The paralytic ileus It is a clinical picture characterized by dysfunction in bowel movements without an obvious structural problem causing it. It differs from mechanical ileus in that the latter causes a physical obstruction of the intestine, internal or external, that does not allow normal intestinal transit.
It is also known as intestinal pseudo-obstruction. This term, imprecise in origin, is still used as an initial diagnosis when the patient's symptoms agree with a picture of ileus and there are no obstacles in intestinal transit. Once the cause is known, it should be named as paralytic ileus or intestinal obstruction.
This picture can affect both the large and small intestines in their entirety. However, paralytic ileus is more likely to involve the ileum, a portion of the small intestine that shares many similarities in name with the disease being described, but is unrelated to each other..
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Paralytic ileus has a wide variety of symptoms, some considered cardinal, including:
Pain is the most important symptom and the first to appear. In paralytic ileus, the pain is usually crampy and intermittent. Its location can help in the diagnosis, so its semiology is essential when evaluating the patient and physical examination.
In terms of frequency and clinic, it is the second most important symptom. In fact, the absence of evacuations is considered the most precise cardinal symptom, since abdominal pain is very nonspecific.
Despite this, not all obstructed patients stop evacuating, since some residual stool in the rectum may be expelled late..
Vomiting is a common symptom but not necessarily all patients present it. Its characteristics provide valuable information at the time of diagnosis. Its content can vary greatly depending on the level of the obstruction.
In proximal obstruction, vomiting is not associated with severe abdominal distention and is abundant. In distal obstruction, vomiting is less frequent but highly offensive due to the increased presence of bacteria at the end of the small intestine. In colonic obstructions, the vomiting is fecaloid or with characteristics similar to stool.
It is a late but very guiding symptom. The more distal the obstruction, the greater abdominal distention there will be.
The presence of gas in the abdominal cavity and its organs is also very useful in the radiological diagnosis of ileus, since it allows observing the air-fluid levels so typical of this pathology.
Some other symptoms that may occur are:
- Diarrhea.
- Lack of appetite.
- Sickness.
- Absence of bowel sounds.
Paralytic ileus is a frequent consequence of intestinal manipulation that occurs during abdominal surgeries. Peristalsis returns to normal between 48 and 72 hours after the operation, always in the absence of infections.
Many other injuries or diseases are associated with paralytic ileus, such as intraperitoneal hemorrhages, renal colic, peritonitis, vertebral and rib fractures, pneumonia, pneumothorax, testicular or ovarian torsion, central nervous system diseases, and sepsis.
Fluid and electrolyte imbalance is the most common medical cause of paralytic ileus in the elderly and chronically ill. These disorders can be reversible as long as replacement therapy is installed quickly and the cause is treated. Hypokalemia is the most common of these disorders.
Some medications can cause transient paralytic ileus. Opioids such as morphine have been associated with intestinal paralysis, and atropine - a frequently used anticholinergic - has a significant adverse effect of intestinal pseudo-obstruction, especially in children.
Other chemicals and drugs can also cause paralytic ileus. The tincture or the extract of belladonna, the nut vomica and the lead are some of these substances. Heroin overdose is characterized by the presence of paralytic ileus among its symptoms.
The therapy of paralytic ileus is aimed at treating the cause that triggered it. Therefore, the diagnosis is essential to establish the appropriate treatment..
Initially, it is important to differentiate it from mechanical ileus, whose treatment is very different, as well as postoperative paralytic ileus, which usually resolves spontaneously in a few days..
The initial steps in treatment are abdominal decompression through the placement of a naso or orogastric tube, omission of the oral route and intravenous administration of fluids, electrolytes and even blood derivatives if necessary. The sooner treatment is started, the more effective it is.
Laboratory and radiological controls are important to evaluate whether ileus management is being successful or not. All of the above added to the patient's clinic will determine if the treatment should be maintained or if any modification is necessary..
If ileus does not improve after several days of treatment, or if it appears to be getting worse, a surgical exploration should be considered..
The maximum waiting time ranges from 5 to 7 days, unless the clinical deterioration is very important and action must be taken immediately..
As the cause is unknown, the only indication for surgery is decompressive therapy. However, in a high percentage of cases the surgeon will find a mechanical, intra or extraluminal obstruction, which had not been located or even suspected.
Chronic idiopathic intestinal pseudo-obstruction is a disease characterized by symptoms of recurrent ileus without apparent organic damage.
Although their cause is still unknown, they have been linked to motor disorders of the intestine. Most patients experience their first episode of pseudo-obstruction in early childhood.
There is some controversy regarding the origin of this disease. Some researchers believe that it is due to abnormalities in the nerve plexuses that supply the intestines and others think that they are alterations in the muscle fibers of the intestinal walls. These patients also have esophageal peristalsis disorders.
Symptoms are the usual ones of any type of ileus, with pain, bloating, vomiting and absence of bowel movements, although diarrhea occasionally occurs..
Treatment is conservative, although it sometimes requires gastric decompression with tubes and intravenous hydration to replace fluids and electrolytes..
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