eMedicine Specialties > Gastroenterology > Intestine

Ileus

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

Introduction

Background

After abdominal surgery, a normal physiological ileus occurs. This type of ileus spontaneously resolves within 2-3 days after sigmoid motility returns to normal. However, the terms postoperative adynamic ileus or paralytic ileus are defined as ileus of the gut persisting for more than 3 days following surgery.1

Ileus occurs from hypomotility of the gastrointestinal tract in the absence of a mechanical bowel obstruction. This suggests that the muscle of the bowel wall is transiently impaired and fails to transport intestinal contents. This lack of coordinated propulsive action leads to the accumulation of both gas and fluids within the bowel. Although ileus has numerous causes, the postoperative state is the most common scenario for ileus development. Frequently, ileus occurs after intraperitoneal operations, but it may also occur after retroperitoneal and extra-abdominal surgery. The longest duration of ileus is noted to occur after colonic surgery.2,3

The clinical consequences of postoperative ileus can be profound. Patients with ileus are immobilized, have discomfort and pain, and are at increased risk for pulmonary complications. Ileus also enhances catabolism because of poor nutrition. Overall, ileus prolongs hospital stays; according to a report by Livingston in 1990, it cost $750 million annually ($1500 per patient) in the United States.1 The main focus of this article is postoperative ileus.

Pathophysiology

According to some hypotheses, postoperative ileus is mediated via activation of inhibitory spinal reflex arcs. Anatomically, 3 distinct reflexes are involved: ultrashort reflexes confined to the bowel wall, short reflexes involving prevertebral ganglia, and long reflexes involving the spinal cord.3 The long reflexes are the most significant. Spinal anesthesia, abdominal sympathectomy, and nerve-cutting techniques have been demonstrated to either prevent or attenuate the development of ileus.4,5

The surgical stress response leads to systemic generation of endocrine and inflammatory mediators that also promote the development of ileus. Rat models have shown that laparotomy, eventration, and bowel compression lead to increased numbers of macrophages, monocytes, dendritic cells, T cells, natural killer cells, and mast cells, as demonstrated by immunohistochemistry.6 Calcitonin gene–related peptide, nitric oxide, vasoactive intestinal peptide, and substance P function as inhibitory neurotransmitters in the bowel nervous system. Nitric oxide and vasoactive intestinal peptide inhibitors and substance P receptor antagonists have been demonstrated to improve gastrointestinal function.7,8

Clinical

History

Patients with ileus typically present with vague, mild abdominal pain and bloating. They may report nausea, vomiting, and poor appetite. Abdominal cramping is usually not present. Patients may or may not continue to pass flatus and stool.

Physical

Patients may have distended and tympanic abdomens, depending on the degree of abdominal and bowel distension. The abdomen may be tender. A distinguishing feature is absent or hypoactive bowel sounds unlike the high-pitched sound of obstruction. The silent abdomen of ileus reveals no discernible peristalsis or succussion splash.

Causes

Most cases of ileus occur after intra-abdominal operations. Normal resumption of bowel activity after abdominal surgery follows a known and predictable pattern.

The small bowel typically regains function within hours. The stomach regains activity in 1-2 days, and the colon regains activity in 3-5 days.9 Serial abdominal radiographs mapping the distribution of radiopaque markers have shown that the colonic gradient for resolution of postoperative ileus is proximal to distal. The return of propulsive activity to the right colon occurs earlier than to the transverse or left colon.10

Other causes of ileus are as follows:

  • Causes of adynamic ileus
    • Sepsis
    • Drugs (eg, opioids, antacids, coumarin, amitriptyline, chlorpromazine)
    • Metabolic (eg, low potassium, magnesium, or sodium levels; anemia; hyposmolality)
    • Myocardial infarction
    • Pneumonia
    • Trauma (eg, fractured ribs, fractured spine)
    • Biliary and renal colic
    • Head injury and neurosurgical procedures
    • Intra-abdominal inflammation and peritonitis
    • Retroperitoneal hematomas

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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