Intestinal impassability

Description:

Intestinal impassability - disturbance of passing of intestinal contents — the food masses and intestinal juice. Distinguish full and partial obstruction; on a current — acute, with sudden disturbance of passability of intestines, and chronic, developing gradually or shown repeated attacks of relative impassability owing to partial disturbance of passability at an adhesive desease (less often) at obturation of a gut slowly growing tumor. On the mechanism intestinal impassability can have dynamic and mechanical character.

Symptoms of Intestinal impassability:

Irrespective of its level and character, pain, vomiting, a delay of a chair and gases are inherent to all types of mechanical intestinal impassability. The main initial symptom of sharply arisen intestinal impassability — sudden severe, quite often cruel pain. At impassability it, as a rule, has skhvatkoobrazny character and matches the next peristaltic wave. In intervals between pains the patient can feel absolutely healthy, the characteristic initial picture of impassability appears during another painful fight.

At a prelum not only guts, but also its mesenteries even in an interval between pains patients feel dull aches, however during another fight they intolerably amplify. Intensity of pain during another fight causes sharp concern. The face is distorted, and some patients accept various forced, sometimes fancy (genucubital, on cards) provisions in a bed. Women usually compare pains to labor pains. The so-called ileusny periodic groan which is gradually accruing and also gradually abating upon termination of a painful fight is characteristic. At height of a pain syndrome emergence of symptoms of shock is possible: skin is pale, becomes covered cold then, pulse becomes frequent, small filling. The sudden easing of pains which is not followed by an otkhozhdeniye a calla and gases can indicate a necrosis of an intestinal loop (though quite often severe pain proceeds also at the developed necrosis). At obturatsionny impassability the termination of painful attacks and transition of colicy pains to constants testify about decrease in a tone of a gut above an obstacle and development of paresis of intestines. At intestinal impassability after deceptive calm peritonitis inevitably develops.

Vomiting at impassability differs in a number of the features allowing to distinguish its true character. At high intestinal impassability vomiting repeats through short periods, always happens repeated. If in the beginning emetic masses are the food remains, then further they represent the plentiful liquid contents getting into a stomach from intestines and which are intensively painted by bile. The above the obstacle, the more intensively vomiting is located. At enteric impassability, unlike food intoxication, vomiting does not give to the patient relief, and he continues to feel desires. The abundance of the emetic masses consisting of bile and intestinal juice without food impurity is also extremely characteristic of high intestinal impassability. The amount of intestinal juice reaches every day 10 — 12 l, than and recurrence of vomiting and abundance of emetic masses speak. All this is aggravated to constants at impassability with formation of a hemorrhagic exudate in an abdominal cavity and quickly leads to considerable dehydration, the progressing loss by an organism of protein and electrolytes, the accruing intoxication. In this regard at patients with high intestinal impassability the pachemia which is shown relative increase in hemoglobin, erythrocytes and a considerable leukocytosis owing to reduction of volume of plasma is quite often observed.

Repeated and plentiful vomiting is characteristic only of the impassability which is localized in an upper part of a small bowel. At other types of its intestinal impassability can not be or it is noted 1 — 2 time.

In later period of intestinal impassability, at development of the peritonitis which is followed by paresis of intestines and complete cessation of its vermicular movement there is vomiting, extremely burdensome for the patient, with the intestinal contents which underwent ichorization and having a disgusting smell (a so-called fecal vomit). Plentiful emetic masses with a fecal smell represents congestive contents of upper parts of intestines. The above the obstacle is located, rather the fecal vomit appears. At very low arrangement of impassability in a large intestine of a fecal vomit can not be absolutely.

Characteristic symptom of intestinal impassability — a delay of a chair and the termination of a passage of flatus. At low, colic, generally tumoral, impassability, despite multi-day lack of a chair, a manual research of an ampoule of a rectum is not found in it by a calla. The rectum is empty and stretched. At high enteric impassability of a delay of a chair quite often it is not observed, emptying of an underlying intestinal tank takes place independent or by means of an enema. Because of existence of a chair intestinal impassability is sometimes denied; the similar mistake is frequent.

The general condition of the patient at low (especially obturatsionny) impassability within 2 — 3 days can remain satisfactory, but quickly worsens at strangulyatsionny impassability, at the high level of an obstacle, and also at dynamic impassability owing to thrombosis of vessels of a mesentery. Pulse at the beginning of a disease is speeded a little up, at an aggravation of symptoms tachycardia reaches 120 beats/min; in process of development of a disease the ABP decreases. Body temperature usually remains normal.

The earliest objective symptom of intestinal impassability is the hyperperistalsis. Sometimes it is possible to see a hyperperistalsis of the inflated intestinal loops at thin patients (a symptom of a visible vermicular movement), however much more often it is palpatorno possible to catch oplotnevayushchiya during the painful fight (with its termination is returned to a former consistence) a gut piece. In a zone of an oplotnevayushchy gut at height of a painful fight sharply strengthened intestinal noise are defined by Auskultativno. Sometimes loud rumbling is heard at distance.

