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Intestinal obstruction is a condition of an acute obstacle to the normal passage of food masses (from the stomach to the anus). It can occur in any part of both the small and large intestines.

The causes of this condition may be different, but the clinical picture, pathogenesis of complications, principles of treatment and the need for emergency measures are the same for all types of intestinal obstruction.

Intestinal obstruction is one of the leading causes of surgical mortality. Without timely treatment, 90% of patients die.

The main causes of death in patients with intestinal obstruction:

1. Shock (painful, hypovolemic);
2. Endotoxicosis;
3. Abdominal sepsis;
4. Peritonitis;
5. Severe electrolyte disturbances.

What kind of obstruction happens?

Based on the mechanism of occurrence, there are two main types of obstruction:

• Dynamic;
• Mechanical.

Dynamic obstruction- this is the result of a violation normal contraction intestinal wall. It may be due to strong spasm, and complete relaxation of the muscles of the intestinal wall. This type obstruction should be treated conservatively; surgical intervention, on the contrary, can aggravate peristalsis disorders.

Mechanical obstruction b is already a real obstacle to the path of food masses in the intestines. It happens:

1. Obstructive;
2. Strangulation;
3. Mixed.

Mechanical obstruction very rarely goes away on its own or with conservative measures. It is this type of obstruction that is an absolute indication for surgery. The causes of mechanical obstruction in the intestine can be:

It is quite easy to suspect intestinal obstruction based on the clinical picture. The main symptoms are pain, vomiting, bloating, and lack of stool. The same symptoms can be observed in other disasters in the abdominal cavity, but in any case, this is an acute condition requiring emergency hospitalization.

If such symptoms are present, the patient is urgently sent to the surgical department. The length of hospitalization determines the prognosis. The later the patient was admitted to the hospital, the higher the mortality rate.

To confirm the diagnosis, an abdominal x-ray is prescribed; emergency irrigoscopy (intestinal x-ray with contrast) or colonoscopy can be performed. Sometimes in difficult cases, diagnostic laparoscopy is performed.

Everything is being done urgently necessary tests. The most important indicators here are the level of hemoglobin, hematocrit, leukocytes, ESR, in the serum - the level of protein, sodium, potassium, creatinine, amylase. The blood type and Rh factor are determined.

Several groups of patients with intestinal obstruction can be distinguished, to which different management tactics are applied:

Preparing for surgery to relieve obstruction

Upon admission of the patient to the hospital:

• Inserting a catheter into a central vein to monitor the central venous pressure and parenteral infusions.
• Catheterization bladder to control diuresis.
• Installation of a nasogastric tube.

Principles of conservative therapy

Conservative therapy is also a method of preoperative preparation (if surgery is still required).

1. Aspiration of stomach contents and upper sections intestines through an installed probe.
2. Carrying out cleansing and siphon enemas. Sometimes this measure can help remove an obstacle (for example, wash away dense fecal debris).
3. Urgent colonoscopy. Conducted from diagnostic purpose, but can also eliminate some types of obstruction (for example, intussusception, or partially expand the intestine during obstruction).
4. Replenishment of fluid and electrolyte losses. To do this, under the control of central venous pressure, diuresis, and plasma electrolytes, infusions of saline, saline solutions, protein hydrolysates, rheological solutions, and plasma are carried out. Typically, the volume of infused funds is up to 5 liters.
5. For increased peristalsis and pain, antispasmodics are prescribed; for intestinal paresis, agents that stimulate peristalsis are prescribed.
6. Antibacterial agents are also prescribed.

Operations for intestinal obstruction

If conservative measures do not eliminate the problem, surgery cannot be avoided. Main tasks surgical intervention :

• Removing the obstacle.
• If possible, eliminate the disease that led to this complication.
• Maximum possible actions for prevention postoperative complications and relapse.

The main stages of the operation and the surgeon’s tactics

1. Anesthesia. Usually this is endotracheal anesthesia with muscle relaxants.

2. Access is most often a wide median laparotomy.

3. Revision of the abdominal cavity. The exact level of the obstacle is located. Above this place, the intestinal loops are swollen, purple-bluish in color, while the efferent intestine is collapsed, the color is usually not changed. The entire intestine is examined, since sometimes obstruction can be determined on different levels simultaneously.

4. Decompression and cleansing of the adductor colon, if this could not be done before surgery. To do this, nasointestinal intubation is performed (through an esophageal tube), or intubation of the intestine itself through a small incision.

5. Directly eliminating the obstacle itself. Several types of interventions can be applied here:

• Enterotomy - the intestinal wall is opened, an obstacle is removed (for example, a ball of roundworms, a foreign body, gallstones) and stitched up.
• If a hernia is strangulated, the strangulated intestinal loops are repositioned.
• In case of strangulation obstruction - dissection of adhesions, tying of knots, elimination of intussusception and volvulus.
• Resection of a section of intestine in the presence of a tumor or intestinal necrosis.
• Bypass anastomosis in cases where it is not possible to remove the obstruction in the usual way.
• A colostomy (permanent or temporary) is usually performed in cases of left hemicolectomy.

6. Assessment of intestinal viability and its resection.

This is a very crucial moment of the operation; the further prognosis depends on it. The viability of the intestine is assessed by its color, contractility and vascular pulsation. Any doubt about the normal condition of the intestine is a reason for its resection.

If there are signs of intestinal necrosis, this area is resected within healthy tissue. There is a rule to resect the intestine 40-60 cm above the border of non-viability and 10-15 cm below it.

During resection small intestine an end-to-end anastomosis is formed. In case of obstruction in the area of ​​the blind, ascending or right half of the transverse colon, a right hemicolectomy is performed with ileotransverse anastomosis.

When the tumor is located in the left half of the colon, a one-stage operation cannot be performed in most cases. In this case, a colostomy is performed with bowel resection, and subsequently a second operation is performed to remove the colostomy and create an anastomosis.

A one-stage radical operation is not performed in case of developed peritonitis. In this case, the surgeon’s task is to remove the obstruction, rinse and drain the abdominal cavity.

