Chronic Obstruction of the Duodenum

Abstract

OBSTRUCTION of the duodenum may be congenital or it may occur acutely or develop slowly. The acute form often follows abdominal operations and is then known as acute dilatation of the stomach. Surgeons of experience are well acquainted with this dread complication. The almost continuous vomiting which accompanies it results in a loss of water and salts, and this, with the associated intoxication, quickly reduces the patient to a critical condition. For these reasons this form of obstruction has been studied very carefully. The chronic form of obstruction has a less dramatic onset and the possibility of its existence is seldom suspected, even by men of wide experience. It has been described under a variety of titles, such as dilated duodenum, stenosis of the duodenum, duodeno-jejunal ileus, arterio-mesenteric duodenal occlusion, megaduodenum and others. Of these, the least satisfactory titles are those which imply that dilatation of the duodenum is an invariable accompaniment of duodenal obstruction. If that were true the diagnosis would be comparatively simple. Any dilatation of the duodenum which occurs as a result of chronic obstruction develops gradually, and there must, therefore, be various stages in its development, from slight delay in emptying of the duodenum to more or less complete obstruction, with tremendous dilatation. The degree of obstruction is not the only factor involved in determining the amount of dilatation. It is obvious that the resistance of the pylorus to retrograde peristaltic movements, the tone of the gastric and duodenal musculature, and the rate at which the obstruction develops are also important factors. Use of the term “chronic obstruction of the duodenum” seems unobjectionable since it neither implies that dilatation exists nor restricts the use of additional descriptive terms. The causes of chronic obstruction are varied. It may be caused by intraduodenal pathology but it is more frequently the result of disease in adjacent viscera. Angulation, adhesions, stenosis, pressure by tumors or inflammatory masses, infiltration, pancreatitis, cholecystitis, and constriction by the root of the mesentery have been described by various observers as occasional causes of chronic obstruction. Jordan (1) describes a type of obstruction due to a kink at the duodeno-jejunal flexure. It is his belief that a kink at the duodeno-jejunal flexure may occur, because the third part of the duodenum is normally firmly fixed over a peritoneal band while the jejunum is unsupported at its commencement. A case of obstruction due to angulation caused by adhesions was observed by Anders (2). Albert J. Ochsner (3) has reported fourteen cases of duodenal obstruction, with dilatation in twelve. In eleven, a pathological gall bladder was found; in one case the duodenum was adherent to the liver and in another there was evidence of ulcer. This is an observation of some importance.