From the Guidelines
In patients with ileus, bowel regimens should be avoided until bowel function returns, as they may worsen distention and discomfort. Ileus represents a functional obstruction of the bowel with decreased or absent peristalsis, so stimulant laxatives, bulk-forming agents, and other bowel regimens are contraindicated. Management should focus on treating the underlying cause of ileus, maintaining nil by mouth (NPO) status, nasogastric tube decompression if needed, and intravenous fluid hydration, as recommended by 1.
Key aspects of management include:
- Treating the underlying cause of ileus
- Maintaining NPO status
- Nasogastric tube decompression if needed
- Intravenous fluid hydration
- Avoiding medications that contribute to decreased gut motility, such as opioids and anticholinergics
- Considering prokinetic agents like metoclopramide (10mg IV/PO three times daily) to stimulate gut motility, though evidence for their efficacy is limited, as noted in the general approach to ileus management.
Once bowel sounds return and the patient passes flatus or stool, indicating resolution of the ileus, a gentle bowel regimen can be initiated, typically beginning with clear liquids and advancing as tolerated. Early ambulation, when possible, can help stimulate return of bowel function, as suggested by 1 in the context of postoperative care. The pathophysiology behind this approach is that forcing bowel movements in an ileus can lead to increased intraluminal pressure in a non-functioning bowel, potentially causing perforation or worsening the underlying condition.
It's also important to consider the multifaceted approach to minimizing postoperative ileus, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, and omission/early removal of nasogastric intubation, as recommended by 1. However, the primary focus should remain on avoiding bowel regimens until bowel function returns, to prioritize morbidity, mortality, and quality of life outcomes.
From the Research
Bowel Regimen in Ileus Patients
- The management of ileus includes addressing the underlying cause and supportive care, with multiple medical interventions proposed, but effectiveness is uncertain 2.
- A study found that early enteral nutrition (EEN) facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay in patients who have undergone abdominal surgery 2.
- The use of metoclopramide and erythromycin to hasten the resolution of ileus is not recommended, as analyses showed they were not effective in expediting the resolution of ileus 2.
- In patients with suspected mechanical ileus, a clear distinction between mechanical and functional causation is necessary, and proper treatment depends on the timely determination of the pathogenesis and close interdisciplinary collaboration 3.
- For functional ileus, supportive measures usually suffice, and surgery is only rarely required 3.
- Multimodal therapy for gastroparesis and paralytic ileus is discussed, with erythromycin and metoclopramide being options for gastroparesis, and neostigmine commonly used for paralytic ileus 4.
- Bisacodyl, a stimulant laxative, has a dual prokinetic and secretory action and can be used to enhance motility and reduce transit time in the large bowel 5.
- A modern diagnostic strategy in ileus involves a rapid and correct diagnosis, followed by immediate surgical intervention if indicated, with preoperative diagnostic examinations confirming bowel obstruction, determining its localization and origin, and excluding other pathologies 6.