IleusDr.Dian Tambunan

Ileus Adynamic ileus Mechanical ileus

Adynamic ileusI.A.

PathophysiologyParalysis of intestinal motility

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

Adynamic ileusD. 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 ileus3. Intraabdominal a. Appendicitis b. Diverticulitis c. Nephrolithiasis d. Cholecystitis e. Pancreatitis f. Perforated Duodenal Ulcer

Adynamic ileusE. Intestinal Ischemia1.

Mesenteric embolism, ischemia or thrombosisRib fracture Vertebral fracture (e.g. lumbar compression fracture)

F. Skeletal injury1. 2.

Adynamic ileusG. Medications1. 2. 3. 4.

5.

Narcotics Phenothiazines Diltiazem or Verapamil Clozapine Anticholinergic Medications

Adynamic ileusIII. 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 ileusIV. SignsA. B.

Quiet bowel sounds Abdominal distentionMechanical Ileus Bowel Pseudoobstruction

V. Differential DiagnosisA. B.

Adynamic ileusVI. Radiology: Refractory ileus courseA. 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 barium3. 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 ileusD. 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 ileusVII. ManagementA.1. 2. 3. 4.

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

B.1. 2.

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

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

Mechanical ileusI.A.1. 2.

TypesSimple mechanical obstructionBowel lumen is obstructed No vascular compromise

B.1. 2. 3.

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

C.1.

Strangulated obstructionBowel lumen and vascular supply is compromised

Mechanical ileusII. Causes A. Most Common CausesPostoperative 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 Cancer1.

Mechanical ileusA.

Intrinsic bowel lesions1.

Congenital anomalies (Pediatric)a. Atresia b. Stenosis c. Bowel duplication

Mechanical ileus2. Stricturesa. 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 ileusC. Extrinsic bowel lesions 1. Adhesiona. 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 ileus3. Small bowel volvulusa. b. c.

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

D. Idiopathic Intestinal Obstruction1. See Bowel Pseudoobstruction

Mechanical ileusIII. Symptoms A. Frequent and recurrent Generalized Abdominal Pain B. Duration: Seconds to minutes1. 2.a. b.

Character: Spasms of crampy abdominal pain FrequencyIntermittent pain initially Every few minutes in proximal obstruction Constant pain suggests ischemia or perforation

c.

Mechanical ileusB. Stool passage1. 2.

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

C. Symptoms more severe in proximal obstruction1.Severe, colicky abdominal pain Constant pain suggests ischemia or perforation Develops over hours and occurs every few minutes Bilious Emesis Mild abdominal distention

Mechanical ileus1. Distal obstruction a. Develops over days and becomes progressively worse b. Emesis may occur and is brown and feculent c. Significant abdominal distention

Mechanical ileusIV. Signs A. Bowel sounds1. 2.

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

B.1.

Tender abdominal massClosed loop Bowel Obstruction may be palpable

C.1.

Abdominal distention and tympany on percussionIndicates distal obstruction

D.

Rectal examination for blood

Mechanical ileusV. Radiology: Flat and upright (or decubitus) abdominal X-Ray A. Sensitivity: 60% (up to 90%) B. Typical findings of Bowel Obstruction1. 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 ileusc .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 Sign1.

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

Mechanical ileusVII. Differential DiagnosisA. 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 ileusVIII. Management: Conservative TherapyA. 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 ileusIX. Management: surgical intervention A. Spontaneous resolution often occurs without surgery1. 2.

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

Mechanical ileusA.1. 2. 3.

Predictors of resolution without surgeryEarly postoperative bowel obstruction Adhesive obstruction (prior laparotomy) Crohn's disease

B.1. 2. 3.

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

Mechanical ileusX. ComplicationsA. 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 adhesionsA.B.

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

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