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Dec 19 Vincent's Dr. An ileus is common after surgery because people are often prescribed medication that can slow intestinal movement. This is a type of paralytic ileus.
In this instance, the intestine is not blocked. The result is little to no movement of digested food through your intestines. Intussusception is the most common cause of an ileus in children. Gastrointestinal symptoms are the most common signs of an ileus. This causes the abdomen to take on a tight and swollen appearance. The treatment for an ileus depends on its severity. However, some bowel material can get through. In this instance, if you are otherwise stable, your doctor may recommend a low-fiber diet.
This can help reduce the bulky stool, making it easier to pass. Treatment will depend on your overall health. For example, extensive abdominal surgery is not suitable for some people.
This includes older adults and those with colon cancer. In this case, a doctor may use a metal stent to make the intestine more open. Ideally, food will start to pass with the stent. Abdominal surgery to remove the blockage or the damaged intestine portion may still be needed, however. If medication is the cause, your doctor may be able to prescribe another medication to stimulate gastrointestinal motility intestine movement.
One medication they may prescribe is metoclopramide Reglan. If possible, discontinuing the medications that caused the ileus can also help.
Treatment without surgery is possible during the early stages of a paralytic ileus. You may still require a hospital stay to get the proper fluids intravenously until the issue is fully resolved.
In addition to intravenous fluid hydration, your doctor may use nasogastric decompression. During this procedure, a tube is inserted into your nasal cavity to reach your stomach. The tube suctions out the extra air and material that you may otherwise vomit. Most surgery-related ileus will resolve within 2 to 4 days after surgery. However, some people do require surgery if the condition does not improve. Your intestines are very long, so you can live without a portion of them. While it may affect the digestive process, most people do live a healthy life with part of their intestine removed.
In some instances, your doctor may have to remove your entire intestine. In this case, your doctor will create a special pouch called an ostomy. This bag allows stool to drain from your remaining gastrointestinal tract. Your doctor will usually first listen to a description of your symptoms. Your doctor may then conduct a physical exam, looking at your abdomen for signs of swelling or tightness.
Your doctor will also listen with a stethoscope to your abdomen for typical bowel sounds. Imaging studies are usually ordered after a thorough physical exam. These can indicate where an ileus is located by showing a buildup of gas, an enlarged intestine, or even an obstruction. Your doctor may use these to identify areas where your bowel content seems to be concentrated. In some instances, your doctor may use a diagnostic procedure known as an air or barium enema. It is characterized by bowel distention, lack of bowel sounds, accumulation of GI gas and fluid, and delayed passage of flatus and stool TABLE 1.
Risk factors for POI include type of surgery and preexisting factors such as GI disease and physical inactivity. POI affects all segments of the GI tract. It usually is uncomplicated and resolves spontaneously within 2 to 3 days, although it may last 6 days or more. The most reliable markers of bowel-function return are having a bowel movement and being able to tolerate oral intake.
An ileus that lasts more than 3 days is considered a paralytic , or adynamic , ileus. Opioid analgesics relieve pain by blocking pain signals through stimulation of opioid receptors mu receptors located on the surface of the nerves that transmit these signals.
The binding of opioid analgesics to mu receptors in the GI tract greatly slows intestinal motility, thereby disrupting normal GI function. The slowing of intestinal motility may cause significant discomfort and pain.
The combination of both endogenous and exogenous opioids may contribute to the development and persistence of ileus. Increased doses of opioid analgesics are related to extended periods of POI.
The effects of anesthesia and antispasmodics on the colon may also cause POI. The large intestine is devoid of intercellular gap junctions, which makes the colon more susceptible to the inhibitory actions of anesthetics. Some studies have shown that thoracic epidurals with bupivacaine hydrochloride significantly reduce ileus versus systemic opioid therapy in patients undergoing abdominal surgical procedures.
Paralytic ileus may result from intraperitoneal or retroperitoneal inflammation e. Gastric and small-intestine recovery is believed to occur first, followed by the return of colonic function. Uncomplicated POI is a self-limiting process. Normal GI motility is a result of several intricate relationships involving hormones, the CNS, the ENS, smooth-muscle activity, and the state of the stomach fed or fasting.
Motility takes place even in the fasting state. This contractile pattern of the bowel, occurring every 1 to 2 hours during a fasting state, is known as the migrating motor complex MMC. Colonic motility is irregular. The colon does not contain gap junctions and thus does not function as a single agent.
