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Paralytic Ileus in the Orthopaedic Patient

Article  in  The Journal of the American Academy of Orthopaedic Surgeons · April 2015

DOI: 10.5435/JAAOS-D-14-00162 · Source: PubMed

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 Review Article

Paralytic Ileus in the Orthopaedic

Patient

Abstract
Alan H. Daniels, MD Paralytic ileus is marked by the cessation of bowel motility. This
Scott A. Ritterman, MD condition is a major clinical concern that may lead to severe patient
morbidity in orthopaedic surgery and trauma patients. Ileus most
Lee E. Rubin, MD
commonly occurs following spinal surgery, traumatic injury, or lower
extremity joint reconstruction, but it may also occur following minor
orthopaedic procedures. Possible consequences of ileus include
abdominal pain, malnutrition, prolonged hospital stay, hospital
readmission, bowel perforation, and death. Therapies used in the
treatment of ileus include minimization of opioids, early patient
mobilization, pharmacologic intervention, and multidisciplinary care.
Orthopaedic surgeons should be aware of the clinical signs and
symptoms of paralytic ileus and should understand treatment
principles of this relatively common adverse event.

P aralytic ileus is defined as a tem-

From the Department of
Orthopaedics, Warren Alpert Medical
School of Brown University/Rhode
Island Hospital, Providence, RI.
Dr. Daniels or an immediate family
member has received nonincome
support (such as equipment or
services), commercially derived
honoraria, or other non-research–
related funding (such as paid travel)
from DePuy and Stryker.
Dr. Ritterman or an immediate family
member has stock or stock options
held in Bristol-Myers Squibb.
Dr. Rubin or an immediate family
member serves as a board member,
owner, officer, or committee member
of the American Academy of
Orthopaedic Surgeons, the American
Association of Hip and Knee
Surgeons, and the Orthopaedic
Research Society.
J Am Acad Orthop Surg 2015;23:
365-372
http://dx.doi.org/10.5435/
JAAOS-D-14-00162
Copyright 2015 by the American
Academy of Orthopaedic Surgeons.
porary cessation of propulsive
contractions of the gastrointestinal
tract, with subsequent gut dilation
and accumulation of secretions and
gas within its lumen.1 It is a relatively
common postoperative complication
following major orthopaedic sur-
gery, occurring in 0.3% to 8.4% of
patients depending on the invasive-
ness and anatomic location of the
surgery.2,3 Ileus commonly presents
with abdominal distention and dis-
comfort, bloating, belching, nausea,
emesis, and constipation. This com-
plication may lead to substantial
morbidity and may be fatal in severe
cases.3-10
Although ileus occurs in ap-
proximately 15% of patients after
abdominal surgical procedures,1 ileus
may also occur in orthopaedic surgery
patients who have not been subjected
to violation of the peritoneal cavity
during their procedures. In these
cases, the causative etiology is likely
multifactorial, including neuro-
genic, inflammatory, hormonal, and
pharmacologic factors.11 In the
orthopaedic population, ileus is
most commonly encountered follow-
ing spine surgery, lower extremity
reconstruction, and traumatic injuries
with or without intra-abdominal
injury. Although much of the avail-
able literature surrounding ileus is
devoted to patients undergoing intra-
abdominal procedures, pain, immo-
bility, and autonomic dysfunction are
shared elements in many surgical
patients and are relevant factors
following orthopaedic surgery.
Ileus is defined as either uncompli-
cated or complicated.12 Uncompli-
cated ileus lasts #3 days and is
self-limiting. Complicated ileus is
associated with prolonged cessation of
gastrointestinal motility and lasts .3
days. Typical symptoms include
abdominal distention, bloating, nau-
sea, emesis, pain, and constipation.13
An important variant of ileus is
Ogilvie syndrome, also known as
acute colonic pseudo-obstruction; this
syndrome is well described in the
orthopaedic literature.14-17 Ogilvie

