Fistula for Hemodialysis: Features of Use and Care - Family Clinic Support Yekaterinburg

Fistula for hemodialysis is a device for repeated hemodialysis. As a result of the impairment of kidney functions, renal failure is developing, accompanied by the removal of nitrogen exchange products, toxins, violation of the balance of electrolyte and acid-alkaline balance. Patients who develop acute or chronic kidney failure are prescribed hemodialysis.

Causes of arteriovenous fistula

Depending on the etiological factor, which caused the formation of shunt between the arterial and venous network, such types of fistula were highlighted:

  • congenital (diagnosed in rare cases)
  • traumatic (wounded bullet or knife)
  • postoperative (including after biopsy organ),
  • infectious genesis,
  • Artificial.

Arteriovenomous fistula The last variety is used in preparing the patient to conduct hemodialysis procedure in order to avoid daily piercing veins before cleaning the blood. In renal failure, treatment with an artificial kidney apparatus is used for a long period of time, with unrequisite, fistulus is removed surgically.

We recommend reading an article about arteriovenous malformation. From it you will learn about the pathology and its symptoms, the threat to the patient, diagnosis and treatment of the disease.

And here more about radio frequency ablation.

Advantages and disadvantages

The phenomenon under consideration has its advantages and disadvantages.

The first category includes:

  1. Easy installation operation.
  2. Light rehabilitation period.
  3. Availability to each patient.
  4. Reality with removal at any convenient moment.

Cons of such a phenomenon:

  1. The inability to accurately predict the consequences in all cases.
  2. The difficulties of the elimination operation in some congenital pathologies.
  3. Risk of re-intervention.

Circulation in the zone

Symptoms of the disease is associated with the localization site of fistula, but there are also general hemodynamic disorders characteristic of all such states:

  • Arterial failure (syndrome of the condemium) - due to the flow of blood in the venous bed in the arteries, blood pressure drops, and the tissue and oxygen deficiency are tested in the zone of blood supply.
  • A drop in systemic blood pressure with manifestations of blood circulation deficiency, shortness of breath, increased pulse frequency.
  • The formation of venous aneurysm under the influence of pressure on which the resistance of the vein wall is not calculated. Over time, a gap with intense bleeding can occur.
  • Vessel thrombosis due to slowing down the blood current in the branches below the fistula zone.

How to prick on hemodialysis

Pravdia rules:

  1. The puncture is carried out at a distance of 3-4 cm from the anastomosis.
  2. The arterial needle to establish antegrade, in the case of retrograde accommodation, the hematoma is possible on the site of the puncture.
  3. The venous needle is installed only on blood flow.
  4. In the case of applying a dialysis dialy diagram, the needle has a blood stream.
  5. The puncture of the fistula is carried out in a new place (there is probably the development of aneurysm due to thinning the walls of the vessel).

Signs of arteriovenous fistula internal organs

The clinical picture with small formations, as a rule, erased. A large discharge of blood leads to a pronounced violation of the body, as its power supply and removal of metabolic products changes.

Dural

If there is a direct message between the artery and the vein, which are located in a solid shell of the head or spinal cord (from Latin durus, solid) fistulas occur. Unlike other abnormalities of the vessel structure, they are acquired.

Their formation is associated with suffered injuries, infectious processes, thrombosis of the vascular bed.

Arteriovenous spinal cord fistula

In its development, the branches of segmental arteries are involved, which depart from the aortic trunk and veins flowing into the general venous plexus. The most characteristic is the location in the lumbar spine. The clinical picture is associated with the squeezing of nerve fibers or the tissue of the spinal cord itself. The course of the disease is usually slowly progressive. The signs of spinal fistula solid shell include:

  • weakness in the legs, up to the pack or paralysis;
  • decline in all types of sensitivity;
  • disorder of the intestine;
  • urinary incontinence;
  • Impotence in men.

Speishes between the arteries and veins of the brain

The fistulas of the brain form a branching of a sleepy or vertebral artery, less often they are located in the brain sinus. The danger of their occurrence is associated with the high risk of gap and hemorrhage in the brain.

At the same time, such symptoms are noted:

  • sharp and intense headache
  • nausea, vomiting,
  • impairment
  • Chaotic movements of eyeballs (Nistagm),
  • noise in ears,
  • Flow of blood pressure.

Fistula brain

Fistula in the kidneys

The main manifestations of the arteriovenous compound in the kidney tissue are:

  • high level of arterial and venous pressure,
  • renal bleeding
  • loss with urine red blood cells and protein,
  • heart failure,
  • Varicose expansion of the veins of seed rockets or ovaries.

Vascular fistulas in the kidneys, as a rule, belong to congenital developmental anomalies. They are distributed throughout the parenchyma, often lead to intense bleeding, and therefore it may be necessary to remove the organ.

Symptoms

Fistulas of small sizes usually have an asymptomatic flow, clinically manifested only with increasing size. In this case, arise:

  • Redness and skin sweering;
  • Well noticeable swollen veins;
  • swelling of the limbs;
  • decrease in blood pressure;
  • Weakness, reduced performance.

Swimmed veins in arteriovenous fistulaSwimmed veins in arteriovenous fistula

At large fistulas there is a significant decrease in blood pressure, which causes the increase in heart rate. This leads to the formation of heart failure, for which is characteristic:

  • cyanosis of the skin;
  • sense of lack of air;
  • dyspnea;
  • Deformation of the fingers along the type of drum sticks (thickening of the terminal phalange).

