MINISTRYOFHEALTHOFUZBEKISTAN

TASHKENTMEDICALACADEMY

"CONFIRM"

ViceRectorofTMA

ProfessorTeshaevO.R.

______

"27"august2015.

Department:FACULTYANDHOSPITALSURGERY

Subject:FACULTYSURGERY

THETOPIC:

ACUTEINTESTINALOBSTRUCTION

Tashkent–2015

Compiledby:

ProfessorKhakimovM.Sh.

associateprofessorBerkinovU.B.

AssistantAsrarov U.А.

Educationtechnologyapproved:

Bysurgicalmeeting

sectionofCPC

Protocolnumber1

Of"27"august2015.

Theme:Acuteintestinalobstruction

1.Tuitiontechnologymodelatpracticallessons

Time–6h / Numberofstudents–8-10pers.
Formoflesson / Practicalclassesintheclinicandworkshopusinginthislesson"BLACK-BOX","WEB".
Place / Departmentoffacultyandhospitalsurgery,trainingroom,dressing.
Structureofthelesson / 1.Introduction
2.Thepracticalpart
-Supervisionofpatients
-Implementationofpracticalskills
-Discussionofthepracticalpart
3.Thetheoreticalpart
-Discussionofthetheoreticalpart
4.Estimation
-Selfappraisalandmutualappraisal
-Appraisalbytheteacher
5.Conclusionmadebytheteacher.
Appreciationofknowledge.
Givingalistofquestionsforthenexttheme.
Theaimofthelesson:clarifyingthethemebyshowingtheimportanceoftopicsforthetrainingofstudents,introducingstudentstheacuteintestinalobstruction,thereasonsfortheirdevelopment,clinicalfeatures,differentialdiagnosis,optimalmethodsoftreatment,postoperativecare,rehabilitatingpatients.
Thepurposeoftheteacher:
  1. Toconsolidateanddeepenthestudents'knowledgeaboutthefeaturesclinicsandcourseacuteintestinalobstruction.
  2. Explaintheprinciplesofthedifferentialdiagnosis.
  3. Students'skillsofself-informeddecision-makingintheappointmentofrehabilitationforpatientswithacuteintestinalobstruction.
  4. Providestudentstheprinciplesofpreventionactivities.
/ Theresultsofstudies:
Astudentshouldknow:
-Diagnosisanddifferentialdiagnosisandcomplications;
-Interpretationoftheresultsofinstrumentaldiagnosticstudiestosubstantiatethediagnosisandthechoiceofarationaltreatment;
-Preoperativecharacteristicsofthiscategoryofpatients;
-Determinethenatureofsurgeryandconservativetreatment,toknowtheircharacteristics;
-Topreventcomplicationsduringandaftersurgery;
-Tolearnaspecialsurveymethods.
Astudentshouldbeableto:
Performpracticalskillstoacquiresomepracticalskillsintheexaminationofpatientswithacuteintestinalobstruction,performspecialtechniques,surveydataofpatientstodetermineindicationsandcontraindicationsforsurgicalinterference.
Methodsandtechniquesoftuition / Methods"BLACK-BOX"and"WEB",graphicorganizer–aconceptualtable.
Theachingfacilities / Manuals,trainingmaterials,slides,videoandaudio,medicalhistory.
Formsoftuition / Individualworkwithpatients,conjointactivityingroups,presentations.
Placefortuition / Audiencechamber,trainingroom,operatingroom,dressing.
Monitoringandestimation / Oralcontrol:questionsforcontrol,solvingthegiventasksingroups;writtencontrol:testing.

2.Motivation

Instillingstudentswiththeneedfortimelydevelopmentofadequateoperationstoseverecomplications,andintheirdevelopment,encounteringwiththemostinformativeandmodernmethodsofdiagnosis,surgicaltreatment,meetingwithpotentialcomplicationsofsurgeryandoperatingoutduringtheperiodofprevention,developmentofclinicalthinkingofstudents.Thedevelopmentofthemodernviewoftheproblemissuesfromtheperspectiveofworldmedicineandgeneralpractice.

