Medical Care
The management of ileus may vary greatly depending on the nature of the disease and the surgical procedure. Management of ileus starts with correction of underlying medical conditions, electrolyte abnormalities, and acid base abnormalities.
Most cases of postoperative ileus resolve with watchful waiting and supportive treatment. Patients should receive intravenous hydration. For patients with vomiting and distention, use of a nasogastric tube provides symptomatic relief; however, no studies in the literature support the use of nasogastric tubes to facilitate resolution of ileus. Long intestinal tubes have no benefit over nasogastric tubes. For postoperative patients receiving vasopressor support, limited data suggest that these patients can be safely initiated and advanced on enteral nutrition; clinicians must take into account the specific vasopressor agent, its dose and changes in regimen, as well as the patient's clinical condition and characteristics. [31]
For patients with protracted ileus, mechanical obstruction must be excluded with contrast studies. Underlying sepsis and electrolyte abnormalities, particularly hypokalemia, hyponatremia, and hypomagnesemia, may worsen ileus. These contributing conditions are easily diagnosed and corrected.
Discontinue medications that produce ileus (eg, opiates). In one study, the amount of morphine administered directly correlated with the time elapsed before the return of bowel sounds and the passage of flatus and stool. [32]
The use of postoperative narcotics can be diminished by supplementation with nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to permitting lower narcotic doses by providing pain relief, NSAIDS may improve ileus by reducing local inflammation. An international multicenter prospective study is in progress to evaluate gastrointestinal recovery following colorectal surgery as well as to assess the role of NSAIDs in accelerating the return of gastrointestinal function. [1] Myoelectric activities recorded from electrodes placed on the colon have revealed faster resolution from ileus in patients given ketorolac versus those given morphine [33] ; however, the drawbacks of NSAID use include platelet dysfunction and gastric mucosal ulceration. Consider the use of a cyclooxygenase-2 selective agent (ie, celecoxib), which negates these adverse effects.
No single objective variable accurately predicts the resolution of ileus. The clinician must assess the overall status of the patient and evaluate for adequate oral intake and good bowel function. A patient's report of flatus, bowel sounds, or stool passage may prove misleading; therefore, clinicians must not rely solely on self-reporting. Indeed, findings from a systematic review indicate that the best clinical endpoint of postoperative ileus is postoperative defecation in conjunction with solid food tolerance, whereas other clinical signs such as the presence of bowel sounds and the passage of flatus don't appear to correlate with complete recovery of bowel motility. [25]
Surgical Care
Yang and Morgan suggest that postoperative restoration of bowel function following a Hartmann procedure using a laparoscopic approach is not only safe and effective but also may result in significantly faster recovery time and fewer postprocedure complications compared to the open approach; therefore, it may be a viable alternative to open Hartmann reversal. [34] Their retrospective study of reversal of Hartmann procedure (2001-2012) comprised 43 patients who underwent laparoscopic reversal and 64 patients who underwent the open reversal procedure.
Although the operative time was longer for the laparoscopic group compared to the open procedure group (276.4 mins vs 242.0 mins; P = 0.02), the time to passage of flatus (2.8 vs 4.0 days; P< 0.001) and feces (4.2 vs 5.6 days; P = 0.02) and the hospital stay (6.7 vs 10.8 days; P< 0.001) were shorter and there were fewer postprocedure complications (14% vs 31%; P = 0.04) in the laparoscopic group. [34] Postoperative ileus occurred in 2% of patients in this group compared to 17% in the group who underwent the open reversal procedure (P = 0.02). However 3 of 43 patients (7%) required conversion to laparotomy. [34]
Encapsulating peritoneal sclerosis is a rare cause of ileus in renal transplant patients during or following peritoneal dialysis. [23] In a case report of 3 patients with this unusual complication, 1 patient improved with conservative therapy and the remaining 2 patients eventually underwent surgical intervention after a long trial of medical management. The authors of the report advised that, before renal transplantation, obtain a detailed history to evaluate for the presence of intermittent bowel obstruction (ie, symptoms) from patients who have previously received peritoneal dialysis. [23]
Diet
It is generally advisable to delay oral feeding until ileus resolves clinically. However, the presence of ileus does not preclude enteral feeding. Postpyloric feeding into the small bowel can be cautiously performed. Start feeds at one-quarter or one-half strength at a slow rate and gradually advance.
Having patients chew gum has been advocated as a means of promoting recovery from postoperative ileus. Chewing gum may constitute a form of sham feeding that stimulates gastrointestinal motility. Meta-analyses have shown that gum chewing can reduce the time to first flatus and passage of feces, and marginally decrease the length of hospital stay after intestinal surgery. [5, 35, 36, 37]
Activity
Conventional wisdom and wide practice foster the notion that ambulation stimulates bowel function and improves postoperative ileus, although this has not been shown in the literature.
In a nonrandomized study evaluating 34 patients, seromuscular bipolar electrodes were placed in segments of the gastrointestinal tract after laparotomy. Ten patients were assigned to ambulate on postoperative day 1, and the other 24 were assigned to ambulate on postoperative day 4. No significant difference between the two groups was displayed in myoelectric recovery in the stomach, jejunum, or colon. [38] Hence, postoperative ambulation remains beneficial in preventing the formation of atelectasis, deep vein thrombosis, and pneumonia but has no role in treating ileus.
Prevention
Enhanced recovery after surgery (ERAS) protocols are being used more and more frequently to decrease the incidence and reduce the duration of postoperative paralytic ileus. These protocols include shorter duration of fasting (2-3 hours for clear fluids), high carbohydrate fluid, no nasogastric tube (NGT), early mobilization, restricted intravenous fluids, early oral feeding, no opiates, analgesia using paracetomal and nonsteroidal anti-inflammatory drugs (NSAIDs), and epidural catheter for postoperative analgesia.
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Postoperative ileus after an open cholecystectomy.
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Ogilvie pseudo-obstruction in a septic elderly patient. Note the massive dilatation of the colon, especially the right colon and cecum.
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Mechanical bowel obstruction due to a left colon carcinoma. Note the paucity of bowel gas throughout the colon.
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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.
Tables
|
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 |
