small bowel injury
Introduction
Introduction to small bowel injury The small intestine occupies the largest position in the abdominal cavity, and the distribution is wide, relatively superficial, and the lack of bone protection is vulnerable to damage. In the open injury, the small intestine injury rate accounts for 25% to 30%, and the closed injury accounts for 15% to 20%. . When any injury to the abdomen needs to be explored, it is necessary to carefully and carefully examine the small intestine. basic knowledge The proportion of sickness: 0.02% - 0.05% Susceptible people: no specific population Mode of infection: non-infectious Complications: peritonitis shock
Cause
Causes of small bowel injury
(1) Causes of the disease
Intestinal injury is caused by direct violence and indirect violence. It is mainly seen in blunt pubar injuries, rupture of the ileum caused by falling or sudden deceleration. It is generally considered that the ruptured part is within 50cm of the proximal jejunum and less than 50cm from the Treitz ligament. The segmental ileum is less than 50cm away from the ileocecal area. Traumatic damage can be generally divided into closed intestinal injury, open intestinal injury and iatrogenic intestinal injury.
Closed intestinal injury
According to the principle of violence, it can be divided into four situations.
(1) Direct violence: The anterior humeral anterior humerus is closer to the abdominal wall than other vertebrae. Direct violence acts on the abdominal wall and transmits to the lumbosacral vertebrae, causing damage to the small intestine or including the mesentery. Under the direct action of strong external force, The intestine is squeezed between the abdominal wall and the spine or the iliac crest to cause a contusion and laceration of the small intestine. Severely, the small intestine can be directly cut off. The injury from the median part of the umbilicus is often injured and the ileum is sometimes accompanied by mesenteric rupture and contusion. Bleeding, external force slightly biased to the body axis can be combined with liver, spleen, kidney, colon damage, when the abdomen is subjected to a large area of violence, can be closed due to duodenal jejunum and lower ileum, so that the upper part of the jejunum is closed. Hemorrhoids, the pressure in the intestines suddenly increases and ruptures. This kind of damage often occurs after a full meal. The rupture and perforation often occur in the side wall of the small intestine that is far from the intestinal part of the intestine filled with violent compression.
(2) Lateral violence: external force can also act on the abdomen in the direction of the body axis, so that the intestine can move rapidly along with the mesentery. When the range of movement exceeds the tolerance of the fixed mesentery or ligament, It may cause tearing of the self-adhesive part of the intestine. The predilection is usually found at the end of the jejunum near the Treitz ligament or the end of the ileum fixed by the peritoneal reflex. In the same way, this injury can also occur in the inflammatory lesions of the abdominal cavity. Abdominal surgery or intra-abdominal medication caused by intra-abdominal pathological adhesions, intestinal and abdominal wall or surrounding tissue, near the organ fixation, from side violence can also cause a partial pressure in the local intestinal tube, the original has been filled with flatulence The intestine can not be used to evacuate external force or there is no room for rotation between the intestines and the intestines. When the fluid pressure in the intestine is sharply increased, the intestine can be ruptured through the oblique passage of the mesenteric wall of the intestinal wall away from the external force. A small perforation occurs, the diameter is generally 0.5 cm, and the surrounding intestinal wall and mesangium are normal, and the damage is easily missed when probed.
(3) Indirect violence and injury: It occurs mostly under the force mechanism against the inertial movement of the intestine. When the patient falls from a height, falls, and the intestine or mesangial at the time of sudden arrest can not resist the pressure exerted by sudden changes in this position. The small intestine is broken or torn by conduction. This damage occurs mostly at the fixed ends of the small intestine, such as the vicinity of both ends of the ileum attached to the posterior abdominal wall and the free ileum junction where the freeness is most common. The small intestine in a filled state.
(4) Strong contraction of own muscles: Inadequate force caused the body to suddenly recline to make the abdominal muscles contract strongly. The increase of intra-abdominal pressure causes the small intestine or mesangial tear, and some abdominal muscle contraction is caused by the normal movement of the intestine. The abdominal contraction caused by the strong contraction of the abdominal muscles is rare. A total of 76-year-old male patients were admitted to the General Hospital of Tianjin Medical University. Because of the heavy lifting of the hands with others, abdominal pain and peritoneal irritation gradually appeared. Surgery confirmed that there was a 0.5 cm ileal rupture and mucosal valgus at 150 cm from the ileocecal area.
