– a violation of the passage of contents through the intestine, caused by obstruction of its lumen, compression, spasm, hemodynamic or innervation disorders. Clinically, intestinal obstruction is manifested by cramping abdominal pain, nausea, vomiting, stool retention and the passage of gas. In the diagnosis of intestinal obstruction, data from a physical examination (palpation, percussion, auscultation of the abdomen), digital rectal examination, and plain radiography are taken into account. abdominal cavity, contrast radiography, colonoscopy, laparoscopy. For some types of intestinal obstruction, conservative tactics are possible; in other cases, surgical intervention is performed, the purpose of which is to restore the passage of contents through the intestine or its external diversion, resection of a non-viable section of the intestine.

General information

Intestinal obstruction (ileus) is not an independent nosological form; in gastroenterology and coloproctology, this condition develops in a variety of diseases. Intestinal obstruction accounts for about 3.8% of all emergency conditions in abdominal surgery. With intestinal obstruction, the movement of contents (chyme) - semi-digested food masses through the digestive tract - is disrupted.

Intestinal obstruction is a polyetiological syndrome that can be caused by many reasons and have various forms. Timely and correct diagnosis of intestinal obstruction are decisive factors in the outcome of this serious condition.

Causes of intestinal obstruction

Development various forms intestinal obstruction has its own reasons. Thus, spastic obstruction develops as a result of a reflex intestinal spasm, which can be caused by mechanical and painful irritation due to helminthic infestations, intestinal foreign bodies, bruises and hematomas of the abdomen, acute pancreatitis, nephrolithiasis and renal colic, biliary colic, basal pneumonia, pleurisy, hemo- and pneumothorax, rib fractures, acute myocardial infarction, etc. pathological conditions. In addition, the development of dynamic spastic intestinal obstruction may be associated with organic and functional lesions nervous system(TBI, mental trauma, spinal cord injury, ischemic stroke, etc.), as well as dyscirculatory disorders (thrombosis and embolism of mesenteric vessels, dysentery, vasculitis), Hirschsprung's disease.

Paralytic intestinal obstruction is caused by intestinal paresis and paralysis, which can develop as a result of peritonitis, surgical interventions in the abdominal cavity, hemoperitonium, poisoning with morphine, salts of heavy metals, food toxic infections, etc.

With various types of mechanical intestinal obstruction, there are mechanical obstacles to the movement of food masses. Obstructive intestinal obstruction can be caused by fecal stones, gallstones, bezoars, and accumulation of worms; intraluminal intestinal cancer, foreign body; removal of the intestine from the outside by tumors of the abdominal organs, pelvis, kidney.

Strangulated intestinal obstruction is characterized not only by compression of the intestinal lumen, but also by compression of the mesenteric vessels, which can be observed with strangulated hernia, intestinal volvulus, intussusception, nodulation - overlapping and twisting of intestinal loops among themselves. The development of these disorders may be due to the presence of a long intestinal mesentery, scar cords, adhesions, adhesions between intestinal loops; sharp decline body weight, long fasting followed by overeating; sudden increase in intra-abdominal pressure.

The cause of vascular intestinal obstruction is acute occlusion of mesenteric vessels due to thrombosis and embolism of the mesenteric arteries and veins. The development of congenital intestinal obstruction, as a rule, is based on anomalies in the development of the intestinal tube (duplication, atresia, Meckel's diverticulum, etc.).

Classification

There are several options for classifying intestinal obstruction, taking into account various pathogenetic, anatomical and clinical mechanisms. Depending on all these factors, a differentiated approach to the treatment of intestinal obstruction is used.

For morphofunctional reasons, they distinguish:

1. dynamic intestinal obstruction, which, in turn, can be spastic and paralytic.

2. mechanical intestinal obstruction, including forms:

• strangulation (volvulus, strangulation, nodulation)
• obstructive (intraintestinal, extraintestinal)
• mixed (adhesive obstruction, intussusception)

3. vascular intestinal obstruction caused by intestinal infarction.

According to the level of location of the obstacle to the passage of food masses, high and low small intestinal obstruction (60-70%) and colonic obstruction (30-40%) are distinguished. According to the degree of obstruction digestive tract intestinal obstruction can be complete or partial; By clinical course– acute, subacute and chronic. Based on the time of formation of intestinal obstructions, congenital intestinal obstruction associated with embryonic intestinal malformations is differentiated, as well as acquired (secondary) obstruction due to other reasons.

There are several phases (stages) in the development of acute intestinal obstruction. In the so-called “ileus cry” phase, which lasts from 2 to 12-14 hours, pain and local abdominal symptoms prevail. The stage of intoxication that replaces the first phase lasts from 12 to 36 hours and is characterized by “imaginary well-being” - a decrease in the intensity of cramping pain, weakening of intestinal peristalsis. At the same time, there is a failure to pass gas, stool retention, bloating and asymmetry of the abdomen. In the late, terminal stage of intestinal obstruction, which occurs 36 hours after the onset of the disease, severe hemodynamic disturbances and peritonitis develop.

