Read 2.6%20THE%20CAUSE%20AND%20PREVENTION%20OF%20POST-OPERATIVE%20ABDOMINAL%20DISTENTION.%20R.C.%20Begg.pdf text version


23, 1943.]





The Cause and Prevention of PostOperative Abdominal Distension.

By R. CAMPBELL BEGG, M.D., F.R.C.S. (Ed.), Specialist in Urology, Johannesburg.

,TT is a .repro~ch to surgery that some degree of meteorism ~ and dIstenSIon should still be considered a normal sequel to abdominal operations, and to other types of procedure such as ~ephrectomy, prostatectomy, etc., in which the peritoneum IS handled. Apart from the pain and discomfort caused. to t~e ro~ust patient delaying his convalescence, postoperatIve dlstenslO!1 and t~e exhaustlDg procedures sometimes used to overcome It may tIp the scale in a weak patient and lead to a fatal result. . After every o~eration. affecting the peritoneum, abeyance The period is longer of IDtestlnal per~stalsls IS the rule. 0.1 ~horter to the nature of the operation, the prehmlDary preparatIon, the kind of anresthetic used and the ~ount administered. The time before peristalsis is resumed IS ~rom. 24. h01;1rs to 72 hours, r~rely longer. This lack of perIstalsIS m Itself causes no dIscomfort. The bowel lies ':lilent witho~t movement, but the tone of the walls is not IDterfered WIth and there is no distension. On the other hand, the introduction of ~he smallest quantity of fluid into th.e s~m~ch durmg the perIod when penstalsis is in abeyance WIll. IDe~Itably c~use a greater or less degree of distension, leadmg I.n some IDstances to paralytic ileus. T~e. dlr~t cause, .then, of post-operative meteorism is the admlDlstratlOn of flUId or food in any form before peristalsis is re-establis~ed as indicated ~y the passage of ±latus per rectum. It .IS a deplora~le thing that the giving of drinks after operatIOn and durmg the negative or non-peristaltic :phase IS still not only largely practised, but actually advocated ID many current textbo~k~. It is indeed amazing that this casual nexus between gIVlDO' of drmks and abdominal distension escaped recognition .for so long. I must adml.t that untIl. SIX years ago it was my practice to en~ourage. patIents, espeCIally prostate and kidney cases, to drmk copIOusly as soon as they were able to do so. In these days there was always anxiety lest the meteorism which was present in some de.gree in all case~, should pro'gress to an unmanageable condlt~on of paralytIc ileus. In the year 1936 I heard Abel ID London expounding his views which wer~ supplementary to his very thoughtful article on the subject of acetylcholine, published in 1933 (Lancet 1933 vo!. ' , 2, p. 1287). Abel's view was as follows: 1. Peristalsis is brought about by the action of Auerbach's plexus in the intestinal wall. 2. The presen~e of acetylcholine (the ester of choline) is necessary ID the IDlestmal wall before peristalsis can occur. 3. By the ~onnation of histamine 01' in some other way, the a,:,allable supply of choline is diminished by' the followlDg: (a) Purgatives or enemas before operations. (b) The operation itself . (c) General ana?6thetics, especially chloroform and ether. 4. The gi,:ing of fluid by the mouth immediately following operatIOns and before sufficient choline has reaccumulat:ed to enable peristalsis to recommence causes gas pams and meteorism. 5. The ~dministration of acetylcholine will reinduce peristalSIS. For. the !ast six Jears I have followed the principles as enuncIated ID the first four clauses, with the result that the fifth ~as never had ~o be considered, because i have not seen the slightest s~ggestlOn of meteorism in any of the operated cases. One patient ~ho had bee!1 operated on for an aberrant yeesel of the left kIdney was madvertently allowed to suck ~ce and ~wallow the ~ater: from it. He developed paralytic ileus whICh lasted. m~e days. Two successive doses, each of 5 c.c., of prostlgmme, finally terminated the complication favourably. · I do not. feel convince~ that the choline theory covers the whole subJect,. or explams ~hy the administration of the smallest quantIty of water mto the stomach in the non-

