intra-abdominal hernia
Introduction
Introduction to intra-abdominal fistula The intra-abdominal organ is displaced from its original position through a normal or abnormal channel or fissure in the abdominal cavity to an abnormal sulcus called intraperitoneal hernias. The contents of the sputum are mainly the stomach and intestines. In the peritoneal sac (such as peritoneal crypt), the sac is a typical sacral sac, and the sac is not a typical intra-abdominal hernia. The clinical symptoms are the same. Organ obstruction is the main symptom. According to statistics, mechanical intestinal obstruction caused by abdominal hernia accounts for 0.22% to 3.5% of acute intestinal obstruction. It is another common cause other than mechanical intestinal obstruction caused by adhesive intestinal obstruction and abdominal incarceration. Preoperative diagnosis Quite difficult. basic knowledge Sickness ratio: 0.5% Susceptible people: no special people Mode of infection: non-infectious Complications: peritonitis shock
Cause
Intestinal fistula
Abdominal organ activity is too large (15%):
The contents of the sputum in the abdomen are mostly organs or organs with excessive activity in the abdominal cavity, such as the small intestine, the greater omentum, the transverse colon and the sigmoid colon. Because the intestinal tract has the largest range of activity in the abdominal cavity, especially those with longer mesenteric, It is easier to shift and penetrate through the above pores.
Increased intra-abdominal pressure (25%):
The presence of normal or abnormal intra-abdominal space or hiatus, as well as excessive intra-abdominal organ mobility, provide a prerequisite for the occurrence of intra-abdominal hernia, but not necessarily all internal hemorrhoids, only increased intra-abdominal pressure, especially sudden increase Under the circumstances, it is possible to cause the organs with excessive activity in the abdominal cavity (such as the small intestine, the greater omentum and the transverse colon) to be displaced into the smaller pores to cause internal hemorrhoids. The factors that can cause the increase of intra-abdominal pressure are: Cough, urinary dying (urethral stricture, prostatic hypertrophy, etc.), difficulty in defecation, vomiting, pregnancy, ascites, abdominal crushing, and vigorous exercise.
Congenital abnormal holes or gaps (10%):
There may be congenital defects or holes in the mesentery, such as congenital mesenteric hiatus, transverse mesenteric hiatus, omental hiatus and broad ligament hiatus. The intestinal fistula can form internal hemorrhoids through these holes and cause obstruction or Incarceration.
The hole or gap formed by the day after tomorrow (8%):
Intestinal fistula can be inserted into the following gap to form internal hemorrhoids, such as poorly repaired mesenteric hiatus in the bowel resection or a tear caused by mesenteric tear in the trauma, abnormal gap formed after gastrointestinal anastomosis, and between the intestine and the lateral peritoneum after sigmoid colostomy Pores, adhesion bands, pores between the intestines formed by surgery or infection, etc.
Causes
1. Common causes:
(1) Normal or abnormal intra-abdominal space, the existence of a hole, provides an anatomical basis for the onset of intra-abdominal hernia.
1 normal intra-abdominal clearance hole:
A. Winslow hole (epiploic foramen): free small intestinal fistula (even transverse colon, gallbladder) can sometimes enter the small omental sac through the retina hole, forming a retina hole, the anterior wall of the ankle ring For the duodenal ligament, it is relatively tough, prone to incarceration, strangulation, and occasionally intestinal fistula can also enter the small omental sac from the stenosis of the stomach ligament or the ligament of the liver and stomach, mostly related to factors such as too long mesentery.
B. Retroperitoneal recess: There are many crypts in the normal posterior peritoneum, such as the paraduodenal recess, the pericecal recess, and the intersigmoid recess. And the sacral recess of the bladder, etc., under normal circumstances, the peritoneal crypts are relatively shallow, which will not cause pathological phenomena and form an ankle ring, but if an abnormality occurs during embryonic development, the above crypt becomes larger. When the depth is deepened, an ankle ring is formed, and the small intestine can enter the crypt to form a sputum in the case of an increase in abdominal pressure, and the tendency to form a sputum can be gradually increased, so that most of the small intestine enters the sputum and is wrapped in After the peritoneal sac.
