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Ileus

Adynamic ileus

Mechanical ileus

Ri

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Adynamic ileus

I. PathophysiologyA. Paralysis of intestinal motility

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Adynamic ileus

II. Causes

A. Abdominal trauma

B. Abdominal surgery (i.e. laparatomy)C. Serum electrolyte abnormality

1. Hypokalemia

2. Hyponatremia3. Hypomagnesemia

4. Hypermagensemia

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D. Infectious, Inflammatory or irritation (bile, blood)

1. Intrathoracic

a. Pneumoniab. Lower lobe rib fractures

c. Myocardial Infarction

2. Intrapelvic

e.g. Pelvic Inflammatory Disease

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3. Intraabdominal

a. Appendicitis

b. Diverticulitisc. Nephrolithiasis

d. Cholecystitis

e. Pancreatitis

f. Perforated Duodenal Ulcer

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Adynamic ileus

E. Intestinal Ischemia

1. Mesenteric embolism, ischemia or

thrombosisF. Skeletal injury

1. Rib fracture

2. Vertebral fracture (e.g. lumbarcompression fracture)

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G. Medications

1. Narcotics

2. Phenothiazines3. Diltiazem or Verapamil

4. Clozapine

5. Anticholinergic Medications

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Adynamic ileus

III. Symptoms

A. Abdominal distention

B. Nausea and Vomiting are variably presentC. Generalized abdominal discomfort

1. Colicky pain of Mechanical Ileus isusually absent

D. Flatus and Diarrhea may still be passed

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Adynamic ileus

IV. Signs

A. Quiet bowel sounds

B. Abdominal distention

V. Differential Diagnosis

A. Mechanical Ileus

B. Bowel Pseudoobstruction

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Adynamic ileusVI. Radiology: Refractory ileus course

A. Indicated to evaluate for Mechanical Ileus

B. Upper GI series and small bowel followthrough

1. May be diagnostic and therepeutic

2. Use gastrograffin instead of barium3. Barium may further obstruct bowel lumen

4. Gastrograffin may stimulate bowel motility

C. Decompress stomach withNasogastric Tube

D. Instill gastrograffin via Nasogastric

Tube

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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 bedistended

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Adynamic ileusVII. Management

A. Initial

1. Limit or eliminate oral intake

2. Intravascular fluid replacement3. Correct electrolyte abnormalities (e.g.

Hypokalemia)

4. Consider Nasogastric Tube placement

B. Refractory Management1. Consider Prokinatics

2. Consider lower bowel stimulation (e.g.Enema)

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VIII. Course

A. Post-operative ileus resolves within

24-48 hours

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Mechanical ileus

I. TypesA. Simple mechanical obstruction

1. Bowel lumen is obstructed

2. No vascular compromise

B. Closed loop obstruction

1. Both ends of a bowel loop are obstructed

2. Results in strangulated obstruction if

untreated3. Rapid rise in intraluminal pressure

C. Strangulated obstruction

1. Bowel lumen and vascular supply is

compromised

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Mechanical ileusII. Causes

A. Most Common Causes1. Postoperative Adhesions (accounts for 50%

of cases)2. Hernia (25% of cases, especially younger

patients)

3. Neoplasms (10% of cases, esp. olderpatients)

a. Colon Cancer (most common)

