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Infiltrating blood-derived macrophages are vital cells playing an anti-inflammatory role in recovery from spinal cord injury in mice. PLoS Med. During this procedure, a tube is inserted into your nasal cavity to reach your stomach. The tube suctions out the extra air and material that you may otherwise vomit. Most surgery-related ileus will resolve within 2 to 4 days after surgery.
However, some people do require surgery if the condition does not improve. Your intestines are very long, so you can live without a portion of them. While it may affect the digestive process, most people do live a healthy life with part of their intestine removed. In some instances, your doctor may have to remove your entire intestine. In this case, your doctor will create a special pouch called an ostomy. This bag allows stool to drain from your remaining gastrointestinal tract.
Your doctor will usually first listen to a description of your symptoms. Your doctor may then conduct a physical exam, looking at your abdomen for signs of swelling or tightness. Your doctor will also listen with a stethoscope to your abdomen for typical bowel sounds. Imaging studies are usually ordered after a thorough physical exam. These can indicate where an ileus is located by showing a buildup of gas, an enlarged intestine, or even an obstruction.
Your doctor may use these to identify areas where your bowel content seems to be concentrated. In some instances, your doctor may use a diagnostic procedure known as an air or barium enema. During this procedure, the doctor inserts air or barium sulfate, a radiopaque substance, through your rectum into your colon.
While the doctor does this, a technician takes X-rays of your abdomen. The air or barium shows up on the X-ray to help the technician view any potential obstruction.
According to research, ileus is the second most common reason for hospital readmission in the first 30 days after surgery. Surgical procedures on the abdomen that involve handling the intestines commonly cause a stoppage of intestinal movement for a period of time. This allows the surgeon to access your intestines. Sometimes normal peristalsis can be slow to return. Other people are more likely to later experience scar tissue formation that can also lead to an ileus.
Aging also naturally slows down how fast the intestines move. An older adult is at greater risk for ileus, especially since they tend to take more medications that could potentially slow the movement of material through the intestines.
However, some conditions may cause a physical blockage, or mechanical obstruction, of the intestines. Necrosis is the untimely death of cells or tissue. It can happen when an obstruction cuts off the blood supply to the intestine. Without blood, oxygen cannot get to the tissue, causing it to die. Dead tissue weakens the intestinal wall, making it easy for the intestine to tear and leak bowel contents.
This is known as a bowel perforation. A bowel perforation due to necrosis can cause peritonitis. This is a serious inflammation in the abdominal cavity caused by bacteria or fungus. Your bowel contains many bacteria, like E. The bacteria are supposed to remain in your intestines, not roam free in your body cavity. Bacterial peritonitis can turn into sepsis , a life threatening condition that can result in shock and organ failure.
Most of the risk factors associated with an ileus, such as injury or chronic illness, are not preventable. However, it should not keep you from having needed surgery. Many clinicians use laxatives as a treatment for paralytic postoperative ileus. No randomized trials evaluating the role of these agents in paralytic postoperative ileus have been conducted, to our knowledge.
Conducting a MEDLINE database search for the key words "laxatives" and "postoperative ileus," only 1 nonrandomized, unblinded trial was found. This trial consisted of 20 patients who underwent radical hysterectomy and were postoperatively treated with 30 mL of milk of magnesia by mouth twice daily and biscolic suppositories every day. This study should be followed by a randomized, prospective, double-blind, controlled study to determine the benefit, if any, of using laxatives. Prostaglandins are known to affect bowel motility.
The mechanism of prostaglandin E 2 and prostaglandin F 2 , although not entirely clear, seems to be the stimulation of acetylcholine release from myenteric plexus neurons. Sympathetic inhibitory input is thought to play a role in the pathogenesis of postoperative ileus. These studies did not demonstrate resolution of postoperative ileus.
Studies , using edrophonium chloride and bethanechol chloride have reported improvement in postoperative ileus in humans, but the adverse effects of these agents limit their use. Acetylcholine is released from the enteric nervous system and causes increased gut wall contractility. Neostigmine is a reversible inhibitor of acetylcholinesterase and as such has been investigated as a potential treatment for postoperative ileus.
Kreis et al recently found that neostigmine therapy significantly increased colonic motility in the early postoperative period in patients undergoing colorectal surgery. These results are encouraging, but the "early postoperative period" is most likely a physiologic ileus, and experiments to determine the effect of neostigmine use on paralytic ileus should be performed.
Metoclopramide hydrochloride is a prokinetic agent that acts as a cholinergic agonist and a dopamine antagonist. At least 6 controlled clinical trials - have investigated the effect of metoclopramide therapy on patients undergoing abdominal surgical procedures.
Although the end points used in the studies differed, none of them had a significant benefit in the treatment of postoperative ileus. Erythromycin is a carbon antibiotic belonging to the macrolide family. The gastrointestinal adverse effects induced by this antibiotic include abdominal cramping, nausea, vomiting, and diarrhea. Erythromycin is a motilin receptor agonist that binds to gastrointestinal smooth-muscle membrane receptors, displacing the endogenous ligand motilin.
