Acute Angulation of the Terminal Ileum as a Cause of Intestinal Obstruction in Certain Cases of Acute Appendicitis
Boston Medical and Surgical Journal
No more frequent and fatal complication of acute appendicitis exists than that comprising the various types of postoperative intestinal stasis. These may be assigned roughly to two main groups : First, those due to failure of peristalsis, resulting in intestinal paresis, distention, and stasis of the fecal current ; and second, those due to mechanical obstruction resulting usually from kinks, twists, adhesions or bands. The most familiar examples of the first group are the cases of paralysis
... ses of paralysis associated with peritonitis, causing a toxemia acting either after absorption or locally on the neuromuscular mechanism of the intestine; the paralysis due to trauma, seen in the course of long abdominal operations involving manipulation and exposure; and that due to mesenteric thrombosis. Many of these cases are relieved spontaneously or by appropriate non-operative measures, but not a few require interference by enterostomy, as an emergency measure to provide drainage until peristalsis may be restored, and no more anxious and difficult decision confronts the surgeon than when to interfere. The cases of mechanical obstruction forming the second group are sharply marked etiologically, but if they occur early they are unfortunately difficult to separate from the paralytic cases. This does not refer to the late secondary cases of ileus occurring weeks, months or years after the operation. Inasmuch as mechanical obstruction, once established, is rarely relieved except by operation, and since the mortality of such secondary interference, high enough anyway, is vastly increased by delay, it becomes imperative to make the diagnosis and proceed to the relief of these cases at the earliest possible moment. Since in appendicitis the area immediately adjacent represents the usual region of peritonitis with resulting possibilities of adhesions, it is natural that the terminal ileum should be the most frequent seat of mechanical obstruction due to this cause. This is recognized by most surgeons and is mentioned by many writers on the subject of the post-operative sequelae of appendicitis. There is a small subdivision of this group of cases which seems to the writer to present a fairly clean-cut clinical picture, and therefore to offer possibilities of early diagnosis and successful interference justifying its brief presentation. Three cases called attention to this condition :-Case 1. Esther C, 7 years of age, entered the City Hospital December 8, 1906, with a story of abdominal pain and vomiting for two days. She presented the clinical picture of a spreading peritonitis of the lower abdomen and pelvis, probably due to appendicitis. Incision behind the right rectus showed free pus in the right iliac and hypogastric regions, and pelvis. The appendix was found acutely inflamed, hanging over the pelvic brim, and adherent to the lateral wall of the pelvis ; the tip of the appendix was perforated and reached to the pelvic floor. The appendix was removed, the pus was wiped away and cigarette drains were carried to the right iliac fossa and pelvis. The case progressed favorably for three days, but on the fourth day distention, constipation and vomiting began. Readjustment of the wicks failing to relieve, the wound was explored hastily and fruitlessly owing to the patient's condition, and an ileostomy was made through a small incision in the left linea semilunaris. This artificial anus tided over the crisis and, on January 1, 1907, a loop of terminal ileum adherent in the pelvis and containing in its proximal portion the artificial opening, was excised and the bowel repaired by end-to-end anastomosis. The patient made a satisfactory recovery. Case 2. Hugh McC, 24 years of age, entered March 6, 1907, with a history of abdominal symptoms for three weeks, becoming acute during the last two days. The abdomen was tender, dull to percussion and spastic in the right iliac and hypogastric regions. Incision showed free turbid fluid and a gangrenous appendix lying in the pelvis. It was removed and the infected area drained. The patient showed marked toxemia but rallied and did well for three days, when vomiting and distention appeared with failure to procure relief by enemata. Time was wasted by these measures and a final ileostomy did not avert a fatal result. Examination through the wound showed the terminal ileum adherent and sharply angulated in the pelvis. Case 3. Edith D., 18 years, single, entered June 30, 1911, with a history of acute abdominal symptoms for four days. The whole lower abdomen was spastic and tender, especially on the right where a mass was palpable. On opening the abdomen through the right rectus a free turbid exúdate was found with an incompletely walled-off abscess occupying the right half of the pelvis and right iliac fossa. The appendix was seminecrotic, perforated, and adherent to the wall of the pelvis and its tip to the pelvic floor. It was removed and the infected area drained in the usual way. Although very ill, the patient began a rapid convalescence with soft abdomen, good bowel movements and diminishing pulse rate. On the sixth day, elevation of the pulse and temperature with other symptoms suggested a residual abscess whose presence was not confirmed by digital examination. Distension began to appear but enemata gave some results. Time was wasted in the adjustment and withdrawal of drains and by palliative measures. On the eighth day vomiting began and the abdomen was reopened. Precious moments were lost in exploring and controlling the distended bowel which threatened fatal evisceration. The condition as to appendicitis was satisfactory, but the terminal ilium was found adherent along the tract formerly occupied by the appendix, and acutely angulated at the floor of the pelvis. The adhesions were separated, the ileum freed and additional drainage of the bowel established by a tube in the proximal limb. The patient left the table exhausted and died in twelve hours. The first misfortune was the failure to establish the diagnosis of obstruction earlier, the second was the choice of an exploration rather than ileostomy to relieve it.