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A14) Post-operative nausea and vomiting
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with nausea and vomiting.
- Review the DDx considerations in a patient with nausea and vomiting.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with nausea and vomiting.
History
A 43-year-old male undergoes an exploratory laparotomy with sigmoid resection and primary anastomosis for perforated diverticulitis with purulent peritonitis. 3L of crystalloids were administered during the four-hour surgery. Two days later, his pain is well controlled with oxycodone and PRN IV hydromorphone. He is started on a clear liquid diet but develops nausea and vomiting. He is not passing gas.
Physical Exam
BMI: 24, BP: 132/81, HR 92, RR 18, Temp 36.2, O2 saturation 100%.
General: the patient is on 150cc/hour maintenance IVF.
Abdomen: Mildly distended.
Labs
Na+: 131mEq/L (nl: 135-145mEq/L); K+: 2.8mmol/L (nl: 3.6-5.2 mmol/L); Mg: 1.1mg/dL (nl: 1.7-2.2 mg/dL)
Provisional Diagnosis
Select the Dx you believe is most appropriate
Adynamic post-operative ileus is the most likely diagnosis. The patient is at significant risk for adynamic post-operative ileus considering the peritonitis, prolonged surgery (>3 hours) with interstinal manipulation, significant crystalloid administration, and metabolic abnormalities (hyponatremia, hypokalemia, hypomagnesemia). This is confirmed with the nausea, vomiting, and abdominal distension.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires routine, but expedited workup.
First Imaging Study
What is the first imaging study you will order?
Radiography is the most appropriate initial exam as it can identify the presence of small bowel distension and can sometimes differentiate between mechanical bowel obstruction and adynamic ileus.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
KUB
There is distension of the small and large bowel
The 3-6-9 rule describes the normal caliber of the small bowel (<3cm), large bowel (<6cm), and cecum (<9cm). In this case, parts of the small bowel and large bowel are dilated.
There is evidence of mechanical bowel obstruction
There is no transition point or air in the rectum, suggesting that there is no mechanical obstruction. Furthermore, a mechanical obstruction would result in more severe distention.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is required as the X-ray strongly suggests the diagnosis.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The signs, symptoms, and imaging workup are consistent with a diagnosis of post-operative ileus.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient's diagnosis requires management but is not immediately life threatening.
Assessment and Plan
Please provide your assessment and plan for this patient
The patient is a 43-year-old male who developed post-operative adynamic ileus. The electrolyte abnormalities should be corrected, the analgesics should be transitioned to a non-narcotic pain regimen, and the IV fluids should be reduced. The patient should be made NPO and a trial of diet advancement should be made when he shows signs of improvement (reduced abdominal distension, passing flatus). If he does not improve in the next days, further imaging workup (CT, small bowel follow-through) to rule out other pathology and placement of a nasogastric tube should be considered.
Lessons Learned:
- Patients who have metabolic abnormalities and have undergone prolonged surgery with intestinal manipulation, crystalloid or blood product administration are at increased risk for post-operative adynamic ileus.
- A KUB revealing distended bowel without a transition point and with air in the rectum can differentiate this from a small bowel obstruction, which would require different management. If the diagnosis is not clear, further imaging can be considered.
Socioeconomic Factors: Prevention of postoperative ileus is important as it is associated with increased length of stay and hospitalization costs.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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