The Morphological Characteristic of the Small Intestine at Sharp Intestinal Impassability
Abstract
To this article it is investigated changes of walls of a small
intestine concerning intestinal impassability. In it many various and
difficult pathological
mechanisms sharp impassability of intestines because of various
etiology, estimating depth and reversibility of damage and the
microcirculation
changes in an intestines wall are revealed.
Keywords: Small Intestine; Mechanisms; Damages; Microcirculation
Introduction
The Sharp Intestinal Impassability (SII) for many years remains
to one of the most actual, complex and stubborn problems of
urgent abdominal surgery [1,2]. Still remain almost not studied the
changes happening in a small intestine after restoration of a bloodgroove
when the gut admits viable and plunges into an abdominal
cavity. At the same time, according to a number of authors, the
small intestine is highly sensitive body concerning ischemia [3,4].
In recent years it isn’t achieved considerable success in the field
of diagnostics and treatment of the sharp intestinal impassability
(SII) which is the reason of 1,2-14,2% of all emergency surgical
interventions. Patients with impassability of intestines make up to
3,5% of total number of patients in surgical hospitals. In structure
of the emergency surgical diseases the share of sharp intestinal
impassability reaches 9,4% [3,5,6]. In absolute numbers there is
steady growth of number of patients to OKN, especially adhesive
as in connection with development of anesthetic equipment
it began to be carried out more difficult, and, therefore, more
traumatic abdominal operations [7-9]. Lethal outcomes at sharp
intestinal impassability make 10,7-64,7% [9-11].Moreover, growth
of a lethality at this pathology is observed and makes 43,7-64,7%
[10,12]. Data on objectification of structural violations which arise
in a wall of a small intestine at sharp intestinal impassability and
their corrections at the person are small, as has defined need of
performance of this work. The purpose of the study- was to study
the state structures of the tissues of the wall of the small intestine
in acute strangulation obstruction in humans.
Methods and Materials
Material was taken during surgery for resection of the small
intestine over the period 2011-2015. According to nosological
units: for acute intestinal obstruction by strangulation type -5 cases
(strangulated femoral hernia in 3 cases, inguinal hernia - 2), about
the thrombosis of the branches of the upper mesenteric arteries and
veins 5 case. In 3 cases, resection was performed about adhesive
intestinal obstruction. As a control used the fragments of the small
intestine, which were taken at autopsy 5 dead through 3-9h after
death from diseases not related to pathology of the gastrointestinal
tract. Pathologically changed organs were fixed in 10% buffer
neutral formalin was paraffin. After posting in paraffin, histological
sections with a thickness of 5-6 microns were made by microtome
“Leica” and were stained with hematoxylin-eosin according to the
morphological division of the study. Histochemical study of the
activity of succinate dehydrogenase and acid phosphatase was
carried out according Burstone [4].
Results and Discussion
Postmortem Examination Revealed the Following: Small
bowel after resection for acute strangulated obstruction was
increased in diameter, inflated, c serous membrane is dim, almostblack,
discharge loop spasmodic. In all cases clinically were
expressed, peritoneal phenomena that have characterized the
presence of acute generalized peritonitis of varying severity. In
lesions the loop of intestine on the basis of massive hemorrhagic
infarction was observed necrosis of the bowel wall. Even with
minor disease duration (6-9h) by staining with hematoxylin and
eosin in the intestinal wall were observed edema, lymphedema,
hemorrhagic infarction of tissues with diffuzomation of purulent
inflammation of the mucosa and pockets of bacteria build-up. In the
dilated vessels of the submucosa of the, stasis of blood, and small
hemorrhages. In the immediate area of necrotic areas (5-10cm),
causing loops of the small intestine blood vessels are filled with
blood. In the mucosa there are significant changes [13-15].
The epithelium of the intestinal villi is separated from the
condensed stroma of the villi throughout the edematous fluid. The
boundaries between the columnar absorptive the enterocytes are
practically the same, their nuclei are frequently displaced in apical
direction. The tops of many of the villi “naked”, their epithelium
slues, which corresponds to the III-severity of morphological
damage of epithelial lining of the villi of the small intestine in C Chiu
et al. [11]. In sections taken at the border of small bowel resection
within life-able fabrics (50cm), there is swelling of all layers of
the bowel wall. Microgametocyte in a state of stasis, a ubiquitous
phenomenon leuko-diapedeses. Loose connective tissue stroma of
the intestinal villi sealed, infiltrated polymorphocellular elements.
