Obstruction of the passage of intestinal contents due to any cause is collectively called intestinal obstruction. It is one of the common surgical emergencies. Sometimes acute intestinal obstruction is difficult to diagnose, and the condition progresses rapidly, often leading to death. The imbalance of water, electrolyte and acid-base balance, as well as the combination of cardiopulmonary insufficiency in patients with advanced age are often the causes of death.
Classification of intestinal obstruction
The classification of intestinal obstruction is to facilitate the understanding of the condition, guide the treatment and estimate the prognosis, and there are usually several classification methods as follows.
1. Classification by etiology
(1) Mechanical intestinal obstruction is the most common clinical obstruction, which is caused by various mechanical factors in the intestine, intestinal wall and outside the intestine.
(2) Dynamic intestinal obstruction
It is caused by the dysfunction of intestinal wall muscle movement without intestinal lumen narrowing, and can be divided into two types: paralytic and spastic. The former is due to the loss of peristaltic ability due to the reflex excitation of sympathetic nerve or toxin stimulation of intestinal canal, so that the intestinal contents cannot run; the latter is due to the excessive excitation of parasympathetic nerve of intestinal canal and excessive contraction of intestinal wall muscles. Sometimes paralytic and spasticity can coexist in different intestinal segments of the same patient, which is called mixed type of dynamic intestinal obstruction.
(3) Hemodynamic intestinal obstruction is due to the formation of thrombus in the mesenteric vessels and vascular embolism, which causes impaired blood circulation in the intestinal tube, resulting in the loss of intestinal peristaltic function and stopping the operation of intestinal contents.
2. Classification according to blood circulation of intestinal wall
(1) Simple intestinal obstruction There is intestinal obstruction without intestinal blood circulation disorder.
(2) Strangulated intestinal obstruction There is intestinal obstruction and blood circulation obstruction of intestinal wall at the same time, and even ischemic necrosis of intestinal tube.
3. Classification according to the degree of intestinal obstruction
It can be divided into complete and incomplete or partial intestinal obstruction.
4. Classification according to the site of obstruction
It can be divided into high small intestine obstruction, low small intestine obstruction and colonic obstruction.
5. Classification according to the severity and urgency of the onset
It can be divided into acute intestinal obstruction and chronic intestinal obstruction.
6. Closed loop intestinal obstruction
This type of intestinal obstruction is most likely to have intestinal wall necrosis and perforation.
The classification of intestinal obstruction is considered from different perspectives, but it is not absolutely isolated. For example, intestinal torsion can be both mechanical and complete, as well as strangulated and closed loop. Different types of intestinal obstruction can be transformed under certain conditions, such as simple intestinal obstruction can develop into strangulated intestinal obstruction if it is not treated in time. Mechanical intestinal obstruction with dilated proximal intestinal canal can also develop into paralytic intestinal obstruction eventually. In incomplete intestinal obstruction, due to inflammation, edema or untimely treatment, it can also develop into complete intestinal obstruction.
Clinical manifestations of intestinal obstruction
1. Adhesive intestinal obstruction
Performance.
(1) Previous history of chronic obstructive symptoms and multiple recurrent acute attacks.
(2) Most patients have a history of abdominal surgery, trauma, bleeding, foreign body or inflammatory disease.
(3) Clinical symptoms are paroxysmal abdominal pain with nausea, vomiting, abdominal distention and cessation of defecation.
Physical examination:
(1) Systemic condition: there are mostly no obvious changes in the early stage of obstruction, and signs of fluid loss may appear in the late stage. When strangulation occurs, systemic toxic symptoms and shock may appear.
Before the development of intestinal obstruction to intestinal strangulation and intestinal paralysis, there are hyperactive bowel sounds, and gas-over-water sound or metallic sound can be heard.
2. Strangulated intestinal obstruction
Performance.
(1) Abdominal pain is persistent and severe abdominal pain with frequent paroxysmal intensification without complete rest intervals, and vomiting cannot relieve abdominal pain and distension.
(2) Vomiting appears early and more frequently.
(3) Systemic changes appear early, such as increased pulse rate, increased body temperature, increased white blood cell count, or a tendency to go into shock early.
(4) Abdominal distension: low-level small bowel obstruction is obvious, and closed-loop small bowel obstruction is asymmetric abdominal distension, isolated distended bowel loops can be palpated, and no defecation.
(5) Continuous observation: elevated body temperature, increased pulse rate, decreased blood pressure, impaired consciousness and other signs of infectious shock can be found, and bowel sounds change from hyperactive to attenuated.
(6) Obvious signs of peritoneal irritation.
(7) Vomit is bloody or anal discharge of bloody fluid.
(8) The abdominal puncture is bloody fluid.
Treatment
1. Adhesive intestinal obstruction
(1) Non-surgical treatment
For simple and incomplete intestinal obstruction, especially for extensive adhesions, non-surgical treatment is generally chosen; for simple intestinal obstruction, 24 to 48 hours of observation is allowed, and for strangulated intestinal obstruction, surgical treatment should be carried out as early as possible, and generally observation should not exceed 4 to 6 hours.
Basic therapy includes fasting and gastrointestinal decompression, correction of water and electrolyte disorders and acid-base imbalance, prevention and control of infection and toxemia.
(2) Surgical treatment
If the condition of adhesive intestinal obstruction does not improve or is aggravated by non-surgical treatment; or if it is suspected to be strangulated intestinal obstruction, especially closed loop intestinal obstruction; or if the recurrent and frequent attacks of adhesive intestinal obstruction seriously affect the quality of life of patients, surgical treatment should be considered. ①Simple cutting and separation of adhesions or small pieces of adhesions. If the intestinal loops with small confined tight adhesions cannot be separated, or if the intestinal tube is necrotic, intestinal resection anastomosis is feasible. ③If the patient’s condition is very poor, or the intraoperative blood pressure is difficult to maintain, it can be preceded by external intestinal placement. ④If the intestinal loops are closely adhered and cannot be resected and separated, lateral anastomosis of the distal and proximal intestines at the site of obstruction is feasible. ⑤ Intestinal alignment is feasible for those with extensive adhesions that repeatedly cause intestinal obstruction.
2. Strangulated intestinal obstruction
(1) Strangulated small intestinal obstruction should be treated by surgery immediately after diagnosis, and the surgical method should be decided according to the cause of strangulation during surgery.
(2) If the patient’s condition is very serious and the intestinal tube is necrotic, and the blood pressure cannot be maintained during the operation, it is feasible to perform external intestinal placement and then perform second-stage anastomosis when the condition improves.
Prevention
According to the causes of intestinal obstruction, certain preventive measures can be taken to effectively prevent and reduce the occurrence of intestinal obstruction.
1. Patients with abdominal wall hernia should be treated in time to avoid intestinal obstruction caused by entrapment and strangulation.
2. Strengthen hygiene propaganda and education, and develop good hygiene habits. Prevent and treat intestinal ascariasis.
3. Patients after major abdominal surgery and peritonitis should be well gastrointestinal decompression, surgical operation should be gentle, and try to reduce or avoid abdominal infection.
4. Early detection and treatment of intestinal tumors.
5. Early activity after abdominal surgery.
The appearance of intestinal obstruction must be handled carefully, not to take drugs indiscriminately, cautiously and carefully, and must go to the local hospital for examination.