Symptoms of intestinal obstruction

Regardless of the type and level of intestinal obstruction, severe pain, vomiting, stool retention and failure to pass gas occur.

Abdominal pain is cramping and unbearable. During a contraction that coincides with a peristaltic wave, the patient’s face is distorted with pain, he groans, and takes various forced positions (squatting, knee-elbow). On high pain attack symptoms of shock appear: pale skin, cold sweat, hypotension, tachycardia. The subsidence of pain can be a very insidious sign, indicating intestinal necrosis and death of nerve endings. After an imaginary lull, on the second day from the onset of intestinal obstruction, peritonitis inevitably occurs.

Another characteristic symptom of intestinal obstruction is vomiting. Particularly abundant and repeated vomiting, which does not bring relief, develops with small intestinal obstruction. First, the vomit contains food debris, then bile, then late period- intestinal contents (fecal vomiting) with putrid smell. With low intestinal obstruction, vomiting, as a rule, is repeated 1-2 times.

A typical symptom of low intestinal obstruction is retention of stool and gas. Finger rectal examination detects the absence of feces in the rectum, distension of the ampulla, gaping of the sphincter. At high obstruction small intestine there may be no stool retention; emptying of the lower parts of the intestine occurs independently or after an enema.

With intestinal obstruction, attention is drawn to bloating and asymmetry of the abdomen, peristalsis visible to the eye.

Diagnostics

Percussion of the abdomen in patients with intestinal obstruction reveals tympanitis with a metallic tint (Kivul's symptom) and dullness of percussion sound. Auscultation in the early phase reveals increased intestinal peristalsis and “splashing noise”; in the late phase - weakening of peristalsis, the sound of a falling drop. With intestinal obstruction, a distended intestinal loop is palpated (Val's symptom); V late dates– rigidity of the anterior abdominal wall.

Of great diagnostic importance is rectal and vaginal examination, which can be used to identify obstruction of the rectum and pelvic tumors. The objectivity of the presence of intestinal obstruction is confirmed by instrumental studies.

A survey X-ray of the abdominal cavity reveals characteristic intestinal arches (gas-swollen intestine with fluid levels), Kloiber's cups (dome-shaped clearings above the horizontal level of fluid), and a symptom of pennation (the presence of transverse striations of the intestine). X-ray contrast examination of the gastrointestinal tract is used in difficult diagnostic cases. Depending on the level of intestinal obstruction, radiography of the passage of barium through the intestines or irrigoscopy may be used. Colonoscopy allows you to examine the distal parts of the large intestine, identify the cause of intestinal obstruction and, in some cases, resolve the phenomena of acute intestinal obstruction.

Carrying out an ultrasound of the abdominal cavity with intestinal obstruction is difficult due to severe pneumatization of the intestine, but the study in some cases helps to detect tumors or inflammatory infiltrates. During diagnosis, acute intestinal obstruction should be differentiated from intestinal paresis - drugs that stimulate intestinal motility (neostigmine); Novocaine perinephric blockade is performed. In order to correct water electrolyte balance appointed intravenous administration saline solutions.

If, as a result of the measures taken, intestinal obstruction does not resolve, mechanical ileus should be considered, requiring urgent surgical intervention. Surgery for intestinal obstruction is aimed at eliminating mechanical obstruction, resection of a non-viable section of the intestine, and preventing recurrent obstruction.

In case of obstruction of the small intestine, resection of the small intestine can be performed with enteroenteroanastomosis or enterocoloanastomosis; deintussusception, unwinding of intestinal loops, dissection of adhesions, etc. In case of intestinal obstruction caused by a colon tumor, hemicolonectomy and temporary colostomy are performed. For inoperable tumors of the large intestine, a bypass anastomosis is performed; If peritonitis develops, transversostomy is performed.

IN postoperative period BCC compensation, detoxification, antibacterial therapy, correction of protein and electrolyte balance, stimulation of intestinal motility.

Prognosis and prevention

The prognosis for intestinal obstruction depends on the start date and completeness of the treatment. An unfavorable outcome occurs with late recognized intestinal obstruction, in weakened and elderly patients, and with inoperable tumors. With pronounced adhesive process relapses of intestinal obstruction are possible in the abdominal cavity.

Prevention of the development of intestinal obstruction includes timely screening and removal of intestinal tumors, prevention of adhesions, elimination of helminthic infestation, proper nutrition, avoiding injury, etc. If you suspect intestinal obstruction, you should immediately consult a doctor.

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MOSCOW STATE MEDICAL AND DENTAL UNIVERSITY

Department of Hospital Surgery

Head department corresponding member RAMS, Honored Scientist,

Professor Yarema I.V.