Sometimes surgical treatment is even divided into three stages: 1 - application of a unloading stoma, 2 - resection of the intestine with a tumor, 3 - creation of an anastomosis and elimination of the stoma.

7. Washing and removing effusion from the abdominal cavity.

8. Drainage of the abdominal cavity.

9. Suturing the wound.

After surgery

The postoperative stage in such patients is very important point treatment, no less significant than the operation itself.

After surgery, the patient is sent to the intensive care unit. Main events:

After 3-4 days, liquid food and drink are allowed. The diet is gradually expanding - slimy porridges, vegetable and fruit purees, meat souffle are allowed, fermented milk products. A diet excluding coarse, spicy foods and foods that cause increased gas formation and fermentation should be followed for up to 2 months.

Features of the operation for the most common types of obstruction

The most common type of small bowel obstruction is obstruction due to adhesive disease. For the colon, this is the blocking of the intestinal lumen by a tumor.

Adhesive intestinal obstruction

Adhesions are scar strands in the form of cords or films that occur after abdominal surgery. Adhesions can cause both obstructive obstruction (squeezing the intestinal lumen) and strangulation (squeezing the intestinal mesentery).

The essence of the operation is to dissect the scar cords and resection of the necrotic area of ​​the intestine. If possible, all adhesions are dissected, and not just those that caused complete obstruction.

The peculiarity of this type of obstruction is that adhesive obstruction is prone to relapse. By cutting adhesions, we create the preconditions for the formation of new adhesions. It turns out to be a vicious circle.

adhesive intestinal obstruction

IN recent years new methods have been proposed for the prevention of relapses in adhesive obstruction. Briefly, their essence is this: lay the loops as correctly as possible small intestine in the abdominal cavity, try to fix them like this (suturing the mesentery). But these methods do not guarantee the absence of relapses.

In addition, laparoscopic removal of adhesive obstruction is gaining popularity. This operation has all the advantages of minimally invasive surgery: low trauma, quick activation, short rehabilitation period. However, surgeons are reluctant to perform laparoscopic operations for intestinal obstruction. As a rule, during such operations it is still often necessary to go into open access.

Intestinal obstruction due to tumor

The tumor nature of obstruction is a special part of surgery. Operations for this type of obstruction are among the most difficult. Often, patients with intestinal tumors are admitted to the hospital for the first time only when a picture of intestinal obstruction has developed; the diagnosis is made on the operating table. Such patients, as a rule, are weakened and anemic long before surgery.

During surgery, there are two tasks: eliminating the obstruction and removing the tumor. Very rarely this can be done at once. Radical surgery cannot be performed b:

1. If it is technically impossible to remove the tumor.
2. Extremely in serious condition.
3. With developed peritonitis.

In these cases, in order to eliminate the obstruction, they are limited to removing the intestinal stoma outside. After eliminating the symptoms of intoxication, the patient is prepared in a few weeks radical surgery– resection of the section of intestine with the tumor and elimination of the colostomy (removal of the colostomy can be delayed and transferred to the third stage).

If the patient’s condition allows, the tumor is removed simultaneously with the elimination of intestinal obstruction. Removal is carried out in compliance with ablastics - that is, as extensively as possible, as a single block with regional lymph nodes. For tumors in the colon, it is usually performed on the right or left side.

right/left hemicolectomy

For tumors of the small intestine – subtotal resection of the small intestine. When the tumor is located in sigmoid colon Hartmann's operation is possible. For rectal cancer, extirpation or amputation of the rectum is performed.

If it is impossible to remove the tumor, palliative operations are performed - an unnatural anus or a bypass anastomosis is created to restore patency.

Forecast

Mortality in acute intestinal obstruction remains quite high - on average about 10%. The prognosis depends on the timing of treatment. For those admitted to the hospital within the first 6 hours from the onset of the disease, the mortality rate is 3-5%. Of those who arrive later than 24 hours, 20-30% already die. Mortality is very high in elderly weakened patients.

Price

The operation to eliminate intestinal obstruction refers to emergency care. It is carried out free of charge at any nearest surgical hospital.

Possibly paid operation, but you need to know clinics that specialize in providing emergency care. The price depends on the volume of intervention. The minimum cost of such operations is 50 thousand rubles. Then everything depends on the length of stay in the hospital.

The cost of laparoscopic surgery for adhesive intestinal obstruction is from 40 thousand rubles.

Video: intestinal obstruction in the program “Live Healthy!”

– a fairly common diagnosis today. Adhesions are strands of connective tissue, as a result of which the internal organs grow together and are displaced.

Causes of intestinal adhesions

Such adhesions appear due to the ability of connective tissue to grow due to exposure to damaging factors. For example, the growth of tissue of this type can be provoked mechanical injuries, diseases caused by acute and chronic infections, the presence of previously accumulated blood, foreign bodies, exposure chemicals etc. If we talk about organs located in the abdominal cavity, in particular the intestines, the causes of adhesions are most often mechanical injuries, as well as contact of the peritoneum with air during surgery. Therefore, intestinal adhesions predominantly occur as a consequence surgical operations. According to statistics, adhesive disease develops in 2-15% of patients who have undergone surgery. Adhesions can appear immediately after any operation on the peritoneum, and several years after a person has undergone such an operation. However, adhesions occur only in those people who have a predisposition to this disease due to the presence of an excess of specific enzymes in the body. Under their influence, during injuries, very large scars. But if there is no such feature in the human body, then adhesions do not develop.

Intestinal adhesions are a serious disease, because as a result of their formation, a person can develop acute intestinal obstruction - a condition that is sometimes even life-threatening. In addition, the occurrence of adhesions is fraught with the appearance pain varying severity and may also negatively affect the functioning of other internal organs.

Types of intestinal adhesions

The process of formation of intestinal adhesions occurs as follows. The walls of the human abdominal cavity are lined peritoneum , which is a connecting cover, with two sides - visceral And parietal . All organs in the abdominal cavity are in contact with each other and with the parietal peritoneum; there are no spaces in the abdominal cavity.

Interorgan adhesions are usually divided into viscero-visceral (in this case, fusion occurs directly between the organs) and viscero-parietal (the intestine fuses with the parietal peritoneum).

