Splashing noise due to intestinal obstruction. Symptoms and treatment of intestinal obstruction

Babuk's sign.

Babuka s. – possible sign intussusception: if after the enema there is no blood in the washing water, palpate the abdomen for 5 minutes. With intussusception, often after a repeated siphon enema, the water looks like meat slop.

Karevsky's syndrome.

Karevsky village – observed in gallstone intestinal obstruction: sluggish alternation of partial and complete obstructive intestinal obstruction.

Obukhovskaya hospital, Hochenegg symptom.

Obukhovskaya hospital. – sign of sigmoid colon volvulus: dilated and empty rectal ampulla during rectal examination.

Rusch's sign.

Rusha s. – observed with intussusception of the colon: the occurrence of pain and tenesmus upon palpation of a sausage-shaped tumor on the abdomen.

Spasokukotsky's symptom.

Spasokukotsky village – a possible sign of intestinal obstruction: the sound of a falling drop is detected by auscultation.

Sklyarov's symptom

Sklyarova s. – a sign of obstruction of the large intestine: a splashing sound is detected in the distended and swollen sigmoid colon.

Titov's symptom.

Titova s. – a sign of adhesive obstruction: the skin-subcutaneous fold along the line of the laparotomy postoperative scar is grasped with the fingers, sharply raised upward and then smoothly lowered. The localization of pain indicates the site of adhesive intestinal obstruction. With a weakly expressed reaction, several sharp twitches of the fold are performed.

Alapy symptom.

Alapi s. – Absence or slight tension of the abdominal wall during intussusception.

Anschotz's sign.

Anschutz s. – swelling of the cecum with obstruction of the lower parts of the colon.

Vayer's symptom.

Bayera s. – asymmetry of abdominal bloating. Observed during volvulus of the sigmoid colon.

Bailey's sign.

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

Bouveret's sign.

Bouveret s. – a possible sign of obstruction of the large intestine: protrusion in the ileocecal region (if the cecum is swollen, the obstruction has arisen in the transverse colon, if the cecum is in a collapsed state, then the obstruction is in good shape).

Cruveillhier symptom.

Cruvelier s. – characteristic of intussusception: blood in the stool or blood-stained mucus in combination with cramping abdominal pain and tenesmus.

Symptom Dance.

Dansa s. – a sign of ileocecal intussusception: due to the movement of the intussuscepted segment of the intestine, the right iliac fossa appears empty upon palpation.

Delbet's symptom.

Triad Delbet.

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

SymptomDurant.

Durana s. - observed when intussusception begins: a sharp tension in the abdominal wall according to the site of insertion.

Frimann-Dahl sign.

Freeman-Dahl s. – in case of intestinal obstruction: in gas-stretched loops of the small intestine, transverse striations are determined radiologically (corresponding to Kerkring’s folds).

Gangolphe symptom.

Gangolfa s. – observed with intestinal obstruction: dullness of sound in sloping areas of the abdomen, indicating the accumulation of free fluid.

Hintze's symptom.

Gintze s. – an x-ray sign indicates acute intestinal obstruction: the accumulation of gas in the colon is determined and corresponds to Wahl’s symptom.

Symptom of Hirschsprung.

Girshsprunga s. – observed during intussusception: relaxation of the anal sphincters.

Hofer's sign.

Hephera s. – with intestinal obstruction, aortic pulsation is best heard above the level of narrowing.

Kiwull symptom.

Kivulya s. – a sign of obstruction of the large intestine (with volvulus of the sigmoid and cecum): a metallic sonority is detected in the distended and swollen sigmoid colon.

Kocher's symptom.

Kohera s. – observed in case of intestinal obstruction: pressure on the anterior abdominal wall and its rapid cessation do not cause pain.

Kloiber's symptom.

Kloibera s. – radiological sign of intestinal obstruction: a survey fluoroscopy of the abdominal cavity reveals horizontal levels of fluid and gas bubbles above them.

Lehmann's sign.

Lehmann s. – radiological sign of intussusception: the filling defect flowing around the head of the intussusception has a characteristic appearance: two lateral stripes of contrast agent between the receiving and invaginated intestinal cylinders.

Mathieu's symptom.

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

Payer's symptom.

Payra s. – “double-barrel”, caused by an inflection of the mobile (due to excessive length) transverse colon at the point of transition to the descending colon with the formation of an acute angle and spurs that inhibit the passage of intestinal contents. Clinical signs; abdominal pain that radiates to the heart and left lumbar region, burning and swelling in the left hypochondrium, shortness of breath, chest pain.

Schimman's symptom.

Shimana s. – a sign of intestinal obstruction (cecal volvulus): palpation reveals sharp pain in the right iliac region and a feeling of “emptiness” in place of the cecum

Schlange symptom (I).

