic substances. The activity of cytochrome P450 reflects the detoxification function of the liver. To reduce drug complications, especially in pregnant women with toxicosis and in patients with purulent-septic complications, the activity of cytochrome P450 is determined, then hepatotropic therapy is prescribed.

Clinically, IP is manifested by symptoms of intoxication encephalopathy: headaches, lethargy or euphoria, heaviness in the head, difficulty speaking or verbosity, constantly closed eyes, “hazy” eyes, sometimes anxiety for life, fear, coma. Severe general condition is accompanied by dyspeptic disorders (dry mouth, nausea, vomiting, lack of a sense of relief after it, bitterness in the mouth). Disorders of the cardiovascular system (tachycardia, less commonly bradycardia, cyanosis, facial hyperemia against the background of severe pallor, hypergenia or hypotension) are early symptoms of IP, which begins septic shock.

Pain syndrome

Pain syndrome is present in almost all patients with purulent tubo-ovarian formations, and the nature of the pain can be different. Particularly characteristic are the growing pains in the lower abdomen or in the iliac regions and the expansion of the zone of pain (to the area of ​​the mesogastrium, while with peritonitis the pain spreads throughout the abdomen). The increasing nature of the pain is accompanied by a deterioration in the general condition of the patient. In a special study, displacement beyond the cervix is ​​sharply painful, symptoms of peritoneal irritation around the palpable tubo-ovarian mass are pronounced.

Pulsating growing pain, persistent fever with a body temperature above 38 ° C, tenesmus, loose stools, the absence of clear tumor contours during gynecological examination, the spread of the zone of symptoms of peritoneal irritation above hypogastrium, the onset and increase of dysuric disorders, the ongoing inflammatory process and the lack of treatment effect ~ all this indicates the threat of perforation or its presence, which is an absolute indication for urgent surgical treatment.

Infectious Syndrome

It goes without saying that the infectious syndrome is present in all patients with purulent tubo-ovarian formations.
It manifests itself in most patients with fever (with a body temperature of 38 ° C or more), in some of them it begins with subfebrile condition and increases, there may be chills, which is not of the nature of tremendous septic chills, followed by a sharp weakness. More often chills, a feeling of cold. Tachycardia corresponds to the severity of fever, with the phenomena of pelvioperitonitis and peritonitis, there is a mismatch of the pulse rate with the patient’s body temperature. The leukocyte intoxication index (LII), ESR, leukocytosis increase in the blood of patients, the number of lymphocytes decreases, the content of stab and segmented neutrophils increases. The increase in LII is associated with the disappearance in the blood of sick eosinophils, an increase in the content of segmented and stab neutrophils, a decrease in the number of lymphocytes and monocytes, and the appearance of plasma cells.

A decrease in the blood content of monocytes and lymphocytes can be regarded as suppression of the immune defense, and the appearance of young and immature forms of neutrophils - as the tension of the compensatory mechanisms for the decontamination of toxins.

The level of substances of medium molecular weight, reflecting the severity of infectious and intoxication syndromes, is significantly higher in patients with purulent processes than in patients with acute inflammation. It should be noted that this indicator is very dynamic and decreases with remission, correlates with the clinical symptoms of intoxication and can serve as a diagnostic and prognostic criterion for the purulent process.

Early renal syndrome

Clinical signs of renal syndrome appear in the early stages of the purulent process, since pelvic fiber and, especially, pre-bladder fiber are involved in the inflammatory process of the pelvis.

Early renal syndrome occurs in 55-65% of patients with purulent inflammation of the uterus. There is an early appearance of protein in the urine, leukocyturia, cylindruria, erythrocyturia, 2/3 of patients are diagnosed with functional disorders of the urinary system due to intoxication, compression of the distal ureter and bladder by an inflammatory tumor. At the same time, in half of patients, a violation of the passage of urine with the development of a hydroureter, hydronephrosis is detected. Subsequently, anterior parametritis can form with suppuration and perforation of ulcers in the bladder and the formation of genitourinary fistulas.

Hemodynamic disorder syndrome

In patients with tubo-ovarian formations, both general and local hemodynamic disorders are observed. Changes in the most important volemic indicators (deficiency of bcc, CPP, bcc) are accompanied by disorders of microcirculation, which subsequently leads to insufficient tissue regeneration.

Syndrome of inflammation of adjacent organs

Purulent inflammation of the uterine appendages is always accompanied by the spread of the infectious process to nearby tissues and organs, as a result of which inflammatory changes in the pelvic peritoneum develop and extensive interorgan fusion, secondary lesions of the appendicular process with the formation of secondary appendicitis are formed. At the same time, inflammatory infiltration appears in adjacent loops of the colon and small intestine with the formation of sigmoiditis, inflammation of the bladder with the phenomena of pyelocystitis, as well as inflammatory and purulent inflammatory changes in the cellulose of parametres (with the development of parametritis), leading to compression of the mouths of the ureters, blocking kidney function, acute or chronic renal failure.

The clinical manifestations of these complications are extremely difficult: intensive therapy in the hospital does not have an effect, intoxication and dynamic intestinal obstruction increase, the zone of peritoneal symptoms expands, the inflammatory tumor grows in size, which ultimately leads to perforation of the abscesses with the formation of the most severe complications - diffuse purulent peritonitis, genitourinary, intestinal, genitourinary and other fistulas. The spread of the purulent process through the fiber from the parametria to the anterior abdominal wall causes the formation of phlegmon, abscesses.

Metabolic disorder syndrome

Metabolic disorders in purulent tubo-ovarian formations are diverse. The most noteworthy are violations of the protein, water-electrolyte balance and acid-base state.

Protein metabolism is impaired due to hypermetabolism, loss of protein with exudate, tissue destruction, urine and vomit. Loss of protein can reach 50-200 g / day. Hypoproteinemia, dysproteinemia with a decrease in the amount of albumin, an increase in the content of globulins due to? - and? -Globulins. Dysproteinemia is accompanied by a violation of nitrogen balance.

Electrolyte disturbances in purulent processes are a consequence of the general reaction of the body to a common inflammatory process. In connection with increased excretion of potassium in the urine, vomit and its exit from the intracellular space in a number of patients, especially with gynecological peritonitis, hypokalemia may be observed that requires correction. As the process progresses, inhibition of excretory function of the kidneys, disorganization of cell metabolism and their death, the potassium content in plasma increases, hypokalemia can be replaced by hyperkalemia. Pronounced hypernatremia is usually not observed, since a significant amount of sodium moves inside the cells, displacing potassium from there, a small amount of sodium is deposited with the edematous fluid in the interstitial space. The change in the concentration of other ions is less pronounced.

The acid-base state is subject to significant fluctuations: as a rule, acidosis develops due to impaired blood circulation in the tissues, hypoxia and disorganization of cell metabolism, the development of respiratory alkalosis.

Clinically metabolic disorders in patients with purulent processes are manifested both before the operation and after it with increasing symptoms of cardiac, respiratory and other types of multiple organ failure, decreased motility of the gastrointestinal tract (GIT) and other disorders.
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