Such a common symptom as abdominal pain should always be treated with caution, because it can be a manifestation of a serious surgical pathology, in which the movement of food contents through the digestive tube is disturbed. This condition can lead to serious consequences, so it is important to recognize it in time and seek medical help in a timely manner.
This condition is characterized by a violation (complete or partial) of the movement of the contents through the intestines.
This is an acute surgical pathology, which is more common in the male population aged 30-60 years. But women, children with such a diagnosis are not at all uncommon for hospitals and clinics. Among all "acute bellies" this diagnosis is established in 5-9% of cases.
This pathology is classified according to the anatomical principle into large intestine (if the process affects the final sections of the gastrointestinal tract) and small intestine (with lesions of the duodenum, jejunum and ileum). By origin - into congenital and acquired.
But more informative is the classification, which reveals the mechanism of the onset of the disease, according to which dynamic and mechanical obstruction is distinguished.
Reasons for the development of a mechanical form
This pathology is called obstructive. The term comes from lat. obturatio - blockage.
- Infringement, twisting of the intestinal loops for each other or around its axis, the formation of nodes, resulting in a violation of the blood supply to the vessels and blocking the blood flow in the loops. This is the situation that the people talk about "intestinal volvulus". The medical name for this phenomenon is strangulation ileus.
- Combination of obturation and infringement. This is a situation in which one loop is introduced, pressed into another, being both a mechanical obstacle and a source of vascular compression and cessation of normal blood flow.
Reasons for the development of a dynamic form
It is based on functional disorders of the motor activity of the gastrointestinal tract, namely:
- persistent spasm
- paresis
- paralysis
Based on the mechanism of motor disorders, this form is divided into paralytic and spastic.
Defects in muscle tone and peristalsis in the form of paralysis and paresis can be observed both in the entire intestine and in its individual sections. The following conditions are capable of provoking motor-evacuation dysfunction and causing paralytic obstruction:
- injuries, operations on the abdominal cavity and gastrointestinal tract
- inflammatory processes: appendicitis, peritonitis, ileitis, cholecystitis
- pathological conditions occurring outside the peritoneum: myocardial infarction, injuries of the spine and skull, pneumonia
- retroperitoneal hematomas, as well as thrombosis of mesenteric vessels, spleen infarcts
- metabolic diseases (diabetic precoma, cystic fibrosis)
Persistent spasm of the intestinal muscles is possible with:
- ascariasis
- hepatic and renal colic
- diseases of the nervous system (hysteria, neurasthenia)
- intoxication of the body, both by products of internal metabolism (with severe renal and hepatic insufficiency), and by substances coming from outside (alcohol, heavy metals)
Adhesions as an etiological factor
Adhesions are able to deform the structure of the organ, tighten, disrupt the anatomical location of the intestinal loops.
Some practicing surgeons single out the adhesive form of impaired conduction of the contents through the intestines, thereby emphasizing the role of the causative factor: the presence of adhesions - connective tissue fibers that form as a result of an inflammatory process or trauma to an organ.
Other authors believe that the adhesive process is more convenient to consider not as a separate form, but as one of the causes of obturation and strangulation obstruction, since these structures can cause both circulatory disorders and block the intestinal lumen.
Both opinions are justified and have the right to exist.
Mechanism of damage development
What is the cause of dangerous surgical pathology is understandable, but what happens inside the intestine when the normal movement of food through it stops?
In general terms, the pathogenesis can be represented as follows:
The contents in the form of food slurry meets an obstacle in its path, stagnation occurs. The intestinal wall is subjected to excessive stretching, it accumulates an excess of digestive juices, bile, pancreatic secretions, gases due to the vital activity of microorganisms and the breakdown of organic acids.
The altered wall is unable to fully carry out absorption, the pressure in it increases, the intestinal loops increase in volume, swell, change color, become purple or cyanotic, or are completely absent.
The pathogenesis of the process and its speed depends on the form of obstruction. With a strangulation form, due to a sharp violation of blood circulation, pathological changes in the intestinal wall grow extremely quickly: its vessels are compressed, blood clots form, and death develops - necrosis.
All processes lead to disruption of the functioning of a part of the intestine or its department. Through a non-functioning organ, pathogenic microorganisms, part of the liquid contents, and bacterial toxins can enter the abdominal cavity. Peritonitis develops.
Such changes in the body cannot but affect the patient's well-being. And if at the initial stages the process is local, limited, albeit with a vivid clinical picture. Then, as the disease progresses, peritonitis develops, followed by sepsis (blood poisoning), multiple organ failure.
At the stage of systemic damage to the body without highly qualified medical care, the disease ends in death.
Symptoms of bowel obstruction
You can suspect the disease by knowing the main signs and symptoms that are characteristic of it. Most often, patients with a confirmed diagnosis, upon contact or initial examination, complain of:
1. Abdominal pain
The earliest, most frequent and common symptom. They can be characterized as cramping, increasing in intensity, like colic with "light" painless intervals during obturation, or as unbearable, constant with ischemic disorders.
2. Vomiting
Occurs in more than 75% of patients. It is characteristic that in the event of a pathology in the high small intestine, vomiting worries quite often, it happens multiple times, and does not bring relief. Reflex incessant vomiting is very characteristic of the strangulation form.
Disturbances in the passage of food in the lower intestinal regions rarely cause this symptom. If vomiting does occur, then in the later stages of the disease, in advanced cases, it has an unpleasant smell of feces due to the decomposition of the contents of the vomit.
3. Lack of stool, violation of gas discharge
These symptoms appear when the lumen of the organ is completely blocked, with partial obstruction, and in the early stages they may be absent.
The stool may be partially present when emptying the departments below the place of the obstacle, but if the focus of the pathology is located in the sigmoid colon and more distally, then the patient cannot recover at all “by and large”.
4. Bloating
A characteristic feature that allows you to make an assumption about the level of patency disorders. If the changes affect the high intestinal sections, swelling is uncharacteristic, since almost all the loops are in a collapsed state.
If the passage is disturbed in the lower small intestine, it is symmetrical.
Colonic pathology is characterized by asymmetry: the right half of the abdomen can be enlarged, corresponding to the lesion of the right colon, or the left - where the opposite sections are located.
Sometimes, with obvious obturation, peristaltic waves and swelling of the loops can be visually observed. In paralytic processes, a symmetrical accumulation of gases without distortions of the abdomen in any part of it is characteristic.
5. Peristaltic noises
Rumbling, gurgling, transfusion - these signs are actively manifested in the first stages of the disease, and indicate a violation of motility and the functioning of the gastrointestinal tract.
In the later stages, with the development of necrosis and peritonitis, all noises subside. This is a prognostically unfavorable sign, "deathly silence" indicates irreversible changes in the organ.
Stages of the disease
There are three consecutive stages of obstruction, each of which corresponds to certain manifestations.
Knowing the features of the clinical picture step by step, the doctor can quickly orient himself, determine exactly how much the patient needs medical care, suggest from the clinic how long the disease has been going on and what condition the intestines are in.
Stage 1 - early
Lasts up to 12 hours. The main complaint of patients is pain. With a mechanical obstruction in the gastrointestinal tract - cramping, with light intervals, with circulatory disorders - unbearable, extremely pronounced (sometimes of such intensity that it can provoke a painful shock)
Stage 2 - intermediate
From 12 to 24 hours. Vomiting, bloating joins the clinic. Repeated profuse vomiting leads to dehydration, thirst.
After drinking the liquid, the patient feels a deterioration in well-being: an increase in pain or vomiting again. The condition progressively worsens from moderate to severe.
The patient is agitated, takes a forced position or cannot find a position that would alleviate his condition, rushes about the bed. The pulse is frequent, weak filling, tachycardia, the skin is pale, cold.
When examined by a surgeon, specific symptoms are revealed: the noise of a splash, a falling drop, Valya, Kivul, which will reliably indicate to the surgeon that obstruction is taking place.
Stage 3 - late
At this stage, the patient's condition is assessed as extremely serious, consistent with the clinic of peritonitis.
There is an increase in body temperature, pulse, respiratory rate, in the analyzes - signs of bright inflammation.
There are no bowel sounds. The body refuses to work, decompensation occurs, multiple organ failure.
Without treatment, the patient at this stage has no chance of surviving.
How to diagnose pathology
In recognizing the pathology, an important role is played by the qualification of the surgeon, his ability to properly examine, palpate the abdomen, collect an anamnesis, quickly orient and decide on the tactics of managing the patient.
This diagnosis does not tolerate slowness and does not allow for a long time to think and wait. As soon as possible, if obstruction is suspected, the patient should perform the following diagnostic studies:
- x-ray examination of the abdomen in a vertical position and a horizontal position on the left side. X-rays can be performed with barium suspension contrast.
The diagnosis will be confirmed by visualized accumulations of gas in the small intestine (normally, there is gas only in the colon), “inverted bowls” - gas above the liquid level, “organ pipes” - swollen loops with gas and liquid. This is how radiologists describe a confirmed bowel obstruction.
- colonoscopy
- irrigoscopy
These methods are used to clarify the pathology in the final sections of the gastrointestinal tract, they will identify the mechanical cause of the lumen closure, more accurately determine the localization of the process.
- laparoscopy
It is used in modern surgery more and more often. Through small incisions on the anterior abdominal wall, the doctor inserts an endoscopic device with a camera into the abdominal cavity, on the monitor screen connected to the endoscope, organs and pathological changes are visualized with high accuracy.
In addition to diagnostic, the method can be used for therapeutic purposes: laparoscopically, some manipulations can be performed to dissect adhesions, remove foreign bodies, and perform detorsion.
