What is the treatment for moderate ileus?

From the Guidelines

The treatment for moderate 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 Treatment

• Minimally invasive surgery to reduce 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 maintain intestinal function and promote recovery
• Laxative administration to prevent constipation and promote bowel movements
• Omission or early removal of nasogastric intubation to reduce the risk of gastric stasis and aspiration

Additional Considerations

• Correction of electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, to prevent worsening of ileus
• Identification and treatment of the underlying cause of ileus to prevent persistent symptoms and complications
• Use of prokinetic agents, such as metoclopramide or erythromycin, may be considered to stimulate bowel function
• Alvimopan, a μ-opioid receptor antagonist, may be used post-operatively to counteract opioid-induced ileus, as supported by evidence from a study published in 2012 1

Evidence-Based Recommendations

The recommendations for the treatment of moderate ileus are based on the most recent guidelines from the Enhanced Recovery After Surgery (ERAS) Society, which emphasize the importance of a multifaceted approach to minimizing postoperative ileus 1. These guidelines are supported by strong evidence and recommend a range of interventions to promote recovery and prevent complications.

From the FDA Drug Label

The efficacy of alvimopan in the management of postoperative ileus was evaluated in 6 multicenter, randomized, double-blind, parallel-group, placebo-controlled studies 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 Patients 18 years of age or older undergoing partial large or small bowel resection surgery with primary anastomosis for colorectal or small bowel disease, total abdominal hysterectomy, or radical cystectomy for bladder cancer were randomly assigned to receive oral doses of alvimopan 12 mg or matching placebo

The treatment for moderate ileus is alvimopan 12 mg administered orally, twice daily, starting on the first postoperative day and continued until hospital discharge or a maximum of 7 days 2.

• Key points:
  • Alvimopan is used to manage postoperative ileus in patients undergoing partial large or small bowel resection surgery
  • The primary endpoint is time to achieve resolution of postoperative ileus
  • Patients receive oral doses of alvimopan 12 mg or matching placebo
  • Treatment is started on the first postoperative day and continued until hospital discharge or a maximum of 7 days

From the Research

Treatment for Moderate Ileus

The treatment for moderate ileus involves addressing the underlying cause and providing supportive care. According to 3, management includes:

• Addressing the underlying cause
• Supportive care
• Multiple medical interventions, although their effectiveness is uncertain

Medical Interventions

Some medical interventions that have been proposed for the treatment of ileus include:

• Metoclopramide: however, 3 found that it was not effective in expediting the resolution of ileus
• Erythromycin: also found to be ineffective in expediting the resolution of ileus by 3
• Early enteral nutrition (EEN): 3 strongly recommends EEN to expedite resolution of ileus in patients who have undergone abdominal surgery
• Neostigmine: 4 found it to be effective in relieving severe abdominal distention and ileus in a patient with severe fecal impaction
• Alvimopan: 5 and 6 found it to be effective in accelerating gastrointestinal recovery and reducing postoperative ileus in patients undergoing bowel surgery

Prevention and Management

Prevention and management of ileus also involve:

• Bowel management protocol using osmotic laxatives: although its effectiveness is uncertain, it appears to be safe 7
• Enteral opioid antagonists: may be a promising strategy for patients treated with high doses of opioids during sedation 7
• Cholinesterase inhibitors: seem safe and could probably be used in case of constipation, but are poorly prescribed 7