Ileus

Adynamic ileus
Mechanical ileus

Ri 金思穎
Adynamic ileus
I. Pathophysiology
A. 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
4. Hypermagensemia
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
F. Skeletal injury
1. Rib fracture
2. Vertebral fracture (e.g. lumbar
compression fracture)
Adynamic ileus
G. Medications
1. Narcotics
2. Phenothiazines
3. Diltiazem or Verapamil
4. Clozapine
5. 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. Quiet bowel sounds
B. Abdominal distention
V. Differential Diagnosis
A. Mechanical Ileus
B. Bowel Pseudoobstruction
Adynamic ileus
VI. Radiology: Refractory ileus course
A. Indicated to evaluate for Mechanical Ileus
B. Upper GI series and small bowel follow
through
1. May be diagnostic and therepeutic
2. Use gastrograffin instead of barium
3. Barium may further obstruct bowel lumen
4. Gastrograffin may stimulate bowel motility
C. Decompress stomach with
Nasogastric Tube
D. 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. Initial
1. Limit or eliminate oral intake
2. Intravascular fluid replacement
3. Correct electrolyte abnormalities (e.g.
Hypokalemia)
4. Consider Nasogastric Tube placement
B. Refractory Management
1. Consider Prokinatics
2. Consider lower bowel stimulation (e.g.
Enema)
Adynamic ileus
VIII. Course
A. Post-operative ileus resolves within
24-48 hours
Mechanical ileus
I. Types
A. 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
untreated
3. Rapid rise in intraluminal pressure
C. Strangulated obstruction
1. Bowel lumen and vascular supply is
compromised
Mechanical ileus
II. Causes
A. Most Common Causes
1. 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
Mechanical ileus
A. Intrinsic bowel lesions
1. Congenital anomalies (Pediatric)
a. Atresia
b. Stenosis
c. Bowel duplication
Mechanical ileus
2. Strictures
a. 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
Mechanical ileus
C. Extrinsic bowel lesions
1. Adhesion
a. 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 defects
c. Obturator hernia
More common in emaciated elderly women
Mechanical ileus
3. Small bowel volvulus
a. Rare compared to colon volvulus
b. More common in Africa, Middle East and
India
c. 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. 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
Mechanical ileus
B. Stool passage
1. Initially may be present despite complete
obstruction
2. Later, obstipation (no stool) in complete
obstruction
C. Symptoms more severe in proximal
obstruction
1. Proximal obstruction
a. Severe, colicky abdominal pain
b. Constant pain suggests ischemia or perforation
c. Develops over hours and occurs every few
minutes
d. Bilious Emesis
e. 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. Initial: High pitched, hyperactive bowel sounds
2. Later: hypoactive or absent bowel sounds
B. Tender abdominal mass
1. Closed loop Bowel Obstruction may be
palpable
C. Abdominal distention and tympany on
percussion
1. 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. Bowel distention proximal to obstruction
2. Bowel collapsed distal to obstruction
3. Upright or decubitus view: Air-fluid levels
4. 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
d. Pseudotumor Sign
1. Bowel loop filled with fluid (resembles mass)
Mechanical ileus
VI. Radiology
A. MRI Abdomen (93% Test Sensitivity for
SBO cause)
B. CT Abdomen (88% Test Sensitivity for
SBO cause)
1. Adjunct to plain XRay to identify obstruction
site
2. Findings
a. Intussusception
b. Volvulus
c. Extraluminal mass (e.g. abscess, neoplasm)
d. Closed loop obstruction
e. Strangulated bowel
Mechanical ileus
VII. 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
Mechanical ileus
VIII. Management: Conservative Therapy
A. Fluid replacement
B. Bowel decompression
1. Nasogastric Tube
2. Long intestinal tube (eg. Cantor) offers no
advantage
C. Antibiotic
1. 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
Mechanical ileus
IX. Management: surgical intervention
A. Spontaneous resolution often occurs
without surgery
1. Partial small bowel obstruction: 75%
2. Complete small bowel obstruction: up to
50%
Mechanical ileus
A. Predictors of resolution without surgery
1. Early postoperative bowel obstruction
2. Adhesive obstruction (prior laparotomy)
3. Crohn's disease
B. Indications for surgery
1. Inadequate relief with Nasogastric tube
placement
2. Persistant symptoms >48 hours despite
treatment (strangulation)
3. Neoplasms
Mechanical ileus
X. Complications
A. Intestinal Ischemia or infarction
B. Bowel necrosis, perforation and bacterial
peritonitis
C. Hypovolemia
D. Complications of surgical intervention if needed
XI. Prognosis: Recurrence of obstruction
due to adhesions
A. Risk after first episode: 53%
B. Risk after more than one episode: 83%
Reference
Family Practice Notebook.com
 Torrey in Marx (2002) Rosen's
Emergency Med, p. 1283-7
 Townsend (2001) Sabiston Surgery, p.
