The electroejaculation method (EEM) is used to collect sperm from men with spinal cord injury and is used when the vibroejaculation method is unsuccessful. The procedure begins with catheterization of the bladder to completely empty it. In this case, the catheter is lubricated with glycerin, but instillation of 2 ml of a 6% solution of Human Tubal Fluid (HTF) and plasmanate is preferable. Urine should be alkaline (pH > 6.5). If necessary, sodium bicarbonate can be taken orally.
Since retrograde ejaculation often occurs with this procedure, an additional 10 ml of tubal fluid simulator and plasmanate is injected into the bladder. This is done in order to preserve sperm suitable for fertilization in the bladder. Then, using an anoscope, the rectum is examined. After this, a well-lubricated rectal probe (a rod with electrodes built into it) is inserted into the rectum, which is placed against the wall of the rectum in the area of the prostate gland and seminal vesicles (Fig. 1).
Rice. 1. Electroejaculation procedure using a rectal probe.
Rectal probe connected to a special electrical device (Fig. 2), the output voltage and current values of which are selected individually for each patient, in accordance with the habitus and nature of the spinal cord injury.
Rice. 2. Device for electroejaculation.
The doctor manually regulates the voltage supplied to the rectal probe, increasing it to a certain value, and then, after some time, decreasing it to zero. The maximum voltage value gradually increases until an erection or ejaculation occurs. Having noted the amount of voltage applied to the rectal probe at which the first erection or ejaculation occurred, the doctor increases the voltage by 30-50%, depending on the rectal temperature and the patient’s sensations. If the rectal temperature approaches 40°C, the electrical parameters change or pause the procedure until the temperature drops below 38°C.
Ejaculation can be completely retrograde. In such cases, the only symptoms that the patient was adequately aroused and retrograde ejaculation occurred is an erection, accompanied by profuse sweating, piloerection, and “goose bumps” in certain areas of the body and buttocks.
The time during which the rectal probe is in the rectum is approximately 10 minutes. The ejaculate is collected in a vessel containing a buffer of 3 ml of tubal fluid, and then placed in a sterile plastic container.
At the end of the procedure, anoscopy and catheterization of the bladder are performed again. Urine collected after ejaculation is sent along with the ejaculate to an artificial insemination laboratory for processing. The patient's medical record records the number of stimulations, as well as the current and voltage required to produce a maximum erection. This information, if necessary, will be useful for the subsequent procedure. The procedure is generally well tolerated by patients. In men with a spinal cord injury, it is usually performed without anesthesia. In men with incomplete spinal cord injury, the procedure may be painful, but Sønksen and Biering-Sørensen (2003) report that only 5% of men require anesthesia to reduce discomfort.
The electroejaculation method can achieve ejaculation in more than 80% of men with all types of spinal cord injury. The resulting ejaculate allows more than 43% of couples to achieve pregnancy using intrauterine or in vitro fertilization methods.
Using vibration or electrical stimulation, sperm can be obtained from almost all men with spinal cord injury.
Possible problems
Retrograde ejaculation
L. N. Indolev in the book “Living in a Wheelchair” regarding hyperreflexia (dysreflexia) writes the following: “Dysreflexia, which appears for a seemingly trivial reason, actually threatens with a stroke and hemorrhage, so first of all it is necessary to detect and eliminate its cause. You need to change your body position, sit with your legs down and loosen your belt, thereby ensuring the flow of blood to your legs. Hands and feet can be immersed in reasonably hot water. By feeling the abdomen above the pubis, determine the fullness of the bladder. Loosen the urinal or straighten the indwelling catheter, which may simply become clogged with mucus or stone. If this is the reason, inject 20-30 cubes of furatsilin or chilled boiled water with a syringe. If urine does not come out when your bladder is full, try to help by gently tapping your lower abdomen. If this does not help, call an ambulance. With a bladder infection, cystitis, its walls become painful, spasm, and cloudy, bad-smelling urine is released in small portions. If the cause of increased blood pressure and headache with throbbing in the temples may be this, remove residual urine through a catheter, then administer a mixture of 10 cubes of a 0.5-1% solution of novocaine or lidocaine in ampoules plus 20 cubes of boiled water. After clamping the catheter for 20 minutes, sufficient to relieve pain and relieve spasm, remove the clamp and release the solution. If the cause of dysreflexia is not found in the bladder (although it is the most common), check with your finger to see if there is a hard fecal plug in the rectum. Insert a candle with novocaine, analgin, etc. You can make a novocaine microenema of 20-30 cubes and remove the plug after 15 minutes. In case of frequent and unclear attacks, you should contact a urologist and get a referral for an ultrasound to exclude or detect the presence of stones in the bladder. In any case, bellataminal is used to relieve the autonomic reaction, and well-known medications are used to normalize blood pressure.”
In general, significant complications from vibroejaculation and electroejaculation are rare. With PVS, chafing of the skin of the penis may occur. In this case, no special treatment is required, and after a short break the procedure is continued. With EJE there is a potential risk of rectal injury.
Hence another name for this method found in the English-language medical literature, - rectal probe electroejaculation (RPE), i.e. electroejaculation using a rectal probe [ Note auto].
Anoscope (Latin anus anus + Greek skopeo to examine, examine; synonym: luminous rectal mirror) an instrument that is a double-leaf rectal mirror with an illuminator.
Piloerection - contraction of the muscles that lift the hair, leading to the formation of goose bumps.
Goals: therapeutic (stimulation of bile outflow, administration of medicinal drugs), diagnostic (diseases of the gallbladder and biliary tract).
Contraindications: acute cholecystitis, exacerbation of chronic cholecystitis and cholelithiasis, gastrointestinal tumor, gastrointestinal bleeding.
To stimulate contraction of the gallbladder, one of the following stimulant substances is used::
§ magnesium sulfate (25% solution - 40-50 ml, 33% solution - 25-40 ml);
§ glucose (40% solution - 30-40 ml);
§ vegetable oil (40 ml).
3 days before the procedure, you should begin preparing the patient for duodenal intubation: give the patient a glass of warm sweet tea at night and place a heating pad on the right hypochondrium.
When preparing for the study, it is necessary to take into account concomitant pathology; sweet tea should not be given in case of diabetes mellitus; a heating pad is not indicated for diagnostic probing if giardiasis is suspected.
Required equipment:
Duodenal tube;
Stimulant substance;
Rack with numbered test tubes, Janet syringe, clamp;
Soft cushion or pillow, towel, napkin;
Rubber gloves.
The order of the procedure (Fig. 10.4):
1. Sit the patient on a chair so that the back rests tightly against the back of the aul, tilt the patient’s head slightly forward.
2. Carefully place the blind end of the probe on the root of the patient’s tongue and ask him to make swallowing movements.
3. When the probe reaches the stomach, apply a clamp to its free end.
4. Place the patient on the couch without a pillow on his right side, inviting him to bend his knees; Place a warm heating pad under your right side (on the liver area).
5.. Ask the patient to continue swallowing the probe for 20-60 minutes until the 70 cm mark.
6. Place the end of the probe into the test tube and remove the clamp; if the olive is located in the initial part of the duodenum, golden-yellow liquid begins to flow into the test tube.
7. Collect 2-3 test tubes of incoming liquid (portion A of bile), apply a clamp to the end of the probe.
If portion A of bile does not arrive, you need to slightly pull the probe back (possible twisting of the probe) or repeat probing under visual x-ray control.
Rice. 10.4. Duodenal sounding.
8. Lay the patient on his back, remove the clamp and inject a stimulant substance through the probe with a Janet syringe, apply the clamp.
9. After 10-15 minutes, ask the patient to lie on his right side again, lower the probe into the next test tube and remove the clamp: a thick, dark olive-colored liquid should flow in (portion B) - within 20-30 minutes, up to 60 ml of bile is released from the bile duct bladder (vesical bile).
If a portion of B does not enter the bile, there is probably a spasm of the sphincter of Oddi. To remove it, the patient should be injected subcutaneously with 1 ml of a 0.1% atropine solution (as prescribed by a doctor!).
10. When a transparent golden-yellow liquid begins to be released (portion C), lower the probe into the next test tube - within 20-30 minutes, 15-20 ml of bile is released from the bile ducts of the liver (hepatic bile).
11. Carefully remove the probe and immerse it in a container with a disinfectant solution.
12. Send the received portions of bile to the laboratory
Enemas
Enema (Greek) klysma- lavage) is a procedure for introducing various liquids into the rectum for therapeutic or diagnostic purposes.
The following enemas are considered therapeutic:
· Cleansing enema: it is prescribed for constipation (cleansing the lower intestine of feces and gases), according to indications - before surgery and in preparation for x-ray and ultrasound examination of the abdominal organs.
· Siphon enema: it is used in case of ineffectiveness of a cleansing enema, as well as when repeated lavage of the colon is necessary.
· Laxative enema: it is prescribed as an auxiliary cleansing agent for constipation with the formation of dense feces. Depending on the type of drug administered, hypertonic, oil and emulsion laxative enemas are distinguished.
· Medicinal enema: it is prescribed for the purpose of administering local and general medications through the rectum.
· Nutrient enema: it is used to introduce water, salt pan and glucose into the body. Other nutrients are not administered using an enema, since digestion and absorption of proteins, fats and vitamins do not occur in the rectum and sigmoid colon.
A diagnostic enema (contrast) is used to determine the capacity of the colon and introduce an X-ray contrast agent (suspension of barium sulfate) into the intestine with some methods of X-ray examination. The most informative is a contrast enema with double contrast - the introduction of a small amount of barium sulfate suspension and subsequent inflating of the intestine with air. This enema is used to diagnose diseases of the colon (cancer, polyps, diverticulosis, ulcerative colitis, etc.).
There are also the concepts of “microenema” (in which a small amount of liquid is administered - from 50 to 200 ml) and “macroenema” (in which 1.5 to 12 liters of liquid are administered).
There are two ways to introduce fluid into the rectum:
Hydraulic (for example, when administering a cleansing enema) - the liquid comes from a reservoir located above the level of the patient’s body;
Pressure (for example, when performing an oil enema) - liquid is injected into the intestines with a special rubber balloon (bulb) with a capacity of 200-250 ml, with a Janet syringe or using a complex pressure device “Colongidromat”.
Absolute contraindications for all types of enemas: gastro-
intestinal bleeding, acute inflammatory processes in the colon, acute inflammatory or ulcerative-inflammatory processes in the anus, malignant neoplasms of the rectum, acute appendicitis, peritonitis, the first days after operations on the digestive organs, bleeding from hemorrhoids, rectal prolapse.
Cleansing enema
Goals:
Cleansing - emptying the lower part of the colon by loosening feces and increasing peristalsis;
Diagnostic - as a stage of preparation for operations, childbirth and instrumental methods for examining the abdominal organs;
Therapeutic - as a stage of preparation for medicinal enemas.
Indications: constipation, poisoning, uremia, enemas before operations or childbirth, to prepare for x-ray, endoscopic or ultrasound examination of the abdominal organs, before administering a medicinal enema.
Contraindications: general.
To perform a cleansing enema, a special device is used (a device for cleansing enema), consisting of the following elements:
1. Esmarch mug (glass, rubber or metal vessel with a capacity of up to 2 liters).
2. A thick rubber tube with a clearance diameter of 1 cm and a length of 1.5 m, which is connected to the tube of Esmarch’s mug.
3. Connecting tube with tap (valve) for current regulation
liquids.
4. Glass, ebonite or rubber tip.
Necessary equipment: warm water in a volume of 1-2 liters, a device for a cleansing enema, a stand for hanging a mug, a thermometer for measuring the temperature of the liquid, an oilcloth, a diaper, a basin, a vessel, marked containers for “clean” and “dirty” intestinal tips, a spatula , Vaseline, protective clothing (mask, medical gown, apron and disposable gloves), containers with disinfectant solution.
The order of the procedure (Fig. 10.5):
Rice. 10.5. Setting up a cleansing enema (hydraulic method).
1. Prepare for the procedure: wash thoroughly
tsuki with soap and warm running water, put on a mask, apron and
Gloves.
2. Pour boiled water or liquid of the prescribed composition, volume (usually 1-1.5 l) and temperature into Esmarch’s mug.
4. Open the tap, fill the tubes (long rubber and connecting), release a few milliliters of water to displace air from the pipes and close the tap.
5. Place a basin on the floor near the couch; put on the couch
oilcloth (its free end should be lowered into the gas in case the patient cannot hold water) and a diaper on top of it.
6. Invite the patient to lie on the edge of the couch on his side (preferably on the left), bending his knees and bringing them to his stomach to relax the abdominal press (if movement is contraindicated for the patient, the enema can also be given with the patient on his back, placing a bed under him); the patient should relax as much as possible and breathe deeply, through the mouth, without straining.
