Value of sonographic ileus diagnosis

Patients in an early state of mechanical bowel obstruction, with unspecific clinical symptoms, negative laboratory findings and no evidence of ileus in plain abdominal X-ray, are a pitfall for diagnosis and therapeutic decisions. In a partly retrospective, partly prospective study 11% (n = 13) of ileus patients admitted to our hospital met these criteria of "early state" bowel obstruction. Using conventional methods of diagnosis, in 6% (n = 7) false negative diagnosis was obtained; 4% (n = 5) were primarily admitted to the internal medical department. In all these cases, abdominal sonography yielded a correct diagnosis by demonstrating specific criteria of bowel obstruction even at onset of disease. The correct diagnosis was uniformly confirmed by early operation.     

Abdominal sonography for the diagnosis of large bowel obstruction

To evaluate the clinical usefulness of abdominal sonography in the diagnosis of large bowel obstruction, the sonography findings of 39 patients with a large bowel obstruction, in the form of a simple obstruction in 36 patients and a sigmoid volvulus in 3, were reviewed in comparison with their plain X-ray findings. Abdominal sonography showed a large bowel obstruction in 33 patients, and an obstructing lesion in 14 of these patients. However, in the other 6 patients, including the 3 with a sigmoid volvulus, the image was disturbed by extensive colonic gas. Although the plain abdominal X-ray films showed no gaseous colonic dilatation, isolated small bowel dilatation was seen in six patients with a large bowel obstruction proximal to the splenic flexure. In five of these six patients, abdominal sonography revealed a dilated colon filled with fluid and feculent contents which was difficult to evaluate on the plain X-ray films. Consequently, abdominal sonography was proven to be useful, especially for detecting X-ray-negative colonic dilatation.     

Accelerated postoperative recovery after colorectal surgery

Accelerated recovery programs are clinical pathways which outline the stages, and streamline the means, and techniques aiming toward the desired end a rapid return of the patient to his pre-operative physical and psychological status. Recovery from colo-rectal surgery may be slowed by the patient's general health, surgical stress, post-surgical pain, and post-operative ileus. Both surgeons and anesthesiologists participate throughout the peri-operative period in a clinical pathway aimed at minimizing these delaying factors. Key elements of this pathway include avoidance of pre-operative colonic cleansing, early enteral feeding, and effective post-operative pain management permitting early ambulation (usually via thoracic epidural anesthesia). Pre-operative information and motivation of the patient is also a key to the success of this accelerated recovery program. Studies of such programs have shown decreased duration of post-operative ileus and hospital stay without an increase in complications or re-admissions. The elements of the clinical pathway must be regularly re-evaluated and updated according to local experience and published data.     

Peritonitis: Pathologic physiology involved in treatment

Peritonitis can usually be divided into an early formative or absorptive stage during which bacteriemia and bacterial toxemia preponderate, and the fully developed later stage in which circulatory disturbances and inhibition ileus preponderate.The most important factors that enter into the production of symptoms are: (a) bacteriemia and toxemia; (b) dehydration and demineralization; (c) reflex symptoms of nausea, anorexia and general depression; (d) inhibition ileus; (e) circulatory disturbances; (f) anoxemia, and (g) starvation.The most important local defensive factors against peritoneal infection are phagocytosis, formation of a fibrinous exudate and early localized intestinal inhibition. The general antibacterial activities are interfered with by anhydremia, demineralization, disturbances of the acidbase balance, anoxemia and circulatory disturbances.The surgical treatment involves the early removal of the focus of infection, with constant consideration of the importance of not disturbing the local defensive mechanisms.Dehydration and demineralization are treated by means of normal saline, Ringer's and Hartmann's solutions.The anoxemia is treated by correcting circulatory disturbances and by the early use of oxygen inhalations.To increase the colloid osmotic pressure of the plasma when a shock syndrome exists, 6 per cent acacia solution with minute doses of pitressin are to be used. (Suprarenal cortex extract may be of some value.)Fluids are not to be administered by mouth during any stage of peritonitis because they stimulate gut activity. However fluids may be given by mouth during the time that duodenal intubation with suction is applied.Proctoclysis and enemas are contraindicated in the early cases of peritonitis due to gangrenous appendicitis, when physiologic rest of the cecum is most desirable.Morphine is needed to control pain. It is doubtful whether deep morphinization has any specific beneficial effect in peritonitis and its deleterious effect upon the respiratory mechanism as well as upon the immune reactions must be borne in mind.The splanchnic vasomotor paralysis may be treated in the early stages only by means of small doses of ephedrine. Ephedrine also probably lessens “weeping” from the peritoneum and plasma loss into the intestine, and its inhibitory effect upon gut motility is of advantage during the early stages.Inhibition ileus and distention are treated by means of duodenal intubation and hypertonic salt solution intravenously. The stimulating effect of hypertonic salt solution upon propulsive intestinal motility contraindicates its use in the early formative stages.Glucose solutions are especially indicated during the starvation stage.Fowler's position is of definite value during the early, formative stages. Later the state of the circulation and the patient's comfort should determine the position of the patient.Mild x-ray treatment during the early formative stages of peritonitis is probably indicated because it raises the antibacterial defense mechanisms.The possibility of a mechanical obstruction occurring in peritonitis, from kinking of the bowel, localized abscess, or from a plastic exudate is to be borne in mind. Enterostomy is indicated only after the simple method of duodenal intubation with suction has been given a trial.Spinal anesthesia is contraindicated during the early absorptive stages of peritonitis because of its stimulating effect upon peristalsis. Ether is contraindicated during any stage of peritonitis.The inefficacy of drainage in general peritonitis cases is briefly discussed.     

