Acute Intestinal Obstruction - What To Do? Symptoms And Treatment

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-07 17:49

Acute intestinal obstruction: symptoms and first aid

What is intestinal obstruction?

Intestinal obstruction is a pathology in which the process of evacuating substances from the intestine is disrupted. It is especially typical for vegetarians and can be dynamic or mechanical.

At the first suspicion of intestinal obstruction, you should immediately contact a surgeon for help. Only he can make a final diagnosis and advise the necessary treatment. It is very dangerous to stop your choice exclusively on folk methods on your own.

Acute obstruction can cause death of a person, so it is so important to know its main symptoms and causes.

Statistics:

• After emergency surgery for intestinal obstruction, about 20% of patients die. If the pathology had a severe course, then these indicators increase to 40%.
• Among all acute conditions requiring surgical treatment, AIO (abbreviation for acute intestinal obstruction) occurs in 8-25% of cases.
• If the cause of intestinal obstruction is a tumor neoplasm, then the number of deaths is 40-45%.
• When the cause of acute intestinal obstruction is adhesions, death occurs in 70% of cases.
• In men, pathology occurs more often than in women - in 66.4% of cases.
• At risk are the elderly, whose likelihood of developing AIO increases 4 times.

Content:

• Causes of acute intestinal obstruction
• Symptoms of Acute Intestinal Obstruction
• Stages of acute intestinal obstruction
• Diagnostics of the acute intestinal obstruction
• What diseases can be confused with intestinal obstruction?
• Treatment of acute intestinal obstruction
• Complications
• Answers to popular questions

Causes of acute intestinal obstruction

Acute intestinal obstruction can be triggered by various reasons. They are divided into predisposing and producing ones. Predisposing causes increase the mobility of the intestinal loops, or immobilize it. This leads to the fact that the organ is in the wrong position, and feces cannot move along it normally.

Predisposing factors can be anatomical and functional.

Anatomical reasons include:

• The presence of adhesions in the peritoneal cavity.
• Meckel's diverticulum.
• Mesentery too narrow or too long.
• The presence of a hole in the mesentery.
• The presence of a hernia. The danger is a hernia of the white line of the abdomen, inguinal and femoral hernia, as well as internal protrusions.
• Organ malformations, for example, a mobile cecum, dolichosigma, etc.
• Peritoneal pockets.
• Tumors of the intestine or organs that are in close proximity to it.

Functional reasons that can cause acute intestinal obstruction include:

• Excessive food intake after prolonged abstinence. If a person has been on a diet for a long time, and then ate a large amount of rough food, the intestines will begin to contract strongly. This can cause intestinal obstruction or "disease of a hungry person" (according to Spasokukotsky).
• Colitis of various genesis.
• Postponed spinal cord injury, TBI.
• Psychological trauma.
• Strokes.
• Dysentery and other conditions that contribute to increased intestinal motility.

Productive causes lead to intestinal spasms and paresis. An excess of food, a sharp increase in intra-abdominal pressure, physical inactivity (forced adherence to bed rest and paralysis) can provoke a similar situation.

Symptoms of Acute Intestinal Obstruction

Intestinal obstruction, as a rule, begins with a sharp, growing, cramping pain in the abdomen and is accompanied by nausea and vomiting. Over time, the contents of the intestines begin to enter the stomach, while vomit has an unpleasant odor characteristic of feces. Constipation and increased gas formation occur. At the initial stage, intestinal peristalsis is preserved, it can be observed through the abdominal wall. The abdomen takes on an irregular shape, swelling rapidly increases.

Symptoms of acute intestinal obstruction:

• Abdominal pain. It occurs in all patients without exception. At an early stage of the development of pathology, pain proceeds as a contraction. It will be concentrated in the area of the abdominal cavity where the collapse formed. The pain is present on an ongoing basis, becomes dull, spreads throughout the abdomen. When the pathology reaches its peak, the pain decreases, but this symptom cannot be called favorable.
• Nausea and vomiting. These symptoms occur in 60-70% of people. They will be the more intense, the more severe the intestinal obstruction. First, bile will be present in the vomit, and then the contents of the intestines. The masses coming out of the mouth begin to smell like feces. Vomiting does not develop immediately, but after it has begun, its cessation is not expected.
• Lack of gas and feces. Even at an early stage of development of intestinal obstruction, feces will be absent. If the intestinal lumen is not completely blocked, then gases and stools may pass, but partially. At the same time, the person does not feel relief, he does not have the feeling that the intestines are completely cleansed.
• Bloating, change in its natural shape. Most often, this symptom characterizes cut-off intestinal obstruction. If the blockage occurs in the area of the small intestine, then the peritoneum will be distended evenly. With the defeat of the large intestine, the abdomen acquires asymmetric features and swells up in one of the areas.
• Forced position of the body - a person lies down and pulls his knees to his stomach. The patient cannot lie quietly, he constantly turns over, as he is pursued by severe pain.
• The general well-being of a person at an early stage of the development of pathology can be called satisfactory. However, if he has intestinal strangulation, then his health worsens in the first few hours from the development of the disorder.
• The blood pressure level falls and the pulse rises, which indicates the development of a state of shock.
• The tongue becomes dry, a yellow coating forms on it, and an unpleasant odor comes from the mouth. If the blockage occurs in the small intestine, the odor will have a fecal tint. The terminal stage of the development of pathology leads to the appearance of cracks in the tongue, after which ulcers form on it. This indicates a severe poisoning of the body, its dehydration and developing peritonitis.

When the patient goes to the doctor, the doctor notes the following clinical picture:

• Palpation of the peritoneum gives a person painful sensations. With deep palpation, a tumor or intussusception can be identified. Also, the doctor can palpate the hernia. The peritoneal wall will be taut, but the abdominal muscles are not tense. Also, the doctor notes an intense contraction of the intestines.
• Thévenard's sign. When pressing on the root of the mesentery of the small intestine (it is located 2 cm below the umbilical fossa), a person experiences painful sensations.
• Val's symptom. On palpation of the anterior abdominal wall, the leading loop is well felt. Its outline can be visualized.
• Anshtutz syndrome. In the right iliac region, the abdomen will be distended.
• Palpation of the invaginate. It is defined in the area of the ileocecal angle and has a sausage-like shape.
• Symptom Hose. Even without special devices, you can see how the patient's stomach swells from gas.
• Sklyarov's symptom. If you shake the front wall of the peritoneum with your hand, you can feel its seething.
• Listening to the abdomen. The doctor will hear a loud noise. If the pathology has already provoked the death of the intestinal walls, then the seething stops, giving way to silence.
• Symptom Loteson. When listening to the anterior wall of the peritoneum, you can hear heart and breathing sounds.
• Syndrome of the Obukhov hospital (a sign of Grekov). The anal opening is dilated, as well as the rectum, but no feces are observed there. This symptom is characteristic of volvulus.
• Kivul's symptom. When tapping the front wall of the abdomen, you can hear a ringing. If it has a metallic tint, then it indicates a balloon symptom (Kivul's symptom). If you tap on the side of your belly, the sound will be somewhat muffled.
• Symptom Tsege-Manteuffel. It is characterized by the fact that when an enema is performed, more than 1.5 liters of liquid does not enter the intestine. This symptom is diagnosed with volvulus of the sigmoid colon.
• Mondor Syndrome. On palpation of the rectum, one can feel a tumor in it and visualize feces, which will have a raspberry color.

Typical manifestations of intussusception are:

• Severe abdominal pain in the type of attack (Tiliax symptom).
• False urge to defecate and palpation of the formation in the peritoneal cavity (Rush symptom).
• The appearance of blood from the anus (symptom of Krovele).
• The setting of an enema leads to the fact that the released contents resemble the appearance of meat slops.

Stages of acute intestinal obstruction

Pathology, despite the acute course, has a certain staging.

Experts distinguish 3 phases:

1 phase - reactive

The duration of the reactive phase is 10-16 hours. During this period, a person experiences intense pain of the type of contractions. At first, they are paroxysmal, with periods of calm, but later they become permanent. The pain is often so severe that a person develops into shock. Doctors call the reactive phase the "Ielius cry."

When the reactive phase has just manifested, the intervals without pain will be frequent, at which time the patient's well-being will return to normal. However, when the intestines are infringed, no light gaps are observed. The pain goes from moderate to acute. High intestinal obstruction is accompanied by nausea and vomiting. With low intestinal obstruction, gas formation increases, there is no stool.

