Abdominal Emergencies Requiring Immediate Operation

Abdominal Emergencies Requiring Immediate Operation MANUEL E. LICHTENSTEIN, M.D.*

ABDOMINAL emergencies which require immediate operation may be classified according to etiology as on the following page. CONDITIONS SIMULATING ACUTE ABDOMINAL EMERGENCIES

Surgeons with experience and judgment are reluctant to operate without convincing evidence that the patient will benefit from an emergency operation. It is necessary to be forever mindful of those nonsurgical conditions which mimic surgical disorders. They must be excluded during a complete examination and whenever possible by such significant laboratory tests as are helpful in diagnosis. Herpes zoster, pneumonia, diaphragmatic pleurisy, coronary disease, renal colic, lead colic, dissecting aortic aneurysms, arteriosclerotic vascular perforations, colitis, tabetic crisis, acute pancreatitis, acute hepatitis, sudden cardiac decompensation with acute hepatomegaly, distended urinary bladder, prostatitis and any other conditions for which surgical operation has been done by error with no benefit to the patient must be excluded. An estimate of the local condition, based on the history of its onset and its course, and an appraisal of the general condition of the patient will determine how safe it is to wait longer, if necessary, in the hope that uncertainties will clear up. Under certain circumstances an exact diagnosis may be impossible to establish. The surgeon may have great difficulty differentiating between a variety of conditions which bleed, perforate or become gangrenous. It is better to recognize the acute surgical abdomen and to act promptly than to wait for further information of a more confirmatory nature in the later stages of the disease, and operate either too late to do good or under circumstances less favorable for recovery.

* Associate Professor of Surgery, Northwestern University Medical School, Chicago. 27

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Manuel E. Lichtenstein TRAUMA

Perforating Wounds

Perforating wounds involving the abdomen are treated by laparotomy as soon after injury as is possible. Shock, hemorrhage, and infection interfere with recovery of the patient when surgery is delayed. Perforating ETIOLOGIC CLASSIFICATION OF ABDOMINAL EMERGENCIES

I. Trauma 1. Penetrating and perforating wounds 2. Indirect and blunt injuries II. Infection 1. Appendicitis, solitary diverticulitis, epiploitis 2. Perforative peritonitis a. Peptic ulcer and rupture of the stomach or duodenum b. Cecal or ileal ulcer c. Foreign bodies-fish and chicken bones, pins, nails, forks, etc. d. Richter hernia and Littre hernia 3. Cholecystitis, empyemia, gangrene, pericholecystic phlegmon with abscess III. Intestinal Obstruction 1. Small intestines a. Simple b. Strangulated 2. Large intestine a. Simple b. Strangulated c. Volvulus d. "Closed loop" IV. Mesenteric thrombosis and embolism V. Hemorrhage 1. Intraperitoneal 2. Retroperitoneal 3. Postoperative 4. Gastrointestinal VI. N ontraumatic rupture of viscera or cysts 1. Ectopic pregnancy 2. Certain ovarian cysts a. Corpus luteum b. Dermoid 3. Pancreatic and chylous cysts 4. Extravasation of urine VII. Miscellaneous 1. Torsion of a pedicle, or embolism or gangrene of omentum, pedunculated fibroid, undescended testicle, appendix epiploica, and hydatid of Morgagni 2. Wound dehiscence with evisceration

wounds of the chest which extend below the thoracic diaphragm and similar wounds of the pelvis and hips which traverse above the pelvic diaphragm produce abdominal injuries which require investigation. Supportive therapy with whole blood and antibiotics are necessary to

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prevent deterioration in the condition of the patient. Delay favors deterioration and invites disaster. Penetrating Wounds

Penetrating wounds should be explored to their depths, bleeding vessels ligated, and if entrance into the peritoneal cavity is noted, exploration of the abdominal viscera must be done. Superficial wounds usually cause no serious injury but many small wounds are deep and may produce serious or fatal injuries when hollow viscera or large vessels are involved. CASE 1. J. D., aged 22, was stabbed with a knife in the right lower quadrant of the abdomen while grappling with a friend. Examination disclosed a wound 1 cm. in length. It was regarded as superficial, for tenderness or rigidity was not present. The wound was closed with a small dressing held with adhesive tape. The assailant and the patient were jailed for engaging in a brawl but were dismissed the following morning. Three days later the patient was admitted to the hospital with a well developed acute diffuse peritonitis and died shortly afterward. At autopsy a rent was found in the cecum at the site of the stab wound. The assailant was now charged with homicide. Failure to explore the wound and when necessary the abdomen is more likely to be fatal than an exploration which discloses no internal injury.

Indirect and Blunt Trauma

Sudden violence as occurs in automobile accidents, falls from scaffolds or other heights or slipping on a pavement usually results in cutaneous, skeletal or muscular injuries. In some patients intra-abdominal injuries occur also. Direct violence against the abdomen, lower chest or pelvis is a more common cause for abdominal injuries. This group of patients with nonpenetrating abdominal trauma frequently have other injuries and present the greatest challenge to the diagnostic acumen of the surgeon. They warrant a most careful study, for an unnecessary laparotomy is not without danger in an individual with related cerebral, thoracic or skeletal trauma. Examination of the Patient

This must be complete and thorough in every case. Wounds elsewhere on the body also require attention and should not be neglected. On suspicion alone every patient with an abdominal injury should be held for observation even when initially there are no findings. When pain is persistent an estimate of the probable internal injury should be made. For example, an injury to the lower left chest or left upper quadrant should focus attention on the spleen. This organ is frequently the cause of death from hemorrhage and a strong suspicion that it has been injured warrants exploration. The decision to operate depends on what evidence of

Manuel E. Lichtenstein

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internal injury is found immediately or what evidence develops in the course of several hours of observation. It is this time that must be well spent, and the following plan has been' of help to determine the need for exploration. 1. A catheter is inserted into the bladder and all urine collected, its volume measured and its content of blood, albumin, casts or cells noted. A Levin tube is passed into the stomach and suction applied. Accurate data are kept on the volume and character of the fluid aspirated from the stomach. The patient is given nothing by mouth except a mouth wash. One liter of 5 per cent dextrose in water is given intravenously at the rate of 1 drop per second. Blood typing is done and blood is cross matched to be available, if necessary. 2. Roentgenograms are made in the horizontal and in the vertical positions. They are useful in detecting pneumoperitoneum or soft tissue shadows, displaced viscera due to hematoma formation, elevation of the diaphragm, free fluid in the peritoneal cavity and fractures of ribs, spine or pelvis. 3. A chart is used to record the following data hourly: B.P. sid 1.

