General Considerations

INTESTINAL OBSTRUCTION Ileus, a functional obstruction of the bowel, is postulated to be the result of stimulation of the splanchnic nerves, leading to neuronal inhibition of coordinated intrinsic bowel wall motor activity. It is expected after any operation in which the peritoneal cavity is violated. Following gastrointestinal surgery, small bowel tone usually returns to normal within 24 h, and colonic function within 3 to 5 days. 9 While ileus can also occur following nongastrointestinal procedures, it is usually secondary to anesthetic agents, and function returns to normal after 24 h. 9 Prolonged ileus can be caused by peritonitis, intraabdominal abscess, hemoperitoneum, pneumonia, electrolyte imbalance, sepsis, and medications.

Presenting symptoms of ileus include nausea, vomiting, obstipation, constipation, abdominal distention, and abdominal pain. When these symptoms are present in the first few days after surgery, they are most often due to adynamic ileus. The symptoms of adynamic ileus are most often mild and respond to nasogastric suction, bowel rest, and intravenous hydration. However, in cases of prolonged ileus, the physician must always look for an underlying cause. Evaluation of patients with suspected ileus includes abdominal radiographs to identify air-fluid levels, chest x-ray, CBC, electrolytes, and urinalysis for secondary causes of ileus.

Mechanical ileus of the bowel is most often secondary to adhesions. Small bowel obstruction above the ligament of Treitz is associated with frequent bouts of bilious emesis. In cases of more distal obstruction, pain and distention become more severe, the frequency and volume of vomiting decrease, and emesis becomes more feculent. Abdominal radiographs demonstrate multiple air-fluid levels and a paucity of gas in the colon; however, with high obstruction, above the ligament of Treitz, there may be no air-fluid levels. In the emergency department, differentiating between functional ileus and mechanical bowel obstruction can be difficult. Both disorders result in varying degrees of abdominal pain, distention, nausea, vomiting, and constipation. Once the diagnosis of mechanical obstruction is confirmed or suspected, surgical consultation is indicated.

INTRAABDOMINAL ABSCESS Intraabdominal abscess is caused most frequently by preoperative contamination, spillage of bowel contents during surgery, contamination of a hematoma, or postoperative anastomotic leaks. Patients may have abdominal pain, nausea, vomiting, ileus, abdominal distention, fever, chills, anorexia, and abdominal tenderness. If the diagnosis is suspected, CT or ultrasound studies of the abdomen are required. The patient should receive broad-spectrum antibiotics. Although some abscesses are amenable to percutaneous drainage, many patients require surgical exploration.

PANCREATITIS Pancreatitis following abdominal surgery is secondary to direct manipulation or retraction of the pancreatic duct. It most commonly occurs following gastric resection, biliary tract surgery, and endoscopic retrograde cholangiopancreatography (ERCP). Clinical presentation varies from mild nausea, vomiting, and abdominal discomfort to intractable vomiting, leukocytosis, and left pleural effusion. Severe hemorrhagic presentation can cause lumbar pain accompanied by blue-gray discoloration of the skin in the flank area (Turner sign) or similar changes around the umbilicus (Cullen sign). While the serum amylase level rises in acute pancreatitis, it is also elevated in patients with severe cholecystitis, renal insufficiency, intestinal obstruction, perforated ulcer, or ischemic bowel. A serum lipase measurement may help to identify those with true pancreatitis, although it may be elevated in a patient with a perforated viscus. Abdominal radiographs may show localized ileus in the region of the pancreas (sentinel loop). CT is useful in defining pancreatic fluid collections or abscesses. Generally, the treatment of postoperative pancreatitis is similar to the treatment of nonoperative pancreatitis: bowel rest, antiemetics, and nasogastric suction.

CHOLECYSTITIS Patients may present during the postoperative period with biliary colic, acute calculous cholecystitis, or acute acalculous cholecystitis. The etiology of these disorders in the postoperative period is not clear. Ultrasound studies of the gallbladder and pancreas should be performed to aid in the diagnosis.

Acalculous cholecystitis is of particular concern in the postoperative period. While it may occur in any age group, it seems to be more common in elderly males. Signs and symptoms are similar to those for calculous cholecystitis, but ultrasound studies fail to reveal gallstones. Liver function studies and the neutrophil count may be normal. Important findings on ultrasonography include gallbladder enlargement, wall thickening, and pericholecystic fluid collection. Hepatobiliary scintigraphy may be helpful. Early diagnosis is critical because early operative intervention can reduce morbidity and mortality rates.

FISTULAS Enterocutaneous fistulas can occur almost anywhere in the gastrointestinal tract and are usually the result of technical complications or direct bowel injury. High-output fistulas can result in electrolyte abnormalities and volume depletion. Fistulas involving the proximal gastrointestinal tract are frequently high output and are of the greatest concern. Sepsis is the other major complication. Most patients require admission, although many fistulas ultimately close spontaneously.

TETANUS While most cases of tetanus in the United States occur after minor trauma, there have been numerous reports of tetanus following general surgical procedures. Clostridium tetani is found in the gastrointestinal tract of 1 percent of the population.10 During gastrointestinal surgery, there is spillage of C. tetani. Proliferation of the organism is facilitated by the presence of devitalized tissue, blood clots, and surgical suture. Incubation can take from 1 to 54 days, at which time the toxin leads to clinical tetanus.11 The classic symptoms of tetanus, trismus and opisthotonos, may not be manifested at initial presentation. Patients may present with nonspecific symptoms of abdominal discomfort, fever, and abdominal wall rigidity. Diagnosis is based on physical examination and a history of inadequate immunization.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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