I-Esophageal Rapture (Boerhaave Syndrome), I-Mallory-Weiss Tears, Nobuhlungu Besifuba Sokuphalaza¶

I-Boerhaave syndrome iyisimo esiphuthumayo esiyingozi, esisongela ukuphila sokuhlinzwa kwesifuba lapho ukuqhuma okungazelelwe, okuqhumayo kwengcindezi ngaphakathi kommizo phakathi nokudonsa ngamandla noma ukuhlanza kuklebhula imbobo ewugqinsi (transmural perforation) yonke indlela odongeni lomminzo ongezansi wethoracic. Ngokungafani nezinyembezi ezikha phezulu i-Mallory-Weiss (eklwebha kuphela ulwelwesi lwe-mucosal olungaphakathi lokuhlangana kwesisu futhi ibangele igazi elibomvu ngokugqamile emhlanzweni ngaphandle kokubhoboza isifuba), i-Boerhaave syndrome iqhumisa isisu esine-asidi, ama-enzyme okugaya ukudla, amathe, izinhlayiya zokudla zingene emlonyeni* we-oral bacteria. indawo ye-pleural **). Ngenxa yokuthi umphimbo awunalo ulwelwesi lwe-serosal oluqinile lwangaphandle, lokhu kungcoliswa kwamakhemikhali namagciwane kubangela ukuthi i-fulminant acute necrotizing mediastinitis, empyema, tension hydropneumothorax, kanye nokushaqeka kwe-septic emahoreni ambalwa. Uma umuntu okade ehosha noma ehlanza (ikakhulukazi uma ezama ukubamba ukuhlanza) ngokuzumayo kuvela isifuba esibuhlungu esingezansi, i-abdome engenhla, noma iqolo, ukuphelelwa umoya, noma amabhamuza omoya ngaphansi kwesikhumba sentamo (i-Mackler's triad), shayela indawo yangakini. izinombolo eziphuthumayo ngokushesha. Ngenkathi usalinde abezimo eziphuthumayo, buyekeza imihlahlandlela ehlobene yezimo eziphuthumayo ku- ukopha emathunjini kanye negazi lokuhlanza, ukuqhekeka kwemithambo yommizo kanye nokopha kwe-cirrhosis, futhi ugwinye ithambo lenhlanzi, ithambo lenkukhu, kanye nokuthinta ukudla.

Ngenxa yokuthi i-Boerhaave syndrome engelashiwe ibulala cishe ngamaphesenti angu-100 (futhi ukufa kuphindeka kabili uma ukuhlinzwa noma ukuvalwa kwe-endoscopic kubambezeleka esikhathini esidlule amahora angu-24), umthetho wakho owodwa obaluleke kakhulu wosizo lokuqala ekhaya uthi I-NPO eqinile (akukho lutho ngomlomo: ngisho nokuphuzwa nokukodwa kwamanzi okugeza umlomo ngemva kokuhlanza), njengoba ukhipha imbobo egobhozayo yonke igodi eliqondile. isifuba sesifuba.

