THE
EARLY
DIAGNOSIS OF ACUTE OB8TRUCTIOK
INTESTISAL
FT FRED 31. DCXJGLASS. M.D.. TOLEDO,OIIIO
T
HE purpose of this paper is to call your attention to a method which enables the diagnosis of acute postoperative intestinal obstruction to be made very early. This has been brought about by the careful study of ci’i cases. I have excluded from this discussion acute obstructions due to cancer or volvulus, strangulated hernia, and mesenteric thrombosis. The cases considered are those occurring postoperatively and can be divided into two groups : first, those occurring during the patient’s stay in the hospital, and second, acute intestinal obstruction developed after the patient has left the hospital. fn the first group, there were 37 cases with 41 operations and 12 deaths, the mortality being 32 per cent. In this group there were ‘3 cases of purulent peritonitis, and of this number there was but one recovery. The accompanying tabulation shows the type of operation preceding the obstruction : After appendectomy, 18 cases, G deaths. After pelvic inflammatory disease, 8 cases, 3 deaths. After large twisted ovarian cyst, 4 cases, 1 (leath. After resection of bowel, 1 case, 1 death. After duodenal ulcer, 1 case, 0 death. After hernia, 2 cases, 0 dcsth. After hysterectomy, I cases, 0 death.
In the second group there were 30 cases with 4 deaths, the mortality being 13 per cent. This offers a marked contrast with the above-mentioned group in which the mortality was 32 per cent. The argument might be advanced that this group contained casesmore or less chronic in type, but careful investigation reveals that 18 of these patients entered the hospital within forty-eight hours after the beginning of the first symptoms and that the other 12 came into the hospital shortly after this forty-eight hour period. In the reexamination of the records of the first group of cases, it is possible to obtain from the charts information which we believe would have made the outcome in this group much more favorable. I am of the opinion that the present signs and symptoms of acute intestinal obstruction as given in the literature and textbooks are found late in the disease. In examination of a suspected case of postoperative intestinal obstruction, the surgeon must inquire first in regard to the type of pain 196
DOUGLASS
:
ACUTE
INTESTIKAL
OBSTRUCTIOK
197
The first symptom and discomfort from which the patient is suffering. of intestinal obstruction is that of intensified abdominal pain, more or This is the type which is chart,ed as “gas” pains but is less localized. distinctly different in that the paiii is much more severe and colicky in nature. Intensification of gas pains occurred in 34 of the 37 cases and
Pig.
I.--Partial
obstruction intwtine.
of one loop, distended. The Distcnilr~l Imp is indirated
rest of the gas is in the large by :~wo\v.
was first noted from tight hours to five days before diagnosis of acute the patient postoperative intestinal obstruction was made. Frequently mill state that she hears or feels rumbling of gas in the abdomen. Sausea is usually not present at this time, but may be. Vomiting at this stage in the disease seldom occurs. Hyperperistalsis is not seen until later. Cpon inspection of the abdomen out notices but slight distent,iou at this stage. Palpation, however, reveals a tenseness of the
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AMERICAiX
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OBSTETRICS
AND
GYNECOLOGY
abdomen. The distention, as ascertained by palpation, is much more constant than noted by inspection. Slight or moderate distention on palpation was found very early in 34 of the 37 cases. Suscultation in our hands has not been illuminating, but probably if done by Dr. King’ would give further proof of obstruction at this stage. Since the work of Case. we are able to confirm these clinical findings
11y mrans of s-ray examination of the abdomen. He called attention to the fact that roent~genograms of the abdomen will show distended loops of small bowel in early obstruction. Quot,ing from Dr. Case’s’ paper :
I)OUGLilSS found
in
the
small
bowel
:
AC’UTE
presents
INTESTlNAL
u characteristic
199
OHSTRI’CTIOX :tppe:lrance;
numerous
small,
ir-
regularly spaced gas areas, giving to the central portion of the abdominal shadow which is in distinct, contr:lst to the gastric the reticulated or web-like aspect, and colonic gas collections. In acute small hoyel nhstluction the :~ppc:trauee of jejune-ileal loops is very striking. Tao tgpes of howl out,liw mny he described: (1) a herringbone apprarance due to the gas rausing thaw folds of Kedrl~in; to stand
Fig.
3.-Ladclerlike
out by contrast, and (2) a ladder Ioops lie parallel. quiring immediate
distention
of ileal loops, seventy-two tion of terminal ileum.
hours
giving a feathery or slashed appwr:rnce arrangement of the shadows of the bowel The latter appearance is patho~nowrnic surgery. ”
after
onwt
: ~jh~:tt.r,,.-
to the intestin:~l loop; coils when the distended of ncnte obstruction re-
Dr. John T. Murphy, of Toledo, as early as 1921. was able to see, by means of the fluoroscope, distended small bowel in one case and confirmed our diagnosis of acute postoperative intestinal obstruction.
