The acute abdomen with special reference to symptoms, diagnosis and surgical treatment

THE ACUTE

ABDOMEN*

WITH SPECIAL REFERENCE TO SYMPTOMS, DIAGNOSIS AND SURGICAL TREATMENT ARKELL

M.

VAUGHN,

M.D.,

P.A.C.S.

Associate CIinical Professor of Surgery, LoyoIa University CHICAGO,

T

HE acute abdomen is one pathologic condition encountered in the genera1 practice of medicine in which quick thinking and sound judgment are of paramount importance, as the mortality rate, in most instances, is in direct proportion to deIay. In this paper the most important and most frequentIy encountered pathoIogic conditions will be discussed. ABDOMINAL

INJURIES

AbdominaI injuries, either open or closed, require immediate attention. Open injuries may be subdivided into (I) those which are Iimited only to the abdomina1 waI1, and (2) those which enter the peritonea1 cavity causing damage to the viscera. A stab or gunshot wound may enter the peritonea1 cavity and cause no damage to the viscera but may introduce infection Ieading to a For the same reason, fata peritonitis. probing of these wounds is dangerous. The symptoms and signs of visceral injury are those of hemorrhage and shock, nameIy, paIIor of the skin and mucous membranes, air hunger, quick, gasping respirations and sighing, coId skin with a temperature, cIammy sweat, subnorma restlessness, dimness of vision, syncope and noises in the ears. The puIse is at first not affected but Iater becomes progressiveIy more rapid, weak and of smaI1 voIume. The bIood picture wiI1 show a Ieucocytosis of from 19,000 to 30,000, with a diminution of the erythrocytes and Iow hemogiobin. Babcock1 differentiates shock from hemorrhage in the foIIowing manner: In shock there is a concentration of bIood. There is a reIative increase of hemogIobin and corpuscIes, and an absence of leucocytosis. Air

ILLINOIS

hunger is less marked, restlessness common and the patient more often unconscious. The patient in shock wiI1 usuaIIy show improvement when given the orthodox treatment in a reasonable Iength of time unless in extremis, while the patient suffering from hemorrhage wiII not, unIess there is a spontaneous arrest or the bIeeding is stopped by surgical intervention. Closed abdomina1 wounds are diagnostic probIems. A history of the nature of the accident is important. Symptoms of both shock and hemorrhage may be present. PhysicaI examination reveaIs rigidity of the abdomina1 wall, hydro- or hemoperitoneum with distention and shifting dependent duIness. Pneumoperitoneum with diffuse tympany and obliteration of the Iiver duIness may be present. An empty Ieaking bIadder may be found. A siIent abdomen is usually diagnostic of peritonitis, whether due to bIood, biIe, urine or infection. The diagnosis is based upon history, symptoms and physical findings. X-ray examination is especially vaIuabIe in cases where there is a ruptured hoIIow viscus. The foIIowing is an illustrative case : A young boy received a severe abdomina1 injury when the rear wheel of a heavily loaded truck passed over his abdomen. There was no visible external injury, but symptoms of hemorrhage were present, with painful, rigid abdomen, retraction of the knees and other signs of internal injury. Immediate Iaparotomy reveaIed about 3 inches of the mesentery torn from its attachment. The bleeding mesenteric vessels were ligated, the damaged bowe1 exteriorized, and the patient treated for hemorrhage and shock. SeveraI weeks later the bowe1 was anastomosed. His life was saved by immediate, conservative surgery.

* From the Surgical Department of Mercy HospitaI-LoyoIa

602

University Clinics, Chicago.

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The treatment of both open and cIosed abdomina1 wounds is surgica1, when indicated. Open injuries invoIving only the abdomina1 waII may be treated conservativeIy. Meyer and Shapiro,2 in a recent very instructive and extensive coIIective review, conclude in part as foIIows: “The poIicy of prompt expIoration in penetrating wounds of the abdomen is estabIished; however, no patient shouId be subjected to Iaparotomy unti1 proper preparation has brought his .systoIic bIood pressure above 80, better go or IOO, unIess the operation is one of ‘Iast resort.’ Secondary shock on a surgica1 service is equivaIent to hemorrhage, and, until the bIeeding vessels are Iigated, shouId not be treated by intravenocIysis but by bIood transfusion. Patients operated on in shock are Iess IikeIy to survive the operative trauma. Correction of shock increases the resistance to peritonitis.” In gunshot or stab wound or in any injury to the bowel where there has been feca1 contamination, the injection of 30 C.C. of coli-bactragen into the peritonea1 cavity within three hours after the contamination will markedIy diminish the chances of genera1 peritonitis, and when bactragen is used it is not necessary to insert drains (Sternberg3). Errors are too frequentIy made in attempting to do too much surgery in a patient suffering from hemorrhage or shock. Additiona surgery can be performed in a second operation when the patient is a better surgica1 risk. It is much more IogicaI to have a Iive patient with a feca1 fistula or artificia1 anus than a dead one with a beautifuIIy performed anastomosis. ACUTE