PULSE

RESP.

Rh. RBC,

Ret.

BOWEL SOUNDS

URINE

STOMACH

2.

4. Re-examination is made often to note significant changes that indicate either hemorrhage, peritonitis or urinary extravasation. Diagnosis

A rapid pulse with a falling blood pressure, hemoglobin, red cell count and hematocrit indicate hemorrhage. A rapid onset of shock suggests hemorrhage from a torn mesentery, large vessel or solid organ. A rapid recovery from shock with a small amount of blood would indicate little hemorrhage has occurred, but failure of shock to respond to continuous blood transfusions does not necessarily mean continued or extensive hemorrhage; for peritonitis, too, may be responsible for shock. Repair of leaking perforations in the gastrointestinal tract is necessary as a resuscitative measure. Resuscitation should continue during and after operation until shock is overcome. Muscular rigidity with absence of intestinal sounds and signs of shock are evidence of leakage from a hollow viscus into the peritoneal cavity. The urine is re-examined for blood to determine the amount of renal bleeding. Bladder injuries may be suspected from the presence of blood in the urine when the kidneys are not involved in trauma. Perforations or tears with leakage may be determined by injecting 250 cc. of sterile saline into the bladder. If this cannot be recovered, a leak in the organ

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is likely. An intravenous pyelogram may show the leak when the opaque medium clears through the kidneys and enters the bladder. Differential Diagnosis

It is difficult to distinguish between muscle rigidity in response to peritoneal irritation and muscle spasm from direct or indirect trauma. The presence of normal bowel sounds would speak against perforative peritonitis. An injury to the deep epigastric vessels with hemorrhage into the abdominal wall may be confusing. Here, too, normal bowel sounds would suggest an abdominal wall injury and warrant the use of a snug binder. Retroperitoneal hemorrhage, kidney injuries and a fracture of the spine are frequently followed by adynamic ileus. In all of these, bowel sounds may be absent or diminished. However, hemorrhage may be detected by a fall in hemoglobin, red cell count and hematocrit, renal injury by urine examination, and the spinal injury by x-ray studies. Most unfortunate is the retroperitoneal rupture of the duodenum. This may be neglected because of the absence of early peritoneal reaction. An xray showing free air about the right kidney is an aid to diagnosis. Injuries to the jejunum and ileum may be unaccompanied by pneumoperitoneum and many hours may elapse before signs of spreading peritonitis are manifest. Exploration of the abdomen done soon enough to see what is injured while the opportunity for repair is yet possible is better than the regret that accompanies an operation done too late or a demonstration of reparable injuries at autopsy. Principles of Surgical Management 1. Muscular relaxation is necessary for a thorough examination of the injured viscera. Ether administered through an endotracheal tube is most satisfactory. 2. The primary incision should be long enough to permit full exposure of the site of injury and give access to all of the viscera. A thoracic injury coexisting with an abdominal injury may require either a transthoracic approach, or a thoraco-abdominal incision in order that the associated chest injury may be cared for and any diaphragmatic defect may be repaired. 3. Control of hemorrhage is the best safeguard against shock and deterioration of the patient during or after surgical intervention. Torn mesenteric vessels must be ligated to prevent an enlarging hematoma in the space between the leaves of the mesentery. 4. A systematic examination of the viscera must be made, keeping in mind that small bowel, transverse colon and sigmoid colon may move away from the site of abdominal trauma because of a mobile mesentery.

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Manuel E. Lichtenstein

5. All gastrointestinal wounds must be closed. A single unsutured perforation may make the most extensive operation useless. Special note should be made of the following: a. Duodenum. Injury to this organ is usually fatal either because of delayed care or neglect of proper care. Extensive mobilization is necessary for adequate visualization and repair of wounds without tension. Fistula formation is a formidable sequel to inadequate closure. The' peritoneum on the lateral side of the duodenum is incised and the organ turned medially. b. Colon. Fixed portions of the colon require mobilization for complete examination. Injuries to the colon, sigmoid and intraperitoneal rectum are sutured. A cecostomy is made for decompression when necessary. Exteriorization of large bowel is done only for extensive injuries to bowel or its mesentery when resection cannot be done safely, or when the condition of the patient warrants this limited procedure. c. Rectum. Wounds of the extraperitoneal rectum are managed by sigmoid colostomy in discontinuity. Drainage of the pararectal space through a postanal incision is done and a large Pezzer catheter is inserted within the anal sphincter to permit exit of any discharges. 6. Excision of devitalized or severely damaged bowel and removal of foreign material should be done with restoration of continuity by the type of anastomosis that can be done readily. Ileostomy must be avoided. 7. Drainage of the contaminated retroperitoneal space and the subphrenic space in liver damage is necessary. 8. Repair of a torn or perforated wall of the bladder is accompanied with drainage of the space of Retzius. An indwelling catheter is necessary to maintain an empty bladder for one week to ten days. 9. The five solid viscera in the abdomen are noted: a. Kidney. Rarely is it necessary to remove a kidney immediately after injury is sustained. However, continuous 'bleeding into the bladder or the development of a progressively enlarging hematoma may make urgent surgery necessary. b. Liver. Active hemorrhage from injuries to the liver are controlled by packing with Gelfoam. Loose fragments of liver and easily accessible foreign bodies are removed. Liver suture may be done when possible. Drainage through a subcostal incision is essential and these drains must be left in place for at least one week to ten days. c. Spleen. Injury to the spleen results in massive hemorrhage, either immediately or after some delay. Splenectomy is the procedure of choice. The danger of late hemorrhage warrants laparotomy on suspicion if clinical evidence and x-ray studies indicate a hematoma is present about the spleen. d. Pancreas. Injuries to this organ are repaired and drainage of the retroperitoneal space and lesser peritoneal cavity are provided.

