Please enable JavaScript.
Coggle requires JavaScript to display documents.
PARALYTIC ILEUS (PERITONITIS (Postoperative (some degree of paralytic…
PARALYTIC ILEUS
PERITONITIS
perhaps as aresult of toxic paralysis of intrinsic nerve plexuses, the bowel in peritonitis becomes atonic - there may be an assoc mechanical obstruction produced by kinking of loops of bowel by fibrinous adhesions so tgat frequently the paralytic ileus is complicated by mechanical obstruction
METABOLIC FACTORS
severe potassium depletion, uraemia and diabetic coma may result in paralytic ileus
-
Postoperative
some degree of paralytic ileus occurs after every laparotomy with some bowel segments affected more than others
complex aetiology: sympathetic overaction, effects of manipulation of the bowel, potassium depletion(when there is excessive preop vomiting), peritoneal irritation from blood or assoc peritonitis and atony of stomach and large bowel, which occurs after every abdo operation for a period of some 24-48h
-
paralytic ileus that persists for more than 48hrs postop probably has other aetiological factor present
-
CLINICAL FEATURES
paralytic ileus is most commonly seen in the postop stage of peritonitis or of major abdo surgery - there is abdo distension, absolute constipation and effortless vomiting
pain is not present apart from the discomfort of the laparotomy wound and the abdominal distension
on examination the pt is anxious and uncomfortable
abdo distended silent and tender
CT or plain Xray of the abdo will show gas distributed throughout the small and large bowel and some fluid levels may be present on an erect abdoXray
the paralytic ileus may merge insidiously into a mechanical obstruction produced by adhesions or bands following abdo surgery and an important ddx lies between these two conditions - important to distinguish as paralytic = conservative and mechanical = surgery
-
TREATMENT
PROPHYLAXIS
biochemical imbalance is corrected preoperatively. The bowel is handled gently at operation. Postoperatively, gastric distension due to air swallowing may require NG suction
IN THE ESTABLISHED CASE
NG suction is employed to remove swallowed air and prevent gaseous distension. aspiration of fluid also helps to relieve the associated gastric dilation. IV fluid and electrolyte therapy is instituted
pethidine (opioid with little effect on intestinal motility) used to allay discomfort + combined with phenothiazine eg prochlorperazine for nausea
will recover unless secondary to an underlying cause eg infection
some evidence of gentle enteral feeding hasten resolution of paralytic ileus, chewng gum has pos effect
absence of evidence of mechan obstruction or infection, prolonged ileus treated pharmacologically
motility stimulants such as metoclopramide (dopamine antag stim gastric emptying and small intestine transit) with erythromycin (stimulate motilin receptor)
PSEUDO-OBSTRUCTION
aka adynamic ileus or ogilvies syndrome - a particular form of paralytic ileus which mainly affects the large bowel
results from interference with the autonomic supply to the gut in which there is predominant sympathetic activity
it typically complicates fractures of the spine or pelvis, retroperitoneal haemorrhage and retroperitoneal surgery, intestinal ischaemia, ureteric colic and occasionally parturition
usually the bowel is unaffected and peristalsis continues and passes intestinal contents into the colon, in particular the caecum, distends enormously, becomes ischaemic and if unrelieved, will perforate
symptoms are typical of large bowel obstruction, with colicky abdo pain, distension and absolute constipation
examination confirms abdo distension and digital examination reveals a capacious empty rectum
TREATMENT
the pt given nothing by mouth and identifiable causes such as electrolyte imbalances are adressed
the colon is decompressed preferably at colonoscopy, although pharmacological treatment using the cholinesterase inhibitor neostigmine may bring resolution
oral laxatives particularly stimulant laxatives should be avoided as can precipitate perforation
-