X-ray diagnosis of acute intestinal obstruction. Diagnosis of acute intestinal obstruction

During the study of the abdomen of patients with suspected acute intestinal obstruction abdominal wall most often it is soft. At 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, it is possible to determine a tympanic sound with a metallic tinge (Kivul's symptom) with percussion. In the later stages of the disease, with a strong stretching of the intestine, the abdominal wall may 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. General state patients with acute intestinal obstruction changes as the disease progresses. At the onset of the disease, body temperature remains normal or reaches only subfebrile figures. 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 cardiovascular system is the first to react. Tachycardia is often ahead of the temperature reaction. Increasing toxicity leads to respiratory failure and neuropsychiatric disorders. Developing dehydration is manifested by a decrease in diuresis, dryness of the 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, the clinical picture of the disease is dominated by pain 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 the purpose of early diagnosis of obstruction of the colon, clarification of 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 x-ray 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, it makes special sense differential diagnosis these forms of intestinal obstruction.

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 of 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

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Intestinal obstruction is a violation of the passage of intestinal contents.

I. Etiology

Distinguish between mechanical and functional reasons intestinal obstruction (Table 1). Mechanical obstruction is more common and usually requires surgical intervention. In 70-80/6 cases it is due to obstruction small intestine, at 20-3096 - thick. In old age, with an increase in the frequency of tumor diseases and diverticulosis of the colon, the frequency of colonic obstruction also increases.

A. Pathology of the peritoneum, abdominal organs and abdominal walls.

The most common cause of small bowel obstruction is adhesions that form after hernia repair and operations on the abdominal organs. Adhesive obstruction often complicates surgical interventions on ground floor abdominal cavity. In developing countries, among the causes of obstruction, the first place is occupied by infringement of the external hernia of the abdomen. Volvulus - pathological torsion of the intestinal loop. The most common volvulus of the sigmoid (70-80% of cases) and caecum (10-20%). inversion sigmoid colon observed with an excessively long mesentery (dolichosigma); constipation is often a provoking factor. Volvulus of the caecum is possible with a congenital violation of its fixation (mobile caecum). predispose to volvulus of the colon mental disorders, old age and a sedentary lifestyle. A loop of the small intestine may twist around an adhesion or a congenital band of the peritoneum. When the small intestine is infringed at two points at once (adhesions or hernial gates), an “off” intestinal loop is formed. Sometimes the cause of obstruction is a large mass formation, squeezing the large or small intestine from the outside.

B. Intestinal pathology.

Among the diseases of the intestine that cause its obstruction, the most common are tumors. Tumors of the colon are more common than tumors of the small intestine. In 50-70% of cases, colonic obstruction is due to cancer; in 20% of patients, colon cancer first manifests itself as acute intestinal obstruction. Intestinal obstruction is typical for the localization of the tumor in the left half of the colon. Volvulus and diverticulitis are also more likely to affect the left side of the colon and are the second most common cause of colonic obstruction.

Table 1 Causes of bowel obstruction

In newborns, intestinal obstruction in most cases is due to atresia. Atresia of the esophagus, anus and rectum are more common than atresia of the small intestine. Of the other causes of obstruction in newborns, in descending order of frequency, there are: Hirschsprung's disease, incomplete intestinal rotation (Ladd's syndrome), and meconium ileus.

B. Bowel obturation.

Intestinal obstruction may be due to swallowed or injected anus foreign body. Less common is obstruction of the colon with fecal stones and barium suspension; even less often - gallstone obstruction. A gallstone that has passed into the intestinal lumen usually gets stuck in the region of the ileocecal valve.

D. Paralytic ileus develops in almost every patient who has undergone abdominal surgery. Of the other causes, pancreatitis, appendicitis, pyelonephritis, pneumonia, fractures of the thoracic and lumbar spine, electrolyte disturbances. The list of causes of paralytic ileus is presented in table.2.

D. Spastic obstruction is extremely rare - in case of poisoning with salts of heavy metals, uremia, porphyria.

E. Hirschsprung's disease (congenital agangliosis of the colon) in newborns and children in the first months of life can be complicated by intestinal obstruction.

