Intestinal failure

Functional intestinal failure - enterargy - is, according to Yu. M. Galperin (1975), a manifestation of a combined disorder of the motor, secretory, digestive and absorptive functions of the small intestine, which leads to its exclusion from metabolic processes and creates the preconditions for irreversible disorders of homeostasis.

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Causes intestinal failure

In recent years, the role of the intestine as a biological barrier not only for intestinal bacteria, but also for digestive metabolites that can penetrate into the blood during intestinal failure (their importance in the pool of toxic substances flooding the body during critical conditions is undeniable) has been increasingly confirmed.

The presence of intestinal failure in children has the most unfavorable effect on the further course of the disease. Therefore, if it is confirmed clinically and laboratory, urgent and most active detoxification measures are necessary, including drug and electrical stimulation of the intestine, as well as extracorporeal detoxification (plasmapheresis, hemosorption, etc.), which help restore the sensitivity of intestinal receptors to the action of endogenous mediators (acetylcholine, histamine, serotonin), other stimulating factors and restore its active peristalsis.

Intestinal failure develops in many diseases that occur in a severe form with high toxemia. Most often, it occurs in diseases directly related to damage to the intestines, abdominal cavity (with acute intestinal infection in young children, peritonitis), as well as in toxic forms of pneumonia, leptospirosis, typhoid fever, sepsis, etc.

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Symptoms intestinal failure

In children with intestinal failure, there is intestinal motor dysfunction (usually in the form of intestinal paresis or paralysis), changes in the nature of stool with signs of impaired digestion. Acute intestinal failure is characterized by the appearance of flatulence in children, a decrease in the frequency of stool or its delay, increased vomiting, the disappearance of peristaltic noises in the abdomen and an increase in symptoms of toxemia. The latter is due to the fact that through the paretically altered intestinal wall, there is a massive entry into the systemic bloodstream (bypassing the liver) of microbial metabolism products and incomplete digestion. Shunting of the liver blood flow and a decrease in the detoxifying function of the liver in combination with acute renal failure lead to the occurrence of a toxic shock in the body, aimed primarily at the central nervous system as a result of the centralization of blood flow.

Confirmation of intestinal failure is provided by electroenteromyogram (EEMG) data, as well as high concentrations of ammonia, phenol, and indican in the blood.

To measure EEMG, you can use the domestic device "EGS-4M" with a frequency band from 0.02 to 0.2 Hz, which allows you to record the electrical activity of the small intestine only. The electrodes are placed on the skin, which makes the procedure absolutely atraumatic and painless for a child of any age. Usually, 3 main indicators are determined: the average number of potential oscillations (P) per unit of time (the number of waves in 1 min), the average amplitude of oscillations (M) in millivolts, and the total energy coefficient (K), calculated using the formula of N. N. Lapaev (1969): K, uel. units = P x M.

In children with toxicosis, the intestinal motor activity changes, which is clearly visible on the EEMG: the amplitude of peristaltic waves decreases, their number per unit of time decreases sharply. With stage III PC, the EEMG shows an almost straight line.

The term "intestinal paresis" is a narrower concept than enterargy or acute functional intestinal failure. It mainly denotes a disturbance of intestinal motor activity.

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Stages

Clinically, intestinal paresis is manifested by an increase in the abdomen due to the cessation of peristalsis, accumulation of gases (flatulence) and fluid in the intestinal lumen. There are 4 degrees of intestinal insufficiency.

1. Moderate flatulence is characteristic of stage I (the anterior abdominal wall is above the conditional line connecting the pubic symphysis and the xiphoid process of the sternum; tympanitis is detected by percussion). Peristaltic noises are clearly audible. Radiologically, uniform gas filling in the small and large intestines is determined with the diaphragm preserved in its usual place.
2. In case of intestinal failure of the second degree, the anterior abdominal wall bulges significantly, palpation of abdominal organs is difficult. Peristalsis is determined unevenly, noises are muffled.
3. Stage III intestinal insufficiency is manifested by significant tension and pastosity of the anterior abdominal wall, bulging or flattening of the navel; hydrocele is possible in boys. Independent stool stops. Peristalsis is heard very rarely, muffled. X-ray examination shows multiple Kloiber cups, the diaphragm is significantly raised upwards.
4. Stage IV intestinal insufficiency is characterized by a purple-blue coloration of the anterior abdominal wall and external genitalia, complete auscultatory muteness (Obukhov hospital symptom), and extremely pronounced general symptoms of intoxication. This degree of intestinal paresis is observed in the terminal stage of the disease.

