(ILEUS)
This is due to a sudden or gradual closure of the intestinal canal
at any point. Closure of the gut may be caused by strangulation,
intussusception, twists and knots, abnormal contents, strictures,
tumors, kinks, spastic states, adhesions, etc.
=Strangulation.=—This is the most frequent cause of acute obstruction
of the bowels. There may be stricture of the bowels due to inflammatory
processes producing bands or adhesions, or due to the adhesion of a
bowel to an abdominal wound; a vitelline remnant, as a blood vessel,
may remain and act as a strangulating cord, or in Meckel’s diverticulum
one end may be attached to a mesentery or abdominal wall and thus form
a ring through which the gut may pass and become strangulated.
Strangulation may take place through the foramen of Winslow or the
foramen ovale, or between the pedicle of a tumor and the abdominal wall.
Peritoneal pouches, mesenteric and omental slits, adherent appendix
or Fallopian tubes and diaphragmatic hernia may be other causes.
An internal strangulation (hernia) may take place in the crural or
inguinal canal, in the umbilicus, in the sacro-sciatic notch or in the
opening through which the infra-pubic vessels pass. In strangulation
there is a constriction of a portion of the bowel causing an arrest of
the circulation of blood at that point, and more or less stoppage of
fecal matter of the intestine.
In ninety per cent of cases the strangulated part is in the lower
abdomen and sixty-seven per cent occur in the right iliac fossa,
according to Fitz.
=Intussusception or Invagination.=—Intussusception is a slipping of a
part of the intestine into another part immediately below it, as the
slipping of a part of a finger of a glove or a coat sleeve into another
part. The portion involved may be anywhere from half an inch to a
foot or more in length. This produces compression and inflammation of
the intestine, and obstruction to the intestinal contents. It occurs
principally in children and is more common in males.
Spasms of the intestinal muscles and perverted peristalsis are probably
the most common causes. One part of the bowel may be dilated and an
adjacent portion contracted, thus allowing an invagination. Diarrhea,
habitual constipation and intestinal polypi are important exciting
causes. Invaginations oftentimes occur just before death, probably due
to irregular peristalsis.
Following engorgement and inflammation of the invaginated portion,
a tumor is usually present, and lymph is exuded which may cause the
layers of gut to adhere, so that the invaginated portion is firmly
held. Necrosis and sloughing are then likely to take place.
Intussusception varies according to location and is named according
to the part of the bowel involved. There are commonly recognized (1)
Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric,
of the small intestines. (3) Colic, of the large intestine. (4)
Colico-rectal, of the colon and rectum. (5) Rectal, of the rectum.
=Twists= and =Knots=.—These occur more frequently in males, usually
between the ages of thirty and forty. In nearly all cases the twist is
axial, accompanied by relaxed and lengthened mesentery. One portion of
the bowel may be twisted about another, or a loop of bowel twisted upon
its long axis. A bowel being impacted or overdistended by feces and
gas, is quite likely to roll on its axis or knot and become dislocated,
its weight and inactivity thus producing compression and obstruction
of the bowels. The volvulus commonly occurs in the large intestine,
at the sigmoid flexure and in the ileo-cecal and cecal regions. It
occasionally occurs in the small intestine.
=Abnormal Contents.=—Obstructions may be caused by gall-stones,
enteroliths, lumbricoid worms, certain medicines (such as magnesia
and bismuth), fruit stones, coins, needles, pins, buttons, etc., and
fecal matter. Foreign bodies usually lodge in the ileo-cecal region
and in the small intestine, while fecal impactions occur in the large
intestine, more frequently in the lower part. Females are more subject
to it than males.
Its causes are many and are similar to those of constipation. Spinal
lesions are very frequent, probably causing paresis or paralysis of
a segment of the bowel; or all the forces that maintain a normal
activity of the intestines may become impaired. Hemmeter[81] says it is
“more frequently the result of defective innervation of the intestine.”
=Impactions= are frequently met with and are easily overlooked
under any diagnosis which does not include thorough palpation of
the abdominal viscera. The impaction may be so large as to produce
dilation of the bowel. The obstructive mass becomes very hard and dry
and perhaps channeled, allowing some material to pass until, finally
a large piece of fecal matter will obstruct the passage completely.
In =diagnosis= it must not be confused with neoplasms, tumors, etc.
Impactions may occur at any point of the colon and the weight so drags
the bowel out of position as to be misleading. The principal points
are the ileo-cecal region, sigmoid flexure, and rectum. Tenderness is
usually present, as may be diarrhea which must not be taken as evidence
that the bowel is clear. Impaction gives rise to many reflex symptoms
and is often the real cause of many mistaken conditions.
Too much cannot be said on the importance of a thorough examination of
colon and its connections, which should be routine of every examination
as the large bowel is impacted much more often than suspected and may
be the seat of many reflex and direct disturbances. The heart may be
affected by weight upon the vessels, gastric disturbances and signs of
auto-intoxication from absorption may appear.
