small bowel injury
Introduction
Introduction The small intestine occupies the largest position in the abdominal cavity, has a wide distribution, is relatively superficial, and lacks bone protection. 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, the examination of the small intestine should be performed carefully, carefully, and regularly. Intestinal damage is caused by direct violence and indirect violence. It is mainly caused by blunt rupture caused by blunt abdominal injury, falling from a height or sudden deceleration.
Cause
Cause
1. Closed intestinal injury can be divided into four situations according to the principle of violent action.
(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 injury 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 humerus to cause contusion and laceration of the small intestine, and the severe small intestine can be directly cut off. Damage from the median part of the umbilicus is often injured and occluded, sometimes accompanied by mesenteric rupture, contusion, and hemorrhage. The external force slightly biased to the body axis can be combined with liver, spleen, kidney, and colon damage. When the abdomen is subjected to a large area of violence, it can be closed due to the duodenal jejunum and the lower ileum at the same time, so that the upper part of the jejunum is closed and the pressure in the intestine is suddenly increased and ruptured. This type of injury often occurs after a full meal, and the rupture and perforation often occurs in the side wall of the small intestine that is far from the intestinal part of the intestine where it is subjected to 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 intestines from the attachment point, which is usually found at the beginning of the jejunum near the Treitz ligament or at the end of the ileum fixed by the peritoneal reflex. By the same token, this injury can also occur in abdominal inflammatory lesions, abdominal surgery or intra-abdominal medications, causing intra-abdominal pathological adhesions, near the intestines and abdominal wall or surrounding tissues and organs. From the side violence can also cause a sudden increase in pressure in a part of the intestine. The original inflated intestine is too late to evacuate the external force or there is no room for rotation between the tortuous filling intestines. When the fluid pressure in the intestine increases sharply, then The infiltration of the intestine can be caused by the oblique penetration of the mesenteric wall of the intestinal wall away from the external force, and the diameter of the intestine is generally 0.5 cm. The surrounding intestinal wall and the mesentery are normal, and the damage is easily detected. Missing.
(3) Indirect violent injury: It occurs mostly under the force mechanism against the inertial movement of the intestine. When the patient falls from a height, falls, or stops, the intestine or mesangium can't resist the pressure exerted by the sudden change of position. The small intestine is broken or torn by conduction. This damage occurs mostly at the fixed ends of the small intestine, such as near the ends of the ileum attached to the posterior abdominal wall and the free ileum junction where the freeness is greatest. It is more common in small intestines that contain a large number of chyme and are in a state of filling.
(4) Strong contraction of the muscles of the body: Inappropriate 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 0.5cm ileal rupture and mucosal eversion at 150cm from the ileocecal area.
2. Open intestinal injury
Mainly for sharp injuries, such as bullets, shrapnel or marble damage, sharp injuries. Open small intestine injury must have foreign matter entering or passing through the abdominal cavity. It may be a single single wound wound or multiple wound wounds. The damaged bowel 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.
Examine
an examination
Related inspection
Small endoscopy, endoscopic ultrasonography, small intestine angiography, abdominal fluoroscopy, oral small intestine angiography
Diagnostic abdominal puncture can get digestive juice or bloody fluid, and there is no difficulty in diagnosis. Abdominal X-ray examination is of limited value, and only a few cases can see free gas under the arm. Part of the 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.
The clinical manifestations of small bowel injury depend mainly on the extent of the injury and the presence or absence of organ damage. Mainly manifested as peritonitis, shock and poisoning can 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 intestinal wall necrosis, perforation caused by peritoneal inflammation.
When the intestine ruptures and perforates, the contents of the intestines overflow, and the peritoneum is stimulated by the digestive juice. The patient may present with severe abdominal pain accompanied by nausea and vomiting. Physical examination showed that the patient was pale, cold skin, weak pulse, shortness of breath, and decreased blood pressure. There may be total abdominal tenderness, rebound tenderness, abdominal muscle tension, mobile dullness positive and bowel sounds disappearing, 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 no clear peritoneal inflammation in a few hours or ten hours due to small cracks in the small intestine or blocked by food debris, fibrin or prominent mucous membranes. The change.
