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Early indications of adhesive small bowel obstruction
EARLY INDICATIONS
OF ADHESIVE SMALL BOWEL
OBSTRUCTION* CLAUDE J. HUNT, M.D. KANSAS CITY, MISSOURI
T
HE earIy diagnosis of smaI1 bowe1 obstruction is reIated to the recognition of three essentia1 cIinica1 manifestations of the disorder and to the proper interpretation of the radiographic findings of an x-ray fiIm of the abdomen. The cIinica1 manifestations are those associated with a particuIar type of pain, visibIe peristaIysis and borborygmus, which may be caIIed the “Big Three” of smaI1 bowe1 obstruction. The pain in this condition is quite characteristic and different from any other type of abdomina1 pain. It is not Iocahzed to any one quadrant of the abdomen but is genera1 in type. It is not constant but periodic in character, Iasts for a minute or so, is cramplike in character, increases in intensity and ends abruptly, onIy to recur in a short time. It is not associated with any tenderness or rigidity except to a slight degree when the obstruction is of a stranguIated type or there are invoIved adhesive bands to the anterior parieta1 peritoneum. Even then the tenderness and rigidity in no way approaches that associated with an acute IocaIized infIammatory process or specific colic. In fact, the coIic of bowe1 obstruction is unlike that of any other kind of abdomina1 coIic because of its diffuse nature, intervals of freedom from pain and absence to a Iarge extent of IocaIized tenderness and rigidity. Associated with this pain there is seen, moving across the abdomen in earIy obstruction, an intestina1 peristalysis that is synchronous with the paroxysm of pain. This Iikewise is periodic in character and stops with the cessation of pain. Often these peristaItic waves may be seen to move across the abdomen in succession at the height of the crisis of pain. Later in the
has deveIoped, process, after distention the phenomenon may not be observed as intestina1 distention Iessens the vioIence of the contraction and the visibiIity of the peristaItic wave. CorreIated with the seizures of pain and the appearance of peristaltic waves there is heard upon Iistening to the abdomen a pecuIiar metaIIic sound which is synchronous with the pain and the visibIe peristaIysis. The noise is unIike any other type of intra-abdomina1 sound, in that it is reIated in time, duration and termination, to the pain and peristalysis. The noise increases in intensity, has a metaIIic ring and ends abruptIy in a crescendo of sound at the termination of the pain, onIy to recur with the next crisis of intestina1 coIic. This is we11 heard by auscuItation with a stethoscope over the abdomen during a paroxysm of pain. It is known as borborygmus. With a consciousness of the reIationship of these symptoms and a recognition of their significance, a clinica diagnosis can be made of smaI1 bowe1 obstruction. If there is a protruding mass on the surface of the abdomen significant of a stranguIated bowe1, the diagnosis is immediately confirmed; or if the abdomen shows evidence of one or more operative incisions, the suspicion of intestina1 obstruction is further increased. These cIinica1 manifestations associated with an increasing abdomina1 distention, without evidence of externa1 stranguIation or incisiona scars upon the abdomen, Iikewise indicate bower obstruction which immediateIy needs further confirmation. The passage of gas, the movement of the boweIs or adequate resuhs obtained from an enema do not indicate that there is no
* From the SurgicaI Service, Research Hospital, 8%
Kansas City, MO.
Amxican
FIG.
I.
Journal of Surgery
Hunt-BoweI
Obstruction
IIIustrates the pattern of bowel distention in simpIe, non-stranguIating obstruction. vaIvuIae conniventes are cIearIy seen in this type of obstruction.
