Symptoms and treatment of intestinal obstruction. Symptoms of intestinal obstruction Symptom "splash noise"

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 - 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 is determined in the area of ​​the left costovertebral angle (with inflammation of the pancreas).

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 when the facial nerve is damaged, accompanied by dry eyes (xerophthalmia), it may be appropriate to temporarily stitch the eyelids - blepharophthalmia.

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. Serum is carefully taken from the test tube with the recipient's blood to be tested and applied to the tablet 1 with a large drop (100 µl).

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 there is a uniformly colored, slightly opalescent liquid in the test tube 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 there is a uniformly colored, slightly opalescent liquid in the test tube 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 in 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 observed 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 increased 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 blood transfusion 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

5. Wit Stetten's symptom- swelling of the left lower quadrant of the abdomen with perforation of the duodenum.

SYMPTOMS: DETECTED WHEN PERCUSSION OF THE PATIENT'S ABDOMEN:

1. Symptom Spizharny-Clark- high tympanitis with percussion between the xiphoid process and the navel. Disappearance of hepatic dullness.

SYMPTOMS DETECTED WHEN AUSCULTATION IN THE ABDOMINAL OF THE PATIENT:

1. Symptom, Brown- crepitus, heard when pressing with a phonendoscope on the right side wall of the abdomen.

2. Brenner's sign- a metallic friction noise, heard over the XII rib on the left in the patient's sitting position. Associated with the release of air bubbles into the subdiaphragmatic space through the perforation.

3. Brunner's sign- diaphragm friction noise, heard under the costal margin (left and right) due to the presence of gastric contents between the diaphragm and the stomach.

4. Gusten's triad- distinct listening to heart tones through the abdominal cavity to the level of the navel, friction noise in the hypochondrium and epigastrium and metallic or silvery noise appears during inspiration and is associated with the release of free gas into the abdominal cavity through the perforation.

Gusten's triad includes the previously described symptoms of Lotey-sen-Bailey-Federechy-Kleybruk-Gyusten, Brenner, Brunner.

OBSTRUCTION OF THE INTESTINE

SYMPTOMS DETECTED IN COMPLAINTS OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Symptom Cruvelier - blood in the stools, cramping pains in the abdomen and tenesmus. characteristic of intussusception.

2. Symptom of Tiliax- pain, vomiting, gas retention. characteristic of intussusception.

3. Carnot sign- pain in< эпигастрии, возникающая при резком разгибании туловища. Характерно для спаечной болезни.

4. Symptom Koenig- reduction of pain after rumbling above and to the left of the navel. Characteristic of chronic duodenostasis.

SYMPTOMS DETECTED AT A GENERAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Val's symptom- stretched intestinal loop, contouring through the anterior abdominal wall.

2. Symptom Shlange-Grekov- intestinal peristalsis visible through the abdominal wall.

3. Bayer's sign- asymmetrical bloating.

4. Symptom of Bouvre-Anshyutz - protrusion in the ileocecal region with obstruction of the colon.

5. Borchardt's triad- swelling in the epigastric region and the left hypochondrium, the impossibility of probing the stomach and vomiting, which does not bring relief. It is observed with torsion of the stomach.

6. Triad Delbe- rapidly growing effusion in the abdominal cavity, bloating, vomiting. Observed with volvulus of the small intestine.

7. Symptom of Karevsky- sluggish current intermittent intestinal obstruction. Observed with intestinal obstruction caused by gallstones.

SYMPTOMS DETECTED BY PALPATION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Symptom of Leotte- the appearance of pain when pulling and shifting towards the skin fold of the abdomen. It is noted with adhesive disease.

2. Kocher's sign- pressure on the anterior abdominal wall and its rapid cessation do not cause pain.

3. Shiman-Dans symptom - on palpation in the region of the caecum, a void is determined, as it were. Observed with volvulus of the caecum.

4. Symptom of Schwartz- in the epigastrium, a painful elastic tumor is palpated with simultaneous bloating. It is observed with acute expansion of the stomach.

5. Symptom Tsulukidze- on palpation of the intussusceptum of the colon, a depression with folded edges is found, around which small tumor-like formations are palpated - fatty suspensions.

SYMPTOMS DETECTED DURING PERCUSSION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Symptom of Kivulya- with percussion of the abdomen and simultaneous auscultation, a sound with a metallic tinge is heard.

