M. F. Otterson

Intestinal obstruction is a violation of the passage of intestinal contents.

I. Etiology

There are mechanical and functional reasons intestinal obstruction (Table 1). Mechanical obstruction is more common and usually requires surgical intervention. In 70-80/6 cases it is caused by obstruction of the small intestine, in 20-3096 - by the large intestine. In old age, with an increase in the incidence of tumor diseases and diverticulosis of the colon, the incidence of colonic obstruction also increases.

A. Pathology of the peritoneum and organs abdominal cavity and abdominal walls.

The most common cause of small intestinal obstruction is adhesions that form after hernia repairs and operations on the abdominal organs. Adhesive obstruction often complicates surgical interventions in the lower abdominal cavity. In developing countries, among the causes of obstruction, strangulation of an external abdominal hernia ranks first. Volvulus is a pathological torsion of an intestinal loop. The most common cases are volvulus of the sigmoid (70-80% of cases) and cecum (10-20%). Volvulus sigmoid colon observed with an excessively long mesentery (dolichosigma); constipation is often a provoking factor. Volvulus of the cecum is possible with a congenital violation of its fixation (mobile cecum). Mental disorders, advanced age and a sedentary lifestyle predispose to colonic volvulus. A loop of the small intestine can twist around a commissure or congenital cord of the peritoneum. When the small intestine is pinched at two points at once (by adhesions or hernial orifices), a “switched off” intestinal loop is formed. Sometimes the cause of obstruction is a large mass formation that compresses the large or small intestine from the outside.

B. Intestinal pathology.

Among intestinal diseases that cause intestinal obstruction, the most common are tumors. Colon tumors are more common than small intestinal tumors. In 50-70% of cases, colonic obstruction is caused by cancer; In 20% of patients with colon cancer, acute intestinal obstruction first manifests itself. Intestinal obstruction is typical for tumor localization in the left half of the colon. Volvulus and diverticulitis also more often affect the left half of the colon and are the second most common cause of colonic obstruction.

Table 1. Causes of intestinal obstruction

Mechanical Pathology of the peritoneum, abdominal organs and abdominal walls Abdominal hernias (external and internal) Volvulus (small, sigmoid, cecum) Congenital cords of peritoneum Compression of the intestine from the outside (tumor, abscess, hematoma, vascular anomaly, endometriosis) Intestinal pathology Tumors (benign, malignant, metastases) Inflammatory diseases (Crohn's disease, diverticulitis, radiation enteritis) Developmental defects (atresia, stenosis, aplasia) Intussusception Trauma (hematoma duodenum, especially against the background of the administration of anticoagulants and hemophilia) Obstruction of the intestine Foreign bodies Gallstones Fecal stones Barium suspension Helminthiasis (tangle of roundworms)

Functional Spasmodic obstruction Hirschsprung's disease Pseudo-obstruction of the intestine -Acute disorders of mesenteric circulation -Occlusion mesenteric artery - Occlusion of the mesenteric vein

In newborns, intestinal obstruction in most cases is caused by atresia. Atresia of the esophagus, anus and rectum are more common than atresia of the small intestine. Other causes of obstruction in newborns, in descending order of frequency, include: Hirschsprung's disease, incomplete intestinal rotation (Ladd's syndrome), and imeconium obstruction.

B. Obstruction of the intestine.

Intestinal obstruction may be caused by ingested or injected anus foreign body. Less common is blockage of the colon with fecal stones and barium suspension; even more rarely - cholelithiasis. Gallstone, released into the intestinal lumen, usually gets stuck in the area of ​​the ileocecal valve.

D. Paralytic intestinal obstruction develops in almost every patient who has undergone abdominal surgery. Other common causes include pancreatitis, appendicitis, pyelonephritis, pneumonia, thoracic and lumbar fractures. parts of the spine, electrolyte disturbances. A list of causes of paralytic ileus is presented in Table 2.

D. Spastic obstruction is extremely rare - with salt poisoning heavy metals, uremia, porphyria.

E. Hirschsprung's disease (congenital aganglionosis of the colon) in newborns and children in the first months of life can be complicated by intestinal obstruction.

G. Pseudo-obstruction of the intestine is a chronic disease characterized by disorders of gastrointestinal motility (usually the small intestine, less often the large intestine and esophagus). Attacks of the disease occur with a clear clinical picture of mechanical obstruction, which is not confirmed either radiographically or during surgery. Sometimes the disease is familial in nature, sometimes combined with autonomic neuropathy or myopathy. However, in most cases the cause cannot be determined. When making a diagnosis, you need to rely on X-ray data; sometimes a diagnostic laparotomy is necessary. Timely differential diagnosis can reduce mortality and severity of complications of mechanical intestinal obstruction.

Table 2. Causes of paralytic ileus

Diseases of the peritoneum and abdominal organs: Inflammation, infection (appendicitis, cholecystitis, pancreatitis) Peritonitis: bacterial (intestinal perforation), aseptic (bile, pancreatic juice, gastric juice) Dehiscence of the surgical wound Mesenteric artery embolism Thrombosis of the mesenteric vein* or artery Intestinal ischemia: shock*, heart failure, use of vasoconstrictors Blunt abdominal trauma* Acute gastric dilatation Hirschsprung's disease Aortoarteritis (Takayasu's disease) with damage to the mesenteric arteries Diseases of the retroperitoneal and pelvic organs Infections: pyelonephritis, paranephritis Ureteral stone, ureteral obstruction Retroperitoneal hematoma: trauma, hemophilia, anticoagulant therapy Tumor: primary (sarcoma, lymphoma) or metastasis Urinary retention Incarceration of the spermatic cord, testicular torsion Pelvic fracture Central nervous system diseases Spinal fracture: lumbar or thoracic Trauma, brain tumor or spinal cord Meningitis Lung diseases and of cardio-vascular system Pulmonary embolism Pneumonia, especially lower lobe Empyema of the pleura Emphysema Intoxication and metabolic disorders Potassium deficiency Sodium deficiency Medicines: ganglion blockers, anticholinergics Diabetic ketoacidosis, diabetic neuropathy Lead poisoning Porphyria Note: * Intestinal necrosis is possible.

H. Acute disorders of mesenteric circulation.

Mesenteric artery occlusion may result from embolism or progressive atherosclerosis; it accounts for 75% of cases of obstruction caused by acute circulatory disorders. Mesenteric vein thrombosis accounts for the remaining 25%. Thrombosis of mesenteric veins often develops against the background of reduced perfusion. All types of acute circulatory disorders can lead to intestinal necrosis and are accompanied by high mortality, especially among the elderly.

II. Pathogenesis

A. Accumulation of gas in the intestine is the leading symptom of intestinal obstruction. Violation of the passage of intestinal contents is accompanied by intensive growth of aerobic and anaerobic bacteria that produce methane and hydrogen. However, most of the intestinal gas is swallowed air, the movement of which through the intestines is also impaired.

Normally, the gastrointestinal glands secrete about 6 liters of fluid during the day, most of which is absorbed in the small and large intestines. Stretching of the intestinal loops during obstruction further stimulates secretion, but inhibits absorption. The result is vomiting, which leads to loss of fluid and electrolytes. Hypokalemia and metabolic alkalosis develop.

