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 works, the name ileus was first encountered, which served as a collective term for various diseases of the abdominal cavity, including obstruction.
Currently, in terms of the incidence of the disease, it ranks fifth among the main forms of "acute abdomen". AIO occurs in all age groups, but most often between the ages of 30 and 60. Obstruction due to intussusception is more often observed in children, strangulation - in middle-aged patients, obturation - in patients over 50 years old. An important feature noted recently is the redistribution in frequency of occurrence of certain forms of AIO. So, such forms as nodulation, intussusception and volvulus 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 adhesions 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 falls on 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. In the subsequent 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 (volvulus, nodulation, internal entrapment)
- Obturation:
a. intraorgan (foreign bodies, fecal and gallstones, helminthic invasion, located in the lumen of the intestine)
b. intramural (tumor, Crohn's disease, tuberculosis, cicatricial stricture affecting the intestinal wall)
v. extraorganic (cysts of the mesentery and ovary, tumors of the retroperitoneal space and pelvic organs, exerting compression of the intestine from outside).
- Mixed:
a. Adhesive obstruction
b. Intussusception
Origin:
- Congenital.
- Acquired.
By 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)
Stage I. Acute violation of the intestinal passage - the stage of "ileus cry" - the first 12 hours from the onset of the disease)
Stage II. Acute violation of intramural intestinal blood circulation
(intoxication phase) - 12-36 hours.
Stage III. Peritonitis - more than 36 hours from the onset of the disease.
Significant disagreements are found in the literature on the question of determining the severity of colonic obstruction. This circumstance has given 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, Russian Academy of Medical Sciences. According to the proposed classification, there are 3 degrees of severity of colonic obstruction:
I degree (compensated). Complaints of recurrent 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, symptoms of intoxication are absent. The results of colonoscopy and irrigography indicate that the tumor narrows the intestinal lumen to 1.5 cm, a small accumulation of gases and intestinal contents in the colon is found.
II degree (subcompensated). Complaints about persistent constipation, lack of independent stool. Taking laxatives is ineffective and has a temporary effect. Periodic bloating, difficulty passing gas. The general condition is relatively satisfactory. Symptoms of intoxication are noticeable. The tumor narrows the intestinal lumen to 1 cm. On X-ray examination, the colon is dilated, filled with intestinal contents. Individual liquid levels (Kloyber bowls) can be detected.
III degree (decompensated). Complaints about the absence of stool and discharge of gas, growing cramping pains in the abdomen and its bloating, nausea, and sometimes vomiting. Expressed signs of intoxication, violation of water and electrolyte balance and CBS, anemia, hypoproteinemia. On X-ray examination, the intestinal loops are dilated, swollen with gas. Multiple fluid levels are detected. As a rule, the majority of patients admitted to an 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 false obstruction syndrome of the colon, first described by N. 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 Ogilvy's syndrome. Bilateral perirenal novocaine blockade according to A.V. has a positive effect. Vishnevsky.
When the clinical manifestations of the disease are accompanied by mild symptoms, we do not diagnose "partial intestinal obstruction", considering it tactically unjustified. In this case, we are talking, most often, about incomplete closure of the intestinal lumen by a growing tumor, adhesions obstruction, or recurrent volvulus. Such a diagnosis confuses the surgeon and leads to delayed operations.
Causes of Acute Intestinal Obstruction
AIO can be caused by multiple causes, which are identified as predisposing and producing factors. The former include anomalies in the development of the intestine and its mesentery, the presence of adhesions, strands, 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 the reasons that, in the presence of predisposing factors, can cause the development of AIO. These are, first of all, acutely developing disorders of the intestinal motor function in the form of hyper- or hypomotor reactions or their combination. This condition can be caused by increased food load, a disorder of the nervous regulation of intestinal motor activity, irritation of the receptors of the 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.
Pathogenesis of acute intestinal obstruction
The 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 carried out 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 (stage I) are associated with impaired intestinal passage. The severity of their occurrence and the intensity of development depend on the morphological and functional characteristics of the disease. So, in cases of dynamic, strangulation and obstructive obstruction, the duration of stage I will be different. It is known that an obstacle along the gastrointestinal tract does not cause any serious consequences if a bypass route is created for the evacuation of intestinal contents. An exception is the strangulated 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 violations of the water-electrolyte balance and the syndrome of endogenous intoxication. Such patients, with the exception of cases of strangulated intestinal obstruction, are shown conservative therapy. The second stage of AIO is characterized by an acute disorder of intramural intestinal hemocirculation. This is no longer just the body's response to the termination 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 intraintestinal pressure up to 30 mm. rt. Art. capillary blood flow in the intestinal wall stops completely. All of the above gives reason to interpret the second stage of AIO as a process of acute disorders of intramural intestinal hemocirculation. Taking into account its progressive nature, at this stage it is no longer possible to adhere to the tactics of dynamic observation of the patient and persistent conservative treatment. It is necessary to set indications for urgent surgical intervention.
Isolation of stage III of 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 the 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 changes in the gastrointestinal tract and abdominal cavity in AIO. The second group reflects the general reaction of the body to the pathological process.
Group I. The earliest and one of the most persistent signs of the disease is pain syndrome. The occurrence of cramping pains is characteristic of acute obstruction of the intestinal lumen and is associated with its peristalsis. Sharp persistent pain often accompanies acutely developed strangulation. If AIO is not diagnosed in a timely manner, then 2-3 days from the onset of the disease, the motor activity of the intestine is inhibited, which is accompanied by a decrease in the intensity of pain and a change in its nature. At the same time, symptoms of endogenous intoxication begin to prevail, which is a poor prognostic sign. The pathognomonic symptom in AIO is stool retention and flatulence. However, with high small bowel obstruction at the beginning of the disease, there may be discharge of gases and stools 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. At first, vomiting is of a reflex nature, and later occurs due to overflow of the proximal gastrointestinal tract. The higher the intestinal obstruction, the more pronounced the vomiting. In the initial stage of colonic obstruction, vomiting may be absent. With low small bowel obstruction, vomiting is observed with large intervals and an abundance of vomit, which acquire the character of intestinal contents with a "fecal" odor. In the later stages of AIO, vomiting is a consequence of not only stagnation, but also endotoxicosis. During this period, vomiting cannot be eliminated even by intestinal intubation.
