Chronic Obstruction of the Small Intestine

Abstract

THE literature is filled with accurate and, we may say, classical descriptions of the X-ray findings in duodenal ulcer and its differential diagnosis. Less accurate, and certainly less in agreement are the findings and their interpretation in conditions involving the second and third portions of the duodenum and the remainder of the small bowel. A great deal of controversy has arisen as to the conditions called chronic duodenal ileus and chronic ileal stasis—stagnation of opaque material in the duodenum and in the terminal portion of the ileum. There is such a large personal factor obviously present in the interpretations that one is almost bewildered by the divergent opinions voiced. There is a clear field of agreement and obvious sound sense in interpreting the findings of the opaque meal study in cases of congenital or neoplastic obstruction of the duodenum or remaining small bowel,—indeed, with any kind of obstruction where there is evident blocking of the lumen of the bowel, with accumulation of opaque mass above the stricture in what is evidently dilated lumen, and lack of opaque mass, or at least scarcity of it, below the stenosis. The difficulties arise in those borderline conditions verging on purely functional disturbances, for such may be called many cases of stasis in the duodenum or terminal ileum. Illustrating some of the statements just recorded may be cited a recent paper by Wheelon (1) in which we find the statement that duodenal retention and reverse motility—passage of barium toward the pylorus—were observed radiologically in seventy-four of a series of seventy-seven patients who came to surgery for the correction of pathologic changes within the abdomen. If the author's observations are correct, it is evident that reversal of motility in the duodenum is by no means an unusual finding. One would certainly be tempted to draw the conclusion that no very great reliance could be placed upon duodenal antiperistalsis as an indicator of serious duodenal or upper jejunal pathology. On the other hand, Schwarz (2), of Vienna, declares that retrograde transport of duodenal contents is seen only in true stasis, and in its most characteristic form in deep duodenal stenosis. Schwarz especially calls attention to the type of broad contraction ring which sweeps before it a considerable mass of duodenal content, and then returns it in the retrograde direction in a manner analogous to the to-and-fro movement of opaque material in the esophagus above a stricture. Normal Duodenal Motor Behavior The writer (3) in 1915, before the American Roentgen Ray Society, described the motor behavior of the duodenum in the following words: “At irregular intervals, depending upon the mechanism which controls the opening of the pylorus, the duodenal bulb contracts, the contraction appearing about two centimeters beyond the pylorus. This contraction is occasionally seen to begin at the pylorus itself.