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Acquired intestinal obstruction.
Bleeding from the digestive tract.
Portal hypertension.
Acquired obstruction of bowel
– Refers to the common diseases of the abdominal
cavity in children who require operative
intervention: are taken a third place after surgery
for acute appendicitis, congenital obstruction. For
a long time was the most frequent cause of
mortality in childhood.
– The reason can be some congenital malformations,
and the appearance of pathological factors that are
explained in the classification.
Classification of Acquired obstruction of bowel
•
Depending on the level: high and low.
•
According to character of the process: acute, chronic, chronic-recurrent.
•
According to a particular mechanism of pathogenesis: mechanical, functional,
strangulated, obstructive, obstructive-strangulated.
•
Mechanical: adhesive, intussusception (invagination of bowel), obstruction of the
lumen of the intestine hair ball, biliary, fecal stones, helminth ravel, compression by
external tumors, cysts, blood vessels and a Meckel`s diverticulum.
•
Dynamic obstruction: paralytic, spastic.
•
Intussusception (invagination of bowel):idiopathic on the basis of polyps, tumors,
Meckel's diverticulum.
Small intestine-small intestine, small intestine-large intestine (ileocecal), large
intestine-large intestine intussusception.
•
Adhesive obstruction: early (paretic, delayed), late (after one month from the date
of the surgery).
• The most common type of the late obstruction of bowel (80%) is an
adhesive intestinal obstruction.
• Depending on the severity of obstruction of bowel may be a
different symptomatic disease. Cramping abdominal pain, vomiting
with intestinal contents, bile, not passing of bowel gas and feces,
anxiety of the child, deterioration of general condition due to
dehydration - the main anamnestic information. Examination of a
patient shows that the patient changes position frequently, in some
cases is knee-elbow position. There are tachycardia, dry tongue,
decreased tissue turgor. At the beginning abdomen is moderately
swollen, soft, involved in breathing, occasionally can be observed
asymmetry of the abdomen. Intestine loops are visible on the front
wall of abdomen, peristalsis is reinforced, can be audible "noise of a
falling drop," "transfusion liquid", drum belly bowel noise
(tympanitis) above the extended Intestine loops. In the rectal
investigation is determined that rectum is inlarged and without fecal
content.
• later arise peritoneal symptoms: tension of the abdominal wall
and other symptoms of irritation of the peritoneum. Very
strong pain (even up to the development of collaptoid
condition) is observed at strangulated ileus in which the
abdomen is soft, painful at the place of a strangulation.
• Diagnosis is clarified by roentgenography in an upright
position (Kloyber`s cups), ultrasound (roentgenograms).
• In acute and subacute, chronic recurrent types of obstruction
initially is used conservative treatment for 8-12 hours [probe
into the stomach, hypertonic solution into the vein (10% NaCl,
2 ml per life-year, 0.05% Neostigmine 0.1 ml per year of life ,
during 30-40 min. siphon enema], which allows to cure
obstruction in 70-80% in patients. If this treatment is
inefficient in children with strangulated ileus, they must be
operated on urgently. A surgeon must eliminate the cause of
ileus, necrotic part of bowel must be removed with the next
creation of anastomosis of bowel if it`s possibly.
Intussusception
Intussusception is the implantation (intrusion) of a gut in to an its
part which is lying below
The components of the intussusception:
•deferent part of the intestine,
•a head of the intussusceptum,
•outer cylinder of the intussusceptum,
•neck of the intussusceptum,
•adducent part of the intestine.
A loop of bowel which was stacked in two cylinders (external and
internal) is named an intussusceptum.
A loop of bowel with intussusceptum is named a vagina of it.
Classification.
Small intestine-small intestine,
small intestine-large intestine (ileocecal),
large intestine-large intestine intussusception
Intussusception - a mixed form of intestinal obstruction:
obstructed, strangulated.
The intravascular hemolysis appears.
Serum is enriched of hemoglobin.
Increases the hydrostatic pressure.
Blood plasma is filtered from the blood in the mucous membrane of intestine.
The child has bloody stools appear dark cherry color.
Blood is not coagulated.
Age of children - 80% are children of first year of life, from 3 to 9 months.
Reasons
Functional:
in boys with a large mass of the body;
wrong feeding of children until one year old;
especially in age of 3-9 months.
Restriction (after 1 year)
Meckel's diverticulum;
Enlarging of lymphatic nodes;
Tumors of the intestine.
Forming Stages of intussusceptum:
hemafecia
determination of intussusceptum in palpation.
- Painful episodes lose sharpness;
- The child is lethargic, does not play, and is sleepy;
- Stomach is enlarged, but soft;
- Vomiting contains greenness and bile.
