Aia kekahi ʻūpā koko i loko o kou aʻa koko ʻōpū? E makaʻala kākou i kēia kūlana weliweli (SMV Thrombosis)!

Ua loaʻa koke anei iā ʻoe kahi ʻeha nui i loko o kou ʻōpū, a i ʻole kahi manaʻo ʻē e like me ka piha ʻana o kou ʻōpū? I kekahi manawa ʻaʻole mākou e nānā nui i kēlā mau mea, akā hiki iā lākou ke lilo i hōʻailona o kahi pilikia olakino koʻikoʻi. I kēia lā e kamaʻilio mākou e pili ana i kahi maʻi kakaikahi akā weliweli loa. ʻO ia hoʻi (SMV Thrombosis) , a i ʻole he ʻōpū koko ma ka aʻa mesenteric kiʻekiʻe.

He aha kēia (SMV Thrombosis)? E hoʻomaopopo maʻalahi kākou?

I ka ʻōlelo maʻalahi, ʻo SMV Thrombosis ka hoʻokumu ʻia ʻana o kahi clot koko (thrombus) i loko o kahi aʻa koko i kapa ʻia ʻo Superior Mesenteric Vein (SMV) i loko o kou ʻōpū. Lawe kēia aʻa koko i ke koko mai kou ʻōpū liʻiliʻi i kou ake. E like me ka paipu wai i paʻa, pale kēia clot koko i ke kahe o ke koko ma waena o nā ʻano kino like ʻole i loko o kou ʻōpū.

Penei ka weliweli o kēia kūlana: Ke hana pono ʻole ke kahe koko, ʻaʻole loaʻa i ko kākou mau kino ka oxygen e pono ai. A laila hoʻomaka nā cell (nā ʻiʻo) i loko o kēlā mau kino e make. Hiki i kēia ʻano hōʻino kino ke hoʻopilikia i ke kino holoʻokoʻa. Inā ʻaʻole mālama koke ʻia kēia kūlana, i kapa ʻia ʻo SMV Thrombosis, hiki i kekahi manawa ke hoʻoweliweli i ke ola.

ʻO kekahi inoa no kēia ʻo "mesenteric venous thrombosis." He inoa maʻamau kēia. ʻO ia hoʻi, hiki ke hana ʻia kahi ʻaʻa koko i loko o ka vein mesenteric kiʻekiʻe, ka vein mesenteric haʻahaʻa, a i ʻole nā ​​​​aʻa koko e lālā ana mai ia mea. Eia nō naʻe, ma kahi o 95% o ka manawa, hana ʻia kēia ʻaʻa koko i loko o ka vein mesenteric kiʻekiʻe, a mākou i ʻōlelo ai ma mua. No laila, hoʻohana pinepine ʻia nā inoa ʻelua no ke kūlana like.

He aha nā ʻano nui o ka Mesenteric Venous Thrombosis?

Hoʻokaʻawale nā ​​​​kauka i kēia kūlana ma muli o ke ʻano o ka puka ʻana o nā hōʻailona.

• ʻOi loa: ʻIke koke ʻia nā hōʻailona, ​​​​i loko o 24 a 72 mau hola o ke kūkulu ʻia ʻana o ke koko. ʻO kēia ka mea maʻamau (60% - 80%) o nā hihia. I kēia hihia, hiki ke hōʻino koke ʻia nā ʻōpū, no ka mea, ʻaʻohe ala o ke koko e hiki ai iā lākou, ke ālai nei ke koko i kēlā ala.
• Subacute: I kēia hihia, ulu mālie nā hōʻailona i kekahi mau lā. ʻAʻole lākou i koʻikoʻi e like me ke kahua koʻikoʻi. Maanei, komo kekahi koko i loko o nā ʻōpū, akā ʻaʻole lawa ka nui. ʻAʻole paha e ʻike kekahi poʻe i ke kauka a hiki i ʻelua pule ʻoiai he mau hōʻailona ko lākou.
• Ke kūlana mau loa: I kekahi manawa ʻaʻohe hōʻailona. ʻO kēia no ka mea ua hana ʻia nā kīʻaha koko liʻiliʻi, e hoʻolako ana i nā ʻōpū me ke koko. ʻIke pinepine nā kauka i kēia mau kūlana mau loa i ka wā o nā hoʻokolohua kiʻi no kekahi kūlana ʻē aʻe. Loaʻa kēia kūlana mau loa ma kahi o 20% a 40% o nā hihia.

