Signs of intestinal obstruction on x-ray. Kloiber cup during x-ray examination of the abdominal cavity

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Description of intestinal diseases using radiological syndromes. Congenital and acquired intestinal anomalies

There are a large number of intestinal diseases. To simplify their description, radiologists have compiled a limited number of radiological syndromes. Thanks to this, the description of the pictures x-ray it becomes much more convenient. Today, almost all diseases are described by five radiological symptoms or their combination. This approach is generally accepted by doctors of various specialties.

Intestinal abnormalities can be either congenital or acquired. This group of conditions can be asymptomatic throughout life, but more often leads to various complications, including inflammation and intestinal obstruction. Detection of anomalies and their treatment is possible only after X-ray of the intestine.

X-ray syndromes of intestinal diseases

Pathological processes in the intestines are described in conclusion by a number of radiological syndromes. They are highlighted in order to objectively describe the phenomenon that is observed on an x-ray.
The number of radiological syndromes is less than the number of diseases, so diagnosis requires a comprehensive assessment of the radiological picture and clinical examination data.

When describing the results of the study, the following radiological syndromes of intestinal diseases are used:

• Dislocation ( bias) intestines. Observed in case of individual features of the intestinal structure, hernias, pathological processes in neighboring organs.
• Occurs with ulcerative defects ( "niche" symptom), with polyps and granulomas ( filling defects), benign and malignant tumors of the intestinal wall.
• Intestinal dilatation. Dilatation of the intestine is observed in the section located in front of the narrowed area. Local expansion can also be a diverticulum - an abnormality in the structure of the intestine, in which a blind saccular formation is observed next to the wall.
• Narrowing of the intestines. The narrowing is caused by scarring and tumor processes.
• Intestinal dysfunction. Intestinal motor function is assessed using a barium passage. Its violation is an acceleration or slowdown in the cleansing of the intestines from barium mass.

The ability to detect some of these syndromes depends on the X-ray technique used. In many diseases, a combination of several of the listed radiological syndromes is observed. The conclusion also indicates the location of the disorders and the presumptive diagnosis.

X-ray picture of congenital anomalies of the position and shape of the intestine

There are a large number of intestinal abnormalities that a child can develop as a result of disorders at the embryonic stage of development. Some of them are asymptomatic throughout life, while others require urgent assistance in the first days of the child’s life. Diagnosis of the intestinal condition of newborns and infants is carried out using ultrasound ( Ultrasound) or computed tomography ( CT), since the use of a contrast agent is difficult for them.

In adults, the best method for diagnosing abnormalities is an x-ray using a barium mass. Anomalies in adults are usually detected when inflammatory complications associated with the unusual position of the intestine appear. The x-ray nature of the anomaly is strictly individual, and a large number of variants are also noted.

The following main anomalies of the position and shape of the intestine are distinguished:

• Movable duodenum. It is an elongation of the initial section of the small intestine. In this case, on the x-ray, the horizontal part of the duodenum is expanded, sagging, the contrast mass is retained in it, and signs of duodenitis are also detected. The mucous membrane and folds are thickened, and slight shading is detected around this section.
• Mobile cecum. This anomaly lies in the fact that the cecum lengthens and descends into the small pelvis, located next to the rectum. This anomaly is important in the diagnosis of appendicitis. As you know, the vermiform appendix is ​​located on the posterior surface of the cecum.
• Dolichosigma. With this anomaly, the sigmoid colon lengthens and acquires additional loops.
• Agangliosis ( Hirschsprung's disease). This anomaly is caused by a violation of the innervation of the large intestine, in which part of the rectum is in a constantly narrowed state. For this reason, the patient suffers from constipation. An x-ray image reveals unevenness of the rectal lumen and weakening of the peristaltic wave in the rectum.

Acquired bowel prolapse ( colonoptosis, enteroptosis

Intestinal prolapse is a condition in which the intestine occupies an abnormally low position, even moving into the pelvis. The term "colonoptosis" refers to the large intestine, and "enteroptosis" refers to the small intestine. This condition disrupts the ability of blood circulation, muscle contraction of the intestinal wall, and can lead to hemorrhoids and a host of unpleasant conditions. Intestinal prolapse causes intestinal pain, bloating, and in severe cases, rectal bleeding.

Intestinal prolapse occurs due to the following factors:

• the main factor is the weakness of the connective tissue and ligaments that support the intestines in the correct position;
• displacement and stretching of these structures cause excessive physical exercise, which is typical for athletes and people of physical labor;
• weakness of abdominal wall muscle tone plays a secondary role in intestinal prolapse.

This pathology is detected through a thorough examination using x-ray methods. Position small intestine assessed by oral x-ray ( through the mouth) contrast agent, and the position of the colon is determined using irrigoscopy. An x-ray reveals a low position of the intestine, a lack of tension and sagging of its sections. The passage of the peristaltic wave is often slow. Sometimes when intestinal prolapse occurs, inflammation of the tissues surrounding the intestines occurs. In this case, the tissue density around the outer contour of the intestine is increased due to inflammatory edema.

Treatment of this condition occurs by following a diet and performing exercises that strengthen the muscles of the abdominal wall. During treatment, the intestines return completely or partially to normal. The disappearance of clinical signs of the disease is confirmed by an x-ray by the return of the intestines to a physiological position.

Intestinal dilatations ( diverticula). X-ray picture

An intestinal diverticulum is an abnormality of the wall in which it protrudes into a pouch-like cavity. The diverticulum communicates with the intestinal lumen, so food can be retained in it. This could potentially lead to inflammation ( diverticulitis). Diverticula can be congenital or acquired; in most cases, they do not pose a threat to health and do not require treatment.

Radiological signs of a diverticulum are:

• additional shadow next to the bowel outline ( filling the diverticulum with barium mass);
• the shadow has a rounded shape and clear, even contours;
• The diverticulum cavity is connected to the intestine by a thin isthmus.

When a diverticulum becomes inflamed, x-rays reveal the following signs:

• increase in size;
• change in shape and blurred contours;
• detection of a horizontal fluid level in the diverticulum ( mucus), as well as a small amount of gas, along with a contrast mass ( so-called three-layer view);
• delay of contrast mass on long term (12 hours or more).

The most common anomaly of the gastrointestinal tract is Meckel's diverticulum. It is a protrusion in the final section of the small intestine, 5 to 7 centimeters long, in place of the embryonic vitelline duct. It can be associated with various complications - inflammation, perforation, as well as intestinal obstruction if it compresses the intestinal wall.

Diagnosis of intestinal stenosis using x-ray methods

Intestinal stenosis is an abnormal condition of the intestine in which the lumen of the intestine is significantly reduced compared to the normal state. Stenosis can be congenital or acquired. Congenital stenosis is most often detected in childhood and is caused by embryonic disorders. Acquired stenosis is associated with various diseases of the gastrointestinal tract.

Intestinal stenosis occurs in the following pathological conditions:

• spasm;
• ulcerative colitis and Crohn's disease;
• scar deformities intestines after burns, operations, injuries;

Intestinal stenosis can be corrected or prevented in most cases by treating the underlying intestinal disease. However, it is almost impossible to cure in case of cicatricial deformities of the intestine. They appear at the site of injury or chronic inflammation (for Crohn's disease, ulcerative colitis) and represent the replacement of damaged mucous membrane with connective tissue. There is a need to distinguish cicatricial deformities of the intestine on an x-ray from tumor processes, since the approach to the treatment of these processes is significantly different.

Cicatricial deformities differ on X-ray from tumor stenoses by the following characteristics:

• large length of the narrowed section;
• the transition to unchanged tissue is gradual, not abrupt;
• peristalsis is weakened, but not absent;
• the folds of the mucous membrane are preserved, but their number decreases;
• the narrowed section of the intestine is easily displaced by pressure on the anterior abdominal wall.

Narrowing ( stenosis) intestines causes the risk of mechanical intestinal obstruction. X-ray examination for narrowing of the intestine is very effective and in most cases allows you to accurately determine the cause of this condition. Depending on the cause and degree of narrowing of the intestine, determined using an x-ray method, doctors choose a method of treating this condition.

Acute bowel conditions ( acute stomach). Diagnosis using X-ray

The term “acute abdomen” refers to a large number of conditions in which the patient requires urgent assistance due to organ damage abdominal cavity. Intestinal lesions are one of the main causes of this condition. Diagnosis of such conditions must be carried out as quickly as possible, therefore the x-ray method is one of the best in such a situation.

Acute bowel conditions include the following:

• intestinal trauma;
• penetration of foreign bodies;
• release of free gas and liquid into the abdominal cavity;
• appendicitis;
• intestinal obstruction;
• volvulus;
• circulatory disorders in the vessels of the intestinal mesentery.

Diagnosis of the condition of the intestine using X-ray methods can be carried out both with and without the use of a contrast agent. In acute conditions, to save time, a survey x-ray of the abdominal cavity is often performed, which clearly shows signs of various intestinal lesions ( gas or liquid in the abdominal cavity or intestinal lumen).

