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Feculent vomiting
Feculent Alex
IX. GASPAR, M.D., Long Beach, California, BYRONhf. bfT~~~s,M.D., Reclondo AND TOM A. KENDIG, M.D., Long Beach, Calij’ornia
HIS article was prompted by experience with a patient who had fecuIent vomiting but did not have intestina1 obstruction, and by the startIing observation of a patient vomiting barium immediately after a barium enema. The vomiting of fecuIent material is given scant attention in medica literature. We have found only five references to this subject since 1900.~~~ The vomiting of formed feces is a rare occurrence. It usually is caused by coprophagy or The vomiting of liquid gastrocolic ktulas. material from the lower part of the small intestine is not as rare. In most clinical instances the resembIance to feces is in odor rather than in appearance. One couId hardly improve upon the description given by HoweI13: “ . . . feca1 vomiting is the last stage of a rising tide of vomit which passes within a few days through a gamut of colors from a biIious yeIIow through light and dark green to this pea soupy, fouI smeIIing vomit, and ends, if the cause has not been removed, in an ebb tide of exhaustion and death.” Until the present study was compIeted the authors were under the impression that fecuIent vomiting was always caused by mechanica intestinal obstruction. However, we have encountered several cases of fecuIent vomiting caused by paralytic obstruction of the bowe1 (adynamIc ileus) and one interesting exampIe of violent reverse peristaIsis. The foIIowing is a brief account of the case of reverse peristalsis: An eighty-one year old white man was admitted to a private hospita1 compIaining of cramping Iower abdomina1 pain and abdomina1 distention. For the preceding month he had noted constipation, “gas pains” in the lower abdomen and distention which was reIieved by enemas and by passing fIatus. The symptoms had become worse during the twenty-four hours before admission and had not been
T
Vomiting Beach,
California,
relieved by enemas. On admission the physical examination was essentiaIIy negative except for lower abdomina1 distention. The peristaltic sounds were not recorded on the clinica chart. Colonic disease was suspected, so a barium enema was given. Numerous smaI1 diverticula of the lower descending and sigmoid portions of the colon were demonstrated. Norma1 reflus of the barium mixture through the iIeocecal vaIve into the terminal iIeum was seen during fluoroscopy. The x-ray of the abdomen taken immediately following fluoroscopy demonstrated marked retrograde reffux of the barium into the proxima1 jejunum. (Fig. I.) The postevacuation film demonstrated that there was reffux of the barium throughout the small bone1 and into the stomach. (Fig. 2.) Immediately after the postevacuation x-ray was made the patient vomited a large amount of the barium mixture. Five hours later x-ray demonstrated that there was still some barium in the stomach and scattered barium in the smal1 bowel and coIon. The patient recovered from his symptoms. A definite diagnosis \vas not established aIthough an episode of mesenteric thrombosis of minor degree was strongI) a condition might have suspected. Such accounted for a disturbance of peristaltic gradients in the intestine. Six months later the patient had an upper gastrointestinal x-ray study Tvhich was essentiaIIy normal and a barium enema which again reveaIed the colonic diverticula and a normal reflux of barium into the smail bowel, but did not demonstrate the abnormal refIux proximalI>even though adequate opportunity was permitted for this to occur. Other interesting exampIes of vioIent reverse peristaIsis were colIected by Weber.” He cited the story of a man who vomited a suppositor) which had been introduced into his rectum. Weber had a persona1 case of a twenty-two year oId woman who had abdominal distention and constipation, and vomited formed feces and scybala at times. These symptoms fol-
Gaspar,
FIG. I. Pre-evacuation ing reflux of barium
WaIIs
barium enema x-ray demonstratinto the proximal jejunum.
