X-ray diagnosis of acquired intestinal obstruction. Diagnosis of acute intestinal obstruction X-ray symptoms of intestinal obstruction
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The use of instrumental research methods for suspected intestinal obstruction is intended both to confirm the diagnosis and to clarify the level and cause of the development of this pathological condition.
X-ray examination- the main special method for diagnosing acute intestinal obstruction. It should be carried out at the slightest suspicion of this condition. Typically, a plain fluoroscopy (x-ray) of the abdominal cavity is performed first. In this case, the following symptoms may be identified.
Intestinal arches(Fig. 48-1) occur when the small intestine is inflated with gases, while horizontal levels of liquid are visible in the lower knees of the arch, the width of which is inferior to the height of the gas column. They characterize the predominance of gas over the liquid contents of the intestine and occur, as a rule, in relatively earlier stages of obstruction.
Rice. 48-1. Plain radiograph of the abdominal cavity. The intestinal arches are visible.
Kloiber bowls(Fig. 48-2) - horizontal levels of liquid with a dome-shaped clearing (gas) above them, looking like a bowl turned upside down. If the width of the liquid level exceeds the height of the gas bubble, then most likely it is localized in the small intestine. The predominance of the vertical size of the bowl indicates the localization of the level in the colon. In conditions of strangulation obstruction, this symptom can occur within 1 hour, and in case of obstructive obstruction - after 3-5 hours from the moment of illness. With small intestinal obstruction, the number of cups varies; sometimes they can be layered one on top of the other in the form of a stepped ladder. Low-grade colonic obstruction in late stages can manifest itself at both colonic and small-bowel levels. The location of Kloiber's cups at the same level in one intestinal loop usually indicates deep intestinal paresis and is characteristic of the late stages of acute mechanical or paralytic intestinal obstruction.
Rice. 48-2. Plain radiograph of the abdominal cavity. Small intestinal fluid levels - Kloiber cups.
Symptom of featheriness(transverse striation of the intestine in the form of an extended spring) occurs with high intestinal obstruction and is associated with edema and distension of the jejunum, which has high circular folds of the mucosa (Fig. 48-3).
Rice. 48-3. Plain radiograph of the abdominal cavity. Symptom of pinnateness (stretched spring).
X-ray contrast examination of the gastrointestinal tract used when there are difficulties in diagnosing intestinal obstruction. Depending on the expected level of intestinal occlusion, a suspension of barium sulfate is either given orally (signs of high obstructive obstruction) or administered by enema (symptoms of low obstruction). The use of a radiopaque contrast agent (in a volume of about 50 ml) involves repeated (dynamic) study of a passage of barium sulfate suspension. Its retention for more than 6 hours in the stomach and 12 hours in the small intestine gives reason to suspect a violation of intestinal patency or motor activity. In case of mechanical obstruction, the contrast mass does not reach below the obstacle (Fig. 48-4).
Rice. 48-4. X-ray of the abdominal cavity with obstructive small bowel obstruction 8 hours after taking a suspension of barium sulfate. Contrasted fluid levels are visible in the stomach and the initial part of the small intestine. The intestinal featheriness is clearly visible.
When using emergency irrigoscopy it is possible to detect obstruction of the colon by a tumor (Fig. 48-5), as well as detect the trident symptom (a sign of ileocecal intussusception).
Rice. 48-5. Irrigogram. Tumor of the descending colon with resolved intestinal obstruction.
Colonoscopy plays an important role in the timely diagnosis and treatment of tumor colonic obstruction. After using enemas for therapeutic purposes, the distal (discharge) section of the intestine is cleared of fecal residues, which allows for a full endoscopic examination. Its implementation makes it possible not only to accurately localize the pathological process, but also to perform intubation of the narrowed part of the intestine, thereby resolving the manifestations of acute obstruction and performing surgery for cancer in more favorable conditions.
Ultrasound The abdominal cavity has little diagnostic capabilities in acute intestinal obstruction due to severe pneumatization of the intestine, which complicates the visualization of the abdominal organs.
However, in some cases, this method makes it possible to detect a tumor in the colon, an inflammatory infiltrate or the head of the intussusception, and to visualize stretched, fluid-filled intestinal loops (Fig. 48-6) that do not peristalt.
Rice. 48-6. Ultrasound scan for intestinal obstruction. Distended, fluid-filled intestinal loops are visible.
