ilieus and how to dx and treat it

core0 · Apr 16, 2007

Hi all. I have had a few patients recently that have developed ilieus post c-section. I am putting this in the general thread because I know that patients develop it from other surgeries as well.
What I don't understand is what I can do to catch it early and hopefully prevent it. Usually when there is stomach pain, we start with pain meds, warm compresses and ambulation as a means of moving the gas through. Our patients are able to eat as soon as they are up to it, whether they have passed gas or not, which I think contributes to it.
Anyway, if it doesn't help they get softly distended and the normal nursing management is then more ambulation, warm drinks, no straws, simethicone as ordered.
The first patient that I had developed increasingly severe pain in her abdomen that worsened steadily, came and went, was only minimally helped with percocet and prevented her from ambulating. She also vomited from the pain. I ran like a madwoman calling doctors and went up the chain of command as best I could without much luck. I was told to 'continue to monitor'. By the grace of god the patient's attending came, took one look, ordered IV morphine stat and imaging. I found out the next day that the patient had a small ilieus that resolved on its own.
The second patient had some pain, not too much. Was softly distended but able to walk. We did hot packs and warm tea and pain meds and she was made comfortable. She ended up with a big ilieus and an NG tube.
Both patients were passing flatus, both were on percocet q4hprn, ibuprofen q6hprn, colace bid and simethicone pchs.
What on earth did I miss? Is there something that I can do to help prevent this? I admit I don't fully understand the pathology. A nurse I work with said its a blockage in the intestine. Would colace benefit? (Both patients were on it bid anyway). The first patient I had go NPO for a while after vomiting, per standard. The other one, who had a worse case, was eating and drinking fine.
I just feel like I missed something, or I should have done something but I don't know what it was.
Input welcomed! :)

You didn't do anything wrong. Ileus is simply one complication of any surgery. There are two type of ileus, paralytic and mechanical. A mechanical ileus is a mechanical obstruction of the bowel, this is usually a surgical problem. What you are describing is a paralytic ileus.

The pathophysiology is hypomotility of the bowel after surgery. This is transiently impaired. There are a number of nervous impulses that make up coordinated propulsive action in the bowel. The lack of these coordinated actions makes gas and fluids accumulate in the bowel. The most common cause of this is intrabdominal surgery. Colonic surgery almost always leads to ileus. In general surgery it is not considered an ileus unless it lasts 3 days.

Other causes include sepsis, electrolyte disturbances, and medications especially opiods (among the many causes). You have to distinguish this from colonic ileus or pseudo-obstruction (Olgivie's) which is a potentially life threatening problem.

Treatment is rest and npo status. There are a number of myths about relieving ileus none of which have any stastical validity. Mobilization is thought to help but there are not studies that show a statistical difference. Similarly NG tubes have not been shown to relieve ileus earlier, but may relieve symptoms. Enteral feeding do not seem to help relieve symptoms but may be tried cautiously.

Medically minimizing opiates helps. This must be balanced with providing pain relief. Colace is of no help and simethicone may relieve symptoms (it probably won't hurt). Erythromycin has been tried but there are not studies that shows it makes a difference. Reglan usually makes things worse. NSAID's have shown to have analgesic and anti-inflammatory properties but must be balanced with platlet dysfunction and possible ulcers in a post partum patient.

Overall the treatment is NPO and wait it out. You proably see less of this is OB since the surgery does not involve bowel manipulation. Also the spinal anesthesia seems to be associated with less ileus than general anesthesia.

David Carpenter, PA-C

NurseCherlove · Apr 16, 2007

Reglan usually makes things worse.

How? Just curious....I'm feeling too lazy to look it up.

Thanks.

core0 · Apr 16, 2007

How? Just curious....I'm feeling too lazy to look it up.
Thanks.

Reglan is a prokinetic that only works on the stomach. So you empty the stomach faster into a hypomotile bowel. Kind of like turning up the pressure on a kinked hose.

David Carpenter, PA-C

chenoaspirit, ASN, RN · Apr 16, 2007

Speaking of Reglan....One of my patients had a bowel resection, became distended, NG put back in. A couple nights later, NG came out, became distended again, NG went back in. NG went in 3 TIMES! The doc ordered Reglan, saying it increases motility. Needless to say, he is still in the hospital after 3 weeks and still distended and puking.

I had a bowel resection back in June and I was in hospital 3 days, no problems at all. But if I were to try to tell a doc that Reglan will make it worse, I would be screamed at. Its good knowing this information about Reglan. I am going to do some research on this. Very interesting.

chenoaspirit, ASN, RN · Apr 16, 2007

The only thing Ive seen work is NPO status until resolved. Patients HATE it and try to sneak and eat, which makes it worse.

I looked up about Reglan and this is what I found, very interesting......

Metoclopramide stimulates motility of the upper gastrointestinal tract without stimulating gastric,

biliary, or pancreatic secretions. Its mode of action is unclear. It seems to sensitize tissues to the action

of acetylcholine. The effect of metoclopramide on motility is not dependent on intact vagal

innervation, but it can be abolished by anticholinergic drugs.