APPENDICITIS

Acute appendicitis is one of the first acute abdominal conditions to be considered. In spite of the advancements made in surgica1 diagnosis and technique in the Iast few years, the mortaIity rate in this --edition has increased. AbeI14 states that ‘re are more than 20,000 deaths per year .tributabIe to this disease, and Herrick

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reports that in cases with peritonitis there is an operative mortaIity of 5 to 30 per cent. As emphasized by Murphy, the symptoms of a typica attack of acute appendicitis, in chronoIogica1 order, are pain, nausea, tenderness and fever. The pain is coIicky in nature, reaching its height in about four hours; it may start in the epigastrium or may be diffuse over the abdomen, Iater becoming IocaIized over McBurney’s point. Nausea, which may be foIIowed by vomiting, appears in from two to four hours after the onset of pain. Vomiting may occur onIy once or twice; however, if it is continuous there is probabIy present either a compIication or another pathoIogic condition. The tenderness at first is diffuse and not marked, but in four to six hours it becomes definite, IocaIizing over McBurney’s point. Rebound tenderness usuaIIy indicates peritonea1 inflammation, either IocaI or generaIized, and cutaneous hyperesthesia eIicited by pinching a raised fold of skin over McBurney’s point is occasionally present. The fever deveIops in from four to twenty-four hours after the onset of pain. UsuaIIy it is not high, ranging from gg to 102 degrees, but more frequentIy remaining under IOO degrees. The more acute the infection, the earlier the temperature. A sudden drop in temperature suggests gangrene, perforation or evacuation of the appendicea1 contents into the cecum. Other symptoms shouId aIso be mentioned. Constipation is usuaIIy present, although Brunn” states that diarrhea is not uncommon in appendicitis. Diarrhea may be present if the exciting etiologic organism is pneumococcus or streptococcus, as we11 as in pelvic appendicitis and many times in appendicitis in children. Tachycardia is a very important cIinica1 diagnostic point. A pulse rate of go to 120 is a more reIiabIe evidence of infection than is increased Persistence of tachycardia temperature. with remission of other symptoms suggests gangrene. BIadder symptoms may resuIt from contact inflammation, as when the

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inffamed appendix lies in proximity to the bIadder or ureter. The findings on physica examination are right rectus muscular rigidity at McBurney’s point, in direct proportion to the intensity and area of the underIying peritonitis. The position of the patient aids in the diagnosis ; for instance, in acute septic appendicitis the patient Iies on his back with the thighs eIevated and the right knee or both knees flexed. This is an important and fairIy constant guide in determining the severity of the attack. Pain on contraction of the right iIiopsoas muscIe by raising the right knee indicates a posterior or retroceca1 appendix. Vagina1 or recta1 examination should be done. In chiIdren recta1 examination is of particuIar vaIue in estabIishing the diagnosis. BIood count wiI1 show a Ieucocytosis of from 9,000 to 18,000 ; this usuaIIy appears earIy with a reIativeIy high proportion of poIymorphonucIear leucocytes. Children under 4 years of age wiI1 usuaIIy show a reIative Iymphocytosis. The diagnosis of acute appendicitis is made from the symptoms and thephysica1 findings. In my opinion the cIinica1 findings are more important in the diagnosis of acute appendicitis than are the Iaboratory findings. If the Ieucocyte count fits the cIinica1 picture, use it; if not, use the cIinica1 findings aIone. The treatment of acute appendicitis is surgery, and the earIier instituted the better. If deIay has occurred and if the appendix appears to be suffIcientIy waIIed off by omentum, then postpone operation as the inffammatory mass may spontaneousIy resoIve or a definite IocaIized abscess may deveIop. If the Iatter occurs, drain the abscess but do not try to remove the appendix as the protective waI1 and the abscess may be broken and a generaIized peritonitis deveIop. The appendix shouId be removed Iater when the infection has subsided. A ruptured appendix with generaIized peritonitis presents a grave probIem ; operation with adequate drainage probabIy offers the patient the

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best chance of recovery. MiIIer’ shows that in chiIdren with generaIized peritonitis the mortaIity rate is Iowered by operation and drainage. In the treatment of ruptured appendix I have obtained exwith peritonitis, tremeIy gratifying resuIts by the insertion of a catheter into the iIeum, if possibIe, or into the cecum through the appendicea1 stump. The catheter is heId in pIace by a purse-string suture around the stump and brought out through the incision or through a stab wound. Distention is reIieved by compressing the bowe1, iIeus is prevented, and the patient’s chances for recovery are greatIy improved. I have never had a feca1 fistuIa develop foIIowing this method of treatment. Decompression of the cecum as described above has been advocated by DeCourcy,8 who shows a reduction in mortaIity to 4 per cent in a series of fifty cases. Serum therapy has been used by PriestIey and McCormackg in the treatment of generaIized peritonitis secondary to rupture of the appendix with some hope of reducing the mortaIity from this compIication. INTESTINAL

