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PubMed1995

Distinction between postoperative ileus and mechanical small-bowel obstruction: value of CT compared with clinical and other radiographic findings.

OBJECTIVE: The expeditious diagnosis of complete and partial mechanical small-bowel obstruction, as opposed to paralytic ileus, during the immediate postoperative period may be difficult on the basis of clinical and plain film radiographic findings. For this reason, we prospectively evaluated the use of CT in this setting and compared it with the clinical and plain film evaluations as well as with various contrast examinations. SUBJECTS AND METHODS: Thirty-six postoperative patients with signs and symptoms of paralytic ileus or mechanical small-bowel obstruction were examined clinically and had plain abdominal radiographs. Based on the findings of these examinations, the surgeon assigned patients to one of the following categories: (1) paralytic ileus, (2) indeterminate, (3) partial mechanical obstruction, or (4) complete mechanical obstruction. CT scans were obtained within 24 hr of the initial diagnostic studies, and patients were then recategorized according to the above classification solely based on CT findings. Initial examination results were then compared with the CT results. In addition, the results of contrast studies, namely, enteroclysis and barium enema, performed after CT small-bowel series, were evaluated. The gold standard for diagnosis was laparotomy in 20 patients, clinical course and follow-up in 13 patients, and clinical course and contrast studies in the other three patients. RESULTS: CT was effective (sensitivity and specificity, 100%) in distinguishing between postoperative ileus and complete mechanical small-bowel obstruction. The combined clinical and plain film findings were often confusing and nondiagnostic (sensitivity, 19%). CT was also valuable in diagnosing and distinguishing partial mechanical small-bowel obstruction from paralytic ileus. Contrast studies (enteroclysis) in four patients with partial mechanical small-bowel obstruction were useful in grading the degree and severity of the obstruction. CONCLUSION: Our results suggest that in the immediate postoperative period, CT is the method of choice for diagnosing mechanical small-bowel obstruction and distinguishing it from paralytic ileus. Contrast studies are useful in further evaluating partial mechanical small-bowel obstruction.

Adolescent↗
PubMedDate not supplied

Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.

Aged↗
PubMed2001

Gallstone ileus: demographic and clinical criteria supporting preoperative diagnosis.

Gallstone ileus is an uncommon intestinal obstruction with unexpectedly high mortality. It is not easy to diagnose this uncommon disease preoperatively. The aim of our study is to establish some simple criteria supporting the suspicion of gallstone ileus in patients with small intestine obstruction. We retrospectively analysed hospital records of 8 patients with gallstone ileus and 1230 cases of mechanical intestinal obstruction, excluding incarcerated external hernias. Gallstones were the cause of occlusion in 0.9% (8/886) of patients with small bowel obstruction. All our 8 patients were women with an average age of 74 years. Gallstone ileus was diagnosed in 18% of elderly (+70 years) women with small intestine obstruction. This rate raised to 36% in this group of elderly women if previous abdominal operations that would produce adhesion were excluded. Previous ultrasonographic examinations had demonstrated gallstones in 5 (62%) patients. Only one patient (12.5%) was diagnosed preoperatively with plain X ray film demonstrating gas in the biliary tract. The obstruction was treated with enterolithotomy. Cholecystectomy was performed in two (25%) patients. The mortality was 25% in early postoperative period. Advanced age, female sex, and positive patient's history of known gallstone in the gallbladder have appeared as strong criteria. Gallstone ileus is a common cause of intestinal obstruction in elderly women with no previous abdominal operations and without incarcerated external hernia. Pneumobilia is more common radiological finding to establish the diagnosis of gallstone ileus in these patients.

Age Factors↗
PubMed1975

[New findings in the differential diagnosis of acute ileus (author's transl)].

Knowledge of the patho-physiological behaviour present in the colon is the deciding factor for a reliable differential diagnosis of mechanical or paralytic ileus. A quick and sure diagnosis can be got with irrigoscopy (barium enema). In paralytic ileus, a radical change in the function of the right colon is present; instead of resorption, exudation and paralysis have taken place. Barium enema shows this behaviour; the left colon stays contracted, the contrast medium passes easily into the right colon, where it mixes with the fluid levels. This picture is proof of paralytic ileus. A completely different picture is to be found in mechanical ileus of the small intestine; the small intestine is gas-inflated, with fluid levels, and passes nothing on to the colon which, therefore, is contracted in its whole length. This picture also is diagnostic. Barium enema is already known in the diagnosis of mechanical ileus of the large intestine. It can also be used in the diagnosis of paralytic enterocolitis (without diarrhoea) in childhood and old age. In the case of post-operative early ileus it gives a quick and sure differential diagnosis.

