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A CASE OF ACUTE GASTRO-DUODENAL ILEUS.
By Capt. R. V. RAJAM, m.b., b.s., Tanjore.
An Indian Christian, male, aged about 50
years, was admitted to the Headquarters Hospital, Palamcottah, with what appeared to
be acute intestinal obstruction. He o-ave a i-,js_
tory of flatulent dyspepsia with &epigastri- discomfort for nearly six or seven years before the onset of his acute condition. On the nio-ht of the attack, some hours before, he had
partaken of an unusually heavy meal at a feast The attack commenced with acute pain in the abdomen and vomiting.
Condition on Admission.?The patient was a
lean emaciated man.^ The abdomen was enor- mously distended. The distension was more
marked in the centre of the abdomen, from the epigastrium to the symphisis pubis.' He was vomiting frequently,#*-?nall quantities of bile- stained fluid mixed with undigested pieces of meat and rice. His facies was typical of some acute intra-abdominal trouble. The temper- ature was subnormal. The pulse was small
in volume and 110 to the minute. There was
no rigidity of the abdominal wall but diffuse tenderness all over the abdomen, especially marked in the supra- and sub-umbilical re-
gions. There was no visible peristalsis. The
pain was diffuse and continuous. A large and high enema of soap and water gave a good result, but the distension and vomiting were unaffected even by repeated enemas. The
patient was prepared for a laparotomy. The abdomen was opened by a sub-umbilical para- rectal incision on the right side. A distended viscus presented at the opening. The incision was enlarged upwards for better exploration. It was found that the stomach was enormous-
ly distended. It filled the whole abdominal
cavity, its greater curvature reaching to the brim of the pelvis. There was no peristaltic movement visible. On manipulation a splash was elicited. With great difficulty the dis- tended paralysed stomach was lifted and gentle exploration revealed a distended duodenum up to its junction with the jejunum. The
duodenum looked more like a distended colon. All the coils of the small intestine as well as the caecum and part of the ascending colon
were in the pelvic cavity and completely col- lapsed. There was no evidence of any ulcer in
the stomach. There was nothing to show the presence of any mechanical obstruction by bands or internal hernia. The abdomen was closed by through and through stitches as tiie
patient's condition was bad, and as I did not understand what I should do for the condition. As soon as the patient recovered from the
anaesthetic, he was placed in the Trendelen-
burg's position and gastric lavage was com- menced. It was repeated every two hours.
Injections of pituitrin and eserin salicylate were given four-hourly. The patient's con-
dition did not improve and he died 48 hours after the operation. A post-mortem examin- ation could not be had as the relatives took
away the body.
A reference to the ordinary text-books on surgery did not help me to understand the cause of this condition. Paralytic ileus of the stomach has been met with as a post-operative complication, especially after operations on
the upper abdomen and biliary passages. But in this case there was no such antecedent cause except the history of epigastric discomfort and flatulent dyspepsia. Then Mr. Wilkie's article on chronic gastro-duodenal ileus in the British Journal of Surgery and his subsequent lecture on the same, published in the British Mcdical Journal of 1922 enlightened me on the patho- genesis of this condition. According to him the condition is not very rare, but the
symptoms have been mistaken for gastric or duodenal ulcer. The disease runs a chronic course, often extending over years, with a great tendency to an acute and fatal exacerbation. It is due to the pressure of the superior mesen- tric vessels on the terminal part of the duode- num, which they cross almost at right angles. Normally with the abdominal viscera in their
proper place and with a normal tonic condition
168 THE INDIAN MEDICAL GAZETTE. [April, 1925.
of the abdominal muscles, this vascular arch does not exert any mechanical pressure on the duodenum. But in conditions where there is a general visceroptosis, especially of the small intestines and proximal colon, the tension on the mesentery caused by the dropping down of the intestines acts on this vascular arch and
compression and mechanical obstruction set in. In the case cited it was observed at the opera- tion that there was marked visceroptosis of the small intestines and proximal colon into the pelvic cavity; and it is quite probably the root cause of the condition. The history of flatulent dyspepsia and epigastric discomfort for a number of years shows that he had been
suffering from chronic gastro-duodenal ileus as a result of the visceroptosis. The acute
and fatal attack for which he sought admission to the hospital had supervened on the chronic condition. As I was quite unaware of this, I did not look for the arch of the superior mesenteric vessels crossing and compressing the terminal part of the duodenum at the time of the operation. Further, even if the condi- tion had been recognised, the state of the
patient was such that no anastomosis opera- tion would have been possible. Operation is not indicated in the acute variety. Only gastric lavage with the patient turned on the face to relieve the pressure on the duodenum has been recommended, and has met with success.
The symptoms of the chronic cases are very liable to be mistaken for gastric or duodenal ulcer, though the latter may arise as a late complication. A long-standing history of flatulent dyspepsia with epigastric discomfort rather than' actual pain, with intervals of re- lative freedom should always raise the sus-
picion of duodenal ileus. Operative treatment has given the best results in chronic cases.
Colopexy suffices to cure the condition in those cases where the tension on the mesentery is due to a mobile and prolapsed proximal colon. But in cases where the drag is due to the pro- lapse of the small intestines, a duodeno-jeju- nostomy has given the best results, that is to say anastomosis of the third part of the duodenum proximal to the obstruction to the first coil of the jejunum.
References.
British Journal of Surgery, October 1921. British Medical Journal, December 23rd, 1922.