Fifty-two acute intestinal obstructions: pathologies.
\r\n\tThis book intends to cover major mineral deficiency problems such as calcium, iron, magnesium, sodium, potassium and zinc. These minerals have very important task either on intracellular or extracellular level as well as regulatory functions in maintaining body homeostasis.
\r\n\r\n\t
\r\n\tBoth macrominerals and trace minerals (microminerals) are equally important, but trace minerals are needed in smaller amounts than major minerals. The measurements of these minerals quite differ. Mineral levels depend on their uptake, metabolism, consumption, absorption, lifestyle, medical drug therapies, physical activities etc.
\r\n\tAs a self-contained collection of scholarly papers, the book will target an audience of practicing researchers, academics, PhD students and other scientists. Since it will be published as an Open Access publication, it will allow unrestricted online access to chapters with no reading or subscription fees.
",isbn:"978-1-83881-085-6",printIsbn:"978-1-83881-081-8",pdfIsbn:"978-1-83881-086-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"8bc7bd085801296d26c5ea58a7154de3",bookSignature:"Dr. Gyula Mozsik and Dr. Gonzalo Díaz-Soto",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8935.jpg",keywords:"Calcium, Iron, Magnesium, Potassium, Sodium, Zinc, Diagnostic tools, Treatments, Food Fortification, Malnutrition, Metabolic Disorders, Lifestyle",numberOfDownloads:900,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 26th 2020",dateEndSecondStepPublish:"June 16th 2020",dateEndThirdStepPublish:"August 15th 2020",dateEndFourthStepPublish:"November 3rd 2020",dateEndFifthStepPublish:"January 2nd 2021",remainingDaysToSecondStep:"10 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Professor Emeritus of Medicine at Univesity of Pecs, Hungary, and recipient of Andre Roberts award from the International Union of Pharmacology in 2014. He published 360 peer-reviewed papers, 196 book chapters, 692 abstracts, 19 monographs, and edited 32 books.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.jpg",biography:"Gyula Mózsik, MD,PhD, ScD(med) is a professor emeritus of medicine at First Department of Medicine, Univesity of Pécs, Hungary. He was head of the Department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition. His research fields are biochemical and molecular pharmacological studies in gastrointestinal tract, clinical pharmacological and clinical nutritional studies, clinical genetic studies, and innovative pharmacological and nutritional (dietetical) research in new drug production and food production. He published around 360 peer-reviewed papers, 196 book chapters, 692 abstracts, 19 monographs, 32 edited books. He organized 38 national and international (in Croatia ,France, Romania, Italy, U.S.A., Japan) congresses /Symposia. He received the Andre Robert’s award from the International Union of Pharmacology, Gastrointestinal Section (2014). 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The block must be complete and permanent.
\nThere are several data that can diversify the intestinal obstruction syndrome. First, the etiology based on a large number of factors that allow the subdivision into mechanical and functional/paralytic obstruction.
\nThe other feature characterizes the syndrome: the seat of the obstruction along the bowel—upper small gut, distal small gut, and large bowel.
\nFinally, the cause of obstruction can involve the vascular supply of an intestinal segment, giving rise to strangulation obstruction that should be differentiated from simple obstruction.
\nThe syndrome of intestinal obstruction with these various etiopathological and clinical features develops the same, overlappable, and pathophysiological alterations.
\nBowel obstruction can be caused by several factors.
\nThe causes of mechanical obstruction can be divided into causes within the bowel lumen, causes in the intestinal wall, and extrinsic causes.
\nThe causes within the bowel are infrequent. They can be due to large gallstones passed into the intestinal lumen by spontaneous bilio-digestive fistulas, most frequently cholecystoduodenal fistulas, very rarely phito-thricobezoar, masses of parasites, food bolus, concretions of barium following barium enema X-ray investigation or X-ray studies with opaque medium.
\nIt is useful to point out that the fecaloma, fecal impaction in the rectal ampulla, based on the damage of the autonomic nervous system in the colorectal wall, can cause chronic alteration of intestinal transit with incomplete obstruction without the pathophysiological alterations of acute gut obstruction.
\nThe causes in the gut wall include the neoplasms of small and large bowel, the congenital atresias, the stenosis due to chronic inflammatory disease (Crohn disease, diverticulitis, etc.), and postanastomotic or posttraumatic structures.
\nThe extrinsic causes include a very large range of pathological conditions: compression by external masses, adhesions, bands, strangulated external or internal hernias, volvulus, and intussusception [1]. In the clinical practice, it should be valuable to distinguish between acute and chronic obstructions. Nevertheless to define both clinical pictures with accuracy is very useful. The acute intestinal obstruction, simple or strangulated forms, is characterized by complete and permanent blockage and consequently the acute pathophysiological syndrome of obstruction may develop with all clinical, laboratory, and instrumental features: bowel dilatation, disturbances of fluids and electrolytes balance, congestion, and ischemic parietal damage, etc.
\nOn the contrary, in the chronic obstruction, the blockage of gut transit is incomplete and the syndrome cannot develop completely and is characterized only by constipation.
\nIntestinal obstruction may be mechanical or paralytic. Mechanical obstruction can be due to intraluminal, intrinsic to the intestinal wall and extrinsic.
\nParalytic ileus due to reduction or the absence of peristalsis can be caused by peritoneal phlogosis, infection, abdominal surgery, pelvic surgery, and some medications such as antidepressant, pain medications, muscle and nerve disorders, and retroperitoneal hemorrhage.
\nThe majority of patients have simple obstruction. On the contrary, there is also strangulation obstruction, usually due to complicated external hernia (abdominal wall) or internal (by congenital defects or postoperative adhesions): in these patients the vascular supply to a strangulated intestinal segment is compromised and consequently intestinal infarction. Strangulation obstruction leads to an increased risk of morbidity and mortality.
\nIn the mechanical occlusion with strangulation, the vascular (arterial and venous) occlusion leads to bowel ischemia and necrosis. The evolution of strangulated bowel is the perforation and peritonitis. The occlusive syndrome becomes worse due to strangulation.
\nIntestinal pseudo-obstruction is a syndrome characterized by a complete dilatation generally of large bowel without mechanical obstacle. The intestinal pseudo-obstruction can affect small or large bowel and it may be possible to differentiate the syndromes with acute or chronic onset and evolution.
\nThe chronic pseudo-obstruction can be idiopathic or secondary to systemic disease.
\nThe examination of homogeneous clinical cases of a single center allows us to clarify the epidemiological features.
\nIn the period 2011–2015, 52 patients have been admitted in our service with the clinical presentation of intestinal obstruction.
\nDemographic data are as follows: 52 patients, 26 males, 26 females, and mean age 67 years (range 27–86 years).
\nAcute mechanical small bowel obstruction was the most frequent (71.2%) with various pathologies: adhesion -relate obstructions, small bowel volvulus, gallstones ileus, malignancies, abdominal wall hernias, internal hernias, carcinomatosis, and ileocecocolic intussusception (Figure 1).
\nCT scan: ileocecocolic intussusceptions.
CT scan: sigmoid volvulus.
The less frequent in our experience were acute large bowel obstructions (28.8%). The more common pathologies were colon and rectal cancer, sigmoid volvulus (Figure 2). We have observed and treated only one patient with acute colonic pseudo-obstruction (Ogilvie’s syndrome) (Table 1).
\n\n | % | \n|
---|---|---|
Adhesions | \n22 | \n42.3 | \n
Small bowel volvulus | \n4 | \n7.7 | \n
Sigmoid volvulus | \n1 | \n1.9 | \n
Right colon cancer | \n3 | \n5.8 | \n
Left colon cancer | \n5 | \n9.6 | \n
Rectal cancer | \n5 | \n9.6 | \n
Ogilvie’s syndrome | \n1 | \n1.9 | \n
Gallstones ileus | \n2 | \n3.8 | \n
Carcinomatosis | \n1 | \n1.9 | \n
Strangulated incisional hernia | \n3 | \n5.8 | \n
Strangulated groin hernia | \n2 | \n3.8 | \n
Strangulated umbilical hernia | \n1 | \n1.9 | \n
Internal hernia | \n1 | \n1.9 | \n
Ileocecocolic intussusception | \n1 | \n1.9 | \n
Total | \n52 | \n\n |
Fifty-two acute intestinal obstructions: pathologies.
\n | % | \n|
---|---|---|
Adhesiolysis | \n18 | \n34.6% | \n
Small bowel resection | \n6 | \n11.5 | \n
Right hemicolectomy | \n4 | \n7.7 | \n
Left hemicolectomy | \n5 | \n9.6 | \n
Intestinal derotation | \n4 | \n7.7 | \n
Cecostomy | \n2 | \n3.8 | \n
Enterotomy and gallstone removal | \n2 | \n3.8 | \n
Anterior rectum resection | \n4 | \n7.7 | \n
Total colectomy | \n1 | \n1.9 | \n
Prosthetic mesh repair incisional hernia | \n3 | \n5.8 | \n
Umbilical hernia repair | \n1 | \n1.9 | \n
Prosthetic mesh repair groin hernia | \n2 | \n3.8 | \n
\n | 52 | \n\n |
Fifty-two acute intestinal obstructions: surgical interventions.
In our experience, all intestinal obstructions have been treated with urgent surgery. Various types of surgical procedures have been employed based on intraoperative pathological findings. They should be useful to underline that the choice of the urgent treatment allowed the resolution of majority of adhesion-related obstructions and small bowel volvulus with the surgical procedure of adhesiolysis and intestinal derotation (42.3%). The intestinal resection has been performed in six cases (11.5%). Ogilvie’s syndrome required cecostomy; colorectal malignancies have been treated with primary tumors resection and delayed intestinal anastomosis. Our surgical interventions are reported in Table 2.
\nIn simple obstruction, important and progressive alterations take place and develop in the gut above the obstruction. Accumulation of gas and liquids with progressive distension in intestinal segments upstream the obstruction and the blockage of content progress change the bacteriological content. Also there are damages of blood circulation in the distended bowel wall. The accumulation of fluid and electrolytes in the obstructed gut and their loss in the general circulation take an important place in the pathophysiology of intestinal obstruction [2, 3].
\nThe distension of obstructed bowel above the obstacle is due to the accumulation of fluid and gas. The intestinal gas that normally progresses by peristaltic movements shows the following composition at the start of occlusion: swallowed air, carbon dioxide (it comes from neutralization of bicarbonates), and later on gas bacterial fermentation. The carbon dioxide that forms in large quantities in the intestinal cavity participates minimally gaseous accumulation because it is largely absorbed by the intestinal mucosa.
