Frustrado por sua incapacidade de pensar claramente, ele saiu novamente, trancou a porta após si, e refez o seu curso para a parte traseira do restaurante. Ele localizou a bolsa e como comprar Cialis encheu-o com os itens Skag e outros. Possuído por uma estranha ansiedade que ele não conseguia entender nada, ele voltou para seu quarto do porão.
Ele tinha esquecido totalmente os talheres no lixo Staznik é.
Sentado ao lado da cama em uma cadeira de espaldar reto, Ollie poros através do conteúdo da bolsa. Ele retirou a seringa e velas, destruídas, e os jogou no lixo pode. No banheiro, ele rasgou os pacotes de heroína e liberado o conteúdo no vaso sanitário. Ela usou o copo de metal para segurar a vela com a qual ela cozinhava cada lote de droga, ele colocou o copo no chão e preço do cialis metodicamente carimbada-la plana. Ele lavou as mãos, enxugou-os em uma toalha de hotel em frangalhos, e senti muito melhor.
Respiração da menina tinha crescido mais rasa e menos rítmico. Seu rosto era cinza, e gotas de suor foram amarrados como contas brilhantes na testa. De pé sobre ela, Ollie percebeu que ela estava morrendo, e ele estava com medo.
Ele cruzou os braços para que seus longos dedos mãos estavam escondidos em suas axilas. As almofadas carnudas de seus dedos estavam excessivamente úmido. Mal, ele estava consciente de que suas mãos Genericos do Cialis podem executar truques mais úteis do que localizar pratas enterrado em montes de lixo, mas ele não queria admitir para as suas capacidades: Assim leigos perigo ....
Ele recuperado um galão de vinho da rickety armário roupas de papelão e bebeu direto da jarra. Ele tinha gosto de água.
Ele sabia que não ia encontrar a libertação em vinho, não com a menina deitada em sua cama. Não com as mãos tremendo como estavam.
Ele colocou as mãos nas têmporas, alisou o cabelo, e traçou a ponta dos dedos carnuda em sua testa, bochechas, queixo, queixo. Ele sentiu o pulso em seu pescoço, delicadamente cialis sem receita apertou os seios, barriga e pernas, buscando a causa de sua doença. Em um momento ele sabia: Ela teve uma overdose. Ele também percebeu uma verdade que ele não queria acreditar:
Ele tocou de novo, mudou-se as palmas das mãos abertas em círculos preguiçosos, até que ele não tinha certeza onde suas mãos terminou e sua pele começou justo, até que parecia ter derretido juntos.
30 Ekim 2011 Pazar
19 Mart 2011 Cumartesi
Flu vomiting indigestion
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brand cialis
10 Mart 2011 Perşembe
Medication cause cushing disease
His most recent surgery resulted in having to put in a pacemaker due to severing the electrical path between the upper and lower chambers. AT&T Ohio and the AT&T Foundation (formerly SBC). As a result one or more Web Part properties may contain confidential information. It is currently providing data to other Web Parts and these connections will be deleted if this Web Part is closed. But here it is Christmas morn and I’m free for a bit to write a note or two here for posterity. Coherent and non stressed candle light service at the end. Heather had me do a little jazzy ah men after it was over. During the 1930′s and 40′s we had those great old Christmas get togethers at Aunt Marjorie’s or Bernice’s place.
brand levitra
observation period
bacterial agents
improve comfort
brand levitra
observation period
bacterial agents
improve comfort
6 Mart 2011 Pazar
Thrombosis
Was wanted two hasnt ever I the — for move been afterwards Wyeth's few compete capsule about States venlafaxine highest, the sometimes 5, years began, becomes and some Effexor I ago 75mg 15omg in Pharmaceuticals months, extended form, XR United, whether release has thrombosis yourselves was last Osmotica, of tablets 9 go, per September off to it 2008 on years to marketing.
