- this is an acute condition, which is characterized by a violation of the passage of food masses through the gastrointestinal tract. If there are symptoms of pathology, it is necessary to be examined by a specialist, since intestinal obstruction can lead to serious complications.

Table 1. Characteristic differences between constipation and intestinal obstruction.

Intestinal obstruction	Constipation
Completely absent stool	Defecation possible, but bowel movements may be incomplete
Severe abdominal pain	Pain syndrome is not typical
No flatulence	Often accompanied by flatulence
There is a pronounced asymmetry of the abdomen	Abdominal asymmetry is not typical
Nausea and repeated vomiting are always present	Nausea and vomiting are almost uncommon, in rare cases - single vomiting
Signs of intoxication	General symptoms are not characteristic

Classification

According to the mechanism of occurrence

The development of intestinal obstruction may be based on various mechanisms, as a result of which the disease is classified into several main types: dynamic and mechanical forms.

Dynamic intestinal obstruction occurs due to a violation of the activity of peristalsis in the digestive system. It is of two types:

• Spastic. Violation of the passage through the intestine appears due to persistent muscle spasm in any area.
• Paralytic. Intestinal obstruction is caused by a pronounced decrease in the activity of contractile fibers - muscle paralysis.

Mechanical intestinal obstruction classified into the following types:

By level of education

Depending on the level at which there is difficulty in the passage of intestinal contents, the following forms of intestinal obstruction are distinguished:

• High. The disorder occurs at the level of the small intestine.
• Low. The digestive system in the large intestine is affected.

By severity

• Complete obstruction. Promotion of the food bolus is completely absent.
• Partial (incomplete) obstruction. Perhaps a slight discharge of food masses, but most of the contents of the intestine do not move towards the exit.

By disease activity

Causes

Causes of mechanical obstruction

• the formation of fecal or gallstones in the intestines;
• blockage of the organ loop with a ball of helminths;
• ectopic bowel cancer;
• obturation with a foreign body;
• compression by neoplasms growing in other organs;
• compression of the vessels of the mesentery, supplying blood to the lower parts of the digestive system;
• strangulated intestinal hernia;
• invaginations, inversions of loops;
• cicatricial processes in the abdominal cavity,.

Causes of spastic obstruction

Causes of paralytic obstruction

• peritonitis;
• hemoperitoneum - accumulation of blood in the abdominal cavity;
• poisoning with poisons - salts of heavy metals;
• morphine overdose;
• severe form of food intoxication;
• massive abdominal surgery.

Diagnostics

Treatment

If there are symptoms of intestinal obstruction, the patient should definitely consult a doctor. When the diagnosis is confirmed, the patient is sent to the hospital.

In acute obstruction in the first 6 hours, it is necessary to restore the passage of food through the intestines using conservative methods. If such measures are ineffective, obstruction is necessarily eliminated with the help of surgical intervention. If the patient develops complications (primarily), then the operation is performed immediately.

Conservative therapy

To reduce the load on the intestines in intestinal obstruction, decompression of the gastrointestinal tract is performed. The contents of the digestive system are excreted through a nasogastric tube. Such an event is more effective with high obstruction. When low, it is recommended to carry out the patient, which can eliminate the violation.

Medical treatment

In parallel with decompression, the patient undergoes symptomatic treatment aimed at stopping the clinical manifestations of the disease:

• (Drotaverine, Papaverine). The drugs relieve cramping abdominal pain and contribute to the normalization of peristalsis.
• Stimulants of intestinal motility (Neostigmine). Drugs are prescribed in the presence of paralytic obstruction.
• Perinephric blockade. The procedure involves the introduction of novocaine, which reduces the sensitivity of nerve fibers and relieve pain.
• Salt solutions (sodium chloride, Disol, Trisol). The drugs reduce the severity of intoxication and improve the general condition of the patient.

If after these measures the signs of intestinal obstruction persist, the patient is prepared for surgery.

Surgery

Surgery methods

The type of operation depends on the level at which the intestinal obstruction is located. However, all interventions have similar steps:

1. Providing access to the intestines.
2. Detection of localization of obstruction.
3. Dissection of the organ wall, evacuation of the contents.
4. Assessment of the viability of intestinal loops.
5. Removal of necrotic areas.
6. Imposing an anastomosis on the ends of the intact intestine.
7. Suturing of the anterior abdominal wall.

If necessary, the operation algorithm is supplemented with other manipulations. So, when loops are untwisted, intussusception is eliminated. Adhesive obstruction requires dissection of adhesions and restoration of the anatomical position of the organs in the abdominal cavity.

In the presence of obstruction caused by an inoperable tumor, it is not always possible to restore intestinal patency. In this case, a colostomy is applied - bringing the colon to the surface of the abdominal wall and communicating its cavity with the external environment. This will allow you to remove feces and stop the phenomenon of obstruction. This operation is palliative (facilitating existence), the presence of a stoma causes significant inconvenience to the patient, but in some cases it is impossible to do without such an intervention.

Rehabilitation after surgery

In the initial recovery period, the patient is given infusion therapy with saline solutions. It is necessary to restore the volume of circulating blood, reduce the intoxication syndrome and improve water-salt metabolism. In severe conditions, blood components can be administered - plasma, erythrocytes, albumin.

To prevent peritonitis, the patient is given antibiotic prophylaxis using a wide spectrum of drugs. Are appointed. In the first few days, nutrition is carried out through a tube or intravenously. After the patient is transferred to a sparing diet, which he must adhere to for several weeks after discharge.

Possible complications and prognosis

Complications of intestinal obstruction include:

• peritonitis - inflammation of the peritoneum;
• ischemia and necrosis of the intestinal area;
• shock state;
• sepsis.

With timely treatment of the patient to the doctor, the prognosis is favorable. In most cases, the patient recovers completely. With late hospitalization, the likelihood of a poor outcome increases. The risk of complications is higher, in 25% of cases a severe course of obstruction ends in death. Therefore, timely hospitalization of the patient is of great importance.

Prevention

• regular preventive examination by a gastroenterologist;
• see a doctor if you have suspicious symptoms.

For the continuation of the topic, be sure to read:

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RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other and unspecified ileus (K56.6)

Gastroenterology, Surgery

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013

Acute intestinal obstruction(OKN) is a syndrome category characterized by a violation of the passage of intestinal contents in the direction from the stomach to the rectum and uniting the complicated course of diseases and pathological processes of various etiologies that form the morphological substrate of acute intestinal obstruction.

I. INTRODUCTION

Protocol name: Acute intestinal obstruction in adults.
Protocol code:

ICD 10 code:
K56.0 - paralytic ileus.
K56.1 - intussusception of the intestine.
K56.2 - volvulus.
K56.3 - ileus caused by gallstones.
K56.4 - another type of closure of the intestinal lumen.
K56.5 - paralytic ileus.
K56.6 Other and unspecified ileus.
K56.7 - paralytic ileus.
K91.3 - postoperative intestinal obstruction.

Abbreviations used in the protocol:
OKN - acute intestinal obstruction
ICD- international classification of diseases
ultrasound - ultrasonography
ECG- electrocardiography
ALT - alanine aminotransferase
AST - aspartate aminotransferase
HIV - AIDS virus
APTT - activated partial thromboplastin time

Protocol development date: 11.09.2013
Patient category: adult patients over 18 years of age
Protocol Users: surgeons, anesthetists, resuscitators, visual diagnostics, nurses.

Acute intestinal obstruction can be caused by numerous causes, which are usually divided into predisposing and producing.

For predisposing reasons include: anatomical and morphological changes in the gastrointestinal tract - adhesions, adhesions that contribute to the pathological position of the intestine, narrowing and lengthening of the mesentery, leading to excessive intestinal mobility, various formations emanating from the intestinal wall, neighboring organs or located in the intestinal lumen, peritoneal pockets and holes in the mesentery. The predisposing causes include a violation of the functional state of the intestine as a result of prolonged starvation. In such cases, the intake of rough food can cause violent peristalsis and intestinal obstruction ("hungry man's disease"). The role of predisposing causes is reduced to the creation of excessive mobility of intestinal loops, or, conversely, its fixation. As a result, the intestinal loops and their mesentery will be able to occupy a pathological position in which the passage of intestinal contents is disturbed.

To producing causes include: a change in the motor function of the intestine with a predominance of spasm or paresis of its muscles, a sudden sharp increase in intra-abdominal pressure, an overload of the digestive tract with abundant coarse food.
Depending on the nature of the triggering mechanism, AIO is divided into mechanical and dynamic, in the vast majority - paralytic, developing on the basis of intestinal paresis. Spastic obstruction can occur with organic spinal disorders.
If an acute violation of intestinal hemocirculation captures extraorganic mesenteric vessels, strangulation OKN occurs, the main forms of which are infringements, torsion and nodulation. Much more slowly, but with the involvement of the entire leading part of the intestine, the process develops with obstructive OKN, when the intestinal lumen is blocked by a tumor or other volumetric formation. An intermediate position is occupied by mixed forms of OKN - intussusception and adhesive obstruction - combining strangulation and obturation components. Adhesive obstruction is up to 70-80% of all forms of OKN.
The nature and severity of clinical manifestations depend on the level of AIO. There are small intestine and colonic OKN, and in the small intestine - high and low.
In all forms of AIO, the severity of disorders is directly dependent on the time factor, which determines the urgent nature of treatment and diagnostic measures.

Note: The following classes of recommendations and levels of evidence are used in this protocol:

Level I - Evidence from at least one well-designed randomized controlled trial or meta-analysis
Level II - Evidence obtained from at least one well-designed clinical trial without adequate randomization, from an analytical cohort or case-control study (preferably from a single center), or from dramatic results obtained from uncontrolled studies.
Level III - Evidence obtained from the opinions of reputable investigators based on clinical experience.

Grade A - Recommendations that have been approved by at least 75% of the multisectoral expert panel in agreement.
Class B - Recommendations that have been somewhat controversial and have not met with consensus.
Grade C - Recommendations that caused real controversy among the group members.

Classification

Clinical classification
In Kazakhstan and other CIS countries, the following classifications are most common:

According to Oppel V.A.
1. Dynamic obstruction (paralytic, spastic).
2. Hemostatic obstruction (thrombophlebetic, embolic).
3. Mechanical with hemostasis (pinching, turning).
4. Mechanical simple (blockage, kink, compression).

According to Chukhrienko D.P.
by origin
1. congenital
2. purchased

According to the mechanism of occurrence:
1. mechanical
2. dynamic

By the presence or absence of circulatory disorders:
1. obstructive
2. strangulation
3. combined

By clinical course:
1. partial
2. complete (acute, subacute, chronic, recurrent)

Morphologically:
dynamic
1. paralytic
2. spastic.

