INTESTINES

From Big Medical Encyclopedia

INTESTINES (intestinum) — the greatest part of the digestive canal which is beginning from a pylorus and coming to an end with an anal orifice. It is body, in Krom there is a digestion of food, its absorption and removal of the formed slags.

EMBRYOLOGY AND COMPARATIVE ANATOMY

Embryology

Fig. 1. Embryonic development of digestive tract: and — formation of an umbilical loop (it is specified by an arrow); — the beginning of turn of an umbilical loop; in — continuation of turn; — lengthening of a small bowel; formation of a caecum; d — final position of intestines; the dotted line designated a projection of a liver.

On the 3rd week of embryonic development primary gut consisting of two layers is formed: internal — from an entoderm and outside — from a visceral mesoderm. At the end of the 4th week of development To. it is generally presented to average (mesenteron) and back (metenteron) by primary gut (duodenum partially develops from a front gut) and stretches from a stomach to a foul place. To. in this stage lies along an axis of a body parallel to the developing neurotubule and has two primary mesenteries: front — ventral and back — dorsal, formed by transition of a visceral mesoderm from an intestinal tube to a somatic mesoderm. By the end of the 4th week of development the front mesentery disappears throughout To. On the 5th week of development growth is observed To. and its lengthening therefore the bend — an umbilical loop (ansa umbilicalis intestini) turned by a convex part forward is formed. The vitelline pedicle (caulis vitellinus) going to a navel is connected with a top of an umbilical loop. Of an upper part of an umbilical loop further are formed the most part of a duodenum, lean and almost all ileal gut, of a top of a loop — final department of an ileal gut, of the bottom — all large intestine (fig. 1). In the next weeks development (7 — the 10th) the strengthened growth in length of a proximal part of an umbilical loop therefore the dorsal mesentery is extended is noted and the turn of a loop is made in such a way that its lower part is in front from extended upper. Primary caecum at the same time is in front under a liver, and mesenteries upper y the lower umbilical loop of parts cross. The vitelline pedicle which is attached to a gut a little proksimalny from a zone of transition of a small bowel in thick is reduced further. However in certain cases it does not disappear and remains for the rest of life in the form of an ileal diverticulum (diverticulum ilei, s. Meckeli). In later stages of development (11 — the 17th week) there is a growth of a distal part of a loop, the caecum falls to the right ileal pole, are formed colonic (ascending, cross, descending and sigmoid) and a rectum. Owing to a decussation of fillet the duodenum appears the abdominal cavity displaced to a back wall. It loses a mesentery (except for initial department), plunges under a parietal peritoneum, holding ekstraperitonealny position. Similar processes of immersion under a parietal layer of a peritoneum happen to the ascending and descending colon. Their mesenteries after turn appear at a back abdominal wall and prilezhat to a parietal layer of a peritoneum. Mesenteries merge with a peritoneum, and both departments of a colon receive mesoperitoneal situation. The mesentery at cross and sigmoid colonic guts remains. On 7 — various types of epithelial cells are differentiated 9th week of development, on 10 — the 11th — forms intestinal fibers and crypts, on And — the 12th — circular folds. Smooth muscular tissue appears on 7 — 8th week (a circular layer) and on 8 — the 9th (a longitudinal layer). The muscular coat of a large intestine forms later (3 — the 4th month of development). On the 5th month of development in a gut follicles appear limf.

Disturbances of an embryogenesis cause inborn malformations To.

The comparative anatomy

Existence of three departments of a gut — front, average and back — is noted already at worms. V K. vertebrata were always distinguished by the specified three departments though degree of complexity of their structure at different animals is not identical. At fishes and amphibians the average gut small, almost direct is also not divided into parts. Cartilaginous fishes for the first time have intestinal glands. The back gut is also short and rectilinear. In its initial part there is a small shoot — a rudiment of a caecum. At reptiles the average gut forms bends, its division into a small and large intestine is planned. In a mucous membrane lymphoid educations in the form of group limf, follicles are defined. The back gut is longer and wider, a caecum in the form of an outgrowth. At birds the average gut long, forms loops; the duodenum rich with intestinal glands and covering a pancreas is well visible. The back gut is more developed, in it there are glands, between an average and back gut there can be a klapanopodobny device, the caecum is well developed. At mammals, and especially at primacies, To. receives most expressed functionally caused difficult design.

ANATOMY AND TOPOGRAPHICAL ANATOMY

Fig. 2. Diagrammatic representation of position of abdominal organs: 1 — a liver; 2 — a gall bladder; 3 — a stomach; 4 — a spleen; 5 — a duodenum; 6 — a jejunum; 7 — an ileal gut; 8 — a caecum with a worm-shaped shoot; 9 — the ascending colon; 10 — a cross colon; 11 — the descending colon; 12 — a sigmoid gut; 13 — a rectum.

Taking into account anatomo-funkts. features To. it is divided into a small bowel (intestinum tenue) and a large intestine (intestinum crassum). Topografo-anatomichesky relationship of abdominal organs is presented in the figure 2.

The small bowel

the Small bowel begins from a stomach and, forming a set of loop-shaped bends, falls into a large intestine. Length of a small bowel at a corpse fluctuates from 4 to 11 m, on average 5 — 7 m. At living people it is shorter — on average than 4,5 m, and women have length of a small bowel less, than at men. Diameter of a small bowel in a proximal part reaches 50 mm and decreases to 30 mm in a final part. Depending on features of a structure, situation and development the small bowel is divided into 3 departments passing each other: duodenum (duodenum), jejunum (jejunum) and ileal gut (ileum). The border between a lean and ileal gut is absent, and the signs distinguishing both guts change gradually on nek-rum an extent. Both departments are mobile and have mesentery (see). Therefore they are called a mesenteric gut (intestinum mesenteriale). It is considered to be that 2/5 mesenteric guts belong to lean, and 3/5 — to an ileal gut. Duodenum (see) differs on anatomo-topographical and funkts, to features. An initial part of a jejunum is slow-moving owing to fixing of a duodenal and jejunal bend and existence of a short mesentery. The gut forms a set of the loops having considerable mobility owing to what their situation is extremely changeable.

Fig. 3. Diagrammatic representation of a structure of a wall of a small bowel: and — a jejunum (1 — circular folds of a mucous membrane; 2 — a serous cover; 3 — uncovered a serous cover a part of a muscular coat; 4 — a mesentery); — an ileal gut (1 — a single lymphatic follicle; 2 — group lymphatic follicles; 3 — a circular fold; 4 — a mesentery).

Wall of a small bowel (fig. 3) consists of a mucous membrane (tunica mucosa), a submucosa (tela submucosa), a muscular coat (tunica muscularis), serous cover (tunica serosa). The mucosal surface of a cover has a characteristic velvety relief at the expense of circular folds, intestinal fibers and intestinal crypts (glands), specific to a small bowel. Circular (kerkringova) folds (plicae circulares, PNA, JNA; plicae circulares Kerkringi, BNA), formed by a mucous membrane and a submucosa, are located perpendicularly to an axis of a gut and borrow 1/2 — 2/3 its perimeters. Length of folds reaches 5 cm, height — 8 mm. Total quantity of folds 650 — 700. The largest of them are in an initial third of a jejunum, and distalny the sizes and quantity of folds decrease.

In the first half of an ileal gut of a fold are flattened, become rare, and the final department of this gut is absent.

Intestinal fibers (villi intestinales) are finger-shaped or leaflike protrusions of a mucous membrane, however without submucosa. In a jejunum of a fiber the longest (to 1,2 mm) and them there is a lot of (30 — 40 on 1 mm2), in an ileal gut they are shorter (to 0,6 mm) and are located more seldom (20 — 30 by 1 mm 2 ). Intestinal crypts [gll. intestinales, PNA; gll. intestinales (Lieberkuehni), BNA; cryptae (glandulae) intestinales, LNH] contrary to fibers represent tubular deepenings of an epithelium in a mucous membrane to its muscular plate. In own layer of a mucous membrane there are accumulations limf, the fabrics forming single (folliculi lymphathici solitarii) and group (folliculi lymphathici aggregati) limf, follicles (a peyerova of a plaque). Single follicles to dia. 0,5 — 3 mm are distributed on all length of a small bowel, and the quantity them increases in lower parts of a small bowel. Group follicles — large accumulations of an adenoid tissue from 2 to 12 mm long, width — 1 — 3 cm, as a rule, are located in a mucous membrane of an ileal gut opposite to the place of an attachment of a mesentery (fig. 3,6). The quantity them is unequal in various age groups: at children up to 10 years — apprx. 50, at adults — to 30, at old men — 10 — 15. The submucosa of a gut consists of friable not properly executed connecting fabric owing to what movement of a mucous membrane and education temporary funkts, its folds is possible.

Fig. 4. The scheme of the spiral course (it is specified by shooters) fibers of a muscular coat of a small bowel.

Muscular coat it is presented by two layers of smooth muscle fibers: longitudinal (stratum longitudinale) and circular (stratum circulare). Bunches of smooth muscle fibers in both layers are oriented not strictly longwise or cross, and is turbinal with various deviation of a spiral turn (fig. 4).

Serous cover is available throughout a lean and ileal gut, except for the place of transition of a visceral peritoneum from a gut to a mesentery where there is a narrow strip of a gut which is not covered with a peritoneum (pars nuda).

Fig. 5. The diagrammatic representation of provision of loops of a small bowel at the lifted big epiploon: 1 — a big epiploon; 2 — a jejunum; 3 — an ileal gut; 4 — a caecum; 5 — the ascending colon; 6 — a cross colon; 7 — the descending colon; 8 — a sigmoid colon.
Fig. 6. The diagrammatic representation of position of a large intestine (loops of a small bowel are removed): 1 — a mesentery of a colon; 2 — a spleen; 3 — a duodenum; 4 — a dvenadtsatiperstnotoshchy bend; 5 — a root of a mesentery; 6 — an ileal gut; 7 — a mesentery of a worm-shaped shoot; 8 — a worm-shaped shoot; 9 — a caecum; 10 — the ascending colon; 11 — gaustra; 12 — the right bend of a colon; 13 — omental shoots; 14 — a free tape; 15 — a cross colon; 16 — the left bend of a colon; 17 — the descending colon; 18 — a sigmoid colon; 19 — a mesentery of a sigmoid gut; 20 — intersigmoid deepening; 21 — a rectum; 22 — a bladder

Topography of a small bowel

Loops of a jejunum lie hl. obr. from above and at the left (according to epigastriß area) and in the middle of an abdominal cavity (according to umbilical area); loops ileal — on the right and from below, it is frequent in a small basin (fig. 5). The provision of loops To. and the direction of the line of an attachment of a root of a mesentery are connected with features of a constitution. Usually the root of a mesentery goes obliquely at the left and from top to down and to the right from the level of a half of a body L2 to the right sacroiliac joint. According to D. N. Lubotsky, at his projection to a front abdominal wall the root of a mesentery lies on the straight line connecting a top of the left axillary hollow to the middle of the right inguinal sheaf.

The large intestine

the Large intestine continues thin and stretches from an ileocecal corner to an anal orifice (see. Anus ). The large intestine (fig. 6) forms protrusion in the beginning — caecum (see) with appendix (see), then surrounds a small bowel, passing in sigmoid gut (see) and in a small basin in a final piece — rectum (see). According to position of a large intestine in it allocate 6 parts: a caecum (cecum), the ascending colon (colon ascendens), a cross colon (colon transversum), the descending colon (colon descendens), a sigmoid colon (colon sigmoideum), a rectum (rectum). Places of transition of the ascending colon in cross and cross — in descending colonic are designated as bends of a colon — right, or hepatic (flexura coli dext., PNA, BNA; flexura coli hepatica, JNA), and left, or splenic (flexura coli sin., PNA, BNA; flexura coli lienalis, JNA). B of communication with nek-ry anatomo-morfol. and funkts, the caecum and a rectum are described by features separately. Other parts of a large intestine combine under the name «colon». Length of a large intestine varies from 110 to 215 cm. Its average length is 1,5 m. At women the large intestine is 5 — 10 cm shorter, than at men. At the living person at rentgenol, a research a little smaller length of a colon — 1,2 — 1,5 m is defined. Diameter of a large intestine makes 7 — 14 cm in initial department and gradually decreases in the caudal direction — to 4 — 6 cm. By outward the large intestine differs from thin in three anatomic educations: tapes of a colon, gaustrama, omental shoots. Tapes of a colon (teniae coli) are located longwise. They are caused by uneven distribution of the longitudinal muscle bundles concentrated in the form of strips in three sites of a gut. Distinguish an omental tape (tenia omentalis) — in the area of an attachment big epiploon (see) and on continuation of this line on other parts of a gut, a mesenteric tape (tenia mesocolica) — in the area of an attachment of a mesentery of a cross colon and on its continuation on other parts of a gut, a free tape (tenia libera) going on the ascending colon and the descending colon on their front surface, and on a cross colon — on back. Width of tapes apprx. 1 cm of Gaustra (haustra coli) are formed in a colon because teniae coli as if pull together and corrugate a gut. From within a gaustra go deep at the expense of semi-lunar folds.

At reduction of a circular layer of a muscular coat of a gut of a gaustra go deep. Gaustra in a distal part of a sigmoid colon are least expressed. Omental shoots (appendices epiploicae) represent the outgrowths of a peritoneum up to 5 cm long containing fatty tissue.

Wall of thick guts consists of mucous, muscular and serous covers and a submucosa. The mucous membrane is deprived of fibers and instead of circular folds in it there are semi-lunar folds (plicae semilunares) consisting of a mucous membrane, a submucosa and a muscular coat. These folds are limited to teniae coli and are between the next gaustra. In a mucous membrane of a large intestine the quantity of intestinal crypts increases in comparison with a small bowel. The submucosa is expressed well.

Muscular coat includes two layers: outside (longitudinal) and internal (circular). Longitudinal muscles are distributed on perimeter of a gut unevenly and concentrated in the form of three tapes, between to-rymi there are only separate muscle bundles. Circular muscles are more developed and though' are found on all gut, most massivna on sites between gaustra.

Serous cover it is formed by a visceral peritoneum, densely prilezhit edges to a muscular coat and completely repeats a relief of an exterior surface of a gut. The colon not throughout is covered with a peritoneum. The ascending and descending colons are located mezoperitonealno, their wall is covered with a peritoneum only from three parties (except for the tail) therefore they are fixed, slow-moving. Cross and sigmoid colons lie intraperitoneally, have mesenteries — a cross colon (mesocolon), a sigmoid colon (mesosigmoideum) — and have big mobility. Sometimes the sigmoid colon is deprived of a mesentery and can be located mezoperitonealno throughout or partially.

Topography of a large intestine

The ascending colon begins from blind in the right ileal pole, is located on the right edge of a back abdominal wall, going from below up to the visceral surface of a liver where, forming the right bend, passes into a cross colon. Length of the ascending colon fluctuates within 12 — 30 cm, making apprx. 20 cm more often. It is projected on the right side area of a front abdominal wall, and its right bend — for the end of the X edge or on L2-3. Behind the ascending colon prilezhit to an ileal, square muscle of a waist and a cross muscle of a stomach, to a medial part of a right kidney, sometimes to the right adrenal gland, from above (the right bend) — to the right hepatic lobe, to a gall bladder, in front — to loops of a small bowel.

Cross colon is located cross, forming convex from top to bottom and kpered a flat arch. At the left it passes into the descending colon, forming the left bend which lies slightly above, than right. Length of a cross colon is from 25 to 68 cm, on average 50 cm. Its mesentery has big mobility, can hold a high position, at Krom the middle part of a gut is projected above a navel, and low — at Krom the loop of a gut reaches a small pelvis. More often the high position of a gut is noted at young people, low — at old men. On average situation the upper edge of a gut corresponds to the line connecting the ends of the right X costal cartilage to the end of the IX left edge. At women the gut is located below, than at men. The cross colon prilezhit from above to a liver, a gall bladder, big curvature of a stomach, bottom edge of a spleen, from below — to loops of a small bowel, in front — to a big epiploon and a front abdominal wall, behind — to a right kidney, a duodenum, to a pancreas, a left kidney and loops of a small bowel.

The descending colon — the narrowest and short (from 9 to 25 cm, are more often than 9 — 12 cm); it is continuation of a cross colon below the left bend and goes on a back abdominal wall to an ileal crest, at the level to-rogo passes into a sigmoid colon. It is projected on the left side area of a front abdominal wall, is more often from the L1 level (more rare than Th12 or L2-3) to L5 — S1. In front and on the right to a gut prilezhat loops of a small bowel, behind — a left kidney, a cross muscle of a waist and an ileal muscle.

Sigmoid colon — the longest part of a colon, stretches from an ileal crest to S3, at the level to-rogo it passes into a rectum. It has two loops: upper, apprx. 15 cm, located in the left ileal pole (colon iliacum), and lower, longer, lying in a small basin (colon pelvinum). Total length of a sigmoid colon varies within 17 — 72 cm, average length of 54 cm. Has a mesentery (height of its 2 — 18 cm, on average 8 cm). The sigmoid colon on a front abdominal wall within the left side, left inguinal and partially pubic area is projected. In front the gut prilezhit to a front abdominal wall, above and to the right of it there are loops of a small bowel, below a bladder, a uterus (at women) and a rectum.

Fig. 7. Diagrammatic representation of arterial arcades: 1 — 3 — a small bowel (1 — arteries of initial department of a jejunum; 2 — arteries of average department of a small bowel; 3 — arteries of final department of an ileal gut); 4 — options of branching of sigmoid arteries.
Fig. A.1. Vessels and nerves of a small bowel and right department of a large intestine: 1 — a big epiploon; 2 — a cross colon and its gaustra; 3 — an average colonic artery; 4 — the left colonic lymph nodes; 5 — a pancreas; 6 — an upper mesenteric node; 7 — an upper mesenteric artery and an upper mesenteric texture; 8 — intestinal arteries and veins; 9 — a small bowel; 10 — intermediate lymph nodes; 11 — upper mesenteric lymph nodes; 12 — - ileal lymph nodes; 13th worm-shaped shoot; 14 — a mesentery of a worm-shaped shoot; 15 — a caecum; 16 — an ileal and colonic artery; 17 — ileal and colonic lymph nodes; 18 - right colonic artery; 19 — an upper mesenteric vein; 20 — the ascending colon; 21 — average colonic lymph nodes.
Fig. A.2. Vessels and nerves of the left department of a large intestine: 1 — a big epiploon; 2 — gaustra of a colon; 3 — a cross colon; 4 — the left colonic lymph nodes; 5 — the descending colon; 6 — lumbar lymph nodes; 7 — the lower mesenteric vein; 8 — the left colonic artery; 9 — a ventral aorta; 10 — the lower mesenteric artery and the lower mesenteric texture; 11 — sigmoid arteries; 12 — an upper hypogastric texture; 13 — a sigmoid colon; 14 — an upper pryamokishechny artery; 15 — a bladder; 16 — the lower vesical artery; 17 — the lower hypogastric texture; 18 — a sacriplex; 19 — an average pryamokishechny artery; 20 — an internal ileal artery and a vein; 21 — a caecum; 22 — an internal ileal lymph node; 23 — a sympathetic trunk; 24 — the general ileal artery and a vein; 25 — the lower vena cava; 26 — a small bowel.

Blood supply

(Tsvetn. fig. A.1 and A.2). Arterial blood supply it is carried out top and bottom by mesenteric arteries. Upper mesenteric artery (. mesenterica sup.) departs from a ventral aorta at the L1 level (more rare than Th12 or L2) and, having given the lower pankreatoduodenalny artery (a. pancreaticoduodenalis inf.), enters a mesentery of a small bowel, follows towards an ileocecal corner, giving consistently branches: to a cross colon — an average colonic artery (a. colica med.), to the ascending colonic — right colonic (a. colica dext.), to a lean and ileal gut — jejunal (aa. jejunales, in number of 6 — 8) and ileal and intestinal arteries (aa. ilei, in number of 10 — 12), coming to an end with an ileal and colonic artery (a. ileocolica) going to an ileocecal corner, a caecum and a worm-shaped shoot. Approaching a wall of a gut, arteries are consistently divided into the ascending and descending branches and, anastomosing with the next arteries, create up to 4 — 5 tiers of arterial arches — arcades (fig. 7, 1-3).

The bigger quantity of arcades forms in the most mobile sites K. Direct arteries depart from the most distal arcades (aa. rectae) entering a gut and forming arterial networks in its walls. Lower mesenteric artery (a, mesenterica inf.) departs from a ventral aorta usually at the L3 level, is more rare than L2 or L4. Its short trunk is soon divided into arteries — left colonic (a. colica sin.), sigmoid (aa. sigmoideae, in number of 1 — 6) and upper pryamokishechny (a. rectalis sup.). The branches of arteries going to a sigmoid gut also create arcades, finding at the same time essential distinctions (fig. 7, 4).

Veins. In a wall of a gut of a vein, forming from venules, form dense venous networks: network of fibers and crypts, subepithelial networks, basal venous network of a mucous membrane, network of a muscular coat, subserosal network, and also powerfully developed submucosal veniplex, in a cut blood from all intramural venous growths flows. Extra organ veins form from direct veins (vv. rectae) and generally match on angio-very tectonics the corresponding arteries. Formed top and bottom mesenteric veins (vv. mesentericae sup. et. inf.) are inflows of a portal vein.

Absorbent vessels and nodes. In a wall of a gut there are following capillary lymphatic networks: fibers, mucous membrane, submucosa, network of a muscular coat, serous cover. From the specified networks the absorbent vessels which are taking away a lymph in regional nodes form. According to A. V. Borisov (1958), there are two groups limf, vessels: the first takes away a lymph from fibers and other parts of a mucous membrane and a submucosa and, pro-butting muscular and serous covers, follows to limf, to nodes of a mesentery (or to retroperitoneal nodes); the second — collects a lymph from networks of a muscular and serous coat and takes away it in the same nodes. Extra organ limf, vessels of a small bowel are 3 — 4 times more, than circulatory. Regional limf, nodes, to the Crimea they follow, are located generally on the course of blood vessels (tsvetn. fig. A.1 and A.2) in a mesentery, concentrating in 3 groups: left — for an initial piece of a jejunum (40 — 70 cm), average — for other part of a jejunum, right — for an ileal gut. Besides, nodes are distinguished depending on their situation: at mesenteric edge of a gut, at the level of intermediate vascular arcades, along proximal vascular arcades (the most considerable group), in a root of a mesentery. For a large intestine there are following groups of nodes: nadobodochny — at edge of a gut, okoloobodochny — at peripheral vascular arcades, intermediate — on the course of branches of colonic arteries, the main nodes — in a root of a mesentery of a cross colon and at the lower vena cava. From the last nodes distribution of a lymph to nodes of a pancreas, to nodes of a root of a mesentery of a jejunum, to preaortal nodes, nodes between an aorta and the lower vena cava is possible.

Fig. 8. The scheme of a parasympathetic innervation of digestive tract (asterisks designated nervous cells on which there is a synoptic switching): 1 — a vagus nerve; 2 — a cross colon; 3 — the descending colon; 4 — a sigmoid colon; 5 — splanchnic pelvic nerves; 6 — a caecum; 7 — the ascending colon; 8 — the right bend of a colon.
Fig. 9. Scheme of the intramural nervous device of a small bowel: 1 — an intermuscular texture of the adult; 2 — nervous cells in a small bowel of the person (according to A.S. Dogel); 3 — sensitive fibers in a small bowel of the adult.

An innervation

the Sensitive innervation To. it is carried out by sensitive fibers of spinal nerves, sensitive fibers of a vagus nerve, at the expense of shoots of sensitive neurocytes of century of N of page. A motive innervation To. provides century of N of page. The sympathetic fibers going to a small bowel come from cells of side horns of Th4 — L2 of segments of a spinal cord (lean — from Th4-8, ileal — from Th4 — L2, to ascending and cross colonic — from Th4 — L1, to descending and sigmoid colonic — from L1-3). Parasympathetic fibers K. come from a dorsal kernel of a vagus nerve and extend in its structure on all to the thin, ascending and cross colon (fig. 8). Parasympathetic fibers to the descending and sigmoid colon originate in side horns of S2-4 of segments. Sinaptichesky switching of preganglionic fibers on postganglionic, on the standard representations, happens for sympathetic fibers in chest nodes of a sympathetic trunk or in nodes of prevertebral neuroplexes (plexus celiacus, plexus mesentericus sup. et inf.), for parasympathetic fibers — in nodes of intramural neuroplexes (fig. 9). However some authors [Klara (M. of Clara), 1953] allow also the mixed localization of cellular accumulations.

Anatomic sources of nerves thin, ascending and parts of a cross colon is the upper mesenteric texture — plexus mesentericus sup., a distal part cross, descending and sigmoid colonic — the lower mesenteric texture — plexus mesentericus inf. (tsvetn. the fig. A.1 and A.2) through which there pass sensitive spinal fibers and fibers of a vagus nerve, preganglionic parasympathetic fibers of a vagus nerve, postganglionic sympathetic (having a synapse in nodes of a sympathetic trunk). Other fibers form synoptic contacts on cells of the specified textures.

Fig. 4. Scheme of an innervation of a small bowel: 1 and 5 — a splanchnic nerve; 2 — a celiac node; 3 — intermuscular (auerbakhovo) a texture; 4 — a submucous plexus; 6 — a vagus nerve 7 — a phrenic nerve. Sensitive fibers — blue; efferent sympathetic — green; efferent parasympathetic — red (preganglionic fibers — a solid line, postganglionic — dotted).

The nervous stipitates containing everything types of fibers follow from textures, generally on the course of blood vessels to a wall of a gut where together with cellular accumulations and their shoots create the intramural nervous device including a submucous plexus (plexus submucosus, s. Meissneri), a muscular and intestinal texture (plexus myentericus, s. Auerbachi) — in a muscular coat, a subserous texture (plexus subserosus) — a subserosal cover, thin nervous stipitates — in all covers, the motive terminations in a muscular coat and muscles of vessels of a wall of a gut and sensitive — in all covers (tsvetn. fig. 4).

Features of anatomy of intestines at children

To. at children differs in a form and the sizes, situation and internal structure. At newborns it has length of 1,8 — 3,6 m (on average apprx. 2,6 m) and on the 1st year of life increases in length at 1/2. The relation of length of a body to length To. at newborns, according to Andronesku (A. Andronescu, 1970), makes 1:8,3, at the child of 1 — 2 years — 1:6,6, at the adult — 1:5,4.

