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Colonic Ileus and Cecal Perforation in Patients Requiring Mechanical Ventilatory Support
Colonic Ileus and Cecal Perforation in Patients Requiring Mechanical Ventilatory Support* Gerald T. Golden, M.D., 00 and James G. Chandler, M.D.t
Massive colonic distention associated with neither small intestinal dilatation nor distal obstruction of the colon occurred in seven patients who were requiring mechanical ventilatory support. In three of these patients, perforation of the cecum was the first sign of their having
I solated colonic ileus, without concomitant small bowel distention and unrelated to any obstructive lesion in the distal colon, has been recognized as a clinical entity for more than 25 years. 1 This report reviews seven patients with this disorder seen during the past five years at a single institution and suggests a previously unrecognized important relationship between modern techniques of mechanical ventilation and rapid cecal overdistention. CLINICAL SERIES
The pertinent data for the seven patients are summarized in Table 1. All of the patients were seriously ill, and all were receiving some form of mechanical ventilatory support when their colonic ileus developed. Distention of the colon first became apparent 8 to 17 days after the onset of the primary illness or operation. In four patients the presentation was typical: they developed progressive abdominal distention over a period of 18 to 24 hours, and examination of their abdomens revealed normal or hyperactive bowel sounds and tympanitic percussion. Roentgenograms showed massive distention of a part or all of the colon but no significant accumulation of gas in the small bowel (Fig 1 ) . In two instances, because the gas ended abruptly at the splenic flexure, distal large intestinal obstruction was strongly suspected, and limited barium contrast enema studies were performed to exclude that diagnosis. Persistent cecal distention for more than 24 hours to a diameter of 9 em or greater prompted tube cecostomy in two of the four patients. The third patient in the typical presentation group was treated for two weeks with nasogastric suction, multiple enemas, and catharsis, without either progression or resolution of the condition, but her distention aggravated her respiratory insufficiency, and the interaction between the two finally provided the impetus for cecostomy °From the Department of Surgery, University of Virginia Medical Center, Charlottesville. 00 Resident in Plastic Surgery. tAssociate Professor of Surgery. Manuscript received January 3; revision accepted April 17. Reprint requests: Dr. Chandler, Department of Surgery, University of Virginia Hosvital, Charlottesville 22901
CHEST, 68: 5, NOVEMBER, 1975
colonic ileus. The high incidence of perforation in this series and the common factor of mechanical ventilation suggests a causal relationship which bas not been noted previously.
after 14 days of nonoperative management. Nasogastric suction and rectal intubations were successful in only one patient, but her colon remained massively distended for six days before it gradually regained normal muscular tone. Three patients presented with signs of perforation without recognized antecedent abdominal distention. They are the last three patients summarized in Table 1, but their histories merit additional scrutiny. CASES
