TTheme of lectureheme of lecture::

ACQUIRED INTESTINAL ACQUIRED INTESTINAL ILEUSILEUS

Plan:Plan:

• Paralytic ileus.

• Obstruction of the small and large bowel.

• Intussusception.

• Adhesive Intestinal Obstruction

ACQUIRED INTESTINAL ILEUSACQUIRED INTESTINAL ILEUS ClassificationClassification

ACQUIRED INTESTINAL ILEUS

Paralytic ileus, (pseudo-obstruction)

mechanical obstructions

simple mechanical obstruction

strangulating obstruction

Causes of paralytic ileusCauses of paralytic ileus• Medications, especially narcotics • Intraperitoneal infection • Mesenteric ischemia Injury to the

abdominal blood supply • Complications of intra-abdominal surgery • Kidney or thoracic disease • Metabolic disturbances (such as decreased

potassium levels) • Cranial and cerebral injuries

ClassificationClassification

• Compensated

• Subcompensated

• Decompensated

Clinical manifestations and Clinical manifestations and diagnostic studiesdiagnostic studies

• Constant gnawing pain

• repeated vomiting

• symmetric abdominal distention

• reduced or absence of peristalsis

• increasing meteriorism

• constipation

• heavy intoxication

Diagnostic studiesDiagnostic studies

• Physical examination

• Ragiological investigation

• Laboratory tests (hypokalemia)

Treatment of paralytic ileusTreatment of paralytic ileus• Para-nephral and pre-sacral novocaine nerve

blocks• Gastric lavage and intestinal intubation• Stimulation of intestinal peristalsis• IV fluids and electrolytes, • a minimal amount of sedatives,• adequate serum K level (> 4 mEq/L [> 4 mmol/L]) • Sometimes colonic ileus can be relieved by

colonoscopic decompression; rarely cecostomy is required. Ileus persisting > 1 wk probably has a mechanical obstructive cause, and laparotomy should be considered.

The mechanical causes of intestinal The mechanical causes of intestinal obstructionobstruction

• Hernias • Postoperative adhesions or scar tissue • Impacted feces (stool) • Gallstones • Tumors • Granulomatous processes (abnormal tissue

growth) • Intussusception • Volvulus • Foreign bodies

Obstruction of the small bowelObstruction of the small bowel

• Abdominal cramps around the umbilicus or in the epigastrium;

• Vomiting starts early • Obstipation occurs with complete

obstruction, but diarrhea may be present with partial obstruction.

• Strangulating obstruction occurs in nearly 25% of cases and can progress to gangrene in as little as 6 h

Obstruction of the large bowelObstruction of the large bowel

• Symptoms usually develop more gradually • increasing constipation • abdominal distention• vomiting (not usually) • lower abdominal cramps • unproductive of feces • distended abdomen • there is no tenderness• the rectum is usually empty

X-ray examinationX-ray examination

• Sign of reversed cups of Kloiber: shows position of air-filled loops of bowel and horizontal levels of the fluid below gas

• Presence of shady fields of the large bowel

• If peritonitis has developed, we can see free gas under the liver, because bowel is damaged

Adhesive Intestinal Obstruction Adhesive Intestinal Obstruction

The incidence of postoperative adhesive obstruction after laparotomy is about

2%. The procedures which have highest risk for adhesive McBurney’s point in pediatric

patients are:1. subtotal colectomy,2. resection of symptomatic Meckel’s diverticulum,3. Ladd’s procedure, and4. nephrectomy.

EtiologyEtiologyThe causes of postoperative McBurney’s point

include adhesions, intussusception,hernia, and tumor. Adhesions are fibrous bands of tissue that form between loops of bowel or between the bowel and the abdominal wall after intraabdominal inflammation. Obstruction occurs when the bowel is “caught” within one of these

fibrous bands in a kinked or twisted position, twists around an adhesive band, or herniates between a band and another fixed structure within the abdomen.

Clinical PresentationClinical Presentation

• cramping abdominal pain,• distension, and vomiting.(bilious or even

feculent).• Inspection of the abdomen may reveal obvious

dilated loops of bowel and distension. • fever, tachycardia, decreased blood pressure,

abdominal tenderness and leukocytosis.

DDifferential diagnosisifferential diagnosis•pancreatitis,

•hepatitis

•biliary tract disease.

•urinary tract infection, nephritis, stones.

•systemic infection.

•colitis, rotavirus.

•pneumonia.