b. Ovarian Cancer

c. Pancreatic cancer

d. Gastric Cancer

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Mechanical ileus

A. Intrinsic bowel lesions1. Congenital anomalies (Pediatric)

a. Atresiab. Stenosis

c. Bowel duplication

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Mechanical ileus

2. Stricturesa. Inflammatory Bowel Disease (e.g. Crohn's Disease)

b. Colon Cancer

c. Intussusception

a. Children: Usually idiopathic

b. Adults: 95% have underlying mechanical cause

c. AIDS may predispose to Intussusception

d. Gallstones that have entered the bowel lumen

a. More common in those over age 65 years

e. Bezoar

f. Barium

g. Ascaris infection

h. Tuberculosis

i. Actinomycosis

j. Diverticulitis

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Mechanical ileus

C. Extrinsic bowel lesions

1. Adhesiona. Abdominal or pelvic surgery

b. Presence of peritonitis or trauma

2. Hernia (higher risk for strangulation)a. Inguinal hernia (direct ,indirect)

b. Internal hernias via mesenteric defectsc. Obturator hernia

More common in emaciated elderly women

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3. Small bowel volvulus

a. Rare compared to colon volvulus

b. More common in Africa, Middle East andIndia

c. Occurs in intestinal malrotation or adhesions

D. Idiopathic Intestinal Obstruction

1. See Bowel Pseudoobstruction

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Mechanical ileus

III. Symptoms

A. Frequent and recurrent Generalized

Abdominal PainB. Duration: Seconds to minutes

1. Character: Spasms of crampy abdominal pain

2. Frequency

a. Intermittent pain initially

b. Every few minutes in proximal obstruction

c. Constant pain suggests ischemia or perforation

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Mechanical ileusB. Stool passage

1. Initially may be present despite completeobstruction

2. Later, obstipation (no stool) in completeobstruction

C. Symptoms more severe in proximalobstruction

1. Proximal obstructiona. Severe, colicky abdominal pain

b. Constant pain suggests ischemia or perforation

c. Develops over hours and occurs every fewminutes

d. Bilious Emesis

e. Mild abdominal distention

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May occur at any point in length of small bowel

Where?

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Mechanical ileus

1. Distal obstruction

a. Develops over days and becomes

progressively worseb. Emesis may occur and is brown and

feculent

c. Significant abdominal distention

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Mechanical ileus

IV. Signs

A. Bowel sounds1. Initial: High pitched, hyperactive bowel sounds

2. Later: hypoactive or absent bowel sounds

B. Tender abdominal mass1. Closed loop Bowel Obstruction may be

palpable

C. Abdominal distention and tympany onpercussion

1. Indicates distal obstruction

D. Rectal examination for blood

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How does it present?

Symptoms:

Colicky abdominal pain, nausea, vomiting, and obstipation.

Continued passage of gas and/or stool beyond 12 hours after

onset of symptoms is characteristic of partial rather than

complete obstruction.

Signs:

Abdominal Distention (Greater the farther distal the

obstruction) and hyperactive, high pitched bowel sounds.

Laboratory Findings: Intravascular volume depletion (consist

of hemoconcentration and electrolyte abnormalities) Mild

leukocytosis.

Features of Strangulated Obstruction (Bowel Infarction):

Acute Abdomen,Tachycardia, localized abdominal tenderness,

fever, marked leukocytosis, and acidosis. Serum levels of

amylase, lipase, lactate dehydrogenase, phosphate, and

potassium may be elevated.

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How is it diagnosed?

Evaluation Goals:

Distinguishing mechanical obstruction from ileus Determining the etiology of the obstruction

Discriminating partial from complete obstruction

Discriminating simple from strangulating obstruction.

History:

Prior abdominal operations

Presence of abdominal disorders (cancer or IBD)

Last BM and Flatus

Pediatrics - Ingestion of foreign body

Physical Exam: Meticulous Search for Hernias (inguinal and femoral)

Rectal Exam to look for gross or occult blood.

The diagnosis is usually confirmed by Radiology

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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. Bowel distention proximal to obstruction

2. Bowel collapsed distal to obstruction

3. Upright or decubitus view: Air-fluid levels4. Supine view findings

a. Sharply angulated distended bowel loops

b. Step-ladder arrangement or parallel

bowel loops

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Abdominal series

1. Radiograph of the abdomen in a supine position

2. Radiograph of the abdomen in an upright position

3. Radiograph of the chest in an upright position.

Most Specific Finding: The Triad

1. Dilated small-bowel loops (>3 cm in diameter)

2. Air-Fluid levels on upright films

3. Paucity of air in the colon.

Sensitivity is 70 to 80%.