The formation of traumatic arteriovenous fistula occurs very quickly, literally for 2-5 hours.

Formation for hemodialysis

In chronic renal failure, the body cannot independently get rid of the metabolic products due to reduced filtration capabilities of renal tissue. In such cases, blood purification procedures are performed by an artificial way. Blood passes through the apparatus of artificial kidney, and then returns to the vascular bed.

The need for daily access to the circulatory network is much easier after stitching the artery with Vienna. The formated fistula is located under the skin, it is easy to puncture, the walls are more dense than the veins, and the rate of blood circulation is higher.

Look at the video about the creation of arthrovenous fistula for hemodialysis:

Methods for diagnosing arteriovenous fistula

Magnetic resonance imaging

Above the area of ​​the estimated arteriovenous fistula, the doctor can hear blood current noise. Blood movement through Av Fistuch creates sounds close to the noise of the car engine.

If the doctor hears this noise, you will need to undergo additional research methods, such as:

  • Ultrasound procedure - This is the most efficient and common method of identifying arteriovenous fistulas of the upper and lower extremities. In this study, the tool, named transducer, lean to the skin. The transducer emits high-frequency sound waves, which are reflected from red blood cells, which makes it possible to estimate the rate of blood flow.
  • Computed tomography (CT). CT allows you to see if the Capillary blood flow passes. You will be injected by contrast, this is a drug that is visible on a computed tomogram. Then the KT scanner will move to take pictures of the alleged affected artery. After that, the pictures will be sent to the computer monitor, to evaluate your doctor.
  • Magnetic resonance angiography (MRA). The MRA can be used if your doctor suggests the presence of arteriovenous fistula in the artery that is deep under the skin. This study allows you to consider the soft tissues of the body. Mra works on the same principle as magnetic resonance tomography (MRI), but includes the use of a special preparation (dye), which allows you to create images of blood vessels. During MRA or MRI, you learn on the table inside the long apparatus, similar to a pipe producing a magnetic field. MRI apparatus uses a magnetic field and radio wave to create images of your body fabrics. Using these pictures, the doctor will be able to detect arteriovenous fistula.

Positive and negative sides of the installation

The formated fistula is located under the skin, it is easy to puncture, the walls are more dense than the veins, and the rate of blood circulation is higher. Thus, it is possible to quickly connect to the machine, the risk of the vessel blocking at the place of constant injury is reduced. The advantages of this technique also include:

  • the use of patient's tissues (low risk of rejection and infection);
  • can work for several years with proper care;
  • There are no violations of systemic hemodynamics, since the connection has a small size.

The main disadvantage of fistula installation is the period of its formation, which can stretch for 30 to 50 days. Part of the patients due to the weak current and low blood pressure, the fistula cannot completely mature, so this method has to abandon.

Advantages, Disadvantages and Possible Complications

Despite the fact that the native arteriovenous fistula is today the gold standard in obtaining permanent vascular access, it, like any technique, has its advantages and disadvantages.

Benefits

The advantages are fashionable to attribute such indicators as:

  • Comfortable localization. The fistula is located close to the surface, which gives easy access to the vessels of the hand.
  • Fully excluded the possibility of rejection, as the patient itself is used exclusively.
  • The internal location minimizes the possibility of infection.
  • There is practically no risk of formation of thromboms.
  • Durability.

disadvantages

Of the shortcomings, the most significant are:

  • The need for expectation while the fistula matures in a fistive hand. Before it is possible to take advantage of vascular access for dialysis, the bloodstream must be sealing and expand the walls of the vessels. Usually it takes 1.5 - 2 months. During this period, a permanent or cuff grade is used.
  • The risk of not ripening the fistula is quite high in patients suffering from hypotension or anemia. With a weak blood flow in veins or low pressure in a coherence, the formation of fistula will not occur.

Also, permanent control over the state of AVF and competent care of the fistulatte hand is important for the patient.

Complications

It is also necessary to know that the creation of fistula violates the usual flow of blood flow. Blood from the artery is not moving slowly along the veins, thin vessels and capillaries, and it quickly returns through the fistula, which creates an extra heart load. And this may affect health. There are such situations as:

  • Oblasting syndrome. The limb below the fistula will be cold, the appearance of signs of necrosis or paresthesia is possible.
  • The formation of aneurysm. Then the risk of perforation and air penetration (embolism) grows.
  • Oxygen starvation of the heart muscle, since most of the blood goes to the pulmonary artery.
  • Carpal tunnel syndrome. Due to the significant expansion of the vein, the vessel can squeeze the middle nerve on the wrist, which can lead to the functional incapacity of the brush.

Preparation for treatment

In order to reduce the risk of postoperative complications before the patient is sent to the operation, such surveys are required:

  • ECG with functional samples,
  • chest radiography,
  • Doppler Vascular Doppler
  • angiography
  • Ultrasound kidneys and hearts
  • blood tests are common, on HIV, viral hepatitis,
  • biochemical study of renal and liver samples, blood electrolytes,
  • Analysis of urine.

All identified disorders should be compensated, and the reception of any medicines is consistent with the Vascular Surgeon.

