Occasional Notes

TREATMENT OF PARALYTIC ILEUS

By S. R. MUKERJI, m.b. (Cal.), m.s. (Cal.)

Honorary Junior Visiting Surgeon, Medical College Hospitals, Calcutta

The treatment of paralytic ileus has presented and still presents extreme difficulties. The

surgeon has to cope successfully with the cause as well as treatment of the inactive bowel. The simultaneous treatment of these two has troubled the surgeons for ages. There are still differ- ences of opinion as regards the management of such cases (Mukerji, 1945, 1947a). A group of surgeons tries to activate the lazy bowel

by cathartics, drugs which will act on the musculature of the gut or its neuromuscular

junction or parasympathetic nerves and help the peristalsis to return. Those who support Robb's (1932) views of paralytic ileus have advocated spinal ansesthesia or splanchnic amesthesia if

possible. The other group of surgeons does not

rely on this conservative line of treatment and has advocated operative drainage of the dis- tended gut, viz enterostomy. In their opinion the distension of the gut when relieved will help in the return of the tone of the gut musculature. Prominent amongst the latter group are Krogius, Heidenhain, Melchior, Hofmeister and Kanusch. Unfortunately, the operative drainage of the distended coils of the paralysed gut has been successful in a few cases only. It has been found that the catheter drainage can relieve

only a segment of the distended coil. So Heidenhain and others, the strong supporters of this group, have recommended the employment of multiple enterostomies. But the very con-

ception as to the genesis of paralytic ileus leads one to conclude that such measures for relief of the gut can be rarely beneficial when the gut is atonic.

t The conservative school has employed hot

stupes to the abdomen, atropin, pituitary extract, pilocarpine, physostigmine, and choline, etc., in the treatment of the distension in the ileus. The principle underlying this therapy is to stimulate the gut and to help in the evacua- tion of the contents of the bowel. But when the gut musculature is paralysed and its efficient propulsive activity has been disorganized, such effects as expected in the conservative line can be rarely successful. Clinically also the results have been disappointing. If the drugs are administered before the gut has entered into the paralytic state and the circulation in the

splanchnic bed is active and normal, one would expect to see the beneficial results of the stimu- lant drugs. So the most valuable agent in the relief of the distension of the gut has been and

Oct., 1948] PARALYTIC ILEUS : MUKERJI 467

is still the suction applied to an indwelling gastric or duodenal tube or Miller-Abbot tube. The other principles of treatment in such

cases are common to both groups of surgeons, viz:

1. To maintain the fluid balance. 2. To keep the patient at rest both' physi-

cally and mentally. 1. Since the work of Coller and Maddock,

the normal quota of fluids necessary to main- tain fluid balance in man has been ascertained as 3.6 to 4 pints daily. But the trouble, here, lies in the fact that additional 6 to 7 litres of body fluids are being lost in the gut lumen by the digestive secretions and a quantity is also being lost as exudate or transudate in the gut wall, peritoneal cavity, etc. So the total quantity required in these cases will be?

Normal requirement -f- X pints where X pints = pints of fluid removed by suction, gastric or duodenal.

Atkins (1942) of Guy's Hospitals advises administration of 8 pints of fluid to such cases m 24 hours by intravenous drip method. In 8 pints of normal saline, there are nearly 75 gm. of salts. But the basic need is 1 to 2 gm. a

day. So a much heated and acrimonious con- troversy has started whether such a large amount of salts should be administered to the patients or not. The main objection is that hyperchlorsemia is likely to ensue this adminis- tration and it will cause hydrsemic plethora. So Atkins has advised that 8 pints of fluid should be as 4 pints of 5 per cent glucose and 4 pints of normal saline. On the other hand Jones and

Morgan advise to administer normal quota, i.e. 4 pints of fluid as (N) saline and the rest as 0.18 per cent sodium chloride solution per rectum. Proctoclysis has been found to start reverse

peristalsis, so much transfusion of huge amount of fluids per rectum is not advisable. The next trouble lies with the question of selecting a proper solution, i.e. proper electrolytes necessary in such cases. Scudder (1941) and his supporters advo- cate sodium chloride. Falconer et al. (1939) advise Ringer's solution. Ringer's solution contains K and Ca ions in addition to sodium chloride. K and Ca have been found to be of much value in ?maintaining the tone of muscles. But it has also been proved by the present author (Mukerji, 1944, 1946, 1947d) that K in high concentration in alkalotic blood damages the muscle. So Ringer's solution can be administered without any untoward results at the beginning of the disease, i.e. when the gut is in the paretic stage and blood K is not high. But in subsequent stages when K content is high administration of Ringer's solution is

unjustifiable. Recently Hartmann's solution and hypertonic

solutions as 25 per cent saline, etc., have been advocated as their administration helps in the return of peristalsis. Hartmann's solution is

nothing but lactate Ringer's solution. They have been found to act directly on the gut muscle. It has been written of hypertonic saline that' not only does it stimulate peristalsis, but it also replaces the chlorides of the depleted plasma and combats the alkalosis which is often present'. This shows that the present ideas in the administration of fluids and electrolytes are being based on the management of alkalosis in such cases.

Oschner and Gage (Maingot, 1936) have shown that hypertonic Ringer's solution stimulates

peristalsis more than does hypertonic saline and that hypertonic Hartmann's solution gives the best results of all. But the danger in using the hypertonic solutions lies in the subsequent lower- ing of blood pressure. This is also the main reason why spinal and splanchnic anajsthesia are fraught with danger. Serum transfusion has been advocated as a

routine line of treatment as paralytic ileus has been found to result from oedema of gut wall which is due to hypoproteinsemia (Leigh, 1942). But the author (Mukerji, 19476) has shown that hypoproteinsemia is a secondary phenomenon only. Moreover if the results of serum trans- fusion are studied from the following table, it will be evident that the results of treatment with serum infusion has not improved the outlook at all.

