During the study of the abdomen of patients with suspicion of acute intestinal obstruction, the abdominal wall often turns out to be soft. With deep palpation, pain in the area of swollen intestinal loops can be determined. In some cases, against the background of asymmetry of the abdomen, it is possible to palpate the bowel loop (Valya's symptom). Above it, it is possible, with percussion, to determine a tympanic sound with a metallic tinge (Kivul's symptom). In the later stages of the disease, with a strong stretching of the intestine, the abdominal wall may become rigid. When it is shaken, splash noise can be detected (Sklyarov's symptom). It is caused by the presence of liquid and gases in the intestinal lumen.
In the first hours of the disease, during auscultation of the abdomen, increased peristalsis noises are heard. With the development of peritonitis, peristaltic murmurs cannot be determined, but respiratory and heart murmurs become audible.
Digital examination of the rectum is of great importance in the diagnosis of acute intestinal obstruction. In this case, not only the nature of pathological discharge (blood, mucus, pus) is assessed, but the cause of the obstruction can also be established: tumor, fecal "blockage", foreign body, etc. Expansion of the rectal ampulla, noted in acute intestinal obstruction, is known as a symptom Obukhov hospital. The general condition of patients with acute intestinal obstruction changes as the disease progresses. At the onset of the disease, the body temperature remains normal or reaches only subfebrile numbers. With the development of peritonitis, the temperature rises significantly. The tongue becomes dry and coated. In the terminal stage of the disease, cracks can be observed in the tongue due to severe intoxication and dehydration.
The cardiovascular system is the first to react to the pathological process in the abdominal cavity caused by acute intestinal obstruction. Tachycardia often outstrips the temperature response. The increasing intoxication leads to respiratory failure and neuropsychiatric disorders. The developing dehydration is manifested by a decrease in urine output, dry skin and mucous membranes, thirst, and sharpening of facial features. In the later stages of acute intestinal obstruction, the phenomena of hepatic and renal failure are observed.
In connection with the dehydration of the body and hemoconcentration in the study of blood, an increase in the number of erythrocytes, an increase in the level of hemoglobin, and high hematocrit are revealed. In connection with the development of inflammation in the abdominal cavity in the study of peripheral blood, leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR may be noted. Severe changes in metabolism can be accompanied by a decrease in the BCC and a decrease in the level of electrolytes in the blood. As the duration of the disease increases, hypoproteinemia, bilirubinemia, azotemia, anemia, and acidosis develop.
In the clinical course of acute intestinal obstruction, there are three periods:
- initial (period of "ileus cry"), in which the body tries to restore the movement of the food bolus through the intestines. At this time, the clinical picture of the disease is dominated by pain and reflex disorders;
- compensatory attempts, when the body is trying to compensate for the growing phenomena of endotoxicosis;
- decompensation or terminal, associated with the development of complications and peritonitis.
Because of the polyetiology of the disease, clinical diagnosis of acute intestinal obstruction is often difficult. In order to clarify the diagnosis, determine the level and cause of obstruction, special research methods are used.
X-ray examination is of particular importance in the diagnosis of acute intestinal obstruction. It begins with a plain x-ray of the chest and abdominal organs.
When chest X-ray, attention is paid to indirect signs of acute intestinal obstruction: the height of the diaphragm, its mobility, the presence or absence of basal pleurisy, disc-shaped atelectasis.
Normally, on plain x-rays of the abdomen, gases in the small intestine are not detected. Acute intestinal obstruction is accompanied by intestinal pneumatosis. Most often, the accumulation of gases in the intestine is observed above liquid levels (Schwarz-Kloyber "bowls"). Due to the folding of the intestinal mucosa, a transverse striation resembling a fish skeleton is often observed in the Schwarz-Kloyber bowls by X-ray. By the size of the Schwarz-Kloyber bowls, their shape and localization, one can judge with relative accuracy the level of intestinal obstruction. With small intestinal obstruction of the Schwarz-Kloyber bowl of small size, the width of the horizontal liquid level in them is greater than the height of the strip of gases above it. With colonic obstruction, horizontal fluid levels are more often located on the flanks of the abdomen, and the number of levels is less than with small bowel obstruction. The height of the strip of gases in the Schwarz-Kloyber bowls with colonic obstruction prevails over the level of liquid in them. In contrast to mechanical acute intestinal obstruction with its dynamic form, horizontal levels are observed both in the small and in the large intestine.
Enterography is used as a radiopaque study for acute intestinal obstruction. In this case, the expansion of the intestinal lumen above the obstacle zone is revealed, narrowing and filling defects caused by tumors are found, and the time of passage of the contrast agent through the intestine is determined. In order to reduce the study time, probe enterography is sometimes used, during which conservative therapeutic measures are also carried out.
