Intestinal obstruction syndrome
Bowel obstruction is a very common surgical emergency in abdominal emergencies, second only to appendicitis. There are many different causes of intestinal obstruction.
Intestinal obstruction is a syndrome caused by the cessation of circulation of digestive juices in the intestinal lumen. Intestinal obstruction due to mechanical obstructions from the Treitz angle to the anus is mechanical intestinal obstruction, intestinal obstruction caused by stopping peristalsis is a functional intestinal obstruction or intestinal obstruction due to paralysis.
Bowel obstruction is a very common surgical emergency in abdominal emergencies, second only to appendicitis. There are many different causes of intestinal obstruction. Symptoms, disorders of the body, site and acute degree vary depending on the mechanism of obstruction (due to constriction or obstruction), the site of obstruction (obstruction in the small intestine or colony). Diagnosis is sometimes difficult, although many modern diagnostic imaging facilities have been applied.
In the past few decades, with the progress of resuscitation anesthesia and the progress of surgery, the mortality and complications after bowel obstruction have improved significantly.
Cause and mechanism of obstruction
Mechanical intestinal obstruction:
Causes in the lumen of the intestine, in the small intestine:
Sticking roundworm, which causes intestinal obstruction, is a common cause in children and adults in rural areas, growing vegetables, and eating unhygienic foods.
Obstructions caused by food residues (bamboo shoots, fibrosis, myrtle ...) are found in the elderly, tooth loss, pancreatic failure or have had gastric bypasses.
Gallbladder stones cause inflammation, perforation in the duodenum and move down the intestine causing obstruction very rare in Vietnam.
In the colon:
The cause of the obstruction may be a tumor, stool in the elderly with prolonged constipation.
Causes in the intestinal wall:
In both the small and colon, obstructive bowel causes can be:
Cancers of the small intestine and colon, with the left most common cancer.
Benign tumors of the large intestinal wall can cause intestinal obstruction, but are uncommon.
Intestinal stenosis due to inflammation or scarring: Intestinal tuberculosis intestinal Chronosis, enteritis after radiation therapy, intestinal stenosis, intestinal stenosis after trauma.
Intestinal canal: Because the upper part of the intestine enters the lower intestine, there are many different types of cage such as ileum cage - ileum, anise cage - colon, cage - colon. Acute cages are common in nursing children, rarely in adults and often in combination with intestinal obstructive causes such as tumors, diverticula ...
Causes outside the intestinal wall:
Ligaments and ligaments of the bowel are the causes for the highest proportion. Of which, over 80% were due to abdominal surgery, the rest had inflammatory, traumatic and congenital origin. Ligaments or ligaments meet two loops of the intestine or attach a loop to the loss of the serosa in the abdominal wall, creating slits and one or more loops in, a stuffy taste at the base of the loops with the mesenteric Allergy causes anemia, necrosis as in a suffocating hernia.
Hernias including abdominal wall hernias (inguinal hernias, thigh hernias, umbilical hernias ...) and internal hernias: occlusive herniation, Winslow slit herniation, Treitz herniation, ...) can cause choking when the intestines enter these holes.
Intestinal twisting is the most severe case of obstructive bowel obstruction. A helix is defined as a twisted loop on its mesenteric shaft. In the small intestine, intestinal torsion is usually the result of an upper intestinal obstruction caused by ligaments attached to the top or legs of the loops. In the colon, intestinal torsion is usually spontaneous due to the long Sigma colon segment, the legs are close together, turned downwards (Sigma's torsion), the torsion of the cecum due to the right colon is not congenital, uncommon.
Thus, the causes of motorized intestinal obstruction can be classified into two groups according to the obstruction mechanism, which are the causes of intestinal obstruction by obstruction and the causes of intestinal obstruction due to constriction of the intestine along with the blood vessels of the corresponding mesenteric segment. This intestinal segment quickly anemia, necrosis.
Intestinal obstruction due to paralysis:
Intestinal obstruction due to paralysis, also known as functional intestinal obstruction accounts for about 5 - 10% of cases, there are many different causes:
Reflective bowel paralysis can occur in ureteral stones, first of all in river column trauma, pelvic rupture due to retroperitoneal hematoma. The causes of peritonitis, gastric perforation, pancreatic juice also cause intestinal paralysis.
