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Diagnosis and Treatment of Duodenal Stasis
Medical Clinics of North America January, 1937. Chicago Number
CLINIC OF DR. RALPH C. BROWN PRESBYTERIAN HOSPITAL
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS DUODENAL stasis may arise from a wide range of pathological processes causing obstruction of the duodenum in any of its four anatomical portions. Thus, duodenal ulcer, car- . cinoma of the papilla of Vater, compression of the duodenum by a diseased gallbladder, adhesive bands constricting the duodenum, and carcinoma of the head of the pancreas, may be noted as not infrequent causes. I shall confine the discussion at this time, however, to the type of chronic duodenal stasis caused by arteriomesenteric compression of the third portion of the duodenum. . The interesting problems involved in the general subject of chronic duodenal stasis cannot be approached with clearness of understanding without brief reference to that relatively recent period in our morphological evolution in which the progenitors of men were four-footed animals, for in the fourfooted animals the entire duodenum is a free intraperitoneal loop, with a mesentery hanging freely down in a vertical plane. When our forbears reared up on their hind legs and began to walk like man, there took place a marked change in the anatomical relationships of the bowel, and especially of the duodenum. The mesoduodenum disappeared, the duodenum posteriorly was deprived of much of its peritoneum, and as a result of the upright posture and rotation of the large bowel around the root of the mesentery, we find in man the third portion of the duodenum lodged in the acute angle between the spine and the root of the mesentery. During the last decade of the last century, Dr. Lewis 169
17 0
RALPH C. BROWN
Dwight, Professor of Anatomy at Harvard University, carried on an intensive study of variations in the anatomical relationships of the third portion of the duodenum, making wax casts in situ in 54 cadavers. These casts of the bowel showed varying degrees of compression of the duodenum in its third portion, as evidenced by indentations produced posteriorly by the spine and anteriorly by the root of the mesentery and the mesenteric artery. Thus it may be readily understood that the duodenum, placed as to its third portion in so precarious a position, may be compressed to a degree giving rise to obstructive symptoms as a result of any factor causing an increased drag on the root of the mesentery, especially when associated with lordosis of the spine. Obstruction of the duodenum by this mechanism was recognized by Rokitansky in 1848. Excellent reviews of the literature with a series of case histories have been published by Kellogg, Higgins, and others. In the 1933 volume of the Transactions of the American Surgical Association may be found a thoroughly sound exposition of the subject by Eugene Pool, Walter Niles, and Kirby Martin. However, careful reading of the case histories recorded by these various writers shows a rather wide and variable range of symptoms resulting from duodenal stasis caused by arteriomesenteric obstruction. The diagnosis can be established with certainty only on the basis of careful roentgenologic observations, and later I shall emphasize the fact that minor degrees of lagging of barium in the second and third portiop.s nf the duodenum are all too frequently interpreted as the basis for variable local and general SUbjective symptoms which a more conservative viewpoint might consider due to causes other than chronic duodenal stasis. In none of these protocols was I able to find a symptom picture showing so clearly the widely intermittent, acute paroxysmal type of attacks suffered by the first 2 cases I shall describe. The first case is that of a physician, age forty-three. For no less than twenty years he had had attacks of agonizing ab~olllinal pain associated with the most intense nausea and
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
I7I
vomiting, each attack lasting from three to five days, the attacks occurring on an average of three to five times yearly. Between attacks he enjoyed a normal digestive function with freedom from abdominal distress. The onset of attacks occurred suddenly without warning symptoms, frequently awaking him from sound sleep. The initial symptoms were nausea and vomiting, immediately followed by severe, rhythmically recurring paroxysms of "tearing" pain, centered just to the right of the umbilicus and radiating to the lumbar region bilaterally. The pain· was severe enough to produce profuse perspiration and render him oblivious to his surroundings. After protracted retching and vomiting some temporary relief from pain might be had, but within a brief time there would be recurrence of intense nausea, vomiting, and rhythmic type of pain. The vomitus at onset was fluid in character, containing mucus and bile. Upon two