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Lecture notes, cheat sheets
Pediatric surgery. Recurrent congenital intestinal obstruction (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 12. Recurrent congenital intestinal obstruction Malformations of the intestine and mesentery in some children cause incomplete narrowing of the lumen of the intestinal tube with a violation of its function, which creates the prerequisites for the periodic occurrence of attacks of acute obstruction. Such conditions can also be associated with the presence of congenital cystic formations of the abdominal cavity and other causes. The first signs of the disease usually occur months or years after birth due to the weakening of the body's compensatory capabilities and changes in the child's diet. Recurrent intestinal obstruction most often occurs in connection with congenital circular stenosis of the ileum and colon, disruption of the normal embryonic turn of the "midgut", incarceration of the intraperitoneal hernia and compression of the intestinal lumen by cystic formation. All types of this disease are characterized by inconsistency of symptoms, but the intermittent nature of obstruction is common. It is far from always possible to establish the cause of congenital recurrent obstruction before surgery, but at the same time there are some features of the clinical picture and treatment of each of the listed groups. 1. Circular stenoses of the intestine clinical picture The clinical picture depends on the degree of narrowing and its localization. The first signs of obstruction with significant narrowing of the lumen of the small intestine are observed in early infancy. The child has periodic bouts of anxiety, bloating, vomiting. The chair is rare, but independent, gases depart. Attacks are short-term, occur several times a day, sometimes much less frequently. The child does not take the breast well, gains little weight. Gradually, the attacks of pain become more intense, stool retention appears, the general condition worsens, and the child is sent to a surgical hospital with a diagnosis of intestinal obstruction. When examining a patient, attention is drawn to bloating and some asymmetry of the abdomen. Visible peristalsis is usually determined. Intestinal noises are heard, percussion - tympanitis. The abdomen is slightly painful, muscle tension is not detected. On digital examination of the rectum, the ampoule is empty, there may be a small amount of feces. There is no chair, gases do not depart. After an enema, a temporary improvement may occur, gases can pass. In cases of acute complete closure of the lumen of the narrowed intestine, bloating is more pronounced, the skin is shiny, palpation is painful. Overstretching of the prestenotic part leads to partial necrosis of the intestinal wall and the development of peritonitis. X-ray examination helps in making a diagnosis. Plain radiographs show many horizontal levels in the upper abdomen and gas-distended loops of the small intestine. A study with a contrast agent is possible only in the "light" interval. Given through the mouth, a liquid suspension of barium sulphate in a serial study (every 2 hours) can be detected due to a long delay above the site of narrowing. In acute cases, such a study is unacceptable. The presence of stenosis of the colon appears at an older age, usually after a year. Initially, parents note frequent stool retention, the presence of vomiting, loss of appetite, an increase in the abdomen, and a lag in physical development. Occasionally there is anxiety, bloating intensifies, but after an enema there is a chair, gases leave, and the child calms down. The phenomena of chronic intoxication are noted. In rare cases, the narrowed section of the intestine can become blocked with a fecal stone or a foreign body, and then a picture of acute obstruction occurs. Less pronounced stenoses for a long time may be accompanied by very poor symptomatology: constipation, mild pain attacks, decreased appetite. With age, the compensatory possibilities of the hypertrophied wall above the located intestine weaken, and the clinical picture becomes more definite. Attacks of pain intensify, repeat more often, usually combined with a long delay in stool. Gradually the stomach increases, there is vomiting. Chronic intoxication, hypochromic anemia develops. On palpation of the abdomen, the large intestine is distended with feces. X-ray examination Diagnosis is aided by radiological examination with a contrast mass, which shows prestenotic expansion and normal distal colon. In some cases, it is possible to contour the place of narrowing. Treatment In the period of recurrence of obstruction, an emergency operation is indicated. Surgical intervention is performed under endotracheal anesthesia and blood transfusion, median laparotomy is performed. 