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Ileus (Adynamic ileus)

Etiologic Factors

Ileus reflects underlying alterations in motility of the gastrointestinal tract, leading to functional
obstruction. From a practical standpoint, ileus represents the interval between abdominal exploration
and the reappearance of flatus and bowel movements. Our understanding of the physiology of ileus
has been hindered by the insensitivity of techniques for studying gastrointestinal motility. Clinically,
bowel sounds and passage of flatus have been used to follow postoperative progress.
Electromyographic or intraluminal pressure recordings have proved to be reproducible and more
objective but have not necessarily correlated with the ability of the different segments of the bowel to
coordinate propulsion of gas and liquid from the stomach to the rectum. More recently, the distribution
of radio-labeled 51CrO4, as it is propelled aborally, has been used as a marker of intestinal transit.
When radioactive markers are given orally after laparotomy, they remain in the stomach for 12 to 24
hours. Although such markers move into the small intestine rapidly, and electromyographic activity
seems normal by 4 to 6 hours after laparotomy, the markers can remain in the small intestine for 3 to
5 days before moving to the transverse colon and beyond for defecation.66 Peritonitis or spillage of
noxious material (acid, bile, stool) leads to increases in delay of marker passage.

Table 27-3. POTENTIAL CONTRIBUTIONS TO PROLONGED ILEUS

NEUROGENIC PHARMACOLOGIC
Spinal cord lesions or injury Anticholinergics
Retroperitoneal process, Opiates
hematoma, tumor Autonomic blockers
Ureteral colic Antihistamines
METABOLIC Psychotropics
Hypokalemia Phenothiazines
Uremia Haloperidol
Ca2+, Mg2+ imbalance Tricyclic antidepressants
Hypothyroidism Clonidine
Diabetic coma or ketoacidosis Vincristine

INFECTIOUS
Systemic sepsis
Pneumonia
Peritonitis
Herpes zoster
Tetanus
Bacterial overgrowth of bowel

A number of factors have been implicated in the development and persistence of ileus (Table 27-3).
These include sympathetic neuronal hyperactivity and increases in endogenous opioid release and
other peptides, such as calcitonin gene-related peptide or motilin.6669 Use of anticholinergic
medications and narcotics delays recovery from ileus.70,71 In clinical studies, the use of patient-
controlled analgesia delivered intravenously delays recovery from ileus compared with the
intramuscular route.71 Also implicated have been solute and electrolyte disturbances such as
hypokalemia and hypercalcemia or hypocalcemia and hypomagnesemia, uremia, diabetic
ketoacidosis, and metabolic conditions such as hypothyroidism. In the current era of laparoscopically
assisted general abdominal surgery, it appears that less invasive access and manipulation of the
bowel may decrease the interval between operation and the passage of flatus and stool.72 There is
also evidence that the interval to toleration of oral diets is shorter than previously thought for patients
undergoing laparotomy or laparoscopy.
BHP

ETHICS ON DISCLOSING MEDICAL ERRORS

Physician error commonly affects patients, physicians, and other health care providers.
Some medical students will witness physicians medical mistakes. The student must then
reconcile conflicting desires to ensure patient welfare through truthtelling with those to
protect and remain loyal to the teaching physician. Facing the dilemma, the medical student
will find many reasons to facilitate disclosure of the error.

A physician has a multifold ethical duty to admit mistakes to the patient. As the
American Medical Association Principles of Medical Ethics states,A physician shall ... be
honest in all professional interactions. Moreover, in cases in which a patient suffers
significant medical complications that may have resulted from the physicians mistake ... the
physician is ethically required to inform the patient of the facts necessary to ensure
understanding of what has occurred. This ethical requirement to inform the patient of the
mistake can be concluded from both deontological and consequentalist perspectives, that is,
both by considering the possible consequences of the action.

The physician must act in the patients best interest at all times. Most often,
disclosure of mistakes would benefit patients. For instance, to gain patient cooperation, it is
often necessary to explain exactly how a condition arose. In some cases, knowledge of
mistake could affect the patients current and future decisions regarding care. Thus, to
maintain autonomy and to give true informed consent, the patient must know of relevant
errors. Also, understanding that a mistake occurred may relieve patients anxieties about
slow recovery or complications. Even knowledge of an iatrogenic cause could allay fears that
a worse problem exists. Providing such relief is an important example of beneficence. To
knowingly allow continued anxiety would constitute maleficence, as the physician would
consciously impair the patients well-being. Furthermore, if the physicians error resulted in
increased costs to the patient, justice would dictate disclosure to ensure patient
compensation. Because a physician must always act in accordance with the principles of the
patient-physician relationship, disclosure is clearly the ethical action after a medical mistake.