occasions the vomitus contained food eaten twenty-four hours previously. During attacks everything ingested would be immediately vomited, hence as the attacks progressed through three to five days continuously day and night, a marked degree of dehydration and profound prostration occurred with great loss of weight. The attacks ended abruptly and within a few hours normal ingestion of food and fluid could be resumed. It should be noted that the patient had no headache, which Dr. erile considers a symptom of so much importance in his group of chronic duodenal stasis cases . . Over a period of twenty years this physician had had scores of attacks of the character described, and the similarity between this clinical picture and that of the gastric crises of tabes dorsalis requires no comment. Physical examination, however, was negative with the exception of emaciation, and syphilis was excluded in so far as possible by serological tests and careful neurological examination. Fluoro~copic examination in this case revealed normal filling of a moderately dilated stomach showing a marked degree of hyperperistalsis. Barium immediately passed on into the duodenum, the cap (showing no defect in contour) and the second portion of the duodenum filling to very large size, the
17 2
RALPH C. BROWN
dilatation extending throughout the entire second portion. In spite of very vigorous peristalsis and an equally marked antiperistalsis throughout the extent of this greatly dilated duodenum, a very long delay occurred before any barium passed on into the jejunum and long ~fter barium had entirely left the stomach, a ,large pool of barium showing a fluid level remained in the dependent part of the second portion of the duodenum. Films show the size of this dilated duodenum to be approximately one third that of the moderately dilated stomach. A diagnosis of duodenojejunal angle obstruction was made and the abdomen was explored by a distinguished surgeon. Finding nothing in the region of the angulation other than the fact that the duodenum was fixed firmly to the abdominal wall by a very short ligament of Treitz, the abdomen was closed after removing the appendix. Two years later the patient returned with a continuation of the same distressing symptoms and as x-ray examination disclosed the same striking evidence of arteriomesenteric duodenal obstruction, a duodenojejunostomy was immediately performed with subsequent complete relief of symptoms during the period of years which has intervened. Fluoroscopic studies made after operation showed normal emptying time of the stomach and duodenum. The second case is that of a young man of twenty-five, who had had paroxysmal attacks of epigastric pain associated with nausea and vomiting for ten years. The attacks would last two to three days, occurring about a year apart, but for the last three years the recurrent attacks had had a duration of about two weeks. The attacks would come on suddenly with severe pain and cramps in the epigastrium, rapidly spreading to the entire abdomen. The pain would double him up and during an attack he could not bear to have the abdomen touched. There would be profuse perspiration and a temperature rise to 102 0 F. and even to 104 0 F. He was often g~ven hypodermics of morphine for relief, always losing a great deal of weight during the attacks and feeling weak for a long time after recovery. He had consulted many physicians and the diagnosis comzoonly made was that of gastritis or appendicitis. He was
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
I73
of robust type, his normal weight being 180 pounds, was married and had two healthy children. This patient entered the hospital on my service as an emergency case, having been suddenly seized with very severe epigastric pain a few hours before admission, associated with the most intense nausea and vomiting. Examination revealed some rigidity in the upper abdomen, no distention, temperature normal, urine normal, leukocytes 20,000. He was doubled up with pain and required morphine. A tumefaction in the right rectus region was seen with visible duodenal peristalsis from right to left. The second day temperature rose to 100° F. and the third day to 102 ° F. Pain, vomiting, fever, and high leukocytosis continued into the fourth day. Blood chlorides dropped to 300 mg. and the clinical picture was that of an acute surgical abdomen due to high intestinal obstruction. x-Ray Findings.