The causes of this form of obstruction are acute diffuse peritonitis, thrombosis of the mesenteric vessels, pancreatitis, biliary and renal colic, abdominal injuries, damage to the spine and spinal cord, acute urinary retention.
The clinical picture depends on the cause of the paralytic obstruction. The main symptoms of this type of acute intestinal obstruction: abdominal distension, lack of peristalsis, pain, nausea, vomiting. They develop against the background of a severe general condition.
In case of acute intestinal obstruction, one should not lose sight of the acute urinary retention, in which the cure is possible with the help of catheterization of the bladder.
Acute mechanical bowel obstruction
At the prehospital stage, the emergency doctor mainly meets with mechanical types of acute intestinal obstruction: strangulation (incarceration, torsion, nodulation of intestinal loops), obstructive (tumor, biliary tract stones, worms, fecal stones or coprostasis), mixed (invagination, adhesive disease) , vascular (thrombosis or embolism of the mesenteric vessels).
In order to simplify the recognition of acute intestinal obstruction at the prehospital stage, three clinical variants of this disease should be distinguished: acute small bowel obstruction, acute colonic obstruction and vascular obstruction.
Acute small bowel obstruction
The onset of this disease is always extremely acute. The leading symptoms of small bowel obstruction are cramping pain, vomiting, violent peristalsis of the intestines, often retention of gas and stool.
Vomiting occurs the earlier, the higher the obstruction of the lumen of the small intestine. Initially, it is vomiting with recently eaten food, after a while - bile, and later with the contents of the small intestine.
In patients with the examination marked tachycardia, asymmetry of the abdomen or a slight swelling.
Late signs of acute intestinal obstruction are some reduction in pain, harsh peristaltic noise, sometimes heard at a distance, or their almost complete absence, splashing noise, falling drop noise, involuntary muscle tension of the anterior abdominal wall, Shchetkin-Blumberg positive symptom.
Acute colonic obstruction
The onset of acute colorectal obstruction is extremely rarely rapid. The full clinical picture of this disease often develops over several days.
The main symptoms of colonic obstruction: absence of stool and gas, flatulence.
Delay of stools and gases may occur suddenly or gradually. Signs of flatulence are increasing every hour. Pain and visible peristalsis of the colon are noted only in the area of the cecum and its ascending part.
Vomiting appears only after prolonged obstruction of the colon.
When the digital examination of the rectum, as a rule, revealed her swollen ampoule.
If acute intestinal obstruction is suspected, a digital rectal examination is a mandatory diagnostic measure.
Thrombosis and embolism of the mesenteric vessels (vascular form of acute intestinal obstruction)
Acute circulatory disorders of the small intestine due to blockage of the mesenteric vessels are much more common than are recognized in clinical practice. This is due to the difficulties in the differential diagnosis of acute stomach diseases. According to statistical observations, approximately 7-10% of all embolisms belong to the mesenteric vessels.
In the diagnosis and differential diagnosis of this disease, it is important to have a history of diseased diseases of the heart and blood vessels that contribute to the onset of the described pathological condition. 80% of patients with acute impairment of the mesenteric blood circulation have suffered from cardiovascular diseases more or less for a long time.
The onset of the disease is characterized by the sudden appearance of acute abdominal pains, which do not have a clear localization and often take on intolerable character. Pain syndrome often occurs on the background of a pronounced collapse, as evidenced by the frequent pulse of weak filling. When feeling the abdomen is soft, moderately painful. The amplification of peristalsis as a result of intestinal ischemia, which is accompanied by loose stools, often bloody, is deceased.
In the clinical picture, from the very beginning, there is a pronounced discrepancy between the severity of the general condition and insignificant objective local findings from the abdominal cavity. Then local clinical manifestations change very quickly. Further deterioration in the general condition of patients is accompanied by the disappearance of peristalsis and the increase in all signs of flatulence. Sometimes when palpating the abdomen, there is an indefinite, resistant formation — a section of the intestine that is turned off from the blood supply.
After 6-8 hours from the onset of the disease, a clinical picture of acute diffuse peritonitis develops with pronounced positive symptoms: dry tongue, tachycardia, nausea, vomiting, involuntary muscle tension of the muscles of the anterior abdominal wall, Shchetkin-Blumberg, Voskresensky positive symptoms.
Acute adhesive intestinal obstruction
Acute adhesive intestinal obstruction, as a rule, begins with cramping abdominal pains, the intensity of which gradually increases. Then join dry mouth, nausea, repeated vomiting, delayed stool and gas, bloating.
When making a diagnosis of acute adhesive intestinal obstruction should take into account such circumstances as previous surgery on the abdominal organs (one or more), a history of similar attacks of abdominal pain, which took place independently or after an enema.
