Post appendectomy ileus

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Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Post appendectomy ileus

Postby Hey Daddy » Wed Jun 28, 2017 11:43 am

Son had an emergency appendectomy 10 days ago. It was a laparoscopic outpatient procedure. He ended up back in the hospital with an ileus and he is still waiting for it to resolve. Needless to say he is starving and miserable but we are very relieved that it is not a cancer recurrence (our first thought when this all started). I know many of you have dealt with this type of situation and I am wondering how long they might continue to wait for his small intestine to come back to life before considering a surgical solution.
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Wed Jun 28, 2017 12:48 pm

Hey Daddy:
The answer to paralytic ileus is rarely surgical.

Paralytic ileus (also known as pseudo-obstruction) is described as a motility paralysis of the small intestine. The small intestine is generally in constant motion, a wiggling and squiggling motility under the moist protective sheet of omentum. This differs from the large intestine that moves 3-4 times a day in waves of paristalsis.

The cause of paralytic ileus can be many. Surgical manhandling of the small intestine is a frequent cause and would be prime suspect in your son's case given his recent laparoscopic surgery for appendicitis. Bacterial leakage associated with the appendicitis may be contributing.

If the cause of your son's immediate ileus is post-operative intestinal trauma, then time and patience will be the guiding principles in treatment. Conservative management includes: Placement of an NG tube to decompress the intestinal tract and for management of intestinal secretions; IV support for hydration and/or parental nutrition; medications such as Raglan to promote GI motility.

Surgery here would be contraindicated as it would cause further intestinal trauma and would aggravate the present intestinal paralysis.

Ileus can also be due to adhesions and "kinking" of a segment of small intestine. In this case, surgery to snip the offending adhesion can be considered after conservative measures to relax the gut (which can ease an intestinal "kink.").

Be aware that pseudo-obstruction can also be due to malignancy at a microscopic level that coats the small intestine. This is more often a late effect in metastatic cancer than would be the case with your son. But it will be on the list of diagnostic possibilities that your son's medical team will be considering.

The best diagnostic tool is a small bowel follow-through study. Here a hefty dose of gastrograffin is ingested orally or administered via NG tube. Gastrograffin is a potent laxative and is used to assess small intestinal motility as monitored by real-time radiology imaging (fluoroscopy). Gastrograffin can also jump-start a small intestine that is slow to move.

I would think your son's medical team would be considering a small bowel follow-through study to better understanding the root cause of the persistent lack of motility. I would query your son's physicians directly about ordering a small bowel follow through study.

Time and patience are often the best treatment measures. I experienced a bout of paralytic ileus that waxed and waned for weeks. It was frustrating beyond reason but did finally resolve. I had NG tube placement and a PICC line for IV parental nutrition.

Sending your son healing wishes and a re-boot of his intestinal tract,
Karen
Last edited by MissMolly on Wed Jun 28, 2017 5:43 pm, edited 3 times in total.
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.

DarknessEmbraced
Posts: 3816
Joined: Sat Nov 01, 2014 4:54 pm
Facebook Username: Riann Fletcher
Location: New Brunswick, Canada

Re: Post appendectomy ileus

Postby DarknessEmbraced » Wed Jun 28, 2017 1:31 pm

I'm sorry your son is going through this and hope his ileus resolves without surgery!*hugs*
Diagnosed 10/28/14, age 36
Colon Resection 11/20/14, LAR (no illeo)
Stage 2a colon cancer, T3NOMO
Lymph-vascular invasion undetermined
0/22 lymph nodes
No chemo, no radiation
Clear Colonoscopy 04/29/15
NED 10/20/15
Ischemic Colitis 01/21/16
NED 11/10/16
CT Scan moved up due to high CEA 08/21/17
NED 09/25/17
NED 12/21/18
Clear colonoscopy 09/23/19
Clear 5 year scans 11/21/19- Considered cured! :)

Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Re: Post appendectomy ileus

Postby Hey Daddy » Thu Jun 29, 2017 7:20 pm

Thank you for the well-wishes and good info. I will ask about the study. My son's ileus is due to an adhesion at the site of the appendectomy. He ate a small amount of food today and has not thrown it up but it is causing some discomfort and may come back up later tonight (it's gotta go somewhere).
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Re: Post appendectomy ileus

Postby Hey Daddy » Thu Jun 29, 2017 8:32 pm

Well he just threw up what he'd eaten today so apparently we are not there yet. It is frustrating; to see if things have awakened they let him eat a little, but if the ileus has not resolved, he gets violently ill which probably causes more trauma to the intestines delaying recuperation even more.
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Thu Jun 29, 2017 9:07 pm

HeyDaddy:
I was wondering how your son was fairing. Thank you for taking the time to post an update.