For the purpose of early diagnosis of obstruction of the colon, clarification of its causes (and in some cases for therapeutic purposes), recto- or colonoscopy is used. Endoscopic manipulations and enemas are not performed before X-ray examinations, since the interpretation of X-ray and fluoroscopy data depends on this.
Ultrasound examination of the abdominal cavity in acute intestinal obstruction is less important than X-ray methods. With the help of ultrasound examination for acute intestinal obstruction, fluid is determined both in the free abdominal cavity and in individual intestinal loops.
Since the tactics and methods of treatment of mechanical and dynamic acute intestinal obstruction are different, the differential diagnosis of these forms of intestinal obstruction has a special meaning.
Unlike acute mechanical intestinal obstruction with its dynamic form, abdominal pain is less intense and often does not take on a cramping character. With dynamic paralytic obstruction, as a rule, the symptoms of the disease that caused ileus prevail. This type of acute intestinal obstruction is manifested by a uniform bloating of the abdomen, which remains soft on palpation. During auscultation of the abdomen with dynamic paralytic intestinal obstruction, peristaltic noises are weakened or not heard at all. The spastic form of acute intestinal obstruction can be manifested by cramping pains, not accompanied by bloating.
Differential diagnosis of forms of acute intestinal obstruction often requires dynamic monitoring of patients, while repeated X-ray examinations of the abdominal organs are of great importance.
H. Maisterenko, K. Movchan, V. Volkov
"Diagnosis of acute intestinal obstruction" and other articles from the section
SEASON 12
Exudative pleurisy
This is a disease characterized by damage to the pleura, followed by the formation of fluids of various nature in its cavity. Most often, this ailment acts as a secondary factor in any pathological changes.
Etiology:
Most of the infectious exudative pleurisy is a complication of pathological pulmonary processes. Moreover, about 80% of cases of hydrothorax are detected in patients with pulmonary tuberculosis.
-Non-infectious exudative pleurisy develops against the background of a wide variety of pulmonary and extrapulmonary pathological conditions.
Chronic renal failure;
Chest injury, in which hemorrhage began into the pleural cavity;
Tumors of the blood, predominantly of a malignant nature;
Chronic circulatory failure;
Lung infarction;
Cirrhosis of the liver (a common cause of right-sided hydrothorax);
Diseases of the connective tissue of an autoimmune nature. These include collagenoses, rheumatism, and so on;
Carcinomatosis, mesothelioma and other malignant tumor-like formations in the lungs;
With inflammation of the pancreas, the development of left-sided hydrothorax is possible.
Classification:
Exudative pleurisy, according to their etiology, are divided into infectious and aseptic.
Given the nature of the exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chyle (chylothorax), purulent (pleural empyema), putrid, mixed.
Distinguish with the flow acute, subacute and chronic exudative pleurisy.
Depending on the localization of the exudate, pleurisy can be diffuse or encapsulated (delimited)... Encapsulated exudative pleurisy, in turn, are subdivided into apical (apical), parietal (paracostal), osteo-diaphragmatic, diaphragmatic (basal), interlobar (interlobar), paramediastinal.
X-ray semitics:
The X-ray picture with exudative pleurisy depends on how much exudate was formed and was not resorbed (reabsorbed) by the pleural sheets. Minimal effusion can be suspected in the presence of indirect manifestations. These include:
- High aperture position.
- Restriction or impairment of her mobility.
- A sharp increase in the distance between the pulmonary field and the gas bubble (more than 1.5 cm, while the normal value does not exceed 0.5 cm).
2-sided supraphrenic pleurisy
The first thing to notice is the sinuses. These are a kind of pockets formed by the pleura in the phrenic-costal region. In the absence of pathology, the sinuses are free and represent corners directed downward (between the edges of the ribs laterally and the diaphragm medially). If the costophrenic sinuses are darkened, this indicates the involvement of the pleura in the process of inflammation. Or there is another disease accompanied by increased fluid synthesis.
The next possible X-ray sign of the appearance of fluid in the pleural fissures is a raincoat darkening. This term reflects the appearance of a shadow that covers the entire pulmonary surface like a cloak. At the same time, darkening can be seen from the lateral side of the chest, as well as along the interlobar pleural sulcus (it divides the lung into lobes). With an increase in the volume of the accumulating liquid, the upper border of the darkened area on the X-ray diffraction pattern is smoothed out. By the level of this border along the ribs, the degree of hydrothorax is determined - a condition characterized by massive effusion into the pleural fissure of various etiology and pathogenesis. But exudative pleurisy rarely reaches such proportions and is limited to the sinuses.
