Ileus post-bowel surgery is typically a normal physiological response that usually lasts less than 72 hours [7]. Delayed return of bowel function and ileus have been reported after colorectal surgery in approximately 10-25% of patients [7,8]. Ileus is often considered resolved once the patient has passed flatus [9]. There is no exact etiology known that causes ileus, and it is thought to be the result of a complex interplay of factors, such as medication, inflammation, and pharmacological agents that interfere with the neuro-hormonal pathway of the bowel loops [7-10]. There are a multitude of factors status post colorectal surgery which can cause prolonged postoperative ileus. These range from pharmacological anesthetic agents, type of surgery, postoperative ambulation, peripheral vascular disease, chronic obstructive pulmonary disease, edema, use of opioids, early enteral nutrition, etc [7-11]. Enhanced recovery after surgery pathway protocols have helped reduce postoperative ileus [9]. However, these protocols cannot be used in emergency surgery, as in our case. Management of postoperative ileus is mainly supportive care in the form of using COX-2 inhibitors, avoiding narcotics, adequate hydration to maintain normovolemia, nutritional support, postoperative ambulation, chewing gum, and time [7-10]. Prolonged postoperative ileus is often challenging to differentiate from mechanical causes of prolonged return of bowel function; they both have similar symptoms of abdominal bloating, distention, pain, nausea, vomiting, and inability to tolerate an oral diet [3,7-10,12]. Mechanical obstruction caused in the early postoperative period after colectomy may be due to anastomotic narrowing, kinking, adhesions, internal herniations, port site herniation, intussusception, leak, intra-abdominal collections, etc. Some of these will resolve with conservative management, like prolonged nasogastric decompression [3,12]. In our patient, however, we feared the risk of recurrent aspiration due to her history of a very large hiatal hernia. If the patient’s condition fails to resolve with conservative treatment, surgical correction may be required [3,12].

Our patient was an 83-year-old female with severe chronic obstructive pulmonary, worsening right-sided heart failure, anasarca, poor functional status, and multiple medical comorbidities - which can all cause prolonged ileus. It was originally thought that her symptoms were the result of a prolonged ileus caused by nonmodifiable risk factors such as age, hypertension, lack of ambulation, malnutrition, chronic obstructive pulmonary disease, peripheral vascular disease, and cardiac disease. Her intermittent symptoms, however, suggested a mechanical cause of her symptoms. Concern for a mechanical cause, in addition to deterioration in her health, led to her second surgery. Interestingly, after having a computed tomography scan with Gastrografin contrast to visualize the patency of the anastomosis, her symptoms temporarily improved. Given her past medical history and multiple risk factors for prolonged ileus, the most reasonable explanation is that her worsening obstruction was due to intramural intestinal edema secondary to right-sided heart failure, hypoalbuminemia, and inflammation. Right-sided heart failure leads to a reduction in cardiac output; as the heart loses its ability to contract, a "backlog" of blood accumulates in the venous circulation [13]. Another consideration is the patient’s prolonged non-ambulatory status. Since pelvic and abdominal bowel loops are in a more dependent position with the patient non-ambulatory, it makes sense how her lack of ambulation could contribute to her edema.

Administering excessive perioperative fluids can lead to intestinal edema, which may then lead to postoperative ileus. Edema causes dysfunction within the intestinal smooth muscle cells and activates intestinal glial cells, which can cause inflammation and reduce colonic motility [14]. This idea is further supported by the patient's improvement following the use of computed tomography with Gastrografin. Gastrografin is a hyperosmolar medium and is able to pull fluid out of the intestinal wall and into the lumen [15]. The use of Gastrografin in our patient reduced her intestinal wall edema and led to a temporary improvement in her symptoms. However, her edema eventually returned, given her underlying medical and nutritional issues, causing her bowel to become edematous again shortly thereafter. Our patient eventually required more aggressive treatment with diuresis to see a lasting improvement in her condition. Her right heart failure, hypoalbuminemia, and non-ambulatory status led to the development of significant intestinal edema, which became a significant contributor to prolonging the physiological return of bowel function.