Malfunctions digestive tract may lead to dangerous conditions. About 3% of such cases in abdominal surgery constitutes intestinal obstruction. Pathology in children and adults develops quickly and has many causes. Already in the first 6 hours from the onset of signs of the disease, the risk of death of the patient is 3-6%.
Classification of intestinal obstruction
The pathology is associated with impaired movement of contents or chyme through the digestive tract. Other names for the disease: ileus, obstruction. The ICD-10 code is K56. Based on its origin, the pathology is divided into 2 types:
- Primary– associated with abnormalities in the structure of the intestinal tube that occur in the womb. It is detected in children in the first years of life. In 33% of newborns, pathology occurs due to intestinal clogging with meconium, the original feces.
- Secondary– acquired disease, develops under the influence of external factors.
According to the level of location of the area of obstruction, the pathology has 2 types:
- Short– affected colon, occurs in 40% of patients.
- High– small intestinal obstruction, accounts for 60% of cases.
According to the mechanisms of development, ileus is divided into the following subtypes:
- Strangulational– blood circulation in the gastrointestinal tract is disrupted.
- Obstructive– Occurs when there is a blockage in the intestines.
- Mixed– this includes intussusception (one section of the intestinal tube is embedded in another) and adhesive obstruction: develops with rough cicatricial adhesions of tissue.
- Spastic– hypertonicity of intestinal muscles.
- Paralytic– the force of movement of the intestinal walls is reduced or absent.
Based on their effect on the functioning of the digestive tract, there are 2 forms of pathology:
- Full– the disease manifests itself acutely, the movement of chyme is impossible.
- Partial– the intestinal lumen is partially narrowed, the symptoms of the pathology are erased.
According to the nature of the course, intestinal obstruction has 2 forms:
- Acute– symptoms arise suddenly, the pain is severe, the condition quickly worsens. This form of pathology is dangerous for the death of the patient.
- Chronic– the disease develops slowly, relapses occur occasionally, constipation and diarrhea alternate. When the intestines are blocked, the pathology moves to the acute stage.
Causes
The development of pathology is based on the following mechanisms:
- Dynamic– failure of intestinal muscle contraction processes. Fecal plugs appear that block the lumen.
- Mechanical– obstruction is associated with the appearance of an obstacle to the movement of feces. Obstacles are created by intestinal volvulus, knots, and bends.
- Vascular– develops when blood flow to an area of the intestine stops and tissues die: a heart attack occurs.
Mechanical
Obstruction develops due to obstacles in the path of chyme (intestinal contents), which appear against the background of such pathologies and conditions:
- fecal and gallstones;
- tumors of the pelvic organs and abdominal cavity– compress the intestinal lumen;
- foreign body;
- bowel cancer;
- strangulated hernia;
- volvulus;
- cicatricial bands, adhesions;
- bending or torsion of intestinal loops, their fusion;
- rise in intra-abdominal pressure;
- overeating after a long fast;
- obturation – blockage of the intestinal lumen.
Dynamic
Pathology develops due to intestinal motility disorders, which occur in 2 directions: spasm or paralysis. Muscle tone increases under the influence of such factors:
- foreign body;
- worms;
- colic in the kidneys, gall bladder;
- acute pancreatitis;
- pleurisy;
- salmonellosis;
- abdominal injuries;
- damage to the nervous system;
- traumatic brain injury;
- circulatory disorders in the vessels of the mesentery.
Dynamic intestinal obstruction with paresis or muscle paralysis develops against the background of the following factors:
- peritonitis (inflammation of the peritoneum);
- operations on the abdominal area;
- poisoning with morphine, salts of heavy metals.
Symptoms
Signs of intestinal obstruction in adults and children in acute form vary depending on the stage of the pathology:
- The early period is the first 12 hours from the onset of ileus. Abdominal bloating, a feeling of heaviness, sharp pain, and nausea appear.
- Intermediate – next 12 hours. The signs of pathology are intensifying, the pain is constant, vomiting is frequent, there are bowel sounds.
- Late – terminal stage, which occurs on the 2nd day. Breathing quickens, temperature rises, and intestinal pain intensifies. Urine is not excreted, there is often no stool - the intestines are completely clogged. General intoxication develops and repeated vomiting occurs.
The main symptoms of intestinal obstruction are stool disturbances, bloating, severe pain, but with a chronic course other signs of pathology appear:
- yellow coating on the tongue;
- dyspnea;
- lethargy, fatigue;
- decreased blood pressure;
- tachycardia.
Intestinal obstruction in children infancy is a dangerous condition when there are such symptoms of pathology:
- vomiting with bile;
- weight loss;
- fever;
- bloating in the upper part of the abdomen;
- gray skin.
Pain
This sign of pathology appears against the background of damage to nerve receptors. On early stage The pain is acute, occurs in attacks within 10-15 minutes, and then becomes constant and aching.
If this symptom disappears after 2-3 days with acute course illness, call an ambulance - intestinal activity has stopped completely
Retention of stool
An early symptom of the disease, which indicates low obstruction. If the problem is in the small intestine, stool is frequent in the first day, constipation and diarrhea alternate. When complete inferior ileus develops, feces stop coming out. With partial constipation, constipation is constant, diarrhea rarely occurs. In children under one year of age, one section of the intestinal tube is often embedded in another, so blood is visible in the stool. In adults, its appearance requires calling an ambulance.
