Definition

Ileus is a partial or complete non-mechanical blockage of the small and/or large intestine.

Description

There are two types of intestinal obstructions, mechanical and non-mechanical.

Mechanical obstructions occur because the bowel is physically blocked and its contents
can not pass the point of the obstruction. This happens when the bowel twists on itself
(volvulus) or as the result of hernias, impacted feces, abnormal tissue growth, or the
presence of foreign bodies in the intestines.

Unlike mechanical obstruction, non-mechanical obstruction, called ileus or paralytic

ileus, occurs because peristalsis stops. Peristalsis is the rhythmic contraction that moves
material through the bowel. Ileus is most often associated with an infection of the
peritoneum (the membrane lining the abdomen). It is one of the major causes of bowel
obstruction in infants and children.

Another common cause of ileus is a disruption or reduction of the blood supply to the
abdomen. Handling the bowel during abdominal surgery can also cause peristalsis to
stop, so people who have had abdominal surgery are more likely to experience ileus.
When ileus results from abdominal surgery the condition is often temporary and usually
lasts only 48–72 hours.

Ileus can also be caused by kidney diseases, especially when potassium levels are
decreased. Heart disease and certain chemotherapy drugs, such as vinblastine (Velban,
Velsar) and vincristine (Oncovin, Vincasar PES, Vincrex), also can cause ileus. Infants
with cystic fibrosis are more likely to experience meconium ileus (a dark green material
in the intestine). Over all, the total rate of bowel obstruction due both to mechanical and
non-mechanical causes is one in one thousand people (1/1,000).

SIGNS AND SYMPTOMS

When the bowel stops functioning, the following symptoms occur:

• abdominal cramping
• abdominal distention
• nausea and vomiting
• failure to pass gas or stool

DIAGNOSIS

When a doctor listens with a stethoscope to the abdomen there will be few or no bowel
sounds, indicating that the intestine has stopped functioning. Ileus can be confirmed by x
rays of the abdomen, computed tomography scans (CT scans), or ultrasound. It may be
necessary to do more invasive tests, such as a barium enema or upper GI series, if the
obstruction is mechanical. Blood tests also are useful in diagnosing paralytic ileus.

Barium studies are used in cases of mechanical obstruction, but may cause problems by
increasing pressure or intestinal contents if used in ileus. Also, in cases of suspected
mechanical obstruction involving the gastrointestinal tract (from the small intestine
downward) use of barium x rays are contraindicated, since they may contribute to the
obstruction. In such cases a barium enema should always be done first.

TREATMENT

Patients may be treated with supervised bed rest in a hospital, and bowel rest—where
nothing is taken by mouth and patients are fed intravenously or through the use of a
nasogastric tube. A nasogastric tube is a tube inserted through the nose, down the throat,
and into the stomach. A similar tube can be inserted in the intestine. The contents are then
suctioned out. In some cases, especially where there is a mechanical obstruction, surgery
may be necessary.

Drug therapies that promote intestinal motility (ability of the intestine to move
spontaneously), such as cisapride and vasopressin (Pitressin), are sometimes prescribed.

ALTERNATIVE TREATMENT

Alternative practitioners offer few treatment suggestions, but focus on prevention by

keeping the bowels healthy through eating a good diet, high in fiber and low in fat. If the
case is not a medical emergency, homeopathic treatment and traditional Chinese medicine
can recommend therapies that may help to reinstate peristalsis.

PROGNOSIS

The outcome varies depending on the cause of ileus.

PREVENTION

Most cases of ileus are not preventable. Surgery to remove a tumor or other mechanical
obstruction will help prevent a recurrence.