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e. Adrenal. Only rarely is this organ involved. Repair and control of bleeding are attempted and devitalized portions are removed. 10. Closure of the abdominal wound is made with precautions taken to avoid evisceration. Drains leave through stab wounds and exteriorized loops of large bowel pass through openings separate from the primary InCISIOn.

Fig. 1. Traumatic perforation of the diaphragm from blunt trauma to the anterior abdominal wall. Incarceration of the stomach in pleural cavity. Note fluid level of the gastric content. No other injury. Reduction of the herniation with closure of the rent in the diaphragm through an abdominal approach was followed by an uneventful recovery.

Summary

All perforating abdominal wounds, all penetrating abdominal wounds which enter the peritoneal cavity and all instances of indirect or blunt trauma associated with evidence of hemorrhage, peritonitis or extravasation of urine require abdominal exploration. Associated wounds elsewhere must not be overlooked. Whole blood to replace that which is lost is necessary to prevent or overcome shock. Antibiotics are given in every case to control infection. Penicillin 400,000 units with streptomycin 0.5 gram; or Terramycin 500 mg. given twice daily is adequate. Fluids for hydration and nutrition are given as in any patient who is unable to be fed orally and who is losing secretions by suction through a nasogastric tube. Some of the late sequelae to abdominal trauma are pancreatic cysts, intestinal obstruction and diaphragmatic hernia (Fig. I), These may have

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Manuel E. Lichtenstein

medicolegal implications and their possible occurrence must be kept in mind. ACUTE APPENDICITIS

Acute appendicitis is a disease that can be eliminated by removal of the diseased appendix. Delay in its removal may result in gangrene or perforation with diffuse peritonitis, localized phlegmon, abscess formation, bowel obstruction, prolonged disability or death. All of these unfavorable developments can be avoided by regarding the condition as an acute abdominal emergency requiring surgery. Diagnosis

Acute appendicitis occurs in all age groups. While the pattern of symptoms is approximately the same in the vast majority of patients there are sufficient variations, especially in the very young and very old, to warrant careful study of any patient with acute abdominal distress on suspicion of acute appendicitis. The aged have mild symptoms and scant findings frequently with the severest disease. The symptoms of acute appendicits in the typical case are well known but a few points bear re-emphasis. 1. The pain may arise suddenly but often it comes on gradually as an ache or colic in the epigastrium or about the umbilicus arid worsens with the progress of the disease. Typical and diagnostic is the shift of this pain to the right lower quadrant. When a mistake in diagnosis is made and neglect of early treatment results, it is usually due to a failure to elicit the "story" of pain, its onset and its course. 2. Anorexia is fairly constant; some feel nauseated while others vomit once or several times. A hearty appetite or repeated vomiting are not typical in acute appendicitis, and the occurrence of nausea or vomiting before the onset of pain speak against this diagnosis. 3. Abdominal tenderness and muscle spasms result from peritoneal irritation and are noted at the site of the diseased appendix. This is the important finding, for it is a clue to the diagnosis and a guide to the location of the appendix within the abdomen. The rectal examination is important, more especially in children, for tenderness here will disclose the low lying or pelvic appendix. Rebound tenderness associated with diminished or absent bowel sounds indicates peritonitis either localized or generalized. 4. Fever of low grade develops after the onset of pain. A sudden drop in temperature suggests gangrene, perforation or evacuation of the appendiceal contents into the cecum. In some a severe chill and a very high temperature may usher in the disease. While infrequent these symptoms do not exclude appendicitis. A pulse rate of 90 to 120 is a

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more reliable evidence of infection than is an increased temperature. Persistence of tachycardia with remission of other symptoms suggests gangrene. 5. A blood count will show a leukocytosis but it is the increase in the polymorphonuclear leukocytes which is more significant than the total number of cells. Other symptoms are equivocal. Constipation is usually present, but diarrhea may also occur, especially in children .. LOCATION

\

\ \

\ \

A_____ I1eoc~cal

L..-

fold

POSITION

B Fig. 2. Anatomic variations of the vermiform appendix.

AnatOlnic Relations

The differences in the symptoms due to variations in the position and station of the appendix (Fig. 2) have not been emphasized and account for mistakes in diagnosis. The position of the appendix varies considerably. It may extend in any direction radiating from its base as the spokes of a wheel radiate from the hub. The station of the appendix varies according to the length of the ascending colon. Urinary symptoms may be associated with a diseased appendix lying on the urinary bladder simulating prostatitis or cystitis; renal colic with cells and albumin in the urine may be due to a diseased appendix lying on a ureter participating in the inflammatory process simulating renal stones; diaphragmatic pain may occur with a high-lying diseased ap-

Manuel E. Lichtenstein

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pendix impinging on the diaphragm, simulating pleurisy or myositis; and physical findings more characteristic of gallbladder disease or gastroduodenal ulcer may be present when the diseased appendix is positioned or stationed adjacent to these organs. The difficulty in diagnosis of the pelvic appendix in the female is notorious and many women in the past have been treated conservatively for salpingitis and have died from a perforated or gangrenous appendix lying in the cul-de-sac. Table 1 DEATHS AND DEATH RATES PER 100,000 POPULATION FROM ApPENDICITIS, UNITED STATES, 1934-1950 DEATH RATE

YEAR

DEATHS

1950 1949 1948 1947 1946

3,080 3,744 4,171 4,786 5,285

2.0 2.5 2.9 3.3 3.8

1945 1944 1943 1942 1941

6,697 7,783 8,108 8,368 10,789

5.1 5.9 6.1 6.3 8.1

1940 1939 1938 1937 1936

12,999 14,113 14,300 15,340 16,480

9.9 10.8 11.0 11.9 12.9

12.7 16,142 1935 14.3 18,129 1934 These figures do not include the armed forces overseas. Source: National Office of Vital Statistics, Bureau of the Census.