One of the local signs of AIO is bloating. "Oblique belly" (Bayer's symptom), when bloating leads to an asymmetry of the abdomen and is located in the direction from the right hypochondrium through the umbilicus to the left iliac region, is characteristic of volvulus of the sigmoid colon. Bowel obstruction caused by obstruction of the lumen of the proximal jejunum leads to bloating in the upper abdomen, 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 (Valya's symptom) was described: 1. Asymmetry of the abdomen; 2. Palpable swollen intestinal loop (elastic cylinder) with high tympanitis; 3. Visible peristalsis. 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 groin areas, as well as the existing postoperative scars on the anterior abdominal wall. When examining patients with AIO, it is very important to remember about the possible parietal (Richter's) infringement 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 restrained hernia, are absent.
On palpation, the abdomen remains soft and slightly painful until peritonitis develops. 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 cecum, the Shiman-Dans symptom is considered pathognomonic, which is defined as a feeling of emptiness on palpation in the right ileal region due to bowel displacement. With colonic obstruction, flatulence is determined in the right iliac region (Anshutz symptom). The symptom described by I.P. Sklyarov ("splash noise") in 1922, detected with a slight concussion of the anterior abdominal wall. Its presence indicates an overflow of fluid and gases in the adducting 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, since gas does not accumulate in the small intestine under normal conditions.
At auscultation of the anterior abdominal wall at the onset of the disease, intestinal noises of various heights and intensity are heard, the source of which is the swollen small intestine that has not yet lost its motor activity. The development of intestinal paresis and peritonitis marks a weakening of intestinal murmurs, which appear in the form of individual weak bursts, reminiscent of the sound of a falling drop (Spasokukotsky's symptom) or the noise of bursting bubbles (Wilms symptom). Soon these sounds cease to be detected. The state of the "silent abdomen" indicates the development of severe intestinal paresis. Due to a change in the resonating properties of the contents of the abdominal cavity, against the background of an enlarged abdomen, heart sounds begin to be heard clearly (Bailey's symptom). At this stage, the clinical picture acute intestinal obstruction more and more combined with the symptoms of generalized peritonitis.
Diagnostics of the acute intestinal obstruction
In diagnostics acute intestinal obstruction a thoroughly collected anamnesis, scrupulous identification of clinical symptoms of the disease, a critical analysis of radiological and laboratory data are of great importance.
Examination of a patient with AIO must be supplemented with a digital examination of the rectum, which allows to determine the presence of feces ("coprostasis"), foreign bodies, a tumor or the head of the invaginate in it. 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."
Group II. The nature of general disorders in AIO is determined by endotoxicosis, dehydration, and metabolic disorders. Thirst, dry mouth, tachycardia, decreased urine output, blood clotting, determined by laboratory parameters, are noted.
A very important diagnostic step is an X-ray examination of the abdominal cavity, which is subdivided into:
- Non-contrast method (plain radiography of the abdominal cavity). Additionally, an overview X-ray of the chest cavity is performed.
- Contrast methods for studying the movement of barium suspension through the intestine after oral administration (Schwarz's test and its modifications), its introduction through a nasoduodenal probe and retrograde filling of the colon with a contrast enema.
Plain images of the abdominal cavity may show direct and indirect symptoms. acute intestinal obstruction... Direct symptoms include:
1. The accumulation of gas in the small intestine is a warning sign, since under normal conditions gas is observed only in the stomach and large intestine.
- The presence of Kloyber's bowls, named after the author who described this symptom in 1919, is considered a classic X-ray sign of mechanical intestinal obstruction. They represent the horizontal fluid levels found in distended bowel loops, which are found 2-4 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 Kloyber's bowls can form after cleansing enemas, as well as in debilitated patients who have been in bed for a long time. Horizontal levels are visible not only in the vertical position of the patient, but also in the lateroposition.
- Symptom of transverse striation of the intestinal lumen, denoted as a symptom of Case (1928), "stretched spring", "fish skeleton". This symptom is considered as a manifestation of edema of the kercring (circular) folds of the mucous membrane of the small intestine. 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 mucous membrane of these parts of the intestine. The clearly visible folds of the small intestine are proof of the satisfactory condition of its wall. The abrasion of the folds indicates a significant violation of intramural hemodynamics.
In cases where the diagnosis of AIO 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 AIO in the 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 observation of the advancement of the contrast mass must be combined with a clinical study of the patient's condition and the conduct of 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 an urgent surgical intervention is raised.
When performing oral contrast enhancement and interpreting the data obtained, it is necessary to take into account the timing of the advancement of the contrast agent through the intestine. In a healthy person, the barium suspension, drunk per os, reaches the cecum after 3-3.5 hours, the right bend of the colon - after 5-6 hours, the left bend - after 10-12 hours, and 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 organs of the abdominal cavity complements the X-ray examination, especially in the early stages of AIO. 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 signs in assessing the stage of AIO are the gut diameter, which can range from 2.5 to 5.5 cm, and its wall thickness, ranging from 3 to 5 mm. the presence of free fluid in the abdominal cavity. With the development of destructive changes in intestinal loops, the thickness from the wall can reach 7-10 mm, and its structure becomes heterogeneous with the presence of inclusions in the form of thin echo-negative stripes.
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 possibility of the method for differential diagnosis of mechanical and dynamic forms of acute intestinal obstruction, for dissection of single adhesions. However, as our experience in using laparoscopy shows, its use in conditions of severe intestinal paresis and adhesions in the abdominal cavity in most cases is not only uninformative, but also dangerous due to the possible occurrence of severe complications. Therefore, the main indication for the use of laparoscopy in AIO is objective difficulties in the differential diagnosis of acute surgical pathology.
Treatment of acute intestinal obstruction
Conservative therapy. Based on the ideas about 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 a 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 for decompression and lavage of the upper digestive tract, which reduces the intracavitary pressure in the intestine and the absorption of toxic products. The pararenal 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 intestinal stimulation, so there is no need to pin great 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 removing the 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 stabilized, protein and electrolyte disturbances 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 the intensive care unit.
