What is the management for a patient with ileus?

From the Guidelines

The management of ileus should prioritize a multifaceted approach 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. The goal is to minimize the duration and severity of ileus, thereby reducing morbidity, mortality, and improving quality of life. Key considerations in the management of ileus include:

• Optimized fluid management to avoid fluid overload, aiming for a weight gain limited to < 3 kg at postoperative day three 1
• Early oral intake to maintain intestinal function, with small portions initially, especially after right-sided resections and small-bowel anastomosis 1
• Avoidance of opioids and use of opioid-sparing analgesia to prevent worsening of ileus
• Early mobilization as soon as possible after surgery to enhance recovery 1
• Correction of electrolyte abnormalities, particularly hypokalemia, to improve gut motility
• Gradual diet advancement once bowel function returns, starting with clear liquids and advancing as tolerated
• Consideration of prokinetic agents or other medications to help manage ileus, although evidence for their efficacy may be limited
• Surgical intervention is rarely needed but may be necessary in cases of mechanical obstruction or failure to resolve with conservative management.

From the FDA Drug Label

For the Relief of Symptoms Associated With Diabetic Gastroparesis (Diabetic Gastric Stasis) Administer 10 mg of metoclopramide 30 minutes before each meal and at bedtime for two to eight weeks, depending upon response and the likelihood of continued well-being upon drug discontinuation.

The management for a patient with ileus is not directly addressed in the provided drug label. However, the label does discuss the management of diabetic gastroparesis, which may be related to ileus in some cases.

• The recommended dosage for diabetic gastroparesis is 10 mg of metoclopramide 30 minutes before each meal and at bedtime for two to eight weeks.
• The label also mentions that severe symptoms may require initial treatment with metoclopramide injection for up to 10 days before switching to oral administration 2. However, since the label does not directly address ileus, this information should be used with caution and in consultation with a healthcare professional.

From the Research

Management of Ileus

The management of ileus involves a multimodal approach, including nonpharmacologic and pharmacologic interventions. Some key points to consider include:

• Early ambulation, although it does not affect the duration of postoperative ileus, has other benefits for patients undergoing abdominal surgery 3
• The use of laparoscopy instead of laparotomy, removal of nasogastric tubes shortly after surgery, restriction of intravenous fluids, and initiation of clear oral liquids and ambulation on the first postoperative day are recommended 3
• Thoracic epidural analgesia using a local anesthetic with or without an epidural opioid analgesic, and systemic nonsteroidal anti-inflammatory drugs for their opioid-sparing effect, may be effective in preventing or ameliorating postoperative ileus 3
• Buprenorphine may be preferred if a systemic opioid analgesic is used, as it has little effect on gastrointestinal smooth muscle 3

Pharmacologic Interventions

Some pharmacologic interventions that have been tried to prevent or ameliorate ileus include:

• Metoclopramide and erythromycin, which may be useful in some cases, such as methamphetamine-induced ileus 4
• Neostigmine, which appears to be useful in reversing ileus caused by anticholinergic drug overdose 5, 6
• However, most pharmacologic interventions that have been tried are ineffective or cause intolerable adverse effects 3

Specific Cases

In specific cases, such as methamphetamine-induced ileus, treatment with intravenous metoclopramide and erythromycin may be effective 4 In cases of anticholinergic-induced ileus, treatment with neostigmine may be useful 5, 6