Major resection for functional gastrointestinal disease

MAJOR RESECTION FOR FUNCTIONAL GASTROINTESTINAL REPORT

AND EVALUATION

DISEASE OF TWO CASES

ALEXANDER STRELINGER, M.D. ELIZABETH, NEW JERSEY ETROSPECTION on the history of medicine reveaIs many conditions, the cause of which at first was misunderstood, but graduahy, at times through tria1 and error method it was identified. Such were malaria, thought at one time to be a miasmatic disease, and tabes which was once described as metasyphilitic. Cure of the disease by various methods was attempted before the true nature of it became known. In some instances the better knowIedge of the disease proved that the empiricaIIy used treatment was correct. Instances of this were quinine for the treatment of malaria, and mercury for the treatment of syphilis. The identification of the cause was often deIayed even when the research worker Iocated it. Thus it happened, that Pettenkoffer drank a culture of cholera bacilIi and did not contact cholera. This, for a while, made doubtful that Koch really identified the pathogenic bacterium of cholera. The tria1 and error method continues in many phases of medicine. At times progress starts by the realization and admission that the cause of a disease or of a disease group is not we11 understood. Martin1 years ago it was smart states : “Twenty medicine to say, ‘If the doctor can not find an organic cause for the patient’s symptoms, that is recognition that he has not of the Iooked far enough. 1’ This indictment examiner was tempered however by the realization and admission that medical knowIedge had not yet progressed suffrcientIy, and even the best doctors were not expected to understand the basis of symptoms, the cause of which had yet to be successfuhy investigated and expIained.”

A number of so-caIIed functional diseases of the gastrointestina1 tract were found to be of psychogenic nature. Constitutiona evidences associated with psychoneurosis, aIso evidences of vasomotor instability, as described by Martin1 are helpful in making the diagnosis.

R

Martin’s

Criteria

I. Certain constitutiona ciated with psychoneurosis

evidence

asso-

:

A. PoorIy deveIoped body B.

Narrow chest and narrow Costa1 angle C. FIaring hips D. Marked Iumbar Iordosis and visceroptosis 2. Evidence

of vasomotor

instabiIity:

A. FIushing B. Sweating C. CoId, clammy hands and feet D. Over IabiIe blood pressure E. Paroxysma tachycardia. Martin uses the term of psychoneurosis in a broad sense: “ . . . it is meant to signify that the symptoms, from which the patient suffers, are due to an imbalance of the vegetative nervous system. The imbaIante is produced in turn through the intervention of the cerebrum and its interpretation of sense perceptions.” The definition of Jewett,2 who evaIuates the gastrointestina neuroses in terms of the psychobioIogicaI unity, is similar. The basis of such disturbances, according to him, rests upon emotiona excitations of the subcortical centers and their conduction through the 72

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sympathetic and parasympathetic pathways to the gastrointestina1 tract. He stresses that, when considering gastrointestina1 neurosis, organic disease must be exchrded, and enumerates symptoms that would indicate it : continued abdomina1 pain, persistent hyperacidity when associated with pain and heartburn, gastric pain associated with subacidity, vomiting or retention, the presence of macroscopic or microscopic bIood in stool or vomitus unIess definiteIy expIained by some other factor, and the presence of profound anemia. Eppinger and Hess3 run a cIose third with their definition : “ Functiona gastrointestinal disorders are caused by sympathetic and parasympathetic imbarance.” The word “ functional ” is embodied in this definition. Instances of gastrointestina1 invalidism caused by psychic mechanism have been numerousIy reported in the Iiterature. It can be stated that the gastroenterologist with an eye on the psychic mechanism often wiI1 suspect the true nature of the patient’s compIaints, when at the same time the excIusiveIy organic minded examiner fails. The idea of psychoneurotic pathogenecity became so we11 entrenched in gastroenteroIogy, that, broadIy speaking, two groups have been established among the causes of gastrointestina1 disease: (I) organic, (2) psychoneurotic. Thus a11 discases that were not organic, were cast upon psychoneurotic waters. But the word “functional” disease stiI1 and concept of lurked in the offing. Bergmann described a number of conditions, the true nature of which Iacked understanding. He emphasized that this may be due Iess to poor conception than to incompIete or ineffrcient methods for examination of function in which changes in form are absent. He showed that critica evaluation of infrequently used laboratory methods, experimental approach or unconventiona1 reasoning permits postuIation of disease entities not known by routine examination. From the many subjects discussed by

