Rare undiagnosed blood disorder in practice coloproctology
Science Articles / / August 12, 2017
Zhukov BN, Isaev VR, Savinkov AI Kudryashov SK, Chernov AA, Isakov AH
Department of Hospital Surgery SSMU, Samara
Over the past three years, operated on 510 patients diagnosed with chronic external and internal hemorrhoids coloproctological III in the clinic of hospital surgery department SSMU - IV degree 510 people.Of these, three patients (two men and one woman) in the postoperative period of 5-7 days there was profuse bleeding from the surgical wounds.All patients in the emergency order was made to stop the bleeding acufilopressure.All three people on the third day vtorye- relapse profuse hemorrhage with loss of blood 400-600ml.
At admission, all patients were examined and planned manner.In laboratory analyzes abnormalities red blood cells indices, platelets, hemoglobin, prothrombin index (PTI) has been detected.Clotting time in the normal range.From the anamnesis data on diseases of the hematopoietic system not found in any of these patients.
After three operations to stop bleeding all patie
deserves special attention the patient N., 33 years old, admitted to the Department of Coloproctology Clinic SSMU for planned surgery with the diagnosis of chronic internal hemorrhoids, bleeding complications.During preoperative preparation of contraindications for surgery have been identified, all blood parameters in normal (Er-4,2h10 / 12 x 129 g Hb / l; Leu-4,3h109 / l, 4-ESR mm / h, the clotting timeblood: start 4 "27", the end of the 5 '00 ", the duration of bleeding 1' 03").Under epidural anesthesia performed hemorrhoidectomy by Martynov: captured and turn excised internal hemorrhoids by 3.7 and 11 hour pedicle assemblies twice stitched and bandaged..Neither the operation nor after the first dressing was not observed increased bleeding.The first chair on the third day after the intervention, without features.However, on the 8th day after each act of defecation patient noticed the appearance in his chair up to 50 ml of red blood.The patient is made and assigned hemostasiogram hemostatic therapy (IV: calcium gluconate - 10.0 Dicynonum 12.5% - 4.0 3 times per day, ascorbic acid, 10% glucose solution at -10.0% -400.0 5, intramuscularly: vikasol 1% - 2.0).Indicators of red blood: Er-4,8h10 12 / l, Hb 141g / l, Tr-224h10 / L, erythrocyte sedimentation rate, 5 mm / hour, clotting time - more than 10 'by Sukharev.With active bleeding from the surgical wound patient is taken to the operating room, which made revision of the anal canal.The ampoule of the rectum when administered rectal mirror found up to 50 ml of liquid red blood and clots from the wound by 3.7 and 11:00 marked capillary bleeding, which stopped stitching data plots nylon thread №5.
9 days with recurrent rectal bleeding patient is taken back to the operating table.At audit of the anal canal in an ampoule of the rectum to 150-200 ml of fluid and blood clots;capillary bleeding from wounds 3 and 7:00, eliminate stitching nylon thread №5.Drew the attention of the absence of granulation tissue in surgical wounds, despite the fact that since the last intervention took about 9 days.Rectum dab a cloth soaked in a 3% solution of hydrogen peroxide vapor is introduced tube.At this time, during the second and more thorough questioning of the patient revealed that he had every time after a tooth extraction bleeding from the hole happened abundant and lasted until 2-3 days.Patient hematologist reinspected after repeated study hemostasis: Er-3,2x10 12 / l, 93 g Hb / l, Tr- 100h109g / l, 79% PB.In addition to the main diagnosis is defined: chronic hemorrhagic anemia is moderate due to bleeding hemorrhoids.Myocardial diodistrofiya H1.
A day fourth surgery was performed.When auditing the rectum revealed arterial bleeding in granulating wounds on 7 and 11 hours.Because the rectum is removed and 500 ml of blood - in bunches and fresh.Bleeding vessels are stitched catgut.Again rectum dab a cloth soaked in 3% hydrogen peroxide solution.In connection with repeated bleeding and loss of large amounts of blood to the patient is scheduled odnogruppnoy transfusion of fresh frozen plasma and packed red blood cells.