- Ultrasound of the OBP (due to the increased accumulation of gases, it may be difficult to conduct it)
Both methods are very informative in determining the fluid in the abdominal cavity, tumors, infiltrates.
Treatment of intestinal obstruction
All patients with a suspected diagnosis should be urgently hospitalized in a surgical hospital.
After a thorough questioning, examination, diagnosis, the doctor determines the type of obstruction and, taking into account the patient's condition, chooses the tactics of treatment.
Patients with an established diagnosis are urgently subject to surgical intervention, with:
- signs of peritonitis
- strangulation form of the disease
Surgical intervention in this form is necessary, since developing blood flow disorders and ischemia very quickly lead to necrosis, necrosis of the organ wall.
- severe obstructive form
- severe intoxication syndrome
- state of shock
In other forms of obstruction (paralytic, spastic), if the patient's condition is stable, therapy begins with conservative methods. In more than half of the cases, such methods are effective and avoid surgery.
Such methods include:
- Enema cleansing or siphon.
- Removal of the contents of the gastrointestinal tract by continuous aspiration - suction with a special device that is inserted through the pharynx and esophagus. This is necessary for unloading, reducing pressure inside the hollow organ.
- Novocaine blockade in the lumbar region on both sides. Allows to stop a pain syndrome.
- Colonoscopy with localization of the process in the distal sections. This method allows in some cases to eliminate torsion of the sigma, as well as endoscopically place a small stent - a metal frame that expands the wall from the inside and eliminates stagnation, removes a mechanical obstacle in the form of a foreign body.
- Medical treatment. Intravenous administration of antispasmodics, non-narcotic analgesics, ganglionic blockers, anticholinesterase substances. With the help of drip infusions, the water and electrolyte balance is corrected, and intoxication is combated.
Important rule: if the choice of a surgeon (according to certain indications) is stopped on conservative therapy, but after 2 hours from its start, the patient does not feel relief, there is no positive dynamics, or the condition worsens, it is necessary to change the treatment tactics in favor of surgery.
Surgical treatment
Before the operation, the patient should be prepared in a short time, which includes catheterization of the bladder, the introduction of saline, plasma-substituting solutions into the vein. This preparation is aimed at stabilizing the patient's vital signs so that he tolerates the surgery well.
Depending on the cause that caused the obstruction, the surgeon performs one or another action aimed at eliminating it. This may be a resection - removal of part of the intestine due to developed necrosis or due to tumor damage, straightening of loops, twists or knots, dissection from rations.
Sometimes situations in the abdominal cavity are so serious that it is difficult to manage with one operation. In such cases, interventions are delayed, in two or three stages.
Any operations are aimed at preserving the organ as much as possible, but if the doctor sees that the intestine is not viable (it is gray, does not peristaltize, the vessels do not pulsate), it is removed.
Any intervention on the intestine is quite traumatic and requires careful monitoring and observation in the postoperative period.
Permeability restored - what's next
If it was possible to cope with the cause of the disease in an operative way, it is very important to stabilize the patient's condition, return him to normal life as soon as possible through the correct management of the postoperative period.
This period includes:
- getting rid of toxins and decay products
Infusion drugs, saline solutions, blood plasma analogues are prescribed. Forced diuresis can be used: the appointment of large volumes of plasma-substituting drugs, and then a diuretic drug that stimulates diuresis. An increase in urine output “washes out” all toxins from the body.
- prevention of possible infection
Be sure to prescribe broad-spectrum antibiotics intravenously, as well as through drainage tubes into the postoperative wound, if necessary.
- prevention of thromboembolism and thrombosis
Tight bandaging of the lower extremities is necessary, the appointment of aspirin, warfarin or heparin, which have a thinning effect on the blood. It is important not to let the patient "stale": to make verticalization as early as possible.
- normalization of bowel function
For several weeks, the contents of the gastrointestinal tract continue to be aspirated through the probe, prokinetics that stimulate motility are administered, sessions of physiotherapeutic procedures with electrical stimulation are prescribed.
Success in the treatment of this pathology depends on timely diagnosis, so you should listen to your body. If he gives signals of trouble in the form of pain in the abdomen, bloating or vomiting, you should not self-medicate, it is better to contact a specialist as soon as possible!
Bowel problems are common in today's population. One of the most dangerous pathologies affecting the intestines is its obstruction. When manifestations of this disease are detected, emergency assistance from surgeons is required. In the absence of treatment, various complications are possible, up to a fatal outcome. The first symptom of obstruction is cramping intensifying pain. In rare cases, the pain syndrome increases gradually.
Etiology of the pathological condition
Intestinal obstruction is a kind of blockage of the intestine, when the contents cannot move to the anus. This provokes a difficulty in the process of emptying the intestines, the discharge of gases, as a result of which they are formed. The clinical picture becomes clearer when the patient's condition deteriorates sharply. The main source of such malaise is irregular emptying. Within the normal range, a person should defecate at least once a day. If the patient suffers from constipation, there are signs of obstruction, you should visit a doctor without delay.
Intestinal obstruction develops due to the influence of various factors. The reasons for its occurrence are mechanical and functional. Mechanical causes include adhesions, mobile caecum, pockets in the peritoneum, lengthening of the sigmoid colon. Functional bowel obstruction occurs against the background of overeating after dietary nutrition, a sudden increase in fresh vegetables and fruits in the diet, as well as the transfer of an infant to formula under the age of one year.
Complete or partial intestinal obstruction of the mechanical type occurs for the following reasons:
- helminthic invasions;
- inflammatory processes;
- the presence of a hematoma;
- oncology;
- hernia and adhesive process;
- changes in the structure of the abdominal cavity;
- improper formation of the intestine;
- fecal, gallstones;
- intestinal obstruction;
- cases of intussusception;
- reduction in the size of the intestinal lumen;
- volvulus of some parts of the intestine;
- congenital strands of the abdominal cavity.
The following factors can provoke functional obstruction: intestinal motility disorders, Hirschsprung disease, spasms and paralytic processes.
Clinical picture of obstruction
If there is suspicion of intestinal obstruction, the patient must be urgently taken to surgery. Timely assistance is the key to a positive prognosis. In some cases, the problem can be eliminated without surgical intervention by surgeons. The main symptom indicating obstruction is the problematic discharge of gases, feces. With partial obstruction or damage to the upper part of the organ, a slight discharge of flatus and scanty stools are observed. Basically, vomiting, nausea, severe cramping pains in the abdomen, bloating and asymmetry of the abdomen are manifested.
In addition to the listed symptoms, there are specific signs that only a doctor can identify. Therefore, urgent hospitalization is a necessary measure. In case of complications, the risk of death, the development of renal and hepatic insufficiency, as well as disorders in the functioning of the heart muscle, increase.
Particular attention should be paid to suspected obstruction in infants. If at least one manifestation of the disease is detected, it is urgent to seek medical help. Symptoms associated with intestinal obstruction:
- gray color of the skin;
- bloating in the upper abdomen of the child;
- weight loss;
- bilious vomiting, especially after feeding;
- elevated body temperature.
The child becomes whiny, capricious and restless, refuses food. In this case, immediately call an ambulance.
Classification of intestinal obstruction
Pathology is complete and partial, proceeds in acute or chronic form.
As for the origin, the disease is congenital or acquired. The cause of the congenital form is the blockage of the intestine with meconium of a dense consistency, as well as the abnormal development of the organ. Given the causes of malaise, the character is dynamic and mechanical.
With partial intestinal obstruction, the symptoms are chronic. The patient from time to time has vomiting, there is a delay in stool and gases, periodic pain. Basically, the clinical picture is not acute. In some cases, the symptoms subside on their own. The disease can last for several decades. If the cause of the pathology is a tumor growing inside, the signs appear and intensify gradually. There is flatulence, constipation, pain and vomiting.
As for the stages of partial blockage, they are replaced by periods of resolution that occur against the background of diarrhea. During this period, the feces become plentiful and liquid, have a putrid odor. The main feature of the partial form of pathology is that over time it can become complete and acute.
Another form of pathology is adhesive obstruction. This type of obstruction is characterized by impaired passage through the organ caused by adhesions in the abdominal cavity. Adhesions and strands are the result of acute, limited peritonitis, injuries of the abdomen, hemorrhage. This type of obstruction can affect any part of the intestine. Most often, adhesions occur in the omentum with a postoperative scar. The basis of the pathology is the incorrect and disturbed peristalsis of this organ, caused by the formation of adhesions. There are several types:
- Obstructive - the onset and course of the disease is acute, sudden. In some cases, chronic obstruction develops into an acute stage.
- Strangulation - manifests itself against the background of infringement of part of the intestine, the mesentery is involved in the process. The course of pathology is stormy, acute. Hemodynamic disorders are manifested, provoking the development of peritonitis and.
- Mixed - pathology combines the features of mechanical and dynamic obstruction.
The next variety is obstruction of the small intestine. Pathology can affect any part of this intestine. At the same time, the part of the intestine, which is located above the site of the lesion, does not stop working, therefore it begins to swell. As for the cause of the malaise, then, most often, it is intestinal obstruction. The main signs of obstruction: vomiting, the presence of severe pain in the epigastric region, aversion to food, flatulence, and dehydration.
The pathology of the large intestine occurs against the background of a violation of the passage through the intestine, accompanied by swelling, cramping pains, difficult passage of flatus, lack of stool, vomiting and flatulence. The disease can be partial or complete. In most cases, the lesion is organic. If the pathology progresses, signs of intoxication increase markedly, metabolism is disturbed, diarrhea is replaced by constipation.