\nNitrogen N2 | \n70% | \n
Oxygen O2 | \n10‒12% | \n
Carbone dioxide CO2 | \n6‒9% | \n
Hydrogen H2 | \n1% | \n
Methane CH4 | \n1% | \n
Hydrogen disulphide | \n1‒10% | \n
Intestinal obstruction: composition of intestinal gas.
On the contrary, the swallowed air significantly contributes to gaseous bowel distension because it contains a high rate of nitrogen content, which is not absorbed: in fact about 70% of the intestinal gas is constituted by nitrogen.
\nFor this reason, the nasogastric aspiration in the patients with intestinal distension should be relevant and useful.
\nA little advantage can be added to gastric aspiration by the administration of pure oxygen to distended patients because increasing the pressure of a gas increases its solubility [4].
\nThe common composition of intestinal gas in obstruction is reported in Table 3 [5, 6].
\nIn the distended bowel above, the obstruction gastrointestinal secretions accumulate in large amounts. This occurs for two reasons: deprivation of the absorptive activity of intestine beyond the obstruction and also damage in fluid and electrolyte exchange in the wall of the obstructed and distended gut [7].
\nSource | \nVolume (ml) | \n
---|---|
Saliva | \n1500 | \n
Gastric secretion | \n2500 | \n
Bile | \n500 | \n
Pancreatic juice | \n700 | \n
Intestinal mucosa secretion | \n3000 | \n
Total | \n8200 | \n
Normal plasmatic volume | \n3500 | \n
Volume of digestive secretion per day.
The saliva, gastric secretion, bile, pancreatic juice, and small intestinal secretion accumulate the total volume of about 8000 ml in 24 h as reported in more detail in Table 4. These fluid secretions are isotonique with the plasma, except for gastric secretion, which has minor sodium concentration (Figure 3) [8].
\nTherefore, normally water and electrolytes absorption is almost complete in the colon. In small bowel obstruction, the function of the colon cannot develop and the total intestinal secretions accumulate in the obstructed gut.
\nBeside the decreased absorption in the obstructed patients, there is also, above the obstacle, increased secretion into the bowel lumen.
\nIn the pathophysiology of intestinal obstruction, the fluid and electrolytes loss plays a very important role. The progressive accumulation of gas and fluid in the intestinal lumen allows the increase in the endoluminal pressure to very high values: in the small bowel the pressure can reach 15 cm H2O, whereas in the colon it can reach 25 cm H2O. In the initial period of mechanical obstruction in the intestinal segments above the obstacle, active peristalsis causes further pressure rise to 20–30 cm H2O [9]. In the large bowel, the intraluminal pressure can reach 50 cm H2O because the pressure increase is based on the product of the pressure value multiplied by bowel diameter. The major detrimental effect of the progressive gut distension and intraluminal pressure increase is the impairment of the intramural circulation of the bowel.
\nElectrolytes composition in blood plasma and digestive secretion.
The experimental studies demonstrated the linear connection between bowel obstruction, increase in intraluminal pressure, gut wall distension, changes in blood flow [10]. In the clinical situations, there are some difficulties to connect the degree of intraluminal pressure, intestinal distension, and the damage of parietal blood perfusion.
\nIn the pathological setting, the increase in the intraluminal pressure should develop slowly and should not reach high degree [11, 12].
\nThe intestinal wall distension in the obstructed patients causes increased distensibility of the gut wall that becomes more vulnerable to a further increment of distension. In this way, a small rise in the intraluminal pressure and the wall distension allows considerable tension in the intestinal wall and increased resistance in the capillaries with damage bowel blood flow.
\nThe ischemic necrosis of obstructed bowel should be caused by progressive thinning of gut wall, reduction of the lumen of vessels, and finally interruption of the blood supply [4].
\nIn the pathogenetic sequence, start a self-handing mechanism because the parietal distension increases the intestinal secretions with further intraluminal fluid accumulation, increased wall distension, impaired parietal blood flow, and finally hypovolemia.
\nThe intestinal secretions enhance because the capillary leak increases the fluid flux to intestinal lumen [12, 13].
\nBeside fluid and electrolytes accumulation in the obstructed bowel, there is further fluid loss with vomiting. The metabolic effects of electrolytes and fluid loss, subtracted from the circulating blood volume and interstitial spaces, depend on the duration and site of obstruction. Proximal small bowel obstructions cause early and abundant vomiting with fluid, Cl, Na, and K loss, and consequently dehydration, hypokalemia, hyponatremia, hypochloremia, and metabolic alkalosis. In these proximal obstructions, the gut distension is less evident. On the contrary, the distal small bowel obstructions show more evident gut distension but the fluid and electrolytes depletion develop slowly, based on late vomiting and longer preserved resorption capacity. The dehydration causes hypovolemia, tachycardia, renal failure, decrease in the central venous pressure (CVP), and cardiac output, finally the hypovolemic shock. Moreover, the bowel distension may cause increase in the endoabdominal pressure with damage of venous return and pulmonary ventilation.
\nNormally, the small intestine contains only transient bacterial flora with scanty growth because of the fluid content and fast transit. In fact, bacteria traverse the small intestine so rapidly that significant growth does not occur.
\nInstead in the case of obstruction and stasis, proliferation by geometrical progression results in rapid colonization of the intestinal lumen [14, 15].
\nIntestinal obstruction: pathophysiological features.
Moreover, the increase in bacterial flora is particularly evident in the anaerobic organisms such as Bacteroides, Coliforms, and Clostridia [16]. The considerable increase in bacteria proliferation does not show clinical effects in the first phase of simple intestinal obstruction before the anatomical and functional impairment of intestinal wall.
\nThe pathophysiological features in intestinal obstruction are summarized in Figure 4.
\nThe interruption of blood flow in an intestinal segment beside the lumen obstruction characterizes the strangulation obstruction. The most frequent causes of strangulation obstruction are incarcerated external hernias (abdominal wall: inguinal, femoral, umbilical, and incisional hernias), internal hernias (fibrous band, paraduodenal, foramen of Winslow, pericecal, intersigmoid, transmesenteric, and retroanastomotic), volvolus, and intussusception.
\nThe pressure in the obstructed intestinal segment exceeds very quickly the pressure venous in the bowel wall and in the corresponding mesentery. The following step is the venous blockage in these vessels, then capillary rupture with hemorrhagic infarction in the submucosa, mucosa, and finally in all layers of intestinal wall.
\nThe ischemic evolution of this condition is preceded by intramural thrombosis veins and is completed with the necrosis that proceeds from the mucosa to the serosa.
\nIn the necrotic intestinal segment, the perforation can occur followed by severe septic peritonitis. Before this final lethal conclusion, the severe septic-toxic conditions can develop in the strangulation occlusion.
\nThe damage of the blood supply and the normal function of intestinal wall allow serious consequences with transudation of toxic materials from Gram-positive and especially Gram-negative anaerobic organisms of intestinal obstructed lumen across the bowel wall in the peritoneal cavity. The systemic effects of the absorption by peritoneal serosa of toxic material are serious hemodynamic alterations, hypovolemia, hypotension, and septic shock. The role of intestinal bacterial flora in the production of the toxic transudation has been demonstrated in the past by Cohn, based on the protective action of antibiotics [17]. Beside the toxic systemic compromissions, in the strangulation obstruction, the metabolic consequences of fluid and electrolytes loss also develop such as in the simple intestinal obstruction.
\nThe pathophysiological syndrome of large bowel obstruction in general terms can be overlapped by small bowel obstruction but differs in the time in which it develops. The obstruction of the right colon is quite similar to distal small bowel obstruction in the pathophysiological evolution.
\nThe distal large bowel obstructions (left, sigmoid colon, and rectum) instead show characteristic pathophysiological and clinical data.
\nLarge bowel obstruction follows a slower course. The symptoms of dehydration are less severe. In the early stages, the colon retains the absorption capacity of fluid and electrolytes. For this reason, it preserves normal blood electrolyte concentration; therefore, the isotonic loss of water and electrolytes is associated with decreased plasma volume: hemoconcentration, decrease of CVP, and oliguria.
\nIn the obstructed colon, the gaseous distension and the endoluminal pressure increase progressively. Consequently, it can develop damage of the blood flow in the parietal vessel earlier and more evident than in the small gut because the colon has the lowest blood flow across the abdominal viscera. The ischemia interests before the mucosa, impairing its functions; furthermore, this condition points out that the intraoperative evaluation of colonic blood perfusion cannot be based only on an external examination of serous membrane.
\nThe increasing endoluminal pressure in the intestinal segment with thin walls, such as cecum, can cause perforation and septic peritonitis. Also in large bowel obstruction, the blockage of intestinal content increases the growth of bacterial flora, and the damage of intestinal wall functions allows the absorption of septic-toxic fluid intestinal content. In the beginning, only the colon is distended but usually the ileocecal valve becomes incompetent and allows the dilatation to progress proximally into the small gut. The presentation of the clinical picture of “closed-loop obstruction” without distension of small bowel that preserves its functions for a short period is quite unusual. This condition is due to competent ileocecal valve with a double obstruction, the valve and colonic obstruction, and the risk in the closed loop with an increase in the intraluminal pressure, obstruction of blood supply, gangrene, perforation, and peritonitis.
\nThe obstructions of large bowel in the majority of cases are due to neoplastic diseases, adhesions, and volvulus.
\nIn the large bowel obstruction, the cramping pain occurs longer than small bowel occlusion.
\nColonic volvulus (cecal or sigmoid) are characterized by a great dilatation of cecum or sigmoid colon on imaging exams (plain radiography—CT scan). The neoplastic obstruction of distal colon or rectum shows great distension of the colon above the obstacle and chronic and progressive symptoms of constipation with the change of regular bowel function toward constipated bowel function, changes of stool caliber, long-term cathartic use. Abdominal CT scan can demonstrate a mass as a cause of large bowel obstruction and synchronous lesions as metastases and enlarged lymph nodes.
\nThere are distension and vomiting in this form of obstruction of the bowel but no mechanical obstruction. The adynamic ileus is due to a paralysis of the musculature of the bowel. Hypokalemia causes intracellular reduction of potassium that is replaced by sodium and consequently depolarization of electric potentials of membranes of muscle and nerve cells, which aggravates the intestinal paralysis.
\nIntestinal motility has dual adjustment, central and peripheral or autonomous: this explains the variability of causes and stimuli that provoke a reflex paresis of the intestinal musculature.
