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!!!