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The Management of the Acute Abdomen
The Management of the Acute Abdomen 'v.
ROSS McCARTY, M.D., F.A.C.S.*
TRAUMA
injuries constitute a large part of the practice of the general medical practitioner, especially those who, of necessity, must combine surgery with medicine. The accident rate, in this high powered motor age, is ever increasing. The changing picture of world events with the possibility of civilian catastrophes in this atomic age, together with the increase in civilian defense activities, clearly emphasizes the importance of this subject. This presentation will attempt to review only the emergencies that may occur within the abdominal cavity, and for brevity, the problems of urology, gynecology, and the associated chest and skeletal injuries have been omitted. It is assumed that the techniques of shock therapy are clearly understood, that diagnostic x-ray studies be fully utilized, and that patients with contaminated wounds will be adequately protected by antibiotics. It seems important that we re-evaluate the type of injuries occurring in our modern age, review the essential points for early diagnosis, and consider the changing needs in their surgical management. Abdominal emergencies may arise from injuries to the intra-abdominal viscera caused by direct trauma to the abdominal wall without penetration, and from injuries to these viscera resulting from penetration of the abdominal wall. TRAUMATIC
Nonpenetrating Injuries
It is important to realize that any organ in the abdomen may be injured or ruptured without external signs of violence. Early diagnosis and treatment are imperative whenever intra-abdominal trauma is suspected, followed by frequent evaluation in an ever changing picture. If intraperitoneal injury is suspected, it is generally unwise to delay opening the abdomen. If rigidity of the abdominal wall is present it is wiser to explore the abdomen than to wait until the diagnosis is clearly defined. In all
* Associate Professor of Surgery, New York University College of Medicine; Visiting Surgeon, Third Surgical Division, and Attending Surgeon, Univers1~ty Hospital, New York University-Bellevue Medical Center, New York, N.Y. 78,9
790
w. Ross McCarty
cases injury to the kidneys, ureters, bladder and urethra may be ruled out by early intravenous pyelograms and the -passing of a catheter. If a definite diagnosis is not possible without exploration, the operative approach can be made through a small midline upper abdominal incision. 'l'his incision is preferred because with it the contents of the upper abdomen can be inspected easily and the injury, if any, quickly identified. If the site of the incision is appropriate adequate extension will generally be possible, but if the incision proves inadequate it can be closed rapidly and a more adequate approach accolnplished. If a traumatic hemoperitoneum is encountered bear in nlind the old aphorism, "follow the clots," and the source will be apparent. A routine of examination should be followed systematically in all cases: the spleen, and splenic pedicle, the liver, gallbladder and bile ducts, the foramen of Winslo\vand head of the pancreas, the kidneys, pelvic organs, the stomach, small and large intestine with special attention to the leaves of the mesentery. The lesser sac should be opened to exanline the body of the pancreas, and the retroperitoneal spaces inspected for hematomas. Rupture of the spleen is perhaps one of the most common major injuries caused by nonpenetrating violence. The diagnosis is usually made by a history of injury, especially to the left upper quadrant; the presence of early shoulder pain, abdominal pain and tenderness; and evidence of internal bleeding. However, in minor lacerations, the symptoms may be delayed and severe internal hemorrhage may not be immediately in evidence. It is worth while noting that in the early phase an abdominal tap may not give any indication of free blood in the abdominal cavity, as the blood clot may be localized in the left upper quadrant. Most splenic injuries occur in healthy spleens; and by splitting the splenic renalligaments with one's finger, one may accomplish rapid mobilization and removal of the organ. Mass ligation of the splenic pedicle is avoided. The pancreas is deeply seated anatomically, hence is usually protected from blunt injury. However, direct blows to the abdominal wall, especially when the body is partly flexed, may impinge an intra-abdominal organ between the solid vertebra and the striking force upon the abdominal wall. If the instrument of trauma is narrow and semiblunt, such as a policeman's club, the handle bar of a bicycle, or the narrow rim of a steering wheel, the injury may be confined to the pancreas. Heavier instruments may cause associated injury to the pancreas and neighboring organs. Mild trauma to the pancreas may be undetected unless the serum amylase determinations are followed periodically or the patient undergoes surgical intervention for other intra-abdominal injuries. Conservative management of pancreatitis of traumatic origin-and I emphasize of traumatic origin-is indicated only when one can eliminate the suspicion of injury to other abdominal organs. Rupture of the pancreas, because of the severity of abdominal symptoms, might be suspected before surgical
The Management of the Acute Abdomen
791
exploration. Lacerations of the organ should be sutured, and drainage of the lesser sac in such cases would be an acceptable surgical procedure. Occasionally the main pancreatic duct may be fractured, but continuity may be re-established by passing a small polyethylene tube into the cut ends of the duct and closing the rent in the organ by interrupted sutures. The liver, because of its location, is extremely vulnerable to trauma. When the diagnosis is a ruptured solid viscus, the chances are equal that the liver and spleen, or both, are involved. Evidence of internal hemorrhage following trauma, with aspiration of frank blood from the abdominal cavity, warrants surgical exploration. We think operative intervention is imperative in all liver injuries. The area should be carefully debrided and hemostasis controlled by mattress sutures. Oxidized cellulose may be of value in certain cases, and in extreme emergencies simple packing of the area may be a life-saving measure. All liver injuries should be drained preferably through stab wounds and not through the original InCISIon. Fewer than 50 cases of injury to the common bile ducts, by blunt trauma, have been reported in the 'medical literature. These mayor may not be associated with liver or gallbladder injury. It is of interest to note that all the patients