-Marked dilatation of second portion of the duodenum with delay in passage of barium into jejunum. A diagnosis of duodenojejunal angle obstruction was made, and twelve days after admission laparotomy showed great dilatation of the duodenum up to the root of the mesentery, but no other pathology with the exception of a slight, recent plastic exudate about the duodenojejunal fossa. An anastomosis between the dilated duodenum and the jejunum was made with uneventful recovery and complete relief from symptoms. Within six weeks the patient had regained the 25 pounds which had recently been lost. Here again we find a clinical picture of clearly intermittent, acute paroxysmal attacks, occurring very many times over a long period of years, causing the patient to be desperately ill for several days, with normal digestion between attacks. There can be no reason to doubt that in this, as in the preceding case, the obstructing factor was arteriomesente~ic occlusion of the third portion of the duodenum. It is interesting to speculate on the mechanism involved. The second case had a history of troublesome constipation. It seems not unlikely that an overloaded colon may have intermittently caused just enough increased traction on the mesenteric root to precipitate the recurrent attacks of duo-
I74
RALPH C. BROWN
denal occlusion. It should again be noted that headache was not a part of the clinical picture. The third case may throw light on the possible influence of two other factors in the causation of arteriomesenteric occlusion and immense dilatation of the duodenum, i. e., emaciation and disturbance of the nerve supply to the duodenum causi~g atony. The patient was a man, thirty-nine years of age, seen in consultation at the Presbyterian Hospital. Four years earlier gallstones had been removed and the duodenum reported normal. Four months before my observation of the case a highly toxic goiter had been diagnosed and ligation of the vessels carried out with no improvement. Weight was rapidly lost and two weeks after ligation of the thyroid vessels he began having attacks of abdominal pain and vomiting, which became progressively more frequent and severe until his condition became desperate. His weight dropped from 125 to 91 pounds, he became delirious, dehydrated, profoundly toxic, and greatly emaciated. Visible gastric peristalsis aRpeared, suggesting duodenal obstruction. x-Ray examination showed an enormously dilated stomach, a distended duodenal cap, and a really colossal degree of dilatation of the second portion of the duodenum. Several minutes elapsed before any barium passed the duodenojejunal flexure. The films of this case show a duodenal shadow approximately the size of a normal stomach. Five weeks later a successful duodenojejunostomy resulted in such great improvement that thyroidectomy could be safely done and the patient made a rapid and complete recovery. In this case it is probable that the emaciation and high degree of thyrotoxicosis CB.M.R. readings ranged from +55 to +59) were direct predisposing causes of the duodenal ileus, possibly through the mechanical effect of the loss of fat, but more probably through a profound dysfunction of the nerve supply to the duodenum causing atony. Our interest· in chronic duodenal stasis stimulated by these observations, we have sought for years for a clear-cut clinical picture resulting from lesser degrees of arteriomesenteric obstruction than were present in the 3 cases just
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
175
described. The net result of this study is an increasing degree of conservatism as to the indications for operation in what may be described as the borderline group of cases, individuals with chronic dyspepsia, absence of demonstrable pathology, and a duodenum which under fluoroscopic study shows some degree of dilatation of the second portion with reverse peristalsis and some cradling of barium. The following cases will serve to illustrate the point. An able business executive, thirty-five years of age, had for fifteen years frequently recurring attacks of burning distress in the epigastrium with associated waves of nausea. Appendectomy had been done without relief. The symptoms were aggravated to a striking degree by fatigue and nervous strain. With the passing of years of poor health repeated and detailed medical examinations were made, with no evidence of pathology of gallbladder or peptic-ulcer type. A period of rigid ulcer treatment failed to give relief. Frequently he would be awakened at night with burning epigastric distress. He had no headaches. Attention was finally drawn to the fluoroscopic observation that with a large, wellfilled duodenal cap the second portion of the duodenum filled to large size, with reverse peristalsis and some delay in the passage of barium into the jejunum. During fluoroscopic examination cramplike pain occurred at the time of the most active reverse peristalsis. Based upon this evidence the abdomen was explored, sharp angulation at the duodenojejunal flexure was found with dilatation and hypertrophy of the duodenum. Duodenojejunostomy was done and thereafter the patient had an appreciable degree of relief from dyspepsia. However, complete digestive health and comfort is enjoyed by this patient only when his constitutionally below par vegetative nervous system is freed from the effects of nervous stress and strain. A young man, twenty-five years of age, came complaining of a similar epigastric burning distress of six years' duration, the symptoms being quite intermittent during the first four years. During the past two years, however, epigastric dis-