Medical therapy
First of all, it is necessary to perform a diagnosis in order to confirm the diagnosis. Urgent measures are taken to help relieve pain shock and quickly replenish the lost fluid. X-ray and ultrasound are required. With the help of a probe, the upper part of the organ is released, with the help of a siphon enema, the lower part. It is mandatory to introduce antispasmodics to relax the muscles of the intestine, to stop the increased peristalsis. In some cases, these measures are enough to restore the work of the digestive tract. If this treatment approach does not help, emergency surgery is required.
Surgery is mandatory in the following situations:
- intussusception;
- volvulus of the small intestine;
- blockage by stones from the gallbladder;
- winding one gut on another.
Depending on how the pathology proceeds, the patient is prescribed an appropriate diet therapy. After the operation, it is forbidden to drink and eat for twelve hours. Nutrition is carried out parenterally: nutrient solutions are administered intravenously. After some time, baby food, fermented milk products are added to the diet. Then the patient is transferred to dietary table number 4, which should be followed for at least 3 months.
Intestinal obstruction is a dangerous disease that requires emergency medical attention. If you notice suspicious symptoms, call an ambulance.
Acute intestinal obstruction (AIO) is a syndrome characterized by a violation of the passage of contents through the digestive tract, due to mechanical obstruction or inhibition of the motor function of the intestine. The first works on intestinal obstruction that have survived to this day are the works of Hippocrates. In his writings, for the first time, the name ileus is found, which served as a collective term for various diseases of the abdominal cavity, including obstruction.
Currently, in terms of frequency of occurrence, the disease ranks fifth among the main forms of "acute abdomen". AIO occurs in all age groups, but is most common between the ages of 30 and 60. Obstruction due to intussusception is more often observed in children, strangulation - in middle-aged patients, obstruction - in patients older than 50 years. An important feature noted recently is the redistribution in frequency of occurrence of individual forms of AIO. Thus, such forms as nodulation, invagination and torsion began to occur much less frequently. At the same time, the frequency of obstructive colonic obstruction of tumor etiology increased. In 75-80% of cases, the cause of mechanical intestinal obstruction is the adhesive process of the abdominal cavity. Despite the evolution of views on the etiology and pathogenesis of AIO, the development of modern diagnostic methods, the improvement of surgical technologies and resuscitation and anesthesia, postoperative mortality ranges from 10% to 25%. The highest percentage of postoperative mortality in AIO occurs at the age of up to 5 years and over 65 years.
Classification
Back in the first half of the 19th century, two types of intestinal obstruction were identified - mechanical and dynamic. Subsequently, mechanical intestinal obstruction Val (Wahl) proposed to divide into strangulation and obturation. The most simple and expedient at the present time can be considered a classification in which the OKN is subdivided according to the morphofunctional nature:
- Dynamic (functional) obstruction (12%):
- Spastic, arising from diseases of the nervous system, hysteria, intestinal dyskinesia, helminthic invasion, etc.
- Paralytic (infectious diseases, thrombosis of mesenteric vessels, retroperitoneal hematoma, peritonitis, diseases and injuries of the spinal cord, etc.
- Mechanical intestinal obstruction (88%):
- Strangulation (torsion, nodulation, internal infringement)
- Obstructive:
a. intraorganic (foreign bodies, fecal and gallstones, helminthic invasion located in the intestinal lumen)
b. intramural (tumor, Crohn's disease, tuberculosis, cicatricial stricture affecting the intestinal wall)
in. extraorganic (cysts of the mesentery and ovary, tumors of the retroperitoneal space and pelvic organs, which compress the intestine from the outside).
- Mixed:
a. Adhesive obstruction
b. Intussusception
Origin:
- Congenital.
- Acquired.
According to the level of obstruction:
- Small intestine: a. high b. low
- Colonic - According to the dynamics of the development of the pathological process
(on the example of adhesive intestinal obstruction)
I stage. Acute violation of the intestinal passage - the stage of "ileus cry" - the first 12 hours from the onset of the disease)
II stage. Acute violation of intraparietal intestinal hemocirculation
(phase of intoxication) - 12-36 hours.
III stage. Peritonitis - more than 36 hours from the onset of the disease.
Significant disagreements are found in the literature on the issue of determining the severity of colonic obstruction. This circumstance gave rise to many classifications of the clinical course of the disease. The most commonly used in urgent coloproctology is the classification developed at the Research Institute of Coloproctology of the Russian Academy of Medical Sciences. According to the proposed classification, there are 3 degrees of severity of colonic obstruction:
I degree (compensated). Complaints of intermittent constipation lasting 2-3 days, which can be eliminated with diet and laxatives. The general condition of the patient is satisfactory, there is periodic bloating, there are no symptoms of intoxication. The results of colonoscopy and irrigography indicate that the tumor narrows the intestinal lumen to 1.5 cm, a slight accumulation of gases and intestinal contents in the colon is detected.
II degree (subcompensated). Complaints about persistent constipation, lack of independent stool. Taking laxatives is ineffective and gives a temporary effect. Periodic bloating, difficulty passing gases. The general condition is relatively satisfactory. Symptoms of intoxication are noticeable. The tumor narrows the intestinal lumen to 1 cm. X-ray examination of the colon is expanded, filled with intestinal contents. Separate liquid levels (Kloiber's cups) can be determined.
III degree (decompensated). Complaints about the lack of stool and gas discharge, increasing cramping abdominal pain and bloating, nausea, and sometimes vomiting. Pronounced signs of intoxication, disturbance of water and electrolyte balance and CBS, anemia, hypoproteinemia. On x-ray examination, the intestinal loops are dilated, swollen with gas. A plurality of fluid levels are defined. As a rule, the majority of patients admitted to the urgent hospital for obstructive colonic obstruction of tumor etiology have a decompensated degree of the disease, which ultimately determines the high incidence of postoperative complications and mortality.
In recent years, the so-called syndrome of false obstruction of the colon, first described by H. Ogilvie in 1948, has been increasingly mentioned. This syndrome manifests itself most often in the form of a clinic of acute dynamic intestinal obstruction due to a violation of sympathetic innervation. Often this condition is observed in the early postoperative period, which leads to repeated laparotomies. Most authors note diagnostic difficulties in establishing Ogilvie's syndrome. A positive effect has a bilateral pararenal novocaine blockade according to A.V. Vishnevsky.
When the clinical manifestations of the disease are accompanied by mild symptoms, we do not make a diagnosis of "partial intestinal obstruction", considering it unjustified in tactical terms. In this case, most often, we are talking about incomplete closure of the intestinal lumen by a growing tumor, adhesive obstruction, or recurrent volvulus. Such a diagnosis disorients the surgeon and leads to belated operations.
Causes of acute intestinal obstruction
OKN can be caused by multiple causes, which are distinguished as predisposing and producing factors. The first include anomalies in the development of the intestine and its mesentery, the presence of adhesions, cords, pockets in the abdominal cavity, pathological formations in the intestinal lumen (tumor, polyps), defects in the anterior abdominal wall, inflammatory infiltrates, hematomas emanating from the intestinal wall or surrounding organs. The second includes causes that, in the presence of predisposing factors, can cause the development of AIO. These are, first of all, acutely developing disorders of the motor function of the intestine in the form of hyper- or hypomotor reactions or a combination of them. This condition may be due to an increased food load, a disorder in the nervous regulation of intestinal motor activity, irritation of the receptors of internal organs by a pathological process that has arisen, drug stimulation, or a sudden increase in intra-abdominal pressure during exercise.
The form of the resulting AIO will depend both on the nature of the predisposing causes and on the type of disturbances in the motor function of the intestine.
The pathogenesis of acute intestinal obstruction
Pathogenesis and causes of death in AIO, not complicated by intestinal necrosis and peritonitis, undoubtedly belong to one of the most complex and difficult sections of surgical pathology. A large number of experimental and clinical studies performed both in our country and abroad are devoted to the study of these issues. Table 1 schematically presents the main components of the pathogenesis of AIO, the development and significance of which is directly proportional to the duration of the disease. The initial manifestations of AIO (I stage) are associated with a violation of the passage through the intestines. The severity of their occurrence and intensity of development depend on the morphological and functional features of the disease. So, in cases of dynamic, strangulation and obturation obstruction, the duration of stage I will be different. It is known that an obstruction along the gastrointestinal tract does not cause any serious consequences if a bypass is created to evacuate the intestinal contents. An exception is the strangulation form of intestinal obstruction, when the mesentery of the intestine is involved in the pathological process from the very beginning, and not so much evacuation as vascular disorders prevail in the pathogenesis of the disease.
In stage I, there are no gross morphofunctional changes in the intestinal wall, there are no disturbances in the water and electrolyte balance and endogenous intoxication syndrome. Such patients, with the exception of cases of strangulation intestinal obstruction, are shown conservative therapy. The second stage of AIO is characterized by an acute disorder of intraparietal intestinal hemocirculation. This is no longer just a reaction of the body to the cessation of the intestinal passage, but deep pathological changes, which are based on tissue hypoxia and the development of violent autocatalytic processes. It was found that with an increase in intra-intestinal pressure up to 30 mm. rt. Art. completely stops the capillary blood flow in the intestinal wall. All of the above gives reason to interpret the second stage of AIO as a process of acute disorders of the intraparietal intestinal hemocirculation. Taking into account its progressive nature, at this stage it is no longer possible to adhere to the tactics of dynamic monitoring of the patient and persistent conservative treatment. It is necessary to put indications for urgent surgical intervention.
