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Diagnosis and treatment of acute abdominal conditions with special reference to roentgenographic findings
Diagnosis and Treatment Abdominal Reference SABURO
From the Department Tokyo, Japan.
Conditions with Special
to Roentgenographic
MATSUKURA,
of Surgery,
Nippon
Findings
M.D. AND AKIRO SHIROTA,M.D., Tokyo, Japan
Medical
School,
However, intestinal obstruction is still ranked second after appendicitis, and can be regarded as a representative acute abdominal disease. In this paper we will discuss the diagnosis and results of treatment of acute abdominal conditions, mainly on the basis of abdominal x-ray findings.
the field of surgery many acute abdominal conditions begin simply with the complaint of abdominal pain. However, the surgeon must diagnose the complaint early and treat it adequately. Furthermore, the character of the abdominal pain does not always agree with the pathoanatomic findings, and there are many other extra-abdominal diseases in which the complaint of abdominal pain is present. It is, therefore, not so easy to make a correct diagnosis simply on the basis of the chief complaint of abdominal pain. The most important reference in diagnosing an acute abdominal disorder is that of the abdominal x-ray findings. During the thirtytwo years from 1935 to 1966, 13,540 patients were admitted to our department and underwent laparotomy. Of these, 7,504 (55.4 per cent), or about half of the patients with laparotomy, had the so-called “acute abdomen” with the chief complaint of abdominal pain, and they had to undergo emergency operation. The main acute abdominal conditions in this group were acute appendicitis, 5,814 cases (77.5 per cent), and acute intestinal obstruction, 839 cases (11.2 per cent), all other diseases accounting for about 11 per cent. The incidence of intestinal obstructions, especially postoperatively, has recently decreased remarkably. The rate of intestinal obstructions in patients with acute abdominal conditions was 16.2 per cent for the sixteen year period from 1935 to 1950, but only 8.9 per cent for the sixteen years from 1951 to 1966.
I
of Acute
N
DIAGNOSIS OF ACUTEINTESTINAL OBSTRUCTION Acute intestinal obstruction should be diagnosed from the patient’s history and present condition, general physical condition, and especially the abdominal findings. However, the causes, sites, and types of intestinal obstruction vary so widely that it is not easy to make the correct diagnosis for each case. Generally speaking, a complex intestinal obstruction is far more difficult to diagnose than a simple one. Furthermore, with the complex obstruction the clinical progression is much more rapid than with the simple obstruction, so that if too much time is spent on the diagnosis, the patient’s life may be endangered. As a representative type of acute intestinal obstruction, we will discuss volvulus of the small intestine, which is not only the most difficult one to diagnose, but also often progresses rapidly and carries an unfavorable prognosis. Of 839 patients with acute mechanical obstruction who were operated upon in our department during the thirty-two years from 1935 to 1966, sixty-two had volvulus of the small intestine. Correct preoperative diagnoses were made in only nineteen cases, whereas the re804
American
Journal
of Surgery
805 TABLE I SYMPTOMCOMPLEX IN SMALL INTESTINAL VOLVULUS
Symptom
Complex
Shock symptoms Mechanical ileus symptoms Local abdominal signs Abdominal x-ray findings Peritoneal exudate History of abdominal operation Leukocytosis Temperature rise
Positive (Per cent)
Negative (Per cent)
100.0 100.0 14.0 17.0 63.0 74.3 91.4 0
0 0 86.0 83.0 37.0 25.7 8.6 100.0
maining cases were diagnosed as strangulation (nineteen patients), adhesion (six patients), or merely obstruction (seventeen patients). Another case was simply noted as “acute abdomen.” This suggests the diagnostic difficulty of this ailment. Some pertinent diagnostic information is as follows : 1. The incidence of volvulus in our department was 116 cases in 839 patients. The site of volvulus was the small intestine in sixty-two patients, including one in whom the whole small intestine, cecum, ascending colon, and part of the transverse colon were involved. The sigmoid colon was involved in forty-seven patients, and the cecum in seven. Thus, volvulus of the small intestine represents the majority of cases, 2. It has been reported that sex and age bear a close relation to the occurrence of volvulus. The disease predominated in males, there being forty-four male and eighteen female patients in our series. Also, patients with involvements of the small intestine were younger than those with lesions of the sigmoid, which occur later in life. 3. A rotation of 360 degrees was observed in thirty-six patients, the greatest rotation being 720 degrees (four patients). In forty-two patients the rotation was clockwise, and in twenty counterclockwise. 4. Symptoms of volvulus cannot be found in the textbooks, and the diagnosis is considered to be very difficult except for experienced specialists. In view of this a “syndrome of volvulus of the small intestine” (Table I) has been formulated by us from our sixty-two cases and may aid in diagnosis. The observed signs are as follows: (1) Symptoms of shock are generally present and unmistakable. (2) Obstruction Vol. 115, June 1968
TABLE II METHODS AND RESULTS OF SURGICAL TREATMENT OF SIXTY-TWO PATIENTS WITH SMALL INTESTINAL VOLVULUS BETWEEN 1935 AND 1966 Operative
Result
Cure Death Total
Detorsion
Method
Anastomosis
Intestinal Resection
41 4
3 1
13 0
45
4
13
Total 57 5 (8.1 per cent) 62 ____
