Intestinal obstruction

introduction

The intestinal obstruction (ileus) means a stop in the transport of food through the intestine, which can have various causes and lead to complications.
It is usually an acute emergency that must be followed by immediate hospital treatment. A distinction can be made between a mechanical and a paralytic ileus (bowel obstruction). The former is based on a spatial constriction of the intestinal lumen, the latter on a stoppage of bowel movement. A distinction can also be made according to the ileus location (Small intestinal ileus / large intestinal ileus) or the age of the patient (Newborn ileus / child ileus / adult ileus), as specific causes are related to age.

frequency

No figures are available on the incidence, but it is assumed that 10% of all patients who arrive at the hospital in an emergency because of severe abdominal pain suffer from an intestinal obstruction (Ileus) is present.

These can be the signs of a bowel obstruction

There are a number of different signs of an intestinal obstruction, which can appear to differing degrees in individual cases. The most common signs are severe abdominal pain that is cramp-like or permanent and usually gets worse. In addition, intestinal obstruction often leads to nausea and multiple vomiting. In extreme cases, you may even vomit feces.

While abdominal pain and vomiting can also occur with a harmless gastrointestinal infection, vomiting is a sure sign of an intestinal obstruction. Further signs can be a lack of bowel movements and when no more winds come off. It can also lead to an increase in the size of the abdomen because no more air and stool can escape from the intestine. In the course of the disease, there may be other, unspecific signs of an intestinal obstruction, such as palpitations, poor circulation, dizziness or even fainting.

Read more on this topic at: These are the signs of a bowel obstruction

This is how you can recognize a bowel obstruction yourself

Whether a person has an intestinal obstruction or not can ultimately only be determined through a medical examination. It is therefore important to call an emergency doctor or go to an emergency room in good time if you have symptoms that may indicate an intestinal obstruction.

You can tell that there may be an intestinal obstruction, among other things, when there is abdominal pain, which becomes more and more severe as the disease progresses.
In addition, nausea and vomiting often occur, with a simultaneous lack of bowel movements and no passage of diapers. With an intestinal obstruction, the abdomen often continues to expand and can feel very hard.
In the event of the symptoms described, a doctor should be alerted or consulted immediately, as treatment as quickly as possible is crucial in the case of an intestinal obstruction. It is a potentially life-threatening disease.

The doctor can usually determine whether there is actually an intestinal obstruction or a harmless cause such as a gastrointestinal infection through a physical examination and, if necessary, an X-ray of the abdomen.

Read about this too This is how you can recognize an intestinal obstruction

The causes of an intestinal obstruction

A mechanical ileus (Intestinal obstruction) is caused by a spatial obstacle to the transport of food, as can occur in a hernia (intestinal hernia), because a loop of intestine pressed into the hernial sac can be pinched off and the passage of food may be obstructed.

The same problem can also arise with twisted, kinked or twisted intestinal loops. After operations in the abdomen, a so-called briden ileus can develop, as external adhesions of the intestinal loops develop, which hinder the free movement of the intestine during its work.
Chronic inflammatory processes (Crohn's disease) can lead to adhesions within the intestine, which also lead to a mechanical handicap.

Furthermore, a tumor that constricts the intestinal lumen and originates from the intestine itself or from neighboring organs, as well as larger foreign bodies or lost large gallstones in the intestine can represent a passage obstacle.
Finally, stool that is difficult to deform or tough, such as ball of feces, meconium (Bad luck), or viscous body secretions in the context of cystic fibrosis for mechanical ileus. In the elderly, balls of feces are mainly caused by insufficient fluid intake or generally from a diet that is too high in fiber, while the meconium is the first baby chair to contain many viscous components that can sometimes cause an intestinal obstruction.

Paralytic ileus (bowel obstruction) occurs, for example, as a result of circulatory disorders such as those that occur in a mesenteric infarction. This can lead to an undersupply of the intestine in the supplying blood vessels of the intestine due to flooding or the formation of a blood clot on site (similar to a heart attack or stroke).

Various types of injury or inflammation in the abdomen can cause reflex bowel movements to stop. Possible causes are an operation, an accident with an abdominal cavity injury, (subsequent) inflammation of the abdomen and its organs, or biliary and renal colic.
Likewise, a long-standing mechanical ileus inevitably leads to a paralytic ileus due to the inflammatory reaction.

In addition, electrolyte changes (hypokalaemia), an excessively high uric acid concentration in the blood due to kidney failure (uremia), and poisoning with opiates or lead lead to paralysis of the intestinal muscles.

