Symptom splashing noise with intestinal obstruction. Acute intestinal obstruction
Causes of the disease
There are a number of factors for the development of acute intestinal obstruction (AIO):
1. Congenital:
Features of anatomy - elongation of sections of the intestine (megacolon, dolichosigma);
Anomalies of development - an incomplete turn of the intestine, agangliosis (Hirschsprung's disease).
2. Purchased:
- unbalanced, irregular diet.
neoplasms of the intestine and abdominal cavity;
foreign bodies in the intestines, helminthiases;
cholelithiasis;
hernia of the abdominal wall;
Risk factors: abdominal surgery, electrolyte imbalance, hypothyroidism, opiate use, acute illness.
Mechanisms of occurrence and development of the disease (pathogenesis)
OKN classification
According to the morphofunctional trait
Dynamic obstruction:
spastic
paralytic
Mechanical obstruction:
strangulation (torsion, nodulation, restrictions)
obstructive (interstitial and extraintestinal forms)
mixed (invagination, adhesive obstruction)
By obstacle level
Small bowel obstruction:
Colonic obstruction
Clinical picture of the disease (symptoms and syndromes)
With the development of OKN, the following symptoms occur:
abdominal pain - a constant early sign of obstruction, usually occurs suddenly, at any time of the day, regardless of food intake (or after 1-2 hours), without precursors;
vomiting - after nausea or on its own, often repeated (the greater the obstruction in the digestive tract, the earlier it occurs and is more pronounced);
retention of stool and gases - sometimes (at the beginning of the disease) there is a "residual" stool;
thirst (more pronounced with high intestinal obstruction);
Valya's symptom - a clearly delimited stretched intestinal loop is determined through the abdominal wall;
visible peristalsis of the intestines;
"oblique" abdomen - gradual and asymmetric bloating;
Sklyarov's symptom - listening to the "splash noise" over the intestinal loops;
a symptom of Spasokukotsky - "the noise of a falling drop";
Kivul's symptom - an enhanced tympanic sound with a metallic tint appears above the stretched loop of the intestine;
a symptom of Grekov or a symptom of the Obukhov hospital - a balloon-like swelling of an empty ampoule of the rectum against the background of a gaping anus;
Mondor's symptom - increased intestinal motility with a tendency to decrease (“noise at first, silence at the end”);
"dead silence" - the absence of intestinal noise over the intestines;
symptom Hoses - the appearance of intestinal motility during palpation of the abdomen.
The clinical course of OKN has three phases (O. S. Kochnev, 1984):
1. "Ileous cry" (stage of local manifestations) - acute violation of the intestinal passage, duration - 2-12 hours (up to 14). The main signs are pain and local symptoms from the abdomen.
2. Intoxication (intermediate, stage of apparent well-being) - a violation of intraparietal intestinal hemocirculation, lasts 12-36 hours. During this period, the pain ceases to be cramping, becomes constant and less intense; the abdomen is swollen, often asymmetrical; intestinal peristalsis weakens, sound phenomena are less pronounced, “the noise of a falling drop” is auscultated; complete retention of stool and gases; there are signs of dehydration.
3. Peritonitis (late, terminal stage) - occurs 36 hours after the onset of the disease. This period is characterized by sharp functional disorders of hemodynamics; the abdomen is significantly swollen, peristalsis is not auscultated; peritonitis develops.
Diagnosis of the form of intestinal obstruction
To select the optimal treatment tactics, differential diagnosis between the forms of AIO should be carried out.
Dynamic spastic obstruction. Anamnesis: injuries or diseases of the central nervous system, hysteria, lead intoxication, ascariasis. Clinically: spastic pains suddenly appear, but there is no intoxication and swelling, rarely - stool retention. Radiologically, small Kloiber bowls can be detected that are displaced.
Dynamic paralytic ileus occurs due to peritonitis as a result of any type of intestinal obstruction, as well as some intoxications or operations in the abdominal cavity. Clinically: increasing intestinal paresis with the disappearance of peristalsis, symmetrical bloating with high tympanitis, disappearance of pain, nausea and repeated vomiting, symptoms of intoxication (rapid pulse, shortness of breath, leukocytosis with a shift to the left, hypochloremia). X-ray: numerous small Kloiber cups with indistinct contours that do not change their location.
Volvulus and nodulation are provoked by adhesions, hypermotility, overeating of a hungry person. Features: acute onset and course; shock and intoxication develop so rapidly that bloating is sometimes minimal; with volvulus of the caecum or sigmoid colon - always asymmetry and Wilms' symptom; inversions are often repeated.
obstructive obstruction most often caused by a tumor of the left side of the colon. Obturation with fecal stones, a ball of ascaris and other foreign objects is possible. Features: slow development, often asymmetric abdomen, frequent change in the shape of feces to "ribbon" or "sheep", repeated loose stools with mucus and blood are possible.
Intussusceptions are often small-colonic. Features: slow development, often asymmetric abdomen, mucus and blood in the feces are possible, tumor-like formations (intussusception) or an area of blunting against the background of high tympanitis can be palpated in the abdomen; the diagnosis can be confirmed by irrigoscopy - a lip-like photograph of the head of the intussusceptum is characteristic.
Mesenteric obstruction- violation of blood circulation in the lower or upper mesenteric vessels. It can be non-occlusive (spasm, decreased perfusion pressure), arterial (with atherosclerosis, hypertension, endarteritis, nodular periarthritis, atrial fibrillation, rheumatic heart disease) or venous (with cirrhosis, splenomegaly, leukemia, tumors). Arterial obstruction (twice as often, mainly in the basin of the superior mesenteric artery) has two stages: anemic (white), lasting up to 3 hours, and hemorrhagic (red). With venous sweating begins immediately.
