Trauma Journal Club July 2015: Paralytic Ileus (Severe Constipation) in Orthopedics

"Paralytic ileus" is a medical term for cessation of bowel motion.  And thats a problem, because our bowels love motion! They are constantly pushing along the food we ingest, like a conveyor belt.  Along the way our body extracts all the good nutrients and gets rid of the waste as poop.  

When our bowels slow down, or stop moving the food, everything starts to back up and bad things happen.  We start to feel sick.  Symptoms include nausea, vomiting, feeling bloated, distended. You cannot eat or drink, so you can quickly become malnurished or dehydrated if things persist for a long time.  When things get really bad, your bowels can become so distended that they burst, leading to serious infections.  

So what does this have to do with orthopedics?  A recent article in JAAOS highlights the close connection between our bowels and orthopedics (see article).  Paralytic ileus can be caused by orthopedic injuries, orthopedic surgeries, or pain medication after surgery or after injury.  

Paralytic ileus is most commonly seen after Spine Surgery (about 3.5% of lumbar spine cases) or after Total Hip Replacement Surgery, but is also commonly see after traumatic injuries like a broken hip (see talk) or pelvis.  

Ogilvie syndrome is a variation of paralytic ileus.  Its technically a "pseudo-obstruction" whereby there is no mechanical reason for the bowel to have shut down, but rather its caused by a combination of medications (like opioids) and baseline constipation.  Its most commonly seen in elderly, demented patients after a broken hip.  It can be a significant source of complicaitons.  

There are a few ways to treat a paralytic ileus.  

Studies (see article) have shown that chewing gun can actually stimulate your bowels to start moving.  You trick your body into thinking new food is entering the system, so your brain tells your bowels to speed up the "conveyor belt".  Just getting out of bed is another treatment.  This is easier said than done when talking about recovery from a total hip or broken hip, but its believed that walking around stimulates our bowels, while lying in bed for a few days on end just slows down everything in our body (almost like hibernating).  Interestingly, there is not strong scientific evidence that "walking therapy" truly works (see article), this practice is encouraged in most every hospital.  

Cutting down on narcotic pain medications, like percocet, oxycodone, vicoden, MS contin, can also help significantly with an ileus.  These medicines stimulate a receptor (the µ-receptor) which is part of the pathway that softens our perception of pain.  But these receptors are also found on our bowels and they block the motion of our bowels.  Therefore, a side effect of narcotics is that our bowels slow down, creating constipation, and ileus in some cases.  Using alternative pain medicine, like NSAIDS or lidocaine pain blocks, reduce the side effects of these medicines.  Also medications that block the activation of the µ-recpetors can prevent the side effects of opioids.  Methylnaltrexone, and Alvimopan are two examples of medications that target µ-receptors in the bowel and have no impact on the pain pathway µ-receptors.  They have shown a lot of promise in treating constipation due to narcotic use.    

Other medications can also be helpful.  A Cochrine review discusses all of the pharmacologic medications for post-surgical ileus (see article).  

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