NONCOPURITY OF THE INTESTINE
NONPRODUCTABILITY intestinal - a violation of the passage of intestinal contents - food masses and intestinal juices. There are complete and partial obstruction; Downstream - acute, with a sudden disruption of intestinal permeability, and chronic, developing gradually or manifested by repeated attacks of relative obstruction due to a partial disruption of patency with adhesive disease and (less often) with gut obturation with a slowly growing tumor. The mechanism of intestinal obstruction can have a dynamic and mechanical nature.
With dynamic obstruction, there is no mechanical obstruction to the movement of intestinal masses. It is caused by a sharp slowdown or complete cessation of intestinal peristalsis (intestinal paresis); Necrosis of the intestinal wall does not usually occur. Dynamic obstruction (paralytic ileus) is a constant symptom of a far-penetrated diffuse peritonitis of any etiology. This or that 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 organs of the abdominal cavity. A characteristic sign of paralytic intestinal obstruction is uniformly swollen, without intestinal peristalsis, "dumb belly". Less often there is a dynamic spastic obstruction (for example, with lead poisoning).
In practical work, there is a much more frequent occurrence of mechanical intestinal obstruction due to the presence of an obstruction in this or that part of the gastrointestinal tract. An important role in the nature of clinical manifestations and the course of intestinal obstruction is the type of mechanical obstruction (obturation or strangulation). When obstructive obstruction closes the lumen of the intestine, and its mesentery remains unaffected, the gut's blood supply is not disturbed. This type includes obstruction when the intestine (usually thick) growing in the lumen of the tumor , compressing the intestine by a tumor or inflammatory conglomerate from the outside, blocking the lumen of the gut with an ascaris ball, a stale or gallstone stone. Obturation obstruction usually develops gradually, from the time of the appearance of the first signs to the expressed phenomena of obstruction, it sometimes passes 3-7 days. Strangulation obstruction occurs much heavier, necrosis of the intestinal wall can occur within 4 to 6 hours from the onset of the disease. In this case, there is compression of the intestinal loop and its mesentery with rapidly advancing disorders of its blood supply. Typical forms of strangulation obstruction are infringement of the intestine with mesenteric cicatricial cords from previous operations, curvature of the intestines and their nodulation. Combined mechanical obstruction occurs when intussusception - along with clogging of the lumen with the intestine (obturation), the vessels of the mesentery of the invaginated loop (strangulation) contract.
In addition to the type of mechanical obstruction, great importance is the level of the obstruction that has arisen along the course of the intestinal tract. The higher the obstruction arises, the harder it is, the more energetic the therapeutic measures it requires. The small intestine is always heavier than the large intestine; The obstruction of the upper parts of the jejunum is much heavier and more dangerous than the terminal loops of the ileum.
Clinical picture . All types of mechanical intestinal obstruction, regardless of its level and nature, are characterized by pain, vomiting , stool and gas retention. The main initial symptom of acute arterial obstruction is sudden strong, often severe pain. In the case of obstruction, it usually has a cramping character and coincides with the next peristaltic wave. In the intervals between contractions the patient can feel perfectly healthy, the characteristic initial picture of the obstruction emerges during the next pain.
In the compression of not only the intestine, but also her mesentery, even in the interval between contractions, the patients feel dull pains, but during the next bout they intensify unbearably. The intensity of pain during a regular bout causes severe anxiety. The face is distorted, and some patients take various forced, sometimes bizarre (knee-elbow, squatting) positions in bed. Women usually compare pain with labor contractions. Characterized by the so-called ileous periodic groan, gradually growing and also gradually subsiding at the end of the pain. At the height of the pain syndrome, the symptoms of shock may appear: the skin is pale, covered with a cold sweat, the pulse becomes frequent, small filling. Sudden relief of pain, not accompanied by the escape of feces and gases, may indicate necrosis of the intestinal loop (although often severe pain continues with the development of necrosis). With obstructive obstruction, the cessation of painful attacks and the transition of cramping pain to constants testify to a decrease in bowel tone above the obstruction and development of the intestinal paresis. With intestinal obstruction after a deceptive calm, peritonitis inevitably develops.
Vomiting with obstruction is characterized by a number of features that make it possible to recognize its true nature. With high intestinal obstruction vomiting is repeated at short intervals, it is always repeated. If at first the vomit masses are the remains of food, then in the future they are a copious liquid content penetrating into the stomach from the intestine and intensely colored with bile. The higher the obstacle, the more vomiting is intense. With intestinal obstruction, unlike food intoxication, vomiting does not bring relief to the patient, and he continues to feel the urge. 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 daily 10 - 12 liters, which explains the multiple vomiting and abundance of vomit. All this is exacerbated by the persistent obstruction of the formation of hemorrhagic effusion in the abdominal cavity and quickly leads to significant dehydration, a progressive loss of protein and electrolytes, and an increase in intoxication. In this regard, patients with high intestinal obstruction often have a thickening of the blood, which is manifested by a relative increase in hemoglobin, erythrocytes and significant leukocytosis due to a decrease in the volume of plasma.
Repeated and profuse vomiting is characteristic only for obstruction, localized in the upper part of the small intestine. With other types of intestinal obstruction, it may not be present or it is observed 1-2 times.
