POP GOES THE ILEUS: OPIOID-INDUCED ILEUS COMPLICATED BY PERFORATION

Abstract

SESSION TITLE: Imaging SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Critically ill patients are at risk for ileus due to electrolyte abnormalities and decreased gastrointestinal perfusion from mechanical ventilation and septic shock. Opioids delay transit in the colon and small bowel by acting on μ, δ, and κ receptors in the enteric system, resulting in constipation and ileus. This case describes an ileus that was evaluated clinically but not radiographically to have resolved due to presence of persistent diarrhea but was actually worsening until the development of fatal cecal perforation. CASE PRESENTATION: A 59 year-old man presented after a witnessed aspiration event. He had a long history of alcoholic cirrhosis and was chronically on lactulose. He arrived at Vidant Medical Center on 12/10/2017 for shortness of breath. On exam, he had ascites but a soft abdomen with present bowel sounds. He vomited and desaturated in the ED. He was intubated for hypoxic respiratory failure and placed on fentanyl drip for analgesia. He passed no stools on day two or three of hospitalization but then developed diarrhea. On day 5 of ICU stay, he developed a distended firm abdomen with hypoactive bowel sounds. KUB showed distended bowel loops with a dilated cecum of 14cm, and ileus was diagnosed, likely secondary to opiates. After metoclopramide, trickle feeds, and methylnaltrexone, he passed 6 loose stools. The ileus was considered resolved due to his bowel movements but was not confirmed radiographically. He was transferred out of the ICU. Once on the floor, he became febrile and tachypneic. His abdomen became firm and tender to palpation. STAT CT abdomen/pelvis found moderate to large volume pneumoperitoneum and thickening of the ascending colon. There was concern for perforation, and he was emergently sent to the OR. In the OR, cecal perforation with gross feculent spillage was noted. He was left in discontinuity and in the SICU developed multi-organ failure and hemorrhage. He developed septic shock and was sent back to the OR where he expired. DISCUSSION: Opioid induced ileus is managed first with prevention by avoiding opioids, but this is a dilemma for ventilated or cancer patients. Typical management of ileus on the floor involves bowel rest and NG tubes until serial KUBs show improvement and stools pass. As he began passing diarrhea on day 3 of ICU stay, had no more abdominal pain, and began eating, it was reasonable to defer imaging. However, ileus can persist with diarrhea. The patient likely would have benefitted from remaining NPO until KUB confirmed improvement. CONCLUSIONS: Further studies should evaluate if imaging recommendations in post-surgical ileus management guidelines are sufficient for opiate-induced ileus. The complex endogenous opiate system in the gut controls motility and secretion. Thus in comparison to post-surgical ileus, clinicians may need more conservative guidelines that encourage prolonged management and closer radiographic monitoring. Reference #1: Kurz A, Sessler D. Opioid-Induced Bowel Dysfunction: Pathophysiology and Potential New Therapies. Drugs. 2003;63(7):649–71. Reference #2: Vazquez-Sandoval A, Ghamande S, Surani S. Critically ill patients and gut motility: Are we addressing it? World Journal of Gastrointestinal Pharmacology and Therapeutics. 2017;8(3):174-179. Reference #3: Holzer P. New approaches to the treatment of opioid-induced constipation. European review for medical and pharmacological sciences. 2008;12(0 1):119-127. DISCLOSURES: No relevant relationships by Nitin Gupta, source=Web Response No relevant relationships by James Powell, source=Web Response