V\u011bt\u0161ina n\u00e1sleduj\u00edc\u00edch chorobn\u00fdch stav\u016f pat\u0159\u00ed mezi vz\u00e1cn\u011bj\u0161\u00ed onemocn\u011bn\u00ed j\u00edcnu, kter\u00e1 spadaj\u00ed sp\u00ed\u0161e do kompetence gastroenterologa [1, 2, 3, 4, 5]. V takto zam\u011b\u0159en\u00fdch publikac\u00edch je mo\u017eno nal\u00e9zt podrobn\u011bj\u0161\u00ed pou\u010den\u00ed a rozs\u00e1hlou literaturu o t\u011bchto stavech. Chirurg se s t\u011bmito chorobami setk\u00e1v\u00e1 p\u0159ev\u00e1\u017en\u011b jen v r\u00e1mci diferenci\u00e1ln\u011b diagnostick\u00fdch \u00favah.<\/p>\n
Jde o blanit\u00e9 \u00fatvary v r\u016fzn\u00fdch et\u00e1\u017e\u00edch j\u00edcnu, \u010dasto p\u016fsob\u00edc\u00ed dysfagii.<\/p>\n
V kr\u010dn\u00ed \u010d\u00e1sti j\u00edcnu se vyskytuj\u00ed membr\u00e1ny vrozen\u00e9, nebo vzniknou obdobn\u00e9 \u00fatvary v pozd\u011bj\u0161\u00ed \u017eivot\u011b, nap\u0159. p\u0159i epidermolysis bullosa, p\u0159i pemfigu, po polept\u00e1n\u00ed \u010di po z\u00e1n\u011btech.<\/p>\n
Ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu maj\u00ed vrozen\u00e9 membr\u00e1ny v\u011bt\u0161inou vztah k vrozen\u00fdm tracheoezofage\u00e1ln\u00edm p\u00ed\u0161t\u011bl\u00edm (viz kap. 7). U dosp\u011bl\u00fdch zde vz\u00e1cn\u011b m\u016f\u017ee b\u00fdt membr\u00e1na p\u0159i Barrettov\u011b j\u00edcnu, v\u011bt\u0161inou ulo\u017eena dist\u00e1ln\u011bji.<\/p>\n
Naz\u00fdv\u00e1 se tak\u00e9 doln\u00ed j\u00edcnov\u00fd kruh [6, 7]. Je to okrouhl\u00fd prstenec v termin\u00e1ln\u00edm j\u00edcnu, v m\u00edst\u011b spojen\u00ed epitelu dla\u017edicov\u00e9ho a cylindrick\u00e9ho. Prstenec je tvo\u0159en membr\u00e1nou, jej\u00ed\u017e horn\u00ed plocha na\u0161edl\u00e9 barvy je kryta epitelem dla\u017edicov\u00fdm, n\u011bkdy rohov\u011bj\u00edc\u00edm, doln\u00ed plocha, r\u016f\u017eov\u00e1, je kryta epitelem cylindrick\u00fdm. Stroma je vazivov\u00e9, bez z\u00e1n\u011btliv\u00fdch zm\u011bn. \u0160\u00ed\u0159e prstence je 2\u20134 mm. N\u011bkdy b\u00fdv\u00e1 p\u0159\u00edtomna hi\u00e1tov\u00e1 k\u00fdla. Soud\u00ed se, \u017ee p\u016fvod je vrozen\u00fd, ale nen\u00ed vylou\u010den ani vznik n\u00e1sledkem refluxu.<\/p>\n
Klinick\u00e9 p\u0159\u00edznaky<\/em>.<\/em> Obt\u00ed\u017ee se manifestuj\u00ed v\u011bt\u0161inou po 50. roce, kdy se prstenec teprve vytvo\u0159il, nebo se projev\u00ed a\u017e v dob\u011b ochabuj\u00edc\u00ed motility. Dysfagie vznik\u00e1, z\u00fa\u017e\u00ed-li se lumen j\u00edcnu na m\u00e9n\u011b ne\u017e 12 mm. M\u016f\u017ee se vyv\u00edjet pozvolna, ale typi\u010dt\u011bj\u0161\u00ed je n\u00e1hl\u00fd za\u010d\u00e1tek po polknut\u00ed v\u011bt\u0161\u00edho