What is the diagnosis and treatment for gastric ileus (postoperative ileus)?

From the Guidelines

Gastric ileus should be managed with a multifaceted approach, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation, as recommended by the most recent guidelines 1.

Key Considerations

• The management of gastric ileus involves addressing the underlying cause and providing supportive care to minimize complications and promote recovery.
• A multifaceted approach is essential, incorporating various strategies to prevent and manage postoperative ileus, as outlined in the ERAS society recommendations 1.
• Optimized fluid management is crucial to prevent fluid overload and ensure adequate hydration, with the aim of limiting weight gain to less than 3 kg at postoperative day three 1.
• Opioid-sparing analgesia is recommended to minimize the risk of worsening ileus, and non-opioid analgesics should be preferred whenever possible 1.
• Early mobilization and ambulation are important to stimulate bowel function and promote recovery.

Treatment Strategies

• Nasogastric tube use should be considered on an individual basis, taking into account the risk of gastric stasis and aspiration related to gut dysfunction, and should be removed as early as possible 1.
• Prokinetic medications, such as metoclopramide or erythromycin, may be used to stimulate gut motility, although evidence for their effectiveness is limited.
• Alvimopan may be considered for postoperative ileus, but its use should be guided by individual patient needs and response.
• Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, should be corrected promptly to prevent worsening of ileus.

Pain Management

• Oral administration of analgesic drugs should be preferred over intravenous route whenever feasible, and drugs absorption may be reasonably warranted 1.
• The intramuscular route should be avoided in postoperative pain management, and epidural and regional anesthesia may be considered in emergency general surgery, whenever feasible and if not delaying the emergency procedures 1.
• Patient-controlled analgesia (PCA) either intravenous or epidural provides superior postoperative pain control and patient satisfaction, even if it increased amount of opioid consumption 1.

From the FDA Drug Label

INDICATIONS & USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide Injection (metoclopramide hydrochloride, USP) is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis

The answer to Gastric ileus is not directly addressed in the provided drug label. However, gastric stasis is mentioned, which can be related to gastric ileus.

• Gastric ileus is not explicitly mentioned, but diabetic gastric stasis is an indication for metoclopramide.
• The drug label does mention the relief of symptoms associated with acute and recurrent diabetic gastric stasis. The FDA drug label does not answer the question.

From the Research

Definition and Incidence of Gastric Ileus

• Gastric ileus, also known as postoperative ileus, is a common challenge in adult surgical patients, with an estimated incidence of 17% to 80% 2.
• The main mechanisms of postoperative ileus pathophysiology include fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation 2.

Causes and Risk Factors

• Bowel dysfunction, especially ileus, is commonly associated with constipation, but abnormal motility can also affect the upper digestive tract 3.
• Critical illness, sepsis, multiorgan failure, sedation (especially opioids), and mechanical ventilation can have a deleterious effect on gut function 3.
• Postoperative adhesions are a major cause of ileus in western countries, while stuck hernias are a major cause in developing countries 4.

Treatment and Management

• Management of ileus includes addressing the underlying cause and supportive care, but the effectiveness of multiple medical interventions is uncertain 2.
• Early enteral nutrition (EEN) has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay 2.
• Cholinesterase inhibitors may be safe and effective in treating constipation, but are poorly prescribed 3.
• A combination of dexamethasone, octreotide, and metoclopramide may lead to relief of obstruction and improvement in symptoms associated with malignant bowel obstruction 5.
• Metoclopramide may have a role in preventing prolonged post-operative ileus in advanced gastric cancer patients undergoing gastrectomy and intra-peritoneal chemotherapy 6.

Prevention and Complications

• Prevention of ileus is crucial, and a multimodal concept is required for successful treatment 4.
• The timeframe for treatment of a complete mechanical obstruction is short, as acute ischemia can lead to necrosis with bowel perforation within 6 hours 4.
• The perioperative lethality for an emergency laparotomy due to an ileus ranges from 5-15% 4.