Chronic obstruction and dilatation of the duodenum

CHRONIC

OBSTRUCTION AND DILATATION DUODENUM JOHN

LUCIUS

MCGEHEE,

OF THE

M.D.

Professor of Surgery, University of Tennessee College of Medicine MEMPHIS, TENNESSEE

A

distinction must be made between the conditions chronic diIatation of the duodenum and chronic obstruction of the duodenum with diIatation. This distinction is made on an etioIogic and anatomic basis. “Chronic diIatation of the duodenum is an abnormal enlargement of a whoIe or a part of the duodenum which may or may not be associated with duodenal retention (stasis) ; it may be of a primary or congenital type or of an acquired type.” (Eusterman. ‘) Congenital Type. Various writers have apphed the terms megaduodenum or megaduodenum congenitum to the congenita1 type. The etioIogic factor is assumed to be some form of neuromuscuIar derangement analogous to that which is supposed to underIy megacoIon or Hirschsprung’s disease. The condition may be present with or without evidence of dysfunction. Dubose2 reported such a case in an infant, and Downes3 a simiIar case in a chiId four and one-half years of age. BaIfour and Gray4 in 1932 reported a case in which the patient was an aduIt 41 years of age, the condition being confrrmed by roentgenoIogic examination and operation. Kraas5 reported six cases in aduIts conhrmed by roentgenoIogic examination and operation. In none of these reported cases was there evidence of mechanica obstruction. Acquired Type. For academic reasons the acquired type of chronic diIatation of the duodenum may be subdivided into three varieties: The first is the functional variety, in which the duodenum is temporariIy diIated due to associated disorders. Signs of dysfunction may or may not be present, and size and function are restored to norma following recovery from the SHARP

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causative disorders. A second variety may be associated with duodenal uIcer, gastric Iues or may foIIow operations. UnIess dilatation is extreme cases of this type are asymptomatic. The third variety, variousIy designated as chronic idiopathic dilatation of the duodenum, chronic duodena1 ileus, chronic duodena1 stasis, or acquired chronic diIatation of the duodenum, is the most important variety of the acquired type. There is much clinical evidence to sustain the concept that chronic duodena1 ileus of the acquired type is a cIinica1 entity. CIinicaIIy, it is very difficuIt and at times impossible to distinguish between this type and chronic duodena1 obstruction with diIatation. In fact, many investigators at differentiation beIieve no attempt shouId be made because the indications for mechanica reIief are the same in both conditions irrespective of the etioIogic factor. The reIation of the root of the mesentery and superior mesenteric vesseIs to the fourth portion of the duodenum, the variations from the norma in rotation of the coIon, the genera1 visceroptosis of the asthenic type of person and the cIinica1 picture of “biIious attacks” with reIief foIlowing vomiting of biIe are suggestive factors giving rise to this condition. HaIpert,6 after post-mortem and anatomic studies, stated that in chronic idiopathic diIatation, obstruction of the duodenum is caused by a fold of mesentery beIonging to the part of the smaI1 intestine which is dispIaced into the peIvis minor. He aIso stated that the occIusion was attributabIe to that type of iIeus in which mechanica factors, but not factors which wiI1 cause stranguIation, are present. He distinguished between this type of arteriomesenteric occlusion and the arteriomesocoIic occIusion associated

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with mobiIe ascending coIon which was first of age which they considered of congenita1 origin. demonstrated by BIoodgood.’ Of the intrinsic acquired forms of duoDuodenal Obstruction with Dilatation. Chronic obstruction of the duodenum with diIatation secondary to the obstruction is a chnical entity of rather frequent occurrence. The term “obstruction” is here intended to convey the idea of mechanica interference with the passage of duodena1 contents. Various types of Iesions act as causative factors; their reIationship was investigated by Rivers and Thiessen,8 who reviewed thirty-live selected cases. In twenty-six cases (74.3 per cent) obstruction occurred at the middIe portion of the duodenum; in three cases (8.6 per cent), at the duodenojejunal angIe. In twenty-three cases (65.7 per cent) the obstruction was due to a malignant Iesion. The causes may be divided into extrinsic and intrinsic and may be congenita1 or acquired. The writer has had no experience with the intrinsic congenita1 type, but Laddg has reported nineteen cases. The FIG. I. Roentgenogram showing the dilated stomach most IikeIy theory to account for this conand duodenum. genita1 defect is that of arrest of deveIopment of the intestine whiIe it is in the soIid dena obstruction, duodena1 carcinoma and stage, i.e., soon after the fifth week of feta1 carcinoma of the ampuIIa of Vater or of the life. This arrest resuIts in either atresia or pancreatic ducts in the duodena1 waI1 are stenosis. The obstruction occurs at about the most frequent causes. (Obstructions the Ievel of the ampuIla, at the junction of due to uIcer are not considered in connecthe hindgut and foregut. tion with this subject.) Foreign bodies, Whether or not this condition is com- such as gaIIstones, a hair ball (Perry and patible with Iife depends entireIy upon the Shaw13), Taenia saginata (Eusterman’) and degree of obstruction. If obstruction is benign tumors, occasionaI1y have been compIete, the average duration of Iife is live reported as causative factors. The extrinsic causes of duodena1 obstrucdays; if it is incompIete and the stenosis is of such degree as not to interfere too much tion are much more frequent than the with the passage of duodena1 contents, life intrinsic causes. The reIativeIy fixed posimay be proIonged indefinitely. Cannon and tion of the duodenum renders it particuHaIpertlO reported a case in an 8 year oId IarIy IiabIe to compression from without, resuIting in obstruction by neopIasms and chiId proved by autopsy. NagIell reported mesenteric adenopathies. This condition such a case in a man 72 years of age, who is we11 iIIustrated by two cases occurring in since chiIdhood had suffered attacks of the writer’s experience during the year epigastric pain, beIching, abdomina1 distention and vomiting. Autopsy reveaIed 1937: the Iumen of the duodenum partially closed CASE I. A negro maIe, 33 years of age, was by a septum above the ampuIIa of Vater. admitted to the John Gaston HospitaI on Judd was _epi_ _ and __ Puestowl2 reported a case of ApriI 8, 1937. His_ chief compIaint . duodenal obstruction in a woman 33 years gastric distress thirty minutes after takmg