treated by operation and drainage survived, whereas all those treated conservatively died. The presence of bile at the tilne of exploration points definitely to the site of injury. In most patients cholecystectomy can be accomplished, but in critical cases simple drainage of the gallbladder is sufficient. The level and degree of laceration of the bile ducts will qefine the surgical procedure. All surgical wounds in patients with traumatic injuries to the ducts must, as in liver injuries, be adequately drained to the exterior. Experience and observations in a large municipal hospital show that the vast majority of injuries to hollow viscera at the time of external trauma occur when the stomach and intestines are distended. Signs of peritonitis and x-ray evidence of free air in the abdominal cavity suggest immediate surgical intervention. The presence of free intestinal contents at the time of exploration again suggests the site of injury. Since multiple perforations may occur, it is essential to check every inch of the intestinal tract. Stomach perforations are sutured, small bowel perforations closed or, jf multiple, resected. The generally accepted policy follo\ving resection is to perform an end-to-end anastomosis of the small intestine whenever feasible. Likewise in the large intestine, indirect traumatic perforations may be closed or resected. The establishment of a transverse colostomy or cecostomy will depend upon the surgical problem. Exteriorization of the damaged colon, in my opinion, is a wartime measure and is seldom required for civilian injuries. Lacerations of the mesentery resulting in embarrassment to the vascularity of the intestine may follo\\T severe trauma to the abdominal wall, especially after the ingestion of quantities of liquid or food. The diagnosis
792
w.
Ross McCYarty
of such a conlplication is difficult, and may not be suspected until continued observation discloses increasing signs of peritoneal irritation. The tears usually occur across the vascular arcades parallel to the mesenteric border. The resulting hemorrhage and devitalization of the blood supply cause intestinal necrosis and peritonitis. Occasionally the tears are longitudinal in character and if the vascular system is involved the results are the same. An actual tear may not occur but hematomas may form within the leaves of the mesentery or at the mesenteric border of the intestine. If these lesions are of sufficient size the vascular supply to the intestine will be interrupted and necrosis vvill result. Retroperitoneal rupture of the small intestine may not be easily recognized. Retroperitoneal rupture of the duodenum in the second and third part may be suspected ,vhen the characteristic signs of intestinal perforation are delayed for from four to six hours, when the right psoas muscle shadow is outlined by free gas on x-ray, a retroperitoneal hematoma is seen at laparotomy, or a characteristic bulging of the parietal peritoneum in the region of the duodenum is present. The injury is usually associated with pancreatic damage. In such cases, the peritoneum on the lateral aspect of the duodenum is incised and the retroperitoneal areas of the duodenum are inspected. Retroperitoneal damage to the large intestine may also go unnoticed, especially if one does not recognize the importance of retroperitoneal hematomas adjacent to the large intestine. Rarely is the large intestine torn completely across; because of its size, vvounds are usually small tears or perforations and can be dealt vvith by simple suture. Occasionally severe flank trauma, with or vvithout injury to the kidney, may result in retroperitoneal damage to the colon. The first indication of such damage preoperatively will be local emphysema spreading from the flank across the abdominal wall and x-ray evidence of gas, from gas-forming organisms in the retroperitoneal tissue. A colostomy, if feasible, may prove a life-saving measure, but it must not be used as an alternative to establishing free and adequate drainage of the retroperitoneal spaces. Routine exploration may reveal a retroperitoneal hematoma in the immediate vicinity of the colon or small areas of emphysema. "fhese areas should always be investigated by incising the peritoneum and actually visualizing the retroperitoneal portion of the intestine. Extensive wounds of the rectum are best managed by a prelirninary proximal fecal diverting colostomy, repair of the damaged tissues when possible, and the establishment of adequate presacral drainage to the exterior. Penetrating Wounds of the Abdolllen
Intra-abdominal injuries fronl penetrating wounds of the abdominal \vall are more common than those associated ,vith indirect force and violence. They are frequently associated with rnultiple injuries to the
The Management of the Acute Abdomen
793
viscera or combined with injuries to other parts of the body. A few fundamental surgical principles that have been found of value in the management of these problems will be reviewed. 1. Penetrating wounds should never be probed to ascertain interabdominal penetration. 2. All suspected penetrations of the abdominal cavity should be explored before the signs of peritonitis develop. 3. Procrastination at this time may result in the loss of a patient who might otherwise have been saved by earlier intervention. 4. All suspected penetrations of the abdominal cavity should be explored. If one is in doubt, a small incision in the region of the penetration, or in the line of the site of an exploratory incision, will permit the surgeon to determine quickly if the peritoneum has been perforated. If the peritoneum is perforated, a complete exploration is mandatory. 5. In the preliminary evaluation and during the emergency treatment, any associated injury may be evaluated and the definitive treatment outlined on a priority basis. Frequently t,vo teams can function simultaneously during the same period of anesthesia, to the benefit of the patient. 6. During the exploration, the complete extent of injury in the abdomen should be evaluated before a procedure is attempted that may subsequently be sacrified. :For example, one may suture a small intestinal perforation, and then discover that multiple perforations and mesenteric damage in the immediate area may necessitate resection of the entire segment. The technique of exploring the abdominal cavity and the managelnent of intra-abdominal injuries secondary to penetrating wounds of the abdominal vvall are essentially outlined for indirect trauma. MASSIVE GASTROINTESTINAL HEMORRHAGE
