Part or all of the intestinal contents can not flow normally and pass through the intestine smoothly, which is called intestinal obstruction and is one of the common acute abdomen in surgery. The following is my understanding of the clinical manifestations, treatment and nursing of intestinal obstruction. Welcome to reading.
The cause of disease
There are many reasons for intestinal obstruction. The causes of intestinal obstruction may be inflammation, tumor, adhesion, hernia, volvulus, intussusception, food block blockage and intestinal stenosis caused by external pressure. Paralytic intestinal obstruction, mesenteric vascular embolism and hypokalemia can also cause intestinal obstruction, and severe infection can also cause intestinal obstruction. 80% of large intestinal obstruction is caused by tumor, and most of them occur in sigmoid colon. Others include diverticulitis, ulcerative colitis and previous surgical history.
According to the etiology of intestinal obstruction, it can be divided into mechanical intestinal obstruction, neurogenic intestinal obstruction and vascular intestinal obstruction.
1. Mechanical intestinal obstruction
(1) Adhesion: It is the most common cause of large intestine and small intestine obstruction. Adhesion caused by surgery or unknown reasons, especially the stimulation of foreign bodies left over from surgery, will make the fibers and scar tissue form a band, which will exert external pressure on the intestinal cavity, or make the intestine adhere to other tissues, causing the intestine to become an angle, or even become the axis of intestinal volvulus, resulting in intestinal obstruction. On the basis of adhesive diseases, improper diet, strenuous exercise or sudden change of body position can all induce intestinal obstruction. Intestinal obstruction caused by adhesion accounts for 20 ~ 40% of all kinds of obstruction; Multiple adhesions increase the possibility of intestinal obstruction.
(2) Intestinal volvulus and intussusception: Intestinal volvulus is a closed intestinal obstruction formed by the rotation of a section of intestine along the long axis of mesentery, which is more common in intestinal volvulus caused by tumor or diverticulum inflammation, mostly in small intestine, followed by sigmoid colon. Torsion of the small intestine is more common in young people, and it is usually caused by strenuous exercise immediately after a full meal. Torsion of sigmoid colon is more common in male elderly, and constipation is common. Volvulus can cause intestinal strangulation and necrosis in a short time due to vascular compression, and the mortality rate is as high as 15 ~ 40%. Intussusception is the peristalsis and compression of proximal intestine to distal intestine caused by various reasons, which is common in infants and patients with colorectal cancer.
(3) Tumors: 80% of mechanical intestinal obstruction in large intestine is caused by tumors, which most often occurs in sigmoid colon. Because the tumor grows slowly and the large intestine cavity is wide, the course of intestinal obstruction is often induced or aggravated by fecal block blocking the obstruction site. Small intestinal obstruction is often the first symptom of small intestinal tumors. Although the small intestine cavity is narrow, there will be no obstruction in the early stage of the tumor because the contents of the small intestine are mostly liquid.
(4) Others: incarcerated hernia and strangulated hernia often cause intestinal obstruction due to blood supply obstruction and functional loss. In addition, congenital intestinal atresia, parasites (ascaris, etc. ), feces, stones, foreign bodies, etc. Can also cause intestinal obstruction.
2. Hemodynamic intestinal obstruction
Intestinal blood flow is supplied by celiac artery trunk and superior and inferior mesenteric arteries, and there are communicating branches at the head of pancreas and transverse colon. Obstruction of blood flow can lead to partial or complete obstruction. Complete intestinal obstruction is common in necrosis caused by mesenteric vascular embolus or embolism, and the mortality rate of acute patients is as high as 75%. Partial intestinal obstruction is seen in abdominal vascular ischemia, and arteriosclerosis is the most common cause.
3. Dynamic intestinal obstruction
Rarely does the intestinal wall itself have no lesions. The muscle function of intestinal wall is disordered due to nerve reflex or toxin stimulation, and intestinal contents can not pass normally, which can be divided into paralytic intestinal obstruction and spastic intestinal obstruction. Paralytic intestinal obstruction can be seen after operation. Peritoneal stimulation and sympathetic nervous system reaction make intestinal peristalsis disappear for more than 72 hours. Neurogenic problems are more likely to occur in major surgery or retroperitoneal surgery. In addition, hypokalemia, myocardial infarction and insufficient blood supply can also cause paralytic intestinal obstruction. Spastic intestinal obstruction is rare, which is caused by abnormal contraction of intestinal wall muscles and can be seen in acute enteritis or chronic lead poisoning.