Dilatation of the sigmoid flexure, especially when it is congenitally
long, may even be so great as to crowd up and interfere with the liver
and diaphragm; in these cases the coats of the intestines are usually
hypertrophied.
=Strictures and Tumors.=—These usually occur in adults, more frequently
in women and generally involve the large intestine and lower part of
the abdomen, most of them occurring in the left iliac fossa. They
frequently result in chronic obstruction. Occasionally, a stricture may
be spastic, due to vertebral lesions, that is severe enough to cause
complete blockage of intestinal contents. These are usually of the
pelvic colon. There are cases where the opposite condition, paralysis
of a section, generally of the small intestine, occurs. This may be
due to injuries to the bowel, or to damage of the blood supply, or to
derangement of the innervation.
Scar tissue, following ulceration of the bowel; tumors of various
kinds; and congenital defects, are possible sources of intestinal
obstruction.
=Symptoms.=—=Acute Obstruction.=—There is constipation, nausea,
vomiting, and pain. The pain is of a colicky nature and may come on
abruptly. After the contents of the stomach have been vomited, the
material becomes colored with bile, and finally stercoraceous vomiting
occurs. Observing the contents vomited (gastric, bile-stained, and
fecal) will greatly aid in the diagnosis. The contents of the bowel,
below the obstruction, may be emptied or complete constipation may
remain. All the symptoms, as a rule, rapidly grow more pronounced. The
pain is more severe; tenderness occurs over the abdomen in limited
areas; there is slight tympany; the eyes are sunken; the skin is cold
and clammy; the pulse is quickened and feeble; there is rapid increase
of leucocytes; the urine highly colored; the tongue is dry and there
is incessant thirst; tenesmus and tumor may be marked, and fever
occasionally occurs. The above condition may continue from three days
to a week, when collapse and death may occur, if relief is not obtained.
=Chronic Obstruction.=—In fecal impactions constipation of long
standing is commonly observed. In some cases the fecal mass has
become channeled, allowing the bowels to remain open; the patient
possibly not knowing that there is any trouble. In fact, diarrhea may
be present, due to irritation above the impaction. Finally, however,
obstruction occurs; the breath is offensive, the appetite is poor, the
abdomen swells, and there is fullness and weight within the abdomen,
accompanied by pain and vomiting. Upon examination before complete
closure, the fecal impactions can easily be felt through the abdomen
externally. The tumor is a yielding mass. It has been mistaken for an
enlarged liver or gall-bladder, a kidney, or a tumor of the stomach
or duodenum. Other symptoms may be present as hiccough, jaundice,
tenesmus, tumultuous peristalsis, local peristalsis, local peritonitis
and collapse. In stricture caused by cicatrices that may have been
formed years before, complete obstruction takes place. Transient
attacks often occur. Usually the general health is greatly impaired
long before complete occlusion.
=Diagnosis.=—A diagnosis can usually be made by careful, thorough
examination through the abdominal wall, in connection with the
symptoms, and the physical signs. The region of intestinal trouble
is manifested by contracted muscles at certain points along the
spinal column, corresponding with the particular portion of the bowel
involved, as indicated under intestinal colic. Examining the patient in
the knee-chest position will often give a better opportunity to locate
and outline the obstruction. Rectal and vaginal examinations should not
be neglected. Intestinal obstruction may be confounded with tumors,
hernia, intestinal colic, enteritis, peritonitis, hepatic colic and
renal colic. =Peritonitis= may be differentiated by the history,
the early fever, diffused tenderness and absence of fecal vomiting.
When =invagination= occurs, besides the symptoms of obstruction, the
age, tenesmus, bloody discharges and the sausage-shaped tumor in the
line of the colon, will be diagnostic. In =stricture=, the history,
gradual onset, and ribbon-like and bloody stools will distinguish that
disorder. In =tumors= the gradual onset, age, bloody discharges, and
cachexia will be important symptoms. X-ray diagnosis may be of value in
certain cases.
=Treatment.=—Treatment of the bowels directly is required, and each
case must depend for its relief upon the ingenuity of the osteopath.
Rules to be followed cannot be given, as cases vary in manner of
involvement and in location, consequently the correction of the
disorder depends as much upon the ability of the osteopath as does the
determination of the diagnosis. Taxis is the method commonly used in
relieving intestinal obstructions, though other methods may be employed.