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him, chronic pancreatitis and dyskinesia of the extrahepatic biIe ducts shouId be mentioned as exampIes of gastrointestina1 disturbances that for the time being cannot be fitted into either the organic or the psychoneurotic group. The division between the basic states, organic, psychoneurotic and functiona1, may be diffrcuIt. Routine examining methods may not discIose organic causes for pyIorospasm. But HoIsti found histoIogica1 evidence of inflammatory changes in the cells of the plexus myogastricus situated in the deeper mucosa1 and muscuIar Iayers in some of these conditions. This finding takes the case out of the rearm of functiona and pIaces it into the organic group. SimiIar in nature in RossIe’9 finding of neuromata in otherwise norma appendices. On the other hand, achyIia or hypersecretion may formerIy have been accepted by some as organic just because definite figures couId be attached to them. Conditions of this sort are not we11 understood. To achieve this it wiI1 be necessary in the future to anaIyze their function and synthetize the clinico-functionaI-pathoIogica1 entity. Martin’s word regarding psychogenic gastroenteroIogica1 afhictions may then be requoted, onIy “psychogenic” wiI1 be suppIanted by one or more words representing new basic patterns. MeanwhiIe, what shaI1 the physician do when he meets a condition faIIing into the obscure category? “NiI nocere.” This is easier said than done. For practica1 purpose it often has to be reduced to the formuIa: Choose the Ieast evi1 among the many. The foIlowing is the record of two cases, in which such reasoning in the treatment of “ functiona ” gastrointestina1 disease Iead to partial resection of the stomach and resection of the ascending colon, respectiveIy. CASE

REPORTS

CASE I. A female patient came under my observation on January IO, 1935. At that time she was thirty-four years old. Partly from her,

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partly from the hospitals to be mentioned, the folIowing history was obtained : The patient took sick about twenty-one

FIG. I. FIGS. I AND 2. Case 1.

OCTOBER. ,943

Resection diagnosis metritis, improve.

of gastric spasm, and chronic endorespectively. Her condition did not In February, 1932, she was examined

FIG. 2.

Preoperative films taken February 9, 1935,

years ago, her symptoms consisting of nausea and pressure in the stomach region. This was continuous though varied in intensity. At that time she was single. On April IO, 1924, she was operated upon at the surgical service of the St. Marian HospitaI in Muhleim-Ruhr, Germany. There was an ulcer found on the anterior surface of the duodenum near the pyIorus. The pylorus was closed by Mertens’s technic, the ulcer was sewn over, and a posterior retrocoIic gastroenterostomy was done. After this operation the patient did not fee1 weI1. She continuously complained of feeling sick to the stomach, nauseousness, postprandial pain, and occasiona vomiting. Various medica measures were tried. She was married and Iater on came to the United States. In 1929 she was admitted to St. Barnabas Hospital in Newark, New Jersey, and a diagnosis of gastric hypermotility was made. In January, 1930, again at St. Barnabas Hospital, a choIecystectomy and an appendectomy were done. She was readmitted to the same hospital in May, 1930, and in June, 1931, with the