June 2015, Vol 23, No 6 365

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Paralytic Ileus in the Orthopaedic Patient
syndrome tends to affect certain
populations, such as elderly nursing
home residents admitted for a hip
fracture; these patients may have
a baseline of chronic constipation and
take a variety of psychiatric medi-
cations for dementia and behavior
control. These medications have
inhibitory effects on gastrointestinal
motility, and when combined with
anesthesia effects and narcotic
administration, Ogilvie syndrome
may arise. This functional, rather
than mechanical, obstruction, con-
sisting of massive dilation of the
cecum and the ascending colon, is the
result of autonomic dysfunction and
the inhibition of parasympathetic
activity on colonic motor function. If
left untreated, toxic megacolon may
occur. Progressive cecal dilation
causes compression of vessels in the
colon wall, leading to ischemia and
bowel wall thinning. Colonic perfo-
ration, intra-abdominal sepsis, and
death may ensue.13
Ileus in the Orthopaedic
Surgery Patient
Ileus following elective spine surgery
is a relatively common adverse event,
occurring in approximately 3.5% of
patients undergoing lumbar spine
surgery.2,4,18,19 Spine surgery is
unique among orthopaedic proce-
dures because the anterior approach
around the peritoneal cavity and into
the retroperitoneal space is com-
monly performed. A retrospective
study that evaluated .200,000 pa-
tients showed an overall ileus inci-
dence depending on the type of
surgical approach taken; patients
undergoing a posterior lumbar spi-
nal fusion had an ileus rate of 2.6%
compared with a rate of 7.5% for
patients undergoing anterior lumbar
spinal fusion.2 For patients who had
both anterior and posterior ap-
proaches, the incidence of ileus was
8.4%. Not surprisingly, patients
366
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
who had ileus had a significantly
longer length of stay (ie, approxi-
mately 2.5 days longer), as well as
greater hospital costs (approxi-
mately $7,000 higher) than did pa-
tients without ileus.
A retrospective review of patients
undergoing lateral lumbar spine sur-
gery reported the incidence of ileus at
7%.4 Independent risk factors cited
in this study included a history of
gastroesophageal reflux disease and
posterior instrumentation.4
A review of patients with ankylosing
spondylitis undergoing spinal osteot-
omy revealed a lower rate of paralytic
ileus in patients undergoing closing
wedge osteotomy compared with pa-
tients undergoing opening wedge os-
teotomy.19 Other complications, such
as superior mesenteric artery syn-
drome and celiac artery compression,
although much less common than
ileus, have been reported following
spinal deformity surgery,20,21 and
should be considered in the differen-
tial diagnosis when postoperative
nausea and vomiting are encoun-
tered. Ogilvie syndrome has also been
reported after lumbar and cervical
surgery, as well as after correction of
spinal deformity.17
The rate of ileus following lower
extremity arthroplasty has been re-
ported between 0.3% and 4% after
primary arthroplasty, and up to
5.6% after revision surgery.3 Patients
confined in bed secondary to ileus
are at a greater risk for venous
thromboembolic disease after total
joint arthroplasty.6 Excessive anti-
coagulation with warfarin and an
international normalized ratio .2.0
may also be independent risk factors
for the development of ileus after
joint arthroplasty surgery.22 Ogilvie
syndrome has been reported in pa-
tients undergoing lower extremity
reconstruction, most commonly
occurring after total hip arthro-
plasty. A retrospective study by
Norwood et al23 found the rate of
Ogilvie syndrome to be 1.3% in
Journal of the American Academy of Orthopaedic Surgeons
patients undergoing total hip arthro-
plasty and 0.6% in patients under-
going total knee arthroplasty. Patients
diagnosed with Ogilvie syndrome
stayed in the hospital approximately 8
days longer than patients without
a diagnosis of Ogilvie syndrome; all
patients in this study responded to
nonsurgical management.
Ileus is also known to occur in
orthopaedic trauma patients,
regardless whether they sustain
abdominal trauma or undergo surgi-
cal procedures. Polytrauma patients
with intra-abdominal injuries who
have undergone an exploratory lap-
arotomy, with or without a bowel
resection, are at a high risk for ileus
because of bowel manipulation and
postoperative narcotic use. In partic-
ular, patients with flexion-distraction
thoracolumbar spinal injuries are at
risk of ileus because of concurrent
spino-abdominal trauma. Similarly,
orthopaedic trauma patients with
spinal injuries and pelvic or long bone
fractures that require surgery are at
risk for the development of ileus
because of narcotic pain medication,
immobility, and autonomic dysfunc-
tion in the perioperative period.
Although much less common than
ileus, and clinically distinct from it,
bowel entrapment within a pelvic
fracture has been reported and is
a potentially fatal complication. This
occult injury typically presents as
a prolonged or intermittent ileus fol-
lowing a pelvic fracture.24 Prompt
recognition and surgical intervention
are important because considerable
morbidity is associated with a delay
in diagnosis.
Pathophysiology of Ileus
The enteric nervous system is
responsible for local regulation of
the gastrointestinal system and is
modulated by the central nervous
system. Acetylcholine, neurokinin
A, and substance P are stimulatory

