Go Thubega ga Mometso (Bolwetse jwa Boerhaave), Dikeledi tsa Mallory-Weiss, le Botlhoko jwa Sehuba jwa go Kgwa¶

Boerhaave syndrome ke boemo jwa tshoganyetso jwa karo ya sehuba jo bo tshosang, jo bo tshosetsang botshelo jo mo go jone go tlhatloga ga kgatelelo ka tshoganyetso, go go thunyang mo teng ga mometso ka nako ya go tlhotlhora kgotsa go kgwa ka maatla go gagola leroba le le bokima jo bo tletseng (transmural perforation) go ralala lebota la mometso le le kwa tlase. Go farologana le keledi ya Mallory-Weiss e e sa reng sepe (e e ngapang fela letlalo le le kafa teng la kgolagano ya mala le mometso mme e baka madi a mahibidu a a phatsimang mo matlhatseng kwantle ga go phunya sehuba), bolwetse jwa Boerhaave bo thunya ka tlhamalalo dikarolwana tsa bateria tse di nang le esiti tsa mala, di-enzyme tsa dijo tsa mathe, leroba la sehuba le le senang megare (sebaka sa mediastinum le sa pleura sa molema). Ka gonne mometso o tlhoka letlalo le le thata la kwa ntle la serosal, kgotlhelo eno ya dikhemikale le ya dibakateria e tsosa mediastinitis e e botlhoko e e bolayang, empyema, hydropneumothorax ya tsitsipano, le go tshoga ga septic mo diureng di se kae fela. Fa motho yo o ntseng a tlhotlhora kgotsa a kgwa (bogolo jang fa a ne a leka go thibela go kgwa ka dikgoka) ka tshoganetso a nna le setlhabi se se botlhoko mo karolong e e kwa tlase ya sehuba, mo karolong e e kwa godimo ya mpa, kgotsa mo mokwatleng, a tlhaela mowa, kgotsa **dipudula tsa mowa tse di phatlogang ka fa tlase ga letlalo la thamo (Mackler's your local triad)**ll, dinomoro tsa tshoganyetso ka bonako. Fa o ntse o letetse bathusi ba kalafi, sekaseka dikaelo tse di amanang le maemo a tshoganyetso mo go go dutla madi mo mpeng le go kgwa madi, go thubega ga methapo ya mometso le go tswa madi ga bolwetse jwa sebete, le lerapo la tlhapi le le meditsweng, lerapo la koko, le go ama ga dijo.

Ka gonne bolwetse jwa Boerhaave jo bo sa alafiwang bo batla bo bolaya ka diperesente di le 100 (mme dintsho di menagana gabedi fa go tswalwa ga karo kgotsa ka endoscope go diega go feta diura di le 24), molao wa gago o le mongwe fela o o botlhokwa thata wa thuso ya potlako kwa gae ke **NPO e e gagametseng (go se tlhatswe sepe ka molomo: le fa e le go nwa gangwe le gape morago ga go nwa). lerothodi la metsi metsoa tšela ka kotloloho tsoa lesoba ka esophagus ka sefuba cavity.

Dira se jaanong¶

1. Leletsa nomoro ya gago ya tshoganyetso ya selegae ka bonako mme o bege fa o belaela gore o na le bolwetse jwa go phunyega ga mometso / Boerhaave. Leletsa 911 kwa United States le Canada, 112 go ralala Kopano ya Yuropa, 999 kwa United Kingdom, 000 kwa Australia, kgotsa tlhola lenaane la rona la dinomoro tsa tshoganyetso. Bolela ka tlhamalalo: "Go belaelwa gore o na le bolwetse jwa Boerhaave / mometso o o thubegileng: botlhoko jo bo botlhoko jwa tshoganyetso mo sehubeng le mo karolong e e kwa godimo ya mokwatla ka bonako fela morago ga go kgwa ka maatla, ka go tlhaela mowa."
2. Gapeletsa NPO e e feletseng, e e gagametseng (MEtsi a a senang sepe, ditšhipisi tsa aese di sena sepe, di-antacid di sena sepe, dipilisi tsa molomo di sena sepe). Morago ga go kgwa, tlholego ya motho ke go nwa galase ya metsi, ginger ale, kgotsa antacid e e metsi go tlhatswa tatso e e botlha mo sehubeng sa gagwe le go ritibatsa go tlhotlhorega ga gagwe. Fa motho a eletsa go tlhatswa molomo, a ka nna a tsholola metsi a a tsididi mme a kgwa diperesente di le 100 tsa one kwa ntle mo sinking, mme ga a tshwanela go le fa e le lerothodi le le lengwe. Seedi se se meditsweng se elela ka tlhamalalo ka keledi e e mo mometso se tsena mo sebakeng sa mediastinum le sa pleura se se dikologileng pelo le mafatlha a molema, se tlhatswa dimilionemilione tsa dibakateria tsa molomo ka tlhamalalo mo sehubeng.
3. Beya molwetse a ntse a eme ka didikirii di le 30 go ya go di le 45 (kgotsa a sekame go le gonnye kwa pele) go nolofatsa go hema le go fokotsa go boela ga esiti. Go rapama ka sephaphathi ka mokwatla go letla esiti ya gastric le bile go tswa mo mpeng go elela kwa godimo go feta mo sehubeng se se kwa tlase sa esophageal sphincter le go tshologela kwa ntle ka esophageal sphincter e e kwa tlase. Go nna o eme go sekae go dirisa maatlakgogedi go boloka esiti ya mala e le kwa tlase mo mpeng mme go thusa mafatlha go atologa kgatlhanong le go tswa ga madi mo maleng a molema kgotsa pneumothorax e e golang.
4. Tlhola motheo wa thamo le marapo a sehuba go bona gore a go na le "rice-krispie" e e phatlogang ka fa tlase ga letlalo (emphysema ya ka fa tlase ga letlalo / Mackler's triad). Ikhutse ka bonolo dipedi tse di sephaphathi tsa dintlha tsa menwana ya gago mo godimo ga khuti e e fa godimo ga lerapo la sehuba (suprasternal notch), go kgabaganya marapo a sehuba a a telele, le Fa o utlwa dipudula tse dinnye tsa mowa di thunya le go phatloga ka fa tlase ga letlalo jaaka pampiri ya dithishu kgotsa ditlhaka tsa raese tse di buduleditsweng (crepitus), kgotsa fa molala o lebega o budulegile mme lentswe la motho le utlwala ka tshoganetso le nko kgotsa le tlhotlhorega, mowa o o tswang mo mometso o o gagogileng o lateditse neck mediastinum.
5. O SE KE wa fa aspirin, ibuprofen, kapa melemo efe kapa efe ya molomo, mme o qobe ho etsa hore motho a kgwe kapa ho kgwa hape. Bolella bathusi ba kalafi ka potlako ha ba fihla hore ba kgone ho fana ka dipilisi tsa ho kgwa ka ditshika (ondansetron) hanghang ho emisa ho kgwa ho eketsehileng (kaha esiti e nngwe le e nngwe e eketsehileng e hlohlora le ho kgwa).
6. Ela tlhoko ka kelotlhoko go bona gore a ga go na go tshoga ka bonako, cyanosis, le pneumothorax e e gagametseng. Fa go gagoga ga mometso go gagola left mediastinal pleura e e bapileng, mowa le seeledi sa mpa di tlala mo lefelong le le dikologileng lefatlha la molema, di phutlhamisa lefatlha mme di kgoromeletsa pelo ya sehuba go ya kwa letlhakoreng la moja.