Intestinal obstruction on plain x-ray

Intestinal obstruction is a condition in which the movement of intestinal contents through the digestive tract is partially or completely stopped. This condition may be caused by external pressure ( tumors, adhesions, anomalies of neighboring organs) or changes within the intestinal wall. There is also separate species dynamic obstruction, in which there is no movement through the intestines due to the cessation of peristalsis.

Intestinal obstruction is diagnosed using a plain X-ray without the use of barium mass. The main radiological symptom is Kloiber's cups - the presence of horizontal levels of fluid in the intestinal loops, above which gas is located in the form of inverted cups. The use of a contrast agent is only possible if a diagnosis of partial rather than complete intestinal obstruction is suspected.

Obstruction in the small intestine is characterized by the following picture:

• pathological formations are located in the center of the abdominal cavity;
• the width of Kloiber's cups exceeds their height, as the small intestine is stretched;
• loops of intestine filled only with gas ( without liquid) create the appearance of “arches”.

Obstruction in the large intestine has the following signs on x-ray:

• pathological formations are located at the edges of the abdominal cavity;
• the height of Kloiber's cups prevails over their diameter, since the wall of the large intestine is less extensible than the wall of the small intestine;
• along the contour of the dilated large intestine ( 7 – 8 cm) haustral retractions can be detected.

Intestinal obstruction is dangerous because as a result of this disease necrosis of the intestinal wall and peritonitis may occur in the most short time. That is why, if this disease is suspected, X-ray diagnostics and prompt assistance to the patient.

Intestinal volvulus. X-ray picture

Intestinal volvulus implies such a change in the position of a section of the intestine relative to its axis, in which blood circulation is disrupted and there is a danger of gangrene ( dying off) of this area. The intestine is not rigidly fixed in the abdominal cavity, so when it is significantly displaced, the vessels can be pinched. This may occur when eating large amounts of food after a long fast.

Intestinal volvulus can occur in the following areas:

• small intestine;
• cecum;
• sigmoid colon.

The clinical picture of volvulus develops extremely quickly, so early diagnosis using an x-ray is of great importance. When intestinal volvulus occurs, an X-ray picture of mechanical obstruction is observed, and the contrast mass stops at the level of intestinal volvulus. When the volvulus is localized in the small intestine ( high obstruction) the images show distension of the stomach and small intestinal loops. For volvulus of the sigmoid colon ( low intestinal obstruction) is characterized by a “coffee bean” shape. The intestine increases sharply in size, but remains divided in the middle by a septum into two lobes.

Intestinal perforation. Detection of free gas, fluid in the abdominal cavity on an x-ray

Intestinal perforation is a violation of the integrity of the intestinal wall and the release of its contents into the abdominal cavity. Due to the large number of microorganisms living in the intestines, this condition can quickly lead to infectious complications. That is why rapid diagnosis using X-rays and treatment of intestinal perforation should be given great attention.

Intestinal perforation can occur due to the following conditions:

• abdominal trauma;
• inflammatory diseases intestines ( ulcer, colitis, enteritis);
• foreign bodies;
• rupture due to intestinal obstruction;
• rupture of intestinal diverticulum;
• decay or rupture of the tumor.

Since patients with intestinal perforation are in serious condition, x-rays are performed for them in a horizontal position without the use of contrast. X-ray confirmation of intestinal perforation is the detection of free gas ( pneumoperitoneum) or liquid. When the patient is in a vertical position, air accumulates in the form of a sickle under the diaphragm, and when the patient is in a horizontal position on his back, it accumulates directly under the anterior wall of the abdominal cavity. When performing an X-ray in a horizontal position, fluid accumulates in the lateral parts of the intestine and radiographically appears as shading of the space around the colon.

Detection of foreign bodies in the intestine using x-ray

Foreign bodies in the intestines are quite rare; they occur mainly in children. As a rule, they can be bones ( chicken, fish), plastic or metal objects. Sharp objects, such as needles, pose a certain danger, as they can lead to perforation and the release of a foreign body into the abdominal cavity.

The following methods of detecting foreign bodies in the gastrointestinal tract using x-rays are distinguished:

• Survey radiography. Allows you to reliably detect only metal objects that are contrasting on x-rays. The bones leave a shadow of low intensity and have an elongated shape.
• X-ray using contrast agent. Intestinal foreign bodies are detected by applying a small amount of contrast agent. The patient drinks 1 glass of barium mass ( 200 ml), after a while takes a few sips of water. Thus, a small amount of barium mass settles on the surface of the foreign body, staining it, and the rest is washed away.

Foreign bodies, as a rule, leave the intestine on their own, naturally, since the intestine has a fairly wide lumen. However, it is advisable that the passage of foreign bodies through the gastrointestinal tract be monitored using a series of x-rays. If the possibility of natural release of foreign bodies is excluded, then the only option is to remove the foreign bodies surgically.

Appendicitis. Diagnosis of appendicitis using intestinal x-ray

Appendicitis is the most common acute bowel disease. It represents inflammation vermiform appendix cecum ( appendix), which is located in the right abdomen. The vermiform appendix is ​​a short ( up to 7 centimeters) area adjacent to the large intestine and does not perform special functions in the body. Inflammation of the appendix occurs due to the closure of its lumen with intestinal contents and the proliferation of pathogenic microorganisms. In the diagnosis of appendicitis and its complications, a special role is played by radiation methods diagnostics

Appendicitis is characterized the following signs on x-ray:

• lack of penetration of the contrast mass into the appendix or partial filling of the appendix;
• in 10% of cases, feces may be present on the x-ray - dense, mineralized formations resembling stones;
• swelling of the cecum is manifested by thickening of the haustra;
• sometimes a clearing corresponding to gas and a horizontal level of liquid can be detected in the appendix cavity;
• depression on the outer contour of the cecum and ileum.

If appendicitis is suspected, irrigoscopy is performed, without any preparatory measures. The X-ray method can also detect complications of appendicitis. When the appendix ruptures, free gas or liquid is present in the right lateral abdomen. The formation of an abscess at the site of the appendix leads to its high density and detection on an x-ray even without the use of a contrast mass. Due to unilateral spasm of the psoas muscle during appendicitis, curvature of the spine is observed in this section.

Peritonitis on x-ray

Peritonitis is an infectious complication of inflammatory and destructive processes in the abdominal organs, including the intestines. Peritonitis occurs after untreated appendicitis, intestinal obstruction, trauma and intestinal rupture. Peritonitis develops quickly, within 2 - 3 days, and can lead to very serious consequences.

On an x-ray, peritonitis can be identified by the following signs:

• practically complete absence peristalsis;
• expansion of the lumen of the large and small intestines;
• the presence of gas and liquid in the intestinal lumen due to paralytic intestinal obstruction;
• blurred relief of the mucous membrane due to swelling and secretion of mucus;
• shading in the area of ​​the lateral canals of the abdominal cavity, which is explained by the accumulation of inflammatory exudate in these areas.

For peritonitis, a survey x-ray is performed, which can reveal the above signs, as well as the root cause of this condition. Sometimes peritonitis is accompanied by the formation of abscesses in the abdominal cavity - limited accumulations of pus, which appear on x-rays as round-shaped and small shading. If peritonitis is detected, immediate surgical treatment is required.

Acute circulatory disorder of the intestinal vessels. Diagnosis of intestinal infarction using x-ray methods

Impaired blood circulation in the intestinal vessels is caused by the closure of the lumen of the vessel with a thrombus. Blood clots can form both directly in the vessels of the intestinal mesentery and in distant places ( for example, in the chambers of the heart). Depending on the size of the thrombus, vessels of different diameters may be affected. The larger it is, the more severe this condition occurs.

Impaired blood circulation in the intestinal vessels can lead to necrosis ( intestinal infarction). If an intestinal infarction is suspected, a survey x-ray or computed tomography is urgently performed. The radiological sign of this pathology is widespread expansion of the intestinal lumen, thickening of the mucous membrane due to edema and hemorrhages. Peristalsis is almost completely absent, as paralytic intestinal obstruction occurs. To determine the exact location of the thrombus, it is necessary to perform angiography, that is, an x-ray of the abdominal vessels with intravenous administration of a contrast agent.

Inflammatory bowel disease on x-ray

Inflammatory bowel diseases are common diseases that are difficult to diagnose and treat. With this group of diseases, chronic inflammation is present in the body, which significantly reduces a person’s quality of life. Intestinal inflammation weakens a person’s immune system due to reduced absorption of nutrients from the food consumed.

The main method for diagnosing inflammatory bowel diseases remains x-ray using a barium contrast mass. However, in this group of diseases, x-rays using a contrast agent are performed with caution, especially with severe symptoms. This is due to the fact that the introduction of a contrast agent can provoke rupture of the weakened intestinal wall.

X-ray diagnostics for inflammatory bowel diseases has the following goals:

• establishing the extent of the affected area;
• clarification of the diagnosis and identification of distinctive signs among a number of other intestinal diseases;
• determination of the possible degeneration of a site of chronic inflammation into a malignant tumor.

Duodenal ulcer on x-ray

Peptic ulcer disease is quite often observed in the initial part of the intestine, the duodenum. This area receives acidic gastric juice, which, despite the abundance of protective mechanisms of the mucous membrane, has an irritating effect on the intestinal wall. Due to the small size of the duodenum, X-rays make it possible to clearly examine all its walls and detect an ulcer with high accuracy.