Vomit
This symptom occurs in 70-80% of patients. At an early stage of the disease, gastric masses come out. After vomiting is frequent, has a yellow or brown tint, putrid smell. Often this is a sign of small intestinal obstruction and an attempt to remove feces. If the colon is affected, the patient experiences nausea, vomiting occurs rarely. On late stages it becomes more frequent due to intoxication.
Gases
The symptom is caused by stagnation of feces, paresis of nerve endings and dilation of intestinal loops. Gases accumulate in the abdomen in 80% of patients; in the spastic form of ileus they rarely appear. With vascular - swelling over the entire surface of the intestine, with mechanical - in the area of the afferent loop. Children under one year old do not pass gas and experience severe abdominal pain. The baby often spits up, cries, refuses to eat, and sleeps poorly.
Valya's symptom
When diagnosing intestinal obstruction, evaluate 3 clinical sign pathologies:
- in the area of blockage, the abdomen is swollen, there is its asymmetry;
- reductions abdominal wall clearly visible;
- the intestinal loop in the area of swelling is easy to feel.
Complications
When fecal debris is not removed from the intestines for a long time, it decomposes and poisons the body. The microflora balance is disturbed, and pathogenic bacteria. They release toxins that are absorbed into the blood. Systemic intoxication develops, metabolic processes fail, and coma rarely occurs.
More than 30% of patients with ileus die without surgery
Death occurs due to the following conditions:
- sepsis – blood poisoning;
- peritonitis;
- dehydration.
Diagnostics
To diagnose and separate intestinal obstruction from acute appendicitis, pancreatitis, cholecystitis, perforated ulcer, renal colic And ectopic pregnancy After examining the patient’s complaints, the gastroenterologist conducts an examination using the following methods:
- Auscultation– intestinal activity is increased, there is a splashing noise (Sklyarov’s symptom) at an early stage of the pathology. Later, peristalsis weakens.
- Percussion– the doctor taps the abdominal wall and, if there is obstruction, detects tympanitis and a dull sound.
- Palpation– in the early stages, Val’s symptom is observed, in the later stages – the anterior abdominal wall is tense.
- X-ray– intestinal arches swollen with gas are visible in the abdominal cavity. Other signs of pathology in the image: Kloiber cups (dome above the liquid), transverse striations. The stage of the disease is determined by injecting a contrast agent into the intestinal lumen.
- Colonoscopy– examination of the colon using a probe that is inserted rectally. The method identifies the causes of obstruction in this area. In case of acute pathology, treatment is carried out during the procedure.
- Abdominal ultrasound– identifies tumors, foci of inflammation, conducts differential diagnosis ileus with appendicitis, colic.
Treatment without surgery
In the chronic course of the pathology, the patient is hospitalized and treated in a hospital.
Before the ambulance arrives, do not take laxatives or do enemas.
Treatment goals:
- eliminate intoxication;
- cleanse the intestines;
- reduce pressure in the digestive tract;
- stimulate intestinal peristalsis.
Decompression
Inspection of intestinal contents is performed using a Miller Abbott probe, which is inserted through the nose. It remains for 3-4 days; in case of adhesions, the period is extended. Chyme is suctioned every 2-3 hours. The procedure is performed under general anesthesia in children and adults under 50 years of age. It is effective for ileus of the upper gastrointestinal tract.
Colonoscopy
A stent is inserted into the narrowed section of the intestinal tube, which widens it. After the procedure he is taken out. The doctor gains access through anal passage, the work is carried out using endoscopic equipment. Cleansing is fast and effective partial obstruction. For children under 12 years of age, the procedure is performed under anesthesia.
Enema
Adults are given 10-12 liters through a glass tube. warm water several approaches before clear liquid comes out. A siphon enema is done to cleanse the lower intestinal sections. Afterwards, the tube is left in the anus for 20 minutes to remove gases. The enema relieves the gastrointestinal tract and is effective in case of obstruction due to a foreign body. The procedure is not performed for rectal tumors, perforation, or bleeding.
Medicines for intestinal obstruction
In the scheme conservative treatment ileus in adults and children the following drugs are used:
- Antispasmodics (Papaverine, No-Shpa)– relax intestinal muscles, improve peristalsis, relieve pain.
- Anticoagulants (Heparin)– thin the blood, prescribed at the early stage of obstruction due to vascular thrombosis.
- Thrombolytics (Streptokinase)– dissolve blood clots, used by injection.
- Cholinomimetics (Prozerin)– indicated for muscle paresis, stimulates intestinal motility.
- Anesthetics (Novocaine)– instantly relieve pain, injected into the perinephric tissue.
Refortan
The product binds water in the body, reduces blood viscosity, improves blood circulation and reduces platelet aggregation. Refortan has a plasma-substituting effect and is available as a solution for infusion. The effect comes quickly and lasts 5-6 hours. The drug rarely causes vomiting, swelling of the legs, or lower back pain. Contraindications:
- hypertension;
- decompensated heart failure;
- pulmonary edema;
- age under 10 years.
Papaverine
The drug relaxes smooth muscle tone, reduces pain and facilitates the movement of chyme through the intestines. Papaverine is produced in the form of tablets, suppositories and solution for injection. The effect occurs within 10-15 minutes, depending on the dose of the product, and lasts from 2 to 24 hours. Rarely, the medicine lowers blood pressure, causes drowsiness, nausea, and constipation. Contraindications:
- liver failure;
- glaucoma;
- age younger than 6 months and older than 65 years;
- traumatic brain injury in the last six months.