In addition, intestinal obstruction can be divided into simple intestinal obstruction and strangulated intestinal obstruction according to whether there is blood supply disorder in intestinal wall. According to the location of obstruction, it can be divided into high-position (upper jejunum) and low-position (terminal ileum and colon) intestinal obstruction; According to the speed of obstruction, it can be divided into acute intestinal obstruction and chronic intestinal obstruction; According to the degree of obstruction, it can be divided into complete and incomplete intestinal obstruction; If both ends of an intestinal loop are completely blocked, such as volvulus, it is called closed loop intestinal obstruction.
physiopathology
The pathophysiological changes of various types of intestinal obstruction are not exactly the same.
1. Pathophysiological changes of intestine
When intestinal obstruction occurs, firstly, the intestinal peristalsis above the obstruction is aggravated, trying to overcome the obstacle of resistance channel; After several hours, the intestinal peristalsis weakened and the pressure in the intestinal cavity temporarily decreased. Obstruction leads to continuous gas accumulation and liquid accumulation in intestinal cavity. Gas accumulation mainly comes from swallowed gas, and part of it is produced by bacterial decomposition and fermentation of intestinal contents. Effusion mainly comes from gastrointestinal endocrine fluid. Under normal circumstances, the small intestine secretes 7-8L intestinal fluid, while the large intestine mainly secretes mucus. A large amount of pneumatosis and accumulated water cause the proximal intestine to expand and swell. Because the small intestine is narrow and active in peristalsis, this change occurs earlier, and the small intestine secretes a lot of intestinal fluid, which has more serious consequences.
With the prolongation and aggravation of the obstruction time, the pressure in the intestinal cavity increases continuously, and the intestinal wall is compressed, which leads to blood supply disorder. First, the venous return of the intestinal wall is blocked, and the intestinal wall is congested and edema, which is dark red; If the pressure is further increased and can not be relieved, the arterial blood flow in the intestinal wall is blocked, thrombosis occurs, the intestinal wall loses its luster and is dark black, and finally it is necrotic and perforated due to ischemia.
2. Systemic pathophysiological changes
When intestinal obstruction occurs, part of intestinal juice can not be reabsorbed and stays in the intestine, while part of it is excreted due to vomiting, which leads to a significant decrease in circulating blood volume, hypotension and hypovolemic shock in patients, and renal blood flow and cerebral blood flow also decrease accordingly. At the same time, due to the decrease of body fluids, the relative increase of blood cells and hemoglobin, blood viscosity, the incidence of vascular obstructive diseases increased, such as coronary heart disease, cerebrovascular disease, mesenteric embolism and so on.
Massive vomiting and intestinal fluid absorption disorder also lead to the loss of water and electrolytes. Patients with high intestinal obstruction lose a lot of gastric acid and chloride ions due to severe vomiting, while patients with low intestinal obstruction lose more sodium and potassium ions. Dehydration and hypoxia make acid metabolites increase sharply, and patients have serious water-electrolyte disorder and acid-base balance disorder.
The huge pressure caused by gas accumulation and liquid accumulation in the intestinal cavity weakens the absorption capacity of the intestine, reduces venous reflux, causes venous congestion, increases vascular permeability, and leads to the infiltration of body fluids from the intestinal wall into the intestinal cavity and abdominal cavity; At the same time, the permeability of intestinal wall increases, intestinal bacteria and toxins penetrate into abdominal cavity, and the retention of intestinal contents leads to bacterial reproduction and a large number of toxins, which can cause peritonitis, sepsis and even systemic infection.
In addition, intestinal cavity dilatation is the increase of intra-abdominal pressure, the increase of diaphragm and the decrease of abdominal breathing, which affects the gas exchange function of lung. At the same time, the reflux of inferior vena cava is blocked, which aggravates circulatory dysfunction.
clinical picture
1. Symptoms
The clinical manifestations of patients with intestinal obstruction depend on the location and scope of the affected intestine, the influence of obstruction on blood supply, whether the obstruction is complete, the causes of obstruction and many other factors, mainly including abdominal pain, vomiting, abdominal distension and stopping defecation and exhaust.