2. Wortmann's symptom- a sound with a metallic tinge is heard only over the swollen large intestine, and over the small intestine - the usual tympanitis.

3. Symptom Mathieu- splashing noise heard in the epigastrium with quick percussion over the navel.

SYMPTOMS DETECTED DURING AUSCULTATION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Sklyarov's symptom- splashing noise in the abdominal cavity.

2. Symptom of Spasokukotsky- - the noise of a "falling drop".

3. Symptom of Gefer- breath sounds and heart sounds are best heard over the constriction. seen in late stages.

SYMPTOMS DETECTED DURING THE FINGER RECAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Grekov's symptom-Hohenega- an empty ampoule-shaped rectum, the front wall of which is protruded by loops of intestines. The anus gapes. A synonym is "a symptom of the Obukhov hospital."

2. Trevs symptom - in the moment the fluid is injected into the rectum, a rumbling is heard at the site of obstruction.

3. Symptom of Zege von Manteuffel- with obstruction of the sigmoid colon, only 200 ml of water can be injected into the rectum. The patient does not hold large doses of water.

SYMPTOMS USED FOR DIFFERENTIAL

DIAGNOSTICS OF INTESTINAL OBSTRUCTION: 1

1. Symptom of Kadyan- for the differential diagnosis of pneumoperitoneum and intestinal paresis. With pneumoperitoneum, hepatic dullness disappears, percussion sound is uniform everywhere, and with intestinal paresis, hepatic dullness does not completely disappear, tympanic sound retains shades.

2. Symptom Babuk- differential diagnosis between a tumor and an intussusceptum. The absence of blood in the wash water after an enema and kneading of a pathological formation indicates the presence of a tumor.

1. Vicker M. M. Diagnosis and medical tactics in acute abdominal diseases (“acute abdomen”). North Caucasian regional publishing house. Pyatigorsk, 1936, 158 pages.

2. Lazovskie I. R. Handbook of clinical symptoms and syndromes. M. Medicine. 1981, pp. 5-102.

3. Lezhar F. Emergency surgery. Ed. N. N. Burdenko, vol. 1-2. 1936.

b4. Matyashin I. M. Symptoms and syndromes in surgery. Kyiv.

|Olshanetsky A. A. Health, 1982, 184 p.

in Gluzman A. M.

5. Mondor G. Urgent diagnosis. Belly, vol. 1-2, M-L. Medgiz, 1939.

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

ICD-10 code

K56 Paralytic ileus and intestinal obstruction without hernia

K56.7 Ileus, unspecified

K56.6 Other and unspecified ileus

Causes of intestinal obstruction

Pathogenesis

In general, the main causes of mechanical obstruction are abdominal adhesions, hernia, and tumors. Other causes include diverticulitis, foreign bodies (including gallstones), volvulus (rotation of the intestine around the mesentery), intussusception (invasion of one intestine into another), and coprostasis. Certain parts of the intestine are affected differentially.

According to the mechanism of occurrence, intestinal obstruction is divided into two types: dynamic (spastic and paralytic) and mechanical (obstructive - when the intestinal lumen is blocked by a tumor, fecal or gallstones and strangulation, compression of the vessels, nerves of the mesentery of the intestine due to infringement, volvulus, nodulation). With adhesive disease and intussusception, intestinal obstruction of a mixed type occurs, since both obturation and strangulation occur in them. By degree - full and partial.

In simple mechanical obstruction, the obturation occurs without a vascular component. Fluid and food entering the intestine, digestive secretions and gas accumulate above the obturation. The proximal segment of the intestine expands, and the distal one collapses. The secretory and absorption functions of the mucous membrane are reduced, and the intestinal wall becomes edematous and stagnant. Significant distension of the intestine is constantly progressing, increasing disturbances in peristalsis and secretion and increasing the risk of dehydration and the development of strangulation obstruction.

Strangulation ileus is an obstruction with impaired circulation; this occurs in almost 25% of patients with small bowel obstruction. It is usually associated with hernias, volvulus, and intussusception. Strangulation ileus can progress to infarction and gangrene in less than 6 hours. Initially, a violation of venous blood flow develops, followed by a violation of arterial blood flow, leading to rapid ischemia of the intestinal wall. The ischemic intestine becomes edematous and imbibed with blood, leading to gangrene and perforation. With colonic obstruction, strangulation rarely occurs (except for volvulus).