Visceral pain, radiates to other organs, develops against the background of spasm, in which the intramural nerve plexuses are irritated. In the future, the intestinal motor function is depleted. The intestines become swollen, strongly stretched. As the swelling increases, the pain becomes constant and intense. There are no periods of enlightenment.

Phase 2 - intoxication

After 12-36 hours, a toxic phase develops, in which organ paresis is observed. The pain becomes constant, the intestines stop contracting, the stomach swells up, takes on an irregular shape.

A person develops vomiting, it is profuse, it is impossible to stop it. The intestines will be full during this period, as will the stomach.

A person refuses water, as he is sick all the time. This leads to dehydration of the body, minerals, electrolytes, enzymes are removed from it. The face becomes like a mask (the face of Hippocrates), the oral mucosa dries up, while the patient himself is very thirsty. He has severe heartburn. Neither feces nor gases come out.

During this period, Valya's symptom, Sklyarov's symptom, Kivul's symptom, a symptom of peritoneal irritation appear. The checklists function suffers. Since a lot of fluid accumulates in the intestine, it begins to seep through its walls. This becomes the first step towards the development of peritoneal inflammation.

3 phase - terminal

After 36 hours, the final stage of the pathology develops. In this case, all organs are affected. The person begins to breathe quickly, the body temperature rises to feverish levels, there is no urination. The abdomen is no longer protruding forward, blood pressure drops, and the pulse becomes very fast, but weak.

From time to time, the patient has vomiting, from which comes the smell of feces. Then the patient develops blood poisoning, failure of internal organs and death occurs.

Diagnostics of the acute intestinal obstruction

If a person has symptoms of acute intestinal failure, it is impossible to hesitate to see a doctor. The surgeon is involved in identifying the violation, who examines the patient and listens to his complaints.

Laboratory methods

In addition to external examination and palpation of the abdominal cavity, the doctor directs the patient for laboratory tests, including:

• General blood analysis. A shift of the leukocyte formula to the left, an increase in ESR and hematocrit are found. This is due to the increasing dehydration of the body, against which the blood becomes thick.
• Blood donation for biochemical analysis. The analysis will increase the level of nitrogen, urea, glucose. At the same time, the values of potassium and sodium, calcium, chloride and proteins fall.
• The urine becomes cloudy and dark in color. The laboratory assistant detects erythrocytes and albumin in it.
• The coagulogram shows blood clotting, the prothrombin index increases, and the blood clotting time becomes shorter.

X-ray

Intestinal X-ray is the most accessible and very informative method for detecting intestinal obstruction. It is low cost and easy to implement. The procedure is performed using barium as a contrast agent. Bowel and abdominal x-rays are performed separately. If it is not possible to clarify the diagnosis, then they resort to irrigoscopy or intestinal examination. These studies allow you to assess the state of different parts of the intestine. Alternatively, an endoscopy of the lower intestine is performed.

During fluoroscopy, the patient must lie (on his side or back) or stand.

A typical picture that the doctor visualizes:

• Kloyber's bowls. This symptom is an accumulation of gas that looks like an inverted bowl. It is this clinical sign that is one of the first to come to light. When the intestines are cut off, the Kloyber bowls are visible on X-ray after 5 hours, and with strangulation of the organ - after an hour. Bowls can be multiple, they are capable of layering one on top of the other, therefore, they resemble a staircase.
• Intestinal arcades. They form in the small intestine. Due to pathology, it swells up, overfills with gases. In the lower sections of the arcades, horizontal liquid levels are noticeable.
• The symptom of pinnation. It develops with high obstruction, since in this case the small intestine is greatly stretched. It is its walls that form folds. In the picture, it looks like a spring that has been stretched.
• X-ray with contrast assumes that the patient has absorbed 50 ml of barium suspension. The doctor then takes a GI scan. They are made several, at certain intervals. If barium remains in the intestines for a long time (longer than 4 hours), it may be a sign of obstruction.

Depending on where the intestinal obstruction has developed, the X-ray picture will be as follows:

• In case of obstruction in the small intestine, Kloyber's bowls will be small. The liquid level is wider than the gas. Regardless of the section of the intestine, the fluid levels in them will be the same. The rosary beads are visible spirals and arcades, represented by the mucous membrane of the organ.
• With obstruction of the jejunum, fluid levels will be located in the epigastric region and in the region of the right hypochondrium.
• If the distal ileum is obstructed, fluid levels will be in the center of the abdomen.
• With an obstruction of the large intestine, fluid levels are located along the sides of the abdomen, but they are much less than in the case of a blockage of the small intestine.
• In dynamic intestinal obstruction, fluid levels are visualized in the small intestine and colon.

