Transcript ACQUIRED INTESTINAL ILEUS

Theme of lecture:
ACQUIRED INTESTINAL
ILEUS
Plan:
• Paralytic ileus.
• Obstruction of the small and large
bowel.
• Intussusception.
• Adhesive Intestinal Obstruction
ACQUIRED INTESTINAL ILEUS
Classification
ACQUIRED
INTESTINAL ILEUS
Paralytic ileus,
(pseudo-obstruction)
mechanical
obstructions
simple mechanical
obstruction
strangulating
obstruction
Causes of paralytic ileus
• Medications, especially narcotics
• Intraperitoneal infection
• Mesenteric ischemia Injury to the
abdominal blood supply
• Complications of intra-abdominal surgery
• Kidney or thoracic disease
• Metabolic disturbances (such as decreased
potassium levels)
• Cranial and cerebral injuries
Classification
• Compensated
• Subcompensated
• Decompensated
Clinical manifestations and
diagnostic studies
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Constant gnawing pain
repeated vomiting
symmetric abdominal distention
reduced or absence of peristalsis
increasing meteriorism
constipation
heavy intoxication
Diagnostic studies
• Physical examination
• Ragiological investigation
• Laboratory tests (hypokalemia)
Treatment of paralytic ileus
• Para-nephral and pre-sacral novocaine nerve
blocks
• Gastric lavage and intestinal intubation
• Stimulation of intestinal peristalsis
• IV fluids and electrolytes,
• a minimal amount of sedatives,
• adequate serum K level (> 4 mEq/L [> 4 mmol/L])
• Sometimes colonic ileus can be relieved by
colonoscopic decompression; rarely cecostomy is
required. Ileus persisting > 1 wk probably has a
mechanical obstructive cause, and laparotomy
should be considered.
The mechanical causes of intestinal
obstruction
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Hernias
Postoperative adhesions or scar tissue
Impacted feces (stool)
Gallstones
Tumors
Granulomatous processes (abnormal tissue
growth)
• Intussusception
• Volvulus
• Foreign bodies
Obstruction of the small bowel
• Abdominal cramps around the
umbilicus or in the epigastrium;
• Vomiting starts early
• Obstipation occurs with complete
obstruction, but diarrhea may be
present with partial obstruction.
• Strangulating obstruction occurs in
nearly 25% of cases and can progress to
gangrene in as little as 6 h
Obstruction of the large bowel
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Symptoms usually develop more gradually
increasing constipation
abdominal distention
vomiting (not usually)
lower abdominal cramps
unproductive of feces
distended abdomen
there is no tenderness
the rectum is usually empty
X-ray examination
• Sign of reversed cups of Kloiber: shows
position of air-filled loops of bowel and
horizontal levels of the fluid below gas
• Presence of shady fields of the large
bowel
• If peritonitis has developed, we can see
free gas under the liver, because bowel is
damaged
Adhesive Intestinal Obstruction
The incidence of postoperative adhesive obstruction
after laparotomy is about
2%. The procedures which have highest risk for
adhesive McBurney’s point in pediatric
patients are:
 1. subtotal colectomy,
 2. resection of symptomatic Meckel’s diverticulum,
 3. Ladd’s procedure, and
 4. nephrectomy.
Etiology
The causes of postoperative McBurney’s point
include adhesions, intussusception,hernia, and
tumor. Adhesions are fibrous bands of tissue that
form between loops of bowel or between the
bowel and the abdominal wall after
intraabdominal inflammation. Obstruction occurs
when the bowel is “caught” within one of these
fibrous bands in a kinked or twisted position,
twists around an adhesive band, or herniates
between a band and another fixed structure
within the abdomen.
Clinical Presentation
• cramping abdominal pain,
• distension, and vomiting.(bilious or even
feculent).
• Inspection of the abdomen may reveal obvious
dilated loops of bowel and distension.
• fever, tachycardia, decreased blood pressure,
abdominal tenderness and leukocytosis.
Differential diagnosis
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pancreatitis,
hepatitis
biliary tract disease.
urinary tract infection, nephritis, stones.
systemic infection.
colitis, rotavirus.
pneumonia.
