Perforation of a thick gut – through damage of a wall of a large intestine at which contents of body get into an abdominal cavity. It is shown by an intensive pain syndrome, tension of muscles of a belly wall, an abdominal distension, nausea, vomiting, lack of appetite, tachycardia and a hyperthermia. Is the medical emergency demanding carrying out the emergency operation. In the absence of treatment is complicated by peritonitis. There is a high probability of a lethal outcome. It is diagnosed on the basis of symptoms and data of a survey X-ray analysis. Treatment – an ushivaniye of a punched opening, a gut resection with creation of a direct anastomoz or imposing of a kolostoma.
Perforation of a thick gut
Perforation of a thick gut – the violation of integrity of a wall of intestines which is followed by an exit of intestinal contents in an abdominal cavity. According to researchers, perforation of a thick gut is the reason of emergence of free gas, the second for prevalence, in an abdominal cavity after a perforation of a stomach and a duodenum. Arises in the field of a blind gut more often, comes to light in other departments of a large intestine less often. Men suffer more often than women. Because of a large number of bacteria in a large intestine perforation of a thick gut quickly is complicated by development of bacterial peritonitis. Death rate at perforations of this anatomic department of intestines reaches 50%. Especially often adverse forecast is noted at development of perforation in elderly people. Treatment is performed by experts in the field of a proktologiya and abdominal surgery.
Reasons of perforation of a thick gut
Allocate perforations of a large intestine of traumatic and not traumatic genesis. First place on prevalence among the reasons of development of not traumatic perforation is won by sharp divertikulita (45-50% of total of cases) which are usually complicated by formation of abscesses. Less often perforation of a thick gut at a colorectal cancer meets. Violation of integrity of a wall of intestines at an oncological disease can turn out to be consequence of disintegration of a tumor or result from an obturation of a gleam of intestines, pressure of kalovy masses upon a wall of a gut, violation of its blood supply and the subsequent necrosis.
Besides, perforation of a thick gut can be observed at an obturation of intestines of not oncological nature, a disease Krone, ulcer colitis and toxic megacolon. In some cases medical procedures, for example, a kolonoskopiya or a rektoromanoskopiya become the reason of a perforation. Frequency of similar complications, according to researchers, makes about 0,2%. The factor increasing probability of not traumatic perforation of a thick gut of any genesis is reception of immunodepressants and some hormonal medicines. Traumatic perforations of a thick gut arise at chipped, cut, chopped and lacerations, and also at the closed damages of a zone of a stomach and are considered in the article "Stomach Injuries".
Symptoms of perforation of a thick gut
The clinical symptomatology of a sharp stomach is characteristic. Patients complain of intensive pains, hold a stomach with hands, spare it at breath, try to keep an immovability, adopting the compelled provision on one side or on a back with the bent legs. Body temperature of patients with perforation of a thick gut is increased at first to subfebrilny, and then to febrilny figures. Weakness, pallor of skin, nausea, vomiting, reduction of amount of urine, tachycardia and violations of breath are noted. The stomach is blown up, the forward belly wall is strained. Pains amplify at a palpation, especially strong morbidity comes to light in a perforation zone.
After a while after perforation of a thick gut intensity of a pain syndrome decreases as receptors of a peritoneum adapt to pathological changes in an abdominal cavity. At development of peritonitis of pain and tension of a belly wall amplify, become poured, extending to all departments of a stomach. At liver percussion at patients the disappearance of hepatic dullness demonstrating availability of gas in an abdominal cavity decides on perforation of a thick gut. In sloping places of a stomach the obtusion of a sound caused by liquid availability can come to light. At an auskultation easing or disappearance of intestinal noise owing to violations of a vermicular movement is defined.
In the presence of the divertikulit which was complicated by abscess with the subsequent perforation of a thick gut during the manual research of a rectum or a palpation of area of a stomach infiltrate can come to light. In certain cases (usually – at malignant tumors or formation of solderings) perforation of a thick gut happens not in an abdominal cavity, and in nearby body, for example, in a vagina or a bladder. In similar cases it is formed enterovaginal or entero the fistula which is followed by release of gases and intestinal contents from an urethra or a vagina.
