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 2–5
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 gene–related 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 ≥
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:
à) paralytic;
á) spastic;
â) hemostatic (embolic, thrombophlebitic).
2.
Mechanical intestinal obstruction(Fig.1):
à) strangulated, volvulus, jamming;(Fig. 2)
á)
obturation (closing of bowel lumen, squeezing
from outside);
â)
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:
à) high;
á)
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 1–2 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 75–80 % 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 85–90% 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 Mondor’s symptom, “noise of beginning, quietness of end”).
There
are other symptoms pathognomic for intestinal obstruction.
The Vala’s symptom is the
limited elastic sausage-shaped formation.
The Sklarov’s 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 Klojber’s bowl. (Fig.3;
Fig.4)
Fig. 3.
Intestinal obstruction.
X-ray examination of abdominal cavity –
presence of the Klojber’s 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 1–2 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 >
·
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
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
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 1,5–2 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 patient’s 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, 5–10 % 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 1,5–2,0 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 15–20 and more litres).
Liquidating
of the intestinal obstruction by such conservative facilities is succeeded in
50–60 % 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
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 30–40 cm of afferent and 15–20 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
anastomosis”side
– 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 8–9 mm and length of 3–3,5 ì with the
plural openings by a diameter 2–2,5 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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