DSA引导下经鼻肠梗阻导管置入治疗难治性粘连性肠梗阻

目的探讨DSA引导下经鼻肠梗阻导管置入治疗难治性粘连性肠梗阻的效果。方法对50例难治性粘连性肠梗阻患者给予DSA引导下经鼻肠梗阻导管治疗,统计置管时间,腹痛、腹胀缓解时间,负压引流量,肛门排气及排便时间;术后第3、6天统计导管进入长度,并复查腹部X线片观察导管头端位置。结果 50例均一次性置管成功,平均置管时间(22.57±6.93)min,患者耐受性均良好,无消化道出血及穿孔发生。45例(45/50,90%)术后腹痛、腹胀明显缓解,平均缓解时间为(9.64±8.33)h。术后第1天负压引流量为(1 500±450)ml,第2天(750±120)ml,第3天(257±112)ml。术后第3天,导管平均进入长度为(195.97±14.63)cm,腹部X线片示导管头端位于远段空肠(第3组小肠);术后第6天,平均导管进入长度为(240.55±17.65)cm,导管头端位于远段回肠。平均肛门排气时间为(2.80±1.01)天,平均排便时间(3.52±1.26)天。结论 DSA引导下经鼻肠梗阻导管治疗难治性粘连性肠梗阻效果较好,可明显改善临床症状,恢复肠管生理功能。     

术中行经鼻肠梗阻导管小肠内排列术治疗腹茧症疗效分析

目的 探讨术中行经鼻肠梗阻导管小肠内排列术对于腹茧症的治疗效果。方法 回顾性分析2009年1月至2018年5月大连医科大学附属第二医院普外科收治的37例腹茧症病人的临床及随访资料,其中16例术中行经鼻肠梗阻导管小肠内排列术治疗（治疗组）,21例同期未行经鼻肠梗阻导管小肠内排列术（对照组）。比较两组病人手术方式、术后排气时间、住院时间、每日胃肠减压引流量、围手术期并发症及预后的差异。结果 与对照组相比,治疗组每日胃肠减压引流量显著升高（P＜0.01）;治疗组Clavien-Dindo并发症分级多分布于0级和1级（81.25%）,而对照组多分布于2级和3级（66.67%）。在出院后6个月的随访中,治疗组中因肠梗阻再入院1例,对照组为10例（P＜0.01）。结论 经鼻肠梗阻导管小肠内排列术在降低腹茧症病人手术并发症发生率及改善预后方面有一定优势。     

Postoperative Pneumoperitoneum: An Unusual Etiology

Although postoperative pneumoperitoneum is a common finding, it is particularly disturbing when there is an increase in the amount of postoperative pneumoperitoneum or when the radiographic finding of pneumoperitoneum is accompanied by such physical findings as increased abdominal tenderness, peritoneal signs or paralytic ileus. Four patients operated upon at the Mount Sinai Hospital are presented. All patients underwent abdominal surgery for treatment of some form of inflammatory bowel disease and all were receiving systemic corticosteroids in the postoperative period. Abdominal findings of tenderness, ileus and peritoneal irritation developed shortly after the removal of Penrose drains in the postoperative period. Pneumoperitoneum was confirmed by abdominal roentgenographs. The first patient in this group underwent a laparotomy with essentially negative findings other than a freely open drain tract. The subsequent three patients were managed by close observation and frequent abdominal radiographs. These three patients had contrast roentgenographic studies of the upper gastrointestinal tract to rule out perforation of a peptic ulcer, and in the patient upon whom reservoir ileostomy had been performed, a contrast study of the reservoir was performed. All patients recovered fully with this management and there were no sequelae. The mechanism for the appearance of pneumoperitoneum after removal of drains, particularly when the patient is receiving systemic corticosteroids, is discussed. Emphasis is placed on the need to consider and rule out perforation of a hollow viscus in this situation before accepting drain removal as the sole cause of post-operative pneumoperitoneum.     