A 59-year-old man with a 20-year history of angina pectoris and an anterior-inferior myocardial infarction six months previously was admitted with excruciating chest pain and signs of aortic valvular insufficiency. Cardiac catheterization confirmed the diagnosis of aortic insufficiency and documented mild left ventricular dysfunction and modest pulmonary hypertension. Eleven days after admission, a No. 12 Starr-Edwards aortic valve prosthesis was inserted. Controlled ventilation was elected for the first 12 postoperative hours, and then the patient was placed on a rigorous program of chest physiotherapy and intermittent positive pressure ventilation every four hours. On the eighth postoperative day while still receiving intermittent positive pressure therapy at four-hour intervals during waking hours, the patient suddenly developed fever and abdominal pain and distention. Roentgenograms revealed free intraperitoneal air, and a laparotomy was undertaken to close a perforation of a presumed peptic ulcer. Instead, a 5-mm hole was found in a flaccid thinwalled cecum with massive soiling of the peritoneum. A tube cecostomy was placed at the site of perforation, the abdomen was thoroughly lavaged, and the patient was given broadspectrum antibiotic therapy. Cultures of the peritoneal fluid grew an Enterococcus and Escherichia coli. Ten days later, the patient was well enough to be discharged, and he remains in good health 18 months following his operations. CAsE6
A 63-year-old woman was admitted with cyanosis, disorientation, and lethargy. She had an 80 pack year history of cigarette smoking and known severe chronic obstructive pulmonary disease. Arterial blood gas analyses while the patient was breathing room air revealed an arterial oxygen
COLONIC ILEUS AND CECAL PERFORATION 661
Table I -Clinical Feature• of Seven Patient& with laolated Colonic lieu• ( 'as••
Diagnosis
:\~•· / S1•x
Ceenl Perforation
Respiratory Support
OnsPt to Cecostomy
:\lanagement
Result
15/ :\l
PnPumonia with aeute rPspiratory failure
Continuous, volume regulatPd
No
3 wk
Ceeostomy
Died ·of pneumonia
2
7a/ :\1
Left upper loiH•!'lomy for ea n·inoma
Intermittent positive pressure
No
8 hr
Cecostomy
Survived
a
88/ F
Chronir ohst rtl<'tivc pulmonary 11iscnse
Intermittent positive pressure
No
Cecostomy
DiPd of pulmonary failure
4
75/ F
607o
third-dPgrce burn; ehronie pulmonary insufficiency
Continuous, volume regulated
No
Nonoperative
Survived
5
5!1/ M
:\ortie valve replaeement; ehronie obstruetivP pulmonary diSI'ase
Continuous, volume rcgulatPd for 12 hr; then intermittent positive pressure
Yes
2 hr
Cecostomy
Survived
f\
63/ F
Chronic' and aeute respiratory insufficiency
Continuous, volume regulated
Yes
1 hr
Cecostomy
Survived
7
il2 i :\l
l\lultiplP trauma; ehronie and acute respiratory insuffieieney
Continuous, volume regulated
Yes
1 hr
Cecostomy
Died of sepsis and pulmonary failure
14 days
pressure ( Pa02 ) of 25 mm Hg, an arterial carbon dioxide tension ( PaC02) of 70 mm Hg, and a pH of 7 .22. Despite digitalization, prednisolone and antibiotic therapy, intermittent positive pressure ventilation, and chest physiotherapy, the patient's pulmonary function did not improve, and controlled ventilation with a nasotracheal tube was begun on the third hospital day. On the next day a tracheostomy was performed. Adequate oxygenation was achieved with a fractional concentration of oxygen in the inspired gas ( FI<>:!) of 0.48 and lO em H20 of positive end-expiratory pressure (PEEP) . Three days later, the patient suddenly developed abdominal distention, tympany over the liver, and a rectal temperature of 39.5•C ( l03.l•F). A chest roentgenogram revealed free air beneath the diaphragm. Laparotomy was done with a presumptive diagnosis of a perforated duodenal ulcer, but a 5-mm perforation of the cecum was found. A tube cecostomy was done, and broad-spectrum antibiotic therapy was given postoperatively. Cultures of the peritoneal fluid grew an Aerobacter species and E coli. The patient was gradually weaned from the ventilator and discharged on the 25th postoperative day.
CASE7
FIGURE l. Supine film of abdomen showing distention of colon without any evidence of small-bowel gas. Distention ends at splenic flexure, but subsequent limited barium contrast enema excluded any physically obstructing lesion (case 3 ) .
