Examination of the intestine with modern methods. Treatment of intestinal obstruction Other research methods
Many methods of intestinal decompression have been proposed, the requirements for which include: the maximum release of the intestine from gas and liquid, the prevention of infection of the abdominal cavity, the unhindered removal of contents in the postoperative period, and the minimal trauma of manipulation.
The elimination of mechanical obstruction does not yet mean the elimination of obstruction in general, since this or that degree of functional obstruction may remain or arise. Therefore, one of the main tasks is the prevention or rapid resolution of 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 way to decompress the intestine 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 allow you to 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. To these shortcomings in such cases, there is a great trauma.
Intestinal decompression by milking
The method of "milking" - moving the contents into the underlying loops - is almost never used, since it is not possible to completely empty the intestines, and a significant injury is caused. Progressive flatulence and fluid accumulation can lead to failure of the sutured puncture or enterotomy. According to the literature, the lethality of patients with acute intestinal obstruction, complicated by the opening of 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 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 was widely used. However, nowadays it is rarely used. This is due to the fact that in this way it is not possible to achieve complete liberation of the intestinal loops. At best, the nearest loops are emptied. Recently, safer methods of bowel decompression using nasojejunal probes have been developed.
Considering that the main disadvantage of suspended enterostomy lies in incomplete emptying of the intestine, it was proposed to introduce into the intestinal lumen not a short, but rather long tube (1.5-2 m) with many side holes (I. D. Zhitnyuk).
However, if the question of the expediency of the intestine over a large area is resolved positively, then the advantages of one or another method of drainage have not yet been finally established. For example, some support the introduction of an intestinal probe 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 probe through the caecum.
Intestinal decompression with a tube
Drainage of the intestine with a long probe allows you to carefully remove the contents directly 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 administration and the type of probe.
Despite the obvious advantages of bowel decompression with a long probe, the method has not yet received wide distribution. The main reason for this, in our opinion, is that passing a probe made from a conventional rubber tube through the entire intestine is associated with great technical difficulties. Such a probe is very soft, constantly bends; in addition, due to the significant friction forces that arise, it is very difficult to bring it to the appropriate place. These factors and the significant traumatization of the intestine associated with them forced many to abandon this method, replacing it with a single removal of intestinal contents.
These shortcomings are practically devoid of an intestinal probe made of a PVC tube. The probe is quite elastic and resilient. When immersed in the intestinal lumen, it, being wetted, freely slides along the mucous membrane, and therefore the manipulation is slightly traumatic and short. At the distal end of the probe, 1-2 round metal 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 control of the location of the distal end of the probe. An equally important design feature of the probes is the presence of a “deaf”, that is, without side holes, a proximal section 65–70 cm long in probes for intubation through the nose and 15–20 cm in probes for insertion through the caecum (or ileostomy, gasgrostomy) . The presence of a "deaf" 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.
Bowel intubation technique
The probe can be inserted through the nose, gastrostomy, ileostomy or cecostomy, rectum Each of the methods has its advantages and disadvantages, which should be considered when choosing the method of intubation in relation to the goals.
Transnasal bowel decompression
Transnasal insertion of a probe for intestinal decompression is usually carried out in conjunction with, which conducts a Vaseline-lubricated probe through the nasal passage through the esophagus into the stomach. Then the surgeon grabs the probe through the wall of the stomach, passes it along the bend of the duodenum until the tip of the probe is found by touch in the initial section of the jejunum under the ligament of Treitz. At first glance, conducting a probe through the duodenum is a difficult manipulation. However, if the probe that appeared in the cardial part of the stomach is pressed against the lesser curvature so that a springy bend in the stomach does not form (and even more so that the probe does not curl up), then it moves on quite easily by the efforts of the anesthesiologist. Further passage of the probe through the intestines is not difficult and takes, as a rule, another 5-15 minutes. It is desirable to hold the probe as low as possible to the ileocecal junction, especially with adhesive intestinal obstruction. In such cases, the probe also ensures the smoothness of the bends of the intestine.
With any method of performing intestinal intubation for decompression, it is necessary to remove the 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 previously closed, since air is sucked into them, and not viscous intestinal contents. The simplest technique is to temporarily seal the holes with adhesive tape, 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 did not justify itself, since after the first turn of the probe in the intestine it is almost impossible to remove the obturating tube.
One of the advantages of transnasal intubation is the preservation of the cleanliness of the surgeon's hands and the operating 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 alimentary canal (stomach, duodenum), which is usually not achieved with retrograde intubation. The only, but very significant drawback of passing the 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 reflux of intestinal contents into the esophagus and its entry into trachea. In this regard, transnasal intubation for intestinal decompression is undesirable in patients over the age of 50-60 years and is contraindicated in concomitant bronchitis, pneumonia.
Prevention of these complications consists in systematic (every 2-3 hours) active aspiration of intestinal contents, fluid intake through the mouth, as soon as the patient becomes adequate after anesthesia. However, the main preventive measure is the timely removal of the probe - no later than 3-4 days. This time is usually sufficient to resolve functional intestinal obstruction.
Transnasal bowel intubation has been the method of choice since flexible PVC tubes have been used.
Intestinal decompression through gastrostomy
This technique has found wide application, especially in pediatric 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 alimentary canal for a long time. The disadvantages of this technique 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 discharge of the stoma from the abdominal wall, which is most common in peritonitis, when the plastic properties of the peritoneum are lost. Therefore, intubation through a gastrostomy is desirable to perform in acute intestinal obstruction and other pathologies that are not complicated by peritonitis.
Bowel decompression through an ileostomy
Ileostomy with intestinal intubation according to Zhitnyuk is currently used quite rarely. This is due to the large deformation of the ileum and the possibility of infection. In addition, intubation is carried out retrograde, that is, from the bottom up, so the end of the probe quickly goes down and the upper sections 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 second 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 probe for more than 5 days. A similar situation is most often observed in the elimination of adhesive intestinal obstruction, which usually affects the ileum. The probe introduced through the caecum, thanks to smooth bends, like a tire, straightens the loops of the intestine. Secondly, the caecum is a fairly large organ, and therefore, if necessary, a three-row purse-string suture can be applied to strengthen the probe without causing a sharp deformation of the intestine. A correctly applied cecostoma (double-row or sin-row submerged purse-string suture) usually closes on its own in the next 5-14 days.
The disadvantages of bowel decompression through the caecum, as with ileostomy, are associated with retrograde passage 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 bellied probe) through this hole and the valve into the caecum. After tying the elastic end of the probe to the 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 technique).
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 hem the caecum to the peritoneum, and then, having previously fenced off the wound with napkins, pass the probe.
Transal intubation
This manipulation, as a rule, supplements the already undertaken bowel 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 must be passed behind 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 the end of any method of intubation is the fixation of the probe (near the nasal passage, to the abdominal wall, to the perineum), as well as the patient's hands, since often, being in an inadequate state, the patient may accidentally remove the probe.
Intestinal decompression with a long intestinal probe is a therapeutic and prophylactic measure: with peritonitis it is 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 bowel kinks and the development of adhesive obstruction.
