A 45-year-old woman is evaluated on postoperative day 3 due to nausea and vomiting. The patient underwent a total abdominal hysterectomy for symptomatic uterine fibroids, and the surgery was complicated by ureter injury and stent placement. She was placed on a clear liquid diet on postoperative day 2, when she began to have some nausea. Since then, the patient has had multiple episodes of vomiting but no hematemesis. She has not passed flatus or had a bowel movement since the surgery. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 80/min. The abdomen is mildly distended and has decreased bowel sounds. The incision is tender to palpation but has no surrounding erythema or discharge. Laboratory results are as follows: Abdominal x-ray is shown in the exhibit. In addition to intravenous fluid administration, which of the following is the best next step in the management of this patient?

Question

A 45-year-old woman is evaluated on postoperative day 3 due to nausea and vomiting.  The patient underwent a total abdominal hysterectomy for symptomatic uterine fibroids, and the surgery was complicated by ureter injury and stent placement.  She was placed on a clear liquid diet on postoperative day 2, when she began to have some nausea.  Since then, the patient has had multiple episodes of vomiting but no hematemesis.  She has not passed flatus or had a bowel movement since the surgery.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 80/min.  The abdomen is mildly distended and has decreased bowel sounds.  The incision is tender to palpation but has no surrounding erythema or discharge.  Laboratory results are as follows:  Abdominal x-ray is shown in the exhibit.  In addition to intravenous fluid administration, which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d896_a1a2_bc81_7308fd32f4cc_MD0003_00 This patient with vomiting and abdominal distension on postoperative day 3 likely has a prolonged postoperative ileus-delayed return of bowel function >72 hours after surgery. Risk factors include surgical complications (eg, ureteral injury), bowel manipulation (eg, laparotomy), and longer surgery duration due to increased intraabdominal inflammation and elevated sympathetic nervous system tone. Patients with postoperative ileus have temporary bowel paralysis (ie, no forward peristalsis), causing backup of gastric secretions and gas that results in abdominal distension and vomiting (eg, hypokalemia, dehydration [elevated creatinine]). Other signs include decreased bowel sounds and absent flatus. Diagnosis is primarily clinical, although imaging can help differentiate ileus from small bowel obstruction (SBO). Abdominal x-rays in patients with ileus typically reveal uniformly dilated bowel loops due to generalized bowel paralysis throughout both small and large bowel. In contrast, patients with SBO have a discrete transition point (ie, the obstruction) that results in dilated small bowel proximal to the obstruction and decompressed large bowel (ie, absent rectal gas) distally. ileus SBO Postoperative ileus typically self-resolves as bowel motility gradually returns; therefore, patients are conservatively managed with antiemetics, bowel rest, and serial examinations. Opiates, which further decrease bowel motility, should be avoided if possible. (Choice B) Broad-spectrum antibiotics are used to treat abdominal infections (eg, acute diverticulitis), not postoperative ileus. This patient is afebrile, has a normal incision, and does not have leukocytosis, making infection unlikely. (Choice C) A rectal enema can treat constipation by increasing pressure against impacted stool. It does not treat ileus and may worsen symptoms (ie, cause more bowel distension) by increasing intraluminal pressure. (Choice D) Small bowel follow-through can be used to diagnose SBO by demonstrating differences in the flow of contrast proximal and distal to an obstruction. It has limited utility in patients with postoperative ileus because bowel dysmotility is generalized. (Choice E) Urgent surgical exploration is indicated in patients with an acute abdomen (eg, perforated bowel). It is not indicated for postoperative ileus unless there are changes between serial examinations (eg, new rebound/guarding). Educational objective: Prolonged postoperative ileus, the delayed return of bowel function >72 hours after surgery, is typically self-resolving; therefore, management is conservative with bowel rest and serial examinations. References: Postoperative ileus: pathophysiology, current therapeutic approaches. (http://www.ncbi.nlm.nih.gov/pubmed/27999957) Postoperative ileus. (http://www.ncbi.nlm.nih.gov/pubmed/31061645)

A 45-Year-Old Woman Is Evaluated on Postoperative Day 3 Due