Mechanical
1. strangulation
2. obstructive
3. mixed

By level of obstruction
1. small intestine (high)
2. colonic (low)

By stages:
Stage 1 (up to 12-16 hours) - violation of the intestinal passage
Stage 2 (16-36 hours) - stage of acute disorders of intraparietal intestinal hemocirculation
Stage 3 (over 36 hours) stage of peritonitis.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

The list of basic and additional diagnostic measures:
1. Complete blood count
2. Urinalysis
3. Determination of blood glucose
4. Microreaction
5. Blood typing
6. Determination of the Rh factor
7. Determination of bilirubin
8. Definition of AST
9. Definition of ALT
10. Determination of thymol test
11. Determination of creatinine
12. Determination of urea
13. Determination of alkaline phosphatase
14. Determination of total protein and protein fraction
15. Determination of blood amylase
16. Coagulogram (prothrombin index, clotting time, bleeding time, fibrinogen, APTT)
17. Blood for HIV
18. ECG
19. Plain radiography of the abdominal organs
20 Plain chest x-ray
21. Ultrasound of the abdominal organs
22. Computed tomography of the abdominal organs
23. Diagnostic laparoscopy
24. Contrast study of the gastrointestinal tract
25. Consultation with a resuscitator
26. Anesthesiologist's consultation
27. Oncologist consultation
28. Consultation of a therapist

Diagnostic criteria

Complaints and anamnesis
OKN is characterized by a variety of complaints made by patients, but the main and most reliable of them can be called the following triad of complaints: abdominal pain, vomiting, stool and gas retention .

1. Stomach ache usually occur suddenly, regardless of food intake, at any time of the day, without precursors. For intestinal obstruction, cramping pains are most characteristic, which is associated with intestinal motility. There is no clear localization of pain in any part of the abdominal cavity. With obstructive intestinal obstruction, pain outside of a cramping attack usually disappears. In the case of strangulation intestinal obstruction, the pains are persistent, sharply intensifying during an attack. Pain subsides only for 2-3 days, when there is depletion of intestinal motility. The cessation of pain in the presence of intestinal obstruction is a poor prognostic sign. With paralytic ileus, the pain is constant, arching, of moderate intensity.

2. Vomit at first it is reflex in nature, with continued obstruction, vomiting of stagnant contents develops, in the late period, with the development of peritonitis, vomiting becomes indomitable, uninterrupted, and the vomit has a fecal odor. The higher the obstruction, the more pronounced the vomiting. In the intervals between vomiting, the patient experiences nausea, he is worried about belching, hiccups. With a low localization of the obstruction, vomiting is observed at large intervals.

3. Stool and gas retention most pronounced with low intestinal obstruction. With high intestinal obstruction at the onset of the disease, some patients may have stools. This is due to the emptying of the intestine located below the obstruction. With intestinal obstruction due to intussusception from the anus, bloody discharge from the anus is sometimes observed, which can cause a diagnostic error when OKN is mistaken for dysentery.

Disease history: it is necessary to pay attention to the intake of copious amounts of food (especially after fasting), the appearance of abdominal pain during physical exertion, accompanied by a significant increase in intra-abdominal pressure, complaints of decreased appetite and intestinal discomfort (periodic pain and bloating; constipation, followed by diarrhea; pathological impurities in feces);

Anamnesis of life is also important. Postponed operations on the abdominal organs, open and closed injuries of the abdomen, inflammatory diseases are often a prerequisite for the occurrence of intestinal obstruction.

Physical examinations:

1. General condition of the patient may be moderate or severe depending on the form, level or time elapsed since the onset of AIO.

2. Temperature in the initial period of the disease does not increase. With strangulation obstruction, when collapse and shock develop, the temperature drops to 36 ° C. In the future, with the development of peritonitis, the temperature rises to subfebrile.

3. Pulse at the beginning of the disease does not change, with an increase in the phenomena of obstruction, tachycardia appears. Note the discrepancy between low temperature and frequent pulse.

4. Skin and mucous membranes: according to their assessment, one can judge the degree of dehydration: dry skin and mucous membranes, decreased skin turgor, dry tongue.

5. Examination of the abdomen a patient who has intestinal obstruction should begin with an examination of typical places of hernial orifice in order to exclude the presence of an external strangulated hernia. Postoperative scarring may indicate adhesive obstruction. Abdominal bloating is one of the most persistent signs of AIO. However, the degree of swelling can be different and depends on the level of obstruction and the timing of the disease. With a high obstruction, swelling may be slight, but the lower the level of the obstruction, the greater the swelling. Particularly significant is swelling with paralytic and colonic obstruction. At the beginning of obstruction, abdominal distention may be small, but as the duration of the disease increases, the degree of flatulence increases. Incorrect configuration of the abdomen and asymmetry are characteristic of strangulation intestinal obstruction. It is not uncommon to see one or more swollen intestinal loops through the abdominal wall. A clearly demarcated stretched intestinal loop contoured through the abdominal wall - Val's symptom - is an early symptom of AIO. On percussion, high tympanitis is heard over it. With torsion of the sigmoid colon, the abdomen appears to be skewed, as it were. In this case, the swelling is located in the direction from the right hypochondrium through the navel to the left iliac region (Schiman's symptom). When examining the abdomen, one can see slowly rolling shafts or suddenly appearing and disappearing protrusions. Often they are accompanied by an attack of abdominal pain and vomiting. Peristalsis visible to the eye - a symptom of Shlange - is more clearly defined with slowly developing obstructive obstruction, when the muscles of the adducting intestine have time to hypertrophy.

6. Palpation of the abdomen painful. There is no tension in the muscles of the abdominal wall. Shchetkin-Blumberg's symptom is negative. With strangulation obstruction, there is a positive symptom of Thevenard - a sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of the mesentery passes. This symptom is especially characteristic of volvulus of the small intestine. Sometimes, with palpation of the abdomen, it is sometimes possible to determine the tumor, the body of the invaginate, the inflammatory infiltrate that caused the obstruction. With a slight concussion of the abdominal wall, you can hear the "splash noise" - Sklyarov's symptom. This symptom indicates the presence of an overstretched paretic loop of the intestine, overflowing with liquid and gaseous contents.

7. Abdominal percussion reveals limited areas of blunting zones, which corresponds to the location of the intestinal loop, filled with fluid and directly adjacent to the abdominal wall. These areas of dullness do not change their position when the patient turns, and this is how they differ from free effusion. Dullness of percussion sound is also detected over a tumor, inflammatory infiltrate or intussusception of the intestine.

8. Auscultation of the abdomen: in the initial period of OKN, when peristalsis is still preserved, numerous ringing noises are heard, resonating in stretched loops. Sometimes you can catch the "noise of a falling drop" - a symptom of Spasokukotsky-Wilms. Peristalsis can be induced or increased by tapping the abdominal wall. In the late period, with an increase in intestinal paresis, the noises become shorter and rarer, but high tones. With the development of intestinal paresis, all sound phenomena disappear and they are replaced by "dead silence", which is an ominous sign. During this period, with a sharp bloating, Bailey's symptom can be determined - listening to breath sounds and heart tones, which are normally not heard through the stomach.

9. Rectal digital examination may reveal a tumor of the rectum, fecal obstruction, head of intussusceptum, and traces of blood. A valuable diagnostic sign characteristic of low intestinal obstruction is atony of the sphincter and balloon-like swelling of the empty ampoule of the rectum (symptom of the Obukhov Hospital) and low capacity of the distal intestine (Tsege-Mantefeil symptom). At the same time, no more than 500-700 ml of water can be injected into the rectum, with further administration, the water will flow back.

Laboratory research:
- complete blood count (leukocytosis, stab shift, accelerated ESR, signs of anemia may be observed);
- coagulogram (signs of hypercoagulability may be observed);
- biochemical blood test (violation of water-electrolyte and acid-base balance).

Instrumental Research

1. Plain radiography of the abdominal organs
Kloiber's bowl - a horizontal level of liquid with a dome-shaped enlightenment above it, which looks like a bowl turned upside down. With strangulation obstruction, they can manifest themselves after 1 hour, and 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 step ladder.
Intestinal arcades. They are obtained when the small intestine is swollen with gases, while horizontal levels of liquid are visible in the lower knees of the arcades.
The symptom of pinnation (transverse striation in the form of a stretched spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular mucosal folds.

2. Abdominal ultrasound
With mechanical intestinal obstruction:
- expansion of the intestinal lumen by more than 2 cm with the presence of the phenomenon of "liquid sequestration" into the intestinal lumen;
- thickening of the wall of the small intestine more than 4 mm;
- the presence of reciprocating movements of the chyme in the intestine;
- an increase in the height of the kerkring folds by more than 5 mm;
- increasing the distance between the kerkring folds by more than 5 mm;
- hyperpneumatization of the intestine in the leading section
with dynamic intestinal obstruction:
- the absence of reciprocating movements of the chyme in the intestine;
- the phenomenon of fluid sequestration into the intestinal lumen;
- unexpressed relief of kerkring folds;
- hyperpneumatization of the intestine in all departments.

3. Contrast study of the gastrointestinal tract It is used less frequently and only when there are difficulties in diagnosing intestinal obstruction, the patient's stable condition, and the intermittent nature of intestinal obstruction. The patient is given to drink 50 ml of barium suspension and a dynamic study of the passage of barium is carried out. Delaying it up to 4-6 hours or more gives grounds to suspect a violation of the motor function of the intestine.

4. Diagnostic laparoscopy(it is used only when the previous methods of instrumental diagnostics are not informative).

5. Computed tomography(it is used only when the previous methods of instrumental diagnostics are not informative, as well as to identify various formations of the abdominal organs that cause AIO) (level of evidence - III, strength of recommendation - A).

Indications for specialist consultations:
- Resuscitator: to determine the indications for the treatment of the patient in the intensive care unit, to agree on the tactics of managing the patient in terms of eliminating violations of water-electrolyte and acid-base balance.
- Anesthesiologist: to determine the type of anesthesia if surgery is necessary, as well as to agree on the tactics of preoperative management.
- Oncologist: if abdominal tumors are suspected, causing AIO.
- Therapist: identification of concomitant somatic pathology, which complicates the course of AIO, and can also complicate the course of the operation and the postoperative period.

Differential Diagnosis

Nosology	Common (similar) signs with OKN	Distinguishing features from OKN
Acute appendicitis	Abdominal pain, stool retention, vomiting.	The pains begin gradually and do not reach such strength as with obstruction; pains are localized, and with obstruction they are cramping in nature, more 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.	Sudden onset, severe abdominal pain, stool retention.	The patient takes a forced position, and with intestinal obstruction, the patient is restless, often changes position. Vomiting is not characteristic of a perforated ulcer, but is often observed with intestinal obstruction. With a perforated ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, while with OKN, the stomach is swollen, soft, and not 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, and with OKN - Kloiber bowls, arcades, a symptom of pinnation
Acute cholecystitis	Sudden onset, severe abdominal pain	Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the right shoulder blade. With OKN, the pain is cramp-like, non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. Increased peristalsis, sound phenomena, radiological signs of obstruction are absent in acute cholecystitis.
Acute pancreatitis	Sudden onset of severe pain, severe general condition, frequent vomiting, bloating and stool retention.	The pains are localized in the upper abdomen, are 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. X-ray with pancreatitis, there is a high standing of the left dome of the diaphragm, and with obstruction - Kloiber's cups, arcades, transverse striation.
Intestinal infarction	Severe sudden pain in the abdomen, vomiting, severe general condition, soft abdomen.	Pain in intestinal infarction is constant, peristalsis is completely absent, abdominal distension is small, there is no asymmetry of the abdomen, “dead silence” is determined during auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a large range of sound phenomena is heard, bloating is more significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, high leukocytosis (20-30 x10 9 /l) is pathognomonic.
Renal colic	Severe pain in the abdomen, 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 visible in the kidney or ureter.
Pneumonia	Rarely there may be abdominal pain and bloating	Pneumonia is characterized by high fever, rapid breathing, blush on the cheeks, and physical examination reveals crepitant rales, pleural friction rub, bronchial breathing, dullness of lung sound. X-ray examination can detect a pneumonic focus.
myocardial infarction	Sharp pains in the upper abdomen, bloating, sometimes vomiting, weakness, lowering blood pressure, tachycardia	With myocardial infarction, there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. An electrocardiographic study helps clarify the diagnosis of myocardial infarction.