Conducting an operation

Creating a fistula for the hemodialization of everything for the installation of arteriovenous fistula is chosen forearm. The resulting anastomosis is called radiocephalus, it is used for it a head vein and radiation artery. There may be the following varieties of blood connection:

  • side surfaces of veins and artery (first technique);
  • Side artery and terminal segment of veins (technically difficult, but the best result);
  • The end connection and the use of the end of the artery and the boc of veins give weak blood flow in the future.

Initially, the artery crossing and the crossing of the artery is carried out, and then the venous segment. After their communication, the surgeon imposes seams on the vessels, then on the wound. Above the anastomosis zone, when listening to the characteristic noise in the form of a trill or cat purr. With the proper imposition of fistula, it is long and has a low timbre.

Restoration after

Hemodialysis is possible only after full ripening of fistula. The fact that it is ready for puncture, such signs are indicated:

  • lack of redness, discharge or inflammatory infiltrate in the seam area;
  • There are constant noise over anastomaosis or vibration, but there is no strong ripple;
  • The vessel has increased in diameter;
  • There is a voltage and increased elasticity of veins of fistulas.

At first, the patient is recommended to hold a hand in an elevated position and ensure complete peace for accelerating wound healing. Then a mandatory complex of medical gymnastics is assigned, but it is not allowed to raise gravity or engage in power exercises.

For how many years is designed

Fistula is a long-term solution, with proper care, several dozen years can be served. The service life depends on how the operation was carried out whether complications arose after the operation or in the process of hemodialysis. In the case of poor-quality formation, anastomosis is possible ineffective due to the insufficient provision of blood flow rate.

The service life can be reduced due to the development of aneurysm complication, fistula thrombosis for hemodialysis.

As a result of injuries in the postoperative period, there is a chance of damage to education. It is necessary to take care of a fistive hand, avoid overvoltage by physical exertion. If you care for a condition, it will allow an anastomosis for a long time.

What information is missing in the article?

  • Detailed review of medicines
  • More practical treatment methods
  • Innovative developments in this area
  • Qualified view of a specialist

Care for fistula

In order to extend the service life of artificial arteriovenous fistula, you need to adhere to such recommendations:

  • daily wash the seam zone in front of dialysis with antibacterial soap, then completely dry the skin;
  • Over the place of the fistula should always be heard noise, therefore, it is listened at least 1 time a day, and all the changes are reported to the doctor;
  • Touching the fistula should not be painful, and the leather above it is not warmer than the surrounding.

Thrombosis as a serious complication

When injuring the hand or squeezing the vessels, the fistula can be blocked due to the occurrence of thrombus, so it is not recommended to be severely bend a hand, and you also need to avoid close clothes, straps, bracelets.

The negative effect on the state of anastomosis has temperature differences. Therefore, it is not recommended to visit the sauna, bath, sunbathing under the outdoor sun, be on the street in very hot weather. Also can not be done hardening or molding, lingering underwear in cold or excessively hot water.

Thrombosis as a complication after installing fistula

To regulate blood pressure level, preparations are taken, which prescribe a doctor, follow the indicators required at least once a day. Patients are advised to drink enough drinking water, and limit strong tea and coffee.

Low and high blood pressure is equally dangerous for the patient, since weak blood flow increases the risk of thrombing, and hypertension can lead to the formation of aneurysm and bleeding after it is ruptured.

Lifestyle

In the first weeks after surgery, it is necessary to ensure a fistive hand. In the afternoon, it is necessary to wear a soft tone orthosis, at night you should put a hand on the elevation.

As Fistula matures, it is worth constantly listening to noise that comes from it. During normal operation, noise will be long and distinct, and each new sound must flow from the previous one.

It should not be too protected by a fistive hand, reasonable physical exertion will only benefit. Full inaction, as well as power movements, requiring voltages are not allowed.

N.B!

No need to be afraid to be triggered to the fistula itself. Easy touch should not cause any discomfort. This should be done constantly, to feel the vibration from the progress of blood flow, and at the same time check the temperature that should not be higher, not lower than other sections.

It is important to constantly control blood pressure, and not to allow its sharp drops.

Hygienic procedures are carried out regularly, separate from other means.

Fistula.

Fistula - a pathological or artificially created hole in the body ( Wikipedia ). With reference to hemodialysis, it means a method that is obtained by veins and artery for further hemodialysis.

Fistula. Introduction

If the kidney is the second heart of a person (so many functions performs this organ), then for the patient on hemodialysis, this role is performed to some extent fistula. A word unfamiliar to most people means "vascular access" - a place where a significant amount of blood is taken to clean in the artificial kidney apparatus and where it is already returned in the form cleared of toxins. It is usually a hand, forearm, although there may be other human organs.

So, the normal work of the body implies the flow of blood flow from the heart to the arteries in the capillaries, then the movement occurs on the veins back. Arteriovenous fistula is an artificially created state of artery and veins, they are "stitched" - as a result, the blood moves according to the veloy and artery, bypassing the capillary network. Naturally, blood flow increases, Vienna swells - which makes it possible to quickly pump blood through special needles.

     Vascular access should:

- Make possible repeated access to circulation.

- ensure sufficient blood flow rate for effective hemodialysis.

- Being made of material that does not cause reactions or predisposition to infection.

Three main types Accomes are: fistula, prosthesis and catheter. When fistula, the surgeon sews together with artery and Vienna most often on hand. The arteries carry blood rich blood from the heart and the lungs to the rest of the body. These vessels selected for fistulas, large and good blood flow in them, but they run deep under the skin, and their puncture is predicted. Veins carry blood back to heart and easy. They are superficially available, but too thin and blood flow on them for dialysis is insufficient.

