eMedicine Specialties > Gastroenterology > Intestine

Ileus: Differential Diagnoses & Workup

Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Coauthor(s): Eseroghene Otah, MD, Locum Tenens General Surgeon, Department of Surgery, Our Lady of Mercy Hospital; Kenneth E Otah, MD, MSc, Postdoctorate Fellow, Department of Internal Medicine, Division of Cardiology, Johns Hopkins Hospital; Oluwagbenga Serrano, MD, Consulting Staff, Lake Havasu Gastroenterology, PC; John Walker, MD, Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center; Avram M Cooperman, MD, Professor of Surgery and Radiation Oncology, Cabrini Medical Center
Contributor Information and Disclosures

Updated: Jun 3, 2008

Differential Diagnoses

Ogilvie Syndrome

Other Problems to Be Considered

The common differentials for ileus are pseudo-obstruction, also referred to as Ogilvie syndrome, and mechanical bowel obstruction.

Pseudo-obstruction is defined as acute, marked distension of the large bowel. As with ileus, it occurs in the absence of a definable mechanical pathology. Several texts and articles tend to use ileus synonymously with pseudo-obstruction or refer to "colonic ileus." However, the 2 conditions are definitely distinct entities. Pseudo-obstruction is clearly limited to the colon alone, whereas ileus involves both the small bowel and colon. The right colon is involved in classic pseudo-obstruction, which typically occurs in elderly bedridden patients with serious extraintestinal illness or in trauma patients. Pharmacologic agents, aerophagia, sepsis, and electrolyte discrepancies may also contribute to this condition.

The condition termed chronic intestinal pseudo-obstruction is also observed in patients with collagen-vascular diseases, visceral myopathy, or neuropathy. This chronic form of pseudo-obstruction involves dysmotility of both the large and small intestine. This dysmotility is due to loss of the migrating motor complex and bacterial overgrowth. This entity manifests as clinical small bowel obstruction.

Physical examination usually reveals marked abdominal distension without pain or tenderness; however, patients may have symptoms mimicking obstruction. Plain abdominal radiography reveals isolated, proximal large bowel dilatation, and contrast imaging distinguishes this from mechanical obstruction. The colonic distension may lead to perforation of the cecum, especially if the cecal diameter exceeds 12 cm. The mortality rate for pseudo-obstruction is 50% if patients progress to ischemic necrosis and perforation.9

Initial treatment includes hydration, rectal and nasogastric tube placement, correction of electrolyte imbalances, and discontinuation of medications that hinder bowel motility. Decompression via colonoscopy is quite effective in relieving pseudo-obstruction. Intravenous neostigmine may also be effective, resulting in resolution of pseudo-obstruction within 10-30 minutes.11 A 2.5-mg dose of neostigmine is slowly infused over 3 minutes under cardiac monitoring to observe for bradycardia. If bradycardia occurs, atropine should be administered. Laparotomy with ostomy creation and bowel resection for peritonitis and ischemia is the last resort.

Mechanical bowel obstruction can be caused by adhesions, volvulus, hernias, intussusception, foreign bodies, or neoplasms. Clinically, patients with obstruction present with severe cramping abdominal pain. The pain is paroxysmal in nature. Physical examination reveals borborygmi coincident with the abdominal cramping. In thin patients, peristaltic waves may be visualized. Auscultation may reveal high-pitched tinkling sounds associated with gurgles and rushes, which is in marked contrast to the hypoactive or absent bowel sounds of ileus. If obstruction is complete, patients report constipation or obstipation. Vomiting may or may not occur if the ileocecal valve is competent and prevents reflux. Peritoneal signs manifest if patients develop a strangulated obstruction or perforation.

Endoscopy and contrast imaging aid in the diagnosis of mechanical bowel obstruction. In mechanical obstruction, the small intestine reveals enlarged bow-shaped intestinal loops with steplike air-fluid levels and the colon may have a paucity of gas on plain radiographs.

The Table summarizes the differences between ileus, pseudo-obstruction, and mechanical obstruction.

Characteristics of Ileus, Pseudo-obstruction, and Mechanical Obstruction

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Table
 IleusPseudo-obstructionMechanical Obstruction (Simple)
SymptomsMild abdominal pain, bloating, nausea, vomiting, obstipation, constipation,Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexiaCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination FindingsSilent abdomen, distension, tympanicBorborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distension, localized tendernessBorborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distension, localized tenderness
Plain RadiographsLarge and small bowel dilatation, diaphragm elevatedIsolated large bowel dilatation, diaphragm elevatedBow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels
 IleusPseudo-obstructionMechanical Obstruction (Simple)
SymptomsMild abdominal pain, bloating, nausea, vomiting, obstipation, constipation,Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexiaCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination FindingsSilent abdomen, distension, tympanicBorborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distension, localized tendernessBorborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distension, localized tenderness
Plain RadiographsLarge and small bowel dilatation, diaphragm elevatedIsolated large bowel dilatation, diaphragm elevatedBow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels


Workup

Laboratory Studies

  • Laboratory studies and blood work should focus on evaluations for infectious, electrolytic, and metabolic derangements.

Imaging Studies

  • On plain abdominal radiographs, ileus appears as copious gas dilatation of the small intestine and colon. With enteroclysis, the contrast medium in patients with paralytic ileus should reach the cecum within 4 hours; if it remains stationary for longer than 4 hours, mechanical obstruction is suggested.12

More on Ileus

Overview: Ileus
Differential Diagnoses & Workup: Ileus
Treatment & Medication: Ileus
Follow-up: Ileus
Multimedia: Ileus
References
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References

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Further Reading

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Keywords

postoperative adynamic ileus, paralytic ileus, pseudo-obstruction, Ogilvie syndrome, mechanical bowel obstruction, postoperative adynamic ileus, paralytic ileus, pseudo-obstruction, Ogilvie syndrome, mechanical bowel obstruction, Ogilvie's syndrome, pseudoobstruction, surgical bowel complications, bowel dysfunction, dysmotility, postoperative bowel dysfunction

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Contributor Information and Disclosures

Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

Eseroghene Otah, MD, Locum Tenens General Surgeon, Department of Surgery, Our Lady of Mercy Hospital
Eseroghene Otah, MD is a member of the following medical societies: Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Kenneth E Otah, MD, MSc, Postdoctorate Fellow, Department of Internal Medicine, Division of Cardiology, Johns Hopkins Hospital
Disclosure: Nothing to disclose.

Oluwagbenga Serrano, MD, Consulting Staff, Lake Havasu Gastroenterology, PC
Disclosure: Nothing to disclose.

John Walker, MD, Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center
John Walker, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Avram M Cooperman, MD, Professor of Surgery and Radiation Oncology, Cabrini Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Ann Ouyang, MBBS, Professor, Department of Internal Medicine, Pennsylvania State University College of Medicine; Attending Physician, Division of Gastroenterology and Hepatology, Milton S Hershey Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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