Fig. 10. The diagrammatic representation of position of intestines at the child of 1,5 years: 1 — a stomach; 2 — bottom edge of a liver; 3 — the left bend of a colon; 4 — a big epiploon; 5 — a cross colon; 6 — the descending colon; 7 — a jejunum; 8 — sigmoid, a colon; 9 — an ileal gut; 10 — a worm-shaped shoot; 11 — a caecum; 12 — the ascending colon; 13 — a round ligament of a liver; 14 — the right hepatic lobe.

Length of a small bowel at newborns fluctuates from 1,5 to 3 m. Especially intensively it grows on the first months of life, and also during 1 — 3 and 13 — 16 years. Diameter of a small bowel on the first year of life reaches 1,6 cm, in 2 years — 2,3 cm and in 3 years — 2,5 cm. At children up to 1,5 years the provision of a small bowel has features because in this age a liver of the big sizes and in an abdominal cavity there are a bladder, a uterus. Owing to a high position of a caecum falling of an ileal gut into thick occurs at the L4 level. Loops of a small bowel are located in the middle between a liver and a cross colon — from above with both a sigmoid colon and pelvic bodies — from below (fig. 10). Only after lowering of a bladder, a uterus (for 7 — 8 months of life), and also partially lower loop of a sigmoid colon of a loop of a small bowel hold characteristic position.

The big epiploon at newborn children is not expressed (has length of 2,5 — 8,5 cm) and therefore loops of a small bowel generally prilezhat to a front abdominal wall. By 3 years the liver relatively decreases, the big epiploon covers loops of a small bowel half. The mesentery of a small bowel at children of the first year of life thin, easily extensible, has length to 6 cm; by 6 years it is extended twice.

The mucous membrane of a small bowel of the baby thin, differs in high-permeability, the submucosa is not expressed. Circular folds flat are also found in newborns only in an initial part of a jejunum. With age the quantity of circular folds increases, reaching a maximum by the period of puberty. The quantity of fibers at babies are much less, than at adults. V K. newborns is on 1 mm2 of 5 — 8 finger-shaped and 2 — 4 leaflike fibers. Premature children of fibers have less, than at full-term. Intestinal crypts of bigger size, than at adults. In a mucous membrane To. babies more adenoid tissue, than at adults contains znachiyelno. Group limf, follicles at chest age is to 100, and after 10 years — to 50. The muscular coat is developed poorly, especially its longitudinal layer. At newborns of an artery and vein of a small bowel are distributed unevenly. Vessels and vascular arcades in a middle part of a small bowel prevail. Limf, vessels are very numerous, networks limf, and circulatory capillaries gustopetlist that testifies to rich vascularization. A differentiation of an intestinal epithelium, formation of intramural neuroplexes at newborns it is not finished and proceeds up to 3 — 5 years.

Fig. 11. The diagrammatic representation of position of a large intestine at the child of 2 years (loops of a small bowel and the most part of a big epiploon are removed): 1 — a stomach; 2 — a duodenum; 3 — the right bend of a colon; 4 — a gastrolic sheaf; 5 — the descending colon; 6 — a cross colon; 7 — a sigmoid colon; 8 — an ileal gut; 9 — a worm-shaped shoot; 10 — a caecum; 11 — the remains of a big epiploon; 12 — the ascending colon; 13 — a hepatoduodenal sheaf; 14 — the right hepatic lobe.

The large intestine of newborns varies on length from 35 to 66 cm. At children it is equal in any age to length of a body. Length of the ascending colon at them is less (2 — 9 cm) than length descending (3 — 12 cm). By 4 years both departments of a colon have equal length, and by 7 years the ratio characteristic of adults is established. The cross colon — the longest department of a colon making 11 — 27 cm lies usually under a liver (fig. 11), but can fall almost to a symphysis. The sigmoid colon at babies also has the considerable length (12 — 29 cm), it already forms loops, but usually lies in an abdominal cavity, quite often adjoining to a caecum and a worm-shaped shoot. Omental shoots in a large intestine at babies are absent, strips and its gaustra are developed poorly and appear aged apprx. 6 months. Semi-lunar folds flat. Circular muscles are also not created completely. Only by 8 years the specified educations take the form characteristic of adults. Already at babies significant individual differences in a structure of vascular system take place. At newborns length of arterial trunks strongly varies: ileal and colonic — from 0,5 to 3 cm, right — from 1,3 to 7,5 cm, sigmoid — from 0,2 to 2 cm. The number of the direct arteries going to a large intestine — from 14 to 32 is unequal.

A radioanatomy

At rentgenol, a research of a loop of a small bowel find preferential in the central departments of a stomach and in a basin. The gut has an appearance of a narrow tape 1 — 2 cm wide (at a relaxation enterografiya width of a jejunum reaches 4 cm, and ileal — 2,5 cm). On contours of a jejunum narrow dredging — reflection of circular folds of a mucous membrane is evenly distributed. On the course of an ileal gut this stepped appearance of contours becomes less and gradually disappears. Thickness of folds decreases from 2 — 3 mm in a jejunum to 1 — 2 mm In ileal. At a research tonic contractions and relaxations, a peristaltics, rhythmical segmentation, the pendulum movements are noted. In an ileal gut it is visible, as a rule segmentation.

At adults gas happens only in a large intestine. Existence it in a small bowel is patol, a sign. The large intestine at peroral contrasting (usually baric suspension) begins to be filled in 1 — 2 hour. In 3 — 6 hours barium reaches the right bend of a colon, in 12 hours — the left bend, in 18 — 24 hours — a rectum. The caecum differs in the largest diameter; in the distal direction the caliber of a gut decreases. The proximal loop of a sigmoid colon is in the left ileal pole, and the distal loop at the S3 level passes into a rectum. The last forms two bends: the sacral, turned by camber kzad, and perineal — camber of a kpereda.

A peculiar form is given to each department of a large intestine of a gaustra — in the blind and ascending guts they are distributed evenly, wide, superficial are more often; in a cross colon — usually deep with the equal rounded-off contours; in descending and sigmoid colonic guts where fecal accumulations already form, gaustra remind beads. Distribution, depth and outlines gaustr change in connection with movements of intestinal contents and the movements of an intestinal wall. It is possible to register big tonic contractions and relaxations of a gut, its peristaltics and segmentation of contents.

Fig. 12. The roentgenogram of area of an ileocecal corner (shooters showed lips of the ileocecal valve).

At irrigoskopiya (see) a large intestine it is filled evenly, its shadow is homogeneous. The gleam of a gut reaches on average 5 cm, and gaustralny retractions superficial. The caecum is located 5 — 10 cm below than the crested line, but during emptying of a gut rises by 2 — 5 cm. The distal loop of an ileal gut falls in blind from the medial or zadnemedialny party. In this place the gut is narrowed and at its edges two dredging — display top and bottom lips of the ileocecal valve (fig. 12) — the bauginiyevy gate are noticeable.

Fig. 13. The roentgenogram of a relief of a mucous membrane of the blind, ascending colon and right bend of a colon (in the drawing change of a relief of a mucous membrane of a large intestine in 3 min. after contrasting is visible on the right).

On an inner surface of a gut to gaustra there correspond semi-lunar folds of a mucous membrane. In a large intestine slanting and cross folds of small caliber prevail. The normal relief of a mucous membrane of a gut is very changeable (fig. 13).

HISTOLOGY

Mucous membrane To. consists of an epithelium, own layer and a muscular plate. The single-layer epithelium covering a mucosal surface of a cover proceeds in intestinal crypts. Distinguish 5 types of the epithelial cells having features in an arrangement and function: epithelial cells with a border with an ischerchenny border, scyphoid enterocytes, intestinal argentaffinotsita (enterokhromaffinotsita), enterocytes with acidophilic granules (apical and granular), beskayemchaty enterocytes.

Fig. 14. Scheme of the Diffraction pattern. An apical part of an intestinal epithelial cell with an ischerchenny border: 1 — the cellular microvillis forming the soaking-up border; 2 — a switching plate; 3 — border between cells; 4 — mitochondrions; 5 — mesosom; 6 — a cytoplasmic reticulum.

Epithelial cells with a border with an ischerchenny border (epitheliocytus intestinalis cum limbo striato, fig. 14) have a set of densely located microvillis (up to 1,1 microns high, up to 0,08 microns thick) which are outgrowths of a plasma membrane. In the center of a microvilli there passes the microtubule accepting in itself radial microtubules [Z. Lojda, 1971]. Cytoplasm of microvillis around tubules consists of the fine ends passing into network of an ectoplasm. Across Peyli and Carlin (S. L. Palay, L. J. Karlin, 1959), microvillis and organellas of cytoplasm of these cells provide process of absorption. Epithelial cells of a large intestine have a similar structure, though differ in details. Microvillis in a large intestine shorter, the cytoplasmic reticulum is developed more weakly.

Scyphoid enterocytes (enterocytus caliciformis) are located between epithelial cells one by one, and the quantity them increases to ileal and colonic guts. Scyphoid enterocytes (see. Scyphoid cells ) in a large intestine differ in nothing from such cells in thin.

Intestinal argentaffinotsita [argentaffinocytus intestinalis (enterochromaffinocytus)] are found in a small amount, is preferential in crypts, and in their small bowel it is more, than in thick. In cytoplasm of apical department of these cells the spherical secretory granules surrounded with a membrane are found. Believe, in particular Kurtts (S. M of Kurtz, 1964), that secretory granules are synthesized or exposed to maturing in a lamellar complex (Golgi's complex). Polak, Pierce and Heath (J.M. Polak, A. G. Pearse, S. M. of Heath, 1975) on the basis gistokhy, researches found hormonal function of enterokhromaffinotsit.

Enterocytes with acidophilic granules (enterocytus cum granulis acidophilis — cells Panetta) are found only at the bottom of crypts groups or odinochno, is preferential in a small bowel. An apical part of cells contains a lot of the secretory, oxyphilic granules produced by a lamellar complex [H. F. Otto, 1973].

Beskayemchaty enterocytes (enterocytus alimbatus) are deprived of microvillis, lie in crypts of all To. They are considered as a source of regeneration of epithelial cells of a mucous membrane. Breeding and migrating, they create generations of the adsorbing epithelial cells and scyphoid enterocytes. Mitotic division of these cells according to Foss (N. of Voss, 1968) happens every the 18th hour. The cycle of movement of the formed cells for replacement of outdated intestinal epithelial cells with a border and scyphoid enterocytes from crypts to a top of a fiber where they are torn away, according to Wright, Watson, Morley (N. Wright, A. Watson, A. Morley, 1973), takes 3 days.

Fig. 7. Scheme of a structure of a wall of a small bowel: 1 — neuroplex of fibers; 2 — an epithelium; 3 — a muscular plate of a mucous membrane; 4, 16 — a single lymphatic follicle; 5 — a submucosa; 6 — a submucous plexus (meyssnerovsky); 7 — a longitudinal muscular layer; 8 — a circular muscular layer; 9 — a serous cover; 10 — an intermuscular texture (auerbakhovo); 11 — an intestinal nerve; 12 — an intestinal vein and an artery; 13 — a subserosal lymphatic texture; 14 — an intermuscular lymphatic texture; 15 — a submucous lymphatic plexus; 17 — central absorbent vessel of a fiber; 18 — a vascular texture of a fiber.

Fibers To. (tsvetn. fig. 5 and 7) are covered, generally with epithelial cells with a border, between to-rymi scyphoid enterocytes and occasionally enterokhromaffinotsita meet. The stroma of a fiber is formed by connecting fabric (lamina propria), in a cut the central milk vessel and a bunch of myocytes are located (smooth muscle tyazh from lamina muscularis mucosae). Directly under a basal membrane of an epithelium capillary and vascular networks lie circulatory and limf. During the filling of vascular networks and capillaries of a fiber eregirutsya owing to what their surface increases and the central milk vessel (a sine of a fiber) extends that promotes absorption of fatty droplets. Reduction of smooth muscle cells contents of a fiber move to larger limf, vessels of a wall of a gut. Reduction and relaxation of fibers happens to 6 times in 1 min.

Crypts — tubular protrusions of an epithelium, can genetically be considered as the reduced glands. At the bottom of crypts the epithelium contains ferruterous cells — the intestinal argentaffinotsita producing intestinal enzymes are in sidewalls the beskayemchaty enterocytes providing completion of an epithelium of fibers, and also scyphoid enterocytes here. At healthy people the fleecy epithelium makes 41 — 46%, an epithelium of crypts — 20 — 26% and lamina propria — 34% of mass of a mucous membrane.

Muscular coat it is formed by the smooth muscle cells having some structural features. The Hun (M. of Gunn, 1971, 1972) described the specialized tyazh going at right angle to the direction of muscle fibers which happen mitochondrial and cytoplasmatic. The author connects an arrangement of these of activity of an unstriated muscle, tyazhy with distribution of types, To. (pendulum movement, rhythmic segmentation, peristaltics).

Serous cover is a visceral layer peritoneums (see).

PHYSIOLOGY

In an oral cavity and in a stomach there are only preparatory stages of process of digestion of feedstuffs. The basic processes of digestion leading to formation of monomeric forms of the feedstuffs suitable for absorption and transition to internal environment of an organism are carried out in a small bowel.

Up to 19 century. To. was considered gl.obr. as the tank and the device which is carrying out absorption. With the advent of methods of studying of intestinal secretion presence at intestinal juice of some digestive enzymes was established. However the traditional research of one liquid part of juice did not allow to find the main mass of the enzymes (which are contained in a dense part). Enzymes found in juice a little or at all did not find, and most of researchers was inclined to deny value them in digestion.

Opening by I. P. Pavlov's school of enterokinase was a turning point in development of ideas of a role of intestinal juice. Exclusive value of some of his agents in digestion was defined. Further works of the Soviet scientists showed the originality of intestinal secretion consisting in department of all main enzymes as a part of a dense part of intestinal juice i.e. which are torn away from a mucous membrane of epithelial cells. Intensive movement of epithelial cells from the basis to tops of fibers and updating of an intestinal epithelium was revealed. A. M. U goal are formulated ideas of membrane digestion (see. Digestion ). The major intestinal enzymes, such as enterokinase, an alkaline phosphatase, etc., are present at large numbers in an intestinal chyme, and at disorder of processes of an inactivation in a large intestine are emitted them in a significant amount with excrements. Thus, the important role was proved To. not only in processes of absorption, but also in digestion of food.

The most important functions of Intestines — secretory, motor, excretory and function absorptions (see).

Fig. 15. The chart characterizing the content of some intestinal enzymes (light columns — a liquid part, the shaded columns — a dense part of intestinal juice; for 100% the content of enzymes in a liquid part is accepted).

Secretory function it is carried out by all departments To. The mucous membrane of a small bowel separates a secret, peculiar on morphology and chemism. The secret received from the isolated piece of a gut in pure form — intestinal juice (succus entericus) — consists of two parts: liquid, containing mineral substances, a significant amount of protein and traces of enzymes, and the dense, insoluble part bearing enzymes (fig. 15) in the structure and presented to hl. obr. the epithelial cells which are torn away from a mucous membrane.

Crypts participate in release of liquid component of juice. However they do not cosecrete enzymes. Formation of characteristic intestinal enzymes happens in that stage when the epithelium is in a middle part of fibers. Arising in crypts, it moves to tops of fibers and there is torn away thanks to what extrusion (allocation) of the cosecreted material in a gleam of guts is carried out. At disintegration of the separated cells the enzymes concluded in them pass into surrounding liquid. It follows from this that ferruterous education To. all his mucous membrane is.

V K. there is a large amount of the enzymes participating in digestion. Enterokinase (see) — the high-specific enzyme catalyzing eliminating from a molecule of trypsinogen of a peptide fragment thanks to what it turns into active trypsin (see). Enterokinase is produced by hl. obr. in a duodenum and in an upper part lean, and in trace amounts — willows other departments of a small bowel. Alkaline phosphatase (see) — enzyme of wide specificity, splits radio bonds in monoester phosphoric to - you (phosphoserine, nucleotides, ethanol amine - and cholinephosphates). Enzyme is intensively produced throughout the most part To., but in a distal part ileal and in a large intestine its development considerably decreases. Nucleases (see) depolymerize nucleinic to - you with formation of nucleotides, and nucleosidases complete this action, dephosphorylating mononucleotides. Cathepsines (see), released at disintegration of a cellular component of intestinal juice, split in the subacidic circle of a squirrel preferential to polypeptides. At an intestinal secret there is a group of peptidases which was also earlier called erepsin, in to-ruyu enter leucineaminopeptidase — the enzyme of wide specificity which is chipping off from peptides the remains with a free amino group, hl. obr. the rest of a leucine, and also other amino acids close to it, the aminotripeptidase splitting preferential tripeptides (see. Aminopeptidases ). A part of peptidases differs in big specificity, napr, the prolinase hydrolyzing the small peptides containing proline on the end of a chain. There is also a row dipeptidases (see), hydrolyzing dipeptides to amino acids.

Among the enzymes influencing carbohydrates it is necessary to call first of all specific for To. enzyme invertase (intestinal alpha glucosidase), edges splits alpha D - glucosidic bonds, in particular sucrose, a maltose and other similar disaccharides (see. Invertases ). There is also an invertase with narrow specificity splitting saccharobiose and raffinose, but not a maltose. Lactase splits lactose on glucose and a galactose. There are also other disaccharidases. At an intestinal secret there is also final dextrinase (oligo-1,6-glucosidase) hydrolyzing bonds in the branching sites of molecules of amylopectin and a glycogen freed after effect of amylase. At small amounts there is an alpha amylase, edges splits an unbranched part of molecules of starch and a glycogen. It has generally pancreatic origin and passes into intestinal juice from blood. gamma Amylase (glucoamylase) — the enzyme which is consistently chipping off the rest of glucose from polysaccharides, hydrolyzing not only alfa-1,4-, but also alpha 1,6 - bonds. It splits starch and a glycogen to glucose, is developed in small amounts by a mucous membrane To. The lipase of an intestinal secret differs from pancreatic in the ability to chip off fat to - that in situation 2 from monoglycerides and, therefore, is monoglitseridlipazy though in a nek-swarm of degree can hydrolyze also bonds fat to - t in situation 1,3 in triglycerides (see. Lipases ). Active function of the intestinal enzymes coming to a cavity of guts is confirmed by positive effect of introduction to a digestive tract of fermental drugs with to lay down. the purpose to the people suffering from hereditary insufficiency or lack of separate intestinal enzymes.

A liquid part of an intestinal secret has alkalescent reaction, contains a number of mineral substances, cations of Na, To, Ca and a number of anions. On the content of these substances intestinal juice considerably differs from a blood plasma. Concentration of bicarbonate in juice of proximal department of a small bowel is twice less than its concentration in a blood plasma, and bicarbonate and chloride are in inverse relation to each other. In an ileal gut the content of bicarbonate higher. Unlike it, tension of CO 2 higher in juice of proximal departments and is lower in an ileal gut. For an explanation of these features the hypothesis is made, according to a cut of a cell of an intestinal epithelium in a nek-swarm of degree H are capable to allocate (enterocytes) + . This process is stronger expressed in a jejunum and decreases towards an ileal gut. Assume, e.g. L. A. Turnberg that in enterocytes there is not electrogene transport to double replacement of Na + on H + and Cl - on HCO 3 - . Allocation of H + leads to reduction of content of bicarbonate in juice. However this hypothesis needs further justification.

A liquid part of juice neutralizes and liquefies intestinal contents, promotes washing of dense food particles from a mucous membrane and to their movement on To. As a part of a liquid part of juice a significant amount of protein separates (apprx. 1,5%), the most part to-rogo belongs to type of mukoproteid. This protein, apparently, promotes enzymatic processing of feedstuffs in a cavity of guts. Further its most part is split and soaked up.

Secretory activity To. it is most intensive in a duodenum and proximal department of a jejunum. In a distal part of an ileal gut its intensity considerably decreases. Essential feature is represented by a proximal part of a duodenum, in a cut duodenal (brunnerova) glands are located. They separate the dense siropoobrazny juice of alkalescent reaction containing 0,5% of organic matters, hl. obr. mucin. Believe that this juice protects a mucous membrane of a duodenum from the possible destroying action salt to - you and proteinases of a gastric chyme.

Regulation of secretory activity To. it is carried out by the local stimulating agents influencing through intramural neuroplexes, hormonal factors and influences of c. N of page. The last render hl. obr. the braking action. So, e.g., according to experimental data of V. V. Savich, at meal secretion from the isolated piece of a gut is late that it is observed only in the conditions of preservation of nervous bonds of a piece with c. N of page. However the nervous impulses going on vagus nerves stimulate secretion of juice in initial department of a duodenum. Nervous impulses play an important role in education and secretion of intestinal enzymes. Section of the nerves going to the isolated piece of a gut involves sharp reduction of development of a number of intestinal enzymes. Further education them is recovered during 1,5 — 2 weeks. Arriving in To. chyme (see) includes mechanical and chemical irritants of local action, secretomotor intestinal juice. The stimulating impact is exerted by the hormone of the peptide nature produced in To. — enterokrinin which stimulates secretory processes in a small bowel. Corticosteroids promote maintenance of a high level of fermentootdelitelny processes in a mucous membrane

of K. V K. is produced many hormones participating in regulation of activity of other departments of a digestive tract. Sekretin (see), developed by a mucous membrane of preferential proximal departments of a small bowel, stimulates secretion of pancreatic juice, brakes the second phase of gastric secretion, excites secretion of juice in a duodenum and detains motility To. The chemical structure of secretin is already known, and it is received in the synthetic way. Cholecystokinin — the pancreozymin which is also produced preferential in a duodenum and a proximal part of a jejunum causes reduction of a gall bladder and stimulates secretion of pancreatic enzymes. The chemical structure of cholecystokinin — pancreozymin is also revealed. In a duodenum specific hormone himodenin, strengthening allocation by a pancreas of chymotrypsinogen is found.

V K. a number of the new hormones and gormonopodobny peptides influencing * functions is found went. - kish. path and metabolic processes: the gastroingibiruyushchy polypeptide (GIP) which is slowing down gastric secretion, playing a major role in effect of hormone enteroanthelone (see); vasoactive intestinal polypeptide (VIP); the bombesin emitted from leather of a frog and the attendee also in a mucous membrane of a duodenum which stimulates gastric and pancreatic secretion; motilin, allocated from extracts of a duodenum, formed in enterokhromaffinny cells, strengthens motor function of a stomach and To.; the somatostatin found in a hypophysis and proximal department To., inhibits a growth hormone and can serve also as the modulator of functions of ferruterous devices of a digestive tract. However the role of gormonopodobny peptides in regulation of functions of an organism is finally not found out.

To. differs in well-marked ability to adaptation. In particular, in it processes of specific fermental adaptation to character of food which are expressed in change of production of separate enzymes (or their groups) depending on amount of the corresponding substrates in food develop. E.g., at increase in food of fraction of sugar or starch there is sharp strengthening of secretion of invertase (alpha glikozidazy) while production of other enzymes remains invariable.

In this way products of other enzymes change (enterokinases, an alkaline phosphatase). Thanks to development of fermental adaptations in To. the known proportion in digestion and absorption of various substrates is supported that is characteristic of the normal course of digestion. However not all enzymes participate in such processes. Some of them, hl. obr. belonging to closing stages of digestion, very poorly participate or do not participate in processes of specific adaptations at all (e.g., totally defined peptidases, an intestinal lipase).

Motor activity includes several types of reductions of muscular layers of a gut. Treat main types of reductions: .ritmichesky segmentation, pendulum movements, peristaltic reductions. The first two are directed to hashing of contents in a certain site of a gut. Rhythmic segmentation consists preferential in reduction of a circular layer of muscles. The site of a gut in several places pereshnurovyvatsya, and its contents form segments. At the next moment there is a relaxation, a cut is replaced by reduction of muscles in other pieces of a gut. At the same time segments are divided into two parts, then these movements repeat in the same sequence again. At such hashing there is no movement of a chyme along K. Sushchestvuyet, however, type of segmentation at which a chyme every time moves in the distal direction a little that is provided with some delay of a distal banner of a gut in comparison with proximal. Also segmenting reductions at which banners are replaced by the general relaxation of a gut are described and only after that there are new reductions in other places. At the same time reductions of a gut are carried out less regularly. Rhythmic reductions of intestinal muscles always happen against the background of the nek-ry tension of muscles of guts — a tone. A certain level of a tone is characteristic of a gut as well as of muscles of other band bodies. The tone is not invariable, it is possible to observe its fluctuations which are expressed in long changes of length and a gleam of certain sites of a gut. The tone of intestinal muscles causes in each certain volume of intestines given the moment.

The pendulum movements are caused by reduction of hl. obr. a longitudinal layer of muscles at nek-rum participation of a circular layer. Reduction of longitudinal muscles causes shortening and by that expansion of the site of a gut. Reduction of circular muscle fibers, on the contrary, narrows a gleam of a gut. Thanks to these reductions the chyme moves in the site of a gut in one, in other party and small oscillating motions of a gut are observed. There is a hashing of a chyme accompanied with its small movement in the distal direction. According to Alvares (W. The page of Alvarez), this type of movements together with previous makes uniform group of rhythmic reductions and has the myogenetic nature. According to Researches P. The rich man, in a duodenum at the level of an opening of the general bilious channel there is a special structure — the sensor of a rhythm setting the frequency of reductions to proximal departments of a small bowel. In the proximal site (70 — 90 cm) this frequency is identical. Then it gradually decreases in the distal direction though the gradient of its changes is not strictly proportional to distance from a sphincter of the gatekeeper.

Peristaltic reductions extend wavy along a gut. The banner of a gut arising in one place is followed by relaxation of the adjacent site which then, in turn, is reduced, but the following site relaxes (see. Peristaltics ). Thanks to it contents move in the distal direction. Such waves of reductions can cover the considerable site in various departments of a small bowel. Sometimes they are observed in several places alternating with not active sites. The peristaltics is most expressed in duodenal and lean guts where the chyme moves ahead several times quicker, than in a middle part of a small bowel. In a final piece of an ileal gut it becomes very active again. Rate of propagation of a peristaltic wave averages 1 — 2 cm/sec. At patol, states there can be a prompt peristaltics. Also antiperistaltic reductions with movement of contents in the proximal direction are in certain cases observed. Believe that in this or that site of a gut at first there is a rhythmic segmentation, then the pendulum movements and only after thorough hashing of a chyme arise peristaltic waves. The peristaltics is caused by reduction of circular and longitudinal layers of a muscular coat and has the coordinating operation of the intramural reflex mechanism in the basis. In addition to peristaltic waves, in To. there are tonic waves. They extend much more slowly and serve as a background on which other types of reductions are imposed. Also not displaced tonic contractions sometimes throughout the considerable site leading to narrowing of a gleam of a gut are observed. Tone of a muscular coat of a gut and intra belly pressure (see) determine pressure in a cavity of a gut, a cut 8 — 9 cm w.g. are on average equal.