Treatment

Treatment Goals: elimination of intestinal obstruction; complete restoration of the passage of intestinal contents; elimination of the cause that caused OKN (if possible).

Treatment tactics

Non-drug treatment:(mode 1, diet 0, decompression of the upper digestive tract through a nasogastric tube (level of evidence - I, strength of recommendation - A) or an intestinal tube inserted with the help of FGDS, siphon enemas) .

Medical treatment:

Pharmacological group	INN	Dosages, frequency of administration, route of administration
Antispasmodics	Drotaverine	0.04/2 ml solution * 3 r / d (i.m. or i.v.)
Cholinesterase inhibitors	Prozerin	0.05% solution 1 ml * 3 r / d (i / m or s / c)
Preparations for rehydration and detoxification for parenteral use	Sodium chloride	0.9% solution in / in the cap (the volume of infusion depends on the body weight and the degree of dehydration of the patient)
	Sodium chloride solution complex	intravenous cap (the volume of infusion depends on body weight and the degree of dehydration of the patient)
	Aminoplasmal	10% solution in / in drip (the volume of infusion depends on the patient's body weight)
	Dextran	in/in drip
Analgesics	Morphine	0.01/1 ml solution i/m
Antibacterial therapy	Cefazolin	1.0 * 3-4 r/d i/m or i/v
	Meropenem	1.0 * 2-3 r/d i/m or i/v

List of essential medicines:
1. Antispasmodic drugs
2. Antibacterial drugs (cephalosporins II-III generation)
3. Analgesics
4. Crystalloid solutions for infusion

List of additional medicines:
1. Means for anesthesia
2. Consumables for laparoscopic or open surgery
3. Antibacterial drugs (β-lactamase inhibitors, fluoroquinolones, carbapenems, aminoglycosides).
4. Novocaine solution 0.5% -1%
5. Narcotic analgesics
6. Colloidal plasma replacement solutions
7. Fresh frozen plasma
8. Blood components

Other types of treatment: bilateral pararenal novocaine blockade (as a method of influencing the autonomic nervous system) (level of evidence - III, strength of recommendation - A).

Surgical intervention:
1. The operation for AIO is always performed under anesthesia by a three-medical team.
2. At the stage of laparotomy, revision, identification of the pathomorphological substrate of obstruction and determination of the operation plan, it is mandatory to participate in the operation of the most experienced surgeon on duty, as a rule, the responsible surgeon on duty.
3. For any localization of obstruction, access is median laparotomy, if necessary, with excision of scars and careful dissection of adhesions at the entrance to the abdominal cavity.
4. Operations for OKN provide for the consistent solution of the following tasks:
- establishing the cause and level of obstruction;
- elimination of the morphological substrate of OKN;
- determination of the viability of the intestine in the area of ​​the obstacle and determination of indications for its resection;
- establishing the boundaries of the resection of the altered intestine and its implementation;
- determination of indications and method of drainage of the intestine;
- sanitation and drainage of the abdominal cavity in the presence of peritonitis.
5. Detection of an obstruction zone immediately after laparotomy does not relieve the need for a systematic revision of the state of the small and large intestines throughout their entire length. Revision is preceded by obligatory infiltration of the root of the mesentery of the small intestine with a local anesthetic solution (100-150 ml of 0.25% novocaine solution). In the case of a pronounced overflow of intestinal loops with contents, the intestine is decompressed using a gastrointestinal probe before revision.
6. Removing the obstruction is the key and most difficult component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of adhesions; resection of the altered intestine; elimination of torsion, intussusception, nodules or resection of these formations without prior manipulations on the altered intestine.
7. When determining the indications for resection of the intestine, visual signs are used (color, swelling of the wall, subserous hemorrhages, peristalsis, pulsation and blood filling of the parietal vessels), as well as the dynamics of these signs after the introduction of a warm solution into the mesentery of the intestine) of a local anesthetic. If there are doubts about the viability of the intestine, especially over its large extent, it is permissible to postpone the decision on resection using a programmed relaparotomy or laparoscopy after 12 hours.
8. When deciding on the boundaries of resection, one should deviate from the visible boundaries of the violation of the blood supply to the intestinal wall towards the adductor section by 35-40 cm, and towards the outlet section by 20-25 cm (level of evidence - III, strength of recommendation - A). The exception is resections near the ligament of Treitz or the ileocecal angle, where these requirements are allowed to be limited with favorable visual characteristics of the intestine in the area of ​​the proposed intersection. In this case, control indicators are necessarily used - bleeding from the vessels of the wall at its intersection and the state of the mucous area.
9. Indications for drainage of the small intestine are:
- overflow with the contents of the leading intestinal loops;
- the presence of diffuse peritonitis with cloudy effusion and fibrin overlays;
- Extensive adhesive process in the abdominal cavity.
10. With colorectal tumor obstruction and the absence of signs of inoperability, one- or two-stage operations are performed depending on the location, stage of the tumor process and the severity of the manifestations of colonic obstruction. An emergency right-sided hemicolectomy in the absence of peritonitis can be completed with a primary ileotransverse anastomosis. In case of obstruction with a left-sided location of the focus of obstruction, resection of the colon is performed with removal of the tumor, which is completed according to the type of Hartmann operation. The primary anastomosis is not superimposed (level of evidence - III, strength of recommendation - A).
11. All operations on the colon are completed with devulsion of the external sphincter of the anus.
12. The presence of diffuse peritonitis requires additional sanitation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.

Preventive actions
In order to prevent acute intestinal obstruction, it is necessary to find and remove intestinal tumors in time. The prevention of intestinal obstruction also includes the fight against constipation. The patient's food should contain foods rich in fiber and vegetable oil. Animal fats require a sharp restriction.
It is required to exclude from your diet: cottage cheese, cheese, cookies, drying. Rice can be eaten in combination with various vegetables. It is also necessary to take laxatives (bisacodyl tablets and suppositories, senna grass). It is necessary that the chair was at least once every three days, and if it is not there, then an increase in the dose of the laxative drug, its replacement, a cleansing enema, or an urgent consultation with a surgeon is required.
Prevention of complications in operated patients with a diagnosis of "acute intestinal obstruction" is reduced to adequate and proper management of the postoperative period (see paragraph 15.6).

Further management.
Enteral nutrition begins with the appearance of intestinal peristalsis through the introduction of glucose-electrolyte mixtures into the intestinal probe.
The extraction of the nasogastrointestinal drainage tube is carried out after the restoration of stable peristalsis and independent stool for 3-4 days (level of evidence - III, strength of recommendation - A). In order to combat ischemic and reperfusion injuries of the small intestine and liver, infusion therapy is carried out (aminoplasmal solution, sodium chloride solution 0.9%, glucose solution 5%, ringer's solution). Antibacterial therapy in the postoperative period should include cephalosporins (level of evidence - I, strength of recommendation - A). To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
Complex therapy should include heparin or low molecular weight heparins for the prevention of thromboembolic complications and microcirculation disorders.
An extract from the uncomplicated course of the postoperative period is made for 10-12 days. The presence of a functioning artificial intestinal or gastric fistula in the absence of other complications allows the patient to be discharged for outpatient treatment with a recommendation for re-hospitalization to eliminate the fistula if it does not close on its own.
If it is necessary to conduct adjuvant chemotherapy and in the absence of contraindications to it in patients with a tumor cause of AIO, it should be carried out no later than 4 weeks after surgery.

Treatment effectiveness indicators:
1. Elimination of symptomatic manifestations of the disease (absence of abdominal pain, absence of nausea and vomiting);
2. Positive X-ray dynamics;
3. Restoration of intestinal patency (regular discharge of stool and gases through artificial (colostomy, ileostomy) or natural openings;
4. Healing of the surgical wound by primary intention, no signs of inflammation of the postoperative wound.

Drugs (active substances) used in the treatment

Groups of drugs according to ATC used in the treatment

Hospitalization

Indications for hospitalization, indicating the type of hospitalization:
The established diagnosis or reasonable assumption of the presence of AIO is the basis for the immediate referral of the patient to the surgical hospital by ambulance in the supine position on a stretcher, followed by mandatory hospitalization on an emergency basis.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. V. S. Saveliev, A. I. Kirienko. Clinical surgery: national guidelines: in 3 volumes - 1st ed. - M.: GEOTAR-Media, 2009. - S. 832. 2. Ripamonti C, Mercadante S. Pathophysiology and management of malignant bowel obstruction. In: Doyle D, Hanks G, Cherny NI, Calman K, editors. Oxford Textbook of Palliative Medicine. 3rd ed. New York, New York Oxford University Press Inc., New York 2005. p. 496-507. 3. Frank C. Medical management of intestinal obstruction in terminal care. Canadian Family Physician. February 1997;43:259-65. 4. Letizia M, Norton E. Successful Management of Malignant Bowel Obstuction. Journal of Hospice and Palliative Nursing.2003 July-September 2003;5(3):152-8. 5. BC Cancer Agency Professional Practice Nursing. Alert Guidelines: Bowel Obstruction. ; Available from: http://www.bccancer.bc.ca/HPI/Nursing/References/TelConsultProtocols/BowelObstruction.htm 6. M.A.Aliev, S.A.Voronov, V.A.Dzhakupov. Emergency surgery. Almaty. - 2001. 7. Surgery: Per. from English, add./Ed. Lopukhina Yu.M., Savelieva V.S. M.: GEOTAR MEDICINE. – 1998. 8. Eryukhin I. A., Petrov V. P., Khanevich M. D. Intestinal obstruction: A guide for physicians. - St. Petersburg, 1999. - 443 p. 9. Brian A Nobie: Small-Bowel Obstruction Treatment & Management. ; Available from: http://emedicine.medscape.com/article/774140-treatment/ 10. Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. Mar 2007;188(3):W233-8. 11. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. Aug 2011;28(8):676-8. 12. Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. Jun 2008;64(6):1651-64.

Information

III. ORGANIZATIONAL ASPECTS OF INTRODUCING THE PROTOCOL

List of developers:
1. Turgunov Ermek Meyramovich - doctor of medical sciences, professor, surgeon of the highest qualification category, head of the Department of Surgical Diseases No. 2 of the Republican State Enterprise on the REM "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan, an independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.
2. Matyushko Dmitry Nikolaevich - Master of Medical Sciences, surgeon of the second qualification category, doctoral student of the RSE on REM "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan

Reviewer:
Almambetov Amirkhan Galikhanovich - doctor of medical sciences, surgeon of the highest qualification category, head of the department of surgery No. 2 of JSC "Republican Scientific Center for Emergency Medical Care".

Indication of no conflict of interest: there is no conflict of interest.

Indication of the conditions for revising the protocol: deviation from the protocol is unacceptable; this protocol is subject to revision every three years, or when new proven data on the diagnosis and treatment of AIO become available.

Attached files

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Intestinal obstruction is an acute pathology that can lead to death. That is why such a common symptom as abdominal pain should not be underestimated, because it can be a sign of surgical pathology. The development of the disease is based on a violation of the promotion of the food bolus along the sections of the intestinal tract.

Most often, the process develops as a result of mechanical obstruction, that is, blockage of the lumen or a disorder of motor function. The process is characterized by a high risk of mortality. It is considered not as a separate pathology, but as a clinical syndrome characterized by a pronounced pathology.