Pehea ka maʻamau o kēia ʻano?

Ua manaʻo ʻia kēia he maʻi laha ʻole . Loaʻa ia ma kahi o hoʻokahi i loko o 5,000 a i hoʻokahi i loko o 15,000 mau maʻi i hoʻokipa ʻia ma ka haukapila.

ʻO ka thrombosis venous mesentericʻOiai hiki ke ulu aʻe i kēlā me kēia makahiki, hoʻopilikia pinepine ia i nā poʻe ma waena o 40-50 mau makahiki.

He aha nā hōʻailona o kēia?

Hiki ke ʻokoʻa loa nā hōʻailona. ʻO kekahi poʻe, ʻoi aku ka poʻe me nā maʻi maʻi mau loa, ʻaʻohe o lākou hōʻailona iki. Eia nō naʻe, i nā kūlana koʻikoʻi, hiki ke loaʻa koke ka ʻūlū nui . I nā kūlana subacute, hiki i ka ʻeha o ka ʻōpū ke hele mai a hala i kekahi mau lā a i ʻole nā ​​pule.

Loaʻa i kekahi poʻe kahi maʻi i kapa ʻia ʻo Portal Hypertension ma muli o kēia maʻi. A laila e ʻike paha ʻoe i nā hōʻailona e like me:

• Ke koko i loko o kou noho.
• Ka luaʻi a me ka luaʻi ʻana, i kekahi manawa me ke koko i loko o ka luaʻi.
• ʻŌpū pehu.
• Ka pehu ʻana o nā wāwae a me nā ʻūhā (Edema) .
• Ka huikau o ka noʻonoʻo.

Inā loaʻa iā ʻoe ka ʻeha ʻōpū hou a i ʻole ka ʻeha ʻana o ka ʻōpū, pono ʻoe e ʻike koke i ke kauka . A laila hiki ke hoʻoholo ʻia ke kumu pololei.

He aha nā kumu o (Superior Mesenteric Vein Thrombosis)?

Ua hoʻokaʻawale nā ​​kānaka noiʻi i nā kumu o kēia i ʻekolu mau ʻāpana nui:

1. Ka hōʻino pololei ʻana i ke aʻa: Hiki ke hōʻino pololei ʻia kou aʻa ma muli o kahi maʻi (muhū) a i ʻole ke ʻoki kino.

2. Kahe koko lohi a ālai ʻia paha: ʻO nā kūlana e like me ka cirrhosis (maʻi akepaʻa), ka hāʻule ʻana o ka puʻuwai, a i ʻole kahi puʻupuʻu a puʻupuʻu paha i loko o ka ʻōpū hiki ke hana i ke kahe koko lohi a ālai ʻia paha i loko o ke aʻa mesenteric a me nā aʻa e pili ana.

3. Nā maʻi kāpili koko: Hoʻonui kēia i ka pilikia o ke kāpili koko ma nā wahi āpau o kou kino.

I kekahi manawa, ʻaʻole hiki i nā kauka ke loaʻa kahi kumu kikoʻī no kēia (idiopathic) .

ʻO wai ka mea i pilikia nui i kēia maʻi?

Aia ʻoe i ka pilikia nui o ka hoʻomohala ʻana i ka SMV Thrombosis inā loaʻa iā ʻoe kekahi o nā kūlana olakino ma lalo nei:

• Nā maʻi ʻeha koko e kū mai ana i ka wā hānau a ma hope paha, me nā mea i hoʻokumu ʻia e kekahi mau lāʻau lapaʻau.
• (Maʻi ʻōpū mumū - IBD) .
• (Cirrhosis) (maʻi akepaʻa).
• (Pancreatitis) (ka mumū o ka pancreas).
• Ka maʻi ʻaʻai pancreatic .
• Ka hāʻule ʻana o ka puʻuwai .
• ʻŌpū nui .
• Loaʻa kahi puʻupuʻu nui a puʻu paha i loko o ka ʻōpū.
• ʻO kekahi mau maʻi viral, me (COVID-19) .