Metoclopramide increases the tone and amplitude of gastric (especially antral) contractions, relaxes the

pyloric sphincter and the duodenal bulb, and increases peristalsis of the duodenum and jejunum

resulting in accelerated gastric emptying and intestinal transit. It increases the resting tone of the lower

esophageal sphincter. It has little, if any, effect on the motility of the colon or gallbladder.

Roy Fokker, BSN, RN · Apr 16, 2007

I can't remember where I read this but there has been suggestions to use chewing gum post op to help move the bowels.

What do y'all think?

Indy, LPN, LVN · Apr 16, 2007

I've never heard of the chewing gum thing.

I've had limited experience with ileus, and I'm including one case of toxic megacolon because the patient was so overwhelmingly sick. In my current facility, there are normally enough standing orders to allow me to choose between reglan, maalox, MOM, and there's normally colace on there somewhere, don't forget the protonix.

So with all that... I like prune juice cocktail to go with the colace if they will take it. That's warm prune juice mixed with MOM. Looks funny, smells funny, you'd have to pay me to take it but they swear it works. I like that for those that have not been much for opiates until they're in the hospital, so their bowels are suddenly more sluggish than normal.

Of course this is in addition to ambulating and fluids! Provided that it's safe for them to do these things. If they don't get results I like to reassess; and if they're not at least passing gas then yeah, it's worrisome. I feel for ya with the c section patients, that need the pain relief, whereas the cardiac patients, half of them didn't have cardiac problems in the first place but just need to poop. So my approach to pain relief is a bit different with that population. Funny story: a hospitalist admitted a guy for chest pain in his forties, with normal PRN meds and only one scheduled: a bottle of mag citrate on admission. He was very much relieved in the morning.

If I get to reglan, it's usually because they've gotten to the point of nausea and possibly distention. If they vomit I'm looking at what they vomit; if I see bile, it's time for an NG tube more than likely, and that's what I'll ask for when I call the doc.

MIA-RN1, RN · Apr 18, 2007

You didn't do anything wrong. Ileus is simply one complication of any surgery. There are two type of ileus, paralytic and mechanical. A mechanical ileus is a mechanical obstruction of the bowel, this is usually a surgical problem. What you are describing is a paralytic ileus.
The pathophysiology is hypomotility of the bowel after surgery. This is transiently impaired. There are a number of nervous impulses that make up coordinated propulsive action in the bowel. The lack of these coordinated actions makes gas and fluids accumulate in the bowel. The most common cause of this is intrabdominal surgery. Colonic surgery almost always leads to ileus. In general surgery it is not considered an ileus unless it lasts 3 days.
Other causes include sepsis, electrolyte disturbances, and medications especially opiods (among the many causes). You have to distinguish this from colonic ileus or pseudo-obstruction (Olgivie's) which is a potentially life threatening problem.
Treatment is rest and npo status. There are a number of myths about relieving ileus none of which have any stastical validity. Mobilization is thought to help but there are not studies that show a statistical difference. Similarly NG tubes have not been shown to relieve ileus earlier, but may relieve symptoms. Enteral feeding do not seem to help relieve symptoms but may be tried cautiously.
Medically minimizing opiates helps. This must be balanced with providing pain relief. Colace is of no help and simethicone may relieve symptoms (it probably won't hurt). Erythromycin has been tried but there are not studies that shows it makes a difference. Reglan usually makes things worse. NSAID's have shown to have analgesic and anti-inflammatory properties but must be balanced with platlet dysfunction and possible ulcers in a post partum patient.
Overall the treatment is NPO and wait it out. You proably see less of this is OB since the surgery does not involve bowel manipulation. Also the spinal anesthesia seems to be associated with less ileus than general anesthesia.
David Carpenter, PA-C

thank you so much for this well-thought out answer. I am going to print it and put it in my notebook at work!

core0 · Apr 18, 2007

I can't remember where I read this but there has been suggestions to use chewing gum post op to help move the bowels.
What do y'all think?

There is one small study on spinal surgery that showed a definite improvement in the gum chewing group. I think this is a good nursing intervention as long as someone doesn't get bent in the NPO department.

David Carpenter, PA-C

Editorial Team / Admin · Apr 18, 2007

Here is a link to an article in Gastroenterology, Feb. '06 regarding gum chewing and ileus:

The study authors present a very persuasive and inexpensive approach to stimulate bowel function in this setting. The cost of gum is approximately 4 cents/stick and the average cost of a hospital room is approximately $1500. Weighed against an extended hospital stay, and given the reported > 79,000 colectomies performed in the United States annually, they estimate a cost savings of approximately $118,828,000 per year. Clearly, more studies are warranted to evaluate the optimal effect of this novel technique -- ie, whether increased frequency/duration of chewing or type of gum (sugarless or not) and use in other surgerical settings that to do not involve colectomy will influence the outcome.

http://www.medscape.com/viewarticle/527602

You might need to register to read the article; free site/registration.

core0 · Apr 18, 2007

Here is a link to an article in Gastroenterology, Feb. '06 regarding gum chewing and ileus:
http://www.medscape.com/viewarticle/527602
You might need to register to read the article; free site/registration.

The article I was referring to was done in the early 90's but had essentially the same result. Unfortunately or fortunately (depends on your perspective) we don't get involved unless the ileus is bad (usually 5 days or more). I think a randomized gum trial would be interesting especially in OB.

David Carpenter, PA-C