ACUTE ILEUS. PATHOGENESIS. CLINIC. DIAGNOSTIC. TACTICS. ACUTE DYNAMIC ILEUS.

ACUTE OBTURATIVE AND STRANGULATED INTESTINAL OBSTRUCTION.

Intestinal obstruction is a complete or partial violation of passing of maintenance by the intestinal tract.

Ileus is commonly defined simply as bowel obstruction. However, authoritative sources define it as decreased motor activity of the GI tract due to non-mechanical causes. In such sense, this does not include motility disorders that result from structural abnormalities, and, therefore, some mechanical obstructions are misnomers, such as gallstone ileus and meconium ileus, and are not true examples of ileus.

Types:

Decreased propulsive ability may be broadly classified as caused either by bowel obstruction or intestinal atony or paralysis. However, there are instances where there are symptoms and signs of a bowel obstruction, but with absence of a mechanical obstruction, mainly in acute colonic pseudoobstruction, also known as Ogilvie's syndrome.

Bowel obstruction. Bowel obstruction (or intestinal obstruction) is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency. The condition is often treated conservatively over a period of 25 days with the patient's progress regularly monitored by an assigned physician. Surgical procedures are performed on occasion however in life-threatening cases, such as when the root cause is a fully lodged foreign object or malignant tumor.

Intestinal atony or paralysis. Paralysis of the intestine is often termed paralytic ileus. To be termed "paralytic ileus", the intestinal paralysis need not be complete, but it must be sufficient to prohibit the passage of food through the intestine and lead to intestinal blockage.

Paralytic ileus is a common side effect of some types of surgery, in these cases it is commonly called postsurgical ileus. It can also result from certain drugs and from various injuries and illnesses, i.e. acute pancreatitis. Paralytic ileus causes constipation and bloating. On listening to the abdomen with a stethoscope, no bowel sounds are heard because the bowel is inactive.

A temporary paralysis of a portion of the intestines occurs typically after an abdominal surgery. Since the intestinal content of this portion is unable to move forward, food or drink should be avoided until peristaltic sound is heard from auscultation of the area where this portion lies.

 

Etiology and pathogenesis

The principal reasons of intestinal obstruction can be:

1) commissures of abdominal cavity after traumas, wounds, previous operations and inflammatory diseases of organs of abdominal cavity and pelvis;

2) long mesentery of small intestine or colon, that predetermines considerable mobility of their loops;

3) tumours of abdominal cavity and retroperitoneal space.

Such principal reasons can cause violation of passing of intestinal maintenance, disorder of suction from the intestine and loss of plenty of electrolytes both from vomiting and in the intestine cavity as a result of disorders of bloodflow in its wall.

Most cases of ileus occur after intra-abdominal operations. Normal resumption of bowel activity after abdominal surgery follows a predictable pattern: the small bowel typically regains function within hours; the stomach regains activity in 1-2 days; and the colon regains activity in 3-5 days.

Serial abdominal radiographs mapping the distribution of radiopaque markers have shown that the colonic gradient for resolution of postoperative ileus is proximal to distal. The return of propulsive activity to the right colon occurs earlier than to the transverse or left colon.

Other causes of adynamic ileus are as follows:

           Sepsis

           Drugs (eg, opioids, antacids, warfarin, amitriptyline, chlorpromazine)

           Metabolic (eg, low potassium, magnesium, or sodium levels; anemia; hyposmolality)

           Myocardial infarction

           Pneumonia

           Trauma (eg, fractured ribs, fractured spine)

           Biliary colic and renal colic

           Head injury and neurosurgical procedures

           Intra-abdominal inflammation and peritonitis

           Retroperitoneal hematomas

 

Causes of Intestinal Obstruction

 

Causes of Intestinal Obstruction

Location

Cause

Colon

Tumors (usually in left colon), diverticulitis (usually in sigmoid), volvulus of sigmoid or cecum, fecal impaction, Hirschsprung's disease, Crohn's disease

Duodenum

Adults

Cancer of the duodenum or head of pancreas, ulcer disease

Neonates

Atresia, volvulus, bands, annular pancreas

Jejunum and ileum

Adults

Hernias, adhesions (common), tumors, foreign body, Meckel's diverticulum, Crohn's disease (uncommon), Ascaris infestation, midgut volvulus, intussusception by tumor (rare)

Neonates

Meconium ileus, volvulus of a malrotated gut, atresia, intussusception

 

Pathophysiology. In simple mechanical obstruction, blockage occurs without vascular compromise. Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel distends, and the distal segment collapses. The normal secretory and absorptive functions of the mucosa are depressed, and the bowel wall becomes edematous and congested. Severe intestinal distention is self-perpetuating and progressive, intensifying the peristaltic and secretory derangements and increasing the risks of dehydration and progression to strangulating obstruction.

According to some hypotheses, postoperative ileus is mediated via activation of inhibitory spinal reflex arcs. Anatomically, 3 distinct reflexes are involved: ultrashort reflexes confined to the bowel wall, short reflexes involving prevertebral ganglia, and long reflexes involving the spinal cord.The long reflexes are the most significant. Spinal anesthesia, abdominal sympathectomy, and nerve-cutting techniques have been demonstrated to either prevent or attenuate the development of ileus.

The surgical stress response leads to systemic generation of endocrine and inflammatory mediators that also promote the development of ileus. Rat models have shown that laparotomy, eventration, and bowel compression lead to increased numbers of macrophages, monocytes, dendritic cells, T cells, natural killer cells, and mast cells, as demonstrated by immunohistochemistry. Macrophages residing in the muscularis externa and mast cells are probably the key players in this inflammatory cascade. Calcitonin generelated peptide, nitric oxide, vasoactive intestinal peptide, and substance P function as inhibitory neurotransmitters in the bowel nervous system. Nitric oxide and vasoactive intestinal peptide inhibitors and substance P receptor antagonists have been demonstrated to improve gastrointestinal function.

Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25% of patients with small-bowel obstruction. It is usually associated with hernia, volvulus, and intussusception. Strangulating obstruction can progress to infarction and gangrene in as little as 6 h. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and perforation. In large-bowel obstruction, strangulation is rare (except with volvulus).

Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation occurs. The risk is high if the cecum is dilated to a diameter 13 cm. Perforation of a tumor or a diverticulum may also occur at the obstruction site.

Pathomorphology

The morphological signs of dynamic intestinal obstruction are: small thickening of wall (at considerable paresis is thinning), friability of tissue (the bowel breaks easily) and presence of liquid maintenance and gases in cavity of bowel. At mechanical obstruction it is always possible to expose the obstacle: strang, commissures, tumours, jammings of hernia, cicatricial strictures, wrong entered drainages, tampons and others like that. In place of compression strangulation is exposed. The bowel loop higher strangulation is extended, and distally collapsed. In case of released invagination on small distance two strangulation furrows are observed, and distally from the second ring cylinder expansion of bowel lumen is observed.

 

Classification

(by D.P.Chuhrienko, 1958)

 

Acute intestinal obstruction is divided:

I. According to morphofunctional signs.

1. Dynamic intestinal obstruction:

) paralytic;

) spastic;

) hemostatic (embolic, thrombophlebitic).

2. Mechanical intestinal obstruction(Fig.1):

) strangulated, volvulus, jamming;(Fig. 2)

) obturation (closing of bowel lumen, squeezing from outside);

) mixed (invagination, spike intestinal obstruction).

II. According to clinical passing.

1. Acute.

2. Chronic.

III. According to the level of obstruction.

1. Small intestinal.

2. Large intestinal:

) high;

) low.

IV. According to the passing of intestinal maintenance.

1. Complete.

2. Partial.

V. According to the origin.

1. Innate.

2. Acquired.

VI. According to development of pathological process.

1. Stage of acute violation of intestinal passage.

2. Stage of hemodynamic disorders of bowel wall and its mesentery.

3. Stage of peritonitis.

 

 

Fig.1. Types of mechanical intestinal obstruction. Obstacle reason of obturation: 1-Obturation; 2-Constriction; 3- Compression; 4- Angulation

 

Fig.2. Mechanical intestinal obstruction. The disorders of blood circulation:

1-Strangulation; 2- Jamming; 3- Volvulus; 4- Invagination

 

Clinical management

Main symptoms:

         moderate, diffuse abdominal discomfort

         constipation

         abdominal distension

         nausea/vomiting, especially after meals

         lack of bowel movement and/or flatulence

         excessive belching

Beginning of clinical signs of intestinal obstruction is sudden in 12 hours after taking the meal. The pain in the abdomen has the intermittent character and is met in all forms of mechanical intestinal obstruction. However, some types of strangulated intestinal obstruction (node formation, volvulus of thin and colons) can be accompanied by permanent pain. It is needed to mark that at spike intestinal obstruction, invagination and obturation cramp-like pain can be considered as pathognomic sign of disease. For paralytic intestinal obstruction more frequent is inherent permanent pain which is accompanied by the progressive swelling of abdomen. At spastic obstruction of intestine the pain is mainly acute, the abdomen is not blown away, sometimes pulled in.

Nausea and vomiting are met in 7580 % patients with the heaviest forms of high level of intestinal obstruction (node formation, volvulus of small intestine, spike obstruction). At obturation obstruction and invagination they are observed not so often.

There is a characteristic thirst which can be considered as an early symptom. Besides, the higher intestinal obstruction, the greater the thirst.

Swelling of abdomen, the delay of emptying and gases are observed in 8590% patients, mainly, with the high forms of obstruction (volvulus of small intestine, spike intestinal obstruction).

Together with that, for invagination emptying by liquid excrement with the admixtures of mucus and blood are more characteristic.

The abdomen may be distended and tympanic, depending on the degree of abdominal and bowel distention, and may be tender. A distinguishing feature is absent or hypoactive bowel sounds, in contrast to the high-pitched sound of obstruction. The silent abdomen of ileus reveals no discernible peristalsis or succussion splash.

In patients during palpation the soft abdomen is observed, sometimes with easy resistance of front abdominal wall, and at percussion high tympanitis. At auscultation at the beginning of disease increased peristaltic noises are present, then gradual fading of peristalsis is positive (the Mondors symptom, noise of beginning, quietness of end).

There are other symptoms pathognomic for intestinal obstruction.

The Valas symptom is the limited elastic sausage-shaped formation.

The Sklarovs symptom is the noise of intestinal splash.

The Kywul's symptom is the clang above the exaggerated bowel.

The Schlange's symptom is the peristalsis of bowel, that arises after palpation of abdomen.

The Spasokukotsky's symptom is noise of falling drop.

The Hochenegg's symptom incompletely closed anus in combination with balloon expansion of ampoule of rectum.

At survey roentgenoscopy or -graphy of the abdominal cavity in the loops of bowels liquids and gas are observed the Klojbers bowl. (Fig.3; Fig.4)

Fig. 3. Intestinal obstruction.

X-ray examination of abdominal cavity presence of the Klojbers bowels

 

 

Fig. 4. Intestinal obstruction.

Mechanism of Klojbers bowels

Presence of liquid levels and air in the intestines

 

Variants of clinical passing and complications

Strangulated obstruction. The ischemic component is the characteristic feature of this form of intestinal obstruction, that is investigation of squeezing of mesentery vessels, which determines the dynamics of pathomorphologic changes and clinical signs of disease, and the basic place among them belongs to the pain syndrome. Consequently, sudden appearance of disease, acuteness of pain syndrome and ischemic disorders in the wall of bowel cause necrosis changes of area of bowel pulling in a process. It is accompanied by the making progress worsening of the patient condition and origin of endotoxicosis.

Obturation intestinal obstruction(Fig. 5), unlike strangulated, pass not so quickly.

Fig. 5. Obturation mechanical obstruction by tumor.

Irrigogram

 

In its clinical picture on the first place there are the symptoms of violation of passage on the intestine (protracted intermittent pain, flatulence), instead of symptoms of bowel destruction and peritonitis.