lowed severe psychic trauma. Her husband had had hemoptysis on the night of marriage and died soon after. Extensive investigation did not reveaI any organic cause of her troubIe. MethyIene bIue given by enema appeared in the vomitus in ten minutes. The patient underwent two Iaparotomies but no abnormalities were found. On one of these occasions the stomach was opened. A third Iaparotomy was performed by Sir Francis Treves and no pathoIogic condition was found. This patient definiteIy exhibited signs of hysteria. Her symptoms were improved when she was Ieft alone. Weber cited Jaccouds’ case of an hysterica woman who vomited feces. Autopsy did not revea1 a cause for the condition. Weber aIso mentioned TuIIio’s patient, in whom reverse peristaIsis couId be observed through the abdomina1 waI1. This peristaIsis started in the region of the sigmoid and progressed to the iIeoceca1 vaIve, and then to the pyIoric region where a Iump formed and increased in size unti1 the patient vomited feces or an enema which had been given. Weber stated that Longmann of New York in 1889 reported the case of a twenty-one year oId woman who vomited scybaIous masses. At Iaparotomy a darning
and
Kendig
FIG. 2. Post-evacuation barium enema x-ray demonstrating refIux of barium into the duodenum and stomach. A, stomach; B, descending duodenum; C, transverse colon.
needie was found impacted in the anterior waI1 of the stomach between the serous and mucous coats. This was removed but the patient had the same symptoms after surgery. She vomited enemas containing indigo in nine minutes. These exampIes probably represent instances of vioIent reverse peristaIsis which certainIy must be the mechanism required to pass formed feces and Iiquid up from the coIon through the iIeoceca1 valve. Such movements are more IikeIy to occur in an intestine with norma muscuIar waIIs than in an intestine weakened by disease or overdistention. Such vioIent antiperistaIsis is more incIined to be due to nervous derangement than to organic obstruction of the intestine. CLINICAL
MATERIAL
a two-year period at the Los Angeles During County Harbor Genera1 HospitaI twentythree cases in which fecuIent vomiting occurred were recorded and the case histories carefuIIy that reviewed. (TabIe I.) It is not surprising most of the cases of fecuIent vomiting were due to mechanical smaI1 bowe1 obstruction and a few due to mechanica Iarge bowe1 obstruction, but it is surprising that four of the
Feculent
Vomiting
cases rvere due to paralytic obstruction iadynamic ileus). These four cases are presented briefly. CASE I. A. D. (Hospital No. 51336), an eighty-six lear old white woman, was admitted to the orthopedic service because of a TABLE
I
klechanical small bowel obstruction.. Adhesions. C.’drcmomatos1s. FemoraI hernia.. Gallstone &us.. Mechanical large bowe1 obstruction. CecaI volvulus.. Carcinoma ot’ sigmoid. Fecal impaction.. Paralytic obstruction (adynamic ileus)
16 9
* z I 3
1 1 I 4
fracture of the right femur through an area of Paget’s disease. On admission abdominal examination was essentially negative except for slight generaIized distention. The distention gradually increased. On the fifteenth hospita1 day the patient vomited a large quantity of feculent material. SurgicaI consultation was requested and the patient was seen at surgica1 rounds on that day. AbdominaI exploration was advised on the basis of enormous distention, feculent vomiting and diIated small bowel seen on x-ray. Bowel sounds were infrequent and high pitched. At surgery a11 of the small bowe1 was noted to be greatIy dilated; however, no point of mechanical obstruction was found although the entire bowel was carefully searched. PostoperativeIy the patient remained distended in spite of a11 efforts to decompress the bowel. Evisceration occurred. Secondary closure of the wound was done but the patient died on the fourteenth postoperative day. There was no autopsy. CASE II. F. M. (HospitaI No. 11693), a ninety-one year old white man, was admitted to the urologic service because of nocturia, suprapubic pain and urinary retention. He had undergone transurethra1 resection of the prostate three years previously. On admission he Lvas found to be in congestive heart failure and to have a moderateIy obese abdomen with no scars. There was slight suprapubic tenderness. There was an easily reducibIe left inguina1 hernia. After admission abdomina1 distention deveIoped and the patient vomited feculent fluid on several occasions. There were no peristaltic sounds. An x-ray of the ab-