662 GOLDEN, CHANDLER
A 52-year-old white man with a longstanding history of "asthma" and of smoking two packages of cigarettes a day was admitted one hour after being in an automobile accident. Initial evaluation revealed pulmonary contusion, fractures of the second to seventh ribs, and fractures of the scapula and lateral malleolus, all on the right side. Diagnostic abdominal paracentesis gave negative results. Blood gas analysis revealed a Pa02 of 60 mm Hg, a PaC02 of 38 mm Hg, and a pH of 7 .38. The patient wa~ treated in the intensive care unit with 100 percent oxygen by mask and chest physiotherapy. He remained stable for 72 hours, but then his pulmonary function deteriorated, requiring a tracheostomy and controlled ventilation. On the seventh day the patient needed an F102 of 0 .65 and 10 em H20 of PEEP to maintain an
CHEST, 68: 5, NOVEMBER, 1975
adequate Pa02. On the following day, blood was aspirated from the patient's nasogastric tube. Esophagogastroscopy revealed acute erosive gastritis; because of continued blood loss, hemigastrectomy and vagotomy were required. Controlled ventilation was continued. On the third postoperative day the patient developed a rectal temperature of 39.5•C ( 103.1 •F), a distended abdomen, and percussion hyperresonance over the liver. His chest film showed free air beneath the diaphragm which was more than the amount present on a chest film taken the first day after his operation. Laparotomy revealed a cecal perforation. The patient was treated with a tube cecostomy and given antibiotic therapy intravenously but he died of sepsis and progressive pulmonary insufficiency six days following the procedure. Cultures of the peritoneal fluid revealed only coliform organisms. CoMMENT
Colonic ileus or pseudo-obstruction was first described in 1948 by Ogilvie. 1 The subject appeared to be little more than a clinical oddity untill971, but in the last four years, there have been five separate reports encompassing a total of 53 cases. 2-6 This sudden renewed awareness of the disorder suggests that there may be an increase in its actual incidence as well. The most widely held hypothesis regarding the etiology of isolated colonic ileus has been an imbalance between parasympathetic and sympathetic stimulation of the boweJ.7·8 In laboratory animals, postoperative ileus can be prevented by prior sympathectomy, and ileus can be induced by stimulation of the sympathetic nervous system. 9 In man, postoperative ileus seems to affect the colon to a much greater extent, and for a longer time, than it does the remainder of the gastrointestinal tract. Using barium contrast radiography, Nachlas et aP 0 demonstrated that small-bowel peristaltic activity returns promptly after uncomplicated intra-abdominal procedures, whereas the return of colonic propulsive activity is usually delayed for three to five days. Acombination of early resumption of small-bowel activity and persistent colonic inertia in conjunction with aerophagia is the best explanation for isolated colonic distention. Perforation of an overdistended cecum is a theoretic possibility mentioned by all of the authors but, in fact, infrequently reported. Wojtalik and his colleagues5 described four cases of perforation but were able to find only 12 previously reported cases. In the combined experience of Adams, 2 Wanebo et al, 3 Goldstein and Babu! and Norton et al, 6 totaling 49 patients, only two spontaneous perforations of the cecum occurred. In contrast, three of our seven patients presented with signs of free intraperitoneal perforation. The common feature was the need for mechanical respiratory support in all seven patients. No previous report has mentioned an association
CHEST, 68: 5, NOVEMBER, 1975
between mechanical ventilation and colonic ileus or cecal perforation. Although the evidence relating cecal distention to ventilatory support and chronic pulmonary disease is entirely circumstantial, the incidence of perforation in this series was striking. Moreover, the cecum became so rapidly distended in three instances that no premonitory abdominal distention was apparent before perforation occurred, in spite of the fact that these patients were being closely monitored in special care units. Even in the four patients who developed the disorder in more typical fashion, the abdominal distention progressed rapidly. Within 24 hours, full-blown isolated colonic ileus was apparent on abdominal films, and in three of the four patients, cecostomy seemed indicated within an additional24 hours. There are several reasons why patients requiring ventilatory support might be especially predisposed to rapidly progressive colonic distention. Positivepressure ventilation has been reported to cause air embolism by simultaneous disruption of adjacent alveoli and small pulmonary blood vessels. 