Yenza lokhu manje¶

1. Shayela inombolo yakini yezimo eziphuthumayo ngokushesha futhi ubike i-Esophageal Perforation/Boerhaave Syndrome esolwayo. Shayela u-911 e-United States nase-Canada, 112 yonkana i-European Union, 999 e-United Kingdom, 000 e-Australia, noma uhlole uhlu lwethu izinombolo eziphuthumayo. Yisho ngokucacile: "I-Boerhaave Syndrome esolwayo / i-ruptured esophagus: isifuba esibuhlungu ngokuzumayo nangaphezulu ngemuva kokuhlanza okunamandla, nokuphefumula."
2. Sebenzisa ngokuphelele, i-NPO eqinile (i-ZERO water, zero ice chips, zero antacids, zero oral pills). Ngemva kokuhlanza, umzwelo ongokwemvelo womuntu uwukuphuza ingilazi yamanzi, i-ginger ale, noma i-antacid ewuketshezi ukuze ahlanze ukunambitheka okumuncu emlonyeni wakhe nokuthobisa isifuba sakhe esishisayo. Uma umuntu efisa ukugeza umlomo wakhe, angase athambise amanzi abandayo futhi akhafulele amaphesenti angu-100 awo kusinki, kodwa akumelwe angalokothi agwinye neconsi elilodwa. Uketshezi olugwinyiwe lugeleza luqonde odambweni lomminzo luye endaweni ye-mediastinum kanye ne-pleural ezungeze inhliziyo nephaphu lesokunxele, lugeze izigidi zamagciwane omlomo angene ngqo esifubeni.
3. Misa isiguli sihlezi siqondile sibe ngamadigri angu-30 kuya kwangu-45 (noma sincike kancane phambili) ukuze unciphise ukuphefumula futhi wehlise i-acid reflux. Ukulala phansi ngomhlane kuvumela i-gastric acid nenyongo ukusuka esiswini ukuthi iyehle iye phezulu nge-sphincter yomminzo engezansi futhi ithulule ngonyembezi lomminzo ungene emgodini wesifuba. Ukuhlala uqonde ngqo kusebenzisa amandla adonsela phansi ukugcina i-asidi yesisu phansi esiswini futhi kusiza amaphaphu ukuthi akhule ngokumelene nokukhula kwe-pleural effusion kwesokunxele noma i-pneumothorax.
4. Hlola isisekelo sentamo nama-collarbones ukuthi "irayisi-krispie" iyaqhekeka yini ngaphansi kwesikhumba (i-subcutaneous emphysema / Mackler's triad). Phumula kahle amaphedi ayisicaba eminwe yakho phezu kwembobo engenhla kwethambo lesifuba (i-notch e-suprasternal), ngaphesheya kwamathambo, kanye nasezinhlangothini zentamo. Uma uzwa amabhamuza omoya amancanyana ephuma futhi eklayeka ngaphansi kwesikhumba njengephepha lethishu noma okusanhlamvu kwerayisi okukhukhumele (crepitus), noma uma intamo ibonakala ikhukhumele futhi izwi lomuntu lizwakala liphuma emakhaleni noma likhala, umoya ophuma kummizo odabukile ulandele i-mediastinum entanyeni.
5. UNGANIKEZI i-aspirin, ibuprofen, nanoma yimiphi imithi ephuzwayo, futhi ugweme ukuphinda ubambe umlomo noma uphalaze. Tshela abezimo eziphuthumayo ngokushesha lapho befika ukuze bakwazi ukunikeza imithi yokwelapha efakwa emithanjeni (ondansetron) ngokushesha ukuze bayeke ukuphindezela (njengoba yonke into eyomile impompa umoya owengeziwe ne-asidi yesisu ngezinyembezi esifubeni).
6. Qapha ngokucophelela ukushaqeka okusheshayo, i-cyanosis, ne-tension pneumothorax. Uma unyembezi lomminzo luklebhula i-pleura eseduze ye-left mediastinal pleura, umoya noketshezi lwesisu kugcwala isikhala esizungeze iphaphu lesokunxele, kugoqe iphaphu futhi kusunduzele inhliziyo ohlangothini lwesokudla lwesifuba.

Isihlahla sesinqumo: ubuhlungu besifuba ngemva kokuhlanza, i-hematemesis, kanye ne-Boerhaave syndrome triage¶

flowchart TD
    Start["Ukubuya ngamandla, Ukoma Komile, noma Ukuhlanza Okulandelwa Ubuhlungu Besifuba, Ubuhlungu Besisu Esingenhla, noma Ukuphalaza Igazi"] --> CheckMackler{"Isinyathelo 1: Hlola i-Boerhaave Syndrome & Mackler Triad Red Flags: Ubuhlungu obungalindelekile obuklebhula isifuba esingezansi noma ubuhlungu beqolo, amabhamuza omoya oqhephukayo ngaphansi kwesikhumba sentamo (crepitus), ukuphefumula kanzima, noma i-Hamman crunch?"}

    CheckMackler -->|"YEBO kunoma iyiphi ifulegi elibomvu"| Boerhaave["OKUSOLWA I-BOERHAAVE SYNDROME (UKUKHISHUKA KWE-ESOPHAGEAL ESOPHAGEAL OKUSOLWAYO): Shayela Izinkonzo Eziphuthumayo (911 / 112 / 999) Ngokushesha; Iwindi legolide lamahora angu-24 lokuvimbela i-Fatal Mediastinitis"]

    CheckMackler -->|"AKUKHO isifuba esinzima noma ubuhlungu beqolo noma i-dyspnea; Isiguli sihlanza imivimbo yegazi ebomvu ngokugqamile ngemva kokuphinda"| MalloryCheck{"Isinyathelo sesi-2: Lingakanani Igazi & Ingabe Isiguli Sinesifo Sokuqina Kwesibindi?"}

    MalloryCheck -->|"I-Cirrhosis eyaziwayo / i-Portal Hypertension NOMA Igazi elinevolumu enkulu, amahlule amnyama, isiyezi, noma indle emnyama"| Varices["I-GI EPHEZULU Esongela Impilo NOMA UKUCHITHWA KWE-VARICEAL: Shayela ku-911 Ngokushesha, Isikhundla Eceleni, I-NPO Eqinile"]

    MalloryCheck -->|"Imivimbo emincane yegazi elibomvu elikhanyayo ngemva kokuhlanzwa okujwayelekile okuningana, akukho buhlungu besifuba, ukuphefumula okuvamile, ukushaya kwenhliziyo evamile kanye ne-BP."| MalloryWeiss["I-Mallory-Weiss Mucosal Tear Esolwayo: Gcina ngokuqinile i-NPO futhi uye eMnyangweni Wezimo Eziphuthumayo Esibhedlela ukuze uhlolwe i-hemoglobin, i-IV proton pump inhibitor, kanye nokubhekwa"]