Intestinal blockage is accompanied by severe intoxication and impaired vital functions. Usually the syndrome is a complication of other diseases, for example, ascariasis, tumors, brain injuries. More often, the pathological process develops in the representatives of the stronger sex. Why does intestinal obstruction occur, how does it manifest itself and how to deal with it?

Causes

The causes of the development of pathology depend on the form of the disease. So, mechanical obstruction, in which there is a physical obstacle to the passage of chyme, is strangulation and obturation. In the first case, the causes may be associated with volvulus of intestinal loops, strangulation, adhesions, or knot formation.

The following reasons can provoke paralytic obstruction:

• trauma or surgery;
• inflammatory processes of the abdominal organs;
• hematoma, thrombosis.

Persistent spasm can be observed with ascariasis, renal or hepatic colic, intoxication, diseases of the nervous system. Congenital obstruction is associated with intrauterine development disorders. The acquired form in childhood is a consequence of inflammatory processes or surgical intervention.

Meconium ileus in newborns is a pathology in which the primary feces acquire a dense and fibrous structure and are difficult to pass. Abnormal meconium blocks the intestines. Its elimination is done with an enema or surgery. When affected, children develop vomiting, followed by constipation. If the obstruction has affected the thick section, the early onset of constipation is characteristic, followed by vomiting.

Development mechanism

The pathogenesis of intestinal obstruction is quite simple. Chyme meets an obstacle in its path, which provokes stagnation in the intestines. As a result, the intestinal wall begins to stretch. It accumulates a large amount of digestive juice, bile, gases.

Pathological changes in the intestinal wall lead to the fact that it cannot fully perform its function, in particular, the absorption of nutrients. As a result, the pressure in it increases. The loops increase in volume, swell, change their color, and peristalsis is significantly weakened or even stops.

Separately, it is worth noting the role of the adhesive process in the pathogenesis or in the mechanism of the development of pathology. Adhesions deform the structure of the intestine, tighten it and disrupt the anatomical arrangement of the loops. In many ways, the pathogenesis depends on the type of obstruction. So, with a strangulation form, due to a sharp deterioration in blood circulation, pathological changes in the intestine develop quite quickly.

Compression of the blood vessels and the formation of blood clots causes the death of the intestinal wall. Such processes cause serious disturbances in the functioning of the body. Because of this, pathogens and their toxins can easily enter the abdominal cavity, which is fraught with the development of peritonitis.

Symptoms

The earliest, most frequent and common symptom of intestinal obstruction (CI) is abdominal pain. It has a cramping character and has a tendency to increase. With ischemic disorders, the pain syndrome is unbearable and permanent. Obturation is characterized by pain of the type of colic with light painless intervals.

Intestinal obstruction manifests itself in the form of unbearable pain

Another characteristic feature is repeated vomiting, which does not bring relief. In the later stages, vomit acquires an unpleasant smell of feces. KN is accompanied by a delay in stool and gases. The nature of the swelling can tell about the localization of the pathological process.

With the defeat of the upper sections of the abdomen becomes asymmetric. If the lower sections are involved in the process, a symmetrical accumulation of gases occurs. How intestinal obstruction develops and manifests itself in a child can be read.

In the development of the disease, three periods are distinguished, each of which has its own clinical symptoms:

• Early. It lasts up to twelve hours. The initial symptom is pain. With obstructive obstruction, it lasts for several minutes, and then passes. During strangulation, the pain flash is permanent and can cause a state of shock. Vomiting occurs rarely and only if there is an obstruction at the very beginning of the small intestine.
• Intermediate. The maximum duration is twenty-four hours. There is bloating, profuse vomiting. Increased symptoms of dehydration.
• Late. Lasts over 24 hours. Body temperature rises, breathing rate accelerates, urine production stops. Perhaps the development of peritonitis and sepsis.

Classification

KH is low and high. In the first case, obstruction of the colon is observed. High intestinal obstruction is present in the thin section. To determine it, a Schwartz test is performed. The specialist conducts x-ray observation of the passage of a contrast agent through the digestive tract, which the patient takes inside.

Pathology is acute and chronic, congenital and acquired, complete and partial. Nevertheless, the main reference point in the classification of CI is the mechanism of its development. In this case, it is divided into three main types: mechanical, dynamic, vascular.

Mechanical

This type of KN is divided, in turn, into three forms:

• strangulation;
• obstructive;
• mixed.

Strangulation obstruction is characterized by compression of the lumen of the organ, as well as clamping of nerves and blood vessels. Developing circulatory disorders can lead to irreversible consequences, up to tissue necrosis. The cause of such a pathological process can be a sharp increase in intra-abdominal pressure, as well as the use of a large amount of roughage after fasting.

The following provoking factors can cause strangulation obstruction:

• infringement of a hernia;
• a sharp collection of body weight;
• intussusception.

The disease manifests itself in the form of abdominal pain, which can cause a state of shock. As the process progresses, nausea, vomiting, which does not bring relief, constipation, and bloating appear. In the second phase of the disease, the symptoms of intoxication increase. There is fecal vomiting. In the third stage, peritonitis develops. The diagnosis is the reason for urgent surgical intervention.

Attention! With strangulation intestinal obstruction, patients scream in pain, and also take a forced position with their legs pressed to their stomachs.

Symptoms of intestinal obstruction may vary depending on the location of the pathology:

• blind section. Pain is localized in the right half or paraumbilical zone. There is vomiting, as well as retention of stools and gases. Due to bloating, asymmetry is observed. X-ray reveals a spherical distended caecum;
• sigmoid colon. It usually occurs in older people with chronic constipation. A painful attack occurs in the lower abdomen and, as a rule, ends with vomiting. The abdomen is sharply swollen, there is a delay in stool and gases. There is a violation of breathing and cardiovascular activity.

Now let's talk about bowel obturation. Blockage of the lumen of the organ can cause neoplasms. Increasing in size, they impede the natural movement of chyme. Given the fact that tumors grow slowly, the clinical picture of obstruction increases gradually. If a foreign object, especially with sharp edges, became the cause of obturation, a pronounced clinical picture is observed.

Chronic constipation thickens the feces, as a result of which they can injure the mucous membrane and, accumulating, block the passage. With complete obturation, peristalsis stops. There is a cramping pain attack. If the contents of the stomach and bile are present in the vomit, this indicates damage to the upper digestive tract. Fecal vomiting is an indicator of a disorder of the lower sections.

Mechanical obstruction can be caused by fecal stones

If a tumor is the cause of the blockage, patients will experience the following symptoms:

• intoxication;
• exhaustion;
• bloating;
• cramping pains;

If gallstones were the cause of the blockage, there will be repeated vomiting with bile impurities. Obturation with fecal stones in the elderly causes intense abdominal pain, gas and stool retention. A characteristic sign of pathology is an empty rectum.

Dynamic

It is also called functional obstruction. In this case, the peristalsis is weakened without the presence of a mechanical obstacle. There is stagnation of the intestinal contents. Often the process is diagnosed in children. The causes of dynamic obstruction are not fully understood. Nevertheless, doctors identify some provoking factors that can cause CI:

• chronic diseases of the gastrointestinal tract;
• belly herbs;
• operation;
• obstruction of blood vessels;
• intoxication;
• foreign objects;
• inflammatory processes.

DTC is spastic and paralytic. The first form occurs quite rarely and provokes its total spasm. Most often this is due to chronic intoxication, increased excitability of the body, or damage to the walls by a foreign body.

The main manifestations of the spastic type include short-term attacks of sharp pain, single vomiting, and a slight increase in body temperature. In addition, there is no urge to defecate for a long time. Along with this, the general condition of the person remains stable. Pathology is treated with conservative methods.

The paralytic type develops against the background of peritonitis or infectious processes. It can also develop after surgical interventions on the abdominal organs. There is an increase in the abdomen in size, frequent bouts of vomiting, as well as retention of feces and gases. The main method of treatment is surgery.

Diagnosis and treatment

In the timely detection of intestinal obstruction, the qualification of the surgeon, as well as his ability to navigate the situation and determine the further tactics of managing the patient, play an important role. The disease does not last long. An X-ray examination should be carried out as soon as possible.

Diagnosis may require colonoscopy, barium enema, laparoscopy, ultrasound, CT. What to do after confirmation of intestinal obstruction? Treatment of intestinal obstruction is carried out in a surgical hospital. Surgery is indicated in such cases:

• development of peritonitis;
• strangulation form;
• severe obturation;
• severe intoxication;
• shock state.

If the operation is not carried out in a timely manner, necrosis of the intestinal wall will develop. In other cases, conservative therapy is prescribed. The treatment process includes a siphon or cleansing enema. Remove the contents of the gastrointestinal tract using continuous aspiration.

For this, suction is performed with a special device that is inserted through the esophagus. To stop a pain attack, it may be necessary to carry out a novocaine blockade in the lumbar region. In some cases, a colonoscopy is used, which allows you to eliminate the volvulus or remove the stone that served as an obstacle to the chyme.

After eliminating the cause of the pathology, it is very important to stabilize the patient's condition. This includes ridding the body of toxins and decay products. For this purpose, infusion drugs are prescribed. Antibacterial agents are prescribed to prevent infection. To prevent thrombosis, tight bandaging of the lower extremities is performed, and blood thinners are also prescribed. Prokinetics will help normalize bowel function.

To eliminate slagging of the intestines in adults, you can use the right diet and drink.

Prevention

It is much easier to prevent the development of pathology than to fight it. The main cause of intestinal slagging is poor ecology and an increase in the content of toxic substances in the atmosphere, food and water. Do not drink raw tap water. The chlorine contained in it forms toxic compounds in the intestines.

Attention! Toxins and toxins accumulate in the intestines for years, poisoning our body. That is why it is important to drink enough water to remove harmful substances.

Today, many products contain various nitrates, pesticides, hormones, antibiotics, and heavy metals. Also, people often mix together incompatible products, such as proteins and carbohydrates. The following symptoms can indicate the slagging of the body:

• weakness, drowsiness;
• headache;
• increased sweating with an unpleasant odor;
• skin rash;
• irritability;
• bags under the eyes;
• cellulite;
• decrease in working capacity;
• bad breath;
• avitaminosis.

Slagging does not allow the intestines to function normally. Slags rot, cause dysbacteriosis, reduced immunity and chronic constipation. Colon cleansing is not a one-time procedure, but a long process. The first step is a gentle cleansing of the contents of the intestine. Further, it is necessary to ensure the normalization of peristalsis. And the final stage is the restoration of microflora.

Laxatives should be used in emergencies. You should not abuse such drugs, because as a result, the intestines may begin to be lazy to perform their functions. With the help of hydrocolonoscopy, it is possible to irrigate the inner surface of the intestine with large amounts of water, but this procedure has a side effect in the form of washing out beneficial bacteria.

The procedure is performed under the supervision of a specialist and is accompanied by a light massage to improve the evacuation of stool. After hydrocoolonoscopy, medications are prescribed to normalize the microflora. An old and effective cleansing method is the enema. It frees a small area of ​​the intestine from the accumulation of feces, improving intestinal patency.

There are also natural cleansing methods. It is necessary to accustom the intestines to empty at the same time after waking up. To do this, drink a glass of boiled water on an empty stomach. Then you can lightly massage the stomach in a clockwise direction. You can also do several sets of squats.