Stages of a desease:
Early symptoms can include nausea, vomiting (sometimes
bile stained (green color), pulling legs to the chest area, and
intermittent moderate to severe cramping abdominal pain. Pain is
intermittent not because the intussusception temporarily resolves,
but because the intussuscepted bowel segment transiently stops
contracting. Later signs include rectal bleeding, often with "red
currant jelly" stool (stool mixed with blood and mucus), and
lethargy. Physical examination may reveal a "sausage-shaped"
mass felt upon palpation of the abdomen.
In children or those too young to communicate their
symptoms verbally, they may cry, draw their knees up to their
chest or experience dyspnea (difficult or painful breathing) with
paroxysms of pain.
Fever is not a symptom of intussusception. However,
intussusception can cause a loop of bowel to become necrotic,
secondary to ischemia due to compression to arterial blood
supply. This leads to perforation and sepsis, which causes fever.
Bleeding in the child always causes great concern and
anxiety as in a parent and in physician. This syndrome is
observed in various diseases of the digestive tract, in different
age groups. The intensity of the bleeding depends on the extent
and amount of damage to blood vessels, coagulation status,
adequacy of remedial measures. The manifestation of bleeding
is determined by the level of bleeding vessels, the intensity of
blood loss.
Hemorrhagic disease of newborn due to insufficient
production of clotting factors in the liver appears the first days
after birth, less changed vomiting , unmodified blood or "coffee
grounds", black, tarry stools, pallor, weakness of the child.
Transfusion of plasma, blood, the introduction of Haemostatics
allows you to quickly arrest the bleeding.
In congenital pyloric stenosis, been vomiting with a
touch of "coffee grounds". Refinement of the diagnosis of
underlying disease and the implementation of treatment
eliminates this symptom.
Diagnosis
Intussusception is often suspected based on history and physical
exam, including observation of Dance's sign. Per rectal
examination is particularly helpful in children as part of the
intussusceptum may be felt by the finger. A definite diagnosis
often requires confirmation by diagnostic imaging modalities.
Ultrasound is today considered the imaging modality of choice
for diagnosis and exclusion of intussusception due to its high
accuracy and lack of radiation. A target-like mass, usually around
3 cm in diameter, confirms the diagnosis. An x-ray of the
abdomen may be indicated for evaluation of intestinal obstruction
or the presence of free intraperitoneal gas; the latter finding
would imply that bowel perforation has already occurred. In
some institutions, air enema is used for diagnosis as the same
procedure can be used for treatment.
Differential diagnosis
Intussusception has three main differential diagnoses. These are
acute gastroenteritis, Henoch–Schönlein purpura, and rectal
prolapse. Abdominal pain, vomiting, and stool with mucus and
blood are present in acute gastroenteritis, but diarrhea is the
leading symptom. Rectal prolapse can be differentiated by
projecting mucosa that can be felt in continuity with the
perianal skin, whereas in intussusception the finger may pass
indefinitely into the depth of sulcus. Henoch–Schönlein
purpura presents the characteristic rash.
Treatment
The condition is not usually immediately life-threatening. The
intussusception can be treated with either a barium or watersoluble contrast enema or an air-contrast enema, which both
confirms the diagnosis of intussusception, and in most cases
successfully reduces it. The success rate is over 80%. However,
approximately 5–10% of these recur within 24 hours
If it cannot be reduced by an enema or if the intestine is
damaged, then a surgical reduction is necessary. In a surgical
reduction, the abdomen is opened and the part that has
telescoped in is squeezed out (rather than pulled out) manually
by the surgeon or if the surgeon is unable to successfully reduce
it or the bowel is damaged, the affected section will be resected.
More often, the intussusception can be reduced by laparoscopy,
whereby the segments of intestine are pulled apart by forceps.
Prognosis
Intussusception may become a medical emergency if not treated
early, as it will eventually cause death if not reduced. In
developing countries where medical hospitals are not easily
accessible, especially when the occurrence of intussusception is
complicated with other problems, death becomes almost
inevitable. When intussusception or any other severe medical
problem is suspected, the person must be taken to a hospital
immediatelyThe outlook for intussusception is excellent when
treated quickly, but when untreated it can lead to death within 2–
5 days. Fast treatment is a necessity, because the longer the
intestine segment is prolapsed the longer it goes without
bloodflow, and the less effective a non-surgical reduction will be.
Prolonged intussusception also increases the likelihood of bowel
ischemia and necrosis, requiring surgical resection.