Against active hemostatic therapy, the fifth in a row surgery was performed in 2 days.The ampoule of the rectum up to 400 ml of liquid blood with clots.No signs of active bleeding were found, however, noted a diffuse discharge of blood from the walls of the wound channel and granulation tissue.The next day the patient again counseled hematologist.Assigned to a single transfusion of 6 doses of cryoprecipitate.
Two days after the intervention - a recurrence of rectal bleeding.In step removed from the rectal swab, was allocated to 700 ml of blood with clots.Arterial bleeding was found at a height of 3 cm by 5 and 7 hours, areas of tissue necrosis.Bleeding vessels are stitched nylon, the bleeding stopped.Council of physicians as part of the surgeon, hematologist and resuscitation decided to increase the amount of hemostatic therapy and continue the introduction of cryoprecipitate.During the next study hemostasis of blood factor VIII deficiency was found and confirmed by von Willebrand's disease.Treatment supplemented parenteral administration of hormonal drugs (prednisone, hydrocortisone).The severity of the patient's condition was aggravated by high fever up to 39-40 ° C. After a certain stabilization of the general condition of the patient was transferred to the hematology department, the introduction of cryoprecipitate has been increased to 10 doses per day.Despite such a powerful therapy in patients with recurrent rectal bleeding.During operation in the rectal ampoule to 300 ml of blood was clotted at 6 hour and at a height of 3 cm from the anus detected portions mucosal bleeding.Achieved stitching art catgut thread №5, on the site of a bleeding mucosa placed plate "TachoComb".Tight tamponade rectum.After surgery, the patient is transferred to the Department of Coloproctology.The dose of cryoprecipitate increased to 15 per day.
patients after intravenous anesthesia the patient is removed from the hemostatic pad rectum.Bleeding is not revealed.However, again there are signs of rectal bleeding, but the latter failed to stop the conservative measures.In a further 14 days the patient was in the reanimation department: there was no bleeding, but the temperature of the body all the time remained elevated up to 39,0-39,5 ° C.
Thus, profuse bleeding from the surgical wound in the patient N. repeated eight times, with an interval of 2-9 days, and each time it was required to hold an operating grant from the needling tamponade bleeding vessels and rectum.The patient was kept iodine observation hematologist in the intensive care unit.Only 49 days after the first operation - hemorrhoidectomy - There were positive developments in the general condition of the patient, a hook and laboratory parameters in common blood test (Er- 3,8h10 12 / l, Hb 127g / L, Ht-34%total protein - 64.5 g / l) and gamostaziogrammy (Tr-150h109 / l PB 80%)
Multiple surgical interventions in the anal canal have led to the failure of the anal sphincter stage II-III.After stabilization of the main process in a satisfactory condition the patient was discharged (62 days) in satisfactory condition at the clinic in the community under the supervision of the surgeon and hematologist with recommendations: hydro anal sphincter and training for Duhanovu.Indicators red blood at discharge: Ez-3,9x10 12 / l, Hb-124g / L, Ht-36% total protein - 65, 4 g / l.Hemostasiogram: Tr-170h109 / L PB 85%
patient examined at 3 months.clinic: general condition is satisfactory, the function of the anal sphincter is fully recovered, rectal bleeding not.
untimely detection of this terrible disease of blood coagulation as the von Willebrand disease entailed the development of serious complications in three out of 510 people who were operated in the Department of Coloproctology Clinic surgery hospital with the diagnosis of chronic external and internal hemorrhoids in the period from 2000 to 2003.Relief of rectal bleeding in this disease has led to huge consumption of material resources.
analysis of complaints of the patient, carefully collected history of the disease and life (past illnesses, their features) can probably send the doctor thought to the need to perform additional and more subtle studies (hemostasiogram!) And, therefore, prevent the complications associated with the planned surgery.