obstruction. It must be remembered that there is nothing wrong with the anatomy and physioIogy of the bowe1 distaI to the obstruction and it can function adequateIy. This apparent function often gives a faIse feeIing of security, onIy to find Iater a obstruction with a possibIe progressive peritonitis from a perforated stranguIated gangrenous bowe1. In fact, the distal bowel may empty itseIf from reffex action due to the presence of the obstruction. This function of the bowe1 dista1 to the obstruction has been emphasized by Wangensteen and GoehI’ and attention caIIed to the disasters which may resuIt if this is not fuIIy recognized. Therefore, it can be said that the movement of the boweIs, the passage of gas or adequate resuIts from an enema by no means indicate the patency of the intestina1 tract. Regurgitant vomiting occurs earIy onIy in high intestina1 obstruction. Since most smaI1 bowe1 obstructions are Iow, this type of vomiting does not occur unti1 proxima1 bowe1 distention has become marked, abdomina1 distention is present and the cIinicaI diagnosis is obvious. EarIy vomiting in Iow smaI1 bowe1 obstruction is reflex in character, as it is in coJonic obstruction.
DECEMBER, 1946
The
Therefore, it can be said that vomiting in the absence of abdomina1 distention may or may not be due to obstruction and further investigation is necessary for diagnosis. The x-ray is the onIy means by which a positive diagnosis can be made of earIy smaI1 bowe1 obstruction. By this means a diagnosis can be made, the approximate site of the Iesion determined and the probabIe nature of the obstruction ascertained. In interpreting an x-ray fiIm of the abdomen, it must be remembered that gas is normaIIy visibIe in the stomach and coIon but not in the smaI1 bowe1 except in infants. Gas is present but is not detectabIe by a radiographic film because it is mixed or emuIsified with the Iiquid contents of the smaI1 bowe1 and becomes discernibIe onIy on an x-ray fiIm when the continuity of the bowe1 is obstructed. Therefore, gas observed in the smaI1 bowe1 by this method is significant of obstruction and it can be detected in a few hours after it has occurred. The pattern which the gas in an obstructed bowe1 assumes determines the probabIe nature of the obstruction. If the obstruction is of a simpIe type due to an anguIation of the bowe1 from an adhesive band or a band passing across the bowe1,
Var.
I.XXII,
No.
6
Hunt-Bowel
Obstruction
American
Journal
of Surgery
867
FIG. 2. Shows a distended loop of smaII bowel which does not assume any definite pattern of bowel distention, as is seen in Figure I. The vaIvuIae conniventes are not seen. The fiIm is quite characteristic of stranguIated obstruction. The resected specimen is shown.
the proximal portion becomes distended and in so doing graduaIIy assumes a definite pattern in which the distended co& arrange themselves in a transverse position to the Iong axis of the body. The vaIvuIae conniventes remain visibIe because the distended bowe1 is fIIIed IargeIy with gas and some Iiquid content and there is no extravasation of bIood into the bowe1, as is present in a stranguIated obstruction. This pattern becomes more pronounced with the advancement of the obstruction until uItimateIy a stairstep arr’angement of the proxima1 distended bowe1 is observed. The thickness of the bowe1 waI1 indicates a reIative degree of pIastic exudate, ffuid or peritonitis. A stranguIated obstruction, however, presents no such arrangement of the boweIs in this transverse position. There is no definite pattern assumed by the distended coils of the bowe1 in this type of obstruction. The distended Ioops arrange themseIves in whatever portion of the abdomen the obstruction occurs and no characteristic pattern is assumed and proxima1 distention above the site of stranguIation is slow to deveIop, as empha-
