Ileus

Dr.Dian Tambunan

Ileus
Adynamic ileus
Mechanical ileus

Adynamic ileus
I.
A.

Pathophysiology
Paralysis of intestinal motility

Adynamic ileus
II. Causes A. Abdominal trauma B. Abdominal surgery (i.e. laparatomy) C. Serum electrolyte abnormality 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia

Adynamic ileus
D. Infectious, Inflammatory or irritation (bile, blood) 1. Intrathoracic a. Pneumonia b. Lower lobe rib fractures c. Myocardial Infarction 2. Intrapelvic e.g. Pelvic Inflammatory Disease

Adynamic ileus
3. Intraabdominal a. Appendicitis b. Diverticulitis c. Nephrolithiasis d. Cholecystitis e. Pancreatitis f. Perforated Duodenal Ulcer

Adynamic ileus
E. Intestinal Ischemia
1.

Mesenteric embolism, ischemia or thrombosis

Rib fracture Vertebral fracture (e.g. lumbar compression fracture)

F. Skeletal injury
1. 2.

Adynamic ileus
G. Medications
1. 2. 3. 4.

5.

Narcotics Phenothiazines Diltiazem or Verapamil Clozapine Anticholinergic Medications

Adynamic ileus
III. Symptoms A. Abdominal distention B. Nausea and Vomiting are variably present C. Generalized abdominal discomfort 1. Colicky pain of Mechanical Ileus is usually absent D. Flatus and Diarrhea may still be passed

Adynamic ileus
IV. Signs
A. B.

Quiet bowel sounds Abdominal distention

Mechanical Ileus Bowel Pseudoobstruction

V. Differential Diagnosis
A. B.

Adynamic ileus
VI. Radiology: Refractory ileus course
A. B.

Indicated to evaluate for Mechanical Ileus Upper GI series and small bowel follow through 1. May be diagnostic and therepeutic 2. Use gastrograffin instead of barium
3. 4.

Barium may further obstruct bowel lumen Gastrograffin may stimulate bowel motility

C. D.

Decompress stomach with Nasogastric Tube Instill gastrograffin via Nasogastric Tube

Adynamic ileus
D. Contrast with Mechanical Ileus

1. Less prominent air fluid levels 2. Generalized involvement of entire GI tract 3. Air filled bowel loops tend not to be distended

Adynamic ileus
VII. Management
A.
1. 2. 3. 4.

Initial
Limit or eliminate oral intake Intravascular fluid replacement Correct electrolyte abnormalities (e.g. Hypokalemia) Consider Nasogastric Tube placement

B.
1. 2.

Refractory Management
Consider Prokinatics Consider lower bowel stimulation (e.g. Enema)

Adynamic ileus
VIII. Course A. Post-operative ileus resolves within 24-48 hours

Mechanical ileus
I.
A.
1. 2.

Types
Simple mechanical obstruction
Bowel lumen is obstructed No vascular compromise

B.
1. 2. 3.

Closed loop obstruction

Both ends of a bowel loop are obstructed Results in strangulated obstruction if untreated Rapid rise in intraluminal pressure

C.
1.

Strangulated obstruction
Bowel lumen and vascular supply is compromised

Mechanical ileus
II. Causes A. Most Common Causes
Postoperative Adhesions (accounts for 50% of cases) 2. Hernia (25% of cases, especially younger patients) 3. Neoplasms (10% of cases, esp. older patients) a. Colon Cancer (most common) b. Ovarian Cancer c. Pancreatic cancer d. Gastric Cancer
1.

Mechanical ileus
A.

Intrinsic bowel lesions

1.

Congenital anomalies (Pediatric)

a. Atresia b. Stenosis c. Bowel duplication

Mechanical ileus
2. Strictures
a. b. c.

d.
e. f. g. h. i. j.

Inflammatory Bowel Disease (e.g. Crohn's Disease) Colon Cancer Intussusception a. Children: Usually idiopathic b. Adults: 95% have underlying mechanical cause c. AIDS may predispose to Intussusception Gallstones that have entered the bowel lumen a. More common in those over age 65 years Bezoar Barium Ascaris infection Tuberculosis Actinomycosis Diverticulitis

Mechanical ileus
C. Extrinsic bowel lesions 1. Adhesion
a. b.

Abdominal or pelvic surgery Presence of peritonitis or trauma

2.

Hernia (higher risk for strangulation)

a. b. c.