2. Open intestinal injury
Mainly for sharp injuries, such as bullets, shrapnel or marble damage, sharp injuries, open small intestine damage must have foreign matter into or through the abdominal cavity, there may be a single single wound injury or multiple wound wounds, subject to injury The damaged intestine can be away from the wound site, often causing multiple intestinal rupture or compound damage.
3. Iatrogenic intestinal injury
Intestinal injury in medical treatment also occurs from time to time. Common causes include inadvertent injury to the intestine during surgical separation of adhesions, flatulent or highly filled intestines during abdominal puncture, accidental injury from endoscopic procedures, and accidental injury to the small intestine during abortion Intestinal perforation or intestinal rupture occurs, and edema of the ileum is sometimes damaged.
(two) pathogenesis
The pathological changes of small intestine injury are determined by the degree and location of the small intestine and the presence or absence of combined damage.
Closed intestinal injury
The pathological manifestations of closed intestinal injury are contusion of the intestinal wall, hematoma and rupture. When the intestinal wall is contused, the injured intestine has only partial congestion, edema, and the tissue continuity of the intestinal wall is not damaged. The blood supply is still much better. Healing, severe contusion can cause the intact intestinal mucosa to lose its proper integrity. The extent of ischemia is more than the degree of collateral circulation compensation. It will eventually develop into ulcers, perforation of intestinal wall necrosis, intestinal contents and bacteria. The perforated intestinal wall enters the abdominal cavity to cause peritonitis, and the contused intestinal wall may also form scarring stenosis after healing.
The pathological changes after the intestinal wall laceration vary with the depth and extent of the injury. For simple mucosal laceration without damage to the muscular layer and simple serosal laceration with a small range, it can rely on the body's own repair ability. Injury healing, no obvious clinical symptoms and no sequelae, damage to the sarcolemma can be obvious osmotic and inflammatory changes, even intestinal rupture in the injured part, if the mucosal laceration involving the submucosal blood vessels can be local bleeding On the basis of infection and intestinal perforation, the heavier intestinal wall laceration, although there is no serious complications in the early stage, in order to prevent the existence of hidden dangers must also emphasize the therapeutic initiative.
The ileum is free in the abdominal cavity compared with other organs, and the chance of hematoma caused by vascular injury is relatively small. However, the upper jejunum and the end of the ileum are relatively fixed, the mesentery is short, and the buffering capacity is lacking. The direct effect of external force can damage the mesentery. Arteriovenous or mesenteric arteries and veins and their branches and blood vessels form a hematoma mass, which poses a serious threat to the intestinal wall. A small amount of persistent hemorrhage can develop along the intestine and develop into a large hematoma affecting the blood supply of the intestine. The hematoma develops to a certain extent and can penetrate the pulp. Membrane or mucous membrane, severe hemorrhagic shock or death, secondary intestinal ulcer, perforation, abdominal abscess, peritonitis, etc. may occur on the basis of hematoma.
2. Open intestinal injury
Open bowel injury is characterized by simultaneous injury of the abdominal wall and the intestine. Sometimes the contents of the intestine are discharged through the wound of the abdominal wall. In the treatment of foreign bodies in the abdominal cavity, attention must be paid to the exit and entrance of the foreign body relative to the intestinal wall. Most of the wounds are trajectory of the mouth and bullets. It can sneak a distance in the intestine, resulting in a long distance between the two ruptures on the surface of the intestine. The extent of damage to the large shrapnel is limited. The steel ball bomb may cause up to dozens of intestinal tube damage, small rupture and wide distribution. It is easy to be missed. When the trajectory of the injury is tangential to the intestine, the penetrating substance just stays in the intestine or the strength of the injury fails to reach the other side of the intestinal wall. There may be only one rupture.
The pathological changes of open small intestine injury are mainly peritonitis. The small perforation has only a small amount of intestinal content into the abdominal cavity. In addition to local peritonitis, there are other symptoms, the small intestine damage is broken, or the time of visiting the hospital is later, the abdominal wall can be passed through the abdominal wall. The contents of the gastrointestinal tract or the spilled gas flow out of the open wound, and more serious damage may flow out of the blood or damaged intestinal tract, omentum and the like through the abdominal wall wound.
Prevention
Intestinal injury prevention
1, diet should pay attention to, eat less spicy, greasy and other irritating food, eat more light and other foods containing more fibrous substances, such as fresh fruits and vegetables, these can help the normal intestinal peristalsis, making The bowel movements are smooth.
2, exercise properly, do not sit and stand for a long time, actively exercise, promote blood circulation in the body, but also enhance the body's resistance.