The following signs of a duodenal ulcer are distinguished:

• Niche defect. This sign is direct evidence of the presence of a duodenal ulcer. On an x-ray, it is characterized by the accumulation of barium mass in the area of ​​​​destruction of the mucous membrane.
• Spasmodic retraction of the opposite wall. This phenomenon represents a protective reaction of the body and almost unmistakably indicates the presence of an ulcer, even if it is not visible upon first examination.
• Thickening of the folds of the mucous membrane ( more than 2.5 mm). It is observed near the ulcerative defect and indicates chronic inflammation.
• Duodenogastric reflux. It represents the return of a certain amount of barium mass back to the stomach. This phenomenon can be seen on x-rays taken with a short time interval. It is not observed in all individuals with duodenal ulcers.
• Accelerated emptying of the duodenum. With this disease, the rate of passage of barium mass through the small intestine is increased.

With a long course of the ulcerative process, the contour of the duodenum on x-ray becomes uneven, narrowed in some areas. This phenomenon is called cicatricial deformation of the small intestine and is observed in many inflammatory bowel diseases. Severe deformation creates serious difficulties in the movement of intestinal contents through the digestive tract.

X-ray signs of enteritis and colitis

Enteritis and colitis are nonspecific inflammatory diseases of the small and large intestines caused by a variety of microorganisms. These diseases can be both acute and chronic, but in any case main role an infectious factor plays a role in their development. Enteritis and colitis are very common. Most people are familiar with them by their characteristic symptoms, namely abdominal pain, upset bowel movements, and bloating. Usually the discomfort lasts several days and goes away on its own.

X-ray examination for enteritis and colitis is usually not prescribed, since the symptoms of this disease are quite clear. However, when chronic course X-ray change is mandatory, since in this case it is necessary to exclude other inflammatory bowel diseases ( Crohn's disease, ulcerative colitis). The X-ray picture of enteritis and colitis has a triad of symptoms that are observed in almost all cases.

X-ray enteritis and colitis are characterized by the following signs:

• Increased amount of mucus. This phenomenon is detected when the intestines are tightly filled with a contrast mass. Near the contour of the mucous membrane, a thin layer of clearing is detected, corresponding to the mucus layer. He performs protective function with inflammation.
• Changes in the relief of the mucous membrane. The folds of the mucous membrane lose their usual direction, become tortuous and somewhat deeper.
• Violation of muscle wall tone. Intestinal peristalsis can be either enhanced or weakened, which is reflected in the acceleration or deceleration of the passage of barium.

Crohn's disease. X-ray picture

Crohn's disease is a disease characterized by inflammation of all layers of the intestinal wall with the formation of granulomas and mucosal defects. Crohn's disease occurs in both adults and children, and infectious and genetic factors play an equal role in the development of this disease. Crohn's disease most often affects the end of the small intestine and the beginning of the large intestine. The X-ray picture and clinical manifestations of this disease in adults and children are different from each other.

X-ray signs of Crohn's disease in children:

• On the relief of the mucous membrane, accumulations of barium mass are revealed, which correspond to areas of ulcers of the mucous membrane ( so-called “contrast agent depot”);
• the contour of the mucous membrane is characterized by clearing ( decreased accumulation of contrast agent) in places where lymphoid tissue granulomas grow;
• the intestine maintains uniform thickness throughout its entire length;
• the loops of the small intestine are located at a short distance from each other, since the space between them is filled with enlarged lymph nodes.

Crohn's disease in adults is characterized by the following signs on x-ray:

• narrowing of the intestines in limited areas ( from 1 to 3 centimeters), caused by cicatricial deformation of the intestine as a result of prolonged inflammation ( "cord" symptom);
• the general relief resembles the picture of a “cobblestone street”;
• deep ulcers penetrate the intestinal wall, creating a characteristic accumulation of contrast agent there ( "brush symptom");
• the disease can be complicated by intestinal perforation in areas of deep ulcerative defects, the formation of fistulas on the skin and in the abdominal cavity.

The course of Crohn's disease in adults differs primarily in that it leads to deformation of the intestinal wall. A pronounced narrowing of the intestinal wall occurs when the disease is more than 3 years old. As a result this complication the width of the intestine decreases from 3–4 centimeters to 5 millimeters. In adults, Crohn's disease is often associated with intestinal obstruction and perforation of intestinal ulcers. Diagnosis of these complications is carried out on the basis clinical picture and x-ray.

Nonspecific ulcerative colitis. X-ray examination, characteristic signs

Nonspecific ulcerative colitis occurs similarly to Crohn's disease, but differs from this disease in that it is localized primarily in the colon. X-ray examination for nonspecific ulcerative colitis, it begins with a plain X-ray. The fact is that in the active form of this disease there are a large number of ulcerative defects in the intestines, which is why the use of a contrast agent is contraindicated. The course of nonspecific ulcerative colitis is divided into three stages.

The following stages of ulcerative colitis are distinguished:

• initial stage. At this stage, x-rays of the large intestine reveal a decrease in the rate of clearance of barium mass. With double contrast, fine granularity of the mucous membrane can be detected. Changes are usually detected first in the rectum.
• Stage of pronounced changes. The outline of the colon mucosa becomes “marbled” or jagged as the barium mass is retained in deep and nearby ulcerative defects. Pseudopolyps are also found - granulomatous projections characterized by a filling defect.
• Stage of intestinal deformation. The intestinal mucosa is completely destroyed over time, and the ulcerative defect passes to the muscle layer of the intestinal wall. Due to the replacement of the intestinal mucosa with connective tissue, it becomes rigid, narrows and shortens. The area before the narrowing, on the contrary, stretches and can reach up to 15 centimeters in diameter. When intestinal ulcers perforate, X-rays reveal free gas in the abdominal cavity.

Nonspecific ulcerative colitis is similar on X-ray to Crohn's disease. A characteristic feature In both diseases, the X-ray image shows a “granite pavement” appearance, in which ulcerative defects alternate with granulomatous formations. The main difference lies in the localization and nature of the spread of inflammation.

Irritable bowel syndrome on x-ray

Irritable bowel syndrome is a long-term disorder of motor function and sensory perception by large intestinal receptors. This syndrome is characterized by bowel dysfunction ( excessively liquid or hard), abdominal pain during bowel movements, observed at least 3 times a week for more than 6 months in a row. The diagnosis of “irritable bowel syndrome” is a functional disorder and assumes the absence organic diseases intestines such as Crohn's disease or ulcerative colitis.

X-ray examination in this condition is carried out, first of all, to exclude tumor or inflammatory phenomena. Using a series of x-rays, the barium passage is assessed. With irritable bowel syndrome, a disturbance in the passage of the peristaltic wave and an increase in the time of bowel movement are noted. If you take an x-ray during the onset of pain in the intestines, you can detect local narrowing of the intestine ( muscle spasm).

Irritable bowel syndrome is only diagnosed if comprehensive examination intestines did not reveal any other pathologies. It occurs quite often - about 30% of patients in gastroenterology departments have this pathology. In the absence of organic changes in the mucous membrane, only symptomatic treatment is carried out. This syndrome may be aggravated by stressful situations Therefore, to prevent it, it is very important to control the level of stress and alternate it with rest.

X-ray diagnosis of intestinal tumor diseases. Bowel cancer

Tumor diseases of the intestine usually occur in old age ( after 60 years). It is believed that the growth of tumors is associated with mutations in cells. They occur when natural process replacing old cells with new ones. Genetic errors during cell reproduction tend to accumulate; at a certain age, such errors lead to the development of tumors.

Intestinal tumors can be of two types:

• benign;
• malignant.

These types of tumors differ significantly from each other in clinical and radiological picture. In benign tumors, the neoplasm grows slowly and adjacent tissues are not destroyed. On X-ray, such tumors have clear boundaries, are small in size and are not connected to neighboring organs. Malignant tumors grow aggressively and rapidly, destroy neighboring tissues, and metastasize. Malignant tumors cause constant malaise, abdominal pain, sometimes bleeding, nausea and vomiting. The uneven edges of the tumor, lack of peristalsis, and large size are clearly visible on x-rays. Sometimes it is possible to detect metastases of malignant tumors in neighboring lymph nodes or organs.

Benign intestinal tumors on x-ray

Benign intestinal tumors are often found in the human body. With tumor sizes up to 2 centimeters, they usually do not cause any symptoms and do not make themselves felt. Such tumors may be discovered accidentally during an X-ray examination. When a benign tumor grows more than 2 centimeters, signs of partial intestinal obstruction appear, including pain during bowel movements.

Intestinal tumors can be of two types according to their structure. More than 90% of intestinal tumors are epithelial and originate from the intestinal mucosa. Another part of the tumors is located in the submucosal or muscle layer and is completely covered with mucous membrane. This group includes fibroma, leiomyoma and some other types of tumors. All of them are called non-epithelial. In addition to differences under microscopic examination, these tumors look different on X-ray.

