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Ileus and obstruction in the critically ill 

Ileus and obstruction in the critically ill
Ileus and obstruction in the critically ill

Philip Stevens

and Paul Dark

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date: 17 May 2022

Obstruction is the commonest cause of acute intestinal failure in critical care. Management is dependent upon whether it is adynamic or mechanical in origin. Paralytic ileus is managed conservatively by correction of electrolyte disturbances, nutritional support, and minimization of enterostatic drug use. Pharmacological agents aimed at reducing sympathetic stimuli may be useful, although widespread application is limited due to anti-muscarinic side effects. Peripherally acting μ‎-opioid receptor antagonists, may have a role, although data in critical illness are lacking. Prokinetic agents have not been shown to reduce ileus in clinical trials. Colonoscopic decompression may be required when conservative management fails. Rarely, surgical decompression becomes necessary if ileus arises in the context of abdominal compartment syndrome. Mechanical obstruction is more likely to require surgery, although adhesional obstruction, responsible for 80% of small bowel obstruction, may settle within 7 days of conservative management. Large bowel obstruction is more commonly due to tumours, diverticular stricture, or volvulus, and more likely to require endoscopic or surgical intervention. The hallmark of obstruction is colic, characterized by an inability to settle, in contrast to the peritonitic patient who lies completely still. Peritonitis in the presence of obstruction indicates possible perforation or necrosis for which urgent operative intervention is required. Clinical features may be absent in sedated patients hence the index of suspicion should remain high in any critically-ill patient intolerant of enteral feeding.

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