|
Arabic
Bengali
Chinese
English
French
German
Hebrew
Hindi
Italian
Japanese
Korean
Malay
Polish
Portuguese
Spanish
Turkish
Ukrainian
Vietnamese|
Lecture notes, cheat sheets
Pediatric surgery. Adhesive intestinal obstruction (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 14. Adhesive intestinal obstruction The adhesive process accompanies any inflammation or injury of the abdominal cavity. Any laparotomy, even carried out under aseptic conditions, can be a predisposing moment to adhesion formation due to the inevitable damage to the serous membrane with tampons, surgical instruments. The process of adhesion formation is associated with the ability of the peritoneum to produce an adhesive exudate that appears when the peritoneum is damaged or inflammation. If there is no infection, then fibrin in the form of thin filaments settles on the damaged surface, and the cellular elements of the exudate undergo evolution and give rise to the formation of elastic and collagen fibers, which, intertwining with fibrin filaments, form a mesh. The surface of the mesh is covered with a thin layer of mesothelium, and thus the peritoneal cover is restored very quickly (in a few hours). In those cases where there is peritonitis, the process of adhesion formation is slower and with various perversions. There is little fibrin in the exudate in the first hours, and its increase is noticeable by the 4-6th day. The death of the mesothelium during inflammation releases thrombase, under the influence of which fibrinogen is converted into fibrin. Other enzymatic processes lead to the formation of elastic and collagen fibers, which, settling on the damaged surface of the intestine, form a delicate mesh, which is subsequently covered with mesothelium. If for some reason these processes do not occur in a timely manner, then granulation tissue appears in the lesion, which gives rise to planar adhesions. This is facilitated by postoperative intestinal paresis. In the next 5-7 days, with a favorable course of the underlying disease, adhesions usually resolve spontaneously. However, the process of eliminating planar adhesions can be longer, and then some of them grow into thin blood capillaries. Gradually (by the 4-6th week) separate cord-like adhesions are formed, the fate of which is different. Most of the resulting adhesions due to the restored peristalsis are overstretched, thinned and atrophied. Less commonly, they grow into larger vessels, muscle fibers, nerve elements, and their resorption becomes impossible. In the postoperative period, in most children, the adhesive process proceeds within the physiological framework and does not cause complications. However, in some cases (especially with persistent intestinal paresis), multiple adhesions stick together intestinal loops, disrupting the passage of contents and creating conditions for the occurrence of obstruction, which is in the nature of obturation. A similar complication of the postoperative period is also observed when the intestinal loops are sealed into the resulting inflammatory infiltrate (abscess) of the abdominal cavity. Formed cord-like adhesions usually do not manifest themselves, but in some children months or years after surgery, they can cause strangulation intestinal obstruction. Thus, acute adhesive intestinal obstruction should be divided into two main groups with certain differences in clinical manifestations, surgical tactics and methods of surgical treatment: early adhesive obstruction - obstructive, developing in the first 3-4 weeks after surgery (kinks of intestinal loops and compression by multiple spikes); late adhesive obstruction - strangulation - occurring months and years after surgery (constriction and compression of the intestine by the remaining cord-like adhesions). Both early and late adhesive obstruction is observed mainly after various acute diseases and injuries of the abdominal organs, less often occurs in connection with "planned" laparotomies. Most often adhesive obstruction complicates acute appendicitis. 