Symptoms and manifestations of the disease depend on the nature of the adhesions, in what place they arose and how much they affect the functioning of the organs that have grown together.

Intestinal adhesions can manifest in different ways. Firstly, symptoms of adhesive disease may not appear at all. In this case, intestinal adhesions are discovered by chance: during an ultrasound examination or during any operation on the peritoneum.

Secondly, with intestinal adhesions, a painful form of the disease may appear. In this case, the patient is bothered by abdominal pain, especially often in the area of ​​scars after surgery. The pain is often nagging and gets worse during physical activity. Sometimes the pain goes away on its own, in other cases it is necessary to prescribe drugs with an analgesic effect.

Thirdly, the manifestation of a painful form of intestinal adhesions with dysfunction of internal organs is possible. Due to the adhesive process, disruptions in the functioning of organs occur gastrointestinal tract. As a result, the patient suffers from, diarrhea , sensations distension after eating, swelling belly .

Another variant of the development of the disease is the most severe. This is the emergence acute adhesive intestinal obstruction . In this case, due to adhesions, there is an obstacle to the passage of contents through the intestinal tube. It's about about very dangerous condition which needs urgent treatment. Otherwise it is inevitable death. Adhesive obstruction is characterized by a sharp onset of pain in the abdominal area. After this, the person begins to vomit, does not pass gas, and does not have bowel movements. At the same time, there is a constant deterioration in the condition. As a result, the patient is forced to seek help from a doctor.

Intestinal obstruction due to intestinal adhesions

This condition is characterized by a violation of the passage of intestinal contents through the intestinal tube. during the development of the disease is disrupted microcirculation in the intestinal wall, the abdominal cavity becomes inflamed. Intestinal obstruction may be dynamic And mechanical .

Reason dynamic obstruction is the resulting spasm of the intestinal wall. Similar phenomenon– consequences of a number of reasons: poisoning toxic substances, severe infections, etc.

At the same time the reason mechanical Obstruction is most often caused by intestinal adhesions. The latter is typical for the small intestine, while at the same time colonic obstruction is provoked in approximately half of the cases malignant tumors . Intestinal obstruction occurs due to compression of the lumen of the intestinal tube by adhesions. In addition, twists and bends of loops may appear around the adhesive cords. Adhesive intestinal obstruction often occurs as a consequence improper diet nutrition. Thus, the onset of the development of obstruction can be provoked by the constant consumption of coarse fiber, food that causes strong gas formation, as well as regular overeating. Sharp attacks of adhesive obstruction appear as a consequence of inflammatory bowel diseases or heavy physical activity.

Symptoms of adhesive intestinal obstruction

As the first symptom of intestinal obstruction due to adhesions, a person experiences pain in the abdominal area. The nature of the pain can vary from gradually increasing to sudden. Periodically, the pain may subside and later resume again. In addition, with obstruction, bloating necessarily occurs, which either appears unevenly or covers the entire abdomen. In most cases, patients complain of retention of gases and stools, although with partial obstruction, gases may periodically pass, and loose, single stools may also occur.

As the disease progresses, vomiting occurs, which is predominantly characterized by stagnant discharge. The disease progresses, and the symptoms described above are joined by symptoms from the respiratory and cardiovascular systems. Thus, the patient may experience , decrease . Also, this state is characterized by alternating depression and excitement. If you have such symptoms, you should immediately call an ambulance.

Diagnosis of adhesive intestinal obstruction

First of all, the doctor must conduct a thorough examination of the patient and also conduct a survey. When diagnosing intestinal adhesions and adhesive obstruction, information about the nature of pain during an attack plays a very important role. The detection of postoperative scars during a physical examination gives reason to suspect the development of adhesive intestinal obstruction. During the diagnostic process, a digital examination of the rectum is also performed. The patient must donate blood for laboratory analysis.

The presence of an adhesive process can be determined by radiography of the abdominal organs. This method most often used in the diagnosis of intestinal obstruction. For a more detailed study, ultrasound is often prescribed and computed tomography. These diagnostic methods are highly accurate.

Doctors

Treatment of adhesive intestinal obstruction

First of all, measures are taken to alleviate the patient’s condition. For this, a special nasogastric tube is used, which is designed to aspirate the contents of the stomach. Solutions are administered intravenously to the patient to restore electrolyte and water balance. After the infusion, the intestines are stimulated by hypertensive enemas and injections anticholinesterase drugs . In the future, the doctor selects treatment tactics on an individual basis.

It should be noted that in approximately eighty percent of cases of intestinal adhesions complicated by intestinal obstruction, it is possible to do without surgery, using exclusively conservative treatment. However, if the doctor suspects that the patient has a violation of the blood supply to the intestines, then the operation must be performed immediately.

Surgical intervention for adhesive obstruction is aimed at removing the obstruction and restoring passage through the intestine. Adhesiolysis - This is the main stage of the operation, during which adhesions are dissected. There are several types of operations that are prescribed depending on the nature of intestinal adhesions. At open operations, manipulations are performed through a large incision, with Video-assisted In surgical interventions, a puncture and a small incision are performed, while the intervention is carried out exclusively through a puncture.

Prevention of intestinal adhesions

To prevent the appearance of intestinal adhesions, it is very important to prevent inflammatory processes in the peritoneal organs and to protect yourself from food poisoning. People who have previously suffered from intestinal obstruction should carefully select their diet and not eat foods containing coarse fiber. No less important is the diet: you need to eat strictly at certain time, you should not overeat, but you also do not need to starve. It is best to eat small, frequent meals.

Experience: From 2003 to 2013, she worked as a pharmacist and manager of a pharmacy kiosk. She was awarded diplomas and decorations for many years of conscientious work. Articles on medical topics were published in local publications (newspapers) and on various Internet portals.

Pathology that interferes with the movement of food remains and gastric enzyme in the rectal area is called “adhesive intestinal obstruction.” It can be caused by many reasons, but, as a rule, it occurs due to surgical intervention. Ignoring signs of the disease and lack of treatment can lead to more serious problems with health.