sousta, oby\u010dejn\u011b ve sp\u011bchu (pov\u011bstn\u00fd \u201esteak house syndrome\u201c po rychl\u00e9m po\u017eit\u00ed \u0159\u00edzku). Sousto se zablokuje nad p\u0159ek\u00e1\u017ekou, vyvol\u00e1 tlak a bolest, p\u0159idru\u017een\u00e1 k\u0159e\u010d br\u00e1n\u00ed pr\u016fchodu do \u017ealudku. V\u011bt\u0161inou si organizmus pom\u016f\u017ee t\u00edm, \u017ee sousto vyvrhne, jindy je t\u0159eba vyjmout je endoskopicky.<\/span><\/p>\n Diagnostika.<\/em> Schatzkiho prstenec prok\u00e1\u017eeme rentgenologicky, ale p\u0159i vy\u0161et\u0159en\u00ed je nezbytn\u00e9, aby dist\u00e1ln\u00ed j\u00edcen byl rozepjat tak, \u017ee po polknut\u00ed kontrastn\u00ed l\u00e1tky pacient zadr\u017e\u00ed dech, dokud sousto nedojde do termin\u00e1ln\u00edho j\u00edcnu.<\/span><\/p>\n Je t\u0159eba odli\u0161it podobn\u00fd z\u00e1\u0159ez v m\u00edst\u011b hi\u00e1tu (ten se pozn\u00e1 tak, \u017ee se zn\u00e1zor\u0148uje p\u0159i vdechu), pop\u0159. i diskr\u00e9tn\u00ed z\u00e1\u0159ez vyzna\u010duj\u00edc\u00ed horn\u00ed hranici vestibula j\u00edcnu. Jsou-li vyvinuty v\u0161echny t\u0159i z\u00e1\u0159ezy, pak Schatzkiho prstenec je prost\u0159edn\u00ed.<\/p>\n Endoskopick\u00fd pr\u016fkaz nen\u00ed snadn\u00fd a da\u0159\u00ed se jen tehdy, poda\u0159\u00ed-li se termin\u00e1ln\u00ed j\u00edcen dostate\u010dn\u011b rozepnout.<\/p>\n L\u00e9\u010dba.<\/em> Mnohdy sta\u010d\u00ed doporu\u010dit, aby posti\u017een\u00fd jedl pomalu a dob\u0159e kousal. Tak\u00e9 <\/span>ezofagoskopie p\u016fsob\u00ed nejen diagnosticky, n\u00fdbr\u017e i terapeuticky. \u00da\u010dinn\u011bj\u0161\u00ed je dilata ce pneumatick\u00e1 \u010di bu\u017eiemi. Opera\u010dn\u00ed excize prstence je nutn\u00e1 jen v\u00fdjime\u010dn\u011b.<\/p>\n Jde o atrofii sliznic tr\u00e1vic\u00ed trubice s poruchou mukokut\u00e1nn\u00edch p\u0159echod\u016f, \u00fatlumem sekrece r\u016fzn\u00fdch \u017el\u00e1z, a n\u00e1sledky tohoto \u00fatlumu.<\/p>\n Pojem epiteloxer\u00f3za [8], ra\u017een\u00fd Charv\u00e1tem, Flusserem a spol. (1952), se sice v literatu\u0159e pro souborn\u00e9 ozna\u010den\u00ed d\u00e1le popisovan\u00fdch n\u00e1lez\u016f neujal, ale jak to charakterizoval prof. Ma\u0159atka, pokl\u00e1dal tento v\u00fdraz za nejlep\u0161\u00ed a vlastn\u011b jedin\u00fd pro shrnut\u00ed skupiny chorobn\u00fdch stav\u016f bl\u00edzce p\u0159\u00edbuzn\u00fdch, ale uv\u00e1d\u011bn\u00fdch pod r\u016fzn\u00fdmi n\u00e1zvy. V\u00fdvoj n\u00e1zor\u016f na jejich klasifikaci a terminologii vypl\u00fdv\u00e1 z tohoto historick\u00e9ho p\u0159ehledu: Roku 1906 podal Paterson prvn\u00ed zpr\u00e1vu o zvl\u00e1\u0161tn\u00edm druhu dysfagie, kter\u00fd