1. Early adhesive intestinal obstruction The occurrence of early adhesive obstruction can occur at various stages of the postoperative period. There is a certain relationship between the timing of the development of complications, its nature and the course of the underlying disease. clinical picture In children with severe intestinal paresis and peritonitis, an early adhesive-paretic form of obstruction develops in the first days after surgery. Due to the severe general condition of the patient and the pronounced symptoms of the underlying disease, the symptomatology of obstruction at first is not clearly expressed and develops gradually. The child complains of periodically increasing persistent pain in the abdomen, not much different from those that occurred due to intestinal paresis. Gradually, the pain becomes cramping, vomiting - more frequent and profuse. If a permanent tube was inserted into the child's stomach, then an increase in the amount of aspirated fluid can be noted. Uniform abdominal distension, typical for paresis, somewhat changes its character - asymmetry appears due to individual intestinal loops overflowing with gas. At times, sluggish peristalsis can be traced through the abdominal wall. Auscultatory periodically revealed weak intestinal noise. Palpation of the abdomen is painful due to existing peritoneal phenomena. Stroking the abdominal wall increases peristalsis and causes repeated bouts of pain. There is no independent stool, after a siphon enema, you can get a small amount of feces, mucus and gases. X-ray examination helps to confirm the diagnosis of obstruction. Plain abdominal radiographs show multiple horizontal levels and gas bubbles in distended intestinal loops. In those cases when the phenomena of adhesive obstruction arose against the background of intensive antiparetic therapy (prolonged epidural anesthesia), the diagnosis is greatly facilitated. After the intervention, the child has a gradual improvement in his general condition, the phenomena of paresis begin to subside, and during this period there are cramping pains in the abdomen, vomiting, asymmetric bloating, visible intestinal motility. They stop passing gases. Voiced intestinal noises are clearly auscultated. However, the period of more vivid symptoms of mechanical obstruction is relatively short, and intestinal paresis progresses. It should be remembered that in the first hours of the onset of adhesive obstruction, each injection of trimecaine into the epidural space increases pain attacks, is accompanied by vomiting, a noticeable revival of the visible peristalsis of intestinal loops located above the site of obstruction. It is extremely rare that acute intestinal obstruction develops in the first 2-3 days after a relatively mild operation, performed on an urgent basis or in a "scheduled" manner. Symptoms occur suddenly against the background of the usual postoperative condition. The child begins to scream from severe pain in the abdomen. There is vomiting of gastric contents. On examination, the abdomen is not swollen, sometimes its asymmetry and visible peristalsis are determined. Palpation is somewhat painful. Periodic ringing intestinal noises are heard. There is no chair, gases do not depart. In such cases, the surgeon should think about the resulting concomitant disease - acute mechanical obstruction of the strangulation type. A simple form of early adhesive obstruction, which develops during the period of subsiding of peritoneal phenomena and improvement in the general condition of the child (5-13 days after surgery), manifests itself most clearly. The child suddenly has paroxysmal pain in the abdomen, the intensity of which gradually increases. Vomiting appears, first with food masses, then with an admixture of bile. When examining the abdomen, asymmetry is revealed due to distended intestinal loops. From time to time you can observe visible peristalsis, which is accompanied by attacks of pain. Loud bowel sounds are heard on auscultation. By percussion, tympanitis is determined over areas of swollen intestinal loops. Palpation may be accompanied by increased peristalsis and repeated pain attacks. In the intervals between attacks, the abdomen is soft and accessible to palpation. Gases periodically pass, the stool may initially be independent. Characteristic of a simple form of early adhesive obstruction is the increase in clinical symptoms. After a few hours, the general condition noticeably worsens, vomiting becomes frequent, the child is sharply worried due to bouts of abdominal pain. There are signs of dehydration. The tongue becomes dry, with a white coating. The pulse is frequent. Data from blood and urine tests without features. Plain radiographic images of the abdominal cavity reveal uneven horizontal levels, without characteristic localization. Attacks of pain can end spontaneously, but more often a temporary cessation of pain is replaced by a repetition of a complex of symptoms of intestinal obstruction. Gases cease to depart, there is no chair. For early adhesive obstruction caused by an inflammatory infiltrate, a relatively gradual onset is also characteristic. However, the phenomena of obstruction are usually preceded by a deterioration in the general condition of the child, an increase in body temperature. A painful dense infiltrate is palpated in the abdominal cavity. The results of