The posterior costal-phrenic sinus is not traced
The accumulation of a large amount of pleural fluid, regardless of the cause, leads to such a phenomenon as displacement of the mediastinum (median shadow) in the direction opposite to the affected one (this applies to unilateral pleurisy). The extent of this bias depends on a number of factors:
- Exudate volume.
- Standing level of the diaphragm.
- The degree of mobility of the mediastinal structures.
- The functional state of the pulmonary formations
When the patient is examined in a horizontal position, a more intense shadow appears already in the lateral regions of the chest. This symptom bears the author's name - the Lenka phenomenon. It is played in a horizontal position or in a Trendelenburg position. Also typical for this situation is a decrease in such an indicator as the transparency of the lung tissue. It is homogeneous and diffuse.
Free liquid spread along the chest wall with a layer of 3.2 cm
Pleurisy involving the mediastinal (mediastinal) pleura is less common. Its characteristics:
- Additional darkening in the area of the middle shadow.
- The clarity of the contours of these formations.
- Variety of shadow shapes: triangular, spindle-shaped or striped (ribbon-like).
When the effusion is located in the interlobar pleura, the X-ray picture has its own peculiarity. It lies in the fact that the blackouts are located along the border between the lobes of the lungs. At the same time, shadows resemble lenses: they have the form of symmetrical formations with biconcave or biconvex outlines. The mediastinum usually does not move intactly with this form of pleurisy.
. 
interlobar pleurisy
With untimely resorption of exudate, the risk of such an outcome as pleural adhesions, mooring lines, which will limit the respiratory excursion of the lungs, increases.
Encapsulated pleurisy of the small interlobar fissure.
X-ray symptoms of intestinal obstruction
Diagnosis of intestinal obstruction is usually aimed at determining, clarifying its nature, differentiating mechanical obstruction from paralytic, establishing the level of obstruction, the state of blood supply to the affected area.
Distinguish between mechanical and dynamic intestinal obstruction.
Dynamic (functional or paralytic) obstruction develops reflexively in various critical conditions: peritonitis, pancreatitis, abscesses of the abdominal cavity and retroperitoneal space, perforations of hollow organs, attacks of urolithiasis, impaired mesenteric circulation, poisoning with various drugs, after surgical trauma.
The leading sign of paralytic obstruction is a decrease in tone, swelling of the small and large intestines. Kloyber's cups are usually absent in case of paralytic obstruction.
With paralytic intestinal obstruction, water-soluble contrast agents can be used, since they, having laxative properties, can accelerate the movement of intestinal contents, thereby providing a therapeutic effect.
Mechanical small bowel obstruction. The cause of mechanical small bowel obstruction is most often strangulation (volvulus, nodule formation), infringement, intussusception, less often obstruction.
The classic radiological signs of mechanical small bowel obstruction, detected by plain radiography of the abdomen, are:
1) overstretched loops of the small intestine above the obstruction site with the presence of transverse striation due to kercring folds;
2) the presence of liquid and gas levels in the lumen of the small intestine (Kloyber's bowl);
3) air arches;
4) lack of gas in the colon.
Normally, the small intestine, unlike the large intestine, does not contain gas. However, with high intestinal obstruction, gas from the colon comes out naturally and therefore may not be detected on radiographs. The absence of gas in the colon indicates complete obstruction of the small intestine. With a high small bowel obstruction, a small amount of gas is detected in the jejunum, since the contents of the jejunum, located proximal to the obstruction site, are thrown into the stomach.
A relatively early sign of small bowel obstruction is isolated distension of the small intestine without fluid levels (a symptom of an "isolated loop"). In the vertical position of the patient, the arcuate curved gas-inflated loop of the small intestine has the form of an arch. Then the liquid levels appear, which at first have the form of the letter "J" with a gas bubble above two liquid levels located at different heights. Sometimes you can see the transfer of fluid from one loop to another. As the liquid accumulates, both levels are connected, as a result of which the picture of an inverted bowl (Kloyber bowl) is formed.
Kloyber's bowls are the most characteristic radiological sign of small bowel obstruction. They represent liquid levels with semi-oval gas accumulations located above them.
With an increase in obstruction with an increase in the amount of liquid, the arches can turn into bowls, and with a decrease in the amount of liquid, the opposite picture arises - the bowls turn into arches.