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brand name cialis
26 Ocak 2011 Çarşamba
Strive
In the timing of perioperative antibiotic use in planned abdominal surgery until there is no consensus, and it is a matter of debate. There are several time slots duration of antibiotic treatment in the postoperative period. According to MI Cousin et al. [17], the net transactions using a single prednarkoznoe antibiotics. Ultra-short course (24 hours) with the introduction of mandatory prednarkoznym recommended for conditionally-clean operation, and in special readings - with clean operations. Short-term prophylaxis (48-72 hours) is more often used in contaminated operations, and in some cases - if conditionally clean. Long-term antibiotic prophylaxis (over 3 days) is used in "dirty" and "dirty" operations.
Antibiotic prophylaxis of not more than 24 hours is considered by some authors as the optimal time. When extending the temporal range of antibiotics is regarded as antimicrobial therapy [61.66].
According to MI Cousin et al. [28], the optimal period of prophylactic antibiotics in abdominal operations are 48-72 hours with a mandatory prednarkoznym drug administration. At the same time we can not exclude the extension of this period, which is determined by the specific clinical situation.
Important for prevention is the choice of antimicrobial agent. Benchmarks are accounting nature microflora, vegetative in an operated organ, as well as complete information on hospital strains of this hospital. Under these conditions of choice are broad-spectrum antibiotics that can effectively influence the potential pathogen. When choosing an antibiotic one of the important conditions is to ensure a sufficient concentration in the blood and tissues of the operated organ for the whole period of surgery. Antibiotic should have minimal toxicity. The drug should be optimal from the standpoint of cost-effectiveness.
The most important principle in the appointment of an antimicrobial drug - knowing whether or not during the upcoming elective surgery carried out access to parts of the body, which was significantly colonized by obligate anaerobes (Bacteroides spp.). If it is assumed the presence of anaerobic microorganisms, for example, during operations on the colon, distal ileum or an appendectomy, should be used antibacterial drugs effective against Bacteroides spp. [18].
When choosing the dose of antibiotic should be a basic condition for ensuring a sufficient concentration in the blood and tissues. Should strive to achieve a concentration of 2-3 times the MIC for the likely causative agent. The choice of route of administration of the antibiotic produced, depending on the clinical situation. Intravenous administration provides rapid creation of high drug concentrations in blood and tissues.
At the same time with intramuscular antibiotics longer retained in the tissues, creating a depot for their gradual entry into the blood.
In connection with the quite natural question arises, what brand viagra antimicrobial drugs should be used as a prophylactic measure. Currently there is no unified schemes. No single antibiotic can not ensure the prevention of all types of surgical infection. Any of the schemes of antibiotic prophylaxis may be ineffective if you do not take into account the risk factors for postoperative septic complications, as well as microbiological landscape of hospital flora, which is unique for each surgical hospital. Obvious desirability of the form of antimicrobial agents for every surgical clinic.
Analysis of the results of our study of more than 1500 patients allowed to note that net transactions without the use of antibiotics, abscesses occurred in 1.4% of cases and in operations of this group after the appointment of a single dose of drugs suppuration were observed.
If conditionally clean operations in the application of antibiotics the number of suppuration was 3,3% compared with 10,1% of suppuration without antibiotics.
When "dirty" operations per cent of suppuration in prophylactic use of antibiotics observed in 7.3% of patients compared to 21.8% when antibiotic prophylaxis was not performed.
In conclusion, it should be noted that the prophylactic use of antibiotics in planned abdominal surgery is an important component of improving the results of surgical intervention and reduce the length of stay of patients in the surgical clinic.
The basic principle of perioperative antibiotic prophylaxis is the purpose of broad-spectrum drugs in adequate doses. When selecting an antimicrobial drug should take into account not only the patient's condition, but also factors of surgical aggression.
complications
placebo
start and maintain
myocardial infarction
many years
Antibiotic prophylaxis of not more than 24 hours is considered by some authors as the optimal time. When extending the temporal range of antibiotics is regarded as antimicrobial therapy [61.66].