Setlhare sa tshwetso: botlhoko jwa sehuba morago ga go kgwa, hematemesis, le go tlhaola bolwetse jwa Boerhaave¶

flowchart TD
    Start["Go Kgwa ka Dikgoka, Go Kgwa go Omile, Kgotsa Go Kgwa go Latelwa ke Botlhoko jwa Sehuba, Botlhoko jwa Karolo e e kwa Godimo ya Mpa, kgotsa go Kgwa Madi"] --> CheckMackler{"Kgato 1: Tlhola Bolwetse jwa Boerhaave & Mackler Triad Difolaga tse di Khibidu: Botlhoko jo bo botlhoko jwa tshoganyetso jo bo gagolang mo sehubeng se se kwa tlase kgotsa mo mokwatleng, dipudula tsa mowa tse di phatlogang ka fa tlase ga letlalo la molala (crepitus), go tlhaela mowa, kgotsa go tlhotlhorega ga Hamman?"}

    CheckMackler -->|"EE go Folaga epe e Khibidu"| Boerhaave["GO BELAELWA GO LE BOTLHOKO JWA BOERHAAVE (GO THUBA GA MOMELO KA GO FETA MO MOTHO): Leletsa Ditirelo tsa Tshoganyetso (911 / 112 / 999) Ka bonako; Lefesetere la Gauta la Diura di le 24 go Thibela Bolwetse jo bo Bolayang jwa Mediastinitis"]

    CheckMackler -->|"GA GO na botlhoko jo bo tseneletseng jwa sehuba kgotsa jwa mokwatla kgotsa go hema botlhoko; Molwetse o kgwa methalo e mehibidu e e phatsimang ya madi morago ga go kgwa"| MalloryCheck{"Kgato 2: Madi a le Kae & A Molwetse o Na le Bolwetse jwa Sebete?"}

    MalloryCheck -->|"Bolwetse jo bo Itsiweng jwa Cirrhosis / Kgatelelo e e Kwa Godimo ya Madi KGOTSA Madi a mantsi, matlhotlhora a mantsho, go tsewa ke sedidi, kgotsa mantle a mantsho"| Varices["GO DUMA MADI A GO TSENYA BOTSHELETSO MO GI GO GODIMO KGOTSA GO RUBAGA GA VARICEAL: Leletsa 911 ka bonako, Boemo mo Letlhakoreng, NPO e e Gagametseng"]

    MalloryCheck -->|"Methalo e mennye ya madi a mahibidu a a phatsimang morago ga go kgwa makgetlo a le mmalwa a a tlwaelegileng, go tlhoka botlhoko mo sehubeng, go hema go go tlwaelegileng, go itaya ga pelo go go tlwaelegileng le BP"| MalloryWeiss["Go belaelwa gore go na le go gagoga ga legogo la Mallory-Weiss: Boloka NPO ka tlhomamo mme o ye kwa Lefapheng la Maemo a Tshoganyetso la Bookelo go ya go tlholwa hemoglobin, go thibela pompo ya porotone ya IV, le go ela tlhoko"]