symptoms, such as abdominal pain, vomiting, and cessation of flatus and evacuation, are observed. (3) In most cases the adbominal distention, increased intestinal peristalsis, and borborygmus, which is usually observed with mechanical obstruction, are not remarkable. (4) Roentgenographically, the so-called obstructive signs, that is, abdominal distention and fluid level, cannot be observed in the majority of the cases. The film show only a gas-negative picture. (5) Intraperitoneal exudate is observed in many cases. (6) Many patients have a history of laparotomy. (7) Leukocytosis is present in many cases. (8) There is no elevation of body temperature. Operations were performed on sixty-two patients, and the results are shown in Table II. Detorsion was carried out in forty-five patients, detorsion with anastomosis in four, and resection of the small intestine in thirteen. A total of five deaths occurred, four after detorsion, and one after anastomosis. The change in mortality between the sixteen years from 1935 to 1950 and the sixteen years from 1951 to 1966 is compared in Table III. In the former period three of 25 patients died (a mortality of 12.0 per cent), but in the latter period only two of thirty-seven patients died (a TABLE III COMPARISON OF RESULTS OF SURGICAL TREATMENT IN SMALL INTESTINAL VOLWLUS FROM THE PERIOD FROM 1935 TO lg.50 AND FROM 1951 TO 1966
Period 1935-1950 1951-1966 Total
Total No. of Cases
No. of Deaths
Mortality (Per cent)
25 37 62
3 2 5
12.0 5.4 8.1
Matsukura
806
mortality of 5.4 per cent). The mortality decreased by nearly half in the latter period, indicating a remarkable improvement in the results of treatment. As a result of statistical observations of sixtytwo cases of small intestinal volvulus, the term “small intestinal volvulus syndrome” was evolved by us, and its diagnosis described. The most important information obtained is from roentgenograms. Since 1940, we have advocated the use of a gas-minus or gas-negative picture, which is entirely different from the hitherto reported pictures of obstruction. Abdominal x-ray findings in acute intestinal obstructions, especially the gas-negative picture of the ileus, will be described. ABDOMINAL
X-RAY
INTESTINAL
FINDINGS
IN
ACUTE
OBSTRUCTION
The roentgenographic diagnosis of an acute abdominal condition is of course made by a scout film examination of the abdomen. The fundamental points are as follows: 1. It is necessary to take a roentgenogram not only of the free gas in the abdominal cavity and the gas in the intestinal loops, but also of the shadows of soft parts, especially the flanks. 2. The roentgenogram should include the diaphragm and the pelvic cavity as well as the flanks, so that it is possible to visualize the whole abdomen.
and Shirota
3. A sagittal projection with the patient in . the supine, upright, and lateral positions, or a horizontal projection with the patient in the supine position, is necessary. Roentgenograms of the patient in the supine and upright positions should be taken, especially with an acute intestinal obstruction. First, thenormal abdominal roentgenographic findings will be discussed as a point of reference. In the hungry adult, gas is present in the stomach and the colon, but not in the small intestine. After a meal, the air swallowed together with the food gathers in the cardia, forming a semilunar stomach bubble under the left hemidiaphragm. In the neonate or in infants, however, gas is always present in the stomach, the small intestine, and the colon. As infants grow, the gas in the small intestine gradually decreases, and at about the age of four or five years it is nearly absent, as in adults. When obstruction occurs in the intestinal canal, gas and liquid are retained in the proximal portion of the canal, exhibiting a typical gas distention of the intestinal loops and fluid level. (Fig. 1.) These effects become visible on roentgenogram about three or four hours after the onset of obstruction, and therefore are the most important aids in early diagnosis. Generally speaking, distention and fluid level of the small intestine with Kerckring’s American
Journal of Surgery
Acute
Abdominal
A
Conditions
807
B
FIG. 2. A, roentgenogram of fifty-seven year old woman (K.K.) in the supine position. The upper part of the jejunum was twisted clockwise by 360 degrees for 70 cm. and was completely necrotic. Recovery was attained by enterectomy, after 1,000 ml. of hemorrhagic ascites was removed. B, roentgenogram of same patient in the upright position shows no gas in the intestinal canal. Shadow in the pelvic cavity indicates the presence of exudate.
folds are observed in the epigastric region of the patients with obstruction of the upper part of the small intestine, and in the mesogastric and hypogastric region and in the pelvic cavity in the patients with obstruction in the lower part of the intestine. When the obstruction occurs in the colon, gas in the small intestine, distention, fluid level, and haustral markings are observed in the upper part of the colon as well. Extremely distended colonic loops and a characteristic S letter or horseshoe appearance are observed, especially in patients with volvulus of the sigmoid colon. Therefore, these x-ray findings are not only the decisive factor in locating the site of obstruction, but also very important in differential diagnoses. In patients with volvulus of the small intestine, however, those characteristic distentions and fluid level are not observed, and instead, as we have emphasized, a gas-minus or gas-negative picture is observed in the majority of cases. (Fig. 2.) A high degree of strangulation and serious mesenteric circulatory disturbance resulting from the volvulus were observed in all cases. Sometimes distention is observed in patients with volvulus of the small intestine. The degree of strangulation is less and the mesenteric circulatory disturbance milder in these patients Vol. 115, June
1968
than in the aforementioned patients in whom a gas-negative picture was obtained. This suggests that the presence of the socalled gas-negative picture is closely related to the degree of strangulation of the intestinal canal and the degree of circulatory disturbance of the involved mesenterium. Detailed clinical and experimental studies were carried out in order to explain under what conditions the characteristic distention and the gas-negative picture are observed. The following four conditions were obtained : 1. The degree of strangulation of the intestinal canal and degree of circulatory disturbance of the involved mesenteric vein have the greatest bearing. When the mesenteric venous flow is stopped while the arterial circulation is maintained, a large amount of exudate is pro-
Inflenrmation Cancer
volvulus
Inlussusception
FIG. 3. Schema of barium enema in large intestinal obstruction.