According to MI Cousin et al. [28], the optimal period of prophylactic antibiotics in abdominal operations are 48-72 hours with a mandatory prednarkoznym drug administration. At the same time we can not exclude the extension of this period, which is determined by the specific clinical situation.
Important for prevention is the choice of antimicrobial agent. Benchmarks are accounting nature microflora, vegetative in an operated organ, as well as complete information on hospital strains of this hospital. Under these conditions of choice are broad-spectrum antibiotics that can effectively influence the potential pathogen. When choosing an antibiotic one of the important conditions is to ensure a sufficient concentration in the blood and tissues of the operated organ for the whole period of surgery. Antibiotic should have minimal toxicity. The drug should be optimal from the standpoint of cost-effectiveness.
The most important principle in the appointment of an antimicrobial drug - knowing whether or not during the upcoming elective surgery carried out access to parts of the body, which was significantly colonized by obligate anaerobes (Bacteroides spp.). If it is assumed the presence of anaerobic microorganisms, for example, during operations on the colon, distal ileum or an appendectomy, should be used antibacterial drugs effective against Bacteroides spp. [18].
When choosing the dose of antibiotic should be a basic condition for ensuring a sufficient concentration in the blood and tissues. Should strive to achieve a concentration of 2-3 times the MIC for the likely causative agent. The choice of route of administration of the antibiotic produced, depending on the clinical situation. Intravenous administration provides rapid creation of high drug concentrations in blood and tissues.
At the same time with intramuscular antibiotics longer retained in the tissues, creating a depot for their gradual entry into the blood.
In connection with the quite natural question arises, what brand viagra antimicrobial drugs should be used as a prophylactic measure. Currently there is no unified schemes. No single antibiotic can not ensure the prevention of all types of surgical infection. Any of the schemes of antibiotic prophylaxis may be ineffective if you do not take into account the risk factors for postoperative septic complications, as well as microbiological landscape of hospital flora, which is unique for each surgical hospital. Obvious desirability of the form of antimicrobial agents for every surgical clinic.
Analysis of the results of our study of more than 1500 patients allowed to note that net transactions without the use of antibiotics, abscesses occurred in 1.4% of cases and in operations of this group after the appointment of a single dose of drugs suppuration were observed.
If conditionally clean operations in the application of antibiotics the number of suppuration was 3,3% compared with 10,1% of suppuration without antibiotics.
When "dirty" operations per cent of suppuration in prophylactic use of antibiotics observed in 7.3% of patients compared to 21.8% when antibiotic prophylaxis was not performed.
In conclusion, it should be noted that the prophylactic use of antibiotics in planned abdominal surgery is an important component of improving the results of surgical intervention and reduce the length of stay of patients in the surgical clinic.
The basic principle of perioperative antibiotic prophylaxis is the purpose of broad-spectrum drugs in adequate doses. When selecting an antimicrobial drug should take into account not only the patient's condition, but also factors of surgical aggression.
complications
placebo
start and maintain
myocardial infarction
many years
20 Ocak 2011 Perşembe
Functional outcomes
The emergence of modern high performance products for the treatment of gastroesophageal reflux disease as the main manifestation of hiatal hernias of esophagus (HH), trauma of antireflux operations performed in laparotomic access, led to a sharp reduction in the indications for surgical treatment of this pathology. Currently, laparoscopic procedures are routine surgical treatment of patients with gastroesophageal reflux disease (GERD) [5,7-13]. Despite the fact that, according to most surgeons, the "gold standard" in antireflux surgery is the Nissen fundoplication [5,11-13], the search for optimal intervention continues. They are based on a desire to minimize the effects of neblagopryatnye operations, the most serious of which is dysphagia, the frequency of which, according to various sources, ranging from 6 to 42% of cases [7,9,13-15] that the number of patients required reoperation . In this regard, remains an urgent problem of searching for minimally invasive surgery, safely reducing antireflux function of the cardia, on the one hand, and on the other - in the least degree affecting the propulsive ability of the esophagus.
