Intestinal impassability – the violation of a passage of contents on intestines caused by an obturation of its gleam, a sdavleniye, a spasm, disorders of haemo dynamics or an innervation. Clinically intestinal impassability is shown by skhvatkoobrazny belly-aches, nausea, vomiting, a delay of a chair and otkhozhdeniye of gases. In diagnostics of intestinal impassability data of fizikalny inspection (a palpation, percussion, a stomach auskultation), a manual rectal research, a survey X-ray analysis of an abdominal cavity, a contrast X-ray analysis, a kolonoskopiya, a laparoscopy are considered. At some types of intestinal impassability conservative tactics is possible; in other cases intervention as which purpose serves restoration of a passage of contents on intestines or its external assignment, a resection of the impractical site of a gut is carried out surgical.
Intestinal impassability (Ilheus) is not an independent nosological form; in gastroenterology and coloproctology this state develops at the most various diseases. Intestinal impassability makes about 3,8% of all medical emergencies in abdominal surgery. At intestinal impassability advance of contents (himus) – the semi-digested food masses on a digestive tract is broken.
Intestinal impassability is a polietiologichesky syndrome which can be caused by a set of the reasons and have various forms. Timeliness and correctness of diagnostics of intestinal impassability are decisive factors in the outcome of this serious condition.
Classification of intestinal impassability
There are several options of classification of intestinal impassability considering various pathogenetic, anatomic and clinical mechanisms. Depending on all these factors the differentiated approach to treatment of intestinal impassability is applied.
For the morfofunktsionalny reasons allocate:
1. dynamic intestinal impassability which, in turn, can be spastic and paralytic
2. the mechanical intestinal impassability including forms:
- strangulyatsiony (, infringement, uzloobrazovaniye)
- obturatsionny (intraintestinalny, ekstraintestinalny)
- mixed (adhesive impassability, an invagination)
3. the vascular intestinal impassability caused by an intestines heart attack.
On obstacle arrangement level for a passage of food masses distinguish high and low tonkokishechny impassability (60-70%), tolstokishechny impassability (30-40%). On extent of violation of passability of a digestive tract intestinal impassability can be full or partial; on a clinical current – sharp, subsharp and chronic. On time of formation of violations of passability of intestines differentiate the congenital intestinal impassability connected with embryonic malformations of intestines, and also the acquired (secondary) impassability caused by other reasons.
In development of sharp intestinal impassability allocate several phases (stages). In a so-called phase of "ileusny shout" which proceeds from 2nd to 12-14 hours pain and local abdominal symptomatology prevail. The stage of intoxication replacing the first phase lasts from 12 to 36 hours and is characterized by "imaginary wellbeing" - reduction of intensity of skhvatkoobrazny pains, weakening of an intestinal vermicular movement. Along with it the neotkhozhdeniye of gases, a chair delay, swelling and asymmetry of a stomach is noted. In a late, terminal stage of the intestinal impassability coming 36 hours later from the beginning of a disease sharp violations of haemo dynamics and peritonitis develop.
Reasons of intestinal impassability
Development of various forms of intestinal impassability is caused by the reasons. So, spastic impassability develops as a result of a reflex spasm of intestines which can be caused mechanical and painful by irritation at helminthic invasions, foreign matters of intestines, bruises and hematomas of a stomach, sharp pancreatitis, a nefrolitiaza and renal colic, bilious colic, basal pneumonia, pleurisy, haemo - and pheumothorax, fractures of edges, a sharp myocardial infarction, etc. pathological states. Besides, development of dynamic spastic intestinal impassability can be connected with organic and functional defeats of nervous system (ChMT, a mental trauma, a spinal trauma, an ischemic stroke, etc.), and also distsirkulyatorny violations (thromboses and embolisms of mezenterialny vessels, dysentery, vaskulita), a disease of Girshprunga.
Result paresis and paralyzes of intestines which can develop owing to peritonitis, surgeries on an abdominal cavity, a gemoperitoniuma, poisonings with morphine, salts of heavy metals, food toksikoinfektion etc. in paralytic intestinal impassability.
At different types of mechanical intestinal impassability takes place mechanical obstacles in a way of advance of food masses. Obturatsionny intestinal impassability can be caused by kalovy stones, bilious concrements, bezoara, a congestion of worms; vnutriprosvetny cancer of intestines, foreign matter; intestines sdaleniye from the outside tumors of abdominal organs, small pelvis, kidney.
Strangulyatsionny intestinal impassability is characterized not only by a sdavleniye of a gleam of a gut, but also a compression of bryzheechny vessels that can be observed at infringement of hernia, a zavorota of guts, an invagination, an uzloobrazovaniye - overlapping and twisting among themselves of gut loops. Development of these violations can be caused by existence of a long bryzheyka of a gut, cicatricial tyazhy, solderings, unions between loops of a kishechyonik; sharp decrease in body weight, long starvation with the subsequent overeating; sudden increase in intra belly pressure.
As the reason of vascular intestinal impassability sharp occlusion of mezenterialny vessels owing to thrombosis and an embolism of bryzheechny arteries and veins acts. Development of congenital intestinal impassability, as a rule, is the cornerstone of anomaly of development of an intestinal tube (doubling, an atresia, a diverticulum, etc.).
