Acquired intestinal ileus


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Acquired intestinal ileus

  2. 2. Plan:Plan: • Paralytic ileus. • Obstruction of the small and large bowel. • Intussusception. • Adhesive Intestinal Obstruction
  3. 3. ACQUIRED INTESTINAL ILEUSACQUIRED INTESTINAL ILEUS ClassificationClassification ACQUIRED INTESTINAL ILEUS Paralytic ileus, (pseudo-obstruction) mechanical obstructions simple mechanical obstruction strangulating obstruction
  4. 4. Causes of paralytic ileusCauses 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
  5. 5. ClassificationClassification • Compensated • Subcompensated • Decompensated
  6. 6. Clinical manifestations andClinical manifestations and diagnostic studiesdiagnostic studies • Constant gnawing pain • repeated vomiting • symmetric abdominal distention • reduced or absence of peristalsis • increasing meteriorism • constipation • heavy intoxication
  7. 7. Diagnostic studiesDiagnostic studies • Physical examination • Ragiological investigation • Laboratory tests (hypokalemia)
  8. 8. Treatment of paralytic ileusTreatment 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 (> 4 mEq/L [> 4 mmol/L]) • Sometimes colonic ileus can be relieved by colonoscopic decompression; rarely cecostomy is required. Ileus persisting > 1 wk probably has a mechanical obstructive cause, and laparotomy should be considered.
  9. 9. The mechanical causes of intestinalThe mechanical causes of intestinal obstructionobstruction • Hernias • Postoperative adhesions or scar tissue • Impacted feces (stool) • Gallstones • Tumors • Granulomatous processes (abnormal tissue growth) • Intussusception • Volvulus • Foreign bodies
  10. 10. Obstruction of the small bowelObstruction 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
  11. 11. Obstruction of the large bowelObstruction 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
  12. 12. X-ray examinationX-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
  13. 13. Adhesive Intestinal ObstructionAdhesive Intestinal Obstruction The incidence of postoperative adhesive obstruction after laparotomy is about 2%. The procedures which have highest risk for adhesive McBurney’s point in pediatric patients are: 1. subtotal colectomy, 2. resection of symptomatic Meckel’s diverticulum, 3. Ladd’s procedure, and 4. nephrectomy.
  14. 14. EtiologyEtiology The causes of postoperative McBurney’s 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.
  15. 15. Clinical PresentationClinical 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.
  16. 16. DDifferential diagnosisifferential diagnosis •pancreatitis, •hepatitis •biliary tract disease. •urinary tract infection, nephritis, stones. •systemic infection. •colitis, rotavirus. •pneumonia.
  17. 17. TreatmentTreatment •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.
  18. 18. Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing a bowel obstruction. intussuscipiens intussusceptum
  19. 19. FrequencyFrequency.. Intussusception is theIntussusception is the predominate cause of intestinal obstructionpredominate cause of intestinal obstruction in persons aged 3 months to 6 years. Thein persons aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 liveestimated incidence is 1-4 per 1000 live births.births. SexSex.. Overall, the male-to-female ratio isOverall, the male-to-female ratio is approximately 3:1.approximately 3:1.
  20. 20. EtiologyEtiology •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 Peyer’s 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 Meckel’s 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.
  21. 21. Pathology/PathophysiologyPathology/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
  22. 22. ClassificationClassification • 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
  23. 23. Colic invaginationColic invagination
  24. 24. Enteric intussusceptionEnteric intussusception
  25. 25. Ileocolic invaginationIleocolic invagination
  26. 26. Ileocecal intussusceptionIleocecal intussusception
  27. 27. 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.
  28. 28. Physical: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. Ruch’s symtom: Appering of the pain and screams during the palpation of intussusception mass under abdominal wall. Dance’s 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.
  29. 29. DDifferential diagnosisifferential diagnosis • includes intestinal colic. • gastroenteritis. • acute appendicitis. • incarcerated hernia. • internal hernia. • volvulus.
  30. 30. Diagnostic studies: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
  31. 31. X-ray examinationX-ray examination:: 1)Intussusception - Plain Film1)Intussusception - Plain Film • May be normal • Soft tissue mass, often in RUQ • Small bowel obstruction • May see intussusceptum
  32. 32. 2)Intussusception – Contrast Enema2)Intussusception – Contrast Enema • Diagnosis and treatment • Media: • Air • Barium • Water soluble contrast
  33. 33. •Pneumoirigograhy X-ray examination
  34. 34. Air contrast enema showsAir contrast enema shows intussusception in the cecum.intussusception in the cecum.
