Roentgen evidence of adhesions of the small intestine

ROENTGEN

ADHESIONS HORACE W.

EVIDENCE OF

OF THE SMALL INTESTINE*

SOPER, M.D.,

AND

J. WILLIAM

THOMPSON,

M.D.

ST. LOUIS, MO.

I

N this paper we wish to direct attention to the possibihty of x-ray diagnosis and operative correction of adhesions

typical pattern of small intestine folIowing appendectomy, of type that produces no symptoms. Five and one-half hour observation.

FIG. I. A

invoIving the smaI1 intestine. The growing interest in roentgen diagnosis of smaI1 intestina1 states is attested by the papers of KornbIum’ and Ritvo.2 The technic is described in Soper’s recent article. Adhesions may be divided into 3 classes. The vast majority are postoperative in character but some are produced by former inffammatory processes. We have designated the usua1 adhesions that foIIow appendectomy as Grade I. In this type the coiIs of the termina1 iIeum are matted together; i.e., adherent to each other. No symptoms are produced by this form. In adhesions of Grade 2 one or more bands are formed which attach a coil of * Submitted

the gut to some neighboring organ or to the abdomina1 waI1. This type may produce no symptoms. However, it forms a trap that

FIG. 2. Another case producing atypicaI pattern that foIlowed appendectomy. pathoIogica1.

to

be

regarded

as

may catch a Ioop of the bowel and produce acute obstruction. Often a patient gives a history of severa attacks of partia1 obstruction, with compIete absence of symptoms between the attacks. The most careful x-ray examination may fai1 to disclose these bands, but the alert observer wiI1 usuaIIy find atypica1 dilated coils. Adhesions of Grade 3 form definite bands which bind down the intestine and form a partia1 stenosis of the Iumen and interfere with function, as iIIustrated by the adhesive’ bands that constrict the termina1 ileum. This type is more easiIy demonstrated by roentgen examination. The symptoms are usuaIIy duI1 pain Iocated

for pubIication 243

Not

June IO, 1930.

FIG. 3. Atypical pattern of smaIl intestine foIlowing appendectomy not regarded as pathoIogica1. Patient, however, devetoped definite attacks of partia1 obstruction and operation disclosed definite adhesive bands binding down termina1 iIeum. This case is of extreme importance inasmuch as it iIIustrates that we are justified in operating on basis of history aIone when no real x-ray evidence is presented.

FIG. g. Twenty-four hour stasis of termina1 iIeum foIIowing attacks of appendicitis. Operation discIosed strong band binding down appendix and iIeum at ileocecal valve.

FIG. 4. Twenty-four hour ilea stasis. Young woman who had severa attacks of partial obstruction following operation for gaIlstones one year ago. Operation strongly advised but decIined unti1 acute compIete obstruction had occurred necessitating immediate surgery. Strong fibrous hands Iocated in ileum. Exitus.

FIG. 6. Partial obstruction of lower iIeum due to MeckeI’s diverticulum. Operation disclosed severa Ioops of ileum attached to diverticulum. hlaIe, aged nineteen years, a chronic invaIid for past two years. He was much emaciated. Note diIatation and saccuIation of ileum on six-hour fiIms, aIso gastric motor delay. Now three years after operation and he has remained in perfect health.

FIG. 7. Patient femaIe, aged fifty-two, had expIoratory abdominal section in 1925 with negative results. Came under our observation in 1927. Atypical loops observed on six-hour film. Patient had suffered from attacks of partia1 intestina1 obstruction since operation. Second operation revealed a band about 3 ft. from ileocecal junction. Good operative recovery. (Lower arrow marks narrowing corresponding to exact Iocation of band.)

Frc. 9. Adhesive bands invoIving lower ileum. Atypical loops were best seen at five and a haIf hour observation. There was no twenty-four hour iIea1 stasis. Operation disctosed a pathologica appendix adhering to termina1 iIeum in such a way as to cause a kinking which resulted in partial obstruction of bowe1. This patient, a femaIe, aged forty years, gave a history of attacks of appendicitis as well as attacks of partial obstruction.

FIG. 8. Same patient as in Figure 7. Norma1 intestinal Ioops three months after operation.

FIG. IO. Same patient as in Figure 9. Film secured six Norma1 intestinal loops. weeks after operation. Patient made perfect recovery and has had no symptoms for past two years.

FIG. II. Two years ago this patient, a robust young man was operated upon for appendicitis. He compIained of pain Iocated at upper part of abdomina1 scar corresponding to diIated Ioop depicted on fiIm. No history of obstruction. Second operation discIosed an adhesive band binding down a Ioop of iIeum. Perfect recovery.

FIG. 12. Atypical loops which apparently indicated adhesions invoIving terminal iIeum. At operation no adhesions found invoIving smaI1 intestine but a strong band caused partia1 stenosis of ascending coIon at junction with cecum. Case of Mill’s recoil phenomenon.

FIG. 13. One year after appendectomy. Patient had succession of attacks of partiai obstruction. At operation firm fibrous bands bound down termina1 ileum. Good recovery.

FIG. 14. Patient, female, aged thirty, operated upon three years ago for pelvic condition. Again one year later for adhesions. She had several attacks of partial obstruction and because of her compIaints and good genera1 condition she was rated as postoperative neurotic. This fiIm secured at six and one-half hour period. Third operation discIosed four definite adhesive bands of Grade 3. One year after operation and she is free from symptoms.

FIG. 15. These atypica1 patterns secured in patient suffering from attack of acute cholecystitis. At operation no adhesions were found. Atypical loops probabIy resuIted from general disturbance in gastrointestina1 motility induced by severe pain. One must not judge smaI1 intestina1 patterns during abdomina1 pain or migraine attack.