Read more on the subject at: Causes of an intestinal obstruction

Cancer as a cause of an intestinal obstruction

Cancer is one of many possible causes of bowel obstruction.
The intestinal tube is either obstructed due to the growth of a colon cancer ulcer from the inside, or a tumor grows in the abdominal cavity, which presses the intestine from the outside. In both cases it can ultimately lead to a complete disturbance of the passage of the bowel and thus a mechanical bowel obstruction. If cancer is the cause of an intestinal obstruction, this is often indicated by irregular stool such as alternation from constipation and diarrhea. Cancer is rarely the cause of a sudden and unsuspected bowel obstruction.

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Adhesions

Adhesions are one of the most common causes of a so-called mechanical bowel obstruction.
A previous operation in the abdominal cavity, which can be decades ago, can lead to adhesions. These can lead to a narrowing and ultimately to the closure of the intestinal tube from the outside. In such a case, surgical removal of the causal adhesions as quickly as possible and the associated restoration of the intestinal passage are decisive. In younger and otherwise healthy patients, this can often lead to healing without consequences. In patients who are already seriously ill or old, or if the operation is too late, an intestinal obstruction caused by adhesions can be fatal.

Further information on this topic can be found at: Adhesions in the abdomen

Can you get a bowel obstruction from constipation?

In extreme cases, constipation can lead to an intestinal obstruction.
As the faeces in the intestine thicken more and more, a backlog occurs, against which the intestine presses unsuccessfully, which is usually expressed in colic-like abdominal pain as well as nausea and vomiting (possibly also vomiting of faeces). In such a case, a doctor must be consulted urgently. Constipation alone, however, is a very common symptom with which there is only very rarely an intestinal obstruction and which can initially be treated with sufficient fluid intake, fiber-rich diet and physical exercise.

Also read:

• Home remedies for constipation
• Constipation- what to do

Can you get a bowel obstruction from laxatives?

The ingestion and especially the abuse of laxatives can trigger an intestinal obstruction or promote its development.
The drugs cause, among other things, a loss of salts such as potassium. A potassium deficiency can paralyze the intestinal muscles and thus lead to intestinal obstruction. Laxatives should therefore only be taken as directed and prescribed by a doctor. Previously, non-drug measures such as drinking enough, fiber-rich diet and physical activity should be exhausted.

More on this: Lactulose

Symptoms of an intestinal obstruction

The acute intestinal obstruction (ileus) shows itself initially as an "acute abdomen" with the unspecific symptoms of rapid onset, severe abdominal pain, a board-tight, sometimes also bloated abdominal wall, nausea and vomiting, possibly also fever and circulatory shock.
If there are high intestinal occlusions in the upper intestine, vomiting of bile can also occur. Due to the postponed further transport of the food, the vomit can be accompanied by thickened food from deeper intestinal sections. Discharge of stool and wind come to a standstill, which may have started in the few days before the main symptoms appeared and should be inquired about in retrospect.
In addition, changes in bowel noises can be seen when listening with a stethoscope: The mechanical ileus (Intestinal obstruction) creates a jet-like noise due to its bottleneck, which is often described as water dripping onto a tin roof. The paralytic ileus is characterized by the fact that nothing at all, i.e. not even the usual intestinal noise, can be heard. If the intestinal obstruction is not treated quickly enough, a breakdown of the intestinal barrier or a rupture of the inflamed intestine can lead to colonization of the abdominal cavity with intestinal germs (peritonitis), which leads to a septic shock and which is fatal with subsequent multi-organ failure.
A creeping start with a preceding, incomplete ileus (subileus) is also possible.

Read more on the topic: Symptoms of an intestinal obstruction

Diarrhea as a symptom of intestinal obstruction

In most cases, an intestinal obstruction is not indicated by the occurrence of diarrhea.
In most cases, the slow occlusion of the intestinal tube leads to a decrease in stool frequency, which ultimately leads to constipation. However, if bloody diarrhea occurs with the corresponding symptoms of an intestinal obstruction, a specialist should be consulted immediately. This phenomenon is a potentially life-threatening emergency situation. Depending on the underlying disease, the intestinal obstruction must be treated surgically. This is especially the case if peritonitis develops or there is a risk of the intestinal wall breaking through.
Depending on the extent of the intestinal obstruction, the affected parts of the intestine must be completely removed during the surgical procedure. However, this therapeutic measure can impair the passage of the chyme and the absorption of certain food components. In addition, depending on the length of the intestinal parts removed, the reabsorption of water from the intestinal lumen can be restricted in the long term. For this reason, the affected patients suffer from recurrent diarrhea after the operation (sometimes for life). Strict regulation of daily fluid intake can help reduce the risk of diarrhea. Partial resections of the large intestine in particular cause long-term diarrhea in many of the affected patients, which is very difficult to treat.

