Postoperative Ileus Clinical Presentation: History and Physical Examination

Sections

Sections Postoperative Ileus
Overview
Presentation
DDx
Workup
Treatment
- Medical Care
- Surgical Care
- Diet
- Activity
- Prevention
- Show All
Medication
Questions & Answers
Media Gallery
Tables
References

Presentation

History and Physical Examination

History

Patients with ileus typically have vague, mild abdominal pain, distention, fullness, and bloating. They may report nausea, vomiting, and poor appetite. Abdominal cramping is usually not present. Patients may or may not continue to pass flatus and stool.

A relapse of paralytic ileus is not uncommon in psychiatric patients with a history of ileus; risk factors include being older, having a history of abdominal surgery, or having a longer duration of psychiatric disorders.^[21]

In renal transplant candidates with a history of peritoneal dialysis treatment, prior to transplantation, carefully evaluate for symptoms of intermittent bowel obstruction.^[22] Encapsulating peritoneal sclerosis is a rare cause of ileus in patients during or following peritoneal dialysis or renal transplantation.^[22]

Physical examination

The abdomen may be distended and tympanic, depending on the degree of abdominal and bowel distention, and may be tender. A distinguishing feature is absent or hypoactive bowel sounds, in contrast to the high-pitched sound of obstruction. The silent abdomen of ileus reveals no discernible peristalsis or succussion splash.

