Intestinal Obstruction

The intestinal obstruction (ileus) means stopping the transport of food through the intestine, which can have various causes and can lead to complications.

It is usually an acute emergency that must be followed by immediate hospital treatment. One can differentiate between a mechanical and a paralytic ileus (intestinal obstruction). The former is based on a spatial narrowing of the intestinal lumen, the latter on the basis of a bowel movement. A distinction can also be made according to the ileus localization (small intestine / large intestine) or the age of the patient (newborn ileus / child ileus / adult ileus), since age causes specific causes.

There are no figures on the incidence, but it is assumed that 10% of all patients who reach the hospital in an emergency because of severe abdominal pain have an intestinal obstruction (ileus).

There are a variety of different signs of an intestinal obstruction, which can occur in individual cases with different degrees of severity. The most common signs are severe abdominal pain, which is cramping or persistent and usually gets worse. In addition, bowel obstruction often causes nausea and repeated vomiting. In extreme cases, feces can even vomit.

While abdominal pain and vomiting can also occur with a harmless gastrointestinal infection, vomiting is a sure sign of an intestinal obstruction. Other signs can be a lack of bowel movements and when there are no more winds. There may also be an increase in the size of the abdomen because no air or stool can escape from the intestine. Other unspecific signs of an intestinal obstruction, such as rapid heartbeat, poor circulation, dizziness or even fainting, may occur in the course of the process.

So you can see a bowel obstruction yourself

Ultimately, it can usually only be determined by a medical examination whether a person has an intestinal obstruction or not. It is therefore important to call an emergency doctor or to go to an emergency department in good time for complaints that may indicate an intestinal obstruction.

You can tell that an intestinal obstruction might be present, among other things, if there is abdominal pain, which becomes increasingly severe in the course.

In addition, nausea and vomiting often occur, with a lack of bowel movements and a lack of winds. With an intestinal obstruction, the belly often blows up and can feel very hard.

In the case of the symptoms described, a doctor should therefore be alerted or consulted immediately, since the fastest possible treatment is crucial for an intestinal obstruction. It is a potentially life-threatening clinical picture.

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

The causes of an intestinal obstruction

A mechanical ileus (intestinal obstruction) is caused by a spatial obstacle to the transport of food, which can occur in the case of a hernia (intestinal hernia), because an intestinal loop pressed into the hernial sac is pinched and the passage of the food can be impeded.

The same problem can also arise with twisted, kinked or intestinal loops. After surgery in the abdominal cavity, a so-called bride ileus can develop, since 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 mechanical disability.

Furthermore, a tumor constricting the intestinal lumen that arises from the intestine itself or from neighboring organs, as well as larger foreign bodies or large gallstones in the intestine that have passed, can be an obstacle to passage.

Finally, difficult-to-deform or tough stools such as feces, meconium (child's speech), or tough body secretions in the context of cystic fibrosis lead to mechanical ileus. Fecal balls in older people are mainly caused by insufficient hydration or generally by a diet high in fiber, while the meconium is the first baby chair to contain many tough components that can sometimes cause an intestinal obstruction.

Paralytic ileus (intestinal obstruction) occurs, for example, through 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 the ingestion or formation of a blood clot on site (similar to a heart attack or stroke).

Different types of injuries or inflammation in the abdominal cavity can result in reflex bowel movements. Possible causes are surgery, an accident with an abdominal injury, an (subsequent) inflammation of the abdominal cavity 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 shifts (hypokalaemia), excessive uric acid concentration in the blood due to kidney failure (uremia), as well as poisoning with opiates or lead lead to paralysis of the intestinal muscles.

Cancer as the cause of an intestinal obstruction

Cancer is one of many possible causes of bowel obstruction.

Either there is a relocation of the intestinal tube due to the growth of an intestinal cancer from the inside or a tumor grows in the abdominal cavity that presses in the intestine from the outside. In both cases, there may ultimately be a complete intestinal disruption to the intestine and thus mechanical bowel obstruction. If cancer is the cause of an intestinal obstruction, however, this is often already indicated by irregular bowel movements such as a change in constipation and diarrhea. Cancer is rarely the cause of a sudden and unsigned bowel obstruction.

Adhesions

Adhesions are one of the most common causes of a so-called mechanical bowel obstruction.