When examining such patients, first of all, the presence of postoperative scars on the anterior abdominal wall, often abdominal swelling and asymmetry, with auscultation of chaotic and a variety of intestinal noise, and the percussion of the anterior abdominal wall reveal a mosaic of percussion tone in its various departments.
The progression of the disease leads to a rapid increase in all signs of intoxication against the background of the development of the clinical picture of acute diffuse peritonitis.
Acute peritonitis is a life-threatening microbial infection of the abdominal cavity, which leads to severe intoxication with damage to many organs. It should be considered as a severe disease. Most often, acute peritonitis occurs as a result of progressive inflammation of the abdominal organs (appendix, gallbladder, pancreas) or their perforation. It can be local and diffuse.
With the development of peritonitis and the spread of the inflammatory process comes the culmination of disorders in various organs and systems. So, along with marked pathological changes in the coagulation system, it causes serious disturbances in the activity of the heart, lungs, kidneys and brain, as well as in all types of metabolism. All this is often manifested in the development of acute paralytic ileus of the intestine.
Patients with acute peritonitis complain of severe weakness, hardly tolerated abdominal pain, nausea, vomiting, dry mouth. When viewed, they reveal pronounced tachycardia at often normal or subfibril body temperature, dry lips, dry tongue, nonparticipation of the anterior abdominal wall in the act of breathing, pronounced soreness of the abdomen and involuntary muscular tension of its walls during superficial percussion and palpation, other positive symptoms of Shchetkin peritoneum irritation - Blumberg, Resurrection.
All patients with acute peritonitis need immediate hospitalization in a surgical hospital. In the presence of frequent vomiting, a probe is inserted into the stomach, and cold is laid down on the stomach. In a serious condition with a drop in blood pressure - oxygen therapy, heart remedies, infusion of saline and plasma substituting solutions.
Diagnosis of intestinal obstruction is a comprehensive examination of the patient, which includes the following activities:
- examination - palpation of the abdomen, determination of skin color, control of body temperature and blood pressure,
- X-ray of the large intestine - if there is a suspicion of an intermediate or late stage, the study is carried out immediately,
- blood test - general and biochemical,
- Ultrasound or CT scan of the abdominal cavity - methods to visualize the cause of obstruction.
In some cases, there are indications for laparoscopy. Most often, this measure is resorted to when the external signs confirm the diagnosis, and the critical condition of the patient does not allow for a complete diagnosis. During laparoscopy, the doctor not only identifies the pathological section of the intestine, but can also proceed directly to therapy.
If the patient is delivered at an early stage in the development of the disease and the methods listed above do not make it possible to establish a diagnosis, contrast radiography is shown every two hours. Until the full clarification of the circumstances, the patient remains in the hospital.
First aid for intestinal obstruction
Intestinal obstruction is a condition that requires surgery. Drug therapy is completely ineffective. Therefore, if you suspect such a condition should immediately seek medical help.
Before the arrival of the ambulance brigade, the patient must be laid on a flat, horizontal surface, to ensure maximum rest.
It is strictly forbidden to cause stool with the use of laxative drugs - the desired effect will not be achieved, but by increasing the frequency of contraction of the intestinal walls, the patient's condition will worsen.
You can give a cool drink in small doses. It is important to monitor the body temperature, blood pressure, pulse. This information will facilitate and speed up the installation of a diagnosis by specialists.
If the patient is in serious condition, the ambulance paramedic may conduct initial therapy, which includes injections of drugs to relieve spasm and injections with plasma-substituting solution. With a strong and painful vomiting, a special probe is installed to facilitate the discharge of vomit.
Treatment of intestinal obstruction
Mechanical obstruction is removed exclusively by surgery. Type of operation depends on the causes of pathology. For example, if the cause of an intestinal blockage is a foreign body that has entered it and the formation of a large fecal stone, a surgical opening of the intestine is indicated. Inversion of the intestines can be corrected by unwinding the loop. To avoid recurrence of the disease, the problem area is fixed or shortened. If the death of intestinal tissues is noted, the atrophied areas are excised followed by intestinal suturing.
Dynamic obstruction allows the use of conservative therapy. In this case, the patient must be under continuous medical supervision, because there is a high risk of sepsis.
Patients with suspected acute intestinal obstruction are immediately delivered to the surgical department. The complex of diagnostic measures depends on the patient's indicators - if the condition is critical, an urgent operation is performed, during which the diagnosis is first confirmed, and then the cause of the pathology is eliminated.
What is intestinal obstruction?