\nIn fact, we have to consider peritonitis, retroperitoneal hemorrhage, renal trauma, renoureteral colic, lesions of dorsal-lumbar spine, pneumonia, and pleurisy basal, some neurological drugs, and finally the laparotomy causing a transient disturbance of gastrointestinal motility (postoperative dynamic ileus).
\nDistension is associated with altered motility to stabilize the occlusive syndrome. In the beginning, the distension stimulates the peristalsis, but, settled the occlusive conditions, with greater distension the inhibitory effect is largest. In fact, the gut distension causes the inhibitory reflex of intestinal motility by receptors of longitudinal musculature of the bowel.
\nThe accumulation of fluid and gas is accompanied by altered functions of intestinal mucosa. Clinical presentation of adynamic ileus is usually less severe than mechanical obstruction.
\nClinical findings are abdominal distension, the absence of flatus and bowel movement, and vomiting. There are no colicky pain and peristalsis because of the intestinal paralysis [18].
\nThe basic radiologic examination shows intestinal distension and some air-fluid levels, i.e., messy. The radiological finding that can confirm the diagnosis of ileus is the air in the colon and rectum, and on abdominal computed tomography (CT), there is no demonstrable mechanical obstruction [19]. Usually, the therapeutic approach is conservative based on the control and improvement of fluid and electrolytes disorders, particularly hypokalemia. It can also be useful in some patients in controlling particular medication as opiates or anticholinergics.
\nDifferent clinical forms are included in the generic diagnosis of “intestinal obstruction”, which are to be distinguished from each other. Therefore, we propose a diagnostic course divided into sequential steps.
\nFirst, a preliminary diagnosis with distinction between simple versus strangulation obstruction is performed.
\nThen, in the first step of the diagnosis, the distinction of mechanical or paralytic obstruction is performed.
\nIn the second step of diagnosis, we assess the level of obstruction, such as high small bowel obstruction, low small bowel obstruction, and large bowel obstruction.
\nFinally, in the third step of diagnosis, the type of obstacle is defined based on imaging examinations.
\nEach data (history, physical examination, laboratory, and instrumental) of the diagnostic evaluation could take on particular characteristic useful for a precise differential diagnosis, such as simple obstruction, strangulation, large bowel obstruction, and so on.
\nIn the history, some data are relevant to the risk of bowel obstruction. Prior abdominal or pelvic surgery and peritoneal sepsis can cause adhesions and bands following any operations or septic process in the abdomen.
\nThe evaluation should be made of inflammatory bowel disease (IBD) or other intestinal inflammation based on the previous diagnosis, therapy, and evolution of the disease.
\nHistory and current evolution of gastrointestinal or gynecologic neoplasms previously treated with surgery, chemotherapy, and irradiation can be risk factors for intestinal obstruction.
\nMost relevant in the history should be the communication of the change in regularity and frequency of bowel movement by an elderly patient due to possibility of undiagnosed colorectal cancer. Clinical features of intestinal obstruction are especially focused on two symptoms and two signs: colicky abdominal pain, absence of flatus or bowel movements, abdominal distension, and vomiting.
\nAbdominal pain is colicky, cramping, due to increased peristalsis, with paroxysms occurring every 4–5 min. In the first phase of obstruction, the abdominal pain should be more severe but if it is prolonged the occlusion for a serious delay in therapy can reduce the intensity of pain because peristalsis stops, so its disappearance should be a bad sign. In the later phase, it also increases abdominal distension and fluid—electrolytes loss [20, 21].
\nPeriumbilical and cramping pain can be due to distal small bowel obstruction. Proximal small bowel obstruction could develop with less pain and distension but severe vomiting.
\nLarge bowel obstruction (especially distal colon) may show pain below umbilicus and the paroxysms may occur longer for intervals of 6–10 min.
\nSevere and continuous pain should suggest strangulation obstruction. The absence of flatus and bowel movement in the true intestinal obstruction is complete. If there is small bowel obstruction, colon may take 1 or 2 days to empty. Indeed, the obstructive syndrome starts with the absence of flatus. The vomiting in the high, proximal small bowel obstruction is profuse and frequent. The higher is the obstruction, the worse is the vomiting. In the large bowel or distal small bowel obstruction, the vomiting can be delayed. After about 3 days of complete obstruction, the vomiting becomes feculent because the change in the intestinal bacterial flora causes a significant increase in anaerobic organisms. In the large bowel, obstruction may appear early vomiting reflex type based on intestinal distension. Abdominal distension should be considered the most frequent physical sign of intestinal obstruction [22–24].
\nThe degree of abdominal distension varies depending upon the site of the obstacle or the extension of the obstructed bowel. In the proximal, small gut occlusion could occur at a lower degree of abdominal distension or no distension: intestinal occlusion without distension. In distal small bowel or large bowel obstruction, the abdominal distension is the most obvious clinical relevance. Abdominal distension is also present and obvious in the patients with dynamic obstruction or intestinal pseudo-obstruction. If distension is conspicuous and other signs are minimal, there is probably large gut obstruction. Sigmoid volvulus can cause extreme distension. On the other hand, in the first phase of obstructive syndrome, the patients with a “closed-loop obstruction” or intestinal hernias or small bowel volvulus with short intestinal segment, abdominal distension can be minimal.
\nBeside the abdominal distension, the physical examination can point out hyperresonance, obstructive gut sounds, and visible peristalsis.
\nIn the obstructed patients, it is possible to hear some characteristic sounds by abdominal auscultation: runs of borborygmi, chorus of tinkling high pitched musical sounds at the same time of peristaltic waves, and colicky pain. These data by auscultation are absent in the patients with abdominal distension by dynamic occlusion. Distended bowel results in hyperresonance or tympany to abdominal percussion, but fluid-filled loops can result in dullness. The visible peristalsis can be seen in very thin patients.
\nSimple obstruction | \nStrangulation obstruction | \n
---|---|
\n | Evidence of abdominal wall incarcerated hernias (groin, femoral, and obturator incisional) | \n
Colicky pain Absent abdominal tenderness | \nFast onset of abdominal pain. Constant pain, not colicky. Abdominal tenderness localized or diffuse | \n
\n | Finally, peritoneal signs due to peritonitis (bowel ischemia, perforation, and peritonitis) | \n
Intestinal obstruction: preliminary differential diagnosis.
\n | Mechanical | \nDynamic | \n
---|---|---|
History | \nPrevious abdominal or pelvic surgery, radiation therapy, history of abdominal malignancy | \nEvery risk factors of dynamic occlusion (causes of reflex paresis) | \n
Pain | \nPresent, colicky | \nAbsent or due to abdominal distension | \n
Vomiting | \nPresent | \nPresent | \n
Abdominal distension | \nPresent | \nPresent | \n
Absence of flatus or bowel movement | \nPresent | \nPresent | \n
Plain radiography | \nBowel distention Evident air-fluid levels differential height, regular arranged disposition | \nBowel distention. Few air-fluid levels—somewhat messy | \n
Intestinal obstruction: first steps differential diagnosis.
The clinical examination should evaluate systemic compromission of intestinal obstruction syndrome. It should be highlighted dehydration, tachycardia, hypotension, reduced urine output, fever, electrolytes alterations, and dry mucus membranes. The physical examination of abdomen will be completed with control of old laparotomy scar, any abdominal wall, or groin hernias.
\nThe examination can identify the abnormal masses, such as abscess, volvulus, and tumor, which can be the cause of obstruction. Abdominal tenderness is not a characteristic feature of uncomplicated obstruction. Obvious tenderness localized or diffuse suggests complicated obstruction: strangulation, perforation, etc.
\nRectal examination is an integral part of a clinical examination. Usually, this examination cannot add further information but it can find rectal neoplastic lesion or mucus or blood that probably suggests a strangulating lesion higher up, intussusception, or inflammatory intestinal lesion such as IBD.
\nBased on the clinical appearance and basic radiological examinations, the first steps of the diagnosis are shown in Tables 5–7.
\n\n | High small bowel occlusion | \nLow small bowel occlusion | \nLarge bowel occlusion | \n
---|---|---|---|
Pain | \nAbsent | \nEvident | \nEvident | \n
Vomiting | \nEarly, copious, continuous | \nLate | \nVery late | \n
Abdominal distension | \nAbsent | \nPresent | \nPresent | \n
Absence of flatus or bowel movement | \nPresent | \nPresent | \nPresent | \n
Plain radiography | \nIs it possible follow the distended bowel segments and hypotize the site of obstruction (transition between dilated proximal and non-dilated distal bowel) | \n
Intestinal obstruction: second-step differential diagnosis.
Routine laboratory studies are not specific for a diagnosis of intestinal obstruction. The laboratory data should evaluate hypovolemia, initial renal failure, hemoconcentration, metabolic abnormalities (hyponatremia, hypokalemia), and leucocytosis.
\nNeutrophylic leucocytosis can signalize complications such as strangulation or ischemic lesions. On the other hand, the anemia can indicate intestinal tumor or IBD.
\nIn the obstructed patients with appearance of systemic compromission (hypothermia, tachycardia, fever, and renal failure), the complete clinical assessment requires arterial blood gas (ABG) and serum lactate. These evaluations can show some different details. Metabolic alkalosis follows severe vomiting. Metabolic acidosis takes place in the case of severe hypovolemia, hypoperfusion, organ failure, and ischemic bowel lesions [25]. The laboratory markers of ischemia to differentiate simple bowel obstruction from strangulation obstruction have been long searched [26]. First, elevated serum lactate (metabolic acidosis) with not very high specificity (sensitivity 90%, specificity 87%) can be used [27, 28]. Cronk et al. has suggested the use, as marker of ischemia with valuable results, of intestinal fatty acid binding protein, connected to necrotic enterocytes [29].
\nThe third step of our assessment of intestinal obstruction can allow the achievement of more defined diagnosis.
\nAbout some imaging modalities, plain radiography is mostly employed. This is very practical and useful because it can confirm basic diagnosis of intestinal obstruction [30]. Usually, there are only few data useful for the distinction between mechanical or dynamic obstruction. Moreover, the plain radiography is widely available and less expensive; its regular performance requires an upright position of patients; the lateral position is a makeshift solution. The supine position shows insufficient results for diagnosis, only bowel distension. The findings of plain radiography in bowel obstruction are as follows:
\nMultiple air fluid levels, more evident based on upright position;
Dilatation of intestinal segments proximal the obstacle and collapse in distal bowel.
Plain radiography: small bowel obstruction.
