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Basis for planned management in intestinal obstruction
BASIS FOR PLANNED MANAGEMENT OBSTRUCTION*
IN INTESTINAL
MANUEL E. LICHTENSTEIN,M.D. Chicago, Illinois
S
IMPLE intestina1 obstruction does not aIways require relief by surgica1 means. In many instances obstruction has been overcome foIIowing a period of pIanned management designed to reIieve the patient of the effects of vomiting and to reIieve the intestina1 cana of distention, with its effects on the genera1 condition of the patient and the IocaI condition in the bowe1. This pIanned management has been caIIed conservative therapy but it is not opposed to surgery when the Iatter is indicated. Obstruction which accompanies or foIIows acute inffammation within the abdomen may be reIieved by treatment directed toward overcoming the inffammatory process. The use of antibiotics or suIfonamides and intravenous infusions of bIood, dextrose, proteins and mineraIs with drainage of an abscess when indicated frequentIy reIieves obstruction. When adhesions foIIowing one or more abdomina1 operations are the cause of obstruction, a period of conservative management may be folIowed by compIete reIief, thereby avoiding the addition of more adhesions by another operation. In some instances, using the same conservative means, compIete obstruction in a sick patient may be converted into an incompIete obstruction and permit improvement in the patient’s condition before surgery is undertaken; whiIe in others sufficient improvement may occur to permit preparation of the patient for what may be an extensive or serious operation in spite of the persistence of the compIete obstruction. Thus conservative management of simpie intestina1 obstruction is not onIy a therapy for the condition but aIso a means * From the Division of Surgery,
of preparation of the patient for the surgica1 reIief of obstruction when this is found to be necessary. The time required for successfu1 conservative therapy is not important so Iong as satisfactory progress is being made. However, persistence in this form of management without evidence of improvement, such as deffation of the bowe1 with a return of norma peristaIsis, is hazardous and surgery must not be deferred. Conservative management must not be confused with negIected or deIayed management which favors disabIing compIications or death. Surgery without deIay is especiaIIy urgent in stranguIation obstruction. In cIosed Ioop obstructions of the Iarge bowe1 immediate decompression is necessary and surgery shouId be done when it is found that recta1 or coIonic irrigations do not reIieve the obstruction. The iIIness of the patient in acute intestina1 obstruction varies in intensity with the grade of the obstruction (compIete or incompIete), its duration, its IeveI in the intestina1 cana (high, intermediate or Iow) and the extent of vascuIar impairment in the invoIved section of bowe1. These factors determine (I) the amount of fIuid and minera Ioss through vomiting or stagnation in the intestina1 Iumen; (2) the extent of intestina1 distention; (3) the severity of toxemia and infection which foIIows gangrene (actua1 or impending) of the invoIved bowe1; and (4) the bIood changes associated with shock, uremia, aIkaIosis, acidosis, hypohydration, etc. AI1 of these factors play a roIe, to a greater or Iesser extent, in the production of symptoms following obstruction due to any of the Iarge variety of pathoIogic Iesions responsibIe for inter-
Northwestern University MedicaI School and the Cook County Graduate of Medicine, Chicago, III.
362
American
Journal
School
of Surgery
Lichtenstein-IntestinaI ference with the passage of intestina1 contents distally in the intestinal canal. Duration. A thorough analysis of the history of the patient’s compIamt, a compIete physical examination and the necessary Iaboratory work frequentIy aid in
Di#estion
Absorption
Obstruction
363
understood folIowing a review of the functionaI anatomy of the intestinal tract. The gastrointestinal canaI embryoIogicaIIy is divided into three divisions: the foregut, the midgut and the hindgut. (Fig. I.) Anatomicahy the foregut is that portion of
Excretion
FIG. I. The three embryologic divisions of the gastrointestinal tract are deIimited by the distribution of three vessek from the abdominal aorta. The foregut supptied by qhe celiac axis is concerned with the process of digestion. The mid-gut 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 non-absorbed residue.
establishing the correct diagnosis before irreversible changes take pIace. The longer the duration the more extensive became the changes in bIood and body tissues and the Iess effective became the propulsive and constrictive efforts of the intestina1 muscuIature. When the bIood suppIy to the boweI is involved, the more certain is the danger of necrosis, peritonitis, shock, toxemia and sepsis. Immediate rehef is imperative. In the presence or absence of strangmation the prompt institution of correctiona therapy as outlined herein wiII obviate many of the unfavorable consequences of proIonged interference with the Aow of intestina1 contents. Level of Obstruction. The variation in symptoms due to obstruction at different IeveIs in the intestina1 cana may be better
September, 1949
the digestive tract which receives its bIood suppIy from the celiac axis of the aorta. PhysioIogicalIy, these organs are concerned with the processes of digestion. AnatomicaIIy, the midgut receives its bIood suppIy from the superior mesenteric artery. The organs suppIied by this .vesseI are the jejunum, iIeum and right half of the coIon. (Fig. 2.) PhysioIogicaIIy, this portion of the intestina1 canal is concerned with absorption. The process of absorption invoIves the seIection of food substances in a reIativeIy dilute state from the intestina1 canaI. If there is but a smaI1 amount of Auid avaiIabIe, absorption may be decreased or deIayed since the passage of materiaIs from the lumen to the bIood stream is a function of the osmotic tension of the soIutes in the bowe1 and that of the bIood in the intestina1 vessels. Therefore,
Lichtenstein-IntestinaI
364
Obstruction maining in the iIeum. The third portion of the midgut is the right half of the coIon. This portion of the bowel absorbs water and saIts. Thus there is no loss of the materiaIs which are secreted into the intestina1 cana for the purpose of preparing food for absorption.
it is necessary for a Iarge amount of water to be secreted into the intestinal lumen. This phase of absorption, diIution of food, is made possibIe by the secretion of succus entericus into the jejunum. The jejunum has a very extensive arteria1 suppIy which furnishes the blood necessary for the pro-
Food
Stomach;
**.*.
*
Dud. j Jejunum
HtGi-i OBSTRUCTION Vomitinq
4
I
Water salts
Ileum
I
,
INTERMEDIATE OBSTRUCTION Vomitlnf and distention
LOW OBSTRUCTION Distention
FIG. z. The mid-gut incIudes the jejunum, iIeum and the right haIf of the colon. The jejunum is Iarge in caIiber and thick-waIIed with many vesseIs to suppIy the Auid needed for succus entericus. A rapid peristaIsis carries this fluid and the food with which it is mixed to the ileum. Here absorption occurs and the residual Auid is taken up by the right haIf of the coIon. Thus the high obstruction occurs in that part of the intestinal cana in which absorption is minimal. The low obstruction occurs in the hindgut after food and water have been absorbed. The intermediate obstruction Iies between the former two.