In =invagination=, raising the buttocks and lowering the chest, with
thorough injection of oil or tepid soapsuds, or an inflation of the
colon with air, may give relief. In addition to thorough but cautious
manipulation of the bowels as in =impaction=, irrigation of the lower
bowel with warm water, soapsuds, or glycerine and water, will usually
be of material aid. In =strangulation=, high injections of warm water,
and assuming the knee-elbow or lateral position, may straighten out
the acute obstruction. =Twists= and =knots= are best relieved by
direct treatment, although injections may be of aid. =Kinks= of the
pelvic colon, ileum, and duodenum are best treated with the patient
in the knee-chest position. =Tumors= and =strictures= will require,
sooner or later, surgical interference in most cases, but to treat as
in impaction will be effective for a short time at least. If there
is no indication of immediate =relief within three days, surgical
interference should be instituted=. Besides the ordinary treatment for
the nausea and vomiting, washing out the stomach will help allay such
disorder, quiet the peristalsis and relieve the abdominal distention
and pressure above the seat of obstruction. Strong thorough treatment
of the spinal nerves to the stomach and intestines will be of great
help in lessening pain, establishing normal peristaltic action and in
suppressing inflammation. The vagi also should be treated for perverted
peristalsis. Hot fomentations will be of service. The nutrition of the
patient is best retained by rectal injections of food.
=Spastic= states, particularly of the pelvic colon, frequently cause
constipation of various degrees of chronicity. Reaching beneath the
spastic area and inhibiting and raising (knee-chest position) the parts
will often give marked relief.
=Adhesions= can often be stretched sufficiently to restore normal
function of the bowels.
Treatment of =impactions= and =abnormal contents= requires an
additional word. The first step is to free the colon of the fecal mass.
The enema is of great assistance in this, for cases of long standing
present a hard, dry mass, often adherent, and the mucous membrane is
sensitive from inflammation. Much abdominal treatment must not be given
until the mass is softened by water. When in the sigmoid or rectum it
may, if not dislodged by repeated enemata, have to be removed by a
colon spoon, perhaps under anesthesia. Impaction of the small intestine
is rare and out of reach of the enema, although if taken as hot as
can be borne, it will exert considerable influence high up. In these
tendencies and in constipation, when the bowel must be kept open before
treatment has produced much effect, there should be an effort made to
break up any cathartic habit which may be formed. The enema is a most
valuable aid, but it must be given correctly. The patient should be
instructed that a fountain syringe is preferable, and that it must
never be taken standing. This merely fills and distends the rectum,
or lower sigmoid at the best, and is passed without any or with very
little effect. Lying on the right side is a very good position, as is
also on the back with hips elevated, but the knee and chest is best in
most cases. The water should be a little above body temperature and can
be saponified or used clear. The effect will be about the same. The
tube should be perfectly smooth and well lubricated and introduction
must be made with care so as not to bruise or irritate. The water,
having been allowed to run to expel the air, may be now started and
will separate the mucous folds and allow easy penetration. The rubber
tube should be held between the thumb and finger, so the flow can be
stopped as soon as it meets an obstruction. When this is passed the
flow can begin again and continue until the required amount (from one
to two quarts for an adult), has been taken, or until the feeling of
distention becomes too great. By following this method, much of the
distress and colicky pains which sometimes accompany an enema, may be
avoided. Water should be held for some minutes, to allow softening of
the fecal mass. In many impactions it is important to get the water
into the ascending colon. For that purpose nothing is better than a
Coles sigmoid irrigator. This is shaped somewhat like the letter S
and is about a foot long from tip to tip. Its introduction is not
difficult, but care must be used. Place the patient on the right side
and stand in front, having the bag suspended near. Introduce the tube
and with slow, gentle pressure let it follow the course of the bowel.
When the splenic flexure is reached, it will stop, but by letting a
little water flow, the bowel will distend and it will pass. When in the
full length, the end will be near the median line and in the transverse
colon. Now let the water flow slowly, stopping frequently, and with
one hand gently lift and work the abdomen. This will both soften the
contents and aid the water in reaching the farthest point. It is not
well to give more than a quart the first time, as there is apt to be
some prostration. The tube also has the mechanical effect of raising
and replacing the sigmoid, descending colon and splenic flexure. When
there is lack of tone to the bowel or when very little stimulus is
needed, a half pint of cold water taken in the morning, will often
act quickly. Appliances which force the water into the bowel when the
patient is sitting, are not recommended, as they tend to stretch the
muscular coat by pressure from lifting a column of water.
=Hernia.=—There are several methods of replacing a hernia. The first
endeavor, in every instance, must be to reduce it, whether it be
strangulated, incarcerated or simply protruded. One of the easiest and
commonest methods is to place the patient on his back, the buttocks
elevated, the legs flexed upon the thighs, the thighs flexed upon the
abdomen, and the limb on the affected side slightly rotated inward, so
that the columns of the ring about the hernia may be relaxed. After the
hernia is protruded a little more, so that its contents may be emptied
readily, a gentle pressure with the thumb and finger is made upon the
upper part of the tumor, when the rest will follow. A gurgling noise
is heard upon reduction. Cases that cannot be reduced and are causing
acute obstruction of the intestines, should be treated surgically.
Incomplete hernia, which does not show externally, may be present and
cause severe reflex symptoms. Considerable attention has been given to
this by some investigators. The patient is placed in the Trendelenburg
position and the bowel lifted out of the fossa. If any signs of
hernia are present a well fitting truss will often cause it to heal.
Exercises, in a few instances, will be beneficial.