Indications for relaparotomy in acute postoperative intestinal obstruction]

For the period of 1977-1987, operations on the abdominal organs were performed in 13,306 patients. Of them, 115 (0.86%) developed 1 to 21 days after the operation acute ileus requiring the performance of emergency relaparotomy. Lethality in this complication was 33.9%. A retrospective analysis of 103 case records and observations on 12 patients who underwent at the early postoperative period emergency laparotomy for acute ileus were performed. The data were entered on a formalized card. The material was processed by means of a computer. The integral criteria for diagnosis of acute postoperative ileus which permitted to predict with an accuracy of 99% the complication serving an indication for relaparotomy were developed.     

The problem of the closed abdominal injury in polytrauma patients]

The histories of 66 patients with blunt abdominal trauma requiring surgery in the period from 1985 to 1989 were analysed. The patients were divided into three groups on the basis of the other injuries present. Group I, isolated blunt abdominal trauma and blunt abdominal trauma with slight concomitant injuries (18 patients, ISS 17.17 +/- 1.40); group II, blunt abdominal trauma with severe concomitant injuries but without craniocerebral trauma (23 patients, ISS 29.34 +/- 1.45); and group III, blunt abdominal trauma with severe concomitant injuries and an additional craniocerebral trauma (25 patients, ISS 31.08 +/- 1.27, GCS: 10.04 +/- 0.88). Initially, the diagnosis was made in 23 cases by means of diagnostic peritoneal lavage and in 43 cases by means of sonography. The subsequent laparotomy revealed the ultrasound findings to have been false-positive in 3 cases. No false-negative ultrasound findings were demonstrated at all. Peritoneal lavage, on the other hand, was found to have yielded false-negative and false-positive findings in 2 cases each. Counting from the time of admission, the time up to diagnosis of the intra-abdominal injury was 85 +/- 14.3 min in group I, 82 +/- 9.9 min in group II, and 86 +/- 12.9 min in group III. Thus, the presence of severe additional injuries did not lead to any significant delay in the diagnosis of blunt abdominal injury requiring surgery. The total mortality rate was 18.18% (group I, 11.1%; group II, 21.7%; group III, 20.0%). Six patients died in the acute phase and a further six patients during their stay on the intensive care ward.     

胆石性肠梗阻的诊治(附11例临床分析)

目的探讨胆石性肠梗阻的临床特点和治疗方法. 方法我院1985年～2000年共收治胆石性肠梗阻11例,术前仅3例确诊.均经手术治疗,其中10例行肠管切开取石,1例因肠坏死切除坏死肠段.失访2例,余9例患者一期术后6～9月行胆囊切除和(或)内瘘修补术. 结果Ⅰ期手术后并发呼吸道感染2例,切口感染1例,随访结果显示Ⅱ期手术后9例患者均获治愈. 结论胆石性肠梗阻术前确诊率低,但及时的B超及X线检查有助于其早期诊断,分期手术治疗胆石性肠梗阻效果显著.     

Examination of the role of abdominal computed tomography in the evaluation of victims of trauma with increased aspartate aminotransferase in the era of focused abdominal sonography for trauma

BACKGROUND: Current evaluation of patients with negative findings on a focused abdominal sonography for trauma scan and an isolated increase of admission hepatic enzymes includes abdominal computed tomography (CT). Many of these patients do not have clinically important hepatic injuries. The purpose of this study was to establish the admission aspartate aminotransferase (AST) level below which patients do not need an abdominal CT for injury evaluation and treatment. METHODS: Patients who were hemodynamically stable, had a focused abdominal sonography for trauma scan with negative findings, and an AST level greater than 200 IU/L were identified over a 1-year period. Medical records were reviewed for demographics, injuries sustained, mechanism, evaluation, interventions, and complications. RESULTS: A total of 67 patients, mostly with blunt trauma, were identified; 42 (63%) had an AST level < 360 IU/L, and 25 (37%) had an AST level > 360 IU/L. Patients with an AST level > 360 IU/L had a 88% chance of having any hepatic injury and a 44% chance of having an injury of grade III or greater (P =.0001). Patients with an AST level of < 360 IU/L only had a 14% chance of having a liver injury and no chance of having an injury of grade III or greater (P =.036). CONCLUSIONS: Clinically important hepatic injuries are not missed if an abdominal CT is only performed for patients with a focused abdominal sonography for trauma scan with negative findings and an AST level of > 360 IU/L. Eliminating unnecessary CT allows for more cost-effective use of resources.     