7. Take a small amount of Vaseline with a spatula and lubricate the tip with it.
8. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the tip into the anus, moving it first towards the navel by 3-4 cm, then parallel to the spine to a total depth of 7-8 cm.
9. Open the tap slightly, making sure that the water does not enter the intestines too quickly, as this may cause pain.
If the patient experiences abdominal pain, it is necessary to immediately pause the procedure and wait until the pain goes away. If the pain does not subside, you should tell your doctor.
10. If the water does not flow, raise the mug higher and/or change the position of the tip, pushing it back 1-2 cm; if water still does not flow into the intestines, remove the tip and replace it (as it may be clogged with feces).
11. At the end of the procedure, close the tap and remove the tip, pressing the patient’s right buttock to the left so that liquid does not leak out of the rectum.
12. Invite the patient to squeeze the anal sphincter himself and hold the water for as long as possible (at least 5-10 minutes).
13. If after 5-10 minutes the patient feels the urge to defecate, give him a bedpan or walk him to the toilet, warning him, if possible, not to release the water immediately, but in portions.
14. Make sure that the procedure was effective; If the patient has emptied only with water and a small amount of feces, after examining the patient by a doctor, the enema must be repeated.
15. Disassemble the system and place it in a container with a disinfectant solution.
16. Remove apron, mask, gloves, wash hands.
The liquid administered through an enema has mechanical and temperature effects on the intestines, which can be regulated to a certain extent. The mechanical effect can be increased or decreased by adjusting the amount of injected liquid (on average 1-1.5 l), pressure (the higher the mug is suspended, the greater the pressure of the injected liquid) and the rate of administration (regulated by the tap of the cleansing enema device). By observing a certain temperature regime of the injected liquid, peristalsis can be enhanced: the lower the temperature of the injected liquid, the stronger the intestinal contractions. Usually, the water temperature for an enema is recommended to be 37-39 °C, but for atonic constipation, cold enemas (up to 12 °C) are used, and for spastic constipation, warm or hot ones are used to reduce spasms (37-42 °C).
Siphon enema
Siphon enema - repeated lavage of the intestines according to the principle of communicating vessels: one of these vessels is the intestine, the second is a funnel inserted into the free end of a rubber tube, the other end of which is inserted into the rectum (Fig. 10.6, a). First, a funnel filled with liquid is raised 0.5 m above the level of the patient’s body, then, as liquid enters the intestines (when the level of decreasing water reaches the narrowing of the funnel), the funnel is lowered below the level of the patient’s body and wait until it begins to flow intestinal contents (Fig. 10.6, 6). The raising and lowering of the funnel alternate, and with each rise of the funnel, liquid is added to it. Siphon lavage of the intestines is carried out until a clean floor comes out of the funnel. Usually 10-12 liters of water are administered. The amount of fluid released must be greater than the volume of fluid administered.
Rice. 10.6. Setting up a siphon enema: a - pour water into the funnel and enter the intestines; b - after lowering the funnel, the contents of the intestines begin to be released through it.
Goals:
Cleansing - achieve effective cleansing of the intestines from feces and gases;
Medical;
Detoxification;
As a stage of preparation for surgery.
Indications: lack of effect from a cleansing enema (due to prolonged constipation), poisoning with certain poisons, preparation for intestinal surgery, sometimes if colonic obstruction is suspected (with colonic obstruction there are no gases in the rinsing waters).
Contraindications: general, serious condition of the patient.
To perform a siphon enema, a special system is used, consisting of the following elements:
Glass funnel with a capacity of 1-2 liters;
Rubber tube 1.5 m long and lumen diameter 1-1.5 cm;
Connecting glass tube (to control the passage of contents);
A thick gastric tube (or a rubber tube equipped with a tip for insertion into the intestines).
A glass tube is used to connect a rubber tube to a thick gastric tube, and a funnel is placed on the free end of the rubber tube.
Necessary equipment: a system for siphon enema, a container with 10-12 liters of clean warm (37 ° C) water, a ladle with a capacity of 1 liter, a basin for rinsing water, oilcloth, a diaper, a spatula, Vaseline, special clothing (mask, medical gown, apron, disposable gloves), containers with disinfectant solution.
Procedure to complete:
1. Prepare for the procedure: carefully you mm
wash your hands with soap and warm running water, put on a mask, apron and gloves.
2. Place a basin on the floor near the couch; put on the couch
oilcloth (the free end of which is lowered into the basin) and a diaper on top of it,
3. Ask the patient to lie on the edge of the couch, on his left side, bending his knees and bringing them to his stomach to relax the abdominal press.
4. Prepare the system, take a small amount of Vaseline with a spatula and lubricate the end of the probe with it.
5. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the probe into the anus to a depth of 30-40 cm.
6. Place the funnel in an inclined position just above the patient’s body level and fill it with 1 liter of water using a ladle.
7. Slowly raise the funnel 0.5 m above the patient’s body level.
8. As soon as the level of decreasing water reaches the mouth of the funnel, lower the funnel below the level of the patient’s body and wait until the funnel is filled with the reverse flow of liquid (water with particles of intestinal contents).
The water should not be allowed to decrease below the mouth of the funnel to prevent air from entering the tube. The entry of air into the system disrupts the implementation of the siphon principle; in this case, you should start the procedure again.
9. Drain the contents of the funnel into a basin.
In case of poisoning, it is necessary to take 10-15 ml of liquid from the first portion of rinsing water for examination.
10.Repeat washing (steps 6-9) until clean wash codes appear in the funnel.
12.Slowly remove the probe and immerse it together with the funnel in a container with a disinfectant solution.
12. Toilet the anus.
13. Remove apron, mask, gloves, wash hands.
The patient's condition should be closely monitored during the procedure, since most patients do not tolerate siphon enema well.
Laxative enema
A laxative enema is used for persistent constipation, as well as for intestinal paresis, when administering large amounts of fluid to the patient is ineffective or contraindicated.
Hypertensive enema provides effective bowel cleansing. promote abundant transudation of water from the capillaries of the intestinal wall into the intestinal lumen and the removal of large amounts of fluid from the body. In addition, a hypertensive enema stimulates the release of copious loose stools, gently enhancing intestinal motility.
Indications: ineffectiveness of the cleansing enema, massive swelling.
Contraindications: general.
For a hypertensive enema, as a rule, one m of the following solutions is used:
10% sodium chloride solution;
20-30% solution of magnesium sulfate;
20-30% sodium sulfate solution.
To perform a hypertensive enema, the prescribed solution (50-100 ml) is heated to a temperature of 37-38 °C. It is necessary to warn the patient not to get up immediately after the enema and try to retain the solution in the intestines for 20-30 minutes.
Oil enema promotes easy passage of large stools even in cases where the introduction of water into the intestines is ineffective.
The effect of oil in the intestines is due to the following effects:
Mechanical - oil penetrates between the intestinal wall and feces, softens feces and facilitates its removal from the intestines;
Chemical - the oil is not absorbed in the intestines, but is partially saponified and broken down under the influence of enzymes, relieving spasms and restoring normal peristalsis.
Indications: ineffectiveness of a cleansing enema, spastic constipation, prolonged constipation, when tension in the muscles of the abdominal wall and perineum is undesirable; chronic inflammatory diseases of the colon.
Contraindications: general.
To perform an oil enema, as a rule, vegetable oils (sunflower, flaxseed, hemp) or petroleum jelly are used. The prescribed oil (100-200 ml) is heated to a temperature of 37-38 °C. An oil enema is usually given at night, and the patient must be warned that after the enema he should not get out of bed until the enema takes effect (usually after 10-12 hours).
Emulsion enema: it is prescribed to seriously ill patients; complete bowel movement usually occurs within 20-30 minutes. To perform an emulsion enema, use an emulsion solution consisting of 2 glasses of chamomile infusion, beaten yolks of one egg, 1 tsp. sodium bicarbonate and 2 tbsp. Vaseline oil or glycerin.
Method of performing a laxative enema. Necessary equipment: a special rubber pear-shaped balloon (pear) or a Janet syringe with a rubber tube, 50-100 ml of the prescribed substance (hypertonic solution, oil or emulsion), heated in a water bath, thermometer, gas, oilcloth with a diaper, napkin, spatula, Vaseline , mask, gloves, containers with disinfectant solutions.
Procedure to complete:
1. Prepare for the procedure: wash your hands thoroughly with soap and running water, put on a mask and gloves.
2. Draw the prepared substance into the bulb (or Janet’s syringe). Remove any remaining air from the solution container.
3. Invite the patient to lie on the edge of the bed on his left side, bending his knees and bringing them to his stomach to relax the abdominal press.
4. Place an oilcloth with a diaper under the patient.
5. Lubricate the narrow end of the pear with Vaseline using a spatula.
6. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the pear into the anus to a depth of 10-12 cm.
7. Slowly squeezing the rubber bulb, introduce its contents.
8. Holding the bulb with your left hand, squeeze it with your right hand from top to bottom, squeezing the remaining solution into the rectum.
9. Holding a napkin at the anus, carefully remove the bulb from the rectum, wipe the skin with the napkin in the direction from front to back (from the perineum to the anus).
10. Close the patient’s buttocks tightly, remove the oilcloth and diaper.
11. Place the pear-shaped balloon (Zhanet syringe) in a container with a disinfectant solution.
12. Remove the mask, gloves, wash your hands.
If a rubber tube is used to perform a laxative enema, you should lubricate it with Vaseline for 15 cm, insert it into the anus to a depth of 10-12 cm and, attaching a filled pear-shaped balloon (or a Janet syringe) to the tube, slowly inject its contents. Then it is necessary to disconnect, without unclenching, the pear-shaped balloon from the tube and. holding the tube with your left hand, squeeze it with your right hand in the “top to bottom” direction, squeezing out the remaining solution into the rectum.
Medicinal enema
A medicinal enema is prescribed in two cases:
For the purpose of direct (local) effect on the intestines: administration of the drug directly into the intestines helps reduce the phenomena of irritation, inflammation and healing of erosions in the colon, and can relieve spasm of a certain area of the intestine. For local effects, medicinal enemas are usually given with chamomile decoction, sea buckthorn or rosehip oil, and antiseptic solutions.
For the purpose of general (resorptive) effects on the body; medications are well absorbed in the rectum through the hemorrhoidal veins and enter the inferior vena cava, bypassing the liver. Most often, painkillers, sedatives, hypnotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs are injected into the rectum.
Indications: local effect on the rectum, administration of drugs for the purpose of resorptive effect; convulsions, sudden agitation.
Contraindications: acute inflammatory processes in the anal area.
30 minutes before the procedure, the patient is given a cleansing enema. Basically, medicinal enemas are microenemas - the amount of substance administered does not, as a rule, exceed 50-100 m. The medicinal solution should be heated in a water bath to 39-40 ° C; otherwise, the colder temperature will cause the urge to defecate, and the medicine will not be retained in the intestines. To prevent intestinal irritation, the drug should be administered with a sodium chloride solution or an enveloping agent (starch decoction) to suppress the urge to defecate. It is necessary to warn the patient that after a medicinal enema he must lie down for an hour.
A medicinal enema is given in the same way as a laxative one.
Nutrient enema (drip enema)
The use of nutritional enemas is limited, since only water, saline, glucose solution, alcohol and, to a minimal extent, amino acids are absorbed in the lower segment. A nutritional enema is just an additional method of introducing nutrients.
Indications: impaired swallowing, esophageal obstruction, severe acute infections, intoxication and poisoning.
Contraindications: general.
If a small amount of solution is administered (up to 200 ml), a nutritional enema is given 1-2 times a day. The solution must be heated to a temperature of 39-40 °C. The procedure for performing the procedure is no different from administering a medicinal enema.
To introduce a large amount of fluid into the body, a drip enema is used as the most gentle and quite effective method. Administered drop by drop and gradually absorbed, the large volume of injected solution does not stretch the intestines and does not increase intra-abdominal pressure. In this regard, increased peristalsis and the urge to defecate do not occur.
As a rule, a drip enema is given with a 0.85% sodium chloride solution, a 15% amino acid solution or a 5% glucose solution. The medicinal solution must be heated to a temperature of 39-40 °C. 30 minutes before administering a drip nutrient enema, it is necessary to administer a cleansing enema.
To perform a nutrient drip enema, a special system is used, consisting of the following elements:
· Esmarch's mug;
· two rubber tubes connected by a dropper;
· screw clamp (it is fixed on a rubber tube above the dropper);
· thick gastric tube.
Necessary equipment: a solution of the prescribed composition and temperature, a system for drip nutrient enema, a stand for hanging a mug, a thermometer for measuring the temperature of the liquid, oilcloth, a basin, a vessel, marked containers for “clean” and “dirty” intestinal tips, a spatula, Vaseline, overalls (bowl, medical gown, apron and disposable gloves), containers with disinfectant solution.