In typical cases, Kloyber's small bowel bowls differ from the colonic ones in that the width of the liquid level in this bowl is greater than the height of the gas bubble above it. In case of obstruction of the colon, the ratio is the opposite - the height of the gas bubble is greater than the width of the liquid level.
Small bowel obstruction is characterized by the presence of multiple bowls in the center of the abdominal cavity, where the loops of the small intestine are located. As the obstruction progresses, the width of the fluid levels increases and the height of the air column decreases.
In case of obturation in the more distal parts of the small intestine, its expanded loops are located parallel to each other, forming a characteristic picture of a "stepladder" on radiographs. Stretched loops of the small intestine are usually oriented obliquely from the lower right to the upper left quadrant of the abdomen. In this case, the blockage area is usually located below the lowest fluid level. Moderately stretched small bowel loops on radiographs can be easily distinguished from gas-containing colon loops.
Small bowel obstruction is characterized by transverse striation of the intestine, due to the display of circularly located kerkring folds extending over the entire diameter of the intestine. This creates a picture that resembles a stretched spring. The transverse striation is visible only in the jejunum, in the ileum it is absent, since there the kercring folds are less pronounced. As the small intestine stretches, the fold pattern becomes blurred, and it can be difficult to distinguish the loops of the small intestine from the large intestine.
The relief of the large intestine when it is swollen is represented by thicker and sparser semilunar folds separating the gaustra, which do not cross the entire diameter of the intestine.
With strangulation obstruction, the symptom of "fingerprints" can be identified.
Mechanical colonic obstruction usually occurs due to obstruction of the lumen by a tumor; Colorectal cancer is the most common cause of colon obstruction. The leading clinical signs of colonic obstruction are stool retention, flatulence and bloating. Clinical symptoms appear later than with small bowel obstruction.
With obstruction of the colon, Kloyber's bowls are observed less often; more often there is a sharp suprastenotic bloating of the intestine.
With the retrograde introduction of a water-barium suspension or air, it is possible to establish the level of the obstacle, as well as to determine the nature of the obstructing tumor, often a filling defect with uneven contours or its shadow against the background of the injected air is revealed.
Intussusception called the introduction of the proximal part of the intestine into the distal one. Distinguish between intestinal, small intestinal-colon (ileocecal) and colon intussusception. The most common is ileocecal intussusception.
On plain radiographs of the abdomen in the acute stage of proximal or distal small bowel obstruction, swollen loops with fluid levels are found. With ileocecal intussusception, there is no gas in the caecum and ascending colon. A valuable method for diagnosing intussusception of the colon is a contrast enema, which can also be a therapeutic procedure. After the injection of a contrast agent, the intussusception may be spread. During irrigoscopy, the following signs can be detected: a filling defect of a semicircular shape, the morphological display of which is an invaginated intestine, a symptom of a bident and a trident, a symptom 
cockades.
Volvulus.
During volvulus, a segment of the intestine (small, blind, or sigmoid) rotates around its own axis, thereby disrupting the blood circulation of the intestine. The complete cessation of blood supply to the intestine quickly leads to the development of gangrene, followed by perforation and the development of peritonitis. The most common cause of bloat is eating large amounts of hard-to-digest foods after fasting. The predisposing factor leading to volvulus is a long mesentery with a narrow root. Early diagnosis of bloat is critical to prognosis. The overall picture depends on the level of volvulus: volvulus of the small intestine is manifested by a high picture, and ileocecal volvulus - by a picture of low obstruction.
With a high volvulus on a plain radiograph, there is a swelling of the stomach and duodenum. The small intestine contains a lot of fluid and little gas. The images taken in the upright position of the patient and in lateroposition show fluid levels. For subacute development of obstruction, a water-soluble contrast agent is used to determine the level of obstruction. The contrast mass stops at the level of the bowel obstruction. However, according to the data of a contrast study, the level of obstruction can be determined in no more than 50% of cases.
With volvulus of the caecum, there is a significant expansion of the segment above the torsion. In this case, the stretched segment is shifted to the left mesogastric and epigastric regions.
For volvulus of the sigmoid colon, the symptom of "car tire" is characteristic. It appears with a significant expansion of the bowel loops above the torsion. At the same time, the intestine swells sharply, taking on the appearance of a swollen chamber, divided by a central septum. Some researchers compare this picture with the shape of a coffee bean, divided by a partition into two lobes. With retrograde filling of the intestine with the help of a contrast enema, the section of the intestine below the obstruction takes on the appearance of a bird's beak. When turning clockwise, the beak is directed to the right, when turning the intestine counterclockwise, it is directed to the left.