G. Pseudo-obstruction of the intestine - chronic illness, characterized by impaired motility of the gastrointestinal tract (usually the small intestine, less often the large intestine and esophagus). Attacks of the disease occur with a bright clinic of mechanical obstruction, which is not confirmed either radiographically or during surgery. Sometimes the disease is familial, sometimes combined with autonomic neuropathy or myopathy. However, in most cases the cause cannot be determined. When making a diagnosis, it is necessary to rely on radiographic data, sometimes a diagnostic laparotomy is necessary. Timely differential diagnosis can reduce mortality and the severity of complications of mechanical intestinal obstruction.

Table 2 Causes of paralytic ileus

Z. Acute disorders of the mesenteric circulation.

Occlusion of the mesenteric artery may be the result of an embolism or progressive atherosclerosis; it accounts for 75% of cases of obstruction due to acute disorders circulation. Mesenteric vein thrombosis accounts for the remaining 25%. Thrombosis of the mesenteric veins often develops against the background of reduced perfusion. All types of acute circulatory disorders can lead to intestinal necrosis and are accompanied by high mortality, especially among the elderly.

II. Pathogenesis

A. The accumulation of gas in the intestine is the leading symptom of intestinal obstruction. Violation of the passage of intestinal contents is accompanied by an intensive growth of aerobic and anaerobic bacteria that form methane and hydrogen. However, most of the intestinal gas is swallowed air, the movement of which through the intestines is also disturbed.

Normally, the glands of the gastrointestinal tract secrete about 6 liters of fluid per day, most of which is absorbed in the small and large intestine. Stretching of the intestinal loops with obstruction further stimulates secretion, but inhibits absorption. The result is vomiting, which leads to loss of fluid and electrolytes. Hypokalemia and metabolic alkalosis develop.

B. Mechanical obstruction of the intestine, in which blood circulation in the intestinal wall is disturbed, is called strangulation. This can occur when the intestine or its mesentery is infringed, and also when the pressure in the lumen of the intestine exceeds the intravascular pressure. As a result, ischemia, necrosis and perforation of the intestine develop. Early diagnosis of strangulation obstruction and urgent surgical intervention can prevent intestinal perforation, reduce the severity of the disease and reduce mortality. Preoperative preparation should be quick and include correction of fluid and electrolyte disturbances.

B. Obstructive obstruction of the colon in cancer and diverticulitis is rarely accompanied by circulatory disorders. The exception is when the function of the ileocecal valve is preserved. In this case, the colon continues to stretch until perforation occurs. According to Laplace's law, the tension of the tube wall is directly proportional to its radius and internal pressure. Perforation occurs more frequently in the caecum, which has the largest radius and hence is subject to greater distension than other parts of the colon. If the diameter of the cecum exceeds 10-12 cm, the probability of perforation is especially high.

III. Clinical picture

The clinical picture depends on the type of intestinal obstruction and the level of obstruction (Table 3). The main symptoms are nausea, vomiting, abdominal pain, bloating, stool and gas retention. Symptoms of peritoneal irritation are a sign of necrosis or perforation of the intestine. Leukocytosis (or leukopenia), fever, tachycardia, localized tenderness on palpation of the abdomen indicate an extremely serious condition of the patient (especially if all four signs are present).

On physical examination, pay attention to postoperative scars and strangulated hernia, sometimes this allows you to immediately diagnose. Be sure to conduct a rectal examination (fecal stones) and analysis of feces for occult blood. Blood in the stool may be due to Crohn's disease, malignant tumor, bowel necrosis or diverticulitis. If an enlarged liver with a bumpy surface is palpated, a metastatic tumor can be assumed. Auscultation of the lungs reveals pneumonia - one of the causes of paralytic ileus.

IV. X-ray examination

If bowel obstruction is suspected, first of all, a survey radiography of the abdominal cavity (standing and lying on the back) and chest (posterior, non-anterior and lateral projections) is performed. A chest x-ray can rule out pneumonia. A CT scan of the abdomen can determine the level and cause of bowel obstruction.

Table 3. Clinical picture at various types bowel obstruction

Table 4. Radiographic signs of intestinal obstruction

A. Abdominal radiographs show accumulation a large number gas in the intestinal lumen (Fig. 1). It is usually possible to determine from the pictures whether the loops of which intestine - small, large, or both - are stretched by gas. In the presence of gas in the small intestine, spiral folds of the mucous membrane are clearly visible, occupying the entire diameter of the intestine (Fig. 2). With the accumulation of gas in the colon, haustra are visible, which occupy only part of the diameter of the intestine (Fig. 3).