B. Mechanical intestinal obstruction, in which blood circulation in the intestinal wall is disrupted, is called strangulation. This can occur when the intestine or its mesentery is strangulated, as well as when the pressure in the intestinal lumen exceeds intravascular pressure. As a result, ischemia, necrosis and perforation of the intestine develop. Early diagnosis of strangulation obstruction and urgent surgical intervention can prevent intestinal perforation, reduce the severity of the disease and reduce mortality. Preoperative preparation should be quick and include correction water and electrolyte disturbances.

B. Obstructive obstruction of the colon in cancer and diverticulitis is rarely accompanied by circulatory disorders. The exception is cases when the function of the ileocecal valve is preserved. In this case, the colon continues to stretch until perforation occurs. According to Laplace's law, the tension of the tube wall is directly proportional to its radius and internal pressure. Perforation most often occurs in the cecum, which has the largest radius and is therefore subject to greater distension than other parts of the colon. If the diameter of the cecum exceeds 10-12 cm, the likelihood of perforation is especially high.

III. Clinical picture

The clinical picture depends on the type of intestinal obstruction and the level of obstruction (Table 3). The main symptoms are nausea, vomiting, abdominal pain, bloating, stool and gas retention. Symptoms of peritoneal irritation are a sign of necrosis or perforation of the intestine. Leukocytosis (or leukopenia), fever, tachycardia, localized pain on palpation of the abdomen indicate an extremely serious condition of the patient (especially if all four signs are present).

During a physical examination, attention is paid to postoperative scars and strangulated hernias, sometimes this allows an immediate diagnosis. A rectal examination (fecal stones) and a stool test for occult blood are required. Blood in the stool may be due to Crohn's disease. malignant tumor, intestinal necrosis or diverticulitis. If an enlarged liver with a lumpy surface is palpated, a metastatic tumor can be assumed. Auscultation of the lungs can reveal pneumonia, one of the causes of paralytic intestinal obstruction.

IV. X-ray examination

If intestinal obstruction is suspected, first of all, a survey X-ray of the abdominal cavity (standing and lying on the back) and chest (in the posterior non-anterior and lateral projections) is performed. A chest x-ray can rule out pneumonia. Using a CT scan of the abdomen, the level and cause of intestinal obstruction can be determined.

Table 3. Clinical picture for various types of intestinal obstruction

Type of obstruction	Bloating, Vomiting			Bowel sounds	Pain on palpation
Without circulatory disturbance High small intestinal	Cramping, in the middle and upper third of the abdomen		Appears at an early stage, mixed with bile, persistent		Weak, spilled
Low small intestinal	Cramping, in the middle third of the abdomen	Appears at an early stage	Appears in later stages with stool odor	Strengthened, waxing and waning in waves	Weak, spilled
Colon	Cramping, in the middle and lower third of the abdomen	Appears in later stages	Appears very late with fecal odor	Usually reinforced	Weak, spilled
Strangulation	Constant, strong, sometimes localized		Persistent	Usually weakened but no clear pattern	Strong, localized
Paralytic	Light, spilled	Appears very early		Weakened	Weak, spilled
Obstruction caused by acute disorders of mesenteric circulation	Constant, in the middle third of the abdomen or back, can be very strong	Appears at an early stage		Weakened or absent	Strong, diffuse or localized
The number of crosses reflects the severity of symptoms

Table 4. Radiological signs of intestinal obstruction

	Paralytic obstruction	Mechanical obstruction
Gas in the stomach
Gas in the intestinal lumen	Scattered throughout the large and small intestine	Just proximal to the obstacle
Fluid in the intestinal lumen
Kloiber cups (X-ray in supine position)
Kloiber cups (standing X-ray)
Fluid levels in adjacent limbs of the intestinal loop (standing radiograph)	They have approximately the same height - the arches, similar to inverted letters U, occupy mainly the middle third of the abdomen	They have different heights - arches that look like inverted letters J. The number of crosses reflects the severity of symptoms
The number of crosses reflects the severity of symptoms

A. X-rays of the abdominal cavity reveal the accumulation of a large amount of gas in the intestinal lumen (Fig. 1). Usually, from the images it is possible to determine which loops of the intestine - small, large, or both - are distended with gas. In the presence of gas in the small intestine, spiral folds of the mucous membrane are clearly visible, occupying the entire diameter of the intestine (Fig. 2). When gas accumulates in the colon, haustrae are visible, which occupy only part of the diameter of the intestine (Fig. 3).

B. With mechanical small intestinal obstruction, there is little or no gas in the colon. With colonic obstruction and intact function of the ileocecal valve, significant swelling of the colon is noted; there may be no gas in the small intestine. Insufficiency of the ileocecal valve leads to distension of both the small and large intestines.

B. Radiographs taken in the standing or lateral decubitus position usually show horizontal levels of fluid and gas. Gas-filled intestinal loops look like overturned cups (Kloiber cups) or arches that look like inverted letters J and U. It can be quite difficult to distinguish paralytic intestinal obstruction from mechanical small bowel obstruction using plain fluoroscopy (Table 4). This requires an X-ray contrast examination of the intestine (with rapid injection of barium or water-soluble contrast into the jejunum through a pasogastric tube). If colonic obstruction is suspected, X-ray contrast studies are contraindicated.

V. Treatment

A. Mechanical intestinal obstruction, as a rule, requires urgent surgical intervention. The duration of the operation is determined by the severity metabolic disorders, duration of occurrence and type of obstruction (if strangulation obstruction is suspected, surgery cannot be postponed). In the preoperative period it is carried out infusion therapy and correction of water and electrolyte disturbances, and also begin intestinal decompression through a nasogastric or long intestinal tube. Antibiotics are prescribed, especially if strangulation obstruction is suspected.

B. The operation can be delayed for following cases:

1. If intestinal obstruction develops in the early postoperative period, intestinal decompression is performed using a nasogastric or long intestinal tube. After some time, the adhesions may resolve and intestinal patency is restored.

2. In case of peritoneal carcinomatosis, they try to avoid surgery and perform intestinal decompression through nasogastric tube. Typically, intestinal patency is restored within three days. If intestinal obstruction in such patients is not due to a tumor, but to another reason, surgical intervention can significantly improve the condition.

3. Intestinal obstruction during exacerbation of Crohn's disease can be resolved with medication and intestinal decompression through a nasogastric or long intestinal tube.

4. With intussusception in children, it is possible conservative treatment: observation and careful attempts to straighten the intussusception using hydrostatic pressure (barium enemas). In adults, this method is not applicable because it does not eliminate the underlying disease that caused the intussusception; urgent surgical intervention is indicated.

5. In case of chronic partial intestinal obstruction and radiation enteritis, surgery can be delayed only if there is no suspicion of strangulation obstruction.

B. The type of operation is determined by the cause of obstruction, the condition of the intestine and other surgical findings. Dissection of adhesions, hernia repair with plastic surgery of the hernial orifice (for internal and external abdominal hernias) are used. In case of space-occupying formations that obstruct the intestinal lumen, it may be necessary to create a bypass intestinal anastomosis, to create a colostomy proximal to the obstruction, or to perform intestinal resection followed by restoration of intestinal continuity.

There is still no consensus regarding the optimal treatment tactics for recurrent small intestinal mechanical obstruction. Two methods have been proposed: “splinting” the small intestine with a long intestinal tube and enteroplication.