Intestinal obstruction - pathology in which the process of evacuation of substances from the intestine is disturbed. It is especially characteristic of vegetarians and can be dynamic or mechanical.
At the first suspicion of intestinal obstruction, you must immediately contact the surgeon for help. Only he can make a final diagnosis and advise the necessary treatment. To stop the choice exclusively on national methods independently is very dangerous.
Acute obstruction can cause a person’s death, so it is important to know its main symptoms and causes.
After an emergency surgery for bowel obstruction, about 20% of patients die. If the pathology had a severe course, then these indicators increase to 40%.
Among all the acute conditions that require surgical treatment, acute intestinal obstruction (abbreviation of acute intestinal obstruction) occurs in 8-25% of cases.
If the reason for intestinal obstruction is a tumor, the number of deaths is 40-45%.
When the cause of acute intestinal obstruction is adhesions, death occurs in 70% of cases.
In men, pathology is more common than in women - in 66.4% of cases.
Older people are at risk, for whom the probability of developing an OC increases 4 times.
Classification of acute intestinal obstruction
In the first half of the 19th century, two types of intestinal obstruction were identified - mechanical and dynamic. Subsequently, the mechanical intestinal obstruction Wal (Wahl) proposed to divide into strangulation and obstructive. The most simple and expedient at the present time can be considered a classification in which OKN is divided by 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 bowel obstruction (88%):
- Strangulation (inversion, nodulation, internal restraint)
A. intraorganic (foreign bodies, fecal and gallstones, worm infestation, located in the intestinal lumen)
b. intramural (tumor, Crohn's disease, tuberculosis, cicatricial stricture affecting the intestinal wall)
at. extraorganized (cysts of the mesentery and ovary, tumors of the retroperitoneal space and organs of the small pelvis, which cause compression of the intestine from the outside).
but. Adhesive obstruction
According to the level of obstruction:
- Enteric: a. high b. low
- Colonic - According to the dynamics of the development of the pathological process
(on the example of adhesive intestinal obstruction)
I stage. Acute violation of intestinal passage - the stage of "ileus cry" - the first 12 hours from the onset of the disease)
Stage II Acute violation of intraparietal intestinal hemocirculation
(phase of intoxication) - 12-36 hours.
Stage III. Peritonitis - more than 36 hours from the onset of the disease.
Significant differences are found in the literature on the determination of the severity of colonic obstruction. This circumstance gave 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 of the Russian Academy of Medical Sciences. According to the proposed classification, there are 3 degrees of manifestation of colonic obstruction:
I degree (compensated). Complaints of recurrent constipation, lasting 2-3 days, which can be eliminated with the help of diet and laxatives. The general condition of the patient is satisfactory, there is a periodic bloating of the abdomen, the symptoms of intoxication are absent.The results of colonoscopy and irrigography show that the tumor narrows the lumen of the intestine to 1.5 cm, there is a small accumulation of gases and intestinal contents in the colon.
II degree (subcompensated). Complaints of persistent constipation, the lack of an independent chair. Taking laxatives is ineffective and gives a temporary effect. Periodic abdominal distension, difficulty passing gas. The general condition is relatively satisfactory. Symptoms of intoxication are noticeable. The tumor narrows the lumen of the intestine up to 1 cm. When X-ray examination, the colon is enlarged, filled with intestinal contents. Individual fluid levels (Kloyber bowls) can be determined.
Grade III (decompensated). Complaints about the absence of a chair and the discharge of gas, increasing cramping abdominal pain and bloating, nausea, and sometimes vomiting. Severe signs of intoxication, violation of water and electrolyte balance and KOS, anemia, hypoproteinemia. When X-ray examination, the intestinal loops are enlarged, inflated with gas. Multiple fluid levels are determined. As a rule, the majority of patients admitted to the emergency 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 colon obstruction syndrome, first described by N. Ogilvie in 1948, has been increasingly mentioned. This syndrome manifests itself most often as a clinic of acute dynamic obstruction of the intestine due to impaired sympathetic innervation. Often this condition is observed in the early postoperative period, which leads to repeated laparotomy. Most authors have noted diagnostic difficulties in establishing Ogilvy syndrome. A positive effect has bilateral perirephral novocainic blockade according to A.V. Vishnevsky.
When the clinical manifestations of the disease are accompanied by dull symptoms, we do not set the diagnosis “partial intestinal obstruction”, considering it to be unjustified in tactical terms. In this case, most often, it is about the incomplete closure of the lumen of the intestine by a growing tumor, adherence obstruction or recurrent torsion. Such a diagnosis confuses the surgeon and leads to late operations.