B. With mechanical small bowel obstruction in the colon, there is little or no gas at all. With colonic obstruction and intact function of the ileocecal valve, significant swelling of the colon is noted, gas may be absent in the small intestine. Ileocecal valve insufficiency leads to distention of both the small and large intestines.

B. On radiographs obtained in a standing position or lying on one side, horizontal levels of liquid and gas are usually visible. Gas-filled intestinal loops have the appearance of inverted bowls (Cloiber's bowl) or arches, similar to the inverted letters J and U. Distinguishing paralytic ileus from mechanical small bowel obstruction using plain fluoroscopy can be quite difficult (Table 4). This requires a radiopaque study of the firebox (with the rapid introduction of barium or water-soluble contrast into the jejunum through a gastric tube). If colonic obstruction is suspected, radiopaque studies are contraindicated.

V. Treatment

A. Mechanical obstruction of the intestine, as a rule, requires urgent surgical intervention. The duration of the operation is determined by the severity of metabolic disorders, the duration of occurrence and the type of obstruction (if strangulation obstruction is suspected, the operation cannot be postponed). In the preoperative period, infusion therapy and correction of water and electrolyte disorders are carried out, and intestinal decompression is started through a nasogastric or long intestinal tube. Antibiotics are prescribed, especially if strangulation ileus is suspected.

B. The operation may be delayed in the following cases:

1. If intestinal obstruction develops early postoperative period, carry out bowel decompression using a nasogastric or long intestinal tube. After some time, adhesions can resolve, and intestinal patency is restored.

2. In case of peritoneal carcinomatosis, they try to avoid surgery and decompress the intestine through a nasogastric tube. Usually, intestinal patency is restored within three days. If the bowel obstruction in such patients is not due to a tumor, but to another cause, surgical intervention can significantly improve the condition.

3. Bowel obstruction during an exacerbation of Crohn's disease can be resolved with drug treatment and bowel decompression through a nasogastric or long bowel tube.

4. With intestinal intussusception in children, it is possible conservative treatment: observation and careful attempts to spread the intussusceptum using hydrostatic pressure (barium enemas). In adults, this method is not applicable because it does not eliminate the underlying disease that caused the intussusception; urgent surgical intervention is indicated.

5. With chronic partial obstruction Intestinal and radiation enteritis surgery can be delayed only if there is no suspicion of strangulation obstruction.

B. The type of operation is determined by the cause of obstruction, the condition of the intestine and other operational findings. Dissection of adhesions, herniotomy with plasty of the hernia ring (with internal and external hernias of the abdomen) are used. In case of mass formations covering the intestinal lumen, it may be necessary to create a bypass interintestinal anastomosis, to apply a colostomy proximal to the obstruction, or to resect the intestine with subsequent restoration of intestinal continuity.

There is still no consensus on the optimal tactics for the treatment of recurrent small bowel mechanical obstruction. Two methods have been proposed: splinting of the small intestine with a long intestinal tube and enteroplication.

Editorial

Rice. 1. Scheme of gas accumulation in the intestinal lumen in various types of intestinal obstruction.

Small bowel obstruction (high obstruction) - pathological condition, in which the evacuation of contents through the small intestine is disturbed. This state diagnosed in patients quite often. Many adverse factors, both external and internal, can provoke blockage of the intestine. Obstruction of this type refers to emergency conditions. This suggests that assistance to the patient should be provided as soon as possible, since otherwise development is possible. serious complications or even death.

Obstruction of the small intestine is expressed by signs such as bloating, impaired discharge stool, nausea and vomiting. In the vomit in this disease, particles of food eaten the day before are noted (fecal vomiting is usually observed with colonic obstruction). If such signs are expressed, the patient should be immediately taken to medical institution to conduct a comprehensive diagnosis and determine further treatment tactics.

The diagnosis of "acute small bowel obstruction" is made on the basis of a visual examination of the patient, as well as the results of laboratory and instrumental diagnostics. The most diagnostic value is instrumental examinations, as they make it possible not only to confirm the diagnosis, but also to accurately identify the site of blockage in the small intestine. Abdominal radiography, ultrasound examination, computed tomography are usually prescribed.

Treatment of small bowel obstruction in most clinical situations is only surgical. Conservative methods of effect do not give. A laparotomy is performed, during which surgeons restore the patency of the small intestine.