  35. 35. Air enema showing the intussusception is in theAir enema showing the intussusception is in the splenic flexure (arrow).splenic flexure (arrow).
  36. 36. Barium enema shows intussusceptionBarium enema shows intussusception in the descending the descending colon.
  37. 37. CT scan reveals the classic ying-yangCT scan reveals the classic ying-yang sign of an intussusceptum inside ansign of an intussusceptum inside an intussuscipiens.intussuscipiens.
  38. 38. UltrasoundUltrasound • 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
  39. 39. Abdominal sonograph reveals the classicAbdominal sonograph reveals the classic target sign of an intussusceptum inside antarget sign of an intussusceptum inside an intussuscipiens.intussuscipiens.
  40. 40. 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.
  41. 41. (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.
  42. 42. ComplicationsComplications:: • Intestinal hemorrhage • Necrosis and bowel perforation • Shock and sepsis
  43. 43. TreatmentTreatment H ydrostatic-pressure reduction S urgical operation Technique
  44. 44. Enema ReductionEnema 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
  45. 45. Non-operative reduction of theNon-operative reduction of the intussusceptionintussusception Richardson balloon for pneumoirigography
  46. 46. Principles of barium enema reductionPrinciples 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
  47. 47. ReductionReduction is marked by: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
  48. 48. Surgical treatmentSurgical treatment indication is: • a shocked child with signs of peritonism • or in whom intussusception does not resolve with a nonoperativ procedure
  49. 49. Preoperative preparation includes:Preoperative preparation includes: • Apply intravenous fluids or blood • Gastric aspiration (stomach has been empty), insert nasogastric tube • Administration of antibiotics
  50. 50. Operative technique:Operative technique: • The intussusception is milked back by progressive compression of the bowel
  51. 51. In severe cases:In severe cases: • Intestinal resection • Placement of ileotransversal anastomosis • Ileostoma and caecostoma placement
  52. 52. BIBLIOGRAPHYBIBLIOGRAPHY • Abasiyanik A, Dasci Z, Yosunkaya A, et al: Laparoscopic-assisted pneumatic reduction of intussusception. J Pediatr Surg 1997 Aug; 32(8): 1147-8[Medline]. • Barr LL: Sonography in the infant with acute abdominal symptoms. Semin Ultrasound CT MR 1994 Aug; 15(4): 275-89[Medline]. • Boehm R, Till H: Recurrent intussusceptions in an infant that were terminated by laparoscopic ileocolonic pexie. Surg Endosc 2003 May; 17(5): 831-2[Medline]. • Chang HG, Smith PF, Ackelsberg J, et al: Intussusception, rotavirus diarrhea, and rotavirus vaccine use among children in New York State. Pediatrics 2001 Jul; 108(1): 54-60[Medline]. • Collins DL, Pinckney LE, Miller KE, et al: Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating room with general anesthesia. J Pediatr 1989 Aug; 115(2): 204-7[Medline]. • Cull DL, Rosario V, Lally KP, et al: Surgical implications of Henoch-Schonlein purpura. J Pediatr Surg 1990 Jul; 25(7): 741-3[Medline]. • Dennison WM, Shaker M: Intussusception in infancy and childhood. Br J Surg 1970 Sep; 57(9): 679-84[Medline]. • DiFiore JW: Intussusception. Semin Pediatr Surg 1999 Nov; 8(4): 214-20[Medline]. • Doody DP: Intussusception. In: Oldham KT, Colombani PM, Foglia RP, eds. Surgery of Infants and Children: Scientific Principles and Practice. Lippincott-Raven; 1997: 1241-8. • Ein SH, Stephens CA: Intussusception: 354 cases in 10 years. J Pediatr Surg 1971 Feb; 6(1): 16-27[Medline]. • Eklof OA, Johanson L, Lohr G: Childhood intussusception: hydrostatic reducibility and incidence of leading points in different age groups. Pediatr Radiol 1980 Nov; 10(2): 83-6[Medline].