peris~altic peri~d causes distension; but empirically and in p~actlce there IS no doubt, as any surgeon can find' out for ~lIDself. I hav.e .some proof that the non-peristaltic period is ~creased by .glVlDg enemas before operation, and it is high

tlIDe that thIS. outmoded custom was completely abandoned except per.haps m cases where the colo~ itself is to be operated 00.. It gIves more .wo~k to ~he nursmg staff, is exhausting not only to th~ patIent s cholme, but to the patient himself, a~d: does no~hlDg but harm. It is probable also that the gIvmg. of saline enemas or a Murphy's rectal drip after the operation also retards the return of peristalsis though on this matter .I call. supply no tangible proof. Both procedures c~lUse dIscomfort and manipulatlOu of the patieut at ~he very tJ?l~ he should. have. the m~ximum rest and quiet. The glvmg ~f pu!gatlves IS, I think, already sufficiently universally dIscredIted. ~other shibboleth that must be discarded is the idea that unnary cas~ should have large quautities of fluid admiuistereed post-operatIvely to eucourage reual secretion. My experience has b~en t!Jat ~hile. this method encourages aud causes abdommal dIstenSIOn, I~ tends for that very reason to hinder adequate renal functIou and may eveu iuduce urremic symptoms. Again, as it is well kuown that merely lying in bed tends to slo~ up the actiou of the bowels, it is desirable that postoperatIve decubitus should be reduced to a minimum. Unless for some special reason the coutrary is indicated, the patient sho~ld be confined to bed before his operatiou only for the penod necessary for the actual skin preparatiou. He should where possible, be admitted to the hosllital ouly the day before the operation itself. Where prelIIDinary preparation is necessary, as in prostate cases, the patient should as far as .mechauically possible, be ambulant during the' waiting perIod. The management of eases may be uaturally divided into the three periodE, namely pre-operative, operative, and postoperative. The conduct of each of these stages influences the questiou of post-operative abdominal disteusion. That of the. first two determines the length of the uon-peristaltic perIOd, that of the last the occurrence or abseuce of distension.

Pre-operative : 1. The patient should carry out his normal activities as far as possible right up to the time of the operation. 2. He should be enco:uraged to drink large quantities of water before the operation to fortify him for the dry period after. it. 3. If the patient's bowels move regularly, no laxative or enem.a sh?uld be given, and. in any c;:ase no enema should be gIven m the 24-hours perIod precedmg operation. Operative: 1. The best types of auresthetic from tlfe point of view of the preservation of choline and consequent favourable postoperative course are in order of merit, probably: local aud regional bl?ck, intraveneous and spinal, gas an.d oxygen, ethyl chlonde, ether and chloroform. For op~ratIon.s which are likely to be prolouged, general anre~thetlcs should be avoided as far' as p05siblA. Gentle haudhng of viscera aud the minimum use of retractors are presupposed. Post-operative : Nothing whatever should be giveu by the mouth or per rectum. Thirst may be partly .assuaged by permitting the patient to wash his mouth out WIth wa~r. Ice. should never be given to suck. The amount of. t~st vanes; that the patient may be fortified to .put u:p WIth It, he should be told that by not drinking he will aV?Id ~e much greater discom_ fort and danger of abdomina~ dlst.enSIon. In minor cases, where per~stalsls may be expected within the first twenty-fonr hours, It may be no great hardship to withhold fluids altogether, but as a ge~eraf rule prOVIsion must be made for giving the necessary liqUld by the intra. venous route. Formerly this procedure. also preseut~d diffic~ties, as severe reactions foIlowe~ mtravenous ~es, uutil. it was discovered that the reactIOns could be ~volded by usmg onl .triple-distilled water. It was the difficulty of PIOCurin.: solutions made of triple-distilled wa~r that led me, in cooperation with a firm of. local cheIDlsts, to arrange for the import aud trial of vacoliters. These have proved of great