It is also useful to use healing mixtures of populists. For example, in the morning on an empty stomach, you can use a mixture of dried fruits, previously soaked in water and scrolled through a meat grinder. You can also add some honey and aloe juice there. Salads from beets, cabbage and carrots help to normalize bowel function. You can also mix raw apple and cabbage. Oven-baked apples work well. Drink a glass of yogurt an hour before bedtime.

Intestinal obstruction is a dangerous pathology that can lead to dangerous complications that threaten life. In most cases, pathology requires surgical intervention, although sometimes the disease can be cured with the help of conservative methods.

The success of treatment largely depends on timely diagnosis, which is why it is important to listen to your body. If he gives signals in the form of pain in the abdomen, bloating, vomiting, then it is better not to self-medicate, but to contact a specialist.

Acute intestinal obstruction (AIO) is a syndrome characterized by a violation of the passage of contents through the digestive tract, due to mechanical obstruction or inhibition of the motor function of the intestine. The first works on intestinal obstruction that have survived to this day are the works of Hippocrates. In his writings, for the first time, the name ileus is found, which served as a collective term for various diseases of the abdominal cavity, including obstruction.

Currently, in terms of frequency of occurrence, the disease ranks fifth among the main forms of "acute abdomen". AIO occurs in all age groups, but is most common between the ages of 30 and 60. Obstruction due to intussusception is more often observed in children, strangulation - in middle-aged patients, obstruction - in patients older than 50 years. An important feature noted recently is the redistribution in frequency of occurrence of individual forms of AIO. Thus, such forms as nodulation, invagination and torsion began to occur much less frequently. At the same time, the frequency of obstructive colonic obstruction of tumor etiology increased. In 75-80% of cases, the cause of mechanical intestinal obstruction is the adhesive process of the abdominal cavity. Despite the evolution of views on the etiology and pathogenesis of AIO, the development of modern diagnostic methods, the improvement of surgical technologies and resuscitation and anesthesia, postoperative mortality ranges from 10% to 25%. The highest percentage of postoperative mortality in AIO occurs at the age of up to 5 years and over 65 years.

Classification

Back in the first half of the 19th century, two types of intestinal obstruction were identified - mechanical and dynamic. Subsequently, mechanical intestinal obstruction Val (Wahl) proposed to divide into strangulation and obturation. The most simple and expedient at the present time can be considered a classification in which the OKN is subdivided according to the morphofunctional nature:

1. Dynamic (functional) obstruction (12%):
2. Spastic, arising from diseases of the nervous system, hysteria, intestinal dyskinesia, helminthic invasion, etc.
3. Paralytic (infectious diseases, thrombosis of mesenteric vessels, retroperitoneal hematoma, peritonitis, diseases and injuries of the spinal cord, etc.
4. Mechanical intestinal obstruction (88%):
5. Strangulation (torsion, nodulation, internal infringement)
6. Obstructive:

a. intraorganic (foreign bodies, fecal and gallstones, helminthic invasion located in the intestinal lumen)

b. intramural (tumor, Crohn's disease, tuberculosis, cicatricial stricture affecting the intestinal wall)

v. extraorganic (cysts of the mesentery and ovary, tumors of the retroperitoneal space and pelvic organs, which compress the intestine from the outside).

1. Mixed:

a. Adhesive obstruction

b. Intussusception

Origin:

1. Congenital.
2. Acquired.

According to the level of obstruction:

1. Small intestine: a. high b. low
2. Colonic - According to the dynamics of the development of the pathological process

(on the example of adhesive intestinal obstruction)

I stage. Acute violation of the intestinal passage - the stage of "ileus cry" - the first 12 hours from the onset of the disease)

II stage. Acute violation of intraparietal intestinal hemocirculation

(phase of intoxication) - 12-36 hours.

III stage. Peritonitis - more than 36 hours from the onset of the disease.

Significant disagreements are found in the literature on the issue of determining the severity of colonic obstruction. This circumstance gave rise to many classifications of the clinical course of the disease. The most commonly used in urgent coloproctology is the classification developed at the Research Institute of Coloproctology of the Russian Academy of Medical Sciences. According to the proposed classification, there are 3 degrees of severity of colonic obstruction:

I degree (compensated). Complaints of intermittent constipation lasting 2-3 days, which can be eliminated with diet and laxatives. The general condition of the patient is satisfactory, there is periodic bloating, there are no symptoms of intoxication. The results of colonoscopy and irrigography indicate that the tumor narrows the intestinal lumen to 1.5 cm, a slight accumulation of gases and intestinal contents in the colon is detected.

II degree (subcompensated). Complaints about persistent constipation, lack of independent stool. Taking laxatives is ineffective and gives a temporary effect. Periodic bloating, difficulty passing gases. The general condition is relatively satisfactory. Symptoms of intoxication are noticeable. The tumor narrows the intestinal lumen to 1 cm. X-ray examination of the colon is expanded, filled with intestinal contents. Separate liquid levels (Kloiber's cups) can be determined.

III degree (decompensated). Complaints about the lack of stool and gas discharge, increasing cramping abdominal pain and bloating, nausea, and sometimes vomiting. Pronounced signs of intoxication, disturbance of water and electrolyte balance and CBS, anemia, hypoproteinemia. On x-ray examination, the intestinal loops are dilated, swollen with gas. A plurality of fluid levels are defined. As a rule, the majority of patients admitted to the urgent hospital for obstructive colonic obstruction of tumor etiology have a decompensated degree of the disease, which ultimately determines the high incidence of postoperative complications and mortality.

In recent years, the so-called syndrome of false obstruction of the colon, first described by H. Ogilvie in 1948, has been increasingly mentioned. This syndrome manifests itself most often in the form of a clinic of acute dynamic intestinal obstruction due to a violation of sympathetic innervation. Often this condition is observed in the early postoperative period, which leads to repeated laparotomies. Most authors note diagnostic difficulties in establishing Ogilvie's syndrome. A positive effect has a bilateral pararenal novocaine blockade according to A.V. Vishnevsky.

When the clinical manifestations of the disease are accompanied by mild symptoms, we do not make a diagnosis of "partial intestinal obstruction", considering it unjustified in tactical terms. In this case, most often, we are talking about incomplete closure of the intestinal lumen by a growing tumor, adhesive obstruction, or recurrent volvulus. Such a diagnosis disorients the surgeon and leads to belated operations.

Causes of acute intestinal obstruction

OKN can be caused by multiple causes, which are distinguished as predisposing and producing factors. The first include anomalies in the development of the intestine and its mesentery, the presence of adhesions, cords, pockets in the abdominal cavity, pathological formations in the intestinal lumen (tumor, polyps), defects in the anterior abdominal wall, inflammatory infiltrates, hematomas emanating from the intestinal wall or surrounding organs. The second includes causes that, in the presence of predisposing factors, can cause the development of AIO. These are, first of all, acutely developing disorders of the motor function of the intestine in the form of hyper- or hypomotor reactions or a combination of them. This condition may be due to an increased food load, a disorder in the nervous regulation of intestinal motor activity, irritation of the receptors of internal organs by a pathological process that has arisen, drug stimulation, or a sudden increase in intra-abdominal pressure during exercise.

The form of the resulting AIO will depend both on the nature of the predisposing causes and on the type of disturbances in the motor function of the intestine.

The pathogenesis of acute intestinal obstruction

Pathogenesis and causes of death in AIO, not complicated by intestinal necrosis and peritonitis, undoubtedly belong to one of the most complex and difficult sections of surgical pathology. A large number of experimental and clinical studies performed both in our country and abroad are devoted to the study of these issues. Table 1 schematically presents the main components of the pathogenesis of AIO, the development and significance of which is directly proportional to the duration of the disease. The initial manifestations of AIO (I stage) are associated with a violation of the passage through the intestines. The severity of their occurrence and intensity of development depend on the morphological and functional features of the disease. So, in cases of dynamic, strangulation and obturation obstruction, the duration of stage I will be different. It is known that an obstruction along the gastrointestinal tract does not cause any serious consequences if a bypass is created to evacuate the intestinal contents. An exception is the strangulation form of intestinal obstruction, when the mesentery of the intestine is involved in the pathological process from the very beginning, and not so much evacuation as vascular disorders prevail in the pathogenesis of the disease.

In stage I, there are no gross morphological and functional changes in the intestinal wall, there are no disturbances in the water and electrolyte balance and endogenous intoxication syndrome. Such patients, with the exception of cases of strangulation intestinal obstruction, are shown conservative therapy. The second stage of AIO is characterized by an acute disorder of intraparietal intestinal hemocirculation. This is no longer just a reaction of the body to the cessation of the intestinal passage, but deep pathological changes, which are based on tissue hypoxia and the development of violent autocatalytic processes. It was found that with an increase in intra-intestinal pressure up to 30 mm. rt. Art. completely stops the capillary blood flow in the intestinal wall. All of the above gives reason to interpret the second stage of AIO as a process of acute disorders of the intraparietal intestinal hemocirculation. Taking into account its progressive nature, at this stage it is no longer possible to adhere to the tactics of dynamic monitoring of the patient and persistent conservative treatment. It is necessary to put indications for urgent surgical intervention.

Isolation of stage III AIO from clinical and pathophysiological positions is associated with the development of peritonitis due to the penetration of microorganisms through the intestinal wall into the free abdominal cavity and a progressive syndrome of multiple organ failure.

Symptoms of acute intestinal obstruction

Clinical picture acute intestinal obstruction consists of 2 groups of symptoms. The first group is directly related to the changes occurring in the gastrointestinal tract and abdominal cavity in AIO. The second group reflects the general reaction of the body to the pathological process.

I group. The earliest and one of the most constant signs of the disease is pain. The occurrence of cramping pains is characteristic of acute obstruction of the intestinal lumen and is associated with its peristalsis. Sharp constant pains often accompany acutely developed strangulation. If AIO is not diagnosed in a timely manner, then on the 2-3rd day from the onset of the disease, intestinal motor activity is inhibited, which is accompanied by a decrease in the intensity of pain and a change in its nature. At the same time, the symptoms of endogenous intoxication begin to prevail, which is a poor prognostic sign. A pathognomonic symptom in AIO is stool retention and flatulence. However, with high small bowel obstruction, at the beginning of the disease, gas and stool may be discharged due to emptying of the distal intestine, which does not bring relief to the patient, which often disorients the doctor. One of the early clinical signs of AIO is vomiting. Its frequency depends on the level of obstruction in the intestine, the type and form of obstruction, the duration of the disease. Initially, vomiting is reflex in nature, and subsequently occurs due to overflow of the proximal gastrointestinal tract. The higher the intestinal obstruction, the more pronounced vomiting. In the initial stage of colonic obstruction, vomiting may be absent. With low small bowel obstruction, vomiting is observed with large intervals and an abundance of vomit, which acquire the character of intestinal contents with a "fecal" smell. In the later stages of AIO, vomiting is a consequence of not only stagnation, but also endotoxicosis. During this period, it is not possible to eliminate vomiting movements even by intestinal intubation.