METHODOLOGICAL DEVELOPMENT ON THE TOPIC:

"ACUTE INTESTINAL OBSTRUCTION"

(for teachers)

Compiled by: assistant Filchev M.I.

Purpose of the lesson:

Based on knowledge of anatomy, etiology, pathogenesis of acute intestinal obstruction, features clinical manifestations diseases in the classroom, students should be taught methods of targeted collection of clinical data, taught techniques for examining patients, taught the ability to draw up an examination plan and method of collecting information, and deciphering the data obtained,

During the lesson, it is necessary to pay attention to differential diagnosis, features of medical tactics, selection of conservative and surgical treatment. Pay attention to the features of preoperative preparation and management, postoperative period.

CLASS VENUE: Training room, surgical wards, diagnostic rooms, operating rooms, dressing rooms, intensive care unit,

CLASS TIME: 4 academic hours.

Lesson plan:

Introductory speech by the teacher (5 min);

Baseline control. Written personal answers to questions asked (15 min);

Formation of the ability to independently manage patients: collecting anamnesis, objective examination, constructing a detailed diagnosis. Prescription of drug treatment (20 min);

Formation of the ability to apply methods of clinical examination of patients, consolidation of the information received, differential diagnosis, development of clinical thinking (60 min);

Demonstration of basic techniques for examining patients, consolidation of learned symptoms of the disease (if necessary);

Indications for surgical treatment methods.

Mastering the basic principles of performing applicable operations. Analysis of treatment tactics (20 min);

Final control (20 min);

Conclusion. Setting a topic for the next lesson.

METHODOLOGICAL COMMENT

Acute intestinal obstruction (AIO) is a syndrome that develops as a result of impaired passage of intestinal contents through the gastrointestinal tract (GIT).

Patients with acute intestinal tract make up 1.2% of the number of people admitted to surgical departments, and 9.4% of patients with acute surgical diseases of the abdominal organs.

The similarity of the clinical manifestations of intestinal obstruction with many diseases of other organs - such as the outcome of some acute inflammatory diseases of the abdominal organs, the complexity of diagnosis, the high likelihood of a patient suffering from this disease contacting a doctor of any specialty, the severity of the patient’s condition and the need for emergency care in some specific cases – is the reason for studying this pathology in the course of surgical diseases.

The primary damaging factors in intestinal obstruction are local changes in the intestine related to its metabolism, function and structure. These disorders are based on stasis of the intestinal contents with increased pressure and stretching of the intestine during its obstruction, as well as pinching of the mesenteric vessels and, to a lesser extent, stasis of the intestinal contents during intestinal strangulation. With the development of intestinal obstruction, intraintestinal pressure can reach 5-18 mmHg, and with active muscle contractions of the intestine it increases to 20-45 mmHg.

The main local factors in the pathogenesis of intestinal obstruction are considered to be a violation of regional blood circulation in the intestine and significant growth intestinal flora(increase in aerobes by 105 and 106 times, respectively, for small and large intestinal obstruction). In this case, the growth occurs mainly due to gram-negative microorganisms.

Progressive hyperosmolarity, determined, on the one hand, by the action of digestive enzymes, and on the other, by a decrease in the utilization of broken down food components, leads to a decrease in water reabsorption when the absorption capacity of the mucous membrane is extremely reduced. The osmolarity factor also plays a critical role in the process of fluid sequestration in the intestine during intestinal obstruction.

The peak of changes in the intestine during its obstruction due to overdistension, hypoxic damage to the intestinal wall and the action of a bacterial factor is a violation of its integrity and the development of peritonitis.

Swift and frequent development multiple organ failure with intestinal obstruction is caused primarily by volemic disorders, centralization of blood circulation, depression of microcirculation and tissue hypoxia.

Research methods Chest X-ray X-ray of the abdominal cavity (vertical and horizontal position on the left side) Ultrasound Contrast examination of the gastrointestinal tract Water-soluble contrast agents CT scan 2

Classification of acute intestinal obstruction Mechanical Small intestinal Functional Colon Obstructive Strangulation Peritonitis Renal colic Violation of mesenteric blood flow 3

4

Causes of strangulation obstruction: entrapment of the loop by adhesions, internal and external hernias, volvulus, intussusception Pathogenesis of strangulation obstruction disturbance of blood supply and irritation of the nervous system due to the involvement of the mesentery in the process with the development of ischemia, necrosis of the intestinal wall and the occurrence of peritonitis Intestinal gangrene is accompanied by the release of endo- and exotoxins, which leads to toxic shock 6

Causes of obstructive obstruction of the adhesions: cicatricial strictures of the tumor. The blood supply to the intestine in the case of obstructive obstruction does not suffer. The clinical manifestations of obstructive obstruction are less pronounced. As the proximal parts distend, vomiting occurs, exacerbating fluid loss. Without treatment, hypovolemic shock develops with high mortality 7