    Boerhaave --> StrictNPO["1. NPO E E GAGAMELENG: O SE KE wa Metsa Le fa e le 1 Sip ya Metsi (Seedi se se meditsweng se tshololela ka tlhamalalo keledi ya mometso mo sehubeng); Nna o eme ka tlhamalalo ka didikirii di le 30 go ya go di le 45 go boloka esiti ya mo mpeng e le kwa tlase"]

    StrictNPO --> HospitalBundle["2. Sephuthelwana sa go Tlhatlhoba Bolwetse ka Bofefo le go Tsosolosa: Ondansetron ya IV, Sethibela-Pompo ya Porotone ya IV, Dibolayamegare tsa IV + Dibolayamegare tsa Mothuthuntshwane (Fluconazole), CT Esophagogram e e nang le Pharologano e e Nyokologang mo Metsing (Gastrografin, NEVER Barium), kgotsa Endoscopair ya Karo"]

Thulaganyo ya mmele le thuto ya malwetse: ke eng fa mometso o gagoga ka metlha mo lefelong le le lengwe fela (Lebota la Morago la Molemeng)¶

E tlhalositswe la ntlha ka 1724 ke ngaka ya Mo-Dutch e bong Herman Boerhaave morago ga gore a dire tlhatlhobo ya setopo sa ga Baron Jan von Wassenaer, Grand Admiral wa Sekepe sa Mo-Dutch (yo o neng a ineela mo moletlong o mogolo, a nwa seokobatsi se se tlhotlhoregang, a phatloga thata, a goa a re "sengwe se se kwa tlase se ne se thubegile ka oli ya motlhware e e kokobetseng mo teng ga leroba la gagwe la sehuba la molema), bolwetse jwa Boerhaave (go thubega ga mometso ka barogenic) bo latela melao e e ka bonelwang pele ya biomechanical.

1. Goreng 90% ya go thubega ga Boerhaave go diragala mo Mometso o o Kwa Tlase wa Molemeng¶

Fa go kgwa go go thunyang go dira gore kgatelelo ya mo teng ga lesedi e nne kwa godimo ga 150 go ya go 300 mmHg, go gagoga go batlile go diragala ka metlha jaaka kgaogano e e emeng ka boleele (boleele jwa disentimetara di le 1 go ya go di le 4) mo leboteng la molema la morago la mometso o o kgakala wa intrathoracic centimeter go ya go4. kgolagano ya mala (fela fa godimo ga diaphragm). Makoa a mane a mmele a kopana mo lefelong leno (Ntlha e e bokoa ya mmele ya ga Korn):

1. Go tlhoka llaga e e kwa ntle ya serosal: Go farologana le mala le mala, a a phuthetsweng ka kobo e e thata, e e nang le ditlhale e e bidiwang serosa (peritoneum ya ka fa teng) e e humileng ka kholajene le ditlhale tse di elastic, mometso wa sehuba ga o na mesifa e e ntshang serosa gotlhelele, dinama tse nyenyane tse lokolohileng tsa mediastinum.
2. Go sesane le go gasagana ga ditlhale tsa mesifa e e boleele: Mo karolong e e kwa tlase ya boraro ya mometso, diphuthelwana tsa mesifa e e borethe e e boleele e e kwa ntle di a fokotsega le go anama jaaka fene fa di ntse di thuma go ya kwa tlase go tsena mo cardia ya mpa.
3. Diphunyego tsa methapo ya methapo ka lebota la mesifa: Kwa leboteng la molema la morago fela fa godimo ga diaphragm, dikala tsa tshika ya ka fa molemeng ya mpa le tshika ya vagus di phunya ka tlhamalalo mo llageng ya mesifa e e sediko, mme di dira gore go nne le diphoso tsa tlholego tsa popego (loci minoris resistentiae).
4. Go tlhoka tshegetso ya dirwe tsa kwa ntle mo letlhakoreng la molema: Fa letlhakore la moja le kwa pele ga mometso o o kwa tlase di tshegediwa kwa ntle ke aorta ya sehuba, lerapo la mokwatla, pericardium, le vena cava, lebota la molema la morago la mometso o o kwa tlase le tshwaragane ka tlhamalalo le soft, compzeroal mediaura ditlhako tsa kgatelelo ya ka fa gare.

2. Letshogo le le bolayang: mediastinitis ya dikhemikale e e latelang ke go tshoga ga ditshedinyana tse dintsi¶

Ka nako ya fa lebota le le kwa tlase la molema la mometso le kgaogana, mowa mongwe le mongwe o molwetse a o hemang o dira jaaka pompo ya vacuum: ka gonne leroba la sehuba (sebaka sa pleura le mediastinum) le nna ka fa tlase ga kgatelelo e e sa siamang ya mo teng ga sehuba (-5 go -10 cmH2O) ka nako ya go hema fa mpa e e ka fa tlase ga diaphragm e le ka fa tlase ga kgatelelo e e siameng ya mo teng ga mpa, diteng tsa mala di tswelela go gogelwa kwa godimo go tswa mo mpeng mme di gasetswa ka keledi ya mometso go tsena mo sehubeng:

• Diura 0 go ya go 6 (Meastinitis ya Dikhemikhale le Go Tshoga ga Sebaka sa Boraro): Esiti ya mala ya hydrochloric (pH 1.5 go ya go 2.0), pepsin, le bile e e buseditsweng morago di sila mafura a mo gare ga mala mme di fisa ka pleura e tshesane ya magareng ya molema e e bonwang, di tshololela seeledi le mowa mo sehubeng sa molema (hydrtyvitoram**le diperesente di le 70 go ya go di le 90 tsa dikgetsi). Go dutla go gogolo ga di- capillary go goga dilitara tsa polasema go tswa mo mading go tsena mo sehubeng, go baka go tshoga ka bonako ga hypovolemic.
• Diura di le 6 go ya go di le 24+ (Bolwetse jo bo bolayang jwa ditshedinyana tse dintsi): Dibaketeria tse di kotsi tsa molomo le tsa GI e e kwa godimo (Streptococcus viridans, Staphylococcus, Dibaketeria tsa mo mpeng le ditshedi tse di sa tlhokeng mowa tsa molomo tse di jaaka Prevotellades* le *Bacterop) ka bonako go kgabaganya difofane tse di sa gagamalang, tse di senang methapo ya mediastinum e e kwa morago e e dikologileng pelo, aorta, le mafatlha, e kgweetsa dintsho go tswa go ka fa tlase ga diperesente di le 10 go ya go di le 15 (fa e ka tswalelwa ka karo mo lobakeng lwa diura di le 12 go ya go di le 24) go fitlha go diperesente di le 40 go ya go di le 60+ pa (fa e ka diega ho 40+).

Go farologanya bolwetse jwa Boerhaave, go gagoga ga Mallory-Weiss, le Dipharologano tsa Mometso¶

Ka gonne maemo otlhe a mararo a akaretsa go tlhotlhora, go kgwa, le matshwao a a kwa godimo a mala, go farologanya Go thubega ga Boerhaave go go feletseng le go thubega ga legogo la Mallory-Weiss** go go sa reng sepe kgotsa go tswa madi a cirrhotic variceal go botlhokwa thata:

Go Lemoga Boraro jwa ga Mackler, Boraro jwa ga Anderson le Letshwao la ga Hamman fa thoko ga bolao¶

Dingaka di ikaegile ka di-triad tse pedi tsa bogologolo tse di fa thoko ga bolao le matshwao a mararo a tlhatlhobo ya mmele go tshwara bolwetse jwa Boerhaave pele ga bo lemogiwa ka tsela e e sa siamang e le go ema ga pelo, go kgaoga ga aorta, go tsenwa ke madi mo makgwafong, kgotsa bolwetse jo bo botlhoko jwa manyike:

1. Boraro jwa ga Mackler (Boraro jwa bukathuto jwa bogologolo jwa bolwetse jwa Boerhaave)¶

1. Go kgwa ka dikgoka kgotsa go tlhotlhora (le fa ka dinako tse dingwe go bakwa ke go gotlhola ka maatla, go tsholetsa bokete jo bo bokete, go thuthumela ga sethoathoa, go gagamala fa o belega, kgotsa go tlhaselwa ke asma).
2. Botlhoko jo bo Bokete jwa Tshoganyetso jwa Sehuba se se kwa Tlase / Epigastric e e kwa Godimo (gantsi bo phatsima ka tlhamalalo go ya kwa mokwatleng wa molema kgotsa legetleng la molema ka mothapo wa phrenic).
3. Emphysema ya ka fa tlase ga letlalo (Cervical Crepitus) mo Molaleng le mo Fossa ya Supraclavicular: Mowa o o meditsweng o o tswang ka lesoba le le kwa tlase la mometso o latela kwa godimo go bapa le difofane tsa fascial tsa mediastinum go tsena mo botlaseng jwa molala, kwa o ka utlwang o thunya jaaka sephuthelwana sa bubble ka fa tlase ga menwana ya gago.

Tlhagiso ya kalafi: Le fa Mackler's triad e le pathognomonic (diperesente di le 100 tsa go tlhatlhoba fa e le teng), dikarolo tsotlhe tse tharo di tlhagelela mmogo fa di tlhagelela la ntlha mo diperesenteng di le 15 go ya go di le 30 fela tsa balwetse ka gonne mowa o ka tsaya diura di le 1 go ya go di le 6 go tsenelela go tswa mo letlalong le le kwa tlase la sehuba go ya kwa godimo mo molaleng. Le ka motlha o se kgaphe kwa thoko bolwetse jwa Boerhaave fela ka gonne crepitus ya thamo e ise e tlhagelele.

2. Boraro jwa ga Anderson le Letshwao la ga Hamman ("Go tlhotlhorega ga Mogare")¶

• Anderson's Triad: Emphysema ya molala o o ka fa tlase ga letlalo + Go hema ka bonako go go seng boteng (tachypnea) + Go gagamala ga mpa (go go bakiwang ke go tenega ga diaphragm le ga epigastric e e kwa godimo go go etsisang ulso ya mpa e e phunyegileng).
• Letshwao la ga Hamman (Mediastinal Crunch): Fa mothusi wa kalafi kgotsa ngaka e reetsa kwa pele ga pelo (precordium) ka stethoscope fa molwetse a robetse ka letlhakore la gagwe la molema, go itaya ga pelo gongwe le gongwe go ntsha modumo o o kwa godimo wa **go tlhotlhorega, go tobetsa, go tlhotlhorega, kgotsa go tlhotlhorega go go tsamaelanang le pelo e tlhotlhora dikgetsana tsa mowa tse di tshwaregileng mo teng ga mediastinum ka mmele.
• Phetogo ya Lentswe ("Rhinolalia" kgotsa "Donald Duck / Brass Voice"): Fa mowa wa magareng o phatlola go ya kwa godimo go tsena mo mafelong a a kwa morago le a a fa thoko ga mometso, lentswe la molwetse ka tshoganyetso le nna le modumo o o sa tlwaelegang, o o kwa godimo, o o bonalang wa nko, o o tlhotlhoregang.

