Adhesive intestinal obstruction in children
Introduction
Introduction to Pediatric Adhesive Intestinal Obstruction Intestinal obstruction formed by intra-abdominal adhesion is extremely common in the clinic. The statistics on the collection of large cases at home and abroad are the most in terms of adhesion or incarceration. With the deepening of medical and health work, the increase of early repair of abdominal hernia will reduce the incidence of incarcerated hernia, and the increase of abdominal surgery will increase the incidence of adhesive intestinal obstruction. basic knowledge The proportion of sickness: 0.01% Susceptible people: children Mode of infection: non-infectious Complications: metabolic acidosis, dehydration, peritonitis, septic shock
Cause
Causes of adhesive intestinal obstruction in children
Infection (25%):
Inflammatory adhesions caused by bacteria or other pathogens, such as chronic tuberculous peritonitis, adhesions during inflammation, acute suppurative or diffuse peritonitis.
Congenital (15%):
Congenital adhesions and cords include post-adhesive adhesions of fecal peritonitis, poor intestinal sling, and residual cords in the Merkel diverticulum.
Injury (25%):
Peritoneal intestinal wall serosa is mechanically irritated, such as surgical trauma, changes in temperature and humidity, and stimulation using chemicals during surgery can cause adhesions.
Foreign body irritant adhesions (15%):
Such as intra-abdominal hemorrhage, bile, meconium and other drugs, adhesions caused by tumor stimulation.
Pathogenesis
The peritoneum has a strong ability to regenerate and repair. The adhesion of the abdominal organs and peritoneum after abdominal operation is the biological protection mechanism of the body against external stimulation. It can limit the inflammation of the abdominal cavity and promote wound healing. On the other hand, the peritoneal adhesion is also The risk of continual intestinal obstruction, after the peritoneum is damaged by any stimulation, initially serous exudation, including fibrin and cellulose deposition, it is due to stimulation of mesothelial cells and deep mast cells, mesothelial cells release clotting activity Enzymes, which promote the conversion of fibrinogen to fibrin, mast cells release histamine, heparin and vasoactive substances, which cause telangiectasia, increase permeability, lead to serous exudation, and the formation of thick and uneven pus in the intestine, 6 ~ 12h to form an easily separated fibrinous adhesion, this adhesion is temporary, such as re-operation within 48h, easier to blunt separation, no surgery, usually self-dissolved within 72h, such as adhesions for more than 3 days no Absorbed, it forms a strong fibrous adhesion, the key factor in this process is the fibrinolytic system, in the cause of peritoneal adhesions The inhibition of fibrinolytic ability is an important factor. When the activity of the plasminogen activator is reduced to less than 60%, adhesion occurs, and on the basis of fibrinosis, collagen fibers are formed to form cellulosic adhesions, and It began to form a relatively tight vascular network, which was difficult to separate and easily oozing. At this time, about 1 week after the injury, the intestines were completely adhered. As the intestinal peristalsis gradually began to absorb, the intestines were loose, but there was still membranous adhesion. This period is about 2 to 3 weeks after the injury. After 1 month, the adhesion is further pulled and absorbed, forming most of the cavity defects, becoming the adhesion zone, and further absorbing to form a narrow, thick cord-like adhesion, and the adhesion is completely absorbed. It takes 1 to 1.5 years. Adhesive intestinal obstruction usually occurs in the small intestine. Colon is extremely rare. Intestinal adhesion can exist for a long time, but it is generally asymptomatic. It can cause adhesive intestinal obstruction in the following cases:
1 The intestine is adhered to the abdominal wall, and the intestinal fistula is folded into an angle or twisted according to the adhesion portion, which often occurs under the incision.
2 Adhesive tape is fixed at both ends, and the intestinal tube is compressed to cause obstruction, and a certain intestinal fistula can be inserted into the ring hole to form an internal hemorrhoid.
