Clinical Signs of Postoperative Ileus
Postoperative ileus presents with nausea, vomiting, abdominal distension, and delayed passage of flatus or stool following surgery. 1
Cardinal Clinical Features
The diagnosis is made when patients exhibit the following constellation of symptoms after abdominal or non-abdominal surgery:
- Nausea and vomiting – often the earliest and most distressing symptoms 1, 2
- Abdominal distension – visible enlargement of the abdomen due to accumulation of gas and fluid 1, 2
- Delayed passage of flatus – failure to pass gas, indicating impaired intestinal motility 1
- Delayed passage of stool – absence of bowel movements beyond the expected postoperative period 1
- Absence or diminished bowel sounds on auscultation 3
Temporal Pattern and Duration
Normal postoperative ileus is an obligatory period of gut dysfunction that occurs after every abdominal surgery, but prolonged ileus extending beyond postoperative day 3-4 represents a pathological state requiring intervention. 1, 4
- The small bowel typically recovers motility within 24 hours 4
- The stomach recovers within 24-48 hours 4
- The colon takes 3-5 days to resume normal function 4
- Ileus persisting beyond 7 days despite optimal conservative management warrants diagnostic investigation to exclude mechanical obstruction or other complications 5
Physical Examination Findings
When examining a patient with suspected postoperative ileus, look for:
- Tympanic percussion over distended bowel loops 5
- Minimal or absent bowel sounds on auscultation, though this finding alone should not delay feeding 5
- Diffuse abdominal tenderness without peritoneal signs (guarding, rebound) – the presence of peritoneal signs suggests complications such as anastomotic leak or intra-abdominal sepsis 5, 6
- Visible abdominal distension with increased girth 1
Associated Symptoms and Complications
Beyond the cardinal features, patients may experience:
- Inability to tolerate oral intake – early satiety or immediate vomiting after attempting to eat 5
- Anxiety and discomfort – patients perceive prolonged ileus as a deviation from expected recovery 7
- Signs of dehydration – dry mucous membranes, decreased urine output, tachycardia 3
- Weight gain >3 kg by postoperative day 3 – indicates fluid overload and predicts prolonged ileus 5, 6
Red Flags Requiring Urgent Investigation
When ileus persists beyond the expected timeframe or presents with concerning features, immediately exclude these serious complications:
- Intra-abdominal sepsis – fever, leukocytosis, peritoneal signs 5, 6
- Mechanical obstruction – complete obstruction presents with colicky pain, high-pitched bowel sounds initially, then silence 5
- Anastomotic leak – fever, tachycardia, peritoneal signs, elevated inflammatory markers 5
- Intestinal ischemia – severe pain out of proportion to examination, metabolic acidosis 6
- Enteritis or infectious colitis (Clostridium difficile, Salmonella) – diarrhea, fever 3, 6
Common Pitfall to Avoid
Do not wait for the return of bowel sounds before resuming oral intake. The absence of bowel sounds does not reliably predict tolerance of oral feeding, and delaying nutrition based solely on this finding prolongs recovery. 5 Early feeding maintains intestinal function even in the presence of ileus and should be initiated with clear liquids and advanced as tolerated. 5