Causes of development and types

Clinicians divide small intestinal obstruction into three types, depending on what causes provoked its manifestation in a sick person. Based on this, obstruction happens:

• intraluminal. In this case, the cause of intestinal blockage lies directly in its lumen. This condition can be caused foreign bodies, which entered the intestine through the upper sections of the digestive tract, gallstones that form in a person with the progression of his cholelithiasis. It is worth noting that this type of disease is diagnosed not only in people from the middle and older age groups, but also in young children (careless swallowing of objects);
• intraparietal. In this case, the cause of small bowel obstruction is the formation of neoplasms of a benign or malignant nature in the walls of the organs. In addition, as causative factor also secrete inflammatory strictures and hematomas. If there is a neoplasm benign, then the treatment of pathology is not difficult. When diagnosing small bowel obstruction, provoked by a cancerous tumor, a resection of a section of the small intestine is required, as well as additional radiation and chemotherapy;
• outdoor. This type of pathology will differ in that the reason for its development lies not in the human intestine itself, but outside it. The main factors contributing to the progression of the disease include the formation of hernias, adhesions after previous operable interventions, and carcinomatosis. The tactics of treatment directly depends on what exactly provoked the blockage of the intestine.

Development mechanism

With partial or complete occlusion of the small intestine, fluid and gases begin to gradually accumulate in the lumen of the organ, localizing at the same time proximal to the place of its anatomical narrowing. A lot of air can accumulate in the intestines - some of it comes with food, and some is produced by the organ itself. This causes one of the symptoms of obstruction - bloating. As a result, the walls of the intestine gradually stretch and the pressure in it increases. During this period, the epithelium, which sent the intestinal lumen from the inside, begins to intensively absorb fluid. All these processes lead to the fact that the natural process blood circulation in the organ, thereby provoking ischemia and necrosis of a certain area.

Unlike partial obstruction, complete obstruction is a very dangerous and emergency condition. Tissue necrotization develops in a short period of time, therefore, assistance should be provided to a person as soon as possible. Differentiation is carried out with an attack of acute appendicitis, acute pancreatitis, renal colic and ectopic pregnancy.

With partial obstruction, only a certain part of the lumen is blocked, which makes it possible for both gases and intestinal contents to gradually move through it. In this case, the symptoms develop gradually, and there is no such intensity in the expression characteristic features. It is also worth noting that a violation of blood microcirculation in the body is not always observed.

Symptoms

In a person with obstruction, the symptoms can be very pronounced, but their intensity can also increase and gradually. It all depends on what exactly provoked the pathology, and how much the lumen in the intestine is blocked. Regardless of the type of obstruction, the patient experiences the following symptoms:

• intense pain syndrome. The pain is very strong and forces a person to take a forced position in order to alleviate it. As a rule, it has a cramping character. During an attack, a person groans, and his face is distorted from unbearable pain. During this period, he may have some symptoms that indicate the gradual development of shock. These include hypotension cardiopalmus, profuse cold sweating, pallor skin. After a while, the pain may subside and then reappear. An alarming symptom is that the pain syndrome disappeared for long time- this may indicate a violation of blood microcirculation in the intestine and the development of necrosis. If assistance is not provided, peritonitis will occur;
• nausea and vomiting. With small bowel obstruction, vomiting is profuse and particles of food that a person has consumed the day before are visible in the vomit. Sometimes there may be vomiting of bile. Fecal vomiting with this type of pathology is not observed, since the upper intestines are affected;
• impaired excretion of feces and gases. It is worth noting that with small bowel obstruction, this symptom may not be present if the intestine is only partially blocked. But in most cases, the patient has persistent constipation. Intestinal peristalsis is disturbed.

When such signs are expressed, the patient is immediately hospitalized in a medical facility for diagnosis and the appointment of the most effective treatment tactics.

Diagnostic measures

First of all, the doctor conducts an examination of the patient, as well as his questioning. To important details, according to which the doctor may suspect small bowel obstruction, include previous operations on organs located in the abdominal cavity, as well as the presence of an underlying disease (for example, inflammatory bowel disease or neoplasms of a benign or malignant nature). Next, the doctor signs a plan of diagnostic measures, which usually includes:

Treatment

Treatment of intestinal obstruction consists of several stages. The first is the replenishment of the water balance. Due to the fact that with obstruction, the intravascular volume of fluid decreases, it must be replenished. Isotonic solutions are given through a vein. In addition, at this time, antibacterial drugs can be included in the therapy plan. medicines, which will help reduce the risk of developing infectious complications with such an ailment.