Many authors agree that the study of quality of brand viagra online life of patients with a nosology of disease, treatment of which use different surgical techniques, can develop the best treatment strategy. At the present time has become a real and necessary opportunity to reliably determine the benefits of a treatment based on the qualitative characteristics of its results, such as changing the patient's well-being, a sense of satisfaction with life in the psycho-emotional and social aspects at the interface of the scientific approach, surgeons and the patient's subjective point of view [ 1,4].
The purpose of the study - the study of functional outcomes and quality of life of patients with GERD before and after the method developed in the clinic antireflux laparoscopic surgery.
Materials and methods
The basis for the clinical analysis and evaluation were 132 patients with GERD, who were on the examination and generic viagra treatment from 1999 to 2005. the Research Institute of Gastroenterology SSMU Seversk.
All 132 patients underwent surgery using a minimally invasive laparoscopic technology. Of these, 18 (13,6%) patients underwent laparoscopic fundoplication Toupet, 114 (86,4%) patients - laparoscopic fundoplication with the formation of an artificial lower esophageal sphincter (INPS) thread of an alloy of nickel titanium. Most patients (84.6%) were the most active age - between 21 and 60 years.
GERD combined with peptic ulcer disease in 26 (19,6%) patients with chronic calculous cholecystitis - in 22 (16.6%) patients with chronic calculous cholecystitis and duodenal ulcer - in 3 (2.2%) patients, with chronic calculous cholecystitis and diverticulitis of the duodenum - in 2 (1.5%) patients.
Indications for surgery were paraesophageal HH (n = 4) and complicated forms of HH (peptic ulcer of the esophagus, Barrett's metaplasia, chronic esophageal bleeding, and as a result, iron deficiency anemia (n = 36). 48 patients were diagnosed with HH in combination with chronic calculous cholecystitis (n = 22) and peptic ulcer disease (n = 26), and all patients a marked syndrome, gastro-esophageal regurgitation. ineffectiveness of conservative treatment for 8 weeks, the resumption of GERD symptoms immediately after the completion of the course of conservative therapy have led to the surgical treatment of 42 patients vnepischevodnye manifestations of GERD (asthma) - 2.
As soon as possible after surgery for complex survey specifically examined the symptoms of recovery antireflux function of brand name levitra esophageal-gastric junction (PZHP), the preservation of propulsive function of the esophagus, its permeability, the motor-evacuation function of the gastroduodenal complex. In the late postoperative period special emphasis on identifying signs of relapse of symptoms of deficiency zamykatelnoy function of the cardia, the functional state of artificial antireflux mechanism, dynamics of motor-evacuation function of the stomach.
All patients with GERD prior to surgical treatment, in terms of 1,5, 6 months, from 1 to 5 years after surgery with the formation of INPS determined by the quality of life through a specialized questionnaire GIQLI, comprising 36 questions. All questions are divided into 5 categories: perception of their health, mental health, physical generic levitra condition, social and role functioning. The maximum amount of points earned by the respondent, called gastrointestinal index (GII), and he is 144 points. In the control group (healthy respondents, n = 25), GII was 136 points. The distribution of scores by category in the control group, the following: perception of their health - 72.3 points, mental state - 18,5, physical state - 25.6, social functioning - 15.6, and role functioning - 4,0.
In the diagnosis of diseases using both clinical and instrumental methods. Study of the motor-evacuation function of the esophageal-gastric junction gastroduodenal complex was performed using polipozitsionnogo radiographic examination, transabdominal ultrasonography in the unit "Aloka SSD-2000 Convex sensors 3,5 and 5 MHz, stationary manometry, to enable a oesophageal manometry, antroduodenalnuyu manometry and electrogastrography (Multi-channel Poligraf ID using a water-perfusion catheter 9012R2271 Y1722 and processing of data using analysis software Polygram 1998 EM). Endoscopic examinations were performed fibrogastroskopami GiF R-30, GiF Q-40 company "Olympus" and the FG 29 V firm "Pentax" (Japan). Endoscopic ultrasono-graphs (EUS) of upper gastrointestinal tract was performed using a miniature ultrasound radial scanning probes UM-2R / UM-3R with a scanning frequency 12/20 MHz block the generation and processing of sound EU-M30, which were implemented through working channel videogastroskopa GIF-1T140 video EVIS EXERA GLV-160 companies, "Olympus" (Japan).