883-8
 Turnage in Feldman (1998) Sleisenger
GI, p. 1799-804
 Matsuoka (2002) Am J Surg 183:614-
7
New Aspect in Treatment of
Adhesive 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-En
Wang
Method
1. From January 1999 to December 2001, 293 patients
with small bowel obstruction due to postoperative
adhesions were retrospectively reviewed .
2. Data collected included the number of admissions,
type of management for each admission, duration of
conservative treatment, and operative findings.
Result
1.Medical treatment:220
Repeated laprotomy:73
2.Period of observation
Medically:2-12 days(average 6.9) (until resolution of
obstruction)
Surgically:1-14 days(average 5.4)(prior to surgery)
3.At surgery,
Adhesions were the only finding:46( 63% of
surgically, 15.7% of all)
Intestinal complication:27(37% of surgically, 9.2% of
all)
#Fever and leukocytosis greater than 15000/mm3
were prediction of intestinal complications
Conclusion
1. With closely monitoring, most patients with
small bowel obstruction due to
postoperative adhesions could tolerate
supportive treatment
2. and recover well averagely within 1 week
3. although some patients require more than
10 days of observation.
2. Laparoscopic compared with
conventional treatment of acute
adhesive small bowel obstruction
British Journal of Surgery ,3 Jul 2003
Volume 90, Issue 9 , Pages 1147 - 1151
C. Wullstein *, E. Gross Chirurgische Abteilung,
Allgemeines Krankenhaus Barmbek, Hamburg,
Germany
Method
Patients with acute SBO treated
laparoscopically (LAP; n = 52) and
conventionally (CONV; n = 52) were
compared in a retrospective matched-pair
analysis.
Conversions were included in the laparoscopic group.
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)
Conclusion
1. Laparoscopic treatment of acute SBO was feasible
in about half of these patients.
2. Postoperative recovery was improved after
laparoscopic procedures but the risk of
intraoperative complications increased .
3. Laparoscopic management of acute SBO seems
justified in patients with fewer than two previous
laparotomies but should not be offered to other
patients because of the unacceptably high risk of
intraoperative bowel perforation.
3.Long tube decompression is
successful in 90% of patients with
adhesive small bowel obstruction.
American Journal of Surgery. 2003 Jun
185(6):512-5,.
Gowen GF
Background
1. In a 1995 prospective randomized study, for patients with
small bowel obstruction (SBO), who do not have strangulation
obstruction or other contraindications
nasogastric suction (short tube), successful in 51%
long tube decompression, successful in 75%
2. Using upper gastrointestinal endoscope, a long tube can be
advanced into the jejunum in 20 minutes, so the delay in
function has been eliminated .
Method
1. From 1983 to 1988, three kinds of long intestinal tubes were
used, the Miller-Abbott Tube ,the Anderson Tube ,and the
Dennis Tube in 17 patients.
2. From 1989 to 2002, the Gowen Decompression,an improved
tube (9 feet long, 18F) was used because it was developed
for endoscopic placement into the small bowel for 20
patients.
3. The 130 cm endoscope was advanced through the mouth and
esophagus into the stomach, and the scope was removed
leaving the tube in the jejunum.
4. 5 cc diatrizoate and 15 cc water were injected into the
balloon ,.The tube was advanced through the nose, 2 inches
per hour .
Result
1. From 1983 to 1988, decompression was
successful in 12 of 17(70%)
2. From 1989 to 2002 with the improved tube,
decompression was successful in 18 of
20(90%)
3. Of the 7 patients who failed a trial with long
tube decompression, all had
enterolysis .Long tube with splint was
placed on the small bowel. No more
recurrences were noted.