For high, especially strangulated, intestinal obstruction progressive growth of clinical signs of disease and violation of secretory function of intestine is inherent. Thus the volume of circulatory blood diminishes, the level of haematocritis rises and leukocytosis grows. There are also deep violations of homeostasis (hypoproteinemia, hypokalemia, hyponatremia, hypoxia and others like that). In patients with low intestinal obstruction above-named signs are less expressed, and their growth is related to more protracted passing of disease. Invagination of bowel which can be characterized by the triad of characteristic signs is the special type of intestinal obstruction with the signs of both obturation and strangulation: 1) periodicity of appearance of the intermittent attacks of pain in the abdomen; 2) presence of elastic, insignificantly painful, mobile formation in an abdominal cavity; 3) appearance of blood in the excrement or its tracks (at rectal examination).(Fig.6.)

Fig. 6. Invagination of small intestine

The special forms of obturation intestinal obstruction is the obstruction caused by gall-stones. The last are got in the small intestine as a result of bedsore in the walls of gall-bladder and bowel, that adjoins to it. It is needed to mention that intestinal obstruction can be caused by concrement with considerably more small diameter than bowel lumen. The mechanism of such phenomenon is related to irritating action of bilious acids on the bowel wall. The last answers this action by a spasm with the dense wedging of stone in the bowel lumen.

Development of intestinal obstruction caused by gall-stones the attack of colic and clinic of acute cholecystitis precede always. Characteristically, that in the process of development of disease the pain caused by acute cholecystitis calms down, whereupon the new pain characteristic of other pathology intestinal obstruction appears.

Dynamic intestinal obstruction is divided into paralytic and spastic(Fig.7). Paralytic obstruction often arises after different abdominal operations, inflammatory diseases of organs of abdominal cavity, traumas and poisonings.

 

Fig.7. Spastic dynamic intestinal obstrucnion

The reason of spastic intestinal obstruction can be the lead poisonings, low-quality meal, neuroses, hysterias, helminthiasis and others like that. Clinic of dynamic intestinal obstruction is always variable in signs and depends on a reason, that caused it. Disease is characterized by pain in the abdomen, delay of gases and emptying. During palpation the abdomen is blown away, painful, however soft. To diagnose this form of intestinal obstruction is not difficult, especially, if its etiology is known.

Hemostatic intestinal obstruction (Fig.8) develops after embolism or thromboses of mesenteric arteries and thromboses of veins, there can be mixed forms. Embolism of mesenteric arteries arises in patients with heart diseases (mitral and aortic failings, heart attack of myocardium, warty endocarditis) and declared by damaging, mainly, upper mesentery arteries. Beginning of disease, certainly, is acute, with nausea, sometimes vomiting. At first there is a picture of acute abdominal ischemic syndrome, that is often accompanied by shock (frequent pulse, decline of arterial and pulse pressure, death-damp, cyanosys of mucus membranes and acrocyanosis). Patients become excitative, uneasy, occupy the forced knee-elbow position or lie on the side with bound legs.

Fig.8. Hemostatic intestinal obstruction. Embolism of upper mesenteric arteries. Necrosis of small intestines.

 

During the examination the abdomen keeps symmetry, abdominal wall is soft, the increased peristalsis is heard from the first minutes during 12 hours (hypoxic stimulation of peristalsis), which later goes out gradually (grave quiet). According to the phenomena of intoxication peritonitis grow quickly. At the beginning of disease the delay of gases and emptying is observed, later there is diarrhea with the admixtures of blood in an excrement. When the last is heavy to set macroscopically, it is needed to explore scourage of intestine.

Small-bowel obstruction (SBO). The most common cause of small-bowel obstruction (SBO) is postsurgical adhesions. Postoperative adhesions can be the cause of acute obstruction within 4 weeks of surgery or of chronic obstruction decades later. The incidence of SBO parallels the increasing number of laparotomies performed in developing countries. Another commonly identified cause of SBO is an incarcerated groin hernia. Other etiologies include malignant tumor (20%), hernia (10%), inflammatory bowel disease (5%), volvulus (3%), and miscellaneous causes (2%). The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and intussusception.

History. Obstruction can be characterized as either partial or complete versus simple or strangulated. No accurate clinical picture exists to detect early strangulation of obstruction.

Abdominal pain, often described as crampy and intermittent, is more prevalent in simple obstruction. Often, the presentation may provide clues to the approximate location and nature of the obstruction. Usually, pain that occurs for a shorter duration of time and is colicky and accompanied by bilious vomiting may be more proximal. Pain that lasts as long as several days, is progressive in nature, and is accompanied by abdominal distention may be typical of a more distal obstruction.

Changes in the character of the pain may indicate the development of a more serious complication (ie, constant pain of a strangulated or ischemic bowel).

Patients also report the following:

           Nausea

           Vomiting - Associated more with proximal obstructions

           Diarrhea - An early finding

           Constipation - A late finding, as evidenced by the absence of flatus or bowel movements

           Fever and tachycardia - Occur late and may be associated with strangulation

           Previous abdominal or pelvic surgery, previous radiation therapy, or both - May be part of the patient's medical history

           History of malignancy - Particularly ovarian and colonic malignancy

 

Physical Examination

Abdominal distention is present. The duodenal or proximal small bowel has less distention when obstructed than the distal bowel has when obstructed. Hyperactive bowel sounds occur early as GI contents attempt to overcome the obstruction; hypoactive bowel sounds occur late.

Exclude incarcerated hernias of the groin, femoral triangle, and obturator foramina. Proper genitourinary and pelvic examinations are essential. Look for the following during rectal examination:

           Gross or occult blood, which suggests late strangulation or malignancy

           Masses, which suggest obturator hernia

Check for symptoms commonly believed to be more diagnostic of intestinal ischemia, including the following:

           Fever (temperature >100F)

           Tachycardia (>100 beats/min)

           Peritoneal signs

No reliable way exists to differentiate simple from early strangulated obstruction on physical examination. Serial abdominal examinations are important and may detect changes early.

Complications of SBO include the following:

           Sepsis

           Intra-abdominal abscess

           Wound dehiscence

           Aspiration

           Short-bowel syndrome (as a result of multiple surgeries)

           Death (secondary to delayed treatment)

Large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. Approximately 60% of mechanical large-bowel obstructions (LBOs) are caused by malignancies, 20% are caused by diverticular disease, and 5% are the result of colonic volvulus. The most common causes of adult large-bowel obstruction are as follows:

           Neoplasm (benign or malignant)

           Stricture (diverticular or ischemic)

           Volvulus (eg, colonic, sigmoid, cecal)

           Incarcerated hernia

           Intussusception, usually with an identifiable anatomic abnormality in adults but not in children

           Impaction or obstipation

           Gallstone ileus

 

Neoplasms and diverticular disease

Obstructions caused by tumors tend to have a gradual onset and result from tumor growth narrowing the colonic lumen.

