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A case of acute post-laparoscopy bowel hypermotility and treatment with hyoscine butylbromide.

Background

Different aetiologies of post-laparoscopy pain are recognised and many modes of perioperative analgesia have been proposed to improve post-operative pain (Mouton et al 1999, Bayar et al 2008, Ng et al 2008, Costello et al 2009). There are no cases in the literature describing acute bowel spasm as a contributor to pain in the immediate post-operative period.

Case report

A 23 year old women with a history of irritable bowel syndrome (IBS) underwent diagnostic laparoscopy to investigate cyclical pelvic pain and dyspareunia. Entry to the peritoneum was via standard closed technique (Veress, C[O.sub.2] insufflation followed by trocar insertion). The pelvic cavity was inspected and one spot of endometriosis was found at the right uterosacral ligament which was treated by diathermy. A dye test was performed and confirmed tubal patency. Laparoscopic ports were removed under direct vision and remaining C[O.sub.2] was released from the abdominal cavity. Neostigmine and glycopyrrolate were used to reverse muscle paralysis and the patient was extubated.

Immediately after extubation the patient complained of severe abdominal pain which was not relieved by morphine. In view of continuing severe pain and distress the patient was again anaesthetised and a repeat laparoscopy was performed to exclude an acute visceral injury as the cause of pain.

On re-inspection of the abdominal cavity no evidence of visceral injury was seen however the small bowel was noted to be distended and hypermotile with markedly increased visible peristalsis. The ascending and transverse colon were also noted to be distended with gas. General surgeons were called and confirmed hypermotility of the small bowel. Intravenous hyoscine butylbromide was given and the hypermotility was noted to improve shortly after. Gas transit from the ascending colon to the descending colon was observed. A flatus tube was passed to attempt to decompress the bowel but no gas was released.

After recovery from the second laparoscopy the pain was much improved and the patient was comfortable.

Discussion

Severe abdominal pain, unrelieved by morphine, is unusual post laparoscopy (Rasanayagam & Harrison 1996). Reinspection of the abdominal cavity revealed distended and hypermotile small bowel which is likely to have been the cause of the patient's severe pain.

Neostigmine is a parasympathomimetic cholinesterase inhibitor that is frequently used to reverse the effects of nondepolarizing neuromuscular blockade (Nair & Hunter 2004). Neostigmine is known to reduce gastric acid output and oesophageal and gastric tone whilst increasing salivation and lower gastrointestinal tract motility, indeed, it is increasingly used to treat paralytic ileus (Ponec et al 1999). Glycopyrrolate is often given with neostigmine to counteract unwanted anticholinergic effects, such as bradycardia. Glycopyrrolate is a synthetic quarternery amine which blocks muscarinic receptors (Mirakhur & Dundee 1983).

It is likely that neostigmine used at reversal precipitated hypermotility of the small bowel in the above patient. Re-inspection of the abdominal cavity at the time of the second laparoscopy confirmed a distinct change in the motility of the small bowel. We treated the patient with IV hyoscine butylbromide, an antimuscarinic, anticholinergic agent used as an abdominal-specific antispasmodic (Tytgat 2008). Rapid normalisation of the small bowel hypermotility was observed: on extubation the severe abdominal pain had resolved. Patients with IBS may experience a heightened response to the gastrointestinal motility increasing effect of neostigmine (Fukundo & Numura 1993).

Conclusion

Severe abdominal pain, unrelieved by morphine, is unusual immediately post-laparoscopy. In this case small bowel hypermotility was implicated and may have been a direct effect of neostigmine used at reversal of muscle relaxation. We propose that IV hyoscine butylbromide is a rapid and effective treatment of neostigmine-induced small bowel hypermotility post laparoscopy. In cases of acute abdominal pain post laparoscopy in patients with a history of IBS, IV hyoscine butylbromide should be considered as a first-line treatment prior to consideration of repeat laparoscopy.

References

Bayar U, Basaran M, Atasoy N, Ayoglu H, Sade H, Altunkaya H 2008 Comparison of satisfaction and pain relief between patients-controlled analgesia and interval analgesia after laparoscopic ovarian cystectomy Journal of Psychosometic Obstetstetrics and Gynaecology 29 (2) 139-45

Costello MF, Abbott J, Katz S, Vancaillie T, Wilson S 2009 A prospective, randomized, double-blind, placebo-controlled trial of multimodal intraoperative analgesia for laparoscopic excision of endometriosis Fertility and Sterility Apr 24 [Epub ahead of print]

Fukudo S, Nomura T, Muranaka M, Taguchi F 1993 Brain-gut response to stress and cholinergic stimulation in irritable bowel syndrome. A preliminary study Journal of Clinical Gastroenterology 17(2) 133-41

Mirakhur RK, Dundee JW 1983 Glycopyrrolate: pharmacology and clinical use Anaesthesia 38 (12) 1195-204

Mouton WG, Bessell JR, Otten KT, Maddern GJ 1999 Pain after laparoscopy Surgical Endoscopy 13 (5) 445-8

Nair VP, Hunter JM 2004 Anticholinesterases and anticholinergic drugs Continuing Education in Anaesthesia, Critical Care & Pain 4 164-168

Ng A, Swami A, Smith G, Emembolu J 2008 Early analgesic effects of intravenous parecoxib and rectal diclofenac following laparoscopic sterilization: a double-blind, double-dummy randomized controlled trial Journal of Opioid Management 4 (1) 49-53

Ponec RJ, Saunders MD, Kimmey MB 1999 Neostigmine for the treatment of acute colonic pseudo-obstruction New England Journal of Medicine 341 (3) 137-41

Rasanayagam R, Harrison G 1996 Pre-operative oral administration of morphine in day-case gynaecological laparoscopy Anaesthesia 51(12) 1179-81

Tytgat GN 2008 Hyoscine butylbromide--a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures Current Medical Research and Opinion 10 [Epub ahead of print]

Dr Tessa J Bonnett

MBChB DCH

Specialty Registrar Obstetrics & Gynaecology, Department of Obstetrics and Gynaecology, Jessop Wing, Royal Hallamshire Hospital, Sheffield

Mr Hany Lashen

MBBCh MRCOG MD

Consultant Gynaecologist, Department of Obstetrics and Gynaecology, Jessop Wing, Royal Hallamshire Hospital, Sheffield

Correspondence address: Dr Tessa J Bonnett, Department of Obstetrics and Gynaecology, Jessop Wing, Royal Hallamshire Hospital, Sheffield. Email: tess.bonnett@virgin.net
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Article Details
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Title Annotation:CASE REPORT
Author:Bonnett, Tessa J.; Lashen, Hany
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:1USA
Date:Dec 1, 2009
Words:947
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