Goreng ditshwantsho tsa kwa bookelong di tshwanetse go dirisa Pharologano e e Nyokologang mo Metsing (Gastrografin) le Barium LE KA MOTLHA go sa le gale¶

Ka gonne di-X-ray tsa sehuba tse di sa raraanang di ka lebega di tlwaelegile ka tsela e e tsietsang mo diureng tsa ntlha di le 1 go ya go di le 3 pele ga di bontsha methalo ya mowa mo gare ga pelo (letshwao la V la Naclerio kwa molelwaneng o o kwa tlase wa molema wa pelo), go tswa madi mo sehubeng sa molema, kgotsa pneumothorax, **Mokgatlho wa Lefatshe Lotlhe wa Ditlhatlhobo tsa Maemo a Tshoganyetso) porothokholo:

1. Teko ya Maemo a Gauta: CT Esophagogram e e Tokafaditsweng ka Pharologano e e nang le Pharologano ya Molomo e e Nyokologang mo Metsing¶

Fa molwetse a tsogile mme a kgona go metsa go dira teko ya go tlhatlhoba bolwetse mo teng ga sekenara sa CT (kgotsa ka tšhupu ya nasoesophageal e e beilweng ka kelotlhoko e e tseneletseng ke mankge): - Dingaka di tsenya Sedirisiwa sa Pharologanyo se se Nwelelang mo Metsing (se se jaaka Gastrografin / diatrizoate meglumine) ka bonako pele ga go dira CT Scan ya Sehuba. - CT scan e na le diperesente di le 92 go ya go di le 100 tsa go nna bosisi, ka bonako fela e bontsha dibudula tse dinnye tsa mowa o o kwa ntle ga lesedi, go nna bokima ga lebota la mometso, go kokoanngwa ga dieledi tsa mometso, le jete e tshweu e e phatsimang ya phapang e e dutlang e e tshologelang kwa ntle ga levinum e e kwa morago kgotsa mometso o o kafa molemeng.

2. Goreng Barium Sulfate e thibetswe gotlhelele jaaka teko ya ntlha ya pharologano¶

3. Motlhala wa go Tlhatlhoba Sehuba (Amylase ya Seeledi sa Pleura le pH)¶

Fa dingaka di tsenya tšhupu ya sehuba mo mading a molema a molwetse wa Boerhaave, seeledi se se ntshiwang gantsi se nkga botlha jaaka diteng tsa mala, se na le dikarolwana tsa dijo, se na le pH e e nang le asiti e e kwa tlase ga 6.0, mme se na le selekanyo se se kwa godimo sa selegu ya amylase ya mathe le gase, se se supang gore

Kalafi e e tlhomameng ya kwa bookelong: fensetere ya karo ya diura di le 24, di-stent tsa endoscopic, le EndoVAC¶

Fa bolwetse jwa Boerhaave bo setse bo lemogilwe kwa lephateng la maemo a tshoganyetso, setlhopha sa bookelo se simolola ka bonako Ngatana ya go Tsosolosa ya WSES / AATS ya go Phanyega ga Mometso:

