Beruflich Dokumente
Kultur Dokumente
Dr.Dian Tambunan
Ileus
Adynamic ileus
Mechanical ileus
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
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 f. Perforated Duodenal Ulcer
Adynamic ileus
E. Intestinal Ischemia
1.
F. Skeletal injury
1. 2.
Adynamic ileus
G. Medications
1. 2. 3. 4.
5.
Adynamic ileus
III. Symptoms A. Abdominal distention B. Nausea and Vomiting are variably present C. Generalized abdominal discomfort 1. Colicky pain of Mechanical Ileus is usually absent D. Flatus and Diarrhea may still be passed
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.
1. 2. 3. 4.
Initial
Limit or eliminate oral intake Intravascular fluid replacement Correct electrolyte abnormalities (e.g. Hypokalemia) Consider Nasogastric Tube placement
B.
1. 2.
Refractory Management
Consider Prokinatics Consider lower bowel stimulation (e.g. Enema)
Adynamic ileus
VIII. Course A. Post-operative ileus resolves within 24-48 hours
Mechanical ileus
I.
A.
1. 2.
Types
Simple mechanical obstruction
Bowel lumen is obstructed No vascular compromise
B.
1. 2. 3.
C.
1.
Strangulated obstruction
Bowel lumen and vascular supply is compromised
Mechanical ileus
II. Causes A. Most Common Causes
Postoperative Adhesions (accounts for 50% of cases) 2. Hernia (25% of cases, especially younger patients) 3. Neoplasms (10% of cases, esp. older patients) a. Colon Cancer (most common) b. Ovarian Cancer c. Pancreatic cancer d. Gastric Cancer
1.
Mechanical ileus
A.
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.
2.
Inguinal hernia (direct ,indirect) Internal hernias via mesenteric defects Obturator hernia More common in emaciated elderly women
Mechanical ileus
3. Small bowel volvulus
a. b. c.
Rare compared to colon volvulus More common in Africa, Middle East and India Occurs in intestinal malrotation or adhesions
Mechanical ileus
III. Symptoms A. Frequent and recurrent Generalized Abdominal Pain B. Duration: Seconds to minutes
1. 2.
a. b.
c.
Mechanical ileus
B. Stool passage
1. 2.
Initially may be present despite complete obstruction Later, obstipation (no stool) in complete obstruction Proximal obstruction
a. b. c. d. e.
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.
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
Mechanical ileus
c .String of pearls sign (specific for obstruction)
1.
Series of small pockets of gas in a row Bowel loop filled with fluid (resembles mass)
d. Pseudotumor Sign
1.
Mechanical ileus
VI. Radiology A. MRI Abdomen (93% Test Sensitivity for SBO cause) B. CT Abdomen (88% Test Sensitivity for SBO cause)
1. 2.
a. b. c. d. e.
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%