A commissure is a cord that is formed from connective tissue. In the future, it promotes the shift and fusion of internal organs. The medical history begins from the moment of damage to the passage. These can be accidental mechanical injuries, infectious diseases, accumulations blood clots and foreign bodies. In some cases, growth of connective tissue is observed, which gives rise to the formation of small processes. In 15% of patients, such adhesions occur after surgery. The disease manifests itself immediately or after long time(up to several years). Some people are predisposed to forming such adhesions. It is caused by an excess of enzymes. In such a situation, the disease can manifest itself even after a minor injury.

Medical history

Even in ancient times, people suffered from symptoms of the disease “intestinal obstruction”. History says that the Danish anatomist Bartholin was the first to diagnose it in 1654. The adhesive process was first described by Hunter in 1797.

But officially the history of the disease dates back to 1906. It was then that Biller was able to demonstrate for the first time an x-ray image of gas bubbles in the abdominal cavity. In 1911, Schwartz proposed using a contrast method for examining the intestines to determine mechanical intestinal obstruction.

In 1910, Weistermann used the method of long-term probe aspiration of gastric contents to treat paresis of the gastrointestinal tract. In 1931, Heller used gastrostomy.

Reasons

Adhesive intestinal obstruction can be of dynamic or mechanical form. The main reason for the emergence of a dynamic form is intestinal cramps. They are provoked by many factors: chemical poisoning, infectious diseases, etc. Signs mechanical obstruction intestines occur in more than 70% of patients. The reason is a huge accumulation of adhesions, tightness of some parts of the intestine during a hernia, volvulus, worms or stones in gallbladder. Other causes of adhesions:

• purulent inflammation and bleeding in the abdominal cavity (for example, peritonitis);
• gastrointestinal ischemia;
• surgical intervention that leads to dryness of the peritoneum (appendectomy, surgery of the uterus and its appendages).

The process of formation of adhesions begins when the resorption of the inflammatory element is disrupted and its replacement with connective tissue. After injury, the abdominal cavity begins to produce exudate with a glue-like consistency. Subsequently, its cells form connective tissue. Fibrin is lost from it, which resolves after complete healing. If fibrin remains in place, then over time it becomes overgrown with collagen and elastic fibers, which ultimately causes the formation of adhesions. In exceptional situations it is observed.

Symptoms

In the acute form of adhesive intestinal obstruction, different signs, which are determined by the duration of the disease. Main characteristics: abrupt start, intense pain in the abdominal area, a large volume of vomit mixed with bile. In later lines, exicosis is observed: facial features sharpen, the tongue becomes dry, the stomach increases in size, and the level of intestinal motility increases. Intestinal loops in a distended state begin to contour through the walls of the peritoneum (Wal's symptom). During a rectal examination, you can notice that the rectal cavity is empty and balloon-like inflated. Radiological symptoms become more pronounced: in the presence of low obstruction, multiple levels of intestine (or Kloiber's cup) are noticeable. At high level they are single and appear as darkening of the lower abdomen.

A smooth onset is also characteristic of the form of the disease that is caused by an inflammatory infiltrate. But before the disease begins to manifest itself, you may notice a weakening of the general condition of the body and an increase in body temperature. In the area of ​​the peritoneum, a compacted accumulation of infiltrates is palpable, delivering painful sensations. Blood tests show the presence of purulent inflammation.

Strangulation obstruction lasts as a hyperacute form. The pain is cramping in nature. There is a regular urge to vomit. Vomit contains food debris and mucus. The level of manifestations of toxicosis and exicosis increases very quickly. At an early stage, the stomach does not swell. It is soft and symmetrical in shape, but with painful symptoms. Peristaltic sounds are clearly audible in the intestinal cavity. Later, the patient appears lethargic and inactive. His signs of toxicosis and peritonitis are increasing.

Diagnostics

Adhesive intestinal obstruction is diagnosed based on the main symptoms and information from the medical history that led to abdominal surgery. Primary diagnostic methods:

• contrasting the intestines with a suspension of barium sulfate and subsequent x-ray examination.

Such an examination will allow you to find out the level of stretching of the intestinal loops, Kloiber's cup, detect darkening in the lower abdomen and stagnation of contrast in some loops.

Today, methods such as CT, laparoscopy, ultrasound of the abdominal organs, and MRI are used to diagnose adhesive intestinal obstruction. With their help, a gastroenterologist or surgeon will be able to determine the cause of the disease, its shape and the level of severity of the damage.

Treatment

Early intestinal obstruction is treated using complex conservative procedures. The hardest thing in this situation is to determine required time treatment and most suitable way surgical intervention. All details are described in detail in the medical history. Before the operation, the patient adheres to a diet consisting of a special nutritional mixture. During this period, additional physical procedures are performed that affect the level of contraction of the colon and reduce the rate of moisture loss in the body. In case of acute obstruction, urgent preoperative measures are prescribed. Apply:

• abdominal lavage;
• enema;
• bilateral renal blockade using novocaine.

In a situation where signs of the disease appear on the third day after the completion of surgical operations, it is necessary to eliminate the paretic element of obstruction. To do this, trimecaine is injected into the epidural space. In addition, siphon enemas, gastric lavage and hypertonic solution sodium chloride ( intravenous administration). All these procedures are carried out in courses.

Surgical intervention for adhesive intestinal obstruction means intestinal resection, adhesive separation, and bypass anastomosis. It is also quite popular surgical method Noble, during which doctors partially or completely disconnect the loops and get rid of adhesions. In this case, parts of the small intestine are placed adjacently, stitched and firmly fixed in this position.

In the postoperative period, the patient is given intravenous blood substitute and saline solution, carry out antibacterial and inflammatory therapy and stimulate intestinal motor activity. At first, the patient is advised to adhere to bed rest. There is also special diet. The time for eating and drinking is determined by the doctor. During the first postoperative month, the patient is under clinical observation and attends physiotherapeutic procedures.