From the editor

Rice. 1. Scheme of gas accumulation in the intestinal lumen in various types of intestinal obstruction.

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.

Acute intestinal obstruction. Classification, diagnosis, treatment tactics

Zmushko Mikhail Nikolaevich
Surgeon, 2nd category, resident 1st TMO, Kalinkovichi, Belarus.

Send comments, feedback and suggestions to: [email protected]
Personal website: http:// mishazmushko.at.tut.by

Acute intestinal obstruction (AIO) is a syndrome characterized by impaired passage of intestinal contents in the direction from the stomach to the rectum. Intestinal obstruction complicates the course various diseases. Acute intestinal obstruction (AIO) is a syndromic category that combines the complicated course of diseases and pathological processes of various etiologies that form the morphological substrate of AIO.

Predisposing factors for acute intestinal obstruction:

1. Congenital factors:

Features of anatomy (elongation of sections of the intestine (megacolon, dolichosigma)). Developmental anomalies (incomplete intestinal rotation, aganglionosis (Hirschsprung's disease)).

2. Acquired factors:

Adhesive process in the abdominal cavity. Neoplasms of the intestines and abdominal cavity. Intestinal foreign bodies. Helminthiases. Cholelithiasis. Abdominal wall hernias. Unbalanced irregular diet.

Producing factors of acute intestinal obstruction:

• A sharp increase in intra-abdominal pressure.

OKN is 3.8% of all urgent illnesses abdominal cavity. In 53% of people over 60 years of age, the cause of acute intestinal intestinal cancer is colon cancer. Frequency of occurrence of OKN by obstacle level:

Small intestine 60-70%

Colon 30-40%

Frequency of occurrence of OKN by etiology:

In acute small intestinal obstruction: - adhesive in 63%

Strangulation in 28%

Obstructive non-tumor origin in 7%

Other at 2%

In acute colonic obstruction: - tumor obstruction in 93%

Colonic volvulus in 4%

Other at 3%

Classification of acute intestinal obstruction:

A. By morphofunctional nature:

1. Dynamic obstruction: a) spastic; b) paralytic.

2. Mechanical obstruction: a) strangulation (volvulus, nodulation, strangulation; b) obstructive (intraintestinal form, extraintestinal form); c) mixed (intussusception, adhesive obstruction).

B. By obstacle level:

1. Small intestinal obstruction: a) High. b) Low.

2.Colonic obstruction.

IN clinical course OKN distinguishes three phases (O.S. Kochnev 1984) :

• The “ileus cry” phase. An acute disturbance of intestinal passage occurs, i.e. stage of local manifestations – lasts 2-12 hours (up to 14 hours). During this period, the dominant symptom is pain and local symptoms from the stomach.
• The intoxication phase (intermediate, stage of apparent well-being), a violation of intrawall intestinal hemocirculation occurs, lasts from 12 to 36 hours. During this period, the pain loses its cramping character, becomes constant and less intense. The abdomen is swollen and often asymmetrical. Intestinal peristalsis weakens, sound phenomena are less pronounced, and the “noise of a falling drop” is heard. Complete retention of stool and gases. Signs of dehydration appear.
• Peritonitis phase (late, terminal stage) – occurs 36 hours after the onset of the disease. This period is characterized by severe functional hemodynamic disorders. The abdomen is significantly distended, peristalsis cannot be heard. Peritonitis develops.

The phases of the course of OKN are conditional and for each form of OKN they have their own differences (with strangulation CI, phases 1 and 2 begin almost simultaneously.

Classification of acute endotoxicosis in CI:

Zero stage.
Endogenous toxic substances (ETS) enter the interstitium and transport media from the pathological focus. Endotoxicosis is not clinically evident at this stage.

The stage of accumulation of products of primary affect.
Through the flow of blood and lymph, the ETS spreads in internal environments. At this stage, it is possible to detect an increase in the concentration of ETS in biological fluids.

Stage of decompensation of regulatory systems and auto-aggression.
This stage is characterized by tension and subsequent depletion of the function of histohematic barriers, the beginning of excessive activation of the hemostatic system, kallikrein-kinin system, and lipid peroxidation processes.

Stage of metabolic perversion and homeostatic failure.
This stage becomes the basis for the development of multiple organ failure syndrome (or multiple organ failure syndrome).

The stage of disintegration of the body as a whole.
This is the terminal phase of the destruction of intersystem connections and the death of the organism.

Causes of dynamic acute intestinal obstruction:

1. Neurogenic factors:

A. Central mechanisms: Traumatic brain injury. Ischemic stroke. Uremia. Ketoacidosis. Hysterical ileus. Dynamic obstruction due to mental trauma. Spinal cord injuries.

B. Reflex mechanisms: Peritonitis. Acute pancreatitis. Abdominal injuries and operations. Injuries of the chest, large bones, combined injuries. Pleurisy. Acute myocardial infarction myocardium. Tumors, injuries and wounds of the retroperitoneal space. Nephrolithiasis and renal colic. Worm infestation. Rough food (paralytic ileus), phytobezoars, fecal stones.

2. Humoral and metabolic factors: Endotoxicosis of various origins, including in acute surgical diseases. Hypokalemia, as a consequence of uncontrollable vomiting of various origins. Hypoproteinemia due to acute surgical disease, wound losses, nephrotic syndrome, etc.

3. Exogenous intoxication: Poisoning with salts of heavy metals. Food intoxication. Intestinal infections (typhoid fever).

4. Dyscirculatory disorders:

A. At the level great vessels: Thrombosis and embolism of mesenteric vessels. Vasculitis of mesenteric vessels. Arterial hypertension.

B. At the level of microcirculation: Acute inflammatory diseases of the abdominal organs.

Clinic.

Square of symptoms in CI.

· Abdominal pain. The pain is paroxysmal, cramping in nature. Patients have cold sweat, pale skin (with strangulation). Patients await the next attacks with horror. The pain may subside: for example, there was a volvulus, and then the intestine straightened, which led to the disappearance of pain, but the disappearance of pain is a very insidious sign, since with strangulation CI necrosis of the intestine occurs, which leads to the death of nerve endings, therefore, the pain disappears.

· Vomit. Repeated, first with the contents of the stomach, then with the contents of 12 p.c. (note that vomiting bile comes from 12 p.c.), then vomiting appears with an unpleasant odor. The tongue with CI is dry.

Bloating, abdominal asymmetry

· Retention of stool and gases is a formidable symptom that indicates CI.

Bowel sounds may be heard, even at a distance, and increased peristalsis is visible. You can palpate a swollen loop of intestine - Val's symptom. It is imperative to examine patients per rectum: the rectal ampulla is empty - Grekov’s symptom or the Obukhov hospital symptom.

Survey fluoroscopy of the abdominal organs: this non-contrast study is the appearance of Kloiber's cups.

Differential diagnosis:

OKN has a number of signs that are also observed in other diseases, which necessitates differential diagnosis between OKN and diseases that have similar clinical signs.

Acute appendicitis. Common signs are abdominal pain, stool retention, vomiting. But pain with appendicitis begins gradually and does not reach the same intensity as with obstruction. With appendicitis, the pain is localized, and with obstruction, it is cramping in nature and more intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction, and not appendicitis. At acute appendicitis There are no radiological signs characteristic of obstruction.