duction of succus entericus. PhysioIogitally, IittIe absorption of water or saIt occurs here. The second portion of the midgut is the iIeum. In the iIeum most of the food is actuaIly absorbed. It is we11 known that chronic diseases invoIving the ileum are frequentIy associated with nutritiona1 disturbances such as anemia and hypovitaminosis. WhiIe the iIeum may absorb Iarge quantities of water and saIts, this wouId be disadvantageous since absorption of water here would concentrate the intestina1 contents and diminish absorption of the nutritiona eIements re-
AnatomicaIIy, the hindgut is suppIied by one bIood vesse1, the inferior mesenteric artery. It incIudes the Ieft haIf of the colon, sigmoid and rectum. The function of the hindgut is to store the non-absorbed residue of the intestina1 contents and at intervaIs to expe1 this materia1 from the intestina1 canal. The foregut and the first portion of the midgut have secretions poured into their Iumens. BeIow the jejunum absorption removes fluid from the intestina1 cana1. IntestinaI obstruction in the jejunum prevents the passage of secretions to the
American
Journal
of Surgery
Lichtenstein-IntestinaI absorptive portion of the intestina1 canal. These secretions either stagnate or are removed by vomiting. Obstruction above this IeveI is caIIed high intestina1 obstruction. Obstrdction beIow the IeveI of the jejunum Ieaves a progressiveIy Ionger portion of the intestina1 surface avaiIabIe for absorption. Obstruction in the absorptive portion of the intestina1 cana may we11 be caIIed intermediate intestina1 obstruction. Obstruction in the Ieft haIf of colon does not interfere with absorption of the fluids poured into the intestinat cana1. WhiIe there may be no immediate Ioss of fluids from the body, the primary diffIcuIty is the inability to expe1 the non-absorbed residue. This resuIts in distention which is characteristic of Iow obstruction. In high obstruction intestinal secretions cannot be absorbed. In Iow obstruction absorption may occur with but sIight impairment for a Iong period of time. It is cIear, then, that high obstructions are most serious since the patients become iI sooner from Ioss of fluids and salts and the symptoms are more pronounced. In these patients who have low obstruction many days may pass with few symptoms. Vomiting. Obstruction above the ampuIIa of Vater resuIts in vomiting with Ioss of gastric secretion. The Ioss of water and chlorides results in chemical changes in the circulating bIood. HydrochIoric acid formation in the stomach is associated with a decrease in chlorides and repIacement of carbonic acid with bicarbonate in the bIood stream. The foIIowing formuIa indicates the probabIe mechanism of hydrochloric acid formation : Stomach Blood r 1 NaHzPOa + NaCI + HCl(PROTEIN) Na2HP04 + HKOZ + NaHC03 T 1 BIood Blood In CelI
The is not takes bined in the
In CeII $ Na2HP04 + NaHzPOd
hydrochIoric acid in the gastric ceI1 free (Iest corrosion of the tissues pIace) but is Iiberated from its comprotein by the action of chloresterase lumen of the stomach.
September,
I 949
Obstruction
3%
NormalIy the chIorides secreted into the stomach are returned to the bIood stream by absorption from the intestina1 cana1. ChIorides Iost in the urine and sweat are repIaced by salt in the ingested food. The bicarbonate resuIting from hydrochIoric acid formation appears in the pancreatic and intestina1 secretions and in the urine (alkaline tide). When absorption is impossibIe, as in high obstruction, vomiting prevents the absorption of chIorides secreted in the stomach and prohibits ingestion of chlorides present in food. This resuIts in bIood changes characterized by a decrease in blood chIoride, an increase in blood bicarbonate and a shift in the bIood pH toward greater aIkaIinity. If this condition continues, the bIood changes may become profound and give rise to aIkaIosis. This condition is characterized by an increase in non-protein and urea nitrogen in the blood and, if progressive, uremic symptoms may deveIop. Vomiting foIIowing obstruction lower in the intestina1 cana removes gastric secretion, pancreatic secretion, bile and succus entericus. (Fig. 3.) This is associated with a Ioss of water, carbonates, bicarbonates and sodium. Definite bIood changes occur. There is a decrease in bIood bicarbonate, a shift in the bIood pH to decreased aIkaIinity and a decrease in bIood sodium. The tissues Iose their capacity to hold water because of the Ioss of sodium. In the past many of the symptoms resuIting from these Iosses were attributed to toxemia. It appears that the symptoms are more IikeIy due to the pathoIogic state associated with the blood changes which foIIow excessive vomiting. It has been pointed out that the most constant change and the one which gives the best index of the true condition of the patient is the eIevation of bIood urea. This results not onIy from vomiting but also from the increased metaboIism of endogenous protein which occurs in the presence of intestina1 obstruction. The Ioss of chIoride varies with the amount of vomiting. The IeveI of the carbon dioxide combining power is variabIe but in general
Lichtenstein-IntestinaI
366
in the presence of decreased chIorides it is eIevated (alkaIosis) and in the presence of normal vaIues for chIoride it is norma or decreased (acidosis). Under the inffuence of satisfactory treatment, whether conservative or surgica1, the bIood chemica1
Obstruction of vomiting and fluid stagnation. Under norma circumstances the average individual excretes from 5 to IO Gm. of sodium chIoride daiIy depending on his or her activities, occupation, natural habits of diet, etc. When no saIt is ingested, urinary
Saliva 1,s 00 cc. Bile 500 cc. ‘\\
L/
“YL+ --
N&I.
juice
2,soocc *- _ _ .::.I : ..I ,,<;y,,:,--‘V ~,~ _.<“;:y :: ; ‘:.y,. yi’ .:.;“.‘.‘~:,‘;,: ,.,,’;.,; w-I_ \ .....,. (,.....‘Z ‘.:..:,.,. ,. .:_.
“Pancreatic juice 700 cc.
:::,.~..~.,~:
Vol
Secretion
ric
Saliva
I,500cc.
Bile
7 gms.
500 cc.
Gastric
juice
2,soocc.
Pancreatic
juice
Intestinal
Secretions
7 ffrnr
.I5 qms.
7oocc.
8 fms.
3,ooocc.
I8 qms.
8,200cc
55 qms.
3,500cc.
23 fms
8.
&
u
ihestinal secretions 3,ooocc.