Features of mesenteric obstruction:
With arterial in the anemic stage - in 1/3 of patients the onset is subacute, the attack is removed with nitroglycerin, as in angina pectoris; in 2/3 - the onset is acute, the pain is very severe;
At first, blood pressure often rises by 50-60 mm. rt. Art. (Boikov's symptom);
The tongue is moist, the abdomen is soft;
Leukocytosis ≥ 15-20 x 10 9 with a low erythrocyte sedimentation rate;
Delayed stool and gases in 25% of patients;
Vomiting and diarrhea mixed with blood - in 50% of patients;
In the stage of infarction, blood pressure decreases, the pulse is filiform, the tongue is dry, the abdomen is somewhat swollen, but still soft, there is no irritation of the peritoneum, the edematous intestine is often palpated (Mondor's symptom);
The diagnosis can be confirmed by angiography or laparoscopy;
Mandatory ECG to rule out myocardial infarction.
Adhesive obstruction. Its frequency is up to 50%. The severity of the clinical course, as with invagination, depends on the severity of strangulation. Diagnosis is the most difficult, as attacks often recur and may resolve on their own (adhesive disease). In case of surgery on the abdominal cavity in history and subacute course, it is necessary to start with the introduction of contrast and control its passage after 1-2 hours.
Differential Diagnosis
AIO has a number of features characteristic of other diseases, which necessitates differential diagnosis.
Acute appendicitis. Common signs of acute appendicitis are abdominal pain, stool retention, and vomiting. However, the pain of appendicitis begins gradually and is not as intense as that of an obstruction. With appendicitis, it is localized, and with obstruction, it is cramping and intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction, and not appendicitis. In acute appendicitis, there are no radiological signs characteristic of obstruction.
Perforated ulcer of the stomach and duodenum. Common symptoms of an ulcer are sudden onset, severe abdominal pain, and stool retention. However, with a perforated ulcer, the patient occupies a forced position, and with intestinal obstruction, he is restless, often changing position. Vomiting is uncommon for perforated ulcers, but is often seen with intestinal obstruction. With an ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, and with intestinal obstruction, the stomach is swollen, soft, slightly painful. With a perforated ulcer, from the very beginning of the disease, there is no peristalsis, "splash noise" is not heard. Radiologically, with a perforated ulcer, free gas is determined in the abdominal cavity, with intestinal obstruction - Kloiber's cups, arcades.
Acute cholecystitis. Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the area of the right shoulder blade. With intestinal obstruction, the pain is cramping, non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. In acute cholecystitis, there is no increased peristalsis, sound phenomena, radiological signs of obstruction.
Acute pancreatitis. Common signs of acute pancreatitis are sudden onset, severe pain, severe general condition, frequent vomiting, bloating, and stool retention. However, with pancreatitis, the pain is localized in the upper abdomen, girdle, and not cramping. Mayo-Robson's sign is positive. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. Radiologically, with pancreatitis, a high standing of the left dome of the diaphragm is noted, and with obstruction - Kloiber's bowl, arcades.
Bowel infarction. With intestinal infarction, as with obstruction, there is a strong sudden pain in the abdomen, vomiting, a severe general condition, a soft stomach. However, pain in intestinal infarction is constant, peristalsis is completely absent, abdominal distention is small, there is no asymmetry of the abdomen, “dead silence” is determined during auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a wide range of sound phenomena are heard, abdominal distention is significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, high leukocytosis is possible (20-30 x 10 9 /l).
Renal colic. Renal colic and intestinal obstruction have similar symptoms, such as severe abdominal pain, bloating, retention of stools and gases, restless behavior of the patient. Pain in renal colic radiates to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive symptom of Pasternatsky. On a plain radiograph, shadows of calculi may be observed in the kidney or ureter.
Pneumonia. Pneumonia may cause abdominal pain and bloating, indicating an intestinal obstruction. However, pneumonia is characterized by high fever, cough, blush. On physical examination, crepitant wheezing, pleural friction noise, bronchial breathing, dullness of pulmonary sound can be detected, X-ray - characteristic changes in the lungs.
Myocardial infarction. With myocardial infarction, there may be a sharp pain in the upper abdomen, its swelling, sometimes vomiting, weakness, lowering blood pressure (BP), tachycardia, that is, signs resembling strangulation intestinal obstruction. However, with myocardial infarction, asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms are not observed, there are no radiographic signs of intestinal obstruction. An ECG study helps clarify the diagnosis of myocardial infarction.
Diagnosis of the disease
Examination scope for OKN
1. Required: general urinalysis, complete blood count, blood glucose, blood group and Rh-affiliation, rectal examination (sphincter tone is reduced, the ampoule is empty, fecal stones are possible as a cause of obstruction, mucus with blood during intussusception, tumor obstruction), ECG , X-ray of the abdominal organs vertically.
2. According to indications: total protein, bilirubin, urea, creatinine, ionic composition; ultrasound examination (ultrasound), chest x-ray, barium passage through the intestines, sigmoidoscopy, irrigography, colonoscopy.
The phases of the course of acute intestinal obstruction are conditional, and each form of obstruction has its own differences (with strangulation intestinal obstruction, phases I and II begin almost simultaneously).
Diagnostics
X-ray examination is the main special method for diagnosing OKN, which can be used to identify the following signs:
1. Kloyber bowl - a horizontal level of liquid with a dome-shaped enlightenment above it, which looks like an inverted bowl. With strangulation obstruction, it can manifest itself after an hour, with obstructive obstruction - after 3-5 hours from the moment of the disease. The number of bowls is different, sometimes they can be layered one on top of the other in the form of a ladder. Fluid levels (small and colonic) localized in the left hypochondrium indicate high obstruction. At small intestinal levels, vertical dimensions predominate over horizontal ones, there are semilunar folds of the mucosa; in the large intestine, horizontal dimensions predominate over vertical ones, haustration is determined.
2. Intestinal arcades appear when the small intestine swells with gases, while there are horizontal levels of fluid in the lower knees of the arcades.
3. The symptom of pinnation occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular mucosal folds.
A contrast study is performed in doubtful cases, with a subacute course. The delay in the passage of barium in the caecum for more than 6 hours against the background of agents that stimulate peristalsis indicates obstruction (normally after 4-6 hours without stimulation).
Indications for conducting studies with the use of contrast in intestinal obstruction are:
1. Confirmation of intestinal obstruction.
2. Suspicion of intestinal obstruction for the purpose of differential diagnosis and complex treatment.
3. OKN in patients who have been repeatedly operated on.
4. Any form of small bowel obstruction (except for strangulation), when as a result of active conservative measures in the early stages of the disease, an obvious improvement can be achieved.