A.I. Kirienko, A.A. Matyushenko
Intestinal obstruction (Latin ileus) is a syndrome characterized by partial or complete disruption of the movement of contents along the digestive canal and caused by a mechanical obstruction or disruption of intestinal motor function
Classification
According to morphofunctional characteristics:
Dynamic (functional) intestinal obstruction - the motor function of the intestinal wall is impaired without a mechanical obstacle to the movement of intestinal contents:
Paralytic intestinal obstruction (as a result of decreased tone of intestinal myocytes);
Spastic intestinal obstruction (as a result of increased tone);
Mechanical intestinal obstruction is occlusion of the intestinal tube at any level, which causes disruption of intestinal transit:
Strangulated intestinal obstruction (Latin strangulatio - “suffocation”) - occurs when the intestinal mesentery is compressed, which leads to malnutrition. Classic examples of strangulated intestinal obstruction are volvulus, nodulation, and strangulation.
Obstructive intestinal obstruction (lat. obturatio - “blockage”) - occurs when there is a mechanical obstruction to the movement of intestinal contents:
intraintestinal without connection with the intestinal wall - the cause may be large gallstones that have entered the intestinal lumen through an internal biliary fistula, fecal stones, helminths, foreign bodies;
intraintestinal, coming from the intestinal wall - tumors, cicatricial stenoses;
extraintestinal - tumor, cysts;
Mixed intestinal obstruction (combination of strangulation and obstruction):
Intussusception as a result of intussusception;
Adhesive intestinal obstruction, which develops due to compression of the intestine by abdominal adhesions.
According to the clinical course: acute and chronic;
According to the level of obstruction: high (small intestinal, proximal to the ligament of Treitz) and low (colic, distal to the ligament of Treitz);
According to the passage of chyme: complete and partial;
By origin: congenital and acquired.
Main symptoms
Abdominal pain is a constant and early sign of obstruction, usually occurring suddenly, regardless of food intake, at any time of the day, without warning; the nature of the pain is cramping. Attacks of pain are associated with a peristaltic wave and are repeated after 10-15 minutes. During the period of decompensation, depletion of energy reserves of the intestinal muscles, the pain begins to be permanent. With strangulation obstruction, the pain is immediately constant, with periods of intensification during a wave of peristalsis. As the disease progresses, acute pain usually subsides on days 2–3, when intestinal peristaltic activity stops, which is a poor prognostic sign. Paralytic intestinal obstruction occurs with constant dull arching pain in the abdomen;
Retention of stool and gases is a pathognomonic sign of intestinal obstruction. This is an early symptom of low obstruction. If its character is high, at the beginning of the disease, especially under the influence of therapeutic measures, there may be stools, sometimes multiple times due to bowel movements located below the obstacle. With intussusception, bloody discharge sometimes appears from the anus. This can cause a diagnostic error when acute intestinal obstruction is mistaken for dysentery;
Bloating and asymmetry of the abdomen;
Vomiting - after nausea or on its own, often repeated vomiting. The higher the obstacle in the digestive tract, the earlier the vomiting occurs and is more pronounced, repeated, and indomitable. Vomiting is initially mechanical (reflex), and then central (intoxication).
Specific symptoms
Val's symptom is a relatively stable, non-moving asymmetrical bloating, noticeable to the eye and detectable by touch;
Shlange's symptom - visible peristalsis of the intestines, especially after palpation;
Sklyarov's symptom - listening to a “splashing noise” over the intestinal loops;
Spasokukotsky-Wilms symptom - “the noise of a falling drop”;
Kivul's symptom is an increased tympanic sound with a metallic tint over a distended loop of intestine;
The symptom of the Obukhov hospital is a sign of low colonic obstruction: balloon-shaped swelling of the empty ampulla of the rectum against the background of a gaping anus;
The Tsege–Manteuffel symptom is a sign of low colonic obstruction: low capacity (no more than 500–700 ml of water) of the distal intestine when performing a siphon enema;
Mondor's symptom - increased intestinal peristalsis is replaced by a gradual extinction of peristalsis (“Noise at the beginning, silence at the end”);
“Dead (grave) silence” - absence of peristalsis sounds; an ominous sign of intestinal obstruction. During this period, with a sharp bloating of the abdomen, you can hear not peristalsis above it, but respiratory sounds and heart sounds, which normally are not conducted through the abdomen;
Schiemann's symptom - with volvulus of the sigmoid colon, the swelling is localized closer to the right hypochondrium, while in the left iliac region, that is, where it is usually palpated, a retraction of the abdomen is noted;
Thevenard's symptom (with strangulation obstruction due to volvulus of the small intestine) is a sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of its mesentery is usually projected.
Intestinal obstruction may be due to the following reasons:
Congenital diseases;
Developmental anomalies;
Spikes;
Development of fibrous tissue (for example, in Crohn's disease);
Tumors.
