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.
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 GI 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 with minimally invasive (eg, laparoscopic) surgery, by the use of patient-controlled or epidural analgesia, and by avoidance of intravenous opioids as well as early ambulation, gum chewing, and initiation of a clear liquid diet.
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.
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.
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.
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.
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 and parenteral administration of fluids and electrolytes. Alvimopan is a peripherally acting mu-opioid receptor antagonist with limited absorption or systemic activity that reverses opioid-induced inhibition of intestinal motility. In five randomized controlled trials ...