blood tests indicate a purulent process. In rare cases, the infiltrate is formed without a noticeable general reaction on the part of the patient, and then the examination of the child in connection with the phenomena of obstruction makes it possible to diagnose the main cause of the developing catastrophe in the abdominal cavity. Early delayed adhesive obstruction, which occurred on the 3-4th week of the postoperative period, usually complicates severe, long-term peritonitis. Clinical symptoms in such cases are more often characteristic of simple early adhesive obstruction - they develop gradually, periodically intensifying. However, obstruction may occur in a child who successfully underwent surgery or was discharged home after surgery for acute appendicitis, abdominal trauma. In this case, obstruction usually proceeds with a violent clinical picture and may be due to strangulation by cord-like adhesions. Treatment Treatment of early adhesive obstruction requires an individual approach depending on the general condition of the child, the development of the underlying disease, associated complications and the time elapsed since the first operation. In all cases, treatment begins with a set of conservative measures, which, being a preoperative preparation, relatively often make it possible to eliminate obstruction. The most difficult and responsible task of the surgeon is to correctly determine the acceptable terms of conservative treatment and, if it is ineffective, to choose a rational method of surgical intervention. Conservative treatment begins after identifying the earliest signs of adhesive obstruction. In all cases, oral feeding is stopped, a set of measures is prescribed that enhance intestinal motility, prevent intoxication and dehydration, and also increase the body's reactive forces. The intensity and duration of conservative treatment depends on the general condition of the child, the presence and stage of intestinal paresis, as well as the timing of the onset of symptoms of early adhesive obstruction. If a complication arose in the first days after surgery against the background of existing peritonitis and severe intestinal paresis II-III degree, then conservative treatment should primarily be aimed at eliminating or reducing the paretic component of obstruction. If in the postoperative period, antiparetic measures included prolonged epidural anesthesia, then usually by the time the child develops adhesive obstruction, intestinal motility is partially restored. In such cases, the introduction of trimecaine into the epidural space is continued at the usual time, and at the same time other therapeutic measures are carried out: the stomach is washed with a 2% soda solution, a siphon enema is administered, a hypertonic saline solution and prozerin are administered intravenously. A similar complex is repeated every 2,5-3 hours. It is more difficult to carry out conservative treatment with the development of adhesive obstruction in children in whom prolonged epidural anesthesia was not used in the postoperative period. In such cases, treatment begins with puncture of the epidural space and administration of trimecaine. At the same time, the stomach is washed, a siphon enema is given and general strengthening measures are carried out. Only after 3-7 blockades (after 7-12 hours) there is usually some improvement in the general condition, and noticeable intestinal motility appears. At the same time, the amount of gastric contents sucked through the tube decreases somewhat. From this time on, the child, simultaneously with the epidural blockade, is prescribed medications that enhance intestinal motility (hypertonic solutions, proserin), gastric lavage and siphon enemas are continued, i.e., the entire complex of conservative treatment begins. In the presence of mechanical obstruction, this contributes to the appearance of characteristic symptoms of ileus - the child begins to periodically worry, complain of increased attacks of pain, abdominal asymmetry appears, and sometimes visible peristalsis. In children with adhesive obstruction and severe intestinal paresis, conservative measures continue for at least 10-12 hours. If during this period the pain attacks increase or remain the same intensity, then an operation is prescribed. In cases where a noticeable improvement in the general condition has occurred, pain has decreased and the amount of sucked gastric contents has decreased, or gases have disappeared with a siphon enema, treatment is continued for another 10-12 hours. Remaining by this time or recurring symptoms of obstruction require surgical intervention. Early adhesive obstruction that occurs during the period of subsiding of