Total
plasma
volume
FIG. 3. The volume of secretions and sodium chloride content derived from the gastrointestinal cana1; continuous absorption is necessary to maintain the plasma voIume. Loss of secretions from the gastrointestinal canal is reflected in the Ioss of pIasma volume and bIood chlorides.
vaIues return to normal, the urea usuaIIy more sIowIy than the other vaIues. In view of this the first indication for therapy when vomiting occurs is the repIacement of the materiaIs lost both quaIitatively and quantitativeIy. The patient who vomits not only Ioses fluids from the body but aIso does not receive fluids which are the daiIy body requirement for the eIimination of waste and reguIation of body temperature. Under norma circumstances the average individua1 requires from 2,000 to 3,000 cc. of water daily for the purposes of eIimination and temperature regmation. In addition to the fluid Iost through vomiting a considerabIe amount of fluid may be immobihzed in the nonabsorbing portion of the intestina1 cana which, because of distention and vascular damage, may be non-functioning. Thus the tota water requirement may vary between 3,000 and 5,000 cc. when the patient is first seen. The Ioss of salts varies with the amount
excretion may remove less than 5 Gm. in twenty-four hours. When the bIood vaIue for sodium chIoride drops from the average of 650 mg. to the critica IeveI of 520 mg., chIoride secretion in the urine may drop to o. Thus at least 5 Gm. of sodium chIoride is necessary to maintain the bIood chIoride IeveI. Gastric juice has approximateIy 4 Gm. of chIoride in 1,000 cc. The amount of saIt to be administered to the patient must incIude the daiIy normal requirement pIus the amount Iost through vomiting and the amount immobiIized in the Iumen of the intestina1 cana1. These amounts vary in different patients. It is unfortunate that a bIood chIoride determination does not aIways aid in estabIishing the degree of chIoride 10s~. TabIe I indicates norma vaIues in the bIood. Profound changes in the bIood resuIting from hypohydration, etc., may be determined by the use of a few Iaboratory tests. However, earIy in obstruction the tendency for homeostasis to maintain norma vaIues in the bIood in American
Journal
of Surgery
Lichtenstein-IntestinaI makes such spite of tissue depletion determinations of less vaIue than a clinical estimate of the patient’s condition. A guide to the amount of Auid necessary to restore the fluid baIance is the quantity of urine secreted. Since water for evapora-
Plasma
NaCI ........ ........ Na .................... CI ................. K ... ............. Ca.
650 340 370 20 10
................
Obstruction
depends on the patient’s requirements. Tht patient is in need of sodium chloride but the quantity of this mineral must be administered in proportion to the patient’s needs. It may be noted (TabIe II) that 4,000 cc. of isotonic saIt soIution contains
TABLE
-
I WhoIe BIood
CeIIs
0 I90
Fe cu
2.7 0. I
................. .................
200 5
3 4 45 0.1 0.01
6 100
1949
[
1.5:1-2:
13 -15 4.5-5.0
Gm. miIIion
Male 42-48 Female 39-45 S.G. BIood I.057 Serum 1.025
I:20
tion to reguIate body temperature has a priority, a scant income wiI1 show a diminished urinary output. The patient shouId be supplied with that quantity of fluid which wil1 afford the eIimination of 1,000 to 1,500 cc. of urine with a specific gravity that varies between 1.010 and 1.020. It is necessary to record the urinary output and keep a record of the voIume injected since the administration of too much fluid may waterIog the patient. It has been found desirabIe to administer 3,000 cc. of fluid intravenously at the rate of one drop per second by continuous infusion over a tweIve-hour period. To suppIy as much as 6,000 cc. when this amount is deemed necessary (this is unusuaI), it may be given at the rate of one drop per second over a period of twenty-four hours. A rapid administration of fluids to a hypohydrated patient increases the urinary output without hydrating the patient. The fluid passes from the bIood stream into the kidneys and is eliminated with a very low specific gravity. This is a waste of fIuids when hydration is desired aIthough it may be desirabIe when toxins are to be eliminated. The quaIity of the soIution administered
80-120 mg. 6.7-7.6 Gm. 0.27 2.7 (I .5-3) 4. I (3.8-6)
Hematocrit
7.45
-
September,
Dextrose Proteins Fibrinogen Serum gIobulin Serum albumin Ratio:A:G Hb RBC
250
420 0
..................
Iodine ................ CO*: (HCOJ .......... pH ..................
BIood Serum
160
P ................... Mg
36:
36 Gm. of saIt. This amount may be much more than is necessary for the patient and may be harmfuI in that the kidneys may not be abIe to eliminate the excess promptIy enough. This wiI1 result in the TABLE INTRAVENOUS
II
SOLUTIONS
-
IOther
NaCI
0.9% NaCI.. ........... 5.0 y0 Dextrose. ......... 5.0 Dextrose in 0.9%
NaCI ................ 2.5v0
Dextrose
GM./I,OOO
SaIts
CC.
-
Dextrose
Proteins
9.0 0.0
9.0
in .45%
NaCI ................ Ringers SoIution. ....... Hartmans Solution. ..... PIasma. ............... Amigen ................
Parrnamine ............ Aminosol. .............. WhoIe BIood Citrated
...
4.5 8.6 6.0
.6 3.6 8.0
9.0 2.0 1.0 0.0 6.5
0.5 4.0
-
25 I
I
67.0 50 60 5o 50 0. 5 35
50
storage of saIt in the body tissues, with the deveIopment of edema. If the patient aIready has renaI damage, the abiIity to eIiminate saIt may be so impaired that edema wiI1 appear more promptIy. One
368
Lichtenstein-IntestinaI
should, therefore, gauge the amount of salt necessary by the voIume of the vomitus plus the amount of secretion that may be removed from the intestina1 cana by suction and the estimated amount of stagnant secretion in the intestina1 lumen. TabIe II lists isotonic soIutions which may be of vaIue in intravenous therapy. The mixture 2.3 per cent d ex t rose with .425 per cent sodium chloride is a most desirabIe soIution because its continuous administration will avoid the possibility of suppIying too much or too IittIe salt. It is an isotonic sohition 4,000 cc. of which contain but 17 Gm. of sodium chIoride. This amount frequentIy is an adequate amount in a twenty-fourhour period for the average individua1 with complete intestina1 obstruction. In the absence of vomiting 4.5 to g Gm. of saIt wiI1 suffice. The continuous use of .g per cent sodium chIoride with or without 5 per cent dextrose supphes too much saIt. The use of 1,000 cc. of isotonic sodium chIoride in distiIIed water or 250 cc. of 2 per cent sodium chIoride as an initia1 dose heIps to restore more promptly the immediate chIoride and sodium shortage. The patient who is neither vomiting nor losing gastrointestina1 secretions by suction or diarrhea is not in need of much saIt. The use of 2.5 per cent dextrose in .45 per cent sodium chIoride soIution is safer since it avoids overmineraIization when doubt exists as to the need for sodium chIoride. Distention. Distention of the abdomen in intestina1 obstruction is caused by the accumuIation of gas and the immobihzation of ffuids in the intestina1 cana1. The gas content represents for the most part (70 per cent) swaIIowed air. The remainder is derived from fermentation or putrefaction of intestina1 contents and from the diffusion of gas from the bIood stream into the Iumen of the bowel. The immobiIization of fluids in the intestina1 cana is due to decreased peristaIsis in compIete obstruction, decreased absorption, venous stagnation and a continuous secretion due to secretagogue stimuIation.