Conservative measures are the preferred strategy for treating intestinal ileus. Decompressing the GI tract is often sufficient to relax the affected segment of intestine so that it can drop down/escape/un-kink from a thickened band of scar tissue or adhesion.

Surgery to clear adhesions runs the known risk of triggering the formation of more scar tissue and adhesion. A catch-22. Surgery to nip the offending bands of scar tissue can set the stage for a proliferation of even more scar tissue/adhesions. This is why surgeons are reluctant to re-enter an abdomen with a prior history of open surgeries.

An abdomen that has been through several open surgical procedures is termed a "hostile abdomen." The abdomen is hostile due to an over-abundance of scar tissue and adhesions. A hostile abdomen is analogous to a dense tropical forest thick with underbrush.

Yin and yang.

Generally speaking, there is a recognized time frame that most surgeons follow for adhesion based ileus/intestinal paralysis. The accepted standard for conservative measures for a small bowel instruction (SBO) is 4 days/96 hours. If there is NO improvement after 4 days/96 hours most surgeons will then proved to a surgical intervention to find, locate, and snip the offending adhesion band. It is often as simple as a snip of the adhesion, effectively freeing the segment of intestine. People awaken in recovery and feel immediately better/well.

Why 4 days/96 hours? If the ileus is caused by a child nsteicting band if scar tissue, further delay can result in lack of blood supply to the segment of intestine and necrosis. 4 days/96 hours is the "sweet spot" - neither too late (further delay causing tissue necrosis) nor too soon (surgery causing additional adhesives).

It sounds as though your son is making incremental progress with conservative management. Slow improvement - at a snail's pace - is par for the course. If he is able to hold down a few bites of soft food take that as a win.

A small bowel follow-through study with gastrograffin would be a test that I suspect your son's medical team of physicians has on its radar if his incremental progress slows or stalls.

Scar tissue itself is opaque to X-rays and CT scans. Evidence of scar tissue causing a kink shows as a visible narrowing or structure. The lsmall bowel follow through study serve as both a diagnostic tool and as a treatment modality. The administered gastrograffin is a nuclear-powered laxative and can reboot intestinal motility that is slow or lethargic. The intestinal power source switches to the "on" position through the kinetic action of the gastrofraffin.

I have, myself, a "hostile abdomen" and have experienced 4 small bowel obstructions that have required hospitalization. On
2 occasions conservative management with an NG tube has been sufficient to see me in my way. On 2 occasions, surgery was recommended to snip the thicken band of scar rissue. Of the 2 surgeries, one surgery was complicated by the finding of a narcotic segment of small intestine, conservative treatment employed too long. My experiences with small bowel obstructions have been been haphazard and uneven, at best.

I will keep all 10 toes and all 10 fingers crossed in symbolic Good Luck to your son that his SBO eases,
- Karen -

Lee
Posts: 6207
Joined: Sun Apr 16, 2006 4:09 pm

Re: Post appendectomy ileus

Postby Lee » Thu Jun 29, 2017 10:10 pm

Don't have any advice to offer. Karen said it best. Butt just wanted to add, hope things get better for your son soon and that he is out of the hospital even faster.

As parents, we don't want to see our kids in the hospital other than for "minor" issues. What your son is dealing with is beyond minor.

all the best to you and your son.

Lee
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 16 years and counting!

Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Re: Post appendectomy ileus

Postby Hey Daddy » Thu Jun 29, 2017 10:48 pm

Thanks Karen,
He has been in this state for 12 days now so I guess we've blown by the 4 day window. When this started he was in Michigan working at a Young Life camp. They took him to a small local hospital as it was the closest facility. The verdict was appendicitis and they did the lap procedure and let him go that day. By that night, my wife had flown up (we live in Georgia) and when, in the wee hours of the morning, he started vomiting she took him back in. He was at the Michigan hospital for 7 days. They tried the gastrograffin but he threw it up. Finally after being pumped full of liquids and laxatives he held down some soft food and had some diarrhea so they discharged him. We flew back home the next day but by that night he was throwing up bright green bile and we ended up at the hospital here where, at least, he is being seen by a doctor whom we know and trust and who knows his history (he's the surgeon that performed his resection last year). I read accounts of these things taking a couple of weeks so we are trying to be patient. My biggest fear, whether rational or not, is that the ileus was the original problem, appendicitis was mis-diagnosed, and that cancer recurrence in the small intestine which has somehow gone undetected on multiple CT scans is at the root of it all. Yeah, I guess you could say I'm a worry wart. I just wish the boy would start shitting again.

