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The Ileus and Oddities After Colorectal Surgery

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The Ileus and Oddities After Colorectal Surgery Tonna McCutcheon , MSN, APRN-BC, CGRN 3.8 ANCC Contact Hours The Ileus and Oddities After Colorectal Surgery ABSTRACT Colorectal surgery is a necessity for many disease processes such as diverticulitis, ulcerative colitis, Crohn disease, and colorectal cancers as well as for the many complications of such conditions. The incidence of overall complications related to colorectal surgery has been reported to be between 10% and 30%. Prevention is the necessary key to avoid complications and this may be improved by adequate selection of appropriate procedures for the patient, good surgical technique, and good postoperative care. Nevertheless, complications do occur intraoperatively or postoperatively and must be managed in a timely manner to improve overall patient outcomes. Such complications include paralytic ileus, anastomotic leak, abdominal sepsis, acute mesenteric ischemia, anastomotic bleeding and hemorrhage, wound infec- tion, anastomotic dehiscence and fi stula formation, small bowel obstruction, and genitourinary complications. olorectal surgery is a necessity for many dis- Postoperative Ileus ease processes as well as for the many com- A postoperative ileus is defined as a temporary paraly- plications that accompany such conditions. sis of a portion of the intestines after abdominal sur- The incidence of overall complications relat- gery. This paralysis is a normal physiological response Ced to colorectal surgery has been reported to be between most often involving the sigmoid colon and resolves in 10% and 30% (Ruis-Tovar, Morales-Castinerias, & 2–3 days postoperatively. Fifty percent of major Lobo-Martinez, 2010). The American Society of abdominal surgeries result in a postoperative ileus Colorectal Surgeons (ASCRS) reported that over an ( Senagore , 2007). If paralysis persists, it is known as a 8-year period (1988–1994), the mortality rate for paralytic or adynamic ileus and is then considered a patients undergoing colorectal surgery was 1.4% if the complication of surgery. A paralytic ileus occurs after procedure was performed by a board-certified colorec- intraperitoneal, retroperitoneal, or extra-abdominal tal surgeon as compared with a 7.3% mortality rate surgery but colonic surgery has the highest rate of when performed by other surgeons (ASCRS, 1996). paralytic ileus with laparoscopic colon surgery having Prevention of complications may be improved by ade- lower occurrence than open colonic procedures ( Cagir , quate selection of appropriate procedures for the 2013). patient, good surgical technique, and good postopera- tive care. Nevertheless, complications do occur intraop- eratively and/or postoperatively and must be managed Causes in a timely manner to improve overall patient outcomes. In general, an ileus causes backup of gas and fluids in the colon and may occur because of activation of Received January 20, 2012; accepted April 26, 2012. inhibitory spinal reflex arcs. Long reflexes involving the spinal cord are linked and spinal anesthesia, About the author: Tonna McCutcheon, MSN, APRN-BC, CGRN, is Colorectal Acute Care Nurse Practitioner, Vanderbilt Medical Center, abdominal sympathectomy, or cutting of nerves may Nashville, Tennessee. lead to a temporary paralysis of the bowel. Another The author declares no conflict of interest. thought is a surgical stress response that causes inflam- Correspondence to: Tonna McCutcheon, MSN, APRN-BC, CGRN, matory and endocrine mediators to be released, thus Vanderbilt Medical Center, 1121 21st Ave. S, S-5410 MCN, Nashville, leading to bowel paralysis. Other reported causes of an TN 37232 ( [email protected] ). ileus include medications (warfarin [Coumadin], opi- DOI: 10.1097/SGA.0b013e3182a71fdf oids, antacids, amitriptyline, and chlorpromazine), 368 Copyright © 2013 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing Copyright © 2013 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited. SSGA200343.inddGA200343.indd 336868 226/09/136/09/13 88:06:06 PPMM The Ileus and Oddities After Colorectal Surgery hypokalemia, hyponatremia, hypomagnesemia, ane- and includes removal of obstruction, repair of hernias, mia, intra-abdominal inflammation or peritonitis, sur- lysis of adhesions, and resection of any ischemic bowel gical manipulation of the intestine, effects of anesthe- ( Ansari , 2012). sia, and retroperitoneal hematomas ( Oncel & Remzi , Pseudo-obstruction is the acute marked distention 2003). Resolution of an ileus is from the proximal or of the large bowel in the absence of definable mechan- right colon to the distal or left colon. Normally the ical pathology (National Digestive Diseases Information small bowel regains function