The combination of artery and veins is the best resolution of the situation. After 4-6 weeks, high pressure and high arterial blood flow lead to the thickening of the vein wall and its dilatation (expansion). As a result, the vessel can be punished with thick needles. Fistula is under the skin and is created only from the patient's tissues. Therefore, fistula is less susceptible to infection and thrombosis in contrast to other access. Fistula can work for years and even decades. Studies have shown that currently fistula is the best access from now existing ones. New surgical methods for creating fistulas, puncture methods and ways of preservation of vessels made a fistulous preferred for most patients.

Actions before surgery:

- After the state of the vessels is evaluated, the place is selected for accessing access, the patient should be well informed about the upcoming operation and explain in detail the rules of postoperative access for access. The patient should know that the hand with a functioning fistula cannot be used for the vein puncture and for monitoring blood pressure.

- Operation is performed under local, regional or general anesthesia. Perhaps before the operation of the preventive purpose of antibiotics.

Postoperative Care of Fistula and Prosthesis

Immediately after surgery, the area of ​​operation should be inspected (at first every half hour) for the subject:

- excess bleeding;

- swelling;

- heat of the limb to make sure that satisfactory peripheral blood circulation;

- the presence of trill (feeling of blood buzz when flowing in fistula) or noise (whistling blood, which can be heard with a stethoscope) obviously indicate the presence of blood flow in fistula;

- to prevent thrombosis should be maintained at an acceptable blood pressure and prevent dehydration;

- Access must be in an elevated position to avoid excess edema and swelling.

Several Fistula Care Rules:

 - Regularly check its functioning, the noise of the fistula should be pulsating, uniform.

- Take care of your hand with a fistula as much as possible. Try not to raise gravity. Do not engage in power sports - martial arts, exercises with weights, prescripts from gender. Although reasonable loads are needed. At the time of the "ripening" of Fistula doctors even recommend classes with a manual expander (as an ordinary rubber ring).

- Do not sleep and do not lie on your hand with a fistula.

- Exclude clocks, bracelets and other decorations, clothes, squeezing, on which hemodialysis access is installed.

- Do not measure blood pressure on your hand with a fistula. All punctures, pricks better produce on the other hand.

- The hemodialysis area should be kept clean, excluding, including lotions, creams and other perfumes.

- the special meaning of cleanliness on the day of dialysis. Before the session, it is recommended to wash the hand with a warm water with soap.

- Monitor arterial pressure. Strong jumps of blood pressure do not differ in the state of fistula. It is not necessary to gain weight too quickly in the interdialysis period.

- Any bleeding is a reason for concern. If, after the hemodialysis session, blood does not stop for a long time, be sure to advise with the doctor.

As imposed Fistula

Native arteriovenous fistula (AVF) is created surgically by stitching the artery and veins. This compound is called an asset and on the site of the operation remains a scar. It takes 1-3 months while the Avf will not become quite powerful to punish its thick needles. Therefore, it is desirable to create fistula early before the start of hemodialysis.

After the fistula is made, a powerful blood flow begins in Vienna, which begins to expand the fistive vein and make its elastic wall. This is arterialization of fistula, which we call the ripening of AVF. About a week later, the patient can start exercises that help the ripening of fistula. It can be a compression of a rubber ball or lifting light cargo.

The most common type of native AVF anastomosis between the radial artery and the head vein is. Stitching produce on the forearm between the wrist and the elbow. This is the so-called radicephlastic fistula.

Exist A number of reasons why AVF cannot be imposed on the patient:

- veins are damaged due to infusion of intravenous drugs

- previously transferred operations on arteries and veins

- Atherosclerosis: plaques or wax cholesterol blocked vessels

- Bad state of the arteries due to diseases of peripheral vessels or severe launched diabetes

- The only working arterie, bringing blood to the brush

- Damage to vessels from intravenous drug administration.

Advantages and flaws of fistula  

     Benefits : Avf is a gold standard for vascular access. As a rule, Fistula works longer than other access and has fewer complications, including infection. To create an AVF use their own patient vessels. If possible, you should always apply fistula.

     disadvantages : The main disadvantage of fistula is the long period of its maturation: 4-6 weeks or more. Some fistulas do not ripen at all. The problem is called early or primary failure.

Fistula may not mature for the following reasons:

- Anastomosis is too small and an insufficient flow of blood comes into the fistula.

- Stenosis formed between the anastomosis and the entrance to the fistula.

- Side veins that depart from the fistive vein reduce blood pressure in the fistule and it is not arterialized.

- The selected surgeon vessel for creating fistula is too small (<2 mm).

FistuloskopiaFistuloskopia is a method for diagnosing fistulas formed in the intestine. Fistulas or fistulas call the pathological formation between the intestinal lumen and the other organ or external environment. This is a severe surgical disease that requires detailed learning and accurate therapy. The survey makes it possible to identify the disease in the early stages, to determine the direction and size of the fistula, find the tactics of treatment.