Minimal or moderate gastrointestinal hemorrhage must be differentiated from massive hemorrhage. Patients with moderate hemorrhage usually respond to conservative Inedical treatment with or without minimal blood replacement. Patients with massive hemorrhage have lost approximately 30 per cent or more of their circulating volume and present all the signs and symptoms of shock. These patients do not respond to conservative medical treatment but require intensive blood replacement, and in a high percentage operative intervention. Massive hemorrhage may occur from any area along the intestinal tract, but usually from the upper part. The vomiting of blood, the passage of tarry stools, dark grapelike material or frank hemorrhage from the rectum is an indication as to the approximate level of bleeding. The bleeding may be due to blood dyscrasias, esophageal varices, gastritis with mucosal ulcerations, inflammatory, benign or malignant lesions of
794
W. Ross M cCarty
the intestine, diverticular, or still other lesions. Frequently the source remains undetermined. The keyword in the management of patients with massive intestinal hemorrhage is stabilization. Irrespective of etiology or age, the amount of blood lost from the circulating volume must be replaced, and the continued loss be adequately compensated by continuous transfusions. The hemoglobin and hematocrit determinations, blood pressure and pulse rate must be stabilized and maintained at approximately norInallevels. If the hemorrhage is not eontrolled and stabilization not established, operative intervention is definitely indicated. Like\vise if temporary stabilization is attained but hemorrhage recurs, surgery is indicated. The decision to intervene should be Inade by a medieal and surgical group that has been in constant attendance or has supervised the rnanagclnent of the patient. It should be borne in mind that blood replaeement cannot be continued beyond a critical point, and that the delay of surgical intervention may result in the loss of the patient's life. An accurate preoperative diagnosis facilitates the surgical approach but occasionally it is impossible to determine the source of bleeding before operation or even during surgical exploration. A high subtotal resection is recommended as an effective Ineasure to control upper intestinal hemorrhage in about 75 per cent of patients in this group. INTESTINAL OBSTRUCTION
The approach to the management of small and large bowel obstruction should be physiological as well as surgical. Small bowel obstructions may be classified as external and internal. These two groups may be subdivided into those in ,vhich the diagnosis has been established early and physiological changes are minirnal, and those in which the diagnosis has been delayed and the distention and electrolyte imbalance are marked. External obstructions are those in which the intra-abdominal contents, usually omentum and small intestine, protrude through congenital or acquired defects of the abdominal wall and become irreducible. Ventral, inguinal and femoral hernias chiefly comprise this group, and are easily recognized not only by the physician but by the patient. Internal obstructions are those occurring within the abdonlen secondary to congenital mal rotations, defects or bands; adhesions; internal hernias; volvuli; and intrinsic lesions of the snlall intestine such a.s benign tumors, neoplasms, gallstones or other foreign bodies. 1-'he early diagnosis of external ineareerated hernia ean be Inade readily. In most instances there has been a hernia present for SOIne tinle, and any change is appreciated by the patient and the physician. Accompanying these local findings there is an increase in the pulse rate, elevation of temperature, abdominal discomfort, anorexia and VOllliting. 'rhese generalized signs and symptoms increase as the tiIne element increases, until
The Management of the Acute Abdomen
795
a full-blown picture of acute intestinal obstruction is present. Leukocytosis may be an indication of change in the bowel wall secondary to an embarrassed blood supply. The early diagnosis of internal obstruction involving the small intestine is more difficult. At its inception the classical picture of intermittent peristaltic pain increasing in frequency and severity, and associated with vomiting, may be presented. Many of these patients have previously been subjected to abdominal surgery. These signs and symptoms together with a roentgenogram of the abdomen showing dilated loops of small intestine, with or without fluid levels, make an early diagnosis comparatively simple. The possibility of intestinal obstruction must be borne in mind in all cases of ill-defined abdominal pain, whether intermittent or constant, especially where previous abdominal surgery has been performed. ~"'re quently, vague intermittent abdominal pain is disregarded by the patient and misinterpreted by the physician as being of little significance. The presence of bowel sounds or the history of bowel movements should never be taken as an indication that obstruction is not present. The importance of early symptoms may not be realized fully until distention, vomiting or even peritonitis develops. Here again early roentgenographic studies of the abdomen with the patient in prone, upright and lateral decubitus positions is of extreme importance. Dilated loops with fluid levels are diagnostic. Severe abdominal pain and shock frequently accompany the onset of a sudden volvulus or internal herniation. Many of these patients are explored for an undiagnosed acute abdominal catastrophe and only at operation is the true cause ascertained. However, some patients following the onset of severe abdominal pain are comparatively free of symptoms and physical signs when admitted to the hospital. If the patient is placed under surgical observation, and the cause of the abdominal pain was due to a volvulus or internal herniation, the true nature of the syndrome would not be appreciated until the abdominal pain had recurred or distention and vomiting appeared. A flat x-ray film of the abdomen of these patients taken soon after admission usually reveals a hairpin or horseshoe type dilatation of a closed loop of obstructed intestine. Check x-ray will show this dilated loop to be consistently present but occasionally shifting to various parts of the abdominal cavity. These findings are indicative of a closed loop obstruction secondary to a volvulus or internal herniation. The diagnosis of late intestinal obstruction can be readily made. The clinical picture of marked distention, vomiting and dehydration is well known. X-ray studies of the abdomen reveal the typical distended loops of small intestine with multiple fluid levels. Paralytic ileus secondary to surgical manipulation, or reflex, usually shows on x-ray a uniform distention of both small and large bowel.