An earlier abdominal surgery, which may have been decades ago, can lead to adhesions. These can lead to a narrowing and ultimately closure of the intestinal tube from the outside. In such a case, the quickest possible surgical removal of the causal adhesions and the associated restoration of the intestinal passage is crucial. In younger and otherwise healthy patients, this can often result in inconclusive healing. In patients who are already seriously ill and elderly, as well as in the event of surgery that is too late, an intestinal obstruction caused by adhesions can be fatal.

Can you get an intestinal obstruction from constipation?

In extreme cases, constipation can lead to an intestinal obstruction.

The thickening of the faeces in the intestine leads to a backlog, against which the intestines unsuccessfully press, which is usually manifested by colic-like abdominal pain as well as nausea and vomiting (possibly also vomiting). In such a case, a doctor must be consulted urgently. However, constipation alone is a very common complaint, with intestinal obstruction only very rarely, and which can initially be treated with adequate hydration, fiber-rich food and physical exercise.

Can I get an intestinal obstruction from laxatives?

Ingestion and, in particular, misuse 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 result in paralysis of the intestinal muscles and thus lead to intestinal obstruction. Laxatives should therefore only be taken according to medical prescription and guidelines. Before that, non-medication measures such as sufficient drinking, fiber-rich food and physical activity should have been exhausted.

Symptoms of an intestinal obstruction

Acute intestinal obstruction (ileus) initially manifests itself as an "acute abdomen" with the unspecific symptoms of rapid onset, severe abdominal pain, a tight, sometimes bloated abdominal wall, nausea and vomiting, possibly also fever and circulatory shock.

With high intestinal obstructions in the area of ​​the upper intestine, vomiting of bile can also occur. Due to the delayed further transport of the food, the vomit may be accompanied by food from deeper parts of the intestine. The stool and wind loss cease, which may have started a few days before the main symptoms appear and can be asked retrospectively.

There are also changes in intestinal noise when listening with a stethoscope: The mechanical ileus (intestinal obstruction) creates a press-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, i.e. not even the usual bowel sound, can be heard. If the intestinal obstruction is not treated quickly enough, a breakdown of the intestinal barrier or a tear in the inflamed intestine can lead to colonization of the abdominal cavity with intestinal germs (peritonitis), which results in septic shock and is fatal with subsequent multi-organ failure.

A gradual start with a preceding, incomplete ileus (subileus) is also possible.

Diarrhea as a symptom of an intestinal obstruction

In most cases, bowel obstruction does not show up as diarrhea.

In most cases, the slow closure of the intestinal tube leads to a decrease in the frequency of stool, which ultimately leads to constipation. However, if bloody diarrhea occurs with the 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 bowel obstruction must be treated surgically. This is particularly the case if there is inflammation of the peritoneum or there is a risk of breakthrough of the intestinal wall.

Depending on the extent of the intestinal obstruction, the affected parts of the intestine must be removed completely during the surgical procedure. This therapeutic measure, however, can affect the passage of the meal and the absorption of certain food components. In addition, the reabsorption of water from the intestinal lumen can be restricted in the long term, depending on the length of the removed intestinal parts. For this reason, the affected patients suffer from recurrent diarrhea after the operation (sometimes for life). The strict regulation of daily hydration 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.

Is there also an intestinal obstruction without pain?

Abdominal pain is typical of an intestinal obstruction and almost always occurs. Nevertheless, a slowly developing bowel obstruction that does not cause pain is not excluded.

Particularly in the case of old or seriously ill, bedridden patients, an intestinal obstruction can creep in without the pain being expressed. However, at least other symptoms then appear, such as vomiting, lack of bowel movements and a significant increase in the size of the abdomen.

Diagnosis of an intestinal obstruction

Intestinal obstruction is initially suspected due to the main symptoms mentioned above.

To further differentiate between possible other diseases with a similar appearance, the abdominal cavity is also listened to (auscultation). A blood sample generally clarifies an inflammatory reaction in the body or some possible causes and other consequences (hypokalaemia, uremia, hyonatremia). An 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 offer the phenomenon of fluid levels, which is typical of the ileus situation. Ultimately, computed tomography offers the possibility of spatial presentation of the intestine and the visualization of the occlusion, while many of the methods mentioned above lead to the suspected diagnosis of intestinal occlusion due to the combination of symptoms and the associated, low-tech examination methods, which due to their explosiveness also indicate the operation draws.