Inguinal hernia (direct ,indirect) Internal hernias via mesenteric defects Obturator hernia More common in emaciated elderly women

Mechanical ileus
3. Small bowel volvulus
a. b. c.

Rare compared to colon volvulus More common in Africa, Middle East and India Occurs in intestinal malrotation or adhesions

D. Idiopathic Intestinal Obstruction

1. See Bowel Pseudoobstruction

Mechanical ileus
III. Symptoms A. Frequent and recurrent Generalized Abdominal Pain B. Duration: Seconds to minutes
1. 2.
a. b.

Character: Spasms of crampy abdominal pain Frequency

Intermittent pain initially Every few minutes in proximal obstruction Constant pain suggests ischemia or perforation

c.

Mechanical ileus
B. Stool passage
1. 2.

Initially may be present despite complete obstruction Later, obstipation (no stool) in complete obstruction Proximal obstruction
a. b. c. d. e.

C. Symptoms more severe in proximal obstruction

1.
Severe, colicky abdominal pain Constant pain suggests ischemia or perforation Develops over hours and occurs every few minutes Bilious Emesis Mild abdominal distention

Mechanical ileus
1. Distal obstruction a. Develops over days and becomes progressively worse b. Emesis may occur and is brown and feculent c. Significant abdominal distention

Mechanical ileus
IV. Signs A. Bowel sounds
1. 2.

Initial: High pitched, hyperactive bowel sounds Later: hypoactive or absent bowel sounds

B.
1.

Tender abdominal mass

Closed loop Bowel Obstruction may be palpable

C.
1.

Abdominal distention and tympany on percussion

Indicates distal obstruction

D.

Rectal examination for blood

Mechanical ileus
V. Radiology: Flat and upright (or decubitus) abdominal X-Ray A. Sensitivity: 60% (up to 90%) B. Typical findings of Bowel Obstruction
1. 2. 3. 4.

Bowel distention proximal to obstruction Bowel collapsed distal to obstruction Upright or decubitus view: Air-fluid levels Supine view findings a. Sharply angulated distended bowel loops b. Step-ladder arrangement or parallel bowel loops

Mechanical ileus
c .String of pearls sign (specific for obstruction)
1.

Series of small pockets of gas in a row Bowel loop filled with fluid (resembles mass)

d. Pseudotumor Sign
1.

Mechanical ileus
VI. Radiology A. MRI Abdomen (93% Test Sensitivity for SBO cause) B. CT Abdomen (88% Test Sensitivity for SBO cause)
1. 2.
a. b. c. d. e.

Adjunct to plain XRay to identify obstruction site Findings

Intussusception Volvulus Extraluminal mass (e.g. abscess, neoplasm) Closed loop obstruction Strangulated bowel

Mechanical ileus
VII. Differential Diagnosis
A. B. C. D. E. F. G. H. I. J. K.

Adynamic Ileus Bowel Pseudoobstruction Ischemic bowel (superior mesenteric syndrome) Gastroenteritis Cholelithiasis Cholecystitis Pancreatitis Peptic Ulcer Disease Appendicitis Myocardial Infarction Pregnancy

Mechanical ileus
VIII. Management: Conservative Therapy
A. B. 1.

2.
C. 1.

2.

Fluid replacement Bowel decompression Nasogastric Tube Long intestinal tube (eg. Cantor) offers no advantage Antibiotic Indications (Not for routine use) a. Surgery planned b. Bowel ischemia or infarction c. Bowel perforation Cover Gram Negatives and Anaerobes a. Second-generation Cephalosporin

Mechanical ileus
IX. Management: surgical intervention A. Spontaneous resolution often occurs without surgery
1. 2.

Partial small bowel obstruction: 75% Complete small bowel obstruction: up to 50%

Mechanical ileus
A.
1. 2. 3.

Predictors of resolution without surgery

Early postoperative bowel obstruction Adhesive obstruction (prior laparotomy) Crohn's disease

B.
1. 2. 3.

Indications for surgery

Inadequate relief with Nasogastric tube placement Persistant symptoms >48 hours despite treatment (strangulation) Neoplasms

Mechanical ileus
X. Complications
A. B. C.

D.

Intestinal Ischemia or infarction Bowel necrosis, perforation and bacterial peritonitis Hypovolemia Complications of surgical intervention if needed

XI. Prognosis: Recurrence of obstruction due to adhesions

A.
B.

Risk after first episode: 53% Risk after more than one episode: 83%

Thank For Your Attentions!!!