If the doctor assumes that the patient develops obstruction of the large intestine, then he prescribes sigmoidoscopy and colonoscopy. These diagnostic techniques allow you to determine the cause of the violation and identify a tumor, foreign bodies or fecal debris.

What diseases can be confused with intestinal obstruction?

Your bowel obstruction symptoms may mimic those of other illnesses. Therefore, there is a possibility of confusing obstruction with such violations as:

• Acute appendicitis. With this disease, severe abdominal pain also occurs, vomiting and constipation may develop. However, with appendicitis, pain originates in the epigastric region, passing into the right iliac region. In case of obstruction, the pain proceeds according to the type of contractions, it is intense, followed by painless periods. Such an intense contraction of the intestines with appendicitis does not occur. If a complete blood count for both pathologies indicates the presence of inflammation, then when an X-ray image of the intestine is taken, there are no signs of obstruction.
• Perforated stomach ulcer. The disease develops as suddenly as intestinal obstruction, the patient has no stool and gas, the stomach hurts badly. If a perforation occurs, then the person will feel very bad. The anterior abdominal wall is very tense, does not take part in breathing. If you try to palpate the intestines, then the person will feel severe pain. In case of obstruction, the organ, on the contrary, is greatly reduced, you can palpate an enlarged loop. With an ulcer, a person does not develop vomiting, the intestines do not contract. During the X-ray, the Kloyber cups are not detected, but free gas is visible in the peritoneal cavity.
• Acute inflammation of the gallbladder. A person has intense pain, he feels sick, his stomach is swollen. However, the pain will be concentrated in the right side, radiating to the shoulder and scapula. In case of obstruction, it will not be possible to clearly limit the site of pain localization. If you palpate the area of the right hypochondrium, then in a patient with cholecystitis, tense muscles can be detected, while the contractile activity of the intestine does not increase, pathological sounds are not heard. With inflammation of the gallbladder, the body temperature rises, jaundice develops.
• Acute inflammation of the pancreas. The pains manifest suddenly, vomiting occurs several times in a row, gases do not go away, the stomach is swollen, the intestines are in a state of paresis. The stomach hurts in the upper part, the pain surrounds the body. With intestinal obstruction, the pain proceeds as contractions. If the abdomen of a patient with pancreatitis is palpated, the swollen colon can be palpated. In addition, bile will be present in the vomit. After a while, the gases will begin to leave, and a chair will appear. In a blood test, the level of diastase rises.
• Myocardial infarction, accompanied by abdominal syndrome. A patient with a heart attack has a swollen stomach, severe pains appear in its upper part, and weakness increases. The person is nauseous, vomiting may open, stool and gas are absent. However, additional signs that indicate a heart attack are: hypotension, deafness of heart sounds, percussion expansion of the borders of the heart, the abdomen does not become asymmetric, the intestines do not contract strongly, and noises appear. To clarify the diagnosis, an electrocardiogram must be performed.
• Renal failure Similar signs are: intense pain in the type of contractions, bloating, absence of stool and gas, increased anxiety of the patient. Distinctive characteristics of renal colic: pain radiates to the genitals, to the lower back, urine is delayed, a person can hardly urinate, blood is present in urine. In the kidneys and in the ureters, calculi are found using X-ray.
• Pneumonia concentrated in the lower lobes of the lungs. Similar symptoms: abdominal muscle tension, abdominal pain. Distinguishing characteristics of pneumonia: pink cheeks, shallow breathing, shortness of breath, chest pain. If you listen to the lungs, you can hear wheezing, crepitations, noises. Radiography helps to make the correct diagnosis.

Treatment of acute intestinal obstruction

If a person develops symptoms that indicate an intestinal obstruction, they should be taken to a health facility as soon as possible. Until that time, until the patient is examined by a doctor, he should not do an enema, it is forbidden to take laxatives, pain relievers or perform gastric lavage. Treatment can be reduced to both taking medications and surgery. It all depends on the characteristics of the course of the disease. With dynamic obstruction, there is the possibility of medical correction, and with mechanical blockage of the intestine, it will not be possible to do without the help of a surgeon. Often, to save the patient's life, the operation is performed on an emergency basis.

