Updated: 6/10/2019

Paralytic / Adynamic Ileus

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Snapshot
  • A 47-year-old woman on the surgery floor complains of abdominal pain and bloating. She was admitted for appendicitis and underwent a laparoscopic appendectomy 2 days ago. She reports feeling fine since the surgery and denies any fever, swelling, hematuria, hematochezia, or nausea. Her last bowel movement was 3 days ago and she denies any flatulence. A physical examination is unremarkable except for a lack of bowel sounds.  
Introduction
  • Clinical definition
    • medical condition characterized by the disruption of the normal coordinated propulsive motor activity (peristalsis) of the gastrointestinal tract without any structural/mechanical obstruction  
  • Epidemiology
    • demographics
      • gastrointestinal/abdominal surgery is the most common cause
    • risk factors
      • gastrointestinal surgery
      • electrolyte imbalance (e.g., hypokalemia or hypercalcemia) 
      • diabetes
      • medications (e.g., opioids or antimuscarinics)
      • spinal cord injury
      • severe illness
      • hypothyroidism
      • acute intermittent porphyria
  • Pathogenesis
    • the degree of intestinal paralysis does not need to be complete but enough to functionally prohibit the passage of food leading to intestinal blockage
    • normal gastrointestinal motility is controlled and facilitated by a complex network of various neural networks and neurohumoral peptides
      • enteric nervous system, which is the intrinsic neural network of the gastrointestinal system
      • extrinsic network consists of the visceral sensory afferents of the vagus, splanchnic, and pelvic nerves as well as the visceral motor efferent of the autonomic nervous system
    • gastrointestinal dysmotility can result from various mechanisms
      • inflammation (e.g., surgery or severe illness)
      • neural reflexes
      • neurohumoral peptides (e.g., certain medications)
Presentation
  • Symptoms 
    • abdominal pain  
      • rarely presents as the colicky pain present in mechanical bowel obstruction
    • nausea
    • vomiting
    • vague discomfort
  • Physical exam
    • abdominal distension
    • lack of bowel sounds on auscultation
      • in contrast to the high-pitched tinkling sounds in mechanical bowel obstruction
    • no abdominal tenderness
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is often based on clinical presentation followed by rule out of other causes of bowel obstruction  
    • imaging
      • abdominal radiograph 
        • best initial test
        • supine and upright views
        • positive findings may show dilated loops of bowel without a transition zone, air-fluid levels, and air in the colon and rectum
        • allows for rule out of other causes of abdominal pain (e.g., perforated viscus)
    • studies
      • laboratory studies are to be ordered given the clinical presentation to determine etiology/cause
      • electrolyte panel
        • hypokalemia and hypercalcemia may worsen ileus; hypomagnesemia can lead to hypokalemia
      • creatinine and blood urea nitrogen
        • uremia can lead to ileus
      • liver function tests, amylase, and lipase
        • pancreatitis may lead to ileus
      • thyroid panel
        • hypothyroidism may lead to ileus  
Differential
  • Mechanical bowel obstruction 
    • differentiating factors
      • physical examination will demonstrate high-pitched tinkling and history will often include colicky abdominal pain
  • Pancreatitis 
    • differentiating factors
      • although can lead to paralytic ileus, patients with pure pancreatitis will not have dilated bowels on imaging
Treatment
  • First-line
    • supportive management
      • NPO or dietary restriction 
      • if severe, nasogastric suction with parenteral nutrition
      • IV fluids
    • address underlying etiology
      • remove offending medication if applicable
      • replace electrolytes
    • facilitate bowel movements
      • lactulose
      • erythromycin
      • neostigmine
        • for severe cases thought to have a neurological component (e.g., Oglivie syndrome)  
Complications
  • Perforation
  • Bowel necrosis/ischemia
  • Peritonitis
  • Hemodynamic instability
  • Death
 

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