Morbidity and Mortality

The seriousness of acute appendicitis has abated in the minds of many because of the progress made in the prevention and control of infection, shock, fluid and electrolyte imbalance, the hazards of anesthesia and thrombosis and embolism. However, in spite of all of our present knowledge, available even in the remotest communities, there are still several thousands who die annually from this common condition (Table 1). When the diagnosis is missed or delayed and complications develop, prolonged periods of hospitalization with dangers just short of death in addition to prolonged convalescence add to the disability from this disease. When one adds the risk of postoperative intestinal obstruction occurring immediately or years after appendectomy, the picture of the seriousness of this disease should be appreciated,

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The greastest danger at present is the injudicious use of sulfonamides or antibiotics for the treatment of any undiagnosed acute abdominal condition which may be acute appendicitis. J. B. Murphy expounded with vigor on the early treatment of appendicitis and warned against the use of morphine which altered the symptoms of the disease unless the diagnosis was certain and surgery was to be done. At present the same warning is still valid, but it should include antibiotics and sulfonamides too. These also cloud the symptoms and make the diagnosis more difficult to establish. The following case abstracts illustrate this: CASE II. W. S., a man aged 42, became ill with acute abdominal pain following a meal with a pineapple dessert. Soon afterwards he became nauseated and vomited the pineapple. When diarrhea developed he believed spoiled food was responsible for his illness. He was treated with sulfonamides and later antibiotics in large doses. His temperature was only slightly elevated, but he did not feel well. After six days he became distended and was hospitalized. The leukocyte count on the seventh day of his illness was 14,400 with 90 per cent polymorphonuclear leukocytes. During the next two days the white count dropped to 12,500 but the polymorphs rose to 95 per cent of the total. An x-ray study on admission showed a pattern of small bowel obstruction. A Miller-Abbott tube was passed with some relief from distention, but recheck films showed a persistent small bowel pattern with no gas in the large bowel. During the four days following admission his general condition worsened. Difficulties in regulation of the electrolytes developed. There was a very low-grade fever, with tenderness in the lower abdomen and tenseness in the pelvis on rectal examination. There had been no bowel movement for four days. The abdomen was silent. In this state, with a history of suspected appendicitis and evidence of a mechanical small bowel obstruction due to an abscess, it was suggested that surgical drainage of the abscess be done. A right rectus incision was made directly over the t.ender area. About 1000 cc. of purulent material without odor was aspirated from an abscess cavity that was lined with adherent loops of ileum forming an acute obstruction. One-half of the necrotic appendix was afloat in the pus while the proximal segment, also necrotic, was still attached to the cecum. This was removed. A silk purse-string suture helped to invert the ligated stump of the appendix into the wall of the cecum. The kinked bowel was liberated sufficiently to permit retained gas in the small bowel to enter the cecum. The peritoneal cavity was suctioned free of fluid, and the abdominal wall was closed without drainage. The postoperative recovery was complicated by a subcutaneous abscess. There was no dihiscence of the abdominal wound, and no hernia resulted. The patient recovered and left the hospital on the seventeenth day after surgery. CASE III. A. K, a woman aged 49, took ill after a meal. Abdominal pain was followed by nausea and vomiting. She was treated for an acute intestinal upset due to spoiled food with sulfa tablets until recurrent vomiting prevented their use. Penicillin was then administered for eight days, when hospitalization was advised. On her admission to the hospital the temperature was 99° F., white count 17,150 with 92 per cent polymorphonuclear leukocytes of which 12 were "stab" cells. A flat plate showed a complete small bowel obstruction in the ileum. A barium enema showed an empty colon. With gastric suction, intravenous solutions of dextrose and minerals, she was relieved slightly, but her abdomen re-

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Manuel E. Lichtenstein

mained distended and tender. From the history, acute appendicitis was the most likely diagnosis, with acute bowel obstruction related to an abscess. At operation 12 days after the onset of symptoms, abscesses were evacuated from behind the uterus, from in front of the uterus, and from the right lower quadrant at the site of a sloughed appendix. Here again there was no odor to the purulent material. The remainder of the appendix was removed. The stump was ligated and inverted into the wall of the cecum; the contents of the distended small bowel were emptied through perforations made in the bowel wall during the manipulations. These openings were sutured when the intestinal canal was emptied of its contents. A Penrose drain was inserted into the abscess cavities adjacent to the uterus, and the abdominal wall was closed. Postoperative recovery was complicated by subcutaneous abscesses. The patient recovered and left the hospital on the eighteenth postoperative day.

The outstanding observation was the relative sterility of the abscesses affected by "flooding" of the patient with millions of units of penicillin and many grams of streptomycin and sulfonamides. These agents control infection but do not influence favorably necrosis and abscess formation. The use of these drugs interfered with an early diagnosis and made prolonged disability possible. T'reatm.ent

The placement of the incision over the site of the appendix facilitates its removal. A standard incision in every case may be useful in most instances but a burden in some. A more versatile application of surgical approaches to the diseased appendix appropriate to each patient makes for better surgery. The physical examination will disclose the point of tenderness which constitutes the guide to the diseased appendix. An incision made over this point, be it high or low, lateral or medial, on the right or left, will expose the disease. Drainage of an abscess should be done lest the abscess perforate into the peritoneal cavity. Perforative appendicitis with diffuse peritonitis presents a grave problem. Surgery, with the aid of antibiotics, blood, other intravenous fluids appropriate to the needs and gastrointestinal suction offers the patient the best prospect for recovery. Errors in Diagnosis. An incision placed over the tender area will be of value if perchance the diagnosis is incorrect. The inflammatory process may involve a Meckel's diverticulum, appendix epiploica, or mesenteric lymph node; or, perforation of bowel by a foreign body, or perforation of a solitary ulcer of the cecum or ileum or a diverticulum, or other disease or condition may be found. Sum.m.ary

,While the physician must be alert to the early recognition of acute appendicitis he can be helped by eliciting a history, making a physical

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examination and noting the laboratory data. To operate for acute appendicitis through error and find another condition just as lethal or disabling is as valuable as though acute appendicitis were present. A policy of subjecting all patients with acute pain in the lower abdomen to appendectomy lest the disease be overlooked is indeed a failure to utilize the knowledge so painstakingly acquired by the profession and an abandonment of that diagnostic acumen which is the goal of every physician. PERFORATED PEPTIC ULCER