Subject to the basic rules of bowel decompression and intubation techniques, the postoperative period proceeds smoothly, without the usual symptoms of intestinal paresis: bloating, shortness of breath, belching, or even vomiting. Sometimes there may be slight flatulence due to gas 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 wash the intestinal lumen with small (300-500 ml) portions of warm isotonic sodium chloride solution (only 1-1.5 liters per session). With the help of washing, it is possible to quickly reduce intoxication; the appearance of peristalsis is noted in some cases by the end of the 1st day after the operation.
An important point in the management of such patients is a strict accounting of the daily amount of fluid released through the probe (excluding flushing). Fluid losses are replenished by administering an adequate amount parenterally. It is not excluded the possibility of prescribing through a directed probe, other drugs, and 2-3 days after - nutrient mixtures.
Frequent auscultation of the abdomen is required to determine the time of occurrence of peristalsis. Objective indicators of its recovery are also the nature and dynamics of the discharge of intestinal contents. The uniform release of fluid through the probe during inspiration indicates its passive outflow 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, the motor function of the intestine is completely restored, as evidenced by auscultation data, independent discharge of gases, the nature of the release of fluid through the probe. All this serves as an indication for the removal of the probe. In some doubtful cases, to assess the state of motility, dynamic x-ray control can be performed with a preliminary introduction through the probe of 40-60 ml of a 50-70% solution of cardiotrast (verografin). Radiographs or survey fluoroscopy after 5-10 minutes give a clear idea of the nature of peristalsis.
The probe is removed by pulling on its end for 15-30 s. In this case, patients usually experience nausea and even retching. With retrograde bowel intubation, the probe is removed more slowly, as it can clot in the terminal ileum.
Bowel decompression has proven to be a highly effective method for the prevention and treatment of functional bowel obstruction. It is indispensable in the surgical treatment of 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 relieve sutures in technically or clinically difficult situations, especially when postoperative peritonitis is possible.
Total intubation of the small intestine is indicated to prevent intestinal paresis after prolonged and traumatic operations on the organs of the abdominal cavity and retroperitoneal space, especially with a history of motor disorders, disorders of water and electrolyte metabolism.
Widely and successfully using this method of intestinal decompression in 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 (serious condition, advanced 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 the probe is inserted transnasally, its oral segment, which does not have holes in the side walls, must be in the esophagus and outside. The last lateral opening, closest to the oral end, must certainly be in the stomach. If this rule is not observed, two complications can be observed. If the tube is inserted too deeply, the stomach will not drain, resulting in regurgitation. If the probe is not inserted deep enough and one of the side holes is in the esophagus or oral cavity, it is possible to throw intestinal contents 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 probe, 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 highly 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 pulled over 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 that time played the role of a conductor. Drainage was saved. The patient recovered.
With retrograde intubation through the appendicocecostomy during the passage of the ileocecal valve, perforation of the wall of the caecum by the tube is possible. We observed such a patient who died of peritonitis. The probe should be inserted slowly. If this manipulation fails, you can use the Sanderson technique. After successfully passing the tube through the ileocecal valve, it is recommended to carefully examine the caecum in the area of the ileocecal angle so that damage does not go unnoticed.
It can be difficult to pass from the cecum to the ileum even with a special probe. If an ordinary rubber tube with many holes is used, then sometimes it is necessary to use a forceps to carry it out, which creates additional difficulties and increases the likelihood of accidental damage to the intestine.
With the forced use of a conventional rubber tube for drainage of the small intestine, another complication may develop. After 5-7 days, when the need for drainage disappears, the tube, when removed, may be pinched in the purse-string suture tightened around it at the base of the cecostomy. 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 opening of the cecostomy. To extract it requires a special surgical intervention.
This complication is not observed when using PVC probes. If, however, a rubber tube is used, then in order to avoid breaking it when removing it, the side holes should be made as small as possible in diameter. The purse-string sutures that screw the intestine at the site of the stoma and provide hermeticism should not be tightened too tightly, and in no case should force be applied when removing the probe. In case of difficult disintubation, it is advisable to turn the tube by 90-180 °, and if this does not help, wait a few days until the ligature weakens or erupts. Unlike nasogastric intubation, when passing the tube retrograde through the caecum, one should not rush to remove it.
Let's look at another complication. At the intersection of the tube of the glove tube graduate, which drains the abdominal cavity, and the probe, which provides decompression of the intestine, the wall of the latter is subjected to compression. In some cases, on the 4-5th day, a bedsore of the intestinal wall develops with the formation. In the patients we observed, after the removal of the tubular part of the graduate for 7-10 days, the fistulas closed on their own. 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 squeeze 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 communicate the intestinal cavity with the external environment in order to decompress 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. Washp in 1879 reported on the imposition of an unloading ileostomy on a patient with a stenosing 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. A favorable outcome after such an operation was first achieved by MausN in 1883. From that moment, enterostomy, as a method of treating intestinal obstruction, began to be used in medical institutions in Europe and America. In 1902, at the 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 of 10 patients with ulcerative colitis and intestinal obstruction in this way. 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, with the accumulation of clinical material, many surgeons began to treat such operations with restraint, which was associated with severe purulent-septic complications and high mortality after stomas. So, I.I. Grekov in 1912 recommended replacing enterostomy by emptying overstretched loops of the intestine by puncturing it, followed by suturing the puncture hole. By this time, the first reports of successful treatment of intestinal paresis with a probe inserted into the stomach and duodenum appear.
Already in 1910, Westermann summarized the experience of treating 15 patients with peritonitis using active gastric aspiration.
CHAPTER 2
Content and gave her high praise. At the suggestion of Kanavel (1916), a duodenal probe was used for this purpose. Wangensteen by 1913 had the experience of treating 32 patients with peritonitis and intestinal obstruction in a similar way. An important event in improving the 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, should have ensured the advancement of the zonades along the intestinal tube. In view of the fact that the probe often folded up in the stomach and did not pass into the duodenum and jejunum, it subsequently received a number of improvements. So ”MO Cantor in 1946 proposed replacing the cuff with a canister filled with mercury. Promotion of the probe along the gastrointestinal tract was carried out due to the fluidity of mercury. In 1948, G.A. Smith proposed a flexible stylet to control the tip of the Zand. The passage of the probe into the jejunum was carried out under x-ray control. D. L. Larson et al. (1962) invented an intestinal tube with a magnet at the end. The movement of the probe was carried out using a magnetic field. However, despite technical improvements in the Miller-Abbott probe, this method later turned out to be of little use for draining 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 studies, and, in addition, the presence of peristaltic activity of the intestine was required. At the suggestion of 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 resumed after the development of suspended enterostomy by Richardson (1927) with the insertion of a probe into the intestinal lumen to feed patients suffering from stomach tumors, as well as Heller's (1931) proposal to use a gastrostomy for the treatment of paralytic ileus. At the same time, F.Rankin (1931) proposed to form 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. He outlined a detailed description of the imposition of a suspended enterostomy in the work “How to reduce postoperative mortality.”
