Volvulus

Inversion of the bowels is a sudden perverted peristaltic movement of the intestinal wall, causing a mechanical impediment to the movement of the contents.

In fact - this is one of the types of intestinal obstruction. It accounts for up to 5%.

A selective study of isolated colonic obstruction showed up to 15%.At the same time, the feeding vessels and nerves are squeezed. As a result, necrosis of the entire affected area is formed, the intestinal wall is destroyed and through it the contents enter the abdominal cavity freely.

Localization and prevalence of

The greatest number of cases are found in people in old age. There is a risk in young women with pregnancy in the third trimester, when the sigmoid colon is shifted toward the growing uterus. The statistics of surgical departments indicate the maximum admission of patients from homes for the elderly and psychiatric hospitals.

By localization of inversion of the intestines revealed in adult patients:

• 80% accounted for the torsion of the sigmoid colon;
• about 15% - gives an anomaly of the caecum;
• up to 5% - other departments( more often in the transverse-rim zone, in the region of the splenic corner).

Multiple torsion possible. Children in the first place - the turn of the small intestine. On the causes and course of pathology in childhood, read this article.

What does it come from?

Causes of curvature of bowels are most often caused by abnormalities of development and a violation of the nervous regulation of contractility. Among congenital anomalies, anatomical discrepancies that increase the mobility of the intestines: lengthening of the mesentery, the absence of a ligamentous apparatus that fixes the intestine to the peritoneum, diverticula.

On the photo, Meckel's diverticulum in the small intestine zone

The acquired diseases include the effects of chronic diseases:

• adhesions between the intestines and internal organs;
• large tumors, cysts displacing the intestinal loops;
• cicatricial changes in the large intestine after inflammation, devoid of nerve endings;
• pathology of the spinal cord;
• taking medications that enhance peristalsis( saline and osmotic laxatives), psychotropic drugs.

Possible complication after colonoscopy procedure. Curvature of the intestines manifests itself in severe course of acute appendicitis, Hirschsprung disease, megacolon, disintegrating tumor, cystic fibrosis of the intestine. Often accompanies senile dementia, mental disorders, multiple sclerosis.

What features of the human body contribute to a twist?

To understand the mechanism of pathology, you need to pay attention to the anatomical structures that support the intestine in a moderately mobile state and provide peristalsis.

The loops of the intestines are "suspended" on the mesentery. This formation serves as a huge ligament, fixing the position of the intestine.

Most of the departments are limited mobility of the duodenum. In it, a wrench is almost impossible. Other loops are able to rotate 90 degrees without signs of obstruction. In the leaves of the mesentery, branches of the vessels and nerve trunks pass. From its condition depends the nutrition of the walls of the intestine and digestive organs, the timely receipt of a nerve impulse from the centers of the brain and spinal cord for the emergence of a wave of movements.

Peristalsis in the intestine occurs around the clock, activated after eating. The motor function not only ensures the transportation of the contents, but also mixes food with enzymes, juices, bacteria. This process allows you to actively absorb the necessary substances into the bloodstream.

Circular and longitudinal muscle fibers create a wave movement in one direction. The strength of peristalsis depends on the amount of food eaten: the more the loops are stretched, the more pronounced the wave of movement. Simultaneously, in the small intestine, 2-3 waves are formed. The large intestine is less active: there are 4 strong contractions in a day.

Revision of the intestine involves inspection of the mesentery condition

Predisposing factors

To the appearance of a bowel inversion,

• results in a sudden increase in intra-abdominal pressure as gravity rises;
• increased intestinal motility after a period of fasting( with pancreatitis, transplant operations, irrational diets);
• sharp overeating after fasting, use of unusual rough meat food;
• resistant locks;
• bowel descending.

Mechanism of formation of

Involvement of guts occurs in one area or in several places at once. Most often formed in the zone of the large intestine, rarely suffers from the small intestine. Twisting usually occurs at an angle of 90 to 180 degrees. There are 2 types of curls depending on the degree of torsion:

• partial - up to 270 degrees;
• full - from 270 to 360.

For sigmoid colon decisive is torsion around the longitudinal direction with an elongated mesentery. Curvature of the intestine is promoted by wrinkling of the mesentery with inflammation of the type of mesosigmoiditis. In this case, the intestinal loop receives an additional support point and folds in the form of a "double-barreled".When turning the blind and small intestine, the main importance is attached to the anomalies of mesentery development.

