ileus - is it all in my head?

[Adragon]

I had emergency abdominal surgery last August to remove my appendix along with lymph nodes and connective tissues that had become badly inflamed and infected.  In December, I had a bout of severe pain and nausea with vomiting. I was hospitalized with an NG tube for about five days.  Since then, I have had a recurrence of the symptoms about every four weeks.  I've been hospitalized six times and the tube is sometimes used and sometimes not used.  The X-rays show an ileus each time I am admitted.  Each time, surgery is mentioned but since the ileus resolves on its own, no surgery is done.  I have seen the surgeon who performed my original surgery in August and he is very hesitant to operate again.  One reason is that I was a dreadful patient (very disoriented and confused after the surgery. Pulled out tubes, etc.) The other is that if adhesions or scarring from the first operation are causing my current problems, another operation could result in similar adhesions and scarring. Of course, I cannot continue being hospitalized every few weeks.  This has become a quality of life issue.

In researching abdominal pain on the web, I've found that there's a very high instance of the pain being psychosomatic or even Munchausen’s.  I very hope that these symptoms *are* all in my head because I definitely do not want surgery and the surgeon doesn't want to do it.

So, here's my odd question.  My pain certainly feels real and the vomiting and x-ray results are real, but could the symptoms still be the result of a psychological problem?  By the way, one doctor did a mesenteric arteriogram and found a slight constriction in one of the arteries so I am going to see a vascular surgeon.

Thanks for any help you can provide.

A

[Kevin Pho, MD]

Hello - thanks for asking your question.

Surgeon has already provided some insight into the possibility of obstruction, so I won't repeat what he said here.  That is certainly a possibility.

If the workup for obstruction is negative (i.e. CT scan and/or upper GI series with small bowel follow through), then the vascular possibility should be considered.  

If there is arterial constriction, your symptoms may be secondary to mesenteric ischemia (i.e. a blockage of the arteries supplying the gut).  Typically, the pain is dull, crampy, epigastric pain, usually within the first hour after eating. The pain can be of variable intensity and location, and may occasionally radiate to the back.  Nausea occurs in 1/3 of patients.

Treatment for mesenteric ischemia includes surgery or stent treatment.  This should be discussed with your personal physician.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[surgeon]

It seems unlikely the arterial issue is significant: when there's restricted blood flow to the gut from such a lesion, typically it causes pain after eating, but not the bloating. Ileus refers to a condition where the bowel muscles are not functioning actively, typically results from surgery for a few days acutely after surgery, or from another acute problem such as infection. What you describe sounds more like an intermittant obstruction than ileus. When and whether to operate for intermittant obstruction is a difficult decision: the only mandatory time is if the process doesn't resolve. How many times before intervention? There's no specific answer. Could the procedure cause new adhesions (which are usually the source of the problem)? Well, yes it could. But the fact is that most people who have had abdominal surgery have adhesions as a result, and most of those never have any trouble at all.  In other words, adhesions are common; problems from them are not all that common. So whereas surgery to fix the problem might result in a new problems, the odds are it won't. It's the bad luck of the draw that you have adhesions in such an orientation that they cause problems. For you to have more problems after fixing them, you'd have to have bad luck again: not impossible, but as you said, if it keeps going on as it is, at some point it seems right to take the plunge and hope for a better outcome, which is likely. As to being a "bad" patient: first, the anesthesiologist can look at what you were given the last time, and use something different. Second, since you were sick the first time -- the infection related to the appendix -- and won't be the second time, it may well be that the reaction will be different, and calmer.