Acute intestinal obstruction symptoms and radiological signs

Intestinal obstruction, ileus – characteristics of the disease

Acute intestinal obstruction (ileus status) is a condition that is clinically manifested by blockage of the intestines. The set of symptoms is a symptom of complications of many diseases of different etiology and prognosis.

Bowel obstruction is a disease that requires rapid diagnosis and immediate treatment, usually surgical. The lack of treatment leads to various pathophysiological mechanisms of disease development. This condition presents a common breakdown of the body and is characterized by the failure not only of the gastrointestinal tract, but also other vital systems and organs.

Bowel obstruction – classification and causes of disease

Classification of intestinal obstruction is based on the signs and symptoms of the disease.

In accordance with the cause of acute intestinal obstruction is divided into mechanical, functional and mixed.

The most common form is the mechanical ileus. The causes of intestinal obstruction vary depending on the patient's age and localization of the disease. The disease most often affects adults than children. Cause of obstruction of the small intestine are mostly adhesions, intestinal obstruction in adults, usually caused by tumor. Neoplastic or inflammatory stenosis cause closure of the lumen of the intestine, gallstones, foreign bodies and parasites cause a blockage of the lumen, adhesions or extraintestinal tumors cause compression of the bowel from the outside.

Severe mechanical ileus is strangulation, which is characterized by impaired blood supply to the intestine. Treatment of acute intestinal obstruction of this type involves urgent surgical intervention.

Functional ileus due to a violation of intestinal motility without any mechanical obstruction to the passage of intestinal contents. It is divided into paralytic and spastic.

Paralytic ileus is caused by paralysis of the intestinal motility. Violation of intestinal motility is a common condition in inflammatory diseases of the abdominal organs, pancreatitis, cholecystitis, appendicitis, diverticulitis and peritonitis. Reflex it is called, for example, renal and hepatic colic, significant blood loss, urine retention, fractures of the vertebrae, and with processes in the intestine of various etiologies. Rarely the paralysis is accompanied by disorders of the internal environment of the body, for example, dehydration, diabetic acidosis, uremia, hypokalemia. Disorders of motility can be caused by certain drugs, such as tricyclic antidepressants, neuroleptics, opioids.

With rare spastic ileus occurs spastic paralysis of the muscles of the intestine, as happens, for example, in cases of poisoning by tin and porphyria.

Pseudoobstruction colon – Ogilvie syndrome – is a rare condition defined by many different factors. Under the common denominator of the reasons that motivate pseudoobstruction considered either the weakening of parasympathetic activity, or metabolic disorders.

Postoperative ileus is a separate group. The etiology of postoperative ileus is multifactorial, and its detailed analysis is beyond the scope of this article.

Pathophysiology of obstruction and the development of the disease

Look at the pathophysiology of the disease, according to recent data, has changed. Indicates that the pathophysiological mechanisms involved in the formation of obstruction, vary depending on height of closing the lumen of the intestine. Thus, the division of the obstruction of the small and large intestine based not only on the localization of the barrier, but the pathophysiological changes.

The barrier in the small intestine is the cause of obstruction in 75-80% of cases. The surface of the mucous membrane of the small intestine is 200-300 m2, which is more than 100 times greater than the surface of the skin. The small intestine, thus has a significant influence on the mediator response of the body. When you stop the passage of contents through the small intestine, which physiologically only slightly colonized by bacteria, comes in a significant of reproductionbacteria, especially Escherichia coli. An increasing number of bacteria that cause hypersecretion of the mucosa and increased blood flow in the intestinal walls. The intestine can be extended, but the intraluminal pressure did not exceed 8 cm H2O and thus has no significant effect on the reduction of blood supply to the intestinal wall.

High ileus suffer approximately 20% of patients with obstruction of the small intestine. The person is vulnerable to large losses of water and electrolytes that cause significant hypovolemia and electrolyte imbalance. Mediator response at high ileus initially insignificant.

Just when obstruction of the small intestine, caused by an obstruction in distal areas, qualitative and quantitative changes of bacterial flora in the small intestine. At the early stage of bacterial toxins do not pass through the mucous barrier, but released endotoxins cause a significant hypersecretion in the lumen of the small intestine, causing hypovolemia. Quickly comes to disruption of mucus barrier and subsequent bacterial translocation. Starting 4 days after the occurrence of intestinal obstruction is provably endotoxinemia. Develops systemic inflammatory response syndrome – SIRS (SIRS – Systemic Inflammatory Response Syndrom) with symptoms of organ dysfunction. If untreated, SIRS goes into multiple organ failure (MOF Multiple Organ Failure). This condition is particularly threatening to people with risk of obstruction in the distal small intestine, but a small group of patients with the barrier in the colon.

For obstruction of the colon, which occurs in 20-25% of cases, is characterized by a gradual increase initially mild clinical picture. Under the sufficiency Bauhinias valve, which occurs approximately in 95% of cases, there is only a swelling of the colon. Unlike the small intestine, the total area of the mucous membrane of the colon is approximately 1 m2. In the large intestine does not reach to the hypersecretion of mucous, hypovolemia is not an early symptom of ileus. Not been shown the release of inflammatory mediators from the colon wall. The antimicrobial barrier of the mucosa is very effective, so even the proportion of bacterial translocation in the development of obstruction of the colon is not important. On the other hand, it is important to increase the amount of gas and feces in the colon, resulting in increased intracavitary pressure to values about 100 mm Hg. At high intraluminal pressure comes to ischemia of the intestinal wall of the colon and, consequently, to its perforation. To ischemia of the bowel can lead to intussusception – introduction of the intestines into the lumen. Swelling and ischemia of the intestines are considered as the main factors causing the development of SIRS. Prognostically very unfavorable is the occurrence of perforation and perforation peritonitis.

If strangulation intersect the above pathophysiological mechanisms caused by bowel obstruction, pathophysiology of acute intestinal ischemia. Severe pain in early ischemia caused by irritation of the spinal sympathetic afferent fibers. This gradually leads to the development of SIRS, sepsis and multiorgan failure.

Clinical picture – symptoms of acute intestinal obstruction

The main symptoms of intestinal obstruction presented by the delay of gases and stool, vomiting due to the accumulation of content over a barrier or reflex by strangulation, bloating and spasmodic pain in the beginning of obstructive ileus, severe or even intolerable pain in the beginning of strangulated ileus.

In the course of the disease, some of the major symptoms of obstruction may be absent. Colic is absent in paralytic ileus, vomiting – in the barrier in the distal colon. Minimal clinical manifestations are present at high ileus where in addition to vomiting, there are no other major symptoms of intestinal obstruction: abdominal distension, flatulence, constipation and pain.

Common symptoms of shock appear quickly during strangulation. In other cases, General symptoms develop with different intensity depending on the height of the barrier in the intestine, functionality Bauhinias damper, the General condition of the person, the stage of the tumor in case of its presence.

Clinical manifestations and functional and obstructive ileus of the small intestine are very similar. Are almost identical clinical picture of obstructive ileus of the colon when the barrier is in the left half of the colon and Ogilvie syndrome.

Diagnosis – intestinal obstruction and its diagnosis

The survey process should lead to rapid diagnosis of the disease. This is especially important during the strangulation, which is a blood disorder and a direct threat to his functioning.

In the diagnosis of obstruction is the recognition of the first signs of strangulation. It is important to determine the height of the barrier, it is situated in the small or large intestine that causes bowel obstruction, is it obstructive or functional. Examination of patients in a state of ileus status must follow the normal procedure of inspectiona patient who present with acute intestinal obstruction. It includes:

• Anamnesis.
• Physical examination.
• A survey of visualization techniques.
• Laboratory and internal survey methods.

In respect of personal history are important, the following facts:

• The volume and number of operations of the gastrointestinal tract.
• Diseases of the intestines and other abdominal organs or of their symptoms.
• Medication.
• The presence of other diseases.

History of present illness focuses on the presence of the main symptoms of intestinal obstruction, which are the delay of gases and stool, vomiting and pain.

An objective examination should not be overlooked and underestimated first "subtle" signs of change in General health, for example, tachycardia, tachypnea and a decrease in blood pressure.

When abdominal x-rays can be seen distended bowel loops filled with fluid and gas, the so-called bowl kloybera and intestinal arch – specific radiological signs of intestinal obstruction.

The exhibition starts from the examination of the abdominal cavity, which examines the degree of its distention, scars from previous surgery, hernia and the condition of the bowel loops. Palpation is necessary to determine the presence and location of hernias and pain points.

Important is auscultation. Instead of the usual sounds when bowel movements heard "metallic sounds" and sounds "of falling drops", which is caused by increased peristalsis above the barrier. Complete dead silence in the abdomen is characteristic of paralytic ileus.

Rectal examination may reveal narrowing of the anus, a stenosing tumor of the rectum in the effusion in the Douglas space in the case of an advanced stage of ileus. Empty, dilated and atonic, the ampoule of the rectum with a loose sphincter is a symptom of a barrier located in the distal colon.

From the survey of visualization techniques, still the first and main project is a native radiograph of the abdomen in standing position. On x-ray for ileus characteristic is the presence of air above the fluid level in a separate bowel loops. In accordance with their distribution, conspicuous on the image, you can accurately determine the location of the barrier. For example, if the barrier is located in the small intestine, as a rule, there are two levels in the epigastrium and a few levels in the middle of the abdomen, in the barrier region of the ileum, the levels are cascaded, throughout the abdomen, there is also dilatation of the small intestine. A large number of levels, and dilatation of the small intestine are characteristic signs of paralytic ileus. Isolated dilation of the small or large bowel, usually caused by inflammation of the environment, pancreatitis, appendicitis, cholecystitis or diverticulitis.