Obstruction
The resuIts of distention are: (I ) portal stagnation; (2) changes in the mucous membrane; (3) toxemia; (4) peritonitis; (5) thoracic disturbances; and (6) a decrease in volume and increase in concentration of the circuIating bIood. PortaI circuIation is assisted by active intestinal motiIity. In compIete obstruction with distention, a marked reduction in motiIity occurs. This decreases the voIume of portal circuIation. When peristalsis returns, the bacteria1 Iaden bIood floods the Iiver and produces the changes which in the past have been responsibIe for the death of the patient foIIowing reIief from the obstruction. Dragstedt has shown that Corynebacterium botuIinum toxin is absorbed by the mucous membrane in an obstructed Ioop of bowe1 but it is not absorbed by the mucous membrane in the unobstructed bowe1. The alteration in the seIective absorption of the mucous membrane may account for the toxic symptoms which appear in this condition. In the presence of distention diffusion of toxins of non-bacteria1 origin through the intestina1 walI occurs. It is thought that these toxins may be absorbed by the Iymphatics and carried to the blood stream. The nature of the toxemia and the origin of the toxins independent of the aIterations in the bIood are as yet not fuIIy understood. Peritonitis can occur as the resuIt of perforation or seepage of bacteria through the waI1 of a distended Ioop of bowe1. Thoracic disturbances accompany marked distention. Descent of the diaphragm is difficuIt and restricted and respiration, both thoracic and abdomina1, is impaired. A varying degree of anoxemia resuhs from the failure of compIete puImonary ventiIation. The respiratory diffrcuIty aIso occasions cardiac distress. A negative intrathoracic pressure is required for the unimpaired passage of blood from the vena cava into the heart. This decrease in bIood voIume flow to the heart further contributes to the anoxemia. In the eIderIy patient the thoracic disturbance resuIting in puImonary disease and anoxia is frequently the cause of death. American
Journal
o.f Surgery
Lichtenstein-IntestinaI The reduction in blood voIume and concentration of the circuIating blood is associated with disturbances in regulation of the body temperature and also the peripheral circuIation. Frequently they are for misinterpretations of responsibIe laboratory data. In view of the results of distention it is obvious that the indication for the treatment of this phase of intestina1 obstruction is decompression of the distended bowe1. This may be accompIished by intubation and suction. The important contributions of Wangensteen and Johnson and the development of the MiIIer-Abbott tube and its modifications have made treatment of this phase of intestina1 obstruction possibIe without resorting to immediate surgery. In some instances decompression by the interna method may be diffIcuIt or impossibIe and the estabIishment of an iIeostomy or cecostomy may be in order. In some cases (incarcerated hernia) prompt surgery may overcome the distention. Inhalation of oxygen has been suggested for its vaIue in the remova of nitrogen by diffusion into the bIood stream. Its genera1 saIutary effect in sustaining an eIderIy patient shouId warrant its more frequent use. Strangulation. The extent of vascuIar impairment pIays a considerabIe roIe in the severity of the iIIness of the patient. When stranguIation of the bowe1 occurs in the free peritonea1 cavity, the symptoms are more severe than when a similar acute stranguIation occurs in a hernia1 sac. As a resuIt of stranguIation, a Ioss of bIood proteins into the Iumen of the bowel and into the peritonea1 cavity occurs. The bowel itself becomes congested and hoIds immobilized a voIume of bIood that is in proportion to the Iength of the invoIved segment. In most instances the venous return is occluded before arteria1 obstruction takes pIace. The amount of bIood pumped into tissues whose veins are occluded may be considerabIe. This loss of blood from the circuIatory system may result in shock and prove fata1. Peritonitis frequentIy accompanies stranguIation and toxemia is often September,
1949
Obstruction
369
the cause of the profound symptoms which may be present. In view of these effects of strangulation it is clear that the indication for therapy for this phase of intestinal obstruction aIone are the restoration of blood proteins and bIood voIume by the use of bIood transfusions and the remova of the dead bowe1 from the peritonea1 cavity as promptIy as the condition of the patient FrequentIy the remova of wiI1 permit. dead bowel is the essentia1 treatment for shock and infection. The vaIue of hemotherapy, serotherapy and chemotherapy for their antitoxic or antibacteria effects must be kept in mind. The possibiIity of infection in any case is so IikeIy that antibiotic therapy shouId be instituted earIy in the course of management. SUMMARY
The duration of symptoms and the IeveI of obstruction determine the intensity of three phases of intestina1 obstruction from the point of view of preoperative therapy. The effects of vomiting may be overcome by the use of the appropriate quaIity of intravenous soIutions in adequate amounts. Distention may be overcome by decompression through intubation and suction or if necessary, iIeostomy, cecostomy or release of incarceration. The effects of stranguIation may be overcome by the remova of the dead bowel from the peritonea1 cavity as promptly as circumstances permit and by the use of bIood or pIasma transfusions. While the patient is being prepared for a prospective operation, certain diagnostic and additiona therapeutic procedures may be carried out. A compIete examination is essentia1 to observe hernias, scars, recta1 tumors, etc. The patient’s stomach is aspirated of its contents and washed out. A suction tube is inserted, continuous suction is instituted and a record is kept of the volume of secretion aspirated. In the absence of acute abdomina1 inff ammation a z-quart enema is given to empty the coIon. A scout film of the abdomen is taken
370
Lichtenstein-IntestinaI
to determine the bowel pattern. If distention decreases, suction is discontinued at intervals and 2 to 4 ounces of minera oil are pIaced in the stomach. This oil is Iooked for in the subsequent washings from the Iarge boweI. If only a smaI1 amount of the enema can be retained, a barium enema may be given and the site of obstruction noted on Aouroscopic examination or in the x-ray fiIm. If repeated enemas fai1 to reIieve the obstruction in the Iarge bowe1, a cecostomy is necessary to overcome the cIosed Ioop obstruction. When oi1 given by mouth faiIs to appear in the washings from the coIon and the intestina1 sounds disappear, compIete obstruction of the smaI1 intestine is present and expIoration of the abdomen is necessary. The presence of oi1 or gas in the washings from the coIon indi-
Obstruction cates that the obstruction is not compIete or that the obstruction is reIieved and urgency for surgica1 treatment is not essentia1. Obstruction Iow in the iIeum is usuaIIy not associated with tenderness in the abdomen. In the absence of infection tenderness indicates vascuIar impairment to the bowel and earIy operation is, therefore, essentia1. CONCLUSIONS
Of diagnostic and therapeutic vaIue are the administration of parentera fluids in adequate quantity and appropriate quaIity, intestina1 decompression, enemas and the use of minera oi1 by mouth. These measures constitute the important conservative and aIso preoperative therapeutic procedures in intestina1 obstruction.
RESIDUAL stones in the biliary tract, pancreatitis, strictures or anguIations of the ducts and hepatitis are some of the more common causes of the postchoIecystectomy syndrome. A recent authority, however, discovered this syndrome in many patients in whom the only obvious disorder on re-operation was faiIure of the first surgeon to remove the cystic duct compIeteIy. It behooves us, therefore, to take a few more minutes time to do a compIete choIecystectomy, making sure to remove the whoIe of the gaIIbIadder and its duct. (Richard A. Leonardo, M.D.)
