Ileus

Bruce T. Noble, MD
The Operative Review of Surgery. 2023; 1:267-273.

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Table of Contents

Definition and Pathophysiology
Presentation
Diagnosis and Treatment
Prevention

References

Definition and Pathophysiology

Also Known as an “Adynamic Ileus”, “Paralytic Ileus”, “Functional Ileus”, or “Postoperative Ileus” (POI)

Definition

  • Generalized Dysfunction of Peristalsis Involving the Entire Gastrointestinal Tract
  • Due to Nonmechanical Factors

Pathophysiology and Phases 1

  • First Phase: Neurological
    • Noxious Spinal Signals Stimulate Enteral Neural Reflexes 2
    • Reflexes Activate Sympathetic Activity within the GI Tract
    • Sympathetic Stimulation Inhibits Normal Peristaltic Contractions
  • Second Phase: Inflammatory
    • Bowel Manipulation and Trauma Activate Macrophages and Stimulate an Inflammatory Response
    • Inflammatory Response Inhibits Normal Peristaltic Contractions
    • Various Neurohormonal Peptides are Also Released and Inhibit Normal Peristaltic Contractions
      • Ex: Nitric Oxide, VIP, and Substance P
    • The Degree of Bowel Manipulation is Directly Related to the Degree of Dysmotility 3,4
    • Inflammatory Effects Can Inhibit the Entire GI Tract and are Not Limited to the Manipulated Segment (“Field Effect”) 5,6
  • Third Phase: Resolution
    • Increased Parasympathetic Tone Reduces the Inflammatory Response
    • Mediated by the Vagal System

Presentation

Risk Factors 1,7-12

  • Surgery (Postoperative Ileus) – Most Common Cause
    • Additional Risks:
      • Open Surgery
      • Prolonged Surgery
      • Lower Gastrointestinal/Colorectal Surgery
      • Significant Blood Loss
    • Some Degree of Ileus After Abdominal Surgery is a Normal Physiologic Response without Serious Complications 13
    • “Obligatory” (Normal) Postoperative Ileus Lasts < 4 Days from Surgery (Exact Definition/Timing is Debated) 14
  • Delayed Enteral Nutrition or Nasogastric (NG) Tube Placement
  • Intraabdominal Infections/Inflammation
    • Gastroenteritis
    • Colitis
    • Pancreatitis
  • Low Potassium
  • Trauma
  • Spinal Cord Injury
  • Severe Burns
  • SIRS/Sepsis
  • Pneumonia
  • Stroke
  • Diabetes and DKA
  • Medications: Opiates, Antihistamines, Anticholinergics, and Alpha-Agonists

Presentation

  • Nausea and Vomiting
    • Risk for Aspiration
  • Abdominal Distention
  • Diffuse and Persistent Abdominal Discomfort or Pain
  • Obstipation (Unable to Pass Flatus or Stool)
  • Presentation is Generally Similar to a Mechanical Bowel Obstruction

Diagnosis and Treatment

Diagnosis

  • Primarily a Clinical Diagnosis Based on History and Physical Exam
  • Laboratory Findings are Generally Nonspecific
  • Radiologic Imaging Used to Rule Out Mechanical Bowel Obstruction
    • Imaging Demonstrates: Uniform Bowel Dilation without a Defined Transition Point
    • Primary Options:
      • Abdominal Plain Film
      • CT with PO and IV Contrast
    • Preferred Testing is Controversial – Although Some Recommend Starting with an Abdominal Plain Film and then Proceeding with CT if Equivocal, Plain Film is Inferior in Evaluating for Mechanical Obstruction and CT is Often Preferred 15
  • Additional Imaging Options:
    • Abdominal Ultrasound (US)
      • Use is Evolving 16,17
      • Benefit of Being Able to Visualize Peristalsis in Vivo
    • Small Bowel Follow Through (SBFT)
      • Considered if Diagnosis Remains Uncertain
      • Follows Progression of Oral Water-Soluble Contrast (Gastrografin) Throughout the GI Tract Over Time

Treatment 18-20

  • Primarily Managed by Supportive Cares
    • Generally Self-Limited and Resolves Within 3-7 Days
    • Non-Narcotic Pain Control and Avoid Opiates as Able
    • Bowel Rest with IV Fluids
    • Electrolyte Replacement (Particularly Potassium and Magnesium)
  • May Require Nasogastric (NG) Tube Decompression for Continuous Emesis or Significant Distention
  • Correct Any Reversible Causes Such as Abscess or Bleeding
  • Repeat Abdominal Imaging After 48-72 Hours if No Improvement Seen

Ileus on Plain Film Imaging 21

Prevention

Proven Preventions

  • Minimally Invasive Surgery 22-24
  • Multimodal Analgesia with Reduced Opioid Use 25
  • Epidural or TAP (Transverse Abdominis Plane) Blocks 26-28
  • Alvimopan (Entereg) 29-31
  • Restricted/Goal-Directed Fluid Administration
    • Liberal Fluid Administration Prolongs Postoperative Ileus 32
  • Correction of Electrolyte Abnormalities
  • *Many Measures are Often Bundled Together Through Institutional ERAS (Enhanced Recovery After Surgery) Protocols

Debated/Questioned Preventions

  • Chewing Gum 33-35
    • Effect is Through “Sham Feeding” to Stimulate Bowel Function
    • With Implementation of Early Enteral Feeding, Benefit of Chewing Gum May be Diminished
    • Otherwise Safe, Inexpensive, and Avoids Risk of Emesis for Patients Otherwise Unable to Tolerate Early Feeding
  • Coffee Consumption 36-40
  • Preoperative Suggestion 41
    • “Visceral Learning” with Preoperative Counseling Including Statements that the Patient Will Not Have Excessive Pain and that they Will Have Rapid Return of Bowel Function
    • Minimal Data Available to Significantly Define the Benefit

Ineffective Preventions

  • Early Ambulation 42
    • Despite No Proven Benefit to Ileus Specifically, Early Ambulation is Associated with Faster Recovery, Fewer Overall Complications, and Should Be Generally Recommended 43
  • Methylnaltrexone (Relistor) 44
    • Mechanism of Action: Peripheral Opioid Receptor Antagonist
  • Routine Delayed Enteral Feeding 45,46
    • Historically, Oral Intake Was Routinely Delayed in the Postoperative Setting Until Return of Bowel Function was Seen for Fear of Ileus Exacerbation and Emesis
    • Early Feeding Has Now Shown to Possibly Decrease Ileus and Hospital Stay with No Increased Risk of Complications 45,46
  • Routine Prophylactic Nasogastric (NG) Tube Decompression 47
    • Prolongs Return to Bowel Function 47

References

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