Heparin
The drug reduces platelet aggregation and slows down blood clotting. After injection intramuscularly, the effect occurs within 30 minutes and lasts 6 hours. The drug works intravenously for 4 hours. Heparin is available as an injection solution. During treatment, the risk of bleeding increases and there is a possibility of an allergic reaction. Contraindications:
- hypertension;
- stomach ulcer.
Streptokinase
The drug dissolves blood clots by stimulating the conversion of blood clots into plasmin. Available in the form of a solution for infusion. The effect occurs within 45 minutes and lasts up to a day. The drug has a large number of contraindications; it is used with caution in elderly people over 75 years of age and with anticoagulants. Adverse reactions:
- bleeding;
- local symptoms allergies – rash, itching, swelling;
- anaphylactic shock;
- hematoma at the injection site.
Folk remedies
For functional chronic obstruction, treatment is carried out at home and alternative medicine recipes are used.
Discuss your treatment plan with your doctor: it may be harmful.
Improve intestinal peristalsis, relieve inflammation and soften stool the following herbs:
- buckthorn bark;
- fennel;
- chamomile;
- toadflax;
- St. John's wort.
When treating with this remedy, drink 1.5-2 liters of water per day - this will prevent stomach pain. Basic recipe: grind 100 g of flaxseed in a coffee grinder, pour in 30 g olive oil cold pressed. Leave for a week, stir or shake the container once a day. Take 1 tbsp. l. half an hour before meals 3 times a day for 10 days.
Beet
Peel the root vegetable, pour cold water and cook over low heat, covered, for 1.5-2 hours until soft. Grate coarsely, add 1 tsp. vegetable oil and honey for every 100 g of dish. Morning and evening, eat 1 tbsp. l. this mixture. Continue treatment until symptoms of obstruction resolve. Prepare a new portion every 2-3 days.
Buckthorn bark
Pour 1 tbsp. l. raw materials half a liter of boiling water. Heat over medium heat, covered, for 30 minutes, leave for an hour. Strain the broth, drink 1 tsp. between meals 5-6 times/day. The product has a strong laxative effect, so if you experience discomfort in the stomach, reduce the frequency of its use to 3-4 times a day. The course of treatment is 10 days. Buckthorn bark is not recommended for children.
Surgery
The operation is performed when therapy does not produce results, the pathology occurs in an acute form, or ileus is associated with volvulus small intestine, gallstones, nodes. Surgery takes place under general anesthesia. In the case of a mechanical form of pathology, the following actions are performed during surgery:
- viscerolysis - dissection of adhesions;
- disinvagination;
- unwinding the knot;
- removal of the area of necrosis.
Enterotomy
During the operation, the anterior abdominal wall is cut with an electric knife or scalpel and the small intestine is opened. The surgeon removes its loop, removes the foreign body and applies sutures. There is no narrowing of the intestinal lumen, its length does not change, and peristalsis is not disturbed. The patient remains in the hospital for 3-10 days. For adults and children, the operation is low-traumatic; the following complications rarely occur:
- inflammation of the abdominal cavity;
- seam divergence.
During surgery, part of the organ is removed. The technique is applied to the duodenum, jejunum, and sigmoid colon for vascular thrombosis, strangulated hernia, tumors. The integrity of the tube is restored by stitching together healthy tissue. Resection is effective for any obstruction, but has many disadvantages:
- Damage blood vessels – occurs during laparotomy intervention.
- Suture infection or inflammation– with an open surgical technique.
- Secondary obstruction– because of education connective tissue in the area of resection.
- Long recovery period– 1-2 years.
Diet for intestinal obstruction
1-2 weeks after surgery and when chronic form pathologies, change your diet taking into account the following principles:
- Avoid alcohol, coffee and carbonated drinks.
- Introduce boiled and steamed vegetables, fruits, lean fish, chicken. Use cottage cheese 0-9%, compotes and jelly. For cereals, give preference to oatmeal, round rice, and buckwheat. Cook porridge in water.
- Eat pureed food in the first month after surgery and during exacerbation of obstruction.
- Eat 6-7 times/day in portions of 100-200 g.
- Reduce the amount of salt to 5 g/day.
- Every day, eat boiled or baked pumpkin, beets, mix them with honey or vegetable oil.
If intestinal obstruction occurs, remove the following foods from your diet:
- apples, cabbage, mushrooms;
- confectionery;
- hot, spicy, salty dishes;
- fresh bakery;
- cream, sour cream;
- milk;
- millet, pearl barley;
- fat meat.
Prevention
To prevent intestinal obstructions, follow these recommendations:
- consult a doctor for abdominal injuries;
- treat gastrointestinal diseases in a timely manner;
- eat right;
- avoid excessive physical activity;
- follow safety precautions when working with chemicals, heavy metals;
- wash fruits and vegetables well;
- undergo a full course of treatment for helminthic infestations;
- after surgery on the abdominal area, follow the recommendations for proper rehabilitation to prevent adhesions.
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1. Wahl's syndrome(adductor loop syndrome): abdomen in “waves”, expansion of the adductor loop, percussion above it - tympanitis, increased peristalsis adducting loop.
2. Mathieu-Sklyarov's symptom -“splashing” noise (caused by sequestration of fluid in the intestines).
3. Spasokukotsky’s symptom- “falling drop” symptom.
4. Grekov’s symptom (Obukhov hospital)- gaping anus, dilated and empty rectum (due to the development colonic obstruction at the level of the left half of the colon).