Cases of acute abdomen (as studied in Medical College Hospital, Calcutta)

Total number of cases

admitted

Number of deaths

Percentage of deaths

Before serum treatment came into vogue

1934

1935

1936

1937

193S

1939

1940

1941

1942

1943

1944

1945

383

334

334

379

471

384

374

369

152

121

139

127

152

132

132

137

Scrum transfusion started

206

165

189

218

74

72

82

101

39.8

37.5

38.0

37.0

32.0

35.0

35.0

35.0

36.0

44.0

43.0

46.0

1946 | Figures are distorted due' to riot-cases of

1947 f diverse and so are not given-

468 THE INDIAN MEDICAL GAZETTE (Oct., 1948

Morphia and its derivatives have been and are still the sheet-anchor in the treatment of

paralytic ileus. These drugs not only keep the patient quiet but also maintain the tone of the gut.

Cathartics and enemata need no stress as their results have been proved already as valueless. Alvarez has shown that catharsis is rather followed by a refractory period during -^hich peristalsis is inhibited. Thus analysing the different methods of up-to-

date treatment of paralytic ileus one is led to

conclude that the main principles are the same always but the divergence lies in the lines followed. But the ultimate aim is to combat the anhydraemia and alkalosis. Unfortunately, the treatment is therapeutic, i.e. when paralytic condition has set in and well advanced. But that by a simple estimation of pH of the blood as the present author (Mukerji, 1947c) has

already shown, one can tell as to whether

paralytic ileus is likely to ensue or not. He has also shown that paretic gut can be made to contract if blood condition is improved. So the treatment of paralytic ileus has been framed by the present author under two headings :

1. Paretic stage when pH of blood shows a

tendency to alkalosis (between 7.4 to

7.65). 2. Paralytic stage when pH of blood shows a

markedly alkaline blood (above 7.65). Cases in the paretic stage are usually cases

of acute abdomen before or just after operation, so the treatment will be discussed under two

groups : (I) Preoperative, and (II) Post-

operative.

(/) Preoperative treatment

1. Administration of fluids (the quantity to be judged by the specific gravity of blood). Fluid is normal saline or Ringer's solution.

2. If abdomen is found distended, intestinal

decompression is instituted.

3. If pH of the blood denotes a markedly alkaline condition of blood, serum should be infused to combat hypoproteinaemia associated with this alkalosis.

By this time the patient is prepared locally and handed over to the surgeon for operation. The operation should be done either with gas and oxygen anaesthesia or local anaesthesia. If ether is used as an anaesthetic, it should be

given along with oxygen. Spinal anaesthesia has been held responsible for acute dilatation of stomach. So it should not be a method of choice in such cases.

(II) Postoperative treatment

1. As outlined before, more than normal quota of fluid is necessary now. Ringer's solution cannot be administered. Hypertonic solutions are dangerous. So the best plan is to administer

the normal quota in the form of normal saline by intravenous drip method and the extra amount either by the method as advised by Atkins or in subcutaneous route.

2. Radiant heat or infra rays on abdomen for half an hour twice daily.

3. Oxygen administration has been experi- mentally proved to have a marked effect on intestinal distension and on intestinal movements

(Schnedorf and Orr). But the methods used to administer oxygen in such cases are and have been ridiculous. The rate of administration should be two litres of oxygen per minute. So the best way to administer oxygen will be to

put the patients in oxygen tent. 4. Morphia gr. six-hourly and patient is

propped up in Fowler's position. 5. Suction applied to an in-lying gastric or

duodenal tube.

Adrenal cortex therapy and vitamin B admin- istration are beneficial adjuvants.

Conclusions.?1. The present author has shown that pH value of blood may serve as a useful guide towards the onset of paralytic ileus and as a guide to further prognosis and treatment.

2. The author has suggested a new plan of treatment in two stages?(a) early or pre- paralytic or paretic stage, and (b) paralytic stage.

3. Administration of oxygen on rational lines seems to have some useful application in the

therapeutics of the paralytic stage.

The writer acknowledges his sincerest thanks to

Dr. A. C. Ukil, Principal cum Superintendent, Medical College Hospitals, for his kind permission to use hos- pital records, and to Colonel F. J. Anderson, i.m.8.

(retd.), for offering facilities to carry on this work.

REFERENCES

Atkins, H. J. B. (1942). After Treatment. Basil , Blackwell and Mott, Ltd., j Oxford, England.

Falconer, M. A., Oster- Arch. Surg., 38, 869. berg, A. E., and Bargen, J. A. (1939).

Leigh, O. C. (1942) .. Surg.Gyn. and Obstet-, 75, 279.

Maingot, R. (1936) .. Post-Graduate Surgery. Appleton-Century Co., London.

Mukerji, S. R. (1944). Science and Culture, 10, 262.

Idem (1945). Med. Coll. Mag., 13, 10.

Idem (1946). Science and Culture, 12, 54.

Idem (1947a). Ann. Biochem. and Exper. Med., 7, 1.

Idem (19476). Ibid., 7, 10.

Idem (1947c). Ibid., 7, 23.

Idem (1947(f). Ibid., 7, 29.

Robb, J. J. (1932) .. Brit. J. Surg., 19, 634.

Scudder, J. (1941) .. Surg. Gyn. and Obstet., 73, 880.