Factors associated with the resolution of postoperative ileus in newborn infants

Reliable indicators of ileus resolution following laparotomy have not been identified in newborn infants. The purpose of this study was to correlate commonly available clinical parameters with the resolution of postoperative ileus in newborn infants after abdominal procedures. The presentation, treatment, and postoperative abdominal examination of 60 consecutive newborn infants who underwent a heterogeneous group of primary abdominal operations were evaluated. No significant association was observed between the time to first bowel movement (resolution of ileus) and age, postconceptual age, weight, degree of intraabdominal contamination, duration of surgery, type of operative procedure, presence or absence of abdominal distension, and time to first bowel sounds. Opioid use was associated with a delay in the time to first bowel movement that was not accounted for by the effects of any other variable. Easily obtainable clinical parameters are not universally useful for predicting the duration of ileus in newborn infants after abdominal surgery. The use of opioids is associated with delayed resolution of ileus. Measures to limit the use of opioids may be effective in shortening the duration of postoperative ileus in newborn infants.     

The meaning of ileus. Its changing definition over three millennia

Ileus comes from the Greek word for twisted. The early classical literature suggests that this term was used for what we now call sigmoid volvulus. The Romans translated this word as volvulus. During later classical times, investigators used ileus and volvulus in describing conditions other than sigmoid volvulus. Roman investigators used ileus to describe midgut volvulus, intussusception, and incarcerated hernias because the symptoms of these conditions were similar. During the Renaissance, ileus, volvulus, and intussusception were synonymous and were closely linked to the volgar terms iliac passion and Miserere Mei. The sine qua non of ileus was the clinical triad of abdominal pain, obstipation, and fecal vomiting. Autopsies in the 16th, 17th, and 18th centuries exposed the various causes of these symptoms. Ileus became the clinical diagnosis whereas such terms as intussusception were used to describe autopsy findings. Physicians classified diseases by symptoms not by cause. During the 19th century, emphasis switched to the pathologic basis of disease. The classification of intestinal obstruction became one of cause. Ileus was abandoned because its classical definition did not encompass all forms of intestinal obstruction. In the last 50 years, ileus has been relegated to mean nonmechanical obstruction that does not initially require operative treatment. Thus, ileus which was the twisted intestine of Ascelpiades, the Miserere Mei of Paré and the iliac passion of Barrough, has come in the 20th century to mean nonmechanical intestinal obstruction.     

An acute obturation in the small intestine caused by phytobezoar in adhesive disease of the abdomen

Six cases of an acute obturation small bowel ileus observation, caused by phytobezoars, are presented. In 5 patients adhesive process in abdominal cavity was revealed after previously performed open operations. In 2 patients ileus was successfully managed using laparoscopic method--there were performed adhesiolysis, phytobezoar fragmentation, using Babcock forceps, and its conduction up to ileocaecal valve. In 2 patients, due to significant adhesive process present, which have interfered with laparoscopic adhesiolysis performance, a conversion was accomplished, adhesiolysis performed, the phytobezoar fragmentation and its conduction into the large bowel done. In one patient enterotomy was conducted, from intestinal lumen an apple was removed. An early adhesive obturaton ileus of small bowel have occurred in one patient. All the patients are alive.     

Importance of sonography in diagnosis of ileus. A retrospective study of 459 patients]

In a retrospective trial we investigated the significance of ultrasound in the diagnosis of intestinal obstruction in 459 patients. The overall sensitivity was 93.7%. In paralysis the correct diagnosis was obtained in 98% of all. Mechanical obstruction was identified in 91%. In cases of incomplete mechanical obstruction sensitivity was 89%. The corresponding value for complete obstruction was 95%. In all patients with negative findings on abdominal x-ray (10%) the correct diagnosis was established by ultrasound. Only in 71% of cases ultrasound was successful differentiating small bowel from large bowel obstruction. The underlying cause of ileus was yielded by ultrasound in 45% of the cases. On the basis of our experience ultrasound is proven to be of significant importance in the diagnosis and differentiation of ileus.     

Effects of intraabdominally insufflated carbon dioxide and elevated intraabdominal pressure on postoperative gastrointestinal transit: an experimental study in mice.