The main radiological symptoms of mechanical intestinal obstruction 1. Kloiber cups 2. Arches 3. Transfusion of fluid from one intestine to another 4. Poststenotic collapse of the intestine 8

Indirect signs: deformation and displacement of the stomach and colon by thin loops containing gas and liquid; presence of fluid in the abdominal cavity, detected by ultrasound 9

Based on the review P-grams, it is necessary to answer the following questions: 1) are there signs of OKN or not? 2) are the detected changes signs of small intestinal or colonic obstruction? 10

P-picture of small intestinal obstruction 1) the levels of liquid and gas form characteristic arches 2) the horizontal levels are wide with a low gas bubble 3) the symptom of fluid transfusion from one loop to another is characteristic 4) the absence of gas in the large intestine 11

Characteristic radiological signs obstructive obstruction of the small intestine can only be determined in half of the patients V. I. Petrov 15

Strangulated small intestinal obstruction Radiologically, the stages of development of STS are distinguished by the degree of intestinal distension, the shape of the bladder, their size and location 16

Stage 1 - isolated intestinal bloating without horizontal levels Stage 2 - p - signs increase, there is an increase in intestinal bloating with the appearance of horizontal levels of fluid, movement of fluid from one loop to another with a change in the location of levels Stage 3 - sharp bloating of the small intestine, multiple horizontal levels 17

Stage 4 - necrosis of all layers of the strangulated part of the intestine occurs, its tone decreases sharply - this is manifested by a decrease in the height of the gas bubble, and the length of the liquid levels increases sharply, they are located on the same line. Gas in the colon is not detected. In stages 1 and 2, dynamic monitoring of the development of the process and contrast studies are permissible. When stages 3 and 4 of the disease are detected, only a single x-ray examination is necessary; urgent surgery is indicated 18

Increased bloating of the small intestine, decrease in gas in the colon, increase in the number of horizontal fluid levels, despite the apparent improvement in clinical symptoms from the conservative therapy, indicate the presence of mechanical fault and are important criteria when determining indications for surgical intervention 19

20

The same observation, 3 hours after taking 50.0 omnipaque, the contrast filled the initial parts of the colon 23

Early (on the 4th day) adhesive small intestinal obstruction, 12/25/02 - repeated relaparotomy - dissection of adhesions 24

P-picture of colonic obstruction, the width of the Kloiber cups is less than the height of the gas bubble above them, significant swelling of the colon and congestion feces above the obstacle with slowly developing colonic obstruction, especially in its right parts, signs of small intestinal obstruction develop Crucial in establishing the correct diagnosis is the determination of persistent retention of the contrast agent over the obstacle while maintaining the fluid level in the small intestine 25

31

Volvulus of the sigmoid colon is the most common type of strangulation obstruction of the large intestine. The main P-sign is a sharp elongation and expansion of the sigmoid colon, turning it into a “car tire” or “double-barreled gun” when the intestine wraps around an axis 36

Volvulus of the sigmoid colon Classic symptoms are expressed only at the height of the disease. With a small accumulation of gas in the sigmoid colon and significantly more content in other parts of the colon, the x-ray picture is not typical. A contrast study - irrigoscopy - plays a decisive role in diagnosis. The contrast mass tightly fills the ampulla of the rectum and the distal part of the sigmoid to the point of torsion, where a narrowing in the form of a “beak” is revealed. 37

39

Functional (dynamic) intestinal obstruction Causes of purulent-inflammatory processes in the abdominal cavity (peritonitis), poisoning due to circulatory disorders in the mesentery, lesions of the reflexogenic zones of the retroperitoneal space (renal colic, trauma to the retroperitoneal space, etc.) 40

Peritonitis is purulent or other inflammation of the peritoneum in response to its direct irritation. Causes are ischemic, inflammatory infectious lesions. There are no specific and undoubted radiological signs of peritonitis 42

Plain radiography of the abdomen Peritonitis is accompanied by reactive paralytic intestinal obstruction, while the gas in the intestinal lumen with elongated horizontal levels increases the diameter of the small intestine to 4-5 cm or more, the folds of the mucosa in the small intestine are often unclearly differentiated, in some loops they can be thickened, uneven expansion and darkening of the spaces between the loops (damage to the peritoneum and the presence of fluid in the abdominal cavity) 43

X-ray. The loops of the small intestine are dilated, the folds and walls are thickened, uneven expansion and darkening of the spaces between the loops. Peritonitis. 45