Perforation can occur in an ischemic area of ​​the intestine (typical of the small intestine) or with significant expansion. The risk of perforation is very high if the caecum is dilated >13 cm. Perforation of the tumor or diverticulum may occur at the site of obstruction.

Symptoms of intestinal obstruction

The symptoms are polymorphic, they depend on the type and height of the intestinal lesion (the higher, the brighter the picture and the faster the stages change), the stage of the disease.

The main symptom is pain: contractions, rather sharp, constantly growing, at first in the area of ​​intestinal obstruction, but may not have a permanent localization, then throughout the abdomen, becomes constant and dull, and practically disappears in the terminal phase.

Flatulence (bloating) is more pronounced in the obstructive form, although it occurs in all types, it determines the asymmetry of the abdomen on examination: with a dynamic form of the large intestine, bloating is uniform throughout the abdomen; upper floor, in case of inversion - in the middle part, with intussusception - in the right half). Delay of stool and gases at the beginning of the disease may not manifest itself, especially with high intestinal obstruction, since stools and gases leave the distal intestines, sometimes even on their own or when performing enemas. On the contrary, vomiting is more characteristic of high intestinal obstruction, it appears faster and more intense. The vomit is first gastric contents mixed with bile, then the contents appear, and finally, the vomit acquires a fecal odor. The appearance of continuous vomiting, which does not bring relief, is more characteristic of the obstructive and adhesive form.

Peristalsis depends on the form and stage. With obstructive and mixed forms, hyperperistalsis is initially noted, sometimes heard at a distance and visible to the eye, accompanied by increased pain. When the process is localized in the small intestine, it occurs early, simultaneously with pain, frequent, short, in the large intestine - peristalsis becomes enhanced later, sometimes on the second day, attacks are rare, long or have a wave-like character. Especially clearly peristalsis is determined by auscultation of the abdomen. Gradually, peristalsis subsides and, with the onset of intoxication, disappears and is not detected even during auscultation. A sign of the transition of the neuro-reflex stage to intoxication is the appearance of dryness of the tongue, sometimes with a “varnished” bright red tint due to dehydration and chloropenia.

Symptoms of intestinal obstruction appear soon after the onset of the disease: spastic pains appear in the navel or in the epigastrium, vomiting and, in case of complete obstruction, bloating. Patients with partial obstruction may experience diarrhea. Severe, persistent pain suggests the development of strangulation syndrome. In the absence of strangulation, pain on palpation is not pronounced. Characterized by hyperactive, high-frequency peristalsis with periods coinciding with spastic seizures. Sometimes dilated bowel loops are palpated. With the development of a heart attack, the abdomen becomes painful and during auscultation, peristaltic noises are not heard or they are sharply weakened. The development of shock and oliguria is an unfavorable symptom indicating advanced obstructive ileus or strangulation.

Signs of intestinal obstruction of the colon are less pronounced and develop gradually compared to small bowel obstruction. Gradual stool retention is characteristic, leading to its complete retention and bloating. There may be vomiting, but it is not characteristic (usually several hours after the onset of other symptoms). Spasmodic pains in the lower abdomen are reflex and are caused by the accumulation of feces. Physical examination reveals a characteristically distended abdomen with a loud rumbling. There is no pain on palpation, and the rectum is usually empty. It is possible to palpate a volumetric formation in the abdomen, corresponding to the area of ​​obstruction by the tumor. General symptoms are mild, and fluid and electrolyte deficiencies are minor.

stages

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

Forms

Obstructive ileus is divided into small bowel obstruction (including the duodenum) and colonic obstruction. Obturation can be partial or complete. Approximately 85% of cases of partial small bowel obstruction resolve with conservative measures, while approximately 85% of cases of complete small bowel obstruction require surgery.

Diagnosis of intestinal obstruction

Mandatory x-rays with the patient in the supine and upright position usually allow the diagnosis of obstruction. However, only with laparotomy can strangulation be finally diagnosed; a complete serial clinical laboratory examination (eg, complete blood count and biochemical analysis, including lactate levels) ensures timely diagnosis.

In the diagnosis, specific symptoms play an important role.