2. Classification of causes: According to the pathogenic factors, there are two types of primary and secondary in the abdomen.
(1) primary intraperitoneal hernias: is the intra-abdominal hernia caused by the infiltration of congenital intra-abdominal pores into the abdominal organs.
1 retroperitoneal hernia: posterior peritoneal hernia is mainly due to the changes in the normal process of small intestine rotation during embryonic development, such as para-duodenal fistula, paracemented sacral paralysis, sigmoid colon fistula and bladder sputum.
2 congenital abnormal hiatal hernia: due to the congenital weakened area or abnormal vascular structure of the mesentery or omentum, in the case of increased abdominal pressure, the weak part ruptures to form internal hemorrhoids, such as congenital mesenteric hernia, reticular hiatus and broad ligament Split holes and so on.
Zimmerman et al believe that the posterior peritoneal hernia is a true intra-abdominal hernia, which does not have a hernia sac rather than a true internal hemorrhoid, while Pennell believes that the latter is a functional internal hernia, an acquired intra-abdominal space due to surgery. For example, the jejunum after gastrectomy, the mesenteric space of the transverse colon, the sigmoid colon ostomy and the lateral abdominal wall gap after Miles surgery should also be functional guilt.
(2) Secondary intraperitoneal hernias: refers to the formation of abnormal, pathological pores following abdominal surgery or abdominal trauma and infection. In some cases, the intestinal tract protrudes into the internal hemorrhoids. Including: internal hemorrhoids after partial gastrectomy, internal stenosis after Roux-en-y anastomosis of common bile duct jejunum, internal hemorrhoids after radical resection of rectal cancer, and intra-abdominal adhesion type internal hemorrhoids.
Pathogenesis
During embryonic development, after the midgut rotates 270° counterclockwise, the cecum is fixed in the right axilla. The mesenteric root merges with the posterior peritoneum and forms a peritoneal wrinkle near the duodenum, the cecum and the sigmoid mesenteric root. The pleats or crypts, such as the crypts are large and deep, or the channels (Winslow holes) left during the formation of the omental sac (small peritoneal cavity) are wide, the intestines can be invaded, and the embryos in the midgut after 10 weeks When returning to the abdominal cavity, the small intestine can also enter the mesenteric mesentery to form internal hemorrhoids.
In addition, iatrogenic trauma, trauma or infection, etc. cause partial defects of organs and tissues, displacement, adhesions, etc., which change the normal anatomical relationship of the body, create new voids, and increase the activity space of abdominal organs and tissues. When the intra-abdominal pressure is increased (such as pregnancy, ascites, squeezing, strenuous activity, etc.), some organs or tissues with large activities such as small intestine, omentum, transverse colon and sigmoid colon can be squeezed into the pores, leading to succession. Intra-abdominal hernia.
If a large number of mesentery, intestinal tube into the narrow pores, it is difficult to self-reset, resulting in the incarceration of the contents of the sputum, with the intestinal venous return obstruction, intestinal wall edema, intestinal lumen expansion, and gradually intestinal wall narrowing necrosis, Perforation and abdominal infection, severe symptoms of systemic poisoning.
Prevention
Intra-abdominal fistula prevention
Congenital (typical sputum) intra-abdominal fistula can not be prevented, but some of the atypical sputum caused by surgery can be prevented, such as the second type of anastomosis of the majority of the stomach, the Roux-Y anastomosis, the colostomy, the Mile, etc. Abnormal anatomy of iatrogenic trauma is an important factor leading to secondary intra-abdominal fistula, and it is easy to cause intestinal obstruction. Therefore, effective measures should be taken in a targeted manner: the wound in the surgical site should not be exposed to the organs for a long time. Outside the abdominal cavity, it should be covered with a wet cotton pad; the wound surface should be smooth and not leave pores; all kinds of anastomosis should meet physiological requirements, no tension; perfect preoperative preparation and effective postoperative treatment.
The active cooperation between the patient and the doctor can ensure the effective implementation of the measures and play an important role in avoiding the formation of abdominal hernia.