Perforated ulcer of the stomach and duodenum. General symptoms are sudden onset, severe abdominal pain, stool retention. However, with a perforated ulcer the patient takes a forced position, and with intestinal obstruction the patient is restless and often changes position. Vomiting is not typical for a perforated ulcer, but is often observed with intestinal obstruction. With a perforated ulcer, the abdominal wall is tense, painful, and does not participate in the act of breathing, while with acute intestinal ulcers, the abdomen is swollen, soft, and slightly painful. With a perforated ulcer, from the very beginning of the disease there is no peristalsis, and the “splashing noise” is not heard. Radiologically, with a perforated ulcer, free gas in the abdominal cavity is determined, and with OKN, Kloiber cups, arcades, and a symptom of pennation.

Acute cholecystitis. Pain in acute cholecystitis is constant, localized in the right hypochondrium, radiating to the right scapula. With OKN, the pain is cramping and non-localized. For acute cholecystitis hyperthermia is characteristic, which does not happen with intestinal obstruction. Enhanced peristalsis, sound phenomena, and radiological signs of obstruction are absent in acute cholecystitis.

Acute pancreatitis. Common signs are the sudden onset of severe pain, severe general condition, frequent vomiting, bloating and stool retention. But with pancreatitis, the pain is localized in the upper abdomen and is girdling and not cramping in nature. A positive Mayo-Robson sign is noted. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. Radiologically, with pancreatitis, a high position of the left dome of the diaphragm is noted, and with obstruction, Kloiber's cups, arcades, and transverse striations are noted.

With intestinal infarction, as with acute infarction, severe sudden pain in the abdomen, vomiting, severe general condition, and a soft abdomen are noted. However, pain during intestinal infarction is constant, peristalsis is completely absent, abdominal bloating is slight, there is no asymmetry of the abdomen, and “dead silence” is determined by auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a wide range of sound phenomena are heard, and abdominal bloating is more significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, and high leukocytosis (20-30 x10 9 /l) is pathognomonic.

Renal colic and acute insufficiency have similar symptoms - severe abdominal pain, bloating, stool and gas retention, restless behavior of the patient. But pain in renal colic radiates to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive Pasternatsky sign. On a plain radiograph, shadows of stones may be visible in the kidney or ureter.

With pneumonia, abdominal pain and bloating may appear, which gives reason to think about intestinal obstruction. However, pneumonia is characterized heat, rapid breathing, blush on the cheeks, and physical examination reveals crepitating rales, pleural friction noise, bronchial breathing, dullness of pulmonary sound. X-ray examination can detect a pneumonic focus.

In myocardial infarction there may be sharp pains in the upper abdomen, bloating, sometimes vomiting, weakness, decreased blood pressure, tachycardia, that is, signs reminiscent of strangulation intestinal obstruction. However, with myocardial infarction there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. An electrocardiographic study helps clarify the diagnosis of myocardial infarction.

Scope of examination for acute intestinal obstruction:

IN mandatory by cito: General urine test, general blood test, blood glucose, blood group and Rhesus affiliation, per rectum (reduced sphincter tone and empty ampoule; possible fecal stones (as a cause of obstruction) and mucus with blood during intussusception, tumor obstruction, mesenteric OKN ), ECG, radiography of the abdominal organs in a vertical position.

According to indications: total protein, bilirubin, urea, creatinine, ions; Ultrasound, x-ray of the chest organs, passage of barium through the intestines (performed to exclude CI), sigmoidoscopy, irrigography, colonoscopy, consultation with a therapist.

Diagnostic algorithm for OKN:

A. Taking an anamnesis.

B. Objective examination of the patient:

1. General examination: Neuropsychic status. Ps and blood pressure (bradycardia - more often strangulation). Examination of the skin and mucous membranes. Etc.

2. Objective examination of the abdomen:

a) Ad oculus: Abdominal bloating, possible asymmetry, involvement in breathing.

b) Inspection of hernial rings.

c) Superficial palpation of the abdomen: identification of local or widespread protective tension in the muscles of the anterior abdominal wall.

d) Percussion: revealing tympanitis and dullness.

e) Primary auscultation of the abdomen: assessment of unprovoked motor activity of the intestines: metallic hue or gurgling, in the late stage - the sound of a falling drop, weakened peristalsis, listening to heart sounds.

f) Deep palpation: determine the pathological formation of the abdominal cavity, palpate internal organs, determine local pain.

g) Repeated auscultation: assess the appearance or intensification of bowel sounds, identify Sklyarov’s symptom (splashing noise).

h) Identify the presence or absence of symptoms characteristic of OKN (see below).

B. Instrumental research:

X-ray examinations (see below).

RRS. Colonoscopy (diagnostic and therapeutic).

Irrigoscopy.

Laparoscopy (diagnostic and therapeutic).

Computer diagnostics (CT, MRI, programs).

D. Laboratory research.

X-ray examination is the main special method for diagnosing OKN. In this case, the following signs are revealed:

• Kloiber's bowl is a horizontal level of liquid with a dome-shaped clearing above it, which looks like a bowl turned upside down. With strangulation obstruction, they can appear within 1 hour, and with obstructive obstruction - after 3-5 hours from the moment of illness. The number of bowls varies, sometimes they can be layered one on top of the other in the form of a stepped staircase.
• Intestinal arcades. They occur when the small intestine becomes distended with gases, while horizontal levels of fluid are visible in the lower arcades.
• The symptom of pinnateness (transverse striations in the form of an extended spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular folds of the mucosa. Contrast examination of the gastrointestinal tract is used when there are difficulties in diagnosing intestinal obstruction. The patient is given 50 ml of barium suspension to drink and a dynamic study of the barium passage is carried out. A delay of up to 4-6 hours or more gives reason to suspect a violation of intestinal motor function.

X-ray diagnosis of acute intestinal obstruction. Already 6 hours after the onset of the disease, there are radiological signs of intestinal obstruction. Pneumatosis of the small intestine is initial symptom, gas is normally found only in the colon. Subsequently, fluid levels in the intestines are determined ("Kloiber cups"). Fluid levels localized only in the left hypochondrium indicate high obstruction. It is necessary to distinguish between small and large intestinal levels. At small intestinal levels, vertical dimensions prevail over horizontal ones, semilunar folds of the mucous membrane are visible; in the large intestine, the horizontal dimensions of the level prevail over the vertical ones, and haustration is determined. X-ray contrast studies with barium administered through the mouth in case of intestinal obstruction are impractical; this contributes to complete obstruction of the narrowed segment of the intestine. Taking water-soluble contrast agents for obstruction promotes fluid sequestration (all radiocontrast agents are osmotically active); their use is possible only if they are administered through a nasointestinal tube with aspiration after the study.
An effective means of diagnosing colonic obstruction and, in most cases, its cause is irrigoscopy. Colonoscopy for colonic obstruction is undesirable, since it leads to the entry of air into the afferent loop of the intestine and may contribute to the development of its perforation.

Tall and narrow bowls in the large intestine, low and wide in the small intestine; not changing position - with dynamic OKN, changing - with mechanical one.
Contrast study carried out in doubtful cases, in subacute cases. Lag passage of barium into the cecum for more than 6 hours against the background of drugs that stimulate peristalsis - evidence of obstruction (normally, barium enters the caecum after 4-6 hours without stimulation).

Indications to conduct studies using contrast in case of intestinal obstruction are:

To confirm the exclusion of intestinal obstruction.

