X-ray diagnostics of intestinal obstruction. Intestinal obstruction

During the study of the abdomen of patients with suspected acute intestinal obstruction, the abdominal wall is most often soft. With deep palpation, soreness in the area of ​​swollen intestinal loops can be determined. In some cases, against the background of the asymmetry of the abdomen, a loop of the intestine can be palpated (Val's symptom). Above it, with percussion, a tympanic sound with a metallic tint can be determined (Kivul's symptom). late dates diseases with a strong stretching of the intestine, the abdominal wall can become rigid. When it is shaken, splashing noise (Sklyarov's symptom) can be detected. It is caused by the presence of fluid and gases in the intestinal lumen.

In the first hours of the disease during auscultation of the abdomen, increased noises of peristalsis are heard. With the development of peritonitis, peristaltic murmurs cannot be determined, but respiratory and cardiac murmurs become audible.

The importance in the diagnosis of acute intestinal obstruction is given to digital examination of the rectum. In this case, not only the nature of the pathological secretions (blood, mucus, pus) is evaluated, but the cause of obstruction can also be established: a tumor, fecal blockage, a foreign body, etc. The expansion of the rectal ampulla, noted in acute intestinal obstruction, is known as a symptom Obukhov hospital. The general condition of patients with acute intestinal obstruction changes as the disease progresses. At the onset of the disease, body temperature remains normal or reaches only subfebrile numbers. With the development of peritonitis, the temperature rises significantly. The tongue becomes dry and coated. In the terminal stage of the disease, cracks may occur in the tongue due to severe intoxication and dehydration.

on the pathological process abdominal cavity, caused by acute intestinal obstruction, the first to react the cardiovascular system. Tachycardia is often ahead of the temperature reaction. Increasing intoxication leads to respiratory failure and neuropsychiatric disorders. Developing dehydration is manifested by a decrease in diuresis, dryness skin and mucous membranes, thirst, sharpening of facial features. In the late stages of acute intestinal obstruction, the phenomena of liver and kidney failure are observed.

In connection with dehydration of the body and hemoconcentration, blood tests reveal an increase in the number of red blood cells, an increase in hemoglobin levels, and high hematocrit numbers. In connection with the development of inflammatory phenomena in the abdominal cavity in the study of peripheral blood, leukocytosis with a shift may be noted. leukocyte formula to the left, an increase in ESR. Severe shifts in metabolism may be accompanied by a decrease in BCC and a decrease in the level of electrolytes in the blood. As the duration of the disease increases, hypoproteinemia, bilirubinemia, azotemia, anemia, and acidosis develop.

AT clinical course acute intestinal obstruction is divided into three periods:

• initial (period of "ileus cry"), in which the body tries to restore the movement of the food bolus through the intestines. At this time in clinical picture diseases are dominated by pain syndrome and reflex disorders;
• compensatory attempts, when the body tries to compensate for the growing effects of endotoxicosis;
• decompensation or terminal, associated with the development of complications and peritonitis.

Due to the polyetiology of the disease clinical diagnostics acute intestinal obstruction is often difficult. In order to clarify the diagnosis, determine the level and cause of obstruction, special methods research.

X-ray examination is of particular importance in the diagnosis of acute intestinal obstruction. It begins with a plain x-ray of the chest and abdomen.

When radiography chest pay attention to indirect signs of acute intestinal obstruction: the height of the diaphragm, its mobility, the presence or absence of basal pleurisy, discoid atelectasis.

Normally, gas in the small intestine is not detected on plain radiographs of the abdomen. Acute intestinal obstruction is accompanied by intestinal pneumatosis. Most often, the accumulation of gases in the intestine is observed above the liquid levels ("Schwarz-Kloiber bowls"). Due to the folding of the intestinal mucosa, X-ray in the Schwartz-Kloiber bowls, transverse striation is often observed, resembling the skeleton of a fish. By the size of the Schwartz-Kloiber cups, their shape and localization, one can judge with relative accuracy the level of intestinal obstruction. With small intestinal obstruction of the Schwartz-Kloiber bowl of small sizes, the width of the horizontal level of the liquid in them is greater than the height of the strip of gases above it. With colonic obstruction, horizontal fluid levels are more often located along the flanks of the abdomen, and the number of levels is less than with small intestinal obstruction. The height of the gas band in the Schwartz-Kloiber cups with colonic obstruction prevails over the liquid level in them. In contrast to mechanical acute intestinal obstruction, in its dynamic form, horizontal levels are observed both in the small and in the large intestine.

Enterography is used as a radiopaque study in acute intestinal obstruction. At the same time, the expansion of the intestinal lumen above the obstruction zone is detected, narrowing and filling defects caused by tumors are detected, and the time of passage of the contrast agent through the intestine is determined. In order to reduce the time of the study, probe enterography is sometimes used, during which conservative therapeutic measures are also carried out at the same time.

For early diagnosis of obstruction colon, clarifying its causes (and in some cases for therapeutic purposes), recto- or colonoscopy is used. Endoscopic manipulations and enemas are not carried out before X-ray studies, since the interpretation of X-ray and fluoroscopy data depends on this.

Ultrasound examination of the abdominal cavity in acute intestinal obstruction is less important than radiological methods. With the help of ultrasound in acute intestinal obstruction, fluid is determined both in the free abdominal cavity and in individual loops of the intestine.

Since the tactics and methods of treatment of mechanical and dynamic acute intestinal obstruction are different, the differential diagnosis of these forms of intestinal obstruction is of particular importance.

In contrast to acute mechanical intestinal obstruction, with its dynamic form, abdominal pain is less intense and often does not take on a cramping character. With dynamic paralytic ileus, as a rule, the symptoms of the disease that caused ileus prevail. This type of acute intestinal obstruction is manifested by uniform bloating of the abdomen, which remains soft on palpation. During auscultation of the abdomen with dynamic paralytic ileus, peristaltic noises are weakened or not heard at all. The spastic form of acute intestinal obstruction can be manifested by cramping pains that are not accompanied by bloating.

Differential Diagnosis forms of acute intestinal obstruction often requires dynamic monitoring of patients, while great importance have repeated x-ray examinations of the abdominal organs.

H.Maisterenko, K.Movchan, V.Volkov

"Diagnosis of acute intestinal obstruction" and other articles from the section

When there is a suspicion that a patient has intestinal obstruction, an instrumental study is required, which helps not only to make a diagnosis, but also to determine the causes of the disease. One of the signs is the Kloiber bowl.

Definition of intestinal obstruction

Simple: when sick, food cannot pass intestinal tract due to mechanical obstructions or impaired bowel function. The main symptoms that a person experiences in this case:

• bloating;
• constipation;
• nausea or vomiting;
• arching pains in the abdomen, sometimes radiating to the back.

Most often, obstruction is a consequence of a change in diet, the appearance of tumors, polyps, or impaired intestinal motility. To determine the disease, it is necessary to do an ultrasound of the gastrointestinal tract.

X-ray examination

At the slightest suspicion of intestinal obstruction, it is necessary to take an x-ray. To begin with, only a survey fluoroscopy is done, in which, according to certain signs, a diagnosis can be made. X-ray - this is the main intestine.

There are 5 main signs of intestinal obstruction:

• intestinal arches;
• Kloiber's bowl;
• lack of gases in the intestine;
• transfusion of fluid from one loop of the intestine to another;
• striation of the intestine in the transverse direction.