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Hf. Ross McCarty
Management of Early Intestinal Obstruction
There is general agreement that patients with early intestinal obstruction admitted to the hospital free of distention and in electrolyte balance ~hould be operated upon immediately. It seems logical that an indwelling intestinal tube should be passed in all cases, whether early or late. Many early cases with history of recurrent attacks of intestinal obstruction have been relieved previously by intubation; patients presenting the possibilities of multiple adhesions, or those in whom there is partial obstruction aggravated by torsion or angulation may be completely relieved by means of the tube. Surgery can be avoided in many of these cases. It is not sufficient merely to pass the tube successfully and then expect the tube together with suction apparatus to overcome all obstructions by some magic formula. In properly managed cases, distention and excessive intestinal contents of the small intestine proximal to the blockage will be relieved, and normal intestinal tone and peristalsis restored. The progress of the tube and relative position of the tip must be followed closely by repeated prone or upright x-ray studies taken every six to eight hours. In certain cases, the tip will be observed to be approximately in the same position on succeeding x-ray plates with an increasing length of tube in the intestines. These findings represent the stoppage of the tube at the point of obstruction and with the feeding of the tube into the nostril of the patient an increasing length ,vhips back and forth in the intestines~ the so-called "whipping of the tube." Failure to note this and appreciate its implications in the earlier studies of intestinal obstruction has resulted in unnecessary delay in surgical intervention. This danger signal should not be overlooked. Confirmation of complete or almost complete block can be obtained by the introduction, without pressure, of a small amount of dilute solution of barium into the aspirating side of the intestinal tube. If a block is present the barium will be observed on the fluoroscopic screen to strike the impasse and flO"\v upward along the tube. Lack of gaseous distention beyond this point is taken as an indication of a simple mechanical block. Fluoroscopic or x-ray evidence of a distended hairpin loop, or a distended long loop beyond the stoppage of barium, is indicative of a closed loop type of obstruction. Armed with these facts the surgeon knows exactly what type and where the obstruction is located. In the first type the release of a simple mechanical block will usually relieve the obstruction and in the second type surgery is facilitated by the knowledge that the intestine above and below the obstructed loop is collapsed, and collapse of the obstructed loop can be readily managed at operation by the use of an aspirating syringe or suction catheter. To repeat, early cases, in the absence of distention and electrolyte
11he A1 anagernenJ of the Acute Abdollle11 ilnbalance, are best operated upon soon. When patients are Inallaged by the intubation Inethod, supportive treatment must be adequately supervised. Managelllent of Late Cases
When one is confronted with the problem of management of a patient in the late stages of obstruction, the philosophy of immediate surgical intervention does not apply. The mortality following immediate operation in this group is prohibitive, not because of the obstruction per se, but because of the superimposed derangement in fluid and electrolytes ,vhich at this point is the most lethal factor. The successful management of these patients adlnitted to the hospital three to four days after the onset of intestinal obstruction vvith severe distention and in acute fluid and electrolyte imbalance can be accomplished in the majority of cases. It is vital to decompress the intestinal tract and replace the fluids and electrolytes prior to operative intervention. The restoration of electrolytes can be accomplished during the early stages of decompression. The decompression can be effected by the passage of anyone of the long, indwelling, enterostolny drainage tubes. Rarely is it necessary to decompress the intestines by a blind, open ileostomy and actual catheterization of the lumen of the bovvel. SUMMARY
1. The importance of trauma in the practice of medicine and surgery has been noted. 2. The diagnosis and treatlnent of the acute abdomen secondary to nonpenetrating and penetrating forms of trauma to the abdominal wall have been reviewed. 3. The management of patients vvith massive intestinal hemorrhage has been discussed. 4. The diagnosis and treatment in the early and late stages of acute intestinal obstruction of the small bowel have been outlined. rfhe advisability of early operative intervention in patients who have not undergone a previous operation and who are in electrolyte balance has been affirmed. The importance of electrolytic restoration and decompression in the late cases of obstruction, prior to surgical intervention, has been emphasized. REFERENCE 1. McCarty, W. Ross: The Management of Small Bowel Obstruction. Surge Clin North Alnerica 2.9: 307 (April) 194D. 550 First Avenue New York 16, N.Y.