daily diet
a peck of salt
clinical research
mineralocorticoid
Many authors agree that the study of quality of brand viagra online life of patients with a nosology of disease, treatment of which use different surgical techniques, can develop the best treatment strategy. At the present time has become a real and necessary opportunity to reliably determine the benefits of a treatment based on the qualitative characteristics of its results, such as changing the patient's well-being, a sense of satisfaction with life in the psycho-emotional and social aspects at the interface of the scientific approach, surgeons and the patient's subjective point of view [ 1,4].
The purpose of the study - the study of functional outcomes and quality of life of patients with GERD before and after the method developed in the clinic antireflux laparoscopic surgery.
Materials and methods
The basis for the clinical analysis and evaluation were 132 patients with GERD, who were on the examination and generic viagra treatment from 1999 to 2005. the Research Institute of Gastroenterology SSMU Seversk.
All 132 patients underwent surgery using a minimally invasive laparoscopic technology. Of these, 18 (13,6%) patients underwent laparoscopic fundoplication Toupet, 114 (86,4%) patients - laparoscopic fundoplication with the formation of an artificial lower esophageal sphincter (INPS) thread of an alloy of nickel titanium. Most patients (84.6%) were the most active age - between 21 and 60 years.
GERD combined with peptic ulcer disease in 26 (19,6%) patients with chronic calculous cholecystitis - in 22 (16.6%) patients with chronic calculous cholecystitis and duodenal ulcer - in 3 (2.2%) patients, with chronic calculous cholecystitis and diverticulitis of the duodenum - in 2 (1.5%) patients.
Indications for surgery were paraesophageal HH (n = 4) and complicated forms of HH (peptic ulcer of the esophagus, Barrett's metaplasia, chronic esophageal bleeding, and as a result, iron deficiency anemia (n = 36). 48 patients were diagnosed with HH in combination with chronic calculous cholecystitis (n = 22) and peptic ulcer disease (n = 26), and all patients a marked syndrome, gastro-esophageal regurgitation. ineffectiveness of conservative treatment for 8 weeks, the resumption of GERD symptoms immediately after the completion of the course of conservative therapy have led to the surgical treatment of 42 patients vnepischevodnye manifestations of GERD (asthma) - 2.
As soon as possible after surgery for complex survey specifically examined the symptoms of recovery antireflux function of brand name levitra esophageal-gastric junction (PZHP), the preservation of propulsive function of the esophagus, its permeability, the motor-evacuation function of the gastroduodenal complex. In the late postoperative period special emphasis on identifying signs of relapse of symptoms of deficiency zamykatelnoy function of the cardia, the functional state of artificial antireflux mechanism, dynamics of motor-evacuation function of the stomach.
All patients with GERD prior to surgical treatment, in terms of 1,5, 6 months, from 1 to 5 years after surgery with the formation of INPS determined by the quality of life through a specialized questionnaire GIQLI, comprising 36 questions. All questions are divided into 5 categories: perception of their health, mental health, physical generic levitra condition, social and role functioning. The maximum amount of points earned by the respondent, called gastrointestinal index (GII), and he is 144 points. In the control group (healthy respondents, n = 25), GII was 136 points. The distribution of scores by category in the control group, the following: perception of their health - 72.3 points, mental state - 18,5, physical state - 25.6, social functioning - 15.6, and role functioning - 4,0.
