Intestinal obstruction

Intestinal obstruction is a serious pathology, consisting in the complete violation of the passage of the contents through the intestine. Symptoms of intestinal obstruction include spasmodic pains, vomiting, bloating, and gas retention. The diagnosis is clinical, confirmed by radiography of the abdominal organs. Treatment of intestinal obstruction consists in intensive infusion therapy, nasogastric aspiration and in most cases complete obturation, surgical intervention.

[1], [2], [3], [4], [5], [6]

Causes of the intestinal obstruction

Localization	Causes
Colon	Tumors (usually in the splenic corner or sigmoid colon), diverticulosis (usually in the sigmoid colon), sigmoid or caecal curvature, coprostasis, Hirschsprung disease
Duodenum
Adults	Cancer of the duodenum or pancreatic head
Newborns	Atresia, curvature, cords, annular pancreas
The jejunum and ileum
Adults	Hernias, spikes (often), tumors, foreign body, Meckel's diverticulum, Crohn's disease (rare), invasion of ascarids, inversion of the intestine, invagination in the tumor (rarely)
Newborns	Meconium obstruction, curvature or malrotation of the intestine, atresia, intussusception

[7], [8], [9], [10]

Pathogenesis

In general, the main causes of mechanical obturation are the adhesive process of the abdominal cavity, hernia and tumor. Other reasons include diverticulitis, foreign bodies (including gallstones), vomiting (turning the gut around the mesentery), intussusception (insertion of one gut into another), and coprostasis. Certain areas of the intestine are affected differentially.

According to the mechanism of origin, intestinal obstruction is divided into two types: dynamic (spastic and paralytic) and mechanical (obturation - in case of obstruction of the lumen of the intestine with a tumor, calves or gallstones and strangulation, compression of the vessels, nerve of the mesentery of the intestine due to infringement, curvature, nodulation). With adhesive disease and intussusception, there is an intestinal obstruction of a mixed type, since both obturation and strangulation occur with them. By degree - to the full and partial.

With simple mechanical obstruction, obturation occurs without a vascular component. Entering the intestinal fluid and food, digestive secrets and gas accumulate above the obturation. The proximal segment of the intestine widens, and the distal part collapses. Secretory and absorption functions of the mucous membrane are reduced, and the intestinal wall becomes edematous and stagnant. Significant stretching of the intestine is constantly progressing, increasing disturbances of peristalsis and secretion and increasing the risk of dehydration and development of strangulation obstruction.

Strangulation intestinal obstruction is obstruction with circulatory failure; this is observed in almost 25% of patients with small intestinal obstruction. This is usually associated with hernias, sprains and invaginations. Strangulation intestinal obstruction can progress to the development of a heart attack and gangrene in less than 6 hours. Initially, there is a violation of venous blood flow, followed by a violation of the arterial blood flow, leading to rapid ischemia of the intestinal wall. The ischemic bowel becomes swollen and gummy, leading to gangrene and perforation. In colonic obstruction, strangulation occurs rarely (except for a curvature).

Perforation can occur in the ischemic area of the intestine (typical of the small intestine) or with significant enlargement. The risk of perforation is very high if the cecum is dilated in diameter> 13 cm. On the site of obturation, perforation of the tumor or diverticulum can occur.

[11], [12], [13], [14], [15], [16], [17], [18], [19], [20]

Symptoms of the intestinal obstruction

Symptoms are polymorphic, they depend on the type and height of the bowel (the higher, the brighter the picture and the more rapid the change of stages), the stage of the disease.

The main symptom is pain: contractions, fairly sharp, constantly increasing, first in the zone of intestinal obstruction, but may not have permanent localization, then throughout the abdomen, it becomes constant and dull, practically disappears in the terminal phase.

Flatulence (swelling of the abdomen) is more pronounced in obturation form, although it occurs in all species; it determines the asymmetry of the abdomen when viewed: in the dynamic form of the large intestine, a uniform blister throughout the abdomen, the small intestine - more often in one abdominal region the upper floor, with a twist - in the middle part, with invagination - in the right half). Stool and gas retention at the onset of the disease may not appear, especially with high intestinal obstruction, as the stool and gases leave the distal parts of the intestine, sometimes even alone or when performing enemas. Conversely, vomiting is more characteristic of high intestinal obstruction, it appears faster and more intense. Vomit initially in gastric contents with an admixture of bile, then the contents appear, and finally, the vomit gets a feces smell. The appearance of continuous vomiting, which does not bring relief, is more typical for obturation and adhesive form.

Peristalsis depends on the form and stage. In obturation and mixed forms, hyperperistalsis is first observed, sometimes audible at a distance and visible to the eye, accompanied by increased pain. When the process is localized in the small intestine, it arises early, simultaneously with pain, frequent, short, in the thick - the peristalsis becomes strengthened later, sometimes on the second day, the seizures are rare, long or wave-like. Especially clearly peristalsis is determined with auscultation of the abdomen. Gradually the peristalsis subsides and with the onset of intoxication comes to naught and is not determined even with auscultation. An indication of the transition of the neuro-reflex stage into intoxication is the appearance of dryness of the tongue, sometimes with a "lacquer" bright red shade due to dehydration and chloropenia.