In case of obstruction, swelling of the prestenotic part of the intestine and collapse of the poststenotic part are noted.
X-ray methods for detecting intestinal obstruction:
Survey fluoroscopy with the patient in an upright position;
Barium contrast (oral or with a contrast enema), if partial obstruction is suspected, to clarify its presence, level and nature.
The main radiological symptom is the presence in the abdominal cavity of multiple pathological levels of fluid with gas above them, which are called “Kloiber cups”.
It is necessary to distinguish small intestinal obstruction from large intestinal obstruction; the location of the Kloiber cups and their characteristics are important here.
For small bowel obstruction:
Pathological levels are located mainly in the central parts of the abdominal cavity;
The diameter of the levels exceeds the height, since the small intestine is capable of stretching;
In the swollen loops of intestine above the levels, transverse folds of the mucous membrane are visible;
Loops of intestine, distended with air, can give a symptom of “arches” above the levels.
For colonic obstruction:
Kloiber's bowls are usually located along the periphery;
The diameter of the levels is less than their height, since the large intestine is not able to expand as much as the small intestine due to the haustra;
In the swollen loops above the levels, haustral retractions can be seen along the contours.
TICKET 12
Exudative pleurisy
This is a disease characterized by damage to the pleura with the subsequent formation of fluid of various natures in its cavity. Most often, this disease acts as a secondary factor of any pathological changes.
Etiology:
Most infectious exudative pleurisy is a complication of pathological pulmonary processes. Moreover, about 80% of cases of hydrothorax are detected in patients with pulmonary tuberculosis.
-Non-infectious exudative pleurisy develops against the background of a variety of pulmonary and extrapulmonary pathological conditions.
Chronic renal failure;
Trauma to the chest, in which hemorrhage began in the pleural cavity;
Blood tumors are predominantly malignant;
Chronic circulatory failure;
Pulmonary infarction;
Cirrhosis of the liver (a common cause of right-sided hydrothorax);
Autoimmune connective tissue diseases. These include collagenosis, rheumatism, etc.;
Carcinomatosis, mesothelioma and other malignant tumor formations in the lungs;
With inflammation of the pancreas, left-sided hydrothorax may develop.
Classification:
Exudative pleurisy, according to its etiology, is divided into infectious and aseptic.
Taking into account the nature of exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chylous (chylothorax), purulent (pleural empyema), putrefactive, mixed.
According to the flow they distinguish acute, subacute and chronic exudative pleurisy.
Depending on the location of the exudate, pleurisy may be diffuse or encysted (limited). Enclosed exudative pleurisy, in turn, is divided into apical (apical), parietal (paracostal), bone-diaphragmatic, diaphragmatic (basal), interlobar (interlobar), paramediastinal.
X-ray semitics:
The X-ray picture of exudative pleurisy depends on how much exudate has formed and has not undergone resorption (reabsorption) by the pleural layers. Minimal effusion can be suspected when indirect manifestations appear. These include:
- High aperture position.
- Restriction or impairment of her mobility.
- A sharp increase in the distance between the pulmonary field and the gas bubble (more than 1.5 cm, while the normal value does not exceed 0.5 cm).
Bilateral supradiaphragmatic pleurisy
The first thing people pay attention to is the sinuses. These are a kind of pockets formed by the pleura in the phrenic-costal region. In the absence of pathology, the sinuses are free and represent angles directed downwards (between the edges of the ribs laterally and the diaphragm medially). If the costophrenic sinuses are darkened, this indicates the involvement of the pleura in the process of inflammation. Or there is another disease accompanied by increased fluid synthesis.
The next possible radiological sign of the appearance of fluid in the pleural fissures is a mantle-like darkening. This term reflects the appearance of a shadow that covers the entire lung surface like a cloak. Darkening can be seen on the lateral side of the chest, as well as along the interlobar pleural groove (it divides the lung into lobes). With an increase in the volume of accumulating liquid, the upper border of the darkened area on the x-ray image is smoothed out. The level of this border along the ribs determines the degree of hydrothorax - a condition characterized by massive effusion into the pleural fissure of various etiologies and pathogenesis. But exudative pleurisy rarely reaches such proportions and is limited to the sinuses.
The posterior costophrenic sinus is not visible
The accumulation of a large amount of pleural fluid, regardless of the cause, leads to a phenomenon such as a displacement of the mediastinum (median shadow) in the direction opposite to the affected one (this applies to unilateral pleurisy). The extent of this shift depends on a number of factors:
- Exudate volume.