Peritoneography technique As a contrast agent, a 30% solution of water-soluble contrast agent (urografin 76%) is used, which is injected into the abdominal cavity through a drainage tube in an amount of 50.0. The first radiograph is performed immediately after completion of the administration, control - after 30 minutes, 60 minutes. and 120 min. - immediately after administration, the nature of its distribution in the abdominal cavity attracts attention - after 30 minutes, if there is no peritonitis, traces of contrast remain on the radiograph or it is not detected at all, but its release into the MVP is observed - after 60 minutes. in the absence of peritonitis, no traces of contrast in the abdominal cavity are detected. - with peritonitis, the picture on control radiographs does not change 48

Ultrasound signs of peritonitis diagnostic value Dont Have; these include: fluid-filled intestinal loops, free fluid in the abdominal cavity, which can accumulate in certain areas (in the pericolic, perihepatic, peri-hepatic space, the bursa of Morisson and the small pelvis. 49

PRESENT EFFORT IN THE ABDOMINAL CAVITY IN AN AMOUNT OF UP TO 100 ml IS NOT DETERMINED DURING AN ULTRASOUND ULTRASOUND CANNOT DISTINGUISH ASCITES, BLOOD, BILE, PUS AND URINE 50

In practice, it is proposed to determine the amount free liquid in three gradations: - an insignificant (small) amount, which corresponds to a volume of up to 200 ml, while the liquid is visualized near the source of peritonitis and in the interloop spaces; - moderate amount, which corresponds to a volume of 200500 ml, exudate is determined in sloping areas of the abdominal cavity (subphrenic, in the pelvis, lateral canals); sonographic determination of a significant amount of effusion of more than 500 ml is noted in cases where intestinal loops “float” in liquid. 51

The most information about the condition of the intestine can be obtained using the ultrasound method by identifying a symptom of intraluminal fluid deposition 53

When fluid accumulates in the intestinal lumen, the following echographic parameters can be determined: the diameter of the intestine, the thickness of its wall, the structure of the wall and internal contents of the intestine, the nature of peristalsis, the accumulation of fluid in the interloop space and in the abdominal cavity. The combination of these changes is interpreted as ultrasound syndrome of intestinal insufficiency (USI) 54

Ultrasound signs of structural changes in the small intestine are: expansion of the lumen of the loops more than 2.5 cm in diameter; thickening of the walls more than 1-2 mm. 55

Functional changes in the small intestine are characterized by a slowdown or complete cessation of peristaltic contractions, a decrease in density and gradual disappearance of echogenic inclusions in the lumen of the dilated intestine, and accumulation of fluid in the intestinal lumen. 56

The highest degree of structural and functional changes small intestine or “intestinal failure syndrome” is: expansion of the lumen to 4-4.5 cm or more, filling it with liquid that does not contain echogenic inclusions, limiting the mobility of loops surrounded by a layer of liquid. there may be a reactive effusion in pleural cavities. 57

Dynamic ultrasound observation makes it possible to determine the criteria for assessing the progression of peritonitis: the dynamics of the amount of free fluid in the abdominal cavity, the dynamics of structural and functional changes in the small intestine, the identification of abscesses of extra-organ localization - organ or 58

Resolution of peritonitis is characterized by: a decrease in the amount of fluid in the free abdominal cavity, a decrease in diameter and gradual restoration of intestinal motility, the appearance of echogenic inclusions in the loops of the small intestine and a gradual increase in their density 59

Computed tomography CT signs of peritonitis are ascites, infiltration of the omentum, mesentery and thickening of the parietal peritoneum. These symptoms are nonspecific and are interpreted depending on the clinical picture. Similar signs are detected in carcinomatosis and peritoneal myxomatosis, in which the clinical symptoms are less pronounced. 65

Accuracy of radiation diagnostic methods In detecting diffuse peritonitis: CT - 95%, ultrasound - 94%, X-ray examination - 41%, For limited peritonitis, respectively: CT - 93%, ultrasound - 86%, X-ray examination - 57%. 66

Analyzing the advantages and disadvantages of methods instrumental diagnostics acute surgical diseases abdominal cavity and their complications, we can conclude that none of the methods is absolutely accurate. The best diagnostic results are achieved when they are used in combination in a certain sequence. 67

Impaired mesenteric circulation The spectrum of clinical manifestations of occlusion of the mesenteric artery or vein is wide - from minor discomfort (abdominal angina) to life-threatening intestinal infarction. 68

The source of arterial embolism is thrombi formed in a post-infarction aneurysm of the left ventricle, thrombi in the left atrium in patients with mitral stenosis or insufficiency atrial fibrillation Thrombosis of the mesenteric vein can be idiopathic or pathologies may arise: portal hypertension, sepsis, various coagulopathies, trauma, paraneoplastic processes, erythremia 69

The clinic distinguishes three stages: initial, latent and terminal initial stage mesenteric artery embolism is characterized by acute onset of pain, excruciating, without clear localization, typically a discrepancy between the severity of pain and the soft abdominal wall, first diarrhea without blood, vomiting, increased peristalsis, later blood appears in the stool, symptoms of shock progress 70