5. Gold's sign- bimanual rectal examination reveals an enlarged (sausage-shaped) afferent intestinal loop.
6. Symptom Dansa - retraction of the right iliac region with ileocecal intussusception (absence of the cecum in “its place”).
7. Tsege-Manteuffel sign- when performing a siphon enema, only up to 500 ml of liquid enters (obstruction at the level sigmoid colon).
8. Bayer's sign- “oblique” belly.
9. Anschutz's sign- swelling of the cecum with colonic obstruction.
10. Bouveret's sign- collapsed cecum with small intestinal obstruction.
11. Gangolf's symptom- dullness in sloping areas of the abdomen (effusion).
12. Kivulya symptom- metallic percussion sound above the abdomen.
13. Rousche's sign- palpation of a smooth, painful formation during intussusception.
14. Alapi symptom- with intussusception, there is no muscular protection of the abdominal wall.
15. Ombredan's symptom- with intussusception, hemorrhagic or “raspberry jelly” type discharge from the rectum.
16. Babuk's sign- with intussusception, the appearance of blood in the rinsing waters after palpation of the abdomen (zone of intussusception) during a primary or repeated enema.
The importance of the diagnostic and treatment complex for intestinal obstruction.
1. distinguishes mechanical CI from functional,
2. allows functional CI,
3. eliminates the need for surgery in 46-52% of patients,
4. prevents the development of additional adhesions,
5. shortens the treatment time for patients with CI,
6. reduces the number of complications and mortality,
7. gives to the doctor powerful method treatment of CI.
RULES FOR EXECUTION OF LDP.
in the absence of obvious mechanical CI:
1. subcutaneous injection of 1 ml of 0.1% atropine sulfate solution
2. bilateral novocaine perinephric blockade with a 0.25% novocaine solution
3. pause 30-40 minutes + treatment of associated disorders,
4. aspiration of gastric contents,
5. siphon enema with assessment of its effect by the surgeon,
6. determination of indications for surgery.
ASSESSMENT OF THE RESULT OF LDP
1. according to subjective data,
2. according to the effect of a siphon enema, according to objective data:
Ø dyspeptic syndrome disappeared,
Ø no bloating or asymmetry of the abdomen,
Ø no " splashing noise»,
Ø ordered peristaltic sounds are heard,
Ø “Kloiber cups” are allowed; after taking a suspension of barium, its passage through the intestines is determined.
REASONS FOR FALSE ASSESSMENT OF LDP
1. analgesic effect of novocaine,
2. assessment of the result only based on subjective data,
3. objective symptoms and their dynamics are not taken into account,
4. The effect of siphon enema is incorrectly assessed.
67. Modern principles of treatment of patients with intestinal obstruction, outcomes, prevention.
TREATMENT OF INTESTINAL OBSTRUCTION Urgent surgery for intestinal obstruction is indicated:
1. If there are signs of peritonitis.
2. Subject to availability obvious signs or suspected strangulation or mixed intestinal obstruction.
In other cases:
1. A diagnostic and treatment appointment is carried out; if the reception is negative, an urgent operation is performed, if it is positive, conservative treatment is carried out.
2. 250 ml of liquid barium sulfate is given orally.
3. Infusion therapy is carried out.
4. The passage of barium is assessed - when it passes (after 6 hours into the colon, after 24 hours into the rectum), the diagnosis of intestinal obstruction is removed, and the patient is subjected to a detailed examination.
The decision on surgery for acute intestinal obstruction should be made within 2-4 hours after admission. When setting indications for surgical treatment patients should undergo brief preoperative preparation.
Surgery for intestinal obstruction involves performing a number of successive steps:
1. Performed under endotracheal anesthesia with myoplegia; in most cases surgical access A midline laparotomy is used.
2. Search and elimination of ileus is carried out: dissection of adhesions, mooring, enterolysis; disinvagination; unwinding of the torsion; bowel resection, etc.
3. After novocaine blockade of reflexogenic zones, decompression (intubation) of the small intestine is performed:
a) nasogastrointestinal
b) according to Yu.M. Dederer (via gastrostomy tube);
c) according to I.D. Zhitnyuk (retrograde through ileostomy);
d) according to Shede (retrograde through a cecostomy, appendicocecostomy).
Intubation of the small intestine for intestinal obstruction is necessary for:
Decompression of the intestinal wall in order to restore microcirculation and intramural blood flow in it.
To remove highly toxic and intensely infected intestinal chyme from its lumen (the intestine in case of intestinal obstruction is the main source of intoxication).
To be carried out in postoperative period intestinal treatment (intestinal dialysis, enterosorption, oxygenation, motility stimulation, restoration of barrier and immune function mucosa, early enteral feeding, etc.).
To create a frame (splinting) of the intestine in a physiological position (without angulation along the “large radii” of intestinal loops). Intestinal intubation lasts from 3 to 8 days (on average 4-5 days).
4. In some cases (resection of the intestine in conditions of peritonitis, resection of the colon, extreme serious condition patient) an intestinal stoma (end, loop or Meidl) is indicated.
5. Sanitation and drainage of the abdominal cavity according to the principle of treating peritonitis. This is due to the fact that in the presence of effusion in the abdominal cavity with ileus, anaerobic microorganisms are inoculated from it in 100% of cases.