Doubling the various divisions of the intestinal tube is accompanied by a
noticeable or not admixture of blood in the stool, anemia and often detectable in
the I-II year of life. Depending on the level of doubling the blood in the stool has a
different color (from almost black to bright). Diagnosis of doubling is very
difficult, but very important an examination is laparoscopy.
Meckel's diverticulum is complicated by bleeding, most often manifested
by the end of the first - the second year of life by the sudden release of blood from
the anus of color "rotten cherries" moderate anxiety, decreased Hb, erythrocyte
count. Moderate pain in the right half of the abdomen, the characteristic color of
blood, ultrasound can clarify the diagnosis and to direct (after haemostatic
activities) on a surgery - removal of diverticulum.
Bleeding from the lower bowel from the colon polyps, ulcerative colitis
are characterized by constant bowel bleeding, the development of anemia. The
diagnosis confirmed by endoscopy. Individual polyps must be removed In total
damage of bowel treatment usually is very expensive, difficult and it doesn`t have
an exact positive result.
Portal hypertension
In medicine, portal hypertension is hypertension (high blood
pressure) in the portal vein and its tributaries.
It is often defined as a portal pressure gradient (the difference in
pressure between the portal vein and the hepatic veins) of 10 mmHg
or greater.
Causes
Causes can be divided into prehepatic, intrahepatic, and
posthepatic. Intrahepatic causes include liver cirrhosis, and hepatic
fibrosis (e.g. due to Wilson's disease, hemochromatosis, or congenital
fibrosis). Prehepatic causes include portal vein thrombosis or
congenital atresia. Posthepatic obstruction occurs at any level
between liver and right heart, including hepatic vein thrombosis,
inferior vena cava thrombosis, inferior vena cava congenital
malformation, and constrictive pericarditis.
Signs and symptoms
Consequences of portal hypertension are caused by blood
being forced down alternate channels by the increased resistance to
flow through the systemic venous system rather than the portal
system. They include:
•Ascites (free fluid in the peritoneal cavity).
•Hepatic encephalopathy.
•Increased risk of spontaneous bacterial peritonitis.
•Increased risk of hepatorenal syndrome.
•Splenomegaly (enlargement of the spleen) with consequent
sequestration therein of red blood cells, white blood cells, and
platelets, together leading to mild pancytopenia.
Portacaval anastomoses: Esophageal varices, gastric varices,
anorectal varices (not to be confused with hemorrhoids), and caput
medusae. Esophageal and gastric varices pose an ongoing risk of
life-threatening hemorrhage, with hematemesis or melena.
Splenomegaly in 4 month old baby with portal hypertension
Diagram of the portal system. BB - Vienna portae, СВ - splenic
Vienna, ВБВ - superior mesenteric Vienna, ЛЖВ - the left
gastric Vienna, НБВ - inferior mesenteric Vienna.
The scheme of portal blood flow in the extrahepatic portal
hypertension. ВБВ - superior mesenteric Vienna, ЛЖВ- the left
gastric Vienna, НБВ - inferior mesenteric Vienna.
Endoscopic picture of esophageal varices
Splenoportography. Portal hypertension.
Blackmore probe (top) and Foley catheter (bottom).
Surgery of devaskulyarisation of stomach and esophagus,
splenectomy (by Sugiura).
X-ray contrast examination of mesenteric vessels in a child
with extrahepatic portal hypertension.
Diagnostics
HVPG (hepatic venous pressure gradient) measurement has been accepted as the golds tandard
for assessing the severity of portal hypertension, and replaced the old one - contrast
angiography. Portal hypertension is defined as HVPG greater than 5mm Hg.
Treatment
Prophylaxis of variceal bleeding
Both pharmacological (B-blocker like Propranolol and isosorbide mononitrate) and endoscopic
(banding ligation) treatment have similar results. TIPS (transjugular intrahepatic portosystemic
shunting) is superior to either of them at reducing rate of rebleeding. Disadvantages of TIPS
include high cost and increased risk of hepatic encephalopathy, and it does not improve the
mortality rate.
Management of active variceal bleeding
After resuscitation, the management of active variceal bleeding includes administering vasoactive
drugs (somatostatin, octreotide or terlipressin), endoscopic banding ligation, balloon tamponade
and TIPS.
Management of ascites
This should be gradual to avoid sudden changes in systemic volume status which can precipitate
hepatic encephalopathy, renal failure and death. The management includes salt restriction,
diuretics (spironolactone), paracentesis, transjugula intrahepati portosystemic shunt (TIPS) and
peritoneovenous shunt.
Control of hepatic encephalopathy
This includes reduction of dietary protein, followed by lactulose and use of oral antibiotics.