sized by Wangensteen. In contrast to a simpIe non-strangulating obstruction, the vaIvuIae conniventes are not seen or easiIJ detected due to the extravasation of bIood into the stranguIated Ioop of bowe1 and into the free abdomina1 cavity. It is important to differentiate, if possibIe, between a simpIe non-stranguIated obstruction and a stranguIated one. In the former the visibility of the bowe1 is not in danger and operation can be deferred until the patient can be physioIogicaIIy prepared for operation by chemica1 and ffuid rehabiIitation and the distended bowe1 decompressed by intestina1 intubation. In stranguIated obstruction the bIood suppIy is damaged, bowe1 gangrene and perforation are imminent and operation cannot be deferred. PhysioIogicaI rehabiIitation must be deferred unti1 during and after surgery because of this impending danger. Through carefu1 correlation of the radiographic pattern of the distended bowe1 with the findings at surgical expIoration we fee1 quite definiteIy that a competent radioIogist can be of great assistance in determining the presence of smaI1 bowe1 obstruction, the approximate site of the Iesion and the
868
American Journalof Surgery
Hunt-BoweI
probabIe nature of the disorder. We have found that by a carefuI study of the pattern of the gaseous distention the immediate urgency of the situation can be determined. We beIieve, aIways, in the immediate operation of a11 earIy smaI1 bowe1 obstructions, but there are many with marked fIuid Ioss and great abdomina1 distention, who are not good subjects physioIogicaIIy or anatomicaIIy for immediate surgery. If in these cases a carefu1 study of the pattern of gaseous distention, as observed in a radiographic fiIm, the Iesion appears to be non-stranguIating, physioIogica1 rehabiIitation and intestina1 intubation may be safeIy accompIished prior to surgery. The operation is then one of eIection and is much more satisfactoriIy and safeIy done, than when great distention is present and anatomica diffIcuIties are great and hazardous. Figure I demonstrates the vaIue of the x-ray in evaIuating the type of smaI1 bowel obstruction. It shows the transverse pattern of the bowe1 distention and the vaIvuIae conniventes are cIearIy seen. The cIinica1 manifestations and radiographic manifestations are those of simpIe obstruction with no evidence of vascuIar damage. The MiIIer-Abbott tube decompressed the distended intestines and aided materiaIIy in the surgica1 approach. Operation reveaIed a simpIe adhesive band obstructing the smaI1 bowe1 by constricting the Iumen. Recovery was prompt after freeing the constricting adhesion. Figure 2 shows an irreguIar type of smaI1 bowe1 distention that conforms to no pattern that is reIated to the Iong axis of the body and the vaIvuIae conniventes are not seen. The clinica manifestation shows an uneven distention in the contour of the abdomen with sIight IocaIized tenderness and rigidity. Immediate operation discIosed a smaI1 bowe1 loop twisted upon itseIf by a band of adhesions attached to the bowe1 mesentery. The bowe1 was bIack and required resection. Recovery was unevent-
Obstruction
DECEMBER, ,946
fu1 after resection and anastomosis. The x-ray was vaIuabIe in determining the nature of the obstruction and the need for immediate surgery. We have found the correIation between the x-ray diagnosis by means of a flat fiIm of the abdomen and the operative findings to be very accurate and have previousIy reported this reIationship in August, Ig44.2 We, therefore, emphasize the importance of competent radioIogica1 assistance in evaIuating the nature of the obstruction of the smaI1 bowe1 and the need for immediate surgery. We know that in some instances of advanced simpIe obstruction surgery is more safeIy and effectiveIy done after physioIogica1 rehabiIitation and intestina1 intubation by the MiIIer-Abbott tube has been satisfactoriIy empIoyed. SUMMARY
The cIinica1 symptoms and signs of smaI1 bowe1 obstruction are characteristic and are unIike any type of intra-abdomina1 disease. The coIic is specific in character and different from other forms of abdomina1 coIic. The x-ray is most vaIuabIe in confirming the diagnosis of smaI1 bowe1 obstruction, in locating the site of the obstruction and in determining to a large extent the nature of the obstruction. The function of the bowe1 dista1 to the obstruction is unimpaired and shouId adequate function take pIace it does not indicate the absence of obstruction. The urgency of immediate surgery is emphasized in stranguIated obstruction in contrast to the feasibiIity of deIaying surgery in advanced simpIe obstruction unti1 physioIogica1 measures and intubation procedures can be adequateIy empIoyed. REFERENCES I. WANGENSTEEN,0. H. and GOEHL, R. 0. EvaIuation of the expukon of enemas as a criterion of intestinaI obstruction. Arch. Int. Med., 46: 669-679, ‘930. 2. HUNT, C. J. CorreIation of the x-ray diagnosis with operative findings in smaI1 intestina1 obstruction. Radiology, 43: 107-114, 1944.
