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12:28. IMPASSABILITY OF THE SMALL BOWEL
The atresia, stenosis, mekoniyevy stopper, illness of Girshprunga, invagination, Mekkel's diverticulum, duplikatura of intestines and the restrained hernia can be the reasons of impassability of a small bowel.
Pathogeny. At an atresia ileal or a jejunum the proximal and distal end comes to an end blindly owing to what integrity of a gut is broken; at the same time even bifurcation of a mesentery is possible. At stenotic, or "sailing", impassability the continuity of a gut remains. The gut loop located above the block considerably is increased in sizes while the distal end of a gut is in the fallen-down state. In rare instances on the course of a gut there are several sites of an atresia; this form of a disease usually has family character. In experiment the atresia (including a rassasyvaniye of a gangrenous gut) managed to be received by pre-natal bandaging of vessels of intestines of a fruit.
Mekoniyevy impassability arises at the birth at 10% of patients with a mucoviscidosis. At the same time the last 20 — 30 cm of an ileal gut have the fallen-down appearance and are filled with lumps blednookrashepny a calla; the loops of a gut located above are stretched by the meconium which filled them which has a consistence of dense syrup or glue. Peristaltic waves are not able to push this viscous weight through loops of an ileal gut. Mekoniyevy impassability can be combined with torsion, an atresia or perforation of intestines. At perforation of in utero there is mekoniyevy peritonitis as a result of which dense commissures in an abdominal cavity are formed. In the post-natal period they can become the reason of commissural impassability of intestines.
At 3% of persons with an illness of Girshprunga the denervated segment takes not only all large intestine, but also distal department of an ileal gut. The proximal part of a small bowel is expanded, walls support her a ganglion and are a little hypertrophied. Then the intermediate site in which the quantity gangliyev is reduced follows; it has the funneled form. The distal denervated segment of a gut is in the fallen-down state.
Clinical manifestations. The child's mother with high impassability of a jejunum has instructions on pregnancy abounding in water; at a mucoviscidosis several cases in one family are possible. In one cases the child is born with the stretched stomach (owing to overflow of loops of intestines meconium), impassability develops in others soon after the birth and increases as a result of swallowing air. Often stretching of a stomach is caused by mekoniyevy peritonitis in the pre-natal period when flowed out in an abdominal cavity of mezkoniya quickly it kaltsifitsirutsya. Usually perforativpy opening is closed till the birth therefore operational treatment is not required, but if perforation remains and free gas in an abdominal cavity is defined, then the patient needs to be operated. Vomiting belongs to early symptoms, at the same time emetic masses is painted by bile. Newborns to an atresia of a small bowel sometimes have unusually plentiful mekoniyevy chair, however at mekoniyevy impassability the chair is absent. If during 24 h after the birth the sizes of a stomach increase, hepatic dullness is not defined perkutorno and there are symptoms of ascites, then it is necessary to think of a piyevmoperitoneuma.
Diagnosis. At mekoniyevy impassability on survey roentgenograms the typical symptom of "opaque glass" or picture "smazannost" in the right lower quadrant of a stomach is visible; these signs are explained by existence in meconium of a set of vials of gas. Besides, on the roentgenograms made at vertical position of the patient at mekoniyevy impassability levels of liquid and gas because of high viscosity of contents of the stretched intestines loops are not visible. Enemas with radiopaque substance (gastrografipy) at suspicion on mekoniyevy impassability should be done carefully as hyper osmolarity of a contrast agent can aggravate dehydration, and increase of intra intestinal pressure — to lead to perforation. After mekopiyevy peritonitis in lateral departments of a stomach it is possible to notice calcificats. Pnevmoperitoiyeum is characterized by existence of a strip of gas between a liver and a diaphragm on the roentgenograms made at vertical position of the patient. At big accumulation of free gas the stomach looks as a soccerball; the round sheaf sometimes is determined by the average line of a stomach.
If survey roentgenograms are insufficiently informative, then for differentiation of enteric and colic impassability it is necessary to resort to an irrigoskopiya, using the baric weight or Gastrografinum. Detection of an underdeveloped large intestine ("mikrokolop") demonstrates that it does not function and that the site of impassability is proksimalny the ileocecal gate. At newborns and children of the first year of life it is impossible to distinguish a small and large intestine of a pas survey roentgenograms.
Treatment. Before operation or attempts "to wash away" a gut by means of radiopaque substances it is necessary to stabilize a condition of the patient by means of introduction of necessary amount of liquids and electrolytes. The accompanying infections it is necessary to treat the corresponding antibiotics. Also preventive introduction of antibiotics is shown.
At an atresia of a lean or ileal gut the expanded proximal part of a gut is resected and impose an anastomosis "the end in the end". In case of a simple mucous membrane instead of a resection of a loop carry out eyuno-or to an ileoplastik with partial excision of a membrane.
Treatment of mekoniyevy impassability is begun with attempts to liquidate the block by means of an enema with Gastrografinum. This drug passes between lumps of fecal masses in terminal department of an ileal gut, gets into the proximal part of a small bowel expanded and hammered with meconium where causes plentiful secretion of liquid in a gut gleam. Thanks to it viscous mekoiiya it is liquefied, and there is an allocation of a liquid chair. There can be a need to repeat an enema in 8 — 12 h. If this procedure is successful, then need for a resection disappears (provided that there is no intestines ischemia).
In 50% of cases the gastrografinovy enema does not give effect and therefore it is necessary to resort to a laparotomy. Make a simple ileotomy, and do a section of such sizes that through it there passed the catheter, and put a purse-string stitch. Through a catheter irrigate a gut cavity with mucolytic means (Acetylcysteinum in concentration less than 5%) and delete its contents. After the end of aspiration the purse-string seam is tightened and about an ostomy leave a small drainage; on it operation comes to the end. It allows to do without resection and an anastomosis.
At a laparotomy concerning a pneumoperitoneum impose kolosty or ileosty in the field of perforation, but if perforation happened in a stomach, duodenal or a jejunum, then method of the choice is sewing up of a perforative opening. There can be a need for transition to parenteral food.