Ileal obstruction

Baroliths are rare complications of barium contrast examinations and are usually seen in colonic diverticula. They are often asymptomatic but may be associated with abdominal pain, appendicitis, and bowel obstruction or perforation. A case of ileal obstruction by a barolith has been reported (12)... 

Duodenal Obstruction 170 Jejunal and Ileal Obstruction 172 Meconium Peritonitis 173 Meconium Ileus 173 Megacystis-Microcolon-Malrotation-Intestinal-Hypoperistalsis Syndrome (MMMIHS) 174... 

Neonates with jejunal or ileal obstruction may also present with bilious vomiting depending on the level (most likely proximal) of obstruction. This clinical symptom is usually less severe than in duodenal obstruction. 

Biliary obstruction due to stone, tumor, or primary biliary cirrhosis Zollinger-Ellison syndrome (causes hyperacidity) bacterial overgrowth and stasis administration of drugs, neomycin, and cholestyramine Ileal disease or resection... 

Medium-chain triglycerides (MCT) are important components of nutritional supplements used in patients with digestive disorders. They therefore can be employed as an easily absorbed source of calories in patients who have a gastrointestinal (Gl) disorder that may result in malabsorption of nutrients. These diseases include pancreatic insufficiency, intraluminal bile salt deficiency due to cholestatic liver disease, biliary obstruction, ileal disease or resection, and disease causing obstruction of intestinal lymphatics. Remember, however, that MCT do not contain polyunsaturated fatty acids that can be used for synthesis of eicosanoids (see Chapter 35). 

The diagnosis is usually apparent on the plain films. The abdominal radiograph shows a few dilated bowel loops (three or four air bubbles), more than in the case of duodenal atresia and fewer than in ileal atresia or in other causes of low bowel obstruction (Fig. 1.14). The loop just proximal to the site of the atresia is frequently disproportionately dilated with a bulbous end. There is no air in the lower portion of the abdomen this is observed most clearly in the upright film (Rathaus and Grunebaum 1992) (Fig. 1.15). The colon cannot be identified and air... 

For practical purposes, the differential diagnosis of low intestinal obstruction in the neonate consists of five conditions. Two conditions involve the distal ileum and include ileal atresia and meconium ileus, and three involve the colon, which are colonic atresia, Hirschsprung s disease, and functional immaturity of the colon that includes meconium plug... 

Fig. 1.18a,b. High intestinal obstruction, a Plain radiograph of a newborn infant that shows an airless abdomen with air only in the stomach. Despite the lack of intestinal air, there is distension of the flanks and elevation of the diaphragms, b Sonography demonstrates the abdominal distension to be produced by fluid-filled intestinal loops. At surgery, a proximal ileal atresia was found... 

Ileal atresia is an important cause for low intestinal obstruction. It represents approximately 50% of small bowel atresias and the etiology is similar to that of jejunal atresia. As jejunal atresias, they are believed to result from an intrauterine vascular injury. Approximately 25% have a history of polyhydramnios (Sweeney et al. 2001). 

Plain film shows numerous dilated loops of bowel occupying the entire abdominal cavity, including the pelvic portion, and multiple air-fluid levels in upright film (Fig. 1.19). With this degree of distension the mucosal pattern of the small bowel is effaced and it is impossible to differentiate the small bowel from the colon (Winters et al. 1992). Examination of the colon is then warranted to disclose the presence or absence of a colonic lesion. In ileal atresia, the colon is normally placed but has an abnormally small caliber, the so-called functional microcolon typical of distal small bowel obstruction (Dalla Vecchia et al. 1998) (Fig. 1.19d,e). The presence of pneumoperitoneum indicates that perforation has occurred and a colon examination is contraindicated. Intraperitoneal calcifications, indicative of meconium peritonitis, are not uncommon in ileal atresia. 

The radiological diagnosis of obstruction is usually visible on the conventional (plain) radiograph. In uncomplicated cases these radiographs of the abdomen are sufficient. The pre-atretic intestinal loops are dilated because of accumulation of large amounts of fluid and fluid levels are usually present on horizontal beam films. In case of jejunal atresia only a few loops of distended jejunum are present in the left upper abdomen, while in ileal atresia many dilated loops are identified. In complicated cases, especially with an abnormally distended and painful abdomen, a colon enema or US can be useful- particularly from the differential diagnostic point of view to exclude meconium ileus or meconium peritonitis. In case of atresia, a microcolon without the presence of meconium is usually found (Devos and Meradji 2003). 

In ultra-short segment Hirschsprung s disease the barium enema may show a large mega-rectum but no other specific findings. In NID, chronic intestinal pseudo-obstruction and total colonic agangiionosis the barium enema is often non-contributory. However, total colonic agangiionosis may sometimes have the appearance of a microcolon and therefore needs to be differentiated form ileal atresia and meconium ileus. 

The enterohepatic circulation of bile acids may be interrupted by biliary obstruction or biliary fistula the events occurring in fat digestion in the absence of bile acids have been discussed. Of more interest are the disturbances in bile acid and fat metabolism occurring when the enterohepatic circulation of bile acids is interrupted by ileal disease or resection. 

It seems evident that (1) if bile acid elimination is inhibited or impaired as a primary phenomenon, e.g., in biliary obstruction and hypercholesterolemia, a decreased catabolism of cholesterol leads to hypercholesterolemia and reduced cholesterol synthesis (2) if bile acid elimination is primarily augmented, e.g., after an external bile fistula, ileal bypass, ileal resection, cholestyramine treatment, or perhaps a diet rich in fibrous material, conversion of cholesterol to bile acids is enhanced, leading almost always, despite stimulated cholesterol synthesis, to a fall in serum cholesterol (3) if endogenous cholesterol production is primarily increased, e.g., by obesity and excess of calories, bile acid synthesis and elimination are augmented, preventing together with increased neutral sterol elimination in some but not all cases the increase of serum cholesterol. This suggests that removal, not production, of cholesterol is the primary factor which determines serum cholesterol level. 

This is a related aspect of malignant ureteric obstruction, in patients with an ileal conduit fol-... 

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