OF ADHESIVE SMALL BOWEL
OBSTRUCTION* CLAUDE J. HUNT, M.D. KANSAS CITY, MISSOURI
T
HE earIy diagnosis of smaI1 bowe1 obstruction is reIated to the recognition of three essentia1 cIinica1 manifestations of the disorder and to the proper interpretation of the radiographic findings of an x-ray fiIm of the abdomen. The cIinica1 manifestations are those associated with a particuIar type of pain, visibIe peristaIysis and borborygmus, which may be caIIed the “Big Three” of smaI1 bowe1 obstruction. The pain in this condition is quite characteristic and different from any other type of abdomina1 pain. It is not Iocahzed to any one quadrant of the abdomen but is genera1 in type. It is not constant but periodic in character, Iasts for a minute or so, is cramplike in character, increases in intensity and ends abruptly, onIy to recur in a short time. It is not associated with any tenderness or rigidity except to a slight degree when the obstruction is of a stranguIated type or there are invoIved adhesive bands to the anterior parieta1 peritoneum. Even then the tenderness and rigidity in no way approaches that associated with an acute IocaIized infIammatory process or specific colic. In fact, the coIic of bowe1 obstruction is unlike that of any other kind of abdomina1 coIic because of its diffuse nature, intervals of freedom from pain and absence to a Iarge extent of IocaIized tenderness and rigidity. Associated with this pain there is seen, moving across the abdomen in earIy obstruction, an intestina1 peristalysis that is synchronous with the paroxysm of pain. This Iikewise is periodic in character and stops with the cessation of pain. Often these peristaItic waves may be seen to move across the abdomen in succession at the height of the crisis of pain. Later in the
has deveIoped, process, after distention the phenomenon may not be observed as intestina1 distention Iessens the vioIence of the contraction and the visibiIity of the peristaItic wave. CorreIated with the seizures of pain and the appearance of peristaltic waves there is heard upon Iistening to the abdomen a pecuIiar metaIIic sound which is synchronous with the pain and the visibIe peristaIysis. The noise is unIike any other type of intra-abdomina1 sound, in that it is reIated in time, duration and termination, to the pain and peristalysis. The noise increases in intensity, has a metaIIic ring and ends abruptIy in a crescendo of sound at the termination of the pain, onIy to recur with the next crisis of intestina1 coIic. This is we11 heard by auscuItation with a stethoscope over the abdomen during a paroxysm of pain. It is known as borborygmus. With a consciousness of the reIationship of these symptoms and a recognition of their significance, a clinica diagnosis can be made of smaI1 bowe1 obstruction. If there is a protruding mass on the surface of the abdomen significant of a stranguIated bowe1, the diagnosis is immediately confirmed; or if the abdomen shows evidence of one or more operative incisions, the suspicion of intestina1 obstruction is further increased. These cIinica1 manifestations associated with an increasing abdomina1 distention, without evidence of externa1 stranguIation or incisiona scars upon the abdomen, Iikewise indicate bower obstruction which immediateIy needs further confirmation. The passage of gas, the movement of the boweIs or adequate resuhs obtained from an enema do not indicate that there is no
* From the SurgicaI Service, Research Hospital, 8%
Kansas City, MO.
Amxican
FIG.
I.
Journal of Surgery
Hunt-BoweI
Obstruction
IIIustrates the pattern of bowel distention in simpIe, non-stranguIating obstruction. vaIvuIae conniventes are cIearIy seen in this type of obstruction.