American
Journal
of Surgery
IN INTESTINAL
MANUEL E. LICHTENSTEIN,M.D. Chicago, Illinois
S
IMPLE intestina1 obstruction does not aIways require relief by surgica1 means. In many instances obstruction has been overcome foIIowing a period of pIanned management designed to reIieve the patient of the effects of vomiting and to reIieve the intestina1 cana of distention, with its effects on the genera1 condition of the patient and the IocaI condition in the bowe1. This pIanned management has been caIIed conservative therapy but it is not opposed to surgery when the Iatter is indicated. Obstruction which accompanies or foIIows acute inffammation within the abdomen may be reIieved by treatment directed toward overcoming the inffammatory process. The use of antibiotics or suIfonamides and intravenous infusions of bIood, dextrose, proteins and mineraIs with drainage of an abscess when indicated frequentIy reIieves obstruction. When adhesions foIIowing one or more abdomina1 operations are the cause of obstruction, a period of conservative management may be folIowed by compIete reIief, thereby avoiding the addition of more adhesions by another operation. In some instances, using the same conservative means, compIete obstruction in a sick patient may be converted into an incompIete obstruction and permit improvement in the patient’s condition before surgery is undertaken; whiIe in others sufficient improvement may occur to permit preparation of the patient for what may be an extensive or serious operation in spite of the persistence of the compIete obstruction. Thus conservative management of simpie intestina1 obstruction is not onIy a therapy for the condition but aIso a means * From the Division of Surgery,
of preparation of the patient for the surgica1 reIief of obstruction when this is found to be necessary. The time required for successfu1 conservative therapy is not important so Iong as satisfactory progress is being made. However, persistence in this form of management without evidence of improvement, such as deffation of the bowe1 with a return of norma peristaIsis, is hazardous and surgery must not be deferred. Conservative management must not be confused with negIected or deIayed management which favors disabIing compIications or death. Surgery without deIay is especiaIIy urgent in stranguIation obstruction. In cIosed Ioop obstructions of the Iarge bowe1 immediate decompression is necessary and surgery shouId be done when it is found that recta1 or coIonic irrigations do not reIieve the obstruction. The iIIness of the patient in acute intestina1 obstruction varies in intensity with the grade of the obstruction (compIete or incompIete), its duration, its IeveI in the intestina1 cana (high, intermediate or Iow) and the extent of vascuIar impairment in the invoIved section of bowe1. These factors determine (I) the amount of fIuid and minera Ioss through vomiting or stagnation in the intestina1 Iumen; (2) the extent of intestina1 distention; (3) the severity of toxemia and infection which foIIows gangrene (actua1 or impending) of the invoIved bowe1; and (4) the bIood changes associated with shock, uremia, aIkaIosis, acidosis, hypohydration, etc. AI1 of these factors play a roIe, to a greater or Iesser extent, in the production of symptoms following obstruction due to any of the Iarge variety of pathoIogic Iesions responsibIe for inter-
Northwestern University MedicaI School and the Cook County Graduate of Medicine, Chicago, III.
362
American
Journal
School
of Surgery
Lichtenstein-IntestinaI ference with the passage of intestina1 contents distally in the intestinal canal. Duration. A thorough analysis of the history of the patient’s compIamt, a compIete physical examination and the necessary Iaboratory work frequentIy aid in
Di#estion
Absorption
Obstruction
363
understood folIowing a review of the functionaI anatomy of the intestinal tract. The gastrointestinal canaI embryoIogicaIIy is divided into three divisions: the foregut, the midgut and the hindgut. (Fig. I.) Anatomicahy the foregut is that portion of
Excretion
FIG. I. The three embryologic divisions of the gastrointestinal tract are deIimited by the distribution of three vessek from the abdominal aorta. The foregut supptied by qhe celiac axis is concerned with the process of digestion. The mid-gut 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 non-absorbed residue.
establishing the correct diagnosis before irreversible changes take pIace. The longer the duration the more extensive became the changes in bIood and body tissues and the Iess effective became the propulsive and constrictive efforts of the intestina1 muscuIature. When the bIood suppIy to the boweI is involved, the more certain is the danger of necrosis, peritonitis, shock, toxemia and sepsis. Immediate rehef is imperative. In the presence or absence of strangmation the prompt institution of correctiona therapy as outlined herein wiII obviate many of the unfavorable consequences of proIonged interference with the Aow of intestina1 contents. Level of Obstruction. The variation in symptoms due to obstruction at different IeveIs in the intestina1 cana may be better
September, 1949
the digestive tract which receives its bIood suppIy from the celiac axis of the aorta. PhysioIogicalIy, these organs are concerned with the processes of digestion. AnatomicaIIy, the midgut receives its bIood suppIy from the superior mesenteric artery. The organs suppIied by this .vesseI are the jejunum, iIeum and right half of the coIon. (Fig. 2.) PhysioIogicaIIy, this portion of the intestina1 canal is concerned with absorption. The process of absorption invoIves the seIection of food substances in a reIativeIy dilute state from the intestina1 canaI. If there is but a smaI1 amount of Auid avaiIabIe, absorption may be decreased or deIayed since the passage of materiaIs from the lumen to the bIood stream is a function of the osmotic tension of the soIutes in the bowe1 and that of the bIood in the intestina1 vessels. Therefore,
Lichtenstein-IntestinaI
364
Obstruction maining in the iIeum. The third portion of the midgut is the right half of the coIon. This portion of the bowel absorbs water and saIts. Thus there is no loss of the materiaIs which are secreted into the intestina1 cana for the purpose of preparing food for absorption.
it is necessary for a Iarge amount of water to be secreted into the intestinal lumen. This phase of absorption, diIution of food, is made possibIe by the secretion of succus entericus into the jejunum. The jejunum has a very extensive arteria1 suppIy which furnishes the blood necessary for the pro-
Food
Stomach;
**.*.
*
Dud. j Jejunum
HtGi-i OBSTRUCTION Vomitinq
4
I
Water salts
Ileum
I
,
INTERMEDIATE OBSTRUCTION Vomitlnf and distention
LOW OBSTRUCTION Distention
FIG. z. The mid-gut incIudes the jejunum, iIeum and the right haIf of the colon. The jejunum is Iarge in caIiber and thick-waIIed with many vesseIs to suppIy the Auid needed for succus entericus. A rapid peristaIsis carries this fluid and the food with which it is mixed to the ileum. Here absorption occurs and the residual Auid is taken up by the right haIf of the coIon. Thus the high obstruction occurs in that part of the intestinal cana in which absorption is minimal. The low obstruction occurs in the hindgut after food and water have been absorbed. The intermediate obstruction Iies between the former two.