5. Diagnosis of early postoperative obstruction in patients undergoing gastric resection. The absence of pyloric sphincter causes unimpeded flow of contrast to the small intestine. In this case, the detection of the "stop-contrast" phenomenon in the outlet loop indicates the need for early relaparotomy.
6. X-ray contrast study for the diagnosis of AIO, which is used only in the absence of a strangulation form of obstruction, which can lead to a rapid loss of viability of the strangulated loop of the intestine (based on clinical data and the results of an abdominal radiography).
7. Dynamic observation of the movement of the contrast mass in combination with clinical observation, during which changes in local physical data and the general condition of the patient are recorded. With an increase in the frequency of local manifestations of obstruction or the appearance of signs of endotoxicosis, it is necessary to carry out an urgent surgical intervention, regardless of the x-ray data characterizing the passage of contrast through the intestines.
An effective method for diagnosing colonic obstruction is irrigoscopy. Colonoscopy is undesirable because it can lead to the entry of air into the drive loop and contribute to the development of its perforation.
Ultrasound signs of intestinal obstruction:
Expansion of the intestinal lumen > 2 cm with the phenomenon of "fluid sequestration";
Small bowel wall thickening > 4 mm;
The presence of a reciprocating movement of chyme in the intestine;
Increase in the height of the mucosal folds> 5 mm;
Increasing the distance between the folds > 5 mm;
Hyperpneumatization of the intestine in the drive part with dynamic intestinal obstruction - the absence of reciprocating movement of chyme in the intestine; the phenomenon of fluid sequestration into the intestinal lumen;
Unexpressed relief of mucosal folds;
Hyperpneumatization of the intestine in all departments.
SYMPTOMS1. Kivul's symptom - with percussion, you can hear a tympanic sound with a metallic tinge over a stretched bowel loop.
Kivul's symptom is characteristic of acute intestinal obstruction.
2. Wilms symptom of a falling drop (M. Wilms) - the sound of a falling drop of liquid, determined auscultatively against the background of peristalsis noises with intestinal obstruction.
3. "splash noise", described by I.P. Sklyarov (1923). This symptom is detected with a slight lateral concussion of the abdominal wall, can be localized or be determined throughout the abdomen. The appearance of this phenomenon indicates the presence of an overstretched paretic loop filled with liquid and gas. Mathieu (Mathieu) described the appearance of splashing noise during rapid percussion of the supra-umbilical region. Some authors consider the appearance of splashing noise a sign of neglect of the ileus and, if it is detected, they consider it an indication of an emergency operation.
4. Rovsing's sign: sign of acute appendicitis; on palpation in the left iliac region and simultaneous pressure on the descending colon, gas pressure is transmitted to the ileocecal region, which is accompanied by pain.
The cause of Rovsing's symptom: there is a redistribution of intra-abdominal pressure and irritation of the interoreceptors of the inflamed appendix
5. Symptom of Sitkovsky: sign of appendicitis; when the patient is positioned on the left side, pain appears in the ileocecal region.
Cause of Sitkowski's symptom: irritation of interoreceptors as a result of pulling on the mesentery of the inflamed appendix
6. Symptom of Bartomier-Michelson: sign of acute appendicitis; pain on palpation of the caecum, aggravated by the position on the left side.
The cause of the symptom of Filatov, Bartemier - Michelson: tension of the mesentery of the appendix
7. Description of Razdolsky's symptom - soreness on percussion in the right iliac region.
The cause of Razdolsky's symptom: irritation of the receptors of the inflamed appendix
8. Cullen's symptom - limited cyanosis of the skin around the navel; observed in acute pancreatitis, as well as the accumulation of blood in the abdominal cavity (more often with ectopic pregnancy).
9. Gray Turner's symptom - the appearance of subcutaneous bruising on the sides. This symptom appears 6-24 months after retroperitoneal hemorrhage in acute pancreatitis.
10. Dalrymple's symptom is an expansion of the palpebral fissure, which is manifested by the appearance of a white strip of sclera between the upper eyelid and the iris, due to an increase in the tone of the muscle that lifts the eyelid.
Dalrymple's symptom is characteristic of diffuse toxic goiter.
11. Symptom Mayo-Robson (pain at the point of the pancreas) Pain in the region of the left costovertebral angle (with inflammation of the pancreas) is determined.
12. Resurrection symptom: a sign of acute appendicitis; when quickly holding the palm along the anterior abdominal wall (over the shirt) from the right costal edge down, the patient experiences pain.
13. Symptom of Shchetkin-Blumberg: after soft pressure on the anterior abdominal wall, the fingers are sharply torn off. With inflammation of the peritoneum, pain occurs, which is greater when tearing off the examining hand from the abdominal wall than when pressing on it.
14. Kerr's symptom (1): sign of cholecystitis; pain when inhaling during palpation of the right hypochondrium.
15. Symptom Kalka - soreness on percussion in the projection of the gallbladder
16. Murphy's symptom: a sign of o. cholecystitis; the patient in the supine position; the left hand is positioned so that the thumb fits below the costal arch, approximately at the location of the gallbladder. The remaining fingers of the hand are along the edge of the costal arch. If the patient is asked to take a deep breath, he will stop before reaching the top, due to a sharp pain in the abdomen under the thumb.
17. Ortner's symptom: a sign of o. cholecystitis; the patient is in the supine position. When tapping with the edge of the palm along the edge of the costal arch on the right, pain is determined.
18. Symptom of Mussi-Georgievsky (phrenicus-symptom): a sign of o. cholecystitis; pain when pressing with a finger over the collarbone between the front legs m. SCM.
19. Lagophthalmos (from the Greek lagoos - hare, ophthalmos - eye), hare eye, - incomplete closure of the eyelids due to muscle weakness (usually a sign of damage to the facial nerve), in which an attempt to cover the eye is accompanied by a physiological turn of the eyeball upwards, the space of the palpebral fissure occupies only the protein coat (Bell's symptom). Lagophthalmos creates conditions for the drying of the cornea and conjunctiva and the development of inflammatory and degenerative processes in them.