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Treatment intestinal failure

Decompression of the gastrointestinal tract (lavage and drainage of the stomach, insertion of a gas outlet tube) is carried out for a long time, sometimes for 24-48 hours until the passage of food in the gastrointestinal tract is restored. It is better to insert a gastric tube through the nose. The stomach is washed with Ringer's solution or another saline solution, or 1-2% sodium bicarbonate solution. The tube is left open and lowered down (below the child's back) to create effective drainage of the stomach contents. The gas outlet tube is inserted into the child's sigmoid colon, i.e. to a depth of at least 10-12 cm. Only in this case can we count on significant effectiveness of this method. After inserting the gas outlet tube, it is advisable to massage the anterior abdominal wall of the child with the palm of the hand, making smooth, gentle, stroking movements along the colon (clockwise).

Detoxification is ensured by IT in the volume of FP or in the rehydration mode with combined exicosis, adding volumes of DVO with mandatory provision of adequate diuresis to the administered volume. Daily administration of albumin and FFP to children (10 ml/kg per day) is indicated, especially in the presence of "coffee grounds" vomiting and grade III intestinal failure. In the case of persistent grade III PI, IT must be combined with hemosorption or plasmapheresis.

Hemosorption as a method of emergency detoxification is preferable in a critical situation (with a lack of time) and with relatively intact hemodynamics in a child. The undoubted advantage of the method is the rapid achievement of a detoxification effect - in 1 hour. L. I. Zavartseva (1997), who has experience in treating about 100 children with PC using hemosorption, believes that if the volume of the external circuit of the device corresponds to the blood volume of infants, this method of detoxification is very effective. Before the procedure, it is better to fill the circuit of the device with albumin or FFP, selected in accordance with the blood group. G. F. Uchaikin et al. (1999) showed that plasmapheresis is also a fairly effective and reliable method of extracorporeal detoxification in children with severe toxicosis and intestinal insufficiency.

Restoration of electrolyte balance is the most important component of intestinal failure treatment. This is especially true for active potassium therapy, which is carried out using intravenous drip infusion of potassium chloride at a daily dose of 3-5 mmol/kg or more in the presence of diuresis and under control of its indicators in the blood. The drug is administered in a glucose solution; its final concentration should not exceed 1%. Children with grade III intestinal failure almost always have severe hyponatremia, and therefore it is necessary to administer balanced salt solutions. L. A. Gulman et al. (1988) recommend that when the sodium level in the blood of children with intestinal failure decreases to < 120 mmol/l, it should be administered for replacement purposes (5-7 ml of a 5% sodium chloride solution) intravenously by slow jet stream in order to increase the sensitivity of intestinal receptors to the action of mediators and restore gastrointestinal peristalsis.

Stimulation of peristalsis (ubretide, proserin, pituitrin, kalimin, aceclidine, etc.) is carried out in age-related doses or by pulse therapy, necessarily against the background of active potassium therapy (with a normal concentration of this cation in the blood). Only in this case is it sufficiently effective.

Electrical stimulation of the intestines for intestinal failure in children is performed using the Amplipulse and Endoton devices. The electrodes are placed on the skin and modulated currents with a strength of 15-50 mA and a frequency of 5 Hz are used; the duration of exposure is 15-20 minutes or more. The procedure is repeated daily. During the procedure, children usually calm down and fall asleep. The effectiveness of the method increases against the background of active detoxification and potassium therapy.

The use of oxygen therapy in the treatment of children with intestinal failure helps restore metabolic processes in tissues, as well as the sensitivity of cell membranes to the action of mediators and, undoubtedly, has an indirect effect on the peristaltic activity of the intestine. In severe intestinal paresis, there is inhibition of the ventilation function of the lungs, including due to the upward displacement of the diaphragm, which significantly complicates the excursion of the chest (restrictive type of respiratory failure). In this case, the implementation of artificial ventilation allows you to gain time to perform the entire complex of therapy and significantly affect the elimination of intestinal hypoxia, as well as the outcome of the disease as a whole.

Normalization and maintenance of the blood circulation system both in the central link (dopamine at a dose of 3-5 mcg/kg per minute, agents that support the BCC - albumin, plasma, red blood cell mass) and in the periphery (rheopolyglucin, trental, etc.) are also an essential component of the enterargy therapy algorithm.

The above treatment complex should be applied in accordance with the severity of intestinal paresis. The criteria for the effectiveness of treatment of such a condition as intestinal insufficiency are a decrease in vomiting and flatulence, activation of peristalsis, passage of gases, and resumption of stopped acts of defecation.