Examination of the intestines using modern methods. Treatment of intestinal obstruction Other research methods
Many methods of intestinal decompression have been proposed, the requirements for which include: maximum release of the intestines from gas and liquid, prevention of infection abdominal cavity, unhindered removal of contents in the postoperative period, minimal traumatic manipulation.
Elimination of mechanical obstruction does not yet mean the elimination of obstruction altogether, since one or another degree of functional obstruction may remain or arise. Therefore, one of the main tasks is to prevent or quickly resolve postoperative intestinal paresis. A relationship has been established between the nature and amount of intestinal contents and the degree of intestinal motility disorders.
Intestinal decompression by puncture
A common method of intestinal decompression was to remove the contents by puncture of the intestinal wall and suction, followed by suturing the hole. The method is simple, but it does not remove at least most of the liquid. Its accumulation continues, and the risk of infection of the abdominal cavity is very high. It is more completely possible to evacuate the contents through the enterotomy opening using an electric suction, or directly through the ends of the transected intestine during its resection. In addition to these disadvantages in such cases, there is a high level of trauma.
Intestinal decompression by milking
The “milking” method - moving the contents into the underlying loops - is almost never used, since it is not possible to empty the intestines completely enough, and the injury is significant. Progressive flatulence and fluid accumulation can lead to failure of the sutured puncture or enterotomy opening. According to the literature, the mortality rate of patients with acute intestinal obstruction, complicated by opening the lumen of the digestive canal, is 3 times higher than that observed in the case of an intact intestine.
Intestinal decompression by enterostomy
At the Research Institute named after. N.V. Sklifosovsky developed a method of intestinal decompression using suspended enterostomy with the introduction of a short tube into the intestinal lumen to create an outflow, which received wide application. However, nowadays it is rarely used. This is explained by the fact that in this way it is not possible to achieve complete release of the intestinal loops. At best, the nearest loops are emptied. IN Lately Safer methods of intestinal decompression using nasojejunal tubes have been created.
Considering that the main disadvantage of suspended enterostomy is incomplete bowel emptying, it was proposed to insert into the intestinal lumen not a short, but a fairly long tube (1.5-2 m) with many side holes (I. D. Zhitnyuk).
However, if the question of the feasibility of the intestine over a long distance is resolved positively, then the advantages of one or another method of drainage have not yet been definitively established. For example, some are proponents of inserting an intestinal tube through a gastrostomy, others prefer retrograde intubation of the intestine through an ileostomy, other authors recommend the use of transnasal decompression, without denying in some cases the positive effect of inserting a tube through the cecum.
Intestinal decompression with a probe
Drainage of the intestine with a long probe allows you to carefully remove the contents immediately during and create conditions in the postoperative period for its unhindered outflow. Compliance with the other two requirements - avoidance of infection and minimal trauma - depends entirely on the method of insertion and the type of probe.
Despite the obvious advantages of intestinal decompression with a long probe, the method has not yet received widespread use. The main reason for this, in our opinion, is that passing a probe made from an ordinary rubber tube throughout the intestine is associated with great technical difficulties. Such a probe is very soft and constantly bends; in addition, due to the significant frictional forces that arise, it is very difficult to bring it to the appropriate place. The listed factors and the significant intestinal trauma associated with them forced many to abandon this method, replacing it with a one-time removal of intestinal contents.
An intestinal tube made from a polyvinyl chloride tube is practically free of these disadvantages. The probe is quite elastic and resilient. When immersed in the intestinal lumen, it, being wetted, slides freely along the mucous membrane, and therefore the manipulation is less traumatic and short-lived. At the distal end of the probe, 1-2 metal round balls (bearings) with a diameter of 5-5.5 mm are mounted at a distance of 15-20 mm from one another. This is necessary for better capture of the probe through the intestinal wall. In addition, the presence of metal allows, if necessary, X-ray inspection of the location of the distal end of the probe. An equally important design feature of the probes is the presence of a “blind”, that is, without side holes, proximal section 65-70 cm long in probes for intubation through the nose and 15-20 cm in probes for insertion through the cecum (or ileostomy, gastrostomy) . The presence of a “blind” end prevents the leakage of intestinal contents through the esophagus into the nasopharynx and trachea during transnasal intubation or protects the skin around the fistula from contamination during cecostomy.
Technique of intestinal intubation
The probe can be inserted through the nose, gastrostomy, ileostomy or cecostomy, rectum. Each method has its own advantages and disadvantages, which should be taken into account when choosing an intubation method in relation to your goals.
Transnasal bowel decompression
Transnasal insertion of a probe for intestinal decompression is usually carried out in conjunction with a tube, which passes a probe lubricated with petroleum jelly through the nasal passage through the esophagus into the stomach. The surgeon then grabs the probe through the wall of the stomach, passes it along the bend of the duodenum until the tip of the probe is felt by touch in the initial part of the jejunum under the ligament of Treitz. At first glance, passing a probe through the duodenum is a difficult manipulation. However, if the probe that appears in the cardiac part of the stomach is pressed against the lesser curvature so that a springy bend does not form in the stomach (and especially so that the probe does not curl up), then it moves forward quite easily with the efforts of the anesthesiologist. Further passage of the probe through the intestines is not difficult and usually takes another 5-15 minutes. It is advisable to place the probe as low as possible to the ileocecal junction, especially in case of adhesive intestinal obstruction. In such cases, the probe also ensures smooth bending of the intestine.
With any method of performing intestinal intubation for decompression, it is necessary to remove intestinal contents as the probe is passed (usually with an electric suction connected to the proximal end of the probe). However, this very important intermediate procedure may turn out to be completely ineffective if the side openings are not first closed, since air is sucked into them rather than viscous intestinal contents. The simplest technique is to temporarily seal the holes with an adhesive plaster, which is then removed at the level of the nasal passage as the probe is immersed. The introduction of a tube of a slightly smaller diameter into the lumen of the probe in order to close the holes from the inside was not justified, since after the first turn of the probe in the intestine, it is almost impossible to remove the obstructing tube.
One of the advantages of transnasal intubation is the preservation of cleanliness of the surgeon's hands and surgical field, since the probe is inserted through a natural opening. This also allows the use of non-sterile probes. An equally important advantage of transnasal conduction is the thorough emptying of the upper parts of the digestive canal (stomach, duodenum), which is usually not achieved with retrograde intubation. The only, but very significant drawback of passing a probe through the nose is the occurrence of inflammation of the upper respiratory tract, pneumonia, because the presence of a foreign body in the nasopharynx makes breathing difficult to a certain extent, and with insufficient care for such patients, the possibility of intestinal contents being thrown into the esophagus and entering the trachea cannot be ruled out. In this regard, transnasal intubation for intestinal decompression is undesirable in patients over the age of 50-60 years and is contraindicated in cases of concomitant bronchitis and pneumonia.
Prevention of these complications consists of systematic (every 2-3 hours) active aspiration of intestinal contents, taking fluids by mouth as soon as the patient becomes adequate after anesthesia. However, the main preventive measure is timely removal of the probe - no later than 3-4 days. This time, as a rule, is sufficient to resolve functional intestinal obstruction.
Transnasal intestinal intubation has been the method of choice since the use of flexible PVC tubes.
Intestinal decompression through gastrostomy tube
This technique has found wide application, especially in children's surgical practice. It is devoid of the main disadvantage of transnasal intubation - the development of complications from the respiratory tract. Using a sufficiently elastic probe, it is easy to pass the bend of the duodenum. The probe can be left in the digestive canal for a long time. The disadvantages of this method of intestinal decompression are the forced deformation of the stomach and its fixation to the anterior abdominal wall, the possibility of infection of the surgeon’s hands and the surgical field. Dangerous complications include the departure of the stoma from the abdominal wall, which most often occurs in peritonitis, when the plastic properties of the peritoneum are lost. Therefore, it is advisable to perform intubation through a gastrostomy tube in case of acute intestinal obstruction and other pathology not complicated by peritonitis.
Bowel decompression through ileostomy
Ileostomy with intestinal intubation according to Zhitnyuk is currently used quite rarely. This is due to large deformation of the ileum and the possibility of infection. In addition, intubation is carried out retrogradely, that is, from bottom to top, so the end of the probe quickly goes down and the upper parts of the digestive canal are not drained, which requires transnasal insertion of a conventional gastric tube. And finally, not in all cases, after removing the probe, the stoma closes on its own, so a repeat operation is required in the future.
Intestinal decompression through cecostomy
The technique has a number of advantages.
Firstly, it is advisable to use it in elderly patients, patients with heart and lung diseases, and especially in cases where they plan to leave the tube for more than 5 days. A similar situation is most often observed when eliminating adhesive intestinal obstruction, which usually affects the ileum. The probe inserted through the cecum, thanks to its smooth bends, like a tire, straightens the loops of the intestine. Secondly, the cecum is a fairly large organ, and therefore, if necessary, a three-row purse-string suture can be applied to strengthen the probe without causing severe deformation of the intestine. A correctly applied cecostoma (with a double-row or single-row submersible purse-string suture) usually closes on its own in the next 5-14 days.
The disadvantages of intestinal decompression through the cecum, as with ileostomy, are associated with retrograde placement of the probe. It is often very difficult to pass the probe through the ileocecal valve into the ileum. In such cases, it is necessary to resort to an additional enterotomy 7-10 cm above the valve and passing a thin metal rod (for example, a button probe) through this hole and the valve into the cecum. After tying the elastic end of the probe to a metal rod, the latter is removed into the ileum along with the probe, removed, the hole in the intestine is sutured, and further intubation is performed in the usual way (Sanderson maneuver).
We must not forget about the danger of tissue infection at the time of intubation. To exclude the possibility of intestinal contents entering the abdominal cavity, it is advisable to first suture the cecum to the peritoneum, and then, having previously fenced off the wound with napkins, insert a probe.