When the obstruction has just begun to develop, it is difficult to identify its shape. Therefore, the doctor postpones the intervention for several hours. If taking medications does not lead to an improvement in well-being, then the patient is referred to the surgical table. Provided that the patient has already been diagnosed with peritonitis or intestinal strangulation, the operation is performed immediately.

Medical correction often allows you to overcome coprostasis, as well as to cope with obstruction against the background of a neoplasm in the intestine.

Medication correction

• Reducing pain intensity, influencing bowel contraction. Paranephral novocaine blockade is performed to reduce pain. Antispasmodics (Atropine, Spazgan, Drotaverin) are administered intravenously. If a patient is diagnosed with intestinal paresis, then Neostigmine, a hypertonic sodium chloride solution, is prescribed to eliminate it, an enema is administered.
• Decompression of the digestive tract. The contents of the stomach must be withdrawn using a tube and a siphon enema through which 10 liters of water are injected. It is possible to carry out such activities only if the patient has not developed peritonitis. If a chyme is found in the stomach, this indicates a severe course of intestinal obstruction. Also, the volumes of injected fluid allow us to make an assumption about the level of obstruction. Decompression makes it possible to normalize the intestinal contractility and improve microcirculation in its walls.
• Prevention or elimination of dehydration. Patients with intestinal obstruction are prescribed infusion therapy. Patients are administered Ringer's solution, glucose, insulin, potassium solution. The volumes of injected solutions are large and cannot be less than 3 liters. Soda is prescribed for patients with metabolic acidosis. During infusion therapy, pressure and urination should be monitored. A catheter is placed in the patient's bladder and in the subclavian vein.
• Bringing blood supply to the digestive system back to normal. For this purpose, albumin, plasma, protein, rheopolyglucin, pentoxifylline, amino acids are used. If indicated, the patient is prescribed cardiotropes. If the patient starts the process of passing gas, there is a chair and the pain passes, then this is a good sign. If, after 2-3 hours, the person's well-being does not improve, he is prepared for surgery.

Operative intervention

If the patient develops a mechanical blockage of the intestine, then the operation is required in 95% of cases. The remaining 4% of patients do not undergo it due to the fact that they are in serious condition. Another 1% of patients simply do not seek medical help and die.

Contraindications to surgery for mechanical blockage of the intestine are only the agony and pre-agony of the patient.

Indications for surgery:

• Developing peritonitis.
• Intoxication and dehydration of the body, which corresponds to the 2nd phase of obstruction.
• Signs indicating intestinal strangulation.

Measures to prepare the patient for the intervention:

• Placement of the probe into the stomach.
• The introduction of drugs that will ensure the work of the circulatory and respiratory system.
• Conducting massive infusion therapy.

A catheter is placed in the patient's bladder, stomach, and central vein. Anesthesia is done endotracheal, the operation is a laparotomy with a midline incision. If the patient has an obstruction due to an infringement of a hernia, then spinal anesthesia can be performed.

The goals that the surgeon pursues:

• Determination of the type of obstruction with an examination of the abdominal organs.
• Elimination of the cause that provoked the blockage. The adhesions or collars of the hernia are dissected, with volvulus or during the formation of a node they are eliminated. They also carry out disinvagination, or plan to resect part of the affected area.
• Assessment of the condition of the intestine and its possibility of further functioning. If the organ has not died, then it will have a burgundy or blue color, its mesentery is smooth, in some of its zones hemorrhages are visible. The vessels continue to pulsate, there are no blood clots. The intestine reacts to exposure to warm saline with hyperemia, increased pulsation and contractions. Removal of the organ is required if blood clots form in the vessels, if it becomes black or dark blue, the mesentery will be dull and covered with hemorrhages. The intestine does not react to treatment with a warm solution.
• Removal of the affected area. The area of the organ that has undergone necrosis, as well as the intestine at a distance of 40 cm from the zone of death, is subject to removal. Then anastomosis is performed.
• Unloading. When the organ loops are overstretched, bowel decompression is performed using nasogastric intubation of the small bowel with a tube. Drainage is performed through an enterostomy or cecostomy.
• Drainage and sanitation of the peritoneum. The abdominal cavity is washed with special compounds and dried. Drainage is taken out through the anterior abdominal wall.

