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A Puzzling Case of Prolonged Post-op Ileus s/p Total Abdominal Hysterectomy
Adam L. Johnson 2/3/16
Case
• Ms. CC is a 52 yo G3P3 POD4 s/p TAH, BSO for b/l ovarian masses who presents to the ED for 2 days of worsening N/V. Pt is vomiting stomach contents, worsened by foods and liquids, associated with abdominal pain and myalgias. Patient denies fevers, chills, cough, diarrhea
• PMHx: Insomnia, ADD • PSHx: Bladder suspension, Tubal ligation, Colonoscopy• Allergies: Bactrim-Rash• Meds: Nortriptyline • PE: Pulse 133. Abdominal exam: she exhibits distension,
diffuse tenderness to palpation. Rest of PE wnl
Post-op Ileus (POI)• POI- Refers to obstipation and intolerance of oral
intake following abdominal or nonabdominal surgery.
• Non-mechanical factors-Inflammation of intestinal smooth muscle
• Post-op ileus-normal, obligatory and physiologic response to abdominal surgery
• Prolonged postoperative ileus->3-5 days absent bowel activity
Luckey A, Livingston E, Tache Y, Mechanisms and Treatment of Posteroperative Ileus 2003
Learning Objectives
• To examine a study describing the mean onset of various bowel recovery checkpoints s/p TAH.
• To recall common risk factors of Post-op ileus and explore obesity’s role in the incidence of POI after TAH
• To examine differences in incidences of POI after TAH, LAVH and TVH.
• To determine the efficacy of alternative methods in treatment of POI
• To take a closer look into the patient’s medical history observing factors plausibly contributing to POI.
Mean Time of Bowel Recovery Checkpoints after TAH
• Placebo arm of double blind study
• 140 TAH Patients• 3 Check points • Provided standardized
timeline for expected bowel recovery
Wolff B, Viscusi E, Delaney C, Du W, Techner L Patterns of GI Recovery after Bowel Resection and Total Abdominal Hysterectomy: Pooled results from the Placebo Arms of Alvimopan phase III North American Trials: Journal of American College of Surgeons, Volume 205 (1)-July, 2007
GI-3recovery
GI-2 recovery
DCOWritten
Mean hrs
69.5 hrs 115.3hrs 79.9 hrs
Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery
• Retrospective Study• 88 patients • Estimate Blood Loss
(EBL) and and Total Opiate Dose TOD)
• EBL and TOD shown to be strong risk factors
• Weakness: Study limited in its ability to produce cause-effect relationships and to control for all possible confounders.
Avo A, Nunoo-Mensah J, Swama B, Gauderman J, Essani R Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery Volume 32 (7)-Jul 1, 2008
Obesity’s Contribution to POI s/p TAH
• Retrospective study• 357 women – 172 Obese (82.5% African-American)– 185 Non-obese women (70% African-American)
• Non-obese women had a significantly higher incidence of ileus (13.5% vs 6.4, p<0.05)
• Disproportionate representation of African-American
Harmanli O, Dandulu V, Lidicker J, Ayaz R, Panganamamula U, Isik E The Effect of Obesity on Total Abdominal Hysterectomy, Journal of Women’s Health Vol 19 November 10, 2010
Obese BMI > 30kg/m2(n=172) n (%)
NonObese BMI< 30kg/m2(n=185)
Ileus 11 (6.4) 25 (13.5)
Incidence of POI s/p TAH vs TVH
TAH TAH TVH TVH
Time periods
Period A+B (n=34)
Period C (n=12)
Period A+B (n=12)
Period C (n=3)
Ileus 3 1 0 0
• Retrospective study over 3 time periods
• 4213 pts– 3220 pts TAH– 993 pts TVH
• Time Periods – Period A: 1976-1983– Period B: 1984-1991– Period C 1994-1997
• Disproportionate sample size
Salamalekis E, Sykiotis C, Conidaris S, Bettas P, Loghis C, Length of Patient Hospitalization after Abdominal and Vaginal Hysterectomy, Journal of Gynecologic Surgery, Volume 15, Number 4 1999
Incidence of POI s/p TAH vs. LAVH
• Retrospective Study• 126 pts – 61 LAVH– 65 TAH
• Gynecologist performed all the surgeries
Arbogast J, Welch R, Riza E, Ricautre E, Pieper D Laparoscopically assisted vaginal hysterectomy appears to be an alternative to total abdominal hysterectomy, Journal of Laparoendoscopic Surgery, Volume 4, Number 3, 1994
LAVH TAH P value
Ileus 0 2 NS
Acupuncture as an Alternative Prevention Strategy for PPOI
• Randomized Acupuncture vs. Usual Care• 85 patients – 44 pts received acupuncture– 41 pts usual care
• Acupuncture no affect on PPOI
Meng Z, Garcia M, Chiang J, Peng H, Shi Y, Electroacupuncture to prevent prolonged postoperative ileus: A randomized clinical trial, World Journal of Gastroenterology, Jan 2010
Nortriptyline: Causative Agent of Ileus
• Case Study 1• 14 1/2 yo woman • Nortriptyline 75 mg• 12 days
• Case Study 3• 81 yo women • Nortriptyline 25mg TID• 2 days
Ellis A, Bigmoid B, Faulker G, Cohen A, Adynamic Ileus and Nortriptyline, Brit med J, 841-842 1966
• Case Study 2• 27 yo woman • Nortriptyline 25mg TID• 8 days
• All women developed ileus
• All regained bowel function after discontinuation
Case Wrap-up • Ms. CC is a 52 yo G3P3 HD#17/POD#21 s/p TAH, BSO
with pathology consistent with Meig’s syndrome readmitted for treatment of post-op ileus vs. SBO.
