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Intestinal obstruction


Intestinal obstruction - violation of the passage of intestinal contents - food masses and intestinal juices. Distinguish between full and partial obstruction; in the course of flow - acute, with a sudden violation of the intestinal patency, and chronic, developing gradually or manifested by repeated bouts of relative obstruction due to a partial patency disorder during adhesion disease and (less commonly) during bowel obstruction with a slowly growing tumor. According to the mechanism, intestinal obstruction can have a dynamic and mechanical character.

With dynamic obstruction there is no mechanical obstacle to the advancement of intestinal masses. It is caused by a sharp slowdown or complete cessation of intestinal motility (intestinal paresis); necrosis of the intestinal wall usually does not occur. Dynamic obstruction (paralytic ileus) is a constant symptom of far-reaching diffuse peritonitis of any etiology. A degree of intestinal paresis often accompanies attacks of renal colic, often complicates fractures of the spine, pelvic bones with extensive retroperitoneal hematomas, abdominal trauma with hemorrhages in the mesentery, can develop after surgery on the abdominal organs. A characteristic sign of paralytic intestinal obstruction is a uniformly swollen, without intestinal peristalsis, “silent stomach”. Less common is dynamic spastic obstruction (for example, with lead poisoning).

In practical work, mechanical intestinal obstruction is much more common due to the presence of an obstacle in a particular section of the gastrointestinal tract. An important role in the nature of clinical manifestations and the course of intestinal obstruction is played by the type of mechanical obstruction (obstructive or strangulation). With obstructive obstruction, the lumen of the intestine closes, and its mesentery remains unaffected, the blood supply to the intestine is not disturbed. This type includes obstruction in case of a tumor growing in the lumen of the intestine (usually a large one), compression of the intestine by a tumor or inflammatory conglomerate from the outside, blockage of the intestinal lumen with an ascaris ball, fecal or gall stone. Obstructive obstruction usually develops gradually, from the moment of the appearance of the first signs to the expressed phenomena of obstruction, sometimes 3 to 7 days pass. Strangulation obstruction is much more difficult, necrosis of the intestinal wall can occur within 4-6 hours from the onset of the disease. In this case, compression of the intestinal loop and its mesentery occurs with rapidly occurring disorders of its blood supply. Typical forms of strangulation obstruction are infringement of the intestine with a mesentery with a scar cord from previous operations, inversion of the intestines and their nodulation. Combined mechanical obstruction occurs during intussusception - along with obstruction of the lumen by the invading intestine (obturation), mesenteric vessels of the invaginated loop are compressed (strangulation).

In addition to the type of mechanical obstruction, the level of the obstacle that arose along the intestinal tract is of great importance. The higher the obstruction occurs, the harder it is, the more vigorous therapeutic measures it requires. Small bowel obstruction is always heavier than large bowel obstruction; obstruction of the upper jejunum is much heavier and more dangerous than the terminal ileal loops.

The clinical picture . All types of mechanical intestinal obstruction, regardless of its level and nature, are characterized by pain, vomiting , and stool and gas retention. The main initial symptom of acute intestinal obstruction is a sudden severe, often severe pain. In case of obstruction, it, as a rule, has a cramping nature and coincides with the next peristaltic wave. In the intervals between contractions, the patient can feel completely healthy, a characteristic initial picture of obstruction appears precisely during the next painful battle.

When squeezing not only the intestine, but also its mesentery, even in the interval between contractions, patients feel dull pain, however, during the next fight, they are unbearably intensified. The intensity of pain during the next bout causes sharp concern. The face is distorted, and some patients take a variety of forced, sometimes bizarre (knee-elbow, squatting) positions in bed. Women usually compare pain with labor pains. The so-called ileus periodic groan is characteristic, gradually increasing and also gradually subsiding at the end of a painful battle. At the height of the pain syndrome, the appearance of shock symptoms is possible: the skin is pale, covered with cold sweat, the pulse becomes frequent, small filling. A sudden weakening of pain, not accompanied by the discharge of feces and gases, may indicate necrosis of the intestinal loop (although often severe pain continues with advanced necrosis). With obstructive obstruction, the cessation of pain attacks and the transition of cramping pains into permanent ones indicate a decrease in bowel tone above an obstacle and the development of intestinal paresis. With intestinal obstruction after a deceptive lull, peritonitis inevitably develops.

Vomiting with obstruction is distinguished by a number of features that make it possible to recognize its true nature. With high intestinal obstruction, vomiting is repeated at short intervals, always repeated. If at first vomit is the remnants of food, then in the future they are abundant liquid contents that penetrate the stomach from the intestines and are intensely stained with bile. The higher the obstacle, the more intense the vomiting . With small bowel obstruction, unlike food intoxication, vomiting does not bring relief to the patient, and he continues to feel the urge. The abundance of vomit, consisting of bile and intestinal juices without food impurities, is also extremely characteristic of high intestinal obstruction. The number of intestinal juices reaches 10 - 12 l daily, which explains the repeated vomiting and the abundance of vomit. All this is exacerbated by the constant formation of hemorrhagic effusion in the abdominal cavity during obstruction and quickly leads to significant dehydration, progressive loss of protein and electrolytes by the body, and increasing intoxication. In this regard, in patients with high intestinal obstruction, blood thickening is often observed, which is manifested by a relative increase in hemoglobin, red blood cells and significant leukocytosis due to a decrease in plasma volume.