More about Kloiber bowls

Let's consider Kloiber's bowls on the roentgenogram in more detail. When such cups are found on the picture, you can see swollen sections of the intestine filled with liquid in a horizontal position (the patient is in a vertical position) and gas. The gas is above the liquid, on the x-ray it appears as a picture in the form of an inverted bowl. Detection of foci in the form of bowls appears only when the x-ray is taken in the vertical or lateral position of the patient.

Usually, with intestinal insufficiency, more than one Kloiber cup appears, there are many of them, and they are located in the area of ​​\u200b\u200bthe loops of the small intestine, approximately in the center of the abdominal cavity. It is noteworthy that the width of the liquid in the bowl must exceed the level of the height of the gases. The bowls can have different sizes, while maintaining the proportionality of height and width.

The appearance of many small foci indicates that a significant amount of fluid accumulates in the small intestine. They are extremely rarely a sign of obstruction of the colon.

Treatment of intestinal failure

First of all, you need to decide on a diet. First you need to strictly follow a diet and not overeat. Overeating can cause deficiency symptoms to worsen, especially if it happens after a long break. Next, you need to give up food that leads to gas formation. Such foods include beans, peas, soybeans, cabbage and other similar products. It is best to eat more often, but in small portions, this will prevent overeating.

Treatment begins with more humane and conservative methods: enemas, removal of the contents of the stomach, the introduction into the body of special solutions on a crystalloid basis, as well as the introduction of protein preparations. With advanced and severe forms, surgical intervention.

Dieting after surgery

After the doctors do, they determine whether it is necessary to carry out the operation or limit themselves to conservative means. In the case when a surgical intervention is performed, after the operation, the patient should neither eat nor drink for 12 hours. In order to enrich the body with nutrients, doctors use a probe or droppers with glucose. After that, you need to eat only liquid nutrient mixtures until the doctor's permission to switch to other foods.

Next comes the zero diet. Its meaning is that you need to take only light food, which is quickly absorbed and does not contain salt. At the same time, you need to eat 6-8 times a day in very small portions, and the calorie content of the entire daily diet should not exceed 1020 calories. Also, you can not eat something cold or hot, all products should be at room temperature and in a jelly-like form.

Kloiber's cup is a formidable symptom, therefore, at the first signs of intestinal failure, you should immediately go to the doctor and take an x-ray of the abdominal cavity.

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.

Acute intestinal obstruction. Classification, diagnosis, treatment tactics

Zmushko Mikhail Nikolaevich
Surgeon, category 2, resident of the 1st department of TMT, Kalinkovichi, Belarus.

Send comments, feedback and suggestions to: [email protected]
Personal website: http://mishazmushko.at.tut.by

Acute intestinal obstruction (AIO) is a syndrome characterized by a violation of the passage of intestinal contents in the direction from the stomach to the rectum. Intestinal obstruction complicates the course of various diseases. Acute intestinal obstruction (AIO) is a syndrome category that combines the complicated course of diseases and pathological processes of various etiologies that form the morphological substrate of AIO.

1. Congenital factors:

2. Acquired factors:

Adhesive process in the abdominal cavity. Neoplasms of the intestine and abdominal cavity. Foreign bodies intestines. Helminthiases. Cholelithiasis. Hernias abdominal wall. Unbalanced irregular diet.

• A sharp increase in intra-abdominal pressure.

Small intestine 60-70%

Colonic 30-40%

The frequency of occurrence of AIO by etiology:

In acute small bowel obstruction: - adhesive in 63%

Strangulation in 28%

Obstructive non-tumor genesis in 7%

Other in 2%

In acute colonic obstruction: - tumor obstruction in 93%

Volvulus of the colon in 4%

Other in 3%

Classification of acute intestinal obstruction:

1. Dynamic obstruction: a) spastic; b) paralytic.

2. Mechanical obstruction: a) strangulation (torsion, nodulation, infringement; b) obstructive (intraintestinal form, extraintestinal form); c) mixed (invagination, adhesive obstruction).

1. Small bowel obstruction: a) High. b) Low.

2. Colonic obstruction.

There are three phases in the clinical course of AIO (O.S. Kochnev 1984) :

• The phase of the "ileous cry". going on acute disorder intestinal passage, i.e. stage of local manifestations - has a duration of 2-12 hours (up to 14 hours). In this period, the dominant symptom is pain and local symptoms from the abdomen.
• The phase of intoxication (intermediate, stage of apparent well-being), there is a violation of the intraparietal intestinal hemocirculation - lasts from 12 to 36 hours. During this period, the pain loses its cramping character, becomes constant and less intense. The abdomen is swollen, often asymmetrical. Intestinal peristalsis weakens, sound phenomena are less pronounced, "the noise of a falling drop" is auscultated. Complete retention of stool and gases. There are signs of dehydration.
• Phase of peritonitis (late, terminal stage) - occurs 36 hours after the onset of the disease. This period is characterized by severe functional disorders of hemodynamics. The abdomen is significantly swollen, peristalsis is not auscultated. Peritonitis develops.

The phases of the course of AIO are conditional and have their own differences for each form of AIO (with strangulation CI, phases 1 and 2 begin almost simultaneously.

1. Neurogenic factors:

A. Central mechanisms: Traumatic brain injury. Ischemic stroke. Uremia. Ketoacidosis. Hysterical ileus. Dynamic obstruction in psychic trauma. Spinal injuries.

B. Reflex mechanisms: Peritonitis. Acute pancreatitis. Abdominal injuries and operations. Injuries of the chest, large bones, combined injuries. Pleurisy. Acute myocardial infarction. Tumors, injuries and wounds of the retroperitoneal space. Nephrolithiasis and renal colic. Worm invasion. Rough food (paralytic food obstruction), phytobezoars, fecal stones.

2. Humoral and metabolic factors: Endotoxicosis of various origins, including acute surgical diseases. Hypokalemia, as a result of indomitable vomiting of various origins. Hypoproteinemia due to acute surgical disease, wound loss, nephrotic syndrome, etc.

3. Exogenous intoxication: Poisoning with salts of heavy metals. Food intoxications. Intestinal infections(typhoid fever).

4. Dyscirculatory disorders:

A. At the level main vessels: Thrombosis and embolism of mesenteric vessels. Vasculitis of the mesenteric vessels. Arterial hypertension.

B. At the level of microcirculation: Acute inflammatory diseases abdominal organs.

The square of symptoms in CI.

· Abdominal pain. The pains are paroxysmal, cramping in nature. Patients have cold sweat, pallor of the skin (during strangulation). Patients with horror expect the next attacks. Pain can subside: for example, there was a volvulus, and then the intestine straightened out, which led to the disappearance of pain, but the disappearance of pain is a very insidious sign, since with strangulation CI, necrosis of the intestine occurs, which leads to the death of nerve endings, therefore, pain disappears.

· Vomit. Multiple, first with the contents of the stomach, then with the contents of 12 p.k. (note that vomiting of bile comes from 12 p.c.), then vomiting appears with an unpleasant odor. The tongue with CI is dry.

Bloating, abdominal asymmetry

· Retention of stool and gases is a formidable symptom that speaks of CI.

Intestinal noises can be heard, even at a distance, increased peristalsis is visible. You can feel the swollen loop of the intestine - Val's symptom. It is imperative to examine patients per rectum: the rectal ampulla is empty - a symptom of Grekov or a symptom of the Obukhov hospital.

Panoramic fluoroscopy of the abdominal organs: this is a non-contrast study - the appearance of Cloiber cups.

Differential Diagnosis:

AIO has a number of features that are observed in other diseases, which necessitates differential diagnosis between AIO and diseases that have similar clinical signs.

