Chinyorwa
Methylene blue yekuvaviwa kunoramba kuripo panobuda tsvina: umbowo nemiganhu
Funga nezvemurwere akaedza kwemwedzi yakawanda makirimu anodzivirira ganda, mishonga inorwisa chakuvhe, mafuta ane steroid, uye kuchinja maitiro ehutsanana, asi achiri kuvaviwa panobuda tsvina usiku hwega hwega. Chiremba anovhiya ura hukuru nemugumo wahwo anotaura nezvejekiseni redhayi rebhuruu muganda rakapoteredza panobuda tsvina. Vaverengi vakawanda vanofungidzira mvura inonyaradza yakafukidza ganda, yakaita seimwe kirimu yekuzora inopinzwa netsono. Kurapa kuri kutaurwa kunoshanda neimwe pfungwa. Kunokuvadza magumo madiki etsinga dzinonzwa ari mudermis, chikamu chemukati cheganda, kuti kudambure kutenderera kwekuvaviwa nekukwenya. Umbowo hunokutsigira hunobva pazvidzidzo zvishoma zvakatevedza mapoka evarwere vakarapwa nevavhiyi, zvisina mapoka ekuenzanisa uye zvine kutevera varwere kusina kuenzana.
Chinyorwa ichi chinoongorora zvinyorwa izvozvo. Chinotsanangura zvinoitwa pakurapa uku nenyanzvi, zvinofanira kutanga zvabviswa pazvingava zvikonzero kuvaviwa kusati kwanzi hakuna chikonzero chinozivikanwa, zvinotaurwa nezvinyorwa zviviri zvikuru, uye panoshaya umbowo. Kuti uzive nezvemushonga wacho pachawo, ona mashandiro anoita methylene blue mumasero, uye ona runyorwa rwakakura rwekushandiswa kwayo mukurapa kwakabvumidzwa nekuchiri kuongororwa.
Kurapa kunoitwa najekiseni, kwete kirimu
Kubaya methylene blue mukati meganda kana pasi paro chaipo pakuvaviwa panobuda tsvina kusina chikonzero chinozivikanwa uye kusingapinduri pakurapwa inzira inopinda mumuviri, inoitwa nenyanzvi yezveutano. Nzira dzakabudiswa muzvinyorwa dzinoisa methylene blue yakasanganiswa kuti isanyanye kusimba mudermis yeganda rinenge rabatwa rakapoteredza panobuda tsvina, pachishandiswa nzira dzisina utachiona. Kazhinji panoshandiswa mushonga unopedza kunzwa panzvimbo iyoyo kana unovhara kunzwa munharaunda yakakura, murwere akarara nedumbu. Chinangwa ndechekuparadza magumo etsinga dzinonzwa ari pedyo nepamusoro peganda pachishandiswa kemikari. American Society of Colon and Rectal Surgeons inotsanangura kubaya mukati nepasi peganda rinenge rabatwa uye inoyambira kuti kuisa mushonga pedyo zvakanyanya nepamusoro peganda kunogona kukonzera kuparara kweganda kana maronda.
Misiyano mitatu inokosha. Chekutanga, methylene blue inozorwa pamusoro peganda haisi iyo nzira yakaongororwa nezvidzidzo izvi, uye hapana umbowo hwakafanana hunoratidza kuti inogona kutsiva kubaiwa mukati meganda. Chechipiri, nzira dzakabudiswa hadzigoni kushandiswa kutsigira kuzvibaya. Kudzora kudzika kwetsono ndicho chinhu chinokosha pakuchengeteka: kubaya pedyo zvakanyanya nepamusoro kunogona kukonzera maronda nekufa kweganda, ukuwo kubaya zvakanyanya mukati kana kushandisa nzira dzine utachiona kuchigona kukonzera mamota ane urwa nekukuvadzwa kwezvikamu zvemuviri. Chechitatu, methylene blue yejekiseni inotengeswa muUnited States yakanyorwa kuti ndeyekurapa methemoglobinemia yakazowanikwa, ichipinzwa mutsinga yeropa; saka kuishandisa mukati meganda rakapoteredza panobuda tsvina kushandiswa kusiri pane zvakanyorwa pamushonga. Vaverengi vari kutora mishonga ine chekuita neserotonin vanofanirawo kuverenga yambiro dzeserotonin syndrome nekudyidzana kwemishonga, dzinotsanangurwa zvakare pasi apa.