Shlange s. – a sign of intestinal paralysis: when listening to the abdomen, complete silence is noted; usually seen with ileus.

Schlange symptom (II).

Shlange s. – visible intestinal peristalsis with intestinal obstruction.

Stierlin's sign.

Shtirlina s. – radiological sign of intestinal obstruction: a stretched and tense intestinal loop corresponds to a zone of gas accumulation in the form of an arch

Taevaenar symptom.

Tevenara s. – a sign of small intestinal obstruction: the abdomen is soft, palpation reveals pain around the navel and especially below it two transverse fingers along the midline. The point of pain corresponds to the projection of the root of the mesentery.

Symptom of Tilijaks.

Tiliaksa s. – Abdominal pain, vomiting, tenesmus and stool retention, and failure to pass gas are observed during intussusception.

Treves symptom.

Trevsa s. – a sign of colonic obstruction: at the moment of fluid administration into the colon, rumbling at the site of obstruction is determined by auscultation.

Symptom Watil.

Valya s. – a sign of intestinal obstruction: local flatulence or protrusion of the intestine above the level of the obstacle (visible asymmetry of the abdomen, palpable intestinal bulge, peristalsis visible to the eye, tympanitis audible upon percussion).

– a violation of the passage of contents through the intestine, caused by obstruction of its lumen, compression, spasm, hemodynamic or innervation disorders. Clinically, intestinal obstruction is manifested by cramping abdominal pain, nausea, vomiting, stool retention and the passage of gas. In the diagnosis of intestinal obstruction, data from a physical examination (palpation, percussion, auscultation of the abdomen), digital rectal examination, plain radiography of the abdominal cavity, contrast radiography, colonoscopy, and laparoscopy are taken into account. For some types of intestinal obstruction, conservative tactics are possible; in other cases, surgical intervention is performed, the purpose of which is to restore the passage of contents through the intestine or its external diversion, resection of a non-viable section of the intestine.

General information

Intestinal obstruction (ileus) is not an independent nosological form; in gastroenterology and coloproctology, this condition develops in a variety of diseases. Intestinal obstruction accounts for about 3.8% of all emergencies in abdominal surgery. With intestinal obstruction, the movement of contents (chyme) - semi-digested food masses through the digestive tract - is disrupted.

Intestinal obstruction is a polyetiological syndrome that can be caused by many reasons and have various forms. Timely and correct diagnosis of intestinal obstruction are decisive factors in the outcome of this serious condition.

Causes of intestinal obstruction

The development of various forms of intestinal obstruction has its own reasons. Thus, spastic obstruction develops as a result of a reflex intestinal spasm, which can be caused by mechanical and painful irritation due to helminthic infestations, intestinal foreign bodies, bruises and hematomas of the abdomen, acute pancreatitis, nephrolithiasis and renal colic, biliary colic, basal pneumonia, pleurisy, hemo- and pneumothorax, rib fractures, acute myocardial infarction and other pathological conditions. In addition, the development of dynamic spastic intestinal obstruction may be associated with organic and functional lesions of the nervous system (TBI, mental trauma, spinal cord injury, ischemic stroke, etc.), as well as circulatory disorders (thrombosis and embolism of mesenteric vessels, dysentery, vasculitis), Hirschsprung's disease.

Paralytic intestinal obstruction is caused by intestinal paresis and paralysis, which can develop as a result of peritonitis, surgical interventions in the abdominal cavity, hemoperitonium, poisoning with morphine, salts of heavy metals, food toxic infections, etc.

With various types of mechanical intestinal obstruction, there are mechanical obstacles to the movement of food masses. Obstructive intestinal obstruction can be caused by fecal stones, gallstones, bezoars, and accumulation of worms; intraluminal intestinal cancer, foreign body; removal of the intestine from the outside by tumors of the abdominal organs, pelvis, kidney.

Strangulated intestinal obstruction is characterized not only by compression of the intestinal lumen, but also by compression of the mesenteric vessels, which can be observed with strangulated hernia, intestinal volvulus, intussusception, nodulation - overlapping and twisting of intestinal loops among themselves. The development of these disorders may be due to the presence of a long intestinal mesentery, scar cords, adhesions, adhesions between intestinal loops; sudden loss of body weight, prolonged fasting followed by overeating; sudden increase in intra-abdominal pressure.

The cause of vascular intestinal obstruction is acute occlusion of mesenteric vessels due to thrombosis and embolism of the mesenteric arteries and veins. The development of congenital intestinal obstruction, as a rule, is based on anomalies in the development of the intestinal tube (duplication, atresia, Meckel's diverticulum, etc.).

Classification

There are several options for classifying intestinal obstruction, taking into account various pathogenetic, anatomical and clinical mechanisms. Depending on all these factors, a differentiated approach to the treatment of intestinal obstruction is used.