808
Matsukura
and Shirota
FIG. 4. A, roentgenogram of twenty-three year of woman (S.U.) in the supine position. The patient had adhesive obstruction due to tuberculous peritonitis, and distention of the small intestine with gas is seen. B, roentgenogram of same patient in the upright position. Not seen with the patient in the supine position, pyrethrum-flower (chrysanthemum) appearance is observed in the right epigastric region (arrow). Also, dome-shaped gas distention and fluid levels in the left abdominal regional are visible.
duced in the strangulated canal and the abdominal cavity, and cramp is remarkable in the lower part of the area of obstruction, thus resulting in the gas-negative picture. Distention is manifested in all other cases. 2. The greater the length of strangulated intestinal canal, the more remarkable is the gasnegative picture. 3. The higher the site of strangulation the more remarkable is the gas-negative picture. 4. The more serious the cramp of the intestinal canal on both sides of the obstruction, the more remarkable is the gas-negative picture. A combination of these four conditions seems to decide the presence or absence of gas. Therefore, the gas-negative picture is also observed in patients with other serious complicated obstructions, such as strangulation ileus, intestinal knot formation, internal hernia incarceration, and intussusception. Since the presence of gas-negative picture was pointed out by us in 1940, Ripstein and Miller [1] in 1950, Thorek [Z] in 1956, Moretz and Morton [3] in 1950, Mellins and Rigler [4] in 1954, Frimann-Dahl [5] in 1960, and Williams [6] in 1962 have also confirmed it. The aforementioned points are from the abdominal roentgenographic findings of acute intestinal obstructions noted by scout film examinations.
In the case of intussusception of the cecum or volvulus of the sigmoid colon, or in other cases in which the symptoms develop rather slowly, a barium enema examination or roentgenography with oral administration of a small amount of barium after a scout film examination will not only clarify the site or the cause of the obstruction but also frequently open a way to restore the normal intestine without a surgical operation. In other words, when the colon is filled with the contrast medium, the site of obstruction becomes obvious since the medium does not enter further. Moreover, as shown schematically in Figure 3, the cause of obstruction can be noted by the form of the medium. For example, when the tip of the medium tapers off and shows an irregular “gnawed” contour, the obstruction is considered to be due to cancer of the colon. When the tapering part extends to a considerable length, it is considered to be due to an inflammatory process. When the tip of the medium tapers off like a beak with a smooth contour, becoming sharp with a large amount of the medium and obtuse with a small amount, the obstruction is considered to be due to volvulus. When the tip of the medium is large and is divided into two tapering ends with a crab claw appearance with a central filling defect, the obstruction is considered to be due to intussusception. It is, therefore, preferable in American
Journal of Surgery
Acute
Abdominal
Conditions
A
809
B
FIG. 5. A, roentgenogram of twenty-five year old man (SD.) in the supine position. This patient had paralytic ileus due to suppurating abdominal peritonitis. Remarkable gas distention of the stomach and small intestine are visible. B, roentgenogram of same patient in the upright position. The site of gas distention of the small intestine is not different from that in the supine position.
the case of intussusception or obstruction of the colon, or when the symptoms develop rather slowly, to perform not only a scout film examination, but also contrast roentgenography with a barium enema or oral administration of a small amount of barium. In cases of ileus the characteristic roentgenographic picture which is clinically important has a chrysanthemum-like appearance. (Fig. 4.) This is produced by a shrinkage of the mesenterium, and can often be seen in the case of an adhesion obstruction due to tuberculous or carcinomatous peritonitis. These are all examples of mechanical obstructions, and it must be noted that differences are observed between the roentgenograms taken with the patient in the supine position and those taken with the patient in the upright position. However, it is noteworthy that in the case of a paralytic obstruction no such difference is noted in roentgenograms taken with the patient in the two positions. (Fig. 5.) The absence of gas distention and fluid level, which are the characteristic roentgenographic findings of intestinal obstructions, is often an important sign of a serious complex ileus such as volvulus. Therefore, one must note that it is dangerous to deny an intestinal obstruction simply because of the absence of characteristic roentgenographic findings. Vol. 115. June 1968
In diagnosing an acute intestinal obstruction it is very important to examine the patient’s abdomen thoroughly and to check his general symptoms, as well as to refer to the abdominal x-ray findings, to judge cautiously on the basis of all the available findings, and to give adequate treatment promptly. We will now describe the results of treatment of patients with such acute intestinal obstructions in our department. RESULTS
OF TREATMENT
INTESTINAL
OF ACUTE
OBSTRUCTION