Transanal intubation
This manipulation, as a rule, complements the already undertaken intestinal decompression by the methods mentioned. It is absolutely indicated for resection of the sigmoid colon with the imposition of a primary anastomosis, and the probe should be passed beyond the anastomosis to the splenic angle of the colon. As an independent method, transrectal decompression is usually used in pediatric practice. For adults, this technique is traumatic. Often there is a need to mobilize the splenic angle of the colon.
A prerequisite for completing any method of intubation is fixing the probe (at the nasal passage, to the abdominal wall, to the perineum), as well as the patient’s hands, since often, being in an inadequate condition, the patient can accidentally remove the probe.
Decompression of the intestine with a long intestinal tube is a therapeutic and preventive measure: in case of peritonitis, it serves as one of the main therapeutic factors, and after the elimination of mechanical intestinal obstruction, it prevents the development of functional obstruction. The presence of a probe in the intestinal lumen, in addition, reduces the likelihood of intestinal kinks and the development of adhesive obstruction.
If the basic rules for intestinal decompression and intubation techniques are followed, the postoperative period proceeds smoothly, without the usual symptoms of intestinal paresis: bloating, difficulty breathing, belching or even vomiting. Sometimes minor flatulence may be observed due to the gas present in the colon during isolated intubation of the small intestine.
In addition to regular (every 2-3 hours) removal of intestinal contents, it is advisable to rinse the intestinal lumen with small (300-500 ml) portions of warm isotonic sodium chloride solution (only 1-1.5 liters for each session). With the help of rinsing, it is possible to quickly reduce intoxication; the appearance of peristalsis is noted in some cases already by the end of the 1st day after surgery.
An important point in the management of such patients is strict recording of the daily amount of fluid released through the tube (excluding flushing). Fluid losses are replaced by administering an adequate amount parenterally. It is possible to prescribe other drugs through a targeted probe, and 2-3 days after - nutritional mixtures.
Frequent auscultation of the abdomen is required to determine the time of onset of peristalsis. Objective indicators of its recovery are also the nature and dynamics of intestinal secretions. The uniform release of fluid through the probe during inspiration indicates its passive flow and the absence of peristaltic waves. And, conversely, periodic, jerky release of intestinal contents indicates the appearance of active intestinal motility. Usually on the 3rd - 4th and, less often, on the 5th day, intestinal motor function is completely restored, as evidenced by auscultation data, spontaneous passage of gases, and the nature of fluid release through the tube. All this serves as an indication for removing the probe. In a number of doubtful cases, to assess the state of motility, dynamic X-ray monitoring can be performed with preliminary administration of 40-60 ml of a 50-70% solution of cardiotrust (Verografin) through a probe. Radiographs or survey fluoroscopy after 5-10 minutes give a clear idea of the nature of peristalsis.
The probe is removed by pulling its end for 15-30 s. In this case, patients usually experience nausea and even the urge to vomit. During retrograde intestinal intubation, the probe is removed more slowly because it may become coiled in the terminal ileum.
Intestinal decompression was high effective method prevention and treatment of functional intestinal obstruction. She is indispensable for surgical treatment general peritonitis, severe forms of functional intestinal obstruction, concomitant mechanical obstruction, especially strangulation with gangrene of the intestine. Decompression is indicated and justified in order to unload the sutures in technically or clinically difficult situations, especially when the development of postoperative peritonitis is possible.
Total intubation of the small intestine is indicated to prevent intestinal paresis after prolonged and traumatic operations on the abdominal and retroperitoneal organs, especially with a history of motor disorders and disturbances of water-electrolyte metabolism.
Widely and successfully using this method of intestinal decompression for peritonitis and intestinal obstruction, we consider it necessary to point out the mistakes made in the process of mastering the technique.
As already mentioned, the transnasal route of insertion of the probe is contraindicated in the presence of pneumonia or in cases where its occurrence is very likely (severe condition, old age, obesity, adynamia due to underlying or concomitant pathology). In 6 patients we observed, pneumonia was the main cause of death.
Complications of bowel decompression
When inserting a probe transnasally, its oral segment, which does not have holes in the side walls, should be in the esophagus and outside. The last side opening, closest to the oral end, must certainly be in the stomach. If this rule is not followed, two complications may occur. If the probe is inserted too deeply, the stomach will not drain, which will manifest itself as regurgitation. If the probe is not inserted deep enough and one of the side holes ends up in the esophagus or oral cavity, reflux of intestinal contents is possible with the threat of regurgitation and aspiration pneumonia. After intubation is completed, the end of the probe protruding from the nose must be sewn to the wing of the nose with a monolithic thread No. 5-6. In one of the patients we observed, this condition was not met. Upon awakening, the patient partially removed the tube, and in the next few hours after the operation, regurgitation of stagnant contents began. It was not possible to insert the probe back into the stomach, and it was extremely undesirable to remove it completely, since the patient had general peritonitis. It is unacceptable to leave a probe through which intestinal contents are poured into the nasopharynx. Therefore, the following solution was found. A rubber tube was inserted onto the part of the probe located in the nasal cavity, pharynx, esophagus and proximal stomach (about 60 cm), which covered the existing side holes. The main probe at this time played the role of a conductor. Drainage was maintained. The patient recovered.
With retrograde intubation through an appendicocecostomy, perforation of the cecal wall by the tube is possible during passage of the ileocecal valve. We observed a patient who died of peritonitis. The probe should be inserted slowly. If this manipulation fails, you can use the Sanderson maneuver. After successfully passing the tube through the ileocecal valve, it is recommended to carefully examine the cecum in the area of the ileocecal angle so that the damage does not go unnoticed.
It can be difficult to pass from the cecum to the ileum even with the use of a special probe. If a regular rubber tube with many holes is used, then sometimes you have to use a forceps to carry it out, which creates additional difficulties and increases the likelihood of accidental damage to the intestine.
If forced to use a regular rubber tube to drain the small intestine, another complication may develop. After 5-7 days, when there is no need for drainage, the tube, when removed, may become pinched in the purse-string suture tightened around it at the base of the cecostoma. Such a ligature, descending from the tube into one of the side holes, cuts it when removing the drainage. Part of the tube remains in the intestine, being fixed in the cecostomy opening. Removing it requires a special surgery.
This complication is not observed when using polyvinyl chloride probes. If you still use a rubber tube, then in order to avoid its breakage during removal, the side holes should be made as small in diameter as possible. The purse-string sutures that screw in the intestine at the stoma site and provide a seal should not be tightened too tightly, and force should never be used when removing the probe. If disintubation is difficult, it is advisable to rotate the tube 90-180°, and if this does not help, wait several days until the ligature loosens or cuts through. Unlike nasogastric intubation, when passing the tube retrogradely through the cecum, there should be no rush to remove it.
Let's consider another complication. At the intersection of the glove tube drainage tube draining the abdominal cavity and the probe providing intestinal decompression, the wall of the latter is subjected to compression. In some cases, on the 4th-5th day, a bedsore of the intestinal wall develops with the formation. In the patients we observed, after removal of the tubular part of the graduate, the fistulas closed on their own within 7-10 days. However, a less favorable outcome is also possible.
In order to prevent this complication, it is necessary to place the abdominal cavity in such a way that they do not put pressure on the intestine; Rigid tubes should not be used; it is possible to remove the tubular part of the tubular-glove graduate earlier.
Intestinal decompression with a long probe radically improves the results of the fight against peritonitis and paralytic ileus. The method should be widely implemented in all surgical hospitals providing emergency care.
The article was prepared and edited by: surgeonFor the first time, the idea of imposing a hole that would connect the intestinal cavity with external environment for the purpose of its decompression, it received its practical implementation in the form of an enterostomy operation, which was performed on a patient with a strangulated hernia by the French surgeon Renaut in 1772. Vashp in 1879 reported the imposition of a discharge ileostomy on a patient with a stenotic tumor of the ascending colon. The outcome of the operation was unfavorable due to mercury poisoning, taken by the patient on the eve of the operation as a laxative. MausN first achieved a favorable outcome after such an operation in 1883. From that moment on, enterostomy, as a method of treating intestinal obstruction, began to be used in medical institutions in Europe and America. In 1902, at a congress of German surgeons, Heidenhain reported on the use of enterostomy in six patients with paralytic obstruction, four of whom recovered. By 1910, Krogis had already experienced 107 such interventions. The term “ileostomy” was proposed in 1913 by Brown, who reported the successful treatment in this way of 10 patients with ulcerative colitis and intestinal obstruction. In Russia, the use of ileostomy in the treatment of peritonitis and intestinal obstruction was supported by A.A. Bobrov (1899) and V.M. Zykov (1900).
However, as clinical material accumulated, many surgeons began to be cautious about such operations, which was associated with severe purulent-septic complications and high mortality after ostomy. Thus, I.I. Grekov in 1912 recommended replacing enterostomy with emptying of overstretched intestinal loops by puncture followed by suturing the puncture hole. By this time, the first reports appeared about the successful treatment of intestinal paresis using a probe inserted into the stomach and duodenum.
Already in 1910, Westermann summarized the experience of treating 15 patients with peritonitis using active aspiration of the gastric
CHAPTER 2
Contents and gave it a high rating. At the suggestion of Kanavel (1916), a duodenal probe began to be used for this purpose. By 1913, Wan-gensteen had experience in treating 32 patients with peritonitis and intestinal obstruction in a similar way. An important event in improving methods of intestinal decompression should be considered the proposal of T. Miller et W. Abbott (1934) to use a probe with a rubber cuff at its end to drain the small intestine. Peristaltic waves, pushing the cuff inflated through a separate channel in the aboral direction, were supposed to ensure the advancement of the probe along the intestinal tube. Due to the fact that the probe often curled up in the stomach and did not pass into the duodenum and jejunum, it subsequently received a number of improvements. Thus, in 1946, M.O. Cantor proposed replacing the cuff with a canister filled with mercury. The probe moved through the gastrointestinal tract due to the fluidity of mercury. In 1948, G.A. Smith proposed a flexible stiletto for controlling the apex of the butt. The probe was inserted into the jejunum under X-ray control. D. L. Larson et al. (1962) invented an intestinal tube with a magnet at the end. The probe was moved using a magnetic field. However, despite the technical improvements of the Miller-Abbott probe, this method later turned out to be of little use for drainage of the small intestine in conditions of persistent paresis. It required lengthy and complex manipulations associated with the forced position of seriously ill patients, frequent control X-ray examinations, and, in addition, required the presence of intestinal peristaltic activity. As suggested by G. A. Smith (1956) and J. C. Thurner et al. (1958), the Miller-Abbott probe began to be used for transnasal intubation of the small intestine during surgery.
