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Key Features

Essentials of Diagnosis

  • Precipitating factors

    • Surgery

    • Peritonitis

    • Electrolyte abnormalities

    • 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

  • Neurogenic failure or loss of peristalsis in the intestine in the absence of any mechanical obstruction

  • Common in hospitalized patients as a result of the following

    • Intra-abdominal processes, such as

      • Recent gastrointestinal or abdominal surgery

      • Peritoneal irritation (peritonitis, pancreatitis, ruptured viscus, hemorrhage)

    • Severe medical illness, such as

      • Pneumonia

      • Respiratory failure requiring intubation

      • Sepsis or severe infections

      • Uremia

      • Diabetic ketoacidosis

      • Electrolyte abnormalities (hypokalemia, hypercalcemia, hypomagnesemia, hypophosphatemia)

    • Medications, such as

      • Opioids

      • Anticholinergics

      • Phenothiazines

  • Postoperative ileus is reduced by

    • Use of patient-controlled or epidural analgesia

    • Avoidance of intravenous opioids

    • Early ambulation

    • Gum chewing

    • Initiation of a clear liquid diet

Clinical Findings

Symptoms and Signs

  • Mild diffuse, continuous abdominal discomfort

  • Nausea and vomiting

  • Generalized abdominal distention

  • Minimal abdominal tenderness

  • No signs of peritoneal irritation

  • Bowel sounds are diminished to absent

Differential Diagnosis

  • Mechanical obstruction of small intestine or proximal colon, eg, adhesions, volvulus, Crohn disease

  • Chronic intestinal pseudo-obstruction

Diagnosis

Laboratory Tests

  • Obtain serum electrolytes, potassium, magnesium, phosphorus, and calcium

Imaging Studies

  • Plain abdominal radiography: air-fluid levels, distended gas-filled loops of small and large intestine

  • Limited barium small bowel series or a CT scan can help exclude mechanical obstruction

Treatment

Medications

  • Alvimopan

    • A peripherally acting mu-opioid receptor antagonist with limited absorption or systemic activity that reverses opioid-induced inhibition of intestinal motility

    • Reduces time to first flatus, bowel movement, solid meal, and hospital discharge in postoperative patients

    • May be considered in patients undergoing partial large or small bowel resection when postoperative opioid therapy is anticipated

Therapeutic Procedures

  • Treat underlying primary medical or surgical illness

  • Nasogastric suction for discomfort or vomiting

  • Restrict oral intake, administer intravenous fluids

  • Liberalize diet gradually as bowel function returns

  • Minimize anticholinergic and opioid medications

  • Severe or prolonged ileus requires nasogastric suction and infusion of parenteral fluids and electrolytes

Outcome

Follow-Up

  • Return of bowel function usually heralded by return of appetite and passage of flatus

  • Serial plain film radiography and/or abdominal CT warranted for persistent or worsening symptoms to distinguish from mechanical obstruction

Prognosis

  • Ileus usually resolves within 48–72 h

  • Following surgery, small intestinal motility normalizes first (within hours), followed by stomach (24–48 h) and colon (48–72 h)

When to Refer

  • Persistent ileus lasting more than 3–5 days warrants further evaluation for underlying cause and to exclude ...

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