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Key Clinical Updates in Intestinal Motility Disorders

In 2019, a small blinded crossover trial of 34 patients with confirmed gastroparesis, the serotonin 5-HT4 receptor agonist, prucalopride (currently FDA approved for treatment of chronic constipation) demonstrated significant improvement in gastric emptying and symptoms compared with placebo.

1. ACUTE PARALYTIC ILEUS

ESSENTIALS OF DIAGNOSIS

  • Precipitating factors: surgery, peritonitis, electrolyte abnormalities, medications, severe medical illness.

  • Nausea, vomiting, obstipation, distention.

  • Minimal abdominal tenderness; decreased bowel sounds.

  • Plain abdominal radiography with gas and fluid distention in small and large bowel.

General Considerations

Ileus is a condition in which there is neurogenic failure or loss of peristalsis in the intestine in the absence of any mechanical obstruction. It is commonly seen in hospitalized patients as a result of (1) intra-abdominal processes such as recent gastrointestinal or abdominal surgery or peritoneal irritation (peritonitis, pancreatitis, ruptured viscus, hemorrhage); (2) severe medical illness such as pneumonia, respiratory failure requiring intubation, sepsis or severe infections, uremia, diabetic ketoacidosis, and electrolyte abnormalities (hypokalemia, hypercalcemia, hypomagnesemia, hypophosphatemia); and (3) medications that affect intestinal motility (opioids, anticholinergics, phenothiazines). Following surgery, small intestinal motility usually normalizes first (often within hours), followed by the stomach (24–48 hours), and the colon (48–72 hours). Postoperative ileus is reduced by the use of patient-controlled or epidural analgesia and avoidance of intravenous opioids as well as early ambulation, gum chewing, and initiation of a clear liquid diet.

Clinical Findings

A. Symptoms and Signs

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.

B. Laboratory Findings

The laboratory abnormalities are attributable to the underlying condition. Serum electrolytes (sodium, potassium), magnesium, phosphorus, and calcium, should be obtained to exclude abnormalities as contributing factors.

C. Imaging

Plain film radiography of the abdomen demonstrates distended gas-filled loops of the small and large intestine. Air-fluid levels may be seen. Under some circumstances, it may be difficult to distinguish ileus from partial small bowel obstruction. A CT scan may be useful in such instances to exclude mechanical obstruction, especially in postoperative patients.

Differential Diagnosis

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.

Treatment

The primary medical or surgical illness that has precipitated adynamic ileus should be treated. Most cases of ileus respond to restriction of oral intake with gradual liberalization of diet as bowel function returns. Severe or prolonged ileus requires nasogastric suction ...

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