- The level of the diaphragm.
- Degree of mobility of mediastinal structures.
- Functional state of pulmonary formations
When the patient is examined in a horizontal position, a more intense shadow appears in the lateral areas of the chest. This symptom bears the author’s name – the Lenk phenomenon. It is played in a horizontal position or Trendelenburg position. Also typical for this situation is a decrease in such an indicator as the transparency of the lung tissue. It is homogeneous and diffuse.
Free fluid spread along the chest wall in a layer of 3.2 cm
Pleurisy involving the mediastinal (mediastinal) pleura is not detected so often. Its characteristics:
- Additional darkening in the mid-shadow area.
- The clarity of the contours of these formations.
- A variety of shadow shapes: triangular, spindle-shaped or strip-shaped (ribbon-shaped).
When the effusion is located in the interlobar pleura, the X-ray picture has its own peculiarity. It lies in the fact that the darkening is located along the border between the lobes of the lungs. In this case, the shadows resemble lenses: they have the form of symmetrical formations with biconcave or biconvex outlines. The mediastinum usually does not move intact anywhere with this form of pleurisy.
. 
interlobar pleurisy
If the exudate is not reabsorbed in a timely manner, the risk of such an outcome as pleural adhesions, moorings, which will limit the respiratory excursion of the lungs, increases.
Ensacculated pleurisy of the small interlobar fissure.
X-ray symptoms of intestinal obstruction
Diagnosis of intestinal obstruction is usually aimed at determining and clarifying its nature, differentiating mechanical obstruction from paralytic, establishing the level of obstruction, and the state of blood supply to the affected area.
There are mechanical and dynamic intestinal obstruction.
Dynamic (functional or paralytic) obstruction develops reflexively in various critical conditions: peritonitis, pancreatitis, abscesses of the abdominal cavity and retroperitoneal space, perforations of hollow organs, attacks of urolithiasis, impaired mesenteric circulation, poisoning with various drugs, after surgical trauma.
The leading sign of paralytic obstruction is a decrease in tone, swelling of the small and large intestines. Kloiber's cups are usually absent in cases of paralytic obstruction.
In case of paralytic intestinal obstruction, water-soluble contrast agents can be used, since they, having laxative properties, can accelerate the movement of intestinal contents, thereby providing a therapeutic effect.
Mechanical small bowel obstruction. The cause of mechanical small intestinal obstruction is most often strangulation (volvulus, nodulation), strangulation, intussusception, and less often - obturation.
Classic radiological signs of mechanical small bowel obstruction, detected by plain radiography of the abdomen, are:
1) overstretched loops of the small intestine above the site of obstruction with the presence of transverse striations due to kerkring folds;
2) the presence of liquid and gas levels in the lumen of the small intestine (Kloiber cup);
3) air arches;
4) absence of gas in the colon.
Normally, the small intestine, unlike the large intestine, does not contain gas. However, with severe intestinal obstruction, gas leaves the colon naturally and therefore may not be detected on x-rays. The absence of gas in the colon indicates complete obstruction of the small intestine. With high small bowel obstruction, a small amount of gas is detected in the jejunum, since the contents of the jejunum, located proximal to the site of obstruction, are thrown into the stomach.
A relatively early sign of small bowel obstruction is isolated small bowel distension without fluid levels ("isolated loop" sign). In the vertical position of the patient, the arcuately curved loop of the small intestine, inflated with gas, looks like an arch. Then the liquid levels appear, which initially look like the letter "J" with a gas bubble above the two liquid levels located at different heights. Sometimes you can see fluid pouring from one loop to another. As the liquid accumulates, both levels are connected, resulting in the appearance of an inverted bowl (Kloiber's bowl).
Kloiber's cups are the most characteristic radiological sign of small intestinal obstruction. They are liquid levels with semi-oval gas accumulations located above them.
As obstruction increases with an increase in the amount of fluid, the arches can turn into cups, and when the amount of fluid decreases, the opposite picture occurs - the cups turn into arches.
In typical cases, Kloiber's small intestinal bowls differ from large intestinal ones in that the width of the liquid level in this bowl is greater than the height of the gas bubble above it. With obstruction of the colon, the relationship is the opposite - the height of the gas bubble is greater than the width of the liquid level.
Small intestinal obstruction is characterized by the presence of multiple cups in the center of the abdominal cavity, where the loops of the small intestine are located. As the obstruction progresses, the width of the fluid levels increases and the height of the air column decreases.