Acute anemia and mesenteric venous thrombosis also paralyze peristalsis in the corresponding intestinal segment.
There are also many other triggers that damage the nerves and muscles of the gut and cause a pseudo-intestinal obstruction, including:
Metabolic disorders: Low blood potassium, hypercalcemia, metabolic acidosis.
Some drugs: Substances of opium, anticholinergic ...
Intestinal damage in systemic diseases: Diabetes, hypothyroidism, porphyrin metabolism disorder, scleroderma.
Localized damage to the intestinal wall disorders (congenital dilated colonic disease), diffuse nerve damage, muscle damage that can cause bowel dyskinesias are collectively known as unknown bowel obstruction chronic causes. Ogilvie syndrome is a special condition, characterized by non-obstructive acute dilatation of the colon.
Consequences of intestinal obstruction
Systemic and local disorders caused by intestinal obstruction vary widely, depending on:
Mechanism of obstruction: Obstruction due to obstruction or strangulation.
Blocked location: obstruction in the small intestine or colon obstruction.
Completely or completely blocked.
Mechanical or functional intestinal obstruction.
Intestinal obstruction due to obstruction
In the intestinal obstruction, the effects on the upper intestinal block are rapid and severe. Initially due to neuromuscular mechanisms, peristaltic waves increase dramatically in the intestinal segment above the obstruction to overcome the obstruction, which causes pain and signs of tightness on the abdominal wall. Later the peristaltic waves gradually decrease and disappear when the intestinal wall is damaged.
The intestine on the obstruction dilates gradually due to the storage of gas and fluid. Over 70% of vapors in the digestive tract are ingested, the remainder is caused by bacteria that decompose food, ferment and generate vapor. The fluid is excreted by the gastrointestinal tract, with intestinal excretion on average 6 liters / 24 hours. Increased pressure in the lumen of the intestine causes venous stasis, decreased capillary perfusion in the intestinal wall, causing intestinal mucosa damage, edema, congestion, leading to gradual reduction, or complete loss of digestion absorption chemicals, causing fluid stagnation in the intestinal lumen.
Vomiting and the high-effusion reflex above the obstruction may reduce the increased pressure in the lumen of the intestine. But excessive vomiting, especially in high intestinal obstruction, aggravates dehydration, electrolyte disturbances and acid-base balance.
The biochemical and hematological tests showed a decrease in circulating volume, blood concentration with hematocrit, blood protein increased.
Na + blood decrease due to fluid stagnation in the intestine contains more Na + .
K + , Cl - blood usually decreases because the vomitus contains more K + , Cl - .
K + in the blood increases in the late stage when cells of the intestinal wall are necrotic, releasing K + .
Urea and creatinine in blood are usually high due to functional renal failure and recover quickly if they are well resuscitated.
Acid alkalosis disorder: Often there is metabolic alkalosis due to vomiting of gastric juice containing more HCl and moving HCO 3 radicals - from the cell to the cell, rarely having metabolic acidosis with high K + blood. Finally, the abdomen is distended, the diaphragm is pushed up, reducing ventilation, affecting the compensation mechanism.
Below the blockage, during the first hours, peristalsis pushes the stool and slightly down, causing the bowel to flatten and no gas.
Colon obstruction, local and systemic consequences occur as in small intestinal obstruction, but later and later. The phenomenon of peristaltic wave increase on the obstruction is rare, the intestine is dilated, contains more gas than fluid due to the fermentation of bacteria in the colon. If the Bauhin valve opens when the pressure in the colon is high due to fluid buildup and vapor above the blockage, the fluid drains into the small intestine and consequently occurs in the intestinal obstruction. If this valve is self-controlled, closed, the colon's stool and gas cannot flow to the small intestine, the colon is very dilated, the pressure in the lumen is very large and there is a risk of colon rupture due to stretch. The pressure is highest in the cecum because the cecum is the largest in size (Laplace's law). Therefore, in colonic obstruction, the most punctured site is in the cecum.
Intestinal obstruction due to constriction
Torsion of the intestine is the most typical and its consequences are also the most rapid and severe of the types of intestinal obstruction due to constriction. Systemic and local disorders are partly due to intestinal effects on obstruction such as obstructive intestinal obstruction, but mainly due to blockage of the intestinal loops and corresponding mesenteric blood vessels.
