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Ileus Adynamic ileus Mechanical ileus.

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Presentation on theme: "Ileus Adynamic ileus Mechanical ileus."— Presentation transcript:

1 Ileus Adynamic ileus Mechanical ileus

2 Adynamic ileus Pathophysiology Paralysis of intestinal motility

3 Adynamic ileus II. Causes Abdominal trauma
Abdominal surgery (i.e. laparatomy) Serum electrolyte abnormality 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypermagensemia

4 Adynamic ileus D. Infectious, Inflammatory or irritation (bile, blood)
1. Intrathoracic Pneumonia Lower lobe rib fractures Myocardial Infarction 2. Intrapelvic e.g. Pelvic Inflammatory Disease

5 Adynamic ileus 3. Intraabdominal Appendicitis Diverticulitis
Nephrolithiasis Cholecystitis Pancreatitis Perforated Duodenal Ulcer

6 Adynamic ileus E. Intestinal Ischemia F. Skeletal injury
Mesenteric embolism, ischemia or thrombosis F. Skeletal injury Rib fracture Vertebral fracture (e.g. lumbar compression fracture)

7 Adynamic ileus G. Medications Narcotics Phenothiazines
Diltiazem or Verapamil Clozapine Anticholinergic Medications

8 Adynamic ileus III. Symptoms Abdominal distention
Nausea and Vomiting are variably present Generalized abdominal discomfort Colicky pain of Mechanical Ileus is usually absent Flatus and Diarrhea may still be passed

9 Adynamic ileus IV. Signs V. Differential Diagnosis Quiet bowel sounds
Abdominal distention V. Differential Diagnosis Mechanical Ileus Bowel Pseudoobstruction

10 Adynamic ileus Decompress stomach with Nasogastric Tube
VI. Radiology: Refractory ileus course Indicated to evaluate for Mechanical Ileus Upper GI series and small bowel follow through May be diagnostic and therepeutic Use gastrograffin instead of barium Barium may further obstruct bowel lumen Gastrograffin may stimulate bowel motility Decompress stomach with Nasogastric Tube Instill gastrograffin via Nasogastric Tube

11 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

12 Adynamic ileus VII. Management Initial Limit or eliminate oral intake
Intravascular fluid replacement Correct electrolyte abnormalities (e.g. Hypokalemia) Consider Nasogastric Tube placement Refractory Management Consider Prokinatics Consider lower bowel stimulation (e.g. Enema)

13 Adynamic ileus VIII. Course
Post-operative ileus resolves within hours

14 Mechanical ileus Types Simple mechanical obstruction
Bowel lumen is obstructed No vascular compromise Closed loop obstruction Both ends of a bowel loop are obstructed Results in strangulated obstruction if untreated Rapid rise in intraluminal pressure Strangulated obstruction Bowel lumen and vascular supply is compromised

15 Mechanical ileus II. Causes Most Common Causes
Postoperative Adhesions (accounts for 50% of cases) Hernia (25% of cases, especially younger patients) Neoplasms (10% of cases, esp. older patients) Colon Cancer (most common) Ovarian Cancer Pancreatic cancer Gastric Cancer

16 Mechanical ileus Intrinsic bowel lesions
Congenital anomalies (Pediatric) Atresia Stenosis Bowel duplication

17 Mechanical ileus 2. Strictures
Inflammatory Bowel Disease (e.g. Crohn's Disease) Colon Cancer Intussusception Children: Usually idiopathic Adults: 95% have underlying mechanical cause AIDS may predispose to Intussusception Gallstones that have entered the bowel lumen More common in those over age 65 years Bezoar Barium Ascaris infection Tuberculosis Actinomycosis Diverticulitis

18 Mechanical ileus C. Extrinsic bowel lesions Adhesion
Abdominal or pelvic surgery Presence of peritonitis or trauma Hernia (higher risk for strangulation) Inguinal hernia (direct ,indirect) Internal hernias via mesenteric defects Obturator hernia More common in emaciated elderly women

19 Mechanical ileus D. Idiopathic Intestinal Obstruction
3. Small bowel volvulus Rare compared to colon volvulus More common in Africa, Middle East and India Occurs in intestinal malrotation or adhesions D. Idiopathic Intestinal Obstruction 1. See Bowel Pseudoobstruction

20 Mechanical ileus III. Symptoms
Frequent and recurrent Generalized Abdominal Pain Duration: Seconds to minutes Character: Spasms of crampy abdominal pain Frequency Intermittent pain initially Every few minutes in proximal obstruction Constant pain suggests ischemia or perforation

21 Mechanical ileus B. Stool passage
Initially may be present despite complete obstruction Later, obstipation (no stool) in complete obstruction C. Symptoms more severe in proximal obstruction 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

22 May occur at any point in length of small bowel
Where? May occur at any point in length of small bowel

23 Mechanical ileus Distal obstruction
Develops over days and becomes progressively worse Emesis may occur and is brown and feculent Significant abdominal distention

24 Mechanical ileus IV. Signs Bowel sounds Tender abdominal mass
Initial: High pitched, hyperactive bowel sounds Later: hypoactive or absent bowel sounds Tender abdominal mass Closed loop Bowel Obstruction may be palpable Abdominal distention and tympany on percussion Indicates distal obstruction Rectal examination for blood

25 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.