Erythromycin therapy did not resolve postoperative ileus in patients who underwent abdominal surgery in the prospective, randomized clinical trials conducted.
Cisapride is a serotonin agonist that facilitates acetylcholine release from the intrinsic plexus. At least 9 randomized clinical trials - have been performed on patients treated with cisapride for postoperative ileus after undergoing various surgical procedures.
However, comparison of these studies is difficult because various end points were used, patients underwent different surgical procedures, and the doses, durations, and routes were variable. In 4 studies, - there was a statistically significant reduction in postoperative ileus. Although these results are encouraging, just as many studies , , reported no statistically significant effects. The questions regarding the effectiveness of cisapride will remain as it has been removed from the market for deleterious side effects.
Ceruletide is a synthetic peptide that may enhance gastrointestinal motility by acting as a cholecystokinin antagonist. Further investigation is needed before clinical use can be recommended. Octreotide is an analogue of somatostatin that is known to inhibit the secretion of many gastrointestinal hormones. Cullen et al showed that octreotide therapy shortens the duration of ileus in the small intestine and colon of dogs.
However, clinical studies are needed to prove its efficacy in humans. Gum chewing may be a simple but effective treatment for postoperative ileus.
Asao et al conducted a randomized, prospective, controlled study on gum chewing as a method to stimulate bowel motility after laparoscopic colectomy for colorectal cancer. The patients chewed gum 3 times a day starting postoperative day 1 until oral intake. The passage of first flatus was on average 1. The first defecation also was significantly earlier in the gum-chewing patients postoperative day 3. However, the length of hospital stay was not significantly different between the 2 groups The authors hypothesize that the aid in recovery from postoperative ileus achieved by gum chewing may be related to the effects of sham feeding.
Sham feeding causes vagal cholinergic stimulation of the gastrointestinal tract and elicits the release of gastrin, pancreatic polypeptide, and neurotensin, all of which affect gastrointestinal motility. Lobo et al wanted to determine the effect of water and salt balance on the recovery of gastrointestinal transit in patients undergoing colonic resection for colon cancer. The primary end points of the study included solid- and liquid-phase gastric emptying as measured by isotope radionuclide scintigraph on the fourth postoperative day, with first flatus and bowel movement serving as secondary end points.
The results demonstrated significantly longer solid and liquid gastric emptying for the standard group vs the restricted fluid group solid: vs 72 minutes; liquid: vs 73 minutes.
Patients receiving restricted fluids passed first flatus 1 day earlier, had the first bowel movement 2. The authors concluded that a positive salt and water balance significant enough to add 3 kg of body weight after colonic resection delays gastrointestinal transit and prolongs hospital stay.
Of all the treatments available Table 2 , which is best? The best treatment currently available is a multimodal regimen. Basse et al examined a multimodal rehabilitation regimen for the treatment of postoperative ileus consisting of continuous epidural analgesia, early oral nutrition and mobilization, and cisapride and laxative treatment with magnesia.
Using this regimen, the authors observed normalization of gastrointestinal transit time within 48 hours of colonic resection compared with matched controls. Gastrointestinal transit time was assessed by an indium In pentetate scintigraphic method. The relative contribution of each modality is unknown. This particular approach is less than ideal, given that cisapride is no longer available.
Also, ambulation has not been shown to improve postoperative bowel motility, although it is beneficial to patients for other reasons. Another study supporting the multimodal approach was conducted on patients undergoing segmental colectomy. The authors used a regimen that included thoracic epidural anesthesia for 48 hours, omission of a nasogastric tube, 1 L of fluid orally on the day of surgery, mobilization within 8 hours of surgery, use of milk of magnesia, and an alteration in the incision curved or transverse to minimize pain and pulmonary dysfunction.
Ninety-five of patients evaluated defecated in 48 to 72 hours. Paralytic postoperative ileus continues to be a significant clinical problem. The etiology of this process can best be described as multifactorial. These factors act simultaneously or at various times during the development of postoperative ileus. The mechanisms involved in paralytic postoperative ileus include inhibitory sympathetic input; release of hormones, neurotransmitters, and other mediators; an inflammatory reaction; and the effects of analgesics.
Experimental studies continue to elucidate the roles and mechanisms of action of all of these factors. Numerous methods have been used in an attempt to alleviate postoperative ileus in the clinical setting, without much success. At this time, it is best to recommend an approach that will decrease factors contributing to paralytic postoperative ileus. This approach would include limiting the administration of narcotics and using alternative analgesics such as nonsteroidal anti-inflammatory drugs and placing a thoracic epidural with local anesthetics when possible.
Selective use of nasogastric decompression and the correction of electrolyte imbalances are also important in the multimodal approach to the treatment of paralytic postoperative ileus. Ongoing research can have a positive impact in areas such as selective opioid antagonist, laparoscopic surgery, and the manipulation of local factors, neurotransmitters, and stress hormones.
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