3.Intraandinterdisciplinarycommunication

Teachingthistopicisbasedontheknowledgebasesofstudentsonanatomy,normalandpathologicalphysiologyofcirculation.Knowledgeacquiredduringthecoursewillbeusedduringthepassageofgastroenterology,internalmedicineandotherclinicaldisciplines.

4.Thecontentoflessons

4.1.Theoreticalpart

Acute intestinal obstruction

Acute intestinal obstruction (acute intestinal obstruction, ileus, acute ileus) - a condition that develops when you stop the passage of the contents of the intestinal tube.

The frequency of acute intestinal obstruction among the acute surgical diseases of the abdominal cavity is most often 3,5-9% ileus occurs in persons aged 40-60 years. In men, it happens more often than women. The number of patients with acute intestinal obstruction highest in summer and autumn (July-October) months, which is associated with greater during this period, the load bowel plant foods containing fiber.

To study various aspects of acute intestinal obstruction has a long history. The first description of the disease attributed to Hippocrates. According to him, ileus causes inflammation associated with the gases formed in the intestines. In the works of Galen, there are arguments about the pathogenesis of the disease «Ileus Inflammatorius», which is the main cause of inflammation associated with gut motility disorders.

These scientists, with little or no laboratory facilities without using practice mortem examination without having advanced knowledge of anatomy and physiology were able to point out the important elements of the pathogenesis of intestinal obstruction - intestinal dysmotility and hyperextension of its gas and liquid.

At the beginning of the XVII century (according to some sources in the XVI century.) Riolan proved the existence of mechanical - obstructive and strangulated - forms of acute intestinal obstruction.

This marked the beginning of efforts to surgery ileus.

It is currently used classification proposed by V.P. Petrov and I.A. Eryuhin (1985):

1. By birth - congenital and acquired.

By congenital bowel obstruction include malformations, atresia of the small and large bowel atresia anus.

2. On the mechanism of - mechanical and dynamic.

2.1 Mechanical intestinal obstruction is divided into obstructive (without compression of the mesenteric vessels), strangulation (with compression of blood vessels) and concomitant (a combination of obstruction with strangulation - intussusception).

2.2 dynamic ileus paralytic and divided into spastic.

3. The level of obstruction to high (small bowel) and low (colonic).

4. The clinical course - full and partial, acute and chronic.

Dynamic (functional) intestinal obstruction called such forms of ileus, in which the cessation of the passage of the contents intestine is due to violation of its motor function. The mechanisms of this disorder diverse as motor control is carried out by a complex set of neurohumoral influences. The basis of functional disorders leading to dynamic obstruction are acute inflammatory processes in the abdominal cavity (cholecystitis, pancreatitis, appendicitis, peritonitis), and retroperitoneal fat (paranephritis, etc.); injury and traumatic surgery, intoxication, acute circulatory disorders in the abdominal (mesenteric vascular thrombosis, myocardial spleen), retroperitoneal hematoma, and others. Metabolic disorders (diabetic, uremic coma), intoxication (lead, morphine) may also lead to the development of dynamic intestinal obstruction.

Dynamic ileus may be spastic and paralytic.

Spastic called a form of dynamic ileus, in which local spastic constriction formed part of the colon on a small usually over. Frequent cause of spastic ileus is poisoning with heavy metal salts. Described spastic obstruction that develops against the backdrop of irritable bowel contents rough, acute surgical diseases and injuries of the abdomen. A separate group of spastic obstruction due to diseases of the central nervous system, for example, hysterical ileus.

Paralytic ileus in the surgical clinic is not uncommon. Diseases such as diffuse peritonitis and acute pancreatitis accompanied by phenomena of dynamic ileus, in which run all the mechanisms of disturbances in motor function intestine. In addition, paralytic ileus develops in the presence of retroperitoneal and mesenteric hematoma, which happens when soft tissue injuries and bone structures after major surgery. The most common variant of dynamic ileus in the surgical clinic - postoperative intestinal paresis. There is a perception that spasm and paresis of the intestine - the components of a single process, into each other.