Latent stage Pain occurs after 6-12 hours, weakens. Gas accumulates in the intestinal lumen and a feeling of fullness occurs. Peristalsis is absent or weakened. Pain and pain on palpation muscle tension The terminal stage develops 12-48 hours after the onset of pain and manifests itself with a classic picture acute abdomen with signs of diffuse peritonitis 71

Plain radiography of the abdomen The study is carried out in the supine position, on the left side and standing. Indirect signs of mesenteric thrombosis 1) symptom of a “gasless abdomen” - when there is no or very little gas in the small and large intestine and diffuse dull darkening 72

Plain radiography of the abdomen 2) isolated distension of the small intestine (y2/3), which is otherwise called false small intestinal obstruction. It is caused by distension of the intestine by gases formed due to the activation of microflora during ischemia of the intestinal wall. Observed in the latent stage 73

Direct signs of impaired mesenteric circulation are thickening of the intestinal wall (due to its swelling and hemorrhages) It is almost always accompanied by expansion of the intestine, while its lumen is narrowed, and the loops are distant from each other The intestinal wall becomes rigid 74

When X-rayed while lying on the back and on the left side, the position of the loops does not change; a characteristic direct sign of the terminal stage is gas bubbles in the intestinal wall and in the vessels, which are almost always combined with dilatation of the small and large intestine 75

Computed tomography Dilation of the loops of the small intestine and thickening of its walls, ascites and infiltration of the mesentery, which are characteristic of peritonitis, are clearly visible on CT. Sometimes a blood clot is visualized in an artery or vein. Gas is very clearly visible in the vessels and in the intestinal wall. If necrosis is significant, gas is detected throughout the root mesentery, portal vein and its branches The final diagnosis of mesenteric circulation disorders is made using angiography 81

Recognition of intestinal diseases is based on clinical, radiological, endoscopic and laboratory data. Colonoscopy with biopsy plays an increasingly important role in this complex, especially in diagnosing the early stages of inflammatory and tumor processes.

Acute mechanical intestinal obstruction. X-ray examination is of great importance in its recognition. The patient is in an upright position and undergoes plain radiographs of the abdominal organs. Obstruction is indicated by swelling of the intestinal loops located above the site of blockage or compression of the intestine. In these loops, gas accumulations and horizontal liquid levels are determined (the so-called bowls, or Kloiber levels). All loops of intestine distal to the site of blockage are in a collapsed state and do not contain gas and liquid. It is this sign - collapse of the poststenotic segment of the intestine - that makes it possible to distinguish mechanical intestinal obstruction from dynamic one (in particular, from paresis of intestinal loops). In addition, with dynamic paralytic obstruction, peristalsis of the intestinal loops is not observed. Fluoroscopy fails to detect movement of contents in the intestine and fluctuations in fluid levels. With mechanical obstruction, on the contrary, repeated images never copy those taken earlier; the picture of the intestine changes all the time.

The presence of acute mechanical intestinal obstruction is determined by two main signs: swelling of the prestenotic part of the intestine and collapse of the poststenotic part.

These signs appear 1-2 hours after the onset of the disease, and after another 2 hours they usually become clear.

It is important to distinguish between obstruction of the small and large intestine. In the first case, the loops of the small intestine are swollen, and the large intestine is in a collapsed state. If this is not clear enough from the images, then retrograde filling of the colon with barium suspension can be performed. In case of small intestinal obstruction, swollen intestinal loops occupy predominantly the central parts of the abdominal cavity, and the caliber of each loop does not exceed 4 - 8 cm. Against the background of the swollen loops, transverse striations are visible, caused by expanded circular (kerkring) folds. Naturally, there are no haustral retractions on the contours of the small intestine, since they occur only in the large intestine.

With obstruction of the large intestine, huge swollen loops with high gas bubbles in them are observed. The accumulation of fluid in the intestine is usually small. Haustral retractions are visible on the contours of the intestine, and arched, rough semilunar folds are also visible. By introducing a contrast suspension through the rectum, it is possible to clarify the location and nature of obstruction (for example, to detect cancerous tumor leading to narrowing of the intestine). We only point out that the absence of radiological signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction the interpretation X-ray picture may be difficult. In these cases, sonography and CT scan. They make it possible to detect stretching of the prestenotic part of the intestine, a break in its image at the border with the collapsed poststenotic part, and a shadow of nodulation.

Diagnosis of acute intestinal ischemia and necrosis of the intestinal wall is especially difficult. When the superior mesenteric artery is blocked, accumulations of gas and liquid are observed in the small intestine and in the right half of the large intestine, and the patency of the latter is not impaired. However, radiography and sonography provide recognition of mesenteric infarction in only 25% of patients. With CT, it is possible to diagnose a heart attack in more than 80% of patients based on thickening of the intestinal wall in the area of ​​necrosis, the appearance of gas in the intestine, as well as in the portal vein. The most accurate method is angiography, performed using spiral CT, magnetic resonance imaging or catheterization of the superior mesenteric artery. The advantage of mesentericography is the possibility of subsequent targeted transcatheter administration of vasodilators and fibrinolytics. Rational research tactics are presented in the diagram below.

