Intestinal obstruction. Specific symptoms of the window Pathogenesis of acute intestinal obstruction

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Acute intestinal obstruction

What is acute intestinal obstruction -

Acute intestinal obstruction(more precisely, intestinal obstruction!) is characterized by a violation of the passage of intestinal contents in the direction from the stomach to the anus. It does not represent any separate nosological form, being a complication of a wide variety of diseases: external abdominal hernias, intestinal tumors, cholelithiasis, etc. But, having arisen, this pathological condition proceeds according to a single “scenario”, causing intoxication and water-electrolyte disorders, accompanied by typical clinical manifestations. In this regard, diagnostic and therapeutic tactics are largely the same with obstruction that is dissimilar in nature. That is why it is traditionally considered separately, like various surgical diseases, both in scientific and educational literature, and in medical statistics.

What provokes / Causes of acute intestinal obstruction:

The development of mechanical (especially strangulation) intestinal obstruction is based on anatomical prerequisites of a congenital or acquired nature. Such predisposing moments the congenital presence of dolichosigmoid, mobile caecum, additional pockets and folds of the peritoneum can serve. More often these factors are of an acquired nature: adhesive process in the abdominal cavity, lengthening of the sigmoid colon in old age, external and internal abdominal hernias.

The adhesive process in the abdominal cavity develops after previously transferred inflammatory diseases, injuries and operations. For the occurrence of acute intestinal obstruction, isolated inter-intestinal, entero-parietal, and parietal-omental adhesions, which form coarse strands and “windows” in the abdominal cavity, are of the greatest importance, which can cause strangulation (internal infringement) of the movable segments intestines. No less dangerous in clinical terms can be flat inter-intestinal, entero-parietal and entero-omental adhesions, with the formation of intestinal conglomerates, leading to obstructive obstruction during functional overload of the intestine.

Another group of acquired factors contributing to the development of intestinal obstruction are benign and malignant tumors of various parts of the intestine, leading to obstructive obstruction. Obturation can also occur due to compression of the intestinal tube by a tumor from the outside, emanating from neighboring organs, as well as narrowing of the intestinal lumen as a result of perifocal tumor or inflammatory infiltration. Exophytic tumors (or polyps) of the small intestine, as well as Meckel's diverticulum, can cause intussusception.

In the presence of these prerequisites, obstruction occurs under the influence producing factors. For hernias, this can be an increase in intra-abdominal pressure. For other types of obstruction, changes in intestinal motility associated with a change in diet are often a provoking factor: eating a large amount of vegetables and fruits in the summer-autumn period; a plentiful meal against the background of prolonged starvation can cause volvulus of the small intestine (it is no coincidence that SI. Spasokukotsky called it the disease of a hungry person); transition from breastfeeding to artificial in children of the first year of life can be a common cause of iliocecal intussusception.

The causes of dynamic intestinal obstruction are very diverse. Most often, paralytic obstruction is observed, which develops as a result of trauma (including the operating room), metabolic disorders (hypokalemia), and peritonitis. All acute surgical diseases of the abdominal organs, which can potentially lead to peritonitis, occur with symptoms of intestinal paresis. A decrease in the peristaltic activity of the gastrointestinal tract is noted when physical activity is limited (bed rest) and as a result of long-term non-stopping biliary or renal colic. Spastic intestinal obstruction is caused by damage to the brain or spinal cord (metastases of malignant tumors, dorsal tassels, etc.), poisoning with heavy metal salts (for example, lead colic), hysteria.

Pathogenesis (what happens?) during acute intestinal obstruction:

pathological anatomy

Pathological changes in both the intestines and the abdominal cavity in acute intestinal obstruction depend on its type. With strangulation obstruction, the blood circulation of the intestinal area is primarily disturbed, therefore its ischemic and necrobiotic changes occur much earlier and are more pronounced. Obstructive obstruction causes secondary disorders of blood flow in the intestinal wall due to overstretching of the adductor section by the contents.

With acutely developed obturation, the pressure in the intestine increases proximal to the level of the obstruction. It swells from overflowing gases and liquid contents. The intestinal wall thickens due to the development of edema, as well as venous congestion and stasis, and acquires a cyanotic character. In the future, it undergoes overstretching and becomes significantly thinner. Increased intra-intestinal pressure up to 10 mm Hg. Art. after 24 hours, it causes hemorrhages and ulcerations in the intestinal wall, which reflects its ischemic damage. If the pressure rises to 20 mm Hg. Art. there are irreversible necrotic changes in its wall.

Destructive changes spread both along the mucous membrane and deep into the intestinal wall up to the serous cover, in connection with which an inflammatory leukocyte infiltration appears in its thickness. Edema spreading to the mesentery increases venous congestion, under the influence of biologically active amines, ischemic paralysis of precapillary sphincters joins, stasis progresses in the vessels of the microvasculature, and aggregation of blood cells increases. The released tissue kinins and histamine disrupt the permeability of the vascular wall, which contributes to interstitial edema of the intestine and its mesentery and fluid leakage, first into the intestinal lumen, and then into the abdominal cavity.

cavity. While maintaining circulatory disorders, the areas of necrobiosis expand and deepen, merging into extensive zones of necrosis of the mucous membrane and submucosal layers. It should be noted that necrotic changes in the serous cover of the intestinal wall appear last and, as a rule, are smaller in length, which often makes it difficult to accurately determine intraoperative areas of non-viability of the intestine. This circumstance must be taken into account by the surgeon, who decides during the surgical intervention the question of the border of the bowel resection.

With the progression of necrosis, perforation of the intestinal wall may occur (we recall once again that the violation of the viability of the intestine occurs much faster with strangulation obstruction). It should be emphasized that in various forms of strangulation intestinal obstruction (retrograde strangulation, volvulus, nodulation), intestinal circulatory disorders are often observed in two or more places. At the same time, the section of the intestine, isolated from the adductor and efferent sections, as a rule, undergoes especially deep and pronounced pathomorphological changes. This is due to the fact that the circulation of the closed loop of the intestine, due to repeated bending of the mesentery, deep paresis, stretching with gases and liquid contents, suffers much more. With persistent obstruction, pathomorphological changes in the organ progress, circulatory disorders worsen, both in the intestinal wall and in its mesentery, with the development of vascular thrombosis and intestinal gangrene.

Pathogenesis

Acute intestinal obstruction causes pronounced disorders in the body of patients, which determine the severity of the course of this pathological condition. In general, one can state its inherent disorders of the water-electrolyte balance and acid-base state, protein loss, endotoxicosis, intestinal insufficiency and pain syndrome.

Humoral disorders associated with the loss of large amounts of water, electrolytes and proteins. The fluid is lost with vomit (irretrievable losses), deposited in the adductor intestine, accumulates in the edematous intestinal wall and mesentery, and is contained in the abdominal cavity in the form of exudate (blocked reserve). If the obstruction is removed, as the processes of filtration and reabsorption normalize, this reserve of water can again take part in the exchange. In conditions of non-eliminated obstruction, fluid loss during the day can reach 4.0 liters or more. This leads to hypovolemia and tissue dehydration, hemoconcentration, microcirculation disorders and tissue hypoxia. These pathophysiological moments directly affect the clinical manifestations of this pathological condition, which is characterized by dry skin, oliguria, arterial hypotension, high hematocrit and relative erythrocytosis.

Hypovolemia and dehydration increase the production of antidiuretic hormone and aldosterone. This results in a reduction in the amount of discharge

urine, sodium reabsorption and significant excretion of potassium. Instead of 3 potassium ions, 2 sodium ions and 1 hydrogen ion enter the cell. Potassium is excreted in the urine and lost in the vomit. This causes the occurrence of intracellular acidosis, hypokalemia and metabolic extracellular alkalosis. A low level of potassium in the blood is fraught with a decrease in muscle tone, a decrease in myocardial contractility and inhibition of intestinal peristaltic activity. In the future, due to the destruction of the intestinal wall, the development of peritonitis and oliguria, hyperkalemia occurs (which is also far from indifferent to the body, one should remember the possibility of potassium cardiac arrest) and metabolic acidosis.

Along with fluid and electrolytes, a significant amount of protein is lost (up to 300 g per day) due to starvation, vomiting, sweating into the intestinal lumen and abdominal cavity. The loss of plasma albumin is especially significant. Protein losses are exacerbated by the prevalence of catabolism processes.

From this it is clear that for the treatment of patients with intestinal obstruction, it is necessary not only to transfuse liquid (up to 5.0 liters on the first day of therapy), but also to introduce electrolytes, protein preparations, and normalize the acid-base state.

Endotoxicosis seems to be an important link in pathophysiological processes in intestinal obstruction. The fluid in the adductor intestine consists of digestive juices, food chyme and transudate (it contains plasma proteins, electrolytes and blood cells), which enters the intestinal lumen due to increased permeability of the vascular wall. Under conditions of disturbed intestinal passage, a decrease in the activity of cavitary and parietal digestion, and the activation of microbial enzymatic cleavage, all this rather quickly decomposes and undergoes decay. This is facilitated by the reproduction of microflora in stagnant intestinal contents. With the acquisition of the dominant role of symbiotic digestion in the intestinal chyme, the number of products of incomplete protein hydrolysis increases - various polypeptides, which are representatives of the group of toxic molecules of medium size. Under normal conditions, these and similar compounds are not absorbed through the intestinal wall. Under conditions of circular hypoxia, it loses the function of a biological barrier, and a significant part of the toxic products enters the general bloodstream, which contributes to the growth of intoxication.

At the same time, the microbial factor should be recognized as the main point in the genesis of endogenous intoxication. In case of intestinal obstruction, the normal microbiological ecosystem is disrupted (I.A. Eryukhin et al., 1999) due to stagnation of the contents, which contributes to the rapid growth and reproduction of microorganisms, as well as due to the migration of the microflora characteristic of the distal intestines to the proximal for which it seems alien (colonization of the small intestine by the colonic microflora). The release of exo- and endotoxins, a violation of the barrier function of the intestinal wall lead to the translocation of bacteria into the portal bloodstream, lymph and peritoneal exudate. These processes underlie the systemic inflammatory response and abdominal surgical sepsis characteristic of acute intestinal obstruction. The development of intestinal necrosis and purulent peritonitis becomes the second source of endotoxicosis. The apotheosis of this process is the aggravation of tissue metabolism disorders and the occurrence of multiple organ dysfunction and insufficiency, which are characteristic of severe sepsis. (See chapters IV and XIII for more on these processes.)

Specific for obstruction are disorders of motor and secretory-resorptive function intestines, which, together with some other pathological manifestations (impaired barrier function, suppression of local immunity, etc.), are currently commonly referred to as "intestinal failure". In the early stage of obstruction, peristalsis intensifies, while the intestinal loop, with its contractions, seems to be trying to overcome the obstacle that has appeared. At this stage, peristaltic movements in the adductor loop are shortened in length, but become more frequent. Excitation of the parasympathetic nervous system while maintaining the obstacle can lead to the occurrence of antiperistalsis. Later, as a result of hypertonicity of the sympathetic nervous system, a phase of significant inhibition of motor function develops, peristaltic waves become rarer and weaker, and in the later stages of obstruction, complete paralysis of the intestine develops. This is based on the increasing circulatory hypoxia of the intestinal wall, as a result of which the possibility of transmitting impulses through the intramural apparatus is gradually lost. Then, the muscle cells themselves turn out to be unable to perceive impulses for contraction as a result of deep metabolic disorders and intracellular electrolyte disturbances. Disorders of the metabolism of intestinal cells are exacerbated by increasing endogenous intoxication, which, in turn, increases tissue hypoxia.

Expressed pain syndrome often develops with strangulation intestinal obstruction due to compression of the nerve trunks of the mesentery. Severe cramping-like pains also accompany obstructive obstruction. This supports disorders of central hemodynamics and microcirculation, which determines the severe course of this pathological condition.

Symptoms of acute intestinal obstruction:

The successful solution of diagnostic issues, the choice of optimal surgical tactics and the scope of surgical intervention for any disease are closely related to its classification.

