prolonged post op ileusprolonged post op ileus

SIXTH POST GRADUATE COURSESIXTH POST GRADUATE COURSEOF THE BELGIAN SECTION OF COLORECTAL SURGERYOF THE BELGIAN SECTION OF COLORECTAL SURGERY

BSCRSBSCRS

COLORECATAL NIGHTMARES

PROLONGED POST OP ILEUSPROLONGED POST OP ILEUS

J-J Houben

U.L.B.Clinique Bruxelloise de Chirurgie Digestive

Gastrospace.com

Clinique Bruxelloise de Chirurgie Digestive

Site Cavell – [email protected]

Nothing else butNothing else buta good gas…

PROLONGED POST OP ILEUS

1. Is it a symptom, a syndrome, a disease, …what else?

2. How to suspect it?

3. How to exclude a collateral disease?

4. How to treat the patient affected by ileus?

5. How to manage the family, the G.P., the nurses….?


Symptom, syndrome, disease, …what else?

Cessation of normal intestinal motility

Af SAfter Surgery

U di bl l d d f i i l f diUnpredictable prolonged dysfunction preventing oral feedingand recovery

Median time Recovery of intestinal activity 6 hoursgastric activity 24 hourscolon activity 40 hours

LIMIT: 72 H (BLANLOEIL 2000)LIMIT: 72 H (BLANLOEIL 2000)


Symptom, syndrome, disease, …what else?

Median time Recovery of intestinal activity 6 hoursgastric activity 24 hourscolon activity 40 hours

Poorly related to : the type of operationthe lengh g

Related to: PainP i t t di (l th)Pre-existent disease (length)Antibiotics


Electrical activity and motility

Increased electrical activity does not always results in increased motility

Intrinsic Myenteric and Submucosal plexuses

Slow waves and Spike potentials

The pattern of electromechanical activity – migration electrical complex

The relaxation induces the contraction (NO,…)


EXTRINSEC PATHWAYSEXTRINSEC PATHWAYS

Hormonal control mechanismsHormonal control mechanismsGASTRINSECRETINESECRETINEGLUCAGONCHOLECYSTOKININVIPVIPDOPAMINEMOTILIN


Pharmacologic agentsMORPHIN METOCLOPRAMIDEMORPHINLOPERAMIDEPHENOTHIAZINES

METOCLOPRAMIDEALIZAPRIDEEPINEPHRINEPHENOTHIAZINES

COLCHICINEANTIBIOTICS

EPINEPHRINENOREPINEPHRINENALOXONE

ALCOLHOLATROPIN

ERYTHOMYCINEDOMPERIDONENSAINSAI

PROTOXYDE CISAPRIDEHALOGENE

GENERALMEDULLAR

NEOSTIGMINEGASTROGRAFINCHARRIER OIL

PERIDURALCHARRIER OILLOCAL ANESTHESIA

PROLONGED POST OP ILEUS IS A SYNDROME

PAINPAIN

ANESTHSIA

HYPOVOLEMIA

HYPOTHERMIA

PARIETAL AGRESSION

BACTERIAL REDUCTION DECREASESBOWEL MOVEMENTSILEUS INCREASED BACTERIALOVERGROWTH



2. When to suspect it?




When to suspect a abnormal ileus• AFTER 4 DAYS• Slow installationSlow installation• No or short free interval• Vomiting are rare Nausea ++Vomiting are rare. Nausea ++• Severe discomfort- abdominal tenderness• No peristaltism no fever (except bacterialNo peristaltism, no fever (except bacterial

translocation)• IIIrd space (fluid entrapment)p ( p )• Gastric residue


43 Y OLD WOMAN TPN FROM 4 YEARSCROHN DISEASE – SMALL BOWEL RESECTIONPERMANENT INTESTINAL ATONIAPERMANENT INTESTINAL ATONIAREFFERRED FOR ILEOSTOMY


NO DISTAL SURURE

PROLONGED POST OP ILEUSCollateral and causal factors

M h i l l i• Mechanical occlusion• Vascular insufficiency

Ab• Abscess• Peritonitis

M t i t i i• Mesenteric tumour invasion• Metabolic causes (Hypokaliemia…)

Di b t• Diabetes• Respiratory insufficiency• …..

PROLONGED POST OP ILEUSPROLONGED POST OP ILEUSCollateral and causal factors

Radiological aspects

• PAF

• CT SCAN

• ULTRASOUND• ULTRASOUND

• RADIOOPAQUE SERIES

PROLONGED POST OP ILEUSCollateral and causal factorsC


• PAF

PROLONGED POST OP ILEUSPROLONGED POST OP ILEUSCollateral and causal factors


• PAF• CT SCAN (Frager 1995)

• ULTRASOUND

• RADIOOPAQUE SERIESSERIES

PROLONGED POST OP ILEUSCollateral and causal factorsCollateral and causal factors


• PAF• CT SCAN• ULTRASOUND

PROLONGED POST OP ILEUSCollateral and causal factorsCollateral and causal factors


• PAF• CT SCAN• ULTRASOUND• GI SERIES


ELECTROLYTE INBALANCE Na+, K+, Ca++, Mg+, Phosphate

BACTERIAL TRANSLOCATION – SEPSIS

DENUTRITION

RESPIRATORY INSUFFISENCY


APPROPRIATE WATER AND SALINE ADM

SELECTED ANTIBIOTHERAPY (CRP level)

INTESTINAL DECOMPRESSIONINTESTINAL DECOMPRESSION gastric suctiongastrostomygastrostomy

TENS (EXP)

PHARMACOLOGIC AGENTS


Pharmacologic agentsPharmacologic agents

MORPHIN EPINEPHRINEO NLOPERAMIDEPHENOTHIAZINES

NOREPINEPHRINENALOXONE

COLCHICINEANTIBIOTICSALCOLHOL

DOMPERIDONE

ALCOLHOLATROPIN

CISAPRIDEMOTILIN

CISAPRIDENEOSTIGMINEGASTROGRAFIN

ENDORPHIN

GASTROGRAFINCHARRIER OILOCTREOTIDE

THE MANAGEMENT OFTHE MANAGEMENT OF COLLATERALS

• Lack of energy• Lack of hope• Lack of strength• Lack of strength• Lack of confidence• Lack of finances

THE MANAGEMENT OFTHE MANAGEMENT OF COLLATERALS

• Lack of energy PROTEO CALORIC SUPPORTPSYCHOLOGICAL SUPPORT• Lack of hope

• Lack of strength

PSYCHOLOGICAL SUPPORTDAILY INFORMATIONMONITORINGLack of strength

• Lack of confidencePHYSIOTHERAPYMOBILISATIONCALL FOR CONSULTANCE• Lack of finances CALL FOR CONSULTANCESOCIAL HELP

An the final word……

PROLONGED POST OP ILEUS IS NOT

A PREEXISTENT DISEASE A RARETYA FATALITYA PSYCHOLOGICAL DISORDERA PSYCHOLOGICAL DISORDER A PERMANENT DISEASEAN INTRACTABLE DISEASEAN INTRACTABLE DISEASEA MISTAKEA FAULT

prolonged post op ileusprolonged post op ileus

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