Procedure to complete:
1. Prepare for the procedure: wash your hands thoroughly with soap and warm running water, put on a mask, apron and gloves.
2. Pour the prepared solution into Esmarch’s mug.
3. Hang the mug on a tripod at a height of 1 m above the patient’s body level.
4. Open the clamp and fill the system.
5. Close the clamp when solution appears from the probe.
6. Help the patient take a position that is comfortable for him.
7. Take a small amount of Vaseline with a spatula and lubricate the ends of the probe with it.
8. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert a thick gastric tube into the anus to a depth of 20-30 cm.
9. Use the clamp to adjust the drop rate (60-80 drops per minute).
10. At the end of the procedure, close the tap and remove the probe, pressing the patient’s right buttock to the left so that fluid does not leak out of the rectum.
11. Disassemble the system and place it in a container with a disinfectant solution.
12. Remove the mask, apron, gloves, wash your hands.
The procedure lasts several hours, the patient can sleep during this time. The duty of the nurse is to constantly monitor the patient’s condition, maintain the rate of administration of drops and the temperature of the solution. To ensure a constant temperature of the injected liquid as it cools, Esmarch’s mug should be covered with heating pads.
Gas outlet pipe
A gas outlet tube is used to remove gases from the intestines during flatulence. The gas outlet tube is a rubber tube 40 cm long with an internal lumen diameter of 5-10 mm. The outer end of the tube is slightly widened, the inner end (which is inserted into the anus) is rounded. At the rounded end of the tube there are two holes on the side wall.
Indications: flatulence, intestinal atony.
Necessary equipment: sterile gas outlet tube, spatula, Vaseline, tray, vessel, oilcloth, diaper, napkins, gloves, container with disinfectant solution.
The order of the procedure (Fig. 10.7):
1, Prepare for the procedure: wash your hands thoroughly with soap and warm running water, put on a mask and gloves.
2. Ask the patient to lie on his left side closer to the edge of the bed and pull his legs towards his stomach.
3. Place an oilcloth under the patient’s buttocks, and lay a diaper on top of the oilcloth.
4. Place a vessel filled one third with water on a chair next to the patient.
5. Lubricate the rounded end of the tube with Vaseline for 20-30 cm using a spatula.
6. Bend the tube in the middle, holding the free end with the ring and little fingers of your right hand and grasping the rounded end like a writing pen.
7. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the gas outlet tube into the anus to a depth of 20-30 cm.
8. Lower the free end of the tube into the vessel and cover the patient with a blanket.
9. After an hour, carefully remove the gas outlet tube from the anus.
10.Place the gas outlet tube in a container with a disinfectant solution.
11. Toilet the anus (wipe with a damp cloth).
12.Remove gloves, mask, wash hands.
Rice. 10.7. Application of a gas outlet tube: a - type of gas outlet tube; b - insertion of a gas outlet tube; c - removal of gases using a gas outlet tube.
Siphon enema (performed by two people) Condition - the procedure is performed in the presence of a doctor
| STEPS | JUSTIFICATION |
| 1. Preparation for the procedure 1. Explain to the patient the essence and course of the upcoming procedure and obtain his consent to perform the procedure | Patient motivation to cooperate. Respect for patient rights to information |
| 2. Prepare equipment | Necessary condition for the procedure |
| 3. Wear gloves and apron | |
| 4. Lay an oilcloth on the sheet covering the couch so that it hangs into the basin, and lay a diaper on top of it. Ask or help the patient to lie on the couch on his left side. His legs should be bent at the knees and slightly brought towards his stomach | If the rectum does not retain water, water will drain into the pelvis. Anatomical feature of the location of the lower part of the large intestine. Facilitation of insertion of probe and water |
| 5. Lubricate the rounded end of the probe with Vaseline for 30-40 cm | Facilitating the insertion of a probe into the intestine, preventing the patient from experiencing unpleasant sensations |
| II. Performing the procedure 6. Spread the buttocks with fingers I and II of the left hand, insert the rounded end of the probe into the intestine with the right hand and move it to a depth of 30 - 40 cm | Provides the ability to effectively carry out the procedure |
| 7. Attach a funnel to the free end of the probe. Hold the funnel slightly inclined, at the level of the patient’s buttocks, and pour 1 liter of water into it from a jug. | Preventing air from entering the intestines |
| 8. Slowly raise the funnel to a height of 1 m. Invite the patient to breathe deeply. As soon as the water reaches the mouth of the funnel, lower it below the level of the buttocks, without pouring water out of it until the funnel is completely filled | Provides control over the flow of water into the intestines and its removal back |
| 9. Drain the water into the prepared container | |
| STEPS | JUSTIFICATION |
| 10. Repeat points 7-9, using 10 liters of water | Ensuring the effectiveness of the procedure |
| GP. Completion of the procedure 11. At the end of the procedure, disconnect the funnel and slowly progressively remove the probe from the intestine, wiping it with toilet paper | Patient safety is ensured The probe is mechanically cleaned |
| "12. Immerse used items in a container with disinfectant. Pour rinsing water down the drain | Ensuring infection safety |
| 13. Wipe the skin in the anal area with toilet paper from front to back (in women) if the patient is helpless. Wash the perineum | Prevention of urinary tract infection and perineal skin maceration |
| 14. Remove gloves and apron. Wash and dry your hands | Ensuring infection safety |
| 15. Help the patient get off the couch (or move him for transport) | Ensuring Patient Safety |
| 16. Make a record of the procedure and the patient’s reaction | Ensuring continuity of nursing care |
Hypertonic enema
12571 0
In acute NK, surgical and conservative treatment is carried out, taking into account both local changes in the intestine and abdominal cavity, and general pathophysiological changes in the body.
Conservative treatment is used according to strict indications: with dynamic NK, in the initial stages of some forms of mechanical NK, namely: a) with adhesive NK; b) in the initial stages of intussusception and volvulus of the sigmoid OC; c) in advanced cases of low obstructive obstruction OK [AA. Shalimov, V.F. Saenko, 1987], as well as in certain forms of obstructive (coprostasis, helminthic glomeruli, gallstones) obstruction.
In case of early hospitalization and the absence of obvious signs of mechanical NK, siphon enemas are performed, decompression of the upper gastrointestinal tract is performed, and if appropriate probes are available, the gastric contents are pumped out and the intestines are intubated. The so-called Smith, Edlich and Leonard steerable probes are especially effective for this purpose. A fibrogastroscope can be used to pass unguided probes through the pylorus. Hemodynamic disturbances in patients in this group are usually not pronounced, and to compensate for the loss of fluid and electrolytes, it is enough to administer 1.5-2 liters of saline solutions, and in case of frequent vomiting, in addition, 300-500 ml of plasma or its substitutes.
In patients with severe symptoms of intoxication (peritonitis with severe strangulation and obstructive NK), conservative treatment is contraindicated.
When carrying out conservative treatment, constant aspiration of gastric and intestinal contents, a siphon enema, and lumbar novocaine blockade according to A.V. are performed. Vishnevsky, ganglion blockers, symlatolytic and antispasmodic agents are used. These measures allow a number of patients to restore the motor function of the stomach and intestines when they are atony. Suction of gastric, especially intestinal contents is indicated for paralytic and partial obstructive NK, the presence of an inflammatory process in the abdominal cavity, adhesive NK, which is especially easy to decompress. For possible perforation of the intestine when the probe is in place for a long time and quickly removed, a very slow (50-60 cm/h) removal of the probe is recommended (V.I. Chernov et al, 1999).
Emptying the distal parts of the intestine is achieved using cleansing and siphon enemas. In order to stimulate intestinal motor function, bilateral lumbar (perinephric) novocaine blockade according to A.B. is widely used. Vishnevsky, which to a certain extent is a therapeutic and diagnostic tool that allows, in some cases, to differentiate mechanical NK from dynamic. An indicator of the effectiveness of conservative treatment is usually the restoration of intestinal patency and an improvement in the general condition of the patient. Restoration of intestinal patency is usually indicated by copious stools with the passage of large amounts of gas, a decrease in flatulence and pain.
When evacuating the contents of the stomach, duodenum and colon, good results are often obtained by a thin double-lumen probe with an inflatable rubber balloon mounted at its end (Miller-Abbott probe), a siphon enema, which allows, in case of obstructive tumor NK, to remove gases and intestinal contents beyond the narrowed area. Intravenous administration of polyionic and plasma-replacing solutions makes it possible to restore the bcc and eliminate hydroionic disorders. The introduction of only polyionic solutions and 5-10% glucose solutions leads to increased sequestration of fluid in the “third” space (due to high osmotic pressure in the intestinal lumen). Therefore, they must be used in combination with plasma and plasma replacement solutions.
It should be noted that in some cases, the passage of a small amount of gases and feces after an enema cannot have any particular diagnostic significance, since they can depart from the distal parts of the obstructed intestine, but the NC as such remains. If it is impossible to perform an enema, it can be assumed that the mechanical obstacle is located in the lower parts of the OC. It is possible to eliminate NK with conservative measures in 40-50% of patients with dynamic NK, adhesive disease, in whom the clinical picture is caused not by a mechanical obstacle, but mainly by a violation of intestinal motor function, in patients with coprostasis, intestinal obstruction with rough, indigestible food, etc.
Conservative treatment (gastric lavage, aspiration of duodenal and intestinal contents, siphon enemas, antispasmodics or anticholinesterase drugs) in the absence of a pronounced effect should be carried out for no more than 3-4 hours. If during this time conservative measures do not produce an effect, then NC is mechanical in nature and emergency surgery is indicated. Prolongation of this period is dangerous due to the possibility of developing irreversible changes in the intestines, abdominal cavity and vital organs. The effectiveness of conservative treatment can be determined by control RI of the abdominal organs; preservation of small intestinal levels usually indicates the lack of result of conservative therapy.
Absolute contraindications to the conservative method of treatment as the main one in the treatment of NK are signs of increasing intoxication and peritonitis.
The tactics should be different for patients delivered early, but in serious condition with obvious strangulation NK (rapid deterioration of hemodynamics, the presence of free fluid in the abdominal cavity, increasing leukocytosis, increased proteolytic activity of the blood).
In case of acute NK, even before surgery, a special correction of the water-electrolyte balance (WEB) is required, i.e. preoperative preparation is necessary. This issue is of particular importance in elderly and senile patients.
Preoperative preparation of these patients should be intensive and take minimal time. Imbalance of EBV disturbances (especially potassium) before surgery can be the cause of a number of complications that develop after surgical trauma (persistent intestinal paresis, acute dilatation of the stomach, atony of the bladder, general muscle adynamia, acidosis, alkalosis, pulmonary complications, decline in cardiovascular activity) [I.D. Ustinovskaya, 1971].
Unliquidated hydroelectrolyte disturbances in the preoperative period increase the risk. During the period of dynamic observation and diagnostic research, the patient should simultaneously be prepared for possible surgery. Preoperative preparation is carried out with intensive infusion therapy. Blood is taken for general analysis, determination of hematocrit, total protein, sodium, potassium and chloride content. If possible, the CBS indicators are examined. Preoperative preparation should not exceed 3-4 hours from the moment the patient is admitted to the hospital. The purpose of this preparation is to replenish the deficit of blood volume, remove the patient from a state of shock and correct pathophysiological disorders occurring in the internal environment of the patient’s body, and impaired functions of vital organs and systems.
Infusion therapy is carried out by administering albumin, plasma and colloidal plasma replacement fluids, macromolecular dextrans, isotonic sodium chloride solution mixed with an equal amount of 1.9% sodium lactate solution, glucose solution, electrolytes, vitamins, protein substitutes in a stream, preferably into two veins at once . To correct acidosis, use a 4% solution of sodium bicarbonate (250-300 ml), Trisbuffer. Its use is indicated for heart patients, as it contains little sodium. However, it should be noted that in case of an overdose, alkalosis, hyperkalemia, and hypotension occur.
In case of microcirculatory disorders, approximately half of the administered polyglucin is replaced with hemodez or rheopolyglucin. If a patient with nodulation or extensive volvulus of the tuberculosis is admitted 8-10 hours after the onset of the disease or later with the threat of bacterial shock, 200-300 mg of prednisolone is added to the administered fluids, bringing its total dose to 800-1000 mg/day.
At the same time, cardiac glycosides, ATP, cocarboxylase, and ascorbic acid are administered. It is recommended to administer the fluid under the control of central venous pressure (CVP), for which purpose a catheter is inserted into the subclavian vein immediately after admission.