MOSCOW STATE MEDICAL AND DENTAL UNIVERSITY
Department of Hospital Surgery
Head Chair, Corresponding Member. RAMS, Honored Scientist,
professor Yarema I.V.
METHODOLOGICAL DEVELOPMENT ON THE TOPIC:
"ACUTE INTESTINAL OBSTRUCTION"
(for teachers)
Compiled by: assistant M.I. Filchev
The purpose of the lesson:
On the basis of knowledge of the anatomy, etiology, pathogenesis of acute intestinal obstruction, the peculiarities of the clinical manifestations of the disease in the classroom, students should be taught the method of purposeful collection of clinical data, teach the methods of examining patients, teach the ability to draw up an examination plan and a method of collecting information, and decipher the data obtained,
During the lesson, it is necessary to pay attention to the differential diagnosis, the peculiarities of medical tactics, the choice of methods of conservative and surgical treatment. Pay attention to the features of preoperative preparation and management, postoperative period.
LOCATION OF THE LESSON: Study room, surgical wards, diagnostic rooms, operating rooms, dressing rooms, intensive care unit,
TIME OF THE LESSON: 4 academic hours.
Lesson plan:
Introductory speech of the teacher (5 min);
Baseline control. Written personal answers to the questions posed (15 min);
Formation of the ability to self-conduct freestyle: taking anamnesis, objective examination, building a detailed diagnosis. Prescribing drug treatment (20 min);
Formation of the ability to apply methods of clinical examination of patients, consolidation of the information received, differential diagnosis, development of clinical thinking (60 min);
Demonstration of the main methods of examining patients, consolidating the learned symptoms of the disease (if necessary);
Indications for surgical methods of treatment. Mastering the basic principles of performing the applied operations. Analysis of treatment tactics (20 min);
Final control (20 min);
Conclusion. Setting the topic for the next lesson.
METHODOLOGICAL COMMENTARY
Introductory word of the teacher
Acute intestinal obstruction is understood as a (AIO) syndrome that develops as a result of a violation of the passage of intestinal contents through the gastrointestinal tract (GIT).
Patients with AIO make up 1.2% of the number of persons admitted to surgical departments, and 9.4% of patients with acute surgical diseases of the abdominal organs.
The similarity of the clinical manifestation of intestinal obstruction with many diseases of other organs - as an outcome of some acute inflammatory diseases of the abdominal organs, the complexity of diagnosis, the greater likelihood of a patient suffering from this ailment going to a doctor of any specialty, the severity of the patient's condition and the need in some specific cases of emergency care - is the reason for studying this pathology in the course of surgical diseases.
The primary damaging factors in intestinal obstruction are local changes in the intestine concerning its metabolism, function and structure. These disorders are based on stasis of intestinal contents with increased pressure and stretching of the intestine during its obstruction, as well as infringement of the mesenteric vessels and, to a lesser extent, stasis of the contents during strangulation of the intestine. With the development of intestinal obstruction, intraintestinal pressure can reach 5-18 mm Hg, and with active muscular contractions of the intestine, it increases to 20-45 mm Hg.
Violation of regional blood circulation in the intestine and a significant increase in intestinal flora (an increase in aerobes by 105 and 106 times, respectively, for small and large intestinal obstruction) are considered as the main local factors in the pathogenesis of intestinal obstruction. In this case, the increase occurs mainly due to gram-negative microorganisms.
Progressive hyperosmolarity determined, on the one hand, by the action of digestive enzymes, and, on the other hand, by a decrease in the utilization of digested food components, leads to a decrease in water reabsorption, when the absorption capacity of the mucous membrane is extremely reduced. The osmolarity factor also plays an important role in the process of sequestration of fluid in the intestine with intestinal obstruction.
The pinnacle of changes in the intestine with its obstruction due to hypoxia, hypoxic damage to the intestinal wall and the action of a bacterial factor are the violation of its integrity and the development of peritonitis.
The rapid and frequent development of multiple organ failure in intestinal obstruction is primarily due to volemic disorders, centralization of blood circulation, depression of microcirculation and tissue hypoxia.
M. F. Otterson
Intestinal obstruction is a violation of the passage of intestinal contents.
I. Etiology
Distinguish between mechanical and functional causes of intestinal obstruction (table. 1). Mechanical obstruction is more common and usually requires surgery. In 70-80 / 6 cases, it is due to obstruction of the small intestine, in 20-3096 - the colon. In old age, with an increase in the incidence of neoplastic diseases and diverticulosis of the colon, the incidence of colonic obstruction also increases.
