Acute Intestinal Obstruction Flashcards
Definition of Acute intestinal obstruction (AIO)
A disease, which is characterized by acute violation of the intestinal contents passage through the gastrointestinal tract.
Causes of acute intestinal obstruction:
Causes of acute intestinal obstruction:
А) Causes that contribute to the development of disease:
а) congenital:
- abnormalities of the intestines, mesenterial and peritoneal (dolichosigma, mobile cecum, developmental defects of the diaphragm and the peritoneum, which lead to the formation of hernial rings, fissures, pouches in abdominal cavity);
b) acquired:
- adhesions, scar tissue bands as a result of surgery and inflammatory processes;
- tumor, inflammatory infiltrates, hematomas;
- presence of foreign bodies in the intestinal lumen, gallstones and other formations that occlude the lumen.
B) Causes that lead to the development of disease:
- developing of the acute disturbances in motility of intestine as hyper or hypomotoric reactions;
- occurrence of spasms and paralysis in various parts of the intestines.
The main clinical signs of acute intestinal obstruction:
А) Complaints:
а) pain:
- suddenly arising;
- paroxysmal;
- increasing;
- nature of pain depends on the type of obstruction of the intestines;
- pain decreases by 2-3rd day, when intestinal peristalsis is depleted;
b) nausea, vomiting:
- variable sign;
- the presence and the frequency depends on the level of the intestinal obstruction, depending on the form and type of obstruction;
- in case of high obstruction repeated vomiting is early occured;
- with accession of peritonitis, vomiting is continuous and with no relief;
c) constipation and gas formation:
- frequent and important symptoms of acute obstruction of the intestines;
- in the initial stage of obstruction, especially at high location of the obstacles, in the first hours is possible the expectoration of gases and feces;
- during conservative therapy, can be achieved defecation and expectoration of gases;
d) abdominal distention - is characteristical for the mechanical and dynamic obstruction of the intestines.
B) Anamnesis:
- development of the disease in the timing aspect;
- previous surgery;
- the variation of the stool over the past months.
C) Objective manifestations:
а) visual inspection:
- general condition depends on the type of obstruction and on its intestinal level;
- the tongue is initially wet, with the development of dehydration becomes dry;
- abdomen is asymmetric, distended (form and asymmetry of the abdomen depends on the location and type of obstacles in the place of obstruction);
b) physical examination:
- hemodynamic parameters (pulse rate, BP) depend on the degree of dehydration and the degree of the circulating blood volume reduction;
- palpation of the anterior abdominal wall: the characteristic and location of pain, symptoms that correspond pathognomonically for intestinal obstruction are evaluated;
- percussion of anterior abdominal wall thympanitis across the whole surface of the abdominal wall;
- auscultation of the abdomen in a first stage of the obstruction, the high-pitched peristaltic sounds can heard due to the movement of fluid and gas in the loops of intestine;
- pathognomonic symptoms of acute obstruction of the intestines:
- Wahl’s sign - asymmetry of the abdomen, high tympanic sound over the distended bowel.
- Schlange’s sign - visible peristalsis.
- Sklyarov’s sign - splashing sounds in the small or large intestine during balloting palpation of anterior abdominal wall.
- Anschutz’s sign - pronounced flatulence in the right iliac area by obstruction of the colon.
- Kivul’s sign metallic sound over bloated intestinal loop by percussion of plessimetr.
- Spasokukotsky’s sign in auscultation ”noise of falling drop” above the stretched loops of intestine.
Formation of the preliminary diagnosis is based on clinical data.
(acute intestinal obstruction)
Preliminary diagnosis is formed on the basis of the patient’s complaints, anamnesis and objective manifestations of disease, confirmed by physical methods of investigation.
To confirm or clarify the diagnosis plain radiography abdominal is performed, in difficult diagnostic cases contrast study of small and large intestines, colonoscopy.
Diagnosis of acute obstruction of intestines:
А) Instrumental diagnosis:
а) plain radiography to identify the Kloiber’s cups and the Kerckring folds:
• bowls of Kloyberg (intestine loops filled with gas and liquid):
- in the small intestine they are low and wide, located closer to the spine;
- in the colon, they are arranged along the periphery of the abdominal cavity, their number is fewer, height of the bowls is bigger, than its width, and on the background gas in the loops of intestine mucosal folds are seen (Kerckring folds);
- with dynamic obstruction horizontal fluid levels are located at the same time in the loops
of the small and large intestines;
b) contrast study of small and large intestines:
- X-ray masses passage through the small and large intestine (determination of the enhanced bowel loops over the place obstacles);
- lower gastrointestinal (GI) tract radiography (helps to determine the location of the obstacles in the colon);
c) urgent endoscopic examination of the colon (sigmoidoscopy, fibrocolonoscopy).
B) Laboratory data:
а) CBC (leukocytosis with a shift to the left, toxic granularity of leukocytes);
b) urinalysis (the presence of protein, erythrocyte, casts);
c) biochemical blood analysis (determination of protein and electrolytes in the blood’s serum).