OBSTRUCTION

Mechanica intestina1 obstruction is the type of iIeus which requires immediate surgery and, as in other acute abdomina1 conditions, the quicker the patient is submitted to surgery the better are the chances for recovery. IntestinaI obstruction may be caused by : I. PathoIogy without the bowe1, stranguIated hernia either interna or externa1 being the most common cause. Adhesive bands, either congenita1 or postoperative, are aIso frequentIy causative factors. Other causes are tumors (renaI, spIenic, pancreatic, ovarian and mesenteric), Iymphatic inflammation, new growths, uterine and ectopic pregnancies, and occasionaIIy gaIIor urinary bIadder stones. 2. PathoIogy within the bowe1 is caused from impacted feces, foreign bodies, parasites, hair baIIs, and gaIIstones which if

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Iarge enough wiII cause obstruction at the iIeoceca1 junction. 3. PathoIogy deveIoping from the wail of the bowe1, such as tumor or carcinoma, is a common cause of intestina1 obstruction. Carcinoma may be the cause of a chronic or partia1 obstruction and then may suddenIy cIose the Iumen, causing an acute obstruction. This is to be considered especiaIIy in patients within the cancer age group who give a history of abdomina1 distress with a change in bowe1 habit. The higher the obstruction the more severe wiI1 be the symptoms. In chiIdren intussusception is the most common cause of obstruction. It is diagnosed by abdomina1 pain, earIy vomiting, paIpabIe mass upon recta1 examination with the characteristic “cranberry sauce” bIood on the examining finger, associated with abdomina1 distention. ChristopherlO has recently reported two additiona cases of intussusception in aduIts, one a high jejuna1 intussusception caused by a papiIIary adenoma and the other a chronic iIeoceca1 intussusception. Acute obstruction is a compIication of regiona enteritis, a recentIy described pathoIogic condition about which there is much discussion at the present time. Jackson” has reviewed the subject and reported severa additiona cases. Other pathoIogic conditions, deveIoping from the waI1 of the bowel and causing obstruction are strictures from heaIed uIcers, tuberculous and syphilitic Lesions, chronic enteritis, diverticuIitis and peridiverticuIitis chiefly of the sigmoid and peIvic colons, benign tumors of the bowI, such as adenomata, Iipomata, myomata, endometria1 adenomata and poIyposis, hemangioma. MucoceIe of the appendix or hematoma of an appendix epipIoica, whiIe very rare, may give rise to acute obstruction. The symptoms of intestina1 obstruction are usuaIIy constant and incIude vomiting, projectiIe in type and containing first the contents of the stomach, then biIe, and then intestina1 contents. The Ioss of hydrochIoric acid in the stomach contents Ieads

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aIkaIosis, whiIe the Ioss of pancreatic juice and biIe Ieads to acidosis. The pain of the abdomina1 coIic is centered around the umbiIicus and is of a twisting, cutting, griping nature. It is constant with exacerbations if the obstruction is compIete, whiIe with incompIete obstruction there are remissions of the pain, and if gangrene is present there is temporary cessation of vomiting and pain. Meteorism or gaseous distention of the intestine is present except in high obstruction. No abdomina1 rigidity is present except when there is, an associated peritonea1 irritation. A noisy abdomen with a metaIIic tinkling and spIashing sound is characteristic in the earIy stages. Obstipation is a constant finding; the feces in the bowe1 beyond the obstruction may be passed but IittIe or no gas wiI1 be expeIIed. The diagnosis of acute mechanical obstruction is made by the presence of intermittent, crampy, coIicky abdomina1 pain foIIowed by nausea and projectiIe feca1 vomiting, without tenderness, rigidity or fever. X-ray examination either by ffat pIate or by ffuoroscopy may revea1 step Iadder-Iike arrangement of distended smaI1 bowel, especiaIIy if the obstruction is Iow. In acute cases, barium is not used in the x-ray examination. The treatment of acute intestina1 obstruction is surgica1 remova of the cause of obstruction as soon as possibIe after the diagnosis is made and with as littIe operative trauma and shock as possibIe. ProIonged and extensive operations are condemned. If a gangrenous piece of bowe1 is found, exteriorize it and do an enterostomy or coIostomy. Later, when the patient is in better physica condition, the bowe1 can be anastomosed. When the viabiIity of a piece of bowe1 is questionable, this piece may be brought up just beneath the skin surface in the incision and packed away from the abdominal cavity with gauze so as not to interfere in any way with the bIood suppIy. If the viabiIity of the bowe1 returns, nothing more need be done except to remove the to

