• Ileus (intestinal obstruction, intestinal paralysis)

    Posted on May 7, 2021 by in Ailments

    Ileus

    Intestinal obstruction and paralysis are known as ileus. You can find out everything about causes, symptoms and therapy here

    This is one of the more serious articles in our library. No metaphors, not much to jest about just the facts. Ileus – briefly explained

    An ileus is a disruption of the transport of the intestinal contents. There is an interruption in the passage of food with an accumulation of food pulp. This passage disruption can be caused either by an obstacle (mechanical ileus) or by intestinal paralysis (paralytic ileus). A mechanical ileus can be caused by a tumor or adhesions. Intestinal paralysis can occur as a result of inflammation, medication or after surgery. The treatment of an ileus depends on its cause. Conservative treatment (without surgery) with food abstinence, fluids and painkillers as well as medication that stimulates the bowel movement is often used. In certain cases, an operation is necessary, for example in the case of a tumor disease of the intestine.

    What is an ileus?

    In the case of an ileus, the intestinal passage stops with a build-up of the food. This happens either through an intestinal obstruction (mechanical ileus) or an intestinal paralysis (paralytic ileus). Both forms mean that the intestinal contents cannot be transported further. Mechanical ileus is the most common form of intestinal obstruction (around 60 percent) and can be an acutely life-threatening clinical picture.

    If the closure is not complete, i.e. there is still a residual passage of food pulp, it is called a subileus.

    Background information – the intestinal passage

    Normally, the intestinal contents are transported through the various passages of the intestine by the smooth muscles of the intestinal wall in undulating movements (intestinal peristalsis) from the stomach towards the anus. The contents of the stomach first reaches the small intestine and from there the large intestine. In the different areas, important food components and fluids are absorbed from the intestine. The human small intestine is about five to six meters long, the large intestine frames the small intestine and is about one meter long. A bowel obstruction can develop in both the small and large intestines.

    Causes: How does an ileus occur?

    A passage disruption can occur due to a mechanical obstacle (mechanical ileus) or due to a disorder of the intestinal peristalsis (see above, paralytic ileus).

    Mechanical ileus (intestinal obstruction): A mechanically caused ileus (occlusive ileus) can be associated with or without disturbance of the blood circulation. There are many different causes of mechanical ileus, but what they all have in common is a stoppage of the intestinal passage due to an obstruction. This can, for example, directly clog the intestine, such as a tumor or ball of feces. Or the intestine is constricted from the outside, for example by connective tissue adhesions (brides) after an intestinal operation, by scarring after inflammatory bowel diseases or healed peritonitis . The following forms lead to an additional disruption of the blood supply (strangulation ileus):

    • Incarceration. Incarceration is an entrapment of intestinal loops. These can become trapped in hernia gaps, such as an inguinal hernia, or between strands of connective tissue (braids). This means that the intestinal passage is no longer possible.
    • Intussusception. An intussusception is understood as the invagination of a piece of intestine into a piece of intestine lying behind it. The intestine pushes itself “into the intestine”, so to speak.
    • Volvulus . A volvulus describes a twisting of the intestine and its associated structures (mesentery, contains nerves and blood vessels).

    Paralytic ileus (intestinal paralysis ): In paralytic ileus, the muscles of the intestinal wall are paralyzed so that the intestinal contents are no longer transported through rhythmic movements of the intestinal wall. Bowel paralysis can have many causes:

    • In the context of inflammation of the abdominal cavity (inflammatory-toxic): An inflammation of the peritoneum (acute peritonitis) can develop, for example, through a breakthrough in the stomach or small intestinal mucosa (perforation). Other possible inflammatory processes in the abdomen can be inflammation of the pancreas , appendix or gallbladder inflammation.
    • After operations in the abdominal cavity or on the spine (reflex): A paralytic ileus can also develop after surgery in the abdominal cavity or on the spine. However, this cannot always be clearly separated from the “normal” intestinal sluggishness after operations (postoperative intestinal atony).
    • Medicinal: Certain medications, for example, opioids, can cause intestinal paralysis.
    • Metabolic disorders (metabolic): In particular, disorders of salt balance (electrolyte disorders) can lead to paralysis of the intestinal muscles. The cause of the electrolyte disturbance can be a severe disturbance of kidney function (renal insufficiency). However, a deficiency in vitamin B, thyroxine, protein, or diabetes mellitus (acidosis) can also trigger intestinal paralysis.
    • Occlusion of a blood vessel (vascular): The acute occlusion of a blood vessel that nourishes the intestinal wall can also be the cause of paralytic ileus.

    A long-standing mechanical ileus can turn into a paralytic ileus.

    Symptoms: what symptoms does an ileus cause?