In regulation of motor activity To. an important role is played by the local incentives influencing mechanioreceptors of a gut. The adequate irritation of any site of a gut excites motility as the same, and underlying sites and strengthens advance of contents in the distal direction. In overlying sites, on the contrary, there is a braking of motility and a delay of movement of contents. Motor activity is also under control of the highest departments of c. N of page. Nervous influences create a certain background for reaction To. to local incentives. The impulses going to To. on vagus nerves, as a rule, render on it exciting, and going on celiac nerves — the braking action. Influence of c. N of page on motor function K. clearly it is shown at emergence of emotional states. Emotions of anger, fear, pain, as a rule, cause oppression of intestinal reductions. However in certain cases at strong emotional experiences it can be observed and the rough peristaltics K. Vydelyaemy adrenal glands adrenaline slows down this function. Among humoral agents the serotonin which is present in To., substance P and, according to most of authors, gastrin stimulate motor activity of a small bowel. Prostaglandins (see) also strengthen reduction of a muscular coat To. Thanks to the regulatory mechanism, all-in these factors, activity of various departments To. it is well coordinate among themselves and undergoes natural changes depending on character of the eaten food. After eating of bread and not crushed meat strong reductions and increase in a tone of proximal departments of a gut (the first phase of motor activity) are observed. This phase proceeds during 1 — 2 hour and then is replaced by the second phase — weaker reductions. The crushed bread, meat with broth, reception of milk and broth render more and more weak influence in the decreasing order. Greasy food causes multiphase changes of motility. In this case strengthening of reductions and a tone of a gut is observed, a cut in 3 — 8 min. is replaced by braking of motility, then again strengthening etc. These changes continue during 2,5 hours then become less expressed.

Emergence of peristaltic waves in a duodenum is closely connected with strengthening of motility of a peloric part of a stomach. Similar to it disclosure of a peloric sphincter, as a rule, involves simultaneous relaxation and the ileocecal valve.

The large intestine performs reservoir function. In this department To. there is an absorption of water, formation of dense contents and at some point its evacuation from an organism.

The mucous membrane of a large intestine is also capable to separate rather intensively the thin intestinal Juice, pH to-rogo caused by presence of bicarbonate can reach 9,05. Formation of a dense part of juice and, respectively, department of enzymes in a large intestine are less intensive, and a set of enzymes are much less, than in a small bowel. A dense part of juice contains a complex of peptidases, invertase, an alkaline phosphatase and some other enzymes. Enterokinase in juice of a large intestine completely is absent.

Motor activity of a large intestine includes several main types of reductions: a) the frequent rather weak reductions participating in local hashing of contents; b) more rare (2 times in 1 min.) strong reductions which are well coordinate in various parts of intestines among themselves; they cause advance of contents along a large intestine; c) the tonic waves which are a little narrowing a gleam of a gut and increasing in it hydrostatic pressure. The first two types of reductions occur against the background of tonic waves.

Implementation of all functions K.g in the normal conditions which are well coordinated among themselves creates favorable conditions for intensive digestion of feedstuffs (see. Digestion ). In proximal departments To. trypsinogen of pancreatic juice turns into trypsin which then activates other pancreatic proteases. Under the influence of active proteinases of a squirrel of food are exposed to intensive hydrolysis with formation of polypeptides and nek-ry amount of free amino acids. Polypeptides are influenced by pancreatic carboxypeptidase and aminopeptidases of intestinal juice that leads to formation of small peptides and release of amino acids.

High-molecular substances are digested in a cavity To., legs as particles of smaller size are formed, processes of membrane digestion begin to play the increasing role. The last proceed on a surface of an intestinal epithelium. Oligomers, in particular small peptides, are affected by the enzymes adsorbed on a glycocalyx and the enzymes included in a membrane of microvillis, and the released monomers directly are transferred to an entrance of system of active transport in enterocytes. The same processes are carried out also concerning oligomers of other chemical nature. There is also an opinion that a nek-swarm the amount of small peptides can pass into cells y there to be exposed to final splitting. As a result of all these processes the ground mass of food proteins passes into blood in the form of amino acids. Various proteins are digested and soaked up in To. with an unequal speed.

Starch and a glycogen of food arrive in To. both in not hydrolyzed look, and in partially split to di - and oligosaccharides under the influence of ptyalin. V K. they are hydrolyzed by pancreatic amylase (see) to a maltose. The remained fragments with a branched chain are split by oligo-1,6-glucosidase. In a gleam of a gut and especially surfaces of enterocytes disaccharides are influenced by the corresponding disaccharidases.

Fats in upper parts To. are exposed to emulsification. This process is caused by a complex of surfactants which enter unsaturated fat to - that, a saturated monoglyceride and zhelchnokisly salts. The two first a component are formed at an initial stage of hydrolysis of fat. Zhelchnokisly salts arrive with bile. They give to the emulsified particles strong electric charge. In the emulsified state fats are split by steapsin preferential to monoglycerides and fat to - t. Monoglycerides, in turn, are split by an intestinal lipase. Cleavage products of fat join in the lipidic complex of bile representing an endogenous micelle structure or form micelles with zhelchnokisly salts and cholesterol in a gleam To. In such look products of digestion of fat are transferred from the place of hydrolysis to the soaking-up surface of an intestinal epithelium where are absorbed. At the same time zhelchnokisly salts pass into a gleam of guts and repeatedly perform the function. In induction stroke monoglycerides are split monoglitseridlipazy To. with release fat to - you and glycerin. In an epithelium To. there is a resynthesis of triglycerides which then make a basis of the chylomicrons coming to a lymph. Micelles, similar the aforesaid, serve as a form of transfer of other substances of the lipidic nature, in particular fat-soluble vitamins, phospholipids, etc.

Functions K. are carried out not only during digestion. During hunger there is a periodic activity including both secretory, and motor components. Through certain time terms (most often apprx. 1,5 hours) dense part of a secret with the high content of enzymes separates. Department of a dense part is followed by a small amount of a thin Juice, secretion continues 15 — 20 min. Such periods match the strong reductions of intestinal muscles characteristic of periodic motor activity

of K. Sostoyaniye of functions K. at early stages of post-natal development has the features. V K. newborns there are already in a significant amount all main intestinal enzymes. Unlike adults, at newborns enzymes are not exposed to a strong inactivation in a large intestine, prevailing in them a bifidoflor does not cause this process, and enzymes in large numbers are emitted with excrements. The inactivation of intestinal enzymes becomes expressed at the age of 3 — 4 years and by 5 — 7 years reaches the same level that at adults. In the period of a neonatality tendency to instability of motor activity is observed nek-paradise To. The big originality during this period represents permeability of a mucous membrane To. for macromolecules. Through a mucous membrane immunoglobulins of maternal milk which in an organism of the child perform protective function inherent in them get into blood in not split look. From To. also the hormones which are present at maternal milk and the glycopeptide which is formed in a stomach of the child of casein of milk, having properties of a gastron get into blood. At an early stage of development in connection with imperfection of neurohumoral regulation of functions sometimes weak irritants (cooling, easy Qatar of upper respiratory tracts and so forth) can lead to considerable disorders of digestive activity.

At advanced and senile age, by data rentgenol, and a wedge, researches, a relief of a mucous membrane and secretory activity To. in most cases significantly do not deviate from norm. Are quite often noted dyskinesia the hypomotor-nogo of type, but they are expressed in much smaller degree, than at some patol, states.

Along with other digestive organs To. is directly involved in the general metabolism. In his cavity a large number of the internal proteins secreted with digestive secrets after performance of the role is split and soaked up. Products of their hydrolysis, being returned to blood, come to the general reserve of amino acids, from to-rogo are partly used for synthesis of the new proteins secreted with secrets. There is, thus, a circulation of proteic matters between blood and the alimentary system. To. is one of the bodies setting this circulation in motion, and, besides, he separates a significant amount of proteins with liquid and dense parts of the secret. To. supports also pechenochnokishechny circulation bile acids (see) and other components bile (see). This circulation is one of the major mechanisms in vneshnesekretorny activity of a liver.

In a mucous membrane of a small bowel under the influence of feedstuffs some hormones of a systemic effect, napr, intestinal glyukagonoid, the stimulating glycogenolysis in a liver are released in blood. V K. also agents who, being soaked up in blood, stimulate secretion of hormones with the corresponding glands are released. Gastroingibiruyushchy polypeptide which, in addition to braking of gastric secretion, exponentiates release by insular tissue of a pancreas of insulin can be an example.

Important aspect of activity To. its participation is in excretory processes. Through To. end products of exchange of hemoglobin and other zhelezoporfirinovy connections are allocated (see. Bilious pigments ) and end products of exchange cholesterol (see). These processes proceed with the participation of intestinal microflora.

INTESTINAL MICROFLORA

Set of the microorganisms inhabiting an intestinal path is characterized by certain patterns of distribution of microbes on various departments To. and a quantitative ratio between representatives of different childbirth. Microflora To. healthy people is called normal, or eubiotichesky. At microscopy in excrements usually find enormous number of microbic cells from which only a part (apprx. 10%) is capable to breed on artificial mediums. Normal apprx. 95 — 99% of the bacteria which are giving in to cultivation it is presented by anaerobe bacterias. The main representatives of anaerobic fecal flora are bakterioida (Bacterioides) and bifidobacteria (Bifidobacterium) — their number in 1 g of excrements reaches respectively 10 5 — 10 12 and 10 8 — 10 10 bacterial cells. Aerobes (see) hl are presented. obr. colibacillus (Escherichia coli) — 10 6 — 10 9 , to enterococci (Streptococcus faecalis) — 10 3 — 10 9 , lactobacilli (Lactobacillus) — to 10 10 cells in 1 g of excrements (see. Colibacillus , Lactobacilli , Enterococci ). There are data on correlation of quantitative maintenance of lactobacilli in saliva and excrements and increase in their quantity at the diet rich with lactose. In addition to the listed microorganisms, in much smaller quantity and with smaller constancy are found koagulazonegativny and koagulazopozitivny staphylococcus, Streptococcus mitis, Streptococcus salivarius, Streptococcus pyogenes, a bacterium of a sort Clostridium (see), Klebsiella (see), Proteus (see), an also Pseudomonas aeruginosa, Alcaligenes faecalis, yeast-like fungi — Candida albicans, Blastocystis hominis (blastocyste), protozoa — Giardia lamblia, Entamoeba coli, Endolimax nana, etc.

Normal microflora is symbiotic and plays important fiziol, a role life activities of a macroorganism. Undoubtedly, value of eubiotichesky flora as factor of nonspecific protection against bacterial intestinal infections, edge is carried out, in particular, by means of the mechanisms called in total by microbic antagonism (see. Antagonism of microbes ). Microflora influences also products of antibodies what data on an underdevelopment of antitelsinteziruyushchy adenoid tissues and low level of serumal gamma-globulins at the animals who are grown up in sterile conditions confirm. Amicrobic animals are more sensitive to endotoxin, are more susceptible to intestinal and system infections and transplantation of tumoral cultures.

Vitaminsinteziruyushchy activity of microorganisms is important for a macroorganism. Enterobakteriya, making a considerable part of aerobic shishechny flora, produce phthiocol. The bacterial flora To, partially provides the needs of a macroorganism for B2, B6, B12, H vitamins, pantothenic and folic to-takh. At disturbance of detoksitsiruyushchy function of a liver and the general resistance of an organism some products of a microbic origin, such as endotoxins, cholesterol, toxic amines, can render patol, impact on a macroorganism.

Microflora in the bottom of a large intestine is most plentiful. In a small bowel where processes of digestion and nutritive absorption are carried out, the microbic number is not enough that is promoted by bacterial action of a gastric juice, a peristaltics and, perhaps, internal antimicrobic causes of a small bowel. In the bottom of an ileal gut, though in smaller quantity, but colonization (settling) by the same bacteria which are found in a large intestine takes place. Microflora of excrements, the most available to a research, represents practically microflora of distal department of a large intestine.

Zhel. - kish. the path of embryos of mammals, including and the person, is sterile, but after the birth colonization by its microorganisms which already by the end of the first days can be found in meconium quickly develops. According to Henel (H. Haenel, 1970), in the first days in meconium of newborns manages to find E. coli, Lactobacillus acidophilus and putrifactive microorganisms — Bacterioides, Veillonella, and also Clostridium and Proteus. On 3 days appear enterokokk and staphylococcus. During the breastfeeding by 5th day bifidobacteria appear and at the same time the number of putrifactive microorganisms considerably decreases. In the further period absence or a small number of putrifactive microorganisms is very characteristic of microflora of the children who are on breastfeeding. Upon transition on the mixed or artificial feeding the players of microflora are changed, hl. obr. due to increase in quantity of putrefactive organisms. Eubiotichesky microflora at children of advanced age and adults is similar both on indicators of the total microbic number, and on a quantitative ratio of the main representatives. At the same time at adults more often than at children, such microorganisms as anaerobic streptococci, Cl meet. tetani, number of kinds of bakterioid, PPLO (mycoplasmataceae), the elementary, etc.

Antigenic properties of the microorganisms which are a part of microflora K. Tak concerning E are of special interest. coli are available data that their serotipovy the structure is characterized by very big identity, and also relative constancy at one individuals and a tendency to intensive change at others, and more clearly it is expressed at adults.

Changes of microflora To., going beyond individual fluctuations and shown disturbance of normal ratios between different childbirth of microorganisms, and also their distribution on different departments To., can arise under the influence of a row patol, processes and external influences. Such changed microflora is called disbiotichesky (see. Dysbacteriosis ). Increase in microbic number in a small bowel with domination usually is characteristic of the expressed disbioz Escherichia (see), bacteria of the sort Klebsiella, lactobacilli and enterokokk. In a large intestine and excrements the quantity decreases or completely disappear bifidobacteria (see), fraction of escherichias, streptococci, stafilokokk, yeast, bacteria of the sort Klebsiella, a protea increases. At children whose microecology more labiln, than at adults, the phenomena of dysbacteriosis can be caused by so slight attachments as banal infections, vaccination, jump of a diet. The reasons of a disbioz adults can have diseases of a stomach which are followed by decrease in gastric acidity, a disease of a liver, kidneys, Pernicious anemia, upper part operations went. - kish. path, disturbance of a vermicular movement, cancer. Disbioz can develop as a result of influence of radioactive materials and treatment by antibacterial drugs. Jumps of structure of fecal microflora in the conditions of stressful situations at the people who were in conditions of imitation of long space flight are described.

Disbiotichesky microflora breaks normal activity went. - kish. a path, is a source of the toxicants which are soaked up in a small bowel. Significant increase in microbic number of opportunistic pathogenic bacteriums which reproduction is normal limited can lead to development inf. processes up to sepsis.

The PATHOLOGICAL ANATOMY

Dystrophy

Fatty not digestive infiltration of an epithelium of fibers meets at an acanthocytosis, at Krom in blood serum there are not enough lipids and cholesterol and there are no p-lipoproteins. Lipidic inclusions find in an epithelium of crypts at tropical fever to a spr (see), poisonings floridziny, starvation, after removal of a pancreas. In own plate of a mucous membrane fatty inclusions appear at intestinal lipodystrophies (see), in the centers of an inflammation, around ulcers. At hereditary lipoidoses of adjournment of lipids and holesterinester find in own plate of fibers, an endothelium limf, vessels and in unstriated muscles.

Gidropichesky dystrophy (see. Vacuolar dystrophy ) it is characterized by emergence in cytoplasm of enterocytes of vacuoles of various sizes. This type of dystrophy is described at cholera.

Carry to extracellular dystrophies fibrinoid transformation (see), hyalinosis (see) and amyloidosis (see).

Fibrinoid swelling meets in day of ulcers To. at a disease Krone (see. Krone disease ), tuberculosis, ulcer nonspecific colitis (see) etc., at allergic reactions etc. The result of fibrinoid swelling are the hyalinosis of postulcer hems and a submucosa. A hyalinosis of small arteries To. meets at an idiopathic hypertensia. An amyloidosis To. it is possible both primary, and secondary. According to Gilles (T. Gilat) et al. (1969), from 70 cases of primary amyloidosis in 68 were found defeats went. - kish. path. Microscopic examination To. reveals deposits of amyloid in walls of arteries and arterioles, glybk of amyloid find also between connective tissue fibers.

Pigmentation meet rather often. Gemoglobinogenny pigments are postponed in fibers as a result of a resorption of blood from a gleam To., at hemochromatosis and a posttransfusion hemosiderosis. In reticular fabric — after hemorrhages in a wall To. at its injuries and various inflammatory processes. At the exhausted patients, at elderly people, and also at hemochromatosis and a hypoalbuminemia in muscle fibers K. find a fine-grained light-brown pigment (tseroid), similar to lipofuscin. It is painted in paraffin sections by Sudan black. In a mucous membrane of a large intestine deposits of a dark-brown pigment (a melanosis or an ochronosis of a large intestine) meet. The caecum, then ascending colonic and a worm-shaped shoot is most pigmented. A pigment, the nature to-rogo it is not established, is located in connective tissue cells and histiocytes.

Disturbances of blood circulation

Hyperemia. The arterial hyperemia of a mucous membrane is observed at various inflammatory processes. It is usually limited to certain pieces To. After the ischemia caused by a prelum ascitic liquid there comes decrease in a tone of vessels. Removal of liquid from an abdominal cavity leads to sharply expressed hyperemia. A mucous membrane bright red, usually with dot hemorrhages. Vessels are injected by blood. Most clearly these changes are expressed at tops of folds. A venous hyperemia of all To. comes at the general circulatory unefficiency, and also at portal hypertensia. The venous hyperemia at fibrinferment of mesenteric veins is most sharply expressed. The gut at the same time looks cyanotic, at a long plethora — with a brownish shade. Gistol, a research reveals expansion of the small veins and capillaries overflowed with blood, a picture of a staz, adjournment of hemosiderin.

Local disturbances of outflow of a venous blood are caused by thrombosis, a prelum. veins a tumor, at torsion of a mesentery, invaginations etc. Also general and local infektsionnotoksichesky processes are the reason of thrombosis. Fibrinferments of mesenteric veins at reception of contraceptive drugs are described. The ascending thrombosis extending from small peripheral veins to larger central is followed by earlier and heavier disturbances of blood circulation, than descending since at ascending collaterals do not manage to develop. Acute disorders of blood circulation

are resulted by necrotic changes of a wall of K. Vnachale they take a mucous membrane, but soon extend to other layers. At damage of a mucous membrane there is a picture of a so-called acute ischemic coloenteritis. Alternation of nekrotizirovanny sites with kept, but sharply plethoric mucous membrane is characteristic of it. At microscopic examination the necrosis of fibers with education on the film surface consisting of slime, fibrin, blood cells, unstructured necrotic masses is visible. Crypts, a submucosa and a muscular layer are kept, in them find only hypostasis and hemorrhages, and in small vessels — blood clots. Morson and Dawson (V. S. of Morson, I. The m of P. Dawson, 1971) consider an ischemic coloenteritis result of not occlusal ischemia.

Thrombosis and an embolism of mesenteric arteries and a vein thrombosis conduct to a necrosis of all layers To. — to a heart attack (see). Despite the termination of inflow of blood, not the ischemic, but hemorrhagic heart attack develops that is explained by inflow of blood to an affected area To. on collaterals. The ischemic heart attack meets much less often, it is found at invaginations To., in the restrained loop of a gut at hernias.

In a nekrotizirovanny wall from a gleam To. quickly microorganisms therefore wet putrefactive develops get gangrene (see). The affected area at the same time extends, has crimson and cyanotic, sometimes black color, the wall becomes bulked up, flabby. At gistol, a research treatment of all layers gemolizirovanny blood, diffusion leukocytic infiltration, a set of colibacilli comes to light.

Short-term acute ischemia (see) and gradually developing ischemia connected with partial closing or a prelum of a gleam of a vessel lead to emergence of ischemic strictures and ulcers. They can be different extent, single and multiple, in a large intestine most often ulcers are located in the field of a splenic corner. The mucous membrane is atrophied or ulcerated, the submucosa is replaced with granulyatsionny and fibrous fabric. Here usually the macrophages containing hemosiderin that testifies to the previous hemorrhage find. Connecting fabric sprouts also own muscular coat.

Necrotic changes of a wall To. various origin can lead to perforation and development of purulent peritonitis. The perforated opening can be the small sizes, it is covered with fibrinopurulent imposings and on opening he manages to be found only at a careful research. Edges of an opening represent nekrotizirovanny fabric, diffuzno infiltrirovanny leukocytes.

Fig. 5. Microdrug of a fiber of a jejunum with limfangiektazy: sharply expanded absorbent vessels (are specified by shooters) in distal department of a fiber; coloring hematoxylin-eosine; x 100.

Disturbance of a lymphokinesis comes at blockade limf, ways due to defeat mesenteric limf, nodes tuberculosis, a lymphogranulomatosis, metastasises of cancer, etc. It is macroscopically visible hilostaz (see. Lymphostasis ), thickening of a mucous membrane. At microscopic examination expansion limf, vessels, fibers comes to light (tsvetn. fig. 5) with a thickening and their deformation, wide network limf, vessels is found also in a submucosa.

Inflammatory changes

Inflammatory changes can be diffusion (see. Enteritis, coloenteritis ) or to strike certain departments To.; in these cases they are called by a jejunitis, an ileitis, sigmoiditis (see), proctitis (see) etc.

V K. all types of an inflammation can meet. At an acute catarrh the uneven plethora and swelling of a mucous membrane is observed. Microscopic examination reveals a hyperemia and its puffiness, a hyperplasia of scyphoid cells with signs of the strengthened education and secretion of slime. Quite often, especially at children, the hyperplasia of elements limf, systems is noted. A. I. Abrikosov (1957), in addition to an acute catarrh, allocates chronic, a cut can be hypertrophic and atrophic.

The fibrinous inflammation seldom happens croupous, is more often diphtheritic. the fibrinous plaque at the same time is soldered to a nekrotizirovanny mucous membrane. Preferential cross folds are surprised. After rejection of a scab there are ulcers. The diphtheritic inflammation meets in a large intestine at dysentery, uraemia, poisonings with mercury, etc.

The necrotic inflammation is characterized by primary necrosis of a mucous membrane with the subsequent inflammatory reaction. According to A. I. Abrikosov, similar necroses are caused by an allergy and have «vascular giperergicheskoye» an origin.

The purulent inflammation meets seldom, usually in a look phlegmons (see). A wall To. at the same time it is thickened, it is diffuzno impregnated with pus. Purulent infiltration can extend to a mesentery, purulent thrombophlebitis with pileflebitichesky abscesses of a liver and a septicopyemia is possible. A limited purulent inflammation — abscess To., the apostematous follicular coloenteritis — affects more often a large intestine. Abscess (see) develops on site follicles, the break leads it to formation of follicular ulcers. Small abscesses on site of crypts usually find in a large intestine at ulcer nonspecific colitis (see).

Specific types of an inflammation. Morson and Dawson (1971) distinguish inflammations To., caused by causative agents of infectious diseases: bacteria, viruses, fungi, protozoa, helminths, etc.; inflammations which communication with causative agents of infectious diseases is conditional, and also various mixed inflammatory defeats

of K. K to the causative agents of infectious diseases causing an inflammation To. e.g., carry: a) cholera vibrio; b) Cl. welchii and Cl. perfringens; at the same time the wall of proximal departments of a jejunum (is more rare ileal and colonic) becomes edematous with a plethora of a serous cover, the mucous membrane nekrotizirutsya, are possible perforation; microscopic examination reveals a necrosis of a mucous membrane with hemorrhagic hypostasis of a submucosa and fibrinous — a serous cover; c) E. coli and staphylococcus (see. Enteritis, coloenteritis ); d) tubercular stick. In this case the inflammation is secondary. Syphilis of intestines meets seldom.

Inflammatory changes To. can be caused entero-and adenoviruses. At a viral hepatitis peculiar defeats of a jejunum which, according to A. F. Blyuger et al. (1973), are characterized by a combination limfotsitoretikulyarny and enterotsitarny reaction meet. At the same time in enterocytes of fibers there occur the expressed dystrophic and even destructive changes, in crypts strengthening of proliferative activity of an epithelium is noted. Along with it there is a noticeable increase in infiltration by lymphoid cells of own plate of a mucous membrane. The enteral phase of hepatitis is allocated, at a cut in a jejunum there occur proliferative and destructive changes of enterocytes and lymphoid reticular macrophages of fibers, as well as proliferative changes in area of crypts.

Mycotic damages of intestines meet quite often. Perhaps, it is connected with broad use of antibiotics, immunosuppressive drugs and glucocorticoids. Mucor and Phiz opus can cause erosion and ulcers in a large intestine. In a circle they are found infiltration polymorphonuclear leukocytes, by hemorrhages, sometimes colossal cells. In the thrombosed vessels fungi are found in a large number.

At histoplasmosis of defeat To. are observed in the form of the plaques which are exposed then to an ulceration.

Inflammations To., caused by protozoa and helminths, are described at a schistosomatosis, a strongyloidosis, a coccidiosis, etc. At the same time pictures of enteritis develop or colitis (see).

To inflammations To., which communication with microorganisms is considered conditional, carry a pseudomembranous coloenteritis, an intestinal lipodystrophy, a disease Krone.

In group of the mixed inflammatory defeats To. include eosinophilic enteritis, an eosinophilic granulematozny polyp (an inflammatory fibrous polyp), «nonspecific ulcerations» To. and its defeats at radiation. «Nonspecific ulcers» meet at men in a lean or ileal gut, usually ulcers single more often, but can be located also with small groups. Diameter of their from 0,5 to 4 cm. As a result of scarring the stricture develops To. and expansion of the overlying site. At microscopic examination the necrosis of a mucous membrane, in its circle — a moderate atrophy of fibers, emergence of the mucous glands similar with peloric (a peloric metaplasia), and inflammatory infiltration comes to light. The submucosa is sclerosed. In small vessels organized blood clots are visible. Own muscular coat remains.