• NGT placed day of admission• HD#6/POD#10 TPN started• HD#8/ POD#12 SBFT-studies showed contrast in the
Colon and rectum • HD#9/POD 13- KUB showed minimal contrast in the
small bowel , distal colon, and rectum w/ non-obstructive pattern
Ms. CC KUB 1/11/16
Enteric tube terminates in the distal stomach. Interval decrease in amount of contrast visualized. minimal contrast in the small bowel , distal colon, and rectum w/ non-obstructive pattern
Case Wrap-up
• Continued conservative management• HD#20/POD#24-Paracentesis• HD#22/POD#26-Colonoscopy. Incomplete due
to incomplete bowel prep. Cultures NGx2 days• Surgery, Gastroenterology, Rheumatology
have all been consulted…STILL PUZZLED!
References• Wolff B, Viscusi E, Delaney C, Du W, Techner L Patterns of GI Recovery after Bowel Resection
and Total Abdominal Hysterectomy: Pooled results from the Placebo Arms of Alvimopan phase III North American Trials: Journal of American College of Surgeons, Volume 205 (1)-July, 2007
• Avo A, Nunoo-Mensah J, Swama B, Gauderman J, Essani R Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery Volume 32 (7)-Jul 1, 2008
• Harmanli O, Dandulu V, Lidicker J, Ayaz R, Panganamamula U, Isik E The Effect of Obesity on Total Abdominal Hysterectomy, Journal of Women’s Health Vol 19 November 10, 2010
• Salamalekis E, Sykiotis C, Conidaris S, Bettas P, Loghis C, Length of Patient Hospitalization after Abdominal and Vaginal Hysterectomy, Journal of Gynecologic Surgery, Volume 15, Number 4 1999
• Arbogast J, Welch R, Riza E, Ricautre E, Pieper D Laparoscopically assisted vaginal hysterectomy appears to be an alternative to total abdominal hysterectomy, Journal of Laparoendoscopic Surgery, Volume 4, Number 3, 1994
• Meng Z, Garcia M, Chiang J, Peng H, Shi Y, Electroacupuncture to prevent prolonged postoperative ileus: A randomized clinical trial, World Journal of Gastroenterology, Jan 2010
• Ellis A, Bigmoid B, Faulker G, Cohen A, Adynamic Ileus and Nortriptyline, Brit med J, 841-842 1966
https://www.youtube.com/watch?v=XxcfYiTLtYU
The role Magnesium oxide + Disodium phosphate shortening time of POI s/p TAH
• Double-blind, placebo-controlled
• Patients 53– Placebo 27 pts– Laxative 26 pts
• Laxatives improves recovery of GI Function:reduced median time to 1st defecation with 24 hrs
Laxative Placebo P
Median time
45 hrs 69 hrs P=<.0001
Hansen C, Sorensen M, Moller C, Ottensen B, Kehlet H, Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double blind, placebo-controlled randomized study American Journal of Obstetrics and Gynecology, Volume 196 (4) Apr 1, 2007
Considering Mu-Receptor Antagonist role in decreasing POI s/p TAH while measuring
• Double-blind, randomized placebo controlled • 519 women (randomized 4:1)• Alvimopan accelerated – 413 pts Alvimopan– 106 pts Placebo
Herzog T, Coleman R, Guerrieri J, Gabriel K, Du W, Techner L, Fort J, Wallin B, A Double-blind, randomized placebo-controlled phase III study of the safety of the alvimopan in patients who undergo simple total abdominal hysterectomy , American Journal of Obstetrics and Gynecology, Volume 195 (2) Aug 1, 2006
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