gastrointestinal neurotransmitters,
whereas vasoactive intestinal peptide
and nitrous oxide are inhibitory to
gastrointestinal motility. Extrinsically,
the sympathetic nervous input has an
inhibitory effect on gastrointestinal
motility, whereas parasympathetic
input increases motility.16 Suppres-
sion of parasympathetic activity and
hyperactivity of the sympathetic ner-
vous system in the postoperative
period as a result of pain may be
contributory.25 Electrolyte abnor-
malities associated with blood loss,
interstitial fluid shifts between com-
partments, and resuscitation post-
operatively are also associated with
ileus.26
Opioid receptors play important
roles in neurohormonal regulation
throughout the central and enteric
nervous systems. Opioid pain medi-
cation activates m-receptors in the
bowel and contributes to decreased
gastrointestinal motility. The cumu-
lative dose of opioid medication has
been shown to be an independent
variable for ileus;27 this suggests that
a multimodal approach to pain
management involving non-narcotic
medications and selective regional
anesthesia should be used whenever
possible.28
Diagnosis
The term postoperative ileus should
not be used as a catch-all phrase for
cessation of bowel function after
surgery. It is important to distinguish
this diagnosis from other causes of
decreased gastrointestinal function,
such as mechanical obstruction of the
large or small bowel. A careful his-
tory and physical examination is the
first step in assessing for paralytic
ileus.
Ileus may present with typical find-
ings of abdominal distention, pain,
bloating, nausea, emesis, and con-
stipation. Patients may also experience
significant eructation (ie, belching)
June 2015, Vol 23, No 6
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Alan H. Daniels, MD, et al
and feelings of gastric reflux or heart- contained perforation, as well as
burn. Patients should be asked about being able to visualize the adjacent
the return of bowel function, either via paracolic structures16 (Figure 4).
production of flatus or bowel move-
ments in the postoperative period;
patients with ileus will have minimal Prevention/Prophylaxis
flatus and a lack of bowel movements.
Chewing gum is a type of sham feed-
Physical examination begins with
ing that promotes intestinal motility
exposing the entire abdomen. The
through cephalic-vagal stimulation. In
appearance of the abdomen should
normal volunteers, chewing gum is
be noted because it is typically dis-
as effective as food in stimulating
tended in the case of ileus. The dis-
cephalic-phase gastric secretion.29,30
tended abdomen may be tympanic on
In meta-analyses devoted to deter-
percussion. Discrete tenderness of the
mining whether chewing gum should
abdomen, in conjunction with leu-
be part of a perioperative protocol to
kocytosis and elevated inflammatory
reduce ileus in patients undergoing
markers, is not typical in a case of
abdominal surgery, results confirmed
ileus and may be a red flag for true
that chewing gum has some beneficial
mechanical obstruction or other
effect.29-31 Virtually all studies eval-
inflammatory process (eg, appendi-
uating the use of chewing gum to
citis, colitis, diverticulitis). Ausculta-
combat ileus have been in patients
tion with a stethoscope typically
undergoing bowel resection or other
yields no bowel sounds. This finding
intra-abdominal procedures, and the
is in direct contrast to Ogilvie syn-
results may or may not be extrapo-
drome in which bowel sounds are
lated to the orthopaedic population.
often preserved as a result of contin-
Although patients who began chew-
ued small bowel function. A firm,
ing gum the morning after intestinal
acutely tender abdomen and/or
surgery had return of flatus and
a guarding response are indications
bowel movements earlier than did
that bowel perforation may have
patients who did not chew gum,29
occurred; if detected, urgent supine
chewing gum may not lead to dif-
and upright abdominal radiography
ferences in length of stay.31 Although
and general surgical consultation are
these analyses are based on small
mandatory.
trials, chewing gum may actually be
If ileus is suspected, a plain abdom-
a cost-effective intervention that can
inal radiograph is a simple and effec-
be considered for selected patients.30
tive screening tool (Figure 1).
Distended loops of small and large
bowel will be seen in a paralytic Treatment After Diagnosis
ileus (Figure 2), but these findings
may be difficult to differentiate from Traditional treatment of an uncom-
a mechanical cause of obstruction. plicated ileus can be initiated once the
Ogilvie syndrome has dilated loops of diagnosis is made. Initially, the
large bowel with normal-appearing patient should be made nil per os.
small bowel (Figure 3). A contrast Significant accumulation of gastric
enema was historically used to diag- and bowel secretions can lead to
nose a large bowel obstruction, but nausea and emesis. Dehydration may
this technique has largely been re- occur as a result of secretion retention
placed with CT. CT scans, with or within the gastrointestinal tract;
without oral contrast, offer the treatment should consist of appro-
advantage of being able to look for priate intravenous fluid resuscitation.
other potential causes of mechanical Although routine use of nasogastric
obstruction, colon wall thinning, and decompression is not warranted for
367
Paralytic Ileus in the Orthopaedic Patient

