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Idiopathic enterospasm of entire ileum and large bowel
IDIOPATHIC ENTEROSPASM OF ENTIRE ILEUM AND LARGE BOWEL* S. THOMAS
GLASSER,
M.D.
Instructor in Surgery and Assistant Attending Surgeon at MetropoIitan and Flower-Fifth NEW
I
enterospasm is an entity of rare occurrence. The diagnosis which is made at operation or autopsy is determined by evidence of spasm and the excIusion of other pathoIogica1 findings. Since no apparent cause for the spastic bowe1 is evident, the condition has been cIassified as “idiopathic.” The causes suggested have been entirely theoretica since autopsy has not reveaIed any information which might offer a possibIe etioIogy. There are no age Iimitations, cases having been reported from three and one-haIf months to seventy years in both sexes. About 160 cases have been recorded in the Iiterature. Spastic iIeus has been encountered in both the Iarge and smaI1 bowe1 or onIy in a smaI1 segment of either, but the terminal iIeum is the most frequent site of occurrence. The invoIved part is contracted to 0.5 cm. in diameter, the serosa1 Iuster is diminished, ischemia is present even to the degree of a bIuish hue and the intestine is unyieIding to the touch. The proxima1 and dista1 ends of the obstruction may be distended or normaI, and in a few cases the proximal end has hypertrophied. However the transition between spastic and norma bowe1 is commonIy abrupt. During operation spasm may persist, be intermittent or disappear with or without the application of heat. The symptomatology resembIes that of an acute intestina1 obstruction. DIOPATHIC
CASE
REPORT
A. R., a white maIe, aged forty-two years, occupation brickIayer, was admitted by ambuIance on September 25, 1932, compIaining of acute abdomina1 pain. About seven hours * From the Service of Dr. J. H. Fobes, Director
Avenue HospitaIs
YORK
before admission, fohowing a bowe1 movement, the patient was suddenIy seized with severe cramp-like pains in the hypogastrium which became more severe during the day. There was no vomiting. The past history was entireIy irreIevant except that the patient had Iost IO pounds during the last two months. PhysicaI examination reveaIed a we11 nourished male appearing in acute pain; temperature 99.6, pulse 80, respiration 26, bIood pressure 130/84, Ieucocyte count 13,280, poIymorphoneutrophiIes 78 per cent, and smaII Iymphocytes 22 per cent. The abdomen was entireIy rigid with marked tenderness, hyperesthesia and rebound tenderness; the Iiver duIIness was obiiterated. No positive findings other than the IocaI condition were ascertained. The provisiona diagnosis was generahzed peritonitis due to a ruptured peptic uIcer and Iaparotomy was performed under gas-oxygenether anesthesia a short time after admission. A right rectus incision was made. There was no free peritoneal fluid. The appendix appeared norma and was removed by the carboIic knife and Iigature method. The entire Iarge gut and the smaI1 intestine up to the jejunum was found coIIapsed in a state of spasm, ending abruptIy at the jejunum, about 0.5 cm. in diameter and appeared bIue in coIor. The mesentery appeared normal. The bowe1 recovered with the appIication of warm saIine. The gaI1 bIadder was thin waIIed and emptied easiIy. The stomach and duodenum showed no pathoIogy. With the index finger through the Foramen of Winslow, palpation reveaIed a moderateIy tibrous pancreas. The kidneys were norma in size and shape. A jejunostomy after the method of WitzeI was performed 6 inches proxima1 to the Iigament of Treitz empIoying a mushroom catheter. AbdominaI cIosure was made in Iayers. Signs of puImonary compIications were manifested on the first postoperative day and of Surgery,
108
MetropoIitan
HospitaI, New York City.
NEW SERIES VOL. XXXIII,
No.
I
GIasser-Enterospasm
x-ray pictures revealed a tuberculosis invoIving the apices. The patient improved rapidIy and seemed we11 on the road to recovery. The enterostomy tube functioned satisfactoriIy and distention was absent. On the third day, the patient suddenIy expired, death being attributed to cardiac faiIure. Autopsy was not obtained. COMMENT
The prominent features in this case were the absence of intestina1 symptoms prior to admission to the hospita1; the absence of abdomina1 pathoIogy except for the spasticity of the intestines; the absence of postoperative distension. For Iack of further evidence, death was attributed to cardiac faiIure. The picture at operation was typica of the entity described as an idiopathic spasticity of the intestines. Our case differed onIy in that it simiIated a ruptured peptic uIcer instead of the usua1 intestinal obstruction.
American Journal of Surgery
*o9
SUMMARY
A case of idiopathic enterospasm of the entire iIeum and Iarge bowe1 is presented. The operative findings, marked spasm of the gut and the absence of any definite pathoIogy, were typica of this condition. Death was apparentIy due to heart faiIure and not to intestina1 obstruction as is occasionally reported. REFERENCES
BIERNATH. Pr;iparat Eines FUes von IIeus durch spastische Darmstenose. Deutscb. med. Wcbnscbr., 39: 2380, 1913. ENGSTADT, J. E. Spastic paraIysis of the jejunum. J. A. M. A., go: 2003, 1927. LANGEMAK. Spastische Erkrankungen des magendarmtrakts. Centdbl. f.d. Grenzgeb. d. Med. u. Cbir., 5: 474, 1902. MATTHEWS, A. A. Enterospasm causing intestina1 obstruction. Northwest Med., 7: 282, 1913. PENDRED, V. Enterospasm, operation, death. &it. Med. J., I: 1292, Igog. SCHMID, H. H. TodesfaII bei spastischen DarmverschIuss. Beitr. z. klin. cbir., 151: 509, 1931. STEIGMANN, FREDERICK and SINGER, HARRY A. Idiopathic spastic iIeus. Am. J. hrg., 27: 342, 1933.