With obstruction in more distal parts of the small intestine, its dilated loops are located parallel to each other, forming a characteristic “stepladder” pattern on radiographs. Stretched loops of the small intestine are usually oriented in an oblique direction from the lower right to the left upper quadrant of the abdomen. In this case, the blockage area is usually located under the lowest level of liquid. Moderately distended loops of the small intestine can be easily distinguished on radiographs from gas-containing loops of the large intestine.
Small intestinal obstruction is characterized by transverse striations of the intestine, caused by the display of circularly located kerkring folds, extending over the entire diameter of the intestine. In this case, a picture appears that resembles an extended spring. Transverse striation is visible only in the jejunum; it is absent in the ileum, since the Kerckring folds are less pronounced there. As the small intestine stretches, the folded pattern blurs, and then it can be difficult to distinguish the loops of the small intestine from the large intestine.
The relief of the large intestine when it is swollen is represented by thicker and sparse semilunar folds separating the haustrae, which do not cross the entire diameter of the intestine.
With strangulation obstruction, a “fingerprint” symptom can be identified.
Mechanical colonic obstruction usually occurs due to obstruction of the lumen by a tumor; The most common cause of colon obstruction is colorectal cancer. The leading clinical signs of colonic obstruction are stool retention, flatulence and bloating. Clinical symptoms appear later than with small intestinal obstruction.
With obstruction of the large intestine, Kloiber cups are observed less frequently; more often there is a sharp suprastenotic bloating of the intestine.
With retrograde injection of a water-barium suspension or air, it is possible to establish the level of obstruction, as well as determine the nature of the obstructing tumor; a filling defect with uneven contours or its shadow against the background of the injected air is often detected.
Intussusception called the introduction of the proximal part of the intestine into the distal one. There are small bowel, small bowel-colic (ileocecal) and colonic intussusception. The most common is ileocecal intussusception.
Plain radiographs of the abdomen in the acute stage of proximal or distal small bowel obstruction reveal distended loops with fluid levels. With ileocecal intussusception, there is an absence of gas in the cecum and ascending colon. A valuable method for diagnosing colon intussusception is a contrast enema, which can also be a therapeutic procedure. After the administration of a contrast agent, the intussusception may straighten. Irrigoscopy may reveal the following signs: a filling defect of a semicircular shape, the morphological reflection of which is an invaginated colon, a symptom of a bident and a trident, a symptom 
cockades.
Inversion.
When a volvulus occurs, a segment of the intestine (small, cecum, or sigmoid) rotates around its own axis, and the blood circulation of the intestine is disrupted. Complete cessation of blood supply to the intestine quickly leads to the development of gangrene, followed by perforation and the development of peritonitis. The most common cause of bloat is eating a large amount of difficult-to-digest food after fasting. A predisposing factor leading to volvulus is a long mesentery with a narrow root. Early diagnosis of volvulus is critical for the prognosis of the disease. The overall picture depends on the level of volvulus: volvulus of the small intestine is manifested by a picture of high obstruction, and ileocecal volvulus is manifested by a picture of low obstruction.
With high volvulus, a plain radiograph shows swelling of the stomach and duodenum. The small intestine contains a lot of liquid and little gas. On photographs taken with the patient in an upright position and in a later position, fluid levels are visible. In subacute cases of obstruction, a water-soluble contrast agent is used to determine the level of obstruction. The contrast mass stops at the level of intestinal obstruction. However, according to contrast studies, the level of obstruction can be determined in no more than 50% of cases.
With cecal torsion, a significant expansion of the segment above the torsion occurs. In this case, the stretched segment shifts to the left mesogastric and epigastric region.
Sigmoid colon volvulus is characterized by the “car tire” symptom. It appears with a significant expansion of the intestinal loops above the torsion. At the same time, the intestine swells sharply, taking on the appearance of a swollen chamber divided by a central partition. Some researchers compare this picture with the shape of a coffee bean, divided by a partition into two lobes. When retrograde filling of the intestine using a contrast enema occurs, the area of the intestine below the obstruction takes on the appearance of a bird's beak. When turned clockwise, the beak is directed to the right; when the intestine is turned counterclockwise, it points to the left.
M. F. Otterson
Intestinal obstruction is a violation of the passage of intestinal contents.
I. Etiology
There are mechanical and functional causes of intestinal obstruction (Table 1). Mechanical obstruction is more common and usually requires surgical intervention. In 70-80/6 cases it is caused by obstruction of the small intestine, in 20-3096 - by the large intestine. In old age, with an increase in the incidence of tumor diseases and diverticulosis of the colon, the incidence of colonic obstruction also increases.