One of the local signs of OKN is bloating. "Oblique abdomen" (Bayer's symptom), when bloating leads to asymmetry of the abdomen and is located in the direction from the right hypochondrium through the navel to the left iliac region, is characteristic of volvulus of the sigmoid colon. Intestinal obstruction caused by obstruction of the lumen of the proximal jejunum leads to bloating in the upper jejunum, while obstruction in the ileum and colon leads to bloating of the entire abdomen. In order to diagnose the mechanical form of intestinal obstruction, a triad of clinical signs (Val's symptom) was described: 1. Abdominal asymmetry; 2. Palpable swollen intestinal loop (elastic cylinder) with high tympanitis; 3. Peristalsis visible to the eye. To identify a possible strangulated hernia, accompanied by a clinic acute intestinal obstruction, it is necessary to carefully examine and palpate the epigastric, umbilical and inguinal regions, as well as the existing postoperative scars on the anterior abdominal wall. When examining patients with AIO, it is very important to remember the possible parietal (Richter) strangulation of the intestine, in which the "classic" clinical picture of complete intestinal obstruction, as well as the presence of a tumor-like formation characteristic of a strangulated hernia, are absent.

On palpation, the abdomen remains soft and slightly painful until the development of peritonitis. However, during the period of active peristalsis, accompanied by an attack of pain, there is tension in the muscles of the anterior abdominal wall. For volvulus of the caecum, the Shiman-Dans symptom is considered pathognomonic, which is defined as a feeling of emptiness on palpation in the right iliac region due to displacement of the intestine. With colonic obstruction, flatulence is determined in the right iliac region (Anschütz symptom). The symptom described by I.P. has a significant diagnostic value. Sklyarov (“splash noise”) in 1922, detected with a slight concussion of the anterior abdominal wall. Its presence indicates overflow with liquid and gases of the adductor intestine, which occurs with mechanical intestinal obstruction. This symptom should be reproduced before setting a cleansing enema. With percussion of the anterior abdominal wall, areas of high tympanitis with a metallic tint (Kivul's symptom) are determined, as a result of developing pneumatosis of the small intestine. This is always a warning sign because gas does not normally accumulate in the small intestine.

During auscultation of the anterior abdominal wall at the beginning of the disease, intestinal noises of varying height and intensity are heard, the source of which is the small intestine, which is swollen, but has not yet lost its motor activity. The development of intestinal paresis and peritonitis marks the weakening of intestinal noises, which appear as separate weak bursts, reminiscent of the sound of a falling drop (Spasokukotsky's symptom) or the noise of bursting bubbles (Wilms' symptom). Soon these sounds also cease to be determined. The state of the "silent abdomen" indicates the development of severe intestinal paresis. Due to a change in the resonant properties of the contents of the abdominal cavity, against the background of an enlarged abdomen, heart tones begin to be clearly heard (Bailey's symptom). At this stage, the clinical picture acute intestinal obstruction more and more associated with symptoms of widespread peritonitis.

Diagnosis of acute intestinal obstruction

In diagnostics acute intestinal obstruction a carefully collected anamnesis, scrupulous identification of the clinical symptoms of the disease, a critical analysis of radiological and laboratory data are of great importance.

Examination of a patient with OKN must be supplemented with a digital examination of the rectum, which allows you to determine the presence of fecal masses (“coprostasis”) in it, foreign bodies, tumors or heads of intussusceptum. The pathognomonic signs of mechanical intestinal obstruction are balloon-like swelling of the empty ampoule of the rectum and a decrease in the tone of the sphincters of the anus (“anus gaping”), described by I.I. Grekov in 1927 as a "symptom of the Obukhov hospital".

II group. The nature of general disorders in AIO is determined by endotoxicosis, dehydration and metabolic disorders. There is thirst, dry mouth, tachycardia, decreased diuresis, blood clotting, determined by laboratory parameters.

A very important diagnostic step is an x-ray examination of the abdominal cavity, which is divided into:

1. Non-contrast method (plain radiography of the abdominal cavity). Additionally, a chest x-ray is performed.
2. Contrast methods for studying the movement of barium suspension through the intestine after oral administration (Schwartz test and its modifications), its administration through a nasoduodenal probe and retrograde filling of the colon with a contrast enema.

Abdominal imaging can show direct and indirect symptoms acute intestinal obstruction. Direct symptoms include:

1. The accumulation of gas in the small intestine is a warning sign, because under normal conditions, gas is observed only in the stomach and large intestine.

1. The presence of Kloiber's cups, named after the author who described this symptom in 1919, is considered a classic radiological sign of mechanical intestinal obstruction. They represent horizontal fluid levels found in distended bowel loops that are detected 2 to 4 hours after the onset of the disease. Attention is drawn to the ratio of the height and width of gas bubbles above the liquid level and their localization in the abdominal cavity, which is important for the differential diagnosis of AIO types. However, it should be remembered that Kloiber's cups can also form after cleansing enemas, as well as in debilitated patients who are in bed for a long time. Horizontal levels are visible not only in the vertical position of the patient, but also in the later position.

1. A symptom of transverse striation of the intestinal lumen, referred to as a symptom of Case (1928), "stretched spring", "fish skeleton". This symptom is considered as a manifestation of edema of the Kerckring (circular) folds of the small intestine mucosa. In the jejunum, this symptom manifests itself more prominently than in the ileum, which is associated with the anatomical features of the relief of the mucosa of these sections of the intestine. Clearly visible folds of the small intestine are proof of the satisfactory condition of its wall. The wear of the folds indicates a significant violation of intramural hemodynamics.

In cases where the diagnosis of OKN presents great difficulties, the second stage of X-ray examination using contrast methods is used.

radiopaque method. Indications for its use can be formulated as follows:

• Reasonable doubts about the presence of a mechanical form of OKN in a patient.
• The initial stages of adhesive intestinal obstruction, when the patient's condition does not inspire concern and there is hope for its conservative resolution
• Dynamic monitoring of the progress of the contrast mass must be combined with a clinical study of the patient's condition and conservative therapeutic measures aimed at resolving intestinal obstruction. In case of aggravation of local signs of AIO and an increase in endotoxicosis, the study is terminated and the question of urgent surgical intervention is raised.

When performing oral contrasting and interpreting the data obtained, it is necessary to take into account the timing of the promotion of the contrast agent through the intestines. In a healthy person, barium suspension, drunk per os, reaches the caecum after 3-3.5 hours, the right bend of the large intestine - after 5-6 hours, the left bend - after 10-12 hours, the rectum - after 17-24 hours. The use of oral radiopaque methods is not indicated for colonic obstruction due to their low information content. In such cases, an emergency colonoscopy is performed.

Ultrasound Scan of the abdominal cavity complements the x-ray examination, especially in the early stages of OKN. It allows you to repeatedly observe the nature of peristaltic bowel movements without exposing the patient to radiation, determine the presence and volume of effusion in the abdominal cavity, and examine patients in the early postoperative period. The most important features in assessing the stage of AIO are the diameter of the intestine, which can range from 2.5 to 5.5 cm, and the thickness of its wall, which is from 3 to 5 mm. the presence of free fluid in the abdominal cavity. With the development of destructive changes in the intestinal loops, the thickness of the wall can reach 7-10 mm, and its structure becomes heterogeneous with the presence of inclusions in the form of thin echo-negative strips.

Laparoscopy. The development of endoscopic research methods in emergency surgery has made it possible to use laparoscopy in the diagnosis of AIO. A number of domestic and foreign authors point to the possibilities of the method for the differential diagnosis of the mechanical and dynamic forms of acute intestinal obstruction, for the dissection of single adhesions. However, as our experience in using laparoscopy shows, it is not only uninformative, but also dangerous to use it in conditions of severe intestinal paresis and adhesive process in the abdominal cavity in most cases due to the possible occurrence of severe complications. Therefore, the main indication for the use of laparoscopy in AIO is the objective difficulties in the differential diagnosis of acute surgical pathology.

Treatment of acute intestinal obstruction

conservative therapy. Based on the concept of the vascular genesis of disorders in strangulation AIO and the rapidity of their development, the only way to treat it is emergency surgery with corrective therapy on the operating table and in the postoperative period. In all other cases, the treatment of AIO should begin with conservative measures, which in 52%-58% of cases have a positive effect, and in the rest of the patients they are the stage of preoperative preparation.

Conservative therapy is based on the principle of "drip and suck" (drip and suck). Treatment begins with the introduction of a nasogastric tube to decompress and flush the upper digestive tract, which reduces intracavitary pressure in the intestine and the absorption of toxic products. The perirenal novocaine blockade according to A.V. has not lost its therapeutic value. Vishnevsky. The setting of enemas is of independent importance only with obstructive colonic obstruction. In other cases, they are one of the methods of stimulating the intestines, so there is no need to place high hopes on their effectiveness. Carrying out drug stimulation of the gastrointestinal tract is justified only with a decrease in the motor activity of the intestine, as well as after the removal of an obstacle in the path of the intestinal passage. Otherwise, such stimulation can aggravate the course of the pathological process and lead to a rapid depletion of neuromuscular excitability against the background of increasing hypoxia and metabolic disorders.

An obligatory component of conservative treatment is infusion therapy, with the help of which the BCC is restored, cardiohemodynamics are stabilized, protein and electrolyte disorders are corrected, and detoxification is carried out. Its volume and composition depends on the severity of the patient's condition and averages 3.0-3.5 liters. In a serious condition of the patient, preoperative preparation should be carried out by the surgeon together with the anesthesiologist-resuscitator in the intensive care unit or intensive care unit.

Operative treatment. Conservative therapy should be recognized as effective if, within the next 3 hours from the moment the patient was admitted to the hospital after enemas, a large amount of gases passed and there was abundant stool, abdominal pain and bloating decreased, vomiting stopped and the general condition of the patient improved. In all other cases (with the exception of dynamic intestinal obstruction), the ongoing conservative therapy should be recognized as ineffective and indications for surgical treatment should be given. With dynamic intestinal obstruction, the duration of conservative treatment should not exceed 5 days. The indication for surgical treatment in this case is the ineffectiveness of ongoing conservative measures and the need for intubation of the intestine in order to decompress it.

Successes in the treatment of AIO are directly dependent on adequate preoperative preparation, the correct choice of surgical tactics and postoperative management of patients. Various types of mechanical acute intestinal obstruction require an individual approach to surgical treatment.

Bowel obstruction- this is a condition in which the movement of intestinal contents through the gastrointestinal tract is disturbed, partial or complete blockade of the small or large intestine, which prevents the normal passage of digested food through the intestinal tract and the excretion of feces, and in case of complete blockage, even gases. Symptoms depend on the location of the blockage and whether it is partial or complete. Small bowel obstruction causes severe stomach pain and vomiting, which can lead to dehydration and shock. If the colon is blocked, the symptoms (severe constipation and pain) develop more slowly. Small bowel obstruction is much more common than colonic ileus.

A partial obstruction in which only fluid passes can lead to diarrhea. The most obvious sign of a bowel obstruction is increasing bloating as the stomach accumulates gas, fluid, and feces. If the obstruction restricts blood supply to the intestines, there is a great risk of tissue death or perforation (rupture) of the intestine (both life-threatening conditions). Complete obstruction of the small intestine, left untreated, can lead to death within one hour to several days.

Symptoms

Alternating attacks of painful spasms.

Increasingly painful bloating.

Progressive constipation that results in an inability to pass feces or sometimes even gas.

Uncontrollable hiccups or belching.

Diarrhea (with partial obstruction).

Weak fever (temperature up to 38 ° C).

Weakness or dizziness.

Bad breath.

Causes

Adhesions (internal scars) from previous surgery.

Strangulated hernia (part of the small intestine protrudes through a weak spot in the abdominal wall, preventing blood from entering it).

Rectal cancer.

Diverticulitis.

Volvulus (twisting or knot in the intestine).

Invagination (putting one part of the intestine over another, like a telescopic tube).

Compaction of food or feces.

Stones in the gallbladder.

