Elaboration of Criteria upon which the Early Diagnosis of Acute Intestinal Obstruction may be Made, with Special Consideration of the Value of X-ray Evidence

Abstract

THE mortality in acute intestinal obstruction continues to be prohibitively high. Recent reports from large municipal hospitals where cases of bowel obstruction are frequently seen indicate that from 35 to 60 per cent of patients operated upon for acute bowel obstruction die (Miller). Despite the fact that marked improvement is manifest in the results of practically all other acute abdominal catastrophes, the mortality of obstruction to-day is almost that of forty years ago. This is due in large measure to late diagnosis, for any number of statistical studies indicate that when cases come to operation early the results compare fairly satisfactorily with the issue attending the surgery of other acute abdominal disorders. Finney reports a mortality of 36 per cent in 217 cases, but within the first 12 hours the mortality was 5 per cent and for the 12-to-24-hour period, 11 per cent. Whereas the mortality in the entire group of 128 cases of acute intestinal obstruction reported by Tuttle was 41.3 per cent, in 13 cases operated upon within 6 hours there were no deaths and in the 25 patients operated upon within 12 hours the mortality was 4 per cent. In 124 cases reported by Brill the mortality for the group was 36.3 per cent, but of the 17 cases operated upon within the first 12 hours there were no deaths, and of 16 cases operated upon between 12 and 24 hours, 12.5 per cent died. Diagnostic Features of Obstruction The criteria upon which the diagnosis of intestinal obstruction is usually made are the following: Pain, nausea and vomiting, obstipation, meteorism, and collapse. All of these symptoms may be observed at some time during the course of obstruction, but usually at not sufficiently early an hour to afford the patient early remedial help. Difficulties in Diagnosis Absence of Local Physical Findings.—There are two factors, I believe, which are largely responsible for the difficulty in making the diagnosis. One of these is the absence of local physical findings in acute bowel obstruction. When obstruction of the strangulating variety is present, local physical findings are usually in evidence; when, however, only the continuity of the bowel is obstructed without vitiation of the blood supply of the intestine, early physical findings are absent. In all other acute abdominal disasters rigidity and tenderness occur early, suggestive of the presence of a serious lesion within. Were acute cases of appendicitis not heralded by the presence of tenderness or rigidity, undoubtedly a larger number would come to operation when peritonitis had already supervened. The very fact, however, that acute intestinal obstruction is the only serious abdominal disorder of an acute nature in which physical findings are absent early is of great importance. When a patient complains of intermittent, crampy, colicky pain, nausea and vomiting, but local physical signs are absent, the presence of bowel obstruction should immediately be accorded serious consideration.