3, personal hygiene should pay attention to, the living environment should not be too humid, dark, it is best to wash the anus with warm water every day, keep the anus around clean, personal hygiene products can not be mixed to avoid infection.
Complication
Complication of small intestine injury Complications peritonitis shock
Complications such as peritonitis, shock and poisoning may occur.
Symptom
Symptoms of small intestine injury Common symptoms Internal bleeding pale pale abdominal muscles Abdominal tenderness Peritoneal irritation Symptoms Abdominal pain Coma Mobility Voiced bowel sounds disappeared Peritonitis
The clinical manifestations of small intestine injury mainly depend on the degree of injury and the presence or absence of organ injury. The main manifestations are peritonitis. Shock and poisoning may not be obvious. Some patients may present with internal hemorrhage, especially hemorrhagic shock with mesenteric vascular rupture.
Intestinal wall contusion or hematoma usually has mild or localized peritoneal irritation in the early stage of injury. There is no obvious change in the whole body. With the absorption of hematoma or the repair of contusion inflammation, abdominal signs can disappear, but it can also be aggravated by pathological changes. Causes necrosis of the intestinal wall, perforation causes peritoneal inflammation.
Intestinal rupture, perforation, intestinal contents overflow, peritoneal stimulation by digestive juice, patients can show severe abdominal pain, accompanied by nausea, vomiting, physical examination revealed pale, cold skin, weak pulse, shortness of breath, blood pressure Decreased, there may be total abdominal tenderness, rebound tenderness, abdominal muscle tension, mobile dullness positive and bowel sounds disappear, and the symptoms of infection poisoning worsen with the time of injury.
Only some patients have pneumoperitoneum after rupture of the small intestine. If there is no pneumoperitoneum, the diagnosis of small intestine perforation cannot be denied. Some patients may have a small gap or food residue due to small intestinal injury, fibrin or prominent mucous membrane blockage may be in a few hours or There is no clear manifestation of peritoneal inflammation within ten hours, called the occult period, and attention should be paid to the changes in abdominal signs.
Intestinal injury can be combined with intra-abdominal parenchymal rupture, resulting in hemorrhage and shock, but also combined with multiple organ and tissue damage, should emphasize the serious understanding of the injury and make a definite diagnosis.
According to the above typical clinical manifestations, the diagnosis is more easy. When the open abdominal injury occurs, the clinician will naturally think about the possibility of intestinal damage. In some cases, even the intestinal contents can be directly swelled; in the closed abdominal injury, the intestine If the rupture is large or the wound is broken, due to the stimulation of a large amount of intestinal contents, acute diffuse peritonitis occurs early, so it is not easy to cause missed diagnosis, but for those who are small and blocked by food or foreign matter, and the mucosa valgus and intestinal wall The strong convulsions, less intestinal contents spillage, peritoneal inflammation and pneumoperitoneum can be atypical, the diagnosis is more difficult.
Examine
Small bowel injury examination
Laboratory inspection
1. Blood test showed that the white blood cell count increased, the hematocrit increased, and the blood volume decreased.
2. Examination of abdominal puncture fluid: The contents of the intestine are seen by the naked eye. The microscopic examination of white blood cells exceeds 5×108/L, and diagnosis can be made.
3. Examination of peritoneal lavage fluid: microscopic examination of leukocytes over 5×108/L suggests intestinal perforation. When red blood cells exceed 1×1010/L, it indicates internal bleeding. Amylase exceeds 128 genius units or greater than 100 s. More than one unit has pancreatic damage.
Film degree exam
1. X-ray examination: abdominal X-ray or radiograph in standing position or lateral position, the presence of free gas under the armpit or free air in the lateral abdomen is the most powerful basis for diagnosing closed injury of the small intestine combined with perforation, but the positive rate is only 30%, in the X-ray examination to exclude abdominal abdomen caused by pneumoperitoneum and iatrogenic pneumoperitoneum.
2. Abdominal puncture: Diagnostic abdominal puncture can be performed for suspected small intestine rupture. Abdominal puncture is one of the commonly used auxiliary diagnosis or diagnosis methods for abdominal injury and acute abdomen. The diagnosis rate of small intestine rupture is 70%-90%. As long as the puncture site does not damage the gallbladder, the bladder, and the intestine that adheres to the abdominal wall, in principle, it can be selected in any part of the abdomen, usually on one side or both sides of the lower abdomen, or on the sides of the upper abdomen according to the mechanism of injury or On both sides of the flat umbilical cord, the injection needle with sufficient length and caliber should be selected when puncture. The needle is too fine to affect the outflow of the contents of the abdominal cavity. Too thick will undoubtedly increase the chance of injury of the abdominal cavity. The angle of the needle should be blunt, and the needle should be able to provide certain Negative pressure, if the turbidity, purulent fluid and intestinal contents are taken out, the possibility of rupture of the small intestine may be considered, and further diagnosis should be confirmed by microscopic examination.