Unlike dynamic, with mechanical intestinal obstruction cease promotion of the contents determined by the mechanical bowel obstruction.

Obstructive ileus (5-8% according to various sources) is caused by the closure of the lumen of the intestine from the inside. The cause of obstruction may be a tumor, a tangle of worms, phytobezoars, gallstones, coarse food supply, fecal stones, foreign bodies. Obstructive ileus may develop as a result of the closure of the lumen of the intestine from the outside during compression of its spikes, tumors or large cysts originating from neighboring organs.

Strangulation IOs occurring in 15-40% of cases differs from obstructive primarily to the fact that in addition to compression of the intestine (from the outside) is compressed and mesentery, which leads to disruption of blood circulation in the segment of intestine. In this form of obstruction increases rapidly destructive changes in the strangulated loop, fast-paced endotoxemia and peritonitis. By type of strangulation ileus include volvulus, nodulation and infringement ulcer in external and internal hernial ring.

Combined forms IOs have symptoms and obstructive and strangulation. A striking example is the mixed nature of IOs intussusception, mostly in children. When bowel intussusception plot with mesentery implemented in the neighboring plot gut lumen and occlusive own wall, and the compression of marginal vessels leads to acute ischemia invaginated intestine.

Some authors distinguish adhesive intestinal obstruction. It emphasizes only the time of the etiological obstruction - the presence of adhesions in the abdominal cavity, which may be the result of surgery or inflammatory diseases of the abdominal cavity. Adhesive ileus may occur by strangulation or obstructive type.

Etiology and pathogenesis. Among the etiological factors of acute intestinal obstruction usually distinguished predisposing and producing.

Predisposing factors form the basis for the subsequent development of acute intestinal obstruction. They may be congenital or acquired.

The birth are all sorts of peculiarities and anomalies of the anatomical structure of the gut and intestinal wall: the extended portion of the intestine (megacolon, dolichosigma), malrotation, congenital stenosis and occlusion of the bowel (eg, achalasia of the rectum), malformations of the neuromuscular apparatus intestine (agangliosis of colon or Hirschsprung's disease).

To acquire factors include adhesions in the abdominal cavity, developing after surgery and inflammatory diseases of the abdominal organs, acquired external and internal hernia, the presence of tumors, gallstones lumen obturation, phytobezoars, fecal stones, helminths. Proved predisposing role irregular, unbalanced and malnutrition in developing predisposition to ileus.

Even if there are several predisposing factors ileus disease develops only when exposed to producing factors. These factors may be a sharp increase in intra-abdominal pressure, heavy exercise, abundant food load. Significant regularities in the distribution of patients with acute intestinal obstruction by sex, age or profession were found. Some authors have noted an increased frequency of bowel obstruction in July-August compared with January-February, but seasonal variation and incidence of the disease appears to be associated with the peculiarities of power in the summer (high fiber plant foods in large quantities).

Common pathophysiological disturbances in acute intestinal obstruction caused mainly by the loss of large amounts of water, electrolytes, proteins, enzymes, disorders of acid-base status, intoxication and the action of bacterial factor. Intensity of these disorders depends on the type and level of obstruction, as well as the time since the onset of illness.

At obstructive ileus main factors determining the severity of the general condition of patients who are losing large amounts of water, electrolytes and protein as with vomitus, and deposit them in the lumen of the gastrointestinal tract.