Causes of acute intestinal obstruction
Acute intestinal obstruction can be triggered by various causes. They are divided into predisposing and producing. Predisposing causes contribute to an increase in mobility of the intestinal loops, or its immobilization. This leads to the fact that the body takes the wrong position, and the fecal masses can not normally move on it.
Predisposing factors can be anatomical and functional.
Anatomical reasons include:
The presence of adhesions in the peritoneal cavity.
Mesentery too narrow or too long.
The presence of holes in the mesentery.
The presence of a hernia. The danger is a hernia of the white line of the abdomen, inguinal and femoral hernia, as well as internal protrusions.
Developmental malformations of the organ, for example, mobile cecum, dolichosigma, etc.
Tumors of the intestine or organs that are in close proximity to it.
The functional reasons that can cause acute intestinal obstruction include:
Excessive eating after long abstinence. If a person has been on a diet for a long time and then has eaten a large amount of coarse food, the intestines will begin to contract strongly. This can cause an intestinal obstruction or a “disease of a hungry person” (according to Spasokukotsky).
Transferred spinal cord injuries, TBI.
Dysentery and other conditions that contribute to increased intestinal contractility.
Producing causes lead to spasms and paresis of the intestines. An oversupply of food, a sharp increase in intra-abdominal pressure, hypodynamia (enforced bed rest and paralysis) can provoke such a situation.
Symptoms of acute intestinal obstruction
Intestinal obstruction usually begins with a sharp, growing, cramping abdominal pain and is accompanied by nausea and vomiting. With the passage of time, the intestinal contents begin to enter the stomach, and the emetic masses have an unpleasant odor characteristic of feces. There is constipation and increased gas formation. The intestinal peristalsis is preserved at the initial stage; it can be observed through the abdominal wall. The abdomen takes on an irregular shape, rapidly swelling.
Symptoms of acute intestinal obstruction:
Abdominal pain. It occurs in all patients, without exception. At the early stage of the development of pathology, pain proceeds according to the type of contractions. It will be concentrated in the place of the abdominal cavity where the collapse has formed. The pain is present on an ongoing basis, becomes dull, spreads throughout the abdomen. When the pathology reaches its peak, the pain is reduced, but this symptom cannot be called favorable.
Nausea and vomiting. These symptoms occur in 60-70% of people. They will be the more intense, the more severe the intestinal obstruction. First, bile will be present in vomiting, and then intestinal contents. The masses emerging from the mouth begin to smell of feces. Vomiting does not develop immediately, but after it has begun, its termination is not expected.
Lack of gas and feces. Even at the early stage of intestinal obstruction, the fecal masses will be absent. If the lumen of the intestine is not completely blocked, gases and stools can move away, but partially. In this case, the person does not feel relief, he does not have a feeling that the intestines are completely cleansed.
Bloating, changing its natural outlines. Most often this symptom characterizes cut-off intestinal obstruction. If the blockage occurs in the small intestine, the peritoneum will be swollen evenly. With the defeat of the large intestine, the stomach acquires asymmetric features and swells in one of the sections.
Forced posture - a person lies down and tightens his knees to the stomach. The patient cannot lie down calmly, he constantly turns over, as he is haunted by severe pain.
The general well-being of a person at an early stage of development of pathology can be called satisfactory. However, if he has a strangulation of the intestine, then the state of health worsens already in the first few hours of the development of the disorder.
The level of blood pressure drops, and the pulse rises, which indicates the development of a state of shock.
The tongue becomes dry, a yellow patina forms on it, and an unpleasant smell emanates from the mouth. If the blockage has occurred in the small intestine, the smell will have a fecal hue. The terminal stage of the development of pathology leads to the appearance of cracks in the tongue, after which ulcers form on it. This indicates severe poisoning of the body, its dehydration and developing peritonitis.
When a patient goes to a doctor, the doctor notes the following clinical picture:
Palpation of the peritoneum gives the person pain. With deep probing, a tumor or invaginate can be identified. The doctor may also palpate a hernia. The peritoneal wall will be stretched, but the abdominal muscles are not tense. The doctor also notes intensive contraction of the intestines.
Sign Tevenar. When pressing on the mesentery root of the small intestine (it is located 2 cm below the umbilical fossa), a person has painful sensations.
Symptom Valya. On palpation of the anterior abdominal wall, the leading loop is well felt. Its outline can be visualized.
Anstyuza syndrome. In the right iliac region, the abdomen will be distended.
Palpation of invaginate. It is defined in the region of the ileocecal angle and has a shape resembling a sausage.
Symptom Hose. Even without special adaptations, one can notice how the patient’s abdomen is swollen with gas.
