What is the treatment for ileus?

From the Guidelines

The treatment for ileus primarily involves a multifaceted approach to minimize its occurrence and impact, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission or early removal of nasogastric intubation, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Minimally invasive surgery to reduce the risk of postoperative ileus
• Optimized fluid management to avoid fluid overload, which can impair gastrointestinal function 1
• Opioid-sparing analgesia to minimize the use of opioids, which can worsen ileus
• Early mobilization to stimulate bowel motility and reduce the risk of ileus
• Early postoperative food intake to maintain intestinal function and reduce the risk of ileus
• Laxative administration, such as bisacodyl, to promote bowel function and prevent constipation 1
• Omission or early removal of nasogastric intubation to reduce the risk of ileus and promote early oral intake

Additional Considerations

• Correction of electrolyte abnormalities, particularly potassium, magnesium, and phosphate deficiencies, which can worsen ileus
• Use of prokinetic agents, such as metoclopramide or erythromycin, to stimulate bowel motility in some cases
• Consideration of alvimopan, a μ-opioid receptor antagonist, to accelerate gastrointestinal recovery and reduce the length of stay in patients undergoing open colonic resection with postoperative opioid analgesia 1

Overall Approach

The goal of treatment is to minimize the occurrence and impact of ileus, reduce the length of stay, and improve patient outcomes. A multifaceted approach that incorporates the key components of treatment and additional considerations is recommended, based on the most recent and highest quality evidence 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 treatment for ileus is not directly addressed in the provided drug label. Ileus is not mentioned, and the indications for metoclopramide injection do not include treatment for ileus.

• The label discusses the use of metoclopramide for diabetic gastroparesis, prevention of nausea and vomiting associated with cancer chemotherapy and postoperative nausea and vomiting, small bowel intubation, and radiological examination.
• There is no information about the treatment of ileus. 2

From the Research

Treatment of Ileus

The treatment of ileus involves addressing the underlying cause and providing supportive care. Some of the key aspects of treatment include:

• Addressing fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation, which are the main mechanisms of postoperative ileus pathophysiology 3
• Using a multimodal approach, which has been shown to be effective in reducing postoperative ileus in patients with cancer who have had abdominal surgery 4
• Considering the use of prokinetic agents, such as metoclopramide, erythromycin, and cisapride, although their effectiveness is uncertain and may depend on the specific condition being treated 3, 5, 6
• Early enteral nutrition (EEN), which has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in patients who have undergone abdominal surgery 3
• Neostigmine, which has been used to treat postoperative ileus in orthopedic spinal patients with acute colonic pseudo-obstruction 7

Medical Interventions

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

• Metoclopramide, which has been shown to reverse decreased gastrointestinal myoelectric and contractile activity in a model of canine postoperative ileus 6
• Erythromycin, which has been used to treat diabetic gastroparesis and appears to improve symptoms of colonic pseudo-obstruction and postoperative ileus 5
• Cisapride, which appears to hold promise for patients with colonic motility disorders and has been associated with an increased return of bowel function in patients with postoperative ileus 5
• Neostigmine, which has been shown to be effective in treating postoperative ileus in orthopedic spinal patients with acute colonic pseudo-obstruction 7

Recommendations

Based on the available evidence, the following recommendations can be made:

• Early enteral nutrition (EEN) is strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 3
• The use of metoclopramide or erythromycin to hasten the resolution of ileus in these patients cannot be recommended for or against due to the low level of evidence 3