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Postoperative Ileus

  • Author: Burt Cagir, MD, FACS; Chief Editor: Julian Katz, MD  more...
 
Updated: Dec 28, 2015
 

Background

Ileus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction. Although the exact pathogenesis of ileus remains multifactorial and complex, the clinical picture appears to be transiently impaired propulsion of intestinal contents. The complex interaction between autonomic and central nervous system function, as well as local and regional substances, may alter the intestinal equilibrium, resulting in disorganized electrical activity and paralysis of intestinal segments. This lack of coordinated propulsive action leads to the accumulation of gas and fluids within the bowel.

Note the images below.

Postoperative ileus after an open cholecystectomy. Postoperative ileus after an open cholecystectomy.
Ogilvie pseudo-obstruction in a septic elderly pat Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.

Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal. Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus.[1] Frequently, ileus occurs after major abdominal operations, but it may also occur after retroperitoneal and extra-abdominal surgery, as well as general anesthesia alone. The longest duration of ileus is noted to occur after colon and rectal surgery.[2, 3] Laparoscopic colon resection has been associated with shorter periods of ileus than open colon and rectal resection.[4]

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 increases the cost of medical care because it prolongs hospital stays.[5] In 1990, Livingston and Passaro estimated that ileus costs $750 million annually ($1500 per patient) in the United States.[1]

Iyer et al assessed healthcare utilization and costs in colectomy surgery patients who developed postoperative ileus versus those who did not.[6] A retrospective cohort study design was used in which 17,876 patients with primary procedure code for colectomy were identified. Mean hospital stay was significantly longer in patients with postoperative ileus (13.8 [13.3] days) compared with patients without postoperative ileus (8.9 [9.5] days; P < .001), and the presence of postoperative ileus was a significant predictor of hospital stay (P < .001).[6] Additional significant predictors of hospital length of stay included female sex (P = 0.002), greater severity level (P < .001), and hospital bed size >500 (P = .013).

The investigators found the presence of postoperative ileus was found to be a significant predictor of hospitalization costs (P < .001), controlling for covariates.[6] The authors concluded that postoperative ileus in colectomy patients is a significant predictor of hospital resource utilization.

The main focus of this article is postoperative ileus.

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Pathophysiology

The exact pathogenesis of ileus remains unclear. Postoperative ileus may be 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.[7, 8]

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.[9] Macrophages residing in the muscularis externa and mast cells are probably the key players in this inflammatory cascade.[10] 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.[11, 12]

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Etiology

Most cases of ileus occur after intra-abdominal operations. Normal resumption of bowel activity after abdominal surgery follows a 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.[13]

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.[14]

Other causes of adynamic ileus are as follows:

  • Sepsis
  • Drugs (eg, anesthesia, opioids, psychotropics, anticholinergics, antacids, warfarin, amitriptyline, chlorpromazine)
  • Endocrine disorders (eg, diabetes, adrenal insufficiency, hypothyroidism)
  • Metabolic (eg, low potassium, magnesium, or sodium levels;  anemia; hyposmolality)
  • Cardiopulmonary failure (eg, myocardial infarction)
  • Pneumonia
  • Trauma (eg, fractured ribs, fractured spine)
  • Biliary and renal colic
  • Neurosurgical procedures, spinal cord and head injuries
  • Intra-abdominal inflammation and  peritonitis
  • Retroperitoneal and mediastinal pathology (eg, hematomas, infections)
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Epidemiology

United States data

Postoperative ileus occurs in approximately 50% of patients who undergo major abdominal surgery.[15] Kuruba et al studied the incidence and risk factors for prolonged ileus in patients undergoing elective colon surgery retrospectively. The incidence of prolonged ileus was similar in patients with epidural versus nonepidural versus laparoscopic surgery. The incidence of prolonged ileus was similar in all 3 groups studied.[16]

A pooled, post-hoc, phase III study analyzed placebo groups and partial bowel resection and total abdominal hysterectomy multicenter trials.[17] Postoperative ileus was still observed in 15% of patients in the partial bowel resection group and in 3% of the total abdominal hysterectomy patients, regardless of the standardized accelerated postoperative care pathway used. This study also provides significant differences in gastrointestinal recovery patterns between bowel resection and total abdominal hysterectomy.

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Contributor Information and Disclosures
Author

Burt Cagir, MD, FACS Clinical Professor of Surgery, The Commonwealth Medical College; Attending Surgeon, Assistant Program Director, Robert Packer Hospital; Attending Surgeon, Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Avram M Cooperman, MD Professor of Surgery and Radiation Oncology, Cabrini Medical Center

Disclosure: Nothing to disclose.

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

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.

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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
  Ileus Pseudo-obstruction Mechanical Obstruction (Simple)
Symptoms Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination Findings Silent abdomen, distention, tympanic Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tenderness Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness
Plain Radiographs Large and small bowel dilatation, diaphragm elevated Isolated large bowel dilatation, diaphragm elevated Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels
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