These can be useful for the diagnosis of mechanical obstruction: the remark of a regular arranged disposition of multiple air fluid levels with evident size increases from each other (Figure 5) [31]. The plain radiography can detect the pneumoperitoneum by intestinal perforation. We have to remember that the remark of less gaseous distension (gasless abdomen) of intestinal loops in obstructed patients can be possible because of a complete fluid filling of loops. Mullaw suggests the evaluation of the string of pearls sign: fluid-filled bowel loops with small amounts of intraluminal gas [32]. Certainly, plain abdominal radiography in upright position can confirm the basic diagnosis of intestinal obstruction with high enough sensitivity (80%) and specificity (75%) [33]. The use of the examination in detecting the site of obstacle and in differentiating the small from large bowel obstruction is very limited.
\nPlain abdominal films, normally upright position if possible, should be the first imaging examination in the diagnostic program of suspected intestinal obstruction because it is readily available and in some cases it is resolvable if the doubt of obstruction is not confirmed. However, normally we must complete the diagnosis with abdominal CT scan. The performance of CT in the diagnostic plan is now valuable. Some data are similar to the findings of plain radiography as bowel dilatation above the obstruction and air-fluid levels. CT scan usually can identify the specific site of obstruction clarifying the transition point of distended and empty loops and also the complete intestinal occlusion. This examination should detect the etiology of obstruction by identifying internal or parietal hernias, neoplastic or inflammatory masses, and recognize the complications such as ischemic/necrotic evolution over all by strangulation obstruction and finally the perforation [32, 34–36]. CT scan can provide other diagnostic information: ascites, rotation of mesentery (whirl sign), mesenteric edema, bowel wall thickening >3 mm, submucosal edema-hemorrhage, venous cutoff sign by venous thrombosis, poor segmental bowel wall enhancement, pneumomatosis intestinalis, edematous mesentery, and hemorrhage in the mesentery. All these findings can suggest complications that have vascular involvement in intestinal obstruction [37–39].
\nAbdominal US is now considered as an integral part of clinical examination and consequently it is currently performed in the patients with abdominal pains. Finally, it can be employed in the patients with contraindications to CT, pregnant patients, and patients with very severe systemic impairment. The contribution of abdominal US to intestinal obstruction diagnosis should be limited to identify intestinal distension, abdominal masses, and internal hernias, which can be site of incarcerated intestinal loops. Abdominal US can provide very few findings about air-fluid levels, the site, etiology, and complications of intestinal obstruction [40].
\nThe accuracy of magnetic resonance imaging (MRI) is almost similar to CT scan for the confirmation of basic diagnosis of obstructions, location, and etiology of the obstruction. This examination shows poor detection of masses and inflammation [41–43].
\nContrast studies, such as water soluble contrast material or contrast fluoroscopy, have indications and purposes rather limited in the obstruction diagnosed as complete and persistent.
\nThe first approach in the management of intestinal obstruction includes the correction of physiologic impairment caused by obstruction. Some measures can be required: the use of a bladder catheter to monitoring urine output, adequate intravenous access, arterial canalization, and CVP monitoring.
\nThe purpose of the therapeutic approach is the correction of hypovolemia and electrolytes depletion with volume resuscitation. The development of fluid-electrolyte replacement and the adequacy of resuscitation should be guided by the degree of systemic impairment and the reaction of the patient to therapy. Therefore, aggressive replacement of fluid and electrolytes can be employed after restoration of renal function. The use of nasogastric tube for the control of severe intestinal distension can be helpful.
\nAntibiotics should be started at the confirmation of diagnosis of intestinal obstruction, mostly if fever, and leucocytosis is present.
\nThe aim of the use of antibiotics is based on the control and treatment of intestinal overgrowth of bacteria and their translocation across the bowel wall [44].
\nAntibiotics, based on the particular type of bacterial overgrowth in the obstruction, could have more coverage against anaerobes and Gram-negative bacteria. The main objective of the therapeutic program of bowel obstruction is to remove the obstacle. Surgery is the leading option.
\nThree criteria guide this therapeutic choice:
\nDegree of impairment of general conditions due to complications: intestinal ischemia, necrosis, perforation, and peritonitis;
Etiology of obstructive syndrome (hypothesized or confirmed);
Type of intestinal obstruction diagnosed (hypothesized or confirmed):
Complete versus incomplete
Small or large bowel obstacle site
Strangulation occlusion
Peritonitis and abdominal sepsis caused by complications of obstructive syndrome (perforation, ischemia, necrosis, etc.) prescribe urgent surgical intervention. The choices of the surgical procedures are conditioned by pathological findings, sometimes intraoperative.
\nClinical instability, diagnostic uncertainly, unexplained leucocytosis and metabolic acidosis, and consequently the doubt of perforation or abdominal sepsis justify the abdominal surgical exploration. Also the suspicion of strangulation occlusion, based on continuous and severe abdominal pains, should prompt surgery.
\nThe surgical choice for irreducible or strangulated hernia of abdominal wall is very obvious.
\nIn the case of high suspicion for digestive malignancy, most frequently in large bowel, surgical intervention should be performed. In these cases, surgical procedures should contemporary treat both diseases, intestinal obstruction and digestive neoplasm: primary resection followed by temporary diversion (Hartmann procedure) or immediate reconstruction.
\nIn summary, for the complete and permanent intestinal obstruction, the surgical intervention should be the first-line option.
\nIn the management of intestinal obstructions, there are some issues under discussion with no simple solution.
\nThe treatment of acute small bowel obstruction should be a common clinical challenge. The choice of operative management within the first 12–24 h from the onset can be followed by nontherapeutic laparotomy with the unfortunate results of further adhesions and postoperative morbidities [45]. Nasogastric decompression, fluid-electrolytes replacement, and careful clinical reassessment can have a considerable success rate in the approach of small bowel obstruction. Unfortunately, failure to acknowledge or late recognition of strangulation obstruction cause increased morbidity and mortality [46–48]. In this complicated setting, the solution is the selection of the patients. Of course, as stated previously, the cases with clinical and/or instrumental evidence of peritoneal phlogosis or perforation are excluded from this evaluation. Some criteria have been proposed to identify the patients with alleged simple small bowel obstruction for immediate operative treatment. Clinical appearance of fast onset of abdominal pain, continuous pain, not colicky, abdominal tenderness localized, or diffuse on physical examination suggest the choice of immediate surgical approach. There are also specific findings on abdominal CT: free intraperitoneal fluid, mesenteric edema, thickened wall, pneumatosis intestinalis, “small bowel feces signs” (gas bubbles and debris within the lumen of obstructed small bowel) [49]. On the other hand, the selected patients’ choice for nonoperative management should be characterized by the following criteria: the absence of abdominal wall hernias, previous abdominal pelvic surgery, previous abdominal malignancies, history and diagnosis of IBD (especially Crohn disease), colicky pain, absent abdominal tenderness on clinical assessment, and finally hemodynamic stability and absence of impairment of general conditions.
\nIn summary, clinically stable patients with partial obstruction can be treated by conservative management [50].
\nConservative management includes intestinal intubation and decompression, aggressive intravenous rehydration, and antibiotics [51].
\nThe results of the conservative management of acute mechanical small bowel obstruction are uncertain and not conclusive, from the data of literature [52]. There are high success rates in the stable patients with incomplete obstruction [53, 54]. Among the patients with adhesive small bowel obstruction, 24.6% of patients are treated with nonoperative management, without surgery or readmission [55]. On the other hand, high rates of recurrence and the risk of complications including vascular impairment were reported [47]. Therefore, among the patients managed conservatively to start with, the operative rates were very high because of the diagnostic difficulty to distinguish simple from strangulation obstruction on clinical and instrumental examinations [56].
\nThe international guidelines [34, 57] for the evaluation and management of small bowel obstruction confirm and summarize the data from the literature.
\nThe guidelines in evidence are as follows:
\nThe instrumental diagnosis should be based on the CT scan of abdomen because it can clarify the grade, severity, and etiology of small bowel obstruction.
Urgent surgical approach is the first option for small bowel obstructions with evidence of peritonitis or clinical deterioration (fever, tachycardia, leucocytosis, and metabolic acidosis).
Patients with partial or complete small bowel obstruction and stable general conditions and without physical and instrumental signs of peritoneal phlogosis can undergo initial nonoperative management.
Water-soluble contrast study can be useful in partial small bowel obstruction not resolved within 48 h based on the improvement of water-soluble contrast on bowel function.
After 3–5 days of conservative management, the patients with small bowel obstruction should undergo surgery;
Laparoscopic treatment can be a safe and possible procedure for small bowel obstruction, but not commonly employed. In fact, its use requires some selection criteria: proximal obstruction, localized distension on radiography, no sepsis, and mild abdominal distension [58–60].
Large bowel obstruction due to colorectal cancer requires the treatment of malignancy and abdominal urgency. The first objective should be the control and management of malignancy. Several factors may influence the therapeutic choice: the location of the tumor (proximal-distal colon), the degree of colonic distension and the impairment of blood flow of intestinal wall, the involvement of the general conditions of the patient with organ failure, dehydration, hypovolemia, and sepsis.
\nIn this scenario, variable and complex, it is very difficult to establish a well-defined and unequivocal line therapy in relation to the surgical procedure to be used. There are several proposals: at the beginning resolution of the occlusive complication only with colostomy (two-stage procedure) followed, sometime later, by resection of neoplastic lesion (with radical surgical criteria or palliative). On the other hand, a one-stage procedure with resection of the tumor (radical or palliative), followed by temporary colostomy (Hartmann’s procedure) or primary anastomosis, can be employed.
\nEndoscopic colonic stents have been proposed in neoplastic obstruction of distal colon for palliation or as a bridge to surgery [61]. With the palliative intent, the colorectal stent can be used as an alternative to colostomy, whereas in the hospitals it can be employed as a bridge to elective surgery with specific expertise [62].
\nThe tumor site along the colon is an important factor for the therapeutic choice. Right colectomy can be defined as the treatment of choice for right-sided colon cancer in obstruction setting. It is a safe technique for one-stage resection and anastomosis [63]. The guidelines of World Society of Emergency Surgery suggest some recommendations on obstructive left colon carcinoma [62]. Hartmann’s procedure should be the preferred choice in the patients with impaired blood supply of intestinal wall and high surgical risk compared to loop colostomy. Hartmann’s procedure shows overlapped survival results compared to segmental colonic resection with primary anastomosis.