Epithelial benign tumors ( polyps) on an x-ray look like this:

• round-shaped filling defect with smooth contour (resembles a hole against the background of the intestinal wall);
• the size of the filling defect is from 1 to 2 centimeters;
• sometimes you can notice the stalk of the tumor in the form of a linear clearing;
• the folds of the mucous membrane are preserved and do not change direction;
• peristalsis is preserved unchanged.

Not epithelial tumors have the following radiological signs:

• the filling defect has a spindle-shaped shape;
• the size of the filling defect ranges from 2 to 5 centimeters;
• the contours are clear and even;
• folds of the mucous membrane are visible against the background of the defect, they go around its perimeter;
• peristalsis is not impaired.

Epithelial tumors always grow inside the intestinal lumen, while non-epithelial tumors can grow outside the intestinal wall. In this case, they create external pressure and can also lead to intestinal obstruction. Benign tumors can become the basis of a peptic ulcer and also lead to malignant tumors. For benign tumors, a wait-and-see approach is usually followed.

Malignant intestinal tumors. Types of intestinal cancer on x-ray

Cancer is a disease characteristic of modern generation. Behind last years The incidence of this disease has increased significantly. Cancer most often affects the large intestine. Malignant tumors, unlike benign ones, have a destructive effect on surrounding tissues and organs. Once metastasized, the tumor process is very difficult to reverse.

Colon cancer is caused by a mutation in epithelial cells, which begin to multiply intensively, forming a tumor node. The tumor grows uncontrollably quickly, and the degree of functional impairment of the intestine depends on the direction of its growth and localization. There are 4 main radiological variants of bowel cancer.

The following types of colon cancer are distinguished:

• Exophytic ( polypoid) cancer. Radiologically, such a tumor resembles a benign polyp, but has some distinctive features. The contours of a malignant tumor are uneven, the folds of the mucous membrane break off, and there is no peristalsis in the tumor area. A node larger than 3 centimeters is also characteristic of a cancerous tumor.
• Primary ulcerative cancer. It is observed if the tumor is a malignant ulcer. In this case, a single defect in the form of a niche, more than 1 cm wide, is found in the intestinal wall. The tumor is flat and shallow. Around it there is a shaft of unchanged mucous membrane, which is discovered when the intestines are partially cleansed of the barium mass. There is also no peristalsis in the area of ​​the ulcerative defect.
• Infiltrative cancer. This cancer grows inside the intestinal wall, while the mucous membrane remains intact. That is why endoscopic examination cannot detect such cancer. On an x-ray, it can be detected by a narrowing of the intestinal lumen, the absence of mucosal folds and peristalsis. The filling defect is flat, and at the border with intact tissue there is a step-like ledge.
• Mixed tumor. The mixed type of tumor combines radiological signs of infiltrative and exophytic cancer. Its detection on an x-ray is not very difficult.

Intestinal sarcoma

Intestinal sarcoma is a malignant nonepithelial tumor. It is characterized by the fact that it grows along the intestinal wall and for a long time does not interfere with the passage of food. Due to the long asymptomatic period, intestinal sarcoma is often detected on late stage when it already metastasizes to neighboring organs.

Intestinal sarcoma most often consists of mutant muscle or lymph cells. On x-rays it measures 4 centimeters or more in diameter, as it is rarely found in small sizes. Unfortunately, it is impossible to distinguish cancer from sarcoma by X-ray, since this question is answered by histological examination.

On an x-ray, sarcoma looks like a tumor with infiltrative ( endophytic) height. It is characterized by a sharp, persistent narrowing of a section of the intestinal wall with a sharp transition at the end of the tumor border. The tumor itself is a filling defect. The intestinal wall is motionless and tightly fused to the surrounding tissues. Since the tumor is located near outer wall intestines ( mesentery), the tumor is characterized by germination into neighboring anatomical formations. The edges of the section of the intestine in which the malignant tumor is located are undermined and may be subject to ulceration.

Determining the stage of colon cancer using x-rays

Determining its stage is of great importance in the prognosis and treatment of colon cancer. Helps with this x-ray method, namely irrigoscopy. The size of the tumor is assessed by injecting a contrast agent. The presence of metastases in the lymph nodes and neighboring organs is visible on plain radiography, however, it is more accurately determined using scintigraphy.

The following stages of intestinal cancer are distinguished:

• Stage I. The tumor node is up to 3 centimeters. Such a tumor is usually located in the mucous membrane or submucosal layer.
• Stage II. The tumor node closes the intestinal lumen to half its width. Regional lymph nodes are not changed on the x-ray, since there are no metastases in them. If the tumor is located in the intestinal wall, it affects all layers, including the muscle layer.
• Stage III. The tumor occupies half of the intestinal lumen, and the x-ray reveals additional shadows corresponding to metastases in the regional lymph nodes.
• Stage IV. The tumor is large, affects neighboring organs, and also compresses neighboring loops of the small intestine. Metastases are found not only in regional lymph nodes, but also in distant organs.

The X-ray method allows you to determine the stage of the tumor, but sometimes this is not enough to choose treatment. Histological structure tumors ( cancer, sarcoma, etc.) can only be detected by examining tumor tissue under a microscope after a biopsy. The best result is obtained by surgical removal of the tumor along with regional lymph nodes.

Where can I get an X-ray of my intestines?

An X-ray of the intestine can be performed in almost any X-ray office. Such offices are necessarily located in all clinics and government diagnostic centers. In addition, private clinics offer intestinal x-rays using modern equipment. Prices for this service may vary in different cities.

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Recognition of intestinal diseases is based on clinical, radiological, endoscopic and laboratory data. Colonoscopy with biopsy plays an increasingly important role in this complex, especially in diagnosis early stages inflammatory and tumor processes.

Acute mechanical intestinal obstruction. X-ray examination is of great importance in its recognition. The patient is in an upright position and undergoes plain radiographs of the abdominal organs. Obstruction is indicated by swelling of the intestinal loops located above the site of blockage or compression of the intestine. In these loops, gas accumulations and horizontal liquid levels are determined (the so-called bowls, or Kloiber levels). All loops of intestine distal to the site of blockage are in a collapsed state and do not contain gas and liquid. It is this sign - collapse of the poststenotic segment of the intestine - that makes it possible to distinguish mechanical intestinal obstruction from dynamic one (in particular, from paresis of intestinal loops). In addition, with dynamic paralytic obstruction, peristalsis of the intestinal loops is not observed. Fluoroscopy fails to detect movement of contents in the intestine and fluctuations in fluid levels. With mechanical obstruction, on the contrary, repeated images never copy those taken earlier; the picture of the intestine changes all the time.

The presence of acute mechanical intestinal obstruction is determined by two main signs: swelling of the prestenotic part of the intestine and collapse of the poststenotic part.

These signs appear 1-2 hours after the onset of the disease, and after another 2 hours they usually become clear.

It is important to distinguish between obstruction of the small and large intestine. In the first case, the loops of the small intestine are swollen, and the large intestine is in a collapsed state. If this is not clear enough from the images, then retrograde filling of the colon with barium suspension can be performed. In case of small intestinal obstruction, swollen intestinal loops occupy predominantly the central parts of the abdominal cavity, and the caliber of each loop does not exceed 4 - 8 cm. Against the background of the swollen loops, transverse striations are visible, caused by expanded circular (kerkring) folds. Naturally, there are no haustral retractions on the contours of the small intestine, since they occur only in the large intestine.

With obstruction of the colon, huge swollen loops with high gas bubbles in them are observed. The accumulation of fluid in the intestine is usually small. Haustral retractions are visible on the contours of the intestine, and arched, rough semilunar folds are also visible. By introducing a contrast suspension through the rectum, it is possible to clarify the location and nature of the obstruction (for example, to detect a cancerous tumor that has led to a narrowing of the intestine). Let us only point out that the absence radiological signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction, interpretation of the X-ray picture may be difficult. In these cases, sonography and computed tomography are of great help. They make it possible to detect stretching of the prestenotic part of the intestine, a break in its image at the border with the collapsed poststenotic part, and a shadow of nodulation.

Diagnosis is especially difficult acute ischemia intestines and necrosis of the intestinal wall. When the superior mesenteric artery is blocked, accumulations of gas and liquid are observed in the small intestine and in the right half of the large intestine, and the patency of the latter is not impaired. However, radiography and sonography provide recognition of mesenteric infarction in only 25% of patients. With CT, it is possible to diagnose a heart attack in more than 80% of patients based on thickening of the intestinal wall in the area of ​​necrosis, the appearance of gas in the intestine, as well as in the portal vein. Most precise method is angiography performed using spiral CT, magnetic resonance imaging or catheterization of the superior mesenteric artery. The advantage of mesentericography is the possibility of subsequent targeted transcatheter administration of vasodilators and fibrinolytics. Rational research tactics are presented in the diagram below.

In case of partial obstruction, repeated examination after 2-3 hours is of great benefit. It is acceptable to administer a small amount of water-soluble contrast agent through the mouth or nasojejunal tube (enterography). In case of volvulus of the sigmoid colon, valuable data are obtained by irrigoscopy. In case of adhesive obstruction, they resort to X-ray examination in different positions of the patient, recording the areas of fixation of intestinal loops.