What gives phystoskopia

Fistuloskopia is made for detailed study and treatment of intestinal fistulas. To select the correct tactics of therapy, you need to accurately determine the location, length, type of fistula. Intestinal fistula is an unnatural passage between the intestine and the external environment or other internal organ. Internal and external education distinguish. The internal state of the intestine with another body, he can undergo asymptomatic and does not go out. External connects the intestine with the skin, while the outdoor exit to the external environment is formed. Through the outer opening of the fistula, gases, feces, mucus are highlighted.

Both internal and external fistula are considered very dangerous diseases. They lead to intoxication of the body, infection, weight loss and beneficial substances, serious mental problems. Inner fistula can connect the intestines with the bladder, urethra, uterus, vagina.

All biological masses passing through the intestines fall into the cavity of these organs. There are also mixed types of fistulas that communicate with the external environment and internal organs.

The reason for such a phenomenon may be congenital pathology in babies. As a rule, such deviations are noticed even during the period of bearing during the ultrasound, but treatment can be prescribed only after delivery. Most of the cases of intestinal fistula falls on acquired forms. This is due to inflammatory processes in a thin or large intestine, among them: tumors, acute appendicitis, Crohn's disease, tuberculosis of the intestinal tube. Also, the formation of such moves lead stupid and penetrating injuries of the abdomen, firearms.

Incorrect operations on the abdominal or intestines or intestines also lead to such complications. The fistula is formed with incorrectly superimposed seams of internal organs, with a non-foreign body (ligature, napkin, tampon). The most dangerous location is the upper external fistula - education in the upper intestinal department. With this history, the patient loses a large amount of liquid and useful minerals, which leads to more serious complications: renal and liver failure, polyorgan deficiency, etc.

Fistulas are diagnosed with an anthem of an abdominal cavity with contrast, abdominal ultrasound, irrigoscopy, multispiral computed tomography.

Medical EndoscopeHowever, the greatest information gives phystoskopia. It is carried out using an endoscope - a thin tube with a diameter of 3-4 mm with a point of lighting and an optical device. The doctor during the procedure introduces this device into the course of the fistula and examines it in detail. This allows you to accurately determine the state of the epithelium inside the formation, set its size and shape.

In the outer fiction, the endoscope is administered through the outer mouth, with internal formations - the device is injected into a thick bowel through the anal hole and lead to fistula. Manipulations are possible only if the diameter of the fistula exceeds 3 mm.

In which cases it is prescribed

Phystoskopia is carried out when the patient has an external or internal fistula in the gastrointestinal tract. Appoint it only in the case of a confirmed diagnosis, if there are no other ways to accurate diagnostics.

The indication of the procedure is internal fistulas, located at no further 25 cm from the anal opening, external and internal fistulas, the diameter of which exceeds 3 mm, exterior bile moves. Such a study is necessary when the X-ray picture is unclear or x-ray is impossible to conduct. Sometimes the doctor needs to clarify the characteristics of the tissues in a fiction to determine the correct treatment, in which case they are sent to endoscopic examination and conduct biopsy. When the morphology of the disease is known, the patient needs therapy, only phystoskopia will also help in such a situation.

Preparation for the procedure

First of all, the patient examines a proctologist or surgeon. Before endoscopic research, the fistula is examined by non-invasive ways, x-ray pictures, ultrasound. After the location of the abnormal station of the patient is set to fistuloskopia.

To carry out this procedure, the patient must prepare. For 24 hours it is prohibited to eat, but you can drink water and other liquids.

Sometimes laxatives are prescribed for additional purification of the intestine, the enema is 12 hours before the procedure.

Principles of holding

Spin of rectumManipulations are carried out in sterile conditions, in the operating room or in the endoscopic office. The room should be equipped with an x-ray or computer installation. First, the patient makes local anesthesia or overall anesthesia, the type of pain relief depends on the severity of the disease and the state of the patient, diagnostic purposes.

Fistuloskopia Stages:

  1. The patient falls on the table. With internal fistulas, they take the position lying on the side, legs are sweeping to the stomach. If external fistulas are investigated, the patient's posture will be selected so that the doctor has easy access to the mouth (external output). Put an anesthetic injection.
  2. The skin or mucous membrane around the outer mouth is treated with an antiseptic and rest sterile napkins. To study internal formations, the same is carried out in the area of ​​the anal hole.
  3. The doctor enters the endoscope tube in the area of ​​interest: the rear pass or hole of the fistula. The procedure occurs under X-ray control or computer technology. The new generation equipment is equipped with a microcamera at the end of the endoscope, the image from it goes to the monitor. So the doctor sees the phased promotion of the device and the environment surrounding it.
  4. In the study through the rectum, gas is introduced into it so that the organs of the organ argue. Gas is safe for the patient, after the procedure, it is pumped out. In this state, the intestine is easier to consider and detect the course of the fistula. After its detection in the hollow tube, the endoscope is inserted into a thin phystoskope. With its help, the stroke of the fistula is washed and examined.
  5. If the detected mouth is less than 3 mm in diameter, it is impossible to study it with a phystoskope. Therefore, during the operation, selective fistulography is carried out: the cavity of the fistula is filled with a contrasting agent and make a number of radiographic shots. Also during the inspection, you can take a piece of material for analysis, make it with miniature tongs.
  6. Upon completion, the tools are retrieved, the endoscope administration zone is once again treated with antiseptic drugs.

After the procedure, the patient at least 3-4 hours is under the supervision of doctors if the disease is not complicated. With open fistulas, the therapy is carried out in the hospital, so the patient remains in the hospital to a worthy adjustment of health.