Occasionally, a swallowed object gets stuck in the digestive tract.

In paralytic ileus, the intestine is not blocked, but it stops contracting and moving its contents. This is almost always seen after gastric surgery and lasts for a few days and then resolves on its own (unlike bowel obstruction that occurs for other reasons).

Violations of immune mechanisms and the importance of the microbial factor in the development of acute intestinal obstruction

From a modern standpoint, the gastrointestinal tract is considered as the most important organ that performs anti-infective defense of the body, and as an essential component of the overall immune system. The vast surface of the gastrointestinal tract is a field where the primary contact of organic and inorganic antigens with immunocompetent cells occurs. In addition, adequate secretory and motor function of the gastrointestinal tract ensures the inclusion of a number of important non-specific defense mechanisms at this stage. From this it is quite clear that a gross violation of the functional state of the gastrointestinal tract, which accompanies the development of acute intestinal obstruction, significantly affects the effectiveness of the anti-infective defense of the body as a whole. A vivid confirmation of this situation is the rate of postoperative infectious complications in this group of patients, significantly higher than similar rates in other acute surgical diseases of the abdominal cavity. Thus, according to studies reflecting the experience of the last two decades, infectious complications in patients with acute intestinal obstruction account for 11-42% and include peritonitis, suppuration of the surgical wound, pneumonia, and septic shock.

A correct understanding of the role of intestinal obstruction in the weakening of the body's antimicrobial defense is impossible without knowledge of the basic provisions that characterize the participation of the gastrointestinal tract in this protection. Discussing the general anti-infective mechanisms of the digestive system, R. Bishop (1985) identifies the following components:

1) acidic environment in the proximal gastrointestinal tract, which is detrimental to most microorganisms;

2) secretory activity of the small intestine with its protective and enveloping (mucus), antimicrobial (lysozyme) and proteolytic (digestive enzymes) actions;

3) the motor function of the intestine, preventing the fixation of microorganisms on its walls;

4) immune mechanisms of the intestinal wall;

5) the normal state of the intestinal microbiological ecosystem.

Most of these factors are significantly affected in acute intestinal obstruction.

Microorganisms, contained in large quantities in the intestine, are in a state of constant interaction with each other and with the macroorganism. This interaction constitutes a special ecosystem, the violation of which drastically changes the living conditions of both the host organism and microorganisms. One of the important conditions for the stability of the ecosystem is the ratio of microorganisms in different parts of the intestine. Normally, the intra-intestinal habitat is inhabited by stable communities of autochthonous (non-alien) microorganisms, the species composition of which varies somewhat depending on the diet and age of a person, but is generally quite constant for certain parts of the gastrointestinal tract.

Allochthonous (alien) microorganisms, as a rule, are present in any habitat, but with a fairly stable composition of the autochthonous flora, they do not affect the structure of the ecosystem.

With the development of intestinal obstruction, the existing ecosystem is destroyed.

Firstly, due to a violation of the motor activity of the intestine, there is a "stagnation" of the contents, which contributes to the growth and reproduction of microorganisms.

Secondly, a violation of constant peristalsis leads to the migration of the microflora characteristic of the distal intestines to the proximal ones, for which this microflora is allochthonous.

Thirdly, the developing circulatory hypoxia of the intestinal wall creates conditions for rapid reproduction and development of anaerobic (mainly non-spore-forming) microflora in the intestine, which "colonizes" the sections of the intestine involved in the process.

The ecosystem is destroyed, microbes are freed from the action of factors that regulate their number, composition and localization. The consequence of this is the proliferation of microbes, the acquisition by a number of opportunistic microorganisms of pronounced pathogenic properties, the release of enterotoxins by microbes that aggressively affect the intestinal wall. Under the conditions of developing intestinal obstruction, the process of destruction of the ecosystem is greatly aggravated by the violation of the antimicrobial defense mechanisms inherent in the unchanged intestinal wall.

Circulatory hypoxia and the associated degeneration of the structural and functional elements of the mucous membrane and submucosa of the intestinal wall inevitably affects all manifestations of the secretory function, including mucus secretion, the release of bactericidal lysozyme by Paneth cells.

An essential role in antimicrobial protection belongs to intestinal proteolytic enzymes, the decrease in secretory activity of which in acute intestinal obstruction was mentioned in the corresponding section.

Finally, it is impossible not to pay attention to the "secretory" immune system of the intestine in intestinal obstruction. The structural basis of this system is represented by intestinal lymphoid elements, the function of which is ambiguous. B-lymphocytes of the intestine produce IgA, which blocks the adhesive antigenic complexes of microbes, promotes their phagocytosis by macrophages and leukocytes, and prevents the penetration of aggressive immune complexes through the mucosal barrier. This explains the damage to the anti-infective defense of the body, which is associated with the failure of the "secretory" intestinal immune system. And such a failure is quite obvious in conditions of hypoxic dystrophy of the structural and functional elements of the intestinal wall and, above all, the mucous membrane.

Freed from regulation by nonspecific and immune factors, allochthonous microorganisms manifest their aggressive function through the enterotoxic action of exo- and endotoxins. Exposure to exotoxins is preceded by the adherence of microbes to the mucosal surface. The exotoxin causes metabolic changes in the epithelial cells, disrupting the ratio between excretion and absorption of fluid. For exotoxins of a number of conditionally pathogenic microorganisms that acquire the possibility of intensive reproduction during stagnation (E. coli), a cytotoxic effect is characteristic, i.e., the ability to destroy the membranes of epithelial cells. Along with hypoxic destruction of the epithelium, this contributes to the invasion of microbes into the intestinal wall, as well as their penetration into the abdominal cavity and the development of diffuse or delimited peritonitis.

The penetration of microbes into the intestinal wall is accompanied by the death of many of them. In this case, endotoxin is released, which, depending on the type of microorganism, causes a complex and ambiguous pathological effect in terms of strength and nature. For endotoxins of the majority of non-spore-forming anaerobes inhabiting the distal intestines, this action is reduced to inhibition of intestinal motility, systemic microcirculation disorders, regulatory disorders of the central nervous system, and metabolic disorders.

Thus, a decrease in the effectiveness of the protective antimicrobial mechanisms of the intestine not only increases the risk of developing infectious complications, but also contributes to the deepening of local and general disorders characteristic of acute intestinal obstruction.

Pathogenetic mechanisms of impaired motor function of the intestine

Over the past 10 years, ideas about the mechanism of the motor function of the digestive tract have become much more complicated. It became clear that, in addition to the central neurotropic inhibitory and stimulating influence, which is carried out due to sympathetic and parasympathetic innervation, the endocrine regulation of intestinal motility is of great importance and, perhaps most importantly in the modern concept, both of these regulatory systems seem to be layered on the system of their own intestinal motor automatism. At the same time, the motor function of each section of the intestine is closely associated with its specific functional tasks in the digestive system, as well as with secretory-resorptive and protective anti-infective functions.

The order of inclusion of pathogenetic mechanisms that disrupt intestinal motility in various forms of intestinal obstruction is ambiguous, but all these mechanisms ultimately affect two main types of intestinal motor activity: the so-called "hungry" peristalsis, carried out in the interdigestive period, and "digestive" peristalsis, accompanying the entry of contents into the gastrointestinal tract.

The first type of peristalsis is regulated by an autonomous myotropic mechanism, an important role in which is played by a pacemaker located in the duodenum and referred to in the literature as basic electrical rhythm (BER), "slow waves", generator potential (GP), pacemaker potential. In this peculiar form of intestinal motor activity, caused by the action of a pacemaker and called the “migrating myoelectric complex” (MMC), in contrast to cardiac automatism, not every impulse is realized, which creates an extremely complex unstable picture.

A purposeful study of MMC allowed the authors to distinguish 4 phases (periods) of the complex: the resting phase, the phase of tonic irregular contractions, the phase of frontal activity (successive propulsive contractions throughout the intestine) and the phase of gradual attenuation. The main one, reflecting the functional essence of the complex, is the phase of frontal activity. Each subsequent MCM occurs only after the decay of the previous one.

The second type of peristalsis, which is primarily characteristic of the small intestine, is "digestive" peristalsis, which is irregular segmental peristaltic contractions. Its occurrence is always accompanied by the termination of MMK. This type of peristalsis is regulated mainly by central neuroendocrine mechanisms, and not by the system of its own intestinal automatism.

With the development of intestinal obstruction, first of all, the ability to develop "digestive" peristalsis is reflexively suppressed, but the main changes in the motor function of the intestine are associated with a violation of the MMC. The appearance of a mechanical obstacle to the passage of intestinal contents interrupts the spread of MMC in the distal direction and thereby stimulates the emergence of a new complex.

Thus, peristaltic movements in the adductor loop are shortened in length and time, but occur more often. The central nervous system also takes part in this process. In this case, the excitation of the parasympathetic nervous system while maintaining the obstacle can lead to the occurrence of antiperistalsis. Then comes the inhibition of motor activity as a result of hypertonicity of the sympathetic nervous system.

A similar violation of the relationship between the sympathetic and parasympathetic links of the neurocrine regulation of peristalsis underlies a number of forms of primary dynamic obstruction, for example, persistent progressive postoperative intestinal paresis. At the same time, the function of the pacemaker is completely preserved, however, MMC induction either does not occur at all, or the ability to reproduce the third phase of the complex, the phase of frontal activity, is lost.

In the future, both with primary dynamic and mechanical obstruction, more persistent mechanisms are activated that cause the progression of paresis. The basis of these mechanisms is 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 are unable to perceive impulses to contract as a result of deep metabolic disorders and intracellular electrolyte disturbances. Metabolic disorders are exacerbated by increasing endogenous intoxication, which in turn increases tissue hypoxia and closes this vicious circle. Finally, under conditions of already developed paresis, the structure of the intestinal microbiological ecosystem is destroyed, as a result of which individual allochthonous microorganisms vegetating in the intestine (E. coli) penetrate the intestinal wall and die there, releasing endotoxins that contribute to the suppression of the contractility of the intestinal muscles.

Thus, in the pathogenesis of violations of the motor function of the intestine in acute obstruction, the following main pathogenetic mechanisms can be distinguished.

1. The occurrence of hypertonicity of the sympathetic nervous system, due to the appearance of a focus of excitation in the form of a pathological process in the abdominal cavity and a pain reaction to this process.

2. Hypoxic damage to the intramural conducting apparatus of the intestinal wall due to circulatory disorders, which prevents the autonomous and central regulation of intestinal motor activity.

3. Metabolic disorders in the muscular tissue of the intestinal wall, caused by circulatory hypoxia and increasing endogenous intoxication.

4. The inhibitory effect on the muscle activity of endotoxins of a number of microorganisms that, under conditions of obstruction, acquire the ability to invade the intestinal wall.

Diagnostics

Medical history and examination.

X-ray to locate the blockage.

Colonoscopy (use of a flexible, lighted tube to look at the large intestine).

X-ray after a barium or hypac enema, which provides a clear image of the colon.

Treatment

Intestinal obstruction is a disease that requires immediate treatment from a specialist. Don't try to treat the blockage yourself with enemas or laxatives.

First, the doctor relieves pressure in the swollen abdomen by removing fluid and gases with a flexible tube inserted through the nose or mouth.

In most cases, surgery is needed to remove the mechanical intestinal blockage. Preparation for surgery often takes six to eight hours to restore fluid and electrolyte balance to prevent dehydration and shock.