Diverticulitis is associated with muscular hypertrophy of the colonic wall. Repetitive episodes of inflammation cause the colonic wall to become fibrotic and thickened, leading to luminal narrowing.

 

Volvuli

A colonic volvulus results when the colon twists on its mesentery, which impairs the venous drainage and arterial inflow. Symptoms of this condition are usually abrupt.

A sigmoid volvulus typically occurs in older, debilitated individuals with a history of chronic constipation, or those living in an institutionalized setting.

A cecal volvulus is caused by a congenital defect in the peritoneum, which results in inadequate fixation of the cecum, and increased cecal mobility. Patients usually present with this disorder in the sixth decade of life.

Intussusception

Intussusception is primarily a pediatric disease; however, it is estimated that between 5% and 16% of all intussusceptions in the Western world occur in adults, of which approximately two thirds of adult intussusception cases are caused by tumors. Two main types of intussusception affect the large bowel: enterocolic and colocolic.

Enterocolic intussusceptions involve both the small bowel and the large bowel. These are composed of either ileocolic intussusceptions or ileocecal intussusceptions, depending on where the lead point is located.

Colocolic intussusceptions involve only the colon. They are classified as either colocolic or sigmoidorectal intussusceptions.

 

Acute colonic pseudo-obstruction/Ogilvie syndrome

Acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, has many etiologies. This disorder is typically seen in elderly patients who are hospitalized with a severe illness. In a retrospective review of more than 1400 cases of acute colonic pseudo-obstruction, the most common predisposing conditions were operative and nonoperative trauma (11%), infections (10%), and cardiac disease (10-18%).

History. Obtain the patient's history of bowel movements, flatus, obstipation (ie, no gas or bowel movement), and symptoms. Attempt to distinguish complete bowel obstruction from partial obstruction, which is associated with passage of some gas or stool, and from ileus. Also inquire about the patient's current and past history in an attempt to determine the most likely cause.

Major complaints in patients with large-bowel obstruction (LBO) include abdominal distention, nausea, vomiting, and crampy abdominal pain. An abrupt onset of symptoms makes an acute obstructive event (eg, cecal or sigmoid volvulus) a more likely diagnosis. A history of chronic constipation, long-term cathartic use, and straining at stools implies diverticulitis or carcinoma.

Changes in the patient's caliber of stools (eg, passage of melanotic bloody stools) strongly suggest carcinoma. When associated with weight loss, the likelihood of neoplastic obstruction increases.

A history of recurrent left lower quadrant abdominal pain over several years is more consistent with diverticulitis, a diverticular stricture, or similar problems.

A history of aortic surgery suggests the possibility of an ischemic stricture.

 

Diagnostic program

1. Anamnesis and physical methods of examination (auscultation of abdomen, percussion and others like that).

2. General analysis of blood, urines and biochemical blood test.

3. Survey sciagraphy of organs of abdominal cavity.

4. Coagulogramm.

5. Electrocardiography.

6. Irrigography.

 

Small-Bowel Obstruction Workup Approach Considerations

If the diagnosis is unclear, admission and observation are warranted to detect early obstructions. Essential laboratory tests are needed; these include the following:

           Serum chemistries - Results are usually normal or mildly elevated

           Blood urea nitrogen (BUN) level - If the BUN level is increased, this may indicate decreased volume state (eg, dehydration)

           Creatinine level - Creatinine level elevations may indicate dehydration

           Complete blood count (CBC) - The white blood cell (WBC) count may be elevated with a left shift in simple or strangulated obstructions; increased hematocrit is an indicator of volume state (ie, dehydration)

           Lactate dehydrogenase tests

           Urinalysis

           Type and crossmatch - The patient may require surgical intervention

           Laboratory tests to exclude biliary or hepatic disease are also needed; they include the following:

           Phosphate level

           Creatine kinase level

           Liver panels

Studies have been performed to evaluate the use of water-soluble oral contrast as a tool in the management of SBO and as a predictive tool for nonoperative resolution of adhesive SBO. It does not cause resolution of the SBO, but it may reduce the hospital stay in patients not requiring surgery.

 

Plain Radiography

Obtain plain radiographs first for patients in whom small-bowel obstruction (SBO) is suspected. At least 2 views, supine or flat and upright, are required. Plain radiographs are diagnostically more accurate in cases of simple obstruction. However, diagnostic failure rates of as much as 30% have been reported.

In one small study, the sensitivity of plain radiography was reported to be 75%, and specificity was reported to be 53%; similar findings were reported in a second study. In another study, plain films were more accurate in the detection of acute SBO and the accuracy was higher if interpreted by more-experienced radiologists.

Plain radiography is of little assistance in differentiating strangulation from simple obstruction. Some have used abdominal radiography to distinguish between complete obstruction and partial or no SBO.

A study by Lappas et al proposed that 2 findings were more predictive of a higher grade or complete SBO: (1) the presence of an air-fluid differential height in the same small-bowel loop and (2) the presence of a mean level width greater than 25 mm.The study found that when the 2 findings are present, the obstruction is most likely high grade or complete. When both are absent, the authors proposed, a low-grade (partial) SBO is likely or nonexistent.

Dilated small-bowel loops with air-fluid levels indicate SBO, as does absent or minimal colonic gas. SBO is demonstrated in the radiographs below.

 

CT scanning

Computed tomography (CT) scanning is the study of choice if the patient has fever, tachycardia, localized abdominal pain, and/or leukocytosis.

CT scanning is useful in making an early diagnosis of strangulated obstruction and in delineating the myriad other causes of acute abdominal pain, particularly when clinical and radiographic findings are inconclusive. It also has proved useful in distinguishing the etiologies of small-bowel obstruction (SBO), that is, in distinguishing extrinsic causes (such as adhesions and hernia) from intrinsic causes (such as neoplasms and Crohn disease). In addition, CT scanning differentiates the above from intraluminal causes, such as bezoars. The modality may be less useful in the evaluation of small bowel ischemia associated with obstruction.

CT scanning is capable of revealing abscess, inflammatory process, extraluminal pathology resulting in obstruction, and mesenteric ischemia and enables the clinician to distinguish between ileus and mechanical small bowel obstruction in postoperative patients.

The modality does not require oral contrast for the diagnosis of SBO, because the retained intraluminal fluid serves as a natural contrast agent.

Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in diameter. A smooth beak indicates simple obstruction without vascular compromise; a serrated beak may indicate strangulation. Bowel wall thickening, portal venous gas, or pneumatosis indicates early strangulation.

One small series reported a sensitivity of 93%, a specificity of 100%, and an accuracy of 94% for CT scanning in the detection of obstructions. Another series reported a sensitivity of 92% and specificity of 71% in the correct identification of partial or complete SBO.

Ultrasonography

Ultrasonography is less costly and invasive than CT scanning and may reliably exclude SBO in as many as 89% of patients; specificity is reportedly 100%.

In a small study by Jang et al in which the use of bedside ultrasonography by emergency physicians was compared with radiography for the detection of small-bowel obstruction (SBO), emergency physician ̶ performed ultrasonography compared favorably with radiography. Dilated bowel on ultrasonography had a sensitivity of 91% and a specificity of 84% for SBO, while radiography had a sensitivity of 46% and a specificity of 66%.

 

Large-Bowel Obstruction Workup.

Approach Considerations

Laboratory studies are directed at evaluating the dehydration and electrolyte imbalance that may occur as a consequence of large-bowel obstruction (LBO) and at ruling out ileus as a diagnosis.

Routine complete blood cell count (CBC), serum chemistries, and urine specific gravity should be evaluated. A decreased hematocrit level, particularly with evidence of chronic iron-deficiency anemia, may suggest chronic lower gastrointestinal (GI) bleeding, particularly due to colon cancer. A stool guaiac test also should be performed, for similar reasons.

Obtain a prothrombin time (PT) as well as a type and crossmatch.

Although bowel obstruction, or even constipation, may mildly elevate the white blood cell (WBC) count, substantial leukocytosis should prompt reconsideration of the diagnosis. Ileus, secondary to an intra-abdominal or extra-abdominal infection or another process, is a possibility.

The suggestion of an abnormal anion gap (see the Anion Gap calculator) also should prompt an arterial blood gas (ABG) measurement and/or a serum lactate level measurement.

 

Plain Radiography

Obtain an upright chest radiograph to determine whether free air is present, which would suggest perforation of a hollow viscus and ileus rather than organic obstruction, as well as flat and upright abdominal radiographs, which may demonstrate dilatation of the small and/or large bowel and air-fluid levels.

Chest radiographs will demonstrate free air if perforation has occurred (see the first image below); abdominal radiographs may be diagnostic of sigmoid or cecal volvulus (ie, kidney bean appearance on the radiograph) (see the second and third images below, respectively). Intramural air is an ominous sign that suggests colonic ischemia. The absence of free air does not exclude perforation (this finding may be absent in half of all perforations).

Tracing colonic air around the colon, into the left gutter, and down into the rectum or demonstrating an abrupt cut-off in colonic air suggests the anatomic location of the obstruction.

A dilated colon without air in the rectum is more consistent with obstruction. The presence of air in the rectum is consistent with obstipation, ileus, or partial obstruction. However, this finding can be misleading, particularly if the patient has undergone rectal examinations or enemas.

 

Radiocontrast Radiography

Contrast studies include an enema with water-soluble contrast (ie, Gastrografin) (see the following images) or computed tomography (CT) scanning with intravenous (IV) and oral (PO) or rectal (PR) contrast. Contrast studies that reveal a column of contrast ending in a "bird's beak" are suggestive of colonic volvulus.

Indications for imaging with contrast

Radiopaque contrast material may be administered and imaging of the colon may be performed under the following circumstances:

           Perform it if the diagnosis of large bowel obstruction is suspected but not proven

           If differentiation between obstipation and obstruction is required

           If localization is required for surgical intervention

 

Water-soluble contrast vs barium

Water-soluble Gastrografin has important advantages over barium as a contrast agent and generally should be used first. Gastrografin usually does not cause chemical peritonitis if the patient has colonic perforation, and it has an osmotic laxative effect that may actually wash out an obstipated colon.

If large-bowel perforation is ruled out using a Gastrografin study but a more detailed anatomic definition is required (particularly of the right colon), a barium enema may be performed.

 

Computed Tomography Scanning

Although computed tomography (CT) scanning is useful to help rule out intra-abdominal abscess or other causes of ileus, this imaging modality is generally not used initially in patients with large-bowel obstruction (LBO), unless the diagnosis is still in question.

CT scanning, particularly with rectal contrast, may demonstrate a mass or evidence of metastatic disease. Generally, the findings do not alter management, because these patients will be explored and operatively decompressed, regardless of the CT scan findings.

CT colography may be useful in evaluating these patients, not only to delineate the source of the obstruction but also to rule out synchronous proximal lesions, which may occur in about 1% of patients and which might motivate a more extended resection if identified and if the patient's condition will tolerate the more extensive procedure.

 

Flexible Endoscopy

Flexible endoscopy preceded by rectal enema may be useful in evaluating left-sided colonic obstruction, including the anatomic location and pathology of the lesion. Because the cecum is not reached in such cases, the endoscopist must be alert to the possibility of incorrectly identifying anatomic landmarks and the location of the obstruction.

An abdominal radiograph with the tip of the endoscope at the site of the obstruction may be extraordinarily helpful in identifying and documenting the location of the large-bowel obstruction (LBO).

Although flexible endoscopy is relatively comfortable for the patient and provides a better view than rigid sigmoidoscopy, rigid sigmoidoscopy may also be used, depending on the availability of resources and training of personnel.

Right-sided colonic obstruction is more difficult to evaluate without first administering an oral bowel preparation, which is contraindicated in the setting of bowel obstruction.

 

Differential diagnostics

           Abortion, Threatened

           Alcoholic Ketoacidosis

           Cholangitis

           Cholecystitis and Biliary Colic in Emergency Medicine

           Cholelithiasis

           Constipation

           Diverticular Disease

           Dysmenorrhea

           Endometriosis

           Inflammatory Bowel Disease

           Mesenteric Ischemia

Intestinal obstruction must be differentiated with the acute diseases of organs of abdominal cavity.

The perforation of gastroduodenal ulcer, as well as intestinal obstruction, passes acutely with inherent to it by sudden intensive pain and tension of muscles of abdomen. However, in patients with this pathology, unlike intestinal obstruction, the abdomen is not exaggerated, and pulled in with wooden belly tension of muscles of front abdominal wall. There is also characteristic ulcerous anamnesis. Roentgenologic and by percussion pneumoperitoneum is observed. Certain difficulties in conducting of differential diagnostics of intestinal obstruction can arise at atipical passing and in case of the covered perforations.

Acute pancreatitis almost always passes with the phenomena of dynamic intestinal obstruction and symptoms of intoxication and repeated vomiting, with rapid growth. During the examination in such patients, unlike intestinal obstruction, rigidity of abdominal wall and painfulness is observed in the projections of pancreas and positive Korte's symptom and Mayo-Robson's. The examination of diastase of urine and amylase of blood have important value in establishment of diagnosis.

Acute cholecystitis. Unlike intestinal obstruction, patients with this pathology complain for pain in right hypochondrium, that irradiate in the right shoulder-blade, shoulder and right subclavian area. Difficulties can arise, when the symptoms of dynamic intestinal obstruction appear on the basis of peritonitis.

The clinic of kidney colic in the signs and character of passing are similar to intestinal obstruction, however, attacks of pain in the lumbar area with characteristic irradiation in genital parts, the thigh and dysuric disorders help to set the correct diagnosis. Certain difficulties in conducting of differential diagnostics also can arise in difficult patients, at frequent vomiting which sometimes can be observed in patients with kidney colic.

 

Table. Characteristics of Ileus, Pseudo-obstruction, and Mechanical Obstruction

 

Ileus

Pseudo-obstruction

Mechanical Obstruction (Simple)

Symptoms

Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia

Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia

Physical Examination Findings

Silent abdomen, distention, tympanic

Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tenderness

Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness

Plain Radiographs

Large and small bowel dilatation, diaphragm elevated

Isolated large bowel dilatation, diaphragm elevated

Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels

 

Tactics and choice of treatment method

During the first 1,52 hours after hospitalization of patient complex conservative therapy which has the differential-diagnostic value and can be preoperative preparation is conducted.

 

Emergency Department Care (SBO)

Initial emergency department (ED) treatment consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, early surgical consultation, and administration of antibiotics. (Antibiotics are used to cover against gram-negative and anaerobic organisms.)

Initial decompression can be performed by placement of a nasogastric (NG) tube for suctioning GI contents and preventing aspiration. Monitor airway, breathing, and circulation (ABCs).

Blood pressure monitoring, as well as cardiac monitoring in selected patients (especially elderly patients or those with comorbid conditions), is important.

 

Nonoperative inpatient care

Continued NG suction provides symptomatic relief, decreases the need for intraoperative decompression, and benefits all patients. No clinical advantage to using a long tube (nasointestinal) instead of a short tube (NG) has been observed.

A nonoperative trial of as many as 3 days is warranted for partial or simple obstruction. Provide adequate fluid resuscitation and NG suctioning. Resolution of obstruction occurs in virtually all patients with these lesions within 72 hours. Good data regarding nonoperative management suggest it to be successful in 65-81% of partial small-bowel obstruction (SBO) cases without peritonitis. Nonoperative treatment for several types of SBO are as follows:

           Malignant tumor - Obstruction by tumor is usually caused by metastasis; initial treatment should be nonoperative (surgical resection is recommended when feasible)

           Inflammatory bowel disease - To reduce the inflammatory process, treatment generally is nonoperative in combination with high-dose steroids; consider parenteral treatment for prolonged periods of bowel rest, and undertake surgical treatment, bowel resection, and/or stricturoplasty if nonoperative treatment fails.

           Intra-abdominal abscess - CT scan ̶ guided drainage is usually sufficient to relieve obstruction

           Radiation enteritis - If obstruction follows radiation therapy acutely, nonoperative treatment accompanied by steroids is usually sufficient; if the obstruction is a chronic sequela of radiation therapy, surgical treatment is indicated

           Incarcerated hernia - Initially use manual reduction and observation; advise elective hernia repair as soon as possible after reduction

           Acute postoperative obstruction - This is difficult to diagnose, because symptoms often are attributed to incisional pain and postoperative ileus; treatment should be nonoperative

           Adhesions - Decreasing intraoperative trauma to the peritoneal surfaces can prevent adhesion formation

 

Conservative Management (LBO)

Medical care of colonic obstruction is directed primarily at supporting the patient and treating any comorbid illnesses. This involves resuscitation, correction of fluid and electrolyte imbalances, and nasogastric decompression to temporarily treat the obstruction and to prevent vomiting and aspiration. Medications that slow colonic motility (eg, narcotics, anticholinergics) should be stopped, if possible.

Oral laxatives are contraindicated if large-bowel obstruction is suspected. If any evidence suggests simple constipation, patients should be managed with transrectal enemas. Tap water, isotonic sodium chloride solution, and a variety of other fluids may be used. In patients with renal insufficiency, the physician should be sensitive to the electrolyte content of the fluid.

If the patients pain is sufficiently severe to merit use of significant analgesics, peritonitis, rather than large-bowel obstruction, should be considered as the first diagnosis.

For a small subset of patients, in whom the obstruction is not only malignant but also reflects substantially disseminated or even inoperable disease, consideration of completely nonoperative palliative therapy within the context of a palliative care or hospice approach may be appropriate. This might include somatostatin therapy and may or may not include nasogastric decompression.

For acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, underlying precipitant factors must be identified and corrected. If no perforation is present, pseudo-obstruction is treated with conservative management for the first 24 hours. This includes bowel rest, hydration, and management of underlying disorders.

Pharmacologic treatment of acute colonic pseudo-obstruction with neostigmine or colonoscopic decompression may be effective in cases that do not resolve with conservative management. Colonoscopic decompression may be successful in as many as 80% of patients with acute colonic pseudo-obstruction.

Surgical intervention for acute colonic pseudo-obstruction is associated with a high mortality and morbidity. This treatment is reserved for refractory cases or cases complicated by perforation.

 

Cleansing enemas

Perform cleansing enemas if obstipation is suspected rather than true large-bowel obstruction. These can also be performed to prepare the distal colon for endoscopic evaluation.

 

Endoscopic reduction of volvulus

Endoscopic reduction is indicated for sigmoid volvulus when peritoneal signs are absent, which would imply dead bowel or perforation. This procedure is also indicated when evidence of mucosal ischemia is not present upon endoscopy. An experienced person should perform the procedure.

Endoscopic reduction is not indicated for the less common cecal or transverse colon volvulus.

A rigid sigmoidoscope may be used if a flexible instrument is not available. The endoscopist must have sufficient experience with this technique.

Reduction of a volvulus does not imply cure. The sigmoid usually revolvulizes if definitive treatment is not carried out.

These patients are generally admitted to the hospital, subjected to mechanical bowel preparation, and managed surgically by sigmoid resection, unless contraindications are present.

 

Reduction of intussusception with barium enema

Barium enema for reduction of intussusception is useful and often successful in children in whom a pathologic leading point for the intussusception is unlikely. This procedure should be performed by an experienced radiologist, because the risk of perforation is significant.

In adults, typically a pathologic leading point for the intussusception is present. Success is far less likely, and patients still require surgery to deal with their pathology.

 

Endoscopic dilation and stenting of colonic obstruction

Endoscopic dilation and stenting of colonic obstruction is indicated for colonic near-total obstruction through which some small amount of lumen remains. The procedure may be palliative in a high-risk patient with an unresectable malignancy, accepting a risk of reobstruction of the stent, or preparatory to surgical resection.

In cases in which the stent is deployed before surgery, this procedure permits relief of the acute obstruction, resuscitation of the patient, and mechanical bowel preparation before a 1-stage colonic resection and reanastomosis, thus avoiding temporary or permanent colostomy.

Endoscopic dilation and stenting of colonic obstruction should be performed only by an endoscopist experienced in such procedures.

Surgical consultation and backup should be available, as the risk of perforation is increased during attempts at such procedures, with a potentially catastrophic result.

Although some experience with stenting has been positive, with some retrospective preference for the Ultraflex stent over the Wallstent because of ease of placement, a multicenter trial of endoscopic stenting using the Wallstent versus surgery for stage IV left-sided colorectal cancer was terminated early because of an unacceptably high incidence of perforation. Whether this finding reflects the technical aspects of the procedure in that study, the particular stent used, or a truly unacceptable incidence of this dangerous complication awaits further study.

 

Dietary considerations

Patients with complete large-bowel obstruction should receive nothing by mouth (NPO). Patients with a partial obstruction may tolerate minimal clear liquids, oral medications, and a gradual bowel preparation.

It is directed on warning of the complications related to pain shock, correction of homeostasis and, simultaneously, is the attempt of liquidation of intestinal obstruction by unoperative methods.

1. The measures directed for the fight against abdominal pain shock include conducting of neuroleptanalgesia, procaine paranephric block and introduction of spasmolytics. Patients with the expressed pain syndrome and spastic intestinal obstruction positive effect can be attained by epidural anaesthesia also.

2. Liquidation of hypovolemia with correction of electrolyte, carbohydrate and albuminous exchanges is achieved by introduction of salt blood substitutes, 510 % solution of glucose, gelatinol, albumen and plasma of blood. There are a few methods suitable for use in the urgent surgery of calculation of amount of liquid necessary for liquidation of hypovolemia. Most simple and accessible is a calculation by the values of hematocrit. If to consider 40 % for the high bound of hematocrit norm, on each 5 % above this size it is needed to pour 1000 ml of liquids.

3. Correction of hemodynamic indexes, microcirculation and disintoxication therapy is achieved by intravenous infusion of Reopolyhlukine and Neohemodes.

4. Decompression of intestine truct is achieved by conducting of nasogastric drainage and washing of stomach, and also conducting of siphon enema. It is needed to underline that technically the correct conducting of siphon enema has the important value for the attempt of liquidation of intestinal obstruction by conservative facilities, therefore this manipulation must be conducted in presence of a doctor. For such enema the special device is used with the rectal tip, by a PVC pipe by a diameter of 1,52,0 cm and watering-can of very thin material. A liquid into the colon is brought to appearance of the pain feeling, then drop the watering-can below the level of patient who lies. The passage of gases and excrement is looked after. As a rule, this manipulation is to repeat repeatedly with the use of plenty of warm water (to 1520 and more litres).

Liquidating of the intestinal obstruction by such conservative facilities is succeeded in 5060 % patients with mechanical intestinal
obstruction.

 

Surgical Intervention

Surgical intervention is directed at relieving the obstruction.

A diverting transverse loop colostomy may be the least invasive procedure for a very ill patient with a left colonic obstruction. It permits relief of the obstruction and further resuscitation without compromising chances for a subsequent resection. A case report described the use of hand-assisted laparoscopy via the loop colostomy site for subsequent resection of the obstructing lesion.

A sigmoid colostomy without resection may be used in patients with a rectal obstruction that cannot be managed without a combined abdominoperineal approach. Cecostomy should not be performed, because the diversion is inadequate.

In younger patients without substantial comorbidity, some surgeons would consider primary anastomosis, rather than ileostomy, in the right colon, assuming no intraoperative hypotension, blood loss, or other complications are present.

If resection and proximal colostomy or ileostomy are performed, a mucous fistula is generally extracted from the distal end, unless the obstruction is rectosigmoid, in which case the distal end may be oversewn or stapled and left to drain transanally.

If the cause of the obstruction can be relieved nonsurgically, through procedures such as decompressing a volvulus, or if the obstruction is only partial, deferring surgery temporarily and supporting the patient while the large bowel is cleansed so that primary anastomosis may be performed more safely is preferable.

A slow preoperative mechanical bowel preparation is indicated for patients who have incomplete obstruction, provided the patient can tolerate it. Some authors prefer polyethylene glycol solutions, such as GO-LYTELY, because they avoid issues of fluid and electrolyte imbalance. The fluid should be administered slowly (rather than given in the standard manner of 1 gal over 4 h), and the patient should be observed for abdominal cramping and intolerance.