Symptom Sklyarov. If you shake the anterior wall of the peritoneum with your hand, you can feel its seething.
Listening to the abdomen. The doctor will hear a lot of noise. If the pathology has already provoked the dying off of the intestinal walls, the seething stops, giving way to silence.
Symptom Lotaysona. When listening to the front wall of the peritoneum, you can hear the heart and respiratory noise.
Syndrome Obukhovsky hospital (a sign of Grekov). The anal opening is enlarged, as well as the rectum, but the feces are not observed there. This symptom is characteristic of twisting intestines.
Symptom Kivulya. When you knock the front wall of the abdomen you can hear the ringing. If it has a metallic tint, then they indicate a balloon symptom (Kivul symptom). If you knock the side of the abdomen, the sound will be somewhat muffled.
Symptom Tsege-Manteufelya. It is characterized by the fact that when performing an enema of more than 1.5 liters of fluid in the intestine is not included. Such a symptom is diagnosed with inversion of the sigmoid colon.
Syndrome Mondor. Palpation of the rectum can be felt in her tumor and visualize the feces, which will have a crimson color.
Characteristic manifestations of invagination are:
Severe pain in the abdomen by type of attack (a symptom of Tiliyks).
False urge to defecate and palpation of education in the peritoneal cavity (symptom of rush).
The appearance of blood from the anus (symptom Roof).
Staging an enema leads to the fact that the outgoing content resembles a kind of meat slop.
1 phase - reactive
The duration of the reactive phase is 10-16 hours. A person in this period, there is intense pain of the type of contractions. At first they are paroxysmal, with periods of calm, but later on they become permanent. Often the pain is so severe that a person develops a shock. Doctors call the reactive phase “an ielius cry”.
When the reactive phase has only manifested, the gaps without pain will be frequent, at this time the patient's well-being normalizes. However, when intestinal infringement there are no light spaces. The pain from moderate to acute. High intestinal obstruction is accompanied by nausea and gagging. With low intestinal obstruction, gas formation increases, there is no stool.
Visceral pain, radiating to other organs, develops on the background of a spasm, in which intramural nerve plexuses are irritated. In the future, the motor function of the intestine is depleted. The intestine becomes swollen, greatly stretched. As the swelling increases, the pain becomes constant and intense. There are no periods of enlightenment.
Phase 2 - intoxication
After 12-36 hours, the toxic phase develops, at which an organ paresis is observed. The pain becomes permanent, the intestine stops contracting, the stomach swells, becomes irregular.
A person develops vomiting, it is abundant, it is impossible to stop it. The intestine during this period will be overfilled, as well as the stomach.
Man refuses water, as he is sick all the time. This leads to dehydration, minerals, electrolytes, and enzymes are derived from it. The face becomes like a mask (Hippocrates face), the oral mucosa dries out, while the patient himself is very thirsty. He has severe heartburn. Neither fecal matter nor gases come out.
During this period, Val's symptom, Sklyarov's symptom, Kivul's symptom, symptom of peritoneal irritation appear. Suffer function lists. As much fluid accumulates in the intestines, it begins to leak through its walls. This becomes the first step to the development of peritoneal inflammation.
3 phase - terminal
After 36 hours, the end stage of pathology develops. At the same time, all organs are affected. The person begins to breathe quickly, the body temperature rises to feverish marks, urination is absent. The abdomen is no longer bulged forward, blood pressure drops, and the pulse becomes very frequent, but weak.
Occasionally, the patient has vomiting, from which the smell of fecal masses emanates. Then the patient develops a blood infection, an insufficiency of the internal organs and death occurs.
In addition to an external examination and palpation of the abdominal cavity, the doctor refers the patient to a laboratory test, including:
General blood analysis. A leukocyte shift to the left, an increase in ESR and hematocrit is detected. This is due to the increasing dehydration of the body, against the background of which the blood becomes thick.
Blood donation for biochemical analysis. The analysis will increase the level of nitrogen, urea, glucose. At the same time, the values of potassium and sodium, calcium, chloride and proteins fall.
Urine becomes turbid, becomes dark in color. A laboratory assistant discovers red blood cells and albumin in it.
The coagulogram shows thickening of the blood, the prothrombin index increases, the clotting time of the blood becomes less.
Intestinal X-ray is the most accessible and very informative method for detecting intestinal obstruction. It has a low cost and is also easy to implement. The procedure is performed using barium as a contrast agent. Separately perform intestinal X-rays and abdominal X-rays. If you can not clarify the diagnosis, then resort to irrigoscopy or enterinoscopy. These studies allow to assess the condition of different parts of the intestine. Alternatively, endoscopy of the lower intestine is performed.
