1. Theme of lecture: ACQUIRED INTESTINAL ILEUS

2. Plan: Paralytic ileus. Obstruction of the small and large bowel.
Intussusception.
Adhesive Intestinal Obstruction

3. ACQUIRED INTESTINAL ILEUS Classification

4. Causes of paralytic ileus
Medications, especially narcotics
Intraperitoneal infection
Mesenteric ischemia Injury to the abdominal blood supply
Complications of intra-abdominal surgery
Kidney or thoracic disease
Metabolic disturbances (such as decreased potassium levels)
Cranial and cerebral injuries

5. Classification
Compensated
Subcompensated
Decompensated

6. Clinical manifestations and diagnostic studies
Constant gnawing pain
repeated vomiting
symmetric abdominal distention
reduced or absence of peristalsis
increasing meteriorism
constipation
heavy intoxication

7. Diagnostic studies Physical examination Ragiological investigation
Laboratory tests (hypokalemia)

8. Treatment of paralytic ileus
Para-nephral and pre-sacral novocaine nerve blocks
Gastric lavage and intestinal intubation
Stimulation of intestinal peristalsis
IV fluids and electrolytes,
a minimal amount of sedatives,
adequate serum K level (> 4 mEq/L [> 4 mmol/L])
Sometimes colonic ileus can be relieved by colonoscopic decompression; rarely cecostomy is required. Ileus persisting > 1 wk probably has a mechanical obstructive cause, and laparotomy should be considered.

9. The mechanical causes of intestinal obstruction
Hernias
Postoperative adhesions or scar tissue
Impacted feces (stool)
Gallstones
Tumors
Granulomatous processes (abnormal tissue growth)
Intussusception
Volvulus
Foreign bodies

10. Obstruction of the small bowel
Abdominal cramps around the umbilicus or in the epigastrium;
Vomiting starts early
Obstipation occurs with complete obstruction, but diarrhea may be present with partial obstruction.
Strangulating obstruction occurs in nearly 25% of cases and can progress to gangrene in as little as 6 h

11. Obstruction of the large bowel
Symptoms usually develop more gradually
increasing constipation
abdominal distention
vomiting (not usually)
lower abdominal cramps
unproductive of feces
distended abdomen
there is no tenderness
the rectum is usually empty

12. X-ray examination
Sign of reversed cups of Kloiber: shows position of air-filled loops of bowel and horizontal levels of the fluid below gas
Presence of shady fields of the large bowel
If peritonitis has developed, we can see free gas under the liver, because bowel is damaged

14. Adhesive Intestinal Obstruction
The incidence of postoperative adhesive obstruction after laparotomy is about
2%. The procedures which have highest risk for adhesive McBurney’s point in pediatric
patients are:
1. subtotal colectomy,
2. resection of symptomatic Meckel’s diverticulum,
3. Ladd’s procedure, and
4. nephrectomy.

15. Etiology
The causes of postoperative McBurney’s point include adhesions, intussusception,hernia, and tumor. Adhesions are fibrous bands of tissue that form between loops of bowel or between the bowel and the abdominal wall after intraabdominal inflammation. Obstruction occurs when the bowel is “caught” within one of these
fibrous bands in a kinked or twisted position, twists around an adhesive band, or herniates between a band and another fixed structure within the abdomen.

16. Clinical Presentation
cramping abdominal pain,
distension, and vomiting.(bilious or even feculent).
Inspection of the abdomen may reveal obvious dilated loops of bowel and distension.
fever, tachycardia, decreased blood pressure, abdominal tenderness and leukocytosis.

17. Differential diagnosis
pancreatitis,
hepatitis
biliary tract disease.
urinary tract infection, nephritis, stones.
systemic infection.
colitis, rotavirus.
pneumonia.

18. Treatment isotonic saline solutions, nasogastric decompression,
correction of electrolyte abnormalities,
IV antibiotics,
Indications for operation include obstipation for 24 hours, continued abdominal pain with fever and tachycardia, decreased blood pressure, increasing abdominal tenderness, and leukocytosis despite adequate resuscitation and medical treatment.The abdomen is opened through a previous incision, if present, and midline, if not. The cecum is identified and the collapsed ileum is followed proximally until dilated bowel and the point of obstruction is identified. The offending adhesive bands are disrupted and the abdomen is closed. Laparoscopic lysis of adhesions is another option and may allow a shorter postoperative recovery and hospital stay. Postoperatively, nasogastric decompression and intravenous fluids are continueduntil return of bowel function and the volume of gastric aspirate decreases.

19. Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing a bowel obstruction.
intussuscipiens
intussusceptum

20. Frequency. Intussusception is the predominate cause of intestinal obstruction in persons aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 live births. Sex. Overall, the male-to-female ratio is approximately 3:1.

21. Etiology
Intussusception is most commonly idiopathic and no anatomic lead point can be identified. Several viral gastrointestinal pathogens (rotavirus, reovirus, echovirus) may cause hypertrophy of the Peyer’s patches of the terminal ileum which may potentiate bowel intussusception.
A recognizable, anatomic lesion acting as a lead point is only found in 2-12% of all pediatric cases. The most commonly encountered anatomic lead point is a Meckel’s diverticulum. Other anatomic lead points include polyps, ectopic pancreatic or gastric rests, lymphoma, lymphosarcoma, enterogenic cyst, hamartomas (i.e., Peutz-Jeghers syndrome), submucosal hematomas (i.e., Henoch-Schonlein purpura), inverted appendiceal stumps, and anastomotic suture lines. Children with cystic fibrosis are at increased risk of intussusception possibly due to thickened inspissated stool.
Postoperative intussusception accounts for 1.5-6% of all pediatric cases of intussusception.