Diet during treatment

The therapeutic complex for intestinal obstruction also includes a special nutritional regimen. The diet is prescribed by a doctor. Make sure that daily dose food was minimal. Try not to overfill or overload your digestive system. The diet should be gentle and include split meals. The interval between meals lasts up to 3 hours. The daily norm of liquids is up to 2 liters. The basis of the diet can be:

• low-fat broths based on meat and vegetables;
• decoctions;
• boiled dishes in a puree state;
• water-based porridge;
• cottage cheese soufflé;
• compote.

– a disorder in the passage of the contents of the digestive tract as a result of the formation of rough cicatricial adhesions in the abdominal cavity. Pathology is caused by various reasons, but most often it is a consequence of surgical intervention. The disease is characterized by severe pain and asymmetrical bloating, vomiting, inability to pass gas and stool, and a gradual increase in signs of intoxication. Diagnosis consists of conducting a survey radiography of the abdominal organs, ultrasound, CT and MRI. Tactics depend on the form of the pathology and the time of its appearance; As a rule, a repeat operation is performed.

General information

Adhesive intestinal obstruction is a violation of the movement of food masses and digestive juices through the intestines, associated with the formation of adhesions. This is a fairly common pathology, which is a serious problem in surgery and gastroenterology, it occupies approximately 30-40% of all types of intestinal obstruction. It appears equally often in both men and women, regardless of age. Relevance of the disease in lately has increased significantly due to the increase in the number and volume of surgical interventions on the abdominal organs. According to many authors, approximately 40% of all operations are accompanied by the appearance of adhesions, while up to 60% of all laparotomies are performed for adhesive intestinal obstruction.

Causes of adhesive intestinal obstruction

The reasons for the formation of adhesions may be traumatic injuries, bleeding into the abdominal cavity, ischemia of the gastrointestinal tract, foreign bodies, negative impact toxins, purulent processes abdominal cavity (peritonitis, appendicular abscess, etc.), surgical interventions, during which drying of the peritoneum occurs (most often these are appendectomies, operations for pathology of the uterus and appendages), genetic predisposition.

The mechanism of formation of adhesions is explained by a disorder in the processes of resorption of inflammatory elements and their replacement by connective tissue. It is known that the peritoneum, in response to injury and any impact, produces exudate, which has adhesive properties. Connective tissue fibers are formed from its cells, fibrin gradually falls out, which should be absorbed after the healing process is completed. If this does not happen, it grows with collagen and elastic fibers, vessels - this is how adhesions are formed.

Symptoms of adhesive intestinal obstruction

Adhesive intestinal obstruction is divided into three types: obstructive, strangulation and combined (with signs of mechanical and dynamic type: usually develops when adhesions form between the focus of inflammation in the abdominal cavity and intestinal loops). There are also hyperacute, acute and chronic forms of pathology, which differ in the speed of development, severity and severity of symptoms.

The obstructive type of pathology is caused by compression of intestinal loops by adhesions, but they do not disrupt its blood supply and innervation. Painful sensations appear suddenly, they are associated with increased peristalsis and are paroxysmal in nature. The time of appearance of vomiting with impurities of bile and greens depends on the level of the obstruction: the higher the obstruction, the faster the vomiting develops. The patient experiences uniform bloating, gases are disturbed, and constipation occurs. The doctor can see bowel movements through the abdominal wall and detect increased sounds.

Strangulation is characterized by compression of the intestinal mesentery and is complicated by necrosis of the digestive tract. Clinical signs develop acutely and suddenly: severe pain in the abdomen without clear localization, pale skin, the patient cannot find comfortable position, refuses food. Intestinal necrosis may cause symptoms to subside, but only for a short time. Vomiting is without impurities, it is of a reflex nature and is caused by trauma to the mesentery. Gradually, there is a delay in the passage of gas and stool. Signs of toxicosis increase rapidly (increased heart rate, changes in blood pressure, weakness, dizziness, dehydration, etc.). At first, the abdomen is soft, but pain causes tension in the abdominal muscles. Peristalsis is invisible to the naked eye.

Adhesive intestinal obstruction, as a rule, is a complication of surgical procedures, and it can develop at different times. In patients with severe peritonitis, pathology is recorded in the first days after surgery. The serious condition of patients and pronounced signs of the underlying pathology mask the symptoms of obstruction. Patients are bothered by periodic cramping pain and vomiting. Asymmetrical bloating gradually develops. Palpation is painful, touching the muscles causes increased pain. There is no chair.

Adhesive obstruction sometimes develops 5-13 days after surgery and improvement in general condition, or 3-4 weeks. In this case, distinct symptoms of the disease are observed: intense periodic pain, frequent vomiting mixed with bile, asymmetrical bloated belly, visible peristalsis, increased bowel sounds. Symptoms gradually increase, independent stool disappears and the patient’s condition sharply worsens.

If the disease develops after a long period of time after the surgical procedure, it is said to be late adhesive intestinal obstruction. The pathology is characterized by the sudden onset of cramping pain, frequent vomiting, severe anxiety and forced positioning of the patient. Gases and stools do not pass away on their own. The abdomen is asymmetrically swollen, touching it intensifies attacks of pain, and peristalsis of the intestinal loops is clearly visible. The patient quickly develops signs of intoxication.

Diagnosis of adhesive intestinal obstruction

Adhesive intestinal obstruction can be suspected based on clinical signs and anamnesis data on previous surgery on the abdominal organs. The main diagnostic methods are considered to be radiological: survey radiography of the abdominal cavity and after contrasting the intestines with a suspension of barium sulfate. These studies can determine the distension of intestinal loops, Kloiber's cups (swollen areas of the digestive tract containing liquid and gases), darkening lower sections abdomen, contrast delay in individual loops, etc.

In recent years, laparoscopy, abdominal ultrasound, CT and MRI have been increasingly used as diagnostic methods. They help the gastroenterologist and surgeon identify the cause of the pathology, as well as the severity and type of damage.

Treatment of adhesive intestinal obstruction

Therapeutic procedures depend on the type of pathology and time of its appearance, as well as the general condition of the patient and concomitant diseases. Treatment of early adhesive intestinal obstruction must begin with conservative methods that allow you to restore the functions of the digestive system and are often preoperative preparations. It is very important to correctly calculate the permissible period of conservative therapy, and if there are no positive results, immediately perform surgery.