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gauze and aIIow the wound to cIose. If, however, the questionabIe piece of bowe1 becomes necrotic, an enterostomy wiI1 spontaneousIy occur and, thereby aid in saving the life of the patient. IIeostomy, coIostomy or cecostomy may be performed proxima1 to the obstruction; these procedures decompress the bowe1 and aIIow it to assume its norma size and function before any further surgery is attempted. Anastomosis shouId never be attempted in a piece of bowel which is markedIy distended. Sufficient fluids in the form of norma saIine with or without gIucose shouId be administered by venocIysis or hypodermocIysis to restore the Iost chIorides. Preadministration is equaIIy operative important with postoperative. The amount varies with the individua1 case and with the condition of the patient, but usuaIIy from 2,000 to 3,000 C.C. in twenty-four hours is sufficient. A Levine tube in the stomach with suction may be necessary to reIieve the distention. Narcotics postoperativeIy may be used when necessary. PEPTIC ULCER The term “peptic uIcer” incIudes both duodena1 and gastric uIcer. A serious compIication in this condition is hemorrhage which is usuaIIy treated medicaIIy. AIIen12 states that duodena1 uIcers rareIy cause fata hemorrhage under the age of 50 years, whiIe beyond this age the mortaIity is 3345 per cent. He advises the operative procedure of Iigation of the artery suppIying the uIcer in the better risk oIder group cases. Means13 believes that operation shouId be Iimited to patients bIeeding after 50 years of age or those having repeated hemorrhage. Acute perforation occurs in a certain percentage of chronic uIcers. The symptoms are vioIent, acute abdomina1 pain which may cause the patient to faI1 to the floor or be unabIe to move. This pain may be referred to the epigastrium, right abdomen, scapuIa or back. Shock with paIIid face, sweating brow, staring eyes may be

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present. Th e patient appears to be in and very apprehensive. Boardagony Iike abdomina1 rigidity is present, which is more marked over the uIcer or McBurney’s point with the patient in a flexed position. These patients cannot Iie fiat; to avoid pain they Iie in a flexed position. Breathing is shaIIow, jerky and costa1. Temperature is norma or sIightIy subnorma1. PuIse is sIow, fuI1 and of norma voIume unti1 peritonitis deveIops. Vomiting is absent unIess ffuid or food is taken. PhysicaI examination reveals free fiuid, rareIy gas in the abdomen, obliteration of Iiver duIness, shifting duIness in the fIanks and evidence of earIy peritonitis in the epigastrium and right iIiac fossa. Vomiting of bIood or its presence in the peritonea1 cavity is unusua1. In acute perforation of an uIcer the diagnosis is made by the history of sudden and very vioIent epigastric pain, causing apparent shock, board-Iike rigidity of the muscles of the anterior abdomina1 waI1, tenderness and duIness in the flanks and peIvis. Pneumoperitoneum may be present. There may be cessation or absence of abdomina1 peristaIsis. The conditionoccurs most frequentIy in maIes who may or may not give an ulcer history. Fiat x-ray pIate or fluoroscopic examination usuaIIy shows air under the diaphragm and this is considered quite diagnostic. The treatment of perforated peptic uIcer is immediate Iaparotomy to stop the Ieak. Any Iapse of time after six hours from the time of perforation gives a poor prognosis, and after thirty-six hours the majority of patients die. Since these uIcers usuaIIy rupture on the anterior waI1, the Iocation of the perforation is quite evident, but because they generaIIy are in shock andare poor surgica1 risks, the Ieast amount of surgery done is good judgment, unIess there are other indications. At operation the perforation is cIosed with a pursestring or superimposed Lembert suture. A piece of omenta1 fat is attached over the sutured perforation and the abdomen is cIosed. A gastroenterostomy or any other

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additiona gastric surgery at this time is to be condemned, unIess there is marked pyIoric or duodena1 obstruction. It is better judgment to perform any further gastric surgery, if necessary, at a Iater date when the patient is in better condition. The question of drains is controversial Since the gastric contents are primariIy steriIe, many surgeons cIose the abdomen without drainage ; others use drains and remove them earIy. Postoperative fluids by venocIysis are essentia1. These patients shouId receive medica treatment for the uIcer foIIowing operation. RUPTURED

ECTOPIC

PREGNANCY

These patients present symptoms of earIy pregnancy and rupture usuaIIy occurs before the tweIfth week. The prodroma1 symptoms are sharp, cutting, crampy, Iow abdomina1 pains progressing in severity as the pregnancy advances. AbnormaI vagina1 bIeeding or spotting of bIood is present in most cases. Decidual tissue may be passed, suggesting an incompIete abortion. Weak speIIs, sometimes severe enough to cause fainting, may be experienced. When rupture occurs there is sudden, severe abdomina1 pain, shock, coIIapse and usuaIIy evidence of intraperitonea1 hemorrhage; the puIse rate is increased and of smaI1 volume; temperature is subnorma earIy but Iater may be eIevated; vomiting sometimes occurs. The Aschheim-Zondek or Friedman test wiI1 often determine the diagnosis before rupture or tuba1 abortion occurs. BimanuaI examination reveaIs a soft and sometimes enIarged uterus. Marked tenderness in the peIvis over the affected adnexa and a paIpabIe mass may be feIt. The abdomen is tender and usuaIIy without rigidity. The cuI-de-sac feels fuI1 and doughy. Posterior coIpotomy with recovery of bIood often aids in making a diagnosis. One can determine the presence of free blood in the peritonea cavity by puncturing the posterior cuI-de-sac with a Iarge needIe and aspirating its contents. Hope14 has shown the