Results of research

Cholangioscopy (choledochoscopy)Modern equipment makes it possible to study in detail the course and structure of the fistula, the causes of its occurrence, the ways to eliminate. Also in some cases during phystoskopia can conduct partial or complete treatment. A fluid, gas, tools are supplied through the instrument tube. So, with a cluster of biomass (blood, feces, mucus), the fistula move is washed with an antiseptic, thanks to this, the test zone is easier to consider. In addition, the antiseptic holds a fistula sanation (cleansing), which reduces the inflammatory process.

If necessary, the doctor can carry out a filling of the lumen, this is considered part of the treatment. In the cavity of the turn, a seal from fast polymerizing materials is placed, antibiotics are also included in the seal. Such a procedure protects the internal organs from foreign masses from entering them, prevents infection and inflammation. When the intestine is reported with a bubble, they talk about a bile fiction. The study of such a phenomenon is combined with choledochoscopy - the diagnosis of the gallbladder.

In such conditions, the examination becomes therapeutic procedure. If the cause of the formation of fistula is a stone, it is removed by forceps through the tube, large stones are crushed and wash.

The same is done when a ligature or bone sequestration is detected in soft tissues. Thus, eliminate the cause of the disease itself, and then prescribe therapy for full recovery.

When to make phystoskopia can not

Unfortunately, not all patients can get such help, because it is not possible to carry out an endoscopic examination. The study is contraindicated in such cases:

  • The patient has decompensated diseases of the cardiovascular system;
  • with severe diseases of the respiratory system;
  • after myocardial infarction;
  • availability of intestinal adhesions;
  • If the diameter of the internal or external mouth is less than 3 mm;
  • acute insufficiency of blood circulation in the brain;
  • With peritonitis.

Do not conduct such manipulations in the first 2 weeks after surgical interventions on a direct or colon. If the patient has one of the contraindications, doctors decide how to replace fistulography. In rare cases, it is carried out in order to treat even against the background of incompatible diseases, if it is vital for the patient.

Possible complications

Fistosticopy has a high resolution, no other method gives such complete information about this disease. The procedure passes almost painlessly, which confirm the reviews of the patients.

The whole process is controlled by experts and computer installations. However, when it is conducted, there is a risk of failures and complications. The root and only complication is damage to the intestinal walls or the fistula itself.

The degree of damage is different, only the upper layer (mucous membrane, blood vessels) may suffer, in severe cases, organs and fistulas are perforation. It entails inflammation, infection, bleeding. Such complications are eliminated immediately during the procedure. In addition, after phystoskopia or selective fistulography, there are sometimes pain in the field of anomalous stroke, such symptoms are considered normal and quickly pass.

Where it is spent

Such technology is carried out in polyclinics and in hospital conditions. The procedure sends a gastroenterologist, a coloproktologist or surgeon. All manipulations on the introduction of devices and diagnostics will be carried out by an endoscopist in the presence of a surgeon and assistants. There is a survey in sterile conditions, in the equipped office. Fistuloskopia services provide government agencies and private clinics. The cost of such a procedure in the institutions of the private segment will be 400-550 dollars, if the state is not complicated. The price of complex manipulations will be up to 2,000 dollars.

As you can see, phychalooscopy is an important method of examination for patients with fistula. It is not necessary to be afraid of the procedure, it is carried out under anesthesia, sedation (therapeutic sleep) or anesthesia. It allows you to accurately explore an abnormal phenomenon and choose a successful treatment tactics, to return to the patient a normal and full-fledged life.

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Fistula

Fistula - This is a pathological channel that connects the hollow organs, natural or pathological cavities of the body among themselves (internal fistula) or with the environment (outer fistula). It is manifested by the presence of a fistula, through which the mucus, pus, the contents of the organ or cavity is distinguished: Cal, urine, saliva, lying, bile. Diagnosed on the basis of clinical symptoms, data of fistulography, other instrumental and laboratory studies. With internal fistulas, endoscopic manipulations are carried out. The treatment is determined by the type of pathology, may be conservative, operational, combined.

General

Fistulas (fistulas) - a large and very different group of pathological conditions found in many areas of practical medicine. They have a congenital or acquired character, arise as a result of the destruction of tissues of various genesis, or are artificially created. It is often difficult to treat, in some cases there are danger to life due to significant losses of liquid, nutrients. The greatest clinical importance due to its prevalence and possible consequences have urogenital and gastrointestinal fistulas.

Fistula

Fistula

Causes of fistula

The immediate cause of the formation of fistulas is violations of the formation or destruction of organs and tissues. Taking into account etiology, the following groups of fistulas are distinguished:

  • Congenital . Appear as a result of disorders of the development of the fetus, which may be due to hereditary diseases, the effects of adverse external and internal factors.
  • Acquired pathological . Forms on the background of inflammatory processes, injuries, damage to the walls of hollow organs by foreign bodies, destruction of malignant tumors, chemicals, radiation exposure. Sometimes they become a complication of surgical treatment of various pathologies.
  • Acquired artificial (stoma) . Specially are created by the operational way to preserve vital activity in violation of the passage of the contents of hollow organs (chimus), secretion (bile) or excretrum (feces, urine), to ensure the flow of nutrients into the body.