Symptoms of intestinal obstruction appear shortly after the onset of the disease: spastic pains appear in the navel or epigastric region, vomiting and, in case of complete obstruction, bloating. Patients with partial obstruction may experience diarrhea. Strong, constant pain presupposes the development of a strangulation syndrome. In the absence of strangulation pain syndrome is not expressed in palpation. Characteristic hyperactive, high-frequency peristalsis with periods that coincide with spastic attacks. Sometimes enlarged intestinal loops are palpable. With the development of a heart attack, the abdomen becomes painful and, when auscultated, peristaltic noises are not listened or they are sharply weakened. The development of shock and oliguria is an unfavorable symptom indicative of neglected obstructive obstruction or strangulation.

The signs of intestinal obstruction of the colon are less pronounced and develop gradually in comparison with intestinal obstruction. Typical gradual stool retention, leading to its full delay and bloating. There may be vomiting, but it is not typical (usually several hours after the onset of other symptoms). Spastic pains in the abdomen are reflex and are caused by accumulation of fecal masses. During a physical examination, a characteristic swollen abdomen with loud rumbling is determined. Morbidity is absent when palpation, and the rectum is usually empty. You can palpate the volumetric education in the abdomen, which corresponds to the tumor obturation zone. The general symptoms are moderately expressed, and the deficiency of fluid and electrolytes is insignificant.

The twist often has a sharp beginning. The pain is continuous, sometimes as a type of colic wavy.

[21], [22], [23], [24], [25], [26], [27]

Stages

In the dynamics, three stages are distinguished: the neuro-reflex, manifested by the syndrome of the "acute abdomen"; intoxication, accompanied by a violation of water-electrolyte, acid-base states, chloropenia, a violation of microcirculation due to thickening of the blood to a greater extent in the portal blood flow system; peritonitis.

[28], [29], [30], [31], [32], [33], [34]

Forms

Obturation intestinal obstruction is divided into a small intestine obturation (including the duodenum) and colonic obturation. Obturation can be partial or complete. Approximately 85% of cases of partial intestinal obstruction are resolved by conservative measures, while approximately 85% of cases of complete enteric obstruction require surgery.

According to the clinical course, acute, subacute and chronic forms differ.

[35], [36], [37], [38], [39], [40]

Diagnostics of the intestinal obstruction

Mandatory radiography in the patient's position on the back and in the vertical position usually allows diagnosing an obturation. However, only with laparotomy can finally diagnose strangulation; a complete consistent clinical and laboratory examination (eg, a general blood test and biochemical analysis, including lactate levels) provides timely diagnostics.

In the diagnosis, a big role is played by specific symptoms.

• The Mathieu-Sklyarov symptom is palpable, with a slight concussion of the abdominal wall, noise is detected, the splash of fluid accumulated in the stretched bowel loop is characteristic of obturation intestinal obstruction.
• Symptom Shimana-Dansa - is typical for ileocecal intussusception - with palpation, the right iliac fossa becomes empty.
• Chugaev's symptom - when sitting on the back with legs tucked up on the abdomen, a deep transverse band is revealed on the abdomen - typical of the strangulation form.
• Symptom Schlange - with palpation of the abdomen marked a sharp increase in peristalsis in the initial stage of obturation and mixed forms.
• With auscultation of the abdomen with simultaneous percussion, you can identify the symptoms: Kivul (metallic sound), Spasokukotsky (the noise of a falling drop), Vilasa (the sound of a bursting bubble).

In the study of the rectum, and this is necessary in all cases of abdominal pathology, it is possible to identify a tumor, the presence of fluid in the small pelvis, a symptom of the Obukhov hospital (the ampoule of the rectum is dilated, the anus is gaping - typical for obturation or strangulation), the Gold symptom (palpable definition bloated loops of the small intestine). When carrying out enemas it is possible to identify the symptom of Tsege-Manteuffel - in the intestinal obstruction of the sigmoid colon, more than 500 ml of water can not be injected directly into the line; a symptom of the Babuk - is typical for invagination - with the primary enema of blood in the washing waters there, after five-minute palpation of the abdomen with a repeated siphon enema, the washings have the form of "meat slops".

