Intestinal insufficiency

Functional intestinal insufficiency - enteralgia is, according to Yu. M. Galperin (1975), the manifestation of a combined disturbance of the motor, secretory, digestive and absorbing functions of the small intestine, which leads to its exclusion from metabolic processes and creates prerequisites for irreversible homeostatic disorders.

[1], [2], [3], [4],

Causes of the intestinal insufficiency

In recent years, the role of the intestine as a biological barrier not only for intestinal bacteria, but also for metabolites of digestion, capable of penetrating into the blood with intestinal insufficiency (their significance in the pool of toxic substances flooding the body under critical conditions, is undoubtedly confirmed).

The presence of intestinal insufficiency in children most unfavorably affects the further course of the disease. Therefore, with its clinical and laboratory confirmation, urgent and most active detoxification activities are necessary, including drug and electrical stimulation of the intestine, as well as extracorporeal detoxification (plasmapheresis, hemosorption, etc.) that help restore the sensitivity of the intestinal receptors to the action of endogenous mediators (acetylcholine, histamine, serotonin ), other stimulating factors and restore its active peristalsis.

Intestinal insufficiency develops in many diseases that occur in severe form with high toxemia. Most often, it occurs in diseases directly related to intestinal damage, abdominal cavity (with OCD in children of early age, peritonitis), as well as toxic forms of pneumonia, leptospirosis, typhoid fever, sepsis, etc.

[5], [6], [7], [8], [9]

Symptoms of the intestinal insufficiency

With intestinal failure in children, motor dysfunction of the intestine (more often in the form of paresis of the intestine or paralysis), a change in the character of the stool with signs of impaired digestion. Acute intestinal failure is characterized by the appearance of flatulence in children, a decrease in stool frequency 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 parietally altered wall of the intestine a massive intake of products of microbial metabolism and incomplete digestion takes place in the systemic bloodstream (bypassing the liver). Bypassing the hepatic blood flow and reducing the detoxifying function of the liver in combination with OPN leads to the appearance 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 insufficiency is given by data of electroencephalogram (EEMG), as well as a high concentration of ammonia, phenol, indica in the blood.

For the measurement of EEMG, the domestic EGS-4M apparatus with a bandwidth of frequencies from 0.02 to 0.2 Hz can be used, which allows recording the electrical activity of only the small intestine. Electrodes are placed on the skin, which makes the procedure absolutely atraumatic and painless for a child of any age. Usually, three main indicators are determined: the average number of oscillations of the potential (II) per unit time (number of waves per minute), the average amplitude of the oscillations (M) in millivolts, and the total energy coefficient (K), calculated from the formula of NN Lapaev 1969): To, uel. Units = П x M.

In children with toxicosis, the motor activity of the intestine changes, which is clearly seen in the EEMH: the amplitude of the peristalsis waves decreases, their number decreases sharply per unit time. With a PC of grade III, a straight line is obtained on the EEMG. 

The term "paresis of the intestine" is a narrower concept than the enteralgia or acute functional intestinal insufficiency. It is mainly a violation of motor activity of the intestine.

[10]

Stages

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

1. Class I is characterized by moderate flatulence (the anterior abdominal wall is above the conditioned line connecting the pubic articulation and the xiphoid process of the sternum, percutaneously determined tympanitis). Peristaltic sounds are audible clearly. Radiographically determined uniform gas filling in the small and large intestines with preservation of the diaphragm in the usual place.
2. With intestinal insufficiency of II degree, the anterior abdominal wall swells considerably, palpation of abdominal cavity organs is difficult. The peristalsis is unevenly defined, the noise is muffled.
3. Intestinal insufficiency of the III degree is manifested by considerable stress and pastowness of the anterior abdominal wall, bulging or flattening of the umbilicus; it is possible to drop the testicles in boys. Self-standing chair stops. Peristalsis is listened very rarely, deafly. X-ray examination shows multiple Kloyber bowls, the diaphragm is essentially raised.
4. For intestinal insufficiency of the IV degree, the crimson-cyanotic color of the anterior abdominal wall and external genital organs, complete auscultation dumbness (a symptom of the Obukhov hospital), the general symptoms of intoxication are extremely pronounced. This degree of intestinal paresis is observed in the terminal stage of the disease.

[11], [12], [13], [14], [15], [16]

Treatment of the intestinal insufficiency

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

Detoxification is provided by carrying out IT in the volume of OP or in the rehydration regime with combined exsicosis, adding volumes of DVO with mandatory provision of adequate volume of diuresis. Children are given daily albumin and FFP (10 ml / kg per day), especially in the presence of vomiting "coffee grounds" and intestinal insufficiency III degree. In the case of a resistant PC of the third degree, IT must necessarily be combined with hemosorption or plasmapheresis.

Hemosorption as a method of emergency detoxification is preferable in a critical situation (with a shortage of time) and with relatively safe hemodynamics in the child. The undoubted advantage of the method is the rapid achievement of the detoxification effect - for 1 hour LI Zavartseva (1997), who has experience in the treatment of about 100 children with PC with hemosorption, believes that when the volume of the external circuit of the device matches the blood volume of infants, this the method of detoxification is very effective. Before the procedure, the device circuit should be filled with albumin or FFP selected in accordance with the group membership of the blood. G. F. Uchaykin et al. (1999) have shown that plasmapheresis is also an effective and reliable method of extracorporeal detoxification in children with severe toxicosis and intestinal insufficiency.

Recovery of electrolyte balance is an important component of the treatment of intestinal failure. This is especially true for active potassium therapy, which is carried out by intravenous drip of potassium chloride in a daily dose of 3-5 mmol / kg and more with diuresis and under the control of its indices in the blood. The drug is administered in a solution of glucose; its final concentration should not exceed 1%. In children with grade III intestinal insufficiency, there is almost always a pronounced hyponatremia, in connection with which it is necessary to introduce balanced saline solutions. L. A. Gulman et al. (1988) is recommended to be injected with a substitute aim (5-7 ml of 5% sodium chloride solution) intravenously slowly in order to increase the sensitivity of the intestinal receptors to the action of mediators and restore peristalsis in the blood of children with intestinal insufficiency of the sodium level <120 mmol / l. GIT.

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

Electrostimulation of the intestine with intestinal insufficiency in children is carried out with the help of Apparatus Amplipulse and Endoton. The skin location of the electrodes and modulated currents of 15-50 mA with a frequency of 5 Hz are used; duration of exposure is 15-20 minutes or more. The procedure is repeated daily. During the procedure, children tend to calm down, fall asleep. The effectiveness of the method increases with the background of active detoxification and potassium therapy.

The use of oxygen therapy in the complex treatment of children with intestinal insufficiency contributes to the restoration of metabolic processes in tissues, as well as the sensitivity of cell membranes to the action of mediators and undoubtedly has an indirect effect on peristaltic activity of the intestine. With severe paresis of the intestine, there is an inhibition of the ventilation function of the lungs, including due to the displacement of the diaphragm upwards, which makes it difficult to tour the chest (restrictive type of respiratory failure). In this case, ventilation allows you to gain time to complete the entire therapy package 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 at the central level (dopamine at a dose of 3-5 mcg / kg per minute, the means supporting bcc, albumin, plasma, erythrocyte mass) and at the periphery (rheopolyglucin, trental, etc.) are also an essential component of the algorithm of therapy of enteralgia.

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