RALPH C. BROWN
tress has been of daily occurrence. The relation to foodtaking is similar to that of peptic ulcer and he gains relief by taking alkalis. Some associated pyrosis and vomiting and a great deal of night pain. No headaches. Previous history negative. Examination showed an individual of normal state of nutrition, normal blood pressure and blood findings. The secretory and motor functions of the stomach were normal. x-Ray examination showed what was reported to be a deformed duodenal cap, whereupon a diagnosis of duodenal ulcer was made and he gained temporary relief for some months on ulcer management, but eighteen months later he returned with the same symptoms. At that time visible gastric peristalsis indicated some degree of duodenal obstruction and ftuoroscopic examination showed a normal duodenal cap, but the second portion of the duodenum filled to very large size with reverse peristalsis and delay in barium passing on into the jejunum. Upon opening the abdomen a band of adhesidns was found stretched across the duodenal cap, and there were some adhesions about an apparently normal gallbladder, but no evidence of peptic ulcer or ulcer scars, nor could any pathology be found at the duodenojejunal angle. Diagnosis, arteriomesenteric obstruction. A duodenojejunostomy was performed with complete recovery of excellent health. Illustrating the type of case in which operation may do more harm than good, however, is the following: a spinster, thirty-seven years of age, a constitutionally below par type, . fatiguing readily, with precordial pain, dyspnea on moderate exertion and right abdominal pain of many years' duration, associated with borborygmi and prodigious eructations. As is unfortunately true of so many chronic dyspeptics, she had had many operations; appendectomy, hysterectomy, an operation for adhesions, and an exploratory operation. Finally her condition was considered so unsatisfactory that upon finding x-ray evidence of a certain degree of duodenal stasis, she was again laparotomized. The second portion of the duodenum w
.
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
177
was performed. This was followed by several subsequent admissions on account of continuation of abdominal pain, nausea, fatigability, and other evidence of vegetative nervous system imbalance. Certainly no appreciable benefit could be credited to the various operative procedures, including the relief of what was believed to be a definite duodenal stasis. It is highly probable that the duodenal stasis in this case was a direct result of the below par state of the vegetative nervous system combined with loss of weight and that it had nothing to do with the initiation of her dyspeptic symptoms. A similar case is that of an undernourished young society girl of nineteen, with a familial type of below par vegetative nervous system, her father being a severe migrainic. The symptom picture was one of dull epigastric pain after eating, anorexia, a spastic bowel, cold moist hands, marked fatigability, and headaches of marked migraine type. On physical examination nothing abnormal could be found, but fluoroscopic examination disclosed a moderate degree of dilatation of the second portion of the duodenum with reverse peristalsis and lagging of barium. A very able internist advised that duodenojejunostomy be done. However, a period of bed rest in seclusion, with a high calorie diet and ample sleep cleared up the dyspepsia within a few weeks, and today, five years later, this young woman is in good health. I believe there are many individuals with chronic dyspepsia and below par vegetative nervous system who may show from time to time such fluoroscopic findings of moderate dilatation of the duodenum, a little reverse persistalsis and possibly some lagging of barium. A great deal of conservatism should be exercised with relation to the operative treatment of this group of cases. I wish strongly to emphasize the relatively insignificant amount of headache in the cases of genuine duodenal stasis on an arteriomesenteric basis that have come under our observation. Dr. Crile has reported good results from duodenojejunostomy in migraine sufferers having duodenal stasis, but until we possess more specific knowledge of the essential VOL. 21-12
RALPH C. BROWN
nature of migraine, it would seem that this operative procedure should be resorted to only in cases where the x-ray findings permit of no doubt as to the existence of definite duodenal obstruction. Moderate increase in the circumference of the second portion of the duodenum with reverse peristalsis and cradling of barium may frequently be observed in normal individuals, hence the need for careful diagnostic study in the borderline cases before advising surgical operation.