ʻO kekahi mau ʻoki ma kou ʻōpū, e like me ka splenectomy, hiki ke hōʻino i ka uhi o loko o kou mau kīʻaha koko (endothelium).Hiki ke hōʻino ʻia. ʻO ka mumū i hana ʻia e kēia hōʻino e hoʻonui i ka pilikia o ke kūkulu ʻia ʻana o ke koko.

He aha nā pilikia e hiki mai ana o ka SMV Thrombosis?

Ke hana ʻia kahi ʻūpā koko i loko o kou mau aa mesenteric, hiki iā ia ke hoʻoulu i ka pehu ʻana i loko o ka ʻiʻo ʻōpū. Hiki iā ia ke alakaʻi i kahi kūlana i kapa ʻia ʻo mesenteric ischemia , ʻo ia hoʻi ka emi ʻana o ke kahe koko i nā ʻāpana o kāu ʻōnaehana hoʻoheheʻe.

Ke loaʻa ʻole i kāu mau ʻōkana ʻai ka nui o ke koko i hoʻopiha ʻia me ka oxygen, ʻaʻole hiki iā lākou ke hana pono. A hoʻomaka ko lākou mau ʻiʻo e make. I kekahi mau hihia, hiki i kēia ke hana i nā lua i loko o nā ʻōpū, e ʻae ana i nā mea o loko o nā ʻōpū e komo i loko o ka hakahaka a puni. I nā hihia ʻē aʻe, hiki i nā bacteria e noho maʻamau ana i loko o kāu ʻōnaehana ʻai ke laha i nā ʻāpana ʻē aʻe o kou kino, kahi i pono ʻole ai lākou. Hiki i kēia ke alakaʻi i ka sepsis (ka lāʻau make koko) a me ka hāʻule ʻana o nā ʻōkana e hoʻoweliweli i ke ola.

No laila, ʻo kēia maʻi i kapa ʻia ʻo (SMV Thrombosis) hiki ke make inā ʻaʻole mālama koke ʻia.

Pehea e ʻike ʻia ai ka Mesenteric Venous Thrombosis?

Hiki i nā kauka ke kānalua i kēia kūlana ma muli o kāu mau hōʻailona. Eia nō naʻe, hiki ke paʻakikī ka ʻike ʻana iā ia no ka mea he nui nā hōʻailona i kikoʻī ʻole . ʻO ia hoʻi, hiki ke hana ʻia e nā ʻano kūlana ʻē aʻe like ʻole. Ke loaʻa iā ʻoe ka ʻeha o ka ʻōpū a i ʻole nā ​​hōʻailona ʻē aʻe, ʻaʻole ʻo ka ʻōpū koko i loko o ka aʻa mesenteric ka mea mua e hiki mai ana i ka noʻonoʻo.

Inā kānalua kāu kauka he ʻūpā koko kou, e hana lākou i kekahi mau hoʻokolohua kiʻi .

Nā Hoʻāʻo Diagnostic (Mesenteric Venous Thrombosis)

ʻO ke ʻano hoʻāʻo maʻamau gula no ka ʻike ʻana i kēia maʻi ʻo CT Angiography . Ma kēia scan, ua hoʻokomo ʻia kahi waihoʻoluʻu kūikawā i loko o kahi aʻa a ʻike ʻia ke koko e kahe ana ma o kou mau aʻa. Hiki i kēia ke hōʻike i ke ʻano o ke kahe ʻana o ke koko ma o nā aʻa a me nā aʻa i loko o kou ʻōpū a inā he ʻūpā koko. Na nā hopena o kēia hoʻāʻo e hoʻoholo i kāu hoʻolālā lapaʻau.

I kekahi manawa, hoʻohana nā kauka i kahi hoʻāʻo i kapa ʻia ʻo MRI Angiography ma ke ʻano he koho ʻē aʻe a i ʻole e hōʻoia i nā hopena maopopo ʻole mai CT Angiography . Hiki ke hoʻohana ʻia kēia mau hoʻāʻo e ʻike pehea ʻoe e pane nei i ka lāʻau lapaʻau.

He aha nā lāʻau lapaʻau no (SMV Thrombosis)?

E hoʻopilikino nā kauka i kāu hoʻolālā lapaʻau i kāu mau pono. ʻO nā pahuhopu nui:

• Hoʻihoʻi i ke kahe o ke koko i kou mau ʻōpū a kōkua iā lākou e hana maʻamau.
• Kāohi a kaupalena paha i ka hōʻino ʻana i kou ʻōpū.
• Ke kāohi nei i ke kūkulu ʻana o nā ʻōpū koko hou a me ka ʻike ʻana i ke kumu.

