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Lecture notes, cheat sheets
Pediatric surgery. Congenital intestinal obstruction (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 11. Congenital intestinal obstruction Violation of intestinal patency can be associated with various factors of a congenital nature. The most common acute obstruction (in newborns). Malformations of the intestine, mesentery and other organs of the abdominal cavity can create anatomical prerequisites for the periodic occurrence of attacks of obstruction in children of any age (recurrent congenital obstruction). These conditions also require urgent surgical care. Acute congenital intestinal obstruction Acute obstruction is most often caused by a malformation of the intestinal tube itself (atresia and stenosis of the intestine). Atresias and subtotal stenoses are clinically indistinguishable from each other. Acute congenital obstruction is often caused by compression of a normally formed intestinal tube (external type of obstruction). Compression can be caused by various reasons: improperly located vessels of the mesentery (more often the duodenum is compressed by the superior mesenteric artery); peritoneal adhesions, a tumor or cyst of the abdominal cavity, an annular pancreas that covers the duodenum in the descending part; violation of embryonic rotation of the midgut. Meconium ileus, which is the earliest and most severe manifestation of congenital cystofibrous degeneration of the pancreas, stands somewhat apart. Unlike other types of obstruction, the lumen of the intestinal tube with meconium ileus is preserved. Obstruction occurs due to blockage of the terminal ileum by altered meconium. Its expanded part can be perforated in utero, which leads to the occurrence of adhesions. In some cases, the contents of the intestine, entering the abdominal cavity, cause a reaction in the body in the form of diffuse small calcification of the peritoneum. Perforation that occurs after the birth of a child is accompanied by the development of peritonitis. Congenital obstruction is usually divided into two groups: high, in which the obstruction is located in the duodenum or the initial part of the jejunum, and low, when obstruction occurs in the more distal parts of the small and large intestines. Combining anatomically different anomalies into one group based on the totality of similarity of symptoms makes possible early and correct diagnosis, as well as pathophysiologically determined preoperative preparation. Clinical picture of high congenital obstruction The clinical picture of high congenital obstruction appears, as a rule, from the first day of life, and sometimes in the first hours after birth. The most consistent and early symptom is vomiting. With duodenal obstruction, vomiting occurs soon after birth, the amount of vomit is abundant, and does not contain any admixture of bile, which enters entirely into the intestine. In case of duodenal obstruction below. Vateri, and also in the presence of an obstruction in the initial part of the jejunum, the vomit is colored with bile. After the newborn is placed on the mother's breast, vomiting becomes repeated and profuse, exceeding the amount of milk the baby has taken. The frequency of vomiting and the amount of vomit varies somewhat depending on the type of obstruction. With atresia it is more frequent, continuous, striking in its abundance. There is sometimes an admixture of blood in the vomit. With partially compensated stenoses, vomiting occurs on the 2-4th day of the child’s life and usually not immediately after feeding, but 20-40 minutes later, sometimes in a “fountain”. Children with high congenital obstruction usually have meconium. If the obstruction is located above p. Vateri, the amount and color of meconium is almost normal and its discharge is observed until the 3-4th day. With lower obstruction, the amount of meconium is small, the consistency is more viscous than in a healthy child, and the color is grayish. These properties of meconium are associated with the impossibility of passage of bile and amniotic fluid into the distal intestines. With atresia and subtotal stenosis, there is usually a single discharge of meconium or in small portions several times within 1-2 days, and thereafter is absent. In newborns with multiple intestinal atresia, no meconium is observed. With congenital torsion, meconium departs, but in a meager amount. This can be explained by the fact that obstruction (volvulus) is formed in the later period of uterine development, after the intestinal tube is largely filled with bile and amniotic fluid. In some cases, in children with incomplete compression of the intestinal lumen, scanty transitional stools may appear on the 6-7th day. The behavior of a child with congenital high intestinal obstruction is normal on the first day, but later lethargy may appear. At first, the newborn actively sucks, but as the general condition worsens, he refuses to breastfeed. Characteristic is the progressive loss of body weight (0,2-0,25 kg per day). Already from the 2nd day the dehydration phenomena are clearly expressed. The abdomen is swollen in the upper sections (especially in the epigastric region) due to the distended stomach and duodenum. In the first days, you can see the waves of peristalsis. After profuse vomiting, swelling in the epigastric region decreases, sometimes completely disappears. There is some retraction of the lower abdomen. On palpation, the abdomen is soft and painless throughout. If the obstruction is caused by a tumor or cyst, then usually these formations are quite easily palpable through a thin and somewhat flabby abdominal wall. In some cases, in children with congenital volvulus, it is possible to palpate a conglomerate with fuzzy outlines in the abdominal cavity. In the blood of patients with high obstruction, biochemical changes occur. Due to prolonged vomiting, hypochloremia develops, the ratio changes and the amount of K ions decreases.