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Ileus is a
temporary arrest of intestinal peristalsis. It occurs most commonly
after abdominal surgery, particularly when the intestines have been
manipulated. Symptoms are nausea, vomiting, and vague abdominal
discomfort. Diagnosis is based on x‑ray findings and clinical impression.
Treatment is supportive, with nasogastric suction and IV fluids.
Etiology
In addition to postoperative causes, ileus also results from intraperitoneal or retroperitoneal inflammation (eg, appendicitis, diverticulitis, perforated duodenal ulcer), retroperitoneal or intra-abdominal hematomas (eg, ruptured abdominal aortic aneurysm, lumbar compression fracture), metabolic disturbances (eg, hypokalemia), or drugs (eg, opioids, anticholinergics, sometimes Ca channel blockers). Ileus sometimes occurs in association with renal or thoracic disease (eg, lower rib fractures, lower lobe pneumonias, MI).
Gastric and colonic motility disturbances after abdominal surgery are common. The small bowel is typically least affected, with motility and absorption returning to normal within hours after surgery. Stomach emptying is usually impaired for about 24 h or more. The colon is often most affected and may remain inactive for 48 to 72 h or more.
Symptoms and Signs
Symptoms and signs include abdominal distention, vomiting, and vague discomfort. Pain rarely has the classic colicky pattern present in mechanical obstruction. There may be obstipation or passage of slight amounts of watery stool. Auscultation reveals a silent abdomen or minimal peristalsis. The abdomen is not tender unless the underlying cause is inflammatory.
Diagnosis
The most essential task is to distinguish ileus from intestinal obstruction. In both conditions, x‑rays show gaseous distention of isolated segments of intestine. In postoperative ileus, however, gas may accumulate more in the colon than in the small bowel. Postoperative accumulation of gas in the small bowel often implies development of a complication (eg, obstruction, peritonitis). In other types of ileus, x‑ray findings are similar to obstruction; differentiation can be difficult unless clinical features clearly favor one or the other. Water-soluble contrast studies may help differentiate.
Treatment
Treatment involves continuous nasogastric suction, npo status, IV fluids and electrolytes, a minimal amount of sedatives, and avoidance of opioids and anticholinergic drugs. Maintaining an adequate serum K level (> 4 mEq/L [> 4 mmol/L]) is especially important. Ileus persisting > 1 wk probably has a mechanical obstructive cause, and laparotomy should be considered. Sometimes colonic ileus can be relieved by colonoscopic decompression; rarely, cecostomy is required. Colonoscopic decompression is helpful in treating pseudo-obstruction (Ogilvie's syndrome), which consists of apparent obstruction at the splenic flexure, although no cause can be found by contrast enema or colonoscopy for the failure of gas and feces to pass this point. Some clinicians use IV neostigmine (requires cardiac monitoring) to treat Ogilvie's syndrome.
Last full review/revision September 2007 by Parswa Ansari, MD
Content last modified September 2007
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