6. Completion of the operation (suturing of the abdominal cavity).
Surgery for intestinal obstruction should not be traumatic or rough. In some cases, one should not engage in long-term and highly traumatic enterolysis, but resort to the application of bypass anastomoses. In this case, the surgeon must use those techniques that he is fluent in.
POSTOPERATIVE TREATMENT
General principles This treatment must be formulated clearly and specifically - it must be: intensive; flexible (if there is no effect, a quick change of appointments should be carried out); comprehensive (all must be used possible methods treatment).
Postoperative treatment is carried out in the intensive care unit and then in surgical department. The patient in bed is in a semi-sitting position (Fovler), the “three catheters” rule is observed. Complex postoperative treatment includes:
1. Pain relief (non-narcotic analgesics, antispasmodics, prolonged epidural anesthesia are used).
2. Carrying out infusion therapy (with crystalloid transfusion, colloidal solutions, proteins, according to indications - blood, amino acids, fat emulsions, acid-base correctors, potassium-polarizing mixture).
3. Carrying out detoxification therapy (carrying out “forced diuresis”, performing hemosorption, plasmapheresis, ultrafiltration, indirect electrochemical oxidation of blood, intestinal dialysis of enterosorption, increasing the activity of the “reserve deposition system”, etc.) -
4. Carrying out antibacterial therapy(based on the principle of treatment of peritonitis and abdominal sepsis):
a) with the prescription of drugs: “ wide range» with effects on aerobes and anaerobes;
b) administration of antibiotics into a vein, aorta, abdominal cavity, endolymphatic or lymphotropic, into the lumen of the gastrointestinal tract;
c) prescription of maximum pharmacological doses;
d) if there is no effect, quickly change assignments.
5. Treatment of enteral insufficiency syndrome. Its complex includes: intestinal decompression; performing intestinal dialysis ( saline solutions, sodium hypochlorite, antiseptics, oxygenated solutions); carrying out enterosorption (using dextrans, after the appearance of peristalsis - carbon sorbents); administration of drugs that restore the functional activity of the gastrointestinal mucosa (antioxidants, vitamins A and E); early enteral nutrition.
6. Stopping system activity inflammatory reaction body (systemic inflammatory response syndrome).
7. Carrying out immunocorrective therapy. In this case, the patient is administered hyperimmune plasma, immunoglobulin, immunomodulators (tactivin, splenin, imunofan, polyoxidonium, roncoleukin, etc.), ultraviolet and intravascular laser irradiation blood, acupuncture neuroimmunostimulation.
8. A set of measures is being taken to prevent complications (primarily thromboembolic, from the respiratory, cardiovascular, urinary systems, from the wound).
9. Corrective treatment of concomitant diseases is carried out.
Complications of gastroduodenal ulcers.
68. Etiology, pathogenesis, gastroduodenal ulcers. Mechanisms of pathogenesis of gastroduodenal ulcers.
ULCER DISEASE is a disease that is based on the formation and long-term course of ulcerative defect on the mucous membrane with damage to various layers of the wall of the stomach and duodenum.
Etiology. Causes:
Social factors(tobacco smoking, unhealthy diet, alcohol abuse, bad conditions and irrational lifestyle, etc.);
Genetic factors (close relatives have a risk of developing peptic ulcer 10 times higher);
Psychosomatic factors (personality types who experience constant internal tension and a tendency to depression are more likely to get sick);
Etiological role Helicobacter pylori is a gram-negative microbe located intracellularly, destroying the mucous membrane (however, there is a group of patients with chronic ulcers who do not have this microbe in the mucous membrane);
Physiological factors– increased gastric secretion, hyperacidity, decreased protective properties and inflammation of the mucous membrane, local microcirculation disorders.
Modern concept etiopathogenesis of ulcers – “Scales Neck”:
Thus, a decrease in protective factors plays a role main role in ulcerogenesis.
Clinic, diagnosis of complications of gastroduodenal ulcers, indications for surgical treatment: perforated and penetrating gastroduodenal ulcers;
PERFORMANCE (OR PERFORATION):
This is the most difficult, rapidly developing and absolutely fatal complication peptic ulcer disease.
The patient can be saved only through emergency surgical intervention,
The shorter the period from the moment of perforation to surgery, the greater the patient’s chances of survival.
| Pathogenesis of perforated ulcer 1. entry of stomach contents into the free abdominal cavity; 2. chemically aggressive gastric contents irritate the huge receptor field of the peritoneum; 3. peritonitis occurs and steadily progresses; 4. initially aseptic, then peritonitis inevitably becomes microbial (purulent); 5. as a result, intoxication increases, which is enhanced by severe paralytic intestinal obstruction; 6. intoxication disrupts all types of metabolism and inhibits cellular functions various organs; 7. this leads to increasing multiple organ failure; 8. it becomes the direct cause of death. | Periods or stages of perforated ulcer (peritonitis) Stage I painful shock or irritation (4-6 hours) - neuro-reflex changes, clinically manifested by severe abdominal pain; Stage II of exudation (6-12 hours) is based on inflammation, clinically manifested by “imaginary well-being” (some reduction in pain is associated with partial death of nerve endings, covering of the peritoneum with fibrin films, exudate in the abdomen reduces friction of the peritoneal layers); Stage III intoxication - (12 hours - 3 days) - intoxication will increase, clinically manifested by severe diffuse purulent peritonitis; Stage IV (more than 3 days from the moment of perforation) is the terminal period, clinically manifested by multiple organ failure. |
Clinic
The classic pattern of perforation is observed in 90-95% of cases:
Sudden, severe “dagger” pain in the epigastric region,
The pain quickly spreads throughout the abdomen,
The condition is deteriorating sharply,
The pain is severe and the patient sometimes falls into state of shock,
Patients complain of thirst and dry mouth,
The patient grabs his stomach with his hands, lies down and freezes in a forced position,
The slightest movement causes increased abdominal pain,
ANAMNESIS
Perforation usually occurs against the background of a long course of peptic ulcer disease,
Perforation is often preceded by a short-term exacerbation of peptic ulcer disease,
In some patients, ulcer perforation occurs without a history of ulcers (approximately 12%),
this happens with “silent” ulcers.