\nThe patients submitted to primary resection and anastomosis have similar mortality-morbidity rates with total or subtotal colectomy and segmental colectomy. The immediate results are similar in these patients (with primary resection and anastomosis) related to the choice of intraoperative colonic irrigation or manual decompression.
\nIntestinal pseudo-obstruction is a syndrome characterized by a complete intestinal dilatation, generally of large bowel, without mechanical obstacle. The proposal nosography of intestinal pseudo-obstruction is reported in Table 8.
\nIntestinal pseudo-obstruction | \n
Acute | \n
Hydro electrolytes alterations | \n
Anticholinergic, ganglionic blocker drugs | \n
Laparotomy | \n
Intraperitoneal diseases (perforation, appendicitis, cholecystitis, pancreatitis) | \n
Extraperitoneal diseases (hematoma, vertebral trauma, pneumonia, myocardial infarct) | \n
Sclerosing therapy of esophagus | \n
Acute colonic pseudo-obstruction | \n
Chronic | \n
Secondary | \n
Endocrine disease (diabetes, hypothyroidism) | \n
Collagenopathies (scleroderma, dermatomyositis) | \n
Neuropathies (Parkinson’s disease, multiple sclerosis) | \n
Degenerative diseases (amyloidosis) | \n
Elevated blood levels of prostaglandin A, E, F | \n
Idiopathic | \n
Hereditary hollow visceral myopathy | \n
Familiar neuronal disease | \n
Intestinal pseudo-obstruction: nosography.
The intestinal pseudo-obstruction can affect small or large bowel and it may be possible to differentiate the syndromes with acute or chronic onset and evolution.
\nParalytic ileus can be inserted in the broader field of acute pseudo-obstructions that are based on pathophysiological impairment of intestinal peristalsis (intestinal paresis). The acute pseudo-obstruction can be caused by severe fluid electrolytes disorders (hypokalemia, hypocalcemia), medications with anticholinergics or opiates, abdominal interventions (postoperative ileus), inflammatory and septic abdominal diseases as peritonitis, pancreatitis, perforations, intestinal ischemia, and retroperitoneal trauma.
\nIn this area, the acute colonic pseudo-obstruction (ACPO) (Ogilvie’s syndrome) should be highlighted. The Ogilvie’s syndrome has been diagnosed in association with various pathologies such as cholecystitis, acute pancreatitis, retroperitoneal traumatic hematoma, Parkinson disease, and so on. The impaired colonic motility should be caused by imbalance in the autonomic nervous system: increase in sympathetic tone and decrease in parasympathetic tone [64]. Increased sympathetic tone to the colon results in the inhibition of colonic motility [65]. The pathologic findings, more evident in the right colon, are distension, fluid-gaseous accumulation, and increased endoluminal pressure. Severe blood circulatory impairment can occur in the large bowel wall with damage of venous return, edema, trophic mucosal alteration to serous, sometimes necrosis, and perforation. The cecum is more dilated colonic section. According to Laplace’s law, the cecum, with its larger diameter, requires less pressure to increase in size and in wall tension. Ischemia, longitudinal splitting of serosa, and herniation of the mucosa and perforation, the so-called “diastasis breaking” of cecum, is caused with the increased wall tension.
\nClinical features are obvious abdominal distension as earliest sign, no tenderness, hyperresonance, or tympany to percussion throughout the abdomen, and no peristalsis and bowel sounds to auscultation. The symptoms are similar to large bowel obstruction and develop over 3–7 days.
\nImaging examinations, plain radiography, CT scan should help to exclude mechanical bowel obstruction. The size of the cecum (more than 8–10 mm) on abdominal films could be useful to decide colonic decompression, surgical or endoscopic, because of the risk of perforation [66].
\nIn the ACPO, conservative treatment can be proposed: no oral intake, nasogastric decompression, correction of fluid and electrolytes disorders, and discontinuance of drugs that inhibit gastrointestinal motility [67].
\nIn the conservative option, the use of pharmacologic agents can be added to increase colonic motility. Several drugs have been employed with nonunique and uncertain results, erytromicin, cisapride, metoclopramide, and neostigmine [68, 69]. The invasive therapeutic approach of Ogilvie’s syndrome includes colonoscopic decompression and surgical intervention. The endoscopic decompression should be a safe and effective procedure for ACPO and has been associated with high success rates (77‒86%) [70].
\nRecurrence rates of colonoscopy decompression are also high, ranging from 20 to 60% [71]. Clinical signs of ischemia, abdominal sepsis, perforation, or failure of conservative management require surgery. The choice of surgical procedure is indicated by intraoperative pathological findings: tube cecostomy, subtotal colectomy, etc.
\nChronic intestinal pseudo-obstruction can be subdivided into secondary and idiopathic. In the first cases, the chronic pseudo-obstructions are part of severe systemic diseases: endocrine diseases (diabetes and hypothyroidism) and collagenopathies (scleroderma, amyloidosis, dermatomyositis, and lupus erythematosus). The chronic intestinal idiopathic pseudo-obstructions are frequently familiar diseases. Pathophysiology is not completely defined and should be based on derangement of autonomic nervous system with alteration of intestinal motility. The pathophysiological findings are hereditary hollow visceral myopathy, familiar neuronal visceral disease, lesion of myenteric plexus, and alimentary tract ganglioneuromatosis.
\nThe role of interstitial cells of Cajal has been hypothesized in the pathogenesis of idiopathic chronic intestinal pseudo-obstruction. Electron microscopy and immunochemistry studies showed a decreased number of interstitial cells of Cajal in the intestinal wall and alterations in interstitial cells of Cajal network [72].
\nAccording to clinical features, the cramping abdominal pain is more frequent; nausea, vomiting, and abdominal distension are occasional, sporadic. There are also alternating diarrhea and constipation and weight loss. Finally, the clinical evolution of the disease is chronic.
\nThe results of the therapy of secondary forms are scantly and uncertain; usually, the therapy is connected with the treatment of the serious systemic diseases. Drugs that stimulate the smooth muscles (acetylcolinesterase inhibitors) can be employed in the idiopathic forms. Surgical procedures are indicated for the treatment of severe and continuous symptomatology that can be related to a portion of the digestive tract or for complete failure of conservative therapy [73].
\nThe author is very grateful to Drs Libero Luca Giambavicchio and Francesco Lapolla for their valuable assistance in the typographical transcription of the manuscript.
\nThe European Environmental Noise Directive 2002/49 [1] implemented in all EU Member States, almost 18 years ago, provided several smart tools to access and manage environmental noise and enhance cities’ development. As the directive stipulates, “it is part of community policy to achieve a high level of health and environmental protection, and one of the objectives to be pursued is protection against noise. In the Green Paper on Future Noise Policy, the Commission addressed noise in the environment as one of the main environmental problems in Europe” [2].
This chapter offers, therefore, an analysis of the tools that have been created in the framework of this directive and aims to show how these specialized tools contribute to an intelligent development of European cities and wider urban territories. The analysis is based on a series of practical cases studies carried out in Greece (and in Europe) and will show how these smart tools had to adapt to the twenty-first-century environmental issues.
The environmental noise directive concerns, since its enforcement in both European and national framework, not only the major agglomerations in EU Member States but also all main transportation infrastructure. Environmental noise is defined by the traffic noise from road, railway, and airport infrastructures combined with industrial sources. Each Member State has incorporated this directive, into its national legislative framework and therefore has the obligation to implement it in their relevant urban agglomerations and territories. This was an important step forward for the environmental noise both on national and European scales, because it created the appropriate framework for policy-makers, politicians, transportation engineers, urban planners, architects, and also every citizen to share information and interact on the definition of all appropriate regulation and mitigation measures. In other words, it allowed the Europeans to address in the same language their concern on the environmental noise issue. A strategic noise map (SNM) is therefore primarily requited allowing to visualize the “decibel” impact of the main sources of environmental noise either at the scale of an agglomeration or at the scale of an transportation or industrial infrastructure. As the next step, a comprehensive noise action plan (NAP) is therefore drawn with the involvement of transportation, planning, and acoustic engineers to access and specify the most appropriate means to achieve the needed noise rehabilitation by mitigation measures. The general framework and the basic homogenous methodology have been applied in the majority of the Member States, and now, 18 years later, we can see the important advantages emerging.
As analyzed above, in this same legislative framework, transportation operators needs to measure and simulate the noise impact on the environment. The noise emitted by a vehicle or an airplane is a dynamic source that evolves in time and space. The environmental noise emitted by the traffic of the road traffic flow (including motorcycles and trucks) over a day is therefore an inexhaustible source of information that continues to evolve (big date issue) and which poses questions to traffic engineers for its measurement, its prediction, and furthermore its management. The European Directive introduces several smart tools in order to solve these problems.
For example, Attiki Odos, the road operator for Athens Ring Road has been awarded in 2003 (Decibel d’Or, Ministère de l’Environnement en France) for its monitoring system with eight permanent monitoring stations that measure in real time road noise traffic (see Figure 1). In Attiki Odos, since its opening in 2004 for the Olympic Games, more than 250,000 vehicles are passing every day [3].
Permanent noise and air pollution monitoring systems deployed on Attiki Odos Ring Road, Athens, in use from 2001 to 2002: view of typical measurement stations and the CUBE measurement system (Dynacoustics & 01dB-ACOEM).
In order to achieve this goal, Members States are applying the directive by using the common indices Lden and Lnight. The European Directive therefore is applied to environmental noise to which humans are exposed by introducing the above noise indicators that shall be determined by homogenous assessment methods. The definition of the Lden level (day-evening-night) is defined by the following formula:
where Lden is expressed in A-weighted decibel or dB(A); Lday is the A-weighted long-term average sound level as defined in ISO 1996-2: 1987, determined over all the day periods of a year; Levening is the A-weighted long-term average sound level as defined in ISO 1996-2: 1987, determined over all the evening periods of a year; Lnightis the A-weighted long-term average sound level as defined in ISO 1996-2: 1987, determined over all the night periods of a year.
As a result, 24-h measurements on Athens peripheral can be presented as follows:
As presented, in Figure 2, these tools allows to sum up 1-year measurement in few values that takes into count the density of the road traffic depending on the hours of the day, the week, and the month. The formula shows that the road traffic is even more annoying at night and in the evening than at the hours of the day. Thatis why the formula introduces a weight system that gives more emphasis to noise sources that appears during the evening and during the night: a penalty of 5 dB(A) for the evening and for 10 dB(A) for the night period (see Eq. (1)).
A typical 24-h measurement in Athens Ring Road (2017) (accessed in three periods: day, evening, and night).