In the diagnosis of diseases using both clinical and instrumental methods. Study of the motor-evacuation function of the esophageal-gastric junction gastroduodenal complex was performed using polipozitsionnogo radiographic examination, transabdominal ultrasonography in the unit "Aloka SSD-2000 Convex sensors 3,5 and 5 MHz, stationary manometry, to enable a oesophageal manometry, antroduodenalnuyu manometry and electrogastrography (Multi-channel Poligraf ID using a water-perfusion catheter 9012R2271 Y1722 and processing of data using analysis software Polygram 1998 EM). Endoscopic examinations were performed fibrogastroskopami GiF R-30, GiF Q-40 company "Olympus" and the FG 29 V firm "Pentax" (Japan). Endoscopic ultrasono-graphs (EUS) of upper gastrointestinal tract was performed using a miniature ultrasound radial scanning probes UM-2R / UM-3R with a scanning frequency 12/20 MHz block the generation and processing of sound EU-M30, which were implemented through working channel videogastroskopa GIF-1T140 video EVIS EXERA GLV-160 companies, "Olympus" (Japan).
daily diet
a peck of salt
clinical research
mineralocorticoid
9 Ocak 2011 Pazar
Vitamin deficiency
Chronic pancreatitis
The clinical picture
For alcoholic pancreatitis is characterized by severe morphological changes of the parenchyma and ducts of the pancreas, including pancreatic duct stones and calcified areas in its parenchyma. The time interval between the onset of regular alcohol consumption and onset of CP is for men from 6 to 17 years and for women from 3 to 13 years [8]. A single dose of alcohol and fatty foods, especially after fasting may be an important factor in the development of CP.
Alcoholic CP arises because of the excessive use of high protein brand viagra and fat food with alcohol, which promotes intrapankreaticheskoy hypertension, or on the background of a diet poor in fat and protein, which causes the elimination of protein from acinar cell cancer, leading to atrophy of its parenchyma and a violation of synthesis inhibitors proteases [8]. This increases the concentration of proteins and enzymes in pancreatic secretions, reduced bicarbonate concentration and emissions of protease inhibitors, pH changes, increasing the content of lactoferrin in the acinar cells, which causes a disturbance of the functional patency of duct gland, it stimulates calcification.
Character of the flow of alcoholic CP is unstable in the early years is often noted for its recurring and the progression of pancreatitis, the death of parenchymal disease of the pancreas gets over the disease-free with constant pain and functional disorders.
Violations of the outflow of pancreatic secretion and development of the secondary CP may be due to intrapapillyarnymi polyps with hyperplasia papillary glands so-called forked RV, which is characterized by incomplete fusion duct systems ventral and dorsal primordia cancer, often in combination with stenosis of the small papilla DC.
Chronic pancreatitis clinically near pathological conditions: pain syndrome, exocrine pancreatic insufficiency, latent or apparent diabetes mellitus, at least - hypoglycemic syndrome, symptoms of cholestasis, impaired duodenal patency; segmental portal hypertension, inflammatory and suppurative complications.
Treatment
Possibilities of conservative treatment in the chronic phase of pancreatitis are limited; of drugs that specifically affect the pathogenesis of CP, are virtually absent. Therefore, major efforts should be aimed at easing pain, rational diet therapy, correction of the external and endocrine insufficiency of the pancreas, as well as the elimination of etiological factors of pancreatitis by arresting the inflammatory process in the biliary tract, anti-alcohol dependent patients.
The need to diet due to the decrease in CP patients body weight, a vitamin deficiency, it is also important in preventing relapses of pancreatitis.
K. Morgenroth et al. [3] recommend the following scheme of dietetics at HP: _ frequent meals with a total energy value of 2500-3000 kcal against adequate enzyme therapy; _ reducing the amount of fat to 60 grams per day (540 kcal) _ the amount of carbohydrates - 300-400 g / day (1200-1600 kcal), if necessary with the introduction of an adequate dose of insulin; _ the amount of protein - 60-120 g / day (320-480 kcal).
Signs of exocrine pancreatic insufficiency (weight loss, steatorrhea, increased flatulence) requires replacement therapy. In addition to the traditionally used pancreatin used modern drugs with a high content of lipase, facilitating the correction of steatorrhea and malabsorption of fat-soluble vitamins. Use of microgranular preparations in capsules that are protected by special coating prevents the deactivation of lipase in the acidic environment of the stomach.