Upon registration early signs diseases, all patients are prescribed parenteral (intravenous) nutrition, as well as measures that improve intestinal motility, prevent the development of intoxication and normalize general condition. If symptoms of the disease appeared 2-3 days after the surgical procedure against the background of intestinal paresis and peritonitis, then it is necessary to eliminate the paretic component of the obstruction: for this purpose, trimecaine is injected into the epidural space. Along with this, gastric lavage, siphon enemas are prescribed, hypertonic sodium chloride solution and neostigmine are infused intravenously. All of the above procedures are carried out in courses (about 2-3) within 24 hours. In the absence of positive dynamics, laparotomy is performed 5-6 hours after the appointment of therapy.

If early strangulation obstruction is suspected, short-term conservative treatment is indicated, followed by surgery followed by supportive therapy and care. Treatment of late obstruction is always surgical; delay can cause necrotic changes in the intestinal walls. Before the surgical procedure, preparations are carried out: the stomach is washed, a siphon enema is done, proserin is administered. If after 2-3 hours the pain subsides and the signs of pathology disappear, then the patient is left in the department under observation and anti-adhesion therapy is prescribed. Otherwise, an operation is immediately performed to separate adhesions, apply a bypass anastomosis, or resection of a section of intestine (the type of intervention is selected individually).

If the patient is taken to the hospital in serious condition, intensive therapy is prescribed to eliminate signs of intoxication, minimal preoperative preparation is given, and the surgical procedure begins immediately.

Prevention and prognosis of adhesive intestinal obstruction

Prevention of adhesive intestinal obstruction consists of careful operation, prevention of drying out of the peritoneum and administration of dry drugs, timely evacuation of blood and foreign objects. After surgery good effect Physiotherapy provides: UHF, electrophoresis, as well as physical therapy and diet. Prognosis of adhesive intestinal obstruction during timely diagnosis and rational therapy are favorable, but the probability of relapse of the pathology is high.

The main cause of adhesive intestinal obstruction is any surgical intervention on the abdominal organs. Congenital adhesions between intestinal loops are rare. Adhesive intestinal obstruction, on average, accounts for 40% of all obstructions encountered in the surgical clinic. According to the timing of occurrence, several forms are distinguished:

1. Early adhesive intestinal obstruction - occurs on time
up to 1 month after surgical treatment:

a) early adhesive paretic intestinal obstruction
- occurs in the first 6 days after surgical treatment
and is more often caused by diffuse purulent peritonitis,
with it there are signs of both paresis and obstruction,

b) early simple intestinal obstruction - occurs
from 6 to 14 days after surgery,

c) early delayed intestinal obstruction -
occurs 3 to 4 weeks after surgery,

d) intestinal obstruction caused by
appendicular infiltrate - may occur in
any time period after the development of the mentioned complication.

2. Late intestinal obstruction - occurs after more than 1
months after surgery.

At early forms intestinal obstruction, loose planar adhesions appear in the abdominal cavity, which are easily torn.

With late intestinal obstruction, a large amount of fibrin precipitates in the abdominal cavity, which can glue intestinal loops to areas of the peritoneum and, over time, dense cord-like adhesions form that cannot be broken.

Clinic

Early adhesive paretic intestinal obstruction

Aching, constant pain

No stool, or scanty and liquid

The abdomen is evenly distended

On palpation, pain is detected throughout the abdomen, and in the far

advanced stages, the tension of the anterior abdominal wall is determined

Perilstatics weakened

All other forms of early impassability With tee, including late

The pain is sharp and cramping in nature

Stool and gas are retained

The abdomen is asymmetrically distended due to overstretched intestinal loops,

obstacles located above

Perilstatics strengthened

Treatment

In the treatment of adhesive intestinal obstruction, 2 treatment methods are used: conservative and surgical.

Conservative therapy aims to empty the intestines and stimulate perilstatics and turns out to depend on the form of intestinal obstruction: paretic - up to 48 hours; simple - up to 24 hours; delayed - up to 12; late - up to 3-6 hours:

Hypertonic or cleansing enema

Administration of drugs that stimulate perilstatics (cerucal,
proserin; Proserin is administered in a dose of 0.1 ml. for 1 year of life in children)

Administration of hypertonic 10% saline solution
in a dose of 1 ml per 1 year of life, in children

Surgical treatment. In the paretic form, when the obstruction cannot be resolved conservatively, a suspension enterostomy is performed to relieve the intestines. In all other forms, adhesions are dissected. At the end of the operation, it is advisable to inject 1-2-3 mg into the abdominal cavity. a suspension of hydrocortisone diluted in 10 ml of 0.25% novocaine to prevent the formation of new adhesions.

In the presence of appendicular infiltrate, without abscess formation, conservative therapy: 2 antibiotics are prescribed wide range actions, 1 is administered intravenously, the other intramuscularly; in addition, UHF, electrophoresis with an antibiotic is prescribed, detoxification and symptomatic therapy are carried out. If intestinal obstruction develops, an operation is performed, which consists of turning off the infiltrate, and an anastomosis is performed: the end of the ileum to the side of the cecum, bypassing the ileocecal angle.

Peritonitis

More often this term is understood acute diffuse widespread process caused by microflora.

Classification

1. According to the nature of microflora penetration into the abdominal cavity:

a) primary (hematogenous, lymphogenous routes, through
fallopian tubes);

b) secondary (from inflammatory foci of the abdominal
cavities).

2. By etiological factor:

a) microflora of the digestive tract (Escherichia coli, staphylococcus, streptococcus, enterococci, non-clostrigial anaerobes, Proteus);

b) Microflora not related to digestive tract(gonococci, pneumococci, mycobacterium tuberculosis);

c) a septic (to blood, urine, bile, pancreatic juice);

d) special (carcinomatous, rheumatic,

fibroplastic - when talc or starch gets in contact with gloves).

5. According to the clinical course:

a) spicy;

b) subacute;

c) chronic.