Repeated and profuse vomiting is characteristic only of obstruction, localized in the upper part of the small intestine. With other types of intestinal obstruction, it may not be present or it is noted 1-2 times.

In a later period of intestinal obstruction, with the development of peritonitis, accompanied by intestinal paresis and complete cessation of its peristalsis, vomiting of intestinal contents, subjected to putrefactive decay and having a disgusting odor (so-called fecal vomiting), is extremely painful for the patient. Abundant vomit with fecal odor is the stagnant contents of the upper intestines. The higher the obstacle, the sooner fecal vomiting occurs. With a very low location of obstruction in the colon, fecal vomiting may not occur at all.

A characteristic symptom of intestinal obstruction is stool retention and cessation of Gases. With low, large bowel, mainly tumor, obstruction, despite the multi-day absence of stool, a digital examination of the rectal ampoule does not reveal feces in it. The rectum is empty and distended. With high small bowel obstruction, retention of the stool is often not observed, there is an independent or using an enema emptying of the underlying intestinal reservoir. Due to the presence of stool, intestinal obstruction is sometimes denied; such a mistake is not uncommon.

The general condition of the patient with low (especially obstructive) obstruction for 2 to 3 days can remain satisfactory, but quickly worsens with strangulation obstruction, with a high level of obstruction, as well as with dynamic obstruction due to mesenteric vascular thrombosis. The pulse at the onset of the disease is somewhat more frequent, with a worsening condition, tachycardia reaches 120 beats / min; as the disease develops, blood pressure decreases. Body temperature usually remains normal.

The earliest objective symptom of intestinal obstruction is increased motility. Enhanced peristalsis of swollen intestinal loops can sometimes be seen in thin patients (a symptom of visible peristalsis), but much more often palpation can be detected on a segment of the intestine that tightens during painful labor (with its end returning to its previous consistency). Auscultation in the area of ​​the densifying gut at the height of the pain of a pain is determined by sharply amplified intestinal noises. Sometimes a loud rumbling is heard from a distance.

In the initial stage of intestinal obstruction, the abdominal wall is soft and supple, often completely painless on palpation, peritoneal symptoms are absent. Unfortunately, the almost constant absence of symptoms characteristic of an acute abdomen (muscle tension of the anterior abdominal wall and sharp pain on palpation, symptoms of irritation of the peritoneum) in the first hours of intestinal obstruction often leads to a fatal denial by the medical worker of an acute catastrophe requiring emergency surgery. When these symptoms appear (i.e., with the development of peritonitis), the operation is often belated and unsuccessful.

Bloating is a characteristic objective symptom of impaired intestinal patency. In contrast to uniform swelling with paralytic obstruction, swelling with a mechanical obstruction is almost always limited and is due to the extended intestinal loop contouring through the abdominal wall. With weakening of peristalsis and loss of muscle tone, expansion and bloating of the intestinal loop above the obstacle develop. This is a later symptom of intestinal obstruction. With bimanual swaying of the abdominal wall over the swollen intestine, the characteristic “splash noise” of the liquid is determined due to the accumulation of a large number of digestive juices in the atonic intestinal loop.

Sometimes it is possible to palpate a fixed and extended loop of the intestine (Valya symptom), with percussion over which a tympanic sound with a metallic tint is determined (positive symptom of Kivul). In the late stages of the disease with severe bowel distension, a characteristic stiffness of the abdominal wall with the consistency of an inflated ball is revealed (a positive symptom of Mondor).

Rectal and vaginal examinations are important in the diagnosis, in which inflammatory infiltration or a tumor in the pelvic cavity, obstruction of the rectum with a fecal stone or tumor, etc. can be detected. When the sigmoid colon is twisted, the gap of the sphincter of the anus and the empty ampule of the rectum are determined.

The diagnosis is based on the following symptoms: cramping pains, vomiting , hyperperistalsis, stool and gas retention. The diagnosis can be confirmed by X-ray examination: for intestinal obstruction, the presence of one or more horizontal fluid levels in the intestinal loops stretched by gas (Kloiber's cup) is pathognomonic.

Treatment . A patient who has been diagnosed or suspected of having intestinal obstruction needs emergency hospitalization in the surgical department. Due to rapidly advancing, progressing, often catastrophic dehydration with high small bowel obstruction, immediate therapy is required to compensate for huge losses of fluid and electrolytes (infusion of 1.5 - 2 l of isotonic sodium chloride solution, 5% glucose solution, polyglucin into the vein); such therapy should be carried out whenever possible and during transportation of the patient. Before examination by a doctor, laxatives, painkillers, enemas and gastric lavages should be administered.

In the hospital, in the absence of pronounced signs of mechanical obstruction, a set of conservative measures is carried out: aspiration of the gastrointestinal contents through a thin probe inserted through the nose; with increased peristalsis, antispasmodics are administered. In case of mechanical obstruction, in the case of conservative therapy ineffectiveness, an emergency operation is performed (dissection of adhesions, unwinding of the inversion, de-intussusception, resection of the intestine with its necrosis, imposition of the intestinal fistula to divert intestinal contents with colon tumors). In the postoperative period, measures continue to normalize water-salt and protein metabolism (intravenous infusion of saline solutions, blood substitutes), anti-inflammatory, anticoagulant therapy, stimulation of the motor-evacuation function of the gastrointestinal tract, etc.

The prognosis for acute intestinal obstruction is always serious, worsens due to frequent difficulties in recognition, often belated surgery; mortality in intestinal obstruction is several times higher than that in other forms of acute abdomen.