Theme of lecture: ACQUIRED INTESTINAL ILEUS

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Theme of lecture ACQUIRED INTESTINAL ILEUS
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Plan

• Paralytic ileus.
• Obstruction of the small and large bowel.
• Intussusception.
• Adhesive Intestinal Obstruction

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ACQUIRED INTESTINAL ILEUS Classification
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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

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Classification

• Compensated
• Subcompensated
• Decompensated

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Clinical manifestations and diagnostic studies

• Constant gnawing pain
• repeated vomiting
• symmetric abdominal distention
• reduced or absence of peristalsis
• increasing meteriorism
• constipation
• heavy intoxication

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Diagnostic studies

• Physical examination
• Ragiological investigation
• Laboratory tests (hypokalemia)

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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 (gt 4 mEq/L gt 4 mmol/L)
• Sometimes colonic ileus can be relieved by
  colonoscopic decompression rarely cecostomy is
  required. Ileus persisting gt 1 wk probably has a
  mechanical obstructive cause, and laparotomy
  should be considered.

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The mechanical causes of intestinal obstruction

• Hernias
• Postoperative adhesions or scar tissue
• Impacted feces (stool)
• Gallstones
• Tumors
• Granulomatous processes (abnormal tissue growth)
• Intussusception
• Volvulus
• Foreign bodies

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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

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Obstruction of the large bowel

• 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

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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

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Adhesive Intestinal Obstruction

• The incidence of postoperative adhesive
  obstruction after laparotomy is about
• 2. The procedures which have highest risk for
  adhesive McBurneys point in pediatric
• patients are
• 1. subtotal colectomy,
• 2. resection of symptomatic Meckels
  diverticulum,
• 3. Ladds procedure, and
• 4. nephrectomy.

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Etiology

• The causes of postoperative McBurneys 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.

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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.

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Differential diagnosis

• pancreatitis,
• hepatitis
• biliary tract disease.
• urinary tract infection, nephritis, stones.
• systemic infection.
• colitis, rotavirus.
• pneumonia.

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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.

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• Intussusception is a process in which a segment
  of intestine invaginates into the adjoining
  intestinal lumen, causing a bowel obstruction.

intussuscipiens
intussusceptum
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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 31.
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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
  Peyers 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 Meckels 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.

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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

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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

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Colic invagination
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Enteric intussusception
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Ileocolic invagination
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Ileocecal intussusception
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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 10-20 of patients.

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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. Ruchs symtom Appering of
  the pain and screams during the palpation of
  intussusception mass under abdominal wall.
  Dances 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.

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Differential diagnosis

• includes intestinal colic.
• gastroenteritis.
• acute appendicitis.
• incarcerated hernia.
• internal hernia.
• volvulus.

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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

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X-ray examination 1)Intussusception - Plain
Film

• May be normal
• Soft tissue mass, often in RUQ
• Small bowel obstruction
• May see intussusceptum

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2)Intussusception Contrast Enema

• Diagnosis and treatment
• Media
• Air
• Barium
• Water soluble contrast

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X-ray examination

• Pneumoirigograhy

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Air contrast enema shows intussusception in the
cecum.
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Air enema showing the intussusception is in
thesplenic flexure (arrow).
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Barium enema shows intussusception in the
descending colon.
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CT scan reveals the classic ying-yang sign of an
intussusceptum inside an intussuscipiens.
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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

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Abdominal sonograph reveals the classic target
sign of an intussusceptum inside an
intussuscipiens.
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• 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.

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• (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.

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Complications

• Intestinal hemorrhage
• Necrosis and bowel perforation
• Shock and sepsis

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Treatment
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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

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Non-operative reduction of the intussusception
Richardson balloon for pneumoirigography
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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

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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

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Surgical treatment

• indication is
• a shocked child with signs of peritonism
• or in whom intussusception does not resolve with
  a nonoperativ procedure

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Preoperative preparation includes

• Apply intravenous fluids or blood
• Gastric aspiration (stomach has been empty),
  insert nasogastric tube
• Administration of antibiotics

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Operative technique

• The intussusception is milked back by progressive
  compression of the bowel

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In severe cases

• Intestinal resection
• Placement of ileotransversal anastomosis
• Ileostoma and caecostoma placement

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