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food, relieved onIy by vomiting. This had been present for a period of about two years, but during the two months preceding admission,

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Iymph nodes ranging in size from the tip of one’s finger to the distal phaIanx of one’s thumb. In the base of the mesentery was found

FIG. 2. Roentgenogram showing the diIated stomach, pylorus and duodenum with obstruction at duodenojejuna1 junction.

vomiting was of daiIy occurrence, the vomitus consisting of food and large quantities of yelIowish watery material. Preceding vomiting there was great upper abdomina1 distention and visible peristaIsis which was reIieved by vomiting. Roentgenologic Examination. SeveraI minutes passed during ffuoroscopy before gastric emptying began. No defect couId be detected in the stomach, which was atonic and dilated. After emptying began, the duodenum fiIIed; it was very large and apparentIy a partiaI obstruction was present in the second portion. There was no evidence of pathoIogy in the stomach and pylorus. There was considerabIe diIatation of the first and second portions of the duodenum. However, some barium couId be seen in the third portion of the duodenum and the jejunum. At six hours there was considerabIe retention of barium in the diIated duodenum, and at twenty-four hours there was stiI1 some barium retained in the diIated duodenum. ConcIusions: partia1 obstruction of the duodenum with diIatation of the first and second portions and stomach. (Fig. I.) Operation. On ApriI 26, 1937, Iaparotomy was done through an upper midIine incision and the foIIowing gross findings were reveaIed: The stomach was diIated; gastro-hepatic omentum contained numerous enIarged firm

a Iarge mass, the size of one’s fist, compIeteIy obstructing the third and fourth portions of the duodenum. The first and second portions of the duodenum were diIated to twice the norma size. The jejunum was empty and contracted. Gastrojejunostomy was done after removing a node for biopsy. IymphadPathologic Report. TubercuIous enitis. After an uneventfu1 convaIescence the patient was discharged from the hospita1 on May 8, 1937, compIeteIy reIieved of his comI, pIaint. He was reported we11 on December 1937. CASE

A white maIe, age 44 years, II. compIained of indigestion, abdomina1 pain, biIious vomiting, increasing in frequency for six months. For the preceding three weeks the vomiting had occurred daiIy, the vomitus consisting of food and biIe-stained material. There had been a Ioss of go pounds in weight. He compIained bitterIy of hunger and weakness. PhysicaI examination was essentiaIIy negative. Roentgenologic Examination. The stomach, pyIorus and duodenum were greatIy diIated, and the duodenum was obstructed at the duodenojejuna1 junction. A Iarge quantity of the barium remained in the stomach and

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duodenum at the end of twenty-four hours. At twenty-four hours there was barium scattered throughout the Iength of the small intestines, which apparentIy was still trickIing through the obstruction at the termina1 portion of the duodenum. (Fig. 2.) The roentgenoIogic diagnosis was obstruction with diIatation of the duodenum at its termina1 portion, probabIy due to carcinoma of the tai1 of the pancreas. Operation. On .January 3, 1937, Iaparotomy reveaIed the folIowing gross findings: An enormousIy diIated stomach and pyIorus, the Iatter easily admitting three fingers. The duodenum was diIated and distended to the size of a coIon. At the duodenojejuna1 junction a hard woody mass, the size of a smaI1 orange, was found invoIving the tai1 of the pancreas. The neopIasm had aIso invaded the waI1 of the jejunum just beIow the Iigament of Treitz. Biopsy reveaIed adenocarcinoma of the pancreas with coIIoid degeneration. Duodenojejunostomy was done.

diIatation is a cIinica1 entity, can be diagnosed as such and is amenabIe to surgica1 treatment with satisfactory end resuIts.