Eight hundred thirty-nine patients with acute mechanical ileus were operated upon during the thirty-two year period from 1935 to 1966 (Table IV.) Seventy-nine of these patients died, giving a mortality of 9.4 per cent. To investigate the change of therapeutic results, the aforementioned period was subdivided into three. In the first period, from June 1935 to November 1950, forty-five of 374 patients died (12.0 per cent mortality); in the second period, from December 1950 to June 1958, twenty-one of 235 patients died (8.8 per cent mortality); and in the third period, from July 1958 to May 1966, thirteen of 230 patients died (5.6 per cent mortality). The mortality with this ailment is also classified according to whether the disorder is simple
Matsukura
810
and Shirota
TABLE RESULTS
OF SURGICAL
TREATMENT
OF 8%
PATIENTS
BETWEEN
19%
ACUTE
AND
MECHANICAL
No. of Cases
No. of Deaths
60 38 31 2 7 138
6 4 4 0 0 14
10.0 10.5 12.9 0 0 10.1
41 23 11 1 11 77
0 3 0 0 0 3
0 13.0 0 0 0 3.8
3 111
3 4 0 1 0 8
62 64 15 3 92 236 374
9 9 4 1 8 31 45
14.5 14.0 26.6 33.3 8.7 13.0 12.0
68 28 21 6 35 158 235
7 2 5 0 4 18 21
10.2 7.1 23.8 0 11.4 11.3 8.9
43 24 30 1 21 119 230
2 1 2 0 0 5 13
No. of Deaths
OBSTRUCTION
Third Period (1958-1966)
MIXtality (Per cent)
No. of Cases
INTESTINAL
1966
Second Period (1950-1958)
First Period (1935-1950)
Type of Mechanical Obstruction
IV WITH
MOrtality (Per cent)
No. of Cases
Total
No. of Deaths
MOKtality (Per cent)
No. of Cases
3.9 16.7 0 50.0 0 7.2
178 85 47 5 11 326
9 11 4 1 0 25
5.0 12.9 8.5 20.0 0 7.7
4.7 4.2 6.7 0 0 4.2 5.6
173 116 66 10 148 513 839
18 12 11 1 12 54 79
10.4 10.4 16.7 10.0 8.1 10.5 9.4
No. of Deaths
MOrtality (Per cent)
Simple Obstruction Adhesive Neoplastic Tuberculous Congenital Other causes Total
Slrangulofed
Obslvuclion
Strangulation v01vu1us Intussusception Knot formation of intestine Strangulated hernia Total Grand total
or complex. For simple ileus, in the first period, fourteen of 138 patients died (10.1 per cent mortality); in the second period three of seventy-seven patients died (3.8 per cent mortality) ; and in the third period, eight of 111 patients died (7.2 per cent mortality). For complex ileus, in the first period, thirty-one of 236 patients died (13.0 per cent mortality); in the second period, eighteen of 158 patients died (11.3 per cent mortality) ; and in the third period, five of 119 died (4.2 per cent mortality). The therapeutic results in our department improved from year to year, as shown in’Table IV; an especially remarkable fall in mortality was observed with simple obstructions, such as adhesion ileus and ileus due to tuberculous disease, and in complex obstructions, such as strangulation ileus in a narrow sense, volvulus, and intussusception. It can be said without exaggeration that in recent years the death rate has been lowered to nearly a half that of the period of ten to twenty years before. Important factors which have contributed to such therapeutic progress in handling intestinal obstructions include the intensive development of antibiotics and an epoch-making advance in anesthesiology. Also, because of the gradual elucidation of the pathophysiology of intestinal obstruction, it has become possible to make an early diagnosis and establish an adequate therapeutic plan. SUMMARY
The
77 24 ;
diagnosis
and treatment
of acute ab-
dominal conditions, with the principal emphasis on abdominal x-ray findings, are discussed. There are various diseases which are classified under the category of acute abdominal conditions, and it is therefore very difficult to make a diagnosis of each of them without making any error. Early diagnosis and adequate treatment are possible if one thoroughly examines the abdominal roentgenographic findings with reference to the various clinical symptoms which accompany the abdominal pain. Needless to say early diagnosis is as important in acute abdominal conditions as it is in any other disease. However, early treatment is postulated even more urgently and the utmost care must be taken not to lose much time in a search for diagnosis, which would thus risk the life of the patient. It is therefore considered necessary to resort to laparotomy without hesitation when a diagnosis of acute abdominal condition is roughly made, even if a more exact and detailed diagnosis is difficult. REFERENCES
1.
and MILLER, G. G. Volvulus of the small intestine. Surgery, 27: 506, 1950. 2. THOREK, P. Surgical Diagnosis. Philadelphia, 1956. J. B. Lippincott Co. 3. MORETZ, W. H. and MORTON, J. J. Acute volvulus of the small intestine. Ann. Swg., 132: 899, 1950. 4. MELLINS, H. 2. and RIGLER, L. G. Roentgen findings in strangulating obstructions of the small intestine. Am. J. Roentgenol., 7: 404, 1954. 5. FRIMANN-DAHL, J. Roentgen Examinations in Acute Abdominal Disease, 2nd ed. Springfield, Ill., 1960. Charles C Thomas. RIPSTEIN,
C.
B.
American Journal of Surgery
Acute Abdominal Conditions 6. WILLIAMS, J. L. Fluid-filled loops in intestinal struction. Am. J. Roentgenol., 88: 677, 1962. ADDITIONAL CITED
EEFEEENCES
ob-
NOT
IN THE TEXT
BRAUN and WORTMANN. Der Darm Verschluss, Berlin 1924. Verlag von Gulius Springer. MATSUKURA, S. Acute intestinal obstruction. J. Japan. S. Sot., 55: 631, 1954. SHIROTA, A. Diagnosis of acute intestinal obstruction and the results of surgical treatment. J. Internat. CoZZ. Surgeons, 41: 590, 1964. SILEN, W., HBIN, M. F., and GOLDMAN, L. Strangulat-
Vol. 115, June 1968
811
ing obstruction of the small intestine. Arch. Surg., 85: 137, 1962. TENDLER, M. J. and CART~RIGHT, R. S. Acute intestinal obstruction: a re-evaluation of therapy. Review of thirty-one years at a University Hospital. J.
Louisiana Slate M. Sot., 108: 4, 1956. TURNER, J. C., DEARING, W. H., and JUDD, E. S. Postoperative morbidity and mortality in intestinal obstruction. Comparative study of 100 consecutive cases from each of the past three decades. Ann. Surg., 147: 33, 1953. WALDRON, G. W. and HAMPTON, J. M. Intestinal obstruction: a half century of comparative analysis. Ann. Surg., 147: 33, 1961.