2. Ledd's syndrome clinical picture The clinical picture of recurrent volvulus of the midgut is notable for its inconstancy. Most often, the first signs of obstruction are vomiting and regurgitation of bile in children during the first months of life. In some cases, the disease is asymptomatic for many years. Characteristic pain attacks can be single, repeated daily or have intervals of several months and even years. In such children, the appetite is usually reduced, they lag behind their peers in physical development. Sometimes the initial manifestations go unnoticed, and the first attack is accompanied by a distinct clinical picture of acute intestinal obstruction. Thus, periodic paroxysmal pain in the abdomen and frequent vomiting suggest recurrent obstruction associated with impaired intrauterine rotation of the midgut. In some cases, one of the recurrences of volvulus is accompanied by a pronounced picture of acute intestinal obstruction. Suddenly, paroxysmal severe abdominal pain appears, repeated vomiting, stool and gas retention. The child's condition deteriorates sharply, he tosses about in bed, takes a forced position. The face has a pained expression, the eyes sink, the pulse is frequent, thready. The collaptoid state develops. When examining a child during a painful attack, there are some swelling of the epigastric region and retraction of the lower abdomen. Palpation is slightly painful, no formations in the abdominal cavity are not determined. On digital rectal examination, the sphincter is well contracted, the rectal ampulla is empty. X-ray examination The most objective data, speaking of obstruction, are obtained by X-ray examination. Plain abdominal radiographs (upright child) show two horizontal levels of fluid corresponding to a distended stomach and duodenum. There is a relatively small amount of gas in the intestines. A contrast study clarifies the diagnosis. This per os suspension of barium sulphate accumulates at the bottom of the stomach and contours the distended duodenum. After a few hours, barium is distributed in small portions throughout the small intestine, the loops of which are presented in the form of a conglomerate. In cases of suspected volvulus, barium enema is desirable to locate the caecum. If the latter is located high, then one can think of Ledd's syndrome or duodenal compression of an abnormally fixed caecum. In a child with normal anatomical relationships, the large intestine (S - shaped, transverse, colon, ascending and blind) has the shape of the letter "P", forming an angle of about 90 in the hepatic and splenic curvature. In children with Ledd's syndrome, the barium-filled sigmoid colon lies more medially, so the transverse colon is, as it were, shortened, located somewhat lower, and the angle between it and the descending colon is rounded and reduced. Differential diagnosis The differential diagnosis is carried out with diseases accompanied by vomiting and bouts of abdominal pain. Worm infestation is a relatively common disease of older children, causing bouts of abdominal pain. Localized pain in the navel. During an attack, there is vomiting, nausea. The brevity of attacks, history data (the presence of worms in the child, etc.), laboratory tests (blood, feces) and examination of the child usually help to recognize the cause of the disease. However, in some children, attacks of pain during helminthic invasion are so strong and prolonged that the surgeon has a reasonable suspicion of mechanical obstruction. In such cases, conventional conservative measures help the differential diagnosis. With helminthic invasion, the pain then stops, gases go off. Sometimes the spasm of the small intestine caused by the presence of ascaris does not go away, attacks of pain remain, and one has to resort to a trial laparotomy. Giardia cholecystitis is similar to recurrent obstruction, the presence of paroxysmal pain in the abdomen. However, their localization in the right hypochondrium, the presence of typical pain points, an enlarged liver, X-ray and laboratory data allow a correct diagnosis. Treatment Treatment of recurrent midgut volvulus can only be surgical. Preoperative preparation of children is limited to gastric lavage. Anesthesia - general, intubation method 3. Internal abdominal hernias The movement of intestinal loops into defects of the mesentery, omentum or pockets of the peritoneum (without the exit of the viscera from the abdominal cavity) is commonly called internal hernias, which in children, as a rule, are congenital. If the displaced intestinal loops are covered with sheets of peritoneum, which form a kind of hernial sac, then such internal hernias are called true. In cases of displacement of organs through the opening in the mesentery or other congenital defects, hernias occur that are not covered by the hernial sac, and they are called false. In children, paraduodenal hernias are predominantly found. clinical picture Internal abdominal hernias (both true and false) can be asymptomatic indefinitely and are first detected by intestinal obstruction in adults or older children. It is not excluded the possibility of acute intestinal obstruction in the neonatal period. However, for internal abdominal hernias in children, the symptomatology of recurrent obstruction is most characteristic. X-ray examination X-ray examination is of little help in recognizing internal abdominal hernias. In rare cases, it is possible to identify gas-filled loops of the small intestine on survey images, concentrated in the form of a regular rounded conglomerate (hernial sac limitation). To clarify the diagnosis, you can use a contrast study of the colon, which has an unusual position, bending around the hernial sac filled with strangulated loops of the small intestine. Differential diagnosis The differential diagnosis, as with other types of congenital recurrent obstruction, is carried out with diseases accompanied by abdominal pain, vomiting and intestinal discomfort. Treatment The operation is usually carried out according to urgent indications. Before the operation, the stomach is washed and intravenous drip infusion of fluid is started. The duration of preoperative preparation is minimal - it is limited by the time necessary for drug preparation for anesthesia. 