CLINIC OF DR. RALPH C. BROWN PRESBYTERIAN HOSPITAL
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS DUODENAL stasis may arise from a wide range of pathological processes causing obstruction of the duodenum in any of its four anatomical portions. Thus, duodenal ulcer, car- . cinoma of the papilla of Vater, compression of the duodenum by a diseased gallbladder, adhesive bands constricting the duodenum, and carcinoma of the head of the pancreas, may be noted as not infrequent causes. I shall confine the discussion at this time, however, to the type of chronic duodenal stasis caused by arteriomesenteric compression of the third portion of the duodenum. . The interesting problems involved in the general subject of chronic duodenal stasis cannot be approached with clearness of understanding without brief reference to that relatively recent period in our morphological evolution in which the progenitors of men were four-footed animals, for in the fourfooted animals the entire duodenum is a free intraperitoneal loop, with a mesentery hanging freely down in a vertical plane. When our forbears reared up on their hind legs and began to walk like man, there took place a marked change in the anatomical relationships of the bowel, and especially of the duodenum. The mesoduodenum disappeared, the duodenum posteriorly was deprived of much of its peritoneum, and as a result of the upright posture and rotation of the large bowel around the root of the mesentery, we find in man the third portion of the duodenum lodged in the acute angle between the spine and the root of the mesentery. During the last decade of the last century, Dr. Lewis 169
17 0
RALPH C. BROWN
Dwight, Professor of Anatomy at Harvard University, carried on an intensive study of variations in the anatomical relationships of the third portion of the duodenum, making wax casts in situ in 54 cadavers. These casts of the bowel showed varying degrees of compression of the duodenum in its third portion, as evidenced by indentations produced posteriorly by the spine and anteriorly by the root of the mesentery and the mesenteric artery. Thus it may be readily understood that the duodenum, placed as to its third portion in so precarious a position, may be compressed to a degree giving rise to obstructive symptoms as a result of any factor causing an increased drag on the root of the mesentery, especially when associated with lordosis of the spine. Obstruction of the duodenum by this mechanism was recognized by Rokitansky in 1848. Excellent reviews of the literature with a series of case histories have been published by Kellogg, Higgins, and others. In the 1933 volume of the Transactions of the American Surgical Association may be found a thoroughly sound exposition of the subject by Eugene Pool, Walter Niles, and Kirby Martin. However, careful reading of the case histories recorded by these various writers shows a rather wide and variable range of symptoms resulting from duodenal stasis caused by arteriomesenteric obstruction. The diagnosis can be established with certainty only on the basis of careful roentgenologic observations, and later I shall emphasize the fact that minor degrees of lagging of barium in the second and third portiop.s nf the duodenum are all too frequently interpreted as the basis for variable local and general SUbjective symptoms which a more conservative viewpoint might consider due to causes other than chronic duodenal stasis. In none of these protocols was I able to find a symptom picture showing so clearly the widely intermittent, acute paroxysmal type of attacks suffered by the first 2 cases I shall describe. The first case is that of a physician, age forty-three. For no less than twenty years he had had attacks of agonizing ab~olllinal pain associated with the most intense nausea and
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
I7I
vomiting, each attack lasting from three to five days, the attacks occurring on an average of three to five times yearly. Between attacks he enjoyed a normal digestive function with freedom from abdominal distress. The onset of attacks occurred suddenly without warning symptoms, frequently awaking him from sound sleep. The initial symptoms were nausea and vomiting, immediately followed by severe, rhythmically recurring paroxysms of "tearing" pain, centered just to the right of the umbilicus and radiating to the lumbar region bilaterally. The pain· was severe enough to produce profuse perspiration and render him oblivious to his surroundings. After protracted retching and vomiting some temporary relief from pain might be had, but within a brief time there would be recurrence of intense nausea, vomiting, and rhythmic type of pain. The vomitus at onset was fluid in character, containing mucus and bile. Upon two occasions the vomitus contained food eaten twenty-four hours previously. During attacks everything ingested would be immediately