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vaIue of the peritoneoscope in the differentia1 diagnosis of this condition, and Ruddock15 shows its vaIue in the diagnosis of other abdomina1 and peIvic pathology. Severe hemorrhage from a ruptured graafian foIIicIe gives a simiIar cIinica1 picture, except that the symptoms of pregnancy are Iacking. The treatment, however, is usuaIIy the same as for ruptured ectopic pregnancy. As soon as the diagnosis is estabIished, immediate operation shouId be performed to stop the hemorrhage. Shock and depression may be out of proportion to the loss of bIood and in those cases a deIayed operation might be advisabIe unti1 the patient is in better condition. This, however, is a point diflicuIt to decide cIinicaIIy. In most cases this condition shouId be considered as a surgica1 emergency. Evidence of intraperitonea1 hemorrhage shouId indicate Iaparotomy. RemovaI of the ruptured tube and Iigation of a11 bIeeding points shouId be done as soon as possibIe, with immediate cIosure. RemovaI of the opposite tube or the appendix shouId not be done, except in the presence of gross pathoIogic changes when the condition of the patient permits further operation. BIood transfusions are especiaIIy vaIuabIe in these cases and shouId be given after the bIeeding is stopped. Shock is treated by venocIysis and hypodermocIysis aIong with the bIood transfusions, and genera1 supportive treatment shouId be instituted. ACUTE

PELVIC

CONDITIONS

Twisted ovarian cysts and uterine fibroids with impending gangrene are other pathoIogic pelvic conditions which require Acute saIpingitis is immediate surgery. best treated ConservativeIy. ACUTE

CHOLECYSTITIS

The etioIogic factors responsibIe for acute choIecystitis are (I) gaIIstones impacted in the cystic duct which interfere with emptying of the galI-bIadder and at times produce, as a resuIt of pressure,

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interference with the circuIation with resuhant edema, congestion and occasionaIIy gangrene and perforation; (2) hematogenous conditions, as from bacteria circuIating in the bIood stream during or foIIowing typhoid fever, septicemia, pneumonia and inffuenza. Rosenow’s experiments Ied him to beIieve that streptococci in the bIood stream have a pecuIiar eIective affinity for the gaII-bIadder. (3) BiIe infection from bacteria in the aIimentary tract. Typhoid fever in earIier Iife has aIways been associated with this mode of infection. PotterI beIieves that biIiary diseases in chiIdren may be caused by contributary factors, such as upper respiratory infections, incIuding inffuenza, pneumonia, scarIet fever, appendicitis, intestina1 parasites and sometimes a history of abdomina1 trauma. (4) Other theories suggested as a mode of infection are Iymphatic-borne infections, infections due to propinquity from another organ, ascending biIiary infections and amebiasis. Acute ChoIecystitis is grouped pathoIogicaIIy by TayIor17 into (I) acute edematous, (2) acute suppurative, and (3) acute gangrenous gaII-bladder, which may be further subdivided into acute gangrenous infarct and acute suppurative gangrene. This grouping is based on the pathologic findings in the gaII-bIadder waI1. Symptoms of acute ChoIecystitis depend upon whether or not the cystic duct is obstructed by a stone. In the simpIe nonobstructive type the attack may be very sIight and commonIy is caIIed acute indigestion or acute biIiousness, rareIy requires morphine for reIief, and usuaIIy subsides under medica management. Acute obstructive ChoIecystitis is characterized by a sudden, severe attack of pain in the upper right abdomina1 quadrant or in the epigastrium and may radiate to the back in the region of the right eIeventh rib, or to the right scapuIa. This pain is due to the passage of a stone down the cystic duct or its impaction in the neck of the gaIIbIadder. The pain is accentuated by the sIightest diaphragmatic movement. ReIief

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may be obtained by attempting a new position, as bending, putting pressure over the back, or by taking a hot bath. The intensity of the pain may become so great as to require morphine. Vomiting and constipation are aImost aIways constant accompaniments. Vomiting may bring reIief and is many times induced by the patient. ChiIIs may be severe but the fever rareIy rises above 102 degrees. The severity of the infection is indicated by the temperature. Marked rigidity over the right rectus muscIe and extreme tenderness on pressure over the right upper quadrant are present. A paIpabIe gaII-bIadder which moves with respiration may be found, but onIy if rigidity of the right rectus muscIe is sIight or absent. Jaundice is rare in uncompIicated cases. The history of previous dyspepsia or distaste for certain foods, such as fats, with the above symptoms, is diagnostic of acute ChoIecystitis. The statistics of Mentzer’* show that 72 per cent of the cases are in femaIes. Leucocytosis of a moderate degree is usuaIIy present but many times is misIeading as to the true underIying pathoIogy and cannot be reIied upon too much. X-ray by means of the gaII-bIadder dye or ffat pIate may be of vaIue. The treatment of acute obstructive ChoIecystitis is surgica1, whether it be remova of the gaII-bIadder, drainage, or a combination of the two. In my opinion, a11 these methods have their merits in especiaIIy indicated cases and no set ruIe can be estabIished. However, Puestow, I g in recent experimenta work, showed that removal of the gaII-bIadder causes a diIatation or paraIysis of the sphincter of Oddi which aIIows free drainage from the biIe passage, thereby reducing intraducta1 pressure. From this it appears IogicaI that choIecystectomy shouId take precedence over the other methods. The present tendency is toward earIy choIecystectomy, as shown by the writings of Heyd,20 CIute,21,22 Mentzer,18 Heuer,23 and others. They beIieve that cystic duct obstruction is the first event in the pathoIogic process

