Intestinal obstruction: Application of some of the newer principles evolved from experimental and clinical experience

Abstract

1. 1. In simple mechanical obstruction of the small bowel, particularly of the duodenum and jejunum, the earliest symptoms are due to dehydration and other chemical changes in the blood and tissues from loss of electrolytes and fixed bases due to vomiting and failure of reabsorption of digestive juices in the lower bowel. Shock-syndrome effects and some nervous factor connected with distention of the gut are important in the production of symptoms of intestinal obstruction. Toxemia ordinarily does not play a rôle in these cases until the intraintestinal pressure has increased to the extent of seriously impairing the circulation in the involved segment of bowel, thus producing gangrenous changes in the mucosa. 2. 2. Paralytic ileus is most frequently due to peritonitis. The inhibition of function of the gut is due to excessive splanchnic irritation. As a result of the inhibition, the intestine distends from the accumulation of gas and liquids. Re-establishing the normal gradient by blocking the splanchnic stimulation, using hypertonic saline solution freely to stimulate peristalsis, and decompressing the distended intestine by a high enterostomy, are recommended. 3. 3. In strangulation obstruction, the profound local circulatory changes result in an early and serious toxemia and shock. Whether the toxemia is due to an enterotoxin or to liberation of toxic substances from gangrenous patches in the gut, has not been settled. It is a clinical fact that the intestine immediately proximal to a simple mechanical obstruction, as well as the markedly distended loops in paralytic ileus, often shows serious damage to the gut wall as the result of the tremendous increase in intraintestinal pressure. Treatment then becomes the same as for strangulation obstruction, namely exteriorization when possible and decompression by enterostomy. 4. 4. The possibility of gas-traps resulting from a primary, simple obstruction because of lengthening and twisting of the intestinal tube must be borne in mind and surgical treatment is to be directed toward overcoming these multiple obstructions. 5. 5. The advantages of a high enterostomy with the introduction of a soft tube for a considerable distance and the production of slow decompression by means of suction from an electric pump are stressed. 6. 6. Conservation of pancreatic juice, particularly when jejunostomies are performed, is desirable, and methods of accomplishing this are described. 7. 7. Blood transfusions, hypertonic and normal saline, and dextrose solutions are definitely indicated in the treatment of various forms of ileus. The effect of hypertonic saline solution on peristalsis and the effect of the large amounts of water contained in normal saline and dextrose solutions upon intestinal secretion are to be borne in mind. They increase intraintestinal pressure and for that reason decompression should accompany the introduction of these solutions whenever conditions permit. 8. 8. The unsatisfactory results that have followed the use of various drugs to stimulate peristalsis are probably due to the fact that they stimulate certain forms of intestinal contractions, but they do not increase propulsive movements. That hypertonic saline solution does increase these latter movements has been shown both experimentally and clinically. 9. 9. The many disadvantages of ether and the advantages of spinal anesthesia are discussed. 10. 10. The fall in blood pressure which occurs with spinal anesthesia, and which can usually be prevented, is due to a dilatation of the smaller vessels of the skin, muscles and splanchnic areas and is not due to a diminution in circulating blood volume as occurs in shock.