The intestinal loop is twisted, congested and dilated, containing mainly fluid, a little bit, except for colonic twisting. There is a lot of gas in the spiral loops due to bacterial fermentation. Stagnation of venous loops in the loops causes plasma and blood to flow into the loops and into the abdomen. Damage to the intestine causes the intestinal mucosa's protective barrier to be damaged. The proliferation of bacteria in the loops is eliminated by stasis in the lumen, allowing the bacterial endotoxins to escape into the peritoneum. Here, the bacterial tos endotoxicity is reabsorbed. Therefore, the mechanism of shock in intestinal obstruction due to constriction is toxic shock, infection combined with shock due to decreased circulating volume. In this type of intestinal obstruction, the corresponding mesenteric artery is also blocked, causing the loops to be anemic and eventually necrotic, breaking into the abdomen causing peritonitis.
In the case of acute intussusception, the cervical block blocks the intussusception along with the mesenteric and leads to local consequences of intra-lumen bleeding, mass necrosis and systemic consequences such as intestinal torsion.
Intestinal obstruction due to intestinal paralysis
In functional intestinal obstruction caused by paralysis, which causes acute diseases in the abdomen, local and systemic consequences vary depending on the cause. In reflex functional paralysis, the consequences of intestinal obstruction to the whole body and in place take place slowly and very late. The intestinal obstruction is very early and abundant, gas distension is primary. Vomiting rarely occurs because the intestines do not have motility. The amount of fluid stagnated in the intestinal lumen is not much, damage in the intestinal wall occurs very late and the mechanism of intestinal reabsorption is preserved for longer. Therefore, systemic and local consequences are mild and late.
Implementing the quadrants
Ask and examine carefully, carefully enough to diagnose obstructive bowel syndrome. Subclinical exams, especially radiographs, are mainly intended to confirm and be able to identify the location of intestinal obstruction, sometimes as obstructive mechanisms and principals.
Muscle symptoms: There are 3 main functional symptoms:
Abdominal pain is always a symptom of the onset of the disease.
The typical painful property in intestinal obstruction is pain to attack. The pain can be gradual or sudden, severe, starts in the belly button or ribs and spreads quickly throughout the abdomen. Inquire carefully about pain properties that can help guide the principle of tension.
In obstructive bowel obstruction, abdominal pain often becomes typical, in addition to being painless or mild.
In intestinal torsion, abdominal pain begins suddenly, intensely such as twisting, persistent pain, without a bout spreading to the back or lumbar region.
Patients find all kinds of positions to relieve pain but not effective.
Vomiting occurs at the same time as pain, but does not relieve the pain. Vomiting at first, after vomiting bile, later the vomit may look like feces.
The vomiting nature depends mainly on the site of obstruction, early and frequent vomiting in high intestinal obstruction, delayed vomiting or only nausea in low intestinal obstruction.
Central secret, defecation:
Hypotension can occur as soon as a few hours after onset of illness.
The secret of defecation is sometimes not clear, in case of high obstruction, defecation can be seen due to the excretion of waste and feces under the obstruction. But even with defecation, it does not relieve pain or relieve stomach pain.
The general condition depends primarily on the mechanism of the intestinal obstruction, the location of the obstruction, and the duration of the obstruction.
Early signs of dehydration and electrolyte disturbances are often unknown.
If you arrive late and the higher the blockage, the more obvious signs of dehydration are with symptoms of thirst, sunken eyes, dry lips, wrinkled skin, less urine, even signs of shock due to decreased volume of circulation.
In intestinal torsion, shock may appear in the first hours of illness due to intoxication.
Soft, bloating abdomen:
The belly is not bloated in the first place and is also very variable. At first only bloating in the middle of the abdomen or in the ribs, then the abdomen gradually swells.
In a high, angled Treitz obstruction, the abdomen is not distended, even the abdomen is flat.
Abdominal distention much in late intestinal obstruction, distension along the colon frame in obstruction - low rectum. Equal direction in intestinal obstruction due to obstruction. Deviation in intestinal twists blocked.
Signs of floating lumps:
You can see the bulge on the abdominal wall, you can feel a stretch, the edge is clear, and the sound is resonant. A very tight and painful, non-moving bowel (VolWahl sign) is a very valuable sign to diagnose as a torsion or congestion obstruction.
Cow snake signs:
During pain, the bowel lumps up and moves on the abdominal wall. This is the most characteristic sign of a mechanical intestinal obstruction. But in the absence of this sign, intestinal obstruction cannot be ruled out.
