Management of Paralytic Ileus
The management of paralytic ileus requires a multifaceted approach including bowel rest, nasogastric decompression, fluid and electrolyte correction, minimizing opioids, early mobilization, and pharmacologic interventions such as neostigmine for established colonic ileus not responding to other measures. 1
Initial Management
Decompression and Bowel Rest
- Nasogastric decompression: Liberal use of enteral decompression with nasogastric tubes when the stomach is dilated 1
- Rectal tubes: Consider for colonic decompression when the colon is dilated 1
- NPO status: Initially withhold oral intake until bowel function returns
Fluid and Electrolyte Management
- Avoid fluid overload: Use a protocol to avoid positive cumulative fluid balance after initial resuscitation 1
- Electrolyte correction: Monitor and correct electrolyte abnormalities, particularly:
- Potassium
- Magnesium (common deficiency that can worsen ileus) 1
- Phosphate
Positioning and Mobilization
- Body positioning: Consider the contribution of body position to intra-abdominal pressure 1
- Early mobilization: Implement as soon as possible to stimulate bowel function 1
- Start with sitting up in bed
- Progress to standing and walking as tolerated
Pharmacologic Management
Medications to Avoid or Minimize
- Opioids: Reduce or eliminate as they significantly worsen ileus 1
- Switch to non-opioid analgesics when possible
- Consider epidural analgesia for pain control (has the added benefit of reducing ileus) 1
Prokinetic Agents
Neostigmine: Recommended for established colonic ileus not responding to other measures 1
- Dosage: 2.5 mg IV over 3-5 minutes (under cardiac monitoring)
- Contraindications: bradycardia, recent myocardial infarction, mechanical obstruction
Promotility agents:
- Metoclopramide: 10 mg IV/PO TID (primarily for upper GI)
- Erythromycin: 250 mg IV/PO QID (motilin receptor agonist)
Laxatives
- Magnesium oxide: Can promote postoperative bowel function 1
- Bisacodyl: 10 mg PO BID can improve postoperative intestinal function 1
Management of Bacterial Overgrowth
Bacterial overgrowth is common in prolonged ileus and can worsen the condition:
Antibiotics: Consider rotating courses of antibiotics 1
- First-line: Rifaximin (preferred if available)
- Alternatives: Metronidazole, ciprofloxacin, doxycycline, or amoxicillin-clavulanic acid
- Use in 2-6 week courses, often rotating between different antibiotics
Bile salt sequestrants: Consider for bile salt malabsorption if present 1
- Cholestyramine or colesevelam
Nutritional Support
Enteral nutrition: Preferred if gut is accessible and functioning partially 1
- Start with clear liquids when bowel sounds return
- Progress to small, frequent, low-fat, low-fiber meals
Parenteral nutrition: Consider if ileus is prolonged (>7 days) and enteral feeding is not possible 1
- Monitor for complications including infections and hepatic dysfunction
Special Considerations
Monitoring
- Regular abdominal examinations to assess for distension, tenderness
- Daily measurement of abdominal girth
- Monitor for urinary retention, which can occur concurrently
Surgical Intervention
- Rarely needed for uncomplicated paralytic ileus
- Consider if:
- Mechanical obstruction cannot be ruled out
- Clinical deterioration despite medical management
- Evidence of bowel ischemia or perforation
Pitfalls and Caveats
Misdiagnosis: Ensure paralytic ileus is not confused with mechanical obstruction, which requires surgical intervention
Medication side effects: Monitor for side effects of prokinetics:
- Neostigmine: bradycardia, bronchospasm, hypersalivation
- Metoclopramide: extrapyramidal symptoms, especially in young patients
Antibiotic complications: Long-term antibiotics can lead to C. difficile infection or antibiotic resistance 1
Fluid balance: Avoid both dehydration and fluid overload, both of which can worsen ileus 1
By systematically addressing the underlying causes and providing appropriate supportive care, most cases of paralytic ileus can be effectively managed without long-term complications.