Ileus CHIRurgie APPetizer Nr. 93-3

Summary

The video provides a clinical and educational overview of ileus, distinguishing mechanical obstruction of intestinal passage from paralysis of the bowel. It reviews causes, symptoms, diagnostic work-up, conservative and surgical treatment, the Bologna guideline for adhesive small-bowel obstruction, and selected endoscopic options.

1. Types and causes

• Mechanical ileus is a physical blockage of intestinal passage.
  • Small-bowel obstruction is commonly caused by adhesions or a single adhesive band (a bridle), often after prior abdominal surgery.
  • Other causes include hernias, twisting of the bowel (volvulus), intussusception, tumors, and—in some cases—food or hair masses.
  • Large-bowel obstruction is most often associated with a stenosing colorectal cancer. Diverticular strictures and, less commonly, inflammatory bowel disease can also cause obstruction.
• Paralytic ileus is impaired or absent bowel movement rather than a physical blockage.
  • Causes include peritonitis, pancreatitis, perforation or anastomotic leakage, and postoperative bowel atony.
  • Opioids can slow bowel movement and cause severe constipation, potentially progressing to subileus or ileus.
• Subileus refers to incomplete obstruction. The video also distinguishes this from terms such as constipation, obstipation, and fecal stasis, while noting that their boundaries can overlap.

2. Pathophysiology and clinical signs

In mechanical obstruction, bowel contents accumulate above the blockage:

• The bowel before the obstruction dilates, while the bowel beyond it becomes narrow or collapsed—the “starvation bowel.”
• This change in bowel diameter can help locate the obstruction on imaging.
• Typical symptoms include abdominal distension, nausea and vomiting, and failure to pass stool or gas. The site of obstruction affects how early vomiting occurs and what it may contain.
• Mechanical ileus may produce high-pitched or forceful bowel sounds; paralytic ileus more often produces weak or absent sounds.
• Fluid can collect in the bowel and be lost from the circulation into a “third space,” causing dehydration, electrolyte abnormalities, and low circulating blood volume.
• Distension and impaired blood supply can lead to bowel-wall edema, ischemia, tissue damage, bacterial leakage, peritonitis, sepsis, or shock. These complications make prompt recognition of ischemia, strangulation, or perforation essential.

3. Diagnosis

Assessment combines the history and physical examination with laboratory tests and imaging:

• Clinical assessment: constipation or failure to pass stool, nausea, vomiting, abdominal distension, percussion findings, and bowel sounds.
• Laboratory tests: inflammatory markers such as white-cell count and CRP; lactate as a possible sign of ischemia; and electrolytes and fluid status.
• Imaging: abdominal X-ray may show dilated bowel loops and fluid levels, but must be interpreted alongside the patient’s clinical condition.
• CT with contrast is emphasized as a key investigation. It can identify the site of a change in bowel caliber, assess bowel condition, and reveal causes such as a tumor or volvulus. Individual adhesions may not be visible; if CT shows a caliber change without another cause, adhesions may be suspected.
• The video describes X-rays as one way to follow the passage of water-soluble contrast through the bowel.

4. Treatment principles

Paralytic ileus

• Treat the underlying cause. For peritonitis, this means controlling the source—such as a perforation, leaking anastomosis, or inflamed segment—and giving antibiotics.
• Postoperative bowel atony is often initially managed conservatively, with time and supportive care. Prokinetic medicines may be considered.
• Do not assume that postoperative sluggishness is harmless: if an anastomotic leak or other complication is suspected, investigate it, including with CT when appropriate.
• For opioid-related constipation, the video recommends reducing opioids when possible and using preventive laxatives such as macrogol.

Mechanical ileus and the decision to operate

• The former rule that every ileus must be operated on immediately is described as outdated. In selected cases, a monitored conservative trial may be appropriate.
• Conservative measures discussed include bowel decompression with a nasogastric tube, intravenous fluids, and water-soluble hyperosmolar contrast given orally or through the tube.
• The contrast may draw water into the bowel and has a laxative effect. Its passage into the colon can help identify patients whose obstruction is resolving without surgery.
• The decision depends on the patient’s clinical course. Persistent or worsening symptoms, pain, or distension make surgery more urgent.
• Suspected ischemia, strangulation, perforation, or peritonitis calls for urgent surgery rather than waiting through a conservative trial.