Abdominal pain has different manifestations in different types of intestinal obstruction. Simple mechanical intestinal obstruction, especially small intestinal obstruction, is characterized by typical, recurrent, rhythmic and paroxysmal colic. The cause of pain is that the intestine strengthens peristalsis and tries to push the intestinal contents through obstruction. The increasing abdominal distension is also one of the causes of pain. The pain site of small intestinal obstruction is generally in the upper abdomen and middle abdomen, and the pain site of colon obstruction is in the lower abdomen. When the interval of abdominal pain is shortened and the degree is aggravated, strangulated intestinal obstruction may occur, and then it will turn into persistent abdominal pain. Paralytic ileus is characterized by persistent swelling and pain.
Vomiting is often reflexive. The time and nature of vomiting are different according to the location of obstruction. In high intestinal obstruction, vomiting occurs early and frequently, and the vomit is mainly gastric juice, duodenal juice and bile. In the later stage, foul-smelling dark liquid appeared due to bacterial reproduction, suggesting that infection may increase. Vomiting in low intestinal obstruction occurs late, and the vomit is often smelly fecal juice. If the vomit is bloody or brown liquid, it often indicates that there is blood supply disorder in the intestine. Paralytic intestinal obstruction, vomiting and overflow.
Abdominal distension generally occurs later, and its degree is related to the obstruction site. Because of frequent vomiting, abdominal distension in high intestinal obstruction is not obvious; Low or paralytic intestinal obstruction has obvious abdominal distension, which is all over the abdomen. The main reason is that vomiting can't completely discharge the contents, which leads to gas accumulation, water accumulation, accumulation of contents, enlargement of intestinal cavity and obvious abdominal distension.
Stopping defecation and exhaust is one of the typical clinical symptoms of intestinal obstruction. However, in the early stage of obstruction, especially high intestinal obstruction, the feces and gas remaining in the intestine below the obstruction can still be discharged, so when there is a small amount of defecation in the early stage, intestinal obstruction cannot be denied. Strangulated intestinal obstruction can discharge bloody mucus-like stool.
Simple intestinal obstruction generally has no obvious change in the early stage, and dehydration signs such as dry mouth, sunken eye socket, poor skin elasticity and oliguria may appear in the late stage. Severe water shortage or strangulated intestinal obstruction may lead to shock signs such as accelerated pulse, decreased blood pressure, pale face and cold limbs.
2. Symbols
Visual diagnosis: simple mechanical intestinal obstruction often appears abdominal distension, intestinal type and peristalsis wave. Abdominal distension is asymmetric during volvulus, but even in paralytic intestinal obstruction. Palpation: Simple intestinal obstruction may have mild tenderness without peritoneal stimulation, strangulated intestinal obstruction may have fixed tenderness with peritoneal stimulation. Percussion: strangulated intestinal obstruction with exudation in abdominal cavity and movable dullness. Auscultation: if you smell the sound of water or metal, the bowel sounds will be excited, which is the performance of mechanical intestinal obstruction; Paralytic intestinal obstruction, bowel sounds weakened or disappeared.
accessory examination
1. Laboratory inspection
In the early stage of simple intestinal obstruction, the change is not obvious. With the development of the disease, due to water shortage and blood concentration, hemoglobin value and hematocrit increase. When strangulated intestinal obstruction occurs, there may be obvious white blood cell count and neutrophil increase. When electrolyte acid-base imbalance occurs, changes in blood sodium, potassium, chlorine and blood gas analysis values may occur.
2. X-ray inspection
Generally, intestinal obstruction occurs for 4 ~ 6 hours, and flatulent intestinal loops and most stepped liquid levels can be seen on X-ray plain films. Is jejunum flatulence visible? Fish ribs? Annular mucosal pattern. In strangulated intestinal obstruction, X-ray examination showed isolated, protruding and swollen intestinal loops, which did not change position with time.
3. Duodenal finger examination
Strangulated intestinal obstruction should be considered when there is blood on the finger cuff; If you feel a lump, it may be a rectal tumor.
Diagnostic points
The patient has abdominal pain, abdominal distension, vomiting, anal defecation stop, and corresponding systemic manifestations.
Abdominal X-ray examination showed intestinal gas loop expansion and gas-liquid plane.
Other auxiliary examinations support the relevant diagnosis, such as duodenal digital examination touching a mass, which may be a rectal tumor; Strangulated intestinal obstruction should be considered when there is blood on the finger cuff. Laboratory examination found dehydration, acid-base water-electrolyte disorder and other manifestations.