Symptoms of intestinal impassability
Irrespective of type and the level of intestinal impassability the expressed pain syndrome, vomiting, a delay of a chair and a neotkhozhdeniye of gases takes place.
Abdominal pains have skhvatkoobrazny intolerable character. During the fight which coincides with a peristaltic wave the face of the patient is distorted from pain, he groans, adopts various compelled provisions (on cards, knee and elbow). At height of a painful attack shock symptoms appear: pallor of skin, cold sweat, hypotonia, tachycardia. Subsiding of pains can be very artful sign testifying to a necrosis of intestines and death of the nervous terminations. After imaginary calm, on second day from the beginning of development of intestinal impassability, inevitably there is peritonitis.
Sign, other, characteristic of intestinal impassability, vomiting serves. Especially plentiful and repeated vomiting which is not giving relief develops at tonkokishechny impassability. In the beginning emetic masses contains the remains food, then bile, in the late period - intestinal contents (kalovy vomiting) with a putrefactive smell. At low intestinal impassability vomiting, as a rule, repeats 1-2 times.
Typical symptom of low intestinal impassability is the delay of a chair and an otkhozhdeniye of gases. The manual rectal research finds absence a calla in a rectum, prolixity of an ampoule, a sphincter gaping. At high impassability of a small intestine of a delay of a chair can not be; depletion of nizlezhashchy departments of intestines happens independently or after an enema.
At intestinal impassability swelling and the asymmetry of a stomach seen approximately a vermicular movement pays attention.
Diagnostics of intestinal impassability
At stomach percussion at patients decides on intestinal impassability timpanit with a metal shade (Kivul's symptom) and obtusion of a perkutorny sound. Auskultativno in an early phase come to light the strengthened intestinal vermicular movement, "splash noise"; in a late phase – weakening of a vermicular movement, noise of the falling drop. At intestinal impassability the stretched intestinal loop (Wal's symptom) is palpated; in late terms – a rigidnost of a forward belly wall.
Important diagnostic value has carrying out a rectal and vaginal research by means of which it is possible to reveal an obturation of a rectum, tumors of a small pelvis. Objectivity of existence of intestinal impassability is confirmed when carrying out tool researches.
At a survey X-ray analysis of a belly polosyota characteristic intestinal arches (the gut inflated by gas decide on liquid levels), Kloyber's bowls (dome-shaped enlightenments over the horizontal level of liquid), a plumosity symptom (existence of a cross ischerchennost of a gut). X-ray contrast research GIT is applied in difficult diagnostic cases. Depending on the level of intestinal impassability the barium passage X-ray analysis on intestines or an irrigoskopiya can be used. Kolonoskopiya allows to examine disteel departments of a large intestine, to establish the reason of an obturation of a gut and in some cases - to resolve the phenomena of ostyory intestinal impassability.
Performing ultrasonography of an abdominal cavity at intestinal impassability is complicated because of the expressed intestines pnevmatization, however the research in some cases helps to find tumors or inflammatory infiltrates. During diagnostics sharp intestinal impassability should be differentiated from an acute appendicitis, probodny stomach ulcer and a 12-perstny gut, sharp pancreatitis and cholecystitis, renal colic, extra-uterine pregnancy.
Treatment of intestinal impassability
At suspicion on intestinal impassability the emergency hospitalization of the patient in a surgical hospital is made. Before survey of the doctor it is categorically forbidden to give enemas, enter anesthetics, to accept laxative medicines, to carry out washing of a stomach.
In the absence of peritonitis in the conditions of a hospital make a GIT decompression by aspiration of gastrointestinal contents via the thin nazogastralny probe and statements of a siphon enema. At skhvatkoobrazny pains and the expressed vermicular movement spazmolitichesky means (atropine, , ) are entered, at intestines paresis – the medicines stimulating motility of intestines (); novokainovy paranefralny blockade is carried out. For the purpose of correction of water and electrolytic balance intravenous administration of salt solutions is appointed.
If as a result of the undertaken measures intestinal impassability is not allowed, it is necessary to think of mechanical Ilheus demanding urgent surgical intervention. Operation at intestinal impassability is directed to elimination of mechanical obstruction, a resection of the impractical site of a gut, prevention of repeated violation of passability.
At impassability of a small intestine the resection of a small intestine with imposing of an enteroenteroanastomoz or enterokoloanastomoz can be carried out; deinvagination, untwisting of a zavorot of loops of intestines, section of solderings etc. At the intestinal impassability caused by a tumor of a thick gut the gemikolonektomiya and imposing of a temporary kolostoma is made. At inoperable tumors of a large intestine it is imposed roundabout ; at development of peritonitis the transverzostomiya is carried out.
In the postoperative period compensation of OTsK, dezintoksikatsionny, antibacterial therapy, correction of proteinaceous and electrolytic balance, stimulation of motility of intestines is carried out.
Forecast and prevention of impassability of intestines
The forecast at intestinal impassability depends on starting date and completeness of volume of the carried-out treatment. The failure comes at late recognizable intestinal impassability, at the weakened and elderly patients, at inoperable tumors. At the expressed adhesive process in an abdominal cavity a recurrence of intestinal impassability is possible.
Prevention of development of intestinal impassability includes timely screening and removal of tumors of intestines, the prevention of an adhesive disease, elimination of a helminthic invasion, healthy nutrition, avoiding of injuries etc. At suspicion on intestinal impassability the immediate address to the doctor is necessary.