Classification of acute intestinal obstruction

Dynamic (functional) obstruction

spastic

Paralytic

Mechanical obstruction

According to the mechanism of development

strangulation(infringement, inversion, knotting)

Obstructive(obturation with a tumor, foreign body, fecal or gallstone, phytobezoar, ball of ascaris)

mixed(invaginated, adhesive)

By obstacle level

high(small intestine)

Low(colonic)

For this pathological condition, the morpho-functional classification is most acceptable, according to which, due to the occurrence, it is customary to distinguish between dynamic (functional) and mechanical intestinal obstruction. With dynamic obstruction, the motor function of the intestinal wall is disturbed, without a mechanical obstacle to the promotion of intestinal contents. There are two types of dynamic obstruction: spastic and paralytic.

Mechanical obstruction characterized by the presence of occlusion of the intestinal tube at any level, which causes a violation of intestinal transit. With this type of obstruction, it is important to distinguish between strangulation and obstruction of the intestine. At strangulation obstructionprimary the blood circulation of the part of the intestine involved in the pathological process suffers. This is due to compression of the vessels of the mesentery due to infringement, volvulus or nodulation, which causes a rather rapid (within a few hours) development of gangrene of the intestinal area. At obstructive intestinal obstruction blood circulation of the above obstacle (leading) section of the intestine is disturbed secondarily due to its overstretching by intestinal contents. That is why necrosis of the intestine is also possible during obturation, but for its development it takes not several hours, but several days. Obturation can be caused by malignant and benign tumors, fecal and gallstones, foreign bodies, roundworms. To mixed forms mechanical obstruction include invagination, in which the mesentery of the intestine is involved in the intussusceptum, and adhesive obstruction, which can occur both in the strangulation type (compression of the intestine with the mesentery by a strand) and in the type of obturation (inflection of the intestine in the form of " double-barreled shotguns").

Diagnostic and therapeutic tactics largely depend on the localization of the obstruction in the intestine, in this regard, according to the level of obstruction, there are: high(small intestine) and low(colonic) obstruction.

In our country, the frequency of acute intestinal obstruction is approximately 5 people per 100 thousand of the population, and in relation to urgent surgical patients - up to 5%. At the same time, in terms of deaths in absolute terms, this pathology shares the first or second place among all acute diseases of the abdominal organs.

Acute intestinal obstruction can occur in all age groups, but is most common between the ages of 30 and 60. Obstruction due to intussusception and malformations of the intestine often develops in children, strangulation forms are mainly observed in patients older than 40 years of age. Obstructive intestinal obstruction due to a tumor process is usually observed in patients older than 50 years. As for the frequency of acute intestinal obstruction, depending on the sex of the patient, in women it is observed 1.5-2 times less than in men, with the exception of adhesive obstruction, which women often suffer from. This type of obstruction accounts for more than 50% of all observations of this pathological condition.

Diagnosis of acute intestinal obstruction:

Leading symptoms acute intestinal obstruction are abdominal pain, bloating, vomiting, stool retention and gases. They have a different degree of severity depending on the type of obstruction, the level and duration of the disease.

pain usually occur suddenly, regardless of food intake, at any time of the day, without any precursors. They are characterized by a cramping-like character associated with periods of intestinal hyperperistalsis, without a clear localization in any part of the abdominal cavity. With obstructive intestinal obstruction outside of a cramping attack, they usually completely disappear. Strangulation obstruction is characterized by constant sharp pains, periodically intensifying. With the progression of the disease, acute pain, as a rule, subsides on the 2-3rd day, when the peristaltic activity of the intestine stops, which is a poor prognostic sign. Paralytic ileus occurs with constant dull arching pains in the abdomen.

Vomit at first it is reflex in nature, with continued obstruction, vomit is represented by stagnant gastric contents. In the late period, it becomes indomitable, vomit acquires a fecal appearance and smell due to the rapid reproduction of Escherichia coli in the upper parts of the digestive tract. Fecal vomiting is an undoubted sign of mechanical intestinal obstruction, but for a confident diagnosis of this pathological condition, you should not wait for this symptom, since it often indicates "the inevitability of a fatal outcome" (G. Mondor). The higher the level of obstruction, the more pronounced the vomiting. In the intervals between it, the patient experiences nausea, he is disturbed by belching, hiccups. With a low localization of the obstruction in the intestine, vomiting occurs later and proceeds at large intervals.

Stool and gas retention - pathognomonic sign of intestinal obstruction. This is an early symptom of low obstruction. With its high character at the beginning of the disease, especially under the influence of therapeutic measures, there may be stools, sometimes multiple, due to the emptying of the intestine located below the obstacle. With intussusception, bloody discharge sometimes appears from the anus. This can cause a diagnostic error when acute intestinal obstruction is mistaken for dysentery.

Anamnesis is important in the successful diagnosis of acute intestinal obstruction. Postponed operations on the abdominal organs, open and closed injuries of the abdomen, inflammatory diseases are often a prerequisite for the occurrence of adhesive intestinal obstruction. An indication of recurrent abdominal pain, bloating, rumbling, stool disorders, especially alternating constipation with diarrhea, can help in the diagnosis of tumor obstructive obstruction.

It is important to note the fact that the clinical picture of high intestinal obstruction is much brighter, with early onset of symptoms of dehydration, severe disorders of the acid-base state and water-electrolyte metabolism.

General condition of the patient may be moderate or severe, depending on the form, level and time elapsed from the onset of acute intestinal obstruction. The temperature in the initial period of the disease does not rise. With strangulation obstruction, when collapse occurs, the temperature can drop to 35 ° C. Later, with the development of a systemic inflammatory reaction and peritonitis, hyperthermia appears. The pulse at the beginning of the disease does not change, the increase in the phenomena of endotoxicosis and dehydration is manifested by tachycardia. Note the clear discrepancy between relatively low body temperature and rapid pulse (symptom of toxic scissors). The tongue becomes dry, covered with a dirty coating.

Examination of the abdomen a patient with suspected intestinal obstruction should definitely start with examination of all possible places of hernia exit, to exclude their infringement as the cause of this dangerous syndrome. Particular attention is needed to femoral hernias in older women. The infringement of a section of the intestine without a mesentery in a narrow hernial orifice is not accompanied by pronounced local pain sensations, therefore, patients do not always actively complain about the appearance of a small protrusion below the inguinal ligament, which precedes the onset of symptoms of obstruction.

Postoperative scars may indicate the adhesive nature of intestinal obstruction. The most constant signs of obstruction include bloating. Its degree can be different, depending on the level of occlusion and the duration of the disease. With high obstruction, it can be insignificant and often asymmetric, the lower the level of the obstruction, the more pronounced this symptom. Diffuse flatulence is characteristic of paralytic and obstructive colonic obstruction. As a rule, as the duration of the disease increases, so does bloating.

Incorrect configuration of the abdomen and its asymmetry are more characteristic of strangulation intestinal obstruction. Sometimes, especially in malnourished patients, one or several swollen intestinal loops can be seen through the abdominal wall, periodically peristalting.

Visible peristalsis- an undoubted sign of mechanical obstruction of the intestine. It is usually determined with slowly developing obstructive tumor obstruction, when the musculature of the adducting intestine has time to hypertrophy.

Local bloating with a swollen loop of intestine palpated in this area, over which high tympanitis is determined (Val's symptom)- an early symptom of mechanical intestinal obstruction. With volvulus of the sigmoid colon, swelling is localized closer to the right hypochondrium, while in the left iliac region, that is, where it is usually palpated, there is a retraction of the abdomen (Schiemann symptom).

Palpation abdomen in the interictal period (during the absence of cramping pain due to hyperperistalsis) before the development of peritonitis, as a rule, it is painless. Tension of the muscles of the anterior abdominal wall is absent, as is the Shchetkin-Blumberg symptom. With strangulation obstruction on the basis of volvulus of the small intestine, it is positive Thevenard's symptom sharp pain when pressing the abdominal wall two transverse fingers below the navel in the middle line, that is, where the root of her mesentery is usually projected. Sometimes during palpation it is possible to determine the tumor, the body of the invaginate or the inflammatory infiltrate that caused the obstruction.

With sukussiya (slight shaking of the abdomen), you can hear the "splashing noise" - Sklyarov's symptom. Its identification is helped by auscultation of the abdomen with a phonendoscope during the hand application of jerky movements of the anterior abdominal wall in the projection of the swollen loop of the intestine. The detection of this symptom indicates the presence of an overstretched paretic loop of the intestine, overflowing with liquid and gaseous contents. This symptom with a high degree of probability indicates the mechanical nature of the obstruction.

Percussion allows you to determine the limited areas of the zones of dullness, which corresponds to the location of the loops of the intestine, filled with fluid, directly adjacent to the abdominal wall. These areas of dullness do not change their position when the patient turns, which is how they differ from dullness caused by effusion in the free abdominal cavity. Dullness is also detected over a tumor, inflammatory infiltrate or intussusception of the intestine.

Auscultation of the abdomen, according to the figurative expression of our surgical teachers, is necessary in order to “hear the noise of the beginning and the silence of the end” (G. Mondor). In the initial period of intestinal obstruction, a sonorous resonating peristalsis is heard, which is accompanied by the appearance or intensification of abdominal pain. Sometimes you can catch the "noise of a falling drop" (symptom of Spasokukotsky - Wilms) after sounds of fluid transfusion in distended bowel loops. Peristalsis can be induced or increased by tapping the abdominal wall or by palpation. As obstruction develops and paresis increases, intestinal noises become short, rare, and higher tones. In the late period, all sound phenomena gradually disappear and are replaced by "dead (grave) silence" - undoubtedly an ominous sign of intestinal obstruction. During this period, with a sharp swelling of the abdomen, one can hear not peristalsis above it, but breath sounds and heart tones, which are normally not carried through the abdomen.

Examination of a patient with acute intestinal obstruction must be supplemented digital rectal examination. In this case, it is possible to determine the "fecal blockage", a tumor of the rectum, the head of the intussusceptum and traces of blood. A valuable diagnostic sign of low colonic obstruction, determined by rectal examination, is atony of the anal sphincter and balloon-like swelling of the empty ampoule of the rectum. (symptom of the Obukhov hospital, described by I.I. Grekov). This type of obstruction is inherent and symptom of Zege-Manteuffel, consisting in the small capacity of the distal intestine when setting a siphon enema. At the same time, no more than 500-700 ml of water can be injected into the rectum.

Clinical manifestations of obstruction depend not only on its type and the level of occlusion of the intestinal tube, but also on the phase (stage) of the course of this pathological process. It is customary to distinguish three stages of acute intestinal obstruction.

1. Initial - stage of local manifestations of acute violation of the intestinal passage lasting from 2 to 12 hours, depending on the form of obstruction. In this period, pain syndrome and local symptoms from the abdomen dominate.

2. Intermediate - stage of imaginary well-being, characterized by the development of acute intestinal failure, water and electrolyte disorders and endotoxemia. It usually lasts from 12 to 36 hours. In this phase, the pain loses its cramping character, becomes constant and less intense. The abdomen is strongly swollen, intestinal motility weakens, a "splashing noise" is heard. The delay of a chair and gases is complete.

3. Late - stage of peritonitis and severe abdominal sepsis, it is often called the terminal stage, which is not far from the truth. It occurs 36 hours after the onset of the disease. This period is characterized by manifestations of a severe systemic inflammatory reaction, the occurrence of multiple organ dysfunction and insufficiency, pronounced intoxication and dehydration, as well as progressive hemodynamic disorders. The abdomen is significantly swollen, peristalsis is not heard, peritoneal symptoms are determined.

Instrumental diagnostics

The use of instrumental research methods for suspected intestinal obstruction is intended both to confirm the diagnosis and to clarify the level and cause of the development of this pathological condition.

X-ray examination remains the main special method for diagnosing acute intestinal obstruction. It should be carried out at the slightest suspicion of this condition. As a rule, an overview fluoroscopy (-graph) of the abdominal cavity is performed first. In this case, the following signs can be identified:

1. Intestinal arches occur when the small intestine is swollen with gases, while in the lower knees of the arcades, horizontal levels of liquid are visible, the width of which is inferior to the height of the gas column. They characterize the predominance of gas over the liquid contents of the intestine and are found, as a rule, in relatively earlier stages of obstruction.

2. Cloiber bowls- horizontal levels of liquid with a dome-shaped enlightenment (gas) above them, which looks like a bowl turned upside down. If the width of the liquid level exceeds the height of the gas bubble, it is most likely localized in the small intestine.

