Management of Postoperative Ileus

Abstract

Postoperative ileus is a clinical impediment of bowel function after recent surgical intervention with many different causative factors. It is characterized by symptoms similar to a mechanical bowel obstruction, and it is important to differentiate between the two. Management is usually supportive in nature and involves identification and treatment of the underlying cause. Prolonged ileus requires a thorough diagnostic investigation and, very rarely, surgical intervention.

Algorithmic Approach

• A. Postoperative ileus typically presents with symptoms of nausea, vomiting, abdominal pain, and abdominal distention postoperatively. Evaluation begins with a comprehensive history and physical examination. History should include assessment of a patient’s past medical history, events during the surgery, and current medications.

• B. After performing a history and physical exam, blood work should be obtained to look for elevations in white blood cells and changes in electrolytes. An abdominal X-ray with supine and upright images should be ordered to look for signs of bowel distention. This will confirm the diagnosis. If a patient develops fevers, tachycardia, peritoneal signs, and/or clinically deteriorates, this is an indication for operative exploration.

• C. Initial treatment for postoperative ileus is supportive. Treat any infectious process with appropriate antibiotics if needed. Provide proper fluid and electrolyte replacement. Medications that slow gastrointestinal (GI) motility, such as opiates, should be limited. Consider nasogastric tube (NGT) placement and supplemental nutrition. Patients should also be on bowel rest and have serial abdominal examinations.

• D. If disease is prolonged without any clinical improvement, a computed tomography (CT) scan may be required to look for certain treatable causes such as fluid collections or abscess formation. Specific disease processes should be treated accordingly. If there is no resolution of symptoms, surgical exploration may be necessary.

Algorithm 51.1