1. Acute intestinal obstruction. Peritonitis.
L. Yu. Ivashchuk

2. Intestinal obstruction is a complete or partial disturbance of intestinal evacuation and peristalsis resulting from various causes which manifests by specific clinical course and morphologic changes of involved part of the bowel
Intestinal obstruction occurs approximately in 9.4 % among urgent abdominal pathology, consisting 1.2 % of all surgical diseases.

3. Classification (by D.P.Chuhrienko)
1. Dynamic intestinal obstruction:
a) paralytic;
b) spastic.
2. Mechanical intestinal obstruction:
a) strangulation;
b) obturation;
c) mixed (invagination).
II. According to the course of pathological process.
1. Stage of acute disturbance of intestinal evacuation and peristalsis.
2. Stage of hemodynamic disorders of the bowel wall and its mesentery.
3. Stage of peritonitis.

4. Etiologic and contributing factors
Adhesions (50 %).
Tumours.
Bile stones.
Inflammatory infiltrates in the abdominal cavity.
Internal hernias.
Increasing of abdominal pressure.
Defects of the peritoneum.
Long mesentery of the bowel.

5. Pathogenesis Vomiting Intestinal block
Transudation of intestinal juice
Vomiting
Intestinal block
Accumulation of intestinal contents
Distention of intestinal wall
Loss of electrolytes, dehydratation, loss of potassium, loss of proteins
Necrosis of the bowel
Peritonitis
Intoxication, hemodynamic disturbances
More higher the obstruction, more severe the pathologic changes

6. Pathogenesis

7. Peculiarities of strangulated intestinal obstruction
Transfusion of large quantity of proteins;
Transfusion of erythrocytes and decreasing of volume of circulating blood;
Severe dehydratation, caused by additional edema of the bowel wall;
Rapid necrosis of intestinal wall with subsequent peritonitis and intoxication.

8. Clinical manifestation
It depends on the level of the block, type and degree of obstruction and its cause.
1. Acute onset of the disease.
2. Periodic acute diffuse pain of wavelike character which results in shock.
3. Constant vomiting and nausea without any relief.
4. Signs of dehydratation and intoxication (The patient looks anxious, with drawn features, hollowed-eyed, his lips and tongue are dry, with brown fur).
5. Retention of stool and gases.

9. Objective examination
1. Signs of shock.
2. Distended and asymmetric abdomen.
3. Splashing sound (Sklyarov’s sign).
4. Increased peristalsis in early period with further absence.
5. Wahl’s sign - high tympanic sound over the distended bowel.
6. PR: empty and distended anus and rectal ampoule - (Grekov’s sign).
7. In intestinal strangulation and advanced cases of obstruction - peritoneal signs.

10. X-ray examination 1. Kloiber's cups (air-fluid level)
2. Intestinal pneumatisation

13. Differential diagnostics of acute intestinal obstruction with perforative peptic ulcer
Sharp acute diffuse pain
Ulcerative anamnesis
Absence of hepatic dullness
On X-ray of the abdomen air above the liver (air sickle)
Rigidity of anterior abdominal wall
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

14. Differential diagnostics of acute intestinal obstruction with acute pancreatitis
Sharp acute constant girdle pain with irradiation into left scapule
Vomiting and nausea without any relief
Mayo-Robson symptom
Increased serum amylase
Increased urinary diastase
No retention of stool and gases
Abdominal distension only in advanced cases.
No increased peristalsis
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

15. Differential diagnostics of acute intestinal obstruction with mesenteric thrombosis
Sharp acute constant pain which results in shock
Abdominal distension.
Decreased peristalsis
Blood stool
Concomitant cardiac pathology
Peritoneal signs
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

16. Differential diagnostics of acute intestinal obstruction with acute cholecystitis
Acute pain in a right hypohondrium with irradiation to the scapula
Muscular tenderness in a right hypohondrium
Vomiting by bile and nausea without any relief
Ortner's symptom, phrenic symptom, Murphy’s sign
Increased serum bilirubin
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

