From the Guidelines
The initial management of large bowel ileus should involve supportive treatment with intravenous crystalloids, anti-emetics, and bowel rest, as recommended by the most recent evidence 1.
Key Components of Treatment
- Intravenous fluid resuscitation with isotonic dextrose-saline crystalloid and balanced isotonic crystalloid replacement fluids containing supplemental potassium to maintain hydration and electrolyte balance 1
- Bowel rest to reduce intestinal workload
- Nasogastric suction for diagnostic and therapeutic purposes, including analyzing gastric contents and preventing aspiration pneumonia 1
- Insertion of a Foley catheter to monitor urine output 1
Additional Considerations
- Pain management with opioid-sparing medications to avoid worsening ileus
- Early ambulation to stimulate bowel function
- Discontinuation of medications that may contribute to decreased bowel motility, if possible
- Correction of underlying conditions, such as infection or electrolyte abnormalities, if present
- Consideration of prokinetic agents, such as metoclopramide or erythromycin, in select cases, although evidence for their efficacy is limited 1
Surgical Intervention
- Rarely needed for uncomplicated ileus, but may be necessary if there is evidence of bowel ischemia, perforation, or if the ileus fails to resolve with conservative management after 3-5 days 1
From the Research
Treatment Options for Large Bowel Ileus
- Neostigmine is a parasympathomimetic drug that can be used to treat large bowel ileus, particularly in cases of acute colonic pseudo-obstruction (ACPO) or Ogilvie's syndrome 2, 3.
- The administration of neostigmine can lead to prompt evacuation of flatus or stool and reduction in abdominal distention, with a median duration of 4-30 minutes 2.
- Other treatment options for ileus include metoclopramide, which can be used to treat vincristine-induced ileus 4, and erythromycin, which can be used in combination with metoclopramide to reduce the rate of treatment failure 5.
- Cholinesterase inhibitors, such as neostigmine, may be safe and effective in treating constipation in critically ill patients, but are often underprescribed 6.
- Prokinetic agents, such as metoclopramide, can be considered as an option for ileus treatment after ruling out the possibility of bowel obstruction 4.
Potential Side Effects and Complications
- The most frequent side effect of neostigmine is abdominal pain/cramping, which can be symptomatic in some cases 2.
- Other potential complications of neostigmine include bradycardia, which is rarely symptomatic and may require treatment with atropine 2.
- Metoclopramide can also cause side effects, such as extrapyramidal symptoms and hyperprolactinemia, which should be monitored and managed accordingly 4.
Prevention and Management
- Preventive measures, such as bowel management protocols using osmotic laxatives, can be implemented to reduce the risk of ileus in critically ill patients, but their effectiveness is still uncertain 6.
- Prophylactic stool softeners should be administered in all patients undergoing chemotherapy with vincristine to prevent gastrointestinal motility disorders 4.