Peritonitis due to perforation of a peptic ulcer is an acute abdominal condition which can be overcome by immediate closure of the perforation. Under certain circumstances nonsurgical treatment may be indicated. ForIllS of Perforation and Their ManageIllent

We recognize three forms of perforated ulcer: (1) the "frank" perforation; (2) the "slow leak;" (3) the "forme fruste." Much of the confusion in the current literature on medical vs. surgical treatment of perforated ulcer is due to a failure to appreciate and distinguish between the three forms. "Frank" Perforation. The "frank" perforation is recognized clinioally by its sudden onset with severe acute abdominal pain and "board like" rigidity of the abdominal muscles. An x-ray study in the upright position or with the patient lying on the left side with the right side up will usually (85 per cent) show free air in the peritoneal cavity. Immediate laparotomy to close the perforation when done within six to eight hours of the onset assures a prompt and uncomplicated recovery. The advantage of the early operation is the control of peritonitis by closure of the perforation and the elimination of any doubt concerning the diagnosis. The "Slow Leak." The "slow leak" perforation gives milder symptoms. Abdominal tenderness and muscle spasm in the epigastrium or on the right side should make one suspicious. An x-ray of the abdomen in the upright position may show a pneumoperitoneum and clinch the diagnosis. A common cause for error is omission of this study. Contamination of the peritoneum soon becomes septic and the patient develops symptoms and signs that simulate perforative appendicitis. This is fortunate for operative intervention on a mistaken diagnosis will establish the correct diagnosis. A further lapse of time permits a large amount of exudate to fill the peritoneal cavity and favors the development of shock. The prognosis becomes poorer with each passing hour. After eighteen to twenty-four hours operation is not of constant value for the perforation may be sealed by plastic exudate, omentum or adjacent viscera. A program of management with suction of the gastric contents, restora-

40

Manuel E. Lichtenstein

tion of blood volume with whole blood, re-establishment of electrolyte and water balance by intravenous solutions of dextrose and minerals, and the control of infection with sulfonamides or antibiotics aid in restoring the patient and permit survival with or without complications. Subphrenic, subhepatic, abdominal or pelvic abscesses may develop and require drainage. Thus while immediate surgery is not urgent in the patient with a late diagnosis, surgical care for complications may be required. Elderly patients do not always respond with "boardlike" rigidity when perforation of an ulcer occurs. It is not suspected until peritonitis and shock occur. Failure to make early use of anx;-ray study to demonstrate

Fig. 3. Pneumoperitoneum. Note outline of superior surface of spleen. This is frequent in perforations into the lesser peritoneal cavity.

a pneumoperitoneum delays the diagnosis. Prompt surgical intervention will lower the mortality and morbidity rate in this condition. The following case report illustrates the tragedy of the delayed diagnosis and the value of an x-ray study of the patient with an acute abdominal condition. CASE IV. J. H., aged 72, a retired office clerk, consulted a physician complaining of pain in the chest, pain in the left shoulder, and diarrhea. He was given medication and returned for te-examination eight hours later. Because of some difficulty in breathing, shoulder and abdominal pain and diarrhea he was sent to a hospital with a diagnosis of possible early pneumonia. Here the abdomen was recorded as being slightly tender but soft. With other laboratory tests, an x-ray of the chest was ordered. The latter was taken at about 4 :30 P.M. but it was not studied at that time. Medication for pneumonia and diarrhea was given. On the following morning the roentgenologist viewed the x-ray film and noted a pneumoperitoneum (Fig. 3). On inquiry he found the patient was still in bed, sicker than he had been the night before and the abdomen was more rigid. In spite of the sudden interest and intensive therapeutic efforts the patient dien

Abdominal Emergencies Requiring Operation

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within 24 hours of admission to the hospital. At autopsy a perforation of a duodenal ulcer with diffuse peritonitis was found. On admission of this patient the abdominal findings were minimal and not suggestive of a perforation to the physician who made the examination, yet the patient already had a pneumoperitoneum recognizable on the x-ray film. The mild initial symptoms are typical of the response of elderly patients to pain. Their muscles do not react as readily to peritoneal irritation.

Fig. 4. Perforation of a duodenal ulcer in the newborn with pneumoperitoneum. Suture of perforation followed by recovery.

The x-ray is also of extreme value in infants and the newborn. Pneumoperitoneum demonstrable by x-ray suggests perforation of a hollow viscus and warrants immediate exploration. In a recent case a perforated duodenal ulcer was found on the third day of life (Fig. 4). The infant survived following closure of the perforation. "Forme Fruste" Perforation. The frustrated form of perforation seals off promptly, perigastritis soon resolves, and the exact cause of the patient's symptoms frequently go unrecognized. A pneumoperitoneum on roentgen examination may establish the diagnosis. Treatment is the same as in the "slow leak" although it need not be as intensive. The immediate danger is the risk of reperforation following a large meal. Anterior and Posterior Perforations. The anterior perforation occurs

Manuel E. Lichtenstein most commonly. It is easily recognized and can be closed promptly. The posterior ulcer may be more difficult of recognition. It must be exposed and sutured (Fig. 5).

Fig. 5 . . B, Perforated ulcer on the posterior surface of the duodenum. Exposure is made through the gastrocolic ligament (A). Closure is made with three sutures (e), which when tied hold a piece of omentum over the lesion (D). SU1Il1llary

The treatment of peritonitis has been stated succinctly as follows: "Remove the focus or close the leak." N onoperative treatment is reserved for the patient who is too late to be benefited by surgery. He should, however, receive the benefit of every therapeutic agent and device. ACUTE CHOLECYSTITIS

If every patient with gallstones had cholecystectomy done when free from acute symptoms, the high mortality rate and prolonged morbidity due to acute cholecystitis, acute hydrops, empyema, gangrene, perfora-