within hours whereas it Clearinghouse, 2013) and is most often limited to and may take 3–5 days for the colon to regain function. occurs in the right colon. Causes and risk factors for development of a pseudo-obstruction include elderly Signs and Symptoms bedridden patients, trauma patients, medications, sep- Signs and symptoms of a paralytic ileus include mild sis, electrolyte imbalance, and aerophagia (swallowing abdominal pain and bloating, nausea, vomiting, poor of too much air). Signs and symptoms include abdom- appetite, distended and tympanic abdomen, constipa- inal distention without pain or tenderness, nausea, tion, obstipation, absent or hypoactive bowel sounds, vomiting, constipation, obstipation, anorexia, hypoac- and passing flatus or stool. Bowel sounds should be tive or hyperactive bowel sounds, local tenderness, auscultated to help differentiate paralytic ileus from a borborygmi, and abdominal distention. mechanical ileus. Continued absence of bowel sounds Diagnosis is made from plain abdominal x-ray suggests paralytic ileus whereas hyperactive bowel films, which will indicate isolated proximal large sounds may indicate a mechanical ileus ( Ruis-Tovar bowel dilatation and an elevated diaphragm. A cecal et al. , 2010). diameter of greater than 12 cm indicates a high risk for cecal perforation, which has a subsequent mortality Differential Diagnoses rate of 50% if ischemic bowel develops, leading to Differential diagnoses for a paralytic ileus include perforation. Contrast imaging is also helpful in distin- mechanical bowel obstruction and pseudo-obstruction. guishing a pseudo-obstruction from a mechanical Mechanical bowel obstruction is defined as a complete obstruction as mentioned earlier. Treatment for a or partial obstruction of the bowel due to a physical pseudo-obstruction includes hydration, nasogastric blockage. It is more common in the small intestine (NG) tube placement, possible rectal tube placement, than in the colon and may be caused by neoplasm, correction of electrolyte imbalance, discontinuation of adhesions from previous surgeries, volvulus, hernia, medications that may promote immotility, or decom- Crohn disease, foreign bodies, and intussusceptions. pression by way of a colonoscopy. Another treatment Mechanical obstruction of the large intestine may be is the administration of intravenous (IV) neostigmine, caused by stricture, impacted feces, volvulus, diverticu- which will resolve a pseudo-obstruction within 10–30 litis, or colon cancer ( Mayo Clinic , 2012). minutes; however, it must be given under cardiac Signs and symptoms include severe abdominal monitoring because there is a high risk of bradycardia. cramping, constipation, obstipation, nausea, vomiting, Surgery is indicated if peritonitis, ischemia, or perfora- anorexia, borborygmi (rumbling sounds caused by gas tion is present and an exploratory laparotomy with moving throughout the intestine), high pitched tinkling bowel resection and placement of an ostomy is the sounds heard upon auscultation, abdominal disten- procedure of choice. tion, and localized tenderness may be present on physical examination. If the patient is thin, peristaltic Laboratory Data waves may be observed as well. If a complete obstruc- Abnormal laboratory values that are seen in a patient tion is present, the patient may present with constipa- experiencing a paralytic ileus include hypokalemia, tion, obstipation, vomiting (depending on the ileocecal hyponatremia, and hypomagnesemia. Leukocytosis valves ability to prevent reflux), and peritoneal signs if may be present; however, it is nonspecific and may be strangulated obstruction or perforation has developed. due to an infectious causes or hemoconcentration. Diagnosis of a mechanical obstruction is most often Serum amylase may increase and hypoproteinemia can made with the use of contrast imaging such as a com- also be present ( Ruis-Tovar et al. , 2010). puted tomographic (CT) scan that will suggest enlarged bow shaped loops of small bowel in a step like pattern, Radiographic Data a colonic gas pattern distal to the lesion, presence of Diagnosis of a paralytic ileus is made from plain air-fluid levels, and a mildly elevated diaphragm abdominal films or a CT scan. Plain films will indicate ( Cagir , 2013). Treatment for a partial mechanical dilatation of the small and large bowel as well as ele- obstruction includes bowel rest and a low-residue diet. vation of the diaphragm. Serial abdominal films are If the obstruction does not resolve or complete obstruc- done daily to evaluate for worsening of the ileus. Most tion is present, surgical intervention may be indicated often a paralytic ileus will resolve over time with VOLUME 36 | NUMBER 5 | SEPTEMBER/OCTOBER 2013 369 Copyright © 2013 Society of Gastroenterology Nurses and Associates.
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