Appendicitis. Clinical signs acute appendicitis is known to every doctor. X-ray examination is a valuable way to confirm the diagnosis and is especially indicated when there is a deviation from the typical course of the disease. The survey tactics are presented in the following diagram.

As can be seen in the diagram, it is advisable to begin the radiation examination with sonography of the abdominal organs. Symptoms of acute appendicitis include expansion of the appendix, filling it with fluid, thickening of its wall (more than 6 mm), identification of stones in the appendix and its fixation, accumulation of fluid near the wall of the appendix and the cecum, hypoechoic image of the abscess, depression from the abscess on the intestinal wall, hyperemia periappendicular tissues (with Doppler sonography).

The main radiological signs of acute appendicitis: small accumulations of gas and liquid in the distal part of the ileum and in the cecum as a manifestation of their paresis, thickening of the wall of the cecum due to its edema, thickening and rigidity of the folds of the mucous membrane of this intestine, stones in the appendix, small effusion in the abdominal cavity, swelling of the soft tissues of the abdominal wall, blurred outline of the right lumbar muscle. An appendicular abscess causes darkening in the right iliac region and a depression on the wall of the cecum. Sometimes a small accumulation of gas is detected in the abscess and in the projection of the appendix. If the appendix is ​​perforated, there may be small gas bubbles under the liver.

CT is somewhat more effective than sonography and radiography in diagnosing acute appendicitis, making it possible to clearly detect thickening of the wall of the appendix and appendiceal abscess.

In chronic appendicitis, deformation of the appendix, its fixation, fragmentation of its shadow during X-ray contrast examination or non-filling of the appendix with barium sulfate, the presence of stones in the appendix, coincidence pain point with the shadow of the process.

Intestinal dyskinesin. X-ray examination is a simple and accessible method of clarifying the nature of the movement of contents through the loops of the small and large intestine and diagnosing various types of constipation (constipation).

Enterocolitis. In acute enterocolitis of various etiologies, similar symptoms are observed. Small gas bubbles with short fluid levels appear in the intestinal loops. The advancement of the contrast agent occurs unevenly; separate accumulations of it are noted, between which constrictions are observed. The folds of the mucous membrane are thickened or not differentiated at all. All chronic enterocolitis, accompanied by malabsorption syndrome, are characterized by common symptoms: dilation of intestinal loops, accumulation of gas and liquid in them (hypersecretion), separation of the contrast mass into separate lumps (sedimentation and fragmentation of contents). The passage of the contrast agent is slow. It is distributed unevenly over the inner surface of the intestine, and small ulcerations may be visible.

Malabsorption. It interferes with the absorption of various components food. The most common diseases are the sprue group. Two of them - celiac disease and non-tropical sprue - are congenital, and tropical sprue are acquired. Regardless of the nature and type of malabsorption, the x-ray picture is more or less the same: dilation of the loops of the small intestine is determined. Fluid and mucus accumulate in them. Because of this, the barium suspension becomes heterogeneous, flocculates, is divided into fragments, and turns into flakes. The folds of the mucous membrane become flat and longitudinal. A radionuclide study with trioleate-glycerol and oleic acid reveals a malabsorption in the intestine.

Regional enteritis and granulomatous colitis (Crohn's disease).

With these diseases, any part of the digestive canal can be affected - from the esophagus to the rectum. However, distal lesions are most common jejunum and the proximal part of the ileum (jejunoileitis), the terminal parts of the ileum (terminal ileitis), the proximal parts of the colon.

There are two stages during the course of the disease. In the first stage, thickening, straightening and even disappearance of folds of the mucous membrane and superficial ulcerations are noted. The contours of the intestine become uneven and jagged. Then, instead of the usual pattern of folds, multiple rounded clearings are found, caused by islands of inflamed mucous membrane. Among them, strip-like shadows of barium deposited in transverse cracks and slit-like ulcers can be distinguished. In the affected area, the intestinal loops are straightened and narrowed. In the second stage, there is a significant narrowing of the intestinal loops with the formation of cicatricial constrictions ranging from 1-2 to 20-25 cm in length. On photographs, the stenotic area may look like a narrow, uneven canal (a “cord” symptom). In contrast to the malabsorption syndrome, there is no diffuse dilation of intestinal loops, hypersecretion and fragmentation of the contrast agent; the granular nature of the relief of the inner surface of the intestine is clearly expressed. One of the complications of Crohn's disease is abscesses, the drainage of which is carried out under radiation control.

Intestinal tuberculosis. The ileocecal angle is most often affected, but even when examining the small intestine, thickening of the folds of the mucous membrane, small accumulations of gas and liquid, and slow progress of the contrast mass are noted. In the affected area, the contours of the intestine are uneven, the folds of the mucous membrane are replaced by areas of infiltration, sometimes with ulcerations, and there is no haustration. It is curious that the contrast mass in the infiltration zone does not linger, but quickly moves further (a symptom of local hyperkinesia). Subsequently, the intestinal loop shrinks, reducing its lumen and limiting displacement due to adhesions.

Nonspecific ulcerative colitis. In mild forms, thickening of the folds of the mucous membrane, pinpoint accumulations of barium and fine jaggedness of the intestinal contours are noted as a result of the formation of erosions and small ulcers. Severe forms are characterized by narrowing and rigidity of the affected parts of the colon. They stretch little and do not expand with retrograde injection of a contrast mass. Haustration disappears, the contours of the intestine become finely jagged. Instead of folds of the mucous membrane, granulations and accumulations of barium appear in the ulcerations. The distal half of the colon and the rectum are predominantly affected, which are sharply narrowed in this disease.

Colon cancer. The cancer appears as a small thickening of the mucous membrane, a plaque, or a polyp-like flat formation. Radiographs reveal a marginal or central filling defect in the shadow of the contrast mass. The folds of the mucous membrane in the area of ​​the defect are infiltrated or absent, peristalsis is interrupted. As a result of necrosis of tumor tissue, an irregularly shaped barium depot may appear in the defect - a reflection of ulcerated cancer. As the tumor continues to grow, predominantly two types of X-ray patterns are observed. In the first case, a tuberous formation is detected, protruding into the intestinal lumen (exophytic type of growth). The filling defect has an irregular shape and uneven contours. The folds of the mucous membrane are destroyed. In the second case, the tumor infiltrates the intestinal wall, leading to its gradual narrowing. The affected section turns into a rigid tube with uneven outlines (endophytic type of growth). Sonography, CT and MRI make it possible to clarify the degree of invasion of the intestinal wall and neighboring structures. In particular, endorectal sonography is valuable in rectal cancer. Computer tomograms make it possible to assess the condition lymph nodes in the abdominal cavity.

Benign tumors. About 95% benign neoplasms intestines are composed of epithelial tumors - polyps. They are single and multiple. The most common are adenomatous polyps. They are small, usually no more than 1-2 cm in size, growths of glandular tissue, often having a stalk (stem). At x-ray examination these polyps cause filling defects in the intestinal shadow, and with double contrast, additional rounded shadows with even and smooth edges.

Villous polyps look slightly different on X-ray examination. A filling defect or an additional shadow with double contrast has uneven outlines, the surface of the tumor is unevenly covered with barium: it flows between the gyri, into the grooves. However, the intestinal wall remains elastic. Villous tumors, in contrast to adenomatous polyps, often become malignant. Malignant degeneration is indicated by such signs as the presence of a persistent depot of barium suspension in the ulceration, rigidity and retraction of the intestinal wall at the location of the polyp, and its rapid growth. The results of colonoscopy with biopsy are decisive.

Acute stomach.

The causes of acute abdominal syndrome are varied. To establish urgent and accurate diagnosis Anamnestic information, the results of a clinical examination and laboratory tests are important. TO radiation research resorted to when it is necessary to clarify the diagnosis. As a rule, it begins with radiography of the chest cavity, since acute abdominal syndrome can be a consequence of irradiation of pain when the lungs and pleura are affected (acute pneumonia, spontaneous pneumothorax, supradiaphragmatic pleurisy).

Then an X-ray of the abdominal organs is performed to identify perforated pneumoperitoneum, intestinal obstruction, kidney and gallstones, calcifications in the pancreas, acute gastric volvulus, strangulated hernia, etc. However, depending on the organization of patient reception in medical institution and the expected nature of the disease, the examination procedure may be changed. At the first stage it can be carried out ultrasonography, which in some cases will allow us to limit ourselves in the future to radiography of the chest organs.

The role of sonography is especially great in identifying small accumulations of gas and liquid in the abdominal cavity, as well as in the diagnosis of appendicitis, pancreatitis, cholecystitis, acute gynecological diseases, kidney damage. If there is any doubt about the results of sonography, CT is indicated. Its advantage over sonography is that gas accumulations in the intestines do not interfere with diagnosis.