BACKGROUND/PURPOSE: Postoperative ileus after abdominal operations is thought to be related to the degree of surgical trauma, and it has been shown that the simple act of opening the peritoneum can decrease gastrointestinal motility. Accordingly, some investigators have shown a reduction in the duration of postoperative ileus after laparoscopic procedures. It is not clear, however, if this reduction is secondary to less manipulation of the viscera or to the lack of an abdominal incision. The aim of this study was to determine the effect of intraabdominal insufflation with CO2 on postoperative gastrointestinal transit. METHODS: Twenty-eight male mice weighing between 25 and 30 g were divided randomly into 4 groups: Control (unoperated), Incision (conventional laparotomy), Cecal (laparotomy plus cecal manipulation), and Insufflation (abdominal insufflation with CO2). Postoperative gastrointestinal motility was assessed by weighing total fecal output over the first 15 postoperative hours. RESULTS: Fecal pellet output over 15 hours in the untreated control group was 1.20 +/- 0.12 g. In mice subjected to peritoneal incision alone, fecal pellet output was significantly decreased to 0.82 +/- 0.11 g (P < .05). However, in mice subjected to abdominal insufflation with CO2, fecal pellet output was not significantly different from untreated controls (1.2 +/- 0.05 g; not significant). Fecal pellet output was markedly reduced by incision combined with cecal manipulation (0.24 +/- 0.02 g, P < .01). CONCLUSIONS: The current study findings show that abdominal insufflation, in a procedure similar to that used during laparoscopic surgery, had no measurable effect on gastrointestinal transit in awake mice. This suggests that the lack of an abdominal incision can contribute to a reduced postoperative ileus after abdominal surgery.     

Stellenwert der Sonographie in der postoperativen Phase

In the early period following surgery, it is very important to reveal any complications. In this article the role of ultrasound in recognizing postoperative complications is demonstrated. Ultrasound findings in typical complications of abdominal surgery such as bleeding, abscess formation, acute cholecystitis, pancreatitis, and postoperative ileus are described. The diagnosis of postoperative bleeding, acute cholecystitis, and ileus is very reliable by ultrasound (sensitivity and specificity >95%). Ultrasonography is inferior to computed tomography in detecting pancreatitis and abscess formation. The guiding of interventions by ultrasound offers additional therapeutic options.     

Jejunal perforation caused by blunt abdominal trauma in a patient with Crohn's disease: Report of a case

We report herein the case of a 23-year-old man with Crohn's disease who was found to have a perforated small bowel following blunt abdominal trauma sustained in a traffic accident. The general findings of diffuse peritonitis were identified by physical examination, and a plain X-ray film showed free air in the abdominal cavity. An emergency laparotomy was performed which revealed three perforated ulcers in the affected intestine. An abrupt increase in intraluminal pressure due to the striking force of the steering wheel to the abdomen was assumed to have been the cause of these perforations.     

Interstitial cystitis and ileus in pediatric-onset systemic lupus erythematosus

A girl aged 11 years presented with autoimmune hemolytic anemia with thrombocytopenia, and subsequently developed severe abdominal pain, vomiting, and pollakiuria. X-ray findings of her abdomen demonstrated paralytic ileus with intestinal wall thickening. Intravenous pyelography revealed bilateral hydroureter with mild hydronephrosis and contracted bladder. Pathological examination of her bladder revealed interstitial cystitis, with evidence of focal deposition of IgG and C3 in a granular pattern on small blood vessel walls. She was diagnosed as having systemic lupus erythematosus (SLE) associated with paralytic ileus and chronic interstitial cystitis. Although initiation of high-dose prednisolone therapy resulted in a gradual improvement in clinical symptoms, reducing the dosage of prednisolone caused a relapse. To our knowledge, the combination of paralytic ileus and chronic interstitial cystitis is quite uncommon in pediatric-onset SLE. Received: 1 September 1999 / Revised: 2 December 1999 / Accepted: 3 December 1999     

Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography

BACKGROUND: Although the accuracy of focused abdominal sonography for trauma (FAST) in adults has been demonstrated, results of this technique in children have been conflicting with few comparisons against computed tomography (CT), the imaging gold standard. METHODS: A total of 160 hemodynamically stable pediatric trauma victims referred for abdominal CT initially underwent rapid screening sonography looking for free fluid. Both studies were interpreted in blinded fashion. RESULTS: Forty-four of the 160 patients had an intraabdominal injury on CT, 24 (55%) of which had normal screening sonography. Fifteen of the 44 (34%) had no free fluid on either modality. Accuracy of sonography compared with CT was 76% with a negative predictive value 81%. CONCLUSIONS: Sonography for free fluid alone is not reliable to exclude blunt intraabdominal injury in hemodynamically stable children given the considerable percentage of injured patients without free fluid. J Pediatr Surg 36:565-569.