Acute appendicitis. Common symptoms are abdominal pain, stool retention, and vomiting. But pain in appendicitis begins gradually and does not reach such strength as with obstruction. With appendicitis, the pains are localized, and with obstruction, they are cramping in nature, more intense. Increased peristalsis and sound phenomena heard in the abdominal cavity are characteristic of intestinal obstruction, and not appendicitis. In acute appendicitis, there are no radiological signs characteristic of obstruction.

Perforated ulcer of the stomach and duodenum. Common symptoms are sudden onset, severe pain in the abdomen, stool retention. However, with a perforated ulcer, the patient takes a forced position, and with intestinal obstruction, the patient is restless, often changing position. Vomiting is not characteristic of a perforated ulcer, but is often observed with intestinal obstruction. With a perforated ulcer, the abdominal wall is tense, painful, does not participate in the act of breathing, while with OKN, the stomach is swollen, soft, and not painful. With a perforated ulcer, from the very beginning of the disease, there is no peristalsis, "splash noise" is not heard. Radiologically, with a perforated ulcer, free gas is determined in the abdominal cavity, and with OKN - Kloiber's cups, arcades, and a symptom of pinnation.

Acute cholecystitis. Pain in acute cholecystitis is permanent, localized in the right hypochondrium, radiating to the right shoulder blade. With OKN, the pain is cramp-like, non-localized. Acute cholecystitis is characterized by hyperthermia, which does not happen with intestinal obstruction. Increased peristalsis, sound phenomena, radiological signs of obstruction are absent in acute cholecystitis.

Acute pancreatitis. Common signs are the sudden onset of severe pain, a severe general condition, frequent vomiting, bloating and stool retention. But with pancreatitis, the pains are localized in the upper abdomen, they are girdle, and not cramping. Mayo-Robson's sign is positive. Signs of increased peristalsis, characteristic of mechanical intestinal obstruction, are absent in acute pancreatitis. Acute pancreatitis is characterized by diastasuria. X-ray with pancreatitis, there is a high standing of the left dome of the diaphragm, and with obstruction - Kloiber's cups, arcades, transverse striation.

With intestinal infarction, as with OKN, there are severe sudden pains in the abdomen, vomiting, a severe general condition, and a soft stomach. However, pain in intestinal infarction is constant, peristalsis is completely absent, abdominal distention is small, there is no asymmetry of the abdomen, “dead silence” is determined during auscultation. With mechanical intestinal obstruction, violent peristalsis prevails, a large range of sound phenomena is heard, bloating is more significant, often asymmetrical. Intestinal infarction is characterized by the presence of embologenic disease, atrial fibrillation, high leukocytosis (20-30 x10 9 /l) is pathognomonic.

Renal colic and OKN have similar symptoms - pronounced pain in the abdomen, bloating, retention of stools and gases, restless behavior of the patient. But pain at renal colic radiate to the lumbar region, genitals, there are dysuric phenomena with characteristic changes in the urine, a positive symptom of Pasternatsky. On a plain radiograph, shadows of calculi may be visible in the kidney or ureter.

With pneumonia, abdominal pain and bloating may appear, which gives reason to think about intestinal obstruction. However, pneumonia is characterized heat, rapid breathing, blush on the cheeks, and physical examination reveals crepitant rales, pleural rub, bronchial breathing, dullness of lung sound. X-ray examination can detect a pneumonic focus.

In myocardial infarction, there may be sharp pains in the upper abdomen, its swelling, sometimes vomiting, weakness, lowering blood pressure, tachycardia, that is, signs resembling strangulation intestinal obstruction. However, with myocardial infarction, there is no asymmetry of the abdomen, increased peristalsis, symptoms of Val, Sklyarov, Shiman, Spasokukotsky-Wilms, and there are no radiological signs of intestinal obstruction. An electrocardiographic study helps clarify the diagnosis of myocardial infarction.

Examination scope for acute intestinal obstruction:

Mandatory for cito: Urinalysis, general analysis blood, blood glucose, blood type and Rh affiliation, per rectum (decreased sphincter tone and an empty ampoule; possible fecal stones (as a cause of obstruction) and mucus with blood during intussusception, tumor obstruction, mesenteric OKN), ECG, radiography of the abdominal organs in vertical position.

According to indications: total protein, bilirubin, urea, creatinine, ions; Ultrasound, chest x-ray, barium passage through the intestines (performed to exclude CI), sigmoidoscopy, irrigography, colonoscopy, consultation of a therapist.

Diagnostic algorithm for OKN:

A. Collection of anamnesis.

B. Objective examination of the patient:

1. General examination: Neuropsychic status. Ps and blood pressure (bradycardia - more often strangulation). Inspection of the skin and mucous membranes. Etc.

2. Objective examination of the abdomen:

a) Ad oculus: Abdominal distention, possible asymmetry, participation in respiration.

b) Inspection of hernial rings.

c) Superficial palpation of the abdomen: detection of local or widespread protective tension of the muscles of the anterior abdominal wall.

d) Percussion: detection of tympanitis and dullness.

e) Primary auscultation of the abdomen: assessment of unprovoked motor activity of the intestine: metallic shade or gurgling, in the late stage - the sound of a falling drop, weakened peristalsis, listening to heart sounds.

f) Deep palpation: determine the pathology of the formation of the abdominal cavity, palpate internal organs to determine local pain.

g) Repeated auscultation: evaluate the appearance or intensification of intestinal noises, identify Sklyarov's symptom (splash noise).

h) To identify the presence or absence of symptoms characteristic of OKN (see below).

B. Instrumental research:

X-ray examinations (see below).

RRS. Colonoscopy (diagnostic and therapeutic).

Irrigoscopy.

Laparoscopy (diagnostic and therapeutic).

Computer diagnostics (CT, MRI, programs).

G. Laboratory research.

X-ray examination is the main special method for diagnosing AIO. In this case, the following signs are revealed:

• Kloiber's bowl is a horizontal level of liquid with a dome-shaped enlightenment above it, which looks like a bowl turned upside down. With strangulation obstruction, they can manifest themselves after 1 hour, and with obstructive obstruction - after 3-5 hours from the moment of the disease. The number of bowls is different, sometimes they can be layered one on top of the other in the form of a step ladder.
• Intestinal arcades. They are obtained when the small intestine is swollen with gases, while horizontal levels of liquid are visible in the lower knees of the arcades.
• The symptom of pinnation (transverse striation in the form of a stretched spring) occurs with high intestinal obstruction and is associated with stretching of the jejunum, which has high circular mucosal folds. A contrast study of the gastrointestinal tract is used for difficulties in diagnosing intestinal obstruction. The patient is given to drink 50 ml of barium suspension and a dynamic study of the passage of barium is carried out. Delaying it up to 4-6 hours or more gives grounds to suspect a violation of the motor function of the intestine.

X-ray diagnosis of acute intestinal obstruction. Already after 6 hours from the onset of the disease, there are radiological signs of intestinal obstruction. Pneumatosis of the small intestine is initial symptom Normally, gas is found only in the colon. Subsequently, fluid levels are determined in the intestines ("Kloiber's cups"). Fluid levels localized only in the left hypochondrium indicate high obstruction. A distinction should be made between small and large intestinal levels. At small intestinal levels, vertical dimensions prevail over horizontal ones, semilunar folds of the mucosa are visible; in the large intestine, the horizontal dimensions of the level prevail over the vertical ones, haustration is determined. X-ray contrast studies with giving barium through the mouth with intestinal obstruction are impractical, this contributes to complete obstruction of the narrowed segment of the intestine. The use of water-soluble contrast agents in obstruction contributes to fluid sequestration (all radiopaque agents are osmotically active), their use is possible only if they are administered through a nasointestinal probe with aspiration after the study.
An effective means of diagnosing colonic obstruction and in most cases its causes is irrigoscopy. Colonoscopy for colonic obstruction is undesirable because it leads to the entry of air into the leading loop of the intestine and may contribute to the development of its perforation.