Inspection and objective examination data:
ü patients lie down and try not to make any movements,
ü the face is sallow-gray, the features are pointed, the gaze is suffering, covered with cold sweat, the lips and tongue are rather dry,
ü arterial pressure slightly reduced, and the pulse is slow,
ü the main symptom is tension in the muscles of the anterior abdominal wall, the stomach is “board-shaped”, does not participate in breathing (in thin people, segments of straight lines of the abdomen appear and transverse folds of skin are noted at the level of the navel - Dzbanovsky’s symptom),
ü palpation of the abdomen accompanied by sharp pain, increased pain in the abdomen, more in the epigastric region, right hypochondrium, then the pain becomes diffuse,
ü strongly positive Shchetkin-Blumberg symptom - first in the epigastric region, and then throughout the abdomen.
Related information.
1. The most important and typical symptoms of mechanical intestinal obstruction are: cramping abdominal pain, vomiting, thirst, stool and gas retention.
2. "Ileus Scream"- with strangulation obstruction, pain occurs acutely, severely, patients scream painfully.
3. Bayer's sign- asymmetry of abdominal bloating, observed with volvulus of the sigmoid colon.
4. Valya's symptom- a loop of intestine fixed and stretched in the form of a balloon with a zone of high tympanitis above it.
5. Schiemann–Dans sign- retraction of the right iliac region during cecal volvulus.
6. Mondor's sign- with severe distension of the intestine, a characteristic rigidity of the abdominal wall is determined, which, upon palpation, resembles the consistency of an inflated ball.
7. Schwartz's sign- upon palpation of the anterior abdominal wall at the site of swelling in the epigastric region, an elastic tumor is determined, which to the touch resembles a soccer ball.
8. Symptom of I. P. Sklyarov- when the abdominal wall is slightly rocked, a splashing sound is produced.
9. Mathieu's symptom- with fast percussion umbilical region splashing noise occurs.
10. Kivulya's symptom- when percussing a swollen area of the abdominal wall, a tympanic sound with a metallic tint is heard.
11. Lothuissen's sign- heard on auscultation of the abdomen breath sounds and heartbeat.
12. Obukhov Hospital symptom ()- balloon-shaped expansion of the empty ampulla of the rectum and gaping of the anus.
13. Spasokukotsky–Wilms sign- the sound of a falling drop is determined by auscultation.
14. Tsege–Manteuffel sign- in case of volvulus of the sigmoid colon, no more than 0.5–1 liters of water can be administered using an enema.
15. Schlange's sign- upon examination, intestinal peristalsis is visible to the eye.
16. Symptom of “deafening silence”- due to intestinal necrosis and peritonitis, peristaltic sounds weaken and disappear.
17. Thévenard's sign- sharp pain when pressing on 2 transverse fingers below the navel along midline, i.e. where the root of the mesentery passes. This symptom is especially characteristic of small intestinal volvulus.
18. Laugier's symptom- if the stomach is large, spherical and convex - an obstacle in the small intestines, if the stomach is large, flat, with widely stretched sides - an obstacle in the large intestines.
19. Bouveret's sign- if the cecum is swollen, then the place of obstruction is in colon, if the cecum is in a dormant state, then there are obstacles in the small intestines.
20. Delbe Triad(with volvulus of the small intestines) - rapidly increasing effusion in the abdominal cavity, bloating and non-fecaloid vomiting.
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Clinical picture
Leading symptoms acute intestinal obstruction - abdominal pain, bloating, vomiting, stool and gas retention. They have varying degrees of severity depending on the type of obstruction and its level, as well as on the duration of the disease.Pain usually occur suddenly, regardless of food intake, at any time of the day, without any warning signs. They are characterized by their cramping nature, associated with periods of intestinal hyperperistalsis, without clear localization in any part of the abdominal cavity. With obstructive intestinal obstruction outside of a cramping attack, they usually disappear completely. Strangulation obstruction is characterized by constant sharp pains, which periodically intensify. As the disease progresses sharp pains, as a rule, subside on the 2-3rd day, when intestinal peristaltic activity stops, which serves as a poor prognostic sign. Paralytic intestinal obstruction occurs with constant dull arching pain in the abdomen.
Vomit at first it is of a reflex nature; with continued obstruction, the vomit is represented by stagnant gastric contents. IN late period it becomes indomitable, the vomit takes on a fecal appearance and smell due to rapid reproduction coli in the upper parts of the digestive tract. Fecal vomiting is an undoubted sign of mechanical intestinal obstruction, but to confidently diagnose this pathological condition you should not wait for this symptom, as it often indicates the “inevitability of death” (Mondor A.). The higher the level of obstruction, the more severe the vomiting. In the intervals between it, the patient experiences nausea, he is bothered by belching and hiccups. With low localization of the obstruction in the intestine, vomiting occurs later and at longer intervals.
