Professional Documents
Culture Documents
Ri
Adynamic ileus
I.
A.
Pathophysiology
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
Adynamic ileus
E. Intestinal Ischemia
1.
Mesenteric embolism, ischemia or thrombosis Rib fracture Vertebral fracture (e.g. lumbar compression fracture)
F. Skeletal injury
1. 2.
Adynamic ileus
G. Medications
1. 2.
3.
4. 5.
Adynamic ileus
III. Symptoms
A. B. C.
Abdominal distention Nausea and Vomiting are variably present Generalized abdominal discomfort 1. Colicky pain of Mechanical Ileus is usually absent Flatus and Diarrhea may still be passed
D.
Adynamic ileus
IV. Signs
A. B.
V. Differential Diagnosis
A. B.
Adynamic ileus
VI. Radiology: Refractory ileus course
A. B.
Indicated to evaluate for Mechanical Ileus Upper GI series and small bowel follow through 1. May be diagnostic and therepeutic 2. Use gastrograffin instead of barium
3. 4.
Barium may further obstruct bowel lumen Gastrograffin may stimulate bowel motility
C.
D.
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.
B.
Initial 1. Limit or eliminate oral intake 2. Intravascular fluid replacement 3. Correct electrolyte abnormalities (e.g. Hypokalemia) 4. 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.
A.
Types
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
B.
C.
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.
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 Inguinal hernia (direct ,indirect) Internal hernias via mesenteric defects Obturator hernia More common in emaciated elderly women
c.
Mechanical ileus
3. Small bowel volvulus
a. Rare compared to colon volvulus b. More common in Africa, Middle East and
Mechanical ileus
III. Symptoms A. Frequent and recurrent Generalized Abdominal Pain B. Duration: Seconds to minutes
1. 2.
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
Proximal obstruction
a. Severe, colicky abdominal pain b. Constant pain suggests ischemia or perforation c. Develops over hours and occurs every few
Where?
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. 2.
Initial: High pitched, hyperactive bowel sounds Later: hypoactive or absent bowel sounds
B.
1.
C.
1.
D.
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.
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.
Intussusception Volvulus Extraluminal mass (e.g. abscess, neoplasm) Closed loop obstruction Strangulated bowel
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.
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. 2.
C.
1.
2.
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.
1. 2. 3.
B.
1.
2.
3.
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
Risk after first episode: 53% Risk after more than one episode: 83%
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
2. 3.
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.