https://orcid.org/0009-0006-4799-4278
Abstract
Adhesive small bowel obstruction (ASBO) in the immediate postpartum period is uncommon and may mimic postoperative ileus. A 26-year-old woman returned 48 hours after repeat cesarean section with abdominal distension, vomiting, and obstipation. Her history included a previous cesarean delivery and prior midline laparotomy for ovarian torsion with appendectomy and right salpingo-oophorectomy. Radiography showed dilated small-bowel loops with air–fluid levels, without initial peritoneal signs. After nasogastric decompression and observation, she deteriorated ~10 hours later with worsening pain, peritoneal signs, hypotension, tachypnea, and hypoxemia. Repeat imaging demonstrated pneumoperitoneum and complex intraperitoneal fluid. Emergency laparotomy revealed dense ASBO, generalized fecal peritonitis, and ileal perforation 20 cm proximal to the ileocecal valve. Segmental ileal resection with end ileostomy was performed. She required 5 days of intensive care. Ileostomy reversal 5 months after discharge was uncomplicated, with no major complications at 3-month follow-up.
Introduction
Postoperative gastrointestinal symptoms after cesarean section are often attributed to ileus and managed conservatively in stable patients [1]. In contrast, adhesive small bowel obstruction (ASBO) may require urgent surgery and remains the leading cause of small bowel obstruction after abdominopelvic operations [2]. Previous abdominal surgery, including cesarean delivery, increases the risk of adhesions and subsequent obstruction [3].
Although uncommon in the immediate postpartum period, ASBO may initially resemble postoperative ileus, creating a potential diagnostic challenge. We report a case of early postpartum ileal perforation secondary to ASBO following repeat cesarean section. This report is presented in accordance with the Surgical CAse REport guidelines [4].
Case report
A 26-year-old woman with class III obesity (body mass index 40.2 kg/m2), chronic hypertension, a previous cesarean delivery, and a prior midline laparotomy for ovarian torsion requiring appendectomy and right salpingo-oophorectomy underwent elective repeat cesarean section. Dense intra-abdominal adhesions were documented intraoperatively.
She returned 48 hours after the cesarean section with progressive abdominal distension, persistent emesis, oral intolerance, and obstipation. At readmission, her blood pressure was 140/93 mmHg, heart rate 128 beats/min, respiratory rate 20 breaths/min, temperature 36.5°C, and oxygen saturation 91% on room air. The abdomen was markedly distended, tympanitic, and diffusely tender, with decreased bowel sounds but no peritoneal signs. Laboratory studies demonstrated leukocytosis (19 100/μl), progressive thrombocytopenia, severe hypoalbuminemia, elevated inflammatory markers, and acute kidney injury. Abdominal radiography showed multiple dilated small-bowel loops with air–fluid levels (Fig. 1).
Radiographic findings consistent with mechanical small bowel obstruction and gastrointestinal perforation. (A) Upright abdominal radiograph demonstrating multiple dilated small-bowel loops (red circle) with several air–fluid levels (yellow lines), findings consistent with mechanical small bowel obstruction. (B) Upright chest radiograph showing bilateral subdiaphragmatic free air (yellow circles), consistent with pneumoperitoneum.
Postoperative ileus and acute colonic pseudo-obstruction were initially considered; however, the severity of symptoms and obstipation raised concern for mechanical obstruction. She was admitted for observation and managed with bowel rest, intravenous fluids, and nasogastric decompression, which yielded ~600 ml of gastric contents and produced transient improvement.
Approximately 10 hours after admission, she developed worsening abdominal pain, evolving peritoneal signs, hypotension (90/40 mmHg), tachypnea (26 breaths/min), and oxygen desaturation to 88%, yielding a quick Sequential Organ Failure Assessment score of 2. Repeat chest radiography revealed bilateral subdiaphragmatic free air (Fig. 1), and point-of-care ultrasonography demonstrated complex free intraperitoneal fluid. Emergency exploratory laparotomy was therefore performed shortly thereafter without computed tomography (CT). The complete clinical sequence is summarized in Supplementary Table S1.
Laparotomy revealed dense omental and small-bowel adhesions requiring extensive adhesiolysis. The distal ileum was congested, edematous, and segmentally discolored (Fig. 2A). Approximately 900 ml of fecaloid and serosanguinous fluid was encountered, consistent with generalized fecal peritonitis and Centers for Disease Control and Prevention (CDC) class IV contamination (Fig. 2B). A full-thickness ileal perforation caused by a constricting adhesive band was identified 20 cm proximal to the ileocecal valve. Segmental ileal resection and end ileostomy were performed (Fig. 2C).
Intraoperative findings and resected specimen. (A) Intraoperative view of the distal ileum showing marked congestion, edema, and segmental discoloration (yellow circle), concerning for compromised bowel viability and prompting segmental resection. (B) Intraoperative view demonstrating fecaloid material within the peritoneal cavity (yellow circle) with active suction during exploratory laparotomy, consistent with generalized fecal peritonitis. (C) Resected distal ileal segment containing the full-thickness perforation located ~20 cm proximal to the ileocecal valve.