Handling principle
Remove obstruction and correct the systemic physiological disorder caused by obstruction.
(1) basic therapy
1. Gastrointestinal decompression
It is one of the important measures to treat intestinal obstruction. Through gastrointestinal decompression, the gas and liquid in the gastrointestinal tract are sucked out, thus reducing abdominal distension, reducing the pressure in the intestinal cavity, reducing bacteria and toxins in the intestinal cavity and improving the blood supply of the intestinal wall.
2. Correct the imbalance of water, electrolyte and acid-base.
According to vomiting and dehydration, urine volume, blood concentration, serum electrolyte value and blood gas analysis results, the amount and type of infusion are determined. People with intestinal obstruction for several days, high intestinal obstruction and frequent vomiting need potassium supplementation. When necessary, plasma, whole blood or plasma substitutes need to be infused to supplement the lost plasma and blood.
3. Prevention and treatment of infection
Use antibiotics to fight intestinal bacteria, prevent infection and reduce the production of toxins.
(2) Remove obstacles
Non-surgical treatment is suitable for simple adhesive intestinal obstruction, dynamic intestinal obstruction, intestinal obstruction caused by ascaris or fecal blockage. Basic therapy can make the intestine rest, relieve symptoms and avoid stimulating intestinal movement.
Surgical treatment is suitable for strangulated intestinal obstruction, tumor, intestinal obstruction caused by congenital intestinal malformation, and patients with intestinal obstruction who are ineffective in surgical treatment. The principle is to use the simplest method to relieve obstruction or restore the patency of intestinal cavity in the shortest time. Methods include adhesion release, intestinal incision to remove foreign bodies, intestinal resection and anastomosis, intestinal volvulus reduction, short circuit operation and enterostomy.
nurse
Nursing evaluation
1. Health history
The patient's age, infection, improper diet, overwork and other incentives, previous history of abdominal surgery and trauma, Crohn's disease, ulcerative colitis, colonic diverticulum, tumor and other medical history.
2. Physical state
The process of evaluating the temporal and dynamic changes of local and systemic signs.
Common nursing diagnosis/problems
(1) Abnormal tissue perfusion is related to the loss of body fluids caused by intestinal obstruction.
(2) Pain, which is related to intestinal contents not working normally or passing through intestinal obstacles.
(3) Comfort changes, abdominal distension and vomiting are related to intestinal cavity effusion and pneumatosis caused by intestinal obstruction.
(d) Lack of body fluids is related to vomiting, fasting, intestinal effusion and gastrointestinal decompression.
(five) electrolyte acid-base imbalance, intestinal cavity effusion, gastrointestinal fluid loss.
(six) potential complications, intestinal necrosis, abdominal infection, shock.
(7) Malnutrition below the body's requirement is related to fasting and vomiting.
Nursing goal
Maintain stable vital signs.
Relieve pain
Relieve abdominal distension and vomiting.
Maintain the acid-base balance of water electrolyte.
Prevention or timely detection of complications
Get enough nutrition.
Nursing measures
The treatment principle of intestinal obstruction is mainly to relieve obstruction and correct the systemic physiological disorder caused by obstruction. The specific treatment should be based on the type and location of intestinal obstruction and the general situation of patients.
(A) non-surgical treatment and nursing
1. Prescribed diet
Patients with intestinal obstruction should fast. If the obstruction is relieved, the patient can eat a liquid diet after the exhaustion, defecation, abdominal pain and abdominal distension disappear, and avoid sweets and milk that are easy to produce gas.
2. Gastrointestinal decompression
Gastrointestinal decompression is one of the important measures to treat intestinal obstruction. By connecting negative pressure, continuous gastrointestinal decompression can suck out the gas and liquid accumulated in the gastrointestinal tract, reduce abdominal distension, reduce the pressure in the intestinal cavity, improve the blood circulation of the intestinal wall, and help improve local and systemic conditions. Observe and record the color, nature and quantity of drainage fluid during gastrointestinal decompression. If bloody fluid is found, the possibility of strangulated intestinal obstruction should be considered.
Relieve pain
After confirming that there is no intestinal strangulation or paralysis, atropine anticholinergic drugs can be used to relieve gastrointestinal smooth muscle spasm and relieve abdominal pain. However, morphine painkillers should not be used at will, so as not to affect the observation of the disease.
