From the Guidelines
Liver cirrhosis can cause focal ileus through several interconnected mechanisms related to portal hypertension and its systemic effects, including congestion of the mesenteric vessels, bowel wall edema, ascites, bacterial overgrowth, and metabolic derangements, as supported by the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1. The pathophysiology of liver cirrhosis leading to focal ileus is complex and multifactorial. Key factors include:
- Increased pressure in the portal venous system leading to congestion of the mesenteric vessels and bowel wall edema, which can impair normal intestinal motility in specific segments.
- Ascites, which can exert external pressure on bowel loops, further compromising peristalsis in focal areas.
- Bacterial overgrowth and translocation from the gut, triggering localized inflammatory responses that can paralyze segments of the intestine.
- Metabolic derangements common in cirrhosis, including hypokalemia and hypomagnesemia from diuretic use, can disrupt normal neuromuscular function of the intestine.
- Hepatic encephalopathy may also contribute by affecting autonomic nervous system regulation of gut motility.
- Medications used to treat complications of cirrhosis, particularly opioids for pain and certain diuretics, can independently slow intestinal transit, as noted in the management of hepatocellular carcinoma 1. Management of focal ileus in liver cirrhosis typically involves:
- Treating the underlying liver disease.
- Correcting electrolyte abnormalities.
- Judicious use of prokinetics.
- Careful fluid management to reduce ascites while maintaining adequate perfusion to the intestine. Additionally, nutritional counseling and management are crucial, as malnutrition is common in cirrhosis and can worsen outcomes, emphasizing the importance of a multidisciplinary approach including specific nutrition counseling to improve patients' long-term outcomes, as recommended in the ESPEN practical guideline on clinical nutrition in liver disease 1.
From the Research
Liver Cirrhosis and Focal Ileus
Liver cirrhosis can cause focal ileus through several mechanisms:
- Gastrointestinal complications are frequent in critically ill cirrhotic patients, and recognition and intervention in a timely manner may minimize morbidity and mortality 2
- Changes in intestinal functions, including small intestinal dysmotility and prolonged orocecal transit time, are common in liver cirrhosis and may contribute to the development of ileus 3
- The gut-liver axis plays a crucial role in the pathophysiology of liver cirrhosis, and alterations in the gut microbiota and intestinal barrier dysfunction may lead to complications such as ileus 3
- Gastrointestinal failure, including gut paralysis or ileus, is frequent in critically ill patients with cirrhosis and is often associated with sepsis or multiorgan failure 4
- The pathogenesis of ileus in liver cirrhosis is multifactorial and may involve factors such as portal hypertension, systemic inflammation, and liver failure 5, 6
Key Factors Contributing to Focal Ileus
Some key factors that may contribute to the development of focal ileus in liver cirrhosis include:
- Small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) 3
- Autonomic neuropathy, metabolic derangements, and diabetic state 3
- Structural and functional changes in the intestinal mucosa, including increased intestinal permeability and altered gut microbiota 3
- Inflammation, sepsis, electrolyte abnormalities, and acidosis 4