In an initial stage of intestinal impassability the abdominal wall happens soft and pliable, quite often absolutely painless at a palpation, peritoneal symptoms are absent. Unfortunately, almost constant lack of symptoms, characteristic of an acute abdomen (a muscle tension of a front abdominal wall and sharp morbidity at a palpation, symptoms of irritation of a peritoneum) during the first hours intestinal impassability often leads to denial by the health worker of the acute accident, fatal for the patient, demanding an immediate surgery. At emergence of these symptoms (i.e. at development of peritonitis) operation quite often is overdue and unsuccessful.

Abdominal distention — a characteristic objective symptom of the broken passability of intestines. Unlike uniform swelling at paralytic impassability swelling at a mechanical obstacle almost always happens limited and is caused контурирующейся through an abdominal wall by the stretched intestinal loop. During the weakening of a vermicular movement and loss of a tone of muscles expansion and inflation of an intestinal loop develop obstacles are higher. It is already later symptom of intestinal impassability. At bimanual rocking of the site of an abdominal wall over the blown-up gut characteristic "capotement" of liquid because of accumulation in an atonichny intestinal loop of a large amount of digestive juices is defined.

Sometimes it is possible to palpate the fixed and stretched intestines loop (Wal's symptom) over which at percussion the tympanic sound decides on a metal shade (a positive symptom of Kivul). In late terms of a disease at the expressed stretching of a gut characteristic rigidity of an abdominal wall with a consistence of a mumpish ball (a positive symptom of Mondor) comes to light.

In diagnosis rectal and vulval researches at which it is possible to find inflammatory infiltrate or a tumor in a cavity of a small pelvis, rectum obturation a fecal stone or a tumor, etc. are important. At torsion of a sigmoid gut define a gaping of a sphincter of an anus and an empty ampoule of a rectum.

Reasons of Intestinal impassability:

At dynamic impassability there is no mechanical obstacle to advance of intestinal masses. It is caused by sharp delay or complete cessation of an intestinal vermicular movement (intestines paresis); the gut wall necrosis at the same time usually does not occur. Dynamic impassability (paralytic Ilheus) is a constant symptom of far come diffuse peritonitis of any etiology. This or that degree of paresis of intestines quite often accompanies attacks of renal colic, often complicates  spinal fractures, pelvic bones with extensive retroperitoneal hematomas, stomach injuries with hemorrhages in a mesentery, can develop after an operative measure on abdominal organs. The characteristic sign of paralytic intestinal impassability which — is evenly blown up without intestinal vermicular movement, "a mute stomach". Less often dynamic spastic impassability (for example meets, at poisonings with lead).

In practical work much the mechanical intestinal impassability caused by existence of an obstacle in this or that department of digestive tract meets more often. The important role in the nature of clinical manifestations and the course of intestinal impassability is played by a type of mechanical impassability (obturatsionny or strangulyatsionny). At obturatsionny impassability the gut gleam is closed, and its mesentery remains unaffected, blood supply of a gut is not broken. Treat impassability at the gut (usually thick) tumor growing in a gleam this look, a gut prelum a tumoral or inflammatory conglomerate from the outside, obstruction of a gleam of a gut a ball of ascarids, fecal or a gallstone. Obturatsionny impassability develops usually gradually, from the moment of emergence of the first signs to the expressed phenomena of impassability passes sometimes 3 — 7 days. Strangulyatsionny impassability proceeds much heavier, the necrosis of an intestinal wall can arise already in 4 — 6 h from the beginning of a disease. In this case there is a prelum of an intestinal loop and its mesentery to quickly coming disorders of its blood supply. Characteristic forms of strangulyatsionny impassability are infringement of a gut with a mesentery a cicatricial tyazh from the previous operations, torsion of guts and their nodulation. The combined mechanical impassability arises at invagination — along with obstruction of a gleam the prelum of vessels of a mesentery of the invaginated loop (strangulation) occurs the implemented gut (obturation).

In addition to a type of mechanical impassability, the level of the intestinal path of an obstacle which arose on the course is of great importance. The above there is an impassability, the heavier it proceeds, especially it demands vigorous medical actions. Enteric impassability is always heavier, than colic; impassability of upper parts of a jejunum is much heavier and more dangerous, than final loops of an ileal gut.

Treatment of Intestinal impassability:

The patient at whom intestinal impassability is diagnosed or suspected needs the emergency hospitalization in surgical department. Owing to quickly coming, progressing, quite often catastrophic dehydration at high enteric impassability the immediate therapy directed to compensation of huge losses of liquid and electrolytes is required (injection in a vein of 1,5 — 2 l of isotonic solution of sodium chloride, 5% of solution of glucose, Polyglucinum); such therapy has to be carried out whenever possible and during transportation of the patient. Before survey by the doctor it is impossible to give purgatives, to administer the anesthetizing drugs, to carry out enemas and gastric lavages.

In a hospital in the absence of the expressed signs of mechanical impassability hold a complex of conservative events: suction of gastrointestinal contents through the stylet entered through a nose; at a hyperperistalsis enter spasmolysants. At mechanical impassability in case of inefficiency of conservative therapy the immediate surgery (an adhesiotomy, untwisting of torsion, a deinvagination, bowel resection is carried out at its necrosis, imposing of intestinal fistula for assignment of intestinal contents at tumors of a large intestine). In the postoperative period continue the actions directed to normalization of water-salt and protein metabolism (intravenous injections of saline solutions, blood substitutes), antiinflammatory, anticoagulating therapy, stimulation motor эвакуаторной to function of digestive tract, etc.