Complication
Intra-abdominal hernia complications Complications peritonitis shock
A large number of mesenteric or intestinal canal can not be self-resetting, and the intestinal stenosis can be complicated. At this time, the passage of the contents of the intestinal cavity and the blood circulation of the intestinal wall are all obstacles, the intestinal flatulence of the patient is obvious, the water and electrolyte metabolism is disordered, and the acid-base balance is imbalanced. Severe peritonitis and toxemia show that toxic shock is more pronounced when intestinal necrosis occurs.
Symptom
Abdominal hernia symptoms Common symptoms Abdominal pain Nausea abdomen has a local or wide... Bowel sound disappears pale pale shock
Intra-abdominal spasm can occur from the newborn to the elderly. The clinical manifestations are a series of symptoms and signs caused by digestive tract obstruction. According to the severity of digestive tract obstruction, the clinical manifestations can be very different:
Chronic incomplete intestinal obstruction
Performance, incomplete intestinal obstruction, can only be a chronic history, symptoms include ambiguous intermittent upper abdominal pain, nausea and vomiting, abdominal distension, etc., intestinal obstruction often occurs after eating, especially after binge eating, intra-abdominal When obstruction of the iliac crest, due to compression of the mesentery, intestinal wall ischemia can cause colic, abdominal pain can sometimes be more severe, and the over-extension or flexion of the trunk can aggravate abdominal pain, which needs to be differentiated from perforation of gastric ulcer.
2. Acute complete intestinal obstruction
Performance, when the sudden increase of intra-abdominal pressure causes a large number of intestinal tubes to break into narrow pores, it can suddenly turn into acute complete obstruction, the disease progresses rapidly, can cause the incarcerated sputum content to be narrower and necrotic in a short time, the patient is On the basis of the above chronic history, symptoms and signs of acute intestinal obstruction suddenly appear, manifested as sudden abdominal cramps, progressive exacerbations, frequent vomiting, abdominal distension, venting, defecation, physical examination, abdominal distension or abdominal limitations Bulging, sometimes visible peristaltic waves, touching the tender mass, bowel sounds hyperthyroidism, if there is peritoneal irritation, the bowel sounds disappear, indicating that the incarcerated sputum content may have been narrowed and necrotic.
Abdominal hernia is rare, mainly manifested as mechanical intestinal obstruction, clinical symptoms are not specific, preoperative diagnosis is quite difficult, often diagnosed by laparotomy after intestinal obstruction, strengthen the understanding of the abdominal hernia and its alertness, familiar with it Symptoms and signs, patients with intestinal obstruction should be highly alert to the possibility of abdominal hernia.
Examine
Intestinal fistula examination
Laboratory inspection
1. Hemoglobin and hematocrit can be increased due to lack of water and blood concentration.
2. Intestinal strangulation is considered when the white blood cell count and neutrophils are significantly elevated.
3. Serum electrolytes (K, Na, Cl-), blood gas analysis and other measurements can reflect the balance of water, electrolyte and acid-base.
Film degree exam
1. X-ray examination: abdominal fluoroscopy, abdominal plain film or CT scan in addition to the general intestinal obstruction signs, there is abnormal accumulation of gas in a certain part of the abdominal cavity, a small group of small intestines gather together, not easy to be displaced, seems to be installed in A bag is inside, while small intestines in other parts of the abdomen are rare.
In Wislow, the stomach is displaced to the left and back, and the colon is displaced downward. The clustered small intestine fluid is concentrated in the small omental sac area. The mesentery is located between the lower cavity and the portal vein. There is a gas-liquid plane in the small omental sac. Multiple gut shadows can be seen in the subhepatic space.
The duodenum can be seen around the small intestine, accumulating in the hernia sac, located in the midline, can not move or disperse, the stomach is pulled down, the colon is behind the small intestine sac, the small intestine in the sac expands and In a stagnant state, the left side of the duodenum can be seen as a group of intestinal fistulas located between the stomach and the pancreas. At the level of the Treitzs ligament or behind the pancreas, the intestines wrapped in a mass lack the interdental interstitial space between the normal intestines. (inter-digitation), intestinal tube dilatation and gas-liquid level; right duodenal paralysis can see dilated bowel and gas-liquid level in the right middle abdomen, jejunal movement, vein branch behind the superior mesenteric artery.