High and narrow bowls in the large intestine, low and wide - in the small intestine; not changing position - with dynamic OKN, changing - with mechanical.
contrast study carried out in doubtful cases, with a subacute course. Lag passage of barium into the caecum for more than 6 hours against the background of drugs that stimulate peristalsis - evidence of obstruction (normally, barium enters the cecum after 4-6 hours without stimulation).

To confirm the exclusion of intestinal obstruction.

In doubtful cases, with suspected intestinal obstruction for the purpose of differential diagnosis and complex treatment.

Adhesive OKN in patients who have repeatedly undergone surgical interventions, with the relief of the latter.

Any form of small bowel obstruction (with the exception of strangulation), when as a result of active conservative measures in the early stages of the process, it is possible to achieve a visible improvement. In this case, there is a need for objective confirmation of the legitimacy of conservative tactics. The basis for terminating the series of Rg-grams is the fixation of the flow of contrast into the large intestine.

Diagnosis of early postoperative obstruction in patients undergoing gastric resection. The absence of pyloric sphincter causes unimpeded flow of contrast into the small intestine. In this case, the detection of the phenomenon of stop-contrast in the outlet loop serves as an indication for early relaparotomy.

1. An X-ray contrast study for the diagnosis of AIO can only be used with full conviction (based on clinical data and the results of an abdominal radiography survey) in the absence of a strangulation form of obstruction, which threatens a rapid loss of viability of the strangulated bowel loop.

2. Dynamic observation of the progress of the contrast mass must be combined with clinical observation, during which changes in local physical data and changes in general condition sick. In the case of aggravation of local signs of obstruction or the appearance of signs of endotoxicosis, the issue of urgent surgical aid should be discussed regardless of the x-ray data characterizing the progress of the contrast through the intestines.

3. If a decision is made to dynamically monitor the patient with control of the passage of the contrast mass through the intestines, then such monitoring should be combined with therapeutic measures aimed at eliminating the dynamic component of obstruction. These activities consist mainly in the use of anticholinergic, anticholinesterase and ganglion blocking agents, as well as conduction (perirenal, sacrospinal) or epidural blockade.

The possibilities of X-ray contrast studies for the diagnosis of OKN are significantly expanded when using the technique enterography. The study is carried out using a sufficiently rigid probe, which, after emptying the stomach, is carried out behind the pyloric sphincter into the duodenum. Through the probe, if possible, completely remove the contents from the proximal jejunum, and then under a pressure of 200-250 mm of water. Art. 500-2000 ml of 20% barium suspension prepared in isotonic sodium chloride solution is injected into it. Within 20-90 minutes, dynamic X-ray observation is carried out. If, during the study, liquid and gas accumulate again in the small intestine, the contents are removed through the probe, after which the contrast suspension is re-introduced.

The method has a number of advantages. Firstly, the decompression of the proximal intestines provided by the technique not only improves the conditions of the study, but is also an important therapeutic measure for AIO, since it helps to restore the blood supply to the intestinal wall. Secondly, the contrast mass, introduced below the pyloric sphincter, gets the opportunity to move much faster to the level of a mechanical obstacle (if it exists) even in conditions of incipient paresis. In the absence of a mechanical obstacle, the passage time of barium into the large intestine is normally 40-60 minutes.

At present, an active tactic for the treatment of acute intestinal obstruction has been adopted.

emergency(i.e. performed within 2 hours from the moment of admission) the operation is indicated for OKN in the following cases:

1. With obstruction with signs of peritonitis;

2. With obstruction with clinical signs of intoxication and dehydration (that is, in the second phase of the course of OKN);

3. In cases where, based on the clinical picture, there is an impression of the presence of a strangulation form of OKN.

A complex of diagnostic and treatment measures and preoperative preparation include:

• impact on the vegetative nervous system- bilateral pararenal novocaine blockade
• Decompression of the gastrointestinal tract by aspiration of the contents through nasogastric tube and siphon enema.
• Correction of water and electrolyte disorders, detoxification, antispasmodic therapy, treatment of enteral insufficiency.

Restoration of bowel function is facilitated by decompression of the gastrointestinal tract, since bloating of the intestine entails a violation of capillary, and later venous and arterial circulation in the intestinal wall and a progressive deterioration in bowel function.

To compensate for water and electrolyte disturbances, the Ringer-Locke solution is used, which contains not only sodium and chlorine ions, but also all the necessary cations. To compensate for potassium losses, potassium solutions are included in the composition of infusion media along with glucose solutions with insulin. In the presence of metabolic acidosis, sodium bicarbonate solution is prescribed. With OKN, a deficiency in the volume of circulating blood develops, mainly due to the loss of the plasma part of the blood, so it is necessary to administer solutions of albumin, protein, plasma, and amino acids. It should be remembered that the introduction of only crystalloid solutions in case of obstruction only contributes to fluid sequestration, it is necessary to administer plasma-substituting solutions, protein preparations in combination with crystalloids. To improve microcirculation, rheopolyglucin with complamin and trental is prescribed. The criterion for an adequate volume of injected infusion media is the normalization of circulating blood volume, hematocrit, central venous pressure, and increased diuresis. Hourly urine output should be at least 40 ml/h.

The discharge of an abundant amount of gases and feces, the cessation of pain and the improvement of the patient's condition after conservative measures indicate the resolution (exclusion) of intestinal obstruction. If conservative treatment does not give an effect within 3 hours, then the patient must be operated on. The use of drugs that stimulate peristalsis, in doubtful cases, reduces the time of diagnosis, and with a positive effect, AIO is excluded.

1. The operation for AIO is always performed under anesthesia by 2-3 medical teams.

2. At the stage of laparotomy, revision, identification of the pathomorphological substrate of obstruction and determination of the operation plan, it is mandatory to participate in the operation of the most experienced surgeon on duty, as a rule, the responsible surgeon on duty.

3. At any localization of obstruction, access is median laparotomy, if necessary, with excision of scars and careful dissection of adhesions at the entrance to the abdominal cavity.

4. Operations for OKN provide for the consistent solution of the following tasks:

Establishing the cause and level of obstruction;

Before manipulations with the intestines, it is necessary to carry out a novocaine blockade of the mesentery (if there is no oncological pathology);

Elimination of the morphological substrate of OKN;

Determining the viability of the intestine in the area of ​​the obstacle and determining the indications for its resection;

Establishing the boundaries of the resection of the altered intestine and its implementation;

Determination of indications for drainage of the intestinal tube and the choice of drainage method;

Sanitation and drainage of the abdominal cavity in the presence of peritonitis.

5. Detection of an obstruction zone immediately after laparotomy does not relieve the need for a systematic revision of the state of the small intestine throughout its entire length, as well as the large intestine. Revision is preceded by obligatory infiltration of the root of the mesentery with a solution local anesthetic. In case of severe overflow of intestinal loops with contents, the intestine is decompressed using a gastrojejunal probe before revision.

6. Removing the obstruction is the key and most difficult component of the intervention. It is carried out in the least traumatic way with a clear definition of specific indications for the use of various methods: dissection of multiple adhesions; resection of the altered intestine; elimination of torsion, intussusception, nodules or resection of these formations without prior manipulations on the altered intestine.