se dnes naz\u00fdv\u00e1 syndrom Plummer\u016fv-Vinson\u016fv<\/i>, podle priority by se v\u0161ak m\u011bl naz\u00fdvat syndrom Kellyho-Paterson\u016fv. <\/i>Plummer vyslovil v roce 1914 n\u00e1zor, \u017ee jde o \u201ehysterickou dysfagii\u201c, kter\u00e1 druhotn\u011b p\u016fsob\u00ed karenci \u017eeleza a vitamin\u016f. Kelly s Patersonem upozornili roce 1919 na \u010dastou koincidenci s rakovinou j\u00edcnu a hltanu. Teprve v roce 1922 Plummer a Vinson uve\u0159ejnili zpr\u00e1vu, kter\u00e1 vzbudila pozornost a spojila s t\u00edmto syndromem jejich jm\u00e9no. Pov\u0161imli si sou\u010dasn\u00e9 atrofick\u00e9 glositidy a an\u00e9mie, a proto vyslovili n\u00e1zor, \u017ee p\u0159\u00ed\u010dinou je karence \u017eeleza a vitamin\u016f komplexu B, odtud n\u00e1zev \u201esideropenick\u00e1 dysfagie\u201c, \u201edysfagie s karenc\u00ed \u017eeleza a komplexu B\u201c, \u201edysfagie u atroficko-sideropenick\u00e9ho syndromu\u201c. Atrofick\u00e9 zm\u011bny v \u00fastech s nedostatkem slin daly vznik dal\u0161\u00edmu n\u00e1zvu \u201eidiopatick\u00e1 xerostomie\u201c.<\/p>\n Roku 1933 \u0161v\u00e9dsk\u00fd oftalmolog Sj\u00f6gren popsal zvl\u00e1\u0161tn\u00ed druh keratokonjunktivitidy spojen\u00e9 s \u00fatlumem sekrece slz a s r\u016fzn\u00fdmi p\u0159\u00edznaky Plummerova-Vinsonova syndromu, n\u011bkdy i s polyartritidou. V literatu\u0159e se uv\u00e1d\u00ed jako zvl\u00e1\u0161tn\u00ed jednotka, av\u0161ak podobnost obou syndrom\u016f je takov\u00e1, \u017ee se nab\u00edz\u00ed jejich spojen\u00ed do spole\u010dn\u00e9ho pojmu epiteloxer\u00f3zy. Ov\u0161em u ka\u017ed\u00e9ho z nich je v klinick\u00e9m obrazu d\u016fraz na jin\u00fdch p\u0159\u00edznac\u00edch.<\/p>\n Atrofick\u00e9 zm\u011bny se projevuj\u00ed zvl\u00e1\u0161t\u011b na sliznici \u00fast, jazyka, hltanu a j\u00edcnu. \u00datlum sekrece slin vede k suchosti \u00fast (xerostomii) a dysfagii bukofarynge\u00e1ln\u00edho typu. Objektivn\u011b se zjist\u00ed atrofick\u00e1 glositida a stomatitida, d\u00e1le angul\u00e1rn\u00ed stomatitida, zv\u011bt\u0161en\u00ed a bolestivost p\u0159\u00edu\u0161n\u00edch \u017el\u00e1z. Na p\u0159edn\u00edm obvodu kr\u010dn\u00ed \u010d\u00e1sti j\u00edcnu pod krikoidn\u00ed chrupavkou se rentgenem zjist\u00ed z\u00e1\u0159ez zp\u016fsoben\u00fd membr\u00e1nou; p\u0159i endoskopii se tato blanka \u010dasto nezjist\u00ed, nebo\u0165 se p\u0159i zav\u00e1d\u011bn\u00ed p\u0159\u00edstroje rozru\u0161\u00ed. \u010cast\u00e9 jsou dal\u0161\u00ed p\u0159\u00edznaky: craurosis vulvae, lomivost neht\u016f, pad\u00e1n\u00ed vlas\u016f. T\u00e9m\u011b\u0159 konstantn\u00ed je sideropenick\u00e1 an\u00e9mie a neur\u00f3za.