4. Compression of the intestinal lumen by cystic formations Cysts of the abdominal cavity and retroperitoneal space, as well as cystic doubling of the gastrointestinal tract in some cases narrow the lumen of the intestinal tube and cause a symptom complex of recurrent obstruction. This complication can occur at any age. clinical picture In cases of compression of the intestinal lumen by a cyst, paroxysmal abdominal pain periodically occurs, the localization of which cannot be detected in young children. Older children complain of pain below the navel. Attacks are accompanied by vomiting, stool retention. When examining a child, one can note the asymmetry of the abdomen due to the protruding tumor-like formation and visible intestinal motility. Superficial careful palpation sometimes manages to determine a moderately mobile and painful cystic mass in the abdominal cavity. Its presence is confirmed by digital examination through the rectum. Identification of a mesenteric cyst of small size is almost impossible due to its easy displacement and difficulties associated with the patient's anxiety. However, often the pain attack goes away on its own, and the child feels healthy again. During the period of pain subsidence, persistent and correctly conducted palpation examination usually reveals a cyst. The cyst of the mesentery, complicated by volvulus of the corresponding loop of the intestine, is manifested by a picture of acute intestinal obstruction. X-ray examination X-ray examination in such cases rarely helps to recognize the true cause of the disease. Differential diagnosis Complicated cysts have to be differentiated from mechanical intestinal obstruction (chronic and acute) caused by other causes. Recognition of the true cause of the disease is difficult due to similar symptomatology and a certain mood of the surgeon, who does not think about the possible presence of a cyst that is rare in children. However, a detailed analysis of the anamnestic data (periodic attacks of pain, constipation, vomiting, abdominal enlargement) and clinical symptomatology (the presence of a cystic mass in the abdominal cavity, atypical manifestations of the alleged intussusception, helminthic obstruction), some radiological findings should be alarming in relation to the complicated mesenteric cyst. Treatment Children with complicated mesenteric cysts should be operated on following the diagnosis. The choice of the method of surgical intervention is determined by the nature of the cyst and the patient's condition. postoperative treatment. All children are prescribed antibiotics intramuscularly, vitamins of groups B and C, heart medications (according to indications), oxygen for the first 2-3 days. In order to prevent pneumonia, the child is given an elevated position, physiotherapy, breathing exercises, and frequent turning in bed are carried out. In the presence of vomiting, the stomach is washed 1-2 times a day with a warm 1% soda solution. If the Ledd operation or the separation of adhesions was performed without violating the integrity of the intestine, then the child begins to drink by the end of the 1st day. For the prevention of pain and the fight against intestinal paresis, long-term epidural anesthesia (3-4 days) is indicated. In cases where a bowel resection was performed or a bypass anastomosis was formed, the child is on parenteral nutrition for 2 days. Compensation for the lack of proteins resulting from chronic malnutrition and losses during surgery is of great importance. The amount of blood plasma and albumin administered depends on age. Blood transfusions are performed no more than 2 times a week. It should be remembered that the best way to restore all types of metabolism is through the mouth, which starts from the 2nd-3rd day. First, the child receives liquid food (broth, jelly, kefir, liquid semolina, grated apple). Then gradually the diet is expanded and increased in volume. In the absence of complications, walking is allowed from the 7-8th day. The stitches are removed on the 9-10th day. Tampons are tightened after 6-7 days, followed by their gradual removal by the 14-16th day. The residual cavity is again loosely plugged after washing with antibiotics, changing the tampons after 3-4 days, preventing the closure of the external opening. Obliteration of the cavity is completed by the end of the 2nd month. In cases where Ledd's operation was performed, X-ray control is performed before discharge to determine the location of the caecum. Surgical treatment of recurrent obstruction in most cases ends successfully. Authors: Drozdov A.A., Drozdova M.V. << Back: congenital intestinal obstruction >> Forward: Acute intestinal intussusception
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