Surgical treatment. Conservative therapy should be recognized as effective if in the next 3 hours from the moment the patient was admitted to the hospital after enemas, a large amount of gas left and there was abundant stool, abdominal pain and swelling decreased, vomiting stopped and the general condition of the patient improved. In all other cases (with the exception of dynamic intestinal obstruction), the conservative therapy carried out 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 the conservative measures and the need for intestinal intubation for the purpose of its decompression.
Success in the treatment of AIO is 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.
- violation of the passage of contents through the intestine, caused by obstruction of its lumen, compression, spasm, hemodynamic or innervation disorders. Clinically, intestinal obstruction is manifested by cramping abdominal pain, nausea, vomiting, stool retention and gas discharge. In the diagnosis of intestinal obstruction, the data of physical examination (palpation, percussion, abdominal auscultation), digital rectal examination, plain radiography of the abdominal cavity, contrast radiography, colonoscopy, laparoscopy are taken into account. With some types of intestinal obstruction, conservative tactics are possible; in other cases, surgical intervention is performed, the purpose of which is to restore the passage of the contents through the intestine or its external abduction, resection of a non-viable section of the intestine.
General information
Intestinal obstruction (ileus) is not an independent nosological form; in gastroenterology and coloproctology, this condition develops in a variety of diseases. Intestinal obstruction accounts for about 3.8% of all emergencies in abdominal surgery. With intestinal obstruction, the movement of the contents (chyme) - half-digested food masses along the digestive tract - is disturbed.
Intestinal obstruction is a polyetiological syndrome that can be caused by many reasons and take different forms. Timeliness and correctness of the diagnosis of intestinal obstruction are decisive factors in the outcome of this serious condition.
Causes of intestinal obstruction
The development of various forms of intestinal obstruction is due to its own reasons. So, spastic obstruction develops as a result of reflex intestinal spasm, which can be caused by mechanical and painful irritation with helminthic invasions, intestinal foreign bodies, bruises and abdominal hematomas, acute pancreatitis, nephrolithiasis and renal colic, biliary colic, basal pneumonia, hemopoleuritis and pneumothorax, rib fractures, acute myocardial infarction and other pathological conditions. In addition, the development of dynamic spastic intestinal obstruction may be associated with organic and functional lesions of the nervous system (TBI, mental trauma, spinal cord injury, ischemic stroke, etc.), as well as dyscirculatory disorders (thrombosis and embolism of mesenteric vessels, dysentery, vasculitis), Hirschsprung's disease.
Paralytic intestinal obstruction is caused by paresis and paralysis of the intestines, which can develop as a result of peritonitis, surgical interventions on the abdominal cavity, hemoperitonium, morphine poisoning, heavy metal salts, food toxicoinfections, etc.
With various types of mechanical intestinal obstruction, there are mechanical obstacles to the advancement of food masses. Obstructive intestinal obstruction can be caused by fecal stones, gall stones, bezoars, accumulation of worms; intraluminal bowel cancer, foreign body; intestinal compression from the outside by tumors of the abdominal cavity, small pelvis, kidney.
Strangulated intestinal obstruction is characterized not only by compression of the intestinal lumen, but also by compression of the mesenteric vessels, which can be observed with infringement of a hernia, volvulus, intussusception, nodulation - overlap and twisting of intestinal loops between themselves. The development of these disorders may be due to the presence of a long mesentery of the intestine, cicatricial cords, adhesions, adhesions between intestinal loops; a sharp decrease in body weight, prolonged fasting followed by overeating; a sudden increase in intra-abdominal pressure.
The cause of vascular intestinal obstruction is acute occlusion of mesenteric vessels due to thrombosis and embolism of the mesenteric arteries and veins. The development of congenital intestinal obstruction, as a rule, is based on anomalies in the development of the intestinal tube (doubling, atresia, Meckel's diverticulum, etc.).
Classification
There are several options for the classification of intestinal obstruction, taking into account various pathogenetic, anatomical and clinical mechanisms. Depending on all these factors, a differentiated approach to the treatment of intestinal obstruction is used.
For morphofunctional reasons, there are:
1. dynamic intestinal obstruction, which, in turn, can be spastic and paralytic.
2. mechanical intestinal obstruction, including the following forms:
- strangulation (volvulus, infringement, nodulation)
- obstructive (intraintestinal, extraintestinal)
- mixed (adhesive obstruction, intussusception)
3. vascular intestinal obstruction due to intestinal infarction.
According to the level of the location of the obstacle for the passage of food masses, there are high and low small intestinal obstruction (60-70%), colonic obstruction (30-40%). According to the degree of violation of the patency of the digestive tract, intestinal obstruction can be complete or partial; according to the clinical course - acute, subacute and chronic. By the time of formation of intestinal obstruction disorders, they differentiate congenital intestinal obstruction associated with embryonic intestinal malformations, as well as acquired (secondary) obstruction due to other reasons.
In the development of acute intestinal obstruction, several phases (stages) are distinguished. In the so-called ileus cry phase, which lasts from 2 to 12-14 hours, pain and local abdominal symptoms prevail. The stage of intoxication, which replaces the first phase, lasts from 12 to 36 hours and is characterized by "imaginary well-being" - a decrease in the intensity of cramping pains, a weakening of intestinal peristalsis. At the same time, there is no discharge of gases, stool retention, bloating and asymmetry of the abdomen. In the late, terminal stage of intestinal obstruction, which occurs 36 hours after the onset of the disease, severe hemodynamic disturbances and peritonitis develop.
Intestinal Obstruction Symptoms
Regardless of the type and level of intestinal obstruction, there is a pronounced pain syndrome, vomiting, stool retention and non-discharge of gases.
Abdominal pains are cramping unbearable. During the contraction, which coincides with the peristaltic wave, the patient's face is distorted from pain, he moans, takes various forced positions (squatting, knee-elbow). At the height of the painful attack, symptoms of shock appear: pallor of the skin, cold sweat, hypotension, tachycardia. The subsiding of pain can be a very insidious sign, indicating intestinal necrosis and the death of nerve endings. After an imaginary lull, on the second day from the beginning of the development of intestinal obstruction, peritonitis inevitably occurs.
