The term "acute abdomen" indicate clinical syndrome that develops when damage and acute diseases of the

abdominal cavity, in
which may require urgent surgical care. The first medical examination of the patient is often done outside the hospital (home or
clinic). The objective of the primary diagnosis is recognition of a dangerous situation and need urgent surgical treatment. In acute
abdominal prognosis worsens with time, so the doctor is obliged to send the patient to hospital, where in the near future should be
carried out the necessary diagnostic and therapeutic measures. Acute surgical diseases of the abdominal cavity occupy a prominent
place among all surgical diseases. During acute surgical diseases of the abdomen mean disease occur suddenly occurring acute and
accompanied by varying degrees of pain, sooner or later become complicated when late to start treatment, acute peritonitis and
who have some common symptoms. Depending on the causes of these diseases can be divided into the following subgroups: acute
inflammatory disease origin (acute appendicitis, acute cholecystitis, acute pancreatitis, acute peritonitis, etc.), acute disease caused
by destruction of the body (perforative gastric and duodenal , gastrointestinal bleeding, uterine tube rupture of ectopic pregnancy,
ovarian rupture, bowel infarction), all types of acute intestinal obstruction, diseases of female genitalia, diseases of mixed genesis
under the influence of enzymes and bacteria (some forms of cholecystitis and pancreatitis), thrombosis of mesenteric vessels open
and closed chest and abdominal injuries, diseases that simulate syndrome "acute abdomen".

The problem of abdominal pain is that pain can be accompanied by an extremely large number of diseases. The cause of pain in the
abdomen is one of the three major nosological groups:
• diseases of the abdominal cavity (including acute, requiring immediate surgery);
• irradiation pain in diseases that are located outside the abdominal cavity (this is so on. Pseudoabdominal syndrome (PAS) -
syndrome, including manifestations that resemble the clinical picture of "acute abdomen", but is formed pathology of other organs -
heart, lungs, pleura, endocrine organs, intoxication, some forms of poisoning, etc.)
• systemic diseases.
Because of this large group of diseases includes those who require urgent surgical treatment, symptom pain will always be treated
as urgent.
Abdominal organs are usually not sensitive to many stimuli when exposed to the skin provoke pain. The main influences to which
visceral sensory fibers are stretching or violation of the bowel wall. These include: stretching of the peritoneum (eg, tumors),
stretching hollow body (eg, bilious colic) or severe reduction of smooth muscles of the intestine (eg, intestinal obstruction). Fiber
nerve endings responsible for pain in hollow organs (intestine, gall bladder, the bladder), localized in the muscular layer. In
parenchymal organs (liver, kidney, spleen) nerve endings are in their capsule and meet its stretching with increasing amount of
authority. For the appearance of pain rate of increase of voltage must be sufficiently large. The gradual increase of the same voltage,
for example, such as in the biliary tract obstruction may occur long painlessly.
Inflammation and ischemia of the body also can cause visceral pain with inflammation may increase the sensitivity of nerve endings
and reduce the threshold to pain from other stimuli. In the mechanism of pain and progression of inflammation involved in many
biologically active substances (bradykinin, serotonin, histamine, prostaglandins, etc.)..
The above pathophysiological mechanisms of abdominal pain often lead to late, at best delays the diagnosis.
It is necessary to confirm the feasibility of using the term "acute abdomen", under which the isolated condition, which develops
within hours or days and are characterized by limited or diffuse manifestations of peritoneal irritation. In the first hour, and
sometimes day, such patients secrete group who require urgent intervention. Do not require surgical treatment patients should be
treated in therapeutic departments: cardiology, pulmonological, gastroenterology and others. Therefore, consider the term "acute
abdomen" purely surgical concept is hardly appropriate, especially because most of the patients do not always require surgical
treatment. Since the main symptom “acute abdomen” is a pain, and the main diagnostic criterion to determine its cause is the
method of differential diagnosis.
Another group consists of intraperitoneal demarcated purulent inflammations and their complications:
 - Acute appendicitis. Regardless of the primary localization of pain in the future, the majority of patients with pain and symptoms of
peritoneal irritation localized in the lower abdomen, while there is a growing leukocytosis with left shift. If there is doubt in the
diagnosis of acute appendicitis, the patient is prescribed spasmodicals, antibiotics and cold on the right iliac area. You can not
prescribe pain medication because it can distort the clinical picture. In the absence of the trend towards normalization of the above
parameters and with an increase of symptoms shown laparotomy.
- Maturation of cysts and diverticula appendix: clinical features that distinguish this disease from acute appendicitis are absent, but
they can be detected during emergency ultrasound.
- Cholecystitis, empyema and hydrops of the gall bladder. This localization of pain is in the right upper abdominal symptoms of
peritoneal irritation or without, with leukocytosis, left shift. In acute chronic cholecystitis in elderly patients with cystic duct clogging
with no signs of inflammation, these signs may be absent. The same symptoms can be observed in patients with acute appendicitis
(at great length and location subhepatic appendix).
The most reliable diagnostic technique in this situation is ultrasound, because the x-ray in acute exacerbations and chronic process is
inefficient.
- Diverticulitis. More common in the sigmoid colon, pain and symptoms of peritoneal irritation, mainly observed in the lower left
abdomen. Often ill elderly people suffering from disorders of the colon, often induce aggravation of persistent constipation (rarely
diarrhea). Often there are phenomena of partial intestinal obstruction. Colonoscopy and irrigoscopy (double-contrast barium enema)
contraindicated in this situation. Medical history, clinical observation and dynamic ultrasound is the most appropriate diagnostic
criteria.
- Acute adnexitis. At the same symptoms of minor irritation of the peritoneum. In clinical and laboratory data may be similar to any
acute abdominal pathology. For differential diagnosis the most appropriate to perform an ultrasound of the pelvic organs, and in her
failure - laparoscopy.
In the presented group of diseases (especially early on) it should be noted the advantage of local symptoms of common disorders.
In the complicated forms of the disease and stabilization of local manifestations of toxicity symptoms begin to increase.

Peritonitis (acute, chronic).

As a result of perforation of inflammatory, suppurative inflammation, ulcer and trophic processes (including ischemic) disorders of
the gastrointestinal tract: appendix, gall bladder, diverticula of the colon (appendix cysts), cysts of the pancreas, reproductive organs
in women. This pains is the result of growing phenomenon of intoxication caused by ulcerative processes in the gastrointestinal
tract: gastric and duodenal ulcers, simple ulcers of the small intestine, colon ulcer with nonspecific ulcerative colitis, ulcers of the
small intestine in typhoid fever.
Diagnosis is based on the detection of fluid and free gas in the abdominal cavity caused by an acute destructive process. The most
informative diagnostic examination is ultrasound (especially in the dynamics), survey radiography and laparoscopy, which can be
simultaneously and treatment procedures.
As a result of traumatic injuries and injuries of hollow organs, postoperative complications: It should specify anamnestic data,
dynamic observation of patients, monitoring of laboratory tests of inflammation, hemoglobin.
- Tuberculous peritonitis: diagnosis extremely difficult. Helps identify adhesive process in the abdominal cavity in the absence of any
pathology of internal organs. Diagnosis is proven in the detection of morphological substrate (during laparoscopy), but there are
forms that occur without tuberculous tubercles - then can help serological diagnosis and therapy of anti-TB drugs. When X-ray can
be detected zvapninnya lymph nodes, used provocative tests.
- Syphilitic peritonitis: experience of the peritoneum expressed perivistseritis proven by serological syphilis. In the presence of fluid in
the abdomen, it may be hemorrhagic.
- Actinomycosis of the peritoneum: a difficult diagnosis, but may be real, when there is actinomycosis of internal organs. Impressions
of the peritoneum at the same time is about 30%.
- Parasitic diseases of the peritoneum: rare and occur usually in the perforation of hollow organs and cysts of the release of
pathogens in the free abdominal cavity.
- Ascites, peritonitis (in patients suffering from liver pathology in the stage of liver cirrhosis with severe portal hypertension).
Suspicion of peritonitis should occur whenever ascites is resistant to the therapy if it is adequate to pathogenetic position. Early
diagnosis is a form of learning ascitic fluid for the presence of fatty acids (bad smell always indicates the presence of
bacterial inflammation).
- Intestinal obstruction (acute, chronic). On the mechanism of development: mechanical (adhesive, resulting in strangulation of
hernia, tumor, intussusception, which occurs more often in children). In adults, intussusception is often the cause of colon polyps,
ulcerative scarring, blockage of the lumen of the alien bodies (bile stones, worms, etc.).

In the diagnosis of this group of patients is of great importance a thorough analysis of historical information (including medicinal)
and the general condition of the patient, namely, vascular lesions in the elderly, suffering from diseases of the heart and blood
vessels that lead to thrombosis and embolism mesenteric veins. This important diagnostic feature is the presence of bloody fluid and
faeces. Particular attention is given to patients with intestinal obstruction, often an early symptom of a tumor obstruction and
requires very careful examination of the obligatory use of colonoscopy. Equally important is a group of paralytic intestinal
obstruction and in this respect the definition of anamnesis is the leading criterion which allows to avoid unnecessary surgery.

Gastrointestinal bleeding
Gastrointestinal bleeding (GI) or gastrointestinal hemorrhage describes every form of hemorrhage (loss of blood) in the
gastrointestinal tract, from the pharynx to the rectum. GI bleeding can occur in any one of these organs. If the bleeding occurs in
your esophagus, stomach, or small intestine, it is considered upper GI bleeding. Gastrointestinal bleeding in the large intestine,
rectum, or anus is called lower GI bleeding. The amount of bleeding you experience can range from a very small amount of blood to
a life-threatening hemorrhage. In some cases, the amount of bleeding may be so small that it only shows up in lab tests.

Causes

Many different things can cause GI bleeding. Bleeding may start because of damage to your digestive tract. This damage may be
caused by infections, alcohol abuse, or certain medicines (such as aspirin). Growths or swollen pockets in your digestive tract may
also cause bleeding. You may have bleeding if you have blood vessels that are not normal. Diseases or other health problems may
cause GI bleeding. Examples include liver disease, stomach ulcers (sores), inflammatory bowel disease, colitis, cancer, or
hemorrhoids. GI bleeding may happen after an injury, such as a blow to the stomach or hard vomiting (throwing up).

The causes of gastrointestinal (GI) bleeding are classified into upper or lower, depending on their location in the GI tract.

Upper GI bleeding

Peptic ulcer disease: Peptic ulcers are localized erosions of the mucosal lining of the digestive tract. Ulcers usually occur in the
stomach or duodenum. Breakdown of the mucosal lining results in damage to blood vessels, causing bleeding.

Gastritis: General inflammation of the stomach lining, which can result in bleeding. Gastritis also results from an inability of the
gastric lining to protect itself from the acid it produces. NSAIDs (nonsteroidal anti-inflammatory drugs), steroids, alcohol, burns, and
trauma can cause gastritis.

Esophageal varices: Swelling of the veins of the esophagus or stomach usually as a result of portal hypertention. Varices most
commonly occur in alcoholic liver cirrhosis. Bleeding from esophageal varices can be massive, catastrophic and occur without
warning.

Mallory-Weiss tear: A tear in the esophageal or stomach lining, often as a result of vomiting or retching. Mucosal tears also can
occur after seizures, forceful coughing or laughing, lifting, straining, or childbirth. Physicians often find tears in people who have
recently binged on alcohol.

Cancer: One of the earliest signs of esophageal or stomach cancers may be blood in the vomit or stool.

Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at
the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta.

Hematobilia, or bleeding from the biliary tree.

Hemosuccus pancreaticus, or bleeding from the pancreatic duct.

Lower GI bleeding

 Diverticulosis: One of the most common causes of lower GI bleeding. Small out-pockets, or diverticula, form in the wall of the colon
(large intestine), usually in a weakened area of the bowel wall. The person may develop several pockets, which are more common in
people who have constipation and strain during a bowel movement.