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ORSTETRICS
Ah’D
GYNECOLOGY
Since Dr. Case’s work, we have observecl the following cases and feel that the “herringbone” appearance comes late, as cloes also the and the amount of distention of the “stepladder” arrangement, bowel depends upon the amount of fluid and gas above the obstruction. We believe that a distended loop or two of small bowel in the presence of clinical signs completes the diagnosis.
Fig.
4.-Marked
distention
of many loops, indicating obstruction This is associated with peritonitis.
of
long
stanrling.
We are of the opinion that \\hen patients are extremely sick and plates are made at the bedside with portable machines, the anteroposterior position may fail to show definite distended loops on a ladder-like arrangement which could be demonstrated by means of lateral plaks or may be noted by one trained in observation of the cross-section of the bowel as seen in the anteroposterior position.
DOUGLASS
:
ACUTE
INTESTINAL
201
OBSTRUCTIOK
The treatment of acute intestinal obstruct,ion in our hands is about the same as that employed by most men. We attempt to overcome obstruction early by freein g t,he bowel when possible and draining the obstructed intestine by ileostomy. The usual supportive measures, as the maintenance of high water intake and blood chloride level by the
Fig.
5.-Massive
use of saline
distention
of only a few hours after onset
intravc~liously
loops. Herringbone of symptoms.
n~ltl by tlirx ll?-l)o(l~,~illovl~sis,
effect
sevent)
-twc
art: follu\~~c(.
331oocltransfusion has been of value in many cases. C~lucoseis giren along with the saline to combat acidosis. The duodenal tube is used early and frequently. Heat in large amount is applied to the abdomen and orer the liver area. Prrfringen’s antitoxin has been used, but we pre unable pt the present time to stat,e its value.
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OBSTETRICS
ASD
GYNE(‘OLOBY
COMMENT
In acute intestinal obstruction there is a definite period when pain is present along wit,h some distention of the abdomen. Such symptoms as vomiting and visible peristalsis of the abdomen a,rc rarely seen .
Fir.
6.-Onset
of first
pain
at ins
4 A.M. the three
X-ray at distended
9 A.M., loops.
02’ five
hours
later,
show-
this early. The chart of the patient will reveal that enemas are productive and the patient is passin, e was b ; and at this time examination of the blood chlorides and nonprotein nitrogen is of lit,tle value, because the obstruction is so early. X-ray examination is very helpful as a
HEYD
:
R6LE
OF
THE
LIVER
IN
ABDOMXAL
SURGERY
203
confirmatory measure; and, because of this, it should be done early in all cases of suspected intestinal obstruction.
The study of the case records has convinced us that the diagnosis of acute intestinal obstruction can be made much earlier than has been tlonc in the past. The use of x-ray has confirmed our clinical suspicion and has made us operat,e upon patients with acute intestinal obstruction much earlier than we previously did. With this in mind, we feel sure that in the future our present mortality rate will be greatly reduced. REFERENCES
(1) Eing, Jams E. : Trans. of American Association of Gynecologists, Obstetricians and Abdominal Surgeons, p. 100, 1928. (2) Case, James I”. : Am. .I. Xoentgenol. 19: 413-425 (May), 1928. 421 MICHIGAN STREET.
THE I’ROTECTIVE
BY (Professor
T
CHAS. of
ROLE OF THE LIVER SIJRGERT
GORDON HEYD, B.A., Surgery,
New
Pork
IN ABDOMINAL
M.D., F.A.C.S., EEW YORK Medical School and Hospital)
Postgradu.ate
HE liver, approximately the same size and weight as the brain, is placed as a buff’er between the portal and systemic circulations. and is interposed between the spleen and the heart. The liver receives the blood from practically the entire viscera of the abdomen, yet the amount of arterial blood supplied to it is very little, as the final divisions of the hepatic artery are small in proportion to the bulk of the gland. It is interesting to visualize the adequate arterial blood supply of the thyroid and the kidney, where the biochemical activity is an oxidation process as compared to that of the liver. The vital functions of the liver are practically carried on with only venous blood. The major portion of the blood that traverses the liver is venous, onesixth to one-eighth of which represents splenic blood. This venous blood contains the by-products of splenic metabolism and the intermediate by-products of digestion. According to Crile the liver has a marked thermogenic function, as one-third of the heat production of the body is due to liver activity. “When the temperature of the liver is reduced one degree, its chemical activity is reduced 10 per cent.” Furthermore, a fall in the temperature of the liver is always preceded by a fall in brain temperature, and resistance to traumatic stimuli is manifest in the brain either before or simultaneously with its effect upon the liver. Renauld Capart states