In case of partial obstruction great benefit brings a repeat study after 2-3 hours. It is acceptable to administer a small amount of water-soluble contrast agent through the mouth or nasojejunal tube (enterography). In case of volvulus of the sigmoid colon, valuable data are obtained by irrigoscopy. At adhesive obstruction resort to X-ray examination in different positions of the patient, recording areas of fixation of intestinal loops.

Appendicitis. Clinical signs acute appendicitis known to every doctor. X-ray examination is a valuable way to confirm the diagnosis and is especially indicated when there is a deviation from the typical course of the disease. The survey tactics are presented in the following diagram.

As can be seen in the diagram, it is advisable to begin the radiation examination with sonography of the abdominal organs. Symptoms of acute appendicitis include expansion of the appendix, filling it with fluid, thickening of its wall (more than 6 mm), identification of stones in the appendix and its fixation, accumulation of fluid near the wall of the appendix and the cecum, hypoechoic image of the abscess, depression from the abscess on the intestinal wall, hyperemia periappendicular tissues (with Doppler sonography).

The main radiological signs of acute appendicitis: small accumulations of gas and liquid in the distal part ileum and in the cecum as a manifestation of their paresis, thickening of the wall of the cecum due to its edema, thickening and rigidity of the folds of the mucous membrane of this intestine, stones in the appendix, a small effusion in the abdominal cavity, swelling of the soft tissues of the abdominal wall, blurred outlines of the right lumbar muscle . An appendicular abscess causes darkening in the right iliac region and a depression on the wall of the cecum. Sometimes a small accumulation of gas is detected in the abscess and in the projection of the appendix. If the appendix is ​​perforated, there may be small gas bubbles under the liver.

CT is somewhat more effective than sonography and radiography in diagnosing acute appendicitis, making it possible to clearly detect thickening of the wall of the appendix and appendiceal abscess.

In chronic appendicitis, deformation of the appendix, its fixation, fragmentation of its shadow during X-ray contrast examination or non-filling of the appendix with barium sulfate, the presence of stones in the appendix, coincidence of the pain point with the shadow of the appendix are noted.

Intestinal dyskinesin. X-ray examination is a simple and accessible method for clarifying the nature of the movement of contents through the loops of the small and large intestine and diagnostics various options constipation (constipation).

Enterocolitis. In acute enterocolitis of various etiologies, similar symptoms are observed. Small gas bubbles with short fluid levels appear in the intestinal loops. The advancement of the contrast agent occurs unevenly; separate accumulations of it are noted, between which constrictions are observed. The folds of the mucous membrane are thickened or not differentiated at all. All chronic enterocolitis accompanied by malabsorption syndrome (malabsorption) are characterized by: general signs: expansion of intestinal loops, accumulation of gas and liquid in them (hypersecretion), division of the contrast mass into separate lumps (sedimentation and fragmentation of contents). The passage of the contrast agent is slow. It is distributed unevenly over the inner surface of the intestine, and small ulcerations may be visible.

Malabsorption. It interferes with the absorption of various components food. The most common diseases are the sprue group. Two of them - celiac disease and non-tropical sprue - are congenital, and tropical sprue are acquired. Regardless of the nature and type of malabsorption, the x-ray picture is more or less the same: dilation of the loops of the small intestine is determined. Fluid and mucus accumulate in them. Because of this, the barium suspension becomes heterogeneous, flocculates, is divided into fragments, and turns into flakes. The folds of the mucous membrane become flat and longitudinal. A radionuclide study with trioleate-glycerol and oleic acid reveals a malabsorption in the intestine.

Regional enteritis and granulomatous colitis (Crohn's disease).

With these diseases, any part of the digestive canal can be affected - from the esophagus to the rectum. However, the most commonly observed lesions are the distal jejunum and the proximal ileum (jejunoileitis), the terminal ileum (terminal ileitis), and the proximal parts of the colon.

There are two stages during the course of the disease. In the first stage, thickening, straightening and even disappearance of folds of the mucous membrane and superficial ulcerations are noted. The contours of the intestine become uneven and jagged. Then, instead of the usual pattern of folds, multiple rounded clearings are found, caused by islands of inflamed mucous membrane. Among them, strip-like shadows of barium deposited in transverse cracks and slit-like ulcers can be distinguished. In the affected area, the intestinal loops are straightened and narrowed. In the second stage, there is a significant narrowing of the intestinal loops with the formation of cicatricial constrictions ranging from 1-2 to 20-25 cm in length. In the photographs, the stenotic area may look like a narrow, uneven canal (a “cord” symptom). In contrast to the malabsorption syndrome, there is no diffuse dilation of intestinal loops, hypersecretion and fragmentation of the contrast agent; the granular nature of the relief of the inner surface of the intestine is clearly expressed. One of the complications of Crohn's disease is abscesses, the drainage of which is carried out under radiation control.