From the Department Tokyo, Japan.
Conditions with Special
to Roentgenographic
MATSUKURA,
of Surgery,
Nippon
Findings
M.D. AND AKIRO SHIROTA,M.D., Tokyo, Japan
Medical
School,
However, intestinal obstruction is still ranked second after appendicitis, and can be regarded as a representative acute abdominal disease. In this paper we will discuss the diagnosis and results of treatment of acute abdominal conditions, mainly on the basis of abdominal x-ray findings.
the field of surgery many acute abdominal conditions begin simply with the complaint of abdominal pain. However, the surgeon must diagnose the complaint early and treat it adequately. Furthermore, the character of the abdominal pain does not always agree with the pathoanatomic findings, and there are many other extra-abdominal diseases in which the complaint of abdominal pain is present. It is, therefore, not so easy to make a correct diagnosis simply on the basis of the chief complaint of abdominal pain. The most important reference in diagnosing an acute abdominal disorder is that of the abdominal x-ray findings. During the thirtytwo years from 1935 to 1966, 13,540 patients were admitted to our department and underwent laparotomy. Of these, 7,504 (55.4 per cent), or about half of the patients with laparotomy, had the so-called “acute abdomen” with the chief complaint of abdominal pain, and they had to undergo emergency operation. The main acute abdominal conditions in this group were acute appendicitis, 5,814 cases (77.5 per cent), and acute intestinal obstruction, 839 cases (11.2 per cent), all other diseases accounting for about 11 per cent. The incidence of intestinal obstructions, especially postoperatively, has recently decreased remarkably. The rate of intestinal obstructions in patients with acute abdominal conditions was 16.2 per cent for the sixteen year period from 1935 to 1950, but only 8.9 per cent for the sixteen years from 1951 to 1966.
I
of Acute
N
DIAGNOSIS OF ACUTEINTESTINAL OBSTRUCTION Acute intestinal obstruction should be diagnosed from the patient’s history and present condition, general physical condition, and especially the abdominal findings. However, the causes, sites, and types of intestinal obstruction vary so widely that it is not easy to make the correct diagnosis for each case. Generally speaking, a complex intestinal obstruction is far more difficult to diagnose than a simple one. Furthermore, with the complex obstruction the clinical progression is much more rapid than with the simple obstruction, so that if too much time is spent on the diagnosis, the patient’s life may be endangered. As a representative type of acute intestinal obstruction, we will discuss volvulus of the small intestine, which is not only the most difficult one to diagnose, but also often progresses rapidly and carries an unfavorable prognosis. Of 839 patients with acute mechanical obstruction who were operated upon in our department during the thirty-two years from 1935 to 1966, sixty-two had volvulus of the small intestine. Correct preoperative diagnoses were made in only nineteen cases, whereas the re804
American
Journal
of Surgery
805 TABLE I SYMPTOMCOMPLEX IN SMALL INTESTINAL VOLVULUS
Symptom
Complex
Shock symptoms Mechanical ileus symptoms Local abdominal signs Abdominal x-ray findings Peritoneal exudate History of abdominal operation Leukocytosis Temperature rise
Positive (Per cent)
Negative (Per cent)
100.0 100.0 14.0 17.0 63.0 74.3 91.4 0
0 0 86.0 83.0 37.0 25.7 8.6 100.0
maining cases were diagnosed as strangulation (nineteen patients), adhesion (six patients), or merely obstruction (seventeen patients). Another case was simply noted as “acute abdomen.” This suggests the diagnostic difficulty of this ailment. Some pertinent diagnostic information is as follows : 1. The incidence of volvulus in our department was 116 cases in 839 patients. The site of volvulus was the small intestine in sixty-two patients, including one in whom the whole small intestine, cecum, ascending colon, and part of the transverse colon were involved. The sigmoid colon was involved in forty-seven patients, and the cecum in seven. Thus, volvulus of the small intestine represents the majority of cases, 2. It has been reported that sex and age bear a close relation to the occurrence of volvulus. The disease predominated in males, there being forty-four male and eighteen female patients in our series. Also, patients with involvements of the small intestine were younger than those with lesions of the sigmoid, which occur later in life. 3. A rotation of 360 degrees was observed in thirty-six patients, the greatest rotation being 720 degrees (four patients). In forty-two patients the rotation was clockwise, and in twenty counterclockwise. 4. Symptoms of volvulus cannot be found in the textbooks, and the diagnosis is considered to be very difficult except for experienced specialists. In view of this a “syndrome of volvulus of the small intestine” (Table I) has been formulated by us from our sixty-two cases and may aid in diagnosis. The observed signs are as follows: (1) Symptoms of shock are generally present and unmistakable. (2) Obstruction Vol. 115, June 1968
TABLE II METHODS AND RESULTS OF SURGICAL TREATMENT OF SIXTY-TWO PATIENTS WITH SMALL INTESTINAL VOLVULUS BETWEEN 1935 AND 1966 Operative
Result
Cure Death Total
Detorsion
Method
Anastomosis
Intestinal Resection
41 4
3 1
13 0
45
4
13
Total 57 5 (8.1 per cent) 62 ____
symptoms, such as abdominal pain, vomiting, and cessation of flatus and evacuation, are observed. (3) In most cases the adbominal distention, increased intestinal peristalsis, and borborygmus, which is usually observed with mechanical obstruction, are not remarkable. (4) Roentgenographically, the so-called obstructive signs, that is, abdominal distention and fluid level, cannot be observed in the majority of the cases. The film show only a gas-negative picture. (5) Intraperitoneal exudate is observed in many cases. (6) Many patients have a history of laparotomy. (7) Leukocytosis is present in many cases. (8) There is no elevation of body temperature. Operations were performed on sixty-two patients, and the results are shown in Table II. Detorsion was carried out in forty-five patients, detorsion with anastomosis in four, and resection of the small intestine in thirteen. A total of five deaths occurred, four after detorsion, and one after anastomosis. The change in mortality between the sixteen years from 1935 to 1950 and the sixteen years from 1951 to 1966 is compared in Table III. In the former period three of 25 patients died (a mortality of 12.0 per cent), but in the latter period only two of thirty-seven patients died (a TABLE III COMPARISON OF RESULTS OF SURGICAL TREATMENT IN SMALL INTESTINAL VOLWLUS FROM THE PERIOD FROM 1935 TO lg.50 AND FROM 1951 TO 1966