    Boerhaave --> StrictNPO["1. I-NPO EQINILE: UNGAgwinyi Ngisho Nokuphuza Okukodwa Kwamanzi (Uketshezi olugwinywe luthela unyembezi esifubeni ngqo); Hlala uqonde ngqo kuma-degree angama-30 kuye kwangama-45 ukuze ugcine i-asidi yesisu iphansi"]

    StrictNPO --> HospitalBundle["2. Inqwaba Esheshayo Yokuxilongwa Nokuvuselela Esibhedlela: IV Ondansetron, IV Proton Pump Inhibitor, Broad-Spectrum IV Antibiotics + Antifungal (Fluconazole), CT Esophagogram With Water-Soluble Contrast (Gastrografin, NEVER Barium), kanye Nokulungiswa Kokuhlinzwa / Endoscopic Stent"]

I-Anatomy kanye ne-pathophysiology: kungani umphimbo uhlezi ukhala endaweni efanayo (Udonga Lwe-Posterolateral Lwesobunxele)¶

Okokuqala kwachazwa ngo-1724 udokotela ongumDashi uHerman Boerhaave ngemva kokuhlola isidumbu sikaBaron Jan von Wassenaer, u-Grand Admiral we-Dutch Fleet (owazitika edilini elikhulu, wakhipha umjuluko, waklabalala, wamemeza ngokuthi "kukhona okuqhume esifubeni sakhe esingezansi," futhi wafa ngemva kwamahora angu-18 edada elishisayo esifubeni sakhe. I-Boerhaave syndrome (i-barogenic esophageal rupture) ilandela imithetho ye-biomechanical ebikezelwayo.

1. Kungani ama-90% e-Boerhaave eqhekeka e-Lower Left Posterolateral Esophagus¶

Lapho ukuhlanza okuqhumayo kushayela ingcindezi ye-intraluminal ngaphakathi kommizo ngenhla 150 kuya ku-300 mmHg, ukudabuka cishe njalo kwenzeka njengokuhlukana kobude obuqondile ** obumasentimitha angu-1 kuye ku-4) odongeni olungemuva kwesobunxele lwe-distal intrathoracic esophagus, ncamashi u-2 kuya ku-4 we-justro ngenhla* i-diaphragm). Ubuthakathaka obune be-anatomical buhlangana kule ndawo ngqo (**Iphuzu le-Korn's anatomical elibuthakathaka **):

1. Ukuntuleka kongqimba lwangaphandle lwe-serosal: Ngokungafani nesisu namathumbu, asongwe ngejazi langaphandle eliqinile, eline-fibrous elibizwa ngokuthi serosa (visceral peritoneum) elicebile nge-collagen kanye nemicu enwebekayo, ithoracic esophagus ayinayo nhlobo i-serosa **, okushiya imicu yemisipha enqunu ixhumeke ngqo kusicubu esinqunu se-loosestinum.
2. Ukuncipha nokusabalala kwemicu yemisipha yelongitudinal: Engxenyeni yesithathu engezansi yomminzo, inqwaba yemisipha ebushelelezi yelongitudinal yangaphandle iyanyakaza futhi ihlukaniseke njengefeni njengoba itshuza phansi ukuze ifake kunhliziyo yesisu.
3. Izimbobo zemithambo-luvo ngodonga lwemisipha: Odongeni olungakwesokunxele lwe-posterolateral ngenhla nje kwe-diaphragm, amagatsha omthambo we-gastric wesokunxele kanye ne-vagus nerve abhoboza ngokuqondile ungqimba lomsipha oyisiyingi, okudala ukukhubazeka kwesakhiwo semvelo (loci minoris resistentiae).
4. Ukuntula kwesitho sangaphandle esiqinisayo ohlangothini lwesobunxele: Ngenkathi uhlangothi lwesokudla nangaphambili komminzo ongezansi kuboshwe ngaphandle yi-thoracic aorta, umgogodla, i-pericardium, ne-vena cava, *udonga lwe-posterolateral lwesobunxele lwe-esophagus engezansi lugoqa ngokuqondile oluthambile, oluhambisanayo lwe-aorta yesokunxele, lunikeza ama-zerouras angaphakathi angemuva

2. I-Cascade ebulalayo: i-chemical mediastinitis elandelwa yi-polymicrobial septic shock¶

Lapho udonga lomminzo olungezansi kwesokunxele luvuleka, wonke umoya isiguli esiwuthathayo ufana nephampu ye-vacuum: ngenxa yokuthi isifuba (i-pleural space kanye ne-mediastinum) sihlala ngaphansi negative intrathoracic pressure (-5 ku -10 cmH2O) ngesikhathi sokuhogela kuyilapho isisu esingaphansi kwe-diaphragm singaphansi kwe-positive intra-abdominal pressure, isisu simuncwa ngokuqhubekayo siye phezulu siphume esiswini futhi sifuthwe ngezinyembezi zomphimbo ziye esifubeni:

