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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 vs Complete
Flatus Complete obstipation
Residual colonic gas No residual colonic gas
above peritoneal reflection
on AXR
Adhesions
60-80% resolve with non-
operative Mx on AXR Stepladder
Must show objective pattern
improvement, if none by Almost all should be
48h consider OR
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