-and Na+. Against the background of exicosis, thickening of the blood is noted: an increase in hematocrit, hemoglobin, an increase in the number of erythrocytes and leukocytes. X-ray examination In the recognition of congenital intestinal obstruction, the radiological method is extremely valuable. The correct interpretation of radiological data helps to navigate the level of obstruction, its nature and is necessary for differential diagnosis. The study of the newborn begins with a survey radiography of the abdominal cavity in the anteroposterior and lateral projections with the child in the vertical position. With high obstruction, radiological symptoms are quite characteristic. Anteroposterior images show two gas bubbles with horizontal levels of liquid, which corresponds to a distended stomach and duodenum, and two horizontal levels located at different heights are also visible on lateral images. The size of gas bubbles is different. With a complete interruption of patency in the underlying sections of the intestine, gas is not detected. Sometimes it is also absent in the stomach, and then the “silent” abdomen is revealed radiologically. In rare cases, with partially compensated stenoses and congenital torsion, single small gas bubbles in the intestine can be seen. The presence of such a radiological picture in combination with clinical data allows us to consider the diagnosis of high congenital obstruction as undoubted. However, children with this type of obstruction are advised to have barium enema to clarify the position of the colon. If the colon is partially filled with contrast, located on the left, one should think about the presence of a torsion of the midgut in a newborn. This clarification of the anatomical cause of obstruction is necessary for the correct calculation of the time of preoperative preparation. Differential diagnosis High congenital obstruction has to be differentiated from some congenital and acquired diseases with similar symptomatology. Pylorospasm is manifested in the first days after birth by vomiting, which is intermittent and less abundant in quantity than with congenital intestinal obstruction. In addition, there is no admixture of bile in the vomit during pylorospasm. However, in cases of duodenal obstruction, p. Vateri bile in vomit also does not happen Plain radiographs usually allow you to clarify the diagnosis by the symptom of two bowls characteristic of high obstruction and the absence of gas in the intestine. X-ray examination with a contrast agent in case of obstruction shows a partial retention of iodolipol in the stomach and its free passage into the duodenum. Suspicion of pyloric stenosis occurs in children with congenital subcompensated stenosis, in which there is a partial intestinal patency. Persistent vomiting, progressive dehydration and emaciation, scanty stools, and epigastric distention with visible gastric peristalsis make these diseases similar. However, permanent staining of vomit with bile can completely eliminate pyloric stenosis. The diagnosis is confirmed by x-ray examination: with pyloric stenosis there is one large gas bubble corresponding to the dilated stomach, in the remaining parts of the intestine a uniform distribution of gas is visible. Congenital diaphragmatic hernia is sometimes accompanied by vomiting, which gives rise to differential diagnosis with high congenital obstruction. In contrast to obstruction in congenital diaphragmatic hernia in a newborn, dysfunctions of the respiratory and cardiovascular systems come to the fore. X-ray examination reveals displacement of the intestine into the chest cavity. Birth trauma to the brain is often accompanied by vomiting with an admixture of bile. However, the passage of meconium is normal. With a brain injury, symptoms of damage to the central nervous system are revealed. The diagnosis is clarified by X-ray examination. Clinical picture of low congenital intestinal obstruction One of the main symptoms of low intestinal obstruction is the absence of meconium. After the introduction of a gas outlet tube or an enema, only lumps of colorless mucus stand out in a newborn. Vomiting appears relatively late, by the end of the 2nd - on the 3rd day of life, and is usually not associated with food intake. The amount of vomit varies (vomiting is often profuse, sometimes resembling regurgitation), but there is always bile staining. Soon the vomiting takes on a meconium character and acquires an unpleasant odor. The child’s behavior in the first hours after birth does not give reason to suspect pathology, but very soon motor restlessness appears, the newborn kicks his legs, refuses to breastfeed or sucks very sluggishly and does not sleep. The general condition quickly deteriorates, intoxication symptoms increase, the child becomes lethargic, adynamic, the skin takes on a gray-sallow color, and the body temperature may be elevated (37,5-38 °C). On examination, even on the first day, a uniform bloating is detected, which progresses rapidly. The size of the abdomen after vomiting does not decrease. Through the anterior abdominal wall, intestinal loops stretched by meconium and gas are contoured. Their peristalsis is often visible, which is not traced in the later periods, since intestinal paresis occurs. Percussion determined tympanitis in all parts of the abdomen. Auscultation revealed rare deaf noises of intestinal peristalsis. Palpation of the abdomen is painful, accompanied by anxiety