<\/p>\n P\u0159\u00edznaky jsou v z\u00e1klad\u011b stejn\u00e9, ale v\u00fdrazn\u011b vystupuje do pop\u0159ed\u00ed \u00fatlum sekrece slz a n\u00e1sledn\u00e1 keratoconiunctivitis sicca. \u010cast\u00e9 jsou i jin\u00e9 projevy pova\u017eovan\u00e9 za autoimunn\u00ed onemocn\u011bn\u00ed: revmatoidn\u00ed artritida, sklerodermie, dermatomyozitida.<\/p>\n Etiologie<\/em>.<\/em> Nen\u00ed zn\u00e1ma ani etiologie, ani patogeneze. Uva\u017eovalo se o mo\u017enosti, \u017ee jde o poruchu enzymov\u00fdch syst\u00e9m\u016f (dysenzym\u00f3zy, enzymopatie) s n\u00e1slednou insuficienc\u00ed koenzymov\u00fdch syst\u00e9m\u016f, proteosynt\u00e9zy a tvorby apoferment\u016f. Dnes se toto onemocn\u011bn\u00ed \u0159ad\u00ed mezi choroby autoimunn\u00ed, resp. kolagen\u00f3zy. Genetick\u00e1 dispozice p\u0159i prim\u00e1rn\u00edm Sj\u00f6grenov\u011b syndromu je spojena nej\u010dast\u011bji se znakem HLA B8 a DR3, pop\u0159. DR4, je-li choroba spojena s revmatoidn\u00ed artritidou.<\/span><\/p>\n Klinick\u00fd obraz a diagnostika<\/em>.<\/em> Oba syndromy postihuj\u00ed p\u0159ev\u00e1\u017en\u011b \u017eeny v klimakteriu. Pro Plummer\u016fv-Vinson\u016fv syndrom je typick\u00e9, \u017ee si \u017eena v p\u00e1t\u00e9m nebo \u0161est\u00e9m desetilet\u00ed za\u010dne st\u011b\u017eovat na polykac\u00ed obt\u00ed\u017ee, odm\u00edt\u00e1 tuh\u00e9 pokrmy, omezuje se na ka\u0161ovitou stravu, hubne, je slab\u00e1, unaven\u00e1, bled\u00e1, siln\u011b nerv\u00f3zn\u00ed. \u010casto se p\u0159idru\u017euje p\u00e1len\u00ed jazyka, suchost v \u00fastech, prask\u00e1n\u00ed a bolest \u00fastn\u00edch koutk\u016f, sv\u011bd\u011bn\u00ed vulvy. P\u0159i anal\u00fdze dysfagie vyjde najevo, \u017ee v\u00e1zne hlavn\u011b dopraven\u00ed sousta do \u00fast\u00ed j\u00edcnu, nemocn\u00e1 \u201enem\u016f\u017ee polknout\u201c, \u201en\u011bco j\u00ed vad\u00ed v krku\u201c, jde tedy o poruchu \u00fastn\u00ed a hltanov\u00e9 f\u00e1ze polyk\u00e1n\u00ed. U Sj\u00f6grenova syndromu naopak nemoc za\u010d\u00edn\u00e1 p\u00e1len\u00edm o\u010d\u00ed, nedostatkem slz a k tomu se p\u0159ipojuje sucho v \u00fastech, pop\u0159. ostatn\u00ed d\u0159\u00edve vyjmenovan\u00e9 p\u0159\u00edznaky. N\u011bkdy se objevuj\u00ed i bolesti kloub\u016f, pop\u0159. z\u00e1n\u011btliv\u00e9 zdu\u0159en\u00ed kloub\u016f.