BTW, in a few weeks he is supposed to go to Nashville for the 2018 Colondar shoot so he needs to get out of this damn hospital and get his strength back!
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Thu Jun 29, 2017 11:33 pm

HeyDaddy:
Your concerns are eloquently articulated and, to be honest with you, valid.

Paralytic ileus wihere there is no mechanical torsion of the intestine nor a constricting band of scar tissue is referred to as a pseudo-obstruction.

Damage to the vagal nerve during intestinal resection surgery or stomach surgery can cause pseudo obstruction. So, too, can bacterial toxins that leak into the normally pristine abdominal cavity (as could be the case with appendicitis or a bowel perforation). Pseudo-obstruction can also be a manifestation of late stage cancer where microscopic cancer cells form a film on the small intestine. This was likely a contributing cause in the recent passing of GrouseMan's dear wife.

If you have your son's consent then talk with his surgeon and medical team, I would share your thoughts and concerns with them just as you expressed here. The Elephant is in the room. You might as well acknowledge it.

CT and MRI imaging are poor at identifying microscopic cancer cell film as may affect small bowel motility. A laparoscopic peak into the abdominal cavity is a fairly reliable tool for detecting cancer cell studding - peaking under the fatty apron of tissue that covers the small intestine, the omentum, and biopsy of tissue and interstitial fluid.

I gather you son has no NG tube at present and that he is able to sip fluids. That is a good sign that there is some functional motility. His intestinal tract is able to mobilize stomach and intestinal secretions down and through the intestinal tract. If his intestinal tract was at a complete stand-still with zero/zilch propulusion, he would be vomiting stomach and intestinal secretions (reverse paristalsis). The body produces about 2 liters of gastric fluids a day.

I had a prolonged case of pseudo-obstruction due to injury of the vagal nerve. It was a waxing and waning paresis that lasted almost 6 months. It was an emotionally taxing experience. My sense of disparity ran deep. Time and patience did show a gradual return of function, but I will be honest that it was slow going. I had placement of an NG tube + suctioning of stomach secretions and IV parental nutrition.

At this juncture, you need more information from your son's physicians. A small bowel follow-through study, repeating with gastrograff? Trial of the medication Reglan to promote a boost of kinetic intestinal motility? Laparoscopic evaluation of the abdomen/pelvis, particularly of the undersurface of the omentum and fluid biopsy? Vagal nerve conduction study?

I would begin pressing your son's medical team for a more energized assessment given 12 days of conservative management are not showing much progress toward resolution or causative understanding of the prolonged ileus.

Chat with your son. What does he think is going on in his body? I find that most people have an intuitive sense of what is ailing their body. Careful listening often reveals valuable cues.

I am sorry that you are dealing with so many unknown variables. Work with your son's medical team to generate some momentum to determining why his small bowel motility is running at low speed.
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Thu Jun 29, 2017 11:52 pm

Adding another possible consideration contributing to your son's ileus may be drugs from any chemotherapy that he has received. Just as people recount peripheral neuropathy of the hands and feet, nerves that facilitate intestinal motility can be affected by neuropathy.

Gastroparesis is associated with delayed stomach emptying and has as one cause platinum-based chemotherapy drugs. Gasteoparesis is a sub-type of neuropathy.

Intestinal paresis can also be a form of collateral damage of chemotherapy.

What chemotherapy drugs did your son receive? This would be another avenue of injury. Neuropathy of the small intestine, chemotherapy induced.
- Karen -
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.

Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Re: Post appendectomy ileus

Postby Hey Daddy » Fri Jun 30, 2017 7:27 am

Thank you for the good suggestions. My son had the 6 month FOLFOX regimen so delayed neuropathy is a potential fit. He had an NG tube for a few days early on and he was throwing up bile every 4 to 6 hours (around the tube). At present he is not on IVs and can sip water but anything approaching solid food causes building pain and eventually gets thrown up. He has been able to pass some gas which helps relieve pressure.