Interest in enterostomy as a drainage operation was renewed after Richardson (1927) developed a suspended enterostomy with insertion of a feeding tube into the intestinal lumen for feeding patients suffering from stomach tumors, as well as Heller's (1931) proposal to use a gastrostomy for the treatment of paralytic intestinal obstruction. At the same time, F. Rankin (1931) proposed forming an ileostomy outside the laparotomy wound. In Russia, for the first time, suspension enterostomy for the treatment of peritonitis and intestinal obstruction was performed by B.A. Petrov in 1935. But a more significant contribution to the development and promotion of this method was made by S.S. Yudin. Detailed description he outlined the application of a suspended enterostomy in his work “How to reduce postoperative mortality”
1Guest among those wounded in the stomach,” published in 1943. This technique found widespread use during the Great Patriotic War in providing surgical care wounded in the stomach.
According to A.A. Bocharov (1947) and S.I. Banaitis (1949), it was performed in no less than 12.8% of operations for gunshot wounds of the abdomen with intestinal damage. In the post-war years, a gradual decline in interest in enterostomy according to S.S. Yudin began. Many authors referred to the fact that in case of intestinal paralysis, it leads to unloading of only that part of the intestine on which it is applied. In addition, the formation of high small intestinal fistulas often led to exhaustion and death of patients. Attitudes to this issue changed after J.W. Baxer in 1959 proposed using long intestinal tubes and intubation of the entire small intestine when applying a suspended enterostomy.
In our country, the technique of decompression of the small intestine through a hanging ileostomy using long intestinal tubes was developed in detail in the early sixties by Professor I.D. Zhitnyuk. Since then, it has been called “retrograde intubation of the small intestine according to I.D. Zhitnyuk” and has been successfully used in the treatment of peritonitis and intestinal obstruction for thirty years.
J.M.Farris et G.K.Smith in 1956 first gave an in-depth analysis and substantiated the advantages of drainage of the small intestine through a gastrostomy. Among domestic surgeons, this method became widespread after the publication by Yu.M. Dederer in 1962 of the results of treatment using gastroenterostomy for patients with paralytic intestinal obstruction.
In 1959, I.S. Mgaloblishvili proposed using an appendicostomy for intubation of the small intestine. However, the method of enterostomy through a cecostomy, proposed in 1965 by G. Scheide, has become more widespread.
With the advent of new designs of nasoenteric probes, many surgeons began to give preference to closed methods of intraoperative drainage of the small intestine. Even such supporters and pioneers open methods drainage, like O.H. Wangensteen and J.W. Baker, began to use nasoenteric drainage in the treatment of peritonitis and intestinal obstruction.
Thus, in the late fifties and early sixties, surgeons already had in their arsenal a number of methods for de-
Compression of the small intestine, and the intestinal tube, according to H.Hamelmann und H.Piechlmair (1961), has become as essential a tool in the operating kit as a scalpel and tweezers
Although sixty years have passed since one of the first reports of the use of small bowel drainage in the treatment of paralytic obstruction, this method has become widespread in the last two decades. This became possible thanks to an in-depth study of the therapeutic possibilities of drainage of the small intestine and intraintestinal transtube therapy, as well as the improvement of intubation methods and techniques, improvement of the design of enterostomy probes and the use of high-quality polymer materials in their manufacture. Determined that healing effect Drainage of the small intestine is not limited to eliminating intraintestinal hypertension and removing toxic substances from the intestine. It has been experimentally established and clinically confirmed that long-term drainage of the small intestine improves microcirculation and blood supply to the mucous membrane, reduces general intoxication and toxemia, helps eliminate dystrophic changes in the intestinal wall, reduces transudation of fluid into its lumen, restores motor activity and absorption capacity, prevents relapses of paralytic and adhesive intestinal obstruction.
There are single emptying of the small intestine and long-term drainage. A single emptying is performed during surgery.
Long-term drainage can be performed using both non-operative and surgical methods. Non-surgical options include: small bowel drainage using Miller-Abbott type tubes, nasoenteric endoscopic intubation and transrectal intubation of the large and small bowels. In turn, surgical methods of drainage are divided into closed, which are carried out without opening the lumen of the gastrointestinal tract, and open, when drainage of the small intestine is associated with the formation of artificial fistulas of the stomach or intestines. In addition, drainage of the small intestine is divided into antegrade and retrograde. With antegrade drainage, intubation is carried out from the upper parts of the digestive tract in the aboral (caudal) direction, with retrograde drainage, the intestine is intubated from bottom to top. Closed surgical methods include nasoenteric drainage and transrectal intubation of the small intestine.
__________________ 69
operating - drainage of the small intestine, enterostomy and cecostomy. In a separate group are combined methods that provide separate drainage of the upper and lower sections of the small intestine. - kshpkiGa also has end-to-end drainage of the entire intestine. With “binned drainage” it can be simultaneously AND open and closed, as well as antegrade and retrograde intestinal intubation.
21 NON-OPERATIVE METHODS OF SMALL INTESTINE Drainage
Non-surgical method of drainage of the small intestine using Miller-Abbott type probes. In 1934, T. M. Sher and W. Abbott reported the successful use of a special probe for decompression of the small intestine, which is a long (up to 3.5 m) soft rubber tube with a diameter of up to 1.5 cm with one or more side holes at the end . The end of the probe is equipped with a cuff that inflates as the probe moves through the gastrointestinal tract. The patient swallows the probe and lies on his right side. Constantly sucking out the contents of the stomach and small intestine, the probe gradually moves 5-7 cm every 30-40 minutes. The position of the probe in the intestine is controlled using x-ray examination. Peristaltic waves, pushing the inflated cuff in the aboral direction, ensure the advancement of the probe to the desired level. The entire procedure for draining the small intestine takes three to four hours. Subsequent improvement of the probe by replacing the rubber cuff with a cartridge of mercury (Cantor probe) contributed to its faster movement through the intestines.
According to Yu.M. Dederer et al. (1971), this method can be effective only in the presence of intestinal peristaltic activity. In addition, it requires lengthy and complex manipulations associated with changing the position of seriously ill patients and frequent control X-ray examinations, but at the same time, successful attempts to insert a probe into the jejunum do not exceed 60%. R. E. Brolin et al. (1987) believe that the use of a closed drainage method using a Miller-Abbott probe is indicated in the presence of partial patency. In this case, the difference between obstruction and partial patency is based on the interpretation of radiographs of the abdomen.
The authors consider the main radiological sign to be the determination of gas in the small and large intestines. Complete obstruction is characterized by the presence of gas in the small intestine with liquid levels. bones and the absence of gas in the large intestine, whereas in cases of partial patency, along with swollen loops of the small intestine, there is gas in the large intestine. The effect of treatment after inserting a probe into the intestine is assessed within the first 6-12 hours. Surgical intervention was required in 38 of 193 (19%) patients with partial patency and 125 of 149 (84%) patients with radiological signs of complete obstruction.
Good results from non-operative decompression of the small intestine were obtained by F.G.Quatromoni et al. (1989) in 41 patients with postoperative small intestinal obstruction. In 10 patients who were re-operated, a mechanical form of obstruction was diagnosed; in one, the cause of persistent paresis was an abdominal abscess.
There are reports of successful treatment using Miller-Abbott and Cantor probes in patients with adhesive intestinal obstruction (Norenberg-Charkviani A.E., 1969; Hofstter S.R., 1981; Wolfson P. et al., 1985).
Insertion of a rigid probe with an olive into the duodenum and jejunum is widely used for emergency probe enterography in the diagnosis of acute intestinal obstruction. In such cases, the probe is equipped with a metal conductor, the end of which is located 10 cm proximal to the initial part of the probe. The advancement of the probe from the stomach into the duodenum is controlled fluoroscopically. The passage of the probe through the pylorus is facilitated by deep breathing movements, as well as the position of the patient on the right side with a turn on the stomach. To eliminate spasm of the pyloric sphincter, 1 ml of proserine is injected subcutaneously. After the probe passes the ligament of Treitz, the metal guide is removed. From 500 to 1000 ml of a 20% suspension of barium sulfate is injected into the intestinal lumen. As a rule, a 20-30-minute X-ray examination provides complete information about the nature of the obstruction (Eryukhin I.A., Zubarev P.N., 1980). If the picture is unclear, the x-ray examination is repeated after two hours. According to K.D. Toskin and A.N. Pak (1988), the diagnostic effectiveness of probe decompression enterography is 96.5%. The detection of traces or accumulation of barium suspension in the cecum, as well as the image of the relief of the colon mucosa on radiographs, excludes acute obstruction. In such cases, the probe
It has a decompression function and is used to introduce b
In connection with the widespread introduction of fibroscopic technology into egg practice, the possibility of non-surgical azoenteric endoscopic drainage of the initial parts of the small intestine has become possible. To date, two methods have been developed for inserting a probe into the small intestine using a fiberscope: through the instrumental channel of the device and in parallel with it under visual control.
In the first case, a tube is inserted for enteral nutrition and through-tube intraintestinal correction of metabolic disorders. The diameter of the probe lumen in this case is 0.2 cm, which is quite enough for infusions. The second method involves inserting a probe for decompression of the initial parts of the small intestine and requires the use of probes with a lumen diameter of 0.4 to 0.8 cm.