For morphofunctional reasons, they distinguish:

1. dynamic intestinal obstruction, which, in turn, can be spastic and paralytic.

2. mechanical intestinal obstruction, including forms:

• strangulation (volvulus, strangulation, nodulation)
• obstructive (intraintestinal, extraintestinal)
• mixed (adhesive obstruction, intussusception)

3. vascular intestinal obstruction caused by intestinal infarction.

According to the level of location of the obstacle to the passage of food masses, high and low small intestinal obstruction (60-70%) and colonic obstruction (30-40%) are distinguished. According to the degree of obstruction of the digestive tract, intestinal obstruction can be complete or partial; according to the clinical course - acute, subacute and chronic. Based on the time of formation of intestinal obstructions, congenital intestinal obstruction associated with embryonic intestinal malformations is differentiated, as well as acquired (secondary) obstruction due to other reasons.

There are several phases (stages) in the development of acute intestinal obstruction. In the so-called “ileus cry” phase, which lasts from 2 to 12-14 hours, pain and local abdominal symptoms prevail. The stage of intoxication that replaces the first phase lasts from 12 to 36 hours and is characterized by “imaginary well-being” - a decrease in the intensity of cramping pain, weakening of intestinal peristalsis. At the same time, there is a failure to pass gas, stool retention, bloating and asymmetry of the abdomen. In the late, terminal stage of intestinal obstruction, which occurs 36 hours after the onset of the disease, severe hemodynamic disturbances and peritonitis develop.

Symptoms of intestinal obstruction

Regardless of the type and level of intestinal obstruction, severe pain, vomiting, stool retention and failure to pass gas occur.

Abdominal pain is cramping and unbearable. During a contraction that coincides with a peristaltic wave, the patient’s face is distorted with pain, he groans, and takes various forced positions (squatting, knee-elbow). At the height of a painful attack, symptoms of shock appear: pale skin, cold sweat, hypotension, tachycardia. The subsidence of pain can be a very insidious sign, indicating intestinal necrosis and death of nerve endings. After an imaginary lull, on the second day from the onset of intestinal obstruction, peritonitis inevitably occurs.

Another characteristic symptom of intestinal obstruction is vomiting. Especially profuse and repeated vomiting, which does not bring relief, develops with small intestinal obstruction. Initially, the vomit contains food debris, then bile, and in the later period - intestinal contents (fecal vomit) with a putrid odor. With low intestinal obstruction, vomiting, as a rule, is repeated 1-2 times.

A typical symptom of low intestinal obstruction is retention of stool and gas. Digital rectal examination reveals the absence of feces in the rectum, distension of the ampulla, and gaping of the sphincter. With high obstruction of the small intestine, there may be no stool retention; emptying of the lower parts of the intestine occurs independently or after an enema.

With intestinal obstruction, attention is drawn to bloating and asymmetry of the abdomen, peristalsis visible to the eye.

Diagnostics

Percussion of the abdomen in patients with intestinal obstruction reveals tympanitis with a metallic tint (Kivul's symptom) and dullness of percussion sound. Auscultation in the early phase reveals increased intestinal peristalsis and “splashing noise”; in the late phase - weakening of peristalsis, the sound of a falling drop. With intestinal obstruction, a distended intestinal loop is palpated (Val's symptom); in the later stages – rigidity of the anterior abdominal wall.

Of great diagnostic importance is rectal and vaginal examination, which can be used to identify obstruction of the rectum and pelvic tumors. The objectivity of the presence of intestinal obstruction is confirmed by instrumental studies.

A survey X-ray of the abdominal cavity reveals characteristic intestinal arches (gas-swollen intestine with fluid levels), Kloiber's cups (dome-shaped clearings above the horizontal fluid level), and a symptom of pennation (the presence of transverse striations of the intestine). X-ray contrast examination of the gastrointestinal tract is used in difficult diagnostic cases. Depending on the level of intestinal obstruction, radiography of the passage of barium through the intestines or irrigoscopy may be used. Colonoscopy allows you to examine the distal parts of the large intestine, identify the cause of intestinal obstruction and, in some cases, resolve the phenomena of acute intestinal obstruction.

Carrying out an ultrasound of the abdominal cavity with intestinal obstruction is difficult due to severe pneumatization of the intestine, but the study in some cases helps to detect tumors or inflammatory infiltrates. During diagnosis, acute intestinal obstruction should be differentiated from intestinal paresis - drugs that stimulate intestinal motility (neostigmine); Novocaine perinephric blockade is performed. In order to correct the water-electrolyte balance, intravenous administration of saline solutions is prescribed.

If, as a result of the measures taken, intestinal obstruction does not resolve, one should think about mechanical ileus, requiring urgent surgical intervention. Surgery for intestinal obstruction is aimed at eliminating mechanical obstruction, resection of a non-viable section of the intestine, and preventing recurrent obstruction.

