Vice-Rector for Studying Process

1

MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICALACADEMY

APPROVED

Vice-rector for studying process

Senior Prof. Teshaev O.R.

«______» ______2011y

Uniform tutorial

Theme: ACUTE ABDOMEN

(Lesson 17)

Prepared by: assistent MurodovAS

Tashkent - 2011

APPROVED

On conference in department of surgical diseases for general practitioners

Head of department______senior prof Teshaev O.R.

Text of lecture accepted by CMC for GP of Tashkent Medical Academy

Report №______from______2011 y

Moderator senior professor Rustamova M.T.

PRACTICAL SESSION № 17

Syndrome: acute abdomen

Topic 6.2.: Acute intestinal obstruction (IPOs). Classification, etiology, clinical symptomatology. Methods of diagnosis and differential diagnosis, treatment. The tactics of GPs in the treatment of acute intestinal obstruction. Indications for surgery. Rehabilitation of patients.

1st place of employment, equipment. Hospital, training room, house hospital, dressing room, operating. Case patients, hospital records and outpatient hospital patients, blood and urine tests, the results of instrumental studies, guidelines, training manual on practical exercises, case studies, test questions, algorithms, performance skills, scripts, interactive teaching methods, standard protocols, handouts of Internet, slides, etc. EMC.

2.Prodolzhitelnost classes - 327 minutes.

3.Tsel classes:

3.1. Learning Objectives:

- To know the causes of acute intestinal obstruction:

- To know the clinic, diagnosis of acute intestinal obstruction:

- Be able to supervise patients with acute intestinal obstruction:

- Be able to identify the main symptoms of the disease;

- Know the methods of examination of patients and interpreting laboratory data, diff. diagnosis;

- Know the basic treatment principles and tactics of the patients.

3.2. The student should know:

Anatomy and physiology of the gastrointestinal tract.

Etiopathogenesis and clinic of the UCN.

Diagnostic methods.

Critical periods of hospitalization.

Complications of IPOs.

Methods of examination of patients;

The tactics of treatment of patients;

Postoperative rehabilitation of patients.

3.3. The student should be able to:

Conduct a clinical examination of patients with IPOs.

Identification of clinical forms of IPOs.

Define the criteria of hospitalization in patients with IPOs.

Formulate and substantiate the clinical diagnosis.

To be able to palpate the abdomen.

Providing immediate assistance in emergency surgery.

Probing and gastric lavage;

To conduct various types of enemas.

Deal with X-ray images.

Implementation of novocaine blockades.

Conducting blockades for pain syndromes.

Participating in a clinical parsing.

Conduct a surveillance card.

To teach the development of risk factors, diagnosis, principles of timely hospitalization and rehabilitation of patients with poststatsionarnoy IPOs.

Motivation

Acute intestinal obstruction is characterized by impaired passage of intestinal contents in the direction from the stomach to the anus. It does not represent some kind of separate nosological form, as a complication of various diseases: abdominal hernia exterior, tumors of the intestine, gallstone disease, etc. But, having arisen, a pathological state ¬ tion takes place on a single "scenario", causing toxicity and water-electrolyte disorders, accompanied by typical clinical manifestations. In this regard, diagnostic and therapeutic tactics in many ¬ gom united under dissimilar in nature obstruction.

Acute intestinal obstruction has long earned the notorious very difficult with the current, difficult to diagnose and adverse outcomes in zabolevaniya.Ona 3.5% of all acute surgical diseases, including deaths from these diseases to an acute intestinal obstruction falls 40%, ie , almost half of all deaths. Among patients operated on for acute intestinal obstruction death rate is also quite large - from 8 to 37%, depending on the timing of the operation and form lesions of the intestine.

The delay in diagnosis, hospitalization, the necessary diagnostic tests, surgery is fraught with grave consequences. World statistics show a direct dependence of the outcome of acute intestinal obstruction on the time elapsed before treatment to the doctor, hospitalization, surgery.

5.Mezhpredmetnye vnutripredmetnye and communication.

Anatomy, regional anatomy, operative surgery, pathological anatomy, patfiziologiya, therapy, infectious diseases, anesthesiology and resuscitation, clinical pharmacology, biochemistry.

Position and syntopy. Transverse colon (mainly the middle part of it) has great mobility and can move upwards, touching the front surface of the stomach, drop down to the level of symphysis pubis or lower - in the pelvic cavity, so its shape is very fickle.

