Bowel obstruction in the aged patient

Bowel Obstruction in the Aged Patient A Review of 300 Cases W. WALLACE

Bowel obstruction in aged patients has had a comparatively high mortality rate; the incidence in each reported series depends on the type of cases that are included. The last 300 patients, sixty-five years or older, with bowel obstruction who were seen during a ten year period (1958 to 1968) at the San Francisco General Hospital were reviewed to determine the results of diagnosis and treatment. A large percentage were poor risk patients and in many cases diagnosis and treatment were delayed because of economic and social factors beyond the control of the hospital. Clinical

Data

The patients in this study ranged in age from sixty-five to ninety-eight years of age with an average age of seventy-seven years. Fifty-two per cent were male and 48 per cent were female. Eighty-four per cent were Caucasian, 9 per cent Negro, and 7 per cent Oriental. Eighteen per cent had a secondary disorder such as diabetes, cardiovascular disease, emphysema, pyelonephritis, or senile dementia. Apart from obstructions due to hernias, 11 per cent had had previous operations or treatment for bowel obstruction. Some had had three or four previous admissions to the hospital for this condition. The causes of bowel obstruction and the mortality are shown in Table I. The types of obstruction were divided into three groups: large bowel obstruction, small bowel obstruction, and hernias causing obstruction. The From

the School of * Chief

Department Medicine, Resident,

of Surgery, University of San Francisco, California. Francisco General San

1935-37.

vol.

118, Octobr

1969

California Hospital,

GREENE,

M.D.,*

San Francisco,

California

number of cases was almost evenly divided between the three groups. The mortality for large and small bowel obstructions was 31.6 per cent and 33.3 per cent, respectively, whereas the mortality for hernial obstructions was 20 per cent. These figures are for all of the patients with obstruction, including thirteen patients whose condition was too poor to permit operation and who died within twenty-four hours after admission to the hospital. The types and number of operations performed on these patients are shown in Table II. Complications (both pre- and postoperative) which presented major problems in the care of these 300 patients with bowel obstruction are listed in Table III. Many of the patients delayed seeking medical treatment for various reasons (socioeconomic, self-treatment, and the like) and presented with findings reflecting the complications of obstruction which were often compounded by other concomitant condit,ions. The complications were primarily cardiovascular and pulmonary in origin but sepsis and genitourinary complications were also fairly frequent. Cardiovascular complications occurred in 21 per cent of the patients. Congestive failure was aggravated in some patients by the increase in intra-abdominal pressure secondary to distention caused by obstruction. In some patients who had received digitalis, toxicity related to hypokalemia developed. Arrhythmias were common and there were five cardiac arrests, two of which were caused by aspiration of vomitus in the preoperative period. Six patients had cerebrovascular accidents within five days after operation and in another four 541

Greene

TABLE

I

Causes of Bowel Obstruction*

No. of Cause Large Bowel Tumors (3 metastatic) Volvulus of sigmoid Diverticulitis Fecal impaction (perforation or ulcer) Fecal impaction (distention small bowel) Volvulus of cecum Total Small Bowel Adhesions Gallstone ileus Tumors (4 metastatic) Venous thrombosis Intramural hematoma Regional enteritis Volvulus of entire small bowel Foreign bodies Total Hernias lnguinal Femoral Umbilical Ventral Internal Total

TABLE

Cases

No. of Deaths

Mortality (Per Cent)

67 11 9

18 4 4

26.8 36.3 44.4

6

5

83.3

6 2 101

... 1 32

... 50.0 31.6

22 2 4 1 ... ...

28.5 40.0 80.0 50.0 ... ...

1 1 93

1 1 31

100.0 100.0 33.3

57 26 10 8 5 106

9 9

15.7 34.6 ... 25.0 20.0 19.8

... 2 1 21

* There was a total of eighty-four deaths (28 per cent mortality) in 300 cases.

