What is the next best step in managing diffuse ileus?

From the Guidelines

The next best step in managing diffuse ileus is to implement a multifaceted approach to minimize postoperative ileus, including optimized fluid management, opioid-sparing analgesia, early mobilization, and early postoperative food intake, as recommended by the ERAS society guidelines 1. This approach is supported by the most recent and highest quality studies, which emphasize the importance of a comprehensive strategy to prevent and manage postoperative ileus. The guidelines suggest that a multifaceted approach, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation, can help minimize postoperative ileus 1.

Some key considerations in managing diffuse ileus include:

• Optimized fluid management to avoid fluid overload and correct fluid status early, aiming to have weight gain limited to < 3 kg at postoperative day three 1
• Opioid-sparing analgesia to reduce the risk of worsening ileus
• Early mobilization to promote intestinal function and reduce the risk of complications
• Early postoperative food intake, with small portions offered initially, especially after right-sided resections and small-bowel anastomosis 1
• Laxative administration to promote bowel movements and prevent constipation
• Omission or early removal of nasogastric intubation to reduce the risk of ileus and promote intestinal function

It is also important to note that parenteral nutrition should be initiated if ileus persists beyond 5-7 days, as recommended by the guidelines 1. Additionally, prokinetic agents like metoclopramide may be considered in select cases, though evidence for their efficacy is limited. Surgery is rarely indicated for uncomplicated ileus but may be necessary if there is concern for mechanical obstruction or other surgical pathology.

Overall, the management of diffuse ileus requires a comprehensive and multifaceted approach that addresses the physiological basis of ileus and supports the patient until normal bowel function returns. By following the ERAS society guidelines and considering the individual needs of each patient, healthcare providers can help minimize the risk of postoperative ileus and promote optimal outcomes.

From the Research

Management of Diffuse Ileus

The management of diffuse ileus involves addressing the underlying cause and providing supportive care.

• The use of promotility agents such as metoclopramide and erythromycin has been studied, but the evidence suggests that they are not effective in expediting the resolution of ileus 2.
• Early enteral nutrition (EEN) has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in adult surgical patients 2.
• Neostigmine has been used to successfully relieve refractory ileus in pediatric patients after liver transplantation, and may be considered early in the treatment of these patients 3.
• External nursing applications, such as abdominal compresses and massages with plant or silver-containing oils and ointments, may be an additional tool in the management of prolonged postoperative ileus 4.
• A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus suggests that a multimodal approach, including avoidance of preoperative fasting and mechanical bowel preparation, use of epidural-local anesthetics, and modification of pain management strategies, may be effective in preventing or limiting the duration of postoperative ileus 5.

Treatment Options

Treatment options for diffuse ileus include:

• Supportive care, such as addressing the underlying cause and providing nutritional support
• Early enteral nutrition (EEN) to facilitate the return of normal bowel function
• Neostigmine to relieve refractory ileus in pediatric patients after liver transplantation
• External nursing applications, such as abdominal compresses and massages with plant or silver-containing oils and ointments
• A multimodal approach to prevent and treat postoperative ileus, including avoidance of preoperative fasting and mechanical bowel preparation, use of epidural-local anesthetics, and modification of pain management strategies 6, 2, 3, 4, 5.