guts – pereknut an intestinal loop around an axis of a bryzheyka with violation of food and blood supply of an intestinal wall, formation of impassability of a digestive tube. The first clinical sign - the sharp skhvatkoobrazny belly-ache which in several hours is replaced by constant pain, feeling of a raspiraniye, vomiting intestinal contents, lack of a chair or diarrhea. The most informative method of diagnostics of a zavorot of guts is the radiological research; control of a biochemical and acid and main condition of blood is obligatory. Treatment of some forms of a zavorot of guts is recommended to be begun with conservative actions, however operation in most cases is required.
guts – the mechanical intestinal impassability developing owing to turn of a loop of intestines around a bryzheechny axis. Has the greatest prevalence among elderly patients (the primary age of patients – and is more senior 60 years). In most cases it is localized in a large intestine: in 80% of cases there is a twisting of a sigmovidny gut, 15% - a blind gut, less than in 5% – cross to a part of intestines, a splenic corner. guts makes about 5% of all cases of obstruction of intestines, 10-15% of all episodes of tolstokishechny impassability.
Is more characteristic of children in a small intestine, anyway connected with congenital pathology. This form of impassability of intestines usually occurs at pregnant women in the third trimester when the increased uterus displaces a sigmovidny gut, provoking it pereknut. A considerable part of patients with zavoroty guts is presented by the contingent of nursing homes and psychiatric clinics.
Reasons of a zavorot of guts
Most often occurs sigmovidny and thin guts. On degree of a perekrut guts divide on partial (to 270 °), full (270-360 °), and also numerous. Emergence of a zavorot of guts is usually connected with congenital features of a bryzheyka of intestines and anomalies of her attachment; an adhesive disease at which solderings pull together separate loops of a gut among themselves, provoking stagnation of contents and stretching of intestines, fixing of loops and bryzheyka. In this situation there are prerequisites for a perekrut of loops of a gut around an axis of too long bryzheyka – from turn on 90 ° before two-triple full twisting from which infringement of vessels and nerves in a bryzheyka results, there is a mechanical obstacle to advance of food masses.
The following factors contribute to development of a zavorot of guts: sharp increase of intra belly pressure at physical activities, a raising of weights; sudden strengthening of peristaltic work of intestines after the compelled starvation, a considerable overeating, the use of unusual food; long resistant locks.
At a zavorota of a small intestine as the reason anomaly of development of a bryzheyka in most cases acts, is more rare – solderings of an abdominal cavity. Usually the turn of loops of intestines happens clockwise, all small intestine can be involved in process completely. As the reasons of a zavorot of a large intestine serve adhesive process, big tumors and cysts of an abdominal cavity, pregnancy, the postoperative period at interventions on the abdominal organs, prescription of medicines strengthening an intestines vermicular movement. Most often guts occurs in the field of sigmovidny department as it has the longest bryzheyka. Much less often guts arises in the right half of an obodochny gut, in the field of a splenic corner.
Pereknut gut loops around a bryzheyka causes squeezing of vessels and nerves because of what food and an innervation of intestines is broken. The vermicular movement at first amplifies, and then there is paresis of the bringing department of intestines - mechanical intestinal impassability develops. guts can complicate the course of such diseases as an acute appendicitis, a disease of Girshprunga, cystous fibrosis of intestines, megacolon, GIT carcinomas, , senile dementia, various mental disorders, multiple sclerosis. Often this pathology develops against the background of reception of psychotropic drugs, salt and osmotic laxatives, after carrying out a kolonoskopiya.
Symptoms of a zavorot of guts
The clinic of a zavorot of guts depends on in what department of intestines happened pereknut. The general criteria of clinical diagnostics are the abdominal pains, considerable swelling and asymmetries of a stomach which are followed by a delay of an otkhozhdeniye of gases and a chair; kalovy vomiting, lack of symptoms of irritation of a peritoneum. Through a forward belly wall the reinflated bringing intestines loop on which at jog pressings splash noise is heard can be palpated, and at percussion – timpanit. Because of the expressed losses of liquid and electrolytes dehydration which is followed by tachycardia develops. At overwind any of departments of intestines the clinic will depend on degree and the speed of a zavorot of guts.