In both cases, manipulations are performed by an endoscopist. According to Yu.M. Pantsyrev and Yu.I. Gallinger (1984), the method of inserting a probe through the instrumental channel of the endoscope is more effective and safe compared to the method of inserting the probe in parallel with the endoscope. Of the 111 observations, the authors did not observe any complications in any of them. The number of unsuccessful attempts does not exceed 1.3%.
Indications for passing the probe through the instrumental channel of the endoscope are organic or functional disorders of the patency of the gastroduodenal zone of the digestive tract (ulcerative or tumor stenosis, impaired passage through the gastroenteric or gastroduodenal anastomosis, gastric atony, postoperative pancreatitis, etc.).
Anesthesia of the pharyngeal mucosa and premedication are carried out to the extent usual for diagnostic gastroduodenoscopy. First, the mucous membrane of the stomach and duodenum is examined and the cause of obstruction is determined. With the duodenal passage preserved, the tip of the endoscope reaches the lower horizontal part of the duodenum, after which an intestinal tube is inserted through the instrumental canal. As the probe moves into the intestinal lumen, the endoscope is removed. In patients with gastroenteroanastomosis, the endoscope is passed 40-50 cm into the outlet loop of the jejunum distal to the anastomosis. If it is not possible to pass the endoscope through the area of narrowing, then you should try to pass the probe through the visible hole. It should be noted that in patients after resection
It is not difficult to find a stomach with atony of the stump and swelling of the anastomotic area from the mouth. When inflated with air, it easily opens and can be easily overcome by the endoscope. The same situation can arise when performing pyloroplasty with a double-row suture and postoperative pancreatitis. In cases of anastomositis, the endoscope is carried out by carefully moving apart the walls of the anastomosis. After removing the endoscope, the free end of the probe is passed through the nasal passage and fixed to the skin of the face with an adhesive plaster or sutured to the wing of the nose. An additional tube is inserted into the stomach. Before administering nutritional mixtures and infusion solutions, the position of the probe and its patency are controlled radiographically using liquid radiopaque agents.
Endoscopic decompression drainage of the initial parts of the small intestine is carried out if there is confidence in the absence. the need for emergency surgery. According to R.E.Brolin et al. (1987), the main indication for its implementation is the need for urgent differential diagnosis between acute small intestinal obstruction and other diseases that are accompanied by impaired passage through the small intestine. G. F. Gowen et al. (1987) and L. Stilianu et al. (1988) set broader indications for endoscopic drainage of the small intestine and recommend a decompression probe as a stage of preoperative preparation in most cases of intestinal obstruction. This allows, according to the authors, to avoid unnecessary laparotomies, to ensure the safety of endotracheal anesthesia, to perform a less traumatic inspection of the abdominal organs and thereby reduce the duration of surgical intervention. As evidenced by the data of T.P.Gurchumelidze et al. (1990), the greatest success with endoscopic intubation can be achieved in the treatment of patients with postoperative paresis or early adhesive small bowel obstruction. The authors resolved postoperative small bowel obstruction in 40 of 54 patients by endroscopic insertion of a probe into the proximal jejunum. The remaining patients underwent surgery within 12 to 48 hours due to the lack of positive dynamics.
"When carrying out decompression probes, you should use
"Little and long gastrointestinal devices (GIF-P3, *SqGIF-QW, GIF-D4 from Olympus, TX-7, TX-8 slim from ACM" or their analogues).
^ jq V. Sinev et al. (1988) suggest pre-inserting the probe channel with a metal string, which allows manipulating the tip of the probe. The rigidity of the probe is reduced by gradually removing the string. Yu.M. Pantsyrev and K) I. Gallinger (1984) recommend stitching the probe with 5-6 silk ligatures in the initial part or applying ribbons that are located at a distance of 4-5 cm from each other. They serve to grasp them with biopsy forceps. In this way, you can easily give the desired directions to the initial part of the probe, especially when passing it from the stomach through the bends of the duodenum.
Before endoscopic drainage begins, the stomach is emptied.
In a position on the left side, an intestinal probe with a diameter of 0.6-0.8 cm is passed through the nasal passage into the cardiac part of the stomach.
A fiberscope is inserted into the stomach and, under visual control, the probe is advanced to the pylorus.
An indispensable condition for successful passage of the probe along the greater curvature to the pyloric canal is good expansion of the stomach with air. The presence of ligatures fixed to the probe facilitates the advancement of the probe into the duodenum. To do this, use the following technique. After identifying the initial end of the probe, the first ligature is grabbed with biopsy forceps, by pulling it, the probe is pressed against the endoscope and in this position is passed into the duodenum. After removing the biopsy forceps from the ligature, the endoscope is returned to the stomach, where the next ligature is captured. The manipulation is repeated until the probe reaches the lower horizontal part of the duodenum or passes the ligament of Treitz. In the absence of ligatures fixed to the probe, the probe is grabbed with forceps by the side holes.
After making sure that the probe is inserted into the small intestine, the endoscope is removed. After removing the endoscope, the string is removed from the probe. The position of the probe and the condition of the intestine are monitored using x-ray examination. To facilitate the implementation of the probe, Yu.M. Pantsyrev and Yu.I. Gallinger (1984) developed endoscopic technique intubation using a metal guide. Endoscope under visual control is carried out as much as possible
Into the duodenum. Then after___ g #-“”-“breathe
A long and rigid metal spiral-shaped probe with a twisted end is inserted into the intestinal lumen - a wire with a diameter of 0.2 cm. The endoscope is removed, and the intestinal probe is placed on a metal conductor and inserted along it into the intestine.
Drainage using a fiberscope is usually well tolerated by patients and takes a relatively short time - from 10 to 30 minutes. The greatest difficulties arise when the probe passes the area of the Treitz ligament. This manipulation can be facilitated by using a probe with an air balloon at its initial part (GowenG.F. etal., 1987). The probe is inserted into the descending part of the duodenum. The balloon is inflated, and further advancement of the probe is carried out due to peristaltic waves that occur as the intestine is emptied. However, T. P. Gurchumelidze et al. (1990) consider intubation complete only when the tip of the probe is distal to the ligament of Treitz or at the level of the duodenojejunal fold. Their analysis of serial radiographs showed gradual spontaneous migration of the probe in the diotic direction.
A prerequisite after completion of drainage is active decompression of the intestine. For this purpose, B.G. Smolsky et al. (1980) and Yu.V. Sinev et al. (1988) proposed using a probe with two channels - perfusion and aspiration. Both channels open to different levels in the intestinal lumen, which makes it possible to carry out not only decompression, but also active intestinal dialysis or enterosorption.
With adequate decompression of the initial parts of the small intestine during the first day after intubation, the amount of aspiration contents when creating a negative pressure of 30-40 mm water column. is at least 1500 ml, on the second day - about 1000 ml, on the third - 800 ml.
In addition, a double-lumen probe allows you to examine the digestive and absorption function of the upper parts of the small intestine and, in accordance with the examination data, select media for enteral nutrition.
Nonoperative transrectal decompression of the large and small intestines is most often used to resolve obstructive colonic obstruction or to correct sigmoid volvulus.
Complete obstruction of the intestine by a tumor is rare, but
“patency appears when the lumen narrows to its depth< 5 х0 д ИМ0 учитывать, что сужение кишки бывает & * 0 не только самой опухолью, но и воспалением окружа- о б уСЛ °тканей и отеком слизистой оболочки. Важное значение при г 0111 * еет functional state bauhinium valve. In cases it functions normally even at far in forms colonic obstruction, and in 20% there is pain and its functional failure, which leads * chabros of colonic contents into the small intestine, its mechanical overdistension and the development of paresis. The colonic and small intestinal obstruction that develops in this way enhances endogenous intoxication and toxemia and may be accompanied by the development of endotoxin shock.
Decompression of the colon using a proctoscope can only be performed for low-lying rectal tumors. After a cleansing enema, the patient undergoes sigmoidoscopy, and a gastric tube with two or three side holes and a rounded end, generously moistened with petroleum jelly, is passed through the canal into the stenosing lumen of the tumor. If the tumor is located above 30 cm from anus To perform decompression, you can use a fibrocolonoscope. However, lavage of the intestine through the manipulation channel of the endoscope is, as a rule, ineffective. Most often, with the help of a fibrocolovoscope, the place of narrowing is found and expanded, and then, under visual control, an enterostomy tube is passed through the visible slit of the canal above the obstruction. In this case, you can use the same techniques as for endoscopic drainage of the initial parts of the small intestine. An endoscope can be passed through a stenotic tumor in cases where it has exophytic growth and the lumen is deformed due to polyp-like growths on the surface of the tumor. To expand the lumen of the channel in the tumor, it is proposed to use electro- and laser photocoagulation (Mamikonov I.L. and Savvin Yu.N., 1980). However, it must be remembered that excessively violent manipulations can cause damage to the intestinal wall and intense bleeding from the tumor.
As the probe advances, the contents of the colon are evacuated using a Janet syringe or using vacuum suction. In most cases, without the control of a fibrocolonoscope, it is not possible to pass the splenic or hepatic flexures of the colon with a probe. However, to decompress the colon and resolve the obstruction, emptying is often sufficient.
76__________________________________________ CHAPTER 2
understanding of its dietary departments. The probe is removed from the intestinal lumen on the second day.
Drainage of the small intestine by passing a probe through the valve of Bauhinium using a fibrocolonoscope is still considered only theoretically and is unlikely to find widespread clinical application in the near future. According to Yu. V. Sinev et al. (1988)”, inserting a probe in this way into the distal parts of the small intestine becomes possible only with careful emptying of the colon from its contents. At the same time, through a biopsy channel with a diameter of 0.5 cm, it is possible to pass an euterostomy probe with a lumen of no more than 0.3 cm, which is not enough for complete decompression.
2.2. OPERATIVE METHODS FOR SMALL INTESTINE DRAINAGE
2.2.1. One-time methods of decompression of the small intestine
Exist various ways a single emptying of the small intestine during surgery.