Read more on the topic: Causes of diarrhea

Is there also an intestinal obstruction without pain?

Abdominal pain is typical of a bowel obstruction and almost always occurs. However, a slowly developing intestinal obstruction that does not cause pain cannot be ruled out.
Especially in old or seriously ill, bedridden patients, an intestinal obstruction can creep in without pain being expressed. However, at least other symptoms then occur, such as vomiting, absent bowel movements and a significant increase in the size of the abdomen.

diagnosis

The suspicion of an intestinal obstruction arises initially due to the main symptoms mentioned above.
In order to further differentiate from possible other diseases with a similar appearance, the above-mentioned listening of the abdominal cavity takes place first (Auscultation). A blood sample generally clarifies an inflammatory reaction in the body or some possible causes and other consequences (Hypokalemia, uremia, hyonatremia). Ultrasound can be used to first narrow down the cause of the disease by observing the occlusion itself and its cause, or typical movement phenomena of the intestine and its filling state, while an x-ray of the abdomen can reveal the phenomenon of fluid levels, which is typical for the ileus situation. Ultimately, computed tomography offers the possibility of a spatial representation of the intestine and the visualization of the obstruction, while many of the above-mentioned methods lead to the suspected diagnosis of intestinal obstruction due to the combination of symptoms and the associated, less technical examination procedures, which, however, due to their explosive nature, also lead to the indication for surgery pulls.

You may also be interested in this topic: Levels of inflammation in the blood

therapy

The main therapeutic options are the operation, which is usually carried out quickly due to the potential life-threatening nature of the clinical picture, especially if the risk of a rupture of the intestinal wall or an already existing peritonitis is expected.
During the operation, invaginations of the intestine, adhesions or any tumors that were responsible for the ileus are removed. It may be necessary to open the intestine and remove the stuck stool, or already undersupplied and dying intestinal sections. In the latter, severe case, it sometimes happens that an artificial anus has to be created for a period of a few months until the two interrupted intestinal ends come together.
Is an infection of the abdominal cavity (Peritonitis) has already taken place, the abdominal cavity is rinsed with antibiotics, which may be necessary again a few days later. To avoid subsequent blood poisoning (sepsisantibiotics are also given intravenously during and after surgery. In other treatment measures, a nasogastric tube is placed in order to relieve the ileus situation and to prevent the patient from vomiting. Infusions can be used to compensate for electrolyte and water imbalances and medication to normalize intestinal activity or to combat nausea and pain can be given.

Read more about this: Treatment of a bowel obstruction

The operation for an intestinal obstruction

Depending on the cause, the intestinal obstruction must be treated surgically. This procedure is performed under general anesthesia. Basically, only the mechanical intestinal obstruction is usually operated on so that normal intestinal passage can be restored at an early stage (emergency!). Paralytic intestinal obstruction is usually first treated with medication that is supposed to stimulate the natural bowel movement again. An incomplete intestinal obstruction (subileus) usually does not require an operation.

During the operation of the mechanical bowel obstruction (so-called bowel decompression), the exact cause is first determined. If these are adhesions in the abdomen, these are loosened. If the intestine has just twisted or otherwise pinched, it is brought back into the correct position.If the intestinal obstruction is caused by hardened intestinal contents, it may be necessary to cut open the intestine and suck out the corresponding contents.

In some cases, however, there is also a constriction in a certain section of the intestine that cannot be resolved by simply relocating the intestine or by suction, for example in the event of a tumor. In this case, this part must be cut out (see also: Removing the large intestine). The two free ends of the intestine are then sewn together again after the diseased part has been removed so that digestion can take place normally again. When removing parts of the intestine, it may be necessary to temporarily place an artificial anus, which can usually be moved back after a few months. An antibiotic will be given to prevent infection during the procedure.

Since some people suffer from intestinal obstruction several times, this can be prevented by over-sewing the attachment of the intestinal loops in the abdominal cavity (so-called Childs-Philipps operation). The intestinal loops are pulled together like an accordion. The risk is that large vessels in the area are injured. This method does not always prevent a further bowel obstruction; in 20% of the cases another occurs.

Another preventive measure to prevent further bowel obstruction is inserting a small bowel probe after the operation. This so-called Dennis probe fixes the small intestine in its correct position for about a week. As a result, the intestine cannot kink and grow together in its optimal position with the abdominal wall and its surroundings. The risk of a new bowel obstruction after this procedure is about 10%.

Please also read: Everything you need to know about the operation of an intestinal obstruction

How long are you in the hospital after an operation with an intestinal obstruction?

