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Management of Postoperative Ileus

12/1/2015 - Sarah M. Appleton, MD

Mentor: L. Chesney Thompson, MD

Editor: Martin E. Olsen, MD

Postoperative ileus is a loss of motility or abnormal peristalsis after surgery causing a functional obstruction without mechanical blockage.  A physiologic ileus can occur up to 72 hours after surgery.  When the ileus is prolonged, creating patient discomfort, intolerance of oral intake, and prolonged hospitalization, it must then, however, be differentiated from other postoperative complications and managed appropriately.

Many risk factors for postoperative ileus exist.  These include: prolonged abdominal or pelvic surgery, laparotomy (which necessitates more bowel manipulation), lower gastrointestinal surgery, intra-abdominal infection, intraoperative bleeding, and narcotic use.

A patient with ileus after surgery typically complains of bloating, increasing abdominal pain, nausea, vomiting, intolerance of oral diet, and absent or minimal flatus.  These symptoms are consistent with a differential diagnosis that includes ileus, small bowel obstruction, bowel injury, intra-abdominal or retroperitoneal bleeding, or intra-abdominal abscess.  Laboratory evaluation is warranted; this includes a complete blood count, electrolytes, creatinine, blood urea nitrogen, amylase, lipase, and liver function tests.  Plain abdominal films can assist in differentiating ileus from small bowel obstruction.  Patients with ileus will have dilated loops of bowel and air in the colon and rectum whereas those with a small bowel obstruction will have air fluid levels and may demonstrate a transition point.  A transition point is represented on imaging as the area between dilated loops of small bowel followed abruptly by decompressed small bowel distally.

Once the diagnosis of ileus has been established, conservative treatment should be initiated.  The patient should have nothing by mouth and nutritional status should be maintained with intravenous fluids.  Electrolytes, including magnesium, should be monitored and replaced as appropriate. Hypokalemia may cause exacerbation of the ileus.  Close observation is recommended to assess for deterioration or a lack of improvement. Narcotic medications should be minimized as they may prolong the recovery process; nonsteroidal anti-inflammatory drugs may be used to manage pain control. 

Patients with persistent vomiting or significant abdominal distention may benefit from decompression of the bowel; this can be accomplished with a nasogastric tube.  When the output of the nasogastric tube is minimal and the patient’s bowel demonstrates return of function, the nasogastric tube should be removed.  If a patient experiences further decompensation or does not improve after 24-48 hours of supportive therapy, additional evaluation, including consideration of computed tomography of the abdomen and pelvis, is warranted to assess for other postoperative complications as discussed in the differential diagnosis above. 

Further Reading:

Antosh DD et a, A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery. Int J Gynecol Obstet. 2013 Aug;122:108-11

Vather R, Bisset I.  Management of prolonged post-operative ileus: evidence-based recommendations.  ANZ J Surg. 2013 May;83(5):319-24

Initial Approval:  March 2010; Revised February 2017

 

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