I have a 25-year-old patient who underwent laparoscopic appendectomy for a ruptured appendix with peritonitis 9 days ago. He still has not opened bowels, has abdominal distension and one episode of vomiting. There is no fever/tachycardia/ hypotension. Bowel sounds are present. CECT revealed no collections, distended jejunum and large bowel, collapsed ileum and sigmoid colon. Sigmoidoscopy was normal, appendix HPE showed no TB or IBD.
He is now on TPN due to malnutrition, medications are erythromycin & mosapride, he is chewing gum daily.
Any thoughts?
He has clinically and radiologically small bowel obstruction possibly due to adhesions.
please do a ct enterography and proceed for diag lap.
Causes of obstruction after appendectomy are peritonitis due to rupture of appendicitis or early adhesions. I think you have to wait with medication (hidration, nasogastrik drenaige, antibotics). If you operate him, new adhesions can be occur. Operation must be performed when vomiting or distention increase.
Dear Dr. Reddy & Dr.Mayir,
Thanks very much for your input. Today he has moved bowels, no vomiting & abd. distension reduced from 71 cm to 69 cm (baseline was 68 cm). So for now I've decided not to operate.
I've recently had a similar case and 'twas mechanical obstruction due to jelly like adhesions near the stump/ligated mesoappendix. Sometimes you have to be bold and if there's no improvement go in. Although he's improved a little doesn't sound like much progress and the suggestion of a cut off on CT suggests mechanical obstruction rather than ileus.
Adhesions can develop very soon. Good luck and let us know how you get on.
BW,
John
Dr. Bunni - thanks for your interest in this case.
There was no cut-off on CT scan. Anyway, he improved over the weekend, he is now passing stools and flatus, so we started him on soft diet. He is being dishcarged today.
be very patient, 10 to 14 days perhaps, if the patient and you are lucky he will be fine after that time without operation.
Sounds good! Would be a hostile abdomen at this stage. Glad to hear he improved. I'm quite conservative but sometimes it's about recognising that window if opportunity for intervention. Fortunately all was good here.
Thanks for sharing that with us.
John
Thank you Dr. Bunni & Dr. Tuchmann for your support. These things are distressing for both patient & surgeon. I guess 'Patience is a virtue'
Hello,
Ileus can last for some time, and in this case has probably been provoked by residual sepsis in the abdominal cavity. I would advise broaden the IV anitbiotic spectrum and wait. It might help to start domperidone 10mg bd, as well as the rest. I recall some surgeons stating in the past that if a ruptured appendix with peritonitis is found on laparoscopy, then it is more prudent to convert to an open operation and do a thorough washout of the abdominal cavity, which I think might limit the course of any ileus should it occur. I would be interested to hear the panel's thoughts on this.
Dear Dr, Singh-Ranger,
I think you are absolutely right to say that thorough wash is vital in ruptured appendicitis, which is what we did in this case. Conversion to open may not be necessary in all cases, especially when expertise is readily available
One of my bosses a renowned Vascular surgeon made me wait for 21 days in a patient with ileus after I had done a leaking AAA repair. Every day he kept saying, "son patience is a virtue" I was told to make sure the patients urea and electrolytes were kept corrected. To my surprise it did work. Most of us as surgeons tend to be knife happy and possibly do not give nature enough chance to seat with the problems. Thank God i have never had this problem ever again.
I had a patient who had a postoperative paralytic ileus for 2 weeks following small and large bowel resection. It finally resolved.
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