Although peritoneal entry increases the severity of POI, duration of surgery does not appear to affect severity. The primary cause of POI is surgery and concomitant opioid treatment. Secondarily, POI may be precipitated by other factors, such as hematoma or infection.
Patients with POI may experience a painful and distended abdomen, vomiting, toxemia, and dehydration. Although the lumen is not occluded, peristalsis fails when the intestinal contents back up, resulting in watery diarrhea. Pain rarely has the classic colicky pattern present in mechanical obstruction. Abdominal tenderness generally is present only when the cause of the ileus is inflammation.
Diagnosis of POI consists of clinical evaluation and, occasionally, x-ray. Pseudo-obstructions involve the colon only, particularly the right colon. Mechanical obstructions may be caused by cancer, hernia, foreign-body ingestion, or other conditions. An x-ray or CT scan may be used to differentiate the type of obstruction versus ileus.
On CT scan, pseudo-obstructions are indicated by a large, isolated colon, whereas mechanical obstructions appear as enlarged bow-shaped loops of small intestine with steplike air-fluid levels. Water-soluble contrast may be used to distinguish the type of ileus. The different obstructions may have similar presentations. Several medications have been used for the treatment and prevention of POI, including FDA-approved drugs that have been used off-label. Metoclopramide is a prokinetic agent that potentially could be used for POI management.
It is used extensively as an antiemetic and as a means of nasoduodenal feeding-tube advancement. A prospective, randomized study assessed metoclopramide for reducing the length of ileus after colorectal surgery in patients who underwent elective abdominal colorectal surgical procedures.
The drug was administered IV every 8 hours from the completion of surgery until a solid-food diet was tolerated. It was concluded that metoclopramide does not significantly alter the course of POI. A double-blind, controlled study of 60 patients found that metoclopramide had a negative effect on the resolution of POI. Another drug that has been used for POI because of its mechanism of action in the GI tract is erythromycin, a macrolide antibiotic that acts at motilin receptors in the intestinal tract and promotes GI motility in disorders such as diabetic gastroparesis.
Like metoclopromide, erythromycin lacks activity in the colon. A prospective, double-blind, randomized, placebo-controlled study of 77 patients investigated whether erythromycin shortened the period of POI. Outcome measures included time to first passage of flatus, first liquid meal, first bowel movement, and total length of hospital stay.
There was no significant difference between the groups. It was concluded that erythromycin did not seem to alter clinical parameters of GI motility after abdominal surgery. Interestingly, it has been suggested that the colon does not possess motilin receptors in the distal portion of the large intestine. In general, prokinetic agents studied for the treatment of POI have yielded inconsistent and marginal results.
Propranolol, a nonspecific beta-receptor antagonist, has been investigated for the treatment of POI; however, it has demonstrated variable results. Neostigmine, an acetylcholinesterase inhibitor, has been used for the treatment of ileus because of its ability to facilitate the activity of acetylcholine and induce GI contractions, especially in the colon.
However, clinical data showing a benefit in accelerating postoperative GI recovery are lacking. Neostigmine was evaluated in surgical patients and medical patients with critical illness-related colonic ileus. Patients were given neostigmine or placebo in a blinded manner. Treatment was administered by continuous IV infusion of 0.
Patients who did not respond to therapy were crossed over to placebo. Overall, 19 of the 24 patients who received neostigmine successfully passed stools, and no patients receiving placebo had bowel movements. The only serious neostigmine-related adverse reaction was increased salivation.
It should be kept in mind that this trial was performed in patients with critical illness-related ileus, not necessarily POI. It should be noted that bradycardia is a side effect associated with neostigmine use owing to its cholinergic properties. Laxatives are a potential therapeutic option for treating POI, but no randomized, controlled trials have assessed their utility in this setting. One nonrandomized study of 20 consecutive patients given laxative agents postoperatively found a reduction in time to flatus and first bowel movement, as well as decreased length of hospitalization, compared with historical controls.
Laxatives have been used with other therapies after abdominal surgery in multimodal rehabilitation studies, with promising results. Gum chewing is theorized to promote physiologic stimulation of the cephalic-vagal axis, thereby increasing bowel motility and GI stimulation without the complications associated with early water intake or postoperative feeding. A systematic review of randomized, controlled trials comparing gum chewing with standard care after elective intestinal surgery was performed.
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