Abdominal Emergencies Requiring Operation tion with peritonitis, either diffuse or localized, stones in the common duct, jaundice, cholangitis, hepatitis, gallstone ileus, biliary fistulas, pancreatitis and carcinoma of the gallbladder would be markedly reduced or eliminated. Thus the recognition of stones in the gallbladder in a patient who has no contraindication to a major surgical operation is reason enough for suggesting removal of the gallbladder. When acute cholecystitis develops in a patient with gallstones, cholecystectomy done within 36 hours of its onset is as satisfactory a procedure as is appendectomy for acute appendicitis. However, the patient must be prepared for operation adequateJy and the course of the inflammatory process must not have progressed to the point where surgical manipulation will jeopardize recovery. Patients with acute symptoms first seen after 36 hours require a longer period for preparation. By the time they are sufficiently prepared for surgery with antibiotics, intravenous solutions of dextrose and minerals, and vitamin K, the inflammatory process shows signs either of subsiding or progressing to form a mass in the right upper quadrant of the abdomen. It would now be better to await further developments in the clinical course before undertaking surgery. Management

The Subsiding Phase. In the subsiding phase it is better to await resolution of the inflammatory process and to postpone cholecystectomy. After subsidence of the inflammatory reaction exploration of the abdomen is better tolerated and manipulations about the biliary passages may be carried out with less risk of injury to the ducts and vessels. The Progressing Phase. In the progressing phase, with evidence of sepsis and the development of a mass in the right upper quadrant, drainage of the bladder and the subhepatic space will relieve the patient. Cholecystectomy should be postponed until a favorable interval free from acute or subacute inflammation is established. Acute cholecystitis is not a static process. Treatment for this condition varies according to its clinical course and the phase of development of the process at the time the patient is first seen. Much of the confusion concerning treatment of this condition is due to a failure to appreciate the changes in the local process and their effect upon the patient. Thus the patient who has already tried home remedies and has otherwise delayed specific medical care for several days is not a candidate for immediate cholecystectomy. Loss of intestinal secretions as well as abstention from food and water leave a deficit in water and electrolyte balance. Infection may complicate this clinical picture. The patient requires intravenous fluids for nutrition, hydration and remineralization; the administration of sedatives, antispasmodics, antibiotics and vitamins. Choice of Operation. 8urgical intervention is urgent and may be lifesaving when drainage is established from an abscess following perfora-

44

Manuel E. Lichtenstein

tion or gangrene of the gallbladder with leakage into the peritoneal cavity. Cholecystostomy will prevent perforation of a distended or gangrenous gallbladder. Cholecystectomy is the ideal operation when done before the disease process has become acutely involved with adjacent organs and unfavorable systemic changes have developed. SUIllIllary

In acute cholecystitis the selection of surgical or nonsurgical therapy depends on the status of the patient and the progress of the local disease. It is better to postpone surgery in the subsiding phase and perform cholecystectomy when conditions are ideal for this operation. In the progressive phase of the disease, drainage of an abscess and drainage of the gallbladder will relieve the patient. Cholecystectomy will be better tolerated with less risk when the inflammatory process has subsided. Patients will profit most when the attending surgeon adapts the treatment to his patient and acts according to his experience and capabilities. INTESTINAL OBSTRUCTION

Etiology

Acute mechanical intestinal obstruction is a local condition in the bowel that is brought on by a variety of causes. The most common is the external incarcerated hernia. The femoral hernia is the one most frequently overlooked in the elderly patient with mild gastrointestinal symptoms. Adhesions or bands from previous abdominal surgery are next in frequency. Strangulation obstruction occurs more frequently in external hernias and as a result of postoperative bands than from any other cause. When no hernia or scar appears an the abdominal wall the cause of acute obstruction varies with the age of the patient. In the newborn, atresia, stenosis and imperforate anus; in infants, intussusception; in children and young adults, Meckel's diverticulum, congenital bands or acquired adhesions from previous infection, mesenteric defects or internal hernias; in older individuals, lesions of the small bowel and colon; and, in the elderly patient, carcinoma, volvulus or diverticulitis of the colon are the usual causes for acute intestinal obstruction. Diagnosis

If surgical operation were done promptly on the basis of a diagnosis made early in the course of acute bowel obstruction, deaths from peritonitis, sepsis and shock associated with strangulation of bowel would be less frequent, and the prolonged disability from the effects of vomiting, distention and toxemia would be proportionately reduced.

Abdominal Emergencies Requiring Operation History and Inspection. Early diagnosis is based on a proper evaluation of the history and the physical examination. An external hernia should be obvious on inspection. An abdominal scar, an old chest wound (diaphragmatic injury) or a history of an old abdominal injury may be a clue to the cause of the acute obstruction. The character of pain should lead one to suspect the diagnosis. Generalized colicky pain without localization of an inflammatory process indicates obstruction. Vomiting occurs with small bowel obstruction and repeated vomiting may become excessive and violent in strangulation. Vomiting is infrequent or absent with large bowel obstruction. In the early case distention, dehydration, obstipation, infection or signs of shock may not be present. These are all late manifestations of the condition and should be prevented by early surgery. Palpation. Abdominal tenderness is usually absent or mild as long as the obstruction remains incomplete or vascular impairment is not present. Strangulation is to be suspected when the onset is associated with intensely severe colicky pain, when fever appears early and when the course is rapidly progressive. In such cases abdominal tenderness is diffuse and more marked, rebound tenderness is often preEent, and there is considerable tenseness of the abdominal wall. This is an urgent indication for surgery. Percussion. Percussion of the abdomen elicits a tympanitic note if distention is present. When the obstruction is in the small intestine, flatness is often noted in the right flank as the result of collapsed ascending colon and terminal ileum. A uscultation. Auscultation yields the pathognomonic sounds-borborygmi. These result from vigorous activity of normal or hypertrophied bowel when distended with gas or fluid. Their resonant quality is characteristic whether the sounds are "loud and booming" or are only heard as a "silvery whisper." Normal peristaltic sounds recur regularly and become louder in the presence of slight obstruction. In the presence of greater obstruction there are short, silent intervals followed by a rush of bubbling sounds and then another period of silence. As the obstruction becomes more complete, the rushes become fewer and fainter and the silent intervals longer. The sounds also become higher pitched and may finally survive only as silvery metallic tinkles. With complete obstruction, the abdomen is silent. In the absence of a history of infection this is a positive indication for surgery. Roentgen Examination. The x-ray film is an important aid in the early diagnosis of small or large bowel obstruction. Films exposed in the horizontal position show the gas pattern typical of each while those taken in the vertical position demonstrate fluid levels. These give the location of the lesion and indicate its probable nature. The presence of pneumoperitoneum indicates perforation has taken place from necrotic bowel due to strangulation or necrosis from excessive distention.