Another symptom characteristic of intestinal obstruction is vomiting. Especially profuse and repeated vomiting, which does not bring relief, develops with small bowel obstruction. At first, the vomit contains food residues, then bile, in the later period - intestinal contents (fecal vomit) with a putrid odor. With low intestinal obstruction, vomiting, as a rule, is repeated 1-2 times.
The typical symptom of low bowel obstruction is stool retention and gas discharge. A digital rectal examination reveals the absence of feces in the rectum, distension of the ampulla, and dehiscence of the sphincter. With a high obstruction of the small intestine, stool retention may not be; emptying of the underlying intestinal tract occurs independently or after an enema.
With intestinal obstruction, attention is paid to the bloating and asymmetry of the abdomen, peristalsis visible to the eye.
Diagnostics
With abdominal percussion in patients with intestinal obstruction, tympanitis with a metallic shade (Kivul's symptom) and dullness of the percussion sound are determined. Auscultation in the early phase reveals increased intestinal peristalsis, "splash noise"; in the late phase - weakening of peristalsis, the noise of a falling drop. With intestinal obstruction, a stretched intestinal loop is palpated (Valya's symptom); in the later stages - the rigidity of the anterior abdominal wall.
Rectal and vaginal examinations are of great diagnostic importance, with the help of which it is possible to reveal obstruction of the rectum, tumors of the small pelvis. The objectivity of the presence of intestinal obstruction is confirmed by instrumental studies.
Plain X-ray of the abdominal cavity reveals characteristic intestinal arches (gas-inflated intestine with fluid levels), Kloyber's bowls (dome-shaped enlightenment above the horizontal fluid level), and pinnation symptom (presence of transverse striation of the intestine). X-ray contrast study of the gastrointestinal tract is used in difficult diagnostic cases. Depending on the level of intestinal obstruction, an x-ray of the passage of barium through the intestine or an irrigoscopy may be used. Colonoscopy allows you to examine the distal parts of the large intestine, identify the cause of intestinal obstruction and, in some cases, resolve the phenomenon of acute intestinal obstruction.
Ultrasound of the abdominal cavity with intestinal obstruction is difficult due to pronounced pneumatization of the intestine, however, the study in some cases helps to detect tumors or inflammatory infiltrates. In the course of diagnosis, acute intestinal obstruction should be differentiated from intestinal paresis - drugs that stimulate intestinal motility (neostigmine); novocaine perirenal blockade is performed. In order to correct the water-electrolyte balance, intravenous administration of saline solutions is prescribed.
If, as a result of the measures taken, intestinal obstruction is not resolved, one should think about mechanical ileus, which requires urgent surgical intervention. The operation for intestinal obstruction is aimed at eliminating mechanical obstruction, resection of a non-viable section of the intestine, and preventing repeated obstruction.
In case of obstruction of the small intestine, resection of the small intestine can be performed with the imposition of enteroenteroanastomosis or enterocoloanastomosis; de-intussusception, unwinding of intestinal loops, dissection of adhesions, etc. In case of intestinal obstruction caused by a tumor of the colon, hemicolonectomy and temporary colostomy are applied. With inoperable colon tumors, a bypass is applied; with the development of peritonitis, transversostomy is performed.
In the postoperative period, the BCC is reimbursed, detoxification, antibacterial therapy, correction of protein and electrolyte balance, stimulation of intestinal motility.
Forecast and prevention
The prognosis for intestinal obstruction depends on the onset and completeness of the treatment. An unfavorable outcome occurs with late recognized intestinal obstruction, in debilitated and elderly patients, with inoperable tumors. With a pronounced adhesive process in the abdominal cavity, relapses of intestinal obstruction are possible.
Prevention of the development of intestinal obstruction includes timely screening and removal of intestinal tumors, prevention of adhesive disease, elimination of helminthic invasion, proper nutrition, avoidance of injuries, etc. If intestinal obstruction is suspected, an immediate visit to a doctor is necessary.
Babuk's symptom.
Babuka S. - a possible sign intestinal intussusception: if there is no blood in the washings after the enema, the abdomen is palpated for 5 minutes. With intussusception, often after repeated siphon enema, the water looks like meat slops.
Karevsky's syndrome.
Karevsky s. - observe with gallstone intestinal obstruction: sluggish current alternation of partial and complete obstructive intestinal obstruction.
Obukhov hospital, symptom of Hochenegg.
Obukhovskaya hospital with. - a sign of volvulus of the sigmoid colon: an enlarged and empty ampulla of the rectum during rectal examination.
Rush symptom.
Rusha s. - observed in case of intussusception of the large intestine: the occurrence of pain and tenesmus on palpation of a sausage tumor on the abdomen ..
Spasokukotsky's symptom.
Spasokukotsky s. - a possible sign of intestinal obstruction: the sound of a falling drop is determined by auscultation.
Sklyarov's symptom
Sklyarova S. - a sign of obstruction of the large intestine: a splash noise is determined in the stretched and swollen sigmoid colon.
Titov's symptom.
Titova S. - a sign of adhesive obstruction: the skin-subcutaneous fold along the line of the laparotomic postoperative scar is grasped with fingers, sharply raised up and then gradually lowered. Localization of pain indicates the place of adhesive intestinal obstruction. With a mild reaction, several sharp folds are produced.
Alapy symptom.
Alapi s. - Absence or slight tension of the abdominal wall with intussusception.
Anschotz symptom.
Anshuttsa s. - Bloating of the cecum with obstruction of the lower parts of the colon.
Symptom Vayer.
Bayer S. - asymmetry of bloating. Observed during volvulus of the sigmoid colon.
Bailey symptom.
Bailey S. - a sign of intestinal obstruction: the transmission of heart sounds to the abdominal wall. The value of the symptom increases when listening to heart sounds in the lower abdomen.
Bouveret symptom.
Bouvere S. - a possible sign of obstruction of the colon: protrusion in the ileocecal region (if the cecum is swollen, obstruction has arisen in the transverse colon, if the cecum is in a collapsed state, then the obstacle is in good shape).