• Mathieu-Sklyarov's symptom - palpation, with a slight shaking of the abdominal wall, noise, a splash of fluid accumulated in the stretched loop of the intestine is detected - it is characteristic of obstructive intestinal obstruction.
• Symptom Shiman-Dans - characteristic of ileocecal invagination - on palpation, the right iliac fossa becomes empty.
• Chugaev's symptom - when lying on the back with legs pulled up to the stomach, a deep transverse strip is revealed on the stomach - it is characteristic of the strangulation form.
• Shlange's symptom - on palpation of the abdomen, there is a sharp increase in peristalsis in the initial stage of obstructive and mixed forms.
• With auscultation of the abdomen with simultaneous percussion, symptoms can be detected: Kivul (metallic sound), Spasokukotsky (noise of a falling drop), Wils (noise of a burst bubble).

When examining the rectum, and this is mandatory in all cases of abdominal pathology, it is possible to detect a tumor, the presence of fluid in the small pelvis, a symptom of the Obukhov hospital (the ampulla of the rectum is enlarged, the anus gapes - characteristic of an obstructive or strangulation form), Gold's symptom (palpation definition of a swollen loops of the small intestine). When conducting enemas, it is possible to identify the Zege-Manteuffel symptom - with intestinal obstruction of the sigmoid colon, it is not possible to enter more than 500 ml of water into the direct line; Babuk's symptom - characteristic of intussusception - during the primary enema there is no blood in the wash water, after a five-minute palpation of the abdomen with a repeated siphon enema, the wash water looks like "meat slops".

If intestinal obstruction is suspected, the condition of all hernial orifices must be checked to exclude infringement. The second obligatory study, even before the enemas, is a survey radiography of the abdominal cavity. Patognomonic for intestinal obstruction are: Kloyber's cups, arches, transverse striation of the small intestine swollen with gases (it is better detected in the supine position in the form of Casey's symptom - a type of circular ribbing resembling a "herring skeleton"). In unclear cases, a contrast x-ray examination of the intestine is performed (the patient is given 100 ml of barium suspension) with repeated examinations of the contrast passage every 2 hours. Signs are: retention of contrast in the stomach or small intestine for more than 4 hours. In case of incomplete intestinal obstruction, the contrast passage is followed up to its removal to the depot above the obstruction site - this sometimes takes up to two days. In intestinal obstruction of the colon, it is desirable to conduct a colonoscopy. If there is a dynamic intestinal obstruction, it is necessary to identify the cause that caused the spasm or paresis: appendicitis, pancreatitis, mesenteritis, thrombosis or embolism of the mesenteric vessels and other acute abdominal pathology.

On plain x-ray, a series of swollen, ladder-like loops of the small intestine is characteristic of small bowel obstruction, but this pattern can also be seen with right flank obstruction of the colon. Horizontal levels of fluid in bowel loops can be detected with the patient upright. Similar, but less pronounced radiological signs can be observed in paralytic ileus (intestinal paresis without obstruction); differential diagnosis of intestinal obstruction can be difficult. Distended bowel loops and fluid levels may be absent in high jejunal obstruction or in strangulated closed-type obstruction (as may be seen with volvulus). The gut altered by a heart attack can create the effect of a volumetric formation on a radiograph. Gas in the intestinal wall (pneumatosis of the intestinal wall) indicates gangrene.

In colonic ileus, abdominal x-ray reveals an expansion of the colon proximal to the obstruction. A volvulus of the caecum may show a large gas bubble occupying the middle of the abdomen or the left upper quadrant of the abdomen. When volvulus of the caecum and sigmoid colon, using a radiopaque enema, it is possible to visualize the deformed obturation zone in the form of a twisting area like a "bird's beak"; this procedure can sometimes actually resolve sigma inversion. If a contrast enema is not feasible, colonoscopy may be used to decompress the sigmoid colon in volvulus, but this procedure is rarely effective in cecal volvulus.

Metabolic therapy is mandatory and similar for both small and large bowel obstruction: nasogastric aspiration, intravenous fluid transfusion (0.9% saline or lactated Ringer's solution to restore intravascular volume), and bladder catheterization to control diuresis. Transfusion of electrolytes should be monitored by laboratory tests, although in cases of repeated vomiting, serum Na and K are likely to be reduced. If bowel ischaemia or infarction is suspected, antibiotics (eg, 3rd generation cephalosporin such as cefotetan 2 g IV) should be given.

Specific events

For duodenal obstruction in adults, resection is performed or, if the affected area cannot be removed, palliative gastrojejunostomy.

With complete obstruction of the small intestine, early laparotomy is preferable, although in case of dehydration and oliguria, the operation may be delayed by 2 or 3 hours to correct fluid and electrolyte balance and diuresis. Areas of specific intestinal damage should be removed.

