Injuries of the intestine: causes, symptoms, diagnosis, treatment
The greatest number of traumatic injuries of the intestine occurs during the wartime - these are mostly gunshot wounds and closed injuries due to the impact of the blast wave. During the Great Patriotic War, injuries to the colon accounted for 41.5% of all wounds of hollow organs. Out of all closed abdominal injuries, 36% were due to closed intestinal injuries; while in 80% of cases, the small intestine was damaged, and in 20% - thick.
In peacetime, intestinal injuries are much less common.
Attempts were made to classify traumatic injuries of the intestine. However, these classifications were not used because of their complexity. The most acceptable, in our opinion, for practical work is the classification proposed by A M. Aminev (1965), which is based on the etiological principle and anatomical localization of lesions of the rectum and large intestine. The drawbacks of this classification include the absence in it of indications for damage to the small intestine.
Damage to the intestine with closed abdominal trauma in peacetime is observed in traffic accidents, falling from a height, strong compression, for example between the buffers of cars. The degree of damage to the intestine may be different: a contusion of the intestinal wall, multiple and single breaks up to a complete transverse rupture of the intestine.
In those cases when the acting force is applied non-perpendicular to the abdomen (obliquely): the gut can come off from the mesentery at the fixation sites (proximal part of the lean and distal ileum).
In connection with the fact that with closed trauma of the abdomen, injuries, as a rule, are combined, in the diagnosis there are significant difficulties. The clinical signs of a ruptured bowel include acute pain in the abdomen at the time of injury, rapid pulse, soreness and tension of the muscles of the abdominal wall during palpation of the abdomen. When percussion draws attention to the decrease in the dimensions of hepatic dullness due to the accumulation of gas in the sub-diaphragmatic space. Clear signs of peritonitis appear some time after the injury.
Open lesions of the intestine occur due to penetration of the abdominal wounds (gunshot, knife or wound with any sharp object).
In the clinical picture of acute injuries, abdominal pain of varying intensity prevails, vomiting, a rapid pulse (more than 100 in 1 min), a tension in the muscles of the abdomen, a sharp pain in palpation. When percussion of the abdomen is defined stupidity in the iliac region as a result of fluid accumulation (poured blood, intestinal contents or inflammatory effusion). There is a delay in the stool. Gases do not depart. On the joining of the paresis of the intestine is evidence of bloating and the absence of noise of peristalsis during auscultation.
A significant place in the diagnosis of open and closed intestinal injuries is given to an x-ray examination of the abdominal cavity, which makes it possible to detect the appearance of free gas, fluid accumulation in the lateral parts of the abdomen, paralytic intestinal obstruction.
Treatment of intestinal injuries is surgical. The method of surgical intervention is chosen depending on the nature of the lesions.
In addition to the above injuries of the intestine, there are traumas attributed by AM Aminev (1965) and BL Candelis (1980) to the category of everyday (intestinal damage during medical manipulations, fractures of pelvic bones, operations on other organs, damage to the intestine by foreign bodies, burns of the intestine, etc.).
Damage to the intestines during medical manipulation AM Aminev divides into 3 groups:
- slight damage (excoriation, cracks, tearing of the anus of the anal ring and mucous membrane). Such types of injuries do not require treatment, their rapid healing takes place;
- trauma of moderate severity (extraperitoneal dissections of the rectum, damage to the intestine without disturbing the integrity of the peritoneum);
- severe damage with violation of the integrity of the peritoneum or surrounding organs, complicated by infection of the abdominal cavity or cell spaces.
Mechanical damage to the rectum can be observed with rectal thermometry, examination in mirrors, cleansing and treatment enemas. We often had to see at a sigmoidoscopic examination superficial traumatic damages of the intestinal wall, caused by the enema tip, when the procedure was not performed in a sufficiently qualified manner. As a rule, it was a defect of the mucous membrane of a triangular shape, located along the anterior wall of the rectum at a distance of 7-8 cm from the anus.
Despite the fact that rectoscopy is considered routine and is widely used in clinical and polyclinic practice, in some cases it may be accompanied by complications, the most severe of which is the perforation of the rectum and sigmoid colon.
Several reasons can contribute to perforation: violation of the technique of research, pronounced pathological changes in the intestinal wall, restless behavior of the patient during the study.
Clinical manifestations of the complication depend on the size of the perforated hole, as well as on the virulence of the intestinal microflora and the degree of bowel clearance before the study.
At the time of damage to the intestinal wall with a sigmoidoscopy, the patient has a mild pain in the lower abdomen, sometimes nausea. Soon these phenomena disappear. Only after 2 h there are signs of a developing complication.
In the last decade, a method such as fibrocolonoscopy has broadly entered clinical practice. The importance of this method for diagnosis of diseases of the colon can not be overestimated. However, there are reports of complications during colonoscopy, of which perforation and bleeding are considered to be the most formidable.
Perforation of the intestine can occur when the intestine is wounded by an endoscope, the bowel is inflated with forced air, pathological changes in the intestinal wall (cancer, ulcerative colitis, Crohn's disease, diverticular disease).
Bleeding is observed during biopsy from vascular formations (hemangiomas), after multiple biopsies in patients with ulcerative colitis and Crohn's disease, and also after electrocoagulation of polyps.
According to experts, any complication after a colonoscopy is a result of a violation of the technique of the study. Practice shows that the frequency of complications decreases as the endoscopist accumulates experience and improves the technique of research.
