Ileus and Bowel Obstruction

Frank A. Sinicrope, MD, FACP.

Ileus, obstipation, and bowel obstruction are encountered frequently in the

cancer patient. Intestinal obstruction refers to the interference of the normal
passage of luminal contents through the gastrointestinal tract, caused by an
intraluminal process or by extrinsic compression. The obstruction can be
partial or complete. Ileus is a failure of normal intestinal motility in the
absence of mechanical obstruction. Toxic megacolon is a type of ileus that
can occur in patients with ulcerative colitis and in which there is transmural
inflammation and colonic dilatation. Obstipation refers to acute abdominal
pain, the ability to pass flatus, but with cessation of bowel movements.
Obstipation is associated with both mechanical obstruction and functional
ileus. The term strangulated obstruction is used if the blood supply of the
involved bowel is compromised. Idiopathic dilatation of the colon in the
absence of mechanical obstruction is referred to as acute colonic
pseudoobstruction or Ogilvie syndrome.
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Clinical Manifestations
Whenever a patient presents with abdominal pain, vomiting, abdominal
distention, and obstipation, intestinal obstruction is the first diagnostic
consideration. A detailed history is a key element in pinpointing the site of
obstruction. It is also important to ascertain the duration of symptoms to
distinguish acute from chronic conditions. A history of previous abdominal
surgery, previous episodes of obstruction, inflammatory bowel disease,
herniation in the abdominal wall or previous incisions, prior abdominal or
pelvic radiation, or previous cancers provide important clues as to cause of
obstruction. A careful medication review that includes narcotic history is
important in discovering the underlying cause of ileus. The clinical features
of ileus or bowel obstruction are dependent on the site of involved intestine.
Proximal obstructions (gastric outlet, duodenum) are associated with
persistent and copious vomiting, modest abdominal pain, and minimal
abdominal distention. Distal small-bowel obstruction is associated with
vomiting that can be malodorous, significant abdominal distention, and pain.
Vomiting is uncommon in colonic obstruction, but pain and distention are
pronounced. The competency of the ileocecal valve is important in the
pathophysiology of colonic obstruction because a competent value precludes
decompression of fluid and gas into the small bowel, resulting in a closed-
loop obstruction. Cecal diameters ≥ 13 cm carry a risk of perforation,
particularly when the obstruction is relatively acute in onset. Ileus is thought
to result from an imbalance between sympathetic and parasympathetic motor
activity, resulting in intestinal atony. In cases of ileus, vomiting is usually
infrequent; pain is mild, and distention is moderate to severe. Typically, the
pain in small-bowel obstruction is crampy, with paroxysms occurring at 4- to
5-min intervals for proximal obstruction and less frequently for more distal
obstruction. The development of continuous, localized, and intense pain
suggests the possibility of strangulated obstruction.
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Etiology
While there are many causes of small-bowel obstruction, the three most
common etiologies are adhesions resulting from prior abdominal surgery,
hernias, and neoplasms, especially malignancy. Obstruction may occur
anytime after the initial abdominal surgery, but the average interval between
the initial operation and development of adhesive obstruction reported in one
study was 6 years.84 Hernias are the second leading cause of obstruction.
Neoplasms cause obstruction of the small intestine as well as the colon.
Malignant etiology should be one's first impression in a large-bowel
obstruction. Obstruction can be caused by primary tumors or by metastatic
cancer, including metastases to the mesentery, serosa of the intestine, or
peritoneal carcinomatosis. In contrast to mechanical obstruction, the cause of
ileus or pseudoobstruction is usually occult and multifactorial. In cancer
patients, the most common causes include opioid use, electrolyte imbalance,
certain chemotherapeutic agents (such as vincristine), and metabolic
disturbances.
Vincristine treatment is associated with adynamic ileus and has been
implicated in some cases of cecal perforation.85Although the etiology of
vincristine-induced ileus is unknown, improvement has been reported with
the use of metoclopramide.86 Cisapride may also be beneficial in that this
agent improves motility throughout the intestinal tract whereas
metoclopramide's effect is limited to the upper GI tract. Patients with
vincristine-induced ileus often have obstipation, and aggressive use of
cathartics may be needed.
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Diagnosis
Inspection of the abdomen may reveal distention, previous surgical scars,
hernias, or masses. The degree of distention varies depending on the level of
obstruction. Distention is marked in distal small-bowel obstruction and long-
standing colonic obstruction. In cases of ileus, the degree of distention is
quite variable. Palpation of the abdomen may reveal areas of marked
tenderness, rebound guarding, or rigidity, indicating a strangulated hernia or a
localized perforation requiring immediate surgical attention. Auscultation of