ROSS McCARTY, M.D., F.A.C.S.*
TRAUMA
injuries constitute a large part of the practice of the general medical practitioner, especially those who, of necessity, must combine surgery with medicine. The accident rate, in this high powered motor age, is ever increasing. The changing picture of world events with the possibility of civilian catastrophes in this atomic age, together with the increase in civilian defense activities, clearly emphasizes the importance of this subject. This presentation will attempt to review only the emergencies that may occur within the abdominal cavity, and for brevity, the problems of urology, gynecology, and the associated chest and skeletal injuries have been omitted. It is assumed that the techniques of shock therapy are clearly understood, that diagnostic x-ray studies be fully utilized, and that patients with contaminated wounds will be adequately protected by antibiotics. It seems important that we re-evaluate the type of injuries occurring in our modern age, review the essential points for early diagnosis, and consider the changing needs in their surgical management. Abdominal emergencies may arise from injuries to the intra-abdominal viscera caused by direct trauma to the abdominal wall without penetration, and from injuries to these viscera resulting from penetration of the abdominal wall. TRAUMATIC
Nonpenetrating Injuries
It is important to realize that any organ in the abdomen may be injured or ruptured without external signs of violence. Early diagnosis and treatment are imperative whenever intra-abdominal trauma is suspected, followed by frequent evaluation in an ever changing picture. If intraperitoneal injury is suspected, it is generally unwise to delay opening the abdomen. If rigidity of the abdominal wall is present it is wiser to explore the abdomen than to wait until the diagnosis is clearly defined. In all
* Associate Professor of Surgery, New York University College of Medicine; Visiting Surgeon, Third Surgical Division, and Attending Surgeon, Univers1~ty Hospital, New York University-Bellevue Medical Center, New York, N.Y. 78,9
790
w. Ross McCarty
cases injury to the kidneys, ureters, bladder and urethra may be ruled out by early intravenous pyelograms and the -passing of a catheter. If a definite diagnosis is not possible without exploration, the operative approach can be made through a small midline upper abdominal incision. 'l'his incision is preferred because with it the contents of the upper abdomen can be inspected easily and the injury, if any, quickly identified. If the site of the incision is appropriate adequate extension will generally be possible, but if the incision proves inadequate it can be closed rapidly and a more adequate approach accolnplished. If a traumatic hemoperitoneum is encountered bear in nlind the old aphorism, "follow the clots," and the source will be apparent. A routine of examination should be followed systematically in all cases: the spleen, and splenic pedicle, the liver, gallbladder and bile ducts, the foramen of Winslo\vand head of the pancreas, the kidneys, pelvic organs, the stomach, small and large intestine with special attention to the leaves of the mesentery. The lesser sac should be opened to exanline the body of the pancreas, and the retroperitoneal spaces inspected for hematomas. Rupture of the spleen is perhaps one of the most common major injuries caused by nonpenetrating violence. The diagnosis is usually made by a history of injury, especially to the left upper quadrant; the presence of early shoulder pain, abdominal pain and tenderness; and evidence of internal bleeding. However, in minor lacerations, the symptoms may be delayed and severe internal hemorrhage may not be immediately in evidence. It is worth while noting that in the early phase an abdominal tap may not give any indication of free blood in the abdominal cavity, as the blood clot may be localized in the left upper quadrant. Most splenic injuries occur in healthy spleens; and by splitting the splenic renalligaments with one's finger, one may accomplish rapid mobilization and removal of the organ. Mass ligation of the splenic pedicle is avoided. The pancreas is deeply seated anatomically, hence is usually protected from blunt injury. However, direct blows to the abdominal wall, especially when the body is partly flexed, may impinge an intra-abdominal organ between the solid vertebra and the striking force upon the abdominal wall. If the instrument of trauma is narrow and semiblunt, such as a policeman's club, the handle bar of a bicycle, or the narrow rim of a steering wheel, the injury may be confined to the pancreas. Heavier instruments may cause associated injury to the pancreas and neighboring organs. Mild trauma to the pancreas may be undetected unless the serum amylase determinations are followed periodically or the patient undergoes surgical intervention for other intra-abdominal injuries. Conservative management of pancreatitis of traumatic origin-and I emphasize of traumatic origin-is indicated only when one can eliminate the suspicion of injury to other abdominal organs. Rupture of the pancreas, because of the severity of abdominal symptoms, might be suspected before surgical
The Management of the Acute Abdomen
791
exploration. Lacerations of the organ should be sutured, and drainage of the lesser sac in such cases would be an acceptable surgical procedure. Occasionally the main pancreatic duct may be fractured, but continuity may be re-established by passing a small polyethylene tube into the cut ends of the duct and closing the rent in the organ by interrupted sutures. The liver, because of its location, is extremely vulnerable to trauma. When the diagnosis is a ruptured solid viscus, the chances are equal that the liver and spleen, or both, are involved. Evidence of internal hemorrhage following trauma, with aspiration of frank blood from the abdominal cavity, warrants surgical exploration. We think operative intervention is imperative in all liver injuries. The area should be carefully debrided and hemostasis controlled by mattress sutures. Oxidized cellulose may be of value in certain cases, and in extreme emergencies simple packing of the area may be a life-saving measure. All liver injuries should be drained preferably through stab wounds and not through the original InCISIon. Fewer than 50 cases of injury to the common bile ducts, by blunt trauma, have been reported in the 'medical literature. These mayor may not be associated with liver or gallbladder injury. It is of interest to note that all the patients treated by operation and drainage survived, whereas all those treated conservatively