Lee,
Thanks. I know are many young people out there in much worse circumstances than my son, but it sure sucks to see someone his age become so familiar with hospitals.
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Fri Jun 30, 2017 10:20 am

HeyDaddy:
Your son's persistent ileus is a rough deal for all concerned - you and your wife, included.

At 2 weeks of watch and wait, I would be talking with your son's medical team to adopt a more energized approach to understanding the root cause of the persistent low motility.

NG tubes are never pleasant to insert but can be immensely relieving once in place. I have even gone so far to request that an NG tube be reinserted during one episode of repeated ileus where the initial NG tube had been removed too early. I was so miserable throwing up over and over and over again.

If your son was vomiting bile and gastric secretions despite placement of an NG tube it is likely the case that the suction was at an insufficient negative pressure. The mg/hg of suction can be raised to more forcefully extract accumulating secretions and bile. It is analogous to adjusting the suction on a Miele vacuum cleaner to a more powerful mode.

You may also want to see if your hospital had a palliative care physician who can intervene. While I understand you trust your son's surgeon, your son's ileus may not have a surgical component in looking for resolution. Palliative care physicians are experts at dealing with complex and complicated medical presentations. Your son's surgeon may be acting with inertia simply because he is contending with symptomatology that is out of his scope of practice.

Large hospitals often have gastroenterologist who are motility specialists. Motility specialists focus on how the intestinal tract works and moves and slithers and contracts. Small/local hospitals will not usually have the resources to support a motility specialist under the umbrella of gastroenterology.

My 6-8 month ordeal with prolonged ileus was surreal. In my case, it was a traction injury to the vagal nerve. Recovery was a long, slow process - a few steps forward and a few steps backward.

Certainly, chemotherapy induced neuropathy should be on the list of differential diagnoses. Bacterial toxicity associated with with the questionable appendicitis or leaky gut is another plausible theory. And, unfortunately, microscopic malignancy forming a thin film coating in the small bowel another line of inquiry.

A small bowel follow-through study or mammotry testing (inserting a thin, flexible tube down the esophagus that measures the contractability of the smooth muscle) are evaluative tools that might shed information.

A trial of the medication Reglan might prove if some evaluative value. Reglan is used in an off-label manner to stimulate intestinal propulsion.

Whatever course of direction you and your son decide, further watch and wait seems to be self-limiting. I would ask of his medical team to adopt an approach with more momentum.
- Karen -
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.

Hey Daddy
Posts: 37
Joined: Wed Nov 30, 2016 8:42 am

Re: Post appendectomy ileus

Postby Hey Daddy » Sat Jul 01, 2017 9:24 am

Well just when we were starting to discuss what to do next, things started working yesterday and today they let us come home. We can enjoy a nice quiet 4th of July weekend at home. Thank you all for your helpful advice and support.
DS dx CC Stage IIB (T4N0M0) 3Aug16, 21 yr old
poorly differentiated, lymphovascular and perineural invasion
CEA 29
Colon resection 4Aug16
CEA 2.5
Genetics testing negative
6 mo FOLFOX Sep16 - Mar17
CT Scan Mar17 clear
Colonoscopy Apr17 clear
CEA 1.8
NED
Emergency appendectomy Jun17
Adhesion surgery to clear small bowel obstruction Dec 17

MissMolly
Posts: 645
Joined: Wed Jun 03, 2015 4:33 pm
Location: Portland, Ore

Re: Post appendectomy ileus

Postby MissMolly » Sat Jul 01, 2017 4:40 pm

HeyDaddy:
That's fantastic news about your son. Totally awesome that his intestinal tract was successfully re-booted with restored intestinal motility. A good story ending.

You were a strong support to your son through the entire ileis ordeal. Best Dad award goes to you.

Best wishes to your son for continued recovery,
- Karen -
Dear friend to Bella Piazza, former Colon Club member (NWGirl).
I have a permanent ileostomy and offer advice on living with an ostomy - in loving remembrance of Bella
I am on Palliative Care for broad endocrine failure + Addison's disease + osteonecrosis of both hips/jaw + immunosuppression. I live a simple life due to frail health.


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