The lint everywhere phenomena subepithelial edema. Columnar
epithelial cells are swollen, their height is reduced, the cytoplasm
is cloudy, the kernel is shifted in the apical direction. The number of
goblet cells increases. The functional properties of the enterocytes
are violated. Dramatically decreasing the activity of succinate
dehydrogenase, which is localised control in the form of dark blue
granules in the apical and basal pole of enterocytes. At a distance
of 50cm from the ligature marks, the number of granules, which
indicate the activity of the enzyme, a minor, is determined only by
pale fine-grained texture. Localization and intensity of staining of
enterocytes in the determination of acid phosphatase changed with
increasing amount of deposited reaction product, in comparison
with the control.
In the study of the bowel wall, which was subjected to resection
regarding thrombosis of the branches of the superior mesenteric
artery and vein, we identified severe ischemic and inflammatory
changes resulting in its loop at a distance of 50cm from the border
of necrosis. At a distance of 10-20cm from the necrotic changed area
of an intestine there is swelling of all membranes of the body wall. In
the mucous membrane, it manifests itself by a significant extension
of subepithelial space. The intestinal villi are of unequal length,
the exposed tops and in some of them the enterocytes listening
from the top to the base of the villi. The enterocytes swollen, their
cytoplasm is cloudy, the nuclei of different sizes are deployed in
the direction of the apical pole is detected karyopyknosis separate
cores. The border of the enterocytes did not distinguish. The degree
of mucosal damage mainly III, sometimes IV sites are characterized
by a degree of damage where there is disintegration of the
lamina propria of the mucous membrane with hemorrhages and
ulceration. Crypts and focal cropped destroyed. In the stroma of the
villi polymorphocellular infiltration (Figures 1a & 1b).
Figure 1: Injuries of a mucous membrane of III degree.
Coloring by hematoxylin and eosin. The increase approx.
10. about 40.
At a distance of 50cm leading loop in the crypts cells stored,
and you can hope for the regeneration of the epithelial layer
of the intestine. The activity of succinate dehydrogenase in
enterocytes dramatically reduced. When setting the reaction to
acid phosphatase, the enterocytes are painted unevenly. Only at
a distance of 50-55cm above the zone of necrosis histological
structure of intestine stabilize while maintaining a slight swelling
and inflammatory lymphocytic infiltration (I-II degree of damage).
In adhesive intestinal obstruction a resection volume were different
- from 20cm to the entire ileum. The section of intestine that
were subjected to resection, as a rule, were deformed, narrowed
in diameter, with a thickened wall. Adhesions consisted of dense
connective tissue, adherent to the serous membrane of bowel
wall. The muscular coat moderately hypertrophied. In the mucosa
revealed significant changes – swelling of the stroma of the villi,
swelling of enterocytes, a decrease in the activity of succinate
dehydrogenase, which is evidence of II-III degree of damage
(Figures 2 & 3).
Figure 2: Micro circulator changes with formation of
a thromboembolic in an intestinal wall. Coloring by
hematoxylin and eosin. The increase approx. 10. about 40.
Figure 3: Dystrophic and necrobiotic changes of the villi
of the mucous membrane. Coloring by hematoxylin and
eosin. The increase approx. 10. about 40.
Thus, despite the complexity and diversity of the pathological
mechanisms of acute intestinal obstruction of different etiology
share key link in determining the depth and reversibility of the
lesion, are microvascular changes in the intestinal wall. They
wear the same type of character, depend on the type of intestinal
obstruction and duration of the postoperative period after resection
of the necrotic modified loop of the small intestine.
Conclusion
a) Histopathological changes and resulting discharge loop
of the intestine of a person at different distances from necrotic
areas have obvious features. Within the conventional resection
of 50 cm lead and 20 cm outlet loop - they differ depending on
the type of obstruction.
b) A comprehensive study of the wall of the remote portion
of the small intestine histological, histochemical methods
with obstruction showed the difficulty of resection in the
conventional boundaries because of its lack of viability.
c) Changes in the enterocytes may serve as an indicator of
damage of the intestinal mucosa in combination with damage
to its nervous structures.
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