duction of succus entericus. PhysioIogitally, IittIe absorption of water or saIt occurs here. The second portion of the midgut is the iIeum. In the iIeum most of the food is actuaIly absorbed. It is we11 known that chronic diseases invoIving the ileum are frequentIy associated with nutritiona1 disturbances such as anemia and hypovitaminosis. WhiIe the iIeum may absorb Iarge quantities of water and saIts, this wouId be disadvantageous since absorption of water here would concentrate the intestina1 contents and diminish absorption of the nutritiona eIements re-
AnatomicaIIy, the hindgut is suppIied by one bIood vesse1, the inferior mesenteric artery. It incIudes the Ieft haIf of the colon, sigmoid and rectum. The function of the hindgut is to store the non-absorbed residue of the intestina1 contents and at intervaIs to expe1 this materia1 from the intestina1 canal. The foregut and the first portion of the midgut have secretions poured into their Iumens. BeIow the jejunum absorption removes fluid from the intestina1 cana1. IntestinaI obstruction in the jejunum prevents the passage of secretions to the
American
Journal
of Surgery
Lichtenstein-IntestinaI absorptive portion of the intestina1 canal. These secretions either stagnate or are removed by vomiting. Obstruction above this IeveI is caIIed high intestina1 obstruction. Obstrdction beIow the IeveI of the jejunum Ieaves a progressiveIy Ionger portion of the intestina1 surface avaiIabIe for absorption. Obstruction in the absorptive portion of the intestina1 cana may we11 be caIIed intermediate intestina1 obstruction. Obstruction in the Ieft haIf of colon does not interfere with absorption of the fluids poured into the intestinat cana1. WhiIe there may be no immediate Ioss of fluids from the body, the primary diffIcuIty is the inability to expe1 the non-absorbed residue. This resuIts in distention which is characteristic of Iow obstruction. In high obstruction intestinal secretions cannot be absorbed. In Iow obstruction absorption may occur with but sIight impairment for a Iong period of time. It is cIear, then, that high obstructions are most serious since the patients become iI sooner from Ioss of fluids and salts and the symptoms are more pronounced. In these patients who have low obstruction many days may pass with few symptoms. Vomiting. Obstruction above the ampuIIa of Vater resuIts in vomiting with Ioss of gastric secretion. The Ioss of water and chlorides results in chemical changes in the circulating bIood. HydrochIoric acid formation in the stomach is associated with a decrease in chlorides and repIacement of carbonic acid with bicarbonate in the bIood stream. The foIIowing formuIa indicates the probabIe mechanism of hydrochloric acid formation : Stomach Blood r 1 NaHzPOa + NaCI + HCl(PROTEIN) Na2HP04 + HKOZ + NaHC03 T 1 BIood Blood In CelI
The is not takes bined in the
In CeII $ Na2HP04 + NaHzPOd
hydrochIoric acid in the gastric ceI1 free (Iest corrosion of the tissues pIace) but is Iiberated from its comprotein by the action of chloresterase lumen of the stomach.
September,
I 949
Obstruction
3%
NormalIy the chIorides secreted into the stomach are returned to the bIood stream by absorption from the intestina1 cana1. ChIorides Iost in the urine and sweat are repIaced by salt in the ingested food. The bicarbonate resuIting from hydrochIoric acid formation appears in the pancreatic and intestina1 secretions and in the urine (alkaline tide). When absorption is impossibIe, as in high obstruction, vomiting prevents the absorption of chIorides secreted in the stomach and prohibits ingestion of chlorides present in food. This resuIts in bIood changes characterized by a decrease in blood chIoride, an increase in blood bicarbonate and a shift in the bIood pH toward greater aIkaIinity. If this condition continues, the bIood changes may become profound and give rise to aIkaIosis. This condition is characterized by an increase in non-protein and urea nitrogen in the blood and, if progressive, uremic symptoms may deveIop. Vomiting foIIowing obstruction lower in the intestina1 cana removes gastric secretion, pancreatic secretion, bile and succus entericus. (Fig. 3.) This is associated with a Ioss of water, carbonates, bicarbonates and sodium. Definite bIood changes occur. There is a decrease in bIood bicarbonate, a shift in the bIood pH to decreased aIkaIinity and a decrease in bIood sodium. The tissues Iose their capacity to hold water because of the Ioss of sodium. In the past many of the symptoms resuIting from these Iosses were attributed to toxemia. It appears that the symptoms are more IikeIy due to the pathoIogic state associated with the blood changes which foIIow excessive vomiting. It has been pointed out that the most constant change and the one which gives the best index of the true condition of the patient is the eIevation of bIood urea. This results not onIy from vomiting but also from the increased metaboIism of endogenous protein which occurs in the presence of intestina1 obstruction. The Ioss of chIoride varies with the amount of vomiting. The IeveI of the carbon dioxide combining power is variabIe but in general
Lichtenstein-IntestinaI
366
in the presence of decreased chIorides it is eIevated (alkaIosis) and in the presence of normal vaIues for chIoride it is norma or decreased (acidosis). Under the inffuence of satisfactory treatment, whether conservative or surgica1, the bIood chemica1
Obstruction of vomiting and fluid stagnation. Under norma circumstances the average individual excretes from 5 to IO Gm. of sodium chIoride daiIy depending on his or her activities, occupation, natural habits of diet, etc. When no saIt is ingested, urinary
Saliva 1,s 00 cc. Bile 500 cc. ‘\\
L/
“YL+ --
N&I.
juice
2,soocc *- _ _ .::.I : ..I ,,<;y,,:,--‘V ~,~ _.<“;:y :: ; ‘:.y,. yi’ .:.;“.‘.‘~:,‘;,: ,.,,’;.,; w-I_ \ .....,. (,.....‘Z ‘.:..:,.,. ,. .:_.
“Pancreatic juice 700 cc.
:::,.~..~.,~:
Vol
Secretion
ric
Saliva
I,500cc.
Bile
7 gms.
500 cc.
Gastric
juice
2,soocc.
Pancreatic
juice
Intestinal
Secretions
7 ffrnr
.I5 qms.
7oocc.
8 fms.
3,ooocc.
I8 qms.
8,200cc
55 qms.
3,500cc.
23 fms
8.
&
u
ihestinal secretions 3,ooocc.