11 An air embolism to the mesenteric arteries could account for the abrupt onset of the colonic ileus in our patients, but no intravascular air was observed in the vessels of the operated patients, and the three deaths in this series were not sudden and unexpected. All of the patients received antibiotic therapy for varying periods of time before they developed colonic distention, raising the possibility that their normal intestinal bacteria flora may have been altered to favor overgrowth of gas-producing organisms. No stool cultures were obtained, but the bacterial growth from the peritoneal fluid of the three patients who developed perforations did not suggest any predominant aberrant organisms. The most plausible link between the two conditions is exaggerated aerophagia. Five of the seven patients in this series, including all three who developed perforations without a recognized prodrome of abdominal distention, had chronic obstructive pulmonary disease. Such patients often have developed a habit of swallowing air to assist in elevating their diaphragms, and there is no reason to suspect that this habit would be abated by a superimposed acute illness. Nasotracheal intubation has been implicated as a cause of obligate aerophagia, but only one patient (case 4) was being mechanically ventilated through a nasotracheal tube at the time that colonic distention developed. 12 Two of the patients who developed perforations had tracheostomies. The other man was receiving intermittent positive-pressure treatments using a semiocclusive mouthpiece and a nose clip which easily could have induced him to swallow an excessive amount of air. The PEEP is
COLONIC ILEUS AND CECAL PERFORATION 663
another factor that may have increased aerophagia. Therapy with PEEP was used in three of the seven patients in the series, and two of these three were patients who presented initially with a cecal perforation. From this experience, we conclude that patients requiring mechanical ventilatory support, and particularly those with acute respiratory failure superimposed on chronic obstructive pulmonary disease, should be watched closely for the earliest evidence of abdominal distention. At the slightest suspicion, abdominal films should be obtained. If the films reveal evidence of mild aerophagia, such as gastric dilatation, patchy small-bowel gas, or an increase in the amount of gas within the colon, nasogastric suction should be instituted and consideration given to early discontinuance of ventilatory assistance. A rectal tube should be passed and suppositories given to stimulate the colon. No absolute rules for treating cecal distention can be given. The data of Lowman and Davis 13 indicate a high risk of cecal perforation when the diameter becomes greater than 9 em in patients with colonic obstruction due to tumor. However, an accurate assessment of percentage risk per unit of time is impossible, and the data may not really be applicable to patients with colonic ileus who, by definition, do not have distal mechanical obstruction. Nevertheless, cecostomy seems the safer choice when the cecal diameter is greater than 12 em on an initial film, persistently greater than 9 em for more than 24 hours, or appears to be rapidly enlarging on serial roentgenograms.
REFERENCES
2 3 4 5 6 7 8
9 10 11
12
13
Ogilvie H : Large intestine colic due to sympathetic deprivation: A new clinical syndrome. Br Med J 2:671673, 1948 Adams JT: Adynamic ileus of the colon: An indication for cecostomy. Arch Surg 109 :503-507, 1974 Wanebo H, ~fathewson C, Conolly B: Pseudo-obstruction of the colon. Surg Gynecol Obstet 133 :44-48, 1971 Goldstein HM, Babu SS : Colonic ileus: An atypical form of adynamic ileus. JAMA 230:1008-1009, 1974 Wojtalik RS, Lindenauer SM, Kahn SS : Perforation of the colon associated with adynamic ileus. Am J Surg 125 :601606, 1973 Norton L, Young D, Scribner R: Management of pseudoobstruction of the colon. Surg Gynecol Obstet 138:595598, 1974 Dunlop JA : Ogilvie's syndrome of false colonic obstruction : A case with post-mortem findings . Br ~led J 1:890891, 1949 Melamed M, Kubian E : Relationship of the autonomic nervous system to "functional" obstruction of the intestinal tract. Radiology 80 :22-29, 1963 Neely J, Catchpole B: Ileus : The restoration of alimentary-tract motility by pharmacological means. Br J Surg 58:21-28, 1971 Nachlas !\f!\I, Younis MT, Roda CP, et al: Gastrointestinal motility studies as a guide to postoperative management. Ann Surg 175 :510-522, 1972 Gold MI, Joseph Sl: Bilateral tension pneumothorax following induction of anesthesia in two patients with chronic obstructive airway disease. Anesthesiology 38:93-96, 1973 Cooper JD, Malt RA: Meteorism produced by nasotracheal intubation and ventilatory assistance. N Eng) J Med 287: 652-653, 1972 Lowman R:\1, Davis L: An evaluation of cecal size in impending perforation of the cecum. Surg Gynecol Obstet 103:711-718, 1956