domen \\as consistent with market1 paralytic ileus. Subsequently bowel sounds returned, distention ciiminished, and gas and feces were passed per rectum. The patient was transferred to the medical service and eventually died of heart failure. There I\-as no autopsy. CASE III. A. S. (Hospital No. 62993), a seventy-four year old white woman, was admitted to the surgical service for treatment of squamous cell carcinoma of the anus. An abdominoperineal resection was performed. The patient had an extremely stormy postoperative course characterized by abdomina1 distention. Feculent fluid was vomited on several occasions despite decompressive measures. The patient died on the fourteenth postoperative day. Autopsy discIosed a dilated small bowel due to peritonitis but no evidence of mechanical small bowel obstruction. CASE IV. I\;‘. C. (Hospital No. x7525), a sixty-one vear old white man, was admitted to the surgical service for treatment of adenocarcinoma of the rectum. At surgery a fixed mass was found at the peritoneal reflection. There were extensive intraabdominal metastases including hepatic metastases. Sigmoid coIostomy was performed. Following surgery abdominal distention occurred. The colostomy was opened but did not function weI1. On the seventh postoperative day the patient vomited feculent materia1. Laparotomy was performed but no point of mechanica intestina1 obstruction could be found. The small bowel and coIon were greatI?: dilated. FoIIowing surgery the patient contmued to vomit feculent fluid in spite of a long intestina1 tube. He died on the twenty-sixth postoperative day. There was no autopsy. COMMENT The termina1 iIeum ordinarily holds fluid material containing many viabIe coliform baciIIi. As a resuIt of increasing distention of the bowe1, intestinal secretion becomes markedly increased and absorption from the intestine concomitantIy decreased. The bowel becomes laden with Iarge quantities of toxic ffuid.6 IndoIe and skatole are produced from trytophane by putrefaction of protein. Methane, methy mercaptan, butyric acid, pheno1 and hydrogen sulfide are additiona substances which are formed and impart the characteristic odor of feces. This fouI-smeIIing fluid fiIIs the bowel Iumen. As a result of inhibition or
383
Gaspar, WaIIs and Kendig FecuIent vomiting is usuaIIy due to mechanica1 intestina1 obstruction but it can be due to paraIytic obstruction (adynamic iIeus). In a two-year period at Los AngeIes County Harbor Genera1 HospitaI there were twenty-three cases of fecuIent vomiting; nineteen were due to mechanica intestina1 obstruction and four were due to paraIytic obstruction. It is important to know that fecuIent vomiting is not necessariIy a pathognomonic sign of mechanica intestina1 obstruction but can aIso occur in paralytic obstruction, particuIarIy in aged patients. Recognition of this fact might avoid needIess surgery in these desperateIy III persons.
paraIysis of the intestine there may be reIaxation of the pyIoric sphincter which aIIows abnorma1 regurgitation of the intestina1 contents into the stomach from which, because of an overflow mechanism, it is vomited. However, according to the metabolic gradient theory of AIvarez, the inflammatory or irritative process causing the distention wiI1 increase the metaboIic rate at the point of irritation, thereby reversing the gradient of the bowe1 and thus causing reverse peristaIsis. It is interesting to note that the four patients in this series who had fecuIent vomiting of paraIytic origin (adynamic iIeus) were in the seventh, eighth, ninth and tenth decades. The patient who had reverse peristaIsis demonstrated on barium enema x-ray study was in the ninth decade. Thus it seems that fecuIent vomiting not due to mechanical intestina1 obstruction is associated with advanced age. PresumabIy this is due to decreased tone of the gastrointestina1 tract Ieading to greater distention and possibIy to easier reversa1 of peristaItic gradients.
REFERENCES I.
BENNETT, W. H. Vomiting considered from some of its surgical aspects, especially with reference to a faecuIent vomit which is sometimes curative. &it.
M. J., I: 691, Igoo. 2. BONNEY, V.
Faecal and intestina1 vomiting and jejunostomy. Brit. M. J., I: 583, 1916. 3. HOWELL, J. FaecaI vomiting. Clin. J., 58: 529, 1929. 4. WEBER, F. P. FaecaI vomiting and reversed peristaIsis in functiona nervous (cerebraI) disease: a summary of cases and concIusions. Brain, 27:
SUMMARY
17% 1904.
5. FERNANDEZ, F. Fecal vomiting.
The vomiting of feces is an unusua1 symptom associated with gastrocoIic fistuIas, coprophagy and vioIent reverse peristaIsis.
g:
308,
Medicina,
6. OCHSNER, A. and GAGE, I. M. Adynamic J. Surg., 20: 378, 1933.
384
Madrid,
1941.
iIeus. Am.