TreatmentTreatment•isotonic saline solutions,•nasogastric decompression,• correction of electrolyte abnormalities,• IV antibiotics,Indications for operation include obstipation for 24 hours,

continued abdominal pain with fever and tachycardia, decreased blood pressure, increasing abdominal tenderness, and leukocytosis despite adequate resuscitation and medical treatment.The abdomen is opened through a previous incision, if present, and midline, if not. The cecum is identified and the collapsed ileum is followed proximally until dilated bowel and the point of obstruction is identified. The offending adhesive bands are disrupted and the abdomen is closed. Laparoscopic lysis of adhesions is another option and may allow a shorter postoperative recovery and hospital stay. Postoperatively, nasogastric decompression and intravenous fluids are continueduntil return of bowel function and the volume of gastric aspirate decreases.

Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing a bowel obstruction.

intussuscipiens

intussusceptum

FrequencyFrequency. . Intussusception is the Intussusception is the predominate cause of intestinal obstruction predominate cause of intestinal obstruction in persons aged 3 months to 6 years. The in persons aged 3 months to 6 years. The estimated incidence is 1-4 per 1000 live estimated incidence is 1-4 per 1000 live births. births. SexSex. . Overall, the male-to-female ratio is Overall, the male-to-female ratio is approximately 3:1. approximately 3:1.

EtiologyEtiology•Intussusception is most commonly idiopathic and no anatomic

lead point can be identified. Several viral gastrointestinal pathogens (rotavirus, reovirus, echovirus) may cause hypertrophy of the Peyer’s patches of the terminal ileum which may potentiate bowel intussusception.

•A recognizable, anatomic lesion acting as a lead point is only found in 2-12% of all pediatric cases. The most commonly encountered anatomic lead point is a Meckel’s diverticulum. Other anatomic lead points include polyps, ectopic pancreatic or gastric rests, lymphoma, lymphosarcoma, enterogenic cyst, hamartomas (i.e., Peutz-Jeghers syndrome), submucosal hematomas (i.e., Henoch-Schonlein purpura), inverted appendiceal stumps, and anastomotic suture lines. Children with cystic fibrosis are at increased risk of intussusception possibly due to thickened inspissated stool.

•Postoperative intussusception accounts for 1.5-6% of all pediatric cases of intussusception.

Pathology/PathophysiologyPathology/Pathophysiology1.The intussusception begins at or near the ileocaecal valve without

local anatomical lesion to cause it2.The mesenteric vassels are drawn between the layers of the

intussusception and compressed.3.The sligth interference with lymphatic and venous drainage results

in edema and an increase of tissue pressure4.Venulus and capillaries became great engorged and bloody edema

fluid drips into the lumen5.The mucosal cells swell into goblet cells and discharge mucus,

which, mixing in the lumen with the bloody transsudate, forms the ‘current-jelly’ stool

6. Edema increases until venous inflow is completely obstructed7. As arterial continues to pump in, tissue pressure rises until it is

higher then arterial pressure, and gangrene results8. Gangrene appears in the outer coat of the intussuseption and

progresses back to the neck of the intussusception9. Rarely the invagination is damaged

ClassificationClassification

• Colic-involving segments of large intestine

• Enteric-involving the small intestine only

• Ileocecal-ileocecal prolapses into cecum drawing the ileum along with it

• Ileocolic-the ileum prolapses through the ileocecal valve into the colon

Colic invaginationColic invagination

Enteric intussusceptionEnteric intussusception

Ileocolic invaginationIleocolic invagination

Ileocecal intussusceptionIleocecal intussusception

Clinical Presentation1. vomiting (85%)-initially, vomiting is nonbilious and

reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious.

2. abdominal pain (83%)-pain is colicky, severe, and intermittent.

3. passage of blood or bloody mucous per rectum (53%).4. a palpable abdominal mass5. lethargy. 6. diarrhea.The classic triad of pain, vomiting, and bloody mucous

stools (“red current jelly”) is present in only one third of infants with intussusception. Diarrhea may be present in 10-20% of patients.

Physical: Physical:

• Usually, the abdomen is soft and nontender early, but it eventually becomes distended and tender.

• A vertically oriented mass may be palpable in the right upper quadrant. Ruch’s symtom: Appering of the pain and screams during the palpation of intussusception mass under abdominal wall. Dance’s symptom: in ileocaecal invagination aconcave right lateral area of abdomen is palpable

• Currant jelly stools are observed in only 50% of cases.

• Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.