died. The presence of bile at the tilne of exploration points definitely to the site of injury. In most patients cholecystectomy can be accomplished, but in critical cases simple drainage of the gallbladder is sufficient. The level and degree of laceration of the bile ducts will qefine the surgical procedure. All surgical wounds in patients with traumatic injuries to the ducts must, as in liver injuries, be adequately drained to the exterior. Experience and observations in a large municipal hospital show that the vast majority of injuries to hollow viscera at the time of external trauma occur when the stomach and intestines are distended. Signs of peritonitis and x-ray evidence of free air in the abdominal cavity suggest immediate surgical intervention. The presence of free intestinal contents at the time of exploration again suggests the site of injury. Since multiple perforations may occur, it is essential to check every inch of the intestinal tract. Stomach perforations are sutured, small bowel perforations closed or, jf multiple, resected. The generally accepted policy follo\ving resection is to perform an end-to-end anastomosis of the small intestine whenever feasible. Likewise in the large intestine, indirect traumatic perforations may be closed or resected. The establishment of a transverse colostomy or cecostomy will depend upon the surgical problem. Exteriorization of the damaged colon, in my opinion, is a wartime measure and is seldom required for civilian injuries. Lacerations of the mesentery resulting in embarrassment to the vascularity of the intestine may follo\\T severe trauma to the abdominal wall, especially after the ingestion of quantities of liquid or food. The diagnosis
792
w.
Ross McCYarty
of such a conlplication is difficult, and may not be suspected until continued observation discloses increasing signs of peritoneal irritation. The tears usually occur across the vascular arcades parallel to the mesenteric border. The resulting hemorrhage and devitalization of the blood supply cause intestinal necrosis and peritonitis. Occasionally the tears are longitudinal in character and if the vascular system is involved the results are the same. An actual tear may not occur but hematomas may form within the leaves of the mesentery or at the mesenteric border of the intestine. If these lesions are of sufficient size the vascular supply to the intestine will be interrupted and necrosis vvill result. Retroperitoneal rupture of the small intestine may not be easily recognized. Retroperitoneal rupture of the duodenum in the second and third part may be suspected ,vhen the characteristic signs of intestinal perforation are delayed for from four to six hours, when the right psoas muscle shadow is outlined by free gas on x-ray, a retroperitoneal hematoma is seen at laparotomy, or a characteristic bulging of the parietal peritoneum in the region of the duodenum is present. The injury is usually associated with pancreatic damage. In such cases, the peritoneum on the lateral aspect of the duodenum is incised and the retroperitoneal areas of the duodenum are inspected. Retroperitoneal damage to the large intestine may also go unnoticed, especially if one does not recognize the importance of retroperitoneal hematomas adjacent to the large intestine. Rarely is the large intestine torn completely across; because of its size, vvounds are usually small tears or perforations and can be dealt vvith by simple suture. Occasionally severe flank trauma, with or vvithout injury to the kidney, may result in retroperitoneal damage to the colon. The first indication of such damage preoperatively will be local emphysema spreading from the flank across the abdominal wall and x-ray evidence of gas, from gas-forming organisms in the retroperitoneal tissue. A colostomy, if feasible, may prove a life-saving measure, but it must not be used as an alternative to establishing free and adequate drainage of the retroperitoneal spaces. Routine exploration may reveal a retroperitoneal hematoma in the immediate vicinity of the colon or small areas of emphysema. "fhese areas should always be investigated by incising the peritoneum and actually visualizing the retroperitoneal portion of the intestine. Extensive wounds of the rectum are best managed by a prelirninary proximal fecal diverting colostomy, repair of the damaged tissues when possible, and the establishment of adequate presacral drainage to the exterior. Penetrating Wounds of the Abdolllen
Intra-abdominal injuries fronl penetrating wounds of the abdominal \vall are more common than those associated ,vith indirect force and violence. They are frequently associated with rnultiple injuries to the
The Management of the Acute Abdomen
793
viscera or combined with injuries to other parts of the body. A few fundamental surgical principles that have been found of value in the management of these problems will be reviewed. 1. Penetrating wounds should never be probed to ascertain interabdominal penetration. 2. All suspected penetrations of the abdominal cavity should be explored before the signs of peritonitis develop. 3. Procrastination at this time may result in the loss of a patient who might otherwise have been saved by earlier intervention. 4. All suspected penetrations of the abdominal cavity should be explored. If one is in doubt, a small incision in the region of the penetration, or in the line of the site of an exploratory incision, will permit the surgeon to determine quickly if the peritoneum has been perforated. If the peritoneum is perforated, a complete exploration is mandatory. 5. In the preliminary evaluation and during the emergency treatment, any associated injury may be evaluated and the definitive treatment outlined on a priority basis. Frequently t,vo teams can function simultaneously during the same period of anesthesia, to the benefit of the patient. 6. During the exploration, the complete extent of injury in the abdomen should be evaluated before a procedure is attempted that may subsequently be sacrified. :For example, one may suture a small intestinal perforation, and then discover that multiple perforations and mesenteric damage in the immediate area may necessitate resection of the entire segment. The technique of exploring the abdominal cavity and the managelnent of intra-abdominal injuries secondary to penetrating wounds of the abdominal vvall are essentially outlined for indirect trauma. MASSIVE GASTROINTESTINAL HEMORRHAGE