Retention of stool and gas- a pathognomonic sign of intestinal obstruction. This early symptom low obstruction. When its character is high, at the beginning of the disease, especially under the influence therapeutic measures, there may be stool, sometimes multiple due to bowel movements located below the obstruction. With intussusception from anus Sometimes bloody discharge appears. This may cause diagnostic error when acute intestinal obstruction is mistaken for dysentery.
Clinical manifestations obstruction depends not only on its type and level of occlusion of the intestinal tube, but also on the phase (stage) of the course of this pathological process.
It is customary to distinguish three stages acute intestinal obstruction:
- Initial- stage of local manifestations acute disorder intestinal passage lasting 2-12 hours depending on the form of obstruction. This period is dominated by pain syndrome and local abdominal symptoms.
- Intermediate- stage of imaginary well-being, characterized by the development of acute intestinal failure, water and electrolyte disorders and endotoxemia. Its duration is 12-36 hours. In this phase, the pain loses its cramping character, becomes constant and less intense. The abdomen is greatly distended, intestinal motility weakens, and a “splashing noise” is heard. Stool and gas retention is complete.
- Late- stage of peritonitis and severe abdominal sepsis, often called terminal stage, which is not far from the truth. It occurs 36 hours after the onset of the disease. This period is characterized by manifestations of a severe systemic inflammatory reaction, the occurrence of multiple organ dysfunction and failure, severe intoxication and dehydration, as well as progressive hemodynamic disorders. The abdomen is significantly distended, peristalsis cannot be heard, and peritoneal symptoms are characteristic.
Diagnostics
Anamnesis
Taking an anamnesis plays an important role in successful diagnosis acute intestinal obstruction. Previous operations on the abdominal organs, open and closed injuries belly, inflammatory diseases often serve as a prerequisite for the occurrence of adhesive intestinal obstruction. Indications of periodic abdominal pain, bloating, rumbling, stool disorders, especially alternating constipation with diarrhea can help in making a diagnosis of tumor obstructive obstruction.It is important to note the fact that the clinical picture of high intestinal obstruction is much more vivid, with the early appearance of symptoms of dehydration, severe disorders of the acid-base state and water-electrolyte metabolism.
General state the patient may be moderate severity or severe, which depends both on the form and level of intestinal obstruction, and the time elapsed from the onset of the disease. The temperature does not increase during the initial period of the disease. With strangulation obstruction, when collapse occurs, the temperature can drop to 35 °C. Subsequently, with the development of a systemic inflammatory reaction and peritonitis, hyperthermia occurs. The pulse at the onset of the disease does not change, the increase in the phenomena of endotoxemia and dehydration is manifested by tachycardia. Note the obvious discrepancy between the relatively low body temperature and rapid pulse (symptom of “toxic scissors”). The tongue is dry and covered with a dirty coating.
Clinical researches
Inspection
Examination of the abdomen of a patient with suspected intestinal obstruction it is necessary to begin with an examination of all possible places hernias coming out to exclude their infringement as the cause of this dangerous syndrome. Special attention necessary to femoral hernia in older women. Strangulation of a section of the intestine without the mesentery in a narrow hernial orifice is not accompanied by pronounced local painful sensations, therefore, patients do not always actively complain about the appearance of a small protrusion below the inguinal ligament, which precedes the onset of symptoms of obstruction.Postoperative scars may indicate the adhesive nature of intestinal obstruction. To the most constant signs obstruction is attributed bloating. Its degree can be different, depending on the level of occlusion and the duration of the disease. With high obstruction, it can be insignificant and often asymmetrical: the lower the level of obstruction, the more pronounced this symptom is. Diffuse flatulence is characteristic of paralytic and obstructive colonic obstruction. As a rule, as the duration of the disease increases, so does the bloating.
Incorrect abdominal configuration and asymmetry more typical for strangulation intestinal obstruction. Sometimes, especially in emaciated patients, it is possible to see one or more distended intestinal loops through the abdominal wall, periodically peristalting. Visible peristalsis- an undoubted sign of mechanical intestinal obstruction. It usually occurs with slowly developing obstructive tumor obstruction, when the muscles of the adductor intestine have time to hypertrophy.
Local bloating with a swollen loop of intestine palpated in this area, over which high tympanitis is determined ( Valya's symptom), is an early symptom of mechanical intestinal obstruction. With volvulus of the sigmoid colon, the swelling is localized closer to the right hypochondrium, while in the left iliac region, that is, where it is usually palpated, a retraction of the abdomen is noted ( Schiemann's sign).
Palpation
Palpation of the abdomen during the interictal period (during absence cramping pain caused by hyperperistalsis) is usually painless before the development of peritonitis. There is no tension in the muscles of the anterior abdominal wall, as well as the Shchetkin-Blumberg symptom. In case of strangulation obstruction due to volvulus of the small intestine, it is positive Thévenard's sign- sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of its mesentery is usually projected. Sometimes upon palpation it is possible to identify the tumor, body of intussusception or inflammatory infiltrate that caused the obstruction.With succussion (a slight shaking of the abdomen), you can hear a “splashing noise” - Sklyarov's symptom. Its identification is helped by auscultation of the abdomen using a phonendoscope while manually applying jerky movements of the anterior abdominal wall in the projection of the swollen loop of intestine. The detection of this symptom indicates the presence of an overstretched paretic loop of intestine, overflowing with liquid and gaseous contents. This symptom most likely indicates the mechanical nature of the obstruction.