Acceptance of enzyme preparations, increasing the viagra help with premature ejaculation content of proteases in the lumen of the initial part of the intestine, can reduce the secretion of the intestinal wall gastrojejunal hormones to relieve the pressure in the ductal system and pancreatic tissue and to arrest the pain syndrome [9].
Depending on the severity of pain in CP can distinguish four levels of possible analgesic effects [3]: abstinence from alcohol, the maximum limitation of animal fats in the diet, receiving enzyme preparations; taking antispasmodics (papaverine) and salicylates (paracetamol) use of neuroleptics and analeptics; appointment of opiate analogues (pentazocine).
Ineffectiveness of such measures is an indication for surgical treatment of patients with CP.
The objectives of surgical treatment of CP are: elimination of the etiologic factors of the secondary, inter alia, holangiogennogo pancreatitis easing pain, the elimination of complications (pseudocyst, pancreatic fistula, bile duct stenosis, pancreatic ascites and pleurisy, septic complications), preservation of RV function, especially the island apparatus [2].
Although surgical treatment can not eliminate the damage pancreas [7], selection of appropriate interventions provides stabilization of the pathological process, slowing down its progression.
Operations on the biliary tract on the cholecystitis and choledocholithiasis, papillostenoza, eliminating the pathogenic mechanisms of secondary holangiogennogo CPs contribute to its regression. In patients with primary alcohol HP complicated by stenosis of the common bile duct, the main task of the operation is to decompress the biliary tract by imposing zhelcheotvodyaschego anastomosis.
Operation of internal drainage duct and pancreatic cysts - pathogenetically substantiated method of correcting intrapankreaticheskoy hypertension, the most important factor of the pathogenesis of primary pancreatic can cut symptoms of CPs (especially pain) and to eliminate its complications (pseudocyst, pancreatic fistula resistant).
Surgical reduction of pressure in the pancreatic duct in patients with CP from 17 to 10.7 mm Hg relieves patients' pain [10]. Although there is no conclusive evidence to improve drainage after pancreatic duct of the exocrine and endocrine functions, possibly partial stabilization gland function and course of pancreatitis. Internal drainage is more justified when stored in one degree or another gland function in the absence viagra can not at all of cachexia, which is expressed steatite and creators; operation is more efficient than the fully discharging ductal system.
Chronic stages
diabetes mellitus
Various nations
The clinical picture
For alcoholic pancreatitis is characterized by severe morphological changes of the parenchyma and ducts of the pancreas, including pancreatic duct stones and calcified areas in its parenchyma. The time interval between the onset of regular alcohol consumption and onset of CP is for men from 6 to 17 years and for women from 3 to 13 years [8]. A single dose of alcohol and fatty foods, especially after fasting may be an important factor in the development of CP.
Alcoholic CP arises because of the excessive use of high protein brand viagra and fat food with alcohol, which promotes intrapankreaticheskoy hypertension, or on the background of a diet poor in fat and protein, which causes the elimination of protein from acinar cell cancer, leading to atrophy of its parenchyma and a violation of synthesis inhibitors proteases [8]. This increases the concentration of proteins and enzymes in pancreatic secretions, reduced bicarbonate concentration and emissions of protease inhibitors, pH changes, increasing the content of lactoferrin in the acinar cells, which causes a disturbance of the functional patency of duct gland, it stimulates calcification.
Character of the flow of alcoholic CP is unstable in the early years is often noted for its recurring and the progression of pancreatitis, the death of parenchymal disease of the pancreas gets over the disease-free with constant pain and functional disorders.
Violations of the outflow of pancreatic secretion and development of the secondary CP may be due to intrapapillyarnymi polyps with hyperplasia papillary glands so-called forked RV, which is characterized by incomplete fusion duct systems ventral and dorsal primordia cancer, often in combination with stenosis of the small papilla DC.