Plain radiograph of the abdominal cavity. Enteric fluid levels and Cloiber cups.

The predominance of the vertical size of the bowl indicates the localization of the level in the large intestine. Under conditions of strangulation obstruction, this symptom may appear within 1 hour, and with obstructive obstruction, within 3-5 hours from the moment of the disease. With small bowel obstruction, the number of bowls varies, sometimes they can overlap one another in the form of a step ladder. Low colonic obstruction in the later stages can manifest as both colonic and small intestinal levels. The location of the Kloiber cups at the same level in one intestinal loop usually indicates the presence of deep intestinal paresis and is characteristic of the late stages of acute mechanical or paralytic ileus.

3. Pinnate symptom(transverse striation of the intestine in the form of a stretched spring) occurs with high intestinal obstruction and is associated with edema and distension of the jejunum, which has high circular folds of the mucosa.

X-ray contrast study gastrointestinal tract is used for difficulties in diagnosing intestinal obstruction.

Depending on the expected level of intestinal occlusion, barium suspension is either given per os (signs of high obstructive obstruction) or administered by enema (symptoms of low obstruction). Oral use of a radiopaque preparation (in a volume of about 50 ml) involves repeated (dynamic) study of barium passage. Its delay for more than 6 hours in the stomach and 12 hours in the small intestine gives reason to suspect a violation of the patency or motor activity of the intestine. With mechanical obstruction, the contrast mass does not enter below the obstacle.

emergency irrigoscopy allows to detect obstruction of the colon by a tumor, as well as to detect trident symptom - sign of ileocecal intussusception.

Irrigoscopy. Tumor of the descending colon with resolved intestinal obstruction.

Colonoscopy currently plays an important role in the timely diagnosis and treatment of tumor colonic obstruction. After enemas performed for therapeutic purposes, the distal (abducting) section of the intestine is cleared of the remnants of feces, which allows a full-fledged endoscopic examination. Its implementation makes it possible not only to accurately localize the pathological process, but also to perform intubation of the narrowed part of the intestine, thereby resolving the phenomena of acute obstruction and performing surgery for cancer in more favorable conditions.

Ultrasound procedure of the abdominal cavity has little diagnostic capabilities in acute intestinal obstruction due to severe pneumatization of the intestine, which complicates the visualization of the abdominal organs. At the same time, in some cases, this method makes it possible to detect a tumor in the large intestine, an inflammatory infiltrate, or an invaginate head.

Clinical signs of acute intestinal obstruction can be observed in a variety of diseases. Ways to rule out non-surgical pathology have been discussed in Chapters I and II of this Guide. It is of fundamental importance that all acute surgical diseases of the abdominal organs, which cause the possibility of the development of peritonitis, proceed with the phenomena of paralytic intestinal obstruction. If the surgeon diagnoses widespread peritonitis, then before the operation (it is mandatory in this case), it is not so important to know whether it is caused by mechanical intestinal obstruction, or whether it itself was the cause of severe dynamic obstruction. This will become clear during the intraoperative revision of the abdominal cavity. It is much more important for the development of adequate diagnostic and therapeutic tactics to determine (naturally, before the development of peritonitis), what type of obstruction the surgeon encountered: strangulation or obstruction (1), high or low (2) and, finally, mechanical or dynamic ( 3). The actions of the surgeon largely depend on the answer to these questions.

1. Strangulation or obturation obstruction? First of all, during the examination, infringement of external abdominal hernias, as a cause of strangulation obstruction, should be excluded. If an infringement is found (see chapter VI), emergency surgical intervention should be performed without any complex instrumental examination.

The strangulation nature of the obstruction, caused by torsion, nodulation, or internal infringement, is indicated by severe persistent pain, which can sometimes intensify, but never completely disappear. It is characterized by vomiting from the very beginning of the disease and quite often by asymmetry of the abdomen. The condition of patients is progressively and rapidly deteriorating, there are no "light" intervals.

2. High or low obstruction? The answer to this question is important, if only because the method of X-ray contrast examination depends on it (dynamic observation of the passage of a barium suspension

or irrigoscopy). High obstruction is characterized by early and frequent vomiting, gas discharge and the presence of stool in the first hours of the disease, rapid dehydration of the patient (dry skin with reduced turgor, a decrease in urine output, low CVP, high hematocrit). For her, local flatulence and Val's symptom are more typical. Panoramic fluoroscopy shows small intestinal levels (with a predominance of the horizontal size of the Kloiber bowl over the vertical one). Low colonic obstruction is manifested by rare vomiting, significantly less pronounced signs of dehydration, positive symptoms of Zege-Manteuffel and the Obukhov Hospital. Plain radiograph shows colonic levels (they can be combined with small intestine with prolonged bowel obstruction).

3. Mechanical or dynamic obstruction? Solution this task is not only difficult, but also extremely responsible. Dynamic obstruction itself usually does not require surgical intervention. Moreover, an unreasonable operation can only aggravate it. On the other hand, with mechanical obstruction, as a rule, surgical treatment is indicated.

The starting points of differential diagnosis in this case should have been the features of the pain syndrome. Unfortunately, dynamic obstruction can manifest itself as cramping (spastic) and dull, arching constant (intestinal paresis) pain. Moreover, dynamic obstruction that accompanies, for example, a long-term non-stopping attack of renal colic, can turn from a spastic type into a paralytic one. Of course, vomiting should be more pronounced with mechanical obstruction, but severe paresis of the gastrointestinal tract is also accompanied by copious amounts of congestive gastric tube discharge, the appearance of intestinal levels on the plain radiograph. This primarily applies to acute pancreatitis. Pronounced prolonged paresis of the stomach and intestines is so inherent in this disease that there is an unwritten rule among surgeons: in all cases of suspected intestinal obstruction, urine should be examined for diastasis. This simple test is often the only way to avoid an unnecessary laparotomy. Local flatulence, the symptoms of Val, Zege-Manteuffel and the Obukhov hospital are inherent only in mechanical obstruction. On the other hand, diffuse flatulence and the absence of these symptoms do not exclude its presence.

Similar diagnostic uncertainty: the patient has a dynamic or mechanical obstruction, which is characteristic of this pathological condition. That is why in many cases they resort to conservative treatment without a final diagnosis and without a final decision on the indications for emergency surgery.

Treatment of acute intestinal obstruction:

Since intestinal obstruction is a complication of various diseases, there is not, and cannot be, a single way to treat it. At the same time, the principles of therapeutic measures in this pathological condition are quite uniform. They can be formulated as follows.

1. All patients with suspected obstruction should be urgently hospitalized in a surgical hospital. The terms of admission of such patients to medical institutions largely determine the prognosis and outcome of the disease. The later hospitalized patients with acute intestinal obstruction, the higher the mortality rate.

2. All types of strangulation intestinal obstruction, as well as any type of intestinal obstruction, complicated by peritonitis, require urgent surgical intervention. Due to the severe condition of the patients, only short-term (no more than 1.5-2 hours) intensive preoperative preparation can be justified.

3. Dynamic intestinal obstruction is subject to conservative treatment, since surgical intervention in itself leads to the occurrence or aggravation of intestinal paresis.

4. Doubts about the diagnosis of mechanical intestinal obstruction in the absence of peritoneal symptoms indicate the need for conservative treatment. It stops dynamic obstruction, eliminates some types of mechanical, serves as preoperative preparation in cases where this pathological condition is not resolved under the influence of therapeutic measures.

5. Conservative treatment should not serve as an excuse for an unreasonable delay in surgical intervention, if the need for it is already overdue. Decreased mortality in intestinal obstruction can be ensured, first of all, by active surgical tactics.

6. Surgical treatment of mechanical intestinal obstruction involves persistent postoperative therapy of water and electrolyte disorders, endogenous intoxication and paresis of the gastrointestinal tract, which can lead to death of the patient even after removing the obstacle to the passage of intestinal contents.

Conservative treatment should purposefully influence the pathogenesis of intestinal obstruction. Its principles are as follows. Firstly, decompression of the proximal gastrointestinal tract should be ensured by aspiration of the contents through a nasogastric or nasointestinal (installed during surgery) probe. The setting of a cleansing and siphon enema, with their effectiveness (“washing out” of dense fecal masses), allows you to empty the large intestine located above the obstacle and, in some cases, resolve the obstruction. In case of tumor colonic obstruction, it is desirable to intubate the narrowed section of the intestine to unload the adductor section. Secondly, correction of water and electrolyte disturbances and the elimination of hypovolemia are necessary. The general rules for such therapy are set out in Chapter III, here we only note that the volume of infusion therapy carried out under the control of CVP and diuresis (catheterization of one of the central veins and the presence of a catheter in the bladder is desirable) should be at least 3-4 liters. It is imperative to replenish potassium deficiency, as it contributes to the aggravation of intestinal paresis. Thirdly, to eliminate hemodynamic disorders, in addition to adequate rehydration, it is necessary to use rheologically active agents - reopoliglyukin, pentoxifylline, etc. Fourth, it is highly desirable to normalize the protein balance with the help of transfusion of protein hydrolysates, a mixture of amino acids, albumin, protein, and in severe cases - blood plasma. Fifth, it is necessary to influence the peristaltic activity of the intestine: with increased peristalsis and cramping pains in the abdomen, antispasmodics (atropine, platifillin, no-shpu, etc.) are prescribed, with paresis - means that stimulate the motor-evacuation ability of the intestinal tube: intravenous administration of a hypertonic solution sodium chloride (at the rate of 1 ml/kg of the patient's body weight), ganglioblockers, prozerin, ubretide, polyhydric alcohols, for example, sorbitol, Bernard's currents on the anterior abdominal wall). And, finally, last thing(in order, but not in importance), measures are vital to ensure detoxification and prevention of purulent-septic complications. For this purpose, in addition to the transfusion of a significant amount of liquid, it is necessary to use the infusion of low molecular weight compounds (hemodez, sorbitol, mannitol, etc.) and antibacterial agents.

Conservative therapy, as a rule, stops dynamic obstruction (it is possible to resolve some types of mechanical obstruction: coprostasis, invagination, volvulus of the sigmoid colon, etc.). This is its role as a diagnostic and therapeutic tool. If the phenomena of obstruction are not resolved, the therapy performed serves as a measure of preoperative preparation, which is so necessary in this pathological condition.

Surgical treatment acute intestinal obstruction suggests a surgical solution following medical tasks.

1. Elimination of obstacles for the passage of intestinal contents.

2. Elimination (if possible) of the disease that led to the development of this pathological condition.

3. Performing bowel resection if it is not viable.

4. Prevention of the growth of endotoxicosis in the postoperative period.

5. Prevention of recurrence of obstruction.

Let us consider in more detail the significance of these tasks and the possibilities of their solution. Removal of mechanical obstruction, that caused intestinal obstruction should be considered as the main goal of surgical intervention. Surgical assistance may vary and, ideally, it will not only eliminate the obstruction, but and eliminates the disease, that caused it, that is, it simultaneously solves two of the above tasks.

An example of such interventions can be resection of the sigmoid colon along with a tumor due to low obturation obstruction, elimination of strangulation obstruction due to infringement of the external abdominal hernia by hernia repair, followed by hernia orifice plasty, etc. At the same time, such a radical intervention is far from always feasible due to the severity of the patient's condition and the nature of the intestinal changes. So, with tumor colonic obstruction, the surgeon may be forced to limit himself to only applying a double-barreled colostomy above the obstacle, postponing the resection of the intestine for some time (at the second stage), when such a traumatic intervention will be possible due to the patient’s condition and intestines. Moreover, sometimes interintestinal anastomosis and/or colostomy closure has to be performed as early as during the third stage of surgical treatment.

During the operation, the surgeon, in addition to eliminating the obstruction, must assess the condition of the intestines, necrosis of which is observed both in the strangulation and obturation nature of this pathological condition. Methods for assessing the viability of the intestine will be described below, here we only indicate that this task is very important, since leaving a necrotic intestine in the abdominal cavity dooms the patient to death from peritonitis and abdominal sepsis.