A. Pathology of the peritoneum, abdominal organs and abdominal walls.
The most common cause of small intestinal obstruction is adhesions that form after hernia repairs and operations on the abdominal organs. Adhesive obstruction often complicates surgical interventions in the lower abdominal cavity. In developing countries, among the causes of obstruction, strangulation of an external abdominal hernia ranks first. Volvulus is a pathological torsion of an intestinal loop. The most common cases are volvulus of the sigmoid (70-80% of cases) and cecum (10-20%). Volvulus of the sigmoid colon is observed with an excessively long mesentery (dolichosigma); constipation is often a provoking factor. Volvulus of the cecum is possible with a congenital violation of its fixation (mobile cecum). Mental disorders, advanced age and a sedentary lifestyle predispose to colonic volvulus. A loop of the small intestine can twist around a commissure or congenital cord of the peritoneum. When the small intestine is pinched at two points at once (by adhesions or hernial orifices), a “switched off” intestinal loop is formed. Sometimes the cause of obstruction is a large mass formation that compresses the large or small intestine from the outside.
B. Intestinal pathology.
Among intestinal diseases that cause intestinal obstruction, the most common are tumors. Colon tumors are more common than small intestinal tumors. In 50-70% of cases, colonic obstruction is caused by cancer; In 20% of patients with colon cancer, acute intestinal obstruction first manifests itself. Intestinal obstruction is typical for tumor localization in the left half of the colon. Volvulus and diverticulitis also more often affect the left half of the colon and are the second most common cause of colonic obstruction.
Table 1. Causes of intestinal obstruction
|
Mechanical
Pathology of the peritoneum, abdominal organs and abdominal walls |
Functional Spasmodic obstruction Hirschsprung's disease Pseudo-obstruction of the intestine |
In newborns, intestinal obstruction in most cases is caused by atresia. Atresia of the esophagus, anus and rectum are more common than atresia of the small intestine. Other causes of obstruction in newborns, in descending order of frequency, include: Hirschsprung's disease, incomplete intestinal rotation (Ladd's syndrome), and imeconium obstruction.
B. Obstruction of the intestine.
Intestinal obstruction may be caused by a foreign body swallowed or inserted into the anus. Less common is blockage of the colon with fecal stones and barium suspension; even more rarely - cholelithiasis. A gallstone that has passed into the intestinal lumen usually gets stuck in the area of the ileocecal valve.
D. Paralytic intestinal obstruction develops in almost every patient who has undergone abdominal surgery. Other common causes include pancreatitis, appendicitis, pyelonephritis, pneumonia, fractures of the thoracic and lumbar spine, and electrolyte disturbances. A list of causes of paralytic ileus is presented in Table 2.
D. Spastic obstruction is extremely rare - with poisoning with salts of heavy metals, uremia, porphyria.
E. Hirschsprung's disease (congenital aganglionosis of the colon) in newborns and children in the first months of life can be complicated by intestinal obstruction.
G. Pseudo-obstruction of the intestine is a chronic disease characterized by disorders of gastrointestinal motility (usually the small intestine, less often the large intestine and esophagus). Attacks of the disease occur with a clear clinical picture of mechanical obstruction, which is not confirmed either radiographically or during surgery. Sometimes the disease is familial in nature, sometimes combined with autonomic neuropathy or myopathy. However, in most cases the cause cannot be determined. When making a diagnosis, you need to rely on X-ray data; sometimes a diagnostic laparotomy is necessary. Timely differential diagnosis can reduce mortality and severity of complications of mechanical intestinal obstruction.
Table 2. Causes of paralytic ileus
|
Diseases of the peritoneum and abdominal organs: Inflammation, infection (appendicitis, cholecystitis, pancreatitis) Peritonitis: bacterial (intestinal perforation), aseptic (bile, pancreatic juice, gastric juice) Dehiscence of the surgical wound Mesenteric artery embolism Thrombosis of the mesenteric vein* or artery Intestinal ischemia: shock*, heart failure, use of vasoconstrictors Blunt abdominal trauma* Acute gastric dilatation Hirschsprung's disease Aortoarteritis (Takayasu's disease) with damage to the mesenteric arteries Diseases of the retroperitoneal and pelvic organs Infections: pyelonephritis, paranephritis Ureteral stone, ureteral obstruction Retroperitoneal hematoma: trauma, hemophilia, anticoagulant therapy Tumor: primary (sarcoma, lymphoma) or metastasis Urinary retention Incarceration of the spermatic cord, testicular torsion Pelvic fracture Central nervous system diseases Spinal fracture: lumbar or thoracic Trauma, tumor of the brain or spinal cord Meningitis Diseases of the lungs and cardiovascular system Pulmonary embolism Pneumonia, especially lower lobe Empyema of the pleura Emphysema Intoxication and metabolic disorders
Potassium deficiency Sodium deficiency Medicines: ganglion blockers, anticholinergics Note: * Intestinal necrosis is possible. |