In doubtful cases, if intestinal obstruction is suspected for the purpose of differential diagnosis and complex treatment.

Adhesive OKN in patients who have repeatedly undergone surgical interventions, with relief of the latter.

Any form of small intestinal obstruction (with the exception of strangulation), when, as a result of active conservative measures in the early stages of the process, visible improvement can be achieved. In this case, there is a need to objectively confirm the legitimacy of conservative tactics. The basis for stopping a series of Rg-grams is to detect the flow of contrast into the colon.

Diagnosis of early postoperative obstruction in patients undergoing gastric resection. The absence of pyloric sphincter ensures the unimpeded flow of contrast into the small intestine. In this case, detection of the stop-contrast phenomenon in the outlet loop serves as an indication for early relaparotomy.

We should not forget that when the contrast agent does not enter the large intestine or is retained in the stomach, and the surgeon, who has focused his main attention on monitoring the progress of the contrast mass, creates the illusion of active diagnostic activity, justifying in his own eyes therapeutic inactivity. In this regard, recognizing in doubtful cases the known diagnostic value of radiocontrast studies, it is necessary to clearly define the conditions that allow their use. These conditions can be formulated as follows:

1. X-ray contrast examination for diagnosing OKN can only be used with complete conviction (based on clinical data and results plain radiography abdominal cavity) in the absence of a strangulation form of obstruction, which poses a threat of rapid loss of viability of the strangulated intestinal loop.

2. Dynamic monitoring of the progress of the contrast mass must be combined with clinical observation, during which changes in local physical data and changes in the general condition of the patient are recorded. In the event of worsening local signs of obstruction or the appearance of signs of endotoxemia, the issue of emergency surgery should be discussed regardless of radiological data characterizing the progress of contrast through the intestine.

3. If a decision is made on dynamic observation of the patient with control over the passage of the contrast mass through the intestines, then such observation should be combined with therapeutic measures aimed at eliminating the dynamic component of obstruction. These measures consist mainly of the use of anticholinergic, anticholinesterase and ganglion blocking agents, as well as conduction (perinephric, sacrospinal) or epidural blockade.

The possibilities of X-ray contrast examination for diagnosing OKN are significantly expanded when using the technique enterography. The study is carried out using a fairly rigid probe, which, after emptying the stomach, is passed through the pyloric sphincter into the duodenum. Through the probe, if possible, completely remove the contents from the proximal sections jejunum, and then under a pressure of 200-250 mm water. Art. 500-2000 ml of 20% barium suspension prepared in an isotonic sodium chloride solution is injected into it. Dynamic X-ray observation is carried out for 20-90 minutes. If during the examination liquid and gas again accumulate in the small intestine, the contents are removed through a probe, after which the contrast suspension is reintroduced.

The method has a number of advantages. Firstly, decompression of the proximal intestine, provided for by the technique, not only improves research conditions, but is also important therapeutic measure with acute intestinal insufficiency, as it helps restore blood supply to the intestinal wall. Secondly, the contrast mass introduced below the pyloric sphincter is able to move much faster to the level of the mechanical obstacle (if it exists) even in the conditions of incipient paresis. In the absence of a mechanical obstruction, the time of passage of barium into the large intestine is normally 40-60 minutes.

Treatment tactics for acute intestinal obstruction.

Currently, active tactics have been adopted for the treatment of acute intestinal obstruction.

All patients diagnosed with ACI are operated on after preoperative preparation (which should last no more than 3 hours), and if strangulation CI is diagnosed, then the patient is taken after a minimum volume of examination immediately to the operating room, where preoperative preparation is carried out by an anesthesiologist together with a surgeon (within more than 2 hours from the moment of admission).

Emergency(i.e., performed within 2 hours from the moment of admission) the operation is indicated for OKN in the following cases:

1. In case of obstruction with signs of peritonitis;

2. In case of obstruction with clinical signs of intoxication and dehydration (that is, in the second phase of the course of OKN);

3. In cases where, based on the clinical picture, one gets the impression that there is a strangulation form of OKN.

All patients with suspected OKN immediately from the emergency room should begin to carry out a set of diagnostic and treatment measures within 3 hours (if strangulation CI is suspected, no more than 2 hours) and if during this time OKN is confirmed or not excluded, surgical treatment is absolutely indicated. And the complex of diagnostic and treatment measures carried out will constitute preoperative preparation. All patients who have been excluded from acute insufficiency are given barium to control passage through the intestines. It is better to operate on adhesive disease than to miss adhesive OKN.

Complex of diagnostic and treatment measures and preoperative preparation include:

• Impact on the autonomic nervous system - bilateral perinephric novocaine blockade
• Decompression of the gastrointestinal tract by aspiration of the contents through a nasogastric tube and siphon enema.
• Correction of water and electrolyte disorders, detoxification, antispasmodic therapy, treatment of enteral insufficiency.

Restoration of intestinal function is facilitated by decompression of the gastrointestinal tract, since intestinal bloating entails disruption of capillary, and later venous and arterial circulation in the intestinal wall and progressive deterioration of intestinal function.

To compensate for water and electrolyte disturbances, a Ringer-Locke solution is used, which contains not only sodium and chlorine ions, but also all the necessary cations. To compensate for potassium losses, potassium solutions are included in the infusion media along with glucose solutions with insulin. In the presence of metabolic acidosis, sodium bicarbonate solution is prescribed. With acute insufficiency, a deficit in circulating blood volume develops mainly due to the loss of the plasma part of the blood, so it is necessary to administer solutions of albumin, protein, plasma, and amino acids. It should be remembered that the administration of only crystalloid solutions in case of obstruction only promotes fluid sequestration; it is necessary to administer plasma-substituting solutions, protein preparations in combination with crystalloids. To improve microcirculation, rheopolyglucin with complamin and trental is prescribed. The criterion for an adequate volume of administered infusion media is the normalization of circulating blood volume, hematocrit, central venous pressure, and increased diuresis. Hourly diuresis should be at least 40 ml/hour.

The passage of copious amounts of gas and feces, cessation of pain and improvement of the patient’s condition after conservative measures indicate the resolution (exclusion) of intestinal obstruction. If conservative treatment does not have an effect within 3 hours, then the patient must be operated on. The use of drugs that stimulate peristalsis in doubtful cases reduces the diagnostic time, and if the effect is positive, they exclude OKN.

Protocols of surgical tactics for acute intestinal obstruction

1. Surgery for acute insufficiency is always performed under anesthesia by 2-3 medical teams.

2. At the stage of laparotomy, revision, identification of the pathomorphological substrate of obstruction and determination of the operation plan, the participation in the operation of the most experienced surgeon of the duty team, as a rule, the responsible surgeon on duty, is mandatory.

3. For any localization of obstruction, access is midline laparotomy, if necessary, with excision of scars and careful dissection of adhesions at the entrance to the abdominal cavity.

4. Operations for OKN involve sequential solution of the following tasks:

Establishing the cause and level of obstruction;

Before manipulations with the intestines, it is necessary to carry out a novocaine blockade of the mesentery (if there is no oncological pathology);

Elimination of the morphological substrate of OKN;

Determining the viability of the intestine in the obstruction zone and determining the indications for its resection;

Establishing the boundaries of resection of the changed intestine and its implementation;

Determination of indications for drainage of the intestinal tube and choice of drainage method;

Sanitation and drainage of the abdominal cavity in the presence of peritonitis.