A. Pathology of the peritoneum, abdominal organs and abdominal walls.
The most common cause of small bowel obstruction is adhesions that form after hernia repairs and operations on the abdominal organs. Adhesive obstruction often complicates surgical interventions on the lower abdominal floor. In developing countries, among the causes of obstruction, the first place is occupied by an infringement of an external hernia of the abdomen. Volvulus is a pathological torsion of the intestinal loop. The most common volvulus of the sigmoid (70-80% of cases) and the cecum (10-20%). Volvulus of the sigmoid colon is observed with an excessively long mesentery (dolichosigma); constipation is often a provoking factor. A volvulus of the caecum is possible with a congenital violation of its fixation (mobile caecum). Mental disorders, old age and a sedentary lifestyle predispose to volvulus of the colon. A loop of the small intestine can twist around a peritoneal adhesion or congenital cord. When the small intestine is pinched at two points at once (adhesions or hernial orifices), an “off” intestinal loop is formed. Sometimes the cause of the obstruction is a large mass that squeezes the large or small intestine from the outside.
B. Pathology of the intestine.
Among the diseases of the intestine that cause its obstruction, the most common are tumors. Colon tumors are more common than small bowel tumors. In 50-70% of cases, the obstruction of the colon is due to cancer; in 20% of patients with colon cancer, acute intestinal obstruction is first manifested. Intestinal obstruction is characteristic of the localization of the tumor in the left half of the colon. Volvulus and diverticulitis are also more likely to affect the left 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 |
Functional Spastic obstruction Hirschsprung's disease Bowel pseudo-obstruction |
In newborns, intestinal obstruction in most cases is due to atresia. Atresia of the esophagus, anus, and rectum is more common than atresia of the small intestine. Other causes of obstruction in newborns, in descending order of frequency, are: Hirschsprung's disease, incomplete bowel turn (Ladd's syndrome), and meconium obstruction.
B. Obturation of the intestine.
Intestinal obstruction can be caused by a foreign body swallowed or inserted into the anus. Less common is the blockage of the colon with fecal stones and barium suspension; even less often - gallstone obstruction. The gallstone that has passed 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 causes include pancreatitis, appendicitis, pyelonephritis, pneumonia, fractures of the thoracic and lumbar spine, and electrolyte disturbances. The list of causes of paralytic intestinal obstruction is presented in Table 2.
D. Spastic obstruction is extremely rare - with poisoning with salts of heavy metals, uremia, porphyria.
E. Hirschsprung's disease (congenital agangliosis 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 impaired motility of the gastrointestinal tract (usually of the small intestine, less often of the large intestine and esophagus). The attacks of the disease occur with a bright clinic of mechanical obstruction, which is not confirmed either by radiography or during the operation. Sometimes the disease is familial, sometimes it is combined with autonomic neuropathy or myopathy. However, in most cases, the cause cannot be established. 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 the severity of complications of mechanical intestinal obstruction.
Table 2. Causes of paralytic intestinal obstruction
|
Diseases of the peritoneum and abdominal organs: Inflammation, infection (appendicitis, cholecystitis, pancreatitis) Peritonitis: bacterial (intestinal perforation), aseptic (bile, pancreatic juice, gastric juice) Discrepancy of the operating wound Mesenteric artery embolism Mesenteric vein * or artery thrombosis Intestinal ischemia: shock *, heart failure, use of vasoconstrictors Blunt abdominal trauma * Acute gastric dilatation Hirschsprung's disease Aortoarteritis (Takayasu's disease) affecting the mesenteric arteries Diseases of the retroperitoneal space and small pelvis Infections: pyelonephritis, paranephritis Ureteral calculus, ureteral obstruction Retroperitoneal hematoma: trauma, hemophilia, anticoagulant therapy Tumor: primary (sarcoma, lymphoma) or metastasis Retention of urine Infringement of the spermatic cord, testicular torsion Fracture of the pelvis Diseases of the central nervous system Fracture of the spine: lumbar or thoracic Trauma, tumor of the brain or spinal cord Meningitis Diseases of the lungs and cardiovascular system Pulmonary embolism Pneumonia, especially lower lobe Empyema of the pleura Emphysema of the lungs Intoxication and metabolic disorders
Potassium deficiency Sodium deficiency Medicines: ganglion blockers, anticholinergics Note: * Possible bowel necrosis. |
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. The share of mesenteric vein thrombosis accounts for the remaining 25%. Mesenteric venous thrombosis often develops against a 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. The accumulation of gas in the intestine is the leading symptom of intestinal obstruction. Violation of the passage of intestinal contents is accompanied by an intensive growth of aerobic and anaerobic bacteria that form methane and hydrogen. However, most of the intestinal gas is swallowed air, the movement of which through the intestines is also impaired.