Conclusion
1. For patients with SBO due to adhesions, a trial with
long tube decompression for 48 to 72 hours is
recommended.
2. For those who failed a trial with the long tube,
laparotomy with enterolysis or bowel resection is
indicated
3. Contraindications to a trial with long tube
decompression include strangulation obstruction,
malignant obstruction, incarcerated hernias, foreign
body, radiation enteritis, and peritonitis
4. If a patient with SBO fails to respond in 48 to 72
hours then laparotomy should be considered .
4. Effects of Dai-kenchu-to, a herbal
medicine, on uterine and intestinal
motility
Phytotherapy Research 15 May 2001
Volume 15, Issue 4 , Pages 302 - 306
Co Pin Murata *, Terumasa Hayakawa, Kazuko Satoh,
Yoshio Kase, Atsushi Ishige, Hiroshi Sasaki , Japan
The effects of both Dai-kenchu-to and PGF2 on
intestinal and uterine motility were studied in
anaesthetized rabbits with force transducers
implanted in the jejunum, ileum and uterus.
Dai-kenchu-to may exert stimulatory effects on
intestinal motility, as PGF2, but has no effect on the
uterine motility.
Suggesting a selective effect on the gastrointestinal
tract. Hence, Dai-kenchu-to may be safer than PGF2
in the treatment of postoperative adhesive ileus in
women .
5. UCSF(University of California):
# A method for treatment and prevention of ileus--compounds
effective either in inhibiting mast cell degranulation, or in
inhibiting tryptase or chymase
#Proteinase-activated receptor 2 (PAR-2) is expressed in colonic
muscle cells, and that activation of PAR-2 inhibits colonic
activity.
#The PAR-2 receptor is activated, at least in part, by tryptase and
chymase .
# Tryptase and chymase were produced in the intestinal wall by
the infiltration and degranulation of mast cells.
# Thus, inhibitors of these specific enzymes, or inhibitors of mast
cell degranulation may be effective in maintaining colonic
motility after surgery.
Case:4C1 3-2 吳阿生
<Brief History >
This is a 74 y/o male with no significant underlying disease had GB
and GBD stone s/p ERCP and papillotomy and lithotripsy in Dec.
2003.
92-12-01 RUQ pain, jaundice , cold sweat->NTUH ER
92-12-02 ERCP 1 (Papillotomy, lithotripsy)
93-03-30: RUQ pain, fever with chills->OPD->admission
93-04-05: ERCP 2 lithotripsy failed due to pailla Vater stenosis,
complicated by post ERCP pancreatitis ,biliary tree
infection and stress ulcer.
93-04-12: sudden onset of abdominal pain with muscle guarding,
r/o septic shock abdominal CT: ileus
93-04-14: F/U abdominal ECHO: dilated CBD and IHD
93-04-15: PTCD
Case:4C1 3-2 吳阿生
93-04-26: Operation1: Choledochoduodenostomy+
cholecystectomy+ Nelaton as CBD stent
93-04-28: Bile leakage(+) ,and infection
93-05-06: subcostal wound infection
93-05-10: Operation2: Jejunostomy with T tube
insertion for feeding
93-05-10 to 93-05-14: persistent fever
Case:4C1 3-2 吳阿生
93-05-14:midline laparotomy wound pus
discharge 300ml,
93-05-15:Operation3: wound debridement,
then sent to 4C1 SICU
93-06-16:Abdominal CT--contrast leakage
accumulating in the retroperitoneal
space
93-06-25:Gastrotomy tube inserted into jejunostomy
due to jejunostomy dysfunction
93-06-29 Tracheostomy
93-07-07~93-07-11 CVVH for poor renal
function
Current Focus Problem:
Jejunostomy dysfunction with ileus since:
#7/27 hypaque study: no abnormal dilatation of the
bowel loops patent of small intestine contrast
opacified at A-colon
#7/30 N-D tube was inserted
#ND feeding: 793ml
#Stool:120ml
#Jejunostomy out:140ml
#Bowel Sound: epigastium-metalic
lower abd-silent
Impression
r/o Adhesive ileus: no evidence of
obstruction
r/o Mechanical ileus: may perform
occult blood of stool, colon
fibroscope
Thank For Your Attentions!!!