Chronic pancreatitis clinically near pathological conditions: pain syndrome, exocrine pancreatic insufficiency, latent or apparent diabetes mellitus, at least - hypoglycemic syndrome, symptoms of cholestasis, impaired duodenal patency; segmental portal hypertension, inflammatory and suppurative complications.
Treatment
Possibilities of conservative treatment in the chronic phase of pancreatitis are limited; of drugs that specifically affect the pathogenesis of CP, are virtually absent. Therefore, major efforts should be aimed at easing pain, rational diet therapy, correction of the external and endocrine insufficiency of the pancreas, as well as the elimination of etiological factors of pancreatitis by arresting the inflammatory process in the biliary tract, anti-alcohol dependent patients.
The need to diet due to the decrease in CP patients body weight, a vitamin deficiency, it is also important in preventing relapses of pancreatitis.
K. Morgenroth et al. [3] recommend the following scheme of dietetics at HP: _ frequent meals with a total energy value of 2500-3000 kcal against adequate enzyme therapy; _ reducing the amount of fat to 60 grams per day (540 kcal) _ the amount of carbohydrates - 300-400 g / day (1200-1600 kcal), if necessary with the introduction of an adequate dose of insulin; _ the amount of protein - 60-120 g / day (320-480 kcal).
Signs of exocrine pancreatic insufficiency (weight loss, steatorrhea, increased flatulence) requires replacement therapy. In addition to the traditionally used pancreatin used modern drugs with a high content of lipase, facilitating the correction of steatorrhea and malabsorption of fat-soluble vitamins. Use of microgranular preparations in capsules that are protected by special coating prevents the deactivation of lipase in the acidic environment of the stomach.
Acceptance of enzyme preparations, increasing the viagra help with premature ejaculation content of proteases in the lumen of the initial part of the intestine, can reduce the secretion of the intestinal wall gastrojejunal hormones to relieve the pressure in the ductal system and pancreatic tissue and to arrest the pain syndrome [9].
Depending on the severity of pain in CP can distinguish four levels of possible analgesic effects [3]: abstinence from alcohol, the maximum limitation of animal fats in the diet, receiving enzyme preparations; taking antispasmodics (papaverine) and salicylates (paracetamol) use of neuroleptics and analeptics; appointment of opiate analogues (pentazocine).
Ineffectiveness of such measures is an indication for surgical treatment of patients with CP.
The objectives of surgical treatment of CP are: elimination of the etiologic factors of the secondary, inter alia, holangiogennogo pancreatitis easing pain, the elimination of complications (pseudocyst, pancreatic fistula, bile duct stenosis, pancreatic ascites and pleurisy, septic complications), preservation of RV function, especially the island apparatus [2].
Although surgical treatment can not eliminate the damage pancreas [7], selection of appropriate interventions provides stabilization of the pathological process, slowing down its progression.
Operations on the biliary tract on the cholecystitis and choledocholithiasis, papillostenoza, eliminating the pathogenic mechanisms of secondary holangiogennogo CPs contribute to its regression. In patients with primary alcohol HP complicated by stenosis of the common bile duct, the main task of the operation is to decompress the biliary tract by imposing zhelcheotvodyaschego anastomosis.
Operation of internal drainage duct and pancreatic cysts - pathogenetically substantiated method of correcting intrapankreaticheskoy hypertension, the most important factor of the pathogenesis of primary pancreatic can cut symptoms of CPs (especially pain) and to eliminate its complications (pseudocyst, pancreatic fistula resistant).
Surgical reduction of pressure in the pancreatic duct in patients with CP from 17 to 10.7 mm Hg relieves patients' pain [10]. Although there is no conclusive evidence to improve drainage after pancreatic duct of the exocrine and endocrine functions, possibly partial stabilization gland function and course of pancreatitis. Internal drainage is more justified when stored in one degree or another gland function in the absence viagra can not at all of cachexia, which is expressed steatite and creators; operation is more efficient than the fully discharging ductal system.
Chronic stages
diabetes mellitus
Various nations
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