Intestinal obstruction (Latin ileus) is a syndrome characterized by partial or complete disruption of the movement of contents along the digestive canal and caused by a mechanical obstruction or disruption of intestinal motor function

Classification

According to morphofunctional characteristics:

Dynamic (functional) intestinal obstruction - the motor function of the intestinal wall is impaired without a mechanical obstacle to the movement of intestinal contents:

Paralytic intestinal obstruction (as a result of decreased tone of intestinal myocytes);

Spastic intestinal obstruction (as a result of increased tone);

Mechanical intestinal obstruction is occlusion of the intestinal tube at any level, which causes disruption of intestinal transit:

Strangulated intestinal obstruction (Latin strangulatio - “suffocation”) - occurs when the intestinal mesentery is compressed, which leads to malnutrition. Classic examples of strangulated intestinal obstruction are volvulus, nodulation, and strangulation.

Obstructive intestinal obstruction (lat. obturatio - “blockage”) - occurs when there is a mechanical obstruction to the movement of intestinal contents:

intraintestinal without connection with the intestinal wall - the cause may be large gallstones that have entered the intestinal lumen through an internal biliary fistula, fecal stones, helminths, foreign bodies;

intraintestinal, coming from the intestinal wall - tumors, cicatricial stenoses;

extraintestinal - tumor, cysts;

Mixed intestinal obstruction (combination of strangulation and obstruction):

Intussusception as a result of intussusception;

Adhesive intestinal obstruction, which develops due to compression of the intestine by abdominal adhesions.

According to the clinical course: acute and chronic;

According to the level of obstruction: high (small intestinal, proximal to the ligament of Treitz) and low (colic, distal to the ligament of Treitz);

According to the passage of chyme: complete and partial;

By origin: congenital and acquired.

Main symptoms

Abdominal pain is a constant and early sign of obstruction, usually occurring suddenly, regardless of food intake, at any time of the day, without warning; the nature of the pain is cramping. Attacks of pain are associated with a peristaltic wave and are repeated after 10-15 minutes. During the period of decompensation, depletion of energy reserves of the intestinal muscles, the pain begins to be permanent. With strangulation obstruction, the pain is immediately constant, with periods of intensification during a wave of peristalsis. As the disease progresses, acute pain usually subsides on days 2–3, when intestinal peristaltic activity stops, which is a poor prognostic sign. Paralytic intestinal obstruction occurs with constant dull arching pain in the abdomen;

Retention of stool and gases is a pathognomonic sign of intestinal obstruction. This is an early symptom of low obstruction. When its character is high, at the beginning of the disease, especially under the influence therapeutic measures, there may be stool, sometimes multiple due to bowel movements located below the obstruction. With intussusception from the anus sometimes appear bloody issues. This can cause a diagnostic error when acute intestinal obstruction is mistaken for dysentery;

Bloating and asymmetry of the abdomen;

Vomiting - after nausea or on its own, often repeated vomiting. The higher the obstacle in the digestive tract, the earlier the vomiting occurs and is more pronounced, repeated, and indomitable. Vomiting is initially mechanical (reflex), and then central (intoxication).

Specific symptoms

Val's symptom is a relatively stable, non-moving asymmetrical bloating, noticeable to the eye and detectable by touch;

Shlange's symptom - visible peristalsis of the intestines, especially after palpation;

Sklyarov's symptom - listening to a “splashing noise” over the intestinal loops;

Spasokukotsky-Wilms symptom - “the noise of a falling drop”;

Kivul's symptom is an increased tympanic sound with a metallic tint over a distended loop of intestine;

The symptom of the Obukhov hospital is a sign of low colonic obstruction: balloon-shaped swelling of the empty ampulla of the rectum against the background of a gaping anus;

The Tsege–Manteuffel symptom is a sign of low colonic obstruction: low capacity (no more than 500–700 ml of water) of the distal intestine when performing a siphon enema;

Mondor's symptom - increased intestinal peristalsis is replaced by a gradual extinction of peristalsis (“Noise at the beginning, silence at the end”);

“Dead (grave) silence” - absence of peristalsis sounds; an ominous sign of intestinal obstruction. During this period, with a sharp bloating of the abdomen, you can hear not peristalsis above it, but respiratory sounds and heart sounds, which normally are not conducted through the abdomen;

Schiemann's symptom - with volvulus of the sigmoid colon, the swelling is localized closer to the right hypochondrium, while in the left iliac region, that is, where it is usually palpated, a retraction of the abdomen is noted;

Thevenard's symptom (with strangulation obstruction due to volvulus of the small intestine) is a sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of its mesentery is usually projected.

Intestinal obstruction may be due to the following reasons:

Congenital diseases;

Developmental anomalies;

Spikes;

Development of fibrous tissue (for example, in Crohn's disease);

Tumors.

In case of obstruction, swelling of the prestenotic part of the intestine and collapse of the poststenotic part are noted.

X-ray methods for detecting intestinal obstruction:

Survey fluoroscopy with the patient in an upright position;

Barium contrast (oral or with a contrast enema), if partial obstruction is suspected, to clarify its presence, level and nature.

The main radiological symptom is the presence in the abdominal cavity of multiple pathological levels of fluid with gas above them, which are called “Kloiber cups”.

It is necessary to distinguish small intestinal obstruction from large intestinal obstruction; the location of the Kloiber cups and their characteristics are important here.

For small bowel obstruction:

Pathological levels are located mainly in the central parts of the abdominal cavity;

The diameter of the levels exceeds the height, since the small intestine is capable of stretching;

In the swollen loops of intestine above the levels, transverse folds of the mucous membrane are visible;

Loops of intestine, distended with air, can give a symptom of “arches” above the levels.

For colonic obstruction:

Kloiber's bowls are usually located along the periphery;

The diameter of the levels is less than their height, since the large intestine is not able to expand as much as the small intestine due to the haustra;

In the swollen loops above the levels, haustral retractions can be seen along the contours.

Research methods Chest X-ray X-ray of the abdominal cavity (vertical and horizontal position on the left side) Ultrasound Contrast examination of the gastrointestinal tract Water-soluble contrast agents CT scan 2

Classification of acute intestinal obstruction Mechanical Small intestinal Functional Colon Obstructive Strangulation Peritonitis Renal colic Violation of mesenteric blood flow 3

4

Causes of strangulation obstruction: entrapment of the loop by adhesions, internal and external hernias, volvulus, intussusception Pathogenesis of strangulation obstruction disturbance of blood supply and irritation of the nervous system due to the involvement of the mesentery in the process with the development of ischemia, necrosis of the intestinal wall and the occurrence of peritonitis Intestinal gangrene is accompanied by the release of endo- and exotoxins, which leads to toxic shock 6

Causes of obstructive obstruction of the adhesions: cicatricial strictures of the tumor. The blood supply to the intestine in the case of obstructive obstruction does not suffer. The clinical manifestations of obstructive obstruction are less pronounced. As the proximal parts distend, vomiting occurs, exacerbating fluid loss. Without treatment, hypovolemic shock develops with high mortality 7

The main radiological symptoms of mechanical intestinal obstruction 1. Kloiber cups 2. Arches 3. Transfusion of fluid from one intestine to another 4. Poststenotic collapse of the intestine 8

Indirect signs deformation and displacement of the stomach and colon by loops of small intestine containing gas and liquid, the presence of fluid in the abdominal cavity, detected by ultrasound 9

Based on the review P-grams, it is necessary to answer the following questions: 1) are there signs of OKN or not? 2) are the detected changes signs of small intestinal or colonic obstruction? 10

P-picture of small intestinal obstruction 1) the levels of liquid and gas form characteristic arches 2) the horizontal levels are wide with a low gas bubble 3) the symptom of fluid transfusion from one loop to another is characteristic 4) the absence of gas in the large intestine 11

Characteristic radiological signs of obstructive obstruction of the small intestine can be determined only in half of the patients V. I. Petrov 15

Strangulated small intestinal obstruction Radiologically, the stages of development of STS are distinguished by the degree of intestinal distension, the shape of the bladder, their size and location 16

Stage 1 - isolated intestinal bloating without horizontal levels Stage 2 - p - signs increase, there is an increase in intestinal bloating with the appearance of horizontal levels of fluid, movement of fluid from one loop to another with a change in the location of levels Stage 3 - sharp bloating of the small intestine, multiple horizontal levels 17

Stage 4 - necrosis of all layers of the strangulated part of the intestine occurs, its tone decreases sharply - this is manifested by a decrease in the height of the gas bubble, and the length of the liquid levels increases sharply, they are located on the same line. Gas in the colon is not detected. In stages 1 and 2, dynamic monitoring of the development of the process and contrast studies are permissible. When stages 3 and 4 of the disease are detected, only a single x-ray examination is necessary; urgent surgery is indicated 18

An increase in bloating of the small intestine, a decrease in gas in the colon, an increase in the number of horizontal fluid levels, despite the apparent improvement in clinical symptoms from conservative therapy, indicate the presence of mechanical CI and are important criteria in determining indications for surgical intervention 19

20

The same observation, 3 hours after taking 50.0 omnipaque, the contrast filled the initial parts of the colon 23

Early (on the 4th day) adhesive small intestinal obstruction, 12/25/02 - repeated relaparotomy - dissection of adhesions 24

