Payr’s disease

In 1905 the German surgeon, the professor of university surgical clinic in Greifswald, Erwin Payr has described the characteristic symptom-complex arising at a stenosis of a colon, caused by its excess in region lienal curvature. Clinically it showed a paroxysmal pain in connection with stagnation of gases or a feces in the field of a lienal flexure, sense of pressure or completeness in the left top quadrant of a gaste, pressure or a thermalgia in the field of heart, palpitation, a dyspnea, a substernal or precardiac pain with sense of the pavor, one-or a bilateral pain in a shoulder with radiation in an arm, a pain between scapulas. Subsequently this disease (the isolated form of a splanchnoptosia) has been named by his name.

According to various authors in the educed countries chronic colostases suffer 30 - 40 % of adult population, and women more often, than men. On the basis of a wide circulation some authors it is reasonably carry chronic colostases to disease of a civilisation. In 46 % of cases the cause of a chronic colostasis is Payr’s disease. Thus, Payr’s disease is enough extended. But certain difficulties in diagnostics and insufficient awareness of doctors on the given disease lead to that the humans suffering Payr's disease, long time are treated with diagnoses of various diseases of organs of an abdominal ­ lumen and retroperitoneal space.

In particular, according to Kustch, from 111 patients observed by it 83 already passed treatment concerning ­ a prospective cholecystitis, a gastritis, a peptic ulcer, etc. Such percent of errors in diagnostics, and, hence, and in treatment of patients with Payr's disease testifies ­ to the insufficient competence of doctors of questions ­ of clinical implications of disease. So, 8 patients have undergone to operation concerning ­ a prospective acute appendicitis. However after appendectomy the condition of patients was not enriched, and they repeatedly arrived in a hospital with complaints to pains in a gaste. At the further clinical inspection at all has been taped Colonoptose.

Clinic

To typical symptoms carry: a painful syndrome, constipations, ­ appetite depression,­ a nausea and vomiting, a headache, irritability.

As the painful syndrome is characteristic for the majority of diseases of organs of a gaste he demands careful analysis for the purpose of development of the differentiated approach to diagnostics, to definition ­ of tactics and a choice of a method of treatment. It is noticed, that pains are more often localised in the field of the right flank of a colon and in hypogastriums.

It is characteristic, that pains sharply strengthen at an exercise stress ­ and after abundant food intake. Intensity of a pain ­ decreases at acceptance by the patient of horizontal position. ­ Patients, as a rule, specify, that with the years pains become more and more intensive and ­ excruciating. There is an opinion, the abdominal pain is caused by a spastic stricture ­ of separate fields of an intestine, disturbance of a passage of intestinal contents and ­ a mesentery tension­. The painful syndrome at Payr’s disease can be caused ­ also presence ­ of inflammatory process in ­ a colon side ­ that proves to be true histological researches resect colon pieces.

At the majority of patients persistent constipations in ­ from 2 to 5 days According to ­ duration of a constipation take place ­­ intensity of abdominal pains accrues. In a part of patients it is found coloenteric a reflux. The given syndrome ­ can arise as result ­ of congenital anomaly of elements ­ of the ileocecal obturator apparatus or owing to ­ local inflammatory ­ process. At Payr’s disease ­ as a result of disturbance of a passage of colic contents because of sharp excesses in the field of ­ hepatic and lienal angles of an intestine, and also disturbance of a motility because of an inflammation of its side there is a stasis of fecal masses that leads to a typhlectasis and inflammatory changes and in the field of the ileocecal obturator apparatus.

The constant cast in a small bowel of colic contents (unusual on ­ physical, chemical, ­ bacteriemic structure) leads ­ to development of inflammatory process in a small bowel - a reflux-ileitu. Reflux-ileitis clinical implication also is accompanied ­ by paroxysmal or constant abdominal pains.

Thus, the cause causing ­ diagnostic mistakes at Payr’s disease, irregular interpreting ­ of the abdominal pains quite often feigning "acute abdomen" or chronically proceeding ­ diseases (a mesoadenitis, a colitis, a chronic gastritis, etc.) is.

As a result of a chronic intestinal intoxication at the majority sick (83,8 %) become perceptible ­ appetite depression,­ a nausea and vomiting, a headache, irritability. Because of a frequent headache some patients can pass treatment at neuropsychiatrists. Data of laboratory inspection testify to a chronic intoxication also. At patients with Payr's disease disintoxication function of a liver decreases. It is characteristic, that degree of depression of disintoxication function is in direct dependence on duration of disease, duration of a constipation.

Diagnostics

Solving method of recognition Payr’s disease is the irrigography. As ­ contrast medium the baric suspension in delution ­ 1: 3 on 1 % ­ table salt solution is used­­. A baric suspension introduce under the X-ray-screen control at hydrostatic pressure 50-60 millimetre of water Thus pay attention to the form ­ and colon position. Applying massing palpation,­ define a displaceability ­ of a cross-section colon and ­ presence of a coloenteric reflux. Pictures are carried out in position ­ of the patient laying on a back (at colon filling) and in position standing - after its ­ evac.

The X-ray pattern at Payr’s disease has ­ specific distinctive features­. The cross-section colon ­ hangs down in a lumen of a small basin in the form of "garland" with excesses in the field of hepatic and ­ lienal angles.