Differential Diagnoses

Chapman SJ, EuroSurg Collaborative. Ileus Management International (IMAGINE): protocol for a multicentre, observational study of ileus after colorectal surgery. Colorectal Dis. 2018 Jan. 20(1):O17-O25. [Medline].
Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci. 1990 Jan. 35(1):121-32. [Medline].
Shibata Y, Toyoda S, Nimura Y, Miyati M. Patterns of intestinal motility recovery during the early stage following abdominal surgery: clinical and manometric study. World J Surg. 1997 Oct. 21(8):806-9; discussion 809-10. [Medline].
Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. 2000 Nov. 87(11):1480-93. [Medline].
Vasquez W, Hernandez AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg. 2009 Apr. 13(4):649-56. [Medline].
Barletta JF, Senagore AJ. Reducing the burden of postoperative ileus: evaluating and implementing an evidence-based strategy. World J Surg. 2014 Aug. 38(8):1966-77. [Medline].
Iyer S, Saunders WB, Stemkowski S. Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm. 2009 Jul-Aug. 15(6):485-94. [Medline].
Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol. 1997 May. 92(5):751-62. [Medline].
Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part II. Am J Gastroenterol. 1997 Jun. 92(6):934-40. [Medline].
Kalff JC, Schraut WH, Simmons RL, Bauer AJ. Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg. 1998 Nov. 228(5):652-63. [Medline]. [Full Text].
Boeckxstaens GE, de Jonge WJ. Neuroimmune mechanisms in postoperative ileus. Gut. 2009 Sep. 58(9):1300-11. [Medline].
Espat NJ, Cheng G, Kelley MC, Vogel SB, Sninsky CA, Hocking MP. Vasoactive intestinal peptide and substance P receptor antagonists improve postoperative ileus. J Surg Res. 1995 Jun. 58(6):719-23. [Medline].
Kalff JC, Schraut WH, Billiar TR, Simmons RL, Bauer AJ. Role of inducible nitric oxide synthase in postoperative intestinal smooth muscle dysfunction in rodents. Gastroenterology. 2000 Feb. 118(2):316-27. [Medline].
Pohl JM, Gutweiler S, Thiebes S, et al. Irf4-dependent CD103+CD11b+ dendritic cells and the intestinal microbiome regulate monocyte and macrophage activation and intestinal peristalsis in postoperative ileus. Gut. 2017 Dec. 66(12):2110-20. [Medline].
Farro G, Stakenborg M, Gomez-Pinilla PJ, et al. CCR2-dependent monocyte-derived macrophages resolve inflammation and restore gut motility in postoperative ileus. Gut. 2017 Dec. 66(12):2098-109. [Medline].
Cameron JL, ed. Current Surgical Therapy. 7th ed. Chicago: Mosby; 2001.
Tollesson PO, Cassuto J, Rimback G. Patterns of propulsive motility in the human colon after abdominal operations. Eur J Surg. 1992 Apr. 158(4):233-6. [Medline].
Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health Syst Pharm. 2007 Oct 15. 64(20 Suppl 13):S3-7. [Medline].
Kuruba R, Fayard N, Snyder D. Epidural analgesia and laparoscopic technique do not reduce incidence of prolonged ileus in elective colon resections. Am J Surg. 2012 Nov. 204(5):613-8. [Medline].
Wolff BG, Viscusi ER, Delaney CP, Du W, Techner L. Patterns of gastrointestinal recovery after bowel resection and total abdominal hysterectomy: pooled results from the placebo arms of alvimopan phase III North American clinical trials. J Am Coll Surg. 2007 Jul. 205(1):43-51. [Medline].
Kitahata R, Nakajima S, Suzuki T, Plitman E, Mimura M, Uchida H. Relapse of ileus in patients with psychiatric disorders: A 2-year chart review. Gen Hosp Psychiatry. 2016 Jan-Feb. 38:31-6. [Medline].
Gokce AM, Ozel L, Ibisoglu S, et al. A rare reason of ileus in renal transplant patients with peritoneal dialysis history: encapsulated peritoneal sclerosis. Exp Clin Transplant. 2015 Dec. 13(6):588-92. [Medline].
Loftus CG, Harewood GC, Baron TH. Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction. Am J Gastroenterol. 2002 Dec. 97(12):3118-22. [Medline].
Wu Z, Boersema GS, Dereci A, Menon AG, Jeekel J, Lange JF. Clinical endpoint, early detection, and differential diagnosis of postoperative ileus: a systematic review of the literature. Eur Surg Res. 2015. 54(3-4):127-38. [Medline].
Kronberg U, Kiran RP, Soliman MS, et al. A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score. Ann Surg. 2011 Jan. 253(1):78-81. [Medline].
Gotz M, Braun G, Jakobs R, et al, fur die Mitglieder der DGVS-Kommission im Anhang. [German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) position statement on endoscopic decompression in acute Ileus]. Z Gastroenterol. 2017 Dec. 55(12):1499-1508. [Medline].
Liang X, Li W, Zhao B, Zhang L, Cheng Y. Comparative analysis of MDCT and MRI in diagnosing chronic gallstone perforation and ileus. Eur J Radiol. 2015 Oct. 84(10):1835-42. [Medline].
Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY: McGraw-Hill; 1999.
Bruns BR, Kozar RA. Feeding the postoperative patient on vasopressor support: feeding and pressor Support. Nutr Clin Pract. 2016 Feb. 31(1):14-7. [Medline].
Cali RL, Meade PG, Swanson MS, Freeman C. Effect of morphine and incision length on bowel function after colectomy. Dis Colon Rectum. 2000 Feb. 43(2):163-8. [Medline].
Ferraz AA, Cowles VE, Condon RE, et al. Nonopioid analgesics shorten the duration of postoperative ileus. Am Surg. 1995 Dec. 61(12):1079-83. [Medline].
Yang PF, Morgan MJ. Laparoscopic versus open reversal of Hartmann's procedure: a retrospective review. ANZ J Surg. 2014 Dec. 84(12):965-9. [Medline].
Purkayastha S, Tilney HS, Darzi AW, Tekkis PP. Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg. 2008 Aug. 143(8):788-93. [Medline].
Shang H, Yang Y, Tong X, Zhang L, Fang A, Hong L. Gum chewing slightly enhances early recovery from postoperative ileus after cesarean section: results of a prospective, randomized, controlled trial. Am J Perinatol. 2010 May. 27(5):387-91. [Medline].
Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. 1990 Dec. 212(6):671-7. [Medline]. [Full Text].
Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U. Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection : Benefit with epidural analgesia. Surg Endosc. 2009 Feb. 23(2):276-82. [Medline].
Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. 1995 Oct. 83(4):757-65. [Medline].
Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000 Feb. 92(2):433-41. [Medline].
Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Surg. 2008 Nov. 95(11):1331-8. [Medline].
Harvey KP, Adair JD, Isho M, Robinson R. Can intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery? A pilot study and literature review. Am J Surg. 2009 Aug. 198(2):231-6. [Medline].
Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009 Apr 4. 373(9670):1198-206. [Medline].
Maron DJ, Fry RD. New therapies in the treatment of postoperative ileus after gastrointestinal surgery. Am J Ther. 2008 Jan-Feb. 15(1):59-65. [Medline].
Yuan CS, Foss JF, Osinski J, Toledano A, Roizen MF, Moss J. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time. Clin Pharmacol Ther. 1997 Apr. 61(4):467-75. [Medline].
Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011 Jan 19. CD003448. [Medline].
Yu CS, Chun HK, Stambler N, et al. Safety and efficacy of methylnaltrexone in shortening the duration of postoperative ileus following segmental colectomy: results of two randomized, placebo-controlled phase 3 trials. Dis Colon Rectum. 2011 May. 54(5):570-8. [Medline].
Earnshaw SR, Kauf TL, McDade C, et al. Economic impact of alvimopan considering varying definitions of postoperative ileus. J Am Coll Surg. 2015 Nov. 221(5):941-50. [Medline].
Taguchi A, Sharma N, Saleem RM, et al. Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med. 2001 Sep 27. 345(13):935-40. [Medline].
Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. 2007 Jan 1. 25(1):47-57. [Medline].
Tan EK, Cornish J, Darzi AW, Tekkis PP. Meta-analysis: Alvimopan vs. placebo in the treatment of post-operative ileus. Aliment Pharmacol Ther. 2007 Jan 1. 25(1):47-57. [Medline].
Zingg U, Miskovic D, Pasternak I, Meyer P, Hamel CT, Metzger U. Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial. Int J Colorectal Dis. 2008 Dec. 23(12):1175-83. [Medline].
Wiriyakosol S, Kongdan Y, Euanorasetr C, Wacharachaisurapol N, Lertsithichai P. Randomized controlled trial of bisacodyl suppository versus placebo for postoperative ileus after elective colectomy for colon cancer. Asian J Surg. 2007 Jul. 30(3):167-72. [Medline].
Traut U, Brugger L, Kunz R, et al. Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database Syst Rev. 2008 Jan 23. CD004930. [Medline].
Wattchow DA, De Fontgalland D, Bampton PA, Leach PL, McLaughlin K, Costa M. Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery - a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo. Aliment Pharmacol Ther. 2009 Nov 15. 30(10):987-98. [Medline].
Yeh YC, Klinger EV, Reddy P. Pharmacologic options to prevent postoperative ileus. Ann Pharmacother. 2009 Sep. 43(9):1474-85. [Medline].
Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum chewing stimulates early return of bowel motility after caesarean section. BJOG. 2009 Sep. 116(10):1334-9. [Medline].
Behm B, Stollman N. Postoperative ileus: etiologies and interventions. Clin Gastroenterol Hepatol. 2003 Mar. 1(2):71-80. [Medline].
Carter S. The surgical team and outcomes management: focus on postoperative ileus. J Perianesth Nurs. 2006 Apr. 21(2A Suppl):S2-6. [Medline].
Delaney CP, Senagore AJ, Viscusi ER, et al. Postoperative upper and lower gastrointestinal recovery and gastrointestinal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials. Am J Surg. 2006 Mar. 191(3):315-9. [Medline].
Houwen RH, van der Doef HP, Sermet I, et al. Defining DIOS and constipation in cystic fibrosis with a multicentre study on the incidence, characteristics, and treatment of DIOS. J Pediatr Gastroenterol Nutr. 2010 Jan. 50(1):38-42. [Medline].
Jones MP, Wessinger S. Small intestinal motility. Curr Opin Gastroenterol. 2006 Mar. 22(2):111-6. [Medline].
Mattei P, Rombeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg. 2006 Aug. 30(8):1382-91. [Medline].
Moore BA, Albers KM, Davis BM, Grandis JR, Toögel S, Bauer AJ. Altered inflammatory gene expression underlies increased susceptibility to murine postoperative ileus with advancing age. Am J Physiol Gastrointest Liver Physiol. 2007 Jun. 292(6):G1650-9. [Medline].
Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs. 2006 Jun. 15(6):696-709. [Medline].
Person B, Wexner SD. The management of postoperative ileus. Curr Probl Surg. 2006 Jan. 43(1):6-65. [Medline].
Saclarides TJ. Current choices--good or bad--for the proactive management of postoperative ileus: A surgeon's view. J Perianesth Nurs. 2006 Apr. 21(2A Suppl):S7-15. [Medline].
Saunders MD. Acute colonic pseudo-obstruction. Gastrointest Endosc Clin N Am. 2007 Apr. 17(2):341-60, vi-vii. [Medline].
Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg. 2006 Feb. 141(2):174-6. [Medline].
Sumi T, Katsumata K, Tsuchida A, Sonoda I, Shimazu M, Aoki T. Evaluation of sequential organ failure assessment score for patients with strangulation ileus. Langenbecks Arch Surg. 2010 Jan. 395(1):27-31. [Medline].
Sutton DH, Harrell SP, Wo JM. Diagnosis and management of adult patients with chronic intestinal pseudoobstruction. Nutr Clin Pract. 2006 Feb. 21(1):16-22. [Medline].
Sanger GJ, Furness JB. Ghrelin and motilin receptors as drug targets for gastrointestinal disorders. Nat Rev Gastroenterol Hepatol. 2016 Jan. 13(1):38-48. [Medline].
Mosinska P, Zielinska M, Fichna J. Expression and physiology of opioid receptors in the gastrointestinal tract. Curr Opin Endocrinol Diabetes Obes. 2016 Feb. 23(1):3-10. [Medline].
Johnson MD, Walsh RM. Current therapies to shorten postoperative ileus. Cleve Clin J Med. 2009 Nov. 76(11):641-8. [Medline].
Park JS, Kim J, Jang WS, et al. Management of postoperative ileus after robot-assisted laparoscopic prostatectomy. Medicine (Baltimore). 2018 Nov. 97(44):e13036. [Medline].
Alhashemi M, Fiore JF Jr, Safa N, et al. Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway. Surg Endosc. 2018 Oct 17. [Medline].