in the out-patient clinic of St. Elizabeth Hospital in Elizabeth, New Jersey and was subsequentIy treated there unti1 September, 1933. Gastric Iavages, insulin injections, diet, alkahs, and barbiturates produced reIative improvement in the patient’s condition around the beginning of the summer 1933. In spite of continued medica efforts this improvement ceased after two months’ duration. Her complaints continued, though her condition was toIerabIe. In January, 1935, she felt worse and nausea and vomiting occurred frequently. She also had violent attacks of postprandial pain and at times pain on an Pureed vegetabIes, appIe empty stomach. sauce, and raw appIes were the best tolerabIe foods. On examination in January, 1935, her face showed a poor color; the heart and abdomina1 organs physicaIIy were essentially negative. Scars of the former operations were visibIe; tenderness was found in the epigzstric region. The blood pressure was 106 over 76. A fractional gastric anaIysis showed bile in all fractions. The free acid ranged from o to 16;

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the total acidity from I I to 32. The stools were positive for occult blood. X-ray examination of the gastrointestinal tract showed a fishhook

FIG. 3. FIGS. 3 AND 4. Case I. Preoperative

shaped stomach with good contours in the ora part. A we11 functioning gastroenterostomy was seen; the afferent Ioop could be filled by pressure for a short distance; the efferent loop filIed readiIy; the emptying of the stomach through the gastroenterostomy was quick. To the right of the gastroenterostomy the aboral part of the stomach was visible. It fiIIed readiIy. There was a vigorous, deeply cutting, irregular peristaIsis on this part, the waves sweeping toward the aboral end of the stomach. At no time was emptying through the pylorus observed. The general appearance of this part was spastic, the contours were never quite normal looking. It was beIieved that the spasm and the hyperperistalsis were caused by some pathological condition; the presence of occult bIood in the stools indicated uIceration of this part of the stomach. 12, 1935, to March 25, 1935, From January the patient was treated medicahy. Diet, alkalis, and feeding through the gastroenterostomy by tube were ineffective. Most of this time the patient was in bed; repeatedly it was necessary to give morphine by injection. The

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radiologicai examination of the stomach was repeated with identical resuIts. Examination of the stools for occult blood twice gave positive

FIG. 4. films taken on March 3, 1935.

resuIts and once a negative result. The patient’s genera1 condition got worse; the pain was steady and intense, and the patient’s menta1 attitude became desperate. She was admitted on March 23, 1935 to St. EIizabeth Hospital, EIizabeth, New Jersey, for the purpose of operative treatment. On March 27, 1935, she was operated upon with the preoperative diagnosis of probable ulcer in the distal one-third of the stomach. The abdominal cavity was opened under novocain field anesthesia and splanchinic anesthesia was induced. The adhesions in the upper part of the abdomen were freed to aIIow inspection and handling of the stomach. The entire body of the stomach appeared to be soft walled and of normal consistency; the site of the gastroenterostomy appeared free of disorders, the stoma adequateIy wide. The stomach continued down to the duodenum with a continuous Iumen. In view of these findings the patient’s complaints, her desperate attitude, the physical and x-ray findings were considered. It seemed that the x-ray findings-no passage through

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the pyIorus that was organica1Iy open, and intense spasm on the distal one-third of the stomach-indicated serious functiona dis-

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and lymphocytes. The submucosa, muscularis and serosa are free and clear.” The patient raIIied well after the operation,

FIG. 5. FIG. 6. 6. Postoperative films taken on ApriI rg, 1935. They show that the blind stomach stump and the anastomosis are shifted more to the right, than they were pre6 shows well that the stoma is wide and the emptying sufftcient, ooerativelv.” Figure _ also that spasm is absent.