Tanga waongorora: kuvaviwa kuzhinji kune chikonzero
Pruritus ani inotsanangura chiratidzo chekuvaviwa panobuda tsvina, kwete chirwere chimwe chete. Mirayiridzo inoisa zvikonzero zvinokonzerwa nezvimwe zvinhu mumapoka ane chekuita nepanobuda tsvina nemugumo weura, ganda, utachiona, muviri wose, kutsamwiswa kweganda, uye pfungwa. Inokurudzira kubvunza nhoroondo yemurwere, kuongorora panobuda tsvina nemugumo weura pachishandiswa anoscopy, uye kuita bvunzo dzakanangana nezvinofungidzirwa kusati kwanzi hakuna chikonzero chinozivikanwa. Mirayiridzo yekushanda yeItalian Society of Colorectal Surgery inotsanangura kuongorora uku, kusanganisira kutora zviyero nekupukuta kana kukwenya zvishoma, bvunzo dzemurabhoritari, kuedza zvinokonzera kusawirirana neganda nekuzvinamira pariri, uye kutora chidimbu cheganda kuti chiongororwe zvichienderana nezvinenge zvaonekwa.
Zvikonzero zvinowanzoitika zvinofanira kubviswa pazvinofungidzirwa zvinosanganisira mamota epanobuda tsvina, kutsemuka kweganda, nzira dzisina kujairika dzinobatana nepanobuda tsvina, tumapundu tweganda, kubuda kwetsvina zvishoma kana kutadza kuidzora, kubuda kwechikamu chemugumo weura kunze, uye mapundu ewarts. Zvimwe zvinosanganisira kuzvimba kweganda nekuda kwekubata sipo, zvipukuti, zvinonhuhwirira, uye zvinhu zvinozorwa paganda, pamwe nehunyoro netsvina isingaoneki inenge yasara paganda. Zvirwere zveganda zvinogona kufanana neizvi zvinosanganisira psoriasis, lichen sclerosus, uye lichen simplex chronicus. Utachiona hunogona kusanganisira Candida, dermatophytes, honye dzepinworm, scabies, uye hunotapuriranwa pabonde. Zvirwere zvemuviri zvinogona kuenderana nekuvaviwa uku zvinosanganisira chirwere cheshuga, chirwere chechiropa chinotadzisa kufamba kwenyongo, chirwere cheitsvo chinogara kwenguva refu, uye kusagadzikana kwegland yethyroid. Zvironda zvinoramba zviripo, zvisina chimiro chakajairika, kana zvinenge zvaita maronda akavhurika zvinoda kutorwa chidimbu kuti chiongororwe, kuitira kubvisa fungidziro yeanal intraepithelial neoplasia kana extramammary Paget disease. Boka diki kwazvo chete rine zviratidzo zvinoramba zviripo uye zvakanyanya pasinei nekuongorora uku nekurapa kusiri kwekupinda mumuviri ndiro rinofungidzirwa kubaiwa jekiseni. Izvi ndizvowo zvinotaurwa nemirayiridzo yeASCRS kuvarwere.
Zvakawanikwa neongororo yakabatanidza zvidzidzo ya2023
Ongororo yakabatanidza umbowo hwakawanda kupfuura dzimwe ndeyemeta-analysis ya2023 yaJia nevamwe, yaive nemapoka ekurapwa chete pasina ekuenzanisa, yakabatanidza zvidzidzo 7 nevarwere 225. Kuvaviwa kwakapera mushure mejekiseni rimwe pa76.1 muzana (95 muzana CI 64.9 kusvika 87.3), kuchikwira kusvika pa85.4 muzana mushure mejekiseni rechipiri. Kuderera kana kusavapo kwezviratidzo kwakashumwa kwaive 75.3 muzana pagore rimwe uye 77.3 muzana pamakore matatu, kuchidzika kusvika pa24.0 muzana pamakore mashanu.