In case of obstruction of the small intestine, resection of the small intestine can be performed with enteroenteroanastomosis or enterocoloanastomosis; deintussusception, unwinding of intestinal loops, dissection of adhesions, etc. In case of intestinal obstruction caused by a colon tumor, hemicolonectomy and temporary colostomy are performed. For inoperable tumors of the large intestine, a bypass anastomosis is performed; If peritonitis develops, transversostomy is performed.

In the postoperative period, BCC replacement, detoxification, antibacterial therapy, correction of protein and electrolyte balance, and stimulation of intestinal motility are carried out.

Prognosis and prevention

The prognosis for intestinal obstruction depends on the start date and completeness of the treatment. An unfavorable outcome occurs with late recognized intestinal obstruction, in weakened and elderly patients, and with inoperable tumors. With a pronounced adhesive process in the abdominal cavity, relapses of intestinal obstruction are possible.

Prevention of the development of intestinal obstruction includes timely screening and removal of intestinal tumors, prevention of adhesions, elimination of helminthic infestations, proper nutrition, avoidance of injuries, etc. If intestinal obstruction is suspected, immediate consultation with a doctor is necessary.

1. Wahl's syndrome(adductor loop syndrome): abdomen in “waves”, expansion of the afferent loop, percussion above it - tympanitis, increased peristalsis of the afferent loop.

2. Mathieu-Sklyarov's symptom -“splashing” noise (caused by sequestration of fluid in the intestines).

3. Spasokukotsky’s symptom- “falling drop” symptom.

4. Grekov’s symptom (Obukhov hospital)- gaping anus, dilated and empty rectum (caused by the development of colonic obstruction at the level of the left half of the colon).

5. Gold's sign- bimanual rectal examination reveals an enlarged (sausage-shaped) afferent intestinal loop.

6. Symptom Dansa - retraction of the right iliac region with ileocecal intussusception (absence of the cecum in “its place”).

7. Tsege-Manteuffel sign- when performing a siphon enema, only up to 500 ml of liquid enters (obstruction at the level of the sigmoid colon).

8. Bayer's sign- “oblique” belly.

9. Anschutz's sign- swelling of the cecum with colonic obstruction.

10. Bouveret's sign- collapsed cecum with small intestinal obstruction.

11. Gangolf's symptom- dullness in sloping areas of the abdomen (effusion).

12. Kivulya symptom- metallic percussion sound above the abdomen.

13. Rousche's sign- palpation of a smooth, painful formation during intussusception.

14. Alapi symptom- with intussusception, there is no muscular protection of the abdominal wall.

15. Ombredan's symptom- with intussusception, hemorrhagic or “raspberry jelly” type discharge from the rectum.

16. Babuk's sign- with intussusception, the appearance of blood in the rinsing waters after palpation of the abdomen (zone of intussusception) during a primary or repeated enema.

The importance of the diagnostic and treatment complex for intestinal obstruction.

1. distinguishes mechanical CI from functional,

2. allows functional CI,

3. eliminates the need for surgery in 46-52% of patients,

4. prevents the development of additional adhesions,

5. shortens the treatment time for patients with CI,

6. reduces the number of complications and mortality,

7. provides the physician with a powerful method of treating CI.

RULES FOR EXECUTION OF LDP.

in the absence of obvious mechanical CI:

1. subcutaneous injection of 1 ml of 0.1% atropine sulfate solution

2. bilateral novocaine perinephric blockade with a 0.25% novocaine solution

3. pause 30-40 minutes + treatment of associated disorders,

4. aspiration of gastric contents,

5. siphon enema with assessment of its effect by the surgeon,

6. determination of indications for surgery.

ASSESSMENT OF THE RESULT OF LDP

1. according to subjective data,

2. according to the effect of a siphon enema, according to objective data:

Ø dyspeptic syndrome disappeared,

Ø no bloating or asymmetry of the abdomen,

Ø no “splash noise”,

Ø ordered peristaltic sounds are heard,

Ø “Kloiber cups” are allowed; after taking a suspension of barium, its passage through the intestines is determined.

REASONS FOR FALSE ASSESSMENT OF LDP

1. analgesic effect of novocaine,

2. assessment of the result only based on subjective data,

3. objective symptoms and their dynamics are not taken into account,

4. The effect of siphon enema is incorrectly assessed.

67. Modern principles of treatment of patients with intestinal obstruction, outcomes, prevention.

TREATMENT OF INTESTINAL OBSTRUCTION Urgent surgery for intestinal obstruction is indicated:

1. If there are signs of peritonitis.

2. If there are obvious signs or suspicion of strangulation or mixed intestinal obstruction.

In other cases:

1. A diagnostic and treatment appointment is carried out; if the reception is negative, an urgent operation is performed, if it is positive, conservative treatment is carried out.