Cancers: One of the early signs of colon or rectal cancers may be blood in the stool.

Inflammatory bowel disease (IBD): Flares of inflammation from IBD often cause mucousy stool that has blood mixed in it.

Infectious diarrhea: Some viruses or bacteria can cause damage to the inner lining of the intestines, which can lead to bleeding.

Angiodysplasia: Along with diverticulosis, this is one of the most common causes of lower GI bleeding. Angiodysplasia is a
malformation of the blood vessels in the wall of the GI tract. These are most commonly in the large intestine and often bleed. The
elderly and people with chronic kidney failure develop the disease most often.

Polyps: Intestinal polyps are noncancerous tumors of the GI tract, occurring mostly in people older than 40 years of age. A small
proportion of these polyps may transform into cancer. Colon polyps may bleed rapidly, or they may bleed slowly and go undetected.

Hemorrhoids and fissures: Hemorrhoids are swollen veins in and around the anus. Repeated stretching from straining during bowel
movements causes them to bleed. Bleeding from hemorrhoids is usually mild, intermittent, and bright red. Anal fissures, or tears in
the anal wall, also may trigger small amounts of bright red bleeding from the anus. Forceful straining during passage of hard stool
usually causes such tears, which can be very painful and may require surgery.
And other causes.

Classification

-         By term:

 Acute
 Chronic

-         By localization:

 Upper gastrointestinal
 Lower gastrointestinal
 mixed bleeding (simultaneously from different parts of the gastrointestinal tract)

-         In obedience to classification of O.O. Shalimov, V.F. Saenko (1987), bleeding divide loss of blood into 3 degrees of weight.

 · I degree - easy, observed at a loss to 20% VCB (volume circulation blood) (till 1000 ml with weight 70 kg).
 · ІІ degree - middle weight, predefined a loss from 20% to 30% VCB (to 1500 ml).
 · ІІІ degree is heavy which answers the loss of more than 1500 ml.

Signs and symptoms

The symptoms of acute GI bleeding depend on where in the digestive tract the bleeding is occurring. Symptoms of upper GI
bleeding can include bright red blood, dark clots, or coffee ground-like material in vomit, or black, tar-like stools. Symptoms of lower
GI bleeding can include passing bright red blood alone or passing blood mixed in stool (turning stool to black or tar like), or bright
red or maroon-colored blood in the stools.

Symptoms of acute bleeding

Specific symptoms:

-         Blood in vomit (hematemesis)

-         Coffee-grounds appearance of vomit

-         Bright red blood coating the stool (hematochezia)

-         Dark blood mixed with the stool (melena)

General symptoms:

 Weakness
 Shortness of breath
 Dizziness
 Rapid pulse
 Decreased blood pressure
 Reduced urine flow
  Abdominal discomfort
 Cold, clammy hands and feet
 Faintness
 Diarrhea
 Confusion
 Disorientation
 Sleepiness

Depending on the degree of bleeding, distinguish:

 I degree - the general state of patient is satisfactory or middle weight, a skin is pale (vascular spasm), pulse appears < 90-
100 b/min., BP - 100-90/60 mm.Hg, an anxiety changes easy dormancy, consciousness gums, breathing often, reflexes are
mionectic, muscles are weakened. The expressed disorders of circulation of blood are not observed.
 A ІІ degree is the general state of middle weight, a patient is put on the brakes, talks in a low voice, slowly, determined the
expressed pallor of skin covers, sticky sweat, pulse - 120-130 b/min., weak filling, BP - 90-80 /50 mm.Hg , frequent shallow
breathing, oliguria. Considerable violations of circulation of blood, metabolism, function of buds, liver, intestine are
marked.
 ІІІ degree - the general state is heavy or extremely heavy, oppression of all of reflexes, skin and visible mucus pale cyanotic
or macula’s (the spasm of vessels changes dilatation). A patient with a question answers slowly, in a low voice, loses
consciousness often, a pulse is threadlike, 130-140 b/min., periodically on peripheral arteries can be not determined,
maximal BP - 0-60 mm.Hg, central venous pressure (CVP) is very low, breathing is superficial, not frequent, extremities and
body are cold by touch. Oliguriya passes to the anury. Without timely indemnification bleeding sick die as a result of
decline of cardiac activity, expressed metabolic violations, necrocytosis liver, buds.

Laboratory and instrumental methods of diagnostics.

Laboratory methods of inspection:

1. Common analysis of blood.

2. Common analysis of urine.

3. Determination of blood and Rh-factor type.

4. Biochemical blood test.

5. Coagulogramm.

6. ECG.

The decline of level of hemoglobin, amount of red corpuscles, Ht appears laboratory researches. At the beginning of bleeding these
indexes do not represent its veritable degree, the decline of them is observed only in a few hours. There is also a decline of level of
general albumen in plasma of blood, violation of electrolyte and nitrous exchange.

The history and physical examination provide vital information on the location, severity, and duration of bleeding and can help
identify patients at increased risk of exsanguination and re-bleeding. It is important to remember that patients with overt major
bleeding from an upper GI source can present with hematochezia. These patients can experience visceral discomfort and orthostatic
symptoms shortly after the onset of bleeding. Abdominal discomfort —especially periumbilical cramping and gaseous distention—
usually indicates rapid intestinal transit of blood and suggests a major bleed.

From the instrumental methods of inspection a major role is played by endoscopic methods which enable to set not only a bleeding
source and its reason but also bleeding stopped to define or lasts.
 Medical tactic and choice of method of treatment.

Medical tactic depends on reason of bleeding, duration of bleeding and his dynamics, degree of bleeding. 
 All of patients with suspicion on the gastrointestinal bleeding of must be hospitalized in a surgical department, and at confirmation
of diagnosis - in a reanimation (O.O. Shalimov, 1987).

Conservative treatment of bleeding is indicated:

а) at a doubtful diagnosis;

b) at bleeding of the first degree, which is shut-down;

c) at the shut-down bleeding, when absent is given about possibility of its relapse;

d) in default of terms for implementation of operation;

e) at presence of heavy accompanying pathology.

Conservative treatment includes:

1. Bed rest.
2. Hunger, later in case of shut-down of bleeding is a Meulengracht’s diet (sour cream, raw frappe eggs)
3. Local hypothermia (cold on the abdomen)
4. Cannulation of two veins, one of which must be central.
5. Introduction of hemostatics (Vicasoly, Dicynon, Chloride of calcium, plasma).
6. Oppression of fibrinolytic activity (Aminocaprony acid, Tranexamic acid).
7. Oppression of gastric secretion (blocks of H2-receptors, PPI).
8. Transfusion of mass of red corpuscles, plasma.

During the EFGDS or colonoscopy it is possible natively to stop bleeding by electro-coagulation, photocoagulation a laser,
application of glue of KL-3.

 Methods of endoscopic stop of bleeding:

1. Cryocautery.

2. Diathermo-coagulation.

3. Electro-coagulation.

4. Laser coagulation.

 A cryocautery is local influence on the area of bleeding by a cold.

         To to, an ampoule is joined a probe which is brought to the area of bleeding from chlorethil through the special reducer.

         Crioelectrocoagulation - by the special device a bleeding area is irrigated by the stream of a liquid nitrogen at a temperature
-280С before formation of “snow cap”.

 Diathermocoagulation. The special probe (mono- or bipolar electrode) is tricked into to the bleeding area and by the short
including of current of high-purity coagulation fabrics to education white a scab.

If directly coagulation a bleeding vessel is not succeeded, it is expedient to conduct coagulation round it, on the stored fabrics,
coagulation a vessel on a draught.
  Most effective is laser coagulation, where depending on power of radiant it is possible to regulate the depth of
coagulation.

Stop bleeding by these methods succeeded in 80-90 % cases. However, in 15-20% in different terms after coagulation there are
relapses of bleeding. For their prophylaxis utilize injection of bleeding area by different blood stop preparations (Noradrenalinum,
96% Ethanol, Dicynon, Aminocaprony acid);

Control of conservative treatment is conducted by measuring of pulse, arterial pressure each 30 minutes, central of venous pressure
- hourly. A blood test is hourly conducted a patient (red corpuscles, hemoglobin, Ht). A patient is conduct intubation of stomach for
control after bleeding, systematic aspiration of gastric contents, permanent cannulation of urinary bladder and control after a
diuresis (it must be selected urine not less than 30 ml/hour).

In patients with uncontrollable esophageal variceal bleeding after failed pharmacologic and endoscopic interventions, balloon
tamponade remains a temporary option. The technique was at first time described by Westphal in 1930 using an esophageal sound
for a cirrhotic patient with a variceal bleed and has since spurred the development of three multiluminal nasogastric balloon tubes
used for the same purpose. The Sengstaken–Blakemore tube was originally described in 1950 and has a 250 mL gastric balloon, an
esophageal balloon, and a gastric suction port. It was later modified to add an esophageal suction port in an effort to decrease the
need for parallel insertion of a nasogastric tube for collection of esophageal secretions above the proximal inflated balloon. This
modification is known as the Minnesota tube. The third is the Linton–Nachlas tube, which has a 600 mL gastric balloon and both
gastric and esophageal aspiration ports. It is used mainly for gastric variceal bleeds. Given that this balloon tamponade has not been
shown to be more effective than pharmacological or endoscopic therapy in the long term and is frequented by re-bleeding after
deflation the balloon, as well as a potentially devastating complication of esophageal rupture, balloon tamponade is typically utilized
as a temporizing measure until more definitive procedures can be employed.

Methods of investigation in thoracic surgery

Thoracic surgery deals with some of the most important organ systems of the body. Their integrated function is vital to life. To this
end, the thoracic surgeon operates on these structures to correct abnormalities of development, relieve obstruction, drain and
contain infections, and extirpate tumors. Adequate function of the heart and lungs must be maintained during operation, which
often requires highly sophisticated techniques and instruments.

Special procedures

1)    Thoracocentesis is simply needle aspiration of the pleural cavity. It is performed both for diagnosis and for treatment of
disorders causing abnormal accumulations of gas or fluid within the pleural space. The accumulations may consist of air
(pneumothorax), blood (hemothorax), serum (pleural effusion, hydrothorax), chyle (chylothorax), pus (empyema), or varying
combinations thereof (hemopneumothorax, pyopneumothorax).

Normally, the pleural cavity is simply a potential space that is under negative pressure (-5 to -10 cm. H2O). The space is bounded by
parietal pleura lining inside of the chest wall and visceral pleura covering the surface of lungs. Normally, the pleural cavity contains
only a few milliliters of lubricating serum to allow frictionless gliding of the apposed pleural surfaces during respiratory excursion.

Since the chest wall is relatively unyielding, accumulations within the pleural space first collapse the ipsilateral lung to impair its
expansion and aeration, proportionate to the volume accumulated. Progressively greater volumes shift the mobile mediastinal
structures to the other side, impairing expansion of the contralateral lung and diminishing the return of venous blood to the heart.
The results a cardiopulmonary dysfunction that is proportionate to the volume and speed with which the gas or fluid accumulates
within the pleural space.

Thoracocentesis is performed aseptically after shaving, scrubbing, and painting the skin with an antiseptic solution. The operator is
gloved and often wears a mask and gown. Skin wheal local anesthetic agent. The needle is introduced just above an appropriate rib
to avoid the intercostal vessels that travel along the inferior rib surface. The patient with pneumothorax is supine, and the needle is
introduced in the second or third intercostal space in the midclaviculary line (parasternally), since air gravitates upward. When fluid is
to be removed, the needle is introduced into the seventh or eighth intercostal space in the midaxillary or posterior axillary line while
the patient is in an upright position, since fluid  gravitates inferiorly. If the fluid is loculated or localized, radiographic examination of
the chest should guide placement of the needle.