Manuel E. Lichtenstein Treatment

The procedures necessary to relieve obstruction vary according to its cause. 1. Enlargement of a narrow ring in incarcerated hernia. Repair of the hernia is secondary. It should not be done when the abdomen is tense due to distention or obesity. 2. Reduction of an intussusception. Mi d l1ut

Celiac a.

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.Left l1astcic a.

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colon

Di~estion

Absorption

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Fig. 6. The three embryologic divisions of the gastrointestinal tract are delimited by the distribution of three vessels from the abdominal aorta. The foregut supplied by the celiac axis is concerned with the process of digestion. The midgut supplied by the superior mesenteric artery is concerned with the process of absorption. The hindgut supplied by the inferior mesenteric artery is concerned with excretion of the nonabsorbed residue.

3. Severance of a band, congenital or acquired. 4. Decompression of large bowel by cecostomy or colostomy for distal lesions as carcinoma or diverticulitis. 5. Incision of the bowel to remove a gallstone, dental plate, peach pit or other obstructing agent. 6. Excision of a benign tumor such as polyp, lipoma or angioma, Meckel's diverticulum, Littre hernia and Richter hernia. 7. Resection of bowel (a) because of gangrene following strangulation, volvulus or intussusception, (b) for removal of a primary lesion with its mesentery.

47

Abdominal Emergencies Requiring Operation

8. Exteriorization of large bowel where resection is impossible. Provision for restoration in continuity must be made. 9. Sidetracking entero-anastomosis when an irremovahle mass involving bowel is the cause of obstruction. 10. Drainage of an abscess causing complete obstruction. Midl\'ut

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Jejunum

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l

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Lett Colon

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HIGH OBSTRUCTION Vomitinfi'

INTERMEDIATE OBSTRUCTION Vomitin\1' and distention

LOW OBSTRUCTION Distention

FIG. 7. The midgut includes the jejunum, ileum and the right half of the colon. The jejunum is large in caliber and thick-walled with many vessels to supply the fluid needed for succus entericus. A rapid peristalsis carries this fluid and the food with which it is mixed to the ileum. Here absorption occurs and the residual fluid is taken up by the right half of the colon. Thus the high obstruction occurs in that part of the intestinal canal in which absorption is minimal. The low obstruction occurs in the hindgut after food and water have been absorhed. The intermediate obstruction lies between the former two.

All of these procedures when done in the appropriate case relieve the patient and permit recovery with the least risk of complications. The details of technique for each are described in all standard works on surgical technique. Carcinoma is the commonest cause of acute mechanical obstruction of the colon. Diverticulitis, too, may do the same. Differences in the anatomy and physiology of the large and small bowel are responsible for the variations in the clinical responses to obstruction (Figs. 6 and 7). The thinner wall and poorer blood supply of the right colon under pres-

48

Manuel E. Lichtenstein

sure make it subject to perforation (Fig. 8). When the ileocecal valve is competent a "closed loop" colon obstruction develops. Cecostomy is the most satisfactory procedure for decompression of the markedly distended colon. The location of the vent does not interfere with subsequent resection of the colon when this is necessary. Supportive Therapy. Supportive therapy consists of maintaining the well-being of the patient and guarding against shock, infection, hypohydration and the alterations in the chemical status of the blood due to

Fig. 8. Pneumoperitoneum following perforation of the cecum in complete large bowel obstruction due to a tumor at the rectosigmoid. Cecostomy and aspiration of the peritoneal fluid was followed by recovery. Three weeks later exploration of the abdomen disclosed extensive metastasis to the peritoneum and liver.

renal impairment or mineral loss. Antibiotics such as penicillin, streptomycin or Terramycin are used. If infection fails to respond, search for an abscess must be made. If this is not present, cultures to reveal the organism will be needed to select a more specific antibiotic or sulfonamide. Intravenous Fluids. Whole blood is used in an amount necessary to bring the red cell count, hemoglobin and hematocrit to the average normal level. Five per cent dextrose in water or 10 per cent levulose in water will hydrate the patient, prevent acidosis and improve renal functions. Normal saline, Ringer's solution, Hartman's solution and Darrow's solution supply the necessarv mineral>! to hring the sodium. potassium.

Abdominal Emergencies Requiring Operation chlorides and bicarbonates to the proper level. The use of laboratory t,ests to determine the level of deficiency and as a check on the amount administered is necessary. N asogastric suction will prevent and relieve distention in the stomach and intestinal canal. Sum.m.ary

The difficulties in the management of acute intestinal obstruction are due to delay in diagnosis and delay in instituting appropriate treatment soon enough. The procedures necessary to relieve the patient are listed and the basis for supportive therapy noted. MESENTERIC EMBOLISM AND THROMBOSIS

Mesenteric embolism and thrombosis are difficult to diagnose. Bowel sounds are absent or feeble. The x-ray film shows distention of both large and small bowel as in adynamic ileus. Adynam.ic Ileus

The common causes are: (1) peritonitis, (2) renal and gallbladder colic, (3) spinal cord and severe central nervous system injury, (4) retro- . peritoneal hemorrhage from any cause, (5) blunt abdominal or operative trauma, (6) prolonged ether anesthesia, (7) infectious fevers and severe general sepsis, and (8) embolism and thrombosis of the mesenteric vessels. The commonest cause of mesenteric artery occlusion is an embolus arising from the valves of the left side of the heart in a patient with serious cardiac disease. Conditions with which venous thrombosis of the mesenteric vessels is most commonly associated are: (1) postoperative splenectomy with extension of the thrombus from the splenic vein into the superior mesenteric vein, (2) hepatic disease, and (3) acute abdominal infections. In the arterial type a limited bowel resection may be necessary. In venous thrombosis involving extensive segments with associated vascular spasm, the use of anticoagulants, procain and papaverine may be of some value. HEMORRHAGE AND NONTRAUMATIC RUPTURE OF VISCERA OR CYSTS

Hemorrhage into the peritoneal cavity, retroperitoneal spaces, or both, frequently give alarming abdominal symptoms followed by collapse and profound shock. The need for urgent care is obvious. The etiology may not be clear, but blood replacement is started and an effort made to establish a working diagnosis.

