From the Guidelines
Initial management of ileus should focus on a multifaceted approach to minimize its occurrence and impact, including optimized fluid management, opioid-sparing analgesia, early mobilization, and early postoperative food intake, as recommended by the most recent guidelines 1. The management of ileus involves several key steps:
- Making the patient nil per os (NPO) to rest the bowel
- Inserting a nasogastric tube for decompression to relieve abdominal distention and prevent vomiting
- Providing intravenous fluid resuscitation to correct electrolyte imbalances, particularly potassium, sodium, and chloride
- Implementing pain management with opioid-sparing approaches when possible to minimize the risk of worsening ileus
- Encouraging ambulation as early as possible, as physical activity stimulates bowel motility
- Discontinuing medications that may worsen ileus, such as opioids, anticholinergics, and calcium channel blockers
- Ordering laboratory tests to assess electrolyte status and identify potential causes
- Utilizing abdominal imaging (X-ray or CT) to confirm the diagnosis and rule out mechanical obstruction
- Considering the use of prokinetic agents like metoclopramide, though evidence for their efficacy is limited
- Using Alvimopan, a peripheral μ-opioid receptor antagonist, postoperatively to accelerate GI recovery, as supported by recent studies 1 Treatment should continue until bowel function returns, as evidenced by passage of flatus or stool, reduced abdominal distention, and return of bowel sounds. Ileus typically resolves within 2-3 days with proper management, but persistent symptoms warrant further investigation for complications or alternative diagnoses. Key aspects of care include:
- Optimized fluid management to prevent fluid overload and ensure adequate hydration
- Opioid-sparing analgesia to minimize the risk of ileus
- Early mobilization to stimulate bowel motility
- Early postoperative food intake to maintain intestinal function and promote recovery
- Consideration of multimodal interventions, including gum chewing, prevention of postoperative nausea and vomiting (PONV), and minimally invasive surgery, to reduce the incidence and duration of ileus, as suggested by recent guidelines 1. The goal of these measures is to reduce morbidity, mortality, and improve the quality of life for patients with ileus, by addressing the underlying cause, managing symptoms, and preventing complications.
From the Research
Initial Management Steps for Ileus
The initial management steps for ileus involve supportive measures to address the underlying causes and alleviate symptoms. These steps include:
- Intravenous rehydration to correct fluid imbalances and prevent dehydration 2
- Correction of electrolyte abnormalities to restore normal electrolyte levels and support intestinal function 2
- Discontinuation of antikinetic drugs that may be contributing to the ileus 2
- Treatment of other contributing disorders, such as infections or metabolic disorders, to address the underlying causes of the ileus 2
Pharmacologic Interventions
In addition to supportive measures, pharmacologic interventions may be used to manage ileus. These include:
- Neostigmine, an anticholinesterase, for pharmacologic colonic decompression in patients with colonic pseudo-obstruction 2, 3
- Methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, to restore postoperative bowel function in patients with opioid-induced bowel dysfunction 4, 5, 6
- Alvimopan, another peripherally active mu-opioid receptor antagonist, to reduce the duration of postoperative ileus after abdominal surgery with bowel resection 4, 6
Specific Considerations
Specific considerations must be taken into account when managing ileus, including: