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Diagnosis and treatment of acute intestinal obstruction. Intestinal obstruction

Problems with the intestines are not that rare. A serious problem for a person can be intestinal obstruction, manifested by unexpected acute abdominal pain that is not associated with an immediate cause. Blockage of the small intestine is called intestinal obstruction; the result is partial or complete blockage of food and even liquid in the digestive organs and, as a result, the inability of the intestines to empty. The disease can develop as a result of past illnesses, after which adhesions appear and various tumors develop. Accompanying obstruction of the small intestine is the accumulation of gases, a feeling of nausea, accompanied by vomiting, and a sharp decline in vitality.

What is intestinal obstruction?

An intestinal obstruction is a blockage of the passage of the small or large intestine, which leads to problems with the passage of food or liquid through the food tube. These types of intestinal problems can arise as a result of hernia, tumors or formed adhesions.

Intestinal obstruction requires proper treatment, otherwise the patient can expect the death of parts of the intestine, which can cause infection and death. Medicine does not stand still and therefore today it is possible to eliminate the disease quickly and efficiently, and in addition to this, it is also possible to improve the functioning of the digestive organs.

Types of intestinal obstruction

In medicine, intestinal obstruction can be acute or chronic; disturbances in the movement of contents can be partial or complete. By origin, intestinal blockage is divided into acquired and congenital, and based on the causes, the disease can be dynamic or mechanical.

Disturbances in the movement of stomach contents caused by adhesive formations of the peritoneum are called adhesive obstruction. Adhesions are formed as a result of abdominal injuries or hemorrhages and have the following types of disease progression: obstructive and strangulation.

Intestinal obstruction with partial obstruction has a chronic form, in which the patient is accompanied by periodic painful sensations, vomiting and difficulty with bowel movements. There are no problems with the treatment of this form of the disease; therapy can be carried out at home. The duration of the disease in some cases reaches more than ten years.

If the disturbance in the movement of stomach contents is caused by a tumor that grows in the middle or outside the intestine, symptoms increase. The patient begins to experience constipation, vomiting, bloating and abdominal pain. The danger of partial intestinal blockage is its possibility of developing into a complete obstruction of an acute type.

Reasons

Obstruction of the small intestine can occur as a result of volvulus, postoperative intestinal adhesions, and tumors of the small intestine. In addition, the development of the disease can be caused by inflammatory processes of the bladder or hernia, congenital or acquired.

Symptoms

A blockage in the small intestine is accompanied by the following symptoms:

  • increased periodic pain;
  • vomiting repeated more than once;
  • increased gas formation and stool discharge;
  • bloating;
  • increased heart rate;
  • decreased blood pressure;
  • dry tongue;
  • modified shape of the abdomen.

Diagnosis of the disease

Obstruction, which relates to the small intestine, can be diagnosed by the following signs:

  • the patient's stomach feels like an inflated ball;
  • in patients with a thin physique, peristalsis is clearly visible;
  • loud rumbling in the stomach and increased bowel noise during the period of cramping pain.

The disease is diagnosed using an x-ray, colonoscopy and rectal examination in males and vaginal examination in females.

Treatment

Treatment of blockage of the small intestine should be carried out in a hospital under the supervision of doctors. First of all, a probe is inserted into the patient’s stomach; in a more serious case, it is necessary, even before the ambulance arrives or on the way to a medical facility, to introduce solutions into the bloodstream that can correct the pathological losses of the body or prevent them. It is strictly contraindicated for a patient to use laxatives.

When the small intestine is partially blocked, folk remedies can help, but you should not self-medicate and should consult your doctor before using them. A good traditional medicine is a decoction of half a kilogram of plums, from which the seeds have been removed. To prepare, you will need the main ingredient, which should be poured with a liter of purified water and left to boil for 60 minutes; after the time has elapsed, the broth should be cooled and taken 3 times a day, half a glass.

Another folk recipe, for the preparation of which you will need to crush a kilogram of sea buckthorn and add cold water (700 ml) and mix thoroughly. Squeeze the juice and drink ½ cup of it throughout the day.

Intestinal obstruction is a condition in which the passage of food through the intestines is disrupted. In this case, a complete or partial disruption of the movement of intestinal contents may occur.

The following groups are most at risk of developing intestinal obstruction:

  • elderly people;
  • persons who have undergone surgery on the intestines and stomach.

Types and reasons

Intestinal obstruction is divided into the following types:

  • dynamic,
  • mechanical,
  • vascular.

The type is determined by the cause that caused this pathological condition.

Causes of dynamic obstruction:

  • constant spasm of the intestinal muscles, which can occur with painful irritation of the intestines by worms, with acute pancreatitis, with traumatic injuries from foreign bodies;
  • paralysis of the intestinal muscles, which develops during surgical interventions, poisoning with morphine-containing drugs, salts of heavy metals, as a result of food infections.

In case of mechanical obstruction, there must be some kind of obstacle:

  • fecal stones, stones from the biliary tract, foreign body, compression of the intestinal lumen from the outside by tumor formations and cystic formations of other organs, intestinal tumors growing into the lumen;
  • volvulus of intestinal loops as a result of intestinal strangulation at the gates of abdominal hernias, adhesions and cicatricial processes, a knot of intestinal loops.

Vascular obstruction is always facilitated by disturbances in the blood supply (thrombosis, embolism) of the mesenteric blood vessels.

Symptoms of intestinal obstruction

Intestinal obstruction is an acute condition, that is, all the symptoms of the disease develop quickly, within a few hours.

There are several characteristic signs of the disease:

  • pain in the abdomen;
  • stool retention;
  • vomit;
  • violation of the passage of gases.

Intestinal obstruction always begins with the appearance of abdominal pain. The cramping nature of the pain is explained by the presence of peristaltic contractions of the intestines, which contribute to the movement of food masses.

In the presence of intestinal volvulus, the pain is immediately intense, unbearable, and constant. If there is another type of intestinal obstruction, the pain may be cramping and gradually increase in intensity. The patient appears in a forced position - he presses his legs to his stomach.

The pain can be so severe that the patient goes into pain shock.

Vomiting develops early if the patient has an obstruction in the upper intestine (small intestine), and the patient experiences it repeatedly, but does not bring relief.

In case of obstruction in the lower intestines, it appears only with the development of general intoxication of the body, after 12-24 hours.

Impaired passage of stool and gases is especially characteristic of lower intestinal obstruction. The patient experiences bloating and rumbling.

If assistance is not provided to the patient, after about a day the patient develops general intoxication of the body, which is characterized by:

  • increased body temperature;
  • increased respiratory movements;
  • peritonitis (damage to the peritoneum);
  • septic process (spread of infection throughout the body);
  • disturbance of urination;
  • severe dehydration.

As a result of general intoxication, if left untreated, the patient may die.

Diagnostics

To make a diagnosis of intestinal obstruction, a number of laboratory and instrumental studies are required:

  • general blood test - there may be an increase in leukocytes during inflammatory processes;
  • a biochemical blood test may indicate metabolic disorders (impaired composition of microelements, decreased protein);
  • X-ray examination of the intestine is mandatory when making this diagnosis. By introducing a radiopaque substance into the intestinal lumen, the level of development of intestinal obstruction can be determined;
  • colonoscopy (examination of the large intestine using a sensor with a video camera at the end) helps with colonic obstruction; irrigoscopy is used to examine the small intestine;
  • Ultrasound examination is not always informative, since with intestinal obstruction, air accumulates in the abdomen, which interferes with the normal assessment of data;

In difficult cases, a laparoscopic examination of the abdominal cavity is performed, in which a sensor with a video camera is inserted into the abdominal cavity through a small puncture. This procedure allows you to examine the abdominal organs and make an accurate diagnosis, and in some cases immediately carry out treatment (volvulus, adhesions).

It is necessary to differentiate intestinal obstruction from:

  • acute appendicitis (ultrasound, localized in the right iliac region);
  • perforated ulcers of the stomach and duodenum (FGDS, radiography with a contrast agent);
  • renal colic (ultrasound, urography).

To clarify the diagnosis, additional research methods are always necessary, since it is impossible to differentiate intestinal obstruction by symptoms alone.

Treatment of intestinal obstruction

If intestinal obstruction is suspected, the patient must be urgently hospitalized in the surgical department.

Important! Self-medication with painkillers and antispasmodics is not allowed.

In the early hours after the onset of the disease, in the absence of severe complications, conservative therapy is carried out.

For conservative treatment the following are used:

  • evacuation of gastric and intestinal contents using intubation;
  • for spasms - antispasmodic therapy (drotaverine, platyphylline); for paralysis - drugs that stimulate motor skills (prozerin);
  • intravenous administration of saline solutions to normalize metabolic processes;
  • siphon enemas;
  • therapeutic colonoscopy, which can eliminate intestinal volvulus and gallstones.

Most often, the patient undergoes surgery, the purpose of which is to eliminate obstruction and remove non-viable intestinal tissue.

The following interventions are carried out:

  • unwinding of intestinal loops;
  • dissection of adhesions;
  • resection (removal) of part of the intestine with subsequent stitching of the ends of the intestine;
  • if it is impossible to eliminate the cause of obstruction, a colostomy is performed (excretion of feces);
  • In case of hernia formations, their plastic surgery is performed.

The duration and result of treatment directly depend on the cause of intestinal obstruction and the date of initiation of treatment.

Complications

If hospitalization is not timely, the following dangerous conditions may develop:

  • pain shock;

Prevention

Preventive measures include:

  • timely diagnosis and treatment of tumor processes in the intestines and neighboring organs;
  • treatment of helminthic infestations;
  • prevention of adhesions after surgery;
  • rational nutrition;
  • maintaining a healthy lifestyle.

Human health and well-being largely depend on the proper functioning of the gastrointestinal tract and the timely removal of waste products from the body. Failure in the normal functioning of the intestines leads to illness, and more serious disorders can cause life-threatening conditions. One of these serious complications is intestinal obstruction.

Intestinal obstruction is a syndrome caused by impaired intestinal motility or mechanical obstruction and leading to the inability to move its contents along the digestive tract.

Intestinal obstruction can be caused by a variety of provoking factors. The generally accepted classification of intestinal obstruction largely helps to understand the cause of the disease.

All forms of intestinal obstruction are divided into the following types:

By origin:

  • Congenital
  • Purchased

Congenital obstruction is diagnosed with congenital pathologies such as the absence of the large, small intestine or anus. All other cases of obstruction are classified as acquired.

According to the mechanism of occurrence, intestinal obstruction occurs

  • Mechanical
  • Dynamic

According to the clinical course

  • Full
  • partial
  • Acute
  • Chronic

According to the options for compressing the vessels supplying the intestine:

  • Strangulation (with compression of mesenteric vessels)
  • Obstructive (when a mechanical obstacle occurs)
  • Combined (in which both syndromes are expressed)

Causes of intestinal obstruction

Let's take a closer look at what factors cause this or that type of intestinal obstruction. The causes of mechanical intestinal obstruction include:

  • Disorders of the structure of internal organs, mobile cecum
  • Congenital cords of peritoneum, abnormally long sigmoid colon
  • Adhesions developing after surgery
  • Strangulated hernia
  • Incorrect formation of the intestines (twisting of intestinal loops, formation of nodes)
  • Closure of the intestinal lumen by cancerous neoplasms and tumors emanating from other abdominal organs
  • Blockage of the intestines by foreign bodies (accidentally swallowed objects, gallstones or fecal stones, accumulation of helminths).
  • Volvulus of one of the intestinal sections
  • Meconium accumulation
  • Narrowing of the intestinal lumen due to vascular diseases, endometriosis
  • Invagination of the intestinal walls, which occurs when one section of it is pulled into another and blocks the lumen

Dynamic intestinal obstruction, in turn, is divided into spastic and paralytic. The spastic form is extremely rare and largely precedes the paralytic state of the intestine. The causes of paralytic ileus are:

  • Traumatic operations on the abdominal organs
  • Peritonitis and inflammatory diseases of internal organs
  • Closed and open abdominal injuries

Sometimes an additional provoking factor causing changes in motility and the development of intestinal obstruction can be a change in diet. Such cases include consuming large amounts of high-calorie food during a long period of fasting, which can provoke intestinal volvulus. A complication can be caused by a sharp increase in the consumption of vegetables and fruits during the season, or the transfer of a child in the first year of life from breastfeeding to artificial feeding.

The main symptoms of intestinal obstruction include:

In addition to these main signs, there are a number of other specific symptoms that only a specialist can understand. During the examination, the doctor may pay attention to characteristic gurgling sounds in the abdominal cavity or their complete absence, which may indicate a complete shutdown of intestinal motility.

If the disease progresses and medical care is not provided, the pain may subside within 2-3 days. This is a bad prognostic sign, as it indicates a complete cessation of intestinal motility. Another ominous sign is vomiting, which can become severe. It can become repeated and indomitable.

First, the contents of the stomach begin to leave, then the vomit mixes with bile and gradually turns greenish-brown. Abdominal tension may be severe and the abdomen may be distended like a drum. As a later symptom, after about a day, absence of stool syndrome and the inability to pass feces may develop.

In the absence of treatment or late seeking medical help, a drop in blood pressure, increased heart rate, and the development of shock are observed. This condition provokes a large loss of fluid and electrolytes with repeated vomiting, intoxication of the body with stagnant intestinal contents. A life-threatening condition develops that requires emergency medical attention.

Diagnostics

If threatening symptoms appear, you must urgently seek medical help and undergo an examination to clarify the diagnosis. After the examination, the patient is prescribed laboratory tests of blood and urine, in addition, it will be necessary to undergo fluoroscopy and ultrasound.

  1. An X-ray examination of the abdominal organs reveals specific symptoms of intestinal obstruction. The images will show swollen intestinal loops, overflowing with contents and gas (the so-called intestinal arches and Kloiber's cups).
  2. An ultrasound examination confirms the diagnosis by the presence of free fluid in the abdominal cavity and distended intestinal loops.

If the diagnosis is confirmed, the patient should be urgently hospitalized in the surgical department. In a hospital setting, it is possible to conduct repeated examinations using irrigoscopy and colonoscopy.

  • Emergency irrigoscopy is performed to identify pathologies in the colon. In this case, the intestine is filled with a barium suspension using an enema and X-ray photographs are taken. This will allow you to assess the dynamics of the disease and determine the level of obstruction.
  • The colon is cleaned with an enema and a flexible endoscope is inserted through the anus to visually inspect the colon. This method allows you to detect a tumor, take a piece of tissue for a biopsy, or intubate a narrowed section of the intestine, thereby eliminating the manifestations of acute intestinal obstruction.

It is important to conduct a vaginal or rectal examination. Thus, it is possible to identify pelvic tumors and obstruction (blockage) of the rectum.

In difficult cases, laparoscopy can be performed in a hospital setting, when an endoscope is inserted through a puncture in the anterior abdominal wall and the condition of the internal organs is visually assessed.

Possible complications

In the absence of medical attention, intestinal obstruction can cause dangerous, life-threatening complications for the patient.

  • Necrosis (death) of the affected area of ​​the intestine. An intestinal obstruction can cause blood flow to a certain area of ​​the intestine to be cut off, causing tissue death and can cause the intestinal wall to perforate and leak contents into the abdominal cavity.
  • Peritonitis. It develops when the intestinal wall is perforated and an infectious process joins. Inflammation of the peritoneum leads to blood poisoning (sepsis). This condition is life-threatening and requires immediate surgical intervention.

Intestinal obstruction in children can be congenital or acquired. In newborns, intestinal obstruction is most often congenital and occurs due to intestinal malformations. This may be an abnormal narrowing of the intestine, strangulation of intestinal loops, an elongated sigmoid colon, disturbances of rotation and fixation of the mid-intestine, anomalies leading to closure of the intestinal walls.

The cause of acute obstruction in newborns may be intestinal blockage with meconium (high-viscosity feces). In this case, the baby has a lack of stool, a large accumulation of gases, due to which the upper part of the tummy swells and vomiting begins with an admixture of bile.

In infants, a specific type of intestinal obstruction such as intussusception is often observed, when part of the small intestine is inserted into the large intestine. Intussusception is manifested by frequent painful attacks, vomiting, and instead of feces, mucus and blood are released from the anus. The development of the anomaly is facilitated by the mobility of the colon and the immaturity of the peristalsis mechanism. This condition is observed mainly in boys aged 5 to 10 months.

Intestinal obstruction in children is often caused by an accumulation of worms. A ball of roundworms or other helminths clogs the intestinal lumen and causes spasm. Intestinal spasm can be very persistent and cause partial or complete obstruction. In addition, sudden changes in diet or earlier initiation of complementary feeding can lead to peristalsis disturbances in children.

In children under one year of age, adhesive intestinal obstruction may be diagnosed, which occurs after operations or due to the immaturity of the digestive system due to birth injuries or intestinal infections. An adhesive process in the abdominal cavity can cause volvulus. Children are very mobile; when running or jumping, a loop of intestine can become wrapped around the cords of the commissure.

Acute adhesive obstruction at an early age is a very dangerous complication, resulting in a high mortality rate. Operations to remove the affected part of the intestine are technically complex; in children it is very difficult to sew together the thin intestinal walls, since there is a high risk of intestinal perforation.

Symptoms of acute obstruction in children manifest themselves in sharp cramping pain, bloating, and painful vomiting. Indomitable vomiting is more often observed with volvulus of the small intestine. First, food remains are present in the vomit, then bile mixed with meconium begins to come out.

If the colon is affected, vomiting may be absent, gas retention, bloating and abdominal tension are noted. The cramping pain is so severe that the child cannot cry. When the attacks of pain pass, the child becomes very restless, cries and finds no rest.

Any type of intestinal obstruction in children requires immediate hospitalization. Congenital intestinal obstruction in newborns is treated surgically. Urgent surgical intervention is necessary in case of intestinal volvulus and other emergency situations. Conservative treatment is carried out in cases where the cause of obstruction is functional impairment.

Once the diagnosis is confirmed, the patient is hospitalized in a surgical hospital. The patient must be examined by a doctor; before the examination, it is forbidden to give the patient painkillers or laxatives, perform an enema or gastric lavage. Emergency surgery is performed only for peritonitis.

In other cases, treatment begins with conservative therapy methods. Therapeutic measures should be aimed at relieving pain, combating intoxication of the body, restoring water-salt metabolism, and removing stagnant intestinal contents.

The patient is prescribed hunger and rest and emergency treatment is started. therapeutic measures:

  • Using a flexible probe inserted into the stomach through the nose, the upper parts of the digestive tract are cleared of stagnant contents. This helps stop vomiting.
  • Intravenous administration of solutions is started to restore the water-salt balance of the body.
  • Painkillers and antiemetics are prescribed.
  • For severe peristalsis, antispasmodic drugs (atropine, no-shpu) are used.
  • To stimulate intestinal motility in cases of severe paresis, proserin is administered subcutaneously

Treatment of functional (paralytic) intestinal obstruction is carried out with the help of medications, which stimulate muscle contraction and promote the movement of contents along the digestive tract. Such obstruction is most often a temporary condition and within a few days, with proper treatment, its symptoms may disappear.

If conservative therapy is ineffective, surgical intervention is performed. In case of intestinal obstruction, operations are aimed at eliminating mechanical blockage, removing the affected part of the intestine and preventing a recurrence of obstruction.

In the postoperative period, measures continue to be taken for intravenous administration of blood substitutes and saline solutions to restore electrolyte balance. Carry out anticoagulant and anti-inflammatory therapy, stimulate motor-evacuation functions of the intestine.

In the first few days after surgery, the patient must remain in bed. You can drink and eat only after the permission and recommendations of your doctor. You should not eat or drink anything for the first 12 hours. At this time, the patient is fed intravenously or using a tube through which liquid nutritional mixtures are supplied. To reduce the load on postoperative sutures, you can only get up and walk after the intervention with a special orthopedic bandage.

Prognosis and prevention of obstruction

A favorable prognosis for the treatment of intestinal obstruction depends on the timeliness of medical care. You cannot delay seeing a doctor, otherwise if severe complications develop, there is a high risk of death. An unfavorable outcome may occur with late diagnosis, in weakened and elderly patients, in the presence of inoperable malignant tumors. If adhesions occur in the abdominal cavity, relapses of intestinal obstruction are possible.

Preventive measures to prevent intestinal obstruction include timely detection and removal of intestinal tumors, treatment of helminthic infestations, prevention of adhesions and abdominal injuries, and proper nutrition.

Treatment of intestinal obstruction with folk remedies

In case of intestinal obstruction, self-medication is extremely dangerous, as it can be fatal. Therefore, traditional medicine recipes can only be used after consultation with a doctor and under his direct supervision.

Traditional methods are used to treat only partial intestinal obstruction, if the disease is chronic and does not require surgical intervention. The patient must choose the optimal treatment method together with the doctor. This approach will avoid exacerbation of the disease and the development of dangerous complications.

Juice from sea buckthorn berries has a pronounced anti-inflammatory effect, and sea buckthorn oil acts as a mild laxative. To prepare the juice, a kilogram of berries is washed, placed in a container and crushed. The crushed berries are mixed and the juice is squeezed out of them. Take 100 g of juice once a day half an hour before meals.

To prepare the oil, 1 kg of sea buckthorn fruit is ground with a wooden spoon and left in an enamel container for a day. After this period, up to 90 g of oil accumulates on the surface of the pureed mass. It is collected and drunk 1 teaspoon three times a day before meals.

  • Treatment with dried fruits. To prepare the remedy, take 10 tablespoons of dried plums, dried apricots, figs and raisins. The dried fruit mixture is washed well and poured with boiling water overnight. In the morning, everything is passed through a meat grinder, 50 g of honey is added and mixed well. Take one tablespoon of the prepared mixture daily before breakfast.
  • Treatment with plum decoction. This decoction acts as a mild laxative. To prepare it, 500 g of pitted plums are washed, filled with cold water and simmered over low heat for about an hour. The finished broth is topped up with water to the previous level and allowed to boil again. Drink chilled, 1/2 glass three times a day.

The main recommendations for intestinal obstruction are to limit the amount of food consumed. In no case should overeating be allowed; this can lead to an exacerbation of symptoms in chronic obstruction. Meals should be fractional, you need to eat every 2 hours, in very small portions. The calorie content of the diet is only 1020 Kcal. Every day the diet should contain carbohydrates (200 g), proteins (80 g), fats (50 g). The maximum volume of liquid should not exceed 2 liters per day.

Products that cause gas formation, whole milk and dairy products, dense dishes, and carbonated drinks are completely excluded. The purpose of such a diet is to eliminate fermentation and putrefactive processes in the gastrointestinal tract. All irritants of mechanical, thermal or chemical types are excluded. Food should be as gentle as possible, pureed or jelly-like, at a comfortable temperature (neither hot nor cold).

The basis of the diet should be weak, low-fat meat broths, mucous decoctions, and pureed or pureed dishes. You can cook pureed porridge in water, cottage cheese and egg soufflés, and light omelettes. It is better to eat meat in the form of steamed cutlets, meatballs, and quenelles. Jelly, fruit jellies, and fermented milk drinks are useful. For drinks, green tea, rosehip, blueberry or quince infusions are preferable.

Excluded from the diet are flour and confectionery products, fried and hard-boiled eggs, fatty meats and fish, pickles, smoked foods, canned meat and fish, and caviar. Raw vegetables, pasta, pearl barley, millet or barley porridge are not recommended. The use of butter is limited; no more than 5 g of butter can be added to dishes per day.

You cannot drink carbonated and cold drinks, cocoa, coffee and tea with milk. Salty and spicy dishes, seasonings, rich fish, meat and mushroom broths are excluded from the menu. You should not eat legumes, greens and vegetables containing coarse fiber (cabbage, radishes, radishes, turnips). All other vegetables must not be eaten raw; they must be boiled, stewed or baked.

In case of intestinal obstruction, the main goal of the diet is to unload the intestines, exclude indigestible food and limit its volume. Such a diet will improve the patient’s condition and help avoid exacerbation of the disease.

In surgery, there is the term “acute five,” which includes diseases that require rapid surgical intervention. This list also includes intestinal obstruction, a disease that can be caused by a variety of factors, which means that no one is immune from it. Therefore, it is important to know why such a pathology occurs, how to recognize it, and whether it is possible to use conservative therapy methods and avoid surgical intervention.

Intestinal obstruction - what is it?

The term “intestinal obstruction” refers to a condition in which the movement of intestinal contents slows down or stops altogether. A healthy intestine has peristalsis - contraction of the intestinal tube so that its contents move through and leave the body naturally.

The cause of intestinal obstruction is the lack of peristalsis, which is caused by various factors. It is important to understand that the condition of intestinal obstruction is very dangerous; if medical assistance is not provided to a person within 24-36 hours from the onset of symptoms, the pathology will lead to death.

Speaking about the reasons why intestinal motility is disrupted, we can highlight:

  • formation of adhesions;
  • tumors that compress areas of the intestinal tube, preventing its contents from passing through the narrow cavity;
  • the presence of foreign objects in the digestive tract;
  • volvulus.

Important! Most often, pathology occurs as a result of surgical interventions performed on the tissues of the digestive tract or organs of the female reproductive system.

Symptoms and signs of the disease

The most important sign of intestinal obstruction is the cessation of stool and gas production. At the same time, the patient’s abdomen swells, and bubbling may be heard.

The second symptom of the disease is pain. It can be periodic or constant, tolerable or strong, leading a person to a state of painful shock - it depends on the stage of the disease.

In most cases, the patient begins to vomit, especially if the small intestine is involved in the process. Sometimes in this way the body tries to get rid of toxins that enter the blood during stagnation of feces, but instead of toxins, the body leaves a large amount of liquid and the person begins to suffer from dehydration.

Even at the earliest stage, the patient experiences severe malaise, his face turns pale, he becomes lethargic and exhausted.

Forms and types of pathology

Intestinal obstruction is classified according to the reasons that caused its occurrence.

Mechanical intestinal obstruction- this is a condition when feces cannot move through the intestinal tube due to a certain obstacle, a kind of barrier.

The following may act as a barrier:

  • fecal stones, which should not be confused with feces: coprolites are more compacted, they have a rounded shape;
  • clumps of hair - paradoxically, this reason is often found among people if they suffer from a neurosis that forces them to literally bite their hair;
  • gallstones that enter the intestines in the presence of cholelithiasis;
  • foreign objects accidentally swallowed during meals;
  • tumors of the intestinal walls or nearby organs that narrow the space of the intestinal tube cavity.

Strangulating intestinal obstruction– a pathology when, due to a number of reasons, the position of certain parts of the intestine changes in such a way that feces cannot pass freely through the digestive tract.

This happens when:

  • volvulus;
  • a knot formed during intestinal volvulus;
  • strangulation of a section of the intestine;
  • intestinal adhesions.

Mixed form– a subtype of intestinal obstruction, when several causes act as provoking factors.

Clinical picture

Most somatic pathologies develop slowly, each stage can flow into another for years, months, or, less often, weeks. But intestinal obstruction develops rapidly, and its three periods total up to 36 hours.

  1. The early period of obstruction of the digestive tract begins from the moment the first symptoms appear and lasts up to 12 hours. At this time, a person experiences paroxysmal pain: in the first hours it appears and then disappears, by the end of the early period it is constantly present, only its intensity changes.
  2. The intermediate period of intestinal obstruction begins after the end of the early period and lasts another 12 hours, that is, at the end of the intermediate period, the day ends from the onset of the first symptoms.
    During these 12 hours, the pain in the abdomen is constant and unbearable, the abdomen swells, and vomiting appears. Due to pain, a person is exhausted and practically unable to move; due to vomiting, a person is dehydrated and may lose consciousness.
  3. Late period - the time after the end of the intermediate period, the beginning of the second day after the first signals of the disease. At this time, the danger of death without promptly taken measures is at its maximum level: the patient breathes quickly, his body temperature rises, and there is a complete absence of urination. By this point, peritonitis and sepsis, as well as multiple organ failure, usually develop.

Thus, the patient’s main task is to assess the seriousness of the situation as early as possible and call an ambulance service, which will admit him to the hospital and perform surgery.

What danger does the disease pose?

The main danger of intestinal obstruction is the high risk of death.

Important! If a person is admitted to the hospital after a day from the onset of abdominal pain, even modern medical technologies and the professionalism of doctors cannot guarantee saving the patient’s life.

Considering the stages of the disease and its development, you can see the main complications that intestinal obstruction causes:

  • intoxication – poisoning of the body with poisons, in this case, its own toxins;
  • peritonitis - an inflammatory process localized in the abdominal region;
  • sepsis - blood poisoning when pathogenic microbes enter it;
  • dehydration of the body - disturbance of water and electrolyte balance, loss of fluid and salts necessary for life;
  • multiple organ failure - cessation of functioning of two or more body systems.

All complications are life-threatening, so intestinal obstruction is dangerous at any stage.

Diagnostic methods

Once a patient enters a medical facility, doctors must quickly diagnose and confirm the disease. It is also important to detect the place, part of the intestine where the obstruction has occurred.

Laboratory diagnostic methods include blood sampling and testing:

  • general (clinical) blood test - intestinal obstruction will be indicated by an increased level of hemoglobin and red blood cells, as a result of dehydration, and an increased level of leukocytes, as a signal of the presence of an inflammatory process.
  • biochemical blood test - pathological confirmation will be a decreasing level of potassium and total protein and an increasing level of urea and creatinine from intoxication.

The main task of diagnosis lies in functional studies:

  • An x-ray of the abdominal cavity allows you to see where the obstruction is localized; in the early stages, a contract x-ray method can be used, when a person drinks a liquid that passes through the digestive tract to the site of the barrier, and its path can be tracked on an x-ray - it will be noticeable due to its contrast;
  • Ultrasound during diagnosis is used to exclude the possibility of tumors in the intestine that caused obstruction;
  • Colonoscopy is a research method in which a probe is inserted into the intestines through the anus, and the image is taken from a camera. located at its tip, visualized on the device monitor;
  • Laparoscopy is a method that combines both diagnosis and treatment: it involves surgical intervention performed through small incisions not exceeding one and a half centimeters.

Traditional treatment

The main method of treating intestinal obstruction is surgery and removal of the obstruction that interferes with the normal functioning of the organ.

In exceptional cases, if the pathology lasts less than 6 hours, you can try using traditional treatment methods, for example:

  • pumping out contents from the stomach;
  • siphon enemas;
  • taking antispasmodics.

All three techniques are used simultaneously. If doctors do not see the effectiveness of reproducible actions, the patient is sent to the operating room.

Medical fact! There are cases when, during diagnostics - colonoscopy, doctors managed to “break through” an obstruction in the intestines, thereby curing the patient and saving him from the need for surgical intervention.

Treatment with traditional medicine

Intestinal obstruction is that rare case when the use of traditional medicine is not only useless, but also dangerous. Every person who cares about their health should know the symptoms of intestinal obstruction and consult a doctor, bypassing any other methods of help.

It is also important to understand that any, even the most effective, folk recipes can be used only after consultation with your doctor.

Prevention

The best way to prevent intestinal obstruction is a proper, healthy, balanced diet. When a person gets the right amount of protein, fat, carbohydrates, fiber and fluid, his body functions correctly. The widespread use of medically questionable diets has increased the number of people hospitalized due to intestinal obstruction. For example, a popular way to lose weight by making fiber the basis of your diet may well cause a “congestion” in the intestinal tube.

Nutrition should not only be correct, but also moderate. You need to eat in small portions, but every 3-4 hours. There is a good way to check whether the portion size is normal: a side dish should fit in the palm of one hand, a light vegetable salad should fit in two palms joined together. The size of a piece of fish, meat or chicken should not be larger than a cigarette pack.

Moderate physical activity, especially walking, is very important for intestinal motility. By spending 20-30 minutes a day walking, you can reduce the risk of pathology several times.

Regular medical examination is necessary for every person interested in living long and being healthy. For example, if the cause of intestinal obstruction is a tumor, then it could well be detected until it began to cause physical discomfort.
For this purpose, in hospitals there is a medical examination - a step-by-step examination method, in which each person can undergo a minimum list of tests, and, if deviations from the norm are detected in the indicators, undergo additional examinations.

According to statistics, 9 out of 10 cases of intestinal obstruction could be prevented with proper nutrition, a healthy lifestyle and regular, at least once a year, visiting a doctor.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other and unspecified intestinal obstruction (K56.6)

Gastroenterology, Surgery

General information

Brief description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Acute intestinal obstruction(ACN) is a syndromic category characterized by a violation of the passage of intestinal contents in the direction from the stomach to the rectum and combines the complicated course of diseases and pathological processes of various etiologies that form the morphological substrate of acute intestinal obstruction.

I. INTRODUCTORY PART

Protocol name: Acute intestinal obstruction in adults.
Protocol code:

ICD 10 code:
K56.0 - paralytic ileus.
K56.1 - intussusception.
K56.2 - intestinal volvulus.
K56.3 - ileus caused by gallstones.
K56.4 is another type of closure of the intestinal lumen.
K56.5 - paralytic ileus.
K56.6 - other and unspecified intestinal obstruction.
K56.7 - paralytic ileus.
K91.3 - postoperative intestinal obstruction.

Abbreviations used in the protocol:
OKN - acute intestinal obstruction
ICD- international classification of diseases
Ultrasound - ultrasound examination
ECG- electrocardiography
ALT - alanine aminotransferase
AST - aspartate aminotransferase
HIV - human immunodeficiency virus
APTT - activated partial thromboplastin time

Date of development of the protocol: 11.09.2013
Patient category: adult patients over 18 years old
Protocol users: surgeons, anesthesiologists, resuscitators, visual diagnostics, nurses.

Acute intestinal obstruction can be caused by numerous reasons, which are usually divided into predisposing and producing.

To predisposing reasons include: anatomical and morphological changes in the gastrointestinal tract - adhesions, adhesions that contribute to the pathological position of the intestine, narrowing and elongation of the mesentery, leading to excessive intestinal motility, various formations emanating from the intestinal wall, neighboring organs or located in the intestinal lumen, peritoneal pockets and openings in the mesentery. Predisposing causes include disruption of the functional state of the intestines as a result of prolonged fasting. In such cases, eating rough food can cause violent peristalsis and intestinal obstruction (“hunger man’s disease”). The role of predisposing causes is reduced to the creation of excessive mobility of intestinal loops, or, conversely, its fixation. As a result, the intestinal loops and their mesentery will be able to occupy a pathological position in which the passage of intestinal contents is disrupted.

To producing causes include: a change in the motor function of the intestine with a predominance of spasm or paresis of its muscles, a sudden sharp increase in intra-abdominal pressure, overload of the digestive tract with abundant roughage.
Depending on the nature of the trigger mechanism, ACI is divided into mechanical and dynamic, in the absolute majority - paralytic, developing on the basis of intestinal paresis. Spastic obstruction can occur with organic spinal disorders.
If an acute disturbance of intestinal hemocirculation involves extraorgan mesenteric vessels, strangulation OKN occurs, the main forms of which are strangulation, volvulus and nodulation. Much more slowly, but with the involvement of the entire adductor intestine, the process develops with obstructive acute intestinal tract, when the intestinal lumen is blocked by a tumor or other space-occupying formation. An intermediate position is occupied by mixed forms of OKN - intussusception and adhesive obstruction - combining strangulation and obstruction components. Adhesive obstruction accounts for up to 70-80% of all forms of OKN.
The nature and severity of clinical manifestations depend on the level of OKN. There are small intestinal and large intestinal OKN, and in the small intestinal – high and low.
In all forms of OKN, the severity of the disorder is directly dependent on the time factor, which determines the urgent nature of diagnostic and treatment measures.

Note: The following grades of recommendation and levels of evidence are used in this protocol:

Level I - Evidence from at least one well-designed randomized controlled trial or meta-analysis
Level II - Evidence from at least one well-designed clinical trial without adequate randomization, from an analytical cohort or case-control study (preferably from a single center), or from dramatic findings in uncontrolled studies.
Level III - Evidence obtained from the opinions of reputable researchers based on clinical experience.

Class A - Recommendations that have been approved by agreement of at least 75% percent of the multi-sector expert group.
Class B - Recommendations that were somewhat controversial and lacked consensus.
Class C - Recommendations that caused real disagreement among group members.

Classification


Clinical classification
In Kazakhstan and other CIS countries, the following classifications are most common:

According to Oppel V.A.
1. Dynamic obstruction (paralytic, spastic).
2. Hemostatic obstruction (thrombophlebetic, embolic).
3. Mechanical with hemostasis (pinching, rotation).
4. Mechanical simple (blockage, bending, compression).

According to Chukhrienko D.P.
by origin
1. congenital
2. purchased

According to the mechanism of occurrence:
1. mechanical
2. dynamic

According to the presence or absence of circulatory disorders:
1. obstructive
2. strangulation
3. combined

According to the clinical course:
1. partial
2. complete (acute, subacute, chronic, recurrent)

By morphological nature:
dynamic
1. paralytic
2. spastic.

Mechanical
1. strangulation
2. obstructive
3. mixed

By level of obstruction
1. small intestinal (high)
2. colon (low)

By stages:
Stage 1 (up to 12-16 hours) - violation of intestinal passage
Stage 2 (16-36 hours) - stage of acute disorders of intramural intestinal hemocirculation
Stage 3 (over 36 hours) stage of peritonitis.

Diagnostics


II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures:
1. General blood test
2. General urine test
3. Determination of blood glucose
4. Microreaction
5. Determination of blood group
6. Determination of Rh factor
7. Determination of bilirubin
8. Definition of AST
9. Determination of ALT
10. Determination of thymol test
11. Determination of creatinine
12. Determination of urea
13. Determination of alkaline phophatase
14. Determination of total protein and protein fraction
15. Determination of blood amylase
16. Coagulogram (prothrombin index, clotting time, bleeding time, fibrinogen, APTT)
17. Blood for HIV
18. ECG
19. Plain radiography of the abdominal organs
20. Plain radiography of the chest organs
21. Ultrasound of the abdominal organs
22. Computed tomography of the abdominal organs
23. Diagnostic laparoscopy
24. Contrast study of the gastrointestinal tract
25. Consultation with a resuscitator
26. Consultation with an anesthesiologist
27. Consultation with an oncologist
28. Consultation with a therapist

Diagnostic criteria

Complaints and anamnesis
OKN is characterized by a variety of complaints presented by patients, but the main and most reliable of them can be called the following triad of complaints: abdominal pain, vomiting, stool and gas retention .

1. Stomach ache usually occur suddenly, regardless of food intake, at any time of the day, without warning. Intestinal obstruction is most characterized by cramping pain, which is associated with intestinal peristalsis. There is no clear localization of pain in any part of the abdominal cavity. With obstructive intestinal obstruction, pain usually disappears outside of a cramping attack. In the case of strangulation intestinal obstruction, the pain is persistent, sharply intensifying during an attack. The pain subsides only after 2-3 days, when intestinal motility becomes exhausted. The cessation of pain in the presence of intestinal obstruction is a poor prognostic sign. With paralytic intestinal obstruction, the pain is constant, bursting, and of moderate intensity.

2. Vomit at first it is of a reflex nature, with continued obstruction, vomiting of stagnant contents develops; in the later period, with the development of peritonitis, vomiting becomes indomitable, continuous, and the vomit has a fecal odor. The higher the obstruction, the more pronounced the vomiting. In the intervals between vomiting, the patient experiences nausea, belching, and hiccups bother him. With low localization of the obstacle, vomiting is observed at large intervals.

3. Retention of stool and gas most pronounced with low intestinal obstruction. With high intestinal obstruction at the onset of the disease, some patients may have stool. This occurs due to the emptying of the intestines located below the obstruction. With intestinal obstruction due to intussusception from the anus, bloody discharge from the anus is sometimes observed, which can cause a diagnostic error when OKN is mistaken for dysentery.

History of the disease: it is necessary to pay attention to the intake of large amounts of food (especially after fasting), the appearance of abdominal pain during physical activity, accompanied by a significant increase in intra-abdominal pressure, complaints of decreased appetite and intestinal discomfort (periodic appearance of pain and bloating; constipation followed by diarrhea; pathological impurities in feces);

Life history is also important. Previous operations on the abdominal organs, open and closed abdominal injuries, and inflammatory diseases are often a prerequisite for the occurrence of intestinal obstruction.

Physical examinations:

1. General condition of the patient may be moderate or severe depending on the form, level or time elapsed from the onset of OKN.

2. Temperature does not increase during the initial period of the disease. With strangulation obstruction, when collapse and shock develop, the temperature drops to 36°C. Subsequently, with the development of peritonitis, the temperature rises to low-grade fever.

3. Pulse at the onset of the disease does not change; with an increase in obstruction, tachycardia appears. Noteworthy is the discrepancy between low temperature and rapid pulse.

4. Skin and mucous membranes: according to their assessment, one can judge the degree of dehydration: dry skin and mucous membranes, decreased skin turgor, dry tongue.

5. Abdominal examination a patient who has intestinal obstruction should begin with an examination of typical sites of the hernial orifice to exclude the presence of an external strangulated hernia. Postoperative scars may indicate adhesive obstruction. The most consistent sign of OKN is bloating. However, the degree of swelling may vary and depends on the level of obstruction and the duration of the disease. With high obstruction, the swelling may be insignificant, but the lower the level of obstruction, the greater the swelling. Bloating is especially significant in cases of paralytic and colonic obstruction. At the beginning of obstruction, abdominal bloating may be slight, but as the duration of the disease increases, the degree of flatulence increases. Irregular abdominal configuration and asymmetry are characteristic of strangulation intestinal obstruction. It is often possible to see one or more distended intestinal loops through the abdominal wall. A clearly demarcated, distended intestinal loop contoured through the abdominal wall - Wahl's symptom - is an early symptom of OKN. On percussion, a high-pitched tympanitis is heard above it. With volvulus of the sigmoid colon, the abdomen appears to be skewed. In this case, the swelling is located in the direction from the right hypochondrium through the navel to the left iliac region (Schiman's symptom). When examining the abdomen, you can see slowly rolling shafts or suddenly appearing and disappearing protrusions. They are often accompanied by an attack of abdominal pain and vomiting. Visible peristalsis - Shlange's symptom - is more clearly visible with slowly developing obstructive obstruction, when the muscles of the adductor intestine have time to hypertrophy.

6. Palpation of the abdomen painful. There is no tension in the abdominal wall muscles. Shchetkin-Blumberg's symptom is negative. With strangulation obstruction, Thevenard's symptom is positive - sharp pain when pressing on two transverse fingers below the navel in the midline, that is, where the root of the mesentery passes. This symptom is especially characteristic of small intestinal volvulus. Sometimes, upon palpation of the abdomen, it is sometimes possible to determine the tumor, the body of the intussusception, the inflammatory infiltrate that caused the obstruction. With a slight concussion of the abdominal wall, you can hear a “splashing noise” - Sklyarov’s symptom. This symptom indicates the presence of an overstretched paretic loop of intestine, overflowing with liquid and gaseous contents.

7. Percussion of the abdomen reveals limited areas of zones of dullness, which corresponds to the location of a loop of intestine filled with fluid and directly adjacent to the abdominal wall. These areas of dullness do not change their position when the patient turns, which is why they differ from free effusion. Dullness of percussion sound is also detected over a tumor, inflammatory infiltrate or intestinal intussusception.

8. Auscultation of the abdomen: in the initial period of OKN, when peristalsis is still preserved, numerous ringing noises are heard, resonating in the stretched loops. Sometimes you can hear the “noise of a falling drop” - the Spasokukotsky-Wilms symptom. Peristalsis can be induced or enhanced by effleurage of the abdominal wall. In the later period, as intestinal paresis increases, the noises become shorter and rarer, but of high tones. With the development of intestinal paresis, all sound phenomena disappear and are replaced by “dead silence,” which is an ominous sign. During this period, with sudden bloating, you can identify Bailey's symptom - listening to respiratory sounds and heart sounds, which are not normally heard through the abdomen.

9. Rectal digital examination can detect a rectal tumor, fecal impaction, head of intussusception and traces of blood. A valuable diagnostic sign characteristic of low intestinal obstruction is sphincter atony and balloon-like swelling of the empty rectal ampulla (Obukhov Hospital symptom) and small capacity of the distal intestine (Tsege-Mantefeil symptom). In this case, no more than 500 - 700 ml of water can be introduced into the rectum; with further administration, the water will flow back out.

Laboratory research:
- general blood test (leukocytosis, band shift, accelerated ESR, signs of anemia may be observed);
- coagulogram (signs of hypercoagulation may be observed);
- biochemical blood test (violation of water-electrolyte and acid-base balance).

Instrumental studies

1. Plain radiography of the abdominal organs
Kloiber's bowl is a horizontal level of liquid with a dome-shaped clearing above it, which looks like a bowl turned upside down. With strangulation obstruction, they can appear within 1 hour, and with obstructive obstruction - after 3-5 hours from the moment of illness. The number of bowls varies, sometimes they can be layered one on top of the other in the form of a stepped staircase.
Intestinal arcades. They occur when the small intestine becomes distended with gases, while horizontal levels of fluid are visible in the lower arcades.
The symptom of pinnateness (transverse striations in the form of an extended spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular folds of the mucosa.

2. Ultrasound examination of the abdominal cavity
For mechanical intestinal obstruction:
- expansion of the intestinal lumen by more than 2 cm with the presence of the phenomenon of “fluid sequestration” into the intestinal lumen;
- thickening of the wall of the small intestine more than 4 mm;
- the presence of reciprocating movements of chyme in the intestine;
- increase in the height of kerkring folds by more than 5 mm;
- increasing the distance between kerkring folds by more than 5 mm;
- hyperpneumatization of the intestine in the adductor region
with dynamic intestinal obstruction:
- absence of reciprocating movements of chyme in the intestine;
- the phenomenon of fluid sequestration into the intestinal lumen;
- unexpressed relief of kerkring folds;
- hyperpneumatization of the intestine in all sections.

3. Contrast study of the gastrointestinal tract used less frequently and only when there are difficulties in diagnosing intestinal obstruction, the patient’s stable condition, or the intermittent nature of intestinal obstruction. The patient is given 50 ml of barium suspension to drink and a dynamic study of the barium passage is carried out. A delay of up to 4-6 hours or more gives reason to suspect a violation of intestinal motor function.

4. Diagnostic laparoscopy(used only when previous instrumental diagnostic methods have little information).

5. Computed tomography(used only when the previous methods of instrumental diagnostics have little information, as well as to identify various formations of the abdominal organs that cause OKN) (level of evidence - III, strength of recommendation - A).

Indications for specialist consultations:
- Resuscitator: to determine indications for treating a patient in an intensive care unit, to coordinate tactics for managing the patient in terms of eliminating disturbances in water-electrolyte and acid-base balance.
- Anesthesiologist: to determine the type of anesthesia if surgical intervention is necessary, as well as agree on tactics for the preoperative period.
- Oncologist: if there is a suspicion of abdominal tumors that caused OKN.
- Therapist: identification of concomitant somatic pathology, which complicates the course of acute insufficiency, and can also complicate the course of the operation and the postoperative period.

Differential diagnosis

Nosology Common (similar) signs with OKN Distinctive features from OKN
Acute appendicitis Abdominal pain, stool retention, vomiting. The pain begins gradually and does not reach such intensity as with obstruction; the pain is localized, and if there is obstruction, it is cramping in nature and more intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction and not appendicitis. In acute appendicitis, there are no radiological signs characteristic of obstruction.
Perforated ulcer of the stomach and duodenum.
Sudden onset, severe abdominal pain, stool retention. The patient takes a forced position, and with intestinal obstruction the patient is restless and often changes position. Vomiting is not typical for a perforated ulcer, but is often observed with intestinal obstruction. With a perforated ulcer, the abdominal wall is tense, painful, and does not participate in the act of breathing, while with acute intestinal ulcers, the abdomen is swollen, soft, and not painful. With a perforated ulcer, from the very beginning of the disease there is no peristalsis, and the “splashing noise” is not heard. Radiologically, with a perforated ulcer, free gas is determined in the abdominal cavity, and with OKN, Kloiber cups, arcades, and a symptom of pennation
Acute cholecystitis Sudden onset, severe abdominal pain Pain in acute cholecystitis is constant, localized in the right hypochondrium, radiating to the right scapula. With OKN, the pain is cramping and non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. Enhanced peristalsis, sound phenomena, and radiological signs of obstruction are absent in acute cholecystitis.
Acute pancreatitis Sudden onset of severe pain, severe general condition, frequent vomiting, bloating and stool retention. The pain is localized in the upper abdomen and is girdling and not cramping in nature. A positive Mayo-Robson sign is noted. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. Radiologically, with pancreatitis, a high position of the left dome of the diaphragm is noted, and with obstruction, Kloiber's cups, arcades, and transverse striations are noted.
Intestinal infarction Severe sudden pain in the abdomen, vomiting, severe general condition, soft stomach. Pain during intestinal infarction is constant, peristalsis is completely absent, abdominal distension is slight, there is no asymmetry of the abdomen, and “dead silence” is determined by auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a wide range of sound phenomena are heard, and abdominal bloating is more significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, and high leukocytosis (20-30 x10 9 /l) is pathognomonic.
Renal colic Severe abdominal pain, bloating, retention of stool and gas, restless behavior of the patient. Pain in renal colic radiates to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive Pasternatsky sign. On a plain radiograph, shadows of stones may be visible in the kidney or ureter.
Pneumonia Rarely there may be abdominal pain and bloating Pneumonia is characterized by high temperature, rapid breathing, blush on the cheeks, and physical examination reveals crepitating rales, pleural friction noise, bronchial breathing, dullness of pulmonary sound. X-ray examination can detect a pneumonic focus.
Myocardial infarction Sharp pain in the upper abdomen, bloating, sometimes vomiting, weakness, decreased blood pressure, tachycardia With myocardial infarction, there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. An electrocardiographic study helps clarify the diagnosis of myocardial infarction.

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Treatment


Treatment Goals: elimination of intestinal obstruction; complete restoration of the passage of intestinal contents; elimination of the cause that caused OKN (if possible).

Treatment tactics

Non-drug treatment:(mode 1, diet 0, decompression of the upper digestive tract through a nasogastric tube (level of evidence - I, strength of recommendation - A) or an intestinal tube inserted using FGDS, performing siphon enemas).

Drug treatment:

Pharmacological group INN Dosages, frequency of administration, route of administration
Antispasmodics Drotaverine 0.04/2 ml solution * 3 times a day (i.m. or i.v.)
Cholinesterase inhibitors Prozerin 0.05% solution 1 ml * 3 times a day (i.m. or s.c.)
Rehydration and detoxification preparations for parenteral use Sodium chloride 0.9% solution intravenously (the volume of infusion depends on the body weight and the degree of dehydration of the patient)
Sodium chloride solution complex IV drop (the volume of infusion depends on the body weight and degree of dehydration of the patient)
Aminoplasmal 10% solution intravenously (the volume of infusion depends on the patient’s body weight)
Dextran IV drip
Analgesics Morphine 0.01/1 ml solution IM
Antibacterial therapy Cefazolin 1.0 * 3-4 times per day IM or IV
Meropenem 1.0 * 2-3 times per day IM or IV


List of essential medicines:
1. Antispasmodic drugs
2. Antibacterial drugs (cephalosporins II-III generation)
3. Analgesic drugs
4. Crystalloid solutions for infusion

List of additional medicines:
1. Anesthesia
2. Consumables for laparoscopic or open surgery
3. Antibacterial drugs (beta-lactamase inhibitors, fluoroquinolones, carbopenems, aminoglycosides).
4. Novocaine solution 0.5% -1%
5. Narcotic analgesics
6. Colloidal plasma replacement solutions
7. Fresh frozen plasma
8. Blood components

Other types of treatment: bilateral perinephric novocaine blockade (as a method of influencing the autonomic nervous system) (level of evidence - III, strength of recommendation - A).

Surgical intervention:
1. Surgery for acute insufficiency is always performed under anesthesia by a three-medical team.
2. At the stage of laparotomy, revision, identification of the pathomorphological substrate of obstruction and determination of the operation plan, the participation in the operation of the most experienced surgeon of the duty team, as a rule, the responsible surgeon on duty, is mandatory.
3. For any localization of obstruction, access is midline laparotomy, if necessary, with excision of scars and careful dissection of adhesions at the entrance to the abdominal cavity.
4. Operations for OKN involve sequential solution of the following tasks:
- establishing the cause and level of obstruction;
- elimination of the morphological substrate of OKN;
- determination of the viability of the intestine in the obstruction zone and determination of indications for its resection;
- establishing the boundaries of resection of the altered intestine and its implementation;
- determination of indications and method of intestinal drainage;
- sanitation and drainage of the abdominal cavity in the presence of peritonitis.
5. Detection of an area of ​​obstruction immediately after laparotomy does not relieve the need for a systematic audit of the condition of the small and large intestines along their entire length. The revision is preceded by mandatory infiltration of the root of the mesentery of the small intestine with a solution of local anesthetic (100-150 ml of 0.25% novocaine solution). In case of severe overfilling of the intestinal loops with contents, before the revision, decompression of the intestine is performed using a gastrointestinal tube.
6. Clearing the obstruction is the key and most difficult component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of adhesions; resection of altered intestine; elimination of torsions, intussusceptions, nodules or resection of these formations without preliminary manipulations on the altered intestine.
7. When determining the indications for intestinal resection, visual signs are used (color, swelling of the wall, subserous hemorrhages, peristalsis, pulsation and blood filling of the parietal vessels), as well as the dynamics of these signs after the introduction of a warm solution into the mesentery of the intestine) of a local anesthetic. If there are doubts about the viability of the intestine, especially over a large extent, it is permissible to postpone the decision on resection, using a programmed relaparotomy or laparoscopy after 12 hours.
8. When deciding on the boundaries of resection, one should retreat from the visible boundaries of the impaired blood supply to the intestinal wall towards the adductor section by 35-40 cm, and towards the efferent section by 20-25 cm (level of evidence - III, strength of recommendation - A). An exception is made for resections near the ligament of Treitz or the ileocecal angle, where it is possible to limit these requirements if the visual characteristics of the intestine in the area of ​​the intended intersection are favorable. In this case, control indicators of bleeding from the vessels of the wall when crossing it and the condition of the mucous area are necessarily used.
9. Indications for drainage of the small intestine are:
- overflow of afferent intestinal loops with contents;
- the presence of diffuse peritonitis with cloudy effusion and fibrin deposits;
- extensive adhesions in the abdominal cavity.
10. In case of colorectal tumor obstruction and the absence of signs of inoperability, one- or two-stage operations are performed depending on the location, stage of the tumor process and the severity of the manifestations of colonic obstruction. It is permissible to complete emergency right-sided hemicolectomy in the absence of peritonitis by applying a primary ileotransverse anastomosis. In case of obstruction with a left-sided location of the obstruction focus, resection of the colon is performed with tumor removal, which is completed according to the Hartmann operation. Primary anastomosis is not performed (level of evidence - III, strength of recommendation - A).
11. All operations on the colon end with devulsion of the external anal sphincter.
12. The presence of diffuse peritonitis requires additional sanitation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.

Preventive measures
In order to prevent acute intestinal obstruction, it is necessary to find and remove intestinal tumors in a timely manner. Prevention of intestinal obstruction also includes the fight against constipation. The patient's food should contain foods rich in fiber and vegetable oil. Animal fats require severe limitation.
You need to exclude from your diet: cottage cheese, cheese, cookies, dry goods. Rice can be eaten in combination with various vegetables. It is also necessary to take laxatives (bisacodyl tablets and suppositories, senna herb). It is necessary that there is stool at least once every three days, and if there is none, then an increase in the dose of the laxative drug, its replacement, a cleansing enema or an urgent consultation with a surgeon is required.
Prevention of complications in operated patients diagnosed with “acute intestinal obstruction” comes down to adequate and correct management of the postoperative period (see paragraph 15.6).

Further management.
Enteral nutrition begins with the appearance of intestinal peristalsis through the introduction of glucose-electrolyte mixtures into the intestinal tube.
Removal of the nasogastrointestinal drainage tube is carried out after the restoration of stable peristalsis and independent stool on 3-4 days (level of evidence - III, strength of recommendation - A). In order to combat ischemic and reperfusion damage to the small intestine and liver, infusion therapy is carried out (aminoplasmal solution, sodium chloride solution 0.9%, glucose solution 5%, ringer's solution). Antibacterial therapy in the postoperative period should include cephalosporins (level of evidence - I, strength of recommendation - A). To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.
In case of uncomplicated postoperative period, discharge is made on the 10-12th day. The presence of a functioning artificial intestinal or gastric fistula in the absence of other complications allows the patient to be discharged for outpatient treatment with a recommendation for re-hospitalization to eliminate the fistula if it does not close on its own.
If adjuvant chemotherapy is necessary and in the absence of contraindications to it in patients with a tumor cause of OKN, it should be carried out no later than 4 weeks after surgery.

Indicators of treatment effectiveness:
1. Elimination of symptomatic manifestations of the disease (no abdominal pain, no nausea and vomiting);
2. Positive x-ray dynamics;
3. Restoration of intestinal patency (regular passage of stool and gases through artificial (colostomy, ileostomy) or natural openings;
4. Healing of the surgical wound by primary intention, no signs of inflammation of the postoperative wound.

Drugs (active ingredients) used in treatment
Groups of drugs according to ATC used in treatment

Hospitalization


Indications for hospitalization indicating the type of hospitalization:
An established diagnosis or a reasonable assumption of the presence of OKN is the basis for the immediate referral of the patient to a surgical hospital by ambulance in a lying position on a stretcher, followed by mandatory emergency hospitalization.

Information

Sources and literature

  1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
    1. 1. V. S. Savelyev, A. I. Kiriyenko. Clinical surgery: national manual: in 3 volumes - 1st ed. - M.: GEOTAR-Media, 2009. - P. 832. 2. Ripamonti C, Mercadante S. Pathophysiology and management of malignant bowel obstruction. In: Doyle D, Hanks G, Cherny NI, Calman K, editors. Oxford Textbook of Palliative Medicine. 3rd ed. New York, New York Oxford University Press Inc., New York 2005. p. 496-507. 3. Frank C. Medical management of intestinal obstruction in terminal care. Canadian Family Physician. 1997 February;43:259-65. 4. Letizia M, Norton E. Successful Management of Malignant Bowel Obstuction. Journal of Hospice and Palliative Nursing.2003 July-September 2003;5(3):152-8. 5. BC Cancer Agency Professional Practice Nursing. Alert Guidelines: Bowel Obstruction. ; Available from: http://www.bccancer.bc.ca/HPI/Nursing/References/TelConsultProtocols/BowelObstruction.htm 6. M.A. Aliev, S.A. Voronov, V.A. Dzhakupov. Emergency surgery. Almaty. - 2001. 7. Surgery: trans. from English, additional / Ed. Lopukhina Yu.M., Savelyeva V.S. M.: GEOTAR MEDICINE. – 1998. 8. Eryukhin I.A., Petrov V.P., Khanevich M.D. Intestinal obstruction: A guide for doctors. – St. Petersburg, 1999. – 443 p. 9. Brian A Nobie: Small-Bowel Obstruction Treatment & Management. ; Available from: http://emedicine.medscape.com/article/774140-treatment/ 10. Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. Mar 2007;188(3):W233-8. 11. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J Aug 2011;28(8):676-8. 12. Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. Jun 2008;64(6):1651-64.

Information


III. ORGANIZATIONAL ASPECTS OF THE INTRODUCTION OF THE PROTOCOL

List of developers:
1. Turgunov Ermek Meiramovich - Doctor of Medical Sciences, professor, surgeon of the highest qualification category, head of the Department of Surgical Diseases No. 2 of the RSE at the Karaganda State Medical University of the Ministry of Health of the Republic of Kazakhstan, independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.
2. Matyushko Dmitry Nikolaevich - Master of Medical Sciences, surgeon of the second qualification category, doctoral student of the RSE at the Karaganda State Medical University of the Ministry of Health of the Republic of Kazakhstan

Reviewer:
Almambetov Amirkhan Galikhanovich - Doctor of Medical Sciences, surgeon of the highest qualification category, head of the department of surgery No. 2 of the Republican Scientific Center for Emergency Medical Care JSC.

Disclosure of no conflict of interest: There is no conflict of interest.

Indication of the conditions for reviewing the protocol: deviation from the protocol is unacceptable; This protocol is subject to revision every three years, or when new proven data on the diagnosis and treatment of acute intestinal tract becomes available.

Attached files

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