Having eliminated obstruction by radical or palliative surgery, the surgeon cannot complete the intervention on this. He must evacuate the contents of the leading sections of the intestine, since the recovery in the postoperative period of peristalsis and absorption of toxic contents from the intestinal lumen will cause an aggravation of endotoxemia with the most deplorable consequences for the patient and the surgeon. At present, the method of choice in solving this problem should be considered intestinal intubation through the nasal passages, pharynx, esophagus and stomach; using a gastrostomy, cecostomy or through the anus. This procedure ensures the removal of toxic contents and the elimination of the consequences of paresis of the gastrointestinal tract, both during surgery and in the postoperative period.

When completing an operation, the surgeon should consider whether the patient is in danger of recurrence of obstruction. If this is highly likely, he should take steps to prevent this possibility. An example is the volvulus of the sigmoid colon, which occurs with dolichosigmoid. Detorsion (untwisting) of the volvulus eliminates non-patency, but does not completely exclude its recurrence, sometimes it develops again in the immediate postoperative period. Therefore, if the condition of the patient (and his intestines) allows, a primary resection of the sigmoid colon should be performed (a radical operation that excludes the possibility of a recurrence of this condition). If this is not possible, the surgeon should perform a palliative intervention: dissect the adhesions that bring the adductor and efferent intestines together and make it possible to torsion, perform mesosigmoplication or sigmopexy (the latter is less desirable, since suturing the dilated intestine to the parietal peritoneum fraught with eruption of seams, and sometimes with internal infringement). The specific actions of the surgeon to prevent the recurrence of obstruction depend on its cause, they will be presented below.

After considering the strategic objectives of the surgical treatment of obstruction, we turn to tactical issues that involve a description of the technical methods for solving the previously listed medical problems. The main points of surgical intervention for intestinal obstruction can be considered as follows:

1. Anesthesia support.

2. Surgical access.

3. Revision of the abdominal cavity to detect the cause of mechanical obstruction.

4. Restoration of the passage of intestinal contents or its removal to the outside.

5. Assessment of intestinal viability.

6. Resection of the intestine according to indications.

7. Imposition of interintestinal anastomosis.

8. Drainage (intubation) of the intestine.

9. Sanitation and drainage of the abdominal cavity.

10. Closure of the surgical wound.

Surgical treatment of acute intestinal obstruction involves intubation endotracheal anesthesia with muscle relaxants(details of anesthetic management of operations, see chapter III). Carry out a wide median laparotomy. This access is necessary in the vast majority of cases, since in addition to the revision of the entire intestine during the intervention, it is often necessary to perform an extensive resection and intubation, as well as sanitation and drainage of the abdominal cavity.

The opening of the abdominal cavity should be carried out very carefully, especially during repeated abdominal operations (which is often with adhesive intestinal obstruction). Accidental damage and opening of the lumen of a sharply dilated adductor intestine, often fixed to the anterior abdominal wall, is fraught with the most adverse consequences. Due to the contamination of the abdominal cavity and surgical wound with highly pathogenic strains of the intestinal microflora, the development of purulent peritonitis and septic (often anaerobic) phlegmon of the anterior abdominal wall is highly likely. Therefore, it is preferable to open the abdominal cavity outside the area of ​​the postoperative scar.

After the evacuation of the effusion (by its nature, one can roughly judge the severity of the pathological process: serous exudate is characteristic of the initial period of obstruction, hemorrhagic evidence of circulatory disorders in the intestinal wall, dirty brown - of intestinal necrosis) produce novocaine blockade of the mesentery root -coy and transverse colon. To do this, use 250-300 ml of a 0.25% solution of novocaine.

Revision of the abdominal cavity should identify the exact localization of intestinal obstruction and its cause. Approximately the location of this zone is judged by the state of the intestine: above the obstacle, the afferent intestine is swollen, overflowing with gas and liquid contents, its wall is usually thinned and differs in color from other departments (from purple-cyanotic to dirty black), the intestine is in a collapsed state, its walls in the absence of peritonitis are not changed. It is important to remember that the obstacle that caused the development of obstruction may be located in several places at different levels, that is why a thorough examination of the entire intestine is necessary: ​​from the pylorus to the rectum.

Often, revision of the intestine, especially with "neglected" obstruction, is difficult due to swollen intestinal loops that literally fall out of the abdominal cavity. It is unacceptable to leave overstretched intestinal loops filled with a large amount of liquid contents outside the abdominal cavity due to the fact that under gravity they can significantly stretch the mesentery, which further exacerbates circulatory disorders in them. In the process of revision, the intestines should be moved very carefully, wrapping them in a towel soaked in hot saline. It should be warned against attempts to reposition them back into the abdominal cavity, as this can lead to a rupture of the thinned intestinal wall. In such cases, it is advisable first of all to empty the leading sections of the intestine from gases and liquid contents. Best to do it right away intestinal intubation by transnasal insertion of a double-lumen Miller-Abbott probe, as it progresses, the intestinal contents are suctioned out. Nasointestinal intubation allows for an adequate revision of the abdominal cavity, ensures bowel emptying on the operating table and in the postoperative period.

Nasointestinal intubation is performed as follows. The anesthesiologist inserts a probe through the lower nasal passage into the pharynx, esophagus, and stomach. Further, the operating surgeon captures it through the wall of the stomach and, moving along the lesser curvature, passes it through the pylorus into the duodenum up to the ligament of Treitz. Following this, the assistant lifts and holds the transverse colon, and the surgeon, by palpation determining the tip of the probe, lowers it into the jejunum (sometimes for these purposes it is necessary to cross the ligament of Treitz). Then the surgeon strings the small intestine onto the probe, passing the latter up to the obstacle, and after its removal - to the ileocecal angle (Fig. 7.5). This procedure is carried out with a constant supply of the probe by the anesthetist. It is important to ensure that the tube does not kink or coil in the stomach or intestines. The proximal openings of the probe must necessarily be in the stomach, and not in the esophagus, which is fraught with aspiration of intestinal contents. On the other hand, if all the holes are located in the intestines, dangerous overflow of the stomach can occur. In some cases, it may be necessary to introduce an additional (second) probe into it.

After performing nasointestinal intubation and detecting an obstacle, they begin to eliminate it: cross the adhesions, unfold the torsion, or perform disinvagination. Elimination of obstructive obstruction in some cases is achieved by enterotomy, in others - with the help of bowel resection, bypass anastomosis or colostomy.

After eliminating the cause of the obstruction, evaluate the viability of the intestine, that in acute intestinal obstruction is one of the most difficult tasks, the correct solution of which may determine the outcome of the disease. The severity of changes in the affected area is determined only after the elimination of obstruction and decompression of the intestine.

The main signs of the viability of the intestine are the preserved pink color, the presence of peristalsis and pulsation of the marginal vessels of the mesentery. In the absence of these signs, with the exception of cases of obvious gangrene, 150-200 ml of a 0.25% solution of novocaine is injected into the mesentery of the small intestine, it is covered with napkins moistened with hot saline. After 5-10 minutes, the suspicious area is re-examined. The disappearance of the cyanotic color of the intestinal wall, the appearance of a distinct pulsation of the marginal vessels of the mesentery and the resumption of active peristalsis allow us to consider it viable.

The non-viable bowel should be resected within healthy tissues. Considering that necrotic changes appear first in the mucous membrane, and the serous integuments are affected in the last turn and can be little changed with extensive necrosis of the intestinal mucosa, resection is performed with the obligatory removal of at least 30-40 cm of the adductor and 15- 20 cm of the efferent loops of the intestine (from the strangulation furrows, the obstruction zone or from the boundaries of obvious gangrenous changes). With prolonged obstruction, a more extensive resection may be required, but the always removed section of the leading section should be twice as long as the outlet. Any doubts about the viability of the intestine in case of obstruction should incline the surgeon to active actions, that is, to resection of the intestine. If such doubts relate to a large section of the intestine, the resection of which the patient may not be able to endure, it can be limited to the removal of a clearly necrotic part of the intestine, the anastomosis should not be applied, the leading and abducting ends of the intestine should be sutured tightly. The wound of the anterior abdominal wall is sutured with rare sutures through all layers. Intestinal contents in the postoperative period are evacuated through a nasointestinal probe. 24 hours after the stabilization of the patient's condition against the background of intensive therapy, a relaparotomy is performed for a second revision of the doubtful area. After making sure of its viability (if necessary, resection of the intestine is performed), the proximal and distal ends of the intestine are anastomosed.

An important role in the fight against endotoxicosis belongs to removal of toxic content, which accumulates in the leading section and loops of the intestine that have undergone strangulation. If earlier (during the revision) intestinal intubation was not performed, it should be performed at this moment. Bowel emptying can be achieved through a nasointestinal tube, or by decanting its contents into the area to be resected. It is undesirable to do this through the enterotomy hole because of the danger of infection of the abdominal cavity, but sometimes it is impossible to do without such a manipulation. Then, through enterotomy in the center of the purse-string suture (in the area of ​​the intestine to be removed), a thick probe is inserted.

The operation is completed with careful washing and draining the abdominal cavity. With a significant amount of exudate and necrotic damage to the intestine (after its resection), drain through counter-trapertures the pelvic cavity and the zone of the most pronounced! changes (for example, side channels). Given the persistence of intestinal paresis in the immediate postoperative period and the increased risk of eventration, the wound of the anterior abdominal wall is sutured especially carefully, in layers. It is advisable to apply on the aponeurosis, in addition to the usual, several “8”-shaped lavsan sutures.

Postoperative management of patients. A feature of the immediate postoperative period in acute intestinal obstruction is the persistence of intestinal paresis, water and electrolyte disorders, acid-base disorders, and severe intoxication. Therefore, all measures aimed at eliminating these pathogenetic moments, started in the preoperative period and carried out during the surgical intervention, must be continued after the operation without fail. Of great importance in the prevention and treatment of intestinal paresis belongs to its decompression. This is effectively achieved by prolonged aspiration of intestinal contents through the Miller-Abbott tube and, to a lesser extent, by aspiration of gastric contents. Aspiration, combined with washing and means of selective decontamination of the intestine, is carried out for 3-4 days, until intoxication decreases and active intestinal motility appears. During this time, the patient is on parenteral nutrition. The daily volume of infusion media is at least 3-4 liters.

Correction of water and electrolyte disorders contributes to the restoration of intestinal function. To stimulate the motor function of the intestine, anticholinesterase drugs (prozerin, ubretide), ganglioblockers (dicolin, dimecolin), hypertonic sodium chloride solution, Bernard currents, cleansing and siphon enemas are used.

More than 75% of all complications that develop in the postoperative period in patients undergoing surgery for acute intestinal obstruction are associated with infection (peritonitis, wound suppuration, pneumonia).

Which doctors should you contact if you have acute intestinal obstruction:

gastroantherologist

Are you worried about something? Do you want to know more detailed information about acute intestinal obstruction, its causes, symptoms, methods of treatment and prevention, the course of the disease and diet after it? Or do you need an inspection? You can book an appointment with a doctor– clinic Eurolaboratory always at your service! The best doctors will examine you, study the external signs and help identify the disease by symptoms, advise you and provide the necessary assistance and make a diagnosis. you also can call a doctor at home. Clinic Eurolaboratory open for you around the clock.

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If you have previously performed any research, be sure to take their results to a consultation with a doctor. If the studies have not been completed, we will do everything necessary in our clinic or with our colleagues in other clinics.

You? You need to be very careful about your overall health. People don't pay enough attention disease symptoms and do not realize that these diseases can be life-threatening. There are many diseases that at first do not manifest themselves in our body, but in the end it turns out that, unfortunately, it is too late to treat them. Each disease has its own specific signs, characteristic external manifestations - the so-called disease symptoms. Identifying symptoms is the first step in diagnosing diseases in general. To do this, you just need to several times a year be examined by a doctor not only to prevent a terrible disease, but also to maintain a healthy spirit in the body and the body as a whole.

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Other diseases from the group Diseases of the gastrointestinal tract:

1. Kivul's symptom - with percussion, you can hear a tympanic sound with a metallic tinge over a stretched bowel loop.

Kivul's symptom is characteristic of acute intestinal obstruction.

2. Wilms symptom of a falling drop (M. Wilms) - the sound of a falling drop of liquid, determined auscultatively against the background of peristalsis noises with intestinal obstruction.

