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Pondering causes of mechanical, paralytic ileuses

JustCoding News: Inpatient, July 18, 2012

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by Robert S. Gold, MD

Let me explain the digestion process.

People intake foods, solids, and liquids that occasionally mix with gases. The contents traverse the esophagus and enter the stomach where they encounter acid. The stomach churns the food and liquid with acid and peptic juices and prepares it for the duodenum. There, bile juices and pancreatic chemicals emulsify the fat. They also break down proteins into amino acids and complex sugars into simple sugars for subsequent absorption in the jejunum and ileum. The residue moves through a 24-foot tunnel before it arrives in the large intestine where bacteria break it down and dry it out by absorption. Finally, the body excretes the waste.

This entire process of transit is called peristalsis. ­During normal peristalsis, the intestinal wall muscles narrow and lengthen periodically. However, the intestinal tract may suffer from many diseases that can interrupt this process.

This column addresses the topic of ileus, which is derived from the Greek term for "twisted." An ileus caused by a length of bowel that is twisted on its mesentery can cause twisting of the veins that drain the length of bowel as well as the arteries that supply that bowel. The length of bowel the artery and vein supply can die, and the twisting causes an obstruction that stops the progression of food through the gastrointestinal tract.

Mechanical ileus

A mechanical ileus (i.e., mechanical obstruction) ­occurs when a physical blockage impedes flow. A nickel swallowed by a patient could become stuck in a portion of the intestinal tract that is smaller in diameter than the coin (e.g., the pylorus, a passage from the stomach to the duodenum, or the ileocecal valve).

A foreign body of sufficient size can cause a mechanical obstruction. A tumor, whether a benign polyp or malignant neoplasm that grows large enough, can also block intestinal flow. Herniation of a length of intestine through a defect in the abdominal wall (e.g., umbilical hernia, inguinal hernia, or paraesophageal hiatal ­hernia) also can block intestinal flow. Herniation through a defect in the fastening of the mesentery inside the abdomen (e.g., paraduodenal fossa hernia or Ladd's bands) can also lead to intestinal blockage.

Blockage can occur when a length of intestine becomes twisted. This occurs with volvulus of the sigmoid, volvulus of the cecum, and adhesions between loops of intestine. Intussusception, which occurs when one portion of the bowel slides into the next, can also cause obstruction. Cystic fibrosis may lead to mechanical obstruction with excessively thick meconium in the bowel of the newborn.
Intestinal content above the area of blockage continues to become backed up to the point at which the patient begins vomiting. The vomitus is usually foul smelling. Mechanical ileuses are treated surgically, which usually resolves the problem completely. This is true even if a portion of the bowel has become gangrenous.

Coders should identify each cause of intestinal obstruction with the most precise code possible. Occasionally, physicians identify a partial small bowel obstruction due to adhesions from prior surgery. Many of these cases resolve spontaneously with bowel rest. If they don't resolve, physicians must explore the bowel and cut or cauterize adhesions to restore normal anatomy.

Paralytic ileus

A paralytic ileus occurs when a lack of synchronized peristalsis occurs in the absence of a physical blockage. Viral or bacterial infections in the gastrointestinal tract usually lead to hypermotility, which often results in diarrhea. However, infection in the abdominal cavity around the intestines can also lead to cessation of neuromuscular coordinated activity and no movement of intestinal content. For example, paralysis can occur when patients undergoing peritoneal dialysis have infected ascites. It can also occur in patients with pelvic or abdominal abscesses from a perforated bowel. Those with pelvic inflammatory disease or benign spontaneous peritonitis can experience the same problem.

If an area of the intestine loses some of its blood supply or venous drainage due to atherosclerosis or portal venous hypertension, peristaltic activity in that area of the bowel may cease. Irritation of the outer peritoneal lining of the intestine due to any cause often results in paralysis of that segment of bowel. This can happen in patients with pancreatitis when digestive enzymes are released into the abdomen. It can also occur in conjunction with abdominal surgery. Each of these scenarios causes cessation of intestinal motility in the area of neuromuscular function disturbance, and the entire bowel swells in size.
Some localized paralyses may occur. For example, this can occur in newborns with Hirschsprung's disease (in which parts of the nervous system in the wall of the large intestine are missing). It may also occur in bedbound patients with chronic constipation that can lead to Ogilvie syndrome (pseudo obstruction).

Coders must always look for the cause of a ­paralytic ileus prior to coding. A physiologic paralytic ileus can ­occur after abdominal surgery when a patient has no other bowel-related problems. Patients receive no ­sustenance by mouth until bowel sounds are heard or the patient passes flatus.

However, when an abnormal process in the abdominal cavity leads to surgery (e.g., appendicitis, diverticulitis, or cholecystitis), the patient invariably had an ileus ­going into surgery. Thus, the patient would naturally have one after the surgery as well. Depending on the severity of the inflammatory response, it could conceivably take as long as one week for the bowel to resume function. When this occurs, the ileus is caused by the disease-not by the surgery.

However, if the surgery led to further problems with the intestines (e.g., anastomotic leak or spillage and contamination of the peritoneal cavity that didn't exist prior to surgery), a prolonged ileus could be a complication of the operation itself.

Not every ileus warrants assignment of a code. For example, an ileus that doesn't prolong a patient's hospital stay beyond the average length of stay isn't codeable, even when documented as a postoperative ileus. This ­reflects the physiologic ileus that follows every abdominal surgery and is part of the recovery. It's not codeable.

However, if the postoperative ileus causes vomiting, or the patient required insertion of a nasogastric tube, coders may be able to report it. Coders can also assign a code for an ileus that is prolonged due to a disease or due to surgery for the condition that caused the ileus. However, coders should not report a complication code because the ileus is not a complication of the surgery.

If the late resumption in bowel activity is due to overuse of pain medication, report a code for the ileus as well as an E code for the adverse effect of the opiates or whatever pain medication led to the ileus.
Finally, if the prolonged ileus occurs due to a complication of surgery (e.g., a leak), assign a complication code.

When the physician cannot determine the cause of the ileus, also consider a complication code if the patient starts vomiting, has had a nasogastric tube inserted, or can't resume eating for five or more days after surgery when all other causes for these symptoms have been ruled out.

Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770-216-9691 or This article was originally published in the July issue of Briefings on Coding Compliance Strategies.


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