The second stage is the removal of accumulated contents from the digestive tract with the help of nasogastric tube. And the third stage is the direct operable intervention, represented by laparotomy. The blockage is eliminated and the functioning of the intestines is normalized. If there are areas of necrosis, then they are resected.

Similar content

Dynamic intestinal obstruction (functional intestinal obstruction) is a disease that consists in a significant decrease or complete cessation of the activity of the affected organ without a mechanical obstacle to progress. During the development of the disease, stagnation of the intestinal contents is often observed. Among other forms of intestinal obstruction, this occurs in every tenth patient. It affects people of any age group, so it is often diagnosed in children.

Intestinal obstruction (intestinal obstruction) is a pathological condition that is characterized by a violation of the movement of contents through the intestines, provoked by a failure in the process of innervation, spasms, obstruction or compression. It is worth noting that this disease is not an independent nosology - it usually progresses against the background of other pathologies of the gastrointestinal tract. The causes of intestinal obstruction are quite diverse.

Paralytic ileus is a pathological condition that is characterized by a gradual decrease in the tone and peristalsis of the human intestinal musculature. This condition is extremely dangerous, because without timely diagnosis and proper treatment, complete paralysis of the organ can occur. Paralytic ileus is more often diagnosed in persons from the middle and older age categories. Restrictions regarding gender or age category, the disease has no.

Obstructive intestinal obstruction is a pathological condition that is characterized by a violation of the movement of contents through the intestine due to compression of the mesentery. It develops due to partial or total overlap of the intestinal lumen. Factors that contribute to the development of obstructive obstruction can be both internal and external. It is also worth noting that, depending on the root cause, the most effective treatment plan will be prescribed. As a rule, obstructive intestinal obstruction is eliminated surgically.

Strangulation intestinal obstruction - a violation of the functioning of the digestive tract, which is characterized not only by blockage of the intestine, but also by compression nerve fibers and mesenteric vessels. This pathological condition is very dangerous, because acute form an illness in a short period of time can be complicated by necrotization of certain parts of the organ, due to a violation of blood circulation in them. In medicine, cases are known when, within twelve hours from the primary expression clinical signs the person was dying.

SURGICAL GASTROENTEROLOGY

surgical gastroenterology

X-RAY DIAGNOSTICS OF PARTIAL INTESTINAL OBSTRUCTION IN DISEASES OF THE SMALL INTESTINE: A LOOK AT THE PROBLEM OF A RADIOLOGIST-GASTROENTEROLOGIST

Levchenko S.V., Kotovshchikova A.A., Orlova N.V.

Central Research Institute of Gastroenterology, Moscow

Levchenko S.V.

Email: [email protected]

The article is devoted to the peculiarities of the method of X-ray examination in the clinical picture of "acute abdomen" and X-ray semiotics of some diseases of the small intestine as a cause of partial intestinal obstruction. Own clinical observations are presented. The long-term experience of the X-ray department of the Central Research Institute for the study of the possibilities of a survey X-ray examination of the abdominal cavity and a contrast study of the small intestine with symptoms of intestinal obstruction is summarized.

The article is devoted to special features of X-ray examining of patients suffering from acute abdomen pain and X-ray paradigma of some intestine diseases as a cause of partial bowel obstruction. Own clinical data are presented. Long-term experience of our X-ray department is summarized. The possibilities of X-ray examining of abdomen with and without contrast in patients with partial bowel obstruction are described.

The authors are sincerely thankful to our Teacher Aleonor S.Sivash

Mechanical or functional obstruction of the small intestine is the most common cause of "acute abdomen" in a gastroenterological clinic. Stasis of the contents over the pathological area indicates narrowing, obstruction or compression of the intestine, but may also be due to dynamic causes: paresis or a reflex reaction. The etiology and manifestations of small bowel obstruction differ from colorectal obstruction. The most common causes of small bowel obstruction are related to previous surgery (75%), other causes include developmental anomalies and Crohn's disease (CD). Small intestine CD is one of the most difficult diseases to diagnose. Difficulties arise from the erased clinical picture(before the development of complications) and the lack of a full-fledged x-ray examination, as well as due to underestimation radiological signs

in the initial stages of the disease or disorders during the study.