Signs of intestinal gas and fluid moving humming:
Is a sign of equivalent value in a diagnosis of mechanical intestinal obstruction.
The abdomen is distended but soft, sometimes there is a reaction to the abdominal wall located on the loops of the intestine being twisted, knocking in the middle of the abdomen due to the gas husband, there may be signs of low turbidity due to the fluid in the abdomen ...
In addition, a careful examination of the abdomen and herniated holes in the abdominal wall can reveal several causes of intestinal obstruction: colonic tumors, small bowel tumors, intussusception, worms, and hernias in the abdominal wall. Inguinal - thigh herniation, umbilical cord hernia ...
Examination of the rectum: hollow rectal balloon, combined with rectal examination and palpation of the abdomen or vagina in women can see some causes of bowel obstruction such as rectal cancer, late intussusception, tumors sigma subframe.
An unprepared abdominal x-ray:
An unprepared abdominal scan is the most important diagnostic imaging method not only to diagnose obstruction, but also to help determine the location of the obstruction and its mechanism. The unprepared abdominal scan is performed in an upright position, lying upright, lying on its side if the patient's condition is severe that does not permit the upright scan.
Signs of intestinal obstruction:
Signs of intestinal dilatation on obstruction, relaxation on recumbent film and water level - slightly on film standing or on the side.
The intestine has no gas below the obstruction, suggestive that the colon is absent, normally in the colon there is somewhat physiological.
Based on the location, amount, and shape of the water level - steam can determine the location of the obstruction in the small intestine or colon:
Small intestinal obstruction has many water levels - slightly, concentrated in the middle of the abdomen, small in size, low arch, thin-walled, wide-walled, with horizontal mucosal folds.
Colonic obstruction has little water level - vapor, large size, high arch, narrow legs, containing more gas than fluid, located at the edge of the abdomen, with bumps and furrows on the intestinal margins.
Sometimes it is difficult to distinguish between a colon obstruction or a small intestinal obstruction. Because when the small intestine twisted, there are no valves in the small intestine and colonic obstruction often leads to dilatation of the small intestine. In intestinal obstruction caused by paralysis, both the small intestine and colon are dilated, mainly dilated, rarely have water - vapor level.
An important negative sign is the absence of free air in the abdomen
Contrast colonic scans are indicated in clinical cases with suspected colonic obstruction. In the case of an enlarged or obstructive colon with fever, it is best to have a colon scan with a diluted water-soluble contrast such as Gastrotropin. Contraindicated when intestinal perforation or suspected perforation.
A contrast colon scan is first to determine the exact obstruction site and to be able to identify the cause of the principle.
In Sigma's colon torsion the contrast stops in the rectum and has a rostrum.
In tumor obstruction, the contrast is stopped at the tumor site and has a small amputation.
In the bowel cage, there is a shape of the bottom of the cup, shaped like a crab.
Small intestinal circulation scan:
Scans the small intestine by giving the patient a contrast pill or placing a catheter down the duodenum and pumping 40-100 water-soluble contrast agents, monitoring the circulation of the contrast agent for 4 - 24 hours and film every 30 minutes.
In acute intestinal obstruction, small intestinal circulation is contraindicated except for repeated postoperative bowel obstruction and incomplete bowel obstruction, after rule of the colon has been ruled out.
Small intestinal circulation can reveal the loops of the small intestine dilated above the obstruction, but the location and cause of the obstruction cannot be ascertained.
Abdominal ultrasound showed a dilated and fluid-filled rupture image due to intestinal obstruction. Some studies also showed that abdominal ultrasound can determine the location of obstruction and obstruction due to the cause of intestinal twisting, intestinal obstruction. In the first stage when the intestine is not dilated, ultrasound can detect a number of causes such as the bowel cage (beer ring shape, sandwich shape), tumors, abscesses in the abdomen ...
Computer tomography and nuclear magnetic resonance imaging:
In recent years, computerized tomography (CCLVT) and nuclear magnetic resonance imaging (CCHT) have also been used in the diagnosis of intestinal obstruction. Pictures of dilated intestines, intestinal gas stasis on CCLVT and CCHT seen early and more specific in the abdominal x-ray is not prepared. In addition, obstructive sites (dilated and collapsed intestinal sites), severe damage to the intestinal wall (> 3 mm thick or <1 mm thin) are visible. Some causes of intestinal obstruction due to obstruction such as tumors of the gastrointestinal tract, mass of worms, worms ...