1. NPO e e gagametseng + Go fokotsa kgatelelo ya Nasogastric: E bewa ka kelotlhoko (gantsi ka fa tlase ga pono ya endoscopic) go goga esiti go tswa mo mpeng.
2. Sethibela Pompo ya Porotone ya Selekanyo se se Kwa Godimo (Pantoprazole kgotsa Esomeprazole IV): Se tlhatlosa pH ya mpa go feta 6.0 go emisa esiti ya haeterokoloriki le pepsin go sila mo gare ga mpa.
3. Dibolayamegare tse di tsenngwang mo ditshikaneng tse di anameng LE Kalafi ya Dibolayamegare tse di Tsenngwang mo Ditshikeng: Go farologana le diphunyego tsa mala a a kwa tlase, diphunyego tsa mometso gantsi di nna le mefuta ya Candida go tswa mo molomong le mometso (bogolo jang mo balwetseng ba ba nwang dithibela-asiti, di-steroid, kgotsa di-alubholated). Dikaelo di akantsha gore go tsenngwe dibolayamegare tsa IV tsa mefuta e e anameng (piperacillin-tazobactam kgotsa carbapenem [meropenem] + vancomycin) LE fluconazole e e tsenngwang mo ditshikaneng kgotsa echinocandine (micafungin/caspofungin).
4. Go tswalwa le go ntsha metsi mo phatlheng (mo gare ga <24-Hour Fesetere ya Gauta):
5. Paakanyo ya Motheo ya Karo (Thoracotomy kgotsa Thoracoscopy / Laparoscopy e e sa Tsenelelang thata): Seelo sa gauta sa hisitori sa balwetse ba ba itekanetseng ba ba nang le kgotlhelo ya sehuba e e sa laolesegeng. Ngaka e e arang ya sehuba e bula sehuba sa molema, e tlhatswa dijo tsotlhe, esiti le mamina go tswa mo sebakeng sa mediastinum le sa pleura, e kgaola dintlha tse di bolayang tsa dikarolo tsa mucosal le tsa mesifa go senola boleele jotlhe jwa keledi ya mucosal (e ka metlha e leng boleele go feta keledi ya mesifa e e kwa ntle), e roka mesifa e e tswalang mesifa e le mebedi le letlhabaphefo le le nang le ditshika la mesifa ya magareng ga ditlhaa, diaphragm, pleura, kgotsa fundus ya mpa (Thal/Dor patch) mo godimo ga mola wa go roka go thibela go thubega, go tlogela ditšhupu tse di bulegileng tsa sehuba go ntsha metsi.
6. Stent ya Tshipi e e Atolosiwang ka Endoscope (SEMS) kgotsa Over-the-Scope Clip (OTSC): Mo dikeleding tse dinnye tse di tshwerweng go sa le gale pele ga sepsis e e anameng ya pleural, kgotsa mo balwetseng ba ba bokoa, dingaka tsa gastroenterent tse di tsenang gare kgotsa dingaka tse di arang tsa sehuba di tsenya silicone e e ka ntshiwang mo letlhakoreng la sehuba ka hare, e kopantswe le ho ntsha metsi ka tjhupu ya sefuba ka letlalo.
7. Go Tswalwa ka Thuso ya Vacuum ya Endoscopic (EndoVAC / EVT): Phitlhelelo e kgolo ya segompieno ya go thubega ga mometso go sa le gale le go diega (>diura di le 24). Sepontšhe sa polyurethane se se gokeletsweng mo tšhupuneng ya go goga ya nasogastric se tsenngwa ka endoscopic ka tlhamalalo mo teng kgotsa mo godimo ga leroba le le phunyegileng ka fa tlase ga kgatelelo e e sa kgaotseng ya lerole (-125 mmHg), go tswelela go goga mamina go tswa mo mediastinum fa go ntse go phutlhamisiwa leroba le go tlhotlheletsa go fola ka bonako ga granulation, go fitlhelela dikelo tsa go tswalwa ga diperesente di le 85 go ya go di le 95.

Ditiragalo tse di kotsi thata le dilo tse di bakang go thubega ga mometso ka ntlha ya go sa kgwa¶

Le fa go kgwa ka dikgoka morago ga go nwa dijo tse dintsi kgotsa bojalwa go dira gore batho ba le bantsi ba nne le bolwetse jwa Boerhaave, dingaka gape di tlhokomela dilo di le mmalwa tse di kgethegileng tse di dirang gore kgatelelo ya mo teng ga mometso e tlhatloge ka tshoganyetso kgatlhanong le sphincter e e kwa godimo e e tswetsweng:

• Hyperemesis gravidarum e e masisi, go kgwa ka kalafi ya dikhemikhale, kgotsa go thibana ga mala: Balwetse ba ba itemogelang go tlhotlhorega go go omileng go go sa kgaotseng mo diureng di le dintsi ba ka tswelela go tswa mo go tlhotlhoregeng go go nnye ga legogo la Mallory-Weiss go ya kwa go thubegeng ga Boerhaave go go feletseng fa melemo ya go lwantsha go kgwa e ka diega.
• Go metsa ka bonako dibolumo tse dikgolo tsa seedi se se nang le khabone kgotsa polyethylene glycol bowel prep: Go nwa dilitara tsa seedi sa go baakanyetsa colonoscopy ka bonako mme morago ga moo o bo o tlhotlhora ka dikgoka kgatlhanong le mala a a bulegileng ke selo se se kwadilweng sentle se se bakang go thubega ga mometso kwa bookelong.
• Ditiro tse di feteletseng tsa Valsalva ntle le go kgwa: Ka sewelo, go thubega ga barogenic esophagus go diragala ka nako ya go tsholetsa dilo tse di bokete (go tsholetsa dilo tse di suleng kgotsa go tlhomama ka glottis e e tswetsweng), go gotlhola go go bogale, status asthmaticus, go thuthumela ga sethoathoa se segolo, kgotsa go tshwarwa ke seterouku ka maatla. Nako le nako fa nngwe ya ditiragalo tseno e latelwa ke botlhoko jo bo gagogang ka tshoganyetso jwa morago ga sehuba le go phatloga ga molala, alafa molwetse ka fa tlase ga porothokholo e e tshwanang e e gagametseng ya NPO le ya dipalangwa tsa tshoganyetso.

Dinomoro tsa maemo a tshoganyetso tsa kgaolo le diporothokholo tsa boemedi¶

Go belaelwa gore go na le bolwetse jwa Boerhaave go tlhoka gore go isiwe ka bonako ka ambulense kwa bookelong jwa maemo a a kwa godimo ka CT scanning ya diura di le 24, Karo ya Thoracic kgotsa Upper-GI, Endoscopy ya Tsereganyo, le Tlhokomelo e e Tseneletseng:

• Dinaga tse di Kopaneng le Canada: Letsa 911. Kopa dipalangwa go ya kwa lephateng le legolo la tshoganyetso la bookelo (le ka motlha e se tleliniki e e ikemetseng ya tlhokomelo ya potlako).
• Bogosi jo bo Kopaneng: Letsa 999 go bona ambulense ya tshoganyetso ya Setlhopha sa ½ ka bonako go ya kwa bookelong jo bogolo jwa maemo a a kwa godimo Lefapha la Tshoganyetso (A&E) le le nang le yuniti ya Karo ya Upper-GI / Oesophagogastric.
• Kopano ya Yuropa: Letsa 112. E laolwa ka fa tlase ga diporothokholo tsa Mokgatlho wa Lefatshe wa Karo ya Tshoganyetso (WSES) ya Maemo a Tshoganyetso a Mometso le Mokgatlho wa Yuropa wa Endoscopy ya Mala (ESGE).
• Australia le New Zealand: Letsa 000 kwa Australia kgotsa 111 kwa New Zealand.
• India le Asia-Pacific: Letsa 112 (kgotsa 108 kwa India), 995 kwa Singapore, 119 kwa Japane le Korea Borwa, kgotsa 999 kwa Malaysia le Hong Kong. Kopa setheo sa thuto e kgolwane se se nang le bokgoni jwa gastroenterology ya pelo kgotsa ya karo.

Dipotso tse di bodiwang kgapetsakgapetsa¶

Ke ka ntlha yang fa go le kotsi go tshwara kgotsa go hupetsa matlhatsa ka dikgoka?¶

Fa mmele wa gago o tsosa reflex ya go kgwa, mesifa ya gago ya diaphragm le ya mpa e a ngotlega ka maatla a magolo go leleka diteng tsa mpa go ya kwa godimo fa sphincter e e kwa godimo ya esophageal e e kwa godimo ga mometso wa gago e iketla ka go itirisa go ntsha kgwa. Fa o tswala molomo le mometso wa gago ka kelotlhoko go ithibela go kgwa phatlalatsa, lekhubu leo ​​la kgatelelo e e kwa godimo la seedi le gase le itaya lebati le le notletsweng kwa godimo ga mometso, le tlhatlosa kgatelelo mo teng ga mometso o o kwa tlase go feta 200 mmHg le go foka lesoba le le feletseng la mometso mo sehubeng sa gago se se kwa tlase.

Ke eng motho yo go belaelwang gore o na le bolwetse jwa Boerhaave a sa kgone go nwa le fa e le gangwe fela metsi morago ga go kgwa?¶

Mo bolwetseng jwa Boerhaave, go na le phatla e e bulegileng e e fetang mo leboteng la mometso o o kwa tlase e e isang ka tlhamalalo mo mediastinum e e senang megare (go dikologa pelo) le mo sebakeng sa pleura sa molema (go dikologa mafatlha a molema). Motho mongwe le mongwe yo o nwang metsi, ginger ale, kana seokobatsi se se thibelang asiti se se metsi se tshologela ka tlhamalalo ka phatla eo mo leroleng la gagwe la sehuba, se rwala dimilionemilione tsa dibakateria tsa molomo le sone mme se akofisa bolwetse jo bo bolayang jwa mediastinitis le go phutlhama ga makgwafo. Fa molomo o latswa botlha morago ga go kgwa, motho yono a ka nna a tlhatswa molomo wa gagwe ka metsi ka iketlo mme a kgwa diperesente di le 100 tsa one mo sinking a sa metse le fa e le lerothodi.

Boraro jwa ga Mackler mo bolwetseng jwa Boerhaave ke eng?¶

Mackler’s triad ke motswako wa dibukathuto tsa bogologolo wa matshwao a mararo a a supang gore mometso o thubegile: (1) go kgwa ka maatla kgotsa go tlhotlhora, go latelwa ka bonako ke (2) botlhoko jo bo botlhoko jwa tshoganyetso, jo bo botlhoko mo sehubeng se se kwa tlase kgotsa mo mpeng e e kwa godimo, le (3) go nna le emphysema e e ka fa tlase ga letlalo le baseath the trapped of the marapo a molaleng a a thunyang le go phatloga jaaka Rice Krispies kgotsa bubble wrap fa a kgomiwa ka bonolo ka dintlha tsa menwana). Ka gonne go ka tsaya diura di le 1 go ya go di le 6 gore mowa o o tswang mo sehubeng o tlhatlogele kwa godimo go tsena mo letlalong la molala, o tshwanetse go leletsa ditirelo tsa tshoganyetso ka bonako fa o na le botlhoko jo bo tseneletseng jwa sehuba morago ga go kgwa le fa go phatloga ga molala go ise go tlhagelele.

Bolwetse jwa Boerhaave bo farologana jang le go gagoga ga keledi ya ga Mallory-Weiss?¶

Maemo ano ka bobedi a bakwa ke go kgwa kgotsa go kgwa ka maatla, ka jalo gantsi a tlhakatlhakanngwa. Go gagoga ga Mallory-Weiss ke go ngapa fela go go seng boteng mo letlalong le le kafa teng la mucosal koo mometso o kopanang le mpa gone; lebota le le kwa ntle la mesifa le nna le sa senyega gotlhelele, ka jalo ga go na sepe se se dutlelang mo sehubeng, botlhoko ga bo botlhofo kgotsa ga bo yo, letshwao le legolo ke go kgwa methalo e mehibidu e e phatsimang ya madi, mme diperesente di le 90 di fola ka botsone mo malatsing a le mmalwa. Letshwao la Boerhaave ke go thunya ka botelele jo bo tletseng mo dikarolong tsotlhe tsa lebota la mometso go tsena mo lerobeng la sehuba; e baka botlhoko jo bo gagogang jwa 10/10 mo sehubeng le mo mokwatleng, go tlhaela mowa, le go tshoga ka bonako ga septic, gantsi go na le madi a mannye kgotsa go se na madi ape mo matlhatseng, mme e tlhoka go tswalwa ka tshoganyetso ka karo kgotsa ka endoscope gore e kgone go tshela.