Since an intestinal obstruction can have very different causes, requires a different extent of surgery and can either take a favorable or a complicated healing process, no general statement can be made about how long one has to stay in hospital after an operation.

However, one week is usually the minimum time that you have to spend in hospital. In some cases, after a complex operation, a stay in the intensive care unit is necessary, so that you have to stay in the hospital for several weeks. Complications such as wound healing disorders can also occur after an operation, which can then also extend the length of stay in the hospital.

How long does it take to heal a bowel obstruction?

How long the healing time after an intestinal obstruction can be very different. A younger person with few previous illnesses has a better chance of recovering quickly than an older or already seriously ill patient. The duration of healing also depends on the cause and the measures taken. With a paralyzed intestinal wall as the cause of the obstruction, which can be remedied promptly, the healing time is often only a few weeks. However, when a serious operation became necessary, in which sections of the intestine had to be removed and an artificial anus had to be placed, a healing period of many months is not uncommon.

prophylaxis

Usually one overtakes Intestinal obstruction no core healthy, which is why responsible Risk factors (Age, tumor, hernia, fiber-rich diet, little fluid intake, chronic bowel disease, previous operations, cystic fibrosis, medication, etc.) only whose reduction or treatment is in the foreground, if they are already known.

forecast

The death rate from intestinal obstruction (Ileus) is given as 10-25% and is strongly dependent on the time between its start and the initiation of a corresponding treatment. If this is started quickly, the prognosis for survival is good, however, renewed occlusions are to be expected, since not all triggering factors can always be completely eliminated and the ileus of the bridle in particular tends to recur.

The long-term consequences of an intestinal obstruction can be very different and depend primarily on how quickly the obstruction was recognized and treated, which therapy was required (surgery or just medication) and the general state of health of the patient before the disease. For example, an intestinal obstruction caused by medication can often be cured without long-term consequences if measures are initiated in good time. However, when surgery is necessary, part of the bowel often has to be removed and lifelong indigestion can result. In some cases an artificial anus must be created. This can often be moved back over time, but in some cases it must remain.

Read more on the subject at: Artificial anus

Intestinal obstruction in the baby

In small children up to the age of three, but usually within the first year of life, the invagination of part of the intestine (so-called intussusception) can also lead to an intestinal obstruction. Boys are affected almost twice as often as girls. In most cases, the cause is unknown and the children are healthy and normal until then. Possible causes are, for example, the swallowing of foreign bodies or previous virus infections. Affected children suffer from wavy abdominal pain, bloated stomach, vomiting, diarrhea and paleness. You cry a lot, appear anxious and tense. In some children, there is also a bloody mucus discharge from the intestines. It is typical that the pain colicky occur and there are painless intervals of a few minutes between episodes. The children often pull their legs up because of the severe pain.

Such an intestinal obstruction must be resolved as soon as possible. A hard roller can often be felt in the lower abdomen in children. The doctor can also take an X-ray or ultrasound. Sometimes the invagination can be resolved with a bowel massage or an enema, but in some cases it occurs again. If these methods do not resolve the intestinal obstruction, the child must be operated on. Ideally, this should be done within 48 hours of the onset of symptoms. As in adults, the bowel is brought back into its correct position. After the procedure, the child must first be monitored in the intensive care unit. During this time, it is nourished by infusions until the intestine has fully recovered and can resume its function. The intestinal obstruction usually heals without complications.

As a preventive measure, parents should ensure that their child is drinking enough fluids, as well as getting enough exercise and eating a balanced diet. In addition, small parts that could be swallowed should be kept away from the child's surroundings.

Read more on the topic: Intestinal obstruction in the baby

Intestinal obstruction in toddlers

An intestinal obstruction in a toddler usually has different causes than in an adult. By far the most common reason for the development of an intestinal obstruction in small children is the so-called "Intussusception". The term "intussusception" describes the invagination of a section of the intestine into a part of the intestinal tube located higher within the gastrointestinal tract. The cause of intestinal obstruction due to intussusception is in most cases unknown. As a result of the intestinal obstruction, the affected small child restricts the passage of the food. An intestinal obstruction caused by intussusception mainly affects small children under the age of three. The majority of cases are observed even in children who are not older than one year.

The symptoms of intestinal obstruction in small children do not differ in principle from the symptoms of adults. The typical symptoms of an intestinal obstruction in toddlers include violent, rippling abdominal pain and vomiting. As a rule, the affected toddler tends to keep his legs in a relaxed position. At the onset of the disease, the toddler has severe diarrhea, which, however, is relieved by pronounced constipation as the disease progresses. Infants affected by intestinal obstruction through intussusception look noticeably ill in most cases. The clear discoloration of the skin color (pale, gray) and the strong perspiration are particularly striking. In the case of intestinal obstruction caused by intussusception, bloody or slimy stools pass very late. An affected toddler typically screams or cries from the severe pain. Most children do not allow themselves to be reassured with such an intestinal obstruction.