FIGS. 5

AND

turbance of the dista1 one-third of the stomach and of the pylorus. Resection of these parts was decided upon. The operation was continued by resecting the stomach from the gastroenterostomy down to the duodenum and cIosing the stomach and the duodenum stump by inversion and by Lambert sutures. The gastroenterostomy itseIf was preserved. The patient received $00 cc. of bIood postoperatively. Dr. CasiIIi examined the resected stomach segment and reported the foIlowing: “Partial resection of the stomach g cm. long. There appears to be no anatomical mark to identify the pylorus. The externa1 surface shows a bluish, slightly echymotic serosa, to which tags of fat are adherent. From this surface there is a linear depression which might be taken as the pyIoric ring. The mucosa is light yeIIow in coIor. The folds are normaIIy distributed, but appear to be sIightIy thickened. M.E.: The mucosa shows superficial erosions. The tunica propria is sIightIy edematous, and contains the usual plasma cells, eosinophiles,

and had an uneventfu1 recovery. The postoperative x-ray contro1 showed a we11 functioning gastroenterostomy, and no particular abnormaIities on the remaining stomach. The clinical condition of the patient improved considerabIy and has remained improved for eight years postoperatively as indicated by the folIowing: The abdomina1 pain ceased completely. The patient’s sleep, very poor preoperatively, is sound and refreshing. The constipation, present for many years preoperativeIy, ceased. Her appetite at times is poor but generally good. Several periods occurred, during which a sick feeling to the stomach was present, but it was always controhed by stomach Iavages. Her headaches continued until 1938, when a vaginal hysterectomy was done; thereafter they ceased. The general condition throughout the years postoperatively was much better than during any period of even a few weeks in the years between the first operation and the partial gastric resection. The pathological disorders Ieading to the preoperative complaints cannot be well classi-

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fied: it was a functional disease, upsetting the neuromuscuIar baIance of a part of the stomach and of the pylorus, causing intense spasm. CASE II. A female patient, thirty-eight years oId, was first examined on October 4, 1941. She gave the folIowing history: She was married and had three children with no miscarriages. She had had rheumatism as a child, scarlet fever at the age of twenty-one, appendicitis at the age of twenty-four. Her main complaint was persistent pain in the right lower quadrant. Her periods, usually normal and on time, became very painful in 1937. Since that same time pain was present in the right lower quadrant, this being fairIy constant. In January, 1939, a physician made the diagnosis of cyst of the right ovary. In January and in March, 1939, she was subjected to two Iaparotomies, in the course of which two tubes and one ovary was removed. FolIowing the second operation thrombophlebitis of the Ieft leg set in which improved graduaIIy. The right lower quadrant pain persisted; from July, 1939, she was treated by another physician for adhesions. In 1941, she was hospitalized again; the “rest of the ovary” and the uterus were removed. FolIowing this operation she was improved for approximateIy six months, though the right lower quadrant pain persisted to a lesser extent; in July, 1941, it increased in intensity. This pain, with varying intensity, was present all the time. During the week preceding the first examination the pain was extremely sharp; it radiated into the back and into the right thigh. Her appetite was diminished by the pain and she was constipated. Coincidentally with walking and bowe1 movements the pain increased. There was no nausea, nor any urinary frequency. Examination on October 4, 1941, and on subsequent dates showed that the patient was fairly well nourished. Physical examination disclosed moderate tenderness in the epigastric region, in the right upper quadrant, and in the lower lumbar region. There was very marked tenderness in the right lower quadrant. No masses were feIt. Her tonsils had been removed and the uterus incIuding the cervix was also removed. The parametrial regions were not painful on pressure. Urine analysis was essentially negative. AnaIysis of the blood showed moderate secondary anemia with 4 per cent stab cells; otherwise it was essentiaIIy negative. In the feca1 matter there was absence of undi-