3. "splash noise", described by I.P. Sklyarov (1923). This symptom is detected with a slight lateral concussion of the abdominal wall, can be localized or be determined throughout the abdomen. The appearance of this phenomenon indicates the presence of an overstretched paretic loop filled with liquid and gas. Mathieu (Mathieu) described the appearance of splashing noise during rapid percussion of the supra-umbilical region. Some authors consider the appearance of splashing noise a sign of neglect of the ileus and, if it is detected, they consider it an indication of an emergency operation.

4. Rovsing's sign: sign of acute appendicitis; on palpation in the left iliac region and simultaneous pressure on the descending colon, gas pressure is transmitted to the ileocecal region, which is accompanied by pain.
The cause of Rovsing's symptom: there is a redistribution of intra-abdominal pressure and irritation of the interoreceptors of the inflamed appendix
5. Symptom of Sitkovsky: sign of appendicitis; when the patient is positioned on the left side, pain appears in the ileocecal region.

Cause of Sitkowski's symptom: irritation of interoreceptors as a result of pulling on the mesentery of the inflamed appendix
6. Symptom of Bartomier-Michelson: sign of acute appendicitis; pain on palpation of the caecum, aggravated by the position on the left side.

The cause of the symptom of Filatov, Bartemier - Michelson: tension of the mesentery of the appendix

7. Description of Razdolsky's symptom - soreness on percussion in the right iliac region.
The cause of Razdolsky's symptom: irritation of the receptors of the inflamed appendix

8. Cullen's symptom - limited cyanosis of the skin around the navel; observed in acute pancreatitis, as well as the accumulation of blood in the abdominal cavity (more often with ectopic pregnancy).

9. Gray Turner's symptom - the appearance of subcutaneous bruising on the sides. This symptom appears 6-24 months after retroperitoneal hemorrhage in acute pancreatitis.

10. Dalrymple's symptom is an expansion of the palpebral fissure, which is manifested by the appearance of a white strip of sclera between the upper eyelid and the iris, due to an increase in the tone of the muscle that lifts the eyelid.

Dalrymple's symptom is characteristic of diffuse toxic goiter.

11. Symptom Mayo-Robson (pain at the point of the pancreas) Pain in the region of the left costovertebral angle (with inflammation of the pancreas) is determined.

12. Resurrection symptom: a sign of acute appendicitis; when quickly holding the palm along the anterior abdominal wall (over the shirt) from the right costal edge down, the patient experiences pain.

13. Symptom of Shchetkin-Blumberg: after soft pressure on the anterior abdominal wall, the fingers are sharply torn off. With inflammation of the peritoneum, pain occurs, which is greater when tearing off the examining hand from the abdominal wall than when pressing on it.

14. Kerr's symptom (1): sign of cholecystitis; pain when inhaling during palpation of the right hypochondrium.

15. Symptom Kalka - soreness on percussion in the projection of the gallbladder

16. Murphy's symptom: a sign of o. cholecystitis; the patient in the supine position; the left hand is positioned so that the thumb fits below the costal arch, approximately at the location of the gallbladder. The remaining fingers of the hand are along the edge of the costal arch. If the patient is asked to take a deep breath, he will stop before reaching the top, due to a sharp pain in the abdomen under the thumb.

17. Ortner's symptom: a sign of o. cholecystitis; the patient is in the supine position. When tapping with the edge of the palm along the edge of the costal arch on the right, pain is determined.

18. Symptom of Mussi-Georgievsky (phrenicus-symptom): a sign of o. cholecystitis; pain when pressing with a finger over the collarbone between the front legs m. SCM.

19. Lagophthalmos (from the Greek lagoos - hare, ophthalmos - eye), hare eye, - incomplete closure of the eyelids due to muscle weakness (usually a sign of damage to the facial nerve), in which an attempt to cover the eye is accompanied by a physiological turn of the eyeball upwards, the space of the palpebral fissure occupies only the protein coat (Bell's symptom). Lagophthalmos creates conditions for the drying of the cornea and conjunctiva and the development of inflammatory and degenerative processes in them.

The cause of damage to the facial nerve, leading to the development of lagophthalmia, is usually neuropathy, neuritis, as well as traumatic damage to this nerve, in particular during surgery for neuroma VIII

cranial nerve. The inability to close the eyelids is sometimes observed in seriously ill people, especially in young children.

The presence of paralytic lagophthalmos or the inability to close the eyes for another reason requires measures aimed at preventing possible damage to the eye, especially its cornea (artificial tears, antiseptic drops and ointments on the conjunctiva of the eyes). If necessary, which is especially likely in case of damage to the facial nerve, accompanied by dry eyes (xerophthalmia), temporary stitching of the eyelids - blepharophthalmia - may be appropriate.

20. Val's symptom: a sign of intestinal obstruction; local flatulence or protrusion of the proximal intestine. Wahl (1833-1890) - German surgeon.

21. Graefe's symptom, or eyelid delay, is one of the main signs of thyrotoxicosis. It is expressed in the inability of the upper eyelid to fall when lowering the eyes down. To identify this symptom, you need to bring a finger, pencil or other object to the level above the patient's eyes, and then lower it down, following the movement of his eyes. This symptom manifests itself when, when the eyeball moves downwards, a white strip of sclera appears between the edge of the eyelid and the edge of the cornea, when one eyelid falls more slowly than the other, or when both eyelids fall slowly and tremble at the same time (see Definition of Graefe's symptom and bilateral ptosis). Eyelid lag is due to chronic contraction of the Müllerian muscle in the upper eyelid.

22. Kerte's symptom - the appearance of pain and resistance in the area of ​​​​the body of the pancreas (in the epigastrium 6-7 centimeters above the navel).

Kerte's symptom is characteristic of acute pancreatitis.

23. Obraztsov's symptom (psoas-symptom): a sign of chronic appendicitis; increased pain during palpation in the ileocecal region with a raised right leg.

^ PRACTICAL SKILLS

1. 
   Compatibility test for blood groups of the ABO system (on the plane)

The test is carried out on a wetted surface plate.

1. The tablet is marked, for which the full name is indicated. and blood group of the recipient, full name and the donor's blood group and blood container number.

2. Carefully take the serum from the test tube with the recipient's blood with a pipette and apply 1 large drop (100 µl) to the tablet.

3. A small drop (10 µl) of donor erythrocytes is taken from a tube segment of a plastic bag with transfusion medium, which is prepared for transfusion to this particular patient, and applied next to the recipient's serum (serum to erythrocyte ratio 10:1).

4. Drops are mixed with a glass rod.

5. Observe the reaction for 5 minutes, while constantly shaking the tablet. After this time, 1-2 drops (50-100 µl) of sodium chloride solution, 0.9% are added.

the reaction in the drop can be positive or negative.

a) a positive result (+) is expressed in agglutination of erythrocytes, agglutinates are visible to the naked eye in the form of small or large red aggregates. The blood is incompatible, it is impossible to transfuse! (see figure 1).

Figure 1. Donor and recipient blood is incompatible

b) with a negative result (-), the drop remains homogeneously colored red, agglutinates are not detected in it. The donor's blood is compatible with the recipient's (see Figure 2).

Figure 2. Donor blood is compatible with recipient blood

3.2. Tests for individual compatibility according to the Rhesus system

3.2.1. Compatibility test using 33% polyglucin solution

The order of the study:

1. For research, take a test tube (centrifuge or any other, with a capacity of at least 10 ml). The tube is labeled, for which the full name is indicated. and blood group of the recipient, and full name of the donor, the number of the container with blood.

2. Serum is carefully taken from the tube with the recipient's blood to be tested with a pipette and 2 drops (100 µl) are added to the bottom of the tube.

3. One drop (50 μl) of donor erythrocytes is taken from a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, into the same tube, 1 drop (50 μl) of a 33% polyglucin solution is added.

4. The contents of the test tube are mixed by shaking and then slowly turned along the axis, tilting almost to a horizontal position so that the contents spread over its walls. This procedure is performed within five minutes.

5. After five minutes, add 3-5 ml of saline to the test tube. solution. The contents of the test tubes are mixed by inverting the test tubes 2-3 times (without shaking!)

Interpretation of reaction results:

the result is taken into account by looking at the test tubes in the light with the naked eye or through a magnifying glass.

If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of a clarified or completely discolored liquid, then the donor's blood is not compatible with the recipient's blood. You can't overflow!

If the test tube contains a uniformly colored, slightly opalescent liquid without signs of erythrocyte agglutination, this means that the donor's blood is compatible with the recipient's blood in relation to antigens of the Rhesus system and other clinically significant systems (see Figure 3).

Figure 3. The results of the study of samples for compatibility according to the Rhesus system (using a 33% polyglucin solution and a 10% gelatin solution)

3.2.2. Compatibility test using 10% gelatin solution

The gelatin solution must be carefully examined before use. When turbidity or the appearance of flakes, as well as the loss of gelatinous properties at t + 4 0 С ... +8 0 С, gelatin is unsuitable.

The order of the study:

1. Take a test tube for research (capacity not less than 10 ml). The test tube is marked, for which the full name, blood group of the recipient and donor, and the number of the container with blood are indicated.

2. One drop (50 µl) of donor erythrocytes is taken from a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, put into a test tube, 2 drops (100 µl) of a 10% gelatin solution heated in a water bath are added to liquefaction at a temperature of +46 0 C ... +48 0 C. From the tube with the recipient's blood, carefully take the serum with a pipette and add 2 drops (100 μl) to the bottom of the tube.

3. The contents of the tube are shaken to mix and placed in a water bath (t+46 0 С...+48 0 С) for 15 minutes or in a thermostat (t+46 0 С...+48 0 С) for 45 minutes.

4. After the end of the incubation, the tube is removed, 5-8 ml of saline is added. solution, the contents of the tube are mixed by one or two inversions and the result of the study is evaluated.

Interpretation of the results of the reaction.

the result is taken into account by viewing the tubes in the light with the naked eye or through a magnifying glass, and then viewed by microscopy. To do this, a drop of the contents of the test tube is placed on a glass slide and viewed under low magnification.

If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of a clarified or completely discolored liquid, this means that the donor's blood is incompatible with the recipient's blood and should not be transfused to him.

If the test tube contains a uniformly colored, slightly opalescent liquid without signs of erythrocyte agglutination, this means that the donor's blood is compatible with the recipient's blood in relation to antigens of the Rhesus system and other clinically significant systems (see Figure 3).
3.3. Gel Compatibility Test

When setting up a gel test, compatibility tests are carried out immediately according to the ABO system (in the Neutral microtube) and a compatibility test according to the Rhesus system (in the Coombs microtube).

The order of the study:

1. Before the study, check the diagnostic cards. Do not use cards if there are suspended bubbles in the gel, the microtube does not contain a supernatant, a decrease in the volume of the gel or its cracking is observed.

2. Microtubes are signed (name of the recipient and number of the donor sample).

3. From a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, 10 μl of donor erythrocytes are taken with an automatic pipette and placed in a centrifuge tube.

4. Add 1 ml dilution solution.

5. Open the required number of microtubes (one each of Coombs and Neutral microtubes).

6. Using an automatic pipette, add 50 µl of diluted donor erythrocytes to Coombs and Neutral microtubes.

7. Add 25 µl of recipient serum to both microtubes.

8. Incubate at t+37 0 C for 15 minutes.

9. After incubation, the card is centrifuged in a gel card centrifuge (time and speed are set automatically).

Interpretation of results:

if the erythrocyte sediment is located at the bottom of the microtube, then the sample is considered compatible (see Figure 4 No. 1). If agglutinates linger on the surface of the gel or in its thickness, then the sample is incompatible (see Figure 4 Nos. 2-6).

№1 №2 №3 №4 №5 №6

Figure 4. The results of the study of samples for individual compatibility according to the Rhesus system by the gel method

3.4. biological sample

To conduct a biological test, blood and its components prepared for transfusion are used.

biological sample carried out regardless of the volume of the hemotransfusion medium and the rate of its administration. If it is necessary to transfuse several doses of blood and its components, a biological test is carried out before the start of transfusion of each new dose.

Technique:

10 ml of blood transfusion medium is transfused once at a rate of 2-3 ml (40-60 drops) per minute, then the transfusion is stopped and the recipient is monitored for 3 minutes, controlling his pulse, respiratory rate, blood pressure, general condition, skin color, measure body temperature. This procedure is repeated twice more. The appearance during this period of even one of such clinical symptoms as chills, back pain, feeling of heat and tightness in the chest, headache, nausea or vomiting, requires immediate termination of the transfusion and refusal to transfuse this transfusion medium. The blood sample is sent to a specialized blood service laboratory for an individual selection of red blood cells.

