腸梗阻 中山大學(xué) 外科學(xué)

1、Intestinal obstructionDefination A blockade of the flow of intestinal content. Anatomic, functional changes but also systemically physiologic disorders.1Clinical manifestations complicatedMost common emergency disease2Etiology and classification 1.According to its basic causes: mechanical, dynamic o

2、bstruction,and obsturction of vascular supply origin 1). Mechanical obstruction from lesions within the wall of the intestine, intrinsic from extra-intestinal lesions , extrinsic from obstructing intra-luminal substances. congenital, inflammatory, neoplastic, or traumatic origin. postoperative adhes

3、ions, congenital origin, Henias Intra-luminal foreign bodies32). Dynamic obstruction（paralytic） Nerval reflex or toxin stimulationmuscle disorder acute diffuse peritonitis, abdominal operation, retroperitoneal hematoma and infection. Spastic obstruction in intestinal functional disorder or toxicatio

4、n.3). Obstruction of blood supply origin thrombosis or embolism, then intestinal paralysis.42.According to whether the vascular supply to intestinal wall is compromised, Simple and strangulation obstruction. Simple obstruction, mechanical without threat to the viability Strangulation obstruction, th

5、e vascular supply is compromised. Not relieved, leads to infarction53.According to obstruction level or site. Proximal, distal intestinal, or large bowel obstruction, or high and low obstruction 4.According to the extent of obstruction Incomplete and complete obstruction, 5.According to mode of onse

6、t and progression of obstruction. Acute and chronic obstruction6PathophysiologyMotility of the small intestineThe intestine contracts vigorouslyThe patient crampy abdominal pain Finally the intestine dilated.7Absorption and secretion water and electrolytes accumulate. a decrease in absorption, an in

7、crease in intestinal secretion.8Infection and toxemiaThe bacteria proliferate, produce toxin.Vascular supply or viability compromised bacteria,toxin diffuse severe peritonitis and toxemia.9Shock Severe dehydration, decrease of blood volume electrolytic disturbance, acid-base imbalance, bacterial inf

8、ection and toxemia, 10Clinical manifestations Nausea and vomiting Colicky abdominal pain Obstipation Abdominal distention. Their onset varies not only with the duration of established obstruction but also with its anatomic site.111.Nausea and vomiting: may be the only symptoms. 1).The nature of the

9、vomitus. undigested food particles. becomes bilious. feculent. 2).The onset and character of vomiting-level. Recurrent vomiting of bile-stained fluid (proximal ) Prolonged nausea precedes vomiting, feculent.(distal) Vomiting a late finding if the ileocecal valve prevents122. Crampy (spastic) abdomin

10、al pain: Absent, Most prominent,paroxysmal,crampy,often diffuse, poorly localized, and lasting 1-3min. Between spasms, pain resolves. Borborygmus loud, coincident with cramps Severe ,continuous abdominal pain suggests intestinal ischemia or peritonitis.133.Abdominal distention: Develop later in the

11、course of obstruction Associated with obstructed site or level. 1)not prominent in proximal intestinal obstruction, 2)prominent and diffuse in distal intestinal obstruction and paralytic obstruction. 3)colon is obstructed, round abdomen.4)intestinal torsion，asymmetrical. 144.Contispation and obstipa

12、tion: The onset of obstipation, a late development. Still pass flatus or feces: the distal, unobstructed intestine empties. partial or incomplete obstruction15Physical Examination the signs of dehydration, sunken eyes, dry mucous membranes, loss of skin turgor, and before resuscitation, resting tach

13、ycardia.16Inspection: The degree of abdominal distention varies with both the duration and the location of the obstruction. Peristalsis occasionally visible, scar/herniaPalpation: Localized tenderness or a tender, palpable mass -closed loop Signs of localized or generalized peritonitis-gangrene or r

14、upture 17 Auscultation: Obstructed bowel sounds(borborygmi)high-pitched,metallic with tinkles, splashes, and rushes coincide with the abdominal colic. With late obstruction , it loses its contractile activity, and rushes may be absent. Borborygmus (Bowel sounds) may be absent in paralytic obstructio

15、n.18Percussion: If the segment of intestine is strangulated, shifting dullness may be evident.Rectal digital examination: Low rectal carcinoma and intussuscepted segment are palpable sometimesLaboratory tests: Serve only to define the fluid and electrolyte status.19Abdominal roentgenograms Supine an

16、d erect abdominal roentgenograms. When small bowel is obstructed, supine:dilated loops of small intestine erect: multiple air-fluid level ,bladder-like When large bowel is obstructed, the image of dilated colon and haustra of colon Occasionally, confirm the diagnosis reveal the cause.202122Diagnosis

17、must make clear the following questions:1.Whether intestinal obstruction exists: Through symptoms and signs, the diagnosis can be made without difficulty. Abdominal roentgenograms is much helpful in diagnosis.232.Whether the obstruction is mechanical or dynamic: mechanical: typical symptoms and sign

18、s. Paralytic: crampy pain absent, distention is prominent 243.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation:1).Abrupt onset with continuous acute abdominal pain,2).Shock3).Manifestation of peritonitis: leukocytosis, hyperthermia.4).Asymmetrical distent

19、ion, local bulge, or mass with tenderness.5).Hemic (hematic) vomitus, drainage 6).Conservative treatment in vain and no improvement in symptoms and signs.7).Isolated, bulged, and distended intestinal loop on roentgenograms. 254.Whether the obstruction is high or low : Vomiting, in proximal intestina

20、l obstruction. Distention in low obstruction, feculent vomitus Abdominal roentgenograms is helpful. 5.Whether the obstruction is complete or incomplete: frequency of vomiting, extent of distention, and roentgenograms.266.Which causes leads to obstruction: According to the age, history, symptoms and

21、signs, roentgenograms. Postoperative adhesionsHeniasCongenital malformations (newborn infants)Intestinal intussusception (children 2years)Obstruction of parasite origin (chilidren)Carcinomas and dry feces (elders)27Treatment or Management The principle: correction of systemic disturbance reduction o

22、f obstruction.28Basic treatment1).Gastrointestinal decompression:2).Correction of water-electrolytic disturbance, acid-base imbalance3).Prevention (Prophylaxis) and treatment of infection and toxemia:29Treatment of obstruction1.Operative treatment strangulation obstruction or obstruction of neoplastic and