26 The diagnosis is usually confirmed by Radiology
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

27 Mechanical ileus V. Radiology: Flat and upright (or decubitus) abdominal X-Ray Sensitivity: 60% (up to 90%) Typical findings of Bowel Obstruction Bowel distention proximal to obstruction Bowel collapsed distal to obstruction Upright or decubitus view: Air-fluid levels Supine view findings Sharply angulated distended bowel loops Step-ladder arrangement or parallel bowel loops

28 Abdominal series Radiograph of the abdomen in a supine position Radiograph of the abdomen in an upright position Radiograph of the chest in an upright position. Most Specific Finding: The Triad Dilated small-bowel loops (>3 cm in diameter) Air-Fluid levels on upright films 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.

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

30 Mechanical ileus c .String of pearls sign (specific for obstruction)
Series of small pockets of gas in a row d. Pseudotumor Sign Bowel loop filled with fluid (resembles mass)


32 Mechanical ileus VI. Radiology
MRI Abdomen (93% Test Sensitivity for SBO cause) CT Abdomen (88% Test Sensitivity for SBO cause) Adjunct to plain XRay to identify obstruction site Findings Intussusception Volvulus Extraluminal mass (e.g. abscess, neoplasm) Closed loop obstruction Strangulated bowel


34 Flat Abdominal Film Dilated Loops of Small Bowel
No Air in Colon or Rectum


36 Upright Abdominal Film
Air - Fluid Levels Dilated Small Bowel

37 Computed Tomographic (CT) scanning
Study preformed with oral and IV contrast. Findings: Discrete transition zone with dilation of bowel proximally and decompressed distally Intraluminal contrast that does not pass beyond the transition zone 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%


39 Dilated Loops of Small Bowel with Air-Fluid levels
Area of non-dilated small bowel. Absence of Air in the Colon.

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

41 Mechanical ileus VII. Differential Diagnosis Adynamic Ileus
Bowel Pseudoobstruction Ischemic bowel (superior mesenteric syndrome) Gastroenteritis Cholelithiasis Cholecystitis Pancreatitis Peptic Ulcer Disease Appendicitis Myocardial Infarction Pregnancy

42 Mechanical ileus VIII. Management: Conservative Therapy
Fluid replacement Bowel decompression Nasogastric Tube Long intestinal tube (eg. Cantor) offers no advantage Antibiotic Indications (Not for routine use) Surgery planned Bowel ischemia or infarction Bowel perforation Cover Gram Negatives and Anaerobes a Second-generation Cephalosporin

43 Mechanical ileus IX. Management: surgical intervention
Spontaneous resolution often occurs without surgery Partial small bowel obstruction: 75% Complete small bowel obstruction: up to 50%

44 Mechanical ileus Predictors of resolution without surgery
Early postoperative bowel obstruction Adhesive obstruction (prior laparotomy) Crohn's disease Indications for surgery Inadequate relief with Nasogastric tube placement Persistant symptoms >48 hours despite treatment (strangulation) Neoplasms

45 Mechanical ileus X. Complications
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 Risk after first episode: 53% Risk after more than one episode: 83%

46 New Aspect in Treatment of Adhesive Ileus
1. Adhesive small bowel obstruction: How long can patients tolerate conservative treatment? World J Gastroenterol Mar 15;9(3): 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

47 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.

48 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

49 Conclusion With closely monitoring, most patients with small bowel obstruction due to postoperative adhesions could tolerate supportive treatment and recover well averagely within 1 week although some patients require more than 10 days of observation.

50 British Journal of Surgery ,3 Jul 2003
2. Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction British Journal of Surgery ,3 Jul 2003 Volume 90, Issue 9 , Pages C. Wullstein *, E. Gross Chirurgische Abteilung, Allgemeines Krankenhaus Barmbek, Hamburg, Germany

51 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.

52 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 CONV (p=0.001) 4.Days of hospital stay LAP CONV (p=0.001)

53 Conclusion Laparoscopic treatment of acute SBO was feasible in about half of these patients. Postoperative recovery was improved after laparoscopic procedures but the risk of intraoperative complications increased . 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.

54 Thank For Your Attentions!!!

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