Intestinal tuberculosis. The ileocecal angle is most often affected, but even when examining the small intestine, thickening of the folds of the mucous membrane, small accumulations of gas and liquid, and slow progress of the contrast mass are noted. In the affected area, the contours of the intestine are uneven, the folds of the mucous membrane are replaced by areas of infiltration, sometimes with ulcerations, and there is no haustration. It is curious that the contrast mass in the infiltration zone does not linger, but quickly moves further (a symptom of local hyperkinesia). Subsequently, the intestinal loop shrinks, reducing its lumen and limiting displacement due to adhesions.

Non-specific ulcerative colitis. In mild forms, thickening of the folds of the mucous membrane, pinpoint accumulations of barium and fine jaggedness of the intestinal contours are noted as a result of the formation of erosions and small ulcers. Severe forms characterized by narrowing and rigidity of the affected parts of the colon. They stretch little and do not expand with retrograde injection of a contrast mass. Haustration disappears, the contours of the intestine become finely jagged. Instead of folds of the mucous membrane, granulations and accumulations of barium appear in the ulcerations. The distal half of the colon and the rectum are predominantly affected, which are sharply narrowed in this disease.

Colon cancer. The cancer appears as a small thickening of the mucous membrane, a plaque, or a polyp-like flat formation. Radiographs reveal a marginal or central filling defect in the shadow of the contrast mass. The folds of the mucous membrane in the area of ​​the defect are infiltrated or absent, peristalsis is interrupted. As a result of necrosis of tumor tissue, an irregularly shaped barium depot may appear in the defect - a reflection of ulcerated cancer. As the tumor continues to grow, predominantly two types of X-ray patterns are observed. In the first case, a tuberous formation is detected, protruding into the intestinal lumen (exophytic type of growth). The filling defect has an irregular shape and uneven contours. The folds of the mucous membrane are destroyed. In the second case, the tumor infiltrates the intestinal wall, leading to its gradual narrowing. The affected section turns into a rigid tube with uneven outlines (endophytic type of growth). Sonography, CT and MRI make it possible to clarify the degree of invasion of the intestinal wall and neighboring structures. In particular, endorectal sonography is valuable in rectal cancer. Computer tomograms make it possible to assess the condition lymph nodes in the abdominal cavity.

Benign tumors. About 95% benign neoplasms intestines are composed of epithelial tumors - polyps. They are single and multiple. The most common are adenomatous polyps. They are small, usually no more than 1-2 cm in size, growths of glandular tissue, often having a stalk (stem). On X-ray examination, these polyps cause filling defects in the intestinal shadow, and with double contrast, additional rounded shadows with even and smooth edges.

Villous polyps look slightly different on X-ray examination. A filling defect or an additional shadow with double contrast has uneven outlines, the surface of the tumor is unevenly covered with barium: it flows between the gyri, into the grooves. However, the intestinal wall remains elastic. Villous tumors, in contrast to adenomatous polyps, often become malignant. On malignant degeneration indicate such signs as the presence of a persistent depot of barium suspension in the ulceration, rigidity and retraction of the intestinal wall at the location of the polyp, its fast growth. The results of colonoscopy with biopsy are decisive.

Acute stomach.

The causes of acute abdominal syndrome are varied. To establish an urgent and accurate diagnosis, anamnestic information and results are important clinical examination And laboratory tests. Radiation examination is used if it is necessary to clarify the diagnosis. As a rule, it begins with x-rays of organs chest cavity, since acute abdominal syndrome can be a consequence of irradiation of pain when the lungs and pleura are affected (acute pneumonia, spontaneous pneumothorax, supradiaphragmatic pleurisy).

Then an X-ray of the abdominal organs is performed to identify perforated pneumoperitoneum, intestinal obstruction, renal and gallstones, calcifications in the pancreas, acute volvulus stomach, strangulated hernia, etc. However, depending on the organization of patient reception in medical institution and the expected nature of the disease, the examination procedure may be changed. At the first stage, an ultrasound examination can be performed, which in some cases will allow us to further limit ourselves to radiography of the chest organs.

The role of sonography is especially great in identifying small accumulations of gas and liquid in the abdominal cavity, as well as in diagnosing appendicitis, pancreatitis, cholecystitis, acute gynecological diseases, kidney damage. If there is any doubt about the results of sonography, CT is indicated. Its advantage over sonography is that gas accumulations in the intestines do not interfere with diagnosis.