paralytic ileus secondary to generalized peritonitis

[usmlemate]

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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-ray 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

[Asclepius1]

Is it High doses of Ilopan and Prostigmin ?

[tranlong]

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-ray 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

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.

[Asclepius1]

My father is in hospital recovering from aorta enurisym in stomach, 2 weeks ago, he has a lazy bowel, exrayed, and reoperated on and there is no bowel obstruction. He is extremely distressed. Hungry, and no bowel movements. Has a bile removing tube in his nose. What can he do whilst recovering to stimulate his bowel into action. Thank you from a worried daughter

[Asclepius1]

Originally Posted by *****e L

My father is in hospital recovering from aorta enurisym in stomach, 2 weeks ago, he has a lazy bowel, exrayed, and reoperated on and there is no bowel obstruction. He is extremely distressed. Hungry, and no bowel movements. Has a bile removing tube in his nose. What can he do whilst recovering to stimulate his bowel into action. Thank you from a worried daughter

[jack1]

Hi everybody,
Well stomach is very sensitive and very important portion of our body most of the disorder started from the stomach .Postoperative ileus is also one of them .There are too much problems come due to the weakness of stomach. Gastrografin dosages are using for the relaxation for such type of huge troubles. Ulcer, Diverticulum, Small bowel obstruction are the examples of disorders which can be removed by using this.

[AUCMD2006]

gastrogafin? what mechanism? gastrogaffin is HIGHLY water soluble which is why you get such poor images with it. as soon as it is infused it dilutes out?

aortic aneurysm in the stomach? you mean an abdominal aortic aneurysm? maybe there is a damaged nerve or the graft is compromising some arterial outlet. an aretriogram would show vascular cmpromise and a barium study woudl show level of problem. if either show block at level of aneurysm he may need a gastrectomy or bowel ressection eventually. maybe putting a jejunostmy feeding tube letting the upper bowel rest for a while then seeing if function returns would work?
for now TPN and NG suction is all you can do since there is no way to speed up bowel recovery.

that is my take based on my limited knowledge base. anyone else?

and the answer is E

[draft]

Why isnt the answer B? - that's what I would think the answer is. A serious infection like htis generally needs to be drained and cleaned out in addition to antibiotics.

And what's "intestinal intubation" does that mean NG suction?

With further thinking today, i'm most likely wrong.
You're right with E.