peritoneal phenomena and improvement in the general condition of the child is also subject to conservative treatment. First, the patient is washed with a stomach and put a cleansing, and then a siphon enema. If, at the same time, gases have not passed and stool has not been obtained, prolonged epidural anesthesia is started. After the introduction of the "dose of action" of trimecaine, intravenous prozerin, a hypertonic saline solution are prescribed, a siphon enema is repeated, and the stomach is washed. All these activities are usually accompanied by some increase in pain (sometimes repeated vomiting) due to the activation of intestinal motility. However, in 1/3 of the children, after 2-3 courses of such therapy, the obstruction phenomena subside, in such cases, conservative measures continue up to 18-24 hours, and they can end with the complete elimination of the complication. If during the first 5-6 hours conservative treatment does not bring relief to the child or has only a temporary effect, relaparotomy is indicated. The same tactics are followed for early adhesive obstruction that has arisen with limited peritonitis due to the emerging infiltrate of the abdominal cavity. If obstruction occurs on the 3-4th week of the postoperative period, the strangulation nature of the ileus is possible. In this regard, short-term intensive conservative therapy is allowed. The patient is washed with a stomach, put a siphon enema. In rare cases, the phenomena of obstruction are eliminated, but usually there is no improvement in the condition, and the child is prescribed an operation. Operative treatment. The volume and nature of the surgical intervention are determined by the form of early adhesive obstruction. It should be remembered that the separation of multiple planar adhesions and the simultaneous "radical" elimination of obstruction is the most risky operation. The inevitable damage of the organized adhesions and the serous cover of the intestine during this intervention creates conditions for the rapid spread of the adhesive process and the recurrence of obstruction. At the same time, if planar "fresh" adhesions are not injured, then with active anti-inflammatory and physiotherapeutic treatment, their reverse development in children occurs relatively quickly. Therefore, in case of early adhesive obstruction, the most correct surgical intervention is the formation of a temporary enterostomy with the expectation of resorption of adhesions and spontaneous restoration of the normal passage of intestinal contents. Surgery for early adhesive obstruction is performed under endotracheal anesthesia and protective blood transfusion. postoperative treatment. All children are given prolonged epidural anesthesia for 4-5 days, and in the presence of an adhesive-paretic form of obstruction, medications are additionally prescribed that enhance intestinal motility. Continue intensive treatment of the underlying disease. Parenteral nutrition is carried out by drip infusions into the subclavian vein. From the 2nd day, anti-adhesion physiotherapy is prescribed. In the presence of an enterostomy, the wound is toileted several times a day and the skin is treated with zinc paste. Sterile napkins are placed on the fistula (do not bandage), which are changed as they get wet and dirty. When a normal stool appears (intestinal patency is restored), the fistula is covered with fatty bandages and bandaged. More often, the enterostomy closes on its own, in some cases it is necessary to eliminate the intestinal fistula by surgery. From the 4th-5th day after the operation of turning off the intestine sealed into the infiltrate, they begin to inject a 5% glucose solution through the fistula (15-20 ml every 2-3 hours), then the amount of liquid is increased to 30-50 ml. When the patency of the disconnected section of the intestine is restored, nutrient solutions of 3-4 ml (broth, glucose, cream) are slowly introduced through the fistula 100-150 times a day, which are partially absorbed. Children are discharged after the stool normalizes. Parents in the clinic are specially trained in the proper care of the child. Repeated examinations by the surgeon are necessary every 2-3 weeks before referral to stage II of the operation. 