The origin of ulcers is connected with the most various reasons, napr, with local action on vessels of the accepted potassium chloride, falling of the ABP at patients with heart diseases, etc.

The characteristic changes of a mucous membrane of a jejunum which are conditionally designated as a jejunitis come to light at not tropical to a spr. At an enterobiopsiya at such patients find shortening and flattening of fibers, deepening of crypts, a thickening of a basal membrane. The mucous membrane looks almost flat. Activity of enzymes of a brush border is reduced, also activity of oxidation-reduction enzymes and acid phosphatase is considerably reduced, and the last gives more diffusion reaction, than normal, concentration of RNA in enterocytes is increased. Electronic microscopic examination finds considerable shortening, expansion, and in places and total disappearance of microvillis of enterocytes. The terminal network is narrowed, mitochondrions and a cytoplasmic reticulum look bulked up, the quantity of ribosomes is reduced, it is a lot of lysosomes, myelin figures and lipidic inclusions. Glycokalexum is kept, however gistokhy, properties of a brush border change: it is almost not painted at CHIC reaction, but gains ability to intensive coloring by alcian blue. Own plate of a mucous membrane plentifully an infiltrirovana lymphoid and plasmocytes, among which at immuno-morfol. a research comes to light many cells containing immunoglobulin G. Similar changes cause disturbance of absorption, connect them with the local damaging action of gluten (gluten) on enterocytes of fibers.

Atonies of intestines can come at peritonitis, renal and hepatic gripes, injuries, abdominal organs operations, at a myocardial infarction and pneumonia. Macroscopically To. looks stretched, its wall is thinned, vessels of a serous cover are full-blooded. Microscopic examination reveals sharp disturbances of blood supply To., hl. obr. in a microcirculator bed in the form of dystonia of capillaries, diapedetic and focal hemorrhages. In intramural nervous gangliya there comes hypostasis of a stroma and a chromatolysis of neurons.

Compensatory and adaptive processes in To. develop after a resection of a stomach and various departments of intestines. K. A. Zufarov allocates three periods in development of the structural changes promoting compensatory adaptations of enterocytes. The first period is characterized funkts, tension of ultrastructures. During this period swelling of mitochondrions and an enlightenment of their matrix is noted. In the second period the hyperplasia of an intestinal epithelium, a hypertrophy of a mucous membrane, increase in number and the sizes of microvillis, a hypertrophy of terminal network and a lamellar complex, expansion of profiles of a rough cytoplasmic reticulum is observed. In the third period there is a stabilization of structural changes.

Fig. 6. Microdrug of a mucous membrane of a jejunum near a gastroenteroanastomosis: the intestinal epithelium (1) on separate fibers is replaced gastric (2); CHIC reaction; X120.

The most brightly adaptive changes after a resection of a stomach come to light near a gastroenteroanastomosis. L. I. Aruin distinguishes four types of such changes. The first type — shortening of fibers and lengthening of crypts. At the expense of it there is sufficient a smaller number of enterocytes (a part them collapses strenuously and torn away) for providing a continuity of an epithelial cover. Lengthening of crypts which cells are saturated with RNA, testifies to the accelerated new growth of an epithelium. The second type — change of qualitative structure of a secret of scyphoid enterocytes, in Krom appears many sulfomucins providing strengthening of protective properties of intestinal slime. The third type — a hyperplasia of scyphoid and apical and granular enterocytes. The fourth type — adaptive substitution of an intestinal epithelium gastric (tsvetn. fig. 6) and education in a jejunum of duodenal glands.

Postmortem changes in To. come very quickly. Within the first hours the autolysis of an epithelium of fibers develops, and they look «naked». Such picture can mistakenly be regarded as «desquamative enteritis». Looking alike supplements with enteritis a posthumous distribution leukocytosis.

METHODS of the RESEARCH

Great value at recognition of diseases To. has anamnesis. Local («intestinal») and general complaints come to light. Among complaints first of all pay attention to the nature of frustration of a chair. Frequency of defecations, quantity and character of fecal masses becomes clear (see. Kal ), existence of sense of relief later defecations (see), the phenomena accompanying it (to pain in the field of an anus, intestinal bleedings, reduction or strengthening of abdominal pains, feeling of swelling and other phenomena). At ponosa (see) a chair frequent, a liquid consistence, at locks (see) defecations are rare and complicated. At an unstable (changeable) chair alternation of locks and ponos is observed. The increased quantity a calla (polyexcrements) testifies to insufficiency of intestinal absorption, napr, at a sprue (see. Malabsorption syndrome ). The remains of badly digested food in Calais can demonstrate disturbances of intestinal digestion, the accelerated evakuatorny function went. - kish. path, insufficiency of gastric and pancreatic secretion. From other local symptoms pay attention to abdominal distention (see. Meteorism ), rumbling and transfusion in a stomach, pain in various departments of a stomach. The nature of the pains connected with pathology To., can be various. At a meteorism of pain most often long, have monotonous character, accrue by the end of day, passages of flatus are facilitated after a chair. Sometimes patients are disturbed by the severe pristupoobrazny pains arising suddenly in different sites of a stomach (colic). Pains can be the constants which are more or less strictly localized, amplify at physical. to loading, jolty driving, at defecation, during an enema that is observed at mezenterialny lymphadenites, periprotsessa. At patients with vascular diseases To. intensity of pains varies from moderate pain after food or physical. loadings to the hardest painful crises. Pains are most often connected with build-up of pressure in thin and in a large intestine that is convincingly proved by means of modern radio telemetric and balloon kimograficheskikh researches. Build-up of pressure in a gut can be caused by a spasm, convulsive reduction of an unstriated muscle, accumulation of gases etc. Pains are caused also by disturbances of blood supply To., irritation of receptors at inflammatory processes. At diseases of a small bowel (except for duodenal) and the right half of thick pain are localized in paraumbilical area (IX and X chest segments), at diseases of the left half of a large intestine — in lower parts of a stomach (XI and XII chest segments), more often at the left. Pains in an anus are characteristic of defeat of distal departments of a large intestine, tenesmus (see) and false desires on defecation. There is a certain communication of complaints of meal, with its character, with time of day, with physical over time. loading, etc. Desires on defecation can soon appear after food (went. - kish. reflex). Rumbling and swelling at diseases To. are most expressed in the second half of day, in the period of more intensive activity of digestive processes. Night intestinal pains, unlike pains at a peptic ulcer, usually arise in the second half of night, sometimes at daybreak that is connected with day-night rhythms of activity To. Emergence of ponos and other dispeptic frustration after reception of certain products, napr, milk, has important diagnostic value. At recognition of defeat of thin department To. the complaints of the general character testimonial of the broken digestion of the main feedstuffs come to light. Here complaints to the general weakness, weight loss, a xeroderma, a hair loss, the increased fragility of nails, bleeding of gums, menstrual disturbances, decrease in libido etc. belong.

At survey pay attention to a form stomach (see), existence of postoperative hems, pigmentation from use of hot-water bottles, a visible intestinal peristaltics. Investigate To. with the help palpations (see), percussions (see) and auscultations (see). At a palpation pay attention to properties of the probed pieces of a large intestine, define their form, size, mobility, morbidity, existence of capotement etc. The small bowel, except for a terminal piece of ileal, is not palpated. At auscultation To. listen to the rumbling and transfusion caused by a peristaltics and passing of vials of gas on loops To., to the filled liquid contents. Existence of these sounds has diagnostic value at a stenozirovaniye To. and its impassability when periodically they can sharply amplify, or at paresis To., when they sharply weaken or disappear completely. A valuable method of a research is also manual inspection of a rectum (see. Rectal research ).

X-ray inspection

X-ray inspection plays an important role in diagnosis of damages and diseases To.

All departments To. investigate before administration of contrast medium to establish distribution in them of gas and contents. Then each part K. study at a different degree of admission it a contrast suspension and at different position of a body of the patient. «Hard» filling is necessary for assessment of situation, a form, size, contours, a smeshchayemost and function of body. Small filling allows to investigate a relief of an inner surface of intestines. Pictures in various provisions (see. A polyposition research) facilitate recognition impassability of intestines (see), appendicitis (see), ulcer nonspecific colitis (see) and adhesive desease (see). At a research K. combine roentgenoscopy and a X-ray analysis. Survey pictures are necessary for studying of topography, size and a form of intestinal loops. Aim roentgenograms allow to study in detail a small segment of a gut, including with the dosed compression. The video magnetic record (see. Television ) and X-ray cinematography (see) give the chance to register all types of intestinal movements. When usual methods are insufficient for diagnosis, resort to pariyetografiya (see), the selection arteriography (see. Seldingera method ) and to other special methods of radiodiagnosis.

Fig. 16. Roentgenograms of a small bowel: 1 — at peroral filling with contrast weight; 2 — at a chrezzondovy enterografiya («hard» filling).

Most fiziol, way of artificial contrasting To. peroral contrasting (a so-called contrast breakfast) by means of 200 ml of a water suspension of fixed white is (100 g of barium sulfate and the same amount of water). In 10 — 15 min. after reception of barium the shadow of the first loops of a jejunum, and in 1,5 — 2 hours — all other departments of a small bowel (fig. 16, 1) is visible. Phases of its filling fix on roentgenograms (usually in 15, 30 min., 1, 2 and 3 hours after oral administration of barium). Shortcomings of this method — duration of a research, big beam loading, difficulty of uniform filling To., projective imposing of loops of a gut at each other. Various receptions for acceleration of a passage of contrast weight on are offered To.: repeated oral administration of small portions of barium, reception at once a big portion (400 ml) of a baric suspension, the accelerated filling by means of additional reception of the cooled water baric suspension, fractional reception of the cooled baric suspension in fiziol, solution. Acceleration of a passage of barium is observed also at introduction of a row pharmakol, drugs (0,5 mg of a prozerin under skin, 40 PIECES of cholecystokinin intravenously, 20 mg of Metoclopramidum intravenously, 30 g of food sorbite inside, etc.). Undesirable effects pharmakorentgenol. techniques strengthening of a tone of a small bowel with narrowing of its gleam, segmentation of contents, increase of secretion are. Therefore introduction pharmakol. it is not necessary to produce drugs at diagnosis of inflammatory diseases To. and at a syndrome of disturbance of absorption. For detection of insufficiency of absorption use food tests. E.g., at disakharidny insufficiency add 25 g of lactose to barium, at the same time the caliber of intestinal loops increases, advance of contrast weight accelerates, liquid contents in a gut increase.

In 5 — 7 hours after oral administration of barium investigate an ileocecal corner, and in 24 hours — all large intestine. The peroral method serves for approximate studying of morphology of a large intestine and for a research of its function. The method is insufficiently informative because of irregularity of filling of a large intestine, hashing of barium with a stake, impossibility of a research of a relief of a mucous membrane. For uniform «hard» filling thin guts use its intubation — a chrezzondovy enterografiya (see. Intubation of intestines ). For a research of a jejunum the end of the extended intestinal probe is left in a duodenum or out on 10 — 15 cm for a dvenadtsatiperstnotoshchekishechny bend. At a postural change of a body and slow swallowing the probe in 2,5 — 3 hours can be entered into an ileal gut. In position of the patient on spin via the probe enter 600 — 800 ml of a baric suspension. Within 7 — 10 min. by means of raying and pictures fix filling of a small bowel (fig. 16, 2) and the beginning of receipt of contrast weight in a caecum. For detailed studying of intestinal loops resort to a relaxation enterografiya. Relaxation of a gut is reached in 8 — 10 min. after an injection of 1 — 2 ml of 0,1% of solution of sulfate atropine intravenously or in 25 — 30 min. after introduction of 4 — 6 ml of 0,1% of solution of Methacinum under skin.

As the basic rentgenol, as method of studying of morphology of a large intestine serves the method of retrograde contrasting (see. Irrigoskopiya ).

Rentgenol, research K. it is widely used for overseeing by dynamics patol, processes at conservative treatment, for studying morfol, and funkts, effects of operative measures on To., for the purpose of diagnosis of postoperative pathology — anastomosites, cicatricial strictures, recurrent tumors.

Endoscopic methods are of great importance in diagnosis of diseases To. (see. Duodenoskopiya , Intestinoskopiya , Kolonoskopiya , Peritoneoskopiya , Rektoromanoskopiya ), allowing to estimate visually character patol, process, to make an aim biopsy of a mucous membrane (for the subsequent gistol, and tsitol, researches), and sometimes and some to lay down. actions (polypectomy, diathermocoagulation of a bleeding point etc.).

Laboratory research

Koprol. the research includes definition of protozoa physical. properties a calla (color, a consistence, reaction) and its microscopy (see. Kal ). Contents in Calais of not enough digested and not soaked up food parts (muscle fibers, cellulose, inside - and extracellular starch, neutral fat, fat to - t, etc.) indirectly confirms disorders of digestive, vsasyvatelny or motive functions K., as well as about disturbances of functions of other departments of system of digestion. Detection of leukocytes, erythrocytes, cells of an intestinal epithelium and slime indicates inflammatory changes of distal departments of a large intestine. Value koprol is big. researches in diagnosis of helminthoses, protozoan invasions. Mikrobiol, the research a calla is necessary at recognition of intestinal infections, dysbacteriosis, and also fungal infections To.

Funkts, methods of a research allow to make idea of a condition of the main functions K., to define extent of their disturbance at various patol, processes, to track efficiency of therapy.

The research of digestive function

In a wedge, practice is used two methodical receptions of a research of digestive function K.: direct definition of activity of digestive enzymes in a mucous membrane of a small bowel, in intestinal juice; a research of a gain of concentration of monomers (monosaccharides, amino acids, etc.) in blood after loading food oligomers, polymers (disaccharides, proteins, etc.). Definition of activity of enzymes in intestinal juice allows to judge a condition of band digestion, and a research of activity of enzymes in homogenate of a mucous membrane of a small bowel and in washouts from it after a desorption — a condition of processes of membrane (pristenochny) digestion. In intestinal juice define activity enterokinases (see) and alkaline phosphatases (see); methods of a research were developed in G. K. Shlygin's laboratory. Activity of these enzymes in juice of duodenal and thin guts at easily proceeding enterita and moderately severe enterita increases that is considered as compensatory reaction; at severe defeats, a mucosal atrophy of a gut — decreases. The research of activity of enzymes allows to define disease severity, to watch dynamics patol, process. About a condition of membrane digestion judge by activity of enzymes in a mucous membrane of the small bowel received by means of an enterobiopsiya. Investigate activity of enzymes in washouts from an integral piece of a mucous membrane of a gut, subjecting it to a preliminary desorption (A. M. Ugolev). This test allows to gain an impression about activity of actually intestinal enzymes translocated on membranes of enterocytes (disaccharidases, peptidases, gamma amylase, etc.), and also the pancreatic enzymes adsorbed on them (alpha amylase, a lipase, etc.) - Investigate activity of enzymes and in homogenate of a mucous membrane of a gut that reflects the general reserve of enzymes in an enterocyte. At recognition of disakharidazny insufficiency (see. Malabsorption syndrome ) define activity of disaccharidases (lactase, invertase, maltase, isomaltase, trehalose, etc.) in a mucous membrane of a small bowel or investigate glycemic curves after peroral loading the corresponding disaccharide. At patients with deficit. disaccharidases activity of enzymes in a mucous membrane of intestines is low, after loading disaccharides do not observe increase in a sugar content in blood or it is insignificant while after loading monosaccharides concentration of sugar in blood increases considerably (more than on 20 mg of %).

A research of vsasyvatelny function

the Most widespread methods of a research of intestinal absorption are based on introduction in To. a certain substance with the subsequent determination of its content in blood, urine, Calais, saliva or in expired air. In the majority they are well had by patients and rather are not labor-consuming. Necessary substances most often enter through a mouth. Results of tests with use of substances which are well acquired by an organism (glucose, triglycerides, fat to - you, amino acids) depend on the speed of exchange processes, intestinal absorption. More fully the condition of processes of absorption is reflected by tests with loading the substances which are only partially participating in metabolism (D-xylose, 3-0-methyl-D-glucose, vitamin B 12 , carotene, etc.). The most exact results gives definition of release of the accepted control substance with a stake since it to a lesser extent depends on a condition of exchange processes in fabrics and on renal clearance, than the content of substances in blood or in urine. Apply a method of the provoked hyperlipemia to a research of absorption of fats: investigated on an empty stomach give fatty loading (1 g of fat on 1 kg of weight of the patient), through certain time terms investigate blood on the maintenance of the general lipids and their components (thin-layer chromatography) or count amount of chylomicrons in blood serum. With normal absorption of fats in intestines loading causes more or less substantial increase of level of lipids in blood in persons. The clinic uses test with loading marked lipids more widely. And rather exact the chemical method of determination of amount of the fat emitted with a stake per day is rather simple. At normal absorption with a stake no more than 5 g of fat are allocated (on nek-an eye to authors, no more than 7 g), the bigger quantity testifies about to a steatorrhea (see) and, therefore, reduced absorption. One of the most exact methods of a research of absorption of carbohydrates is test with D-xylose. Its option with loading of 5 g of D-xylose is most physiologic; excretion of this monosaccharide decides on urine in a 5-hour portion. Normal with urine for this period it is allocated on average apprx. 1/3 entered xyloses. At malabsorption excretion of D-xylose with urine decreases. For sensitization of test and identification reserve funkts, abilities of a small bowel carry out the test twice — originally by a traditional technique and repeatedly in 1 — 2 day, and in 1,5 hours prior to reception of xylose the examinee eats 100 g of the fat-free beef (A. V. Frolkis, R. K. Bushkova, 1976). At kept funkts, reserves of a small bowel loading by meat causes substantial increase of absorption of D-xylose. At defeat of a small bowel the gain of excretion of xylose is insignificant or is absent. Apply tests with marked albumine of human serum, marked amino acids to a research of absorption of proteins, amino acids. Tests with the non-radioactive amino acids (the glycine tolerant test) are less informative. From methods of a research of absorption of vitamins the greatest distribution was gained by the test with marked polyneuramin 12 . Quite simple method of a research of absorption of salts is test with potassium iodide. 0,25 g of potassium iodide enter orally. Time of emergence of iodine in saliva (starched reaction) is noted, at disturbances of absorption time of emergence of iodine in saliva is late. Test is way of approximate assessment of a condition of intestinal absorption.

In a small bowel the perfused technique allows to receive the most exact idea of processes of absorption and secretion. In a jejunum distalny a duodenal and lean bend under rentgenol, control enter thin (to dia. 8 mm) polyethylene three - or the four-channel probe. Inflating of the cylinder attached to one of channels allows to create the closed intestinal segment which is perfused with constant speed. The entered solution along with examinees substances contains not absorbed tap polyethyleneglycol. Comparison of concentration of this tap in perfusate and in aspiration test allows to define precisely amount of the soaked-up liquid, and comparison of concentration of examinees of substances — extent of their absorption. The method of an eyunoperfuziya allows to determine the speed of transit of liquid by a small bowel also. This method differs in the accuracy of results. Methods of a research of vsasyvatelny function K., based on other principles (e.g., a method of balances), are applied seldom because of their complexity, labor input and inaccuracy.

A research of motive function

Methods of a research of a physical activity To. are divided into four groups: registration of changes of intra intestinal pressure; registration of the electric potentials connected with motor activity To.; rentgenol, overseeing by advance of a contrast agent on To.; registration of the sound phenomena arising at the movements K.

The ways based on registration of intra intestinal pressure are deprived subjectivity since record of pressure is made in the graphic way, and changes of pressure can be precisely measured. These methods allow is long to watch motility of intestines. V K. enter a tiny rubber bulb (balloon graphical method) or an open catheter, by means of tubes connect them to the strain gages transforming fluctuations of pressure to electric signals which amplify by means of the electromanometer and are registered the electric recorder. In the analysis of the received curves consider the general time of activity of a gut, quantity of waves in 1 hour, a ratio of waves of various amplitude. A radio telemetric research (see. Endoradiozondirovaniye ) make using the special capsule (radiopills, an endoradiosonde). Methods of registration of the sound phenomena arising at the movements K. (fonoenterografiya), did not gain distribution. Also the elektroenterografiya which is carried out by means of an elektrogastrograf of EGS-4 is seldom applied.

A research of secretory (excretory) function

Allocation by an intestinal wall of protein from blood — fiziol, process. In certain conditions it can amplify, and the organism begins to lose a significant amount of protein (an exudative enteropathy) with a stake. For recognition of the strengthened release of protein in To. use tracer techniques, a research of protein in intestinal juice and in Calais. A research of soluble protein to Calais (electrophoresis) — rather simple method of identification of the increased loss of protein with a stake. This method allows to define also in Calais the protein of other nature in particular getting to kcal at an inflammation of distal departments of a large intestine. By an original method of a research K. the definition in Calais enterokinase and an alkaline phosphatase allowing to judge a condition of chemism in a large intestine is.

Methods of an intravital morphological research

the Biopsy of a small bowel make (enterobiopsiya) or blindly by means of the aspiration probe, most often in a proximal loop of a jejunum, or an aim biopsy through intestinoskop. As contraindication to carrying out a blind enterobiopsiya serve stenoses of a small bowel (danger of jamming of the capsule of the probe), hemorrhagic diathesis, a hypertension, severe forms of atherosclerosis. Before production of a biopsy of a small bowel it is recommended to carry out rentgenol, a research of a stomach and To., and also to define prothrombin time (see), blood clotting time (see), duration of bleeding (see. Bleeding time ). The piece of a mucous membrane of the small bowel received at a biopsy can be investigated by means of usual light microscopy or stereoscopic microscopy (see. Microscopic methods of a research). The stereoscopic microscopy does not demand pretreatment of material and takes not enough time; the mucous membrane keeps the color that allows approximately to natural conditions to consider vorsina of a small bowel. The method gives the chance to obtain bystry indicative information on a condition of a mucous membrane, to choose the site for gistol, researches. At assessment gistol, drugs the descriptive characteristic of the revealed changes is given, and also quantitative measurement of basic elements gistol, structures of a mucous membrane is taken (see. Morphometry medical ).

Distinguish a normal mucous membrane of a small bowel, hron, a jejunitis without atrophy, hron, a jejunitis with a partial fleecy atrophy, hron, a jejunitis with a subtotal fleecy atrophy. The biopsy of a large intestine is made precisely at a kolonoskopiya or a rektoromanoskopiya. Distinguish a normal mucous membrane of a large intestine, a superficial inflammation, a diffusion inflammation, a mucosal atrophy of a large intestine.

Tracer techniques

Methods of radio isotope diagnosis are based on the studying of ways of assimilation and allocation which arrived in To. marked connections that gives the chance to estimate it funkts, a state. At visualization in the way scannings (see) or stsintigrafiya (see) the form, situation and partially (on distribution of radioisotope) function K can be studied.

Most methods of a research of secretory and vsasyvatelny functions using radiofarm were widely used. the drugs which are exposed to digestion and absorption in To. During the studying of absorbing function K. the elementary tracer technique is the test consisting in emergence of the radioiodine accepted through a mouth or entered via the duodenal probe in a thyroid gland found by means of the gamma probe connected to the radiometer. More physiologic and diagnostically justified is use of marked proteins, fats and vitamins. Drugs enter inside, count the radioactivity allocated with urine or a stake by means of the well counter or method of the external account and establish the size of digestion and absorption of these drugs (see. Absorption, methods of a research ). The most sensitive test at diseases To. there was a use of marked lipids which use is based that at disturbances of vneshnesekretorny function of a pancreas process of splitting marked is broken 131 The I neutral fat (trioleate-glycerin, sunflower-seed oil, etc.) at normal absorption marked fat to - you, and at diseases To. digestion and that, and other lipid is broken. For studying of vsasyvatelny ability of an intestinal wall by more rational use fat to - you (olein), marked is 131 I, edges is soaked up, passing process of splitting. Its increased allocation with a stake is the direct instruction on disturbance of absorption in To. Researches by means of marked neutral fats and olein to - you can be conducted consistently one by one or at the same time. At a simultaneous research enter trioleate-glycerin, marked 131 I, and olein to - that, marked 82 Br. Based on the ratio of radioactive bromine and iodine in blood and Calais judge the digesting ability and absorption of fats and find out the reason of insufficiency To. For studying funkts, states To. also marked proteins are used (albumine, marked 131 I, etc.). Studying of absorption by means of vitamin B 12 , marked 58 Co, allows to gain an impression about absorbing capacity of a small bowel and a condition of an internal factor of Kasl. Use for these purposes of radioactive iron matters at diseases To., followed by blood losses. Data on absorption in intestines of a number of electrolytes with the help 42 K, 24 Na, 22 Na, 47 Ca, 46 Ca, etc. characterize went. - kish. phase of water and electrolytic exchange of an organism.

At administration of the same marked drugs in a rectum study absorbability in a large intestine; the data obtained at this research can be used for assessment of distribution of damages of a mucous membrane of this department To.

Secretory function K. study by means of the combined administration of albumine, marked 131 I, intravenously and ion-exchange resins parenterally or intravenous administration of marked krupnomolekulyarny connections (polyvinylpirrolidone, marked 131 I, etc.) with the subsequent determination of radioactivity the external account or in biol, substrates of an organism.

For the purpose of studying motor evakuatornoy functions K. in the conditions close to physiological, apply a method of visualization of body (scanning, a stsintigrafiya) with administration of the radioactive materials which are badly absorbed in To. (Bengalese pink, marked 131 I, colloid 198 Au). The method is based that the specified marked connections are practically not soaked up in To., and therefore the radiation of drug registered by means of the external account allows to track its kinetics on went. - kish. to a path. It gives the chance to estimate quantitatively motive function of a stomach and To., and also to study situation and a form of these bodies in the course of digestion. This method is valuable at a research directly after an operative measure when usual rentgenol. the research is complicated.

Use of these or those tracer techniques for recognition of diseases To. perhaps, e.g., at diagnosis of its new growths. At chronic blood losses for the purpose of detection of hemorrhages in To., at differential diagnosis of anemias use marked erythrocytes (see. Anemia , Gastrointestinal bleeding )

PATHOLOGY

Malformations

Malformations To. are observed preferential at children's age, since the period of a neonatality. Taking into account features of an embrio-pathogeny they can be subdivided into the following groups: anomalies of rotation To., anorectal anomalies, an atresia and a stenosis To., inborn megacolon, Mekkel's diverticulum, K. Chastot's doubling of spread of separate malformations To. it is not finalized. In total one child with a malformation To. meets on 2,5 — 3 thousand which were born.