ʻO ka mālama wikiwiki ke kī i ka hoʻopakele ʻana i nā ola.ʻO ka wikiwiki o ka loaʻa ʻana o ka lāʻau lapaʻau, ʻoi aku ka maikaʻi o kou kūlana o ka hopena holomua. Ma muli o ke ʻano o kou kūlana (ʻoi a maʻi paha) a me kona koʻikoʻi, hiki i kāu kauka ke hoʻohana i hoʻokahi a ʻoi aku paha o kēia mau lāʻau lapaʻau:

• ʻO ka Anticoagulation: ʻO kēia ka lāʻau lapaʻau mua a nā kauka e hoʻohana ai. Pili kēia i ka hāʻawi ʻana iā ʻoe i ka lāʻau lapaʻau e kōkua i ka hoʻoheheʻe ʻana i ke koko a pale i nā koko hou mai ka hoʻokumu ʻana. Hoʻomaka ka nui o nā kauka ma ka hāʻawi ʻana iā ʻoe i kahi lāʻau i kapa ʻia ʻo heparin intravenously, a laila e hoʻohana i kahi lāʻau lapaʻau e like me warfarin . Pono kekahi poʻe e lawe i kēia lāʻau lapaʻau no kahi o ʻeono mahina, aʻo kekahi poʻe e pono paha e lawe lōʻihi. Inā he maʻi koko ʻoe, a inā he koko ʻoe no ke kumu ʻole, pono paha ʻoe e lawe i kēia lāʻau lapaʻau no ke koena o kou ola.
• Thrombolysis: Ma kēia kaʻina hana, hoʻohana kāu kauka i kahi catheter e hoʻokomo i ka lāʻau lapaʻau i loko o kou mau aa e hoʻoheheʻe i ke clot . Hāʻawi pinepine ʻia kēia lāʻau lapaʻau no 24 a 72 mau hola.
• Thrombectomy: He hana ʻoki kēia e wehe ai i kahi ʻūpā koko . Hoʻohana wale ʻia kēia lāʻau lapaʻau i nā hihia palena wale nō, no ka laʻana , i ka poʻe ʻaʻole hiki ke loaʻa ka thrombolysis . Hiki i nā kauka ke hana i kēia kaʻina hana me ka hoʻohana ʻana i ke ʻoki hāmama a i ʻole nā ​​​​​​ʻano minimally invasive.
• ʻO ka ʻoki ʻana i ka ʻōpū: Pili kēia i ka wehe ʻana i kahi ʻāpana o kou ʻōpū ma ke ʻoki ʻana . Inā ua ālai ke koko i ke kahe koko i kou ʻōpū a ua hōʻino mau loa, pono paha ʻoe e hana i kahi ʻoki ʻana i ka ʻōpū liʻiliʻi a i ʻole kahi colectomy ʻōpū nui. Inā hoʻomaka ʻoe i ka anticoagulation ma ka haukapila, e nānā kāu kauka i kāu mau hōʻailona e ʻike inā pono ʻoe i ke ʻoki ʻana a i ʻole inā he mau pilikia.

Nā pilikia o ka mālama ʻana

ʻO ka pilikia maʻamau o ka mālama ʻana, ʻo ia ke kahe ʻana o ke koko (nui a liʻiliʻi paha). Eia nō naʻe, he mea nui e hoʻomanaʻo he make kēia maʻi inā ʻaʻole mālama ʻia . No laila, ʻoi aku ka nui o nā pono o ka mālama ʻana ma mua o nā pilikia o nā pilikia hiki ke loaʻa.

Hiki ke pale ʻia ka SMV Thrombosis?

ʻAʻole hiki iā ʻoe ke pale mau i nā ʻūpā koko. Eia nō naʻe, hiki iā ʻoe ke lawe i kahi ala proactive i kou olakino ma ka pale ʻana a me ka mālama ʻana i nā kūlana kumu he nui e hoʻonui ai i kou pilikia. Eia kekahi mau ʻōlelo aʻoaʻo:

• E hele i kahi hoʻokolohua lapaʻau i hoʻokahi manawa i ka makahiki.
• E lawe i kāu lāʻau lapaʻau e like me ke kauoha a kāu kauka.
• E haʻi i kāu kauka inā loaʻa iā ʻoe nā hōʻailona hou a inā paha e loli kāu mau hōʻailona.
• E nīnau i kāu kauka i nā hoʻololi o ke ʻano o kou nohona e pono ai ʻoe e hana e pono ai kou olakino.