Failure of fixation factors and disruption of normal motor activity lead to the creation of a mechanical obstacle for the passage of intestinal contents, stagnation, infringement of vessels and nerves, and ischemia of the walls. At the first stage, peristalsis intensifies. Then paresis develops in the zone of the leading part of the intestine. The patient is necrotizing the wall, stopping movement of stool and gases through the intestine. Decay of tissues leads to severe peritonitis.

If the cause is an adhesion process, the obstruction in the sigmoid colon is formed gradually

Symptoms

The course of the disease and the symptomatology depend on the localization of the site of obstruction. Common signs: abdominal pain, swelling of the resulting loop with asymmetry of the abdominal form, gas retention and defecation, vomiting by calves, absence of irritation of the peritoneum.

The sign of the turn of the intestines is the palpable perezroduty bowel loop. Jogging motions cause "splashing noise".In patients due to persistent vomiting, a significant amount of fluid and electrolytes is lost. There is a tachycardia, an arrhythmia of cardiac contractions.

Curvature of the small intestine

The main clinical symptom is acute cramping pain, of considerable intensity, localized in the epigastric zone, around the navel, rarely below. At the same time, the patient experiences vomiting of food eaten. It is important that it does not decrease with time, but increases. Vomit appears cal. Intoxication increases. Peristalsis fades and is not tapped.

Torsion in the zone of the sigmoid colon

Pathology proceeds acutely or subacute. In an acute case - there are sudden cramping pains in the left part of the abdomen, vomiting, the condition quickly becomes heavy due to intoxication, shock. Peritonitis develops in a few hours. In subacute form - the deterioration of the patient comes in a few days. Pain sometimes disappears, bloating occurs later, the condition is tolerated more easily. Vomiting joins in the late stage.

Characteristics of diagnostic signs:

• in rectal examination reveal an empty expanded ampoule of the rectum;
• abdomen has oblique asymmetry;
• if you make an enema, the fluid quickly exits without stool.

Inversion in the ileocecal angle zone

Pathology is caused by two types of mechanism:

• strangulation - at the same time the blind and ileum is twisted around the mesentery;
• obturative - formed by turning the cecum around its own longitudinal axis or transversely.

Symptoms of intestinal obstruction are delayed up to 10 days. Then there is an attack of intense pain in the navel, vomiting increases. If at the beginning of the disease scanty fecal masses and gases departed, then later defecation and gas evolution cease. The palpable perargus is determined in the left side of the abdomen. On the right, emptiness is formed, since the cecum moves upward and toward the center.

Complications of

Pathology occurs with severe severe complications in the form of rupture of the intestine, fecal peritonitis, sepsis, hypovolemic shock due to fluid loss. With a longer subacute flow, one can form: cysts in the mesentery, stenosis of the intestinal loop, ascites.

Diagnosis

Suspicion occurs after a survey and examination of a patient with the listed symptoms. Confirm the diagnosis is assisted by radiographic examination of the abdominal organs with contrasting suspension of barium salt. If the sigmoid colon is involved in the curvature, on the roentgenogram, there is a redundant sigma with an upper border near the dome of the diaphragm.

Fluid levels in the upper and lower parts are necessarily observed. The curvature of the cecum is determined in the right side of the abdominal cavity. Here they find a round, swollen and wrinkled loop in which there is liquid. The width of the loop at the liquid level can reach up to 20 cm.

On the overview radiograph, with vertical position of the patient, the fluid levels in the large intestine are seen.

. At the X-ray picture of the twisting of the loops of the small intestine, several levels of liquid are visible against the background of the asleep final section. Passage of barium is delayed at the place of the curtain. In the large intestine, it is not found after 6-12 hours.

The method of irrigography is carried out by introducing contrast with the enema and subsequent radiographs. It shows, when the curvature is localized in the sigmoid colon, that it has a beak-like formation with an over-aroused loop above it. The direction of "beak" indicates the mechanism of twisting( clockwise or vice versa).