     Diagnostic thoracocentesis is performed when physical examination and radiographic examination of the chest disclose pleural
collections (generally fluid) of an unknown type. Generally, only a few milliliters of the fluid are aspirated, with no attempt being
made to tap the pleural space dry. The aspirate can be inspected, cultured, stained, examined cytologically, and tested for clotting
properties, specific gravity, pH, and chemical constituents. Definitive treatment is facilitated when one knows the precise nature of
the pleural effusion.

An attempt is made to evacuate the pleural fluid or air totally in a thoracocentesis performed for therapeutic purposes. The visceral
and parietal pleural surfaces are thereby apposed to one another and help seal off the source of leakage of air or blood. Removal of
large amounts of pus aids in the supportive treatment of empyema and thins the fibrous “peel” that subsequently forms.
Occasionally, drugs are injected into the pleural space (fibrinolytic enzymes, antibiotics) before withdrawal of the needle. Diagnostic
and therapeutic thoracocenteses are often combined.

Complications of thoracocentesis are few:

 bacteria may be introduced if the needle is dirty, if the skin is inadequately prepared, or if the needle is inserted through a
contaminated area of the chest wall;
 air is sucked into the pleural space if the needle, tubing, or syringe becomes disconnected, because of the negative
intrapleural pressure;
 the lung may be punctured by the needle tip, provoking a pneumothorax or hemothorax.

These complications are minimized by careful attention to the technique.

2)    Pleural space drainage. Underwater-seal drainage is the standard technique of closed tube drainage of the pleural space to
remove pleural space air or fluid aseptically and encourage lung expansion. It is also known as a Bülau drain or an intercostal
catheter. It is selected in preference to thoracocentesis when the leakage is expected to continue for some time (hours or days), with
rapid reaccumulation likely after simple needle aspiration.

In keeping with the principles outlined for thoracocentesis, the chest tubes are introduced aseptically high anteriorly for the removal
of air, and low and laterally when fluid is removed. They may be inserted through a trochar under local anesthesia, but more
commonly they are left indwelling at the conclusion of thoracotomy operations in which functioning lung tissue remains in the
hemithorax. Tube drainage is not used after total pneumonectomy because the risk of postoperative air leak or infection is low, and
the serum that fills the empty hemithorax obliterates the space created by the removal of the lung. The process is completed by the
organization of the fluid mainly through the action of fibroblasts to produce a fibrothorax.

The principles of underwater-seal drainage (Fig. 2): the fluid or blood enters the bottle under the surface of the water, with the
length of glass tubing immersed determining the positive pressure that must be exerted by the patient before drainage occurs. Air
bubbles off through the vent in the top of the bottle while fluid accumulates in the bottle. The fluid cannot backtrack up the tubing
to reenter the pleural space. If the tubes aren’t plugged, one can tell that an air leak has sealed when bubbling ceases and that
pleural fluid has disappeared when the fluid level in the bottle becomes stabilized. The tubes are generally removed at this time.

Open tube drainage of the pleural space simply communicates the pleural space directly to the outside, generally through one or
two hard rubber tubes. The tubes are introduced through an appropriate intercostal space, or (preferably) through the bed of a short
segment of resected rib. Open tube drainge is simpler and quicker than closed tube (underwater-seal) drainage, but it can be used
only under the following circumstances:

-         when contamination is already present (empyema);

-         when the negative intrapleural pressure has been lost;

-         when the lungs and mediastinal structures are fairly fixed, or stabilized, so that they cannot be dislocated.

With these limitations, the open tube method is usually restricted to the drainage of chronic empyema.
3)    Tracheobronchial toilet is essential at all times and is automatically carried out by all of us as we periodically change position,
sigh, breathe deeply, clear our throats, or cough. Maintenance of a clear airway is especially important in patients with lung disease
or postoperative patients. It is accomplished best by the patient himself with frequent changes in position, periodic deep breathing,
and vigorous coughing. In most instances such measures insisted on by nursing and physiotherapy personnel will prevent atelectasis
and encourage expansion of the lung, the two main goals of postpulmonary resectional care.

-         Endotracheal  suction is one of the techniques to facilitate tracheobronchial toilet (Fig. 3). The irritation that the tube
provokes in the trachea itself generally induces uncontrollably vigorous coughing, raising sputum and dislodging mucus plugs that
are then sucked out. Saline and mucolytic agents can be injected through the tube to liquefy secretions and improve cleansing of
the respiratory tree. A “trap” in the tubing allows collection of the aspirate for examination and culture. The apparatus must be
sterilized before being used.

Administration of oxygen before, during, and after endotracheal  suction reduces hypoxic complications.

-         Periodic assisted ventilation bronchoscopy and tracheostomy are more extreme measures used without delay if simpler
methods fail. Ventilation can be assisted by bag and mask but is administered more effectively when one passes an endotracheal
tube and ventilates with a bag. Irrigation and aspiration can be performed through the tube, and poorly aerated or atelectatic areas
of lung are expanded to improve respiratory exchange. If ventilation is impaired because of an obstructing mucus plug or thick
secretions the patient can’t raise, bedside bronchoscopy may be required. This is most easily accomplished with a flexible fiberoptic
bronchoscope.

Tracheostomy allows irrigation, aspiration, and assisted ventilation, reduces respiratory “dead space”. However, it is accompanied by
desiccation of  inspired air, loss of phonation, and occasionally misadventures such as erosion of the trachea and bleeding.

4)    Bronchoscopy allows visualization of the interior of the trachea and main bronchi through an illuminated, rigid, tubelike
instrument. The bronchoscope is introduced with topical (local) anesthesia in the cooperative and sedated adult but requires general
anesthesia in children and uncooperative adults. Mucosal ulceration, inflammation, or tumors can be seen at bronchoscopy, as well
as deviation, distortion, and narrowing of the trachea and bronchi. Secretions can be aspirated, foreign bodies removed, and
suspicious mucosal lesions biopsied through the bronchoscope. The rigid bronchoscope complemented by the use of telescope lens
systems allows visualization of the airway to segmental bronchi and is therefore of greatest use in centrally located proximal lesions.

Direct examination of subsegmental bronchi is possible by means of the flexible bronchofiberscope, which utilizes the fiberoptic
principle allowing the visual image to be transmitted along a curved pathway. Because of this unique property and a relatively small
diameter, the device can be manipulated into subsegmental bronchi, thereby expanding direct airway visualization. In addition, the
instrument provides access to distal bronchi for the passage of brush catheters and small biopsy forceps.

5)    Bronchography allows roentgenographic visualization of the smaller ramifications of the tracheobronchial tree.

Roentgenograms are taken in different projections after a rather viscid radiopaque material has been injected endobronchially
through a nasotracheal catheter. The patient is positioned appropriately to allow filling of any or all of the lung segments.
Bronchography outlines filling defects caused by tumors or foreign bodies, localizes endobronchial obstruction, and diagnoses
bronchiectasis and abnormalities of position of the various lung segments. Once widely used, it is now of limited use.

6)    Mediastinoscopy and anterior mediastinotomy. Biopsy of mediastinal lymph nodes is more likely to yield a diagnosis in
patients with pulmonary disease than biopsy of more distant regional lymph nodes. These procedures require general anesthesia.
Mediastinoscopy is performed by insertion of a lighted scope through a small cervical incision in the suprasternal notch. The
instrument is passed along the anterior surface of the trachea deep to the pretracheal fascia to the level of the bifurcation of the
trachea. Lymph nodes adjacent to the trachea, proximal right and left bronchi, and subcarinal area are visualized and biopsed.
Anterior mediastinotomy is an extrapleural mediastinal exploration through the bed of the second or third costal cartilages. These
procedures are nearly always diagnostic in sarcoidosis or lymphoma with hilar adenopathy and are of great value in assessment of
mediastinal spread of bronchogenic carcinoma.

7)    Lung biopsy. For diffuse disease of the pulmonary parenchyma it may be necessary to obtain a specimen of the lung for
analysis. A trephine air drill or cutting needle may be used percutaneously to allow biopsy of the lung but carries the hazard of
pneumohemothorax. Open biopsy of the lung through small anterior thoracotomy is usually the best means of obtaining adequate,
representative tissue.

Chest trauma
Thoracic injuries account for 25 % of the deaths from trauma. 50 % of patients which die from multiple injuries also have a significant
thoracic injury. Open injuries are caused by penetrating trauma from knives or gunshots. Closed injuries occur after blasts, blunt
trauma, and deceleration. Road traffic accidents are the most common cause, there are 60-90% cases of the closed injuries of thorax.

The amount of patients with the trauma of thorax steadily grows in connection with technical progress and increased motorization
of the country.
In the economically developed countries trauma, as a reason of death, occupies the third place after cardio-vascular and oncologic
diseases.

More than one hundred thousand persons annually die in the USA from accidents, and trauma remains the leading reason of death
of people of able to work age.

Trauma of thorax is one of the heaviest types of injury.

Lethality at the heavy trauma of thorax remains high and makes from 10 to 35 %, and at the concomitant injuries of other organs,
met in 80 % cases, it is increased to 50-60 %. Among reasons of lethality from a trauma the trauma of thorax occupies the second
places after the craniocerebral trauma.

Multiple rib fructures, often seen after steeringwheel injuries (Fig. ), produce an unstable segment of the chest wall that on
inspiration moves paradoxically inward and on expiration balloons outward (flail chest). The inspiratory concavity in the chest wall
compresses the underlying lung, shifts the mediastinum to the opposite side, impairs venous return to the heart, and limits
expansion of the good lung. Tachypnea increases the movement of the chest wall (mediastinal flutter) to aggravate these changes.

 Principal reasons of death of victims with the trauma of thorax are the injury of lung, wounds of heart, fat embolism, bleeding,
traumatic pneumonia.

Probability of fatal outcomes for victims with the heavy injuries of thorax depends on age, amount and severity of concomitant
injuries, and also on before existing changes in vital organs (lungs, heart, liver, kidneys etc.).

In a clinical picture accepted and next classification of trauma of thorax is used (E.A. Wagner, 1981)

- Isolated is a trauma of one organ within the limits of one anatomic area.
- Plural is a trauma of a few organs within the limits of one anatomic area.
- Multitrauma or polytrauma is a injury of a few organs in different anatomic areas.
- Combined trauma is injuries, arising up at affecting organism etiologic different injuring factors.

All traumas of thorax are divided by 2 large groups: opened and closed.

Classification of the opened injuries of thorax /wounds of thorax/

On localization of injury: one-sided and two-sided.

According to type scotching weapon: stab-cutting and gunshot [missile] wound.

In grain wound channel: blind and through.

In grain wounds: penetrating and nonpenetraiting. The injury of parietal sheet of pleura serves as a criterion.

Penetrating wounds are divided by 2 groups: with the injury of organs and without a injury.

A separate group is select thoracoabdominal wounds at which a diaphragm and wound channel passes through two cavity: pleura
and abdominal.

Thoracoabdominal wounds are divided by the followings groups: without the injury of organs of abdominal and thoracic regions
with the injury of organs of thoracic cavity with the injury of organs of stomach and retroperitoneum space
with the injury of organs of thorax, stomach and retroperitoneum space.
Classification of the closed trauma of thorax

1. Without the injury of bone sceleton of thorax are injuries, haematomas, tear of tissues.
2. With the injury of bone sceleton of thorax are fractures of ribs, breastbone, collar-bone, shoulder-blade.

a)     Without the injury of viscera.

b)    With the injury of viscera (lung, heart and large vessels, trachea and bronchus, esophagus and organs of posterior mediastinum).

Classification of the closed injuries of thorax (on  And. Е. Romanenko, 1982).