It is one of the main smart tool since it can give at a specific point one value for a big data problem: if we take a measurement each second, it summarizes 1 year of measurement that is to say 60 s × 60 min × 24 h × 365 days, for example, 31,536,000 s of potential measurement period per year. Practically, these measurements based on 24-h periods can be repeated and used to calibrate acoustic models in order to simulate with the best accuracy the environmental noise propagation (from a road section scale to the whole agglomeration scale). For example, a part of the strategic noise map of Athens simulated on CadnaA software and calibrated with 24-h measurements is presented in Figure 3.
Part of the strategic noise map of Athens (2016) [
Scientific papers published by several teams have shown comparison from real in situ Lden 24-h measurements and the one simulated has a correlation index more than R > 0.91 [5] (see Figure 4).
Lden index (Athens SNM). Correlation measured vs. calculated levels [
The measurement indices, therefore, can be simulated with high precision, and in its average, it resists the qualitative and quantitative variations of the yearly average traffic. Another word, with the above strategic noise map correlation methodology, measurements and simulations of the noise indices are energetically correct and express the quantity of noise than a monitoring station may record during the whole year at a specific point (something that is practically and financially impossible to do).
As a result, the use of both Lden and Lnight indices appears to be an adequate and quite adapted even intelligent tool that allows transportation operators and urban municipalities to assess the environmental noise impact of the development of cities on a “long term” (yearly operation). In Europe, the majority of municipalities with more than 100,000 inhabitants and the major transport operators (cars, trains, and planes) produced strategic noise maps, updated every 5 years, according to the directive; however their implementation has in several cases been delayed. Besides the fact that in some European countries the administration did not keep up with this pace, we need to underline that in some cases the early implementation of permanent surveillance systems was introduced (e.g., the Athens Ring Road and the Athens International Airport) [5, 6].
As per the previous analysis, the relevant European acoustic criteria, which can be measured and predicted, are smart tools for expressing simply the amount of acoustic energy received at a point exposed to different sources of environmental noise. It is thus possible to edit strategic noise maps and link them to the relevant geographical information systems. Thus, these maps become strategic because they can easily express the amount of people exposed to different sound levels. These noise classes has been standardized (in dB(A) and a corresponding color in the map, as per Figure 3 where the noise classes for Lden and the relative color code were used as standardized by European Directive 2002/49).
GIS systems can easily cross statistical inhabitants’ localization with SNM and bring to the light the number of people exposed to several noise levels. Based on the European Directive-introduced noise indices, each Member State has the right to adapt in their national legal framework specific limits to define the level of noise pollution (see Table 1).
Environmental noise levels | Lden | Lnight |
---|---|---|
Greece (GR) | <70 dB(A) | <60 dB(A) |
Europe (min exposure levels for SNM) | <55 dB(A) | <50 dB(A) |
National regulations concerning maximum values of noise pollution indicators (i.e., for Lden and Lnight) in Greece compared to European recommendations for population exposure [7].
One might criticize the fact that not all European countries have the same limit values [7]. Indeed, as shown in Table 1, GR requirements are less demanding (therefore easier to reach) than those recommended by the European Union as a min population exposure level. This is rather a delicate subject that deserves some explanation since European standards are often proposed by Northern Europe Member States for which the economic and social development is often considered more advanced than for Southern Europe Member States. It is the intelligence of the directive and its criteria that gives the possibility of each Member State to adjust its limit levels according to its own geography, climate, lifestyle, social structure, and economy. The GR limit levels may seem extremely easier to achieve than the German ones. It must be understood, however, that Greece, Spain, or Southern Italy are characterized by Mediterranean climate conditions and lifestyle that are quite different from those of, for example, Berlin, Copenhagen, or Stockholm. The periods of the typical day expressing the levels of noise correspond rather to lifestyles of Northern and Western Europe than to Southern Europe. Although it is less and less the case in national capitals and large urban agglomerations (e.g., Madrid, Athens, Nicosia, Rome, or Naples), the peaks of activities are, for example, often 2–3 h after Paris relevant ones. The clipping 07:00–19:00 for Lday, 19:00–23:00 for Levening, and 23:00–07:00 for Lnight are not quite adaptable for Greece or Cyprus, for example. The evening in a GR city is maybe the noisiest period of the day, with GR people working—in the private sector especially in commerce—until 21:00, and going for dinner toward 22:00 or even 23:00; therefore the relevant noise measurements will weigh more in the general formula of the Lden, as per the penalties introduced in Eq. (1).
Following the European common methodology as per the latest update of the Annex II introduced recently by the European Directive 2015/996 [8], many agglomeration and transport operators present and share their results on the European portal of the European Environmental agency, the noise Observation and Information service for Europe [7]. Main results of most of the main cities and infrastructure of the majority of European members States member states are available. With a simple “click,” it is easy to get the following information: total of people exposed to noise from road traffic (but also railway and airport traffic are available), during the day and during the night. It shows how much people are exposed to high level of noise and present graphics that describes the statistical partition of this exposure.
For example, in Figure 5, main results are presented for Amsterdam (Haarlem) and Berlin. The web site, trough popup windows, explained clearly how much people are disturbed by noise traffic in the two cities: almost 600,000 inhabitants for both cases with approximately 50,000 more for Berlin. These data, from the noise exposure point of view, are comparable because they describe the same family of criteria (Lden, Lday, Lnight), because methodology to measure, calculate, or simulate these values is also standardized. Surely, such comparison is quite helpful for law makers, in each country, to organize their policy for noise mitigation. Noise issues, even if they concern almost the same amount of people in Berlin or in Amsterdam, cannot be dealt in the same way when one knows the specificity of each country concerning town planning, building density, urban sprawl, etc.
Visualization of the number of people exposed to high level of road traffic (more than Lden > 55 dB(A)) in Amsterdam (Haarlem) and Berlin agglomerations (source: European Environment Agency portal) (noise observation and information service for Europe web site—
Even so the portal is missing information for some Member States, it is already a huge step forward in order to understand the noise issue at the national and European scale. Data are comparable (they use the same criteria), and the map representation of this data allows also transversal analysis regarding noise exposure, data traffic, and territorial properties.
In the same idea, airports have been mapped, and their strategic noise maps and have shown their influence on the city they border, as in Alikarnassos municipality close to Heraklion International Airport Nikos Kazantzakis in Crete in Greece [4]. The use of Lden and advanced prediction models calibrated with in situ 24-hour measurements allows to predict, with high precision, the environmental noise levels in any agglomeration. In this example, the main idea of an appropriate and effective noise action plan was to relocate the international airport from this area to a less built environment almost 20 km far away from the city center (project in execution stage).
In the example above, the comparison of the two SNM presents the impact of the environmental noise generated by the air traffic and especially its influence on the whole neighborhood studied here. This tool intelligently reinforces the scenario for moving the airport to a less developed area [9, 10]. Therefore by providing a common framework, the EU Member States have introduced intelligent tools that allow the simple translation and assessment of a large number of sources of environmental noise.
These tools are accessible to all the graphic representations, and the results are shareable with all the main decision-makers in a given agglomeration who ensure their participation in the decisions aiming to address the sustainable development of the acoustic environment of the cities.
According to the European Directive, after the execution of SNM, appropriate noise action plans have been drawn in agreement with the existing and foreseen local policies. Those action plans as also the relevant SNMs are linked with geographical information system, so the smartness of the criteria is very much linked with its capacity to correlate the acoustic data with any data within the GIS database of the strategic noise maps and noise action plans, even if they are represented in two dimensions, with a common height level of 4 m. They are actually calculated in full three-dimensional geographical system in order to simulate properly the sound propagation in a complex city 3D environment. Tools have been built in order to integrate the exact topography of the relevant study area and of course the influence of the built space on noise propagation (the building in its three dimensions including reflection characteristics). Therefore it is very efficient for all actors (politicians, mayors, town planners, engineers, acousticians) to represent the data on a map on a satellite view of the city, where a distinct color palette represents the accessed noise class (for every 5 dB) as per Figures 4 and 6 and as also per the South Athens SNM relevant indexes hereafter (Figure 7).
NAP for Alikarnassos district in Heraklion area adjacent to the International Airport Nikos Kazantzakis: on the left: Lden road and on the right: Lden road and air traffic [
Lden strategic noise maps for South Athens agglomeration (2017) and partial view of the GIS 3D model.
By building the acoustic model on a complete GIS environment, it is also possible to calculate the exact number of people exposed to relevant levels of noise. It is also possible to zoom in the model and see if a specific building depending on its orientation is exposed or not to high level of noise. GIS contains a set of full data regarding the number and the geolocalization of the points of interest and sensitive receptors, for example, hospitals, education buildings, religion buildings, parks, and quite zones. So it is quite easy, after the superimposition the noise level contours on the GIS platform, to execute a quantitative analysis on the exposure factor. Previous studies have shown that, on Athens Ring Road (see Figure 2), noise exposure needs to be monitored for more than 170 points of interest as hospital, clinics, maternity, childcare, education buildings, cultural uses, and worship places [4]. Thus, for a municipality, it is possible to prioritize and focus accordingly on appropriate public and private policies and launch mitigation programs aiming to improve the acoustic environment enveloping these sensitive receptors.
Similar conclusions were drawn specifically for the airport noise exposure. For example, in Heraklion, within the relevant NAP, specific studies were completed in order to access the cost for the acoustic insulation and the rehabilitation of both public and private buildings in the case of a “no-moving” scenario for the international airport [4]. In this case the relevant costs of implementing an effective acoustic insulation regulation in buildings and maintaining the airport activity were calculated, in order to improve the acoustic environment of the district of Alikarnassos.
In this perspective, noise action plans have been accessed in order to minimize the population noise exposure. More than 3000 m2 of noise barriers have been completed on the Athens Ring Road during the last years [11]. Their implementation was based on the provisions of the European Directive 2002/49, and the GR legal framework introduced max thresholds for the relevant indices Lden, Ln, and Lde, for example, 70, 60, and 67 dB(A), respectively. When the statutory limits of the noise indices were exceeded, the implementation of immediate mitigation measures was suggested (e.g., noise barriers). The implementation of esthetic noise barriers with effective acoustic heights up to 4.5 m was proven successful and very well welcomed by the habitants. In order to resolve the issue of the environmental noise exposure on the population exceeding the existing criterion and limit, a full analysis of the implementation of adequate noise barriers was executed for all within the Noise Action Plan 2017 for the Athens Ring Road [11] (Figure 8).