The cause of damage to the facial nerve, leading to the development of lagophthalmia, is usually neuropathy, neuritis, as well as traumatic damage to this nerve, in particular during surgery for neuroma VIII
cranial nerve. The inability to close the eyelids is sometimes observed in seriously ill people, especially in young children.
The presence of paralytic lagophthalmos or the inability to close the eyes for another reason requires measures aimed at preventing possible damage to the eye, especially its cornea (artificial tears, antiseptic drops and ointments on the conjunctiva of the eyes). If necessary, which is especially likely in case of damage to the facial nerve, accompanied by dry eyes (xerophthalmia), temporary stitching of the eyelids - blepharophthalmia - may be appropriate.
20. Val's symptom: a sign of intestinal obstruction; local flatulence or protrusion of the proximal intestine. Wahl (1833-1890) - German surgeon.
21. Graefe's symptom, or eyelid delay, is one of the main signs of thyrotoxicosis. It is expressed in the inability of the upper eyelid to fall when lowering the eyes down. To identify this symptom, you need to bring a finger, pencil or other object to the level above the patient's eyes, and then lower it down, following the movement of his eyes. This symptom manifests itself when, when the eyeball moves downwards, a white strip of sclera appears between the edge of the eyelid and the edge of the cornea, when one eyelid falls more slowly than the other, or when both eyelids fall slowly and tremble at the same time (see Definition of Graefe's symptom and bilateral ptosis). Eyelid lag is due to chronic contraction of the Müllerian muscle in the upper eyelid.
22. Kerte's symptom - the appearance of pain and resistance in the area of the body of the pancreas (in the epigastrium 6-7 centimeters above the navel).
Kerte's symptom is characteristic of acute pancreatitis.
23. Obraztsov's symptom (psoas-symptom): a sign of chronic appendicitis; increased pain during palpation in the ileocecal region with a raised right leg.
^ PRACTICAL SKILLS
Compatibility test for blood groups of the ABO system (on the plane)
The test is carried out on a wetted surface plate.
1. The tablet is marked, for which the full name is indicated. and blood group of the recipient, full name and the donor's blood group and blood container number.
2. Serum is carefully taken from the test tube with the recipient's blood to be tested and applied to the tablet 1 with a large drop (100 µl).
3. A small drop (10 µl) of donor erythrocytes is taken from a tube segment of a plastic bag with transfusion medium, which is prepared for transfusion to this particular patient, and applied next to the recipient's serum (serum to erythrocyte ratio 10:1).
4. Drops are mixed with a glass rod.
5. Observe the reaction for 5 minutes, while constantly shaking the plate. After this time, 1-2 drops (50-100 µl) of sodium chloride solution, 0.9% are added.
the reaction in the drop can be positive or negative.
a) a positive result (+) is expressed in agglutination of erythrocytes, agglutinates are visible to the naked eye in the form of small or large red aggregates. The blood is incompatible, it is impossible to transfuse! (see figure 1).
Figure 1. Donor and recipient blood is incompatible
b) with a negative result (-), the drop remains homogeneously colored red, agglutinates are not detected in it. The donor's blood is compatible with the recipient's (see Figure 2).
Figure 2. Donor blood is compatible with recipient blood
3.2. Tests for individual compatibility according to the Rhesus system
3.2.1. Compatibility test using 33% polyglucin solution
The order of the study:
1. For research, take a test tube (centrifuge or any other, with a capacity of at least 10 ml). The tube is labeled, for which the full name is indicated. and blood group of the recipient, and full name of the donor, the number of the container with blood.
2. Serum is carefully taken from the tube with the recipient's blood to be tested with a pipette and 2 drops (100 µl) are added to the bottom of the tube.
3. One drop (50 μl) of donor erythrocytes is taken from a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, into the same tube, 1 drop (50 μl) of a 33% polyglucin solution is added.
4. The contents of the test tube are mixed by shaking and then slowly turned along the axis, tilting almost to a horizontal position so that the contents spread over its walls. This procedure is performed within five minutes.
5. After five minutes, add 3-5 ml of saline to the test tube. solution. The contents of the test tubes are mixed by inverting the test tubes 2-3 times (without shaking!)
Interpretation of reaction results:
the result is taken into account by looking at the test tubes in the light with the naked eye or through a magnifying glass.
If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of a clarified or completely discolored liquid, then the donor's blood is not compatible with the recipient's blood. You can't overflow!
If there is a uniformly colored, slightly opalescent liquid in the test tube without signs of erythrocyte agglutination, this means that the donor's blood is compatible with the recipient's blood in relation to antigens of the Rhesus system and other clinically significant systems (see Figure 3).
Figure 3. The results of the study of samples for compatibility according to the Rhesus system (using a 33% polyglucin solution and a 10% gelatin solution)
3.2.2. Compatibility test using 10% gelatin solution
The gelatin solution must be carefully examined before use. When turbidity or the appearance of flakes, as well as the loss of gelatinous properties at t + 4 0 С ... +8 0 С, gelatin is unsuitable.
The order of the study:
1. Take a test tube for research (capacity not less than 10 ml). The test tube is marked, for which the full name, blood group of the recipient and donor, and the number of the container with blood are indicated.
2. One drop (50 µl) of donor erythrocytes is taken from a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, put into a test tube, 2 drops (100 µl) of a 10% gelatin solution heated in a water bath are added to liquefaction at a temperature of +46 0 C ... +48 0 C. From the tube with the recipient's blood, carefully take the serum with a pipette and add 2 drops (100 μl) to the bottom of the tube.
3. The contents of the tube are shaken to mix and placed in a water bath (t+46 0 С...+48 0 С) for 15 minutes or in a thermostat (t+46 0 С...+48 0 С) for 45 minutes.
4. After the end of the incubation, the tube is removed, 5-8 ml of saline is added. solution, the contents of the tube are mixed by one or two inversions and the result of the study is evaluated.
