Ileus

What is Ileus?

An ileus, also sometimes known as a paralytic ileus or functional ileus, occurs when there is a non-physical slowdown or halt in the passage of food and liquids through the intestines. Bowel obstruction, on the other hand, is a physical blockage in the intestines caused by a material like a tumor, adhesion, hernia, or something else. Even though these two conditions might seem similar, their treatments are often very different and depends on the specific cause.

Commonly, ileus can occur after abdominal or retroperitoneal surgery but it can also occur in patients who are severely ill, including those with septic shock or who are on mechanical ventilation. There tends to be a delay in the ability to feed properly after an ileus, contributing to a significant economic impact in the U.S. An ileus typically starts to show 3 to 5 days after the surgery and it generally lasts between 2 to 3 days. The small intestines usually begin functioning first (0-24 hours), followed by the stomach (24-48 hours), and finally, the colon (48-72 hours). If ileus lasts longer than 2 or 3 days without any signs of a physical blockage, it is diagnosed as a prolonged ileus.

What Causes Ileus?

An ileus is a condition where the intestines do not work properly, causing a blockage in the digestive system. The exact cause is not yet fully understood, but there are several known risk factors that can increase the chance and duration of having an ileus.

These risk factors include:

• Long or complicated surgeries in the abdomen or pelvic area
• Surgery on the lower part of the gastrointestinal tract (which includes the small intestine and colon)
• Open surgery (a larger cut rather than keyhole surgery)
• Surgery in the retroperitoneal space (the area behind the stomach and intestines)
• Taking opioids (a type of strong painkiller)
• Inflammation inside the abdomen (which may be due to severe infection or inflammation of the tissue that lines the inside of the abdomen)
• Cancer that has spread to the tissue lining the inside of the abdomen
• Complications around the time of surgery (like pneumonia, a lung infection, or an abscess, which is a buildup of pus)
• Bleeding during or after surgery
• Hypokalemia, a condition where there is an unusually low level of potassium in the blood
• Delay in starting feeding through the mouth or placing a tube into the stomach to deliver nutrition.

These risk factors can affect the intricate system of nerves and immune responses in the body. Certain medications, like opioids, high blood pressure medication, and anti-nausea drugs, as well as health conditions like pneumonia, stroke, and imbalances in the body’s electrolytes (important minerals in your body), can also play a role in causing an ileus.

Risk Factors and Frequency for Ileus

The likelihood of getting ileus, a digestive condition, can vary a lot. It can depend on the type of surgery a person has, how much the bowel is handled during surgery, and other health conditions the person might have before surgery. Operations that involve the lower abdomen, particularly ones with large cuts and a lot of handling of the intestines, can increase the risk of ileus. On the other hand, surgeries like gallbladder removal, which are usually done with a special camera and small cuts (laparoscopic surgery), can lower the risk because they don’t involve much handling of the intestines. According to several studies, the chances of getting ileus after surgery can range from 10 to 20% depending on the kind of operation.

Signs and Symptoms of Ileus

When a patient has an issue with their bowel, it usually comes on gradually, not all of a sudden like it does with a mechanical bowel blockage. They will often have stomach swelling and bloating. The pain typically is spread out across the abdomen and doesn’t go away but doesn’t show signs that the lining of their abdomen is inflamed. Common symptoms include feeling sick to their stomach and throwing up, having a hard time passing gas, and not being able to handle eating. When examined, the patient’s stomach is usually swollen and sounds like a drum when tapped lightly. They may also have slight tenderness throughout their abdomen. Instead of the enhanced bowel sounds you’d hear early on with a mechanical blockage, their bowel sounds may be faint or not there at all, though this could also happen in the late stage of a mechanical blockage.

• Gradual onset of stomach swelling and bloating
• Widespread, persistent abdominal pain without signs of abdominal lining inflammation
• Nausea and vomiting
• Trouble passing gas
• Inability to tolerate eating
• Stomach sounds like a drum when tapped lightly and shows mild tenderness
• Faint or non-existent bowel sounds, unlike the loud sounds early on with a mechanical blockage

Testing for Ileus

If you’re experiencing certain symptoms, your doctor might suspect you have a stomach or intestinal blockage, which could be due to two types of conditions, a blockage called a “mechanical obstruction,” or a slower than usual movement of your food and liquid through your intestines, known as “ileus”. Telling these conditions apart isn’t easy, but it’s essential because the treatments are different.

The first step in diagnosis might be taking X-rays of your abdomen. The images obtained can show whether there are widened small intestines in your belly, which can indicate a problem. However, your doctor would still expect to see air in your large intestine and rectum if it’s only an ileus. If these first images aren’t clear, the doctor might need to take a special type of X-ray using a method called computed tomography (CT). A CT scan takes a series of pictures from different angles to create a more complete and detailed picture of your insides.

The CT scan is done after you are given things to drink and an injection to help make the pictures clearer. This can help highlight a potential blockage and can also show up other problems inside your belly, like a tumor or pus-filled, infected area (an abscess).

Your doctor will also want to do some blood tests. These tests will look for any issues that could have caused an ileus, such as low potassium levels or signs of infection. The test is a ‘complete blood count,’ which will check for a low red blood cell count (anemia) that could show bleeding, or a high number of white blood cells, which can suggest an abscess, infection, or lack of blood supply to your intestines. A separate test will check your body’s balance of minerals and replace any that are too low or too high.