Figure 1

Algorithm demonstrating a strategy for evaluation of suspected ileus. NPO = nothing by mouth, WBC = white blood cell count.

every patient with ileus, selective use
of nasogastric tubes in intractably
nauseated patients or in patients at
a high risk of aspiration should be
a consideration.
Electrolyte abnormalities (ie, sodium,
potassium, chloride, calcium, magne-
sium) should be assessed and corrected
when ileus is diagnosed. Hyponatremia,
hypokalemia, and hypocalcemia have
all been seen in association with ileus
and are thought to contribute to gas-
trointestinal dysfunction.
Early ambulation has been postu-
lated to have a prokinetic effect on
the gastrointestinal system, although
the mechanism of ambulation on
ileus resolution is unclear, and direct
evidence of its utility is lacking.32
Early ambulation in orthopaedic
patients has known benefits,
including the prevention of venous
thromboembolic disease and respi-
ratory infections postoperatively.
Early ambulation is a simple, inex-
pensive investment of resources
after orthopaedic surgery, and it
should be included as part of
a comprehensive early rehabilita-
tion protocol whenever permissible.

368 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Alan H. Daniels, MD, et al

Pharmacologic Figure 2
Interventions
Prokinetic motility drugs are com-
monly used following abdominal
surgery to prevent ileus, although
a Cochrane review33 published in
2008 examined 39 randomized
controlled trials and found most
medications to be of little or no
benefit. Erythromycin used as an
early treatment for the prevention of
ileus demonstrated no clinical effect
in all trials included in this review.
Alvimopan, a m-opioid antagonist
that was still in an investigational
stage, was the only medication
whose use was supported.33
Antiemetics can be used to help
alleviate nausea associated with ileus.
Metoclopramide has both antiemetic
and prokinetic effects. It increases
gastric emptying and, to a lesser
extent, increases esophageal and small
bowel motility. It exerts minimal ef-
fects on the distal small bowel and the
colon. However, metoclopramide
does not decrease the length of ileus,
and it can lead to agitation or dystonic
reactions in up to 20% of patients.34
Pantothenic acid, also known as
vitamin B5, has been proposed as
a treatment of ileus. In a randomized
study of orthopaedic patients,35 the
administration of dexpanthenol (ie,
an alcohol derivative of pantothenic
acid) significantly decreased the time
from surgery to the first bowel
movement. The study also showed
a dose-response relationship between
pantothenic acid and the decreasing
time from surgery to the first bowel
movement.35
Neostigmine is an acetylcholines- Initial standing preoperative lateral (A) and AP (B) radiographs demonstrating
terase inhibitor that increases cho- a large amount of bowel gas in a 16-year-old girl with an L3-4 flexion-distraction
linergic (ie, parasympathetic) activity spinal injury. Postoperative lateral (C) and AP (D) radiographs demonstrating
paralytic ileus.
within the gastrointestinal tract,
leading to increased gastrointestinal
motility. In a randomized trial,36 patients in the treatment group had cramping, moderate to severe ab-
patients with Ogilvie syndrome were resolution of pseudo-obstruction at dominal pain, excessive salivation,
randomly assigned to receive either 2 an average of 4 minutes. Treatment and emesis. Two patients in the
mg of neostigmine or saline; 10 of 11 adverse effects were abdominal study group were treated with

June 2015, Vol 23, No 6 369

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Paralytic Ileus in the Orthopaedic Patient

