Clinical Science Session - Ileus Obstruktif

1. Obstructive ileus is a condition characterized by a blockage in the intestines. 2. Ileus obstructive refers to a situation where there is a hindrance in the normal flow of the intestines. 3. The term obstructive ileus is used to describe a condition where there is an obstruction in the intestines, causing a disruption in the normal movement of food and fluids. Ileus refers to the intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction. The diagnosis is often associated with surgery, medications, trauma, peritonitis, or severe illness. Mechanical obstruction has to be ruled out, and the diagnosis of ileus is dependent on radiographic evidence, usually on a CT scan or small bowel series. This activity reviews the evaluation and management of an Ileus and highlights the role of the interprofessional team in improving care for patients with this condition.

Objectives:

Identify the etiology of ileus.
Outline the typical presentation of a patient with ileus.
Review the management options available for ileus.
Identify interprofessional team strategies for improving care coordination and outcomes in patients with ileus.
Access free multiple choice questions on this topic.
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Introduction

Ileus, also known as paralytic ileus or functional ileus, occurs when there is a non-mechanical decrease or stoppage of the flow of intestinal contents.[1][2] Bowel obstruction is a mechanical blockage of intestinal contents by a mass, adhesion, hernia, or some other physical blockage. These two diseases may present similarly, but treatment can be very different depending on the underlying pathology.

Ileus is an often unavoidable consequence of abdominal or retroperitoneal surgery, but can also be found in severely ill patients with septic shock or mechanical ventilation. Due to the delayed refeeding syndrome seen after an ileus, postoperative ileus has a large economic impact in the United States alone.[3] An ileus usually manifests itself from the third to the fifth day after surgery and usually lasts 2 to 3 days with the small bowel being the quickest to return to function (0 to 24 hours), followed by the stomach (24 to 48 hours), and lastly the colon (48 to 72 hours).[2][4][5] A prolonged ileus is diagnosed if the ileus exceeds 2 to 3 days with the continued absence of obstruction signs.[6]

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Etiology

The cause of ileus has yet to be clearly defined. There are, however, several risk factors that have been shown to increase the likelihood and endurance of an ileus.[7]

Prolonged abdominal/pelvic surgery
Lower gastrointestinal (GI) surgery
Open surgery
Retroperitoneal spinal surgery
Opioid use
Intra-abdominal inflammation (sepsis/peritonitis)
Peritoneal carcinomatosis
Perioperative complications (pneumonia, abscess)
Bleeding (intraoperative or postoperative)
Hypokalemia
Delayed enteral nutrition or nasogastric (NG) tube placement
The risk for an ileus is influenced by a variety of fx

1. ILEUS OBSTRUCTIVE PRECEPTOR: nyenyeyeye PRESENTER: INTAN

2. ANATOMY OF SMALL INTESTINE The small intestine is a tubular structure that extends from the pylorus to the cecum. The estimated length varies depending on whether radiologic, surgical, or autopsy measurements are made. In the living, it is thought to measure 4 to 6 meters. The small intestine consists of three segments lying in series: the duodenum, the jejunum, and the ileum.

3. ANATOMY OF SMALL INTESTINE The duodenum, the most proximal segment, lies in the retroperitoneum immediately adjacent to the head and inferior border of the body of the pancreas. The duodenum is demarcated from the stomach by the pylorus and from the jejunum by the ligament of Treitz. The jejunum and ileum lie within the peritoneal cavity and are tethered to the retroperitoneum by a broad-based mesentery. The ileum is demarcated from the cecum by the ileocecal valve.

4. ANATOMY OF SMALL INTESTINE The small intestine contains internal mucosal folds known as plicae circulares or valvulae conniventes that are visible upon gross inspection. These folds are also visible radiographically and help in the distinction between small intestine and colon. These folds are more prominent in the proximal intestine than in the distal small intestine. Other features evident on gross inspection that are more characteristic of the proximal than distal small intestine include larger circumference, thicker wall, less fatty mesentery, and longer vasa recta.