Athens Ring Road NAP (2017) [
The early surveillance of Athens’ road traffic made it possible even during the early years of the operation to implement a comprehensive program for noise management and monitoring. As the construction of the motorway is at a level of −14 m below the ground level, very often, Attiki Odos was partially covered to reduce noise emissions and minimize the local residents’ noise exposure. Most of the time, it was a good opportunity to introduce sports and social facilities (soccer fields, tennis courts, playgrounds, parks, etc.) and rehabilitate effectively the urban environment (Figure 9).
(Left) Attiki Odos selected partial covers, under construction and in use [
The development of an urban agglomeration is therefore strongly conditioned by the results of the noise monitoring and the implementation of the relevant smart tools ensuring effective keys to the decision-makers introducing appropriate measures. In another scale, the GR medium-sized city of Volos (approximately 120,000 inhabitants), on the east coast of Greece, has set up one of the main elements of its action noise plan. Indeed, the entrance of the city was a source of important road traffic noise because of continuous congestion effects in selected intersections. The NAP proposed the installation of five one-level roundabouts in order to streamline traffic, reduce traffic speeds, and thus reduce the noise emitted by vehicles. In the late 2018, four roundabouts are already constructed, and local studies and monitoring programs have already shown the positive impact of these mitigation measures concerning the environmental noise [9] (Figure 10).
Location of the four roundabouts already in full operation in Volos, Greece [
Another good example of the use of these smart tools can be presented also in the city of Volos. Indeed, after the 1955 devastating earthquake, the largely destroyed large part of the city was rebuilt by following an orthogonal layout plan where horizontal (toward the seafront) streets manage both main urban and transit traffic and the perpendicular ones the secondary traffic. In this sense, between the two main horizontal road axes of the city center (see Figure 11), the municipality during the SNM study requested to access the possibility to rehabilitate the acoustic environment between the perpendicular street network by means of full or even semi-pedestrianization. Lden and Lnight contours were predicted resulting in that no impact on noise exposure is to be expected for these mitigation measures with most of the building facades in this internal network to be still exposed at Lden levels of 75 dB(A) shown in the figure in blue color.
Lden noise action plan maps—impact of the noise mitigation measures (cancel traffic in all perpendicular small streets at Volos city center) (2012) [
The smartness of these tools made therefore it possible to evaluate that the noise impact of this small-scale traffic cancellation in the affected inner network would not change the noise exposure of the residential buildings; therefore the noise factor was not a potential evaluation parameter in order to decide such an important measure within the city.
The European Directive 2002/49 has established for all Member States a legal and technical framework for managing noise issues in large urban centers and along roads and railways and in the vicinity of airports and industries. The intelligence of these tools lies mainly in the way of measuring and predicting noise and introducing criteria that offer longtime period indices (a whole day/a whole year). These tools have been used for more than 18 years until now and have allowed to have a very precise idea of the environmental conditions in which the inhabitants are exposed to noise. The strategic noise maps are associated with noise action plans accessed by transportation and noise specialists in collaboration with city planners, architects, and policy-makers in order to minimize the impact of environmental noise on the population. The directive gives powerful and intelligent tools to observe the existing situation and its expected development. For example, between 2008 and 2010, Attiki Odos, by monitoring the traffic noise, realized that the noise emissions diminished because the Athenians were reducing the use of their vehicles forced by the economic pressure imposed by governments during the crisis in the country [13].
Noise action plans have to be published and publicly discussed between citizen and policy-makers. These important public meetings are delicate because they support environmental and political disputes that often go beyond the scope of the directive. In several cases residents do not fully understand both measurements and simulation in the strategic noise maps and especially noise simulations adjusted on the facade of their building. In general they consider themselves more exposed and therefore more annoyed compared to the relevant strategic noise maps suggest. There are many reasons for that. The environmental noise is predominant in the city, but it is not based on only one distinct potential source of discomfort. Other sources, such as two-wheeled motorcycles and motopeds, heavy vehicles, amplified music emissions, and neighborhood noise, are in several cases far more important. For these cases, the 24-h measurement and prediction of both the Lden and Lnight indexes as average per a year period do not reflect what a given inhabitant experiences in their everyday life. The political dimension is particularly important, and many municipal councils hesitate to communicate any result because they are afraid to generate more complaints after the publication of both SNM and NAP that must be explained, and public discussion might choose in between the various options available that commits public funding.
In many cases and especially in Members States of Southern Europe, the noise action plans are not always considered as an obligation by the policy-makers and the head of the municipalities. From a legal point of view, it is very difficult to depict clearly the responsible if the objectives of the action plan are not achieved, and this is generated by important bureaucratic obstacles and the local legal framework that do not clearly establish the relevant responsibilities among the different branches of the central and regional governments. The municipalities cannot be considered economically responsible for not having met the objectives of the action plan if there is a lack of necessary funding from the central government especially in period of economic crisis as recently in several Member States of the EU. This is especially true for the municipalities, but this is different in the case of private transportation network operators who are responsible for monitoring environmental parameters of their infrastructure by receiving, accessing, and resolving relevant complaints from local residents. By introducing continuous noise monitoring programs and noise mapping in order to verify compliance of the enforced limit values in order to protect inhabitants from noise exposure by implementing appropriate measurement mitigation and operation measures [5, 10].
Not all the EU Member States have followed the same pace in the implementation of the European Directive. Some published their strategic noise maps online, very fast, immediately after the directive enforcement, because it corresponds a clear political will of the decision-makers; some delayed because they needed the directive to be introduced in their respective national legislation. In some countries, several rounds succeeded one another based on the directive’s provision to update the data and the relevant results every 5 years (three rounds until now). Whatever the case in which the Member States found themselves, after so many years of operation, many thought that the situation could be improved and achieve a homogenous level of completion.
The primary issue discussed and accessed in the relevant EU committees was to establish a more correct and homogenous methodology for calculating and simulating the propagation of the environmental noise sources introduced by the directive. In fact, the method used until 2018 has often been criticized for not being sufficiently precise as regards the emitted noise of different sources and the effects of soil on propagation. Technical improvements have been proposed and adopted by all users by introducing recently the Commission Directive (EU) 2015/996 of 19 May 2015 establishing common noise assessment methods according to Directive 2002/49/EC of the European Parliament and of the Council, introducing the CNOSSOS-EU methodology, to be enforced obligatorily, by all Members States on 31 December 2018. In particular, within this methodology, two-wheeled noise and a new aircraft database were taken into account in the calculations, simulating noise events that in most urban situations are consisting of an acoustic degradation factor, by themselves [8]. The annual average of the Lden and Lday indices tends to erase the noisy passage of two wheels or a specific aircraft near a receptor (front of a given building) not only in terms of sound energy received but rather on the impact of the average value to express (or not) an annoyance. In the same way also the other modes of transport as the railway have been also introduced in order to better take into account the specifics of each sound source.
Thus, when Greece and Cyprus start implementing the European Directive 2002/49, the country was inspired by other European similar study cases and had also the capacity to move on several open discussions and innovative approaches. Indeed, from 2012, without interruption, the main urban agglomerations of these SE countries were able to publish their results on SNM and NAP regarding the noise environment: Volos, Larissa, Chania, Heraklion, Agrinio, Corfu, Thessaloniki, Athens, Nicosia, Larnaka, and Lemessos. Especially in Greece the operation started with medium-sized agglomerations in Volos and Larissa in 2012, and it led the authors to propose specific adjustments.
Indeed, starting with the city of Volos in central Greece, we have proposed to proceed a little further than the directive’s exact specifications and demands. Firstly, because already extensive measurement monitoring programs were executed [4, 9], it was established that the levels of the directive’s noise indices were compatible with the measured ones but relatively low in a general point of view and outside the influence of the main road axes, population is not exposed to high levels as per the national legislation. However, a noise action plan was drafted, including a general plan aiming to preserve the qualities of the sound environment (especially actions to enforce where and when the urban environment is not too noisy). The NAPs are calibrated based on the acoustic monitoring program in the city and have taken also into account a large interview campaign with residents of five selected neighborhoods within the urban agglomeration. The interview campaign, through comprehensive questionnaires performed in local residents, aimed to describe the sounds they hear on a typical week day, to establish the noise sources that they like and those that are uncomfortable, and finally to assess the sources of environmental noise when they perceive them, for example, at home, at work, etc.
Many cities in Europe are undergoing major structural changes and are investing heavily to accommodate more than 70% of the world’s population that is projected to be living in urban areas [14] by 2050. Cities are becoming increasingly dense and are forced to implement more and more diversified transport offers. Of course the so-called ecological transport is more numerous, but it is not sure whether they are quieter. Indeed, mass public transport is increasing, solving road traffic problems but not necessarily lowering the noise levels to which people are exposed. At the same time, airplane traffic is exploding and projection gives in this sector. In this context, to create new urban centers and minimize travel, many cities in Europe are trying to build eco-neighborhoods or eco-districts in which all energy dimensions are particularly studied. It is interesting to note that the contribution of the European Directive and its intelligent tools moves from a simple reduction of noise sources to a more qualitative management of the sound environment [15]. The sound dimension is still a dimension of the projects which is not treated as much as that of the energy consumption, but it does not prevent that these questions are now around a global strategy of application of the European Directive. Urban planners, architects, and engineers tried to apply the following principles [16]:
Remoteness of dwellings and points of interest from major transport noisy infrastructures
Protection of buildings by noise barriers, mounds, and site topography
Protection of public spaces and sensitive buildings by using other less sensitive building as a “noise barriers” (parking, commercial spaces, offices, industries)
Orientation of the buildings according to the strategic noise maps of noise and potential for apartment openings on calm areas
Maximum reduction of the use of the car in these spaces
Promotes shared modes of transport and soft and alternative modes
Promotes the presence of vegetation, loose soil, and “natural” sound sources
But more fundamentally, the Greek experience in the application of the Directive 2002/49/EC has revealed another dimension which has led the authors to propose specific adjustments. In 2012 (relatively late compared to other Member States and the provisions of the directive), with the experience of applying this directive on the country’s main transport infrastructures (roads and airports), the engineering teams, in collaboration with the transportation environmental acoustics and architects, introduced qualitative soundscape analysis tools toward a more efficient assessment and a complete list of recommendations relative to the quality of the sound environment.
They practically note the discrepancy between the values of the relevant noise indices and the common perception of urban sound environments. These elements are all more glaring as the sources of environmental noise are relatively low and much less troublesome. In these medium urban agglomerations, because of their size and their evolution process, residents defend very strongly the identity of their neighborhood, and they describe the sound qualities of these neighborhoods as a very important element in their style of life.