He aha ka mea e hana inā loaʻa iaʻu (SMV Thrombosis)?

E haʻi aku kāu kauka iā ʻoe i ka mea e manaʻo ai i kou wā e mālama ai a hoʻōla. E wehewehe lākou i ka pilikia o ka hoʻomohala ʻana i nā ʻōpū koko hou a me nā lāʻau lapaʻau a lākou e ʻōlelo ai e hōʻemi i kēlā pilikia. He mea nui loa ia e hahai pololei i ka hoʻolālā lapaʻau a kāu kauka. Hiki i kēia ke komo pū me ka lawe ʻana i ka lāʻau lapaʻau no ke koena o kou ola. E kōkua kēia i ka pale ʻana i ka hoʻokumu hou ʻana o nā ʻōpū koko.

Ka nānā ʻana i ka pane i ka lāʻau lapaʻau

Inā ʻoe e lawe ana i ka lāʻau anticoagulant, pono ʻoe e loaʻa i nā hoʻāʻo koko maʻamau e hōʻoia i ka lawe ʻana i ka nui kūpono o ka lāʻau. E nānā pū kāu kauka iā ʻoe no kekahi kahe koko.

He aha ka nānā ʻana no kēia kūlana?

ʻO ke kanaka maikaʻi loa e nīnau e pili ana i kou ʻano, ʻo ia kāu kauka. E nānā lākou i kou mōʻaukala olakino a me ke kūlana a hāʻawi iā ʻoe i kahi manaʻo o ka mea e manaʻo ai. Ma keʻano laulā, ʻo kou ʻano me ka Mesenteric Venous Thrombosis e pili ana i kekahi mau kumu:

• kou mau makahiki.
• Ke koʻikoʻi o kou kūlana.
• ʻO kahi kikoʻī o ke koko.
• Nā pilikia olakino ʻē aʻe āu.
• ʻO ka nui o ka pōʻino i kou ʻōpū.
• Inā paha e pono e wehe ʻia kahi ʻāpana o kou ʻōpū.
• Pehea ka wikiwiki o kou loaʻa ʻana o ka lāʻau lapaʻau.

Hiki ke make ka Mesenteric Venous Thrombosis . I ke kahua koʻikoʻi, piʻi ka pilikia o ka make me kēlā me kēia hola e hala ana ma hope o ka hoʻomaka ʻana o nā hōʻailona. Inā ʻaʻole mālama ʻia no nā hola he 24 a ʻoi, he make pinepine ke ʻano.

Āhea wau e ʻike ai i kaʻu kauka?

I kou ho'ōla ʻana mai ka lāʻau lapaʻau, he mea nui e mālama i kou manaʻo a e haʻi i kāu kauka inā he loli kekahi mea. E haʻi aku kāu kauka iā ʻoe i ka pinepine o kou hele ʻana mai no nā manawa hoʻopaʻa. E mālama iā lākou i ka manawa. E kōkua kēia i kāu kauka e nānā i kou kūlana a ʻike i nā pilikia hou (e like me ke koko hou). Eia naʻe, ʻoiai i ka wā o kāu lāʻau lapaʻau, inā loaʻa iā ʻoe kekahi mau hōʻailona hou a i ʻole he hopohopo paha, mai kānalua e kāhea koke i kāu kauka.

Āhea wau e hele ai i ka ʻOihana Pōpilikia (ETU) ?

Inā loaʻa iā ʻoe ka ʻeha nui o ka ʻōpū a i ʻole nā ​​hōʻailona ʻē aʻe o (SMV Thrombosis) , e kelepona koke i ka 911 a i ʻole kāu helu ulia pōpilikia kūloko. Mai hoʻokaʻulua. He mea nui loa kēia inā he mau kumu pilikia kou no (SMV Thrombosis) . ʻO ka mālama mua ʻana ke ala wale nō e hoʻopakele ai i ke ola.

He aha nā nīnau e pono iaʻu e nīnau aku i kaʻu kauka?