1Guest at the wounded in the stomach”, published in 1943. This technique was widely used during the Great Patriotic War in the provision of surgical care to the wounded in the stomach.
According to A.A. Bocharov (1947) and S.I. Banaitis (1949), it was performed in at least 12.8% of operations for gunshot wounds of the abdomen with intestinal damage. In the postwar years, a gradual decline in interest in enterostomy according to S.S. Yudin began. Many authors have referred to the fact that in case of paralysis of the intestine, it leads to unloading of only that part of the intestine on which it is imposed. In addition, the formed high enteric fistulas often led to exhaustion and death of patients. The attitude to this issue changed after J.W.Baxer in 1959 suggested using long intestinal probes when applying a suspended enterostomy and intubating the entire small intestine.
In our country, the technique of decompression of the small intestine through a suspended ileostomy using long intestinal probes 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 for the first time gave an in-depth analysis and substantiated the advantages of draining 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 with gastroenterostomy in patients with paralytic ileus.
I.S.Mgaloblishvili in 1959 proposed to use appendicostomy for intubation of the small intestine. However, the method of enterostomy through the 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 proponents and pioneers of open drainage methods as 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 - early sixties, surgeons were already armed with a number of ways to de-
Compression of the small intestine, and the intestinal probe, according to H.Hamelmann und H.Piechlmair (1961), has become the same indispensable tool in the operating kit, like a scalpel and tweezers
Despite the fact that sixty years have passed since one of the first reports on the use of drainage of the small intestine in the treatment of paralytic obstruction, this method has become widespread in the last two decades. This became possible due to a deep study of the therapeutic possibilities of drainage of the small intestine and intra-intestinal tube therapy, as well as the improvement of methods and techniques of intubation, the improvement of the design of enterostomy probes and the use of high-quality polymeric materials in their manufacture. It has been established that the therapeutic effect of drainage of the small intestine is not limited to the elimination of intra-intestinal hypertension and the removal of 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 to eliminate dystrophic changes in the intestinal wall, reduces extravasation of fluid into its lumen, restores motor activity and absorption capacity, prevents relapses of paralytic and adhesive intestinal obstruction.
There is a single emptying of the small intestine and its long-term drainage. A single emptying is performed during the operation.
Long-term drainage can be performed both non-operatively and surgically. Non-surgical methods include: drainage of the small intestine using Miller-Abbott probes, nasoenteric endoscopic intubation, and transrectal intubation of the colon and small intestine. 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 side of the upper parts of the digestive tract in the aboral (caudal) direction, with retrograde, the intestine is intubated from the bottom up. Closed surgical methods include nasoenteric drainage and transrectal intubation of the small intestine.
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operating - drainage of the small intestine, enterostomy and cecostomy, In a separate group, combined methods that presuppose separate drainage of the upper and lower parts of the tonsil - kshpkiGa also through drainage of the entire intestine. With "binned drainage, at the same time it can be AND open and closed, as well as antegrade and retrograde intubation of the intestine.
21 NON-OPERATIVE METHODS OF DRAINAGE OF THE SMALL INTESTINE
Non-surgical method of drainage of the small intestine using probes of the Miller-Abbott type. T.Msheer and W.Abbott in 1934 reported on 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 up to 1.5 cm in diameter 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 the right side. Constantly sucking the contents of the stomach and small intestine, the probe gradually, every 30-40 minutes moves forward by 5-7 cm. The position of the probe in the intestine is controlled by 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. The subsequent improvement of the probe by replacing the rubber cuff with a canister of mercury (Cantor's probe) contributed to its faster progress 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 a change in the position of seriously ill patients and frequent control x-ray studies, but at the same time, successful attempts to insert a probe into the jejunum do not exceed 60%. R.E. Brolin et al. (1987) consider that the use of a closed drainage method using a Miller-Abbott probe is indicated in the presence of partial patency. The distinction between obstruction and partial patency is based on the interpretation of abdominal radiographs.
The authors consider the definition of gas in the small and large intestines to be the main radiological sign. Complete obstruction is characterized by the presence of gas in the small intestine with fluid levels. bones and the absence of gas in the colon, while in cases of partial patency, along with swollen loops of the small intestine, there is gas in the colon. The effect of treatment after inserting the probe into the intestine is evaluated during 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-surgical decompression of the small intestine were obtained by F.G. Quatromoni et al. (1989) in 41 patients with postoperative small bowel 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 with 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).
The introduction 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. The probe in such cases is supplied with a metal conductor, the end of which is located 10 cm proximal to the initial part of the probe. Promotion of the probe from the stomach into the duodenum is controlled fluoroscopically. The passage of the probe through the pylorus is facilitated by deep respiratory movements, as well as the position of the patient on the right side with a turn on the stomach. To eliminate the spasm of the pyloric sphincter, 1 ml of prozerin is injected subcutaneously. After the probe passes over the ligament of Treitz, the metal conductor is removed. From 500 to 1000 ml of 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, x-ray examination is repeated after two hours. According to K.D. Toskin and A.N. Pak (1988), the diagnostic efficiency of probe decompression enterography is 96.5%. Detection of traces or accumulation of barium suspension in the caecum, as well as the image of the relief of the mucous membrane of the colon on radiographs, reject acute obstruction. The probe in such cases you-
Removes the decompression function and is used to introduce b
In connection with the widespread introduction of fibroscopic technique in yaichny practice, the possibility of non-surgical azoenteric endoscopic drainage of the initial sections of the small intestine has appeared. To date, two methods have been developed for inserting a probe into the small intestine using a fiberscope: through the instrumental channel of the apparatus and in parallel with it under visual control.
In the first case, the introduction of the probe is carried out for enteral nutrition and through the tube intra-intestinal correction of metabolic disorders. The diameter of the probe lumen in this case is 0.2 cm, which is quite enough for infusion. The second method involves the introduction of a probe for decompression of the initial sections 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 introducing the probe through the instrumental channel of the endoscope is more effective and safe compared to the method of passing the probe in parallel with the endoscope. Of the 111 observations, none of the authors observed any complications. 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 gastroentero- or gastroduodenal anastomosis, gastric atony, postoperative pancreatitis, etc.).
Anesthesia of the pharyngeal mucosa and premedication are carried out in the amount usual for diagnostic gastroduodenoscopy. First, an examination of the mucous membrane of the stomach and duodenum is carried out, the cause of the obstruction is established. With a preserved duodenal passage, the tip of the endoscope reaches the lower-horizontal part of the duodenum, after which an intestinal probe 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 inserted 40-50 cm into the outlet loop of the jejunum Distal to the anastomosis. If the endoscope cannot be passed through the narrowing area, then an attempt should be made to pass the probe through the visible hole. It should be noted that in patients after resection
The stomach with atony of the stump and edema of the anastomosis area is not difficult to find from the mouth. When inflated with air, it opens easily and is freely overcome by the endoscope. The same situation may arise during the formation of pyloroplasty with a two-row suture and postoperative pancreatitis. With the phenomena of anastomosis, the endoscope is carried out by carefully pushing 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 the introduction of nutrient mixtures and infusion solutions, the position of the probe and its patency are controlled radiologically using liquid radiopaque substances.