Blood and biochemical tests:
The blood and biochemical tests have no diagnostic value but are mainly to evaluate the effects of intestinal obstruction, especially electrolyte disturbances, acid-base balance, and help in correcting disorders in the period. before, during and after surgery.
Blood test: the number of red blood cells increases, hematocrit increases due to dehydration, blood concentration increases.
Na + : Normal or mildly reduced in late stage.
K + : Decreases in early stage, increases in late stage.
Cl _ : Reduce
pH: Increases in the early stage and decreases in the late stage.
HCO 3 - : Increase in the early stage and decrease in the late stage
Urea, creatinine: Normal or slight increase in the early stage, much increase in late obstruction.
Standing in front of obstructive bowel syndrome requires meticulous, thorough and systematic examination to distinguish mechanical intestinal obstruction from reflex muscle obstruction and firstly eliminate medical diseases, not surgery.
Kidney Cramps: Kidney cramping pain caused by stones often causes bowel paralysis. The feature of constriction pain is pain in the lumbar region down the groin. Ultrasound and angiogram help confirm diagnosis.
Myocardial infarction, expressed in the abdomen: Diagnosis is determined based on the electrocardiogram and the elevation of specific enzymes.
Liver cramping pain: Pain in the lower right rib spread to the back and right shoulder, rarely signs of functional intestinal obstruction attached.
The other less common medical conditions: As hyperparathyroidism, metabolic disorders porphyrin, lead poisoning, acute gastric relaxation, some drugs cause paralytic ileus, lower K + blood. It is necessary to associate disease-specific symptoms with the patient's condition, and make appropriate paraclinical examination for definitive diagnosis.
Surgical diseases with fever of the abdominal cavity: Such as appendicitis, generalized peritonitis, and focal peritonitis may present with reflex intestinal obstruction, but are often easy to diagnose. infection and abdominal wall symptoms characteristic of each disease)
Acute pancreatitis: The clinical manifestations of acute pancreatitis are severe pain, constant pain in the navel area, vomiting, abdominal distention, and a reaction to the umbilical cartilage. Shock was early and severe. Diagnosis is confirmed by assaying blood and urine amylase, lipase and imaging methods such as computed tomography and magnetic resonance imaging.
Mesenteric infarction: Usually occurs in patients with cardiovascular diseases. The clinical presentation is functional intestinal obstruction with severe pain throughout the abdomen, abdominal wall reaction and severe shock. Doppler ultrasound, tomography of the abdomen helps confirm the disease.
The rupture of retroperitoneal artery: In addition to signs of functional intestinal obstruction, abdominal pain is often severe, constantly accompanied by a drop in blood pressure, a systolic sound is heard in the abdomen. Diagnosis is confirmed based on angiogram Doppler and computer tomography.
Intestinal obstruction due to paralysis: The abdomen is painless but has bloating, no signs of snake crawling and sounds silent on the abdomen. Body condition has changed little. Intestines dilate the entire small intestine and colon, with no water-vapor levels on unprepared abdominal film. Medical treatment, no surgery
Clinical form according to the mechanism of action
Intestinal obstruction due to obstruction:
The disease starts slowly, pain becomes typical but not severe, vomiting is little.
There was no shock, no fever, and the overall condition was less affected.
Steady bloating, often with signs of a snake crawling and the hum of digestive juices and gas moving through the intestines during pain.
In obstruction due to obstruction often have many levels of water-vapor, arranged in layers, depending on the location of the obstruction in the colon or small intestine that has a different picture and arrangement. The intestinal obstruction has a lot of water-vapor levels, concentrated in the middle of the abdomen, small in size, low arch, wide legs, thin walls, arranged from the left side to the right pelvic fossa, shaped the transverse folds of the small intestine. Colonic obstruction has low water-vapor level, large size, high arch, narrow legs, contains more gas than fluid, is located at the edge of the abdominal cavity, has bumps and grooves on the intestinal margin.
Intestinal obstruction due to constriction:
Clinical manifestations: The disease usually starts suddenly, violently, with very intense first pain.