In some cases, decompression of the small intestine is carried out without opening its lumen by sequentially squeezing (“squeezing”) the contents retrograde into the stomach or, more often, antegrade into the large intestine. Despite the fact that most authors speak out against this method, considering it traumatic and ineffective, there are also its supporters. Thus, P.D. Rogal and A.A. Plyapuk (1977) in patients with intestinal obstruction recommend using a gentle method of one-time movement of intestinal contents to the underlying sections.
GG consists in the fact that after eliminating the cause of the obstruction, the perioperative surgeon holds the 111 intestine between the first and other fingers of the left hand with a damp gauze napkin, covering its lumen, and between the second and third fingers of the right hand “And stretches it, easily bringing it closer walls (Fig. 17). This pboase moves the intestinal contents to the underlying sections. At this time, the assistant intercepts the intestine, freed from contents, every 15-20 cm.
In some cases, to free the intestine from its contents, it is punctured with a thick needle. However, in this way it is not always possible to free even a single loop of intestine from gases, much less liquid contents. In order to achieve sufficient bowel emptying, it must be punctured in many places, which is ineffective and dangerous in relation to infection of the abdominal cavity. Therefore this method is used
fti ">
 |
| GLAVd |
Rice 19. Emptying the thin pen with help electric suction,
very rarely. Much more often, a specially designed trocar with two side holes is used for this purpose (Dederer Yu.M., 1971). One of them with a wide lumen is connected to an electric suction, the second is smaller and serves to flush the tube if it becomes clogged with dense contents. The trocar stylet is used to pierce the wall of the overstretched small intestine in the center of a previously applied purse-string suture. The stylet rises to the upper position, and the sleeve moves along the lumen of the intestine (Fig. 18). Intestinal contents are evacuated using an electric suction. To empty nearby loops, either the intestinal contents are “squeezed” to the puncture site, or a probe is inserted into the intestine through the end hole of the trocar. After evacuation of the intestinal contents, the trocar is removed, the purse-string suture is tightened, and two or three additional seromuscular sutures are applied.
Many surgeons perform an enterotomy to empty the small intestine. Between two thread-holders, the tip of an electric suction is inserted into the lumen of the intestine and, with its help, the nearest sections of the intestine are first released, and then other overstretched loops of intestine are threaded onto the suction tip (Fig. 19). N.Balsano and M.Reynolds (1970) suggested using a No. 22 Foley catheter for aspiration of contents from the small intestine.
 |
Rns. 20. One-time emptying connection with a Foley catheter.
the bosom of the catheter is filled with 3 ml of water, which ensures its free movement, prevents the mucous membrane from sticking to the probe opening and prevents leakage of small intestinal contents through the enterotomy opening in addition to the probe (Fig. 20). At the end of the procedure, the hole in the intestine is sutured in the transverse direction with a double-row suture.
Emptying the small intestine through one of the ends of the resected section is a fairly common method of one-time decompression. Removal of intestinal contents is carried out using the tip of an electric suction device or by inserting a probe into the intestinal lumen. After bowel emptying, its continuity is restored or the proximal end is brought out in the form of an enterostomy.
Despite their apparent simplicity, the listed methods have a number of significant drawbacks. They are not aseptic and can lead to microbial contamination of the surgical field. These methods can only empty the closest loops of intestine. In addition, there is a danger of failure of the sutures placed on the altered intestinal wall. Therefore, recommendations to perform a single decompression of the small intestine using closed methods, transnasally or transrectally, are fully justified.
2.2.2. Nasoenteric drainage
The serial production of standard nasoenteral tubes, the elimination of the need for special opening of the lumen of the hollow neoplasms and the formation of external gastric or intestinal soups, made it possible to recommend nasoenteral drainage as the method of choice for the prevention and treatment of enteral insufficiency.
For this purpose, probes made of durable elastic material, resistant to the effects of gastric and intestinal contents, having thermolability, radiopaqueness and not containing harmful chemical impurities. Their diameter does not exceed 1.2 cm, the channel lumen is 0.8 cm. The “working part” of the probe with side holes placed through 6-8 cm has a length of 160-170 cm with a total length of 250-300 cm. The end of the probe is equipped with a conductor in in the form of an olive, which is made of the same material, has the same diameter and is dumbbell-shaped connected to the main part of the probe (Fig. 21). At a temperature of 37°C and above, the probe becomes soft and does not injure the intestinal wall. In the absence of a standard probe, nasoenteral drainage can be performed using a long (250-300 cm) rubber or silicone tube with a lumen of 0.4-0.8 cm. To make the probe elastic, a mandrel made of stainless wire is inserted into its lumen. The initial part of the probe is closed with a plug made of rubber or silicone, which makes manipulations safe. It is advisable to make the end of the mandrin in the form of an olive-shaped thickening, which significantly reduces trauma to the mucous membrane when passing the probe through the lumen of the esophagus, stomach and duodenum. For free sliding of the conductor inner surface The probe is lubricated with petroleum jelly or glycerin. Biopsy forceps of a fibrogastroduodenoscope or a fluoroplastic catheter with a diameter of 0.2 to 0.3 cm can be used as a guide.
There are reports of drainage of the small intestine using a soluble probe created from a synthetic protein (Jung D. et al." 1988). Dissolution of the probe in the intestinal lumen occurs on the 4th day from the moment of intubation. The authors used the probe in the treatment of 52 patients with adhesive intestinal obstruction. There were no complications associated with the presence of such a probe in the lumen of the intestine and stomach, as well as relapses of adhesive obstruction.
After deciding on nasoenteric drainage, the surgeon
Rice. 21. Odioluminal nasoenteric tube.
audits upper section abdominal cavity. Frees the subhepatic space from adhesions and adhesions. Palyshtorno evaluates the condition of the abdominal esophagus, stomach and duodenum. Examines the area of the duodenojejunal flexure.
During the adhesive process, the small intestine is released throughout its entire length. Deserosed areas are sutured before intubation begins. If there is a tumor of the cardioesophageal zone, a chronic gastric or duodenal ulcer, or a stenotic tumor of the gastric outlet, one should refuse to pass the probe through the stomach and perform intubation of the small intestine using one of the retrograde methods.
Before inserting an intestinal tube into the esophagus, the anesthesiologist controls the stretching of the endotracheal tube cuff. Zon-Dom empties his stomach. Complete relaxation and depth of anesthesia are achieved. The olive of the intestinal probe is generously lubricated with petroleum jelly, and its free end is connected to the electric suction system.
The anesthesiologist moves the probe through the external opening of the nasal passage into the esophagus. The probe can also be inserted through the mouth. However, in postoperative period This position of the probe can cause vomiting and disrupt the act of swallowing. Therefore, after intubation is completed, the free end of the probe is transferred to the nasal passage (Fig. 22).
 |
| mixing upwards of the shields into the two cartilages. |
| . |
 |
Rice. 22. Transfer of the nasoeutheral probe from the oral cavity into one of the ducts.
In 80% of cases, the probe is inserted into the esophagus without much effort. But sometimes difficulties arise during intubation due to the pressure of the intubated trachea on the anterior wall of the esophagus, insufficient or excessive elasticity of the probe, narrow nasal passage, curvature of the nasal septum,
To eliminate compression of the esophagus by the intubated trachea, upward displacement of the thyroid cartilage may be effective (Fig. 23). If there is no effect, you can use the following technique. Forefinger right hand is inserted into the oral cavity, the tip of the probe is felt and pressed against the back wall of the pharynx, and the probe is pushed into the esophagus (Fig. 24). Sometimes the passage of the probe is controlled using a laryngoscope (Fig. 25).
Yu.P. Svirgunenko et al. (1982) and B.K. Shurkalin et al. (1986) to successfully advance the probe through the esophagus, they suggested intubating it with an endotracheal tube (Fig. 26). According to the authors, an endotracheal tube installed in the esophagus reliably acts as a conductor, facilitating passage of the probe into the stomach and protecting the mucous membrane of the nasopharynx and esophagus from
control
In addition, with the help of an inflatable cuff, the respiratory tract is protected from gastrointestinal
| yay |
s PZHI mogo. For the same purpose, E.S. Babiev (1983) proposed using a conductor probe up to 100 cm long and 1.5 cm in diameter.
"Through the lumen, the initial part of the intestinal probe is introduced, after which both probes are advanced into the stomach. The guide probe is removed
after* the end of the intestinal probe with side holes is in the duodenum. In G. Dorofeev et al. (1986) successfully use a thick rubber gastric tube as a guide probe.
V.V. Izosimov and V.A. Borisenko (1984) recommend passing a guide probe along the entire length of the small intestine. A thin polyvinyl chloride tube is used as an intestinal tube. The guide tube is removed after intubation is completed. P.Yu. Plevokas (1989) significantly improved the conductor probe by equipping it with metal rings. The rings create protrusions on the wall of the probe that are convenient for gripping, holding and guiding the probe through the intestine. The length of the guide probe is 170-200 cm, the outer diameter is 1.2 cm. The inner tube, which is left in the intestinal lumen for its decompression, has a length of 300-350 cm and a diameter of 0.5 cm.
As the probe advances, the surgeon from the abdominal cavity directs it along the greater curvature of the stomach and fixes it with his right hand in the area of the outlet section. With the left hand, the end of the probe is directed through the pylorus into the duodenal bulb. Often, spasm of the pyloric sphincter interferes with the advancement of the probe. The reason for this may be traumatic manipulations and lack of coordinated actions between the surgeon and anesthesiologist. In such cases, the following technique can help manipulate the probe. With the right hand, through the anterior wall of the stomach at the border of its body and the antrum, the probe is grasped at a distance of 2-3 cm from the olive. The pyloric sphincter is fixed with two fingers of the left hand from the side of the duodenum. The ring of the pyloric sphincter, under the control of the fingers of the left hand, is “strung” onto the olive of the probe (Fig. 27). As soon as the end of the probe is in the duodenal bulb, the surgeon moves the enterostomy tube in the distal direction with his right hand, synchronously with the movements of the anesthesiologist. With the fingers of the left hand, he controls and directs its end down and backward to the lower horizontal bend and further to the left towards the Treitz ligament.
