Author – reader R.Ya. Kushnir

LECTURE:Surgical diseases of large intestine and rectum. Acute intestinal obstruction. Hemorrhoids. Anal fissure. Rectal prolapse. Paraproctitis. Etiology, pathogenesis, clinic, diagnostic and treatment. • Author – reader R.Ya. Kushnir

Acute intestinal obstruction Intestinal obstruction is a complete or partial violation of passing of maintenance by the intestinal truct.

The principal reasons of intestinal obstruction 1) commissures of abdominal cavity after traumas, wounds, previous operations and inflammatory diseases of organs of abdominal cavity and pelvis; 2) long mesentery of small intestine or colon, that predetermines considerable mobility of their loops; 3) tumours of abdominal cavity and retroperitoneal space

Classification(by D.P.Chuhrienko, 1958) • Acute intestinal obstruction is divided: • I. According to morphofunctorial signs. • 1. Dynamic intestinal obstruction: • а) paralytic; • b) spastic; • c) hemostatic (embolic, thrombophlebitic).

Classification • 2. Mechanical intestinal obstruction: • а) strangulated, volvulus, jamming; • b) obturation (closing of bowel lumen, squeezing from outside); • c) mixed (invagination, spike intestinal obstruction). • II. According to clinical passing. • 1. Acute. • 2. Chronic.

Classification • III. According to the level of obstruction. • 1. Small intestinal. • 2. Large intestinal: • а) high; • б) low. • IV. According to the passing of intestinal maintenance. • 1. Complete. • 2. Partial.

Classification • V. According to the origin. • 1. Innate. • 2. Acquired. • VI. According to development of pathological process. • 1. Stage of acute violation of intestinal passage. • 2. Stage of hemodynamic disorders of bowel wall and its mesentery. • 3. Stage of peritonitis.

Clinical symptomes • The Vala’s symptom is the limited elastic sausage-shaped formation. • The Sklarov’s symptom is the noise of intestinal splash. • The Kywul's symptom is the clang above the exaggerated bowel. • The Schlange's symptom is the peristalsis of bowel, that arises after palpation of abdomen.

Clinical symptomes • The Spasokukotsky's symptom is ”noise of falling drop”. • The Hochenegg's symptom — incompletely closed anus in combination with balloon expansion of ampoule of rectum. • At survey roentgenoscopy or -graphy of the abdominal cavity in the loops of bowels liquids and gas are observed — the Klojber’s bowl.

Obturation obstruction

Diagnostic program • 1. Anamnesis and physical methods of examination (auscultation of abdomen, percussion and others like that). • 2. General analysis of blood, urines and biochemical blood test. • 3. Survey sciagraphy of organs of abdominal cavity. • 4. Coagulogramm. • 5. Electrocardiography. • 6. Irrigography.

X-ray films

Conservative treatment • 1. The measures directed for the fight against abdominal pain shock include conducting of neuroleptanalgesia, procaine paranephric block and introduction of spasmolytics. • 2. Liquidation of hypovolemia with correction of electrolyte, carbohydrate and albuminous exchanges is achieved by introduction of salt blood substitutes, 5–10 % solution of glucose, gelatinol, albumen and plasma of blood.

Conservative treatment • 3. Correction of hemodynamic indexes, microcirculation and disintoxication therapy is achieved by intravenous infusion of Reopolyhlukine and Neohemodes. • 4. Decompression of intestine truct is achieved by conducting of nasogastric drainage and washing of stomach, and also conducting of siphon enema.

Operative treatment. • 1. According to middle laparotomy executed the novocaine blockade of mesentery of small and large intestine and operative exploration of abdominal cavity organs during which the reason of intestinal obstruction and expose viability of intestine is set.

Operative treatment. • 2. Liquidation of reasons of obstruction. • 3. Intubation. • 4. Sanation and draining of abdominal cavity.

Hemorrhoids • Hemorrhoids from Greek mean bleeding. Nowadays hemorrhoids are volume increase or dilation of cavernous bodies in rectum.

Classification • Hemorrhoids by etiological signs are divided onto innate and acquired, by localization – internal (submucosal), external and mixed (combined). • By clinical course hemorrhoids are: acute and chronic, not complicated and complicated (thrombosis, strangulation of hemorrhoids). There also define primary and secondary hemorrhoids.

Hemorrhoids

Diagnostic program • Anamnesis and physical data. • Examination of anal region. • Finger investigation of rectum. • Examination of rectum by rectal mirror.

Diagnostic program • Rectoromanoscopia. • General analysis of blood and urine. • Coagulogram. • Sedimentation reactions (Reaction of Wassermann).

Conservative treatment • Medicamentous therapy includes prescription of anti bleeding remedies and analgetics, antiseptics, anti-inflammatory remedies (orally, intravenously and locally as rectal suppositoria). • They also use physiotherapeutic methods (UHF, darsonvalization), treating physical training for strengthening of abdominal muscles and diaphragm, pelvis, spa treatment (H2S baths, mud and radon sanatoria).

Indications for surgical treatment • frequent bleedings from hemorrhoidal nodes that are accompanied with anemia, big nodes that worsen defecationm inflammation, prolapse and strangulation of nodes. • There are known more than 30 methods of hemorrhoids’ extraction.

Rectal prolapse • Prortusion of the rectum through the anal orifice, may be partial or complete. • Partial: protrusion of mucosa and submucosa outside the anus for 1 – 4 cm. • Complete: full – thickness prolapse of the whole rectum, reaching up to 10 – 15 cm in length.

Clinical findings • Lax anal sphincter and perineal descent. Patient is asked to strain to find out the extent of prolapse. • Rectal examination and sigmoidoscopy will help to exclude other distal bowel pathology.

Clinical findings • Complications: • irreducibity; • ulceration; • bleeding; • strangulation; • or perforation of the bowel.

Conservative treatment • Conservative Elevation of the bed and application of a cold compress to reduce the oedema. Once oedema subsides, prolapse can be reduced by gentle manual compression.

Surgical treatment • Operative treatment The definitive treatment in surgery. • Partial prolapse can be treated by • submucosal injection of phenol; • excision of prolapsed mucosa; • circumferential wiring of the anus (in unfit patients). • Complete prolapse A surgical approach is needed. Operations are performed by the perineal or abdominal approach.

Author – reader R.Ya. Kushnir