Etiology

Most often there is widespread purulent peritonitis. Frequent causes are:

destructive appendicitis;

destructive forms acute cholecystitis;

diseases of the stomach and duodenum;

ulcer, cancer, complicated by perforation;

acute pancreatitis;

perforation of diverticula and colon cancer;

thrombosis of the vessels of the mesentery of the small and large intestine, penetrating

injuries, anastomotic failure.

Pathogenesis

The pathogenesis of peritonitis can be divided into three stages.

1- Reactive stage. Develops in the first day after the development of peritonitis. Contact with the peritoneum of microorganisms causes local inflammatory reaction with typical signs: hyperemia, edema, increased capillary permeability, exudation. In response to this, swelling and infiltration of the greater omentum, intestine and its mesentery occur. Fibrin falls out, which helps to delineate the source of infection. The activity of macrophages and leukocytes increases.

In response to the influence of factors that led to the development of peritonitis, the hypothalamic-pituitary system is activated, which is accompanied by the release of large amounts of catecholamines and glucocorticoids. The latter stimulate the secretion of interleukins. This sets off a chain reaction to inflammation.

2. Toxic stage. Develops within 24-72 hours. Conditioned
entry into the general bloodstream of endo- and exotoxins, interleukins,
protein products that are formed in large quantities
during the breakdown of leukocytes (lysosomal enzymes, proteases,
polypeptides). The phagocytic activity of leukocytes decreases,
interleukins cause a strong pyrogenic reaction and contribute to
release of kinins, which in turn leads to a sharp
dilatation of peripheral vessels, decrease in peripheral
resistance, drop in blood pressure. In response to this
microcirculation disturbance develops and DIC syndrome With
consumption coagulopathy. If protective forces macroorganism
turn out to be unable to localize the process, then diffuse
peritonitis.

3. Terminal stage. Develops within 72 hours from the moment
development of peritonitis. Characterized by endotoxic shock.
Severe intoxication of the central nervous system develops with the development of adynamia or even
convulsive syndrome. At this stage, even intensive activities
may turn out to be ineffective, and the death of the patient occurs.

Fundamental points in the pathogenesis of the development of peritonitis are: hemodynamic disorders, changes in the respiratory system, impaired renal and liver function, impaired intestinal motor activity.

Hemodynamic disorders. At the very beginning of peritonitis, in response to stress, the following occurs: increased heart rate, increased blood pressure, increased minute and stroke volume of cardiac output. In the terminal stage as a result

the development of hypovolemia, which develops due to: vomiting, swelling and exudation of the peritoneum, fluid deposition in the paralytic intestine - blood pressure decreases, tachycardia increases, cardiac output and stroke volume decrease due to low venous blood return.

Changes in the respiratory system. Develop in toxic and terminal stages. Caused by the development of hypovolemia, which develops for the reasons described above. Violation of microcirculation leads to the opening of arteriovenous shunts, and a lack of blood supply to the lung tissue develops, and this in turn leads to the development of acidosis in the tissue, against the background of which porosity sharply increases vascular wall, and swelling of the pulmonary tissue develops (shock lung). As a result, cardiopulmonary failure develops.

Liver dysfunction. In the terminal and toxic stages, microcirculation is disrupted, which undoubtedly affects the liver in the form of hypoxia of its tissue. In response to this, substances are released into the tissue of the liver itself, which also lead to hypoxia of the organ. The liver is no longer capable of performing protein-forming and detoxifying functions. As a result, it develops liver failure.

Renal dysfunction. As a result of the development of hypovolemia for the reasons described above, blood flow centralizes, which leads to spasm of the kidney vessels. As a result, diuresis decreases down to anuria with the subsequent development of acute renal failure.

Impaired intestinal motor function. At first, intestinal atony is of a reflex nature and helps limit the inflammatory process. Later, as a result of toxic effects on the neuromuscular system, paralytic obstruction occurs. Blood supply and microcirculation in the intestine are also affected, which undoubtedly contributes to the development of paralysis of the wall.

Clinic

1. Pain syndrome. The pain is intense, constant, throughout the abdomen,
intensify when changing position. Patients in a forced position:

on the side with legs adducted. On palpation, the pain is stronger at the site of the primary lesion. In the toxic stage, pain decreases slightly.

2. Dyspeptic syndrome. Rarely seen in the reactive stage
vomiting, since intestinal paralysis has not yet developed. Subsequently

vomit a large number stagnant contents, does not bring relief. In the terminal stage, vomiting will be intestinal contents with a fecal odor.

3. Inflammation syndrome. From the onset of peritonitis, the temperature rise will be within the subfebrile range, but as the process progresses, especially in the toxic stage, it will reach hectic levels. Blood leukocytosis, increasing from the moment of development of peritonitis, will reach a maximum and the toxic stage, followed by gradual development leukopenia due to depletion of protective factors. ESR increases from the very beginning of the development of the process and remains high in the terminal stage. In the terminal stage, scissors also appear between temperature and pulse, which suggests that in the terminal stage, intoxication syndrome comes first.

4. SSS and DS. Since the development of peritonitis tah ika rdia will increase, which will be due to the reactive release of catecholamines, glucocorticoids and an increase in temperature in the reactive stage. In the first stage, tachycardia will reach 100-110 beats per minute. In the toxic and terminal stages, tachycardia will be caused mainly by hypovolemia, hyperthermia and toxemia and can reach 120-130 beats per minute. Heart sounds normal in the reactive stage, will become deaf in the toxic and terminal stages, which is due to the toxic effect of biologically active substances and hypovolemia. Blood pressure in the first stage may be normal, increased or decreased. It will be reduced if a hollow organ is perforated, which will be accompanied by strong pain impulses. In the second stage, the pressure will be reduced for all the reasons described above.

5. Skin and mucous membranes. First it will be detected I have dry mucous membranes By Loss of the mouth and cheeks, which will be largely determined by temperature at first. In the last two stages it reveals there is total dryness mucous membranes. Brush-like tongue, multiple cracks around the mouth. In the terminal stage we see the mask of Hippocrates, which indicates gravest violation water-electrolyte metabolism. The skin will initially be cyanotic, followed by the development of acrocyanosis, and in the terminal stage it will be gray.