Adynamic IleusAka: Paralytic Ileus, Adynamic Bowel Obstruction,

Functional Bowel Obstruction, Neurogenic Bowel Obstruction

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1. Pathophysiology
1. Paralysis of intestinal motility
2. Causes
 1. Abdominal trauma
2. Abdominal surgery (i.e. laparatomy)
3. Serum electrolyte abnormality
1. Hypokalemia
2. Hyponatremia
3. Hypomagnesemia
4. Hypermagensemia
4. Infectious, Inflammatory or irritation (bile, blood)
1. Intrathoracic
1. Pneumonia)
2. Lower lobe rib Fractures
3. Myocardial Infarction
2. Intrapelvic (e.g. Pelvic Inflammatory Disease)
3. Intraabdominal
1. Appendicitis
2. Diverticulitis
3. Nephrolithiasis
4. Cholecystitis
5. Pancreatitis
6. Perforated Duodenal Ulcer
5. Intestinal Ischemia
1. Mesenteric embolism, ischemia or thrombosis
6. Skeletal injury
1. Rib Fracture
2. Vertebral Fracture (e.g. lumbar compression Fracture)
7. Medications
1. Narcotics
2. Phenothiazines
3. Diltiazem or Verapamil
4. Clozapine
5. Anticholinergic Medications
3. Symptoms
1. Abdominal distention
2. Nausea and Vomiting are variably present
3. Generalized abdominal discomfort
1. Colicky pain of Mechanical Ileus is usually absent
4. Flatus and Diarrhea may still be passed
4. Signs
1. Quiet bowel sounds
2. Abdominal distention
5. Differential Diagnosis
1. Mechanical Ileus
2. Bowel Pseudoobstruction
3. See Ileus for diagnostic approach
6. Radiology: Plain Flat and Upright Abdominal XRay
1. Contrast with Mechanical Ileus
 2. Less prominent air fluid levels
3. Generalized involvement of entire GI tract
4. Air filled bowel loops tend not to be distended
7. Radiology: Refractory ileus course
1. Indicated to evaluate for Mechanical Ileus
2. Upper GI series and small bowel follow through
1. May be diagnostic and therepeutic
2. Use gastrograffin instead of barium
1. Barium may further obstruct bowel lumen
2. Gastrograffin may stimulate bowel motility
3. Decompress stomach with Nasogastric Tube
4. Instill gastrograffin via Nasogastric Tube
3. CT Abdomen
8. Management
1. Initial
1. Limit or eliminate oral intake
2. Intravascular fluid replacement
3. Correct electrolyte abnormalities (e.g. Hypokalemia)
4. Consider Nasogastric Tube placement
2. Refractory Management (anecdotal evidence only)
1. Consider Reglan 0.1 mg/kg/dose
2. Consider lower bowel stimulation (e.g. Fleets Enema)
9. Course
1. Post-operative ileus resolves within 24-48 hours

HYPOKALEMIA

1. Pathophysiology
1. Approximate Total body potassium = 55 meq/kg
2. Serum Potassium decreased 1 meq/dl: 350 meq K+ deficit
3. Serum Potassium less than 2 meq/dl: 1000 meq K+ deficit
2. Symptoms and Signs (when Serum Potassium < 2.5)
1. General
1. Malaise
2. Fatigue
2. Neurologic
1. Weakness
2. Decreased Deep Tendon Reflexes
3. Paresthesia
4. Cramps
5. Restless legs Syndrome
6. Rhabdomyolysis
7. Paralysis
3. Gastrointestinal
1. Constipation
 2. Ileus
3. Exacerbated Hepatic Encephalopathy
4. Cardiovascular
1. Orthostatic Hypotension
2. Hypertension
3. Arrhythmias (especially with Digoxin use)
5. Renal
1. Metabolic Alkalosis
2. Polyuria, Polydipsia
3. Decreased GFR
4. Glucose Intolerance
3. Labs
1. Electrocardiogram
1. T Waves flattened
2. Prominent U Waves
3. ST depression
4. Diagnosis
1. Exclude Transcellular Potassium Shift
2. Check 24 hour Urine Potassium and Urine Sodium
1. Sample should have total Urine Sodium > 100 meq
3. Interpretation
1. Urine Potassium <20 meq/day
1. Extrarenal Potassium Loss
2. Urine Potassium >20 meq/day
1. Renal Potassium Loss
5. Management
1. See Potassium Replacement