Barium Sulfate↗
PubMed2001

Factors associated with the resolution of postoperative ileus in newborn infants.

Reliable indicators of ileus resolution following laparotomy have not been identified in newborn infants. The purpose of this study was to correlate commonly available clinical parameters with the resolution of postoperative ileus in newborn infants after abdominal procedures. The presentation, treatment, and postoperative abdominal examination of 60 consecutive newborn infants who underwent a heterogeneous group of primary abdominal operations were evaluated. No significant association was observed between the time to first bowel movement (resolution of ileus) and age, postconceptual age, weight, degree of intraabdominal contamination, duration of surgery, type of operative procedure, presence or absence of abdominal distension, and time to first bowel sounds. Opioid use was associated with a delay in the time to first bowel movement that was not accounted for by the effects of any other variable. Easily obtainable clinical parameters are not universally useful for predicting the duration of ileus in newborn infants after abdominal surgery. The use of opioids is associated with delayed resolution of ileus. Measures to limit the use of opioids may be effective in shortening the duration of postoperative ileus in newborn infants.

Abdomen↗
PubMed1987

Meconium ileus: a fifteen-year experience with forty-two neonates.

From 1969 to 1984, 42 neonates were managed for meconium ileus caused by cystic fibrosis. Simple, uncomplicated meconium ileus occurred in 24 infants (57%) and complicated meconium ileus occurred in 18 (43%). Meglumine diatrizoate (Gastrografin) enema completely relieved the obstruction in 13 patients with simple meconium ileus (54%) and caused colonic and rectal perforations in three (13%). Six operative procedures were used in 29 patients: double enterostomy (seven), resection with primary anastomosis (seven), Bishop-Koop enterostomy (seven), intraluminal lavage (four), colostomy (three), and Mikulicz enterostomy (one). Postoperative complications included malabsorptive diarrhea (nine), pneumonia (three), intestinal obstruction (two), total parenteral nutrition-catheter sepsis (two), and anastomotic leak (one). Infants managed nonoperatively by Gastrografin enema had a significantly shorter hospitalization (average, 15 days) than those undergoing operation for simple meconium ileus (54 days) and complicated meconium ileus (111 days). Postoperative survival rate was 100% with a late survival rate of 86%.

Cystic Fibrosis↗
PubMed1976

[Paralytic and postoperative ileus (author's transl)].

Paralytic ileus is always a reaction of the organism to a disturbance usually due to metabolism. A treatment without elimination of the eliciting cause seems, therefore, to have little point. The efficacy of many substances given to stimulate peristalsis has not been proved. Drawing off the contents of the stomach and controlled infusion therapy, on the other hand, are important parts of the treatment, as for mechanical ileus. For the surgical emptying of the intestine, the most suitable procedure is retrograde squeezing of the intestinal contents to the stomach and aspiration through a nasal sound. Enterotomies should be avoided if at all possible. Surgical intervention for paralytic ileus is most frequently necessary in the postoperative phase, usually caused by a peritonitis with or without anastomotic failure. Differentiation from mechanical obstruction is not always possible. In the Erlangen Hospital, 233 patients were treated for postoperative ileus from 1965 to 1974. All patients with a mechanical ileus were operated on, the mortality was 17%. Of 123 patients with a paralytic ileus, 82 were operated on and 45 died. The mortality was almost equally high in patients not operated on.

Adult↗
PubMed2005

The duration of postoperative ileus after elective colectomy is correlated to surgical specialization.

AIM: Postoperative ileus is an important factor of complications following gastrointestinal procedures. Its pathophysiology and the parameters, which may impact on its duration, remain unclear. The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after elective colorectal surgery. METHODS: From July 2002 to September 2003, all patients who underwent laparotomy for colectomy (laparoscopic resections excluded) with either an ileotransverse, colocolic, or high colorectal anastomosis were entered in this prospective study. The intervals in hours between the end of the surgical procedure and passing of flatus (PG) and passing of stool (PS) were recorded by an independent investigator. PG and PS were eventually correlated with the following parameters: type of colectomy, early removal of nasogastric tube (NGT), mechanical bowel preparation (MBP), type of underlying disease, systemic administration of opiates, and surgical training (colorectal fellowship or other). RESULTS: One hundred twenty-four patients were entered in this study. Four patients (3.2%) developed septic complications (3 anastomotic leaks and 1 intraabdominal abscess) and were excluded from the analysis. Median age in this population was 68 (range 30-95) years. Mean duration of postoperative ileus was 70+/-28 h (PG) and 99+/-34 h (PS). The type of colectomy, underlying disease, MBP, and early NGT removal failed, in univariate analysis, to correlate with the duration of postoperative ileus. By contrast, time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [56+/-23 vs 74+/-28 h (PG); 82+/-26 vs 103+/-35 h (PS), p=0.004], as well as in patients who received systemic opiates for less than 2 days [64+/-27 vs 75+/-28 h (PG), p=0.04; 88+/-32 vs 108+/-33 h (PS), p=001]. CONCLUSION: Restoration of normal intestinal function after elective open colectomy takes 3 (PG) to 4 (PS) days. In our series, specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus. Surgical specialization should be considered an important parameter in future clinical trials aiming to minimize postoperative ileus.