Period 1935-1950 1951-1966 Total
Total No. of Cases
No. of Deaths
Mortality (Per cent)
25 37 62
3 2 5
12.0 5.4 8.1
Matsukura
806
mortality of 5.4 per cent). The mortality decreased by nearly half in the latter period, indicating a remarkable improvement in the results of treatment. As a result of statistical observations of sixtytwo cases of small intestinal volvulus, the term “small intestinal volvulus syndrome” was evolved by us, and its diagnosis described. The most important information obtained is from roentgenograms. Since 1940, we have advocated the use of a gas-minus or gas-negative picture, which is entirely different from the hitherto reported pictures of obstruction. Abdominal x-ray findings in acute intestinal obstructions, especially the gas-negative picture of the ileus, will be described. ABDOMINAL
X-RAY
INTESTINAL
FINDINGS
IN
ACUTE
OBSTRUCTION
The roentgenographic diagnosis of an acute abdominal condition is of course made by a scout film examination of the abdomen. The fundamental points are as follows: 1. It is necessary to take a roentgenogram not only of the free gas in the abdominal cavity and the gas in the intestinal loops, but also of the shadows of soft parts, especially the flanks. 2. The roentgenogram should include the diaphragm and the pelvic cavity as well as the flanks, so that it is possible to visualize the whole abdomen.
and Shirota
3. A sagittal projection with the patient in . the supine, upright, and lateral positions, or a horizontal projection with the patient in the supine position, is necessary. Roentgenograms of the patient in the supine and upright positions should be taken, especially with an acute intestinal obstruction. First, thenormal abdominal roentgenographic findings will be discussed as a point of reference. In the hungry adult, gas is present in the stomach and the colon, but not in the small intestine. After a meal, the air swallowed together with the food gathers in the cardia, forming a semilunar stomach bubble under the left hemidiaphragm. In the neonate or in infants, however, gas is always present in the stomach, the small intestine, and the colon. As infants grow, the gas in the small intestine gradually decreases, and at about the age of four or five years it is nearly absent, as in adults. When obstruction occurs in the intestinal canal, gas and liquid are retained in the proximal portion of the canal, exhibiting a typical gas distention of the intestinal loops and fluid level. (Fig. 1.) These effects become visible on roentgenogram about three or four hours after the onset of obstruction, and therefore are the most important aids in early diagnosis. Generally speaking, distention and fluid level of the small intestine with Kerckring’s American
Journal of Surgery
Acute
Abdominal
A
Conditions
807
B
FIG. 2. A, roentgenogram of fifty-seven year old woman (K.K.) in the supine position. The upper part of the jejunum was twisted clockwise by 360 degrees for 70 cm. and was completely necrotic. Recovery was attained by enterectomy, after 1,000 ml. of hemorrhagic ascites was removed. B, roentgenogram of same patient in the upright position shows no gas in the intestinal canal. Shadow in the pelvic cavity indicates the presence of exudate.
folds are observed in the epigastric region of the patients with obstruction of the upper part of the small intestine, and in the mesogastric and hypogastric region and in the pelvic cavity in the patients with obstruction in the lower part of the intestine. When the obstruction occurs in the colon, gas in the small intestine, distention, fluid level, and haustral markings are observed in the upper part of the colon as well. Extremely distended colonic loops and a characteristic S letter or horseshoe appearance are observed, especially in patients with volvulus of the sigmoid colon. Therefore, these x-ray findings are not only the decisive factor in locating the site of obstruction, but also very important in differential diagnoses. In patients with volvulus of the small intestine, however, those characteristic distentions and fluid level are not observed, and instead, as we have emphasized, a gas-minus or gas-negative picture is observed in the majority of cases. (Fig. 2.) A high degree of strangulation and serious mesenteric circulatory disturbance resulting from the volvulus were observed in all cases. Sometimes distention is observed in patients with volvulus of the small intestine. The degree of strangulation is less and the mesenteric circulatory disturbance milder in these patients Vol. 115, June
1968
than in the aforementioned patients in whom a gas-negative picture was obtained. This suggests that the presence of the socalled gas-negative picture is closely related to the degree of strangulation of the intestinal canal and the degree of circulatory disturbance of the involved mesenterium. Detailed clinical and experimental studies were carried out in order to explain under what conditions the characteristic distention and the gas-negative picture are observed. The following four conditions were obtained : 1. The degree of strangulation of the intestinal canal and degree of circulatory disturbance of the involved mesenteric vein have the greatest bearing. When the mesenteric venous flow is stopped while the arterial circulation is maintained, a large amount of exudate is pro-
Inflenrmation Cancer
volvulus
Inlussusception
FIG. 3. Schema of barium enema in large intestinal obstruction.