• Amahora 0 kuya ku-6 (Chemical Mediastinitis and Third-Space Shock): I-Hydrochloric stomach acid (pH 1.5 kuya ku-2.0), i-pepsin, ne-bile egaywe kabusha igaya amafutha aphakathi nendawo futhi ishise i-pleura ye-mediastinal encane kwesokunxele, ithela uketshezi nomoya engxenyeni yesifuba esingakwesokunxele (**u-0, kwesokunxele se-hydropne engu-0) amacala). Ukuvuza okukhulu kwe-capillary kudonsa amalitha e-plasma kuphume emgudwini wegazi kuya esifubeni, kubangele ukushaqeka okusheshayo kwe-hypovolemic.
• Amahora 6 kuya ku-24+ (Fulminant Polymicrobial Necrotizing Mediastinitis): Amagciwane omlomo nangaphezulu e-GI (Streptococcus viridans, Staphylococcus, Enterobacterales, ama-anaerobes omlomo afana ne-Prevotella kanye ne-Bacteroides i-multiple* yezinhlobo*, *** izindiza ze-avascular ze-posterior mediastinum ezizungeze inhliziyo, i-aorta, namaphaphu, ukushayela ukufa kusuka ku-*ngaphansi kuka-10 kuya kumaphesenti angu-15 ** (uma zivalwe ngokuhlinzwa phakathi kwamahora angu-12 kuya kwangu-24) kufika ku-40 kuya ku-60+ amaphesenti (uma ibambezelekile emahoreni angama-24 kuya kwangu-48).

Ukuhlukanisa i-Boerhaave syndrome, izinyembezi ze-Mallory-Weiss, kanye ne-Esophageal Varices¶

Ngenxa yokuthi zontathu lezi zimo zihilela ukuqaqanjelwa, ukuhlanza, kanye nezimpawu ezingenhla zesisu, ukuhlukanisa ukujiya okugcwele Ukugqabuka kwe-Boerhaave nokukhala okukha phezulu I-Mallory-Weiss mucosal izinyembezi noma ukuphuma kwegazi kwe-cirrhotic variceal kubalulekile:

Ukuqaphela i-Mackler's Triad, i-Anderson's Triad, ne-Hamman's Sign eceleni kombhede¶

Odokotela bathembele kuma-triad amabili ajwayelekile aseceleni kombhede kanye nezimpawu ezintathu zokuhlolwa ngokomzimba ukuze babambe i-Boerhaave syndrome ngaphambi kokuba ihlonzwe kabi njengesifo senhliziyo, i-aorta dissection, i-pulmonary embolism, noma i-pancreatitis eyingozi:

1. I-Mackler's Triad (I-classic textbook triad ye-Boerhaave syndrome)¶

1. Ukuhlanza Okunamandla Noma Ukuphinda Ubuye (yize ngezinye izikhathi kubangelwa ukukhwehlela okunodlame, ukuphakamisa izinsimbi, isithuthwane, ukudonsa kanzima lapho ebeletha, noma ukuhlaselwa yisifuba somoya).
2. Isifuba Sesifuba Esinamandla Esinamandla Esiphansi Esingezansi / Ubuhlungu Be-Epigastric Engenhla (imvamisa buphuma buqonde emuva kwesokunxele noma ihlombe lesobunxele nge-phrenic nerve).
3. I-Subcutaneous Emphysema (Cervical Crepitus) Entanyeni kanye Ne-Supraclavicular Fossa: Umoya ogwiniwe ophuma ngembobo yomphimbo engezansi ulandelela phezulu eduze kwezindiza ze-fascial ze-mediastinum phakathi kwentamo, lapho ungawuzwa uphuma njengokugoqa kwebhamuza ngaphansi kweminwe yakho.

Isixwayiso somtholampilo: Nakuba i-triad ka-Mackler iyi-pathognomonic (iphesenti elingu-100 lokuxilonga uma likhona), zonke izingxenye ezintathu zivela ndawonye ekubonisweni kokuqala ngamaphesenti angu-15 kuya kwangu-30 kuphela eziguli ngoba umoya ungathatha 1 kuya kumahora angu-6 ukubhoboza kusukela esifubeni esingezansi kuya esikhumbeni sentamo. Ungalokothi ukhiphe i-Boerhaave syndrome ngoba nje i-neck crepitus ayikaveli.

2. I-Anderson's Triad kanye Nesibonakaliso sikaHamman ("I-Mediastinal Crunch")¶

• I-Anderson's Triad: I-subcutaneous neck emphysema + Ukuphefumula okungajulile ngokushesha (tachypnea) + Ukuqina kwesisu (okubangelwa ukucasuka kwe-diaphragmatic kanye ne-epigastric engenhla elingisa isilonda esiswini esinembobo).
• I-Hamman's Sign (I-Mediastinal Crunch): Lapho umsebenzi wezimo eziphuthumayo noma udokotela elalele ngaphambili kwenhliziyo (precordium) nge-stethoscope ngenkathi isiguli silele ngohlangothi lwaso lwesobunxele, konke ukushaya kwenhliziyo kuveza umsindo omkhulu onomsindo, ochofozayo, ohlikihlayo, noma ophuphumayo ohambisana nokushaya kwenhliziyo (okubangelwa ukushaya kwenhliziyo) umoya uvaleleke ngaphakathi kwe-mediastinum.
• Ukushintsha Kwezwi ("Rhinolalia" noma "Donald Duck / Brass Voice"): Njengoba umoya we-mediastinal uhlahlela phezulu ungene endaweni ye-retropharyngeal kanye ne-parapharyngeal yomphimbo, kungazelelwe izwi lesiguli lithatha i-timbre eyinqaba, ephezulu, ekhalayo, ekhalayo amahora ngaphambi kokuba kubonakale ukuvuvukala kwentamo okubonakalayo.