Minimal or moderate gastrointestinal hemorrhage must be differentiated from massive hemorrhage. Patients with moderate hemorrhage usually respond to conservative Inedical treatment with or without minimal blood replacement. Patients with massive hemorrhage have lost approximately 30 per cent or more of their circulating volume and present all the signs and symptoms of shock. These patients do not respond to conservative medical treatment but require intensive blood replacement, and in a high percentage operative intervention. Massive hemorrhage may occur from any area along the intestinal tract, but usually from the upper part. The vomiting of blood, the passage of tarry stools, dark grapelike material or frank hemorrhage from the rectum is an indication as to the approximate level of bleeding. The bleeding may be due to blood dyscrasias, esophageal varices, gastritis with mucosal ulcerations, inflammatory, benign or malignant lesions of
794
W. Ross M cCarty
the intestine, diverticular, or still other lesions. Frequently the source remains undetermined. The keyword in the management of patients with massive intestinal hemorrhage is stabilization. Irrespective of etiology or age, the amount of blood lost from the circulating volume must be replaced, and the continued loss be adequately compensated by continuous transfusions. The hemoglobin and hematocrit determinations, blood pressure and pulse rate must be stabilized and maintained at approximately norInallevels. If the hemorrhage is not eontrolled and stabilization not established, operative intervention is definitely indicated. Like\vise if temporary stabilization is attained but hemorrhage recurs, surgery is indicated. The decision to intervene should be Inade by a medieal and surgical group that has been in constant attendance or has supervised the rnanagclnent of the patient. It should be borne in mind that blood replaeement cannot be continued beyond a critical point, and that the delay of surgical intervention may result in the loss of the patient's life. An accurate preoperative diagnosis facilitates the surgical approach but occasionally it is impossible to determine the source of bleeding before operation or even during surgical exploration. A high subtotal resection is recommended as an effective Ineasure to control upper intestinal hemorrhage in about 75 per cent of patients in this group. INTESTINAL OBSTRUCTION
The approach to the management of small and large bowel obstruction should be physiological as well as surgical. Small bowel obstructions may be classified as external and internal. These two groups may be subdivided into those in ,vhich the diagnosis has been established early and physiological changes are minirnal, and those in which the diagnosis has been delayed and the distention and electrolyte imbalance are marked. External obstructions are those in which the intra-abdominal contents, usually omentum and small intestine, protrude through congenital or acquired defects of the abdominal wall and become irreducible. Ventral, inguinal and femoral hernias chiefly comprise this group, and are easily recognized not only by the physician but by the patient. Internal obstructions are those occurring within the abdonlen secondary to congenital mal rotations, defects or bands; adhesions; internal hernias; volvuli; and intrinsic lesions of the snlall intestine such a.s benign tumors, neoplasms, gallstones or other foreign bodies. 1-'he early diagnosis of external ineareerated hernia ean be Inade readily. In most instances there has been a hernia present for SOIne tinle, and any change is appreciated by the patient and the physician. Accompanying these local findings there is an increase in the pulse rate, elevation of temperature, abdominal discomfort, anorexia and VOllliting. 'rhese generalized signs and symptoms increase as the tiIne element increases, until
The Management of the Acute Abdomen
795
a full-blown picture of acute intestinal obstruction is present. Leukocytosis may be an indication of change in the bowel wall secondary to an embarrassed blood supply. The early diagnosis of internal obstruction involving the small intestine is more difficult. At its inception the classical picture of intermittent peristaltic pain increasing in frequency and severity, and associated with vomiting, may be presented. Many of these patients have previously been subjected to abdominal surgery. These signs and symptoms together with a roentgenogram of the abdomen showing dilated loops of small intestine, with or without fluid levels, make an early diagnosis comparatively simple. The possibility of intestinal obstruction must be borne in mind in all cases of ill-defined abdominal pain, whether intermittent or constant, especially where previous abdominal surgery has been performed. ~"'re quently, vague intermittent abdominal pain is disregarded by the patient and misinterpreted by the physician as being of little significance. The presence of bowel sounds or the history of bowel movements should never be taken as an indication that obstruction is not present. The importance of early symptoms may not be realized fully until distention, vomiting or even peritonitis develops. Here again early roentgenographic studies of the abdomen with the patient in prone, upright and lateral decubitus positions is of extreme importance. Dilated loops with fluid levels are diagnostic. Severe abdominal pain and shock frequently accompany the onset of a sudden volvulus or internal herniation. Many of these patients are explored for an undiagnosed acute abdominal catastrophe and only at operation is the true cause ascertained. However, some patients following the onset of severe abdominal pain are comparatively free of symptoms and physical signs when admitted to the hospital. If the patient is placed under surgical observation, and the cause of the abdominal pain was due to a volvulus or internal herniation, the true nature of the syndrome would not be appreciated until the abdominal pain had recurred or distention and vomiting appeared. A flat x-ray film of the abdomen of these patients taken soon after admission usually reveals a hairpin or horseshoe type dilatation of a closed loop of obstructed intestine. Check x-ray will show this dilated loop to be consistently present but occasionally shifting to various parts of the abdominal cavity. These findings are indicative of a closed loop obstruction secondary to a volvulus or internal herniation. The diagnosis of late intestinal obstruction can be readily made. The clinical picture of marked distention, vomiting and dehydration is well known. X-ray studies of the abdomen reveal the typical distended loops of small intestine with multiple fluid levels. Paralytic ileus secondary to surgical manipulation, or reflex, usually shows on x-ray a uniform distention of both small and large bowel.