 

Carcinoma

In most patients, the obstructing lesion is resected. Because the colon has not been cleansed, anastomosis is often risky. After resection, most surgeons perform a proximal colostomy if the obstruction is on the left side or ileostomy if it is on the right side.

In patients with substantial comorbidity and surgical risk or in the presence of an unresectable tumor, a diverting proximal colostomy or ileostomy may be performed without resection.

Left vs right colon carcinoma. Surgical treatment of left colon carcinoma includes resection without primary anastomosis or resection with primary anastomosis and intraoperative lavage. Endoscopically placed expandable metal stents can be used to relieve the large-bowel obstruction, thus allowing for a primary colorectal anastomosis.

Right colonic obstructions are treated with a right colectomy and a primary anastomosis between the ileum and the transverse colon. Patients with high-risk features for surgery (advanced age, complete obstruction, or severe comorbidities) may benefit from stent placement until patient can be optimized for a surgical procedure. Palliative colorectal stents are an option in patients who are poor surgical candidates or have advanced cancer.

 

Diverticulitis

Patients with persistent obstruction secondary to diverticular disease despite appropriate medical management are treated surgically. Surgical resection follows the same principles as the treatment of carcinomas. Elective colonic resection is offered to patients with recurrent disease.

 

Sigmoid vs cecal volvulus

Sigmoidoscopy with volvulus reduction is the procedure of choice for sigmoid volvuli. Second choice is sigmoid colectomy.

The primary treatment of cecal volvuli is also surgical. A cecopexy often needs to be performed to prevent recurrence. Second choice is colonoscopy, due to the high risk of colonic perforation.

Intussusception

Adult colonic intussusception is treated with primary colon resection without prior reduction.

Patients with dynamic paralytic intestinal obstruction are expedient to stimulation of peristalsis of intestine to be conducted, besides, necessarily after infusion therapy and correction of hypovolemia. A lot of kinds of stimulation of intestine peristalsis are offered. Most common of them are:

1) hypodermic introduction of 1,0 ml of 0,05 % solution of proserin; 2) through 10 min 60 ml intravenously stream of 10 % solution of chlorous sodium; 3) hypertensive enema.

Surgical treatment of intestinal obstruction must include such important moments:

1.           According to middle laparotomy executed the novocaine blockade of mesentery of small and large intestine and operative exploration of abdominal cavity organs during which the reason of intestinal obstruction and expose viability of intestine is set.(Fig.9)

 

Fig.9.Intestinal obstruction.

Overblowning of small intestine

The revision at small intestine obstruction begins from the Treitz' ligament to iliocecal corner. At large intestine obstruction the hepatic, splenic and rectosigmoid parts are observed intently. Absence of pathological processes after revision needs the examination of places of cavity and jamming of internal hernia: internal inguinal and femoral rings, obturator openings, pockets of the Treitz' ligament, Winslow's opening, diaphragm and periesophageal opening.

2. Liquidation of reasons of obstruction (scission of connection, that squeezes a bowel, violence of volvulus and node formation of loops, desinvagination, deleting of obturative tumours and others like that).

It is needed to mark that the unique method of liquidation of acute intestinal obstruction does not exist. At the lack of viability of bowel the resection of nonviable area is executed with 3040 cm of afferent and 1520 cm of efferent part with imposition of side-to-side(Fig. 10; Fig. 11) anastomosis or end-to-end(Fig.12).

 

Fig 10.The resection of the small intestine with imposition of

anastomosisside to side

-mobilization of segment of the small intestine

-peritonization of the stump of bowel

Fig.11. Enteroenteroanastomosis side-to-side is formed.

 

ABC

 

Fig 12. The resection of the small intestine

with imposition of end-to-end anastomosis

A- mobilization and removing of the changed loop of the bowel

B- formation of the back lip of anastomosis

C- Final view of enteroenteronastomosis

 

3. Intubation. (Fig.13) Decompression of intestine foresees conducting in the small intestine of elastic probe by thickness of 89 mm and length of 33,5 with the plural openings by a diameter 22,5 mm along all probe, except for part, that will be in the oesophagus, pharynx and outwardly. A few methods of conducting of probe are offered in a bowel (nasogastric, through gastrostomy, ceco- or appendicostoma). Taking it into account, such procedure needs to be executed individually and according to indications.

Fig. 13. Nasogastrointestinal probe

Each of them has the advantages and failings. In connection with the threat of origin of pneumonia, entering an intubation probe to the patients of old ages is better by means of gastrostomy. Most surgeons avoid the method of introduction of probe through ceco- or appendicostoma because of technical difficulties of passing in a small intestine through a Bauhin's valve.(Fig.14)

Fig.14. Types of decompression of digestive tract

 

Today the most wide clinical application has intubation of intestine extracted by the nasogastric method with the use of other thick probe as explorer of the first (by L.J. Kovalchuk, 1981)(Fig.15). Such method not only simplifies procedure of intubation but also facilitates penetration through the piloric sphincter and duodenojejunal bend, and also warns passing of intestinal maintenance in a mouth cavity and trachea. Thus probe is tried to be conducted in the small intestine as possible farther and deleted the next day after appearance of peristalsis and passage of gases, however not later than on 7th days, because more protracted sign of probe carries the real threat of formation of bedsores in the wall of bowel.

 

 

1. Gastric probe-guide is placed2. Beginning of intubation 3. Intubation till caecum

through the gastric probe-guide

distally to pylorus per os

 

 

4. Removing of gastric probe 5. Fixation of proximal part

of intestinal probe to the nasal cathether

 

6. Removing of proximal part of intestinal7. Proximal part is removed

through the nose probe from the oral cavity through the nose

 

8. Final view of nasogastrointestinal intubation

Fig.15. Principles of nasogastrointestinal intubation

4. Sanation and draining of abdominal cavity is executed by the generally accepted methods of washing of antiseptic. Draining of the abdominal cavity it is needed from four places: in both iliac areas and both hypochondrium, better by the coupled synthetic drain pipes.

 

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Prepared ass. Romaniuk T.