Kungani izithombe zasesibhedlela kufanele zisebenzise I-Water-Soluble Contrast (Gastrografin) kanye ne-NEVER Barium kusenesikhathi¶

Ngenxa yokuthi i-X-ray yesifuba esicacile ingabukeka ngendlela ekhohlisayo evamile emahoreni angu-1 kuya kwangu-3 ngaphambi kokubonisa imivimbo yomoya ye-mediastinal (uphawu lwe-V lwe-Naclerio* emngceleni ongezansi kwesokunxele wenhliziyo), ukuphuma kwe-pleural kwesokunxele, noma i-pneumothorax, World Society of Emergency Surgery (WSES) imihlahlandlela yokuxilonga:

1. Ukuhlolwa Okujwayelekile Kwegolide: I-CT Esophagogram Ethuthukisiwe Ngokuqhathanisa Nomlomo Oncibilika Ngamanzi¶

Uma isiguli siphapheme futhi sikwazi ukugwinya ukuhlolwa kokuxilonga ngaphakathi kwe-CT scanner (noma ngeshubhu le-nasoesophageal elibekwe ukunakekelwa okwedlulele nguchwepheshe): - Odokotela banikeza klzzwxh:0024 ngokushesha aphambi kokwenza i-Thoracoabdominal CT Scan**. - I-CTcan inokuzwela amaphesenti angama-92 kuye kwayi-100, ngokushesha abonisa amabhamuza amancane omoya we-extraluminal mediastinal, ukujiya kodonga lomminzo, amaqoqo oketshezi lwe-perisophageal, kanye nendiza emhlophe ekhanyayo yokuhluka okuvuzayo ephuma kumminzo we-posterolateral wesokunxele ku-mediastinum noma i-pleural cavity yesokunxele.

2. Kungani i-Barium Sulfate inqatshelwe ngokuphelele njengokuhlola kokuqhathanisa kokuqala¶

3. I-Diagnostic Thoracentesis Clue (Pleural Fluid Amylase ne-pH)¶

Lapho odokotela befaka ishubhu lesifuba emthonjeni we-pleural wesokunxele wesiguli sase-Boerhaave, uketshezi olukhanyisiwe luvame ukunuka muncu njengokungathi lungaphakathi esiswini, luqukethe izinhlayiya zokudla, lune-acidic pH engaphansi kuka-6.0, futhi lunezinga eliphezululamathe le-amylase, okufakazela ukuthi amathe nejusi yesisu kuphuma kumminzo.

Ukwelashwa okuqondile esibhedlela: iwindi lokuhlinzwa lamahora angama-24, ama-endoscopic stents, kanye ne-EndoVAC¶

Uma i-Boerhaave syndrome isitholwe emnyangweni wezimo eziphuthumayo, ithimba lesibhedlela ngokushesha liqala WSES / AATS Esophageal Perforation Resuscitation Bundle:

1. I-NPO Eqinile + Ukuwohloka Kwe-Nasogastric: Kubekwe ngokucophelela (ngokuvamile ngaphansi kokubonwa kwe-endoscopic) ukuze kudonswe i-asidi iphuma esiswini.
2. I-High-Dose Intravenous Proton Pump Inhibitor (Pantoprazole noma i-Esomeprazole IV): Yenyusa i-pH yesisu ngaphezu kuka-6.0 ukuze imise i-hydrochloric acid ne-pepsin ekugayeni i-mediastinum.
3. I-Broad-Spectrum Intravenous Antibiotic KANYE Nokwelapha Nge-Intravenous Antifungal: Ngokungafani nokubhobozwa kwamathumbu angezansi, ukubhoboza komminzo kuvame ukuthwala izinhlobo ze-Candida* eziphuma emlonyeni nakumminzo (ikakhulukazi ezigulini ezithatha izivimba ze-asidi, ama-steroid, noma utshwala), okuphinda kabili ukufa uma kungelashwa. Imihlahlandlela incoma ukumbozwa kwe-antibacterial ye-spectrum IV ebanzi (piperacillin-tazobactam noma i-carbapenem [meropenem] + vancomycin) KUNYE ne-fluconazole ye-intravenous noma i-echinocandin (micafungin/caspofungin).
4. Ukuvalwa kanye Nokuthuthwa kwamanzi Kokubhobozwa (Ngaphakathi kwe <24-Hour Iwindi Legolide):
5. Ukulungiswa Kokuhlinzwa Okuyinhloko (I-Thoracotomy noma I-thoracoscopy / I-Laparoscopy Evama Kancane): Izinga legolide lomlando leziguli ezinempilo ezinokungcoliswa kwesifuba okungaguquliwe. Udokotela ohlinza isifuba uvula isifuba sesokunxele, ahlanze konke ukudla, i-asidi, nobomvu kusuka ku-mediastinum ne-pleural space, anqume imiphetho ye-necrotic ye-mucosal ne-muscular layers ukuze kuvezwe ubude obugcwele bokudabuka kwe-mucosal (okuhlala isikhathi eside kunokukhala kwemisipha yangaphandle), ukuthunga i-mucosa ehlukene ye-muscular ne-vascular layer. imisipha ye-intercostal, i-diaphragm, i-pleura, noma i-fundus yesisu (i-Thal/Dor patch) phezu komugqa we-suture ukuvimbela ukuphuka, okushiya amashubhu esifuba abanzi ukuze akhiphe amanzi.
6. I-Endoscopic Self-Expanding Covered Metal Stent (SEMS) noma i-Over-the-Scope Clip (OTSC): Ngezinyembezi ezincane ezibanjwa kusenesikhathi ngaphambi kokusabalala kwe-pleural sepsis, noma ezigulini ezibuthaka, odokotela be-gastroenterologist abangenele noma odokotela abahlinzayo besifuba babeka i-silicone embozwe nge-stent ekhishwayo embozwe nge-silicone ngaphakathi komminzo ngamunye. i-chest tube drainage.
7. I-Endoscopic Vacuum-Assisted Closure (EndoVAC / EVT): Impumelelo yesimanje yakho kokubili kokuqubuka komminzo kwangaphambi kwesikhathi nokubambezelekile (>amahora angu-24). Isipontshi se-polyurethane esixhunywe kwishubhu lokumunca i-nasogastric sifakwa endoscopically ngqo ngaphakathi noma ngaphezulu komgodi wokubhoboza ngaphansi kwengcindezi eqhubekayo ye-vacuum negative (-125 mmHg), ngokuqhubekayo ukuncela ubomvu ngaphandle kwe-mediastinum ngenkathi igoqa i-cavity futhi ivuselela ukuphulukiswa kwe-granulation ngokushesha, ifinyelela **85 kuya ku-95% amazinga okuvala **.

Izimo ezinobungozi obukhulu kanye nezimbangela ezingahlanzi zokuqhekeka kwe-barogenic esophageal¶

Nakuba ukuhlanza okunamandla ngemva kokudla kakhulu noma ukuphuza utshwala kubangela izimo eziningi ze-Boerhaave Syndrome, odokotela baphinde babheke izimbangela ezimbalwa ezikhethekile lapho umfutho we-intra-esophageal ukhuphuka ngokuzumayo ngokumelene ne-sphincter engenhla evaliwe:

• I-hyperemesis gravidarum enzima, ukuhlanza ngamakhemikhali, noma ukuvinjwa kwamathumbu: Iziguli ezibhekana nokuguquguquka okungapheli phakathi namahora zingathuthuka ukusuka ekuklwekeni okuncane kwe-Mallory-Weiss mucosal kuya ekuqhumeni okukhulu kwe-Boerhaave uma imishanguzo ye-antiemetic ibambezeleka.
• Ukungenisa ngokushesha umthamo omkhulu woketshezi olune-carbonated noma i-polyethylene glycol bowel prep: Ukuphuza amalitha oketshezi lokulungiselela i-colonoscopy ngokushesha bese ubuyisela ngamandla esiswini esigobile kuyimbangela yasesibhedlela ebhalwe phansi yokugqabuka komminzo.
• I-Valsalva inyakaza ngokwedlulele ngaphandle kokuhlanza: Akuvamile, ukugqashuka kommizo we-barogenic kwenzeka ngesikhathi sokuphakamisa amandla kakhulu (ukuphakamisa umzimba noma i-squats ene-glottis evaliwe), ama-paroxysms anobudlova wokukhwehlela, isimo se-asthmaticus, isithuthwane esikhulu se-mal mal, noma ukucindezela ngamandla ngesikhathi sokubeletha. Noma nini lapho noma yisiphi salezi zenzakalo silandelwa ukudabuka kungazelelwe ubuhlungu be-retrosternal kanye ne-neck crepitus, phatha isiguli ngaphansi kwe-NPO eqinile efanayo kanye nephrothokholi yezokuthutha eziphuthumayo.

