Case Details

General Surgery Surgical Gastroenterology

Indian Doctors Network posted a case

11 months ago

VOMITING AND ABDOMINAL DISTENSION

Courtesy: 100 cases in surgery

History
You are called to the ward at 3 a.m., to see a 20-year-old man with persistent vomiting. He had an emergency laparotomy 3 days previously. The doctor on call earlier had prescribed anti-emetics for the patient, without carrying out a full assessment. The patient is extremely distressed and the nurse in charge is concerned about his sudden deterioration. You retrieve
the operation note and find the patient had undergone a ‘normal’ laparotomy for trauma.
The small and large bowel were both examined carefully and no injury was found. He had made a good recovery and had been moved onto free fluids earlier in the day. There was no nasogastric tube left after the operation, and the urinary catheter had been removed.

Examination
The patient is rolling around in the bed having just vomited. His blood pressure is 120/75mmHg and pulse rate 110/min. He has a midline incision covered with a dry dressing.
The abdomen is distended and tympanic. On palpation, he is tender around the incision only. There are no bowel sounds on auscultation.

Questions
• What is shown on the abdominal X-ray?
• What are the most common causes?
• What is the most likely cause in this patient?
• How would you manage the patient?

ANSWER
When assessing a postoperative patient on the ward it is important to read the operation note as well as making a physical assessment. Unexpected findings or difficulties during the procedure should be documented, and this may aid your clinical decision making.
This patient has a postoperative paralytic ileus. An ileus is a normal physiological event after abdominal surgery. It usually resolves spontaneously within 2–3 days of the procedure. Paralytic ileus is defined as ileus of the intestine persisting for more than 3 days after surgery. His bowels had not returned to normal function by day 3 and he had started free fluids that morning. This resulted in vomiting and abdominal discomfort.
A nasogastric tube should be placed to decompress the bowel, and a urinary catheter inserted to monitor his urine output. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief, rather than opiates, as these will not affect bowel motility.

The most common cause of an ileus is an intra-abdominal operation. Other factors can prolong an ileus and should be looked for and corrected if possible. This patient has hypokalaemia which should be corrected.

Causes Of Ileus:
• Sepsis: intra-abdominal inflammation and peritonitis
• Drugs: opioids, antacids
• Metabolic: hypokalaemia, hyponatraemia, hypomagnesia, anaemia
• Myocardial infarction
• Pneumonia
• Head injury and neurosurgical procedures
• Retroperitoneal haematomas

For patients with protracted ileus, mechanical obstruction should be excluded by a smallbowel follow through or a computerized tomography scan. Before further investigation,
underlying sepsis or electrolyte abnormalities should be corrected. Medications that produce ileus (e.g. opiates) should also be stopped.

KEY POINTS
• Postoperative ileus should resolve after 2–3 days.
• Electrolyte abnormalities are a common cause of paralytic ileus during the postoperative period.



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