808
Matsukura
and Shirota
FIG. 4. A, roentgenogram of twenty-three year of woman (S.U.) in the supine position. The patient had adhesive obstruction due to tuberculous peritonitis, and distention of the small intestine with gas is seen. B, roentgenogram of same patient in the upright position. Not seen with the patient in the supine position, pyrethrum-flower (chrysanthemum) appearance is observed in the right epigastric region (arrow). Also, dome-shaped gas distention and fluid levels in the left abdominal regional are visible.
duced in the strangulated canal and the abdominal cavity, and cramp is remarkable in the lower part of the area of obstruction, thus resulting in the gas-negative picture. Distention is manifested in all other cases. 2. The greater the length of strangulated intestinal canal, the more remarkable is the gasnegative picture. 3. The higher the site of strangulation the more remarkable is the gas-negative picture. 4. The more serious the cramp of the intestinal canal on both sides of the obstruction, the more remarkable is the gas-negative picture. A combination of these four conditions seems to decide the presence or absence of gas. Therefore, the gas-negative picture is also observed in patients with other serious complicated obstructions, such as strangulation ileus, intestinal knot formation, internal hernia incarceration, and intussusception. Since the presence of gas-negative picture was pointed out by us in 1940, Ripstein and Miller [1] in 1950, Thorek [Z] in 1956, Moretz and Morton [3] in 1950, Mellins and Rigler [4] in 1954, Frimann-Dahl [5] in 1960, and Williams [6] in 1962 have also confirmed it. The aforementioned points are from the abdominal roentgenographic findings of acute intestinal obstructions noted by scout film examinations.
In the case of intussusception of the cecum or volvulus of the sigmoid colon, or in other cases in which the symptoms develop rather slowly, a barium enema examination or roentgenography with oral administration of a small amount of barium after a scout film examination will not only clarify the site or the cause of the obstruction but also frequently open a way to restore the normal intestine without a surgical operation. In other words, when the colon is filled with the contrast medium, the site of obstruction becomes obvious since the medium does not enter further. Moreover, as shown schematically in Figure 3, the cause of obstruction can be noted by the form of the medium. For example, when the tip of the medium tapers off and shows an irregular “gnawed” contour, the obstruction is considered to be due to cancer of the colon. When the tapering part extends to a considerable length, it is considered to be due to an inflammatory process. When the tip of the medium tapers off like a beak with a smooth contour, becoming sharp with a large amount of the medium and obtuse with a small amount, the obstruction is considered to be due to volvulus. When the tip of the medium is large and is divided into two tapering ends with a crab claw appearance with a central filling defect, the obstruction is considered to be due to intussusception. It is, therefore, preferable in American
Journal of Surgery
Acute
Abdominal
Conditions
A
809
B
FIG. 5. A, roentgenogram of twenty-five year old man (SD.) in the supine position. This patient had paralytic ileus due to suppurating abdominal peritonitis. Remarkable gas distention of the stomach and small intestine are visible. B, roentgenogram of same patient in the upright position. The site of gas distention of the small intestine is not different from that in the supine position.
the case of intussusception or obstruction of the colon, or when the symptoms develop rather slowly, to perform not only a scout film examination, but also contrast roentgenography with a barium enema or oral administration of a small amount of barium. In cases of ileus the characteristic roentgenographic picture which is clinically important has a chrysanthemum-like appearance. (Fig. 4.) This is produced by a shrinkage of the mesenterium, and can often be seen in the case of an adhesion obstruction due to tuberculous or carcinomatous peritonitis. These are all examples of mechanical obstructions, and it must be noted that differences are observed between the roentgenograms taken with the patient in the supine position and those taken with the patient in the upright position. However, it is noteworthy that in the case of a paralytic obstruction no such difference is noted in roentgenograms taken with the patient in the two positions. (Fig. 5.) The absence of gas distention and fluid level, which are the characteristic roentgenographic findings of intestinal obstructions, is often an important sign of a serious complex ileus such as volvulus. Therefore, one must note that it is dangerous to deny an intestinal obstruction simply because of the absence of characteristic roentgenographic findings. Vol. 115. June 1968
In diagnosing an acute intestinal obstruction it is very important to examine the patient’s abdomen thoroughly and to check his general symptoms, as well as to refer to the abdominal x-ray findings, to judge cautiously on the basis of all the available findings, and to give adequate treatment promptly. We will now describe the results of treatment of patients with such acute intestinal obstructions in our department. RESULTS
OF TREATMENT
INTESTINAL
OF ACUTE
OBSTRUCTION
