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Visiting department: digestive internal medicine and surgical treatment cost: the charging standards of different hospitals are inconsistent, and the cure rate of the top three hospitals in the city is about (1000-5000 yuan): treatment cycle: treatment method: drug treatment and surgical treatmentGeneral treatment of spontaneous esophageal rupture
1. Spontaneous esophageal rupture is generally longitudinal, rarely transverse, and its length is generally 4cm ~ 7cm. If the breach is small, the patient will come to the clinic immediately, the food residue entering the pleural cavity is less, the thoracic cavity is drained thoroughly, the infection can be controlled in time, and it can be repaired without surgery, so the chance of healing the breach is great. If the breach is large, the amount of stomach contents entering the pleural cavity is large, the food residue is not drained clean, the patient comes to the diagnosis late, the lung expands poorly, or the diagnosis is delayed, resulting in empyema, mediastinitis, etc., then simple drainage, nasal feeding or jejunostomy often forms chronic esophageal-pleural-cutaneous fistula, and the chance of self-healing of the breach is very small.
Once this disease is diagnosed, antibiotics should be given immediately, shock should be rescued, surgical treatment should be carried out as soon as possible, irritating fluid should be removed, and esophageal rupture should be sutured. If no more than 24 hours after rupture, active early thoracotomy and local esophageal repair surgery will also have the opportunity of healing. If the thoracic cavity is washed clean, the drainage after thoracic cavity operation is smooth, the lung expands well, and the breach is healed by parenteral nutrition support or jejunostomy nutrition support, the treatment time can be shortened and complicated treatment measures can be avoided.
2. The treatment and prognosis of spontaneous esophageal rupture are closely related to the diagnosis, the size of rupture, the amount of contents entering the thoracic cavity and stomach, and the degree of pollution. It is generally believed that rapid diagnosis and surgical repair are the key to successful rescue. During operation, esophageal fissure is sutured and mediastinal and thoracic drainage is performed. However, in recent years, there have been successful cases of conservative treatment in internal medicine. That is, the self-expanding metal bracket is used for packing in the early stage of perforation, If there is pleural effusion or mediastinal effusion, puncture and catheter drainage under the guidance of B-ultrasound, At the same time, the application of broad-spectrum antibiotics, especially the third generation cephalosporins and new quinolones, and metronidazole are helpful to treat anaerobic infections. Strengthening supportive treatment, especially the proper application of intravenous total nutrition therapy, has a positive effect on accelerating the healing of esophageal perforation. Once esophageal-pleural-cutaneous fistula is formed, it needs to be repaired later, and even partial esophagectomy and intestinal tube instead of esophagus are needed. Sometimes, partial rib resection is needed to eliminate pus cavity and fistula.
Second, the treatment principles of spontaneous esophageal injuries with different classifications are different.
1. Esophageal intermural perforation is a benign process, and complete perforation rarely occurs, so it can be treated conservatively. Anti-inflammatory fasting treatment can be cured within 1 ~ 2 weeks. If an abscess forms in the wall, surgical drainage is required.
2. MalloryWeiss syndrome is often treated by non-surgical treatment. The main cause of treatment of gastrointestinal bleeding. After replenishment of blood volume, upper gastrointestinal endoscopy should be performed as soon as possible to make a clear diagnosis and find the tear site. If there is active bleeding, electrocoagulation can be used to stop bleeding. In case of emergency, three-lumen tube can be temporarily used for hemostasis. If bleeding has stopped, conservative treatment such as antacid and H2 receptor blocker can be used. After 12 ~ 24h conservative treatment is ineffective, but the patients who continue to bleed or bleed again can be treated surgically. Those who can't tolerate surgery can puncture femoral artery percutaneously and inject embolic agent into left gastric artery to stop bleeding.
3. Conservative treatment of Boerhaaave syndrome is ineffective and easy to cause serious complications, so thoracotomy is an emergency. If it is found within 6 ~ 12 hours, the laceration should be repaired early. In those with delayed discovery, closed drainage is difficult to be successfully repaired by surgery, and gastrostomy decompression is performed to prevent reflux, and silicone tube is inserted into jejunum for feeding or parenteral nutrition support. After that, the fistula was closed by elective surgery. If the esophageal fissure is more than half of the solid diameter of esophagus, the onset is more than 24 hours, the local inflammation is serious and it is difficult to repair, and the general condition can tolerate the operation, it is feasible to remove the esophageal fissure and anastomosis of esophagus and thoracic drainage.
Third, the prognosis
Rapid diagnosis and immediate surgical repair are the key to save patients from death. Closely observe the condition to prevent delay in diagnosis. According to statistics, without treatment, about 25% died within 12 hours, 35% lived to 24 hours, 11% lived to 48 hours, and all died within one week.
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