Isolation of stage III AIO from clinical and pathophysiological positions is associated with the development of peritonitis due to the penetration of microorganisms through the intestinal wall into the free abdominal cavity and a progressive syndrome of multiple organ failure.
Symptoms of acute intestinal obstruction
Clinical picture acute intestinal obstruction consists of 2 groups of symptoms. The first group is directly related to the changes occurring in the gastrointestinal tract and abdominal cavity in AIO. The second group reflects the general reaction of the body to the pathological process.
I group. The earliest and one of the most constant signs of the disease is pain. The occurrence of cramping pains is characteristic of acute obstruction of the intestinal lumen and is associated with its peristalsis. Sharp constant pains often accompany acutely developed strangulation. If AIO is not diagnosed in a timely manner, then on 2-3 days from the onset of the disease, intestinal motor activity is inhibited, which is accompanied by a decrease in the intensity of pain and a change in its nature. At the same time, the symptoms of endogenous intoxication begin to prevail, which is a poor prognostic sign. A pathognomonic symptom in AIO is stool retention and flatulence. However, with high small bowel obstruction, at the beginning of the disease, gas and stool may be discharged due to emptying of the distal intestine, which does not bring relief to the patient, which often disorients the doctor. One of the early clinical signs of AIO is vomiting. Its frequency depends on the level of obstruction in the intestine, the type and form of obstruction, the duration of the disease. Initially, vomiting is reflex in nature, and subsequently occurs due to overflow of the proximal gastrointestinal tract. The higher the intestinal obstruction, the more pronounced vomiting. In the initial stage of colonic obstruction, vomiting may be absent. With low small bowel obstruction, vomiting is observed at large intervals and an abundance of vomit, which acquire the character of intestinal contents with a "fecal" smell. In the later stages of AIO, vomiting is a consequence of not only stagnation, but also endotoxicosis. During this period, it is not possible to eliminate vomiting movements even by intestinal intubation.
One of the local signs of OKN is bloating. "Oblique abdomen" (Bayer's symptom), when bloating leads to asymmetry of the abdomen and is located in the direction from the right hypochondrium through the navel to the left iliac region, is characteristic of volvulus of the sigmoid colon. Intestinal obstruction caused by obstruction of the lumen of the proximal jejunum leads to bloating in the upper jejunum, while obstruction in the ileum and colon leads to bloating of the entire abdomen. In order to diagnose the mechanical form of intestinal obstruction, a triad of clinical signs (Val's symptom) was described: 1. Abdominal asymmetry; 2. Palpable swollen intestinal loop (elastic cylinder) with high tympanitis; 3. Peristalsis visible to the eye. To identify a possible strangulated hernia, accompanied by a clinic acute intestinal obstruction, it is necessary to carefully examine and palpate the epigastric, umbilical and inguinal regions, as well as the existing postoperative scars on the anterior abdominal wall. When examining patients with AIO, it is very important to remember the possible parietal (Richter) strangulation of the intestine, in which the "classic" clinical picture of complete intestinal obstruction, as well as the presence of a tumor-like formation characteristic of a strangulated hernia, are absent.
On palpation, the abdomen remains soft and slightly painful until the development of peritonitis. However, during the period of active peristalsis, accompanied by an attack of pain, there is tension in the muscles of the anterior abdominal wall. For volvulus of the caecum, the Shiman-Dans symptom is considered pathognomonic, which is defined as a feeling of emptiness on palpation in the right iliac region due to displacement of the intestine. With colonic obstruction, flatulence is determined in the right iliac region (Anschütz symptom). The symptom described by I.P. has a significant diagnostic value. Sklyarov (“splash noise”) in 1922, detected with a slight concussion of the anterior abdominal wall. Its presence indicates overflow with liquid and gases of the adductor intestine, which occurs with mechanical intestinal obstruction. This symptom should be reproduced before setting a cleansing enema. With percussion of the anterior abdominal wall, areas of high tympanitis with a metallic tint (Kivul's symptom) are determined, as a result of developing pneumatosis of the small intestine. This is always a warning sign because gas does not normally accumulate in the small intestine.
During auscultation of the anterior abdominal wall at the beginning of the disease, intestinal noises of varying height and intensity are heard, the source of which is the small intestine, which is swollen, but has not yet lost its motor activity. The development of intestinal paresis and peritonitis marks the weakening of intestinal noises, which appear as separate weak bursts, reminiscent of the sound of a falling drop (Spasokukotsky's symptom) or the noise of bursting bubbles (Wilms' symptom). Soon these sounds also cease to be determined. The state of the "silent abdomen" indicates the development of severe intestinal paresis. Due to a change in the resonant properties of the contents of the abdominal cavity, against the background of an enlarged abdomen, heart tones begin to be clearly heard (Bailey's symptom). At this stage, the clinical picture acute intestinal obstruction more and more associated with symptoms of widespread peritonitis.
Diagnosis of acute intestinal obstruction
In diagnostics acute intestinal obstruction a carefully collected anamnesis, scrupulous identification of the clinical symptoms of the disease, a critical analysis of radiological and laboratory data are of great importance.
Examination of a patient with OKN must be supplemented with a digital examination of the rectum, which allows you to determine the presence of fecal masses (“coprostasis”) in it, foreign bodies, tumors or heads of intussusceptum. The pathognomonic signs of mechanical intestinal obstruction are balloon-like swelling of the empty ampoule of the rectum and a decrease in the tone of the sphincters of the anus (“anus gaping”), described by I.I. Grekov in 1927 as a "symptom of the Obukhov hospital".
II group. The nature of general disorders in AIO is determined by endotoxicosis, dehydration and metabolic disorders. There is thirst, dry mouth, tachycardia, decreased diuresis, blood clotting, determined by laboratory parameters.
A very important diagnostic step is an x-ray examination of the abdominal cavity, which is divided into:
- Non-contrast method (plain radiography of the abdominal cavity). Additionally, a chest x-ray is performed.
- Contrast methods for studying the movement of barium suspension through the intestine after oral administration (Schwartz test and its modifications), its administration through a nasoduodenal probe and retrograde filling of the colon with a contrast enema.
Abdominal imaging can show direct and indirect symptoms acute intestinal obstruction. Direct symptoms include:
1. The accumulation of gas in the small intestine is a warning sign, because under normal conditions, gas is observed only in the stomach and large intestine.
- The presence of Kloiber's cups, named after the author who described this symptom in 1919, is considered a classic radiological sign of mechanical intestinal obstruction. They represent horizontal fluid levels found in distended bowel loops that are detected 2 to 4 hours after the onset of the disease. Attention is drawn to the ratio of the height and width of gas bubbles above the liquid level and their localization in the abdominal cavity, which is important for the differential diagnosis of AIO types. However, it should be remembered that Kloiber's cups can also form after cleansing enemas, as well as in debilitated patients who are in bed for a long time. Horizontal levels are visible not only in the vertical position of the patient, but also in the later position.
- A symptom of transverse striation of the intestinal lumen, referred to as a symptom of Case (1928), "stretched spring", "fish skeleton". This symptom is considered as a manifestation of edema of the Kerckring (circular) folds of the small intestine mucosa. In the jejunum, this symptom manifests itself more prominently than in the ileum, which is associated with the anatomical features of the relief of the mucosa of these sections of the intestine. Clearly visible folds of the small intestine are proof of the satisfactory condition of its wall. The wear of the folds indicates a significant violation of intramural hemodynamics.
In cases where the diagnosis of OKN presents great difficulties, the second stage of X-ray examination using contrast methods is used.
radiopaque method. Indications for its use can be formulated as follows:
- Reasonable doubts about the presence of a mechanical form of OKN in a patient.
- The initial stages of adhesive intestinal obstruction, when the patient's condition does not inspire concern and there is hope for its conservative resolution
- Dynamic monitoring of the progress of the contrast mass must be combined with a clinical study of the patient's condition and conservative therapeutic measures aimed at resolving intestinal obstruction. In case of aggravation of local signs of AIO and an increase in endotoxicosis, the study is terminated and the question of urgent surgical intervention is raised.
When performing oral contrasting and interpreting the data obtained, it is necessary to take into account the timing of the promotion of the contrast agent through the intestines. In a healthy person, barium suspension, drunk per os, reaches the caecum after 3-3.5 hours, the right bend of the large intestine - after 5-6 hours, the left bend - after 10-12 hours, the rectum - after 17-24 hours. The use of oral radiopaque methods is not indicated for colonic obstruction due to their low information content. In such cases, an emergency colonoscopy is performed.
Ultrasound Scan of the abdominal cavity complements the x-ray examination, especially in the early stages of OKN. It allows you to repeatedly observe the nature of peristaltic bowel movements without exposing the patient to radiation, determine the presence and volume of effusion in the abdominal cavity, and examine patients in the early postoperative period. The most important features in assessing the stage of AIO are the diameter of the intestine, which can range from 2.5 to 5.5 cm, and the thickness of its wall, which is from 3 to 5 mm. the presence of free fluid in the abdominal cavity. With the development of destructive changes in the intestinal loops, the thickness of the wall can reach 7-10 mm, and its structure becomes heterogeneous with the presence of inclusions in the form of thin echo-negative strips.
Laparoscopy. The development of endoscopic research methods in emergency surgery has made it possible to use laparoscopy in the diagnosis of AIO. A number of domestic and foreign authors point to the possibilities of the method for the differential diagnosis of the mechanical and dynamic forms of acute intestinal obstruction, for the dissection of single adhesions. However, as our experience in using laparoscopy shows, it is not only uninformative, but also dangerous to use it in conditions of severe intestinal paresis and adhesive process in the abdominal cavity in most cases due to the possible occurrence of severe complications. Therefore, the main indication for the use of laparoscopy in AIO is the objective difficulties in the differential diagnosis of acute surgical pathology.