Eight hundred thirty-nine patients with acute mechanical ileus were operated upon during the thirty-two year period from 1935 to 1966 (Table IV.) Seventy-nine of these patients died, giving a mortality of 9.4 per cent. To investigate the change of therapeutic results, the aforementioned period was subdivided into three. In the first period, from June 1935 to November 1950, forty-five of 374 patients died (12.0 per cent mortality); in the second period, from December 1950 to June 1958, twenty-one of 235 patients died (8.8 per cent mortality); and in the third period, from July 1958 to May 1966, thirteen of 230 patients died (5.6 per cent mortality). The mortality with this ailment is also classified according to whether the disorder is simple
Matsukura
810
and Shirota
TABLE RESULTS
OF SURGICAL
TREATMENT
OF 8%
PATIENTS
BETWEEN
19%
ACUTE
AND
MECHANICAL
No. of Cases
No. of Deaths
60 38 31 2 7 138
6 4 4 0 0 14
10.0 10.5 12.9 0 0 10.1
41 23 11 1 11 77
0 3 0 0 0 3
0 13.0 0 0 0 3.8
3 111
3 4 0 1 0 8
62 64 15 3 92 236 374
9 9 4 1 8 31 45
14.5 14.0 26.6 33.3 8.7 13.0 12.0
68 28 21 6 35 158 235
7 2 5 0 4 18 21
10.2 7.1 23.8 0 11.4 11.3 8.9
43 24 30 1 21 119 230
2 1 2 0 0 5 13
No. of Deaths
OBSTRUCTION
Third Period (1958-1966)
MIXtality (Per cent)
No. of Cases
INTESTINAL
1966
Second Period (1950-1958)
First Period (1935-1950)
Type of Mechanical Obstruction
IV WITH
MOrtality (Per cent)
No. of Cases
Total
No. of Deaths
MOKtality (Per cent)
No. of Cases
3.9 16.7 0 50.0 0 7.2
178 85 47 5 11 326
9 11 4 1 0 25
5.0 12.9 8.5 20.0 0 7.7
4.7 4.2 6.7 0 0 4.2 5.6
173 116 66 10 148 513 839
18 12 11 1 12 54 79
10.4 10.4 16.7 10.0 8.1 10.5 9.4
No. of Deaths
MOrtality (Per cent)
Simple Obstruction Adhesive Neoplastic Tuberculous Congenital Other causes Total
Slrangulofed
Obslvuclion
Strangulation v01vu1us Intussusception Knot formation of intestine Strangulated hernia Total Grand total
or complex. For simple ileus, in the first period, fourteen of 138 patients died (10.1 per cent mortality); in the second period three of seventy-seven patients died (3.8 per cent mortality) ; and in the third period, eight of 111 patients died (7.2 per cent mortality). For complex ileus, in the first period, thirty-one of 236 patients died (13.0 per cent mortality); in the second period, eighteen of 158 patients died (11.3 per cent mortality) ; and in the third period, five of 119 died (4.2 per cent mortality). The therapeutic results in our department improved from year to year, as shown in’Table IV; an especially remarkable fall in mortality was observed with simple obstructions, such as adhesion ileus and ileus due to tuberculous disease, and in complex obstructions, such as strangulation ileus in a narrow sense, volvulus, and intussusception. It can be said without exaggeration that in recent years the death rate has been lowered to nearly a half that of the period of ten to twenty years before. Important factors which have contributed to such therapeutic progress in handling intestinal obstructions include the intensive development of antibiotics and an epoch-making advance in anesthesiology. Also, because of the gradual elucidation of the pathophysiology of intestinal obstruction, it has become possible to make an early diagnosis and establish an adequate therapeutic plan. SUMMARY
The
77 24 ;
diagnosis
and treatment
of acute ab-
dominal conditions, with the principal emphasis on abdominal x-ray findings, are discussed. There are various diseases which are classified under the category of acute abdominal conditions, and it is therefore very difficult to make a diagnosis of each of them without making any error. Early diagnosis and adequate treatment are possible if one thoroughly examines the abdominal roentgenographic findings with reference to the various clinical symptoms which accompany the abdominal pain. Needless to say early diagnosis is as important in acute abdominal conditions as it is in any other disease. However, early treatment is postulated even more urgently and the utmost care must be taken not to lose much time in a search for diagnosis, which would thus risk the life of the patient. It is therefore considered necessary to resort to laparotomy without hesitation when a diagnosis of acute abdominal condition is roughly made, even if a more exact and detailed diagnosis is difficult. REFERENCES
1.
and MILLER, G. G. Volvulus of the small intestine. Surgery, 27: 506, 1950. 2. THOREK, P. Surgical Diagnosis. Philadelphia, 1956. J. B. Lippincott Co. 3. MORETZ, W. H. and MORTON, J. J. Acute volvulus of the small intestine. Ann. Swg., 132: 899, 1950. 4. MELLINS, H. 2. and RIGLER, L. G. Roentgen findings in strangulating obstructions of the small intestine. Am. J. Roentgenol., 7: 404, 1954. 5. FRIMANN-DAHL, J. Roentgen Examinations in Acute Abdominal Disease, 2nd ed. Springfield, Ill., 1960. Charles C Thomas. RIPSTEIN,
C.
B.
American Journal of Surgery
Acute Abdominal Conditions 6. WILLIAMS, J. L. Fluid-filled loops in intestinal struction. Am. J. Roentgenol., 88: 677, 1962. ADDITIONAL CITED
EEFEEENCES
ob-
NOT
IN THE TEXT
BRAUN and WORTMANN. Der Darm Verschluss, Berlin 1924. Verlag von Gulius Springer. MATSUKURA, S. Acute intestinal obstruction. J. Japan. S. Sot., 55: 631, 1954. SHIROTA, A. Diagnosis of acute intestinal obstruction and the results of surgical treatment. J. Internat. CoZZ. Surgeons, 41: 590, 1964. SILEN, W., HBIN, M. F., and GOLDMAN, L. Strangulat-
Vol. 115, June 1968
811
ing obstruction of the small intestine. Arch. Surg., 85: 137, 1962. TENDLER, M. J. and CART~RIGHT, R. S. Acute intestinal obstruction: a re-evaluation of therapy. Review of thirty-one years at a University Hospital. J.
Louisiana Slate M. Sot., 108: 4, 1956. TURNER, J. C., DEARING, W. H., and JUDD, E. S. Postoperative morbidity and mortality in intestinal obstruction. Comparative study of 100 consecutive cases from each of the past three decades. Ann. Surg., 147: 33, 1953. WALDRON, G. W. and HAMPTON, J. M. Intestinal obstruction: a half century of comparative analysis. Ann. Surg., 147: 33, 1961.