What is the management of ileus?

From the Guidelines

The management of ileus should involve 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 Components of Ileus Management

• Minimally invasive surgery to reduce tissue trauma and promote faster recovery
• Optimized fluid management to prevent fluid overload and maintain electrolyte balance
• Opioid-sparing analgesia to minimize the risk of opioid-induced ileus
• Early mobilization to stimulate bowel function and prevent complications
• Early postoperative food intake to promote bowel recovery and reduce the risk of malnutrition
• Laxative administration to prevent constipation and promote bowel motility
• Omission or early removal of nasogastric intubation to reduce the risk of gastric stasis and promote bowel recovery

Additional Considerations

• Correction of electrolyte abnormalities, particularly potassium, magnesium, and phosphate, to promote bowel motility
• Discontinuation of medications that slow gut motility, such as anticholinergics and opioids, when possible
• Use of prokinetic agents, such as metoclopramide or erythromycin, may be considered, though evidence for their efficacy is limited
• Alvimopan, a peripherally acting mu-opioid receptor antagonist, can be used to reduce opioid-induced ileus

Monitoring and Complications

• Patients should be closely monitored for signs of complications, such as mechanical obstruction or perforation
• Persistent cases of ileus require investigation for underlying causes and potentially necessitate surgical intervention
• The use of epidural analgesia and regional anesthesia may be beneficial in reducing postoperative pain and promoting bowel recovery, as suggested by recent guidelines 1

From the FDA Drug Label

Postoperative ileus is the impairment of gastrointestinal motility after intra-abdominal surgery or other, non-abdominal surgeries. The primary endpoint for all studies was time to achieve resolution of postoperative ileus, a clinically defined composite measure of both upper and lower gastrointestinal recovery Alvimopan achieves this selective gastrointestinal opioid antagonism without reversing the central analgesic effects of µ-opioid agonists.

The management of ileus includes the use of alvimopan, a selective antagonist of the cloned human µ-opioid receptor.

• Key points:
  • Alvimopan antagonizes the peripheral effects of opioids on gastrointestinal motility and secretion.
  • It achieves selective gastrointestinal opioid antagonism without reversing the central analgesic effects of µ-opioid agonists.
  • The primary endpoint for all studies was time to achieve resolution of postoperative ileus, a clinically defined composite measure of both upper and lower gastrointestinal recovery.
• Clinical studies: Six multicenter, randomized, double-blind, parallel-group, placebo-controlled studies evaluated the efficacy of alvimopan in the management of postoperative ileus 2, 2, 2.

From the Research

Management of Ileus

The management of ileus involves addressing the underlying cause and providing supportive care. Several medical interventions have been proposed, but their effectiveness is uncertain 3.

• Causes of Ileus: Ileus can be caused by various factors, including postoperative pain, use of narcotics for analgesia, electrolyte imbalances, and manipulation of the bowel during surgery 4.
• Treatment Options: Treatment options for ileus include early refeeding, gum chewing, and the use of tube feeds 4.
• Role of Alvimopan: Alvimopan has been shown to significantly impact ileus, length of stay, and readmission after intestinal surgery, regardless of the risk of ileus 5, 6.
• Early Enteral Nutrition (EEN): EEN has been strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 3.
• Pharmacological Interventions: The use of metoclopramide and erythromycin to hasten the resolution of ileus is not recommended due to lack of evidence 3.
• Conservative Management: Conservative management of ileus, particularly of the small bowel, can often be successfully treated without surgery 7.
• Interdisciplinary Collaboration: Proper treatment of ileus depends on the timely determination of the pathogenesis and close interdisciplinary collaboration 7.