need help on a pt with severe abd distention

[agurf]

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Hi!

I have a patient, 67 yo a/p sigmoid resection for diverticulitis. Had G-tube put during surgery. POD#5, afeb, still no flatus, NG in, putting out a lot, suddenly develops severe abd distention, emesis.

What is the best way to decompress him, assuming there is no perforation. G-tube was to gravity at the time. Some say: suction to G-tube, some would drop NGT, some would do neither.

Any ideas?



This is the only professional surgical forum I know. Anyone knows any other, i.e. where attendings and residents discuss cases an such..


thank you.
Surg intern, SUNY

 

[ecpiii]

Hey doc,
This could be Ogilve's syndrome (colonic pseudo-obstruction). Older, POD4-8, although it is classically spine surgery that does it, but colon surgery can interfere with nervous system input. What does the KUB show? If it is cecal to rectal pan-distention without evidence of obstruction from fecal matter, conservative treatment for the functional ileus would include NG decompression, frequent rolling Q2 hrs, enemas, and the slightly more successful neostigmine 2mg slow IV push over 3-4 minutes. Have your EKG, atropine and suction ready! There is a nice review article by Tenofsky PL et al in Archives Surgery 2000 Jun;135(6):682-6. After neostigmine, think about colonic decompression, especially if the cecum gets >12cm dilated. Good luck...

 

[droliver]

No this is NOT Ogilve's syndrome & the silly suggestions of neostigmine, supositories, & enemas on a fresh anastamosis will hurt people.

First off- you're still recently post-op, & common things being common you prob. just need to wait this out. Lesson of the day: G-tubes do not effectively decompress the GI tract most of the time for high ouput illeus pictures. Put an NGT in and make sure you don't get dehydrated by not compensating for the fluid shifts. Also with an NGT in & unusually high output, check films to make sure you have migrated past the pylorus which will inflate your output. If you have persistant SB dilation on serial films for days you have to consider the potential for an early adhesive related obstruction or some rotational obstruction from your colonic mobilization which can rarely neccessitate reexploration. In the face of a procedure for diverticulitis (I'm assuming this was acute, no?) you also need some index of suspicion for post-op pelvic collections for extremely long prolonged illeus (you might expect a slower return of GI fn. with active diverticulitis anyway). Watch for some of the other surrogates for this besides fever/WBC - slight Cr bumps, incr. billirubin, tachycardia

 

[tussy]

I need a little more info:

Was this an elective resection or emergent? Was a primary anastomosis done or did the patient have a Hartmann procedure with an end sigmoid colostomy? Is there a loop ileostomy to protect the anatomosis? I don't quite understand why one would place a G-tube at the time of surgery?

What do your plain abdo films show? Are they consistent with an ileus or SBO? Is there colonic air? Free air? As Droliver suggested, i would check your NG placement and make sure it's not past the pyloris.

If the plain films are consistent with an ileus, and the patient otherwise looks well (no leukocytosis, fever, etc) you probably just have to wait it out. Correcting electrolyte abnormalities and fluid balance will help, as will ambulating the patient.

If the patient looks unwell, then a double contrast CT scan may help exclude an abscess, anastomotic leak or mechanical SBO.

Goodluck, and let us know how your patient is doing.