What is the treatment for postoperative ileus?

From the Guidelines

Post-operative ileus treatment should involve a multimodal approach focusing on early mobilization, pain management, and gradual diet advancement, as recommended by the most recent guidelines 1. The treatment of post-operative ileus involves a combination of strategies to minimize its occurrence and duration.

• Early mobilization is crucial, as movement stimulates bowel function.
• Pain control should utilize non-opioid medications when possible, including acetaminophen and NSAIDs like ketorolac, as opioids can worsen ileus.
• Prokinetic medications may help, including metoclopramide or erythromycin.
• Alvimopan, a peripherally acting mu-opioid receptor antagonist, can be used for patients undergoing bowel resection who receive opioids.
• Nasogastric tube decompression may provide symptomatic relief for significant distension or vomiting.
• Diet should be advanced gradually from clear liquids to solid food as tolerated, guided by return of bowel sounds, passing flatus, or bowel movements.
• Adequate hydration and electrolyte balance must be maintained with IV fluids until oral intake is sufficient, with a focus on avoiding fluid overload and maintaining a near-zero fluid balance 1. These interventions work by addressing the neurogenic, inflammatory, and pharmacologic factors that contribute to post-operative bowel dysfunction, helping to restore normal gastrointestinal motility. The use of minimally invasive surgery, optimized fluid management, and opioid-sparing analgesia are also key components of enhanced recovery after surgery (ERAS) protocols, which have been shown to reduce the incidence and duration of post-operative ileus 1. Additionally, the avoidance of routine nasogastric tube placement and the use of chewing gum have been suggested as potential strategies to reduce the risk of post-operative ileus 1. Overall, a comprehensive approach to post-operative ileus treatment, incorporating these various strategies, can help to minimize its impact on patient outcomes and quality of life.

From the FDA Drug Label

Metoclopramide Injection is indicated for the prophylaxis of postoperative nausea and vomiting in those circumstances where nasogastric suction is undesirable The answer to treating post op ileus is not directly addressed in the provided drug label, as postoperative ileus is not explicitly mentioned. However, postoperative nausea and vomiting is mentioned as an indication for metoclopramide.

• Metoclopramide may be used to stimulate gastric emptying, but its use in treating post op ileus is not directly stated. 2

From the Research

Treatment Options for Postoperative Ileus

• The treatment of postoperative ileus is multifactorial and can involve a combination of different approaches 3.
• Limitation of narcotic use by substituting alternative medications such as nonsteroidals and placing a thoracic epidural with local anesthetic when possible can help reduce the duration of postoperative ileus 3.
• The selective use of nasogastric decompression and correction of electrolyte imbalances are also important factors to consider 3.
• Symptomatic relief with nasogastric suction is a common treatment approach for postoperative ileus 4.
• Prokinetic drugs, such as metoclopramide, have been studied for their effectiveness in treating postoperative ileus, but the results are mixed 5, 6, 7.
• Metoclopramide has been shown to reduce nausea and emesis postoperatively, but its effect on postoperative ileus is not significant in most cases 6, 7.
• Combined use of gum-chewing and parenteral metoclopramide has been studied, but it was found to have no effect on the duration of postoperative ileus following abdominal surgeries in adult surgical patients 5.

Factors Affecting Postoperative Ileus

• The duration of postoperative ileus correlates with the degree of surgical trauma and is most extensive after colonic surgery 3.
• Postoperative ileus can develop after all types of surgery, including extraperitoneal surgery 3.
• The etiology of postoperative ileus is multifactorial, and it is best treated with a combination of different approaches 3.

Types of Postoperative Ileus

• There are two types of ileus: postoperative and paralytic 4.
• Postoperative ileus resolves spontaneously after two to three days, and probably reflects inhibition of colonic motility 4.
• Paralytic ileus is more severe, lasts more than three days, and seems to represent inhibition of small bowel activity 4.