P-picture of colonic obstruction, the width of Kloiber's cups is less than the height of the gas bubble above them, significant swelling of the colon and accumulation of feces above the obstacle with slowly developing colonic obstruction, especially in its right parts, signs of small intestinal obstruction develop. Determination of a persistent delay in contrast is of decisive importance in establishing the correct diagnosis substances over the obstacle while maintaining the fluid level in the small intestine 25

31

Volvulus of the sigmoid colon is the most common type of strangulation obstruction of the large intestine. The main P-sign is a sharp elongation and expansion of the sigmoid colon, turning it into a “car tire” or “double-barreled gun” when the intestine wraps around an axis 36

Volvulus of the sigmoid colon Classic symptoms are expressed only at the height of the disease. If there is a small accumulation of gas in sigmoid colon and significantly higher content in other parts of the colon, the x-ray picture is not typical. A contrast study - irrigoscopy - plays a decisive role in diagnosis. The contrast mass tightly fills the ampulla of the rectum and the distal part of the sigmoid to the point of torsion, where a narrowing in the form of a “beak” is revealed. 37

39

Functional (dynamic) intestinal obstruction Causes of purulent-inflammatory processes in the abdominal cavity (peritonitis), poisoning due to circulatory disorders in the mesentery, lesions of the reflexogenic zones of the retroperitoneal space (renal colic, trauma to the retroperitoneal space, etc.) 40

Peritonitis is purulent or other inflammation of the peritoneum in response to its direct irritation. Causes are ischemic, inflammatory infectious lesions. There are no specific and undoubted radiological signs of peritonitis 42

Plain radiography of the abdomen Peritonitis is accompanied by reactive paralytic intestinal obstruction, while the gas in the intestinal lumen with elongated horizontal levels increases the diameter of the small intestine to 4-5 cm or more, the folds of the mucosa in the small intestine are often unclearly differentiated, in some loops they can be thickened, uneven expansion and darkening of the spaces between the loops (damage to the peritoneum and the presence of fluid in the abdominal cavity) 43

X-ray. The loops of the small intestine are dilated, the folds and walls are thickened, uneven expansion and darkening of the spaces between the loops. Peritonitis. 45

Peritoneography technique As a contrast agent, a 30% solution of water-soluble contrast agent (urografin 76%) is used, which is injected into the abdominal cavity through a drainage tube in an amount of 50.0. The first radiograph is performed immediately after completion of the administration, control - after 30 minutes, 60 minutes. and 120 min. - immediately after administration, the nature of its distribution in the abdominal cavity attracts attention - after 30 minutes, if there is no peritonitis, traces of contrast remain on the radiograph or it is not detected at all, but its release into the MVP is observed - after 60 minutes. in the absence of peritonitis, no traces of contrast in the abdominal cavity are detected. - with peritonitis, the picture on control radiographs does not change 48

Ultrasound signs of peritonitis have no diagnostic value; these include: fluid-filled intestinal loops, free fluid in the abdominal cavity, which can accumulate in certain areas (in the pericolic, perihepatic, peri-hepatic space, the bursa of Morisson and the small pelvis. 49

PRESENT EFFORT IN THE ABDOMINAL CAVITY IN AN AMOUNT OF UP TO 100 ml IS NOT DETERMINED DURING AN ULTRASOUND ULTRASOUND CANNOT DISTINGUISH ASCITES, BLOOD, BILE, PUS AND URINE 50

In practice, it is proposed to determine the amount of free fluid in three gradations: - an insignificant (small) amount, which corresponds to a volume of up to 200 ml, while the fluid is visualized near the source of peritonitis and in the interloop spaces; - moderate amount, which corresponds to a volume of 200500 ml, exudate is determined in sloping areas of the abdominal cavity (subphrenic, in the pelvis, lateral canals); sonographic determination of a significant amount of effusion of more than 500 ml is noted in cases where intestinal loops “float” in liquid. 51

The most information about the condition of the intestine can be obtained using the ultrasound method by identifying a symptom of intraluminal fluid deposition 53

When fluid accumulates in the intestinal lumen, the following echographic parameters can be determined: the diameter of the intestine, the thickness of its wall, the structure of the wall and internal contents of the intestine, the nature of peristalsis, the accumulation of fluid in the interloop space and in the abdominal cavity. The combination of these changes is interpreted as ultrasound syndrome of intestinal insufficiency (USI) 54

Ultrasound signs of structural changes in the small intestine are: expansion of the lumen of the loops more than 2.5 cm in diameter; thickening of the walls more than 1-2 mm. 55

Functional changes in the small intestine are characterized by a slowdown or complete cessation of peristaltic contractions, a decrease in density and gradual disappearance of echogenic inclusions in the lumen of the dilated intestine, and accumulation of fluid in the intestinal lumen. 56

The highest degree of structural and functional changes in the small intestine or “intestinal failure syndrome” is: expansion of the lumen to 4-4.5 cm or more, filling it with fluid that does not contain echogenic inclusions, limiting the mobility of loops surrounded by a layer of fluid. there may be reactive effusion in the pleural cavities. 57

Dynamic ultrasound observation makes it possible to determine the criteria for assessing the progression of peritonitis: the dynamics of the amount of free fluid in the abdominal cavity, the dynamics of structural and functional changes in the small intestine, the identification of abscesses of extra-organ localization - organ or 58

Resolution of peritonitis is characterized by: a decrease in the amount of fluid in the free abdominal cavity, a decrease in diameter and gradual restoration of intestinal motility, the appearance of echogenic inclusions in the loops of the small intestine and a gradual increase in their density 59

Computed tomography CT signs of peritonitis are ascites, infiltration of the omentum, mesentery and thickening of the parietal peritoneum. These symptoms are nonspecific and are interpreted depending on the clinical picture. Similar signs are detected in carcinomatosis and peritoneal myxomatosis, in which the clinical symptoms are less pronounced. 65

Accuracy of methods radiology diagnostics In identifying diffuse peritonitis: CT - 95%, ultrasound - 94%, X-ray examination - 41%, For limited peritonitis, respectively: CT - 93%, ultrasound - 86%, X-ray examination - 57%. 66

Analyzing the advantages and disadvantages of methods for instrumental diagnosis of acute surgical diseases of the abdominal cavity and their complications, we can conclude that none of the methods is absolutely accurate. The best diagnostic results are achieved when they are integrated use in a certain sequence. 67

Impaired mesenteric circulation The spectrum of clinical manifestations of occlusion of the mesenteric artery or vein is wide - from slight discomfort (abdominal angina) to life-threatening intestinal infarction. 68

The source of arterial embolism is thrombi formed in a post-infarction aneurysm of the left ventricle, thrombi in the left atrium in patients with mitral stenosis or atrial fibrillation insufficiency Thrombosis of the mesenteric vein can be idiopathic or pathologies may occur: portal hypertension, sepsis, various coagulopathies, trauma, paraneoplastic processes, erythremia 69

In the clinic, three stages are distinguished: initial, latent and terminal. The initial stage of mesenteric artery embolism is characteristic acute occurrence pain, painful, without clear localization, typical discrepancy between the severity of pain and the soft abdominal wall; first, diarrhea without blood, vomiting, increased peristalsis; later, blood appears in the stool; symptoms of shock progress 70

Latent stage Pain occurs after 6-12 hours, weakens. Gas accumulates in the intestinal lumen and a feeling of fullness occurs. Peristalsis is absent or weakened. Pain and pain on palpation muscle tension The terminal stage develops 12-48 hours after the onset of pain and manifests itself with the classic picture of an acute abdomen with signs of diffuse peritonitis 71

Plain radiography of the abdomen The study is carried out in the supine position, on the left side and standing. Indirect signs of mesenteric thrombosis 1) symptom of a “gasless abdomen” - when there is no or very little gas in the small and large intestine and diffuse dull darkening 72

Plain radiography of the abdomen 2) isolated distension of the small intestine (y2/3), which is otherwise called false small intestinal obstruction. It is caused by distension of the intestine by gases formed due to the activation of microflora during ischemia of the intestinal wall. Observed in the latent stage 73

Direct signs of impaired mesenteric circulation are thickening of the intestinal wall (due to its swelling and hemorrhages) It is almost always accompanied by expansion of the intestine, while its lumen is narrowed, and the loops are distant from each other The intestinal wall becomes rigid 74

When X-rayed while lying on the back and on the left side, the position of the loops does not change, a characteristic direct sign terminal stage- gas bubbles in the intestinal wall and in the vessels, which are almost always combined with dilatation of the small and large intestine 75

Computed tomography Dilation of the loops of the small intestine and thickening of its walls, ascites and infiltration of the mesentery, which are characteristic of peritonitis, are clearly visible on CT. Sometimes a blood clot is visualized in an artery or vein. Gas is very clearly visible in the vessels and in the intestinal wall. If necrosis is significant, gas is detected throughout the root mesentery, portal vein and its branches The final diagnosis of mesenteric circulation disorders is made using angiography 81

– a violation of the passage of contents through the intestine, caused by obstruction of its lumen, compression, spasm, hemodynamic or innervation disorders. Clinically, intestinal obstruction is manifested by cramping abdominal pain, nausea, vomiting, stool retention and the passage of gas. In the diagnosis of intestinal obstruction, data from a physical examination (palpation, percussion, auscultation of the abdomen), digital rectal examination, plain radiography of the abdominal cavity, contrast radiography, colonoscopy, and laparoscopy are taken into account. For some types of intestinal obstruction, conservative tactics are possible; in other cases, surgical intervention is performed, the purpose of which is to restore the passage of contents through the intestine or its external diversion, resection of a non-viable section of the intestine.