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with infection secondary to the obstruction. They therefore advocate remova before the secondary infection occurs. Preoperative administration of gIucose and saIine shouId be given, preferabIy by venocIysis. Th is stores gIycogen in the Iiver, corrects any abnorma1 chemistry in the body, and baIances the body fluids. Postoperative care must include adequate ffuid intake and the treatment of compIications, if any occur. ACUTE

PANCREATITIS

While this condition is rather infrequent, it is one of the most serious and carries one of the highest mortaIity rates of a11 acute abdomina1 conditions. There are severa theories as to its etioIogy (Lewis24) but the “common channe1 theory” is the one most commonIy accepted. Since it usuaIIy foIIows or is associated with choIeIithiasis, it is thought that the ampuIIa of Vater becomes occIuded or partiaIIy so, causing biIe to flow from the common duct into the duct of Wirsung. The anatomic reIations of these two ducts couId in the majority of cases make this possibIe. The pathoIogy is a matter of the degree of destruction, ranging from acute hemorrhagic pancreatitis to acute gangrenous pancreatitis to acute suppurative pancreatitis, which may be diffuse or IocaI. The onset of symptoms is sudden and vioIent with agonizing, excruciating pain. The pain is so severe that Iarge repeated doses of morphine may be required. Shock is a characteristic finding and in very severe cases is accompanied by cyanosis, paIIor, coId and cIammy skin. The temperature is subnorma with a rapid, weak puIse. Vomiting of biIe and stomach contents usuaIIy occurs, and jaundice may appear earIy. The abdomen is distended and gives evidence of free ffuid and earIy peritonitis. Epigastric tenderness and rigidity in the Ieft upper quadrant is present. Diagnosis is diffIcuIt, but the history of gaII-bIadder disease and sudden onset with shock are heIpfu1 aIong with an increase usuaIIy of the bIood amyIase.

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DeKIimko25 vaIues the Ieucocyte count highIy; it usuaIIy varies from 12,000 to 20,000. The symptoms cIoseIy simuIate those of acute perforated peptic uIcer and acute choIecystitis and Iater bowel obstruction. The treatment of acute pancreatitis is surgica1. This consists usuaIIy of a right transrectus vertica1 incision. The purpose is to evacuate pancreatic &id, cIots, necrotic masses and to decrease the pressure of biIe in the ampuIIa of Vater. AbeIIz6 states that the pancreatic tissue shouId not be interfered with but that gauze or drains shouId be inserted down to it. If the condition of the patient permits, the biIe tract may be drained. This is especiaIIy indicated in the more chronic cases. RecentIy discussion has arisen as to the advantage of deIayed operation. This is probabIy advisabIe in seIected cases in the hands of seIected surgeons, but due to the diffrcuIty of correctIy diagnosing the condition there probabIy wouId be many ruptured peptic uIcers diagnosed as acute pancreatitis by the average surgeon and hence deIay wouId, in the majority of cases, mean the death of the patient. DIVERTICULITIS

DiverticuIitis is inffammation of a preexisting intestina1 diverticuIum. This diverticuIum may be present in any part of the gastrointestina1 tract and give no symptoms unti1 compIications arise. One frequentIy encounters MeckeI’s diverticuIum Iocated in the Iower iIeum about 30 to 150 cm. above the iIeoceca1 vaIve. OccasionaIIy it is Iined, or at Ieast partiaIIy so, by tissue which histoIogicaIIy is the same as gastric mucosa containing chief and acid ceIIs secreting hydrochIoric acid. UIceration and perforation may occur in these cases. Symptoms may be lacking, but when present, are due to compIications, as catarrha1 inffammation (MeckeI’s diverticuIitis), uIcerations, hemorrhage, perforation or gangrene. In such instances the symptoms consist of pain, nausea, vomiting, IocaIized tenderness, rigidity and in-

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creased Ieucocyte count. These symptoms make it almost impossible to differentiate it from appendicitis. Other conditions which require differentiation are stranguIation of the bowel as in a hernial sac, twists or attachments causing symptoms of bowe1 obstruction, and foreign bodies retained within the Iumen. The treatment for inflammation or obstruction is the operative remova of the diverticuIum with closure as in appendicitis. Adherent or obstructed intestine shouId be freed or, if gangrenous, resected or exteriorized with an enteroanastomosis or enterostomy. The coIon, and especiaIIy the sigmoid, are the most frequent Iocations for herniations of the mucosa through weakened circuIar muscIe. These herniations often enter the fatty tabs, cause rotation of the bowe1 toward the mesenteric attachment, coIIect and retain feca1 masses, cause irritation, uIceration, and many times perforation. Carcinoma 0ccasionaIIy resuIts. constipation, Symptoms are chronic chronic catarrha1 colitis with passage of bIood-stained mucus. In acute inflammation there is sudden acute pain in the Ieft Iower quadrant or in the peIvis, with Iower abdomina1 rigidity and sometimes a paIpabIe tender mass, with fever and Ieucocytosis. Perforation may occur, usuaIIy into the bIadder. X-ray and proctoscopic examination aid in the diagnosis, as does the history of an obese person over 50 years of age with chronic constipation. Treatment is medica in about 85 per cent of cases, if there are no compIications. SurgicaI treatment of the complications is often 0nIy paIIiative. MESENTERIC