Cruveillhier symptom.
Cruvelier with. - characteristic of intestinal intussusception: blood in the stool or blood-stained mucus in combination with cramping abdominal pain and tenesmus.
Dance symptom.
Dansa s. - a sign of ileocecal intussusception: due to the movement of the invaginated segment of the intestine, the right iliac fossa is empty on palpation.
Delbet symptom.
Delbet triad.
Delbe s. - Observed during volvulus of the small intestine: rapidly increasing effusion in the abdominal cavity, abdominal distension and non-tecaloid vomiting.
SymptomDurant.
Duran S. - observe at the beginning of intussusception: a sharp tension of the abdominal wall according to the site of introduction.
Frimann symptom - Dahl.
Freeman - Dalia S. - with intestinal obstruction: in the loops of the small intestine stretched with gas, the transverse striation is radiologically determined (corresponds to kerkring folds).
Gangolphe symptom.
Gangolf s. - observed with intestinal obstruction: dullness of sound in the sloping places of the abdomen, indicating the accumulation of free fluid.
Hintze symptom.
Gintze S. - X-ray sign indicates acute intestinal obstruction: the accumulation of gas in the large intestine is determined corresponds to Valya's symptom.
Hirschsprung symptom.
Girshsprunga s. - Observe with intussusception of the intestine: relaxation of the sphincters of the anus.
Hofer symptom.
Gefer s. - with intestinal obstruction, the pulsation of the aorta is best heard above the level of narrowing.
Kiwull symptom.
Kivulya s. - a sign of obstruction of the large intestine (with volvulus of the sigmoid and cecum): a metallic sonority is determined in the stretched and swollen sigmoid colon.
Kocher symptom.
Kochera S. - Observe with intestinal obstruction: pressure on the anterior abdominal wall and its rapid cessation does not cause pain.
Kloiber symptom.
Kloyber S. - X-ray sign of intestinal obstruction: with plain fluoroscopy of the abdominal cavity, horizontal fluid levels and gas bubbles above them are found.
Lehmann symptom.
Lehmann s. - X-ray sign of intestinal intussusception: a filling defect flowing around the invaginate head has a characteristic appearance: two lateral stripes of contrast agent between the receptive and invaginated intestinal casts.
Mathieu symptom.
Mathieu S. - a sign of complete intestinal obstruction: with rapid percussion of the supra-umbilical region, a splash noise is heard.
Payr symptom.
Payra S. - "double-barreled", caused by the bending of the mobile (due to excessive length) of the transverse colon at the place of transition to the descending colon with the formation of an acute angle and spurs, inhibiting the passage of intestinal contents. Clinical signs; abdominal pain that radiates to the heart and left lumbar region, burning and swelling in the left hypochondrium, shortness of breath, chest pain.
Schiman symptom.
Shimana S. - a sign of intestinal obstruction (volvulus of the caecum): on palpation, a sharp soreness in the right ileal region and a feeling of "emptiness" in the place of the cecum are determined
Schlange symptom (I).
Hose with. - a sign of intestinal paralysis: when listening to the abdomen, complete silence is noted; usually seen with ileus.
Schlange symptom (II).
Hose with. - visible intestinal peristalsis with intestinal obstruction.
Stierlin symptom.
Stirlina S. - X-ray sign of intestinal obstruction: a stretched and tense intestinal loop corresponds to a zone of accumulation of gases in the form of an arch
Taevaenar symptom.
Tevenara s. - a sign of small bowel obstruction: the abdomen is soft, palpation reveals soreness around the navel and especially below it by two fingers of the transverse fingers along the midline. The point of tenderness corresponds to the projection of the mesenteric root.
Tilijaks symptom.
Tiliaksa S. - Observe with nvagination of the intestine abdominal pain, vomiting, tenesmus and stool retention, non-discharge of gases.
Symptom Treves.
Trevsa S. - a sign of large bowel obstruction: at the time of introduction of fluid into the large intestine, rumbling at the site of obstruction is auscultated.
Watil symptom.
Valya S. - a sign of intestinal obstruction: local flatulence or protrusion of the intestine above the level of the obstacle (visible asymmetry of the abdomen, palpable intestinal bulge, visible peristalsis with the eye, tympanitis audible during percussion).
Causes of the disease
There are a number of factors in the development of acute intestinal obstruction (AIO):
1. Congenital:
Features of anatomy - lengthening of sections of the intestine (megacolon, dolichosigma);
Anomalies of development - incomplete bowel rotation, agangliosis (Hirschsprung's disease).
2. Purchased:
- unbalanced, irregular diet.
intestinal and abdominal neoplasms;
foreign bodies in the intestines, helminthiasis;
cholelithiasis;
hernia of the abdominal wall;
Risk factors: abdominal surgery, electrolyte imbalance, hypothyroidism, opiate use, acute illness.
Mechanisms of the onset and development of the disease (pathogenesis)
Classification of OKN
By morphofunctional characteristic
Dynamic obstruction:
spastic
paralytic
Mechanical obstruction:
strangulation (volvulus, nodulation, restrictions)
obstructive (interstitial and extraintestinal forms)
mixed (intussusception, adhesive obstruction)
By obstacle level
Small bowel obstruction:
Colonic obstruction
The clinical picture of the disease (symptoms and syndromes)
With the development of AIO, the following symptoms are encountered:
abdominal pain is a constant early sign of obstruction, usually occurs suddenly, at any time of the day, regardless of food intake (or after 1-2 hours), without precursors;
vomiting - after nausea or on its own, often repeated (the larger the obstacle in the digestive tract, the earlier it occurs and is more pronounced);
stool and gas retention - sometimes (at the onset of the disease) "residual" stool is observed;
thirst (more pronounced with high intestinal obstruction);
Valya's symptom - a clearly delimited stretched intestinal loop is determined through the abdominal wall;
visible intestinal peristalsis;
"Oblique" abdomen - gradual and asymmetric bloating;
Sklyarov's symptom - listening to the "splash noise" over the intestinal loops;
Spasokukotsky's symptom - "the noise of a falling drop";
Kivul's symptom - an intensified tympanic sound with a metallic tinge appears above the stretched bowel loop;
a symptom of Grekov or a symptom of the Obukhov hospital - balloon-like swelling of an empty ampoule of the rectum against the background of a gaping anus;
Mondor's symptom - increased intestinal motility with a tendency to decrease ("noise at first, silence at the end");
"Dead silence" - the absence of intestinal noises above the intestines;
symptom Hoses - the appearance of intestinal peristalsis on palpation of the abdomen.