IX. GASPAR, M.D., Long Beach, California, BYRONhf. bfT~~~s,M.D., Reclondo AND TOM A. KENDIG, M.D., Long Beach, Calij’ornia
HIS article was prompted by experience with a patient who had fecuIent vomiting but did not have intestina1 obstruction, and by the startIing observation of a patient vomiting barium immediately after a barium enema. The vomiting of fecuIent material is given scant attention in medica literature. We have found only five references to this subject since 1900.~~~ The vomiting of formed feces is a rare occurrence. It usually is caused by coprophagy or The vomiting of liquid gastrocolic ktulas. material from the lower part of the small intestine is not as rare. In most clinical instances the resembIance to feces is in odor rather than in appearance. One couId hardly improve upon the description given by HoweI13: “ . . . feca1 vomiting is the last stage of a rising tide of vomit which passes within a few days through a gamut of colors from a biIious yeIIow through light and dark green to this pea soupy, fouI smeIIing vomit, and ends, if the cause has not been removed, in an ebb tide of exhaustion and death.” Until the present study was compIeted the authors were under the impression that fecuIent vomiting was always caused by mechanica intestinal obstruction. However, we have encountered several cases of fecuIent vomiting caused by paralytic obstruction of the bowe1 (adynamIc ileus) and one interesting exampIe of violent reverse peristaIsis. The foIIowing is a brief account of the case of reverse peristalsis: An eighty-one year old white man was admitted to a private hospita1 compIaining of cramping Iower abdomina1 pain and abdomina1 distention. For the preceding month he had noted constipation, “gas pains” in the lower abdomen and distention which was reIieved by enemas and by passing fIatus. The symptoms had become worse during the twenty-four hours before admission and had not been
T
Vomiting Beach,
California,
relieved by enemas. On admission the physical examination was essentiaIIy negative except for lower abdomina1 distention. The peristaltic sounds were not recorded on the clinica chart. Colonic disease was suspected, so a barium enema was given. Numerous smaI1 diverticula of the lower descending and sigmoid portions of the colon were demonstrated. Norma1 reflus of the barium mixture through the iIeocecal vaIve into the terminal iIeum was seen during fluoroscopy. The x-ray of the abdomen taken immediately following fluoroscopy demonstrated marked retrograde reffux of the barium into the proxima1 jejunum. (Fig. I.) The postevacuation film demonstrated that there was reffux of the barium throughout the small bone1 and into the stomach. (Fig. 2.) Immediately after the postevacuation x-ray was made the patient vomited a large amount of the barium mixture. Five hours later x-ray demonstrated that there was still some barium in the stomach and scattered barium in the smal1 bowel and coIon. The patient recovered from his symptoms. A definite diagnosis \vas not established aIthough an episode of mesenteric thrombosis of minor degree was strongI) a condition might have suspected. Such accounted for a disturbance of peristaltic gradients in the intestine. Six months later the patient had an upper gastrointestinal x-ray study Tvhich was essentiaIIy normal and a barium enema which again reveaIed the colonic diverticula and a normal reflux of barium into the smail bowel, but did not demonstrate the abnormal refIux proximalI>even though adequate opportunity was permitted for this to occur. Other interesting exampIes of vioIent reverse peristaIsis were colIected by Weber.” He cited the story of a man who vomited a suppositor) which had been introduced into his rectum. Weber had a persona1 case of a twenty-two year oId woman who had abdominal distention and constipation, and vomited formed feces and scybala at times. These symptoms fol-
Gaspar,
FIG. I. Pre-evacuation ing reflux of barium
WaIIs
barium enema x-ray demonstratinto the proximal jejunum.