Total
plasma
volume
FIG. 3. The volume of secretions and sodium chloride content derived from the gastrointestinal cana1; continuous absorption is necessary to maintain the plasma voIume. Loss of secretions from the gastrointestinal canal is reflected in the Ioss of pIasma volume and bIood chlorides.
vaIues return to normal, the urea usuaIIy more sIowIy than the other vaIues. In view of this the first indication for therapy when vomiting occurs is the repIacement of the materiaIs lost both quaIitatively and quantitativeIy. The patient who vomits not only Ioses fluids from the body but aIso does not receive fluids which are the daiIy body requirement for the eIimination of waste and reguIation of body temperature. Under norma circumstances the average individua1 requires from 2,000 to 3,000 cc. of water daily for the purposes of eIimination and temperature regmation. In addition to the fluid Iost through vomiting a considerabIe amount of fluid may be immobihzed in the nonabsorbing portion of the intestina1 cana which, because of distention and vascular damage, may be non-functioning. Thus the tota water requirement may vary between 3,000 and 5,000 cc. when the patient is first seen. The Ioss of salts varies with the amount
excretion may remove less than 5 Gm. in twenty-four hours. When the bIood vaIue for sodium chIoride drops from the average of 650 mg. to the critica IeveI of 520 mg., chIoride secretion in the urine may drop to o. Thus at least 5 Gm. of sodium chIoride is necessary to maintain the bIood chIoride IeveI. Gastric juice has approximateIy 4 Gm. of chIoride in 1,000 cc. The amount of saIt to be administered to the patient must incIude the daiIy normal requirement pIus the amount Iost through vomiting and the amount immobiIized in the Iumen of the intestina1 cana1. These amounts vary in different patients. It is unfortunate that a bIood chIoride determination does not aIways aid in estabIishing the degree of chIoride 10s~. TabIe I indicates norma vaIues in the bIood. Profound changes in the bIood resuIting from hypohydration, etc., may be determined by the use of a few Iaboratory tests. However, earIy in obstruction the tendency for homeostasis to maintain norma vaIues in the bIood in American
Journal
of Surgery
Lichtenstein-IntestinaI makes such spite of tissue depletion determinations of less vaIue than a clinical estimate of the patient’s condition. A guide to the amount of Auid necessary to restore the fluid baIance is the quantity of urine secreted. Since water for evapora-
Plasma
NaCI ........ ........ Na .................... CI ................. K ... ............. Ca.
650 340 370 20 10
................
Obstruction
depends on the patient’s requirements. Tht patient is in need of sodium chloride but the quantity of this mineral must be administered in proportion to the patient’s needs. It may be noted (TabIe II) that 4,000 cc. of isotonic saIt soIution contains
TABLE
-
I WhoIe BIood
CeIIs
0 I90
Fe cu
2.7 0. I
................. .................
200 5
3 4 45 0.1 0.01
6 100
1949
[
1.5:1-2:
13 -15 4.5-5.0
Gm. miIIion
Male 42-48 Female 39-45 S.G. BIood I.057 Serum 1.025
I:20
tion to reguIate body temperature has a priority, a scant income wiI1 show a diminished urinary output. The patient shouId be supplied with that quantity of fluid which wil1 afford the eIimination of 1,000 to 1,500 cc. of urine with a specific gravity that varies between 1.010 and 1.020. It is necessary to record the urinary output and keep a record of the voIume injected since the administration of too much fluid may waterIog the patient. It has been found desirabIe to administer 3,000 cc. of fluid intravenously at the rate of one drop per second by continuous infusion over a tweIve-hour period. To suppIy as much as 6,000 cc. when this amount is deemed necessary (this is unusuaI), it may be given at the rate of one drop per second over a period of twenty-four hours. A rapid administration of fluids to a hypohydrated patient increases the urinary output without hydrating the patient. The fluid passes from the bIood stream into the kidneys and is eliminated with a very low specific gravity. This is a waste of fIuids when hydration is desired aIthough it may be desirabIe when toxins are to be eliminated. The quaIity of the soIution administered
80-120 mg. 6.7-7.6 Gm. 0.27 2.7 (I .5-3) 4. I (3.8-6)
Hematocrit
7.45
-
September,
Dextrose Proteins Fibrinogen Serum gIobulin Serum albumin Ratio:A:G Hb RBC
250
420 0
..................
Iodine ................ CO*: (HCOJ .......... pH ..................
BIood Serum
160
P ................... Mg
36:
36 Gm. of saIt. This amount may be much more than is necessary for the patient and may be harmfuI in that the kidneys may not be abIe to eliminate the excess promptIy enough. This wiI1 result in the TABLE INTRAVENOUS
II
SOLUTIONS
-
IOther
NaCI
0.9% NaCI.. ........... 5.0 y0 Dextrose. ......... 5.0 Dextrose in 0.9%
NaCI ................ 2.5v0
Dextrose
GM./I,OOO
SaIts
CC.
-
Dextrose
Proteins
9.0 0.0
9.0
in .45%
NaCI ................ Ringers SoIution. ....... Hartmans Solution. ..... PIasma. ............... Amigen ................
Parrnamine ............ Aminosol. .............. WhoIe BIood Citrated
...
4.5 8.6 6.0
.6 3.6 8.0
9.0 2.0 1.0 0.0 6.5
0.5 4.0
-
25 I
I
67.0 50 60 5o 50 0. 5 35
50
storage of saIt in the body tissues, with the deveIopment of edema. If the patient aIready has renaI damage, the abiIity to eIiminate saIt may be so impaired that edema wiI1 appear more promptIy. One
368
Lichtenstein-IntestinaI
should, therefore, gauge the amount of salt necessary by the voIume of the vomitus plus the amount of secretion that may be removed from the intestina1 cana by suction and the estimated amount of stagnant secretion in the intestina1 lumen. TabIe II lists isotonic soIutions which may be of vaIue in intravenous therapy. The mixture 2.3 per cent d ex t rose with .425 per cent sodium chloride is a most desirabIe soIution because its continuous administration will avoid the possibility of suppIying too much or too IittIe salt. It is an isotonic sohition 4,000 cc. of which contain but 17 Gm. of sodium chIoride. This amount frequentIy is an adequate amount in a twenty-fourhour period for the average individua1 with complete intestina1 obstruction. In the absence of vomiting 4.5 to g Gm. of saIt wiI1 suffice. The continuous use of .g per cent sodium chIoride with or without 5 per cent dextrose supphes too much saIt. The use of 1,000 cc. of isotonic sodium chIoride in distiIIed water or 250 cc. of 2 per cent sodium chIoride as an initia1 dose heIps to restore more promptly the immediate chIoride and sodium shortage. The patient who is neither vomiting nor losing gastrointestina1 secretions by suction or diarrhea is not in need of much saIt. The use of 2.5 per cent dextrose in .45 per cent sodium chIoride soIution is safer since it avoids overmineraIization when doubt exists as to the need for sodium chIoride. Distention. Distention of the abdomen in intestina1 obstruction is caused by the accumuIation of gas and the immobihzation of ffuids in the intestina1 cana1. The gas content represents for the most part (70 per cent) swaIIowed air. The remainder is derived from fermentation or putrefaction of intestina1 contents and from the diffusion of gas from the bIood stream into the Iumen of the bowel. The immobiIization of fluids in the intestina1 cana is due to decreased peristaIsis in compIete obstruction, decreased absorption, venous stagnation and a continuous secretion due to secretagogue stimuIation.