2. 250 ml of liquid barium sulfate is given orally.

3. Infusion therapy is carried out.

4. The passage of barium is assessed - when it passes (after 6 hours into the colon, after 24 hours into the rectum), the diagnosis of intestinal obstruction is removed, and the patient is subjected to a detailed examination.

The decision on surgery for acute intestinal obstruction should be made within 2-4 hours after admission. When indications for surgical treatment are given, patients should undergo brief preoperative preparation.

Surgery for intestinal obstruction involves performing a number of successive steps:

1. Performed under endotracheal anesthesia with myoplegia; In most cases, the surgical approach is a midline laparotomy.

2. Search and elimination of ileus is carried out: dissection of adhesions, mooring, enterolysis; disinvagination; unwinding of the torsion; bowel resection, etc.

3. After novocaine blockade of reflexogenic zones, decompression (intubation) of the small intestine is performed:

a) nasogastrointestinal

b) according to Yu.M. Dederer (via gastrostomy tube);

c) according to I.D. Zhitnyuk (retrograde through ileostomy);

d) according to Shede (retrograde through a cecostomy, appendicocecostomy).

Intubation of the small intestine for intestinal obstruction is necessary for:

Decompression of the intestinal wall in order to restore microcirculation and intramural blood flow in it.

To remove highly toxic and intensely infected intestinal chyme from its lumen (the intestine in case of intestinal obstruction is the main source of intoxication).

For carrying out intestinal treatment in the postoperative period (intestinal dialysis, enterosorption, oxygenation, motility stimulation, restoration of the barrier and immune function of the mucosa, early enteral feeding, etc.).

To create a frame (splinting) of the intestine in a physiological position (without angulation along the “large radii” of intestinal loops). Intestinal intubation lasts from 3 to 8 days (on average 4-5 days).

4. In some cases (resection of the intestine in conditions of peritonitis, resection of the colon, extremely serious condition of the patient), the imposition of an intestinal stoma (end, loop or Meidl) is indicated.

5. Sanitation and drainage of the abdominal cavity according to the principle of treating peritonitis. This is due to the fact that in the presence of effusion in the abdominal cavity with ileus, anaerobic microorganisms are inoculated from it in 100% of cases.

6. Completion of the operation (suturing of the abdominal cavity).

Surgery for intestinal obstruction should not be traumatic or rough. In some cases, one should not engage in long-term and highly traumatic enterolysis, but resort to the application of bypass anastomoses. In this case, the surgeon must use those techniques that he is fluent in.

POSTOPERATIVE TREATMENT

The general principles of this treatment must be formulated clearly and specifically - it must be: intensive; flexible (if there is no effect, a quick change of appointments should be carried out); complex (all possible treatment methods must be used).

Postoperative treatment is carried out in the intensive care unit and then in the surgical department. The patient in bed is in a semi-sitting position (Fovler), the “three catheters” rule is observed. The complex of postoperative treatment includes:

1. Pain relief (non-narcotic analgesics, antispasmodics, prolonged epidural anesthesia are used).

2. Carrying out infusion therapy (with transfusion of crystalloids, colloid solutions, proteins, according to indications - blood, amino acids, fat emulsions, acid-base correctors, potassium-polarizing mixture).

3. Carrying out detoxification therapy (carrying out “forced diuresis”, performing hemosorption, plasmapheresis, ultrafiltration, indirect electrochemical oxidation of blood, intestinal dialysis of enterosorption, increasing the activity of the “reserve deposition system”, etc.) -

4. Conducting antibacterial therapy (based on the principle of treating peritonitis and abdominal sepsis):

a) with the prescription of drugs: “broad spectrum” with effects on aerobes and anaerobes;

b) administration of antibiotics into a vein, aorta, abdominal cavity, endolymphatic or lymphotropic, into the lumen of the gastrointestinal tract;

c) prescription of maximum pharmacological doses;

d) if there is no effect, quickly change assignments.

5. Treatment of enteral insufficiency syndrome. Its complex includes: intestinal decompression; carrying out intestinal dialysis (saline solutions, sodium hypochlorite, antiseptics, oxygenated solutions); carrying out enterosorption (using dextrans, after the appearance of peristalsis - carbon sorbents); administration of drugs that restore the functional activity of the gastrointestinal mucosa (antioxidants, vitamins A and E); early enteral nutrition.

6. Relieving the activity of the systemic inflammatory response of the body (systemic inflammatory response syndrome).

7. Carrying out immunocorrective therapy. In this case, the patient is administered hyperimmune plasma, immunoglobulin, immunomodulators (tactivin, splenin, imunofan, polyoxidonium, roncoleukin, etc.), ultraviolet and intravascular laser irradiation of blood, and acupuncture neuroimmunostimulation are performed.