The high mobility of the transverse colon and a different position, which it can borrow in the abdomen, are the reason that sometimes the transverse colon can be the content of the umbilical, inguinal or femoral hernias.

Above and right of the initial part of the transverse colon is in contact with the visceral surface of the right lobe of the liver and gallbladder. If the transverse colon is located high in the epigastrium, it covers not only the right lobe of the liver and gall bladder, but also square, and sometimes the left share a liver. In the middle of the intestine is bordered by the front surface of the stomach or located in the greater curvature of his, with which it is connected through the gastro-colic ligament. Left colon transversum in contact with facies colica lienis, bottom with loops of small intestine, sometimes with a loop of sigmoid colon, back to the duodenum and pancreas, and in front of the anterior abdominal wall.

In the left upper quadrant transverse colon becomes the descending colon, forming a left curvature, flexura coli sinistra, which is somewhat above the right curvature, and the adherent connective tissue fibers with adipose capsule of the left kidney. Between the diaphragm and the left curvature of the colon is stretched diaphragmatic ligament, colon, lig. phrenicocolicum, limiting blind pocket, saccus lienalis, which houses the anterior pole of the spleen.

Descending colon, colon descendens, a continuation of the transverse colon. It is located on the left side of the abdomen over the left hypochondrium to the left iliac fossa. Its length ranges from 5-20 cm, with an average of 15 cm diameter descending colon somewhat smaller than the diameter and the ascending colon up to 3 - 5cm.

Attitude to the peritoneum. Descending colon is covered by the peritoneum in front and the sides and rear wall of its adherent to the retroperitoneal fat. The width of the retroperitoneal colon 0,3-4 cm Approximately one quarter of cases the descending colon has a mesentery, which reaches a length of 8.1 cm

Sigmoid colon, colon sigmoideum, begins in the left iliac fossa or at the level of the iliac crest and ends in the pelvis at the level II-III sacral vertebrae. The length of the sigmoid colon from 20 to 75 cm, on average - 40 cm

Attitude to the peritoneum, mesentery. Sigmoid colon is completely covered by peritoneum and is connected to the abdominal wall through the mesentery, whose length ranges from 10-17 cm root of mesentery begins in the left iliac fossa, crosses the ilio-psoas muscle, the left ureter and common iliac vessels and ends at the level II -III sacral vertebrae.

At the base of the mesentery is often mezhsigmovidny pocket, recessus intersigmoideus. This pocket is easy to detect when a loop sigmoid colon to lift up and stretch its mesentery. Usually it is a small cavity length of 1.9 cm and 1.4 cm in about one third of cases it is absent.

Position and syntopy. Since the sigmoid colon has a relatively long mesentery, it can move freely in the various departments of the abdominal cavity: a midline abdominal cavity in the pelvis, in the right iliac fossa, upward toward the liver or stomach. However, most often a loop of sigmoid colon descends down the left iliac fossa, crosses the greater psoas muscle and is located in the pelvic cavity.

Sigmoid colon over a large area in contact with the loops of the small intestine, and sometimes intertwined with them pretty strong spikes, some parts of it may be adjacent to the anterior abdominal wall. The top loop of sigmoid colon may come into contact with all organs of the abdomen and pelvic cavity, excluding the pancreas.

Rectum, rectum, is the final section of the colon. The upper limit corresponds to approximately its II-III sacral vertebrae.

The shape of the rectum is dependent on the degree of its filling. Distinguish ampullar form when the ampoule is well marked, and cylindrical - if the ampule is not expressed.

Rectum is divided into the ampullar part, ampulla recti, and the anal canal, canalis analis.

Ampullar part of the intestine most extended and occupies about two-thirds of its entire length. At the top it turns into the sigmoid colon and below - in the anal canal, ending rectum (anus).

The length of the rectum in the range of 12-18 cm, and the ampullar part of it is 8-10 cm, and the anal canal - 4-6 cm

In the anus is the internal sphincter of the rectum, m. sphincter ani internus, which consists of circular smooth muscle fibers. From the outside it is surrounded by circular muscle bundles, which form the outer sphincter, m. sphincter ani externus.