Severe, continuous, painless abdominal pain, pain spreading to the back, front of the spine or down to the coccyx region, pain makes the patient nervous and frightened.
Vomiting a lot.
Shock appeared soon after the first hours, shock became worse and worse. The body temperature rises slightly, with separation between pulse and temperature.
The abdomen is distorted, a stuffy bowel can be felt like a ball, stretched, not moving and very painful (sign of Von Wahl).
There was no sign of a snake crawling and his stomach was silent to hear.
Rectal examination: Douglas is full and painful due to blood fluid in the peritoneum.
On the unprepared abdominal film, a twisted, congested bowel obstruction appears early and is characterized by a single, dilated, fluid-filled lumbar, low in gas, fluid and slightly separated by a horizontal level, horseshoe-shaped, the legs of the bowel are not equal and are clustered at one point. Depending on the location of the blockage in the colon or small intestine, the image and effects of the upper and lower intestine are different. In the small intestine, at first there is only a single dilated loop, fixed on many different scans, smooth walls, loss of horizontal mucosal folds due to edema and bleeding in the wall. Later, the loops of the intestines have a false image of a tumor due to fluid storage, no gas. Above the obstruction, there are only a few water-vapor levels at first - later, there are more water-vapor levels, especially when the small intestinal obstruction is low. Under the blockage, the colon frame is normal, creating a stretched framework around the small intestine, in the colon, depending on the twisted intestine, there are different images. In the Sigma colonic torsion, on the abdominal imaging film is not prepared to see a single, dilated, U-shaped loop upside down, containing more gas than fluid, the legs bunched together, going diagonally from the left pelvic fossa to the right rib., there may be two levels of water and vapor in the loops. Colon, contrast stopped at the connection of the rectum and colon Sigma, has a rostrum. In cecal torsion, on an unprepared cartilage X-ray, there is a shape of an enlarged loops, only with gas, with a horizontal axis or an oblique axis in front of the spine. The intestine above the dilated obstruction can reach the small intestine, the lower intestine collapses, no gas. Colonic contrast imaging allows precise location of occlusion to be determined. dilated, U-shaped upside down, containing slightly more fluid, legs bunched up, going diagonally from the left pelvic fossa to the right rib, there may be two levels of water and vapor in the loops. Colon, contrast stopped at the connection of the rectum and colon Sigma, has a rostrum. In cecal torsion, on an unprepared cartilage X-ray, there is a shape of an enlarged loops, only with gas, with a horizontal axis or an oblique axis in front of the spine. The intestine above the dilated obstruction can reach the small intestine, the lower intestine collapses, no gas. Colonic contrast imaging allows precise location of occlusion to be determined. dilated, U-shaped upside down, containing slightly more fluid, legs bunched up, going diagonally from the left pelvic fossa to the right rib, there may be two levels of water and vapor in the loops. Colon, contrast stopped at the connection of the rectum and colon Sigma, has a rostrum. In cecal torsion, on an unprepared cartilage X-ray, there is a shape of an enlarged loops, only with gas, with a horizontal axis or an oblique axis in front of the spine. The intestine above the dilated obstruction can reach the small intestine, the lower intestine collapses, no gas. Colonic contrast imaging allows precise location of occlusion to be determined. rostrum. In cecal torsion, on an unprepared cartilage X-ray, there is a shape of an enlarged loops, only with gas, with a horizontal axis or an oblique axis in front of the spine. The intestine above the dilated obstruction can reach the small intestine, the lower intestine collapses, no gas. Colonic contrast imaging allows precise location of occlusion to be determined. rostrum. In cecal torsion, on an unprepared cartilage X-ray, there is a shape of an enlarged loops, only with gas, with a horizontal axis or an oblique axis in front of the spine. The intestine above the dilated obstruction can reach the small intestine, the lower intestine collapses, no gas. Colonic contrast imaging allows precise location of occlusion to be determined.
Clinical form by location of obstruction
Small intestinal obstruction:
The onset and nature of abdominal pain depend mainly on the cause, the mechanism of obstruction, but vomiting is often abundant and appears early. The secret of defecation is not clear in the early hours, there may be defecation due to the obstruction of the lower part. Abdominal distention around navel, not distended or deflated if obstruction is close to Treitz angle. Dehydration and electrolytes appear early and severe.