1. On the presence of injuries of other organs:

1. Isolated trauma.
2. Combined trauma.
2. On the mechanism of trauma:
1. Hurt.
2. Compression.
3. Concussion.
4. Fracture.
3. In grain injuries of thorax:
1. without violation of integrity.
2. with violation of integrity of ribs, breastbone, spine.
4. In grain injuries of organs of thoracic cavity:
1. without the injury of viscera.
2. with the injury of viscera (lung, heart and large vessels, trachea and bronchus, esophagus).
5. On the presence of complications:
1. Uncomplicated.
2. Complicated:
- early complications (pneumothorax, hemothorax, subcutaneous emphysema, pneumomediastinum, floated
fracture of ribs, traumatic shock, asphyxia);
- late complications (traumatic pneumonia, pleurisy, festering diseases of lungs and pleura).
6. On the state the cardiovascular and respiratory systems:
1. Without the phenomena respiratory and cardiovascular insufficiency.
2. Sharp respiratory insufficiency (I, II, III degrees).
3. Acute respiratory failure (I, II, III degrees).
7. On the degree of severity of trauma:
1. Easy.
2. Middle.
3. Heavy.

Injury of bones of thorax.

The direct action on the chest wall of injuring factor results in the fracture of ribs and breastbone. The fracture of breastbone often
arises up as a result of trauma at the helm of car, localized in most cases in the upper and middle third.

In 41-48% cases fractures of ribs recognized too late. It is related to that at the plural trauma of thorax basic attention is spared the
injury of intrathoracic organ, requiring urgent treatment, and diagnostics of fractures of ribs is moved aside on the second plans.
Depending on the mechanism of trauma the fractures of ribs are subdivided into direct, arising up in the place of blow, undirected,
arising up in the distance from the place of blow, and combined.

The so-called "fenestrated" fractures of ribs flow especially heavily. There are fractures for to 2-3 anatomic lines, attended   with
pathological mobility of area of thorax. This phenomenon, observed at 17,8% patients, in literature described under the different
names: "floated thorax", "float of thorax", " fenestrated fractures of ribs", "costal panels".

Classification of floated fracture of ribs:

1. A central floated segment is plural fractures of ribs on parasternal or middle-clavicular lines.

 2. An anterior-lateral floated segment is plural fractures of ribs on parasternal and anterior-axillar lines.
3. A lateral floated segment is plural fractures of ribs on front and back axillar lines.
4. A back floated segment is plural fractures of ribs on back-axillar and paravertebral lines.

Clinical staging and diagnostics

Patients complaints on a sharp local painfullness in the site of injury, which increases at the deep breathing, cough and change of
position of body of patient; shortness of breath at peace, general weakness. Patients indicate on a trauma.

Complaints from the side of other organs and systems: sense of interruptions in area of heart.

Anamnesis of life: the presence of harmful habits and chronic diseases is specified.

The general state of patient, as a rule, varies from the middle degree of severity to extremely heavy. Cyanosis of skin covers is
possible. Examination of hypoderm, palpation of lymphatic nodes, thyroid and thoracic glands.

Tachycardia is typifying heart sounds are muffled, arrhythmia is possible.  Inspection of the state of musculoskeletal system:
(examination and palpation).

 Examination of thorax and upper respiratory tracts, palpation of thorax, percussion and auscultation of lungs. Pain in a thorax is the
leading clinical syndrome for the fracture of ribs and breastbone.

Instrumental diagnosis programme

1)    Blood test – as the result of possible bleeding (decline of Hb, red (blood) cells), increase of ESR.

2)    Determined the measure of bleeding.

3)    Blood group and Rh-factor.

4)    Urine test – changes can be absent.

5)    Coagulogram.

6)    X-ray examination of thorax: the fractures of ribs, breastbones, pneumothrax, haemothorax.

7)    ECG (tachycardia, signs of myocardium hypoxia).

8)    Bronchoscopy: receipt of scarlet blood from bronchus at the injury of lung.

9)    Ultrasonic research of pleura cavity: hemothorax is determined in a pleura.

10)                      Ultrasound research of heart is most informing at the trauma of heart: the decline of contractile function of
myocardium, the external and internal fractures of heart are visualized.

11)                      Puncture of pleura cavity – serves as diagnostic and medical manipulation at suspicion on a hemopneumothorax.

12)                      An angiography enables to specify a diagnosis and exactly to define the place of defeat of heart, aorta and other
large vessels of mediastinum.

13)                      Thoracoscopy is a high-informing method, allows to specify character, localization of injury.

Treatment of fractures of bones of thorax depends on the size of trauma, presence of concomitant injuries of intrathoracic organs
and complications. The basic method of treatment of the uncomplicated single fractures of ribs is conservative.

Treatment of the flail chest initially follows the principles of advanced trauma life support. Further treatment includes:

 Good pain management includes intercostal blocks and avoiding opioid pain medication as much as possible. This allows
much better ventilation, with improved tidal volume, and increased blood oxygenation.
 Positive pressure ventilation, meticulously adjusting the ventilator settings to avoid pulmonary barotrauma.
 Chest tubes as required.
 Adjustment of position to make the person most comfortable and provide relief of pain.
 Aggressive pulmonary toilet

Surgical fixation can help in significantly reducing the duration of ventilatory support and in conserving the pulmonary function.

A person may be intubated with a double lumen tracheal tube. In a double lumen endotracheal tube, each lumen may be connected
to a different ventilator. Usually one side of the chest is affected more than the other, so each lung may require drastically different
pressures and flows to adequately ventilate.

The traumas of lung, arising up at road traffic accidents, are subdivided into fractures and contusions.

Choice of medical tactics: Medical tactics at the traumatic injury of lung depends on the type of injury. Contusion of lung mainly
subject conservative treatment. Treatment of fractures of lung and penetrable wounds of thorax with the injury of lung mainly
surgical and depends on the degree of destructions of pulmonary tissue.

Operative measures divided as reanimation, urgent, deferred urgent and deferred.

Reanimation operations are indicated to suffering with the heavy trauma of intrathoracic organs and uncontrolled bleeder expressed
acute respiratory failure or their combinations which conservative treatment having no prospects at. An operation is conducted
regardless of severity of the state of patient, at once after determination threatening life of injury, during 20-30 min from the
moment of hospitalization. Reanimation thoracotomy, reanimation tracheotomy, thoracocentesis and draining of mediastinum.

Urgent operations (produced during 0,5 - 2 h after hospitalization) are indicated to suffering with the expressed signs of shock and
in less degree - bleeding and respiratory insufficiency.

The deferred urgent are performed through 2-6 h after hospitalization. These operative interferences are produced to the patients
with the vast injuries of soft tissure of thorax, plural fractures of ribs, fracture of lung, by a hemopneumothorax and with other
complications of trauma, when intensive therapy directed on the removal of hypovolemia, anaemia, hypoxia, acidosis, appears
uneffective.

Surgical interferences, executed after 6 h from the hospitalization, after the treatment from a grave condition and relative correction
of haemodynamic indexes named as the deferred operations.

At suspicion on haemothorax with a diagnostic and medical purpose pleura puncture is used. Discovery at puncture more than 100
ml of the blood and repeated its accumulation is an indication to the draining.

Indications to thoracotomy at the trauma of thorax:

- continuing intrapleural bleeding, more than 150 - 200 ml of blood during an hour;
- intrapericardial bleeding with development of cardiac tamponade;
- extrapericardial cardiac tamponade;

-         hemorrhage in the mediastinum with the compression of respiratory tracts and main blood vessels;

-         increasing, in spite of draining, tense pneumothrax and mediastinal emphysema.

A primary value after operation has prophylaxis of atelectasiss, pneumonias, abscesses of lungs, empyemas of pleura, pericarditises,
pulmonary embolism, suppurations.

Puncture of pleura cavity. Puncture of pleura cavity serves as diagnostic and medical manipulation at suspicion on a
hemopneumothorax.
Research of content of pleura cavity is the test of Ruvilua-Greguara – estimated as positive when clotting of the extracted blood
and specifies on the continuing bleeding in pleura cavity.

Pneumothorax

A pneumothorax is an abnormal collection of air in the pleural space.

Classification of pneumothorax.

1. On prevalence of process:
1. One-sided.
2. Bilateral.
3. On the degree of detelectasis:
1. Partial (a detelectasis is to 1/3 volume).
2. Subtotal (a detelectasis is to 2/3 volume).
3. Total (a detelectasis is a more than 2/3 volume).
4. On the mechanism of origin:
1. Closed.
2. Opened.
3. Valvular.

Closed pneumothorax is complication, which arises up at the injury of visceral sheet of pleura, results in entering of air pleura cavity
and stipulates the collapse of lung. At the closed trauma of thorax reason of origin of closed pneumothorax is a perforation of
visceral pleura and pulmonary tissue by injured fragment of rib.

Opened pneumothorax arises up because of formation of defect of chest wall at massive traumas and free receipt of air during
inhalation in a pleura cavity, and at expiration - outside.

Valvular pneumothorax arises up at the injury of pulmonary tissue or chest wall with formation of valve, when air on inhalation
enters pleura cavity, and on expiration, in connection with closing of valve, keeps indoors outside.

Subcutaneous emphysema. Reason of origin of this complication is an injury of parietal and visceral sheets of pleura by fragment of
rib with inflow of air from pulmonary tissue in pleura cavity and through the injured chest wall (fracture of intercostal muscles) in
hypoderm.

Mediastinal emphysema.

It is complication is characterized by accumulation of air in the adipose tissue of mediastinum.

Reason of mediastinum emphysema are partial or complete fractures of trachea, bronchus, esophagus and in a number.

Hemothorax
It is an accumulation of blood in a pleura cavity. Reason of origin of this complication is an injury of vessels of chest wall, pleura, lung
and mediastinum.

Classification of hemothorax (Е. And. Wagner, 1981г.)

 1. On prevalence of process:
1. One-sided.
2. Bilateral.
3. On the size of blood loss:
1. Small (a loss is a to 10% volume of circulatory blood
2. Middle (loss to 10 - 20% circulating blood volume)
3. Large (loss to 20 - 40 % circulating blood volume)
4. Total (more than 40% circulating blood volume)
5. On continuation of bleeding:
6. With continueing bleeding.
7. With the stopping bleeding.

      IV. On the presence of clots in a pleura cavity.

1. Coagulated.
2. Uncoagulated.
3. On the presence of infectious complications:
1. Uninfected (Germ-free).
2. Infected.

Chylothorax – the accumulation of lymphatic fluid (which can have the appearance of pus) whithin the pleural cavity following
thoracic duct trauma (blunt and penetrating injuries or surgical procedures – dissections around the subclavian artery for patent
ductus, coarctation of the aorta, esophagogastrectomy), obstruction by malignant disease (particularly lymphomas and carcinomas
of the lung and brest), and congenital defects (usually also associated with ascites). By far the most common is trauma, about half
the cases.

Spontaneous chylothorax occurs in the newborn and causes symptoms of tachypnea, cyanosis, and chest wall retractions. In older
children chylothorax with symptoms of respiratory difficulty, cough or recurrent pneumonias indicate an intrathoracic anomaly.

Aspiration alone is effective therapy in children. It will usually be successful in benign cases but is frequently ineffective for
chylothorax caused by tumors. The cause should always be sought.

Lung abscess
The acute abscess of lung (AAL) regard to the group of purulent-destructive affectation of this organ and primary are the cause of
necrosis of pulmonary parenchyma.

Depending on resistant of organism of patient, type of microbial flora and

correlation of alterative-proliferate processes, evolution or sequestration with separation of necrotic focuses or making progress of
purulent-putrid lysis of surrounding tissues.
A pathological process in lungs is characterized by dynamism and one form of development of disease can pass to other. The
infection is usually polymicrobic.

Abscessing pneumonia is characterized by the multiple destructive foci 0.3-0.5 cm in size, within 1-2 segments of lungs, which is not
disposed to progression. The destruction is accompanied by expressed perifocal infiltration of a pulmonary tissue.

The acute (simple) abscess of lung is the purulent or putrid lysis of necrotic focuses of pulmonary tissues, more frequent only within
the limits of one segment with forming of one or a few cavities filled by pus and surrounded by peryfocal inflammatory infiltration of
pulmonary tissues. A purulent cavity in a lung here more frequent than all is delimited from the unaffected areas by a pyogenic
capsule.

