6 Adynamic ileus E. Intestinal Ischemia F. Skeletal injury Mesenteric embolism, ischemia or thrombosisF. Skeletal injuryRib fractureVertebral fracture (e.g. lumbar compression fracture)
7 Adynamic ileus G. Medications Narcotics Phenothiazines Diltiazem or VerapamilClozapineAnticholinergic Medications
8 Adynamic ileus III. Symptoms Abdominal distention Nausea and Vomiting are variably presentGeneralized abdominal discomfortColicky pain of Mechanical Ileus is usually absentFlatus and Diarrhea may still be passed
9 Adynamic ileus IV. Signs V. Differential Diagnosis Quiet bowel sounds Abdominal distentionV. Differential DiagnosisMechanical IleusBowel Pseudoobstruction
10 Adynamic ileus Decompress stomach with Nasogastric Tube VI. Radiology: Refractory ileus courseIndicated to evaluate for Mechanical IleusUpper GI series and small bowel follow throughMay be diagnostic and therepeuticUse gastrograffin instead of bariumBarium may further obstruct bowel lumenGastrograffin may stimulate bowel motilityDecompress stomach with Nasogastric TubeInstill gastrograffin via Nasogastric Tube
11 Adynamic ileus D. Contrast with Mechanical Ileus 1. Less prominent air fluid levels2. Generalized involvement of entire GI tract3. Air filled bowel loops tend not to be distended
13 Adynamic ileus VIII. Course Post-operative ileus resolves within hours
14 Mechanical ileus Types Simple mechanical obstruction Bowel lumen is obstructedNo vascular compromiseClosed loop obstructionBoth ends of a bowel loop are obstructedResults in strangulated obstruction if untreatedRapid rise in intraluminal pressureStrangulated obstructionBowel 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 CancerPancreatic cancerGastric Cancer
17 Mechanical ileus 2. Strictures Inflammatory Bowel Disease (e.g. Crohn's Disease)Colon CancerIntussusceptionChildren: Usually idiopathicAdults: 95% have underlying mechanical causeAIDS may predispose to IntussusceptionGallstones that have entered the bowel lumenMore common in those over age 65 yearsBezoarBariumAscaris infectionTuberculosisActinomycosisDiverticulitis
18 Mechanical ileus C. Extrinsic bowel lesions Adhesion Abdominal or pelvic surgeryPresence of peritonitis or traumaHernia (higher risk for strangulation)Inguinal hernia (direct ,indirect)Internal hernias via mesenteric defectsObturator herniaMore common in emaciated elderly women
19 Mechanical ileus D. Idiopathic Intestinal Obstruction 3. Small bowel volvulusRare compared to colon volvulusMore common in Africa, Middle East and IndiaOccurs in intestinal malrotation or adhesionsD. Idiopathic Intestinal Obstruction1. See Bowel Pseudoobstruction
20 Mechanical ileus III. Symptoms Frequent and recurrent Generalized Abdominal PainDuration: Seconds to minutesCharacter: Spasms of crampy abdominal painFrequencyIntermittent pain initiallyEvery few minutes in proximal obstructionConstant pain suggests ischemia or perforation
21 Mechanical ileus B. Stool passage Initially may be present despite complete obstructionLater, obstipation (no stool) in complete obstructionC. Symptoms more severe in proximal obstructionProximal obstructionSevere, colicky abdominal painConstant pain suggests ischemia or perforationDevelops over hours and occurs every few minutesBilious EmesisMild 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 worseEmesis may occur and is brown and feculentSignificant abdominal distention
24 Mechanical ileus IV. Signs Bowel sounds Tender abdominal mass Initial: High pitched, hyperactive bowel soundsLater: hypoactive or absent bowel soundsTender abdominal massClosed loop Bowel Obstruction may be palpableAbdominal distention and tympany on percussionIndicates distal obstructionRectal 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 ileusDetermining the etiology of the obstructionDiscriminating partial from complete obstructionDiscriminating simple from strangulating obstruction.History:Prior abdominal operationsPresence of abdominal disorders (cancer or IBD)Last BM and FlatusPediatrics - Ingestion of foreign bodyPhysical 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 ileusV. Radiology: Flat and upright (or decubitus) abdominal X-RaySensitivity: 60% (up to 90%)Typical findings of Bowel ObstructionBowel distention proximal to obstructionBowel collapsed distal to obstructionUpright or decubitus view: Air-fluid levelsSupine view findingsSharply angulated distended bowel loopsStep-ladder arrangement or parallel bowel loops
28 Abdominal seriesRadiograph of the abdomen in a supine positionRadiograph of the abdomen in an upright positionRadiograph of the chest in an upright position.Most Specific Finding: The TriadDilated small-bowel loops (>3 cm in diameter)Air-Fluid levels on upright filmsPaucity 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 locatedSoft tissue across entire lumenColon Gas PatternPeripheral LocatedMostly not overlappingHaustra markings
30 Mechanical ileus c .String of pearls sign (specific for obstruction) Series of small pockets of gas in a rowd. Pseudotumor SignBowel 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 siteFindingsIntussusceptionVolvulusExtraluminal mass (e.g. abscess, neoplasm)Closed loop obstructionStrangulated bowel
36 Upright Abdominal Film Air - Fluid LevelsDilated 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 distallyIntraluminal contrast that does not pass beyond the transition zoneColon 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%
42 Mechanical ileus VIII. Management: Conservative Therapy Fluid replacementBowel decompressionNasogastric TubeLong intestinal tube (eg. Cantor) offers no advantageAntibioticIndications (Not for routine use)Surgery plannedBowel ischemia or infarctionBowel perforationCover Gram Negatives and Anaerobesa Second-generation Cephalosporin
43 Mechanical ileus IX. Management: surgical intervention Spontaneous resolution often occurs without surgeryPartial small bowel obstruction: 75%Complete small bowel obstruction: up to 50%
44 Mechanical ileus Predictors of resolution without surgery Early postoperative bowel obstructionAdhesive obstruction (prior laparotomy)Crohn's diseaseIndications for surgeryInadequate relief with Nasogastric tube placementPersistant symptoms >48 hours despite treatment (strangulation)Neoplasms
45 Mechanical ileus X. Complications Intestinal Ischemia or infarctionBowel necrosis, perforation and bacterial peritonitisHypovolemiaComplications of surgical intervention if neededXI. Prognosis: Recurrence of obstruction due to adhesionsRisk 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 Method1. 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 observationMedically: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 ConclusionWith closely monitoring, most patients with small bowel obstruction due to postoperative adhesions could tolerate supportive treatmentand recover well averagely within 1 weekalthough 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 obstructionBritish Journal of Surgery ,3 Jul 2003Volume 90, Issue 9 , PagesC. 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) werecompared 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=0.1562.PostOP complication(Pulmonary, Cardiac, Deep vain thrombosis, Death…)LAP 10/52 (19.2%) CONV 8/52 (40.4%) p=0.0323.Bowel movement, days after OPLAP CONV (p=0.001)4.Days of hospital stayLAP CONV (p=0.001)
53 ConclusionLaparoscopic 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.
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