H. Acute disorders of mesenteric circulation.
Mesenteric artery occlusion may result from embolism or progressive atherosclerosis; it accounts for 75% of cases of obstruction caused by acute circulatory disorders. Mesenteric vein thrombosis accounts for the remaining 25%. Thrombosis of mesenteric veins often develops against the background of reduced perfusion. All types of acute circulatory disorders can lead to intestinal necrosis and are accompanied by high mortality, especially among the elderly.
II. Pathogenesis
A. Accumulation of gas in the intestine is the leading symptom of intestinal obstruction. Violation of the passage of intestinal contents is accompanied by intensive growth of aerobic and anaerobic bacteria that produce methane and hydrogen. However, most of the intestinal gas is swallowed air, the movement of which through the intestines is also impaired.
Normally, the gastrointestinal glands secrete about 6 liters of fluid during the day, most of which is absorbed in the small and large intestines. Stretching of the intestinal loops during obstruction further stimulates secretion, but inhibits absorption. The result is vomiting, which leads to loss of fluid and electrolytes. Hypokalemia and metabolic alkalosis develop.
B. Mechanical intestinal obstruction, in which blood circulation in the intestinal wall is disrupted, is called strangulation. This can occur when the intestine or its mesentery is strangulated, as well as when the pressure in the intestinal lumen exceeds intravascular pressure. As a result, ischemia, necrosis and perforation of the intestine develop. Early diagnosis of strangulation obstruction and urgent surgical intervention can prevent intestinal perforation, reduce the severity of the disease and reduce mortality. Preoperative preparation should be quick and include the correction of water and electrolyte disturbances.
B. Obstructive obstruction of the colon in cancer and diverticulitis is rarely accompanied by circulatory disorders. The exception is cases when the function of the ileocecal valve is preserved. In this case, the colon continues to stretch until perforation occurs. According to Laplace's law, the tension of the tube wall is directly proportional to its radius and internal pressure. Perforation most often occurs in the cecum, which has the largest radius and is therefore subject to greater distension than other parts of the colon. If the diameter of the cecum exceeds 10-12 cm, the likelihood of perforation is especially high.
III. Clinical picture
The clinical picture depends on the type of intestinal obstruction and the level of obstruction (Table 3). The main symptoms are nausea, vomiting, abdominal pain, bloating, stool and gas retention. Symptoms of peritoneal irritation are a sign of necrosis or perforation of the intestine. Leukocytosis (or leukopenia), fever, tachycardia, localized pain on palpation of the abdomen indicate an extremely serious condition of the patient (especially if all four signs are present).
During a physical examination, attention is paid to postoperative scars and strangulated hernias, sometimes this allows an immediate diagnosis. A rectal examination (fecal stones) and a stool test for occult blood are required. Blood in the stool may be due to Crohn's disease, malignancy, intestinal necrosis, or diverticulitis. If an enlarged liver with a lumpy surface is palpated, a metastatic tumor can be assumed. Auscultation of the lungs can reveal pneumonia, one of the causes of paralytic intestinal obstruction.
IV. X-ray examination
If intestinal obstruction is suspected, first of all, a survey X-ray of the abdominal cavity (standing and lying on the back) and chest (in the posterior non-anterior and lateral projections) is performed. A chest x-ray can rule out pneumonia. Using a CT scan of the abdomen, the level and cause of intestinal obstruction can be determined.