Mucosa in the anal part of the intestine forms a longitudinal folds in the form of beads, columnae analis. These folds, going down, some thicken and fuse together, forming of hemorrhoidal zone, zona haemorrhoidalis, in the submucosal layer which is located venous plexus.

At the top of the ampoule of the rectum has folds of the mucous membrane, called the third sphincter. The mucosa of the rectum emptied going into numerous folds, which disappear when filled with ulcers.

The upper section of the rectum partially offset in the frontal plane and is located a few left of the midline, due to left-sided position of the sigmoid colon.

The rectum is curved in the sagittal plane. Its upper section forms an arc of the sacrum, flexura sacralis, corresponding to bending the sacrum and coccyx. Lower part of intestine, leaning over the top of the coccyx, forming an arc of perineal, flexura perinealis, convexity facing anteriorly. The extreme anterior portion of the arc corresponds to the prostate and removed from the anus about 6-7 cm

Attitude to the peritoneum. The transition line of the peritoneum in front of the rectum is located in the transverse direction and laterally is obliquely backwards and upwards towards the Cape.

In men, the peritoneum, passing from the bladder to the rectum, the top cover of the seminal vesicles and forms pryamokishechnopuzyrnoe space, excavatio rectovesicalis, corresponding to approximately the level IV-V sacral vertebrae. The deepest part of the rectal-vesical space is at a distance of 6-8 cm from the anus. On both sides rectal-vesical space is limited to the peritoneum folds of the same name, reaching in the anteroposterior direction from the bladder to the rectum.

In women, the peritoneum covering the rear surface of the uterus, as well as some back of the vagina, passes to the front wall of the rectum and forms a rectouterine space, excavatio rectouterina. On both sides, this space is limited to two peritoneal folds, plicae rectouterinae, coming from the side and rear walls of the uterus to the side wall of the rectum ampulla. The deepest part rectouterine space is at a distance of b-6 cm from the anus, and therefore available for research through the vagina and rectum.

In the upper section of the rectal-vesical and rectouterine space can penetrate the loops of the small intestine, sigmoid colon, and sometimes the cecum with the appendix. In these spaces usually collects exudate or pus in the inflammatory processes in the abdominal cavity, as well as blood in the damaged organs of the abdomen or pelvis.

16. Innervation of the left colon. 1 - colon transversum; 2 - nerve branches plexus mesenterici inferioris; 3-a. colica sinistra; 4 - aa. sigmoideae; 5 - colon descendens; 6 - nerve branches plexus mesenterici inferioris; 7 - colon sigmoideum; 8 - plexus mesentericus inferior; 9 - a. mesenterica inferior.

Innervation of the rectum by the branches going from the border of the sacral sympathetic trunk and branches of the sympathetic plexus surrounding the rectal artery. In addition, the innervation of the rectum are involved branches, going from II, III, IV sacral nerve roots.

6.Soderzhanie classes.

6.1. Theoretically part.

The term "acute abdomen" refers to a clinical syndrome that develops in injuries and acute diseases of the abdominal cavity, which requires or may require urgent surgical care. The first medical examination of the patient is often performed outside the hospital (at home or in the clinic). The task of initial diagnosis is to recognize a dangerous situation and the need for urgent surgical treatment. In acute abdominal prognosis worsens with time, so the doctor must quickly to hospitalize the patient in profile institution, where the next time the patient should be carried out the necessary diagnostic and therapeutic measures. Even in cases of suspected acute abdomen patient should be hospitalized immediately.

For a given pathological condition is most appropriate morpho-functional classification, according to which by reason of the occurrence ¬ veniya decided to allocate a dynamic (functional) and mechanical bowel obstruction ¬ Kuyu. In dynamic obstruction disturbed motor function of the intestinal wall without mechanical pre ¬ obstructions to promote intestinal contents. There are two types of dynamic obstruction: spastic and paralytic.