A gangrenous abscess is purulent-putrid disintegration of area of necrosis of pulmonary tissues (lobe, segment) is characterized by
propensity to sequestration and poor separation from the unaffected areas. A gangrenous abscess is yet named the delimited
gangrene.

Several underlying cause must be considered:

 1. Aspiration of vomitus: probably the most common cause of lung abscess, it happens especially in alcoholics, epileptics,
patients with central nervous system diseases, and patients who have been unconscious for long periods of time.
2. Bronchial obstruction with infection distal to the point of obstruction: carcinoma, bronchial adenoma, and foreign body
are causes.
3. Pneumonia: the type of organism determines the pattern of resulting lung abscess. The Pneumococcus and Klebsiella
produce multilocular cavities, usually in the upper lobes. Staphylococcus, the most common cause of lung abscess in
infants and children, produces a necrotizing bronchopneumonia leading to multiple abscesses, which can become huge
with bronchial obstruction and air trapping.
4. Abscess from infected cysts or from breakdown of a bronchial carcinoma: infection destroys the lining of a cyst, making it
very difficult to determine its true nature. The “carcinomatous abscess” is one of the many faces of lung carcinoma.
5. Abscess caused by trauma: infection of a hematoma or embedded foreign material.
6. Extension from abdominal infection: subdiaphragmatic abscess and amebic infection of the liver are the usual precursors.
7. Metastatic septic abscess: seeding of the bloodstream from a distant focus (soft tissue, liver, etc.) is the method of spread
of the infected material to the lungs. The abscesses are usually small and multiple.

Classification of purulent diseases of lungs by A.A. Shalimov:

1. Acute purulent diseases of lungs:

1)    acute abscessing pneumonia;

2)    acute single abscesses;

3)    acute plural abscesses;

4)    acute gangrenous abscesses;

5)    widespread gangrene.

2. Chronic purulent diseases of lungs:

1)    chronic pneumonia;

2)    chronic single abscesses;

3)    chronic plural abscesses;

4)    purulent-inflammatory bronchiectases on etiology:

а) acquired; b) congenital; c) cylindrical; d) saccular; e) mixed.

5)    purulent-inflammatory cysts of lungs;

6)    purulent-inflammatory parasite cysts of lungs (echinococcus);

7)    pneumosclerosis;

8)    purulent-inflammatory polycystosis of lungs;

9)    mycosis purulent-inflammatory processes (actinomycosis, aspergillosis).

It is necessary to find out the terms of work (work with harmfuls, dusty, toxic gases); how often has the cold diseases; use of alcohol,
smoking, narcotics; peculiarities of life of patient; is he under observation due to TB or has permanent contact with TB patient. All
these information can specify on the fact of decline of immunity as factors promote to the AAL development.
 

Clinical staging and diagnostics

Clinical signs of lung abscess are fever, cough, production of purulent sputum, anemia, and patient may have foul breath.

At examination the affected half of thorax delays in the act of breathing. By percussion is marked dullness of pulmonary sound over
the place of location of abscess (in the phase of the purulent-necrotic lysis of lung), and after the opening of abscess to the bronchi
may appears tympanic percutory sound.  By auscultation in the first phase of disease detected weakening vesicular breathing, in the
second phase may detected “amphoric” breathing. Frequency of respiratory excursion depends on the volume of affectation of
pulmonary tissues - different degree of expression tachypnea.

Diagnosis programme

1. Blood test: moderate anemia, leucocytosis with a deviation to the left, high ESR.
2. Urine test: the changes are unspecific.
3. Biochemical blood test: decline of level of general albumen, dysproteinemia.
4. Coagulogramm: violations of coagulation of blood to side of hypercoagulation.
5. Immunological tests: the decline of indexes of cellular immunity
6. Bacteriological research of sputum, content of cavity of abscess: gives possibility detect microbe flora, which are the cause
of destructive purulent process and define the sensitiveness of the last to antibacterial preparations.
7. X-ray research of organs of chest in two projections: In the phase of acute infiltration on X-ray films determined infiltration
of pulmonary tissues as focal (rounded) shade. In the phase of draining of abscess through bronchi on X-ray film
determined one or a few cavities of destruction, more frequent with the horizontal level of liquid and peryfocal
inflammatory infiltration of pulmonary tissues around a cavity. The superexhibited pictures or tomograms help to discover
the cavities of disintegration in lungs. By tomography pulmonary sequesters can be diagnosed.
8. Spyrography - lowering the vital capacity (VC) and maximal ventilation of lungs (MVL) diminishment on 25-30%, the
decline saturation by oxygen of the arterial blood less than 90%.
9. Fibrobronchoscopy: in the phase of draining of abscess through bronchi the phenomena of purulent tracheobronchitis is
determined. It is possible to define localization of abscess by the mouth of draining bronchi.

Complications of lung abscess include brain abscess, empyema, septicemia, and endotoxic shock.

The differentiated diagnosis at acute abscesses is necessary to be performed with: cavernous tuberculosis, actinomycosis,
echinococcus, suppuration of cyst of lung, interlobar encapsulated pleurisy, focal pneumonia, and also tumors and primary
bronchiectases in the phase of abscessing.

Cavernous tuberculosis is usually eliminated at the study of anamnesis, absence of Mycobacterium tuberculosis and X-ray changes
of lungs characteristic for tuberculosis.

For actinomycosis the presence in sputum of druses is characteristic, finding out which is uneasy, the repeated careful researches are
required in this case. For actinomycosis involving in the process of surrounding organs and thoracic wall is characteristic.

At the purulent parasite (echinococcus) and acquired cysts of lung the state of patient is not such heavy, as in case of  acute abscess,
is not marked preceding inflammation of lung; at X-ray research determined round, clear shades with absence of
peryfocal inflammation.

It is necessary to remember that a acute abscess from the gangrene of lung can be distinguished on the clinical development,
because all signs of acute abscess are expressed more considerably, intoxication is more expressed. X-ray research at the gangrene
of lung exposes the presence of the continuous darkening of part of lung on the side of affectation with gradual transition to the
normal pulmonary picture on periphery. With development of putrid pyopneumothorax darkening occupies all half of thorax.

Tactic of treatment of patients with the acute abscesses of lungs depends on the stage of purulent-destructive process.

In stages of acute infiltration - conservative therapy in combination with bronchologic methods is preferable.
In the stage of draining of abscess through bronchi - active administration of bronchologic methods of sanation (including most
effective - microtracheostomy) on a background conservative therapy.

In the case of insufficient drainage of abscess through bronchi or it complete absence (blocked abscess) are used punctions and
drainings surgical methods.

The pathogenetic grounded conservative therapy is directed on the straggle against infection which caused a purulent-destructive
process in a lung.

Conservative treatment:

The regime is a semi bed.

Diet — with a high power value of albumins in food ration. Food must contain the promoted amount of vitamins.

Medicinal therapy:

-         antibiotics for empiric therapy (before the get of results of inoculation and determination of sensitivity of antibiotics to
microbial flora) more frequent than all are used synthetic penicillins, macrolides (sumamed), ftorhinolons of III-IV generations,
cephalosporins of III-IV generations;

-         unspecific anti-inflammatory drags — Meloxicam, Ketoprophen and his derivates (oruvel, ketonal), which are used as
injections and tablets forms;

-         immunocorrectors therapy (levamizol/decaris for 0,15 in days - 3 days with interruptions for 14 days, during 4-6 months);

-         direct anticoagulants – Heparin, Fragmin, Nadroparin;

-         preparations making better the escalator function of lights (mucolytic) – Ambroxol hydrochloride, Acetylcysteine and other;

-         desintoxic therapy – Sorbilact, Reosorbilact, Reombirin;

-         infusion therapy – Ringer solutions, 5% of Glucose, normal saline.

Postural drainage, bronchoscopic aspiration are included in treatment.

Indications to operative interference:

1. Insufficient of draining of AAL through a bronchial tree.

2. Peripheral undrained abscess of lung.
3. Peripheral abscess of lung, the diameter of cavity of which exceeds 5 sm.
4. Appearance of complications (pyopneumothorax).
5. Distribution of purulent-destructive process (gangrene of lung).
6. Chronic abscess.

Gangrene of lung. Bronchiectatic disease.

Gangrene of lung.

The gangrene of lung is necrosis of pulmonary tissues under act of toxins and violation of feed, which does not have clear borders.
Between the acute abscess of lung and gangrene of lung a lot in common, but, nevertheless, most authors consider these diseases
independent. At AAL the inflammatory reaction and purulent focus has the limited character, and at the gangrene of lung is necrosis
of pulmonary tissues, have not clear borders. At the gangrene of lung a necrotic process spreads in pulmonary tissues diffusely. The
areas of normal tissues without noticeable borders pass to changed, losing a clear structure pulmonary tissues which also without
clear borders. Thus pulmonary tissues have the appearance of grey-green mass with foul smell. Usually is affected lobe, two lobes or
all lung.

Polymicrobe floras are the origin affectation of lung: staphylococci, gram-negative bacterias and different anaerobes. The supporting
factors in appearance of gangrene are disorder of passage in bronchus with evolution of atelectasis, disorder of blood circulation;
creation of the reserved space in the area of atelectasis and stopping of clearing of bronchial tubes from an infection by
expectoration; and, especially, influence of a plenty of toxins of developing microorganisms on tissues of lung.

Clinic of gangrene of lung

A high temperature, which does not lowering long time, or has vibrations, in the morning and in the evening. A painful cough with
especially foul sputum is characteristic.

Sputum has the appearance of foamy liquid, dirtily-grayish color, sometimes with the raspberry or chocolate coloring which is
explained by the parenchimatose bleeding from disintegrating tissues.

At precipitation the sputum divides on 3 layers: upper is liquid, middle is serous, lower is dense, consisting of granulated mass and
fragments of pulmonary tissues.

A plenty of sputum is usually expectorated at mornings and is accompanied by a excruciating cough.

Patients complain on several pains in the affected half of thorax. It is related to affectation of pleura, which is rich by the nervous
endings.

The state of patients at the gangrene of lung is always heavy.

They weaken quickly, is exhausted, sweating, absence of appetite, making progress anemia is marked.

At percussion dullness of percutory sound with the unclear spreader borders is marked.

At auscultation there is a plenty of different calibers rales. A frequent and small pulse, deaf tone of hearts. At the beginning of
disease leucocytosis with the change of leucocytes formula to the left side registers in a blood.

At X-ray research usually detected the intensive darkening of part of lung with gradual transition to the normal pulmonary picture
on periphery.

If gangrene makes progress, and spreads on peripheral regions of lung, as result, parenchyma of lung disintegrates as sequesters
and gets in a pleura cavity - develops the putrid pyopneumothorax and illness acquires the septic form.

Bronchiectatic disease

Bronchiectasis is the irreversible morphological changes (dilatation, deformation) and functional inferiority of bronchial tree,
resulting in the chronic purulent disease of lungs.

Among other diseases of lungs bronchiectatic disease makes from 10 to 30%, and at fluorography this disease detects approximately
at 1-2 from 1000 inspected. More than at the half of patients it is diagnosed under age 5 years and at one third of all patients - on
the first year of life.
Men are ill in 1,3-1,9 times more frequent, than women.
Among the adult population (from sectional information) frequency of bronchiectatic disease makes from 2 to 4%.

A left lung is affected in 2-3 times more frequent, than right.

In child’s age predominant left-side bronchiectasis.

Inflammatory bronchiectasis can be result from pulmonary infections, asthma, and bronchial obstruction (i.e., aspirated foreign
body).

The pathogenesis: the smaller bronchi become obliterated, and the larger proximal bronchi undergo dilatation and widening
during the healing, fibrotic phase of the inflammatory process. Sinusitis and allergy are common.