Specificity is low, because ileus and colonic obstruction have similar

appearing findings.

Despite some limitations, Plain films remain an important study

because of their widespread availability and low cost.

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Small Bowel Gas Pattern

Centrally located

Soft tissue across entire lumen

Colon Gas Pattern

Peripheral Located

Mostly not overlapping

Haustra markings

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Mechanical ileus

c .String of pearls sign (specific for

obstruction)

1. Series of small pockets of gas in a row

d. Pseudotumor Sign

1. Bowel loop filled with fluid (resembles mass)

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http://images.google.com.tw/imgres?imgurl=http://learn.wwtc.edu/pathology/imagefile/images/Abileus.jpg&imgrefurl=http://learn.wwtc.edu/pathology/imagefile/ileus.htm&h=540&w=432&sz=33&tbnid=JEIOE3a35_0J:&tbnh=130&tbnw=104&start=47&prev=/images?q=+ileus&start=40&hl=zh-TW&lr=&ie=UTF-8&sa=N

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VI. Radiology

A. MRI Abdomen (93% Test Sensitivity forSBO cause)

B. CT Abdomen (88% Test Sensitivity forSBO cause)1. Adjunct to plain XRay to identify obstruction

site

2.

Findingsa. Intussusceptionb. Volvulus

c. Extraluminal mass (e.g. abscess, neoplasm)

d. Closed loop obstruction

e. Strangulated bowel

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http://images.google.com.tw/imgres?imgurl=http://www.asahi-net.or.jp/~tv4m-tkhs/ILEUS/SPGR.jpg&imgrefurl=http://www.asahi-net.or.jp/~tv4m-tkhs/ILEUS/ILEUS.html&h=340&w=340&sz=25&tbnid=EBFIOnV52QQJ:&tbnh=115&tbnw=115&start=59&prev=/images?q=+ileus&start=40&hl=zh-TW&lr=&ie=UTF-8&sa=N

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Flat Abdominal Film

Dilated Loops of Small Bowel

No Air in Colon or Rectum

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Air - Fluid Levels

Dilated Small Bowel

Upright Abdominal Film

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Computed Tomographic (CT) scanning

Study preformed with oral and IV contrast.

Findings:

1. Discrete transition zone with dilation of bowel proximally and

decompressed distally

2. Intraluminal contrast that does not pass beyond the transition zone

3. Colon containing little gas or fluid.

Strangulation:

Suggested by thickening of the bowel wall, pneumatosis intestinalis (air in

the bowel wall), portal venous gas, mesenteric haziness, and poor uptake

of intravenous contrast into the wall of the affected bowel.

Offers a global evaluation of the abdomen.

Important when intestinal obstruction represents only one possible diagnosis

in all acute abdominal conditions.

Sensitivity 80 to 90% (More sensitive the higher grade obstruction)

Specificity 70 to 90%

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Dilated Loops of Small Bowel with Air-Fluid levels

Area of non-dilated small bowel.

Absence of Air in the Colon.

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Pneumatosis Intestinalis

Dilated Loops of SB

Air in Wall of SB

No Air in Colon

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Mechanical ileusVII. Differential Diagnosis

A. Adynamic Ileus

B. Bowel Pseudoobstruction

C. Ischemic bowel (superior mesenteric syndrome)

D. Gastroenteritis

E. Cholelithiasis

F. Cholecystitis

G. Pancreatitis

H. Peptic Ulcer Disease

I. Appendicitis

J. Myocardial Infarction

K. Pregnancy

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Mechanical ileusVIII. Management: Conservative TherapyA. Fluid replacementB. Bowel decompression

1. Nasogastric Tube

2. Long intestinal tube (eg. Cantor) offers noadvantage

C. Antibiotic1. Indications (Not for routine use)

a. Surgery planned

b. Bowel ischemia or infarction

c. Bowel perforation

2. Cover Gram Negatives and Anaerobes

a. Second-generation Cephalosporin

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IX. Management: surgical intervention