If the presence of an intestinal obstruction is suspected, the toddler should be presented to a pediatrician (pediatrician) immediately. In order to check the suspicion, he will extensively examine the abdomen of the toddler. An intestinal obstruction due to intussusception can in most cases already be felt from the outside. In addition, performing an ultrasound examination (sonography) can help diagnose "Intestinal obstruction due to intussusception“To secure. If the ultrasound findings are unclear, imaging can also be done by taking an X-ray of the abdomen.

In the early stages, the intestinal obstruction in small children can often be resolved by an enema and / or targeted massage of the abdomen. If this does not succeed within a very short time or if an intestinal obstruction occurs again despite successful treatment, surgical therapy must be initiated. During a surgical procedure under general anesthesia, the attending physician exposes the everted bowel and relocates the individual sections to their original position.

Intestinal obstruction in the infant

Even in babies, intestinal obstruction is usually triggered by intussusception. Both the typical symptoms and the treatment are the same as those in toddlers. Another common cause of intestinal obstruction in infants is the so-called "Meconium ileus“(Ileus corresponds to the technical term for intestinal obstruction). The term "meconium" means the counting, sticky fetal stool. In this infant disease, bowel obstruction is caused directly by this sticky stool.

In most cases (over 90 percent of known cases), the intestinal obstruction is associated with cystic fibrosis (synonym: cystic fibrosis). In the context of this hereditary clinical picture, there is a loss of function of a certain chloride channel (CFTR). As a result of this loss of function, highly viscous, tough mucus is formed in the gastrointestinal tract. The secretion of pancreatic enzymes is also restricted in the context of cystic fibrosis. In the affected infants, tough secretions are secreted and the food components are broken down inadequately. The consequence is often the sticking of the intestinal lumen and the development of an intestinal obstruction. An infant suspected of having an intestinal obstruction should be examined by a pediatrician immediately. Signs of cystic fibrosis can usually be seen quickly during a clinical examination. Especially the so-called "Chloride sweat test“Plays a crucial role in the diagnosis of intestinal obstruction in infants. Imaging procedures in the form of x-ray images of the abdomen (empty abdomen) show in most cases granulated intestinal loops that are expanded like blisters. In technical terms, this phenomenon is called "Neuhauser sign". In the case of a positive result that confirms the presence of an intestinal obstruction in the infant, appropriate therapy should be initiated immediately. As a rule, the treating specialist begins with a gastrografin enema performed under fluoroscopy. In this way, the meconium can possibly be promoted. In most infants, this method must be repeated several times to fully restore the intestinal passage. If complications arise during this first attempt at therapy, the affected infant must be treated surgically as soon as possible.

The prognosis of this form of intestinal obstruction in infants is very good with prompt diagnosis and rapid initiation of therapy. However, if the intestinal obstruction is based on cystic fibrosis, there are no chances of a cure despite good treatment options. The intestinal obstruction can be corrected, but the underlying disease cannot be cured.

Why are intestinal obstruction more common in older people?

There are several reasons why bowel obstruction is more common in older people than in younger people.
This is mainly due to the fact that the various causes of an intestinal obstruction appear more frequently with increasing age. In addition to adhesions, abdominal wall fractures are also more likely in old people. These are one of the most common causes of intestinal obstruction. In addition, older people are usually more likely to take medication that can promote the occurrence of an intestinal obstruction, such as certain pain relievers.

In addition, older people often exercise less and drink less, which also contributes to poorer intestinal passage and thus increases the risk of suffering an intestinal obstruction. In addition, long-term consequences of certain chronic diseases can trigger or promote the occurrence of an intestinal obstruction, such as diabetes (“diabetes”). These long-term effects occur more frequently with increasing age and also increase the risk of an intestinal obstruction. Likewise, the risk of intestinal infarction increases with age due to increasing calcification of the blood vessels and cardiac arrhythmias, which can also be a possible cause of an intestinal obstruction.

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history

Ileus (Intestinal obstruction) comes from gr. 'Eleios', the place where a snake has curled up, which pictorially did and will do justice to the patient writhing in pain. So described Hippocrates about 400 years before Christ the manifestation of illness. Circa 350 BC is through Praxagoras, a doctor in the tradition of Hippocrates ’even one Ileus surgery described.