2. B-ultrasound: abnormal echoes of a certain part of the abdominal cavity, with or without intestinal peristalsis, the internal tubular or cystic morphology of the mass changes with time and diet.
3. Other examinations: If the selective mesenteric angiography shows abnormal mesenteric blood vessel orientation and distribution, it is helpful for diagnosis.
Diagnosis
Diagnosis and identification of intra-abdominal fistula
diagnosis
History
(1) The patient has a history of chronic, incomplete or complete intestinal obstruction, such as intermittent upper abdominal pain, nausea and vomiting, abdominal distension, etc., after eating, no remission is aggravated, and over-extension or flexion of the trunk can aggravate symptoms. The treatment is improved or the symptoms and signs disappear.
(2) On the basis of general chronic intestinal obstruction, it suddenly turns into acute complete obstruction, and can not be explained by other reasons.
(3) The onset is sudden and sharp, the abdomen touches the mass, and there is no history of abdominal mass in the past, which can rule out intestinal obstruction caused by other factors such as intestinal torsion, intussusception and intestinal tumor.
(4) Patients with acute intestinal obstruction, who have the above clinical manifestations and have a history of chronic abdominal pain without history of surgery, should consider congenital intra-abdominal fistula. If there is a history of gastrointestinal surgery, the possibility of acquired abdominal hernia should be considered.
2. Clinical features
(1) Abdominal pain: The internal hemorrhoids secondary to abdominal surgery have severe abdominal pain; accompanied by strangulated intestinal obstruction, abdominal pain is persistent and paroxysmal aggravation; retinal sac, crypt sputum can cause chronic simpleness Intestinal obstruction, mostly mild abdominal pain.
(2) vomiting and constipation: duodenal paralysis, postoperative gastrectomy, frequent vomiting and constipation, crypt sputum, retinal sac and other non-incarcerated intra-abdominal fistulas are more nausea-free Vomiting and constipation.
(3) abdominal distension and mass: incarcerated abdominal inguinal hernia can cause abdominal distension, retinal capsule, duodenal paralysis can form a mass in the upper abdomen and localized abdominal distension, and the percussion is drum sound, other Most types of internal hemorrhoids cannot touch the mass.
(4) internal hemorrhoids after abdominal surgery: more than the recovery of intestinal function and start eating, sudden severe abdominal pain, vomiting, stop defecation and exhaust, and have pale complexion, rapid pulse rate and cold limbs and other shock symptoms and peritoneal irritation .
3. Auxiliary diagnosis: X-ray barium angiography is helpful for the diagnosis of internal hemorrhoids, and the location and type of internal hemorrhoids can be clarified. In order to avoid aggravating intestinal obstruction, a safer water-soluble iodine agent can be used for angiography, after intestinal obstruction is formed. Abdominal X-ray film can show multiple liquid level, mesenteric angiography can assist diagnosis, B-ultrasound can detect abnormal gas accumulation in a certain part of the abdomen, or see a small group of small intestines gather together, not easy to be Going, similar to being packed in a bag.
4. Exploratory laparotomy: When there is some kind of intestinal obstruction, such as nausea, vomiting, bowel sounds, intestinal bleeding and abnormal augmentation in a certain part of the abdomen, laparotomy should be performed in time, and whether the diagnosis can be confirmed It is the intra-abdominal hernia and its location and type.
Differential diagnosis
Intestinal obstruction caused by abdominal hernia, the beginning is mostly simple, and then become strangulated, the internal hemorrhoids are not easy to make a correct diagnosis, often through laparotomy to be clear, therefore, when suspected of this disease, the first should be Other common identification of intestinal obstruction, small omental capsule, duodenal paralysis, early paroxysmal colic with nausea, vomiting, should also be differentiated from cholelithiasis, acute gastric torsion, acute pancreatitis.