The European Directive on noise environment has introduced the possibility for all Member States to develop a specific methodology in order to preserve and protect quite areas. The directive gives several recommendations, and many cities in Europe develop their own guidelines to identify them and protect them. Climate conditions and social behaviors are however quite different between, for example, London and Thessaloniki, so, once again, the smart thing to do was not to decide what it could be good as a max noise level for all involved in a so diverse European Union. Quantitative criteria (Lden, Lnight, Levening, Lday) had to be completed with more qualitative criteria, and the notion of soundscapes was useful for that: “a soundscape is the acoustic environment as perceived by humans, in context” popularized by Schafer [17] who describes how people like to listen to the sounds and the noises of their environment when they are not annoyed and when they describe qualities of their neighborhood.
In this context, NAPs were completed with soundscape action plans based on the analysis of the relevant quantitative mapping. Many times, specific areas are selected because they are representative of noise and soundscape issues in link with urban development. Several strategies are defined for the protection, the management, and the creation on soundscapes in these areas.
The identification of these zones allows its protection and restoration of those responsible for the development of the agglomeration’s urban space (municipalities, architects, urban planners) within the physical city development. Consequently, this quantitative measure does not translate itself all the quality parameters of the acoustic environment of the area. For these reasons we consider it interesting to grow along with the “quantitative” mapping and a “qualitative” mapping of the acoustic environment. To ensure the appropriate assessment tools to city authorities in order for them to act on upgrading the sound identity of the subregion proposed below, the following mapping investigations have been realized.
The city center of Thessaloniki where we applied this methodology is described hereafter based on the following series of diverse layers of mapping [18]:
Urban typology map: This map describes mainly the propagation space of sounds and noise and shows on 2D drawings the section of the streets, road, boulevard, and avenues of the studied area (U- or L-shaped roads or open road). This map makes it possible to evaluate the qualities of the urban spaces in which sounds and noise spread (sound space more or less closed, even reverberant or open space) (Figure 12).
Spatio-acoustic typology map: This map presents the potential acoustic effect that can be created by the urban forms: filers, reverberation, silence islet, cutting effect, etc.) (Figure 13).
Map of predominant uses of the public spaces: This map shows the most prevalent uses of public spaces (traffic, shops and shopping areas, services, pedestrians, services, etc.)
Map of predominant uses of building uses: This map presents the main uses of the buildings of the area studied: residential building, point of interests, shops and shopping areas, services, industrials, crafting, etc. (Figure 14).
Map of sound markers and sound signals of identity’s characteristics: This map shows the sounds that characterize a place and that are often quoted by residents (Figure 15).
Soundscape maps: This map is a drawing of different areas where the soundscape that one can experiment is remarkable and has been described by the majority of people interviewed. It describes the main sound and noise sources heard on site, their relation in intensity and in time, and the way they are interpreted by the residents. This map actually regroups the results of the previous analysis (Figure 16).
Lden strategic noise map for Thessaloniki city center (left) and the relevant urban typology map of the center area (right).
Spatio-acoustic typology map for Thessaloniki city center (right) urban typology map.
Map of predominant uses of the public spaces and building in Thessaloniki city center.
Map of sound markers and sound signals of identity’s characteristics of Thessaloniki city center.
Soundscape maps of Thessaloniki city center (each color represents an area where pass by people experiment some remarkable soundscapes).
The creation of these mapping databases in correlation with the quantitative noise measurements allows in-depth analysis of the acoustic qualities and noise characteristics of a given neighborhood while they are not only clarifying the reasons for acoustic quality existence at the neighborhood scale but also annoyance problems. All the previous maps are fully correlated with the relevant noise action plan map of the area produced as per the European Directive guidelines (Figure 17
Noise action plan maps for Thessaloniki city center.
At the same time, they facilitate the decision-making in relation to the urban agglomeration planning (sources, propagation conditions, ground coverings, social organization of the city, etc.). All these overlapping maps consist for the authors a significant improvement of the available tools provided by the directive. These tools make it possible to articulate a complete quantitative and quantitative approach to the urban space and introduce, as well as the physical acoustic one, the results of interviews and all in situ observations. In this way, these tools compile users’ points of view and produce a more general vision of how the sound environment of a neighborhood is perceived by the inhabitants. He accumulates the opinions and the points of view and allows to evaluate the factors that shape the originality of these places. It does not reduce the potential noise problems that managers have to deal with but, on the contrary, emphasizes their magnitude and characteristics by drafting a noise action plan for the soundscape as well. These plans aim also to reduce the areas exposed to high noise levels, thus not only reducing the noise exposure of residents but also preserving, managing, or even creating new soundscapes.
In the example, the historic center of Thessaloniki, which is the subject of numerous renovation projects, the specifics of the action plans can be summarized as follows (Figure 18):
(From left to right) Stock Exchange District, Freedom Square, and Agia Sophia Achiropiitou axis localization in Thessaloniki center.
Thessaloniki will be equipped shortly with a very modern subway whose main objective will of course be to decongest the urban arteries from the excessive road traffic of today. In this sense, a lot of public space has been the subject of international architectural competitions aiming at their rehabilitation and renovation. In this sense, NAPs, completed by a relevant soundscape action plan (SAP), will allow to introduce a series of development for the city and its neighborhoods:
The rehabilitation principle (especially in Stock Exchange District) will have a positive impact on noise exposure. By reducing in general the use of the private car in such environment, the impact will be important because the buildings themselves by their masses and their heights will protect the area from main surrounding circulation axes. By limiting car traffic (streets becoming pedestrian and semi-pedestrian), it will ensure higher importance to the sounds characterizing the recreational and touristic activities’ sound signatures (coffee and food places, taverns, bars, clubs, live music, shopping).
On the north-south axes of Saint Sophia and Achiropiitou (east side of city center), the architectural project selected defends the idea to introduce more (sounds) of nature along the street: water fountains and surfaces, pedestrian areas, benches, etc. will give the opportunity to residents, consumers, and tourists to enjoy the location during the whole week. The light slope from north to south (until the sea level) with relevant urban interventions will help to disconnect the square from the noise traffic impact from Egnatia Avenue, one of the most busy road axes of Thessaloniki. In this case, noise reduction within soundscape creations is expected to manage the main sound ambiances for this district and for the next years.
Regarding finally Freedom Square, the challenge was to radically change its architectural image. From the visual aspects, the architectural competition selected a project that will highlight the square. From the acoustic point of view, the challenge is much harder because actually the square is only used by road traffic, parking, and also bus and taxi stations. The natural parameter is highlighted by planting more trees, deciduous and evergreen, and by using on the ground a combination of soil and aged blocks. The project increase also the spaces dedicated to pedestrians by closing the south part of a street. These actions will change the sonic identity of the place if they are fully implemented and then properly maintained (especially regarding the vegetation introduced in the area). It will not be expected to achieve important reduction of the noise exposure from road traffic especially in the sea front, but it will change the space propagation properties and the inhabitant perception. The foreseen interventions is expected to offer several new ways to use this area in an enhanced sound environment, implementing adequate seating possibilities and meeting points, coffee shops, cultural exhibition areas, and with the parking area to be relocated.
The tools presented in this chapter can be considered as quite intelligent because they can handle a large amount of data related to environmental noise and the urban soundscape. The mapping features representing these data and their relevant analysis, coupled with the use of detailed geographic information systems, allow to reveal a number of strategies to reduce residents’ noise exposure and negative reactions and, above all, to ensure a quality sound environment (soundscape) that characterizes their neighborhood and their city.
Environmental Noise Directives 2002/49/EC and 2015/996/EC need to be implemented along with soundscape analysis in order to propose a more extended and complete noise action plan that considers the urban environment as a whole and not only specific noise sources. In case studies where the environmental noise is very important (as for example, in proximity of major international airports) such study give guidelines to follow for several scenarios and of course including also severe operation measures and even relocation if needed. By embracing a broader framework, acoustic and transportation consultants along with the municipality’s officials may develop efficient tools and comprehensive noise action plans that go beyond the simplified issue of noise and offer an expanded view of the situation. The question is therefore not only to specify the tools to develop the city without noise but especially the use of intelligent tools that allow a city to evolve with all its sonorities and soundscapes, toward the noise abatement which is undoubtedly the first preoccupation of the Member States managing adequately all environmental noise dimensions and introducing the proper solutions. An action guide for environmental noise and the soundscape is therefore a powerful intelligent tool that seeks to manage an environmental problem while keeping what makes the identity (sound) of neighborhoods, all over urban agglomerations in Europe.
The main criticism that can be formulated about this approach lies in the forms of consultation of residents and citizens. Until now, it is often more practical to conduct in situ interviews with the residents of the area. The duration of studies, constrained for economic reasons, does not allow time to “hear the opinion” of everyone. Although the survey techniques used show recurrences in the opinions of interviewees, one could imagine that a system of automatic soundscape perception could be more effective than the method used. Citizen participation through mobile phones for the measuring and the qualification of noise sources and soundscapes has been developed in the recent years and might be used in this purpose. Noise-Capture is described as the scientific tool for environmental noise assessment [19]. The project gives the opportunity to any Android mobile phone to participate in the creation of a strategic noise map. The tool offers the capacity to share the measurement and display maps created by all the users, for example, at Vieux Port area in Marseilles [20] (Figures 19 and 20).
Noise map visualization at Vieux Port of Marseilles (NoiseCapture application) [
Zoomed in view of Vieux Port of Marseilles (NoiseCapture application) [
On both figures above, and at different scales, these tools present a new approach of strategic noise mapping, by indicating noise value and noise source characteristics recorded (noises, soundscapes, etc.). This map created by various independent users depending on the hour of the day, the duration of the measurement, allows an interesting representation of the sound environment as experimented by the residents.
These new tools are complementary to the European Directives’ provisions and methodological tools, but indeed they are somehow smarter in their ability to massively aggregate noise measurements, predictions, and comments of residents. Therefore the environmental mapping will introduce new ways of representing complex and dynamic sound phenomena in an urban area ensuring deeper analysis in order to understand and fully access all elements of the soundscape contributing in the formation of the sound identity of neighborhoods and cities. Enriched with all these approaches, there is no doubt that the city will be better equipped by many intelligent tools to proceed in its development by ensuring a sustainable sound environment.
Both authors, Prof. Konstantin Vogiatzis and Associate Prof. Nicolas Rémy, declare no conflict of interest.
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