5. Detection of an area of ​​obstruction immediately after laparotomy does not relieve the need for a systematic audit of the condition of the small intestine along its entire length, as well as the large intestine. The revision is preceded by mandatory infiltration of the mesenteric root with a solution local anesthetic. In case of severe overflow of the intestinal loops with contents, before the revision, decompression of the intestine is performed using a gastrojejunal tube.

6. Clearing the obstruction is the key and most difficult component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of multiple adhesions; resection of altered intestine; elimination of torsions, intussusceptions, nodules or resection of these formations without preliminary manipulations on the altered intestine.

7. When determining the indications for intestinal resection, visual signs are used (color, swelling of the wall, subserous hemorrhages, peristalsis, pulsation and blood filling of the parietal vessels), as well as the dynamics of these signs after the injection of a warm solution of local anesthetic into the intestinal mesentery.

The viability of the intestine is assessed clinically based on the following symptoms (the main ones are pulsation of the mesenteric arteries and the state of peristalsis):

Intestinal color (bluish, dark purple or black coloring of the intestinal wall indicates deep and, as a rule, irreversible ischemic changes in the intestine).

The condition of the serous membrane of the intestine (normally, the peritoneum covering the intestine is thin and shiny; with intestinal necrosis, it becomes swollen, dull, dull).

The state of peristalsis (the ischemic intestine does not contract; palpation and tapping do not initiate a peristaltic wave).

The pulsation of the mesenteric arteries, which is clear normally, is absent in vascular thrombosis that develops during prolonged strangulation.

If there are doubts about the viability of the intestine over a large area, it is permissible to postpone the decision on resection, using a programmed relaparotomy after 12 hours or laparoscopy. The indication for bowel resection in acute intestinal tract is usually bowel necrosis.

8. When deciding on the boundaries of resection, you should use protocols developed on the basis clinical experience: retreat from the visible boundaries of the violation of the blood supply to the intestinal wall towards the adductor section by 35-40 cm, and towards the efferent section 20-25 cm. The exception is resection near the ligament of Treitz or the ileocecal angle, where it is possible to limit these requirements with favorable visual characteristics of the intestine in area of ​​the proposed intersection. In this case, control indicators are necessarily used: bleeding from the vessels of the wall when crossing it and the condition of the mucous membrane. It is also possible to use | transillumination or other objective methods of assessing blood supply.

9. If indicated, drain the small intestine. Indications see below.

10. In case of colorectal tumor obstruction and there are no signs of inoperability, one-stage or two-stage operations are performed depending on the stage tumor process and severity of manifestations of colonic obstruction.

If the cause of obstruction cancer tumor, various tactical options can be taken.

A. For a tumor of the cecum, ascending colon, hepatic angle:

· Without signs of peritonitis, right hemicolonectomy is indicated.
· In case of peritonitis and serious condition of the patient - ileostomy, toilet and drainage of the abdominal cavity.
· In case of inoperable tumor and absence of peritonitis - iletotransversostomy

B. For a tumor of the splenic angle and descending colon:

· Without signs of peritonitis, left-sided hemicolonectomy and colostomy are performed.
· In case of peritonitis and severe hemodynamic disturbances, transversostomy is indicated.
· If the tumor is inoperable - bypass anastomosis, with peritonitis - transversostomy.
· For a tumor of the sigmoid colon - resection of the section of intestine with the tumor with the imposition of a primary anastomosis or Hartmann's operation, or the imposition of a double-barreled colostomy. The formation of a double-barreled colostomy is justified if it is impossible to resect the intestine against the background of decompensated OOCN.

11. Elimination of strangulation intestinal obstruction. In case of knot formation or torsion, remove the knot or torsion; in case of necrosis - intestinal resection; with peritonitis - intestinal stoma.
12. In case of intussusception, deintussusception and Hagen-Thorn mesosigmoplication are performed, in case of necrosis - resection, in case of peritonitis - ilestomy. If the intussusception is caused by Meckel's diverticulum, resection of the intestine along with the diverticulum and intussusception.
13. In case of adhesive intestinal obstruction, intersection of adhesions and elimination of “double-barreled guns” are indicated. In order to prevent adhesive disease, the abdominal cavity is washed with fibrinolytic solutions.
14. All operations on the colon end with devulsion of the external anal sphincter.
15. The presence of diffuse peritonitis requires additional sanitation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.

Decompression of the gastrointestinal tract.

Great importance in the fight against intoxication is attached to the removal of toxic intestinal contents that accumulate in the adductor section and intestinal loops. Emptying the afferent sections of the intestine provides intestinal decompression, intraoperative elimination of toxic substances from its lumen (detoxification effect) and improves the conditions for manipulation - resections, intestinal suturing, anastomoses. It is indicated in cases where the intestine is significantly distended with fluid and gas. It is preferable to evacuate the contents of the afferent loop before opening its lumen. The optimal option for such decompression is nasointestinal drainage of the small intestine according to Wangensteen. A long probe passed through the nose into the small intestine drains it throughout. After removal of intestinal contents, the tube may be left in place for prolonged decompression. In the absence of a long probe, intestinal contents can be removed through a probe inserted into the stomach or colon, or it can be expressed into the intestine to be resected.
Sometimes it is impossible to perform intestinal decompression without opening its lumen. In these cases, an enterotomy is made and the intestinal contents are evacuated using an electric suction. During this manipulation, it is necessary to carefully delimit the enterotomy opening from the abdominal cavity to prevent infection.

The main objectives of extended decompression are:

Removal of toxic contents from the intestinal lumen;

Carrying out intraintestinal detoxification therapy;

Impact on the intestinal mucosa to restore its barrier and functional consistency; early enteral nutrition of the patient.

Indications for small intestinal intubation(IA Eryukhin, VP Petrov) :

1. Paretic state of the small intestine.
2. Resection of the intestine or suturing of a hole in its wall in conditions of paresis or diffuse peritonitis.
3. Relaparotomy for early adhesive or paralytic intestinal obstruction.
4. Repeated surgery for adhesive intestinal obstruction. (Pakhomova GV 1987)
5. When applying primary colonic anastomoses for acute intestinal failure. (VS Kochurin 1974, LA Ender 1988, VN Nikolsky 1992)
6. Diffuse peritonitis in 2 or 3 tbsp.
7. The presence of an extensive retroperitoneal hematoma or retroperitoneal phlegmon in combination with peritonitis.

General rules for drainage of the small intestine:

Drainage is carried out with stable hemodynamic parameters. Before it is carried out, it is necessary to deepen the anesthesia and inject 100-150 ml of 0.25% novocaine into the root of the mesentery of the small intestine.

It is necessary to strive for intubation of the entire small intestine; It is advisable to advance the probe using pressure along its axis, and not by manually pulling it through the intestinal lumen; To reduce the invasiveness of the manipulation, the small intestine should not be emptied of liquid contents and gases until the end of intubation.

After drainage is completed, the small intestine is placed in the abdominal cavity in the form of 5-8 horizontal loops, and is covered with a greater omentum on top; The intestinal loops should not be fixed to each other using sutures, since the very placement of the intestine on the enterostomy tube in the specified order prevents their vicious arrangement.