Classification

Originally:

- primary (innate);

- secondary (acquired).

By kinds of dilatation of bronchi or accoding to anatomical type:

- cylindrical;

- saccular;

- cyst like form (fusiform);

- mixed.

By distribution:

- limited;

- widespread;

- one-sided;

- bilateral (with pointing of exact localization according segmental structure).

By expressivity of clinical displays:

- with unexpressed symptomatic;

- mild form;

- middle expressed;
- heavy;

- heavy complicated form.

By the clinical feature:

- phase of remission;

- phase of attack - more common in spring and in autumn.

Clinical staging and diagnostics

The symptoms are those of recurrent pulmonary infection: fever or evening subfebrile temperature, morning cough, production of
foul-smelling sputum (mucous-serous), hemoptysis, chest pain, anorexia, gradually increase pallor of skin covers, asthenia, general
weakness, and retarded physical development.

Discomfort or dull, increasing in the period of intensification of inflammatory process pains in a thorax is connected, mainly, with the
affectation of mucous bronchial tree and reactive pleurisy.

A pain syndrome is almost marked at every second patient.

Dyspnoea is present at 40% of patients and grows as far as making progress of disease.
After such intensifications long time is saved cough with sputum, shortness of breath, indisposition.

It is multiplied the amount of sputum gradually, the expressed intensifications in the first years of disease are not observed.

During inspection is unpleasant smell from mouth, edema of face is marked.

Common state of patient in the period of intensification more frequent of middle degree of heavity.

Constitutional features - asthenic is more frequent. Socioeconomic problems are common.

         Inspection of the state of bones-muscles systems: at the protracted presence of disease fingers as drumsticks (clubbing),
deformation of nail plates - «watch glasses». Chronic purulent intoxication can be result of affectation of long tubular bones with
development of sclerosis of bone tissues and origin of inflammatory changes in joints.

Symptomatic detected at the physical inspection of thorax is very various and is determined by localization of affectation, phase of
disease, expressivity of anatomic changes, presence or absence of concomitant changes in surrounding pulmonary tissues.

At examination the affected half of thorax delays in the act of breathing (at the massive affectation).

The percutory changes are not characteristic.

By auscultation: at centrally located or, especially, «dry» bronchiectasis the changes can be absent, but at filling by sputum of
saccular bronchiectasis quite often possible listen above affectation  the rales which have different calibers, at times of big sonority,
sometimes with a «metallic» tint.  On the whole an auscultative picture can be described as pied.

Diagnosis programme:

1. Blood test: in the phase of intensification appears anemia, high leucocytosis of peripheral blood, the ESR increase. In a
period of remission these changes are expressed indistinctly.
2. Urine test: the changes are unspecific, meet albumin urea, cylinder urea.
 3. Biochemical blood test: hypoproteinemia, dysproteinemia.
4. Coagulogram: violations of coagulation of blood in side hypercoagulation.
5. Clinical analysis of sputum: the presence of a plenty of leucocytes, elastic fibers is marked.
6. Immunological tests: the decline of indexes of reactivity of organism is characteristic, in particular cellular immunity.
7. Bacteriological research of sputum, washing waters of bronchial tubes, content of cavity of abscess: allows detecting the
microbial flora and defining the sensitiveness of the last to antibiotics preparations.
8. X-ray research of organs of thorax in two projections: diminishment of volume and compression of shade of the affected
regions of lung is marked, segmental and lobar atelectasis, presence of pleura adhesions, hyperplasia and compression of
lymphatic nodes of root of lung, increase of airiness of his unaffected departments due to local emphysema, high standing
and limitation of excursion of diaphragm, on the side of affectation.
9. Spyrography are the low indexes LVL, decline of compensate possibilities of lungs in combination with hyperventilation,
decline of satiation of arterial blood by oxygen.
10. Fibrobronchoscopy: gives information about the degree of expressivity and localization of inflammatory process in a
bronchial tree, rules out tumor or foreign body.
11. Bronchography is the most important diagnostic examination.

Differential diagnostics: with TB, chronic pneumonia, chronic bronchitis, chronic abscesses, cancer and cysts of lungs.

Kartagener’s syndrome is the combination of situs inversus, chronic sinusitis, bronchiectasis and sterility resulting from abnormal
ciliary action. This disease is genetically inherited.

         Complications of the disease are hemorrhage, empyema, and metastic spread of the infection (brain abscess).

Treatment of patients with bronchiectatic disease is complex, directed on the stragl against an already present infection, on its
warning, and also on maintenance of bronchial drainage and restoration of protective forces of organism; the surgical methods of
treatment are used if necessary.

1)    The regime is general. Stimulation of motive activity of patients, respiratory gymnastics and physical culture. Treatment by
position is used - postural drainage, when chouse such position of trunk which is optimum for expectoration of bronchial content.

2)    Diet - with high energy content with high level of albumens and vitamins.

3)    Medicaments therapy:

-         antibiotics for empiric therapy (before the receipt of results of inoculation and sensitivity of bacterial flora) more frequent than
all are used synthetic penicillins, macrolids (sumamed), ftorhinolons of III-IV generations, cephalosporins III-IV generations;

-         unspecific anti-inflammatory drags;    

-         immunocorrector therapy;

-         preparations making better the escalator function of lungs;

-         desintoxic therapy;

-         infusion therapy is the Ringer solutions, 5% of glucose, normal saline;

-         inhalations - antibacterial preparations (in accordance with the sensitiveness of microflore), muco- and photolytic preparations
(tripsin, ribonuclease, desoxyribonuclease, terrytilin), stimulations of cough by daily insufflations of different solutions through a
catheter, entered through  microtracheostomy;

-         bronchoscopy sanation with performing bronchial lavage with solutions of antiseptics.

The basic indications for operative treatment of patients with bronchiectasis:

- one-sided affectation with abscess formation, hemoptysis or bleeding, uncomplying to conservative treatment;
- one-sided processes with the big volume of sputum and expressed intoxication;
- one-sided making progress processes with frequent attack.

The most frequent postoperative complications are:

-         atelectasis;

-         pneumonia;

-         bronchial fistula;

-         empyema of pleura;

-         postoperative hemoptysis and pulmonary bleeding.

Acute and chronic empyema of pleura

Acute empyema of pleura is the limited or diffuse inflammation of visceral and parietal pleura, characteristic by accumulation of pus
in a pleura cavity and accompanying by the signs of purulent intoxication and quite often respiratory insufficiency.

Empyemas are the most common exudative type of pleural effusion. They may be classified into three categories based on the
chronicity of the disease process. The acute phase is characterized by pleural effusion of low viscosity and cell count. The transitional,
exudative, or fibrinopurulent phase, which can begin after 48 hours, is characterized by an increase in white blood cells in the pleural
effusion. The effusion is turbid, begins to loculate, and is associated with fibrin deposition on visceral and parietal pleurae and
progressive lung entrapment. The organizing phase occurs after as little as 1 to 2 weeks and is associated with an ingrowth of
capillaries and fibroblasts into the pleural rind and inexpansile lung.

An empyema may occur by direct contamination of the pleural space through wounds of the chest (trauma or surgery), by
hematologic spread (bacteremia or sepsis), by direct extension from lung parenchymal infection (parapneumonic or
postpneumonic), by rupture of an intrapulmonary abscess or infected cavity, or by extension from the mediastinum
(esophageal perforation). Most often, empyemas are the result of a primary infectious process in the lung. Historically, these
infections were commonly due to Streptococcus  or Pneumococcus pneumoniae;  today gram-negative and anaerobic organisms are
common causes of empyema. Tuberculous empyema has had a recent resurgence.

At the abscesses of lungs empyema of pleura develops at 8-11 % of patients,

and at the gangrene of lung – at 55-90 %.

In single case empyema can develop, as complication of purulent or parasite cyst, disintegrating cancer, spontaneous
pneumothorax.

Secondary empyema of pleura can develops by a contact way, at suppuration of wounds of chest, osteomyelitis of ribs, spine,
breastbones, chondritis, lymphadenitis, mediastinitis, pericarditis.

The acute inflammatory diseases of abdominal region can be the source of infection of pleura in rare case (subdiaphragmal abscess,
purulent cholecystitis, pancreatitis and others). Penetration of microbes from an abdominal region to pleura takes place through
lymphatic vessels and fissures in a diaphragm, or through hematogenic way.

Classification of empyema of pleura:

I. By etiology:

1. Unspecific:

-         purulent
-         putrid

-         anaerobic

2. Specific:

-         tuberculosis

-         mycotic

-         syphilitic

3. Mixed

II. By pathogenesis:

1. Primary

-         traumatic

-         postoperative

2. Secondary

-         para- and meta pneumonic

-         contact

-         metastatic

III. By the clinical feature:

1. Acute (to 3 months)

2. Chronic (over 3 months)

IV. By the presence of destruction of lung:

1. Empyema of pleura without destruction of lung (simple).

2. Empyema of pleura with destruction of lung.
3. Pyopneumothorax.

V. According to connection with an external medium:

1. Closed.
2. Opened:

-         with bronchopleural fistula;

-         with pleurodermal fistula;

-         with bronchopleurodermal fistula;

-         by the latticed lung;

-         with other hollow organs.

VI. By spreads:

1. Delimited

-         apical

-         paramediastinal

-         supradiaphragmal

-         interlobar

-         parietal
2. Widespread

-         total

-         subtotal

Clinical staging and diagnostics

Usually the disease begins suddenly, increase of temperature up to 38-39 0 C, pain in the chest and shortness of breathing, also can
be a general weakness, bad appetite, insomnia and other, evidences of intoxication.

The pain syndrome – arises up, as a rule on the side of affectation and has permanent character, increasing at the deep breathing,
cough, at change position of body.

Sometimes may be present pain in upper part of abdomen due to irritation of diaphragm.

Cough – quite often with expectoration plenty of sputum, the volume depends from intensivety affectation of lung’s parenchyma,
presence of bronchopleural fistula.

It is necessary to pay the special attention to social status of patient.

The common state of patient  middle or heavy gravity. Consciousness as a rule is clear. Constitutional features – asthenic is more
frequent.

Skin covers are pale.

A bad breath from mouth is marked.

A patient prefers to be in the forced position – sitting or lying on healthy side.

Tachycardia is characteristic and in mostly cases is related to the increase of temperature of body. The tones of heart are weak. There
is tendention to hypotony. Development of pulmonary-cardiac insufficiency with increasing decompesation of circulation of blood
and hypertension in a small circle is possible, to what indicated in an accent of the 2 tones on a pulmonary artery.

Limitation of respiratory excursion of the affected half of thorax,

smoothed out of intercostal intervals, local edema of skin and subcutaneus fat above the region of accumulation of pus in a pleura
cavity is marked.
In future tissues of pectoral wall in this area become dense, painfulness increases, hyperemia of skin appears.

At percussion dullness above the area of accumulation of liquid is determined. In absence of air and adhesions in a pleura cavity the
upper border corresponds to the Ellys-Damuazo line.

At auscultation weakening of the vesicular breathing up to complete it absence over big accumulation of liquid is marked. Above the
area of the compressed lung is bronchial breathing, is sometimes there are moist rales of different calibers, sometimes sound of
friction of pleura due to a fibrin’s pleurisy around the cavity of empyema.

If there is bronchopleural fistula and cavity it is good draining through bronchi, can be listens the amphoryc breathing. Increase of
bronchophony sound above the region of accumulation of liquid is very characteristic.

