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The British Journal of Radiology, 73 (2000), 951955

2000 The British Institute of Radiology

Adynamic ileus after Caesarean section mimicking


intestinal obstruction: ndings on abdominal
radiographs
B F KAMMEN, MD, M S LEVINE, MD, S E RUBESIN, MD and I LAUFER, MD
Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia,
PA 19104, USA

Abstract. The purpose of this study was to determine the spectrum of ndings and the frequency
of apparent distal colonic obstruction on abdominal radiographs in women with obstructive
symptoms following Caesarean section. A search of radiology les yielded 21 patients who had
abdominal radiographs because of obstructive symptoms during the early post-operative period.
The radiographs were reviewed retrospectively to characterize the bowel gas patterns in these
patients. Medical records were also reviewed to determine the treatment and patient course.
Abdominal radiographs showed ndings suggestive of distal colonic obstruction in 15 patients
(71%), small bowel obstruction in 2 (10%), adynamic ileus in 3 (14%) and a normal bowel gas
pattern in 1 (5%). In all 15 patients with apparent distal colonic obstruction, there was minimal or
no gas in the rectosigmoid, with an associated pelvic mass representing the enlarged post-partum
uterus, which compressed the rectosigmoid and prevented it from lling with gas. All 21 patients
had rapid clinical or radiographic improvement on conservative management, indicating a
transient post-operative ileus. Radiologists should be aware of the limitations of abdominal plain
radiographs following Caesarean section so that a post-operative ileus is not mistaken for a distal
colonic obstruction and conservative measures can be undertaken to decompress the bowel until
the ileus resolves.
It is well known that women who undergo
Caesarean section may develop an acute postoperative ileus characterized by transient, occasionally severe, colonic dilatation that resolves
spontaneously [17]. We have noticed that this
adynamic ileus is sometimes manifested on
abdominal radiographs by marked colonic dilatation with minimal or absent gas in the rectosigmoid, mimicking the appearance of a distal
colonic obstruction. We therefore performed a
retrospective study of abdominal radiographs in
women with obstructive symptoms following
Caesarean section to determine the spectrum of
radiographic ndings and the frequency of
apparent distal colonic obstruction in these
patients.

Materials and methods


Approximately 3200 Caesarean sections were
performed at our hospital during the 8-year
period between 19901998. A computerized
search of radiology les showed that 26 of the
patients had abdominal radiographs after surgery.
Received 10 January 2000 and in revised form 3 April
2000, accepted 10 April 2000.
Address correspondence to Dr M S Levine.
The British Journal of Radiology, September 2000

22 of these patients had radiographs during the


early post-operative period because of obstructive
symptoms, including abdominal distention in 12
patients, nausea and vomiting in eight and
abdominal pain in eight. The abdominal radiographs and medical records were available for
review in the 21 cases who comprised our study
group.
When abdominal radiographs are obtained in
our department for possible intestinal obstruction,
the protocol includes both supine and upright
lms to assess for the presence of free intraperitoneal air or airuid levels in the bowel, whereas
portable abdominal radiographs are generally
obtained with the patient in a supine position
only. In our series, the examinations consisted of
supine and upright abdominal radiographs in 18
patients and supine portable abdominal radiographs alone in three. Six patients also had
vertical beam left lateral views of the pelvis to
facilitate passage of gas into the rectosigmoid and
to differentiate adynamic ileus from distal colonic
obstruction more easily [8]. Initial abdominal
radiographs were obtained an average of 3 days
after Caesarean section (range 16 days). 12
patients had one set of abdominal radiographs
and nine had serial studies, with an average of
three additional sets of radiographs (range 17).
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B F Kammen, M S Levine, S E Rubesin and I Laufer

The initial abdominal radiographs were


reviewed retrospectively by two of the authors
to characterize the bowel gas patterns in these 21
patients. A diagnosis of small bowel obstruction,
colonic obstruction or adynamic ileus was made,
based on the presence and degree of bowel
dilatation and the distribution of dilated bowel.
When the colon was dilated, the distal extent of
colonic dilatation was also noted. The average
luminal diameter of the dilated small bowel was
3.5 cm (range 2.55.5 cm) and the average
luminal diameter of the dilated colon was
6.4 cm (range 49 cm). Upright abdominal radiographs were evaluated for the presence or absence
of airuid levels in the dilated loops of bowel.
Left lateral projections of the pelvis were also
evaluated for the presence or absence of gas in the
rectosigmoid. Finally, radiographs were evaluated
for the presence or absence of free intraperitoneal
air, pneumatosis, thumbprinting or a pelvic mass
(representing the enlarged post-partum uterus).
When more than one set of abdominal radiographs had been obtained, all subsequent radiographs were reviewed to determine the
radiographic course.
As a separate part of the study, the original
radiological reports were reviewed to determine
the impression at the time the abdominal radiographs had been obtained. Medical records were
also reviewed to determine the treatment and
patient course.