7. When determining the indications for resection of the intestine, visual signs are used (color, swelling of the wall, subserous hemorrhages, peristalsis, pulsation and blood filling of the parietal vessels), as well as the dynamics of these signs after the introduction of a warm solution of local anesthetic into the mesentery of the intestine.

The viability of the intestine is evaluated clinically on the basis of the following symptoms (the main ones are the pulsation of the mesenteric arteries and the state of peristalsis):

The color of the intestine (bluish, dark purple or black staining of the intestinal wall indicates deep and, as a rule, irreversible ischemic changes in the intestine).

The condition of the serous membrane of the intestine (normally, the peritoneum covering the intestine is thin and shiny; with necrosis of the intestine, it becomes edematous, dull, dull).

The state of peristalsis (the ischemic intestine does not contract; palpation and tapping do not initiate a peristaltic wave).

The pulsation of the mesenteric arteries, distinct in normal conditions, is absent in vascular thrombosis that develops with prolonged strangulation.

8. When deciding on the boundaries of resection, one should use the protocols that have developed on the basis of clinical experience: deviate from the visible boundaries of the violation of blood supply to the intestinal wall towards the leading section by 35-40 cm, and towards the outflow section by 20-25 cm. The exception is resections near ligament of Treitz or ileocecal angle, where these requirements are allowed to be limited with favorable visual characteristics of the intestine in the area of ​​​​the proposed intersection. In this case, control indicators are necessarily used: bleeding from the vessels of the wall when it is crossed and the state of the mucous membrane. Perhaps, also, the use of | transillumination or other objective methods for assessing blood supply.

9. If there are indications, drain the small intestine. See indications below.

10. With colorectal tumor obstruction and the absence of signs of inoperability, one-stage or two-stage operations are performed depending on the stage of the tumor process and the severity of the manifestations of colonic obstruction.

A. With a tumor of the blind, ascending colon, hepatic angle:

· Without signs of peritonitis, a right-sided hemicolonectomy is indicated.
· With peritonitis and severe condition of the patient - ileostomy, toilet and drainage of the abdominal cavity.
In case of inoperable tumor and absence of peritonitis - iletotransversostomy

B. With a tumor of the splenic angle and descending colon:

· Without signs of peritonitis, a left-sided hemicolonectomy, colostomy is performed.
In case of peritonitis and severe hemodynamic disturbances, transversostomy is indicated.
· If the tumor is inoperable - bypass anastomosis, with peritonitis - transversostomy.
With a tumor sigmoid colon- resection of a portion of the intestine with a tumor with the imposition of a primary anastomosis or Hartmann's operation, or the imposition of a double-barreled colostomy. The formation of a double-barreled colostomy is justified if it is impossible to resect the intestine against the background of decompensated OKI.

11. Elimination of strangulation intestinal obstruction. When knotting, inversion - eliminate the knot, inversion; with necrosis - resection of the intestine; with peritonitis - intestinal stoma.
12. In case of invagination, deinvagination, Hagen-Thorne meso-sigmoplication is performed, in case of necrosis - resection, in case of peritonitis - ilestomy. If intussusception is due to Meckel's diverticulum - bowel resection along with diverticulum and intussusceptum.
13. In adhesive intestinal obstruction, the intersection of adhesions and the elimination of "double-barreled" are indicated. In order to prevent adhesive disease, the abdominal cavity is washed with fibrinolytic solutions.
14. All operations on the colon are completed with devulsion of the external sphincter of the anus.
15. The presence of diffuse peritonitis requires additional sanitation and drainage of the abdominal cavity in accordance with the principles of treatment of acute peritonitis.

Decompression of the gastrointestinal tract.

The main objectives of extended decompression are:

Removal of toxic contents from the intestinal lumen;

Conducting intra-intestinal detoxification therapy;

Impact on the intestinal mucosa to restore its barrier and functional viability; early enteral nutrition of the patient.

1. Paretic state of the small intestine.
2. Resection of the intestine or suturing of the hole in its wall in conditions of paresis or diffuse peritonitis.
3. Relaparotomy for early adhesive or paralytic ileus.
4. Repeated surgery for adhesive intestinal obstruction. (Pakhomova GV 1987)
5. When applying primary colonic anastomoses with OKN. (VS Kochurin 1974, LA Ender 1988, VN Nikolsky 1992)
6. Diffuse peritonitis in 2 or 3 tbsp.
7. The presence of an extensive retroperitoneal hematoma or phlegmon of the retroperitoneal space in combination with peritonitis.

General rules for drainage of the small intestine:

Drainage is carried out with stable hemodynamic parameters. Before its implementation, it is necessary to deepen anesthesia and introduce 100-150 ml of 0.25% novocaine into the root of the mesentery of the small intestine.

It is necessary to strive for intubation of the entire small intestine; it is advisable to advance the probe due to pressure along its axis, and not by manually pulling it along the intestinal lumen; to reduce the trauma of manipulation until the end of intubation, do not empty the small intestine from liquid contents and gases.

After completion of drainage, the small intestine is placed in the abdominal cavity in the form of 5-8 horizontal loops, and is covered with a greater omentum from above; it is not necessary to fix the loops of the intestine among themselves with the help of sutures, since the very laying of the intestine on the enterostomy tube in the indicated order prevents their vicious location.

To prevent the formation of bedsores in the intestinal wall, the abdominal cavity is drained with a minimum number of drains, which, if possible, should not come into contact with the intubated intestine.

Exists 5 main types of drainage of the small intestine.

1. Transnasal drainage of the small intestine throughout.
   This method is often referred to as Wangensteen (Wangensteen) or T.Miller and W.Abbot, although there is evidence that the pioneers of transnasal intubation of the intestine with the Abbott-Miller probe (1934) during the operation were G.A.Smith(1956) and J.C.Thurner(1958). This method of decompression is the most preferable due to minimal invasiveness. The probe is passed into the small intestine during surgery and is used for both intraoperative and prolonged decompression of the small intestine. The disadvantage of the method is a violation of nasal breathing, which can lead to a deterioration in the condition of patients with chronic diseases lungs or provoke the development of pneumonia.
2. Method proposed J.M. Ferris and G.K. Smith in 1956 and described in detail in Russian literature Yu.M.Dederer(1962), intubation of the small intestine through a gastrostomy, is free from this disadvantage and is indicated in patients in whom it is impossible to pass a probe through the nose for some reason or a violation of nasal breathing due to the probe increases the risk of postoperative pulmonary complications.
3. Drainage of the small intestine through an enterostomy, for example, the method I.D. Zhitnyuk, which was widely used in emergency surgery before the advent of commercially available tubes for nasogastric intubation. It involves retrograde drainage of the small intestine through a suspension ileostomy.
   (There is a method of antegrade drainage through the jejunostomy along J. W. Baker(1959), separate drainage of the proximal and distal small intestine through a suspended enterostomy along White(1949) and their numerous modifications). These methods seem to be the least preferred due to possible complications on the part of the enterostomy, the danger of the formation of a small bowel fistula at the site of the enterostomy, etc.
4. Retrograde drainage of the small intestine through a microcecostomy ( G.Sheide, 1965) can be used when antegrade intubation is not possible.
   Perhaps the only drawback of the method is the difficulty of passing the probe through the Baugin valve and the dysfunction of the ileocecal valve. Cecostoma after removal of the probe, as a rule, heals on its own. A variant of the previous method is the proposed I.S. Mgaloblishvili(1959) a method of drainage of the small intestine through the appendix.
5. Transrectal drainage of the small intestine is used almost exclusively in pediatric surgery, although successful use of this method in adults has been described.

Numerous combined methods of drainage of the small intestine have been proposed, including elements of both closed (not associated with opening the lumen of the stomach or intestine) and open methods.

