Our cme article Ileus in Adults: Pathogenesis, investigation and treatment has stirred up some controversy. This has come as no great surprise to us (1): interestingly, treatment of mechanical ileus in the context of malignant stenosis in cancer of the lower or middle third of the rectum has not been discussed. This is because a three-step procedure (insertion of double-barrel stoma at the ileus, neoadjuvant therapy, rectal resection preserving the protective stoma, removal of stoma at end of treatment) may be necessary depending on tumor stage, in addition to the one- or two-step procedures mentioned in the article. For the sake of completeness, this should not go unmentioned.
In his comment on the treatment and prophylaxis of opioid-induced ileus, Dr. Nickel states that the use of the drug combination oxycodone + naloxone for manifest opioid-induced ileus has no positive effect. We agree, there are no relevant studies. Regarding use to prevent constipation, the data is indeed controversial. Therefore the drug can be used, but it is true that no clear recommendation can be made.
Discussion is most needed regarding radiological diagnostics and the value of ultrasound in confirming a diagnosis of mechanical ileus. It should be noted at the outset that our article did not concern patients with “abdominal complaints of unclear etiology and coprostasis,” as often seen in primary care practices or for “semielective” clarification in hospitals. Rather, it concerned often critically ill patients with severe clinical symptoms up to and including the complete disease pattern of acute abdomen. In the German-speaking world there are no guidelines for this issue (the quotation in Dr. Lang’s discussion piece concerns diagnosis of sigmoid diverticulitis, not mechanical ileus); when writing this article, we therefore referred to the recommendations from the English-speaking world (www.uptodate.com). In these the wording regarding the value of computed tomography and ultrasound for mechanical ileus is clear. A reference is made to the only prospective study that directly compared computed tomography and ultrasound; this found computed tomography to be significantly superior (2).
We do agree with the authors of the discussion pieces that ultrasound can be unreservedly recommended for the diagnosis of abdominal pain of unclear etiology. It is also, of course, the first-line method for children and pregnant women. We therefore entirely agree with PD Dr. Seitz’s call for improved ultrasound training.
However, where mechanical ileus with complications is suspected on the basis of thorough history, physical examination, and elevated signs of infection, we believe that ultrasound is insufficient. The question of inexperienced examiners cannot be ignored, particularly regarding length of service, especially as the consequences are so far-reaching (surgery versus conservative therapy). In addition, for patients with manifest ileus, acute abdomen is not unusual, in addition to severe tympanites. In our experience, any attempt to expel intra-abdominal gases via compression of the abdominal wall or patient positioning is not tolerated by patients. Evaluation of peristalsis, often put forward as an argument “for ultrasound and against computed tomography,” is not of use in manifest ileus, as there is complete intestinal paralysis due to bacterial translocation. Computed tomography imaging, in contrast, detects the cause of obstruction as well as its precise location and potential complications. Furthermore, computed tomography can be immediately evaluated both remotely and by the operating surgeon and can be consulted again at the operating table if findings are unclear. Also worthy of mention is the advantage of an orally administered contrast medium, which has been shown to be associated with shorter hospital stays and lower surgical exploration rates (3, 4).
In conclusion, we would like to thank our readers for the highly interesting specialized discussion. All the discussion pieces have further convinced us that the development of an interdisciplinary guideline for functional and mechanical ileus is long overdue in an era of evidence-based medicine.
On behalf of the authors:
PD Dr. med. Tim O. Vilz
Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Vilz TO, Stoffels B, Straßburg C, Schild HH, Kalff JC: Ileus in adults—pathogenesis, investigation and treatment. Dtsch Arztebl Int 2017; 114: 508–18 VOLLTEXT|
|2.||Suri S, Gupta S, Sudhakar PJ, et al.: Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol 1999; 40: 422–8 CrossRef MEDLINE|
|3.||Abbas S, Bissett IP, Parry BR: Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database Syst Rev 2007: CD004651 CrossRef|
|4.||Zielinski MD, Haddad NN, Cullinane DC, et al.: Multi-institutional, prospective, observational study comparing the gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg 2017; 83: 47–54 CrossRef MEDLINE|