The urgency of transfusion of blood components does not exempt from performing a biological test. During it, it is possible to continue the transfusion of saline solutions.

When transfusing blood and its components under anesthesia, the reaction or incipient complications are judged by an unmotivated increase in bleeding in the surgical wound, a decrease in blood pressure and an increase in heart rate, a change in the color of urine during catheterization of the bladder, and also by the results of a test to detect early hemolysis. In such cases, the transfusion of this hemotransfusion medium is stopped, the surgeon and the anesthesiologist-resuscitator, together with the transfusiologist, are obliged to find out the cause of hemodynamic disorders. If nothing but transfusion could cause them, then this hemotransfusion medium is not transfused, the issue of further transfusion therapy is decided by them, depending on clinical and laboratory data.

A biological test, as well as an individual compatibility test, is also mandatory in cases where an individually selected in the laboratory or phenotyped erythrocyte mass or suspension is transfused.

After the end of the transfusion, the donor container with a small amount of the remaining hemotransfusion medium used for testing for individual compatibility must be stored for 48 hours at a temperature of +2 0 С ... +8 0 С.

After the transfusion, the recipient observes bed rest for two hours and is observed by the attending physician or the doctor on duty. Every hour his body temperature and blood pressure are measured, fixing these indicators in the patient's medical record. The presence and hourly volume of urination and the color of urine are monitored. The appearance of a red color of urine while maintaining transparency indicates acute hemolysis. The next day after the transfusion, a clinical analysis of blood and urine is mandatory.

In case of outpatient blood transfusion, the recipient after the end of the transfusion should be under the supervision of a doctor for at least three hours. Only in the absence of any reactions, the presence of stable blood pressure and pulse, normal urination, the patient can be released from the hospital.

1. 
   Determination of indications for blood transfusion

Blood transfusion is a serious intervention for the patient, and indications for it must be justified. If it is possible to provide effective treatment of the patient without a blood transfusion, or it is not certain that it will benefit the patient, it is better to refuse a blood transfusion. Indications for blood transfusion are determined by the purpose that it pursues: compensation for the missing volume of blood or its individual components; increased activity of the blood coagulation system during bleeding. Absolute indications for blood transfusion are acute blood loss, shock, bleeding, severe anemia, severe traumatic operations, including those with cardiopulmonary bypass. Indications for transfusion of blood and its components are anemia of various origins, blood diseases, purulent-inflammatory diseases, severe intoxication.

Definition of contraindications to blood transfusion

Contraindications for blood transfusion include:

1) decompensation of cardiac activity with heart defects, myocarditis, myocardiosclerosis; 2) septic endocarditis;

3) hypertension stage 3; 4) violation of cerebral circulation; 5) thromboembolic disease; 6) pulmonary edema; 7) acute glomerulonephritis; 8) severe liver failure; 9) general amyloidosis; 10) allergic condition; 11) bronchial asthma.

1. 
   Definition of indications

^ Patient preparation to blood transfusion. In the patient

admitted to the surgical hospital, determine the blood type and Rh factor.

Studies of the cardiovascular, respiratory, urinary

systems in order to identify contraindications to blood transfusion. 1-2 days before

transfusions produce a complete blood count, before transfusion of the patient's blood

should empty the bladder and bowels. Blood transfusion is best

in the morning on an empty stomach or after a light breakfast.

Choice of transfusion environment, transfusion method. Transfusion of whole

blood for the treatment of anemia, leukopenia, thrombocytopenia, coagulation disorders

system, when there is a deficiency of individual blood components, is not justified, since

how other factors are spent to replenish individual factors, the need for

the introduction of which the patient is not. The therapeutic effect of whole blood in such cases

lower, and the blood flow is much greater than with the introduction of concentrated

blood components, for example, erythrocyte or leukocyte mass, plasma,

albumin, etc. So, with hemophilia, the patient needs to enter only factor VIII.

To cover the needs of the body in it at the expense of whole blood, it is necessary

inject a few liters of blood, while this need can only be met

a few milliliters of antihemophilic globulin. With plaster and

afibrinogenemia, it is necessary to transfuse up to 10 liters of whole blood to replenish

fibrinogen deficiency. Using the fibrinogen blood product, it is enough to inject

its 10-12 g. Transfusion of whole blood can cause sensitization of the patient,

the formation of antibodies to blood cells (leukocytes, platelets) or plasma proteins,

which is fraught with the risk of severe complications with repeated blood transfusions or

pregnancy. Whole blood is transfused for acute blood loss with a sharp

decrease in BCC, with exchange transfusions, with cardiopulmonary bypass during

time of open heart surgery.

When choosing a transfusion medium, one should use the component in which

the patient needs, also using blood substitutes.

The main method of blood transfusion is intravenous drip using

subcutaneous vein punctures. With massive and prolonged complex transfusion

therapy, blood along with other media is injected into the subclavian or external

jugular vein. In extreme situations, blood is injected intra-arterially.

Grade validity canned blood and its components for

transfusions. Before transfusion determine the suitability of blood for

transfusions: take into account the integrity of the package, expiration date, violation of the regime

storage of blood (possible freezing, overheating). Most expedient

transfuse blood with a shelf life of no more than 5-7 days, since with elongation

storage period in the blood, biochemical and morphological changes occur,

which reduce its positive properties. On macroscopic examination, blood

must have three layers. At the bottom is a red layer of erythrocytes, it is covered

a thin gray layer of leukocytes and a slightly transparent

yellowish plasma. Signs of unsuitable blood are: red or

pink coloration of the plasma (hemolysis), the appearance of flakes in the plasma, turbidity,

the presence of a film on the surface of the plasma (signs of blood infection), the presence

clots (blood clotting). For urgent transfusion of unsettled blood

Malfunctions of the digestive tract can lead to dangerous conditions. About 3% of such cases in abdominal surgery is intestinal obstruction. Pathology in children and adults develops rapidly, has many causes. Already in the first 6 hours after the onset of signs of the disease, the risk of death of the patient is 3-6%.

Classification of intestinal obstruction

Pathology is associated with a violation of the movement of the contents or chyme through the digestive tract. Other names for the disease: ileus, obstruction. The ICD-10 code is K56. By origin, pathology is divided into 2 types:

• Primary- associated with anomalies in the structure of the intestinal tube that occur in the womb. It is detected in children in the first years of life. In 33% of newborns, pathology occurs due to clogging of the intestines with meconium - the original feces.
• Secondary- an acquired disease that develops under the influence of external factors.

According to the level of location of the obstruction site, the pathology has 2 types:

• Short- affects the large intestine, occurs in 40% of patients.
• High- small bowel obstruction, accounts for 60% of cases.

According to the mechanisms of development, ileus is divided into the following subspecies:

• strangulation- blood circulation in the digestive tract is disturbed.
• obstructive- occurs when the intestines are blocked.
• Mixed- this includes invagination (one section of the intestinal tube is introduced into another) and adhesive obstruction: it develops with rough cicatricial tissue adhesions.
• Spastic- hypertonicity of the intestinal muscles.
• Paralytic- the strength of the movement of the intestinal walls is reduced or absent.

According to the effect on the functioning of the digestive tract, 2 forms of pathology are distinguished:

• Complete- the disease manifests itself acutely, the movement of chyme is impossible.
• Partial- the intestinal lumen is partially narrowed, the symptoms of the pathology are erased.

By the nature of the course, intestinal obstruction has 2 forms:

• Acute- symptoms appear abruptly, pain is severe, the condition deteriorates rapidly. This form of pathology is dangerous with the death of the patient.
• Chronic- the disease develops slowly, occasionally there are relapses, constipation and diarrhea alternate. With blockage of the intestine, the pathology passes to the acute stage.

The reasons

The following mechanisms underlie the development of pathology:

• Dynamic- failure of the processes of contraction of the muscles of the intestine. There are fecal plugs that clog the lumen.
• Mechanical- obstruction is associated with the appearance of an obstacle in the way of the movement of feces. An obstacle is created by volvulus, knots, bends.
• Vascular- develops when blood stops flowing to the intestinal area and tissues die off: a heart attack occurs.

Mechanical

Obstruction develops due to obstacles in the path of chyme (intestinal contents), which appear against the background of such pathologies and conditions:

• fecal and gallstones;
• tumors of the pelvic organs and abdominal cavity - compress the intestinal lumen;
• foreign body;
• bowel cancer;
• infringement of a hernia;
• volvulus;
• scar bands, adhesions;
• inflection or torsion of intestinal loops, their fusion;
• rise in intra-abdominal pressure;
• overeating after a long fast;
• obturation - blockage of the intestinal lumen.

Dynamic

Pathology develops due to intestinal motility disorders that occur in 2 directions: spasm or paralysis. Muscle tone increases under the influence of such factors:

• foreign body;
• worms;
• colic in the kidneys, gallbladder;
• acute pancreatitis;
• pleurisy;
• salmonellosis;
• abdominal trauma;
• damage to the nervous system;
• traumatic brain injury;
• circulatory disorders in the vessels of the mesentery.

Dynamic intestinal obstruction with paresis or muscle paralysis develops against the background of such factors:

• peritonitis (inflammation of the peritoneum);
• operations on the abdomen;
• poisoning with morphine, salts of heavy metals.

Symptoms

Signs of intestinal obstruction in adults and children in acute form vary depending on the stage of the pathology:

1. The early period is the first 12 hours from the beginning of the ileus. There are bloating, a feeling of heaviness, sharp pain, nausea.
2. Intermediate - the next 12 hours. Signs of pathology intensify, pain is constant, vomiting is frequent, there are intestinal noises.
3. Late - the terminal stage, which occurs on the 2nd day. Breathing quickens, temperature rises, intestinal pains intensify. Urine is not excreted, there is often no stool - the intestines are completely clogged. General intoxication develops, repeated vomiting appears.

The main symptoms of intestinal obstruction are a violation of the stool, bloating, severe pain, but in a chronic course, other signs of pathology appear:

• yellow coating on the tongue;
• dyspnea;
• lethargy, fatigue;
• pressure reduction;
• tachycardia.

Intestinal obstruction in infants is a dangerous condition when there are such symptoms of pathology:

• vomiting with bile;
• weight loss;
• fever;
• bloating in the upper part;
• dullness of the skin.

pain

This sign of pathology appears against the background of damage to nerve receptors. At an early stage, the pain is acute, occurs in attacks after 10-15 minutes, after which they become constant and aching.

If this symptom disappears after 2-3 days with an acute course of the disease, call an ambulance - intestinal activity has stopped completely

stool retention

An early symptom of the disease, which indicates low obstruction. If the problem is in the small intestine, frequent stools on the first day, constipation and diarrhea alternate. With the development of a complete lower ileus, stool ceases to come out. With partial - permanent constipation, diarrhea rarely occurs. In children under one year old, often one section of the intestinal tube is introduced into another, so blood is visible in the feces. In adults, its appearance requires an ambulance call.

Vomit

This symptom occurs in 70-80% of patients. At an early stage of the disease, gastric masses come out. After vomiting is frequent, has a yellow or brown tint, putrid odor. Often this is a sign of obstruction of the small intestine and an attempt to remove feces. With the defeat of the thick - the patient experiences nausea, vomiting is rare. In the later stages, it becomes more frequent due to intoxication.

gases

The symptom is caused by stagnation of feces, paresis of nerve endings and expansion of intestinal loops. Gases in the abdomen accumulate in 80% of patients; with a spastic form of ileus, they rarely appear. With vascular - swelling over the entire surface of the intestine, with mechanical - in the area of ​​\u200b\u200bthe adductor loop. In children up to a year, gases do not come out, there are severe pains in the abdomen. The kid often spits up, cries, refuses to eat, sleeps badly.

Val's symptom

When diagnosing disorders of intestinal patency, 3 clinical signs of pathology are evaluated:

• in the blockage zone, the stomach is swollen, there is its asymmetry;
• contractions of the abdominal wall are clearly visible;
• the intestinal loop in the area of ​​swelling is easy to feel.