Diagnosis programme

1. Blood test: moderate anemia, leucocytosis with neutrophilia, by the change of leukocyte formula to the left, the ESR
increase.
2. Urine test: the changes are unspecific is presence of signs of toxic nephropathy: albuminuria, cylindruria.
3. Biochemical blood test: it is sharply expressed hypoproteinemia, dysproteinemia.
4. Coagulogramm: disorder of coagulative function of blood to side hypercoagulation with diminishment of time of
coagulation of blood, considerable increase of level of fibrinogen.
5. Research of electrolytes of blood: hyperpatassemia explainable by disintegration of tissues and elements of blood is
marked.
6. Immunological tests: the decline of indexes of reactivity of organism is characteristic.
7. Bacteriological research of sputum, washing waters of bronchial tree, content of pleura cavity: allows to detect the
microbial flora, which are the cause of inflammatory process and define the sensitiveness of the last to antibacterial
preparations.
8. X-ray research of organs of thorax: X-ray research at acute empyema of pleura and pyopneumothorax has most value,
allows performs exact verification of diagnosis and detect the nearest tactic of treatment of patient.
9. Polypositional roentgenoscopy is more informing allowing to localize the region of affectation, exactly to define the
degree of collapse of lung and displacement of mediastinum, tracheal deviation to the other side, amount of liquid, to
expose the pathological changes in pulmonary parenchyma, to choose a point for adequate draining of pleura cavity,
especially at limited empyema.
10. Pleurography in 3 projections is the very informing method of research. It allows to estimate the sizes of cavity, character
of its walls, presence of sequesters and fibrins stratifications.
11. Tomography - this research is not so informative if there is collapse of lung or presence considerable quantity of liquid in
a pleura cavity. It is therefore expedient to execute it after draining of pleura cavity and liberation of it from pus. If the lung
of collapsed more than on a 1/4 volume, interpretation of tomography information is difficult.
12. Spyrography are the low indexes VVL, decline of compensate possibilities of lungs in combination with hyperventilation,
decline of satiation of arterial blood by oxygen.
13. Fibrobronchoscopy: gives information about the degree of expressed of inflammatory process in a tracheobronchial tree,
allows defining the mouth of draining bronchi (at presence of destruction in pulmonary tissues).
14. Diagnostic thoracocentesis with smear and culture of the purulent fluid.

Differential diagnostics: pneumonia, obturated atelectasis of lung, hydrothorax, abscesses of lung, subdiaphragmal abscess, cancer
of lung in the stage of disintegration and presence of cancer pleurisy, tumors of pleura, purulent cysts, echinococcus, diaphragmal
hernia.

Complications of empyema include empyema necessitatis (spontaneous decompression of pus through the chest wall), chronic
empyema (with entrapped lung and
pulmonary restrictive disease), osteomyelitis or chondritis of the ribs or vertebrae, pericarditis, mediastinitis, the development of a
bronchopleural fistula, or disseminated
infection of the central nervous system.

Treatment

Treatment of empyema is dependent on its phase but involves the identification and systemic treatment (antibiotics) of the causative
organism and complete drainage
of the pleural space. In the acute and early fibrinopurulent phases, complete thoracentesis can be both diagnostic and therapeutic if
the effusion is drained entirely. The prior administration of antibiotics may lead to a sterile tap, but Gram stain (organisms), cell
count (polymorphonuclear leukocytic predominance in bacterial empyema and lymphocytic predominance in tuberculous
empyema), chemistries (protein, LDH, amylase, and glucose), and pH (<7.3) all can be useful in making the diagnosis.
Tube thoracostomy may be indicated for pleural drainage if thoracentesis fails or the empyema has progressed beyond its earliest
stages. Chest tube insertion, however,
can be ineffective if the empyema has become loculated or organized. VATS (Video-assisted thoracoscopic surgery) empyema
drainage with early pleural débridement has the added advantage of more complete pleural drainage by visualizing and breaking
down loculations. Full lung expansion and the prevention of complications is the goal of the procedural intervention. Occasionally,
radiologically guided catheter drainage can be a useful adjunct to these surgical procedures. Thoracotomy with débridement or
formal decortication in later-stage empyema is reserved for treatment failures with persistent sepsis. Management of
parapneumonic effusion and empyema requires individualization of care owing to multiple factors that affect outcome. A patient’s
general health, existence of comorbidities, underlying pulmonary disease,
and causative pathogen all dictate clinical outcome and have an impact on the relative risks and benefits of treatments. No
algorithmic approach is applicable to all
patients. Basic principles (established by Clagett and Geraci more than 40 years ago) that apply to all successful interventions include
early detection of empyema, rapid and effective pleural drainage, and complete lung re-expansion. Effective treatments lead to
decreased morbidity and mortality of empyema.

Postoperative complications:

-         postoperative bleeding;

-         development of remaining cavity;

-         suppuration of postoperative wound;

-         insufficiency  of bronchial stump after resection methods;

-         development of stump region abscess.

Mediastinal diseases
Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. Mediastinitis is usually results from an
infection. It may occur suddenly (acute) or may develop slowly and get worse over time (chronic)

1. Acute mediastinitis.

Method of contamination are direct penetrating trauma; hematogenous, or spread from thoracic viscera (heart, lungs, esophagus, or
from chest wall); from the neck along fascial planes; direct extension from the lungs or pleura.

Symptoms and signs are high fever, pain under the sternum; highly toxic state; dysphagia; hacking cough; mediastinal and
subcutaneous emphysema; edema of chest wall; prominence of veins on chest wall.

Etiology:
 1. 60 % caused by ruptured esophagus (carcinoma, from endoscopy);
2. Spread by blood or lymphatic drainage from thoraracic viscera;
3. Spread from neck along the visceral fascial planes from infection in neck;
4. Extension from empyema or lung abscess.

X-ray findings: widening of mediastinum, displacement of trachea; interstitial emphysema; fluid level of abscess; extravasation of
swallowed contrast material.

Treatment: drainage is most  important; antibiotics are only a helpful adjunct.

2. Chronic mediastinitis.

Method of contamination are same as acute.

Symptoms and signs: usually insidious in onset; weakness; weight loss; chronic cough; anemia; chest pain; low-grade fever;
symptoms of superior vena caval obstruction; swelling of face and neck; esophageal obstruction; occasionally esophagobronchial
fistula with lithoptysis.

Etiology: a granulomatous infection, often not specifically identified; histoplasmosis is the most common cause, tuberculosis.

X-ray findings are paratracheal mass, subcarinal or paresophageal; 50 % not calcified, one third heavily calcified.

Treatment – largely nonsurgical; treatment for specific infection if found (tuberculosis, actinomycosis, histoplasmosis); mediastinal
granulomas should be removed if heavily calcified.

Mediastinal neoplasms

Mediastinal tumors arise from the mediastinum proper, adjacent structures, and outside the thoracic cavity. In general, they produce
symptoms by compression or interference with function of mediastinal organs, or by the development of infection or malignant
change in the tumor itself.

Extraneous lesions simulating primary mediastinal neoplasms are the following:

1. Thyroid: extension of a cervical goiter through the thoracic inlet, or truly aberrant thyroid tissue;
2. Chest wall neoplasms: they may have no palpable external component: chondroma, chondrosarcoma, chordoma, Ewing’s
sarcoma;
3. Congenital or acquired herniations through the diaphragm;
4. Aneurysms of the great vessels;
5. Mediastinal meningoceles: 70 % have stigmas of neurofibromatosis;
6. Achalasia of the esophagus.

Neurogenic tumors make up about 30 % of all mediastinal tumors, teratomas about 15 %, cysts 15 %, thymomas 10 %, goiter 10 %
and all others 20 %; about 15 % are malignant. 

Anterior mediastinum

Intrathoracic goiter are almost always extensions of cervical goiters. The trachea is displaced and the neck veins are prominent
because of compression, which accounts for symptoms of dyspnea, stridor, dysphagia, and facial swelling. Plain X-ray show a high
lobulated shadow in the anterior mediastinum with displacement of the trachea, and barium swallow proves the mass moves with
deglutition; failure of the mass to move with deglutition indicates either that the goiter may be malignant or that some other
diagnosis must be entertained. Removal is recommended, generally with cervical thyroidectomy.

Thymomas are composed of the normal cellular elements of the thymus, except usually lacking Hassall’s corpuscles. Initially
encapsulated, they later invade locally as low-grade malignancies, especially when accompanied by myasthenia gravis. The degree of
malignancy depends on its behavior (i.e., gross findings) and not on histological appearance. Calcification is sometimes seen, but this
is not a sign of benignity. They are slow growing, with as long as 10 years elapsing with little enlargement seen. Thymomas often are
totally asymptomatic, but when large, they produce pain, venous obstruction, stridor, cough, and dyspnea. Surgical excision is
recommended, with postoperative irradiation  if the thymoma is malignant clinically.

Dermoid cyst (bening teratomas) histologically contain only tissue of ectodermal origin. They are usually large and unilocular and
found in middle-aged patients.

True teratomas contain elements of all three germ layers, commonly with hemorrhagic or polycystic areas; 70 % ultimately become
malignant. The usual symptoms of mediastinal teratoma are cough, pain, and dyspnea, but they may rupture into the pleura,
pericardium, and blood vessels. Expectoration of hair is pathognomic; hemorrhage may be severe. X-ray examination is diagnostic if
cartilage, bone, or teeth are seen in a tumor high in the anterior mediastinum. The preferred treatment is surgical removal.

Pericardial cysts are fairly common, arising from a pinched-off portion of the pleuroperitoneal membrane, which occurs during the
formation of the diaphragm. They are always anterior (usually on the right side) and close to the cardiophrenic angle.  They contain
fluid similar to pericardial fluid, prompting the descriptive term “springwater” cysts. They have sometimes a pedicle attached to the
pericardium. Pericardial cysts are always benign and usually are asymptomatic.

Posterior mediastinum

Neurogenic tumors comprise over 90 % of posterior mediastinal tumors. The main histological types are the ganglioneuroma,
neurofibroma, neurilemoma, and the highly malignant neuroblastoma. Neurofibromas and neurilemomas are frequently associated
with intercostal nerves, ganglioneuromas with the sympathetic chain.

Neurogenic mediastinal tumors are often asymptomatic, discovered on incidental X-ray examination of the chest as a “cannonball”
lesion; spreading of the involved intercostal space and rib erosion are highly suggestive of neurogenic tumor. Occasionally a tumor
will proceed dumbbell fashion through an intervertebral foramen to cause paraplegia. Mediastinal neurofibromas are associated with
general neurofibromatosis. Treatment is surgical removal followed by irradiation.

Enterogenous cysts are generally seen lying along the right side of the esophagus in infants and young children, probably because
of displacement by the aorta. They often  are associated with abnormally formed vertebral bodies, to which they may attach, and
occasionally extend through the diaphragm to stomach or intestine. Enterogenous cysts have walls of smooth muscle with an inner
linig of mucosa. If the mucosa actively secretes, expancion and perforation may occur, but these cysts are asymptomatic if the lining
is inactive. Large cysts cause obstructive symptoms (cough, dyspnea). Total surgical removal is the recommended treatment.

Middle mediastinum

The lymphoma family of mediastinal tumors includes leukemia, Hodgkin’s disease, and lymphosarcoma, the latter accoding for 60 %
of the total. Hepatosplenomegaly, lymphadenopathy, and fever are wellknown systemic manifestations of lymphoma.

Bronchogenic cysts sometimes occur in the midmediastinum; they have been discussed in the section on congenital malformations
of the lungs.

Diseases of the breast

Diseases of the breast originate from four basic pathological processes: disturbances of hormonal activity, irritant effects of retained
secretions, infection, and tumors.

Mastitis
 – one of inflammatory diseases of mammary gland - lactational and nonlactational.

Lactational mastitis (LM) makes about 95% of acute inflammatory diseases of mammary gland. LM occupies one of the first places
(26-67%) in the structure of postdelivery purulent-inflammatory complications on a background of lactation.

Acute LM develops in 2,4-18,0% of childbearing age woman.

More often develops after the first births. After the second births mastitis develops in 20% women, and after the third - only in single
cases.

Basic etiologic factors: microtrauma of nipples of mammary gland (cracks and excoriation of nipples, damage of gland skin),
lactostasis.