On x-ray of the abdomen is not prepared, there are many levels of water vapor, concentrated in the middle of the abdomen, small size, low arch, wide legs, thin walls, arranged from the lower left flank to the right pelvic fossa, transverse mucosal folds of the small intestine. In the case of Treitz angular obstruction, only a single water-vapor level is observed below the left flank or in front of the spine.
The onset of illness is usually gradual, the pain is milder and milder. Vomiting, sometimes just nausea. The secret of defecation appeared early. Bloating a lot, along the colon frame, total bloating if blocked late. Abdominal distortion if colonic torsion. The signs of dehydration and electrolytes are usually mild and appear late.
On unprepared abdominal film, there is little water-vapor level, large size, high arch, narrow legs, containing more fluid, located at the edge of the abdomen, there are bumps and grooves on the intestinal margin, in the spiral Sigma colon, saw an enlarged bowel, U-shaped upside down, legs bunched in the left pelvic fossa. Colonic contrast allows precise identification of location and cause.
Clinical form by cause
Diagnosing the cause of bowel obstruction before surgery is very important to prognosis and to choose an appropriate treatment strategy, but is often difficult and mostly delayed in surgery except for some typical diseases.
Causes of the small intestine:
Small intestinal obstruction:
Rarely spontaneous, usually due to ligaments or slots, holes appear after abdominal surgery. The illness has a sudden, intense onset with a typical abdominal pain characteristic of sudden, intense, twisted, continuous, non-flustered, localized pain that spreads to the back. Abdominal distortion has localized abdominal wall response. Palpation can see a tight, fixed and very painful loops. There was no sign of a snake crawling, his stomach was silent to hear. Usually there is light weight and shock occurs in the first hours. Radiographic signs are very tight or absent in cases of intestinal obstruction due to hernias. It should be noted that there are no clinical signs and radiographs of absolute value to distinguish between obstructive small bowel obstruction and obstructive intestinal obstruction.
Hernia of stuffy abdominal wall:
In the presence of a primary obstruction of the intestine, systematically needing all the hernias in the abdominal wall such as inguinal hernias, thighs, umbilical cord, middle white line to determine if it is a abdominal wall hernia. stuffy or not, especially wall hernias, thigh hernias in fat women is easy to miss. Diagnosis of a herniated hernia is usually easy when the teacher blocks the hernia down, cannot rise on its own, it is very painful, especially when you touch the neck of the hernia.
Acute intussusception is common in babies who are still suckling and plumping. Onset suddenly with symptoms of crying bouts of babies, quitting feeding, vomiting and bloody diarrhea. Abdominal examination usually reveals a cage located below the right flank, above the navel or below the left flank. Examination of the rectum with blood. Ultrasound showed images of a beer ring and a sandwich. Colon-shaped contrast scans are crab-shaped, cup bottom.
Intestinal obstruction caused by roundworm:
Common in children, typical clinical and radiological signs are obstructive small bowel obstruction. Touching the abdomen always sees worms. In terms of progress, in many cases, the worms cluster gradually out, the patient defecates and no intestinal obstruction. Therefore, in cases of mild pain, slight bloating and worms need careful monitoring to make the right decision.
Bowel obstruction caused by food residue mass:
Common in the elderly, losing all teeth, in people with endocrine pancreatic failure or had gastric bypass. Before that, we ate foods high in fiber (bamboo shoots, jackfruit fibers) or acrid fruit (sim, green guava). Signs of atypical obstruction of the small intestine, abdominal distention more or less depending on the obstruction position, may still have a stool, the disease may increase or decrease intermittently. On the x-ray, the abdomen has a lot of water-vapor levels in the small intestine, but there may still be some gas in the colon.
Obstruction caused by small bowel tumor:
The disease progresses slowly, sometimes with incomplete obstruction, and often precedes Koenig. A lump may be palpable around the navel. In cases of incomplete obstruction, circulation of the small intestine can be of diagnostic value.
Causes of the colon:
Bowel obstruction caused by colorectal cancer:
The most common is intestinal obstruction due to left colon cancer, especially Sigma colon segment, may or may not have a history of blood mucus defecation and hemophilia syndrome (Duval syndrome). Abdominal pain is usually mild, late vomiting or just nausea, bloating along the colon frame and rarely palpable. For bowel obstruction caused by right colon cancer, the clinical picture has the appearance of a low small bowel obstruction and often palpable tumor in the right iliac fossa or right rib. Colon-frame contrast imaging showed amputation in the colon with tumor. Bowel obstruction caused by rectal cancer has clinical manifestations similar to obstruction caused by left colon cancer, but has a history of rectal syndrome and blood mucus defecation. Rectal examination can palpate tumors 10 cm or less from the edge of the anus.