Figure 3 Figure 4

A, Abdominal CT scan with contrast demonstrating diffuse distention of the large

AP radiograph demonstrating
distended colonic loops, consistent
with Ogilvie syndrome, in an 89-year-
old man 1 day following
intramedullary nailing of a left
intertrochanteric femur fracture. The
patient became hypotensive and
unresponsive with abdominal
distention. A chest radiograph
revealed free air caused by colonic
perforation. Open colon resection
was attempted; however, the patient
expired during surgery.
atropine following the development
of symptomatic bradycardia.36 In
seven patients who underwent
orthopaedic spine surgery (ie, pos-
terior lumbar fusion, anteroposterior
lumbar fusion, lumbar laminectomy,
Harrington rod stabilization of sco-
liosis), and who also received 2 mg of
neostigmine, six of seven patients
had prompt return of bowel function
at an average of 5.25 minutes. This
study excluded patients with a his-
tory of bradycardia or broncho-
spasm.18 Prior to the administration
of neostigmine, mechanical bowel
obstruction, perforation, and bowel
ischemia must be ruled out.
m-Opioid receptors (along with k
and D receptors) are important medi-
ators of the effects of opioids. The
m-receptor is important in normal
gastrointestinal function; its activation
decreases gut motility. Not surpris-
ingly, m receptors in the enteric ner-
vous system are an attractive target for
and small bowel with no apparent transition zone in a patient with paralytic ileus.
B, Abdominal CT scan demonstrating dilated loops of small bowel (white arrow),
a transition zone, and collapsed small bowel loops (red arrow) in a patient with
mechanical small bowel obstruction.
intervention; methylnaltrexone is one
such selective m-receptor antagonist. It
does not cross the blood-brain barrier;
thus, it does not interfere with opioid
pain medication. It has a short half-life
of 2 to 3 hours and is administered
intravenously or subcutaneously every
6 hours. Methylnaltrexone has been
studied in opioid-induced constipation
and was found more effective than
placebo at producing a bowel move-
ment at doses of 0.15 mg/kg and 0.3
mg/kg.26 Methylnaltrexone has also
been used successfully in the treatment
of Ogilvie syndrome.37
Alvimopan is another m-receptor
antagonist, specific for gastrointestinal
receptors, and it has a higher receptor
affinity than methylnaltrexone. It is
approved for use for the treatment of
ileus in patients undergoing a bowel
resection, and it has been used for the
prevention of postoperative ileus in
patients who have undergone bowel
resection.38,39 Although its popularity
has not yet spread beyond patients
undergoing abdominal surgery, there
may be clinical applicability in high-
risk orthopaedic patients. The half-life
of alvimopan is 2.5 to 6 hours, and it
is administered orally twice daily. The
dose for preventing postoperative ileus
is 12 mg twice daily until the first
flatus.39 In a randomized trial of pa-
tients with opioid-induced bowel
dysfunction, 54% of patients receiving
a low dose of 1 mg daily had a bowel
movement within 8 hours of admin-
istration compared with 43% of pa-
tients receiving 0.5 mg daily, and with
29% of patients receiving a placebo.
Alvimopan did not antagonize opioid
pain medication effects.40 A similar
study of patients receiving opioids also
showed more spontaneous bowel
movements in patients randomized
to alvimopan, without requiring an
increased narcotic dose.41
Surgical Treatment of Ileus
Surgery is not indicated in a true
paralytic ileus in the absence of bowel
perforation or ischemia. In general,
surgical consultation early in the
course of ileus is important to rule out
more dangerous causes of cessation
of bowel function. Ogilvie syndrome
may lead to ischemic changes within
the colon, perforation, sepsis, and
even death; thus, whenever a diagno-
sis of Ogilvie syndrome is suspected
because of cecal dilation observed on
radiographic imaging, immediate
surgical consultation is indicated.

370 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Historically, it was thought that
colonic decompression via colonos-
copy was indicated in select patients
with Ogilvie syndrome. Recurrence of
dilation after endoscopic decompres-
sion approaches 40%.42 Surgery is
associated with a high mortality rate;
thus, it should be considered as
a measure of final resort and in cases
of bowel perforation. Colectomy
should be reserved for patients who
have sustained a perforation, who are
at risk for such an event, or who have
ischemic changes in the colon.
Summary
Though typically self-limiting, ileus
may have substantial implications in
terms of delayed patient mobiliza-
tion, discomfort in the perioperative
period, malnutrition, prolonged
hospital stay, hospital readmission,
and death in rare cases. In the current
age of healthcare spending in which
length of stay and hospital costs are
being closely monitored, preventing
and treating ileus are important fac-
tors in optimizing patient outcomes.
Use of regional anesthesia when
possible, early postoperative mobili-
zation, prompt recognition of ileus,
correct diagnosis, and early treat-
ment interventions are important to
achieving optimal outcomes.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 10,
26, 28, 33, and 38-41 are level I
studies. References 3, 6, 18, 30, 31,
and 35 are level II studies. References
1, 2, 4, 5, 7, 13, 14, 19, 20, 22, 27, and
32 are level III studies. References 15,
17, 21, 24, and 37 are level IV studies.
References 8, 9, 11, 12, 16, 25, 34,
and 42 are level V expert opinion.
References printed in bold type are
those published within the past 5
years.
June 2015, Vol 23, No 6
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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