obstruction. It must be remembered that there is nothing wrong with the anatomy and physioIogy of the bowe1 distaI to the obstruction and it can function adequateIy. This apparent function often gives a faIse feeIing of security, onIy to find Iater a obstruction with a possibIe progressive peritonitis from a perforated stranguIated gangrenous bowe1. In fact, the distal bowel may empty itseIf from reffex action due to the presence of the obstruction. This function of the bowe1 dista1 to the obstruction has been emphasized by Wangensteen and GoehI’ and attention caIIed to the disasters which may resuIt if this is not fuIIy recognized. Therefore, it can be said that the movement of the boweIs, the passage of gas or adequate resuIts from an enema by no means indicate the patency of the intestina1 tract. Regurgitant vomiting occurs earIy onIy in high intestina1 obstruction. Since most smaI1 bowe1 obstructions are Iow, this type of vomiting does not occur unti1 proxima1 bowe1 distention has become marked, abdomina1 distention is present and the cIinicaI diagnosis is obvious. EarIy vomiting in Iow smaI1 bowe1 obstruction is reflex in character, as it is in coJonic obstruction.
DECEMBER, 1946
The
Therefore, it can be said that vomiting in the absence of abdomina1 distention may or may not be due to obstruction and further investigation is necessary for diagnosis. The x-ray is the onIy means by which a positive diagnosis can be made of earIy smaI1 bowe1 obstruction. By this means a diagnosis can be made, the approximate site of the Iesion determined and the probabIe nature of the obstruction ascertained. In interpreting an x-ray fiIm of the abdomen, it must be remembered that gas is normaIIy visibIe in the stomach and coIon but not in the smaI1 bowe1 except in infants. Gas is present but is not detectabIe by a radiographic film because it is mixed or emuIsified with the Iiquid contents of the smaI1 bowe1 and becomes discernibIe onIy on an x-ray fiIm when the continuity of the bowe1 is obstructed. Therefore, gas observed in the smaI1 bowe1 by this method is significant of obstruction and it can be detected in a few hours after it has occurred. The pattern which the gas in an obstructed bowe1 assumes determines the probabIe nature of the obstruction. If the obstruction is of a simpIe type due to an anguIation of the bowe1 from an adhesive band or a band passing across the bowe1,
Var.
I.XXII,
No.
6
Hunt-Bowel
Obstruction
American
Journal
of Surgery
867
FIG. 2. Shows a distended loop of smaII bowel which does not assume any definite pattern of bowel distention, as is seen in Figure I. The vaIvuIae conniventes are not seen. The fiIm is quite characteristic of stranguIated obstruction. The resected specimen is shown.
the proximal portion becomes distended and in so doing graduaIIy assumes a definite pattern in which the distended co& arrange themselves in a transverse position to the Iong axis of the body. The vaIvuIae conniventes remain visibIe because the distended bowe1 is fIIIed IargeIy with gas and some Iiquid content and there is no extravasation of bIood into the bowe1, as is present in a stranguIated obstruction. This pattern becomes more pronounced with the advancement of the obstruction until uItimateIy a stairstep arr’angement of the proxima1 distended bowe1 is observed. The thickness of the bowe1 waI1 indicates a reIative degree of pIastic exudate, ffuid or peritonitis. A stranguIated obstruction, however, presents no such arrangement of the boweIs in this transverse position. There is no definite pattern assumed by the distended coils of the bowe1 in this type of obstruction. The distended Ioops arrange themseIves in whatever portion of the abdomen the obstruction occurs and no characteristic pattern is assumed and proxima1 distention above the site of stranguIation is slow to deveIop, as empha-