Irving Berlin In the Smithsonian Institution in Washington, D.C. stands an old upright piano whose mahogany woodwork bears distinct signs of wear. A similar piano, bearing the marks of similar wear, stands in an office in Manhattan. Two things about both of them sets them apart from other pianos. One is a lever underneath the keyboard that can change the sound of the notes struck, just as the movement of a gearshift in a car can change the sound of the engine. The other thing they have in common is that they are both instruments on which Irving Berlin trans-
664 GOLDEN, CHANDLER
formed the popular song. In all his years (he was born in 1888) Irving Berlin never learned how to play a conventional piano properly. He created something like 3 ,000 songs and influenced practically every song writer for three generations by pounding the black notes in the key of F sharp and by using that little lever to convert them into a fuller range of sound. He has never learned how to read music. Freedland, M: Irving Berlin, New York, Stein and Day, 1974
CHEST, 68: 5, NOVEMBER, 1975
Massive colonic distention associated with neither small intestinal dilatation nor distal obstruction of the colon occurred in seven patients who were requiring mechanical ventilatory support. In three of these patients, perforation of the cecum was the first sign of their having
I solated colonic ileus, without concomitant small bowel distention and unrelated to any obstructive lesion in the distal colon, has been recognized as a clinical entity for more than 25 years. 1 This report reviews seven patients with this disorder seen during the past five years at a single institution and suggests a previously unrecognized important relationship between modern techniques of mechanical ventilation and rapid cecal overdistention. CLINICAL SERIES
The pertinent data for the seven patients are summarized in Table 1. All of the patients were seriously ill, and all were receiving some form of mechanical ventilatory support when their colonic ileus developed. Distention of the colon first became apparent 8 to 17 days after the onset of the primary illness or operation. In four patients the presentation was typical: they developed progressive abdominal distention over a period of 18 to 24 hours, and examination of their abdomens revealed normal or hyperactive bowel sounds and tympanitic percussion. Roentgenograms showed massive distention of a part or all of the colon but no significant accumulation of gas in the small bowel (Fig 1 ) . In two instances, because the gas ended abruptly at the splenic flexure, distal large intestinal obstruction was strongly suspected, and limited barium contrast enema studies were performed to exclude that diagnosis. Persistent cecal distention for more than 24 hours to a diameter of 9 em or greater prompted tube cecostomy in two of the four patients. The third patient in the typical presentation group was treated for two weeks with nasogastric suction, multiple enemas, and catharsis, without either progression or resolution of the condition, but her distention aggravated her respiratory insufficiency, and the interaction between the two finally provided the impetus for cecostomy °From the Department of Surgery, University of Virginia Medical Center, Charlottesville. 00 Resident in Plastic Surgery. tAssociate Professor of Surgery. Manuscript received January 3; revision accepted April 17. Reprint requests: Dr. Chandler, Department of Surgery, University of Virginia Hosvital, Charlottesville 22901
CHEST, 68: 5, NOVEMBER, 1975
colonic ileus. The high incidence of perforation in this series and the common factor of mechanical ventilation suggests a causal relationship which bas not been noted previously.
after 14 days of nonoperative management. Nasogastric suction and rectal intubations were successful in only one patient, but her colon remained massively distended for six days before it gradually regained normal muscular tone. Three patients presented with signs of perforation without recognized antecedent abdominal distention. They are the last three patients summarized in Table 1, but their histories merit additional scrutiny. CASES