Interpretation of the results of the reaction.
the result is taken into account by viewing the tubes in the light with the naked eye or through a magnifying glass, and then viewed by microscopy. To do this, a drop of the contents of the test tube is placed on a glass slide and viewed under low magnification.
If agglutination is observed in the test tube in the form of a suspension of small or large red lumps against the background of a clarified or completely discolored liquid, this means that the donor's blood is incompatible with the recipient's blood and should not be transfused to him.
If the test tube contains a uniformly colored, slightly opalescent liquid without signs of erythrocyte agglutination, this means that the donor's blood is compatible with the recipient's blood in relation to antigens of the Rhesus system and other clinically significant systems (see Figure 3).
3.3. Gel Compatibility Test
When setting up a gel test, compatibility tests are carried out immediately according to the ABO system (in the Neutral microtube) and a compatibility test according to the Rhesus system (in the Coombs microtube).
The order of the study:
1. Before the study, check the diagnostic cards. Do not use cards if there are suspended bubbles in the gel, the microtube does not contain a supernatant, a decrease in the volume of the gel or its cracking is observed.
2. Microtubes are signed (name of the recipient and number of the donor sample).
3. From a segment of the tube of a plastic bag with a transfusion medium, which is prepared for transfusion to this particular patient, 10 μl of donor erythrocytes are taken with an automatic pipette and placed in a centrifuge tube.
4. Add 1 ml dilution solution.
5. Open the required number of microtubes (one each of Coombs and Neutral microtubes).
6. Using an automatic pipette, add 50 µl of diluted donor erythrocytes to Coombs and Neutral microtubes.
7. Add 25 µl of recipient serum to both microtubes.
8. Incubate at t+37 0 C for 15 minutes.
9. After incubation, the card is centrifuged in a gel card centrifuge (time and speed are set automatically).
Interpretation of results:
if the erythrocyte sediment is located at the bottom of the microtube, then the sample is considered compatible (see Figure 4 No. 1). If agglutinates linger on the surface of the gel or in its thickness, then the sample is incompatible (see Figure 4 Nos. 2-6).
№1 №2 №3 №4 №5 №6
Figure 4. The results of the study of samples for individual compatibility according to the Rhesus system by the gel method
3.4. biological sample
To conduct a biological test, blood and its components prepared for transfusion are used.
biological sample carried out regardless of the volume of the hemotransfusion medium and the rate of its introduction. If it is necessary to transfuse several doses of blood and its components, a biological test is carried out before the start of transfusion of each new dose.
Technique:
10 ml of blood transfusion medium is transfused once at a rate of 2-3 ml (40-60 drops) per minute, then the transfusion is stopped and the recipient is monitored for 3 minutes, controlling his pulse, respiratory rate, blood pressure, general condition, skin color, measure body temperature. This procedure is repeated twice more. The appearance during this period of even one of such clinical symptoms as chills, back pain, feeling of heat and tightness in the chest, headache, nausea or vomiting, requires immediate termination of the transfusion and refusal to transfuse this transfusion medium. The blood sample is sent to a specialized blood service laboratory for an individual selection of red blood cells.
The urgency of transfusion of blood components does not exempt from performing a biological test. During it, it is possible to continue the transfusion of saline solutions.
When transfusing blood and its components under anesthesia, the reaction or incipient complications are judged by an unmotivated increase in bleeding in the surgical wound, a decrease in blood pressure and an increase in heart rate, a change in the color of urine during catheterization of the bladder, and also by the results of a test to detect early hemolysis. In such cases, the transfusion of this hemotransfusion medium is stopped, the surgeon and the anesthesiologist-resuscitator, together with the transfusiologist, are obliged to find out the cause of hemodynamic disorders. If nothing but transfusion could cause them, then this hemotransfusion medium is not transfused, the issue of further transfusion therapy is decided by them, depending on clinical and laboratory data.
A biological test, as well as an individual compatibility test, is also mandatory in cases where an individually selected in the laboratory or phenotyped erythrocyte mass or suspension is transfused.
After the end of the transfusion, the donor container with a small amount of the remaining hemotransfusion medium used for testing for individual compatibility must be stored for 48 hours at a temperature of +2 0 С ... +8 0 С.
After the transfusion, the recipient observes bed rest for two hours and is observed by the attending physician or the doctor on duty. Every hour his body temperature and blood pressure are measured, fixing these indicators in the patient's medical record. The presence and hourly volume of urination and the color of urine are monitored. The appearance of a red color of urine while maintaining transparency indicates acute hemolysis. The next day after the transfusion, a clinical analysis of blood and urine is mandatory.
In case of outpatient blood transfusion, the recipient after the end of the transfusion should be under the supervision of a doctor for at least three hours. Only in the absence of any reactions, the presence of stable blood pressure and pulse, normal urination, the patient can be released from the hospital.
Determination of indications for blood transfusion
Blood transfusion is a serious intervention for the patient, and indications for it must be justified. If it is possible to provide effective treatment of the patient without a blood transfusion, or it is not certain that it will benefit the patient, it is better to refuse a blood transfusion. Indications for blood transfusion are determined by the purpose that it pursues: compensation for the missing volume of blood or its individual components; increased activity of the blood coagulation system during bleeding. Absolute indications for blood transfusion are acute blood loss, shock, bleeding, severe anemia, severe traumatic operations, including those with cardiopulmonary bypass. Indications for transfusion of blood and its components are anemia of various origins, blood diseases, purulent-inflammatory diseases, severe intoxication.
Definition of contraindications to blood transfusion
Contraindications for blood transfusion include:
1) decompensation of cardiac activity with heart defects, myocarditis, myocardiosclerosis; 2) septic endocarditis;
3) hypertension stage 3; 4) violation of cerebral circulation; 5) thromboembolic disease; 6) pulmonary edema; 7) acute glomerulonephritis; 8) severe liver failure; 9) general amyloidosis; 10) allergic condition; 11) bronchial asthma.
Definition of indications
^ Patient preparation to blood transfusion. In the patient
admitted to the surgical hospital, determine the blood type and Rh factor.
Studies of the cardiovascular, respiratory, urinary
systems in order to identify contraindications to blood transfusion. 1-2 days before
transfusions produce a complete blood count, before transfusion of the patient's blood
should empty the bladder and bowels. Blood transfusion is best
in the morning on an empty stomach or after a light breakfast.