Hiki ke ʻokoʻa kāu mau nīnau ma muli o kou kūlana a me ke kahua o ka mālama ʻana. Eia kekahi mau nīnau maʻamau e kōkua iā ʻoe e loaʻa ka ʻike āu e pono ai. Hiki iā ʻoe ke nīnau i kēia mau nīnau ma hope o kou ʻike ʻia ʻana (a i ʻole no kahi mea aloha):

• Pehea ke koʻikoʻi o koʻu kūlana?
• He aha ka lāʻau lapaʻau āu e hoʻāʻo mua ai?
• He aha nā lāʻau lapaʻau ʻē aʻe e pono ai iaʻu?
• He aha nā pahuhopu o ka mālama ʻana?
• He aha nā kūlana o ka holomua ʻana o ka lāʻau lapaʻau?
• Aia kekahi mau pilikia i ka lāʻau lapaʻau?
• Pehea koʻu manaʻo?
• He aha nā hālāwai hoʻi e pono ai iaʻu ke hele?
• Pono anei au e hoʻololi i kaʻu mau lāʻau lapaʻau a i ʻole nā ​​manawa aʻu e lawe ai iā lākou?
• He aha nā hoʻololi o ke ʻano o ka nohona āu e ʻōlelo nei iaʻu e hana ma hope o koʻu hoʻōla ʻana?

He mea maʻamau ke makaʻu i ka wā e ʻike ai ʻoe he ʻūpā koko kou ma kekahi wahi o kou kino. I ke kūlana e like me SMV Thrombosis , hiki i kēlā ʻūpā koko ke hoʻoweliweli i ke olakino o kou ʻōpū, a hiki ke hana i nā pilikia e hoʻoweliweli ai i ke ola.

Inā he mau kumu pilikia kou a i ʻole kahi mea aloha no ka hoʻomohala ʻana i ka SMV Thrombosis , e kamaʻilio me kāu kauka e pili ana i kou pae pilikia pilikino a pehea e hoʻokele ai. ʻAʻole hiki iā ʻoe ke pale mau i nā ʻōpū koko. Akā, ʻo ka loaʻa ʻana o nā nānā lapaʻau a me ka ʻike ʻana i nā hōʻailona hiki ke kōkua iā ʻoe e loaʻa kahi hōʻailona a me ka mālama ʻana i ka wā mua. Hiki i kēlā hana mua ke hoʻopakele i ke ola.

Nā mea nui a mākou e hoʻomanaʻo ai (Leka Lawe-Home)

• ʻO ka (SMV Thrombosis) he ʻūpā koko i loko o kahi kīʻaha koko nui i loko o ka ʻōpū. He mea koʻikoʻi loa kēia a hiki ke hoʻoweliweli i ke ola inā ʻaʻole mālama koke ʻia.
• Inā ʻike ʻoe i nā hōʻailona e like me ka ʻeha ʻōpū nui koke, ka pehu ʻana, ka nausea, ka luaʻi ʻana, a i ʻole ke koko i loko o kou ʻōpala, mai hoʻokaʻulua. E ʻimi koke i ke kōkua lapaʻau.
• Inā he mau kumu pilikia kou no kēia (e like me nā maʻi ʻaʻai koko, maʻi akepaʻa, maʻi mumū ʻōpū), e kamaʻilio me kāu kauka e pili ana i ia mea a hana i nā hana e pono ai.
• Inā ua ʻike ʻia ʻoe ua loaʻa iā ʻoe ka maʻi, e hahai pono i ka lāʻau a kāu kauka e hāʻawi ai iā ʻoe. ʻOiai inā pono ʻoe e lawe i ka lāʻau lapaʻau no ke koena o kou ola, hiki iā ia ke kōkua i ka hoʻopakele ʻana i kou ola.
• ʻO ka ʻike mua ʻana a me ka mālama koke ʻana ke ala maikaʻi loa e pale aku ai i kēia maʻi. No laila e makaʻala i nā hōʻailona a e ʻike koke i ke kauka inā he kānalua kāu.

ʻO ka Thrombosis SMV, ka Thrombosis Venous Mesenteric, ka ʻūpē koko, ka ʻeha o ka ʻōpū, ka aʻa mesenteric kiʻekiʻe, ka ʻōnaehana hoʻoheheʻe, ka mālama ʻana i ka pilikia