From the Guidelines
The initial management for a patient with ileus involves bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of supportive treatment, including intravenous crystalloids, anti-emetics, and bowel rest, as soon as possible 1. The patient should be made nil by mouth (NPO) to prevent further intestinal distension.
Key Components of Initial Management
- Intravenous fluids, typically crystalloids like normal saline or lactated Ringer's solution, should be administered to correct fluid and electrolyte imbalances caused by vomiting, decreased oral intake, and third-spacing of fluids.
- A nasogastric tube should be placed for decompression to relieve pressure, reduce vomiting, and prevent aspiration.
- Pain management with opioids may be necessary, though used cautiously as they can worsen ileus.
- Regular monitoring of vital signs, abdominal examination, and laboratory values (electrolytes, complete blood count, and renal function) is essential.
- Correction of electrolyte abnormalities, particularly potassium, is important for bowel function.
- Antibiotics are not routinely needed unless there's suspected infection.
- The underlying cause of ileus should be identified and addressed, as ileus is often secondary to other conditions like recent surgery, electrolyte disturbances, or medications. While other studies discuss the management of malignant bowel obstruction and the role of multidisciplinary settings in decision-making 1, the initial management of ileus, as per the question, is best guided by the principles outlined in the most recent and directly relevant study 1.
From the Research
Initial Management of Ileus
The initial management of a patient with ileus (intestinal obstruction) involves supportive measures to address the underlying causes and alleviate symptoms.
- Intravenous rehydration to correct fluid imbalance and prevent dehydration 2
- Correction of electrolyte abnormalities, as electrolyte imbalance can exacerbate the condition 2, 3
- Discontinuation of antikinetic drugs that may be contributing to the ileus 2
- Treatment of other contributing disorders, such as infections or metabolic disorders 2
Specific Therapies for Colonic Pseudo-Obstruction
For patients with colonic pseudo-obstruction, specific therapies may be necessary, including:
- Neostigmine (an anticholinesterase) for pharmacologic colonic decompression 2, 4, 5, 3, 6
- Colonoscopic decompression for patients who do not respond to neostigmine or have severe colonic dilatation 4, 3
Predictors of Successful Outcome
Studies have identified predictors of successful outcome following neostigmine therapy in acute colonic pseudo-obstruction, including:
- Postoperative patients are more likely to respond to neostigmine therapy 3
- Patients without electrolyte imbalance or antimotility agents are more likely to respond to neostigmine therapy 3
- Neostigmine is a safe and effective option for patients with acute colonic pseudo-obstruction who failed to respond to conservative management 6