Choice of transfusion environment, transfusion method. Transfusion of whole
blood for the treatment of anemia, leukopenia, thrombocytopenia, coagulation disorders
system, when there is a deficiency of individual blood components, is not justified, since
how other factors are spent to replenish individual factors, the need for
the introduction of which the patient is not. The therapeutic effect of whole blood in such cases
lower, and the blood flow is much greater than with the introduction of concentrated
blood components, for example, erythrocyte or leukocyte mass, plasma,
albumin, etc. So, with hemophilia, the patient needs to enter only factor VIII.
To cover the needs of the body in it at the expense of whole blood, it is necessary
inject a few liters of blood, while this need can only be met
a few milliliters of antihemophilic globulin. With plaster and
afibrinogenemia, it is necessary to transfuse up to 10 liters of whole blood to replenish
fibrinogen deficiency. Using the fibrinogen blood product, it is enough to inject
its 10-12 g. Transfusion of whole blood can cause sensitization of the patient,
the formation of antibodies to blood cells (leukocytes, platelets) or plasma proteins,
which is fraught with the risk of severe complications with repeated blood transfusions or
pregnancy. Whole blood is transfused for acute blood loss with a sharp
decrease in BCC, with exchange transfusions, with cardiopulmonary bypass during
time of open heart surgery.
When choosing a transfusion medium, one should use the component in which
the patient needs, also using blood substitutes.
The main method of blood transfusion is intravenous drip using
subcutaneous vein punctures. With massive and prolonged complex transfusion
therapy, blood along with other media is injected into the subclavian or external
jugular vein. In extreme situations, blood is injected intra-arterially.
Grade validity canned blood and its components for
transfusions. Before transfusion determine the suitability of blood for
transfusions: take into account the integrity of the package, expiration date, violation of the regime
storage of blood (possible freezing, overheating). Most expedient
transfuse blood with a shelf life of no more than 5-7 days, since with elongation
storage period in the blood, biochemical and morphological changes occur,
which reduce its positive properties. On macroscopic examination, blood
must have three layers. At the bottom is a red layer of erythrocytes, it is covered
a thin gray layer of leukocytes and a slightly transparent
yellowish plasma. Signs of unsuitable blood are: red or
pink coloration of the plasma (hemolysis), the appearance of flakes in the plasma, turbidity,
the presence of a film on the surface of the plasma (signs of blood infection), the presence
clots (blood clotting). For urgent transfusion of unsettled blood
5. Wit Stetten's symptom- swelling of the left lower quadrant of the abdomen with perforation of the duodenum.
SYMPTOMS: DETECTED WHEN PERCUSSION OF THE PATIENT'S ABDOMEN:
1. Symptom Spizharny-Clark- high tympanitis with percussion between the xiphoid process and the navel. Disappearance of hepatic dullness.
SYMPTOMS DETECTED WHEN AUSCULTATION IN THE ABDOMINAL OF THE PATIENT:
1. Symptom, Brown- crepitus, heard when pressing with a phonendoscope on the right side wall of the abdomen.
2. Brenner's sign- a metallic friction noise, heard over the XII rib on the left in the patient's sitting position. Associated with the release of air bubbles into the subdiaphragmatic space through the perforation.
3. Brunner's sign- diaphragm friction noise, heard under the costal margin (left and right) due to the presence of gastric contents between the diaphragm and the stomach.
4. Gusten's triad- distinct listening to heart tones through the abdominal cavity to the level of the navel, friction noise in the hypochondrium and epigastrium and metallic or silvery noise appears during inspiration and is associated with the release of free gas into the abdominal cavity through the perforation.
Gusten's triad includes the previously described symptoms of Lotey-sen-Bailey-Federechy-Kleybruk-Gyusten, Brenner, Brunner.
OBSTRUCTION OF THE INTESTINE
SYMPTOMS DETECTED IN COMPLAINTS OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Symptom Cruvelier - blood in the stools, cramping pains in the abdomen and tenesmus. characteristic of intussusception.
2. Symptom of Tiliax- pain, vomiting, gas retention. characteristic of intussusception.
3. Carnot sign- pain in< эпигастрии, возникающая при резком разгибании туловища. Характерно для спаечной болезни.
4. Symptom Koenig- reduction of pain after rumbling above and to the left of the navel. Characteristic of chronic duodenostasis.
SYMPTOMS DETECTED AT A GENERAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Val's symptom- stretched intestinal loop, contouring through the anterior abdominal wall.
2. Symptom Shlange-Grekov- intestinal peristalsis visible through the abdominal wall.
3. Bayer's sign- asymmetrical bloating.
4. Symptom of Bouvre-Anshyutz - protrusion in the ileocecal region with obstruction of the colon.
5. Borchardt's triad- swelling in the epigastric region and the left hypochondrium, the impossibility of probing the stomach and vomiting, which does not bring relief. It is observed with torsion of the stomach.
6. Triad Delbe- rapidly growing effusion in the abdominal cavity, bloating, vomiting. Observed with volvulus of the small intestine.
7. Symptom of Karevsky- sluggish current intermittent intestinal obstruction. Observed with intestinal obstruction caused by gallstones.
SYMPTOMS DETECTED BY PALPATION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Symptom of Leotte- the appearance of pain when pulling and shifting towards the skin fold of the abdomen. It is noted with adhesive disease.
2. Kocher's sign- pressure on the anterior abdominal wall and its rapid cessation do not cause pain.
3. Shiman-Dans symptom - on palpation in the region of the caecum, a void is determined, as it were. Observed with volvulus of the caecum.
4. Symptom of Schwartz- in the epigastrium, a painful elastic tumor is palpated with simultaneous bloating. It is observed with acute expansion of the stomach.
5. Symptom Tsulukidze- on palpation of the intussusceptum of the colon, a depression with folded edges is found, around which small tumor-like formations are palpated - fatty suspensions.
SYMPTOMS DETECTED DURING PERCUSSION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Symptom of Kivulya- with percussion of the abdomen and simultaneous auscultation, a sound with a metallic tinge is heard.