Sigma colon torsion:
Meet in middle-aged people and older, with a history of constipation and abdominal pain that is semi-occlusive but goes away on its own. The most important clinical sign is that the abdomen is very distended and distorted, the bowel stretches from the left pelvic fossa to the lower right flank, does not move, and sounds (trisomy Vol Wahl). An unprepared abdominal scan showed an enlarged bowel, U-shaped upside down, legs clustered in the left pelvic fossa. Colon-shaped contrast imaging has a rostrum.
The reason is that the colon must not stick to the posterior abdominal wall. Common in young people, in history there was pain in the right rib and went away on its own. Severe and sudden pain next to the right navel, vomiting and much, urinary retention. The abdomen is distorted in the upper left region, round or oval in shape. An unprepared cartilage X-ray shows a very enlarged bowel, with a water-vapor level located below the left flank, rarely in the middle of the abdomen.
Early postoperative bowel obstruction:
Early postoperative bowel obstruction is intestinal obstruction that occurs in the first 4-6 weeks after abdominal surgery. Diagnosis of intestinal obstruction soon after surgery is often difficult and needs to distinguish three types of intestinal obstruction
Mechanical intestinal obstruction:
After surgery, the patient had a return to the medium. Then the obstructive berries suddenly reappear, but there is no fever. In this case, the cause of intestinal obstruction is usually mechanical due to the ligament or hernias formed after surgery.
Intestinal obstruction due to paralysis after surgery:
4-5 days after surgery, the patient does not have a backbone, abdominal distension a lot but no pain or pain rarely palpable, vomiting little or just nausea, no signs of snake crawling and belly silent when listening to the abdomen, not prepared to see total relaxation of the intestine (small intestine and colon).
Intestinal obstruction due to inflammatory foci in the abdomen:
After surgery, if the patient has slowed or no defecation, high fever, bloating and pain, it is necessary to think of infectious complications in the abdomen such as peritonitis, intra-abdominal abscess due to podium, fistula. intestinal nodules.
Progression and prognosis
The progression and prognosis of intestinal obstruction depends primarily on the occlusion mechanism, followed by the site of the obstruction (high or low obstruction) and early or late intervention.
The prognosis of obstructive bowel obstruction depends primarily on the lack of anemia in the blocked bowel. In small intestinal torsion and right colon torsion, early irreversible intestinal damage occurs, after 6-12 hours with clinical signs of shock and diffuse abdominal wall reflex. That explains the very urgent emergency surgery when it is suspected that intestinal torsion is suspected. Progression of anemia in the sigmoid torsion occurs similarly but more slowly because the Sigma colonic torsion occurs slowly, sometimes incomplete torsion and can unscrew.
For obstructive small bowel obstruction, its course and prognosis depend on the obstruction syndrome. If left late, the clinical picture will gradually change: the pain will decrease, vomiting more and vomit such as feces, rapid pulse, difficulty breathing, gradually rising fever, a haggard expression. The abdomen shows signs of reaction and cramps, there is no sound of gas and fluid movement in the intestinal lumen. After 24-36 hours, there may be signs of renal failure, circulatory failure, lung complications due to inhalation of vomit.
In the intestine, in the course of the disease, the following complications may occur:
Causing intestinal twisting, intestinal congestion.
Causes intestinal perforation.
The prognosis of cancer-induced low colonic obstruction depends on the complete or incomplete obstruction, whether or not there is a combination of abscesses around the tumour, and whether van Bauhin is self-controlled. In the case of complete obstruction, the valve Bauhin closes, the bowel feces and gas cannot flow up the ileum, the colon is very dilated, pressure in the colon is very high and can cause colon rupture. When the diameter of the colon is more than 9 cm, the risk of colon rupture is very high. If the Bauhin valve opens, the stool and colon gas rise into the ileum, reducing the pressure of the colon and the risk of colon rupture less and later. In this case, the local effects and the higher risk of abdominal rupture are the systemic effects. In the colon obstruction not completely under the effect of medical treatment can eliminate the intestinal obstruction.