4. Nursing care of vomiting
When vomiting, you should sit up or turn your head to one side, and clean up the vomit in your mouth in time to avoid aspiration of pneumonia or suffocation; Observe and record the color, character and quantity of vomit. Rinse your mouth after vomiting and keep your mouth clean.
5. Record the amount of liquid in and out.
Accurately record the amount of liquid input, at the same time record the amount of drainage, vomiting and excretion, urine volume of gastrointestinal drainage tube, and estimate the amount of sweating and breathing, so as to provide basis for clinical treatment.
6. Relieve bloating
In addition to gastrointestinal decompression, hot compress or massage the abdomen, acupuncture and moxibustion at bilateral Zusanli points; If there is no strangulated intestinal obstruction, paraffin oil can also be injected from the stomach tube, 20 ~ 30 ml each time, which can promote intestinal peristalsis.
7. Correct water-electrolyte disorder and acid-base imbalance.
Is an extremely important measure. The basic solution is glucose and isotonic saline. In severe cases, whole plasma or whole blood must be infused. The type and amount of infusion depend on vomiting, gastrointestinal decompression, signs of water shortage, urine volume and the results of serum sodium, potassium, anxiety and blood gas analysis.
8. Prevention and treatment of infection and toxemia
The application of antibiotics can prevent bacterial infection and reduce toxin production.
9. Closely observe the changes of the disease.
Regularly measure and record body temperature, pulse, respiration and blood pressure, and closely observe abdominal pain, bloating, vomiting and abdominal signs. If the patient's symptoms and signs are not improved or aggravated, the possibility of intestinal strangulation should be considered.
Strangulated intestinal obstruction may cause serious consequences, which must be found in time and treated as soon as possible. The clinical features of strangulated intestinal obstruction are:
Abdominal pain occurs suddenly, starting with persistent severe pain, or there is still persistent severe pain between paroxysmal aggravations, bowel sounds are not hyperactive, and vomiting occurs early, violently and frequently;
The condition develops rapidly, and shock appears in the early stage, and the improvement after anti-shock treatment is not significant;
There are obvious symptoms of peritoneal irritation, increased body temperature, increased pulse rate and increased white blood cell count;
Abdominal distension is asymmetric, and there are local bulges or tender masses in the abdomen;
Vomiting, gastrointestinal decompression extract, bloody anal discharge, or bloody liquid extracted by abdominal puncture;
After active non-surgical treatment, symptoms and signs did not improve significantly;
Abdominal x-ray, consistent with strangulated intestinal obstruction characteristics. These patients are in critical condition, and most of them are in shock. Once it happens, they need to make emergency preoperative preparations to buy time for rescuing patients.
(2) postoperative care
Observe the changes of illness and vital signs. Observe whether there is abdominal pain, bloating, vomiting and exhaust. If there is abdominal drainage, the color, nature and quantity of drainage fluid should be observed and recorded.
Body position and blood pressure are stable, and then the patient is given a semi-recumbent position.
Diet, postoperative fasting and rehydration should be carried out during fasting. After the intestinal peristalsis is restored and there is exhaust, a small amount of liquid can be started, and there is no discomfort after eating, and it will gradually transition to semi-liquid; The feeding time of intestinal anastomosis should be postponed appropriately.
Observation and nursing of postoperative complications, especially strangulated intestinal obstruction, such as abdominal pain, persistent fever, increased white blood cell count, red and swollen abdominal incision, and more malodorous liquid flowing out in the later stage, should be alert to the possibility of intra-abdominal infection and intestinal fistula and actively deal with it.
Nursing evaluation
(a) whether the vital signs are stable and whether the tissue perfusion is back to normal.
(2) Whether the pain is relieved.
(3) Whether the patient is comfortable, whether abdominal pain, abdominal distension and vomiting are relieved, and whether intestinal peristalsis returns to normal.
(four) whether to supplement enough liquid, dehydration or electrolyte acid-base imbalance is treated accordingly.
(five) whether the complications have been prevented or found in time.
(six) whether to take enough nutrition.
health education
(a) tell patients to pay attention to food hygiene, do not eat unclean food, and avoid overeating.
(2) Instruct patients to digest food easily after discharge and eat less irritating food; Avoid abdominal cold and strenuous activities after meals; Keep the stool unobstructed.
(3) The elderly constipation should take laxatives in time to keep the stool unobstructed.
(4) If you have abdominal pain and bloating, stop exhausting and defecating after discharge and see a doctor in time.
;