In addition to reasons arising from these principles, consideration of future


consequences also compels the physician to disclose errors. Accurate information could
improve the patients subsequent treatment. Other caregivers can then work with better
facts, while the cooperation of the informed patient greatly facilitates recovery. Additionally,
disclosure could aid in relief of the physicians own emotional stress while fostering a
stronger patient-physician bond. These practical results alone suggest disclosure is the best
course of action.

While it is relatively clear that a physician has the ethical obligation to admit medical
errors, what should the medical student do when the physician refuses to disclose a
mistake? In determining a course of action, the medical student must consider duties to the
patient, physician, and him or herself. It is inappropriate for the student to unilaterally
disclose the error, yet the student must not allow the patient to be deceived.

Although the students responsibility to the patient does require acting to facilitate
disclosure, the same responsibility precludes responding to patient queries by accusing the
physician of error. In clinical situations, the medical student has a unique relationship with
the patient. The student often accepts the description student doctor and thus is obligated
to maintain ethical conduct appropriate for a physician. As such, all of the reasons for
physician disclosure considered above also apply to the medical student. However, there are
also reasons a medical student should not independently tell a patient of a physicians
mistake. The students limited medical knowledge may make it difficult to explain the nature
of the error adequately. Also, a small number of patients specify before treatment that they
do not wish to know if anything goes wrong. Moreover, the attending physician may see
reason to wait before disclosing his or her error. For example, it might be prudent to wait until
the patient has achieved a certain degree of recovery before mistakes by the physician are
discussed. In any of these cases, for the medical student to preempt the physician would do
a gross disservice to the patient by undermining the relationship and trust between the
patient and attending physician. Instead, the student could tell the patient that he or she
would like to invite the physician to help explain the circumstances. The student must ensure
that disclosure of the physicians error does occur, but only after discussing situation with the
attending physician.

Not only do duties to the patient necessitate disclosure but the student can help the
physician avoid negative consequences by doing so. Telling the physician the patient would
like a clear explanation of the current circumstances gives the physician an opportunity to
discuss the mistake with the patient. It alerts the physician that the patient is concerned
about the cause of the complications. Communicating this concern may allow the physician
to resolve anxiety before hostility develops. This can save the physician from future
emotional strain and legal repercussions. Indeed, there is some indication patients may be
less likely to pursure litigation if the physician promptly admits a medical mistake. Risk
management organizations note patients often file lawsuits out of anger not having been told
the truth about their conditions. Likewise, surveyed patients responded they would be
significantly less likely to file a lawsuit if the attending physician informed them of a mistake
than if they found out by some other means.

These admissions can be very difficult and painful. Yet when the physician takes
responsibility for the mistake, both physician and patient benefit. Admittedly, this reasoning
may provide a little comfort to the student when facing the attending physician. Nonetheless,
the student can minimize awkwardness by discussing the matter with the physician
appropriately. The student may privately approach the physician and nonconfrontationally
state that the patient has asked about the situation, and the student would appreciate the
physicians help in informing the patient of the mistake. While approaching the physician
may remain difficult, it remains the duty of the student to both the patient and the attending
physician to encourage disclosure.

Unfortunately, an attending physician may not be eager to admit a mistake. In such a


case, the student has an additional responsibility to him or herself and fellow students to
pursue disclosure.
Ethical actions are often unpleasant and difficult to perform. Yet in doing so, the
student develops professionally in reaffirming personal ethical standards and learning
firsthand how to manage conflicting priorities. To ignore the opportunity would be to abandon
a chance to learn how to handle medical errors, an ability that will most likely be needed in
the future. By pursuing disclosure, the student further ensures that peers will not be required
to maintain silence when other medical mistakes occur; the act serves to defy the stigma of
admitting a mistake. Beyond duties to the patient and physician, the student has a
responsibility to him or herself to practice responsible medicine. This responsibility begins as
a student; there is no easier way to learn to be an ethical physician than to engage in ethical
practice from the start.

CRP:

Broadly speaking, any question that we want answered and any assumption or assertion
that we want to challenge or investigate can become a research problem or a research topic
for our study. The formulation of research problem is the first and most important step of the
research process. It is like the identification of a destination before undertaking a journey. A
research problem is like the foundation of a building. The type and design of the building is
dependent upon the foundation. If the foundation is well-designed and strong we can expect
the building to be also. The research problem serves as the foundation of a research study, if
it is well formulated, we can expect good study to follow.

Table 1. Sources of research problem (four of P)


Aspect of a study About Study of

Study Population People Individuals, organization, groups, and communities

Subject area Problem Issues, situations, associations, needs, population


composition, profiles, etc.

