A 75-year-old woman presents to the emergency department with perforated diverticulitis and undergoes emergent surgery in which there is diffused fecal contamination. She is admitted to the ICU postoperatively, where she remains on broad-spectrum antibiotics and is hemodynamically stable. She is started on clear liquids on postoperative day 2. On postoperative day 4 her abdomen is distended, and she is vomiting and has no ostomy output. An abdominal X-ray shows diffusely dilated loops of small bowel.
What is the best next step in management of this patient?A. Nasogastric tube placement
Correct Answer: A
This patient has a postoperative ileus. Following any operation, there is a risk of postoperative ileus, and diffuse contamination is another risk factor. Additionally, opiates administered postoperatively may contribute to ileus. An ileus usually presents a few days after the operation with increased abdominal distention, nausea, and vomiting, along with minimal to no bowel function. The management of an ileus involves placement of a nasogastric tube for decompression, initiating intravenous fluids for resuscitation, minimizing narcotics, and electrolyte monitoring and repletion as needed. Often these will resolve on their own in several days, but if not resolving, particularly in the setting of a rising WBC or fevers, it may also be important to look for an underlying cause, such as abscess. At this point, there is no need for urgent reexploration. Enemas, while effective in the management of constipation, are not effective in helping resolve an ileus, as the issue is primarily one of reduced small bowel motility. Promotility agents are not effective in the management of ileus, and any delay in placement of a nasogastric tube (ie with attempted management solely with antiemetics) not only fails to resolve the ileus but may increase the risk of aspiration if the patient continues to vomit. Also, endoscopy is not necessary for diagnosis or treatment of ileus.