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 easier. In the case of open abdominal injury, clinicians will naturally think about the possibility of intestinal damage. In some cases, even the contents of the intestine may be directly swelled. In closed abdominal injury, the intestine is broken or the wound is broken. Stimulation of the contents, acute diffuse peritonitis occurs early, so it is not easy to cause missed diagnosis. For those who are small and blocked by food or foreign bodies, the mucosal valgus and the intestinal wall are strongly paralyzed, the intestinal contents are less spilled, the peritoneal inflammation and pneumoperitoneum are atypical, and the diagnosis is difficult.
1. Diagnosis based on preoperative diagnosis is mainly based on:
1 There is a direct or indirect history of violent trauma, and the action site is mainly located in the abdomen.
2 has spontaneous abdominal pain and persists.
3 abdominal pain is fixed or the range is gradually enlarged.
4 have peritoneal irritation.
5 Follow-up found that abdominal symptoms aggravated but no 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 location of the injury, the size of the external force, the direction, the reaction of the patient after the injury; a comprehensive and careful examination of the body, the location of the abdominal tenderness, the range, the change of the dullness of the liver, 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 cannot be diagnosed for a while, pay special attention to the first impression, dynamic observation, and repeated comparison. During the observation period, it should be hospitalized in principle, and no anesthesia and analgesic drugs should be used. For patients with multiple trauma, due to complicated and critical illness, they should only pay attention to obvious injuries other than the abdomen, such as fractures, head injury, or combined shock, coma, and cover up. The performance of abdominal injuries. Such patients should be treated with other combined injuries while actively resisting shock, and closely observe changes in abdominal signs. The clinical manifestations of small bowel injury depend on the extent of the injury, the time of injury, and whether it is accompanied by other organ damage.
Diagnosis
Differential diagnosis
Differential diagnosis of small bowel injury:
1. Stomach injury: Due to the large degree of gastric activity and protection by rib arch, the incidence of simple gastric injury accounts for only 1 to 5% of abdominal abdominal injuries in abdominal blunt trauma; but in penetrating abdominal injuries ( Especially gunshot wounds, the rate of gastric injury is higher, accounting for 10 to 13%, and the fourth is the internal organ injury. Due to anatomical relationship, gastric injury often combined with other visceral injuries, especially abdominal penetrating injuries, including 34% of liver injury, 30% of spleen injury, 31% of small intestine injury, 32% of large intestine injury, and 11% of pancreatic injury. The mortality rate of simple gastric injury is 7.3%, and the mortality rate of combined injury is as high as 40%.
2, liver damage: the liver is the largest substantial organ in the abdominal cavity, responsible for the important physiological functions of the human body. Hepatocytes are poorly tolerant to hypoxia, so hepatic arteries and portal veins provide a rich blood supply, and large and small bile ducts and blood vessels accompany bile. It is located deep in the right upper abdomen and has protection from the lower chest wall and diaphragm. However, due to the large size of the liver and the fragility of the liver, once it is vulnerable to violence, it may cause intra-abdominal hemorrhage or bile leakage, causing hemorrhagic shock or biliary peritonitis. The consequences are serious and must be diagnosed and treated correctly.
3, kidney damage: the kidney is deep in the body, and there is protection of the fat sac and surrounding tissue structure, less chance of injury. Kidney damage is mostly caused by firearm injuries, stab wounds and local direct or indirect violence. According to the degree of trauma, it is divided into four types: contusion, laceration, laceration and kidney injury. Kidney damage accounts for about 65% of all genitourinary tract injuries. Causes of blunt injury (80%), penetrating wounds (increased during war and high crime areas), and iatrogenic injuries (due to surgery, extracorporeal shock wave lithotripsy or Renal biopsy. Complications include bleeding, extravasation, abscess formation, and high blood pressure.