Pathogenesis

Congenital fistulas become a consequence of underdevelopment or improper development of organs and parts of the body. Since they are formed naturally, their walls are covered with epithelium. Acquired fistulas appear in the breakthrough of content, accompanied by the destruction of already formed tissues. The walls are represented by granulations, outside as a result of the scarring in time, a layer of dense connective tissue is formed.

The special group are lpside fists, whose epithelium mucosa moves into the epithelium of the skin. They relate to epithelision, but are created artificially. Epithelized fistures are not closed independently. Granulating fistulas are capable of healing when the process is eliminating (usually inflammatory), which supports the outflow of the contents through the channel.

Classification

Currently, researchers, as well as specialists in the field of surgery, use the following systematization of fistulas:

  • By origin : Congenital, acquired (pathological and artificial).
  • By structure : epithelision, granulation, lipidoids.
  • In relation to the environment : External (connect the cavity with an external environment), internal (connect two cavities).
  • Localization : gastric, intestinal, rectal, tracheopic, bronchial, uranginal, rectovagal, near-dry.
  • By type of separation : mucous, purulent, cartoons, urinary, likvorn, etc.

Symptoms of fistula

A common feature of the disease is the presence of a pathological communication between two or more cavities or the cavity of the body and the environment. With outer fistulas during the inspection, the hole (stroke) is detected. The edges of the opening are inflamed, macerated because of skin irritation. The number and nature of the discharge differences vary depending on the type of fistula, the characteristics of the pathological process.

Internal fistulas are manifested by the presence of an atypical separated from any natural opening. Significant loss of fluid and nutrients in some types of fistulas are the cause of depletion, coarse violations of all types of exchange, which can lead to patient death.

Sweistse of the digestive system

Can be formed throughout the gastrointestinal tract, from the esophagus to the rectum, to be outdoor or internal. Gastric fistulas usually have an artificial origin (gastrostoma), esophageal are provoked by the pathological process, the intestines are artificial (colostomy, ileostoma, cepostom) and pathological. The first place among the causes of the formation of esophageal fistulas occupy tumors, intestinal - inconsistency of anastomoses.

The formation of outer fistulas is accompanied by the advent of infiltration. With internal fistulas, the clinical picture resembles the span of a hollow organ. During the tracheopic, slices of food slices from the upper respiratory tract. The inner gastrointestinal fistula is manifested by a crawling vomit, a hollow smell of mouth. With an outer formed fiction on the skin, a move with esophageal, gastric or intestinal separated, with an incomparable - purulent wound, at the bottom of which is visible to the loop of the intestine, the wall of the stomach.

Typical diarrhea, vomiting, autoinoxication. The rate of depletion and development of exchange disorders depends on the diameter of the fistula - the more wider, the faster the symptoms are exacerbated. Dehydration, exhaustion, shrimp edema, anemia are possible. Inxication, exchange disorders lead to changes from the liver and kidney. In severe case, renal and liver failure are developing.

Sweat bubble

Bile fistulas are usually becoming a complication of gallstone disease, there are external or internal, can be combined with grooves with stomach, intestine, pleural cavity, bronchus. Outdoor fistulas are accompanied by the formation of a bull hole or purulent separated, internal - symptoms of cholangitis, diarrhea, weight loss, intoxication.

Rectal fistula

Includes various forms of paraproititis and rectovaginal fistulas. Paraproktitis occurs with purulent inflammation of the wall of the intestine and the paragreus tissue, manifests itself with pain, feeling of the foreign body, common symptoms of intoxication. From the rear pass, a pus is released on the bubble of the perianal zone, a hole with purulent separated is detected. With rectovaginal fistulas from the vagina, gases, feces are distinguished from the vagina. Hellish pain in the crotch, inflammatory diseases of the genital organs, urinary tract.

Urogenital fistula

They are formed between the genital organs and the urethra, ureters or bladder. Develop after severe and complicated childbirth, operations, radiation therapy. The most common - urethro-vaginal and bubble-vaginal fistulas. It is less common to bubble-uterine, ureter-vaginal and other options.

Accompanied by the leaking urine from the genital organs, the appearance of blood in the urine during menstruation. Usually painless. Do not pose a threat to life, but significantly reduce its quality, cause social deadaption. Have great clinical significance due to high prevalence (0.6-2%).

Bronchial fistula

More often after operations on the lungs, are characterized by the appearance of communication with the skin, pleural cavity or hollow organs - the esophagus, the stomach, intestine, the bubble bubble. They manifest themselves with shortness of breath, cough, isolation of pus or atypical content (food, bile) from the respiratory tract, weakness, sweating, increasing body temperature.

Ligature fistula

Ligatured fistula - frequent complication (up to 5%) surgical interventions, especially when operations on abdominal organs, small pelvis. Developed due to rejection of non-disseminating threads, which are in the depths of the tissues. During the formation period, pains, intoxication are noted, after the formation of the fistulous stroke, the state is normalized. Fistulas are prone to chronic recurrent flow until the removal or independent revelation of the thread.

Complications

The most common complications of any fistula are purulent and non-national inflammatory processes, including the formation of abscesses and undertaking with the damage to neighboring anatomical structures, chronic inflammation of various organs (cystitis, vaginites, proctitis). In severe cases, sepsis is possible.

Swiss significantly worsen the quality of life, often becoming the cause of working capacity, negatively affect socialization. With external fistulas, dermatitis are often developing, a cosmetic defect is formed. With complete fistulas of the internal organs, cachexia is observed, polyorgan deficiency.