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gested elements, inflammatory eIements, ova, or ameba; there was occuIt blood three plus on one instance and negative on two other occasions. Intravenous pyeIogram produced good visualization of both pelves, a11 calices and both ureters; there were no abnorma1 features. A gaIIbIadder series produced good visualization and good contraction. During a barium enema, barium entered the terminal iIeum ; the colon tract showed no abnorma1 features. The emptying film showed considerable residue in the whole colon tract. A gastrointestinal series and later on a series for small intestinal detail showed no abnorma1 features. While the examination was in progress, the patient was kept on smooth diet, belladonna and mucilose. She spent the greater part of the day in bed. The pain persisted with varying intensity. On October 29, 1941, the pain became very intense whiIe moving the bowels; after the movement a large amount of red, partly cIotted bIood was discharged by rectum. On October 3 I, 1941, the bIeeding re-occurred under simiIar conditions. It was verified that the fecal matter was intimately mixed with blood, and that free blood folIowed the fecal matter. The patient was hospitalized at St. EIizabeth HospitaI. Proctoscopy was done on the foIlowing day; the scope was inserted for a length of 6 inches; there was no source of bleeding found on this length. The location of the pain and the intestinal bIeeding indicated that the pain was connected with the right coIon. The absence of any pathoIogica1 condition by barium enema and the negative features of the examination of the fecal matter suggested that any possibIe disturbance in the right colon was of some unusual nature. The patient suffered much and repeatedIy required morphine. She was seen in consultation by Dr. Casilli, Dr. Gerendasy, and Dr. Tator. Dr. CasiIIIi suggested that malignant degeneration of a polyp on the basis of poIyposis of the colon might be present; as further probabilities he mentioned a bleeding MeckeI’s diverticuIum and simpIe adhesions. Dr. Gerendasy and Dr. Tator did not make a probable diagnosis. Al1 three consuItants beIieved that expIoration was indicated. On November IO, 1941, the patient was operated upon and Iaparotomy was done. Except for numerous adhesions, particularIy dense around the right colon, no definite

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disorder was found, though the entire length of the small and of the large intestinal tract was examined. Some uncertainty was experienced about a possible disturbance in the ascending coIon, that might be identitied if dense adhesions were absent. Even though the operative exploration, inspection, and a paIpation of the Iarge intestines did not disclose any disorder, a norma coIon wouId not bleed. This fact was accepted as evidence of some pathologica condition in the Iarge intestina1 tract in the painfu1 area, the ascending coIon. Resection of the ascending colon and side-toside ileotransversostomy was done with closure of the abdomen. Pathological and histological examination of the resected termina1 ileum and of the ascending coIon did not identify any

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I am compelled to say that the patient presented features suggesting psychic elements. This did not enter into the decision for resection because the x-ray findings indicated a disturbance in the dista1 stomach pouch and this was naturalIy considered organic. On operation, however, the grossIy non-organic nature of the disease was reveaIed. The decision for resection was made with the patient under an anesthetic and with an open abdomen. Cases of intense spasm are reported, and some of them, for instance, the one cited by Granet,7 are stated to have come about by psychoneurosis. CarefuI evaIuation of these reports wiII fai1 to convince a11 readers uniformIy of the psychoneurotic disorder. nature of the spasm. Very few instances of The convaIescence of the patient started achaIasia of the cardia proved definitely with moderate shock that was controIIed by to be due to psychoneurosis. The same transfusion. On the third postoperative day is true of biIiary diskinesia. AI1 this wouId, the incision opened and pus and feca1 matter were discharged. This was the beginning of a in retrospect tend to strength the argufecal fistuIa; several months later it had to be ment in favor of resection which was done cIosed operativeIy. Except for these complicaon the first patient. In the second case a tions the postoperative course was undisturbed. possibIe absence of readiIy provable organic About sixteen months have passed since the disease was considered preoperativeIy; last operation. The patient is relieved of the the genera1 make-up of the patient, her right lower quadrant pain. Her persistent congenera1 attitude, buiId and appearance stipation is considerably lessened and she has were such that psychoneurosis couId be a norma bowe1 movement nearIy every day. excIuded with reasonable certainty. AppIyHer appetite is good. There is no recurrence of ing to her Martin’s criteria, this exclusion the intestinal bleeding. She does her housework and in addition to this for the last six weeks she wouId be repeated. has also been doing factory work. WhiIe the After psychoneurosis is eIiminated, the time eIapsed since the operation is not too long, operative risk must be considered. This it is much Ionger than the period folIowing the shouId be reasonabIe when measured by third operation upon this patient, during which the degree of the patient’s suffering. The she had onIy partia1 relief and otherwise no first patient was desperate. It was thought relief for four years preceding the right coIon that there was an ulcer in the spastic resection. stomach pouch. She was wiIIing to subject Both cases are unusual. It is understood * herseIf to any operative procedure that that onIy conditions of more or Iess heId out a reasonabIe promise for improvement. The second patient was sufferobscurity are considered here. Under such three circumstances it becomes imperative to ing less. WhiIe she underwent Iaparotomies to obtain reIief, her suffering exhaust a11 means of medical treatment; the physician must register faiIure by persisted and gross intestina1 bIeeding occurred. These facts estabIished comsuch means, before any operative treatpIiance with the ruIe suggested above. ment can be considered. FoIlowing this, If operative treatment is decided upon, must be definiteIy expsychoneurosis the type and extent of it shouId be based cIuded. Martin’s criteria may be found on reasonabIe IocaIization of the end heIpfu1. AppIying them to the first case