Endoscopic decompression drainage of the initial sections of the small intestine is carried out with 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 bowel 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) put 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. According to the authors, this makes it possible to avoid unnecessary laparotomies, secure endotracheal anesthesia, less traumatic revision 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. In 40 out of 54 patients, postoperative small bowel obstruction was resolved by the authors by endoscopic insertion of a probe into the proximal jejunum. The rest of the patients underwent surgery within 12 to 48 hours due to the lack of positive dynamics.
"tGya carrying out decompression probes should be used-
"Lisie and long gastrointestinal apparatuses (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 that allows the probe tip to be manipulated. The stiffness of the probe is reduced by gradually withdrawing 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, which are located at a distance of 4-5 cm from each other. They serve to capture them with biopsy forceps. Thus, it is easy to give the desired direction of the initial part of the probe, especially when passing it from the stomach through the bends of the duodenum.
Before starting endoscopic drainage, the stomach is emptied.
In the position on the left side through the nasal passage into the cardial part of the stomach, an intestinal probe with a diameter of 0.6-0.8 cm is passed.
A fiberscope is inserted into the stomach and, under visual control, the probe moves towards the pylorus.
An indispensable condition for the successful passage of the probe along the greater curvature to the pyloric canal is a good air expansion of the stomach. The presence of ligatures fixed to the probe makes it easier to move the probe into the duodenum. For this, the following approach is used. After detecting the initial end of the probe, the first ligature is captured with biopsy forceps, by pulling it up, 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 returns 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 beyond the ligament of Treitz. In the absence of ligatures fixed to the probe, the probe is grasped with forceps by the side holes.
After making sure that the probe is passed into the small intestine, the endoscope is removed. After removing the endoscope from the probe, the string is removed. The position of the probe and the condition of the intestine are monitored by X-ray examination. To facilitate the insertion of the probe, Yu.M. Pantsyrev and Yu.I. Gallinger (1984) developed an endoscopic technique of intubation along a metal guide. Endoscope under visual control as much as possible
Into the duodenum. Then through___ g #-""-"breathe
a long and rigid metal spiral probe with a twisted end is inserted into the lumen of the intestine - a wire "with a diameter of 0.2 cm. The endoscope is removed, and the intestinal probe is attached to a metal conductor and inserted through it into that intestine.
Drainage with 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 through the region of the ligament of Treitz. This manipulation can be facilitated by the use of a probe with an air balloon on its initial part (Gowen G.F. et al., 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 bowel 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 a gradual spontaneous migration of the probe in the diotal direction.
An obligatory condition after the end of drainage is active decompression of the intestine. For this purpose, B.G. Smolsky et al. (1980) and Yu.V. Sinev et al. (1988) suggested using a probe with two channels - perfusion and aspiration. Both channels open at 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 sections of the small intestine during the first day after intubation, the amount of aspiration content when creating a negative pressure of 30-40 mm of water. 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 suction function of the upper small intestine and, in accordance with the examination data, select media for enteral nutrition.
Non-surgical transrectal decompression of the colon and small intestine is most often used to resolve obstructive colonic obstruction or to eliminate volvulus of the sigmoid colon.
Complete obstruction of the intestine by a tumor is rare, but
“Permeability appears when the lumen narrows to its deo< 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 функциональное состояние баугиниевой заслонки. В случаев она нормально функционирует даже при далеко за- формах толстокишечной непроходимости, а у 20% боль-^юдается ее функциональная несостоятельность, что ведет * savory colonic contents into the small intestine, its mechanical overstretching and the development of paresis. The colonic obstruction that has developed in this way enhances endogenous intoxication and toxemia and may be accompanied by the development of endotoxin shock.
Decompression of the colon with a rectoscope can only be performed with low-lying tumors of the rectum. After a cleansing enema, the patient undergoes sigmoidoscopy, and through the canal into the stenosing lumen of the tumor, a gastric tube richly moistened with vaseline oil with two or three side holes and a rounded end is passed. If the tumor is located above 30 cm from the anus, a fibrocolonoscope can be used to perform decompression. However, bowel lavage through the manipulation channel of the endoscope, as a rule, is ineffective. Most often, with the help of a fibrocoloscope, the place of narrowing is found and expanded, and then, under the control of vision, an enterostomy tube is passed through the visible gap of the channel above the place of the obstacle. In this case, you can use the same techniques as for endoscopic drainage of the initial sections of the small intestine. An endoscope can be passed through a stenotic tumor if it has exophytic growth, and the lumen is deformed due to polypoid 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 with Janet's syringe or with the help of 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
dietary divisions. The probe is removed from the intestinal lumen on the second day.
Drainage of the small intestine by passing a probe through the Bauginian valve using a fibrocolonoscope is still considered only theoretically and is unlikely to find wide clinical application in the near future. According to Yu. V. Sinev et al. (1988) "introducing the probe in this way into the distal small intestine becomes possible only with careful emptying of the large intestine from the contents. At the same time, an eaterostomy probe with a lumen of no more than 0.3 cm can be passed through a biopsy channel with a diameter of 0.5 cm, which is not enough for full decompression.
2.2. SURGICAL METHODS OF DRAINAGE OF THE SMALL INTESTINE
2.2.1. Single methods of decompression of the small intestine
There are various ways to empty the small intestine once during surgery.
In some cases, decompression of the small intestine is carried out without opening its lumen by sequential extrusion (“milking”) of the contents retrogradely into the stomach or, more often, antegradely into the large intestine. Despite the fact that the majority of 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 sparing technique of a single movement of the intestinal contents to the underlying sections.
GG consists in the fact that after the cause has been eliminated, the obstruction - the perforating surgeon with a wet gauze napkin holds 111 lu of the intestine between the first and the remaining fingers of the left hand, covering its lumen, and between the second and third fingers of the right ru "And stretches it, easily bringing it closer walls (Fig. 17). In this way, the contents of the intestine move to the underlying sections. At this time, the assistant intercepts the intestine freed from the 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 separate loop of the intestine from gases, and even more so from liquid contents. In order to achieve sufficient emptying of the intestine, it must be punctured in many places, which is ineffective and dangerous in relation to infection of the abdominal cavity. Therefore, this method is applied
fti ">
 |
| Glavd |
Rice 19. Emptying the fine nozzle help electric pump,
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 is clogged with dense contents. The wall of the overstretched small intestine is pierced with a trocar stylet in the center of the previously applied purse-string suture. The stylet is raised to the upper position, and the sleeve moves along the intestinal lumen (Fig. 18). Intestinal contents are evacuated using an electric pump. To empty the nearby loops, the intestinal contents are either “chipped off” to the puncture site, or a probe is inserted into the intestine through the end opening of the trocar. After the evacuation of the intestinal contents, the trocar is removed, the purse-string suture is tightened, and two or three serous-muscular sutures are additionally applied.