50

Manuel E. Lichtenstein

Ectopic Pregnancy

The "ruptured" ectopic pregnancy with typical history and findings does not present a problem, for the timely exposure and removal of the involved tube stops further loss of blood. More difficult is the diagnosis of ectopic pregnancy with repeated small hemorrhages. On examination a small mass occupying the position of a tube may be found. A likely history presumptive of pregnancy, the finding of blood on diagnostic puncture of the cul-de-sac, or an elevation in the quantitative van den Bergh test warrants exploration of the abdomen. Removal of the involved tube will prevent the possibility of a sudden exsanguinating hemorrhage. Hemorrhagic Corpus Luteum

Rupture of a corpus luteum with severe hemorrhage presents the same symptoms as intraperitoneal hemorrhage from an ectopic pregnancy but there is no evidence of pregnancy. Rupture of Intra-abdominal Blood Vessels

Arteriosclerotic Vessels and Aneurysms. Rupture or leakage from a . diseased vessel in an elderly patient is usually accompanied by acute abdominal pain frequently followed by nausea, vomiting and collapse. On examination there is evidence of cardiovascular disease. Locally, a tender mass is felt. Abdominal aneurysms other than arteriosclerotic may perforate and form a mass in the retroperitoneal space with encroachment upon a ureter, the bladder or rectum. Conservative management is desirable but continued hemorrhage with a reduction in hemoglobin, red cells and hematocrit in spite of blood replacement may make exploration for control of bleeding urgent. Abdominal Apoplexy. A clinical syndrome has been described of signs and symptoms correlated with the progressive stages of hemorrhage. Perforation of a mesenteric vessel occurs with or without injury, physical strain or exertion and bleeding takes place between the leaves of the mesentery. There occurs dull, "dragging," "pulling" or "tearing," often severe, persistent and increasing abdominal pain which gradually subsides but often recurs. Renewal of hemorrhage follows any exertion, such as eating, vomiting or catharsis. If the hematoma ruptures into the peritoneal cavity, sudden severe, diffuse pain with shock and collapse occurs. The decision for or against surgical intervention depends upon the amount, duration and recurrence of bleeding but rupture into the peritoneal cavity makes abdominal exploration urgent. Blood clots are evacuated, and bleeding points are ligated by transfixion sutures in the mesentery. Rupture of Utero-ovarian Veins. Hemorrhage from ruptured utero-

Abdominal Emergencies Requiring Operation

51

ovarian veins during pregnancy produces sudden unilateral abdominal pain which may become diffuse and be followed by shock. The diagnosis of the exact cause of bleeding is difficult unless this syndrome is kept in mind. Bleeding confined to the posterior retroperitoneal spaces produces unilateral flank pain. Bleeding into the peritoneal cavity produces peritoneal irritation that quickly spreads to the entire abdomen. The following brief case report illustrates the features of this syndrome. CASE V. M. S., aged 28, pregnant 26 weeks, developed pain and tenderness in the right flank. The initial diagnosis was acute appendicitis. At operation through a limited muscle~splitting incision a discolored hemorrhagic ovary was found and removed. Postoperatively the patient did not do well. She became distended and presented the picture of adynamic ileus. When this was relieved, after one week, she presented the picture of shock and profound anemia with a considerable amount of fluid in the peritoneal cavity. Exploration of the abdomen now disclosed the peritoneal cavity and retroperitoneal space filled with blood. There was active bleeding from the right utero-ovarian veins. These were difficult to control by ligation because of extensive infiltration of blood into the tissues about the ureter. A pack was used for compression. This was removed after five days. An uneventful postoperative course followed except for miscarriage at the time of surgery.

Postoperative Hem.orrhage

This may occur from slipping of a ligature on an important vessel. An open appendiceal artery may lose enough blood into the peritoneal cavity to produce shock and collapse. Failure to occlude splenic veins following splenectomy may do the same. Reoperation to control hemorrhage is indicated in these or any other circumstances characterized by loss of blood into the peritoneal cavity. Gastrointestinal Hem.orrhage

Hemorrhage from the gastrointestinal canal may require urgent surgical attention to control bleeding. 1. Gastric hemorrhage from a gastric or duodenal ulcer does not always respond to conservative management. Unless transfusions are given to prevent deterioration in the patient's condition, death may occur from open vessels in the ulcer. Operation is done promptly for recurrent persistent massive hemorrhage as soon as recovery from initial shock takes place and adequate preparation by transfusions for the operative procedure are completed. Gastric resection is the procedure of choice. 2. Colon hemorrhage may be massive. The patient who is exsanguinated from loss of blood and has already received a dozen or score of blood transfusions without cessation in bleeding requires exploration for control of the bleeding point. As soon as the initial shock is overcome with adequate blood replacement the abdomen is opened and the intestinal canal is inspected for the level of blood accumulation. The absence

52

Manuel E. Lichtenstein

of blood above the ileum indicates bleeding from the colon. The colon is exposed and the site of hemorrhage established. Right hemicolectomy, left hemicolectomy and sigmoidectomy are the segmental resections that afford ligations of main vessels to control bleeding. 3. Recurrent hemorrhage from the gastrointestinal canal in a patient who has had several complete and thorough gastrointestInal studies which did not disclose the source of blood loss should be explored very early in the course of the next hemorrhage. The upper level of blood in the bowel is a clue to the site of the bleeding point. MISCELLANEOUS

Miscellaneous acute abdominal conditions which require surgery may be encountered when operation is undertaken for any of the conditions mentioned previously. For example, torsion with gangrene of the omentum, a pedunculated fibroid, an undescended testicle or' hydatid of Morgagni, and rupture of a chylous, pancreatic or ovarian cyst may produce a variety of symptoms of varying intensity. Preoperative diagnosis is unusual, the diagnosis usually being made at the time of operation. Postoperative dehiscence of a wound with evisceration is an obvious reason for wound closure. This may be done with interrupted, full thickness, nonabsorbable sutures. 25 E. Washington Street Chicago 2, Illinois