With a decompression and detoxification purpose, the probe is installed in the intestinal lumen for 3-6 days, the indication for removal of the probe is the restoration of peristalsis and the absence of congestive discharge along the probe (if this happened on the first day, then the probe can be removed on the first day). With a frame purpose, the probe is installed for 6-8 days (no more than 14 days).

Finding the probe in the intestinal lumen can lead to a number of complications. This is primarily bedsores and perforation of the intestinal wall, bleeding. With nasointestinal drainage, the development of pulmonary complications (purulent tracheobronchitis, pneumonia) is possible. Suppuration of wounds in the area of ​​stoma is possible. Sometimes nodular deformation of the probe in the intestinal lumen makes it impossible to remove it and requires surgical intervention. From the ENT organs (nosebleeds, necrosis of the wings of the nose, rhinitis, sinusitis, sinusitis, bedsores, laryngitis, laryngostenosis). In order to avoid complications that develop when the probe is removed, a soluble probe made of synthetic protein is proposed, which absorbs on the 4th day after surgery ( D. Jung et al., 1988).

Colon decompression in colonic obstruction will be achieved colostomy. In some cases, transrectal colonic drainage with a colonic tube is possible.

Contraindications for nasoenteric drainage:

• Organic disease of the upper gastrointestinal tract.
• Varicose veins of the esophagus.
• Esophageal stricture.
• Respiratory failure 2-3 st., severe cardiac pathology.
• When it is technically impossible or extremely traumatic to perform nasoenteric drainage due to technical difficulties (adhesions of the upper abdominal cavity, impaired patency of the nasal passages and upper gastrointestinal tract, etc.).

Postoperative treatment of AIO includes the following mandatory directions:

Reimbursement of BCC, correction of electrolyte and protein composition blood;

Treatment of endotoxicosis, including mandatory antibiotic therapy;

Restoration of the motor, secretory and absorption functions of the intestine, that is, the treatment of enteral insufficiency.

Literature:

1. Norenberg-Charkviani A. E. " Acute obstruction intestines”, M., 1969;
2. Savelyev V. S. "Guidelines for emergency surgery of the abdominal organs", M., 1986;
3. Skripnichenko D.F. "Emergency abdominal surgery", Kyiv, "Health", 1974;
4. Hegglin R. "Differential diagnosis of internal diseases", M., 1991.
5. Eryuhin, Petrov, Khanevich "Intestinal obstruction"
6. Abramov A.Yu., Larichev A.B., Volkov A.V. and others. Place of intubation decompression in surgical treatment adhesive small bowel obstruction // Tez. report IX All-Russian. congress of surgeons. - Volgograd, 2000.-S.137.
7. The results of the treatment of acute intestinal obstruction // Tez. report IX All-Russian. congress of surgeons.-Volgograd, 2000.-p.211.
8. Aliev S.A., Ashrafov A.A. Surgical tactics for obstructive tumor obstruction of the colon in patients with increased operational risk / Grekov Bulletin of Surgery.-1997.-No. 1.-S.46-49.
9. Order of the Ministry of Health of the Russian Federation of April 17, 1998 N 125 "On the standards (protocols) for the diagnosis and treatment of patients with diseases of the digestive system".
10. A practical guide for IV-year students of the Faculty of Medicine and the Faculty of Sports Medicine. Prof. V.M.Sedov, D.A.Smirnov, S.M.Pudyakov "Acute intestinal obstruction".

TICKET 12

Exudative pleurisy

This is a disease characterized by damage to the pleura with the subsequent formation of a liquid of various nature in its cavity. Most often this disease acts as a secondary factor of any pathological changes.

Etiology:

Most infectious exudative pleurisy is a complication of pathological pulmonary processes. At the same time, about 80% of cases of hydrothorax are detected in patients with pulmonary tuberculosis.

-Non-infectious exudative pleurisy develop against the background of a variety of pulmonary and extrapulmonary pathological conditions.

kidney failure in chronic form;

Chest injury, in which hemorrhage began in the pleural cavity;

Tumors of the blood are predominantly malignant;

Chronic circulatory failure;

lung infarction;

Cirrhosis of the liver (a common cause of right-sided hydrothorax);

Connective tissue diseases of an autoimmune nature. These include collagenoses, rheumatism, etc.;

Carcinomatosis, mesothelioma and other malignant tumor-like formations in the lungs;

With inflammation of the pancreas, the development of left-sided hydrothorax is possible.

Classification:

Exudative pleurisy, according to its etiology, is divided into infectious and aseptic.

Given the nature of the exudation, pleurisy can be serous, serous-fibrinous, hemorrhagic, eosinophilic, cholesterol, chylous (chylothorax), purulent (pleural empyema), putrefactive, mixed.

Distinguish with the flow acute, subacute and chronic exudative pleurisy.

Depending on the location of the exudate, pleurisy can be diffuse or encysted (delimited). Encapsulated exudative pleurisy, in turn, is divided into apical (apical), parietal (paracostal), bone-diaphragmatic, diaphragmatic (basal), interlobar (interlobar), paramediastinal.

X-ray:
The X-ray picture with exudative pleurisy depends on how much exudate was formed and did not undergo resorption (reabsorption) by pleural sheets. Minimal effusion can be suspected when indirect manifestations appear. These include:

• High diaphragm position.
• Restriction or violation of its mobility.
• A sharp increase in the distance between the lung field and the gas bubble (more than 1.5 cm, while normal value does not exceed 0.5 cm).

2-sided supraphrenic pleurisy

The first thing they pay attention to is the sinuses. These are a kind of pockets formed by the pleura in the diaphragmatic-costal region. In the absence of pathology, the sinuses are free and are corners directed downward (between the edges of the ribs laterally and the diaphragm medially). If the costophrenic sinuses are darkened, this indicates the involvement of the pleura in the inflammation process. Or there is another disease, accompanied by increased fluid synthesis.

The next possible radiological sign of the appearance of fluid in the pleural fissures is a cloak-like darkening. This term reflects the appearance of a shadow that covers the entire lung surface like a cloak. Darkening in this case can be seen from the lateral side of the chest, as well as along the interlobar pleural sulcus (it divides the lung into lobes). With an increase in the volume of the accumulating liquid, the upper border of the darkened area on the radiograph is smoothed out. According to the level of this border along the ribs, the degree of hydrothorax is determined - a condition characterized by a massive effusion into the pleural fissure of various etiology and pathogenesis. But exudative pleurisy rarely reaches such proportions and is limited to the sinuses.

The posterior costophrenic sinus is not visible

Cluster a large number pleural fluid, regardless of the cause, leads to such a phenomenon as the displacement of the mediastinum (median shadow) in the direction opposite to the affected one (this applies to unilateral pleurisy). The extent of this bias depends on a number of factors:

• volume of exudate.
• diaphragm level.
• The degree of mobility of mediastinal structures.
• Functional state of lung formations

When the patient is examined in a horizontal position, a more intense shadow appears already in the lateral regions of the chest. This symptom bears the author's name - the Lenk phenomenon. It is played in the horizontal or Trendelenburg position. Also typical for this situation is a decrease in such an indicator as the transparency of lung tissue. It is homogeneous and diffuse.

Free fluid spread along the chest wall in a layer of 3.2 cm

Pleurisy involving the mediastinal (mediastinal) pleura is not so common. Its characteristics:

• Additional darkening in the area of ​​the median shadow.
• The clarity of the contours of these formations.
• A variety of shadow shapes: triangular, spindle-shaped or striped (ribbon-like).