3. Peritoneal lavage: In order to improve the early diagnosis of intestinal perforation and internal hemorrhage, 250-500 ml of normal saline was injected through the catheter after abdominal ablation, and the body position was appropriately changed and the liquid part poured into the abdominal cavity was aspirated after a short pause. By observing its color, turbidity, odor and laboratory examination and analysis to determine the intra-abdominal condition.
4. Ultrasonic examination: Ultrasound has no damage to the human body, the equipment is simple, the cost is low, and it can be repeated at the bedside. It can also guide the specific puncture site for interventional diagnosis, which plays an important role in the diagnosis of abdominal injury. It has been reported that B-ultrasound The minimum amount of ascites that can be found is about 200ml, which can show a local hypoechoic liquid dark area in the crypt, depression or gap of the abdominal cavity, followed by sound and shadow. When there is gas in the abdominal cavity, the gas can be used in the abdominal cavity. The large mobility, light weight and scattering of ultrasound are found in the sky-facing side of gravity, close to the abdominal wall and moving with the body position, B-ultrasound shows thickening of the intestinal wall of the hematoma and Liquid dark area, surrounded by strong light group reflection with unstable sound and shadow.
5. CT examination: CT is diagnosed by X-ray absorption and computerized imaging. The detection rate of early detection of free air in the early stage of CT can reach 48%-70%, the resolution is higher than ultrasound, and the positioning is accurate. , can be repeated, to facilitate the diagnosis of substantial organ damage and internal bleeding, CT examination can determine the location and size of the hematoma.
6. Selective angiography: Selective angiography for the diagnosis of disease through arterial, venous and capillary visualization, the most suitable for the diagnosis of vascular injury, especially active hemorrhage, the use of angiography for intestinal injury with mesenteric vascular rupture Have a certain effect.
Diagnosis
Diagnosis and diagnosis of small intestine injury
Diagnostic abdominal puncture can get digestive juice or bloody liquid, no difficulty in diagnosis, abdominal X-ray examination is limited in value, only a few cases can see free gas under the armpit, some small intestine blunt injury, early (within 6 hours after injury) often no obvious Symptoms and signs, difficult to diagnose, should be closely observed, abdominal puncture can provide strong evidence.
It is differentiated from gastric damage, spleen damage, liver damage, and kidney damage.
1. Diagnosis basis
The basis for clear diagnosis before surgery is mainly:
1 There is a direct or indirect history of violent trauma, and the action site is mainly located in the abdomen;
2 have spontaneous abdominal pain and persistence;
3 abdominal pain is fixed or the range is gradually enlarged;
4 have peritoneal irritation;
5 follow-up examination found that abdominal symptoms were aggravated but no signs of internal bleeding;
6 has a free gas sign under the armpit;
7 limited small intestine gas-liquid level;
8B super has a partial liquid dark area or free air in the abdominal cavity;
9 abdominal puncture with ascites;
10 have toxic shock in infection.
2. Diagnostic attention problems
In order to improve the early diagnosis rate, the following points should be noted in the diagnosis process:
(1) Detailed inquiry and physical examination: such as the injured part, the size of the external force, the direction, the reaction of the patient after the injury; carry out a comprehensive and careful physical examination, the part of the abdominal tenderness, the range, the change of the liver dullness, whether there is a mobile dullness, the intestine The change of the beep should be checked one by one.
(2) Close observation: For those who can not be diagnosed for a while, pay special attention to the first impression, dynamic observation, repeated comparison, in principle, should be hospitalized during the observation period, no anesthesia and analgesic drugs should be applied; for patients with multiple trauma, due to complicated conditions And critically, often only pay attention to obvious damage outside the abdomen, such as fractures, head injury, or combined with shock, coma, masking the performance of abdominal injuries, such patients should actively treat other combined injuries while anti-shock, and closely observe Changes in abdominal signs, the clinical manifestations of small bowel injury depends on the extent of the injury, the time of injury and whether it is accompanied by other organ damage.