3 parts or most of the intestines adhere to a group, and the intestines are excessively folded and twisted, causing incomplete or complete intestinal obstruction.
4 a certain segment of intestinal fistula and distant adhesions, such as jejunum and pelvic adhesions, pulling the intestine into an acute angle can also cause intestinal obstruction, the above situation, generally caused by simple intestinal obstruction, such as concurrent torsion band or internal hemorrhoids affect blood supply, that is The formation of strangulated intestinal obstruction, in addition, a large amount of intestinal contents reached the adhesion after eating, causing intestinal peristalsis can occur intestinal torsion, can also promote the formation of intestinal obstruction.
In short, adhesions occur in the abdominal cavity, which is related to unexplained individual factors. Adhesive fibers can be completely absorbed, and there are also extensive adhesions. After a long period of time, a few fiber bundles remain, but the degree of adhesion and damage, foreign bodies There is a clear connection between the severity of stimulation, the intensity of physical stimulation, the use of antibiotics in the abdominal cavity, and the general condition. The stronger the stimulation, the more adhesions occur, and the poor systemic conditions such as low protein will delay the recovery process. The pathological changes of adhesion formation are Consistently, due to the protective inflammatory response, a large amount of fibrinogen oozes out and becomes fibrin and deposits on the peritoneum and intestinal serosal membrane to form a soft and extensive fibrin-like adhesion between the intestinal tract. Paste, can be gently separated, does not damage the intestinal serosa, most of them do not cause obstruction, after the inflammation is subsided, most of the fibrin membrane is absorbed, the fibrin membrane is incompletely absorbed, and gradually formed Collagen fibers form fibrous membrane adhesion, and the remaining fibrous adhesive membrane is pulled and ruptured through the peristalsis of the intestinal tract. Leaving the adhesive tape cable, or another part of the intestine loop into groups close adhesion, causing intestinal twisting, luminal stenosis after it has become the main risk based adhesive ileus.
In summary, the production of intra-abdominal adhesions, absorption is related to individual factors, individual differences are great, but the occurrence of adhesions is still the extent of damage, the amount of foreign bodies, the intensity of physical stimulation, the concentration of antibiotics applied in the abdominal cavity, the virulence of bacteria The number, local blood circulation and other conditions, the stronger the stimulation, the more adhesions, the systemic malnutrition, the low protein, the longer the absorption and repair, or even the absorption can form a permanent posterior adhesion, on the basis of adhesion, any Causes the intestinal peristalsis hyperthyroidism, rhythm disorder, such as cold, high fever, overeating, etc. can induce the onset of acute intestinal obstruction, obstruction of the proximal intestinal fistula, the lumen of the intestine is filled with gas and liquid, intestinal fistula below the obstruction point Reduced without gas, if the local intestinal blood circulation is blocked, the intestinal necrosis will occur soon, and it will develop into diffuse peritonitis and toxic shock. A few can also be perforated at the proximal or necrotic site of obstruction.
Prevention
Pediatric adhesion intestinal obstruction prevention
Acquired adhesive intestinal obstruction is a common complication of intra-abdominal surgery. How to prevent adhesion during surgery is an extremely important research topic. In the literature, various agents and substances such as heparin and double have been applied in the literature. Coumarin, dextran, dexamethasone, indomethacin, ibuprofen, hyaluronidase, streptokinase, silicone oil, etc., theoretically prevent adhesion, but the actual effect is not certain, pending further research, surgery Should be carefully operated, do not damage too much tissue, stop bleeding thoroughly, to prevent the formation of hematoma and adhesion, the intestine can not be exposed to the abdominal cavity too long, the gauze pad covering the organ should not be too long, must be exposed for a long time Timely replacement of warm salt water gauze, the temperature should not be too high, 35 ~ 40 ° C is the most suitable, the talcum powder on the gloves must be rinsed, talcum powder can cause adhesions in the abdominal cavity, patients with peritonitis surgery, abdominal cavity pus should try to absorb If necessary, thoroughly flush the abdominal cavity with an aqueous solution containing gentamicin and metronidazole, and place the abdominal drainage. The drainage tube was removed 24 to 48 hours after surgery, and the peritoneum was sutured. The device should be flat, the uneven line can form adhesion, the anterior peritoneum should be sutured as much as possible, the posterior peritoneal defect can be reluctantly sutured, help the child to change position and early waking activity, defecation, exhaust, early feeding, and promote the intestine Creeping recovery, but also oral domperidone, cisapride (Prebos) and other gastrointestinal motility drugs, occasionally can also be applied to neostigmine, early postoperative application of ultrashort wave therapy, can help the recovery of bowel movement, prevention or Reduce intestinal adhesion obstruction.