Treatment Options for Ileus

Ileus is a condition that occurs when the normal flow of food and fluids through your intestines comes to a halt. Notably, this condition is not due to a physical blockage. While we continue to research better treatments, let’s discuss what’s available right now for managing an ileus.

The typical course of treatment for ileus consists of rest, first for you and then for your bowels. This means you’ll temporarily stop eating or drinking and instead, you’ll receive fluids intravenously (through a tube into your vein) to prevent dehydration. Alongside fluids, doctors may opt to place a tube through your nose that goes down into your stomach (known as nasogastric decompression) to help alleviate discomfort and bloating.

At one point it was believed that resting your bowels and providing fluids would improve outcomes and lower complications. But recent studies imply that these treatments may not be as effective as once thought. Alternatively, a less conventional method like chewing gum has shown promise. Chewing gum might help get your gut moving again by triggering a gut brain signal (cephalocaudal reflex), which encourages intestinal movement (peristalsis) and reduces inflammation.

It is important to note that while there have been many attempts to find drug treatments (like antibiotics and other types of medications) for ileus, none have proven consistently successful so far.

A primary aspect of managing ileus is treating the condition that led to it in the first place. For instance, if an infection or imbalance of electrolytes (minerals in your body that have an electric charge) is the cause of your ileus, these underlying conditions must be treated. If you are heavily dependent on opioids for pain relief, you may need to reduce their usage to manage your ileus as these medications can often cause or worsen the condition. These interventions can be challenging, particularly in severe cases where the patient is critically ill and unable to move around much.

If you’re unable to eat for a prolonged period (usually over seven days), doctors may recommend a form of nutrition that is given through a vein, which is called total parenteral nutrition (TPN). This allows your body to receive the nutrients it needs while giving your bowels a chance to recover. Also, taking a diverse approach to managing pain and encouraging movement as soon as possible may also be helpful.

In the situation where you’ve recently had surgery (known as postoperative ileus), prevention is highly crucial. Various strategies have shown potential in reducing the chance of ileus after surgery, including a specialized recovery plan, regional anesthesia, medications that spare the use of opioids, and minimally invasive procedures like laparoscopy.

What else can Ileus be?

When assessing an ileus, or a lack of movement in the intestines, doctors need to rule out more serious conditions. These could include:

• Small bowel obstruction
• Abdominal abscess
• Perforation in the gut

Some of these conditions may need medical intervention, making it important to correctly identify them. The key condition to identify separately from an ileus is an obstruction.

People with an obstruction in the bowel after surgery often experience a return of their bowel function and ability to eat, followed by symptoms such as nausea, vomiting, stomach swelling, and pain. On the other hand, a patient with an ileus typically won’t see their bowel function or ability to eat returning. Severe pain, vomiting that smells like fecal matter, or a swift onset or progression of pain or swelling tend to be signs of an obstruction rather than an ileus.

To distinguish between the two, doctors are increasingly using a type of imaging test, such as a small bowel follow-through with gastrografin or water-soluble contrast. These techniques are useful for identifying small bowel obstructions.

Gastrografin, a contrast agent, has been shown to be a useful treatment for obstructions caused by internal scar tissues. However, its effectiveness in treating a postoperative ileus hasn’t been conclusively proven; it may ease some symptoms, but it doesn’t reduce the duration of the ileus or the patient’s hospital stay.

What to expect with Ileus

Generally, people recover well from an ileus, a condition where the intestines don’t move food properly. However, it’s not exactly known how many days it might take for bowel function to return fully. Having an ileus can increase the duration of a hospital stay and disrupt normal eating habits.

Longer hospital stays could increase the risk of hospital-acquired infections. If the ileus lasts for a longer period, patients might need Total Parenteral Nutrition (TPN), a method of feeding that bypasses the gastrointestinal tract. Like most medical procedures, TPN has its own advantages and possible risks.

Possible Complications When Diagnosed with Ileus

The main complications are linked to extended hospital stays and subsequent treatments needed due to a slowed or stopped bowel movement (also known as “prolonged ileus”). Such treatments may include a line for delivering medicines or fluids directly into the large vein (also known as a “peripheral inserted central catheter line”), total parenteral nutrition (TPN – which is a method of feeding when oral intake is not sufficient), or a tube placed through the nose into the stomach (“NG tube placement”). Occasionally, severe nausea and vomiting may increase the risk of accidentally inhaling foreign material into the lungs (a condition called “aspiration”).

Here are the possible complications:

• Extended hospital stay
• Need for additional procedures due to slowed or stopped bowel movement
• Possibility of a line inserted for delivering medicines or fluids
• Requirement for a method of feeding when oral intake isn’t sufficient (TPN)
• Tube placement through the nose into the stomach
• Possibility of aspiration due to severe nausea and vomiting

Preventing Ileus

From a surgery point of view, it’s very important to explain to patients both the benefits and potential risks involved, including the possibility of developing a condition called ileus. Ileus is a disruption in the normal movement of your digestive tract. This condition can be prevented via a team effort by both the patient and healthcare professionals such as nurses, pharmacologists, and physical/occupational therapists.

One effective way to prevent ileus is encouraging patients to get up and move around, also known as ambulation. Another approach is following enhanced recovery after surgery (ERAS) protocols. These are specifically designed medical guidelines intended to minimize surgical stress and accelerate recovery post-surgery. Teaching patients about the significance and benefits of these measures can improve their understanding of their condition and their commitment to follow these guidelines. The purpose of these steps is to promote better health outcomes and improve the patient’s experience after surgery.