Nhamba idzi dzinoda kuverengwa nokungwarira. Zvidzidzo zvakabatanidzwa zvaiva zvidzidzo zvemapoka evarwere zvisina mapoka ekuenzanisa, zvakaitwa kubva muna 1979 kusvika muna 2019, zvine nzira, kusimba kwemisanganiswa, nezviyero zvemigumisiro zvakasiyana. Kusiyana kwemigumisiro pakuwongorora nenhamba kwaive kwakakura. Zvikamu zvemigumisiro yenguva refu hazvibvi kuboka rimwe chete rakateverwa kwemakore mashanu. Zvidzidzo zvidiki zvakasiyana zvakapa mashoko panguva dzakasiyana, saka nhamba yemakore mashanu haina hwaro hwakasimba. Matambudziko aiwanzoitika aive kusara kweruvara rwebhuruu muganda kwenguva pfupi uye kusanzwa pakapoteredza panobuda tsvina. Zvakashumwa zvaisanganisira utachiona hweganda nezviri pasi paro hunonzi cellulitis, kuungana kweropa munyama kunonzi hematoma, kubuda kwetsvina zvishoma kwenguva pfupi, kutadza kubudisa weti, mota rine urwa pedyo nepamusoro peganda, uye kuchinja kwekunzwa kunogara kwenguva refu. Zvinokosha kuti chidzidzo chekare chaEusebio nevamwe (1990) chakashuma kufa kweganda chakanga chisiri pakati pezvidzidzo zvinomwe zvakabatanidzwa. Saka mashoko anopa chivimbo pamusoro pekuchengeteka ari mumeta-analysis haarevi kuti kufa kweganda hakuna kumboitika. Pfupiso yedu yekuchengeteka kwemethylene blue inoisa zviitiko izvi mumamiriro azvo.
Zvakawanikwa nechidzidzo chimwe chete chakakura kupfuura zvimwe
Chidzidzo chimwe chete chakakura kupfuura zvimwe ndecheongororo ya2019 yaKim nevamwe yakatarisa kumashure padhatabhesi yemashoko akaunganidzwa varwere vachiteverwa kubva pakutanga. Pavarwere 362 vakauya vachivaviwa panobuda tsvina, 259 vakaita zviri nani nekurapa kusiri kwekupinda mumuviri, kuchisara 103 vane zviratidzo zvakanyanya zvisingapinduri pakurapwa, vakabva varapwa nejekiseni mukati meganda. Nzira yakashandiswa yakasanganisa 5 mL yemethylene blue yekutanga ine kusimba kwe1 muzana ne15 mL yelidocaine ine kusimba kwe1 muzana. Izvi zvakapa 20 mL yemusanganiswa wekubaya une kusimba kwekupedzisira kunenge 0.25 muzana, wakabaiwa pachishandiswa mushonga wekutindivadza werudzi rwesaddle block. Musiyano uyu pakati pekusimba kwemushonga wekutanga nekusimba kwemusanganiswa wekupedzisira unowanikwa kazhinji muzvinyorwa: mapepa anoti 1 muzana anowanzoreva mushonga wekutanga, kwete musanganiswa wakaderedzwa kusimba unozobaiwa.
Pamavhiki matanhatu, 87 pavarwere 96 vakateverwa (90.6 muzana) vakanzi vakaita zviri nani. Varwere vasere vakazobaiwa zvakare, uye vashanu vacho vakaita zviri nani. Pamakore matatu, 53 pavarwere 62 vaivepo kuti vaongororwe kwenguva refu (85.5 muzana) vakanga vaita zviri nani, uye pakati pe53 vakatanga vapindura pakurapwa, 4 (7.5 muzana) vakavaviwa zvakare. Kuderera kwehuwandu hwevarwere vakaramba vachiteverwa kunoderedza kusimba kwenhamba idzi: 62 chete kubva pa103 vekutanga ndivo vakapa mashoko emakore matatu. Ruvara rwebhuruu rwakaramba rwuri muganda re84 pa96 (87.5 muzana) pamavhiki matanhatu, kazhinji ruchidzikira kusvika patunzvimbo tudiki twakaita semusoro wetsono panenge pamavhiki mana. Hematoma yakaitika mu6 pa62 (9.7 muzana) uye yakapera yega. Vanyori vakashuma kuti muboka ravo hamuna kubuda kwetsvina zvishoma, cellulitis, kufa kweganda, kana mamota ane urwa.
