What is the best course of action for a patient one week postoperative from a right hemicolectomy, presenting with abdominal and shoulder pain, a distended abdomen, and an ileus, but no nausea or vomiting?

Urgent Diagnostic Imaging Required for Suspected Intra-Abdominal Complication

This patient requires immediate CT imaging with IV contrast to rule out serious postoperative complications, particularly anastomotic leak, intra-abdominal abscess, or internal hernia, as shoulder pain one week after right hemicolectomy is a red flag for diaphragmatic irritation from free air or fluid. 1, 2

Critical Red Flags in This Presentation

The combination of findings is concerning for complications beyond simple ileus:

• Shoulder pain at one week postoperatively suggests diaphragmatic irritation from subphrenic fluid collection, abscess, or free air 1
• Persistent ileus at 7 days exceeds the expected 3-5 day resolution window and warrants investigation for mechanical obstruction or complications 2, 3
• Abdominal distension with pain may indicate evolving peritonitis, abscess formation, or bowel obstruction 1, 2

The absence of nausea/vomiting does not exclude serious pathology—anastomotic leaks and contained perforations can present with subtle symptoms initially. 1

Immediate Diagnostic Workup

Obtain CT abdomen/pelvis with IV contrast immediately to evaluate for:

• Anastomotic leak or dehiscence at the ileocolic anastomosis 1
• Intra-abdominal or pelvic abscess formation 1
• Internal hernia through mesenteric defects 1
• Bowel obstruction from adhesions 1
• Portal/mesenteric venous thrombosis (rare but reported after right hemicolectomy) 4

Laboratory assessment should include:

• Complete blood count (elevated WBC suggests infection/abscess) 2
• Electrolytes, particularly potassium and magnesium (correct abnormalities that impair motility) 2, 3
• Lactate (elevated suggests bowel ischemia or sepsis) 3

Management Based on Imaging Findings

If Abscess or Contained Leak Identified:

Percutaneous drainage is first-line for accessible collections >3 cm 1

• PCD allows source control while avoiding reoperation in most cases 1
• Obtain fluid cultures to guide antibiotic therapy 1
• Broad-spectrum antibiotics covering enteric organisms 1
• Serial imaging to confirm resolution 1

Surgical exploration indicated if:

• Hemodynamic instability or septic shock 1
• Free perforation with generalized peritonitis 1
• Failed percutaneous drainage after 48-72 hours 1

If Internal Hernia or Mechanical Obstruction:

Proceed to diagnostic laparoscopy within 12-24 hours in stable patients with persistent pain and inconclusive findings 1

• Start exploration from ileocecal junction working proximally 1
• Inspect mesenteric defects at the anastomosis 1
• Assess bowel viability; resect if ischemic 1
• Close mesenteric defects with non-absorbable suture 1

If Simple Prolonged Ileus Without Complications:

Continue conservative management with escalation:

Optimize fluid and electrolyte balance:

• Correct hypokalemia and hypomagnesemia immediately 2, 3
• Maintain euvolemia with isotonic fluids, avoiding overload 2, 3
• Target weight gain <3 kg from baseline to prevent intestinal edema 2, 3

Nasogastric decompression:

• Place NGT only if severe distension, vomiting, or aspiration risk 2, 3
• Remove as soon as possible—prolonged decompression worsens ileus 2, 3

Implement opioid-sparing analgesia:

• Transition to multimodal pain control (acetaminophen, NSAIDs if appropriate, gabapentinoids) 2, 3
• Minimize or eliminate opioids as they directly inhibit GI motility 2, 3

Pharmacologic interventions:

• Bisacodyl 10-15 mg orally daily to TID once oral intake tolerated 2, 3
• Magnesium oxide orally 2, 3
• Consider metoclopramide 10-20 mg PO QID as prokinetic 2, 3
• For refractory ileus, consider neostigmine or water-soluble contrast as rescue therapy 2, 3

Early mobilization and nutrition:

• Aggressive ambulation immediately 2, 3
• Encourage small portions of oral intake even without bowel sounds 2, 3
• If oral intake inadequate for >7 days, initiate tube feeding 2, 3

Critical Pitfalls to Avoid

Do not attribute all symptoms to "expected postoperative ileus" at one week—this timeline demands investigation for complications 2, 3

Do not delay imaging in a patient with shoulder pain—this suggests diaphragmatic irritation from intra-abdominal pathology requiring urgent intervention 1

Do not continue aggressive IV fluids beyond euvolemia—fluid overload causes intestinal edema and prolongs ileus 2, 3

Do not maintain prolonged NGT decompression unless absolutely necessary for severe symptoms—it paradoxically extends ileus duration 2, 3

Do not overlook thromboembolic complications—ensure adequate VTE prophylaxis and consider portomesenteric thrombosis if pain persists despite negative initial imaging 1, 4

Thromboprophylaxis Considerations

Extend thromboprophylaxis beyond discharge if risk factors present (age >65, obesity, prior VTE, prolonged immobility from ileus) 1

• Continue low-molecular-weight heparin for at least 8 weeks postoperatively 1
• 91% of post-discharge thromboembolic events occur within 60 days 1