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 disease progresses rapidly, often resulting in death of the patient. The current mortality rate is generally 5% to 10%, and 10% to 20% for those with strangulated intestinal obstruction. Water, electrolyte and acid-base balance imbalance, as well as the patient’s age combined with cardiopulmonary insufficiency are often the causes of death.
I. Classification
The classification of intestinal obstruction is to facilitate the understanding of the condition, guide the treatment and estimate the prognosis, and there are usually the following classification methods.
1.Classification by etiology.
(1) Mechanical intestinal obstruction: it is the most common clinically and is due to the obstruction of the passage of intestinal contents 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 and there is no intestinal lumen narrowing, and it can be divided into two kinds of paralysis and spasticity. The former is due to sympathetic nerve reflex excitation or toxin stimulation of the intestinal tube and loss of peristaltic capacity, so that the intestinal contents can not run; the latter is due to parasympathetic excitation of the intestinal tube and excessive contraction of the intestinal wall muscles. Sometimes paralytic and spasticity can coexist in different intestinal segments in the same patient, which is called mixed type of power intestinal obstruction.
(3), hemodynamic intestinal obstruction: It 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 the blood circulation of intestinal wall.
(1) Simple intestinal obstruction: there is intestinal obstruction without intestinal blood circulation disorder.
(2) Strangulated intestinal obstruction: the presence of intestinal obstruction and the occurrence of intestinal wall blood circulation disorder, and even intestinal ischemic necrosis.
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 intestinal obstruction, low small intestinal 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 type 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 timely. Mechanical intestinal obstruction with dilated proximal intestinal canal can also develop into paralytic intestinal obstruction eventually. Incomplete intestinal obstruction can also develop into complete intestinal obstruction due to inflammation, edema or untimely treatment.
Clinical manifestations
1.Adhesive intestinal obstruction performance:
(1), previous history of chronic obstruction 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 stopping defecation.
2, strangulated intestinal obstruction performance:
(1), abdominal pain is continuous severe abdominal pain, frequent paroxysmal intensification, no complete rest interval, vomiting can not make abdominal pain abdominal distension relief.
(2) Vomiting appears early and frequently.
(3), early appearance of systemic changes, such as increased pulse rate, increased body temperature, increased white blood cell count, or early tendency to shock.
(4), abdominal distension: low small bowel obstruction is obvious, closed loop small bowel obstruction is asymmetric abdominal distension, isolated distended bowel loops can be palpated, no defecation.
(5), continuous observation: elevated body temperature, accelerated 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), abdominal puncture for bloody fluid.
III. Examination
1.Adhesive intestinal obstruction.
(1) Laboratory examination: there is usually no abnormal finding in the early stage of obstruction. White blood cell count, hemoglobin, hematocrit, carbon dioxide binding capacity, serum potassium, sodium, chloride and urine and stool routine should be routinely checked.
(2) Auxiliary examination: X-ray standing abdominal plain film examination: 4-6 hours after the occurrence of obstruction, the distended intestinal collaterals and most gas and liquid planes can be seen on the abdominal plain film. If the standing abdominal plain film shows a fixed position of coffee bean-like pneumoperitoneum, the presence of intestinal strangulation should be alerted.
2, strangulated intestinal obstruction.
(1) Laboratory tests: ① increased white blood cell count, left shift of neutrophil nuclei, blood concentration. (2) Metabolic acidosis and disturbance of water-electrolyte balance. (3) Elevated serum creatine kinase.
(2) Auxiliary examination: X-ray standing abdominal plain film shows fixed isolated intestinal loops in the shape of coffee beans, pseudotumor and petal, and widened intestinal gap.
IV. Treatment
1.Adhesive intestinal obstruction.
(1), non-surgical treatment: for simple, incomplete intestinal obstruction, especially extensive adhesions, non-surgical treatment is generally selected; for simple intestinal obstruction can be observed for 24 to 48 hours, for strangulated intestinal obstruction should be surgical treatment as soon 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. Traditional Chinese medicine and acupuncture therapy can also be used.
(2) Surgery: If the condition of adhesive intestinal obstruction is not improved or aggravated by non-surgical treatment; or if it is suspected to be strangulated intestinal obstruction, especially closed loop intestinal obstruction; or if adhesive intestinal obstruction has recurrent and frequent attacks, which seriously affects the quality of life of patients, surgery 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 For those with extensive adhesions and repeated intestinal obstruction, intestinal alignment is feasible.
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.
V. 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 health promotion and education, and develop good hygiene habits. Prevent and treat intestinal ascariasis.
3, after major abdominal surgery and patients with 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.