Page 24 of 73 INTESTINES INVAGINATION
Invagination — a telescopic vklinivaniye of a segment of a digestive tract in a nearby caudal segment.
At children from 2 months to 6 flyings invagination is the most frequent reason of impassability. Most often invagination arises aged from 3 till 36 months. In rare instances of invagination there comes spontaneous recovery, but usually uncured invagination conducts to death of the patient.
Etiology and epidemiology. The reason of the majority of cases of invagination remains obscure. Incidence peaks in spring and autumn time are noted. Correlation with an adenoviral infection is established; invagination can be complication of an acute gastroenteritis. Increase in number of lymphatic follicles of a small bowel (peyerovy plaques) can play a part: in reply to a pas increase in mass of lymphatic fabric the gut reacts strengthening of a vermicular movement that can lead to invagination. It is necessary to pay attention to that fact that the peak of incidence is necessary a pas age when the child begins to receive many foodstuff, new to it. Approximately at 5% of patients it was succeeded to establish the invagination reasons. Among them — the inverted diverticulum of an ileal gut, a polyp of intestines, a duplikatur and a lymphosarcoma. Very seldom this state complicates Shepleyn's illness — Genokh when the intramural hematoma puts in the next segment. The postoperative invagiiation which is always localized in an ileal gut belongs to rare forms.
Pathogeny. The most frequent types of invagination are implementation of an ileal gut in colonic, an ileal gut in ileal and then in colonic; less often the caecum puts in colonic and absolutely seldom invagination takes only an ileal gut. It is necessary to refer invagination of a worm-shaped shoot to casuistry. The implemented part of a gut pulls for itself a mesentery owing to what venous outflow is broken. Stagnation of blood conducts to hypostasis and bleeding of a mucous membrane of an intussusceptum, emergence of a bloody chair, sometimes with slime impurity. The top of the invaginated gut can reach to cross, descending and even a sigmoid colon up to an anus. After idiopathic invagination finishes, the top of the put part of a gut remains edematous and reinforced, on its serous surface deepenings are visible. Within the first days of infringement of a gut in most cases does not occur, but gangrene and shock can develop further.
Clinical manifestations. In typical cases the healthy child suddenly has attacks of the most severe pains which repeat through small periods and are followed by strong desires to defecation. In an initial stage in intervals between attacks the child feels well, plays, but if invagination independently does not finish, the patient becomes sleepy, weakens. Further the shocklike state with rise in temperature to 41 ° can develop. Pulse is weak, threadlike, breath superficial and noisy, at pain the child groans. Vomitings, especially at the beginning of a disease are typical. Later emetic masses is painted by bile. In the first several hours after emergence of symptoms allocation normal a calla is possible, but then the amount of excrement sharply decreases or, more often, there is no chair at all; gases almost do not depart. Blood appears in Calais in the first 12 h, but sometimes only in 1 — 2 day, and in rare instances blood in fecal masses does not happen at all. In 60% of cases containing slime and blood of kcal has an appearance of currant jelly. At some patients the disease is expressed only by irritability and the periodic or increasing drowsiness.
At a palpation of a stomach sensitive kolbasovidny education which amount and density increase at a painful attack is defined. It is most often localized in the right upper quadrant of a stomach, its long axis is located in the cranial and caudal direction. If education is in epigastriums, then its long axis is located cross. In 30% of cases palpatorno the thickening is not defined. The zone of invagination can be defined easier by conjoined manipulation through a front abdominal wall and a rectum in intervals between pain paroxysms. Availability of bloody slime on a finger after rectal research confirms the diagnosis of invagination. In process of development of impassability of intestines tension and morbidity of a stomach increase. Very seldom invaginated gut prolabirut in an anus. Loss such differs from a prolapse of the rectum in the fact that in the first case between the dropped-out gut and a wall of a rectum the free space is defined.
The clinical picture of ileal and ileal invagination is less typical, symptomatology same, as at impassability of a small bowel. Recurrent invagination belongs to rare states. Chronic invagination at which symptoms are shown benign through certain periods on-vidimomug is connected with acute enteritis and is observed at children of any age.
Diagnosis. The anamnesis and physical data are rather typical and allow to make the diagnosis quite precisely. On the survey roentgenogram of an abdominal cavity it is possible to see dense weight in the field of invagination. At an irrigoskopiya defect of filling or impression in the place of a delay of a baric suspension is defined by the put gut (fig. 12-16). In the center of an intussusceptum the narrow strip of the barium which got into the squeezed gut gleam is traced, and on the periphery of an intussusceptum are visible flow barium between folds of a mucous membrane, especially after bowel emptying. It is necessary to carry intussusceptum shift under pressure of baric weight to important radiological signs and stretching of a small bowel gases owing to impassability. Ileal and ileal invagination at an irrigoskopiya usually does not manage to be diagnosed, however intestines stretching gases allows to suspect this state.
