Treatment.
—Spontaneous cure of an intussusception by a sloughing process has been mentioned above. Cure may also occur by spontaneous reduction. It would seem possible also only in recent cases and in the enteric forms. Cure may also occur by formation of a fecal fistula, although this is most rare.
3. Volvulus.
—The term “volvulus” implies some form of twisting or of revolution of a part of the bowel upon itself or its mesenteric axis, the result being knotting or intertwining of intestinal coils to an extent causing their partial and finally complete obstruction. A common site for volvulus is the sigmoid flexure. Still no part of the intestine which hangs loosely is exempt.
The most common causes of volvulus are chronic constipation and fecal impaction, with distention and ptosis. Intestine thus displaced and overloaded becomes more or less paralyzed, its circulation more or less impeded, and any twist which has once occurred is not likely to right itself. The twisted loop having been engorged becomes distended with gases, and thus tends to increase the difficulty. In these cases the bowel loop is closed at both ends. Unless relief be afforded by operation it is a question merely of how soon the loop will become gangrenous from aggravation of every one of the features above recounted. Bowel thus involved permits easy passage of bacteria, and thus to the other features are rapidly added a septic peritonitis. The resulting abdominal distention may appear early and will become more prominent.
4. Ileus from Fecal Impaction.
—A condition of extreme coprostasis, or fecal impaction, to a degree producing actual obstruction, may occur without necessary volvulus or twisting of any portion of the bowel. As fecal impaction increases the overloaded bowel becomes more and more paralyzed until there may occur final and complete arrest of peristalsis, with gradual development of symptoms of obstruction. The longer the condition persists the less the prospect of restoration of peristaltic movement. Moreover the condition may be complicated by the development of ulcers above the obstructed segment, known as stercoral ulcers, due partly to gangrene from pressure and partly to the chemical effects of long-retained decomposing material. They may appear as sloughs of the mucous membrane and finally lead to perforation.
This form of ileus is more common in the large than in the small intestine, and especially so in the cecum. Here there is little chance of retrograde movement, while fecal matter coming down from above will continue to pack the colon, and thus the cecum may have to bear the brunt of great pressure. The amount of fecal matter which may be thus collected is sometimes astonishing, for the bowel may dilate to the diameter of six or even ten inches, and contain many pounds of impacted feces. Such masses of collected feces can usually be palpated through the abdominal wall, and will at least indicate the location of the principal disturbance, if not its actual character.
5. Strictures.
—The most common causes of cicatricial stenosis in large or small intestine are the results of cicatricial contraction following recovery from local ulceration or repair of injury, as, for instance, after reduction of a strangulated hernia. The exact character of the ulcer does not matter. Any lesion which may granulate and heal will also contract, and the extent of the stricture will be proportionate to the area first involved. Should this extend well around the mucous membrane there may be a distinct annular stricture. Stricture may also result from infiltration and thickening in connection with a more active diseased process, and such a condition may be multiple. This is particularly true in cancerous involvement of the bowel.