What is the management for a 50-year-old male, status post laparoscopic-assisted sigmoid and low anterior resection with primary anastomosis and loop ileostomy, presenting with nausea (N), vomiting (V), gassiness, abdominal fullness, and hiccups, after receiving Zofran (ondansetron)?

From the Guidelines

For a 50-year-old male experiencing nausea, vomiting, abdominal fullness, gassiness, and hiccups following recent laparoscopic sigmoid and low anterior resection with loop ileostomy, I recommend metoclopramide 10 mg IV or orally every 6 hours to address both nausea and promote gastric emptying, as it is the only FDA-approved medication for gastroparesis 1.

Treatment Approach

To manage the patient's symptoms, a multi-faceted approach is necessary.

• For nausea and vomiting, ondansetron 4-8 mg bid or tid can be considered, as it has been shown to be effective in improving nausea and vomiting in patients with refractory gastroparesis symptoms 1.
• For gas relief, simethicone 80-125 mg orally every 6 hours as needed can help break up gas bubbles.
• For persistent hiccups, baclofen 5-10 mg orally three times daily could be effective, or chlorpromazine 25-50 mg orally or IV if severe.

Additional Considerations

These symptoms are common after abdominal surgery due to manipulation of the bowel, effects of anesthesia, and postoperative ileus.

• Encouraging early ambulation, taking small sips of clear liquids, and avoiding carbonated beverages will also help.
• If symptoms persist or worsen, particularly if accompanied by fever, severe pain, or absence of bowel function, further evaluation is necessary to rule out complications like anastomotic leak or bowel obstruction.

Medication Selection

The selection of medications should be based on the patient's specific symptoms and medical history.

• Metoclopramide is the only FDA-approved medication for gastroparesis, and it has been shown to be effective in improving nausea and vomiting, as well as promoting gastric emptying 1.
• Ondansetron and other 5-HT3 receptor antagonists can be considered for nausea and vomiting, but their efficacy in gastroparesis has not been extensively studied 1.

From the FDA Drug Label

Giving a promotility drug such as metoclopramide theoretically could put increased pressure on suture lines following a gut anastomosis or closure The patient had a recent laparoscopic assisted sigmoid and low anterior resection colon w/ primary anastomosis, loop ileostomy. The use of metoclopramide may put increased pressure on the suture lines. Therefore, the use of metoclopramide for this patient's gas and hiccups is not recommended due to the potential risk of compromising the suture lines following the gut anastomosis. 2 2

From the Research

Patient Symptoms and Treatment Options

• The patient is experiencing nausea and vomiting (n/v), gassiness, feeling of fullness of the abdomen, and hiccuping after a laparoscopic assisted sigmoid and low anterior resection colon with primary anastomosis and loop ileostomy.
• The patient was given Zofran for nausea and is requesting medication for gas and hiccups.
• According to 3, hiccups can be a sign of underlying pathology, and the most common cause is GERD, which can be treated with a proton pump inhibitor (PPI).
• 4 suggests that several pharmacologic treatments, including baclofen, gabapentin, and metoclopramide, have been successful in treating hiccups, but no specific recommendations can be made due to limited evidence.

Pharmacologic Treatment Options for Hiccups

• 4 and 5 mention that baclofen, gabapentin, and metoclopramide may be effective in treating hiccups, with baclofen and gabapentin being less likely to cause side effects during long-term therapy.
• 6 is a protocol for a systematic review and meta-analysis of the effectiveness and safety of metoclopramide in treating intractable hiccup, which may provide more evidence on its efficacy in the future.
• 7 suggests that persistent hiccups can be a sign of a serious disorder and requires extensive diagnostic testing, and treatment should be directed at the underlying condition.

Treatment Approach

• Given the patient's symptoms and the lack of clear evidence on the most effective treatment for hiccups, a treatment approach that addresses the underlying cause of the hiccups, such as GERD, may be necessary 3.
• The use of pharmacologic agents such as baclofen, gabapentin, or metoclopramide may be considered, but the choice of treatment should be individualized based on the patient's underlying comorbidities and the etiology of the hiccups 4, 5.