Chapter 14. ACUTE INTESTINAL OBSTRUCTION (AIO)

Definition and statistical data

Acute intestinal obstruction (ileus) is a complication of many diseases which is characterized by complete impairment of the contents passage through the intestine due to a mechanical obstacle of intestinal motor function disturbance manifesting itself in stools and gases retention with further development of severe homeostasis impairments.

It is observed in the majority of cases in people of 30-60 years old (in men somewhat more frequently than in women). About 50.000 operations for AIO are performed annually in Russia. In the structure of urgent surgical pathology AIO takes about 4-5%, mortality rate constitutes from 12 to 40%.

Normothermia

Dynamic

Mechanical

Paralytic

Obturational

Strangulational

Complaints

Pain in the abdomen of continuous overpressing character, nausea, recurrent vomiting, non-passage of stools and gases, pronounced weakness.

Abdominal pain of colicy character (after the colic the pain completely disappears), nausea, recurrent vomiting, non-passage of stools and gases, pronounced weakness.

Intensive continuous abdominal pain increasing in spastic intestinal contraction, recurrent vomiting, non-passage of stools and gases, pronounced weakness.

Anamnesis

It is characteristic for inflammatory processes in the abdominal cavity which result in disseminated peritonitis (acute appendicitis, perforating ulcer, acute salpingitis);

- inflammatory processes in the retroperitoneal space (pancreonecrosis, paranephritis);

-traumas of the abdominal cavity including operation ones;

- retroperitoneal hematoma;

- inflammatory processes in the intestine (Crohn's disease of the small and large intestines);

- diabetes mellitus, atherosclerosis, vasculites.

The pain often appears gradually, first it is of col-icy and then of continuous character. Helminthiasis, cholelithiasis are possible. Surgery on the abdominal organs. Anemia, defecation impairment, pathological admixures in the stools as the signs of an intestinal tumor are also possible.

Sudden appearance of an intensive pain. Hernia-carrying, surgery on abdominal organs are possible.

Polyposis of the small and large intestines, bloody admixture in the stools as the signs of invagination.

Examination

Homogenous abdominal distention.

Asymmetric abdominal distention (Wahl's sign) and visible intestinal peristalsis in high obstruction. Homogenous abdominal distention in the obstacle at the level of sigmoid colon or rectum.

Palpation

Tenderness in all portions, abdominal wall resistance, positive peritoneal signs. At percussion - thympanitis.

Moderate tenderness, abdominal wall resistance. At percussion - thympanitis. Palpable neoplasms (invaginate, tumor, entropion, node formation) are possible. Positive "Obukhov's clinic" sign - anal constrictor atony and distension of the rectum empty ampulla.

Auscultation

Reduced or lacking peristalsis. "Splashing sound" in the distended loops, "falling drop sound".

In the beginning - intensification of peristalsis. Further on - reduced or lacking peristalsis, "splashing sound" in the distended loops, "falling drop sound".

Pulse

Tachycardia.

It does not change for a long time.

There is tachycardia from the onset of the disease.

Arterial pressure (AP)

Hypotension.

It does not change for a long time.

There is hypotension from the onset of the disease.

Body T°

Hyperthermia.

Normothermia.

Roentgenological investigation

High diaphragm cupola, atelectases, exudate in the pleura are possible. Distended intestinal loops, "Kloiber's cups", prevalence of gas over fluid.

In the process development there is the same picture as in paralytic AIO. In contrastive investigation - there is steady retention of the contrast passage near the obstacle (before the obstacle - in antegrade passage, after the obstacle - in irrigoscopy).

US, CT

Fluid in free abdominal cavity. Distended by the gas intestinal loops. Intralumen deposition of the fluid, widening of the lumen of the small intestine, thickening of its folds.

In the process development there is the same picture as in paralytic AIO. Presence of both enlarged and collapsed intestinal loops. Detection of a tumor, invaginate is possible.

Laparoscopy

Distended hyperemic loops, turbid exudate, fibrin layers.

In the process development there is the same picture as in paralytic AIO. Detection of hernial hili, adhesions, tumors is possible. Intestinal collapse lower the place of the obstacle.

Colonoscopy

It is not performed.

In high AIO there is intestinal collapse. In low AIO a tumor or compression from the outside are detected.

Spastic obstruction in modern conditions occurs extremely rarely. The clinical picture manifests by a cramping pain. Vomiting is rarely observed. Abdominal distention is absent. In the anamnesis there are professional harms (contacts with heavy metals) or helminthiasis.

The basic signs of hemostatic obstruction with intestinal necrosis are acute pain, hypotension, bloody admixture in the stools ("raspberry jelly")

With progression of any form of mechanical AIO the clinical picture more and more resembles paralytic AIO due to the secondary paralysis of the intestinal wall ("intestinal tiredness", hypokalemia). The clinical picture develops more rapidly and is more pronounced in high obstruction, especially in the jejunum. In all forms of AIO there is inevitable aggravation of endogenic intoxication, hypovolemia, pronounced impairments of water-electrolytic, protein, fat and carbohydrate balance, acido-basic status, as well as the development of peritonitis and polyorganic insufficiency.