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Clinical Findings
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A Symptoms and Signs
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Patients who are conscious report mild diffuse, continuous abdominal discomfort with nausea and vomiting Generalized abdominal distention is present with minimal abdominal tenderness but no signs of peritoneal irritation (unless due to the primary disease) Bowel sounds are diminished to absent
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B Laboratory Findings
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The laboratory abnormalities are attributable to the underlying condition Serum electrolytes, including potassium, magnesium, phosphorus, and calcium, should be obtained to exclude abnormalities as contributing factors
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C Imaging
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Plain film radiography of the abdomen demonstrates distended gas-filled loops of small and large intestine Airfluid levels may be seen Under some circumstances, it may be difficult to distinguish ileus from partial small bowel obstruction A limited barium small bowel series or a CT scan may be useful in such instances to exclude mechanical obstruction, especially in postoperative patients
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INTESTINAL MOTILITY DISORDERS 1 Acute Paralytic Ileus
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Differential Diagnosis
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Ileus must be distinguished from mechanical obstruction of the small bowel or proximal colon Pain from small bowel mechanical obstruction is usually intermittent, cramping, and associated initially with profuse vomiting Acute gastroenteritis, acute appendicitis, and acute pancreatitis may all present with ileus
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ESSENTIALS OF DIAGNOSIS
Precipitating factors: surgery, peritonitis, electrolyte abnormalities, medications, severe medical illness Nausea, vomiting, obstipation, distention Minimal abdominal tenderness; decreased bowel sounds
Treatment
The primary medical or surgical illness that has precipitated adynamic ileus should be treated Most cases of ileus respond
Gastrointestinal Disorders
to restriction of oral intake with gradual liberalization of diet as bowel function returns Severe or prolonged ileus requires nasogastric suction and parenteral administration of fluids and electrolytes Alvimopan is a new peripherally acting muopioid receptor antagonist with limited absorption or systemic activity that reverses opioid- induced inhibition of intestinal motility This agent is not yet approved by the FDA However, in five randomized controlled trials, it reduced the time to first flatus, bowel movement, solid meal, and hospital discharge compared with placebo in postoperative patients
Tan EK et al Meta-analysis: alvimpan vs placebo in the treatment of post-operative ileus Aliment Pharmacol Ther 2007 Jan 1;25(1):47 57 [PMID: 17042776]
CMDT 2008
distention is frequently noted by the clinician as the first sign, often leading to a plain film radiograph that demonstrates colonic dilation Some patients are asymptomatic, although most report constant but mild abdominal pain Nausea and vomiting may be present Bowel movements may be absent, but up to 40% of patients continue to pass flatus or stool Abdominal tenderness with some degree of guarding or rebound tenderness may be detected; however, signs of peritonitis are absent unless perforation has occurred Bowel sounds may be normal or decreased
B Laboratory Findings
Laboratory findings reflect the underlying medical or surgical problems Serum sodium, potassium, magnesium, phosphorus, and calcium should be obtained Significant fever or leukocytosis raises concern for colonic ischemia or perforation
2 Acute Colonic Pseudo-obstruction (Ogilvie s Syndrome)
ESSENTIALS OF DIAGNOSIS
Severe abdominal distention Arises in postoperative state or with severe medical illness May be precipitated by electrolyte imbalances, medications Absent to mild abdominal pain; minimal tenderness Massive dilation of cecum or right colon
C Imaging
Radiographs demonstrate colonic dilation, usually confined to the cecum and proximal colon The upper limits of normal for cecal size is 9 cm A cecal diameter greater than 10 12 cm is associated with an increased risk of colonic perforation Varying amounts of small intestinal dilation and air-fluid levels due to adynamic ileus may be seen Because the dilated appearance of the colon may raise concern that there is a distal colonic mechanical obstruction due to malignancy, volvulus, or fecal impaction, a CT scan or water-soluble (diatrizoate meglumine) enema may sometimes be performed
General Considerations
Spontaneous massive dilation of the cecum and proximal colon may occur in a number of different settings in hospitalized patients Progressive cecal dilation may lead to spontaneous perforation with dire consequences The risk of perforation correlates poorly with absolute cecal size and duration of colonic distention Early detection and management are important to reduce morbidity and mortality Colonic pseudo-obstruction is most commonly detected in postsurgical patients (mean 3 5 days), after trauma, and in medical patients with respiratory failure, metabolic imbalance, malignancy, myocardial infarction, congestive heart failure, pancreatitis, or a recent neurologic event (stroke, subarachnoid hemorrhage, trauma) Liberal use of opioids or anticholinergic agents may precipitate colonic pseudo-obstruction in susceptible patients It may also occur as a manifestation of colonic ischemia The etiology of colonic pseudo-obstruction is unknown, but either an increase in gut sympathetic activity or a decrease in sacral parasympathetic activity of the distal colon, or both, is hypothesized to impair colonic motility
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