Izinombolo zezimo eziphuthumayo zesifunda kanye nezinqubomgomo ze-ejensi¶

I-Boerhaave syndrome esolwayo idinga ukuthuthwa kwe-ambulensi ngokushesha ukuya esibhedlela semfundo ephakeme i-CT scanning yamahora angu-24, Ukuhlinzwa Kwesifuba noma Upper-GI, I-Interventional Endoscopy, kanye Nokunakekelwa Okujulile:

• I-United States ne-Canada: Dayela u-911*. Cela izinto zokuhamba eziya emnyangweni omkhulu wezimo eziphuthumayo esibhedlela (ungalokothi ube umtholampilo ozimele wokunakekelwa okuphuthumayo).
• E-United Kingdom: Dayela u-999* ukuze uthole i-ambulensi yesimo esiphuthumayo Yesigaba ½ esibhedlela esikhulu esibucayi Umnyango Wezimo Eziphuthumayo (A&E) esineyunithi Yokuhlinza E-Upper-GI/Oesophagogastric.
• I-European Union: Shayela 112. Iphethwe ngaphansi kwe- World Society of Emergency Surgery (WSES) Izinkombandlela Zezimo Eziphuthumayo kanye ne-European Society of Gastrointestinal Endoscopy (ESGE) amaphrothokholi.
• I-Australia ne-New Zealand: Dayela u-000* e-Australia noma 111 eNew Zealand.
• I-India ne-Asia-Pacific: Dayela u-112* (noma 108 e-India), 995 e-Singapore, 119 e-Japan naseNingizimu Korea, noma 999 e-Malaysia nase-Hong Kong. Cela isikhungo semfundo ephakeme esinekhono le-cardiothoracic noma lokuhlinza le-gastroenterology.

Imibuzo ejwayelekile ukubuzwa¶

Kungani kuyingozi ukubamba ngamandla noma ukuvala ukuhlanza?¶

Uma umzimba wakho uvusa i-reflex yokuhlanza, i-diaphragm yakho nemisipha yesisu ifinyela ngamandla amakhulu ukukhiphela isisu phezulu kuyilapho i-sphincter ephezulu ye-esophageal engaphezulu komphimbo wakho ikhululeka ngokuzenzakalelayo ukukhipha ukuhlanza. Uma ubophela umlomo nomphimbo wakho uvale ukuze uziyekise ukuhlanza esidlangalaleni, lelo gagasi lomfutho ophezulu woketshezi negesi lishaya umnyango okhiyiwe phezulu kommizo, umfutho we-spiking ngaphakathi kommizo ongezansi udlule u-200 mmHg futhi uvuvuze imbobo ewugqinsi kwesokudla odongeni lomminzo olungezansi kwesokunxele lungene emgodini wakho wesifuba.

Kungani umuntu okusolakala ukuthi yi-Boerhaave syndrome engakwazi ukuphuza ngisho isiphuzo esisodwa samanzi ngemva kokuhlanza?¶

Ku-Boerhaave syndrome, kunembobo evulekile odongeni lomminzo ongezansi oholela ngqo ku-mediastinum oyinyumba (ezungeze inhliziyo) kanye nesikhala se-pleural kwesokunxele (ezungeze iphaphu lesokunxele). Konke ukuphuzwa kanye kwamanzi, i-ginger ale, noma i-antacid ewuketshezi umuntu ayigwinya iwathela aqonde kuleyo mbobo endaweni yesifuba, ethwele izigidi zamagciwane omlomo ngawo futhi asheshise i-necrotizing mediastinitis ebulalayo kanye nokuwa kwamaphaphu. Uma umlomo uzwakala umuncu ngemva kokuhlanza, lowo muntu angase ageze kancane umlomo wakhe ngamanzi bese ekhafula amaphesenti angu-100 awo kusinki ngaphandle kokugwinya iconsi.

Iyini i-mackler's triad ku-Boerhaave syndrome?¶

I-Mackler's triad iyinhlanganisela yakudala yezimpawu ezintathu ezikhomba umminzo odabukile: (1) ukuhlanza okunamandla noma ukuhlehla, okulandelwa ngokushesha (2) ngokuzumayo, okubuhlungu kwesifuba sesifuba esingezansi noma ubuhlungu obungaphezulu besisu, kanye (3) ne-subcutaneous emphysema (amagwebu omoya avaleleke ngaphansi kwesikhumba se-cospilellar kanye ne-popopopopopopopopo yentamo noma i-ribble bubbles bopha lapho uthintwe ngobumnene ngeminwe). Ngenxa yokuthi kungathatha ihora eli-1 kuye kwayi-6 ukuze umoya osuka esifubeni ukhuphuke uye esikhumbeni sentamo, kufanele ushayele abezimo eziphuthumayo ngokushesha ukuze uthole ubuhlungu obukhulu besifuba ngemva kokuhlanza ngisho noma ukuklayeka kwentamo kungakaveli.