Complication
Pediatric adhesion intestinal obstruction complications Complications, metabolic acidosis, dehydration, peritonitis, septic shock
Often the following symptoms:
1. Acidosis and dehydration:
Due to frequent vomiting, loss of large amounts of digestive juice, and inability to eat and fever, the child gradually develops dehydration acidosis. Strangulated intestinal obstruction is more severe at the beginning of dehydration.
Second, intestinal perforation:
Intestinal perforation is a pathological change in the intestine that is characterized by necrosis of the intestinal wall, which ultimately leads to perforation. After the intestinal contents enter the abdominal cavity, if it is a small amount, it can be confined by the intraperitoneal omentum. If it is a large amount, it will enter the abdominal cavity completely. The whole abdomen will be severely painful, and the abdominal muscles will be tight and stiff, which may cause shock.
Abdominal pain in acute intestinal perforation often occurs suddenly, with persistent severe pain, which often makes the patient unbearable and exacerbates during deep breathing and coughing.
The extent of pain is related to the extent to which peritonitis spreads. The patient took the supine position and the two lower limbs flexed and did not want to turn. Abdominal examination showed that the respiratory movement was significantly weakened, the abdominal muscle plate was hard, the bowel sounds weakened or disappeared, and the liver dullness circle was reduced or disappeared. X-ray examination revealed that there was free gas under the armpit.
Third, peritonitis:
Peritonitis is a serious disease common to surgery caused by bacterial infections, chemical stimuli or injuries. Most are secondary peritonitis, original organ infections in the abdominal cavity, necrotic perforation, trauma and so on.
The main clinical manifestations are abdominal pain, abdominal tenderness, abdominal muscle tension, as well as nausea, vomiting, fever, elevated white blood cells, severe blood pressure drop and systemic toxicity in severe cases. If not treated promptly, it can die of toxic shock. Some patients may have pelvic abscess, intestinal abscess, and underarm abscess, axillary abscess, and adhesive intestinal obstruction.
Fourth, septic shock:
Septic shock, also known as septic shock, refers to sepsis syndrome caused by products such as microorganisms and their toxins.
Microorganisms, their toxins, and cell wall products in infected areas invade the blood circulation and activate various cellular and body fluid systems of the host.
The production of cytokines and endogenous mediators affects various organs and systems of the body, affecting its perfusion, leading to ischemia and hypoxia, metabolic disorders, dysfunction, and even multiple organ failure.
Symptom
Pediatric adhesion intestinal obstruction symptoms common symptoms abdominal distension abdominal pain bowel aphid intestinal obstruction colon obstruction dehydration shock
Abdominal pain
For the earliest symptoms, abdominal pain is mainly caused by intestinal obstruction, proximal intestinal lumen enlargement and strong contraction of the intestinal wall. The initial abdominal pain is very sharp in the early stage of strangulated intestinal obstruction. Individual sick children may have early shock, accompanied by abdominal pain. Vomiting began because the nerves of the peritoneum and mesentery were stimulated and reflexed, and then due to intestinal obstruction, recurrent flow of intestinal contents caused repeated vomiting, high obstruction occurred early vomiting, green water, low obstruction occurred later, vomiting, including stool.