GLASSER,
M.D.
Instructor in Surgery and Assistant Attending Surgeon at MetropoIitan and Flower-Fifth NEW
I
enterospasm is an entity of rare occurrence. The diagnosis which is made at operation or autopsy is determined by evidence of spasm and the excIusion of other pathoIogica1 findings. Since no apparent cause for the spastic bowe1 is evident, the condition has been cIassified as “idiopathic.” The causes suggested have been entirely theoretica since autopsy has not reveaIed any information which might offer a possibIe etioIogy. There are no age Iimitations, cases having been reported from three and one-haIf months to seventy years in both sexes. About 160 cases have been recorded in the Iiterature. Spastic iIeus has been encountered in both the Iarge and smaI1 bowe1 or onIy in a smaI1 segment of either, but the terminal iIeum is the most frequent site of occurrence. The invoIved part is contracted to 0.5 cm. in diameter, the serosa1 Iuster is diminished, ischemia is present even to the degree of a bIuish hue and the intestine is unyieIding to the touch. The proxima1 and dista1 ends of the obstruction may be distended or normaI, and in a few cases the proximal end has hypertrophied. However the transition between spastic and norma bowe1 is commonIy abrupt. During operation spasm may persist, be intermittent or disappear with or without the application of heat. The symptomatology resembIes that of an acute intestina1 obstruction. DIOPATHIC
CASE
REPORT
A. R., a white maIe, aged forty-two years, occupation brickIayer, was admitted by ambuIance on September 25, 1932, compIaining of acute abdomina1 pain. About seven hours * From the Service of Dr. J. H. Fobes, Director
Avenue HospitaIs
YORK
before admission, fohowing a bowe1 movement, the patient was suddenIy seized with severe cramp-like pains in the hypogastrium which became more severe during the day. There was no vomiting. The past history was entireIy irreIevant except that the patient had Iost IO pounds during the last two months. PhysicaI examination reveaIed a we11 nourished male appearing in acute pain; temperature 99.6, pulse 80, respiration 26, bIood pressure 130/84, Ieucocyte count 13,280, poIymorphoneutrophiIes 78 per cent, and smaII Iymphocytes 22 per cent. The abdomen was entireIy rigid with marked tenderness, hyperesthesia and rebound tenderness; the Iiver duIIness was obiiterated. No positive findings other than the IocaI condition were ascertained. The provisiona diagnosis was generahzed peritonitis due to a ruptured peptic uIcer and Iaparotomy was performed under gas-oxygenether anesthesia a short time after admission. A right rectus incision was made. There was no free peritoneal fluid. The appendix appeared norma and was removed by the carboIic knife and Iigature method. The entire Iarge gut and the smaI1 intestine up to the jejunum was found coIIapsed in a state of spasm, ending abruptIy at the jejunum, about 0.5 cm. in diameter and appeared bIue in coIor. The mesentery appeared normal. The bowe1 recovered with the appIication of warm saIine. The gaI1 bIadder was thin waIIed and emptied easiIy. The stomach and duodenum showed no pathoIogy. With the index finger through the Foramen of Winslow, palpation reveaIed a moderateIy tibrous pancreas. The kidneys were norma in size and shape. A jejunostomy after the method of WitzeI was performed 6 inches proxima1 to the Iigament of Treitz empIoying a mushroom catheter. AbdominaI cIosure was made in Iayers. Signs of puImonary compIications were manifested on the first postoperative day and of Surgery,
108
MetropoIitan
HospitaI, New York City.
NEW SERIES VOL. XXXIII,
No.
I
GIasser-Enterospasm
x-ray pictures revealed a tuberculosis invoIving the apices. The patient improved rapidIy and seemed we11 on the road to recovery. The enterostomy tube functioned satisfactoriIy and distention was absent. On the third day, the patient suddenIy expired, death being attributed to cardiac faiIure. Autopsy was not obtained. COMMENT
The prominent features in this case were the absence of intestina1 symptoms prior to admission to the hospita1; the absence of abdomina1 pathoIogy except for the spasticity of the intestines; the absence of postoperative distension. For Iack of further evidence, death was attributed to cardiac faiIure. The picture at operation was typica of the entity described as an idiopathic spasticity of the intestines. Our case differed onIy in that it simiIated a ruptured peptic uIcer instead of the usua1 intestinal obstruction.
American Journal of Surgery
*o9
SUMMARY
A case of idiopathic enterospasm of the entire iIeum and Iarge bowe1 is presented. The operative findings, marked spasm of the gut and the absence of any definite pathoIogy, were typica of this condition. Death was apparentIy due to heart faiIure and not to intestina1 obstruction as is occasionally reported. REFERENCES
BIERNATH. Pr;iparat Eines FUes von IIeus durch spastische Darmstenose. Deutscb. med. Wcbnscbr., 39: 2380, 1913. ENGSTADT, J. E. Spastic paraIysis of the jejunum. J. A. M. A., go: 2003, 1927. LANGEMAK. Spastische Erkrankungen des magendarmtrakts. Centdbl. f.d. Grenzgeb. d. Med. u. Cbir., 5: 474, 1902. MATTHEWS, A. A. Enterospasm causing intestina1 obstruction. Northwest Med., 7: 282, 1913. PENDRED, V. Enterospasm, operation, death. &it. Med. J., I: 1292, Igog. SCHMID, H. H. TodesfaII bei spastischen DarmverschIuss. Beitr. z. klin. cbir., 151: 509, 1931. STEIGMANN, FREDERICK and SINGER, HARRY A. Idiopathic spastic iIeus. Am. J. hrg., 27: 342, 1933.