During the performance of fluoroscopy, the patient must lie (on the side or on the back), or stand.
The characteristic picture that the doctor visualizes:
Kloiber bowls. This symptom is a collection of gases that look like inverted bowls. This clinical sign is revealed one of the first. When the intestine is chopped off, the Kloyber bowl is visible on the X-ray after 5 hours, and when the organ is strangulated, in an hour. Bowls can be multiple, they can layered one on top of another, therefore they resemble the look of a ladder.
Intestinal arcades. They are formed in the small intestine. Because of the pathology, it swells up, is filled with gases. In the lower sections of the arcades, horizontal liquid levels are noticeable.
Symptom of feathering. It develops with high obstruction, since in this case the small intestine is strongly stretched. Its walls form folds. In the picture it looks like a spring, which stretched.
X-ray with contrast involves the patient’s absorption of 50 ml of barium mist. Then the doctor takes a GI tract. They make several, with certain time intervals. If barium remains in the intestine for a long time (longer than 4 hours), then this may be a sign of obstruction.
Depending on where the intestinal obstruction has developed, the X-ray picture will be as follows:
When obstruction in the small intestine Kloyber bowls will be small. The width of the liquid level exceeds the height of the gas. Regardless of the intestinal section, the fluid levels in them will be the same. Rosary visible spirals and arcades, represented by the mucous membrane of the body.
With obstruction of the jejunum, the fluid levels will be located in the epigastric region and in the region of the right hypochondrium.
When obstruction of the distal ileum fluid levels will be located in the center of the abdomen.
When obstruction of the large intestine fluid levels are located on the side of the abdomen, but they are much less than in the case of blockage of the small intestine.
In dynamic intestinal obstruction, fluid levels are visualized in the small and colon.
If the doctor assumes that the patient develops a large bowel obstruction, then he will prescribe a sigmoidoscopy and colonoscopy. These diagnostic methods allow you to determine the cause of the violation and to identify a tumor, foreign bodies or fecal blockages.
What diseases can be confused with intestinal obstruction?
Symptoms of intestinal obstruction may resemble signs of other diseases. Therefore, it is likely to confuse obstruction with such disorders as:
Acute appendicitis. In this disease, severe abdominal pain also occurs, vomiting and constipation may develop. However, with appendicitis, pain originates in the epigastric region, moving to the right iliac region. In case of obstruction, pain proceeds according to the type of contractions, it is intense, replaced by painless periods. There is no such intensive bowel contraction in appendicitis. If a complete blood count for both pathologies indicates an inflammation, then when performing an X-ray image of the intestine there are no signs of obstruction.
Perforated gastric ulcer. The disease also develops suddenly, as well as intestinal obstruction, the patient does not have a chair and gas, the stomach hurts a lot. If perforation happened, the person will feel very bad. The anterior abdominal wall is very tense, does not participate in breathing. If you try to palpate the intestines, then the person will feel severe pain. In case of obstruction, on the contrary, the organ is greatly reduced, it is possible to palpate an enlarged loop. When an ulcer in a person does not develop vomiting, the intestine is not reduced. During X-rays, Kloyber’s bowls are not detected, but free gas is seen in the peritoneal cavity.
Acute inflammation of the gallbladder. A person has intense pain, he is sick, his stomach is swollen. However, the pain will be concentrated in the right side, radiating to the shoulder and shoulder blade. When obstruction clearly limit the location of the pain will not succeed. If you palpate the region of the right hypochondrium, a patient with cholecystitis can detect tense muscles, while the contractile activity of the intestine is not enhanced, pathological sounds are not audible. With inflammation of the gallbladder, body temperature rises, jaundice develops.
Acute inflammation of the pancreas. The pains manifest suddenly, vomiting happens several times in a row, gases do not leave, the stomach is swollen, the intestine is in a state of paresis. It hurts the stomach in the upper part, the pain girdles the body. With intestinal obstruction, pain proceeds according to the type of contractions. If you palpate the stomach of a patient with pancreatitis, you can feel the swollen colon. In addition, bile will be present in the vomit. After some time, the gases will begin to depart, a chair will appear. In the blood test increases the level of diastase.
Myocardial infarction, accompanied by abdominal syndrome. A patient with a heart attack has a swollen abdomen, severe pains in his upper part, weakness increases. A person becomes sick, vomiting may occur, and stools and gases are absent. However, additional signs that indicate a heart attack are: hypotension, deafness of heart tones, percussion expansion of the borders of the heart, the stomach does not become asymmetric, the intestine does not contract much, and no noise appears. To clarify the diagnosis, you need to perform an electrocardiogram.