A 59-year-old man with a 20-year history of angina pectoris and an anterior-inferior myocardial infarction six months previously was admitted with excruciating chest pain and signs of aortic valvular insufficiency. Cardiac catheterization confirmed the diagnosis of aortic insufficiency and documented mild left ventricular dysfunction and modest pulmonary hypertension. Eleven days after admission, a No. 12 Starr-Edwards aortic valve prosthesis was inserted. Controlled ventilation was elected for the first 12 postoperative hours, and then the patient was placed on a rigorous program of chest physiotherapy and intermittent positive pressure ventilation every four hours. On the eighth postoperative day while still receiving intermittent positive pressure therapy at four-hour intervals during waking hours, the patient suddenly developed fever and abdominal pain and distention. Roentgenograms revealed free intraperitoneal air, and a laparotomy was undertaken to close a perforation of a presumed peptic ulcer. Instead, a 5-mm hole was found in a flaccid thinwalled cecum with massive soiling of the peritoneum. A tube cecostomy was placed at the site of perforation, the abdomen was thoroughly lavaged, and the patient was given broadspectrum antibiotic therapy. Cultures of the peritoneal fluid grew an Enterococcus and Escherichia coli. Ten days later, the patient was well enough to be discharged, and he remains in good health 18 months following his operations. CAsE6
A 63-year-old woman was admitted with cyanosis, disorientation, and lethargy. She had an 80 pack year history of cigarette smoking and known severe chronic obstructive pulmonary disease. Arterial blood gas analyses while the patient was breathing room air revealed an arterial oxygen
COLONIC ILEUS AND CECAL PERFORATION 661
Table I -Clinical Feature• of Seven Patient& with laolated Colonic lieu• ( 'as••
Diagnosis
:\~•· / S1•x
Ceenl Perforation
Respiratory Support
OnsPt to Cecostomy
:\lanagement
Result
15/ :\l
PnPumonia with aeute rPspiratory failure
Continuous, volume regulatPd
No
3 wk
Ceeostomy
Died ·of pneumonia
2
7a/ :\1
Left upper loiH•!'lomy for ea n·inoma
Intermittent positive pressure
No
8 hr
Cecostomy
Survived
a
88/ F
Chronir ohst rtl<'tivc pulmonary 11iscnse
Intermittent positive pressure
No
Cecostomy
DiPd of pulmonary failure
4
75/ F
607o
third-dPgrce burn; ehronie pulmonary insufficiency
Continuous, volume regulated
No
Nonoperative
Survived
5
5!1/ M
:\ortie valve replaeement; ehronie obstruetivP pulmonary diSI'ase
Continuous, volume rcgulatPd for 12 hr; then intermittent positive pressure
Yes
2 hr
Cecostomy
Survived
f\
63/ F
Chronic' and aeute respiratory insufficiency
Continuous, volume regulated
Yes
1 hr
Cecostomy
Survived
7
il2 i :\l
l\lultiplP trauma; ehronie and acute respiratory insuffieieney
Continuous, volume regulated
Yes
1 hr
Cecostomy
Died of sepsis and pulmonary failure
14 days
pressure ( Pa02 ) of 25 mm Hg, an arterial carbon dioxide tension ( PaC02) of 70 mm Hg, and a pH of 7 .22. Despite digitalization, prednisolone and antibiotic therapy, intermittent positive pressure ventilation, and chest physiotherapy, the patient's pulmonary function did not improve, and controlled ventilation with a nasotracheal tube was begun on the third hospital day. On the next day a tracheostomy was performed. Adequate oxygenation was achieved with a fractional concentration of oxygen in the inspired gas ( FI<>:!) of 0.48 and lO em H20 of positive end-expiratory pressure (PEEP) . Three days later, the patient suddenly developed abdominal distention, tympany over the liver, and a rectal temperature of 39.5•C ( l03.l•F). A chest roentgenogram revealed free air beneath the diaphragm. Laparotomy was done with a presumptive diagnosis of a perforated duodenal ulcer, but a 5-mm perforation of the cecum was found. A tube cecostomy was done, and broad-spectrum antibiotic therapy was given postoperatively. Cultures of the peritoneal fluid grew an Aerobacter species and E coli. The patient was gradually weaned from the ventilator and discharged on the 25th postoperative day.
CASE7
FIGURE l. Supine film of abdomen showing distention of colon without any evidence of small-bowel gas. Distention ends at splenic flexure, but subsequent limited barium contrast enema excluded any physically obstructing lesion (case 3 ) .
662 GOLDEN, CHANDLER
A 52-year-old white man with a longstanding history of "asthma" and of smoking two packages of cigarettes a day was admitted one hour after being in an automobile accident. Initial evaluation revealed pulmonary contusion, fractures of the second to seventh ribs, and fractures of the scapula and lateral malleolus, all on the right side. Diagnostic abdominal paracentesis gave negative results. Blood gas analysis revealed a Pa02 of 60 mm Hg, a PaC02 of 38 mm Hg, and a pH of 7 .38. The patient wa~ treated in the intensive care unit with 100 percent oxygen by mask and chest physiotherapy. He remained stable for 72 hours, but then his pulmonary function deteriorated, requiring a tracheostomy and controlled ventilation. On the seventh day the patient needed an F102 of 0 .65 and 10 em H20 of PEEP to maintain an
CHEST, 68: 5, NOVEMBER, 1975