If the cause of the obstruction was a gallstone, cholecystectomy may be performed at the same time or later. Surgical interventions should be performed to prevent recurrence of the obturation, including hernia repair, removal of foreign bodies, and removal of adhesions. In some patients with signs of early postoperative obturation or recurrence of obstruction caused by adhesions, in the absence of abdominal symptoms, simple intestinal intubation with a long intestinal tube may be undertaken instead of surgery (many consider nasogastric intestinal intubation as the standard as the most effective standard).

Disseminated cancer of the abdominal cavity obstructing the small intestine is the main cause of mortality in adult patients with malignant diseases of the gastrointestinal tract. Bypass anastomoses, surgical or endoscopic stenting can improve the course of the disease for a short time.

Cancer diseases that obstruct the colon are most often subject to simultaneous resection with the imposition of a primary anastomosis. Other options include an unloading ileostomy and a distal anastomosis. Sometimes unloading colostomy with delayed resection is necessary.

If the obturation is caused by diverticulosis, perforation often occurs. Removal of the affected area can be quite difficult, but it is indicated in case of perforation and general peritonitis. Bowel resection and colostomy are performed without anastomosis.

Coprostasis usually develops in the rectum and can be resolved with digital examination and enemas. However, the formation of single- or multi-component fecal stones (i.e., with barium or antacids) that cause complete obstruction (usually in the sigmoid colon) requires laparotomy.

Treatment of cecal volvulus consists of resection of the involved site and anastomosis, or fixation of the caecum in its normal position with cecostomy in debilitated patients. In volvulus of the sigmoid colon with an endoscope or a long rectal tube, decompression of the loop can often be induced, and resection and anastomosis can be performed in a delayed period of several days. Without resection, intestinal obstruction almost inevitably recurs.

1. The most important and typical symptoms of mechanical intestinal obstruction are: cramping abdominal pain, vomiting, thirst, stool and gas retention.
2. "Ileous Scream"- with strangulation obstruction, pain occurs sharply, strongly, patients scream painfully.
3. Bayer's symptom- asymmetry of bloating, observed with volvulus of the sigmoid colon.
4. Val's symptom- fixed and stretched in the form of a balloon loop of the intestine with a zone of high tympanitis above it.
5. Shiman-Dans symptom- retraction of the right iliac region with volvulus of the caecum.
6. Symptom of Mondor- with a strong stretching of the intestine, the characteristic rigidity of the abdominal wall is determined, which, on palpation, resembles the consistency of an inflated ball.
7. Schwartz symptom- during palpation of the anterior abdominal wall, an elastic tumor is determined in the area of ​​swelling in the epigastric region, which resembles a soccer ball to the touch.
8. Symptom of I. P. Sklyarov- with a slight swaying of the abdominal wall, a splashing noise is obtained.
9. Symptom Mathieu- with rapid percussion of the umbilical region, splashing noise occurs.
10. Symptom Kivulya- with percussion of the swollen area of ​​the abdominal wall, a tympanic sound with a metallic tint is heard.
11. Symptom of Lotheissen On auscultation of the abdomen, breath sounds and heartbeats are heard.
12. Symptom of the Obukhov hospital ()- balloon-like expansion of the empty ampoule of the rectum and gaping of the anus.
13. Symptom Spasokukotsky-Wilms- the noise of a falling drop is determined by auscultation.
14. Zege-Manteuffel symptom- with volvulus of the sigmoid colon with the help of an enema, it is possible to enter no more than 0.5–1 l of water.
15. Hose symptom- on examination, intestinal peristalsis is visible to the eye.
16. Symptom of "Deathly Silence"- due to intestinal necrosis and peritonitis, peristaltic noises weaken and disappear.
17. Symptom Thevenard- sharp pain when pressing on 2 transverse fingers below the navel in the midline, i.e., where the root of the mesentery passes. This symptom is especially characteristic of volvulus of the small intestine.
18. Symptom Laugier- if the belly is large, spherical and convex - an obstruction in the small intestines, if the belly is large, flat, with widely stretched sides - an obstruction in the large intestines.
19. Symptom of Bouvre- if the caecum is swollen, then the place of obstruction is in the colon, if the caecum is in a dormant state, then the obstruction is in the small intestines.
20. Triad Delbe(with volvulus of the small intestines) - a rapidly growing effusion in the abdominal cavity, bloating and non-fecaloid vomiting.

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 implementation.

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 Kerckring 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).