Complications

When fecal blockages are not removed from the intestines for a long time, they decompose and poison the body. The balance of microflora is disturbed, pathogenic bacteria appear. They release toxins that are absorbed into the blood. Systemic intoxication develops, metabolic processes fail, and coma rarely occurs.

More than 30% of patients with ileus die without surgery

Death occurs due to such conditions:

• sepsis - blood poisoning;
• peritonitis;
• dehydration.

Diagnostics

To diagnose and separate intestinal obstruction from acute appendicitis, pancreatitis, cholecystitis, perforated ulcers, renal colic and ectopic pregnancy, the gastroenterologist, after studying the patient's complaints, conducts an examination using the following methods:

• Auscultation- intestinal activity is increased, there is splashing noise (Sklyarov's symptom) at an early stage of the pathology. Later, peristalsis weakens.
• Percussion- the doctor taps the abdominal wall, with obstruction, reveals tympanitis and a dull sound.
• Palpation- in the early stages, Val's symptom is observed, in the later stages - the anterior abdominal wall is tense.
• radiograph- intestinal arches swollen with gas are visible in the abdominal cavity. Other signs of pathology in the picture: Kloiber cups (dome above the liquid), transverse striation. The stage of the disease is determined by the introduction of a contrast agent into the intestinal lumen.
• Colonoscopy- the study of the colon with a probe that is inserted rectally. The method reveals the reasons for the obstruction of this area. In the acute course of the pathology, treatment is carried out during the procedure.
• abdominal ultrasound- reveals tumors, foci of inflammation, conducts differential diagnosis of ileus with appendicitis, colic.

Treatment without surgery

In the chronic course of the pathology, the patient is hospitalized and treated in a hospital.

Before the ambulance arrives, do not take laxatives, do not do enemas

Treatment goals:

• eliminate intoxication;
• cleanse the intestines;
• reduce pressure in the digestive tract;
• to stimulate intestinal peristalsis.

Decompression

The revision of the intestinal contents is performed using the Miller Abbott probe, which is inserted through the nose. It remains for 3-4 days, with spikes the period is extended. The suction of chyme is carried out every 2-3 hours. The procedure is performed under anesthesia in children and adults under 50 years of age. It is effective in ileus of the upper gastrointestinal tract.

Colonoscopy

A stent is inserted into the narrowed portion of the intestinal tube, which expands it. After the procedure, it is removed. The doctor gets access through the anal passage, the work is carried out with endoscopic equipment. Cleansing is fast, effective with partial obstruction. For children under 12 years of age, the procedure is performed under anesthesia.

Enema

Adults are injected through a glass tube with 10-12 liters of warm water in several approaches until a clear liquid comes out. A siphon enema is done to cleanse the lower intestinal sections. After the tube is left in the anus for 20 minutes to remove gases. Enema unloads the gastrointestinal tract, is effective for obstruction due to a foreign body. The procedure is not performed for tumors of the rectum, perforation, bleeding.

Medicines for intestinal obstruction

In the scheme of conservative treatment of ileus in adults and children, the following drugs are used:

• Antispasmodics (Papaverine, No-Shpa)- relax the intestinal muscles, improve peristalsis, relieve pain.
• Anticoagulants (Heparin)- thin the blood, are prescribed at an early stage of obstruction with vascular thrombosis.
• Thrombolytics (Streptokinase)- dissolve blood clots, are used by injection.
• Cholinomimetics (Prozerin)- are indicated for muscle paresis, stimulate intestinal motility.
• Anesthetics (Novocain)- instantly relieve pain, are introduced into the perirenal tissue.

Refortan

The agent binds water in the body, reduces blood viscosity, improves its circulation and reduces platelet aggregation. Refortan has a plasma-substituting effect and is available as a solution for infusion. The effect comes quickly, lasts 5-6 hours. The drug rarely causes vomiting, swelling of the legs, back pain. Contraindications:

• hypertension;
• decompensated heart failure;
• pulmonary edema;
• age under 10 years old.

Papaverine

The drug relaxes the tone of smooth muscles, reduces the strength of pain and facilitates the movement of chyme through the intestines. Papaverine is produced in the form of tablets, suppositories and injections. The effect occurs in 10-15 minutes, depending on the dose of the drug, lasts from 2 to 24 hours. Rarely, the drug reduces pressure, causes drowsiness, nausea, and constipation. Contraindications:

• liver failure;
• glaucoma;
• age younger than 6 months and older than 65 years;
• traumatic brain injury in the last six months.

Heparin

The drug reduces the adhesion of platelets and slows down blood clotting. After an intramuscular injection, the effect occurs after 30 minutes and persists for 6 hours. Intravenously, the drug works for 4 hours. Heparin is released as a solution for injection. During treatment, the risk of bleeding increases, there is a possibility of an allergic reaction. Contraindications:

• hypertension;
• stomach ulcer.

Streptokinase

The drug dissolves blood clots by stimulating the conversion of blood clots into plasmin. Available in the form of a solution for infusion. The effect occurs after 45 minutes, lasts up to a day. The drug has a large number of contraindications, it is used with caution in the elderly over 75 years of age and with anticoagulants. Adverse reactions:

• bleeding;
• local allergy symptoms - rash, itching, swelling;
• anaphylactic shock;
• hematoma at the injection site.

Folk remedies

With functional chronic obstruction, treatment is carried out at home and alternative medicine recipes are used.

Discuss the treatment plan with your doctor: it can be harmful.

Improve intestinal peristalsis, relieve inflammation and soften stool such herbs:

• buckthorn bark;
• fennel;
• chamomile;
• toadflax;
• St. John's wort.

When treating with this remedy, drink 1.5-2 liters of water per day - this will prevent stomach pain. Basic recipe: Grind 100 g of flaxseed in a coffee grinder, pour 30 g of cold-pressed olive oil. Infuse for a week, stir or shake the container once a day. Take 1 tbsp. l. half an hour before meals 3 times a day for 10 days.

Beet

Peel the root crop, fill it with cold water and cook on low heat under the lid for 1.5-2 hours until soft. Grate coarsely, add 1 tsp. vegetable oil and honey for every 100 g of the dish. In the morning and evening, eat 1 tbsp. l. this mixture. Treat until symptoms of obstruction are relieved. Prepare a new batch every 2-3 days.

Buckthorn bark

Pour 1 tbsp. l. raw materials with half a liter of boiling water. Warm over medium heat under the lid for 30 minutes, leave for an hour. Strain the broth, drink 1 tsp. between meals 5-6 times / day. The remedy has a strong laxative effect, so if discomfort occurs in the abdomen, reduce the frequency of its use to 3-4 times / day. The course of treatment is 10 days. Buckthorn bark is not recommended for children.

Surgery

The operation is performed when therapy fails, the pathology proceeds in an acute form, or the ileus is associated with volvulus of the small intestine, gallstones, and nodes. The surgery takes place under general anesthesia. With a mechanical form of pathology during the operation, the following actions are performed:

• viscerolysis - dissection of adhesions;
• disinvagination;
• knot unwinding;
• removal of the area of ​​necrosis.

Enterotomy

During the operation, the anterior abdominal wall is cut with an electric knife or scalpel and the small intestine is opened. The surgeon removes her loop, removes the foreign body and stitches. Narrowing of the intestinal lumen does not occur, its length does not change, peristalsis is not disturbed. The patient stays in the hospital for 3-10 days. For adults and children, the operation is less traumatic, rarely there are such complications:

• inflammation of the abdominal cavity;
• seam split.

During the operation, part of the organ is removed. The technique is applied to the duodenum, jejunum, sigmoid colon with vascular thrombosis, strangulated hernia, tumors. The integrity of the tube is restored through suturing healthy tissue. Resection is effective for any obstruction, but has many disadvantages:

• Damage to blood vessels- Occurs during laparotomy.
• Infection or inflammation of the suture– with open technique of operation.
• Secondary obstruction- due to the formation of connective tissue in the resection area.
• Long recovery period- 1-2 years.

Diet for intestinal obstruction

1-2 weeks after the operation and in the case of a chronic form of pathology, change the diet, taking into account the following principles:

• Avoid alcohol, coffee and carbonated drinks.
• Introduce boiled and steamed vegetables, fruits, lean fish, chicken into the diet. Eat cottage cheese 0-9%, compotes and kissels. From cereals, give preference to oatmeal, round rice, buckwheat. Boil porridge in water.
• Eat pureed food in the first month after surgery and when the obstruction worsens.
• Eat 6-7 times / day in portions of 100-200 g.
• Reduce the amount of salt to 5 g/day.
• Every day, eat boiled or baked pumpkin, beets, mix them with honey or vegetable oil.

In case of violation of intestinal patency, remove the following foods from the diet:

• apples, cabbage, mushrooms;
• confectionery;
• spicy, spicy, salty dishes;
• fresh bakery;
• cream, sour cream;
• milk;
• millet, barley;
• fat meat.

Prevention

To prevent intestinal obstruction, follow these recommendations:

• consult a doctor for abdominal injuries;
• treat gastrointestinal diseases in a timely manner;
• eat right;
• avoid excessive physical activity;
• observe safety precautions when working with chemicals, heavy metals;
• wash fruits and vegetables well;
• undergo a full course of treatment for helminthic invasions;
• after surgery on the abdomen, follow the recommendations for proper rehabilitation to prevent adhesions.

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Causes of the disease

There are a number of factors for the development of acute intestinal obstruction (AIO):

1. Congenital:

Features of anatomy - elongation of sections of the intestine (megacolon, dolichosigma);

Anomalies of development - an incomplete turn of the intestine, agangliosis (Hirschsprung's disease).

2. Purchased:

neoplasms of the intestine and abdominal cavity;

foreign bodies in the intestines, helminthiases;

cholelithiasis;

hernia of the abdominal wall;

• unbalanced, irregular diet.

Risk factors: abdominal surgery, electrolyte imbalance, hypothyroidism, opiate use, acute illness.

Mechanisms of occurrence and development of the disease (pathogenesis)

OKN classification

According to the morphofunctional trait

Dynamic obstruction:

spastic

paralytic

Mechanical obstruction:

strangulation (torsion, nodulation, restrictions)

obstructive (interstitial and extraintestinal forms)

mixed (invagination, adhesive obstruction)

By obstacle level

Small bowel obstruction:

Colonic obstruction

Clinical picture of the disease (symptoms and syndromes)

With the development of OKN, the following symptoms occur:

abdominal pain - 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 greater the obstruction in the digestive tract, the earlier it occurs and is more pronounced);

retention of stool and gases - sometimes (at the beginning of the disease) there is a "residual" stool;

thirst (more pronounced with high intestinal obstruction);

Valya's symptom - a clearly delimited stretched intestinal loop is determined through the abdominal wall;

visible peristalsis of the intestines;

"oblique" abdomen - gradual and asymmetric bloating;

Sklyarov's symptom - listening to the "splash noise" over the intestinal loops;

a symptom of Spasokukotsky - "the noise of a falling drop";

Kivul's symptom - an enhanced tympanic sound with a metallic tint appears above the stretched loop of the intestine;

a symptom of Grekov or a symptom of the Obukhov hospital - a 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 noise over the intestines;

symptom Hoses - the appearance of intestinal motility during palpation of the abdomen.

The clinical course of OKN has three phases (O. S. Kochnev, 1984):

1. "Ileous cry" (stage of local manifestations) - acute violation of the intestinal passage, duration - 2-12 hours (up to 14). The main signs are pain and local symptoms from the abdomen.

2. Intoxication (intermediate, stage of apparent well-being) - a violation of intraparietal 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 peristalsis weakens, sound phenomena are less pronounced, “the noise of a falling drop” is auscultated; complete retention of stool and gases; there are signs of dehydration.

3. Peritonitis (late, terminal stage) - occurs 36 hours after the onset of the disease. This period is characterized by sharp functional disorders of hemodynamics; the abdomen is significantly swollen, peristalsis is not auscultated; peritonitis develops.

Diagnosis of the form of intestinal obstruction

To select the optimal treatment tactics, differential diagnosis between the forms of AIO should be carried out.

Dynamic spastic obstruction. Anamnesis: injuries 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. Radiologically, small Kloiber bowls can be detected that are displaced.