Diagnostics

Taking into account the localization of the fistula, the diagnosis is established by doctors of various specialties - surgeons, gynecologists, urologists, etc. In the process of diagnosing and determining the treatment plan, take into account the history of the disease, clinical symptoms, additional research data. The survey plan includes:

  • Collect anamnesis. Anamnesis often detected operations or chronic diseases. The formation of external fistulas is preceded by the appearance of pain, infiltrate, which is revealed with the separation of pus, and then the contents of a particular organ. The formation of internal fistulas is accompanied by pain, intoxication, other symptoms depending on the location of the fistula.
  • Visual inspection. In the presence of a hole on the skin by the nature of the discharge, the involved body is determined, by the number of separated - the size of the fistula. Assess the overall condition of the patient, identify signs of exhaustion, violation of the functions of various organs.
  • Samples with dyes. Sometimes to clarify the localization of the fistula, the determination of the number of strokes, the detection of the chapels is used by methylene blue and other solutions that are administered orally or insert into a natural hole.
  • Lab tests. When studying the separated bilirubin, amylase, urea and other compounds can be detected, which in doubtful cases makes it possible to confirm the damage to a certain body.
  • Fistulography. It is the most common visualization method for diagnosing outdoor fistulas. The contrast is injected into the hole, according to the pictures, the affected organ, accurate localization of the fistula, the direction of the stroke, the presence of the chapels is determined.
  • Radiography with contrast. With internal lesions, irrigography, a radiography of a stomach or esophagus with a barium. The contrast comes through the wall of the organ on the skin, in the adjacent organs or cavities, which allows you to clarify the features of the fistula.
  • Endoscopic research . To detect fistula, determine their location and diameter of the holes are performed by gastroscopy, colonoscopy, bronchoscopy, cystoscopy, etc.

Some internal fistulas represent substantial diagnostic difficulties, found only during operational interventions. Differential diagnosis is carried out between different types of fistula, with inflammatory diseases, other pathological processes.

Treatment of fistula

Tactics of treatment is determined by the type of fistula. Granulating fistulas can be closed against the background of conservative therapy, with epithelision, recovery is possible only after the implementation of operational intervention. Along with the elimination of the main pathology, the correction of exchange disorders plays an important role, competent care for the hole.

Conservative therapy

Mandatory condition for closing the fistula is to eliminate the cause of its appearance. If it is impossible to influence the etiological factor, the purpose of therapy becomes the preparation of a patient to the operation. Treatment provides for general and local events. It is shown in the case of all types of fistulas - both epithelized and granulating. Includes:

  • Caring for fistula. It is necessary to regularly carry out the skin toilet around the hole, lubricate the skin with protective pastes. With artificial fistulas, training is required for the use of urine and carriagorics.
  • Limiting the allocation of content. In some localizations, fistulas, for example, their rectovaginal location, the closure of the fistula in some cases can be achieved by unloading the intestine on the background of the enema, a special diet.
  • Other local exposures. Chemical solutions, the use of enzymatic drugs, carrying out local autohemotherapy can be effective. Tissue regeneration is stimulated by injection of collagen gel with fibroblasts.
  • Correction of general disorders. With significant losses, protein, water and electrolytes show the compilation of an individual diet, infusion therapy with the introduction of albumin, saline solutions, other compounds.
  • Anti-inflammatory therapy. In secondary infection, antibacterial drugs, immunocormers, disinfectants are prescribed.

Surgery

Surgical interventions are conducted with epithelized, formed granulating, spongy fistulas. Taking into account the features of the location of the fistula and the state of the surrounding tissues, the following operations are performed:

  • Excision of a fistula. It is made after staining with methylene blue or other solution, which allows you to accurately set the features of the stroke, reveal the chapels. The move is removed together with the surrounding changed tissues, the wound is stolen, drain.
  • Exciration with the replacement of the defect. Sometimes after removal of the changed area, there is a lack of fabrics either when tissue crossing their excessive tension is observed. In such cases, the fistula is covered by transposition of the skin-muscular or muscle flap, adipose tissue on the vascular leg.
  • Precision organ . With some fistulas of the hollow organs, for example, with intestinal options, partial excision of the organ is the optimal option. The operation can be carried out in one or two stages. In the second case, the bypass anastomosis for unloading by stopping the passage of the contents is pre-impose.

The removal of altered tissues is often complemented by actions aimed at preventing the repeated formation of a fistula. For this, parts of the fascia, mesh implants are placed between the disassembled cavities. In the postoperative period, standard therapeutic measures are carried out - dressing, antibiotic therapy, anesthetic therapy.

Forecast

The forecast is determined by localization, type and time of the existence of the fistula, the prevalence of changes in the surrounding tissues, the nature of the main pathology, the degree of violation of the homoseostasis of the patient's body, the presence of concomitant diseases. Fistulas, even granulating, rarely succumb to conservative treatment. After excision, he often has a recovery. In some types of fistula, accompanied by severe exchange disorders, especially with high gastrointestinal, lethal outcome is possible.

Prevention

Preventive measures include timely treatment of diseases that can lead to the formation of fistulas. It is necessary to prevent the emergence of infections in the wound channel zone, comply with the technique of imposition of anastomoses, ensure unloading of the operated authorities at the stage of preparation for intervention and postoperative recovery.

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