Acute Post-Operative Dilatation of the Stomach

JAMES R. TORBERT
1909 Boston Medical and Surgical Journal  
In looking up the convalescence of the first 100 cases of Cesarían section at the Boston Lying-in Hospital, the writer came upon this final note on two of the early cases: Persisent vomiting; no result from treatment; patient gradually failed; death at the end of thirty-six hours; no autopsy. The following experience which befell me on a case of Cesarían section may fall in the same class and I believe the results in my case are of sufficient interest to report, at the same time giving a brief
more » ... ime giving a brief review of the literature upon this interesting subject. The patient was a primipara, age nineteen, with a generally contracted pelvis ; the fetal head was resting upon the symphysis pubis, and under an anesthetic could not be brought into the pelvis. The operation was the regular one done by most of the operators at the hospital, the uterus being delivered through the abdominal incision, the abdominal contents protected anterior incision of the uterine wall, the operation completed taking about thirty minutes. She made a good ether recovery, her pulse coming down to 100 at the end of twenty-four hours; the bowels were moved by enemata on the second day, and the convalescence seemed to be progressing satisfactorily. About 4 a.m., on the third day, she was reported by the nurse to be having a great deal of abdominal pain, to be vomiting large amounts of brownish-green fluid, to have a pulse of 160, of poor quality. Seen a short time after this, she was the picture of extreme shock, the pulse could not be obtained at the wrist at all, her extremities were cold, the faciès were those of impending death, and altogether the picture was bad. We at once considered the possibility of sepsis, hemorrhage and a possible breaking open of the wound. The dressing was taken down and the wound looked satisfactory, but the appearance of the abdomen at once attracted attention; there was a tremendous amount of distention of the upper abdomen, the lower segment being soft. Closer inspection showed a balloon-shaped tumor extending from the ensiform down to the fundus of the uterus just below the umbilicus. When she vomited, this tumor was much accentuated, and on percussion proved to correspond to the stomach. She had been in this condition now about three hours and was not improving, so a stomach tube was introduced well into the stomach, and the effect was immediate, and enormous amount of gas and about a quart of the same dirty fluid came up. The stomach was then washed out with two gallons of luke-warm water, she was given morphia, i gr., and placed upon her side; in twenty minutes she was asleep. The most striking feature was the immense physical relief to the patient and the immediate retraction of the stomach. Por the next twenty-four hours all food was stopped by mouth; she received continuous salt solution by rectum and enough morphia to keep her quiet. By enemata, the bowels were relieved of quantities of gas. There was no further vomiting and the pulse gradually came down to normal. The case was apparently one of acute post-operative dilatation of the stomach quickly relieved by the passage of the stomach tube, the treatment at the same time establishing the diagnosis. Since reporting this case at the Obstetrical Society, two others have been brought to my attention, and as both illustrate important points in the condition, and absolutely confirm the existence of this condition, they will be briefly reported in this paper. The second case was one which occurred during an abdominal operation by Dr. W. P. Graves, and I take this opportunity of acknowledging his kindness in giving me the data to use. His patient was a woman aged forty-three. The operation was done Feb. 2, 1909. It was a supravaginal hysterectomy for multiple fibroids and pelvic inflammatory disease. There was no previous history of digestive disturbances. On making the abdominal incision, the lower border of the stomach was noticed to be at the level of the umbilicus. During the operation the patient did not take ether well in the Trendelenburg position, and strained and coughed at different times. The intestines interfered somewhat with the operation, and the gauze packing was changed two or three times to keep the bowels out of the field of operation. At each change the stomach appeared lower in the abdominal cavity. After the operation for hysterectomy was finished, the gauze packing was removed from the abdomen and the appendix was amputated. By this time it was found that the lower border of the stomach was within one inch of the symphysis pubis, and almost completely filled the abdominal cavity. Considerable difficulty was encountered in sewing up the peritoneum. When the wound was finished, the abdomen had the appearance of a full-term pregnancy, or of a large ovarian cyst. The stomach tube was passed, and with the expulsion of a large amount of gas, the tumor collapsed. No digestive disturbance followed the operation. This case showed perfectly the condition, the stomach was seen and felt, and the passage of the tube at once relieved the condition. The third case was a primípara who I saw first one week before she was delivered. She came to me with a history of constant gastric disturbances throughout the entire pregnancy. In fact, upon questioning, she admitted stomach disturbance of years' duration. Her bowels were straightened out and she was put on a course of treatment to relieve the stomach. One week later, on account of a deformed pelvis, a Cesarían section was performed. She was a very poor ether subject and vomited throughout the operation. The stomach was washed out on the table without much apparent relief to her condition. She had an excessively fat abdominal wall, so was sutured in layers. During the suture of the peritoneum, the stomach was found below the umbilicus and was constantly in the field of operation; the second passage of the tube made it a simple affair and the wound was closed without further difficulty. The interesting feature of this case was that she continued vomiting, and the stomach was continually dilating for three days, so that the stomach was washed on a four-hour interval for those three days. The lavage seeming to take care of the dilatation for about four hours, the fourth day after one lavage she stopped, and while she had still some discomfort, the stomach contracted to about two inches above the umbilicus, where it was on her discharge at the end of four Weeks. Brinton, in 1859, first called attention to the condition known as acute dilatation of the stomach, but it is only in the past few years that its existence as a post-operative complication has
doi:10.1056/nejm190908121610703 fatcat:7m7rfuhaybdqdmmn2ad7rs27be