Forcing the advancement of the probe through the intestine when felt
 |
| ________ |
| CHAPTER 2 |
| " |
Rice. 27. Passing the probe into duodenum.
obstacles are unacceptable. In such cases, the duodenum is mobilized according to Kocher (Fig. 28).
When the probe appears in the initial section of the jejunum, it is grabbed by three fingers of the right hand and advanced 10-15 cm. In the stomach, the probe is placed along the lesser curvature.
An obstacle to the advancement of the probe in the area of the duodenojejunal junction may be additional bends of the initial section of the jejunum, fixed by the ligamentous apparatus of the peritoneum or by adhesions. In such cases, you should try to grab the olive of the probe and move it in the distal direction with stringing movements (Fig. 29).
To make it easier to capture the probe through the intestinal wall, a number of devices have been recommended. Thus, A.L. Prusov and N.S. Poshshdopulo (1983) proposed putting red rubber rings on the “working part” of the probe every 4 cm. Intubation is carried out through the mouth. After its completion, the probe is transferred to one of the nasal passages. A.I.Antukh (1991) uses gelatin to form thickenings of the esophagus. According to the author, gelatin couplings dissolve under the influence of intestinal juices on the third day and do not interfere with the removal of the probe. For the same purpose, it was proposed to equip the initial part of the probe with one or more cuffs made of
Rice. 28. Passing the probe to the ligament Trend.
latex rubber (Miller-Abbott probe) (Nelson R.L., Nyhys L.M., 1979; Seidmon E.J. et al., 1984). The cuffs are inflated in the stomach and thus create convenience when passing the probe through the bends of the duodenum.
To facilitate intubation of the intestine and prevent damage, some authors inflate it with oxygen or air (Prusov A.L., Papandopulo N.S., 1983; Weller D.G. et al., 1985). For this purpose, before intubation, a thin polyvinyl chloride tube with a diameter of 2-2.5 mm with several side holes in its initial part is inserted into the lumen of the probe, through which oxygen or air is supplied during intubation. Using this technique, D-G. Weller et al. (1985) managed to significantly reduce intestinal trauma, and the drainage procedure itself was performed within 30 minutes.
If the probe is curled up in the stomach in the form of rings, then straighten 6141 It is possible to corrugate the initial section of the small intestine with subsequent
Rice. 29. Carrying out zonea to the initial Department thin intestines-
by further pulling the probe in the distal direction. Less beneficial is having the tube tightened by an anesthesiologist.
In the absence of intestinal paresis (Fig. 3O), the probe is advanced by “stringing” intestinal loops onto it. Having corrugated 8-10 cm of the intestine, the surgeon synchronously with the anesthesiologist pushes the ovary, straightening the intestine in the proximal direction. Bowel intubation in such cases can be accelerated* if the surgeon
Rns. thirty. Carrying out nasoenteric probe through the intestinal lumen.
pool in the area of the Treitz ligament, and the assistant guides the olive of the probe along the intestinal lumen.
Drainage of the small intestine using the transnasal method is carried out in most cases along its entire length (total nasoenteric drainage). However, there are reports (Gauens Y.K. et al., 1985; Pashkevich I.F., Shestopalov A.E., 1989; Werner R. et al., 1984) about successful long-term decompression of the small intestine by draining only its initial part over 20-70 cm (proximal nasoenteric drainage). For these purposes, employees of the Moscow City Research Institute of Emergency Medicine named after. KV.Sklifosovsky developed a canal multifunctional nasoenteral probe with several holes in its distal part. The probe is inserted during the operation behind the ligament of Treitz by 50-70 cm. Aspiration of intestinal fluid is carried out through one of the probe channels by creating a vacuum of 20-40 mm water column.
However, achieving adequate decompression of **Ppsh in this way is possible only with moderate peritonitis and preserved KV1 oven peristalsis. In conditions of persistent intestinal paresis
| - | ||
Rice. 81. Position of the nasoenteral tube in the digestive tract -
Intubation of the entire small intestine is necessary. In this regard, N.S. Uteshev et al. (1985) proposed to first perform total intubation of the small intestine, and after emptying it, insert a double-lumen probe 50 cm behind the ligament of Treitz.
It should also be noted that even in cases of total intestinal intubation, soon after restoration of its motility, the initial part of the probe shifts in the proximal direction.
*rvm a day after surgery, in the presence of peristaltic gas, the probe is dislocated by 15-20 cm, and by the fifth day 2/3 of the small intestine remains intact. To hold the probe in the *^ position M. Regent et al. (1974) and H.W.Waclawiczek ^iS?) consider necessary him behind the Bauginian barrier - the cecum. When using the Miller-Abbott-Kerp probe (1980) and L. Nitzche et E. Hutter (1984), its fixation was carried out by inflating the cuff in the cecum. The authors left the probe in this position for 7-8 days.
The impossibility of simultaneous separate drainage of the thin gut and stomach is the main disadvantage of standard nasoenteral tubes. The difference in intraluminal pressure in the small intestine and stomach not only disrupts the drainage function of the tube, but also leads to stagnation of gastric and duodenal contents, which accumulate in the stomach as a result of intestinal paresis and disruption of the obturator function of the pyloric sphincter. An overfilled stomach increases the gag reflex and requires additional emptying.
Thus, out of 114 patients observed by us, in whom, during transnasal intubation, for one reason or another, the side holes of the probe were left in the lumen of the stomach, in 67 (58%) drainage function the probe was possible only under the condition of active aspiration using a Janet syringe or vacuum suction. However, in 23 patients (20.8%), complete decompression could not be obtained, and gastric contents were evacuated using an additional probe. In addition, it was impossible for these patients to undergo complete intestinal therapy. Enterosorbents administered along the path of least resistance through the side openings first of all enter the stomach.
Vomiting during drainage with a single-lumen probe was observed in 36% of patients. Moreover, it occurred with the same frequency both in cases of leaving the side holes of the tube in the stomach and without them. Among postoperative complications in these patients, pneumonia and purulent tracheobronchitis are most often observed, the specific gravity of which is 21.1% and 12.7%, respectively (Table 22).
According to autopsy data, regurgitation of gastric contents during vomiting was the cause of death in 5 patients operated on for intestinal obstruction.
In this regard, when performing nasoenteral intubation, it is necessary to strive with a bottom-lumen probe during the operation
Table 22 Frequency of postoperative infectious-inflammatory diseases
respiratory complications at transnasal drainage of the small intestine
| 91 34 57 , 249 |
| 35 21 11 5 |
Naeoenteric intubation with a single-lumen probe:
Leaving holes
tube in the stomach
Without leaving a hole
probe in the stomach Separate drainage of the small intestine and stomach:
Separate probes
Double lumen naeogastro-
enteral tube
Total:
Note. The probe in the lumen of the small intestine in the presented groups of patients was no younger than three days of the postoperative period.
insert an additional tube into the stomach. With its help, intestinal contents that accumulate in the stomach during intubation are easily evacuated. It is technically more difficult to insert the tube into the stomach when nasoenteric intubation is performed. In such cases, a technique is used in which the probe is advanced into the esophagus with the index finger inserted into the oral cavity. To impart elasticity to the probe, a metal string is inserted into its lumen. The free ends of both probes are placed in one nasal passage and separately fixed to the wings of the nose.
In exceptional cases, an unloading gastrostomy is applied.
Separate drainage of the small intestine and stomach allows not only decompression of the gastrointestinal tract, but also complete transtube intestinal therapy. However, as experience has shown, drainage of the small intestine and stomach with separate probes has a number of disadvantages. Patients have a harder time tolerating the presence of two probes in the pharynx and
At the same time, the irresistible desire that arises does not stop even suturing them to the wings of the ulcer. The presence of two probes in the ulcer and esophagus is especially difficult for elderly and old age, suffer from chronic diseases of the cardiovascular and respiratory systems. These patients are more likely to develop bedsores of the esophagus, and disruption of the closure function of the pdial sphincter more often than with drainage with a single probe leads to reflux esophagitis and regurgitation of gastric contents. In this regard, in domestic and foreign literature it has been proposed different kinds probes with separate drainage of the stomach and small intestine (Gauens Y.K. et al., 1986; Tamazashvili T.Sh., 1986; Schmoz G, et al., 1983; Seidmon E.J. et al., 1984; Xaicala J. et al., 1985). However, most of them have a complex technical design and recommendations for reusable use, which is unsuitable for hospitals involved in emergency abdominal surgery. Thus, for the purpose of simultaneous and separate drainage of the stomach and small intestine, T.Sh. Tamazashvili (1986) proposed the use of a nasoenteric tube, which at the level of the body of the stomach has a chamber equipped with a ball valve. The valve allows the contents of the stomach to pass through and at the same time prevents the simultaneous entry of intestinal contents. The probe proposed by E. J. Seidmon et al. (1984), in addition to two channels, it is equipped with cuffs, one of which, in order to prevent regurgitation of intestinal contents into the stomach, is inflated in the lumen of the duodenum. The stomach is drained through an additional channel of the probe.
It should be emphasized that the main disadvantage of the proposed multichannel probes is the small diameter of the channels intended for drainage of the intestine and stomach. As shown by experimental and clinical researches, the lumen diameter, allowing for adequate decompression of the gastrointestinal tract, must be at least 0.4 cm, which is currently technically permissible in the manufacture of only double-lumen probes. The creation of three or more channels leads to an increase in the diameter of the probe, which makes it difficult to pass it through the nasal passages and the esophagus.