If obstruction is suspected, the first X-ray examination is a plain radiograph of the abdominal cavity. Before the advent modern technologies(ultrasound method, X-ray computed tomography, angiography, etc.), widely used in the diagnostic process for emergency conditions at present, for many decades, the main method has remained radiological, and, in particular, a survey radiological examination of the abdomen in the vertical and horizontal position of the patient, as well as in lateroposition. At the same time, the horizontal position of the patient makes it possible to better study the degree of expansion of the intestinal loops and exclude toxic dilatation of the colon. A feature of the study of patients with the clinical picture "acute abdomen"

is the need to identify radiological signs characteristic of acute illness of one or another organ of the abdominal cavity, as soon as possible in a sparing mode for the patient. I would like to emphasize that the survey radiograph of the abdominal cavity, along with the ultrasound method and X-ray computed tomography is still relevant. The radionuclide method and magnetic resonance imaging have not yet become widely used in the study of patients in urgent situations.

Despite the huge amount of literature devoted to radiodiagnosis in " acute abdomen”, the interpretation of the plain radiograph is not as simple as it is commonly believed. Clinicians look at it easily, from their point of view, the clinical suspicion of obstruction is confirmed when fluid levels are determined in the small intestine. For the radiologist, the value of this symptom is important, but should be questionable and the need for a balanced assessment, since this is not an absolute sign of obstruction.

A number of circumstances should be borne in mind: 1) obstruction may be without visible fluid levels, when gas has not yet accumulated or intra-abdominal pressure is so high (particularly with ascites) that accumulation of gas is very slow or even impossible; 2) the formation of fluid levels may be due to the presence of gas and a small amount of fluid in the gastrointestinal tract in patients with diarrhea and malabsorption due to hypersecretion and malabsorption; 3) even the presence of fluid levels in combination with the expansion of intestinal loops is not enough to conclude small bowel obstruction. The cause of this picture may be drug-induced hypotension, developmental anomalies, pseudo-obstruction, Neish syndrome (N13b), amyloidosis, scleroderma, and most often severe celiac disease. The fact remains that the practical radiologist should know that obstruction is characterized by the expansion of intestinal loops filled with large amounts of gas, only if the diseases listed above are excluded.

METHOD OF X-RAY EXAMINATION AND INTERPRETATION OF X-RAY SYMPTOMS IN SUSPECTED SMALL INTESTINAL OBSTRUCTION

The technique of survey polypositional X-ray examination consists in the production of a direct anterior image of the abdominal cavity - at a vertical stand, a direct posterior image of the abdominal cavity - on a table for pictures or on a gurney, laterograms - when the patient is positioned on the left side - on a table for pictures or at a vertical stand ( if necessary - laterogram

and on the right side). The main condition that must be observed when taking pictures of the abdominal cavity is obligatory receipt on the picture, images of all parts of the abdominal cavity (both domes of the diaphragm, both lateral canals and the cavity of the small pelvis).

The classic signs of small bowel obstruction are early stages disease is the predominance of gas over liquid, while the arches are "steep", and their number depends on the level of the obstacle: the lower the obstacle, the greater the number of arches. In addition, in the early stages, Kerkring's folds of moderately dilated intestinal loops with clear contours are clearly visible in the form of a "spring" (Fig. 1).

With the progression of the process, the amount of fluid in the lumen of the loops increases, the arches gradually become more gentle; separate "bowls" of Kloiber appear with a short liquid level, indicating the preservation of the tone of the intestinal wall.

At this stage, it is very important to remember the possibility of a discrepancy between the severity of radiological signs and the not very bright clinical picture of obstruction (the so-called "scissors" symptom).

With further accumulation of fluid in the lumen of the loops, the differentiation of the folds of the mucous membrane disappears; liquid prevails over gas; the small bowel arches disappear and only Kloiber's "bowls" with a wide horizontal liquid level and a low gas bubble above it are revealed (Fig. 2).

Nota bene! On the later dates intestinal obstruction due to a significant accumulation of fluid in the intestinal lumen of the "bowl" of Kloiber may disappear, a symptom of "pearl" appears, when only small accumulations of gas in the form of a chain of small bubbles are detected on the radiograph (Fig. 3).

This picture can be regarded as a false positive by inexperienced clinicians and radiologists.

In the absence of contraindications, the next main step should be a contrast study of the small intestine, if necessary - probe enterography, supplemented by drug hypotension (Fig. 4).