THROMBOSIS

Mesenteric thrombosis is fortunateIy an infrequent disease, attacking chiefly men past 40 years of age, usuaIIy with a history endocarditis, or arterioof myocarditis, scIerosis. The superior mesenteric artery is most frequentIy invoIved, rareIy the inferior mesenteric, as shown by Gambee.27 Symptoms are sudden, vioIent, diffuse abdomina1 pain with coIIapse, foIIowed by

Acute

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MARCH, 1940

hematemesis and meIena. Temperature is subnormal early but Iater rises with signs of iIeus and peritonitis. Diagnosis is extremely difflcuIt and is rareIy made preoperativeIy. If the patient has had previous heart disease or arterioscIerosis with the above symptoms, if there is a paIpabIe mass, a Ieucocyte count of 20,000 or higher, with 85 per cent or more polymorphonuclear Ieukocytes, the diagnosis is more certain. Acute pancreatitis, perforated peptic uIcer and intestina1 obstruction must be differentiated. Treatment is immediate Iaparotomy, the necrotic bowe1 being exteriorized or resected. The entire intestina1 tract should be carefuIIy inspected so that no infarcts are overlooked. GENERAL

CONDITIONS

The foIIowing are some conditions which may simuIate an acute abdomen but do not require abdominal surgery: Rena1 coIic, especiaIIy if on the right side, may cIoseIy simuIate acute appendicitis; pneumonia and acute pericarditis are common causes of abdomina1 pain in children; food and Iead poisoning may become confused with an acute surgica1 abdomen; tabetic crisis often simuIates an acute abdomen in the adult; coronary disease, thrombosis, angina pectoris (MohIer,2* Morrison,2g Anderson,30 Patterson,31 Burns,32 and Aynesworth33) ; spontaneous idiopathic hemopneumothorax (Hurxtha134) ; mesenteric Iymphadenitis (BeI135); pulmonary tubercuIosis (McReynoIds36) ; juveniIe diabetes meIIitus (Newcomb37) ; bIood dyscrasias, as Henoch’s purpura, sickIe-ceI1 anemia and abdomina1 aIIergy (Althausen, Deamer and Kerr,38 Campbe11,39 Davis40) ; subarachnoid hemorrhage (Thurston41); hemorrhage into a hydatid of Morgagni (Zener42) ; arachnoidism (Morton43) and periarteritis nodosum (Sawyer44). SUMMARY I. Pain is the chief symptom acute abdomen. 2. EarIy diagnosis of an acute abdomen is essentia1.

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3. The most frequent and important surgica1 conditions of the abdomen have been discussed. 4. Diseases both common and rare which give abdomina1 pain but do not require abdomina1 surgery have been mentioned. 3. Immediate conservative surgery, when indicated, has been stressed. REFERENCES

BABCOCK, W. W. Textbook of Surgery. PhiIadelphia, 1935. W. B. Saunders. 2. MEYER, K., and SHAPIRO, P. Treatment of abdomina1 injuries. Internat. Abst. Surg., 66: 245257 (March) 1938. background and 3. STEINBERG, B. Experimental cIinicaI an&cation of the Escherichia coIi and gum tragacanth mixture (coIi-bactragen) in prevention of peritonitis. Personal communication; aIso Am. J. Clin. Path., 6: 3 (May) 1936. ABELL, I. Acute abdomina1 catastrophies. J. A. M. A., 109: 1241-1245 (Oct. 16) 1937. HERRICK, F. C. Acute appendicitis with peritonitis. Surg., Gynec. w Obst., 65: 68-72 (JuIy) 1937. BRUNN, H. Acute peIvic appendicitis. Surg., Gynec. ti Obst., 63: 583-592 (Nov.) 1936. MILLER, E. M., and TURNER, E. C. Surgical management of acute appendicitis, and its compIications in chiIdren. Il/inors M. J., 72: 3, 222-226 I.

!Sept.)

1937.

8. DECOURCY, J. L. Care of the ruptured appendix. Surg., Gynec. ti Obst., 63: 756760 (Dec.) 1936. 9. PRIESTLEY, T. J.. and MCCORMICK, C. J. GeneraIized peritonitis secondary to rupture of the appendix; to serum with specia1 reference therapy. Surg., Gynec. Ed Obst., 63: 675-680 (Nov.) 1936. IO. CHRISTOPHER, F. Intussusception in aduIts. Two additiona cases. Surg., Gynec. ti Obst., 63: 670673, 1936.