Program Contents, structure, outcomes, attributes,


satisfaction, consumers, service providers, etc

Phenomeno Cause and effect relationships, the study of a


n phenomenon itself, etc

Most research on a particular P may vary from study to study but generally in practice most
research studies are based upon at least a combination of two Ps.

When selecting a research problem/topic there is a number of considerations to keep in


mind. These help to ensure that our study will be manageable and that you will remain
motivated. These considerations are:

Interest : Select a topic that really interests you; this one of the most important
considerations. A research endeavour is usually time-consuming, and
involves hard work and possibly unforeseen problems. If you select a
topic which does not greatly you, it could become extremely difficult to
sustain the required motivation, and hence the completion time could
be affected
Magnitude : You should have sufficient knowledge about the research process to
be able to visualize the work involved in completing the proposed
study. Narrow the topic down to something manageable, specific and
clear. It is extremely important to select a topic that you can manage
within the time and resources at your disposal.

Measurement of : If you are using a concept in your study, make sure you are clear
concepts about its indicators and their measurement. For example if you plan to
measure the effectiveness of a health promotion program, you must
be clear as to what determines effectiveness and how it will be
measured. Do not use concept in your research problem that you are
not sure how to measure. This does not mean you cannot develop a
measurement procedure as the study progresses. While most of the
developmental work will be done during your study, it is imperative
that your reasonably clear about the measurement of this concept at
this stage.

Level of : Make sure you have an adequate level of expertise for the task you
expertise are proposing. Allow for the fact that you will learn during the study
and may receive help from your research supervisors an others, but
remember you need to do most of the work yourself.

Relevance : Select a topic that is relevance to you as a professional. Ensure that


your study ads to the existing body of knowledge, bridges current
gaps or is useful in policy formulation. This will help you to sustain
interest in the study.

Availability of : If your topic entail collection of information from secondary sources


data (office records, client records, census or other already-published
reports, ect.), before finalising your topic, make sure that these data
are available and in the format you want.

Ethical issues : Another important consideration in formulating a research problem is


the ethical issues involved. In the course of conducting a research
study, the study population may be: adversely affected by some of the
question (directly indirectly); deprived of an intervention; excepted to
share sensitive and private information; or excepted to be simply
experimental guinea pigs. How ethical issues can affect the study
population and how ethical problems can be overcome should be
thoroughly examined at the problem formulation stage.

Diagnosis
Because ileus is a predictable consequence of laparotomy, it is important to distinguish normal
postoperative ileus from what some authors have termed paralytic ileus. The distinction is based on
time since operation and clinical circumstances. For example, for a patient who has undergone
elective cholecystectomy, the normal period for the ileus should not be more than 48 hours. For the
patient who has undergone a low anterior resection of the colon, 3 to 5 days before passage of flatus
would not be unexpected. Thus, the absence of bowel sounds, flatus, or bowel movements beyond
the expected period indicates delayed resolution.

When the patients postoperative ileus has extended beyond the expected period, plain films of the
abdomen reveal gas in segments of both the small and large bowel (Fig. 27-10). The patient may
experience discomfort and distention as swallowed air fills loops that do not have effective peristalsis.
The differential diagnosis includes mechanical obstruction from early postoperative adhesions (see
earlier). To differentiate early postoperative obstruction from ileus, contrast studies or a CT scan is
helpful. The latter may be useful if other abdominal pathology, such as an abscess, could be
contributing to the clinical picture. The flow of contrast to the large bowel excludes the diagnosis of
complete small bowel obstruction but does not necessarily exclude a partial obstruction. A number of
interventions have been advocated for reducing the period of ileus. In recent years, prokinetic agents
such as metoclopramide, cisapride, and erythromycin have been evaluated in this clinical setting. For
certain forms of upper gastrointestinal ileus (eg, after a Whipple procedure), such medications may be
effective in promoting gastric emptying.74 There has been little success in using these agents to
shorten recovery times after lower abdominal procedures.75,76 Recent experimental studies have
used pharmacologic interventions specifically directed at abnormal release of neurotransmitters or
hormones that might prolong ileus. Agents as diverse as opioid antagonists, a somatostatin analogue,
sympatholytic agents, local anesthetics, and nonsteroidal antiinflammatory drugs such as ketorolac
promote faster recovery to normal myoelectric activity and shorten intestinal transit times.67
69,72,77,78 Few of these interventions have been evaluated clinically. Measures to prevent
prolongation of ileus include meticulous technique in the operating room, minimal use of narcotics for
analgesia, correction of electrolyte or metabolic imbalances, and early recognition of septic
complications that may contribute to prolongation beyond the expected period for ileus.

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