To prevent the formation of bedsores in the intestinal wall, the abdominal cavity is drained with a minimum number of drains, which, if possible, should not come into contact with the intubated intestine.

Exists 5 main types of drainage of the small intestine.

1. Transnasal drainage of the small intestine throughout.
   This method is often called by the name Wangensteen or T. Miller and W. Abbot, although there is evidence that the pioneers of transnasal intubation of the intestine with the Abbott-Miller probe (1934) during surgery were G.A.Smith(1956) and J.C.Thurner (1958). This method decompression is most preferable due to its minimal invasiveness. The probe is inserted into the small intestine during surgery and is used simultaneously for both intraoperative and prolonged decompression of the small intestine. The disadvantage of the method is considered to be impaired nasal breathing, which can lead to a deterioration in the condition of patients with chronic lung diseases or provoke the development of pneumonia.
2. Method proposed J.M.Ferris and G.K.Smith in 1956 and described in detail in the domestic literature Y.M.Dederer(1962), intubation of the small intestine through a gastrostomy, does not have this drawback and is indicated in patients in whom passing a probe through the nose is impossible for some reason or in whom nasal breathing impairment due to the probe increases the risk of postoperative pulmonary complications.
3. Drainage of the small intestine through an enterostomy, for example, a method I.D. Zhitnyuk, which was widely used in emergency surgery before the advent of commercially available nasogastric intubation tubes. It involves retrograde drainage of the small intestine through a hanging ileostomy.
   (There is a method of antegrade drainage through a jejunostomy J. W. Baker(1959), separate drainage of proximal and distal sections small intestine through a hanging enterostomy White(1949) and their numerous modifications). These methods seem to be the least preferable due to possible complications from the side of enterostomy, the danger of the formation of an intestinal fistula at the site of enterostomy, etc.
4. Retrograde drainage of the small intestine through a microcecostomy ( G.Sheide, 1965) can be used if antegrade intubation is impossible.
   Perhaps the only drawback of the method is the difficulty of passing the probe through the valve of Bauhinius and disruption of the function of the ileocecal valve. Cecostoma after removal of the probe, as a rule, heals on its own. A variant of the previous method is the one proposed I.S. Mgaloblishvili(1959) method of drainage of the small intestine through an appendicostomy.
5. Transrectal small bowel drainage is used almost exclusively in pediatric surgery, although successful use of this method in adults has been described.

Numerous combined methods of drainage of the small intestine have been proposed, including elements of both closed (not associated with opening the lumen of the stomach or intestine) and open techniques.

For decompression and detoxification purposes, the probe is installed in the intestinal lumen for 3-6 days, the indication for removing the probe is the restoration of peristalsis and the absence of stagnant discharge from the probe (if this happened on the first day, then the probe can be removed on the first day). For frame purposes, the probe is installed for 6-8 days (no more than 14 days).

The presence of a probe in the intestinal lumen can lead to a number of complications. These are primarily bedsores and perforations of the intestinal wall, bleeding. With nasointestinal drainage, the development of pulmonary complications (purulent tracheobronchitis, pneumonia) is possible. Suppuration of wounds in the stoma area is possible. Sometimes nodular deformation of the probe in the intestinal lumen makes it impossible to remove it and requires surgical intervention. From the ENT organs (nosebleeds, necrosis of the wings of the nose, rhinitis, sinusitis, sinusitis, bedsores, laryngitis, laryngostenosis). To avoid complications that develop when removing the probe, a soluble probe made of synthetic protein is proposed, which dissolves on the 4th day after surgery ( D. Jung et al., 1988).

Decompression of the colon in case of colonic obstruction will be achieved colostomy. In some cases, transrectal drainage of the colon with a large tube is possible.

Contraindications to nasoenteric drainage:

• Organic disease of the upper gastrointestinal tract.
• Varicose veins of the esophagus.
• Esophageal stricture.
• Respiratory failure grade 2-3, severe cardiac pathology.
• When performing nasoenteric drainage is technically impossible or extremely traumatic due to technical difficulties (adhesions of the upper abdominal cavity, obstruction of the nasal passages and upper gastrointestinal tract, etc.).

Postoperative treatment of OKN includes the following mandatory areas:

Reimbursement of blood volume, correction of electrolyte and protein composition of the blood;

Treatment of endotoxicosis, including mandatory antibacterial therapy;

Restoration of motor, secretory and absorption functions of the intestine, that is, treatment of enteral insufficiency.

Literature:

1. Norenberg-Charkviani A. E. “Acute intestinal obstruction”, M., 1969;
2. Savelyev V. S. “Guide to emergency surgery of the abdominal organs”, M., 1986;
3. Skripnichenko D.F. " Emergency surgery abdominal cavity", Kyiv, "Zdorovya", 1974;
4. Hegglin R. « Differential diagnosis internal diseases", M., 1991.
5. Eryukhin, Petrov, Khanevich “Intestinal obstruction”
6. Abramov A.Yu., Larichev A.B., Volkov A.V. and others. The place of intubation decompression in the surgical treatment of adhesive small intestinal obstruction // Proc. report IX All-Russian Congress of Surgeons. - Volgograd, 2000.-P.137.
7. Results of treatment of acute intestinal obstruction // Proc. report IX All-Russian Congress of Surgeons.-Volgograd, 2000.-P.211.
8. Aliev S.A., Ashrafov A.A. Surgical tactics for obstructive tumor obstruction of the colon in patients with increased surgical risk/Grekov Journal of Surgery.-1997.-No. 1.-P.46-49.
9. Order of the Ministry of Health of the Russian Federation dated April 17, 1998 N 125 “On standards (protocols) for the diagnosis and treatment of patients with diseases of the digestive system.”
10. Practical guide for fourth year students of the Faculty of Medicine and Faculty sports medicine. Prof. V.M. Sedov, D.A. Smirnov, S.M. Pudyakov “Acute intestinal obstruction.”

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Application instrumental methods studies for suspected intestinal obstruction are intended both to confirm the diagnosis and to clarify the level and cause of the development of this pathological condition.

X-ray examination- basic special method diagnosis of acute intestinal obstruction. It should be carried out at the slightest suspicion of this condition. Typically, a plain fluoroscopy (x-ray) of the abdominal cavity is performed first. In this case, the following symptoms may be identified.

Intestinal arches(Fig. 48-1) occur when the small intestine is inflated with gases, while horizontal levels of liquid are visible in the lower knees of the arch, the width of which is inferior to the height of the gas column. They characterize the predominance of gas over the liquid contents of the intestine and occur, as a rule, in relatively earlier stages of obstruction.

Rice. 48-1. Plain radiograph of the abdominal cavity. The intestinal arches are visible.

Kloiber bowls(Fig. 48-2) - horizontal levels of liquid with a dome-shaped clearing (gas) above them, looking like a bowl turned upside down. If the width of the liquid level exceeds the height of the gas bubble, then most likely it is localized in the small intestine. The predominance of the vertical size of the bowl indicates the localization of the level in the colon. In conditions of strangulation obstruction, this symptom can occur within 1 hour, and in case of obstructive obstruction - after 3-5 hours from the moment of illness. With small intestinal obstruction, the number of cups varies; sometimes they can be layered one on top of the other in the form of a stepped ladder. Low-grade colonic obstruction in late stages can manifest itself at both colonic and small-bowel levels. The location of Kloiber's cups at the same level in one intestinal loop usually indicates deep intestinal paresis and is characteristic of the late stages of acute mechanical or paralytic intestinal obstruction.