TABLE

II

Surgical

Procedures

Procedure Initial Definitive Procedures Hernia repair Resection of small bowel Lysis of adhesions Cecostomy Colostomy Resection of large bowel Reduction of volvulus Enterotomy (gallstones) Enteroenterostomy Incidental Procedures Tracheostomy Orchiectomy Secondary closure (dehiscence) Gastrostomy

542

No. of Patients

106 45 42 41 14 12 9 4 2

11 7 5 2

III

Complications No. of Cases

Per Cent

Cardiovascular Congestive heart failure, arrhythmias Cardiac arrest Cerebrovascular accident Pulmonary infarcts Phlebitis Total

38 5 10 7 3 63

12.7 1.7 3.3 2.3 1.0 21.0

Pulmonary Pneumonia Atelectasis Total

56 4 60

18.7 1.3 20.0

Complication

Sepsis Wound infection Peritonitis (gangrene, perforation) Gram-negative shock or septicemia Total

21 16

7.0 5.3

4 41

1.3 13.6

Genitourinary Infections Acute renal failure Total

17 7 24

5.7 2.3 8.0

Miscellaneous Fluid and electrolyte imbalance Paralytic ileus Senile or postoperative psychosis Total

10 13 16 39

3.3 4.3 5.3 13.0

this condition developed later. Seven patients had symptomatic pulmonary infarcts. A large number had varicose veins, but only three had phlebitis. Severe pulmonary complications occurred in sixty patients (20 per cent) whereas minor pulmonary complications occurred in about half as many more. Forty patients (18.7 per cent) had pneumonia within five days of admission to the hospital. Four patients had atelectasis and required bronchoscopy and vigorous tracheobronchial suctioning. Eleven tracheostomies were performed to aid in the management of pulmonary complications. Four patients had pneumonia directly attributable to aspiration of vomitus. One had tension pneumothorax after a bleb was ruptured in the postoperative period. Sepsis was a major problem in forty-one patients (13.6 per cent). Wound infections were responsible for half of these complications (twenty-one cases) whereas peritonitis secThe American Journal of Surgery

Bowel

ondary to gangrene or perforation occurred in sixteen cases (5.3 per cent). Eight patients had peritonitis when admitted to the hospital; they were too ill for immediate operation and died within twenty-four hours before their general condition could be improved. Two other patients with peritonitis refused operation and subsequently died. Four patients had gram-negative shock or septicemia. Genitourinary tract complications were a major problem in twenty-four patients (8.0 per cent). Many male patients had some problem with urinary retention and required catheterization but only seventeen (5.7 per cent) had severe infections of the genitourinary tract. Seven patients had renal shutdown and three of these died. In two this condition developed within the first five days of hospitalization and in five it occurred after the fifth day. There were a number of miscellaneous complications. Ten patients had severe disorders of electrolyte and fluid balance; thirteen patients had severe paralytic ileus and in sixteen psychoses developed and the patients required restraints and special care. The causes of death are listed in Table IV. Eighty-four of the 300 patients died, an overall mortality of 28.0 per cent. In other series reported between 1952 and 1960 [l-S], the mortality ranged from 10.9 to 37.7 per cent with an average of 23.8 per cent. The variation in the mortalities may be related to delays in treatment, and the type of cases included in the series. In this series, all patients with a proved diagnosis of bowel obstruction were included even if they refused operation or were too ill for anything but symptomatic or supportive therapy. In the latest death statistics for the United States (1966), 74 per cent of the deaths from intestinal obstructions and hernias were in patients over sixty-five years of age and about half of these patients were between seventy and eighty-five years [91. In this study, half of the deaths occurred in patients between the ages of seventy and eighty years. As shown in Table IV, one third of the eighty-four deaths (33.3 per cent) were due to pneumonia and 27.4 per cent were due to sepsis, caused mainly by peritonitis. Cardiovascular problems caused 22.6 per cent of the deaths whereas embolism was responsible for death in 6 per cent. Four deaths resulted from Vol. 116. October

1969

TABLE

IV

Obstruction in the Aged

Cause of Death

No. of Deaths

Per Cent

28

33.3

23

27.4

Cardiovascular Congestive failure, arrest, cerebrovascular accident

19

22.6

Embolism Pulmonary, brain, superior mesenteric artery

5

6.0

Cause of Death Pulmonary Pneumonia Sepsis Peritonitis shock

and gram-negative

Postoperative Acute

Shock

Renal Failure

Staphylococcus

Enterocolitis

Fluid and Electrolyte

Imbalance

4

4.8

3

3.6

1

1.2

1

1.2

shock within a few hours after operation and three deaths were attributed to renal shut down. One patient died from staphylococcus enterocolitis and another from complications of fluid and electrolyte imbalance. Comments Early diagnosis and treatment are necessary to reduce the mortality and morbidity in aged patients with bowel obstruction. Other complicating conditions must be vigorously treated if they are delaying definitive treatment of the obstruction. The diagnosis of bowel obstruction may be difficult at times, especially in cases of obstruction high in the small bowel. Gastrografin or a similar contrast medium given orally or by tube may be of value in determining the presence of mechanical obstruction in either the small or large bowel. The duration of symptoms as well as the temperature and leukocyte count may indicate whether a strangulated obstruction with gangrenous bowel is present. The findings vary greatly in aged patients and probably depend on the ability of the body to respond to stimuli which usually are active but which may be decreased or absent in aged patients. Leukocytosis, fever, and rigidity usually indicate a complication such as gangrene or perforation but these conditions can be present without these findings [JO]. It is essential to search for hernias in pa643