Tafura yekunaka kwezvidzidzo nekutevera varwere
Tafura iri pasi apa ndiyo inonyanya kushandiswa sehwaro hweongororo iyi. Kusimba kwemisanganiswa kwakaiswa chiratidzo chenyeredzi kufungidzira kwemusanganiswa wekupedzisira, nokuti mapepa akati wandei akashuma kusimba kwemushonga wekutanga chete.
| Chidzidzo | Marongerwo nevarwere | Nzira yekubaya | Kutevera varwere | Kubudirira kwekurapa nekudzoka kwezviratidzo | Migumisiro isingadiwi |
|---|---|---|---|---|---|
| Wolloch naDintsman, 1979 | Chidzidzo cheboka revarwere, n=9 | Inenge 10 kusvika 15 mL yemusanganiswa we1%, pasi peganda | Mwedzi 3 kusvika 15 | 8 pa9 vakaita zviri nani mushure mejekiseni rekutanga; 9 pa9 mushure mekubaiwa zvakare | Fivha kweinenge zuva rimwe, 1 pa9 |
| Eusebio, Graham, naMody, 1990 | Chidzidzo cheboka revarwere, n=23 | Kusvika 30 mL yemusanganiswa we0.5%, kupinzwa mukati meganda | Vakapindura pakurapwa vakateverwa kupfuura mavhiki 12, vamwe kusvika makore 9 | 21 pa23 vakatanga vapindura zvizere kana zvishoma; zviratidzo zvakadzoka mu4 pa18 vakapindura (22%) pakuteverwa kwenguva refu | Kufa kweganda pakudzika kwaro kwose, 3 pa23 (13%), zvichida kubviswa kwenyama yakafa |
| Farouk naLee, 1997 | Chidzidzo cheboka rakateverwa kubva pakutanga, n=6 | 10 mL yemushonga wekutanga we1% pamwe nemushonga wekutindivadza nemvura ine munyu, kusimba kwekupedzisira kunenge 0.44%* | Makore 3 ari pakati nepakati, kubva pa2 kusvika pa5 | 5 pa6 vakatanga kuita zviri nani zvikuru; kudzoka kwezviratidzo kwakaunganidzwa kwaive kunenge 20% pagore 1, 40% pamakore 2, 60% pamakore 3 | Kutadza kubudisa weti, mota rine urwa pedyo nepamusoro peganda, kutadza kudzora tsvina kwenguva pfupi, chimwe nechimwe mu1 pa6 |
| Botterill naSagar, 2002 | Chidzidzo cheboka rakateverwa kubva pakutanga, n=25 | 5 mL yemushonga wekutanga we1% pamwe nelignocaine nehydrocortisone, kusimba kwekupedzisira kunenge 0.25%* | Mwedzi 11 iri pakati nepakati, kubva pa2 kusvika pa25 | 16 pa25 vasina zviratidzo mushure mejekiseni rimwe; 22 pa25 (88%) mushure mekubaiwa zvakare | Kubuda kwetsvina zvishoma kwenguva pfupi, 1 pa25, kwemazuva anenge 2 |
| Mentes nevamwe, 2004 | Chidzidzo chakatevera varwere kubva pakutanga, vasina kugoverwa mumapoka netsaona, n=30 | Inenge 15 mL ine kusimba kwekupedzisira kwe1%, kubva pamushonga wekutanga we2% wakaderedzwa kusimba nechiyero chinenge 1:1, mukati meganda pamwe nepasi peganda pedyo nepamusoro | Mwedzi 12 kune vakawanda; mwedzi 5 kusvika 24 | 24 pa30 vasina zviratidzo pamwedzi 1; vanenge 28 pa30 mushure mekurapwa zvakare; 23 pa30 pamwedzi 12; kudzoka kwezviratidzo muvanenge 5 pa28 (18%) | Cellulitis yakapera yega, 2 pa30 (7%) |
