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Pathophysiological features and phases of a current of postoperative intestinal impassability

Searches of clinical possibilities of early diagnostics of an intestinal hypertensia have forced us to address to researches referred on studying of interrelation pathophysiological, morfologiechkih and endotoksicheskih changes, applying thus the syndromic approach.

Proceeding from that understanding, that the intestinal hypertensia is an initial syndrome of acute intestinal impassability, we consider, that the high pressure in a small bowel lumen potentsiiruet inflammatoryly - degenerate reaction in enterocytes mucous, but thus does not reach level of necrotic changes. The intestinal hypertensia can last 6-8 hours from the moment of the disease beginning, and this period of time can be enlarged depending on obturation level.

Morphological researches testify that kariotsitolizis a mucosa and podslizistogo a nervous plexus begins from 6-7 o'clock from the beginning of postoperative intestinal impassability, and at a peritonitis already later 3-4 hours. Kariotsitolizis accrues and after 24 hours covers all layers of an intestinal wall, including a serous cover (Andreev M. JU. 2004).

It is necessary to allocate two basic stages which can be parted on local and universal. At a local stage there are insignificant necrobiotic changes in a kind kariotsitolizisa in a mucosa and podslizistom a layer. At a universal stage there are fabric necrosises which get through all layers of a wall of an intestine up to a serous cover.

Depending on obturation level the local stage can last from 6 till 40 o'clock, and, at high impassability - no more than 24 hours. The termination of a local stage and its transition in the universal corresponds

To the beginning of occurrence of a peritonitis as are characterised by rising of permeability of vessels and small bowel walls, that in turn, leads eliminatsii intestinal flora in abdominal полость*.

Reduction of terms of a local stage of intestinal insufficiency characteristic for high intestinal impassability defines more serious clinical current of disease, fast development of metabolic shifts and an endointoxication. For specification of character of a current of postoperative intestinal impassability the analysis in 56 case histories of patients operated concerning postoperative acute intestinal impassability is carried out. The purpose of this analysis was to tap terms of a syndrome of an intestinal hypertensia at a high and low obturation, taking for a basis identity of morphological criteria irrespective of obturation level. At an estimation of clinico-morphological aspects both in that and in other case, at a syndrome of an intestinal hypertensia despite an inflation and a stretching of an intestine colour of its serous integument has been kept, and peristaltic movements of an intestine after evacuation of its contents were quickly restored. The developed clinic of a syndrome of an intestinal hypertensia at patients of high intestinal impassability was distinctly formed at the first 14 o'clock, and at low – in the first 18.

Intraoperatsionnaja the picture of a local stage of an intestinal hypertensia, irrespective of its level consisted available inflammatory changes in a kind of a thickening of a wall, an edema, a hyperemia, resulting departments, but thus an exudate in an abdominal cavity did not find out. Definitive formation of a local stage at high impassability was equaled on the average to 21 hour, and at low 26 hours.

If during operation insignificant signs of a peritonitis were found out even, considered, that the local stage has passed in the universal. For high impassability time of development of a universal stage sotavilo on the average 30 hours, at low over 35 hours from the disease beginning.

*Попов JU.P.earl etapnaja diagnostics of postoperative complications in abdominal surgery. / JU.P. Priests, L.A.Magomedov, K.A.Akilin, P.A.Popov, D.S.Simonov, V.A.Makarov//Scientifically-practical magazine "Surgeon" - 2014. - № 4. - S.33-37.

To establish as it is possible obektivizirovat each stage of pathological process have carried out the analysis of 55 X-ray analysises and 50 reports of ultrasonic research of patients operated concerning acute intestinal impassability.

At the analysis of roentgenograms, we have paid attention that such well-known symptoms as liquid moving to a small bowel, the isolated inflation, bowls Klojbera, at a low obturation were defined on the average at 5-6 o'clock later, that is, in this case it is possible to consider, that the intestinal hypertensia proceeds longer time so both necrotic changes and a peritonitis develop later. It is possible to consider as other important conclusion that the radiological semiology of an intestinal hypertensia both at high, and at low impassability leaves much to be desired. Only at 15 % of patients at high and at 32 % at the low the diagnosis on the basis of a X-ray inspection is established. At the same time, at increase of a clinical picture of disease efficiency of a X-ray inspection it was enlarged and at a stage of intestinal insufficiency the radiological diagnosis has been put at 32 % at high, and in 72 % at low intestinal impassability. The big role directed by the diagnosis in slozhnoklinicheskih observations is played by use of a passage of barium (Schwarz's assay) which is effective both on early, and later stages of intestinal impassability. Efficiency of radiodiagnosis of a syndrome of an intestinal hypertensia at carrying out of this assay has made 52 % at high, and 65 % at low intestinal impassability.

Nevertheless, the case history analysis testifies to high enough percent of the diagnostic mistakes which frequency is especially high at early stages of disease that forces to conduct search of new methods of research.

Last years ultrasonic methods of research activly take root into practice of work of the surgeon. The cores Ouses-signs we

Considered an edema and a thickening of a wall of an intestine, change of character of a peristalsis, overflow of an intestine with a stretching of its lumen. It is necessary to notice, that at high impassability they arise at 5-7 o'clock earlier. If there are such Ouses-symptoms as a free liquid in an abdominal cavity, the peristalsises corresponding to a universal stage of disease it is possible to ascertain, that at their high intestinal impassability it is possible to establish disturbance at 6-12 o'clock earlier.

There are also ultrasonic data, characteristic for a syndrome of an intestinal hypertensia. It is a syndrome of rising of endoluminal deposition, an antiperistalsis and a stomach paresis. These signs are characteristic for a high obturation and are absent at the low. It is necessary to note, Chtouz-research has appeared more sensitive method for early diagnostics of a syndrome of an intestinal hypertensia as the positive take has been reached in 73 %.

Ouse-simpotomatika a universal syndrome it is similar both at high, and at low intestinal impassability. The thickening of a wall of an intestine, endoluminal deposition of a liquid, lumen expansion, a free liquid in an abdominal cavity, is thus taped by peristalsis change. Accordingly in this stage of development of pathological process the quantity of positive takes of Ouse-diagnostics which reached 87 % was enlarged also.

Pathophysiological bases of development of intestinal impassability vysogo and low level are in many respects identical, but also at the same time differ on character and gravity metabolicheschkih processes. Intestinal impassability already at a stage of an intestinal hypertensia quickly enough is high there be to rasvitiju a metabolic alkalosis as it is accompanied by repeated vomiting, loss of electrolytes, dehydrations, level of bicarbonates grows. Thus such well-known signs of an inflammation as temperature, a blood leukocytosis can be absent while insufficiency cardiovascular,

Respiratory systems, renal insufficiency, can accrue quickly enough.

At low intestinal impassability the syndrome of an intestinal hypertensia is accompanied by increase of signs of a metabolic acidosis because of a considerable quantity sequestration sozherzhimogo a small bowel in a lumen of resulting loops, the bicarbonate maintenance decreases on 28-30 %, loss of electrolytes and a dehydration accrue gradually. Possibly therefore it does not become perceptible clinically expressed organnyh disturbances of cardiovascular and respiratory systems.

Further pathophysiological metabolic disturbances progress and at a syndrome of intestinal insufficiency they correspond to signs of a deep metabolic alkalosis. The decompensation organnyh disturbances at high intestinal impassability develops much faster, than at the low.

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A source: MAGOMEDOVA Lyudmila Atstsikadievna. Early stage diagnosis of postoperative abdominal complications in gynecology. Thesis for the degree of candidate of medical sciences. Moscow - 2015. 2015

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