In this regard, we have developed a double-lumen nasogastro-enteric tube for simultaneous separate drainage of the colon and stomach (priority certificate for the invention No. 4935940 dated May 12, 1991) (Fig. 32, Fig. 33). The probe is an elastic, thermolabile and radiopaque polychlorovite
Rice. 33. General view of the gastro-eutheric probe in mass production, a nyl tube with a plugged working end and a club-shaped guide part (A). The working part of the probe contains a channel (B) with 40-50 side holes located at a distance of 5 cm from each other, which serves for drainage of the small intestine, and a channel (B), in the initial part of which there are 3-4 holes for drainage of the stomach. Transition part(E) is a solid tube 30 cm long, which corresponds to the length of the duodenum. It has no lateral openings and is a continuation of the intestinal canal. The gastric canal of the probe in the initial section of the transition part is closed with a silicone sleeve, the diameter of which corresponds to 1/2 of the lumen of the probe. The length of the working part of the intestinal canal is from 1.6 m to 2 m. Diameter
k can be seen from the data presented in Table 22, the yay in patients with a drained small intestine with a double-lumen gastroenteric tube decreased to 10.5% and was significantly less than in the groups of patients who were drained with a single-lumen probe or separately with intestinal and gastric tubes. The number of purulent tracheobron-hits has decreased. This made it possible to expand the indications for intubation of the small intestine using the transnasal method in elderly and senile patients.
ages.
In most cases, patients do not tolerate a long stay of the probe in the nasopharynx and often remove it independently in the first hours after surgery. Therefore, reliable fixation of the probe at the nasal passage is necessary. Most often, given the importance of long-term intestinal drainage, the probe is fixed by suturing it to the wing of the nose. This is especially true for elderly and senile people, patients with unstable mental health, as well as with severe intoxication syndrome and delirium. G.-A.Sh. Kagan (1982), citing the traumatic nature of this method, proposed using a ligature previously drawn around the nasal septum to fix the probe. Patients in such cases, according to the author, experience less discomfort. E. J. Seidmon et al. (1984) proposed a special design that involves fixing the probe in the nasal passages by inflating a cuff made of soft latex rubber. In addition, the probe can be secured with bandage straps, the ends of which are drawn and tied around the head. R.Sh. Vakhtaigishvili and M.V. Belyaev (1983) suggest using a probe with a loop specially designed for passing the bandage strap.
2,2.3. Transrectal intubation of the small intestine Transrectal intubation of the small intestine for the purpose of its long-term decompression has become widespread in pediatric surgery
(Doletsky S.Ya. et al., 1973; Topuzov V.S. et al., 1982; Ba^ G.A., Roshal L.M., 1991). This is due to the physiological and ashtomo-topographical characteristics of the child’s intestines, as well as the difficulties of managing the postoperative period in this category of patients with nasal and transfistular drainage methods. In adults, inserting a probe through the colon into the small intestine is a more traumatic manipulation, especially when passing the probe through the splenic angle and the Bauhinian valve. In addition, the tube, which has side holes, in the lumen of the colon quickly becomes clogged with feces and ceases to drain the intestine. However, there are reports of the successful use of long-term transrectal intubation in the treatment of intestinal obstruction and peritonitis in adults (Zaitsev V.T. et al., 1977; Lyubenko LA. With al., 1987; Griffen W., 1980). According to these authors, the proportion of transrectal drainage of the small intestine ranges from 9 to 11%.
Bowel intubation(lat. in, inside + tuba pipe; syn. intestinal probing) - insertion of a tube into the intestinal lumen for diagnostic and therapeutic purposes.
A tube may be inserted into the small intestine through the mouth or nose, through a gastrostomy tube or ileostomy tube; into the colon - transanally or through a colostomy.
Diagnostic intestinal intubation is used to obtain material for histological, cytological and other studies. In 1967, Y. A. Fox proposed a method of blind probing of the colon to obtain the contents and biopsy of the colon mucosa.
In 1955, D. H. Blankenhorn et al. proposed a method of intestinal intubation, the essence of the cut is that a long (8-10 m) thin (1-1.5 mm) polyvinyl chloride probe with a mercury weighting agent is inserted through the nose. The probe passes through the entire digestive tract. In this way, the length of the intestine was measured, sensors were passed through the probe to determine pH, electrical activity, and the contents were obtained through the probe for biochemical research.
This probe was also used to insert the endoscope into the colon and terminal ileum. The method is dangerous because complications such as intestinal perforation, injury to the intestinal wall with a probe or the end of an endoscope are possible. These diagnostic methods completely replaced by endoscopy methods based on the use of fiber optics (see Intestinoscopy, Colonoscopy).
In 1910, Westerman pioneered the use of insertion of a tube through the nose into the stomach and duodenum in the treatment of peritonitis. Mat as (R. Matas, 1924), Wangesteen (O. H. Wangesteen, 1955) successfully used constant aspiration of the contents of the small intestine for mechanical and dynamic intestinal obstruction.
For more efficient suction of the contents of the small intestine, various modifications of thin single- and double-channel intestinal probes have been developed that can move throughout the intestine.
Therapeutic intestinal intubation is used for intestinal paresis and paralysis, for acute inflammatory diseases, after major and traumatic operations on the abdominal organs, for the prevention and treatment of intestinal obstruction; for feeding patients in the early postoperative period, for fixing the intestines in a certain position after reconstructive operations such as Noble's operation (see Noble's operation).
During therapeutic intestinal intubation, the contents are evacuated from the small intestine, which is overfilled and distended with liquid and gases, since overflow with contents leads to disruption of blood flow in the vessels of the intestinal wall, their thrombosis, necrosis and perforation of the intestinal wall. For this purpose, it is most advisable to use the Abbott-Miller probe.
Small bowel intubation through the mouth or nose can be used preoperatively, intraoperatively, and postoperatively.
Methodology
In order to prepare for surgery or when trying to conservatively treat patients with intestinal obstruction, intubation of the small intestine is performed with the patient sitting or reclining.
After anesthesia, e.g. Dicaine solution, the mucous membrane of the pharynx, through the lower nasal passage, the probe is passed into the esophagus, and then into the Stomach. Turn the patient on the right side and advance the probe to the second mark (pyloric level), inflate the cuff of the probe, and at the same time aspirate the contents using a vacuum apparatus. After emptying the stomach, the probe is slowly advanced to the third mark, and then the cuff along with the probe slowly moves during intestinal peristalsis (15 - 20 cm per hour) to a level of 2-3 m. X-ray control is required, especially during the passage of the probe through the pylorus and through the small intestine (up to 3-4 times depending on the advancement of the probe).
When performing intubation on the operating table, the probe is first inserted into the stomach, and further along the intestine the probe is directed by the surgeon from the side of the opened abdominal cavity. After passing the probe, the head end of the table is raised. The duration of the probe is 3-7 days, depending on the restoration of intestinal motility and the patency of the probe.
Intubation of the intestine through the mouth and nose gives a good therapeutic effect, but inserting a probe (even a Cantor probe with a weight at the end) is difficult in case of intestinal paresis. Prolonged presence of a probe in the intestine can lead to the development of various complications: sinusitis, otitis, pneumonia, esophagitis, stenosis of the esophagus and pharynx, rupture of varicose veins of the esophagus, perforation of the esophagus, stomach, and intestines.
Intubation of the small intestine through a gastrostomy (Fig. 1) or ileostomy is also used, which can be done due to the impossibility of passing a probe through the mouth or nose. To intubate the small intestine, a thin long rubber tube with multiple holes is inserted through the ileostomy, which empties significant sections of the intestine (I. D. Zhitnyuk, 1965).
Intubation of the lower segments of the colon is sometimes used for the conservative treatment of sigmoid volvulus. In these cases, in sigmoid colon A thick gastric tube is inserted through a sigmoidoscope.
In order to protect the anastomotic sutures on the colon, a number of surgeons use transanal intubation of the colon. Use specially designed single- or double-channel probes or a thick gastric tube. The probe is inserted during surgery above the anastomosis (Fig. 2) for 3-5 days and removed after restoration of intestinal function.
Bibliography: Berezov Yu. E. Surgery of stomach cancer, M., 1976, bibliogr.; Galperin Yu. M. Paresis, paralysis and functional intestinal obstruction, M., 1975, bibliogr.; Dederer Yu. M. Pathogenesis and treatment of acute intestinal obstruction, M., 1971, bibliogr.; Zhitnyuk I. D. Treatment of dynamic obstruction in peritonitis, Vestn, hir., t. 95, No. 12, p. 8, 1965; Rozanov I. B. and Stonogin V. D. On the prevention of insufficiency of the duodenal stump after gastrectomy, Surgery, No. 6, p. 31, 1965, bibliogr.; Simonyan K. S. Adhesive disease, M., 1966, bibliogr.; Surgery of the digestive organs, ed. I. M. Matyashina et al., vol. 3, p. 9 and others, Kyiv, 1974; Shalkov Yu. L., Nechitailo P. E. and Grishina T. A. Method of intestinal decompression in the treatment of functional intestinal obstruction, Vestn, hir., t. 118, no. 2, p. 34, 1977.,
V. P. Strekalovsky.
The rectal probing technique is effective and necessary to clarify the topographical features of rectal fistulas. A well-performed procedure will help the doctor determine
- the direction of the anal fistula relative to the intestinal wall,
- changes in the relief of the fistula course and its length,
- the presence of additional cavities.
Probing of the rectum becomes especially informative for the diagnosis of chronic paraproctitis, since it allows one to identify the connection of the fistulous tract directly with the lumen of the rectum.
How is the procedure done?
To carry out the procedure, a button-shaped metal probe with a small round thickening at the end is used. The patient takes a supine position on a gynecological chair. Since probing is often accompanied by pain, the procedure is carried out “under the guise” of high-quality and safe painkillers.
The doctor carefully inserts the probe through the external opening of the fistula tract, gradually moving it deeper into the fistula.
Additional diagnostic information is provided by finger-probe examination. It allows you to determine the thickness of the tissue between the probe during the fistula and the finger that the doctor inserts into the lumen of the anal canal.
Large tissue thickness often indicates a complex fistula. A simple fistula tract is more characterized by minimal tissue thickness when probing the rectum.