Many surgeons perform an enterotomy to empty the small intestine. Between two threads-holders, an electric suction tip is inserted into the intestinal lumen and with its help, the nearest sections of the intestine are first released, and then other overstretched intestinal loops are strung on the suction tip (Fig. 19). N. Balsano and M. Reynolds (1970) suggested using a Foley catheter No. 22 for aspiration of contents from the small intestine.
 |
Rns. 20. Single emptying knshkn 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 two-row suture.
Emptying the small intestine through one of the ends of its resected section is a fairly common method of single decompression. Removal of the contents of the intestine in this case is carried out using the tip of the electric suction or by passing a probe into the lumen of the intestine. After emptying the intestine, its continuity is restored or the proximal end is brought out in the form of an enterostomy.
Despite their apparent simplicity, these methods have a number of significant drawbacks. They are not aseptic and can lead to microbial contamination of the operating field. These methods can only empty the nearest intestinal loops. 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 by closed methods transnasally or transrectally are fully justified.
2.2.2. Nasoenteric drainage
The serial production of standard nasoenteric probes, the need for a special opening of the lumen of hollow o nov and the formation of external gastric or intestinal cheeks made it possible to recommend nasoenteric drainage as the method of choice for the prevention and treatment of enteral insufficiency.
For this purpose, probes are currently used, made of durable elastic material, resistant to the effects of gastric and intestinal contents, having thermal lability, radiopacity and not containing harmful chemical impurities. Their diameter does not exceed 1.2 cm, the channel lumen is 0.8 cm. 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, nasoenteric drainage can be performed using a long (250-300 cm) rubber or silicone tube with a lumen of 0.4-0.8 cm. To give the probe elasticity, a stainless wire mandrel is inserted into its lumen. The initial part of the probe is closed with a plug cut out of rubber or silicone, which makes manipulations safe. The end of the mandrin should be made in the form of an olive-shaped thickening, which greatly reduces the injury to the mucous membrane when the probe is passed through the lumen of the esophagus, stomach and duodenum. For free sliding of the conductor, the inner surface of the probe is lubricated with vaseline oil or glycerin. As a conductor, biopsy forceps of a fibrogastroduodenoscope or a fluoroplastic catheter with a diameter of 0.2 to 0.3 cm can be used.
There are reports of drainage of the small intestine using a soluble probe made from synthetic protein (Jung D. et al. "1988). The 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. Complications associated with the stay of such a probe in the lumen of the intestine and stomach, as well as relapses of adhesive obstruction were not observed.
After deciding on nasoenteric drainage, the surgeon
Rice. 21. Single translucent nasoenteric probe.
examines the upper abdomen. Frees the subhepatic space from adhesions and adhesions. Palyshtorno assesses the condition of the abdominal esophagus, stomach and duodenum. Examines the area of the duodenojejunal flexure.
During the adhesive process, the small intestine is secreted throughout. Deserated areas are sutured prior to intubation. In the presence of a tumor of the cardioesophageal zone, a chronic gastric or duodenal ulcer, a stenosing tumor of the gastric outlet, one should refuse to pass the probe through the stomach and intubate the small intestine using one of the retrograde methods.
Before inserting the intestinal tube into the esophagus, the anesthesiologist controls the stretching of the cuff of the endotracheal tube. Zon-Dom empties the stomach. Complete relaxation and depth of anesthesia are achieved. The olive of the intestinal probe is abundantly lubricated with vaseline oil, and its free end is connected to the electric suction system.
The anesthesiologist through the external opening of the nasal passage moves the probe into the esophagus. You can enter the probe through the mouth. However, in the postoperative period, this position of the probe can cause vomiting and disrupt the act of swallowing. Therefore, after the end of intubation, the free end of the probe is transferred to the nasal passage (Fig. 22).
 |
| mixing up the shields in the cartilage. |
| . |
 |
Rice. 22. Transfer of the nasoeutheral tube from the oral cavity to one of the vossial passages.
In 80% of cases, the probe is inserted into the esophagus without much effort. But sometimes there are difficulties 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 an intubated trachea, upward displacement of the thyroid cartilage may be effective (Fig. 23). If there is no effect, you can use the following method. The index finger of the right hand is inserted into the oral cavity, the tip of the probe is groped 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) for the successful advancement of the probe through the esophagus proposed to intubate it with an endotracheal tube (Fig. 26). According to the authors, the endotracheal tube installed in the esophagus reliably performs the role of a conductor "facilitates the passage of the probe into the stomach and protects the mucosa of the nasopharynx and esophagus from
control
In addition, with the help of an inflatable cuff, the respirator - ^ gI are protected from getting into them the gastrointestinal
| yaye |
s pzhi mogo. For the same purpose, E.S. Babiev (1983) proposed to study a probe-conductor up to 100 cm long and 1.5 cm in diameter.
"th lumen is inserted the initial part of the intestinal probe, after which both probes move into the stomach. The guide probe is removed
after * the end of the testinal probe with side holes is in the duodenum. In G. Dorofeeev et al. (1986) successfully use a thick rubber gastric "tube" as a guide tube.
V.V.Izosimov and V.A.Borisenko (1984) recommend conducting a probe-guide along the entire length of the small intestine. A thin PVC tube is used as an intestinal probe. The probe guide is removed after the end of intubation. P.Yu. Plevokas (1989) improved the probe-conductor to a large extent by equipping it with metal rings. The rings create protrusions on the wall of the probe that are convenient for gripping, holding and holding 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 side of the abdominal cavity directs it along the greater curvature of the stomach and fixes it with the right hand in the region of the exit section. With the left hand, the end of the probe is directed through the pylorus into the duodenal bulb. Often, a spasm of the pyloric sphincter interferes with the progress of the probe. The reason for this may be traumatic manipulations and the lack of coordinated actions of the surgeon and anesthetist. In such cases, the following technique may 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 captured at a distance of 2-3 cm from the olive. The pyloric pulp is fixed with two fingers of the left hand from the side of the duodenum. The ring of pyloric pulp under the control of the fingers of the left hand is "strung" on the olive of the probe (Fig. 27). As soon as the end of the probe is in the duodenal bulb, the surgeon with his right hand, synchronously with the movements of the anesthesiologist, advances the enterostomy tube in the distal direction. With the fingers of the left hand, he controls and directs its end down and backwards to the lower horizontal bend and further to the left towards the ligament of Treitz.
Forcing the movement of the probe through the intestine when feeling
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| ________ |
| CHAPTER 2 |
| " |
Rice. 27. Holding the probe in duodenum.
obstacles are unacceptable. In such cases, the duodenum is mobilized according to Kocher (Fig. 28).
When a 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 adhesions. In such cases, you should try to grab the olive of the probe and draw it in the distal direction with stringing movements (Fig. 29).