Dynamic paralytic ileus occurs due to peritonitis as a result of any type of intestinal obstruction, as well as some intoxications or operations in the abdominal cavity. Clinically: increasing intestinal paresis with the disappearance of peristalsis, symmetrical 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 Kloiber cups with indistinct contours that do not change their location.

Volvulus and nodulation are provoked by adhesions, hypermotility, overeating of a hungry person. Features: acute onset and course; shock and intoxication develop so rapidly that bloating is sometimes minimal; with volvulus of the caecum or sigmoid colon - always asymmetry and Wilms' symptom; inversions are often repeated.

obstructive obstruction most often caused by a tumor of the left side of the colon. Obturation with fecal stones, a ball of ascaris and other foreign objects is possible. Features: slow development, often asymmetric abdomen, frequent change in the shape of feces to "ribbon-like" or "sheep", repeated loose stools with mucus and blood are possible.

Intussusceptions are often small-colonic. Features: slow development, often asymmetric abdomen, mucus and blood in the feces are possible, tumor-like formations (intussusception) or an area of ​​bluntness against the background of high tympanitis can be palpated in the abdomen; the diagnosis can be confirmed by irrigoscopy - a lip-like photograph of the head of the intussusceptum 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 begins immediately.

Features of mesenteric obstruction:

With arterial in the anemic stage - in 1/3 of patients the onset is subacute, the attack is removed with nitroglycerin, as in angina pectoris; in 2/3 - the onset is acute, the pain is very severe;

At first, blood pressure often rises by 50-60 mm. rt. Art. (Boikov's symptom);

The tongue is moist, the abdomen is soft;

Leukocytosis ≥ 15-20 x 10 9 with a low erythrocyte sedimentation rate;

Delayed stool and gases 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 filiform, the tongue is dry, the abdomen is somewhat swollen, but still soft, there is no irritation of the peritoneum, the edematous intestine is often palpated (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 invagination, depends on the severity of strangulation. Diagnosis is the most difficult, as attacks often recur and may resolve on their own (adhesive disease). In case of surgery on the abdominal cavity in history and subacute course, it is necessary to start with the introduction of contrast and control 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, the pain of appendicitis begins gradually and is not as intense as that of an obstruction. With appendicitis, it is localized, and with obstruction, it is cramping and intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction, and not appendicitis. In acute appendicitis, there are no radiological signs characteristic of obstruction.

Perforated ulcer of the stomach and duodenum. Common symptoms of an ulcer are sudden onset, severe abdominal pain, and stool retention. However, with a perforated ulcer, the patient occupies a forced position, and with intestinal obstruction, he is restless, often changing position. Vomiting is uncommon for perforated ulcers, 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 stomach is swollen, soft, slightly painful. With a perforated ulcer, from the very beginning of the disease, there is no peristalsis, "splash noise" is not heard. Radiologically, with a perforated ulcer, free gas is determined in the abdominal cavity, with intestinal obstruction - Kloiber's cups, arcades.

Acute cholecystitis. Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the area of ​​the right shoulder blade. 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, radiological 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, girdle, and not cramping. Mayo-Robson's sign is positive. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. Radiologically, with pancreatitis, a high standing of the left dome of the diaphragm is noted, and with obstruction - Kloiber's bowl, arcades.

Bowel infarction. With intestinal infarction, as with obstruction, there is a strong sudden pain in the abdomen, vomiting, a severe general condition, a soft stomach. However, pain in intestinal infarction is constant, peristalsis is completely absent, abdominal distention is small, there is no asymmetry of the abdomen, “dead silence” is determined during auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a wide range of sound phenomena are heard, abdominal distention is significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, high leukocytosis is possible (20-30 x 10 9 /l).

Renal colic. Renal colic and intestinal obstruction have similar symptoms, such as severe abdominal pain, bloating, retention of stools and gases, 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 symptom of Pasternatsky. On a plain radiograph, shadows of calculi may be observed in the kidney or ureter.

Pneumonia. Pneumonia may cause abdominal pain and bloating, indicating an intestinal obstruction. However, pneumonia is characterized by high fever, cough, blush. On physical examination, crepitant wheezing, pleural friction noise, bronchial breathing, dullness of pulmonary sound can be detected, X-ray - characteristic changes in the lungs.

Myocardial infarction. With myocardial infarction, there may be a sharp pain in the upper abdomen, its swelling, sometimes vomiting, weakness, lowering blood pressure (BP), tachycardia, that is, signs resembling strangulation intestinal obstruction. However, with myocardial infarction, asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms are not observed, there are no radiological signs of intestinal obstruction. An ECG study helps clarify the diagnosis of myocardial infarction.

Diagnosis of the disease

Examination scope for OKN

1. Mandatory: general urinalysis, complete blood count, blood glucose, blood group and Rh-affiliation, rectal examination (sphincter tone is reduced, the 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, barium passage through the intestines, sigmoidoscopy, irrigography, colonoscopy.

The phases of the course of AIO are conditional, and each form of obstruction has its own differences (with strangulation intestinal obstruction, phases I and II begin almost simultaneously).

Diagnostics

X-ray examination is the main special method for diagnosing OKN, which can be used to identify the following signs:

1. Kloyber bowl - a horizontal level of liquid with a dome-shaped enlightenment above it, which looks like an inverted bowl. With strangulation obstruction, it can manifest itself after an hour, with obstructive obstruction - after 3-5 hours from the moment of the disease. The number of bowls is different, sometimes they can be layered one on top of the other in the form of a ladder. Fluid levels (small and colonic) localized in the left hypochondrium indicate high obstruction. At small intestinal levels, vertical dimensions predominate over horizontal ones, there are semilunar folds of the mucosa; in the large intestine, horizontal dimensions predominate over vertical ones, haustration is determined.

2. Intestinal arcades appear when the small intestine swells with gases, while there are horizontal levels of fluid in the lower knees of the arcades.

3. The symptom of pinnation occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular mucosal folds.

A contrast study is performed in doubtful cases, with a subacute course. The delay in the passage of barium in the caecum for more than 6 hours against the background of agents that stimulate peristalsis indicates obstruction (normally after 4-6 hours without stimulation).

Indications for conducting studies with the use of contrast in intestinal obstruction are:

1. Confirmation of intestinal obstruction.

2. Suspicion of intestinal obstruction for the purpose of differential diagnosis and complex treatment.

3. OKN 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, an obvious improvement can be achieved.

5. Diagnosis of early postoperative obstruction in patients undergoing gastric resection. The absence of pyloric sphincter causes unimpeded flow of contrast to the small intestine. In this case, the detection of the "stop-contrast" phenomenon in the outlet 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 strangulation form of obstruction, which can lead to a rapid loss of viability of the strangulated loop of the intestine (based on clinical data and the results of an abdominal radiography).

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 an urgent surgical intervention, regardless of the x-ray data characterizing the passage of contrast through the intestines.

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";

Small bowel wall thickening > 4 mm;

The presence of a reciprocating movement of chyme in the intestine;

Increase in the height of the mucosal folds> 5 mm;

Increasing the distance between the folds > 5 mm;

Hyperpneumatization of the intestine in the drive part with dynamic intestinal obstruction - the absence of reciprocating movement of chyme in the intestine; the phenomenon of fluid sequestration into the intestinal lumen;

Unexpressed relief of mucosal folds;

Hyperpneumatization of the intestine in all departments.

Grandma symptom.

Babuka s. - possible sign intestinal intussusception: if there is no blood in the wash water 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. - observed with gallstone intestinal obstruction: sluggish current alternation of partial and complete obstructive intestinal obstruction.

Obukhov hospital, Hochenegg symptom.

Obukhov hospital with. - a sign of volvulus of the sigmoid colon: an enlarged and empty ampoule of the rectum during rectal examination.

Rush sign.

Ruscha s. - observed with intussusception of the colon: the occurrence of pain and tenesmus on palpation of a sausage-like tumor on the abdomen.

Symptom of Spasokukotsky.

Spasokukotsky village. - 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 colon: in the stretched and swollen sigmoid colon, splashing noise is determined.

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 lifted up and then smoothly lowered. Localization of pain indicates the place of adhesive intestinal obstruction. With a mild reaction, several sharp twitches of the fold are produced.

Symptom Alapy.

Alapi s. - Absence or slight tension of the abdominal wall with intussusception of the intestine.

Anschotz symptom.

Anschutz s. - swelling of the caecum with obstruction of the lower parts of the colon.

Bayer symptom.

Bayer s. - asymmetry of bloating. Observe with volvulus of the sigmoid colon.

Bailey's symptom.

Bailey s. - a sign of intestinal obstruction: the transmission of heart tones to the abdominal wall. The value of the symptom increases when listening to heart sounds in the lower abdomen.

Symptom Bouveret.

Bouveret s. - a possible sign of colon obstruction: protrusion in the ileocecal region (if the caecum is swollen, the obstruction occurs in the transverse colon, if the caecum is in a collapsed state, then the obstruction is in good shape).

Symptom Cruveillhier.

Cruvelier s. - characteristic of intussusception: blood in the stool or blood-colored mucus, in combination with cramping pain in the abdomen and tenesmus.

Symptom Dance.

Dansa s. - a sign of ileocecal invagination: due to the movement of the invaginated segment of the intestine, the right iliac fossa is empty on palpation.

Symptom Delbet.

Triad Delbet.

Delbe s. - observed with volvulus of the small intestine: rapidly increasing effusion in the abdominal cavity, abdominal distension and non-fecaloid vomiting.

SymptomDurant.

Duran s. - observed at the beginning of invagination: a sharp tension of the abdominal wall, according to the place of introduction.

Symptom Frimann-Dahl.

Freeman-Dal s. - with intestinal obstruction: in the loops of the small intestine stretched by gas, the transverse striation is determined radiologically (corresponding to the Kerkring folds).

Gangolphe symptom.

Gangolfa s. - observed with intestinal obstruction: dullness of sound in sloping areas 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 colon is determined, which corresponds to Val's symptom.

Hirschsprung symptom.

Hirschsprung s. - observed with intussusception of the intestine: relaxation of the sphincters of the anus.

Symptom Hofer.

Gefera s. - with intestinal obstruction, the pulsation of the aorta is best heard above the level of narrowing.

Kiwul symptom.

Kivulya s. - a sign of obstruction of the large intestine (with volvulus of the sigmoid and caecum): a metallic sonority is determined in the stretched and swollen sigmoid colon.

Symptom Kocher.

Kocher s. - observed with intestinal obstruction: pressure on the anterior abdominal wall and its rapid cessation do not cause pain.

Kloiber symptom.

Kloiber s. - X-ray sign of intestinal obstruction: with a survey fluoroscopy of the abdominal cavity, horizontal levels of fluid and gas bubbles above them are detected.

Symptom Lehmann.

Lehmann s. - X-ray sign of intussusception of the intestine: a filling defect flowing around the head of the intussusceptum has a characteristic appearance: two lateral strips of a contrast agent between the perceiving and invaginated intestinal cylinders.

Symptom Mathieu.

Mathieu s. - a sign of complete intestinal obstruction: with a quick percussion of the supra-umbilical region, splashing noise is heard.

Symptom Payr.

Payra s. - "double-barreled", caused by a kink of the mobile (due to excessive length) transverse colon at the point of transition to the descending colon with the formation of an acute angle and a spur that inhibit the passage of intestinal contents. Clinical signs; pain in the abdomen, which radiates to the region of the heart and the left lumbar region, burning and swelling in the left hypochondrium, shortness of breath, pain behind the sternum.

Symptom of Schiman.

Shiman s. - a sign of intestinal obstruction (volvulus of the caecum): palpation is determined by a sharp pain in the right iliac region and a feeling of "emptiness" in the place of the caecum

Schlange symptom (I).

Hose with - a sign of intestinal paralysis: when listening to the abdomen, there is complete silence; usually seen in ileus.

Schlange symptom (II).

Hose with - visible peristalsis of the intestine with intestinal obstruction.

Symptom of Stierlin.

Stirlin 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 pain corresponds to the projection of the root of the mesentery.

Symptom of Tilijaks.

Tiliaxa s. - observed with nvagination of the intestine, abdominal pain, vomiting, tenesmus and stool retention, non-excretion of gases.

Treves sign.

Trevsa s. - a sign of colonic obstruction: at the time of the introduction of fluid into the colon, 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, peristalsis visible to the eye, tympanitis audible with percussion).