Ileus Differential Diagnoses

  • Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC; Chief Editor: Julian Katz, MD   more...
 
Updated: Apr 8, 2011
 
 

Diagnostic Considerations

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

Pseudo-obstruction

Pseudo-obstruction is defined as acute, marked distention 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 distention without pain or tenderness; however, patients may have symptoms mimicking obstruction. Plain abdominal radiography reveals isolated, proximal large bowel dilatation, as shown in the image below, and contrast imaging distinguishes this from mechanical obstruction.

Ogilvie pseudo-obstruction in a septic elderly patOgilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

The colonic distention 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.[12]

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.[14] 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 obstruction

Mechanical bowel obstruction can be caused by adhesions, volvulus, hernias, intussusception, foreign bodies, or neoplasms. Patients present with severe cramping abdominal pain that 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, imaging reveals enlarged bow-shaped loops of small intestine with steplike air-fluid levels; the colon may have a paucity of gas distal to the lesion on plain radiographs, as demonstrated in the images below.

Mechanical bowel obstruction due to a left colon cMechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon. Contrast study, in the same patient as in Media FiContrast study, in the same patient as in Media File 3, showing the classic "apple-core" lesion of colon carcinoma.

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

Table. Characteristics of Ileus, Pseudo-obstruction, and Mechanical Obstruction (Open Table in a new window)

IleusPseudo-obstructionMechanical Obstruction (Simple)
SymptomsMild abdominal pain, bloating, nausea, vomiting, obstipation, constipationCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexiaCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination FindingsSilent abdomen, distention, tympanicBorborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tendernessBorborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, 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

Differential Diagnoses

Proceed to Workup
 
 
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: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Coauthor(s)

Ese Otah, MD, FACS  Consulting Surgeon, Center For General and Laparoscopic Surgery, PA; Consulting Staff, St Luke's Sugar Land Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann Sugar Land Hospital

Ese Otah, MD, FACS is a member of the following medical societies: American College of Surgeons and Association of Women Surgeons

Disclosure: Nothing to disclose.

Kenneth E Otah, MD, MSc, FACC  Consulting Staff, Methodist and Memorial Hermann Hospital Systems, Total Heart Cardiovascular Consultants, LLC

Kenneth E Otah, MD, MSc, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, and Association of Black Cardiologists

Disclosure: Nothing to disclose.

Oluwagbenga Serrano, MD  Consulting Staff, Lake Havasu Gastroenterology, PC

Disclosure: Nothing to disclose.

John A Walker, MD  Consulting Staff, Gastroenterology Consultants PC; Consulting Staff, Department of Gastroenterology, Rogue Valley Medical Center, Providence-Medford Medical Center, Surgery Center of Southern Oregon and Ashland Community Hospital

John A 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of 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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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Postoperative ileus after an open cholecystectomy.
Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.
Mechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon.
Contrast study, in the same patient as in Media File 3, showing the classic "apple-core" lesion of colon carcinoma.
Table. Characteristics of Ileus, Pseudo-obstruction, and Mechanical Obstruction
IleusPseudo-obstructionMechanical Obstruction (Simple)
SymptomsMild abdominal pain, bloating, nausea, vomiting, obstipation, constipationCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexiaCrampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination FindingsSilent abdomen, distention, tympanicBorborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tendernessBorborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, 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
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