5. ILEUS OBSTRUCTIVE

6. DEFINITION Obstruksi usus adalah salah satu gangguan dalam saluran pencernaan yang terjadi akibat adanya penyumbatan dalam usus, baik usus besar maupun usus halus . Kondisi ini menyebabkan makanan dan cairan tidak bisa melewati usus dengan baik dan menimbulkan tekanan pada usus

7. Epidemiology Mechanical small bowel obstruction is the most frequently encountered surgical disorder of the small intestine. Small and large bowel obstructions are similar in incidence in both males and females The overriding factor affecting incidence and distribution depends on patient risk factors Intra-abdominal adhesions related to prior abdominal surgery account for up to 75% of cases of small bowel obstruction.

8. ETIOLOGY intraluminal (e.g., foreign bodies, gallstones, or meconium) intramural (e.g., tumors , Crohn’s disease–associated inflammatory strictures) extrinsic (e.g., adhesions, hernias, or carcinomatosis)

9. PATHOPHYSIOLOGY Partial/complete obstruction : onset of obstruction, gas and fluid accumulate within the intestinal lumen proximal to the site of obstruction -> distension -> increases intraluminal & intramural pressure -> colicky pain, diarrhea Obstruction -> changes in luminal floral -> translocation of bacteria to the regional lymph node Increase in intramural pressure -> decrease intestinal microvascular perfusion -> ischemia -> necrosis (strangulated bowel obstruction) Closed loop obstruction : the accumulating gas and fluid cannot escape either proximally or distally from the obstructed segment, leading to a rapid rise in luminal pressure and a rapid progression to strangulation.

10. Clinical manifestation Colicky abdominal pain Nausea Vomiting -> proximal Obstipation Tachycardia Localized abdominal tenderness Fever Marked leukocitosis Acidosis

11. Anamnesis Riwayat operasi Riwayat konsumsi obat-obatan Nyeri kolik Nyeri meningkat setelah makan Mual & muntah BAB terakhir Flatus

12. Pemeriksaan fisik Inspeksi : distensi abdomen, darm contour, darm steifung Palpasi : Nyeri tekan , massa , Perkusi : hipertympanic Auskultasi : Metallic sound, hiperperistaltik , Tanda dehidrasi (+) Rectal touche : ampula recti kolaps

13. DIAGNOSIS The abdominal series consists of (a) a radiograph of the abdomen with the patient in a supine position, (b) a radiograph of the abdomen with the patient in an upright position, and (c) a radiograph of the chest with the patient in an upright position the triad of dilated small bowel loops (>3 cm in diameter), air-fluid levels seen on upright films, and a paucity of air in the colon

14. DIAGNOSIS CT Scan with contrast discrete transition zone with dilation of bowel proximally, decompression of bowel distally, intraluminal contrast that does not pass beyond the transition zone, and a colon containing little gas or fluid

15. DIAGNOSIS Closed-loop obstruction is suggested by the presence of a U-shaped or C-shaped dilated bowel loop associated with a radial distribution of mesenteric vessels converging toward a torsion point. Strangulation is suggested by thickening of the bowel wall, pneumatosis intestinalis (air in the bowel wall), portal venous gas, mesenteric haziness, and poor uptake of intravenous contrast into the wall of the affected bowel

16. Therapy NPO Fluid Resucitation usually associated with a marked depletion of intravascular volume due to decreased oral intake, vomiting, and sequestration of fluid in bowel lumen and wall. NGT Decompression The stomach should be continuously evacuated of air and fluid using a nasogastric (NG) tube. Effective gastric decom- pression decreases nausea, distention, and the risk of vomiting and aspiration The operative procedure performed for small bowel obstruction varies according to the etiology of the obstruction. For example, adhesions are lysed, tumors are resected, and hernias are reduced and repaired. Regardless of the etiology , the affected intestine should be examined, and nonviable bowel should be resected. Criteria suggesting viability are normal color , peristalsis, and marginal arterial pulsations

17. Differential Diagnosis Viral or bacterial gastroenteritis Paralytic ileus Mesenteric ischemia Acute pancreatitis Intussusception Constipation

18. Differential Diagnosis Bowel necrosis and perforation Sepsis Wound dehiscence Intra-abdominal abscess Aspiration Inflammatory bowel syndrome

19. Prognosis If any strangulated bowel is left untreated, there is a mortality rate of close to 100%. However, if surgery is undertaken within 24-48 hours, the mortality rates are less than 10%. Factors that determine the morbidity include the age of patient, comorbidity, and delay in treatment. Today, the overall mortality of bowel obstruction is still about 5%-8%.