In patients admitted in serious condition, but at a later stage (3-4 days and later), preoperative preparation should be much longer, since homeostasis disturbances in them depend not only on the severity of the process, but also on the greater extent of its duration . The time for preoperative preparation of such patients can reach up to 3-4 hours. In this case, a simple rule is used: each day of illness requires at least 1 hour of preoperative preparation [Yu.M. Pantsyrev, 1988]. This is an approximate rule; the preparation time is adjusted depending on the clinical picture, hemodynamic parameters, electrolyte composition of the blood plasma, etc. If there is a threat of intestinal necrosis, the preoperative preparation time is sharply reduced.
In patients delivered late, when the entire gastrointestinal tract located above the obstruction is significantly overstretched with liquid and gases, intestinal decompression is of great importance in preoperative preparation: first, the gastric contents are pumped out, then a probe for intestinal intubation is inserted through the nose, gradually moving it into distally and at the same time sucking out the intestinal contents.
It should be taken into account that the fluid deficit in the body on the 3-4th day of the disease can reach 6-8 liters or more, therefore the main therapeutic measure is the administration of large quantities of isotonic (Ringer's solution) or weakly hypertonic (1-1.5% - j) saline solutions and 5% glucose solution. After diuresis is restored, 150-200 ml of a 1% potassium chloride solution is added to the administered fluids. At low blood pressure, a polyglucin solution, plasma or albumin is added to saline solutions. Albumin is recommended to be administered at the end of preoperative preparation, since it easily diffuses into the lumen of the obstructed intestinal loop and, increasing the osmotic pressure there, promotes the transudation of fluid into its lumen. Thiamine or, better yet, cocarboxylase, ATP in large doses (up to 2 g), and cardiac glycosides are administered. After administering 1.5-2 liters of saline solutions, 300-500 ml of hemodez or rheopolyglucin are added to them. If renal function is not restored, it is advisable to administer the same amount of mannitol.
To judge the severity of dehydration and evaluate preoperative preparation, the time during which the patient did not take food or water is determined, and the amount of vomit and urine excreted over the last 24 hours is estimated. “Unnoticeable losses” should also be calculated based on the fact that they amount to 1-1.5 l/day for a person with an average body weight.
You should pay attention first of all to dry skin and CO, tissue turgor disorders. Important information is provided by the determination of hematocrit and, if possible, bcc. The loss of electrolytes is judged by the content of sodium, potassium and chlorides in the blood plasma, however, the administration of saline solutions should be started immediately after the patient’s admission, without waiting for test results, which are of great importance for further correction of infusion therapy, the effectiveness of which is also judged by the amount of secreted urine using an indwelling catheter inserted into the bladder. It should be 40-50 ml/h with full compensation of losses. Another sign of sufficiency of fluid administration is a decrease in the relative density of urine below 1020 and normalization of hematocrit values. With strangulation NK, the operation is performed against the background of infusion therapy, without waiting for complete compensation of the disturbed homeostasis. Delaying surgery for impending intestinal necrosis is a mistake.
A rough estimate of the amount of plasma lost can be given by changes in the amount of fluid evacuated from the abdominal cavity and strangulation loop of the intestine. With a light and light pink color of the liquid, the volume of lost plasma is approximately 1/3 of the volume of the evacuated liquid, with a dark red or brown color - from 1/2 to 1/3 of its volume. If plasma losses are small, they can be compensated by the introduction of plasma substitutes. In case of very large plasma losses (during strangulation of a significant part of the TC), plasma replacement fluids and plasma are administered in approximately equal volumes, with preference given to low molecular weight plasma substitutes (hemodee, rsopolyglucin, neocomlensan), especially in cases of severe microcirculation disorders. Compensation for cellular protein loss is not such an urgent task, and it is carried out in the postoperative period.
The approximate volume of red blood cells excluded from the circulating blood can be determined by the hemoglobin content in the abdominal cavity and the lumen of the intestinal strangulation loop. The resected intestinal loop also contains blood, the amount of which averages 40-60% of its mass. If calculations carried out in this way show that no more than 20% of the total mass of red blood cells is excluded from circulation (which contributes to the loss of 1 liter of blood for a person with average body weight), there is no need for blood transfusion and one can limit oneself to the introduction of plasma and its substitutes. In case of more massive loss of red blood cells, freshly citrated or canned blood of short-term storage is transfused (shelf life up to 3-4 days). The amount of blood transfused should be 1.5-2 times less than the volume of lost blood, and the amount of plasma and plasma substitutes should be correspondingly greater than the volume of plasma loss in order to create moderate hemodilution. This helps improve microcirculation.
Elimination of the source of shockogenic influences, metabolic and hemodynamic disorders, as well as the causes that give rise to them, serves as a reliable guarantee of a successful impact on protective reactions and improved treatment results. Depending on the nature of the homeostasis disturbance, various solutions are used. If the patient, along with symptoms of extracellular dehydration (nausea, vomiting, dry tongue and dry mouth without thirst, hypotension, frequent weak pulse, dizziness, headache, etc.), also has an increase in indicators indicating hemoconcentration, as well as a decrease in electrolytes, It is recommended to use a polyionic composition: glucose 15 g, sodium chloride 4.5 g, potassium chloride 3.7 g, calcium chloride 0.2 g and distilled water up to 500 ml in an amount of 1000-2000 ml. With normal or elevated sodium levels, but with a deficiency of only potassium, a mixture is used (which is a 5% glucose solution, 1 liter of which contains 7.4 g of potassium chloride, i.e. decinormal concentration), 1 ml of which contains 0.1 meq each of potassium and chlorine.
When replacing lost water and electrolytes before surgery, consideration should be given to administering fluids during and after surgery. If disturbances in water and electrolyte metabolism are combined with the development of metabolic acidosis, a 4.2% sodium bicarbonate solution is used; in case of respiratory acidosis, oxygen therapy is used. When using corrective mixtures, vitamins C and group B are additionally introduced, as well as insulin 1 unit per 3-4 g of glucose.
Potassium deficiency is eliminated by slow intravenous administration of Le Quesne solution in the AA modification. Krokhalev (3.0 potassium chloride, 2.0 sodium chloride per 1 liter of 3% glucose solution) in the amount of 1 liter. For better utilization of potassium by cells, a 40% glucose solution with insulin is administered.
To correct impaired protein metabolism, mixtures of free amino acids are used in ratios corresponding to those in the blood of a healthy person.
To replenish energy reserves, add 100 ml of a 40% glucose solution with insulin to both solutions.
At all costs, one should not strive to fully compensate for all the fluid and electrolytes lost by the body before surgery, as this may be associated with an unreasonably long delay in surgical intervention, and too rapid administration of large quantities of solutions can lead to dangerous overload of the heart, especially in persons elderly and senile age.
With ongoing preoperative preparation, 2-3 hours is enough to administer 1-1.5 liters. The remaining amount required for full compensation must be administered during and after surgery.
When replenishing fluid losses in cardiac patients, as well as in any case when intravenously administering large amounts of fluid (over 200 ml/h), the patient should be auscultated every 30 minutes in order to promptly recognize congestive wheezing in the lungs and reduce the rate of administration.
To determine the required rate of introduction of solutions, you can use the following approximate formula:
(Number of milliliters of liquid)/(4 x number of hours before surgery)=Number of drops per minute
The effectiveness of the measures taken can be judged by the level and improvement of pulse filling, an increase in blood pressure, an increase in the amount of urine excreted (40-50 ml/h with a specific gravity below 1020), and a decrease in hematocrit. It is recommended to administer saline solutions under the supervision of a urine test until the amount of chlorine in the urine becomes normal. This will indicate sufficient compensation for sodium losses, although the latter do not exactly coincide with chlorine losses, but generally correspond to them.
There is a more accurate way to determine chlorine deficiency: chlorine, as an extracellular ion, is distributed in the extracellular fluid, which makes up about 20% of all body fluids. The chlorine content in extracellular fluid is on average 10 3 meq/l. Thus, the total amount of chlorine is 10 3 x 20% of body weight. Based on these data, chlorine deficiency can be calculated using the formula (Alder, 1960):
Chlorine deficiency = (Body weight (kg) x 10 3 mEq/l)/5
To this number should also be added chlorides, corresponding to the extracellular part of the water, which is introduced to cover the deficiency. Extracellular water makes up about 1/3 of the total body water. Thus, a more accurate formula can be represented as follows:
Amount of chlorine required for replacement (meq) = (Body weight (kg) x 10 3 meq/l)/5 + (Estimated water deficit (l))/3
If there are no signs of hypokalemia (electrocardiogram (ECG)), the amount contained in the administered Ringer's solution before surgery is sufficient. In addition, effective compensation for potassium deficiency can be carried out only if the kidneys have good function and the amount of urine excreted is normal, since potassium is absorbed relatively slowly by cells, and the accumulation of its excess amount in the blood plasma can lead to deterioration in activity and even cardiac arrest.
At very late stages of admission of patients (4-5 days and later), in whom, as a result of “imperceptible” losses, relatively more fluid is lost than electrolytes, the concentration of the latter in body fluids, despite the losses, may increase, and, therefore, dehydration will become hypertonic (cellular). In such cases, pronounced metabolic acidosis is always observed. Treatment should begin with the administration of isotonic solutions of glucose and bicarbonate or sodium lactate, followed by an infusion of plasma, and only later, when diuresis begins to recover, isotonic saline solutions are administered.
With strangulation NK, fluid losses are very significant and can occur in a short time. Plasma losses are also much greater than with obstructive NK, and unlike the latter, a significant volume of red blood cells are often excluded from circulation due to their deposition in the wall and lumen of the strangulated intestinal loop and sweating into the abdominal cavity (which gives the transudate a hemorrhagic character).
During preoperative preparation, oxygen therapy is carried out, cardiac and painkillers (promedol, fentanyl) are administered.
The operation is performed under combined endotracheal surface anesthesia with nitrous oxide with the use of depolarizing muscle relaxants. To avoid possible regurgitation, it is necessary to empty the stomach before surgery. The increased sensitivity of patients with NK to barbiturates and muscle relaxants should also be taken into account. This type of anesthesia provides a sufficient depth of anesthesia and good relaxation of the abdominal wall muscles.
The surgical approach for NK should create the most favorable conditions for revision of the abdominal cavity not only manually, but also visually, determining the level of the obstacle and performing the necessary intervention. More often, a wide mid-median laparotomy is used, in which the incision can be extended upward or downward, depending on the nature of the detected pathology. This incision allows you to perform a full revision with the least trauma and more quickly and perform the entire required volume of the operation.
When a patient is admitted in the early stages of the disease, when there is still no sharp intestinal bloating, it is not difficult to establish the location and nature of NK and it can be eliminated quite easily without resorting to intestinal eventration. The intestinal loops adjacent to the wound are removed into the wound and 100-150 ml of 0.25% novocaine are injected at the root of its mesentery. The same is done with the transverse mesentery and in the solar plexus area. Such a blockade allows you to remove afferent impulses, which do not stop under the influence of anesthesia. It prevents the development of shock during surgery. After the novocaine blockade, the effusion present in the abdominal cavity is removed and an inspection of the intestine begins. The location of the NK is usually determined by the state of the strangulated intestinal loops: above the obstacle they are swollen, below - collapsed. It is best to begin the inspection of the intestine from the ileocecal angle. Often, such a revision and identification of NK sites are difficult due to severe intestinal bloating. When the obstruction is localized in the colon, the colon is usually sharply swollen. This sign is very characteristic, and having discovered it, you should immediately begin to audit the OK. If there is pathology in the OC itself or in the final section of the ileum, the cause of obstruction is detected immediately. At the same time, measures are taken to prevent cooling and drying of the intestinal loops.
Moving from the ileocecal angle up along the TC, they reach the site of the obstacle. In case of sudden bloating and overflow of contents, the intestines should be emptied first. This significantly reduces the trauma of the operation and makes it easier to perform. In addition, removal of the contents of the distended intestine (decompression) contributes to the early restoration of the tone of the intestinal wall, its blood supply, reduction of intraintestinal pressure, early restoration of peristalsis and resolution of the phenomena of postoperative paralytic NK.
To empty the intestines of stagnant contents, closed methods (transnasal) of TB intubation with a probe with multiple holes are often used, while simultaneous suction of stagnant contents (Figure 4) already on the operating table. Similar decompression is continued in the postoperative period. In the absence of a long special probe, you can use a regular probe inserted into the stomach or into the initial part of the colon.
Figure 4. Transnasal intubation of TB
In some cases, if it is impossible to use a closed method, there is a danger of intestinal rupture, they resort to entrostomy or bowel evacuation through a gestrostomy. Bowel emptying by enterotomy is performed through the collapsed intestine, i.e. below the obstacle. When the intestine is necrotically changed, its distal segment is taken out of the surgical field and the proximal segment is crossed through it within healthy tissues and the part of the intestine to be resected is removed.
Decompression of the stomach and upper intestines is recommended to be performed both during surgery and in the postoperative period, also with the help of a special probe inserted through a gastrostomy (Yu.M. Dederer, 1971), to empty the intestinal loops, as with cecostomy (D.A. Arapov and V.V. Umansky, 1971).