Treatment of acute intestinal obstruction
conservative therapy. Based on the concept of the vascular genesis of disorders in strangulation AIO and the rapidity of their development, the only way to treat it is emergency surgery with corrective therapy on the operating table and in the postoperative period. In all other cases, the treatment of AIO should begin with conservative measures, which in 52%-58% of cases have a positive effect, and in the rest of the patients they are the stage of preoperative preparation.
Conservative therapy is based on the principle of "drip and suck" (drip and suck). Treatment begins with the introduction of a nasogastric tube to decompress and flush the upper digestive tract, which reduces intracavitary pressure in the intestine and the absorption of toxic products. The perirenal novocaine blockade according to A.V. has not lost its therapeutic value. Vishnevsky. The setting of enemas is of independent importance only with obstructive colonic obstruction. In other cases, they are one of the methods of stimulating the intestines, so there is no need to place high hopes on their effectiveness. Carrying out drug stimulation of the gastrointestinal tract is justified only with a decrease in the motor activity of the intestine, as well as after the elimination of an obstacle in the path of the intestinal passage. Otherwise, such stimulation can aggravate the course of the pathological process and lead to a rapid depletion of neuromuscular excitability against the background of increasing hypoxia and metabolic disorders.
An obligatory component of conservative treatment is infusion therapy, with the help of which the BCC is restored, cardiohemodynamics are stabilized, protein and electrolyte disorders are corrected, and detoxification is carried out. Its volume and composition depends on the severity of the patient's condition and averages 3.0-3.5 liters. In case of a serious condition of the patient, preoperative preparation should be carried out by the surgeon together with the anesthesiologist-resuscitator in the intensive care unit or intensive care unit.
Operative treatment. Conservative therapy should be recognized as effective if, within the next 3 hours from the moment the patient was admitted to the hospital after enemas, a large amount of gases passed and there was abundant stool, abdominal pain and bloating decreased, vomiting stopped and the general condition of the patient improved. In all other cases (with the exception of dynamic intestinal obstruction), the ongoing conservative therapy should be recognized as ineffective and indications for surgical treatment should be given. With dynamic intestinal obstruction, the duration of conservative treatment should not exceed 5 days. The indication for surgical treatment in this case is the ineffectiveness of ongoing conservative measures and the need for intubation of the intestine in order to decompress it.
Successes in the treatment of AIO are directly dependent on adequate preoperative preparation, the correct choice of surgical tactics and postoperative management of patients. Various types of mechanical acute intestinal obstruction require an individual approach to surgical treatment.
Partial bowel obstruction can occur when a person's bowel passage is not completely closed. In this case, a certain amount of feces still passes through the barrier. Symptoms appear depending on the stage of the disease. Partial intestinal obstruction can be treated with medication.
But in severe cases, other methods of therapy are used.
Symptoms of partial intestinal obstruction
The symptomatology of the phenomenon under consideration depends on the cause of its occurrence. More often the disease occurs against the background of adhesive disease.
The essence of the disease: after an injury or inflammatory process, overgrown scars appear in the intestinal area.
They compress the intestines in one or more places. This interferes with the free passage of feces through the intestines.
Partial intestinal obstruction occurs due to the presence of cysts and tumors of a malignant or benign nature.
The tumor can be localized outside the intestine, but gradually it begins to put pressure on the intestine, pinching it.
The neoplasm can be located inside the organ, completely closing the passage.
In both situations, the patient's health deteriorates sharply.
Partial intestinal obstruction can develop into a complete one when the vessels that supply blood to the intestines are pinched.
Children are more likely to suffer from this pathology after surgery performed in the abdominal cavity.
As soon as intestinal obstruction begins, the patient's condition deteriorates sharply.
- The presence of pain shock is noted, there is a sharp dehydration, progressive endotoxicosis develops.
- The cyanotic color of the lips is visually noticeable, the face is suffering and haggard.
- Patients feel severe cramping pains that do not subside completely.
- There is a swollen abdomen, continuous vomiting of food consumed and products that have stagnated in the intestines.
- After blockage, defecation occurs. At this time, the lower part of the intestine is emptied.
- Body temperature remains normal, but if there is a severe case, it drops.
- Frequent breathing, dry tongue with white coating - the main symptom of the disease after blockage.
- Bloating may or may not be noticeable. The symptoms of Thevenard, Val and Sklyarov are characteristic.
With the help of auscultation, increased peristalsis during pain can be determined.
In the presence of effusion in the lower abdomen, the percussion sound is shortened.
If there is flatulence, a tympanic sound is heard.
Diagnosis of partial obstruction
On visual examination, when there is partial intestinal obstruction, Shiman's symptom appears.
It is characterized by bloating, while the left iliac region sinks.
The abdomen is palpated gently. Pain is noted at the site of intestinal blockage.
There is a noticeable tremor of the peritoneal wall, which causes a "splash noise". When the rectum is examined, its emptiness and swelling are visible.
The process of intussusception can be found in people of any age, but it is more often diagnosed in children under 5 years of age.
During such obstruction, one section of the intestine is introduced into another.
In this case, a cylinder is formed, consisting of 3 tubes of the intestine, which pass one into the other.
The outer cylinder is called the perceiver, and the inner and middle cylinders are called the generators.
- The place where the inner cylinder passes into the middle one is called the head of the intussusceptum.
- The place where the outer cylinder passes into the middle one is the neck of the intussusception.
There are two types of invaginations, depending on the side into which the introduction occurs: descending and ascending.
Partial intestinal obstruction in the presence of adhesions in the peritoneal cavity can proceed according to the chronic type.
The patient has a painful sensation in the abdomen, a delay in defecation, gases, vomiting is present.
Symptoms are not acute, they can occur periodically for decades.
Attacks are stopped by conservative methods or go away on their own.
In the presence of a tumor inside the intestine or outside, the closure of the passage progresses gradually.
The larger the tumor, the more often attacks of pain, vomiting and flatulence occur.
The moments when the passage closes are replaced by diarrhea. Fecal secretions have an unpleasant rotten smell. They are plentiful. They have a liquid consistency.
Other symptoms
The main feature of the pathology under consideration is that the disease can at any time turn into complete intestinal obstruction.
This occurs against the background of malnutrition of the intestinal walls.
When the vessels that provide blood circulation to the intestines are pinched, necrosis of its walls occurs.
After that, the main symptoms of complete intestinal obstruction appear (severe pain that does not subside after a spasm; nausea and severe vomiting; gas retention, defecation).
Symptoms are highly dependent on the location of the blockage and the type of patency.
There may be a complication in the form of dehydration (against the background of excessive vomiting and defecation).
Obstruction is more common in the small intestine than in the large intestine.
Partial intestinal obstruction, when only fluid passes through the obstruction, can cause diarrhea.
One of the main signs of obstruction is bloating, as it accumulates a lot of gases and other biological fluids.
Additional symptoms include:
- painful sensations that alternate with attenuation;
- nausea and excessive vomiting;
- very painful bloating;
- constipation, which progresses and prevents the process of defecation and even the removal of gases;
- hiccups or belching that are not controlled by the patient;
- diarrhea when only fluid passes;
- a slight increase in temperature;
- general weakness and frequent dizziness;
- foul odor from the mouth.
Complications with obstruction
If proper attention is not paid to the treatment of partial intestinal obstruction, life-threatening complications can occur:
- Death (necrosis) of the damaged part of the intestine - the blood stops flowing to the intestine, as the vessels are clamped. This can lead to decomposition of the intestines. Its contents begin to enter the abdominal cavity.
- Peritonitis, which occurs when the intestinal walls decompose and an infectious disease is added to the obstruction, leading to blood poisoning. This complication can lead to the death of the patient. In this case, urgent surgical treatment is necessary.
To determine partial intestinal obstruction, you can use not only a visual examination, but also additional diagnostic methods.
These include an x-ray of the intestine with an additional study of contrast agents.
A general blood test is used. With the phenomenon under consideration, the values of many components in the blood change.
The abdomen is palpated and auscultated. The patient's history is being collected, early symptoms are possible, which are characteristic of.
Ultrasound examination is an informative diagnosis of the disease. With the localization of the disease in the colon, an irrigoscopy is performed.
Treatment of partial intestinal obstruction
To improve the patient's well-being, procedures are carried out to reduce pressure on the intestines and release its patency.
Such therapy is indicated if the obstruction is outside the bowel. There are no symptoms of peritonitis.
If the obstruction is localized inside the intestine, the treatment is only surgical.
If surgery is necessary, the following procedures are performed:
- Perform the removal of an obstruction that interferes with the passage of feces. If the localization site is the small intestine, a resection is performed, which completely frees the passage. Sometimes it is necessary to carry out a complex of two or three operations.
- Parts of the intestine that have died must be removed completely.
- Before surgery, the patient is given broad-spectrum antibiotics. This prevents the manifestation of symptoms of the infectious process.
To restore patency, a special probe or medicines are used.
If a child has intussusception, a barium enema may help.
It is possible to aspirate the contents of the stomach and upper intestine to the obstruction, followed by the use of cleansing enemas.
A successful outcome depends on the timely accurate diagnosis of the disease and early treatment.
If you allow the death of the intestine and the release of the contents into the abdominal cavity, the prognosis is negative.
If dynamic intestinal obstruction occurs, which is caused by a violation of the contractions of its walls, drugs that stimulate peristalsis are used.