For the convenience of capturing the probe through the intestinal wall, recommending a number of devices. So, 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. AI Antukh (1991) uses gelatin to form thickenings of the esophagus. According to the author, gelatin sleeves dissolve on the third day under the action of intestinal juices and do not interfere with the extraction of the probe. For the same purpose, it was proposed to supply the initial part of the probe with one or more cuffs made of
Rice. 28. Carrying out 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 inflate 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., PapandopuloN.S., 1983; Weller D.G. et al., 1985). For this purpose, before intubation, a thin PVC tube with a diameter of 2-2.5 mm is inserted into the lumen of the probe with several lateral holes in its initial part, through which oxygen or air is supplied into the intubation time. With the help of this technique, D-G. Weller et al. (1985) was able to significantly reduce the trauma of the intestine, and the drainage procedure itself was performed within 30 minutes.
If the probe is folded in the stomach in the form of rings, then straighten 6141 It is possible by corrugating the initial section of the small intestine with
Rice. 29. Holding zonea to primary Department thin guts-
next pulling the probe in the distal direction. Less advantageous is the tightening of the probe by the anesthetist.
In the absence of intestinal paresis (Fig. 30), the probe advances due to the “stringing” of intestinal loops on it. Having corrugated 8-10 cm of the intestine, the surgeon simultaneously with the anesthetist pushes the ovary, straightening the intestine in the proximal direction. Bowel intubation in such cases can be accelerated* if the surgeon is manipulative.
Rns. thirty. Holding nasoenteric probe through the intestinal lumen.
to pool in the area of the ligament of Treitz, and the assistant to direct the olive of the probe along the intestinal lumen.
Drainage of the small intestine by the transnasal method is carried out in most cases throughout its entire length (total nasoenteric drainage). However, there are reports (Gauens Ya.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 section for 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 multi-channel multifunctional nasoenteric probe with several holes in its distal part. The probe is inserted during the operation for the ligament of Treitz by 50-70 cm.
However, to achieve adequate decompression in this way is possible only with moderate peritonitis and preserved HF1 peristalsis. In conditions of persistent intestinal paresis
| - | ||
Rice. 81. The position of the nasoenteral probe in the digestive tract
intubation of the entire small intestine is required. In this regard, N.S. Uteshev et al. (1985) proposed to perform total intubation of the small intestine first, 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 intubation of the intestine, soon after the restoration of its motility, the initial part of the probe is displaced in the proximal direction.
*rvm 24 hours after the operation, in the presence of peristaltic e o ^ti, the probe will be mixed by 15-20 cm, and by the fifth day, 2/3 of the small intestine remain intra-VV. To hold the probe in the *^ position M.Regent et al. (1974) and H.W. Waclawiczek ^iS?) consider it necessary to carry it out behind the Bauginian barrier-caecum. When using the Miller-Abbott? Kern probe (1980) and L. Nitzche et E. Hutter (1984), its fixation was carried out by inflating the cuff in the caecum. In this position, the authors left the probe for 7-8 days.
The impossibility of simultaneous separate drainage of the small intestine and stomach is the main disadvantage of standard nasoenteric probes. The difference in intraluminal pressure in the small intestine and stomach not only disrupts the drainage function of the probe, but also leads to stagnation of gastric and duodenal contents, which accumulates in the stomach as a result of intestinal paresis and impaired obturator function of the pyloric sphincter. Overfilling of the stomach increases the gag reflex and requires additional emptying.
Thus, out of 114 patients observed by us, in whom, for one reason or another, the lateral openings of the probe were left in the lumen of the stomach during transnasal intubation, in 67 (58%) the drainage function of the probe was possible only under the condition of active aspiration using a Janet syringe or vacuum suction . However, in 23 patients (20.8%), full decompression could not be obtained, and the evacuation of the contents of the stomach was carried out using an additional probe. In addition, it was impossible for these patients to produce a full-fledged intestinal therapy. Entered enterosorbents along the path of least resistance through the side holes first of all enter the stomach.
Vomiting during drainage with a single-lumen probe was noted in 36% of patients. At the same time, it occurred with the same frequency both in cases of leaving the side holes of the probe in the stomach, and without them. Among the postoperative complications in these patients, pneumonia and purulent tracheobronchitis are most often observed, the proportion of which is 21.1% and 12.7%, respectively (Table 22).
According to autopsy data, regurgitation of gastric contents during vomiting caused the death of 50 patients operated on for intestinal obstruction.
In this regard, when performing nasoenteric intubation
Table 22 The frequency of postoperative infectious-inflammatory
respiratory complications at transnasal drainage of the small intestine
| 91 34 57 , 249 |
| 35 21 11 5 |
Naeoenteral intubation with a single lumen probe:
Leaving holes
probe in the stomach
Without leaving a hole
probe in the stomach Separate drainage of the small intestine and stomach:
Separate probes
Double-lumen gastro-
enteral probe
Total:
Note. The probe in the lumen of the small intestine in the presented groups of patients was not younger than three days of the postoperative period.
insert an additional tube into the stomach. With its help, intestinal contents accumulating during intubation in the stomach are easily evacuated. It is technically more difficult to insert a probe 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 give the probe elasticity, a metal string is introduced 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 makes it possible not only to decompress the gastrointestinal tract, but also to carry out full-scale intra-gastrointestinal therapy. However, as experience has shown, drainage of the small intestine and stomach with separate probes has a number of disadvantages. Patients are more difficult to tolerate the presence of two probes in the throat and
At the same time, the emerging irresistible desire for nAoco*-^^^ does not stop even suturing them to the wings of the ulDVL. In particular, the presence of two probes in the esophagus and the esophagus is especially hard for patients of elderly and senile age, suffering from chronic diseases of the cardiovascular and dy-dj! 1 l noy systems. These patients are more likely to develop decubitus ulcers of the esophagus, and a violation of the closing function of the pdial sphincter, more often than with drainage with one probe, leads to reflux esophagitis and regurgitation of gastric contents. In this regard, various types of probes with separate drainage of the stomach and small intestine have been proposed in domestic and foreign literature (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 unacceptable for hospitals involved in emergency abdominal surgery. So, for the purpose of simultaneous and separate drainage of the stomach and small intestine, T.Sh. The valve passes the contents of the stomach and at the same time prevents the simultaneous flow of the intestinal. 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 experimental and clinical studies have shown, the diameter of the lumen, which allows for adequate decompression of the gastrointestinal tract, must be at least 0.4 cm, which is currently technically acceptable in the manufacture of only two-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 *ACs and the esophagus.
In this regard, we have developed a double-lumen nasogastro-enteral probe for simultaneous separate drainage of the dextrous intestine 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 polychlorinated
Rice. 33. General view of the gastroeutheral probe in serial production, Nil pipe 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 (C), in the initial part of which there are 3-4 holes for draining the stomach. The transition part (E) is a one-piece tube 30 cm long, which corresponds to the length of the duodenum. It is devoid of lateral openings and is a continuation of the intestinal canal. The gastric canal of the probe in the initial section of the transitional part is closed with a silicone sleeve, the diameter of which corresponds to 1/2 of the probe lumen. 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, in patients with a drained small intestine with a double-lumen gastroenteric probe, it decreased to 10.5% and was significantly less than in groups of patients who were drained with a single-lumen probe or with separate intestinal and gastric probes. The number of purulent tracheobron-hit decreased. This made it possible to expand the indications for transnasal intubation of the small intestine in elderly and senile patients.
ages.