17. Conservative treatment
Conservative treatment is indicated only in:
1. Adhesive obstruction without signs of strangulation.
2. Initial stages of invagination.
3. Initial stages of low obturation
Gastric decompression
Siphon enema
Paranephral procaine block
Ganglio- and sympatholytics
Correction of water-electrolyte balance

18. Surgical treatment
is indicated only if no improvement during 3-4 hours of conservative treatment
Wide laparotomy
Procaine block of mesenteric root
Revision of intestine and detecting of the level and cause of obstruction
Decompression of intestine proximal to the obstruction
Assessing of viability of the bowel (peristalsis, colour, vascular pulsation)
Removal of the obstruction (division of adhesions, intestinal resection, collateral anastomosis)
External drainage of intestine (nasogastrointestinal intubation, rectal tube)

20. Strangulation intestinal obstruction
1. Volvulus, (torsion).
2. Nodulus (knots).
3. Hernial strangulation (incarceration).
4.Invagination (refers to mixed forms of intestinal obstruction)
Causes
Elongation of intestinal loop.
Increasing of abdominal pressure.
Long mesentery of the bowel.
Cicatrical shortening of mesenteric root.
Adhesions
Extensive functional overload of the bowel.

21. Volvulus (torsion) Small intestine volvulus
Clinically manifests by high strangulation intestinal obstruction
Cecal volvulus, sigmoid volvulus
Clinically: low strangulation intestinal obstruction
asymmetric abdomen
by palpation enlarged and displaced colon (like balloon)
retracted right or left iliac region
Treatment: detorsion, division of adhesions, cecopexia, colon resection

23. Nodulus
It is the most severe type of strangulation with manifestation of a high strangulated obstruction which rapidly results in shock, bowel necrosis and peritonitis
Treatment:
very short preoperative period (less 1 hour)
untie of the bowel node (till 4-5 hours from the onset)
resection of the bowel

24. Invagination
It is the insertion of one part of the bowel into the lumen of another
Clinically:
signs of obturation and in advanced cases the strangulation ileus
elastic, painful, tumourlike formation in the abdomen
blood in stool (or during rectal examination)
Treatment:
desinvagination or resection

26. Paralytic ileus Abdominal Other Retroperitoneal peritonitis
mesenteric thromboses
hemoperitoneum
pancreatitis
postoperative ileus
Retroperitoneal
phlegmone
hematoma
renal colic
spinal trauma
Other
cranial trauma
acidosis
diminished potassium
hypoproteinemia
uremia

27. Spastic ileus Abdominal Other Retroperitoneal hepatic colic
ascaridosis
Retroperitoneal
renal colic
Other
lead poisonong

28. Treatment of dynamic ileus
1. Cholynomymetics (Proserin, ubretid).
2. Intravenous infusion of hypertonic solution (10 % NaCl).
3. Hypertonic enema.
4. Oil enema.
5. Gastric decompression.
6. Paranephral novocaine block.
7. Ultrasound stimulation.

29. ACUTE PERITONITIS

30. Peritonitis – is the acute or chronic peritoneal inflammation with characteristic local and general changes in the organism and severe dysfunction of vital organs
Acute peritonitis complicates approximately % of all “clear” operations, and 20 % of all inflammatory pathology of the abdominal cavity.
Mortality rate of peritonitis rises to %.

