Ileus

Adynamic ileus
Mechanical ileus

Ri

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.
2.

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

Adynamic ileus
G. Medications
1.
2.
3.
4.
5.

Narcotics
Phenothiazines
Diltiazem or Verapamil
Clozapine
Anticholinergic Medications

Adynamic ileus
III. Symptoms

C.

Abdominal distention
Nausea and Vomiting are variably present
Generalized abdominal discomfort
1.
Colicky pain of Mechanical Ileus is
usually absent

D.

Flatus and Diarrhea may still be passed

A.
B.

Adynamic ileus
IV. Signs
A.
B.

Quiet bowel sounds

Abdominal distention

V. Differential Diagnosis
A.

Mechanical Ileus

B.

Bowel Pseudoobstruction

Adynamic ileus
VI. Radiology: Refractory ileus course

Indicated to evaluate for Mechanical Ileus

A.
B.

Upper GI series and small bowel follow through

1. May be diagnostic and therepeutic
2. Use gastrograffin instead of barium
3.
4.

C.

D.

Barium may further obstruct bowel lumen

Gastrograffin may stimulate bowel motility

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.

Initial
1. Limit or eliminate oral intake
2. Intravascular fluid replacement
3. Correct electrolyte abnormalities (e.g. Hypokalemia)
4.

B.

Consider Nasogastric Tube placement

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.

B.

C.

Simple mechanical obstruction

1. Bowel lumen is obstructed
2. No vascular compromise
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
Strangulated obstruction
1.
Bowel lumen and vascular supply is
compromised

Mechanical ileus
II. Causes
A. Most Common Causes
1.

2.
3.

Postoperative Adhesions (accounts for 50% of

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

Character: Spasms of crampy abdominal pain
Frequency

1.
2.

a.
b.
c.

Intermittent pain initially

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

Mechanical ileus
B. Stool passage
1.
2.

Initially may be present despite complete obstruction

Later, obstipation (no stool) in complete obstruction

C. Symptoms more severe in proximal obstruction

1.

Proximal obstruction

Severe, colicky abdominal pain

Constant pain suggests ischemia or perforation
Develops over hours and occurs every few minutes
Bilious Emesis
Mild abdominal distention

Where?

May occur at any point in length of small

bowel

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.

B.
C.

2.

Initial: High pitched, hyperactive bowel sounds

Later: hypoactive or absent bowel sounds

Tender abdominal mass

1.

Closed loop Bowel Obstruction may be palpable

Abdominal distention and tympany on

percussion
1.

Indicates distal obstruction

Rectal examination for blood

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.

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

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

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.

Small Bowel Gas Pattern

Centrally located
Soft tissue across entire lumen
Colon Gas Pattern
Peripheral Located
Mostly not overlapping
Haustra markings

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.
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

Flat Abdominal Film

Dilated Loops of Small Bowel

No Air in Colon or Rectum

Upright Abdominal Film

Air - Fluid Levels

Dilated Small Bowel

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%

 Dilated Loops of Small Bowel with Air-Fluid levels

Area of non-dilated small bowel.
Absence of Air in the Colon.

Pneumatosis Intestinalis
Dilated Loops of SB
Air in Wall of SB
No Air in Colon

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.

C.

2.

1.

A.

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.

Predictors of resolution without surgery

1.
2.
3.

B.

Early postoperative bowel obstruction

Adhesive obstruction (prior laparotomy)
Crohn's disease

Indications for surgery

1.
2.

3.

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%

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.

Thank For Your

Attentions!!!