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12/1/2015

Management of Postoperative Ileus

Postoperative ileus is an absent 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 be differentiated from other postoperative complications and managed appropriately.

Many risk factors for postoperative ileus exist, including prolonged abdominal or pelvic surgery, laparotomy (which necessitates more bowel manipulation), lower gastrointestinal surgery, intra-abdominal infection, intraoperative bleeding, and narcotic use. Enhanced Recovery After Surgery (ERAS) protocols incorporate efforts to prevent postoperative ileus through preoperative and postoperative interventions.

A patient with ileus after surgery typically complains of bloating, increasing abdominal pain, nausea, vomiting, intolerance of oral diet, and absent or minimal flatus.  The differential diagnosis for these symptoms includes ileus, small bowel obstruction, bowel injury, intra-abdominal or retroperitoneal bleeding, and intra-abdominal abscess.  Laboratory evaluation is warranted including 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 volume 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.

Patients with persistent vomiting or significant abdominal distention may benefit from decompression of the bowel with a nasogastric tube.  The nasogastric tube should be removed when the output of the nasogastric tube is minimal, and the bowel demonstrates return of function.  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.

Further Reading:

Antosh DD1, Grimes CL, Smith AL, et al, A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery. Int J Gynaecol Obstet. 2013 Aug;122(2):108-11. doi: 10.1016/j.ijgo.2013.03.014. Epub 2013 May 22.

Vather R, Bisset I.  Management of prolonged post-operative ileus: evidence-based recommendations.  ANZ J Surg. 2013 May;83(5):319-24. doi: 10.1111/ans.12102. Epub 2013 Feb 19.

Committee on Gynecologic Practice. ACOG Committee Opinion, #750 - Perioperative pathways: enhanced recovery after surgery. Obstet Gynecol. 2018 Sep;132(3):e120-e130. doi: 10.1097/AOG.0000000000002818. Erratum in: Obstet Gynecol. 2019 Jun;133(6):1288. Obstet Gynecol. 2019 Nov;134(5):1121.

 

Initial Approval: March 2010; Reaffirmed September 2018. Revised March 2020; Revised November 2021; Reaffirmed September 2023

 

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