8. A set of measures is being taken to prevent complications (primarily thromboembolic, from the respiratory, cardiovascular, urinary systems, from the wound).

9. Corrective treatment of concomitant diseases is carried out.

Complications of gastroduodenal ulcers.

68. Etiology, pathogenesis, gastroduodenal ulcers. Mechanisms of pathogenesis of gastroduodenal ulcers.

ULCER DISEASE is a disease that is based on the formation and long-term course of an ulcerative defect on the mucous membrane with damage to various layers of the wall of the stomach and duodenum.

Etiology. Causes:

Social factors (tobacco smoking, unhealthy diet, alcohol abuse, poor conditions and irrational lifestyle, etc.);

Genetic factors (close relatives have a 10-fold higher risk of developing peptic ulcers);

Psychosomatic factors (personality types who experience constant internal tension and a tendency to depression are more likely to get sick);

Etiological role of Helicobacter pylori - a gram-negative microbe, located intracellularly, destroys the mucous membrane (however, there is a group of patients with chronic ulcers in whom this microbe is absent in the mucous membrane);

Physiological factors - increased gastric secretion, hyperacidity, decreased protective properties and inflammation of the mucous membrane, local microcirculation disorders.

Modern concept of etiopathogenesis of ulcers - “Scales of the Neck”:

Thus, a decrease in protective factors plays a major role in ulcerogenesis.

Clinic, diagnosis of complications of gastroduodenal ulcers, indications for surgical treatment: perforated and penetrating gastroduodenal ulcers;

PERFORMANCE (OR PERFORATION):

This is the most severe, rapidly developing and absolutely fatal complication of peptic ulcer disease.

The patient can only be saved through emergency surgery.

The shorter the period from the moment of perforation to surgery, the greater the patient’s chances of survival.

Clinic

The classic pattern of perforation is observed in 90-95% of cases:

Sudden, severe “dagger” pain in the epigastric region,

The pain quickly spreads throughout the abdomen,

The condition is deteriorating sharply,

The pain is severe and the patient sometimes goes into a state of shock,

Patients complain of thirst and dry mouth,

The patient grabs his stomach with his hands, lies down and freezes in a forced position,

The slightest movement causes increased abdominal pain,

ANAMNESIS

Perforation usually occurs against the background of a long course of peptic ulcer disease,

Perforation is often preceded by a short-term exacerbation of peptic ulcer disease,

In some patients, ulcer perforation occurs without a history of ulcers (approximately 12%),

this happens with “silent” ulcers.

Inspection and objective examination data:

ü patients lie down and try not to make any movements,

ü the face is sallow-gray, the features are pointed, the gaze is suffering, covered with cold sweat, the lips and tongue are rather dry,

ü blood pressure is slightly reduced and the pulse is slow,

ü the main symptom is tension in the muscles of the anterior abdominal wall, the stomach is “board-shaped”, does not participate in breathing (in thin people, segments of straight lines of the abdomen appear and transverse folds of skin are noted at the level of the navel - Dzbanovsky’s symptom),

ü palpation of the abdomen accompanied by sharp pain, increased pain in the abdomen, more in the epigastric region, right hypochondrium, then the pain becomes diffuse,

ü strongly positive Shchetkin-Blumberg symptom - first in the epigastric region, and then throughout the abdomen.

Related information.

5. Symtom Vit Stetten- bloating of the left lower quadrant of the abdomen due to perforation of the duodenum.

SYMPTOMS: DETECTED BY PERCUSSION OF THE PATIENT’S ABDOMEN:

1. Spizharny-Clark sign- high tympanitis on percussion between the xiphoid process and the navel. Disappearance of liver dullness.

SYMPTOMS DETECTED BY AUSCULTATION IN THE PATIENT'S ABDOMEN:

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

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

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

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

The Gustin triad includes the previously described symptoms of Lotey-Sen-Bailey-Federecchi-Claybrook-Gustin, Brenner, Brunner.

INTESTINAL OBSTRUCTION

SYMPTOMS REVEALED IN COMPLAINTS OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Cruvelier's symptom - blood in the stool, cramping abdominal pain and tenesmus. Characteristic of intussusception.

2. Tiliax's sign- pain, vomiting, gas retention. Characteristic of intussusception.

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

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

SYMPTOMS REVEALED DURING A GENERAL INSPECTION OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Valya's symptom- a distended intestinal loop contouring through the anterior abdominal wall.

2. Schlange-Grekov sign- intestinal peristalsis visible through the abdominal wall.

3. Bayer's sign- asymmetrical bloating.

4. Bouveray-Anschutz symptom - protrusion in the ileocecal region with obstruction of the large intestine.

5. Borchardt's triad- bloating in the epigastric region and left hypochondrium, inability to probe the stomach and vomiting that does not bring relief. Observed during gastric volvulus.