Fig. 12-16. Invagination in proximal part of a cross colon. Contrast weight around the invaginated gut creates the picture reminding a spring.
Differential diagnosis. It is especially difficult to diagnose invagination of intestines if it arose against a gastroenteritis; in such cases of the doctor change of disease, character of pain, vomiting and emergence of rectal bleedings have to guard. The bloody chair and colicy pains accompanying an acute coloenteritis differ from those at invagination in smaller expressiveness and an irregularity. Besides, at a coloenteritis the condition of the child during the interpainful periods at the beginning of a disease is heavier, than at invagination. Bleeding from a diverticulum of an ileal gut usually is not followed by pains. The anaphylactoid purpura is also followed by kolikoobrazny pains, but at the same time usually, though not always, joint symptoms and hemorrhages in other bodies are noted; as invagination can be complication of this disease, it is reasonable to carry out an irrigoskopiya.
Treatment. Elimination of invagination of intestines — urgent action which needs to be carried out right after establishment of the diagnosis and intense preoperative training (administration of liquids and blood for the prevention of shock and stabilization of water-salt balance). At the very beginning of a disease when there is no prostration yet, shock and irritation of a peritoneum, in 75% of cases it is possible to straighten an intussusceptum by means of hydrostatic pressure under radiological control.
The ungreased catheter cylinder of Foley is entered into a rectum and inflate a cuff. Buttocks strong clamp and fix an adhesive plaster. Then enter a baric suspension into a gut by gravity from height which is not exceeding 90 cm over a surface of a x-ray table. It is forbidden to press on a front abdominal wall during procedure. Baric weight slowly moves ahead in the proximal direction, displacing defect of filling in the same direction. Free filling of a small bowel, disappearance of the palpated tumor, a passage of flatus and a calla, improvement of the general condition of the child testifies to a raspravleniya of invagination. If there are any doubts concerning the received effet, then make an urgent trial laparotomy.
If signs of intestinal impassability, especially lasting disease of 48 h and more developed, then do not apply the described method of treatment as it is accompanied by danger to perforate the invaginated gut. In cases of podvzdoshnopodvzdoshny invagination the barium enema has no diagnostic value and the hydrostatic method of elimination of invagination is also not applied. This type of invagination can develop gradually after a laparotomy; in such cases it is necessary to resect a gut. The right-hand cross periomphalic section gives good access to the ascending colon. If it is not possible to straighten invagination hands and if the gut is already impractical, then make a resection with imposing of an anastomosis "the end in the end" to recover integrity of a gut.
Forecast. Uncured invagination at babies practically always conducts by a lethal outcome; chances of recovery depend on terms of the beginning of medical actions. Most of children recovers if invagination manages to be liquidated in the first 24 h, but if this term is exceeded, then mortality sharply increases, especially after third day. Quite often happens that during transportation of the patient and preparation it to operation invagination spontaneously finishes.
In children's hospital Toronto recurrence of invagination after its elimination by means of a barium enema is noted in 10% of cases, after an intestines raspravleniye by a surgical way — in 2 — 5%, after bowel resection recurrence was not. It is improbable that the invagination caused by a lymphosarcoma, a polyp or the inverted diverticulum of an ileal gut can be straightened by means of a barium enema. In such cases the adequate and timely carried out surgical intervention allows to reduce mortality sharply.
Polyps of a large intestine
Polyps of a large intestine very seldom serve as the reason of impassability of intestines. The exception is made by cases when the polyp causes invagination of a large intestine in thick. The main sign of a polyp — painless rectal bleeding. Polyps consist of granulyatsionny fabric and cystous cavities, have rather narrow leg; approximately in 80% of cases polyps at children single, are located within reach of a sigmoskop. In literature there are no messages on a malignancy of juvenile polyps. The majority of them disappears spontaneously, apparently, owing to a necrosis when twisting a leg. Low located polyps delete as follows: by means of a sigmoskop the polyp is removed outside through an anus, tied up at the basis and cut. The high-quality new growths located out of reach of a sigmoskop diagnose by method of a double contrast study of a large intestine;
if the polyp remains within several years, then it should be removed by means of a colonoscope. This method has advantages before a laparotomy and a colotomy, but nevertheless it is necessary to resort to the last if the polyp is located on the wide basis.