Period after surgery

If the operation is successful, then the patient is placed in the intensive care unit. There he must spend at least 3 days.

The main areas of treatment and care:

• Prevention of dehydration, intoxication and infection of the body.
• Elimination of violations from the respiratory system and the cardiovascular system.
• The use of electrolytes to normalize the acid-base environment.
• Improvement of rheological parameters of blood.
• Preventing the formation of blood clots. For this purpose, Fraxiparine is used.
• To strengthen the body, vitamins and immunomodulators are administered.
• To prevent intestinal paralysis, its work is supported with the help of enemas, Prozerin, Cerucal, electrical stimulation, etc.

In the first 3 days, the person must be in the intensive care unit. He is given percussion massage of the sternum, breathing exercises are performed. This is necessary to normalize the functioning of the respiratory system.

The patient should be lifted out of bed as early as possible. This is done so that the intestines begin to contract and not develop stagnation. It is recommended for the patient to get up for 2-3 days if there are no contraindications.

The first 3 days a person receives parenteral nutrition. It is important to monitor his pulse, breathing rate, and the quality of the discharge from the drain. During the same period, he receives antibiotics and anti-inflammatory drugs.

For 4-7 days, the patient is transferred to the general ward. There he must observe a half-bed regime. The tube is removed from the stomach. From this time on, a person should receive food as usual, but it is served in a semi-liquid and grated form (table 1A).

The bandage is changed for 2 days, the drainage is removed on day 4, if there is no discharge from it.

The patient should use a bandage so that the stitches do not come apart. From day 5, you need to start doing gymnastics under the supervision of a doctor. The patient continues to receive vitamins, antibiotics, immune stimulants. The menus are gradually expanding.

On the 8-10th day after the operation, the person is transferred to table 15. He is already allowed to leave the ward.

The stitches will be removed on days 9-10. If no complications develop, the patient is discharged.

In the next 3 months, a person will need to follow a strict menu, give up vegetables that stimulate gas formation, from pickled and salty foods, from fatty foods and semi-finished products.

Complications

The postoperative period is associated with the risk of the following complications:

• Intestinal loop necrosis. In this case, a second operation is performed, the affected area is removed, an anastomosis is applied, or the stoma is removed.
• Bleeding. A second laparotomy is required, during which the source of bleeding is eliminated.
• Insolvency of the sutures of the intestinal anastomosis. At the same time, relaparotomy is performed, an unnatural anus is created, and drains are removed.
• Interintestinal abscess. Relaparotomy and abscess sanitation are performed.
• Intestinal fistula. Conservative therapy is performed, with the treatment of the fistula with disinfecting ointments and pastes. In the future, the loop with the fistula must be removed by performing intestinal intubation.
• Adhesion formation. Relaparotomy with fistula dilution, intestinal intubation are performed.

Answers to popular questions

• Is it possible to make a prognosis for acute intestinal obstruction? The sooner the patient receives help, the more favorable he is. Concomitant diseases are important, as well as the age of the patient. For the elderly and frail people, the prognosis worsens. If the operation was carried out in the first 6 hours from the development of obstruction, then the patient is most often saved.
• If the obstruction develops in a pregnant woman, what is the prognosis? The gestation period is an additional risk factor for the development of intestinal obstruction. It most often occurs in the 2nd and 3rd trimester of pregnancy, less often in the 1st trimester. In 25-50% of cases, pathology leads to the death of a woman, and the child is born dead in 60-75% of cases. However, provided that the operation was performed in the first 3 hours after the manifestation of obstruction, the death of the patient happens only in 5% of cases.
• What is chronic intestinal obstruction? It develops against the background of the presence of adhesions in the abdominal cavity, or with a tumor that cannot be removed. The patient is prescribed medication. If there is no effect, then an operation is performed. At the same time, each intervention carries the risk of new adhesions formation. Alternatively, a colostomy may be formed.

Article author: Mochalov Pavel Alexandrovich | d. m. n. therapist

Education: Moscow Medical Institute. IM Sechenov, specialty - "General Medicine" in 1991, in 1993 "Occupational Diseases", in 1996 "Therapy".