The main objective of surgical intervention is to eliminate a mechanical obstruction or create a bypass for intestinal contents. The nature of the measures taken depends on the causes of obstruction, the condition of the intestines and the patient. In case of small intestinal obstruction, one should strive for complete elimination of the cause, up to intestinal resection with the imposition of an interintestinal anastomosis (dissection of adhesions, intestinal resection for a tumor, intestinal dissection with removal of gallstones, etc.). This rule does not apply to colonic obstruction, in the treatment of which the simultaneous application of an interintestinal anastomosis leads to insufficient sutures and the development of peritonitis. Only if the tumor is located on the right side, obstructing the OC, in young patients with unadvanced NC, right-sided hemicolectomy with ileotransverse anastomosis is considered acceptable (Figure 5). In other cases, two-stage and three-stage operations are considered more appropriate. A two-stage operation - resection of the intestine bearing the tumor, with the imposition of an unnatural anus (AP) on the adducting loop, the second stage is an anastomosis between the adducting and efferent loops.
Figure 5. Right hemicolectomy (scheme): a - boundaries of intestinal resection (shaded); b — ileotranseverzoanastomosis is applied
Three-stage operation - unloading cecostoma or unnatural ZP proximal to the site of obstruction; resection of the OC area with the tumor with interintestinal anastomosis; closed cecostomas.
If there is a constriction of the intestine with adhesions or cords, it is eliminated by dissecting it. When the intestine is constricted by a soldered appendix (40), an ileal diverticulum, or a fallopian tube, the adhesions are cut at the apex of these organs so as not to open their lumen. During volvulus, the intestine and its mesentery are devalued (turned) in the direction opposite to the direction of volvulus. In some cases (volvulus of the sigmoid colon, cecum), detorsion is supplemented with fixation surgery. In case of volvulus of the sigmoid OK and gross changes in its walls, it is recommended to perform a two-stage resection of the intestine. In the first stage, the corresponding section of the intestine is removed and the unnatural gastrointestinal tract is ground up; in the second stage, it is eliminated.
For PC caused by gallstones, an enterotomy is performed, the stone is removed and the intestinal incision is sutured.
After eliminating the obstacle, the state of viability of the affected intestinal loop is assessed, but if it is clearly non-viable, its resection is carried out even before the obstacle is eliminated. In this case, first of all, it is necessary to bandage or at least immediately clamp the vessels of the mesentery. This should be done in order to avoid the entry of toxic substances flowing from the strangulation loop of the intestine.
If the viability of the intestine is impaired and its obvious necrosis, intestinal resection is performed (Figure 6). It should be remembered that intestinal necrosis begins with CO and its signs in the serous membrane may be absent. To determine the viability of the intestine, a number of techniques are used. When warmed, the intestine that has changed its appearance, if viable, usually turns pink, peristalsis and a distinct pulsation of blood vessels appear. The peritoneum of a viable intestine is usually shiny. To more quickly identify the latter, 0.2-0.3 ml of a 0.01% solution of acetylcholine 1:10 can be injected into the mesentery of a questionable area of the intestine.
Figure 6. TB resection:
a — intersection of the mesentery, its wedge-shaped resection; b — intersection of the intestine between the clamps; c — formation of an end-to-end anastomosis; d — final view of the small intestinal anastomosis
A viable intestine reacts with the rapid appearance of vigorous peristalsis [V.V. Ivanov, 1966]. For this purpose, transillumination is used - luminescent research (M.Z. Seagal, 1973). Intestinal viability is determined using local intestinal thermometry by the difference in temperature between healthy and altered intestines. A temperature difference of more than 2 o C indicates deep damage to the intestinal wall (K.Ya. Chuprakova and L.A. Kozmina, 1973).
To determine the viability of the intestinal wall, the “wet paper” symptom is used: if, after the formation of a fold from the intestinal wall, it does not straighten out, then it is considered that the intestinal loop is not viable.
In all cases, if there is suspicion of intestinal wall nonviability, it is recommended to perform its resection.
When a knot is formed between the thin and sigmoid OC, the knot is untied after the sigmoid OC is emptied using a puncture. If it is not possible to untie the knot between the loops of the colon, then there is a need to dissect the intestinal loop that formed the knot and release the strangulated intestinal loop, and then restore the integrity of the dissected intestine.
If intussusception is present, disinvagination is performed (Figure 7). After this, it may be necessary to fix the intestinal wall to the anterolateral abdominal wall with interrupted sutures. If it is impossible to perform disinvagination or the inserted intestine is necrotic, intestinal resection is performed.
Figure 7. Disinvagination: a - conventional method; b - according to Hutchinson; c - according to Feldman
With obstructive NC, an obstacle obstructing the intestinal lumen is eliminated (dissection of adhesions that caused obstruction). During resection, it is necessary to dissect the intestine proximally from the obstacle at a distance of 20-30 cm. A large amount of liquid content accumulated in the intestinal lumen must be emptied. The significance of the latter is significantly great in terms of reducing intoxication, eliminating pressure on the intestinal wall and restoring its tone. For this purpose, a purse-string suture is placed on the opposite edge of the mesenteric attachment or the intestinal lumen is opened in its center. A glass tube with a diameter of 10-12 mm and a length of about 15 cm is inserted into the lumen of the latter. A rubber tube is attached to the glass tube. The purse string suture is tightened around the tube, but not tied. The assistant helps to empty the intestinal contents without putting unnecessary pressure on it.
After emptying the intestinal contents, the tube is removed from the lumen, the purse-string suture is tied and several interrupted sutures are placed on top. A number of authors recommend that in particularly severe cases, enterostomy be performed in one or more places.
Bowel resection should be performed within healthy tissue. In this case, the adductor knee is resected over a long distance - up to 50 cm from the area of necrosis, the abductor - up to 20 cm. In case of extensive intestinal necrosis, Trasylol is administered during surgery for 1-2 days of the postoperative period.
Anastomosis after intestinal resection is best done end-to-end (A.A. Shalimov, V.F. Saenko, 1987). When resection of necrotic intestine, the necrotic mesentery should also be removed, since leaving it can cause peritonitis and death. Peritonitis and the patient's serious condition are not a contraindication to resection of non-viable intestine. In cases of NK caused by inflammatory infiltrates and a powerful adhesive process, bypass anastomoses are performed. After completion of the operation, the abdominal cavity is drained, irrigated with an antibiotic solution (intraoperative sanitation) and tightly sutured. If indicated, the abdominal cavity is drained to drain exudate and administer antibiotics in the postoperative period. Intraoperative unloading of the dilated section of the intestine helps restore microcirculation in the intestinal wall, its tone and peristalsis. Unloading of the dilated segment can be achieved by transnasally introducing perforated probes into the TC during surgery or introducing similar probes through a gastro- or cecostomy (Figure 8, 9).
Figure 8. Intubation of TB through a gastrostomy tube
Figure 9. Intubation of TB through a cecostomy
In the postoperative period, a set of therapeutic measures is carried out aimed at preventing and removing the patient from a state of shock, correcting disorders of water-salt and protein metabolism, preventing and treating complications. Active infusion therapy is carried out until stable improvement in the patient's condition. In the first days, the stomach and upper intestines are emptied with a nasointestinal tube. In case of severe TB paresis, an enterostomy was traditionally placed in one or several places. In recent years, our observations show that intraoperative nasointestinal intubation makes it possible, even on the operating table, to quickly empty the intestines of putrefactive contents and gases, restore the tone of the intestinal wall, improve its blood circulation and motor function. Our experience shows that intraoperative nasointestinal intubation is a fairly effective means of eliminating intoxication of the body and restoring intestinal motility.
In the postoperative period, the patient is constantly monitored, hemodynamic parameters are determined, and daily fluid loss is measured (the amount of fluid released from the stomach and intestines through an endotracheal tube, with vomiting, etc.).
The main objectives of treating patients with NK after surgery are:
1) restoration of changes in the internal environment of the body and maintenance of its normal composition;
2) accurate compensation and maintenance of the normal volume of intracellular, extracellular fluid and circulating blood in general by calculating external losses (vomiting) and internal movements (transudation into the abdominal cavity and intestinal lumen), as well as “imperceptible” losses under the control of diuresis;
3) restoration of the body’s electrolyte balance;
4) compensation of protein losses by transfusion of plasma and protein preparations;
5) elimination of violations of the WWTP;
6) improving the function of vital organs;
7) restoration of bcc;
8) elimination of hemomicrocirculation disorders and improvement of the rheological properties of blood;
9) combating pain shock (drugs, analgesics);
10) prevention of hypoxia, anoxia and cerebral edema - oxygen therapy and plasma transfusion;
11) maintaining liver function by infusion of glucose solutions with insulin, administration of vitamins, glutamic acid, proteins in an easily digestible form;
12) restoration of the amount of fluid in the body and oncotic pressure of the blood;
13) improvement of blood supply to the kidneys, precise control of diuresis;
14) combating intoxication (detoxification) by introducing broad-spectrum antibiotics into the abdominal cavity, intestinal lumen and parenterally, carefully removing transudate from the abdominal cavity, treating intestinal loops;
15) combating overdistension of intestinal loops and restoration of intestinal motility by evacuation of intestinal contents during surgery, intestinal decompression in the postoperative period by constant suction of gastric contents, stimulation of its motor function;
16) parenteral nutrition;
17) decrease in blood proteolytic activity;
18) stimulation of the body’s immunoactive forces.
All these therapeutic measures must be individualized in accordance with the characteristics of the course of the disease in a given form and in a given patient.
Very diverse processes occur in the body of one and the same patient, and accordingly, treatment should be comprehensive. To fulfill both requirements - an individual approach and complexity, it is necessary to know the nature of the processes occurring in the body of a given patient and be able to evaluate them quantitatively.
It is necessary in each specific case to know and be able to calculate how much of a particular solution should be administered, what is preferable to transfuse in this case - plasma, glucose or salt solutions, isotonic or hypertonic solutions, etc. The variety of disorders that occur in the patient’s body as a result of NK can be divided into the following main groups:
1) loss of the most important components of the human body - water, electrolytes, plasma, cellular protein, red blood cells, leading to disruption of homeostasis;
2) discoordination of regulatory mechanisms - nervous endocrine system, enzymatic processes;
3) dystrophic processes in the cells of vital organs, developing as a result of intoxication and disruption of the composition of the internal environment of the body.
Advances in the treatment of NK, achieved in recent years, are largely associated with the restoration of homeostasis, replenishment of losses of fluid, proteins and electrolytes. Recently, in connection with the development of our knowledge regarding the nature of disorders of the internal environment of the body, intensive therapy measures aimed at correcting regulatory mechanisms are becoming increasingly important. Modern methods of studying the nature of changes in the internal environment of the body help to accurately assess the nature of the pathological processes occurring in the patient’s body. However, most of these methods require a certain period of time, complex equipment and therefore are of little use in emergency surgery, especially in regional conditions. Based on this, you can use simple methods for quantitative assessment of disturbances in the volume of water, salts, proteins, changes in blood volume, etc., which can help the surgeon develop the correct treatment plan.
For example, knowledge of the clinic, the symptomatology of dyshydria and blood and urine tests are sufficient to determine the form of dehydration. The significance of this is very great, since intensive care measures that are life-saving in one form of dehydration can be harmful or even disastrous in another. In the late stage of the disease, compensation for impairment of CBS becomes of certain importance. Here it is necessary to know exactly the nature of the changes occurring, since therapeutic measures for acidosis (observed in most cases in the later stages of the disease) and alkalosis are diametrically opposed. In the late stages of acute NK, metabolic acidosis is observed in the vast majority of cases. When compensating for losses of water and electrolytes, the use of adrenal cortex preparations involved in the regulation of water-salt metabolism may be important.
These drugs can be administered in the postoperative period only according to strict indications, when there is indeed convincing evidence of depletion of the function of the adrenal cortex. On the other hand, glucocorticoids improve hemodynamic parameters during shock, as they contribute to the compaction of walls, capillaries and a decrease in their permeability, enhance the response of smooth muscle elements of blood vessels to pressor impulses and norepinephrine, and normalize the electrolyte exchange of the myocardium and the vascular wall (Yu.M. Dederer, 1971) .
Protein losses must be urgently compensated, for which it is recommended to transfuse liquids containing plasma proteins or solutions of large-molecular plasma substitutes. Compensation for their losses, which is not as urgent as compensation for losses of intracellular proteins, consists of parenteral administration of solutions of amino acids, protein hydrolysates and oral administration of proteins with food. Due to the fact that extracellular proteins are lost mainly as a result of transudation into the abdominal cavity, lumen and wall of the obstructed loop, these losses can be approximately estimated by measuring the volume of transudate in the abdominal cavity, the contents of the obstructive (or strangulation) loop and determining the percentage of protein in them. You can use an approximate calculation based on the average protein content in the transudate: light or pink transudate contains 2-3% protein; with dark hemorrhagic coloring, the protein content in it increases to 4-5%. The loss of cellular protein should be compensated based on the fact that a person’s daily protein requirement is on average 100-120 g.