Damage to the anal area and rectum with sharp and blunt objects is a type of trauma that is rare. To describe such a trauma in the literature of the XIX century, the term "drop on the count" was used. Describes cases of falling on the handle of a mop, a ski stick, an umbrella handle. As a result of the injury, acute pain occurs in the anus, up to pain shock, bleeding. There are desires for defecation, feces and gases passing through the wound channel. In this type of injury, extensive and severe injuries develop, such as rupture of the rectum and sphincter walls, perforation of the pelvic peritoneum, damage to nearby organs.
Cases of damage to the rectum and sigmoid colon due to gynecological and urological operations, medical abortions and obstetric care are described. Rectal injury leads to infection, resulting in numerous complications (cystitis, pyelitis, phlegmon, rectovaginal and other fistulas, peritonitis).
Damage to the intestine by foreign bodies. As is known, foreign bodies enter the intestine when swallowed, inserted through the anus, penetrate from neighboring organs and form them in the gut lumen (stool stones).
Swallowed small objects, as a rule, move freely along the digestive tract and are excreted naturally. An emergency situation occurs when a foreign body damages the gut or leads to the development of obstructive obstruction.
Acute foreign bodies can cause perforation of any part of the intestine with the formation of an abscess, which can be taken as a malignant tumor during examination and even during surgery.
In the rectum through the anus, foreign bodies sometimes get into medical procedures (most often the enema tip), rectal masturbations, and are also the result of criminal acts. Foreign bodies can penetrate into the intestine also from neighboring organs and tissues, for example, with gunshot wounds.
To casuistry are cases where the napkins and gauze swabs left in the abdominal cavity penetrated into the intestine through the formed decubitus and left naturally through the anus.
And finally, it should be said about the foreign bodies formed in the gut lumen - fecal stones. It is believed that with normal bowel function, the formation of stool stones is hardly possible. Certain conditions are required to allow the stone to form and remain in the gut lumen for a long time. One of the main conditions is the difficulty of evacuating the intestinal contents, which occurs due to a number of reasons (cicatrical stricture of bowel, violation of innervation, intestinal atony).
In the center of the stool there are dense indigestible particles. This includes fruit bones, suspension of barium sulfate, gallstones, etc. Gradually, stones "enveloped" with feces, soaked in salts, acquire considerable density. Some types of long-lasting medicines (sodium bicarbonate, bismuth nitrate, magnesium salts) can contribute to the consolidation of stones. Such dense salt impregnated stones are called true coprolites, unlike false ones, which do not have time to be impregnated with salts and remain softer. False coprolits can exit through the anus alone after the oil enemas or can be extracted through the anus with a finger (fully or in parts). An example of false coprolites are stool stones, formed in elderly patients with intestinal atony.
To remove true coprolites of a large size, one must resort to surgery (laparotomy, proctomy). Unrecognized stool stones can cause gut perforation or lead to intestinal obstruction.
Spontaneous ruptures of the rectum. This includes traumatic ruptures of the rectum due to increased intra-abdominal pressure. The immediate cause of such trauma is usually a one-stage significant increase in intra-abdominal pressure during lifting of weights, during defecation, urination, abdominal shock, coughing, falling, or during labor. The rupture is easier to treat the pathologically altered rectum. Therefore, most often spontaneous ruptures can be observed in persons suffering from prolapse of the rectum, as in this pathology the intestinal wall becomes thinner and sclerotic.
Signs of rupture of the intestine are a sharp pain in the lower abdomen and anus in the moment of rupture, the allocation of blood from the anus. Often there is a prolapse of loops of the small intestine through the anus.
Chemical burns of the rectum and large intestine. Burns of the mucous membrane of the rectum and large intestine are found when the ammonia, concentrated sulfuric acid is mistakenly introduced into the rectum, or when certain substances with a therapeutic purpose are introduced.
The characteristic clinical symptoms of a chemical burn of the rectum and large intestine include pain localized in the lower abdomen and in the course of the colon, frequent desires, secretion of blood and bloody films from the anus. With severe lesions, vomiting, chills, fever are observed.
According to the data of VI Oskretov and co-authors. (1977), the introduction of 50-100 ml of ammonia into the rectum in the experiment caused a burn of the rectus and distal sigmoid colon, 400 ml - a burn of the entire colon.
Treatment of patients with chemical lesions of the colon of the large intestine begins with the washing of the intestine with warm water (3-5 liters) or neutralizing solution (if the substance that caused the burn is known). In addition, analgesics, sedatives, cardiovascular agents are administered. Then they are prescribed oily microclysters (fish oil, sea buckthorn oil, dog rose, tampons with Vishnevsky ointment). With severe burns (necrosis of the intestinal wall) surgical treatment.
Discontinuities of the intestine from the effects of compressed air have been known in the literature since the beginning of the 20th century. This injury was first described by G. Stone in 1904. Most often, such damage is the result of careless handling of a hose from a compressed air cylinder. A jet of air penetrates through the anus in the intestine, tears it and fills the abdominal cavity. In this case, the ampoule of the rectum, which is protected when blown by the walls of the small pelvis, is usually not damaged. Discontinuities occur in the pendulum department, which lies above the pelvic diaphragm, and in various parts of the large intestine.
Most often, the gaps are localized in the area of the bends (rectosigmoid section, curvature of the sigmoid colon, splenic flexure). As a result of injury under the influence of compressed air, stool masses are sprayed over the abdominal cavity. If the parietal peritoneum is broken simultaneously with the gut, intermuscular and subcutaneous emphysema occurs. There are growing phenomena of extra- or intraperitoneal bleeding associated with vascular damage. Delay with surgery contributes to the development of pelvic peritonitis.