2. Wortmann's symptom- a sound with a metallic tinge is heard only over the swollen large intestine, and over the small intestine - the usual tympanitis.
3. Symptom Mathieu- splashing noise heard in the epigastrium with quick percussion over the navel.
SYMPTOMS DETECTED DURING AUSCULTATION OF THE ABDOMEN OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Sklyarov's symptom- splashing noise in the abdominal cavity.
2. Symptom of Spasokukotsky- - the noise of a "falling drop".
3. Symptom of Gefer- breath sounds and heart sounds are best heard over the constriction. seen in late stages.
SYMPTOMS DETECTED DURING THE FINGER RECAL EXAMINATION OF A PATIENT WITH INTESTINAL OBSTRUCTION:
1. Grekov's symptom-Hohenega- an empty ampoule-shaped rectum, the front wall of which is protruded by loops of intestines. The anus gapes. A synonym is "a symptom of the Obukhov hospital."
2. Trevs symptom - in the moment the fluid is injected into the rectum, a rumbling is heard at the site of obstruction.
3. Symptom of Zege von Manteuffel- with obstruction of the sigmoid colon, only 200 ml of water can be injected into the rectum. The patient does not hold large doses of water.
SYMPTOMS USED FOR DIFFERENTIAL
DIAGNOSTICS OF INTESTINAL OBSTRUCTION: 1
1. Symptom of Kadyan- for the differential diagnosis of pneumoperitoneum and intestinal paresis. With pneumoperitoneum, hepatic dullness disappears, percussion sound is uniform everywhere, and with intestinal paresis, hepatic dullness does not completely disappear, tympanic sound retains shades.
2. Symptom Babuk- differential diagnosis between a tumor and an intussusceptum. The absence of blood in the wash water after an enema and kneading of a pathological formation indicates the presence of a tumor.
1. Vicker M. M. Diagnosis and medical tactics in acute abdominal diseases (“acute abdomen”). North Caucasian regional publishing house. Pyatigorsk, 1936, 158 pages.
2. Lazovskie I. R. Handbook of clinical symptoms and syndromes. M. Medicine. 1981, pp. 5-102.
3. Lezhar F. Emergency surgery. Ed. N. N. Burdenko, vol. 1-2. 1936.
b4. Matyashin I. M. Symptoms and syndromes in surgery. Kyiv.
|Olshanetsky A. A. Health, 1982, 184 p.
in Gluzman A. M.
5. Mondor G. Urgent diagnosis. Belly, vol. 1-2, M-L. Medgiz, 1939.
Grandma symptom.
Babuka s. - possible sign intestinal intussusception: if there is no blood in the wash water after the enema, the abdomen is palpated for 5 minutes. With intussusception, often after repeated siphon enema, the water looks like meat slops.
Karevsky's syndrome.
Karevsky s. - observed with gallstone intestinal obstruction: sluggish current alternation of partial and complete obstructive intestinal obstruction.
Obukhov hospital, Hochenegg symptom.
Obukhov hospital with. - a sign of volvulus of the sigmoid colon: an enlarged and empty ampoule of the rectum during rectal examination.
Rush sign.
Ruscha s. - observed with intussusception of the colon: the occurrence of pain and tenesmus on palpation of a sausage-like tumor on the abdomen.
Symptom of Spasokukotsky.
Spasokukotsky village. - a possible sign of intestinal obstruction: the sound of a falling drop is determined by auscultation.
Sklyarov's symptom
Sklyarova s. - a sign of obstruction of the colon: in the stretched and swollen sigmoid colon, splashing noise is determined.
Titov's symptom.
Titova s. - a sign of adhesive obstruction: the skin-subcutaneous fold along the line of the laparotomic postoperative scar is grasped with fingers, sharply lifted up and then smoothly lowered. Localization of pain indicates the place of adhesive intestinal obstruction. With a mild reaction, several sharp twitches of the fold are produced.
Symptom Alapy.
Alapi s. - Absence or slight tension of the abdominal wall with intussusception of the intestine.
Anschotz symptom.
Anschutz s. - swelling of the caecum with obstruction of the lower parts of the colon.
Bayer symptom.
Bayer s. - asymmetry of bloating. Observe with volvulus of the sigmoid colon.
Bailey's symptom.
Bailey s. - a sign of intestinal obstruction: the transmission of heart tones to the abdominal wall. The value of the symptom increases when listening to heart sounds in the lower abdomen.
Symptom Bouveret.
Bouveret s. - a possible sign of colon obstruction: protrusion in the ileocecal region (if the caecum is swollen, the obstruction occurs in the transverse colon, if the caecum is in a collapsed state, then the obstruction is in good shape).
Symptom Cruveillhier.
Cruvelier s. - characteristic of intussusception: blood in the stool or blood-colored mucus, in combination with cramping pain in the abdomen and tenesmus.
Symptom Dance.
Dansa s. - a sign of ileocecal invagination: due to the movement of the invaginated segment of the intestine, the right iliac fossa is empty on palpation.
Symptom Delbet.
Triad Delbet.
Delbe s. - observed with volvulus of the small intestine: rapidly increasing effusion in the abdominal cavity, abdominal distension and non-fecaloid vomiting.
SymptomDurant.
Duran s. - observed at the beginning of invagination: a sharp tension of the abdominal wall, according to the place of implementation.
Symptom Frimann-Dahl.
Freeman-Dal s. - with intestinal obstruction: in the loops of the small intestine stretched by gas, the transverse striation is determined radiologically (corresponding to the Kerckring folds).
Gangolphe symptom.
Gangolfa s. - observed with intestinal obstruction: dullness of sound in sloping areas of the abdomen, indicating the accumulation of free fluid.
Hintze symptom.
Gintze s. - X-ray sign indicates acute intestinal obstruction: the accumulation of gas in the colon is determined, which corresponds to Val's symptom.
Hirschsprung symptom.
Hirschsprung s. - observed with intussusception of the intestine: relaxation of the sphincters of the anus.
Symptom Hofer.
Gefera s. - with intestinal obstruction, the pulsation of the aorta is best heard above the level of narrowing.