Anomalies of rotation (disorders of turn K., incomplete turn K., a malrotation To.) arise when in an embryogenesis the normal turn does not come to an end, also one or several pieces proceed incorrectly or in the opposite direction To. (usually blind and duodenal guts) are fixed by commissures (embryonal tyazha) in abnormal situation.

Fig. 17. Diagrammatic representation of incomplete turn of intestines: a prelum of a duodenum embryonal tyazha (are specified by an arrow).

At incomplete turn the caecum usually is located in epigastriß area or near a duodenum (fig. 17). From a caecum there are tyazh of a peritoneum to back or a sidewall of a stomach, causing a prelum of the descending part of a duodenum. To abnormal situation K. lack of a mesenteriopexy accompanies that promotes torsion To., which can occur during the embryonal and post-natal periods. Torsion leads to a prelum of a proximal part of a jejunum, and also to a mesenteric thrombosis, necrosis of an average gut. A prelum of a duodenum and torsion To. meet as separately, and in a combination, in the latter case call pathology Ladd's syndrome (see. Impassability of intestines, at children ). These disturbances are connected with frustration of the second period of turn K.

Also other options inherent, in particular, to disturbances of the third period of turn K are observed.: high position of a caecum (caecum subhepaticum), mobile caecum (caecum mobile), retrocecal provision of a worm-shaped shoot (appendix retrocaecalis). A peculiar picture is observed in cases of turn K. in the opposite direction: over an upper mesenteric artery there is a cross colon, and over it a duodenum.

A wedge, manifestations of anomalies of rotation To. hl are variable and depend. obr. from the complications arising afterwards. Embryonal tyazh in some cases squeeze a gleam of a duodenum, and then the picture of acute high intestinal impassability develops. Symptoms at torsion of a small bowel are brightest. In cases of a moderate prelum of a gleam To. the phenomena of the partial alternating obstruction prevail, recurrent pains in a stomach are observed. Duration of light intervals — from several days to several months. The diagnosis in these cases is established at more advanced age. Incomplete turn K. can be an accidental find at rentgenol, a research or on operation.

Diagnosis of anomalies of rotation To. is based on a X-ray contrast research, a cut begin with administration of air (at newborns) or a baric suspension through a rectum. In not clear cases a research K. carry out after administration of barium through a mouth. Judge existence of incomplete turn on the basis of the following signs: a) verkhnegorizontalny and the descending parts of a duodenum are expanded, a distal part it is located vertically and is easily displaced at a palpation; b) To. it is located unusually — all large intestine is at the left, and thin on the right; c) the caecum at repeated researches does not change localization and is usually located in an upper quadrant.

Treatment of anomalies of rotation To. in most cases operational. At acute impassability the emergency intervention at any age is shown. At hron, recurrent impassability, depending on degree of manifestation of signs, operation is carried out in an urgent or planned order. Asymptomatically the proceeding and accidentally found anomalies of operational correction are not subject, however it is necessary to inform parents of the child on a case of a possible disease of an acute appendicitis on them, the picture to-rogo in similar situations is atypical.

Fig. 18. The diagrammatic representation of some stages of operation at Ladd's syndrome (a prelum of a duodenum and torsion of intestines): and — untwisting of torsion (it is specified by an arrow) and a section embryonal tyazhy (dash line), squeezing a duodenum; — fixing duodenal (1) and the blind person (2) guts.

The essence of an operative measure consists in a section tyazhy, elimination of torsion. The caecum is reduced to the right ileal area and fixed without tension to a parietal peritoneum 2 — 3 seams. If it does not work well, the dome it is fixed to a sigmoid gut seromuskulyarny seams. The duodenum is also fixed to a parietal peritoneum (fig. 18).

The immediate and long-term results of operational treatment of anomalies of rotation To. at children in most cases good.

by Fig. 19. Diagrammatic representation of some types of atresias and intestinal stenoses: and — a single atresia; — a multiple atresia; in — narrowing of a gut with gradation; — a hymenoid form of a stenosis; shooters specified places of pathology

Atresia and stenosis of thin and colonic guts are a consequence of disturbance of a stage of vacuolation in the course of embryonic development To. also arise in those places where vacuoles did not connect or the layer of endodermal cells disappeared not completely. Various anatomic options of this pathology (fig. 19) meet. The most frequent localization — duodenal and a jejunum, the most rare — a colon. A wedge, manifestations are caused by extent of closing of a gleam To. and level of localization of an obstacle. At the atresia and sharp degree of a stenosis which are localized at the level of a duodenum (see) and initial department of a jejunum, observe a picture build in high impassability To., for a cut the vomiting arising from the first hours of life and gradually amplifying especially after feeding is characteristic. The stomach is blown up in epigastriß area and moderately sunk down in lower parts. As a rule, the single otkhozhdeniye of meconium in quantity a little smaller, than at the healthy child is noted. At the same degrees of an obstacle in the level of ileal and colonic guts the picture of acute low impassability develops To., the main symptom a cut — lack of an otkhozhdeniye of meconium even after enemas. Vomiting develops with 2 — the 3rd day of life, does not depend on feeding, and soon emetic masses has impurity of intestinal contents. Abdominal distention accrues, early there are signs peritonitis (see) owing to perforation of a hyperinflate intestinal wall. Unsharply expressed narrowing of upper parts To. long time can remain hidden, and symptoms of a disease are shown at more advanced age in the form of vomiting, vomiting by congestive gastric contents. Abdominal distention in epigastriß area, a visible peristaltics of a stomach is quite often noted. The chair is normal, it is sometimes detained for several days. Babies badly put on weight. Narrowing of ileal and colonic guts has scantier symptomatology in the beginning: easy locks and painful attacks, loss of appetite. In process of easing of compensatory abilities To. the picture becomes more certain — painful attacks become more intensively and repeat more often, the delay of a chair is longer, the stomach increases, there is vomiting; intoxication, hypochromia anemia develops hron.

Diagnosis is based on complex assessment a wedge, symptoms and data survey and contrast rentgenol, researches K. In cases of chronically proceeding disease kliniko-rentgenol, the picture gives the grounds to make the diagnosis of a megaduodenum, the megaileuma, megacolon, one of the reasons of which is an inborn stenosis To.

Treatment operational. Operation after the corresponding preparation is carried out in the emergency or planned order. The type of intervention is chosen according to character and level of an obstacle: a membranectomy of a duodenum at its stenosis or a bypass anastomosis at an atresia, bowel resection with an anastomosis the end in the end, etc.

The forecast at an atresia To. at newborns it is always serious; at a stenosis the forecast is in most cases favorable.

Anorectal anomalies represent group of inborn malformations of an anus and a rectum: lack of an anal orifice, an obliteration of all rectum or its terminal department, a stricture of a rectum (see. Anus , Rectum ).

Inborn megacolon — expansion of all large intestine or speak rapidly it with a hypertrophy of a wall, caused by anomaly of a peripheral nervous system — absence or reduction gangliyev (see. Megacolon ).

Doubling (an accessory stomach, duplication To., the enterokistoma) arises for the reasons which are not found out still up to the end. One of the most widespread hypotheses of Bremer (J. L. Bremer, 1944) treats it as disturbance of vacuolation of a gut when, e.g., recovery of a gleam happens not in the center of a gut, and two parallel rows on a certain site; two equivalent tubes form.

Fig. 20. Diagrammatic representation of some forms of doubling of intestines: and — a habit view of the doubled small bowel (it is specified by an arrow); — d — in a section (the additional tube is connected to the main): — in an upper part, in — in a lower part, one or both the ends, d — the isolated doubling — an enterokistoma (shooters specified the direction of the food gruel arriving from a stomach).

Doubling represent the spherical or extended educations, thick-walled, closely soldered to adjacent site K. and located on a mesenteric or side edge. Duplication can be isolated or be reported proximal, distal or both ends with a gleam of the main tube (fig. 20). Sometimes doubling has an appearance of a diverticulum which, unlike Mekkel's diverticulum, is supplied with a mesentery. The structure of a wall of additional education, despite considerable looking alike the main intestinal tube, differs in a number of features, in particular existence of epithelial heterotopic structures. More than in half of cases doubling is localized on the course of a small bowel. The isolated forms are observed in 80% of cases which are reported with the main tube — in 20%.

A wedge, manifestations quite widely vary depending on localization, size and a form patol. educations, the come complications. A frequent symptom are the abdominal pains arising as owing to restretching of walls of a cyst the accumulating liquid, and owing to the developing impassability To. During an attack of pains sometimes there is vomiting, tension of belly muscles, a visible peristaltics of guts is noted. Impassability in one cases happens acute, in others has character hron, recurrent. Sometimes the child has intestinal bleedings of various intensity caused by a local necrosis, inflammatory process or existence of a round ulcer at a heterotopy of a mucous membrane of a stomach. On site a round ulcer and a local inflammation there can be a perforation of a wall of additional education, the picture of acute purulent peritonitis with the corresponding symptomatology develops.

The diagnosis is difficult and is put, as a rule, by process of elimination, and also during trial laparotomies (see). The wedge, symptomatology, palpatorny definition in an abdominal cavity of tumorous education forms the basis for the last. At the reported forms the correct diagnosis can be promoted rentgenol, by a research K. At localization of duplication in a large intestine diagnosis is a little facilitated. Existence of an additional anal orifice can be a reliable symptom, auxiliary signs can be considered doubling sexual and urine of the removing bodies.

Treatment only operational. Various localizations and forms of doubling demand in each case of use of various operational receptions. In a most cases the isolated removal of duplication is impossible, and it is resected together with related department of a digestive tube.

The forecast in uncomplicated cases is favorable.

Mekkel's diverticulum (see. Mekkelya diverticulum ) results from the wrong and unfinished involution of an embryonal enteroumbilical gastric channel.

A diverticulum of intestines — the inborn or acquired protrusion of a wall To., reported with its gleam. Meets in thick and duodenal guts more often. The wedge, symptomatology arises, as a rule, at emergence of complications — intestinal bleeding or a diverticulitis (see. Diverticulum ). Treatment is usually operational, however in some cases it is necessary to be limited to conservative actions.

Damages

Damages To. arise at a stupid injury of a stomach or getting (knife, fire) wounds stomach (see) and at wound of a gut from within foreign bodys (see).

The closed damages can arise owing to blow in a stomach a hoof, a fist, a leg, the jumped aside subject (pigs, boards, etc.), prelums between buffers, at a collapse of the fallen houses, falling from height. Damages were observed To. from strong reductions of a prelum abdominale without immediate effect of external force on walls of a stomach. Gaps are possible To. at reposition of hernia. At application of force in the slanting direction to a stomach there can be separations To. from a mesentery, ruptures of an intestinal wall at the fixed places (initial department lean and final department of an ileal gut) as a result of shift and an excessive tension. Similar gaps occur sometimes and during the falling on legs or on buttocks, sometimes even from insignificant height.

In wartime the closed damages To. influences of a blast (shock) wave result, during the falling from height, blows in a stomach, a prelum of a trunk heavy objects, fragments of constructions, etc. In the Great Patriotic War of 1941 — 1945 the closed damages To. made 36% to number of all closed damages of bodies of a stomach, at the same time, by data I. D. Krivorotova (1949), in 80% of cases was damaged a small bowel, and in 20% — thick.

Open damages (wounds) are a consequence of the getting wounds of a stomach. In peace time of wound To. can be caused by horns of an animal, a pitchfork, a knife, a sharp object; during war — it is generally gunshot wounds.

In the Great Patriotic War at wounded with damage of hollow bodies of a stomach the isolated and combined wounds of a large intestine made 56%, and thin — 55% of cases. The combined and multiple wounds were more often observed To. Missile wounds prevailed. Bullet wounds of hollow bodies most often were through, and fragmental — blind people.

The pathological anatomy

the Damage rate of a gut at the closed injury of a stomach happens various — from a bruise of its wall to a complete separation on all circle. At bruises of walls of guts petekhialny hemorrhages on serous and mucous covers, multiple and massive hematomas on a big extent of guts, anguishes of a serous cover are observed. Gaps happen single and multiple. Gaps occur in a lower part of an ileal gut more often. The sizes and a form of the formed defect can fluctuate in considerable limits. They can have an appearance of widely gaping round, oval or rhomboid openings with numerous hemorrhages in an intestinal wall or to be slit-like, are more often located cross and at free edge of a gut. Sometimes the full cross break of a gut meets.

At open damages To. in a wound opening if it not really a little, almost always drops out a mucous membrane of a gut; she lays down on a serous cover of a gut on edge of an opening like the roundish roller. It does not occur at small openings and at the wounds which are followed by big destruction of a mucous membrane. Loss of a mucous membrane interferes with covering of a wound of an intestinal wall by adjacent bodies. Therefore at wound of a gut there is an outpouring of contents in an abdominal cavity and emergence of diffuse peritonitis (see).

In the presence of a wide wound of an abdominal wall intestinal loops can have to stream in a wound and their contents outside.

On the nature of damage all gunshot wounds To. superficial ruptures and wounds of a wall are divided into contusions of walls with formation of subserous and submucosal hematomas, both from serous, and from a mucous membrane, perforated defects of a wall with loss and without loss of a mucous membrane, cross gaps (full, incomplete), longitudinal ruptures, separations of part K. from a mesentery.

Wound of a gut is always followed by bleeding, especially if the mesentery is damaged. The blood streaming in an abdominal cavity does not turn even in trace amounts and, mixing up» with intestinal contents, promotes development of an infection, edges quickly spreads to all departments of an abdominal cavity.

A clinical picture

at the time of a rupture of a gut at a stupid injury of a stomach severe pains in a stomach develop, shock (see), a muscle tension (see. Muscular protection symptom ) and morbidity at a palpation. Pulse is speeded up, language wet. At percussion reduction of the extent of hepatic dullness due to accumulation of gas in subphrenic space is defined. Further the stomach begins to be blown up, pulse becomes frequent, language becomes dry and the typical picture of diffuse peritonitis develops.

For open damage (wound) To. the triad of symptoms is characteristic: shock, blood loss and peritonitis. Abdominal pains of various intensity are observed at all wounded, pains in the field of side departments of a stomach are noted at damage of the corresponding pieces of a large intestine. Also vomiting (65% of cases), dryness of language, a delay of a chair and gases (91%), increase of pulse (St. 100 blows in 1 min.), a muscle tension of a stomach (75%) with sharp morbidity is observed at a palpation, Shchetkin's symptom — Blyumberg on all stomach. At percussion of a stomach dullness in sloping places, testimonial of availability of blood, the streamed contents is defined To. or inflammatory exudate. Most often accumulation of liquid is defined in ileal areas. Lack of noise of a vermicular movement during the listening of a stomach and swelling confirm the come paresis To.

The diagnosis at the closed injury is based on data of the anamnesis, the stated above symptoms and data rentgenol, researches.

The rupture of a small bowel at a part of patients causes emergence of free gas in an abdominal cavity.

At other patients radiodiagnosis is based on indirect signs — fluid accumulation in side departments of a stomach and in a basin, paralytic impassability To. The intraperitoneal rupture of a large intestine, as a rule, gives a picture of a pneumoperitoneum. At an extra peritoneal gap accumulation of gas is observed in retroperitoneal space (see) and sometimes in an abdominal wall. In doubtful cases in the diagnostic relation the laparocentesis (see) or the emergency laparoscopy is shown (see. Peritoneoskopiya ). At unconvincing or doubtful results of these methods sometimes it is necessary to resort to a diagnostic laparotomy.

For establishment of the topical diagnosis at open damages To. some data can be obtained at a research of localization of wound openings. At the isolated wounds of a small bowel inlet wound openings are located on a front abdominal wall (60,8% of cases) more often, and a half of them is localized in its lower part. At localization of wound openings behind in buttocks and a sacrum also wounds of a small bowel are more often observed. At the isolated wounds of a large intestine wound openings are located preferential in side departments of a front abdominal wall and is almost equally frequent in upper, average and lower its departments or in lumbar area. Sharply expressed phenomena of peritonitis and shock to a certain extent are characteristic of the isolated wounds of a small bowel rather serious condition of wounded during the first hours after wound. At the isolated wounds of a large intestine which are not followed by massive destructions or bleeding rather satisfactory general condition of the wounded is quite often observed. It is possible to diagnose wound of a gut quite often on character of the contents following from a wound To.

Treatment

At all types of damages To. only early operation is only a rational method of treatment. First of all it is necessary to bring the patient out of shock. Along with holding antishock actions attentive constant overseeing by change of a state is necessary. Increase of the peritoneal phenomena or deterioration in the general state are the indication to the emergency laparotomy. If it is not possible to bring during 1 — 2 hour the patient out of shock, then operational treatment is shown. It is the best of all to make operation under an endotracheal anesthesia, local anesthesia does not give the chance to make careful audit of abdominal organs.

Preference is given to the median laparotomy convenient for bystry audit and a hemostasis, sometimes with an additional section in the transverse and kosopoperechny direction. The loop of a gut which dropped out at wound is washed, the wound of a stomach in this place is a little expanded, produce anesthesia of a mesentery and the unimpaired loop is set in an abdominal cavity. The damaged loop is wrapped a napkin and left on an abdominal wall. Further surgical tactics depends on the found changes. At plentiful bleeding first of all find its source and make its final stop. Only after that pass to careful audit of bodies of a stomach, to detection of damages and the solution of a question of the volume of an operative measure, a cut shall have the expressed savings character. Unconditional preference is given to organ-preserving types of surgical interventions.

At damages of loops of a small bowel make sewing up of a wound in transverse direction (in order to avoid narrowing) two rows of seams. An enterectomy make preferential at full breaks it, existence of the wounds in a wall of a gut reaching the considerable sizes, the multiple wounds of a gut which are close located one from another at a separation of a mesentery.

At injuries of a large intestine by a main type of an operative measure also sewing up of wounds a three-row seam is. At big wounds of a large intestine, its partial or complete separations, at the wounds which are followed by disturbance of an integrity of vessels of a mesentery it is possible to make a resection or that is more reasonable at serious condition of the wounded, removal of the damaged site of a gut with formation of fecal fistula (see. Intestinal fistulas). The final stage of a chrevosecheniye at wounds To. the toilet of an abdominal cavity is: removal of the particles which got to it a calla, clots and an inflammatory exudate with the subsequent washing of an abdominal cavity of 3 — 5 l warm fiziol, solution. For the prevention of postoperative paresis To. sometimes make suspended enterostomy (see. Enterostomy ). By an effective method of prevention and treatment of peritonitis at wounds To. also the hl is intravenous, intramuscular. obr. systematic intraperitoneal introduction through thin drainages of antibiotics of a broad spectrum of activity. At common forms of peritonitis use of a method is shown peritoneal dialysis (see), consisting in the round-the-clock introduction within 3 — 4 days to an abdominal cavity with the subsequent evacuation through drainages of large amounts of the liquid (to 5 — 6 l) containing antibiotics.

The most terrible complications are peritonitis, paralytic impassability of intestines (see), suppuration of a wound of an abdominal wall, eventration of loops of a small bowel (see. Eventration ), formation of interintestinal abscesses and intestinal fistulas.

Wounds of a gut from within acute foreign bodys demand also immediate surgery.

Stage treatment

the First and pre-medical help in the battlefield or in the center of mass defeat at open damages To. consists in imposing on a wound of a big aseptic bandage. The dropped-out loops To. do not set, and fix a bandage to an abdominal wall. Both at open, and at the closed damages To. introduction of analgetics from the syringe tube and bystry evacuation from the battlefield is necessary in regimental medical aid station (see) or directly in medical and sanitary battalion (see), and in the conditions of GO — in group of first aid (see).

The first medical assistance on PMP consists in correction of bandages, administration of antitetanic serum with anatoxin, analgetics and antibiotics. According to indications carry out antishock therapy. Hemotransfusion is allowed only at life-threatening blood loss. At the closed damages To. before establishment of the exact diagnosis it is necessary to be careful concerning use of analgetics. All victims with the opened or closed damages To. first of all evacuate in MSB or cold season of victims before evacuation wrap O. V OHM in a blanket, sleeping bags and lay over hot-water bottles.

The qualified help to victims with damage To. (or OHM About) includes urgent operation in MSB. The choice of optimum terms of the beginning of operation by the victim in state of shock is always a question at issue of surgical tactics. It is necessary to refuse completely the recommendation occurring in practice — before to bring out of shock, and then to operate since it does irreparable harm. In some cases operation can be the most effective method of controlling with shock and a collapse owing to a stop of bleeding and elimination of the factors causing irritation of a peritoneum (sewing up of a wound To.).

Operation is contraindicated at critical condition of victims when it does not improve, despite intensive antishock actions. Operation is contraindicated also at an otgranicheniya of inflammatory process in a stomach after long terms from the moment of wound and satisfactory condition of struck. In all other cases the laparotomy and the more urgently is shown, than shock is heavier.

Operation is performed under the general anesthesia with muscle relaxants. Completion of blood loss during operation and after its end — one of the central moments of the resuscitation help.

In the conditions of civil protection of victims with damages To. evacuate in OPM where complex therapy of shock is carried out, according to indications enter anesthetics, cardiovascular and respiratory means, antibiotics and serums. In OPM surgeries according to vital indications (the proceeding intra belly bleeding) depending on a medical situation can be performed. In particular, at mass receipt if in the course of medical sorting is established that victims with damage To. it will not be possible to send to operational OPM in the next few hours, they should be evacuated urgently in corresponding pro-thinned out-tsu hospital base (see).

Specialized medical aid at damage To. it is carried out in specialized surgical hospitals of GB of the front or in-tsakh hospital base. It consists in an aftercare struck, operated in MSB, OMO or OPM, in performing the surgeries which are not executed at the previous stages, identification and treatment of late complications and also in carrying out recovery operations. Concerning victims whom did not operate at the previous stages, surgical tactics, generally same, as in MSB, OMO or OPM.

At the combined radiation damages, i.e. the injuries of intestines flowing against the background of radial illness (see), add treatment of radiation defeat and its effects to operational and conservative treatment of victims.

Diseases

Intestinal syndromes

concern To the most important of them a syndrome of insufficiency of digestion, a syndrome of insufficiency of absorption, a syndrome of an exudative enteropathy. These syndromes of a polietiologichna, they are observed not only at pathology To., but also at diseases of other bodies.

Syndrome of insufficiency of digestion — a wedge, the symptom complex caused by disturbance of digestion of feedstuffs owing to deficit of digestive enzymes (see. Enzymopathies ) on intestinal membranes (disturbance of membrane digestion), in a cavity of a small bowel (disturbance of band digestion). Main reasons: insufficient production of digestive enzymes small bowel or pancreas, disturbances of the conditions necessary for normal functioning of these enzymes. Insufficient products of enzymes in a small bowel can be a consequence of genetic defect or result acquired patol, the processes disturbing synthesis of intestinal enzymes. Functioning of digestive enzymes suffers at reduced ability of a mucous membrane of a small bowel to adsorb them on the surface, at disturbances of motor function K., at change of reaction of an intestinal chyme, at the increased bacterial population of a small bowel, etc. Enzymopathies of a small bowel are the leading pathogenetic mechanism of a syndrome of insufficiency of digestion.

There is a classification of enzymopathies of a small bowel. Inborn enzymopathies: 1) insufficiency of disaccharidases (deficit of lactase without lactosuria; lactases with a lactosuria; invertases and isomaltases; trehaloses); 2) insufficiency of peptidases (inborn gluten enteropathy); 3) insufficiency of enterokinase. Acquired enzymopathies (mono enzymopathies, a polyenzymopathy): 1) inflammatory (coloenterites, disease Krone, ulcer colitis, diverticulites, etc.); 2) functional (at diskineziya To.); 3) infectious (dysentery, salmonellosis, etc.); parasitic (lambliasis, etc.); 4) post-resection (enterectomy); 5) gastrogenic (peptic ulcer, gastritises); 6) pankreatogenny (pancreatitis, mucoviscidosis); 7) hepatogenous (hepatitises, cirrhoses of a liver); 8) medicamentous (at reception of antibiotics, tsitostatik); 9) beam; 10) endocrine (at diabetes, a hyperthyroidism, etc.).

The syndrome of insufficiency of digestion irrespective of the nature of a basic disease is followed by ponosa, a meteorism and other dispeptic frustration. Quite often into the forefront symptoms of intolerance of certain feedstuffs act. Disturbance of digestive processes leads to disorders of absorption of feedstuffs since products of incomplete hydrolysis are badly soaked up, and in this regard also the general condition of patients suffers. One of the most frequent forms of insufficiency of digestion is the intolerance disaccharides (see). 25 — 30% of carbohydrates of food are the share of disaccharides that testifies to importance of this type of digestive frustration. To development of disakharidazny insufficiency (see. Malabsorption syndrome ) along with hereditary factors, patol. processes in system of digestion, iatrogenic influences also some household intoxications, napr, an alcohol abuse can promote. Most often the lactose intolerance meets. It especially hard proceeds at early children's age when after consumption of milk profuse diarrhea develops, excrements become liquid, volume, foamy. Patients are disturbed by nausea, vomiting, abdominal pains, swelling, there comes exhaustion. Adults have a wedge, displays of a disease are less expressed. In 1 — 2 hour after reception of milk the feeling of completeness in a stomach, swelling appears. In some cases at adults the disease can hard proceed, with attacks of partial intestinal obstruction. Lactose in itself, as well as other disaccharides, has no toxic effect. The split disaccharides are soaked up in a small bowel, getting in thick, they are exposed to bacterial decomposition with education organic to - t, hl. obr. milk and acetic which have osmotic activity and cause inflow of a large amount of water in To., what brings to a diarrhea, to a meteorism. With a stake in the increased quantities it is allocated milk to - that, disaccharides, pH of excrements decreases. Despite a low lactase activity, structural disturbances of a mucous membrane of a small bowel are absent. At deficit of invertase and isomaltase of a ponosa and other dispeptic phenomena appear at inclusion in food of sucrose and starch. Disaccharide trehalose in food of the person meets in mushrooms, at deficit of trehalose the use them in food causes ponosa. Insufficiency of an enteropeptidaza, the main enzyme of a proteopepsis, can be inborn and acquired. At the same time band digestion and, apparently, membrane digestion as activity of enzyme in a mucous membrane of a small bowel is higher, than in juice suffers.