lowed severe psychic trauma. Her husband had had hemoptysis on the night of marriage and died soon after. Extensive investigation did not reveaI any organic cause of her troubIe. MethyIene bIue given by enema appeared in the vomitus in ten minutes. The patient underwent two Iaparotomies but no abnormalities were found. On one of these occasions the stomach was opened. A third Iaparotomy was performed by Sir Francis Treves and no pathoIogic condition was found. This patient definiteIy exhibited signs of hysteria. Her symptoms were improved when she was Ieft alone. Weber cited Jaccouds’ case of an hysterica woman who vomited feces. Autopsy did not revea1 a cause for the condition. Weber aIso mentioned TuIIio’s patient, in whom reverse peristaIsis couId be observed through the abdomina1 waI1. This peristaIsis started in the region of the sigmoid and progressed to the iIeoceca1 vaIve, and then to the pyIoric region where a Iump formed and increased in size unti1 the patient vomited feces or an enema which had been given. Weber stated that Longmann of New York in 1889 reported the case of a twenty-one year oId woman who vomited scybaIous masses. At Iaparotomy a darning
and
Kendig
FIG. 2. Post-evacuation barium enema x-ray demonstrating refIux of barium into the duodenum and stomach. A, stomach; B, descending duodenum; C, transverse colon.
needie was found impacted in the anterior waI1 of the stomach between the serous and mucous coats. This was removed but the patient had the same symptoms after surgery. She vomited enemas containing indigo in nine minutes. These exampIes probably represent instances of vioIent reverse peristaIsis which certainIy must be the mechanism required to pass formed feces and Iiquid up from the coIon through the iIeoceca1 valve. Such movements are more IikeIy to occur in an intestine with norma muscuIar waIIs than in an intestine weakened by disease or overdistention. Such vioIent antiperistaIsis is more incIined to be due to nervous derangement than to organic obstruction of the intestine. CLINICAL
MATERIAL
a two-year period at the Los Angeles During County Harbor Genera1 HospitaI twentythree cases in which fecuIent vomiting occurred were recorded and the case histories carefuIIy that reviewed. (TabIe I.) It is not surprising most of the cases of fecuIent vomiting were due to mechanical smaI1 bowe1 obstruction and a few due to mechanica Iarge bowe1 obstruction, but it is surprising that four of the
Feculent
Vomiting
cases rvere due to paralytic obstruction iadynamic ileus). These four cases are presented briefly. CASE I. A. D. (Hospital No. 51336), an eighty-six lear old white woman, was admitted to the orthopedic service because of a TABLE
I
klechanical small bowel obstruction.. Adhesions. C.’drcmomatos1s. FemoraI hernia.. Gallstone &us.. Mechanical large bowe1 obstruction. CecaI volvulus.. Carcinoma ot’ sigmoid. Fecal impaction.. Paralytic obstruction (adynamic ileus)
16 9
* z I 3
1 1 I 4
fracture of the right femur through an area of Paget’s disease. On admission abdominal examination was essentially negative except for slight generaIized distention. The distention gradually increased. On the fifteenth hospita1 day the patient vomited a large quantity of feculent material. SurgicaI consultation was requested and the patient was seen at surgica1 rounds on that day. AbdominaI exploration was advised on the basis of enormous distention, feculent vomiting and diIated small bowel seen on x-ray. Bowel sounds were infrequent and high pitched. At surgery a11 of the small bowe1 was noted to be greatIy dilated; however, no point of mechanical obstruction was found although the entire bowel was carefully searched. PostoperativeIy the patient remained distended in spite of a11 efforts to decompress the bowel. Evisceration occurred. Secondary closure of the wound was done but the patient died on the fourteenth postoperative day. There was no autopsy. CASE II. F. M. (HospitaI No. 11693), a ninety-one year old white man, was admitted to the urologic service because of nocturia, suprapubic pain and urinary retention. He had undergone transurethra1 resection of the prostate three years previously. On admission he Lvas found to be in congestive heart failure and to have a moderateIy obese abdomen with no scars. There was slight suprapubic tenderness. There was an easily reducibIe left inguina1 hernia. After admission abdomina1 distention deveIoped and the patient vomited feculent fluid on several occasions. There were no peristaltic sounds. An x-ray of the ab-