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21. ETIOLOGY The most frequently encountered factors are abdominal operations, infection and inflammation, electrolyte abnormalities, and drugs.

22. PATHOPHYSIOLOGY Following most abdominal operations or injuries, the motility of the gastrointestinal tract is transiently impaired. Among the proposed mechanisms responsible for this dysmotility are surgical stress induced sympathetic reflexes, inflammatory response mediator release, and anesthetic/analgesic side effects; each of which can inhibit intestinal motility. Small-intestinal motility returning to normal within the first 24 hours after laparotomy and gastric and colonic motility returning to normal by 48 hours and 2 to 5 days, respectively. Since small bowel motility is returned before colonic and gastric motility, listening for bowel sounds is not a reliable indicator that ileus has fully resolved. Functional evidence of coordinated gastrointestinal motility in the form of passing flatus or bowel movement is a more useful indicator.

23. CLINICAL MANIFESTATION Inability to tolerate liquids and solids by mouth, nausea, and lack of flatus or bowel movements are the most common symptoms Vomiting Abdominal distension Although bowel sound characteristics are not diagnostic, they are usually diminished or absent. The clinical manifestations of chronic intestinal pseudo-obstruction include variable degrees of nausea and vomiting and abdominal pain and distention

24. DIAGNOSIS Definition of prolonged postoperative ileus has been varied but generally diagnosed if ileus persists beyond 5 days postoperatively. Patient medication lists should be reviewed for the presence of drugs, especially opiates, known to be associated with impaired intestinal motility. with prolonged postoperative ileus being defined as “two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after day 4 postoperatively without prior resolution of postoperative ileus.

25. DIAGNOSIS Measurement of serum electrolytes may demonstrate electrolyte abnormalities commonly associated with ileus. Abdominal radiographs are often obtained, but the distinction between ileus and mechanical obstruction may be difficult based on this test alone. In the postoperative setting, CT scanning is the test of choice as it can demonstrate the presence of an intra-abdominal abscess or other evidence of peritoneal sepsis that may be causing ileus and can exclude the presence of complete mechanical obstruction.

26. DIFFERENTIAL DIAGNOSIS

27. TREATMENT Limiting oral intake and correcting the underlying inciting factor. If vomiting or abdominal distention are prominent, the stomach should be decompressed using a nasogastric tube. Fluid and electrolytes should be administered intravenously until ileus resolves. If the duration of ileus is prolonged, total parental nutrition (TPN) may be required.

28. The administration of nonsteroidal anti-inflammatory drugs such as ketorolac and concomitant reductions in opioid dosing have been shown to reduce the duration of ileus.

29. Many studies have also suggested that limiting intra- and postoperative fluid administration can also result in reduction of postoperative ileus and shortened hospital stay. Furthermore, studies have shown that early postoperative feeding after GI surgery is generally well tolerated and can lead to reduced postoperative ileus and a shorter hospital stay. Although prokinetic agents have been tried to promote return of GI motility, they are associated with efficacy- toxicity profiles that are too unfavorable to warrant routine use. Recently, administration of alvimopan, a novel peripherally active mu opioid receptor antagonist with limited oral absorp- tion, has been shown to reduce duration of postoperative ileus, hospital stay.

30. COMPLICATION Most of the complications come from the prolonged hospital stay and the possibility for subsequent procedures for a prolonged ileus (peripheral inserted central catheter line, TPN, NG tube placement). There is the possibility of aspiration with increasing nausea and vomiting.

31. PROGNOSIS Having an ileus is only harmful in terms of the length of stay and decreased nutrition. Longer hospital stays increase the risk of nosocomial infections, and a prolonged ileus may lead to the need for TPN, which has its own risks and benefit.

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