Management of postoperative ileus

May 1, 2008

Postoperative ileus is a common result after major abdominal surgery, and frequently resolves within days after surgery. However, prolonged ileus can result in increased pain and morbidity and increased time to hospital discharge. A multimodal approach using preventive and therapeutic strategies can definitively mange postoperative ileus.

Key Points

Clinical consequences of postoperative ileus can be profound. Discomfort and pain related to postoperative ileus contribute to overall postoperative pain and lead to decreased mobility. The resulting decrease in mobility can lead to increased morbidity, including pulmonary complications such as atelectasis and pulmonary embolism. Moreover, postoperative ileus mitigates the benefits of enteral feeding on the immune system and the associated decreased risk of infections.2 Collectively, these problems result in increased length of hospital stay and health care costs. The economic impact of ileus is profound: an estimated $750 million to $1 billion in the United States.3,4

Clinical features

Other common physical findings include abdominal distention and tympany to percussion. Abdominal tenderness is a nonspecific finding, and may be simply related to incisional pain. However, significant tenderness should raise alarm for more significant pathology, such as bowel injury or ischemia.

When ileus is prolonged, it is imperative to rule out other etiologies for the derangement in bowel function, such as mechanical bowel obstruction and acute colonic pseudo-obstruction. Causes of mechanical bowel obstruction in the postoperative period include adhesions, hematomas, abscesses, intussusception, and ischemic stricture.6

Clinically, patients with obstruction present with severe cramping and abdominal pain that is paroxysmal in nature, and auscultation may reveal high-pitched tinkling sounds associated with gurgles and rushes. Persistent fevers, elevated white blood cell count, or decreasing hematocrit should raise suspicions for intra-abdominal processes such as abscesses or hematomas. Localized tenderness, fever, tachycardia, and peritoneal signs suggest bowel ischemia or perforation, a condition necessitating surgical intervention. Although bowel injury during laparoscopic urologic surgery is rare, if left uncorrected, its sequelae may be devastating, including cardiopulmonary arrest and subsequent sepsis.7 Persistent focal pain in a trocar site with abdominal distention, diarrhea, and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury, and should therefore be taken very seriously.