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Prof dr Marija Lukač
UVOD
Razumevanje poremećaja intestinalne rotacije i
fiksacije je ključno za dečje lekare jer se većina
ovih problema manifestuje u detinjstvu
EMBRIOLOGIJA
STADIJUM I
4-10 nedelja: protruzija srednjeg creva
i razvoj fiziološke umbilikalne hernije
EMBRIOLOGIJA
STADIJUM II
10-12 nedelja: srednje crevo se vraća u
abdomen, prvo tanko crevo a na kraju
cekokolična vijuga; cekum inicijalno leži levo,
rotira se za 270 suprotno od kazaljke i leže u
desnu ilijačnu jamu; istovremeno se
duodenojejunalna vijuga (Treitzov ligament)
rotira suprotno od kretanja kazaljke oko a.
mes. super.
EMBRIOLOGIJA
STADIJUM III
Fuzija pojedinih delova mezenterijuma
sa fiksacijom cekuma, ascendentnog i
descendentnog kolona.
Treitzov ligament je normalno fiksiran
levo od kičme iznad ili u nivou pupka.
Cekum je fiksiran u desnom ilijačnom
kvadrantu.
POREMEĆAJI ROTACIJE
KOMPLETNA NONROTACIJA SREDNJEG CREVA
NAJČEŠĆA: izostanak rotacije i
duodenojejunalne i cekokolične vijuge
NAJČEŠĆI RAZLOGVOLVULUSA
SREDNJEG CREVA
PREZENTACIJA MALROTACIJE
AKUTNIVOLVULUS
DUODENALNA OPSTRUKCIJA
INTERMITENTNI/HRONIČNI BOL
ASIMPTOMATSKI/SLUČAJNI NALAZ
0,2%
Najčešće u doba novorođenčeta (70%) i mladog
odojčeta (mlađeg od godinu dana 90%)
U dece mlađe od godinu dana
povraćanje žučnog sadržaja mora se
smatrati kao moguća posledica
malrotacije sve dok se ne dokaže
suprotno
VOLVULUS MALROTACIJA SA VOLVULUSOM
KLINIČKA SLIKA
NEONATALNI PERIOD
1. Rekuretna subakutna opstrukcija sa
intermitentnim povraćanjem žučnog
sadržaja
2. Strangulacioni ileus kao posledica
volvulusa srednjeg creva
KLINIČKA SLIKA
NEONATALNI PERIOD
Količni bolovi, povraćanje žučnog
sadržaja, moguće krvavog, distenzija i
bol abdomena ,prisustvo tamne krvi u
stolici i šok. Strangulacija progredira u
gangrenu, perforaciju i peritonitis, a
edem i eritem abdominalnog zida
postaju uočljivi
DIJAGNOSTIKA
RTG nativni:
visoka
opstrukcija
creva –
zahteva dalje
radiografsko
ispitivanje da
bi se isključio
ili potvrdio
volvulus
MALROTACIJA SA VOLVULUSOM
RADIOGRAFIJA - ZBUNJUJUĆA
NATIVNI SNIMAK ABDOMENA JE ČESTO
NORMALAN ALI OBELEŽJA KOJA UKAZUJU NA
MALROTACIJU SA ILI BEZVOLVULUSA SU
DISTENDIRAN ŽELUDAC I PROKSIMALNI
DUODENUM
OSKUDAN GAS DISTALNO BILO U CELOM
ABDOMENU ILI UNILATERALNO
DIJAGNOSTIKA
EHO nalaz: a. mez.sup.
(SMA) i v.mez.sup.
(SMV) menjaju
položaj: normalno
SMV je desno od SMA;
kod malrotacije, SMV
može ležati direktno
ispred ili levo od SMA.
Važno je da normalan
odnos SMA/SMV ne
isključuje malrotaciju, i
pasaža ostaje zlatni
standard.