| Sutherland, Faragher, naFrizelle, 2009 | Chidzidzo cheboka rakateverwa kubva pakutanga nemuvhiyi mumwe chete, n=49 | 10 mL yemushonga wekutanga we1% pamwe nebupivacaine ine adrenaline nemethylprednisolone, kusimba kwekupedzisira kunenge 0.32%* | Kunyanya mavhiki 4 ne8 | 47 pa49 (96%) vakaita zviri nani; zviratidzo zvakapera zvizere mu28 pa49 mushure mejekiseni rimwe, 32 pa49 (65%) mushure mekubaiwa zvakare | Kuchinja kwekugona kudzora tsvina mu7 pa49 (14%), kwakapera mukati memazuva anenge 10 kusvika kumavhiki 6; kuderera kwekunzwa kunoshungurudza mu2 pa49 (4%) |
| Samalavicius nevamwe, 2012 | Chidzidzo cheboka rakateverwa kubva pakutanga, n=10 | Yakashumwa se15 mL yemusanganiswa we1%, mukati meganda | Mwedzi 47 iri pakati nepakati, kubva pa29 kusvika pa60 | Zviratidzo zvakapera mu10 pa10 pakazosvika mavhiki 4; zvakadzoka mu8 pa10 (80%) pakucherechedzwa kwenguva refu | Kusanzwa nekusara kweruvara muganda kwenguva pfupi; kuzvimba kusvika pamwedzi inenge 2; hapana kufa kweganda kwakashumwa |
| Kim, Kim, naLee, 2019 | Ongororo yakatarisa kumashure padhatabhesi yemashoko akaunganidzwa varwere vachiteverwa kubva pakutanga, n=103 vakarapwa | 5 mL yemushonga wekutanga we1% pamwe ne15 mL yelidocaine ye1%, kusimba kwekupedzisira kunenge 0.25%* | Mavhiki 6 (96 pa103) nemakore 3 (62 pa103) | 87 pa96 vakaita zviri nani pamavhiki 6 (91%); 53 pa62 vakaita zviri nani pamakore 3 (86%); zviratidzo zvakadzoka mu4 pa53 vakapindura pakurapwa (8%) | Kusara kweruvara muganda mu84 pa96 pamavhiki 6 (88%); hematoma mu6 pa62 (10%); hapana kubuda kwetsvina zvishoma, cellulitis, kufa kweganda, kana mota rine urwa |
Maitiro anooneka mumitsara iyi akafanana. Kupindura pakurapwa pakutanga kunowanzova kwakawanda, asi kufungidzira kwekudzoka kwezviratidzo kunoenderana zvikuru nenguva inocherechedzwa varwere uye huwandu hunoramba huchiteverwa. Samalavicius akashuma kupera kwezviratidzo kwe100 muzana pakutanga, asi kudzoka kwekupedzisira kwe80 muzana panguva yekutevera yepakati nepakati yemwedzi 47; Kim akashuma kudzoka kuri pasi pe8 muzana pamakore matatu pakati pevakapindura pakurapwa vakaramba vachiteverwa. Mapoka madiki, kubaiwa zvakare, zviyero zvemigumisiro zvakasiyana, uye kuderera kwevarwere vanoramba vachiteverwa zvinoita kuti kuenzanisa zvakananga kusavimbike.