Adult↗
PubMed2005

Gastrokinetic effect of ghrelin analog RC-1139 in the rat. Effect on post-operative and on morphine induced ileus.

We aimed to confirm the gastrokinetic effect of ghrelin analog, RC-1139, in the presence of opiates. Gastric emptying was verified in rats by counting stomach residue 15 min after gavage of methylcellulose. Normal rats: RC-1139 (0, 0.25, 1.0, 2.5 mg/kg i.v.) decreased methylcellulose left in stomach (47, 36, 12, 10% of ingested solution). Post-operative ileus (post-op. ileus) ileus: gastric residue decreased from 88 to 66, 53, 51% with RC-1139 0, 1.0, 2.5, 10 mg/kg. Morphine in post-op. ileus: gastroparesis was corrected at 10 mg/kg (54%). Ghrelin analog RC-1139 is a potent gastrokinetic in rat; it reversed gastric post-op. ileus, even in the presence of opiates.

Animals↗
PubMed2005

The ICAM-1 antisense oligonucleotide ISIS-3082 prevents the development of postoperative ileus in mice.

Intestinal manipulation (IM) during abdominal surgery triggers the influx of inflammatory cells, leading to postoperative ileus. Prevention of this local muscle inflammation, using intercellular adhesion molecule-1 (ICAM-1) and leukocyte function-associated antigen-1-specific antibodies, has been shown to shorten postoperative ileus. However, the therapeutic use of antibodies has considerable disadvantages. The aim of the current study was to evaluate the effect of ISIS-3082, a mouse-specific ICAM-1 antisense oligonucleotide, on postoperative ileus in mice. Mice underwent a laparotomy or a laparotomy combined with IM after treatment with ICAM-1 antibodies, 0.1-10 mg kg(-1) ISIS-3082, saline or ISIS-8997 (scrambled control antisense oligonucleotides, 1 and 3 mg kg(-1)). At 24 h after surgery, gastric emptying of a 99mTC labelled semi-liquid meal was determined using scintigraphy. Intestinal inflammation was assessed by myeloperoxidase (MPO) activity in ileal muscle whole mounts. IM significantly reduced gastric emptying compared to laparotomy. Pretreatment with ISIS-3082 (0.1-1 mg kg(-1)) as well as ICAM-1 antibodies (10 mg kg(-1)), but not ISIS-8997 or saline, improved gastric emptying in a dose-dependent manner. This effect diminished with higher doses of ISIS-3082 (3-10 mg kg(-1)). Similarly, ISIS-3082 (0.1-1 mg kg(-1)) and ICAM-1 antibodies, but not ISIS-8997 or higher doses of ISIS-3082 (3-10 mg kg(-1)), reduced manipulation-induced inflammation. Immunohistochemistry showed reduction of ICAM-1 expression with ISIS-3082 only. ISIS-3082 pretreatment prevents postoperative ileus in mice by reduction of manipulation-induced local intestinal muscle inflammation. Our data suggest that targeting ICAM-1 using antisense oligonucleotides may represent a new therapeutic approach to the prevention of postoperative ileus.

Animals↗
PubMed2003

Tyrphostin AG 126 inhibits development of postoperative ileus induced by surgical manipulation of murine colon.