In the later period of intestinal obstruction, with the development of peritonitis accompanied by intestinal paresis and complete cessation of its peristalsis, there is an extremely painful vomiting for the patient with intestinal contents that have been putrefied and have a disgusting smell (so-called vomiting). Abundant emetic masses with a feces smell represent stagnant contents of the upper intestine. The higher the obstacle is, the sooner will there be vomiting . At a very low location of obstruction in the colon, vomiting may not be at all.
A characteristic symptom of intestinal obstruction is the stool retention and the cessation of Gaza's withdrawal. With a low, large intestine, mostly swelling, obstruction, despite the many-day absence of stools, finger examination of the ampulla of the rectum does not reveal feces in it. The rectum is empty and stretched. With high intestinal obstruction, stool retention is often not observed, there is an independent or with the enema emptying the underlying intestinal reservoir. Because of the presence of a chair, at times intestinal obstruction is denied; Such a mistake is not uncommon.
The general condition of the patient with a low (especially obturation) obstruction within 2 to 3 days may remain satisfactory, but deteriorates rapidly in case of obstructive obstruction, with a high obstruction level, and also with dynamic obstruction due to mesentery vascular thrombosis. Pulse at the beginning of the disease is somewhat rapid, with a deterioration of the tachycardia reaches 120 beats / min; As the disease progresses, blood pressure decreases. Body temperature usually remains normal.
The earliest objective symptom of intestinal obstruction is enhanced peristalsis. Intensified peristalsis of swollen intestinal loops can sometimes be seen in thin patients (a symptom of visible peristalsis), but much more often palpation is possible to catch a slice of the intestine during the pain (with its end returns to its former consistency). Auscultatory in the area of the sponging intestine at the height of the pain is determined sharply increased intestinal noises. Sometimes a loud rumbling can be heard from a distance.
In the initial stage of intestinal obstruction, the abdominal wall is soft and supple, often quite painless for palpation, peritoneal symptoms are absent. Unfortunately, the almost constant absence of symptoms characteristic of the acute abdomen (the tension of the muscles of the anterior abdominal wall and the sharp tenderness of palpation, the symptoms of irritation of the peritoneum) in the first hours of intestinal obstruction often leads to a fatal illness for the patient denying an acute catastrophe that requires emergency surgery. When these symptoms appear (that is, with the development of peritonitis), the operation is often belated and unsuccessful.
Bloating is a characteristic objective symptom of impaired intestinal permeability. Unlike a uniform swelling with paralytic obstruction, bloating at a mechanical obstruction is almost always limited and is caused by an elongated intestinal loop contouring through the abdominal wall. With the weakening of peristalsis and the loss of muscle tone, the expansion and swelling of the intestinal loop above the obstruction develop. This is a later symptom of intestinal obstruction. In the bimanual wiggle of the abdominal wall above the swollen bowel, a characteristic "splash" of the fluid is determined due to the accumulation in the atonic intestinal loop of a large number of digestive juices.
Sometimes it is possible to palpate a fixed and stretched bowel loop (Val's symptom), with percussion over which a tympanic sound with a metallic tinge is identified (a positive symptom of Kivul). In late terms of the disease with a pronounced stretching of the intestine, the characteristic rigidity of the abdominal wall with the consistency of the inflated ball is revealed (a positive symptom of Mondor).
Important in the diagnosis are rectal and vaginal examinations, in which it is possible to detect an inflammatory infiltrate or a tumor in the pelvic cavity, obturation of the rectum by a calcified stone or tumor, etc. When the sigmoid colon is turned, the gap in the sphincter of the anus and the empty ampulla of the rectum are determined.
The diagnosis is based on the following symptoms: cramping pain, vomiting , hyperperistaltic, stool and gas retention. The diagnosis can be confirmed by roentgenologic examination: for intestinal obstruction pathognomonic presence of one or several horizontal levels of fluid in the gastrointestinal loops stretched by the gas (Clauber's bowl).
Treatment . The patient, who is diagnosed or suspected of intestinal obstruction, needs emergency hospitalization in the surgical department. Due to rapidly advancing, progressive, often catastrophic dehydration with high intestinal obstruction, immediate therapy is needed to compensate for huge losses of fluid and electrolytes (infusion of 1.5-2.0 liters of isotonic sodium chloride solution, 5% glucose solution, polyglucin into the vein); Such therapy should be carried out whenever possible and during the transportation of the patient. Before examination, the doctor should not give laxatives, administer pain medications, perform enemas and gastric lavage.
In the hospital, in the absence of significant signs of mechanical obstruction, a complex of conservative measures is performed: the aspiration of gastrointestinal contents through a thin probe inserted through the nose; With increased peristalsis inject antispasmodics. With mechanical obstruction, in the case of ineffectiveness of conservative therapy, an emergency operation is performed (dissection of the adhesions, unwinding of the curvature, deinvagination, gut resection with its necrosis, imposition of intestinal fistula for the removal of intestinal contents in tumors of the large intestine). In the postoperative period, measures aimed at normalizing water-salt and protein metabolism (intravenous infusions of saline solutions, blood substitutes), anti-inflammatory, anticoagulant therapy, stimulation of the motor-evacuation function of the gastrointestinal tract, etc., continue.
The prognosis for acute intestinal obstruction is always serious, worsening due to frequent difficulties in recognition, often a belated operation; Lethality with intestinal obstruction is several times higher than that of other forms of acute abdomen.