Table 3. Clinical picture for various types of intestinal obstruction
|
Type of obstruction |
Bloating, Vomiting |
Bowel sounds |
Pain on palpation |
||
|
Without circulatory disturbance High small intestinal |
Cramping, in the middle and upper third of the abdomen |
Appears at an early stage, mixed with bile, persistent |
Weak, spilled |
||
|
Low small intestinal |
Cramping, in the middle third of the abdomen |
Appears at an early stage |
Appears in later stages with stool odor |
Strengthened, waxing and waning in waves |
Weak, spilled |
|
Colon |
Cramping, in the middle and lower third of the abdomen |
Appears in later stages |
Appears very late with fecal odor |
Usually reinforced |
Weak, spilled |
|
Strangulation |
Constant, strong, sometimes localized |
stubborn |
Usually weakened but no clear pattern |
Strong, localized |
|
|
Paralytic |
Light, spilled |
Appears very early |
Weakened |
Weak, spilled |
|
|
Obstruction caused by acute disorders of mesenteric circulation |
Constant, in the middle third of the abdomen or back, can be very strong |
Appears at an early stage |
Weakened or absent |
Strong, diffuse or localized |
|
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The number of crosses reflects the severity of symptoms |
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Table 4. Radiological signs of intestinal obstruction
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Paralytic obstruction |
Mechanical obstruction |
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Gas in the stomach |
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Gas in the intestinal lumen |
Scattered throughout the large and small intestine |
Just proximal to the obstacle |
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Fluid in the intestinal lumen |
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Kloiber cups (X-ray in supine position) |
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Kloiber cups (standing X-ray) |
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Fluid levels in adjacent limbs of the intestinal loop (standing radiograph) |
They have approximately the same height - the arches, similar to inverted letters U, occupy mainly the middle third of the abdomen |
They have different heights - arches that look like inverted letters J. The number of crosses reflects the severity of symptoms |
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The number of crosses reflects the severity of symptoms |
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A. X-rays of the abdominal cavity reveal the accumulation of a large amount of gas in the intestinal lumen (Fig. 1). Usually, from the images it is possible to determine which loops of the intestine - small, large, or both - are distended with gas. In the presence of gas in the small intestine, spiral folds of the mucous membrane are clearly visible, occupying the entire diameter of the intestine (Fig. 2). When gas accumulates in the colon, haustrae are visible, which occupy only part of the diameter of the intestine (Fig. 3).
B. With mechanical small intestinal obstruction, there is little or no gas in the colon. With colonic obstruction and intact function of the ileocecal valve, significant swelling of the colon is noted; there may be no gas in the small intestine. Insufficiency of the ileocecal valve leads to distension of both the small and large intestines.
B. Radiographs taken in the standing or lateral decubitus position usually show horizontal levels of fluid and gas. Gas-filled intestinal loops look like overturned cups (Kloiber cups) or arches that look like inverted letters J and U. It can be quite difficult to distinguish paralytic intestinal obstruction from mechanical small bowel obstruction using plain fluoroscopy (Table 4). This requires an X-ray contrast examination of the intestine (with rapid injection of barium or water-soluble contrast into the jejunum through a pasogastric tube). If colonic obstruction is suspected, X-ray contrast studies are contraindicated.
V. Treatment
A. Mechanical intestinal obstruction, as a rule, requires urgent surgical intervention. The timing of the operation is determined by the severity of metabolic disorders, how long ago it occurred and the type of obstruction (if strangulation obstruction is suspected, the operation cannot be postponed). In the preoperative period, infusion therapy and correction of water and electrolyte disturbances are carried out, and intestinal decompression is started through a nasogastric or long intestinal tube. Antibiotics are prescribed, especially if strangulation obstruction is suspected.
B. The operation may be delayed in the following cases:
1. If intestinal obstruction develops in the early postoperative period, intestinal decompression is performed using a nasogastric or long intestinal tube. After some time, the adhesions may resolve and intestinal patency is restored.
2. In case of peritoneal carcinomatosis, they try to avoid surgery and perform intestinal decompression through a nasogastric tube. Typically, intestinal patency is restored within three days. If intestinal obstruction in such patients is due to a cause other than a tumor, surgery can significantly improve the condition.
3. Intestinal obstruction during exacerbation of Crohn's disease can be resolved with medication and intestinal decompression through a nasogastric or long intestinal tube.
4. For intussusception in children, conservative treatment is possible: observation and careful attempts to straighten the intussusception using hydrostatic pressure (barium enemas). In adults, this method is not applicable because it does not eliminate the underlying disease that caused the intussusception; urgent surgical intervention is indicated.
5. In case of chronic partial intestinal obstruction and radiation enteritis, surgery can be delayed only if there is no suspicion of strangulation obstruction.
B. The type of operation is determined by the cause of obstruction, the condition of the intestine and other surgical findings. Dissection of adhesions, hernia repair with plastic surgery of the hernial orifice (for internal and external abdominal hernias) are used. In case of space-occupying formations that obstruct the intestinal lumen, it may be necessary to create a bypass intestinal anastomosis, to create a colostomy proximal to the obstruction, or to perform intestinal resection followed by restoration of intestinal continuity.
There is still no consensus regarding the optimal treatment tactics for recurrent small intestinal mechanical obstruction. Two methods have been proposed: “splinting” the small intestine with a long intestinal tube and enteroplication.
From the editor
Rice. 1. Scheme of gas accumulation in the intestinal lumen in various types of intestinal obstruction.