Manipulation of the bowel during abdominal surgery leads to a period of ileus, which is most severely manifested after procedures that directly involve the colon. Ileus is associated with the increased expression of proinflammatory cytokines and chemokines, a leukocytic infiltration into the muscularis, and the release of mediators from resident and infiltrating leukocytes that directly inhibit intestinal smooth muscle contractility. Phosphorylation of tyrosine residues on regulatory proteins by protein tyrosine kinases (PTKs) occurs at multiple steps in the signaling cascades that regulate the expression of proinflammatory genes. The purpose of this study was to determine whether inhibition of PTK activity will attenuate the inflammatory response associated with colonic ileus and lead to improved function. Using a rodent model of colonic postoperative ileus, we demonstrate that a single bolus injection of the PTK inhibitor tyrphostin AG 126 (15 mg/kg sc) before surgery significantly attenuates the surgically induced impairment of colonic contractility both in vivo and in vitro. Improvement in function was associated with a reduction in magnitude of inflammatory cell infiltrate and with a decrease in transcription of genes encoding proinflammatory mediators IL-1beta and monocyte chemoattractant protein (MCP)-1, inducible nitric oxide synthase, and cyclooxygenase-2. Furthermore, tyrphostin AG 126 pretreatment significantly inhibited activation of multifactorial transcription factor NF-kappaB, which could form the basis for reduction in proinflammatory mediator expression. These data demonstrate for the first time that inhibition of PTK activity may represent a novel approach for management of ileus in the clinical setting.

Animals↗
PubMed2006

[Clinical use of endoscopic ileus tube drainage in preoperative therapy for acute low malignant colorectal obstruction].

OBJECTIVE: To evaluate the clinical use of endoscopic ileus tube drainage in preoperative therapy for acute low malignant colorectal obstruction. METHODS: From Nov. 2004 to Dec. 2005, 15 cases with acute low malignant colorectal obstruction received emergency colonoscopy and endoscopic ileus tube drainage was performed. Radical resection was then performed after seven days of drainage. RESULTS: Endoscopic ileus tube drainage was successful in 13 cases, and failed in 2 cases because the guide wire cannot be inserted through the tumor in one case, and in the other case the tumor was located in the middle of the transverse colon so that the ileus drainage tube was not long enough. Abdominal girth decreased from (91+/- 4) cm to (82+/- 2) cm after tube drainage. The everyday drainage volume minus rinsing volume ranged from - 600 ml to 3200 ml. Abdominal X ray showed that obstruction was relieved. Intra-operative exploration revealed that colon edema was not evident, which increased resection rate. CONCLUSION: Endoscopic ileus tube drainage is effective, safe and maybe the first choice of acute low malignant colorectal obstruction.

Acute Disease↗
PubMed1998

A model to investigate postoperative ileus with strain gauge transducers in awake rats.

BACKGROUND: Postoperative ileus influences patients well-being, hospital stay, and health cost, and postoperative inhibition of colonic motility is a major contributor to postoperative ileus. Experimental models for investigating postoperative ileus are needed. In particular, recording of postoperative colonic motility in awake rats has not been described yet. MATERIAL AND METHODS: Gastric, small intestinal, and colonic motility were recorded with strain gauge transducers in awake rats, and the effects of anesthesia and abdominal surgery on gastrointestinal motility were investigated. RESULTS: Ether anesthesia increased gastric motility and inhibited small intestinal motility, while enflurane anesthesia had only minor effects on gastrointestinal motility. Abdominal surgery inhibited gastric, small intestinal, and colonic motility, and a detailed analysis of gastrointestinal motility in our postoperative ileus model is given. CONCLUSIONS: We established a model to record gastric, small intestinal, and colonic motility in awake rats postoperatively. We could demonstrate that enflurane anesthesia had little effect on gastrointestinal motility, while laparotomy and short manipulation of the cecum produced a prolonged inhibition of gastrointestinal motility. Our model could be used to investigate postoperative ileus, particularly of the colon, in awake rats.

Abdomen↗
PubMed1994

Hypermagnesemia-induced paralytic ileus.

Hypermagnesemia is a well-known cause of hypotension and cardiac dysfunction but not well recognized is the induction of paralytic ileus. This report details the second and third adult patients reported with hypermagnesemia-induced paralytic ileus. The first patient was a 65-year-old white woman with normal renal function, who had consumed large amounts of magnesium citrate and milk of magnesia. As magnesium blood level fell from 5.1 mg/dl on admission to 2.4 mg/dl on day 3, the vomiting, obstipation, and abdominal distension resolved. The second patient was a 67-year-old woman with mild renal insufficiency, who consumed a large amount of Epsom salts containing magnesium sulfate to treat her constipation. Magnesium levels of 8.1 mg/dl on admission fell to below 3.1 mg/dl on the third hospital day and the paralytic ileus resolved. Mechanical obstruction was ruled out by colonoscopy, gastrographin enema, and barium small bowel series in both patients. Although the clinical findings of muscle weakness, flaccid paralysis, respiratory muscle paralysis or cardiac arrest due to hypermagnesemia are well described in the literature, intestinal smooth muscle dysfunction leading to paralytic ileus has only been reported in one other adult patient. The laboratory and clinical course of these two patients strongly suggest a causal relationship between hypermagnesemia and paralytic ileus.