I I. JACKSON, A. S. RegionaI enteritis. Surg., Gynec. &+ Obst., 63: I-IO (July) 1937. 12. ALLEN, A. Acute massive hemorrhage from the upper gastro-intestina1 tract: with specia1 reference to peptic uIcer. Surgery, 5: 712-731 (Nov.) 1937. 13. MEANS, J. H. Treatment of peptic uIcer. Indications for surgery. Sure.. Gvnec. TV Obst.. 66: 264-268 (Feb.7 1938. _ IA. HOPE. R. B. DifferentiaI diagnosis of ectooic gestation by peritoneoscopy. Surg., Gynec. ‘t!? Obst., 64: 229234 (Feb.) 1937. 15. RUDDOCK, J. C. Peritoneoscopy. Surg., Gynec. &+ Obst., 65: 623-639 (Nov.) 1937. 16. POTTER, A. H. BiIiarv disease in young subject. Surg., Gynec. ti Obst:, 66: 6o4--6rd(Ma&h) 1.938. 17. TAYLOR. F. Acute era11bIadder. Sure.. Gvnec. ti - ’ ” Obst.,‘63: 298-3o7-(Sept.) 1936. 18. MENTZER, S. H. Obstructive cholecystitis, with particuIar reference to acute obstructive cholecystitis and its sequeIae. Surg., Gynec. ti Obst., 62: 879886 (May) 1936. lg. PUESTOW, C. B. Persona1 communication. 20. HEYD, C. G. “Acute ChoIecystitis”-Why deIay? Surg., Gynec. w Obst., 65: 550-551 (Oct.) 1937.

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21. CI.UTE, H. M. Immediate vs. deIayed surgery in acute cholecystitis. Surg., Gynec. @ Obst., 66: 122-123 (Jan.) 1938. 22. CLUTE, H. M., and LEMBRIGHT, J. F. Immediate surgery in acute choIecystitis. New England J. Med., 28: 72-74 (Jan.) 1938. 23. HEUER, G. J. Surgical treatment of acute choIecystitis. New York State J. Med., 26: 1643-1650 (Nov.) 1936. 24. LEWIS, DEAN. Practice of Surgery. Hagerstown, W. F. Prior and Co., Vol. 7. 25. DEKLIMKO. D. Sureical treatment of acute oancreatitis.‘Surg., Ginec. Ed Obst., 63: 89-95 (JuIy) 1936. 26. ABELL, I. Acute pancreatitis. Surg., Gynec. @ Obst., 66: 348-353 (Feb.) 1938. 27. GAMBEE, L. P. Occlusion of the inferior mesenteric vessels. West. J. Surg., 45: 105-112 (Feb.) 1937. 28. MILITER, H. K. Coronary thrombosis simuIating acute surgica1 abdomen (two cases). M. Clin. Nortb America, 17: 719-725, 1933. 29. MORRISON, W. A. Coronary disease with reference to the acute abdomen. West. J. Surg., 42: 308317, 1934. 30. ANDERSON, J. P. Differentiation between coronary thrombosis and ‘acute abdomina1 condition. J. A. M. A., 91: 944947, 1928. 31. PATTERSON, R. V. Coronary thrombosis with specia1 reference to its differentiation from abdomina1 surgica1 conditions. J. Med. Sot. New Jersey, 31: 75-82 (Feb.) 1934. 32. BURNS. G. R. Heart conditions simuIatina acute abdominal symptoms. Canad. M. A. 2.) 25: 424-428, I 93 1. 33. AYNESWORTH, K. H. Epigastric symptoms in acute Iung and heart disease. Ann. Surg., 105: 845-854, 1937. 34. HURXTHAL, L. M. An unusua1 case of spontaneous idiopathic hemopneumothorax with certain features resembling an acute surgica1 abdomen. New England J. Med., 198: 13. 687-689 (May) 1928. 35. BELL, L. P. Mesenteric Iymphadenitis simulating an acute abdomina1 condition. Surg., Gynec. @ Obst., 45: 465-473 (Oct.) 1927. 36. MCREYNOLDS, R. Errors in diagnosis of the surgica1 abdomen. Illinois M. J., 44: 430-435 (Dec.) ‘923. 37. NEWCOMB, A. L. Acute abdominal pain in juveniIe diabetes meIIitus. Zllinois M. J., 68: 544-546 (Dec.) 1935. 38. ALTHAUSEN, T. L., DEAMER, W. C., and KERR, W. J. FaIse “acute abdomen.” II. Henoch’s purpura and abdominal aIIergy. Ann. Surg., 106: 242-251, 1937. 39. CAMPBELL, E. H. Acute abdomina1 pain in sickIe ceI1 anemia. Arch. Surg., 31: 607, 1935. 40. DAVIS. E. T. Henoch’s ouroura simulatinn acute appendicitis. Brit. M. J., 2: 793, 1932. hemorrhage simu4’. THURSTON, G. Subarachnoid Iating “acute abdomen.” Lancet, 2: I ‘94-I ‘95, 1937. 42. ZENER, F. B. Hemorrhage into hydatid of Morgagni simulating acute appendicitis. Am. J. Surg., 37: 106-108 (JuIy) 1937. 43. MORTON, C. B. Acute abdomina1 symptoms in arachnoidism. Arch. Surg., 26: 64-71, 1933, 44. SAWYER, C. F. Periarteritis nodosa. Personal communication. 1

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