Renal failure. Similar symptoms are: intense pains like contractions, abdominal distension, lack of stools and gas, increased anxiety of the patient. Distinctive characteristics of renal colic: pain radiates to the genitals, lower back, urine lingers, a person can urinate with difficulty, blood is present in the urine. In the kidneys and in the ureters with the help of X-rays concrements are detected.
Pneumonia, concentrated in the lower lobes of the lungs. Similar symptoms: abdominal muscle strain, abdominal pain. Distinctive characteristics of pneumonia: pink cheeks, shallow breathing, shortness of breath, chest pain. If you listen to the lungs, you can hear wheezing, crepitations, noise. Expose the correct diagnosis helps radiography.
Treatment of acute intestinal obstruction
If a person develops symptoms that indicate intestinal obstruction, he should be taken to a medical facility as soon as possible. Until such time as the patient is examined by a doctor, he should not undergo an enema, it is forbidden to take laxatives, painkillers or perform gastric lavage. Treatment can be reduced both to taking medications and to surgery. It all depends on the features of the disease. In case of dynamic obstruction, there is the possibility of medical correction, and in case of mechanical blockage of the intestine, it will not be possible to do without the help of a surgeon. Often, to save the life of a patient, an operation is performed on an emergency basis.
When the obstruction has just begun to develop, it is difficult to identify its shape. Therefore, the doctor postpones the intervention for several hours. If medication does not lead to an improvement in well-being, the patient is sent to the surgical table. Provided that the patient has already been diagnosed with peritonitis or intestinal strangulation, the operation is carried out immediately.
Drug correction can often overcome coprostasis, as well as cope with obstruction against the background of neoplasm in the intestine.
Reducing the intensity of pain, affecting the contraction of the intestine. Perirenal novocaine blockade is performed to reduce pain. Intravenous spasmolytics are administered (Atropine, Spazgan, Drotaverinum). If the patient is diagnosed with intestinal paresis, then Neostigmine, a hypertonic sodium chloride solution, is prescribed to eliminate it, and an enema is performed.
Decompression of the digestive tract. The contents of the stomach must be extracted using a probe and a siphon enema, through which 10 liters of water are injected. It is possible to carry out similar actions only provided that the patient did not develop peritonitis. If chyme is detected in the stomach, this indicates a severe course of intestinal obstruction. Also, the volume of injected fluid allows us to make an assumption about the level of obstruction. Conducting decompression makes it possible to normalize the intestinal contractility and improve microcirculation in its walls.
Preventing or eliminating dehydration. Patients with intestinal obstruction prescribe infusion therapy. Ringer's solution, glucose, insulin, and potassium solution are administered to patients. The volume of injected solutions are large and can not be less than 3 liters. Soda is prescribed to patients with metabolic acidosis. During infusion therapy, pressure and urination should be monitored. The patient is placed a catheter in the bladder and subclavian vein.
Bringing the blood supply to the digestive organs. For this purpose, albumin, plasma, protein, reopolyglukine, pentoxifylline, amino acids are used. If there are indications, the patient is prescribed cardiotropes. If the patient starts the process of discharge of gases, there is a chair and pain passes, then this is a good sign. If after 2-3 hours the person’s well-being does not improve, they prepare him for the operation.
If the patient develops mechanical obstruction of the intestine, then surgery is required in 95% of cases. The remaining 4% of patients do not conduct it due to the fact that they are in serious condition. Another 1% of patients simply do not seek medical help and die.
Contraindications to surgery for mechanical blockage of the intestine are only agony and predagonia of the patient.
Indications for surgery:
Intoxication and dehydration of the body, which corresponds to phase 2 of obstruction.
Signs indicating intestinal strangulation.
Measures to prepare the patient for intervention:
Putting the probe into the stomach.
The introduction of drugs that will ensure the functioning of the circulatory and respiratory systems.
Conducting massive infusion therapy.
The patient is placed a catheter in the bladder, in the stomach and in the central vein. Anesthesia is done endotracheal, surgery - laparotomy with a midline incision. If the patient has obstruction due to incision of a hernia, then spinal anesthesia can be performed.
The goals pursued by the surgeon:
Determining the type of obstruction with the inspection of the abdominal cavity.
Eliminate the cause that caused the blockage. Adhesions or throats of a hernia are dissected; they are eliminated when inverted intestines or when forming a node. Also carry out disinvagination, or plan to resect part of the affected area.
Assessment of the state of the intestine and its possible further functioning. If the organ is not dead, it will have a burgundy or blue color, its mesentery is smooth in some of its areas hemorrhages are visible. Vessels continue to throb, no blood clots. On exposure to warm saline, the intestine responds with hyperemia, increased pulsation and contractions. Removal of the organ is required in the case of the formation of blood clots in the vessels, if it acquires a black or dark blue color, the mesentery will be dull and covered with hemorrhages. The intestine does not react to the treatment with a warm solution.
