What is the initial treatment for ileus?

Initial Treatment for Ileus

The initial treatment for ileus should be isotonic intravenous fluids such as lactated Ringer's or normal saline solution, which are essential for management when ileus is present. 1

Pathophysiology and Approach to Treatment

Ileus refers to the partial or complete functional obstruction of the intestine without mechanical blockage, characterized by absent or uncoordinated intestinal muscle contractions. This condition can lead to:

• Intestinal dilatation
• Increased luminal pressure
• Gut wall ischemia
• Fluid sequestration
• Bacterial overgrowth

Initial Management Algorithm

1. Intravenous Fluid Resuscitation

   • Administer isotonic fluids (lactated Ringer's or normal saline)
   • Continue IV hydration until clinical improvement is noted
   • Monitor for resolution of ileus signs (return of bowel sounds, passage of flatus/stool)

2. Supportive Measures

   • NPO (nothing by mouth) until ileus resolves
   • Nasogastric tube decompression if significant abdominal distention or vomiting
   • Correction of electrolyte abnormalities, particularly potassium, magnesium, and calcium
   • Discontinuation of medications that may worsen ileus (opioids, anticholinergics)

3. Treat Underlying Causes

   • Identify and address precipitating factors:
     • Post-surgical inflammation
     • Electrolyte disturbances
     • Medications
     • Infections/sepsis
     • Metabolic disorders

Evidence-Based Recommendations

The 2017 IDSA guidelines specifically address ileus management, stating that "isotonic intravenous fluids such as lactated Ringer's and normal saline solution should be administered when there is ileus (strong, moderate)" 1. This recommendation is based on moderate-quality evidence and carries a strong recommendation, indicating its importance in clinical practice.

Special Considerations

• Monitoring: Regular assessment of vital signs, abdominal examination, and fluid status is essential
• Duration: IV rehydration should be continued until "pulse, perfusion, and mental status normalize and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus" 1
• Transition to Oral Intake: Once ileus resolves, gradual reintroduction of oral fluids followed by solid foods

Potential Complications and Pitfalls

• Intra-abdominal Hypertension: Found in up to 20% of critically ill patients with ileus 2
• Bacterial Translocation: Prolonged ileus can lead to bacterial overgrowth and systemic infection
• Fluid and Electrolyte Imbalances: Careful monitoring is required to prevent overcorrection or undercorrection
• Delayed Recognition: Failure to recognize persistent ileus can lead to bowel ischemia, perforation, and sepsis

Early and aggressive fluid resuscitation remains the cornerstone of ileus management, with additional therapies directed at the underlying cause. Surgical intervention is rarely needed for functional ileus but may be necessary if mechanical obstruction cannot be ruled out or if complications develop.