Greene

tients with signs and symptoms suggestive of obstruction. This is especially important in obese patients in whom a small bulge through a hernial orifice might be overlooked. Internal hernias must also be considered when no other cause for obstruction is evident. Two patients had paracecal hernias in this series and in one patient a loop of bowel herniated through a small hole in an otherwLe normal omentum. One source of error in the diagnosis of with gangrenous strangulated obstruction bowel was in patients admitted with mesenteric artery thrombosis. Errors were made both ways. Two patients were diagnosed as having mesenteric artery thrombosis but at autopsy were found to have gangrenous bowel due to adhesions. Eight others were diagnosed as having bowel obstruction with peritonitis and were found to have mesenteric artery thrombosis. (These cases were not included in the statistics.) The diagnosis of obstruction from high fecal impactions presented problems in twelve cases ; six of these patients had an ulcer or associated perforation at the site of impaction. One patient was admitted to the hospital twice in two years for an obstructing fecal mass in the ascending colon. The etiology in these cases i’s not known but may result from localized areas of decreased motility of the bowel caused by changes in the innervation secondary to circulatory changes. This may also be the cause of so-called “pseudo-obstruction” which is seen in the aged and may result in an acquired megacolon [11]. Three such cases caused problems in diagnosis. The preoperative treatment of aged patients with bowel obstruction can be extremely rewarding [18-1.41, and includes improving the electrolyte and fluid balance and decompressing the stomach and bowel. Other conditions such as diabetes and cardiac arrhythmias can be evaluated and treatment started. Antibiotics should be administered if it is thought that gangrenous bowel is present. No time should be spent in attempting to pass “long tubes” except in patients who have had repeated operations for obstruction. Even those patients with a history of recurrent obstruction who do not improve rapidly after conservative measures should be operated upon. Operations on aged patients with acute obstruction should be restricted to the essential procedure necessary to relieve the obstruction, 544

leaving more definitive procedures until the patient’s condition is improved. The bowel must be handled gently to avoid hypotension which may accompany manipulation of the bowel. Decompression of the bowel with a trocar or large needle may be of great value. Resections of devascularized bowel or exteriorization of the affected bowel should be carried out if possible. The usual indications of return of blood supply and viability must be observed if one is to avoid serious complications. One patient in this series had perforation and fatal peritonitis after laparotomy; during laparotomy a loop of bowel thought to be viable was not resected and underwent progressive changes resulting in gangrene. Enterotomy for gallstone ileus, with resection of damaged bowel if necessary, is all that should be performed in the aged patient. Cholecystectomy and closure of a fistula if present has been suggested [I51 but this should not be encouraged in the emergency situation. Severe complications and one death followed attempts to do this in two patients in this series. Volvulus of the sigmoid colon can frequently be reduced with a sigmoidoscope and a rectal tube and was tried in most of the cases in this series. There were two recurrences. If the blood supply is impaired and resection is not feasible, the proximal end of the colon may be brought out as an end colostomy and the distal end as a mucous fistula or it may be closed and dropped back into the pelvis. Routine closures for exploratory incisions in which retention sutures are used through all layers down to the peritoneum is advisable for the average patient. Rapid closure with through and through sutures is advisable for the very ill patient. If the wound is infected, the skin may be left open and a secondary closure is made later. Five of the patients who were operated upon had dehiscence of the wound. When the site of a complete obstruction of the large bowel can be diagnosed preoperatively, a decompressing procedure is all that is indicated. In this series, cecostomy was the procedure of choice as opposed to colostomy. A colostomy is a more efficient diverting procedure but cecostomy can generally be performed more rapidly and easily and often seemed to be a life-saving measure in desperately ill patients. Some of the patients were operated The American