<\/span><\/p>\n Objektivn\u011b jsou zji\u0161\u0165ov\u00e1ny zm\u011bny na sliznici \u00fast, \u00fastn\u00edch koutc\u00edch a na vulv\u011b. Laboratorn\u011b jsou nejst\u00e1lej\u0161\u00ed p\u0159\u00edznaky sideropenie, zvl\u00e1\u0161t\u011b pokles koncentrace hemoglobinu a hladiny plazmatick\u00e9ho \u017eeleza. Typick\u00e1 je achlorhydrie. Vz\u00e1cn\u011bj\u0161\u00ed je hepatomegalie a splenomegalie. \u010casto se objevuje typick\u00fd n\u00e1lez rentgenologick\u00fd. P\u0159i rutinn\u00edm vy\u0161et\u0159en\u00ed j\u00edcnu se m\u016f\u017ee p\u0159ehl\u00e9dnout, ale p\u0159i c\u00edlen\u00e9m vy\u0161et\u0159en\u00ed lze zjistit pod horn\u00edm \u00fast\u00edm j\u00edcnu z\u00e1\u0159ez z ventr\u00e1ln\u00ed strany ve v\u00fd\u0161i 5.-6. kr\u010dn\u00edho obratle, kter\u00fd je zp\u016fsoben membr\u00e1nou, tj. jemnou vazivovou blankou, skl\u00e1daj\u00edc\u00ed se p\u0159ev\u00e1\u017en\u011b z epitelu. P\u0159i ezofagoskopii se n\u011bkdy nezjist\u00ed, proto\u017ee ji tubus p\u0159i zav\u00e1d\u011bn\u00ed rozru\u0161\u00ed.<\/p>\n U Sj\u00f6grenova syndromu se p\u0159i obarven\u00ed prok\u00e1\u017eou v limbu rohovky eroze a p\u0159i kvantitativn\u00edm stanoven\u00ed slz jejich nedostatek. Diferenci\u00e1ln\u00ed diagn\u00f3za<\/em>.<\/em> Globus hystericus se p\u0159i povrchn\u00edm pohledu m\u016f\u017ee podobat syndromu Plummerovu-Vinsonovu. Postihuje rovn\u011b\u017e \u017eeny, ale nejen v klimakteriu, a projevuje se st\u00e1l\u00fdm pocitem ciz\u00edho t\u011blesa (\u201ekoule\u201c) v krku, kter\u00fd v\u0161ak nijak nevad\u00ed p\u0159i polyk\u00e1n\u00ed. Nejde tedy o dysfagii. Jde o afekci psychogenn\u00ed, vyvolanou du\u0161evn\u00edm konfliktem nebo stressem.<\/span><\/p>\n D\u00e1le je t\u0159eba vylou\u010dit r\u016fzn\u00e9 nemoci \u00fast a hltanu, zp\u016fsobuj\u00edc\u00ed bukofarynge\u00e1ln\u00ed dysfagii, a druhotn\u00e9 poruchy \u00fastn\u00ed a hltanov\u00e9 sliznice p\u0159i zhoubn\u00fdch a syst\u00e9mov\u00fdch onemocn\u011bn\u00edch, kolagen\u00f3z\u00e1ch, avitamin\u00f3z\u00e1ch apod.<\/p>\n Diagnostick\u00fd postup.<\/em> Za\u010d\u00edn\u00e1 se inspec\u00ed \u00fastn\u00ed dutiny a hltanu, pop\u0159. odborn\u00fdm vy\u0161et\u0159en\u00edm stomatologick\u00fdm. N\u00e1sleduje rentgenov\u00e9 vy\u0161et\u0159en\u00ed j\u00edcnu (membr\u00e1na), vy\u0161et\u0159en\u00ed hematologick\u00e9 (an\u00e9mie, sideropenie) a o\u010dn\u00ed (keratokjunktivitida) (Schirmer\u016fv test), nezbytn\u00e9 je d\u00e1le vy\u0161et\u0159en\u00ed imunologick\u00e9. Fakultativn\u00ed je ezofagoskopie, vy\u0161et\u0159en\u00ed \u017ealude\u010dn\u00ed sekrece, revmatologick\u00e9, gynekologick\u00e9 a ko\u017en\u00ed vy\u0161et\u0159en\u00ed.<\/span><\/p>\n L\u00e9\u010dba.