Treatment first of all is directed to a basic disease. In cases of the selection enzymatic defects, especially at disakharidazny insufficiency, the exception of a diet of the corresponding products is required. At a lactose intolerance exclude from food milk, kefir, the chocolate possessing at similar states aperient action. Butter and cheese are usually well transferred. To babies appoint artificial milk, free of lactoses. Stimulation of enzymatic function of a small bowel of hl. obr. at the acquired intestinal enzymopathies it can be reached by purpose of Corontinum (Falicorum, diphryl), phenobarbital, Nerobolum, folic to - you.

Syndrome of insufficiency of absorption (malabsorption) — wedge. the symptom complex caused by disturbance of food of an organism owing to disorders of processes of absorption in a small bowel. The main mechanisms of this syndrome are structural changes of a mucous membrane of a small bowel, disturbance of processes of digestion of feedstuffs, frustration of specific transport mechanisms, intestinal dysbacteriosis, motive disturbances To. (see. Malabsorption syndrome ).

Syndrome funkts, insufficiency of absorption — rather seldom found inborn disturbance of absorption in a small bowel of monomers (monosaccharides, amino acids) caused by deficit in a mucous membrane To. specific enzymes carriers. At glyukozogalaktozny malabsorption transport of glucose and a galactose through an intestinal wall therefore inclusion in food of the products containing these sugar causes a diarrhea is broken. Splitting of disaccharides is not broken. At fructose malabsorption went. - kish. disturbances come after reception of fructose, other monosaccharides are soaked up well. Funkts, a syndrome of proteinaceous malabsorption is not always followed by ponosa. It is characterized by deficit of the amino acids which were not absorbed derivatives of amino acids, an allergy. At tryptophane malabsorption there is an isolated inborn defect of transport of tryptophane which is followed by locks, fever, consecutive infection. Diapers of such patients (the disease is shown soon after the birth) are painted by oxidates of an indican in blue color.

Syndrome of an exudative enteropathy (see. Enteropathy exudative ) — a wedge, the symptom complex arising owing to the increased release of protein from a blood channel in To. and its losses with a stake. Primary exudative enteropathy is observed at a rare disease — an idiopathic intestinal lymphangiectasia — the congenital anomaly which is characterized by expansion limf, vessels of a small bowel. Secondary exudative enteropathies meet more often than primary. They are divided into enteropathies owing to diseases To., gastrogenic, pankreatogenny, hepatogenous, etc.

For a wedge, pictures peripheral hypostases, in hard cases ascites, an exudate in a pleural cavity, dystrophic changes of various bodies are characteristic. The hypoproteinemia is observed, at the same time the content in blood of albumine and gamma-globulins most decreases. Unlike a nephrotic syndrome, ROE increases slightly or remains normal; concentration of fibrinogen and other factors of coagulant system of blood changes a little. Due to intestinal exudation of transferrin the iron deficiency anemia can develop. With protein calcium is lost that leads to spasms of gastrocnemius muscles, in hard cases — to a tetany. Loss of ceruloplasmin causes deficit of copper in an organism. In blood the maintenance of lipids, cholesterol decreases. The lymphopenia arises owing to loss of lymphocytes with a lymph through To. For treatment appoint a diet with the increased protein content, but poor in fats (for unloading limf, vessels); parenteral administration of proteinaceous drugs is shown, at bent to an infection — gamma-globulin; introduction of Spironolactonums, drugs of calcium, iron, vitamin D, corticosteroids, anabolic hormones, adrenomimetichesky means, the drugs oppressing a fibrinolysis is reasonable.

Functional diseases

Dyskinesia (an irritable colon, a spastic colitis, pseudomembranous colitis) — the disturbances of motor function of a large intestine caused by disorders of regulation and to a lesser extent a small bowel. Dyskinesia To. are one of the most frequent diseases of the digestive system, meet usually at the age of 20 — 50 years, women are ill approximately twice more often than men. At primary diskineziya motor disturbances To. — basis of a disease. Them the psychogenic factors disturbing nervous control of motor function K are the most frequent reasons. Usually it is the long negative emotions which are quite often arising at children's age. The known role is played also by disturbances humoral and first of all hormonal regulation of intestinal motility, the use of the food containing few slags. Dyskinesia To. can arise because of food allergy, as a result of abuse of drugs. Secondary dyskinesia To. appear at diseases of other bodies (a peptic ulcer, hepatitis, diseases of bilious ways, a pancreas, kidneys and urinary tract, closed glands, disturbances of mezenterialny blood circulation, etc.). In similar cases motor frustration To. are a consequence of reflex influences from the struck body, endocrine influences or result from the same reasons, as a basic disease. Clinical forms of primary diskineziya To.: with neurogenic locks (see), with bezbolevy ponosa (nervous diarrhea, emotional diarrhea with change of locks and ponos); with the isolated pain syndrome without frustration of a chair (a painful form). At diskineziya coordination of separate types of the movements K is broken., in various pieces of a gut there are hyperkinetic (spastic) or hypokinetic (atonic) changes, but usually both types of frustration are combined. At diskineziya with locks, especially at men, hyperkinetic disturbances prevail, certain sites of a large intestine spastic are reduced (kolospazm).

For most of patients with diskineziya To. abdominal pains are characteristic. Pains can be felt in all stomach or in its certain sites. At the extended sigmoid colon they can be localized not in left, and in the right ileal area. Quite often these pains simulate diseases of other bodies. At preferential dyskinesia of a caecum of pain can simulate the appendicitis, pains caused by motor disturbances in the field of the right bend of a colon — cholecystitis, and caused by motor disturbances in the area • the left bend of a colon (a syndrome of a splenic corner) — heart diseases, etc. Abdominal pains can vary from the long aching pains to attacks of intestinal colic. Quite often intensity of pains, time of their emergence and localization change. There are no periods of good health which are inherent to organic diseases To. Sometimes abdominal pains appear after food (strengthening of motility), are followed by swelling, but are never facilitated of meal, often amplify at various emotional influences. Locks are one of the most frequent symptoms diskinezy K. Neredki of mucifying, edges or is mixed with a stake, or is on its surface. Sometimes slime is emitted independently in the form of films — mucous colic (see. Colic mucous ). In some cases the strong mental overstrain can be followed by allocation of a significant amount of liquid slime. At food allergy (see) acute colicy pains in a stomach (intestinal crisis), a frequent liquid chair with allocation of mucous films quite often appear, in Calais sometimes find eosinophils, Sharko's crystals — Leyden. Similar states often are followed by other allergic symptoms (a small tortoiseshell, a Quincke's edema, migraine, etc.). In cases of nervous diarrhea of an excrement liquid, kashitseobrazny or watery, without slime and blood, are not followed by pains. For diskineziya To. signs of the general vasculomotor lability are characteristic: heartbeat, pressure sense in a breast, an asthma, bystry fatigue at small physical. loadings, perspiration, headaches, face reddening, cold wet brushes, etc. Course of a disease long. The disease can be complicated by colitis (coloenteritis) at abuse of drugs, in particular laxatives, and also because of accession of consecutive infection. Sometimes dynamic intestinal impassability with attacks of paroxysmal gripes («belly epilepsy») develops.

The diagnosis of dyskinesia To. becomes reliable only after an exception of organic diseases To. At a palpation of a stomach the reduced painful pieces of a large intestine, sometimes peristaltiruyushchy near at hand are found spastic. Certain sites of a gut can be weakened, expanded. At a manual research (see. Rectal research ) the rectum is usually empty, reduced, painful. At an irrigoskopiya (see) find spastic haustration, filling of a large intestine discontinuous, painful, its capacity is reduced. At kolonoskopiya (see) a mucous membrane of a large intestine can be injected or congestive, but does not bleed, it is covered with slime, the gut spastic is reduced by places. At a biopsy To. changes are not found. Koprogramma normal.

At secondary diskineziya To. first of all treatment of a basic disease, the psychotherapy including a detailed explanation to the patient of essence of a disease and on the basis a wedge is carried out., rentgenol, and endoscopic data a motivated exception of an organic disease (it is especially important at a cancerophobia). At dominance of hyperkinetic motor disturbances with the expressed spastic phenomena temporarily appoint a sparing diet with restriction of food stimulators of intestinal motility. After reduction or complete cessation of spastic frustration a sparing diet replace with the diet rich with food slags (boiled carrots and beet, buckwheat cereal, apples crude and in dishes, prunes, otrubyany bread, etc.) with restriction of the products causing the increased gas generation and being irritants of a mucous membrane went. - kish. path. Cabbage, nuts, alcohol, chocolate are excluded bean. Depending on a condition of the mental sphere appoint antidepressants or sedative drugs. The combination of that and others, napr, amitriptyline and Elenium is quite often shown. The combination of these drugs to analgetics is possible. From the means normalizing intestinal motility at dominance of hyper motor disturbances spasmolysants, ganglioblokator, peripheral and central cholinolytics, adrenergic, antihistaminic drugs are shown. At dominance of hypomotor disturbances appoint antikholinesterazny drugs (prozerin, Kalyminum), simpato-and adrenolytic drugs (drugs of Rauwolfia, beta-blockers), polyneuramin 1 . At the mixed frustration Metoclopramidum (a raglan, cerucal) normalizing motor function of a large intestine is shown. Also combined drugs containing alkaloids of an ergot, belladonna, barbiturates are recommended (Belloidum, etc.). At locks appoint magnesium oxide, at ponosa — calcium carbonate, drugs of bismuth, phosphate codeine.

Prevention: strengthening of a nervous system, sports, sufficient physical. activity, observance of a day regimen, diet, timely treatment of other diseases.

Vascular diseases

Under vascular diseases To. mean the wedge, symptom complexes developing owing to disturbance of its blood supply. Depending on the nature of vascular defeats, their degrees and jokes distinguish hron, intestinal ischemia, ischemic colitis (coloenteritis), fibrinferments and embolisms of mesenteric vessels with heart attacks To.

Chronic intestinal ischemia — the syndrome of abdominal pains and disturbances of intestinal functions connected with insufficiency of blood supply To. (see. Belly toad ). The disease develops in 90% of cases as a result of atherosclerotic damage of mesenteric arteries, most often an upper mesenteric artery. The promoting factors: hypertension, obesity, diabetes, smoking, alcoholism. Also various inflammatory diseases of arteries can be the reason hron, intestinal ischemia, nonspecific aortoarteriit, etc., a fibromuskulyarny hyperplasia. The syndrome of intestinal ischemia sometimes arises without organic changes of mesenteric arteries - it is so naz .funktsionalny intestinal («prefuzionny») ischemia. The similar state can be a consequence of frustration of cardiovascular system (heart failure, paroxysmal disturbances of a rhythm, shock, etc.). Funkts, intestinal ischemia of the toksiko-allergic nature meets as result of treatment by a foxglove (at persons at the age of 70 years and is more senior), treatments of bleedings from a gullet octapress other (a synthetic derivative of vasopressin), reception of a dezeril (the antagonist of serotonin). Cases of intestinal ischemia at treatment are described by penicillin, Streptokinasa. A peculiar form of intestinal ischemia is «the syndrome of dumping from a mesenteric artery» when at obstruction of an ileal artery during muscular exercises blood is dumped through collaterals from vessels of an abdominal cavity in vessels of the lower extremities. Here the phenomenon of «burglarizing» — derivation from the pool of mesenteric vessels of a part of blood takes place.

The most often found atherosclerotic form hron, intestinal ischemia arises usually after 50 years at patients with generalized forms of atherosclerosis. Men are ill by 4 times more often than women. In typical cases the characteristic triad a wedge, symptoms is observed: abdominal pains after food, the signs of malabsorption, intra belly noise found at auscultation. Abdominal pains (belly toad) appear most often in 10 — 15 min. after food (load of badly krovosnabzhayemy belly bodies). In the beginning pains arise only after plentiful meal, further — after each food irrespective of character of the eaten food. Pains can develop in connection with physical. loading, especially during the walking after food. Dull aches, at some patients last several hours, can be like colic, sometimes are followed by an eructation, the vomiting which is not giving relief. At meal in small doses of pain it is less, patients begin to eat only in the small portions or in general are afraid of food. Pains are localized in umbilical area or at the left in a lower part of a stomach, sometimes in epigastriß area, give to a back, can amplify in a prone position. Localization of pains not always corresponds to an arrangement of the affected artery. Quite often pains stop after reception of nitroglycerine. In some cases during attacks of a belly toad the ABP raises. In clinic hron, intestinal ischemia the sprue can dominate, and then pains are shown only in late stages of a disease. There comes the progressing lose of weight. About 1/4 patients complain of ponosa. The chair sometimes with a fetid smell, contains particles of undigested food. Desires to defecation appear after each meal. There can be locks. Steatorrhea (see) it is noted approximately in 40% of cases. Quite early symptom is the meteorism reaching sometimes the greatest intensity at height of digestion (a meteorism of tension). Quite often abdominal distention is followed by block, drowsiness, an adynamy. Funkts, tests reveal changes which meet also at other forms of malabsorption. In initial stages of a disease the mucous membrane of a small bowel is not changed, then the atrophy intestinal vorsinony gradually develops there Can be concealed hemorrhages. Intra belly vascular noise meet various frequency. Usually it is pressure systolic vascular murmurs, from the gentle scraping, low timbre blowing to rough. The erased forms hron, intestinal ischemia are shown by unpleasant feelings in a stomach after food, a meteorism, locks. At aortografiya (see) find a stenozirovaniye in celiac, upper or lower mesenteric arteries or lack of filling of arteries during the filling a contrast agent distally of the located branches, and sometimes late retrograde filling of branches, and then a trunk of arteries. Approximately in 20 — 40% of cases at an angiography of changes do not find.

Ischemic colitis (and coloenteritis) — a wedge, the symptom complex caused by structural changes To. owing to considerable disturbances of mesenteric blood supply. It can develop as later stage hron, intestinal ischemia or as an acute disease at considerable obstructions of mesenteric vessels. The disease is described in 1966 by Marston (A. M. Marston) et al. Most often is caused by atherosclerosis of mezenterialny vessels. It can be observed at a nonspecific aortoarteriit, at a hemorrhagic capillary toxicosis, a nodular periarteritis, a system lupus erythematosus and some other diseases. Cases of the ischemic colitis arising owing to obstruction of veins of intestines, phlebothromboses at the women using inside contraceptive means are described. The nature of defeat To. at ischemic colitis depends on caliber of the struck vessel, existence of collaterals, speed of development of process, a condition of an indestinal flora and other factors. Segmented colitis with fibrous changes in a wall of a gut, gradual narrowing of insufficiently vaskulyarizovanny gut and formation of ischemic structures To. develops at obstruction of less large vessels. At the easiest high-quality form of a disease there can come involution of changes in a gut since small vessels at well developed collaterals are blocked. This form has favorable outcomes.

At ischemic colitis the area of a splenic corner of a large intestine usually is surprised. Persons get sick 50 years are more senior. The disease most often begins sharply with severe spastic pains in the left half of a stomach like a belly toad. The meteorism, vomiting and other dispeptic frustration are observed. In 45% of cases — ponosa, in 55% — a bloody chair, at a part of patients — both symptoms. There can be locks or alternation of locks and ponos, sometimes tenesmus. Quite often body temperature increases. At a palpation of a stomach the expressed morbidity on the course of the descending colon, tension of a front abdominal wall in the left half of a stomach (symptoms of local peritonitis). In some cases the clinic of the acute belly accident develops. At a rektoromanoskopiya (see) a mucous membrane of a gut normal, in a gut the blood which is going down from more high-located departments To is visible. At a kolonoskopiya (see) the mucous membrane of a large intestine is edematous, in the field of ischemia there can be ulcer defects, polipovidny educations. At rentgenol. a research pseudo-polypiform defects, disturbances of haustration, stricture of hl are defined. obr. in the field of a splenic corner To. The selection mesenteric angiography or an aortografiya has important diagnostic value. At ulcer colitis, unlike ischemic colitis, in cases when the left bend of a colon, as a rule, is surprised also the rectum is surprised.

The diagnosis of vascular diseases To. shall be established carefully only after an exception more often of the meeting diseases. Funkts, disturbances To. and the more so it morfol, changes appear only during the narrowing of a gleam of mesenteric vessels for 50% and more, and in cases with smaller narrowing only when there are accompanying frustration, napr, a ciliary arrhythmia. The most reliable diagnostic method is the angiography.

Treatment consists in purpose of a sparing diet, spasmolytic drugs, cholinolytics, analgetics, nitrates. Expansion of mesenteric vessels is promoted by alpha adrenoblockers, beta adrenostimulyatory, furosemide, a glucagon. At consecutive infection appoint antibiotics and streptocides. The most effectively operational treatment — an endarteriektomiya, plastics of vessels (see. Blood vessels ). Anticoagulants are not effective. Cardiac glycosides are not shown since cause narrowing of mesenteric vessels.

Heart attack of intestines arises owing to thrombosis or an embolism of mesenteric vessels, it is the most frequent at the patients having heart diseases and vessels. Heart attacks of a small bowel are more often observed. A heart attack of a large intestine — the rare disease arising owing to obstruction of branches of the lower mesenteric artery.

Thrombosis of mesenteric arteries is observed, as a rule, at atherosclerotic changes of vessels. Embolisms of mesenteric arteries are observed at rheumatic and septic endocarditises, aneurisms of heart and aorta, ulcer atherosclerosis of mesenteric arteries etc. At thrombosis or an embolism of one of branches of a mesenteric artery there is hemorrhagic heart attack (see) owing to a pelting of blood a reversed current on veins. Thrombosis and embolisms are observed more often in system of an upper mesenteric artery. At obstruction of a trunk of an upper mesenteric artery the small bowel and the right half thick can become lifeless, at obstruction of the lower mesenteric artery — the left half of a large intestine. Thrombosis of mesenteric veins arises at a septicaemia, after thrombosis of a portal vein, at inflammatory processes and new growths To. and other abdominal organs.

The disease begins with the cruel colicy pains in a stomach arising more often suddenly. At damage of an upper mesenteric artery of pain are localized preferential in the right ileal area, in right hypochondrium and about a navel, at damage of the lower mesenteric artery — in the left ileal area, irradiate in a sacrum; tenesmus with scanty bloody separated can be noted. An important symptom is collapse (see). Features of the patient are pointed, skin is covered cold then, a Crocq's disease, fall of temperature at the beginning of a disease, pulse frequent, to threadlike, vomiting. Non-constant symptoms: a diarrhea with plentiful liquid allocations, in late stages — intestinal bleeding (see. Gastrointestinal bleeding ), the phenomena of impassability of intestines quickly develop (see). Perkutorno is marked out a wide zone of obtusion without clear boundary. A stomach at a palpation soft or with a small muscle tension. Sometimes in an abdominal cavity the soft motionless education increasing within several hours is defined. One of characteristic signs — sharp increase in quantity of leukocytes (to 50 000). ROE is accelerated. Sometimes the disease begins in the form of attacks, the following one by one. The first — more or less heavy, the second and the subsequent — rough with cruel pains, between them — a light interval of various duration. Rather slow and not so menacing development of a disease in the form of attacks of the uncertain abdominal pains sometimes stopping, and then renewing is less often observed. These pains can be explained with thrombosis of small branches of mesenteric vessels or only their spasm. Morfol, changes of an intestinal wall in these cases do not occur. At fibrinferment of larger branches there are severe pains, hypostasis, staz and gangrene quickly develops To.

In recognition of a disease the anamnesis (heart troubles, obliterating atherosclerosis etc.), character of a current and symptoms is of great importance. The diagnosis is difficult since pathognomonic signs are not enough. Clinic of thrombosis of vessels To. it is usually difficult to differentiate with displays of acute pancreatitis, acute appendicitis and mechanical impassability To. For the purpose of differentiation it is reasonable to resort to such methods of a research as an irrigoskopiya, a laparoscopy, and in some cases and the selection angiography of mesenteric arteries.

Treatment of a heart attack To. only operational. Make a resection of devitalized loops of a gut, sometimes it is necessary to delete practically all small bowel. The known value has use of anticoagulating therapy (heparin, Streptasum), edges is more effective at administration of anticoagulants directly in mesenteric arteries by their catheterization. However the expressed effect at the majority; it does not give patients in connection with bystry development of necrotic changes in a gut. The attempt of an embolectomy from an upper mesenteric artery is justified, however and this intervention cannot often prevent the progressing necrosis To. in view of development of the accruing thrombosis of distal arteries of a gut.

The forecast is adverse, especially at extensive necrosis To.

Inflammatory diseases

Phlegmon — the acute purulent inflammation of an intestinal wall with preferential defeat of a submucosa, in a cut is noted purulent treatment or full fusion of fabrics.

Phlegmon of a small bowel meets rather seldom, phlegmon of a large intestine — slightly more often and makes 10% of all phlegmons went. - kish. path. For the first time phlegmons of a large intestine were described in 1883 by Albers.

Causative agents of phlegmon more often happen a streptococcus, staphylococcus, a pneumococcus, colibacillus is more rare. Bacteria are found in the thickness of a wall of a gut. Depending on ways of penetration of activators to a wall of a gut of phlegmon are divided on enterogenous and hematogenous. Development of phlegmons is promoted by wounds, a stupid injury, cysts, fecal stones, foreign bodys, colitis, excesses of a gut, the breaking-up tumors, a pneumatosis of a gut, an ulcer, diverticulums, etc. Phlegmons can result also from a drift of activators from the remote center (furuncles, pneumonia, quinsies). The phlegmon of a caecum which extended from the inflamed worm-shaped shoot can become a basic disease after subsiding of primary center in a shoot.

Extent of inflammatory process in a wall of a gut varies over a wide range — from several centimeters to 1 m and more. Phlegmons To. are observed both at adults, and at children aged from 2 months and is more senior.

The disease begins suddenly: there are abdominal pains, nausea, vomiting, at phlegmon of a large intestine — a delay of a chair and gases. A condition of patients heavy, body temperature usually subfebrile, but can reach also high figures — to 39 °. Pulse is speeded up. Sometimes abdominal pains are followed by ponosa without slime and blood. The palpation of a stomach is painful, Shchetkin's symptom — Blyumberg (see. Shchetkina-Blyumberg symptom ) positive, the muscle tension of a stomach can sometimes be absent, the quantity of leukocytes is increased, ROE is accelerated.

It is difficult to distinguish a disease, and in the beginning, as a rule, make such diagnoses as an acute abdomen, a septic state, peritonitis of not clear origin, food poisoning, a helminthic invasion. At assessment of each symptom of a disease it is possible to suspect phlegmon of a gut, but the diagnosis is finalized during a laparotomy. The struck gut is edematous, a dense or pasty consistence, on a serous surface there are fibrinous or purulent imposings. In an abdominal cavity find muddy exudate or a bloody exudate.

Treatment only operational. At limited process bowel resection is shown. In cases when phlegmon occupies big extent, and a condition of the patient heavy, it is necessary to delimit the struck gut tampons from an abdominal cavity and at an opportunity to remove outside. Use of antibiotics of a broad spectrum of activity is obligatory. If there are abscesses of a wall of a gut or a mesentery, then they should be opened and drained, previously having isolated napkins an abdominal cavity.

The forecast is adverse at extensive phlegmons, it is better — at limited. Thanks to use of antibiotics of a broad spectrum of activity the percent of a postoperative lethality manages to be lowered.

Abscess of a gut can arise against the background of the available phlegmon, and also at serious septic conditions (metastatic abscesses). Owing to a serious general condition of the patient diagnosis of abscess of a gut is complicated. In cases when abscess is a complication of phlegmon to lay down. tactics is same, as at phlegmon.

An ileitis terminal (see. Krone disease ) represents the nonspecific inflammatory disease of an unknown etiology having a recurrent current.

Nonspecific ulcer colitis (see. Ulcer nonspecific colitis ) — the disease of an unknown etiology which is characterized by a diffusion inflammation of thick and direct guts, formation in them of ulcers and intestinal bleedings.

An inflammation of a caecum — typhlitis (see) — it is characterized by dull ache, swelling and rumbling in the right ileal area; ponosa are replaced by locks. Temperature subfebrile or normal, but at an aggravation of process increases to 38 — 39 °. The disease cannot almost be distinguished from an acute appendicitis. In this regard treatment, as a rule, operational. During operation usually make appendectomy and at the same time find true nature of a disease. In the postoperative period the sparing diet, antibiotics of a broad spectrum of activity is reasonable.

An inflammation of a sigmoid colon — sigmoiditis (see) it can be combined with proctitis (see) and quite often leads to polypostural growths and ulcerations. Patients complain of the pains in the left half of a stomach giving to a waist or to a crotch, persistent locks. In Calais impurity of blood sometimes is found. At a rektoromanoskopiya ulcers and narrowings of a gut are visible.

Treatment depends by nature diseases. The diet directed to elimination of locks, oil enemas is reasonable. At a purulent parasigmoiditis operation is shown.

Chronic ulcer bacterial dysentery meets seldom. Ulcers can exist many years, not be epithelized, often be exposed to a malignancy. Ulcers sometimes are complicated by perforation with development of peritonitis or phlegmon of pelvic and retroperitoneal cellulose. Bleedings from dysenteric ulcers are observed seldom. It is long the existing ulcers can be complicated by the stenosis of a gut which is the indication to surgical treatment. Along with operational treatment appoint antibiotics, vaccinotherapy, sulfanamide drugs and a dietotherapy (see Dysentery).

Typroid ulcers of a wall of a small bowel in the area izjyazvivshikhsya limf, follicles in 0,5 — 1,5% of cases on 9 — from an onset of the illness lead the 15th day to perforation and peritonitis. Treatment only surgical (see. Typhoid ).

Perikolita are characterized by plentiful growth of connecting fabric and formation of membranes, crossing points, powerful hems and thickenings of a mesentery that leads to an union of separate loops of a gut among themselves, with the next bodies and with a pristenochny peritoneum. The expressed cicatricial changes of a mesentery of a sigmoid colon create the conditions favoring to its torsion.

A variety of forms of perikolit depends from etiol, factors. Emergence of perikolit is promoted by limited colitis (see), simple ulcers, distribution of inflammatory process from the next bodies, effects of the postponed peritonitis, the injuries which are followed by subserous hemorrhage, frequent incomplete torsions of a gut at a long mesentery, etc. A considerable part of patients perikolity does not show any complaints. A part of patients quite often has severe pains, funkts, frustration To. and phenomena of intestinal impassability. Perikolita of a caecum are sometimes shown as appendicitis (see). A symptomatic treatment, and also directed to elimination of the reason of a perikolit. Separation of commissures, even with the subsequent peritonization, recrudesces (see. Adhesive desease ).