Results
Radiographic ndings
Abdominal radiographs demonstrated ndings
suggestive of distal colonic obstruction in 15
(71%) of the 21 patients. These patients all had
varying degrees of colonic dilatation, with or
without small bowel dilatation, and minimal or
no gas in the rectosigmoid (Figures 1a and 2a). In
all cases, airuid levels were present in the
dilated bowel loops on upright radiographs
(Figure 1b). In the 15 patients with ndings
suggestive of distal clonic obstruction, the descending colon was the most distal segment of
dilated bowel in 13 (87%) and the transverse colon
in 2 (13%). In all 15 cases, there was increased soft
tissue density in the pelvis, representing the
enlarged post-partum uterus. Of the 15 patients,
six also had left lateral projections of the pelvis.
In four cases, these additional radiographs
showed minimal or no gas in the rectosigmoid,
supporting a diagnosis of distal colonic obstruction (Figure 2b). In the remaining two, these
projections showed gaseous lling of the rectosigmoid, indicating a likely ileus.
In 2/21 patients (10%), abdominal radiographs
demonstrated ndings suggestive of small bowel
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obstruction, with dilated small bowel and a


paucity of colonic gas on supine radiographs
(Figure 3) and airuid levels in the dilated small
bowel loops on upright radiographs. Both of these
patients also had evidence of a pelvic mass. In 3
patients (14%), abdominal radiographs showed
ndings suggestive of adynamic ileus, with diffuse
dilatation of small bowel and colon (including the
rectosigmoid) on supine radiographs and airuid
levels in the dilated bowel loops on upright
radiographs. These three patients also had
evidence of a pelvic mass. In 1 patient (5%),
abdominal radiographs showed a normal bowel
gas pattern. There was no evidence of free
intraperitoneal air or of thumbprinting or pneumatosis of the bowel in any of the 21 cases.
In a separate review of the original radiological
reports from these 21 patients, the initial impression was a post-operative adynamic ileus in 9
(43%), possible colonic obstruction in 8 (38%),
possible small bowel obstruction in 3 (14%) and a
normal bowel gas pattern in 1 (5%).

Treatment and course


All 21 patients were managed conservatively by
stopping oral intake and reducing analgesics.
Nasogastric tubes were also placed for decompression of the bowel in nine patients, and Miller
Abbott tubes in two patients (the two with
isolated small bowel dilatation). All 21 patients
had spontaneous resolution of symptoms over an
average follow-up period of 4 days (range 110
days), strongly favouring an adynamic postoperative ileus. Nine patients also had follow-up
abdominal radiographs that showed decreasing
distention of small bowel and/or colon over an
average period of 6 days (range 310 days).
Therefore, the follow-up studies also strongly
favoured a transient post-operative ileus as the
cause of these ndings.

Discussion
Women may develop a severe post-operative
colonic ileus (also known as colonic pseudoobstruction) following Caesarean section [17]. In
our study, symptoms severe enough to warrant
abdominal radiographs were present in 21
patients, which constituted less than 1% of all
patients who underwent Caesarean section during
an 8-year period. 15 (71%) of these 21 patients
had a post-operative ileus that mimicked the
radiographic ndings of distal colonic obstruction
(Figures 1 and 2a). In such cases, the ndings
were characterized by dilatation of the colon, with
or without small bowel dilatation, and with
minimal or no gas in the rectosigmoid.
Although the radiographic appearance favoured
The British Journal of Radiology, September 2000

Adynamic ileus after Caesarean section

(a)

(b)

Figure 1. 35-year-old woman with post-operative ileus mimicking distal colonic obstruction, 3 days after
Caesarean section. (a) Supine abdominal radiograph shows dilated colon to the level of the descending colon,
with no gas in the rectosigmoid. Also note increased soft tissue density in the pelvis, representing the enlarged
post-partum uterus. (b) Upright abdominal radiograph shows airuid levels in the dilated colon.