vomited, hence as the attacks progressed through three to five days continuously day and night, a marked degree of dehydration and profound prostration occurred with great loss of weight. The attacks ended abruptly and within a few hours normal ingestion of food and fluid could be resumed. It should be noted that the patient had no headache, which Dr. erile considers a symptom of so much importance in his group of chronic duodenal stasis cases . . Over a period of twenty years this physician had had scores of attacks of the character described, and the similarity between this clinical picture and that of the gastric crises of tabes dorsalis requires no comment. Physical examination, however, was negative with the exception of emaciation, and syphilis was excluded in so far as possible by serological tests and careful neurological examination. Fluoro~copic examination in this case revealed normal filling of a moderately dilated stomach showing a marked degree of hyperperistalsis. Barium immediately passed on into the duodenum, the cap (showing no defect in contour) and the second portion of the duodenum filling to very large size, the
17 2
RALPH C. BROWN
dilatation extending throughout the entire second portion. In spite of very vigorous peristalsis and an equally marked antiperistalsis throughout the extent of this greatly dilated duodenum, a very long delay occurred before any barium passed on into the jejunum and long ~fter barium had entirely left the stomach, a ,large pool of barium showing a fluid level remained in the dependent part of the second portion of the duodenum. Films show the size of this dilated duodenum to be approximately one third that of the moderately dilated stomach. A diagnosis of duodenojejunal angle obstruction was made and the abdomen was explored by a distinguished surgeon. Finding nothing in the region of the angulation other than the fact that the duodenum was fixed firmly to the abdominal wall by a very short ligament of Treitz, the abdomen was closed after removing the appendix. Two years later the patient returned with a continuation of the same distressing symptoms and as x-ray examination disclosed the same striking evidence of arteriomesenteric duodenal obstruction, a duodenojejunostomy was immediately performed with subsequent complete relief of symptoms during the period of years which has intervened. Fluoroscopic studies made after operation showed normal emptying time of the stomach and duodenum. The second case is that of a young man of twenty-five, who had had paroxysmal attacks of epigastric pain associated with nausea and vomiting for ten years. The attacks would last two to three days, occurring about a year apart, but for the last three years the recurrent attacks had had a duration of about two weeks. The attacks would come on suddenly with severe pain and cramps in the epigastrium, rapidly spreading to the entire abdomen. The pain would double him up and during an attack he could not bear to have the abdomen touched. There would be profuse perspiration and a temperature rise to 102 0 F. and even to 104 0 F. He was often g~ven hypodermics of morphine for relief, always losing a great deal of weight during the attacks and feeling weak for a long time after recovery. He had consulted many physicians and the diagnosis comzoonly made was that of gastritis or appendicitis. He was
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
I73
of robust type, his normal weight being 180 pounds, was married and had two healthy children. This patient entered the hospital on my service as an emergency case, having been suddenly seized with very severe epigastric pain a few hours before admission, associated with the most intense nausea and vomiting. Examination revealed some rigidity in the upper abdomen, no distention, temperature normal, urine normal, leukocytes 20,000. He was doubled up with pain and required morphine. A tumefaction in the right rectus region was seen with visible duodenal peristalsis from right to left. The second day temperature rose to 100° F. and the third day to 102 ° F. Pain, vomiting, fever, and high leukocytosis continued into the fourth day. Blood chlorides dropped to 300 mg. and the clinical picture was that of an acute surgical abdomen due to high intestinal obstruction. x-Ray Findings.-Marked dilatation of second portion of the duodenum with delay in passage of barium into jejunum. A diagnosis of duodenojejunal angle obstruction was made, and twelve days after admission laparotomy showed great dilatation of the duodenum up to the root of the mesentery, but no other pathology with the exception of a slight, recent plastic exudate about the duodenojejunal fossa. An anastomosis between the dilated duodenum and the jejunum was made with uneventful recovery and complete relief from symptoms. Within six weeks the patient had regained the 25 pounds which had recently been lost. Here again we find a clinical picture of clearly intermittent, acute paroxysmal attacks, occurring very many times over a long period of years, causing the patient to be desperately ill for several days, with normal digestion between attacks. There can be no reason to doubt that in this, as in the preceding case, the obstructing factor was arteriomesente~ic occlusion of the third portion of the duodenum. It is interesting to speculate on the mechanism involved. The second case had a history of troublesome constipation. It seems not unlikely that an overloaded colon may have intermittently caused just enough increased traction on the mesenteric root to precipitate the recurrent attacks of duo-