adequate Pa02. On the following day, blood was aspirated from the patient's nasogastric tube. Esophagogastroscopy revealed acute erosive gastritis; because of continued blood loss, hemigastrectomy and vagotomy were required. Controlled ventilation was continued. On the third postoperative day the patient developed a rectal temperature of 39.5•C ( 103.1 •F), a distended abdomen, and percussion hyperresonance over the liver. His chest film showed free air beneath the diaphragm which was more than the amount present on a chest film taken the first day after his operation. Laparotomy revealed a cecal perforation. The patient was treated with a tube cecostomy and given antibiotic therapy intravenously but he died of sepsis and progressive pulmonary insufficiency six days following the procedure. Cultures of the peritoneal fluid revealed only coliform organisms. CoMMENT
Colonic ileus or pseudo-obstruction was first described in 1948 by Ogilvie. 1 The subject appeared to be little more than a clinical oddity untill971, but in the last four years, there have been five separate reports encompassing a total of 53 cases. 2-6 This sudden renewed awareness of the disorder suggests that there may be an increase in its actual incidence as well. The most widely held hypothesis regarding the etiology of isolated colonic ileus has been an imbalance between parasympathetic and sympathetic stimulation of the boweJ.7·8 In laboratory animals, postoperative ileus can be prevented by prior sympathectomy, and ileus can be induced by stimulation of the sympathetic nervous system. 9 In man, postoperative ileus seems to affect the colon to a much greater extent, and for a longer time, than it does the remainder of the gastrointestinal tract. Using barium contrast radiography, Nachlas et aP 0 demonstrated that small-bowel peristaltic activity returns promptly after uncomplicated intra-abdominal procedures, whereas the return of colonic propulsive activity is usually delayed for three to five days. Acombination of early resumption of small-bowel activity and persistent colonic inertia in conjunction with aerophagia is the best explanation for isolated colonic distention. Perforation of an overdistended cecum is a theoretic possibility mentioned by all of the authors but, in fact, infrequently reported. Wojtalik and his colleagues5 described four cases of perforation but were able to find only 12 previously reported cases. In the combined experience of Adams, 2 Wanebo et al, 3 Goldstein and Babu! and Norton et al, 6 totaling 49 patients, only two spontaneous perforations of the cecum occurred. In contrast, three of our seven patients presented with signs of free intraperitoneal perforation. The common feature was the need for mechanical respiratory support in all seven patients. No previous report has mentioned an association
CHEST, 68: 5, NOVEMBER, 1975
between mechanical ventilation and colonic ileus or cecal perforation. Although the evidence relating cecal distention to ventilatory support and chronic pulmonary disease is entirely circumstantial, the incidence of perforation in this series was striking. Moreover, the cecum became so rapidly distended in three instances that no premonitory abdominal distention was apparent before perforation occurred, in spite of the fact that these patients were being closely monitored in special care units. Even in the four patients who developed the disorder in more typical fashion, the abdominal distention progressed rapidly. Within 24 hours, full-blown isolated colonic ileus was apparent on abdominal films, and in three of the four patients, cecostomy seemed indicated within an additional24 hours. There are several reasons why patients requiring ventilatory support might be especially predisposed to rapidly progressive colonic distention. Positivepressure ventilation has been reported to cause air embolism by simultaneous disruption of adjacent alveoli and small pulmonary blood vessels. 11 An air embolism to the mesenteric arteries could account for the abrupt onset of the colonic ileus in our patients, but no intravascular air was observed in the vessels of the operated patients, and the three deaths in this series were not sudden and unexpected. All of the patients received antibiotic therapy for varying periods of time before they developed colonic distention, raising the possibility that their normal intestinal bacteria flora may have been altered to favor overgrowth of gas-producing organisms. No stool cultures were obtained, but the bacterial growth from the peritoneal fluid of the three patients who developed perforations did not suggest any predominant aberrant organisms. The most plausible link between the two conditions is exaggerated aerophagia. Five of the seven patients in this series, including all three who developed perforations without a recognized prodrome of abdominal distention, had chronic obstructive pulmonary disease. Such patients often have developed a habit of swallowing air to assist in elevating their diaphragms, and there is no reason to suspect that this habit would be abated by a superimposed acute illness. Nasotracheal intubation has been implicated as a cause of obligate aerophagia, but only one patient (case 4) was being mechanically ventilated through a nasotracheal tube at the time that colonic distention developed. 12 Two of the patients who developed perforations had tracheostomies. The other man was receiving intermittent positive-pressure treatments using a semiocclusive mouthpiece and a nose clip which easily could have induced him to swallow an excessive amount of air. The PEEP is
