Subinternship Surgery · Year 4 · from Subinternship Surgery

Case 1: Managing Postoperative Ileus and Pain

Patient Presentation

Demographics: 52-year-old female

Chief Complaint: POD 3 following open sigmoid colectomy for diverticular disease

History of Present Illness: Ms. Rodriguez underwent an elective sigmoid colectomy with primary anastomosis for recurrent diverticulitis. She has been progressing slowly postoperatively with persistent nausea and abdominal distension. No flatus or bowel movement since surgery.

Post-Operative Course:

  • POD 0-1: Stable, started on clear liquids per ERAS protocol
  • POD 2: Nausea with attempted diet advancement, returned to NPO
  • POD 3: Continued distension, complaining of diffuse crampy abdominal discomfort

Current Medications:

  • Hydromorphone PCA 0.2mg q8min (using 15mg/day total)
  • Ondansetron 4mg IV q8h PRN
  • Enoxaparin 40mg SQ daily
  • IV LR at 100 mL/hr

Physical Examination:

  • Vitals: T 37.6C, HR 94, BP 118/72, RR 16
  • Abdomen: Moderately distended, tympanic to percussion, diffusely tender without peritoneal signs, hypoactive bowel sounds, wound intact with staples
  • JP drain: 25mL serosanguinous over 24h

Laboratory Studies:

  • WBC: 11,200 (down from 13,000 POD 1)
  • K: 3.2 mEq/L
  • Mg: 1.6 mg/dL

Imaging:

  • KUB: Dilated loops of small bowel with air-fluid levels, no free air, gas present in colon

Clinical Questions

  1. Is this ileus or mechanical small bowel obstruction? How do you differentiate?

| Feature | Ileus | Mechanical SBO | |---------|-------|----------------| | Timing | Early postop (expected POD 1-5) | Later (often >POD 5-7) | | Bowel sounds | Absent or hypoactive | High-pitched, hyperactive | | Pain character | Diffuse, mild | Colicky, cramping | | Distension | Diffuse | May be localized | | Imaging | Diffuse dilation, no transition | Clear transition point | | Flatus | Absent | May have initially, then stops |

Assessment: This is postoperative ileus

  • Timing appropriate (POD 3)
  • Diffuse dilation without transition point
  • Hypoactive bowel sounds
  • No peritoneal signs concerning for leak or obstruction
  1. What factors are contributing to her ileus, and what interventions can help?

Contributing Factors & Interventions:

| Factor | Intervention | |--------|--------------| | High opioid use (15mg hydromorphone/day) | Transition to multimodal: scheduled acetaminophen, ketorolac if safe, gabapentin; reduce PCA demand dose | | Hypokalemia (K 3.2) | Replete K to >4.0 mEq/L | | Low magnesium (1.6) | Replete Mg to >2.0 mg/dL | | Limited mobility | Increase ambulation to QID with assistance | | Continued NPO | Continue NPO but consider NGT if worsening |

Additional Measures:

  • Gum chewing (sham feeding stimulates motility)
  • Ensure SCDs on, not causing discomfort limiting mobility
  • Consider alvimopan (Entereg) if available and indicated
  1. Her pain is not well-controlled despite PCA. How do you optimize multimodal analgesia?

Multimodal Pain Management Protocol:

| Agent | Dose | Mechanism | Notes | |-------|------|-----------|-------| | Acetaminophen | 1g IV/PO q6h scheduled | Central/peripheral | First-line, no GI effects | | Ketorolac | 15-30mg IV q6h x 48h | NSAID | Check renal function, avoid if Cr elevated | | Gabapentin | 100-300mg TID | Neuropathic | Reduces opioid requirements | | Lidocaine patch | 5% over incision | Local anesthetic | Non-systemic option |

Reduce PCA:

  • Decrease demand dose to 0.15mg
  • Add 4-hour lockout maximum
  • Goal: 50% reduction in opioid use
  1. On POD 4, she develops tachycardia (HR 112) with a temperature of 38.6C. What is your differential and workup?

Differential Diagnosis (5 W's + anastomotic leak):

  1. Anastomotic leak (HIGH PRIORITY) - Tachycardia often first sign
  2. Wind - Pneumonia/atelectasis
  3. Water - UTI
  4. Wound - SSI (early for POD 4)
  5. Walking - DVT/PE
  6. Wonder drugs - Drug fever

Workup:

  • CBC, BMP, lactate, procalcitonin
  • Blood cultures x 2
  • Urinalysis and culture
  • Chest X-ray
  • CT abdomen/pelvis with IV and oral contrast (rule out leak)
  • Consider lower extremity duplex if PE suspected

If CT shows anastomotic leak:

  • NPO, IV fluids, broad-spectrum antibiotics
  • Surgical consultation for washout vs. IR drainage
  • Notify attending immediately

Clinical Image

Image: Plain abdominal radiograph demonstrating dilated loops of small bowel consistent with ileus. Note the diffuse distribution of gas without a clear transition point. Source: Wikimedia Commons. License: CC BY-SA 3.0.

Image Attribution: Ileus X-ray. Wikimedia Commons. CC BY-SA 3.0.

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