When plasma proteins are lost, the most urgent task is to eliminate hemodynamic disorders, primarily by normalizing oncotic pressure and, consequently, restoring volume.
For this purpose, only colloidal solutions of large molecular compounds that can provide sufficient CODE can be used. In addition to plasma and blood serum, solutions of large-molecular plasma substitutes of a non-protein nature (polyglucin, dextran) can also be used. These substances perform the function of maintaining oncotic pressure. Losses of extracellular protein (plasma) must be urgently compensated even before surgery, since a decrease in blood volume predisposes to shock.
Compensation for intracellular protein losses is carried out by parenteral administration of solutions of amino acids, protein hydrolysates and oral administration of proteins.
To cover the loss of extracellular protein, it is necessary to transfuse plasma or serum in an amount of at least half the volume of fluid evacuated from the intestinal lumen and abdominal cavity.
To cover the body's minimum need for protein consumed as a result of metabolic processes, the introduction of 300-400 ml of plasma per day is sufficient.
Replacement of extracellular protein is especially important in the preoperative period and during surgery, when it is necessary to quickly eliminate hemodynamic disturbances, restore bcc and retain fluid in the vascular bed by increasing oncotic pressure [Yu.M. Dederer, 1971]. In the postoperative period, the loss of proteins due to transudation processes is practically not observed; proteins are lost during natural metabolic processes, and therefore their parenteral administration can be stopped when intestinal function is restored and it becomes possible to administer them with food.
When deciding on the amount of plasma to be transfused to a patient with NK, it is necessary to take into account both the duration of the disease and the general condition of the patient. The above rules are useful as a guide for determining the loss of extracellular protein when circumstances do not allow resorting to more complex research methods.
With strantulation forms of NK, a significant decrease in blood volume is also observed, which leads to severe hemodynamic disturbances. It has been established (Yu.M. Dederer, 1971) that BCC in strangulation forms can decrease by 30% or more.
Losses of water and electrolytes during NK must be quickly and adequately compensated. At the same time, it is important to know the nature of dehydration developing during acute NK, since therapeutic measures for different types of the latter are not the same.
It is necessary to solve two main questions: 1) how much fluid the patient has lost and 2) what solutions and in what ratios need to be administered.
In elderly and senile patients, the introduction of fluid into the bloodstream causes additional stress on the heart if a large volume is administered quickly, without taking into account the individual characteristics of the state of the cardiovascular system. In each specific observation, the question of choosing an infusion medium or optimal combinations of several media, the volume of liquid, its distribution in time and the sequence of administration is decided individually. The rate of administration of solutions in patients with severe impairment of cardiac contractile function should not exceed 60 drops/min.
With the initial hypohemodynamic type of circulatory disorder, it is considered advisable to administer drugs in the following sequence: glucose solutions, protein drugs, saline solutions. In cases of pronounced hyperdynamic blood circulation, infusion therapy begins with saline solutions, then glucose solutions and protein preparations are introduced.
To normalize hemomicrocirculation and improve metabolic acidosis, it is advisable to achieve moderate hemodilution (hematocrit 35) and warm the injected solutions to body temperature.
Colloidal solutions and protein preparations (plasma, albumin, protein) in combination with crystalloids are effective in eliminating hypovolemia. When the phenomena of extracellular hypohydration predominate, sodium chloride solutions with a limited infusion of glucose are used, which is administered only after compensation of the osmotic deficiency in the extracellular fluid. If the phenomena of cellular hypohydration predominate, infusion therapy should begin with the introduction of iso- or hypotonic glucose solutions to replenish water losses.
Correction of hydroionic disorders must meet the following requirements: 1) replenishment of the loss of intracellular fluid; 2) restoration of the total amount of water, primarily in the intracellular space; E) combined replenishment of fluid loss in the extracellular space and electrolyte deficiency.
For replacement therapy, the following is necessary: a) a basal solution to replace water losses (glucose, fructose solution); b) the main solution to compensate for the loss of water and electrolytes, Rinter-Lactate solution; c) three solutions to compensate for the loss of electrolytes: sodium chloride, sodium lactate, potassium chloride.
When the electrolyte composition is normalized using a solution of potassium chloride, the CBS stops.
Compensation for the disturbed sodium balance is carried out in accordance with the level of sodium in the plasma.
While diuresis remains negative in the postoperative period, potassium administration should be abstained, but if diuresis is sufficient, on the contrary, potassium administration should be given importance.
To cover the body's energy costs, 600-1000 ml of 10%, 20% glucose solutions are administered with the addition of the required amount of insulin (1 unit of insulin per 4 g of glucose). To maintain myocardial metabolism, cocarboxylase, adenosine triphosphoric acid, vitamin preparations, and cardiac glycosides are used.
The amount of glucose is limited to 1 liter based on the following considerations: the body loses fluid without loss of electrolytes through evaporation through the skin and during respiration. These losses amount to about 1 liter, the remaining losses (with urine, sweat, food juices) occur with the simultaneous loss of electrolytes and therefore must be replaced with saline solutions or other liquids containing electrolytes.
The amount of protein-containing fluids, as a rule, is about 20-25% of the total volume of fluid administered (until the patient begins to take protein-containing substances orally).
The remaining amount of fluid is administered in the form of polyelectrolyte isotonic saline solutions, the volume of which was 1.5-2 l/day in the first days after surgery. When the patient begins to drink, the amount of saline solution administered decreases. When suctioning the contents of the gastrointestinal tract by intubation, the amount of saline solutions increases according to the amount of evacuated contents.
For a more or less correct calculation of fluid and electrolyte losses, it is necessary to know the clinical signs of a particular condition. Signs of water intoxication are salivation, lacrimation, vomiting, diarrhea, skin swelling and signs of increased intracranial pressure (headache, disorientation, muscle twitching, bradycardia, hypertension). Signs of salt intoxication include anorexia, nausea, vomiting, hoarseness, subcutaneous edema, pulmonary edema, ascites, hydrothorax. General symptoms of salt deficiency: weakness, motor restlessness, “silence in the stomach,” and later peripheral vascular collapse. Since the above symptoms are partly nonspecific, it is highly desirable to determine the hematocrit, chloride and sodium content in the blood.
Adequate compensation for the loss of potassium ions is very important in the postoperative period. Its amount in digestive juices and sweat is 2-3 times greater than in plasma, so excessive loss of digestive juices through vomiting can lead to a significant deficiency of potassium in the body. This is also facilitated by sweating, which in some patients is quite profuse. In the postoperative period, when diuresis is normalized, potassium chloride is administered (2.5 g in 1 liter of isotonic glucose solution).
If the preoperative potassium deficiency was small and the postoperative period proceeds smoothly, this amount is sufficient to cover the minimum daily requirement. In cases where the patient is admitted late, as well as in the postoperative period, a significant amount of potassium is lost, which means that the amount of potassium chloride solution increases. Considering that digestive juices contain an average of 10 meq/l of potassium, 0.75 g of potassium chloride (250 ml of 0.3% solution) should be administered for each liter of evacuated contents.
Additionally, the amount of potassium that the patient is expected to have lost before surgery is administered. An average of 70-100 meq (2.7-4 g) of potassium is released from the body per day (Yu.M. Dederer, 1971); if the duration of the disease is 3 days and during this period the patient did not eat food and was not given potassium supplements, then the loss of potassium is at least 210 mEq (8.1 g), which corresponds to 15 g of potassium chloride. Given the presence of potassium reserves in the body and the danger of rapidly introducing too large quantities, these losses should be compensated gradually.
When administering potassium solutions, it is necessary to follow some rules: 1) diuresis is absolutely necessary - 40-50 mg eq/hour; 2) solutions should not contain more than 30-40 meq of potassium per liter; 3) maximum daily dose - 3 mEq per 1 kg of weight; 4) the maximum rate of administration is 20 mEq/h. Overdose can lead to cardiac arrest at serum levels of 7-14 mEq/L. Potassium overdose is best recognized by changes in the ECG (Yu.M. Dederer, 1971).
In the first days of the postoperative period, the most characteristic change in CBS is metabolic acidosis. In the future, especially with prolonged suction of intestinal contents, hypokalemic alkalosis may develop, which is explained by the loss of potassium in digestive juices and urine. In addition, increased secretion of the antidiuretic hormone aldosterone by the adrenal glands during a stressful situation also increases potassium excretion. Aldosterone sharply reduces sodium excretion and causes increased water resorption in the kidneys and contributes to a decrease in COD in the extracellular space (A.S. Sons and I.F. Lvov, 1966). The authors showed that with the introduction of mineralocorticoids, the amount of sodium in the blood serum increases significantly, which is the result of the mobilization of inactive sodium that does not participate in metabolism due to insufficient secretion of mineralocorticoids by the adrenal cortex (depletion of the adrenal cortex). In this regard, mineralocorticoids are also used in the complex of therapeutic measures for NK.
Glucose-electrolyte mixtures are also used to correct potassium levels. Up to 200-600 mmol of potassium is administered per day in the form of panangin and potassium chloride solutions.
Energy costs are replenished by using various combinations of glucose solutions and amino acids (2500-3000 cal).
In order to enhance the absorption of nitrogen from administered drugs, they should be combined with the administration of anabolic steroids, insulin, and a complex of vitamins.
Detoxification is carried out using antitoxic drugs and the method of forced diuresis. Normalization of CBS is carried out taking into account electrolyte shifts. Metabolic acidosis is corrected by the use of sodium bicarbonate, lactasol, trisamine; in case of metabolic alkalosis, potassium deficiency is compensated by introducing large doses of ascorbic acid, enzyme inhibitors (trasylol 300 thousand units/day or its analogues). To combat infection, along with the rational use of antibiotics, taking into account the sensitivity of the microflora, passive and active immunization is used. It is advisable to administer parenterally or orally solutions of potassium chloride in an amount adequate to the daily loss for 3-5 days after normalization of its content in plasma.
If there are signs of shock, colloidal solutions (about 15-20 ml/kg body weight) are administered to replace fluids, followed by electrolyte infusion solutions. If there are no signs of shock, therapy with electrolyte infusion solutions is started immediately.
It should be borne in mind that an excess amount of injected fluid, if it is not too large, does not pose any particular danger with normal kidney function, but it is undesirable in the presence of pathological changes in the kidneys or heart.
To calculate the total amount of fluid administered, add up the volume of vomit, urine (excreted from the onset of the disease), transudate, intestinal contents and “imperceptible” losses.
In cases where it is difficult to take into account fluid losses from the onset of the disease based on calculations, it is necessary to make a rough estimate based on the duration of the disease, the form of NK, clinical signs, and the severity of dehydration (dry skin and CO, blood pressure).
A simple, although not particularly accurate, calculation of fluid loss can be made based on the hematocrit, using the Vandall formula:
where G is the hematocrit indicator.
Control of the amount of urine excreted is very important, especially in the postoperative period. The production of a normal amount of urine per day (1400 ml) is a fairly reliable indicator of the adequacy of the amount of fluid administered. To do this, a catheter is inserted into the bladder and the amount of urine is measured every hour (normally 50-60 ml are released per hour).
It is necessary to accurately take into account the amount of fluid introduced and removed from the body. A patient weighing 70 kg should receive 3.5 liters of fluid per day plus the amount that he loses through drainage or vomiting.
Treatment of general dehydration consists of a combination of administration of basic solutions and glucose solutions. The administration of hypertonic solutions is strictly contraindicated, since even a temporary increase in osmotic pressure in the extracellular space will increase cellular dehydration and worsen the patient’s condition for some time [Yu.N. Dederer, 1971].
Adequate dosage of administered fluid and electrolytes can be carried out if their losses are known using modern methods for studying EBV. However, in patients with NK, in most cases, a significant part of laboratory tests cannot be carried out, since they take too much time, and in the 1-2 hours that the surgeon has at his disposal, he must not only assess the degree of loss of EBV solutions, but also have time to prepare the patient. In addition, these patients are often admitted at night when the laboratory is closed, and in most hospitals, especially in rural ones, EBV testing is usually not performed.
Thus, if for research work these studies are of undoubted value, then in practical work the surgeon has to rely on clinical data and some simple laboratory tests that can be performed in most medical institutions. In such cases, you should pay attention to the following points:
1) the patient’s complaints and medical history (thirst, nausea, frequency of vomiting, duration of the disease, amount of vomit, amount of urine);
2) examination data (skin turgor, CO dryness, pulse, blood pressure, NS disorders);
3) the amount of fluid taken in and excreted (urine, vomit, aspirated contents of the stomach and intestines);
4) hematocrit indicator;
5) the amount of protein in the blood plasma;
6) determination of the content of electrolytes in blood plasma;
7) determination of the content of electrolytes in urine and evacuated contents of the stomach and intestines.