2J 1943.


u e and have overcome the nuisance o[ air-block in the regular delivery of the drop_ As soon as the patient returns to bed a shouldered needle of the Hamilton Bailey type hould 'be inserted into the saphenous vein in the neighbo~r hood of the internal malleolu _ By this means normal sahne with 5 per cent. dextrose is administered at the rate of ab~ut 40 drops a minute. The usual sharp needl~ ~s supphed wIth the vacoliter should not be used. AdmmIstratton of the fluid by the arm is uncomfortable for the patient and. intereres with nursing. With the shouldered needle, p.lIlt:ng IS. as a rule unnecessary though long sandbags may be used a leg su'pports. A hot-water bottle or electric~lly heated pad should be applied along t~e cou.rse of the vem, but not until the effect of the anresthetlc, spmal or general, has worn off, as there is danger of a b~rn. The initial thirst usually wears off after the first vacohter or two. The u e of this method of admini tering fluid post-operatively neyer causes waterlogg~ng or pulmonary rede~a. When the patient ceases to be thirsty, the rate of drip may be slowed down and after the first 24 hours only 5 per cent. dextrose ho~ld be given. In male patients the first danger ign is redema of the scrotum. This rarely appears, but .when it does the rate of drip should be markedly decreased. As a rule, indeed, the drip may be di continued, as the body will contain enough fluid to keep the patient comfortable until peristal is is resumed. If the veins show mal'ked inflammation on the second day, another vein should be u ed if it is considered necessary to continue giving fluid. The first sign of returning peristalsi~ will be ~ int.estinal rumbling in the upper abdomen of whIch the patten.t IS co.ncious which can be detected by a stethoscope or Without It. Within a few hours flatus is expelled per rectum. Two ounces of water (not iced) is then given by mouth every half-hour for two hours, and if no discomfort foll~ws any quantity of water or tea may be drunk and the patIent can go at once on to a light diet, fo~low.ed he. JClext day by a full diet, if there is no contraindicatIOn as lD the case of operations involving the alimentary tract direct. After open prostate or bladder operations, flatus is usually pa sed in 24 hours or 36 hours. In renal case one may have to wait 72 hours or longer. I have never seen t~e return of peri talsis delayed beyond 84 hour~. The penod after various procedures vanes, but I have no definite data on this question. The intraperitoneal ca es I haye done, never of course with actual opening of the bowel except in transplantation of the ureters, showed a return of peristal is at an earlier period than. the ~idney: It is striking how the strength of the pattents IS mamtamed when they do not have to recover from abdominal distension as well as from the operation. It is quite common for nephrectomy patients to be up on the fifth day and be fully active on the tenth day. One ob tac1e ha till toO be urmounted in the chemical inflammation of the vein caused by the prolonged introduction of dextrose. This inflammation invariably occurs in some degree by the second or third day. It cau be partly prevented by never letting the rate of the drip exceed forty drops per minute and by the application of continuous heat lllong the line of the vein. The technique of removing the needle i important. If it is simply pulled out and a dry dres ina applied, there is likely t-o be sub equent trouble. There is always a column of gIuc05e solution in the vein. The latter on withdrawal of the needle should be milked fr()llD ahove down until bright 'Pure blood appeal's, and fomentations should be applied however clean the external wound appears. With this precaution the inflammation in the vein completely subsides in a day or two. The extra cost of this post-operative treatment may amount to a few pounds, which is more than. compensated [or by the shortened stay in the nursing home or ho pilal. No attention need as a rule be paid to the bowels. It is common for a .natural motion to occur on the fifth or ixth day. If not, a. mild laxative piU on the even in of the sixth or seventh day i adequate.