Media Gallery

Postoperative ileus after an open cholecystectomy.
Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.
Mechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon.
Contrast study, in the same patient as in the previous image with mechanical bowel obstruction due to a left colon carcinoma. This image shows the classic "apple-core" lesion of colon carcinoma.

of 4

	Ileus	Pseudo-obstruction	Mechanical Obstruction (Simple)
Symptoms	Mild abdominal pain, bloating, nausea, vomiting, obstipation, constipation	Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia	Crampy abdominal pain, constipation, obstipation, nausea, vomiting, anorexia
Physical Examination Findings	Silent abdomen, distention, tympanic	Borborygmi, tympanic, peristaltic waves, hypoactive or hyperactive bowel sounds, distention, localized tenderness	Borborygmi, peristaltic waves, high-pitched bowel sounds, rushes, distention, localized tenderness
Plain Radiographs	Large and small bowel dilatation, diaphragm elevated	Isolated large bowel dilatation, diaphragm elevated	Bow-shaped loops in ladder pattern, paucity of colonic gas distal to lesion, diaphragm mildly elevated, air-fluid levels

Author

Burt Cagir, MD, FACS Clinical Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Guthrie Robert Packer Hospital; Attending Surgeon, Guthrie Robert Packer Hospital and Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, Association of Program Directors in Surgery, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Acknowledgements

Avram M Cooperman, MD Professor of Surgery and Radiation Oncology, Cabrini Medical Center