Portion intake of 200-400 ml of barium suspension allows most patients to evenly fill the entire small intestine, and the production of images after 30, 60, 120 and 180 minutes with minimal radiation exposure to the patient makes it possible to obtain maximum information about all parts of the small intestine. In the case of partial intestinal obstruction, a contrast study reveals the level of the obstruction, the degree of prestenotic expansion, and often the extent and nature of the intestinal lesion (Fig. 5).

The duration of the x-ray examination can increase up to 6, 12, 24 hours. Among

patients of TsNIIG the most common causes partial intestinal obstruction were abdominal adhesive disease and Crohn's disease.

Obstruction of the small intestine in CD, requiring surgical intervention, occurs, according to the literature, in 13-15% of cases. Under our supervision for 10 years (2001-2011) in the Department of Intestinal Pathology of the Central Research Institute of Human Resources, there were 126 patients with CD of the small intestine aged from 23 to 77 years. Approximately half of patients (53%)

the disease was diagnosed at the age of 23 to 30 years. In 82.5%, the diagnosis was established within 2 to 7 years from the onset of clinical symptoms. In 36 patients (30%), an acute form of CD was observed. 30 patients with small bowel obstruction caused by CD of the small intestine were operated on. Resection of the terminal ileum was performed in 17 patients, segment of the ileum and jejunum - in 9 patients, resection of the ileum and right-sided hemicolectomy - in 4 patients. The problem arises when the disease reaches the stage of stenosis. The degree of obstruction may decrease after conservative therapy, including specific anti-inflammatory drugs and corticosteroids. However, attacks of obstruction may recur, especially in patients with multiple strictures on the background of fibrosis and thickening of the intestinal wall.

Preoperative x-ray examination allows for a differential diagnosis with other diseases, in CD to establish the degree of narrowing, extent, upper limit, to exclude the "jumping" nature of the bowel lesion, i.e., the presence of changes in other departments, alternating with normal areas. After resection with progression of CD

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Rice. 1. Multiple "steep" small bowel arches predominantly in the upper abdominal cavity, the loops are moderately stretched, the Kerckring folds are preserved, gas prevails over the liquid: small bowel obstruction

Rice. 2. Multiple wide levels of fluid, mucosal folds are not differentiated (smoothed), fluid prevails over gas: Kloiber's "cups". Progressive small bowel obstruction

Rice. 3. Single small accumulations of gas in the projection of the proximal loops of the small intestine, the absence of gas in the colon: the x-ray picture is suspicious for intestinal obstruction

Rice. 4. In a contrast study, signs of impaired patency of the small intestine (single levels of fluid, moderate prestenotic dilatation of the middle loops of the small intestine up to 4-5 cm, fluid in the lumen of the small intestine)

Rice. 5. Short stricture in the terminal ileum with incomplete fistulous tracts and signs of partial small bowel obstruction (moderate prestenotic expansion): Crohn's disease III degree

Rice. 6. Probe enterography: adhesive disease of the abdominal cavity, intermittent small bowel obstruction (during compression (b), the loops are not divorced, fixed in the form of a "trefoil")

new strictures are formed, postoperative adhesions develop, which leads to relapses of obstruction.

Probe enterography allows you to metered and quickly introduce the required amount of contrast into the small intestine (up to 600-900 ml), while avoiding excessive overlapping of loops. If necessary, it is possible to introduce air through the probe and obtain a double contrast pattern. Drug hypotension (M-anticholinergics) allows a differential diagnosis between the organic stricture of the intestine and spastic "bridges", exclude the stricture and confirm the adhesive process as the cause of intermittent intestinal obstruction (Fig. 6).

On a specific clinical example, we want to demonstrate that gas and liquid levels in the small intestine are not always signs of patency disorders. In severe celiac disease with smoothness of the Kerkring folds, hypotension of the loops, and malabsorption syndrome, an x-ray pattern resembling intestinal obstruction is possible (Fig. 7).

Thus, it must always be remembered that the X-ray picture of dilated intestinal loops with fluid levels is not a pathognomonic sign of small bowel obstruction, while their absence does not exclude the presence of the latter in the patient. Only the cooperation of radiologists and clinicians with a comprehensive analysis of symptoms allows a correct diagnosis of the disease.

Rice. Fig. 7. An example of a false x-ray picture of small bowel obstruction in a patient with severe celiac disease (hypotonic loops with saccular dilatations imitate fluid levels during a non-contrast study, Kerckring's folds are not differentiated)

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