Ileus and Obstruction in the Surgical Critical Care Patient

Gastrointestinal dysfunction is a common occurrence in the critically ill surgical patient as both a contributor to disease progression and a consequence of critical illness. Failure of motility may ultimately progress to obstruction, either functional (e.g., paralytic ileus) or mechanical (e.g., small bowel obstruction). Obstruction leads to bowel distention, fluid sequestration in the lumen and wall of the bowel, alterations in mucosal integrity, and bacterial overgrowth, which results in not only local bowel ischemia but also distant organ damage due to the release of inflammatory cytokines. Although postoperative ileus is a common condition, in the critically ill patient, it may signify a serious complication such as anastomotic leak or sepsis; therefore, management is directed toward identification and treatment of the underlying cause. Regarding small bowel obstruction (SBO), management hinges on whether or not the bowel is strangulated, and the need for operation should be addressed at every step of the evaluation. Although most patients are successfully treated without operation, SBO is a surgical disease, a fact underscored by the improved outcomes seen in patients admitted to a surgical service. Large bowel obstruction is a surgical emergency that requires prompt decompression either by colonoscopy or surgery. Regardless of the etiology of gastrointestinal dysfunction, emergency surgery is required in patients with signs of bowel strangulation or perforation such as tachycardia, peritonitis, fever, or leukocytosis. Key words: acute colonic pseudo-obstruction, adhesive small bowel disease, ileus, large bowel obstruction, Ogilvie syndrome, small bowel obstruction bowel perforation, volvulus