Acute Obstruction of the Small Bowel

Abstract

The material for this paper has been collected during the past fifteen years from the records of the Maine General Hospital, where it has been a routine procedure during this period to take a “scout film” in all undiagnosed acute abdominal cases, particularly cases in which intestinal obstruction is suspected. Three hundred and fifty cases of either small or large bowel obstruction have been studied. Of these, 100 cases have had both roentgen-ray studies and surgical confirmation of the diagnosis of small bowel obstruction. The purpose of this paper is to correlate the roentgen with the surgical findings in this latter group of cases. It is further our purpose to show, as has frequently been reported by others, that with adequate roentgen study, not only is the diagnosis highly accurate, but the location of the lesion may be approximated in a large percentage of cases and in some the nature of the obstruction may be anticipated. Cases of external hernia and of carcinomatosis and peritonitis, where the obstruction was of secondary importance, have been excluded. This corresponds to reports from the Massachusetts General Hospital by Scudder, Richardson, McIver, McKittrick and Sarris. Since Case, in 1920, reported on “a new aid in the early recognition of postoperative ileus,” a mass of literature has appeared on this subject. This has been adequately reviewed in the recent books of Wangensteen and Golden and no attempt will be made to reduplicate their extensive studies. Roentgen Study For the past fifteen years, it has been our routine practice to obtain a “scout film” in all acute abdominal cases. This is studied immediately. If further information is desired, an upright film may be taken including the diaphragm, to determine the presence of a pneumoperitoneum or fluid levels. A decubitus film with the right or left side up, or a lateral view in the supine position if the patent is acutely ill, will give the same information and will also help to identify further the point of obstruction. In the study of all films the following points are kept in mind: 1. Abnormal gas shadows, due to: a. (a) Intestinal tract (what part?) b. (b) Pneumoperitoneum c. (c) Air in biliary tract 2. Possible causes of mechanical or reflex ileus a. (a) Gallstones b. (b) Renal stones c. (c) Fecaliths d. (d) Foreign bodies 3. Abnormal soft-tissue shadows 4. Bone abnormalities For the purpose of this analysis, the presence of abnormal intestinal gas will be discussed. Air in the small bowel, except in the very young, is abnormal but does not necessarily indicate obstruction. After an enema, fluid and gas may pass through the ileocecal valve into the small bowel, but in such cases the gas is minimum in amount and is limited to the terminal ileum, which shows no dilatation. Occasionally in the presence of a large bowel obstruction segments of small bowel may show dilatation. In one of our cases this was explained on the basis of obstruction not only of the large bowel but also of the terminal ileum.