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Ileus, Adhesions, Intussusception, and Closed-Loop Obstructions
Ileus
Ileus is the failure of intestinal peristalsis caused by loss of coordinated gut motility without evidence of mechanical obstruction. In children, it is most often associated with abdominal surgery or infection (gastroenteritis, pneumonia, peritonitis). Ileus also accompanies metabolic abnormalities (e.g., uremia, hypokalemia, hypercalcemia, hypermagnesemia, acidosis) or administration of certain drugs, such as opiates, vincristine, and antimotility agents such as loperamide when used during gastroenteritis.
Ileus manifests with nausea, vomiting, feeding intolerance, abdominal distention with associated pain, and delayed passage of stool and bowel gas. Bowel sounds are minimal or absent, in contrast to early mechanical obstruction, when they are hyperactive. Abdominal radiographs demonstrate multiple air-fluid levels throughout the abdomen. Serial radiographs usually do not show progressive distention as they do in mechanical obstruction. Contrast radiographs, if performed, demonstrate slow movement of barium through a patent lumen. Ileus after abdominal surgery generally resolves in within 72 hr.
Treatment involves correcting the underlying abnormality, supportive care of comorbidities, and mitigation of iatrogenic contributions. Electrolyte abnormalities should be identified and corrected, and narcotic agents, when used, should be weaned as tolerated. Nasogastric decompression can relieve recurrent vomiting or abdominal distention associated with pain; resultant fluid losses should be corrected with isotonic crystalloid solution. Prokinetic agents such as erythromycin are not routinely recommended. Selective peripheral opioid antagonists such as methylnaltrexone hold promise in decreasing postoperative ileus, but pediatric data are lacking.
Bibliography
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Vather R, Bissett I: Management of prolonged post-operative ileus: evidence-based recommendations. ANZ J Surg 2013; 83: pp. 319-324.
Adhesions
Adhesions are fibrous tissue bands that result from peritoneal injury. They can constrict hollow organs and are a major cause of postoperative small bowel obstruction. Most remain asymptomatic, but problems can arise any time after the 2nd postoperative wk to yr after surgery, regardless of surgical extent. In one study, the 5-yr readmission risk because of adhesions varied by operative region (2.1% for colon to 9.2% for ileum) and procedure (0.3% for appendectomy to 25% for ileostomy formation/closure). The overall risk was 5.3% excluding appendectomy and 1.1% when appendectomy was included.
The diagnosis is suspected in patients with abdominal pain, constipation, emesis, and a history of intraperitoneal surgery. Nausea and vomiting quickly follow onset of pain. Initially, bowel sounds are hyperactive, and the abdomen is flat. Subsequently, bowel sounds disappear, and bowel dilation can cause abdominal distention. Fever and leukocytosis suggest bowel necrosis and peritonitis. Plain radiographs demonstrate obstructive features, and a CT scan or contrast studies may be needed to define the etiology.
Management includes nasogastric decompression, intravenous fluid resuscitation, and broad-spectrum antibiotics in preparation for surgery. Nonoperative intervention is contraindicated unless a patient is stable with obvious clinical improvement. In children with repeated obstruction, fibrin-glued plication of adjacent small bowel loops can reduce the risk of recurrent problems. Long-term complications include female infertility, failure to thrive, and chronic abdominal and/or pelvic pain.
Acknowledgment
Andrew Chu, MD contributed to the prior version of this chapter.
Bibliography
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Grant HW, Parker MC, Wilson MS, et. al.: Adhesions after abdominal surgery in children. J Pediatr Surg 2008; 43: pp. 152-156.
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