It is known that during the day a healthy person in the lumen of the stomach and intestine is released from 8 to 10 liters of digestive juices, containing a large amount of enzymes, proteins and electrolytes. Under normal conditions, most of them are reabsorbed in the upper gastrointestinal tract. In acute obstructive obstruction in the intestines above place obstacles begin to accumulate gas, bloating occurs intestinal loops and broken processes of absorption. In this connection, digestive juices reabsorption not occur, a so-called "sequestration" of the liquid in the "third" space, and they are turned off from metabolic processes. Sequestration of fluid in the "third" space due to the stagnation of intestinal contents in the afferent loop, compression of blood vessels in the intestine submucosa edema and plasma in the intestinal wall, its lumen, the abdominal cavity. In the afferent intestine as a result of fermentation and putrefaction formed osmotically active substances that increase the sequestration of fluid which also contributes to the selection of biogenic amines (histamine, tryptamine, serotonin).

Per day obstructions in the "third" space can be deposited to 8-10 liters of digestive juices that, on the one hand, leads to severe dehydration and, on the other - creates heavy mechanical load on the intestinal wall, compressing the submucosal blood vessels, primarily - veins. If not made timely decompression, in the intestinal wall develop necrobiotic changes and perforation may occur. Last in connection with the structural features of the vessels of the intestinal wall most often develops in areas opposite the place of occurrence of the mesenteric vessels. In response to the mechanical stress of the stomach and intestinal gas and liquid contents irritation occurs vomiting center and there is repeated vomiting. Vomiting at high (intestinal) obstruction occurs at an earlier date than the low obstruction. As a result, "sequestration" in the intestinal lumen loss with vomiting and severe dehydration develops Last occurs due to reduction of extracellular (mostly) and intravascular sectors. Found that in the early period of acute obstruction decrease in extracellular fluid volume may reach 50% or more.

The loss of water and electrolytes (already observed in the first 24 hours) leads to hemodynamic disturbances, decreased glomerular filtration in the kidneys and a decrease in diuresis. In response to acute dehydration it developed, reducing the volume of the extracellular sector and the loss of sodium ions comes increased production and secretion of aldosterone As a result, decreases the excretion of sodium and chloride in the urine, there is a delay in their body. However, in parallel with this process is enhanced urinary excretion of potassium, which aldosterone action mechanism does not apply. Loss of potassium ions with vomit and urine very quickly leads to a deficiency of potassium in the body and the development of hypokalemia.

Potassium - the basic cellular cation, the functional significance of which for the body is extremely large. Potassium is involved in all the redox processes, is a part of enzyme systems involved in the synthesis of proteins, glycogen, affects the functional state of the nervous and muscular system. In terms of hypokalemia develop severe pathophysiological disorders. The most important of these muscular hypotonia, weakening of tendon reflexes, severe weakness, apathy, cardiovascular disorders (decrease in blood pressure, cardiac arrhythmias), lowering the tone of intestinal muscles, intestinal paresis.

To maintain homeostasis and restore normal potassium concentration in the blood plasma and in the extracellular fluid body begins to consume potassium cells. When this occurs the movement of cells during potassium extracellular liquid, and hydrogen and sodium ions from the extracellular fluid into the cell.

Due to the movement of these ions in body change the acid-base state, which is to develop alkalosis extracellular and intracellular acidosis.

At low (colonic) obstruction vomiting in the early period of the disease is not specific. In connection with this loss of water, electrolytes and protein occur to a lesser extent than at high obstruction. That is why in this type of obstruction in the early period is not observed severe cardiovascular disorders, electrolyte balance and acid-base changes state. In the future, due to increased energy costs and malabsorption available glycogen in the body are rapidly disappearing. After the glycogen energy cost for coating start consumes cellular proteins and fats.

During the combustion of proteins and fats accumulate in the body and acidic metabolic products released endogenous water (1 g during the combustion of fat released endogenous 1ml of water). Changing the acid-base status of extracellular alkalosis, which had in the early period of obstruction, is replaced by acidosis. Last in connection with the inevitable reduction in urine output becomes decompensated.