<\/em> Osv\u011bd\u010den\u00e9 jsou substitu\u010dn\u00ed l\u00e9ky: kyselina chlorovod\u00edkov\u00e1, \u017eelezo, vitaminy komplexu B, um\u011bl\u00e9 slzy obsahuj\u00edc\u00ed metylcelul\u00f3zu a polyvinylalkohol. P\u0159i t\u011b\u017e\u0161\u00edm posti\u017een\u00ed, zvl\u00e1\u0161t\u011b kloub\u016f, se pou\u017e\u00edvaj\u00ed steroidy, event. imunosupresiva, proti xerostomii prostigmin, p\u0159i bolesti slinn\u00fdch \u017el\u00e1z analgetika. Dysfagie se n\u011bkdy uprav\u00ed po dilataci j\u00edcnu \u010di diagnostick\u00e9 ezofagoskopii. V\u00fdznamn\u00e9 je l\u00e9\u010den\u00ed neuropatie.<\/span><\/p>\n Progn\u00f3za.<\/em> U epiteloxer\u00f3z je zv\u00fd\u0161en\u00e9 riziko karcinomu, a to nejen v oblasti or\u00e1ln\u00ed atrofick\u00e9 sliznice, n\u00fdbr\u017e i jinde v tr\u00e1vic\u00edm \u00fastroj\u00ed a jin\u00fdch org\u00e1nech. Rovn\u011b\u017e je zv\u00fd\u0161en v\u00fdskyt malign\u00edch lymfom\u016f. Tato sn\u00ed\u017een\u00e1 rezistence v\u016f\u010di zhoubn\u00e9mu bujen\u00ed je pravd\u011bpodobn\u011b podm\u00edn\u011bna imunologickou poruchou, patrnou v n\u011bkter\u00fdch p\u0159\u00edznac\u00edch i laboratorn\u00edch n\u00e1lezech.<\/span><\/p>\n Vznik\u00e1 nej\u010dast\u011bji v oblasti horn\u00edho \u00fast\u00ed j\u00edcnu n\u00e1sledkem permanentn\u00ed sondy, zalo\u017een\u00e9 pro ods\u00e1v\u00e1n\u00ed \u017ealude\u010dn\u00edho obsahu nebo pro enter\u00e1ln\u00ed v\u00fd\u017eivu. Mnoho z\u00e1le\u017e\u00ed na kvalit\u011b c\u00e9vky a zp\u016fsobu o\u0161et\u0159ov\u00e1n\u00ed. P\u0159i nevhodn\u00e9m tvrd\u00e9m materi\u00e1lu a nev\u0161\u00edmavosti person\u00e1lu m\u016f\u017ee vzniknout u\u017e po 24 hodin\u00e1ch.<\/p>\n Podobn\u00fd v\u0159ed vznik\u00e1 i v termin\u00e1ln\u00edm j\u00edcnu, av\u0161ak zde nen\u00ed p\u0159\u00ed\u010dinou ani tak otlak jako sp\u00ed\u0161e reflux \u017ealude\u010dn\u00edho obsahu kolem c\u00e9vky. V\u0159ed tohoto typu je \u010dast\u011bj\u0161\u00ed p\u0159i intermitentn\u00edm krmen\u00ed, naopak je vz\u00e1cn\u00fd p\u0159i tzv. plynul\u00e9 v\u00fd\u017eiv\u011b, p\u0159i n\u00ed\u017e se do \u017ealudku nebo do st\u0159eva nep\u0159etr\u017eit\u011b vkap\u00e1v\u00e1 nebo vh\u00e1n\u00ed pumpou v\u00fd\u017eivn\u00e1 suspenze. P\u0159i u\u017eit\u00ed modern\u00edch sond o mal\u00e9m pr\u016fm\u011bru je tato komplikace dnes vz\u00e1cn\u00e1.<\/p>\n Jin\u00e9 typy j\u00edcnov\u00fdch v\u0159ed\u016f v oblasti dla\u017edicov\u00e9ho epitelu byly sice v\u00fdjime\u010dn\u011b tak\u00e9 popisov\u00e1ny, ale pravd\u011bpodobn\u011b se b\u011b\u017en\u011b nevyskytuj\u00ed.<\/p>\n V\u0159edy v j\u00edcnu se vyskytuj\u00ed p\u0159i aktinomyk\u00f3ze (s tvorbou p\u00ed\u0161t\u011bl\u00ed), blastomyk\u00f3ze, leukemii, lymfogranulomu, vz\u00e1cn\u011b p\u0159i luetick\u00e9m gumatu, snad i p\u0159i tuberkol\u00f3ze, kter\u00e1 se sp\u00ed\u0161e kombinuje s aktinomyk\u00f3zou.