31. ETIOLOGY As the complication of surgical pathology Primary peritonitis
Appendicitis – 50 %
Cholecystitis – 16 %
Perforation of gastric ulcer and cancer – 7 %
Pancreatitis – 6 %
Mesenteric thrombosis – 6 %
Colon cancer – 2 %
Postoperative peritonitis – 13 %
Primary peritonitis
Tuberculosis, canceromatosis, pneumonia, streptococcal infection, gonorrhea
Toxico-chemical aseptic peritonitis
Blood, urine, bile, pancreatic juice

32. CLASSIFICATION According to the extension of inflammatory process:
Local – involvement of 1 anatomic area,
Diffuse – involvement of 3-6 anatomic area,
Generalized – involvement of all peritoneum.
According to the character of the exudate: serous, fibrinous, fibrino-purulent, purulent, hemorrhagic, septic.
According to the stages:
Reactive (first 24 hours) maximal manifestation of local signs of the disease;
Toxic (24-72 hours) – gradual reducing of local signs and increasing of general intoxication.
Terminal (after 72 hours) – severe, often unreversable intoxication with vital function decompensation.

34. PATHOGENESIS Pathogenic microorganisms Intoxication Hypovolemia
Disfunction of vital organs

35. PATHOGENESIS Reactive stage Toxic stage Terminal stage
Exsudation
Reabsorption of the microorganisms and toxins
Bacterial contamination
Inflammatory reaction of the peritoneum
Disturbances of vital organ function, polyorganic insufficiency
Hypovolemia, disturbances of water-electrolytic and protein balance
Toxic and hypovolemic shock
Intoxication
Paralytic ileus
Reactive stage
Toxic stage
Terminal stage

36. CLINICAL MANIFESTATIONS
Reactive stage
Sharp intensive pain.
Forced patient's position in bed.
Tachycardia /min.
Dryness of tongue.
Abdominal tension over the site of inflammatory process or desk-like abdomen.
Peritoneal signs (Blumberg’s sign)
Decrease of peristalsis
X-ray examination could reveal pneumoperitoneum, Kloiber's cups, intestinal pneumatisation, pleurisy, lung atelectases

37. CLINICAL MANIFESTATIONS
Toxic stage
Decrease of pain.
Intensive vomiting.
Positive peritoneal signs (Blumberg’s sign)
Decrease of abdominal tension, abdominal distension.
Absence of peristalsis, paralytic ileus.
Tachycardia >120 /min.
Hypotonia.
Tachypnea.
Increase of body t° (> 38° C).
Dry tongue (like a brush).
Euphoria.

38. CLINICAL MANIFESTATIONS
Terminal stage
Disturbanses of CNS (adynamia, euphoria, psychomotoric excitement).
Facies Hyppocratica (prostration, face with drawn features, hollowed eyes).
Anuria.
Shallow breathing.
Fecal vomiting, absence of peristalsis, abdominal distension paralytic ileus.
Positive peritoneal signs (Blumberg’s sign).
Thread-like pulse (impossible to count), hypotonia.
Cardiac arrhythmia, cardiac failure.
Disturbanses of blood coagulation.

39. Differential diagnostics
Signs
Abdominal (peritoneal)
Thoracoabdominal
Pulmonary, pleural
Cardiac
Onset of the disease
Gradual in inflammatory processes, sudden in perforation, trauma
Gradual
Sudden
Anamnesis
The disease begins from the pain in abdominal region
Often previous cold factor
Cardiac pathology In anamnesis
Pain in the abdomen
Appears suddenly, permanent, increases during cough, accompanied by vomiting
Appears gradually, permanent, diffuse, considerably increases during deep breathing
Appears gradually, diffuse, increases during physical loading
Face
Pale, with drawn features and hollowed eyes
Hyperemic, cyanosis
Acrocyanosis, fear in eyes
Pulse
Frequent, weak
Full, tachycardia in relation to the body temperature
Weak, often arrhythmia
Tongue, lips
Dry, coated tongue
Moist tongue, lips are cyanotic, with herpes
Moist tongue