A. Spontaneous resolution often occurs

without surgery1. Partial small bowel obstruction: 75%

2. Complete small bowel obstruction: up to

50%

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A. Predictors of resolution without surgery1. Early postoperative bowel obstruction

2. Adhesive obstruction (prior laparotomy)

3. Crohn's disease

B. Indications for surgery1. Inadequate relief with Nasogastric tube

placement2. Persistant symptoms >48 hours despite

treatment (strangulation)

3. Neoplasms

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Mechanical ileus

X. Complications

A. Intestinal Ischemia or infarction

B. Bowel necrosis, perforation and bacterialperitonitis

C. Hypovolemia

D. Complications of surgical intervention if needed

XI. Prognosis: Recurrence of obstructiondue to adhesions

A. Risk after first episode: 53%

B. Risk after more than one episode: 83%

New Aspect in Treatment of

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New Aspect in Treatment ofAdhesive Ileus

1.Adhesive small bowel obstruction:

How long can patients tolerate

conservative treatment?World J Gastroenterol 2003 Mar 15;9(3):603-605

Shou-Chuan Shih, Kuo-Shyang Jeng, Shee-Chan Lin,

Chin-Roa Kao, Sun-Yen Chou, Horng-Yuan Wang,

Wen-Hsiung Chang, Cheng-Hsin Chu, Tsang-EnWang

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Method

1. From January 1999 to December 2001, 293 patientswith small bowel obstruction due to postoperativeadhesions were retrospectively reviewed .

2. Data collected included the number of admissions,type of management for each admission, duration ofconservative treatment, and operative findings.

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Result1.Medical treatment:220

Repeated laprotomy:732.Period of observation

Medically:2-12 days(average 6.9) (until resolution ofobstruction)

Surgically:1-14 days(average 5.4)(prior to surgery)3.At surgery,

Adhesions were the only finding:46( 63% ofsurgically, 15.7% of all)

Intestinal complication:27(37% of surgically, 9.2% ofall)#Fever and leukocytosis greater than 15000/mm3

were prediction of intestinal complications

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Conclusion

1. With closely monitoring, most patients withsmall bowel obstruction due topostoperative adhesions could toleratesupportive treatment

2. and recover well averagely within 1 week

3. although some patients require more than

10 days of observation.

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2. Laparoscopic compared withconventional treatment of acute

adhesive small bowel obstructionBritish Journal of Surgery ,3 Jul 2003Volume 90, Issue 9 , Pages 1147 - 1151C. Wullstein *, E. Gross Chirurgische Abteilung,

Allgemeines Krankenhaus Barmbek, Hamburg, Germany

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Method

Patients with acute SBO treated

laparoscopically (LAP; n = 52) and

conventionally (CONV;n

= 52) werecompared in a retrospective matched-pair

analysis.

Conversions were included in the laparoscopic group.

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Result

1.IntraOP major complication:

(Perforation ,Hemorrhage ,Injury to mesentery)

LAP 15/52 (28.8%) CONV 8/52 (15.4%) p=0.156

2.PostOP complication(Pulmonary, Cardiac, Deep vain thrombosis, Death)

LAP 10/52 (19.2%) CONV 8/52 (40.4%) p=0.032

3.Bowel movement, days after OP

LAP 3.5 CONV 4.4 (p=0.001)

4.Days of hospital stay

LAP 11.3 CONV 18.1 (p=0.001)

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Conclusion

1. Laparoscopic treatment of acute SBO was feasiblein about half of these patients.

2. Postoperative recovery was improved after

laparoscopic procedures but the risk ofintraoperative complications increased .

3. Laparoscopic management of acute SBO seemsjustified in patients with fewer than two previous

laparotomies but should not be offered to otherpatients because of the unacceptably high risk ofintraoperative bowel perforation.

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Thank For Your Attentions!!!