Features of a clinical picture of perforation of a thick gut depend on the level of a perforation, the size of a punched opening, existence or lack of obstruction of a large intestine. As a rule, proximal defeat of a thick gut proceeds heavier because of a bystry dissemination of liquid intestinal contents on an abdominal cavity. An exception are cases when obstruction of intestines becomes the reason of perforation of a thick gut. In similar cases the periods of false wellbeing caused by reduction of pressure of contents by an intestinal wall are expressed more brightly, than usually. Sometimes perforation of a thick gut proceeds with indistinctly expressed symptomatology because of the small size of a punched opening or proximity of the epiploon interfering a contents exit in an abdominal cavity.
Because of a significant amount of bacteria in intestines contents at perforation of a thick gut peritonitis usually develops quicker, than at damage of other departments of a GIT. Are observed vomiting by intestinal contents and violations of haemo dynamics with falling of arterial pressure. Gross violations of activity of various bodies and systems are noted, including – a liver, kidneys, cardiovascular system and a brain. There are frustration of all types of exchange. At aggravation of the phenomena of peritonitis at patients with perforation of a thick gut the acute liver failure can develop. In the absence of treatment there comes the lethal outcome. A considerable part of patients perishes even when performing the qualified surgeries and resuscitation actions.
Diagnostics of perforation of a thick gut
The perforation of a large intestine is diagnosed by the proctologist on the basis of complaints, the given fizikalny survey, tool and laboratory researches. Diagnosis "perforation of a thick gut", as a rule, does not cause difficulties. Symptoms of sharp abdominal accident are supplemented with data of the radiological researches demonstrating availability of free gas in an abdominal cavity. On the survey roentgenograms executed in a standing position, gas usually well is looked through under a diaphragm. At impossibility to execute a X-ray analysis in a standing position of the patient with suspicion stack on perforation of a thick gut sideways and leave for several minutes that gas managed to move better it was looked through in pictures.
At perforation of the thick gut which arose owing to intestinal impassability in pictures Kloyber's bowls can be found (blackouts in the form of the turned bowls with the horizontal level of liquid under the sites of intestines inflated by gas). In doubtful cases carry out a peritonealny unleavened wheat cake with the subsequent research of liquid on the content of blood, intestinal contents, bacteria and leukocytes. Laboratory analyses during the first hours after perforation of a thick gut usually maloinformativna. It is noted with shift to the left. At development of peritonitis electrolytic frustration come to light. At violation of functions of a liver and development of a sharp renal failure corresponding changes from blood and urine are found.
Treatment of perforation of a thick gut
At perforation of a thick gut the emergency surgical intervention is shown (except for perforation cases in other body). Because of increase in risk of development of a lethal outcome at an operation delay the average duration of preoperative preparation in similar cases makes only 2-4 hours. Medical tactics is defined taking into account the cause and localization of perforation of a thick gut, expressiveness of peritonitis and some other factors. Usually carry out washing of an abdominal cavity and imposing of a kolostoma. In the absence of symptoms of peritonitis and the small punched opening limited to an epiploon the ushivaniye of a punched opening or a resection of a thick gut is in some cases admissible.
Operation for perforation of a thick gut is performed under an endotrakhealny anesthesia, against the background of intravenous transfusion of solutions of electrolytes. The abdominal cavity is drained. In the postoperative period exercise control of pulse, pressure and an hourly diuresis. At the expressed blood loss to patients with perforation of a thick gut make blood transfusion and blood substitutes. Intravenously enter antibiotics of a broad spectrum of activity. Continue infusions of solutions of electrolytes for restoration of water-salt and acid-base balance. At repeated emergence of symptoms of peritonitis by the patient with perforation of a thick gut carry out a relaparotomiya. At formation of intestinal fistulas the emergency operation is not required, planned inspection is admissible. Medical tactics is defined taking into account the reasons of development of the svishchevy courses.
The forecast at perforation of a thick gut in general adverse, more than a half of patients with this pathology perishes from peritonitis. The most significant factor is the period from the moment of emergence of the first symptoms until performing surgery. The this time span is longer, the chances of a happy end are lower. Among other circumstances influencing the forecast at perforation of a thick gut – age of the patient (the patient is more senior, the probability of a favorable outcome is lower) and existence or absence of heavy somatic pathology.