Differential diagnosis of acute obstruction of the intestines:
А) Stage of intestinal passage violations:
- acute pancreatitis;
- acute appendicitis complicated by peritonitis;
- renal colic.
B) Stage of violations of intramural intestinal blood circulation:
- acute pancreatitis complicated by pancreatogenic ascites;
- thromboembolism of the mesenteric vessels.
C) Stage of peritonitis:
- perforated ulcer in the stage of peritonitis;
- acute appendicitis complicated by peritonitis;
- acute pancreatitis complicated by purulent peritonitis
Clinic-statistical classification of acute intestine obstruction:
ICD10 Diagnosis Code K56 Paralytic ileus and intestinal obstruction without hernia
Layout of the clinical diagnosis: acute {EX}, {BX} obstruction of {LX} ({RX}), {FX stage}
Reason:
E1 mechanical {XX}:
(X1) obturative
(X2) strangulation
(X3) mixed
E2 dynamic {XX}:
(X1) paralytic
(X2) spastic
Form:
B1 low
B2 high
Location:
L1 small intestine
L2 colon
L3 small intestine and colon
Characteristic of the process:
R1 adhesive obstruction
R2 volvulus of the small intestine
R3 sigmoid volvulus
R4 cecal volvulus
R5 transverse colon volvulus
R6 formation of nodule in the small intestine
R7 intestinal obstruction by a gallstone
R8 intestinal obstruction by tangle of ascarids
R9 intussusception
Stage of the process:
F1 I stage (stage of the intestinal passage violations)
F2 II stage (stage of violation of intramural intestinal blood circulation)
F3 III stage (stage of peritonitis)
Organization of surgical care for patients with acute intestine obstruction
In case of suspicion of intestine obstruction, urgent consultation of surgeon and targeted examination is indicated.
General principles of the organization of medical care for acute obstruction of the intestines:
А) Preparation for the surgery (not more than 2 hours from the admission of the patient to the hospital time):
• the “rule of three catheters” is mandatory:
- a tube into the stomach;
- a catheter into the bladder (diuresis control);
- catheter into a central vein (for infusion therapy, taking into account the degree of dehydration, under the control of a central venous pressure).
B) Analgesia - endotracheal anesthesia.
C) General principles of the operative treatment:
- midline laparotomy;
- elimination of obstruction;
- determining the viability of colon:
• intestine color;
• intestine peristalsis;
• pulsation of the mesenteric vessels;
- tube decompression of the small intestine or colon;
- in case of intestine’s necrosis resection of the changed part of the colon with the retreat from the
border of necrosis in the proximal direction by 40 cm and in the distal direction 20-25 cm.
D) postoperative treatment in the ICU.
Definition of Dynamic Intestine Obstruction
Dynamic intestine obstruction is caused by dysfunction of tone of its muscular system (spastic) or it has a reflexive character due to irritation of the neuromuscular apparatus of the intestine (paralytic).
Types of dynamic intestine obstruction:
- paralytic intestine obstruction;
- spastic intestine obstruction.
Causes of dynamic intestine obstruction:
А) Paralytic intestine obstruction (paresis of the small and large intestines):
- after operations on the abdominal organs;
- due to inflammatory and destructive processes in the abdominal cavity;
- due to abdominal injuries as well as chest and spine.
B) Spastic obstruction of the intestines (spasm of the intestinal wall):
- due to foreign body;
- due to increased general nervous excitability (hysteria);
- due to chronic or acute poisoning;
- reflex effect in hepatic and renal colic
Clinical manifestations of dynamic obstruction of intestines:
А) Spastic intestine obstruction:
- paroxysmal pain;
- vomiting;
- delay of flatus or bowel movements;
- possible contact with toxic substances in anamnesis ;
- during an objective examination spastic colon is palpated;
- radiologically hyperpneumatosis of the intestines.
B) Paralytic obstruction of the intestines:
- the patient’s condition is usually severe;
- severe intoxication due to the underlying disease (peritonitis) with the symptoms of paralytic intestine’s obstructions.
Diagnosis of dynamic obstruction of intestines:
• clinical examination:
- complains;
- anamnesis morbi;
- objective data;
- laboratory diagnostics;
- instrumental diagnostics:
- plain radiography of abdomen;
- contrast radiography of the small and large intestines
Therapeutic tactics in dynamic obstruction of intestines:
- preference is given to drug therapy;
- most importantly the treatment of the underlying disease, which led to the emergence of dynamic intestine obstruction.
Definition of Obturative obstruction
A disturbance of the passage of food and intestinal masses due to obstruction of the intestine lumen or due to pressure from the outside with no involvement in the pathological process of the mesenteric vessels.
Causes of obturative intestinal obstruction
А - intestine obstruction with a gallstone;
B - obturation of the intestine by a tumor;
C - compression of the intestine from outside;
D - deformation of the intestine due to adhesive process