40. Differential diagnostics
Signs
Abdominal (peritoneal)
Thoracoabdominal
Pulmonary, pleural
Cardiac
Abdominal palpation
Painful, during deep palpation pain increases
Painful, pain increases during superficial palpation
Slightly painful, during deep palpation pain does not increase
Tension of abdominal wall
Marked expressed, especially in the site of the source of peritonitis
Expressed in the upper parts of the abdomen
Slightly expressed or absent
Blumberg’s sign
Positive
Negative
Intestinal peristalsis
Diminished, then disappears
Not changed
Dynamics of peritoneal signs
Progress
Regress
X-ray of the chest
Pathological changes are absent
Signs of pneumonia, pleurisy
ECG
Without changes
Substantial changes

41. Postoperative peritonitis
Signs
Noncomplicated postoperative period
Postoperative peritonitis
General condition
Improves to 3-4th day
Worsening to 3-4th day
Pulse
Normal to 3-4th day
Rapid pulse, not related to t°
Body t°
Increased all the time
Abdominal distension
Appears to 3-4th day and relief after the enema, flatus tube
Progressively increases, enema and flatus tube inefficient
Peristalsis
Restores
Absence of peristalsis
Abdominal pain
Disappears on 1st-2nd day
Progressively increases
Abdominal tension
Disappears to 3-4th day

42. Postoperative peritonitis
Signs
Noncomplicated postoperative period
Postoperative peritonitis
Tongue
Cleans and wet to 2-3rd day
Dry and coated all the time
Thirst
Disappears after infusion therapy
Increases despite adequate infusion therapy
Stool evacuation
Appears to 5-6th day
Absent
Nausea
Not typical
Typical
Vomiting
Arterial pressure
Correspond with preoperative
Hypotonia
Diuresis
Normal
Decreased

43. TREATMENT
Peritonitis is the absolute indication for the operative treatment
Tasks:
Removal of the source of inflammation
Evacuation of the exsudate and fibrin
Washing of the abdominal cavity
Satisfactory draining of the abdominal cavity

44. Surgical treatment Medial laparotomy Depending on the cause:
append- or cholecystectomy
suturing of perforative ulcer
resection of the colon with colostomy
reinforcement of anastomosis suture
Sanation and washing of the abdominal cavity
Intestinal intubation
Procaine block of mesenteric root
Drainage of the abdominal cavity, peritoneal lavage

47. Pre- and postoperative treatment
Antibacterial therapy, anti-inflammatory therapy
Correction of blood rrheology
Immunocorrection
Correction of water-electrolyte and protein balance
Desintoxication
Renewal of peristalsis
Correction of cardiac activity and breathing
Parenteral nutrition

48. Subdiaphragmatic abscess
Causes:
Surgical operations (operations for stomach cancer and ulcer, pancreatic resections, operations for stomach peritonitis and intestinal obstruction, splenectomy)
Abdominal trauma (hematoma, bile accumulation)
Purulent processes of the organism (paranefritis, liver abscess, pleural empyema)
Classification:
Left-, rightside, bilateral
Intra-, exraperitoneal

49. Subdiaphragmatic abscess
Clinical manifestation:
Intensive pain in upper part of the abdomen
Phrenicus-sign
Hectic temperature
Intoxication
Restriction of breathing, paradox breathing

50. Diagnostic: X-ray of the abdomen and chest Ultrasound examination
CT scanning

52. Pelvic abscess Causes: Appendicitis Perforation of colon diverticula
Residual peritonitis
Purulent gynecologic complications

53. Pelvic abscess
Clinic of irritation of pelvic organs (dysuria, pulling rectal pain, tenesmi).
Pain in the lower abdomen.
Painfullness of anterior rectal wall and posterior vaginal vault.
Intoxication

54. Interintestinal abscess
Causes:
Surgical operations
Residual peritonitis
Manifestation:
Intensive pain in the abdomen
Peritoneal signs
Relapse of inflammatory manifestation
Hectic temperature
Intoxication
Restriction of breathing, paradox breathing

55. TREATMENT
Abdominal abscesses are the absolute for the operative treatment: drainage of the abscess
Tasks:
Preference of extraperitoneal access
Evacuation of the pus and washing of the abscess cavity
Drainage of the abscess cavity