Normally, the glands of the gastrointestinal tract secrete about 6 liters of fluid during the day, most of which is absorbed in the small and large intestines. Stretching the intestinal loops with obstruction further stimulates secretion, but inhibits absorption. The result is vomiting, which leads to the loss of fluids and electrolytes. Hypokalemia and metabolic alkalosis develop.
B. Mechanical obstruction of the intestine, in which blood circulation in the intestinal wall is disturbed, is called strangulation. This can occur when the intestine or its mesentery is pinched, as well as when the pressure in the lumen of the intestine exceeds the intravascular pressure. As a result, ischemia, necrosis and bowel perforation develop. Early diagnosis of strangulated obstruction and urgent surgical intervention can prevent bowel perforation, reduce the severity of the disease and reduce mortality. Preoperative preparation should be quick and include correction of water-electrolyte disturbances.
B. Obstructive obstruction of the colon in cancer and diverticulitis is rarely accompanied by circulatory disorders. The exceptions are 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 often occurs in the cecum, which has the largest radius and is therefore more severely stretched 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 on the level of the obstacle (Table 3). The main symptoms are nausea, vomiting, abdominal pain, bloating, stool and gas retention. Symptoms of peritoneal irritation are signs of bowel necrosis or perforation. Leukocytosis (or leukopenia), fever, tachycardia, localized tenderness on palpation of the abdomen indicate an extremely serious condition of the patient (especially if all four signs are present).
During physical examination, attention is paid to postoperative scars and strangulated hernias, sometimes this allows an immediate diagnosis. Be sure to conduct a rectal examination (fecal stones) and an analysis of feces for occult blood. Bloody stool may be due to Crohn's disease, cancer, bowel necrosis, or diverticulitis. If an enlarged liver with a bumpy surface is palpable, a metastatic tumor can be assumed. Auscultation of the lungs reveals pneumonia - one of the causes of paralytic intestinal obstruction.
IV. X-ray examination
If there is suspicion of intestinal obstruction, first of all, an overview X-ray of the abdominal cavity (in a standing position and lying on the back) and chest (in the rear, not anterior and lateral projections) is performed. Chest x-ray can rule out pneumonia. A CT scan of the abdomen can determine the level and cause of intestinal obstruction.
Table 3. Clinical presentation for various types of intestinal obstruction
|
Obstruction type |
Bloating, Vomiting |
Intestinal noises |
Tenderness to palpation |
||
|
No circulatory disorders High small bowel |
Cramping, in the middle and upper third of the abdomen |
Early onset, mixed with bile, stubborn |
Weak, spilled |
||
|
Low small intestinal |
Cramping, in the middle third of the abdomen |
Appears at an early stage |
Appears in later stages with fecal odor |
Reinforced, rise and fall in waves |
Weak, spilled |
|
Colonic |
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 |
Stubborn |
Usually weakened, but there is no clear pattern |
Strong, localized |
|
|
Paralytic |
Light, spilled |
Appears very early |
Weakened |
Weak, spilled |
|
|
Obstruction due to acute disorders of mesenteric circulation |
Persistent, in the middle third of the abdomen or back, can be very severe |
Appears in the early stage |
Weakened or absent |
Strong, spilled, or localized |
|
|
The number of crosses reflects the severity of symptoms |
|||||
Table 4. X-ray signs of intestinal obstruction
|
Paralytic obstruction |
Mechanical obstruction |
|
|
Gas in the stomach |
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Gas in the intestinal lumen |
Dispersed throughout the colon and small intestine |
Only proximal to the obstacle |
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Fluid in the intestinal lumen |
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Kloyber's bowls (X-ray in the supine position) |
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Kloyber's bowls (radiograph in a standing position) |
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Fluid Levels in Adjacent Knees of the Loop (Standing X-ray) |
They are about the same height - arches, similar to inverted U letters, occupy mainly the middle third of the abdomen |
Are of different heights - arches that look like inverted Js The number of crosses reflects the severity of symptoms |
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The number of crosses reflects the severity of the symptoms |
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A. Radiographs 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 stretched by 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 large intestine, gaustra are visible, which occupy only a part of the intestinal diameter (Fig. 3).
B. With mechanical small bowel obstruction in the large intestine, little or no gas. With large bowel obstruction and intact function of the ileocecal valve, significant swelling of the large intestine is noted; gas may be absent in the small intestine. Insufficiency of the ileocecal valve leads to stretching of both the small and large intestines.