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effect of the disorder, as has been described above. When this is possible, the IogicaI step is the destruction of such IocaIized end effect. This is the process in a sense when treating achalasia of the cardia; the end effect of the disturbance as we observe it, is muscle spasm of the cardia. Overstretching the muscIe renders it incapabIe of further spasm. Thus the end effect is destroyed. In the two cases reported a part of an organ seemed to be the seat of the end effect and removal of the offending organ seemed to be the IogicaI step. Quoting Bergmann* it becomes obvious that a type of major resection is practiced daily, based much on the same reasoning, though the reasoning is often forgotten or equaIIy frequently suppressed from consciousness : “What is the nature of the not a11 too satisfying gastritis and ulcer treatment of our day? Is it anything else but soothing of the mucosa, reIaxation of the muscuIar Iayers by atropin, GIaubersaIts or diIute silvernitrate spray, and the keeping away of further harm? Lest we treat the ‘functio but by medica Iaesa,’ not etioIogicaIIy, attack on the pathoIogica1 attitude of the organ or of the whoIe body, the primitive, extensive operation becomes crippIing, unavoidabIe. HaIf of the stomach, or even more has to be removed, but the specimen wiI1 0nIy revea1 an uIcer of a few millimeters in diameter ahead or past the pyIoric ring surrounded for good measure with inflammation in its very immediate neighbor-

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hood. The resection is functiona therapy, because it removes parts of the ‘stomachduodenum,’ which induces the generation of acid. This generation is one of the factors, which, much in contradiction to Konjetzny’s postuIates, is essentia1 /1to produce an uIcer: it is the peptic factor. Therefore, whenever the primitive ‘determatoIogy’ of mucosa1 therapeutics Iead to abysmal failure, the extensive resection to my mind is stiI1 the best treatment.” CONCLUSION

Under exceptional circumstances a major resection carrying considerabIe risk becomes justified for treatment of gastrointestina1 disease of uncertain nature. Two cases are cited to iIIustrate this statement. An attempt is made to define specific criteria for such a procedure. REFERENCES I. MARTIN, LAY. Psychogenic basis of gastrointestinal symptoms. Souib. M. J., 32: 825, 1939. 2. JEWETT, STEPHEN, P. Psychosomatic manifestation of gastrointestina1 disorders. Med. C/in. North America, 26: 877, 1942. 3. EPPINGER, H. and HESS, L. Zur Pathologic des vegetativen Nervensystems. Ztscbr. f. klin. Med., 67: 345, 1909. 4. BERGMANN, GUSTAV VON. Funktionelle Pathologic. BerIin, 1932. Julius Springer. g. Quoted by Cunha, F. Idiopathic benign hypertrophic pytoritis. Am. J. Surg., 33: 21, 1936. 6. Quoted by Gustav von Bergmann. 7. GRANET, E. TotaI gastrospasm; psychoIogic factors involved in etiology; case. Psycbom. Med., 2: 17, ‘940.