Anastomotic leak + paralytic ileus

Question 1

Anastomotic leaks

Answer 1

Leak of luminal contents from a surgical join

Question 2

Complications of anastomotic leaks

Answer 2

Sepsis

Multi organ failure

Question 3

Patient risk factors for anastomotic leak

Answer 3

Medication (such as corticosteroids and immunosuppressants)

Smoking or alcohol excess

Diabetes Mellitus

Obesity or malnutrition

Question 4

Surgical risk factors for anastomotic leak

Answer 4

Emergency surgery

Longer intra-operative time

Peritoneal contamination (e.g from pus, faeces or GI contents)

Oesophageal-gastric or rectal anastomosis

Question 5

Clinical features of anastomotic leaks

Answer 5

Abdominal pain and fever.

Present between 5-7 days post-operatively.

May have delirium or prolonged ileus

On examination:

• pyrexial
• tachycardic
• +/- peritonism.
• check for faeculent / purulent material or bile in any drains

Question 6

Investigations for anastomotic leak

Answer 6

CT scan with contrast CAP or AP

Bloods - clotting

VBG - lactate

Group and save + cross match

Question 7

Mx of anastomotic leak

Answer 7

Urgent senior review

NBM
Broad spec abx
IV fluids
Catheter

Collection <5cm:
- intravenous antibiotics

Collection > 5cm:

• drained percutaneously
• exploratory laparotomy
• washout and drainage
• stoma

Question 8

Post-operative ileus

Answer 8

deceleration or arrest in intestinal motility after surgery

• functional bowel obstruction

Question 9

Patient factors for Post-operative ileus

Answer 9

Increased age

Electrolyte derangement e.g. Na+, K+ and Ca2+

Neurological disorders (e.g. Dementia or Parkinson’s Disease)

Use of anti-cholinergic medication

Question 10

Surgical factors for Post-operative ileus

Answer 10

Use of opioid medication

Pelvic surgery

Extensive intra-operative intestinal handling

Peritoneal contamination (by free pus or faeces)

Intestinal resection

Question 11

Clinical Features of post-operative ileus

Answer 11

Failure to pass flatus or faeces

Bloating and distention

Nausea and vomiting (or high NG output)

Absent bowel sounds

Question 12

Difference between mechanical obstruction and paralytic ileus

Answer 12

Tinkling bowel sounds in mechanical obstruction

Absent bowel sounds in paralytic ileus

Question 13

Ix paralytic ileus

Answer 13

Bloods - electrolytes

CT AP with oral contrast

Question 14

Mx of paralytic ileus

Answer 14

NBM

Daily bloods

Mobilisation

Reduce opiate analgesia

Question 15

Patient advice for paralytic ileus

Answer 15

warn patients that once it does settle, they may well have very watery stool for the first 2–3 bowel movements

Question 16

Prophylactic measures to prevent paralytic ileus

Answer 16

Minimise intra-operative intestinal handling

Avoid fluid overload (causing intestinal oedema)

Minimise opiate use

Encourage early mobilisation