<\/p>\n Pro \u00faplnost lze uv\u00e9st erozivn\u00ed a v\u0159edovit\u00e9 defekty p\u0159i ezofagitid\u011b 3. a 4. stupn\u011b. Tyto l\u00e9ze jsou mnohotn\u00e9. Problematick\u00e1 je ot\u00e1zka granulomat\u00f3zn\u00ed ezofagitidy, kterou n\u011bkte\u0159\u00ed pova\u017euj\u00ed za j\u00edcnovou lokalizaci Crohnovy nemoci. Zde rovn\u011b\u017e b\u00fdvaj\u00ed v\u0159edovit\u00e9 l\u00e9ze.<\/p>\n Jde o jednu nebo n\u011bkolik pod\u00e9ln\u00fdch trhlin pronikaj\u00edc\u00edch do podsliznice v m\u00edst\u011b ezofagogastrick\u00e9ho p\u0159echodu a zp\u016fsobuj\u00edc\u00edch akutn\u00ed kr v\u00e1cen\u00ed (syndrom Malloryho-Weiss\u016fv). Tento syndrom popsali Mallory a Weiss v roce 1929 jako n\u00e1sledek zvracen\u00ed po alkoholick\u00e9m excesu. Brzy se v\u0161ak uk\u00e1zalo, \u017ee m\u016f\u017ee vzniknout i p\u0159i zvracen\u00ed z jin\u00e9 p\u0159\u00ed\u010diny, a dokonce i v\u016fbec bez zvracen\u00ed. Patogenn\u00edm mechanizmem je zde asi n\u00e1hl\u00e9 rozep\u011bt\u00ed kardie, pop\u0159. dyskineze. N\u00e1sledkem natr\u017een\u00ed sliznice a submuk\u00f3zy dojde k profuzn\u00edmu krv\u00e1cen\u00ed z mohutn\u00fdch c\u00e9vn\u00edch pleten\u00ed a t\u00e9m\u011b\u0159 v\u017edy k hematemezi. Na rozd\u00edl od hematemeze p\u0159i krv\u00e1cen\u00ed ze \u017ealudku nebo dvan\u00e1ctn\u00edku b\u00fdv\u00e1 vyzvracen\u00e1 krev aspo\u0148 z\u010d\u00e1sti sra\u017een\u00e1, tj. nezm\u011bn\u011bn\u00e1 \u017ealude\u010dn\u00ed kyselinou. Tato l\u00e9ze je p\u0159\u00ed\u010dinou 5\u201310 % akutn\u00edch tr\u00e1vic\u00edch krv\u00e1cen\u00ed.<\/p>\n Diagnostika. P\u0159i typick\u00e9 anamn\u00e9ze lze ezofagogastrickou trhlinu d\u016fvodn\u011b p\u0159edpokl\u00e1dat, objev\u00ed-li se hematemeze popsan\u00e9ho typu po d\u00e9letrvaj\u00edc\u00edm zvracen\u00ed. Diagn\u00f3zu lze potvrdit jen endoskopicky, a to gastroskopi\u00ed, v\u010detn\u011b inverze. Trhlina se jev\u00ed jako<\/span> 5 mm a\u017e n\u011bkolik cm dlouh\u00fd defekt nasedaj\u00edc\u00ed na ezofagogastrick\u00fd p\u0159echod, n\u011bkdy p\u0159ev\u00e1\u017en\u011b na stran\u011b j\u00edcnu, jindy na stran\u011b \u017ealudku. V intrahemoragick\u00e9 f\u00e1zi se m\u00e1lokdy zastihne a defekt by tehdy ani nebyl viditeln\u00fd. V \u010dasn\u00e9 f\u00e1zi posthemoragick\u00e9 se jev\u00ed jako \u0161t\u011brbinov\u00fd defekt kryt\u00fd koagulem nebo fibrinem. Je \u010dasto skryt \u0159asami kardie a mus\u00ed se po n\u011bm c\u00edlen\u011b p\u00e1trat. \u010casto je trhlin v\u00edce. Rentgenov\u00e9 vy\u0161et\u0159en\u00ed u t\u00e9to l\u00e9ze selh\u00e1v\u00e1, ale pom\u016f\u017ee vylou\u010dit jin\u00fd zdroj krv\u00e1cen\u00ed.