When the effusion is located in the interlobar pleura, the x-ray picture has its own peculiarity. It lies in the fact that the blackouts are located along the border between the lobes of the lungs. Shadows at the same time resemble lenses: they have the form of symmetrical formations with biconcave or biconvex outlines. The mediastinum usually does not move anywhere intact with this form of pleurisy.

.
interlobar pleurisy

With untimely resorption of exudate, the risk of such an outcome as pleural adhesions, moorings, which will limit the respiratory excursion of the lungs, increases.

Encapsulated pleurisy of the small interlobar fissure.

X-ray symptoms of intestinal obstruction

Diagnosis of intestinal obstruction is usually aimed at determining, clarifying its nature, differentiating mechanical obstruction from paralytic, establishing the level of obstruction, the state of blood supply to the affected area.

There are mechanical and dynamic intestinal obstruction.

Dynamic (functional or paralytic) obstruction develops reflexively in various critical conditions: peritonitis, pancreatitis, abscesses of the abdominal cavity and retroperitoneal space, perforations of hollow organs, seizures urolithiasis, violation of mesenteric circulation, poisoning by various medicines after surgical trauma.
The leading sign of paralytic ileus is a decrease in tone, swelling of the small and large intestines. Kloiber's cups are usually absent in paralytic ileus.
With paralytic ileus, water-soluble contrast agents can be used, since they, having laxative properties, can accelerate the passage of intestinal contents, thereby providing a therapeutic effect.

Mechanical small bowel obstruction. The cause of mechanical small bowel obstruction is most often strangulation (torsion, nodulation), infringement, intussusception, less often obturation.

The classic radiological signs of mechanical small bowel obstruction, detected by a plain radiography of the abdomen, are:
1) overstretched loops of the small intestine above the site of obstruction with the presence of transverse striation due to Kerckring folds;

2) the presence of liquid and gas levels in the lumen of the small intestine (Kloyber's bowl);

3) air arches;

4) the absence of gas in the colon.

Normally, the small intestine, unlike the large intestine, does not contain gas. However, in severe intestinal obstruction, gas from the colon passes naturally and therefore may not be detected on x-rays. The absence of gas in the colon indicates complete obstruction of the small intestine. With high small bowel obstruction, a small amount of gas is detected in the jejunum, since the contents of the jejunum, located proximal to the obturation site, are thrown into the stomach.
Relatively early sign Small bowel obstruction is an isolated distention of the small intestine without fluid levels ("isolated loop" symptom). In the vertical position of the patient, the arched loop of the small intestine inflated with gas has the appearance of an arch. Then liquid levels appear, which initially look like the letter "J" with a gas bubble above two liquid levels located at different heights. Sometimes you can see the overflow of fluid from one loop to another. As the fluid accumulates, both levels are connected, resulting in an inverted bowl pattern (Cloiber's bowl).
Cloiber cups are the most characteristic radiological sign of small bowel obstruction. They are liquid levels with semi-oval gas accumulations located above them.
With an increase in obstruction with an increase in the amount of liquid, the arches can turn into bowls, and with a decrease in the amount of liquid, the opposite picture occurs - the bowls turn into arches.
In typical cases, Kloiber's small intestine bowls differ from large intestine ones in that the width of the liquid level in this bowl is greater than the height of the gas bubble above it. With obstruction of the colon, the ratio is reversed - the height of the gas bubble is greater than the width of the liquid level.
Small bowel obstruction is characterized by the presence of multiple cups in the center of the abdominal cavity, where the loops of the small intestine are located. With the progression of obstruction, the width of the fluid levels increases, and the height of the air column decreases.
With obturation in the more distal parts of the small intestine, its expanded loops are parallel to each other, forming a characteristic stepladder pattern on radiographs. Distended loops of the small intestine are usually oriented obliquely from the lower right to the upper left quadrant of the abdomen. In this case, the area of ​​blockage is usually located under the lowest level of the liquid. Moderately distended loops of the small intestine on radiographs are easily distinguished from gas-containing loops of the large intestine.
Small bowel obstruction is characterized by a transverse striation of the intestine, due to the display of circularly located Kerckring folds that extend over the entire diameter of the intestine. In this case, a picture appears that resembles a stretched spring. The transverse striation is visible only in the jejunum; it is absent in the ileum, since the kerkring folds are less pronounced there. As the small intestine stretches, the folded pattern is smeared, and then it can be difficult to distinguish the loops of the small intestine from the large intestine.

The relief of the large intestine during its swelling is represented by thicker and rarer semilunar folds separating the haustra, which do not cross the entire diameter of the intestine.
With strangulation obstruction, a symptom of "fingerprints" can be detected.

Mechanical colonic obstruction usually occurs on the basis of obstruction of the lumen by a tumor; most common cause colonic obstruction is colorectal cancer. The leading clinical signs of colonic obstruction are stool retention, flatulence and bloating. Clinical symptoms appear later than with small bowel obstruction.
With obstruction of the colon, Kloiber's cups are less common; more often there is a sharp suprastenotic swelling of the intestine.
With the retrograde introduction of a water-barium suspension or air, it is possible to establish the level of the obstacle, as well as determine the nature of the obturating tumor, often a filling defect with uneven contours or its shadow against the background of the injected air is detected.

invagination called the introduction of the proximal part of the intestine into the distal. Distinguish between intestinal, small intestine-colon (ileocecal) and colon intussusception. The most common is ileocecal intussusception.
Plain radiographs of the abdomen in the acute stage of proximal or distal small bowel obstruction show swollen loops with fluid levels. In ileocecal intussusception, there is a lack of gas in the caecum and ascending colon. A valuable method for diagnosing intussusception of the large intestine is a contrast enema, which can be both a medical procedure. During barium enema, the following signs can be detected: a filling defect of a semicircular shape, the morphological display of which is an invaginated intestine, a symptom of a bident and a trident, a symptom
cockades.

Volvulus.
When volvulus, a segment of the intestine (small, blind or sigmoid) rotates around its own axis, while the blood circulation of the intestine is disturbed. Complete cessation of blood supply to the intestine quickly leads to the development of gangrene, followed by perforation and the development of peritonitis. The most common cause of bloat is the ingestion of large amounts of indigestible food after fasting. A predisposing factor leading to volvulus is a long mesentery with a narrow root. Early diagnosis of volvulus is critical to disease prognosis. The overall picture depends on the level of volvulus: volvulus of the small intestine is manifested by a picture of high, and ileocecal volvulus - by a pattern of low obstruction.
With a high volvulus, a survey radiograph shows swelling of the stomach and duodenum. The small intestine contains a lot of fluid and little gas. In the pictures taken in the vertical position of the patient and in the later position, fluid levels are visible. In subacute obstruction, a water-soluble contrast agent is used to determine the level of obstruction. The contrast mass stops at the level of bowel obstruction. However, according to the contrast study, the level of obstruction can be determined in no more than 50% of cases.
When volvulus of the caecum occurs a significant expansion of the segment above the torsion. In this case, the stretched segment is displaced to the left mesogastric and epigastric region.
For volvulus of the sigmoid colon, the symptom of a "car tire" is characteristic. It appears with a significant expansion of the intestinal loops above the torsion. At the same time, the intestine swells sharply, taking the form of an inflated chamber, divided by a central septum. Some researchers compare this picture with the shape of a coffee bean, divided by a partition into two parts. With retrograde filling of the intestine with a contrast enema, the section of the intestine below the obstruction takes on the appearance of a bird's beak. When turning clockwise, the beak is directed to the right, when turning the intestine counterclockwise - to the left.