Removal of the affected area. To be removed is that part of the organ that has undergone necrosis, as well as the intestine at a distance of 40 cm from the zone of dying. Then perform the anastomosis.
Unloading. When the loops of the organ have been over-stretched, bowel decompression is performed using nasogastric intubation of the small intestine with a probe. Drainage is carried out through enterostomy or cecostomy.
Drainage and sanitation of the peritoneum. The abdominal cavity is washed with special compounds, dried. Drainage out through the anterior abdominal wall.
Period after surgery
If the operation is successful, the patient is placed in the intensive care unit. There he must spend at least 3 days.
The main directions of treatment and care:
Prevention of dehydration, intoxication and infection of the body.
Elimination of respiratory and cardiovascular disorders.
The use of electrolytes for the normalization of the acid-base environment.
Improve blood rheology.
Preventing the formation of blood clots. For this purpose, use Fraksiparin.
To strengthen the body, vitamins and immunomodulators are injected.
To prevent intestinal paralysis, his work is supported with the help of enemas, Prozerin, Cerukal, electrostimulation, etc.
In the first 3 days a person must be in the intensive care unit. He carried out percussion massage of the sternum, perform breathing exercises. It is necessary to normalize the work of the respiratory system.
It is necessary to lift the patient from a bed as soon as possible. This is done so that the intestines begin to contract and not develop stagnation. It is recommended that the patient get up for 2-3 days, if there are no contraindications.
The first 3 days a person receives parenteral nutrition. It is important to control his pulse, respiration rate, and quality of discharge from the drainage. In the same period, he receives antibiotics and anti-inflammatory drugs.
For 4-7 days the patient is transferred to the general ward. There he must comply with the half-bed mode. The probe from the stomach is removed. From now on, a person should receive food as usual, but it is served in a semi-liquid and ground form (table 1A).
Bandage change Adam's 2 days, drainage is removed on day 4, if there is no discharge from it.
To avoid seams, the patient should use a bandage. From the 5th day you need to start performing gymnastics under the supervision of a physician. The patient continues to receive vitamins, antibiotics, immunity stimulants. Menu smoothly expand.
On the 8-10 day after the operation, the person is transferred to the table number 15. He is already allowed to leave the chamber.
Stitches will be removed on day 9-10. If no complications develop, the patient is discharged.
In the next 3 months, the person will need to comply with a strict menu, abandon vegetables that stimulate gas formation, pickled and salted dishes, from fatty foods and convenience foods.
The postoperative period is associated with the risk of the following complications:
Necrosis of the intestinal loop. In this case, perform a second operation, remove the affected area, impose an anastomosis, or remove the stoma.
Bleeding. Repeated laparotomy is required during which they eliminate the source of bleeding.
Insolvency of intestinal anastomosis sutures. At the same time perform relaparotomy, create an unnatural anus, drainage output.
Inter-intestinal abscess. Perform relaparotomy and sanitation abscess.
Intestinal fistula. Perform a conservative therapy, with the treatment of fistula disinfecting ointments and pastes. In the future, a loop with a fistula must be removed by performing intestinal intubation.
The formation of adhesions. Perform a relaparotomy with breeding fistula, bowel intubation.
Answers to popular questions
Is it possible to make a prognosis for acute intestinal obstruction? The sooner the patient is treated, the more favorable it is. The importance of comorbidities, as well as the age of the patient. For older and weakened people, the prognosis is worsening. If the operation was carried out in the first 6 hours from the development of obstruction, then the patient most often can be saved.
If obstruction has developed in a pregnant woman, what is the prognosis? The period of gestation is an additional risk factor for the development of intestinal obstruction. Most often it happens in the 2nd and 3rd trimester of pregnancy, less often in the 1st trimester. In 25-50% of cases, pathology leads to the death of a woman, and a child is born dead in 60-75% of cases. However, provided that the operation was performed in the first 3 hours of the obstruction manifest, the death of the patient happens only in 5% of cases.
What is chronic intestinal obstruction? It develops against the background of the presence of adhesions in the abdominal cavity, or with a tumor that cannot be removed. The patient is prescribed medication. If no effect, then carry out the operation. At the same time, each intervention involves the risk of the formation of new adhesions. Alternatively, a colostomy may be formed.
Education: Moscow Medical Institute. I. M. Sechenov, specialty - “Medicine” in 1991, in 1993 “Occupational diseases”, in 1996 “Therapy”.
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