In the case of timely and correct treatment, the prognosis is favorable. Symptoms of the disease are eliminated as soon as possible.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013
Other and unspecified ileus (K56.6)
Gastroenterology, Surgery
general information
Short description
Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013
Acute intestinal obstruction(OKN) is a syndrome category characterized by a violation of the passage of intestinal contents in the direction from the stomach to the rectum and uniting the complicated course of diseases and pathological processes of various etiologies that form the morphological substrate of acute intestinal obstruction.
I. INTRODUCTION
Protocol name: Acute intestinal obstruction in adults.
Protocol code:
ICD 10 code:
K56.0 - paralytic ileus.
K56.1 - intussusception of the intestine.
K56.2 - volvulus.
K56.3 - ileus caused by gallstones.
K56.4 - another type of closure of the intestinal lumen.
K56.5 - paralytic ileus.
K56.6 Other and unspecified ileus.
K56.7 - paralytic ileus.
K91.3 - postoperative intestinal obstruction.
Abbreviations used in the protocol:
OKN - acute intestinal obstruction
ICD- international classification of diseases
ultrasound - ultrasound procedure
ECG- electrocardiography
ALT - alanine aminotransferase
AST - aspartate aminotransferase
HIV - AIDS virus
APTT - activated partial thromboplastin time
Protocol development date: 11.09.2013
Patient category: adult patients over 18 years of age
Protocol Users: surgeons, anesthetists, resuscitators, visual diagnostics, nurses.
Acute intestinal obstruction can be caused by numerous causes, which are usually divided into predisposing and producing.
For predisposing reasons include: anatomical and morphological changes in the gastrointestinal tract - adhesions, adhesions that contribute to the pathological position of the intestine, narrowing and lengthening of the mesentery, leading to excessive intestinal mobility, various formations emanating from the intestinal wall, neighboring organs or located in the intestinal lumen, peritoneal pockets and holes in the mesentery. The predisposing causes include a violation of the functional state of the intestine as a result of prolonged starvation. In such cases, the intake of rough food can cause violent peristalsis and intestinal obstruction ("hungry man's disease"). The role of predisposing causes is reduced to the creation of excessive mobility of intestinal loops, or, conversely, its fixation. As a result, the intestinal loops and their mesentery will be able to occupy a pathological position in which the passage of intestinal contents is disturbed.
To producing causes include: a change in the motor function of the intestine with a predominance of spasm or paresis of its muscles, a sudden sharp increase in intra-abdominal pressure, an overload of the digestive tract with abundant coarse food.
Depending on the nature of the triggering mechanism, AIO is divided into mechanical and dynamic, in the vast majority - paralytic, developing on the basis of intestinal paresis. Spastic obstruction can occur with organic spinal disorders.
If an acute violation of intestinal hemocirculation captures extraorganic mesenteric vessels, strangulation OKN occurs, the main forms of which are infringements, torsion and nodulation. Much more slowly, but with the involvement of the entire leading part of the intestine, the process develops with obstructive OKN, when the intestinal lumen is blocked by a tumor or other volumetric formation. An intermediate position is occupied by mixed forms of OKN - intussusception and adhesive obstruction - combining strangulation and obturation components. Adhesive obstruction is up to 70-80% of all forms of OKN.
The nature and severity of clinical manifestations depend on the level of AIO. There are small intestine and colonic OKN, and in the small intestine - high and low.
In all forms of AIO, the severity of disorders is directly dependent on the time factor, which determines the urgent nature of treatment and diagnostic measures.
Note: The following classes of recommendations and levels of evidence are used in this protocol:
Level I - Evidence from at least one well-designed randomized controlled trial or meta-analysis
Level II - Evidence obtained from at least one well-designed clinical trial without adequate randomization, from an analytical cohort or case-control study (preferably from a single center), or from dramatic results obtained from uncontrolled studies.
Level III - Evidence obtained from the opinions of reputable investigators based on clinical experience.
Grade A - Recommendations that have been approved by at least 75% of the multisectoral expert panel in agreement.
Class B - Recommendations that have been somewhat controversial and have not met with consensus.
Grade C - Recommendations that caused real controversy among the group members.
Classification
Clinical classification
In Kazakhstan and other CIS countries, the following classifications are most common:
According to Oppel V.A.
1. Dynamic obstruction (paralytic, spastic).
2. Hemostatic obstruction (thrombophlebetic, embolic).
3. Mechanical with hemostasis (pinching, turning).
4. Mechanical simple (blockage, kink, compression).
According to Chukhrienko D.P.
by origin
1. congenital
2. acquired
According to the mechanism of occurrence:
1. mechanical
2. dynamic
By the presence or absence of circulatory disorders:
1. obstructive
2. strangulation
3. combined
By clinical course:
1. partial
2. complete (acute, subacute, chronic, recurrent)
Morphologically:
dynamic
1. paralytic
2. spastic.
Mechanical
1. strangulation
2. obstructive
3. mixed
By level of obstruction
1. small intestine (high)
2. colonic (low)
By stages:
Stage 1 (up to 12-16 hours) - violation of the intestinal passage
Stage 2 (16-36 hours) - stage of acute disorders of intraparietal intestinal hemocirculation
Stage 3 (over 36 hours) stage of peritonitis.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
The list of basic and additional diagnostic measures:
1. Complete blood count
2. Urinalysis
3. Determination of blood glucose
4. Microreaction
5. Blood typing
6. Determination of the Rh factor
7. Determination of bilirubin
8. Definition of AST
9. Definition of ALT
10. Determination of thymol test
11. Determination of creatinine
12. Determination of urea
13. Determination of alkaline phosphatase
14. Determination of total protein and protein fraction
15. Determination of blood amylase
16. Coagulogram (prothrombin index, clotting time, bleeding time, fibrinogen, APTT)
17. Blood for HIV
18. ECG
19. Plain radiography of the abdominal organs
20 Plain chest x-ray
21. Ultrasound of the abdominal organs
22. Computed tomography of the abdominal organs
23. Diagnostic laparoscopy
24. Contrast study of the gastrointestinal tract
25. Consultation with a resuscitator
26. Anesthesiologist's consultation
27. Oncologist consultation
28. Consultation of a therapist
Diagnostic criteria
Complaints and anamnesis
OKN is characterized by a variety of complaints made by patients, but the main and most reliable of them can be called the following triad of complaints: abdominal pain, vomiting, stool and gas retention .
1. Stomach ache usually occur suddenly, regardless of food intake, at any time of the day, without precursors. For intestinal obstruction, cramping pains are most characteristic, which is associated with intestinal motility. There is no clear localization of pain in any part of the abdominal cavity. With obstructive intestinal obstruction, pain outside of a cramping attack usually disappears. In the case of strangulation intestinal obstruction, the pains are persistent, sharply intensifying during an attack. Pain subsides only for 2-3 days, when there is depletion of intestinal motility. The cessation of pain in the presence of intestinal obstruction is a poor prognostic sign. With paralytic ileus, the pain is constant, arching, of moderate intensity.
2. Vomit at first it is reflex in nature, with continued obstruction, vomiting with stagnant contents develops, in the late period, with the development of peritonitis, vomiting becomes indomitable, uninterrupted, and the vomit has a fecal odor. The higher the obstruction, the more pronounced the vomiting. In the intervals between vomiting, the patient experiences nausea, he is worried about belching, hiccups. With a low localization of the obstruction, vomiting is observed at large intervals.
3. Stool and gas retention most pronounced with low intestinal obstruction. With high intestinal obstruction at the onset of the disease, some patients may have stools. This is due to the emptying of the intestine located below the obstruction. With intestinal obstruction due to intussusception from the anus, bloody discharge from the anus is sometimes observed, which can cause a diagnostic error when OKN is mistaken for dysentery.
Disease history: it is necessary to pay attention to the intake of copious amounts of food (especially after fasting), the appearance of abdominal pain during physical exertion, accompanied by a significant increase in intra-abdominal pressure, complaints of decreased appetite and intestinal discomfort (periodic pain and bloating; constipation, followed by diarrhea; pathological impurities in feces);
Anamnesis of life is also important. Postponed operations on the abdominal organs, open and closed injuries of the abdomen, inflammatory diseases are often a prerequisite for the occurrence of intestinal obstruction.
Physical examinations:
1. General condition of the patient may be moderate or severe depending on the form, level or time elapsed since the onset of AIO.
2. Temperature in the initial period of the disease does not increase. With strangulation obstruction, when collapse and shock develop, the temperature drops to 36 ° C. In the future, with the development of peritonitis, the temperature rises to subfebrile.
3. Pulse at the beginning of the disease does not change, with an increase in the phenomena of obstruction, tachycardia appears. Note the discrepancy between low temperature and frequent pulse.
4. Skin and mucous membranes: according to their assessment, one can judge the degree of dehydration: dry skin and mucous membranes, decreased skin turgor, dry tongue.
5. Examination of the abdomen a patient who has intestinal obstruction should begin with an examination of the typical places of the hernial orifice in order to exclude the presence of an external strangulated hernia. Postoperative scarring may indicate adhesive obstruction. Abdominal bloating is one of the most persistent signs of AIO. However, the degree of swelling can be different and depends on the level of obstruction and the timing of the disease. With a high obstruction, swelling may be slight, but the lower the level of the obstruction, the greater the swelling. Particularly significant is swelling with paralytic and colonic obstruction. At the beginning of obstruction, abdominal distention may be small, but as the duration of the disease increases, the degree of flatulence increases. Incorrect configuration of the abdomen and asymmetry are characteristic of strangulation intestinal obstruction. It is not uncommon to see one or more swollen intestinal loops through the abdominal wall. A clearly demarcated stretched intestinal loop contoured through the abdominal wall - Val's symptom - is an early symptom of AIO. On percussion, high tympanitis is heard over it. With torsion of the sigmoid colon, the abdomen appears to be skewed, as it were. In this case, the swelling is located in the direction from the right hypochondrium through the navel to the left iliac region (Schiman's symptom). When examining the abdomen, one can see slowly rolling shafts or suddenly appearing and disappearing protrusions. Often they are accompanied by an attack of abdominal pain and vomiting. Peristalsis visible to the eye - a symptom of Shlange - is more clearly defined with slowly developing obturation obstruction, when the muscles of the adducting intestine have time to hypertrophy.