    The complaints are based, for one, on the affected area of ​​the intestine. With a ileus of the small intestine, nausea and vomiting, a bloated stomach and, later on, stool and wind retention often occur quickly. In the case of a large intestinal ileus, the symptoms are usually less pronounced and develop a little more slowly, leading to a bloated stomach, abdominal cramps, stool and wind retention.

    The symptoms can also vary depending on the cause. In the case of a mechanical ileus, severe colic-like abdominal pain can suddenly set in. With a paralytic ileus, the pain is less severe, but the abdomen is very distended.

    Pallor, cold sweat and an accelerated pulse herald an impending circulatory failure.

    Diagnosis: how is an ileus diagnosed?

    The previous history (anamnesis) and the medical examination, especially listening to the abdomen with a stethoscope, provide important information. Ringing, metallic intestinal noises suggest a mechanical ileus, as the intestine is working harder in front of the obstacle (hyperperistalsis). In the case of intestinal paralysis (paralytic ileus), however, there are no intestinal noises (“dead silence”).

    An ultrasound examination is part of the further diagnosis of the abdomen. Expanded intestinal loops may be seen here. The motility of the bowel and any so-called “free fluid” that may be present can also be assessed. An X-ray of the abdomen (while standing, if this is not possible in the left side position), fluid build-up in the intestinal lumen (mirror formation) can indicate an ileus. Free air in the abdomen, outside the intestines, can also be seen in the X-ray. It can indicate a perforated bowel. In larger clinics, computed tomography is now part of the diagnosis of ileus. In it you can see tumors that are hindering the passage, sometimes there are also strands of adhesions visible or when drama loops have “twisted”.

    Therapy: How is an ileus treated?

    In principle, one can differentiate between conservative and surgical therapy. Conservative means: without surgery. In the vast majority of cases, regardless of whether it is a paralytic or mechanical ileus, the ileus is treated conservatively. Therefore, a conservative attempt at therapy is usually started first. An operation is always necessary if this fails, or if the intestine is threatened with dying off (twisted, circulatory disorders, braids) or if there is already a breakthrough (perforation).

    • Conservative treatment

    The focus here is on compensating for the fluid and salt displacements caused by the ileus (substitution therapy) and relieving the distended intestine. Placing a nasogastric tube – a thin tube that is inserted through the nose into the throat and from there through the esophagus into the stomach – is uncomfortable, but is especially important if you are sick or vomit. Through the probe, the fluid can drain from the intestine into a bag, the muscles relax and then, in the best case, resume their work. Food abstinence is also necessary so that there is no further strain or stretching of the intestine. In the case of paralytic ileus, medication can help get the bowel moving again. Painkillers and, if necessary, antibiotics are also given. Both fluid and medication are administered directly into the blood vessel system via a venous access.

    • Operative treatment

    If a conservative attempt at therapy fails, surgery may be necessary. Often adhesions are the cause of the occlusion. Once these have been resolved, the bowel can work normally again after some recovery. In the case of an acute intestinal obstruction with a ruptured intestine or a circulatory disorder, an operation as quickly as possible is necessary to remove the obstacle to the passage and, if necessary, the damaged section of the intestine. Which surgical procedure is used depends on the cause of the intestinal obstruction. It is important to allow a passage through the intestine again and to eliminate existing circulatory disorders, for example in the case of twisting. Because if a section of the intestine is not supplied with blood, it dies (necrosis). Most operations for ileus are performed using a larger, central incision in the abdomen (so-called laparotomy).

    Depending on the cause, surgical therapy can be carried out directly. For example, twisting, insertion or connective tissue strands (clamps) can only be resolved with one operation. Diseased sections of the intestine that do not recover during the operation are removed immediately. The healthy ends of the intestine are then either sewn directly to one another or connected to one another at the sides. An inflamed appendix or the blockage of a blood vessel (artery) can also be surgically removed. During these operations, the bowel must be relieved and nursed for a long time, otherwise, it would no longer recover. In this case, an artificial connection is created between the still healthy section of the intestine and the abdominal wall to the outside (stoma attachment), the section behind the stoma then has time to recover. In most cases, this is only temporary and after the colon had time to heal, the artificial connection will be reversed.

    Complications: What can be the consequences of an ileus?

    Both mechanical and paralytic ileus lead to an increased accumulation of fluid and gases, which leads to expansion and overinflation of the affected section of the intestine. This increase in pressure has a negative impact on the blood supply to the affected area (microcirculation disorder). This in turn can lead to a disruption of the barrier function of the intestinal wall. This means that it becomes more permeable so that a lot of fluid flows into the intestine. The result can be a significant volume deficiency (hypovolemia) in the bloodstream. Bacteria can also migrate more easily through the intestinal wall and thus cause severe inflammation of the abdominal cavity (peritonitis) and blood poisoning ( sepsis ).

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