22. Pathology/Pathophysiology
1.The intussusception begins at or near the ileocaecal valve without local anatomical lesion to cause it
2.The mesenteric vassels are drawn between the layers of the intussusception and compressed.
3.The sligth interference with lymphatic and venous drainage results in edema and an increase of tissue pressure
4.Venulus and capillaries became great engorged and bloody edema fluid drips into the lumen
5.The mucosal cells swell into goblet cells and discharge mucus, which, mixing in the lumen with the bloody transsudate, forms the ‘current-jelly’ stool
6. Edema increases until venous inflow is completely obstructed
7. As arterial continues to pump in, tissue pressure rises until it is higher then arterial pressure, and gangrene results
8. Gangrene appears in the outer coat of the intussuseption and progresses back to the neck of the intussusception
9. Rarely the invagination is damaged

23. Classification Colic-involving segments of large intestine
Enteric-involving the small intestine only
Ileocecal-ileocecal prolapses into cecum drawing the ileum along with it
Ileocolic-the ileum prolapses through the ileocecal valve into the colon

24. Colic invagination

25. Enteric intussusception

26. Ileocolic invagination

27. Ileocecal intussusception

28. Clinical Presentation
1. vomiting (85%)-initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious.
2. abdominal pain (83%)-pain is colicky, severe, and intermittent.
3. passage of blood or bloody mucous per rectum (53%).
4. a palpable abdominal mass
5. lethargy.
6. diarrhea.
The classic triad of pain, vomiting, and bloody mucous stools (“red current jelly”) is present in only one third of infants with intussusception. Diarrhea may be present in 10-20% of patients.

29. Physical:
Usually, the abdomen is soft and nontender early, but it eventually becomes distended and tender.
A vertically oriented mass may be palpable in the right upper quadrant. Ruch’s symtom: Appering of the pain and screams during the palpation of intussusception mass under abdominal wall. Dance’s symptom: in ileocaecal invagination aconcave right lateral area of abdomen is palpable
Currant jelly stools are observed in only 50% of cases.
Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
Fever is a late finding and is suggestive of enteric sepsis.

30. Differential diagnosis
includes intestinal colic.
gastroenteritis.
acute appendicitis.
incarcerated hernia.
internal hernia.
volvulus.

31. Diagnostic studies:
Laboratory investigation usually is not helpful in the evaluation of patients with intussusception. Leukocytosis can be an indication of gangrene if the process is advanced. Dehydration is depicted by electrolyte imbalances.
X-ray examination: barium enema or pneumoirigography
Sonography CT

32. X-ray examination: 1)Intussusception - Plain Film
May be normal
Soft tissue mass, often in RUQ
Small bowel obstruction
May see intussusceptum

33. 2)Intussusception – Contrast Enema
Diagnosis and treatment
Media:
Air
Barium
Water soluble contrast

34. X-ray examination
Pneumoirigograhy

35. Air contrast enema shows intussusception in the cecum.

36. Air enema showing the intussusception is in the splenic flexure (arrow).

37. Barium enema shows intussusception in the descending colon.

38. CT scan reveals the classic ying-yang sign of an intussusceptum inside an intussuscipiens.

39. Ultrasound
The typical appearance is described variously as a "target sign" a doughnut sign, pseudokidney, or a sandwich sign.
Colour Doppler has been used to assess bowel viability and as a prognostic sign that reduction will be successful

40. Abdominal sonograph reveals the classic target sign of an intussusceptum inside an intussuscipiens.

41. Intussusception.
(A) Longitudinal sonogram of a child with the typical clinical presentation of intussusception. This is a longitudinal sonogram through the intussusception. There are multiple lymph nodes (arrows) in the intussusception. (B) Transverse sonogram of the intussusception showing the multiple lymph nodes (arrows) within the intussusception. If lymph nodes are seen within an intussusceptum it has been reported that it is more difficult to reduce the intussusception.

42. (C) Transverse sonogram of an intussusception showing the color flow within the intussusceptum. This indicates that the intussusception is still viable. When no color flow is seen on Doppler, suspicion must be raised that the intussusception is no longer viable and the risk of perforation is high.

43. Complications: Intestinal hemorrhage Necrosis and bowel perforation
Shock and sepsis

44. Treatment

45. Enema Reduction
Personal comfort level is probably the best contrast selection criterion
All have similar rates of reduction (75-85%) and perforation (1-2%)
End point - free reflux into small bowel and reduction of mass
Often see edema of ileocecal valve
Main goal is to prevent unnecessary open reduction, select patients who need resection

46. Non-operative reduction of the intussusception
Richardson balloon for pneumoirigography

47. Principles of barium enema reduction
1. Perform nasogastric suction: administer 4 fluids or blood and antibiotics
2. Insert ungreased Foley catheter in rectum, distend ballon and pull down against levator. Strap in place
3. Wrap legs
4. Let barium run from height of 30 cm in above table
5. X-ray intermittently
6. Stop if barium column is stationary and its unchanging for 10 min
7. Reduction

48. Reduction is marked by:
free from of barium meal into small bowel
expulsion of feces and air with the barium
disappearing of intussusception mass
response of child-clinical improvement of the patient, who may fall into a natural sleep

49. Surgical treatment indication is:
a shocked child with signs of peritonism
or in whom intussusception does not resolve with a nonoperativ procedure

50. Preoperative preparation includes:
Apply intravenous fluids or blood
Gastric aspiration (stomach has been empty), insert nasogastric tube
Administration of antibiotics

51. Operative technique:
The intussusception is milked back by progressive compression of the bowel

52. In severe cases: Intestinal resection
Placement of ileotransversal anastomosis
Ileostoma and caecostoma placement

53. BIBLIOGRAPHY
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