Severe Paralytic Ileus and Pneumoperitoneum Without Perforation Following Epidural Morphine in a Young Post-gastrectomy Patient

Postoperative ileus (POI) is a relatively common complication of abdominal surgery that typically resolves with conservative treatment. However, in rare cases, it may progress to a more severe condition. We present the case of a 25-year-old man who developed severe POI and pneumoperitoneum without gastrointestinal perforation after receiving continuous epidural morphine following gastrectomy. Postoperative analgesia was maintained with the continuous epidural administration of morphine and ropivacaine. On postoperative day 2, the patient experienced worsening abdominal pain. Imaging studies revealed the presence of free intra-abdominal gas, a dilated intestinal tract, and portal venous gas. Emergency surgery was performed due to suspected intestinal necrosis; however, no perforation or obstruction was identified. The findings were attributed to increased intraluminal pressure and mucosal injury resulting from paralytic ileus. An ileal tube was inserted for decompression. Following the second surgery, persistent abdominal distention prompted the discontinuation of epidural morphine. Subsequent improvement in bowl dilation was observed; the patient has remained in stable condition since. In this case, opioid-induced suppression of gastrointestinal motility likely contributed to the development of severe paralytic ileus and pneumoperitoneum. Although epidural morphine is generally considered safe, its potential impact on gastrointestinal function warrants caution. Regular monitoring of gastrointestinal motility and early intervention are essential during opioid use. This case report underscores the importance of risk assessment in postoperative pain management.