2. Late adhesive intestinal obstruction Late adhesive obstruction usually develops several months or years after the transferred laparotomy among the full health of the child. Less often, obstruction is preceded by periodic pain attacks in the abdomen or other symptoms of discomfort associated with adhesive disease. clinical picture The child suddenly develops severe cramping pains in the abdomen. Soon the vomiting starts. Attacks of pain become sharp and frequent. Small children periodically scream worried, take a forced position. There is no chair, gases do not depart. The abdomen is asymmetrical due to the protruding swollen loop of the intestine. Peristalsis is clearly visible, which increases when the abdominal wall is stroked. Initially, the abdomen is painless on palpation. Percussion determined moving tympanitis. A digital examination of the per rectum shows some relaxation of the sphincter of the anus and an empty ampoule of the rectum. Colorless mucus or a small amount of feces may pass behind the finger. The general condition of children with late adhesive obstruction rapidly worsens due to dehydration, intoxication and adjoining intestinal paresis. X-ray examination X-ray examination helps the diagnosis. Plain abdominal radiographs show horizontal levels and low levels of gas in the lower regions. Differential diagnosis Differential diagnosis is carried out with other types of acute intestinal obstruction. Anamnesis data (transferred laparotomy) or a postoperative scar on the anterior abdominal wall found during examination usually allows you to correctly resolve the issue of the causes of obstruction. Treatment Treatment of late adhesive obstruction, as a rule, should be prompt. Delay in surgical intervention can lead to necrosis of the intestinal wall due to the likely strangulation of cord-like adhesions. Preoperative preparation. If the patient was admitted within the first 12 hours after the onset of obstruction symptoms and his general condition is regarded as satisfactory, then preoperative preparation should simultaneously serve as a conservative treatment of obstruction. Gastric lavage, siphon enema, prozerin are prescribed, bilateral perirenal novocaine blockade according to A. V. Vishnevsky is performed. If during the period of 2-3 hours of treatment the pain in the abdomen does not stop, the stool is not obtained and the gases are not removed, the child is operated on. In cases of complete resolution of the phenomena of obstruction, the patient is left in the clinic for active observation and anti-adhesion therapy. With late admission, the general condition of children is usually severe. In such cases, intensive treatment is begun, aimed at eliminating exicosis and intoxication. Install the device for intravenous drip infusion. At the same time, a clinical and biochemical blood test is performed, the state of the acid-base state is determined. According to the indications, cardiac agents, oxygen therapy are prescribed. Produce gastric lavage and siphon enema. Improving the general condition, reducing intoxication and dehydration allow you to proceed with the operation. Preoperative preparation is carried out no more than 2-3 hours. postoperative treatment. The child is given epidural anesthesia for 3-5 days (in the presence of paresis of II-III degree, the whole complex of antiparetic therapy is performed), hormones are prescribed at an age dosage (2-3 days), antibiotics (5-7 days) and cardiac drugs (according to indications) . In cases of severe paresis or bowel resection, parenteral nutrition is indicated for 3-4 days. All children from the 2nd day undergo physiotherapy (5 days of UHF currents, then iontophoresis with KI). From the 2nd day (if the operation was not accompanied by bowel resection), the patient is allowed to drink and a liquid table is prescribed. After the discharge of the child, anti-adhesion physiotherapy and long-term dispensary observation are indicated. Authors: Drozdov A.A., Drozdova M.V. << Back: Acute intestinal intussusception >> Forward: Dynamic intestinal obstruction (Spastic ileus. Paralytic ileus)
▪ Stocks and bods market. Crib ▪ History of psychology. Lecture notes
The existence of an entropy rule for quantum entanglement has been proven
09.05.2024 Mini air conditioner Sony Reon Pocket 5
09.05.2024 Energy from space for Starship
08.05.2024
▪ Artificial electronic language prototype ▪ Video games on the real world map ▪ Space debris sensor to be installed on ISS ▪ Red wine speeds up fat burning in the liver ▪ Chinese astronauts fly to the moon
▪ section of the site Metal detectors. Article selection ▪ article Gentlemen Prefer Blondes. Popular expression ▪ article What direction of the mental number line is innate? Detailed answer ▪ Article The series is tripartite. Legends, cultivation, methods of application ▪ article Current regulator on trinistor. Encyclopedia of radio electronics and electrical engineering
Home page | Library | Articles | Website map | Site Reviews
www.diagram.com.ua |
We recommend interesting articles Section 
See other articles Section 
Latest news of science and technology, new electronics:
All languages of this page