On January 26, 1937, the patient was discharged from the hospita1 after a satisfactory convaIescence, reIieved of his vomiting and the pangs of hunger, having gained 7 pounds in weight. His death occurred six months later, but it was not due to starvation.

Imperfect rotation of the colon in feta1 Iife, which brings the superior mesenteric vesseIs to Iie across the duodenum, and imperfect fixation of the coIon (colon mobiIe of Waugh23) are the ultimate etioIogic factors in this condition. A case reported by the writer25 iIIustrates and substantiates this contention :

Post-operative adhesions may obstruct to variabIe degrees the upper jejunum, producing signs of duodena1 obstruction and shouId be sought for as possibIe causes in al1 cases with histories of previous operative procedures. CongenitaI anomaIies, fauIty rotation and bands not infrequently cause duodena1 obstruction, the point of obstruction usuaIIy being at the duodenojejuna1 angIe. Chronic duodena1 obstruction with diIatation as a cIinica1 entity from pressure of the overIying mesenteric pedicIe has been a debatabIe question for many years and has been discussed by many writers pro and con. NotabIy, BIoodgood,14,15 WiIkie,l6*‘7 HaIpert,6 Leveuf, l8 DuvaI, Roux and B& cI&re,lg BaIfour and Gray,4 Devine,m Higgins,21 Judd,12 the KeIIoggs,22 Waugh,23 Robertson,24 McGehee and Anderson25 and many others. It is the writer’s opinion that chronic duodena1 obstruction with

FIG. 3. Roentgenogram before operation, showing the dilated and obstructed first and second portions of the duodenum.

CASE III. An 18 year oId femaIe who had since the suffered from “bilious attacks” sixth week of Iife finaIIy presented the cIinica1 picture of duodena1 obstruction. She was of the asthenic visceroptotic type. Roentgenographic examination gave evidence of definite obstruction and diIatation of the termina1 portion of the duodenum. (Figs. 3 and 4.) ExpIoration reveaIed the stomach to be dilated, the waIIs thin, the pylorus patuIous, admitting two fingers. The duodenum was mobiIe, attached by a mesentery; the first, second and third portions were diIated to three times the norma size (size of one’s wrist). Upon raising the transverse mesocoIon, the greatIy diIated duodenum was seen buIging through the transverse mesocoIon. The diIatation of the duodenum extended to the point of crossing of the superior mesenteric artery, but at this same point there was considerabIe drag of the mesocolon, which was reIieved by

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Iifting the mobiIe coIon. The jejunum was empty and smaIIer than norma by one-haIf the norma circumference. Upon pulling up the

FIG. 4. Appearance

of the stomach and duodenum at the end of six hours, showing the gastric and duodenal retention.

mesentery the distended third portion of the duodenum was seen to empty into the jelunum filling it. The ascending coIon was mobile,

attached by a mesentery. It couId be lifted out of the abdomina1 cavity. A submesocoIic duodenojejunostomy was done between the third portion and the jejunum; aIso a coIopexy after the technique of Waugh.23 Two years have passed since this operation. The patient has been weI1; she reports no indigestion and no bilious attacks. She considers herseIf compIeteIy relieved. The diagnosis of this form of obstruction must be based on the sum tota of obtainabIe information from the history of inter“ biIious attacks ” from infancy, mittent positive roentgenographic findings and positive operative evidence of duodena1 obstruction with diIatation of the arteriomesenteric type. While the condition is found in the neurovisceroptotic type of

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individua1, it must be borne in mind that a11 neurovisceroptotic individuals are not aIso necessariIy affIicted with chronic duodena obstruction with diIatation. Where the necessary evidence (bilious attacks from infancy plus roentgenographic evidence pIus operative findings) is present, the operation duodenojejunostomy first suggested by Barker and BIoodgood and first performed by StaveIyz6 meets the operative indications and gives satisfactory end results. It is easy to perform in the suitabIe cases (those where the obstruction and dilatation actuaIIy exist and are demonstrable) ; diffIcuIty of access and performance usuaIIy means very questionabIe indication and an end resuIt disappointing to the patient and embarrassing to the surgeon. The reported poor resuIts by certain surgeons are the resuIts of the appIication of a sound surgica1 principIe in the absence of a positive indication-a definite obstructing mechanism. The dogmatic negation of the “superior mesenteric artery pressure” theory and the substitution therefor of the indefinite terms “ eurosisn “20 or “neuromuscuIar derangeto sound ment “24 are not conducive thinking and are not in accord with authenticated cIinica1 observation or cIinical end results. CONCLUSIONS I.