The collapse of the cellular proteins also leads to the release of a large number of cellular potassium. When oliguria potassium. As acidic metabolites retained in the body, and in the later stages of obstruction hypokalemia replaced hyperkalemia. Last for the body is also very dangerous. In the context of hyperkalemia with cardiovascular activity and disturbed functional state of the central and peripheral nervous system. Appear arrhythmias, heart block, atrial fibrillation, convulsions and coma. Differences in metabolism disorders at high and low intestinal obstruction, which were observed in the early period, at a later period are erased.

In acute intestinal strangulation obstruction causes such as metabolic disorders, as well as in acute obstructive ileus. However strangulation comes a greater reduction in circulating blood volume. Due to compression of the mesenteric vessels and damage (especially thin-walled veins) in the lumen of the intestine strangulated in its walls and in the abdominal cavity with severe forms of strangulation obstruction (node, volvulus, or infringement of several intestinal loops) may accumulate more than 38% of all circulating in the blood vessels .

In the pathogenesis of common disorders in strangulation are important responses to painful stimuli, due to compression of the nerve plexus or torsion of the mesentery of the intestine, as well as necrobiotic changes in the intestinal wall, followed by peritonitis and intoxication.

Pathological anatomy. The most pronounced changes occur during the strangulation ileus. They are characterized by impaired blood circulation and lymph flow, alterative-destructive processes and inflammatory reactions. The degree of changes of the intestinal wall depends on the timing strangulation, but there is no clear correspondence. This may be due to varying degrees of compression of the veins in the area of ​​strangulation. The most pronounced changes in the gut sections subjected strangulation, in place oflocalization of strangulation furrows and which leads the department intestine. Discharge of intestinal loops undergo pathological changes to a lesser extent.

In the intestinal loops leading department in the early hours of the disease has increased, peristalsis and the expansion of the lumen of the intestinal loops. In the walls of the intestine occurs plethora veins, turning into blood stasis. Edema of all layers of the bowel wall. In the mucosa appear necrosis. In the mucosal and submucosal layers hemorrhage occur which are of different shapes and sizes.In the later stages of obstruction leading to intestinal loop perforation appear. Necrotic changes are more pronounced in the mucosa, they extend proximally visible when viewed from the outer areas of necrosis in the 40-60 cm.

Changes in the internal organs in acute intestinal obstruction non-specific and reflect the effects of hypovolemic shock, metabolic disorders, and peritonitis.

Clinic and diagnostics. The clinical picture fully reflects the stages of the pathogenesis of IPOs, which allows a clear staging three phases of the disease.

First, the initial phase, or phase "ileus shouting," corresponds to the first stage of the pathogenesis of intestinal obstruction. Periodically developing peristaltic wave form typical cramping, alternating light intervals. Pain during labor sharp, extremely intense. Described the development of shock-like states against the background of these pains.

There is a difference between the nature of the pain associated with obstructive and strangulated ileus forms. When strangulation fights are almost constant character or the strengths aching, periodically escalating battle. When obstructive ileus after the bout of pain is usually almost completely disappear, the patient feels much better. In the early stages of such IOs "light" intervals are long enough, which may cause diagnostic errors. The peculiarity of pain in any form of obstruction is provocative action palpation of the abdomen, causing contractions. Intestine responds to mechanical impact reduction. Deep palpation of the abdomen provokes peristaltic waves, and the patient, a new pain attack.

Irradiation of pain is not typical at IOs, has almost no diagnostic value.

Typical signs of acute intestinal obstruction occurring in 70-90% of cases, are nausea and vomiting. In the first phase of the disease is vomiting reflex character, vomit presented gastric and duodenal contents, while no signs of stagnation. Pathogenetic significance of vomiting at this stage - aggravation of water and electrolyte losses.

Delay of the chair is not a permanent feature of acute intestinal obstruction and is found only in 60-70% of patients. In this case, more than half of the cases against the backdrop of a delay chair saved carminative. A one-time (and sometimes even multiple) chair is possible with small bowel obstruction, fecal formed from the intestinal contents remaining in the distal to the level of obstruction of the intestine.