Ke ka ntlha yang fa bolwetse jwa Boerhaave bo lemogiwa ka tsela e e sa siamang gantsi jaana mo diureng di le mmalwa tsa ntlha?¶

Ka gonne bolwetse jwa Boerhaave bo tlhagelela ka botlhoko jo bo gagogang ka tshoganyetso jwa sehuba, botlhoko jwa mokwatla, go tlhaela mowa, go fufulelwa le kgatelelo e e kwa tlase ya madi, kwa tshimologong dingaka le bathusi ba kalafi ba akanya ka maemo a tshoganyetso a a tlwaelegileng thata a sehuba a a tshwanang le go ema ga pelo (myocardial infarct), go gagoga ga aorta (aortic dimona in . embolism), seso se se phunyeleditsweng mo mpeng, kgotsa bolwetse jo bo botlhoko jwa manyike. Go bolelela mooki wa triage le ngaka ka tlhamalalo gore botlhoko jwa sehuba bo iteile ka nako e e tshwanang ya go tsholetsa kgotsa go kgwa go go omileng go go bogale ke selo sa konokono se se dirang gore go dirwe CT esophagogram ya pharologano ka bonako.

Ke ka ntlha yang fa go falola go wela tlase thata jaana fa bolwetse jwa Boerhaave bo sa alafiwe mo lobakeng lwa diura di le 24?¶

Fa go lemogiwa gore go na le mometso o o thubegileng le go baakanngwa ka karo (kgotsa go tswalelwa ka stent ya endoscopic kgotsa sepontšhe sa vacuum) mo diureng tsa ntlha di le 12 go ya go di le 24, dintlha tsa mesifa ya mometso di sa ntse di itekanetse e bile di tshwara meroko sentle, mme seno se felela ka gore motho a kgone go falola ka diperesente di le 85 go ya go di le 90+. Morago ga diura di le 24 go ya go di le 48 tsa go ina mo esiti ya mala, diensaeme tsa tshilo ya dijo, le dibakateria tsa molomo, dintlha tsa mometso di ruruga, di bola, e bile di phatloga jaaka pampiri e e metsi ya dithishu (e sa kgone go tshwara ditlhako), fa mediastinitis e e tlhomilweng ya polymicrobial le septic drive up to40.

Metswedi le kaelo ya semmuso¶

• Mokgatlho wa Lefatshe wa Karo ya Tshoganyetso (WSES, Boditšhabatšhaba): Maemo a Tshoganyetso a Mometso: Dikaelo tsa WSES (Chirica et al., Lekwalodikgang la Lefatshe la Karo ya Maemo a Tshoganyetso, tsela ya go tlhatlhoba CT esophagogram e e nwelelang mo metsing, go akaretsa diokobatsi le dibolayamegare, <24-hour paakanyo ya karo kgatlhanong le go tsenngwa ga stent ka endoscope le kalafi ya EndoVAC).
• Mokgatlho wa Yuropa wa Endoscopy ya Mala (ESGE, Yuropa): Kaelo ya ESGE ya go Tlhatlhoba le go Laola Diphunyego tsa Mala (Go akaretsa le Bolwetse jwa Boerhaave, Distente tsa Tshipi tse di Atolosiwang ka Botsone tse di Khurumeditsweng, OTSC, le Kalafi ya Endoscopic Vacuum).
• Mokgatlho wa Amerika wa Karo ya Sehuba (AATS) & Mokgatlho wa Dingaka tsa Sehuba (STS, United States): Dikaelo tsa Tumelano ya Baitseanape ka ga Taolo ya go Punyega ga Mometso le Bolwetse jo bo Botlhoko jwa Mediastinitis.
• Kholetšhe ya Amerika ya Mala (ACG, United States): Dikaelo tsa Kalafi tsa go Laola go Dula Madi mo Mala a a Kwa Godimo, Bolwetse jwa Mallory-Weiss, le Kgobalo ya Mometso e e Bakiwang ke Barogenic.
• Setheo sa Bosetšhaba sa Boitekanelo le Tlhokomelo ya Boleng jo bo kwa Godimo (NICE) & Mokgatlho wa Karo ya Mala a a Kwa Godimo wa Great Britain le Ireland (AUGIS, United Kingdom): Taolo ya Tshoganyetso ya go Punyega ga Mala (Bolwetse jwa Boerhaave) Maemo a Kalafi.

Dikaedi tse di tsamaelanang¶

• Go dutla madi mo mpeng, go kgwa madi (hematemesis) le melena .
• Go thubega ga ditshika tsa mometso, go dutla madi ga bolwetse jwa sebete, le bolwetse jwa boboko jwa sebete
• Lerapo la tlhapi le le meditsweng, lerapo la koko, le go ama ga dijo tsa mometso
• Go anya ntho ya sehuba le go gagamala ga pneumothorax thuso ya potlako
• Go phatlolwa ga aorta le go thubega ga aorta ya mo mpeng