Chronic duodenal obstruction with diIatation does exist as a cIinicopathoIogic entity. 2. Its causes are extrinsic and intrinsic, congenita1 and acquired, a11 acting mechanicaIIy. 3. It can be positiveIy diagnosed by a carefu1 consideration of the history, the physica examination and the roentgenoIogic findings. 4. The operation of duodenojejunostomy in properIy seIected cases fuIfiIs the surgica1 indications and gives satisfactory end resuIts. REFERENCES GEORGE B. The Stomach and DuoI. EUSTERMAN, denum. PhiIa., 1936. W. B. Saunders & Co.

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2. DUBOSE, F. G. Megaduodenum: report of a case in an infant. Surg., Gynec. Ed Obst., 29: 278, 1919. ,3. DOWNES, W. A. Giant duodenum, with report of a case in a child. Ann. Sum.. 66: 416. Ior7. 4. BALFOUR, D. C., and GRAY: H. K.‘DuodenaI iIeus; congenital deformity of the duodenum. Surg. Clin. North America, 12: 862, 1932. 5. KRAAS, E. Beitrag zur Atiologie und Klinik der chronischen Duodenalstenose und Megaduodenums. Be&. z. klin. Cbir., 157: 489, 1933. 6. HALPERT, BELA. The arteriomesenteric occlusion of the duodenum; an anatomical study. Bull. Jobn Hopkins Hosp., 38: 409, 1926. 7. BLOODGO~D, J. C. Dilatation of the duodenum in reIation to surgery of the stomach and colon. J. A. M. A., 59-z 1;7, 1912. 8. RIVERS, A. B., and THIESSEN, N. W. Obstruction of the upper portion of the small intestine; a cIinica1 study. Am. J. Digest. Dis. TV Nutr., I: 9% 1934. g. LADD, W. E. Congenital obstruction of the smaII intestine. J. A. M. A., IOI: 1453, 1933. IO. CANNON, P. R., and HALPERT, B. CongenitaI stenosis of the third portion of the duodenum with acute occlusion and rupture of stomach. Arch. Patb., 8: 61 I, 1929. I I. NAGLE, G. W. UnusuaI conditions of the duodenum and their significance; membranous obstruction of the Iumen, diverticuIa and carcinoma. Arch. h-g., II: 529, 1925. 12. JUDD, E. S., and PUESTOW, C. B. Chronic duodena1 obstruction. Surg. Clin. North America, 13: 807, ‘933. 13. PERRY, E. C., an d SHAW, L. E. On Diseases of the duodenum. Guy’s Hosp. Rep., 50: 171, 1893.

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of 14. BLOODGOOD, JOSEPH COLT. Chronic ditatation the duodenum. Internat. Surg. Digest., I: 259, 1926. 15. BLOODGOOD, JOSEPH COLT. Acute diIatation of the stomach-gastromesenteric iIeus. Ann. Surg., 46: 736, ‘907. 16. WILKIE, D. P. D. Chronic duodena1 iIeus. Am. J. M. SC., 173: 643, 1927. 17. WILKIE. D. P. D. Chronic duodena1 iIeus. Brit. J. Surg., g: 204, rg2r-22. 18. LEVEUF, J. Chronic occIusions of the duodenum. Rev. crit. de patb. et de tberap., 2: 77, 1931. and BI?CL&RE. The Duodenum: 19. DUVAL, Roux MedicaI, Radiologic and Surgical Studies (Translated by Quain). St. Louis, 1928. C. V. Mosby Co. 20. DEVINE, H. B. Basic principIes and supreme diIIicuIties in gastric surgery. Surg., Gynec. ti Obst., 41: 688, 1925. 21. HIGGINS, C. C. Chronic duodena1 iIeus with report of 56 cases. Arch. Surg., 13: I, 1926. 22. KELLOGG, E. L., and KELLOGG, W. A. Chronic duodenal obstruction with duodenojejunostomy as a method of treatment; report of 41 operations. Ann. Surg., 73: 578, 1921. 23. WAUGH, GEORGE E. The morbid consequences of a mobiIe ascending coIon with a record of I 80 operations. Brit. J. Surg., 17: 343, 1920. 24. ROBERTSON, GEORGE. Acute diIatation of the stomach and intestinal tube with consideration of “chronic duodena1 iIeus.” Surg., Gynec. PY Obst., 40: 206, 1925. 25. MCGEHEE, JOHN LUCIUS, and ANDERSON, W. D. Chronic obstruction and dilatation of the duodenum. Ann. Surg., 105: 741, 1937. 26. STAVELY, A. L. Acute and chronic gastro-mesenteric ileus with cure in a chronic case by duodenojejunostomy. Bull. Jobns Hopkins Hosp., rg: 252, 1908.