Ileum is the final segment of the small intestine that connects it to the large intestine. In this condition, functional paralysis occurs without mechanical obstructions in the ileum. This functional motor paralysis of the digestive tract occurs due to the failure of the functioning of nervous bundles. Those nervous bundles situated in the small intestine called the myenteric plexus and sub-mucous plexus. The normal contractile waves that occur in the small intestine are called peristaltic waves. In paralytic ileus, the intestine becomes unable to transmit peristaltic waves. Which results in the collection of food, fluid, and gas inside the lumen of the intestine.
Commonly, the ileum, a part of the small intestine, is often affected. However, the colon and stomach can also be affected occasionally—this accumulation of fluid and gas inside the gut lumen results in the following.
Vvomiting, abdominal distention, a decrease in bowel sounds, and absolute constipation.
Causes for Paralytic Ileus
- Conditions that cause abdominal cavity inflammation can predispose to this condition. These conditions can be systemic infections or local conditions that exacerbate inflammatory reactions. Conditions such as appendicitis, pancreatitis, peritonitis, cholecystitis, gastroenteritis, diverticulitis, inflammatory bowel disease, and sepsis.
- Electrolyte imbalances. Ex :- Reduced potassium levels (hypokalemia), increased glucose levels (hyperglycemia), reduced magnesium levels (hypo-magnesia), and reduced phosphate levels (hypophosphatemia) in the blood.
- Some medications known to reduce gut mortality. Ex :- anticholinergics, opioids, tricyclic antidepressants, and phenothiazines can also be causative factors for this condition.
- Also, some diseases such as renal failure, respiratory failure, pneumonia, spinal cord injuries, and diabetic-related conditions such as ketoacidosis, heart attacks, and thyroid diseases can cause paralytic ileus.
- Paralytic ileus is most common in the postoperative period after surgeries. It normally lasts from a few hours to 24 h in the small bowel, from 24 to 48 h in the stomach, and from 48 to 72 h in the colon; although the duration correlates with the degree of surgical trauma and is most extensive following colon and rectal surgeries. This can occur after all types of surgery including extra-peritoneal ones.
Clinical Features of Paralytic Ileus
- Abdominal distention is usually not accompanied by colicky-type abdominal pain but can have some tenderness.
- Absent bowel opening and complete constipation.
- Intolerance of oral diets.
- Absence or delayed passage of flatus.
- Bowel sounds are absent during auscultation.
- Increased respiratory rate and increased heart rate can be present due to dehydration.
- Vomiting and nausea.
- Abdominal discomfort.
Complications
- Reduced blood pressure.
- Overgrowth of bacteria in the gastrointestinal tract.
- Increased abdominal pressure can lead to dysfunction in multiple organs such as cardiovascular, hepatic, pulmonary, renal, and neurological systems.
- If not intervened in proper time and not corrected this can lead to even death of the patients.
Diagnosis of Paralytic Ileus
- Initially, your doctor will ask a few questions. Which regarding the history of your presentation to assess the risk factors and this will be followed by a clinical examination. During examination doctor will auscultate for bowel sounds and absent bowel sounds are suggestive of paralytic ileus.
- Next, you will be recommended to undergo radiological investigations to confirm the diagnosis. A plain X‐ray of the abdomen taken in the upright posture. It will indicate dilated loops of the bowel with multiple fluid levels; indicating distention with fluid and air in all of the small bowel and much or all of the large bowel.
- Computed tomography (CT) scan of the abdomen and pelvis can also be used to confirm the diagnosis of paralytic ileus which occurs in post-operative periods. Multiple air‐fluid levels throughout the abdomen, elevated diaphragm, dilatation of both large and small intestine, and no evidence of mechanical obstruction are a few of the findings in CT scans suggestive of paralytic ileus.
- Also blood investigations will also be used to identify any electrolyte abnormalities that can predispose to paralytic illness.
Treatment
- Most commonly this condition resolves spontaneously within a few days and can be named as a self-limiting condition. These patients improve without any medical treatments and normally correction of dehydration along with correction of any electrolyte abnormalities are the only interventions required. If it lasts for more than 5 days it is important to meet your healthcare provider and investigate further to implement a suitable management plan.
- The first step in the management of paralytic ileus is identifying the causative factor of this condition. If it is not known yet, your doctor will recommend a few blood and radiological investigations to identify the cause. Then the cause must be corrected initially which includes correction of any fluid or electrolyte deficits by giving fluid and nutrients parenterally.
- Fluid replacement must be done to reach ongoing losses (e.g., nasogastric aspirates) and baseline daily requirements, long‐standing fluid deficits, and third‐space loss as well.
- Fluids and food intake by mouth are withheld until bowel sounds reappear and flatus passed.
- The nasogastric tube is a thin tube that can be passed through your nose to your stomach to drain out air or fluid that gets accumulated inside the stomach.
- If it doesn’t improve even after the above management steps, pharmacological agents that promote contractions of the gastrointestinal tract known as pro-kinetics will be prescribed.
- It is physiologically important that a patient should not remain obstructed for more than 48 has both the ensuing local bowel and systemic complications can worsen the prognosis of such patients.
Prevention of Paralytic Ileus
- Preventative measures include avoiding unnecessary exposure and excessive handling of the bowel or traction during surgery. Choosing laparoscopic methods is important in this case.
- Close monitoring of electrolyte and fluid status of patients who are in the postoperative period to correct any abnormalities before it results from the occurrence of paralytic illness.
- Chewing is a suggested preventive measure that can be implemented for post-operative patients to avoid the occurrence of paralytic ileus. Because chewing stimulates the nerve called the Vagus Nerve, which promotes bowel contractions and the release of normal GI tract hormones. Because of this mechanism chewing cab prevent paralysis and promote bowel contractions. Hence gum chewing is recommended as it is a cost-effective and easy-to-implement intervention to reduce the incidence of postoperative ileus following abdominal surgery.
- Early feeding resumption during the postoperative period is also another preventive measure.
- Drinking coffee is also known to prevent the development of paralytic ileus in post-operative patients.
- A Japanese herbal medication known as Dai-ketchup-to is also used in traditional medicine.
Dietary Modification
- It is important to ensure that you are having a balanced diet that is enriched with all nutrients essential for your healthy well-being.
- A diet that is low in fat, fiber, lactose, and fructose is normally recommended by doctors.
- The best is to have five or six meals per day while avoiding very heavy meals.
- Liquid meals will be easy for you to digest and having dietary supplements will ensure that you are getting all the multi-nutrients required by your body
- Cooked vegetables and liquidizing them by passing them through a blender will make them easier for you to digest.
References
- Bailey and Love’s Short Practice of Surgery- 27th Edition
- Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
- Oxford Handbook of Clinical Medicine – 10th Edition
- Browse’s Introduction to the Symptoms and Signs of Surgical Disease – 4th Edition – Norman L. Browse, John Black, Kevin G. Burnand and William E.G. Thomas