2. Bloating
High obstruction only upper abdominal distension, low abdominal distension is more obvious, intestinal type and intestinal peristaltic wave can be seen, auscultation of bowel sounds is metallic sound or gas over water sound.
3. No defecation
Obstruction can initially discharge the stool accumulated in the distal end of the obstruction, and then no longer defecate and ventilate, due to frequent vomiting, loss of a large amount of digestive juice, and due to inability to eat and fever, the disease gradually develops dehydration acidosis, strangulated intestinal obstruction The symptoms of dehydration begin to be severe. A small number of children have extensive adhesions in the peritoneal cavity. The intestinal tube is bound by adhesion for a long time. Clinically, some simple simple intestinal obstruction may occur. Frequent abdominal pain, vomiting, and sometimes abdominal distension occur, and self-reliance after 1 to 3 days. Large abdominal type and peristaltic wave can be seen in the abdomen during the attack. It is often caused by some factors to cause complete intestinal obstruction, that is, acute exacerbation of chronic adhesive intestinal obstruction.
Examine
Examination of children with adhesive intestinal obstruction
Generally, white blood cells are slightly elevated, and there is a neutral left shift phenomenon. If there is intestinal necrosis, white blood cells can be very high, blood biochemical performance is hypotonic dehydration, and peritonitis, white blood cells of abdominal puncture fluid increase significantly, strangulated intestinal obstruction For bloody ascites.
1. Abdominal X-ray and plain film
It can be seen that the small intestine is inflated with tension and liquid level, the colon is not inflated, and the colonic intestine sees colonic contracture without gas, which can be diagnosed as complete mechanical small bowel obstruction. When the intestinal obstruction is adhered, the abdominal X-ray plain film is characterized by uneven expansion of the intestine. The size of the gas-liquid plane varies, and there is no extent of intestinal dilatation in the right abdomen. Occasionally, a small intestinal gas shadow may appear, suggesting incomplete intestinal obstruction. When abnormal intestinal fistula is found, it is like a coffee bean. "C" shape, is a typical complete and strangulated intestinal obstruction X-ray image, if necessary, can take lateral X-ray film, compared with the standing position, can also be used for incomplete intestinal obstruction The fluoroscopy was performed to observe the obstruction site and the degree of obstruction, and the diagnosis was confirmed.
2. Abdominal ultrasound examination
For special causes of intestinal obstruction, such as cysts, tumors, etc., B-mode ultrasound examination can be identified, and those with experience can detect the shape of the obstruction site, whether it is complete obstruction.
Diagnosis
Diagnosis and diagnosis of adhesive intestinal obstruction in children
diagnosis
Paroxysmal abdominal cramps and repeated vomiting, vomit is yellow-green liquid, even for fecal-like, no defecation, venting, physical examination of the intestines and hearing high-pitched bowel sounds, you can diagnose the intestines Obstruction, if there is intra-abdominal infection, trauma and surgical history, etc., should consider congestive intestinal obstruction, abdominal X-ray and plain film, barium enema and other related examinations can help diagnose.
Differential diagnosis
Should be differentiated from intestinal fistula, acute gastroenteritis.
Intestinal fistula: Intestinal fistula, also known as spastic colic, is the most common functional abdominal pain in children with acute abdominal pain. The abdominal pain of a child can last for a few minutes or tens of minutes, and it is time to stop. After repeated episodes of tens of minutes or hours, abdominal pain can no longer occur. Individual children, their recurrent abdominal pain can be delayed for several days, the degree of abdominal pain is also different, and severe cases can appear on the spot. Vomiting can occur, the vomit is the contents of the stomach or contains bile, and the antispasmodic can be relieved.
Acute gastroenteritis: a history of unclean diet, often vomiting and diarrhea, some with fever and other infection symptoms.