Mechanical obstruction is characterized by occlusion of the intestinal tube at any level, which results in a violation of intestinal transit. With this type of obstruction in principle you ¬ division strangulation obstruction and bowel. When strangulation opaque ¬ divergence primarily involved in the circulation suffers pathologists ¬ cesses the site intestine. This is due to compression of the vessels bry ¬ zheyki at the expense of, or twisting uzloobrazovaniya that is to willingly ¬ fast (within hours) the development of gangrene intestine area. When obstructive ileus circulation is located above the barrier (leading) part of the intestine decreases again ¬ violation in connection with his hyperextension of intestinal contents. That is why if possible obstruction bowel necrosis, but its development requires not just a few hours and several days. Obturation can be caused by malignant and benign tumors, fecal and gallstones, foreign bodies, ascarids. To a mixed mechanical obstruction include intussusception, in which a swarm ¬ intussusceptum involved mesentery of the intestine, and adhesive neproho ¬ trons, which can occur as a type of strangulation (compression extrusion intestine with the mesentery), and the type of obstruction (ne ¬ regib intestine in the form of "shotgun").

Diagnostic and therapeutic tactics are largely dependent on the location of obstacles in the intestine, therefore, the level of obstruction distinguished: high (enteric) and low (colonic) obstruction.

E tiology

The basis of mechanical (particularly strangulated) intestinal obstruction are the anatomical prerequisites for congenital or Priobja ¬ retennogo character. Such moments may serve as predisposing ¬ innate presence Dolichosigmoid live, mobile cecum, additional ¬ Tel'nykh pockets and folds of the peritoneum. Most often these factors are acquired ¬ character: adhesions in the abdominal cavity, the lengthening of the sigmoid colon in old age, external and internal abdominal hernias.

Adhesions in the abdominal cavity develops after previously carried over ¬ hay inflammatory diseases, injuries and surgeries. For the occurrence of ¬ acute intestinal obstruction are the most important isolated ¬ the induced mezhkishechny, gastro-parietal and parietal-packing seam forming in the abdominal cavity coarse strands and "windows" that could cause strangulation (internal infringe ¬ of) of the movable segments intestine. No less dangerous in clinical terms may be flat mezhkishechny, parietal and entero-entero-packing the seam, with the formation of intestinal conglomerates, which lead to under ¬ obstructive ileus in functional re ¬ gruzke intestine.

Another group of acquired factors contributing to the development ¬ tiyu intestinal obstruction, benign and malignant are ¬ governmental tumors of various departments of the intestine, leading to obtura ¬ tional obstruction. Obturation can also arise due to compression of the intestinal tube outside the tumor originating from adjacent organs ¬ electrons, as well as narrowing of the lumen of the intestine as a result of perifocal tumor or inflammatory infiltration. Exophytic tumor (or polyps) of the small intestine, and Meckel's diverticulum can cause invagination.

In the presence of these prerequisites obstruction occurs under the influence of manufacturing factors. For those of hernia may be for ¬ vyshenie intra-abdominal pressure. For other types of obstruction as a provoking factor often act changes motorized ¬ ki intestine associated with changes in eating regime: the use of large amounts of fruits and vegetables in summer and autumn, abundant ¬ ny meals on the background of prolonged fasting can cause small bowel volvulus (accidental , SR. Spasokukotsky called it the disease of ¬ lodnogo person), the transition from breastfeeding to artificial in infants may be a frequent cause of ileocecal intussusception.

Causes of dynamic intestinal obstruction is very diverse ¬ HN. Occurs most often in paralytic ileus, Didactic ¬ yasya as a result of trauma (including OS), metabolic races ¬ stroystv (hypokalemia), peritonitis. All acute surgical diseases of ¬ the abdominal cavity, which could potentially lead to a ne ¬ ritonitu, occur with symptoms of paresis of the intestine. Reducing peristal-optical activity of the gastrointestinal tract is marked at the restriction ¬ chenii physical activity (bed rest) and as a result of prolonged ¬ but not cropped or biliary colic. Spastic intestinal obstruction nuyu ¬ cause lesions of the brain or spinal cord (metastatic cancers, amyelotrophy, etc.), poisoning by salts of heavy metals (eg lead colic), hysteria.

Pathogenesis.

Acute intestinal obstruction causes a marked disturbances in the body of patients, determining the severity of the pathological condition of ¬. In general, we can state the inherent disorder of water and electrolyte balance and acid-base status, protein loss, endotoxicosis, intestinal failure and pain.

The pathogenesis of acute intestinal obstruction is rapid and profound metabolic disorder. Obstacle - increased peristalsis - paresis - an inflammation of the bowel wall - peritonitis. Fast absorption is disturbed (the higher the level of obstruction, the faster and deeper than there are violations of water-elektolitnogo exchange), since the digestive juices are allocated mainly in the upper and absorbed - at lower levels.