Treatment
• isotonic saline solutions,
• nasogastric decompression,
• correction of electrolyte abnormalities,
• IV antibiotics,
Indications for operation include obstipation for 24 hours,
continued abdominal pain with fever and tachycardia, decreased
blood pressure, increasing abdominal tenderness, and
leukocytosis despite adequate resuscitation and medical
treatment.The abdomen is opened through a previous incision, if
present, and midline, if not. The cecum is identified and the
collapsed ileum is followed proximally until dilated bowel and
the point of obstruction is identified. The offending adhesive
bands are disrupted and the abdomen is closed. Laparoscopic
lysis of adhesions is another option and may allow a shorter
postoperative recovery and hospital stay. Postoperatively,
nasogastric decompression and intravenous fluids are
continueduntil return of bowel function and the volume of gastric
aspirate decreases.
Intussusception is a
process in which a segment of
intestine invaginates into the
adjoining intestinal lumen,
causing a bowel obstruction.
intussuscipiens
intussusceptum
Frequency. Intussusception is the
predominate cause of intestinal obstruction
in persons aged 3 months to 6 years. The
estimated incidence is 1-4 per 1000 live
births.
Sex. Overall, the male-to-female ratio is
approximately 3:1.
Etiology
• Intussusception is most commonly idiopathic and no anatomic
lead point can be identified. Several viral gastrointestinal
pathogens (rotavirus, reovirus, echovirus) may cause hypertrophy
of the Peyer’s patches of the terminal ileum which may potentiate
bowel intussusception.
• A recognizable, anatomic lesion acting as a lead point is only
found in 2-12% of all pediatric cases. The most commonly
encountered anatomic lead point is a Meckel’s diverticulum. Other
anatomic lead points include polyps, ectopic pancreatic or gastric
rests, lymphoma, lymphosarcoma, enterogenic cyst, hamartomas
(i.e., Peutz-Jeghers syndrome), submucosal hematomas (i.e.,
Henoch-Schonlein purpura), inverted appendiceal stumps, and
anastomotic suture lines. Children with cystic fibrosis are at
increased risk of intussusception possibly due to thickened
inspissated stool.
• Postoperative intussusception accounts for 1.5-6% of all
pediatric cases of intussusception.
Pathology/Pathophysiology
1.The intussusception begins at or near the ileocaecal valve without
local anatomical lesion to cause it
2.The mesenteric vassels are drawn between the layers of the
intussusception and compressed.
3.The sligth interference with lymphatic and venous drainage results
in edema and an increase of tissue pressure
4.Venulus and capillaries became great engorged and bloody edema
fluid drips into the lumen
5.The mucosal cells swell into goblet cells and discharge mucus,
which, mixing in the lumen with the bloody transsudate, forms the
‘current-jelly’ stool
6. Edema increases until venous inflow is completely obstructed
7. As arterial continues to pump in, tissue pressure rises until it is
higher then arterial pressure, and gangrene results
8. Gangrene appears in the outer coat of the intussuseption and
progresses back to the neck of the intussusception
9. Rarely the invagination is damaged
Classification
• Colic-involving segments of large intestine
• Enteric-involving the small intestine only
• Ileocecal-ileocecal prolapses into cecum
drawing the ileum along with it
• Ileocolic-the ileum prolapses through the
ileocecal valve into the colon
Colic invagination
Enteric intussusception
Ileocolic invagination
Ileocecal intussusception
Clinical Presentation
1. vomiting (85%)-initially, vomiting is nonbilious and
reflexive, but when the intestinal obstruction occurs,
vomiting becomes bilious.
2. abdominal pain (83%)-pain is colicky, severe, and
intermittent.
3. passage of blood or bloody mucous per rectum (53%).
4. a palpable abdominal mass
5. lethargy.
6. diarrhea.
The classic triad of pain, vomiting, and bloody mucous
stools (“red current jelly”) is present in only one third of
infants with intussusception. Diarrhea may be present in 1020% of patients.
Physical:
• Usually, the abdomen is soft and nontender early, but it
eventually becomes distended and tender.