and the cry of the child. With meconium obstruction, sometimes (on the first day after birth) it is possible to palpate a sausage-shaped mobile tumor corresponding to the terminal ileum stretched by meconium. If there is an obstruction caused by compression of the intestine by a cyst or tumor, then the latter are determined quite clearly. Digital examination through the rectum is sometimes able to identify a neoplasm that may close the entrance to the pelvis. Examination in other cases of low obstruction does not reveal pathology. Colorless mucus leaves behind the finger. Atresia of the ileum, as well as the large intestine, can be complicated by meconium peritonitis, which occurs due to perforation of the overstretched blind end of the intestine. The general condition of the child at the same time deteriorates sharply, vomiting becomes continuous, body temperature rises. The anterior abdominal wall becomes pasty, a network of dilated venous vessels is visible. Swelling soon appears in the groin and perineum (especially the scrotum). The abdominal wall is tense. Only early diagnosis of this complication can give some confidence in a favorable outcome of treatment. X-ray examination X-ray examination begins with survey pictures of the abdominal cavity. Radiographs show swollen intestinal loops with multiple uneven horizontal levels (obstruction of the distal ileum and colon) or several large gas bubbles with wide levels (obstruction of the jejunum or ileum, meconium ileus). If low intestinal obstruction is suspected, a study is performed with a water-soluble contrast agent injected into the rectum with a syringe through a catheter. With low obstruction, radiographs show a sharply narrowed large intestine filled with a contrast agent. Perforation of the expanded part of the intestine above the site of obstruction is usually detected radiographically by the presence of free gas in the abdominal cavity. Differential diagnosis With low congenital obstruction, there are similar symptoms with dynamic obstruction (intestinal paresis) and Hirschsprung's disease. These diseases must be excluded, since an erroneous laparotomy in the presence of dynamic obstruction or Hirschsprung's disease will lead to a sharp deterioration in the general condition of the child. Paralytic obstruction (as opposed to congenital) occurs gradually against the background of a severe general illness (peritonitis, pneumonia, sepsis, enterocolitis), usually 5-10 days after the birth of a child. The phenomena of obstruction in intestinal paresis are not expressed clearly enough, less constantly. From the anamnesis, it turns out that the meconium in the child departs normally, and on examination there is usually a stool (after a gas tube or an enema). Differential diagnosis is helped by X-ray examination with the introduction of a contrast agent through the rectum. With paralytic obstruction, well-formed rectum and sigmoid colon with a normal lumen are detected. Hirschsprung's disease (acute form) from the first days of life is manifested by the absence of an independent stool. Unlike congenital mechanical low obstruction, it is relatively easy to achieve discharge of gases and fecal masses by conservative methods (abdominal massage, introduction of a gas outlet tube, enema). Decisive in the diagnosis is a contrast X-ray study, which reveals the expansion of the lumen of the large intestine, characteristic of Hirschsprung's disease, with the presence of a narrowed zone of agangliosis. Treatment Treatment of congenital intestinal obstruction is a complex section of childhood surgery. Mortality remains high until recently. The prognosis of the disease depends mainly on timely diagnosis, correct surgical correction of the defect, rational preoperative preparation and postoperative management. Preoperative preparation is carried out strictly individually. In newborns with high intestinal obstruction, the duration and quality of preoperative preparation depend on the severity of the condition, the time of admission to the hospital, and the presence of complications. If the diagnosis is established on the first day after birth, then the preparation for the operation does not exceed 3-6 hours and is limited to general measures (warming the child, the introduction of cardiac drugs, oxygen therapy), as well as removing the contents of the stomach through a thin rubber catheter, which is inserted through the nose. Suction of liquid and gas from the stomach is necessary in all cases. The catheter is left in the stomach to continuously aspirate fluid during surgery. In case of late admission (2-4 days), in addition to general measures, it is necessary to begin compensation of the water-salt balance sharply disturbed as a result of prolonged vomiting before the operation. In addition, in these children, in connection with the phenomena of associated pneumonia, respiratory acidosis is often expressed, which also requires correction. The child is given a venesection of the external jugular vein or a puncture of the subclavian vein and intravenous fluids are started (10% glucose solution, protein preparations - albumin, plasma). The duration of preoperative preparation of children in this group is 12-24 hours. If congenital volvulus is suspected after an X-ray examination (irrigography), then the duration of preparation is sharply reduced (3-4 hours) due to the risk of intestinal necrosis. When conducting fluid therapy, one should not achieve a quick and complete correction (until normal blood tests are obtained) of water-salt disorders. In the preoperative period, children are in an incubator (28-32 °C) and constantly receive oxygen. In cases of aspiration pneumonia, active anti-inflammatory therapy