(a)

(b)

Figure 2. 31-year-old woman with post-operative ileus mimicking distal colonic obstruction on abdominal radiograph and vertical beam left lateral projection of pelvis obtained 2 days after Caesarean section. (a) Supine
abdominal radiograph shows dilated small bowel and colon, with absence of gas in the rectosigmoid and
increased soft tissue density in the pelvis. (b) Left lateral view of pelvis shows dilated colon (arrows) in the lower
abdomen, with absence of gas in the rectosigmoid, a nding usually indicative of distal colonic obstruction. The
enlarged post-partum presumably compressed the rectosigmoid, preventing it from lling with gas.
The British Journal of Radiology, September 2000

953

B F Kammen, M S Levine, S E Rubesin and I Laufer

Figure 3. 31-year-old woman with post-operative ileus


mimicking small bowel obstruction, 5 days after
Caesarean section. Supine abdominal radiograph
shows dilated small bowel in the left side of the
abdomen, with a paucity of colonic gas. Also note
increased soft tissue density in the pelvis and the
MillerAbbott decompression tube with its tip
(arrow) in the duodenum.

a distal colonic obstruction, clinical and/or radiographic follow-up in all cases indicated that these
ndings were caused by a transient post-operative
ileus.
We considered the possibility that the plain
radiographic ndings in these 15 patients could
have resulted from a true mechanical obstruction
by an enlarged post-partum uterus compressing
the rectosigmoid. However, ultrasound studies
have shown that the enlarged post-partum uterus
gradually involutes, returning to its original size
over a period of 68 weeks [9, 10]. If the
radiographic ndings resulted from mechanical
obstruction of the rectosigmoid by an enlarged
uterus, these ndings would therefore be expected
to resolve gradually as the uterus involuted.
However, the obstructive symptoms in our
patients resolved on conservative management
over an average period of only 4 days, and followup abdominal radiographs showed decreasing
distention of bowel over an average period of
only 6 days. The rapid and dramatic improvement
in these patients therefore indicates that dilatation
of bowel was caused by a transient post-operative
ileus and not by mechanical obstruction by an
enlarged post-partum uterus.
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Instead, we believe that the enlarged postpartum uterus prevents gas from entering the
rectosigmoid in these patients with a postoperative ileus, creating the erroneous impression
of a distal colonic obstruction. When an adynamic ileus is suspected, left lateral radiographs of
the pelvis or prone abdominal radiographs
facilitate passage of gas into the rectosigmoid,
often enabling differentiation of an adynamic
ileus from a true mechanical obstruction [8]. Use
of these additional projections is based on the
assumption that the rectosigmoid will distend
with gas in patients with an adynamic ileus but
not in patients with a distal colonic obstruction.
However, the rectosigmoid remained collapsed in
four of six patients in whom left lateral radiographs of the pelvis were obtained (Figure 2b).
This presumably resulted from the enlarged postpartum uterus compressing the rectosigmoid and
preventing it from lling with gas. It is therefore
important to recognize that additional projections
to facilitate passage of gas into the rectosigmoid
are unlikely to be helpful in differentiating a postoperative ileus from a distal colonic obstruction
following Caesarean section.
On the basis of our ndings, we believe that
abdominal radiographs have limited value in
patients with obstructive symptoms following
Caesarean section as the vast majority of patients
are found to have a transient post-operative ileus
regardless of the bowel gas pattern. These radiographs are mainly helpful for assessing the degree
of dilatation of the bowel and the need for
decompression. For this reason, supine abdominal
radiographs are probably adequate in most cases
without the need for additional upright, decubitus
or vertical beam projections. Rarely, however,
upright radiographs or even abdominal CT scans
may be required for further investigation of
patients with clinical signs of post-operative
ischaemia or perforation.
Patients who develop an adynamic ileus following Caesarean section are almost always treated
conservatively, with reduction of oral intake to a
minimum, nasogastric decompression and
decreased use of analgesics for pain control.
Occasionally, in patients with a severe postoperative ileus, the caecum may become massively
dilated, increasing the risk of caecal perforation
[11]. In such cases, a rectal tube or even a
caecostomy may be required to decompress the
bowel. In our series, however, the ileus resolved
spontaneously in all cases without need for
endoscopic or surgical decompression of the
bowel.
In conclusion, radiologists should be aware of
the limitations of abdominal plain radiographs
following Caesarean section, so that a postoperative ileus is not mistaken for a distal colonic
The British Journal of Radiology, September 2000

Adynamic ileus after Caesarean section

obstruction and so conservative measures can be


undertaken to decompress the bowel until the
ileus resolves.

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