Bowel resection may be necessary. After removal of the blocked part of the bowel, the separated ends may be reattached, although an ileostomy or colostomy (surgery in which an opening is made in the abdomen so that the waste products of the bowels can be expelled into an external sac) may be required.

Features of anesthetic support for the treatment of intestinal obstruction

Complex multicomponent anesthetic management of surgical intervention for acute intestinal obstruction is a direct continuation of therapeutic measures initiated in the preparatory period, against which anesthesia itself is carried out.

Pay special attention to the initial period of anesthesia. Introductory anesthesia should be carried out as quickly as possible. Immediately before the administration of anesthetics (eg, barbiturates), 5 mg of tubocurarine chloride or another non-depolarizing relaxant is administered intravenously to eliminate regurgitation associated with muscle fibrillation and increased intragastric pressure, which are observed in the case of the use of depolarizing relaxants. For the same purpose, auxiliary ventilation at this stage is carried out with oxygen through the mask of the anesthesia machine only with obvious oppression of external respiration and extremely carefully, and after the introduction of depolarizing relaxants immediately before intubation, the authors recommend performing the Sellick maneuver. For this purpose, the esophagus is pressed by pressing the larynx against the spine. After tracheal intubation, the cuff on the tube is immediately inflated, then the probe is reintroduced into the stomach to empty the proximal gastrointestinal tract.

The choice of the main inhalation anesthetic is determined by the material support and experience of the anesthetist, however, in elderly debilitated patients with signs of cardiovascular or hepatic insufficiency, it is preferable to use halothane and avoid the use of ether.

Non-inhalation types of anesthesia are used extremely rarely for AIO, since the surgical aid requires wide access, good visibility, and sufficient relaxation of the muscles of the abdominal wall. Only in the event that in sharply weakened patients the operation is obviously palliative and is not accompanied by an extensive revision of the abdominal cavity, other types of anesthesia (local, intravenous) can be used. In the hands of an experienced anesthesiologist, in the presence of a highly qualified surgical team and with a short duration of the disease, epidural anesthesia or combined types of anesthesia are effective. In our clinic in recent years, out of 977 operations, inhalation endotracheal anesthesia was used in 754 patients (77.2%), local anesthesia - in 77 (7.9%), epidural - in 18 (1.8%), intravenous anesthesia - in 7 (0.7%) and combined anesthesia in 121 patients (12.4%).

During the entire anesthesia and during the withdrawal from anesthesia, the main parameters of life support are monitored based on clinical criteria or monitoring data.

Regurgitation of acidic gastric contents into the tracheobronchial tree is justifiably considered the most formidable complication of anesthesia. More often this happens when entering anesthesia, but it can also occur at the final stage, after disintubation of the trachea. In this case, if the contents of the stomach have a pH below 2.5, there is an acute widespread bronchospasm (Mendelssohn's syndrome).

If, despite the implementation of all preventive measures, regurgitation has occurred, it is necessary to perform a thorough sanitation of the tracheobronchial tree by washing it with isotonic sodium chloride solution, 1 2% sodium bicarbonate solution. In addition, intravenous administration of eufillin (5-10 ml of a 2.4% solution), glucocorticoids (up to 300 mg of hydrocortisone) and antihistamines (tavegil, suprastin) are used in standard doses.

Preoperative preparation for the treatment of intestinal obstruction

The volume and content of preoperative preparation in patients with AIO are determined primarily by the duration of hospitalization and the severity of the general condition. In all cases, the training program is set by the anesthesiologist, surgeon and therapist. In this case, it is permissible to single out and consider two typical variants of the development of the disease. In the first variant, the rapid onset of the disease, severe pain syndrome and frequent vomiting make the patient seek medical help at an early date, and the consequence of this treatment is an early referral to hospitalization. In these patients, the duration of the disease is usually short, the effects of dehydration and endotoxicosis are not pronounced.

In the second variant, which is more typical for elderly and senile patients, the clinical picture develops gradually, gradually, without a bright manifestation, which, however, does not indicate a lesser severity of the pathological process. Late treatment and late hospitalization, along with more pronounced pathomorphological consequences, lead to decompensation of important vital functions, metabolic disorders, dehydration and endotoxicosis. The most difficult situation arises at that stage of the process, when developing peritonitis with its complex and formidable pathogenetic mechanisms superimposes on the disorders caused by acute intestinal obstruction.

In the first case, the tasks of the anesthesiologist to participate in preoperative preparation are greatly simplified.

Measures to empty the gastrointestinal tract may be limited to a single insertion of a thick tube and gastric emptying. In the operating room, the probe is re-introduced to empty the stomach from the contents accumulated in it during the preparation period. After that, the probe is removed.

Also, the bladder is emptied immediately before the operation. If, against the background of a pronounced pain syndrome, there is a reflex urinary retention, the bladder is emptied with a catheter.

Conducting infusion therapy for 1.5-2 hours in this group of patients also does not cause any particular difficulties. The rate of infusion can be quite high, providing the introduction of up to 1-2 liters of liquid during this period. At the same time, to prevent transcapillary migration, G. A. Ryabov (1983) recommends administering 12–13 g of dry matter of albumin or 200 ml of plasma for each 1 liter of solutions. Before the operation, hygienic preparation of the skin in the area of ​​the proposed intervention is also carried out.

In the second variant of the development of AIO, the tasks of preoperative preparation become much more complicated. This applies to all of its components. Emptying the gastrointestinal tract with a probe inserted into the stomach is carried out continuously. Also, a catheter in the bladder is constantly maintained throughout the entire preparatory period for the purpose of hourly (and sometimes minute) control of diuresis during infusion therapy.

Infusion therapy is designed to provide several tasks. First of all, this is the elimination of volemic disorders, the degree of which is determined by the indicators of the bcc and its components. The complexity of this task is associated with limited preparation time and, at the same time, with the need to be careful in increasing the rate of infusion (especially in elderly patients) against the background of cardiopulmonary decompensation. The main criteria for assessing the sufficiency of infusion therapy and its rate are CVP, hematocrit, pulse rate, hourly diuresis. Many authors recommend measuring CVP every 15-20 minutes or after the introduction of 400-500 ml of a solution. With a rapid increase in CVP up to 200 mm of water. Art. and above the rate of infusion must be reduced.

No less difficult is another task of infusion therapy - the elimination of tissue hypohydration. This task cannot be performed within the scope of preoperative preparation. Its implementation continues, during the anesthetic support of the operation, further in the postoperative period. This often requires a very significant volume (up to 70-100 ml or more per 1 kg of the patient's body weight) and a rather complex composition of the injected infusion media. However, more often the anesthesiologist has to use those media that are at his disposal, combining the introduction of solutions of electrolytes, glucose, polyglucin and low molecular weight dextrans.

Often, during preoperative preparation, it becomes necessary to regulate the rate of fluid administration, use cardiotonic, antiarrhythmic drugs, or use hormonal drugs (prednisolone, hydrocortisone) to stabilize hemodynamics at a level that allows the operation to begin.

In this regard, in the course of preoperative preparation, along with the determination of CVP and hourly diuresis, it is necessary to constantly monitor the heart rate, their rhythm, the level of systolic and diastolic blood pressure, and the adequacy of external respiration. For a comprehensive assessment of these indicators, it is advisable to use monitoring observation.

Decompression of the upper digestive tract and rational infusion therapy are the means by which the patient's body is detoxified during preoperative preparation. Naturally, a complete solution to this problem can only be associated with adequate surgical intervention and the implementation of special measures to combat endotoxicosis in the postoperative period.

Preventive antibiotic therapy occupies a special place among the activities of the preoperative period. Its meaning in OKN is determined by the high risk of purulent postoperative complications. According to many authors, the frequency of infectious postoperative complications in intestinal obstruction ranges from 11 to 42%. This is due to a number of circumstances, the most important of which are dysbacteriosis and movement of microflora unusual for them into the proximal sections of the intestine, a decrease in secretory immunity and the barrier function of the gastrointestinal tract, as well as general immunosuppression. It is quite obvious that against such a background, additional tissue trauma and mechanical destruction of biological barriers (peritoneum, intestinal wall), inevitable during the intervention, create additional prerequisites for the development of an infectious process. In this regard, the creation of the necessary therapeutic concentration of antibacterial drugs in the tissues by the time of surgery can be a useful and decisive factor in the postoperative course of the disease.

This question was specially studied in the clinic in relation to two antibiotics: kanamycin sulfate and cefazolin. The choice of antibiotics was determined by the breadth of their spectrum of action, high activity against most pathogens of infectious complications in acute diseases of the abdominal organs.

In experimental and clinical study of the pharmacokinetics of these drugs in strangulation and obturation AIO, it was found that the peak of their concentration in the tissues of the abdominal organs and intraperitoneal exudate occurred by the end of the 1st hour after intramuscular injection, and the decrease in effective concentration occurred after 3-4 hours. This determined the method of preventive antibiotic therapy in patients with AIO. The use of this technique, since 1979, has reduced the incidence of severe postoperative infectious complications in all forms of acute intestinal obstruction from 19.3 to 13.2%.

It should be emphasized that the above program of preoperative preparation can only be regarded as indicative. The specific volume and content of therapeutic measures are determined individually depending on the form of AIO, the severity of the process, the age of the patients and the presence of concomitant diseases. However, with individual differences in the training program, its installation requirements must be observed, and the total period of the preoperative period with an established diagnosis and indications for surgery should not exceed 1.5–2 hours.

The results of surgical treatment of the intestine

According to the data, out of 978 patients with a confirmed diagnosis, small bowel obstruction was detected in 872. Of these, 856 were operated on. In 303 patients, bowel resection became necessary during the operation. In 13 patients, the resection was extensive (50–70% of the total length of the small intestine) and in 12 patients it was subtotal (70–80% of the total length of the small intestine).

Postoperative complications developed in 332 (40.1%) of the operated patients with small bowel obstruction. Of this group, in the vast majority of cases (52.6%), complications were represented by suppuration of the surgical wound. In 6.7% of patients there was a failure of the sutures of the interintestinal anastomosis after resection of the intestine in the conditions of developing peritonitis. In 10.7% of cases, the progression of the existing peritonitis without suture failure was noted, and in 4.7% - the development of late delimited intraperitoneal abscesses. In other cases, complications were due to concomitant diseases of the cardiovascular system (16.2%) or the development of pneumonia in the postoperative period in debilitated patients. After operations for acute small bowel obstruction, 123 (14.37%) patients died. In 56.2% of them, the cause of death was infectious complications in the abdominal cavity. 33.7% had acute complications from the cardiovascular system. 8.3% had pneumonia and 1.8% had other complications.

In 30.8% of patients in this group, death occurred in the first 3 days after surgery, in 17.2% - on days 4-10, and in other cases - in a later period.

The analyzed group consisted only of those patients in whom the diagnosis of acute small bowel obstruction with the obligatory inclusion of the pathogenetic component of intraparietal hemocirculation disorders was not in doubt. Excluded from the analysis were patients with episodic intestinal obstruction, which proceeded as intestinal colic and was quickly eliminated by the use of simple therapeutic measures. Thus, if we focus on the true, held acute small bowel obstruction, then it remains an urgent problem of emergency abdominal surgery, the solution of which requires further intensive efforts of researchers and practical surgeons.

Prevention

Eat foods rich in dietary fiber.

Prostate Prostates (Greek) - standing in front. Our health is a state of delicate balance, which is provided by many body systems.

The first thing to pay attention to is the condition of the teeth. If the teeth react painfully to cold or hot,