Obstruction
The resuIts of distention are: (I ) portal stagnation; (2) changes in the mucous membrane; (3) toxemia; (4) peritonitis; (5) thoracic disturbances; and (6) a decrease in volume and increase in concentration of the circuIating bIood. PortaI circuIation is assisted by active intestinal motiIity. In compIete obstruction with distention, a marked reduction in motiIity occurs. This decreases the voIume of portal circuIation. When peristalsis returns, the bacteria1 Iaden bIood floods the Iiver and produces the changes which in the past have been responsibIe for the death of the patient foIIowing reIief from the obstruction. Dragstedt has shown that Corynebacterium botuIinum toxin is absorbed by the mucous membrane in an obstructed Ioop of bowe1 but it is not absorbed by the mucous membrane in the unobstructed bowe1. The alteration in the seIective absorption of the mucous membrane may account for the toxic symptoms which appear in this condition. In the presence of distention diffusion of toxins of non-bacteria1 origin through the intestina1 walI occurs. It is thought that these toxins may be absorbed by the Iymphatics and carried to the blood stream. The nature of the toxemia and the origin of the toxins independent of the aIterations in the bIood are as yet not fuIIy understood. Peritonitis can occur as the resuIt of perforation or seepage of bacteria through the waI1 of a distended Ioop of bowe1. Thoracic disturbances accompany marked distention. Descent of the diaphragm is difficuIt and restricted and respiration, both thoracic and abdomina1, is impaired. A varying degree of anoxemia resuhs from the failure of compIete puImonary ventiIation. The respiratory diffrcuIty aIso occasions cardiac distress. A negative intrathoracic pressure is required for the unimpaired passage of blood from the vena cava into the heart. This decrease in bIood voIume flow to the heart further contributes to the anoxemia. In the eIderIy patient the thoracic disturbance resuIting in puImonary disease and anoxia is frequently the cause of death. American
Journal
o.f Surgery
Lichtenstein-IntestinaI The reduction in blood voIume and concentration of the circuIating blood is associated with disturbances in regulation of the body temperature and also the peripheral circuIation. Frequently they are for misinterpretations of responsibIe laboratory data. In view of the results of distention it is obvious that the indication for the treatment of this phase of intestina1 obstruction is decompression of the distended bowe1. This may be accompIished by intubation and suction. The important contributions of Wangensteen and Johnson and the development of the MiIIer-Abbott tube and its modifications have made treatment of this phase of intestina1 obstruction possibIe without resorting to immediate surgery. In some instances decompression by the interna method may be diffIcuIt or impossibIe and the estabIishment of an iIeostomy or cecostomy may be in order. In some cases (incarcerated hernia) prompt surgery may overcome the distention. Inhalation of oxygen has been suggested for its vaIue in the remova of nitrogen by diffusion into the bIood stream. Its genera1 saIutary effect in sustaining an eIderIy patient shouId warrant its more frequent use. Strangulation. The extent of vascuIar impairment pIays a considerabIe roIe in the severity of the iIIness of the patient. When stranguIation of the bowe1 occurs in the free peritonea1 cavity, the symptoms are more severe than when a similar acute stranguIation occurs in a hernia1 sac. As a resuIt of stranguIation, a Ioss of bIood proteins into the Iumen of the bowel and into the peritonea1 cavity occurs. The bowel itself becomes congested and hoIds immobilized a voIume of bIood that is in proportion to the Iength of the invoIved segment. In most instances the venous return is occluded before arteria1 obstruction takes pIace. The amount of bIood pumped into tissues whose veins are occluded may be considerabIe. This loss of blood from the circuIatory system may result in shock and prove fata1. Peritonitis frequentIy accompanies stranguIation and toxemia is often September,
1949
Obstruction
369
the cause of the profound symptoms which may be present. In view of these effects of strangulation it is clear that the indication for therapy for this phase of intestinal obstruction aIone are the restoration of blood proteins and bIood voIume by the use of bIood transfusions and the remova of the dead bowe1 from the peritonea1 cavity as promptIy as the condition of the patient FrequentIy the remova of wiI1 permit. dead bowel is the essentia1 treatment for shock and infection. The vaIue of hemotherapy, serotherapy and chemotherapy for their antitoxic or antibacteria effects must be kept in mind. The possibiIity of infection in any case is so IikeIy that antibiotic therapy shouId be instituted earIy in the course of management. SUMMARY
The duration of symptoms and the IeveI of obstruction determine the intensity of three phases of intestina1 obstruction from the point of view of preoperative therapy. The effects of vomiting may be overcome by the use of the appropriate quaIity of intravenous soIutions in adequate amounts. Distention may be overcome by decompression through intubation and suction or if necessary, iIeostomy, cecostomy or release of incarceration. The effects of stranguIation may be overcome by the remova of the dead bowel from the peritonea1 cavity as promptly as circumstances permit and by the use of bIood or pIasma transfusions. While the patient is being prepared for a prospective operation, certain diagnostic and additiona therapeutic procedures may be carried out. A compIete examination is essentia1 to observe hernias, scars, recta1 tumors, etc. The patient’s stomach is aspirated of its contents and washed out. A suction tube is inserted, continuous suction is instituted and a record is kept of the volume of secretion aspirated. In the absence of acute abdomina1 inff ammation a z-quart enema is given to empty the coIon. A scout film of the abdomen is taken
370
Lichtenstein-IntestinaI
to determine the bowel pattern. If distention decreases, suction is discontinued at intervals and 2 to 4 ounces of minera oil are pIaced in the stomach. This oil is Iooked for in the subsequent washings from the Iarge boweI. If only a smaI1 amount of the enema can be retained, a barium enema may be given and the site of obstruction noted on Aouroscopic examination or in the x-ray fiIm. If repeated enemas fai1 to reIieve the obstruction in the Iarge bowe1, a cecostomy is necessary to overcome the cIosed Ioop obstruction. When oi1 given by mouth faiIs to appear in the washings from the coIon and the intestina1 sounds disappear, compIete obstruction of the smaI1 intestine is present and expIoration of the abdomen is necessary. The presence of oi1 or gas in the washings from the coIon indi-
Obstruction cates that the obstruction is not compIete or that the obstruction is reIieved and urgency for surgica1 treatment is not essentia1. Obstruction Iow in the iIeum is usuaIIy not associated with tenderness in the abdomen. In the absence of infection tenderness indicates vascuIar impairment to the bowel and earIy operation is, therefore, essentia1. CONCLUSIONS
Of diagnostic and therapeutic vaIue are the administration of parentera fluids in adequate quantity and appropriate quaIity, intestina1 decompression, enemas and the use of minera oi1 by mouth. These measures constitute the important conservative and aIso preoperative therapeutic procedures in intestina1 obstruction.
RESIDUAL stones in the biliary tract, pancreatitis, strictures or anguIations of the ducts and hepatitis are some of the more common causes of the postchoIecystectomy syndrome. A recent authority, however, discovered this syndrome in many patients in whom the only obvious disorder on re-operation was faiIure of the first surgeon to remove the cystic duct compIeteIy. It behooves us, therefore, to take a few more minutes time to do a compIete choIecystectomy, making sure to remove the whoIe of the gaIIbIadder and its duct. (Richard A. Leonardo, M.D.)
American
Journal
of Surgery