The clinical course of AIO has three phases (O.S. Kochnev, 1984):
1. "Ileus cry" (stage of local manifestations) - acute violation of the intestinal passage, duration - 2-12 hours (up to 14). The main signs are abdominal pain and local symptoms.
2. Intoxication (intermediate, stage of apparent well-being) - violation of intramural intestinal hemocirculation, lasts 12-36 hours. During this period, the pain ceases to be cramping, becomes constant and less intense; the abdomen is swollen, often asymmetrical; intestinal motility weakens, sound phenomena are less pronounced, "the noise of a falling drop" is heard; complete retention of stool and gases; signs of dehydration appear.
3. Peritonitis (late, terminal stage) - occurs 36 hours after the onset of the disease. This period is characterized by severe functional disorders of hemodynamics; the stomach is significantly swollen, peristalsis is not heard; peritonitis develops.
Diagnostics of the form of intestinal obstruction
To select the optimal treatment tactics, differential diagnosis should be carried out between the forms of AIO.
Dynamic spastic obstruction. Anamnesis: trauma or diseases of the central nervous system, hysteria, lead intoxication, ascariasis. Clinically: spastic pains suddenly appear, but there is no intoxication and swelling, rarely - stool retention. X-ray can detect small Kloyber cups, which are displaced.
Dynamic paralytic obstruction occurs due to peritonitis as a result of any type of intestinal obstruction, as well as with some intoxications or operations in the abdominal cavity. Clinically: increasing intestinal paresis with the disappearance of peristalsis, symmetric bloating with high tympanitis, disappearance of pain, nausea and repeated vomiting, symptoms of intoxication (rapid pulse, shortness of breath, leukocytosis with a shift to the left, hypochloremia). X-ray: numerous small Kloyber bowls with indistinct contours, which do not change their position.
Volvulus and nodulation are provoked by adhesions, hypermotility, overeating of a hungry person. Features: sharp start and stroke; shock and intoxication develop so quickly that sometimes bloating is minimal; with volvulus of the caecum or sigmoid colon - always asymmetry and Wilms' symptom; turns are often repeated.
Obstructive obstruction is most often caused by a tumor in the left side of the colon. Obturation with fecal stones, roundworm ball and other foreign object is possible. Features: slow development, often asymmetric abdomen, frequent changes in the shape of feces to "ribbon-like" or "sheep", repeated loose stools with mucus and blood are possible.
Intussusceptions are often small intestine. Features: slow development, often asymmetric abdomen, possible mucus and blood in the feces, in the abdomen, tumor-like formations (invaginate) or a dull area against the background of high tympanitis can be palpated; the diagnosis can be confirmed by irrigoscopy - a lip-like photograph of the invaginate head is characteristic.
Mesenteric obstruction- violation of blood circulation in the lower or upper mesenteric vessels. It can be non-occlusive (spasm, decreased perfusion pressure), arterial (with atherosclerosis, hypertension, endarteritis, nodular periarthritis, atrial fibrillation, rheumatic heart disease) or venous (with cirrhosis, splenomegaly, leukemia, tumors). Arterial obstruction (twice as often, mainly in the basin of the superior mesenteric artery) has two stages: anemic (white), lasting up to 3 hours, and hemorrhagic (red). With venous sweating, sweating begins immediately.
Features of mesenteric obstruction:
With arterial in the anemic stage - in 1/3 of patients, the onset is subacute, the attack is relieved by nitroglycerin, as in angina pectoris; in 2/3 - the onset is acute, the pain is very strong;
At first, blood pressure often rises by 50-60 mm. rt. Art. (Boykov's symptom);
Tongue moist, belly soft;
Leukocytosis ≥ 15-20 x 10 9 with a low erythrocyte sedimentation rate;
Stool and gas retention in 25% of patients;
Vomiting and diarrhea mixed with blood - in 50% of patients;
In the stage of infarction, blood pressure decreases, the pulse is threadlike, the tongue is dry, the abdomen is somewhat swollen, but still soft, there is no peritoneal irritation, the edematous intestine is often palpable (Mondor's symptom);
The diagnosis can be confirmed by angiography or laparoscopy;
Mandatory ECG to rule out myocardial infarction.
Adhesive obstruction. Its frequency is up to 50%. The severity of the clinical course, as with intussusception, depends on the severity of strangulation. Diagnosis is the most difficult, since seizures are often repeated and can go away on their own (adhesive disease). In case of a history of abdominal surgery and a subacute course, it is necessary to start with the introduction of contrast and control of its passage after 1-2 hours.
Differential diagnosis
AIO has a number of features characteristic of other diseases, which necessitates differential diagnosis.
Acute appendicitis. Common signs of acute appendicitis are abdominal pain, stool retention, and vomiting. However, pain with appendicitis begins gradually and is not as intense as with obstruction. With appendicitis, it is localized, and with obstruction - cramping and intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction, not appendicitis. In acute appendicitis, there are no radiological signs inherent in obstruction.
Perforated ulcer of the stomach and duodenum. Common symptoms of ulcers are sudden onset, severe abdominal pain, and stool retention. However, with a perforated ulcer, the patient takes a forced position, and with intestinal obstruction, he is restless, often changes position. Vomiting is uncommon for a perforated ulcer, but is often seen with intestinal obstruction. With an ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, and with intestinal obstruction, the abdomen is swollen, soft, slightly painful. With a perforated ulcer, from the very beginning of the disease, peristalsis is absent, the "splash noise" is not heard. Radiographically, with a perforated ulcer, free gas in the abdominal cavity is determined, with intestinal obstruction - Kloyber's bowls, arcades.
Acute cholecystitis. Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the area of the right scapula. With intestinal obstruction, the pain is cramping, non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. In acute cholecystitis, there is no increased peristalsis, sound phenomena, and X-ray signs of obstruction.
