Intestinal Obstruction.
Synonyms:—Ileus; occlusion of the bowel.
Definition:—Intestinal obstruction is a condition of the bowel in which normal peristalsis and evacuation are markedly hindered or entirely prevented.
Etiology:—There are three types of intestinal obstruction:
(a) That due to paralysis of peristalsis.
(b) That due to excessive peristalsis; i. e., spasm of the bowel.
(c) That due to mechanical obstruction, as twisting or volvulus, intussusception, kinking by bands of fibrous tissue, hernia, stricture, neoplasms, foreign bodies, pressure and congenital malformation.
This condition may occur either in an acute or in a chronic form. The acute cases are most commonly due to paralysis, spasm, volvulus, intussusception, adhesions and hernia, and the chronic cases to tumors, either within the bowel lumen or external to the bowel and pressing upon its walls from without; also to fecal impaction.
Symptomatology:—As will be readily seen, the symptoms will vary with the cause of the obstruction. In general, however, there is a well-marked train of symptoms clearly distinguishing the acute cases, which are in their order, pain, nausea or vomiting, tympany and coprostasis.
A discussion of the more common forms is necessary.
Intussusception:—Clinically three types may be recognized: the ultra-acute, death resulting within twenty-four hours; the acute, death resulting in the first week unless the condition is relieved, and the sub-acute, lasting a month or more. The small intestine may be involved alone: the ileum and cecum may be invaginated within the colon; a portion of the colon may be invaginated within its own lumen; the rectum may be involved alone.
The first symptom is most commonly sudden and violent pain, which subsides and recurs. Vomiting soon occurs in the great majority of cases, and nausea is always present. Vomiting may not appear for hours in adults, and may even be absent. Bloody mucus is passed from the bowel after the contents below the invagination are evacuated, especially in children. Tenesmus is usually felt and is severe. Sometimes the tumor may be felt and peristaltic waves seen through the abdominal wall.
Strangulation:—Bands of adhesions may form, most commonly at the site of an operation on the abdominal viscera, and these may kink the bowel, or the latter may become looped beneath them. The symptoms are sudden pain of great intensity, which continues, though there are remissions in intensity. The pulse is rapid and becomes weak. The temperature is usually elevated from one to three degrees. Vomiting becomes established within thirty-six hours and is fecal in character. After the bowels are evacuated early in the attack, constipation is absolute.
At first it may be possible to palpate the kink of the bowel, but tympany develops, which soon obscures the palpatory findings. Tenderness may be marked over a portion of the abdomen, and this is often at a distance from the strangulation. Sleep is impossible. The patient has an anxious expression, bodily weakness develops, but the mind is alert. While intussusception is most common in children, strangulation is seen most commonly in adults.
Volvulus:—This condition is most frequently found after middle age, and in men more commonly than in women. The small intestine is involved and is usually twisted, with the mesentery as an axis. Pain is not so constant or severe a symptom as in other acute forms of intestinal obstruction, but abdominal distention is marked. Constipation is absolute and there is considerable vomiting.
Paralytic ileus is a condition which usually occurs after operations upon the abdominal organs. There are seldom malformations or malpositions of the intestines. The muscular fibers are simply paralyzed. Vomiting, meteorism and constipation are the conspicuous symptoms.
Obstruction from Foreign Bodies.—Indigestible articles swallowed are an occasional cause of intestinal obstruction. Gall stones and enteroliths are more common causes. The symptoms are not so severe as in the foregoing forms. Constipation is the most marked. Tenderness is usually present, with occasional attacks of colicky pain. Vomiting is excited by the taking of food. The symptoms are in general those of a severe form of gastro-intestinal catarrh, with the exception that there is constipation instead of diarrhea. Gall stones and enteroliths are often passed, and should be looked for in the bowel movements obtained.
Diagnosis:—The diagnosis of intestinal obstruction may be difficult in the early stages and must be differentiated chiefly from appendicitis. In this the early localization of the appendiceal pain, the history of other attacks, the leucocyte count, and the rigidity of the right rectus muscle will help to decide in favor of appendicitis. The obstinate constipation, the developing abdominal distention, the rapid pulse, and the fecal character of the vomitus will point toward intestinal obstruction.
In gall stone colic a history may be obtained of previous attacks; there may be jaundice; there is tenderness over the gall bladder and the liver, and the pain is reflected to the region of the right shoulder blade.
In renal colic the pain is distinctly in the lumbar region, and if reflected is reflected to the pelvis and thigh. Blood is usually found in the urine.
Prognosis:—The prognosis depends upon the age of the patient and the type of the obstruction. It is not good in infants, while the causes producing intestinal obstruction in adults are usually remediable if recognized early and appropriate operative measures can be employed. Of course, the prognosis in cases due to neoplasms is the prognosis of these diseases themselves.
Treatment:—So insidious is this condition in most cases that it is considered only a case of constipation and physics will have been administered in nearly every case before the physician is consulted. Physics should be avoided in all cases. It is a good plan, however, to thoroughly evacuate the bowel below the obstruction; this may be accomplished by the use of enemata. While the obstruction can only be overcome by surgical means, in most of the cases, medical treatment of the symptoms is of great importance. The pain should be controlled, usually with hypodermics of morphin; other remedies are either temporary or inefficient; for the vomiting it may be necessary to irrigate the stomach. No food or drink should be taken into the stomach, if possible, during the existence of the condition.
If the obstruction is due to impaction alone, high rectal injections persistently repeated will ultimately succeed in removing them; or an injection of olive oil may be used. It is a good plan to invert the patient and use a fountain syringe held sufficiently high to produce considerable hydrostatic pressure. This may be alternated with massage or manipulation of the abdominal walls, conducted systematically and carefully.
If the case be one of intussusception, distention of the bowels with water, or inflation with gas or air, should be practiced. There should be some remedy given which would produce complete muscular relaxation, if this has not been accomplished by the original hypodermic injection of morphin.
If these measures repeated and persisted in for from twelve to eighteen hours are not successful, a surgical operation must be performed without further delay. Early operations are successful in a large majority of cases; the danger lies in procrastination.