6. Belly. P On superficial palpation, total pain is determined, but it is more pronounced at the point of localization of the primary focus. When a hollow organ is perforated, a board-shaped abdomen may first be observed. Shchetkin's symptom is detected in all parts, but is more pronounced in the area of ​​primary localization of the lesion. As intestinal paralysis progresses, intestinal distension will be detected. Free fluid (exudate) can be determined; if this is a breakthrough of a hollow organ, then the disappearance of hepatic dullness is determined. In the toxic and terminal stages, auscultation of the abdomen reveals the symptom of deathly silence.

Clinic of the reactive stage. The reactive stage lasts up to 24 hours and is characterized by pronounced pain syndrome. Upon objective examination: the patient’s condition is serious; forced position - knee-elbow, taken to reduce the tension of the inflamed peritoneum; skin pale, which is due to the strong influence of the sympatho-adrenal system in response to pain impulses; tachycardia; the temperature often remains normal; blood pressure increased; chest type of breathing by sparing the abdomen; polyuria. When examining the abdomen: stomach flat as a board; superficial palpation is sharply painful; deep palpation is impossible; perilstatics are preserved.

Clinic of the toxic stage. This stage is caused by the accumulation of toxins in the blood (presence of infection, the effect of waste products and decay of microorganisms, resorption of purulent exudate). Complaints: reduction of pain, which is due to paralysis of peritoneal receptors; nausea; vomit; headache; decreased appetite; sleep disturbance. Upon objective examination: the patient’s condition is extremely serious; the skin is gray, pale; tendency to hyperthermia; tachycardia; low filling pulse; decreased blood pressure; reduction in numbers breathing movements due to toxic effects on respiratory center. When examining the abdomen: the abdomen is enlarged due to bloating of the paretic intestine; all symptoms of peritoneal irritation are identified; perilstatics is sluggish; physiological functions are disrupted.

Terminal stage clinic. This stage is caused by general intoxication, which is aggravated by multiple organ failure. There are no active complaints. Successive stages develop terminal state: preagonia, terminal pause, agony, clinical death. The patient's position is passive. The skin is gray, cold, acrocyanosis. The patient is inhibited. The pulse is threadlike, blood pressure is critically reduced. Renal and liver failure develops, followed by the development of oligo- and anuria. When examining the abdomen: the abdomen is sharply distended due to pronounced flatulence; dullness is determined in sloping places percussion sound due to the accumulation of free fluid; there is dead silence in the stomach, the sound of splashing, the phenomenon of a falling drop.

Diagnostics

1. Anamnesis data and clinical picture.

In OAK leukocytosis up to 28-20 with a shift to the left, accelerated ESR

3. The TAM contains protein and a small number of leukocytes.

4. On X-ray: gas accumulation under the right or left dome
diaphragm during perforation of a hollow organ; limited mobility
diaphragm during localization pathological process on the top floor.

2. swollen intestinal loops, fluid levels - Kloiber cups in case of paralytic obstruction.

5. Ultrasound - swollen intestinal loops, clarifies the localization of the primary
focus - cholecystitis, pancreatitis; accumulation of exudate.

6. Laparoscopy - complete visualization of peritonitis with the primary focus.

Modern principles treatment

1. Absolute reading for emergency surgical treatment.

2. High quality and short preoperative preparation sick.

| 3. Midline laparotomy with anation of the primary focus, drainage of abscesses, mechanical cleansing of the abdominal cavity, washing with aseptic solutions during and after surgery.

4. Massive antibacterial therapy broad antibiotics
spectrum to determine the sensitivity of the isolated microflora.

5. Elimination of paralytic obstruction through aspiration
through a nasointestinal tube, stimulation of intestinal activity
anticholinesterase drugs.

6. Correction of water and electrolyte balance disorders.

7. Correction and maintenance of functional level at an optimal level
conditions of the cardiovascular system, cardiovascular system, liver, kidneys.

8. In the postoperative period, peritoneal dialysis is performed,
lavage, lymph and hemosorption, HBO.

Diseases of the rectum

Haemorrhoids

This is an expansion of the cavernous bodies of the rectum.

Etiology

1. Impaired blood outflow through the cavernous bodies.

2. Congenital expression of groups of cavernous bodies.

3. Congenital functional deficiency of connective tissue in the cavernous bodies.

4. Violation of the nervous regulation of the tone of the venous wall.

5. Increased venous pressure in the cavernous bodies as a result of increased venous pressure (constipation, liver cirrhosis with portal hypertension, pregnancy, alcohol abuse).

Classification

1. By localization:

a) internal hemorrhoids (located above
recto-anal line under the mucosa
the lining of the rectum;

b) external - located below this line under the skin;

c) mixed - a combination of external and internal
hemorrhoids.

2. By stages clinical course:

a) Stage 1 - nodes prolapse from the anal canal only
during the act of defecation and then independently
are adjusted;

b) Stage 2 - nodes fall out during bowel movements and large
physical activity; do not straighten on their own
and require manual adjustment;

c) Stage 3 - nodes fall out even with minor
physical activity, do not correct themselves.

3. For complications:

a) uncomplicated;

o) complicated (thrombosis of external hemorrhoidal

knot, infringement of internal hemorrhoids);

1. Sensation of a foreign body in the anus. 2.Bleeding - main symptom hemorrhoids. Occurs at the time of defecation or immediately after it. Blood covers the top of the stool.

3.Pain is not characteristic symptom hemorrhoids and occurs only when there is a complication. It occurs at the time of defecation and continues for some time after.

4. Upon examination, hemorrhoids are revealed.

Diagnostics

1. Complaints.

2. Clinical picture.

3. Objective examination.

4. Digital examination of the rectum.

5. Anoscopy.

6. Sigmoidoscopy.

1. Conservative treatment indicated for stage 1. Diet therapy,
elimination of constipation, physiotherapy, sclerotherapy.

2. Surgical treatment is indicated for stages 2-3. Consists in
excision of hemorrhoids.