the abdomen may reveal periods of increasing bowel sounds with periods of
relative quiet. With obstruction, the bowel sounds are usually high-pitched or
musical. In cases of prolonged obstruction and ileus, bowel sounds may
disappear as a consequence of decreased motility. Laboratory studies are
useful in the diagnosis of ileus or pseudoobstruction which can be caused by
an electrolyte imbalance. Metabolic abnormalities and electrolyte
derangements are commonly associated with, and are a consequence of,
prolonged intestinal obstruction.
Abdominal radiography is extremely helpful in confirming the diagnosis of
obstruction, differentiating ileus from obstruction, and localizing the level of
obstruction. A complete abdominal series that includes an upright chest film,
an upright and supine abdominal film, and a lateral decubitus abdominal film
should be obtained. Patients with a complete small-bowel obstruction
generally have dilated intestinal loops proximal to the obstruction and no gas
in the colon or rectum. Abdominal radiography may also show multiple air-
fluid levels with distended loops of bowel. The rectum will be devoid of any
gas in cases of colonic obstruction, but the proximal colon may or may not
have gas. Abdominal radiography may also show free air, indicating
perforation, or air in the intestinal wall, indicating pneumatosis or bowel
ischemia. Approximately 20% to 30% of patients with small-bowel
obstruction produce equivocal or normal abdominal radiographs.87,88 In cases
of ileus, gas is generally present throughout the intestinal tract, including the
rectum, but it is sometimes difficult to distinguish obstruction from ileus on
the basis of abdominal plain radiography alone.
Contrast studies are helpful in differentiating between obstruction and ileus,
identifying the site of obstruction, and differentiating between partial and
complete obstruction. If colonic obstruction has been ruled out or is deemed
very unlikely, barium sulfate can be given orally for an antegrade contrast
study since net secretion in the intestinal lumen keeps the barium in solution.
Water-soluble contrast agents such as diatrizoate meglumine (Gastrografin)
usually get diluted (because of the large amount of fluid present within the
obstructed bowel) and prevent the definition of distal obstruction. If colonic
obstruction is suspected, a Gastrografin or barium enema should be done as
the first test. Care is taken to avoid getting a large amount of barium above
the obstruction, which can become inspissated due to net absorption of fluid
in the colon, and which can be removed only at the time of operation.
Computed tomography is an excellent test in patients with suspected or
known malignancy and in identifying recurrence, inflammatory mass, and
extrinsic obstruction by masses. The demonstration of a transition zone with
dilated fluid-, air-, or air-fluid-filled loops above collapsed loops of bowel
distally suggests the presence of small-bowel obstruction. CT is very
sensitive (90%) for high-grade obstruction, but sensitivity is low (50%) for
low-grade obstruction.89 Computed tomography also detects air in the bowel
wall or in the peritoneal cavity in cases of perforation.
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Treatment
The most important principle for the treatment of ileus is to treat the
underlying cause. Other important steps to take are (1) limiting oral intake;
(2) maintaining intravascular volume; (3) correcting electrolyte
abnormalities, especially hypokalemia; (4) stopping the administration of the
offending drugs, if possible; (5) using nasogastric suction; (6) decompressing
the rectum with a tube; and (7) frequently changing the position of the
patient. These conservative measures are successful in the majority (85%) of
patients in a mean of 3 days.90 In patients with bowel obstruction, a Foley
catheter is suggested to measure intake and output and also to assess the
immediate effects of fluid resuscitation on urine output. A nasogastric tube
should be placed to decompress the stomach and intestine and to avoid
further abdominal distention. A surgical consultation should be obtained to
determine whether operative treatment or expectant management should be
employed. This decision depends on the patient's clinical condition and
underlying pathology, the degree of obstruction, the rapidity with which the
obstruction developed, the presence of strangulation or perforation, and any
signs of peritonitis. Intravenous antibiotics covering gram-negative and
anaerobic bacteria should be started in cases of suspected inflammatory mass
or perforation. A cautious endoscopy may be attempted in cases of distal
obstructions that require further diagnostic evaluation or in cases of
pseudoobstruction with a very dilated bowel segment, for placement of a
decompression tube. In some patients with unresectable solid malignancy,
intestinal bypass procedures can be performed for palliation and to improve
the quality of their remaining life. Alternatively, decompressive gastrostomy
tube placement can be used for palliation of patients with multiple sites of
malignant small intestinal obstruction, and in some cases, for peritoneal
carcinomatosis. Recently, the use of self-expanding metal stents for acute
colonic obstruction before elective surgery has been reported as having a high
success rate. The mean time between stent placement and surgery was 8.6
days.91
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