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

7. Karevsky's sign- sluggish intermittent intestinal obstruction. It is observed with intestinal obstruction caused by gallstones.

SYMPTOMS REVEALED WHEN PALPATIZING THE ABDOMINAL OF A PATIENT WITH INTESTINAL OBSTRUCTION:

1. Leotta's sign- the appearance of pain when pulling and moving towards the skin fold of the abdomen. It is noted in adhesive disease.

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

3. Schiemann-Dans symptom - upon palpation in the area of ​​the cecum, a kind of emptiness is determined. Observed during cecal volvulus.

4. Schwartz's sign - a painful elastic tumor is palpated in the epigastrium with simultaneous bloating. Observed with acute dilatation of the stomach.

5. Tsulukidze’s symptom- upon palpation of the intussusception of the colon, a depression with folded edges is detected, around which small tumor-like formations are palpated - fatty pendants.

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

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

2. Wortmann's sign- a sound with a metallic tint is heard only over the swollen large intestine, and over the small intestine - ordinary tympanitis.

3. Mathieu's sign- splashing sound heard in the epigastrium with rapid percussion above the navel.

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

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

2. Spasokukotsky's symptom- - the noise of a “falling drop”.

3. Gepher's symptom- Breath sounds and heart sounds are best heard above the site of narrowing. Observed in later stages.

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

1. Grekov's symptom-Hohenega- an empty ampulla-shaped rectum, the anterior wall of which is protruded by intestinal loops. The anus is gaping. The synonym is “symptom of the Obukhov hospital.”

2. Trevs's symptom - in When fluid is introduced into the rectum, a rumbling sound is heard at the site of obstruction.

3. Tsege von Manteuffel's sign- in case of obstruction of the sigmoid colon, only 200 ml of water can be introduced into the rectum. The patient cannot retain large doses of water.

SYMPTOMS USED TO DIFFERENTIALLY

DIAGNOSIS OF INTESTINAL OBSTRUCTION: 1

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

2. Babuk's sign- differential diagnosis between a tumor and intussusception. The absence of blood in the washing water after an enema and kneading of a pathological formation indicates the presence of a tumor.

1. Vikker M. M. Diagnosis and medical tactics for acute abdominal diseases (“acute abdomen”). North Caucasus regional publishing house. Pyatigorsk, 1936, 158 pp.

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

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

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

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

V Gluzman A. M.

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

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

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

Classification

Back in the first half of the 19th century, two types of intestinal obstruction were identified - mechanical and dynamic. Subsequently, Wahl proposed dividing mechanical intestinal obstruction into strangulation and obstruction. The simplest and most appropriate classification at present can be considered in which OKN is divided according to its morphofunctional nature:

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

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

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

V. extraorgan (cysts of the mesentery and ovary, tumors of the retroperitoneal space and pelvic organs, causing compression of the intestine from outside).

1. Mixed:

A. Adhesive obstruction

b. Intussusception

By origin:

1. Congenital.
2. Acquired.

By level of obstruction:

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

(using the example of adhesive intestinal obstruction)

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

Stage II. Acute disturbance of intramural intestinal hemocirculation

(intoxication phase) - 12-36 hours.

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

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

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

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

III degree (decompensated). Complaints about the absence of stool and the passage of gas, increasing cramping pain in the abdomen and bloating, nausea, and sometimes vomiting. Severe signs of intoxication, impaired water-electrolyte balance and CBS, anemia, hypoproteinemia. On X-ray examination, the intestinal loops are dilated and inflated with gas. Many liquid levels are determined. As a rule, the majority of patients admitted to an urgent hospital due to obstructive colonic obstruction of tumor etiology have a decompensated degree of the disease, which ultimately determines the high rate of postoperative complications and mortality.

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

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

Causes of acute intestinal obstruction

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

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

Pathogenesis of acute intestinal obstruction

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

In stage I, there are no gross morphofunctional changes in the intestinal wall, no disturbances in water-electrolyte balance and endogenous intoxication syndrome. For such patients, with the exception of cases of strangulation intestinal obstruction, conservative therapy is indicated. The second stage of OKN is characterized by an acute disorder of intramural intestinal hemocirculation. This is no longer just a reaction of the body to the cessation of intestinal passage, but profound pathological changes, which are based on tissue hypoxia and the development of rapid autocatalytic processes. It has been established that with an increase in intraintestinal pressure to 30 mm. rt. Art. capillary blood flow in the intestinal wall completely stops. All of the above gives grounds to interpret the second stage of OKN as a process of acute disturbances of intramural intestinal hemocirculation. Taking into account its progressive nature, at this stage it is no longer possible to adhere to the tactics of dynamic monitoring of the patient and persistent conservative treatment. It is necessary to establish indications for urgent surgical intervention.