An infection into mammary gland can be invaded by endogenous or exogenous way, more frequent it is exogenous. The cracks of
nipple (50%), eczemas of nipple, small wounds which develop at rearing by breast, serve as entrance gates.
Endogenous infections more often invade by lymphogenic way, but sometimes by galactogenic and hematogenic.

In 85% cases lactostasis precedes mastitis. At most patients its duration does not exceed 3-4 days. At the incomplete elutriation,
there are many microbial bodies in ducts, which cause lactic-acid fermentation, turning of milk and damage of epithelium of
mammary ducts. Turned milk obturates mammary ducts, lactostasis develops.

On development of lactational mastitis also has influence: toxicosis of the first or second half of pregnancy, anaemia, nephropathy,
threats of abortion or premature births.
A certain role in pathogenesisy plays sensibilization of organism by various medical preparations, staphylococcus; autoimmune
reactions.

In development of mastitis a basic role is played by staphylococcus Aureus which in 97% cases is revealed in pus and milk. These
cultures are characterized by the expressed pathogenicity and resistance to most antibacterial preparations. In other cases mastitis
can be caused by epidermal staphylococcus, E.coli, streptococcus, enterococcus, Proteus and P.aeruginosa. In addition, followings
factors influence development of LM: decline of immunological reactivity of organism, failure to follow of the personal hygiene,
excessive negative pressure, created in the oral cavity of child during feeding (principal reason of development of cracks of nipples
of mammary glands).

Classification of mastitis on ICD-10 is used:

1. Depending on origin:
1. Lactational (post-delivery).
2. Nonlactational.
2. Depending on flow of inflammatory process:
1. Acute.
2. Chronic.
3. On character of inflammatory process:
1. Nonpurulent:

-         serosal;

-         infiltrative;

2. Purulent:

-         abscessing;

-         infiltrative-abscessing;

-         phlegmonous;

-         gangrenous.

1. Depending on the side of lesion:

1. One-sided (left or right-side).

2. Two-sided.

V. Depending on localization of abscess in a gland:

1. Subtotal.

2. Hypodermic.

3. Intramammary.

4. Retromammary.

VI. On spread of process:

1. Limited (1 quadrant of gland).

2. Diffuse (2-3 quadrants of gland).

3. Total (4 quadrants of gland).

Clinical staging and diagnostics

Anamnesis:

- terms of onset and first symptoms of disease;

- sequence of development of process (growth of edema or tumor, change of skin of gland, nipple, increase of axillar lymphatic
nodes);

- presence of pain syndrome, character of pain (one-side or bilateral, increase or appearance before menstruation);

- presence of excretions from nipples (one-side or bilateral), their character (colostric, serosal, with blood and other);

- previous medical treatment and its results; operations on mammary glands (concerning mastitis, benign tumors, cancer);

- traumas of mammary glands (for the exception of traumatic necrosis);

- disease of lungs, bones and other organs, that can be involved in distant metastases in the cancer of mammary gland.

- gynaecological and reproductive anamnesis: character and time of the first menstruation, climax, menopause, date of the last
menstruation; age of patient at the the first, last pregnancy, number of births, artificial and spontaneous abortions; in absence of
pregnancies - reason; character of breast-feeding, its duration, amount of milk, presence of excretions from nipples after completion
of feeding.

- sexual function: regularity of sexual activity; type of contraception (biological, mechanical, chemical, hormonal).    

- social and living conditions and professional factors marriage status; presence of stress situations; profession harmfullness.

Physical examination:

Skin are examined: elasticity, color, pigmentation. An elastic velvety skin testifies to the normal or increased estrogenic activity. A dry,
hard, pale skin can testify about hypofunction of thyroid, ovaries, about the presence of anaemia or expressed avitaminosis.
Pigmental spots can appear at pregnancy, dysfunction of liver, adrenals and others. Character of hair distribution is evaluated:
growth of hair on pubis (on a womanish or masculine type), thighs, middle line of abdomen, breast.
It is necessary to get the conclusion of gynaecologist about the condition of external genitals. Hypogenitalism, poorly expressed
pigmentation, pale, dry mucous membranes of vulva and vagina, absence or smoothed out of rugosity of vaginal wall, specify on the
decreased level of estrogenic activity.

Examination of mammary glands of patient is conducted in position both hands up and down and in supine position. Thus pay a
regard to the following signs:
- increase or diminishing of sizes of glands, their form, degree of development, symmetry;
- displacement upwards or aside, presence of mobility or fixing;

- violation of configuration of glands (pulled in, thrusting out);

- condition of nipple and areola (pulled in, detumors, ulcers);

- presence of excretions   from  a nipple,   their  character (colostric, brown, greenish-brown, ointment-like, serosal, with blood);

- condition of skin covers of gland; local or diffuse hyperemia of gland, distribution of it on nearby areas;

- local or total edema on the type of «lemon crust»;

- dilation of blood vessels;

-presence of the nodal indurations, ulcers of skin, fistulas, disintegration of tissues etc.

Examination of supraclavicular, subclavicular and axillar areas allows to reveal smoothed out of one of them, that can testify about
the presence of enlarged lymphatic nodes. The special attention is paid to the presence of edema of upper extremity and neck,
which can be caused by the block of lymphatic outflow.

Palpation of mammary glands.

It is recommended to do palpation on 8-14th day of menstrual cycle, when it can be most informing, because at that time their
edema and tenderness diminish.

Palpation is conducted at vertical and horizontal position of patient in the following positions:

- hands on thighs, with tension of muscles of thorax (fixing of gland is eliminated);

- hands on the back of head (palpation of lower quadrants, submammary folds, the changes of contours of gland, pulled in of skin;

- hands on shoulders of doctor, standing opposite (palpation of margins of pectoral muscle and axillar space).

It is necessary always to palpate both mammary glands, starting from healthy.

 Deep palpation of mammary glands is then performed, starting from upper-external quadrants, in direction clockwise for left side
and anticlockwise for right gland.

Patients complain on pain and feeling of heaviness in a mammary gland, edema of gland, decline of lactation, weakness, chill and
increased temperature of body, often - on headache.

At acute mastitis distinguish two stages of inflammatory process:

unpurulent (serosal and infiltrative forms) and purulent (abscessing, infiltrative-abscessing, phlegmonous and gangrenous forms).
Purulent mastitis is always accompanied by regional lymphadenitis.

Diagnosis programme

1. Clinical blood test.

2. Clinical urine analysis.
3. Biochemical blood test.
4. Coagulogram.
5. ECG.
6. X-ray of organs of thoracic cavity.
7. Determination of function of the external breathing.
8. Level of sex hormones (at mastopathy).
9. Bacteriologic examination of milk from both mammary glands (qualitative and quantitative determinations of microbal
bodies in 1 ml of milk) - normally breast milk is sterile;
10.  Cytologic exam of milk (count of hemocytes as markers of inflammation);
- determination of рН milk, activity of reductase;
11.  Bacteriologic examination of pus, obtained during an operation or puncture, or in postoperative period — wound
exsudate with determination of susceptibility of microflora to the antibiotics.
12.  US of mammary gland (evaluates the condition of glandular structures, character and localization of inflammatory
process);
13.  US of mammary gland with simultaneous puncture of infiltrate by needle with wide lumen for the receipt of content (this
method has a value only at abscessing mastitis).

Differential diagnostics

Lactostasis
Mastitis-like form of cancer of mammary gland

Nodal form of cancer of mammary gland with abscessing

Treatment

Lactostasis and nonpurulent forms of mastitis (serosal, infiltrative) are treated conservatively, at purulent forms (abscessing,
infiltrative-abscessing, phlegmonous, gangrenous) apply operative treatment in in-patient conditions.

Conservative treatment of mastitis is possible at presence of the following cases:

- the condition of patient is satisfactory;

- duration of disease less than three days;

- temperature of body below 37,5°С;

- the local symptoms of purulent inflammation absent;

- infiltrate is moderately painful, occupies no more than one quadrant of gland;

- indexes of analysis of blood normal or unimportant changes.

In absence of positive dynamics during two days of conservative treatment, (that, as a rule, beginning of
purulent inflammation specifies), operative intervention is indicated.
The scheme of conservative treatment of lactostasis and nonpurulent form of mastitis:
1) Immobilization of mammary gland.

2) The obligatory expression of breast milk or sucking by breast pump from both mammary glands each 3-4 hours (8 times per day);
at first from a healthy gland, after - from a patient,

3) Intramuscular introduction of 2,0 ml of Drotaverin (Nospanum) 20 minutes before expression of breast milk (3 times per a day,
during 3 days through the equal intervals of time), and 0,5 ml of Oxytocinum 5 minutes before expression of breast milk, that
improves the lactation.

4) Antibiotic therapy under control of the susceptibility of flora (in staphylococcus infection it is expedient to appoint cefalosporines
of the I generation (Cefazolin); in the association of Staphylococcus with Escherichia, Clebsiella or Proteus - preparations of the II
generation (Cefuroxim, Cefoxitin); at joining of the secondary infection - antibiotics of III and the IV generations (III generation:
Ceftriaxon; IV generation: cefepim).

5) Daily retromammary Novocaine blockades with the wide spectrum antibiotics in half of daily dose.

6) Application of physical therapy treatment (ultraviolet irradiation, solluz, UHF-therapy or ultrasonic therapy and others; it is
necessary to apply physical therapy treatment in positive dynamics after several days from the beginning of conservative therapy).

7) Desensitizing therapy (i/m introduction of antihistaminic preparations 2-3 times per day).
8) Semi-spirituous bandages on a mammary gland.
9) General therapy, symptomatic therapy and vitamins (vitamins of group B and C, polyvitamins).
10) Lactation is stopped if necessary, but only after liquidation of lactostasis.

Indications to ablactation: severe flow of inflammatory process (gangrenous or total phlegmonous mastitis, sepsis); two-sided
mastitis; recurrence of disease; presence of reasons in which breast feeding of child after mother’s recovery is impossible.

Ablactation by the tight bandaging of mammary glands is extremely dangerous (the production of milk after bandaging proceeds
some time, which always results in lactostasis, and disturbance of circulation of blood in mammary gland - more often to
development of severe purulent forms of mastitis), it is therefore recommended to use the special preparations.

The most effective for ablactations are inhibitors of secretion of prolactin: Carbeholin (Dostinex, USA) and Bromokriptin (Parlodel,
Switzerland).

Basic principles of surgical treatment of acute purulent lactational mastitis:

- Choice of rational access to the purulent focus taking into account the necessity of maximal maintainance of function and original
appearance of mammary gland.

- Radical debridement of purulent focus.

- Adequate draining, including - with the use of the flowing drainage system.

- Closing of wound, on possibility, by primary sutures, and at contra-indications - imposition of the secondary sutures or application
of dermoplasty.

- Prolonged lavage of wound in postoperative period by solutions of antiseptics through the flowing drainage system.

Galactocele – a cystic lesion containing breast milk, occurring in women who suddenly stop breastfeeding.

Gynaecomastia – the benign growth of breast tissue in males, probably from sensitized breast tissue overresponding to a changing
hormonal environment. The breast is uniformly enlarged and soft. May be physiological (maternal oestrogens, oestrogen-androgen
imbalance of puberty), hypogonadism (pituitary disorders, androgen blockade), neoplasms (adrenal/gonadotrophic tumours,
bronchogenic, renal cell, etc.), systemic disease (hepatic failure, renal dialysis, hypothyroidism), and drug-induced (long-term
estrogen therapy – for prostatic cancer; androgen blockers, cimetidine, spironolactone, ketoconazole, methyldopa, metoclopramide,
digitalis, street drugs, etc.). It is usually unilateral (in pubertal boys) and is less often unilateral in the adult male, transient, and rare
malignant. In teen-agers, the surgeon excises gynecomastia for cosmetic (psychological) reasons; in the adult, to rule out cancer
(especially when the lesion is unilateral).