domen \\as consistent with market1 paralytic ileus. Subsequently bowel sounds returned, distention ciiminished, and gas and feces were passed per rectum. The patient was transferred to the medical service and eventually died of heart failure. There I\-as no autopsy. CASE III. A. S. (Hospital No. 62993), a seventy-four year old white woman, was admitted to the surgical service for treatment of squamous cell carcinoma of the anus. An abdominoperineal resection was performed. The patient had an extremely stormy postoperative course characterized by abdomina1 distention. Feculent fluid was vomited on several occasions despite decompressive measures. The patient died on the fourteenth postoperative day. Autopsy discIosed a dilated small bowel due to peritonitis but no evidence of mechanical small bowel obstruction. CASE IV. I\;‘. C. (Hospital No. x7525), a sixty-one vear old white man, was admitted to the surgical service for treatment of adenocarcinoma of the rectum. At surgery a fixed mass was found at the peritoneal reflection. There were extensive intraabdominal metastases including hepatic metastases. Sigmoid coIostomy was performed. Following surgery abdominal distention occurred. The colostomy was opened but did not function weI1. On the seventh postoperative day the patient vomited feculent materia1. Laparotomy was performed but no point of mechanica intestina1 obstruction could be found. The small bowel and coIon were greatI?: dilated. FoIIowing surgery the patient contmued to vomit feculent fluid in spite of a long intestina1 tube. He died on the twenty-sixth postoperative day. There was no autopsy. COMMENT The termina1 iIeum ordinarily holds fluid material containing many viabIe coliform baciIIi. As a resuIt of increasing distention of the bowe1, intestinal secretion becomes markedly increased and absorption from the intestine concomitantIy decreased. The bowel becomes laden with Iarge quantities of toxic ffuid.6 IndoIe and skatole are produced from trytophane by putrefaction of protein. Methane, methy mercaptan, butyric acid, pheno1 and hydrogen sulfide are additiona substances which are formed and impart the characteristic odor of feces. This fouI-smeIIing fluid fiIIs the bowel Iumen. As a result of inhibition or
383
Gaspar, WaIIs and Kendig FecuIent vomiting is usuaIIy due to mechanica1 intestina1 obstruction but it can be due to paraIytic obstruction (adynamic iIeus). In a two-year period at Los AngeIes County Harbor Genera1 HospitaI there were twenty-three cases of fecuIent vomiting; nineteen were due to mechanica intestina1 obstruction and four were due to paraIytic obstruction. It is important to know that fecuIent vomiting is not necessariIy a pathognomonic sign of mechanica intestina1 obstruction but can aIso occur in paralytic obstruction, particuIarIy in aged patients. Recognition of this fact might avoid needIess surgery in these desperateIy III persons.
paraIysis of the intestine there may be reIaxation of the pyIoric sphincter which aIIows abnorma1 regurgitation of the intestina1 contents into the stomach from which, because of an overflow mechanism, it is vomited. However, according to the metabolic gradient theory of AIvarez, the inflammatory or irritative process causing the distention wiI1 increase the metaboIic rate at the point of irritation, thereby reversing the gradient of the bowe1 and thus causing reverse peristaIsis. It is interesting to note that the four patients in this series who had fecuIent vomiting of paraIytic origin (adynamic iIeus) were in the seventh, eighth, ninth and tenth decades. The patient who had reverse peristaIsis demonstrated on barium enema x-ray study was in the ninth decade. Thus it seems that fecuIent vomiting not due to mechanical intestina1 obstruction is associated with advanced age. PresumabIy this is due to decreased tone of the gastrointestina1 tract Ieading to greater distention and possibIy to easier reversa1 of peristaItic gradients.
REFERENCES I.
BENNETT, W. H. Vomiting considered from some of its surgical aspects, especially with reference to a faecuIent vomit which is sometimes curative. &it.
M. J., I: 691, Igoo. 2. BONNEY, V.
Faecal and intestina1 vomiting and jejunostomy. Brit. M. J., I: 583, 1916. 3. HOWELL, J. FaecaI vomiting. Clin. J., 58: 529, 1929. 4. WEBER, F. P. FaecaI vomiting and reversed peristaIsis in functiona nervous (cerebraI) disease: a summary of cases and concIusions. Brain, 27:
SUMMARY
17% 1904.
5. FERNANDEZ, F. Fecal vomiting.
The vomiting of feces is an unusua1 symptom associated with gastrocoIic fistuIas, coprophagy and vioIent reverse peristaIsis.
g:
308,
Medicina,
6. OCHSNER, A. and GAGE, I. M. Adynamic J. Surg., 20: 378, 1933.
384
Madrid,
1941.
iIeus. Am.