Kiwul symptom.
Kivulya s. - a sign of obstruction of the large intestine (with volvulus of the sigmoid and caecum): a metallic sonority is determined in the stretched and swollen sigmoid colon.
Symptom Kocher.
Kocher s. - observed with intestinal obstruction: pressure on the anterior abdominal wall and its rapid cessation do not cause pain.
Kloiber symptom.
Kloiber s. - X-ray sign of intestinal obstruction: with a survey fluoroscopy of the abdominal cavity, horizontal levels of fluid and gas bubbles above them are detected.
Symptom Lehmann.
Lehmann s. - X-ray sign of intussusception of the intestine: a filling defect flowing around the head of the intussusceptum has a characteristic appearance: two lateral strips of a contrast agent between the perceiving and invaginated intestinal cylinders.
Symptom Mathieu.
Mathieu s. - a sign of complete intestinal obstruction: with rapid percussion of the supra-umbilical region, splashing noise is heard.
Symptom Payr.
Payra s. - "double-barreled", caused by a kink of the movable (due to excessive length) transverse colon at the point of transition to the descending colon with the formation of an acute angle and a spur that inhibit the passage of intestinal contents. Clinical signs; pain in the abdomen, which radiates to the region of the heart and the left lumbar region, burning and swelling in the left hypochondrium, shortness of breath, pain behind the sternum.
Symptom of Schiman.
Shiman s. - a sign of intestinal obstruction (volvulus of the caecum): palpation is determined by a sharp pain in the right iliac region and a feeling of "emptiness" in the place of the caecum
Schlange symptom (I).
Hose with - a sign of intestinal paralysis: when listening to the abdomen, there is complete silence; usually seen in ileus.
Schlange symptom (II).
Hose with - visible peristalsis of the intestine with intestinal obstruction.
Symptom of Stierlin.
Stirlin s. - X-ray sign of intestinal obstruction: a stretched and tense intestinal loop corresponds to a zone of accumulation of gases in the form of an arch
Taevaenar symptom.
Tevenara s. - a sign of small bowel obstruction: the abdomen is soft, palpation reveals soreness around the navel and especially below it by two fingers of the transverse fingers along the midline. The point of pain corresponds to the projection of the root of the mesentery.
Symptom of Tilijaks.
Tiliaxa s. - observed with nvagination of the intestine, abdominal pain, vomiting, tenesmus and stool retention, non-excretion of gases.
Treves symptom.
Trevsa s. - a sign of colonic obstruction: at the time of the introduction of fluid into the colon, rumbling at the site of obstruction is auscultated.
Watil symptom.
Valya s. - a sign of intestinal obstruction: local flatulence or protrusion of the intestine above the level of the obstacle (visible asymmetry of the abdomen, palpable intestinal bulge, peristalsis visible to the eye, tympanitis audible with percussion).
symptom of Kocher-Volkovich - the movement of pain from the epigastric region to the right lower quadrant of the abdomen.
Symptom Kocher-Volkovich is characteristic of acute appendicitis
2. Symptom "splash noise".
Gurgling sound in the stomach, heard in the supine position with short, quick strokes of the fingers on the epigastric region; indicates the presence of gas and liquid in the stomach, for example, with hypersecretion of the stomach or with a delay in the evacuation of its contents. with pyloric stenosis)
Ticket number 2.
1. Determination of the size of the hernial orifice.
Determining the size of the hernia orifice is possible only with reducible hernias (with irreducible strangulated hernias, it is impossible to determine the hernial orifice).
After reduction of the hernia with the tips of one or more fingers, the size of the hernial orifice in two dimensions or their diameter (in cm), as well as the condition of their edges, are determined.
Hernial orifices are the most accessible for research in umbilical, epigastric and median postoperative hernias, in hernias of other localization they are less accessible.
The determination of the hernial ring in umbilical hernias is carried out by palpation of the bottom of the umbilical fossa.
In case of inguinal hernias, the examination of the hernial orifice (external inguinal ring) in men is carried out in the position of the patient lying down, with the index or 3rd finger through the lower pole of the scrotum.
2.Technique and interpretation of these cholegrams before and intraoperative.
Interpretation of the data of endoscopic retrograde choledochal pancreatography (ERCP): the size of the intrahepatic bile ducts, hepaticocholedochus, the presence of calculi in the gallbladder, choledochus, narrowing of the distal choledochus, contrasting of the Wirsung duct, etc.
Intraoperative cholangiography technique:
b) a water-soluble contrast agent (bilignost, biligrafin, etc.) is injected by puncture or through the cystic duct; after the injection of a contrast agent, a picture is taken on the operating table.
The morphological state of the biliary tract is assessed - the shape, size, presence of stones (cellularity, marbling of the shadow or its absence (“silent bubble”), the presence of filling defects); length, tortuosity of the cystic duct, width of the common bile duct; the flow of contrast into the duodenum.
Ticket number 3.
1. Palpation of the gallbladder (symptom of Courvoisier).
Palpation of the gallbladder is performed in the area of its projection (the point of intersection of the outer edge of the rectus abdominis muscle and the costal arch, or slightly lower if there is an increase in the liver), in the same position of the patient and according to the same rules as during palpation of the liver.
An enlarged gallbladder can be palpated as a pear-shaped or ovoid formation, the nature of the surface of which and the consistency depend on the condition of the gallbladder wall and its contents.
In the case of obstruction of the common bile duct by a stone, the gallbladder relatively rarely reaches large sizes, since the long-term sluggish inflammatory process that occurs in this case limits the extensibility of its walls. They become lumpy and painful. Similar phenomena are observed with a tumor of the gallbladder or the presence of stones in it.
It is possible to feel the bladder in the form of a smooth, elastic, pear-shaped body in case of obstruction of the exit from the bladder (for example, with a stone or with empyema, with dropsy of the gallbladder, compression of the common bile duct, for example, with cancer of the pancreatic head - Courvoisier-Guerrier symptom).
Symptom Courvoisier (Courvoisier): palpation of an enlarged distended painless gallbladder in combination with obstructive jaundice caused by a tumor.