a small intestine it is shown by developing of sharp intensive skhvatkoobrazny pains in an epigastriya or okolopupochny area, is more rare in the lower departments of a stomach. Emergence of pain is followed by vomiting the eaten food which gradually becomes frequent and amplifies, emetic masses becomes kalovy. At initial stages the kcal can depart, after kcal and gases do not depart. At the beginning of a disease the intestines vermicular movement considerably amplifies, however in the next hours it gradually fades and is replaced by intestines paresis. Reblow-up of loops of a gut meets at a partial zavorot more often, and at full turn at thin patients in an abdominal cavity it is possible to probe a conglomerate of the overwound loops. A condition of the patient at a zavorota of a small intestine extremely heavy, intoxication phenomena are expressed.
Pereknut a sigmovidny gut can sharply proceed or . Sharp a sigmovidny gut it is shown by skhvatkoobrazny pains in the left half of a stomach, kalovy vomiting, sharp falling of arterial pressure. At this form of a zavorot of guts the nekrotization occurs very quickly, peritonitis develops during the first hours diseases. The subsharp form of a perekrut of a sigmovidny gut is developed gradually, proceeds easier. Most often patients ask for medical care in several days from the beginning of a disease, showing complaints to recurrent pains, an abdominal distension and only at late stages – vomiting. At a rectal research the expanded and empty ampoule of a rectum is defined. Are characteristic of a zavorot of a sigmovidny gut a symptom of a slanting stomach of Bayer (asymmetry of a stomach due to protrusion of the inflated loop of intestines which is settling down from left to right from top to down); Tsege-Manteyfel's symptom (at statement of a siphon enema all entered liquid quickly leaves intestines, the calla and gases does not contain impurity).
guts in the field of an ileotsekalny corner can proceed as strangulyatsionny (at simultaneous overwind blind and podvzdoshny guts around a bryzheyka) or obturatsionny (at turn of a blind gut around the longitudinal or cross axis) intestinal impassability. The delay of emergence of symptomatology of a zavorot of guts in this case can make up to ten days though episodes of presentation of complaints in two hours after end of a perekrut are known. There are pristupoobrazny, very intensive pains around a navel, the frequent exhausting vomiting. At the beginning of a disease perhaps otkhozhdeny the poor number of kalovy masses, then the chair and gases cease to be allocated. In the left half of a stomach the reinflated intestines loop is defined, over it the timpanichesky sound is listened. At a stomach palpation in right to a flanka emptiness as the overwound blind gut is displaced to the center or up is defined.
The current of a zavorot of guts can be complicated by perforation of a gut, peritonitis, development of a generalized infection, critical dehydration and gipovolemichesky shock. At a long current of a subsharp zavorot of guts formation of a cyst of a bryzheyka, stenosis of an intestinal loop, hilezny ascites is possible.
Diagnostics of a zavorot of guts
Primary complaints arising at a zavorota of guts force the patient to address for consultation of the gastroenterologist. After clinical examination and diagnostics of a zavorot of guts the patient goes to a surgical hospital. At a zavorota of a sigmovidny gut the survey X-ray analysis reveals the gut increased in sizes which upper bound can reach a diaphragm. Two levels of liquid – in proximal and disteel departments of intestines are accurately visible. At a zavorota the blind person of a gut in the right half of belly area is defined the roundish, reinflated gaustrirovanny loop, width of horizontal level of liquid can reach 20 cm. In case of a perekrut of loops of a small intestine in it multiple levels of liquid are also defined; distalny department of intestines narrow, fallen down. At a barium passage X-ray analysis on a small intestine the contrast delay at the level of a zavorot of guts, lack of contrast in a thick gut in 6-12 hours from the beginning of a research is noted.
When carrying out an irrigografiya in the place of a zavorot of a sigmovidny gut the symptom of "beak" over which intestines are pereraznut considerably is defined. Determine the direction of a perekrut by orientation of a tip of "beak" – clockwise or against. At a zavorota of a blind gut contrast does not pass further the middle of the ascending part of an obodochny gut. The most informative method of a research is the multislice spiral computer tomography of abdominal organs. "Spiral" is defined on MSKT in the place of a zavorot of guts, loops of intestines are expanded, the thickening of a wall of a gut and a bryzheyka at the expense of hypostasis is obviously visualized.