Rice. 48-2. Plain radiograph of the abdominal cavity. Small intestinal fluid levels - Kloiber cups.

Symptom of featheriness(transverse striation of the intestine in the form of an extended spring) occurs with high intestinal obstruction and is associated with edema and distension of the jejunum, which has high circular folds of the mucosa (Fig. 48-3).

Rice. 48-3. Plain radiograph of the abdominal cavity. Symptom of pinnateness (stretched spring).

X-ray contrast examination of the gastrointestinal tract used when there are difficulties in diagnosing intestinal obstruction. Depending on the expected level of intestinal occlusion, a suspension of barium sulfate is either given orally (signs of high obstructive obstruction) or administered by enema (symptoms of low obstruction). The use of a radiopaque contrast agent (in a volume of about 50 ml) involves repeated (dynamic) study of a passage of barium sulfate suspension. Its retention for more than 6 hours in the stomach and 12 hours in the small intestine gives reason to suspect obstruction or motor activity intestines. In case of mechanical obstruction, the contrast mass does not reach below the obstacle (Fig. 48-4).

Rice. 48-4. X-ray of the abdominal cavity with obstructive small bowel obstruction 8 hours after taking a suspension of barium sulfate. Contrasted fluid levels are visible in the stomach and the initial part of the small intestine. The intestinal featheriness is clearly visible.

When using emergency irrigoscopy it is possible to detect obstruction of the colon by a tumor (Fig. 48-5), as well as detect the trident symptom (a sign of ileocecal intussusception).

Rice. 48-5. Irrigogram. Tumor of the descending colon with resolved intestinal obstruction.

Colonoscopy plays an important role in timely diagnosis and treatment of tumor colonic obstruction. After using enemas for therapeutic purposes, the distal (discharge) section of the intestine is cleared of fecal residues, which allows for a full endoscopic examination. Its implementation makes it possible not only to accurately localize the pathological process, but also to intubate the narrowed part of the intestine, thereby resolving the manifestations acute obstruction and perform surgery for cancer under more favorable conditions.

Ultrasound The abdominal cavity has little diagnostic capabilities in acute intestinal obstruction due to severe pneumatization of the intestine, which complicates the visualization of the abdominal organs.

However, in some cases, this method makes it possible to detect a tumor in the colon, an inflammatory infiltrate or the head of the intussusception, and to visualize stretched, fluid-filled intestinal loops (Fig. 48-6) that do not peristalt.

Rice. 48-6. Ultrasound scan for intestinal obstruction. Distended, fluid-filled intestinal loops are visible.

A.I. Kirienko, A.A. Matyushenko

Often in surgical practice a condition such as intestinal obstruction occurs. This condition can be congenital or acquired. In the first case, it is diagnosed immediately after birth in babies. The human intestine consists of several sections: the small and large intestines. This pathology can form in any area. The total length of the adult human intestine is about 4 meters. Most often, intestinal obstruction is caused by a narrowing of the intestinal lumen or functional disorders. What is the etiology of manifestation and treatment of this pathology?

Features of the disease

Intestinal obstruction is a condition characterized by difficulty in the passage of food due to obstruction or dyskinesia. This acute condition requiring urgent medical care. This pathology can develop for several reasons. The main causes of impaired motility or intestinal blockage are:

As for dynamic blockage of the intestine, it forms against the background of paresis or decreased peristalsis. Paresis often occurs against the background of diseases of other internal organs.

Intestinal obstruction can be caused by poor nutrition (overeating after temporary fasting, abuse of high-calorie foods) and physical inactivity.

Clinical manifestations

Intestinal obstruction has some specific symptoms. In acute bowel obstruction, symptoms may include:

• bloating;
• rumbling;
• severe pain;
• vomiting;
• difficulty in bowel movement;
• abdominal muscle tension;
• increase in heart rate;
• decrease in pressure.

Symptoms of intestinal obstruction appear sequentially. In the early stages, patients complain of pain syndrome. Pain caused by food accumulation in the intestines has the following characteristics:

• has a spastic character;
• most often felt in the navel or epigastrium;
• occurs acutely;
• repeats every 10-15 minutes;
• associated with a peristaltic wave.

In the paralytic form of the disease, the pain is dull, bursting and constant.

Intestinal obstruction is always accompanied by retention of stool and gases. These are the most specific signs. Lack of stool is late sign this pathology. Often patients experience repeated vomiting. Against this background, dehydration develops and shock may develop. A medical examination can reveal asymmetry of the abdomen due to the accumulation of gases and feces.

There are specific signs that help make a diagnosis. Intestinal obstruction is characterized positive symptoms Valya. This symptom consists of local flatulence, the presence of visible peristaltic movements and the presence of a tympanic sound upon percussion.

Intestinal obstruction is also determined by the presence of other symptoms (Bailey, Alapi, Kivulya, Duran).

Diagnostic measures

Obstruction is clinically similar to other diseases (pancreatitis, appendicitis, perforation of an ulcer, acute form cholecystitis, ectopic pregnancy, renal colic). An experienced doctor must know not only the causes and symptoms of acute intestinal obstruction, but also diagnostic methods. Diagnostics includes:

• patient interview;
• palpation of the abdomen;
• percussion;
• measurement of blood pressure, pulse and body temperature;
• carrying out X-ray examination using barium suspension;
• Ultrasound of the abdominal organs;
• colonoscopy;
• general and biochemical analysis blood;
• Analysis of urine.

In children and adults with such pathology, irrigoscopy is not performed. Intestinal obstruction is most clearly visible on x-ray. Specific signs in this situation are Kloiber's bowls and arches. The cups on the x-ray are positioned bottom up. These are areas of the intestine where gas has accumulated and the loops have become swollen. In addition, intestinal obstruction is detected in the presence of transverse striations of the intestine. With the help of X-ray examination it is possible to find the area of ​​obstruction.

The diagnosis is confirmed by ultrasound results. Identification of signs of intestinal obstruction is an indication for hospitalization of the patient.

Restoring patency

In the absence of complications, treatment of intestinal obstruction can be conservative. It involves the use of antispasmodics and painkillers. For intestinal atony, Proserin is indicated. This remedy stimulates peristalsis. Treatment should be aimed at eliminating the underlying cause of the pathology. If this strangulated hernia, held surgical treatment. In severe cases, detoxification therapy is carried out. To cleanse the stomach, siphon enemas can be prescribed. Often put gastric tube. Treatment folk remedies also possible.

Surgical treatment is organized if conservative therapy is ineffective. As with diseases of the rectum, patient preparation is required. General anesthesia is performed. To prevent blood clots, the patient's legs are bandaged. Most effective method- use of antithromboembolic stockings. To eliminate intestinal obstruction, a laparotomy is performed. In the period after surgery, patients must follow a diet and bed rest. If intestinal obstruction is diagnosed in newborns, treatment is only surgical.

Prevention of this pathological condition involves early detection and treatment of hernias, proper nutrition, timely treatment constipation Thus, obstruction of the small or large intestine can lead to serious consequences and even cause the death of a sick person.

Acute intestinal obstruction in the absence of timely assistance can lead to the following complications: peritonitis, necrosis of part of the intestine, abdominal sepsis.