Miganhu inofanira kurangarirwa nemuverengi
Hapana chidzidzo chakagovera varwere mumapoka netsaona chinotsigira kurapa uku. Kufungidzira kwose kwekubudirira kuri pamusoro kunobva pazvidzidzo zvemapoka zvisina mapoka ekuenzanisa kana paboka rakaongororwa pachitariswa kumashure. Saka kupindura kunokonzerwa nekutenda kuti munhu arapwa, kudzokera kwemamiriro kune mwero wawo wepakati, uye matanho ehutsanana aiitwa panguva imwe chete hazvigoni kupatsanurwa kubva pamugumisiro wekurapa. Nzira dzinosiyana pachikamu cheganda chinobaiwa, huwandu hwemvura, mashumirwo ekusimba kwemusanganiswa, kusanganiswa kwemushonga wekutindivadza, uye kushandiswa kwesteroid. Izvi zvinoreva kuti hapana mwero wemushonga wakamisikidzwa: enzanisa kusimba kwemisanganiswa yekupedzisira, kwete zvakanyorwa pamishonga yekutanga. Mapoka evarwere 6 kusvika 103 haagoni kuratidza kuti zviitiko zvisingawanzoitiki, zvakadai sekusawirirana kwakanyanya nemushonga kana zvinoitika mumuviri wose, zvinoitika kangani. Uye muzvidzidzo zvakawanda, kutevera varwere kuti vaone kudzoka kwezviratidzo mushure menguva refu hakuna kukwana.
Nhoroondo yekufa kweganda inofanira kutaurwa pachena. Varwere vatatu pa23 muchidzidzo chaEusebio cha1990 vakaita kufa kweganda pakudzika kwaro kwose, zvichida kubviswa kwenyama yakafa. Kubvira ipapo, nzira dzakashandiswa dzava kuenda kumisanganiswa yekupedzisira yakaderedzwa kusimba uye kubaya mukati meganda panzvimbo pekuisa zvakadzika. Zvidzidzo zvakazotevera zvinoshuma matambudziko akareruka, asi chiitiko chekare ichi chikamu cheumbowo huripo uye chinoyambira kuti nzira iyi isashandiswa pasina kungwarira.
Yambiro dzemishonga ine migumisiro mumuviri wose dzinofanirawo kufungwa nezvadzo. Mashoko azvino ekupa methylene blue yejekiseni ane yambiro yakaiswa mubhokisi pamusoro peserotonin syndrome inogona kuuraya kana ichishandiswa nemishonga ine chekuita neserotonin nemaopioid. Anotaurawo mishumo yeanaphylaxis, uye anorambidza kushandiswa kana munhu aine kushomeka kweG6PD kana kusawirirana kwakanyanya nemadhayi ethiazine. Yambiro idzi dzinobva zvikuru pakushandisa mushonga mutsinga yeropa kuti usvike mumuviri wose, uye huwandu hunosvika mumuviri wose mushure mekubaya pakapoteredza panobuda tsvina hahuna kuyerwa zvakakwana. Saka hazvifaniri kungofungidzirwa kuti hadzina basa. Zivisa nyanzvi yezveutano nezvemishonga yose yekurapa kuora mwoyo, maopioid, uye mamiriro eG6PD usati waitirwa chero kurapa kwemethylene blue.
Ndiani angakurukura izvi nenyanzvi yezveutano
Vanogona kufungidzirwa nzira iyi vashoma: vane kuvaviwa kusina chikonzero chinozivikanwa kunoramba kuripo mushure mekutsvaga zvimwe zvikonzero uye kutadza kwematanho ekurapa asingapindi mumuviri, kwakanyanya zvokuti vangabvuma kusara kweruvara muganda, kusanzwa, uye njodzi diki yeutachiona kana kuchinja kwekugona kudzora tsvina. Uya nenhoroondo yezviratidzo zvichienderana nenguva, kurapwa kwawakamboitwa nemazuva akwo, mishumo yebvunzo inosanganisira anoscopy uye kutorwa kwechidimbu chenyama kupi zvako kuti chiongororwe, pamwe nerunyorwa ruzere rwemishonga. Mibvunzo inobatsira yakaunganidzwa mumibvunzo yedu yekubvunza nyanzvi yezveutano nezvemethylene blue. Usatsvaga jekiseni kumurapi asingaiti kuongorora kwezvikonzero, uye usamboedza kuzvibaya.