Laboratory analyses can indicate moderate increase in level of leukocytes and speed of subsidence of erythrocytes at the beginning of a disease, but in process of increase of a necrosis of intestines these indicators will increase considerably. Biochemical blood test does not reveal pathology, however decrease in level of albumine in blood is noted, against the background of vomiting the amount of potassium and chlorine decreases. The acid and main condition of blood is broken towards acidosis, decrease in level of bicarbonates.
Diagnostics of a zavorot of guts at pregnancy is complicated as use of radiological techniques is limited. Inspection of the pregnant woman is begun with performing ultrasonography of an abdominal cavity, at suspicion on guts it is not recommended to carry out a kolonoskopiya, the diagnostic laparoscopy will be the most informative method.
It is necessary to differentiate guts with divertikulezy, tumors and concrements, solderings of intestines. a sigmovidny gut in clinic it is similar to a colon cancer, ischemia of a bryzheyka. a blind gut most often confuse to an acute appendicitis, a rupture of a cyst and an apopleksiya of an ovary, renal colic, inflammatory pathology of a thick gut.
Treatment of a zavorot of guts
At the beginning of diagnostic search the patient can be in office of gastroenterology, however after diagnosis it has to be transferred to a surgical hospital. Conservative therapy and preparation for operation are begun with introduction of the nazogastralny probe for unloading of intestines, removal of stagnant contents and gases. The purpose of infusional therapy is restoration of liquid balance, water and electrolytic balance of blood, protein level. Antibacterial therapy is obligatory if peritonitis or sepsis is suspected – it is begun immediately after hospitalization of the patient in a hospital if these complications are excluded – in two hours prior to operation.
a small intestine it is treated in exclusively operational way. During operation the surgeon has to try to straighten pereknut loops, in the presence of a necrosis of guts the segmentary resection of a small intestine, imposing of an anastomoz of a small intestine in thin or thick is made. If during operation peritonitis comes to light – the ileostoma is imposed, in three months reconstructive operation is made. Operation at a zavorota the blind person of a gut pursues the purpose carrying out a gemikolektomiya with imposing of an interintestinal anastomoz or ileostoma (in the presence of inflammatory exudate in an abdominal cavity). At too weakened patients the chreskozhny tiflostomiya can be carried out – it will allow to improve a condition of intestines, to stabilize the patient.
It is preferable to begin therapy of a zavorot of a sigmovidny gut with a rektoromanoskopiya or a kolonoskopiya during which enter a flexible tube for unloading of intestines into a sigmovidny gut. If necessary, after a decompression radical operation to which indications are sharp a sigmovidny gut, lack of effect of conservative therapy is made.
After operation it is necessary to continue massive antibacterial and infusional therapy, to carry out observation of the patient for early identification of complications: accession of an infection, insolvency of seams on a gut, formation of interintestinal abscesses and fistulas, development of a generalized infection.
Forecast and prevention of a zavorot of guts
As guts in most cases develops at elderly patients, the forecast at this disease is rather serious, caused by the bad initial state of health, existence of the heavy accompanying pathology. Mortality at late identification of a zavorot of guts (more than three days from the beginning of a disease) reaches 40%, and a postoperative lethality – 30%. After endoscopic treatment of a zavorot of guts a half of patients has disease recurrence.
Prevention of a zavorot of guts requires control of appointment and reception psychotropic and the depletive, medicines which are strengthening or slowing down an intestines vermicular movement. The amount of rough food fibers in a diet has to be sufficient, but not superfluous. After surgeries prevention of formation of solderings without fail has to be carried out.
|Ultrasonography in gastroenterology||2201 rivers. 892|
|Consultations in gastroenterology||2044 . 547|
|X-ray analysis in gastroenterology||1947 . 244|
|X-ray analysis in gastroenterology||4441 rivers. 119|
|Consultations of surgeons||1973 . 476|
|Endoscopy in a proktologiya||6711 . 330|
|Endoscopy in a proktologiya||2216 . 330|
|Resection of a small intestine gastroenterologies / Operations||60507 . 60|
|Tomography in gastroenterology||7849 . 51|
|Enterostoma and enteroanastomoza gastroenterologies / Operations||47998 . 27|