I74
RALPH C. BROWN
denal occlusion. It should again be noted that headache was not a part of the clinical picture. The third case may throw light on the possible influence of two other factors in the causation of arteriomesenteric occlusion and immense dilatation of the duodenum, i. e., emaciation and disturbance of the nerve supply to the duodenum causi~g atony. The patient was a man, thirty-nine years of age, seen in consultation at the Presbyterian Hospital. Four years earlier gallstones had been removed and the duodenum reported normal. Four months before my observation of the case a highly toxic goiter had been diagnosed and ligation of the vessels carried out with no improvement. Weight was rapidly lost and two weeks after ligation of the thyroid vessels he began having attacks of abdominal pain and vomiting, which became progressively more frequent and severe until his condition became desperate. His weight dropped from 125 to 91 pounds, he became delirious, dehydrated, profoundly toxic, and greatly emaciated. Visible gastric peristalsis aRpeared, suggesting duodenal obstruction. x-Ray examination showed an enormously dilated stomach, a distended duodenal cap, and a really colossal degree of dilatation of the second portion of the duodenum. Several minutes elapsed before any barium passed the duodenojejunal flexure. The films of this case show a duodenal shadow approximately the size of a normal stomach. Five weeks later a successful duodenojejunostomy resulted in such great improvement that thyroidectomy could be safely done and the patient made a rapid and complete recovery. In this case it is probable that the emaciation and high degree of thyrotoxicosis CB.M.R. readings ranged from +55 to +59) were direct predisposing causes of the duodenal ileus, possibly through the mechanical effect of the loss of fat, but more probably through a profound dysfunction of the nerve supply to the duodenum causing atony. Our interest· in chronic duodenal stasis stimulated by these observations, we have sought for years for a clear-cut clinical picture resulting from lesser degrees of arteriomesenteric obstruction than were present in the 3 cases just
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
175
described. The net result of this study is an increasing degree of conservatism as to the indications for operation in what may be described as the borderline group of cases, individuals with chronic dyspepsia, absence of demonstrable pathology, and a duodenum which under fluoroscopic study shows some degree of dilatation of the second portion with reverse peristalsis and some cradling of barium. The following cases will serve to illustrate the point. An able business executive, thirty-five years of age, had for fifteen years frequently recurring attacks of burning distress in the epigastrium with associated waves of nausea. Appendectomy had been done without relief. The symptoms were aggravated to a striking degree by fatigue and nervous strain. With the passing of years of poor health repeated and detailed medical examinations were made, with no evidence of pathology of gallbladder or peptic-ulcer type. A period of rigid ulcer treatment failed to give relief. Frequently he would be awakened at night with burning epigastric distress. He had no headaches. Attention was finally drawn to the fluoroscopic observation that with a large, wellfilled duodenal cap the second portion of the duodenum filled to large size, with reverse peristalsis and some delay in the passage of barium into the jejunum. During fluoroscopic examination cramplike pain occurred at the time of the most active reverse peristalsis. Based upon this evidence the abdomen was explored, sharp angulation at the duodenojejunal flexure was found with dilatation and hypertrophy of the duodenum. Duodenojejunostomy was done and thereafter the patient had an appreciable degree of relief from dyspepsia. However, complete digestive health and comfort is enjoyed by this patient only when his constitutionally below par vegetative nervous system is freed from the effects of nervous stress and strain. A young man, twenty-five years of age, came complaining of a similar epigastric burning distress of six years' duration, the symptoms being quite intermittent during the first four years. During the past two years, however, epigastric dis-