Recognition of bowel diseases is based on clinical, radiological, endoscopic and laboratory findings. An increasing role in this complex is played by colonoscopy with biopsy, especially in the diagnosis early stages inflammatory and tumor processes.

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

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

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

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 on the pictures, then retrograde filling of the colon with barium suspension can be done. Swollen intestinal loops with small bowel obstruction occupy mainly the central parts of the abdominal cavity, and the caliber of each loop does not exceed 4–8 cm. Against the background of swollen loops, transverse striation is visible, due to expanded circular (kerkring) folds. Of course, there are no gaustral retractions on the contours of the small intestine, since they occur only in the large intestine.

With obstruction of the colon, there are huge swollen loops with high gas bubbles in them. The accumulation of fluid in the intestine is usually small. On the contours of the intestine, gaustral retractions are outlined, arched rough semilunar folds are also visible. By injecting a contrast suspension through the rectum, it is possible to clarify the location and nature of obstruction (for example, to detect a cancerous tumor that led to a narrowing of the intestine). We will only point out that the absence of radiological signs does not exclude intestinal obstruction, since in some forms of strangulation obstruction, the interpretation of the radiological picture can be difficult. In these cases, sonography and computed tomography are of great help. 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 blockage of the superior mesenteric artery, there are accumulations of gas and fluid 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 directed transcatheter administration of vasodilators and fibrinolytics. Rational research tactics are presented in the diagram below.

At partial obstruction re-examination after 2-3 hours is of great benefit. It is acceptable to introduce a small amount of a water-soluble contrast agent through the mouth or nasojejunal probe (enterography). With volvulus of the sigmoid colon, valuable data is obtained with barium enema. With adhesive obstruction, they resort to x-ray examination in different positions of the patient, registering areas of fixation of intestinal loops.

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

As can be seen in the diagram, it is advisable to start an X-ray 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), detection of stones in the appendix and its fixation, accumulation of fluid near the wall of the appendix and the caecum, hypoechoic image of the abscess, impression from the abscess on the intestinal wall, hyperemia periappendicular tissues (with Doppler sonography).

The main radiographic signs of acute appendicitis: small accumulations of gas and fluid in the distal ileum and in the cecum as a manifestation of their paresis, thickening of the wall of the caecum due to its edema, thickening and rigidity of the mucosal folds of this intestine, stones in the appendix, small effusion in the abdominal cavity, swelling of the soft tissues of the abdominal wall, blurring of the outlines of the right lumbar muscle. Appendicular abscess causes darkening in the right iliac region and depression on the wall of the caecum. Sometimes a small accumulation of gas is determined in the abscess and in the projection of the process. When the process is perforated, there may be small bubbles of gas under the liver.

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

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

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

Enterocolitis. In acute enterocolitis of various etiologies, similar symptoms are observed. Small bubbles of gas appear in the intestinal loops with short liquid levels. The promotion of the contrast agent is uneven, there are separate accumulations of it, between which constrictions are observed. The mucosal folds are thickened or not differentiated at all. For all chronic enterocolitis, accompanied by a syndrome of malabsorption (malabsorption), common signs are characteristic: expansion of intestinal loops, accumulation of gas and liquid in them (hypersecretion), separation of the contrast mass into separate lumps (sedimentation and fragmentation of the contents). The passage of the contrast medium is slow. It is distributed unevenly over the inner surface of the intestine, small ulcerations can be seen.

Malabsorption. With it, the absorption of various components of food is disturbed. The most common diseases of the sprue group. Two of them - celiac disease and non-tropical sprue - are congenital, and tropical sprue - acquired. Regardless of the nature and type of malabsorption, the x-ray picture is more or less the same: the expansion of the loops of the small intestine is determined. They accumulate fluid and mucus. Because of this, the barium suspension becomes inhomogeneous, flocculates, divides into fragments, turns into flakes. The folds of the mucous membrane become flat and longitudinal. In a radionuclide study with trioleate-glycerol and oleic acid, malabsorption in the intestine is established.

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 in the course of the disease. In the first stage, thickening, straightening and even disappearance of folds of the mucous membrane and superficial ulceration are noted. The contours of the intestine become uneven, jagged. Then, instead of the usual pattern of folds, multiple rounded enlightenments are found, due to islands of the inflamed mucous membrane. Among them, strip-like shadows of barium deposited in transverse cracks and slit-like ulcers can stand out. In the affected area, the intestinal loops are straightened, narrowed. In the second stage, there is a significant narrowing of the intestinal loops with the formation of cicatricial constrictions from 1-2 to 20-25 cm long. In contrast to the syndrome of impaired absorption, there is no diffuse expansion 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, which are drained under radiation control.

Tuberculosis of the intestine. Most often, the ileocecal angle is affected, but already in the study of the small intestine, thickening of the mucosal folds, 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). In the future, the intestinal loop shrinks with a decrease in its lumen and limitation of displacement due to adhesions.

Nonspecific ulcerative colitis. In mild forms, thickening of the mucosal folds, pinpoint accumulations of barium, and fine serrations of the intestinal contours as a result of the formation of erosions and small ulcers are noted. severe forms characterized by narrowing and rigidity of the affected parts of the colon. They stretch a little, do not expand with the retrograde introduction of a contrast mass. Gaustration disappears, the contours of the intestine become finely serrated. Instead of mucosal folds, granulations and accumulations of barium appear in ulcerations. The distal half of the large intestine and the rectum are mainly affected, which is sharply narrowed in this disease.

Colon cancer. Cancer occurs as a small mucosal thickening, plaque, or polyp-like flat mass. On radiographs, a marginal or central filling defect is determined in the shadow of the contrast mass. Mucosal folds in the area of ​​the defect are infiltrated or absent, peristalsis is interrupted. As a result of tumor tissue necrosis, an irregularly shaped barium depot may appear in the defect - a display of ulcerated cancer. As the tumor grows further, mainly two variants of the radiographic picture are observed. In the first case, a tuberous formation is revealed, 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 can clarify the degree of invasion of the intestinal wall and adjacent structures. In particular, endorectal sonography is valuable in rectal cancer. Computed tomography makes it possible to assess the condition lymph nodes in the abdominal cavity.

benign tumors. About 95% benign neoplasms intestines are 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 have a stalk (stem). On x-ray examination, these polyps cause filling defects in the shadow of the intestine, and with double contrasting, additional rounded shadows with even and smooth edges.

Villous polyps on x-ray look a little different. A filling defect or an additional shadow with double contrasting have uneven outlines, the surface of the tumor is unevenly covered with barium: it flows between the convolutions, into the grooves. However, the intestinal wall retains elasticity. Villous tumors, in contrast to adenomatous polyps, often become malignant. Malignant degeneration is indicated by 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.

Sharp belly.

Causes of the syndrome acute abdomen varied. For the establishment of an urgent and accurate diagnosis, anamnestic information, results of a clinical examination and laboratory tests. X-ray examination is used if necessary to clarify the diagnosis. As a rule, it begins with an x-ray of the chest cavity, since the syndrome of an acute abdomen may be the result of irradiation of pain when the lungs and pleura are affected ( acute pneumonia, spontaneous pneumothorax, supraphrenic pleurisy).

Then, an x-ray of the abdominal organs is performed in order to recognize perforated pneumoperitoneum, intestinal obstruction, kidney and gallstones, calcifications in the pancreas, acute gastric volvulus, strangulated hernia, etc. However, depending on the organization of admission of patients in medical institution and the expected nature of the disease, the order of examination can be changed. At the first stage, an ultrasound examination can be carried out, which in some cases will allow us to limit ourselves to x-rays of the chest organs in the future.

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