Intraoperative cultures demonstrated polymicrobial enteric growth, predominantly Escherichia coli. Initial meropenem and vancomycin therapy was subsequently narrowed to meropenem. The patient required 5 days of intensive care and remained hospitalized for ~1 month. Limited marginal ileostomy necrosis was managed conservatively without revision. Ileostomy reversal was performed ~5 months after discharge, and at 3-month follow-up she had normal intestinal function without recurrent obstruction, infection, or other major complication.
Discussion
Early postpartum ASBO remains an uncommon but important diagnostic consideration because its initial presentation may overlap with postoperative ileus and acute colonic pseudo-obstruction [5, 6]. In the present case, progressive obstipation, radiographic evidence of small-bowel dilatation, and subsequent physiological deterioration favored a mechanical process rather than a functional disorder. Similar obstetric case reports have described delayed recognition of intestinal obstruction resulting in bowel compromise, perforation, and sepsis [7–9]. The patient’s prior cesarean section, history of a midline laparotomy, and documented dense adhesions at repeat cesarean delivery represented established risk factors for severe adhesive disease [3].
A relevant feature of this case was the decision to proceed directly to surgical exploration without obtaining a CT scan. At the time of clinical reassessment, the combination of pneumoperitoneum, complex intraperitoneal fluid, worsening abdominal findings, and progressive physiological deterioration strongly suggested hollow viscus perforation. Under these circumstances, additional imaging was unlikely to alter management and would have delayed definitive treatment. Surgical exploration was therefore prioritized to achieve definitive diagnosis and source control. This approach is consistent with the Bologna guidelines, which discourage non-operative management of ASBO in the presence of peritonitis, bowel ischaemia, or clinical deterioration [10].
Recent population-level data further support this approach, demonstrating shorter hospital stays and higher rates of optimal outcomes when operative intervention is not delayed in patients with complicated ASBO [11]. Contemporary emergency general surgery algorithms similarly advocate prompt operative management when bowel compromise or physiological instability is suspected [12].
The operative strategy was influenced by generalized fecal peritonitis, CDC class IV contamination, hemodynamic instability, severe hypoalbuminemia, and acute organ dysfunction. Although primary anastomosis may be feasible in selected haemodynamically stable patients with limited contamination, the combination of severe physiological derangement and extensive contamination favored segmental resection with end ileostomy in the present case [10, 13, 14]. This approach avoided primary anastomosis in a patient with severe contamination while allowing definitive source control and physiological recovery before delayed reconstruction.
Although operative treatment of ASBO is often approached cautiously because of concerns regarding future adhesion formation, surgery remains mandatory in the presence of perforation and sepsis. Furthermore, long-term data suggest that operative management of ASBO may reduce recurrence compared with repeated non-operative treatment [15]. In this patient, extensive adhesiolysis and treatment of the obstructing adhesive band may also reduce the risk of future obstructive episodes.
This report is limited by its single-patient design, which precludes broader generalization. CT was not performed because immediate operative intervention was required once clinical and radiographic evidence of perforation emerged. Follow-up after ileostomy reversal was limited to 3 months, restricting assessment of late recurrent obstruction and other adhesion-related complications.
Conclusion
Early postpartum ASBO may mimic postoperative ileus, potentially delaying recognition of evolving bowel compromise. In this patient, progressive physiological deterioration, pneumoperitoneum, and complex intraperitoneal fluid prompted immediate operative exploration without prior CT, revealing adhesive obstruction complicated by ileal perforation and fecal peritonitis. This case highlights the importance of repeated clinical reassessment and timely surgical intervention in postpartum patients with previous abdominal surgery.
Author contributions
Federico Sacasa (Conceptualization, Investigation, Data curation, Methodology, Writing—original draft), Oscar Guevara (Investigation, Data curation, Writing—review & editing), Blanca Sacasa (Investigation, Data curation, Writing—review & editing), Karen Delgado (Investigation, Data curation, Writing—review & editing), Katerin Yaritza Hernández Reyes (Writing—review & editing, Project administration), and William Vanegas (Supervision, Validation, Writing—review & editing)
All authors approved the final manuscript.
Conflicts of interest
The authors declare that they have no conflicts of interest related to this work.
Funding
No funding was received.
Ethical approval
Due to the specific nature of case reports, which involve retrospective descriptions of clinical observations and interventions that have already been performed, our institution does not require formal ethical approval for single-patient case reports. All identifying information has been completely anonymized to ensure patient confidentiality in accordance with institutional and journal guidelines.
Consent
Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Provenance and peer review
Not commissioned; externally peer reviewed.
Guarantor
Federico Sacasa and William Vanegas.
AI-assisted technologies
The manuscript was written by the authors. ChatGPT (OpenAI) was used only for minor language editing (grammar and phrasing). It was not used to generate scientific content or analyze data.
