Intestinal Obstruction

Abstract

ALTHOUGH considerable literature has accumulated on the diagnosis and treatment of intestinal obstruction, the mortality rate, at least for acute obstruction, remains practically what it was a decade ago. If the clinician will persist in waiting for obstipation and fecal vomiting, he will raise the mortality rate from 5 per cent for early cases, to over 50 per cent for advanced cases. The clinician would do well to come to the roentgenologist for help before the diagnosis is obvious. We feel that the roentgenologist may assume considerable responsibility, even in the very early cases. Since the work of Schwartz, in 1911, and Case, in 1914, we have been convinced that gas in the small bowel means stasis. Why, then, has not the roentgenologist solved the problem of the late diagnosis and the resultant high mortality? Although my study includes only 100 cases, I feel the reasons are clear. First, a significant number of clinicians are still not fully aware of the value of flat films of the abdomen in intestinal obstruction; second, the clinician frequently is fooled by the passage of small amounts of gas and feces, and third, some practice and considerable patience are necessary before one can become adept in recognizing the early partial obstruction in the flat film of the abdomen. Diagnosis.—The diagnosis of intestinal obstruction by means of flat films of the abdomen, rests entirely upon the recognition of large amounts of gas in the small bowel, or the lack of continuity of the gas column in the large bowel. Thus, it becomes entirely a question of differentiating the small from the large bowel. At first thought, this may seem very simple, and, in the usual case of dynamic small-bowel obstruction, the problem is relatively easy. Frequently, however, the films are extremely difficult to interpret. In such cases, one must make multiple exposures in prone, supine, and even lateral positions, and patiently study each collection of gas for the characteristic appearance of the small bowel. When there are the typical “stepladder” layers of small bowel, it is not necessary to be a roentgenologist to make the diagnosis. But, if we are to be true specialists, we must be able to recognize the very early case, when the distention is only slight. In common with other authors, the writer has found the demonstration of Kerkring folds to be absolutely pathognomonic of the small bowel. However, these fine folds are not always visualized satisfactorily. In reviewing all my films, I have come to the conclusion that the difficulties were nearly always due to poor films. It is believed, therefore, that the technically good film is the secret of successful diagnosis. This point cannot be stressed too much. Roentgenologists demand the sharpest exposures in chest films, and yet they are frequently satisfied with poor films of the abdomen, forgetting that the Kerkring folds of the small bowel are as delicate as the fine bronchial markings of the chest.