Treatment of acute intestinal obstruction

Treatment of intestinal obstruction is conservative and surgical. Conservative treatment is a part of complex therapy of ileus at the time of diagnosis, during preparation for surgery and in the postoperative period. Only in some cases of functional obstruction conservative therapy is enough to control the situation. Basic and life-saving treatment for intestinal obstruction due to mechanical causes, is an operation that usually should be carried out urgently. Absolute indications for emergency surgery are strangulation and mesenteric ischemia. Only in some exceptional cases, when mechanical obstruction is possible to be conservative, therefore, to postpone the operation. The decision that the patient will be operated on urgently, accordingly, that operation may be delayed, must be planted by a qualified opinion of the leading specialist surgeon is as important as the decision to use surgical intervention.

Direct action of conservative treatment of the obstruction are to provide venous access by introducing the peripheral or Central venous catheter, nasogastric tube and urinary catheter. It is necessary to control basic vital functions. Introduced a Central venous catheter allows to control the values of Central venous pressure. Urinary catheter and nasogastric tube are needed to monitor fluid balance. A low urine output is not only an expression of hypovolemia but can also be a sign of kidney function in the context of incipient organ failure. You always need to keep in mind and heal the body. Parenteral, complemented by the missing liquid volume is adjusted ion imbalance kompensiruet diabetes and other diseases in case of their presence.

Properly conducted intensive conservative treatment may be at high ileus completely hide the clinical symptoms of the disease, of which remain only the high branches with a nasogastric tube.

In the case of disorders of organ systems necessary to support their functions, mainly the respiratory system. Urgent surgical intervention begins after the necessary effective overallpreparation of the patient. Long ineffective training of the human condition from mechanical obstruction does not improve.

When paralytic ileus to control the condition is a sufficient continuation of conservative treatment. These measures include:

• Continued parenteral nutrition.
• Medical support bowel.
• Welcome osmotic drugs.
• The use of enemas.
• Treatment of opportunistic diseases.

An important condition for successful surgical treatment of mechanical intestinal obstruction is the observance of the General principles of operation. Expertise in the operation, which is complicated by the presence of dilated and filled bowel loops aimed at determining the cause of intestinal obstruction. Decompression of the dilated bowel obstruction is provided by aspiration of intestinal contents. Intraoperative treatment filled and dilated bowel requires sufficient caution, patience and experience of the operating surgeon. Inherit remove, or bypass the barrier of the intestinal passage, or the establishment of differentiated stoma above the barrier.

In the case of strangulation it is necessary to free the intestine by interrupting the strangulation of the strip, the release of hernia, derotation when valvule and desinvagination with intussusception. After the relief of strangulation it is necessary to assess the viability of the released part of the intestine. Irreversibly affected part of the bowel needs to be resected, and the continuity of the digestive tract restored intestinal anastomosis. If hit more than a long stretch of the small intestine and its viability remains unclear, it is possible to stop the operation and to plan, "second look" surgery. In the case of multiple lesions of the small intestine it is recommended that a greater number of adhesions, as in the case of partial relaxation of adhesions in the postoperative period may again be clinically manifested obstruction of the unprocessed segment.

As already mentioned, the most common cause of intestinal obstruction is a tumor of the colon, colorectal cancer, localized mainly in the left half. Previously, the usual procedure, including the creation of derivative stoma above the barrier, bowel resection with the tumor, and finally the abolition of the stoma that burdened with high total mortality, the frequent violation of the sequence of necessary operations and long re-hospitalization due to these negative reasons not applicable today. Currently in obstructive ileus of the colon is predpochtenie single-stage surgery in which removing the cause of ileus, and intestinal passage, if possible, restored intestinal anastomosis.

The operating stroke in intestinal obstruction must meet the criteria of oncologic principles, including lymph node dissection.

Alternative to surgical treatment of obstruction in the left half of the colon, accumulation of quantity of intestinal contents in the colon, is the Subtotal colectomy with primary anastomosis ileocolonic. Colon removal with the content reduces the risk of intraoperative contamination of the surgical field, moreover, ileocolonic anastomosis is safer than a colorectal anastomosis. The disadvantage, especially in elderly patients, may be an increase in the frequency of stools relative to incontinence and frequent diarrhea.

In the absence of conditions for the establishment of a direct anastomosis, for example, when stercoral peritonitis in patients with already developed MOF operation is performed Hartmann. We are talking about a resection with end colostomy and closure of the cecum without primary anastomosis.

In patients with cancer metastases can hold a limited resection of intestine with anastomosis. In patients with advanced cancer based on the organs of the abdominal cavity, where it may already be present carcinomatosis, chronic obstruction is surgically difficult to resolve.

In tumors of the colon with acute obstruction in some cases can be managed by recanalization of the tumor with a laser or a metal stent.

Laparoscopic treatment ileum of the small intestine is possible, but is hampered by a large number of cases when it is necessary to abandon this method. Thus, when deciding about the methods of therapy ileum of the small intestine is recommended to perform preoperative selection of patients suitable for laparoscopic surgery.

Acute intestinal obstruction alone is not recommended to treat,it is better to consult a doctor!