Therapy of an intestinal obstruction

Among the therapeutic options, the main focus is on surgery, which is usually done quickly due to the potential life-threatening nature of the clinical picture, especially when there is an expected risk of a breakthrough of the intestinal wall or an existing peritonitis.

During the operation, intestinal indentations, adhesions or any tumors that were responsible for the ileus are removed. It may be necessary to open the bowel and remove the stagnant stool or undersupplied and dying sections of the bowel. In the latter, severe case, it sometimes happens that an artificial bowel exit has to be created for a period of a few months until the two interrupted bowel ends are brought together.

If an infection of the abdominal cavity (peritonitis) has already occurred, the abdominal cavity is flushed with antibiotics, which may be necessary again a few days later. To prevent subsequent blood poisoning (sepsis), antibiotics are also administered intravenously during and after the operation. In addition to other treatment measures, a gastric tube is placed in order to relieve the ileus situation and to protect the patient from possible stool breakdown. Infusions can compensate for derailments in the electrolyte and water balance, and medication can be given to normalize bowel activity or to combat nausea and pain.

Surgery for an intestinal obstruction

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

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

In some cases, however, there is also a constriction in a certain section of the intestine, which cannot be solved by simply relocating the intestine or suctioning, for example in the case of tumor involvement. In this case, this part must be cut out (see also: removing the colon). 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 again normally. When removing parts of the intestine, it may be necessary to temporarily put an artificial intestinal exit, which can usually be moved back after a few months. An antibiotic is given to prevent infections during the procedure.

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

Another preventive measure to prevent further bowel obstruction is to insert a small intestine tube after the operation. This so-called Dennis probe fixes the small intestine in its correct position for about a week. This prevents the intestine from kinking and, in its optimal position, growing together with the abdominal wall and its surroundings. The risk of having a new bowel obstruction after this procedure is about 10%.

Duration of the operation

Ileus surgery is a major procedure that can take several hours. The exact duration of the operation depends on the cause of the bowel obstruction. Kinks and intertwinements can be removed relatively quickly and the intestine can be repositioned. The surgeon can also remove uncomplicated adhesions and straps within the scheduled operating time.

However, if a tumor that constricts the intestinal lumen or entire parts of the intestine have to be removed, the duration of the operation increases accordingly. In many cases, an artificial intestinal exit must be created after an intestinal resection. However, this is a routine step that can be done quickly.

Aftercare

After the operation, the wound is treated with wound drainage and covered with sterile bandages. The patient then comes to the recovery room, where he wakes up from the anesthesia under constant medical supervision. The newly operated patient is then transferred to the ward, where he has to stay for several days.

The patient receives medication that relieves pain and the hospital staff cares for the surgical wound. For the first few days after the operation, the patient is not allowed to eat anything and is fed via infusions (parenteral nutrition). After that, you can start with light food (soup, porridge, yoghurt, etc.), so that the intestine can slowly get used to food again and begins to digest. It is important that the patient strictly follow the doctor's instructions, since overloading the intestine with unsuitable food leads to serious complications and the need for another operation.

Length of hospital stay

As a rule, patients who have had an ileus operation can expect to be hospitalized for at least four days. If complications have arisen during the operation or if entire parts of the intestine had to be removed, the length of hospital stay is increased. In such cases, patients may need to stay in the hospital for up to two weeks or more.

Duration of the entire healing

The duration of the entire healing depends strongly on whether it is a mechanical or paralytic intestinal obstruction and what caused it. Mechanical bowel obstruction is usually treated surgically and is associated with a longer hospital stay.

A paralytic ileus must not be operated on, but must be treated conservatively with medication, intestinal enemas and massages. Accordingly, the hospital stay is shorter. Depending on how serious the intestinal obstruction was and whether complications occurred, the healing process can take weeks to months.

What are the risks in the operation?

In recent years, many new surgical methods have been established, which means that even large operations are associated with fewer risks and complications for the patient. However, as with any operation, ileus surgery has certain risks that cannot be completely prevented.

During the operation, the intestine can tear or otherwise be damaged, causing bacteria to enter the abdominal cavity and cause peritonitis. There is also a risk of severe bleeding in the abdomen or damage to other abdominal organs due to vascular injuries.