Irrigoscopy with blindness of the cecum delays the contrast in the middle zone of the ascending gut. The most reliable method is multislated spiral computed tomography. It allows you to see spiral torsion, thickened intestinal walls and altered mesentery. In laboratory tests on the appearance of necrotic changes in the wall of the intestine and their distribution indicate: the growth of leukocytosis and ESR.

With what diseases differentiate

Curvature is differentiated from the main pathology, which also causes obstruction. The group of similar diseases includes:

• diverticulosis;
• adhesion;
• tumors of the intestine( torsion of the sigmoid colon similar to the current on the cancer of the descending department);
• thromboembolism of the mesenteric artery with ischemia;
• acute appendicitis( with a turn of the caecum);
• attack of renal colic;
• colitis.

Women are necessarily examined by gynecologists to exclude the rupture of the ovarian cyst or apoplexy, ectopic pregnancy, swelling of the uterus, appendages.

Treatment of

The patient enters a dubious diagnosis in the gastroenterological or surgical department of the hospital. After confirming the curvature of the intestines, it must be transferred to surgery. It is possible to treat the disease only surgically.

Preparation for the operation is:

• in the decompression procedure - insertion of the probe through the nose, suction of stagnant contents and gases when turning the loops of the small intestine, if the pathology is located at the level of the sigmoid colon, do rheromomanoscopy or colonoscopy to introduce a thin flexible tube and discharge the intestine;
• massive intravenous infusion therapy to compensate for fluid loss, electrolytes, removal of intoxication;
• alkalizing blood with sodium bicarbonate solution;
• supports the level of protein, carbohydrates to provide the body with energy, plastic material.

Antibiotics are prescribed to prevent and treat peritonitis. The amount of surgical intervention depends on the patient's condition and the level of curvature. In the absence of necrosis, the surgeon tries to straighten the twisted loops, fix them to the mesentery. The presence of necrosis requires the removal( resection) of the damaged part of the intestine, in the small intestine, segmental resection is most often performed with the creation of an anastomosis between the ends or from the small intestine to the large intestine.

Intestinal stoma is connected to the

calorimeter. If peritonitis is found in the abdominal cavity, it is necessary initially to get rid of the inflammation of the peritoneum. Therefore, on the skin of the abdomen, the stoma is extracted, through which the stool masses leave. The final reconstructive surgery is performed after 3 months. During this time the patient's condition is stabilized, there is an opportunity to create an interstitial anastomosis.

Continues intravenous fluids, restoring electrolyte balance. Significant threat is the joining of the infection( interintestinal abscesses, fistulas, sepsis).Therefore, antibiotic therapy is prescribed.

Features of nutrition after operation

In the postoperative period, nutrition is carried out 1-2 days parenterally with special solutions containing a minimum of proteins, fats and carbohydrates. With a lack of protein there is a risk of divergence of the joints. The first day of drinking is forbidden, you can only moisten your lips with water.

On the second day, when the patient is in a stable condition, the doctor allows you to drink water, drink a portion of low-fat chicken broth, mucilage porridge without milk and sugar. On the third day, the patient is assigned a table number 1a, consisting of vegetable broth, mucous soups, jelly. After 5 days the diet is consistently expanded, the transition from table 1b to the first is carried out.

Catering requires restrictions:

• everything cooked steamed, boiled and grinded;
• each serving should not exceed 100 ml( half a cup);
• feeding takes place every 2.5 hours;
• in the diet requires protein of animal origin due to low-fat meat, chicken, cooked without spices;
• kefir and cottage cheese are allowed to be fat-free;
• wheat bread, dried, without crusts;
• fruit juices are bred in half with water( grapes, pears, sour apples, citrus fruits are forbidden);
• vegetables are served in a grated form, boiled( cabbage, turnip, radish are excluded);
• prohibited legumes, mushrooms, fat confectionery, yeast pastries.

Forecast

Since older patients are more likely to be operated on, the outcome of the treatment is affected by the overall condition of the patient, concomitant diseases. Mortality in case of late treatment( more than three days from the manifestation of the first symptoms) is 40%.In the postoperative period - 30%.In operated patients there are often complications, relapses.

Inversion of the intestines is a very dangerous pathology. It should be closely monitored by elderly patients receiving laxatives and psychotropic drugs. You can not overfeed a man in old age, let's eat too much fiber( vegetables and fruits).Provision of care means reasonable restrictions.