is prescribed. The degree of preparation for surgery is judged by the improvement in general condition and the emerging trend towards normalization of biochemical blood parameters. With low intestinal obstruction, preoperative preparation usually does not exceed 2-3 hours and consists of general measures (warming the child, the introduction of cardiac drugs, vitamins, antibiotics, gastric lavage) and in severe cases (with pronounced intoxication, hyperthermia) is aimed at an intensive fight with these conditions. The short duration of preoperative preparation in children with low intestinal obstruction is associated with early developing severe complications: intestinal perforation, peritonitis. postoperative treatment. The patient is placed in a heated incubator with a temperature of 29-3 ° C and 100% humidity, constantly given humidified oxygen, cardiac drugs and antibiotics for 7-8 days. A feature of caring for newborns who have undergone surgery for obstruction is the mandatory constant suction of the contents from the stomach (every 3-4 hours) until the discharge of green fluid stops. Extensive manipulations on the intestine lead to a profound violation of its motility within a few days. In cases where an anastomosis has been created, its patency is restored gradually, and the accumulation of a significant amount of intestinal contents above the anastomosis may be accompanied by suture divergence. In order to prevent intestinal paresis and more quickly restore its function, epidural anesthesia is used in all newborns operated on for congenital intestinal obstruction. In the first 2-3 days, children are completely on parenteral nutrition. Feeding through the mouth after surgery for high obstruction begins on the 3-4th day, low - not earlier than the 4-5th day. First give expressed breast milk in fractional doses (5-7 ml) after 2 hours (alternating with 5% glucose solution). The amount of milk is gradually increased, bringing to the age norm by the 8-12th day. After the creation of intestinal anastomoses, a slow increase in the amount of fluid administered through the mouth is shown (due to the insufficient function of the formed anastomosis). In children, after the formation of a “unloading” Y-shaped anastomosis, fluid administration through the drainage begins the next day after surgery (3-5 ml every 2 hours), and from the 3-4th day dosed oral feeding is prescribed. A drainage inserted into the proximal (dilated) section of the intestine serves for periodic (every 2-4 hours) suction of stagnant contents, a decrease in which indicates the normal function of the anastomosis. This is usually noted on the 6-8th day. Then the drains are removed. A newborn is applied to the breast of the mother's mother after the amount of fluid administered through the mouth corresponds to the age norm. From the first days after the operation, UHF currents are prescribed to the area of the solar plexus, and then, from the 5-6th day, potassium iodide iontophoresis for the prevention of adhesive obstruction. The skin sutures of the wound of the anterior abdominal wall are removed on the 10-11th day after the operation. The management of children with meconium ileus after the operation of creating an enterostomy according to Mikulich has some features. The child is injected with a 5% solution of pancreatin (7-5 ml) twice a day for 4-5 days into the afferent and outlet ends of the excreted intestine, which helps soften the meconium and mechanically remove it. Parenteral nutrition is carried out for the first 3-4 days, and then fractional feeding through the mouth begins according to the above scheme. At the same time, it is recommended (V. Toshovsky and O. Vichitil) 6-fold injection into the stomach of 0,5 ml of a 5% solution of pancreatin (3 ml per day). Establishing a diet in the future, it is necessary to introduce a lot of proteins and vitamins (especially vitamin A) with food, sharply limiting fats. Complications in the postoperative period are observed mainly in children admitted late after birth. The most severe complication is peritonitis, which occurs due to insufficiency of the anastomotic sutures. Fecal peritonitis develops so quickly that the measures taken (reoperation, antibiotics, general strengthening treatment) are rarely successful. Therefore, only the prevention of such a complication is an effective measure to reduce postoperative mortality. Aspiration pneumonia is a frequent and severe complication that occurs mainly when the basic rules for managing such patients are violated at all stages of treatment. A set of measures recommended by specialists and for all children after surgery is aimed at preventing and treating aspiration pneumonia (constant suction of the contents of the stomach, cardiac agents, alkaline aerosols, humidified oxygen, physiotherapy). Adhesive obstruction. This complication is rarely observed in the postoperative period. Treatment begins with conservative measures. The ineffectiveness of the therapy within 18-24 hours is an indication for surgical intervention - the formation of a bypass anastomosis or separation of adhesions (with late obstruction). The divergence of the edges of the postoperative wound and bowel eventration are most often associated with early removal of sutures. In such cases, emergency surgery is indicated - layer-by-layer suturing of the abdominal wall. Authors: Drozdov A.A., Drozdova M.V. << Back: Gastric obstruction (Prepyloric gastric obstruction. Pyloric stenosis) >> Forward: Recurrent congenital intestinal obstruction (Circular intestinal stenosis. Ledd syndrome. Internal abdominal hernias. Compression of the intestinal lumen by cystic formations)
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