The identification of stage III OKN from a clinical and pathophysiological point of view is associated with the development of peritonitis due to the penetration of microorganisms through the intestinal wall into the free abdominal cavity and the progressive syndrome of multiple organ failure.

Symptoms of acute intestinal obstruction

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

Group I. The earliest and one of the most persistent signs of the disease is pain. The occurrence of cramping pain is characteristic of acute obstruction of the intestinal lumen and is associated with its peristalsis. Sharp, constant pain often accompanies acutely developed strangulation. If OKN is not diagnosed in a timely manner, then on days 2-3 from the onset of the disease, intestinal motor activity is inhibited, which is accompanied by a decrease in pain intensity and a change in its nature. In this case, symptoms of endogenous intoxication begin to prevail, which is a poor prognostic sign. The pathognomonic symptom of ACI is stool retention and non-passage of gas. However, with high small-intestinal obstruction at the beginning of the disease, the passage of gases and stools may be observed due to emptying of the distal parts of the intestine, which do not bring relief to the patient, which often disorients the doctor. One of the early clinical signs of OKN is vomiting. Its frequency depends on the level of obstruction in the intestine, the type and form of obstruction, and the duration of the disease. Initially, vomiting is of a reflex nature, and subsequently occurs due to overflow of the proximal parts of the gastrointestinal tract. The higher the intestinal obstruction, the more severe the vomiting. In the initial stage of colonic obstruction, vomiting may be absent. With low small intestinal obstruction, vomiting is observed with large intervals and an abundance of vomit, which takes on the character of intestinal contents with a “fecal” odor. In the later stages of acute insufficiency, vomiting is a consequence not only of stagnation, but also of endotoxicosis. During this period, it is not possible to eliminate vomiting even by intestinal intubation.

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

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

When auscultating the anterior abdominal wall at the onset of the disease, intestinal sounds of varying height and intensity are heard, the source of which is the small intestine that is swollen, but has not yet lost motor activity. The development of intestinal paresis and peritonitis marks a weakening of intestinal sounds, which appear in the form of separate weak bursts, reminiscent of the sound of a falling drop (Spasokukotsky's symptom) or the noise of bursting bubbles (Wilms' symptom). Soon these sounds are no longer detectable. The condition of a “silent abdomen” indicates the development of severe intestinal paresis. Due to changes in the resonating properties of the contents of the abdominal cavity, against the background of an increased abdominal volume, heart sounds begin to be clearly heard (Bailey's symptom). At this stage the clinical picture acute intestinal obstruction increasingly combined with the symptoms of widespread peritonitis.

Diagnosis of acute intestinal obstruction

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

The examination of a patient with acute intestinal tract must be supplemented with a digital examination of the rectum, which allows one to determine the presence of feces (“coprostasis”), foreign bodies, a tumor or the head of the intussusception. Pathognomonic signs of mechanical intestinal obstruction are balloon-like swelling of the empty ampulla of the rectum and decreased tone of the anal sphincters (“anal gaping”), described by I.I. Grekov in 1927 as a “symptom of the Obukhov hospital.”

Group II. The nature of general disorders in acute insufficiency is determined by endotoxicosis, dehydration and metabolic disorders. Thirst, dry mouth, tachycardia, decreased diuresis, and blood thickening, determined by laboratory parameters, are noted.

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

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

Abdominal imaging may reveal direct and indirect symptoms acute intestinal obstruction. Direct symptoms include:

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

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

1. A symptom of transverse striation of the intestinal lumen, referred to as Case's symptom (1928), “stretched spring”, “fish skeleton”. This symptom is considered as a manifestation of edema of the kerkring (circular) folds of the small intestinal mucosa. In the jejunum, this symptom manifests itself more prominently than in the ileum, which is due to the anatomical features of the relief of the mucous membrane of these parts of the intestine. Clearly visible folds of the small intestine are evidence of the satisfactory condition of its wall. The wear of the folds indicates a significant disruption of intramural hemodynamics.

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

X-ray contrast method. Indications for its use can be formulated as follows:

• Reasonable doubts about the presence of a mechanical form of OKN in the patient.
• Initial stages of adhesive intestinal obstruction, when the patient’s condition is not alarming and there is hope for its conservative resolution
• Dynamic monitoring of the progress of the contrast mass must be combined with a clinical study of the patient’s condition and the implementation of conservative therapeutic measures aimed at resolving intestinal obstruction. If local signs of acute insufficiency worsen and endotoxemia increases, the study is stopped and the question of emergency surgery is raised.

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

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

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

Treatment of acute intestinal obstruction

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

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

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

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

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