To combat intoxication during NK, the following measures are proposed:
1) suppression of the vital activity of microflora located in the intestinal lumen and beyond, through local and general use of antibiotics and other antibacterial agents;
2) removal of toxic substances from the body by evacuation of transudate from the abdominal cavity and intestinal contents by abdominal dialysis, as well as treatment of the abdominal organs with surfactants;
3) the introduction of specific antitoxic serums, which, however, has not yet left the experimental stage;
4) nonspecific increase in the patient’s body’s resistance to toxic substances through the administration of adrenal hormones.
Due to the fact that toxic products are mainly exo- and endotoxins of microorganisms, suppressing the viability of the latter can help reduce intoxication. For this purpose, it is recommended to administer broad-spectrum antibiotics into the intestinal lumen through a tube. At the same time, intestinal decompression carried out with this technique helps prevent the development of microbes and necrobiotic processes in it.
Detoxification of the body is achieved by restoring normal diuresis. This requires adequate replacement of fluid losses. A good detoxification effect is provided by stimulation, forcing diuresis by administering Lasix (30-40 mg) with moderate hemodilution. Good adsorbents of toxins that promote their elimination by the kidneys are synthetic plasma expanders (reopolyglucin, neocomlensan, hemodez, neodez).
Hyperbaric oxygen therapy (HBO) and the administration of vitamins and glucose may be of some importance for normalizing the function of internal organs. The latter is especially necessary when infusions of cardiac muscle tonics are used as an energy resource.
The use of HBOT promotes earlier normalization of homeostasis parameters and restoration of intestinal function.
Oxygen therapy is carried out during the first 2-3 days after surgery. It brings significant benefits, reduces hypoxia, improves the absorption of gases in the intestines, and therefore reduces bloating. Oxygen therapy is delivered in a humidified form through a catheter. Oxygen barotherapy is very effective.
For patients in serious condition, in whom depletion of adrenal cortex function can be expected, 100-125 mg of hydrocortisone is added to the administered fluids within 2-4 days after surgery, reducing the dosage to 50 mg by the 3-4th day.
Cardiac medications are prescribed depending on the state of the heart and blood pressure. It is recommended to avoid the use of potent vasoconstrictors to avoid subsequent vascular collapse. If there are signs of decline in cardiac activity, intravenous infusions of strophanthin (injected as part of administered glucose solutions in small doses) and cordiamine (2 ml 3-4 times a day) are prescribed. To improve metabolic processes, vitamins B and C are administered parenterally (until intestinal function is normalized and, therefore, the patient can receive adequate nutrition).
If anuria develops, a lumbar novocaine blockade should be performed according to Vishnevsky, and mannitol should be administered (500-1000 ml of a 10% solution).
More than 1/4 of all complications developing in the postoperative period in patients undergoing surgery for acute NK are associated with infection. The most serious infectious complication of acute NK, often occurring even before surgery, is peritonitis, the prevention and treatment of which is one of the main tasks of the postoperative period. In this regard, it is necessary to carry out antibacterial therapy using the most powerful agents, such as antibiotics. In this case, permanent monitoring of the sensitivity of microbial flora to antibiotics should be considered an indispensable condition for the effectiveness of antibiotic therapy. Broad-spectrum antibiotics are usually used: aminoglycosides (monomycin, kanamycin, gentamicin) and semisynthetic penicillins (oxacillin, ampicillin, etc.), as well as cephalosporins (ceporin), which are administered intramuscularly, intravenously, endolymphatically, intraperitoneally.
To prevent thromboembolic complications, a set of measures is carried out: elastic compression of the veins of the lower extremities, active regimen, prescription of antiplatelet agents, direct and indirect anticoagulants.
To prevent the occasional thrombosis of small veins of the intestinal wall, heparinization is started (20-30 thousand units/day).
One of the features of the postoperative period in acute NK is the presence of intestinal paresis, therefore measures aimed at emptying the intestine, restoring its peristalsis and activating its motor function are important. Combating paresis and paralytic NK and stimulating intestinal motor function are an important task of the postoperative period.
Evacuation of contents from intestinal loops that are sharply overfilled with liquid and gases is an important stage of the operation. If the afferent loop is slightly swollen, then evacuation should not be carried out, and the contents of the strangulated intestinal loop are removed with the resected loop. Outdated techniques (for example, removal of one of the loops followed by enterotomy and evacuation of intestinal contents by “milking”), associated with violations of asepsis with traumatization of the intestinal loops, should not be used.
Intestinal decompression for the purpose of preventing and treating paresis is carried out using various methods. The most effective of them are those that ensure the evacuation, first of all, of intestinal contents from the upper intestines.
In order to restore the tone and motor function of the stomach and intestines in the postoperative period, continuous aspiration of gastrointestinal contents is performed.
Emptying the gastrointestinal tract is achieved by periodic gastric lavage using a thin nasogastric tube inserted into the stomach through the nose, or, which is much more effective, by constant aspiration with a thin probe using suction devices. Cleansing enemas help to empty the intestines and restore its tone. However, their use requires taking into account the nature of the operation. Inserting a gas tube may be effective.
A good drainage effect is observed when the sphincter is stretched at the end of the operation. In patients who are not undergoing resection of the OC, a siphon enema can be used.
Emptying the bowel with an endotracheal tube (nasointestinal intubation during surgery) is very effective.
Constant removal of stagnant intestinal contents with a probe reduces the effects of intoxication and improves its tone. In addition, constant intestinal decompression creates the most favorable conditions for restoring intestinal motility. When intestinal motility is restored and bowel noise appears, suction is stopped and the probe is removed.
The essence of intestinal intubation with a probe inserted transnasally or (if indicated) through a gastrostomy tube is that a rubber or plastic probe equipped with holes is passed through the nose or gastrostomy tube into the stomach, duodenum and colon. Passing the probe may present some difficulties. After the probe is passed into the area of the duodenum - the small intestinal flexure, its end may rest against the intestinal wall and it must be given the correct direction in this place. If a significant part or almost all of the TC is involved in the pathological process, the probe can be passed to the end of the TC. The last hole in the wall of the tube should be located in the antrum of the stomach. The insertion site of the probe into the stomach is sealed with several purse-string sutures or as with Witzel gastrostomy.
In cases where only the lower parts of the TC are overfilled with liquid and gases, it is considered advisable to pass the endotracheal tube through the cecostomy into the TC in the oral direction (see Figure 9).
If intestinal resection or enterotomy has been performed, or if there are signs of peritonitis, microirrigators are inserted into the abdominal cavity to administer antibiotics. The abdominal cavity is usually sutured tightly. After the operation is completed, the anal sphincter is stretched.
Of particular importance in the immediate postoperative period is parenteral nutrition, which is associated with limited oral intake of nutrients, increased breakdown of tissue protein and significant losses of nitrogen. Consequently, parenteral nutrition in the immediate postoperative period should be aimed, along with the correction of energy and water-salt metabolism, and at restoring a positive nitrogen balance (N.H. Malinovsky et al, 1974; A.B. Sudzhyan, 1991).
To ensure regular peristalsis, it is first necessary to correct the water and electrolyte balance.
Elimination of postoperative paresis or intestinal atony is also achieved by improving mesenteric circulation using hyperosmolar-hyperoncotic solutions at a rate of 8 ml/kg of body weight. In some cases, especially with established intestinal atony, it is considered necessary to repeat the infusion. This takes into account contraindications (heart failure, organic kidney damage, dehydration) and the risk of hyperosmolar coma. It should be remembered that all degrees of hypoproteinemia can lead to a decrease in gastrointestinal motility up to the development of paralytic NK.
In order to stimulate intestinal motility, ganglion-blocking agents are used - α and β-adrenergic blockers (dimecoline, etc.), which inhibit inhibitory efferent impulses in the ganglia and simultaneously stimulate the motility of the intestinal muscles [N.M. Baklykova, 1965; A.E. Norenberg-Charkviani, 1969].
Stimulation of peristalsis (and at the same time replenishment of chloride deficiency) is facilitated by the intravenous administration of 20-40 ml of 10% sodium chloride solution. A.P. Chepky et al. (1980) against the background of balanced transfusion therapy, the next day after surgery, 400-800 ml of a 15% sorbitol solution and 2-3 ml of 20% calcium pantothenate are prescribed. If there is no effect, aminazine is additionally administered a day later (0.2-0.3 ml of a 2.5% solution 3-4 times a day), followed by a cleansing enema.
This therapy continues for 3-4 days. The use of cholinesterase inhibitors to enhance parasympathetic innervation (1-2 ml of 0.05% proserin solution) and m-cholinergic drugs (aceclidine - 1-2 ml) with repeated cleansing and hypertonic enemas is indicated.
For early restoration of intestinal motor function, guanitidine, isobarine and ornid are used. Ornid is administered intravenously at 0.5-1 ml of a 5% solution.
Aminazine has great activity [Yu.L. Shalkov et al., 1980], which is used in 1 ml of 2.5% solution 2 times a day.
Leridural anesthesia has a good effect.
In cases of severe postoperative intestinal paresis, lumbar novocaine blockade according to Vishnevsky often gives a good therapeutic effect. Electrical stimulation is also used in the complex of therapeutic measures aimed at restoring the motor-evacuation function of the gastrointestinal tract. In the absence of mechanical causes and an increase in peritonitis, a positive effect is achieved after 4-5 sessions of electrical stimulation.
When signs of restoration of the motor, digestive and absorption functions of the intestine appear, enteral tube feeding is advisable, which reduces the number of complications associated with the need for long-term parenteral nutrition (complications during catheterization of large veins, allergic reactions, risk of infection). A nasojejunal probe can be used for this purpose.
In addition to the means used to stimulate intestinal motility, a necessary condition for restoring peristalsis is the normalization of metabolism, compensation for the deficiency of proteins, fluids and electrolytes, increasing the dose of administered vitamins, and the introduction of vikasol, against the background of which the effectiveness of other means increases [Yu.N.Dederer, 1971].
For the same purpose, adrenolytic drugs are prescribed (they are contraindicated when blood pressure decreases) or novocaine blockade, after which a 10% hypertonic solution of sodium chloride is infused intravenously (0.5 ml of a 10% solution per 1 kg of patient weight). The infusion can be repeated 2-3 times a day. After intravenous administration of sodium chloride, a siphon enema is performed 30 minutes later.
Stimulation of intestinal motility with drugs for severe paresis should be combined with constant suction of gastric contents or, which is much more effective, with intestinal intubation.
Nutrition of patients begins as soon as the evacuation function of the stomach and intestines is restored. In case of obstruction with significant distension of the intestinal loops, restoration of peristalsis occurs no earlier than after 3-4 days. In case of colonic obstructive obstruction, ileocecal intussusception, the motor function of the stomach and colon is usually not impaired. These patients are allowed to take liquid food the very next day after surgery.
After resection of the colon, if the remaining part of the intestine is functionally complete, it is allowed to drink the next day. In cases where a thin tube is inserted into the patient's intestines through the nose, drinking is allowed the next day after surgery. Another day, soft-boiled eggs, jelly, liquid semolina porridge, a small piece of butter, and broth are allowed. In the following days, it is necessary to provide a sufficient amount of protein in the diet of patients.
In acute NK, despite the progress achieved, mortality remains high and averages 13-18% (M.I. Kuzin, 1988).
The main reason for the high mortality rate is late hospitalization of patients and profound disorders of salt, water and protein metabolism, as well as intoxication, which develops as a result of the breakdown of intestinal contents and the formation of a large number of toxic substances. In this disease, the mortality rate is equal to the time (number of hours) that elapsed from the onset of the disease to surgery.
Timely hospitalization and early surgical intervention are the main guarantee for a favorable treatment outcome. According to statistics, mortality among patients with acute NK who were operated on in the first 6 hours is 3.5%, and among those operated on after 24 hours - 24.7% or more.
During a medical examination, almost every third patient is diagnosed with abnormalities in the functioning of the digestive system. If a patient complains of pain in the abdomen and anorectal area, persistent constipation, bleeding from the rectum, he experiences weight loss, unfavorable blood counts (low hemoglobin, high ESR), then an experienced coloproctologist will definitely prescribe colonoscopy examination of the intestines.
Colonoscopy is a modern instrumental research method used to diagnose pathological conditions of the colon and rectum. This procedure is carried out using a special device - a colonoscope, and allows you to visually assess the condition of the large intestine along its entire length (about 2 meters) in a matter of minutes.