Ihluke kanjani i-Boerhaave syndrome kune-Mallory-Weiss izinyembezi?¶

Zombili lezi zimo zibangelwa ukuhlehla ngamandla noma ukuhlanza, ngakho-ke zivame ukudideka. Ukudabuka kwe-Mallory-Weiss kuwukuklwebheka okungashoni kulwelwesi lwamafinyila olungaphakathi lapho umphimbo uhlangana nesisu; udonga olungaphandle lwemisipha luhlala luqinile ngokuphelele, ngakho-ke akukho lutho oluvuzayo esifubeni, ubuhlungu buncane noma abukho, uphawu oluyinhloko ukuhlanza imivimbo ebomvu yegazi, futhi amaphesenti angu-90 aphulukisa ngokwawo phakathi nezinsuku ezimbalwa. I-Boerhaave syndrome ukuvunguza okujiyile kuzo zonke izingqimba zodonga lomminzo ukuya emgodini wesifuba; kubangela u-10/10 ukuklebhuka kwesifuba nobuhlungu beqolo, ukuphelelwa umoya, kanye nokushaqeka ngokushesha kwe-septic, ngokuvamile negazi elincane noma elingenalo nhlobo emhlanzweni, futhi kudinga ukuhlinzwa okuphuthumayo noma ukuvalwa kwe-endoscopic ukuze uphile.

Kungani i-Boerhaave syndrome ivame ukutholakala ngokungeyikho emahoreni ambalwa okuqala?¶

Ngenxa yokuthi i-Boerhaave syndrome iveza ubuhlungu besifuba obudabula kungazelelwe, ubuhlungu beqolo, ukuphelelwa umoya, ukujuluka, kanye nomfutho wegazi ophansi, odokotela kanye nabezimo eziphuthumayo baqale bacabange ngezimo eziphuthumayo zesifuba ezivame kakhulu njengokuhlaselwa yinhliziyo (i-myocardial infarction), i-aorta edabukile (i-aortic dissection), ihlule legazi ephashini (i-pulmonary acute embolism), isisu esibuhlungu. Ukutshela umhlengikazi kanye nodokotela ngokucacile ukuthi ubuhlungu besifuba bufike ngesikhathi lapho ukomisa okunamandla noma ukuhlanza kuyinkomba eyinhloko eyenza umehluko osheshayo we-CT esophagogram.

Kungani ukusinda kwehla kakhulu uma i-Boerhaave syndrome ingelashwa kungakapheli amahora angama-24?¶

Lapho i-esophagus ephukile ixilongwa futhi ilungiswa ngokuhlinzwa (noma ivalwe nge-stent endoscopic noma isiponji se-vacuum) phakathi namahora angu-12 kuya kwangu-24 okuqala, imiphetho yemisipha yommizo isenempilo futhi ibambe kahle imithungo, okuholela kumaphesenti angu-85 kuya kwangu-90+ izinga lokusinda. Ngemuva kwamahora angama-24 kuye kwangama-48 wokucwiliswa ku-asidi yesisu, ama-enzyme okugaya ukudla, namagciwane omlomo, imiphetho yomminzo iyavuvukala, i-necrotic, futhi inyakaze njengephepha lezicubu ezimanzi (elingakwazi ukubamba ama-sutures), kuyilapho kusungulwe i-polymicrobial mediastinitis kanye nokufa kwe-septic shock drive kuze kufike kumaphesenti angama-40 kuye kwangama-60 noma ngaphezulu.

Imithombo neziqondiso ezisemthethweni¶

• I-World Society of Emergency Surgery (WSES, International): Izimo Eziphuthumayo Ze-Esophageal: Izinkombandlela ze-WSES (Chirica et al., I-World Journal of Emergency Surgery, indlela yokuxilonga ye-CT esophagogram encibilikayo emanzini, ukumbozwa kwe-antibacterial kanye ne-antifungal, <24-hour ukulungiswa kokuhlinzwa ngokumelene ne-endoscopic stenting kanye ne-EndoVAC therapy).
• I-European Society of Gastrointestinal Endoscopy (ESGE, Europe): ESGE Guideline on Diagnosis and Management of Gastrointestinal Perforations (Kubandakanya I-Boerhaave Syndrome, I-Self-Expanding Metal Stents, OTSC, kanye ne-Endoscopic Vacuum Therapy).
• I-American Association for Thoracic Surgery (AATS) & Society of Thoracic Surgeons (STS, United States): Iziqondiso Zokuvumelana Kochwepheshe Ngokuphathwa Kwe-Esophageal Perforation kanye Ne-Acute Mediastinitis.
• I-American College of Gastroenterology (ACG, United States): Iziqondiso Zomtholampilo Zokuphathwa Kokopha Kwesisu Esingenhla, I-Mallory-Weiss Syndrome, Nokulimala Kwe-Barogenic Esophageal.
• I-National Institute for Health and Care Excellence (NICE) & Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS, United Kingdom): Ukulawulwa Okuphuthumayo Kwe-Oesophageal Perforation (Boerhaave Syndrome) Amazinga Omtholampilo.

Iziqondiso ezihlobene¶

• Ukopha emathunjini, igazi lokuhlanza (hematemesis), kanye ne-melena
• I-Esophageal varice iyaphuka, ukopha kwe-cirrhosis, kanye ne-hepatic encephalopathy
• Ithambo lenhlanzi eligwinywe, ithambo lenkukhu, kanye nokuthinta ukudla kommizo
• Ukuncela inxeba lesifuba kanye ne-tension pneumothorax usizo lokuqala
• I-aortic dissection kanye ne-aortic aneurysm yesisu ephukile