6. Palpation of the abdomen painful. There is no tension in the muscles of the abdominal wall. Shchetkin-Blumberg's symptom is negative. With strangulation obstruction, there is a positive symptom of Thevenard - a sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of the mesentery passes. This symptom is especially characteristic of volvulus of the small intestine. Sometimes, with palpation of the abdomen, it is sometimes possible to determine the tumor, the body of the invaginate, the inflammatory infiltrate that caused the obstruction. With a slight concussion of the abdominal wall, you can hear the "splash noise" - Sklyarov's symptom. This symptom indicates the presence of an overstretched paretic loop of the intestine, overflowing with liquid and gaseous contents.
7. Abdominal percussion reveals limited areas of blunting zones, which corresponds to the location of the intestinal loop, filled with fluid and directly adjacent to the abdominal wall. These areas of dullness do not change their position when the patient turns, and this is how they differ from free effusion. Dullness of percussion sound is also detected over a tumor, inflammatory infiltrate or intussusception of the intestine.
8. Auscultation of the abdomen: in the initial period of OKN, when peristalsis is still preserved, numerous ringing noises are heard, resonating in stretched loops. Sometimes you can catch the "noise of a falling drop" - a symptom of Spasokukotsky-Wilms. Peristalsis can be induced or increased by tapping the abdominal wall. In the late period, with an increase in intestinal paresis, the noises become shorter and rarer, but high tones. With the development of intestinal paresis, all sound phenomena disappear and they are replaced by "dead silence", which is an ominous sign. During this period, with a sharp bloating, Bailey's symptom can be determined - listening to breath sounds and heart tones, which are normally not heard through the stomach.
9. Rectal digital examination may reveal a tumor of the rectum, fecal obstruction, head of intussusceptum, and traces of blood. A valuable diagnostic sign characteristic of low intestinal obstruction is atony of the sphincter and balloon-like swelling of the empty ampoule of the rectum (symptom of the Obukhov Hospital) and low capacity of the distal intestine (Tsege-Mantefeil symptom). At the same time, no more than 500-700 ml of water can be injected into the rectum, with further administration, the water will flow back.
Laboratory research:
- complete blood count (leukocytosis, stab shift, accelerated ESR, signs of anemia may be observed);
- coagulogram (signs of hypercoagulability may be observed);
- biochemical blood test (violation of water-electrolyte and acid-base balance).
Instrumental Research
1. Plain radiography of the abdominal organs
Kloiber's bowl - a horizontal level of liquid with a dome-shaped enlightenment above it, which looks like a bowl turned upside down. With strangulation obstruction, they can manifest themselves after 1 hour, and with obstructive obstruction - after 3-5 hours from the moment of the disease. The number of bowls is different, sometimes they can be layered one on top of the other in the form of a step ladder.
Intestinal arcades. They are obtained when the small intestine is swollen with gases, while horizontal levels of liquid are visible in the lower knees of the arcades.
The symptom of pinnation (transverse striation in the form of a stretched spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular mucosal folds.
2. Abdominal ultrasound
With mechanical intestinal obstruction:
- expansion of the intestinal lumen by more than 2 cm with the presence of the phenomenon of "liquid sequestration" into the intestinal lumen;
- thickening of the wall of the small intestine more than 4 mm;
- the presence of reciprocating movements of the chyme in the intestine;
- an increase in the height of the kerkring folds by more than 5 mm;
- increasing the distance between the kerkring folds by more than 5 mm;
- hyperpneumatization of the intestine in the leading section
with dynamic intestinal obstruction:
- the absence of reciprocating movements of the chyme in the intestine;
- the phenomenon of fluid sequestration into the intestinal lumen;
- unexpressed relief of kerkring folds;
- hyperpneumatization of the intestine in all departments.
3. Contrast study of the gastrointestinal tract is used less frequently and only in case of difficulties in diagnosing intestinal obstruction, stable condition of the patient, intermittent nature of intestinal obstruction. The patient is given to drink 50 ml of barium suspension and a dynamic study of the passage of barium is carried out. Delaying it up to 4-6 hours or more gives grounds to suspect a violation of the motor function of the intestine.
4. Diagnostic laparoscopy(it is used only when the previous methods of instrumental diagnostics are not informative).
5. Computed tomography(it is used only when the previous methods of instrumental diagnostics are not informative, as well as to identify various formations of the abdominal organs that cause AIO) (level of evidence - III, strength of recommendation - A).
Indications for specialist consultations:
- Resuscitator: to determine the indications for the treatment of the patient in the intensive care unit, to agree on the tactics of managing the patient in terms of eliminating violations of water-electrolyte and acid-base balance.
- Anesthesiologist: to determine the type of anesthesia if surgery is necessary, as well as to agree on the tactics of preoperative management.
- Oncologist: if abdominal tumors are suspected, causing AIO.
- Therapist: identification of concomitant somatic pathology, which complicates the course of AIO, and can also complicate the course of the operation and the postoperative period.
Differential Diagnosis
| Nosology | Common (similar) signs with OKN | Distinguishing features from OKN |
| Acute appendicitis | Abdominal pain, stool retention, vomiting. | The pains begin gradually and do not reach such strength as with obstruction; pains are localized, and with obstruction they are cramping in nature, more intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction and not appendicitis. In acute appendicitis, there are no radiological signs characteristic of obstruction. |
|
Perforated ulcer of the stomach and duodenum. |
Sudden onset, severe abdominal pain, stool retention. | The patient takes a forced position, and with intestinal obstruction, the patient is restless, often changes position. Vomiting is not characteristic of a perforated ulcer, but is often observed with intestinal obstruction. With a perforated ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, while with OKN, the stomach is swollen, soft, and not painful. With a perforated ulcer, from the very beginning of the disease, there is no peristalsis, "splash noise" is not heard. Radiologically, with a perforated ulcer, free gas is determined in the abdominal cavity, and with OKN - Kloiber bowls, arcades, a symptom of pinnation |
| Acute cholecystitis | Sudden onset, severe abdominal pain | Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the right shoulder blade. With OKN, the pain is cramp-like, non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. Increased peristalsis, sound phenomena, radiological signs of obstruction are absent in acute cholecystitis. |
| Acute pancreatitis | Sudden onset of severe pain, severe general condition, frequent vomiting, bloating and stool retention. | The pains are localized in the upper abdomen, are girdle, and not cramping. Mayo-Robson's sign is positive. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. Radiologically, with pancreatitis, a high standing of the left dome of the diaphragm is noted, and with obstruction - Kloiber's cups, arcades, and transverse striation. |
| Intestinal infarction | Severe sudden pain in the abdomen, vomiting, severe general condition, soft abdomen. | Pain in intestinal infarction is constant, peristalsis is completely absent, bloating is small, there is no asymmetry of the abdomen, “dead silence” is determined during auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a large range of sound phenomena is heard, bloating is more significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, high leukocytosis (20-30 x10 9 /l) is pathognomonic. |
| Renal colic | Severe pain in the abdomen, bloating, retention of stools and gases, restless behavior of the patient. |
Pain in renal colic radiates to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive symptom of Pasternatsky. On a plain radiograph, shadows of calculi may be visible in the kidney or ureter. |
| Pneumonia | Rarely there may be abdominal pain and bloating | Pneumonia is characterized by high fever, rapid breathing, blush on the cheeks, and physical examination reveals crepitant rales, pleural friction rub, bronchial breathing, dullness of lung sound. X-ray examination can detect a pneumonic focus. |
| myocardial infarction | Sharp pains in the upper abdomen, bloating, sometimes vomiting, weakness, lowering blood pressure, tachycardia | With myocardial infarction, there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. An electrocardiographic study helps clarify the diagnosis of myocardial infarction. |
Treatment
Treatment Goals: elimination of intestinal obstruction; complete restoration of the passage of intestinal contents; elimination of the cause that caused OKN (if possible).
Treatment tactics
Non-drug treatment:(mode 1, diet 0, decompression of the upper digestive tract through a nasogastric tube (level of evidence - I, strength of recommendation - A) or an intestinal tube inserted with the help of FGDS, siphon enemas) .
Medical treatment:
| Pharmacological group | INN | Dosages, frequency of administration, route of administration |
| Antispasmodics | Drotaverine | 0.04/2 ml solution * 3 r / d (i.m. or i.v.) |
| Cholinesterase inhibitors | Prozerin | 0.05% solution 1 ml * 3 r / d (i / m or s / c) |
| Preparations for rehydration and detoxification for parenteral use | Sodium chloride | 0.9% solution in / in the cap (the volume of infusion depends on the body weight and the degree of dehydration of the patient) |
| Sodium chloride solution complex | intravenous cap (the volume of infusion depends on body weight and the degree of dehydration of the patient) | |
| Aminoplasmal | 10% solution in / in drip (the volume of infusion depends on the patient's body weight) | |
| Dextran | in/in drip | |
| Analgesics | Morphine | 0.01/1 ml solution i/m |
| Antibacterial therapy | Cefazolin | 1.0 * 3-4 r/d i/m or i/v |
| Meropenem | 1.0 * 2-3 r/d i/m or i/v |
List of essential medicines:
1. Antispasmodic drugs
2. Antibacterial drugs (cephalosporins II-III generation)
3. Analgesics
4. Crystalloid solutions for infusion
List of additional medicines:
1. Means for anesthesia
2. Consumables for laparoscopic or open surgery
3. Antibacterial drugs (β-lactamase inhibitors, fluoroquinolones, carbapenems, aminoglycosides).
4. Novocaine solution 0.5% -1%
5. Narcotic analgesics
6. Colloidal plasma replacement solutions
7. Fresh frozen plasma
8. Blood components
Other types of treatment: bilateral pararenal novocaine blockade (as a method of influencing the autonomic nervous system) (level of evidence - III, strength of recommendation - A).
