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Originally Posted by usmlemate
A 12-year-old boy has recently had an appendectomy for acute appendicitis. Four days after the operation he developed abdominal distention, absolute constipation, and effortless vomiting. On present examination the patient is anxious and uncomfortable. The abdomen is distended, silent, and tender. A plain x-*** of the abdomen showed gas distributed throughout the small and large gut and some fluid levels were present. He was diagnosed to have advanced paralytic ileus secondary to generalized peritonitis (login to see figure 1). The best treatment in addition to the usual supportive measures would be:
A. High doses of Ilopan and Prostigmin
B. Prompt reoperation to place multiple drains and search for local abscesses
C. Prompt reoperation to drain the obstructed intestine by ileostomy
D. Fibrinolysis to ablate adhesions
E. Intestinal intubation and continuous suction
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The correct answer is E. Intestinal intubation and continuous suction
Some degree of paralytic ileus occurs after every laparotomy. Its etiology is complex. This includes:
sympathetic over action
the effects of manipulation of the bowel
potassium depletion (where there has been excessive pre-operative vomiting)
peritoneal irritation from blood or associated peritonitis, and
the atony of the stomach and the large bowel.
The above occur after every abdominal operation for a period of about 24 to 48 hours. The distention which occurs on the first and second postoperative day is probably produced by swallowed air passing through the small intestine, where peristalsis usually remains fairly normal post-operatively, to the colon, which is atonic and produces a functional hold up.
Paralytic ileus, which persists for more than 48 hours post-operatively, probably has some other etiological factor present. In the established case of paralytic ileus, continuous nasogastric suction is employed to remove swallowed air and prevent gaseous distention. The aspiration of the fluid also helps to relieve the associated gastric dilatation. Intravenous fluid and electrolytes are instituted with careful biochemical control. Pethidine and chlorpromazine are used to allay discomfort and nausea. Eventually patience is rewarded and recovery from the ileus will occur unless it is secondary to some underlying cause, such as infection.
In the absence of any evidence of mechanical obstruction or infection, prolonged stubborn ileus is occasionally treated pharmacologically by means of guanethidine in order to block sympathetic inhibition of the intestine, this is followed by parasympathetic stimulation, either with a cholinergic agent (bethanecol chloride) or an anticholinesterase drug (e.g. Prostigmin). One should not initially stimulate the bowel with parasympathomimetic drugs.
Reoperation should not be planned because it may be possible to control infection by antibiotics in the hope that the ileus will resolve.
Fibrinolysis has no place in the management of intestinal ileus.