The operation on the intestine can lead to adhesions on the intestinal loops as part of the healing process, which can lead to intestinal obstruction again. Another risk is that the wound will not heal properly or the scar will break through the abdominal wall.

Ileus surgery is a difficult operation that can be associated with many complications. However, an intestinal obstruction represents an absolute emergency situation in which action must be taken quickly, otherwise it will lead to organ failure and can be fatal.

How high the risk for the actual occurrence of these undesirable side effects depends above all on the age of the patient, his general condition, accompanying illnesses and the cause of the intestinal obstruction. The doctor provides the patient with extensive information about possible risks and complications before the procedure.

Long-term consequences of an operation

The operation of an intestinal obstruction can have long-term consequences. If intestinal tissue is removed during the operation, the risk increases that adhesions of connective tissue form at this point, which later reduce the diameter of the intestine and lead to a new intestinal obstruction.

Especially after removing a section of the intestine, the operation can lead to indigestion and changes in bowel movements. The symptoms depend on whether parts of the small or large intestine have been removed and how much has been cut out. Most of the time, the stool becomes thinner and more common. The patients have to pay attention to their diet and adapt to the new circumstances. Before the intervention, the doctor explains in an educational interview how the digestion will change as a result of the operation and what the consequences are for the person concerned.

After an intestinal resection, an artificial intestinal exit (double-sided or terminal stoma) is often created, which can be moved back to the abdomen after a few weeks, when the surgical wound has healed. In some cases, however, the artificial intestinal exit must remain permanently. This is especially the case when the colon has to be partially or completely removed. In the case of the permanently existing artificial intestinal exit, the remaining section of the small intestine is sewn directly to an exit on the abdominal wall. The contents of the intestine are emptied using a bag attached to the abdominal wall.

When does an intestinal obstruction have to be operated on?

The treatment method depends on the type of intestinal obstruction. Only a mechanical bowel obstruction is operated on, whereas a paralytic ileus cannot be treated surgically. The treatment of a paralytic ileus lies in eliminating the cause and conservative therapy.

A mechanical ileus is basically treated with surgery. Surgical intervention as early as possible reduces the risk of serious complications, such as an intestinal perforation or bacterial inflammation of the peritoneum (perotinitis).

Only in a few cases is an immediate operation of an ileus postponed, for example if the general condition of the patient is so bad that the risk of an operation would be too high. Then the first step is to stabilize the patient with electrolyte infusions and other circulatory support measures to such an extent that surgery is possible.

How much intestine can / must be removed?

The decision as to whether and if so how much bowel has to be removed during an ileus operation depends on the cause of the bowel obstruction. Is it a simple mechanical bowel obstruction with a benign cause, e.g. If a hernia or inguinal hernia causes pinching, the affected section can simply be moved back to the normal position and surgical removal of a section of the intestine (resection) is not necessary.

The situation is different if a tumor has grown into the intestinal mucosa and causes the occlusion. Then the entire part of the intestine affected by the tumor must be removed completely. The same applies to a strongly thickened and scarred intestinal wall, which often forms after chronic inflammation. In some cases, the blood supply can no longer be maintained due to the mechanical clamping and parts of the undersupplied intestine die. In such a case, the dead tissue must be removed completely.

Forecast

The mortality rate in intestinal obstruction (ileus) is given as 10-25% and is strongly dependent on the time between the start and the initiation of appropriate treatment. If this is started quickly, the prognosis regarding survival is good, however, new closings are to be expected, since not all triggering factors can always be completely eliminated and especially the bridging ileus 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 only medication) and the general state of health of the patient before the illness. For example, an intestinal obstruction triggered 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 intestine often has to be removed and life-long indigestion can occur. In some cases, an artificial intestinal exit must also be created. This can often be moved back in the course, but in some cases it must remain.

Why is bowel obstruction more common in older people?

There are several reasons why bowel obstruction occurs more often in older people than in younger people.

This is mainly due to the fact that the different causes of an intestinal obstruction occur with increasing age. In addition to adhesions, abdominal wall fractures are also more likely in older people. These are one of the most common causes of bowel obstruction. In addition, older people are more likely to take drugs that can promote the appearance of an intestinal obstruction, such as certain pain relievers.

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