Penyusun : Bachtiar Surya

Ismet
Syahbudin
Liberty
Asrul
Budi Irwan

ILEUS

Department of Surgery Faculty of Medicine

North Sumatra Univercity-Adam Malik Hospital
Medan
 DEFINITION
Ileus, refers to limited or absent intestinal passage

Mechanical (Dynamic ) ileus refers to a lack of

passage due to an obstruction, which can be
located anywhere in the bowel

Paralytic (adynamic) (Fungsional) ileus

Paralytic ileus refers to a lack of passage due to
paralysis of the bowel,
Etiopathogenesis
Ileus - Obstruction = Dynamic = Mechanical
- Paralytic = Adynamic = Functional

Speed of onset :
- Acute
- Chronic
The extent of obstruction
-Partial
-Complete
The type of obstruction
-Simple
-Closed-loop
-Strangulation
 MECHANICAL OBSTRUCTION

Common causes of obtruction at each age group

Neonate -Congenital atresia

-Volvulus neonatum
-Meconeum ileus
-Hirschsprungs disease
-Imperforate anus
Infant -Stranggulated inguinal hernia
-Intussuception
-Complication of Meckels diverticulum
-Hischsprungs diseases
 Young adult -Adhesions and bands
-Strangulated ing.hernia

Middle age -Adhesesion and band

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus

Elderly -Adhesion and bands

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus
-Impacted faeces
 Incidence
May occur at any age
70 percent small bowel,
30 percent large bowel
 Diagnoctic Studies
Laboratory test--->Fecal Occult Blood Test
Sigmoidoscopy
X ray examination
Plain X ray --- Erect and lying down -
routinely
Follow-through studies after ingestion of
radiopague meal --- gastrografin
Barium enema X ray
 Clinical Picture
The classic quartet
Colicky abdominal pain
Abdominal distension
Vomiting
Decreased passage of stool or flatus
 Clinical Manifestations
Vital Sign
Hypovolumic shock Tachicardia Hypotension RR Fever
Abdominal
Colicky pain
On Inspection
Abdominal distension
Visible peristalsis
Scars Adhesion
On Auscultation borborygmi
metallic sound
Palpation--- palpable mass
DRE (Digital Rectal Examination )

Vomiting - Consists food and gastric chyme- bile faeculent

 Adynamic vs Mechanical
Ileus Obstruction
Gas diffusely through Large small intestinal
intestine, incl. colon loops, less in colon
May have large diffuse Definite laddered A/F
A/F levels levels
Quiet abdomen Tinkling, quiet= late
No obvious transition Obvious transition point
point on contrast study on contrast study
Peritoneal exudate if
No peritoneal exudate
peritonitis
Mechanical Obstruction
Adynamic Ileus
 Barium enema X ray
transition point on contrast study
 Pathophysiology
1. Fluid disturbances Massive third space losses 8 10 L of fluid
are secreted
Sequestration within the dilated loop
Hypovolumic shock oliguria, hypotension, hemoconcentration

2. Electrolyte depletion

3. Bacteriology
-Rapid colonisation

4. Bowel distension--increased intraluminal pressure ACS

impedement in venous returnarterial insufficiency

5. Pathology
-High intra luminar pressure- oedematous cyanosis
intraperitoneal exudation necrosis
perforationperitonitis
 Important Problem
Site Small Bowel vs. Large Bowel
Etiology
Partial vs. complete
Simple vs. strangulated
Fluid & electrolyte status
Operative vs. non-operative management
 Site?
Small Bowel vs. Large Bowel
Scenario
prior operations in bowel habits
Clinical picture
scars, masses/ hernias
amount of distension/ vomiting
Radiological studies
gas in colon?, volvulus?, transition point, mass
(Almost) always operate on LBO, often
treat SBO non-operatively
bent inner tube = Coffe bean appearance
Bird Beak
 Etiology?
Outside the wall (Extrinsic)

Inside the wall (Intrinsic)

Inside the lumen

Lesions Extrinsic to Intestinal Wall
Adhesions (usually postoperative)
Hernia
-- inguinal, femoral, umbilical
Neoplastic
extraintestinal neoplasm
Intra-abdominal abscess
Volvulus (sigmoid, cecal)
Lesions Intrinsic to Intestinal Wall
Congenital Neoplastic
Malrotation Primary neoplasms
Duplications/cysts Metastatic neoplasms
Traumatic
Inflammatory
Hematoma
Crohn's disease
Ischemic stricture
Infections Miscellaneous
Tuberculosis Intussusception
Actinomycosis Endometriosis
Diverticulitis Radiation
 Intraluminal/ Obturator Lesions
Gallstone
Enterolith
Bezoar
Foreign body
Parasit
Common Causes SBO
 Common Causes of LBO
Colon cancer
Diverticulitis
frequency
Volvulus
Hernia
 Causes of Adynamic Ileus
Following celiotomy
small bowel- 24h, stomach- 48h, colon- 3-5d
Inflammation e.g. Peritonitis
Retroperitoneal disorders e.g. ureter, spine, blood
Thoracic conditions e.g. pneumonia, # ribs
Systemic disorders e.g. sepsis, hyponatremia,
hypokalemia, hypomagnesemia
Drugs e.g opiates, psychotropics
 Partial
Flatus
Residual colonic gas
above peritoneal reflection
Adhesions
60-80% resolve with non-
operative Mx
Must show objective
improvement, if none by
48h consider OR
vs Complete
Complete obstipation
No residual colonic gas
on AXR
on AXR Stepladder
pattern
Almost all should be
operated on within 24h
 Is there strangulation?
4 Cardinal Signs
1. fever
2. tachycardia
3. localized abdominal tenderness
4. leukocytosis
0/4 0% strangulated bowel
1/4 7%
2-3/4 24%
4/4 67%
process accelerated with closed-loop obstr.
 Management of Bowel Obstruction
Principles

Fluid resuscitation
Electrolyte, acid-base correction
Close monitoring
Foley, Central line
NGT decompression
Antibiotics
Informed concent
Exploratory laporotomy
 Resuscitation
Massive third space losses as fluid and
electrolytes accumulate in bowel wall and lumen
Depend on site and duration
proximal- vomiting early, with dehydration,
hypochloremia, alkalosis
distal- more distension, vomiting late, dehydration
profound, electrolyte abnormalities
Requirements = DEFICIT + MAINTENANCE +
ONGOING LOSSES
 Operative Indications
Incarcerated or strangulated hernia
Peritonitis
Pneumoperitoneum
Suspected strangulation
Closed loop obstruction
Complete obstruction
Large bowel obstruction
Small bowel obstruction
When is it safe NOT to operate?
Adynamic ileus
SMALL bowel obstruction if adhesions
suspected etiology
 Exploratory Laparotomy
Inspected and palpated the Caecum
-Distended--- colon obstruction
-Collapsed-- small bowel obstruction
Distended SBO - Prevent Abd.Comp.syndrom
-Retrograde milkingby Jones and Matheson(1968)
-canula inserted + pursetring suture ?
-Enterostomy
Distended LBO- Prevent Abd.Comp.Syndrom
-canula inserted + pursestring suture
-Caecostomy