Surgical intervention:
1. The operation for AIO is always performed under anesthesia by a three-medical team.
2. At the stage of laparotomy, revision, identification of the pathomorphological substrate of obstruction and determination of the operation plan, it is mandatory to participate in the operation of the most experienced surgeon on duty, as a rule, the responsible surgeon on duty.
3. For any localization of obstruction, access is median laparotomy, if necessary, with excision of scars and careful dissection of adhesions at the entrance to the abdominal cavity.
4. Operations for OKN provide for the consistent solution of the following tasks:
- establishing the cause and level of obstruction;
- elimination of the morphological substrate of OKN;
- determination of the viability of the intestine in the area of the obstacle and determination of indications for its resection;
- establishing the boundaries of the resection of the altered intestine and its implementation;
- determination of indications and method of drainage of the intestine;
- sanitation and drainage of the abdominal cavity in the presence of peritonitis.
5. Detection of an obstruction zone immediately after laparotomy does not relieve the need for a systematic revision of the state of the small and large intestines throughout their entire length. Revision is preceded by obligatory infiltration of the root of the mesentery of the small intestine with a local anesthetic solution (100-150 ml of 0.25% novocaine solution). In the case of a pronounced overflow of intestinal loops with contents, the intestine is decompressed using a gastrointestinal probe before revision.
6. Removing the obstruction is the key and most difficult component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of adhesions; resection of the altered intestine; elimination of torsion, intussusception, nodules or resection of these formations without prior manipulations on the altered intestine.
7. When determining the indications for resection of the intestine, visual signs are used (color, swelling of the wall, subserous hemorrhages, peristalsis, pulsation and blood filling of the parietal vessels), as well as the dynamics of these signs after the introduction of a warm solution into the mesentery of the intestine) of a local anesthetic. If there are doubts about the viability of the intestine, especially over its large extent, it is permissible to postpone the decision on resection using a programmed relaparotomy or laparoscopy after 12 hours.
8. When deciding on the boundaries of resection, one should deviate from the visible boundaries of the violation of the blood supply to the intestinal wall towards the adductor section by 35-40 cm, and towards the outlet section by 20-25 cm (level of evidence - III, strength of recommendation - A). The exception is resections near the ligament of Treitz or the ileocecal angle, where these requirements are allowed to be limited with favorable visual characteristics of the intestine in the area of the proposed intersection. In this case, control indicators are necessarily used - bleeding from the vessels of the wall at its intersection and the state of the mucous area.
9. Indications for drainage of the small intestine are:
- overflow with the contents of the leading intestinal loops;
- the presence of diffuse peritonitis with cloudy effusion and fibrin overlays;
- Extensive adhesive process in the abdominal cavity.
10. With colorectal tumor obstruction and the absence of signs of inoperability, one- or two-stage operations are performed depending on the location, stage of the tumor process and the severity of the manifestations of colonic obstruction. An emergency right-sided hemicolectomy in the absence of peritonitis can be completed with a primary ileotransverse anastomosis. In case of obstruction with a left-sided location of the focus of obstruction, resection of the colon is performed with removal of the tumor, which is completed according to the type of Hartmann operation. The primary anastomosis is not superimposed (level of evidence - III, strength of recommendation - A).
11. All operations on the colon are completed with devulsion of the external sphincter of the anus.
12. The presence of diffuse peritonitis requires additional sanitation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.
Preventive actions
In order to prevent acute intestinal obstruction, it is necessary to find and remove intestinal tumors in time. The prevention of intestinal obstruction also includes the fight against constipation. The patient's food should contain foods rich in fiber and vegetable oil. Animal fats require a sharp restriction.
It is required to exclude from your diet: cottage cheese, cheese, cookies, drying. Rice can be eaten in combination with various vegetables. It is also necessary to take laxatives (bisacodyl tablets and suppositories, senna grass). It is necessary that the chair was at least once every three days, and if it is not there, then an increase in the dose of the laxative drug, its replacement, a cleansing enema, or an urgent consultation with a surgeon is required.
Prevention of complications in operated patients with a diagnosis of "acute intestinal obstruction" is reduced to adequate and proper management of the postoperative period (see paragraph 15.6).
Further management.
Enteral nutrition begins with the appearance of intestinal peristalsis through the introduction of glucose-electrolyte mixtures into the intestinal probe.
The removal of the nasogastrointestinal drainage tube is carried out after the restoration of stable peristalsis and independent stool for 3-4 days (level of evidence - III, strength of recommendation - A). In order to combat ischemic and reperfusion injuries of the small intestine and liver, infusion therapy is carried out (aminoplasmal solution, sodium chloride solution 0.9%, glucose solution 5%, ringer's solution). Antibacterial therapy in the postoperative period should include cephalosporins (level of evidence - I, strength of recommendation - A). To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
Complex therapy should include heparin or low molecular weight heparins for the prevention of thromboembolic complications and microcirculation disorders.
An extract from the uncomplicated course of the postoperative period is made for 10-12 days. The presence of a functioning artificial intestinal or gastric fistula in the absence of other complications allows the patient to be discharged for outpatient treatment with a recommendation for re-hospitalization to eliminate the fistula if it does not close on its own.
If it is necessary to conduct adjuvant chemotherapy and in the absence of contraindications to it in patients with a tumor cause of AIO, it should be carried out no later than 4 weeks after surgery.
Treatment effectiveness indicators:
1. Elimination of symptomatic manifestations of the disease (absence of abdominal pain, absence of nausea and vomiting);
2. Positive X-ray dynamics;
3. Restoration of intestinal patency (regular discharge of stool and gases through artificial (colostomy, ileostomy) or natural openings;
4. Healing of the surgical wound by primary intention, no signs of inflammation of the postoperative wound.
Drugs (active substances) used in the treatment
Groups of drugs according to ATC used in the treatment
Hospitalization
Indications for hospitalization, indicating the type of hospitalization:
The established diagnosis or reasonable assumption of the presence of AIO is the basis for the immediate referral of the patient to the surgical hospital by ambulance in the supine position on a stretcher, followed by mandatory hospitalization on an emergency basis.
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
- 1. V. S. Saveliev, A. I. Kirienko. Clinical surgery: national guidelines: in 3 volumes - 1st ed. - M.: GEOTAR-Media, 2009. - S. 832. 2. Ripamonti C, Mercadante S. Pathophysiology and management of malignant bowel obstruction. In: Doyle D, Hanks G, Cherny NI, Calman K, editors. Oxford Textbook of Palliative Medicine. 3rd ed. New York, New York Oxford University Press Inc., New York 2005. p. 496-507. 3. Frank C. Medical management of intestinal obstruction in terminal care. Canadian Family Physician. February 1997;43:259-65. 4. Letizia M, Norton E. Successful Management of Malignant Bowel Obstuction. Journal of Hospice and Palliative Nursing.2003 July-September 2003;5(3):152-8. 5. BC Cancer Agency Professional Practice Nursing. Alert Guidelines: Bowel Obstruction. ; Available from: http://www.bccancer.bc.ca/HPI/Nursing/References/TelConsultProtocols/BowelObstruction.htm 6. M.A.Aliev, S.A.Voronov, V.A.Dzhakupov. Emergency surgery. Almaty. - 2001. 7. Surgery: Per. from English, add./Ed. Lopukhina Yu.M., Savelieva V.S. M.: GEOTAR MEDICINE. – 1998. 8. Eryukhin I. A., Petrov V. P., Khanevich M. D. Intestinal obstruction: A guide for physicians. - St. Petersburg, 1999. - 443 p. 9. Brian A Nobie: Small-Bowel Obstruction Treatment & Management. ; Available from: http://emedicine.medscape.com/article/774140-treatment/ 10. Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. Mar 2007;188(3):W233-8. 11. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. Aug 2011;28(8):676-8. 12. Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. Jun 2008;64(6):1651-64.
Information
III. ORGANIZATIONAL ASPECTS OF INTRODUCING THE PROTOCOL
List of developers:
1. Turgunov Ermek Meyramovich - doctor of medical sciences, professor, surgeon of the highest qualification category, head of the department of surgical diseases No. 2 of the Republican State Enterprise on the REM "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan, an independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.
2. Matyushko Dmitry Nikolaevich - Master of Medical Sciences, surgeon of the second qualification category, doctoral student of the RSE on REM "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan
Reviewer:
Almambetov Amirkhan Galikhanovich - doctor of medical sciences, surgeon of the highest qualification category, head of the department of surgery No. 2 of the Republican Scientific Center for Emergency Medical Care JSC.
Indication of no conflict of interest: there is no conflict of interest.
Indication of the conditions for revising the protocol: deviation from the protocol is unacceptable; this protocol is subject to revision every three years, or when new proven data on the diagnosis and treatment of AIO become available.
Attached files
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