16. Patient had uterine suspension operation ten years ago. Acute intestinal obstruction occurred Nov. g, 1929. Operation disclosed strong band binding down the terminal ileum. Loop tremendously distended and congested; no resection done. Dec. 27, 1929 when patient was having mild attacks of acute obstruction. Final good function foIlowed mild laxatives and smooth diet.

FIG. 17. Same patient as Figure 16. Review of her history discIosed symptoms of dysfunction of smaU intestine. This film was made three years ago and reveals atypical loops which were not recognized at that time.

FIG. 19. This fiIm was secured prior to the operation FIG. 18. Appendix

operation two years ago. Colicky pains, nausea and vomiting attacks since. Roentgen examination showed atypica1 duodenal pattern as barium was Ieaving stomach. At operation duodenal Ioop found to be adherent to abdominat waI1. Good recovery.

FIG. 20. In reviewing

her history we can read partia1 obstruction. This six-hour fiIm taken in 1924 with gastric motor insuffciency, duodena1 cap deformity and atypica1 Ioops expIains many of her attacks which were erroneousIy attributed to gaIlstones.

in patient aged sixty-five. Had suffered from duodenaIuIcer and gaIIstones but refused surgery. Stones can be seen in upper right quadrant. The gallstone attacks aIways atypical in character. She suddenIy deveIoped symptoms of very acute obstruction and was operated upon. Lower dilated loop designated by arrow found to be jejunum. Bowel was aImost gangrenous but circulation returned and resection was not done. Good recovery. Her origina operation was for uterine suspension twenty years ago.

I his rrlm shows a tremendous distension of entire smaI1 intestine taken just before operation. Genera1 peritonitis present. No obstruction. It is obviousIy characteristic of i1eu.s.

FIG. 21.

22. Patient femaIe, aged fifty-one. Entered St. Luke’s Hospital with symptoms of acute intestinal obstruction April 2, 1929. Eighteen months ago her kidney was removed and peritonitis deveIoped. This film was secured and operation advised but declined. She eventuaIIy recovered from attack, but atypical pattern remains and doubtIess other attacks wiI1 occur.

FIG.

FIG. 23. This is position of smaI1 intestine assumed in postoperative hernia following operation for pus appendix one year ago. No obstructive sym!xoms. No operation advised.

FIG. 24. AtypicaI loops occurring in case of achyIia gastrica with diarrhea. making a diagnosis of atypica1 patterns in diarrhea conditions.

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One shouId be extremely

carefu1 of

Soper & Thompson-Intestinal

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in the region of the constriction, intermittent in character, often nausea and anorexia. A history of partiaI attacks of obstruction is usualIy obtained. It is obvious that adhesions of a11 3 types may exist in the same patient. We present x-ray fiIms iIIustrating the various types. The attached Iegends give an epitome of the case history. that operative interWe emphasize ference is not advised unIess the cIinica1 history is clear. Concise statements may be diflicuIt to elicit in a psychotic individua1, but we are confident that this procedure wiI1 rescue many patients who are diagnosed as suffering from a postoperative neurosis. OPERATIVE

TECHNIC

SpinaI anesthesia is of extreme importance, inasmuch as it produces perfect reIaxation of the intestine and the colIapsed gut is easiIy handled, thus preventing trauma. At operation the termina1 iIeum is identified near the iIeoceca1 valve and it is carefuIIy foIIowed back toward the jejunum and the abnorma1 attachments dissected free. Any eviscerated Ioops are carefuIIy covered with moist gauze sponges made from cotton of fine weave. The bowel is aIways manipuIated with the utmost gentIeness and respect for its property of producing an inflammatory exudate which results in aggIutination of the peritonea1 surfaces of the Ioops. The abdomen is then closed without drainage, care being taken to pIace the omentum between the intestine and the abdominal waI1 to prevent them from becoming adherent. The postoperative treatment is of extreme importance, We must avoid every thing that might incite peristaItic movement of the smaIf intestine. During the first seventy-two hours after operation

Adhesions

rules must be rigidIy the folIowing enforced. I. No food or water is given by mouth. FrequentIy moisten the tongue and lips with coId water. 2. The patient is sustained by the free use of intravenous gIucose and saIine soIution. 3. No vomiting is permitted. The Levin intranasal catheter is kept in the stomach and the contents syphoned unti1 a11 danger from accumuIation of gastric secretion is over. 4. No enema or passage of the coIon tube is permitted. 5. No Iaxative is given. The patient is kept under the constant inffuence of morphine. It is given hypodermaticaIIy by the overIapping method, i.e., every four to six hours in doses sufficient to produce mentaI caIm and physica rest. The dosage wiI1 vary from one-twelfth to one-fourth grain. Care must be exercised that the patient does not emerge from the morphia influence unti1 the seventy-two hour period has eIapsed. After this time the usua1 symptomatic treatment is employed. CONCLUSIONS I. Adhesions of the smaI1 intestine that give symptoms can as a ruIe be detected by careful roentgen examination. 3. ReIief may be obtained by surgica1 operation and strict observance of a postoperative regime. 3. X-ray fiIms are shown iIIustrating the diagnosis and differentia1 diagnosis of adhesions, with abstract of case records. REFERENCES

K. The significance of smaII intestina1 stasis. J. Radiol., 13: 17, Igzg. 2. RITVO, M. Roentgen diagnosis of Iesions of the jejunum atid ileum. Am. J. Roencgaol., 23: No. 2, I. KORNBLUM,

1930.

3. SOPER, H. W. The roentgen-ray

diagnosis of Iesions of the smaII intestine. Am. J. Roentgenof., zz: No. 2. iOi”IIg,

1929.