If various diseases are suspected, an intestinal examination is required. It involves examining the mucous membrane and determining peristalsis. There are small and large intestines. Inspection of the initial sections is difficult. Instrumental diagnostic methods are complemented by laboratory tests, palpation and questioning of the sick person.
Instrumental examination of the intestine
Intestinal examination is performed according to certain indications. Patients can be both adults and children. There are endoscopic and non-endoscopic techniques. In the first case, the mucous membrane is examined from the inside using a camera. This is the most informative way to identify various diseases. It is necessary to examine a person if he has the following symptoms:
- constant or intermittent abdominal pain;
- bowel dysfunction such as constipation or diarrhea;
- vomiting feces;
- bloating;
- the presence of blood or other pathological impurities in the stool.
The following studies are most often organized:
- fibroesophagogastroduodenoscopy;
- colonoscopy;
- sigmoidoscopy;
- anoscopy;
- irrigoscopy;
- computed tomography or magnetic resonance imaging;
- capsule colonoscopy;
- radionuclide research;
- radiography.
Sometimes laparoscopy is performed. A therapeutic and diagnostic procedure in which the abdominal organs are examined from the outside. During the examination of patients, the following diseases can be identified:
- benign and malignant tumors;
- ulcerative colitis;
- Crohn's disease;
- diverticula;
- polyps;
- duodenal ulcer;
- duodenitis;
- enterocolitis;
- proctitis;
- haemorrhoids;
- anal fissures;
- condylomatosis;
- paraproctitis.
Endoscopic examination of the duodenum
FEGDS allows you to check the condition of the duodenum. This endoscopic method patient examinations. It allows you to examine only the initial part of the small intestine. FEGDS is often performed for therapeutic purposes. During the study, it is possible to stop bleeding or remove a foreign body. There are planned and urgent FEGDS.
The advantages of this study are:
- rapidity;
- information content;
- good tolerance;
- safety;
- low invasiveness;
- painlessness;
- the possibility of implementation within the walls of the clinic;
- availability.
Disadvantages include discomfort during insertion of the probe and unpleasant sensations during the cessation of anesthesia. FEGDS is performed if the following pathology is suspected:
- ulcer;
- gastroduodenitis;
- bleeding;
- cancer of the papilla of Vater;
- duodenitis;
- gastrointestinal reflux.
Before FEGDS, preparation is required. It includes not eating immediately before the procedure and following a diet for several days. 2-3 days before the test, you need to exclude spicy foods, nuts, seeds, chocolate, coffee and alcoholic drinks. You need to have dinner the night before no later than 6 pm.
In the morning you cannot have breakfast and brush your teeth. The duodenum and stomach should be examined in a lying position on the left side with the knees pressed to the body. A thin tube with a camera is inserted through the patient's mouth. Local anesthesia is performed. This ensures the procedure is painless. The person should not talk during the examination. You should only swallow saliva with your doctor's permission. You can eat only 2 hours after the test.
Contraindications to FEGDS are:
- curvature of the spinal column;
- atherosclerosis;
- mediastinal neoplasms;
- history of stroke;
- hemophilia;
- cirrhosis;
- myocardial infarction;
- narrowing of the lumen of the esophagus;
- bronchial asthma in the acute phase.
Relative limitations include severe hypertension, angina pectoris, lymphadenopathy, acute inflammation of the tonsils, mental disorders, inflammation of the pharynx and larynx.
Carrying out colonoscopy of the intestines
The main instrumental method for diagnosing colon diseases in women and men is colonoscopy. It comes in classic and capsule versions. In the first case, a fiber colonoscope is used. This is a flexible probe that is inserted into the intestine through the anus.
The possibilities of colonoscopy are:
- removal of foreign objects;
- restoration of intestinal patency;
- stopping bleeding;
- biopsy;
- removal of tumors.
Not everyone knows how to prepare for this procedure. The main goal is to cleanse the intestines. For this, enemas or special laxatives are used. In case of constipation, it is additionally prescribed Castor oil. An enema is performed when defecation is delayed. To carry it out you will need an Esmarch mug and 1.5 liters of water.
For 2-3 days you need to adhere to a slag-free diet. It is prohibited to consume fresh vegetables, fruits, herbs, smoked meats, pickles, marinades, rye bread, chocolate, peanuts, chips, seeds, milk and coffee. The evening before the procedure, you need to cleanse your intestines. Drugs such as Lavacol, Endofalk and Fortrans are used.
Colonoscopy is performed under local anesthesia. The procedure is less pleasant than FEGDS. A probe with a camera at the end is inserted into the rectum. The doctor examines all parts of the large intestine, starting with the rectum. The expansion of the intestine occurs due to the injection of air. This study lasts 20-30 minutes. If a colonoscopy is performed incorrectly, the following complications are possible:
- bleeding;
- perforation of the intestine;
- bloating;
- fever;
- pain.
When worsening general condition After the procedure you need to visit a doctor. Normally, in a healthy person, the mucous membrane of the large intestine is pale pink. It is shiny, without ulcerative defects, protrusions and growths, smooth with slight striations. The vascular pattern is uniform. Lumps, pus, blood, fibrin deposits and necrotic masses are not detected. Absolute contraindications to colonoscopy are peritonitis, severe cardiac and respiratory failure, heart attack, severe ischemic stroke and pregnancy.
X-ray examination of the intestine
Methods for examining the intestines include irrigoscopy. This is a type of radiography that uses a dye. This study allows us to determine pathological changes mucous membrane. The relief of the intestine is assessed in detail. Contrasting can be simple or double. In the first case, barium sulfate is used. In the second, additional air is introduced.
The advantages of irrigoscopy are:
- safety;
- painlessness;
- availability;
- information content;
The condition of the colon (ascending, transverse and descending), sigmoid and rectum is assessed. It is recommended to administer contrast not through the mouth, but through the rectum using an enema. During the examination, the patient lies on his side with his upper leg pressed to his stomach. A rectal tube is inserted through which a barium solution is injected.
Then a survey photo is taken. After this, the person being examined has a bowel movement. Next, a repeat photo is taken. There are the following indications for irrigoscopy:
- suspicion of a tumor;
- blood in stool;
- presence of stool with pus;
- pain during bowel movements;
- bloating with stool retention;
- chronic constipation and diarrhea.
There are 3 main methods of preparing for the procedure:
- cleansing enemas;
- taking the drug Fortrans;
- carrying out colon hydrotherapy.
A conclusion is drawn from the photograph. If uneven haustra folds and areas of intestinal narrowing are detected in combination with incomplete removal of contrast during bowel movements, irritable bowel syndrome can be suspected. If during the examination an uneven diameter of the colon, narrowing of the lumen against the background of spasm and areas of asymmetrical contraction are detected, this indicates ulcerative colitis. Irrigoscopy should not be performed on pregnant women, intestinal perforation, diverticulitis, ulcers and severe heart failure.
Conducting a capsule study
Modern methods of examining the intestines include capsule colonoscopy. Its difference is that nothing is inserted into the patient’s anus. It is enough to take one capsule equipped with two chambers. The advantages of this study are:
- safety;
- simplicity;
- no need for anesthesia;
- no radiation exposure;
- minimally invasive;
- the possibility of examining the intestine without a cleansing enema.
Disadvantages include the inconvenience of processing the received data and difficulty in swallowing. The picture of the intestine with the capsule is recorded on a special device that is worn on the belt. This study has limited application. It's expensive. A capsule study is performed when colonoscopy and irrigoscopy are not possible.
Complications include delayed capsule clearance. Some patients develop allergic reactions. The study is carried out on an outpatient basis. The person does not need to be in the hospital. After swallowing the capsule, you can go about your daily activities. Preparation includes the use of laxatives.
Examination using a sigmoidoscope
To examine the final sections of the intestine, sigmoidoscopy is often organized. The procedure is performed using a sigmoidoscope. It is a lighting device with a metal tube. The thickness of the latter varies. Using a sigmoidoscope, you can examine the mucous membrane of the sigmoid and rectum at a distance of up to 35 cm from the anus.
- pain in the anus during bowel movements and at rest;
- persistent constipation;
- unstable stool;
- bleeding from the rectum;
- the presence of mucus or pus in the stool;
- feeling of a foreign body.
The study is carried out for chronic hemorrhoids and inflammation of the colon. Sigmoidoscopy is contraindicated in cases of acute anal fissure, narrowing of the intestine, massive bleeding, acute paraproctitis, peritonitis, cardiac and pulmonary failure. Preparation is similar to that for a colonoscopy.
Immediately before inserting the sigmoidoscope tube into the anus, it is lubricated with Vaseline. The device is advanced during pushing. To straighten the folds of the intestines, air is pumped. In the presence of large quantity An electric suction can be used to remove pus or blood. If necessary, material is taken for histological analysis.
Other research methods
A modern method for diagnosing intestinal diseases is magnetic resonance imaging. It can be performed with double contrast. The dye is administered intravenously and through the mouth. This method cannot replace a colonoscopy. He is auxiliary. The advantages of MRI are painlessness, information content and lack of radiation exposure.
Layer-by-layer images of the organ are taken. The doctor receives a three-dimensional image on the screen. Tomography is based on the use of magnetic fields. The latter are reflected from the nuclei of hydrogen ions of tissues. Before an MRI, you need to cleanse your colon and follow a diet for several days. The procedure lasts about 40 minutes. Pictures are taken while the patient is holding his breath.
The patient is placed on a platform and the body is secured with straps. Methods for examining patients include anoscopy. It can be used to examine the final section of the intestinal tube. An anoscope will be required. This is a device that consists of an obturator, a tube and a lighting handle.
A digital rectal examination is often required before anoscopy. This is done in order to assess the patency of the intestine. If necessary, anesthetic ointment is used. Thus, if intestinal pathology is suspected, it is necessary to carry out instrumental study. It is impossible to make a diagnosis based on questioning, examination and palpation.