C. Radiographs taken while standing or lying on its side usually show horizontal levels of liquid and gas. Gas-filled intestinal loops look like inverted bowls (Kloyber's bowls) or arches, similar to inverted letters J and U. Distinguishing paralytic intestinal obstruction from mechanical small bowel obstruction using plain fluoroscopy can be quite difficult (Table 4). This requires a radiopaque study of the intestinal tract (with the rapid introduction of barium or a water-soluble contrast into the jejunum through a pazogastric tube). If you suspect colonic obstruction, 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 of metabolic disorders, the duration of the onset and the type of obstruction (if there is a suspicion of strangulation obstruction, the operation cannot be postponed). In the preoperative period, infusion therapy and correction of water-electrolyte disturbances are carried out, and intestinal decompression through a nasogastric or long intestinal tube is also started. Antibiotics are prescribed, especially if strangulation obstruction is suspected.
B. The operation can be delayed in the following cases:
1. If intestinal obstruction develops in the early postoperative period, decompression of the intestine is performed using a nasogastric or long intestinal tube. After a while, adhesions can dissolve, and intestinal permeability is restored.
2. In case of peritoneal carcinomatosis, they try to avoid surgery and carry out decompression of the intestine through a nasogastric tube. Usually, intestinal patency is restored within three days. If the intestinal obstruction in such patients is not due to a tumor, but to another reason, surgery can significantly improve the condition.
3. Bowel obstruction during exacerbation of Crohn's disease can be resolved with medication and bowel decompression through a nasogastric or long bowel tube.
4. With intussusception of the intestine in children, conservative treatment is possible: observation and careful attempts to straighten the intussusception using hydrostatic pressure (barium enemas). In adults, this method is inapplicable, since 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, the operation can be postponed only if there is no suspicion of strangulation obstruction.
B. The type of operation is determined by the cause of the obstruction, the condition of the intestine and other operational findings. Dissection of adhesions, hernia repair with plastic hernial orifice (for internal and external abdominal hernias) are used. With masses that close the intestinal lumen, it may be necessary to create a bypass interintestinal anastomosis, to impose a colostomy proximal to the obstacle, or to resect the intestine with subsequent restoration of intestinal continuity.
There is still no consensus regarding the optimal tactics for treating recurrent small bowel mechanical obstruction. Two methods have been proposed: “splinting” of the small intestine with a long intestinal probe and enteroplication.
From the editorial board
Rice. 1. Diagram of the accumulation of gas in the intestinal lumen with various types of intestinal obstruction.
Signs of intestinal obstruction on X-ray allow diagnosing pathology at the earliest stages of its course. In this case, the radiologist takes a picture of the abdominal cavity, both in the format of an overview projection, as well as in its lateral, necessarily posterior projections. This will be discussed below.
Signs of intestinal obstruction
Speaking about what medical signs of intestinal obstruction on the X-ray exist, which manifest themselves on the obtained X-ray, it all depends on its classification and type - mechanical or paralytic:
1. On an X-ray of the peritoneum and its cavity, radiologists reveal a certain accumulation of gases. As a rule, the image allows you to accurately show whether the loop of the large or small intestine, or both of them are simultaneously stretched under the influence of accumulated gases. So, when diagnosing gases in the small intestine, the folds that form on the mucous membrane in the form of a spiral, which occupy the entire space of the intestine diameter, will be clearly visible on the X-ray. If the accumulation occurs in the large intestine, the image will clearly show the gaustra, which occupy only a part in the diameter of the examined intestine.2. In the case of diagnosing a mechanical type of intestinal obstruction, little or no gas will accumulate in the colon itself. When the ileocecal valve malfunctions, the picture will clearly show bloating, an unnatural stretching of the accumulated gases of both the colon and the small intestine.
3. If the X-ray is performed in the supine position, on the side or standing of the patient, then when diagnosing the pathology, signs of intestinal obstruction on the X-ray will manifest themselves in the form of horizontal levels of gas and liquid. In this case, the gas-filled bowel loops will look like inverted bowls - in medicine this is called the Kloyber's bowl, arches that will resemble inverted letters of the English alphabet. It can be an inverted English J or U and will occupy the middle part of the abdomen, about a third of the area.
As a result, it is possible to summarize what to distinguish among themselves, to accurately diagnose paralytic obstruction in the intestine from mechanical obstruction with the help of a survey fluoroscopy is very problematic. In this case, doctors prescribe an X-ray study using a contrast agent - such a solution is the injected barium or water-soluble contrast agents that are injected into the intestine under study using a probe. But all this concerns only the method of studying constipation and blockage of the small intestine, since when examining the colon and diagnosing the development of obstruction in it, such a study is contraindicated.
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