Acute pancreatitis. Common signs of acute pancreatitis are sudden onset, severe pain, severe general condition, frequent vomiting, bloating, and stool retention. However, with pancreatitis, the pain is localized in the upper abdomen, encircling rather than cramping. Mayo-Robson's symptom is positive. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Diastasuria is characteristic of acute pancreatitis. Radiographically, with pancreatitis, there is a high standing of the left dome of the diaphragm, and with obstruction - the Kloyber bowl, arcade.
Intestinal infarction. With intestinal infarction, as well as with obstruction, severe sudden abdominal pain, vomiting, severe general condition, soft abdomen are observed. However, pain in intestinal infarction is constant, peristalsis is completely absent, abdominal distension is small, there is no abdominal asymmetry, and auscultation reveals “dead silence”. With mechanical intestinal obstruction, violent peristalsis prevails, a large range of sound phenomena is heard, abdominal distension is significant, often asymmetric. An intestinal infarction is characterized by the presence of an embologic disease, atrial fibrillation, and high leukocytosis (20-30 x 10 9 / l) is possible.
Renal colic. Renal colic and intestinal obstruction have similar symptoms, such as severe abdominal pain, bloating, stool and gas retention, and 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 Pasternatsky symptom. On a plain radiograph in the kidney or ureter, shadows of calculi may be observed.
Pneumonia. With pneumonia, abdominal pain and bloating may occur, indicating a bowel obstruction. However, pneumonia is characterized by high fever, cough, blush. On physical examination, crepitant rales, pleural friction noise, bronchial breathing, dullness of pulmonary sound can be detected, radiological - characteristic changes in the lungs.
Myocardial infarction. With myocardial infarction, there may be sharp pain in the upper abdomen, bloating, sometimes vomiting, weakness, decreased blood pressure (BP), tachycardia, that is, signs resembling strangulated intestinal obstruction. However, with myocardial infarction, abdominal asymmetry, increased peristalsis, symptoms of Valya, Sklyarov, Shiman, Spasokukotsky-Wilms are not observed, there are no radiological signs of intestinal obstruction. An ECG study helps to clarify the diagnosis of myocardial infarction.
Diagnosis of the disease
Examination scope for AIO
1. Mandatory: general urine analysis, general blood test, blood glucose, blood group and Rh affiliation, rectal examination (sphincter tone is reduced, ampoule is empty, fecal stones are possible as a cause of obstruction, mucus with blood during intussusception, tumor obstruction), ECG , X-ray of the abdominal organs vertically.
2. According to indications: total protein, bilirubin, urea, creatinine, ionic composition; ultrasound examination (ultrasound), chest x-ray, passage of barium through the intestines, sigmoidoscopy, irrigography, colonoscopy.
The phases of the course of AIO have a conditional character and for each form of obstruction - their own differences (with strangulated intestinal obstruction of the I and II phases begin almost simultaneously).
Diagnostics
X-ray examination is the main special method for diagnosing AIO, with the help of which the following signs can be identified:
1. Kloyber's bowl is a horizontal liquid level with a dome-shaped enlightenment above it, which looks like an inverted bowl. With strangulated obstruction, it can appear within an hour, with obstructive obstruction - after 3-5 hours from the moment of the disease. The number of bowls varies, sometimes they can be layered one on top of the other in the form of a ladder. Fluid levels (small and large intestine) localized in the left hypochondrium indicate high obstruction. At small intestinal levels, the vertical dimensions prevail over the horizontal ones, the existing semilunar folds of the mucous membrane; in the large intestine, horizontal dimensions prevail over vertical ones, and haustration is determined.
2. Intestinal arcades appear when the small intestine is swollen with gases, while there are horizontal fluid levels in the lower knees of the arcades.
3. The symptom of pennation occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular folds of the mucous membrane.
A contrast study is carried out in doubtful cases, with a subacute course. A delay in the passage of barium in the cecum for more than 6 hours against the background of drugs stimulating peristalsis indicates obstruction (normally - after 4-6 hours without stimulation).
The indications for conducting studies with the use of contrast with intestinal obstruction are:
1. Confirmation of intestinal obstruction.
2. Suspicion of intestinal obstruction for the purpose of differential diagnosis and complex treatment.
3. AIO in patients who have been repeatedly operated on.
4. Any form of small bowel obstruction (except for strangulation), when, as a result of active conservative measures in the early stages of the disease, it is possible to achieve an obvious improvement.
5. Diagnosis of early postoperative obstruction in patients who underwent gastric resection. The absence of pyloric pulp causes the unhindered supply of contrast to the small intestine. In this case, the detection of the "stop-contrast" phenomenon in the branch loop indicates the need for early relaparotomy.
6. X-ray contrast study for the diagnosis of AIO, which is used only in the absence of a strangulated form of obstruction, which can lead to a rapid loss of viability of the strangulated bowel loop (based on clinical data and the results of plain radiography of the abdominal cavity).
7. Dynamic observation of the movement of the contrast mass in combination with clinical observation, during which changes in local physical data and the general condition of the patient are recorded. With an increase in the frequency of local manifestations of obstruction or the appearance of signs of endotoxicosis, it is necessary to carry out urgent surgical intervention, regardless of the radiological data characterizing the passage of the contrast through the intestine.
An effective method for diagnosing colonic obstruction is irrigoscopy. Colonoscopy is undesirable because it can lead to the entry of air into the drive loop and contribute to the development of its perforation.
Ultrasound signs of intestinal obstruction:
Expansion of the intestinal lumen> 2 cm with the phenomenon of "fluid sequestration";
Thickening of the wall of the small intestine> 4 mm;
The presence of a reciprocating movement of the chyme along the intestine;
Increase in the height of the mucosal folds> 5 mm;
Increase in distance between folds> 5 mm;
Hyperpneumatization of the intestine in the drive part with dynamic intestinal obstruction - the absence of reciprocating movement of the chyme along the intestine; the phenomenon of sequestration of fluid into the intestinal lumen;
Indistinct relief of mucosal folds;
Intestinal hyperpneumatization in all departments.