<\/p>\n L\u00e9\u010dba. T\u00e9m\u011b\u0159 v\u017edy se vysta\u010d\u00ed s l\u00e9\u010den\u00edm konzervativn\u00edm, podobn\u00fdm jako p\u0159i akutn\u00edm krv\u00e1cen\u00ed z jin\u00e9 p\u0159\u00ed\u010diny, pop\u0159. dopln\u011bn\u00fdm endoskopickou koagulac\u00ed. Zcela v\u00fdjime\u010dn\u011b je nutn\u00fd chirurgick\u00fd v\u00fdkon, tj. pro\u0161it\u00ed \u2013 opich trhliny z gastrotomie.<\/span><\/p>\n V\u011bt\u0161ina n\u00e1sleduj\u00edc\u00edch chorobn\u00fdch stav\u016f pat\u0159\u00ed mezi vz\u00e1cn\u011bj\u0161\u00ed onemocn\u011bn\u00ed j\u00edcnu, kter\u00e1 spadaj\u00ed sp\u00ed\u0161e do kompetence gastroenterologa [1, 2, 3, 4, 5]. V takto zam\u011b\u0159en\u00fdch publikac\u00edch je mo\u017eno nal\u00e9zt podrobn\u011bj\u0161\u00ed pou\u010den\u00ed a rozs\u00e1hlou literaturu o t\u011bchto stavech. Chirurg se s t\u011bmito chorobami setk\u00e1v\u00e1 p\u0159ev\u00e1\u017en\u011b jen v r\u00e1mci diferenci\u00e1ln\u011b diagnostick\u00fdch \u00favah. Membr\u00e1ny a prstence Jde o blanit\u00e9 \u00fatvary […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":80,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-858","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/858","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=858"}],"version-history":[{"count":11,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/858\/revisions"}],"predecessor-version":[{"id":3830,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/858\/revisions\/3830"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=858"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Epiteloxer\u00f3zy<\/h6>\n
Syndrom Plummer\u016fv-Vinson\u016fv (Kellyho-Patterson\u016fv)<\/h6>\n
Syndrom Sj\u00f6gren\u016fv<\/h6>\n
\nSialografie prok\u00e1\u017ee zm\u011bny na v\u00fdvodech slinn\u00fdch \u017el\u00e1z. Imunologick\u00e9 n\u00e1lezy jsou zn\u00e1my hlavn\u011b u syndromu Sj\u00f6grenova: Je p\u0159\u00edtomna polyklon\u00e1ln\u00ed gamapatie IgM, nespecifick\u00e9 a specifick\u00e9 org\u00e1nov\u00e9 protil\u00e1tky. Nej\u010dast\u011bj\u0161\u00ed je pozitivita revmatoidn\u00edch faktor\u016f a antinukle\u00e1rn\u00edch protil\u00e1tek. Pro prim\u00e1rn\u00ed Sj\u00f6gren\u016fv syndrom jsou specifick\u00e9 autoprotil\u00e1tky proti nukleoprotein\u016fm SS-Ba, SS-A (tzv. extrahovateln\u00e9 nukle\u00e1rn\u00ed antigeny).<\/p>\nV\u0159edovit\u00e9 poruchy j\u00edcnu<\/h5>\n
Dekubit\u00e1ln\u00ed (otlakov\u00fd) v\u0159ed<\/h6>\n
Specifick\u00e9 v\u0159edy<\/h6>\n
V\u0159edovit\u00e9 l\u00e9ze p\u0159i z\u00e1n\u011btu<\/h6>\n
Ezofagogastrick\u00e1 trhlina<\/h6>\n
Literatura<\/h3>\n
\n