RALPH C. BROWN
tress has been of daily occurrence. The relation to foodtaking is similar to that of peptic ulcer and he gains relief by taking alkalis. Some associated pyrosis and vomiting and a great deal of night pain. No headaches. Previous history negative. Examination showed an individual of normal state of nutrition, normal blood pressure and blood findings. The secretory and motor functions of the stomach were normal. x-Ray examination showed what was reported to be a deformed duodenal cap, whereupon a diagnosis of duodenal ulcer was made and he gained temporary relief for some months on ulcer management, but eighteen months later he returned with the same symptoms. At that time visible gastric peristalsis indicated some degree of duodenal obstruction and ftuoroscopic examination showed a normal duodenal cap, but the second portion of the duodenum filled to very large size with reverse peristalsis and delay in barium passing on into the jejunum. Upon opening the abdomen a band of adhesidns was found stretched across the duodenal cap, and there were some adhesions about an apparently normal gallbladder, but no evidence of peptic ulcer or ulcer scars, nor could any pathology be found at the duodenojejunal angle. Diagnosis, arteriomesenteric obstruction. A duodenojejunostomy was performed with complete recovery of excellent health. Illustrating the type of case in which operation may do more harm than good, however, is the following: a spinster, thirty-seven years of age, a constitutionally below par type, . fatiguing readily, with precordial pain, dyspnea on moderate exertion and right abdominal pain of many years' duration, associated with borborygmi and prodigious eructations. As is unfortunately true of so many chronic dyspeptics, she had had many operations; appendectomy, hysterectomy, an operation for adhesions, and an exploratory operation. Finally her condition was considered so unsatisfactory that upon finding x-ray evidence of a certain degree of duodenal stasis, she was again laparotomized. The second portion of the duodenum w
.
DIAGNOSIS AND TREATMENT OF DUODENAL STASIS
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was performed. This was followed by several subsequent admissions on account of continuation of abdominal pain, nausea, fatigability, and other evidence of vegetative nervous system imbalance. Certainly no appreciable benefit could be credited to the various operative procedures, including the relief of what was believed to be a definite duodenal stasis. It is highly probable that the duodenal stasis in this case was a direct result of the below par state of the vegetative nervous system combined with loss of weight and that it had nothing to do with the initiation of her dyspeptic symptoms. A similar case is that of an undernourished young society girl of nineteen, with a familial type of below par vegetative nervous system, her father being a severe migrainic. The symptom picture was one of dull epigastric pain after eating, anorexia, a spastic bowel, cold moist hands, marked fatigability, and headaches of marked migraine type. On physical examination nothing abnormal could be found, but fluoroscopic examination disclosed a moderate degree of dilatation of the second portion of the duodenum with reverse peristalsis and lagging of barium. A very able internist advised that duodenojejunostomy be done. However, a period of bed rest in seclusion, with a high calorie diet and ample sleep cleared up the dyspepsia within a few weeks, and today, five years later, this young woman is in good health. I believe there are many individuals with chronic dyspepsia and below par vegetative nervous system who may show from time to time such fluoroscopic findings of moderate dilatation of the duodenum, a little reverse persistalsis and possibly some lagging of barium. A great deal of conservatism should be exercised with relation to the operative treatment of this group of cases. I wish strongly to emphasize the relatively insignificant amount of headache in the cases of genuine duodenal stasis on an arteriomesenteric basis that have come under our observation. Dr. Crile has reported good results from duodenojejunostomy in migraine sufferers having duodenal stasis, but until we possess more specific knowledge of the essential VOL. 21-12
RALPH C. BROWN
nature of migraine, it would seem that this operative procedure should be resorted to only in cases where the x-ray findings permit of no doubt as to the existence of definite duodenal obstruction. Moderate increase in the circumference of the second portion of the duodenum with reverse peristalsis and cradling of barium may frequently be observed in normal individuals, hence the need for careful diagnostic study in the borderline cases before advising surgical operation.