A colonoscope is a flexible long probe, the end of which is equipped with a special illuminated eyepiece and a miniature video camera capable of transmitting an image to a monitor. The kit includes a tube for supplying air to the intestine and forceps intended for biopsy (sampling of histological material). Using a video camera, the device is capable of photographing those areas of the intestine through which the probe passes and displaying an enlarged image on the monitor screen.
This allows a specialist, a coloproctologist, to examine the intestinal mucosa in detail and see the smallest pathological changes. Colonoscopy is indispensable for timely detection and this procedure has many possibilities, which is why specialists prefer this study to other diagnostic methods.
Colonoscopy options
What opportunities does examination with a colonoscope provide?
The above possibilities make the colonoscopy procedure the most informative diagnostic method. It is performed in many public and private medical institutions. According to the recommendation of the WHO (World Health Organization), as a preventative measure, it is advisable for every patient over 40 to undergo a colonoscopy once every five years. If a person comes to the doctor with characteristic complaints, a study is prescribed without fail. What are the indications for this procedure?
Colonoscopy examination of the intestines is prescribed in the following cases:
In addition, a colonoscopy is performed in case of suspicion of Crohn's disease, ulcerative colitis and the presence of malignant tumors. The examination will help identify manifestations of diseases (ulceration of the mucous membrane), and if a tumor is detected, take a piece of tissue for a biopsy.
Contraindications to the examination
There are conditions in which colonoscopy is not advisable, as the procedure can lead to serious complications. Colonoscopy is not done in the following cases:
In such conditions, the risk to the patient’s health during the procedure is too high, so colonoscopy is replaced by other, alternative examination methods.
How to prepare for the procedure?
In order for the procedure to proceed without difficulties and complications, preliminary preparation is necessary. Preparation for intestinal colonoscopy includes two important points:
- following a slag-free diet,
- high-quality intestinal cleansing.
Diet before intestinal colonoscopy (correct menu)
It is clear that the procedure requires thorough and complete cleaning of the digestive tract. This is necessary in order to free the intestinal walls from toxins and remove feces, which will create obstacles during the advancement of the diagnostic probe. Preparatory activities should begin 2-3 days before the procedure. In this case, you do not need to fast, you just need to follow the doctor’s instructions and adhere to a special diet.
The following should be excluded from the diet:
All these products are difficult to digest or cause excessive gas formation in the intestines.
- Wheat bread made from wholemeal flour
- Lean boiled meat (beef, poultry) or fish
- Diet broths
- Dry biscuits (biscuits)
- Fermented milk drinks (kefir, yogurt, natural yogurt)
On the eve of the procedure, the last meal is allowed no later than 12:00. You can then drink liquids (water, tea) throughout the day. The last meal should be 20 hours before the start of the examination. On the day of the examination, it is forbidden to eat food; you can only drink weak tea or drinking water.
Further preparation for colonoscopy of the intestines involves cleansing the intestines. To do this, you can use one of two methods:
Cleansing with an enema
To ensure high-quality preparation, on the eve of the procedure and twice immediately before the examination.
The day before, it is better to cleanse the intestines in the evening, at intervals of one hour, for example at 20.00 and 21.00. For a cleansing enema, use 1.5 liters of distilled warm water. That is, in the evening, 3 liters of liquid are introduced into the intestines and washed until “clean” water comes out. In the morning, the intestines are also cleaned with an enema twice, with an interval of one hour. To facilitate cleansing, you can use mild laxatives or castor oil the day before the procedures.
Cleansing with modern drugs
In many cases, it is quite difficult to independently perform high-quality bowel cleansing with enemas, and sometimes very painful, especially for inflamed hemorrhoids. Special medications that facilitate and stimulate bowel movements come to the rescue. They should be taken one day before the procedure. Colon cleansing before colonoscopy can be done with the drug Fortance, which was created specifically for preparation for diagnostic studies.
The dosage of Fortanza will be individually calculated by the doctor, based on the patient’s body weight. The calculation is made from the ratio: one sachet per 20 kg of weight. So, if a patient weighs 80 kg, then to carry out a complete cleansing of the intestines, he needs 4 sachets of Fortrans. For one package you need to take one liter of warm boiled water. Thus dissolve all 4 packets. You should start taking the solution two hours after your last meal.
The entire prepared solution must be drunk, but this does not mean that you need to take 4 liters of solution at a time. It is recommended to pour the liquid with the dissolved drug into a glass and drink it in small sips, with breaks of 10-20 minutes. Thus, taking breaks between glasses with the solution, you should drink the entire volume of liquid in about 2-4 hours. It turns out that the intake rate will be approximately one hour per liter of solution.
If it is not possible to drink the entire volume of liquid, since a gag reflex may occur due to a not entirely pleasant taste, then you can divide it and drink 2 liters in the evening and another two liters in the morning. To make it easier to take, doctors advise drinking the solution in small sips, without holding it in your mouth so as not to feel the taste. Immediately after taking another glass, you can take a sip of lemon juice or suck on a piece of lemon, this will eliminate nausea.
After the last dose of Fortrans, defecation may continue for another 2-3 hours. Therefore, the time of use should be calculated correctly, and if you finish the remainder of the drug in the morning, then the last glass of the solution should be drunk 3-4 hours before the start of the colonoscopy procedure. The drug Fortans is not absorbed into the bloodstream and is excreted unchanged, so there is no need to fear an overdose.
In some cases, when using Fortrans, adverse reactions occur in the form of flatulence, abdominal discomfort or allergic manifestations.
Another effective drug that can be used to cleanse the intestines before a colonoscopy -
Lavacol. It is applied in the same way. The difference is that the sachet with the drug must be dissolved in a glass (200 ml) of boiled water. For complete cleansing, you need to drink 3 liters of solution, one glass every 20 minutes. This drug is easier to tolerate and has a salty taste, so side effects such as nausea and vomiting are rare. Recommended reception hours are from 14.00 to 19.00. Some abdominal discomfort may occur after the first doses of the drug.
These products are designed specifically for preparation for endoscopic examinations; they cleanse the intestines efficiently and gently, causing minimal inconvenience to the patient.
How is the colonoscopy procedure performed?
The procedure technique is simple. We will tell you about the main nuances so that the patient can imagine how an intestinal colonoscopy is performed.
Thus, the large intestine is visually examined throughout its entire length. If no serious pathologies are detected, the procedure takes about 15 minutes; diagnostic or therapeutic actions may require more time.
If a biopsy is necessary, local anesthetics are injected through a special channel of the endoscopic device, then a small piece of tissue is cut off and removed with special forceps.
During a colonoscopy, polyps or small benign formations can be removed by using a special loop to grab the growths at the base, cut them off and remove them from the intestine.
How painful is the procedure?
Many patients are concerned about the pain of the upcoming procedures. Before starting the procedure, the doctor must explain how an intestinal colonoscopy is performed and resolve the issue of pain relief. In many specialized clinics, the procedure is performed without anesthesia, since the manipulation usually does not cause severe pain.
The patient may feel some discomfort when pumping air to straighten the folds of the large intestine or when the diagnostic probe passes through some anatomical bends of the intestine. These moments are usually easily tolerated; doctors recommend listening to your body and if severe pain occurs, immediately inform the specialist performing the manipulation. This will help avoid complications such as damage to the intestinal wall. Sometimes during the procedure there may be a urge to defecate; at such moments, doctors recommend breathing correctly and deeply.
In special cases, when the patient has adhesive disease or acute inflammatory processes in the rectum, severe pain is possible during the procedure. In such a situation, a colonoscopy of the intestine is performed under anesthesia. Usually the anesthesia is short-term, since the procedure itself does not take more than 30 minutes.
There are several alternative research methods, these are:
But this procedure is still in many ways inferior to classical colonoscopy. It does not allow identifying pathological formations whose size is less than 10 mm. Therefore, in many cases, such an examination is preliminary and after it a classic colonoscopy procedure is necessary.
After the procedure: possible complications
During the examination, air is pumped into the intestinal cavity. When the procedure is completed, it is removed by suctioning with a colonoscope. But in some cases, an unpleasant feeling of discomfort and bloating remains. To eliminate these sensations, the patient is recommended to drink activated carbon, which is first dissolved in a glass of water. The patient is allowed to eat and drink immediately after the examination.
The procedure must be carried out in a specialized institution, by a competent and experienced specialist. If the manipulation is carried out according to all the rules, then this method is completely harmless and does not entail adverse consequences. However, as with any medical intervention, there is a risk of complications:
- Perforation of the intestinal walls. It is observed in approximately 1% of cases and most often occurs as a result of ulceration of the mucous membrane or purulent processes in the intestinal walls. In such cases, urgent surgical intervention is performed to restore the integrity of the damaged area.
- Bleeding in the intestines. This complication is quite rare and can occur both during and after the procedure. Eliminated by cauterization or injection of adrenaline.
- Abdominal pain after the procedure. Most often they appear after removal of polyps and are eliminated with analgesics.
The patient should urgently consult a doctor if, after the colonoscopy procedure, he has a fever, vomiting, nausea, dizziness, or weakness. If complications develop, loss of consciousness, bleeding from the rectum or bloody diarrhea may occur. All these manifestations require immediate medical attention. But such complications are rare; usually the procedure is successful and does not entail adverse consequences.
Colonoscopy is recommended for regular colonoscopy for people over 50 years of age. This makes it possible to detect colorectal cancer in the early stages of development and gives a chance to defeat the disease.
Price
The cost of examining the intestines using colonoscopy in Moscow depends on several factors: the level of the clinic or diagnostic center, equipment with modern equipment and the qualifications of endoscopists.
The average price for the procedure is in the range of 4500-7500 rubles. In some elite clinics, the cost of an examination can reach up to 18,000 rubles. If anesthesia is used, the procedure will be more expensive. In general, the price of the examination is quite reasonable and affordable for any patient.
The main purpose of the intestinal examination is to check for the presence of affected areas in order to assess the nature and extent of changes, as well as the presence of neoplasms. An intestinal examination using modern methods is carried out by a proctologist and provides the opportunity to assess the patient’s condition and make an accurate diagnosis.
Modern methods of intestinal diagnostics
Today, a proctologist uses a variety of diagnostic methods, with the help of which it is possible to conduct a large-scale study of pathologies of the colon, perineum and anal canal. Modern methods of intestinal diagnostics include:
- conducting a finger examination;
- anoscopy;
- endoscopic ultrasound examination;
- fibrocolonoscopy;
- irrigoscopy;
- sigmoidoscopy;
- performing laboratory stool analysis;
- probing of the small intestine.
Digital examination of the rectum
A digital examination of the rectum is indicated in the presence of abdominal pain and dysfunction of the intestines and pelvic organs. During the examination, the patient needs to push a little to relax the muscles.
Anoscopy
Anoscopy is a method of examining the rectum by examining its internal surface. For this, a special instrument is used - an anoscope, which is inserted into the rectum to a depth of 12-14 cm through the anus. Anoscopy is indicated if there are complaints of pain localized in the anus, discharge of blood, pus or mucus, bowel problems (constipation, diarrhea), or suspicion of rectal disease. Before anoscopy, preparation is necessary, which includes a cleansing enema performed after normal bowel movements, and abstinence from food until the examination.
Endoscopic ultrasound examination
During an endoscopic ultrasound examination, an ultrasound probe is inserted into the patient's rectum to the site where the tumor has formed. Using this sensor, with fairly high accuracy, it is possible to make a correct diagnosis, determine the depth of damage to the intestinal wall by a tumor, and metastases in neighboring organs surrounding the rectum. The study determines the condition of the peri-rectal lymph nodes.
Fibercolonoscopy
To perform fibrocolonoscopy, a long, thin and flexible endoscope is used, at the end of which a lens and a light source are located. The study consists of inserting the device along the entire length of the colon through the patient’s anus.
Irrigoscopy
Irrigoscopy is a method of x-ray examination of the colon, for which a special contrast agent is used. The results of the study allow us to evaluate the shape, length, location of the organ, extensibility and elasticity of the walls. With the help of irrigoscopy, it is possible to identify pathological changes in the relief of the mucous membrane of the colon and pathological neoplasms in it.
Sigmoidoscopy
Sigmoidoscopy refers to the examination of the rectum, for which a rigid tubular endoscope is used. Using sigmoidoscopy, the doctor evaluates the relief, color, elasticity of the mucous membrane, localization of pathological neoplasms and motor function of the rectum.
Laboratory analysis of stool
Probing of the small intestine
To probe the small intestine, a three-channel probe is used, with which you can obtain the contents in the small intestine. Balloons made of thin rubber are attached to the ends of two tubes; the third tube has a hole at the end. After the probe is inserted into the small intestine, the balloons are inflated with air, and they isolate the area of the small intestine that lies between them. Intestinal contents are collected through a free tube.