Tuberculosis of intestines — rare disease. Primary tuberculosis To. in the past arose at inclusion in food of the infected products, hl. obr. milk from the cows affected with tuberculosis. Mycobacteria of tuberculosis can get in To. with a phlegm at a pulmonary tuberculosis, a hematogenous and lymphogenous way at suffering from tuberculosis lungs and other bodies. Secondary tuberculosis To. quite often proceeds it is hidden against the background of a basic disease and can be a pathoanatomical find. Sometimes it is found accidentally during operation for an acute abdomen or a tumor of an ileocecal corner. Favourite localization of tuberculosis in To. the ileocecal department is. In an ileal gut there are ulcers which often merge. Mesenteric limf, the nodes affected with tuberculosis form tumorous conglomerates. At hematogenous defeat of a gut the disseminated multiple defects of an intestinal mucous membrane are found. By data A. I. Abrikosova (1956), is almost found in 90% of the patients who died from a pulmonary tuberculosis tubercular defeat To. Primary tubercular complex in To. meets considerably less than in lungs. Usually primary center is located in a mucous membrane of terminal department of an ileal gut, it has an appearance of a small ulceration in the area limf, a follicle. In the subdug regions and at the bottom of an ulceration on a serous cover find small yellowish hillocks, they in the form of a chain go in the direction of mesenteric regional limf, a node, in Krom the picture of a tyromatosis is noted. Thus primary intestinal tubercular complex forms. During the progressing growth of primary affect, hematogenous, lymphogenous, and also limfozhelezisty generalization is possible. Process can be both acute, and chronic.

Fig. 3. A tubercular ulcer in an ileal gut.

Defeats To. are possible also at hematogenous tuberculosis. In a mucous membrane (generally in its follicles) ileal (less often) thick guts hillocks appear, they nekrotizirutsya, and then ulcerate (tsvetn. fig. 3). Ulcers are located cross to a longitudinal axis To., often happen circular, to the subdug edges and an uneven bottom. On a peritoneum small hillocks are visible. During the healing of ulcers there can occur narrowing of a gleam To. A microscopic picture of primary, hematogenous and secondary tuberculosis To. it is similar to that, edges it is observed in other bodies.

Small - and krupnobugorkovy rashes on a mucous membrane and a submucosa To. can proceed asymptomatically or be followed by nonspecific symptoms. Usually complicated forms give clear symptomatology (ulcer, stenosing, hypertrophic). Colicy pains in a stomach, a meteorism are observed. Ponosa or alternation of ponos and locks, signs of partial intestinal obstruction sometimes appear. At patients appetite decreases, temperature increases, they are pale, lose flesh. In excrements there can be blood, the concealed intestinal hemorrhages are frequent. At a palpation the distal site of an ileal gut is probed in the form of the condensed painful tyazh which is quite often changing the consistence. The caecum is blown up, condensed, painful, is sometimes probed in the form of pear-shaped consolidation, at the same time infiltrate decreases towards the ascending colon. The caecum gradually loses the mobility. In certain cases at the accompanying mesadenitis in ileocecal area it is possible to probe increased limf, nodes, and even tumorous education. The course of a disease long, remissions alternate with a recurrence. Occasionally the disease is complicated by perforation of ulcers, acute intestinal bleeding (see. Gastrointestinal bleeding ).

There are no pathognomonic symptoms. Deterioration in the general condition of patients at a stable pulmonary tuberculosis gives the grounds to assume tuberculosis To., especially in the presence of frustration of a chair, abdominal pains. Reaction to the occult blood, soluble protein in Calais positive. At a blood analysis are found the anemia accelerated by ROE. Is important rentgenol. research. Though tubercular process in 90% of cases is defined in ileocecal area, funkts, disturbances are registered on everything To. Contrast weight is distributed in loops of a small bowel unevenly. Their folds are thickened. In a gleam of guts small accumulations of gas and liquid are found. Advance of barium on a small bowel is slowed down. In the field of defeat of a fold are thickened or are not visible at all. Contours of a gut are not equal, haustration disappears. The distal loop of an ileal gut often turns into the rigid straightened tube.

Fig. 21. Roentgenograms of intestines at tuberculosis: and — a survey picture, blind (1) and ascending colonic (2) guts are wrinkled, their contours are not equal; a delay of barium in a small bowel; — an aim picture of a caecum, infiltration and puffiness of a mucous membrane with deformation of its relief.

Small flakes of barium settle in ulcerations, and infiltrates in a mucous membrane sometimes cause serious defects of filling. In struck the blind and ascending guts contrast weight is not late (see. Shtirlina symptom ). As a result of wrinkling the struck department To. it is shortened and deformed, and its gleam decreases (fig. 21). The Smeshchayemost of intestinal loops because of unions is limited. In diagnosis of tuberculosis of a large intestine an important role is played by a kolonoskopiya. At a laparoscopy, as a rule, find the expressed commissural process which is sharply limiting diagnostic opportunities of this method.

Tuberculosis mesenteric limf, nodes (a tubercular mesadenitis) can complicate tuberculosis To., arises in connection with lymphogenous distribution of tubercular bacteria from intrathoracic limf, nodes more often. Pains in umbilical area, in side departments of a stomach, sometimes poured on all stomach, amplify during the walking and other movements, during an enema. At a palpation morbidity at the left and slightly higher than a navel at the L2 level, and also knutr from a caecum (Shternberg's symptom) is defined. The increased mesenteric nodes are probed not often. The caecum is usually painless, functions K. are broken to a lesser extent, than at a tubercular ileotyphlitis. The general phenomena of intoxication are less expressed. However at secondary defeat mesenteric limf, vessels (tabes mesenterica) sprues, an exudative enteropathy can develop.

Specific therapy by antitubercular drugs with respect for the principles of treatment of patients with diseases is necessary To. (see. Colitis , Enteritis, coloenteritis ). At perforation of ulcers, formation of fistulas, a stenosis of a gut — surgical treatment.

Syphilis of intestines meets seldom. At a gummous form on a mucous membrane single or multiple gummas which grow in a gleam of a gut that are formed; leads to its stenozirovaniye. At an ulcer form there can come the perforation of ulcers. At the same time find a picture of typical syphilitic panarterites and pan-phlebitis in vessels. At a hyperplastic form the wall of a gut is thickened, there is its stenozirovaniye. There are no specific symptoms, in initial stages of a disease a symptomatology of a coloenteritis. At development of stenotic processes in To. there are symptoms of intestinal impassability. In diagnosis the important role belongs serol, to a research. Also favorable result of specific treatment is considered.

Parasitic diseases

To parasitic diseases To. the processes in it caused by helminths belong patol (see. Helminthoses ), protozoa (see. Amebiasis , Balanthidiasis , Coccidiosis , Lambliasis ), fungi (see. Actinomycosis , Candidiasis ). Diseases To., caused by protozoa, in a midland and in sowing. districts meet seldom, they are extended by hl. obr. in districts with hot climate. At a lambliasis, a coccidiosis preferential small bowel is surprised, the disease proceeds as a coloenteritis. At an amebiasis, a balanthidiasis the large intestine suffers, the disease proceeds as dysentery. At an actinomycosis To. the granulematozno-purulent inflammation of an intestinal wall, fascinating and surrounding fabrics takes place. Most often process is localized in ileocecal department To. Patients complain of the pains in the field of a caecum sometimes simulating appendicitis, dispeptic frustration. At a palpation in ileocecal area, and sometimes and in other departments of a stomach, in the thickness of a front abdominal wall dense infiltrates are defined. At an actinomycosis of a rectum quite often there are fistulas around an anal orifice. Patients are exhausted, anemic. At a candidiasis To. the bloody mucous diarrhea is observed, in Calais a large number of fungi is found. The disease can be complicated by a perforation of kandidomikozny ulcers and peritonitis.

Process sometimes takes To. throughout. Treatment of fungus diseases To. it is carried out by purpose of antifungal antibiotics, a specific immunotherapy, use of drugs of iodine, drugs of a quinolinic row (delagil, etc.), streptocides, vitamins.

Other diseases

Pneumatosis intestinalis (see. Pneumatoses ) — a rare disease, at Krom in a wall of a gut the gas bubbles from several millimeters to 2 — 7 cm in size containing nitrogen, oxygen, carbon dioxide gas and hydrogen are formed.

Fig. 22. Roentgenogram of a large intestine: shooters specified multiple diverticulums.

Divertuculosis of a large intestine (a diverticular disease) — the disease which is characterized by education in a large intestine of blind sacculate protrusions — diverticulums. In a large intestine false usually meet diverticulums (see) since only the mucous membrane of a gut through the openings in a muscular layer located along vessels is stuck out. A divertuculosis of a large intestine — a widespread disease. In 2/3 cases the disease begins aged 60 years are more senior. On observations S. V. Hermann (1974), a divertuculosis of a large intestine comes to light at 3% of the patients having «intestinal» complaints. In most cases find multiple diverticulums, most often in a sigmoid colon, is more rare in proximal departments of a large intestine, in a rectum diverticulums do not meet at all. Pathogenetic factors of a divertuculosis consider weakness of a muscular coat of a gut, excessive pressure in To. Weakness of a muscular coat of a large intestine can be promoted food the low-slag refined food, obesity, by disturbances of blood supply To. Peynter, Berkitt pointed to it, e.g., (N. S. Painter, D. P. Burkitt, 1975). Weakness of a muscular coat of a gut increases with age. Food slags are an important stimulator motor evakuatornoy activity To., and insufficient contents in food can lead them to its easing. Modern ways of processing of feedstuffs substantially promote destruction of cellular covers, fibrous structures, and the refined products stimulate activity of a muscular coat a little To., as explains, according to some authors, relative increase of a divertuculosis of K. U of patients with a divertuculosis of a large intestine is noted strengthening of motor function K., and also increase in intracavitary pressure in a sigmoid gut in comparison with healthy faces. Believe that increase in intra intestinal pressure promotes protrusion of a mucous membrane and formation of diverticulums. The sites of walls of a large intestine turned to a mesentery where blood vessels get through a muscular coat are places of the smallest resistance of an intestinal wall. Here the ground mass of omental shoots is located that also weakens an intestinal wall. In places of the smallest resistance at increase in intracavitary pressure there is also a prolapse of a mucous membrane of a gut. The uncomplicated divertuculosis can proceed asymptomatically. Often there are a wedge, signs characteristic of dyskinesia To. (abdominal pains, locks, morbidity at a palpation spastic the reduced pieces of a large intestine). Proctorrhagias, sometimes considerable occur at 10 — 30% of patients with a divertuculosis. Diverticulums are rather easily distinguished at rentgenol, a research (fig. 22). They have an appearance of the sacks filled with contrast weight connected by the channel (neck) with a gleam K. Diametr of their from 0,2 to 6 cm, and the quantity can reach many tens. Rektoromanoskopiya does not find diverticulums. At a kolonoskopiya diverticulums come to light in the form of small pockets which mouth has the rounded or slit-like shape.

Diverticulitis of a large intestine — the most frequent complication of a divertuculosis. According to S. V. Hermann, the diverticulitis occurs at 65% of patients with a divertuculosis of a large intestine, according to Horner (J. N of Horner, 1958) — at 50%. Premises for development of a diverticulitis are accumulation of slime, stagnation of fecal masses, growth of microflora in diverticulums. Believe that the diverticulitis is result micro and macroperforation of separate diverticulums with the subsequent development of a peridiverticulitis and perikolit. Patients complain of the pains which are localized preferential in lower parts of a stomach, more often at the left, locks or ponosa, a meteorism, there can be tenesmus. Temperature increases, ROE accelerates, the leukocytosis is noted, sometimes there are dysuric phenomena. At a palpation of a stomach morbidity on the limited site of an abdominal wall, its resistance, sometimes tumorous education is defined. The wedge, currents hron, a diverticulitis allocate three options: latent, kolitopodobny and in the form of abdominal crises. Disease persistent with bent to a recurrence. Complications: massive bleedings, intestinal impassability, perforation with development of peritonitis, formation of fistulas. At rentgenol, a research the spasm of the relevant department of a gut, an inflammation of her mucous membrane, not filling or deformation of a diverticulum is found in patients with a diverticulitis, and at break — escaping it contrast weight in an abscess cavity or in an abdominal cavity. At a rektoromanoskopiya approximately at a half of patients with a diverticulitis find signs of a proctosigmoiditis.

The patient appoint the diet rich with food slags, at a diverticulitis from ponosa — to short time a sparing diet. At an aggravation of a diverticulitis the bed rest, antibiotics of a broad spectrum of activity, almost insoluble streptocides, eubiotik, spasmolytic drugs, cholinolytics is shown. For improvement of a trophicity of fabrics appoint pirimidinovy derivatives (methacil). It is reasonable to include adsorbents in complex therapy of patients with a diverticulitis (drugs of bismuth, aluminum, pectin, etc.). At the complicated diverticulitis (perforation, abscesses, fistulas, impassability, etc.) operational treatment is shown.

Mucous cyst — rather rare disease To., most often meets in a worm-shaped shoot (see. Mucocele ).

Tumors

Tumours of a small bowel

Tumours of a small bowel happen high-quality (polyps, leiomyomas, lipomas, fibromas, hemangiomas, lymphangiomas, neurinoma, carcinoid) and malignant (sarcoma, cancer).

Benign tumors meet rather seldom. They develop from various fabrics which are a part of an intestinal wall therefore their structure is very various. They are divided on exophytic and endophytic. Men and women get sick with an identical frequency preferential at the age of 40 — 50 years.

Exophytic tumors originate from elements of a submucosa or a muscular coat while endophytic — from subserosal a layer of a gut. Exophytic tumors seldom reach big size, and endophytic quite often can be the considerable sizes.

Leiomyoma (see) it is most often localized in an ileal gut. Exophytic leiomyomas quite often have a leg, can squeeze a gut and cause impassability To.

Polyps (see. Polyp, polyposes ) in a small bowel meet seldom. According to literary data, almost at a half of patients cancer transformation of polyps of a small bowel takes place. Therefore at the solution of a question of the volume of an operative measure polyps should be regarded as potentially malignant tumor. Polyposes of a small bowel quite often serves as manifestation of defeat as this disease of all went. - kish. path.

Lipomas (see) happen endophytic and exophytic. Endophytic lipomas develop from a subserosal layer of a gut, exophytic — from a submucosa y are stuck out in a gleam of a gut. Endophytic lipomas sometimes reach in the weight of several kilograms. In most cases lipomas happen single as the exception meets lipomatoz guts.

Fibromas (see. Fibroma, fibromatosis ) are most often localized in initial and final departments of a small bowel. Sometimes enclavomas take place — fibromyomas (see), fibromiksoma. Endophytic fibromas usually do not lead to change of a gleam of an intestinal tube, proceed asymptomatically, quite often being a find during operations and autopsies.

Hemangiomas (see) and lymphangiomas (see) in most cases are section finds, are only occasionally shown by intestinal bleedings during lifetime. Hemangiomas often have the small sizes, microscopically find a vascular structure, sometimes extend on everything To.

Neurinoma (see) more often represent manifestation of the general neurofibromatosis (see).

Carcinoid tumors (see. Carcinoid ) a small bowel across Dokkerti (M. V. of Dockerty) 23% among tumors of this localization borrow. The tumor most often is located in final department of an ileal gut and is less often observed in a jejunum. Perhaps multiple defeat by carcinoid of a small bowel, and also the malignant course of a disease which is characterized by emergence of the remote metastasises.

Benign tumors of a small bowel sometimes a long time exist asymptomatically and come to light only at suddenly come obturation of a gut. Especially it belongs to exophytic tumors which even on reaching the big sizes seldom conduct to a stenozirovaniye of an intestinal gleam and to invagination. However sometimes they are shown a wedge, a picture of the acute intestinal impassability caused by torsion of the struck loop of a small bowel (see. Impassability of intestines ). Acute intestinal impassability at benign tumors To. quite often more or less long prodromal stage precedes. At this time patients have abdominal pains of spastic character, nausea, occasionally vomiting, a delay of a chair and gases. At carcinoid, a hemangioma and a leiomyoma of a small bowel intestinal bleedings can be observed various weight.

In the anamnesis it is necessary to pay attention to existence went. - kish. discomfort. Important signs are melena (see) and palpation in a stomach of smooth, easily movable tumor. Radiological the tumor of a small bowel comes to light hardly. Lipomas and fibrolipomas give roundish or oval defect with equal or wavy contours, differ in small intensity of a shadow, are often distinguished in the period of invagination of a gut. Carcinoids and lymphoma remind adenomatous polyps, are located in distal department of an ileal gut more often. Leiomyomas form impression in a wall of a gut and before development of an ulceration do not break structure of a mucous membrane. Hemangiomas and lymphangiomas cause lobular defects, sometimes with additional pristenochny shadows of expanded vascular conglomerates (phleboliths» facilitating diagnosis are in rare instances visible). Is of great importance in diagnosis also intestinoskopiya (see).

Benign tumors of the small sizes delete in the way enterotomies (see), at large tumors carry out bowel resection. At carcinoid operation of the choice is the resection of the struck segment of a gut together with a mesentery, edges are might contain limf, nodes with metastasises.

The forecast at benign tumors of a small bowel depends on weight of the arisen complications (impassability, bleeding). In the absence of them and timely operational treatment the immediate and long-term results, as a rule, favorable.

Fig. 23. Macrodrug of the site of a jejunum: all thickness of a wall of the Gut is replaced with tumoral fabric of sarcoma (it is specified by shooters).

Malignant tumors. Sarcoma (see) a small bowel meets more often sarcomas of other localizations. Most often meet lymphosarcoma (see) and reticulosarcoma (see) which in most cases strike initial department lean (fig. 23) and final department of an ileal gut. At defeat of a considerable part of a small bowel the wedge, a picture of malabsorption can be observed. Meets at any age, but a thicket at the age of 20 — 40 years. Men and women get sick equally often. Sarcomas of the small sizes in the form of polyps on the wide basis can conduct to invagination. Metastasises extend in limf, nodes of a mesentery in the beginning, and then a hematogenous way to the remote bodies (a liver, kidneys, lungs, a pleura, chest vertebras); dissimination on a peritoneum and development is quite often observed ascites (see).

In the absence of narrowing of a gut into the forefront the general symptoms of a disease act: non-constant abdominal pains, loss of appetite, weight loss, weakness, pallor of integuments, sometimes polyserositis (see). Local signs come to light much later, is frequent in an end-stage of development of a tumor. Complications are perforation of a tumor, intestinal impassability, intestinal bleedings.

The diagnosis presents great difficulties due to the lack of pathognomonic symptoms. The main symptoms of a disease are the probed fast-growing hilly tumor, ascites, disturbance of intestinal passability, temperature of remittiruyushchy character.

Fig. 24. Roentgenograms of a small bowel at a lymphosarcoma: 1 — a survey picture (loops of a gut are expanded, contain gas, their walls are rigid, are not equal); 2 — an aim picture (roundish defects of filling — are specified by shooters — in places of tumoral nodes).

Rentgenol, a picture of diffusion malignant defeats of a small bowel at lymphosarcomas and reticulosarcomas is peculiar. She sometimes reminds regional enteritis since the gut is surprised on a considerable extent and there are permanent changes of a relief of a mucous membrane with small roundish enlightenments, the alternating narrowings and expansions of intestinal loops, roughness of their contours (fig. 24). Recognition is helped by presence of larger, than at enteritis, regional defects, more considerable narrowing of intestinal loops on an extent, destruction of folds of a mucous membrane, absence deep and oblong shape of ulcerations.

Fig. 25. Macrodrug of a small bowel: a metastasis of an adenocarcinoma in a lymph node (it is specified by shooters)

Cancer of a small bowel meets seldom. A. G. Varshavsky on 36 000 autopsies found 15 cases of cancer of a small bowel (0,04%). More often persons at the age of 40 — 60 years get sick. In most cases the tumor is localized in initial department lean and final department of an ileal gut. The adenocarcinoma meets more often, it is less often observed solid and mucous cancer (see). Metastasises extend on limf, to ways of a mesentery (fig. 25), reach prevertebral limf, nodes; the remote metastasises are found in a liver, ovaries, lungs, bones.

Kolikoobrazny abdominal pains, nausea, heartburn, an eructation, vomiting are observed. Then there comes weakness, exhaustion, dehydration, anemia. The phenomena of intestinal impassability arise in a late stage as liquid contents of a small bowel freely pass long time through the narrowed place. There can occur perforation of a wall of a gut because of restretching and an ulceration it above the place of narrowing.

An important diagnostic symptom is detection of a melena (see), and also periodic emergence of partial intestinal obstruction, in late stages at a palpation find irregular shape a hilly low-painful mobile tumor. Has the known help in diagnosis rentgenol. research. At localization of a tumor in initial department of a jejunum signs of a duodenostaz come to light (expansion of a gleam of a duodenum, a long delay of a contrast suspension in it, existence of an antiperistalsis). It is much more difficult to diagnose the tumor which is localized on average and distal departments of a small bowel and without signs of a stenosis. It begins with a small thickening of a mucous membrane, emergence on it of a plaque or polipopodobny flat education. In such cases flat limited regional can be found and the central defect of filling or even flattening of a wall of a gut on the limited site with loss of a vermicular movement is much more rare. If in this plaque there is a necrosis and the ulcer develops, then in the center of defect is defined irregular shape of depot of barium or on a relief of a mucous membrane the resistant contrast spot appears. Further increase in a tumor can give the picture reminding a saucer-shaped carcinoma of the stomach or is more often the polypostural tumor pressing in a gleam of a gut. Folds of a mucous membrane are destroyed, the basis of a tumor usually is more than its height. At arteriography disturbances of the vascular drawing, the raised vascularization, an erosion of walls of arteries are found.

In certain cases cancer grows at hl. obr. on an extent, leads to infiltration of a big segment of a gut, and at a skirrozny form to its expressed narrowing. The gut turns into a rigid tube with uneven outlines. This picture should be differentiated with a stricture because of a disease Krone, with effects of the postponed heart attack of a wall of a gut, and also radiation defeat. In the latter case the anamnesis, equal contours of narrowing helps. In doubtful cases the intestinoskopiya is decisive for diagnosis.

At malignant tumors produce, otstupya from edges of a tumor not less than 10 cm, bowel resection together with a mesentery outside probed in it limf, nodes. At localization of a tumor in distal segments of an ileal gut together with a resection of the site of the last make right-hand hemicolectomies) with ileotransverzoanastomozy on the right (see. Ileotransversostomy ). At neudalimy crayfish impose a bypass entero-enteroanastomosis. At a high arrangement of a tumor in a jejunum and its germination in a pancreas, a mesentery of a cross colon and other bodies impose a gastroenteroanastomosis (see. Gastroenterostomy ) with a Brownian interintestinal anastomosis. The back gastroenteroanastomosis should not be imposed since at germination of a tumor in a mesentery of a cross colon there can quickly occur narrowing of an anastomosis or its obturation.

After radical operations for initial stages of cancer favorable immediate results are noted, and concerning sarcomas average life expectancy makes at best 3 — 4 years. In inoperable cases radiation therapy can prolong life of patients a little.

Fig. 26. A lipoma of a cross colon (it is specified by an arrow): above the roentgenogram at an irrigoskopiya; below — macrodrug.

Tumors of a large intestine

Benign tumors meet quite often. They can come from any fabric making a wall of a gut. From not epithelial tumors lipomas (fig. 26), fibromas, myomas, neurofibromas, neurinoma, cavernous angiomas and lymphangiomas which are located subserozno or in a submucosa meet. Having reached the considerable sizes, they can obturirovat a gleam of a gut or lead to invagination. Carry polyps to epithelial tumors. Carcinoid tumors meet seldom, being located preferential in a caecum.

Fig. 27. The aim roentgenogram at an irrigoskopiya of a sigmoid gut: a large juvenile pediculated polype (it is specified by an arrow).

Benign tumors proceed often for a long time without symptoms, but they can cause a stenosis of a gut, invagination and bleeding. At a polypose of a large intestine of an excrement can be liquid with impurity of blood and slime, anemia is quite often observed. Polyps in 50 — 60% of cases are a source of developing of a colon cancer therefore they are considered as a precancerous disease. The important role in their diagnosis belongs to an irrigoskopiya, at a cut polyps most often are found. Single polyps, group of polyps and total polyposes meet. The adenomatous polyp at a regional arrangement has an appearance of a flat plaque, a semicircular ledge or education on a leg, and in a fasny projection — roundish accurate defect of filling against the background of not changed folds of a mucous membrane. The surface of a polyp of a besstrukturn, the sizes are small (0,5 — 1 cm). Only juvenile polyps large and dense (fig. 27). Adenopapillomatozny polyps too large, with a pulled surface, do not change the form and size at a compression.

Total, or diffusion, polyposes it is shown by incomplete reduction of a large intestine during the emptying, replacement of a normal relief of a mucous membrane with multiple small round defects of filling. For specification of distribution and number of polyps it is necessary to investigate all digestive tract. Differential diagnosis of different types a polypose [family polyposes, Gardner's syndrome (see. Gardner syndrome ), Peytts's syndrome — Egersa (see. Peyttsa-Egersa syndrome )] it is possible if to consider the family anamnesis and results a wedge, inspections, in particular existence of pigmentation, tumors of soft tissues, defeats of c. N of page, etc.

It is difficult to distinguish a polyp from a small cancer tumor. In favor of cancer and for malignant transition tells retraction of a wall of a gut towards the basis of a polyp, roughness of its surface and the big extent of defect (more than 1 cm), rather rapid growth. The more dominance of the basis over height of defect, the is more probable cancer. Most often the fleecy tumor (papillary adenoma) affecting hl passes into cancer. obr. distal department of a large intestine, having an appearance of round defect of filling with a characteristic combination of small netting to circular lamination and wavy contours. The shadow of a tumor against the background of gas is not intensive. Emergence in the center of defect of depot of barium, roughness of contours and acceleration of growth speak about probable malignant regeneration. In some cases, especially at polyps of the small sizes, at rentgenol, a research they do not manage to be found. The leading role in diagnosis of such polyps belongs to the endoscopic research (a rektoromanoskopiya, a kolonoskopiya) allowing to establish localization and the size of polyps, exact quantity them, and, above all to make an aim biopsy.

All benign tumors of a large intestine are subject to removal. At a polypose the resection of the struck part or removal of all large intestine is shown. At the separate polyps having a leg less traumatic is electrothermic coagulation through rektoskop or a colonoscope. The subsequent is obligatory gistol, a research of remote polyps. At detection of several polyps of a large intestine the endoscopic polypectomy is carried out in stages.