In most cases, patients do not tolerate long-term presence of the probe in the nasopharynx and often remove it on their own already in the first hours after the operation. Therefore, it is necessary to securely fix the probe at the nasal passage. Most often, given the importance of long-term drainage of the intestine, 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 mentality, as well as with severe intoxication syndrome and delirium. G.-A.Sh. Kagan (1982), referring to the invasiveness of this method, suggested using a ligature previously held 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 provides for the fixation of the probe in the nasal passages by inflating a cuff made of soft latex rubber. In addition, the probe can be fixed with bandage ribbons, the ends of which are held and tied around the head. R.Sh. Vakhtaigishvili and M.V. Belyaev (1983) propose to use a probe with a loop specially designed for holding a bandage bandage.
2.2.3. Transrectal intubation of the small intestine
(Doletsky S.Ya. et al., 1973; Topuzov V.C. et al., 1982; Ba^ G.A., Roshal L.M., 1991). This is due to the physiological and ash * tomo-topographic features of the child's intestines, as well as the difficulties in managing the postoperative period in this *■ category of patients with nasoenteral and transfistular drainage methods. In adults, the introduction of a probe through the large intestine into the small intestine is a more traumatic manipulation, especially when passing the probe through the splenic angle and Bauhin's valve. In addition, the tube, which has side holes in the lumen of the colon, is quickly clogged with feces and stops draining the intestine. Nevertheless, 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 et 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 in, inside + tuba pipe; syn. bowel probing) - the introduction of a tube into the intestinal lumen for diagnostic and therapeutic purposes.
The tube can be inserted into the small intestine through the mouth or through the nose, through a gastrostomy or ileostomy; into the colon - transanally or through a colostomy.
Diagnostic Intubation of the intestine is used to obtain material for histological, cytological and other studies. In 1967, Fox (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. offered a technique of an Intubation of intestines, an essence a cut consists that through a nose enter long (8 10 m) thin (1-1,5 mm) PVC probe with a mercury weighting agent. The probe passes through the entire digestive tract. In this way, the length of the intestine was measured, sensors were passed along the probe to determine pH, electrical activity, and contents for biochemical research were obtained through the probe.
This probe has also been used to insert an endoscope into the colon and terminal ileum. The method is dangerous, since complications such as perforation of the intestine, injuries of the intestinal wall with a probe or the end of the endoscope are possible. These diagnostic methods have been completely replaced by methods of endoscopy based on the use of fiber optics (see Intestinoscopy, Colonoscopy).
In 1910, Westerman (Westerman) first used the introduction of a tube through the nose into the stomach and duodenum in the treatment of peritonitis. Mat as (R. Matas, 1924), Vangesten (O. H. Wangesteen, 1955) successfully used continuous aspiration of the contents of the small intestine with mechanical and dynamic intestinal obstruction.
For more efficient suction of the contents of the small intestine, various modifications of thin one- and two-channel intestinal probes have been developed that can move through the intestine.
Therapeutic Intubation of the intestine is used for paresis and paralysis of the intestine, 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 intestine in a certain position after reconstructive operations such as the Noble operation (see Noble operation).
During therapeutic intubation of the intestine, the contents are evacuated from the overflowing and distended fluid and gases of the small intestine, since overflow with contents leads to impaired blood flow in the vessels of the intestinal wall, their thrombosis, necrosis and perforation of the intestinal wall. For this purpose, the most appropriate use of the Abbott-Miller probe.
Intubation of the small intestine through the mouth or nose can be used in the preoperative period, during surgery and in the postoperative period.
Methodology
In order to prepare for surgery or when trying to conservatively treat patients with intestinal obstruction, intubation of the small intestine is performed in the patient's sitting or reclining position.
After anesthesia, for example. solution of dikain, the mucous membrane of the pharynx through the lower nasal passage, the probe is passed into the esophagus, and then into the stomach. The patient is turned to the right side and the probe is advanced to the second mark (pylorus level), the cuff of the probe is inflated, and the contents are simultaneously aspirated using a vacuum apparatus. After emptying the stomach, the probe is slowly advanced to the third mark, and then the cuff together with the probe is slowly displaced during intestinal motility (15–20 cm per hour) to a level of 2–3 m. X-ray control is mandatory, especially during the passage of the probe through the pylorus and in the small intestine (up to 3-4 times depending on the progress of the probe).
When carrying out intubation on the operating table, the probe is first introduced into the stomach, and then the surgeon directs the probe along the intestine from the side of the opened abdominal cavity. After carrying out 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, however, the passage of the probe (even the Cantor probe with a weighting agent at the end) is difficult with intestinal paresis. Prolonged stay of the probe in the intestine can lead to the development of various complications: sinusitis, otitis, pneumonia, esophagitis, stenosis of the esophagus and pharynx, ruptures of varicose veins of the esophagus, perforation of the esophagus, stomach, intestines.
Use also an intubation of a small bowel through a gastrostomy (fig. 1) or an ileostomy, edges can be made in view of impossibility of carrying out a probe through a mouth or a nose. For intubation of the small intestine, a thin long rubber tube with multiple holes is inserted through the ileostomy, which empties significant segments of the intestine (ID Zhitnyuk, 1965).
Intubation of the lower segments of the colon is sometimes used for the purpose of conservative treatment of volvulus of the sigmoid colon. In these cases, a thick gastric tube is inserted into the sigmoid colon through a sigmoidoscope.
In order to protect the sutures of the anastomosis on the colon, a number of surgeons use transanal intubation of the colon. Use a special design single or double-channel probes or a thick gastric tube. The probe is inserted during the operation above the anastomosis (Fig. 2) for 3-5 days and removed after the restoration of bowel function.
Bibliography: Berezov Yu. E. Surgery of stomach cancer, M., 1976, bibliogr.; Halperin 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 ID 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 resection of the stomach, Surgery, No. 6, p. 31, 1965, bibliogr.; Simonyan K. S. Adhesive disease, M., 1966, bibliogr.; Surgery of the digestive system, ed. I. M. Matyashina and others, 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 method of probing the rectum is effective and necessary to clarify the topographic features of the fistulas of the rectum. A well-performed procedure will help the doctor to establish
- the direction of the anal fistula relative to the intestinal wall,
- changes in the relief of the course of the fistula and its length,
- additional cavities.
Probing of the rectum for the diagnosis of chronic paraproctitis becomes especially informative, since it allows you to identify the message of the fistulous tract directly with the lumen of the rectum.
How is the procedure?
For the procedure, a buttoned metal probe is used, which has a small round thickening at the end. 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 fistulous tract, gradually moving it deep into the fistula.
Additional diagnostic information is provided by probe-finger examination. It allows you to determine the thickness of the tissues 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. For a simple fistulous tract, the minimum thickness of tissues during probing of the rectum is more characteristic.