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Management of Early Intestinal Obstruction
There is general agreement that patients with early intestinal obstruction admitted to the hospital free of distention and in electrolyte balance ~hould be operated upon immediately. It seems logical that an indwelling intestinal tube should be passed in all cases, whether early or late. Many early cases with history of recurrent attacks of intestinal obstruction have been relieved previously by intubation; patients presenting the possibilities of multiple adhesions, or those in whom there is partial obstruction aggravated by torsion or angulation may be completely relieved by means of the tube. Surgery can be avoided in many of these cases. It is not sufficient merely to pass the tube successfully and then expect the tube together with suction apparatus to overcome all obstructions by some magic formula. In properly managed cases, distention and excessive intestinal contents of the small intestine proximal to the blockage will be relieved, and normal intestinal tone and peristalsis restored. The progress of the tube and relative position of the tip must be followed closely by repeated prone or upright x-ray studies taken every six to eight hours. In certain cases, the tip will be observed to be approximately in the same position on succeeding x-ray plates with an increasing length of tube in the intestines. These findings represent the stoppage of the tube at the point of obstruction and with the feeding of the tube into the nostril of the patient an increasing length ,vhips back and forth in the intestines~ the so-called "whipping of the tube." Failure to note this and appreciate its implications in the earlier studies of intestinal obstruction has resulted in unnecessary delay in surgical intervention. This danger signal should not be overlooked. Confirmation of complete or almost complete block can be obtained by the introduction, without pressure, of a small amount of dilute solution of barium into the aspirating side of the intestinal tube. If a block is present the barium will be observed on the fluoroscopic screen to strike the impasse and flO"\v upward along the tube. Lack of gaseous distention beyond this point is taken as an indication of a simple mechanical block. Fluoroscopic or x-ray evidence of a distended hairpin loop, or a distended long loop beyond the stoppage of barium, is indicative of a closed loop type of obstruction. Armed with these facts the surgeon knows exactly what type and where the obstruction is located. In the first type the release of a simple mechanical block will usually relieve the obstruction and in the second type surgery is facilitated by the knowledge that the intestine above and below the obstructed loop is collapsed, and collapse of the obstructed loop can be readily managed at operation by the use of an aspirating syringe or suction catheter. To repeat, early cases, in the absence of distention and electrolyte
11he A1 anagernenJ of the Acute Abdollle11 ilnbalance, are best operated upon soon. When patients are Inallaged by the intubation Inethod, supportive treatment must be adequately supervised. Managelllent of Late Cases
When one is confronted with the problem of management of a patient in the late stages of obstruction, the philosophy of immediate surgical intervention does not apply. The mortality following immediate operation in this group is prohibitive, not because of the obstruction per se, but because of the superimposed derangement in fluid and electrolytes ,vhich at this point is the most lethal factor. The successful management of these patients adlnitted to the hospital three to four days after the onset of intestinal obstruction vvith severe distention and in acute fluid and electrolyte imbalance can be accomplished in the majority of cases. It is vital to decompress the intestinal tract and replace the fluids and electrolytes prior to operative intervention. The restoration of electrolytes can be accomplished during the early stages of decompression. The decompression can be effected by the passage of anyone of the long, indwelling, enterostolny drainage tubes. Rarely is it necessary to decompress the intestines by a blind, open ileostomy and actual catheterization of the lumen of the bovvel. SUMMARY
1. The importance of trauma in the practice of medicine and surgery has been noted. 2. The diagnosis and treatlnent of the acute abdomen secondary to nonpenetrating and penetrating forms of trauma to the abdominal wall have been reviewed. 3. The management of patients vvith massive intestinal hemorrhage has been discussed. 4. The diagnosis and treatment in the early and late stages of acute intestinal obstruction of the small bowel have been outlined. rfhe advisability of early operative intervention in patients who have not undergone a previous operation and who are in electrolyte balance has been affirmed. The importance of electrolytic restoration and decompression in the late cases of obstruction, prior to surgical intervention, has been emphasized. REFERENCE 1. McCarty, W. Ross: The Management of Small Bowel Obstruction. Surge Clin North Alnerica 2.9: 307 (April) 194D. 550 First Avenue New York 16, N.Y.