General information

Intestinal obstruction (ileus) is not an independent nosological form; in gastroenterology and coloproctology, this condition develops in a variety of diseases. Intestinal obstruction accounts for about 3.8% of all emergency conditions in abdominal surgery. With intestinal obstruction, the movement of contents (chyme) - semi-digested food masses through the digestive tract - is disrupted.

Intestinal obstruction is a polyetiological syndrome that can be caused by many reasons and have various forms. Timely and correct diagnosis of intestinal obstruction is decisive factors in the outcome of this serious condition.

Causes of intestinal obstruction

Development various forms intestinal obstruction has its own reasons. Thus, spastic obstruction develops as a result of a reflex intestinal spasm, which can be caused by mechanical and painful irritation due to helminthic infestations, intestinal foreign bodies, bruises and hematomas of the abdomen, acute pancreatitis, nephrolithiasis and renal colic, biliary colic, basal pneumonia, pleurisy, hemo- and pneumothorax, rib fractures, acute myocardial infarction and other pathological conditions. In addition, the development of dynamic spastic intestinal obstruction may be associated with organic and functional lesions of the nervous system (TBI, mental trauma, spinal cord injury, ischemic stroke, etc.), as well as circulatory disorders (thrombosis and embolism of mesenteric vessels, dysentery, vasculitis), Hirschsprung's disease.

Paralytic intestinal obstruction is caused by intestinal paresis and paralysis, which can develop as a result of peritonitis, surgical interventions in the abdominal cavity, hemoperitonium, poisoning with morphine, salts heavy metals, food poisoning, etc.

With various types of mechanical intestinal obstruction, there are mechanical obstacles to the movement of food masses. Obstructive intestinal obstruction can be caused by fecal stones, gallstones, bezoars, and accumulation of worms; intraluminal intestinal cancer, foreign body; removal of the intestine from the outside by tumors of the abdominal organs, pelvis, kidney.

Strangulated intestinal obstruction is characterized not only by compression of the intestinal lumen, but also by compression of the mesenteric vessels, which can be observed with strangulated hernia, intestinal volvulus, intussusception, nodulation - overlapping and twisting of intestinal loops among themselves. The development of these disorders may be due to the presence of a long intestinal mesentery, scar cords, adhesions, adhesions between intestinal loops; sharp decline body weight, prolonged fasting followed by overeating; sudden increase intra-abdominal pressure.

The cause of vascular intestinal obstruction is acute occlusion of mesenteric vessels due to thrombosis and embolism. mesenteric arteries and veins The development of congenital intestinal obstruction, as a rule, is based on anomalies in the development of the intestinal tube (duplication, atresia, Meckel's diverticulum, etc.).

Classification

There are several options for classifying intestinal obstruction, taking into account various pathogenetic, anatomical and clinical mechanisms. Depending on all these factors, a differentiated approach to the treatment of intestinal obstruction is used.

For morphofunctional reasons, they distinguish:

1. dynamic intestinal obstruction, which, in turn, can be spastic and paralytic.

2. mechanical intestinal obstruction, including forms:

• strangulation (volvulus, strangulation, nodulation)
• obstructive (intraintestinal, extraintestinal)
• mixed (adhesive obstruction, intussusception)

3. vascular intestinal obstruction caused by intestinal infarction.

According to the level of location of the obstacle to the passage of food masses, high and low small intestinal obstruction (60-70%) and colonic obstruction (30-40%) are distinguished. According to the degree of obstruction of the digestive tract, intestinal obstruction can be complete or partial; according to the clinical course - acute, subacute and chronic. Based on the time of formation of intestinal obstructions, congenital intestinal obstruction associated with embryonic intestinal malformations is differentiated, as well as acquired (secondary) obstruction due to other reasons.

There are several phases (stages) in the development of acute intestinal obstruction. In the so-called “ileus cry” phase, which lasts from 2 to 12-14 hours, pain and local abdominal symptoms prevail. The stage of intoxication that replaces the first phase lasts from 12 to 36 hours and is characterized by “imaginary well-being” - a decrease in the intensity of cramping pain, weakening of intestinal peristalsis. At the same time, there is a failure to pass gas, stool retention, bloating and asymmetry of the abdomen. In the late, terminal stage of intestinal obstruction, which occurs 36 hours after the onset of the disease, severe hemodynamic disturbances and peritonitis develop.

Symptoms of intestinal obstruction

Regardless of the type and level of intestinal obstruction, severe pain, vomiting, stool retention and failure to pass gas occur.

Abdominal pain is cramping and unbearable. During a contraction that coincides with a peristaltic wave, the patient’s face is distorted with pain, he groans, and takes various forced positions (squatting, knee-elbow). At the height of a painful attack, symptoms of shock appear: pale skin, cold sweat, hypotension, tachycardia. The subsidence of pain can be a very insidious sign, indicating intestinal necrosis and death of nerve endings. After an imaginary lull, on the second day from the onset of intestinal obstruction, peritonitis inevitably occurs.

Another characteristic symptom of intestinal obstruction is vomiting. Especially profuse and repeated vomiting, which does not bring relief, develops with small intestinal obstruction. Initially, the vomit contains food debris, then bile, and in the later period - intestinal contents (fecal vomit) with a putrid odor. With low intestinal obstruction, vomiting, as a rule, is repeated 1-2 times.

A typical symptom of low intestinal obstruction is retention of stool and gas. Digital rectal examination reveals the absence of feces in the rectum, distension of the ampulla, and gaping of the sphincter. At high obstruction small intestine, there may be no stool retention; emptying of the lower parts of the intestine occurs independently or after an enema.

With intestinal obstruction, attention is drawn to bloating and asymmetry of the abdomen, peristalsis visible to the eye.

Diagnostics

Percussion of the abdomen in patients with intestinal obstruction reveals tympanitis with a metallic tint (Kivul's symptom) and dullness of percussion sound. Auscultation in the early phase reveals increased intestinal peristalsis, “splash noise”; V late phase– weakening of peristalsis, noise of a falling drop. With intestinal obstruction, a distended intestinal loop is palpated (Val's symptom); in the later stages – rigidity of the anterior abdominal wall.

Important diagnostic value has a rectal and vaginal examination, with the help of which it is possible to identify obstruction of the rectum and pelvic tumors. The objectivity of the presence of intestinal obstruction is confirmed by instrumental studies.

A survey X-ray of the abdominal cavity reveals characteristic intestinal arches (gas-swollen intestine with fluid levels), Kloiber's cups (dome-shaped clearings above the horizontal level of fluid), and a symptom of pennation (the presence of transverse striations of the intestine). X-ray contrast examination of the gastrointestinal tract is used in difficult diagnostic cases. Depending on the level of intestinal obstruction, radiography of the passage of barium through the intestines or irrigoscopy may be used. Colonoscopy allows you to examine distal sections colon, identify the cause of intestinal obstruction and, in some cases, resolve the phenomena of acute intestinal obstruction.

Carrying out an ultrasound of the abdominal cavity with intestinal obstruction is difficult due to severe pneumatization of the intestine, but the study in some cases helps to detect tumors or inflammatory infiltrates. During diagnosis, acute intestinal obstruction should be differentiated from intestinal paresis - drugs that stimulate intestinal motility (neostigmine); Novocaine perinephric blockade is performed. In order to correct the water-electrolyte balance, it is prescribed intravenous administration saline solutions.

If, as a result of the measures taken, intestinal obstruction does not resolve, mechanical ileus should be considered, requiring urgent surgical intervention. Surgery for intestinal obstruction is aimed at eliminating mechanical obstruction, resection of a non-viable section of the intestine, and preventing recurrent obstruction.

In case of obstruction of the small intestine, resection of the small intestine can be performed with enteroenteroanastomosis or enterocoloanastomosis; deintussusception, unwinding of intestinal loops, dissection of adhesions, etc. In case of intestinal obstruction caused by a colon tumor, hemicolonectomy and temporary colostomy are performed. At inoperable tumors a bypass anastomosis is performed on the large intestine; If peritonitis develops, transversostomy is performed.

In the postoperative period, BCC replacement, detoxification, antibacterial therapy, correction of protein and electrolyte balance, and stimulation of intestinal motility are carried out.

Prognosis and prevention

The prognosis for intestinal obstruction depends on the start date and completeness of the treatment. An unfavorable outcome occurs with late recognized intestinal obstruction, in weakened and elderly patients, and with inoperable tumors. With a pronounced adhesive process in the abdominal cavity, relapses of intestinal obstruction are possible.

Prevention of the development of intestinal obstruction includes timely screening and removal of intestinal tumors, prevention of adhesions, elimination of helminthic infestation, proper nutrition, avoiding injury, etc. If you suspect intestinal obstruction, you should immediately consult a doctor.