• A vertically oriented mass may be palpable in the right
upper quadrant. Ruch’s symtom: Appering of the pain and
screams during the palpation of intussusception mass
under abdominal wall. Dance’s symptom: in ileocaecal
invagination aconcave right lateral area of abdomen is
palpable
• Currant jelly stools are observed in only 50% of cases.
• Most patients (75%) without obviously bloody stools have
stools that test positive for occult blood.
• Fever is a late finding and is suggestive of enteric sepsis.
Differential diagnosis
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includes intestinal colic.
gastroenteritis.
acute appendicitis.
incarcerated hernia.
internal hernia.
volvulus.
Diagnostic studies:
 Laboratory investigation usually is not helpful in
the evaluation of patients with intussusception.
Leukocytosis can be an indication of gangrene if
the process is advanced. Dehydration is
depicted by electrolyte imbalances.
• X-ray examination: barium enema or
pneumoirigography
• Sonography
• CT
X-ray examination:
1)Intussusception - Plain Film
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May be normal
Soft tissue mass, often in RUQ
Small bowel obstruction
May see intussusceptum
2)Intussusception – Contrast Enema
• Diagnosis and treatment
• Media:
• Air
• Barium
• Water soluble contrast
X-ray examination
•Pneumoirigograhy
Air contrast enema shows
intussusception in the cecum.
Air enema showing the intussusception is in the
splenic flexure (arrow).
Barium enema shows intussusception
in the descending colon.
CT scan reveals the classic ying-yang
sign of an intussusceptum inside an
intussuscipiens.
Ultrasound
• The typical appearance is described
variously as a "target sign" a doughnut
sign, pseudokidney, or a sandwich sign.
• Colour Doppler has been used to assess
bowel viability and as a prognostic sign
that reduction will be successful
Abdominal sonograph reveals the classic
target sign of an intussusceptum inside an
intussuscipiens.
Intussusception.
(A) Longitudinal sonogram of a
child with the typical clinical
presentation of intussusception.
This is a longitudinal sonogram
through the intussusception.
There are multiple lymph nodes
(arrows) in the intussusception.
(B) Transverse sonogram of the
intussusception showing the
multiple lymph nodes (arrows)
within the intussusception. If
lymph nodes are seen within an
intussusceptum it has been
reported that it is more difficult to
reduce the intussusception.
(C) Transverse sonogram
of an intussusception
showing the color flow within
the intussusceptum. This
indicates that the
intussusception is still viable.
When no color flow is seen
on Doppler, suspicion must
be raised that the
intussusception is no longer
viable and the risk of
perforation is high.
Complications:
• Intestinal hemorrhage
• Necrosis and bowel perforation
• Shock and sepsis
Treatment
Technique
Hydrostatic-pressure reduction
Surgical operation
Enema Reduction
• Personal comfort level is probably the best
contrast selection criterion
• All have similar rates of reduction (75-85%)
and perforation (1-2%)
• End point - free reflux into small bowel and
reduction of mass
• Often see edema of ileocecal valve
• Main goal is to prevent unnecessary open
reduction, select patients who need resection
Non-operative reduction of the
intussusception
Richardson balloon for pneumoirigography
Principles of barium enema reduction
1. Perform nasogastric suction: administer 4 fluids or
blood and antibiotics
2. Insert ungreased Foley catheter in rectum, distend
ballon and pull down against levator. Strap in place
3. Wrap legs
4. Let barium run from height of 30 cm in above table
5. X-ray intermittently
6. Stop if barium column is stationary and its
unchanging for 10 min
7. Reduction
Reduction is marked by:
• free from of barium meal into small
bowel
• expulsion of feces and air with the
barium
• disappearing of intussusception mass
• response of child-clinical improvement of
the patient, who may fall into a natural
sleep
Surgical treatment
indication is:
• a shocked child with signs of peritonism
• or in whom intussusception does not
resolve with a nonoperativ procedure
Preoperative preparation includes:
• Apply intravenous fluids or blood
• Gastric aspiration (stomach has been
empty), insert nasogastric tube
• Administration of antibiotics
Operative technique:
• The intussusception
is milked back by
progressive
compression of the
bowel
In severe cases:
• Intestinal resection
• Placement of ileotransversal anastomosis
• Ileostoma and caecostoma placement
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