sized by Wangensteen. In contrast to a simpIe non-strangulating obstruction, the vaIvuIae conniventes are not seen or easiIJ detected due to the extravasation of bIood into the stranguIated Ioop of bowe1 and into the free abdomina1 cavity. It is important to differentiate, if possibIe, between a simpIe non-stranguIated obstruction and a stranguIated one. In the former the visibility of the bowe1 is not in danger and operation can be deferred until the patient can be physioIogicaIIy prepared for operation by chemica1 and ffuid rehabiIitation and the distended bowe1 decompressed by intestina1 intubation. In stranguIated obstruction the bIood suppIy is damaged, bowe1 gangrene and perforation are imminent and operation cannot be deferred. PhysioIogicaI rehabiIitation must be deferred unti1 during and after surgery because of this impending danger. Through carefu1 correlation of the radiographic pattern of the distended bowe1 with the findings at surgical expIoration we fee1 quite definiteIy that a competent radioIogist can be of great assistance in determining the presence of smaI1 bowe1 obstruction, the approximate site of the Iesion and the
868
American Journalof Surgery
Hunt-BoweI
probabIe nature of the disorder. We have found that by a carefuI study of the pattern of the gaseous distention the immediate urgency of the situation can be determined. We beIieve, aIways, in the immediate operation of a11 earIy smaI1 bowe1 obstructions, but there are many with marked fIuid Ioss and great abdomina1 distention, who are not good subjects physioIogicaIIy or anatomicaIIy for immediate surgery. If in these cases a carefu1 study of the pattern of gaseous distention, as observed in a radiographic fiIm, the Iesion appears to be non-stranguIating, physioIogica1 rehabiIitation and intestina1 intubation may be safeIy accompIished prior to surgery. The operation is then one of eIection and is much more satisfactoriIy and safeIy done, than when great distention is present and anatomica diffIcuIties are great and hazardous. Figure I demonstrates the vaIue of the x-ray in evaIuating the type of smaI1 bowel obstruction. It shows the transverse pattern of the bowe1 distention and the vaIvuIae conniventes are cIearIy seen. The cIinica1 manifestations and radiographic manifestations are those of simpIe obstruction with no evidence of vascuIar damage. The MiIIer-Abbott tube decompressed the distended intestines and aided materiaIIy in the surgica1 approach. Operation reveaIed a simpIe adhesive band obstructing the smaI1 bowe1 by constricting the Iumen. Recovery was prompt after freeing the constricting adhesion. Figure 2 shows an irreguIar type of smaI1 bowe1 distention that conforms to no pattern that is reIated to the Iong axis of the body and the vaIvuIae conniventes are not seen. The clinica manifestation shows an uneven distention in the contour of the abdomen with sIight IocaIized tenderness and rigidity. Immediate operation discIosed a smaI1 bowe1 loop twisted upon itseIf by a band of adhesions attached to the bowe1 mesentery. The bowe1 was bIack and required resection. Recovery was unevent-
Obstruction
DECEMBER, ,946
fu1 after resection and anastomosis. The x-ray was vaIuabIe in determining the nature of the obstruction and the need for immediate surgery. We have found the correIation between the x-ray diagnosis by means of a flat fiIm of the abdomen and the operative findings to be very accurate and have previousIy reported this reIationship in August, Ig44.2 We, therefore, emphasize the importance of competent radioIogica1 assistance in evaIuating the nature of the obstruction of the smaI1 bowe1 and the need for immediate surgery. We know that in some instances of advanced simpIe obstruction surgery is more safeIy and effectiveIy done after physioIogica1 rehabiIitation and intestina1 intubation by the MiIIer-Abbott tube has been satisfactoriIy empIoyed. SUMMARY
The cIinica1 symptoms and signs of smaI1 bowe1 obstruction are characteristic and are unIike any type of intra-abdomina1 disease. The coIic is specific in character and different from other forms of abdomina1 coIic. The x-ray is most vaIuabIe in confirming the diagnosis of smaI1 bowe1 obstruction, in locating the site of the obstruction and in determining to a large extent the nature of the obstruction. The function of the bowe1 dista1 to the obstruction is unimpaired and shouId adequate function take pIace it does not indicate the absence of obstruction. The urgency of immediate surgery is emphasized in stranguIated obstruction in contrast to the feasibiIity of deIaying surgery in advanced simpIe obstruction unti1 physioIogica1 measures and intubation procedures can be adequateIy empIoyed. REFERENCES I. WANGENSTEEN,0. H. and GOEHL, R. 0. EvaIuation of the expukon of enemas as a criterion of intestinaI obstruction. Arch. Int. Med., 46: 669-679, ‘930. 2. HUNT, C. J. CorreIation of the x-ray diagnosis with operative findings in smaI1 intestina1 obstruction. Radiology, 43: 107-114, 1944.