COLONIC ILEUS AND CECAL PERFORATION 663
another factor that may have increased aerophagia. Therapy with PEEP was used in three of the seven patients in the series, and two of these three were patients who presented initially with a cecal perforation. From this experience, we conclude that patients requiring mechanical ventilatory support, and particularly those with acute respiratory failure superimposed on chronic obstructive pulmonary disease, should be watched closely for the earliest evidence of abdominal distention. At the slightest suspicion, abdominal films should be obtained. If the films reveal evidence of mild aerophagia, such as gastric dilatation, patchy small-bowel gas, or an increase in the amount of gas within the colon, nasogastric suction should be instituted and consideration given to early discontinuance of ventilatory assistance. A rectal tube should be passed and suppositories given to stimulate the colon. No absolute rules for treating cecal distention can be given. The data of Lowman and Davis 13 indicate a high risk of cecal perforation when the diameter becomes greater than 9 em in patients with colonic obstruction due to tumor. However, an accurate assessment of percentage risk per unit of time is impossible, and the data may not really be applicable to patients with colonic ileus who, by definition, do not have distal mechanical obstruction. Nevertheless, cecostomy seems the safer choice when the cecal diameter is greater than 12 em on an initial film, persistently greater than 9 em for more than 24 hours, or appears to be rapidly enlarging on serial roentgenograms.
REFERENCES
2 3 4 5 6 7 8
9 10 11
12
13
Ogilvie H : Large intestine colic due to sympathetic deprivation: A new clinical syndrome. Br Med J 2:671673, 1948 Adams JT: Adynamic ileus of the colon: An indication for cecostomy. Arch Surg 109 :503-507, 1974 Wanebo H, ~fathewson C, Conolly B: Pseudo-obstruction of the colon. Surg Gynecol Obstet 133 :44-48, 1971 Goldstein HM, Babu SS : Colonic ileus: An atypical form of adynamic ileus. JAMA 230:1008-1009, 1974 Wojtalik RS, Lindenauer SM, Kahn SS : Perforation of the colon associated with adynamic ileus. Am J Surg 125 :601606, 1973 Norton L, Young D, Scribner R: Management of pseudoobstruction of the colon. Surg Gynecol Obstet 138:595598, 1974 Dunlop JA : Ogilvie's syndrome of false colonic obstruction : A case with post-mortem findings . Br ~led J 1:890891, 1949 Melamed M, Kubian E : Relationship of the autonomic nervous system to "functional" obstruction of the intestinal tract. Radiology 80 :22-29, 1963 Neely J, Catchpole B: Ileus : The restoration of alimentary-tract motility by pharmacological means. Br J Surg 58:21-28, 1971 Nachlas !\f!\I, Younis MT, Roda CP, et al: Gastrointestinal motility studies as a guide to postoperative management. Ann Surg 175 :510-522, 1972 Gold MI, Joseph Sl: Bilateral tension pneumothorax following induction of anesthesia in two patients with chronic obstructive airway disease. Anesthesiology 38:93-96, 1973 Cooper JD, Malt RA: Meteorism produced by nasotracheal intubation and ventilatory assistance. N Eng) J Med 287: 652-653, 1972 Lowman R:\1, Davis L: An evaluation of cecal size in impending perforation of the cecum. Surg Gynecol Obstet 103:711-718, 1956
Irving Berlin In the Smithsonian Institution in Washington, D.C. stands an old upright piano whose mahogany woodwork bears distinct signs of wear. A similar piano, bearing the marks of similar wear, stands in an office in Manhattan. Two things about both of them sets them apart from other pianos. One is a lever underneath the keyboard that can change the sound of the notes struck, just as the movement of a gearshift in a car can change the sound of the engine. The other thing they have in common is that they are both instruments on which Irving Berlin trans-
664 GOLDEN, CHANDLER
formed the popular song. In all his years (he was born in 1888) Irving Berlin never learned how to play a conventional piano properly. He created something like 3 ,000 songs and influenced practically every song writer for three generations by pounding the black notes in the key of F sharp and by using that little lever to convert them into a fuller range of sound. He has never learned how to read music. Freedland, M: Irving Berlin, New York, Stein and Day, 1974
CHEST, 68: 5, NOVEMBER, 1975