5. Vit Stetten's symptom- Bloating of the left lower quadrant of the abdomen with perforation of the duodenum.
SYMPTOMS: DETECTED IN PERCUSSION OF THE PATIENT'S ABDOMINAL:
1. Symptom of the Speejar-Clark- high tympanitis with percussion between the xiphoid process and the navel. Disappearance of hepatic dullness.
SYMPTOMS DETECTED DURING AUSCULTATION IN THE ABDOMINAL OF THE PATIENT:
1. Symptom, Brown- crepitus, heard when pressing the phonendoscope on the right side wall of the abdomen.
2. Brenner's symptom- metallic friction noise heard above the XII rib on the left in the sitting position of the patient. Associated with the release of air bubbles into the subphrenic space through the perforation.
3. Brunner's symptom- the noise of friction of the diaphragm, heard under the costal edge (left and right) due to the presence of gastric contents between the diaphragm and the stomach.
4. Gusten's triad- clear listening to heart sounds through the abdominal cavity to the level of the navel, friction noise in the hypochondria and epigastrium, and metallic or silvery noise appears when inhaling and is associated with the release of free gas into the abdominal cavity through the perforation.
Gusten's triad includes the previously described symptoms of Lotey-sen-Bailey-Federechi-Kleybrook-Gusten, Brenner, Brunner.
INTESTINAL OBSTRUCTION
SYMPTOMS DETECTED IN COMPLAINTS OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Symptom Cruvelier - blood in the stool, cramping abdominal pain and tenesmus. It is characteristic of intussusception.
2. Tiliax symptom- pain, vomiting, delay in passing gas. It is characteristic of intussusception.
3. Carnot's symptom- pain in< эпигастрии, возникающая при резком разгибании туловища. Характерно для спаечной болезни.
4. Koenig's symptom- reduction of pain after rumbling above and to the left of the navel. Typical for chronic duodenostasis.
SYMPTOMS DETECTED DURING THE GENERAL EXAMINATION OF THE PATIENT WITH INTESTINAL OBSTRUCTION:
1. Valya's symptom- a stretched intestinal loop, contouring through the anterior abdominal wall.
2. Schlange-Grekov symptom- intestinal peristalsis visible through the abdominal wall.
3. Bayer's symptom- asymmetric bloating.
4. Symptom Bouvray-Anschutz - protrusion in the ileocecal region with obstruction of the colon.
5. Borchardt's triad- bloating in the epigastric region and left hypochondrium, inability to probe the stomach and vomiting, which does not bring relief. Observed during gastric torsion.
6. Delbe Triad- rapidly growing effusion in the abdominal cavity, bloating, vomiting. Observed with volvulus of the small intestine.
7. Karevsky's symptom- sluggish flowing intermittent intestinal obstruction. It is observed with intestinal obstruction caused by gallstones.
SYMPTOMS DETECTED IN PALPATION OF THE ABDOMINAL OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Leott's symptom- the appearance of pain when pulling and shifting towards the skin fold of the abdomen. It is noted with adhesive disease.
2. Kocher's symptom- pressure on the anterior abdominal wall and its rapid termination does not cause pain.
3. Symptom of Shiman-Dance - on palpation in the area of the cecum, it is as if emptiness is determined. Observed with volvulus of the cecum.
4. Schwartz's symptom - in the epigastrium, a painful elastic tumor is palpable with simultaneous distension of the abdomen. It is observed with acute expansion of the stomach.
5. Symptom Tsulukidze- on palpation of the colon invaginate, a depression with folded edges is found, around which small tumor-like formations - fatty suspensions - are palpated.
SYMPTOMS DETECTED IN ABDOMINAL PERCUSSION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Kivul's symptom- with abdominal percussion and simultaneous auscultation, a sound with a metallic tinge is heard.
2. Wortmann's symptom- a sound with a metallic tinge is heard only over the swollen colon, and over the small one - the usual tympanitis.
3. Symptom Mathieu- a splash noise heard in the epigastrium with rapid percussion above the navel.
SYMPTOMS DETECTED DURING AUSCULTATION OF THE ABDOMINAL IN A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Symptom Sklyarov- splash noise in the abdominal cavity.
2. Symptom Spasokukotsky- - the noise of the "falling drop".
3. Gefer's symptom- Respiratory murmurs and heart sounds are best heard over the site of constriction. Observed in later stages.
SYMPTOMS DETECTED IN FINGER RECTAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Grekov's symptom-Hohenega- an empty ampoule-shaped rectum, the front wall of which protrudes the loops of the intestines. The anus gapes. Synonym - "symptom of the Obukhov hospital."
2. Symptom Trevs - in the moment the fluid is introduced into the rectum, a rumbling is heard at the place of obstruction.
3. Symptom Tsege von Manteuffel- with obstruction of the sigmoid colon, only 200 ml of water can be injected into the rectum. The patient does not hold large doses of water.
SYMPTOMS USED FOR DIFFERENTIAL
DIAGNOSTICS OF INTESTINAL OBSTRUCTION: 1
1. Symptom of Kodian- for differential diagnosis of pneumoperitoneum and intestinal paresis. With pneumoperitoneum, hepatic dullness disappears, the percussion sound is uniform everywhere, and with intestinal paresis, hepatic dullness does not completely disappear, the tympanic sound retains its shades.
2. Symptom Babuk- differential diagnosis between tumor and invaginate. The absence of blood in the washing water after the enema and kneading of the pathological formation indicates the presence of a tumor.
1. Vicker M. M. Diagnostics and medical tactics for acute abdominal diseases ("acute abdomen"). North Caucasian Regional Publishing House. Pyatigorsk, 1936, 158 pages.
2. Lazovskie I.R. Handbook of clinical symptoms and syndromes. M. Medicine. 1981, pp. 5-102.
3. Lejar F. Emergency surgery. Ed. N.N.Burdenko, vol. 1-2. 1936.
b4. Matyashin I.M. Symptoms and syndromes in surgery. Kiev.
|Olshanetsky A.A. Health, 1982, 184 p.
v Gluzman A.M.
5. Mondor G. Emergency diagnostics. Belly, v. 1-2, M-L. Medgiz, 1939.
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