If various diseases are suspected, an examination of the intestine is required. It involves examining the mucous membrane and determining peristalsis. Distinguish between small and large intestine. Inspection of the initial sections is difficult. Instrumental diagnostic methods are supplemented by laboratory tests, palpation and questioning of a 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:
- persistent or intermittent abdominal pain;
- violation of the stool by the type of constipation or diarrhea;
- vomiting of feces;
- bloating;
- the presence of blood or other pathological impurities in the feces.
The following studies are most often organized:
- fibroesophagogastroduodenoscopy;
- colonoscopy;
- sigmoidoscopy;
- anoscopy;
- irrigoscopy;
- computed or magnetic resonance imaging;
- capsule colonoscopy;
- radionuclide research;
- radiography.
Sometimes a laparoscopy is performed. Therapeutic and diagnostic procedure, in which the organs of the abdominal cavity are examined from the outside. During the examination of patients, the following diseases can be detected:
- 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 is an endoscopic method for examining patients. It allows you to examine only the initial section of the small intestine. FEGDS is often performed for therapeutic purposes. During the study, you can stop the bleeding or remove the foreign body. There are planned and urgent FEGDS.
The benefits of this study are:
- rapidity;
- information content;
- good tolerance;
- safety;
- low invasiveness;
- painlessness;
- the possibility of implementation within the walls of the clinic;
- availability.
The disadvantages include discomfort during the introduction of the probe and discomfort during the withdrawal of anesthesia. FEGDS is performed if the following pathology is suspected:
- ulcer;
- gastroduodenitis;
- bleeding;
- cancer of Vater's papilla;
- duodenitis;
- gastrointestinal reflux.
Before FEGDS preparation is required. It includes not eating immediately before the procedure and following a diet for several days. Spicy foods, nuts, seeds, chocolate, coffee and alcoholic beverages should be excluded from the diet 2-3 days before the study. Dinner on the eve should be no later than 18 pm.
In the morning you can not eat breakfast and brush your teeth. It is necessary to examine the duodenum and stomach in the supine 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 carried out. This ensures a painless procedure. During the examination, the person should not talk. Saliva should be swallowed only with the permission of a doctor. You can eat only 2 hours after the study.
Contraindications for FEGDS are:
- curvature of the spinal column;
- atherosclerosis;
- neoplasms of the mediastinum;
- a 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.
Performing an intestinal colonoscopy
The main instrumental method for diagnosing diseases of the colon in women and men is colonoscopy. It is classic and capsule. In the first case, a fibrocolonoscope is used. This is a flexible tube that is inserted into the intestine through the anus.
The possibilities of colonoscopy are:
- extraction of foreign objects;
- restoration of intestinal patency;
- stop bleeding;
- biopsy;
- removal of tumors.
How you can prepare for this procedure, not everyone knows. The main goal is to cleanse the intestines. For this, enemas or special laxatives are used. In case of constipation, castor oil is additionally prescribed. An enema is performed when a bowel movement is delayed. To carry it out, you will need a mug of Esmarch and 1.5 liters of water.
Within 2-3 days you need to follow a slag-free diet. It is forbidden to eat fresh vegetables, fruits, herbs, smoked meats, pickles, marinades, rye bread, chocolate, peanuts, chips, seeds, milk and coffee. On the evening before the procedure, it is required to clean the intestines. Used drugs such as Lavacol, Endofalk and Fortrans.
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. The following complications are possible with an incorrectly performed colonoscopy:
- bleeding;
- perforation of the intestine;
- bloating;
- fever;
- pain.
If the general condition worsens after the procedure, you should visit a doctor. Normally, in a healthy person, the mucosa of the large intestine is pale pink. It is shiny, without ulcerative defects, protrusions and outgrowths, smooth with slight striation. The vascular pattern is uniform. Seals, pus, blood, fibrin deposits and necrotic masses are not determined. Absolute contraindications to colonoscopy are peritonitis, severe heart 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 you to determine the pathological changes in the mucosa. The bowel relief is assessed in detail. Contrasting is simple and double. In the first case, barium sulfate is used. In the second, air is additionally 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 inject contrast not through the mouth, but through the rectum using an enema. During the examination, the patient is on his side with his upper leg pressed to his stomach. A rectal tube is installed through which a barium solution is injected.
Then an overview photo is taken. After that, the examined person empties the intestines. Next, a second photo is taken. There are the following indications for irrigoscopy:
- suspicion of a tumor;
- blood in the stool;
- the presence of stool with pus;
- pain during bowel movements;
- bloating with stool retention;
- chronic constipation and diarrhea.
There are 3 main methods of preparation for the procedure:
- cleansing enemas;
- taking the drug Fortrans;
- carrying out hydrocolonotherapy.
A conclusion is drawn from the picture. Irritable bowel syndrome can be suspected if uneven folds-gaustras, areas of narrowing of the intestine in combination with incomplete excretion of contrast during defecation are detected. If during the examination an uneven diameter of the colon, a narrowing of the lumen against a background of spasm, and areas of asymmetric contraction are found, this indicates ulcerative colitis. Barium enema should not be performed in pregnant women, with 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 introduced into the anus of the patient. 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.
The disadvantages include the inconvenience of processing the received data and the difficulty of swallowing. A picture of the intestine with a capsule is recorded on a special device that is worn on a belt. This study is of limited use. It is costly. A capsule examination is performed when it is impossible to carry out colonoscopy and barium enema.
Complications include a delay in the removal of the capsule. 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 with 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 is different. Using a sigmoidoscope, you can examine the mucosa 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 chair;
- bleeding from the rectum;
- the presence of mucus or pus in the feces;
- feeling of a foreign body.
The study is carried out in chronic hemorrhoids and inflammation of the colon. Sigmoidoscopy is contraindicated in acute anal fissure, narrowing of the intestine, massive bleeding, acute paraproctitis, peritonitis, heart and lung failure. The preparation is similar to that for a colonoscopy.
Immediately before the introduction of the tube of the sigmoidoscope into the anus, it is lubricated with petroleum jelly. The advancement of the device is carried out during attempts. To straighten the folds of the intestine, air is pumped. In the presence of a large amount of pus or blood, an electric pump can be used. If necessary, material is taken for histological analysis.
Other research methods
Magnetic resonance imaging is a modern method for diagnosing bowel diseases. It can be done with double contrast. The dye is administered intravenously and through the mouth. This method cannot replace a colonoscopy. He is supportive. The advantages of MRI are painlessness, information content and the absence of radiation exposure.
Layered pictures 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 tissue hydrogen ions. Before an MRI, you need to clean the intestines and follow a diet for several days. The procedure takes about 40 minutes. Pictures are taken while the patient is holding his breath.
The patient is placed on the platform and the body is fixed with straps. The methods of examination of patients include anoscopy. With it, you can examine the final section of the intestinal tube. An anoscope is required. This is a device that consists of an obturator, a tube and a light handle.
Before anoscopy, a digital rectal examination is often required. This is done in order to assess the patency of the intestine. If necessary, an anesthetic ointment is used. Thus, if intestinal pathology is suspected, an instrumental study is mandatory. It is impossible to make a diagnosis on the basis of a survey, examination and palpation.