5. Bologna guideline: adhesive small-bowel obstruction

The video presents the Bologna guideline algorithm as a useful framework for thinking through suspected adhesive small-bowel obstruction:

1. Initial assessment: Take the history, examine the patient, and obtain laboratory tests.
2. Look for signs requiring emergency surgery. The video highlights peritonitis, strangulation, intestinal ischemia or hemorrhage, and concerning findings such as elevated lactate.
3. Use CT with water-soluble contrast when the cause or need for surgery is uncertain. Assess the cause of obstruction and look for signs of ischemia or strangulation.
4. If emergency features are absent, consider conservative treatment: intravenous fluids, nasogastric decompression, and water-soluble contrast.
5. Check whether contrast reaches the colon, generally with follow-up imaging after 24–48 hours, as described in the video.
   • If it reaches the colon and the patient improves, continue conservative treatment.
   • If it does not reach the colon or the obstruction persists, proceed toward surgical exploration.
6. Consider surgery if conservative treatment fails. The video lists persistent obstruction beyond 72 hours, nasogastric drainage above 500 mL on day three, peritonitis or ischemia, worsening pain, CRP above 75 mg/L, white-cell count above 10,000/mm³, or more than 500 mL of free intra-abdominal fluid as concerning criteria.
7. Choose the operative approach according to the case and experience. Laparoscopy may be considered in selected patients, particularly when the history suggests limited prior surgery and a single adhesion; extensive previous surgery or complex adhesions may favor open surgery.

The presenter says the guideline is not routinely used as a formal clinical checklist in their practice, but considers it a helpful teaching structure.

6. Nasogastric tube placement, as described in the video

The video gives a practical outline for inserting a nasogastric tube in an awake patient:

• Explain the procedure and its purpose, and prepare the patient.
• Gather the tube, throat anesthetic spray, lubricating/local-anesthetic gel, water with a straw or spout, a syringe, a stethoscope, and fixation tape. The video notes that a chilled tube or one with a guidewire may be easier to handle.
• Position the patient supine with the upper body raised and the chin tucked toward the chest.
• Apply pharyngeal anesthetic spray and let the patient swallow; lubricate the tube with gel.
• Let the patient choose the nostril they feel is more open, then advance the tube gently while asking them to swallow repeatedly.
• If the tube meets resistance or appears in the mouth, reassess its course.
• The video describes advancing to roughly 50 cm, checking placement by injecting air and listening over the upper abdomen, then securing the tube and connecting drainage.

7. Operative causes and procedures

The causes of obstruction may only become clear during surgery:

• Single adhesive band: Cut the band (adhesiolysis/bridolysis); the bowel is then inspected for other problems. The video notes this can sometimes be done laparoscopically.
• Extensive adhesions: Release the adhesions and decompress the bowel.
• Incarcerated hernia: Repair the hernia; resect bowel if it is damaged, then decide whether to reconnect the bowel or create a stoma.
• Volvulus or strangulation: Assess bowel viability and resect damaged bowel when necessary, with anastomosis or stoma depending on the situation.
• Intussusception: More common in children and uncommon in adults; treatment may require operative reduction.
• Tumors: Colorectal tumors are a more frequent cause of obstructive tumor-related ileus than small-bowel tumors. Peritoneal carcinomatosis can also obstruct the bowel and may limit surgical options.

8. Endoscopic and palliative options

For malignant obstruction or cases not readily corrected surgically, the video mentions:

• PEG (percutaneous endoscopic gastrostomy) for draining a persistently distended stomach, potentially as an alternative to a long-term nasogastric tube.
• PEC (percutaneous endoscopic colostomy) to decompress the colon, described as uncommon.
• Self-expanding metal stents (SEMS) to relieve a colonic narrowing, either as a bridge to surgery or for palliation.
• Lumen-apposing metal stents (LAMS) to create an internal bypass between obstructed bowel segments under endoscopic ultrasound guidance.

The video concludes by recapping the distinctions between mechanical and paralytic ileus and directing viewers to related channel videos for further detail.

Speakers and sources featured

• Main presenter: The Surgery Appetizer channel’s presenter; the supplied metadata identifies him as Prof. Dr. Burkhard von Rahden. No other speaker is clearly heard in the subtitles.
• Andreas Koch: Credited by the presenter with suggesting the Bologna guideline.
• An unnamed channel member: Represented by a question about whether the Bologna guideline is used in clinical practice.
• Bologna guidelines for adhesive small-bowel obstruction: The video refers to the guideline update published in 2018, citing Ten Broek et al.
• A 2007 meta-analysis: Mentioned in relation to oral water-soluble contrast in adhesive small-bowel obstruction.
• Other Surgery Appetizer videos: Referenced for related topics, including endoscopic palliation of malignant ileus and a case of closed-loop obstruction.