Aged↗
PubMedDate not supplied

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound.

BACKGROUND: Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. METHODS: We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. RESULTS: Rigler's triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. CONCLUSION: The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings.

Aged↗
PubMed2003

Comparison of surgical treatments of gallstone ileus: preliminary report.

Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 1% to 4% of all intestinal obstructions. In the group of patients over 65 years of age, gallstones cause about 25% of all non-strangulated obstructions of the small bowel. Gallstone ileus is burdened with high mortality rate, ranging from 12% to 18%, and most patients are of advanced age, with many other concomitant diseases that may increase the operative risk. The purpose of this study was to compare the two investigated surgical procedures: treatment of intestinal obstruction alone or combined with urgent cholecystectomy and fistula repair. Analysis of 30 patients undergoing operation for gallstone ileus at the Clinical Hospital "Sestre milosrdnice" between 1985 and 2001 is presented. Patients were treated either for ileus alone (group 1, 11 patients) or as one-stage procedure with urgent fistula closure (group 2, 19 patients). Operating time was significantly longer for the one-stage procedure. Complications occurred in 3 of 11 patients (27.3%) from group 1 and in 11 of 18 patients (61.1%) from group 2 (one tailed, p = 0.043). One patient in group 1 died and two patients in group 2 died. Urgent fistula repair was significantly associated with the occurrence of complications (odds ratio [OR] 12.1, 95% confidence internal [95% CI] 1.2-121.5). Simple enterotomy should be the procedure of choice for patients with gallstone ileus. The one-stage procedure including urgent fistula repair should be reserved only for highly selected patients with absolute indications.

Aged↗
PubMed2001

Intraperitoneal capsaicin treatment reduces postoperative gastric ileus in awake rats.

INTRODUCTION: Postoperative gastric ileus interferes with postoperative recovery of the patients. Previous studies suggest that capsaicin-sensitive afferent neurons are involved in the mediation of postoperative gastric ileus. METHODS: A group of rats were equipped with a strain gauge transducer sutured to the gastric wall. Gastric motility was recorded after intraperitoneal injection of capsaicin (0.1 micromol/kg and 1 micromol/kg) or vehicle. The rats were given 2 days of recovery before gastric motility was investigated in a postoperative ileus model. RESULTS: Pretreatment with capsaicin 2 days prior to abdominal surgery significantly increased postoperative gastric motility, with complete recovery of gastric motility at 30 min postoperatively (with the baseline motility index set at 100+/-4%, the gastric motility index 30-45 min postoperatively was 64+/-4% for the vehicle, 138+/-20% for capsaicin 0.1 micromol/kg, and 110+/-12% for capsaicin 1 micromol/kg: P=0.0008 vehicle vs capsaicin). In contrast, capsaicin treatment 2 h prior to abdominal surgery did not increase postoperative gastric motility (gastric motility index 30-45 min postoperatively was 64+/-4% for the vehicle and 51+/-8% for capsaicin 0.1 micromol/kg). The acute intraperitoneal injection of capsaicin decreased gastric motility by about 50-60%, the response lasting for 15-30 min. CONCLUSIONS: Intraperitoneal capsaicin treatment 2 days prior to abdominal surgery resulted in immediate recovery of postoperative gastric motility, indicating an important role for serosal visceral afferent nerve fibers in the mediation of postoperative gastric ileus. Possibly, capsaicin or vanilloid (capsaicin) receptor agonists can be used to treat postoperative ileus in the future.

Animals↗
PubMed2003

Adenosine A1 receptor blockade reverses experimental postoperative ileus in rat colon.

Inhibition of colonic propulsive motility is the main contributor to postoperative ileus in humans. Experimental models for investigating colonic propulsion in surgically induced postoperative ileus have not previously been available. This study was designed to assess whether adenosine A(1) receptor antagonists (R)-1-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl) acryloyl]-piperidin-2-yl acetic acid (FK352) and 8-cyclopentyl-1, 3-dipropylxanthine (DPCPX) reverse the colonic motility disorder in newly developed rat experimental ileus models. When rats underwent anesthesia (pentobarbital) or surgical traumas (partial gastrectomy, cecectomy or gentle touching of the colon with fingers), colonic propulsive motility was evaluated by migration of intracolonically injected dye in awake unrestrained rats. Propulsive motility resulted in significant decrease after the treatment of the anesthesia or partial gastrectomy. Intravenous administration of either adenosine A(1) receptor antagonist reversed the slowed colonic propulsion in these experimental ileus models. The present study suggests that the blockade of adenosine A(1) receptors has therapeutic potential for postoperative ileus.

Anesthesia↗