Malignant tumors. According to section the statistician, a colon cancer takes the third place among malignant tumors went. - kish. a path also makes 98 — 99% of all cancer tumors of intestines. The main place is taken by adenocarcinomas (60 — 70%), solid and mucous forms meet less often. The primary and multiple colon cancer makes 4,3 — 6,2%. M. F. Gulyakin, I. Yu. Yudin, B. M. Tsarev et al. (1972) observed a primary and multiple colon cancer (to 6 at the same time) at the 27th persons. Innidiation of a primary and multiple colon cancer arises considerably less than solitary tumors of this localization.

Characteristic signs of initial stages of a colon cancer do not exist. The anamnesis matters only since then when disturbances of normal activity appear To. or general symptoms of a disease.

Fig. 1. Macrodrug of the ascending gut from polipovidny adenokartsikomy.
Fig. 2. Macrodrug of a caecum with mucous cancer.

In the right half of a large intestine exophytic crayfish are more often observed (tsv. fig. 1 and 2) which long do not infiltrirut a wall of a gut and therefore a wedge, a picture is not followed by signs of intestinal impassability. Often the general manifestations in the form of intoxication, temperature increase, weight loss, anemia come to light. Endophytic growth is more often characteristic of tumors of the left half of a large intestine. In process of growth they tsirkulyarno stenose a gleam of a gut that can lead to development of intestinal impassability. The general symptoms of a colon cancer are abdominal pains, disturbances of normal function of a gut, mucifying, blood, sometimes pus. The heaviest complication is perforation of a wall of a gut. The fecal peritonitis developing at the same time is characterized by extremely heavy current and usually has a failure.

Fig. 28. The roentgenogram of a colon at an irrigoskopiya: a big cancer tumor (regional defects of filling) of the ascending colon (it is specified by shooters).

The wedge, inspection of the patient comes down to the general survey, a palpation of a stomach, a research of excrements on availability of blood. At an arrangement of a tumor closer it it is possible to reveal and produce 30 cm from an anus a biopsy at a rektoromanoskopiya. The great value in diagnosis of a colon cancer has irrigoskopiya, edges allows to find it in 80 — 85% of cases (fig. 28). Irrigoskopiya) cannot substitute for a research of a large intestine by means of reception of a baric suspension through a mouth. Characteristic rentgenol, symptoms of a colon cancer are the central or regional defect of filling, atipichesky reorganization of a relief of a mucous membrane and defect on a relief, narrowing of a gut, roughness of contours, lack of haustration on the limited site, expansion of a gut is higher and lower than the fragment affected with a tumor, incomplete evacuation of a baric suspension from a gut after its emptying, break of folds, a delay of advance of baric weight at the lower pole of a tumor at retrograde filling with air, an additional shadow on its background. An exact diagnostic method of a colon cancer, its especially early forms, the kolonoskopiya is, in time a cut it is necessary to make a biopsy of a tumor for the subsequent histologic research.

The most effective method of treatment — an operative measure. The senile age of patients, the sizes of a tumor, its union with the next bodies in most cases shall not be a contraindication to radical operation. Character and volume of operation depend on whether it is necessary to operate patients in a planned order, after special preparation, or at acute intestinal impassability or perforation of a gut.

At uncomplicated forms of cancer of the right half of a large intestine make right-hand hemicolectomy (see). At very weakened patients with signs of intestinal impassability it is necessary to dismember operation on two stages and at first to impose ileotransverzoanastomoz (see. Ileotransversostomy ), and later 2 — 3 weeks at operability of a tumor to remove the right half of a large intestine together with a tumor. At the expressed impassability of intestines as the first stage it is necessary to impose unloading intestinal fistula (cecostomies, an ileostomy).

At localization of a tumor in an average third of a cross colon make sectoral bowel resection. At localization of a tumor in the field of the left bend of a colon and the descending colon make a left-side hemicolectomy with imposing of a transverzosigmoanastomoz. At localization of a tumor in a sigmoid colon make a resection of the last. Patients with localization have tumors in distal departments of the left half of the large intestine complicated by intestinal impassability at operability of a tumor make an obstructive resection according to Hartmann. At a nonresectable tumor it is more reasonable to resort to imposing of unloading fecal fistula (a transverzostomiya, cecostomies).

Surgical treatment at perforation of a colon cancer first of all shall be directed to elimination of peritonitis and a source of its distribution. In the presence of peritonitis operation shall be sparing; a toilet and drainage of an abdominal cavity, removal on a front abdominal wall of a segment of a gut with a perforated tumor with the subsequent removal it.

At impossibility of radical operation and threat of development of intestinal impassability make palliative operations. The best option is creation of a bypass anastomosis for the purpose of unloading of a gut and removal of intoxication; at impossibility of its performance impose an unnatural anus proksimalny tumors (see. Anus praeternaturalis ).

The lethality after the operations executed in a planned order fluctuates from 2,2%, according to O. P. Amelina, to 5,4% — according to B. A. Petrov.

The peritonitis resulting from insufficiency of seams of an intestinal anastomosis is the main reason for death of patients after operation. Quite often infection limf, nodes and limf, ways from a tumor happens the reason of peritonitis. Survival within 5 years after radical operations makes 56%, according to Bacon (H. E. Bacon), and 73,6% — according to A. M. Ganichkin. At the patients who are in satisfactory condition, many authors suggest to make an oncotomy and in the presence of the single remote metastasises. S. A. Holdin, B. A. Petrov, Bacon, etc. believe that the chemotherapy after such operations renders additional effect.

Metastasises in limf, nodes and after radical operations develop in internals (a liver, lungs, appendages of a uterus, bone) at young patients more often. As a recurrence and metastasises of a tumor arise in the first 2 years after operation more often, repeated researches of patients every 3 — 6 month within 2 years after an extract from a hospital and 1 — 2 time a year further are desirable. At identification of a recurrence and single metastasises at the general satisfactory condition the attempt of repeated operation can be made. Even lobectomy (see), made in connection with a solitary metastasis in a lung, sometimes prolongs life of the patient for the term of more than 5 years. The worst forecast at repeated operations is connected with a recurrence and metastasises in mesenteries of thick and thin guts.

At chemotherapy of a colon cancer are effective 5-ftoruratsit also Phthorafurum. More sensitive to chemotherapy, on N. G. Blochina's observations, ferruterous and solid and ferruterous forms of cancer — mucous cancer appear more resistant. 5-Ftoruratsit in 15 — 25% of cases makes impact not only on primary tumor, but also on metastasises and even on a recurrence. In this regard there is a need of repeated courses of treatment. The direct effect of treatment by Phthorafurum reaches 50%, but also this drug does not give permanent remissions. The basis for the termination of chemotherapy are diarrhea, stomatitis, a leukopenia.

The question of expediency of additional chemotherapeutic treatment after radical operations remains diskutabelny. Experience of Oncological scientific center of the USSR Academy of Medical Sciences showed that use for this purpose does not detain a 5-ftoruratsil development of metastasises and a recurrence.

Sarcoma of a large intestine makes 1 — 2% among all malignant tumors of this localization. Most often the caecum is surprised. Men get sick more often than women; the age of patients is not more senior than 30 years more often. Usually also reticulosarcomas which differ in big bent to the early and remote innidiation in both the hematogenous, and lymphogenous way meet lympho-.

In spite of the fact that sarcomas differ in rapid growth and reach the considerable sizes, they rather seldom cause intestinal impassability. The diagnosis can be promoted detection of the low-painful tumor of a dense consistence which is well displaced with a smooth surface at rather top general condition of the patient and his young age.

Treatment of sarcomas of a large intestine is carried out by the same principles, as cancer. Short-term results of operation satisfactory since young people on age patients well transfer them. However the long-term results it is much worse, than at cancer, because of more malignant nature of sarcomas and their bigger bent to innidiation.

Tumors of a worm-shaped shoot meet seldom, carcinoid is most often observed. The sizes of a tumor fluctuate from microscopic to 7 cm in the diameter. Metastasises are observed very seldom.

The clinic has no pathognomonic signs. As a rule, for patients it is mistakenly diagnosed acute or hron, appendicitis, apropos to-rogo make a laparotomy.

For radical treatment of carcinoid of a worm-shaped shoot there is enough appendectomy. At localization of a tumor at the basis of a shoot along with appendectomy make a resection of an adjacent part of a wall of a caecum. If the tumor extends to a caecum, sprouts its wall, carry out a right-hand hemicolectomy.

Radiation therapy at malignant tumors. Radio sensitivity of malignant tumors To. depends from gistol, structures of a tumor. Most radiochuvstvitelna of sarcoma of a small bowel both the least mucous and colloid colon cancer. Metastasises in limf, nodes both sarcoma, and cancer, and also a recurrence after operational treatment have bigger radio sensitivity in comparison with primary tumor as a result of decrease in degree of a differentiation of secondary tumors.

Due to the frequent recurrence after operational treatment of malignant tumors To. in certain cases for the purpose of their prevention preoperative is shown radiation therapy (see). Especially it is shown in all resectable cases at big distribution of tumoral process (a remote gamma therapy, a bremsstrahlung with energy of 15 — 25 MEV). Irradiate two opposite fields through the trellised diaphragms covering clinically defined tumor and the next regional lymph nodes with a single dose 180 — 200 I am glad also to the general — to 4500 I am glad. Under the influence of radiation considerable reduction of a tumor, especially sarcomas is noted, up to the seeming disappearance at a wedge, inspection. However in 2 — 3 weeks the laparotomy with careful audit of an abdominal cavity and a resection of the struck gut is always shown. In cases if preoperative radiation therapy was not carried out, and at operation involvement in process of a serous cover of a gut comes to light, then in 10 — 14 days after operation on condition of a safe current of the postoperative period radiation therapy using colloid solutions of radioactive gold is shown. The puncture of an abdominal cavity is made a long fine needle with a blunt end after anesthesia of skin and soft tissues of 0,25% solution of novocaine on the right or to the left of the centerline is 2 — 3 cm lower than a navel. Through a needle previously enter 200 ml of 0,25% of solution of novocaine then the needle is connected a polyethylene tube to the protective syringe into an abdominal cavity, with the help to-rogo enter solution 198 Au activity 100 — 150 mkyur. Then through the same needle in addition enter 200 ml of 0,25% of solution of novocaine.

After introduction 198Au to the patient each 20 — 30 min. for uniform contact of all bodies and a parietal peritoneum with radioactive solution within a day recommend to change situation. At full disintegration of isotope the general dose in an epiploon reaches 10 000 is glad, in a peritoneum of a small pelvis — apprx. 8000 is glad.

At initially nonresectable tumors remote radiation therapy is shown under the same conditions, as well as in the preoperative period, but with the general dose at sarcomas apprx. 5000 I am glad also cancer — 6000 I am glad. After the carried-out radiation therapy at patients it becomes frequent possible a resection of the struck gut. The complications connected with the carried-out radiation therapy, as a rule, are not observed. A little development of commissural process in the irradiated area complicates carrying out operation.

At the combined treatment results improve in comparison with purely operational method of treatment.

Operations

Preoperative preparation

At operations on To., made in the emergency order and undertaken, as a rule, concerning damages or complications of various diseases To. (peritonitis, intestinal bleeding, impassability), preoperative preparation shall be carried out jointly by the surgeon, the anesthesiologist, the resuscitator, it is desirable in chamber or intensive care unit. It whenever possible shall not proceed more than 1,5-2 hours during whom under control of pulse, the ABP, the central venous pressure, an hourly diuresis is carried out intravenous infusion of 2 — 2,5 l of blood-substituting solutions (reopoliglyukin, 5 — 10% solution of glucose etc.) or blood.

Depending on indicators of an acid-base state and water and electrolytic balance make intravenous administration of 4 — 5% of solution of soda (at acidosis) or (at an alkalosis) 7 — 10% of solution of calcium chloride, 1% of solution of potassium chloride and concentrated (10 — 20%) solutions of glucose. At serious condition of the patient (big blood loss, high impassability or the started peritonitis) intravenous infusion of low-molecular dextrans for prevention and correction of the progressing disturbances of microcirculation has special value that is one of the main reasons of frequent development in such patients of an acute renal failure.

The main criterion of necessary volume of the liquid entered intravenously, and also speeds of its introduction not pulse and the ABP, but initial volumes of the circulating blood, the dynamic indicators of the central venous pressure and an hourly diuresis which are most precisely reflecting a condition of the central hemodynamics is. In this regard patients need to enter a constant catheter into a bladder, the constant probe in a stomach, and also to make a puncture of a subclavial or internal jugular vein for systematic control of the central venous pressure and performing intravenous infusions.

At the planned operative measures made on a small bowel, preoperative preparation, as a rule, comes down to abstention of meal during 12 — 14 hours before operation and to cleansing enemas the night before and in the morning in day of operation. Preparation of cardiovascular and respiratory systems has no features in comparison with other interventions on abdominal organs.

Preparation for planned operation on a large intestine if opening of its gleam is supposed, shall pursue two aims: emptying of all went. - kish. a path from contents and suppression of pathogenic flora of a large intestine. It allows to operate on a «empty» large intestine and to reduce infection of an abdominal cavity and an operational wound that gives the chance considerably to reduce the frequency of such heavy postoperative complications as insufficiency of seams of an anastomosis and peritonitis. In the absence of signs of disturbance of a passage on went. - kish. to a path preoperative preparation is begun in the morning on the eve of operation with giving laxative (castor oil, sulfate magnesia) with simultaneous transfer of the patient into the diet including only liquid food ingredients (broth, kefirs, kissel) which almost completely are soaking up in a small bowel. After the act of defecation, usually in several hours, put (in the evening, and also in the morning in day of operation) cleansing enemas to pure water. Suppression of pathogenic microflora of a large intestine is carried out by oral administration of the antibiotics of a broad spectrum of activity (Kanamycinum, Monomycinum) which are not soaking up in intestines in a combination with streptocides (Ftalazolum, Sulfadimezinum) or use of strongly operating antibacterial drugs, napr, nalidixic to - you. These drugs give on the eve of operation 4 times a day in 4 hours and in the morning in 2 hours prior to it. In case of persistent locks or signs of partial obstruction appoint laxative and transfer patients to a zero table in 3 days prior to operation during which the patient accepts antibiotics or antiseptic agents, and in the morning and in the evening it is given enemas by cleansing.

Anesthesia

Both at emergency, and at planned operations on To. use of the endotracheal anesthesia with muscle relaxants creating optimal conditions for an operative measure is the most reasonable. In certain cases, generally at small operations when do not make broad audit of an abdominal cavity (e.g., during the imposing of intestinal fistulas), use of local anesthesia is admissible, to-ruyu reasonable to supplement with a neyroleptanalgeziya.

Indications

1) in the emergency surgery — the closed and open damages To., acute intestinal impassability, perforation of ulcers, diverticulums and tumors, the profuse intestinal bleedings which are not stopped by conservative actions, acute dilatation of a large intestine at nonspecific ulcer colitis, thrombosis or a vascular embolism To., acute purulent inflammatory diseases To. (e.g., phlegmon), need of imposing of nutritious or unloading intestinal fistulas, some malformations To.; 2) at planned interventions — benign and malignant tumors of a small and large intestine, diffusion polyposes of a large intestine, the complicated forms of a disease Krone and nonspecific ulcer colitis, tuberculosis To., cicatricial stenoses To., various options of megacolon, a mobile caecum (at recurrent impassability To.).

Types of operations

1) creation of nutritious or unloading intestinal fistulas; 2) sewing up of wounds To. at its damages or perforative openings; 3) opening of a gleam To. (an enterotomy, a colotomy) for removal of foreign bodys, single benign tumors; 4) creation of a bypass enteric or colic anastomosis at neudalimy obstacles for a passage on To.; 5) bowel resection at its necrosis, tumors, diverticulums etc.; 6) a subtotal resection and full removal of a large intestine at her multiple tumors, some forms diffusion a polypose and nonspecific ulcer colitis; 7) at some types of malformations and megacolon K.; 8) blood clot - and embolectomies from upper mesenteric vessels at their fibrinferment (usually in combination with a resection of devitalized departments To.).

Fig. 29. The diagrammatic representation of operation of wedge-shaped excision of a wall of a small bowel at the basis of a diverticulum: 1 — a diverticulum, 2 — a small bowel.
Fig. 30. The diagrammatic representation of a stage of an enterectomy (the gut is mobilized, vessels are tied up).

The enterectomy

the Wedge-shaped resection of the site of a gut is made, e.g., at regional infringement of a wall of a gut, partial damage of a wall, a polyp, a diverticulum of a small bowel (fig. 29).

After borders of the site which is subject to removal are defined start bandaging of the vessels feeding it. Vessels tie up in the field of the distal abenteric branches of a mesenteric artery which are directly going to an intestinal wall between a gut and the next to it a vascular arcade (fig. 30). It is not necessary to tie up the main vessels feeding the site of a gut at a root of a mesentery since at the same time blood supply of the neighboring, not subject to removal sites of a gut can be broken, especially if the mesentery is edematous or impregnated with blood. The last circumstance interferes with identification of separate vessels and makes impossible exact definition of the site of a gut which is supplied with blood from the specified branches. Bandaging at a root of a mesentery is necessary at malignant tumors when together with a tumor it is necessary to make perhaps fuller removal limf, nodes and vessels of a gut. For bandaging of vessels directly at a gut do openings in the avascular place of a mesentery and prisoners of a branch between them press two styptic clips, and then cross between them vessels. Thus, the gut is separated from a mesentery on a necessary extent then the crossed vessels tie up silk. The surgery field is delimited gauze napkins. The site of a gut separated from a mesentery delete after crossing it at each end between presses. The ends of the crossed gut, without removing presses, pull together and in the beginning sew noose silk serous and muscular sutures (see. Intestinal seam ). Further the ends of a gut together with the presses imposed on them cut, otstupya 1 — 1,5 cm from the line of seams, and contents delete from the bringing and taking away ends of a gut with a suction and impose enteroenteroanastomoz (see). At significant difference of diameters of the sewed sites of a gut them it is reasonable to sew up a gleam tightly with a two-row seam, and enteroenteroanastomoz to impose by the principle a side sideways, otstupya from the end of 1 — 1,5 cm. After imposing of an anastomosis connect seams cuts in a mesentery and recover its integrity in order to avoid infringement in this place of loops of guts.

At more extensive defeats of a small bowel there is a need of a resection of sites of its various extent. The bowel resection exceeding 1,5 m always conceals danger of the subsequent digestive disturbances. Cases of death from exhaustion at a resection of 1,5 — 2 m of a gut are described. Apparently, the sizes of the resected site, how many size of the rest of guts and its ability to digestion matter not so much.

After extensive enterectomies patients suffer from frequent ponos which gradually stop, and at some of them normal digestion is recovered further, at a number of patients of a ponosa renew at each disturbance of a diet and many of them become disabled, constantly need the food containing many proteins, well acquired carbohydrates and, whenever possible, there are not enough fats. At the persistent diarrhea which is not giving in to conservative actions operational treatment — inversion short (5 — 7 cm) a segment of an ileal gut is shown.

The resection of a large intestine

the Resection of a large intestine is carried out usually at tumors or torsion. This operation is accompanied by big dangers, than an enterectomy because a wall of a large intestine thinner, and contents are more infected.

Ways of a resection of a large intestine: 1) a single-step resection of a large intestine with an anastomosis of the crossed ends; 2) a resection of a large intestine with simultaneous imposing of unloading intestinal fistula; 3) double-stage resections with outside withdrawal of intestinal contents or the same with a preliminary internal interintestinal anastomosis; 4) three-moment operations with preliminary outside assignment of intestinal contents.

In daily surgical practice the single-step intraperitoneal resection of a sigmoid gut with an anastomosis the end in the end is applied. Depending on the extent of defeat of a gut basic process undertakes resections of various volumes of a gut.

At cancer of the blind and ascending colonic guts all right half of a large intestine to the level of an average colonic artery with crossing of its right branch and with the site of an ileal gut 20 — 25 cm long is subject to removal. Together with a gut delete a back leaf of a peritoneum with blood vessels, limf, nodes and all retroperitoneal fatty tissue one block (see. Hemicolectomy ). At cancer of the right bend and right third of a cross colon limits of a resection reach an average third of a cross colon. At the same time cross ileal and colonic and intestinal right and average colonic arteries and veins, regional limf, nodes of the right half of a large intestine and terminal department ileal delete all.

At cancer of an average third of a cross colon it is accepted to resect a cross colon otstupya in both parties from a tumor on 5 — 6 cm with crossing at the same time of an average colic artery and a vein and removal limf, nodes of this group together with wedge-shaped excision of a mesentery of a cross colon. A continuity of a gut recover imposing of an anastomosis the end in the end for what it is necessary to mobilize the right and left bends of a colon. At badly prepared for operation K., with a significant amount of contents, it is reasonable to unload an anastomosis by imposing of fistula on a caecum.

If cancer is localized in the left third of a cross colon, the left bend and the descending colon, the resection is made ranging from an average third of a cross colon to a mobile part of an upper third of a sigmoid colon with crossing of the ascending branch of the lower mesenteric artery and the left colonic artery. Recovery of a continuity of a gut is reached by imposing of an anastomosis between a cross colon and sigmoid. At cancer of the bottom of the descending colon the left-side hemicolectomy is shown. At all types of a resection of the large intestine made concerning tumors the technique with preliminary bandaging of vessels is most preferable that interferes with dissimination of tumor cells at mobilization of the gut bearing a tumor and causes the best long-term results. Same promotes and hard bandaging of a large intestine is higher and lower than a tumor that interferes with distribution of tumor cells on the course of operation in related departments of a gut.

After considerably executed hemicolectomy there is a need for recovery of passability of an intestinal tube: at a right-hand hemicolectomy — ileotransverzoanastomoz (see. Ileotransversostomy ), at left-side — an anastomosis of a cross colon with a rectum (rektotransverzoanastomoz).

Ileotransverzoanastomoz can be executed isoperistaltically and antiperistaltically. At the seeming physiology of the first way in the distal ends of two pieces of a gut after imposing of an anastomosis two blind pockets where contents stagnate are formed and can cause an inflammation. During the imposing of an anastomosis antiperistaltically these phenomena are not observed, the anastomosis functions well. An ileotransversostomy or transverzosigmo-, - a proctostomy can be executed and as independent interventions without bowel resection — as a bypass anastomosis, most often at a nonresectable tumor of the right or left half of a large intestine. Such bypass anastomosis as an ileocecostomy, an ileosigmostomiya, a sigmoproktostomiya are less often applied.

Hartmann's operation is offered for removal of tumors of distal department sigmoid or proximal department of a rectum. After excision of an affected area of a gut the central end it is removed in the form of a single-barreled unnatural anus, and distal sewn up and left in the form of a cul-de-sac. At mobilization of a gut during this operation it is necessary to avoid bandaging of vessels of distal department of a gut that can lead it to a necrosis.

At serious condition of the patient, especially at the expressed impassability To., the three-moment resection of a large intestine (Shloffer's operation) is shown. The first moment of operation consists in imposing of a tsekostoma. When the general condition of the patient improves, make the second moment — a resection of an affected area of a gut. The third moment of operation consists in closing of fistula of a caecum.

At a long mesentery sigmoid colonic or a caecum there is a disease state which received the name a mobile caecum (caecum mobile), a dolichosigma, a megasigmoid, etc. Various methods of operational fixing of these departments of a gut are developed (see. Megacolon , Caecum ).

At a mobile caecum the operation of a typhlopexy which received the name of operation of Vilms, or a tsekoplikation can be executed. Operation consists in immersion of a gut in a blind pocket which is created after flaking of a knaruzha of a rag of a dissect parietal peritoneum. The worm-shaped shoot is deleted at the same time. The edge of a peritoneal rag is sewn to a front surface of a caecum. There are also other methods of operational treatment (fixing of a caecum to a parietal peritoneum, «suspension» by means of mylar tapes). However results of all these interventions, according to various authors, are not identical.

At torsion of a sigmoid colon various methods of operational correction are offered. A main objective of these operations fixing of a gut by means of rags of a dissect parietal peritoneum. Operations are ineffective as they can cause excesses of narrowing of a gut. Operations of a mesosigmoidopexy on Gagen-Thorn have bigger distribution, at a cut stitch a mesentery of a sigmoid gut on all height 3 — 4 (better P-shaped) silk seams. During the tightening of seams the mesentery gathers in folds and is considerably shortened.

Postoperative maintaining and complications

Lech. actions after the operations performed in the emergency order depend on indicators of the central hemodynamics, an acid-base state and water and electrolytic balance at operated. The main objective after operations on To. — fight against paresis went. - kish. a path, arising at the vast majority of patients. For prevention of paresis reasonablly early rising and feeding (digestible food) of patients since starvation and long horizontal position complicate normalization of motor activity went. - kish. path. Stimulation it is made the complex of conservative actions including perinephric blockade, intramuscular introduction of a prozerin, Pituitrinum, ubretid, intravenous administration of 10% of solution of sodium chloride, ganglioblokator (Dimecolinum).

The most terrible complication arising after operations on To., insufficiency of the stitches put on its wall is (is more often during creation of an anastomosis). This complication meeting at a large intestine operations more often leads to development of peritonitis or formation of intestinal fistula. Emergence of insufficiency of seams is promoted bad preoperative preparation of intestines, progressing of paresis went. - kish. a path, defects of the operational equipment, the expressed inflammatory changes of a wall of a gut, exhaustion and anemia at which trophic properties of the sewed fabrics sharply worsen.

After a large intestine operation it is necessary to feed within 4 — 5 days the patient with digestible food (a table 0) with obligatory giving a liquid paraffin on 30 g 3 times a day to prevent formation of the dense fecal masses capable it is easy to injure walls of an anastomosis and to cause emergence of insufficiency of seams. For the same reason after these operations within a week it is impossible to give enemas.



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A. V. Frolkis; L. I. Aruin (stalemate. An.), I. A. Ishmukhametov, A. B. Kozlova (I am glad.), A. I. Lyonyushkin (it is put. hir.), L. D. Lindenbraten (rents.), K. M. Lisitsyn (soldier.), S. S. Mikhaylov (An.), V. A. Polyakov (GO), B. I. Sokolov (Abd. hir.), Yu. A. Ratiner (mikr.), G. K. Shlygin (physical.), I. Yu. Yudin (PMC).

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