Percussion
Percussion makes it possible to identify limited areas of zones of dullness, which correspond to the location of intestinal loops filled with fluid, directly adjacent to the abdominal wall. These areas of dullness do not change their position when the patient turns, which is why they differ from dullness caused by effusion in the free abdominal cavity. Dullness is also detected over a tumor, inflammatory infiltrate or intestinal intussusception.Auscultation
Auscultation of the abdomen, in the figurative expression of our surgical teachers, is necessary in order to “hear the noise of the beginning and the silence of the end” (Mondor A.). In the initial period of intestinal obstruction, loud, resonant peristalsis is heard, which is accompanied by the appearance or intensification of abdominal pain. Sometimes you can hear the “noise of a falling drop” ( Spasokukotsky-Wilms symptom) after the sounds of fluid transfusion in distended intestinal loops. Peristalsis can be induced or enhanced by tapping the abdominal wall or palpating it. As obstruction develops and paresis increases, bowel sounds become short, rare and of higher pitch. In the late period, all sound phenomena gradually disappear and are replaced by “dead (grave) silence” - undoubtedly an ominous sign of intestinal obstruction. During this period, with a sharp bloating of the abdomen, you can listen not to peristalsis, but to respiratory sounds and heart sounds, which are not normally conducted through the abdomen.Digital rectal examination
The examination of a patient with acute intestinal obstruction must be supplemented digital rectal examination. In this case, it is possible to identify a “fecal blockage”, a tumor of the rectum, the head of the intussusception and traces of blood. Valuable diagnostic sign low colonic obstruction, determined by rectal examination - atony of the anal sphincter and balloon-like swelling of the empty ampulla of the rectum ( Obukhov Hospital symptom, described by I.I. Grekov). This type of obstruction is also characterized by Tsege-Manteuffel sign, which consists in the small capacity of the distal intestine when performing a siphon enema. In this case, no more than 500-700 ml of water can be introduced into the rectum.A.I. Kirienko, A.A. Matyushenko
Kocher-Volkovich symptom – movement of pain from the epigastric region to the right lower quadrant of the abdomen.
The Kocher-Wolkovich symptom is characteristic of acute appendicitis
2. Symptom "splashing noise".
A gurgling sound in the stomach, heard in the supine position with short, quick blows of the fingers on the epigastric region; indicates the presence of gas and liquid in the stomach, for example, with hypersecretion of the stomach or with delayed evacuation of its contents. with pyloric stenosis)
Ticket number 2.
1. Determination of the size of the hernial orifice.
Determining the size of the hernial orifice is possible only with reducible hernias (with irreducible strangulated hernias, it is impossible to determine the hernial orifice).
After the hernia has been reduced, the size of the hernial orifice in two dimensions or its diameter (in cm), as well as the condition of its edges, are determined using the tips of one or several fingers.
The hernial orifices are most accessible to research for umbilical, epigastric and median postoperative hernias; for hernias of other localizations they are less accessible.
Determination of the hernial orifice in umbilical hernias is made by palpation of the bottom of the umbilical fossa.
For inguinal hernias, examination of the hernial orifice (external inguinal ring) in men is carried out with the patient lying down, using the index or 3rd finger through the lower pole of the scrotum.
2.Technique and interpretation of pre- and intraoperative cholegram data.
Interpretation of endoscopic retrograde cholangiopancreatography (ERCP) data: dimensions of the intrahepatic bile ducts, hepaticocholedochus, presence of stones in the gallbladder, common bile duct, narrowing of the distal common bile duct, contrasting of the Wirsung duct, etc.
Technique of intraoperative cholangiography:
b) a water-soluble contrast agent (bilignost, biligrafin, etc.) is introduced by puncture or through the cystic duct; after the administration of the contrast agent, an image is taken on the operating table.
The morphological state of the bile ducts is assessed - shape, size, presence of stones (cellularity, marbling of the shadow or its absence (“silent bubble”), presence of filling defects); length, tortuosity of the cystic duct, width of the common bile duct; entry of contrast into the duodenum.
Ticket number 3.
1. Palpation of the gallbladder (Courvoisier’s symptom).
Palpation of the gallbladder is carried out in the area of its projection (the point of intersection of the outer edge of the rectus abdominis muscle and the costal arch or slightly lower if there is an enlargement of the liver), in the same position of the patient and according to the same rules as when palpating the liver.
Increased gallbladder can be palpated in the form of a pear-shaped or ovoid formation, the nature of the surface of which and consistency depend on the condition of the bladder wall and its contents.
In case of blockage of the common bile duct by a stone, the gallbladder relatively rarely reaches large sizes, since the resulting long-term, sluggish inflammatory process limits the extensibility of its walls. They become lumpy and painful. Similar phenomena are observed with a tumor of the gallbladder or the presence of stones in it.
You can palpate a bladder in the form of a smooth elastic pear-shaped body in case of obstruction of the exit from the bladder (for example, with a stone or with empyema, with hydrocele of the gallbladder, compression of the common bile duct, for example, with cancer of the head of the pancreas - Courvoisier-Guerrier symptom).
Courvoisier's sign: palpation of an enlarged, distended, painless gallbladder in combination with obstructive jaundice caused by a tumor.
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