MALROTACIJA SA VOLVULUSOM
*Indikovana dopler
ultrasonografija
DIJAGNOSTIKA
CT pregled
MALROTACIJA SA VOLVULUSOM
PASAŽATANKIH CREVA
URGENTNA
OBAVEZUJUĆA
KOD SVAKOG POVRAĆANJA ZELENOG
SADRŽAJA
DIJAGNOSTIKA
Pasaža creva,
ZLATNI
STANDARD
MALROTACIJA SA VOLVULUSOM
DIJAGNOSTIKA
Pasaža creva
Duodenum se
spušta
paralelno
desno od
kičme
MALROTACIJA SA VOLVULUSOM
DIJAGNOSTIKA
Znak vadičepa
MALROTACIJA SA VOLVULUSOM
DIJAGNOSTIKA
Delimična
opstrukcija
duodenuma
sa dilatacijom I
i II segmenta –
znak vadičepa
MALROTACIJA SA VOLVULUSOM
DIJAGNOSTIKA
Znak kljuna –
kompletna
opstrukcija na
nivou
duodenuma
MALROTACIJA SA VOLVULUSOM
DIJAGNOSTIKA
Malrotacija
bez volvulusa
MALROTACIJA SA VOLVULUSOM
IRIGOGRAFIJA
POZICIJA CEKUMA JEVEOMA
PROMENLJIVA I U 15% SLUČAJEVA
MALROTACIJE JE UREDNA
IRIGOGRAFIJA NEPOUZDANA
DIJAGNOSTIKA
IRIGOGRAFIJA
U 85% pacijenata
pozicija cekuma
ukazuje na
malrotaciju
MALROTACIJA SA VOLVULUSOM
I DRUGA STANJA ILI SINDROMI
KONGENITALNA DIJAFRAGMALNA HERNIJA
GASTROŠIZA
OMFALOCELA
NONROTACIJA
PRUNE – BELLY SINDROM
POSLE NEONATALNOG DOBA
Većina starijih* pacijenata ima hronične simptome
10 -14% razvije volvulus srednjeg creva
sa nekrozom
30% intermitentno povraćanje
20% količni abdominalni bol
* Starijih od mesec dana
MALROTACIJA KAO SLUČAJNI NALAZ
LADD-OVA PROCEDURA
DA NE
?
LEČENJE
1.Supraumbilikalna
transverzalna incizija
i brza evisceracija
creva
Kolon obuhvata
bazu mezenterijuma
tankih creva
Proksimalni
duodenum je
dilatiran i obuhvaćen
vijugama kolona
VOLVULUS
LEČENJE
2.DETORKVACIJA
VOLVULUSA-tanko
crevo se rotira
suprotno od kazaljke
VOLVULUS
LEČENJE
Peritonealni nabori
se pružaju od ascen.
kolona do
duodenuma i desnog
lateralnog zida
abdomena (LADD-
ove bride)
VOLVULUS
3. Ladd-ova
procedura
LEČENJE VOLVULUS
Kompletna Ladd-
ova procedura
4. Odvajanje priraslica mezenterijuma izmedju
duodenuma i tankog creva što proširuje bazu
mezenterijuma i sprečava recidive
LEČENJE
6. Apendektomija
Nekroza creva –
resekcija (sindrom
kratkog creva -
dugotrajnaTPN)
***Transplantacija
VOLVULUS
5. Provera
prohodnosti
duodenuma
ZAKLJUČAK
2. Ishod nakon Laddove procedure za izolovanu malrotaciju je
veoma povoljan, a za volvulus zavisi od intenziteta
strangulacije i vremena operacije
1. Volvulus se javlja u 45-65% dece sa malrotacijom i
mortalitet iznosi 7-15%
ZAKLJUČAK
3. Najčešća postoperativna komplikacija je athezivni ileus 3 -5%,
recidiv < 10%
4. Nekroza i resekcija više od 75% tankog creva je udružena sa
sindromom kratkog creva
5. 18% dece sa sindromom kratkog creva na dugotrajnojTPN
imalo je dijagnozu volvulusa
6. Transplantacija tankih creva – našim pacijentima
nedostupna
ZAKLJUČAK
 DIJAGNOSTIKA I OPERATIVNO LEČENJE
VOLVULUSA JE JEDNO OD NAJURGENTNIJIH
STANJA
 BRZINA U DELOVANJU SPAŠAVA I
PACIJENTA I LEKARA
HVALA NA PAŽNJI !
ZAGRLIMO NEKOG !
PROŠETAJMO DO
KALEMEGDANA,
GDE DUNAV LJUBI
SAVU

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1.-Volvuluv prezentacija za studente-VOLVULUS.pptx