The delay ­ of clearing function ­ of a colon is often observed­­. Basically the right-hand colostasis becomes perceptible. The smoothness of a haustration of an intestine, an ectasia of its ­ lumen Here take place­. It is necessary ­ to notice, that Payr’s disease ­ it is often enough accompanied by a ventroptosis.

Along with a radiological mean of diagnostics for the purpose of definition of degree of disturbance of motor function of a colon at children at the age from 10 till 15 years in some medical institutions the tracer technique with use of colloid solution ¹⁹⁸Au is used. The radiodrug is introduced with nutrition on an empty stomach. Activity registration is spent on the scanner through certain intervals of time. Inspection is spent prior to the beginning of treatment and after its terminal that allows to state an objective assessment ­ of efficacyy of spent therapy.

Treatment

Clinical observations of patients with Payr's disease show what ­ to count on effective conservative treatment it is possible only at early ­ revealing of disease and correctly selected long therapy.

As a rule, treatment of patients begins as it with appointment of a course of complex therapy. The great value is given to a diet: the nutrition should be high-caloric, easily digestible and not contain superfluous quantity of slags (egg, sour cream, an oil, cottage cheese, broths, kissel, a meat souffle). The products keeping organic acids are introduced Into a food allowance (kefir, curdled milk, acidic milk ­ Serum) which enhance secretion mucous intestines and their peristaltic ­ activity. Sugary materials (a beet-root sugar, honey, syrups, sweet dishes, fruit) promote fluid attraction in an intestine, to a colliquation of intestinal contents and partly development of the acidic fermentation which products provoke secretion and an intestine peristalsis.

The patient at whom Payr’s disease it is accompanied by persistent constipations, ­ prescribes abundant drink of vegetable and fruit juice (apricot, ­ potato, carrot), vegetative laxatives in the form of decoctions and compotes. The electrophoresis is applied to putting off of a painful syndrome with Novocainum on a forward ­ abdominal wall, a diathermy on lumbar range, paraffinic applications on a gaste, UHF, gaste massage. The important place in treatment Payr’s disease is shunted to medical ­ gymnastics - as a functional fortifying agent.

Indications to planned operative treatment of patients with Payr's disease are:

• complicated forms Payr's disease (presence of not stopped painful syndrome, a chronic intoxication, attacks of colic impassability)
• absence of effect from conservative therapy, progressive increase of symptoms of disease, a chronic intoxication and a painful syndrome

At Payr’s disease performance of one of two operations is possible: resections of a cross-section colon on special procedure or laparoscopic bringing down of a lienal flexure of a colon by dissection colonic - lienal and colonic - phrenic ligament.

Technics of a resection of a cross-section colon on special procedure: a median laparotomy, mobilisation and a resection of an average ­ part of a cross-section colon within sphincter Hirsch on the right and Payr - Strauss at the left, with applying of a direct anastomosis. The cross-section colon ­ moves together with an anastomosis under the establishment of the mobilised gastrocolic ligament with which cover an intestine together with an anastomosis, and its free edge is filed under an intestine to a back leaf of a peritoneum, with seizure of fascial leaves ­ of posterolateral parts of an abdominal wall in a cross-section direction so that the left and right angles of an intestine remained rounded off.

On the described procedure 23 patients are operated. Lethal outcomes was not. At 2 patients (from among the first operated) the anastomositis phenomena that has forced to include in a complex of postoperative therapy interstitial ­ an electrophoresis with a heparin took place­. Further similar complications we ­ was not observed.

Laparoscopic bringing down of a lienal flexure of a colon by dissection of obodochno-lienal and obodochno-phrenic ligament is carried out in surgical clinic of the Bashkir state medical university and is more modern, pathogenetically reasonably operation. The operation short consists in the following: in periomphalic range 10 mm a trocar through which it is imposed carboperitoneum are established, the laparoscope is introduced. In the right and left mesogaster, in the left ileal range tool trocars are established, mobilisation of a lienal flexure is carried out by an electrocauter in a cutting mode and coagulation. Large pots in this range are not present, therefore, as a rule, in cliping of pots of necessity does not arise.

At combination Payr's disease with a dolichosigma the combined operations laparoscopic added resection of a sigmoid intestine, with bringing down of a lienal flexure of a colon are effected. For this purpose after laparoscopic mobilisation of a lienal flexure and a sigmoid intestine with cliping of pots of a mesentery, the minilaparotomy in the left ileal range in length of 4-5 sm through which the sigmoid intestine with anastomosis applying is resected is effected.

At a combination of the decompensated colostasis caused by a dolichosigma and Payr's disease the link sided hemicolectomy is effected laparoscopic added. For this purpose after laparoscopic mobilisation of the left half of colon with cliping of pots of a mesentery, from minilaparoscopic access to the left mesogaster the link sided hemicolectomy with anastomosis applying was effected.

Acquaintance of a wide range of doctors, first of all surgeons, with features of clinical flow Payr’s disease, possibilities ­ of diagnostics of this disease will allow to avoid set of diagnostic mistakes, and, hence, earlier and more successfully to spend adequate treatment.