If intestinal obstruction is suspected, it is necessary to check the condition of all hernial gates to prevent infringement. The second mandatory study, even before the enema, is a survey of the abdominal cavity. Pathognomonic for intestinal obstruction are: Clauber's bowls, arches, transverse striation of the swollen gases of the small intestine (it appears better in the supine position in the form of Casey's symptom - a kind of circular ribbing resembling the "skeleton of herring"). In vague cases, contrast radiographic examination of the intestine is performed (the patient is given 100 ml of barium suspension) with repeated examinations of the contrast passage every 2 hours. Signs are: a delay in contrast in the stomach or small intestine more than 4 hours. With incomplete intestinal obstruction, the passage of contrast is traced before it is removed to the depot above the obstacle site - this sometimes takes up to two days. When intestinal obstruction of the colon, it is desirable to perform a colonoscopy. If there was a dynamic intestinal obstruction, it is necessary to identify the cause that caused spasm or paresis: appendicitis, pancreatitis, mesenteritis, thrombosis or embolism of mesenteric vessels and other acute abdominal pathology.

With conventional radiography, the display of a number of swollen loops of the small intestine resembling a ladder is characteristic of small intestinal obstruction, but such a picture can also be observed in cases of obstruction of the right flank of the large intestine. Horizontal levels of fluid in the intestinal loops can be detected with the patient's vertical position. Similar, but less pronounced, radiologic signs can also be observed with paralytic intestinal obstruction ( intestinal paresis without obturation); differential diagnosis of intestinal obstruction can be difficult. Swollen bowel loops and fluid levels may be absent with high jejunal obturation or with a closed-type strangulation obturation (which can occur when turning). A bowel altered by a heart attack can create a volume effect on the radiograph. Gas in the wall of the intestine (pneumatosis of the intestinal wall) indicates gangrene.

In colonic intestinal obstruction, the radiography of the abdominal cavity reveals the expansion of the colon proximal to the obstruction zone. When turning the cecum, a large gas bubble can be identified that occupies the middle of the abdominal cavity or the left upper quadrant of the abdomen. When turning the blind and sigmoid colon using an X-ray contrast enema, one can visualize the deformed zone of obturation in the form of a twisting site like "bird's beak"; this procedure can sometimes actually resolve the sigmoid turn. If the contrast enema is not feasible, colonoscopy can be used to decompress the sigmoid colon when turning, but this procedure is rarely effective when turning the cecum.

[41], [42], [43], [44], [45], [46]

Treatment of the intestinal obstruction

Patients with suspected intestinal obstructive obstruction should be hospitalized. Treatment of intestinal obstruction should be carried out simultaneously with the diagnosis. The surgeon must always be involved in this process.

Metabolic therapy is mandatory and similar in both thin and colonic obstructive obstruction: nasogastric aspiration, intravenous fluid transfusion (0.9% physiological saline or Ringer's lactated solution to restore intravascular volume), and bladder catheterization to control diuresis. Transfusion of electrolytes should be controlled by laboratory tests, although in cases of repeated vomiting Na and K serums are likely to be reduced. If there is a suspicion of intestinal ischemia or a heart attack, it is necessary to prescribe antibiotics (eg, cephalosporin of the 3rd generation, type cefotetan 2 g IV).

Specific activities

When obturation of the duodenum in adults, resection is performed or, if the lesion can not be removed, palliative gastroeurostonomy.

With complete obturation of the small intestine, early laparotomy is preferred, although in the case of dehydration and oliguria, the operation can be delayed for 2 or 3 hours to correct the water-electrolyte balance and diuresis. Zones of specific intestinal lesion should be removed.

If the cause of obturation was gallstones, cholecystectomy can be performed simultaneously or later. Surgical aids should be performed to prevent recurrence of obturation, including plastic hernia, removal of foreign bodies and removal of adhesions. In some patients with signs of early postoperative obturation or relapse of obturation caused by the adhesion process, in the absence of abdominal symptoms, simple intubation of the intestine with a long intestinal tube can be undertaken instead of surgery (many consider the standard nasogastric intubation as the most effective intestine).

Disseminated cancers of the abdominal cavity, which surrounds the small intestine, is the main cause of mortality of adult patients with malignant gastrointestinal diseases. Bypass anastomoses, surgical or endoscopic stenting can short-term improve the course of the disease.

Cancer diseases surrounding the large intestine are most often subjected to a one-stage resection with the imposition of a primary anastomosis. Other options include unloading ileostomy and distal anastomosis. Sometimes unloading colostomy with delayed resection is necessary.

If the obturation is caused by a diverticulosis, often there comes a perforation. Removal of the affected area can be quite difficult, but it is indicated in the case of perforation and general peritonitis. Resection of the intestine and colostomy without anastomosis is performed.

Coprostasis usually develops in the rectum and can be resolved by finger research and with the help of enemas. However, the formation of single or multicomponent fecal stones (i.e. With barium or antacids) that cause complete obturation (usually in the sigmoid colon) requires laparotomy.

Treatment of blindness of the cecum consists in resection of the involved site and formation of an anastomosis or in fixation of the caecum in its normal position with caecostomy in weakened patients. When turning the sigmoid colon with an endoscope or a long rectal tube, one can often cause decompression of the loop, and resection and anastomosis should be performed in a delayed period for several days. Without resection, intestinal obstruction almost inevitably recurs.