Journal

of Surgery

Bowel Obstruction in the Aged

upon while under local anesthesia. Most of these patients had resection of the colon at a later date without the need for colostomy. In aged patients with strangulated hernias, release of the strangulation is the primary object of treatment and the type of repair is secondary. Massive strangulated hernias were often treated only by releasing the strangulation and closing the necks of the sacs. The postoperative care of these aged patients must be directed at reducing the complications which lead to high mortality and morbidity. Careful supervision of circulatory functions and of fluid and electrolyte administration combined with intensive efforts to aid respiratory functions will do much to prevent the most common complications. Early ambulation, if possible, together with deep-breathing exercises reinforced with the cautious use of intermittent positive breathing apparatuls and endotracheal aspiration are most important. Opiates should be administered in small amounts only and bronchodilating agents may be of benefit in patients with emphysema. Tracheostomy should not be delayed if it is evident that the patient is having increasing respiratory difficulty. Antibiotics should be given if there are signs of pneumonia or peritonitis. Nasogastric suction is almost essential for one to two days in patients who have had an acute bowel obstruction but the tubes should be removed as soon as possible. Suction by means of a gastrostomy was used in two cases without complications but was not a routine measure. Sepsis and urinary tract infections must be vigorously treated with the proper antibiotics or antiseptios, as determined by culture and sensitivity studies. Summary Three hundred cases of bowel obstruction in patients over sixty-five years of age are reviewed. The obstructions were almost evenly divided among conditionIs arising in the large bowel, the small bowel, and those caused by hernias. The mortality for obstructions arising in the large and small bowel was slightly over 30 per cent whereas the mortality for obstructions from hernia was about 20 per cent. Many

Vol. 118. October 1969

complicationls appeared to be primarily cardiovascular and pulmonary in origin, but sepsis and genitourinary complications were also frequent. Early diagnosis and treatment with special care to prevent complications are necessary if the mortality and morbidity statistics are to be improved. References 1. OWEN, R. A. C. and MURPHY, A. F. Surgery 2. 3. 4.

5.

6.

7. 8. 9.

10. 11.

12. 13. 14. 15.

in old age. B&t. M. J., 2: 186, 1952. GOLDSTEIN,M. S., BEYE, C. L., and ZIFFREN, S. E. Intestinal obstruction in the aged. J. Am. Geriatrics Sot., 1: 205,1953. STANDEVEN,A. Acute abdomen diseases in old age. Bait. M. J.. 2 : 1184.1955. WANTZ~ G. E. and GLENN, F. Intestinal obstruction in the aged. J. Am. Geriatrics Sot., 3 : 974, 1955. WANGESTEEN,0. H. Intestinal Obstruction: A Physiological, Pathological and Clinical Consideration with Emphasis on Therapy, Including Description of Operative Procedure, 3rd ed. Springfield, Ill., 1955. Charles C Thomas. BENEDECK,T. E. and RAFUCCI, F. L. Intestinal obstructions: an analysis of 275 cases with operation. Arch. Surg., 75: 179, 1957. WELCH, C. E. Intestinal Obstruction. Chicago, 1958. Year Book Publishers, Inc. GLENN. F.. MOORE.W. W.. and BEAL. .T. M. Surgery’ in the ‘Aged, p: 243. New York, 1960. McGraw-Hill, Inc. Vital Statistics of the United States, 1966. Vol. 2. Mortalitv. Part B. United States Department of Health, Education and Welfare, Washington, D. C., 1968. U. S. Government Printing Office. SILEN, W., HEIN, M. F., and GOLDMAN,L. Strangulation obstruction of the small intestine. Arch. Surg., 85 : 121, 1962. BERENYI,M. R. and SCHWARZ,G. S. Megasigmoid syndrome in diabetes and neurologic disease: review of 13 cases. Am. J. Gastroenterol, 47: 311, 1967. ZIFFREN,S. E. Management of the Aged Surgical Patient. Chicago, 1960. Year Book Publishers, Inc. JESSEPH,J. E. and HARKINS, H. N. Geriatric Surgical Emergencies. Boston. 1963. Little. Brown & Co. MITTY, W. F. Surgery in the Aged (75 Years of Age and Over). Springfield, Ill., 1966. Charles C Thomas. COOPERMAN, A. M., DICKSON,E. R., and REMINE, W. H. Changing concepts in the surgical treatment of gallstone ileus: A review of 15 cases with emphasis on diagnosis and treatment. Ann. Surg., 167: 377, 1968.

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