the peritoneum from within or .\\:ithout and certain other operations in which large quantities of' 'histamine are produced in the tissues. 2. The non·peristaltic period last from a few hours to three and a half days. It is lengthened b,r variou facto~'s, among which are prolonged decubItus pnor to operatIon, pre· operative purgati\'es or enemas, prolonged gene:al anre .thesla especially with chloroform or ether, rough handlmg of tI sues, and undue use of retractors during operation. 3. Distension may be completely avoided. by ~he ,,".ithholding of all fluid or food durmg the non-penstaltIc perIOd, the termination of which is indicated by the pa sa e of flatus per rectum. . '" ., . 4. Durina the non-pen ta.tlc pen.Jd the patient s metaboltc requirements can be adequately met by the .administration of water, odium chlonde and dextro e by the mtra'-enou route.


An X-Ray dtlas 0/ ilicosis. By Artllur J. Amor, M.D. (Lond.), .l1.Sc. (Walest. Pp. xii and 206; 72 plates. Bristol: John Wrigkt and 0118 Ltd. Price 30s. net.

The major part of this work is made up of a series of excellent pla~es illl!strating silicosis in all its aspect. and !t differential diagnOSIs. The plates show antero-postenor radIOgram of the che t printed as negatives, and a few phot-ographs o[ specimens and radiograms of speci~en .. The X-ray illust~a. tion are very fine; the ouly pOSSible Improvement, which publishers have not yet achieved, is to publish them as tra?s. parencies. A series illustrates the normal and non-specific changes. another specific changes. The first series includes Types 1, 2, 3, 4 o[ the South African Miners' Phthisis Bureau classifications, and the second Types 5, 6, 7 and 8. A further series shows stages of coalescence of the silicotic mottling, the author grading the ca es as first, second, and third stage according to whether the mottling is discreet or of varying degrees o[ coa~e cenc,:. Next there.. ~s a ~eries iflu, sUico-tuberculo I , eqUivalent t-o the mfectlve senes , With it fonr types of the Miners' Phthisis Bureau. There are·then seen three film of what the author terms "acnte silicosis". The following series shows typical film. of silicosi~ as it occur in variou indu tries; the author conSIders that different types of reaction in the lungs can be observed according to the type of dust in the industry. Films of cases for the hrematite ore indu try, tin-mining, slate-quarrying, pott~ry,. refactory brick manufacture _andstone indu try, sand.blastlDg and metalgrinding and coal-mining industrie are illu trated, and it is true that there appears t-o be certain general differences from the cla ical picture of the quartz-miner best kuown in outh Africa; but the differences are ill·defined, and there is much overlapping, so that indi.vidual. ca es of any typ.e might. be found in any of the mdustrles. A short serIes showmg complications other than tuberculosis is followed by a final ection dealin~ with differential diagno i fr~m mili~ry tube:· culo is (chromc and acute), acute tuberculo IS, carcmomato IS of the lung, and other pneumonokonioses such as a bestosis. The author does not lay such stres on the infective element as doe the Miner' Phthisis Bureau, and in noting this himself, he apparently prefers the classification used by utherland and Bryson (H.M. tationery Office, 1930). It does not seem to be appreciated how large is the material on which the Miners' Phthisis Bureau has based it conclo ions. The author does not mention the number o[ cases which he has used to study-in one place he mentions fifty; in contrast, there are a tually 1,000 po t·mortem radiological correlations made b:the Mmers' Phthi is Bureau in ten year, and the number of X-ray examinations annually has avera ed round fifteen thou and. If it i true that the radiolo ical appearance varies in tI e ilicosis of different trades, the uth Afri an experience gives a one· ided outlook on the problem; but it would need an inve tigation greater than appears to have been made by the author to e tabli h thi , and one at lea t on tHe scale of the uth African. . K. M.

L Po t-operative abdominal distension and paralytic ileu are cau ed by gi\-ing food or fluid by mouth during the non-peri taltic period which follows all operation affectin


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