• Fever is a late finding and is suggestive of enteric sepsis.

DDifferential diagnosisifferential diagnosis

• includes intestinal colic.

• gastroenteritis.

• acute appendicitis.

• incarcerated hernia.

• internal hernia.

• volvulus.

Diagnostic studies:Diagnostic studies:

Laboratory investigation usually is not helpful in the evaluation of patients with intussusception. Leukocytosis can be an indication of gangrene if the process is advanced. Dehydration is depicted by electrolyte imbalances.

• X-ray examination: barium enema or pneumoirigography

• Sonography• CT

X-ray examinationX-ray examination::

1)Intussusception - Plain Film1)Intussusception - Plain Film

• May be normal

• Soft tissue mass, often in RUQ

• Small bowel obstruction

• May see intussusceptum

2)Intussusception – Contrast Enema2)Intussusception – Contrast Enema

• Diagnosis and treatment

• Media: • Air

• Barium

• Water soluble contrast

•Pneumoirigograhy

X-ray examination

Air contrast enema shows Air contrast enema shows intussusception in the cecum. intussusception in the cecum.

Air enema showing the intussusception is in theAir enema showing the intussusception is in thesplenic flexure (arrow).splenic flexure (arrow).

Barium enema shows intussusception Barium enema shows intussusception in the descending colon.in the descending colon.

CT scan reveals the classic ying-yang CT scan reveals the classic ying-yang sign of an intussusceptum inside an sign of an intussusceptum inside an

intussuscipiens.intussuscipiens.

UltrasoundUltrasound

• The typical appearance is described variously as a "target sign" a doughnut sign, pseudokidney, or a sandwich sign.

• Colour Doppler has been used to assess bowel viability and as a prognostic sign that reduction will be successful

Abdominal sonograph reveals the classic Abdominal sonograph reveals the classic target sign of an intussusceptum inside an target sign of an intussusceptum inside an

intussuscipiens.intussuscipiens.

Intussusception.

(A) Longitudinal sonogram of a child with the typical clinical presentation of intussusception. This is a longitudinal sonogram through the intussusception. There are multiple lymph nodes (arrows) in the intussusception. (B) Transverse sonogram of the intussusception showing the multiple lymph nodes (arrows) within the intussusception. If lymph nodes are seen within an intussusceptum it has been reported that it is more difficult to reduce the intussusception.

(C) Transverse sonogram of an intussusception showing the color flow within the intussusceptum. This indicates that the intussusception is still viable. When no color flow is seen on Doppler, suspicion must be raised that the intussusception is no longer viable and the risk of perforation is high.

ComplicationsComplications::

• Intestinal hemorrhage

• Necrosis and bowel perforation

• Shock and sepsis

TreatmentTreatment

H yd ros ta tic -p ressu re red u c tion S u rg ica l op era tion

Tech n iq u e

Enema ReductionEnema Reduction • Personal comfort level is probably the best

contrast selection criterion • All have similar rates of reduction (75-85%)

and perforation (1-2%)• End point - free reflux into small bowel and

reduction of mass • Often see edema of ileocecal valve• Main goal is to prevent unnecessary open

reduction, select patients who need resection

Non-operative reduction of the Non-operative reduction of the intussusceptionintussusception

Richardson balloon for pneumoirigography

Principles of barium enema reductionPrinciples of barium enema reduction

1. Perform nasogastric suction: administer 4 fluids or blood and antibiotics

2. Insert ungreased Foley catheter in rectum, distend ballon and pull down against levator. Strap in place

3. Wrap legs4. Let barium run from height of 30 cm in above table5. X-ray intermittently6. Stop if barium column is stationary and its

unchanging for 10 min7. Reduction

ReductionReduction is marked by: is marked by:

• free from of barium meal into small bowel

• expulsion of feces and air with the barium

• disappearing of intussusception mass

• response of child-clinical improvement of the patient, who may fall into a natural sleep

Surgical treatmentSurgical treatment

indication is:

• a shocked child with signs of peritonism

• or in whom intussusception does not resolve with a nonoperativ procedure

Preoperative preparation includes:Preoperative preparation includes:

• Apply intravenous fluids or blood

• Gastric aspiration (stomach has been empty), insert nasogastric tube

• Administration of antibiotics

Operative technique:Operative technique:

• The intussusception is milked back by progressive compression of the bowel

In severe cases:In severe cases:

• Intestinal resection

• Placement of ileotransversal anastomosis

• Ileostoma and caecostoma placement

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